vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 43 correlation between radiographic grading of osteoarthritis, pain severity and functional status in knee osteoarthritis patients annisa dwi khairina,1 marina a. moeliono,2 andri reza rahmadi3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: osteoarthritis is a joint degenerative disease characterized with structural changes of joint. the structural changes can be assessed with radiological assessment. major clinical manifestations may include pain, inflammation, and stiffness, resulting in limitations for performing daily activities. the purpose of this study was to determine the correlation between radiographic grading of osteoarthritis, pain severity, and lower extremities functional status in patients with knee osteoarthritis. methods: the study involved 29 patients with knee osteoarthritis in dr. hasan sadikin general hospital, bandung and bandung district general hospital during the period of august to october 2014 using the cross sectional method. this study used nrs (numeric rating scale) for pain severity assessment, kellgrenlawrence criteria for radiographic grading of osteoarthritis, and modified lower extremity funcional scale for functional status assessment. the data were analyzed using statistical analysis tools. if the data were normally distributed, the correlation test will be carried out by using the pearson correlation test and if the data were not normally distributed then the spearman’s correlation test will be used. results: correlation coefficient between severity of pain and functional status is r= -0,439 with p value= 0.17 (p<0.05). there was no significant correlation between radiographic grading of osteoarthritis and functional status (p > 0.05). conclusions: the severity of pain correlates with the functional status of patients with osteoarthritis of the knee, while radiographic grading of osteoarthritis does not correlate with functional status. keywords: kellgren-lawrence criteria, knee osteoarthritis, modified lower extremity functional scale, radiographic grading correspondence: annisa dwi khairina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: annisadwikhairina@gmail.com introduction osteoarthritis is a degenerative joint disease characterized by degeneration of the articular cartilage, hypertrophy of bone at the margin, and changes in synovial membrane.1 osteoartritis is the most common disease that is equal to 50–60% of the total of rheumatic diseases in indonesia.2 major clinical manifestations of osteoarthritis are pain, swelling, and stiffness.3 the world health organization reports that 80% of patients with osteoarthritis will have limitations in movement, and 25% cannot perform daily activities of live.4 several studies have been conducted to determine the relationship between clinical symptoms with disability and radiographic results using the western ontario and mcmaster universities osteoarthritis index (womac) questionnaire.5 besides womac, there are also other measurement tools to measure functional status, namely the lower extremity functional scale (lefs). this study used the lower extremity functional scale because it was recommended by several other studies as a measurement of functional status in osteoarthritis because it is able to distinguish between pain and physical function.6,7 the daily living activities of people in indonesia are slightly different from the community activities in other cultures, therefore, this study used lefs that has been modified in accordance with daily activities in indonesia. the purpose of this study was to analyze the correlation between the radiographic grading of osteoarthritis, severity of pain and functional status by the modified lower extremity functional scale on patients with knee osteoarthritis. amj. 2018;5(1):43–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1335 althea medical journal. 2018;5(1) 44 amj march 2018 methods the study was conducted at the polyclinic of physical medicine and rehabilitation and the polyclinic of rheumatology of internal medicine dr. hasan sadikin general hospital bandung and bandung district general hospital during the period of august to october 2014. the study was approved by the health research ethics committee of the faculty of medicine, universitas padjadjaran, the ethics committee of the general hospital dr. hasan sadikin, and the ethics committee of the bandung district general hospital. the cross sectional method was used in this study. the sample size was calculated using the formula of correlation analysis that established the value of α= 0.05, it is worth 1.96 zα, zβ value= 0.84, and the minimum correlation value considered significant is 0.4, then the calculated sample size obtained was 46. inclusion criteria for this study were patients with clinical and radiological diagnosis of knee osteoarthritis, age range between 50 to 70 years, cooperative and willing to answer questions in the questionnaire. exclusion criteria were knee osteoarthritis patients who did not have the required data according to the study and patients with a diagnosis other than osteoarthritis in the lower extremities. patients who had agreed to be involved as study subjects then recorded their identity (name, age, gender, and diagnosis), radiographic grading of osteoarthritis, severity of pain, and functional status. the radiographic grading of osteoarthritis assessment used the kellgren-lawrence criteria, which was divided into four levels of severity. the assessment of radiographic grading was obtained from the results of the radiological diagnosis which has been performed by a radiologist. the severity of pain was assessed using the numeric rating scale (nrs). the higher the number on a scale of 0–10 showed more severe levels of pain felt by the patient. the assessment was categorized as no pain (0), mild pain (1–3), moderate pain (4–6), and severe pain (7–10). patients were asked about the pain during the day they come to the health facilities. the lower extremity functional status was assessed using the modified lower extremity functional scale questionnaire, which was a translation and modification of the lower extremity functional scale (lefs). the modification was adjusted to the conditions of people’s daily activities in indonesia and had been validated. the modified lower extremity functional scale contained 22 questions about patients’ difficulties in performing daily activities. the level of difficulty in performing the activities in the questions were assessed in a scale of 0–4. the lower the value, the more severe difficulties patients experienced. the value of each question was then summed up and the maximum value of the modified lower extremity functional scale obtained was 88 which showed no limitations to perform the activity. the data were analyzed using statistical analysis tools. if the data were normally distributed, the correlation test will be carried out by using the pearson correlation test and if the data were not normally distributed then spearman’s correlation will be used. results the total respondents during the study period were only 29 patients compared to the need of minimum sample (46 samples). most of the respondents were female. regarding age, the average age was 58 yearswith the youngest age was 50 years and the oldest was 70 years. based on the kellgren-lawrence criteria, there were no subjects with radiographic grade iv and most of the subjects had radiographic grade ii (79.3%). most of the patients experienced pain in the moderate pain category (62.1%). results of the lower extremities functional status assessment using the modified lower extremity functional scale obtained an average value of 60.93, with a minimum value of 31 and maximum value of 84 from the total maximum value of 88. there was a significant correlation between severity of pain with functional status, with a value of r = -.439, and no significant correlation between radiographic grading of osteoarthritis and functional status (table 2). discussions the main problem due to damage to the joint cartilage in osteoarthritis is pain and disruption of related joint function.8 activities such as climbing stairs, getting up from the chair, and running cause pain in people with knee osteoarthritis.9 pain is a decisive reason why patients are seeking treatment. this study proved that all patients who were present in health care felt pain. this study found that 34.5% of the subjects reported mild pain, moderate pain 62.1%, and 3.4% severe pain. althea medical journal. 2018;5(1) 45annisa dwi khairina, marina a. moeliono, andri reza rahmadi: correlation between radiographic grading of osteoarthritis, pain severity and functional status in knee osteoarthritis patients the variation of pain in osteoarthritis patients was explained through a study by neogi et al.10, that one can adapt every day to overcome the pain and avoid activities that cause pain. based on the calculation performed in this study, there was a significant correlation between severity of pain with functional status, with a value of r= -.439 and p<0.05. this correlation showed the more severe pain experienced by the patients with knee osteoarthritis, the greater limitation of the lower extremity function. there was no significant correlation between the radiographic grading of osteoarthritis with lower extremity functional status in patients with osteoarthritis of the knee. this study showed similar results with other studies even using the modified lower extremity functional as a measurement for functional status. cubukcu et al.5 conducted a study in turkey using womac to assess the grading of pain and functional status, reported the same results that pain on the knee affects the ability to perform daily activities in patients with osteoarthritis and there is no correlation between functional status and radiographic grading of osteoarthritis. a study performed by ay and evcik11 using vas to assess the grading of pain and womac to assess the functional status of the subject also had similar results. another study also reported that pain affects the level of functional limitations in performing daily activities.12 the correlation between radiographic findings in osteoarthritis with functional status showed different results compared with the results of a research by szebenyi et al.13 the radiological changes in the structure of the tibiofemoral and patellofemoral on the knee joints were associated with functional limitations in osteoartritis patients. this findings could be explained because in this study the radiological assessment of osteoarthritis only used the kellgren-lawrence criteria which did not assess more specifically, therefore the correlation found was different. furthermore, no correlation between the radiographic grading of osteoarthritis with functional status in this study could be found as 96.6% of the subjects of this study were table 1 study subjects characteristics data characteristics total n=29 % sex male 1 3.4 female 28 96.6 diagnosis oa genu bilateral 18 62.1 oa genu dekstra 5 17.2 oa genu sinistra 6 20.7 radiographic grading of osteoarthritis (kellgren-lawrence criteria) i 5 17.2 ii 23 79.3 iii 1 3.4 iv 0 0 severity of pain no pain (0) 0 0.0 mild pain (1-3) 10 34.5 moderate pain (4-6) 18 62.1 severe pain (7-10) 1 3.4 table 2 correlation test result functional status correlation coefficient sig. radiographic grading of osteoarthritis -.226 .239 severity of pain -.439* -.017* note: *. correlation is significant at the 0.05 level (2-tailed). althea medical journal. 2018;5(1) 46 amj march 2018 women. muraki et al.14 in japan reported that the knee pain has a strong association with the radiological joint space narrowing, especially in men, and women more often feel pain even without radiological changes. another study also stated that the pain severity is not correlated with the radiographic grading of osteoarthritis.5 moreover, there is no correlation between severity of pain and radiographic grading of osteoarthritis. a limitation of this study was the number of patients with osteoarthritis of the knee did not meet the minimum requirement number of samples so its significance couldnot be determined. the conclusion of this study is the severity of pain correlates with the functional status of patients with osteoarthritis of the knee, while radiographic grading of osteoarthritis does not correlate with functional status. references 1. dorland wan. dorland’s illustrated medical dictionary. 32th ed. philadelphia, pa: saunders; 2011. 2. nainggolan o. prevalensi dan determinan penyakit rematik di indonesia. maj kedokt indon. 2009;59(12):588–94. 3. dieppe pa, lohmander ls. pathogenesis and management of pain in osteoarthritis. lancet. 2005;365(9463):965–73. 4. who. chronic rheumatic conditions. geneva. [cited 2014 february 11]. available from: http://www.who.int/chp/ topics/rheumatic/en/. 5. cubukcu d, sarsan a, alkan h. relationships between pain, function and radiographic findings in osteoarthritis of the knee: a cross-sectional study. arthritis. 2012;2012:984050. 6. hoogeboom tj, bie rad, broeder aad, ende chvd. the dutch lower extremity functional scale was highly reliable, valid and responsive in individuals with hip/ knee osteoarthritis. bmc musculoskelet disord. 2012;13(117):10. 7. pua yh, cowan sm, wrigley tv, bennell kl. the lower extremity functional scale could be an alternative to the western ontario and mcmaster universities osteoarthritis index physical function scale. j clin epidemiol. 2009;62(10):1103–11. 8. enohumah ko, imarengiaye co. pain in osteoarthritis. afr j biomed res. 2008;11(2):119–28. 9. felson dt. osteoarthritis of the knee. n engl j med. 2006;354(8):841–8. 10. neogi t, nevitt mc, yang m, curtis jr, torner j, felson dt. consistency of knee pain: correlates and association with function. osteoarthr cartil. 2010;18(10):1250–5. 11. ay s, evcik d. effectiveness of pain, disease severity and radiological grading on disability of daily living activities in knee osteoarthritis. turk j rheumatol. 2008;23(1):14–7. 12. neogi t. the epidemiology and impact of pain in osteoarthritis. osteoarthr cartil. 2013;21(9):1145–53. 13. szebenyi b, hollander ap, dieppe p, quilty b, duddy j, clarke s, et al. associations between pain, function, and radiographic features in osteoarthritis of the knee. arthritis rheum. 2006;54(1):230–5. 14. muraki s, oka h, akune t, mabuchi a, en-yo y, yoshida m, et al. prevalence of radiographic knee osteoarthritis and its association with knee pain in the elderly of japanese population-based cohorts: the road study. osteoarthr cartil. 2009;17(9):1137–43. 257 althea medical journal. 2017;4(2) suspectable risk factors of congenital anomaly in dr. hasan sadikin general hospital, bandung, indonesia pradistya syifa yudiasari¹, akhmad yogi pramatirta², sharon gondodiputro³ 1faculty of medicine universitas padjadjaran, 2department of obstetric and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 1department of public health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: congenital anomaly is a disease of structural or functional alteration since birth. the cause of congenital anomaly is genetic, environtment, and unknown. the cause of congenital anomaly is unknown, made congenital anomaly is difficult to detect. therefore, the objective of this study was to identify the suspectable risk factors of congenital anomaly. methods: this was a descriptive study. about 78 samples were taken by purposive sampling from medical records of patients with congenital anomaly in pediatric surgery ambulatory unit at dr. hasan sadikin general hospital (rshs), bandung from september to november 2014. from the selected medical records, an interview was carried out to the parents’ patient to identify some suspectable risk factors. the collected data were analyzed and presented in tables. results: from 78 medical records, hirschprung disease was the highest among all type of congenital anomaly (29%). the characteristic of congenital anomaly was mothers in the age of 20–35 years (65%), fathers’ age was more than 20 years old, family history of congenital anomaly was 1%, there was no history of previous congenital anomaly in previous pregnancy, infection history was 3%, history of medication was 11.5%, mother’s bmi was in normal term (18.5─24.9) as much as 65%, no history of radiation, there was no history of chronic alcohol. history of smoking/passive smoking was high (65%). conclusions: hirschprung disease is the highest rate disease in congenital anomaly and smoking is a highest suspectable risk factor contribute to congenital anomaly. keywords: congenital anomaly, hirschprung, infection, smoking correspondence: pradistya syifa yudiasari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, phone: +62 81221332215 email: pradistyayudiasari@yahoo.com introduction congenital anomaly is a disease of structural or functional alteration since birth. congenital anomaly can cause spontaneous abortion, disability, and death at birth.1 in 2007 the prevalence of congenital anomaly in indonesia was 6% and congenital anomaly was the majority cause of the late neonatal death.2 there are three causes of congenital anomalies: genetic (20%), environment (10%), and unknown causes (70%). the congenital anomaly detection is hard, thus, prevention is not easy to be done. this study was carried out to identify to identify the suspectable risk factors of congenital anomaly . methods a descriptive study was carried out to 78 samples. the samples were taken using purposive sampling method, from patients’ medical record continued with patients’ parents interview in pediatric surgery ambulatory unit , dr. hasan sadikin general hospital (rshs), bandung, from september to november 2014. ethical clearance was given by the education and research division of rshs. an inclusion criterion in this study was pediatric patients in rshs who were diagnosed with congenital anomaly. this study had 17 variables, which consisted of type of congenital anomaly, parents’ age, parents’ occupation, history of amj. 2017;4(2):257–60 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1095 althea medical journal. 2017;4(2) 258 amj june 2017 congenital anomaly in the family, history of congenital anomaly in previous pregnancies, history of infections, history of medication, mothers’ body mass index (bmi), history of exposure to radiation, history of mothers’ disease, alcohol consumption, smoking, physical abnormalities in parents, congenital anomaly detection,. the collected data were analyzed using frequency tabulation and were presented with tables. results in this study, the highest number of congenital anomalies found was hirschprung disease (29%), followed by anorectal malformation system (28%). in this study, the majority of mothers’ age (63% of all 78 samples) was in 20─35 years old age group. this age range is women’s productive time to start a family, especially in indonesia. the percentage of women with high risk occupation was 1%. the highest percentage of women’s occupation in this study was housewife. most women in indonesia tend to dedicate their time for family than working, which usually is men’s job as the head of the family. all fathers’ age in this study was above 20 years old. this age was also a productive table 1 distribution of congenital anomalies characteristics system congenital anomalies type frequency n=78 persentage (%) congenital anomalies type based on body system digestive fistula 3 4% anorectal malformation 22 28% mislocated anus 1 1% hirschprung disease 23 29% abdominal wall gastroschizis 1 1% hernia 6 8% omphalocele 2 3% rectocele 1 1% genital hipospadia 12 15% hydrocele 1 1% uretrocele 1 1% chromosomal anomalies down syndrome 4 5% turner syndrome 1 1% table 2 distribution of the parents’ age and occupation characteristics category frequency n=78 percentage(%) mothers’ age ≤20 years old 2 2% 20–35 years old 49 63% >35 years old 27 35% mothers’ occupation job with risk 1 1% fathers’ age ≤20 years old 0 0% >20 years old 78 100% fathers’ occupation jobs with risk 6 8% 259 althea medical journal. 2017;4(2) pradistya syifa yudiasari, pramatirta, sharon gondodiputro: suspectable risk factors of congenital anomaly in dr. hasan sadikin general hospital, bandung, indonesia relationship with congenital anomaly because almost all of the respondents worked with no risk. preconception screening showed that there were not many patients with congenital anomaly in family or previous pregnancy. bmi variable in this study was mostly normal, this result was relevant with other researches.4 but, high bmi value might cause cardiovascular anomaly in neonatal.4 maternal disease which might cause congenital anomaly was diabetes, which showed 6% value in other researches.1,3 this showed an insignificant relationship between diabetes and congenital anomaly. there was no history of alcohol consumption in pregnancy in this study. this might be caused by low alcohol consumption in indonesia. in other studies, alcohol consumption might cause neonatal death in every age.1,5 teratogenic medication might become a risk for congenital anomaly occurrence. but, it was also found several medications which might cause congenital anomaly in other studies such as nsaid.6 nsaid might cause cleft lip, spine anomaly, and others.6 antiretroviral consumption might also cause congenital anomaly.7 however, there are several medications which might prevent congenital anomaly prevalence, for example, folic acid consumption in pre-conception time.8 this can decrease neural tube defect risk.1,9 medications found in this study was nsaid and herbal medicine consumption. histories of infection found in this study were toxoplasma and chikungunya infection. there was no radiation exposure history found. the highest percentage of characteristics found in this study was smoking, which was 65%. mostly, the smokers were the fathers.1 further usg examination was supposed to be done though low socioeconomic value in patients’ parents needs to be considered. other studies showed that antenatal care was not done in indonesia while as we know, age for men to start a family or to work. the majority of fathers’ occupation were not a high risk one, with entrepreneur being the highest percentage in this study. patients’ fathers were mostly work as merchant or stall seller. preconception screenings showed that congenital anomaly found in patients were mostly the first case in the patients’ family because the number of congenital anomaly history in the study subjects was low. the majority of mothers’ bmi were normal. this showed that mothers’ nutritional statuses were still controlled. there were no physical abnormalities in parents. in all patients there was no maternal history of disease, such as congenital anomaly in the previous pregnancy. the histories of infectious disease found were chikungunya and toxoplasmosis. the history of medication found was herbal medicine consumption in pregnancy. there was no alcohol consumption in pregnancy. sixty-five percent of the fathers were smoking during pregnancy. this number was quite high, thus, smoking might contribute to congenital anomaly. discussion the highest number of congenital anomaly found in this study was hirschprung disease, which was 29% of all 78 patients, of digestive system. whilst in other studies, the highest number of congenital anomaly found was central nervous system, spina bfida.3,9 congenital anomaly risk was higher in women younger than 20 years old and older than 35 years old, while in other study, congenital anomaly was found more in women older than 35 years.3 this might be caused by low number of samples in this study, narrow study area, which was limited to one hospital only, and common productive age in subjects which ranged between 20 to 35 years old. meanwhile, fathers in other studies had similar mean age.3 parents’ occupation did not show table 3 preconception screening characteristics category frequency n=78 percentage(%) history of congenital anomaly in family yes 1 1% mothers’ bmi <18.5 12 16% 18.5−24.9 51 65% 25 –29.9 13 17% ≥ 30 2 2% althea medical journal. 2017;4(2) 260 amj june 2017 antenatal care is a tool which can be used to detect congenital anomalies. previous studies showed that congenital anomaly happened more frequently in parents who did not do continuous antenatal care.9,10 primary care doctor also has to be more alert in 37 to 42 weeks of gestational age, since neonatal death occurs more frequently in those age period.10 this evidence shows that antenatal care is important. one of several limitations of this study is medical records in dr. hasan sadikin general hospital are not written completely. another limitation is samples were not taken maximally because the information found in medical records was limited. samples taken were also not sufficient, since this study was done on one location only, which was dr. hasan sadikin general hospital, bandung in conclusions, smoking is a characteristic found with a highest percentage 65% of all patients characteristic found in parents of patients with congenital anomaly. thus, smoking can be considered as a high risk characteristic in this study. the highest percentage of congenital anomaly was hirschprung disease (29%). preconceptional examination must be done as initial screening method of congenital anomaly. other things that can be done include family risk screening, genetic counseling, prenatal or postnatal maternal disease which might affect the child’s condition, multivitamin consumption, like folic acid consumption. primary care doctors have to have a good communication skill if they want to let the patients’ parents know that they have a risk of having baby with congenital anomaly, especially for mothers, who usually have more difficulty in accepting the reality that their children are diagnosed with congenital anomaly.11 mothers’ food, medication, and health condition have to be checked in pregnancy. those things might affect fetus’ development directly, thus, controlling those things might decrease congenital anomaly incidence in the future. finally, several suggestions are proposed to improve future studies similar with this study. first, medical records’ recording system needs to be done so that other causes and factors affecting congenital anomaly incidence can be acknowledged. analytic case control study can also be done to see whether there is any relationship between risk factors which might affect the occurrence of congenital anomaly. references 1. who. birth defects. geneva: sixty-third world health assembly; 2010. http:// www.searo.who.int/topics/birth_defects/ en/ 2. badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia riset kesehatan dasar: laporan nasional 2007. .jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2008 3. made prabawa. angka kejadian bayi lahir dengan kelainan kongenital [thesis]. semarang: universitas diponegoro; 1998. 3. best ke, tennant pwg, bell r, rankin j. impact of maternal body mass index on the antenatal detection of congenital anomalies. bjog. 2012;119(12):1503─11. 4. o’leary c, jacoby p, d’antoine h, bartu a, bower c. heavy prenatal alcohol exposure and increased risk of stillbirth. bjog. 2012;119(8):945─52. 5. hernandez rk, werler mm, romitti p, sun l, anderka m. nonsteroidal antiinflammatory drug use among women and the risk of birth defects. am j obstet gynecol. 2012;206(3):228.e1–8. 6. knapp km, brogly sb, muenz dg, spiegel hm, conway dh, scott gb, et al. prevalence of congenital anomalies in infants with in utero exposure to antiretrovirals. pediatr infect dis j. 2012;31(2):164–70. 7. czeizel ae. the primary prevention of birth defects: multivitamins or folic acid? int j med sci. 2004;1(1):50─61. 8. parmar a, rathod sp, patel sv, patel sm. a study of congenital anomalies in newborn. natl j integr res med. 2010;1(1):13–7. 9. rosenstein mg, cheng yw, snowden jm, nicholson jm, caughey ab. risk of stillbirth and infant death stratified by gestational age. obstet gynecol. 2012;120(1):76─82. 10. fonseca a, nazaré b, canavarro mc. patterns of parental emotional reactions after a pre-or postnatal diagnosis of a congenital anomaly. j reprod infant psychol. 2011;29(4):320–33. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 530 amj december 2017 association between age and histopathological grade of bladder urothelial carcinoma dionisius alby,1 abdul hadi hassan,2 jupiter sibarani3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: bladder cancer, particularly urothelial carcinoma, is prevalent in male and ≥55 years old population. grade of the bladder tumor affects clinical characteristics, management, and prognosis of the patient. this study aimed to analyze the association between age and histopathological grade of bladder urothelial carcinoma. methods: this cross-sectional analytical study was approved by the ethical clearance committee of dr. hasan sadikin general hospital, involving 241 medical records of bladder urothelial carcinoma patients in the department of anatomical pathology at dr. hasan sadikin general hospital during 2009–2013. chisquare test was applied to 45 patients with complete record of histopathological grade. results: most of the subjects were 65 years old. male patients were the most frequent. the proportion of low-grade carcinoma in <65 years old age group was only 39.1%, while in ≥65 years old age group was 72.7%. the proportion of high-grade carcinoma in <65 years old age group reached 60.9%, which was 27.3% higher than in ≥65 years old age group. chi-square test result showed a statistically significant difference between histopathological grade of urothelial carcinoma in <65 years and ≥65 years age groups (p=0.023). conclusions: proportion of high-grade and low-grade urothelial carcinoma between <65 years and ≥65 years age groups are statistically different; therefore, an association between age and histopathological grade of bladder urothelial carcinoma is shown. keywords: age, bladder cancer, histopathological grade, urothelial carcinoma correspondence: dionisius alby, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: the_ion@hotmail.com introduction bladder cancer ranks 11th and contributes 3.1% of all the cancer incidence worldwide. bladder cancer ranks 7th in male with 330.000 incidences and mortality rate around 120.000 annually.1 the incidence is higher in male compared to female with 3–3.5 : 1 ratio.2 more than 90% bladder cancer are found in ≥55 years old age group.3 most malignant tumors originate from transitional cell, which then are classified as urothelial (transitional) cell carcinomas.2the grade of bladder tumor affects the patient’s clinical feature, management, and prognosis.2,4–6 unfortunately, in indonesia, the populationbased data regarding cancer prevalence, incidence, and mortality rate have not been established yet. the existing data are hospitalbased data or the incidence rate estimated from neighboring countries.7 the increasing number of tobacco smokers, higher intensity of occupational chemical exposure, and aging population significantly increase the number of bladder carcinoma cases in developing countries.4 many epidemiological studies reported this higher incidence of bladder urothelial carcinoma in the elderly group.2 however, there have been few studies that show the association between age and histopathological grade of bladder urothelial carcinoma.8 therefore, this study aimed to analyze the association between age and histopathological grade of bladder urothelial carcinoma. amj. 2017;4(4):530–3 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1263 althea medical journal. 2017;4(4) 531 methods the study subjects were patients with bladder urothelial carcinoma in the department of anatomical pathology at dr. hasan sadikin general hospital during 2009–2013. the inclusion criteria for this research were bladder urothelial carcinoma cases with complete records of the patient’s age and urothelial carcinoma histopathological grade. the exclusion criteria were cases that were histopathologically diagnosed as bladder urothelial carcinoma with incomplete data of the urothelial carcinoma grade. observation was conducted with total sampling techniques of medical records data from 2009 to 2013. this study was an analitical study with a cross-sectional design. furthermore, this study compared the histopathological grade of bladder urothelial carcinoma between the elderly group and other age group to assess the association between age and histopathological grade of bladder urothelial carcinoma. generally, the worldwide cut off point for elderly group varies between 60–65 years old. this study took into consideration that in the bladder carcinoma management being 65 years old and over is a factor for not applying radical cystectomy, and also the increasing life expectancy in indonesia, from 64.5 years old in 2000 to 69.65 years old in 2011. therefore in this study, 65 years old and over were used as the cut off point for the elderly group. this study was conducted by collecting secondary data from patient’s medical records after obtaining permission from the ethical clearance committee of dr. hasan sadikin general hospital. out of all the medical record data, only those that met the inclusion criteria were used in this study. then, data from medical records were classified into several age groups. subsequently, urothelial carcinoma histopathological grade of each group was observed. the collected data were then analyzed with a statistical program. moreover, the hypothesis testing for comparative study with categorical variable, chi-square test, was used. the p-value of less than 0.05 was considered statistically significant. results this dstudy used 245 primary bladder urothelial carcinoma cases recorded in the department of anatomical pathology at dr. hasan sadikin general hospital during 2009–2013. the 241 cases with complete data regarding age on medical records showed that the mean age of the patients was 60.2±12.5 years old with a median of 61 years old. the youngest case of bladder urothelial carcinoma was found in a-29-year-old patient, while the oldest was 87 years old. the male to female ratio reached 7.9:1, with the number of male patient was 214 cases (88.8%). out of the whole 241 cases, 45 cases were histopathologically graded, and included in the comparative hypothesis testing. furthermore, most subjects of this study were 65 years old. additionally, the histogram figure also showed that the data were not figure age distribution of bladder urothelial carcinoma dionisius alby, abdul hadi hassan, jupiter sibarani: association between age and histopathological grade of bladder urothelial carcinoma althea medical journal. 2017;4(4) 532 amj december 2017 normally distributed (figure). according to the descriptive analysis, the mean age of high-grade urothelial carcinoma cases was 57.95±13.7 years and low-grade urothelial carcinoma cases was 64.5±11.2 years. according to the saphiro-wilk test, the normality testing for data distribution isused for age to histopathological grade variable, and showed that the data were normally distributed (p=0.065 and p=0.999, consecutively lowgrade and high-grade) (table). moreover, 20 cases of high-grade urothelial carcinoma were found with 14 cases from <65 years age group and 6 cases from ≥65 years age group. whereas, 25 cases of low-grade urothelial carcinoma were found with 9 cases from <65 years age group and 16 cases from ≥65 years age group. a cross tabulation was performed with the age group as independent variable and urothelial carcinoma grade classification as dependent variable. all cells in 2x2 table fulfilled the condition of expected value >5; thus, the chi-square test could be conducted. the chi-square test resulted in statistically significant difference between the proportion of urothelial carcinoma for both histopathological grade in <65 years age group and ≥65 years age group. (p=0.023). discussion bladder cancers are malignancies that occur in the wall structure of the bladder. around 95% bladder tumors originate from epithelial cells, hence its malignant form acquired the carcinoma suffix.2 most malignant tumors originate from transitional cells, which are then classified as urothelial (transitional) cell carcinomas.2 the mean age of the bladder urothelial carcinoma patients in this study was 60.2 years. this result did not differ much from the previous result at cipto mangunkusumo general hospital, jakarta (56.5 years old) and several foreign studies (60.2–61.9 years old).6,8–10 the number of male bladder urothelial carcinoma cases greatly exceeded female cases. male to female ratio reached 7.9:1. this result was still in the variation range reported in other researches (6–10:1).6,8–10 this result occurred because this study only analyzed the bladder urothelial carcinoma, while the proportion of urothelial carcinoma in female was not as high as male.11 the current use the grading system, was due to the result of the international society of urological pathology (isup) consensus in 1998 which was adopted by the world health organization (who) in 2004. this system classifies bladder urothelial carcinoma into low and high grade.2 according to several studies, both bladder urothelial carcinoma grades differ in its molecular pathogenesis. deletions of 9p/9q are found in more than 50% urothelial carcinoma of all types and grades. the deletions are also the early development of tumor cells.2,12,13 alteration in fibroblast growth factor receptor 3 gene (fgfr3) and transforming protein p21 (hras) form non-invasive papillary urothelial carcinoma, low-grade.5,13 whereas mutated p53 gene produces carcinoma in situ, noninvasive papillary urothelial carcinoma, highgrade and progression to infiltrating urothelial carcinoma.5,13 besides, the bladder urothelial carcinoma spreading characteristic shows a tendency to specific grades; non-invasive to low-grade,while infiltrating to high-grade.13 in this study, there were differences in the proportion of low-grade and high-grade bladder urothelial carcinoma between <65 years age group and ≥65 years age group. the proportion of low-grade carcinoma in <65 years age group was only 39.1%, while in ≥65 years age group was 72.7%. the proportion of high-grade carcinoma in <65 years age group reached 60.9%, 27.3% than in ≥65 years age group. the chi-square analytical test resulted in statistically significant difference (p=0.023). this result suggested that there was an association between age and histopathological grade of bladder urothelial carcinoma. albeit, this result contradicted with several previous studies which showed increasing age associates with increasing proportion of poorly differentiated (low-grade) bladder table descriptive statistic of urothelial carcinoma urothelial carcinoma grade age (y.o) mean±std. deviation minimum–maximum low-grade 64.48±11.2 35–83 high-grade 57.95±13.7 33–86 althea medical journal. 2017;4(4) 533 urothelial carcinoma.8 this might be caused by several factors, such as insufficient data which met the inclusion criteria and classification of research subjects into two uneven age groups. limitations of this retrospective study were the difficulties of comprehensive data acquirements regarding bladder urothelial carcinoma patient’s histopathologic grade. besides, this study was a hospital-based study, so the available data did not cover the whole bladder urothelial carcinoma cases in the population. therefore, a reconsideration of those factors may be required before the study results are utilized. further researches are expected to overcome the limitations in this study to prove the existence of an association between age and histopathological grade of bladder urothelial carcinoma. this can be carried out when the complete data regarding the histopathologic grade of bladder urothelial carcinoma in each patient’s medical record are available as well as sufficient resources to conduct a community-based research. in addition, balancing the classification into different age groups can help to obtain better results. the increasing proportion of elderly in the population lead to the increasing number of bladder cancer cases. histopathological grade and age of bladder cancer patients are closely related to the patient’s management and prognosis.2,4–6,14 therefore, a good understanding between the two are required. it can be concluded that bladder urothelial carcinoma is mostly found in male and 65 years old patients. analytically, the proportion of low-grade and high-grade urothelial carcinoma differs between <65 years age group and ≥65 years age group. thus, showing an association between age and histopathological grade of bladder urothelial carcinoma. references 1. ferlay j, soerjomataram i, ervik m, dikshit r, eser s, mathers c, et al. globocan 2012 v1.0, cancer incidence and mortality worldwide: iarc cancer baseno. 11 [internet] lyon, france: iarc; 2013 [cited 2014 february 24]. available from: http:// globocan.iarc.fr. 2. epstein ji. the lower urinary tract and male genitalia system. in: kumar v, abbas ak, fausto n, aster jc, editors. 2010 robbins and cotran pathologic basis of disease. 8thed. philadelphia: saunders elsevier; 2010. p. 976–981. 3. ploeg m, aben kh, kiemeney l. the present and future burden of urinary bladder cancer in the world. world j urol. 2009;27(3):289–293. 4. belldegrun a, rochelle jl, shuch b. urology. in: brunicardi fc, andersen dk, billiar tr, dunn dl, hunter jg, matthews jb, et al., editors. 2010 schwartz’s principles of surgery. 9thed. usa: the mcgraw–hill companies, inc; 2010. 5. jacobs bl, lee ct, montie je. bladder cancer in 2010: how far have we come. ca cancer j clin. 2010;60(4):244–272. 6. wempy s, chaidir am, marto s, rainy u. survival of patients with transitional cell carcinoma of the urinary bladder in indonesia: a single institution review. asian pac j cancer prev. 2011;12:549–553. 7. shin hr, carlos mc, varghese c. cancer control in the asia pacific region: current status and concerns. jpn j clin oncol. 2012;42(10):867–881. 8. gupta p, jain m, kapoor r, muruganandham k, srivastava a, mandhani a. impact of age and gender on the clinicopathological characteristics of bladder cancer. indian j urol. 2009;25(2):207–210. 9. matalka i, bani–hani k, shotar a, bani hani o, bani–hani i. transitional cell carcinoma of the urinary bladder: a clinicopathological study. singapore med j. 2008;49(10):790–794. 10. yavari p, sadrolhefazi b, mohagheghi ma, mehrazin r. a descriptive retrospective study of bladder cancer at a hospital in iran (1973–2003). asian pac j cancer prev. 2009;10(4):681–684. 11. iarc. world cancer report 2008. lyon, france: iarc library cataloguing data; 2008. 12. kaufman ds, shipley wu, feldman as. bladder cancer. the lancet. 2009;374(9685):239–249. 13. pasin e, josephson dy, mitra ap, cote rj, stein jp. superficial bladder cancer: an update on etiology, molecular development, classification, and natural history. rev urol. 2008;10(1):31–43. 14. shariat sf, sfakianos jp, droller mj, karakiewicz pi, meryn s, bochner bh. the effect of age and gender on bladder cancer: a critical review of the literature. bju int. 2009;105: 300–308. dionisius alby, abdul hadi hassan, jupiter sibarani: association between age and histopathological grade of bladder urothelial carcinoma vol 4 no 4 final.indd althea medical journal. 2017;4(4) 501 correlations between copd assessment test and modified british medical research council scoring and degree of airflow limitation dian nuryanda,1 hendarsyah suryadinata,2 ambrosius purba3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology faculty of medicine, universitas padjadjaran abstract background: chronic obstructive pulmonary disease (copd) assessment test (cat) and modified british medical research council (mmrc) dyspnea scale are tools used to assess health status in copd patients, while forced expiratory volume in one second (fev1) may represent the degree of airflow limitation. assessment of copd patients is rarely performed comprehensively. this study aimed to determine the relationships of cat and mmrc dyspnea scale and the degree of airflow limitation in copd patients. methods: the study was conducted from september until october 2014 after obtaining approval from the hasan sadikin general hospital ethics committee. this observational analytic study was performed on 77 medical records of copd patients at hasan sadikin general hospital. patients’ medical records included in this study were those with spirometry measurements results, cat and mmrc dyspnea scale scoring. data normality was analyzed using kolmogorov-smirnov test. pearson’s correlation was used for parametric variables. spearman’s correlation was used for non-parametric variables. results: results showed pearson’s correlation of cat and fev1 (p value=0.035 and r=0.240), and spearman’s correlation of mmrc dyspnea scale and fev1 (p value=0.198 and r=0.148). conclusions: cat scoring is significantly correlated with the degree of airway limitation. mmrc dyspnea scale is not significantly correlated with the degree of airway limitation. keywords: chronic obstructive pulmonary disease (copd), copd assessment test (cat), degree of airway limitation, modified british medical research council (mmrc) correspondence: dian nuryanda, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: diannuryanda@yahoo.com introduction the world health organization (who) categorizes chronic obstructive pulmonary disease (copd) as the third leading cause of death in non-communicable disease. the burden of copd is predicted to increase in the coming years.1,2 the goal of copd assessment is to determine the disease severity, the impact towards patient’s health status, and risks that may arise such as exacerbations, hospital admissions, or even death. eventually, the goal of this assessment is to achieve a guide therapy for copd patients. airway obstruction in copd can be assessed by spirometry measurement. while the patient’s health status can be assessed by tools such as copd assessment test (cat) and modified medical research council (mmrc) dyspnea scale.1 furthermore, forced expiratory volume in one second (fev1) after bronchodilator administration shows the degree of obstruction in copd and represents the disease severity. cat is a valid and reliable tool to assess health status in copd patients; it consists of eight items that assess the patient’s general condition. cat is an easy and applicable tool to use.3 mmrc dyspnea scale is developed to help in determining the degree of dyspnea on emphysema patient clinically, it assess patient’s limitation in daily activity.4 the routine examination on copd patients at hasan sadikin general hospital is only by performing a spirometry examination without health status assessment similar to the recommendation of the global initiative for chronic obstructive lung disease (gold), although those tools assess different things. amj. 2017;4(4):501–5 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1258 althea medical journal. 2017;4(4) 502 amj december 2017 the aim of this study was to determine the relationship between pulmonary function examination represented by fev1 with cat and mmrc dyspnea scale scoring among copd patients. methods the population of this study is patients with confirmed copd. samples were obtained from medical records of patients visiting the pulmonary clinic, internal medicine department, at hasan sadikin general hospital, bandung. data were taken after the approval from hasan sadikin general hospital ethics committee was obtained. data were taken to fulfill the minimum size of sample. this study was conducted in the department of internal medicine, respirology sub division on september–october 2014. the sampling method used in this study was purposive sampling. moreover, the inclusion criteria were patients with confirmed diagnosis copd and complete medical records, containing the observed variables, fev1 measurement result, cat and mmrc scoring results. patients who had asthma as comorbid and fev1/forced volume capacity (fvc) ≥70% were excluded from this study. out of 80 samples that were included in this study, 3 of them were excluded. table 1 characteristic of the subjects characteristic n=77 age (year) 69 (50–89) gender male 56 (72.7) female 21 (27.3) spirometry measurement results (%) fev1 pre-bronchodilator 48.30 ± 11.6 fvc pre-bronchodilator 60.58 ± 13.2 fev1 post-bronchodilator 52.5 ± 11.8 fvc post-bronchodilator 63.54 ± 13.1 fev1/fvc pre-bronchodilator 63.6 (47.4–69) fev1/fvc post bronchodilator 66.7 (49.3-69.9) spirometry classification gold 1 1 (1.3%) gold 2 43 (55.8%) gold 3 33 (43.9%) gold 4 0 mmrc dyspnea scale 1 20 (26%) 2 26 (22.38%) 3 24 (31.2%) 4 7 (9.1%) 5 0 cat ≤10 0 11–20 27 (35.1%) 21–30 42 (54.5%) >30 8 (10.4%) althea medical journal. 2017;4(4) 503 table 2 data analysis result fev1 post-bronchodilator sig. (2-tailed) correlations coefficient (r) cat 0.035 -0.240 mmrc 0.198 -0.148 dian nuryanda, hendarsyah suryadinata, ambrosius purba: correlations between copd assessment test and modified british medical research council scoring and degree of airflow limitation this was an observational analytical study with a cross sectional design. the data were analyzed using a statistic analytic computer program. normality of the data was tested using kolmogorov-smirnov test. in addition, pearson’s correlation test was used to analyze correlation of parametric variable, while spearman’s correlation test was used to analyze nonparametric variable. results based on characteristic of the subjects, the age of subjects ranged from 50–89 years, and males were more common than females. spirometry assessment result showed that most of the subjects were in moderate–severe classification based on gold. while, mmrc dyspnea scale scoring result of the subjects waswere ranged from 1–4, and for cat was ranged from 12 for the minimum score, and 35 for the maximum score (table 1). moreover, pearson’s test was performed on fev1 post bronchodilator administration and cat scoring. results of the analysis showed that there was a significant relationship between the two variables with p=0.035 (p<0.05). a poor correlation between the two variables is indicated by the value of the correlation coefficient (r) of 0.24. the direction of the correlation showed the inverse relationship between the two variables. in the event of an increase in cat scoring result, a decline in the value of fev1 post bronchodilator can be observed. spearman’s test was performed on fev1 post bronchodilator and scoring results were obtained using mmrc dyspnea scale. the data showed different results from the pearson’s test. while the correlation test showed no significant relationship between the two variables, indicated with p=0.198 and the value of the correlation coefficient (r) 0.148 (p>0.05). discussion previous studies that discussed the relationship between the health status of copd patients with fev1 assessment results provide variations in results, starting from a weak correlation and insignificant to a strong correlation and significant.5-9 the results in this study found that cat had a significant but weak correlation with fev1 post bronchodilator administration, while mmrc did not provide a significant relationship. similar results were obtained in the study conducted by garrido et al.6, which mentioned that the decline in fev1 measurement results are significantly correlated (r=0.38; p<0.001) with a reduced quality of life in copd patients assessed by the physical component score (pcs). garrido et al.6 also found that fev1 post bronchodilator administration is related to the mental component score (mcs), but with a weak correlation (r=0.12). the result of this study suggested a relationship between the degrees of airflow limitation that is indicated by a decrease in fev1 post bronchodilator administration with the patient’s quality of life. the severity of copd affects health status of patients, both mentally and physically. furthermore, tsilligiani et al.7 conducted a similar study analyzing the fev1 post bronchodilator administration with the copd patient’s health status. questionnaires were used to assess the health status in this study, including st. george respiratory questionnaire (sgrq), copd control questionnaire (ccq), the quality of well being (qwb) scale, as well as the chronic respiratory questionnaire (crq).7 in this study, both cat and mmrc dyspnea scale were not used. the study by tsilligiani et al.7 supported the results of this study. the questionnaire that provides the most robust correlation to fev1 is shown by qwb, ccq, and crq, while the correlation shown by the other questionnaire were poor.7 this is due to the use of different questionnaires . in addition, yeo et al.8 conducted a study that conflicted with the results of this study. yeo et al.8 stated that there is no significant correlation between the disease severities based on gold staging represented by the percentage of fev1 post bronchodilator administration with health status questionnaire assessed using sgrq. besides, althea medical journal. 2017;4(4) 504 amj december 2017 yeo et al.8 mentioned that there is a tendency in which the patients with more severe illness have poorer health status, but there is no significant difference between patient’s health status and the disease severity. this is due to copd patients may experience a wide range of declining health status, independent to the severity of the disease. a research conducted by voll-aanerud et al.9 regarding the association of symptoms and the severity of copd respiration on health related quality of life (hrqol) using sf-12 questionnaire showed similar results. the sf-12 questionnaire assessed hrqol with 2 components, physical component score (pcs) and mental component score (mcs). a rise in the pcs and mcs shows a better hrqol. results obtained from this study are the pcs and mcs scoring result were more significantly associated with respiratory symptoms compared to the severity of copd.9 previous literatures found that the fev1 measurement result only shows a lung function abnormalities without being able to assess the health status of a copd patients.1,7,9,10 in this study, the mmrc dyspnea scale did not significantly correlate with decreasing fev1 post bronchodilator administration. it could be said that the health status assessed by the mrc dyspnea scale, which is namely the limitation in performing daily activities and possible risks of exacerbation, did not have a significant correlation with the disease severity measured by fev1 post bronchodilator administration. this happens due to the etiology of shortness of breath or disability arises not only because of the obstruction of the respiratory tract, so that in the event of a declining lung function did not significantly occur also with shortness of breath. breathlessness in patients with copd is a typical symptom.7 a declining fev1 post bronchodilator were not associated with the risk of exacerbations of copd patients. study that conducted by pitta et al.5 showed that reduction in daily activities of copd patients does not depend on the disease severity determined only by the measurement of fev1. although the declined fev1 is indicated to the deterioritation of airflow limitation, but it should not be used by itself to rule out the disease severity.5-7 moreover, gold mentioned that in each respective gold category, the health status of a patient with copd can vary from patients with good health status to poor health status.1 this could be the influencing factors to the correlations between the disease severity which is indicated by the results of measurements of fev1 post bronchodilator administration with both cat and mmrc dyspnea scale, as discussed by yeo et al.8 as previous studies mentioned before, it can be concluded that the dissimilarities in the results of this study is also influenced by other factors such as gender, age, comorbid disease, and the patient’s condition at the time of examination; stable copd patients give different test results with patients who are experiencing an exacerbation. an important goal that must be achieved in the health status assessment of patients with copd is the provision of both pharmacological and non-pharmacological treatment according to the needs of the patient. routine examination of patients with copd by spirometer is not sufficient to assess the health status of the patient. gold mentioned that the assessment of copd patients should include a separate assessment of the 4 following, namely the risk of exacerbations, symptoms experienced by patients at this time, abnormality in spirometry measurement results, and comorbids experienced by the patient.1 the limitation of this study was using the cross sectional study design; this method is considered to have a greater likelihood of bias. the available data show no information of comorbids suffered by the patients and the patients’ condition during examination, whether they were in a stable condition or were experiencing exacerbations, as these things can be a confounding factor to this study. the number of samples and the age were not normally distributed; which is also considered as a limitation in this study. by understanding the relationship between health status assessments and spirometry measurements results shown in this study, it is expected that the process of examination and assessment of copd patients in all health facilities can be performed comprehensively in accordance with the recommendations given by gold. references 1. vestbo j, hurd s, agusti a, jones p, vogelmeier c, anzueto a, et al. global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: gold executive summary. am j respir crit care med. 2014;187(4):347–65. 2. who. global status report on noncommunicable diseases 2010: description of the global burden of ncds, althea medical journal. 2017;4(4) 505 their risk factors and determinants. geneva: who library cataloguing-inpublication data; 2011. 3. jones p, harding g, berry p, wiklund i, chen w, kline leidy n. development and first validation of the copd assessment test. eur respir j. 2009;34(3):648–54. 4. jones pw, nadeau g, small m, adamek l. characteristics of a copd population categorised using the gold framework by health status and exacerbations. respir med. 2014;108(1):129–35. 5. pitta f, takaki my, oliveira nhd, sant’anna tjp, fontana ad, kovelis d, et al. relationship between pulmonary function and physical activity in daily life in patients with copd. respir med. 2008;102(8):1203–7. 6. garrido pc, diez jdm, gutierrez jr, centeno am, vazquez ge, angel gdm, et al. negative impact of chronic obstructive pulmonary disease on the health-related quality of life of patients. results of the epidepoc study. health qual life outcomes. 2006;4:31:1–9. 7. tsiligianni i, kocks j, tzanakis n, siafakas n, van der molen t. factors that influence disease-specific quality of life or health status in patients with copd: a review and meta-analysis of pearson correlations. prim care respir j. 2011;20(3):257–68. 8. yeo j, karimova g, bansal s. co-morbidity in older patients with copd—its impact on health service utilisation and quality of life, a community study. age ageing. 2006;35(1):33–7. 9. voll-aanerud m, eagan tm, wentzellarsen t, gulsvik a, bakke ps. respiratory symptoms, copd severity, and health related quality of life in a general population sample. respir med. 2008;102(3):399– 406. 10. wise ra. chronic obstructive pulmonary disease: clinical course and management. in: fishman ap, elias ja, fishman ja, grippi ma, senior rm, pack ai, editors. fishman’s pulmonary diseases and disorders. 4th ed. new york: mc graw hill; 2008. p. 729–46. dian nuryanda, hendarsyah suryadinata, ambrosius purba: correlations between copd assessment test and modified british medical research council scoring and degree of airflow limitation althea medical journal. 2017;4(2) 278 amj june 2017 relationship between types of cervical spinetrauma and occurrence of neurological deficits syaiful anwar,1 agus hadian rahim,2 farhan anwary3 1faculty of medicine universitas padjadjaran, 2department of orthopaedic and traumatology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: about 3,500 people died each year due to neck injury, according to a study in the usa. trauma at cervical spine level causes injury in soft tissue, cervical vertebrae, and spinal cord that can cause neurological deficits. the aim of this study was to analyze the relationship between type of cervical trauma and the occurrence of neurological deficits. methods: an analytic study was carried out to 121 medical records of patients diagnosed with cervical spine trauma at dr. hasan sadikin general hospital bandung in the period of january 2010−december 2012. data were classified according to age, sex, period of initial visit to hospital, mechanism of trauma, cervical trauma type, fracture’s or dislocation’s location (without any other vertebral injury) and neurological status. the collected data were analyzed using chi-square test and presented in tables. results: there were 121 cases of cervical spine trauma. most patients were male and in the productive age group (30−44 years). most of the initial visits to the hospital were in 2010 and most of the mechanism was traffic accident (46.28%), while soft tissue injury was the most common type of cervical trauma (54.54%) and lower cervical vertebrae was the most common location of fractures or dislocations (76.36%). sixty two patients were recorded with neurological deficits. chi-square test of relationship between the type of cervical trauma and the occurrence of neurological deficit was statistically significant (p=0.000). conclusions: there is relationship between the type of cervical trauma and occurrence of neurological deficits. keywords: cervical spine trauma, neurological deficit, soft tissue injury correspondence: syaiful anwar, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85729815515 email: syaiful.anwar.ipung@gmail.com introduction trauma at cervical spine could cause injury in its soft tissue and vertebrae. cervical spine traumas caused various impact and severity, from the mild impact such as neck ligament injuries and in worse case vertebral injuries, to the most severe impact such as death.1-4 a study in the united states showed that 5-10% of those trauma was severe trauma. on the average, 3,500 people died each year due to neck injury.2 anatomically, spinal cord is located inside the vertebrae (vertebral foramina). cervical vertebrae were designed to protect the spinal cord. spinal cord is one of the central nervous system in human body.5,6 if the cervical vertebrae were damaged, the spinal cord would be affected which could cause neurological deficit. neurological deficit may vary from losing either the motor or sensory function. the aim of this study was to analyze the association between the type of cervical trauma and occurrence of neurological deficits. methods this study was a cross sectional study and conducted at dr. hasan sadikin general hospital bandung using the medical records of patients diagnosed with cervical spine trauma from january 2010 to l december 2012. data were taken from the patients’ medical records who were admitted to the inpatient unit at dr. hasan sadikin general hospital. the inclusion amj. 2017;4(2):278–81 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1084 279 althea medical journal. 2017;4(2) criteria were all of the patients diagnosed with trauma at cervical spine level without any other level of vertebral injury. the collected data was grouped according to age: less than 15 years , 15–29 years , 30– 44 years , and more than 59 years ; sex; period of initial visit to hospital as in year 2010, 2011, and 2012; mechanism of trauma e.g. in traffic accident, fall from height, blunt trauma, and others; type of cervical spine trauma e.g. in cervical vertebrae injury, cervical soft tissue injury; fracture or dislocation’s location e.g. in cervical vertebrae (c1-c2), lower cervical vertebrae (c3-c7); with or without neurological deficit. furthermore, chi-square test was used as statistical test where p<0.05 was considered as significant value. results this study collected about 121 medical records of patients diagnosed with cervical spine trauma from january 2010 to december 2012. according to sex, cervical spine trauma patients were dominated by male. while, according to age distribution, most cervical spine trauma patients were aged 30–44 years. the rest of them were distributed equally in other groups. the most common cervical spine table 1 distribution of cervical spine trauma according to sex, age, period of initial visit to hospital, mechanism of trauma, type of trauma, and location of fracture/ dislocation characteristic total n(%) sex male 106(87.60%) female 15(12.39%) age <15 years old 3(2.47%) 15–29 years old 40(33.05%) 30 44 years old 45(28.92%) 45–59 years old 22(18.28%) >59 yearsold 21(17.35%) period of initial visit to hospital 2010 36(29.75%) 2011 33(27.27%) 2012 52(42.97% mechanism of trauma traffic accident 56(46.28%) fall from height 48(39.66%) blunt trauma 7(5.78%) others (shot, punctured) 10(8.26%) type of trauma cervical vertebrae injury 55(45.45%) cervical spine soft tissue injury 66(54.54%) location of fracture or dislocation upper cervical vertebra 13(23.63%) lower cervical vertebra 42(76.36%) syaiful anwar, agus hadian rahim, farhan anwary: relationship between types of cervical spine trauma and occurrence of neurological deficits althea medical journal. 2017;4(2) 280 amj june 2017 trauma mechanism was traffic accident, which occurred in 56 people (46.28%) (table 1). a number of 62 patients had neurological deficits. fifty one of them were caused by cervical vertebral injuries while the other 11 were caused by cervical spine soft tissue injuries. fifty nine patients did not have neurological deficits. on the other hand, there were more patients with cervical spine soft tissue injuries than patients with cervical vertebral injuries (6:5) (table 2). this study revealed that there was a relationship between the type of cervical spine trauma and the incidence of neurological deficit. discussion this study revealed that more male patients had cervical spine trauma compared to female patients. this result corresponded with a previous study stating that cervical spine trauma occurred more in male patients.1,7,8 this higher occurrence of cervical spine trauma in males might be caused by the more dangerous activities that were performed by males such as high velocity driving. furthermore, cervical spine trauma cases increased from 2010 until 2012 although it seemed to decrease slightly in 2011. most cervical spine trauma cases were found in 2012, comprising 52 cases, which was higher than in 2011 and 2010. it was probably caused by the difficulty in finding complete data from older medical records. moreover, most of the patients were aged 30–44 years which corresponded with a previous study stating that cervical spine trauma occurred at the age of 31 until 40 years at most.9 people at age ranging from 30 until 40 years, as mentioned above, were still in their productive age. additionally, many activities were related to height and high velocity in productive age, like repairing pieces of roof and driving a motorcycle. fewer cervical spine traumas could be seen in 15-year old children, since they did not performed many dangerous activities. there was also a high occurrence of cervical spine trauma (40 cases) at the age of 15 until 29 years . additionally, mechanism of cervical spine trauma was mainly traffic accident, followed by falling from height. this statement corresponded with a previous study that pointed out that most mechanism of cervical trauma are activities related to high velocity and height.1,10,11,14 accidents in high velocity can cause sudden flexion or extension at the neck which later will cause injuries of soft tissue and the cervical vertebrae itself. corresponding to another previous study, in this study cervical vertebrae c3 until c7 are also found to be the main location for fractures in cervical trauma cases.1,10 it might be caused by a higher flexibility of the vertebrae at this level compared to the other vertebrae. thus, vertebrae at this level were more prone to injuries. in this study, the number of patients with cervical spine soft tissue injuries was more than patients with cervical vertebral injury. it corresponded with a previous study. anatomically, soft tissues surrounded the cervical vertebrae at the outside. thus, the cervical soft tissue was the first to be injured. but the structure of the cervical soft tissue itself was indeed soft and less tough than the cervical vertebrae. thus, the cervical soft tissue was definitely more fragile than cervical vertebrae. 9,12 neurological deficits were more common in patients with cervical vertebral injuries than in patients with cervical spine soft tissue injuries only. besides, cervical vertebrae injury was worse than soft tissue injury, because in vertebral injury cases, penetrated trauma occurred stronger and deeper as seen from the vertebral structure and location which were surrounded by soft tissues. furthermore, anatomically the spinal cord was inside the vertebrae, so it was possible that this spinal cord structure was affected by the cervical vertebrae injury, which explained the occurrence of neurological deficits. table 2 type of cervical trauma and neurological deficit neurological deficit ( + ) neurological deficit ( ) total significance cervical vertebrae injury 51 4 55 p=0.000 cervical spine soft tissue injury 11 55 66 total 62 59 121 281 althea medical journal. 2017;4(2) syaiful anwar, agus hadian rahim, farhan anwary: relationship between types of cervical spine trauma and occurrence of neurological deficits although neurological deficits occurred mainly in cervical vertebrae injuries, there should be consideration for the data in this study about the high occurrence of neurological deficits in soft tissue injuries (11 cases). the neurological deficits could occur when sudden flexion-extension movements caused tears at the intervertebral disc. the spinal cord would be affected so that neurological deficits might occur. statistical test results from the type of cervical trauma and neurological deficit variables showed significance (p=0.000). p was valued less than 5%.13 it showed meaningful significance. thus, it can be concluded that there is a relationship between the type of cervical trauma and incidence of neurological deficit incidence. this study has limitation because of the difficulty to obtain complete medical records about cervical spine trauma at dr. hasan sadikin general hospital. references 1. torretti ja, sengupta dk. cervical spine trauma. indian j orthop. 2007; 41(4):255−67. 2. david bl, brian sg, edmond ah, francisco t, eric ll, john dh, et al. neck trauma. medscape. 2012. [cited 2013 february 27]. available from: http://emedicine. m e d s c a p e . c o m / a r t i c l e / 8 2 7 2 2 3 overview#a0199 3. thompson wl, stiell ig, clement cm, brison rj. association of injury mechanism with risk cervical spine fractures. cjem. 2009;11:14−22. 4. milby ah, halpern ch, guo w, stein sc. prevalence of cervical spinal injury in trauma. neurosurg focus. 2008; 25(5):e10. 5. moore kl, afd. clinically oriented anatomy. 5th ed. baltimore : lippincot williams and wilkins. 2006. p. 478−545, 1046−83. 6. rahim ah. vertebra. jakarta: sagung seto.2012. p. 46−9 7. nathens ab. national trauma data bank 2010 annual report. chicago: ammerican college surgeon; 2010. 8. graber ma, kathol m. cervical spine radiograph in trauma patient. am fam physician. 2005;59(2)331−42 9. ning gz, yu tq, feng sq, zhou xh, ban dx, liu y, et al. epidemiology of traumatic spinal cord injury in tianjin, china. spinal cord. 2011;49(3):386−90. 10. van den berg me, castellote jm, mahillofernandez i, de pedro-cuesta j. incidence of spinal cord injury worldwide : a systematic review. neuroepidemiology. 2010;34(3):184−92. 11. lawrence sc, robert b, molly gk. spinal cord injuries. 2012. [cited 2013 february 28]. available from: http://emedicine. medscape.com/article/793582-overview 12. miles ka, maimaris c, finlay d, barnes mr . the incidence and prognostic of radiological abnormalities in soft tissue injuries to the cervical spine. skeletal radiol. 2006;17(7):493−6 13. sopiyudin dm. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika. 2008. 14. ryan md, henderson jj. the epidemiology of fracture and fracture–dislocation of the cervical spine. injury. 2007;23(1):38−40. vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 86 amj june 2019 parents’ knowledge and children’s toilet training practices: study in kindergartens in jatinangor anne shafira purnama claytonia aziz,1 yudith setiati ermaya,2 nur melani sari2 1faculty of medicine universitas padjadjaran indonesia 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: anne shafira purnama claytonia aziz, faculty of medicine, universitas padjadjaran jalan raya bandung-sumedang km 21, jatinangor, sumedang, jawa barat, indonesia, email: annespcaziz@gmail.com introduction toilet training is a method to habituate children to defecate and urinate in the toilet. it has many methods to be conducted, and guidance by parents is needed.1 besides that, this training can also be management for constipation. it is a behavior modification that has a purpose to make children have a regular pattern of defecation.2,3 children with constipation have a lower quality of life than those without the symptom. although constipation rarely causing a lifethreatening complication, this condition can disturb children’s psychological and their relationship with friends, even create stress in the family. one-third of constipated children continue to have constipation in adulthood despite receiving any treatment.4,5 in indonesia, the prevalence of functional constipation in children with age lower than 5 years old is 4.4%.6 toilet training has been shown to decrease the prevalence of constipation. this is evidenced by the study conducted by xini7 as which showed the success of toilet training as a treatment of constipation.7 some aspects have to be considered before doing the training, such as children’s readiness, parents’ understanding, and good toileting practice are important aspects that have to be known by parents. those aspects can increase children’s capability during the toilet training period.8 the children need parent’s help in doing selfcare, including toilet practices. therefore, parents must have good knowledge so that children can carry out the toilet training correctly. in indonesia, there has not been any study about the correlation between the knowledge and practice of toilet training. the objective of the present study was to find out amj.2019;6(2):86–90 abstract background: constipation has serious threats for children, however, this condition can be treated by toilet training. the level of parents’ understanding of defecation affects the success of the training to reduce the symptom of constipation. this study aimed to assess the knowledge of the parents and their children’s practice in toilet training at kindergarten. methods: this was an analytic study with a cross-sectional method which conducted at kindergartens in jatinangor, selected by a total random sampling method. a self-made validated questionnaire was distributed to parents asking about knowledge and toilet training. incomplete answer sheets and parents who did not come to school by the time of the study were excluded. result: in total, 111 parents returned the questionnaire, and most of the parents (98.19%) had good knowledge regarding toilet training. moreover, most of the children (96.39%) were also good at practicing the toilet training. there was a strong and significant correlation between parents’ knowledge and the children’s practice of toilet training with coefficient correlation 0.701 and p-value <0.05. conclusions: good knowledge of parents help the children practicing toilet training, therefore, education to new parents is necessary. keywords: constipation, knowledge, practice, questionnaire, toilet training althea medical journal. 2019;6(2) 87 the correlation between the knowledge of the parents and children’s practice of toilet training at kindergarten in jatinangor. methods this was an analytic study with cross-sectional method using primary data obtained through self-filling questionnaires. subjects of the study consisted of 111 parents of the students of the kindergartens or known as “taman kanakkanak (tk)” who were recruited using total random sampling. there were 5 kindergartens selected from 17 kindergartens in jatinangor area after the randomization. parents’ consent was obtained before data collection. the inclusion criteria of this study were parents of the children at the selected kindergartens, parents who could communicate well and agreed to be the respondents of this study. the incomplete answer sheets and parents who did not come to school by the time of data collection were excluded. the evaluation method used in this study was a self-made questionnaire that consisted of demographic information and details of 28 questions about knowledge and 8 questions about the practice. it was a modification of the questionnaire used in the previous study by considering a factor that affects the training. it had been validated using 30 samples that were not included in this study. the items that were not valid and reliable yet were modified to reach the alpha cronbach level of 0.71 points. the study was conducted in march until may 2017. ethical approval was granted from the research ethics committee of universitas padjadjaran, district level implementation unit of kindergarten, and each headmaster of 5 kindergartens in jatinangor. all data were analyzed using microsoft excel 2016 and spss version 20. the data were presented in frequency and percentage whichever appropriated. for the parents’ level of knowledge and children’s practice, “good” is represented by parents who had >75% correct answer, “enough” is for 50–75% and “poor” is for <50%. the correlation of the variables was analyzed using rank spearman correlation to define the power and the significance of the correlation of the variables considered when the p-value was <0.05. results table 1 showed that most of the subjects were female (85.59%) and the mean age was 34.07 ± 4.71 years old. the educational status varied table 1 characteristics of the subject variables n % age (years) 21–30 35 31.53 31–40 62 55.85 41–50 13 11.71 >50 1 0.90 mean ± sd 34.07 ± 4.71 sex male 16 14.41 female 95 85.59 education elementary school 3 2.70 junior high school 18 16.21 senior high school 48 43.24 associate degree 10 9.00 bachelor degree 21 18.91 graduate degree 2 1.80 unidentified 9 8.10 anne shafira purnama claytonia aziz et al.: parents’ knowledge and children’s toilet training practices: study in kindergartens in jatinangor althea medical journal. 2019;6(2) 88 amj june 2019 among the subjects, but most of the subjects were graduated from senior high school (sekolah menengah atas, sma) and there were 9 subjects with unknown educational background. table 2 showed the characteristics of the toilet habits of the children based on the questionnaire answered by their parents. regarding the bowel habit, most of the children used a water closet (93.7%). meanwhile, the age when they start to defecate on the toilet varied among the children. in the bowel position criteria, most of the children’s bowel position during defecation was squatting (74.8%). table 3 showed that in both groups, most of the children started to defecate in the toilet at the age of 2 years old (boys: 38.5%. girl: 47.5%). in the boy group, there were 3.8% of children that have not started to defecate in the toilet. table 4 showed the level of parents’ knowledge and children’s practice of toilet training. it showed that most of the parents had a good knowledge regarding toilet training (98.19%) and most of the children also good at practicing toilet training (96.39%). there were no parents with poor knowledge nor children with poor practice regarding toilet training. table 5 showed the correlation between the parents’ knowledge and the children’s practice of toilet training using the rank spearman correlation test showed that the coefficient correlation is 0.701 and the p-value was table 2 characteristics of toilet habits of the children variable n % bowel habit use a water closet 104 93.7 use diaper 5 4.5 others 2 1.8 age when starting to defecate in the toilet (year) 1 year old 26 23.4 2 years old 48 43.2 3 years old 28 25.2 4 years old 7 6.3 have not started yet 2 1.8 bowel position during defecation squat 83 74.8 sit 23 20.7 stand up 5 4.5 others table 3 age of children when they start to defecate in the toilet. age gender boys girls n % n % 1 y.o 14 26.9% 12 20.3% 2 y.o 20 38.5% 28 47.5% 3 y.o 13 25% 15 25.4% 4 y.o 3 5.8% 4 6.8% have not started yet 2 3.8% althea medical journal. 2019;6(2) 89 <0.05, which meant the correlation between the variables were strong and scientifically significant. discussion functional constipation is a common pediatric problem worldwide that can be characterized by an infrequent bowel movement, hard and/or large stools, painful defecation, fecal incontinence, and is often accompanied by abdominal pain. these symptoms can have a significant impact on child’s well-being and health-related quality of life.9 the fact that the symptoms of functional defecation disorders are chronic leads children into a process of ill-adaptation to the act of evacuation, conditioning them to inhibit it, which result in emotional consequences, such as increased anxiety levels, negative self-esteem, and withdrawal from social intercourse, especially at school.9 toilet training is a method to habituate children to defecate and urinate in the toilet. in this study, it shows that most of the respondents have a good knowledge regarding toilet training (98.19%). moreover, most of the children’s practice of toilet training is also good (96.39%). this study also shows that the knowledge level of the parents and the children’s practice of toilet training has a strong and significant correlation (coefficient correlation 0.701, p-value <0.05). it can be concluded that the better level of parent’s knowledge will bring a better level of children’s practice. in indonesia, the prevalence of constipation in children below 5 years old is 4.4%. this may be related to the high level of knowledge and practice of parents in performing toilet training.6 the age for toilet training is 2 to 4 years when the child usually shows readiness. the age for starting toilet training is varied in different cultures. it is suggested that the appropriate age of toilet training initiation is at the minimal age of 18 months when the neurodevelopment of the children is adequate. the starting age to do toilet training has the highest number at the 2-year-old age (table 4). this result is matched with the normal starting age.10 thus, in this study, most of the children start to defecate in the toilet at the age of 2 years old (43.20%), consistent with the literature. generally, girls have faster development than boys which can be seen from their practice of self-care independently such as wearing clothes and finishing toilet training earlier than boys. the fact that boys do urinate and defecating with two different positions (standing and sitting/squatting), it is assumed to be one of the factors causing them to learn more slowly. conditions that create stress in children can inhibit the process of development, which can make the child urinate and defecate in places that are not appropriate.11 however, in this study, boys and girls have similar dissemination of starting age table 4 the level of parents’ knowledge and children’s practice of toilet training variable n % parent’s knowledge good 109 (98.19%) enough 2 (1.81%) poor children’s practice good 107 (96.39%) enough 4 (3.61%) poor table 5 correlation of the parent’s knowledge and children’s practice correlation coefficient correlation p-value parents’ knowledge of children’s practice of toilet training 0.701 0.00* note: based on rank spearman correlation, *p-value <0.005 anne shafira purnama claytonia aziz et al.: parents’ knowledge and children’s toilet training practices: study in kindergartens in jatinangor althea medical journal. 2019;6(2) 90 amj june 2019 for toilet training (table 3). all findings in this study represent the result of the questionnaire about the understanding and practice of toilet training. this is in accordance with the study that says those things are appropriate with the good methods of toilet training. the difference in outcomes of this study compared with previous studies may be due to several factors, including the types of methods used and the involved samples. the previous study regarding the impact of the health education to the parents’ attitude towards toddler’s toilet training, involving parents who graduated from elementary school, senior high school and college.8 the limitation of this study was the usage of the questionnaire as the tools of data collection. the respondents’ answer is difficult to be confirmed and might not reflect the real situation. directly observation of the children’s practice in the toilet training has been suggested for further study, rather than asking the parents to fill in the questionnaire. as a conclusion, most parents in jatinangor have good knowledge about toilet training and most of the children also good at practicing the toilet training. there is a strong correlation between the parent’s knowledge and the children’s practice regarding toilet training. further analysis is recommended for the correlation between the prevalence of constipation in children and the level of knowledge and practices of toilet training. references 1. musfiroh m, wisudaningtyas bl. penyuluhan terhadap sikap ibu dalam memberikan toilet training pada anak. jurnal kesehatan masyarakat. 2014;9(2):157–66. 2. tanto c. kapita selekta kedokteran. jakarta: media aesculapius; 2014. 3. rajindrajith s, devanarayana nm. constipation in children: novel insight into epidemiology, pathophysiology and management. j neurogastroenterol motil. 2011;17(1):35-47. 4. wang c, shang l, zhang y, tian j, wang b, yang x, et al. impact of functional constipation on health-related quality of life in preschool children and their families in xi’an, china. plos one. 2013;8(10):e77273. 5. dolgun e, yavuz m, çelik a, ergün mo. the effects of constipation on the quality of life of children and mothers. turk j pediatr. 2013;55(2):180–5. 6. levy ei, lemmens r, vandenplas y, devreker t. functional constipation in children: challenges and solutions. pediatric health med ther. 2017;8:19–27. 7. xinias i, mavroudi a. constipation in childhood. an update on evaluation and management. hippokratia. 2015;19(1):11–9. 8. kusumaningrum a, natosba j, julia el. pengaruh pendidikan kesehatan terhadap perilaku orangtua dalam toilet training toddler. jurnal ilmu kesehatan masyarakat. 2011;2(2):97–102. 9. koppen ij, lammers la, benninga ma, tabbers mm. management of functional constipation in children: therapy in practice. paediatr drugs. 2015;17(5):349– 60. 10. hooman n, safaii a, valavi e, alavijeh za. toilet training in iranian children, a cross-sectional study. iran j pediatr. 2013;23:154-8. 11. lawal to, michael gc, aliyu i. toilet training and parental help-seeking behavior toward elimination disorders: our experience in a semi-urban setting. med j dy patil vidyapeeth. 2019;12(1):28– 33. althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 129 distribution of skin prick test results in rhinitis allergic patients at dr. hasan sadikin general hospital bandung gama antares,1 arif dermawan,2 yenti permata3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology–head and neck surgery faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital,bandung, 3department of anatomy, biology cell and phsyology faculty of medicine universitas padjadjaran abstract background: allergic rhinitis (ar) is an inflammation condition in nasal mucous because of type 1 hypersensitivity. skin prick test is one of the diagnostic tests to diagnose ar. purpose of this study was to know the distribution of skin prick test in ar patients. methods: this study used retrospective descriptive method as cross sectional design. this study was performed from 1 august to 31 october 2014. this study used medical record as secondary data at department of otorhinolaryngology–head and neck surgery of dr. hasan sadikin general hospital. there were 175 cases which fulfilled the inclusion criteria of the study. the data were then analyzed using computer program. results: forty seven cases were positive for house dust (26.8%), 127 cases were positive for dust mite (72.5%), 85 cases were positive for rice pollen (48.5%), 62 cases were positive for maize pollen (35.5%), 56 cases were positive for mixed fungi (32%), 100 cases were positive for cockroach (57.1%), 63 cases were positive for horse dander (36%), 50 cases were positive for cat dander (28.5%), 93 cases were positive for dog dander (53.1%), and 38 cases were positive for chicken feather (21.9%). conclusions: the most aeroallergen making positive result in skin prick test is dust mite. [amj.2017;4(1):129–32] keywords: aeroallergen, allergic rhinitis, allergy, skin prick test correspondence: gama antares, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8972816537 email: gamaantares@gmail.com introduction rhinitis is an inflammatory condition of the nasal mucosa which is marked by sneezing, stuffy, runny, and itchy nose. allergic rhinitis (ar) is the most common form of rhinitis1,2 caused by allergens and mediated by type 1 hypersensitivity process. the prevalence of ar in both developed and developing countries keeps increasing. the prevalence of ar differs by countries. this difference is probable caused by geographical differences.3 the cumulative prevalence of ar is about 20%. in canada, it is estimated that 20–30% of the populations suffer from ar. in 2008, it was reported that 2.34% of the total population in indonesia suffer from ar. meanwhile, the province of west java has ar prevalence of 3.62%.4 previous studies reported that global ar prevalence keeps increasing.1,5 diagnosis of ar is achieved from history of allergic symptoms, physical examination, and supporting examination. supporting examination was conducted by using allergens to induce immunoglobulin e (ige) reaction in ar patients’ skin. there are several tests that can be conducted on the skin: skin scratch test, skin prick test (spt), intradermal test, and patch test.1,6 previous studies reported that out of all the types of supporting examination to diagnose ar, spt is the most widely used.1 this study aimed to discover the distribution of inhaled allergens spt results among ar patients. althea medical journal. 2017;4(1) 130 amj march 2017 methods this was a descriptive study conducted from august 1 to october 31, 2014. this study used the medical records of ar patients with history of inhaled allergens spt at department of otorhinolaryngology–head and neck surgery dr. hasan sadikin general hospital. this study collected secondary data from the medical records in the above-mentioned clinic after gaining approval from health research ethics committee of dr. hasan sadikin general hospital. the study population was ar patients with history of spt from january 1 to december 31, 2013. sampling was collected by total sampling method. the inclusion criterion in this study was ar patients with history of inhaled allergens spt. a hundred and seventy five ar patients were found with history of spt. patients with incomplete medical records were excluded. the collected variables were age, patient’s frequency according to gender, inhaled allergens spt results, and aria-who classification. the collected data were then analyzed using computer program. results the patient age characteristic was described in table 1. most of the study subjects were in young adult period (21–40%). out of 175 subjects, 69 (39.9%) were males and 106 (60.1%) were females (table 1). the mean age of the subjects was 29 years old and the median age was 25 years old. the disease severity was mostly from moderate to severe (table 2). the spt results showed that dust mites had the highest percentage (72.6%) while chicken feather had the lowest percentage (21.7%) (table 3 and 4). discussion the ar patients usually complain about stuffy nose, runny nose, sneezing, and itchy nose. ar usually attacks people from the school and productive age groups. inhaled allergen is the type of allergen that predominantly causes ar.1 this study found that there were more female ar patients. this finding is not so different from the previous study by melati sudiro et al.7 who reported that 55.3% of ar patients are females.7 the age group with the highest frequency was the 21–40 year old group. the largest groups were the school and productive age groups. this was probably because people coming from the two age groups are frequently exposed to some specific allergens. occurrence of ar symptoms will disturb daily activities to a large extent. based on that, ar must table 1 patients frequency based on gender and age group age group (years) gender percentage (%) male female <10 7 6 7.4 11–20 12 26 21.7 21–40 33 50 47.4 41–60 15 22 21.1 61–80 2 2 2.3 total 69 106 100 table 2 patients frequency based on aria-who classification classification number of patients percentage mild intermittent 39 22.3 moderate or severe intermittent 11 6.3 mild persistent 54 30.9 moderate or severe persistent 71 40.6 althea medical journal. 2017;4(1) 131gama antares, arif dermawan, yenti permata: distribution of skin prick test results in rhinitis allergic patients at dr. hasan sadikin general hospital bandung be diagnosed accurately and given rational treatment. unsuitable treatment will result in decreased work productivity and loss of academic time in students.7 the spt results of ar patients were also observed in this study. the highest number of positive result came from dust mites. this conforms to a study in korea.8 the korean study discovered that dust mites are the most dominant inhaled allergen.8 however, another study in iran9 found that dust mite allergy is only positive in 20% of the subjects.9 on the contrary, saleh et al.10 found that the allergen with the most positive results is mold.10 the difference in the dominant allergens can be attributed to the different demographic factors which can influence the types of allergen presence in there.1 the high number of positive spt results caused by dust mites in this study was made possible by frequent exposure to the allergen. the habitat of dust mites was in many places in the house: mattresses, beds, and bed sheets. dust mites grow well in the tropical climate.11,12 dust mite allergens come from their body parts or the digestive enzymes contained in their feces.12–14 the continuous exposure can induce the human immune system to be sensitized against certain allergens. the findings of this study were in agreement by a previous study which found that the moderate or severe persistent ar has the highest frequency compared to the other types.7 one limitation of this study was that the data used in this study were only collected from the medical records at department of otorhinolaryngology–head and neck surgery table 3 results of skin prick test allergen + ++ +++ ++++ house dust 128 13 17 14 3 dust mites 48 16 18 36 57 rice pollen 90 22 26 28 9 maize pollen 113 25 22 14 1 mixed fungi 119 26 15 11 4 cockroaches 75 21 31 33 15 horse dander 112 28 16 16 3 cat dander 125 19 11 14 6 dog dander 82 17 18 30 28 chicken feather 137 15 11 11 1 table 4 distribution of spt results based on positive grade allergen + & ++ percentage +++& ++++ percentage total house dust 30 17.1 17 9.7 47 (26.8) dust mites 34 19.4 93 53.1 127 (72.5) rice pollen 48 27.4 37 21.1 85 (48.5) maize pollen 47 26.9 15 8.6 62 (35.5) mixed fungi 41 23.4 15 8.6 56 (32) cockroaches 52 29.7 48 27.4 100 (57.1) horse dander 44 25.1 19 10.9 63 (36) cat dander 30 17.1 20 11.4 50 (28.5) dog dander 35 20.0 58 33.1 93 (53.1) chicken feather 26 14.9 12 6.9 38 (21.8) althea medical journal. 2017;4(1) 132 amj march 2017 dr. hasan sadikin general hospital in 2013. it is suggested to conduct further studies with larger population, more comprehensive variables, and more extensive discussion. medical records should also be written in legible handwriting to expedite studies on ar cases. common people should pay more attention to the cleanliness of their houses and workplaces to prevent exposure of dust mites. the conclusion of this study is that dust mites are the allergen with highest positive spt results. the 20–40 year old age group is the group with the highest frequency. based on aria-who classification, the type of ar with highest number is moderate or severe persistent ar. references 1. bousquet j, khaltaev n, cruz aa, denburg j, fokkens wj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008 update (in collaboration with the world health organization, ga(2)len and allergen). allergy. 2008;63 suppl 86:8– 160. 2. pawankar r, canonica g, holgate s, lockey r, editors. wao white book on allergy 2011–2012: executive summary. winconsin: world allergy organization; 2011. 3. lima rg, pastorino ac, casagrande rr, sole d, leone c, jacob cm. prevalence of asthma, rhinitis and eczema in 6 7 years old students from the western districts of sao paulo city, using the standardized questionnaire of the “international study of asthma and allergies in childhood” (isaac)-phase iiib. clinics (sao paulo). 2007;62(3):225–34. 4. departemen kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2007. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2008. 5. shah a, pawankar r. allergic rhinitis and co-morbid asthma: perspective from india aria asia-pacific workshop report. asian pac j allergy immunol. 2009;27(1):71–7. 6. bauchau v, durham sr. prevalence and rate of diagnosis of allergic rhinitis in europe. eur respir j. 2004;24(5):758–64. 7. melati sudiro, teti madiadipoera, purwanto bambang. eosinofil kerokan mukosa hidung sebagai diagnostik rinitis alergi. mkb. 2005;42(1):6–11. 8. shin jh, kim bg, cho jh, kim sw, lee bj, kim yw, et al. skin prick testing of patients with allergic rhinitis and/or asthma: a study in catholic medical center, korea. j rhinol. 2012;19(1):29–34. 9. fereidounia m, hossinia rf, azada fj, assarehzadegan ma, varasteh a. skin prick test reactivity to common aeroallergens among allergic rhinitis patients in iran. allergol immunopathol (madr). 2009;37(2):73–9. 10. saleh bt, abd ai, saleh ri, mohammed ts, aljubory ah. a study of skin prick test reactivity to common aeroallergens among patients with allergic rhinitis in salahelden governorate. tikrit j pure sci. 2011;16(4):40–4. 11. tsai1 lc, peng hj, lee cs, chao pl, tang rb, tsai jj, et al. molecular cloning and characterization of full-length cdnas encoding a novel high-molecular-weight dermatophagoides pteronyssinus mite allergen, der p 11. allergy. 2005;60(7):927– 37. 12. nurmatov u, van schayck cp, hurwitz b, sheikh a. house dust mite avoidance measures for perennial allergicrhinitis: an updated cochrane systematic review. allergy. 2012;67(2):158–65. 13. shin jw, sue jh, song tw, kim kw, kim es, sohn mh, et al. atopy and house dust mite sensitization as risk factors for asthma in children. yonsei med j. 2005;46(5):629– 34. 14. jeong ky, park jw, hong cs. house dust mite allergy in korea: the most important inhalant allergen in current and future. allergy asthma immunol res. 2012;4(6):313–25. althea medical journal. 2017;4(3) 353 correlation between short-term memory and achievement of athletes ryandika elvereza mustari,1 leonardo lubis,2 nani kurniani3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine, universitas padjadjaran, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: human activity is largely related to thought processing or cognition. one of the most important components of cognition is memory. individuals who undergo heavy activities, such as athletes, use a lot of memory in the subject’s activities, especially during competitions. the purpose of this study was to find out whether there was a correlation between the capability of short term memory with the performance of an athlete during a competition, especially those measured by achievements. methods: this study was an analytic observational correlation study with a cross-sectional design and involved 201 athletes as respondents from 12 branches of sports. the study was conducted in the indonesian national sports committee (koni) building from september to november 2015. digit span forward and backward were used to collect short term memory data and was performed after a consent form and the respondent’s identity was recorded. the athlete’s achievements data was gathered by an interview and recapitulation of athlete’s achievements in the last five years. results: oa total of 186 data was analyzed and found a negative and insignificant correlation between achievement and short-term memory based on digit span tests both forward (r=0.095 p=0.196) and backward(r=0.039 p=0.196). conclusions: there is no correlation between short term memory and the achievements of an athlete. keywords: achievement, athlete, short term memory correspondence: ryandika elvereza mustari, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: ryand1195@gmail.com introduction the mind’s ability is the competence for thinking and processing thought from all sources. the received information will be processed and attained systematically in the human mind.the capability of thought arrangement is called cognition.1 a study by bull et al.2, shows that there is a relationship between the cognitive ability and achievements in grade 4 students in an elementary school in usa, especially in reading and mathematics. this proves the importance of cognition especially in an individual’s life performance, one of them being achievements.2 the most important part in information processing is memory. after processing, the information will be stored in the brain for future reuse in many daily activities. there are three types of memory which is differentiated by the length of time in the memory storage named longterm, intermediate and short-term memory.3 short term memory has a storage capacity of about seven items for 20–30 seconds.4 short term memory is needed in the recalling of information that originated from long term memory, the selection of information, repetition of information that are received and stored, and also as a choosing response, which plays a vital role in all the individual activities. a study by swanson5 proves that the short term verbal memory has a relationship with achievements especially in language studies and mathematics in children and adults. furthermore, short term memory is also needed in a special community, such as athletes. a few studies have proven that routine exercises could increase the cognitive function including memory.6,7 athletes undergo routine exercises to improve the performance on the field during a competition and to maintain good physique. an athlete’s sports performance on the field consists of the athlete’s capability and achievement, the characteristics of their performance in a competition, a fair behavior, integrity, and an appreciation for friend or foe.8 amj. 2017;4(3):353–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1180 althea medical journal. 2017;4(3) 354 amj september 2017 short-term memory plays a role in an athlete’s performance, for example, an athlete is required to remember strategic tactics instructed by the coach either before or during a break in competitions to maximize the athlete’s performance. the performance of an athlete can be clearly seen and measured through the achievements, namely the medals. to our knowledge, there is not a study that shows a correlation between short term memory and an athlete’s achievements. this study aimed to discover and analyse the correlation between short term memory and the athlete’s achievements. methods a cross-sectional analytic study was conducted from september to november 2015 in the indonesian national sports committee (komite olahraga nasional indonesia, koni) west java building, and approved by the health and research ethics committee, faculty of medicine, universitas padjadjaran. the subjects for this study were 201 athletes of west java koni from 12 branches of sports comprising pencak silat, judo, athletics, archery, fencing, taekwondo, rock climbing, boxing, heavy lifting, gymnastics, wrestling and kempo. the sample collection in this study was obtained used the total sampling method and the correlative analysis sample size formula with α 5%, β 10%, and r 0,7 from previous studies, and turned out to be 14.5 the inclusion criteria were athletes who were willing to participate in the study, had filled out an informed consent form, and completed 90– 100% of their training program. short term memory was assessed by using the digit span forward and backward instrument that was part of the wechsler adult intelligence scale (wais) iv and wechsler intelligence scale for children (wisc) iv cognition test which was validated.9–12 additionally, training before handling, suitability test for intra-observers and inter-observers, and athlete identification was conducted before data collection. digit span forward test was performed by requesting the athlete to repeat a sequence of numbers stated by an examiner. a score of 2 was given if the athlete repeated the sequence correctly, while a score of 0 was given if the sequence could not be repeated accurately. the questionnaire with two wrong answers was considered finish, and the athlete’s score was written on an evaluation form. digit span backward test was then carried out, where an athlete repeated the numbers stated by an examiner but in a backwards table 1 characteristics of participants variables frequency percentage (%) sex male 91 49 female 95 51 sport pencak silat 23 12 judo 21 11 athletics 12 6 archery 14 8 fencing 15 8 taekwondo 14 8 rock climbing 20 11 boxing 6 3 pabbsi 12 6 gymnastics 15 8 wrestling 4 2 kempo 30 16 althea medical journal. 2017;4(3) 355ryandika elvereza mustari, leonardo lubis, nani kurniani: correlation between short-term memory and achievement of athletes sequence. a score of 2 was given if the athlete repeated the backwards sequence correctly, while a score of 0 was given if the backwards sequence could not be repeated accurately. the questionnaire with two wrong answers was considered finish, and the athlete’s score was written on an evaluation form. the achievement data was about the latest medals attained by the athletes from previous competitions, and information was obtained from interviews with the athletes. the medals might be gold, silver or bronze that the athlete received in state, national or international events. the data was analyzed using statistical application. the normality test was performed using the kolmogorov-smirnov test. the normality results were used to determine the type of correlation test that would be conducted. results out of 201 athletes included in the study, 186 eligible athletes were recruited, and 15 were excluded as they had not completed the tests. according to the branch of sports, the highest frequency of respondents was from the kempo branch (16.1%) and was dominated by female athletes (51.1%) (table 1). the results showed that either the independent or dependent variables presented a data distribution which was not normal. thus, to display the statistics of this study in a descriptive way, a median was used as a measurement of central tendency and a minimum maximum as a measurement of table 2 measurement of study data dispersion median minimum maximum score achievement 3 1 16 digit span forward 10 6 16 digit span backward 6 4 16 dispersion (table 2). moreover, results of the spearman’s test showed an insignificant negative correlation between digit span forward and achievements, as well as between digit span backward and achievements (table 3). discussions the spearman correlation test showed that there was a negative and insignificant correlation between the short term memory and the athlete’s achievements. additionally, a study by cdc13 showed that physical activities could influence the cognitive ability of someone by an increase in the growth of brain capillaries, oxygenation, blood pressure, neurotrophin production, number of neurotransmitters, growth of nerve cells in the hippocampus, development of nerve connections, volume of brain tissue and density of interneuron relationships. this causes an increase in the functionality of attention, information processing, information storage and repetition; it also increases coping mechanism, heightens positive behavior and reduces the sensation of pain.this study also showed that there was an influence of physical activity to academic performance. aerobic exercises in the form of group games, especially those that needed complex motoric activities (example; football), could increase prefrontal cortex activities, and increased the positive marginal effect in mathematical achievements. furthermore, sun et al.14 stated that the brain’s functional magnetic resonance table 3 correlation analysis test result digit span forward digit span backward achievement spearman correlation -0.095 -0.039 p-value (2-tailed) 0.196 0.594 n 186 186 althea medical journal. 2017;4(3) 356 amj september 2017 imaging (fmri) test results on the prefrontal cortex activitiy especially in the dorso lateral prefrontal cortex has a major role in the short term memory function. short term memory has a correlation with achievements in language studies and mathematics in children and adults.5 this shows that short term memory influences an individual’s achievement. there are a few factors that influence the memory function of an individual, one of it is concentration. duration, intensity and time of stress as intrinsic factors could also influence memory.15 stress will activate the hypothalamic-pituitary-adrenal (hpa) axis and increase the rate of glucocorticoid, cortisol in humans. the increase of the glucocorticoid rate could decrease memory function.15,16 athletes are people who experience a lot of physical activities with specific training regimes. the main purpose of an athlete is to win competitions and to garner achievements in the form of medals.17 sports performance of athletes are influenced by cognitive function, stress factor, confession of physical or mental mistakes on the field, frequent endurance of pain and unease on the field, seeing successful or cheating rivals on the field, getting a violation from the referee, and being reprimanded by the coach. the failure of the coping mechanism with acute stress levels could lead to change in the psycho-behavioral processes of the athlete.18 this study was not focused on the measurement of short term memory quality as an effect of an athlete’s physical activity. this study was focused on the short term memory and the achievement of athletes due to a relationship between athletes who endure loads of exercise and the increase of cognitive function, especially the short term memory. in conclusion, there is no correlation between the west java koni athlete’s short term memory capability and their achievements, and this may occur due to a few factors that in turn influenced the athlete’s performance on the field aside from the short term memory. there are also factors that influenced short term memory when the test is conducted, such as concentration. this study has several limitations. the researcher did not measure the stress factor and the concentration that may influence the athlete’s achievements in competitions and memory function during data collection. this is due to the insufficient study time. recommendations for athletes are to maintain factors that can influence the athlete’s performance on the field. one of them is the role of koni to measure also the cognitive function and stress factor of the athletes regularly before a match. recommendations for a future study are to conduct carry out a study with cohort method by measuring the short term memory of the athletes before a competition and to observe the development of the athlete’s performance. further recommendations are to measure and to control positive factors that may influence the short term memory or an individual’s performance. additionally, to evaluate the part of the brain that activates the short term memory directly during the study by using fmri. references 1. singh m, narang m. cognitive enhancement techniques. int j inf technol knowl manag. 2014;7(2):49–61. 2. bull r, espy ka, wiebe sa. short-term memory, working memory, and executive functioning in preschoolers: longitudinal predictors of mathematical achievement at age 7 years. dev neuropsychol. 2008;33(3):205–28. 3. guyton a, john eh. thoughts, consciousness,and memory. in: schmitt w, rebecca g, folcher ma, editors. textbook of medical physiology. 11st ed. philadelphia, pa : saunders/elsevier; 2011. p. 723–6. 4. cowan n. what are the differences between long-term, short-term, and working memory? prog brain res. 2008;169(1):323–38. 5. swanson hl. short-term memory and working memory: do both contribute to our understanding of academic achievement in children and adults with learning disabilities? j learn disabil. 1994;27(1):34–50. 6. nanda b, balde j, manjunatha s. the acute effects of a single bout of moderateintensity aerobic exercise on cognitive functions in healthy adult males. j clin diagn res. 2013;7(9):1883–5. 7. mayers lb, redick ts, chiffriller sh, simone an, terraforte kr. working memory capacity among collegiate student athletes: effects of sport-related head contacts, concussions, and working memory demands. j clin exp neuropsychol. 2011;33(5):532–7. 8. arai a, ko yj, ross s. branding athletes: exploration and conceptualization of athlete brand image. sport manag rev.2014;17(2):97–106. 9. drozdick lw, cullum cm, antonio s. althea medical journal. 2017;4(3) 357 expanding the ecological validity of wais-iv and wms-iv with the texas functional living scale. hhs public access. 2015;18(2):141–55. 10. holdnack j, zhou x, larrabee g, millis s, salthouse t. confirmatory factor analysis of the wais-iv/wms-iv. nih public access. 2013;18(2):178–91. 11. mcfarland dj. modeling individual subtests of the wais iv with multiple latent factors. plos one. 2013;8(9):1–7. 12. kaufman a. test review: wechsler intelligence scale for children, fourth edition (wisc-iv). j psychoeduc assess. 2006;24(3):278–95. 13. cdc. the association between schoolbased physical activity, including physical education, and academic performance. 2010;2(1):1–84. 14. sun x, zhang x, chen x, zhang p, bao m, zhang d, et al. age-dependent brain activation during forward and backward digit recall revealed by fmri. neuroimage. 2005;26(1):36–47. 15. sandi c, pinelo-nava mt. stress and memory: behavioral effects and neurobiological mechanisms. neural plast. 2007;1(3):1–20. 16. sandi c. glucocorticoids act on glutamatergic pathways to affect memory processes. trends neurosci. 2011;34(4):165–76. 17. yarrow k, brown p, krakauer jw. inside the brain of an elite athlete: the neural processes that support high achievement in sports. nat rev neurosci.2009;10(8):585–96. 18. bahramizade h, besharat ma. the impact of styles of coping with stress on sport achievement. procedia–social behav sci. 2010;5(2):764–9. ryandika elvereza mustari, leonardo lubis, nani kurniani: correlation between short-term memory and achievement of athletes vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 175 macrosomic newborn and glucose level in lean pregnant diabetes mellitus patients at dr. soetomo general hospital surabaya sonea venugopal,1 hermanto tri joewono,2 pudji lestari3 1faculty of medicine universitas airlangga surabaya, indonesia, 2department of obstetrics & gynaecology faculty of medicine universitas airlangga/dr. soetomo general hospital surabaya, indonesia 3department of public health faculty of medicine universitas airlangga surabaya, indonesia correspondence: sonea venugopal, faculty of medicine universitas airlangga, jl. professor dr. mustopo no.47, pacar kembang, jawa timur, indonesia, email: soneavenugopal96@hotmail.com introduction newborn macrosomia, a newborn with the birthweight of more than 4000g has a high percentage in indonesia, that has reached 6.4%.1 gestational diabetes mellitus (gdm), defined as glucose intolerance in variable degree with onset during pregnancy, is a risk factor for the development of fetal macrosomia, there are more than 150,000 cases of gdm in indonesia with the prevalence ranging from 1.9 to 3.6% across the country. pregnancies, that are closely linked to diabetes, poor blood sugar control, may cause complications for the mother and child being born. even according to research results conducted by the health research institute confidential inquiry into maternal and child health (cemach), although mother blood sugar levels has been controlled, a baby still has risk of complications. newborn by mother diabetics has risk of 5 times greater for death, would have birth defect risk of 2 times larger, and can be born with weights of more than 4000 grams or greater.2 several studies have been conducted on risk factors of macrosomia, however, information and study in macrosomia complications are scarce.3 fetal macrosomia may result in complications such as shoulder dystocia, birth asphyxia, nerve injuries, clavicular and humerus fractures in neonates, leading to admission to the intensive-care nursery and an increased of perinatal mortality for the newborn. furthermore, vaginal and perineal trauma, uterine rupture, postpartum infection and hemorrhage to the mother may occur.4 therefore, this study was conducted to identify the relationship between macrosomia and glucose level during pregnancy. result of this study is expected to assess the importance of glycemic control to decrease the incidence of newborn macrosomia. amj. 2018;5(4):175–8 abstract background: gestational diabetes mellitus, defined as glucose intolerance in variable degree with onset during pregnancy, is a risk factor for the development of fetal macrosomia, a newborn with the birthweight of more than 4000g. the objective of this study was to explore an association between glucose level in lean pregnant diabetes mellitus patients, resulting in babies and the incidence of macrosomia in dr soetomo general hospital in surabaya. methods: this was a retroprospective analytic study with a cross sectional design by using medical records at dr. soetomo general hospital surabaya, collected from january 2016 to december 2017. the correlation between fasting glucose level, 2-hour postprandial glucose and glucose level at the time of birth and weight of newborn was assessed. results: controlled and uncontrolled fasting glucose level, 2-hour postprandial glucose level and glucose level at the time of birth of mother were not significantly associated with macrosomia newborns. macrosomia newborn were born with gestational diabetes mellitus mothers compare with pregestational mellitus mothers. conclusions: there is no association between macrosomia with glucose level of lean gestational and pregestational diabetes mellitus, however, therapeutic approach such as physical exercise should be implemented to reduce effects of uncontrolled glucose level. keywords: gestational diabetes mellitus, macrosomia, glucose level althea medical journal. 2018;5(4) 176 amj december 2018 methods this was an analytic retrospective cross sectional study, conducted after obtaining approval from the health research ethics committee of the faculty of medicine, universitas airlangga/dr. soetomo general hospital, surabaya. a total data on newborns from medical record from the year 2016 to 2017 medical record data of newborns at the delivery room of obstetrics and gynaecology department were collected. the inclusion criteria were data of women who had gestational and pre-gestational diabetes mellitus aged 21–35 years old with a normal pre-pregnancy body mass index of lower than 25 and had a complete medical data of glucose level. data on women who had a history of smoking or still smoke as well as previous history of pregnancy complications other than diabetes mellitus were excluded from this study. the measurement of fasting plasma glucose (fpg) level, 2 hour postprandial (2hpp) and glucose at the time of birth were categorised based on glycemic targets in pregnancy by american diabetes association (ada) year 2016 guidelines.5 glycemic status was designated as controlled with fpg ≤95 mg/dl, 2hpp ≤120mg/dl and glucose at the time of birth ≤120mg/dl. the results were analysed using fisher’s exact test to assess statistical table 1 clinical characteristic among gestational and pregestational diabetes women with controlled and uncontrolled fasting plasma glucose level at dr. soetomo general hospital, surabaya from january 2016 to december 2017 fasting plasma glucose level total n(%) p-value*controlled (≤95mg/dl) uncontrolled (>95mg/dl) n(%) n(%) age (years) 31–35 9(69.2) 13(65) 22(66.7) 0.714 26–30 4(30.8) 6(30) 10(30.3) 21–24 1(5) 1(3) parity nullipara 4(30.8) 4(20) 8(24.2) 0.681 multipara 9(69.2) 16(80) 25(75.8) mode of delivery caesarean 10(76.9) 16(80) 26(78.8) 1.000 vaginal 3(23.1) 4(20) 7(21.2) total 13(39.4) 20(60.6) 33(100) note: *fisher’s exact test table 2 fasting plasma glucose level among gestational and pre-gestational diabetes women and macrosomia state in newborn in delivery room of dr. soetomo general hospital, surabaya from january 2016 to december 2017. state in newborn p-value*non-macrosomia macrosomia n(%) n (%) controlled 13 (100%) 0.508 uncontrolled 18 (90%) 2 (10%) total 31 (93.9%) 2 (6.1%) *note: fisher’s exact test althea medical journal. 2018;5(4) 177sonea venugopal, hermanto tri joewono, pudji lestari: macrosomic newborn and glucose level in lean pregnant diabetes mellitus patients at dr. soetomo general hospital surabaya significance. a p-value <0.05 was considered statistically significant. results in total, there were 33 data of pregnant women with poor glycemic control. glycemic status was more likely to be poorly controlled among older patients, multipara patients and caesarean delivery was mode of delivery (table 1). discussions this study has assessed the association between uncontrolled and controlled glucose level in lean gestational and pregestational diabetes mellitus women, resulting in birth of newborns with macrosomia. uncontrolled blood glucose levels has been found in majority of the patients, and older age of pregnant women (31–35 years old) tends to have more uncontrolled glucose level, although no significant association between age and glycemic control. this result is in contrast to other study that showed that younger patients had more uncontrolled glucose level.6 in line with the study among chinese women in singapore7, our result showed that the majority of uncontrolled glucose level was among multipara women, however, no statistically significant association of parity with uncontrolled glucose level has been found in this research. more than half of patients (78.8%) with gestational and pregestational table 3 two-hour postprandial glucose level among gestational and pregestational diabete women and macrosomia state in newborn in delivery room of dr. soetomo general hospital, surabaya from january 2016 to december 2017. 2-hour postprandial glucose level state in newborn p-value*non-macrosomia macrosomia n (%) n (%) controlled 7(100%) 1.000 uncontrolled 24 (92.3%) 2 (7.7%) total 31 (93.9%) 2 (6.1%) *note: fisher’s exact test table 4 glucose level at birth among gestational and pregestational diabetes women and macrosomia state in newborn in delivery room of dr. soetomo general hospital, surabaya from january 2016 to december 2017 glucose level at birth state in newborn p-value*non-macrosomia macrosomia n (%) n (%) controlled 15 (93.8%) 1 (6.3%) 1.000 uncontrolled 16 (94.1%) 1 (5.9%) total 31 (93.9%) 2 (6.1%) *note: fisher’s exact test table 5 diabetes state among pregnant women with newborn macrosomia in delivery room of dr. soetomo general hospital, surabaya from january 2016 to december 2017 non-macrosomia macrosomia p-value n (%) n (%) gestational 22(70.97) 2(6.45) 1.000 pregestational 9(29) total 31(93.9%) 2(6.1%) *note: fisher’s exact test althea medical journal. 2018;5(4) 178 amj december 2018 diabetes underwent caesarean section, as delivery need to be well planeed.8 again, no significant association can be erected between fasting and postprandial glycemia with increased caesarean rates as shown in other study among urban women in sri lanka.9 the prevalence of newborn macrosomia among women with uncontrolled glucose level is 6.1%, similar to other study, yet there no association between glucose control in pregnancy.10 in contrast to a general thought of a significant association between glucose control and macrosomia newborn.11 moreover, study showed that pregestational diabetic mellitus patients is significantly associated to small birth weight and appropriate birthweight newborn.12 the limited number of pregestational and gestational women over two year period is an obstacle in this study. therefore, further research on larger population is needed. in addition, this research has analysed fasting plasma glucose level and 2-hour postprandial glucose level within two weeks of birth as well as glucose at the time of birth to identify uncontrolled and controlled glucose level. however, this data does not represent glucose control for the whole duration of pregnancy. a better glicemic state such as hba1c may serve as a good indicator for this study. in conclusion, no association between fasting plasma glucose, 2-hour postprandial glucose and glucose at the time of birth of lean gestational and pregestational diabetes mellitus patients and macrosomic newborn have been found. references 1. purnamasari d, waspadji s, adam j, rudijanto a, tahapary d. indonesian clinical practice guidelines for diabetes in pregnancy. journal of the asean federation of endocrine societies, 2013;28(1):9–13. 2. cyganek k. risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control. endocrine 2017;55(2):447–55. 3. najafian m, cheraghi m. occurrence of fetal macrosomia rate and its maternal and neonatal complications: a 5-year cohort study. isrn obstet gynecol. 2012;2012:353791. 4. guy mm, yves ii, charles km, didier mn, sandra ym, ngoyaurelie kk, et al. effect of gestational diabetes mellitus on macrosomia infants. int j cur res rev. 2017; 9(4):41–5. 5. american college of obstetricians and gynecologists’ committee on practice bulletins–obstetrics. practice bulletin no 173: fetal macrosomia. obstet gynecol. 2016; 128(5):e195–e209. 6. gopinath b, prasad sm, jayarama n, prabhakara k. study of factors associated with poor glycemic control in type2 diabetic patients. global journal of medicine and public health. 2013;2(2):1– 5. 7. mueller nt, mueller nj, odegaard ao, gross md, koh wp, yuan gm, et al. higher parity is associated with an increased risk of type-ii diabetes in chinese women: the singapore chinese health study. bjog. 2013;120(12):1483–9. 8. nadir s, jamil s, hamid m. the prevalence of macrosomia in newborns and its association with maternal diabetes. j med sci.2015;23(1):3–6. 9. eslamian l, akbari s, marsoosi v, jamal a. effect of different maternal metabolic characteristics on fetal growth in women with gestational diabetes mellitus. iran j reprod med. 2013; 11(4):325–34. 10. bianchi c, de gennaro g, romano m, aragona m, battini l, del prato s, et al. pre-pregnancy obesity, gestational diabetes or gestational weight gain: which is the strongest predictor of pregnancy outcomes? diabetes res clin pract. 2018;144:286–93. 11. ma x, zhang t. the effect of blood glucose control on pregnancy outcomes in pregnant women with gestational diabetes mellitus. int j clin exp med. 2017;10(11):15510–5. 12. kanda e, matsuda y, makido y, matsui h. risk factors associated with altered fetal growth in patients with pregestational diabetes mellitus. j matern fetal neonatal med. 2012; 25(8):1390–4. vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 16 amj march 2018 characteristics of liposarcoma patients: 5-year data miftahur rahmah,1 afiati,2 unwati sugiri3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of dermatovenereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: liposarcoma is the second highest soft tissue sarcoma in adults with prevalence of 15% to 25%. if the size of liposarcoma is very large, it may cause abdominal pain, weight loss, gastrointestinal bleeding, even kidney failure. therefore, for early detection of liposarcoma, the characteristics of liposarcoma should be investigated. this study aimed to determine liposarcoma characteristics based on age, sex, location and histopathologic type according to who (world health organization) classification of tumors 2013. methods: a descriptive study was conducted from august to october 2015 at the department of anatomic pathology, dr. hasan sadikin general hospital, bandung, indonesia. data was obtained from database of patients with liposarcoma at the department of anatomic pathology in the period of january 2010 to december 2014. the collected data was presented in the form of figures and tables. results: out of 102 cases, the percentage of liposarcoma was highest between the age of 50 and 59 years (31.37%), followed by the age of 40–49 years (28.43%). the percentage were slightly higher in males (54.9%) compared to females with a ratio of 1.22:1. femur (23.52%), intraabdomen (22.55%) and retroperitoneum (11.76%) were the most common locations affected. the most common histopathologic subtype was myxoid liposarcoma (52.95%) exceeding a half of the total cases. conclusions: liposarcoma most likely occurs in the age range of 40–60 years, the percentage is slightly higher in males, and abdomen and lower extremities are the most common location affected. myxoid liposarcoma is the most common subtype. keywords: liposarcoma, lower extremities, myxoid liposarcoma correspondence: miftahur rahmah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: amahmiftah95@gmail.com introduction liposarcoma is a malignant tumor that consists of differentiated fat cells and the second highest soft tissue sarcoma in adults.1,2 prevalence of liposarcoma reached 15% to 25% of all sarcomas.3 histologically, the world health organization (who) classifies liposarcoma into five subtypes, namely atypical lipomatous tumor/well differentiated, dedifferentiated, myxoid, pleomorphic and liposarcoma not otherwise specified.4 clinically, liposarcoma is difficult to be diagnosed because it grows slowly and silently with no typical symptoms.1 hence, a pathology examination is very important to diagnose liposarcoma. liposarcoma usually occurs in the retroperitoneum and extremities.1,5–8 retroperitoneal liposarcomas are difficult to treat and have higher rates of local recurrence, moreover it may cause death from uncontrolled local effects.6,9 if the tumor is very large, it may cause abdominal discomfort, abdominal pain, weight loss, gastrointestinal bleeding, even kidney failure.2,10–12 the only effective treatment for retroperitoneal liposarcoma is complete surgical resection.6,9,13–16 data relating to age and sex are helpful for early detection of liposarcoma, meanwhile data about location and histopathological type of liposarcoma is important to predict tumor’s prognosis.1,2,9 unfortunately, there is no data about liposarcoma’s characteristics at dr. hasan sadikin general hospital bandung, indonesia. therefore, the objectives of this study were to identify the characteristics of liposarcoma based on age, sex, location and histopathological findings according to who classifications of tumors 2013. amj. 2018;5(1):16–20 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1329 althea medical journal. 2018;5(1) 17 methods this descriptive study was conducted from august to october 2015 at the department of anatomic pathology, dr. hasan sadikin general hospital, bandung. ethical clearance was approved by the health research ethics committees of the faculty of medicine universitas padjadjaran. the study data were obtained retrospectively by total sampling method from the database of patients with liposarcoma in the department of anatomic pathology, dr. hasan sadikin general hospital during the period of january 2010 to december 2014. the variables collected in this study were patient age, sex, tumor location, and histopathological type of tumor according to who classifications of tumors 2013 (atypical lipomatous tumor, dedifferentiated, myxoid, pleomorphic and liposarcoma not otherwise specified).4 patients with incomplete data were excluded from the study. the collected data were presented in the form of frequency and proportion (percentage). results a total of 102 cases of liposarcoma were collected in this study. the percentage of cases increased from year 2011 to 2014 (figure 1). the percentage of cases was slightly higher on males compared to females with a ratio of 1.22:1. the highest percentage was between the age of 50–59 years, followed by the age of 40–49 years, whereas the youngest patient was 18 years old and the oldest was 78 years old. most of the liposarcoma location was in the abdomen, followed in the lower extremities. liposarcoma found in the abdomen was mostly located in the intra abdomen (23 cases), followed in the retro peritoneal (12 cases), kidney (2 cases), and abdominal wall (one case). moreover, liposarcoma found in the upper extremities, was mostly located in the femur (24 cases), gluteus (7 cases), cruris (2 cases), pedis (2 cases), and popliteal (one case). the neck was the rarest affected location. in this study, the most common histopathological type that occured was myxoid liposarcoma (52.95%), exceeding a half of the total cases (table). discussion liposarcoma is a malignant tumor that consists of differentiated fat cells, and is the second highest soft tissue sarcoma in adults with prevalence reached 15% to 25% of all sarcomas.1–3 in this study, the precentage of liposarcoma increased from 2011 to 2014. according to several literatures, liposarcoma is commonly found between the age of 40 and 60 years with slightly male predominance, although the precentage of retro peritoneal liposarcoma is higher in females.1,2,5,8,17 this is similar with this study which revealed that the highest percentage of liposarcoma are between the age of 50 and 59 years. the percentage of liposarcoma in this study was slightly higher in males than females with a ratio of 1.22:1. however, a study in japan stated that liposarcoma affected both sexes equally.5,17 miftahur rahmah, afiati, unwati sugiri: characteristics of liposarcoma patients: 5-year data figure percentage of liposarcoma cases at dr. hasan sadikin general hospital, bandung, in 2010 – 2014 althea medical journal. 2018;5(1) 18 amj march 2018 liposarcoma usually arises from deepseated, well-vascularized structures, and rarely from submucosal or subcutaneous fat.2,4 abdomen and proximal extremities are the most common locations affected but some studies in south korea, japan and new delhi reported that liposarcoma may also arise in the mesentery and abdominal wall.1,2,7–9,16–18 the percentage of liposarcoma reached 24% of extremity sarcoma and occurred in the lower extremities four times more than in the upper extremities and reached 41% of retroperitoneal sarcoma.2,9 this was similar to this study in which the femur, intraabdomen, and retro peritoneum were the most common locations affected by liposarcoma. the world heatlh organization classifies liposarcoma into atypical lipomatous tumors, dedifferentiated liposarcoma, myxoid liposarcoma, pleomorphic liposarcoma and liposarcoma not otherwise specified.4 this histologic diversity influences biologic behaviour and prognosis of liposarcoma.1,2 atypical lipomatous tumors are classified as intermediate or locally aggressive tumors because they grow slowly and do not metastasize, whereas the other types are malignant.4 the pleomorphic liposarcoma is a high-grade tumor and often metastasize accounting for the decreased rate of survival, whereas myxoid liposarcoma is a low-grade tumor which grows slowly.9,16 dedifferentiated table characteristics of liposarcoma’s patients based on age, sex, location and histopathological findings variable n=102 % sex male 56 54.9% female 46 45.1% age (year) 56.6± 9.7 56.6± 9.7 10–19 1 0.98% 20–29 6 5.88% 30–39 12 11.77% 40–49 29 28.43% 50–59 32 31.37% 60–69 18 17.65% 70–79 4 3.92% location 20 27.8 head 7 6.86% neck 2 1.96% trunk 3 2.94% abdomen 38 37.26% pelvis and perineum 5 4.90% upper extremities 11 10.78% lower extremities 36 35.30% histopathologic feature atypical lipomatoustumors 27 26.47% dedifferentiated liposarcoma 6 5.88% myxoid liposarcoma 54 52.95% pleomorphic liposarcoma 8 7.84% liposarcoma not otherwise specified 7 6.86% althea medical journal. 2018;5(1) 19miftahur rahmah, afiati, unwati sugiri: characteristics of liposarcoma patients: 5-year data liposarcoma contains an abrupt transition between atypical lipomatous tumors and highgrade nonlipogenic sarcoma, histologically. approximately 40% of dedifferentiated liposarcoma will recur locally in 10–20 years after therapy, 17% will metastasize, and 28% of patients will die as a result of this tumor.7,9 according to who classification of tumors 2013, the largest subgroup of liposarcoma which accounts for 40–45% of all liposarcoma is atypical lipomatous tumors whereas, the rarest subtype is pleomorphic liposarcoma which accounts for 5% of all liposarcomas.2,5,16 a study from the memorial sloan-kettering cancer center also stated that the most common subtype of liposarcoma are atypical lipomatous tumors and dedifferentiated liposarcoma.9 on the contrary, myxoid liposarcoma was the most common subtype that occured in this study (52.43%), and was double the atypical lipomatous tumors, whereas the rarest subtype was dedifferentiated liposarcoma which only accounted for 5.82% of all cases. this was similar to a study in new delhi which stated that myxoid liposarcoma is the most common type of liposarcoma, and is found in 50% cases.18 another study in tunisia also stated that myxoid liposarcoma is the second most common type of liposarcoma and represents 20 to 50% of all liposarcomas.2 different study locations may have impacts on the differences of the largest and the rarest subtype in each country. the cause of the high percentage of myxoid liposarcoma at dr. hasan sadikin general hospital, bandung was unknown, and requires a further study. the limitation of this study was that there was some missing data in 2010, so that it could not be recorded and processed. the conclusion of this study is liposarcoma most likely occurs between the ages of 40 and 60 years. the incidence is slightly higher in males, which occurs most commonly in the femur, intraabdomen, and retroperitoneum with myxoid liposarcoma as the most common subtype occurrence references 1. lu j, qin q, zhan l, yang x, xu q, yu j, et al. computed tomography manifestations of histologic subtypes of retroperitoneal liposarcoma.asian pac j cancer prev. 2014;15(15):6041–6. 2. ouni fe, jemni h, trabelsi a, maitig mb, arifa n,rhouma kb, et al. liposarcoma of the extremities: mr imaging features and their correlation with pathologic data. orthop traumatol surg res. 2010;96(8):876–83. 3. goldblum jr, folpe al,weiss sw. enzinger and weiss’s soft tissue tumors. 6th ed. philadelphia: saunders; 2014. p. 443–521. 4. fletcher cdm, bridge ja, hogendoorn pcw, mertens f. who classification of tumours of soft tissue and bone. 4th ed. lyon: iarc; 2013. p. 19–44. 5. tsuruta a, notohara k, park t, itoh t. dedifferentiated liposarcoma of the rectum: a case report. world j gastroenterol. 2012;18(41):5979–81. 6. lu w, lau j, xu md, zhang y, jiang y, tong hx, et al. recurrent abdominal liposarcoma: analysis of 19 cases and prognostic factors. world j gastroenterol. 2013;19(25):4045– 52. 7. cha ej. dedifferentiated liposarcoma of the small bowel mesentery presenting as a submucosal mass. world j gastrointest oncol. 2011;3(7):116–8. 8. takeda k, aimoto t, yoshioka m, nakamura y, yamahatsu k, ishiwata t, et al. dedifferentiated liposarcoma arising from the mesocolon ascendens : report of a case. j.nippon med sch. 2012;79(5):385–90. 9. crago am, singer s. clinical and molecular approaches to well-differentiated and dedifferentiated liposarcoma. curr opin oncol. 2011;23(4):373–8. 10. perez-ponce y, castellanos-alejandre r, guerrero-romero jf, estrada-leon f, torres-lobaton a. retroperitoneal liposarcoma as etiology of abdominal pain. case report and literature review. cir cir. 2008;76(1):77–82. 11. wanchick k, lucha p. dedifferentiated retroperitoneal liposarcoma presenting as lower gastrointestinal bleeding, a case report and review of the literature. mil med. 2009;174(3):328–30. 12. gupta a, pacha o, skaria r, huynh t, truong l, abdellatif a. retroperitoneal sarcoma presenting as acute renal failure, secondary to bilateral renal artery invasion. clin nephrol. 2012;78(2):164–8 13. petronella p, scorzelli m, lannacci g, feretti m, fiore a, freda f, et al. clinical considerations on the retroperitoneal liposarcomas. ann ital chir. 2012;83(1):35– 9. 14. na jc, choi kh, yang sc, han wk. surgical experience with retroperitoneal liposarcoma in a single korean tertiary medical center. korean j urol. 2012;53(5):310–6. 15. milone m, pezzullo ls, salvatore g, althea medical journal. 2018;5(1) 20 amj march 2018 pezzullo mg, leongito m, esposito fmi. management of high-grade retroperitoneal liposarcomas: personal experience. updates surg. 2011;63(2):119–24. 16. lee sy, goh bkp, teo mcc, chew mh, chow pkh, wong wk, et al. retroperitoneal liposarcomas: the experience of a tertiary asian center. world j surg oncol. 2011;9(1):1–6. 17. kumar v, abbas ak, fausto n, aster jc. robbin and cotran pathologic basis of disease. 8th ed. philadelphia: saunders; 2010. p. 1248–50. 18. jain sk, mitra a, kaza rc, malagi s. primary mesentericliposarcoma: an unusual presentation of a rare condition. j gastrointestoncol. 2012;3(2):147–50. althea medical journal. 2017;4(2) 238 amj june 2017 impact of training on improving proper handwashing practices among elementary school students theruna huthamaputiran,1 sunarjati sudigdoadi,2 andriana purnama3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: hand washing is among the most effective ways to prevent diseases. in indonesia, only a quarter of the entire population practice proper handwashing techniques. of these, children are the most vulnerable group for contracting diseases. nevertheless, they also are crucial agent for behavior transformation as they are keen and open to new ideas. therefore, this study was conducted to determine if training would have an improvement on a proper hand washing practices among elementary school students. methods:an observational descriptive study design using random sampling was conducted from september to november 2013 in jatinangor subdistrict, west java, indonesia using primary data of one hundred elementary school students from four elementary schools. questionnaires were given after informed consent. a demonstration on hand washing techniques and education on proper hand washing practices was then given. two weeks later, the same questionnaire was given to measure the influence of the training. the collected data were presented using frequency tabulation. results: before the training on proper hand washing practices was conducted, only 86.9% students were practicing it properly. after the training was given, 90.7% of the students were doing it properly. for the hand washing technique, only 66.8% of students knew the correct steps before the intervention was given and 78.7% students did them correctly after the intervention. conclusions:the training shows an overall improvement on the students’ hand washing practices. keywords: elementary school students, hand washing, jatinangor, technique, training correspondence: theruna huthamaputiran, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6283816260482 email: halcyondays_24@yahoo.com introduction our hands are the part of our body that serve as the port of entry for microbes. it is essential to practice proper hand washing as it is the initial defense of various hand borne transmissible diseases.1 worldwide diarrheal diseases were significant contributors of child mortality under 5 years of age. in indonesia2, diarrhea is responsible for 25–31% deaths of children. only 23.2% of the entire populations have correct hand washing habits which is usually only done before having meals and after defecating.2 various studies indicate that hand washing with soap is among the most effective and inexpensive ways to prevent diarrheal diseases.3,4 current evidence shows the usage of soap decreases the incidence of diarrhea by 53%.5 shockingly, even developing countries display low incidence of hand washing with soap ranging only from 0 to 20%.6 the main organism causing diarrhea among children is escherichia coli.7 it can be transmitted from infected feces to people through water and food, person-to-person contact, or direct contact.8 intervention on hand hygiene and proper hand washing technique shows tendency to improve hand washing habits and practices.9 therefore, inspiring school students to develop proper hand washing behavior will lead them to maintain this behavior into adulthood, and this will contribute in fulfilling the fourth millennium development goal which is to reduce child mortality.1 the aim of this study was to evaluate the implementation of hand washing among amj. 2017;4(2):238–41 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1073 239 althea medical journal. 2017;4(2) elementary school students after training. methods a descriptive study was conducted from september–november 2013 in four elementary schools (cileles, cikeruh i, sayang, and cipacing i) in jatinangor, west java, indonesia. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. a total of 124 sixth grade students were selected randomly from a total of 1,438 students. selected students were given informed consent form to be approved by their parents or guardians. selection criteria were based on the students’ willingness to participate in this study. students who were absent on the day the data were taken and those who did not complete the questionnaire appropriately were excluded from the study. a total of 100 students fulfilled the criteria with a response rate of 80.6%. they were given their first questionnaire the next day. it consisted of three sections, the first was about their identity (name, gender and age) and the second section was about their hand washing practice consisting of ten questions. in the third section, the students were required to match randomized pictures to their appropriate techniques of hand washing. after collecting these initial questionnaires, the proper hand washing steps were demonstrated and they were taught the proper hand washing practices. after two weeks, the same questionnaire was given to these students. the collected data were then classified into pre-intervention and post-intervention data based on questionnaire 1 and 2 respectively. the frequencies of correct and wrong answers were then calculated to see if the training had any influence on them. results most of the questions had a positive response except on the questions regarding the usage of towels or tissues to dry hands, washing hands before meals, and the hand washing practices after cleaning or disposing trash (table 1). in terms of hand washing practices, there were increases of correctness in most of the steps, except the step number 2 (table 2). discussion this study discovered that before the training of a proper hand washing practices were performed, lesser students used to practice proper hand washing practices, but after the training, the number of students washing their hands after certain scenario increased. table 1 hand washing practice before and after training question before after yes no yes no do you always wash your hands with tap water? 94 6 100 0 do you always use soap to wash your hands? 87 13 97 3 do you always use tissues or towels to dry your hand? 91 9 91 9 do you always wash your hands after using the toilet? 94 6 96 4 do you always wash your hands before meals? 93 7 93 7 do you always wash your hands after meals? 98 2 100 0 do you always wash your hands after sneezing or coughing? 57 43 66 34 do you always wash your hands after cleaning or disposing trash? 91 9 89 11 do you always wash your hands when you fall down? 75 25 84 16 do you always wash your hands after touching or playing with animals? 89 11 91 9 theruna huthamaputiran, sunarjati sudigdoadi, andriana purnama: impact of training on improving proper handwashing practices among elementary school students althea medical journal. 2017;4(2) 240 amj june 2017 however, there were still a few questions that show no improvement or even became worse after the intervention. it showed that question 2 had the most difference while question 3 and 5 had no changes. also note that question 8 had negative difference after the intervention was given. when asked further about question 3, in which the respondents were asked if they use hand towels or tissues to dry their hands after washing their hands, they replied that they do not always have access to hand towels or tissues after washing their hands, so they will wipe their hands on their clothes or not wipe at all. this will later on develop into a habit, and further into a social norm. question 5 which asked the respondents if they wash their hands before meals, showed that they were reluctant and avoided to answer the questions asked to them. then it can be seen that there is lack of influence and supportive role of their parents or families to exercise the proper habits and etiquettes of hand washing. a similar study conducted by peananukulbut10 in 2012 on the elementary school students of selat sub district showed that students not washing hands before meals are the third highest. question 8 exhibited a negative outcome. it is because there is a reduction of 2 students washing their hands after taking out the thrash. number of students answering correctly increased after the intervention was given compared to previous number of students. question 3 showed the highest improvement. however, question 2 showed a negative improvement. the increase in step 3 suggested that the intervention had made them aware of why it is important to lather their hands before proceeding to other steps. in addition, another reason why students skip or do not practice a few steps correctly was also found while demonstrating the proper hand washing techniques to the students, which was because they felt hand washing habits should not take a lot of time. when observed, they tended to not wash their hands with soap and just proceed to rub their palms and the back of their hands like step 4. despite that, step 2 showed a decrease of 2 students failing to match the correct steps with their appropriate description. step 10 received the least increase. this can be considered normal because previously, even without the intervention, 92 students already managed to get the correct answer compared to 94 after intervention. this small increase of students using the disposable towels or tissues to wipe their hands after washing hands can be attributed to the lecture given by the lecturer as to why drying hands is important after washing hands. this fact is bolstered by the fact that most visited schools do not have a tissue box or a towel dispenser in their toilets. it was then inferred that the students may be simply hindered by the lack of facilities that the schools offer. limitations of this study included the dishonesty of the student in answering the questionnaires which result in a few invalid results. this can be attributed to the lack of supervision when conducting this study. therefore, the study on the subsequent schools was repeated with supervision of table 2 proper hand washing technique hand washing steps before after correct wrong correct wrong 1 78 21 94 6 2 100 0 97 3 3 45 55 78 22 4 49 51 74 26 5 40 60 57 43 6 38 62 61 39 7 79 21 89 11 8 68 32 57 43 9 79 21 86 14 10 92 8 94 6 241 althea medical journal. 2017;4(2) theruna huthamaputiran, sunarjati sudigdoadi, andriana purnama: impact of training on improving proper handwashing practices among elementary school students their teachers. further limitations included the lack of given concentration during demonstration and education. some of the students were not paying attention during the demonstration, thus, when they were asked to fill in the questionnaire after the intervention was given, a few of them tended to copy their classmate’s answers and not answering their questionnaires honestly. furthermore, it is also worth stating that the results of this questionnaire should be higher than that of what is actually practiced by the students in reality. most of the students claimed that they can properly execute the hand washing steps, but when asked to demonstrate personally, they tended to make mistakes. other factors included subject recall bias. it was also noted that when the students were asked why they do not washing their hands after throwing rubbish, they tended to forget to wash their hands. this is also coherent with the results outlines in this previous study.10 based on the results of the study, most students showed improvement after the intervention was given. therefore, it can be concluded that the education on proper hand washing practice and training on proper hand washing techniques had a positive impact on the students. as a recommendation for future studies, the study should be conducted in small groups of 5 students instead of 25 for each school where the students will be asked to perform hand washing steps individually to know if they really understand the proper techniques. teachers should aid the researcher and be more attentive in controlling the classroom to maintain discipline to avoid dishonest answers and students copying each other. more awareness posters, stickers, and materials to improve knowledge and awareness of hand washing should be available in schools to increase awareness among their students. teachers and the school curriculum should integrate personal hygiene as a core value to instill these traits in their students and create generation of young students that are aware of the importance of hand washing. from this study, it can be concluded that there is a modest positive impact on the students’ hand washing practices and techniques after the intervention was given. references 1. world alliance for patient safety. whoguidelines on hand hygiene in health care: advanced draft. geneva: who press.2006. 2. unicef indonesia. ringkasan kajian: air bersih, sanitasi & kebersihan. jakarta: unicef; 2012 [cited 2013 november 12]. available from: www.unicef.or.id 3. fewtrell l, kaufmann rb, kay d, enanoria w, haller l, colford jm. water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta–analysis. lancet infect dis. 2005;5(1):42–52. 4. curtis v, cairncross s. effect of washing hands with soap on diarrhoea risk in the community: a systematic review. lancet infect dis. 2003;3(5):275–81. 5. luby sp, agboatwalla m, feikin dr, painter j, billhimer w, altaf a, et al. effect of handwashing on child health: a randomised controlled trial. lancet. 2005;366(9481):225–33. 6. scott b, curtis v, rabie t, garbrah– aidoo n. health in our hands, but not in our heads: understanding hygiene motivation in ghana. health policy plann. 2007;22(4):225–33. 7. greene le, freeman mc, akoko d, saboori s, moe c, rheingans r. impact of a school– based hygiene promotion and sanitation intervention on pupil hand contamination in western kenya: a cluster randomized trial.am j trop med hyg. 2012;87(3):385– 93 8. ejemot–nwadiaro ri, ehimi je, meremikwu mm, critchley ja. hand washing for preventing diarrhoea. cochrane database of syst rev. 2008;1:cd004265 9. apriany d. perbedaan perilaku mencuci tangan sebelum dan sesudah diberikan pendidikan kesehatan pada anak usia 4–5 tahun. jurnal keperawatan soedirman. 2012;7(2):60−6. 10. setyautami t, sermsri s, chompikul j. proper hand washing practices among elementary school students in selat sub– district, indonesia. j pub health dev. 2012;10(2):3–20. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 1 peer pressure and smoking behavior in elementary school students sinthura vimalan subramaniam,1 arifah nur istiqomah,2 eddy fadlyana3 1faculty of medicine universitas padjadjaran, 2department of psychiatry faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background:adolescence is an important period in which many individuals are vulnerable to onset and progression of smoking. peers are strongly associated with adolescent smoking initiation. this study is conducted to determine whether there is a relationship between peer pressure and smoking behavior in male elementary school students. methods: a cross-sectional study was conducted in october 2014. respondents were male students from grade four and five from state elementary schools (sdn) in jatinangor district who voluntarily followed the research procedure. the sampling method used in this study was two-stage cluster sampling. a validated questionnaire was provided after getting informed consent from the respondents. the data analysis was performed using chi-square test. results: as much as 110 male subjects were included in the study. data showed that 57 students (51.8%) which were more than half of the number of students ever smoked and 53 students never smoked. out of 110 students, 69 students (62.7 %) experienced peer pressure and 41 students (37.3%) never experienced peer pressure. the result of chi-square test from the study showed that the p-value is 0.000. conclusions: there is a relationship between peer pressure and smoking behavior in male elementary school students in jatinangor district. [amj.2017;4(1):1–5] keywords: male elementary school students, peer pressure, smoking behavior correspondence: sinthura vimalan subramaniam, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822281194 email: sinthuravimalan@gmail.com introduction cigarette smoking still remains as the most vital preventable cause of death.1 according to the world health organization (who), indonesia is the third largest country in the world in addition to china and india for number of smokers which reached about 146,860,000 people.2 commonly, people start smoking during adolescence and early age of smoking initiation is associated with more severe outcome later in life.3 in indonesia the age of start smoking is getting younger day by day.2 peers and family are identified as important factors for initiation of tobacco use as well as for its continuation and progressive use later on.4 based on a survey which studies both peer and parents factors, peers have a greater influence than parents on adolescent smoking.5 a study conducted in nigeria6 on tobacco use in school students has discovered that the use of tobacco among youth is greatly influenced by peer pressure.6 in indonesia the age of start smoking is getting younger and prevalence of smoking among children reached the alarming rate.2 out of 70 million children in indonesia, 25.9 million (37%) of children smoke tobacco.2 previous data from a national study in indonesia shows that the smoking behavior is dominant in male compared to female in adolescent more than ten years old.2 the objectives of this study was to analyze the relationship between peer pressure and smoking behavior in male elementary school students. althea medical journal. 2017;4(1) 2 amj march 2017 methods a cross-sectional study was conducted in october 2014 in elementary schools in jatinangor district. data was collected from grade four and five male students from several elementary schools in jatinangor district. the study was conducted after getting clearance from the ethical committee. a validated and reliable questionnaire was provided to students after getting permission from the head of the schools. the sampling method used in this study was the two-stage cluster sampling. in the first stage, three elementary schools were randomly selected which were sdn neglasari, sdn sayang and sdn cibeusi. in the second stage, a number of grade four and five students of those three particulars schools were selected according to the simple stratified random sampling. a total of 122 respondents were given questionnaires with their consent. the subjects of the study were included if they were male students from grade four and five and voluntarily followed the study procedure. the subjects were excluded from the study if they incompletely and incorrectly filled in the questionnaire. students were told to answer all the questions provided in the questionnaire. in order to make sure that the students answered the questions correctly, they were told to always ask to clear their doubt regarding the items in the questionnaire. this could make them understand and fill in the questionnaire correctly. the main purpose of giving a questionnaire was to access students’ smoking behavior and to determine whether they experienced peer pressure in their daily life. the questionnaire was created in such a way that it was easily understood by students. the questionnaire was constructed based on modification of a questionnaire from a similar previous study and students were required to choose the best answer from the options provided. first, before conducting the study the student’s grade was identified. informed consent was given to the students regarding the objective of the study and their willingness to participate in the study, then students have to fill in the questionnaire on their own. peer pressure was evaluated based on the influence exerted by a peer group or an individual encouraging other individuals to smoke. there were six questions in the questionnaire to access both direct and indirect peer pressure and students have to answer ‘yes’ or ‘no’ to the questions provided. for direct peer pressure three questions were provided such as “whether any of their peers offer cigarette to them”, “whether their peers ask to smoke with them” and “whether their peers force them to smoke”. for accessing indirect peer pressure, three questions also asked such as “whether he feels being avoided by his peers if he does not smoke”, “whether he feels the need to show-off to his peers that he smokes” and “whether he finds his peers ‘cool’ if they smoke”. students were considered to have experienced peer pressure if they answered ‘yes’ to any of these six questions provided in the questionnaire. they were considered to have never experienced peer pressure if they answered ‘no’ to all the six questions. in order to access smoking behavior of the students, one question was asked to which students had to answer ‘yes’ or ‘no’.. students were considered ever smoked if they answered ‘yes’ and considered never smoked if they answered ‘no’ to this question. the questionnaire was initially given to 122 students from three schools previously selected for this study who met the inclusion criteria. from the previously selected 122 students, only 110 students were included in the study. twelve students were excluded because they incompletely and incorrectly filled in the questionnaire. furthermore, the univariate and bivariate analysis were included to analyze data in this study. univariate analysis was used to describe the characteristics of students, number of students who experienced and never experienced peer pressure, and smoking behavior of students whether they ever or never smoked. univariate data was presented in the form of frequency distribution tables. moreover, bivariate analysis was used to examine whether there was a relationship between peer pressure and smoking behavior in male elementary school students. the chisquare test was performed using computer and a statistically significant result was considered when p<0.05. results more than half of the number of students were from grade five (53.6%). the majority of students who participated in this study were with age of 11 (47.3 %) and followed by age of ten (table 1). out of 110 students who were included in this study, 57 students (51.8%) ever smoked. this study also showed that 69 students (62.7 %) from the total of students experienced peer pressure (table 2). data showed that 76 students (69.09%) althea medical journal. 2017;4(1) 3 from the total of students had smoking peer and the remaining 30.91% of them did not have smoking peer. most students experienced direct peer pressure in the form of cigarettes offered by peer (44.55 %), followed by students who were asked by peer to smoke with them (43.64 %). indirect peer pressure in the form of the need to ‘show-off ’ to peer that they smoked was reported as the least form of peer pressure experienced by students with only 11 students (table 3). the majority of students who experienced peer pressure reported as ever smoked (81.2%). out of 41 students who never experienced peer pressure, 40 students (97.6 %) never smoked (table 4). chi-square test was performed to find whether there was a relationship between peer pressure and smoking behavior. the result of the test showed that the p value was 0.000. discussion a total of 57 students (51.8 %) which was more than half of the number of students reported as ever smoked. based on 69 students who experienced peer pressure, 56 of them (81.2%) ever smoked. forty students (97.6%) out of 41 students who never experienced peer pressure reported as never smoked. the percentage of ever smoking students in male elementary school students in jatinangor district was high if compared with a study conducted by huang et al.7 in southern taiwan. the study conducted by huang et al.7 shows that the percentage of ever smokers in elementary school students is 13.7% in which 9.23% of them are male and 4.47% are female. from the total of 1,213 male students who participated in the study, 217 students (17.9%) are ever smokers and 996 students (82.1%) are never smokers. based on this study it can be concluded that there is a relationship between peer pressure and smoking behavior in adolescent. a study by san san et al.8 on risky behavior and associated factors among medical students and community youth in myanmar shows the rate of smoking in community youth in myanmar is 28.8%. the study by san san et al.8 shows that the presence of friends who are smokers as well sinthura vimalan subramaniam, arifah nur istiqomah, eddy fadlyana: peer pressure and smoking behavior in elementary school students table 1 characteristics of students characteristics of respondents frequency (n=110) percentage % grade 4 51 46.4 5 59 53.6 age 9 3 2.7 10 48 43.6 11 52 47.3 12 7 6.4 table 2 frequency and percentage of smoking behavior of students and students who experienced and never experienced peer pressure variables frequency (n=110) percentage (%) smoking behavior ever smoked 57 51.8 never smoked 53 48.2 peer pressure experienced 69 62.7 never experienced 41 37.3 althea medical journal. 2017;4(1) 4 amj march 2017 as peer pressure are significant contributor factors for smoking. this is a cross-sectional study which includes respondents aged 15 to 24 years. a self-administered questionnaire is used as the method for data collection in this study. another study by jeganthan et al.9 on smoking stage relation to peer, school and parental factor in secondary school students in malaysia shows that 19.3% are susceptible never smokers, 5.5% are current smokers, 6% are experimenters and 3.1% are exsmokers. this study also indicates that high peer pressure to smoke and having a best friend as smoker increases the odd of being a susceptible never smoker and ever smoker. high peer pressure to smoke proves to have the strongest effect on current smokers in this study. this study uses the longitudinal design in which data was collected by use of a validated questionnaire as the tool to collect data. subjects are selected from students aged 12 to 13 in secondary schools. a study on factors related to tobacco use among students in middle schools in china by qing et al.10 shows that the prevalence of ever smoking is 19.7 % in which 25.3% of them are male and 13.4% of them are female. this study also proves that peer pressure is one of the factors that have significant relationship with smoking behavior. this study includes 3.231 student aged 12 to17 and subjects are randomly selected through a three-stage stratified cluster sampling in this study. both the validated questionnaire and interview are used as the method for data collection in this study. another cross-sectional study on peer pressure and tobacco smoking among undergraduate students conducted by ukwayi et al.11 shows 55.8% of respondents use tobacco daily, 20.8 % occasionally use tobacco, 11.7 % use once a week and 10.8% use tobacco 3 to 4 times in a week. this study shows that 46% of cigarette use among undergraduate students is caused by peer pressure. subjects for this study are selected by purposive sampling. hundred and twenty table 4 cross-tabulation of peer pressure and smoking behavior variable alternative answer smoking behavior total p-valueever smoked never smoked f % f % f % peer pressure experienced 56 81.2 13 18.8 69 100.0 0.000 never experienced 1 2.4 40 97.6 41 100.0 total 57 51.8 53 48.2 110 100.0 table 3 indicators of peer pressure indicators of peer pressure yes no total frequency % frequency % frequency % smoking peer 76 69.09 34 30.91 110 100.0 peers offer cigarette 49 44.55 61 55.45 110 100.0 peers ask to smoke with them 48 43.64 62 56.36 110 100.0 peers force to smoke 34 30.91 76 69.09 110 100.0 feeling of being avoided by peers if don’t smoke 35 31.82 75 68.18 110 100.0 feel the need to show-off to peers that they smoke 11 10.00 99 90.00 110 100.0 feel that their peers are ‘cool’ if they smoke 17 15.45 93 84.55 110 100.0 althea medical journal. 2017;4(1) 5 smoking students comprising of both female and male students who are selected through purposive sampling are included in the study. a validated questionnaire is used as a method for data collection. there are several limitations and recommendations for this study. this study only includes peer factor as one of the factors that influence smoking behavior of adolescents. other factors such as the parental factor and exposure to smoking related advertisement which have great influence on the smoking behavior of adolescents should be included in further studies for future intervention programs. since the frequency of ever smoking students is high in elementary school students therefore intervention programs on prevention of tobacco use should be started at early age which can prevent the initiation of early adolescent smoking behavior. in conclusion, there is a relationship between between peer pressure and smoking behavior in male elementary school students in jatinangor district. references 1. heydari g, yousefifard m, hosseini m, ramezankhani a, masjedi mr. cigarette smoking, knowledge, attitude and prediction of smoking between male students, teachers and clergymen in tehran, iran, 2009. int j prev med. 2009;4(5):557–64. 2. ellizabet al. stop merokok; sekarang atau tidak sama sekali. 1st ed. jogjakarta: garailmu; 2010. 3. adams ml, jason la, pokorny s, hunt y. the relationship between school policies and youth tobacco use. j sch health. 2009;79(1):17–23. 4. u.s. department of health and human services. preventing tobacco use among youth and young adults: a report of the surgeon general. atlanta: centers for disease control and prevention, national center for chronic disease prevention and health promotion office on smoking and health; 2012. 5. simons-morton bg, farhat t. recent findings on peer group influences on adolescent smoking. j prim prev. 2010;31(4):191–208. 6. adebiyi ao, faseru b, sangowawa ao, owoaje et. tobacco use amongst out of school adolescents in a local government area in nigeria. subst abuse treat prev policy. 2010;5:24–8. 7. huang h-l, chen f-l, hsu c-c, yen y-y, chen t, huang c-m, et al. a multilevelbased study of school policy for tobacco control in relation to cigarette smoking among children in elementary schools: gender differences. health educ res. 2010;25(3):451–63. 8. san san h, myo o, yoshida y, sakamoto j. risk behaviours and associated factors among medical students and community youths in myanmar. nagoya j med sci. 2010;72(1–2):71–81. 9. jeganathan pd, hairi nn, al sadat n, chinna k. smoking stage relations to peer, school and parental factors among secondary school students in kinta, perak. asian pac j cancer prev. 2013;14(6):3483–9. 10. qing y, termsirikulchai l, vatanasomboon p, sujirarat d, tanasugarn c, kengganpanich m. factors related to tobacco use among middle school students in china. southeast asian j trop med public health. 2011;42(5):1249–61. 11. 11. ukwayi jk, eja of, unwanede cc. peer pressure and tobacco smoking among undergraduate students of the university of calabar.cross river state. high educ stud. 2012;2(3):92–101. sinthura vimalan subramaniam, arifah nur istiqomah, eddy fadlyana: peer pressure and smoking behavior in elementary school students vol 6 no 2 full text.indd althea medical journal. 2019;6(2) 65 clinical and laboratory manifestation of children with acute lymphoblastic leukemia as an assessment of severity: a study in dr. hasan sadikin general hospital yohana kusuma angkasa,1 nur suryawan,2 delita prihatni3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: yohana kusuma angkasa, faculty of medicine universitas padjadjaran,jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: yohanaksma@gmail.com introduction mutation of lymphoid progenitor cells in the bone marrow which induces excessive and uncontrolled lymphoid cell proliferation causes acute lymphoblastic leukemia (all).1 acute lymphoblastic leukemia is the most common leukemia diagnosed in children with the highest prevalence of rate in children aged 2–5 years old and predominantly in boys.2,3,4 twenty-six percent of all malignancy cases diagnosed in the usa in 2014 is acute lymphoblastic leukemia.3 it is also one of the malignancies with high incidence rate in indonesia, as shown in dr. hasan sadikin general hospital reports where fifty-one new cases of all had been found in 2010–2011, while 76 new cases were found in 2014.5,6 it is known that half of the pediatric patients with malignancy in 2006 had been admitted to dharmais national cancer hospital with advanced stage condition. lack of knowledge about any signs or symptoms of the disease has been the cause of such conditions.7 clinical features presenting in all are various. generally, the first signs and symptoms are often non-specific which caused by anemia, such as irritability, anorexia, weakness, and pallor. fever and infection might occur due to neutropenia, while thrombocytopenia might cause hemorrhages. leukemic cells could infiltrate various organs resulting in other clinical features including hepatomegaly, splenomegaly, lymphadenopathy, and even amj. 2019;6(2):65–70 abstract background: acute lymphoblastic leukemia (all) is a disease caused by a mutation of lymphoid progenitor cells in bone marrow, that induces uncontrolled lymphoid cell proliferation. all is the most common type of leukemia in children. various clinical and laboratory manifestation makes the diagnostic process more complicated. this study aimed to observe the clinical and laboratory manifestation of children with all in dr. hasan sadikin general hospital for diagnostic and assessment. methods: the design of this study was a descriptive cross-sectional with a total sampling method. data of all children under 18 years old with all diagnosed in 2015 to 2017 were included. the diagnosis of all was confirmed by examination of hematology indices, peripheral blood smear, and bone marrow aspiration classified by fab. inaccessible or incomplete medical records were excluded. results: in total, 192 data of all patients were included. most all patients predominantly occurred in boys (59.9%), and the age group of 1–5 years old (40.6%). the clinical manifestations were pallor (89.6%), hepatomegaly (79.7%) and fever (75%). most patients experienced severe anemia with hemoglobin level <7g/dl (44.8%), leukocytosis >20.000 cells/mm3 (46.9%), severe thrombocytopenia with platelet count <20.000 cells/mm3 (51%), and blast cells count >50% (45.3%). based on fab classification, the majority of the patients were classified as all type l2 (65.6%). conclusions: clinical and laboratory manifestation of all patients can be used as a parameter for diagnostic and assessment of severity. earlier diagnosis would result in better prognosis and more precise treatment for all patients. keywords: acute lymphoblastic leukemia, all, severity althea medical journal. 2019;6(2) 66 amj june 2019 nerve involvement.4 diagnosis and classification all can be determined based on clinical and laboratory examination. data supporting diagnosis can be obtained from peripheral blood smear examination or bone marrow aspiration.8 early signs of all can be observed as abnormal blood examination, which is anemia, thrombocytopenia, and leukocytosis. blast cells commonly found in the peripheral blood smear. bone marrow aspiration acts as the gold standard in diagnosing all. when bone marrow aspiration result shows more than 5% of blast cells count, we can presume the patient as having leukemia; while for all definite diagnosis, more than 20% on blast cells count is needed. differentiation of all and aml will be determined by cell morphology obtained from bone marrow aspiration classified based on french american british (fab) classification. this classification depends on cell size, chromatin, nucleoli, and cytoplasm.4 classification based on the world health organization (who) can be done if the sample is examined using molecular method and then flow cytometri.9 dr. hasan sadikin general hospital’s procedure for diagnosing all consists of anamnesis, physical and laboratory examination such as hematology indices, peripheral blood smear, and bone marrow examination.5 data on clinical and laboratory manifestation of all in children in dr. hasan sadikin general hospital bandung is still unknown. aim of this study was to give more information on clinical and laboratory manifestation of all in children in dr. hasan sadikin general hospital bandung. this information could help in detecting and diagnosing all leading to more precise treatment and better prognosis. methods the design of this study was a descriptive cross-sectional study. data were obtained from inpatient medical record unit dr. hasan sadikin general hospital bandung during 2015–2017. subjects were all medical records of children who had been diagnosed with all for the first time in dr. hasan sadikin general hospital and confirmed with hematology examination, peripheral blood smear, and bone marrow aspiration, with total sampling method. exclusion criteria were inaccessible or incomplete medical records. clinical manifestations data was collected, including pallor, fever, hemorrhage, seizure, infiltrative presentation (hepatomegaly, splenomegaly measured by schuffner line which depends on enlargement of spleen measured from left costal margin to right anterior superior iliac spine, and lymphadenopathy); as well as and laboratory data, including hematological examination (hemoglobin, leukocyte, thrombocyte), peripheral blood smear for blast cell counting, and bone marrow aspiration to classify all based on fab classification, depending on morphological including cell size, chromatin, nucleoli, and cytoplasm.4 data were obtained from the medical record after ethical clearance was granted, issued by the research ethics committee of universitas padjajaran bandung (no. 219/ un6.kep/ec/2018) and research licensing letter issued by the research ethics commitee of dr. hasan sadikin general hospital bandung (no. lb.02.01/x.2.2.1/9373/2018.) data were presented in tables. table 1 characteristics of acute lymphoblastic leukemia patients total n % gender boy 115 59.9 girl 77 40.1 age < 1 year old 7 8.9 > 1–5 years old 78 40.6 > 5–10 years old 56 29.2 > 10–18 years old 41 21.4 althea medical journal. 2019;6(2) 67yohana kusuma angkasa et al.: clinical and laboratory manifestation of children with acute lymphoblastic leukemia as an assessment of severity: study in dr. hasan sadikin general hospital results there were 192 subjects from 284 medical records complying inclusion criteria. most of the excluded medical records were due to inaccessibility or insufficiency data. as shown in table 1, the highest incidence rate occurred in boys (155 patients, 59.9%) and children with age category of >1–5 years old (78 patients, 40.6%). the clinical features of all were shown in table 2. pallor was the most common presenting complaint (n172;89.6%), followed by fever (n144; 75%). as for clinical findings, hepatomegaly was mostly found (n 153; 79.7%), classified into less than 5 cm enlargement group (n117;60.9%), while hemorrhage was mostly seen as skin manifestations (n63;32.8%). lymph node enlargement was found (n131; 68.2%) with cervical as the most affected area; and schuffner i-ii, as the most common grade of splenomegaly, was detected (n72; 37.5%). severe anemia (hb<7 g/dl) was seen (n86; 44.8%), where asleucocytosis was found (n90; 46.9%). most patients (n98; 51%) table 2 clinical manifestation of acute lymphoblastic leukemia patient clinical features total n % pallor 172 89.6 fever 144 75 hemorrhage gum 44 22.9 epistaxis 27 14.1 skin 63 32.8 gi tract 15 7.8 intracranial 1 0.52 eye 5 2.6 urinary tract 2 1 others 9 4.7 seizure lymphadenopathy cervical 131 68.2 axillary 22 11.5 inguinal 36 18.8 others 3 1.6 hepatomegaly < 5cm 117 60.9 5–10 cm 34 17.7 >10cm 2 1 splenomegaly schuffner i-ii 72 37.5 schuffner iii-iv 49 25.5 schuffner v-vi 2 1 schuffner vii-viii althea medical journal. 2019;6(2) 68 amj june 2019 were classified into severe thrombocytopenia group. blast cell count >50% acquired from peripheral blood smear examination was also found (n 87; 45.3%) as shown in table 3. furthermore, there were 33 samples of 192 all patients whose bone marrow aspiration (bma) classification based on fab was not listed in the medical records. for further classification, 2 patients were classified as bilineage leukemia, 2 as early phase leukemia, and 3 others as preleukemia. the most common type of all based on fab classification was l2 (n 126; 65.6%), whereas l1 and l3 were found in 21 (10.9%) and 5 (2.6%) patients, respectively. discussions our study has shown that acute lymphoblastic leukemia (all) has been predominantly occurred in boys and children aged >1– 5 years old, consistent with several previous studies in some parts of the world as reported from the usa and southern china.10,11 acute lymphoblastic leukemia patients have various clinical features. infiltration of blast cells to bone marrow would suppress normal cell proliferation which caused varied presentations in each patient. the earliest manifestations are caused by anemia resulting in pallor and weakness, thrombocytopenia resulting in bleeding, and neutropenia resulting in fever.4 pallor, hepatomegaly, and fever are found to be the most common presenting clinical manifestation of all. this is consistent with findings from previous studies that fever, pallor, and hepatosplenomegaly are the main presenting complaints of all.12,13 in addition to their infiltration to bone table 3 laboratory features of acute lymphoblastic leukemia patients laboratory features total n % hematology hemoglobin (g/dl) < 7 86 44.8 7–9.9 73 38 10–10.9 16 8.3 ≥11 17 8.9 leukocyte(cells/mm3) <10,000 76 39.6 10,000–20,000 26 13.5 >20,000 90 46.9 thrombocyte (cells/mm3) <20,000 98 51 20,000-50,000 58 30.2 >50,000-100,000 21 10.9 >100,000-150,000 8 4.2 >150,000 7 3.6 blast cell count <20% 50 26 20–50% 55 28.6 >50% 87 45.3 bone marrow aspirations l1 21 10.9 l2 126 65.6 l3 5 2.6 althea medical journal. 2019;6(2) 69 marrow, leukemic cells also infiltrate other organs. spleen, liver, and lymph nodes are the most common infiltrated organs.4 as seen in this study where hepatomegaly, splenomegaly, and lymphadenopathy are commonly presented in all patients. similarly, reported in iran, where main extramedullary symptoms are splenomegaly, followed by hepatomegaly and lymphadenopathy.14 blood examinations in all patients will commonly show anemia, thrombocytopenia, and leukocytosis. these abnormalities are due to uncontrolled and excessive lymphoid cell proliferation and blast cells infiltrations to bone marrow which caused suppression of normal cell proliferation.4 as shown in this study, most of the patients have severe anemia (<7g/dl). these findings are similar to other reports where a large proportion of all patients are classified for having severe anemia.12,15 leukocytosis is commonly presented in all patients. similarly to the findings in iran and brazil, where most patients have leukocytosis.14,16 the majority of the patients have severe thrombocytopenia or decreased platelet count.17 similarly founded in brazil where the majority of their all patients have thrombocytopenia.15 the differentiation process of lymphoid cells is blocked in all patients, while their production and proliferation are uncontrolled, which result in blast cells findings in peripheral blood smear and bone marrow. all can be presumed with blast cells count results >5%, however for definite diagnosis of all, 20% blast cells or more is needed.4 based on the result from peripheral blood smear, a large proportion of all patients have >50% of blast cells. this result was in sync with another study in indonesia which reported that in almost all cases, peripheral blood smear would present higher blast cells count.17 based on this study, the majority of the patients classified as l2 type. similarly found in eastern iraq and india, where the most dominant type was l2, followed by l1 and l3.12,18 the limitation of this study was inaccessible medical record data or incomplete data which caused data to be excluded, resulting in a lower sample population. to conclude, acute lymphoblastic leukemia(all) cases predominantly occur in boys and children between 1-5 years old. pallor, hepatomegaly, and fever are the main presenting clinical features, while the most common laboratory features found in children with all are severe anemia, leukocytosis, and severe thrombocytopenia, with blast cells count >50%. all l2 is the most common type of all based on fab classification. by understanding clinical and laboratory manifestation of all, this will help in the diagnosis and assessment of severity which, and thus better prognosis and more precise treatment. references 1. terwilliger t, abdul-hay m. acute lymphoblastic leukemia: a comprehensive review and 2017 update. blood cancer j. 2017;7(6):e577. 2. starý j, hrušák o. recent advances in the management of pediatric acute lymphoblastic leukemia. f1000res. 2016;5:2635. 3. ward e, desantis c, robbins a, kohler b, jemal a. childhood and adolescent cancer statistics. ca cancer j clin. 2014;64(2):83– 103. 4. roganovic j. acute lymphoblastic leukemia in children. in: guenova m, editor. leukemia. london: intech open; 2013. p. 39–74. 5. suryawan n, idjradinata p, reniarti l. hubungan subtipe sel limfosit dengan tingkat remisi pascakemoterapi fase induksi leukemia limfoblastik akut. sari. pediatri. 2017;18(6):448–52. 6. inten y, reniarti l, chairulfatah a. hubungan kadar procalcitonin dengan demam neutropenia pada leukemia limfoblastik akut anak. sari pediatri. 2015;17(38):267–72. 7. tehuteru es. mewaspadai gejala kanker pada anak. buletin jendela data & informasi kesehatan. 2015;semester 1:25–9. 8. tanzilia mf, cahyadi a, hernaningsih y, retnowati e, ugrasena idg. cd4+ t-cell, cd8+ t-cell, cd4+/cd8+ ratio, and apoptosis as a response to induction phase chemotherapy in pediatric acute lymphoblastic leukemia. paediatr indones. 2017;57(3):138–43. 9. abdul-hamid g. classification of acute leukemia. in: antica m, editor. acute leukemia: the scientist’s perspective and challenge. london: intech open. 2011p. 10. barrington-trimis jl, cockburn m, metayer c, gauderman wj, wiemels j, mckeancowdin r. trends in childhood leukemia incidence over two decades from 19922013. int j cancer. 2017;140(5):1000–8. 11. li sy, ye jy, meng fy, li cf, yang mo. clinical characteristics of acute lymphoblastic yohana kusuma angkasa et al.: clinical and laboratory manifestation of children with acute lymphoblastic leukemia as an assessment of severity: study in dr. hasan sadikin general hospital althea medical journal. 2019;6(2) 70 amj june 2019 leukemia in male and female patients: a retrospective analysis of 705 patients. oncol lett. 2015;10(1):453–8. 12. shalal hh, mahmood ns, alchalabi maq. clinical, hematological, and laboratory presentation of acute lymphoblastic leukemia of children in diyala province/ eastern iraq. int j res med sci. 2017;5(10):4227–33. 13. omari as al, hussein ta, albarrak ka, habib ak, sambas aa, sheblaq n, et al. clinical characteristics and outcomes of acute lymphoblastic leukaemia in children treated at a single tertiary hospital in riyadh , saudi arabia. journal of health specialties. 2018;6(1):14–8. 14. pahloosye a, hashemi as, mirmohammadi sj, atefi a. presenting clinical and laboratory data of childhood acute lymphoblastic leukemia. iran j ped hematol oncol. 2011;1(3):71–7. 15. lustosa de sousa dw, de almeida ferreira fv, cavalcante félix fh, de oliveira lopes mv. acute lymphoblastic leukemia in children and adolescents: prognostic factors and analysis of survival. rev bras hematol hemoter . 2015;37(4):223–9. 16. ibagy a, silva db, seiben j, winneshoffer ap, costa te, dacoregio js, et al. acute lymphoblastic leukemia in infants: 20 years of experience. j pediatr (rio j). 2013;89(1):64–9. 17. rahadiyanto ky, liana p, indriani b. pola gambaran darah tepi pada penderita leukimia di laboratorium klinik rsup dr. mohammad hoesin palembang. mks. 2014;46(4):259–65. 18. singh g, parmar p, kataria sp, singh s, sen r. spectrum of acute and chronic leukemia at a tertiary care hospital , harayana, india. int j res med sci. 2016;4(4):1115–8. vol 6 no 4 full text final.indd althea medical journal. 2019;6(4) 159 the pattern of iodine food source intake in early adolescents in junior high school in jatinangor siti nur fatimah,1 che wan nurdamia,2 faisal3 1department of public health faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: siti nur fatimah, department of public health faculty of medicine, universitas padjadjaran, jalan eyckman no. 38 bandung, indonesia, e-mail: st_nurf@yahoo.com amj. 2019;6(4):159–63 abstract background: iodine is one of the essential micronutrients for normal growth, development, and metabolism throughout life. studies about the pattern of iodine food source intake in indonesia are lacking. the aim of this study was to assess the current pattern of iodine food source intake among early adolescents. methods: this was a cross-sectional study, the pattern of iodine food source intake in early adolescents aged 11–14 years attending junior high school in jatinangor sumedang, indonesia was assessed from september to october 2014, by validated food frequency questionnaire (ffq). eating patterns were divided into four categories based on indonesian recommended dietary allowance (rda). results: the average iodine daily intake of the subjects was 356.27 mcg. the highest frequency of the iodine intake category was adequate in students aged 11–12 years old (100%), compared to aged 13–14 years old (79.2%). conclusions: the daily iodine intake in junior high school students is sufficient. further assessment in areas elsewhere in west java needs to be conducted to have a better picture of the pattern of iodine food source intake in adolescents. keywords: early adolescents, food source, iodine intake introduction adolescence is a particularly unique period in life because it is a transition between childhood and adulthood, characterized by a growth spurt with physiological changes until reaching approximate adult status.1 according to the world health organization (who), early adolescence has been defined as the age of 10–14 years.2 nutrition plays an essential role, as nutrition influences development and growth throughout infancy, childhood, and adolescence. it is, however, during the period of adolescence that nutrient needs are the greatest.3 iodine is one of the essential micronutrients for normal growth, development, and metabolism throughout life.4 the iodine has the main role in the synthesis of thyroid hormones, thyroxine (t4) and triiodothyronine (t3).4 the thyroid hormone is important to maintain the normal secretion of growth hormone by the pituitary gland, thus, when iodine food source intake is inadequate, the thyroid hormone synthesis is impaired, resulting in a series of functional and developmental abnormalities. based on the recent estimates, the iodine intake of 29.8% or 240.9 million school-age children and early adolescents worldwide is insufficient. the highest proportions of insufficiency are found in 76 million children and early adolescents in southeast asia, exceeding other country regions.5 conversely, thyroid function may also be affected when there is an excess intake of iodine. the study about the pattern of iodine food source intake among early adolescents in indonesia is lacking, therefore, we were althea medical journal. 2019;6(4) 160 amj december 2019 interested to assess the iodine food source intake among early adolescence in jatinangor. methods descriptive research was conducted using a cross-sectional design in september–october 2014 to assess the pattern of iodine food source intake among early adolescents aged 11–14 years old who were attending a junior high school in jatinangor, sumedang district, indonesia. all procedures performed in this study were approved by the health research ethics committee of faculty of medicine, universitas padjadajaran with the number of ethical clearance was no. 384/un6.c2.1.2/ kepk/pn/2014. besides, the study had obtained permission from the respective junior high school authority. using a cluster random sampling method, a junior high school had been selected. the data was collected using validated food intake analyzing tool in the form of a questionnaire and was self–conducted to find out how the pattern of iodine food source intake in early adolescents. the semi–quantitative food frequency questionnaire (ffq) was used to assess the frequency of which food items or food groups were consumed during a specified period time. specific food or comprehensive item list were used to record intakes over a given period (day, week, month, year) with ranking subjects into broad categories of the low, medium, and high intakes of food components. the advantage of this method is rapid, with the low respondent burden and high response rate. before the ffq was distributed, students table 1 characteristics of junior high school students (n=80) in jatinangor characteristics n % sex male 31 38.8 female 49 61.2 age (years) 11 2 2.5 12 30 37.5 13 34 42.5 14 14 17.5 table 2 the iodine intake among junior high school students (n=80) in jatinangor, based on the group of age category group for age category n % 11–12 years old adequate 32 100 mild deficiency moderate deficiency deficiency 13–14 years old adequate 38 79.2 mild deficiency 3 6.3 moderate deficiency 1 2.1 deficiency 6 12.4 were given an adequate explanation and food models were used to help answer the ffq. data obtained were converted to the size and weight based on the household size contained in the food model and food consumption survey individuals and were adjusted according to the frequency of food consumed at once. after household food in grams was obtained, then the data was totaled to calculate the iodine intake received. after the calculation of iodine intake from ffq, the adequacy of iodine in percentage was measured based on the indonesian recommended dietary allowance (rda) by indonesia’s health ministry in 2005. the percentage was obtained from the formula of% rda, which was iodine intake (μcg) from ffq/standard iodine intake. then, the value percentage of rda obtained was categorized althea medical journal. 2019;6(4) 161 into four based on the nutritional health center personnel handbook department of health republik of indonesia (depkes, ri) (1990) with cut–off points: adequate ≥100% rda, mild deficiency >80–99% rda, moderate deficiency 70–80% rda, and deficiency <70% rda. according to the indonesian recommended dietary allowance (rda) guideline published in 2013, the recommended iodine intake for age 10–12 years old was 120 mcg and for age 13–15 years old was 150 mcg, respectively. all data were collected and analyzed using excel 2010 and spss 17.00 software for windows. results in total, 80 junior high school students were included, consisting of 31 (38.8%) males and 49 (61.30%) females. the characteristic of these young adolescents had been presented in table 1. the age of the students was in the range between 11 to 14 years old conform to the age of junior high school students. furthermore, the age was grouped into age 11–12 years old and 13–14 years old (table 2). the average daily iodine intake among the junior high school students was 356.27 (sd±222.76) mcg, with the minimum iodine intake was 66.41 mcg and the maximum iodine intake was 976.68 mcg. the students in a group of 11–12 years old were all categorized as having adequate iodine intake; whereas only 79.2% of the students in a group of 13–14 years old were categorized as having adequate iodine intake, and thus 20.8% had an inadequate iodine intake; of whom 12.4% was deficient to iodine. altogether, 10 of 80 (12.5%) of this study participants had a deficiency in iodine intake. the analysis did not separate the results of iodine intake between boys and girls, because there was no difference in iodine requirements between boys and girls. there were various iodine intakes among junior high school students, in which the frequency of the top ten in each category was presented in table 3. the most daily consumed of iodine food sources were rice, eggs, tea, cireng, instant coffee; whereas tropical fruit and seafood-based snack were consumed less often, in the range of 40–78 respondents. the most daily consumed of vegetables and fruits that contained iodine were tomato and banana. interestingly, some of the respondents had never eaten some food such as seaweed, shrimp, mussel, or salted eggs. siti nur fatimah et al.: the pattern of iodine food source intake in early adolescents in junior high school in jatinangor table 3 frequency of top ten iodine food source intake among junior high school students in jatinangor days (n) weeks months 2 months 1x/6 months 1x/years never (n) rice (78) fried rice strawberry strawberry avocado shrimp seaweed (48) egg (44) ice cream chocolate ultra milk chocolate, vanilla, strawberry, potato mussel mussel shrimp (36) tea (42) porridge avocado salted egg shrimp seaweed mussel (31) cireng(40) tahu bulat fish ball seaweed strawberry avocado salted egg (26) instant coffee (37) instant noodle mango avocado seaweed strawberry potato(18) balabala (35) balabala apple mussel mango bakso tahu siomay avocado (10) fried tofu (34) bakso tahu siomay banana shrimp fish ball mango frisian flag condensed milk (8) instant noodle (29) tomato tahu bulat carrot porridge chocolate bread tomato (7) pisang goreng aroma(28) watermelon watermelon mango chocolate bread salted egg pisang goreng aroma(7) chocolate bread (26) chocolate bread ice cream chocolate apple salted egg apple chocolate bread (6) note: bakso tahu siomay= dumpling; pisang goreng aroma= caramelized banana althea medical journal. 2019;6(4) 162 amj december 2019 discussion based on food frequency questionnaire (ffq) analysis, the average daily iodine food source intake among junior high school students was 356.27 mcg. this result conforms with a previous study showing a normal average of iodine food source intake in children, which was 300 mcg/l, and the daily iodine is measured using urinary iodine (ui) concentration,6 suggestings that ffq analysis might be useful to assess the iodine food source intake. according to the indonesian recommended dietary allowance (rda) guideline published in 2013, the recommended iodine intake is 120 mcg for age 10–12 years old and 150 mcg for age 13–15 years old.7 our study has shown that in the category of age of 11–12 years old the intake is all adequate, whereas age 13–14 years old has lower percentage for adequate iodine intake (79.2%). interestingly, a study in malaysia8 using semi–quantitative ffq has shown that the majority of the respondents have daily iodine intake above the normal requirement for a specific age. this finding might be caused by excessive iodine intake which is mainly associated with their dietary iodine food source intake.8 it is important to increase iodine food sources intake related to the role of iodine as thyroid hormone precursors. excessive iodine intake may cause an increase in thyroid volume. moderately high of iodine food source intake in the range of 300–500 mcg/d is well tolerated in healthy children, however, iodine intake in this range has no benefit and might cause an adverse effect.6 the iodine food source intake that mostly consumed daily by our study participants is white rice and egg, whereas seaweed, shrimp, mussel are the lowest consumed, similar to a study in pakistan.8 of note, seafood such as fish, seaweed and salts are the best sources of iodine, next to milk and vegetables.9 taken into account, a community movement has been raised by the government to eat more fish since indonesia is a country with two-third of the region is the ocean. furthermore, according to rda, iodized salt is also contributing to fulfilling the amount of iodine food source intake. previous studies have shown that the national coverage of households with iodized salt >5 ppm is reported to be 78.2% in 1995 and increased to 81.5% in 1999. recently, salt containing iodine in indonesia has been defined as a minimum of 30 ppm.10 our data shows that the respondents in this study in the category age of 13–14 years old is in lower categories (20.8%); of whom 6.3% is mild, 2.1% is moderate and 12.4% in deficiency state of iodine deficiency intake, that might possibly due to inadequate iodine food source intake; thus in total of 12.5% of our study participants (mostly in age of 13–14 years old) has iodine deficiency intake. one of the factors that may cause this problem is the differences in cost prizes between iodized salt and non-iodized salt, which in turn caused the poorer families to prefer to buy based on the price alone. education among the mothers may also influence the use of iodine salt.10 inadequate iodine food source intake would impair thyroid hormone synthesis, resulting in hypothyroidism. limitations in this study are encountered, among others is the lack of educational background and economic status of the families. this study is also limited in the method by only using the food frequency questionnaire (ffq), which might have led to recall bias. the alternative method to accurately measure the iodine intake is by using urinary iodine (ui) concentration measurement. in conclusion, the consumption of iodine food source intake in our study at junior high school students aged between 11 to 14 years old is adequate, with the average of iodine food source intake is 356.27 mcg. special attention is required that older age students are the ones that have iodine deficiency intake. iodine intake in daily consumption of regularly consumed food such as rice and eggs needs to be enriched with other sources, especially milk, fish and other sea origin products such as seaweed or shrimp. references 1. mansourian m, marateb hr, kelishadi r, motlagh me, aminaee t, taslimi m, et al. first growth curves based on the world health organization reference in a nationally–representative sample of pediatric population in the middle east and north africa (mena): the caspian–iii study. bmc pediatr. 2012;12:149. 2. world health organization. nutrition in adolescence: issues and challenges for the health sector: issues in adolescent health and development. geneva: who press; 2005. 3. mondal n, sen j. prevalence of stunting and thinness among rural adolescents of darjeeling district, west bengal, india. italian j pub health. 2010;7(1):54–61. 4. gunnarsdottir ir, dahl l. iodine intake in althea medical journal. 2019;6(4) 163 human nutrition: a systematic literature review. food nutr res. 2012;56:19731. 5. andersson m, karumbunathan v, zimmermann mb. global iodine status in 2011 and trends over the past decade. j nutr. 2012;142(4):744–50. 6. zimmerman mb, ito y, hess sy, fujieda k, molinari l. high thyroid volume in children with excess dietary iodine intakes. am j clin nutr 2005;81(4):840–4. 7. kementerian kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia no. 75 tahun 2013 tentang angka kecukupan gizi yang dianjurkan bagi bangsa indonesia. jakarta: kemenkes ri; 2013. p. 5–10. 8. taib sm, isa zm. dietary iodine from interview–based semi–quantitative food frequency questionnaire: correlation with 24h dietary recall. pakistan j nutr. 2013;12(7):688–91. 9. imdad s, muzaffar r, shoukat ms. evaluation of impact of dietary pattern on iodine and thyroid status of adolescent girls in lahore. biomedica. 2013;29(3):139–46. 10. semba rd, de pee s, hess sy, sun k, sari m, bloem mw. child malnutrition and mortality among families not utilizing adequately iodized salt in indonesia. am j clin nutr. 2008;87(2):438–44. siti nur fatimah et al.: the pattern of iodine food source intake in early adolescents in junior high school in jatinangor 173 althea medical journal. 2017;4(2) vitamin c intake and risk factors for knee osteoarthritis nadia ayu destianti,1 siti nur fatimah,2 sumartini dewi3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: knee osteoarthritis (oa) is a degenerative disease of the knee joints characterized by progressive softening and disintegration of articular cartilage. in oa, which is influenced by several risk factors, free radicals are increased by local ischemia in the cartilage. as an exogenous antioxidant, vitamin c also plays an important role in collagen and glycosaminoglycan synthesis. this study was carried out to identify vitamin c intake as well as risk factors in knee oa. methods: the study population was determined by non-probability sampling with convenient approach to knee oa patients at the rheumatology outpatient clinic of dr. hasan sadikin general hospital in october– november 2013. data were obtained through questionnaire interview about risk factors, severity index of oa and vitamin c intake profile. data presentation was conducted by descriptive method. results: there were 47 patients diagnosed with knee oa in the rheumatology outpatient clinic. the result showed that 7 patients (14.9%) had low vitamin c intake for the last 3 months. there were 30 patients with family history of oa (63.8%). thirty two patients (68.1%) were passive smokers, 44 patients (93.6%) had history of repeated use of knee joints and majority of respondents had obesity. conclusions: most of the subjects have sufficient vitamin c intake and more than half have risk factors that may contribute to the incidence of knee oa. keywords: knee osteoarthritis, risk factors, vitamin c intake correspondence: nadia ayu destianti, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81224112223 email: nadiaayud@gmail.com introduction the disease pattern of the developing world has shifted from infectious and acute diseases to chronic and degenerative diseases.1 osteoarthritis (oa) is a degenerative joint disease associated with damage to the joint cartilage and one of the 10 most common disabilities in the developing country. the oa most frequently attacks the spine, hip, knee and ankle. the prevalence of oa is about 50– 60% from 23.6–31.3% of the total patients with joint disease in indonesia.2 prevalence of knee oa is quite high at 14.9% in women and 8.7% in men.3 in oa, free radicals level elevated in cartilages by local ischemia degrade its components, triggering synovial and immune responses that promotes further cartilage damage.4 to protect the cells and organ systems, humans have evolved a highly sophisticated antioxidant protection system, which can be either naturally produced in situ (endogenous) or externally supplied through foods and supplements (exogenous). as one of the exogenous antioxidants, vitamin c is critical to bone health, acting as sulfate carrier in glycosaminoglycan synthesis which may be relevant to oa etiology because depletion of sulfated proteoglycans from the articular cartilage extracellular matrix is one of the earliest expressions of oa, which eventually leads to degeneration of the cartilage.5 concentration of vitamin c in the body is mostly determined by its dietary intake. adequacy of vitamin c in the body may help to slow down the progression of oa. the objectives of this study was to identify the dietary intake of vitamin c and risk factors for knee osteoarthritis methods this study was conducted in the rheumatology outpatient clinic of dr. hasan sadikin general hospital bandung, west java, indonesia amj. 2017;4(2):173–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1067 althea medical journal. 2017;4(2) 174 amj june 2017 from october to november 2013. this study was approved by the health research ethics commitee of the faculty of medicine, universitas padjadjaran. the sampling method used was non-probability sampling (convenience sampling) and the minimal sample needed for this study was determined through the categorical descriptive formula. data was taken from 46 patients who were diagnosed as having knee osteoarthritis (oa) by doctors of the rheumatology outpatient clinic of dr. hasan sadikin general hospital bandung, and was validated by the consultant of rheumatology. the subjects were patients who fulfilled the inclusion and exclusion criteria. the inclusion criteria were patients aged 40–70 years as well as willing to answer the questions in the questionnaire. the exclusion criteria were patients with dementia, patients who had knee traumatic history and had undergone menisectomy (knee joint surgery). furthermore, respondents were asked to sign the inform consent form, and then interviewed using a questionnaire for identification of risk factors related to osteoarthritis. the western ontario and mcmaster universities arthritis index (womac) form was used to classify respondents oa severity and the food frequency questionnaire (ffq) form to find out about the respondents dietary vitamin c intake for the last 3 months which were obtained through frequency and amount of fruit and vegetables that respondents ate every day or week or month. respondents were asked to indicate risk factors such as lifestyle information about smoking routine as well as history of smoking and passive smokers history at home, metabolic information about body weight history and body height, biomechanical factor information about occupational history and history of daily activities that included repeated use of knee joints, and genetic information about family history of knee oa. the womac form consists of 24 questions divided into 3 parts. part 1 is about the pain that the patient feels for the last 48 hours when doing 5 activities, for example: walking on a flat surface, going up and down stairs, disturbing pain at night while sleeping, sitting or lying and standing upright. part 2 is about stiffness or a sensation of decreased ease in moving joint that the patient has in their knee during the last 48 hours while doing these 2 activities: after awakening in the morning and after sitting, lying, or resting in the day. part 3 consists of 17 questions about difficulties the patient has experienced in doing daily physical activities due to the patient’s hip/ knee during the last 48 hours, this mean the ability to move around and look after oneself. each of the questions is scaled from 0–10 by visual analog scale. afterwards, each of the respondents’ severity indices are calculated and classified into 3 classes of oa severity from mild, moderate to severe. the ffq is a tool used to assess individual dietary intake history using a list of foods on which respondents report their usual consumption frequency over a given period. the quantitative food frequency used in this study included more precise food portion size estimates in household measures. the ffq used in this study consisted of a list of fruit and vegetable containing vitamin c, their frequency every day, week and month as well as each portion size. seasonal fruit and vegetable were excluded in this questionnaire to minimize bias. the statistical analysis was calculated by used of microsoft office excel. the presentation of data was performed by used of the descriptive method through frequency distribution tables about dietary intake of vitamin c, risk factors of knee oa and womac severity index of oa. results this study discovered that most of the patients were middle-aged females. most of the respondents completed the senior high school (38.3%). based on the respondent’s occupation, 46.8% were government employer (table 1). dietary intake of vitamin c was assessed using the food frequency questionnaire. this questionnaire assessed the daily fruit and vegetable containing vitamin c intake of respondents for the last 3 months. only 7 patients (14.9%) had low daily dietary intake of vitamin c (table 2). furthermore, risk factors for knee oa were determined by what was presented, mostly the respondents were passive smokers in their home (68.1%) and 53.2% of the respondents had body mass index (bmi) more than normal which was divided into 2 categories, overweight and obese. more than a half of knee oa patients showed history of repeated use of knee joints in three categories, stood for 2 hours or more (59.6%), walked for 2 hours or more (57.4%) and went up and down stairs for more than 2 times (51.1%). family history was present in 25 patients (53.2%) (table 3). knee oa severity of each patient was 175 althea medical journal. 2017;4(2) nadia ayu destianti, siti nur fatimah, sumartini dewi: vitamin c intake and risk factors for knee osteoarthritis table 1 characteristic of respondents characteristic frequency % sex female 42 89.4 male 5 10.6 age (years old) < 50 7 14.9 50–60 26 55.3 > 60 14 29.8 education level did not graduate elementary school 1 2.1 graduated elementary school 6 12.8 graduated junior high school 2 4.3 did not graduate senior high school 1 2.1 graduated senior high school 18 38.3 graduated academy 10 21.3 graduated scholar 8 17 graduated magister 1 2.1 occupation government employer 22 46.8 entrepreneur 2 4.3 retired 10 21.3 housewife 12 25.5 never worked 1 2.1 table 2 dietary intake of vitamin c classification rda classification frequency % low (<75 mg) 7 14.9 normal (75–1000 mg) 40 85.1 excess (>1000 mg) 0 0 total 47 100 note : rda = recommended dietary allowance assessed using the womac form. there were 41 patients (87.2%) with mild osteoarthritis and 6 patients (12.8%) with moderate osteoarthritis. there was no patient with severe osteoarthritis (table 4). discussion this study discovered that several risk factors contributed to the incidence of knee osteoarthritis. the percentage of people with knee oa aged less than 50 years was lower than those aged older than 50 years. this findings was similar to a study conducted by patil et al.6 the proportion of women with disorders was higher compared to men. a study carried out by patil et al.6 also observed that oa is higher in women (65.7%) than men (34.3%). patients, who graduated from academy and above, show lower incidence of althea medical journal. 2017;4(2) 176 amj june 2017 knee osteoarthritis compared to the patients with lower educational level. it was suspected that the higher the level of education, the higher the level of knowledge and awareness of health was. based on the respondents’ characteristics, the public servants occupation showed a higher level of osteoarthritis (46.8%) than other occupations. this difference might be due to the lack of physical activity, mobility, social issues as well as work that put extra load on the knee joints (e.g. lifting patients and pushing beds for nurse as public servants).7 dietary intake of vitamin c assessed by the food frequency questionnaire showed 85.1% of patients had normal vitamin c intake based on angka kecukupan gizi indonesia (akg), 2004, while the rest of 14.9% patients had low level of vitamin c intake. this result roughly correlated with the literature which stated that higher plasma vitamin c is found in patients with lower grade of oa, and in this study 41 patients (87.2%) had mild oa severity index.8 other risk factors was smoking. this study table 3 risk factors for knee osteoarthritis risk factors frequency % active smoker yes 4 8.5 used to 6 12.8 no 37 78.7 passive smoker yes 32 68.1 no 15 31.9 body mass index normal 22 46.8 overweight 9 19.2 obese 16 34 history of repeated use of knee joints lifting/pushing heavy objects 20 42.6 stands for 2 hours/more 28 59.6 walks for 2 hours /more 27 57.4 up and down stairs more than 2 times 24 51.1 squat for more than 2 hours/repeatedly 15 31.9 family history of knee osteoarthritis yes 25 53.2 no 21 44.7 unknown 1 2.1 table 4 knee osteoarthritis severity womac classification frequency % mild (<=80) 41 87.2 moderate (81–160) 6 12.8 severe (>160) 0 0 total 47 100 note: womac = the western ontario and mcmaster universities arthritis index 177 althea medical journal. 2017;4(2) revealed that most of the patients were passive smokers which proved the free radical theory of oa was caused by many factors such as smoking, both active and passive, pollutants, and free radicals produced by environment around the patients.9 more than half of the patients had body mass index higher than normal (53.2%), this is in agreement with the risk factors of oa found in the study conducted by patil et al.6 moreover, the history of repeated use of the knee was observed as 42.6% for lifting or pushing heavy objects, 59.6% for standing for 2 hours or more, 57.4% for walking for 2 hours or more, 51.1% for climbing up and down stairs for more than 2 times and 31.9% for squatting for more than 2 hours or repeatedly. these results agreed with the theory of repetitive use of knee joints as risk factors for developing knee oa. it was stated that workers performing repetitive tasks as part of their occupations for many years are at high risk of developing oa in the joints they use repeatedly for example, workers whose jobs require regular knee bending or lifting or carrying heavy loads have a high rate of knee oa.10 additionally, osteoarthritis is also influenced by genetic factors such as familial history, it corresponded with the results of our study which showed more than a half of the patients (53.2%) had family history of knee osteoarthritis from their mother, father, or other siblings.10 this study had limitations. the use of food frequency questionnaire that rely on the patient’s memory may cause a recall bias. moreover, to understand what the researcher asked and the patient’s cooperation may lead to bias. in conclusion, most of the respondents have sufficient profile of vitamin c intake. more than a half of the respondents have significant risk factors which may contribute to the incidence of knee osteoarthritis. these risk factors can be prevented with a healthy lifestyle as well as awareness of factors that may induce osteoarthritis in the later life. references 1. who. global health and aging. national institute on aging, national institute of health, u.s. department of health and human services; 2011.p.9–11. 2. nainggolan o. prevalensi dan determinan penyakit rematik di indonesia. maj kedokt indon. 2009;59(12):588–94. 3. quintana jm, arostegui i, escobar a, azkarate j, goenaga jl, lafuente i. prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in an older population. arch intern med. 2008;168(14):1576–84 4. ziskoven c, jager m, zilkens c, bloch w, brixius k, krauspe r. oxidative stress in secondary osteoarthritis: from cartilage destruction to clinical presentation? orthop rev (pavia). 2010;2(2):e23. 5. peregoy j, wilder fv. the effects of vitamin c supplementation on incident and progressive knee osteoarthritis: a longitudinal study. public health nutr. 2011;14(4):709–15. 6. patil ps, dixit ur, shettar cm. risk factors of osteoarthritis knee – a cross-sectional study. iosr jdms. 2012;2(5):8–10. 7. palmer kt. occupational activities and osteoarthritis of the knee. br med bull. 2012;102:147–70. 8. naskar ds, dawn di, sarkar ds, de dc, biswas dg. a comparative study between plasma vitamin c level and severity of knee osteoarthritis. iosr-jdms. 2013;4(1):10– 4. 9. loeser rf. molecular mechanisms of cartilage destruction in osteoarthritis. j musculoskelet neuronal interact 2008;8(4):303–6. 10. felson dt. osteoarthritis. in: anthony s, fauci m, editor. harrison’s rheumatology. 2nd ed. new york: the mcgraw-hill companies, inc.; 2010. p. 223–34. nadia ayu destianti, siti nur fatimah, sumartini dewi: vitamin c intake and risk factors for knee osteoarthritis althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 36 amj march 2017 histopathologic distribution of appendicitis at dr. hasan sadikin general hospital, bandung, indonesia, in 2012 tara zhafira,1 herry yulianti,2 maman wastaman3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: appendicitis is a medical emergency and a common cause of emergency surgeries worldwide. its frequency is varied based on many factors, including age and sex. histopathologic examination is a gold standard for diagnosis, and complications like gangrene formation and perforation lead to high mortality and morbidity in almost all age groups. this study was conducted to describe the distribution pattern of appendicitis according to age, sex, and histopathologic type. methods: this cross-sectional study was carried out in the department of pathology anatomy, dr. hasan sadikin general hospital, bandung, indonesia, from august–october 2013. secondary data were obtained from medical records of january 1st to december 31st, 2012. a total of 503 out of 516 cases were included to be reviewed. age, sex, and histopathologic type from medical records were then evaluated. any specific case and perforation were also noted. results: data showed the highest prevalence of appendicitis occurred in the 1019 age group (28.4%) and in the female group (52.3%). acute appendicitis was more common than chronic appendicitis in both sexes and all age groups. perforation rate was high (41.4%), and was more prevalent in male (54.9%) and in the 0–9 age group (65.7%). conclusions: appendicitis, both acute and chronic, is more distributed in the second decade, and is slightly more prevalent in females. acute cases are more common than chronic. perforation rate is significant and peaks in the first decade and in males. [amj.2017;4(1):36–41] keywords: acute appendicitis, chronic appendicitis, distribution correspondence: tara zhafira, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281311349612 email: tarazhafira@yahoo.com introduction appendicitis is a medical emergency and a common cause of emergency surgery worldwide.1,2 frequency of appendicitis is varied by population, age, sex, socioeconomic status, and race. untreated appendicitis may be complicated with gangrene formation and perforation, leading to a high morbidity and mortality in almost all age groups.3 to prevent morbidity and mortality, which is about 2% associated with perforation, timely surgery is needed.4 however, gold standard for diagnosis of appendicitis is the histopathology examination.5 clinically and histologically, appendicitis is divided into acute and chronic appendicitis.6,7 acute appendicitis is more prevalent in male than female.2-5 it is commonly seen in the second decade of age, with lifetime risk of 7%.1-3 chronic appendicitis, in the other hand, is more frequent in female and in >25 years of age.8 perforation is more prevalent in male and in the age of 0 to 9 years and >50 years.3 this study was conducted to explain the distribution pattern of appendicitis according to age, sex, and the histopathologic type. methods this cross-sectional study was conducted at the department of anatomical pathology, dr. hasan sadikin general hospital, bandung, indonesia, august–october 2013. the secondary data were collected after permission letters had been issued by the health research ethics committee (komite etik penelitian kesehatan/ kepk) and the research site. medical records from january 1st to december 31st, 2012, were collected using total population technique. an inclusion criterion was histopathologic diagnosis of appendicitis. patient’s age, sex, althea medical journal. 2017;4(1) 37 and histopathologic type of appendicitis were noted. medical record with incomplete data was excluded. the obtained data were then evaluated using a spreadsheet software program. the patient’s age was divided into 7 groups, with a 10 years range for each group while the patient’s sex was divided into male and female. the histopathologic types were divided into acute and chronic, based on conclusion of the histopathologic examination noted in the records. frequency of each group was then calculated. any perforation and specific cases were also noted. results there were 516 medical records which fulfilled the inclusion criterion. among 516 cases, 13 were excluded: 12 due to incompleteness of data (there were no age information in 5 cases, no sex information in 7 cases) and 1 case was considered inappropriate for the evaluation (the age recorded was 5 month and too extreme for the evaluation). a final 503 cases were included for the review. furthermore, the age of the population was ranged from 1 to 81 years, with a mean (sd) of 28.1 (15.3) years. the peak incidence of appendicitis occurred in the 10 to 19 years group, counting for 28.4% of all cases. there was 52.3% proportion of female, with male: female ratio 1:1. this study also showed 96 (19.1%) of the pediatric population (aged 0 to 15 years) was with male predominance (61.5%) and mean (sd) of 10.7 (3.6) years (table 1). in this study, male were more distributed in the 0-9 and in ≥50 years of age. females were predominated in the 10-49 years group (figure 1). mean age (sd) for male was 28.6 (17.3) and for female was 27.8 (13.2). there were 495 cases (98.4%) of acute appendicitis in this study. incidence of acute appendicitis was higher than the chronic appendicitis in both sexes and all age groups (table 2). from 8 chronic cases, 3 were specific for tuberculous appendicitis, consisting of 2 male and 2 patients from the 20 to 29 years group. according to age, acute appendicitis was more prevalent in the 10 to 19 years group, while chronic appendicitis was higher in the 20 to 29 years group. both acute and chronic appendicitis were predominated by female. there was 100% rate of acute appendicitis in the pediatric population aged 0 to 15 years. among the acute appendicitis cases, 205 perforated cases were noted (table 2). this complication was peaked in the 10 to 19 years age group and in male. there were also 59 perforated cases observed in the pediatric population aged 0 to 15 years in this study. perforation rate was calculated by dividing tara zhafira, herry yulianti, maman wastaman r: histopathologic distribution of appendicitis at dr. hasan sadikin general hospital, bandung, indonesia, in 2012 table 1 distribution of appendicitis according to age, sex and histopathologic type variable n % age (years) 0–9 35 7 10–19 143 28.4 20–29 132 26.2 30–39 75 14.9 40–49 58 11.5 50–59 38 7.6 ≥60 22 4.4 sex male 240 47.7 female 263 52.3 histopathologic type of appendicitis acute 495 98.4 chronic 8 1.6 althea medical journal. 2017;4(1) 38 amj march 2017 numbers of perforated cases by numbers of acute cases. with 205 perforated cases and 495 acute cases, the total perforation rate was 41.4%. perforation rate peaked at 65.7% and was observed in the 0 to 9 years age group (figure 2). there was also perforation rate of 60.8% observed in the pediatric population. according to sex, perforation rate of male (54.9%) was higher than female (29.1%). gradual decrease of perforation rate was observed from the first to the third decade (65.7% to 28.7%). discussions the results showed a peak incidence of appendicitis in the 10 to 19 years group. additionally, similar results were obtained figure 1 sex distribution of appendicitis according to age table 2 mann whitney analysis result variable acute perforation chronic n % n n % age (years) 0–9 35 7.1 23 0 0 10–19 142 28.7 63 1 12.5 20–29 129 26.1 37 3 37.5 30–39 73 14.7 33 2 25 40–49 57 11.5 23 1 12.5 50–59 37 7.5 17 1 12.5 ≥60 22 4.4 9 0 0 sex male 237 47.9 130 3 37.5 female 258 52.1 75 5 62.5 althea medical journal. 2017;4(1) 39tara zhafira, herry yulianti, maman wastaman r: histopathologic distribution of appendicitis at dr. hasan sadikin general hospital, bandung, indonesia, in 2012 by chamisa et al.2, sulu et al.3, kalliakmanis et al.9 and chandrasegaram et al.10 those series stated that appendicitis is higher in the second decade. however, different results are concluded by makaju et al.4 and zulfikar et al.11 there is a higher prevalence of appendicitis in the 21 to 30 years age group in their studies. besides, female was more prevalent in this study. similar results were observed by kalliakmanis et al.9, namsawang et al.12, shrestha et al.13 and sgourakis et al.14 however, there were also some series that revealed opposite findings.2-5,10,11 histopathologic examination is a gold standard for diagnosing appendicitis.5 it serves two purposes, which are to confirm the diagnosis and to disclose any additional pathology that may be unseen in surgeries but can affect the management.11 besides, clinically and histopathologically, appendicitis is divided into acute and chronic appendicitis.6,7 acute appendicitis is marked by neutrophil infiltration in the appendiceal wall. based on the pathologic stages, acute appendicitis can be further divided into early acute, acute suppurative, acute gangrenous, and perforative.4,6,15 early acute appendicitis is macroscopically defined by dull serosal surface of appendix. microscopically, it shows perivascular and mild to moderate transmural neutrophil infiltration. acute suppurative appendicitis is marked macroscopically by serosal fibrinopurulent exudates and microscopically by dense transmural neutrophilic infiltration with mucosal ulceration. acute gangrenous is marked grossly by greenish-black necrosis. it shows extensive mucosal ulceration and hemorrhage necrosis of all layers under the microscope.4,15 this grouping of acute appendicitis, however, was not applied in our study site at the time of this study was conducted. the histopathologic type of appendicitis was defined as acute and chronic only. in this study, acute appendicitis was more prevalent than chronic appendicitis. some studies concluded similar results, with the incidence of chronic appendicitis ranged from 0.58% to 6.55%.4,11,14,16 this study found that the incidence of acute appendicitis peaked in the 10 to 19 years group and was gradually decreasing afterwards, consistent with the result concluded by chandrasegaram et al.10 female population was predominant both in acute and chronic appendicitis. the existence of chronic appendicitis is controversial, but safaei et al.8 concluded that it should be considered as an independent diagnostic entity. on histopathologic examination, it shows inflammatory infiltrates consisting of lymphocytes, histiocytes, and eosinophils with fibrosis of the appendiceal wall.8 in this study, chronic appendicitis was higher in the 20 to 29 years group. a study conducted by shrestha et al.13 showed similar result, stating chronic appendicitis is more common in the 21 to 40 years group, while safaei et al.8 stated that its incidence is higher in >25 years of age and in female. there were 3 (0.59%) cases of tuberculous appendicitis in this study. besides, tuberculous appendicitis was also observed by makaju figure 2 perforation rate according to age althea medical journal. 2017;4(1) 40 amj march 2017 et al.4 and zulfikar et al.11 with a rate of 0.58% and 3%, respectively. tuberculous appendicitis is rare in the western world, and is thought to be caused by the poor hygiene and low socioeconomic level in an area.11,17 macroscopically there are inflammation and thickening of the appendiceal wall. it is often adhered to the surrounding bowel with associated lymphadenitis. histologically, lymphoid hyperplasia and caseating granuloma are observed. mucosal ulcer can also be seen. organism is rare, but can be found by staining to reveal the acid fast bacily (afb).18 furthermore, perforation is one of appendicitis complications and may cause high mortality and morbidity rate than the nonperforated cases.3,19 timely surgery is mandatory to prevent this outcome.15 perforation rate observed in this study was considerably high compared to the other studies which ranged from 0.8% to 20%.3-5, 10,11 however, a significant perforation rate (34%) was also found by chamisa et al.2 considering the age group, perforated appendicitis peaked in the 0 to 9 years group in our study as shown by sulu et al.3 besides in the early ages, the literature also stated that perforation is prevalent in the elderly group. nonspecific symptoms and laboratories, delayed admission, communication problems, and socioeconomic factors were hypothesized to be the cause of higher perforation rate, especially in younger age and elderly.3,19 there were two distinctive patterns of perforated appendicitis in this study, consistent with the study conducted by chandrasegaram et al.10 which showed gradual decrease of perforation rate from the first to third decade and an advance of perforation rate with age. the latter can be seen in this study by the consistent high rates of perforation in >30 years groups. incidence of perforated appendicitis was higher in male in this study, which was consistent with the results concluded by sulu et al.3 and nabipour et al.5 the higher incidence of appendicular faecoliths and calculi found in male was proposed to be an explanation of higher perforation rate in this group.19 studies conducted by chamisa et al.2, chandrasegaram et al.10, shrestha et al.13 and barreto et al.19 however, did not obtain the same outcome. the series observed perforated appendicitis is more commonly seen in female.2,10,13,19 appendicitis is also a common cause of acute abdomen and emergency abdominal surgeries in children.16 among 19.1% of pediatric population in this study with mean age (sd) of 10.7 (3.6), males were predominant. a study of children appendicitis by monajemzadeh et al.16 revealed mean age (sd) of 6.9 (3.5) and male predominance. however, uba et al.20 observed female predominance in the pediatric population. the literature stated that the histopathologic type more commonly observed in children was acute appendicitis, with the rate of chronic appendicitis only 0.8%.16 this study showed a hundred per cent acute appendicitis in children. acute appendicitis in early ages is theorized to be caused by lymphoid hyperplasia.3 it is characterized by the increasing of lymphoid tissues’ size due to immunological reaction against infected agents like virus. lymphoid hyperplasia alone, however, can cause symptoms.20 interestingly, perforation rate in pediatric population of this study was higher than the results concluded in studies conducted by monajemzadeh et al.16 and uba et al.20 which are 13.8% and 25%, respectively. delay of diagnosis caused by children’s inability to communicate precisely the explanation for their symptoms is considered to be the cause of high perforated cases in children.16 this study was limited by the less specific histopathologic classification of acute appendicitis. therefore, the histopathologic results could not be presented based on the pathologic stages, which are early acute, acute suppurative, and acute gangrenous. in conclusion, appendicitis is more distributed in the 10 to 19 years group and in females. acute appendicitis is more commonly encountered than chronic appendicitis in both sexes and all age groups. there is a considerably high perforation rate, which peaks in the 0 to 9 years group and in males. a further study of appendicitis distribution in another site is recommended. references 1. kumar v, abbas ak, fausto n, aster jc. pathologic basis of disease. 8th ed. philadelphia: saunders elsevier; 2005. p. 826–7. 2. chamisa i. a clinicopathological review of 324 appendices removed for acute appendicitis in durban, south africa. ann r coll surg engl. 2009;91(8):688–92. 3. sulu b, gunerhan y, palanci y, isler b, caglayan k. epidemiological and demographic features of appendicitis and influences of several environmental factors. ulus travma acil cerrahi derg. 2010;16(1):38–42. althea medical journal. 2017;4(1) 41 4. makaju r, mohammad a, shakya a. acute appendicitis: analysis of 518 histopathologically diagnosed cases at the kathmandu university hospital, nepal. kathmandu univ med j. 2010;8(30):227– 30. 5. nabipour f. histopathologic feature of acute appendicitis in kerman-iran from 1997-2003. am j environ sci. 2005;1(2):130–2. 6. rosai j. rosai and ackerman’s surgical pathology. 10th ed. edinburgh: mosby elsevier; 2011. p. 714–6 7. berger dh, jaffe bm. schwartz’s principles of surgery. 9th ed. new york: mcgraw-hill; 2010. p. 1073–89. 8. safaei m, moeinei l, rasti m. recurrent abdominal pain and chronic appendicitis. j res med sci. 2004;9(1):11–4. 9. kalliakmanis v, pikoulis e, karavokyros i, felekouras e, morfaki p, haralambopoulou g, et al. acute appendicitis: the reliability of diagnosis by clinical assessment alone. scand j surg. 2005;94(3):201–6. 10. chandrasegaram md, rothwell la, ethan i, miller rj. pathologies of the appendix: a 10-year review of 4670 appendectomy specimens. anz j surg. 2012;82(11):844– 7. 11. zulfikar i, khanzada tw, sushel c, samad a. review of the pathologic diagnoses of appendectomy specimens. annals of king edward medical university. 2009;15(4):168–70. 12. namsawang p. pathological findings of vermiform appendix in surin hospital. medical journal of srisaket surin buriram hospitals. 2009;24(1):199–208. 13. shrestha r, ranabhat sr, tiwari m. histopathologic analysis of appendectomy specimens. journal of pathology of nepal. 2012;2(3):215–9. 14. sgourakis g, sotiropoulos gc, molmenti ep, eibl c, bonticous s, moege j, et al. are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coprolith? world j gastroenterol. 2008;14(20):3179–82. 15. sujata j, zeeba j, siafia r. appendicitishistology specific incidence trends in a semi urban population in new delhi: a study of 262 cases. bangladesh j med sci. 2012;11(3):201–205 16. monajemzadeh m, hagghi-ashtiani m, montaser-kouhsari l, ahmadi h. pathologic evaluation of appendectomy specimens in children. iran j pediatr. 2011;21(4):485–90. 17. igho oe. unusual histological findings of the appendix following appendectomy, a ten year histopathologic study. continental j biomedical sciences. 2012;6(1):41–5. 18. lamps lw. infectious causes of appendicitis. infect dis clin north am. 2010;24(4):995–1018. 19. barreto sg, travers e, thomas t, mackillop c, tiong l, lorimer m, et al. acute perforated appendicitis: an analysis of risk factors to guide surgical decision making. indian j med sci. 2010;64(2):58–65. 20. uba a, lohfa e, ayuba m. childhood acute appendicitis: is routine appendicectomy advised? j indian assoc pediatr surg. 2006;11(1):27–30. tara zhafira, herry yulianti, maman wastaman r: histopathologic distribution of appendicitis at dr. hasan sadikin general hospital, bandung, indonesia, in 2012 althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 58 amj march 2017 incidence of postoperative nausea and vomiting in dr. hasan sadikin general hospital bandung period may to october 2013 aisyah ummu fahma,1 iwan fuadi,2 jimmy setiadinata3 1faculty of medicine, universitas padjadjaran, 2department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anantomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: postoperative nausea and vomiting (ponv) is common complication in patients undergoing surgery with anesthesia. the incidence of ponv is ranging between 20% and 30%. despite many other studies about ponv in other regions, the descriptive data about ponv in dr. hasan sadikin general hospital bandung is still unknown. the aim of this study was to determine the incidence of ponv in dr. hasan sadikin general hospital bandung. methods: this descriptive study used a cross-sectional method. as many as 521 medical records in departement of anesthesiology and intensive care dr. hasan sadikin general hospital bandung from may 5th to october 31st 2013 were reviewed. the subjects were taken by using total sampling technique. data collected were gender, age, type of surgery, type of anesthesia, duration of surgery, administration of nitrous oxide, and administration of neostigmine. results: of 521 patients,the incidence of ponv was 20.5%. female had higher incidence of ponv than male. postoperative nausea and vomiting was the most frequent in the age category 6−20 years old. the ear nose and throat (ent) surgery was revealed as surgery with the highest incidence. regional anesthesia had a higher incidence than general anesthesia. operation lasting 181−210 minutes was considered as category which ponv mostly occured. patients receiving nitrous oxide were more likely to experience ponv, and patients who were given neostigmine as muscle relaxant had lower incidence of ponv compared to those who were not. conclusions: the incidence of ponv was similar to the study presumed earlier and this may influenced by many factors including patients, surgical, and aenesthtical factor. [amj.2017;4(1):58–63] keywords: anesthesiology, incidence, postoperative nausea, vomiting. correspondence: aisyah ummu fahma, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85263862979 email: aisyah.fahma@ymail.com introduction postoperative nausea and vomiting (ponv), is defined as nausea and/or vomiting occuring within 24 hours after surgery. the ponv is a common problem following surgery and anesthesia and it is anesthesiology’s “big little problem”. some efforts are focused on strategies to reduce the frequency of this problem. nausea is an unpleasant sensation in the epigastrium that is associated with an urge to vomit while vomiting is the forceful expulsion of gastric contents. avoiding ponv becomes the main priority for doctors and patients. ponv is still a big problem, besides dissatisfaction and discomfort of the patient and healthcare staff, medical risks such as increased abdominal pressure, increased central venous pressure, aspiration of gastric contents, sympathetic nervous system response with increasing blood pressure and heart rate as well as parasympathetic responses producing bradycardia and hypotension. it also results in increased morbidity, prolonged post anesthesia care unit stays and increased cost related to length of hospital stay. most patients consider that nausea and vomiting is more disturbing than the operation itself.1−5 nausea and vomiting in the postoperative period occurs in 20% to 30% of patients. in10% althea medical journal. 2017;4(1) 59 of patients, ponv occurs in recovery room and in 30% patients 24 hours after surgery. the incidence of ponv varies with many potential causes.this depends on involving anesthetic agents, the type of procedure, and patient factors.2,3,6,10 despite many other studies about ponv in the other regions, the descriptive data about the incidence of ponv in dr. hasan sadikin general hospital bandung is still unknown. considering the huge effects of ponv, this study was aimed to determine the incidence of ponv in dr. hasan sadikin general hospital bandung. methods this cross-sectional descriptive study was conducted in the department of anesthesiology and intensive care, dr. hasan sadikin general hospital bandung. this study collected and analyzed data from medical records of postoperative patients in dr. hasan sadikin general hospital bandung from may 5th to october 31st 2013 that were selected by using total sampling method. inclusion criteria of this study was all the patients who had undergone elective surgery with anesthesia and was in recovery room 2 hours postoperative. incomplete medical record was excluded from this study. data were collected and analyzed based on gender, age, types of surgery, types of anesthesia, duration of surgery, administration of nitrous oxide, and administration of neostigmine. secondary data were collected from each subject, then organized and analyzed using descriptive statistical analysis. frequency and percentage of the mentioned variables were calculated. table 1 distribution of postoperative nausea and vomiting based on age age (year) population (n) frequency of ponv percentage <1 9 0 0 1−5 16 0 0 6−20 70 19 27.1 21−30 54 5 9.2 31−60 290 64 22.1 >60 82 19 23.2 total 521 107 20.5 aisyah ummu fahma, iwan fuadi, jimmy setiadinata: incidence of postoperative nausea and vomiting in dr. hasan sadikin general hospital bandung period may to october 2013 table 2 distribution of postoperative nausea and vomiting based on types of surgery type of surgery population (n) frequency of ponv percentage pediatric surgery 10 0 0 digestive surgery 125 30 24.0 oral surgery 35 4 11.4 plastic surgery 39 2 5.1 neurological surgery 17 1 5.9 genitourinary surgery 34 9 26.5 gynecological surgery 92 16 17.4 oncology surgery 80 23 28.8 ortophaedic surgery 54 11 20.4 ent surgery 25 9 36.0 thorax and cardiovascular surgery 10 2 20.0 total 521 107 20.5 note: ent=ear nose and throat althea medical journal. 2017;4(1) 60 amj march 2017 results in total, 521 postoperative patients were analyzed. incidence of ponv in dr. hasan sadikin general hospital bandung was 20.5% which occurred on 107 post-operative patients. the ponv on female (22.6%) was 1.3 times more prevalent than male (17.7%). ponv was more frequent among patients age 6 to 20 years old (27.1%) (table 1). the ear nose and throat (ent) surgery was the most frequent cause of postoperative nausea and vomiting (36.0%), followed by oncology surgery (28.6%) and genitourinary surgery (26.5%) (table 2). patients who had undergone surgery with regional anesthesia, would have a higher risk of ponv (27.5%)(table 3). the highest percentage of postoperative nausea and vomiting based on duration of surgery was on category 181−210 (50.0%) (table 4). incidence of ponv is higher on patient who have received nitrous oxide (22.7%) than those who have not (table 5). incidence of ponv increased among patients who had not received neostigmineand allowed to recover spontaneously from muscular blockade (26.5%)(table 6). discussions the ponv is one of the commonest postoperative complication which sometimes is more disturbing than the operation itself. the complex act of vomiting is controlled by the emetic center in which can be stimulated table 3 distribution of postoperative nausea and vomiting based on types of anesthesia type of anesthesia population (n) frequency of ponv percentage general anesthesia 481 96 19.9 regional anesthesia 40 11 27.5 total 521 107 20.5 table 4 distribution of postoperative nausea and vomiting based on duration of surgery duration of surgery (minutes) population (n) frequency of ponv percentage <30 10 0 0 30–60 45 9 20.0 61–90 17 1 5.9 91–120 139 21 15.1 121–150 43 11 25.6 151–180 145 30 20.7 181–210 8 4 50.0 211–240 59 21 35.6 241–270 2 0 0 271–300 18 5 27.8 301–330 − − − 331–360 20 2 10.0 361–390 3 0 0 391–420 2 0 0 421–450 − − − 451–480 10 3 30.0 total 521 107 20.5 althea medical journal. 2017;4(1) 61aisyah ummu fahma, iwan fuadi, jimmy setiadinata: incidence of postoperative nausea and vomiting in dr. hasan sadikin general hospital bandung period may to october 2013 by several areas, including afferents from pharynx, gastrointestinal tract, mediastinum, as well as afferent from the higher cortical centers and the chemoreceptor trigger zone (ctz) in the area postrema.5,12 there are many surgery procedures and aenesthetic drugs which are able to stimulate the emetic center.7 ponv is influenced by many factors, they are patient, surgical, aenesthetic and postoperative factor.11 according to the study’s result, the incidence of ponv in dr. hasan sadikin general hospital bandung from may 5th to october 31st 2013 was 20.5%. based on literature, incidence of ponv was ranged between 20% and 30%.8,9 nausea and vomiting in females was about 1.3 times as common as in males. koivuranta et al.14 reported that the proportion of females was about twice as male and men are generellay less succeptible to nausea.10,12 based on other studies, female sex was an important risk factor for ponv that maybe caused by variations in serum gonadotropin or other hormon levels. some studies were even concerned with the relationship of ponv and phase of menstrual cycle. particularly, female who is on 3rd−4th week of their menstruation cycles was more tend to experience ponv caused by changing and high level of progesteron, estrogen and gonadotropin hormone level.8,11,12 furthermore, female who undergone gynecology surgery increase the risk of ponv caused by stimulation of afferents in uterus, broad ligament and cervix.15 incidence of ponv was higher in category age 6−20 years old. based on theories, the percentage of ponv on patient’s age that is less than 12 months is low. infant and adolescent patients have an increased risk ponv. ponv decreases as patient age. it is unclear whether this resulted purely from age itself or difference of aenesthetic drugs used and surgical procedure performed.7 in the present study, there was variation in the incidence of ponv based on the type of surgery. the study results showed that the highest percentage of ponv was on category of ent surgery, followed by the patients with oncological surgery, and genitourinary surgery. according to the literature, the procedure on middle ear will stimulate vestibular afferent nerve that will stimulate the vomiting center.7,8,10,11 despite the high incidence of ponv in surgeries mentioned earlier, ponv was also common in patients with digestive surgery, and ortophaedic surgery. it has to be noted that the emetic center is stimulated by several visceral afferents including digestive tract, and manipulation in this area could activate gastrointestinal responses.1,7,10 also, laparoscopy was one of the procedure performed in digestive surgery. based on the references, laparoscopic surgeries was known to be a risk of ponv. it might be due to increase in carbondioxide absorbtion into the intestine and increase intraabdominal pressure.11 another literature showed that incidence of ponv was also high in orthopaedic procedure, but the mechanism was still unclear.8 this study results revealed that patients who received regional anesthesia were more table 5 distribution of postoperative nausea and vomiting based on anesthesia inducing agent agent used for anesthesia maintenance population (n) frequency of ponv percentage nitrous oxide 317 72 22.7 without nitrous oxide 204 35 17.2 total 521 107 20.5 table 6 distribution of post operative nausea and vomiting based on administration of reverse muscle relaxant agent used for recover from muscular blockade population (n) frequency of ponv percentage neostigmine 404 76 18.8 without neostigmine 117 31 26.5 total 521 107 20.5 althea medical journal. 2017;4(1) 62 amj march 2017 likely to experience ponv than patients with general anesthesia. meanwhile, a study conducted by aftab et al.13 in karachi reported that patients who received general anesthesia experienced three times more incidence of ponv, compared to regional anesthesia. this differences might be due to the limitation of the study. according to the study results, the highest percentage of ponv based on duration of surgery was on category 181−210 minutes (50.0%). the study conducted by ku et al.8 in singapore reported that the incidence of ponv was 2.7% in surgery with duration less than 30 minutes, and 27.7% in patients with operation lasting 150−180 minutes. this possibilities might happen because in long duration of surgery, patient received larger number of potentially emetic drug.7 in this study, incidence of ponv in patients receiving nitrous oxideas anesthetic maintenance is 5.5% higher than who did not. this was similar to the study conducted by doubravska et al.11 which noted that the incidence of ponv innitrous oxide were higher than those not (15.8% vs 2.4%). earlier study suggested that nitrous oxide causes stimulation of the medullary periventricular dopaminergic system, which includes the ctz, and this could be responsible for the nausea and vomiting observed after nitrous oxide anaesthesia.8 according to the study results, the incidence of ponv in patients receiving neostigmine as muscle relaxant and patients who spontaneously recovered from muscular blockade were 18.8% and 26.5% respectively, while the study conducted by kim et al.15 reported that patients treated with neostigmine had higher rates of ponv (68% vs 32%).this discrepancy may attributable due to the limititation of the study. from 521 respondents who had undergone elective surgery with anesthesia at the dr. hasan sadikin general hospital, 20.5% experienced postoperative nausea and vomiting. female has the highest incidence based on gender. patients aged 6-20 years old, patients with ent, oncological and genitourinary surgery had an increased risk of ponv. based on category of anesthesia, ponv in patients receiving regional anesthesia was more common. based on duration of surgery, category 181-210 minutes was the highest duration on the incidence of ponv. the ponv was more prevalent to patients receiving nitrous oxide than those who did not. patients who were given neostigmine as reverse muscle relaxant had a lower incidence of ponv than the patients who recovered spontaneously. reccomendation of this study is about data completeness in medical record should be corrected. many incomplete data made difficult to find the exact result. to know more about ponv, for further research, it needs to be conducted with larger population and more variable included. references 1. mccracken g, houston p, lefebvre g. guideline for the management of postoperative nausea and vomiting. j obstet gynaecol can. 2008;30(7):600−7. 2. finks jf. complication of laparoscopic surgery. in: mulholland mw, doherty gm, editors. complication in surgery. 2nd ed. philadelphia: lippincott william & wilkins; 2011. p. 529. 3. fowler ma, spiess bd. post anesthesia recovery. in: barash, g. p, cullen, f b, editors. clinical anesthesia. 6th ed. philadelphia: lippincott william & wilkins; 2009. p. 1441. 4. apfel cc, korttila k, abdalla m, kerger h, turan a, vedder i, et al.. a factorial trial of six interventions for the prevention of postoperative nausea and vomiting. n engl j med. 2004;350(24):2441−51. 5. riad w, marouf h. combination therapy in the prevention of ponv after strabismus surgery in children: granisetron, ondansetron, midazolam with dexamethasone. middle east j anesthesiol. 2009;20(3):431−6. 6. mansour, nassef a, moussa ma, ashraf a. effect of preoperative hydration on postoperative nausea and vomiting. bull alex fac med. 2007;43(4):1037–41. 7. islam s, jain pn. post-operative nausea vomiting (ponv): a review article. indian j anaesth. 2004;48(4):253−8. 8. norred cl. antiemetic prophylaxis: pharmacology and therapeutic. aana j. 2003;71(2):133−40. 9. chatterjee s, rudra a, sengupta s. current concepts in the management of postoperative nausea and vomiting. anesthesiol res prac. 2011;2011:748031. 10. doubravska l, dostalova k, fritscherova s, zapletalova j, adamus m. incidence of postoperative nausea and vomiting in patients at a university hospital. where are we today? biomed pap med fac univ palacky olomouc czech repub. 2010;154(1):69−76. althea medical journal. 2017;4(1) 63 11. ku cm, ong bc. postoperative nausea and vomiting : a review of current literature. singapore med j. 2003;44(7):366−74. 12. apfel cc. postoperative nausea and vomiting. in: miller rd, editor. miller’s anesthesia. 7th ed. california: elsevier; 2005. p. 86. 13. east jm, mitchell di. postoperative nausea and vomiting in laparoscopic versus open cholecystectomy at two major hospital in jamaica. west indian med j. 2009;58(2):130−7. 14. kim s, shin y, oh y, lee j, ching s, choi y. risk assessment of postoperative nausea and vomiting in the intravenous patientcontrolled analgesia environment: predictive values of the apfel’s simplified risk score for identification of high-risk patients. yonsei med j. 2013;54(5):1273−81. 15. aftab s, khan ab, raza g. the assessment of risk factors for postoperative nausea and vomiting. j coll physicians surg pak. 2008;18(3):137−41. aisyah ummu fahma, iwan fuadi, jimmy setiadinata: incidence of postoperative nausea and vomiting in dr. hasan sadikin general hospital bandung period may to october 2013 247 althea medical journal. 2017;4(2) hemoglobin level, energy intake, and body mass index of kebersihan, keindahan, kenyamanan lingkungan workers in an academic institution carmelia cantika maharani,1 reni farenia,2 pandji irani fianza3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: productivity is a priority that is required from every worker. work productivity of each person is different. the important factors of work productivity are hemoglobin level, energy intake, and body mass index (bmi). the objective of the study was to identify hemoglobin level, energy intake, and bmi of kebersihan, keindahan, kenyamanan lingkungan (k3l) workers in universitas padjadjaran, jatinangor. methods: a descriptive study was carried out to 80 k3l workers in universitas padjadjaran on october 2014. the total number of 80 workers was chosen with cluster random method. primary data consisted of hemoglobin level measured by hemocue®hb 201+, dietary consumption recall (2x24 hours), and anthropometry data (weight and height). the collected data were analyzed and presented by frequency tabulation and percentage. results:the study showed that more than a half of subjects (77%) had normal hemoglobin level. the majority of subjects (47%) had low energy intake. most of subjects (59%) had normal bmi, 12% subjects were underweight, 18% subjects were overweight, and 11% subjects were obesity. conclusions: the majority of k3l workers have normal hemoglobin level, energy intake deficiency, and normal bmi. keywords: body mass index, energy intake, hemoglobin. correspondence: carmelia cantika maharani faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287774623773 email: carmeliacantika@gmail.com introduction productivity is a priority that is required from every worker. internal factors that determine work productivity consist of health, nutrition, education, and motivation of workers. health factors which related significantly to work productivity is hemoglobin level in blood.1 low hemoglobin level will reduce the ability to perform physical activity due to decrease of oxygen exchange efficiency in skeletal muscle. thus, anaerobic metabolism occurs and it produces lactic acid.2 the accumulation of lactic acid leads to muscle fatigue and slow muscle work continuity, hence decrease the work capacity.2 wolgemuth et al.1 showed that 1.3 g/dl increase in hemoglobin level was associated with 5.6% significant productivity gains of road workers in kenya. besides hemoglobin level, energy intake has an important role in work productivity. deficiency energy intake leads to lack energy to work and do activities.3 study had shown that energy deficiency may decrease work capacity ;thus decrease work productivity.4 workers who have normal body mass index (bmi) would have higher productivity rather than those who have underweight and overweight bmi.3,5,6 underweight bmi indicates chronic energy deficiency meanwhile overweight and obese bmi make workers slow and inhibit in work. universitas padjadjaran as one of the leading academic institutions/universities in indonesia, has kebersihan, keindahan, kenyamanan lingkungan (k3l) workers who has important role in keeping the university tidy and clean. the k3l workers consist of 415 workers ,and were already divided into eight group based on different working area. each working area has different coverage, ranged between 15.682 m2 to 81.288 m2. amj. 2017;4(2):247–51 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1089 althea medical journal. 2017;4(2) 248 amj june 2017 therefore, each worker has 341 m2-1,767 m2 working area. the k3l workers work from 7 a.m. until 3 p.m. wide working area and long working hours make k3l workers need to be healthy, so they have an optimal condition; thus leads to high productivity. an indicator of k3l workers’ productivity can be observed by their attendance record. mean attendance of workers in a month reached 65-85%. according to the interview with chief of k3l, he stated that many workers only worked for half day. the objective of the study was to identify the hemoglobin level, energy intake, and bmi of kebersihan, keindahan, kenyamanan lingkungan (k3l) workers in universitas padjadjaran, jatinangor. methods this study was carried out using descriptive method on october 2014 in jatinangor. the population of this study was 415 of k3l workers. the criteria of study sample were k3l workers who work in universitas padjadjaran jatinangor in 2014. the total number of 80 workers was chosen with cluster random method. ten workers were chosen randomly from each eight working area. primary data consisted of hemoglobin level, energy intake, and anthropometry data (weight and height). blood samples were taken for hemoglobin measurement using peripheral blood. hemoglobin level was measured by hemocue®hb 201+ then classified into world helath organization (who) category. energy intake measured by 24 hours dietary recall (2x24 hours). dietary habits were investigated to determine the adequacy of workers’ diet particularly for calories. the interviewer investigated all of food consumed by subjects in the last 24 hours for two times without consecutive manner. data were collected in household measurements then it converted into gram unit. then the dietary data were analyzed by using nutrisurvey application. the energy intake data from the application were categorized into recommended daily allowance (rda) 2004.7 meanwhile the height was measured by microtoise (accuracy 0.5 cm) and weight was measured by weight scales camry (accuracy 0.1 kg). after that, bmi was calculated by equation weight(kg) / height2 (m2). the result would be classified into bmi category according to ministry of health republic of indonesia 2003. this study had been approved by health research ethics committee faculty of medicine universitas padjadjaran. results study samples were 80 workers with equal proportions between females and males, 40 (50%) workers. study subjects were differentiated into females and males because of having differentiation in cut off hemoglobin, energy intake, and bmi categories. all of the study subjects were in productive age. productive age ranged from 15 to 64. most of study subjects were in age group 30-49. mean of the age of study subjects was 37. age factors should be concerned because it has influence in energy intake requirement of each individual. table 1 characteristics of study subjects (n=80) characteristics females males total % n= 40 n= 40 n= 80 age (year) 19−29 7 18 25 31 30−49 29 17 46 58 50−64 4 5 9 11 educational background not graduated from elementary school 6 4 10 13 elementary school 19 17 36 45 junior high school 10 11 21 26 senior high school 5 8 13 16 249 althea medical journal. 2017;4(2) carmelia cantika maharani, reni farenia, pandji irani fianza: hemoglobin level, energy intake, and body mass index of kebersihan, keindahan, kenyamanan lingkungan workers in an academic institution table 2 frequency distribution of hemoglobin level category hemoglobin level category females males total n % n % n % low 11 28 7 18 18 23 normal 29 72 33 82 62 77 total 40 100 40 100 80 100 the classification of age group was adjusted with age category in rda (2004). almost half of the study subjects (45%) had the last educational background in elementary school and even 13% had not finished elementary school (table 1). mean of hemoglobin level of females subjects was 12.76±1.35 g/dl. instead, mean of hemoglobin level of males subjects was 14.19±1.48 g/dl. as shown in table 2, most of the study subjects had normal hemoglobin. 23% subjects had low hemoglobin level, consist of 28% females and 18% males. frequency of low hemoglobin or anemia was greater in females than males. as shown in table 3, the lowest mean energy intake was recorded in 19−29 age group females and 50−64 age group males. in females subject, the highest mean energy consumption level was presented in 30−49 age group females, and 19−29 age group males. as shown in table 4, 37 (47%) study subjects had less energy intake than the recommendation. females subjects have greater number of workers who had exceeded energy intake category than males. the frequency of study subjects that had exceeded energy intake was 13%. means of bmi study subjects were 24.79±4.16 in females and 20.60±4.04 in males. the highest bmi was presented by females and the lowest bmi was in males. as shown in table 5, this study discovered that 59% subject had normal bmi. besides, 12% subjects had underweight bmi consisting of 3% females ,and 20% males. subject with bmi status obesity was 11% ,and all of them was females. table 3 energy intake of study subjects age (year) females males mean±sd* (kcal**) max (kcal) min (kcal) mean consumption level (%rda#) mean±sd (kcal) max (kcal) min (kcal) mean consumption level (%rda) 19−29 1585.23±492 2485.8 111.3 83.5 2003±624 3697.8 1124.3 82 30−49 1774.10±448 2773.2 1147 93.7 1920.3±338 2576.6 1307.3 80 50−64 1659.67±438 2160.6 1214.4 91.2 1906.3±194 2174.3 1695.8 92.5 total 1729.61±449 2773.2 1111.3 91.6 1955.8±472 3697.8 1124.3 82 note: * standard deviation, ** kilocalories, # recommended daily allowances table 4 frequency distribution of energy intake category energi intake category females males total n % n % n % low 16 40 21 53 37 47 normal 16 40 16 40 32 40 excess 8 20 3 7 11 13 total 40 100 40 100 80 100 althea medical journal. 2017;4(2) 250 amj june 2017 discussion ithe results of this study showed that more than half of subjects had normal hemoglobin level. approximately 23% subjects had anemia which consists of 11 females subjects, and 7 males subjects. the proportion subjects that had anemia were greater in females subjects (61%). these findings are similar to those of wolgemuth et al.1, sinclair and hinton8, pasricha et al.9 that prevalence of anemia was greater in females than males. women are more susceptible to have anemia because of inadequate iron, and protein intake, inadequate absorption, or increase demand of iron as in menstrual period, pregnancy, and lactation.9 despite most of study subjects had normal hemoglobin level category. about more than 90% subjects had marginal hemoglobin level between normal and low. it can be caused by the lack variation of food consumed by study subjects, such as lack of red meat, and vegetables consumption. this study’s result similar to the findings in kenyan workers.1 this study had 47% subjects who had deficiency energy intake based on rda 2004. the recommendation requirement of energy intake of females subjects whose 19−29 age group is 1900 kcal. females subjects whose age group 30−49 needs 1800 kcal while subjects in age group of 50−64 needs 1750 kcal. the requirement of energy intake of males subjects whose 19−29 age group is 2550 kcal. males subjects whose age group 30−49 needs 2350 kcal while subjects inage group of 50−64 needs 2250 kcal.8 this study showed that subjects who had the lowest energy intake were age group 50−64. there is 5% reducing of energy requirements as it increases with age in 50−64 that may have contributed into the result of this study.7 study had proven that energy intake deficiency leads to reduce energy production in body ;thus it results in lower productivity.3 if the amount of energy is not sufficient, our body will break down the energy reserves.2 deficiency energy intake in the study subjects may have been caused by lacking knowledge of good nutrition. the highest educational level reached by this study subjects was senior high school and most of them had latest educational level in elementary school. as the increase of educational level, there is increase in health, and nutrition’s knowledge.10 low socioeconomic level may have influenced the ability to purchase food. besides most of the study subjects only ate once or twice in a day with none or rare consumed snacks. this result was similar to those reported in factory’s workers in semarang.3,4 workers with most deficiency energy were also found in kenyan workers.1 the proportion of the subjects that had exceeded energy intake was greater in females than males. these findings are similar to those study in bangladesh. they stated that females workers who were better in knowledge, and understanding about relation between food, and health were able to try consuming healthy food.10 better nourished female workers can be caused by their role in foods preparation. since their frequent access to food during its preparation may have contributed the additional quantities of calories to their diets.1 this study showed that 12% study subjects was underweight, 59% was normal, 18% was overweight, and 11% was obesity. the bmi is determined by the equilibrium of energy intake and physical activity. work load of k3l workers were hygiene maintenance such as street cleaning, garbage accumulation and transport, drainage cleaning; also park maintenance such as watering, cleaning, weed cutting, soil crumbling, dried leaf cutting, fertilizing, and pest controlling. low bmi status can be caused by the imbalance between less energy intake but more energy was used in the physical activities of workers. meanwhile, table 4 frequency distribution of bmi category bmi category females males total n % n % n % underweight 1 3 8 20 9 12 normal 18 45 29 73 47 59 overweight 12 30 3 7 15 18 obesity 9 22 0 0 9 11 total 40 100 40 100 80 100 251 althea medical journal. 2017;4(2) study subjects which had normal bmi but low energy intake may have been caused by the difference in the work load proportion of each workers. imbalance state between work load and working hours also may have contributed to this condition. these can be explained by workers with less work load but had the same working hours made the workers to have more less productive leisure time in work . workers who bmi status is overweight and obesity can be explained by their exceeded energy intake with less energy used in work. low work motivation or less work load than others may have contributed to this condition . the result of this study was contrast with utami3 which stated that most of the factory workers had low bmi. however the pieces of study conducted by adrianto and ningrum11 towards semarang factory workers and mahardika and roosita12 towards factory workers in west java revealed similar results that most of their workers had normal bmi. thus, it can be concluded that most of k3l workers have normal hemoglobin level, deficiency energy intake, and normal bmi. limitation of this study was the accuracy of 24 hours dietary recall which depends on study subjects’ memories (recall bias ) and local language problem . it may have contributed in high subjectivity in data collection. adjusting the eating habit of subjects and more complete food model could increase the accuracy of 24 hours dietary recall results. in order to increase worker productivity, it is suggested that the workers should be educated about dietary habit, healthy food resources and nutritional balance. universitas padjadjaran also should give extra feeding in between working hours so the increase of energy intake could increase work productivity. besides universitas padjadjaran should implement further study about physical fitness of workers and the efficiency of work load and working hours. they could also give the workers additional job in their leisure time so the working time would be more efficient and may increase workers’ income. references 1. wolgemuth jc, latham mc, hall a, chesher a, crompton dw. worker productivity and the nutritional status of kenyan road construction laborers. am j clin nutr.1982; 36(1):68−78. 2. guyton ac, hall je. textbook of medical physiology. 11 ed. usa: saunders co. university of mississipi school of medicine; 2005.p.79−80,864−75. 3. utami sr. status gizi, kebugaran jasmani dan produktivitas kerja pada tenaga kerja wanita. kemas. 2012;8(1):74−80. 4. hapsari ob, kartini a. pengaruh minuman karbohidrat elektrolit terhadap produktivitas kerja. journal of nutrition college. 2013; 2(4):564−70. 5. adi dpgs, suwondo a, lestyanto d. hubungan antara iklim kerja, asupan gizi sebelum bekerja, dan beban kerja terhadap tingkat kelelahan pada pekerja shift pagi bagian packing pt. x, kabupaten kendal. jurnal kesehatan masyarakat. 2013; 2(2):1-11 6. adak dk, gautam rk, gharami ak. assessment of nutritional status through body mass index among adult males of 7 tribal populations of maharashtra, india. mal j nutr. 2006; 12(1):23−31. 7. hardinsyah, riyadi h, napitupulu v. angka kecukupan energi, protein, lemak dan serat makanan. prosiding widyakarya nasional pangan dan gizi viii. 2004:p.17−9. 8. sinclair lm, hinton ps. prevalence of iron deficiency with and without anemia in recreationally active men and women. j am diet assoc. 2005;105(6):975−8. 9. pasricha sr, drakesmith h, black j, hipgrave d, biggs ba. control of iron deficiency anemia in lowand middle-income countries. blood. 2013;121(14):2607−17. 10. alam n, roy sk, ahmed t, ahmed am. nutritional status, dietary intake, and relevant knowledge of adolescent girls in rural bangladesh. j health popul nutr. 2010;28(1):86−94. 11. adrianto eh, ningrum dna. hubungan antara tingkat kesegaran jasmani dan status gizi dengan produktivitas kerja. kemas. 2010;5(2):145–50. 12. mahardikawati va, roosita k. aktivitas fisik, asupan energi, dan status gizi wanita pemetik teh di ptpn viii bandung, jawa barat. j gizi pangan. 2008;3(2):79–85. carmelia cantika maharani, reni farenia, pandji irani fianza: hemoglobin level, energy intake, and body mass index of kebersihan, keindahan, kenyamanan lingkungan workers in an academic institution althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 152 amj march 2017 relationship between nutritional status and flat foot in children joyce phua pau fung,1 yoyos dias ismiarto,2 wulan mayasari3 1faculty of medicine universitas padjadjaran, 2department of orthopaedi and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: pediatric flatfoot has been reported as the highest clinical complains for foot problems in pediatric department. nutritional status has showed great influence on the occurrence of flat foot. there are many debates regarding whether underweight or overweight children are more prone to flatfoot. the aim of this study was to analyze the relationship between nutritional status and flatfoot in children. methods: a cross sectional study was conducted from july to october 2015 in 3 primary schools in kecamatan jatinangor. there were 259 children of grade 4 to 5 included in this study. flatfoot screening was based on measurement of footprint and calculation using chippaux-smirak index (csi). the height and weight of children were measured to obtain their body mass index (bmi). nutritional status was classified based on cdc bmi-for-age growth charts. analysis was done using chi-square test. results: there was significant association between nutritional status and flatfoot with p value<0.001.the prevalence of flatfoot in children grade 4to5is40%. when compared to the normal weight children, the overweight children showed prevalence ratio of 1.97(95% ci:1.47 to 2.64) while the underweight children showed prevalence ratio of 1.34 (95% ci:1.78 to 2.25).this stated that the risk of developing flat foot was higher in overweight children. conclusions: there is significant association between nutritional status with children grade4 to 5. overweight children are more prone to flat foot. [amj.2017;4(1):152–6] keywords: chippaux-smirak index, nutritional status, pediatric flat foot correspondence: joyce phua pau fung, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281802263823 email: joycefung37@gmail.com introduction flat foot has been reported as the highest clinical complain for foot problem in pediatric department.1 in 2005, the prevalence of flat foot in children aged 3 to 6 was more than 40%.2 based on the bio med central musculoskeletal disorder research, the prevalence of flatfoot in children of aged 2 to 6 years was between 21% to 57%.3 flatfoot is a condition where the foot arch is collapsed with the entire sole touching the ground. there are 2 types so flatfoot. flexible flatfoot is characterized by flattening of arch during weight bearing and rigid flat foot is characterized by stiff, fixed arch even without weight bearing. many factors are associated with flatfoot. there are ligament laxity, collagen disorder, muscular and neurologic abnormalities.1 foot arch is essential for human gait and support. physiologically, the foot arch not only serves as a shock absorber but it is also ideally distributes the bodyweight. without an arch, the foot will be more rigid leading to a greater impact from our body weight to be transmitted to the skeletal system.4 as times go by, this will lead to the development of musculoskeletal disorders such as spine disorder.5 furthermore, flat foot patient will suffer from pain in their foot, instability as well as limitation in traveling long journey.6 if there is no proper treatment towards this condition, a child might have delay in motor development.7 over decades, there have been many debates regarding the effect of nutritional status towards pediatric flatfoot. based on the research conducted by pfeiffer et al.2, it is postulated that obese and overweight children have a higher prevalence in flatfoot due to excessive loading on the feet. however, there althea medical journal. 2017;4(1) 153 was one research conducted in australia which stated that heavier children had less flatfoot.2,8 this study was carried out to analyze the relationship between nutritional status and flat foot in children. methods a cross sectional study was conducted from july to october 2015 in 3 primary schools located in jatinangor sub-district, sumedang district,west java province, indonesia. the target population was grade 4 to 5 primary school children in kecamatan jatinangor. the samples were selected by multistage sampling method. in the first stage, 3 primary schools were randomly selected from a total of 29 primary schools in kecamatan jatinangor. the selected primary schools were sdn jatiroke 1, sdn paripurna and sdn cikeruh 1. from each selected schools, only children from grade 4 and 5 ranging from 9 to 12 years old were chosen. at this range of ages, the development of foot arch almost reach edit speak and the flatness of foot arch will be more remarkable. lastly, all the children from grade 4 and 5 were included as the research sample, which consist of 288 children. the inclusion criteria in this study were primary school children of grade 4 to 5 in kecamatan jatinangor children who were present in class during data collection, willing to participate and had their parents signed the inform consent form. children who were not in grade 4 to 5 and had any abnormalities in foot besides flatfoot are excluded. all the subjects must fulfill the inclusive and exclusive criteria before being selected as research subject. the study was conducted after obtaining clearance from the health research ethical committee. prior to data collection, informed consent was carried out by explaining the procedure, benefit and risk of this research. clinical diagnosis of flat foot was based on the measurement of footprint obtained and calculation of chippaux-smirak index (csi). foot print method is a standardized method used for flat foot screening.9 in this method, a child was asked to stepped on an ink print mat (podograph) and after a few minutes the child was asked to step on a paper. this was followed by calculation of chippauxsmirak index to determine the percentage of foot arch. chippaux-smirak index is a highly sensitive foot print measurement, having a predictive probability of more than 90%.9 the csi was defined as ratio of the length of line b (narrowest point on foot arch) divided by the length of line a (maximum width at the metatarsals) (b/a×100%).10 csi consist of five categories which were 0%: high arch foot; 0.1% to 29.9%: normal arched foot; 30% to 39.9%: intermediate foot; 40% to 44.9%: low arch foot;>45%:flatfoot.11 in this study, flat foot was diagnosed when either side of the foot had an abnormal depression of the foot arch. the height and weight of the children were measured according to standard procedure.12 the height was measured to the nearest 0.1cm with a calibrated stadiometer (model apahw002) and the weight was measured to the nearest 0.01kg with a calibrated electronic scale. the body mass index was then calculated by dividing weight (kg) by the square root of height. the classification system for children nutritional status according to the cdc bmi for-age growth charts were underweight (<5th percentile), normal (5th percentile to< 85th percentile) and overweight (>85th percentile).13 the data was analyzed using computer. all the data collected were cross checked for completeness and accuracy. chi square test was used to determine the relationship of nutritional status and flat foot in children. the assumption of chi-square must be fulfilled.14 the risk of difference group of nutritional status in developing flat foot is determined by calculating the prevalence ratio. the result is statistically significant when the p value is <0.05. results in this study, the amount of subjects from grade 4 to 5 was 288 children. however, there were 29 children who failed to fulfill the inclusion criteria. thus, only 259 children were included in this study. among the 259 children ranging from 9-12 years old, 103 children were diagnosed to have flat foot. the prevalence of flat foot in this study was 40%. the demographic characteristics of the subjects were shown in table 1. based on the results in table 1, there was no difference in the prevalence of flat foot in male and female children. the median age was homogenous for flatfoot and non flat foot children. the three selected schools have also showed not much difference in the proportion of flat foot in children. the chisquare results were presented in contingency table (table 2). the difference in prevalence of flat foot from the 3 groups of nutrition status was significant with p value <0.001. overweight children showed the joyce phua pau fung, yoyos dias ismiarto, wulan mayasari: relationship between nutritional status and flat foot in children althea medical journal. 2017;4(1) 154 amj march 2017 highest prevalence among the children with flat foot. the results of prevalence ratio were showed in table 2. the normal weight children were used as a control for underweight and overweight children to determine the risk of malnutrition in developing flatfoot. the comparison between normal weight and overweight children were found to be significant with p value <0.001 but the results for comparison between underweight and normal weight children were not significant as the interval crossed.1 this stated that overweight children had a higher risk of developing flatfoot compared to underweight and normal weight children. discussion in this study, the results revealed that there was no difference in the proportion of flatfoot in male versus female children. in most researches, boys were claimed to have a higher prevalence of flatfoot than girls. hazzaa et al.15 reported that the proportion of flatfoot in male was 52% and female was 49%. however, there were also some researches that stated female children had higher prevalence of flatfoot compare to male. this is showed in kachoosangy et al.16 study where the prevalence of flat foot in female was 75.2% male was 72.6%. however, the mechanism that differ the proportion of flatfoot in both sex is not well understood.2,17 the main findings of the study are nutritional status is strongly associated with pediatric flat foot with overweight children as the highest risk of developing flat foot compared to normal weight and underweight children. in this study, the risk of developing flatfoot in overweight children is almost twice higher than underweight children. this finding is consistent with the previous research that reported overweight children had flatter foot compare to normal and underweight children. for example, pfeiffer et al.2 demonstrated that the probability of flatfoot in overweight and obese children were 3 times more than normal weight children. there was a study conducted in spain which reported that the arch height in obese children increased at the rate of 3.7% which is 1.1% slower than the normal weight children.10 however, findings from evans8 demonstrated that flat foot was lesser in heavy children. this table 1 characteristic of subjects characteristics flat foot totalyes no (n=103) (n=156) gender,(%) male (53)40 % (81)60 % 134 female (50)40% (75)60% 125 age,years,median(range) 10(9–12) 10(8–12) 10(8–12) school,(%) sdncikeruh1 (27)40% (40)60% 67 sdnparipurna (44)38% (72)62% 116 sdnjatiroke1 (32)42% (44)58% 76 table 2 association between nutritional status and flatfoot in children nutritional status flat foot flatfoot (%) prevalence ratio (95%ci)*yes no underweight 9 12 43 1.34(0.78 to2.25) normal 58 123 32 1.0 overweight 36 21 63 1.97(1.47 to2.64) note: pvalue <0.001,ci=confident interval althea medical journal. 2017;4(1) 155joyce phua pau fung, yoyos dias ismiarto, wulan mayasari: relationship between nutritional status and flat foot in children is because the results between flatfoot and anthropometric factors in evans’8 study were not significant. there were a few theories that supported the result of this study which stated that overweight children had a higher risk of developing flatfoot. one of them were obese children had higher adiposity underneath the foot, which lowers the height of the foot arch leading to the development of flatfoot.18 according to chougala et al.19, obese children showed higher dynamic and static plantar pressure. this results in structural changes and increase in surface contact between the sole and the ground.19 another theory is that the increased amount of fats in belly contribute to the weakening of surrounding muscles of the foot which can deviate the line of gravity, thus applying greater force on the foot.19 in long term, the internal structure of the foot might develop pathologies and injuries.17 this will predispose to clinical disorder like foot pain, instability, spine injury and scoliosis.5 physicians should be aware that reduction in body weight in overweight children can be effective in management of flat foot. additional research is recommended to study the effect of weight towards flatfoot as part of the management. there were a few limitations in this study. first, this study used a cross sectional design and were unable to prove the causal relationship between the variables. a new prospective study to determine the causal relationship between the variable is recommended. furthermore, this study did not control for genetic and physical activity which are confounding to the results.20 in conclusion, overweight children have greater risk of developing flatfoot than underweight children and normal weight children. references 1. halabchi f, mazaheri r, mirshahi m, abbasian l. pediatric flexible flatfoot; clinical aspects and algorithmic approach. iran j pediatr. 2013;23(3):247 –60. 2. pfeiffer m, kotz r, ledl t, hauser g, sluga m. prevalence of flat foot in preschool-aged children. pediatrics. 2006;118(2):634 –9. 3. shih yf, chen cy, chen wy, lin hc. lower extremity kinematics in children with and without flexible flatfoot: a comparative study. bmc musculoskeletal disorders. 2012;13(1):31– 40. 4. tortora gj, nielsen mt. the skeletal system: the appendicular skeleton. in: principles of human anatomy. 12th ed. new jersey: john wiley & sons, inc; 2014. p. 258 5. taylor ed, theim kr, mirch mc, ghorbani s, tanofsky-kraff m, adler-wailes dc, et al. orthopedic complications of overweight in children and adolescents. pediatrics. 2006;117(6):2167–74. 6. trattler r, trattler s. flat feet: pes planus, fallen arches. in: trattler r, trattler s. better health through natural healing: how to get well without drugs or surgery. 3rd ed. california: north atlantic books; 2013. p. 264 – 5 7. chen kc, tung lc, tung ch, yeh cj, yang jf, wang ch. an investigation of the factors affecting flatfoot in children with delayed motor development. res dev disabil. 2014;35(3):639–45. 8. evans am. the paediatric flat foot and general anthropometry in 140 australian school children aged 7-10 years. j foot ankle res. 2011;4(1):12 –19 9. chen kc, yeh cj, kuo jf, hsieh cl, yang sf, wang ch. footprint analysis of flatfoot in preschool-aged children. eur j pediatr. 2011;170(5):611–7. 10. pita-fernández s, gonzález-martín c, seoane-pillado t, lópez-calviño b, pértegadíaz s, gil-guillén v. validity of footprint analysis to determine flatfoot using clinical diagnosis as the gold standard in a random sample aged 40 years and older. j epidemiol. 2015;25(2):148 – 54. 11. sacco icn, noguera gc, bacarin ta, casarotto r, tozzi fl. alteração do arco longitudinal medial na neuropatia periférica diabética. acta ortop bras. 2009;17(1):13 – 6. 12. cdc. national health and nutrition examination survey: anthropometry procedures manual: national center for health statistics; 2007 [cited 2015 11 november]. available from: http:// w w w. c d c . g o v / n c h s / d a t a / n h a n e s / nhanes_07_08/manual_an.pdf. 13. chung s. body mass index and body composition scaling to height in children and adolescent. ann pediatr endocrinol metab. 2015;20(3):125– 9. 14. mchugh ml. the chi-square test of independence. biochem med (zagreb). 2013;23(2):143–9. 15. hazzaa hh, el-meniawy gh, ahmed se, bedier mb. correlation between gender and age and flat foot in obese children. trends in applied sciences research 2015;10(4):207–15. althea medical journal. 2017;4(1) 156 amj march 2017 16. kachoosangy ra, aliabadi f, ghorbani m. prevalence of flat foot: comparison between male and female primary school students. irj. 2013;11(2):22–4. 17. dowling am, steele jr, baur la. what are the effects of obesity in children on plantar pressure distributions? int j obes relat metab disord. 2004;28(11):1514– 9. 18. mickle kj, steele jr, munro bj. the feet of overweight and obese young children: are they flat or fat? obesity (silver spring). 2006;14(11):1949–53. 19. chougala a, phanse v, erohit khanna e, panda s. screening of body mass index and functional flat foot in adult: an observational study. int j physiother res. 2015;3(3):1037–41. 20. mauch m, grau s, krauss i, maiwald c, horstmann t. foot morphology of normal, underweight and overweight children. int j obes. 2008;32(7):1068–75. althea medical journal. 2017;4(3) 309 identification of pathogen protozoans (cryptosporidium spp and giardia lamblia) from canteen’s water-sources at jatinangor, west java, indonesia komathi nair murugesan,1 ridad agoes,2 sri yusnita irda sari3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: the prevalence of intestinal protozoan infection caused by cryptosporidium spp and giardia lamblia has been rapidly increasing in developing countries. contamination of water-sources by intestinal protozoans can spread infection to humans when it is consumed without any specific treatment. jatinangor is an educational area where many universities are located and many students live in this area. this study aimed to identify the presence of intestinal protozoa (cryptosporidium spp and giardia lamblia) in watersources used by canteens at jatinangor area to detect the magnitude of protozoans intestinal infections. methods: a descriptive cross sectional study was carried out from august to september 2014. raw water samples from reservoir tanks, water containers and tapwater were taken from all canteens located along the main road of jatinangor. samples were centrifuged and divided into two portions; two drops from the first test tube was stained with lugol solution and observed by 2 observers under a light microscope for giardia lamblia, and sediments from the second test tube was stained using acid fast staining then observed for cryptosporidium spp under the light microscope. results: out of 50 samples, 26 were positive for parasites, of which 22 (44%) were contaminated by cryptosporidium spp and 4 (8%) were contaminated by giardia lamblia. conclusions: half of the raw water-sources in jatinangor are contaminated by cryptosporidium spp and giardia lamblia. proper water treatment should be implemented by the owners of the canteens before it is consumed as drinking water. keywords: cryptosporidium spp, giardia lamblia, water-source correspondence: komathi nair murugesan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: komathi920215@gmail.com introduction parasites are known as living organisms which depends on other organism to continue living. it builds a parasitic relationship with the depending organism by living on or in the particular organism.1 humans are wellknown hosts where these parasites choose to live in. parasites which live in the digestive tract of humans are called intestinal parasites. intestinal parasites cause a wide range of parasitic infections in humans.1,2 according to the world health organization (who), intestinal parasite infections have been spreading almost throughout the world with increasing number of occurrence.3 parasites are commonly divided into two major groups: parasitic protozoa and parasitic helminthes. protozoans which are commonly found are cryptosporidium spp and giardia lamblia.2,4 protozoan parasites can be detected through the characteristic of their cyst or oocyst.5 protozoan usually multiply rapidly in host and causes an acute onset of symptoms. the intestinal protozoans are one of the common human gastrointestinal infections.3 intestinal parasitic infection commonly occurs through soil transmitted or waterborne parasites. the transmission mostly goes through fecal to oral route.1 poor sanitation and water supplies often lead to water contamination.6,7 water transmitted intestinal parasites often cause various water-borne diseases involving gastrointestinal tract such amj. 2017;4(3): 309–14 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1175 althea medical journal. 2017;4(3) 310 amj september 2017 as diarrheal diseases.8 indonesia is a high populated country with poor water quality, sanitation and hygiene problems. previous studies have claimed that gastrointestinal disorders particularly diarrhea has been the main problem faced by the citizens.9 jatinangor is a subdistrict in sumedang, west java province which is known as an educational area since many universities are located in this area and many students live in this area. the populationof students has been increasing each year. most of the students have their lunch and dinner in the canteens which are easily found along the main road of jatinangor. these canteens can be a source of infection where intestinal protozoan can be transmitted through contaminated water and food.10 canteens in the student area are often cheap and easily available, however the cleanliness and hygiene has been an issue which often arises due to the location and the water supply to the canteens. the water supply in jatinangor area comes from various water-sources such as from the municipal tap water, river, ground water from dug-wells or bore-holes, spring water and rain water depending on the location. the type of water-source, treatment and storage management towards the water plays a role on the level of contamination of the water by intestinal parasites.11 therefore, the aim of this study was to identify the presence of intestinal parasites (cryptosporidium spp and giardia lamblia) in water-sources used in canteens in jatinangor in order to detect the magnitude of intestinal protozoan infection. methods this descriptive study used the cross sectional method and was carried out from august to september 2014. water-sources which were used by canteens for cooking, washing and also as source of drinking water were collected, while identification of the protozoans was conducted in the parasitology laboratory, faculty of medicine, universitas padjadjaran. the study took place at canteens located along the main road (jalan raya jatinangor) between the the institute of local government (ipdn) and robita dharma corporation which lies at the eastern part of universitas padjadjaran was labelled as the mark point, and samples were collected approximately 500 meters to the left and right direction from the campus. all canteens located along the main road or jalan raya jatinangor were selected using the total sampling method to collect raw water samples. the canteen owners were given an informed consent letter and a questionnaire to be filled in. data from the questionnaires described the characteristics of the canteen such as the type of water-source used, the way of storing water and the kind of water treatment method used. the raw water samples were obtained in a 1.5 liter water container. before collecting the water sample, the water container was rinsed three times using the water sample directly from the water-source thoroughly. this method was used for water sample collection since the identification was intended to find the cyst of the protozoans. the samples were directly brought to the parasitology laboratory of faculty of medicine of universitas padjadjaran and examined by 2 observers. next, the sample was filtered and about 10cc of sample was placed in a centrifugation tube and was centrifuged for 5 minutes at the speed of 2000 rpm. the centrifuged water was then separated into two test tubes (test tube a & b). furthermore, water in test tube a was stained with lugol solution and was observed under the microscope with 40x magnificence for giardia lamblia. then, water in test tube b was stained using modified acid fast staining and cryptosporidium spp was observed via a light microscope with the magnificence of 100x. after the results were obtained, data was presented in a table in the form of frequency and percentage. this study was conducted with the approval of the health research ethics committee, faculty of medicine, universitas padjadjaran and permission from the local authority was given by the hegarmanah subdistrict. results about 80 canteens were identified along the main road in jatinangor, however only fifty canteens participated in the water sample collection as described in figure 1. the number of cryptosporidium spp in raw water-source was higher than of giardia lamblia. however, the number of raw water-source without any presence of cryptosporidium spp and giardia lamblia was slightly higher (table 1). out of 50 samples of raw water collected from the canteens in jatinangor area, 22 (44%) water samples showed positive for cryptosporidium spp and 4 (8%) water samples showed positive for giardia lamblia. it also showed that out of 50 canteens, 24 (48%) water samples were free from these parasites althea medical journal. 2017;4(3) 311komathi nair murugesan, ridad agoes, sri yusnita irda sari: identification of pathogen protozoans (cryptosporidium spp and giardia lamblia) from canteen’s water-sources at jatinangor, west java, indonesia table 1 frequency of intestinal parasites (cryptosporidium spp and giardia lamblia) found in water-sources used by canteens in jatinangor area intestinal parasites n =50 % cryptosporidium spp 22 44.0 giradia lamblia 4 8.0 others entamoeba coli 2 4.0 naegleria fowleri 4 8.0 negative 18 36.0 figure 1 the location of study site (table 1). a high number of canteens got their watersource from deep wells either dug-well or bore-hole, while spring water was usually distributed through pipes from the area of manglayang hill, while municipal tap water was only available in the area of the institute of local government. moreover, 47 (94%) of the canteens got their water-source from ground water. out of the 47 samples 20 were positive for cryptosporidium spp and 4 were positive for giardia lamblia. spring water used by 2 (4%) of the canteens contained cryptosporidium spp. municipal tap water was only used by 1 (2%) canteen and it was negative for both the protozoans (table 2). from the type of water-source used, the water tank reservoir was mostly used to store raw water for daily usage; this type of reservoir was usually located outside the house. followed by the water container which was placed inside the house, and also the direct tap water from the municipal water company (table 3). furthermore, 92% of the canteens stored their water in a water-tank reservoir, almost half of the water was contaminated and mostly with cryptosporidium spp. all of the water in the water-container was contaminated with cryptosporidium spp. however, municipal tapwater showed no contamination (table 3). the water-sources were used for cooking, washing and as a source of drinking water. only 29 out of 50 canteens clean the watercontainer minimal once in a year. besides, the practice of storage cleaning and water contamination showed only 34.4% of the water was contaminated if the water storage althea medical journal. 2017;4(3) 312 amj september 2017 was cleaned minimal once in a year, compared to 76.2% of the water contamination if the storage was never cleaned (table 4). discussion based on the study performed, the results showed that 22 (44%) of the samples were positive for cryptosporidium spp. this protozoa is not easily eliminate by chlorination, the cysts are able to withstand in chlorine water for about 3.5 to 10.6 days.12,13 however, boiling the water is still effective as water treatment method for most protozoan cysts. the outcome for giardia lamblia was much lower compared to cryptosporidium spp, which was 4 (8%) positive, since cryptosporidium spp survives longer compared to giardia lamblia in water.13 giardia lamblia cyst can be in any environmentally exposed water-sources but to increase the identification, a high sensitivity method and big sample size should be used.14 apart from that, the contamination by giardia lamblia is closely related to the weather condition.14 throughout the period of the study, jatinangor was experiencing a dry season which could be the reason for the altered outcome. besides, it was noticed that out of 50 water samples 24 (48%) was negative for cryptosporidium spp and giardia lamblia. the study showed that most of the canteens in jatinangor area used deep wellwater as their raw water-source. the deep well-water has higher contamination rate for cryptosporidium spp and giardia lamblia15, particularly unprotected deep well can be easily contaminated by animal and human feces.6,16 municipal tap-water had negative for both the parasites, this might be due to the proper treatment before the water was distributed to the consumers through the pipe distribution. apart from that, the most common water storage used by the canteens in jatinangor area was the water tank reservoir, which could accumulate about 1000 liter of water and was usually placed at the attics or the rooftop of the building. it was usually made out of polypropylene plastic or stain-less steel. from the data collected, it showed that the water tank reservoir had the highest level of contamination, followed by the water container inside the house which came in smaller size than the tank, and was usually easily moved and stored. lastly, the municipal tap-water is a water system from the community water system supplied through a pipeline directly to the households which again showed zero contamination. additionally, water storage cleaning is essential to reduce the risk of contamination; most of the water storage which have never been cleaned regularly are known to be table 3 type of water storage and intestinal protozoan contamination type of water storage (n=50) cryptosporidium spp (n,%) giardia lamblia (n,%) negative results (n,%) total (n,%) water tank reservoir (n=46) 20 (40) 4 (8) 22 (44) 46 (92) water container (n=3) 2 (4) 0 1 (2) 3 (6) municipal tap water (n=1) 0 (0) 0 (0) 1 (2) 1 (2) table 2 type of water-source and intestinal protozoan contamination type of water source (n=50) cryptospordium spp (n,%) giardia lamblia (n,%) negative results (n,%) total (n,%) deep well water (n=47) 20 (40) 4 (8) 23 (46) 47 (94) municipal tap water (n=1) 0 (0) 0 (0) 1 (2) 1 (2) spring water (n=2) 2 (4) 0 (0) 0(0) 2 (4) table 4 water storage cleaning and intestinal protozoan contamination water storage cleaning cryptosporidium spp giardia lamblia % minimal once in a year (n=29) 9 1 34.4 never (n=21) 13 3 76.2 althea medical journal. 2017;4(3) 313 contaminated by the intestinal protozoans. cryptosporidium spp and giardia lamblia are resistant towards chlorination therefore, they could survive,17 however cleaning the water storage regularly might reduce the risk of contamination. further proper water treatment is still needed before consuming the water as drinking water. the study was conducted with a minimal number of samples due to the time limitation, and many of the canteens refused to participate in the study. therefore, the sample should be increased to obtain a more significant outcome. on top of that, most of the water-sources obtained were from deep wells, therefore this would have affected the outcome. in a further study, samples should be taken from more various sources. due to the time limitation, water-sources can be only obtained from canteens located along jalan raya jatinangor and not further than that. moreover, a further study should be conducted during the whole year to identify the protozoans in the dry and wet seasons. during this study the climate in jatinangor was not favorable, as the dry seasons reduce the risk of water contamination.18,19 lastly, a further study is recommended since this study was only carried out specifically on water-sources which was used for washing, rinsing and cooking, thus identification of intestinal parasites in drinking water should be conducted in the future to figure out the effectiveness of water treatment. giardia lamblia has been detected positive in such low percentage due to its method used; a higher sensitivity method such as polymerase chain reaction (pcr) should be used to identify the intestinal parasites. it can be concluded, that cryptosporidium spp is the most protozoan that contaminates the water, and deep well-water has a higher range of contamination compared to other water-sources. therefore, further treatment should be performed such as boiling the water until it is at rolling boil temperature, which has higher chances of eliminating the parasites.20 owners of a canteen should be also well guided towards maintaining better water treatment and hygiene. besides, watersources and cleanliness of canteens should be regularly monitored by the higher authorities. lastly, the community should be counseled about the importance of water, hygiene and sanitation. references 1. brooks gf, carroll kc, butel js, morse sa, mietzner ta. medical parasitology. in: sakanari ja, mckerrow mjh, editors. jawetz, melnick & adelberg’s medical microbiology. 25th ed. new york: the mcgraw-hill companies; 2010. p. 665–72. 2. haque r. human intestinal parasites. j health popul nutr. 2007;25(4):387–91. 3. mchardya ih, wua m, shimizu-cohena r, couturierb mr, humphriesa rm. detection of intestinal protozoa in the clinical laboratory. j clin microbiol. 2014;52(2):712–20. 4. cacciò sm, thompson r, mclauchlin j, smith hv. unravelling cryptosporidium and giardia epidemiology. trends parasitol. 2005;21(9):430–7. 5. carmena d, aguinagalde x, zigorraga c, fernández-crespo jc, ocio ja. presence of giardia cysts and cryptosporidium oocysts in drinking water supplies in northern spain. appl microbiol. 2006;102(3):619– 29. 6. ayalew d, boelee e, endeshaw t, petros b. cryptosporidium and giardia infection and drinking water sources among children in lege dini, ethiopia. tropical medicine & international health. 2008;13(4):472–5. 7. lim yal, ahmad r a, smith h v. current status and future trends in cryptosporidium and giardia epidemiology in malaysia. j water health. 2008;6(2):239–254. 8. fletchera sm, stark d, harkness j, ellisa j. enteric protozoa in the developed world: a public health perspective. clin microbiol rev. 2012;25(3):420–49 9. indonesia unicef. water, sanitation & hygiene. 2012 [cited 2014 july 14 ]; available from: http://www.unicef.or.id/. 10. dawson d. foodborne protozoan parasites. intl j food microbiol. 2005;103(2):207–27. 11. who. water, sanitation, hygiene and health. world health organization; 2012 [cited 2014 july 15]; available from: http://www.who.int. 12. yoder js, wallace rm, collier sa, beach mj, hlavsa mc. cryptosporidiosis surveillanceunited states 2009–2010.morbidity and mortility weekly report. 2012;61(5):1– 12. 13. betancourt wq, mena kd. assessment of waterborne protozoan passage through conventional drinking water treatment process in venezuela. j water health. 2012;10(2):324–36. 14. azman j, init i, wan yusoff ws. occurrence of giardia and cryptosporidium (oo)cysts in the river water of two recreational areas in selangor, malaysia. trop biomed. komathi nair murugesan, ridad agoes, sri yusnita irda sari: identification of pathogen protozoans (cryptosporidium spp and giardia lamblia) from canteen’s water-sources at jatinangor, west java, indonesia althea medical journal. 2017;4(3) 314 amj september 2017 2009;26(3):289–302 15. mtapuri-zinyowera s, ruhanya v, midzi n, berejena c, chin’ombe n, nziramasanga p, et al. human parasitic protozoa in drinking water sources in rural zimbabwe and their link to hiv infection. germs. 2014;4(4):86– 91. 16. who. household water treatment and safe storage. 2013 [cited 2014 october 22]; available from: http://www.wpro.who. int/environmental_health /documents/ docs/household_ water_treatment_safe_ storage_ participant.pdf. 17. bajer a, toczylowska b, bednarska m, sinsk e. effectiveness of water treatment for the removal of cryptosporidium and giardia spp. epidemiol infect [online journal] 2012 [cited 2014 july 25]. available from: http://journals.cambridge.org. 18. kurniawana a, karyadib t, dwintasaria sw, saria ip, yunihastutib e, djauzib s, et al. intestinal parasitic infections in hiv/ aids patients presenting with diarrhoea in jakarta, indonesia. oxford journals. 2009;103(9):892–8. 19. onichandran s, kumar t, salibay cc, dungca jz, tabo hal, tabo n, et al. waterborne parasites: a current status from the philippines. parasit vectors. 2014; 7:244–52. 20. sodha sv, menon m, trivedi k, ati a, figueroa me, ainslie r, et al. microbiologic effectiveness of boiling and safe water storage in south sulawesi,indonesia. j water health. 2011;2:577–85. althea medical journal. 2018;5(2) 98 amj june 2018 visual inspection test with acetic acid for cervical cancer screening: willingness and acceptability among reproductive age and married women rozaliamisah binti hassan,1 edwin armawan,2 insi farisa desy arya3 1faculty of medicine universitas padjadjaran, indonesia, 2department of obstetric and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia abstract background: cervical cancer is a preventable disease, thus early screening test should be performed for early cervical cancer prevention. previous studies showed that among all of the screening techniques, visual inspection with acetic acid is an alternative, simple safe cervical cancer prevention technique. this study aimed to identify the willingness and acceptability of visual inspection with acetic acid among reproductive age and married women as cervical cancer prevention. methods: a descriptive cross-sectional study was conducted among 100 reproductive age and married women in jatinangor subdistrict west java in 2014. a validated questionnaire was used to obtain information about the respondents’s characteristics, risk factors of cervical cancer, willingness and acceptability of visual inspection using acetic acid test (via). the collected data were presented using tables. results: out of 100 respondents, 93% ever heard of cervical cancer, however 79% were aware of cervical cancer. as high as 96% were aware of the importance of cervical cancer screening, however 36% were aware of cervical cancer screening, and 19% were aware of via test. while 83% never had previous education on cervical cancer, 91% reported willingness to take part on cervical cancer education and 83% willingness of cervical cancer screening. noted 17% were non-acceptance of via test for future cervical cancer screening due to their busy life and afraid of the outcome result. conclusions: the majority of reproductive age and married women are willing and accept via test for cervical cancer screening. keywords: acceptability, cervical cancer, visual inspection with acetic acid, willingness correspondence: rozaliamisah binti hassan, taman batik lot no. 31, jalan kg lok batik, 89208 tuaran sabah, malaysia, email: drrozalia_hassan@yahoo.com introduction cervical cancer is a major public health problem and become the second most common cancer in women worldwide.1,2 in indonesia, the data from thirteen pathology centers show that cervical cancer stands the first-ranked among all cancers followed by cancers of the ovary, uterus, vulva, and vagina.3 human papillomavirus(hpv) is the primary cause of infection with high-risk genotypes of human invasive cervical cancer; over 70% of all cervical cancers are attributable to infection with hpv-16 and 18.4,5 the associated risk factors include young age at first intercourse less than 16 years, multiple sexual partners, cigarette smoking, race, high parity, and lower socioeconomic status.6 undoubtedly, in kecamatan jatinangor, one of the densely populated areas in west java7, there is still no other exact evidence for this study to state on the real cervical cancer statistics among women of reproductive age. due to the high prevalence of cervical cancer, screening testing is the most important test for early detection of the cancer. various tests have been developed. visual inspection using acetic acid (via test) emerges as a low-cost test for use in low-resource settings where it can be performed by auxiliary health professionals.8 therefore, the objectives of this study were to identify the willingness and acceptability of via test among reproductive age and married women in jatinangor area. amj. 2018;5(2):98–104 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1419 althea medical journal. 2018;5(2) 99 methods this study was a descriptive cross-sectional study using questionnaires, with samples selected by simple random sampling. and was conducted from september-november 2014. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran and kabupaten sumedang official of the local development and planning office (badanperencanaan pembangunan daerah, bappeda). written informed consent was obtained from all women, prior to the interview. one hundred married, reproductive age and literate women were included as respondents for this study. the validation and reliability table 1 distribution of general characteristics of respondents, kecamatan jatinangor year 2014 (n=100) characteristics frequency (total, n = 100) percentage (%) age < 20 years old 2 2 20-30 years old 59 59 30–40 years old 27 27 >40 years old 12 12 ethnicity sundanese 97 97 javanese 2 2 others 1 1 marital status married 98 98 widowed 2 2 educational level primary 15 15 secondary 39 39 tertiary 46 46 occupation yes 83 83 no 17 17 salary per month <rp 1 million/ month 65 65 rp 1-5 million/ month 27 27 >rp 5 million/ month 8 8 husband’s occupation yes 97 97 no 1 1 others 2 2 husband’s salary per month <rp 1 million/ month 26 26 rp 1-5 million/ month 50 50 >rp 5 million/ month 22 22 others 2 2 rozaliamisah binti hassan, edwin armawan, insi farisa desy arya: visual inspection test with acetic acid for cervical cancer screening: willingness and acceptability among reproductive age and married women althea medical journal. 2018;5(2) 100 amj june 2018 test for the questionnaire was performed on 29 respondents by using cronbach’s alpha and if showed that the coefficient reliability was 0.706 were considered as reliable. the target population included all selected reproductive age and married women in kecamatan jatinangor. it is noted that 19 is the minimum age to get married for male and 16 is the minimum age to get married for female in indonesia.9as the theory of willingness is defined as an openness to risk opportunity, related to individual willingness to do under some circumstances.10 in this study, the willingness was measured by asking their willingness to take part in cervical cancer screening. meanwhile, acceptability examines the relationships between beliefs, attitudes and behavior, which emphasizes the importance of understanding how judgments are made about whether or not to accept a proposition.10in this study, acceptability was measured by asking the respondents’ acceptance of via test as cervical cancer screening in the future. the respondents were asked about their characteristics (age, ethnicity, marital status, educational level, occupation, salary per month, husband’s occupation and husband’s salary per month). risk factors contributed to the prevalence of cervical cancer were also identified (age of marriage, age at first sexual intercourse, number of lifetime sexual partners, number of living children, smoking and contraception use). the respondents were asked about their awareness of cervical cancer, willingness and acceptability of visual inspection with acetic acid as cervical cancer screening with a yes and no answer. the reasons for non-willingness and nonacceptance of visual inspection with acetic acid as cervical cancer screening were table 2 frequency of reports of known risk factors for cervical cancer among study respondent, kecamatan jatinangor, 2014 (n=100) risk factors for cervical cancer frequency (total, n = 100) percentage (%) age of marriage <20 years old 17 17 20-30 years old 83 83 30-40 years old 0 0 >40 years old 0 0 age at first sexual intercourse <20 years old 17 17 20-30 years old 83 83 30-40 years old 0 0 >40 years old 0 0 number of lifetime sexual partner 1 100 100 >1 0 0 number of living children 0 24 24 1-2 51 51 3-4 17 17 ≥5 8 8 smoking yes 11 11 no 89 89 contraception use yes 22 22 no 78 78 althea medical journal. 2018;5(2) 101 table 3 respondents’ awareness of cervical cancer, kecamatan jatinangor, 2014 (n=100) awareness of cervical cancer frequency (total, n = 100) percentage (%) aware of cervical cancer yes 79 79 no 21 21 ever heard of cervical cancer yes 93 93 no 7 7 aware of cervical cancer screening yes 36 36 no 64 64 aware of importance for cervical cancer screening yes 96 96 no 4 4 aware of visual inspection using acetic acid (via test) yes 19 19 no 81 81 table 4 respondents’ willingness and acceptability of visual inspection with acetic acid as cervical cancer screening, kecamatan jatinangor, 2014 (n=100) frequency, (total, n = 100) percentage (%) previous information related to cervical cancer yes 17 17 no 83 83 willingness to take part in cervical cancer information yes 91 91 no 9 9 willingness to cervical cancer screening yes 83 83 no 17 17 acceptance of via test as cervical cancer screening in the future yes 83 83 no 17 17 included as well. data from respondents were analyzed using a descriptive analysis and were presented using frequency distributions. results this study revealed the majority of the respondents were between 20-30 years old (59%). sundanese (97%) was the predominant ethnicity of the respondents. others (1%) were meant for respondents whose ethnicity were not among both sundanese and javanese. married women accounted for 98%. there was low frequency of primary educational level (15%). it was noted, almost all respondents had rozaliamisah binti hassan, edwin armawan, insi farisa desy arya: visual inspection test with acetic acid for cervical cancer screening: willingness and acceptability among reproductive age and married women althea medical journal. 2018;5(2) 102 amj june 2018 an occupation (83%) and a salary rate of less than rp1 million per month (65%). still there were few of them whose salary were more than rp 5 million per month (8%). husband’s occupation had a high frequency (97%) and husband’salary p was between rp 1-5 million per month (50%). others (2%) were meant for their deceased husband (table 1). regarding risk factors contributed to the prevalence of cervical cancer, this study discovered that the age of marriage of less than 20 years accounted for 17% and the age of first sexual intercourse was at rate of 17%. there was none with number of lifetime sexual partner of more than one. the number of living children was equal and more than 5 children accounted the least for 8%. it noted low frequency among smoking respondents as 11% and as low as 22% of them used contraception (table 2). furthermore, based on the respondents’ awareness of cervical cancer, 79% of the respondents were aware of cervical cancer, as high as 93% ever heard of cervical cancer, and still about 7% never heard of cervical cancer. even though only approximately 36% of them were aware of cervical cancer screening, about 96% of all respondents were aware of the importance for cervical cancer screening. a substantial 19% of the respondents were aware of via test (table 3). this study discoveref that 83% of the respondents never had previous information on cervical cancer. as high as 91% of them were willing to take part in cervical cancer education and 83% of the respondents were willing to be screened for cervical cancer. overall, there was a high rate of acceptance for via test as cervical cancer screening in the future (83%). reasons for non-acceptance of via test as cervical cancer screening in the future have been written by the respondents via the questionnaires. of 100 respondents who took part in this study, 83% of respondents accepted the iva test as cervical cancer screening in the future, and as low as 17% of respondents rejected it. the majority of respondents’ non-acceptance of via test as cervical cancer screening in the future were due to their fear of knowing the results and because they were busy. discussions the study provided information about willingness and acceptability of visual inspection with acetic acid as cervical cancer screening among reproductive age and married women in kecamatan jatinangor in 2014. overall, there were positive outcomes from this study. the majority of respondents were between the ages of 20-30 (59%) which indicated early marriage among them. the sundanese was the highest frequency distribution of ethnicity with 97%, only 2% of them were javanese, and others were 1%. most of the women were married (98%) and widowed (2%) which meant their husbands had passed away. the educational level at highest frequency was the tertiary level (46%), yet this did not always indicate high awareness of cervical cancer. however, a previous study showed that the awareness level would have been much higher if the respondents were among high education level.10 the study showed a high rate as 46% of the respondents were with tertiary education level, followed by the secondary level (39%) and primary level (15%). almost all of them had an occupation (83%) and only 17% did not have an occupation and stayed as housewives. overall, their salaries were less than rp1 million per month (65%) and were considered as low income status. in addition, almost all their husband had an occupation (97%), only 1% did not have an occupation, and others (2%) indicated their deceased husband. their husband’s salary was between rp1-5 million per month (50%) which implied a low income status. however, this information did not always prove any relation to high or low willingness and acceptability of the study. moreover, the results showed the distribution related risk factors for cervical cancer were included. in worrisome states, there were about 17% of respondents at early age of marriage and meant for having early sexual intercourse simultaneously. the study found that these could contribute for the risk of cervical cancers.11 there were 100% of women with only 1 partner in a lifetime and this was somehow a relief for not being a risk for cervical cancer. however, the number of living children was equal and more than 5 children was 8% which proved to be a risk for cervical cancer.12 fortunately, there were only a few women smoking (11%) and only a few of them used contraception (22%). regarding the use of contraception, this variable could be considered as the risk factor for cervical cancer.13 additionally, the respondents’ awareness of cervical cancer showed an interesting finding that there was still high awareness of cervical althea medical journal. 2018;5(2) 103 cancer (79%) and a high rate for “ever heard of cervical cancer” (93%). surprisingly, only a few (36%) among the respondents were aware of cervical cancer screening, and about 19% of them were aware of the via test. quite a remarkable finding was that as high as 96% were aware of the importance for cervical cancer screening. furthermore, the frequency distribution demonstrated only 17% of women had previous education on cervical cancer, a previous study found this variable has a strong relation with the high outcome for the risk of cervical cancer.10 interestingly, the willingness to take part in cervical cancer education was high at 91% and 83% were willing to be screened for cervical cancer. moreover, 83% of the respondents accepted via test as cervical cancer screening in the future. the respondents stated the reasons for non-acceptance of via test, and most of them wrote that their non-acceptance were due to their fear of the outcome result, besides they were busy. a previous study found that other reasons for non-acceptance of cervical cancer screening among the respondents include the cost of test related issues, religious denial, requires partners permission, time to take the test/long waiting time, pregnant/recently delivered, afraid to take the test, taken the test before, had surgery of the vulva and no reason.10 as for the limitation of study, the researcher did not measure unmarried and reproductive age women. this should be measured for more variation and clear data. then, there was limited variation for ethnicity and religion and a limited list of variables for education level, as such, the data for illiterate respondents. next, there was no list for types of occupation for the respondent’s husband which was important for measuring the level of their socioeconomic status. also, the variables were listed without the types of contraceptives. hopefully, there will further studies on measuring association or correlation study regarding the cervical cancer prevention as part of health promotion. besides, it is best to proceed on more interesting topic under cervical cancer study for on-going research. in conclusion, the majority of reproductive age and married women in kecamatan jatinangor are willing and accepted via test for cervical cancer screening. the researcher discovers the need to educate reproductive age and married women in kecamatan jatinangor for cervical cancer prevention and demonstrates their willingness to be screened for cervical cancer and visual inspection with acetic acid would be acceptable as cervical cancer screening. last but not least, the researcher includes recommendations throughout the study. practically, education on cervical cancer should be organized as a part of on-going health education, so women can get access and implement visual inspection with acetic acid as cervical cancer screening in all health care centers, since it is the safest, cheapest and highly sensitive screening test for cervical cancer. references 1. kotaniemi-talonen l, malila n, anttila a, nieminen p, hakama m. intensified screening among high risk women within the organised screening programme for cervical cancer in finland. acta oncol. 2011;50(1):106–11. 2. vesco kk, whitlock ep, eder m, burda bu, senger ca, lutz k. risk factors and other epidemiologic considerations for cervical cancer screening: a narrative review for the u.s. preventive services task force. ann intern med.2011;155(10):698–705. 3. nuranna l, aziz mf, santoso cornain, gatot purwoto, sigit purbadi, setyawati budiningsih, et al. cervical cancer prevention program in jakarta, indonesia: see and treat model in developing country. j gynecol oncol. 2012;23(3):147–52. 4. bosch fx, qiao yl, castellsague’ x. chapter 2 the epidemiology of human papillomavirus infection and its association with cervical cancer. int jf gynecol obstet. 2006;94(suppl 1):s8–s21. 5. smith js, lindsay l, hoots b, keys j, franceschi s, winer r, et al. human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: a meta-analysis update. int j cancer. 2007;121(3):621–32. 6. harris rp, helfand m, woolf sh, lohr kn, mulrow cd, teutsch sm, et al. current methods of the us preventive services task force: a review of the process. am j prev med. 2001;20(3 suppl):21–35. 7. kecamatan jatinangor. potensi kecamatan jatinangor triwulan ii tahun 2009. sumedang: kecamatan jatinangor; 2013. 8. international agency for research on cancer. cervix cancer screening: iarc handbook of cancer prevention. 10th ed. lyon, france: iarc pr; 2005. 9. kementerian agama republik indonesia. peraturan menteri agama republik rozaliamisah binti hassan, edwin armawan, insi farisa desy arya: visual inspection test with acetic acid for cervical cancer screening: willingness and acceptability among reproductive age and married women althea medical journal. 2018;5(2) 104 amj june 2018 indonesia nomor 11 tahun 2007 tentang pencatatan nikah. jakarta: kementerian agama republik indonesia; 2007. 10. ezechi oliver c, gab-okafor chidinma v, ostergren olof per , pettersson odberg. willingness and acceptability of cervical cancer screening among hiv positive nigerian women. bmc public health. 2013;13:46. 11. rositch af, gatuguta a, choi ry, guthrie bl, mackelprang rd, bosire rose, et al. knowledge and acceptability of pap smears, self-sampling and hpv vaccination among adult women in kenya. plos one. 2012;7(7):e40766. 12. were e, nyaberi z, buziba n. perceptions of risk and barriers to cervical cancer screening at moi teaching and referral hospital (mtrh), eldoret, kenya. afr health sci. 2011;11(1):58–64. 13. nene b, jayant k, arrossi s, shastri s, budukh a, hingmire, et al. determinants of womens participation in cervical cancer screening trial, maharshtra, india. bull world health organ.2007;85(4):264–72. vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 144 amj september 2019 the air quality and detection of streptococcus pneumoniae in the pediatric ward of dr. hasan sadikin hospital bandung thiban raj manoraj,1 yanti mulyana,2 sri endah rahayuningsih3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: thiban raj manoraj, faculty of medicine, universitas padjadjaran jalan raya bandung-sumedang km 21, jatinangor, sumedang, jawa barat, indonesia, email: thiban_1990@yahoo.com introduction the air quality has given its importance as public health concern since 1952, in time when there was a large increase in deaths during the severe air pollution episode in london, england.1 indoor air quality (iaq) is the nature of air inside a building that affects the health and well-being of its occupants. prevention from infection of hospital workers and patients is accomplished by the control of iaq.2 especially in a pediatric ward, the air quality should be maintained at its best level since sick children have immature respiratory systems and low immune systems. the full maturation of lungs in human beings happens only 10 years after birth and not immediately after partus.3 therefore, bad iaq in the pediatric ward will make sick children vulnerable to any microorganisms in the air and may cause nosocomial infection. nosocomial infection is the infection occurring in patients during their stay in the hospital or another healthcare facility, to which the infection is not present or incubating at the time of admission. more than 1.4 million patients around the world suffer at any time with about 90,000 deaths per year due to nosocomial infection. contamination and transmission through the air occur through droplets that can directly spread and be acquired by patients, or otherwise indirectly through medical device contamination. the air exchange rate, the number of activity carried out and the number of people in the ward amj.2019;6(3):144–8 abstract background: nosocomial infection can be acquired by inhalation of droplets from contaminated air. in children, nosocomial pneumonia is mainly caused by streptococcus pneumoniae. this study aimed to explore the air quality level and to detect streptococcus pneumonia in the air of the pediatric ward of dr. hasan sadikin hospital, bandung. methods: this was an observational descriptive study conducted in the pediatric ward of dr. hasan sadikin hospital in november 2012. the different number of modified tryptic soy agar (tsa) plates with 4% blood were exposed and placed in various rooms of the ward for 30 minutes between 12.00 pm to 1.00 pm at heights between 1.0m to 1.5m and according to the respectively room air volume. after exposure, these plates were then incubated for 48 hours at 35°c. the colony forming units (cfu) on each plate was counted per replicate organism detection and counting (rodactm). detection of streptococcus pneumonia was performed by detecting any round α-hemolytic colonies on the tsa plate, confirmed by gram staining, optochin susceptibility test, and the bile solubility test. result: the air quality in 13 rooms of the pediatric ward was generally poor ranging from 27.5 to 232.0 cfu/30 min, however, the concentration of microorganisms per cubic meter air was from 0.198 to 4.296 cfu/m3. moreover, streptococcus pneumoniae was not present in the air of the ward. conclusions: although streptococcus pneumoniae has not been detected, the air quality in the pediatric ward of dr. hasan sadikin hospital, bandung is generally poor. general precautions need to be enhanced to increase the air quality in the hospital. keywords: air quality, pediatric ward, streptococcus pneumoniae althea medical journal. 2019;6(3) 145 determines the number of microorganisms in the air which indirectly determines the air quality.4 nosocomial pneumonia mostly affects infants, young children and adults age 65 and above. the second most common nosocomial infection in the united states is pneumonia. pneumonia accounts for 15% of all nosocomial infections and it is the second most common after urinary tract infection (uti). the crude mortality rate and the attribute mortality rate of nosocomial pneumonia are 20% to 50% and 30% to 33% respectively. sixty percent of all deaths attributed to nosocomial infections are due to pneumonia.5 pneumonia specifically affects the lungs and it is a severe form of acute lower respiratory infection and it is the number one killer in children under 5 years old of age. streptococcus pneumoniae is the most common cause of pneumonia among children in the world.6 in a vaccine trial data recently acquired, over 50% of pneumonia cases in africa are caused by streptococcus pneumoniae.6 in developing countries, over 150 million cases of pneumonia occur in children under five years old every year. out of this large number, 2 million children will finally die and about 11 million to 20 million of them will need admission in healthcare facilities.6 the prevalence of childhood pneumonia in indonesia is 6 million.7 indonesia is also one of the 15 countries in which the childhood pneumonia cases account for three-quarters of childhood pneumonia worldwide.6 according to the indonesian health profile 2007, there are 477,420 under-five children who have pneumonia and pneumonia causes deaths of 22.3% infants and 23.6% children under five years old.7 the incidence of pneumonia cases in children under five years old who receive treatment in dr. hasan sadikin hospital, bandung in the years 2010 and 2011 are 259 and 394 respectively. this study aimed to explore the air quality level in the pediatric ward of dr. hasan sadikin hospital, bandung and whether streptococcus pneumonia was present in the respectively ward. methods this observational descriptive study was carried on in the pediatric ward of dr. hasan sadikin hospital, bandung, in november 2012. the air samples were obtained by placing opened petri dishes containing modified tryptic soy agar (tsa) with 4% blood plates in all rooms in the wards for 30 minutes at any time between 12.00 pm and 1.00 pm. each room was allocated with a different number of modified tsa with a 4% blood plates to collect air samples according to their respective air volumes. the designation was one modified tsa with 4% blood plate for 25m3 air volume of the room. these plates were placed near doors, on tables and near patients’ beds at any height between 1.0 to 1.5 meters above the floor level. after 30 minutes, these exposed plates were covered with their lids and placed in anaerobic cans before being incubated microaerophically8 for 48 hours at 35ºc. the air quality was reported in mean cfu/30 minutes for each room. the number of perreplicate organism detection and counting (rodactm) plate was then counted. according to rodactm 0-25 cfu was designated as good, 26-50 was fair and >50 was poor.9 the concentration of microorganisms per cubic meter of air (cfu/m3) was calculated by dividing the mean cfu value counted with the volumes of the respective rooms. this cfu/m3 value for each room was then compared with the hospital environmental health requirements by the minister of health of the republic of indonesia. the normal value was<200 cfu/m3. for the detection of streptococcus pneumoniae, the colonies formed on the modified tsa with 4% blood plates were viewed thoroughly for any round α-hemolytic colonies.10 if there was a presence of such colony, then gram staining was performed in which positive for the presence of streptococcus pneumoniae would give dark blue color upon staining. then, optochin susceptibility test was performed to check for any zone of inhibition. a zone of inhibition of ≥14 mm indicated a positive test. another test was also performed; the bile solubility test which would give a positive result for streptococcus pneumoniae.11,12 when there was no round α-hemolytic colony was found, it was reported as negative for the detection of streptococcus pneumoniae, and the other three tests were not carried out. results in total, there were thirteen rooms the pediatric ward of dr. hasan sadikin hospital, bandung, and the cfu per 30 minutes formed on each agar plate is placed in those rooms were depicted in table 1. the mean of cfu/30 minutes which determined the air quality level was compared to the criteria of contamination thiban raj manoraj et al.: the air quality and detection of streptococcus pneumoniae in the pediatric ward of dr. hasan sadikin hospital bandung althea medical journal. 2019;6(3) 146 amj september 2019 by rodactm for each room. interestingly, round α-hemolytic colonies were not observed in tsa plates, suggesting that streptococcus pneumoniae was not present in the air of all rooms in the pediatric ward of dr. hasan sadikin hospital. according to rodactm contamination criteria classification, no single room in the pediatric ward of dr. hasan sadikin hospital, bandung was recorded as good for their air quality; the air quality in rooms 1 and 2 was fair, whereas, the air quality in rooms 3 to 13 were poor. however, based on the air quality guidelines published by the hospital environmental health requirements by the minister of health of the republic of indonesia, all the 13 rooms had less than 200 cfu/m3 of microorganisms ranging from 0.198 cfu/ m3 to 4.296 cfu/m3, thus these rooms had acceptable environmental health. discussion this study has shown that streptococcus pneumoniae was not detected in the air of all rooms in the pediatric ward of dr. hasan sadikin hospital, bandung, suggesting that there is thus no transmission of streptococcus pneumoniae from patients or any other occupants of the ward through droplets. therefore, pediatrics or children who are admitted to the pediatric ward of dr. hasan sadikin hospital, bandung is safe enough from acquiring nosocomial pneumonia caused by streptococcus pneumoniae. interestingly, the air quality in rooms 1 and 2 are generally better than the other 11 rooms in the pediatric ward of dr. hasan sadikin hospital, bandung. this is because rooms 1 and 2 are neonatology wards. since neonates are newborns and their immune systems are still weak and not developed yet to combat pathogens, rooms 1 and 2 are kept as clean as possible. anybody including healthcare personnel entering rooms 1 and 2 must wash their hands first at the water pipes prepared outside; they must also remove whatever footwear they are wearing. the instructions to wash hands and to remove footwears are clearly stated on the doors of rooms 1 and 2. washing hands and removing footwears before entering those rooms reduce the likelihood of microorganisms from entering the rooms. microorganisms are significantly reduced by soaps used to wash hands before they enter. beside, only these two rooms are air-conditioned. since, the air-conditioned rooms 1 and 2 have better air qualities compared to the other rooms in the ward, it suggests that air conditioning may play a major role in maintaining the air quality inside buildings, because air conditioning units have the capability of circulating air from inside buildings to the outside and vice table 1 the colony forming unit per 30 minutes formed on each agar plate placed in 13 rooms in the pediatric ward of dr. hasan sadikin hospital, bandung room no cfu/30min mean a b c d e f 1 26 32 27 22 34 24 27.5 2 34 27 36 41 19 22 29.8 3 92 83 108 77 92 78 88.3 4 115 119 122 146 152 120 129.0 5 133 153 106 125 172 98 131.2 6 190 156 244 180 246 145 193.5 7 79 96 74 90 84.8 8 154 152 163 165 158.5 9 119 176 153 114 140.5 10 194 234 268 232.0 11 132 97 117 115.3 12 83 74 66 74.3 13 49 64 56.5 note: cfu/30 minutes; colony forming unit per 30 minutes althea medical journal. 2019;6(3) 147thiban raj manoraj et al.: the air quality and detection of streptococcus pneumoniae in the pediatric ward of dr. hasan sadikin hospital bandung versa. this ensures that the air inside the pediatric ward to be all the time changing; removing microorganisms from indoor to outdoor. air conditioning units also can clean the air via filters fitted in them. these filters are responsible for filtering dust and microparticles and help in maintaining good air quality. interestingly, room 10 where is recorded to be the highest value for the concentration of microorganisms per cubic meter of air (4.296 cfu/m3) is a gastroenterology ward with 8 persons including 3 patients during the time of observation. this room is one of the smallest rooms in the pediatric ward, where there is a possibility for the concentration of microorganisms in the air to be very high, leading to the worst air quality. these microorganisms mainly come from the skin and the respiratory system of the people. aside from that, room 10 also has only one door and the windows are all not opened. this leads to poor air ventilation as air takes a long time to circulate in and out of the room. there is no constant changing of the indoor air leading to an accumulation of microorganisms to increase due time. most importantly, room 10 also has a toilet. since a toilet is considered to be dirty, and microorganisms accumulate there constantly, it can be a cause for the increase of microorganisms in room 10. the source of these microorganisms in the toilet can be from the excretions of people like the urine and feces or even from the phlegm or sputum. these microorganisms from the toilet are then brought out to room 10 by people who use the toilet. according to the criteria of contamination by rodactm, the air quality in the pediatric ward of dr. hasan sadikin hospital, bandung is poor. it may be caused by the air ventilation in the ward which is generally bad. although there are many windows and doors in the ward, they are almost closed all the time. this makes the condition inside the ward to be stuffy as there is a very limited circulation of air. when there is limited circulation of the air, there is no changing of indoor air as stated above. indoor air is limitedly exchanged with fresh outdoor air. this leads to an accumulation of microorganisms in the indoor air of the rooms in the pediatric ward which are suspended in the air. the pediatric ward is almost always crowded with people. doctors, nurses, medical interns, trainee nurses, attendants, cleaners, nutritionists, parents, family members, and other companions are always in the ward. microorganisms can be brought by this crowd into the ward. these microorganisms are mainly transmitted from the skin and the respiratory tract of these people in the form table 2 concentration of microorganisms per cubic meter of air(cfu/m3) in the rooms of pediatric ward in dr. hasan sadikin hospital, bandung room the concentration of microorganisms per cubic meter of air (cfu/m3) 1 0.198* 2 0.215* 3 0.636** 4 0.930** 5 0.946** 6 1.395** 7 1.019** 8 1.904** 9 1.688** 10 4.296** 11 2.135** 12 1.376** 13 1.404** note: rodactm contamination criteria classification; the air quality was fair* or poor **. the cfu/m3 value for each room was compared with the hospital environmental health requirementsby minister of health of the republic of indonesia. the normal value was <200 cfu/m3. althea medical journal. 2019;6(3) 148 amj september 2019 of droplets or bioaerosol. therefore, a big crowd can influence the indoor air quality as microorganisms in the form of droplets or bioaerosol will be accumulated by this large number of people in the air of the ward. this study has limitations, that this study is a single time of observation. more time frame periods might give useful data. as a positive control situation, the room occupied with pneumonia patients might be examined for the presence of streptococcus pneumoniae. to conclude, although streptococcus pneumoniae is not detected, the air quality in the pediatric ward of dr. hasan sadikin hospital, bandung is generally poor. the healthcare workers like doctors, nurses, medical interns, and trainee nurses may wear hand gloves and mask to cover their mouths and nose. furthermore, they need to wash their hands accordingly. the air ventilation system needs to be refreshed and the general precautions need to be enhanced to increase the air quality in the hospital. references 1. hasselback p, taylor e. air quality health index variation across british columbia. interior health. 2010 [cited 2013 january 29]. available from: https://www2.gov. bc.ca/assets/gov/environment/air-landwater/air/reports-pub/aqhi-variation-bc. pdf 2. leung m, chan ah. control and management of hospital indoor air quality. med sci monit. 2006;12(3):sr17–23. 3. sadler tw. langman’ s medical embryology. 11th ed. philadelphia: lippincott williams & wilkins; 2009. p. 206. 4. ducel g, fabry j, nicolle l. prevention of hospital acquired infections: a practical guide. med j armed forces india. 2004;60(3):312. 5. tablan oc, anderson lj, besser r, bridges c, hajjeh r, et al. guidelines for preventing healthcare-associated pneumonia, 2003: recommendations of cdc and the healthcare infection control practices advisory committee. mmwr recomm rep. 2004;53(rr-3):1–36. 6. wardlaw t, johansson ew, hodge m. pneumonia:the forgotten killer of children. geneva: unicef/who; 2006. 7. departemen kesehatan republik indonesia. profil kesehatan indonesia 2007. jakarta:departemen kesehatan republik indonesia; 2008. 8. brooks gf, carroll kc, butel js, morse sa. jawetz, melnick & adelberg’s medical microbiology. 24th ed. mcgraw-hill companies; 2007. p. 241-243 9. becton, dickinson and company. bbltm prepared rodactm plates. spark, md, usa: becton, dickinson and company; 2005. [downloaded on 22 march 2012] available at: http:// l e g a c y. b d . c o m / d s / t e c h n i c a l c e n t e r / inserts/8835631jaa(0205).pdf. 10. shimeld la, rodgers at. essentials of diagnostic microbiology. clifton park, united states: delmar cengage learning; 1999. p 117-130. 11. kaijalainen t. the identification of streptococcus pneumoniae. volumes 11. oulu, finland: national public health institute; 2006. p. 32. 12. perilla mj, ajello g, bopp c, elliot j, facklam r, knapp js, et al. manual for the laboratory identification and antimicrobial susceptibility testing for bacterial pathogens of public health importance in the developing world: haemophilus influenzae, neisseria meningitidis, streptococcus pneumoniae, neisseria gonorrhoea, salmonella typhi, shigella, and vibrio cholerae. geneva: cds information resource center, who; 2003. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 94 amj march 2017 five years facts of bladder cancer at west java’s top referral hospital, in indonesia vivien kate perix,1 sri suryanti,2 aaron tigor sihombing3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: bladder cancer is the second most common genitourinary cancer and its incidence is rising 15% annually in indonesia. smoking is the leading risk factor of bladder cancer and two thirds of men in indonesia smokes. this study was conducted to describe the characteristics of bladder cancer based on sex, age and histopathology type in west java’s top referral hospital, indonesia. methods: this study was a descriptive study conducted during theperiod of september to november 2015 using 372 histopathological medical records of patients who had primary and secondary bladder cancer at the pathology department, dr. hasan sadikin general hospital bandung from january 2010 to december 2014. data were collected using total sampling method based on the characteristics of age, sex histopathology type, and staging of bladder cancer. results: out of the 372 cases, 298 cases were male and 38 cases were female with a male to female ratio of 7.8:1. the age group with the highest incidence was the 50–59 years old group. infiltrating urothelial carcinoma was the most common histopathology type (71.1%) in primary cancers, 66.1% of cases was muscle invasive while 33.9% was non muscle invasive. staging pt1 had the most number of cases. the most common site of origin for secondary neoplasm was cervix with adenocarcinoma as the most common histopathology type. conclusions: bladder cancer is more common in male than female and peaks at the sixth decade of life. infiltrating urothelial carcinoma is the most common histopathology type. [amj.2017;4(1):94–9] keywords: age, bladder cancer, histopathology type, sex correspondence: vivien kate perix, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81802265201 email: vperix@gmail.com introduction bladder cancer is the second most common genitourinary cancer and accounts for 3.2% of the total cancer cases worldwide.1 based on globocan data 2012, the incidence of bladder cancer patients in indonesia for both sexes is 3.2 per 100,000.1 this incidence is increasing 15% per annum in the last decade in indonesia.2 the mortality rate is 1.7 per 100,000 cases.1 bladder cancer is three times more common in male than female.3 however, in women, the disease has a higher mortality and presents in a more advanced stage.4 the peak of bladder cancer is in the sixth or seventh decade.3 the most common histopathology type is infiltrating urothelial carcinoma.2 the most important risk factor for bladder cancer is smoking.5 two thirds of the indonesian population of male smokes and west java has the second highest number of smokers in indonesia.6 occupation exposure for example azo dyes used in textile industries is also associated with elevated bladder cancer risk. west java accounts for the highest clothing production in indonesia. the increasing number of smokers and exposure to occupational carcinogens along with the increasing geriatric population in west java will increase the incidence of bladder cancer in west java, in addition increasing the burden of cancer in indonesia. based on the factors above and the differences in genetic composition in indonesians, the objective of the study was to describe the characteristics of patients althea medical journal. 2017;4(1) 95 with bladder cancer based on age, sex and histopathology type at dr. hasan sadikin general hospital bandung as west java’s top referral hospital from january 2010 to december 2014. methods this was a descriptive study of all primary and secondary bladder cancer cases from 1st january 2010 to 31st december 2014 (5 years) that were collected from the pathology department at dr. hasan sadikin general hospital bandung. this study was carried out during 6 months from july to december 2015 using medical records. the inclusion criteria of the study were histopathological medical records of patients who were diagnosed with bladder cancer comprising the age, sex and histopathology type. data was excluded if the medical records were not complete or unclear. from 381 cases of bladder cancer during the period, nine cases were excluded. the total sampling method was used to obtain the samples. bladder tumours were classified histopathologically according to the world health organization (who)/international society of urological pathology consensus classification 2004 which classified the tumours into urothelial tumours, squamous neoplasms, glandular neoplasms, neuroendocrine tumours, melanocytic tumours, mesenchymal tumours, haematopoietic and lymphoid tumours.7 pathological staging was specified according to tmn system with the following stages, pt1: invasion of lamina propria, pt2: invasion of muscularis propria, pt3: invasion of perivesical fat and pt4: invasion of surrounding organs.7 the data was presented in frequency distribution. ethical clearence was given by the health research ethics committee of dr. hasan sadikin general hospital. results the total number of bladder cancer cases recorded at the department of anantomical pathology in dr. hasan sadikin general hospital bandung was 372 cases, consisting of 336 cases of primary bladder cancer and 36 cases of secondary bladder cancer. vivien kate perix, sri suryanti, aaron tigor sihombing: five years facts of bladder cancer at west java’s top referral hospital, in indonesia table 1 frequency of bladder cancer patients based on year year total malignant tumor cases in dr. hasan sadikin general hospital bladder cancer % 2010 4,695 66 1.41 2011 3,476 71 2.04 2012 3,662 57 1.56 2013 3,468 93 2.71 2014 3,206 85 2.68 total 18,507 372 2.02 table 2 characteristics of primary bladder cancer patients based on age and sex age in years sex number of cases % male female <40 30 1 31 9.2 40–49 32 6 38 11.3 50–59 94 11 105 31.3 60–69 65 7 72 21.4 70–79 64 12 76 22.6 80–89 13 1 14 4.2 total 298 38 336 100.0 althea medical journal. 2017;4(1) 96 amj march 2017 the highest number of cases and frequency recorded was in year 2013, followed by year 2014. the least number of cases was found in year 2012, however the lowest frequency was found in year 2010 (table 1). the incidence of bladder cancer was higher in men (88.7%) compared to women (11.3%) with the male to female ratio was 7.8:1. for male the highest incidence was found in the age group 50–59 years while in female, the highest incidence was in the age group 50–59 years and 70–79 years. the oldest age reported was 87 years with histopathological type infiltrating urothelial carcinoma. the youngest age reported was 9 years old with histopathological type rhabdomyosarcoma (table 2). the most common histopathology type was urothelial neoplasias, which was divided into invasive (71.1%) and non invasive neoplasias (15.2%). in this study, the invasive urothelial neoplasia, infiltrating urothelial carcinoma had the highest percentage of cases. the next most common histopathology type was squamous cell carcinoma which constituted 6.3% of the total cases, followed by adenocarcinoma (5.3%). the least common histopathology type was rhabdomyosarcoma (2.1%) (table 3). the invasive urothelial carcinoma that invaded the lamina propria, pt1 (66.1%) was the most common staging reported followed by pt4 (22.2%). the least common staging was pt3 (2.09%), that had invaded the perivesical fat. 33.9% of the patients had muscleinvasive disease at the time of the presentation while the remaining 66.1% had non muscle-invasive disease (pt1) (table 4). there was a total of 36 secondary bladder cancer cases, 63.9% of the cases were female while 36.1% of the cases were male with a male to female ratio of 0.6:1. the most common age group was 40-49 years old. the most common table 3 characteristics primary bladder cancer patients based on histopathology type according to who classification 2004 histopathology type number of cases % invasive urothelial neoplasias infiltrating urothelial carcinoma 239 71.1 non-invasive urothelial neoplasias non invasive papillary urothelial neoplasm of low malignant potential 26 7.7 non invasive papillary urothelial carcinoma, low grade 20 6.0 non invasive papillary urothelial carcinoma, high grade 5 1.5 squamous cell carcinom 21 6.3 adenocarcinoma 18 5.3 rhabdomyosarcoma 7 2.1 total 336 100.0 table 4 pathologic staging of infiltrating urothelial carcinomaaccording to who classification 2004 based on sex stage sex total % male female pt1 141 17 158 66.1 pt2 22 1 23 9.6 pt3 5 0 5 2.1 pt4 51 2 53 22.2 total 219 20 239 100.0 althea medical journal. 2017;4(1) 97vivien kate perix, sri suryanti, aaron tigor sihombing: five years facts of bladder cancer at west java’s top referral hospital, in indonesia histopathology type was adenocarcinoma (36.1%). the least common histopathology type was rhabdomyosarcoma (2.8%). cervix was the most common site of origin for secondary bladder cancer accounting for 52.8% of the cases, followed by prostate (13.9%). the least common site of origin was intra abdomen, vulva and ileum (table 5). discussion in this study, the incidence of bladder cancer was higher in men than women, with the male to female ratio of 7.8:1. this ratio is comparable to previous studies in india3 (8.6:1) and malaysia8 (9.4:1) but was higher table 5 characteristics of secondary bladder cancer characteristics number of cases sex male 13 female 23 male to female ratio 0.6:1 age (years) <40 7 40–49 12 50–59 11 60–69 5 70–79 1 80–89 0 histopathology type adenocarcinoma 13 squamous cell carcinoma 7 rhadmonyosarcoma 1 not specified 15 origin cervix 19 prostate 5 ovarian 3 colon 3 rectum 2 intra abdomen 2 vulva 1 ileum 1 than other studies conducted in surabaya, indonesia9 and nepal10 with ratio of 3–4:1. the higher incidence in men may be attributed to the higher exposure to carcinogens as smoking is the leading risk factor of bladder cancer and west java has the second highest number of smokers aged more than 10 in indonesia.6 the lower incidence in female may be attributed to the decreased exposure to carcinogens from cigarettes in addition to less occupational exposure as less number of women work outside their homes. the mean age of diagnosis in this study was 58.5 which is similar to other studies in north india11 (59.0) and indonesia9 (57.8). in this study, 79.5% of the patients were older than 50 years and this was similar as reported in north india11 which was 83.7%. overall, the highest incidence was in the age group 50– 59 years. this is similar to a previous study in surabaya, indonesia.9 in male, the highest incidence was in the age group 50–59 years while in female, the incidence peaks at the age group 50–59 years and 70–79 years. a study in nepal10 and north india11 showed an older age group for male, 61–70 years as the peak age group, while the peak age group for female were similar, 51–60 years and 71–80 years.10 the lower peak incidence age group of men in indonesia is linked to the higher number of smokers who start smoking at a younger age of 10 years which increases the exposure of carcinogens at an earlier age. infiltrating urothelial carcinoma was the most common histopathology type in this study. this is coherent with other studies which reported similar findings of infiltrating urothelial carcinoma being the most common type, however the percentage in this study was much lower than reported in other studies.3,8,10,11 squamous cell carcinoma prevalence varies in different parts of the world and is higher in egypt8 where schistosomiasis is endemic. in this study the prevalence was 5.4% which is comparable to the study in nepal10 but was much higher than reported in the study conducted in malaysia8 (1.2%) and north india11 (2.5%). the histopathology type adenocarcinoma was accounted for 5.6% of the total cases and is similar to the study in malaysia8(6.0%) but studies in nepal12 and india3 showed a lower percentage of 0.93% and 1.25%respectively. numerous studies have been published to show the survival rate differences between invasive and non-invasive tumours. in this study, the urothelial tumors which were invasive was 82.4% while the non-invasive althea medical journal. 2017;4(1) 98 amj march 2017 urothelial tumours was 17.6%. the percentage of non-invasive tumours reported is much lower than the previous study conducted in malaysia.8 in terms of age, young people tend to develop more non-invasive urothelial tumours rather invasive urothelial tumours and this is the characteristic of bladder cancer that differentiates it from other cancers where younger people develop more aggressive forms of the disease. however in this study, there was a higher percentage of invasive urothelial tumours in young people compared to non-invasive tumours. this is different from the studies in taipei13 and greece14 where there are more non-invasive tumours than invasive tumours at time of presentation in younger people. in this study, 33.9% of the patients had muscle-invasive disease at the time of the presentation while the remaining 66.1% had non muscle-invasive disease. this is different from other previous studies where there is a higher percentage of muscle invasive rather than non muscle-invasive disease.10 in this study, women had less invasive and less aggressive form of the disease and is thus similar to a previous study in austria.15 this is opposing to other previous studies conducted in india and nepal which stated that women have more invasive and more aggressive form of disease at time of diagnosis.3,10,12the less aggressive and less invasive form of bladder cancer in women as reported in this study, attributed to the prompt diagnosis by clinicians when presenting symptoms occurred. secondary cancers that invade or infiltrate the bladder are very rare. in this study, there were only 36 cases reported in the period of 5 years and accounts for 9.7% of the total bladder cancer cases. in a previous study, it was reported that secondary bladder neoplasm represents 2% of the total malignant bladder neoplasm.16 the percentage of secondary tumours in this current study was much higher than the previous study. the most common histopathology type of secondary bladder cancers reported was adenocarcinoma (36.1%). since adenocarcinomas are rare in primary bladder neoplasm, when an adenocarcinoma histopathology type is found, the pathologist should carry out further investigation of possible metastasis of other origin as the presence of adenocarcinomas was high in secondary neoplasms in this study. some tumors of histopathology type were not specified, because more immunohistochemical workup is needed to identify the tumours that are present with less histological characteristics.7 in this study, the most common sites of origin in secondary bladder neoplasms were the cervix in female and prostat in male. in previous studies, the most common site of origin is from colonic carcinomas, prostate, rectum and uterine cervix .7,17 from this study, it can be concluded that bladder cancer is more common in male than female. bladder cancer peaks at the 6th decade for male while in female, it peaks at the 6th and 8th decade. infiltrating urothelial carcinoma is the most common histopathology type overall while rhabdomyosarcoma is the most uncommon histopathology type in primary bladder cancers. there are more non muscles invasive tumours (stage pt1) present. the most common site of metastasis to the bladder is the cervix in female and prostate in male. the limitation of this study is that there were many missing medical records as they were not stored in electronic form. future efforts must focus on analyzing the significance between bladder cancer and smoking as its main risk factor in west java. the high number of bladder cancer cases in male in their 50’s indicates a need for screening for bladder cancer to ensure better care and less mortality rate. references 1. ferlay j, soerjomataram i, ervik m, dikshit r, eser s, mathers c, et.al. globocan 2012cancer incidence and mortality worldwide. international agency for research on cancer2013. [cited 2015 may 20]. available from: http://globocan.iarc. fr. 2. wempy supit, chaidir a mochtar, marto sugiono, rainy umbas. survival of patients with transitional cell carcinoma of the urinary bladder in indonesia: a single institution review. asian pac j cancer prev. 2011;12(2):549–53. 3. gupta p, jain m, kapoor r, muruganandham k, srivastava a, mandhani a. impact of age and gender on the clinicopathological characteristics of bladder cancer. indian j urol. 2009;25(2):207–10. 4. fajkovic h, halpern ja, cha ek, bahadori a, chromeckitf, karakiewicz pi, et al. impact of gender on bladder cancer incidence, staging, and prognosis. world j urol. 2011;29(4):457–63. 5. freedman nd, silverman dt, hollenbeck ar, schatzkin a, abnet cc. association between smoking and risk of bladder althea medical journal. 2017;4(1) 99 cancer among men and women. jama. 2011;306(7):737–45. 6. kementerian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2013. 7. eble j, sauter g, epstein j, sesterhenn i,editors. pathology and genetics of tumours of the urinary system and male genital organs. lyon: iarc press; 2004. 8. kong chc, singam p, hong ge, cheok lb, azrif m, tamil am, et al. clinicopathological features of bladder tumours in a single institution in malaysia. asian pac j cancer prev. 2010;11(1):149–52. 9. asro abdih, wahjoe djatisoesanto, sunaryo hardjowijoto. profile of bladder transitional cell cancer in soetomo hospital surabaya.juri. 2014;21(2):1–6. 10. joshi hn, makaju r, karmacharya a, karmacharya rm, shrestha b, shrestha r, et al. urinary bladder carcinoma: impact of smoking, age and its clinicopathological spectrum.kathmandu univ med j.2013;4(44):292–5. 11. beniwal k, goel s, rana p. clinicopathological analysis of urinary bladder tumors at a tertiary care institute in north india. int j sci stud. 2015;12(2):96–9. 12. vaidya s, lakhey m, sabira k, hirachand s. urothelial tumours of the urinary bladder: a histopathological study of cystoscopic biopsies. j nepal med assoc. 2013;52(191):475–78. 13. wen y-c, kuo j-y, chen k-k, lin at, chang y-h, hsu y-s, et al. urothelial carcinoma of the urinary bladder in young adults— clinical experience at taipei veterans general hospital. j chin med assoc. 2005;68(6):272–5. 14. nomikos m, pappas a, kopaka m-e, tzoulakis s, volonakis i, stavrakakis g, et al. urothelial carcinoma of the urinary bladder in young adults: presentation, clinical behavior and outcome. adv urol. 2011;2011(1):1–4. 15. horstmann m, witthuhn r, falk m, stenzl a. gender-specific differences in bladder cancer: a retrospective analysis. gend med. 2008;5(4):385–94. 16. andrás c, tóth l, pósán j, csiki e, tanyi m, csiki z, et al. occurrence of bladder metastasis 10 years after surgical removal of a primary gastric cancer: a case report and review of the literature. j med case rep. 2013;7(204):1–4. 17. morichetti d, mazzucchelli r, lopezbeltran a, cheng l, scarpelli m, kirkali z, et al. secondary neoplasms of the urinary system and male genital organs. bju int. 2009;104(6):770–6. vivien kate perix, sri suryanti, aaron tigor sihombing: five years facts of bladder cancer at west java’s top referral hospital, in indonesia vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 439 three-year study of geriatric skeletal muscle strength at a top referral general hospital, west java, indonesi sigop elliot parsaulian lumbantoruan,1 vitriana,2 lazuardhi dwipa3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: one of the aging effects is the decrease of skeletal muscle strength. the objectives of this study was to analyze the geriatric skeletal muscle strength by hand grip strength according to the characteristics of the elderly. methods: an analytic retrospective study was carried out to 99 medical records of elderly who sought medication at the geriatric policlinic of dr. hasan sadikin general hospital as the top referral hospital in west java, indonesia from 2012–2014. the result of hand grip strength measurement were grouped based on the characteristics of gender, age, body mass index (bmi), barthel index score, mini nutritional assessment (mna) score, number of disease and number of medication. all data were taken from patient’s medical records. the collected data were statistically analyzed with unpaired t-test and one way anova test. results: among the 99 subjects, most of the subjects were male, under 80 years old, independent living persons, had normal bmi, and normal nutritional level according to mini nutritional assessment. most of the subjects had more than 3 diseases per person and less than 5 sorts of medication. male had higher hand grip strength compared to female and it was statistically significant (p=0.04). based on adl score, independent living had higher hand grip strength compared to other level (p=0.008). conclusions: from all the variables measured, only gender and activity daily living level contibute to the hand grip strength. keywords: elderly, hand grip strength, muscle strength correspondence: sigop elliot parsaulian lumbantoruan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: sigopelliot@gmail.com introduction the world today is entering the era of aging population with the number of older people increasing significantly throughout the world. in 2010, there are 18.043.712 of older adult or 9% of the entire population in indonesia.1 as a human gets older, the body experienced the process of aging toward a worse level of health condition followed by decrement of body function which cause people more prone to disease or even death.2,3 one of the declining body function is the body musculoskeletal system. the skeletal muscle as part of the system also experience a decrease through loss of muscle mass and muscle quality as it lost its contractile tissues followed by massive fat deposition.4 these conditions directly affect the muscle strength and muscle performance in conducting the functions which can cause limitations to older adult in performing their daily living day-to-day activities (activity daily living/adl). the final effect is the decline of the quality of life which caused loss of independence in the advanced age people. in general, the muscle strength of the hand could be used to see the skeletal muscle strength.5 this study aimed to measure the skeletal muscle strength by measuring the hand muscle strength based on the characteristics of gender, age, body mass index (bmi), level of independence, nutritional status, number of disease and number of medication taken in geriatric patients. furthermore, geriatric patients have characteristics which distinct them from other general older adults since geriatric patients have more than one disease (multi-morbidity) resulting from disruption of amj. 2017;4(3):439–43 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1195 althea medical journal. 2017;4(3) 440 amj september 2017 body functions and/or physiological systems as well as problematic social conditions. all of these contribute as the risks of accelerated muscle strength loss.6 methods a retrospective descriptive study design with population of outpatients in the geriatric polyclinic at dr. hasan sadikin general hospital bandung was conducted from may to september 2014. data collection was obtained from medical records of patients from 2012 to 2014 (3 years data). the sample was obtained through total sampling technique. the collected data were results of the hand grip strength test by using the hand grip dynamometry, which were then grouped into several characteristics based on gender, age, bmi, barthel index of activity daily living (adl) score, mini nutritional assessment (mna) score, number of disease and number of medication taken by the patients. the result of the measurement with the hand grip dynamometry was compared to the cut–off produced by the asian working group of sarcopenia (awgs) in japan. the results were considered low if the subject had the hand grip strength <30.3 kg in man and <19.3 kg in woman.7 age was grouped into three age groups which were young-old (60–69 years of age), middle old (70–79 years of age) and very old (80 years of age or above). the bmi was classified into four groups based on gender which were underweight (<17 kg/m2 for female, <18 kg/m2 for male), normal (17–23 kg/m2 for female, 18–25 kg/m2 for male), overweight (>23–27 kg/m2 for female, >25–27 kg/m2 for male) and obesity (>27 kg/m2 for male and female). barthel index or adl barthel score is a tool consisting of 10 questions aimed at measuring the performance of older adult in conducting the activity of daily life. based on the span of score from 0–20, the results of measurement/adl score were divided into four groups, namely the independent group for a score of 20, light dependence for score of 12–19, dependence for score of 9–11 and total dependence for score of 0–4.8 the mna score was a tool consisting of 18 questions which was designed and validated to quickly assessed the nutritional status of older adults. the mna scores were then grouped into three groups based on the score that were normal (24–30), risk of malnutrition (17–23.5) and malnutrition (≤16.5).9 the number of diseases were grouped into 2 groups of <3 and ≥3 diseases. the number of medication taken by table 1 subject characteristics based on age groups, body mass index (bmi), activity daily living (adl) level, mini nutritional assessment (mna) level, number of diseases and number of medication characteristics n (%) gender male 57(57.6) female 42(42.4) age group 60–69 years old 43 (43.4) 70–79 years old 44 (44.4) ≥80 years old 12 (12.2) body mass index (bmi) underweight 7 (7.1) normal 45 (45.5) overweight 18 (18.2) obese 29 (29.3) activity daily living (adl) level independent 80 (80.8) light dependent 17 (17.2) dependent 1 (1.0) total dependent 1 (1.0) mini nutritional assessment (mna) level normal 77 (77.8) risk of malnutrition 18 (18.2) malnutrition 4 (4.0) number of disease <3 diseases 24 (24.2) ≥3 diseases 75 (75.8) number of medication ≤5 medication 59 (59.6) >5 medication 40 (40.4) the patients (polypharmacy) was divided into 2 groups, namely which used ≤5 medications and >5 medications. all the informations were obtained through the patient’s medical records. furthermore, the inclusion criteria in this study were the medical records that had information of the hand grip strength althea medical journal. 2017;4(3) 441 table 2 means and standard deviation of hand grip dynamometry result based on gender, age group, body mass index, adl level, mna level, number of diseases and number of medication. characteristics hand grip strength x ̅ (sd) combined means p value*male female gender 25.92 (6.02) 17.35 (4.37) 21.85 (6.80) 0.04** age group 60–69 years old 29.60 (6.95) 17.96 (4.60) 21.75 (7.71) 0.905*** 70–79 years old 25.01 (5.68) 16.58 (4.14) 22.13 (6.55) ≥80 years old 23.14 (2.13) 15.30 (2.76) 21.18 (4.15) body mass index (bmi) underweight 19.62 (2.99) 15.56 (1.45) 17.88 (3.14) 0.260*** normal 27.30 (6.78) 17.51 (4.50) 22.85 (7.62) overweight 25.87 (3.43) 17.36 (4.70) 22.03 (5.82) obesse 25.31 (5.77) 17.48 (4.66) 20.99 (6.45) activity daily living (adl) level independence 26.31 (6.13) 18.18 (4.14) 22.76 (6.69) 0.008*** light dependence 22.76 (5.07) 15.57 (3.85) 18.11 (5.46) dependence 17.10 (0) 17.10 (0) total dependence 7.90 (0) 7.90 (0) mini nutritional assessment (mna) level normal 26.91 (5.99) 17.22 (3.96) 22.26 (7.04) 0.309*** risk of malnutrition 22.55 (4.80) 19.43 (4.99) 21.16 (5.00) malnutrition 20.90 (8.34) 11.40 (5.93) 17.15 (8.89) number of disease <3 diseases 25.30 (4.02) 17.80 (4.00) 21.61 (6.37) 0.285** ≥3 diseases 26.08 (6.48) 17.18 (4.55) 22.00 (7.10) number of medication ≤5 medication 25.04 (5.23) 16.34 (4.63) 21.06 (6.58) 0.702** >5 medication 27.3 (7.02) 18.71 (3.67) 23.02 (7.04) notes: *p-value: <0.05 = significant result, >0.05 = insignificant result, **unpaired t-test,*** anova test, x ̅: means of hand grip dynamometry test, sd= standard deviation sigop elliot parsaulian lumbantoruan, vitriana, lazuardhi dwipa: three-year study of geriatric skeletal muscle strength at a top referral general hospital, west java, indonesia result showed that the data were normally distributed (p=0.200).the data were further analyzed with unpaired t-test and one way anova test. results out of 223 samples, 99 or only about 44.3% of the medical records had complete data that was needed in the study. the subjects were then divided into two groups based on gender of the subjects. there were 57 (57.5%) through the hand grip dynamometry test, characteristics of the patients, namely gender, age, bmi, adl score, mna score, number of disease and number of medication. the exclusion criteria were medical records with incomplete data needed in this study. this study had obtained the permission from the health research ethics comittee of dr. hasan sadikin general hospital. the analysis of the data was conducted by determining the data distribution for the handgrip strength using the kolmogorov-smirnov method, and the althea medical journal. 2017;4(3) 442 amj september 2017 male and 42 (42.5%) female included in this study and grouped into several characteristics (table 1). this study discovered that most of the subjects were male, under 80 years old, independent persons, had normal bmi, and normal nutritional level according to mna. hence, most of the subjects had more than 3 diseases per person. the results of hand grip dynamometry test were then grouped into the subject’s characteristics such as age group, bmi, adl level, mna level, number of disease and number of medication taken by the patient based on gender of the subject (table 2). furthermore, this study discovered that only gender and activity daily living level contibuted to the hand-grip strength. male had higher hand-grip strength compared to female which was statistically significant (p=0.04). based on adl score, independent level had higher hand-grip strength compared to other levels (p=0.008). discussion based on the cut-off according to awgs from japan, the subjects of the study both men and women have a lower hand-grip strength than the awgs cut-off. there was significant difference in the hand-grip strength of both sexes. male subjects have greater skeletal muscle strength as showed by bigger hand-grip strength compared to female, as male subjects tend to have bigger muscle strength and were better in terms of usage of the hands and fingers that involves the function of nerves as in a study conducted by kubota and demura.10 in a study conducted by irawan and kuswardhani in denpasar, bali, indonesia11, it also stated that men have a better hand-grip strength than women because of the larger muscle mass in men and better physical performance than women. besides, the hormone factor also plays a role in these differences. higher testosterone in men give the effect of increasing of mass and muscle power as well as bone in a parallel way while women being with a higher estrogene hormone than testosterone, tend to have a faster bone growth only compared to the muscle mass growth which makes females have a lower muscle mass and thus lower muscle strength.12 based on age group, the results of hand-grip strength test were better in the younger age group compared to the older age group without a significant difference between the groups. a study conducted by vianna et al.13 reported, there is a curvalinear relationshipbetween muscle strength and age where the muscle strength significantly increase with age and peak at 30 years of age. this condition is later followed by declining of muscle strength due to the aging of the body. the declining of hand-grip strength occurs at the age of 30 years in males and 50 years old in females13 with higher hand-grip strength compared to the other three groups, which were without a significant difference between each group. according to the study conducted in india14, the value of hand muscle strength was better in the group with a normal bodyweight in both gender groups because nutritional status affects the muscle strength and quality. in the group with an underweight bmi, the muscle strength has declined due to lack of energy, while in the group of overweight and obese, it is probably due to the change in muscle tissues as it is infiltrated by the body fat and change in type i and type ii muscle fibre distributions which change the muscle strength.14 there was significant difference in the result of hand-grip strength test between the groups of adl scale. the subjects in the independent group have a better result than the sample from the other status of adl. in the study conducted by cuesta-vargaz and pérezcruzado15, there were a positive correlation between adl score and hand-grip strength. the study of taekema et al.16 also stated that there is a correlation between the low result of hand-grip strength with low adl score and low independency. it is assumed that adl or low level of daily activity will further speed up the declining of the muscle strength.16 in both genders, the means of hand-grip strength was higher in the subjects with normal nutritional status compared to the group of either with the risk of malnutrition or even malnutrition. in the study of i wayan ambartana17, it is found that nutritional status positively correlates with hand muscle strength. the subjects with malnutrition possess a lower mass and function of muscle despite age. chronic loss of nutrition and energy will decline either the body fat tissue or muscle mass which later affect the strength of the muscle.17 moreover, the number of diseases could not represent the equivalent between the number of diseases and declining of hand muscle strength. this is also the limitation of this study as we only consider the number of disease without looking into the type and severity of the diseases which might affect the hand-grip strength either directly or indirectly. althea medical journal. 2017;4(3) 443 the number of consumption of drugs could not show a parallel with the hand-grip strength. this conditon showed that the drugs consumed by the subjects in the clinic did not provide any adverse effect in the change of muscle strength. this also meant that the number of drugs did not interact with the muscle strength. the fact that this study was conducted in a policlinic, made it possible that the subjects were well-controlled and maintained which might slow the effect in the change of muscle strength. the less complete medical records caused a limitation in the number of data which can be used, and may also reduce the quality of the study so that an increase in the number of medical record data is necessary for improvement in the quality and provision of basic data essential for a further study. it can be concluded that gender and adl level contribute to hand-grip strength in elderly. references 1. badan pusat statistik indonesia. perkembangan beberapa indikator utama sosial-ekonomi indonesia mei 2013. jakarta: badan pusat statistik; 2013. p.14– 5. 2. pusat data dan informasi kementerian kesehatan ri. gambaran kesehatan lanjut usia di indonesia. buletin jendela data dan informasi kesehatan. 2013; semester i:1–18. 3. miller ra. biology of aging and longevity. in: halter jb, ouslander jg, tinetti me, studenski s, high kp, asthana s. hazzard’s geriatric medicine and gerontology. 6th ed. new york: the mcgraw-hill companies; 2009. p. 3–4. 4. jones te, stephenson kw, king jg, knight kr, marshall tl, scott wb. sarcopenia– mechanisms and treatments. j geriatr phys ther. 2009;32(2):83–9. 5. 5. wind ae, takken t, helders pj, engelbert rh. is grip strength a predictor for total muscle strength in healthy children, adolescents, and young adults. eur j pediatr. 2010;169(3):281–7. 6. andri, damping ce. peranan psikiatri geriatri dalam penanganan delirium pasien geriatri. maj kedokt indon. 2007;57(7):227–32. 7. chen lk, liu lk, woo j, assantachai p, auyeung tw, bahyah ks, et al. sarcopenia in asia: consensus report of the asian working group for sarcopenia. jama. 2014;15:95–101. 8. houlden h, edwards m, mcneil j, greenwood r. use of the barthel index and the functional independence measure during early inpatient rehabilitation after single incident brain injury. clin rehabil. 2006;20(2):153–9. 9. tsai ac, hsu h-y, chang t-l. the mini nutritional assessment (mna) is useful for assessing the risk of malnutrition in adults with intellectual disabilities. j clin nurs. 2011;20(23–24):3295–303. 10. kubota h, demura s. gender differences and laterality in maximal handgrip strength and controlled force exertion in young adults. health. 2011;3(11):684–88. 11. putu putrawan ib, tuty kuswardhani ra. faktor-faktor yang menentukan kekuatan genggaman tangan pada pasien lanjut usia di panti wredha tangtu dan poliklinik geriatri rsup sanglah, denpasar. j peny dalam. 2009;12(2):87–91 12. lang tf. the bone-muscle relationship in men and women. j osteoporos. 2011;2011:702735. 13. vianna lc, oliveira rb, araujo cg. agerelated decline in handgrip strength differs according to gender. j strength cond res. 2007;21(4):1310–4. 14. lad up, satyanarayana p, shisode-lad s, siri ch c, kumari nr. a study on the correlation between the body mass index (bmi), the body fat percentage, the handgrip strength and the handgrip endurance in underweight, normal weight and overweight adolescents. j clin diagn res. 2013;7(1):51–4. 15. cuesta-vargas, pérez-cruzado d. relationship between barthel index with physical tests in adults with intellectual disabilities. springerplus. 2014;3:543. 16. taekema dg, gussekloo j, maier ab, westendorp rg, de craen aj. handgrip strength as a predictor of functional, psychological and social health. a prospective population-based study among the oldest old. age ageing. 2010;39(3):331–7. 17. i wayan ambartana. hubungan status gizi dengan kekuatan otot lanjut usia di kelurahan gianyar, kabupaten gianyar, provinsi bali. jig. 2010;1(1):67–74. sigop elliot parsaulian lumbantoruan, vitriana, lazuardhi dwipa: three-year study of geriatric skeletal muscle strength at a top referral general hospital, west java, indonesia vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 208 amj december 2018 qualitative analysis of establishing diagnosis and management of hypertension from patient’s perspective in jatinangor yulia sofiatin,1 nazmun lailah,2 trully deti rose sitorus,3 rully m. a. roesli4 1department of public health faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3 department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 4department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: nazmun lailah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: nazmun.fkunpad@gmail.com introduction hypertension is the main cause of cardiovascular diseases such as heart attack stroke, renal failure, and early death.1 globally, 26.4% of the adult population have hypertension and this number is predicted to rise to 29.2% in year 2025.2 in indonesia3, according to the indonesian basic health research (riset kesehatan dasar, riskesdas) survey in 2013, prevalence of hypertension is 26.5%. west java is the province with the third highest prevalence of hypertension 29.4%.3 meanwhile, jatinangor, one of the districts in sumedang, west java province, has an even higher prevalence of 37.8%.4 based on 2007–2010 data from the national health and nutrition examination survey (nhanes), 33% of young adults in the united states have hypertension.5 among all young adults with hypertension, 82% are aware of ones condition, 75% consume antihypertensive drugs but only 53% are able to achieve a controlled blood pressure level. in addition to the results, another study by hamzah et al.6 in jatinangor, showed that only 35% of hypertensive patients consume medications but only 6% reach a controlled blood pressure. a previous study in jatinangor also demonstrated that there is no correlation between correct use of drug and achievement of blood pressure control.7 the study reported that patients consuming the proper drugs might still have an uncontrolled blood pressure. however, the patients consuming improper drugs achieve a controlled blood amj. 2018;5(4):208–13 abstract background: blood pressure control is necessary to prevent complications in patients with hypertension. a previous study in jatinangor showed the failure of controlling blood pressure even with pharmacological treatment. proper diagnosis and effective management are considered to influence the condition. this study was performed to describe the process of establishing diagnosis and management for hypertension from the patient’s perspective in jatinangor. methods: a phenomenological approach was used. data were collected through semi-structured questions in focus group discussions (fgds) led by a moderator. participants of fgds were patients with hypertension who had undergone antihypertensive drugs therapy based on a previous study, and were invited by the local health cadres. the study was held in two villages in jatinangor, namely hegarmanah and cilayung in the period of july to august 2015. data were presented as narration and figures. results: there were five and eight hypertensive participants for hegarmanah and cilayung villages fgd, respectively. diagnosis of hypertension in fgd participants was not only confirmed by doctors but also other health professionals, due to various accessibilities to health care facilities. diagnosis establishment and management of hypertension were not following the protocol. education on pharmacological and non-pharmacological management was provided by health professionals, however still lacked details and was not reviewed on every visit, resulting in a lack of compliance. conclusions: process of establishing diagnosis and management of hypertension from the patient’s perspective in jatinangor is unfortunately not following the protocol, thus may influence the blood pressure control outcome. keywords: diagnosis establishment, focus group discussion, hypertension, hypertension management althea medical journal. 2018;5(4) 209 pressure. proper establishment of diagnosis and effective management are keys for achieving controlled blood pressure in patients with hypertension. there are two concepts related to patients and health professionals role.8 the accurate diagnosis is influenced by the understanding of health professionals towards the process of diagnosing hypertension, while in hypertension management the health professional plans the comprehensive treatment and educate the patients. afterwards, it depends on whether the patient will follow the planned program or not. the purpose of this study was to investigate the process of establishing diagnosis and management from the perspective of patients in the community. methods this study was designed as a qualitative descriptive study using a phenomenological approach. data were collected through focus group discussions (fgds). the fgd was chosen since it provided an efficient, fast, and economical method in obtaining qualitative data. it developed more socially-oriented environment so that the participants would feel free to share information and answer the questions spontaneously.9 two fgds were conducted in hegarmanah and cilayung village, jatinangor district, representing rural and urban areas. a session of fgd with health professionals working within the area were served as a triangulation process. data were collected in the period of july to august 2015. the ethical approval for the study was obtained from the health research ethics committee, faculty of medicine, universitas padjadjaran bandung, no. 589/un6.c1.3.2/ kepk/pn/2015. the fgd participants were respondents from a previous study who were diagnosed with hypertension and underwent antihypertensive drugs therapy.7 subjects were recruited using the purposive sampling method.10 the list of eligible subjects was sent to the local health cadres and they selected the subjects based on adjacent residence to ensure participants’ attendance. then, a few days prior to the fgd, the cadre informed the selected subjects to join the fgd. each fgd was led by a moderator who is specialized in internal medicine with experience in fgd. the fgd was guided by semi-structured questions on establishing diagnosis and management of hypertension (figure 1). fgds were held in sundanese language as the majority of the respondents felt more comfortable using their local language. before each fgd was conducted, the moderator explained the purpose of the study and requested consent to audio-record the discussion. transcriptions in bahasa indonesia were made by two authors independently, and then compared to find any essential disparities which will be reconfirmed together. the data analysis included coding, categorization, theme formation, and conclusion. results all informants were patients with hypertension. there were five informants from hegarmanah village with initial blood pressure establishment of hypertension • who diagnosed that you had hypertension? • what was the basis of such diagnosis? • how was the patients’ experience in the process of establishing diagnosis of hypertension? management of hypertension • how was the education given regarding the plan of hypertension management? • how was the non-pharmacological therapy of hypertension given to the patient? • did the patients consume medication for hypertension? if yes, from whom did they get the medication? • if the drugs was given by health professionals, how was the education about the drugs (type, dosage, frequency, side effect, etc) given? figure 1 semi-structured questions as guideliness for moderator yulia sofiatin, nazmun lailah,trully deti rose sitorus, rully m. a. roesli: qualitative analysis of establishing diagnosis and management of hypertension from patient’s perspective in jatinangor althea medical journal. 2018;5(4) 210 amj december 2018 ranging between prehypertension stage i and hypertension stage ii. from cilayung village, there were eight informants who joined fgd with initial blood pressure ranging between stage i and ii hypertension, prior gestational hypertension. hypertension was diagnosed on the first visit in almost all of the informants, and all of them received a drug treatment on the first visit. the diagnosis of hypertension among fgd informants in hegarmanah village was confirmed by medical doctors, either by a private doctor, doctor or nurse at the primary health center (pusat kesehatan masyarakat, puskesmas). on the other hand, in cilayung village, midwives and mantri (licensed nurses who are accustomed to prescribe drugs in regions with lack of doctors) were also involved in hypertension diagnosis. one of the informants was diagnosed with gestational hypertension without prepregnancy blood pressure information by a midwife. midwives in cilayung village provide health care privately (at home), while at the integrated health post they mainly focus on maternal and child care (pos pelayanan terpandu, posyandu), as well as at the puskesmas pembantu. the mantri is a wellknown nurse in cilayung village who works in hospital and practice privately at home. the variation of health professionals who diagnose hypertension are due to different accessibility of health care facilities between the two villages (figure 2). hegarmanah village is located near the main road with a strategic access to health care facilities including puskesmas as well as private doctors. meanwhile, cilayung village’s location is far from jatinangor’s main road with the nearest available health care facilities only midwives and puskesmas pembantu, and without the availability of public transportation. the best so-called public transportation was ojek (motorcycle taxi), the cost was idr 20,000.00 one way to and from puskesmas. this situation inhibited informants from coming to puskesmas to collect drugs provided through the universal health coverage (jaminan kesehatan nasional, jkn). health professionals confirmed the shortage of medical doctors in the area, thus the task of diagnosing and treating wase shifted to the nurse. some nurses provided private medical practice in their neighbourhood. awareness among informants were low, some of them were diagnosed as hypertensive after their admission to hospital due to complications. the fact that hypertension is not always symptomatic resulted in a lack of awareness to get their blood pressure checked or managed causes complications that need urgent measures including hospitalization. figure 2 map of health care facilities in the study area (scale:1:106) althea medical journal. 2018;5(4) 211yulia sofiatin, nazmun lailah,trully deti rose sitorus, rully m. a. roesli: qualitative analysis of establishing diagnosis and management of hypertension from patient’s perspective in jatinangor despite the low awareness, there is a blood pressure check peddler who offers blood pressure measurement house to house. however, a fgd informant remarked that they no longer trusted the peddler as he was also selling drugs and herbal medications so that the result mentioned was often higher than the actual blood pressure. health professionals confirmed the presence of the peddlers, and their practice was institutionally prohibited through the village officer’s monitoring. all fgd informants were treated with drugs on the first meeting without any lifestyle modification education. the duration of drug treatment varied. informants from hegarmanah received medication for a week, and were recommended to control afterwards. informants from cilayung received medication for three days and were not recommended to control. some of the informants received medicines for a longer period. this condition was confirmed. the reasons included the concern that those patients would not follow the life-style modification, nor return to the health facility after they felt better. education on the antihypertensive drugs given was still limited to explanations about the type and frequency. an informant admitted that the education provided by the doctor during the next visit was not different from the first visit with the addition to regularly take the drugs. most of the informants could not recall what the doctor had suggested regarding the medicine. all informants admitted to receive education on non-pharmacological management involving lifestyle modifications such as reducing salty foods consumption including salted fish, and fatty foods, increasing physical activity as well as avoiding excessive stress. fruit and vegetables consumption was also advised; however, the term fruit was falsely assumed to ‘imported’ fruits they had to buy, they did not consider the local fruit grown around their living area, such as papaya, will give the same benefit to their health. health profesionals admitted of delivering education; however they also doubted their own ability in communicating the right messages. the notion that hypertension generally does not generate symptoms has also not been fully understood by fgd participants. almost all participants believed that headache and dizziness were the signs that they had high blood pressure. thus, if they did not feel as such, they did not need to consume antihypertensive drugs. moreover, they considered that their blood pressure would always be constant; when their blood pressure increased during treatment they thought that the drug was a failure. unfortunatelly, the similar concepts were also embraced by some health professionals. therefore, education from health professionals on factors that raise blood pressure was needed; however education for health profesionals was also necessary. discussions in this study, the process of establishing diagnosis of hypertension according to patients’ experience in jatinangor was still not following the protocol. patients diagnosed with hypertension received antihypertensive drugs on the first visit, despite the stage of their hypertension condition. according to the canadian hypertension education program recommendation 2015 which was adopted by the indonesian society of hypertension (inash), hypertension should be established within several visits, except in the cases of hypertensive urgency and emergency.11 this condition will lead to overdiagnosis of hypertension and overtreatment which further leads to high cost. general practitioners are authorized for diagnosing hypertension as well as providing full treatment for those without complications. with the shortage of gp, these tasks are shifted to nurses and, midwives who are licensed to particular regions. this arrangement will help the community to get closer to health services. however they should have additional and updated competence, and even the gps need the update. a study on hypertension management from the general practitioner’s perspective was previously conducted by howes et al.12 through fgd. this study showed that the doctors need consistent and accurate measurement, and reading of patients’ blood pressure as well as skill improvement, especially regarding the diagnostic guideline and management of hypertension. the provider’s adherence in following available clinical guidelines is an obstacle in achieving controlled blood pressure level in patients with hypertension.8 one of the reasons stated by the providers is the difficulty in the health system, which is insufficient time for patient consultations, making it hard for them to observe the diagnostic and management guideline for hypertension. moreover, the ability to follow current information development is also a hindrance as well as their own disbelief towards available althea medical journal. 2018;5(4) 212 amj december 2018 guidelines, whether it would yield better results or the opposite.8 in the era of universal coverage, when drugs are provided by the government, the protocol of drug dispensing, especially to residents of remote areas should be re-arranged to increase the compliance. the phenomenon occurring in cilayung village showed the lack of health care facilities in the region, which then caused a lack of awareness on hypertension. this was previously proven by a participant who developed an organ dysfunction due to high blood pressure without being detected with high blood pressure. this lack of awareness on hypertension as in developing countries, which is probably caused by poor accessibility of healthcare facilities was also shown in another study.13 management of hypertension is divided to pharmacological and non-pharmacological therapy. the principle of hypertension management is to primarily encourage a lifestyle modification, afterwards if the controlled blood pressure level of <140/90 or <130/80 mmhg in patients with diabetes or renal disease is not achieved, then the administration of antihypertensive drugs can carried out. there is an exception in the treatment of hypertensive crisis, in which the administration of antihypertensive drugs to the patient should be carried out right away. a lack of adherence to the protocols, especially on the administration of antihypertensive drugs before diagnosis of hypertension was confirmed and unsuitable competency for establishing diagnosis might be the answers for the low relationship between correct drugs consumption with achievement of controlled blood pressure in hypertensive patients. the use of antihypertensive drugs on patients with high blood pressure may decrease the risk for stroke and other cardiovascular disease.14 the administration of antihypertensive drugs by health professionals for the fgd participants was still not following the protocol. according to the esh-esc guidelines 2013, stage i and ii hypertensive patients should be encouraged to first modify their lifestyle for a month and a week, afterwards antihypertensive drugs can be given if a controlled blood pressure level is unattainable.15 however, another research stated that administration of antihypertensive drugs to patients with risk, without considering their blood pressure, is given to patients with any grade of blood pressure.16 education on pharmacological and nonpharmacological therapy given towards patients or patients’ family is proven to increase patients’ compliance.17 a study in southwest nigeria18 using fgd showed that one factor mentioned by the participant as the cause of low compliance to hypertension therapy is the low level of knowledge regarding hypertension itself. for instance, participants assume if there is no symptom felt, then it is not necessary to consume antihypertensive medicine.11 so that, education should not be limited to hypertension management, but also includes factors influencing blood pressure and possible complications in order to raise patients’ knowledge on their disease.1 the limitations of this study is that there is not one member examining the discussion transcripts to increase the reliability of the study, which is due to the limited time provided. in addition, non-verbal interactions between fgd participants failed to be well documented due to the lack of field-notes. this study concludes that the process of establishing diagnosis and management for hypertension from patients’ perspective in jatinangor is still not following the protocols, thus may influence the blood pressure control outcome. the disconcordance of education received by patients and provided by the health profesional needs to be assessed in order to plan a better hypertension prevention program, both primary and secondary. references 1. world health organization. a global brief on hypertension: silent killer, global public health crises (world health day 2013). geneva: who; 2013. 2. kearney pm, whelton m, reynolds k, muntner p, whelton pk, he j. global burden of hypertension: analysis of worldwide data. lancet. 2005;365(9455):217–23. 3. departemen kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan, republik indonesia; 2013. 4. fihaya fy, sofiatin y, ong pa, sukandar h, roesli rm. prevalence of hypertension and its complications in jatinangor 2014. j hypertens. 2015;33(suppl2):34–5. 5. go as, mozaffarian d, roger vl, benjamin ej, berry jd, blaha mj, et al. heart disease and stroke statistics--2014 update: a report from the american heart association. circulation. 2014;129(3):28–292. althea medical journal. 2018;5(4) 213 6. hamzah nka, roesli rm, sofiatin y, sukandar h. awareness, treatment and control of hypertension in jatinangor subdistrict between march-november 2014. j hypertens. 2015;33(suppl2):34–5. 7. putra mrd, sofiatin y, hidayat em, sukandar h, roesli rm. correlation between the correct use of drug and the achievement of blood pressure control. j hypertens. 2015;33(suppl2):34–5. 8. khatib r, schwalm j-d, yusuf s, haynes rb, mckee m, khan m, et al. patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and metaanalysis of qualitative and quantitative studies. plos one. 2014;9(1):1–12. 9. onwuegbuzie aj, dickinson wb, leech nl, zoran ag. a qualitative framework for collecting and analyzing data in focus group research. int j qual meth. 2009;8(3):1–21. 10. wong lp. focus group discussion: a tool for health and medical research. singapore med j. 2008;49(3):256–60. 11. daskalopoulou ss, rabi dm, zarnke kb, dasgupta k, nerenberg k, cloutier l, et al. the 2015 canadian hypertension education program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. can j cardiol. 2015;31(5):549–68. 12. howes f, hansen e, nelson m. management of hypertension in general practice: a qualitative needs assessment of australian gps. aust fam physician. 2012;41(5):317– 23. 13. pereira m, lunet n, azevedo a, barros h. differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries. j hypertens. 2009;27(5):963– 75. 14. mazzaglia g, ambrosioni e, alacqua m, filippi a, sessa e, immordino v, et al. adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients. circulation. 2009;120(16):1598– 605. 15. mancia g, fagard r, narkiewicz k, redon j, zanchetti a, böhm m, et al. 2013 esh/ esc guidelines for the management of arterial hypertension. eur heart j. 2013:31(7):1281–357. 16. law m, morris j, wald n. use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. bmj. 2009;338(1):1–19. 17. osterberg l, blaschke t. adherence to medication. n engl j med. 2005;353(5):487–97. 18. osamor pe, owumi be. factors associated with treatment compliance in hypertension in southwest nigeria. j health popul nutr. 2011;29(6):619–28. yulia sofiatin, nazmun lailah,trully deti rose sitorus, rully m. a. roesli: qualitative analysis of establishing diagnosis and management of hypertension from patient’s perspective in jatinangor vol 5 no 2 full text edit.indd althea medical journal. 2018;5(2) 57 effect of antihyperglycemic agents on hemoglobin a1c level in type 2 diabetes mellitus patients tasya kamila,1 vycke yunivita kusumah dewi,2 miftahurachman3 1rsud mampang prapatan jakarta, indonesia, 2department of basic medicine faculty of medicine, universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: type 2 diabetes mellitus (t2dm) patients require continuous lifelong attention to pharmacotherapy to achieve and maintain optimal glucose control, which can be monitored through measuring hba1c. this study aimed to see the comparrison of hba1c levels before and after a minimum of two months use of antihyperglycemic agents in patients with t2dm. methods: this analytical cross-sectional study used medical records of patients with t2dm in the center of outpatient medical records at the department of clinical pathology, dr. hasan sadikin general hospital, in 2013. sampling was conducted using consecutive sampling technique. the data analysis used the paired t-test and wilcoxon test for not normal data distribution. results: before and after a minimum of two months use of antihyperglycemic agents, hba1c concentration was 7.15% (6.1–12.2) and 7.3% (5.9–11.9) respectively. statistically, the difference of hba1c concentration of t2dm patients between those period was not significant (0.15%; p=0,812). mean hba1c concentration was found with greatest decrease in patients treated with sulfonylurea (2.25%), followed by insulin (0.1%). there were increases in mean hba1c concentration in patients treated with metformin (0.05%), metformin+insulin (1.1%), sulfonylurea +metformin (0.6%), sulfonylurea+alpha-glucosidase inhibitor (1.1%), and sulfonylurea + metformin + alpha-glucosidase inhibitor (0.05%). conclusions: there is no significant difference of hba1c levels before and after two months to two years use of antihyperglycemic agents in t2dm patients. this result showed the importance of comprehensiveness in t2dm therapy. the therapy should not merely consist of antihyperglycemic medication alone, but also physical exercise, lifestyle modification, and diet control. keywords: antihyperglycemic agents, diabetes mellitus, hba1c correspondence: tasya kamila, rsud mampang prapatan, jalan kapten tendean no. 9, mampang prapatan, jakarta selatan, indonesia, email: tasyakamila94@gmail.com introduction diabetes mellitus is one of the noncommunicable diseases (ncd) which will be the cause of increase in mortality in the next decade.1 indonesia ranked seventh as the country with the highest number of diabetes patients in 2012. prevalence of diabetes mellitus in indonesia kept increasing in the last 30 years and recently become the third leading cause of death in indonesia. it is estimated that with this growing prevalence, diabetes mellitus will put huge burden and challenges to the indonesian healthcare system.2 type 2 diabetes mellitus (t2dm) is characterized by insulin resistance that leads into a state of hyperglycemia. high blood glucose concentrations if left untreated can increase the risk of acute and chronic complications. hence, t2dm patients require lifelong scrutiny to lifestyle and pharmacotherapy, which is an antihyperglycemic agent, to attain and maintain optimal glucose control.3 the effect of lifestyle and pharmacotherapy to glucose levels can be monitored by measuring blood glucose and hba1c. besides hba1c a glycated hemoglobin is the recommended measurement as it can describe both fasting and postprandial glucose concentrations within six to twelve weeks.4,5 antihyperglycemic agents have effects that persisted for up to two years in lowering hba1c levels.6 amj. 2018;5(2):57–63 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1414 althea medical journal. 2018;5(2) 58 amj june 2018 according to the american diabetes association (ada) and indonesian society of endocrinology (perkumpulan endokrinologi indonesia, perkeni), the hba1c target for patients with t2dm is less than 7%.3,7 previous studies conducted in 2003 and 2010 showed that more than half of the patients with t2dm in primary health cares in indonesia8 and the endocrine clinic of dr. hasan sadikin hospital general hospital9 did not reach the hba1c target. however, these studies could not conclude that the vast majority of diabetic treatment was unsuccessful because they ignored the time when the measurement of hba1c was performed, which may result in higher hba1c measurement if performed at least two months prior to the antihyperglycemic medication. therefore, the purpose of this study was to analyze the difference in hba1c before and after two months to two years use of antihyperglycemic agents in patients with t2dm. methods this analytical cross-sectional study used the medical records of patients with type 2 diabetes mellitus dated 1 january–31 december 2013 at the endocrine outpatient clinic of dr. hasan sadikin general hospital (rshs), bandung, indonesia. data were collected using consecutive sampling technique from september to october 2014. the used of medical records had been approved by the health research ethics committee of rshs. medical records that had hba1c measurement data before and after two months to two years use of antihyperglycemic agents met the inclusion criteria. medical records with a history of abnormal bleeding in two to three months prior to hba1c measurement, as it may mask low in hba1c levels, were excluded. data of antihyperglicemic medications collected were the latest antihyperglycemic agents prescribed by the physician. the hba1c measurement was performed by the department of clinical pathology of rshs. furthermore, data of antihyperglycemic medication and hba1c level before and after a minimum of two months use of antihyperglycemic agents were used in the analysis. additionally, types of antihyperglycemic agents, the patient’s age, and the number of months between the last visits were used as descriptive data. moreover, the analysis of differences in hba1c level before and after a minimum of two months use of antihyperglycemic agents in patients with type 2 diabetes mellitus was performed using the paired t-test and non-parametric wilcoxon test if the data notes: su = sulfonylurea; met = metformin; agi = alpha-glucosidase inhibitor; n = number of patients figure 1 characteristics of antihyperglycemic agents used in type 2 diabetes mellitus patients of endocrine outpatient clinic, dr. hasan sadikin general hospital, period 2013 n 0 5 10 15 20 25 30 35 column3 column3 drug class althea medical journal. 2018;5(2) 59tasya kamila, vycke yunivita kusumah dewi, miftahurachman: effect of antihyperglycemic agents on hemoglobin a1c level in type 2 diabetes mellitus patients distribution was not normal. the analyses were performed using analysis software. the minimum hba1c difference between before and after use of antihyperglycemic agents was statistically significant if p≤ 0.05. results a total of 137 medical records were successfully collected. figure 1 showed the characteristics of antihyperglycemic agents used in type 2 diabetes mellitus patients. furthermore, 14 types of antihyperglycemic agent prescribed with insulin were the most agents prescribed. fourteen types of antihyperglycemic agents prescribed can be grouped into larger groups, namely monotherapy (38.5%), a combination of two oral hypoglycemic drugs (oha) (23.4%), a combination of three ohas (11.3%), one oha + insulin (6.1%), a combination of two ohas + insulin (1.5%), and insulin (28.6). from these groups, monotherapy was the most given therapy. there were 20 medical records that met the inclusion and exclusion criteria. characteristics of antihyperglycemic agents that met the inclusion and exclusion criteria, as well as their sociodemographic characteristics and timeliness of patients’ control showed that most of the samples were female and aged 61–70 years (table 1). based on the data in the collected medical records, the physician would prescribe antihyperglycemic agents that would be used up in 3 months if taken appropriately as directed by the physician. patients who visited the doctor within a period of less than or equal to 3 months after the last visit was said to be timely control, while patients who visited the doctor within a period of more than 3 months was said to be not timely control. overall, the majority of patients was timely control. however, the patients with sulfonylurea+alpha-glucosidase inhibitors prescribed medication tended to be not timely control. moreover, hba1c data at before and after two months to two years of antihyperglycemic table 1 sociodemographic characteristic and punctuality control parameter antihyperglycemic class n(%) su+met su+ agi su su+agi+met insulin met met+insulin total gender male 0 (0) 0 (0) 1 (50) 0 (0) 1 (50) 0 (0) 0 (0) 2 (10) female 8 (100) 3 (100) 1 (50) 2 (100) 1 (50) 2 (100) 1 (100) 18 (90) age group 41—50 2 (25) 1 (33) 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) 4 (20) 51—60 2 (25) 1 (33) 2 (100) 0 (0) 1 (50) 0 (0) 0 (0) 6 (30) 61—70 4 (50) 1 (33) 0 (0) 2 (100) 1 (50) 2 (100) 0 (0) 10 (50) control time timely 5 (62.5) 1 (33) 1 (50) 2 (100) 1 (50) 1 (50) 1 (100) 12 (60) not timely 3 (37.5) 2 (66) 1 (50) 0 (0) 1 (50) 1 (50) 0 (0) 8 (40) notes: su = sulfonylurea; met = metformin; agi = alpha-glucosidase inhibitor table 2 hba1c difference before and after 2 months to 2 years of antihyperglycemic medication hba1c level n median (minimum–maximum) p hba1c before antihyperglycemic medication 20 7.15% (6.1–12.2) 0.812hba1c after 2 months to 2 years of antihyperglycemic medication 20 7.3% (5.9–11.9) notes: p = probability althea medical journal. 2018;5(2) 60 amj june 2018 table 3 characteristics of hba1c concentrations for drug classes, punctuality of control, and age groups parameter n median hba1c δ pbefore medication (%) after minimum 2 months of medication (%) drug class su 2 9.25 7 2.25 su+met 8 6.95 7.55 0.6 su+met+agi 3 6.95 7 0.05 su+agi 2 10.6 11.7 1.1 met 2 6.85 6.9 0.05 insulin 2 8.1 8 0.1 met+insulin 1 6.1 7.2 1.1 control time timely 12 7.15 7.3 0.15 0.2 not timely 8 8.6 8 0.6 0.49 age group 41—50 4 8.65 10.75 2.1 0.273 51—60 6 8.9 8.4 0.5 0.893 61—70 10 6.8 6.95 0.15 0.399 notes: su = sulfonylurea; met = metformin; agi = alpha-glucosidase inhibitor; p = probability table 4 treatment success (based upon perkeni’s hba1c recommended goals for t2dm patients) antihyperglycemic agent hba1c goals achievement totalattain (hba1c<7%) fail (hba1c≥7%) n % n % su 1 5 1 5 2 su+met 3 15 5 25 8 su+met+agi 0 0 3 15 3 su+agi 1 5 1 5 2 met 1 5 1 5 2 insulin 1 5 1 5 2 met+insulin 0 0 1 5 1 total 7 35 13 65 20 notes: su = sulfonylurea; met = metformin; agi = alpha-glucosidase inhibitor; p = probability althea medical journal. 2018;5(2) 61 medication showed abnormal data distribution using the shapiro-wilk test. data were analyzed using the wilcoxon test and found that the difference in hba1c between before and after two months to two years of antihyperglycemic medication was not statistically significant (p=0.812) (table 2). data of the characteristics of hba1c concentrations for drug classes, punctuality of control, and age groups showed that the concentration of hba1c prior taking antihyperglycemic medications vary in each type of drug, punctuality of control, and age groups. additionally, administration of combination of three oha (sulfonylurea+alpha-glucosidase inhibitor+metformin) resulted in the highest median hba1c concentration. there was a decrease in hba1c between before and after two months to two years use of sulfonylurea and metformin. hba1c concentration before and after taking antihyperglycemic medications tended to be low in timely control patients compared to not timely control patients. hba1c decreased in the 51–70 age group while experienced an increase in the 41–50 age group (table 3). the treatment success based upon perkeni’s hba1c recommended goals for t2dm patients, namely the treatment of type 2 diabetes was considered to have failed when the patients did not attain hba1c less than 7% after 2-3 months of medication. overall, the majority of patients (65%) did not attained the recommended goals of hba1c (table4). discussion this study discovered that the types of oha prescribed at rshs’s endocrine outpatient clinic was sulfonylurea, alpha-glucosidase inhibitor, and metformin. recently, there are various types of oha available that have fewer side effects with great benefits for patients with type 2 diabetes, for example glucagonlike polypeptide-1 (glp-1) receptor antagonist and dipeptidyl peptidase-4 (dpp-4) inhibitors. 10 as the vast majority of t2dm patients in rshs’s endocrine outpatient clinic did not attain recommended goals of hba1c, other types of oha could be taken into consideration. the majority of patients were with type 2 diabetes control timely. however, patients given sulfonylurea+alpha-glucosidase inhibitors tended to not control timely. this can be due to the discomfort the patient felt because of the side effects caused by sulfonylurea and alpha-glucosidase inhibitors, i.e. moderatesevere hypoglycemia, increased body weight, and gastrointestinal side effects.10 the impact of delayed time control may be the reason why hba1c goals were not attained. the difference in median hba1c before and after at least 2 months of medication was not statistically significant (0.15%; p=0.812). this result was not in accordance with the previous systematic review and meta-analysis of double-blinded, randomized controlled trials of antihyperglycemic agents, which indicates that the use of agi, metformin, and su each can reduce hba1c by approximately 1 to 1.25% when compared with placebo. 6 insulin can reduce hba1c by approximately 1.5 to 3.5%.7 this discrepancy may occur due to the different sample size and showed that the management given to t2dm patients in clinical practice was not comprehensive, such as low encouragement in implementing diet control, physical exercise, and healthy lifesytle in addition to the use of antihyperglycemic agents. less aggressive therapy intensification and lack of attention to a healthy lifestyle can lead to median hba1c difference between before and after minimum of two months of antihyperglycemic medication were not significant.11 the american association of clinical endocrinologists (aace) in glycemic control algorithm publication in 2013 suggested toraising the treatment to the next step if hba1c goal is not attained after three months of treatment.10 in addition to the use of antihyperglycemic agents, ada’s and perkeni’s type 2 diabetes mellitus therapeutic algorithm emphasis on the practice of healthy lifestyle.3,7 lifestyle management consists of reducing excess body weight through caloric restriction, limiting sodium intake below 2.300 mg/day, increasing consumption of fruits, vegetables and low-fat dairy products, avoiding excessive alcohol consumption, and increasing physical activities.11 the practice of healthy lifestyle has a great effect on body mass index (bmi). a retrospective cohort study conducted in overweight and obesse patients with type 2 diabetes showed the importance of weight loss to achieve the treatment goal, which for every 10% intentional weight loss by calorie-restricted diet, the estimated reduction in hba1c concentration is 0.81%.12 however, most patients still considered practice of healthy lifestyle less important. a study showed that the majority of patients with type 2 diabetes who were given lifestyle intervention alone did not return for follow-up compared with patients who were prescribed drug.13 it is necessary to emphasis the tasya kamila, vycke yunivita kusumah dewi, miftahurachman: effect of antihyperglycemic agents on hemoglobin a1c level in type 2 diabetes mellitus patients althea medical journal. 2018;5(2) 62 amj june 2018 importance of healthy lifestyle to patients with type 2 diabetes so that treatment goals can be achieved. in addition to doctor’s efforts in treatment intensification and healthy lifestyles education, there is another attempt to attain the treatment goal of patients with type 2 diabetes mellitus, for example with diabetes self-management education (dsme). dsme is an ongoing process to facilitate diabetic patients with the knowledge, skills, and abilities necessary for self-care. one study showed a significant decrease in hba1c concentration in patients with type 2 diabetes mellitus with dsme compared with routine treatment.14 basically hba1c concentration in the blood is determined by the concentration of glucose in the blood and life span of red blood cells. thus in some cases the levels of hba1c does not truly describe the longterm glycemic control in patients. several factors are known to influence the outcome of the hba1c measurement as triglycerides levels, bilirubin levels, chronic liver disease, hemoglobinopathy, iron deficiency, vitamin b 12 deficiency, blood urea levels, alcoholism, and the consumption of drugs such as aspirin and opiates.15,16 the existence of these factors was not completely written in the medical record, thus these factors may also caused insignificant differences in median hba1c before and after two months to two years. additionally, hba1c levels before starting antihyperglycemic medication varied in each type of antihyperglycemic agent, punctuality control, and age groups (table 3). this also may caused the difference in median hba1c varied in every type of antihyperglycemic agent, punctuality control, and age groups. every 1% higher baseline hba1c concentrations, cause greater 0.01% decreases in hba1c after three months antihyperglycemic medication.6 due to the limitations of this study, i.e. the small sample size, hba1c baseline group division was not performed. this study was only intended to analyze the treatment of type 2 diabetes in clinical practice, it could not be used as a reference for what type of antihyperglycemic agent had the best effect. perkeni stated the therapy is said to fail when the t2dm patient did not attain the goal of hba1c <7% after 2-3 months of therapy. approximately 65% of medical records did not reach the target (table 4). these data confirmed a previous study conducted at rshs in 2010 which claimed more than 50% of patients with type 2 diabetes do not attain hba1c goal.9 the same condition did not only happen in indonesia. a larger study conducted involving 21,267 diabetic patients in hawaii showed that despite good adherent to their medications, 56.1% of patients with type 2 diabetes mellitus do not meet the target hba1c of less than 7%.17 this study concludes that there is no significant difference of hba1c levels between before and after two months to two years use of antihyperglycemic agents in t2dm patients. diabetes mellitus is a complex, chronic, and progressive metabolic disease influenced by social, behavior, and environmental factors. increasing insulin resistance and declining in β-cell function from time to time resulting in lower glycemic control.3 therefore, a gradual and thorough treatment, i.e. a healthy lifestyle and the use of antihyperglycmeic agents, is necessary to control blood glucose. references 1. alwan a, armstrong t, bettcher d, branca f, chisholm d, ezzati m, et al. global status report on noncommunicable diseases 2010. italy: who; 2011. 2. soewondo p, ferrario a, tahapary dl. challenges in diabetes management in indonesia: a literature review. globalization health. 2013;9:63. 3. nathan dm, buse jb, davidson mb, ferrannini e, holman rr, sherwin r, et al. medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the american diabetes association and the european association for the study of diabetes. diabetes care. 2009;32(1):193–203. 4. kennelly pj, rodwell vw. proteins: myoglobin & hemoglobin. in: murray rk, bender da, botham km, kennelly pj, rodwell vw, weil pa, editors. harper’s illustrated biochemistry. 28th ed. united states: the mcgraw-hill companies, inc; 2009. 5. sikaris k. the correlation of hemoglobin a1c to blood glucose. j diabetes sci technol. 2009;3(3):429–38. 6. sherifali d, nerenberg k, pullenayegum e, cheng je, gerstein hc. the effect of oral antidiabetic agents on a1c levels: a systematic review and meta-analysis. diabetes care. 2010;33(8):1859–64. 7. perkumpulan endokrinologi indonesia. konsensus pengendalian dan pencegahan diabetes mellitus tipe 2 di indonesia 2011. jakarta: pb perkeni; 2011. althea medical journal. 2018;5(2) 63 8. soegondo s, prodjosudjadi w, setiawati a. prevalence and risk factors for microalbuminuria in a cross-sectional study of type-2 diabetic patients in indonesia: a subset of demand study. med j indones. 2009;18(2):124–30. 9. kusniyah y, nursiswati, rahayu u. hubungan tingkat self care dengan tingkat hba1c pada klien diabetes melitus tipe 2 di poliklinik endokrin rsup dr. hasan sadikin bandung. bandung: universitas padjadjaran; 2016. [cited 2018 may 15] available from: http://repository. unpad.ac.id/8976/ 10. garber aj, arbahamson mj, barzilay ji, blonde l, bloomgarden zt, bush ma, et al. american association of clinical endocrinologists’ comprehensive diabetes management algorithm 2013 consensus statement--executive summary. endocr pract. 2013;19(3):536–57. 11. american diabetes association. standards of medical care in diabetes. diabetes care. 2018;41(supplement 1):s1–2. 12. shantha gp, kumar aa, kahan s, cheskin lj. association between glycosylated hemoglobin and intentional weight loss in overweight and obese patients with type 2 diabetes mellitus: a retrospective cohort study. diabetes educ. 2012;38(3):417–26. 13. reinehr t, schober e, roth cl, wiegand s, holl r. type 2 diabetes in children and adolescents in a 2-year follow-up: insufficient adherence to diabetes centers. horm res. 2008;69(2):107–13. 14. steinsbekk a, rygg lø, lisulo m, rise mb, fretheim a. group based diabetes self-management education compared to routine treatment for people wit type 2 diabetes melitus. a systemic review with meta-analysis. bmc health serv res. 2012;12:213. 15. unnikrishnan r, anjana rm, mohan v. drugs affecting hba1c levels. indian j endocrinol metab. 2012;16(4):528–31. 16. gallagher ej, le roith d, bloomgarden z. review of hemoglobin a(1c) in the management of diabetes. j diabetes. 2009;1(1):9–17. 17. juarez dt, ma c, kumasaka a, shimada r, davis j. failure to reach target glycated a1c levels among patients with diabetes who are adherent to their antidiabetic medication. popul health manag. 2014;17(4):218–23. tasya kamila, vycke yunivita kusumah dewi, miftahurachman: effect of antihyperglycemic agents on hemoglobin a1c level in type 2 diabetes mellitus patients vol 4 no 4 final.indd althea medical journal. 2017;4(4) 495 application of scoring system components in children diagnosed with tuberculosis in jatinangor primary health care, sumedang mutiara azhara nurwanti,1 chrysanti,2 sri sudarwati3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr hasan sadikin general hospital bandung indonesia abstract background: diagnosis of tuberculosis in children is very difficult. scoring system is used to diagnose tuberculosis in children in indonesia. the aim of this study was to determine the application of scoring system components in children diagnosed with tuberculosis in the primary health care. methods: this cross-sectional study was conducted in jatinangor primary health care, sumedang in september–october 2013. data were obtained from 59 medical records of pediatric patients diagnosed with tuberculosis in 2010–2012, and recorded on the application of scoring system components including tuberculosis contact history, tuberculin skin test, fever, cough, nutritional status, lymph node enlargement, swelling of bones or joints, and chest x-ray. results: all scoring system components either with tuberculosis contact history, fever, cough, nutritional status, lymph node enlargement, swelling of bones or joints, and chest x-ray were performed on all of the children diagnosed with tuberculosis, except the tuberculin skin test was performed only on 38 (64%) children. most frequent clinical symptoms were cough (97%), while fever and malnutrition occurred in 69% and 19% of children, respectively. conclusions: the application of scoring system components in children diagnosed with tuberculosis in jatinangor primary health care is not having problems, except for the tuberculosis skin test. most frequent clinical symptoms of childhood tuberculosis in this study are cough. keywords: children diagnosed with tuberculosis, jatinangor primary health care, scoring system correspondence: mutiara azhara nurwanti, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: mutiaraazh@gmail.com introduction in 1993, the world health organization (who) declared tuberculosis (tb) as a global public health emergency due to the increasing cases of tb and numerous patients who could not be healed.1 based on the data from who, there were nearly 9 million new tb cases. out of the 9 million tb cases each year, approximately 1 million (11%) of cases occurred in children (<15 years old).2 indonesia ranks third in the category of countries with the greatest incidence of tb cases in the world after india and china.1 based on the current situation, the development of tb report in indonesia in january–june 2011 issued by the directorate general of disease control and the ministry of health that referred to the global tuberculosis control who report, 2011, the proportion of childhood tb patients in 2011 was 1.7%– 17.2% with the lowest proportion found in southeast sulawesi and the highest in west java.3 diagnosing tb in children is very difficult, since childrenhave paucibacillary tb and are difficult in expectorate sputum useful for microbiological examination which is the gold standard for diagnosing tb.4 therefore, the respirology unit in coordination with indonesian pediatric society (idai-ikatan dokter anak indonesia created guidelines for diagnosing tb using a scoring system. the criteria used in the scoring system are tb contact history, tuberculin skin test (tst), nutritional status, fever, cough, lymph nodes enlargement, swelling of the bones or joints, and chest x-ray. children are diagnosed with tb if they get a score ≥6.1 the scoring system used in the national tb program is amj. 2017;4(4):495–500 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1185 althea medical journal. 2017;4(4) 496 amj december 2017 implemented throughout the health service, including primary health care. however, the availability of laboratory equipment in primary health care is very limited.5 in fact, the use of the scoring system in primary health care requires a complete tool to fit the scoring system components to acquire a more accurate diagnosis and to avoid over diagnosis that cause overtreatment. therefore, this study was conducted to determine the application of scoring system components in children diagnosed with tb in jatinangor primary health care, sumedang. methods this cross-sectional study was conducted in jatinangor primary health care, sumedang in september–october 2013, using secondary data from medical records of pediatric patients who were diagnosed with tb at the directly table 1 characteristic of study subjects variable n=59 (%) sex male 29(49) female 30(51) age (years) 0–4 24(41) 5–9 25 (42) 10–14 10(17) region cipacing 12(20) hegarmanah 8(13) jatiroke 4(7) cikeruh 7(12) cisempur 2(3) sayang 2(3) cibeusi 9(15) cilayung 2(3) mekar galih 3(5) jatimukti 2(3) cintamulya 4(7) cileles 1(2) others (outside jatinangor) 3(5) observed treatment short-course (dots) clinic in jatinangor primary health care in 2010–2012. this study was conducted after obtaining approval from the health research ethics committee of the regional development planning agency, department of health, and head of primary health care. in this study, with a proportion of 17.2%, confidence interval 95%, and precision 10%, the minimum sample required was 55. furthermore, the researcher assigned 80 study subjects. a total of 80 medical record data were obtained from medical records of 114 pediatric patients diagnosed with tb in the period 2010–2012 using the scoring system, to be sampled by a simple random sampling. furthermore, out of 80 data, 21 data were excluded due to incomplete data about the use of the scoring system (referral patient from other health care). end total of the study subjects were 59 medical record data. from the 59 medical record data retrieved, data regarding the application of scoring system components included tb contact history, tst, fever, cough, nutritional status, lymph node enlargement, swelling of bones or joints, and chest x-ray. the 59 medical record data noted whether all components of the scoring system were examined and asked the patients, and then recorded the number of fulfillment of the value of each scoring system components. afterward, data were analyzed using microsoft office excel 2007. results furthermore, from 59 study subjects, the highest number of children was found in the age group 5–9 years (42%). study subjects were scattered throughout jatinangor region, with the highest number found in cipacing region (table 1). all components of scoring system were performed on all of children diagnosed with tb, either with tb contact history, malnutrition, fever, cough, lymph node enlargement, and swelling of bones or joints, and chest x-ray, except for the tst component. most of the children had tb contact history (71%). out of the 38 children assessed for tst, 82% showed positive results. almost all children (97%) diagnosed with tb showed cough symptoms, and only 2% of children showed symptoms of swelling of bones or joints (table 2). children are diagnosed with tb if they get a score ≥6. most of the children diagnosed with tb got score 6 (figure). althea medical journal. 2017;4(4) 497mutiara azhara nurwanti, chrysanti, sri sudarwati: application of scoring system components in children diagnosed with tuberculosis in jatinangor primary health care, sumedang discussion in this study, children diagnosed with tb were greater in the age group 5–9 years (42.4%). this result is in contrast to previous studies conducted by wu et al.6 in china, marais et al.7 in south africa, and lestari et al.8 in 6 provinces of indonesia who stated that the prevalence of tb is more common in children <5 years old (39.5%, 77.8%, and 53% respectively). out of 25 children diagnosed tb in the age group 5–9 years, 23 children showed symptoms of cough. this might cause over diagnosed with cough-related asthma. furthermore, a study conducted by marais et al.9 showed the incidence of asthma increased in the age group 5–9 years, which has the samsymptom as tb namely cough >2weeks. one of the recommendations from who for diagnosing tb in children is to ask tb contact history.2 according to a study conducted by iskandar et al.10, adults with acid fast bacilli negative has the possibility to cause tb infections by 10% and is likely to cause tb disease by 16%. in the study conducted by singh et al.11, it concluded that the risk of childhood tb disease increases significantly (77.8%) in children who have contact with acid fast bacilli positive. however in this study, contact history with adults with acid fast table 2 fulfillment of the value of each scoring system components value scoring system components n=59 (%) tb contact history score 0: no contact 17(29) 2: family report, acid fast bacilli negative, does not know, or does not clear 26(44) 3: family report, acid fast bacilli positive 16(27) tst* score 0: negative 7(18) 3: positive (≥10 mm or ≥5 mm on the state of immune suppression) 31(82) nutritional status score 0: normal 48(81) 1: below the red line (road to health card) or weight/age < 80% 11(19) 2: clinical malnutrition (weight/age <60%) 0(0) fever without apparent cause score 0: no fever 18 (30) 1: fever ≥2 weeks 41 (69) cough score 0: no cough 2(3) 1: cough ≥3 weeks 57(97) lymph nodes enlargement (coli, axilla, inguinal) score 0: no enlargement 25(42) 1: enlargement ≥1 cm, the amount >1, no pain 34(58) swelling of the bones or joints (hip, knee, phalanges) score 0: no swelling 58(98) 1: there is swelling 1(2) chest x-ray score 0: normal or not clear 14 (24) 1: suggestive tb 45 (76) note: * from 59 subjects, only 38 (64%) subjects were examined tst althea medical journal. 2017;4(4) 498 amj december 2017 bacilli negative occurred in 44% of children diagnosed with tb, whereas a contact history with adults with acid fast bacilli positive occurred in 27% of children. dissimilarities occurred due to different study populations, the study by iskandar et al.10 was conducted at balai kesehatan paru masyarakat (bkpm) bandung, west java on under-five children, and the study by singh et al.11 was conducted in india on hospital-based under-five children. the tuberculin skin test is one of the important tools for diagnosing tb in children. the positive result indicates that the patient has been infected by m. tuberculosis; therefore, to be used as a tool for diagnosing tb in children, it must be accompanied by clinical symptoms or other diagnostic criteria. sensitivity and specificity of the tst is estimated to be 95 %.12 false-negative results may occur if the tst is performed at the beginning of infection, using inactive antigen (due to poor storage or inadequate administration), viral and bacterial infection, or because of immune suppresion.2 false-positive results can occur due to infection by nontuberculous mycobacteria, and bcg vaccination.2 although tst is an important diagnostic tool, the provision of equipment and materials for the tst is still limited. as stated in the national strategy for controlling tb in indonesia 2010–2014, many primary health care services lack laboratory facilities, both tst or chest x-ray, so that children are not examined with tst and chest x-ray.5 hence in this study, 36% of children were not examined with tst. on the other hand, in this study most of the study subjects who were examined with tst, 82% showed positive tst, which was less than in the study conducted by marais et al.7, which indicated that from all children diagnosed with tb, 94.4% shows positive tst. this may occur due to the difference in study region and tst examiner. moreover, lymph nodes enlargement often occurs in childhood tb, due to the active response of lymph nodes and small pliable airways.13 based on the study by marais et al.14, the most common extra-thoracic tb is peripheral lymphadenitis with cervical lymph node enlargement which has the greatest occurrence. lymph nodes enlargement is found in 58% of children, and swelling of bones or joints occurred only in 2%. this result is consistent with a study by walakandou et al.15, who showed the most common clinical symptoms is lymph node enlargement and no one has shown swelling of bones. in addition, chest x-ray is not the main diagnostic tool in childhood tb. chest x-ray findings in childhood tb is highly variable including enlarged hilar or subcarinal lymph nodes, infiltrates, atelactasis, pleural effusion, and cavities parenchyma.12 however, the most common picture found in childhood tb is enlarged hilar or subcarinal lymph nodes because childhood tb is primary tb.2 furthermore, villiers et al.16 stated that the diagnosis of tb in children using chest x-ray have a sensitivity of 38.8% and a specificity of 74.4%, in addition to the interpretation of chest x-ray which has a high subjectivity, so it is concluded that the chest x-ray is a weak indicator for diagnosing pulmonary tb in children.17 in this study, most of the study subjects (76%) showed suggestive tb on chest figure number of children in each of the total scoring system althea medical journal. 2017;4(4) 499 x-ray, less than the study conducted by marais et al.7 in south africa, showing that all children diagnosed with tb disease show suggestive tb on chest x-ray. this may occur because of dissimilarities in the study population and the number of children diagnosed with tb. one of the who recommendations which stated that to diagnose tb in children can be seen in the presence of any clinical symptoms, like chronic cough, fever, and weight loss.2 the incidence of cough and fever symptoms in this study was higher (97% and 69% respectively) than the crosssectional study by marais et al.7 that showed symptoms of cough and fever appeared 44% and 22.2% of children respectively, and a study by kruk et al.18 showed symptoms of cough and fever appeared 54.5% and 18.2% of children respectively. this may be due to over-diagnosed with cough-related asthma. out of 21 children who were not examined with tst, 20 children showed symptoms of cough, seven children got tst negative, and all of the children showed symptoms of cough. moreover, a study conducted by marais et al.9 showed the proportion of asthma and tb in children <13 years old are 15.9% and 10.6% respectively, with the same symptom that is cough >2weeks. recurrent cough in asthma occurs only at night, while coughing in tb is a persistent cough that occurs day and night. fever in tb is low-grade fever that occurs daily especially in the evening. while the weight loss is lower (19%) compared to the results of the study by marais et al.7 in 2005 (27.8%). furthermore, the study conducted in south africa in 2002 by marais et al.7, compared the clinical symptoms in children without tb and children with tb in a high burden community which stated that the usual clinical symptoms suffered by the child is coughing, weight loss, fever, anorexia, fatigue, night sweats, and difficulty breathing. however, only the symptoms of weight loss, either alone or in combination with other clinical symptoms (cough), which are significantly more common clinical symptoms suffered by children with tb. a prospective study conducted by marais et al.19 in the same country in 2003–2005 stated that the combination of a cough ≥2 weeks, weight loss, and fatigue provides reasonable diagnostic accuracy with sensitivity 62.6% and specificity 89.8%. in this study, the clinical symptoms which always occurred were either fever ≥2 weeks, malnutrition, cough ≥3 weeks, lymph nodes enlargement, or swelling of the bones or joints along with other components of the scoring system. therefore, symptombased screening should be considered to diagnose tb in children in resource-limited settings like primary health care. children are diagnosed with tb if they get a score ≥6. in this study, most of the children diagnosed with tb (60%) got score 6. the maximum score in this study was 10 which was of one child (2%). unfortunately, researchers have not found a study showing the number of children in each of the total scoring system. besides in indonesia, the scoring system is also used by other countries with different components. in the scoring system recommended by the brazilian ministry of health20, the components used are clinical symptoms of fever, cough, loss of energy, weight loss, night sweats >2 weeks, chest x-ray, history of contact with adult tb <2 years, bcg vaccination and tst, and nutritional status. in the scoring system of indonesia, night sweats and bcg vaccination components are not included, besides the definition for history of contact is different. this study was concerned with the symptom of cough which occurred on 97% of children. therefore, suggestions for a further study on pediatric patients who showed clinical symptoms of coughing should be followed and evaluated as well as the disease progression until completion of treatment, including to detecting the possibility of overdiagnosis. perhaps it is necessary to conduct training about how to diagnose tb in children for the primary health care staff. the limitations of the study were, this study was conducted only in one area of primary health care and did not perform sensitivity and specificity testing since scoring system is the diagnostic tools. hence, a further study needs to be conducted in larger regions of primary health care and examination of the sensitivity and specificity of scoring system. in conclusion, the application of scoring system components in children diagnosed with tb in jatinangor primary health care is not having problems, except for the tst. most frequent clinical symptoms of tb in this study are cough. references 1. kementerian kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia tentang pedoman penanggulangan tuberkulosis (tb). jakarta: kementerian kesehatan republik indonesia; 2009. 2. world health organization (who). mutiara azhara nurwanti, chrysanti, sri sudarwati: application of scoring system components in children diagnosed with tuberculosis in jatinangor primary health care, sumedang althea medical journal. 2017;4(4) 500 amj december 2017 guidance for national tuberculosis programmes on the management tuberculosis in children. geneva, switzerland: who; 2006. 3. ditjen pp&pl kementrian kesehatan ri. laporan situasi terkini perkembangan tuberkulosis di indonesia. jakarta: kementrian kesehatan ri; 2011. 4. marais bj, gie rp, schaaf hs, beyers n, donald pr, starke jr. childhood pulmonary tuberculosis: old wisdom and new challenges. am j respir crit care med. 2006;173(10):1078–90. 5. kementrian kesehatan republik indonesia. strategi nasional pengendalian tb di indonesia 2010–2014. jakarta: direktorat jendral pengendalian penyakit dan penyehatan lingkungan, 2011. 6. wu x-r, yin q-q, jiao a-x, xu b-p, sun l, jiao w-w, et al. pediatric tuberculosis at beijing children’s hospital:2002–2010. pediatrics. 2012;130:e1433–40. 7. marais bj, obihara cc, gie rp, schaaf hs, hesseling ac, lombard c, et al. the prevalence of symptoms associated with pulmonary tuberculosis in randomly selected children from a high burden community. arch dis child. 2005;90(11):1166–70. 8. lestari t, probandari a, hurtig ak, utarini a. high caseload of childhood tuberculosis in hospitals on java island, indonesia: a cross sectional study. bmc public health. 2011;11:784. 9. marais bj, gie rp, obihara cc, hesseling ac, schaaf hs, beyers n. well defined symptoms are of value in the diagnosis of childhood pulmonary tuberculosis. arch dis child. 2005;90(11):1162–5. 10. iskandar h, nataprawira hmd, garna h, djais jtb. tuberculosis prevalence among underfive children in household contact with negative acid fast bacilli adult pulmonary tuberculosis. pediatrica indonesiana. 2008;48:18–22. 11. singh m, mynak ml, kumar l, mathew jl, jindal sk. prevalence and risk factors for transmission of infection among children in household contact with adults having pulmonary tuberculosis. arch dis child. 2005;90(6):624–8. 12. cruz at, starke jr. pediatric tuberculosis. pediatr rev. 2010;31(1):13–25. 13. britton p, perez-valez cm, marais bj. diagnosis, treatment, and prevention of tuberculosis in children. nsw public health bulletin. 2013;24(1):15–21. 14. marais bj, gie rp, schaaf hs, hesseling ac, enarson da, bayers n. the spectrum of disease in children treated for tuberculosis in a highly endemic area. int j tuberc lung dis. 2006;10(7):732–8. 15. walakandou lr, umboh a, wahani a. the occurence and is factors of tuberculosos in children with close contact to adult lung tuberculosis. pediatrica indonesiana. 2010;50:233–38. 16. marais bj, pai m. recent advances in the diagnosis of childhood tuberculosis. arch dis child. 2007;92(5):446–52. 17. villiers rv, andronikou s, westhuizen svd. specificity and sensitivity of chest radiographs in the diagnosis of paediatric pulmonary tuberculosis and the value of additional high-kilovolt radiographs. australas radiol. 2004;48(2):148–53. 18. kruk a, gie rp, schaaf hs, marais bj. symptom-based screening of child tuberculosis contacts: improved feasibility in resource-limited settings. pediatrics. 2008;121(6):e1646–52. 19. marais bj, gie rp, hesseling ac, schaaf hs, lombard c, enarson da, et al. a refined symptom-based approach to diagnose pulmonary tuberculosis in children. pediatrics. 2006;118(5):e1350–9. 20. sant’anna cc, santos marc, franco r. diagnosis of pulmonary tuberculosis by score system in children and adolescents: a trial in a reference center on bahia, brazil. braz j of infect dis. 2004;8(4):305–10. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 121 health-seeking behavior of dengue hemorrhagic fever patients in several hospitals in bandung west java indonesia ressa novita afandi,1 bachti alisjahbana,2 ardini s. raksanagara3 1faculty of medicine universitas padjadjaran bandung, indonesia, 2department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, bandung, indonesia abstract background: dengue hemorrhagic fever is one of the major global public health problems. secondary prevention of dengue fever must be conducted to prevent high mortality rate by giving appropriate diagnosis and early management. this study was conducted to identify health-seeking behavior in dengue hemorrhagic patients and its related factors. methods: this study involved 98 dengue hemorrhagic patients from four hospitals in bandung region during july until november 2014. the hospitals were 2 public hospitals and 2 private hospitals. a questionnaire and in depth interview were used to collect the data. results: among 98 patients, 54 patients (55%) sought a right medical treatment timely, whereas 44 patients (45%) delayed. the first seeking behaviour to treat the disease was using over-the-counter drugs, followed by visiting a private clinic doctor. the second choice to seek health care was going to a private clinic doctor and hospital. conclusions: health-seeking behavior in dengue hemorrhagic patients in bandung is inappropriate which can cause delay in treatment. keywords: health-seeking behavior, dengue hemorrhagic fever, dengue hemorrhagic fever patients correspondence: ressa novita afandi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: ressa.novita@yahoo.com introduction in 2009, the world health organization reported that there were 50.000.000 cases of dengue infection every year around the world and about five hundred thousand cases required hospitalization. the percentage of mortality cases was 2.5% of the total cases in the world. indonesia has the highest number of dengue cases and mortality in south east asia.1 a report by who stated that 25.000 out of 150.000 cases in indonesia occurred in jakarta and west java. fatal case was 1% of the total cases.1 a previous study reported that incidence rate of dengue fever in west java in 2005 is 18 cases per 1000.2 delayed diagnosis and handling are factors causing the dengue fever become severe and unhelped.3,4 rapid diagnosis and handling rely on the availability of health care service facilities and on the awareness of each individual in seeking health care. each individual plays an important role in managing ones health, including the responsiveness to seek health care service for diagnosing and treating the diseases. a study about human treatment behaviour in africa showed that the first aid for treating malaria was using overthe-counter (otc) drugs and herbs which were not prescribed by a doctor. this study also reported that mortality is induced by poor access to health care service and severity of the disease.5 false understanding of the disease, which was considered as a self–limiting disease, was the cause of this phenomenon.4 prognosis of dengue fever depends on responsiveness to the treatment and the clinical manifestation. the slower response in handling the disease, the worse prognosis and clinical manifestation of the disease are.6 secondary prevention of the dengue fever is aimed to prevent death. one of the secondary preventions of dengue is by rapid diagnosis and handling. every individual should understand the golden period for treating the disease. this study was conducted to describe the health seeking behaviour of dengue fever patients. amj. 2018;5(3):121–6 althea medical journal. 2018;5(3) 122 amj september 2018 methods this study used a descriptive quantitative design and was conducted at four hospitals in bandung between july–november 2014. the hospitals were ujungberung district hospital, al–ihsan district hospital, bina sehat hospital, and amc hospital. subjects of the study were patients with dengue fever. patients with dengue fever were determined by using the diagnostic criterion of who. positive for three of four criteria are needed to prove as dengue fever. the criteria are fever 2–7 days, leucopenia <5000 cell/mm3, thromobocytopenia <150.000 cell/mm3, and a positive immunoglobulin test.1,8 the exclusion criteria were, a patient who has other working diagnosis (e.g. typhoid fever) and who filled the quesionnaire incompletely. the data were collected by direct interview using a questionnaire. the permission for data collection was approved by the involving hospitals before the study was conducted and also the permission from the selected patients were obtained by signing an informed consent form. this study obtained ethical clearance from the ethical committee of dr. hasan sadikin general hospital bandung. data collection was obtained by purposive random sampling. a minimum sample was determined using the descriptive category formula (d=0.1). the minimum sample was 97 subjects.7 the data were processed using microsoft excel and spss for windows and the results were shown by tables. the results were divided into 2 groups. the first group was for favorable behavior and the second group was for unfavorable behavior. favorable behavior was used for subjects who did the treatment for maximum 3 days, therefore the subjects measured at maximum on day 4th of admission were favorable.1 furthermore, lawrence w. green explained that the 3 factors which influence the behaviour are predisposing factor (knowledge and attitude), enabling factor (access), and reinforcing factor (economy and education).9 score of knowledge was collected from the total score of answers of the subject in the questionnaire. score of attitude was collected from the total score of answers of the subject in the quesionnaire, then measured by the likert scale. score of aspect was collected from the total score of answers of the subject in the quesionnaire measured, then by thurstone scale. access was measured by calculating the distance between home and hospital, cost for transportation and every difficulty in reaching the hospital. economic status was measured by the monthly salary. out of the 100 subjects table 1 distribution of respondent characteristics respondent characteristics total (n=98) percentage (%) age group <11 years 30 31 11–20 years 16 16 21–30 years 15 15 31–40 years 18 18 41–50 years 9 9 >50 years 10 10 sex male 42 43 female 56 57 diagnosis criteria fever 2–7 days 98 100 leucopenia ≤5000 cell/mm3 98 100 trombocytopenia <150.000 sel/mm3 98 100 igg dan igm / tested 12/12 12 duration of fever before hospital admission median (range) 4 days (2–7 days) althea medical journal. 2018;5(3) 123ressa novita afandi, bachti alisjahbana, ardini s. raksanagara: health-seeking behavior of dengue hemorrhagic fever patients in several hospitals in bandung west java indonesia interviewed, 98 subjects were included in the study and 2 subjects were excluded because they were diagnosed with typhoid. results of the 98 inpatients who were enrolled in the study, female was more dominant than men with a median age of 22 years (range 1 year to 80 years). all patients showed symptoms, signs and findings resembling dengue fever. the group undergoing early treatment consisted of 59 (60%) people and late treatment was 39 people (40%). from the 98 patients interviewed, only 12 patients got the immunoglobulin test. dengue fever health-seeking behavior can be seen from the way of treatment and response time to treatment of the respondents. most respondents were using over-the-counter drugs on the first treatment and others chose going to a private clinic doctor. while, on the second treatment, respondents chose visiting a doctor at a private clinic or hospital (table 2). some respondents still used herbal remedies or traditional medicine, despite being hospitalized. the cumulative result was the number of respondents who were admitted to hospital with the highest jump in the third treatment. theorder of treatment of respondents was found in figure. table 2 health-seeking pattern health-seeking sequence 1st 2nd 3rd 4th 5th over-the-counter (otc) drugs 47 (48%) 5 (5%) 0 (0%) 0 (0%) 0 (0%) traditional/herbal 3 (3%) 4 (4%) 2 (2%) 5 (5%) 1 (1%) midwife 4 (4%) 2 (2%) 0 (0%) 0 (0%) 0 (0%) small primary health centre 1 (1%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) main primary health centre 7 (7%) 6 (6%) 2 (2%) 0 (0%) 0 (0%) private clinic doctor 27 (28%) 37 (38%) 10 (10%) 1 (1%) 0 (0%) private practice doctor 7 (7%) 12 (12%) 4 (4%) 0 (0%) 0 (0%) hospital 2 (2%) 31 (32%) 54 (55%) 20 (20%) 1 (1%) cumulative inpatient 1 (1%) 27 (28%) 77 (79%) 97 (99%) 98 (100%) figure health-seeking pattern althea medical journal. 2018;5(3) 124 amj september 2018 in the group of respondents who did the first treatment using over the counter drugs/ traditional medicine, 22 of them were late. while in the group who went to a paramedic/ midwife/health center and clinic the first time, three people were late in each group. in the group who went to the private doctor the first time, eleven people were late. of all respondents, 18 of them had bad step treatment. out of the eighteen people, eight people were treated twice using different overthe-counter drugs/traditional medicine, four people came to the hospital more than once due to lack of bed, two people came to primary health care three times, and four people took own medication after visiting a primary health care. of the 18 patients, only five people had early treatment. the predisposing factors were obtained from the knowledge and attitudes of respondents values (table 3). most of the respondents answered the questions correctly. however, many respondents did not know the name of dengue fever mosquito intermediaries. less than 30% of respondents had a good attitude. overview supporting factors would be obtained from the description of aspects of the respondent’s access. reinforcing factors were obtained from the economic and educational background of the respondents. most respondents (57%) had a salary above the minimum wage of west java. in 2014, the minimum wage of west java was rp 1,700,000.00. while the value of very less than the minimum wage was revenue less than usd 300,000.00. regarding education, table 2 health-seeking pattern variable total respondent (%) favorable (n=54) unfavorable (n=44) total (n=98) predisposing factor knowledge good 24 (44%) 18 (41%) 42 (43%) enough 26 (48%) 20 (45%) 46 (47%) poor 4 (8%) 6 (14%) 10 (10%) attitude good 16 (29%) 10 (23%) 26 (27%) enough 36 (67%) 33 (75%) 69 (70%) poor 2 (4%) 1 (2%) 3 (3%) enabling factor access good 21 (39%) 11 (25%) 32 (33%) enough 30 (55%) 26 (59%) 56 (57%) poor 3 (6%) 7 (16%) 10 (10%) reinforcing factor income more than minimum wage 32 (59%) 24 (55%) 56 (57%) less than minimum wage 21 (39%) 19 (43%) 40 (41%) very less than minimum wage 1 (2%) 1 (2%) 2 (2%) education undergraduate from elementary 16 (30%) 18 (41%) 34 (35%) elementary 4 (7%) 9 (20%) 13 (13%) junior high school 8 (15%) 3 (7%) 11 (11%) senior high school 20 (37%) 14 (32%) 34 (35%) university 6 (11%) 0 (0%) 6 (6%) althea medical journal. 2018;5(3) 125 most respondents (35%) did not graduate from elementary and high school. discussions out of the 98 respondents, 54 have a favourable practice, 26 late seeking treatments, 18 were unfavourble as 5 people did not show good step approach, and 13 were late and did not show good approach. the respondents who took unfavourable path for treatment seeking, problems might occur due to two things: the patient or the primary health care. it can be seen in the results of studies which showed, the most delays are caused by the negligence of a doctor who did a blood test on the third day of fever. most treatment of the patients who do not have a good step is also caused by doctors who do not perform good education to the patients. however, some other problems are caused by the patients themselves. in this study, the first treatment most widely performed was the use of over the counter drugs, and visit to a private clinic doctor. these results are similar to previous studies in cambodia4 which stated that the majority of cambodia’s population in some regions choose to buy drugs at the drug store, use herbal remedies, and go to a private surgeon as the first treatment. in the group of patients treated with the over-the-counter drugs/traditional remedies at first time, 26 people had an unfavorable behavior and 9 of them had bad step. eight patients underwent treatment with the overthe-counter drugs/traditional remedies twice because the first drug taken did not have effect and were recommendations from other people to change treatment. of the eight people, six people were late. one patient did a bad step treatment because the hospital was full on the first admission, so the blood test was performed on the next day. this delay could be caused by many respondents thought that the fever was a common fever as in the previous study.10 three out of five respondents went to a paramedic/midwife late at the hospital. while from respondents who went to the clinic first, three people were late and two of them did a bad step treatment. respondents went to the primary health care three times. the best blood test was on the second visit or no longer than the third day so that delays could be prevented. in the group of respondents who went to the private doctor first, 13 were classified as unfavorable and 7 of them were bad step. three of the four respondents who treated themselves after all overdue health care, were late. distrust of the patient and patient’s errors obstructed the detection of dengue fever. three respondents came to the hospital more than once due to lack of bed at the hospital. one of them came first on the third day and was not checked, and the otherst were not treated because the hospital was crowded. the occurring problems lead to many delays and bad step treatments among health care workers who are less prepared, clinics and hospitals that do not have a blood test facility and unavailability of beds. these weaknesses are the biggest factors which cause the patient who go to hospital late for definitive treatment. the level of knowledge wasbetter of respondents who performed favorable compared to the unfavorable. this is consistent with previous studies that claimed positive results in knowledge and health education.11 the educational background also affects the knowledge background of the respondent. the picture showed the attitudeof the majority of respondents answered already quite well. however, there were some respondents who considered dengue fever was not a contagious infection because they had a person to person transmission. some respondents only knew that dengue fever was caused by mosquitoes and was not contagious. while those who knew that dengue fever is an infectious disease, did not hesitate to reply that dengue fever is considered an infectious disease. based on a previous study, this behavior differs from the selection of the treatment in question in a population that does not have dengue fever.12 a study in kudat13 reported, most respondents choose to go to the hospital as a major option. it shows that behavior is not only dependent on the predisposing factors but also on the supporting and reinforcing factors. access is important in determining the action of the respondents. as previous studies stated that the affordability of a treatment has an effect on behavior; this study also showed the same result.4 respondents who had access due to the short distance, low cost, and easiness to go to hospital, were more quickly in response to cases of dengue fever. on the other hand, respondents who due to the long distance, high cost, and difficulties getting to hospital were many in the poor groups. respondents who received a good treatment behavior had an income above the minimum wage which was more than those who received bad treatment. the number of respondents whose income was far below the minimum ressa novita afandi, bachti alisjahbana, ardini s. raksanagara: health-seeking behavior of dengue hemorrhagic fever patients in several hospitals in bandung west java indonesia althea medical journal. 2018;5(3) 126 amj september 2018 wage was also less than those who received bad treatment. this is consistent with studies in africa which stated that the lower the income, the higher the level of morbidity.14 however, this study did not show the significancy. behavior patterns of dengue fever treatment in hospitals in bandung area were drawn from the manner and time of treatment. for treatments, over-the-counter drugs and doctor’s private clinic were the first treatment options that were most and reached the highest leap of hospital admission on the fourth day. existing factors influencing behavior were knowledge, attitudes, access, economic, and past education. these factors thought did not have differences between the good and the bad. this study has several limitations. the researcher can only obtain the data of hospitalized patients in class ii and iii with an excuse not to disrupt the service. with these limitations, patients are less diverse, especially on the economic status. economic factors, education, and knowledge classify similarly. in addition, this study is biased since it only examined the inpatients and did not examine the outpatients. this study concludes that health seekingbehavior in patients with dengue hemorrhagic patients is inappropriate which can cause the delay of treatment, and the patient’s options before going to hospital are time-consuming. in order to discover t most influential factor further research is needed. with the data of this study, health workers are expected to increase knowledge about dengue treatment protocols for the appropriate time to diagnose. moreover, the knowledge of society should be improved further by education, both counseling in society and counseling conducted by primary care physicians. in addition, the government is expected to improve the infrastructure and programs with the objective to optimize facilities for accessing health services. thus, increasing the capacity of early detection of dengue fever with systematic referral patterns, early and good ladder treatment can be accomplished. references 1. who regional office for south-east asia. comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. new delhi:who;2011. 2. porter kr, beckett cg, kosasih h, tan ri, alisjahbana b, rudiman pif, et al. epidemiology of dengue and dengue hemorrhagic fever in a cohort of adults living in bandung, west java, indonesia. am j trop med hyg. 2005;72(1):60–6. 3. guha–sapir d, schimmer b. dengue fever: new paradigms for a changing epidemiology. emerg themes epidemiol. 2005;2(1):1–10. 4. khun s, manderson l. health seeking and access to care for children with suspected dengue in cambodia: an ethnographic study. bmc public health. 2007;7(1):262. 5. müller o, traoré c, becher h, kouyaté b. malaria morbidity, treatment-seeking behaviour, and mortality in a cohort of young children in rural burkina faso. trop med in health. 2003;8(4):290–6. 6. tanner l, schreiber m, low jg, ong a, tolfvenstam t, lai yl, et al. decision tree algorithms predict the diagnosis and outcome of dengue fever in the early phase of illness. plos neglected tropical diseases. 2008;2(3):e196. 7. dahlan ms. besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan. jakarta: salemba medika; 2009. 8. shah i, katira b. clinical and laboratory profile of dengue, leptospirosis and malaria in children: a study from mumbai. arch dis child. 2007;92(6):561. 9. notoatmodjo pds. promosi kesehatan teori dan aplikasi. jakarta: rineka cipta; 2005. 10. kamat vr. “i thought it was only ordinary fever!” cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in tanzania. soc sci med. 2006;62(12):2945–59. 11. kenkel ds. health behavior, health knowledge, and schooling. j polit econ. 1991:287–305. 12. onwujekwe o, chukwuogo o, ezeoke u, uzochukwu b, eze s. asking people directly about preferred health–seeking behaviour yields invalid response: an experiment in south–east nigeria. j public health. 2011;33(1):93–100. 13. wn r, masturoh i, hendri j, ipa m. gambaran perilaku pencarian pengobatan penderita demam berdarah dengue di kabupaten ciamis propinsi jawa barat. aspirator: jurnal penelitian penyakit tular vektor. 2010;2(2). 14. cisse b, luchini s, moatti jp. progressivity and horizontal equity in health care finance and delivery: what about africa?. health policy. 2007;80(1):51–68. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 407 five years data of vaginal swab examination on sexual assault cases inwest java top referral hospital, indonesia machrani febriastry,1 chevi sayusman,2 zulvayanti3 1faculty of medicine universitas padjadjaran, 2department of legal and forensic medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: vaginal swab test is one of the way to prove that penile penetration has occurred by detection of spermatozoa or seminal fluid components in vaginal fluid of sexual assault victims. it is also used for detecting sexually transmitted infection (sti) in thevictims and identifying perpetrators’ dna. the objective of this study was to describe vaginal swab examination result on sexual assault cases in dr. hasan sadikin general hospital, bandung so it can be used as an evaluation material for the management of sexual assault cases and a reference for subsequent researches related to sexual assault. methods: descriptive study was carried out using medical records and visumetrepertum of sexual assault victims who underwent vaginal swab examination at dr. hasansadikin general hospital, bandung from2010 to2014. of 62 medical records which met the inclusion criteria, 3 were excluded. a total of 59 medical records were included as study subjects. data taken were victims’ age, sexual assault’s time, examination time, penile penetration and intra-vaginal ejaculation history, also vaginal swab and sti examination result. the data were processed and presented using a frequency distribution table. results: spermatozoa were found in 13 cases (22.03%). spermatozoa were found at latest 96 hours since assault. none of the victims was detected with sti. conclusions: the successful rate of spermatozoa detection by conducting vaginal swab in dr. hasansadikin general hospital, bandung is 22.03%. spermatozoa can be detected even 72 hours post assault. keywords: seminal fluid, sexual assault, spermatozoa, vaginal smear, vaginal swab correspondence: machrani febriastry, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: machrani_febriastry@yahoo.com introduction sexual assault is all forms of action or words with unwanted sexual connotations or the forcing of an individual to partake in any activity that goes against their sexuality.1 according to the data from indonesia’s national commission on violence against women (komisi nasional anti kekerasan terhadap perempuan, komnas perempuan) in 2013, there were 5,626 sexual assault cases on indonesian women. these figures have not been yet an accurate depiction of the real total of occurrences due to high number of underreported cases.2 in reported sexual assault cases, forensic examination will be conducted to gather evidence that can be used in the court, either to support or to overrule the allegations of sexual assault.3 one of forensic examination’s components is vaginal swab examination aimed to prove that penile penetration has occurred by detecting the perpetrators’ spermatozoa or seminal fluid components in victim’s vagina. vaginal swab is also taken for identifying perpetrator and detecting sexually transmitted infection (sti) on the victims.1 vaginal swab examination usually consists of microscopic observation accompanied by acid phosphatase (ap) test. more advanced testing involves prostate-specific antigen (psa) or semenogelin (sg) assay.1,3 deoxyribonucleic acid (dna) testing is done for perpetrators’ identification purpose.4 sexually transmitted infection examinations are done to detect trichomonasvaginalis, chlamydia trachomatis, and neisseria gonorrhea.1,3 in dr. hasan sadikin general hospital bandung, as one amj. 2017;4(3):407–12 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1190 althea medical journal. 2017;4(3) 408 amj september 2017 of west java top referral hospital, vaginal swab examination only consists of cytological observation of vaginal smear that shows the presence of spermatozoa and pathogens including trichomonasvaginalis, also the condition of vaginal epithelial cells and vaginal normal flora. there are no fixed procedures regarding the management of sexual assault victim but a brief clinical forensic guideline on obstetric and gynecologic cases from the department of legal and forensic medicine is available. the purpose of this study was to describe vaginal swab examination results on sexual assault cases in dr. hasan sadikin general hospital bandung from 2010 to 2014. methods this study was a descriptive quantitative study with cross-sectional approach. this study used medical records and visum et repertum from the department of legal and forensic medicine, the obstetrics and gynecology polyclinic, and the emergency department of dr. hasan sadikin general hospital, bandung from january 2010 to december 2014. the data collected were age of the victims, time of sexual assault, time of examination, history of penile penetration, history of intra-vaginal ejaculation, vaginal swab examination results in the form of spermatozoa presence and morphologyand the results of sti test. the sequence of examinations on sexual assault cases in dr. hasan sadikin general hospital, bandung were as following: anamnesis was done followed by physical examination, and swabs of vaginal fluid were collected and smeared on microscope slides by a specialist or resident of obstetrics and gynecology department, in either the outpatient polyclinic or the emergency department. the slides were then sent to the anatomic pathology laboratory to be observed under a microscope with papanicolau staining. afterward, if the victim had brought vise request from the police, they were reffered to the forensic science department to have a visum et repertum. this study used a total sampling method due to the small number of cases. the inclusion criteria in this study were female patients who experienced sexual assault and underwent vaginal swab examination. subjects were excluded when the medical records or the visum et repertum and/or the vaginal swab examination results were absent. from 62 medical records which met the inclusion criteria, 3 were excluded due to the absence of vaginal swab examination result. therefore, a total of 59 medical records were included in this study as study subjects. the data were processed and presented using a frequency distribution table. this study was approved by the health research ethics committee of dr. hasan sadikin general hospital, bandung. the results of sti test were found in 24 medical records. the test was conducted by microscopic evaluation on vaginal swabs in papanicolau staining to identify trichomonasvaginalis but the tests for detecting chlamydia trachomatis and neisseria gonorrhea were not carried out. the results were all negative (100%). results the characteristics of study subjects were described in this study (table 1). the age table 1 characteristics of sexual assault victims who had undergone vaginal swab examination characteristic n (%) age* (n= 59) 0–14 years old 21 (35.59) 15–24 years old 29 (49.15) 25–44 years old 9 (15.25) span of time between incident and tests 0–23 hours 26 (44.07) 24–47 hours 12 (20.34) 48–72 hours 6 (10.17) >72 hours 15 (25.42) penile penetration yes 38 (64.41) no 6 (10.17) unknown 8 (13.56) no data 7 (11.86) intra-vaginal ejaculation yes 7 (11.87) no 13 (22.03) unknown 18 (30.51) no data 21 (35.59) note: *the total of months (1–11) and the total of minutes and seconds (1–59) are rounded to the lower value althea medical journal. 2017;4(3) 409machrani febriastry, chevi sayusman, zulvayanti: five years data of vaginal swab examination on sexual assault cases inwest java top referral hospital, indonesia categories for study subjects were classified according to the united nations guidelines on age classification for the victims of criminal cases. the majority of victims were 15–24 years old (49.15%) and were examined in less than 24 hours after the incident (44.07%). cases with unknown penile penetration and/ or intra-vaginal ejaculation represented the victims who could not recall or were not aware of the details of incident. the absence of history of penile penetration and/or intravaginal ejaculation in their medical records was classified as no data. from 59 cases, spermatozoa were positive in 13 cases (22.03%) and 46 cases (77.97%) were negative. there were two cases (3.39%) with the finding of spermatozoa after 72 hours -incident which were specifically at 78 and 96 hours (table 2). spermatozoa with tails were no longer found 48 hours post-incident. spermatozoa motility was not stated in the examination results. this study also described spermatozoa detection result based on the history of penile penetration and intra-vaginal ejaculation (table 3). discussion the majority of victims were in the age of 15– 24 years old (49.15%) followed by the age of 0–14 years old (35.59%). those age categories represented children, teenagers, and young adults.5 previous studies mentioned that those age groups are easily victimized due to low physical strength, vulnerability to threats, or lack of access to and knowledge about health or law facilities to disclose the incident they had experienced.6,7 however, the subjects for this study were only victims who underwent vaginal swab examination, that the particular theory cannot be strengthened using this data. the data showed that vaginal swab examination was mostly done on children and teenagers, because thevictims often has no cognition about the occurence of penile penetration and/or ejaculation or uncooperative during table 2 spermatozoa test results based on the span of time between incident and testing* and morphology characteristic 0–23 hours 24-47 hours 48-71 hours >72 hours total n (%) n (%) n (%) n (%) n (%) positive intact 5 (8.47) 2 (3.39) 7 (11.86) only head 3 (5.09) 1 (1.69) 2 (3.39) 6 (10.17) negative 21(35.6) 7 (11.86) 5 (8.47) 13 (22.04) 46 (77.97) note: *the total of minutes and seconds (1–59) are rounded to the lower value table 3 spermatozoa detection results based on patient admission with penile penetration and intra-vaginal ejaculation characteristic detected undetected n (%) n (%) penile penetration yes 9 (23.68) 29 (76.32) no 6 (100) unknown 2 (15.38) 6 (84.62) no data 2 (28.57) 5 (71.43) intra-vaginal ejaculation yes 2 (28.57) 5 (71.43) no 13 (100) unknown 5 (27.78) 13 (72.22) no data 6 (28.57) 15 (71.43) althea medical journal. 2017;4(3) 410 amj september 2017 anamnesis. therefore, no penetrations and/ or ejaculations were admitted but the physical examination results indicate a suspicion of penetration occurence like signs of trauma on the victim’s genitals and the presence of blood or lacerations on the hymen.1,8 majority of victims reported the incident and examined themselves in a period of less than 24 hours but there were still some victims who delayed their report, even until months or years after the incident. this delay can hinder examination result because quality and availability of evidences on the victim’s body will be more optimal optimal if taken in less than 24 hours and decrease drastically after 72 hours.1,6,7,9 a lot of factors were contributed to the delay in reporting such as the victim’s age, the familiarity between the victim and the perpetrator, the occurence of penetration, and also psychological factors, such as fear of the perpetrator’s threats or social stigma.8 there was no different number of spermatozoa between the victims examined less than 24 hours and in 24–48 hours. there were 2 cases (3.39%) with spermatozoa finding 72 hours post-incident which were specifically at 78 and 96 hours. spermatozoa with tails were no longer found 8 hours postincident. this result showed a similarity to the previous studies which discovered that spermatozoa can be found even 72 hours postincident with a maximum time period of 120 hours; intact spermatozoa can be found at a maximum of 26 hours.9,10 sperm motility can also be used as an indicator of the occurence of recent sexual assault, because motile sperm can only be found within 6–12 hours after incident.10 admission of penile penetration is one of the main indicators to perform vaginal swab examination. this study found that the majority of victims who underwent vaginal swabbing had admitted the occurrence of penile penetration as the spermatozoa or seminal fluid canserve finding can be a solid proof for the victim’s admission.9 a vaginal swab examination would be still done even though there were non-admission of intra-vaginal ejaculationbecause , the victim may be not aware of the ejaculation occurrence.11,12 some victims,mostly children, only admitted digital penetration, but vaginal swab examination was still conducted because there were other incidents that may involve penile penetration or there were difficulties for the victim to recall the entire chronology of the incident because of lack of understanding of the whole situation and post-incident psychological trauma.13 spermatozoa were found in 23.68% of victims who admitted penile penetration and 28.57% of those who divulged intravaginal ejaculation. the successful rate of spermatozoa detection in few studies was only 15–45%.9,14,15 it is to be noted that failure to detect semen or spermatozoa does not mean that sexual contact did not occur.3 some literatures mentioned that spermatozoa cannot be found because (i) the perpetrator did not ejaculate, (ii) the span of time between the incident and the examination was long, (iii) the victim had cleaned her vagina after the incident, (iv) the collection and handling of samples was incorrect, (v) the examination process was ineffective, (vi) the perpetrator has a zoospermia or aspermia, (vii) the perpetrator used condoms, (viii) or the victim had bacterial vaginosis that spurs the immune system activity and increases the rate of sperm degradation.12,16,17 to increase the successful rate of detection, a site of swabbing plays an important role. vaginal swabs should be taken on posterior fornix (high vaginal swab) as well as on vaginal wall (low vaginal swab), because posterior fornix often becomes a site of seminal fluid pooling.1 an alternative of vaginal swabs is to examine cervical swab, considering that spermatozoa lasts longer in the cervix (maximum of 179 hours).10 it is also possible to take extra-genital swab to detect spermatozoa in the external genitalia, anticipating extra-vaginal ejaculation.12 an alternative of the smear technique can be also done, to extract the swabs before smearing it onto a microscope slide. this technique can increase the detection of spermatozoa as much as 6–7%.9 aside from spermatozoa examination,ap test is a primary examination that can be done to detect seminal fluid in the vaginal canal, especially in forensic field. acid phosphatase is an enzyme produced by the prostate,is found on high levels in the seminal fluid, and can be positive in absence of spermatozoa under the microscope.10 semenogelinor psa test a detects seminal fluid and has higher sensitivity and specificity than ap test. however, the fast rate of degradation and decreased activity of these substances leads to ineffectiveness of the test to detect seminal fluid after 24–48 hours postcoitus.16 vaginal swab can also be used as a specimen for male dna isolation from sperm cells to provide solid identification of the perpetrator.3 the most common method used at the moment is the short tandem repeats analysis (str) althea medical journal. 2017;4(3) 411 using a dna sequencer. the analysis result of the vaginal swab specimenwas then matched with the dna database or the suspect’s dna.4 results of sexually transmitted infection test were obtained in 24 medical records. microscopic observation on vaginal swab was done to identify trichomonasvaginalis. other non-sti-causing bacteria or fungi were not recorded in this study. no victim was detected with trichomonasvaginalis. this was in conjunction to other studies that discovered the prevalence of trichomonas vaginalisin sexual assault victim (0–19%).13,18 however, negative test results didnot necessarily indicate a lack of infection as stis could take between 3 days and 3 months of incubation period.1 sexually transmitted infection examination provides more medical than legal use. the conducting of stiis stilldebated. in adult victims, stis might be preexisting; it can be used as a defense by the alleged perpetrator3,19 but in children and pre-pubertal victims, preexisting stis is rare, so the presence of a sti, especially the same sti as in the alleged perpetrators, might be used as an evidence to support the sexual assault charges.3 limitation of this study included the possibility of information bias from victims’ anamnesis and lack of information written in some medical records. twenty one medical records could not be accessed due to inaccessible storage of medical records dated before 2014 from emergency department of dr. hasan sadikin general hospital, bandung. it can be concluded that the successful rate of spermatozoa detection in dr. hasan sadikin general hospital, bandung is 22.03%. spermatozoa can be detected even 72 hours post assault. there is a need to establish a fixed procedure regarding sexual assault cases management and further training for healthcare workers on management of sexual assault cases to achieve constant improvements in quality of care and evidence collection. anamnesis, physical examination, and the writing of medical records should be done as thoroughly as possible. time of incident, history of penetration and ejaculation should be obtained to provide a clear basis for the next diagnostic examination. spermatozoa examination should be conducted even 72 hours has passed. the use of rapid test for psa or sg is also recommended for sexual assault cases due to the tests’ high sensitivity and specificity,easy to use, and fast determination of the result.20 the dna examination is especially very useful in identifying the perpetrator for the prosecution of suspect.3 the lackness of this examination is the cost that is considerably expensive. other sti examinations can also be done based on individual needs. improvements on medical records filing and storage will be a huge benefit for further research and legal purposes. hopefully, dr. hasan sadikin general hospital, bandung can become an integrated center of management for sexual assault cases. references 1. world health organization. guidelines for medico-legal care of victims of sexual violence. geneva: world health organization; 2003. 2. komisi nasional anti kekerasan terhadap perempuan. kegentingan kekerasan seksual: lemahnya upaya penanganan negara. jakarta: komnas perempuan; 2014. 3. united states department of justice. office on violence against women. a national protocol for sexual assault medical forensic examinations: adults/adolescents [internet] 2013 [cited 2015 january 7]. available from:http://www.ncjrs.org/ pdffiles1/ovw/206554.pdf. 4. gunasekera rs, haschke j, costas eh. the judicial use of dna evidence and forensic expert testimony in the criminal justice system. j forensic res. 2010;1(2):104–7. 5. mcfarlane j, malecha a, watson k, gist j, batten e, hall i, et al. intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes. obstet gynecol. 2005;105(1):99–108. 6. akinlusi fm, rabiu ka, olawepo ta, adewunmi aa, ottun ta, akinola oi. sexual assault in lagos, nigeria: a five year retrospective review. bmc womens health. 2014;14(1):114–20. 7. de oliveira aded nl, de oliveira sf, da silva dalcin bl, de moraes tm, cavalcanti mt. children and adolescents victimized by sexual abuse in the city of rio de janeiro: an appraisal of cases. j forensic leg med. 2007;14(4):216–20. 8. bicanic iae, hehenkamp lm, van de putte em, van wijk aj, de jongh a. predictors of delayed disclosure of rape in female adolescents and young adults. eur j psychotraumatol. 2015;6(1):1–9. 9. sathirareuangchai s, phobtrakul r, phetsangharn l, srisopa k, petchpunya s. comparative study of spermatozoa detection using the genital swab versus bedside smear slide technique in sexual assault patients. j forensic leg med. machrani febriastry, chevi sayusman, zulvayanti: five years data of vaginal swab examination on sexual assault cases inwest java top referral hospital, indonesia althea medical journal. 2017;4(3) 412 amj september 2017 2015;35(1):69–72. 10. willott gm, allard je. spermatozoa— their persistence after sexual intercourse. forensic sci int. 1982;19(2):135–54. 11. killick sr, leary c, trussell j, guthrie ka. sperm content of pre-ejaculatory fluid. hum fertil (camb). 2011;14(1):48–52. 12. astrup bs, thomsen jl, lauritsen j, ravn p. detection of spermatozoa following consensual sexual intercourse. forensic sci int. 2012;221(1-3):137–41. 13. girardet rg, lahoti s, howard la, fajman nn, sawyer mk, driebe em, et al. epidemiology of sexually transmitted infections in suspected child victims of sexual assault. pediatrics. 2009;124(1):79– 86. 14. jänisch s, meyer h, germerott t, albrecht u-v, schulz y, debertin a. analysis of clinical forensic examination reports on sexual assault. int j legal med. 2010;124(3):227– 35. 15. ingemann-hansen o, brink o, sabroe s, sorensen v, charles av. legal aspects of sexual violence–does forensic evidence make a difference?. forensic sci int. 2008;180(2-3):98–104. 16. culhane jf, nyirjesy p, mccollum k, casabellata g, di santolo m, cauci s. evaluation of semen detection in vaginal secretions: comparison of four methods. am j reprod immunol. 2008;60(3):274– 81. 17. elgendy is, hassan na. medicolegal study of child sexual abuse in greater cairo, egypt, during a 7-year period: 2005–2011. am j forensic med pathol. 2013;34(4):335–41. 18. ononge s, wandabwa j, kiondo p, busingye r. clinical presentation and management of alleged sexually assaulted females at mulago hospital, kampala, uganda. afr health sci. 2005;5(1):50–4. 19. lewis-o’connor a, franz h, zuniga l. limitations of the national protocol for sexual assault medical forensic examinations. j emerg nur. 2005;31(3):267–70. 20. pang bc, cheung bk. identification of human semenogelin in membrane strip test as an alternative method for the detection of semen. forensic sci int. 2007;169(1):27–31. 197 althea medical journal. 2017;4(2) coverage of vitamin a supplementation among under-five children in hegarmanah village, jatinangor in august 2014 nadia asmarani hidayat putri,1 isriati,2 julistio t.b. djais3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the vitamin a supplementation program conducted every february and august aims to reduce children morbidity and mortality. mother’s knowledge on the importance of vitamin a is crucial to succeeding this program. this study aimed to examine the coverage of the program among under-five children and the mother’s knowledge about vitamin a supplementation in hegarmanah village, jatinangor in august 2014. methods: this was a descriptive cross-sectional study involving mothers of children aged 6−59 months in eight rws in hegarmanah village. the mothers were interviewed to find out whether their children received vitamin a supplementation. additional questionnaire-based data about mother’s knowledge on vitamin a was also collected. the subjects in this study were the mothers of 220 under-five children. data collection was obtained by direct interviews with the mothers during their visit to the puskesmas or during home visits to children who missed the posyandu appointments. results: two hundred and fourteen (97.27%) children received vitamin a supplementation and only 6 (2.73%) did not. the questionnaires revealed that 94 children (96%) received vitamin a, while 4 (4%) did not. the mother’s level of knowledge in vitamin a was either poor (1%), moderate (37%), or good (62%). conclusions: the coverage of vitamin a supplementation in hegarmanah village reaches 97.27% and the mother’s understanding about vitamin a is generally good. keywords: posyandu, sweeping, under-five children, vitamin a correspondence: nadia asmarani h.p, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81274683934 email: nadiasmarani.hp@gmail.com introduction vitamin a has a role in the maintenance of the integrity of epithelial, immune, and reproductive cells.1 vitamin a deficiency is one of the causes of immune system depression which affect about 130 million preschool children and 7 million pregnant women mostly in developing countries.2 vitamin a deficiency in under-five children can also cause mortality risk up to 20-30%.1 xerophthalmia among preschool children amounts to about 5 million cases, 10% of which can potentially lead to blindness.3 even though there has already been significant improvements, vitamin a deficiency is still the cause of at least 650,000 young children deaths annually, which are related to diarrhea, measles, malaria, and other infections.4−5 several studies have stated that vitamin a coverage in several other countries, such as ghana, zambia, and nepal, is much higher than the percentage of vitamin a supplement capsules in indonesia.6,7 the government has shown much efforts in reducing the number of vitamin a deficiency-related deaths by some strategies that involve distributing vitamin a capsules every 6 months and promoting consumption of food high in vitamin a.8 these programs are effective to fulfill the needs of vitamin a, as proven by increased distribution percentage of vitamin a capsules in the provinces of indonesia. according to the basic health research (riskesdas) 2010, the distribution percentage of vitamin a capsules among 6−59 months old children was 69.8% and increased to 75.5%.9 furthermore, the vitamin a supplementation program has shown significant improvement, which is a decrease in the number of under-five children amj. 2017;4(2):197–203 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1079 althea medical journal. 2017;4(2) 198 amj june 2017 with serum retinol levels lower than 20µg/dl (from 50% to 14.6%). high dose of vitamin a supplementation twice a year for 6−59 months old children has decreased under-five mortality rate by as much as 23%.1,10 the vitamin a supplementation program is still the main choice in dealing with vitamin a deficiency cases. however, there is still a need for other efforts in the future to achieve sustainable prevention; one of them is vitamin a fortification in food sources. education and nutritional knowledge are also important especially for mothers to improve the growth and development of children.1 as it is a public health program, puskesmas jatinangor distributes vitamin a supplementation to under-five children in every village in kecamatan (district) jatinangor in february and august. besides, this program requires continuous support and periodic follow-ups to maintain the rate of vitamin a supplementation distribution among underfive children. based on the points above, this study set out to find the coverage of vitamin a supplementation among under-five children in august 2014 and the level of mother’s knowledge on the importance of vitamin a. methods this was a descriptive study with a crosssectional approach so as to obtain an accurate description of the coverage of vitamin a supplementation distribution among underfive children in hegarmanah village, kecamatan jatinangor in august 2014. the subjects were the mothers of under-five children aged 6−59 months old. this study was conducted in 8 out of 14 posyandu and from these posyandu 220 mothers were selected. data was collected by direct interview with the children’s mothers at the posyandu or at their respective homes if they did not come to the posyandu. another set of data was collected from the mothers in posyandu hegarmanah from august to october 2014 to find out the distribution and their knowledge about vitamin a by using a questionnaire which had enquiries on the distribution and knowledge about vitamin a capsules. the inclusion criterion in this study was the mother of children older than 6 months as of july 2014. mothers of younger children were excluded. the validated questionnaire comprised identity, distribution, and maternal knowledge on vitamin a. then, the collected data was analyzed by a statistical software. the distribution and frequency of the data were presented in tables. the ethical clearance was granted by the health research ethics committee faculty of medicine universitas padjadjaran, bandung. informed consent was also given by the posyandu workers and the selected mothers. results there were 220 under-five children spread across the eight selected posyandu, 214 (97.27%) children received vitamin a capsules in august 2014. the number of children who did not receive vitamin a capsules was 6 (2.72%) (table 1). in overall, the coverage of vitamin a supplementation can be seen in table 2. furthermore, the result of the questionnaire about the mother’s vitamin a knowledge was secondary data. the subjects in this study were 98 mothers of under-five children who came to the posyandu and had provided their general characteristics of educational background and occupation to be collected as data in this study. the mothers generally had junior high school education (41%) or senior high school education (47%). a minor proportion of mothers had a higher education. in the occupation aspect, most mothers were housewives (74%). a minority had a profession, such as civil servant (1%) and salesperson (4%). from the data provided by the mothers through the questionnaire, it was discovered that 94 (96%) out of 98 children received vitamin a supplement while 4 (4%) did not. it was almost similar to the result gathered from 214 children which showed that 97.27% of the children received vitamin a supplement. in this study, educational background or occupation did not have a significant effect on the coverage of vitamin a supplementation (table 3). furthermore, the distribution and knowledge on vitamin a supplementation in posyandu hegarmanah, jatinangor were based on the questionnaire. moreover, t data obtained from questionnaires revealed that most parents (94%) were aware of the government’s free vitamin a supplementation program for underfive children in the posyandu. additionally, 70% of the mothers knew that vitamin a supplement was given twice a year. besides, 92% of the mothers knew and participated in the free vitamin a supplementation program. furthermore, 68% of the mothers knew that posyandu would give one capsule during a home visit if they did not get any vitamin a 199 althea medical journal. 2017;4(2) nadia asmarani h.p., isriati, julistio t.b. djais: coverage of vitamin a supplementation among under-five children in hegarmanah village, jatinangor in august 2014 table 1 coverage of vitamin a capsule supplement in eight rws in hegarmanah village in august 2014 rw number of children aged 6-59 months number of children aged 6-59 months who came to posyandu and received vitamin a number of children aged 6-59 months who did not come to posyandu and vitamin a sweeping number of children aged 6-59 months who did not come to posyandu nor receive vitamin a capsule frequency percentage (%) frequency percentage (%) frequency percentage (%) 1 24 12 50 9 38 3 12.5 2 20 20 100 0 0 0 0 3 57 50 88 7 12 0 0 4 33 24 73 7 21 2 6 5 23 20 87 3 13 0 0 6 24 19 79 5 21 0 0 7 26 23 88 3 12 0 0 8 13 9 69 3 23 1 7.69 total 220 177 80.45 37 17 6 2.72 table 2 coverage of vitamin a supplementation among under-five children in hegarmanah village, jatinangor in august 2014 frequency percentage(%) children who received vitamin a 214 97.27 children who did not receive vitamin a 6 2.72 supplement. a proportion of the mothers (40.82%) also knew that they could also get vitamin a supplement from the puskesmas (table 4). moreover, data results showed that the mother’s knowledge could be classified into three categories: good, moderate, and poor (table 5). results based on mother’s knowledge about vitamin a supplementation were that half of the number of mothers had good knowledge and received vitamin a supplementation while, only three people with good knowledge did not receive vitamin a. other than that, 35 mothers who received vitamin a had moderate knowledge and another one had poor knowledge. overall, it could be observed that mothers still received vitamin a regardless of their knowledge about it (table 5). discussions this study involved under-five children in hegarmanah as subjects. based on direct interviews with mothers of the children in 8 rws in hegarmanah, it revealed that the coverage of vitamin a supplementation in august 2014 was 97.27%, while the other 2.72% did not receive it. similar findings were also reflected in the results of the questionnaire in eight posyandu about the distribution of and mother’s knowledge on vitamin a supplementation: 96% of the children received it while the other 4% did not. according to the regulations in renstra kementerian kesehatan dan rencana pembinaan gizi masyarakat tahun 2010-2014, nutritional management development is indicated by nutritional repair and the phasing of targeted indicators up to 2014, one of which is the percentage of children aged 6−59 months that receive vitamin a capsule. the target in 2012 was 80% and increases to 85% in 2014.11 in overall, it could be concluded that the coverage of the vitamin a supplementation program in hegarmanah village (97.27%) had exceeded the targeted value. this was also the case with the coverage in february 2014 (98%). this achievement proved the efficiency and effectiveness of posyandu in carrying out its role as health care service provider. vitamin a supplements were not only distributed during posyandu activities but althea medical journal. 2017;4(2) 200 amj june 2017 also during home visits by the posyandu cadres. this study revealed that more than half of the families were visited by the cadres at their homes. sweeping or home visits was one of the efforts directed to increase the coverage of vitamin a supplementation. children and babies who did not receive vitamin a supplements during posyandu activities would be tracked down and visited at their homes; the supplement would then be given at their homes.10 if there were still some children or babies who did not receive their share of vitamin a supplement, then cadres should make efforts to successfully deliver the supplement even if the designated period of time had passed. through this strategy, the coverage of vitamin a supplementation could actually reach 100%.11 unfortunately, sweeping caused the mothers to prefer staying at home and waiting to be visited instead of coming over to the posyandu. vitamin a supplementation program was still the preferred method of managing vitamin a deficiency; however, other methods have to be performed in the future to ensure sustainability, such as vitamin a fortification in food sources, nutritional education, etc.10,12,18 another study mentions education table 4 distribution and mother’s knowledge on vitamin a supplementation in posyandu hegarmanah, jatinangor based on results of the questionnaire distribution and mother’s knowledge yes no not sure f (%) f (%) f (%) knows about the government’s free vit. a supplementation program for under-five children in posyandu 92 93.88 6 6.12 0 0.00 vit. a supplement is given twice a year 68 69.39 9 9.18 21 21.43 vit. a supplement is given 3 times a year 20 20.41 47 47.96 31 31.63 parents participate in the vit. a supplementation program 91 92.86 3 3.06 4 4.08 posyandu gives vit. a supplement during home visit if the parents have not received vit. a 67 68.37 21 21.43 10 10.20 if the child does not get vit. a, it is still available at the puskesmas 40 40.82 27 27.55 31 31.63 table 3 common characteristics of mothers based on questionnaire responses characteristics frequency percentage (%) educational background elementary school 9 9.18 junior high school 40 40.82 senior high school 46 46.94 higher education 3 3.06 occupation housewife 73 74.49 civil servant 1 1.02 factory worker 12 12.24 sales 4 4.08 other 8 8.16 children who received vit. a 94 96 children who did not receive vit.a 4 4 total 98 100 201 althea medical journal. 2017;4(2) as an important factor in the distribution of vitamin a capsules. children with parents who only had primary school education or lower had a higher risk of not receiving the vitamin a capsule compared to those with parents who had at least junior high school education.14,16 semba and grover16 stated that there is a significant difference between the coverage of vitamin a supplementation with parent’s educational background. higher educational background of parents will result in a higher coverage. additionally, a previous study also states that there is a difference between mothers with high and low educational background: mothers with lower education tend to miss out on the vitamin a supplementation.13,17,20 fortunately, the program was carried out extensively in hegarmanah village and was able to reach out to all elements of the community regardless of the level of education or knowledge. when the mothers and their children missed the posyandu activities, the supplement was given during the sweeping. this was proven by the finding that the mothers, even with different levels of knowledge, all still received vitamin a supplement. as such, in this study, maternal education and knowledge were not important determinants of the coverage of vitamin a supplementation. nevertheless, the result of this study still showed some indications of mothers’ who were still unsure about the vitamin a supplementation program. this was reflected in the fair number of mothers who were unsure whether the supplement was given two or three times a year. besides, some mothers were also unsure whether or not they could get it from at the local puskesmas. thus, it can be concluded that there is still a lack of socialization by the puskesmas. most people are only participating in posyandu activities because they are invited by cadres and not because of their awareness of their children’s needs. the coverage of vitamin a supplementation for under-five children in posyandu hegarmanah, jatinangor was 97.27% by visiting the posyandu or home visits. sweeping or home visits was one of the efforts performed by the cadres to ensure the coverage of vitamin a supplementation also reached those who did not attend posyandu activities. the weakness of this method was that mothers became too lazy and preferred staying at home than participating in posyandu activities. in other words, the mothers lacked awareness regarding the importance of vitamin a . mothers’ knowledge affected her children’s growth and development. if one had the understanding and the awareness of a particular object, he/she would seek to treat the object in the best way that was known to him/her. however, the extensive nature of the vitamin a supplementation program covered most of the mothers regardless of their level of knowledge. vitamin a supplementation for underfive children needed to be well-integrated with the existing health programs, such as , posyandu still held a crucial role in sustaining the coverage of the vitamin a supplementation program. a comprehensive revitalization of the posyandu would be an accurate step to further increase its coverage.9 the author recommends socialization and education as the suitable way to generate an effective social participation in the community and also increase the public awareness. the vitamin a supplementation program should be promoted prior to the scheduled time (february and august) so as to increase the coverage by involving the community itself, increasing the people’s knowledge and awareness to stimulate motivation to participate. promotion can be performed by spreading information formally through seminars, table 5 coverage of vitamin a supplementation based on mother’s knowledge on vitamin a mother’s knowledge vit. a distribution did not receive received total f % f % f % good 3 4.92 58 95.08 61 100 moderate 1 2.78 35 97.22 36 100 poor 0 0.00 1 100.00 1 100 total 4 4.08 94 95.92 98 100 nadia asmarani h.p., isriati, julistio t.b. djais: coverage of vitamin a supplementation among under-five children in hegarmanah village, jatinangor in august 2014 althea medical journal. 2017;4(2) 202 amj june 2017 training, education, or promotions between other activities. some informal methods would be through stickers, posters, banners, and other media. the socialization can be conducted by the local health authority, hospital, and puskesmas jatinangor to provide the community with the information on the benefits, food sources, and dangers of deficiency of vitamin a. furthermore, the people are recommended to increase their knowledge on the symptoms of deficient or excessive vitamin a in the body. the data in this study should be considered before conducting further studies so that they can be better and more beneficial. limitations of this study are the lack of time and costs. the author recommends to conduct a further study with larger population coverage. references 1. herman s. masalah kurang vitamin a (kva) dan prospek penanggulangannya. media litbang kesehatan. 2007;17(4):40−4. 2. who. who guideline: vitamin a supplementation in infants and children 6–59 months of age. geneva: who press; 2011. 3. dole k, gilbert c, deshpande m, khandekar r. prevalence and determinants of xerophtalmia in preschool children in urban slums, pune, india-a preliminary assessment. opthalmic epidemiol. 2009;16(1):8−14. 4. semba rd, de pee s, sun k, campbell aa, bloem mw, raju vk. low intake of vitamin a-rich foods among children, aged 1235 months, in india: association with malnutrition, anemia, and missed child survival interventions. nutrition. 2010; 26(10):958−62. 5. kassu a, andualem b, van nhien n, nakamori m, nishikawa t, yamamoto s, et al. vitamin a deficiency in patients with diarrhea and hiv infection in ethiopia. asia pac j clin nutr. 2007;16(suppl 1):323−8. 6. most, usaid micronutrient program. cost analysis of the national vitamin a supplementation programs in ghana, nepal, and zambia: a synthesis of three studies. arlington, virginia usa: usaid; 2004. 7. nguyen am, grover ds, sun k, raju vk, semba rd, schaumerg da. coverage of the vitamin a supplementation programme for child survival in nepal: success and challenges. paediatr int child health. 2012;32(4):233−8. 8. berger sg, de pee s, bloem mw, halati s, semba rd. malnutrition and morbidity among children not reached by the national vitamin a capsule programme in urban slum areas of indonesia. public health. 2008;122(4):371−8. 9. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar. jakarta: kementerian kesehatan republik indonesia; 2010. 10. ridwan e. cakupan suplementasi kapsul vitamin a dalam hubungannya dengan karakteristik rumah tangga akses pelayanan kesehatan pada anak balita di indonesia analisis data riskesdas 2010. buletin penelitian sistem kesehatan. 2013;16(1):1-9. 11. riyadi s. rencana kerja pembina gizi masyarakat tahun 2013. jakarta: direktorat bina gizi masyarakat dan kia; 2013. 12. bendech ma, cusack g, konate f, toure a, ba m, baker sk. national vitamin a supplementation coverage survey among 6−59 months old children in guinea (west africa). j trop pediatr. 2007;138(4):787−92. 13. semba rd, de pee s, sun k, akhter n, bloem mw, raju vk. coverage of vitamin a capsule programme in bangladesh and risk factors associated with nonreceipt of vitamin a. j health popul nutr. 2010;28(2):143−8. 14. grover ds, de pee s, sun k, raju vk, bloem mw, semba rd. vitamin a supplementation in cambodia: program coverage and association with greater maternal formal education. asia pac j clin nutr. 2008;17(3):446−50. 15. rahman m. micronutrient profile of children and women in rural bangladesh: study on available data for iron and vitamin a supplementation. east afr j public health. 2009;6(1):102−7. 16. semba rd, de pee s, sun k, bloem mw, raju vk. coverage of the national vitamin a supplementation program in ethiopia. j trop pediatr. 2008;54(2):141−4. 17. semba rd, de pee s, sun k, bloem mw, raju vk. the role of expanded coverage of the national vitamin a program in preventing morbidity and mortality among preschool children in india. j nutr. 2010;140(1):208s−12s 18. semba rd, de pee s, sun k, akhter n, bloem mw, raju vk. coverage of vitamin a capsule programme in bangladesh and risk factors 203 althea medical journal. 2017;4(2) associated with non-receipt of vitamin a. j health popul nutr. 2010;28(2):143−8. 19. choi y, bishai d, hill k. socioeconomic differentials in supplementation of vitamin a: evidence from the philippines. j health popul nutr. 2005;23(2):156−64. 20. demissie t, ali a, mekonen y, haider j, umeta m. magnitude and distribution of vitamin a deficiency in ethiopia. food nutr bull. 2010;31(2):234−41. nadia asmarani h.p., isriati, julistio t.b. djais: coverage of vitamin a supplementation among under-five children in hegarmanah village, jatinangor in august 2014 vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 1 serum trace elements and antioxidant vitamins among male patients with prostate disorders in the delta region of nigeria bhaguetai joseph aghawegbehe,1 adedeji david atere,1,2* david bolaji akinbo,3 olumide faith ajani,4 raphael usiosefe erhunmwunse1 1department of medical laboratory science, university of benin, benin city, edo state, nigeria 2department of medical laboratory science, achievers university, owo, ondo state, nigeria 3department of medical laboratory science, afe babalola university, ado ekiti, ekiti state, nigeria, 4axios foundation, abuja, federal capital territory, nigeria correspondence: a. d. atere, department of medical laboratory science, achievers university, owo, nigeria. e-mail: ateread@gmail.com, tel.: +2348039501172 introduction prostate related complications account for approximately 25 % of the reason males from late 40s visit the urology clinics in nigerian hospitals, including symptoms of prostatitis, benign prostatic hyperplasia (bph) or prostate cancer (pca).1 although the main cause of bph and pca is not yet known, however, variations in the concentrations of some serum trace element such as zinc, copper, iron, cadmium, selenium and certain antioxidant vitamins such as vit a, vit c and vit e are known to associate with the function of specific organs such as prostate, breast, muscle, stomach, kidney, and colon. assessing the variations in trace elements and antioxidant vitamins, can be epidemiologically significant in the early prediction, identification, and treatment of prostate complications.2 therefore, evaluating these trace elements and antioxidant vitamins could be useful in preventing some adverse clinical conditions and complications that can result in death due to the insufficiency or excess availability of these biochemical analytes in prostate complications.3 the prostate contains some smooth muscles that help in expelling seminal fluid during ejaculation. this relatively alkaline, milky fluid secreted by the prostate nourishes and amj. 2019;6(1):1–6 abstract background: prostate cancer remains the commonest form of cancer among nigerian males, constituting 13.3% of all male cancers encountered in this region. trace elements and antioxidant vitamins may be of epidemiological significance in the early prediction and treatment of prostate complications. the study aimed to explore the serum trace elements, antioxidant vitamins concentration and serum prostate specific antigen (psa) among male with prostate disorders in the delta region of nigeria. methods: blood specimens were collected from males with symptoms of prostatitis (n=70), benign prostatic hyperplasia (bph; n=60) and prostate cancer (pca; n=70), alongside with apparently healthy male subjects (n=60). the levels of trace elements and antioxidant vitamins were evaluated. fluorescence immunoassay technique was used to assess the expression of psa. results: compared with the controls, pca patients had a significantly increased level of vitamin a (p<0.05), however, no significant differences in the serum levels of trace elements and antioxidant vitamins between subjects with prostate disorders and control group (p>0.05). interestingly, there was a significant positive correlation between prostate specific antigen, trace elements and vitamins in bph group (p<0.05). conclusions: prostate disorders such as prostatitis, bph and pca may be associated with elevated levels of psa, but, does not affect the circulating expression of some serum trace elements and antioxidant vitamins. keywords: antioxidants, prostate disorder, prostate specific antigen, trace elements althea medical journal. 2019;6(1) 2 amj march 2019 protects the sperm. in humans, the seminal fluid is largely composed of simple sugars and accounts for about 30% of semen volume with spermatozoa and fluid from the seminal vesicle. the protein composition is less than 1% and comprises of prostate specific antigen (psa), prostatic acid phosphatase, proteolytic enzymes and beta-microseminoprein. prostate secretions also contain zinc, having a concentration of 500 to 1000 times more than the zinc concentration in the blood. the prostatic normal functions are regulated by dihydrotestosterone, which is mainly produced by the testicle.4 an apparently healthy prostate is approximately the size of a walnut, and grows consistently bigger as the age increases. however, problems can arise when it grows too large as commonly seen from age 40. thus, the risk of prostate complications increases dramatically with age as men increase in age too. prostate cancer is a tumor of the prostate gland, representing one of the most common cancers affecting older men in developed countries and a major cause of death for aged men.5 some previous reports have revealed high prevalence of prostate cancer in nigeria; with prevalence rates of 127/100,000 men in 1997 and 114/100,000 men in 2002.6,7 prostate cancer is the commonest cancer among nigerian males and has been estimated to constitute 13.3% of all male cancers.8 it has been documented that the serum levels of psa is widely used as a biomarker for early detection of prostate complications and its elevation in the serum is suggestive of prostate disorders.9 trace elements are vital components of body fluids and tissues which are required by the body in small amounts (usually less than 1 to 10 parts per million) for a range of functions. metals such as iron and copper are required by the human body in trace (milligram) quantities, while other metals like the chromium, manganese, fluoride, iodide, cobalt, selenium, silicon, arsenic, boron, and vanadium are only needed in ultra-trace (microgram) quantities.10 trace elements are major components of living structures and various studies have proven their existence in various forms keeping a dynamic balance status in the human body.11 variations in the concentration of trace elements and antioxidant vitamins affect the proper functioning of different organs and tissues in the body. the insufficiency or excess of trace elements can prompt body metabolic disorder and cellular growth disturbance, even mutation and cancerization.11,12 this study therefore investigated the relationship between serum trace elements and antioxidant vitamins status of subjects with prostate disorders in the nigeria delta region and their possible utilization in the management of prostate complications. methods this research was conducted in warri, delta state, nigeria. a total of 200 male subjects aged 48 to 80 years who attended the urology clinics in four hospitals in warri (warri general hospital, westend hospital, lilly hospital and capitol hill hospital) were recruited as subjects for this study, and were further grouped into three, comprising of patients with prostatitis (n=70), bph (n=60) and pca (n=70). the durations of the prostate disorders at the point of sample collection were 0 to 1 year for prostatitis, 0 to 5 years for bph and 0 to 5 years for pca. only subjects presenting with symptoms of prostatitis, bph and pca with known psa values were recruited for this research. male subjects who did not have prostate related complications and those who were presenting with other renal disorders were excluded from the study. a pre-designed structural questionnaire was utilized to collect bio-data, clinical data and socio-demographic characteristics of the patients. as control group, 60 apparently healthy adult male subjects who were age and socio-economic status matched were included. subjects participating in this study were fully briefed on the research protocols in the clinics after which they were required to sign a written consent. ethical approval for the study was obtained from delta state hospital management board ethical review committee with registration number chw/ ecc.vol1/072. five milliliters (5 ml) of venous blood was aseptically collected using standard phlebotomy technique. serum obtain adequate amount of serum for the analysis. serum was separated from the blood after retraction by centrifuging for 5 minutes at 4000 rpm, into micro centrifuge tubes and stored at -200c until time of analysis. the trace elements were analysed using single quadrupole icp-ms (thermo scientific co., ma, usa). vit a and vit e were analysed using an integrated analytical system of hplc 2695 (waters gentech scientific inc., ny, usa) integrity system equipped with a uvvis detector (waters 996) with the range of althea medical journal. 2019;6(1) 3a.d atere et al: serum trace elements and antioxidant vitamins among male patients with prostate disorders in the delta region of nigeria table 1 serum levels of trace elements (iron, copper, selenium) and vitamins (vit a and vit e) and prostate specific antigen of study subjects of patients with prostate disorders attending the urology clinics in nigerian hospitals parameters patients (n=200) control (n=60) p-value fe (µg/dl) 113.93±3.17 116.25±5.04 0.701 cu (µg/dl) 130.78±2.04 136.65±5.47 0.332 se (µg/l) 0.46±0.01 0.47±0.02 0.734 vit a (µg/l) 65.37±1.11 64.00±3.12 0.687 vit e (µg/l) 1.04±0.03 1.09±0.05 0.501 psa (ng/dl) 19.29±2.45 1.15±0.85 0.000* note: fe=serum iron, cu=serum copper, se=serum selenium, vit a=vitamin a, vit e=vitamin e, psa=prostate specific antigen; values are expressed as mean ± sd, * significant at p≤0.05 190–800 nm. chromatographic separations were performed on a lc-nh2-np column (25 cm 4.6 mm, 5μm) with the supelguard tm lc-nh2-np precolumn supel-co (merck, taufkirchen, germany). the psa was analysed using ichromatm psa (boditech med, uk) which was a fluorescence immunoassay (fia) for the quantitative determination of psa. data obtained were analysed using descriptive and inferential statistical tools. descriptive statistics were mean ± standard deviation (s.d), while inferential statistics used were student t-test, analysis of variance with post hoc to access the source of significance and pearson correlation using the statistical package for social sciences (spss version 21.0, chicago, il) software. the level of significance was set at p<0.05. results this study explored the levels of serum trace elements (iron, copper, selenium) and antioxidant vitamins (vit a, and vit e) among patients with prostatitis, bph, pca and compared with healthy male subjects as a control group. result showed that no significant difference in the levels of serum trace elements (iron, copper, selenium) and antioxidant vitamins (vit a and vit e) between prostate disorders patients in general and control group (p >0.05) (table 1), however, the level of serum psa was significantly increased in the prostrate disorder group compared to the control (p <0.000). interestingly, serum iron levels in the bph group were significantly decreased (p<0.05) table 2 serum levels of trace element (iron, copper, selenium) and vitamins (vit a and vit e) and prostate specific antigen of patients with prostate disorders, including prostatitis, benign prostatic hyperplasia or prostate cancer attending the urology clinics in nigerian hospitals parameters control (n=60) prostatitis (n=70) bph (n=60) prostate cancer (n=70) fe (µg/dl) 116.25±16.89 119.69±21.22a 105.88±25.71b 120.19±14.79a cu (µg/dl) 136.66±18.31 133.42±19.92a 128.03±15.40a,b 130.98±9.50a,b se (µg/l) 0.47±0.07 0.49±0.09 0.43±0.10a 0.49±0.06 vit a (µg/l) 64.16±9.75 63.88±12.96 58.77±9.44a 72.70±3.90b vit e (µg/l) 1.09±0.17 1.09±0.22 0.83±0.33a,b 1.15±0.13a psa (ng/dl) 1.15±0.85 7.04±2.03a 19.80±6.96a,b 68.38±30.25a,b, c note: fe=serum iron, cu=serum cupper, se=serum selenium, vit a= vitamin a, vit e= vitamin e, psa= prostate specific antigen; values are expressed as mean ± sd, asignificantly different from control group at p< 0.05, bsignificantly different from prostatitis group at p< 0.05, csignificantly different from bph group at p< 0.05 althea medical journal. 2019;6(1) 4 amj march 2019 compared to the control group and other prostatic disorders, while it significantly increased (p<0.05) in the prostate cancer group than other test groups and control group. serum vit a levels was also significantly increased (p<0.05) in the group with prostatic cancer compared with other test groups and control group. there were significant increases (p<0.05) in the psa levels of the various test groups with prostatitis, bph and prostatic cancer respectively compared with the control group (table 2). other serum trace elements and antioxidant vitamins however showed no significant difference between the various study groups (p>0.05). the relationship between the variables in the control, prostatitis, bph and prostate cancer with psa were assessed (table 3). iron, copper, selenium, vit a and vit e showed significant positive relationship of the control subjects with psa, while other groups showed no significant correlation with psa. vit a and vit e however showed very high significant positive and negative relationship respectively with psa (r=0.71 and r=-0.82). discussion serum expressions of trace elements such as fe, cu, and se, some antioxidant vitamins (vit a and vit e) and psa, have been assessed in male patients with prostate disorders and apparently healthy controls. the prostate disorders patients include male presenting with symptoms of prostatitis, bph and prostate cancer who have known psa values. the presence of trace elements and antioxidant vitamins has been associated with the proper functioning of different organs and tissues.11 however, our result shows that there is no difference in the serum levels of most of the trace elements (copper, selenium) and antioxidant vitamin namely vit e between subjects with prostate disorder and the control group, however, only iron and vit a has shown an increased levels in the prostate cancer group, suggesting that cancer of the table 3 correlation of trace elements and vitamins among patients with prostate disorders r p prostatitis (n=70) fe (µg/l) 0.02 0.85 cu (µg/l) -0.01 0.95 se (µg/l) 0.02 0.85 vit a (µg/l) -0.02 0.93 vit e (µg/l) -0.02 0.93 bph (n=60) fe (µg/dl) 0.01 0.94 cu (µg/dl) 0.10 0.45 se (µg/l) 0.01 0.93 vit a (µg/l) 0.71 0.00* vit e (µg/l) -0.82 0.00* prostate cancer (n=70) fe (µg/dl) -0.20 0.21 cu (µg/dl) 0.12 0.44 se (µg/l) -0.20 0.21 vit a (µg/l) -0.34 0.08 vit e (µg/l) 0.09 0.65 note: * correlation is significant at the 0.05 level (2-tailed) althea medical journal. 2019;6(1) 5 prostate alters the serum concentration of these analytes. contrarily, onyema-iloh et al.3 has reported significantly reduced serum levels of selenium, zinc, vitamin e and c, and higher levels of copper, when compared to the apparently healthy control group. some trace elements have been reported of playing a major role in the biology of cancer; however, there is still a gap in our understanding of the relationship between the function of trace elements and the initiation, advancement and inhibition of carcinogenic process of the prostate gland.13 trace elements are a major constituent of biological structures, albeit the increasing queries on the toxicity of these elements to human health at concentrations higher than required for biological functions and whether they are truly essential. in this study, there was no significant difference in the serum expression of trace elements and vitamins in the prostatitis and bph test subjects when compared to the control group. this finding contradicts other studies on the association of trace elements and some vitamins with prostate disorders.2,3,14–16 on the other hand, a significant increase in the serum level of vit a was observed in the prostatic cancer group compared to the control with other vitamins and trace elements showing no significant difference which negates the reports of other previous similar studies.3 furthermore, psa is observed to be positively correlated with trace elements and vitamins in the control subjects. vitamin a, its natural and synthetic analogs have been reported to enhance prostate cancer risks and it is remarkable that the bph group investigated in this study showed positive correlation of psa with vitamin a. one mechanism of vit a enhancement of cancer risk is by its interaction with zinc which could result in the proliferation of prostatic epithelial cells.17 there is however a concurrent negative correlation of psa with vitamin e in the bph group investigated in the study. various forms of vit e possess antiinflammatory and antioxidant properties and have been reported to have numerous benefits for men with prostate disorders including inhibiting the growth of human and animals’ prostate tumors.18 there was no significant correlation between psa, trace elements and vitamins in the other test groups. this study therefore suggests that a variation in the serum levels of psa does not affect the concentration of trace elements and vitamins present in these subjects. this is consistent with the findings of donkena et al.19 showing that daily intake of vit a, vit e or serum α-tocophenrol does not correlate with increased prostate cancer risk. several studies have shown a correlation between prostate disorders and elevated serum levels of psa.2,20 the patients with prostatitis, bph and pca showed higher levels of psa than the control group thereby correlating with the studies listed above. the limitation of study is lacking data on the correlation between multivitamin usage and a family history of cancer. although the association of vitamins usage and elevation of psa has been established in prostate disorders, information about the duration of vitamin and trace element use could have been relevant in determining if their correlation is restricted to long-term users. as a conclusion, prostate disorders such as prostatitis, benign prostatic hyperplasia and prostate carcinoma are associated with elevated levels of prostate specific antigens (psa), with no significant alteration in the serum levels of some trace elements and antioxidant vitamins. these findings reveal the lack of clinical significance of these trace metals and vitamins as screening tools for the diagnosis and therapy of prostate complications and disorders. further studies are encouraged to uncover the mechanistic role of trace elements and vitamin supplements in the elevation of psa in prostate disorders and critical areas of early detection that several investigators have not been able to explore. acknowledgments: authors appreciate the support of all the participants and they are grateful to the staff of the various hospitals for their cooperation in specimens collection. we are also grateful to prof. h.b. osadolor for his help in the study design. conflicts of interest: the authors declare that this manuscript was approved by all authors and no competing interest exists. funding: self-sponsored references 1. bracarda s, de cobelli o, greco c, prayergalleti t, valdagni r, gatta g, et al. cancer of the prostate. crit rev oncol hematol. 2005;56(3):379–96. 2. kaba m, pirincci n, yuksel mb, gecit i, gunes m, ozveren h, et al. serum levels of trace elements in patients with prostate cancer. asian pac j cancer prev. 2014;15(6):2625– 9. 3. onyema-iloh bo, meludu, sc, iloh e, nnodim j, onyegbule o, mykembata b. biochemical changes in some trace a.d atere et al: serum trace elements and antioxidant vitamins among male patients with prostate disorders in the delta region of nigeria althea medical journal. 2019;6(1) 6 amj march 2019 elements, antioxidant vitamins and their therapeutic importance in prostate cancer patients. asian journal of medical science. 2015;6(1):95–7. 4. adedapo ks, arinola og, shittu ob, kareem oi, okolo ca, nwobi ln. diagnostic value of lipids, total antioxidants, and trace metals in benign prostate hyperplasia and prostate cancer. niger j clin pract. 2012;15(3):293–7. 5. cedars mi, taymans se, depaolo lv, warner l, moss sb, eisenberg ml. the sixth vital sign: what reproduction tells us about overall health. proceedings from a nichd/cdc workshop. hum reprod open. 2017;2017(2):hox008 6. kolawole ao. feasible cancer control strategies for nigeria: mini-review. american journal of tropical medicine & public health. 2011;1(1):1–10. 7. duru r, njoku o and maduka i. oxidative stress iindicators in patients with prostate disorders in enugu, south-east nigeria. biomed res int. 2014;2014:313015. 8. ezenwa ev, tijani kh, jeje a, ogunjimi a, ojewola, r. prevalence of prostate cancer among nigerians with intermediate total prostate specific antigen levels (4-10ng/ ml): experience at lagos university teaching hospital, nigeria. the internet journal of urology. 2012;9(3):1–5. 9. pérez-ibave dc, burciaga-flores ch, elizondo-riojas má. prostate-specific antigen (psa) as a possible biomarker in non-prostatic cancer: a review. cancer epidemiol. 2018;54:48–55. 10. zaichick v, zaichick s. ratios of selenium/ trace element contents in prostate gland as carcinoma’s markers. j tumor med prev. 2017;1(2):1–12. 11. navarro sa, rohan te. trace elements and cancer risk: a review of the epidemiologic evidence. cancer causes control. 2007;18(1):7–27. 12. demir c, demir h, esen r, sehitogullari a, atmaca m, alay m. altered serum levels of elements in acute leukemia cases in turkey. asian pac j cancer prev. 2011;12912):3471–4. 13. geraki k, farquharson mj, bradley da. concentrations of fe, cu and zn in breast tissue: a synchrotron xrf study. phys med biol. 2002;47(13):2327–39. 14. mahabir s, spitz mr, barrera sl, beaver sh, etzel c, forman mr. dietary zinc, copper and selenium and risk of lung cancer. intl j of cancer. 2007; 120(5):1108–15. 15. zowczak m, iskra m, torlinski l, cofta s. analysis of serum copper and zinc concentration in cancer patients. biol trace elem res. 2001;82(1–3): 1–8. 16. adaramoye oa, akinloye o, olatunji ik. trace elements and vitamin e status in nigerian patients with prostate cancer. afr health sci. 2010;10(1):2–8 17. mondul am, watters jl, mannisto s, weinstein sj, snyder k, virtamo j, et al. serum retinol and risk of prostate cancer. am j epidemiol. 2011;173(7):813–21. 18. huang y, wu r, su zy, guo y, zheng x, yang cs, et al. a naturally occurring mixture of tocotrienols inhibits the growth of human prostate tumor, associated with epigenetic modifications of cyclin-dependent kinase inhibitors p21 and p27. j nutr biochem. 2017;40:155–63. 19. donkena kv, karnes rj, young cyf. vitamins and prostate cancer risk. molecules. 2010;15(3):1762–83. 20. vardhan sp, krishnamma m, naidu jn, naidu mp. study of insulin resistance and antioxidant vitamin status in prostate cancer patients. international journal of medical science. 2014;2(2):643–6. vol 4 no 3 full text final.indd althea medical journal. 2017;4(3) 461 burden of pediatric cancer treatment: results of online pediatric cancer registry prototype 1 at a third referral hospital in indonesia nur melani sari,1 lelani reniarti,1 nur suryawan,1 susi susanah,1 kurnia wahyudi2 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 2department of public health faculty of medicine universitas padjadjaran abstract background: despite the impressive progress of high-income countries, childhood cancer survival remains low in low and middle-income countries. cancer is yet to be considered as a significant public health issue which has implicate only few pediatric cancer registry has been well established. the study aimed to describe the burden of pediatric cancer treatment in a third referral hospital in indonesia through pediatric cancer registry. methods: a-three-year retrospective analysis of 15 pediatric cancer diagnosed in children aged under 14 years was conducted at dr hasan sadikin general hospital, bandung. data were extracted from online bandung pediatric cancer registry prototype 1 and analyzed for age, gender, type of cancer. the outcomes were classified as treatment abandonment, treatment refusal, interrupted treatment, death during treatment, and completed treatment. results: seven-hundred and seventy-three children, 452 males and 321 females, were diagnosed with 15 types of malignancies. peak incidence for each malignancy was different: at a young age was found in retinoblastoma and hepatoblastoma (mean; 3yo) while at adolescence in bone tumor and chronic myelocytic leukemia (9.1; 10 yo respectively). distribution of the foremost malignancies recorded was: acute lymphoblastic leukemia (44.5%), retinoblastoma (15.2%), and non-hodgkin lymphoma (8.9%). the cancer cure rate was very low (9.5%), treatment abandonment was still high (41.7%) and most patients died (27.8%) in the course of therapy either from advanced disease, infection, or late presentation. meanwhile, 167 patients still continued the interrupted treatment. conclusions: cancer management is the burden for hospital, however the general outcome is very poor. keywords: cancer management, developing countries, health care burden, pediatric cancer registry introduction the incidence of pediatric cancer is increasing, data from the international agency for research on cancer (iarc) showed approximately 175,000 new cases of childhood cancer (0–14 years) per year. most new cases (84%) or 147,000 new cases occur in developing countries that are associated with lower life expectancy.1 currently, in developing countries the priority of health development is prevention of infectious diseases and nutritional improvements in accordance with the global commitments of the sustainable developmental goals (sdg), however with improved nutrition and decreased infectious diseases cannot protect children from cancer.2 in addition, the increase in industrialization and urbanization life also contributes to the increase in incidence of cancer. indonesia as a developing country currently, faces the burden of multiple diseases, namely the increase of non-infectious diseases, one of which is childhood cancer.2,3 the prevalence of cancer patients in indonesia regardless of age is 1.4 per mil’ which may not describe the real number because there are still many unreported cases. moreover, indonesia did not have the real number of pediatric cancer.4 compared to highincome countries (hics), the annual incidence of childhood cancer is approximately 140 per 1 million children younger than age 15 years. incidence rates from low and middle income country (lmic) registries are generally correspondence: dr. nur melani sari, spa.,m.kes, hematology and oncology division department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung-indonesia email: nur.melani.sari@unpad.ac.id amj. 2017;4(3):461–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1204 althea medical journal. 2017;4(3) 462 amj september 2017 significantly lower, as annual rates per 1 million children of 45.6 in namibia and 64.4 in india, respectively. some of this variation may relate to differences in environmental exposures or to biologic susceptibility. furthermore, cancer management strategies in lmics started from understanding the burden and the importance of managing childhood cancer such as in indonesia. the burden of cancer in indonesia was unknown mainly because of lack of statistics or underreporting like the other lmics. from a survey of health care workers in 10 lmics, including bangladesh, philippines, tanzania, and vietnam, only 15–37 percent of the expected patients were seen.5 however, deficiencies in diagnosis and registration likely contributed significantly to differences in the reported incidence of cancer, both overall and of particular sub types. moreover, expansion of current cancer registries, improvement in diagnosis and registration, and novel methodologies are needed to establish the true pediatric cancer burden. high quality pediatric cancer registry is still a luxury in lmics that still needs to be established and developed in lmics such as indonesia.2,6 the bandung pediatric cancer registry as a hospital-based cancer registration is the first step in establishing regional and national cancer registries. hospital cancer registration is an important data supplier in some hospital cancer registries in some developing countries. in addition, registration of quality cancer hospitals with good data quality and ongoing implementation is a solid framework for regional and national cancer registration planning.7 the outcomes are the other side of the problems of childhood cancer in lmics which show that the cure rate is very low and the treatment abandonment is high.8 the study was aimed to describe the burden of pediatric cancer treatment in one of the third referral hospital in indonesia through online bandung pediatric cancer registry prototype 1. methods the study setting was at dr. hasan sadikin hospital (rshs), the third referral hospital in west java with almost 1000-bed capacity. dr hasan sadikin general hospital is the core in pediatric oncology services in west java. the hematology oncology unit of the department of child health has 32-bed capacity and offers chemotherapy. moreover, radiation therapy and radio nuclear treatment are also available. however, there is still inadequate human resource especially the typical nurse who has the capacity in providing chemotherapy care. meanwhile, most medical expenses are charged to the national insurance (badan penyelenggara jaminan sosial, bpjs). basic diagnostic investigations such as complete blood count, liver and kidney function tests are readily available. diagnostic tests such as histopathology are also available however; the diagnosis was mostly based on fine needle aspiration biopsy. though, this unite serves immunohistochemistry, cytology, and molecular diagnostics were not available as well as imaging modalities were limited with one magnetic resonance imaging (mri) and two computerized tomography (ct) imagers. multiple treatments with chemotherapy, radiation and surgery are offered at the hospital. chemotherapy protocols are derived from evidence-based protocols. however, regardless of the protocol, inconsistent availability of cytotoxic drugs often dictated the regimen delivered to the patients. a pre-existing database of online bandung pediatric cancer registry had been established at dr. hasan sadikin bandung in 2016. the data based collected medical information such as laboratory, pathology and radiology results as well as demographic data. there were two registrars focused for inputting data from medical records, and one validator. moreover, online bandung cancer registry was a customized cancer registry which followed the principle of hospital based cancer registry and accommodated the function of electronic medical record. this registry could be accessed by a special code by an authorized person. all children aged 0–14 years who were admitted to the paediatric oncology ward, department of child health between january 2014 and december 2016 with confirmed cancer were enrolled in online bandung pediatric cancer registry. the initial inclusion criteria for the study was limited to patients registered in the database. clinical diagnoses were typically established based on history, physical exam, chest x-ray, ultrasound and occasionally ct scan. based on medical record reviews, one outcome assignment was determined for each patient with treatment abandonment/ treatment default: as absence from curedirected therapy for four or more weeks and the patient was not a candidate for palliative care. upfront treatment abandonment also known as treatment refusal occurred if the patient fails to start treatment to accomplish cure or definitive control. interrupted treatment: the althea medical journal. 2017;4(3) 463nur melani sari, lelani reniarti, nur suryawan, susi susanah, kurnia wahyudi: burden of pediatric cancer treatment: results of online pediatric cancer registry prototype 1 at a third referral hospital in indonesia category of interrupted treatment includes the terminology describing missed treatment: if the patient misses some therapy but not to extent impacting disease control, lost to follow up (ltfu) for a short duration while on treatment (less than the time period that would define abandonment for patients with that diagnosis), refusal of specific treatment components for a specified time, and discontinued treatment with a specified intent. complete treatment: completion or treatment to accomplish cure or definitive control. death during treatment: if the patient died during the cure of directed treatment due to advance disease, infection, toxicity of chemotherapy.8,9 online bandung pediatric cancer registry prototype 1 is a new online web-based cancer registry which inputs all data from the pediatric hematology oncology division. the obtained data were later imported into a password-protected microsoft excel 2010 and underwent descriptive analysis. results the online database included 773 children admitted to the pediatric oncology ward, figure 1 distribution of pediatric cancer patients in west java province figure 2 distribution of pediatric cancer patients based on type of malignancies althea medical journal. 2017;4(3) 464 amj september 2017 department of child health, dr. hasan sadikin hospital with a confirmed malignancy during the enrollment period (2014–2016). the online bandung pediatric cancer registry was a new registry which input all the data from medical records of pediatric cancer during the period 2014–2016 including the new cases and follow up of the patients as online medical records. the distribution of pediatric cancer patients at dr. hasan sadikin hospital during study period showed patients mostly came from all regions around west java province, figure 3 the outcome of pediatric cancer treatment table 1 respondent’s general characteristics diagnosis of malignancy treatment abandonment n (%) interrupted treatment n (%) completed treatment n (%) death during treatment n% acute lymphoblastic leukemia (all) 103 (30.5%) 115(33.4%) 18 (5.2%) 108(31.3%) acute myeloblastic leukemia (aml) 20(51%) 4(10.2%) 0 (0%) 15(38.4%) retinoblastoma 45(38.1%) 16(13.6%) 43(36.4%) 14(11.9%) chronic myelocytic leukemia (cml) 16(94.1%) 0(0%) 0(0 1(5.9%) non hodgkin lymphoma 35(50.7%) 7(10.1%) 3(4.3%) 24(34.7%) hodgkin lymphoma 7(70%) 1(10%) 2 (20%) 0(0%) neuroblastoma 8(29.6%) 5(18.5%) 2(7.4%) 12(44.4%) osteosarcoma 21(63.6%) 2(6.1%) 1(3%) 9(27%) lch (langerhans histiocytosis) 6(60%) 2(20%) 1(10% 1(10%) wilms tumor 8(33.3%) 5(20.8%) 4(16.7%) 7(29.1%) testicular cancer 11(78.6%) 1(7.1%) 0(0%) 2(14.3%) ovarian cancer 5(55.5%) 1(11.1%) 0(0%) 3(27.4%) brain tumor 21(77.8%) 3(11.1%) 0(0%) 3(11,1%) rhabdomyosarcoma 11(45.8%) 3(12.55) 0(0%) 10(41.6%) hepatoblastoma 2(28.5%) 0(0%) 0(0%) 5(71.4%) total 321 (41.5%) 165 (21.33%) 74( 9.5%) 214(27.7%) abandonament althea medical journal. 2017;4(3) 465nur melani sari, lelani reniarti, nur suryawan, susi susanah, kurnia wahyudi: burden of pediatric cancer treatment: results of online pediatric cancer registry prototype 1 at a third referral hospital in indonesia except from bogor, depok, and tangerang who preferred going to jakarta region (figure 1). regions located close to dr. hasan sadikin hospital had the highest number of patients coming to dr. hasan sadikin hospital, respectively kabupaten bandung, kota bandung, and garut. they were diagnosed with 15 types of malignancies during the study period (figure 2). the distribution of the foremost malignancies recorded were as follows: acute lymphoblastic leukemia (all) (44.5%), retinoblastoma (15.2%), and nonhodgkin lymphoma (8.9%). the number of patients consisted of 452 male and 321 female, presenting male to female ratio of 1.4:1. the peak incidence for each malignancy was different, at younger age was found in retinoblastoma and hepatoblastoma (mean; 3yo) while at adolescence in bone tumor and chronic myelocytic leukemia (cml) (9.1; 10 y.o respectively). the treatment outcome of pediatric cancer at dr. hasan sadikin general hospital was still unsatisfactory. the cancer cure rate was very low (9.5%), treatment abandonment was still high (41.7%) and most of the patients died (27.8%) in the course of therapy either from advanced disease, infection, or late presentation addressing palliative care management which started at early presentation. in addition, 167 patients still continued their interrupted treatment (figure 3). furthermore, cml, testicular cancer, brain tumor, and osteosarcoma were the four diagnoses which have the highest number of treatment abandonment among 15 type of childhood cancer diagnosis (table 1). discussion cancer registration is an indispensable instrument in cancer control programs.2 the history of cancer registry in indonesia began at the department of pathology, diponegoro university in semarang in 1970, and the semi population based cancer incidence data have been available since 1985, allowing comparisons across the country focused on gastrointestinal malignancies. there is currently a new major effort started by the dharmais national cancer center jakarta to set up a partial population-based registry in 2007. until now there is no specific cancer registry for pediatric population.10,11 the online bandung pediatric cancer registry prototype 1 was the first attempt to help measuring the burden of pediatric cancer patients in west java province. the online pediatric cancer registry is intended to widen utilization among hospitals in indonesia which serve pediatric oncology treatment, starting from creating a hospital based cancer registry. the online bandung pediatric cancer registry prototype 1 was established in 2016 which complied with the principle of cancer registration including data collection, verification, validation, management and analysis, and data publication. this new application also accommodates the use of srikandi and canreg5 iarc.12 based on this registry we found that mostly patients came from kabupaten bandung (17.8%), which is an industrial district, however we could not find any relationship between socio environmental factors except the distance of dr. hasan sadikin general hospital from the patient’s residence was close enough for parents to travel with their children to seek for medical services at dr. hasan sadikin general hospital. a study in africa13 found that demography was one of the factors of treatment abandonment for childhood cancer lower risk if patients were residing in the same location with the cancer center (odds ratio [or]=0.41 (95% confidence interval [ci]: 0.21–0.81; p=0.01).13 perez et al.14, furnished some evidence that living in the proximity of industrial (<2.5 km) and urban sites may be a risk factor for childhood leukemia. further investigations should be conducted to explore this factor in our population. the industrial site referred to in peres’ study was particularly the site of glass and mineral fibers (or2.42;95% ci¼1.49– 3.92), surface treatment using organic solvents (or1.87;95% ci1.24–2.83), galvanization (or1.86;95% ci1.07–3.21), production and processing of metals (or1.69;95 ci1.22–2.34), and surface treatment of metals (or1.62;95% ci1.22–2.15), and urban areas (or 1.36;95% ci1.02–1.80). the most frequent cancer type among children between 0–14 years old in lmics in asia15 were as follows: leukemia (35.8%), brain tumor (12.4%), nonhodgkin lymphoma (7.4%), hodgkin lymphoma(4.3%), kidney tumor 3.9%, liver 2.1 %, ovary tumor 1.3%. this was in line with the new data from distribution of the most common cancers in children less than 15 years of age in selected populations around the world which showed that leukemia was the most common among the pediatric malignancies (51%), followed by brain tumor (17%), non-hodgkin lymphoma (11%), hodgkin lymphoma (5%), kidney tumor (6%), and other (10%).16 comparing those data with althea medical journal. 2017;4(3) 466 amj september 2017 data in dr. hasan sadikin general hospital, the differentiation was on the second rank which was retinoblastoma in our population and brain tumor in the other populations. furthermore, some factors contributing to these were the difficulty of diagnosis of brain tumor, late presentation of brain tumor, and unregistered cases of brain tumor. in addition, retinoblastoma in our registry was the second common pediatric malignancy. there were some factors contributing to this, which might be due to the national eye cancer hospital location in bandung, thus most of the case across indonesia referred to dr. hasan sadikin hospital, or the detection of retinoblastoma in west java was well established so more patients could undergo treatment. the number of new cancer cases in children at dharmais cancer hospital between 2010–2013 showed different results, lymphoma is the second most common cause after leukemia.4 due to sporadic data around hospitals in indonesia, it was common if we found variation in pediatric cancer. thus, it is essential that a national pediatric cancer registry should be immediately established. the abandonment of treatment is a major cause of therapeutic failure in these resourcepoor countries, affecting up to 50–60% of cases. abandonment constitutes failure to start or complete curative treatment.9 this study found that the number of treatment was 41.5%. these numbers should be considered and not to be ignored. in 2010, pediatric oncology in development countries (podc) has developed a special working group for these problems and made some recommendations which are (1) abandonment of treatment should be documented as an adverse event in childhood cancer studies in resource poor countries. patients who do not begin or complete treatment should not be excluded from survival analyses. event-free survival should be analyzed in two ways: by treating abandonment as an adverse event and by censoring cases at the time of abandonment for some children may be cured if they abandoned treatment after completing most of their planned therapy, these two estimates may reflect the upper and lower bounds of the true event-free survival estimate; (2) abandonment of treatment may be defined as a failure either to begin (conventionally termed refusal) or to continue the planned course (abandonment), because both are likely to have related underlying causes and could benefit from similar interventions. however, the timing of abandonment should be documented to help to identify related factors. third, treatment in resource poor settings may be interrupted for various reasons, including financial and transportation difficulties. when such interruptions herald full abandonment and what the effect on outcomes will be are difficult to predict. treatment abandonment is a complex and multifactorial phenomenon. with increased recognition of the role of treatment abandonment on global pediatric cancer outcomes, factors beyond social/ economic status and beliefs have emerged. our results provided insights regarding the role of established determinants of treatment abandonment in different geographical and economic contexts, allow probing of key determinants by deliberating their mechanisms, and allow building an expanded conceptual model of established and emerging determinants treatment abandonment.17 our study did not explore the factor that might contribute to the determinant of treatment abandonment or interrupted treatment, such as diagnosis, treatment, prognosis, social economic factor. the limitation of our medical records is the unavailability of data in medical records whether the intended treatment is curative or palliative. this study can describe the burden of pediatric cancer management in tertiary hospitals in indonesia, hence we should have a strategy to improve pediatric oncology services including endeavors to make rshs as a dedicated hospital for pediatric oncology treatments, and to make collaborations in hic through twinning programs. references 1. stefan dc. pediatric hematology-oncology in countries with limited resources: a practical manual. new york: springer; 2014. 2. valsecchi mg, steliarova-foucher e. cancer registration in developing countries: luxury or necessity?. lancet oncol. 2008;9(2):159-67. 3. howard sc, mentzer ml, william ja, quintana y, pui c-h, robison ll, et al. childhood cancer epidemiology in low income countries. cancer. 2008;112(3):461–72. 4. pusat data dan informasi . situasi penyakit kanker. buletin jendela data dan informasi kesehatan. 2015;1(2):1–11. 5. ribeiro rc, steliarova-foucher e, magrath i, lemerle j, eden t, forget c, cavalli f. baseline status of paediatric oncology in althea medical journal. 2017;4(3) 467nur melani sari, lelani reniarti, nur suryawan, susi susanah, kurnia wahyudi: burden of pediatric cancer treatment: results of online pediatric cancer registry prototype 1 at a third referral hospital in indonesia ten low-income or mid-income countries receiving my child matters support: a descriptive study. lancet oncol. 2008;9(8):721–29. 6. gupta s, aitken jf, bartels u, brierley j, dolendo m, fried p, et al. paediatric cancer stage in population-based cancer registries: the toronto consensus principles and guideline. lancet. 2016;17(4):163–72. 7. bray f, znaor a, cueva p, korir a, swaminathan r, ullrich a, et al. planning and developing population-based cancer registration in low-and middle-income settings. 2014. 8. weaver ms, arora rs, howard sc, salaverria ce, liu y-l, ribeiro rc, et al. a practical approach to reporting treatment abandonment in pediatric chronic conditions. pediatr blood cancer. 2015;62(4):565–70. 9. mostert s, arora rs, magda arreola pb, friedrich p, gupta s, kaur g. abandonment of treatment for childhood cancer: position statement of a siop podc working group. lancet oncol. 2010;12(8):719–720 10. wahidin m, noviani r, hermawan s, andriani v, ardian a, djarir h. population-based cancer registration in indonesia. asian pacific j cancer prev. 2012;13(4):1709–10. 11. ali k, sutaryo, purwanto i, mulatsih s, supriyadi e, widjajanto ph, et al. yogyakarta pediatric cancer registry: an international collaborative project of university gadjah mada, university of saskatchewan, and the saskatchewan cancer agency. asian pacific j cancer prev. 2010;11(1):131–6. 12. ervik m. a brief introduction to canreg5. lyon, france: international agency for research on cancer; 2012 [cited 2017 august 2]; available from: http:// g i c r. i a r c . f r / p u b l i c / d o c s / 2 0 1 2 0 3 2 9 canregwebinar1_slides.pdf 13. slone js, chunda-liyoka c, perez m, mutalima n, newton r, chintu c, et al. pediatric malignancies, treatment outcomes and abandonment of pediatric cancer treatment in zambia. plos one. 2016;9(2):89102. 14. javier garcía-pérez, gonzalolópez-abente, dianagómez-barroso, antonio moralespiga, elenapardoromaguera, ibontamayo, et al. childhood leukemia and residential proximity to industrial and urban sites. environt res. 2015;140(1):542–53. 15. ribeiro rc, antillon f, pedrosa f, pui c-h. global pediatric oncology: lessons from partnerships between high-income countries and lowto mid-income countries. j clin oncol. 2016;34(1):53–61. 16. friedrich p, lam cg, kaur g, itriago e, ribeiro rc, arora rs. determinants of treatment abandonment in childhood cancer: results from a global survey. plos one. 2016;11(10):1–5. althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 133 diagnostic value of narrow band imaging in diagnosing nasopharyngeal carcinoma debbi yuniserani,1 bethy s. hernowo,2 agung dinasti permana3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of otorhinolaryngology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: carcinoma is the most common tumor in nasopharynx. endoscopy is used to determine the presence of lesions suspected of malignancy. narrow band imaging is an endoscopic technique that uses narrow–band spectrum as a filter to determine any mucosal vascular changes in carcinoma. narrow band imaging can early detect superficial mucosal lesions that are difficult to detect with conventional endoscopy, so that diagnosing is more accurate and occurrence of unnecessary biopsies can be reduced. this study aimed to determine diagnostic value of narrow band imaging in diagnosing nasopharyngeal carcinoma. methods: this diagnostic test study was conducted at department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital, bandung from september to october 2014. twenty four patients with clinical signs and symptoms of nasopharyngeal carcinoma that fulfilled the study criteria were assigned using consecutive sampling to examine with narrow band imaging and histopathology examination. the data were then analyzed with 2x2 table to determine sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. results: in this study, the results of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in diagnosing nasopharyngeal carcinoma using narrow band imaging were 93.75%, 62.5%, 83.3%, 83.3%, and 83.3%, respectively. conclusions: sensitivity of narrow band imaging is 93.75%. [amj.2017;4(1):133–7] keywords: diagnostic test, narrow band imaging, nasopharyngeal carcinoma correspondence: debbi yuniserani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 83816734032 email: serra_debb@yahoo.com introduction carcinoma is type of tumor that is mostly discovered in nasopharynx. in indonesia, prevalence of nasopharyngeal carcinoma is about 6 cases per 100,000 with 12,000 new cases per year. nasopharyngeal carcinoma is one of five highest frequencies of malignancy in indonesia.1 it is often discovered in adult than children and the increasing starts at the age 30 with peak age between 40 and 60 years old.2,3 nasopharyngeal carcinoma is also more common in men than women with ratio 2–3:1.3 difficulty in diagnosing nasopharyngeal carcinoma from clinical symptom often happens because the location of nasopharynx and the symptom is not specific.4 definitive diagnosis that is used for nasopharyngeal carcinoma is biopsy-endoscope combination.5 endoscopy is usually used to detect any possible malignancy of lesion.5 however, conventional endoscopy has limitation in detecting superficial lesion that makes unnecessary biopsy often happen.6,7 narrow band imaging is an endoscope technique that uses narrow–band spectrum as a filter to increase the visualization of vascular pattern. narrow band imaging can detect superficial lesion, so that unnecessary biopsy can be reduced.7,8 although study about narrow band imaging is increased like in digestive system, it is not in head-neck region including nasopharynx.9 this study aimed to determine the diagnostic value of narrow band imaging in diagnosing nasopharyngeal carcinoma. methods this study was a diagnostic test study with histopathology as a gold standard. sampling althea medical journal. 2017;4(1) 134 amj march 2017 technique was a consecutive sampling method with sample size was 24 samples. this study was conducted from september 1 to october 31, 2014 at department of otorhinolaryngologyhead and neck surgery, dr. hasan sadikin general hospital, bandung and was approved by health research ethics committee. population of this study was patients with clinical signs and symptoms of nasopharyngeal carcinoma at department of otorhinolaryngology-head and neck surgery, dr. hasan sadikin general hospital, bandung. inclusion criteria were new cases of suspected nasopharyngeal carcinoma, while exclusion criteria were patients with 1) recurrent nasopharyngeal carcinoma, 2) history of radioteraphy, 3) history of hematologic diseases, and 4) history of biopsy in nasopharynx. after informed consent, the subjects were given nasal decongestion containing lidocaine 10%. then, they were examined with narrow band imaging through nose and mucosa of nasopharynx that were obsessed and assessed based on predetermined criteria. positive criteria of narrow band imaging are: 1) absence of the normal pattern of nasopharyngeal mucosa, 2) irregular vascular pattern with figure 1 nasopharyngeal carcinoma (+) a. brownish spot, b&c. irregular vascular pattern with brown spot a b c althea medical journal. 2017;4(1) 135debbi yuniserani, bethy s hernowo, agung dinasti permana: diagnostic value of narrow band imaging in diagnosing nasopharyngeal carcinoma brown, and/or 3) irregular follicle pattern with pale peripheral and central brownish. negative criteria of narrow band imaging are: 1) regular follicle pattern, 2) pale central and dark peripheral follicle pattern.10 biopsy procedures would be conducted and samples were examined histopathologically. data from both examinations that had been collected would be tabulated and converted into 2x2 tables to determine sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. results data characteristics including age group and sex can be seen in table 1 and table 2. the data were divided into two groups; carcinoma and non-carcinoma based on histopathological diagnosis. in carcinoma group, there were 1) non-keratinizing and undifferentiated nasopharyngeal carcinoma. meanwhile, in non-carcinoma group, there were lymphoma and inflammation of the nasopharynx. generally, the highest frequencies were from age group 41–50 years and 51–60 years, which consist of 7 subjects each, and the lowest frequencies were from the age group 61–70 years old and 81–90 years, which consist of 1 subject each. in carcinoma cases, the most common was revealed from age group 41–50 years, which consists of 7 subjects. from all cases, the sex characteristics were figure 2 nasopharyngeal carcinoma (–) a. regular follicle pattern, b. regular vascular pattern table 1 age group characteristics age group histopathology total carcinoma non-carcinoma <31 2 1 3 31–40 2 1 3 41–50 7 0 7 51–60 4 3 7 61–70 1 0 1 71–80 0 2 2 81–90 0 1 1 total 16 8 24 a b althea medical journal. 2017;4(1) 136 amj march 2017 higher in men (16 samples) than women (8 samples). in this study, the sensitivity was 93.75%, specificity was 62.5%, positive predictive value was 83.3%, negative predictive value was 83.3%, and accuracy was 83.3%. discussion from 16 nasopharyngeal carcinoma patients, most of subjects were from age group 41–50 years old consisting of male patients (10 samples) which was higher than female patients (6 samples). these data are similar to literatures that mention the age peak–of nasopharyngeal carcinoma at the age 40–60 years and more common happen in men than women.2,3 nasopharyngeal carcinoma is more common in men, which is caused by prolonged exposure to risk factor like smoking which can increase the disease.11,12 in this study, the sensitivity was 93.75%, specificity was 62.5%, positive predictive value was 83.3%, negative predictive value was 83.3%, and accuracy was 83.3%. the sensitivity result showed that ability of narrow band imaging to detect patients with nasopharyngeal carcinoma is about 93.75%. this result is similar to wang’s13 study that the result is about 97.1% and wen’s14 study that the result is about 93.9%. specificity result showed that ability of narrow band imaging to eliminate patients with non-nasopharyngeal carcinoma is about 62.5%. compared to previous studies (wang13 is 93.33% and wen14 is 94.1%), the specificity from this study is lower. thus, it might be due to inability of narrow band imaging to differ types of malignancy (like lymphoma and carcinoma) or total of sample is less compared to previous studies. positive predictive value result showed that the probability of subjects with positive narrow band imaging will actually have nasopharyngeal carcinoma by 83.3%. negative predictive value result showed that the probability of subjects with negative narrow band imaging will actually not have nasopharyngeal carcinoma by 83.3%. both values are also similar to previous studies.13,14 accuracy result showed that the accuracy of narrow band imaging in the diagnosing of nasopharyngeal carcinoma is 83.3% . based on this study, it can be concluded that the sensitivity of narrow band imaging is 93.75%. limitation of this study was the samples used in this study were too small that affect narrow band imaging value. in addition, subjects in this study were mostly at late stage. it is recommended for further study to discuss about narrow band imaging in wider population. references 1. adham m, kurniawan an, muhtadi ai, roezin a, hermani b, gondhowiardjo s, et al. nasopharyngeal carcinoma in indonesia: epidemiology, incidence, signs, and symptoms at presentation. chin j cancer. 2012;31(4):185–96. 2. thompson lr. update on nasopharyngeal carcinoma. head neck pathol. table 2 sex characteristics sex histopathology total carcinoma non-carcinoma man 10 6 16 woman 6 2 8 total 16 8 24 table 3 diagnostic values narrow band imaging histopathology total positive negative positive 15(a) 3(b) 18 negative 1(c) 5(d) 6 total 16 8 24 althea medical journal. 2017;4(1) 137 2007;1(1):81–6. 3. barnes l, eveson jw, reicchart p, sidransky d, editors. world health organization classification of tumours: pathology and genetics of head and neck tumours: lyon: iarc press;2005. 4. cengiz k, kumral tl, yildirim g. diagnosis of pediatric nasopharynx carcinoma after recurrent adenoidectomy. case rep otolaryngol. 2013;2013:653963. 5. chan at, gregoire v, lefebvre jl, licitra l, hui ep, leung sf, et al. nasopharyngeal cancer: ehns–esmo–estro clinical practice guidelines for diagnosis, treatment and follow–up. ann oncol. 2012;23 suppl 7:vii 83–5. 6. tabuchi k, nakayama m, nishimura b, hayashi k, hara a. early detection of nasopharyngeal carcinoma. int j otolaryngol. 2011;2011:638058. 7. piazza c, del bon f, nicolai p. narrow band imaging in endoscopic evaluation of head and neck mucosal cancer. j ent masterclass.2012; 5(1):59–64. 8. lukes p, zabrodsky m, plzak j, chovanec m, betka j, foltynova e, et al. narrow band imaging–endoscopic method for detection of head and neck cancer. in: amornyotin a, editor. endoscopy. intech; 2013. available from: https://www.intechopen.com/ books/endoscopy/narrow-band-imagingnbi-endoscopic-method-for-detection-ofhead-and-neck-cancer 9. piazza c, dessouky o, peretti g, cocco d, de benedetto l, nicolai p. narrow band imaging: a new tool for evaluation of head and neck squamous cell carcinomas. acta otorhinolaryngol ital. 2008;28(2):49–54. 10. thong jf, ranjini ks, loke d, mok pkh. use of narrow–band imaging in detection of nasopharyngeal carcinoma. j laryngol otol. 2013;127(2):163–9. 11. kumar s. epidemiological and etiological factors associated with nasopharyngeal carcinoma. icmr bull. 2003;33(9):1–9. 12. nesic v, sipetic s, vlajinac h, stosic–divjak s, jesic s. risk factors for the occurrence of undifferentiated carcinoma of nasopharyngeal type: a case–control study. srp arh celok lek. 2010;138(1–2):6–10. 13. wang wh, lin yc, lee kf, weng hh. nasopharyngeal carcinoma detected by narrow–band imaging endoscopy. oral oncol. 2011;47(8): 736–41. 14. wen yh, zhu xl, lei wb, zeng yh, sun yq, wen wp. narrow–band imaging: a novel screening tool for early nasopharyngeal carcinoma. arch otolaryngol head neck surg. 2012;138(2):183–8. debbi yuniserani, bethy s hernowo, agung dinasti permana: diagnostic value of narrow band imaging in diagnosing nasopharyngeal carcinoma vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 47 complications of fracture treatment by traditional bonesetters in west java, indonesia putri liana warman,1 yoyos dias ismiarto,2 undang ruhimat3 1faculty of medicine universitas padjadjaran, 2department of orthopaedi and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of radiology faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia abstract background: traditional medicine practices are still occurring especially in developing countries such as indonesia. one of the traditional practitioners is the traditional bonesetter (tbs). due to lack of knowledge of human anatomy, physiology, infection prevention and control, the practices of the tbs has a risk to increase the complications in fractured patients. the objectives of this study was to identify the complications of fractured patients treated by the tbs who were admitted to dr. hasan sadikin general hospital in west java, indonesia methods: this descriptive study involved 86 medical records of fractured patients admitted to the hospital, from january to december 2014. the collected data were gender, age, admission time after occurrence of the fracture, site of the fracture and early or delayed complications. moreover, those data were analyzed and presented using frequency tabulation. results: out of 86 patients; 61 (70.93%) were males; 16 (18.60%) were 21–30 years old; 25 (29.07%) had fractures 1–3 months before admitted to the hospital; 83 (96.51%) had closed fractures. there were 86 patients with 109 fractures location; 66 (76.74%) had fractures in one location; 41 (37.61%) had femoral fractures. half of the patients had malunion. conclusions: the most complication is malunion. keywords: fracture, malunion, traditional bonesetter correspondence: putri liana warman, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: putrilianawarman@gmail.com introduction a fracture is the structural discontinuity of a bone.1 the treatment of fractures is carried out by the orthopaedic practitioners by reduction and immobilization.2 nevertheless, people in developing countries are still looking for traditional healers to solve their health problems including fractures. these traditional healers are called traditional bonesetters (tbs) or dukun patah tulang.3,4 there are many factors that cause people choose the tbs instead of doctors, among others, suggested by friends or close relatives, perception of the society that bonesetters are better than doctors in treating fractures, cost of treatment, accessibility, cultural beliefs and fear of surgery.5,6 most of the fractured patients with a history of tbs treatment were admitted to the health care units with complications. the results of tbs practice are often poor, in fact it can cause disability in patients.7 this happens because the tbs does not have the knowledge of human anatomy, physiology, radiology, and also infection prevention and control.6 most of the fractures treated by tbs occurred in upper and lower extremities.8 the long-term effects that occur as the result of complications greatly affects the quality of life due to disability especially when it occurs in the lower extremities.7 therefore, the objectives of this study was to identify the complications of fracture treatment by tbs admitted to dr. hasan sadikin general hospital, west java, indonesia. amj. 2018;5(1):47–52 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1336 althea medical journal. 2018;5(1) 48 amj march 2018 methods a quantitative decriptive study was carried out using medical records of fractured patients admitted to dr hasan sadikin general hospital from january to december 2014. the total medical records collected were 307 and 180 medical records from the outpatient and inpatient departments respectively. from those medical records, only 86 medical records met the inclusion criteria. patients with additional treatment history after the patients came to tbs were excluded. patients data, such as gender, age, date of fracture, date of admission, site of fracture, and complications occured were taken from medical records. the type of complications was divided into early and delayed complications. the collected data were analyzed using computer and presented by frequency tabulation. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital bandung number lb.04.01/a05/ec/260/vii/2015. results this study discoverd that out of 86, 63 patients (73.26%) were males. patients had the variative range of age from 1 to 79 years. the majority of patients fell within the age range 21-30 years (18.60%). each patient had different chronicity which were seen from the length of time, from the date of fractures to the admission time. most of the patients were admitted to the hospital in 1-3 months (29.07%) after the fractures occurred. in this study, there were 86 fractured patients with 109 locations of fracture. most of the patients had closed fractures (96.51%) and had fractures in one location (76.74%), and seventy one (37.61%) of fractures were femoral fractures (table 1). regarding complications, most of the patients had only one complication, and delayed complications with malunion as the most common complication. (table 2). early complications were neurologic impairment, compartment syndrome, gangrene, soft tissue injury, wound infection, and sepsis. delayed complications were avascular necrosis, chronic osteomyelitis, malunion, nonunion, joint stiffness, delayed union, secondary osteoarthritis, muscle atrophy, and volksmann contracture. discussions this study discovered that most of the fractured patients treated by the tbs were predominantly male. this result correlated with previous studies, which stated that the majority of fractured patients were male.7,9 regarding age, the majority of patients were in their productive age. these findings were similar to a study in nigeria by onymaechiet et al.8 who described the average age was 36.8 years and by dada et al.10 with the average age 29.49 years. in this study the male and productive age being preponderance correlated with the higher mobilization of males during the productive age which figure total medical records that met the inclusion criteria althea medical journal. 2018;5(1) 49putri liana warman, yoyos dias ismiarto, undang ruhimat: complications of fracture treatment by traditional bonesetters in west java, indonesia table 1 characteristics of patients characteristics frequency (n=86) percentage (%) sex female 23 26.74 male 63 73.26 age 86 100.00 <10 years 10 11.60 11–20 years 15 17.40 21–30 years 16 18.60 31–40 years 14 16.30 41–50 years 12 14.00 51–60 years 13 15.10 61–70 years 4 4.70 71–80 years 2 2.30 admission time < 1 week 7 8.14 1 week–< 1 month 10 11.63 1–3 months 25 29.07 4–6 months 15 17.44 7–9 months 7 8.14 10–12 months 8 9.30 > 12 months 14 16.28 type of fracture closed 83 96.51 open 3 3.49 number locations of fracture 1 site 66 76.74 2 sites 17 19.77 3 sites 3 3.49 site of fracture n=109 upper extremities humerus 9 8.26 radius 10 9.17 ulna 3 2.75 hand 3 2.75 lower exstremities femur 41 37.61 tibia 21 19.27 fibula 16 14.68 foot 6 5.50 althea medical journal. 2018;5(1) 50 amj march 2018 can make the higher risk of fractures, as the most common etiology of fracture is traffic accident.4,7,9 closed fractures are the type of fractures mostly treated by the tbs.10 this situation was also discovered in this study. this phenomenon occurred because most of the tbs refused to treat patients with open table 2 distribution of fracture complications due to bonesetter treatment characteristics outpatients (orthopaedic and traumatology clinics) inpatient from emergency unit from clinics frequency (n) percentage (%) frequency (n) frequency (n) number of complication n=61 n=6 n=19 1 complication 34 55.74 4 14 2 complications 14 22.95 2 2 > 2 complications 1 1.64 0 1 no complication 12 16.67 0 2 type of complication n=64 n=8 n=21 early complication 5 7.81 3 4 delayed complication 59 92.19 5 17 complication n=64 n=8 n=21 wound infection 0 0 1 1 compartment syndrome 0 0 1 1 neurologic impairment 5 7.81 0 0 gangrene 0 0 1 1 sepsis 0 0 0 1 joint stiffness 6 9.38 1 1 avascular necrosis 1 1.56 0 1 chronic osteomyelitis 1 1.56 0 1 soft tissue injury 1 1.56 0 1 mal–union(shortening. angulation, and rotation) 35 54.69 3 10 delayed union 1 1.56 0 0 non-union 12 18.75 0 2 secondary osteoarthritis 1 1.56 0 1 muscle atrophy 1 1.56 0 0 volksmann contracture 0 0 1 0 althea medical journal. 2018;5(1) 51 fractures and preferred to refer those patients to the hospitals.3 this study discovered that the most frequent complication was malunion, followed by nonunion. similar studies conducted in nigeria and at dr. abdoer rahem hospital, east java gave the same results.7,10 in europe11 and many developed countries that suppressed traditional medicine practices, the most complication occurred in fractured patients treated by doctors was post-surgical infection.1 those complications after the tbs treatment occurred due to the method used in managing fractures. the methods used by the tbs are massage, splinting, and traction of the fracture area. these methods can cause a shift in the area of the fractures.10,12,13 splinting performed by the tbs, using bamboo or palm branches is often too tight, so it can cause gangrene.10,14 in this study, 2 patients had gangrene. gangrene is the most severe complication and can lead to death.8,10 furthermore, femoral fractures were the most common site of fracture, which differs from the previous study, as tibial fractures had the greatest number.8 the location of femur is deeper than tibia because the femur is covered by thick muscles and fat tissues. it can cause the massage and splinting conducted by the tbs may not be an effective treatment for femoral fractures. moreover, this causes a greater risk of complications in femoral fractures compared to other sites of the extremities. this study has some limitations. the process of fracture healing includes many factors among others age, previous medical history, and nutrition. in this study those factors were not considered, so the complications occurred merely because of mismanagement by the tbs. it can be concluded that the most common complication is malunion early complications are neurologic impairment, compartment syndrome, gangrene, soft tissue injury, wound infection, and sepsis. delayed complications are avascular necrosis, chronic osteomyelitis, malunion, nonunion, joint stiffness, delayed union, secondary osteoarthritis, muscle atrophy, and volksmann contracture references 1. nayagam s, salomon, louis., warwick, david. apley`s system of orthopaedics and fractures. 9th ed. london: hodder arnold; 2010. 2. adi mahartha gr, maliawan s, kawiyana ks. management of fracture of musculosceletal trauma. e-journal medika udayana. 2013;2(3):548–60. 3. nwachukwu bu, okwesili ic, harris mb, katz jn. traditional bonesetters and contemporary orthopaedic fracture care in a developing nation: historical aspects, contemporary status and future directions. open orthop j. 2011;5(1):20–5. 4. sari ap, priambodo a, pramono d. faktor-faktor yang berhubungan dengan keterlambatan berobat pada pasien patah tulang yang menggunakan sistem pembiayaan jamkesmas (studi kasus di rsup dr. kariadi semarang tahun 2012). medico. 2012;1(1):1–13. 5. ekere a, echem r. patronage of traditional bone setters for musculoskeletal conditions: a one-year study. port harcourt med j. 2012;6(2):215–24. 6. onyemaechi no, lasebikan oa, elachi ic, popoola so, oluwadiya ks. patronage of traditional bonesetters in makurdi, northcentral nigeria. patient pref adherence. 2015;9(1):275–9. 7. wahyudiputra ag, khoirur hd, hakim ra, narendra mr. spektrum penderita neglected fracture di rsud dr. abdoer rahem–januari 2012 s/d desember 2013. cdk. 2015;42(2):97–100. 8. onyemaechi noc. complications of musculoskeletal injuries treated by traditional bonesetters in a developing country. indian j appl res. 2014;4(3):313– 6. 9. owumi b, taiwo pa, olorunnisola a. utilization of traditional bone-setters in the treatment of bone fracture in ibadan north local government. int j humanities soc science invention. 2013;2(5):47–57. 10. dada a, giwa s, yinusa w, ugbeye m, gbadegesin s. complications of treatment of musculoskeletal injuries by bone setters. west afr j med. 2009;28(1):333–7. 11. selin h. encyclopaedia of the history of science, technology, and medicine in nonwestern cultures. 2nd ed. massachusetts: springer science & business media; 2013. 12. eze kc. complications and co-morbidities in radiographs of patients in traditional bone setters’ homes in ogwa, edo state, nigeria: a community-based study. eur j radiol. 2012;81(9):2323–8. 13. chowdhury m, khandker h, ahsan k, mostafa d. complications of fracture putri liana warman, yoyos dias ismiarto, undang ruhimat: complications of fracture treatment by traditional bonesetters in west java, indonesia althea medical journal. 2018;5(1) 52 amj march 2018 treatment by traditional bone setters at dinajpur. dinajpur med col j. 2011;4(1):15–9. 14. panda ak, rout s. puttur kattu (bandage)–a traditional bone setting practice in south india. j ayurveda integr med. 2011;2(4):174–8. vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 136 amj september 2019 biofilm formation in reverse osmosis water at hemodialysis units in two hospitals bandung aswin yeoh kit shawn,1 sunarjati sudigdoadi,2 diah dhianawaty2 1faculty of medicine universitas padjadjaran bandung, indonesia, 2departement of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: aswin yeoh kit shawn, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia email: aswinyeoh@hotmail.com introduction reverse osmosis (ro) membranes and all pipes in the water treatment and inlet lines to the dialysis machine must be periodically disinfected to prevent the development of biofilms.1 bacteria in natural aquatic environments do not usually live as a single free-swimming microscopic cell, but rather as communities of microorganisms that are attached to a surface known as biofilm.2 once these biofilms are formed, they are resistant to disinfectant.3 due to ineffectiveness of the disinfectant to remove the biofilm, the colonies of bacteria continue to proliferate and release endotoxins and bacterial fragments into the water. formation of biofilm enables the bacteria to survive the harsh environment, the host immune system, antimicrobial therapy and disinfectant.3-5 pseudomonas sp., acinetobacter sp. and serratia sp. are among the known biofilm formers.4,6,7 continuous prolonged exposure to endotoxin will cause chronic inflammation in the hemodialysis patient. chronic inflammation has been known to cause protein wasting, increased insulin resistance and promote atherosclerosis.8 due to the implication of preserved biofilms in the hemodialysis unit, this study aimed to determine which genus or species of bacteria in ro water was able to form a biofilm. methods this study was performed using a descriptive laboratory study design where ro water samples were taken from two hospitals in bandung and transported in the icebox to maintain the temperature to the microbiology amj. 2019;6(3):136–9 abstract background: bacteria in aquatic environments do not usually live as a single free-swimming microscopic cell, but rather as communities of microorganisms that are attached to a surface in the form of biofilm. biofilm is a major cause of concern to the medical world, as it protects the bacteria from a harsh environment, the host immune system, antimicrobial therapy, and even disinfectant. the aim of this study was to determine which genus or species of bacteria in reverse osmosis (ro) water was able to form a biofilm. methods: water samples were taken from ro water of water treatment in hemodialysis (hd) centers at two hospitals in bandung; at each point of the water treatment plant, bacteria were cultured. any growth of bacteria was tested with a tube method to determine the formation of biofilm. results: micrococcus luteus, citrobacter diversus, enterobacter aerogenes, pseudomonas sp., serratia sp., acinetobacter sp. were able to form biofilm while klebsiella pneumoniae and staphylococcus saprophyticus were not. conclusions: most bacteria isolated from ro water can form a biofilm, and a few are not. this study is successfully to check the possibility of biofilm formation of ro water, therefore, disinfecting ro water regularly is important and highly encouraged. keywords: bacteria, biofilm formation, hemodialysis, reverse osmosis althea medical journal. 2019;6(3) 137 laboratory in the faculty of medicine universitas padjadjaran. the water samples were then processed immediately to ensure the viability of the bacteria. the identification of the bacteria genus found in ro water was examined in a separate experiment. the experiment was conducted from september to november 2014. after the identification of the genus of bacteria, the bacteria were assessed for biofilm formation. the method to detect the formation of biofilm by the bacteria was conducted by tube method as described elsewhere.9 the tube method was a qualitative method with the usage of simple equipment to assess biofilm formation by adhesion of biofilm to the wall of the tube.9,10 the media used was trypticase soy broth (tsb) containing 1% glucose and the reagents were consisting of deionized water or distilled water, phosphate-buffered saline at ph 7.3, 0.1% crystal violet with identified bacterial genus from ro water. in brief, the volume of 10ml tsb was poured into test tubes and autoclaved for sterilization. a loopful of desired bacteria was transferred to the prepared tsb using an aseptic technique. the test tubes were incubated for 18 to 24 hours at 37°c in an incubator. the tubes were decanted and washed three times with phosphate-buffered saline (ph 7.3) to remove planktonic cells. the tubes were then air dried up to 10 minutes. next, the tubes were stained with 0.1% crystal violet and left for 30 minutes at room temperature. the tubes were then washed two times with deionized water or distilled water to remove the excess stain. the tubes were inverted and allowed to air dry. the formation of a ring at the liquid interface was not considered a positive result. a positive result for biofilm formation was observed when a visible film stained by crystal violet lines the wall and the bottom of the tube. this experiment was repeated 3 times to ensure valid results. three sets of tubes containing tsb inoculated respectively with figure 1 positive control tubes aswin yeoh kit shawn et al.: biofilm formation in reverse osmosis water at hemodialysis units in two hospitals bandung note: tube 1 staphylococcus aureus atcc 25923; tube 2 -klebsiella pneumoniae atcc 700603; tube 3 pseudomonas aeruginosa atcc 27853. tube 4 as a negative control. the red arrow as the indicator of an example of biofilm formation. althea medical journal. 2019;6(3) 138 amj september 2019 staphylococcus aureus atcc 25923, klebsiella pneumoniae atcc 700603 and pseudomonas aeruginosa atcc 27853 were used as positive controls for biofilm formation and a tube containing tsb without any inoculation was used as the negative control (figure 1). results our study showed that various genus or species of bacteria could form biofilm as shown in table 1. micrococcus luteus, citrobacter diversus, enterobacter aerogenes, pseudomonas sp., serratia sp., acinetobacter sp. were able to form biofilm; while klebsiella pneumoniae and staphylococcus saprophyticus were not. discussion our study result has shown that the majority of the bacteria isolated from ro water are able to form a biofilm, similar to various studies.6,7,12-17 enterobacter aerogenes have been known to have biofilm formation of regulatory protein bssr which might contribute to the formation of biofilm.18 the exceptions are klebsiella pneumoniae (k. pneumoniae) and staphylococcus saprophyticus (s. saprophyticus) that cannot form biofilm in our study, that is also confirmed in other studies.19,20 biofilm formation needs close attention in hemodialysis units. biofilm can protect bacteria from disinfectant,3 and biofilm thus can decrease the effectiveness of the disinfectant. therefore, the colonies of bacteria can continue to proliferate and can release endotoxins or bacterial fragments into the water. continuous prolonged exposure to endotoxin or bacterial fragments have been known to cause protein wasting, increased insulin resistance and promote atherosclerosis in hemodialysis patients.8 as this study requires the observation of crystal violet colour as an indicator for biofilm formation, this test tube test can be easily performed in simple laboratories. this research is limited by human eyesight and hence, the result is subjective. also, to confirm that there is biofilm former, this research should be tested against other methods for assessing biofilm formation such as tissue culture plate. more advanced research is needed to further identify the types of bacteria with the ability to form biofilm in ro water. effective disinfectant can be deployed before any formation of biofilm occurred. to identifying the types of bacteria, different types of disinfectants should be explored for the effective elimination of biofilm. to conclude, the majority of bacteria isolated from ro water are able to form a biofilm, for examples micrococcus luteus, citrobacter diversus, enterobacter aerogenes, table 1 genus or species of bacteria with the ability to form biofilm from ro water in two hospitals in bandung bacteria genus/species number of isolates number of isolates able to form biofilm micrococcus luteus 10 10 pseudomonas sp. 6 6 acinetobacter sp. 5 5 bacillus sp. 5 5 serratia sp. 3 3 yersinia pseudotuberculosis 3 3 enterobacter aerogenes 2 2 citrobacter diversus 2 2 klebsiella pneumoniae 2 moraxella sp. 1 1 staphylococcus epidermidis 1 1 staphylococcus saprophyticus 1 total 41 38 althea medical journal. 2019;6(3) 139aswin yeoh kit shawn et al.: biofilm formation in reverse osmosis water at hemodialysis units in two hospitals bandung pseudomonas sp., serratia sp., acinetobacter sp., and only a few of bacteria which are not able to form a biofilm, such as klebsiella pneumoniae and staphylococcus saprophyticus. this study has shown that it is important to disinfect ro water regularly. further studies are needed to identify potential agents able to destroy biofilms. references 1. glorieux g, neirynck n, veys n, vanholder r. dialysis water and fluid purity: more than endotoxin. nephrol dial transplant. 2012;27(11):4010–21. 2. petri wa jr., mann bj, huston cd. microbial adherence. in: mandell gl, bennett je, dolin r, editors. mandell, douglas, and bennett’s principles and practice of infectious diseases. 7th ed. philadelphia: churchill livingstone elsevier; 2010. p. 22. 3. bridier a, briandet r, thomas v, duboisbrissonnet f. resistance of bacterial biofilms to disinfectants: a review. biofouling. 2011;27(9):1017–32. 4. espinal p, martí s, vila j. effect of biofilm formation on the survival of acinetobacter baumannii on dry surfaces. j hosp infect. 2012;80(1):56–60. 5. flemming hc, wingender j. the biofilm matrix. nat rev microbiol. 2010;8(9):623– 33. 6. de kievit tr. quorum sensing in pseudomonas aeruginosa biofilms. environ microbiol. 2009;11(2):279–88. 7. morohoshi t, shiono t, takidouchi k, kato m, kato n, kato j, et al. inhibition of quorum sensing in serratia marcescens as-1 by synthetic analogs of n-acylhomoserine lactone. appl environ microbiol. 2007;73(20):6339–44. 8. carrero jj, avesani cm, mahmut iy, bengt l, stenvinkel p. low-grade persistent inflammation and immune dysfunction in uremia. in: henrich wl, editor. principles and practice of dialysis. 4th ed. philadelphia: wolters kluwer health/ lippincott williams & wilkins; 2009. p. 385. 9. hirshfield in, barua s, basu p. overview of biofilms and some key methods for their study. in: goldman e, green lh, editors. practical handbook of microbiology. 2nd ed. florida: taylor & francis; 2008. p. 679. 10. oliveira a, cunha mdl. comparison of methods for the detection of biofilm production in coagulasenegative staphylococci. bmc res notes. 2010;3(1):260. 11. ira p, sujatha s, chandra ps. virulence factors in clinical and commensal isolates of enterococcus species. indian j pathol microbiol. 2013;56(1):24–30. 12. newman ja, rodrigues c, lewis rj. molecular basis of the activity of sinr, the master regulator of biofilm formation in bacillus subtilis. j biol chem. 2013;288(15):10766–78. 13. matsuura k, asano y, yamada a, naruse k. detection of micrococcus luteus biofilm formation in microfluidic environments by ph measurement using an ion-sensitive field-effect transistor. sensors (basel). 2013;13(2):2484–93. 14. bai x, wu f, zhou b, zhi x. biofilm bacterial communities and abundance in a full-scale drinking water distribution system in shanghai. j water health. 2010;8(3):593– 600. 15. prieto c, serra do, martina p, jacobs m, bosch a, yantorno om. evaluation of biofilm-forming capacity of moraxella bovis, the primary causative agent of infectious bovine keratoconjunctivitis. vet microbiol. 2013;166(3–4):504–15. 16. fey pd, olson me. current concepts in biofilm formation of staphylococcus epidermidis. future microbiol. 2010;5(6):917–33. 17. sun yc, koumoutsi a, darby c. the response regulator phop negatively regulates yersinia pseudotuberculosis and yersinia pestis biofilms. fems microbiol lett. 2009;290(1):85–90. 18. national center for biotechnology information. biofilm formation regulatory protein bssr [enterobacter aerogenes kctc 2190]. maryland: national center for biotechnology information, u.s. national library of medicine; 2014. [cited 2014 november 22] available from: http:// www.ncbi.nlm.nih.gov/gene/10793176. 19. maldonado nc, de ruiz cs, cecilia m, nader-macias me. a simple technique to detect klebsiella biofilm-forming-strains. inhibitory potential of lactobacillus fermentum crl 1058 whole cells and products. commun curr res educ top trends appl microbiol. 2007;1:52–9. 20. gundogan n, ataol o. biofilm, protease and lipase properties and antibiotic resistance profiles of staphylococci isolated from various foods. afr j microbiol res. 2013;7(28):3582–8. 217 althea medical journal. 2017;4(2) blood glucose level and hba1c in pediatric patients with diabetes mellitus type 1 anisha sefina priatna,1 r.m.ryadi fadil,2 nugroho harry susanto3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: diabetes mellitus (dm) is a common disease found all over the world, including indonesia. the dm often found in pediatric patients is dm type 1. the dm patients with uncontrolled blood glucose will likely suffer multiple organ damage, most notably to the kidneys, eyes, heart, and nerves. to help monitor blood glucose levels, lab checkups such as fasting blood glucose, 2 hours postprandial, and hemoglobin a1c (hba1c) levels are done. the aim of this study was to determine the profile of blood glucose and hba1c in pediatric patients with dm type 1. methods: the study was held in august to october 2014, using descriptive method and cross sectional design. data were obtained from 28 medical records of dm type 1 patients in the department of child health at dr. hasan sadikin general hospital. the variables of this study were blood glucose level and hba1 in three consecutive examinations. the collected data was presented in tables. results: the patients were 19 female and 9 male, most of the patients aged between 11–15 years old. data reported that on first, second, and third examination, most subjects had both fasting blood glucose and 2 hours postprandial blood glucose levels over 180 mg/dl. on first and second hba1c checkup, most subjects had values over 10%, and on third checkup had results ranging from 8 to 9.9%. conclusions: most patients are girls and aged between 11–15 years old. the most have uncontrolled blood glucoselevel and hba1c levels. keywords: blood glucose levels, hba1c, diabetes mellitus type 1 correspondence: anisha sefina priatna, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8121455786 email: anisha_sefina@yahoo.com introduction diabetes mellitus (dm) is a common disease found all over the world. currently, approximately 2.8% of the world’s population has dm, and study estimated, it will reach 4.4% by 2030,1 including dm type 1 patients. according to the basic health reserach (riset kesehatan dasar/riskesdas), in indonesia there was an increase of dm patients from 1.1% by 2007 to 2.1% by 2013. the dm that develops in children is dm type 1. the dm type 1 is caused by an autoimmune process, resulting in destruction of pancreatic beta cells and thus, the decrease of insulin production. this abnormality in pancreas is usually permanent. dm type 1 commonly develops in children aged 7–15 years old, although it can occur at all ages.2 most parents are unaware that their children suffers dm type 1, mainly due to lack of knowledge about dm type 1.3 the typical clinical presentation of dm type 1 is polyuria, polydipsia, polyphagia and progressive loss of body weight despite adequate if not excessive eating. mostly, dm type 1 patients are diagnosed after suffering complications such as diabetic ketoacidosis (dka).4 dm patients with uncontrolled blood glucose levels will suffer in various organ–kidneys, eyes, heart and neurologic– dysfunctions.5 the hyperglycemic state cause functional alterations and target of organ damage. fasting blood glucose (fbg), 2 hours post prandial (2hpp) blood glucose, and hemoglobin a1c (hba1c) are laboratory parameter to monitor the blood glucose levels. blood glucose and hba1c monitoring amj.2017;4(2):217–20 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1074 althea medical journal. 2017;4(2) 218 amj june 2017 are essential in preventing complications especially dka. hba1c measurement provides the overview of average blood glucose levels within eight to twelve weeks duration.7 some advantages of hba1c test are; that it can be done anytime and it does not need any specific preparation such as fasting. hba1c and blood glucose measurement results are used to diagnose dm. diagnosis of dm when hba1c levels ≥6.5%. internal committee and american diabetes association in 2010 recommended that hba1c measurement, can be used for screening in individuals with high risk for diabetes.8 the aim of this study was to determine the profile of blood glucose level and hba1c in dm type 1 pediatric patients. methods this descriptive study was carried out using medical records of dm type 1 patients in dr. hasan sadikin general hospital. all subjects that fulfilled the inclusion criteria, that was having the hba1c measurements in three consecutive from august to october 2014. this study had been approved by the health research ethics committee dr. hasan sadikin general hospital bandung. from 42 subjects, 14 subjects did not meet the inclusion criteria, and the other 28 subjects that fulfilled the inclusion criteria were studied further. data that was used as variables were characteristics (age, gender), fasting blood glucose measurement, 2 hours post prandial blood glucose (2hppbg) measurement, and hba1c measurement. the collected data were presented in tables. from 20 subjects, in the first measurement, 13 subjects had blood glucose levels over 180 mg/dl. in the second measurement, majority of the subjects were still inside the over 180 mg/dl category, even though there were 3 subjects decrease. note that in the second measurement, 1 subject had no result. in the third measurement, 9 subjects were in the over 180 mg/dl category, which showed 1 subject decrease compared to the second measurement. however, the number of subjects were the same (9 subjects) in the less than 180 mg/dl category, and there were two subjects without results. from 28 subjects, in the first measurement, the majority of subjects had hba1c levels above 10%, which categorized them in poor metabolic control. in the second measurement, most subjects were still in the poor metabolic control category, with 1 subject decrease. in the third measurement, there was a large decrease table 1 subject characteristics patient profile n gender male 9 female 19 age < 5 years old 3 6–10 years old 7 11–15 years old 14 > 15 years old 4 in the poor metabolic control category, as much as 6 subjects, making most subjects in this measurement, as much as 13 subjects, categorized in moderate metabolic control. results this study discovered that from 28 patients, most of them were female and between 11 to 15 years old (table 1). from 20 subjects, in the first measurement, most subjects (14 subjects), had fasting blood glucose levels over 180 mg/dl. in the second measurement, most subjects still had fasting blood glucose levels over 180 mg/dl, but it were 3 subjects less. in the third measurement, majority of the subjects still had fbg levels over 180 mg/dl, and there were 2 subjects increase compared to the second measurement. from 20 subjects, in the first measurement, 13 subjects had blood glucose levels over 180 mg/dl. in the second measurement, majority of the subjects were still inside the over 180 mg/dl category, even though there were 3 subjects decrease. note that in the second measurement, 1 subject had no result. in the third measurement, 9 subjects were in the over 180 mg/dl category, which showed 1 subject decrease compared to the second measurement. however, the number of subjects were the same (9 subjects) in the less than 180 mg/dl category, and there were two subjects without results. from 28 subjects, in the first measurement, the majority of subjects had hba1c levels above 10%, which categorized them in poor metabolic control. in the second measurement, most subjects were still in the poor metabolic control category, with 1 subject decrease. in the third measurement, there was a large decrease in the poor metabolic control category, as 219 althea medical journal. 2017;4(2) anisha sefina priatna, r.m.ryadi fadil, nugroho harry susanto: blood glucose level and hba1c in pediatric patients with diabetes mellitus type 1 much as 6 subjects, making most subjects in this measurement, as much as 13 subjects, categorized in moderate metabolic control. discussions in this study, most dm type 1 subjects were girls, and most dm type 1 subjects were aged between 11–15 years old. this was concordant to the general subjects characteristics in the study conducted by maahs et al.9 this results were also well-suited to the theory mentioning the onset of dm type 1 increase in puberty and more common in girls. this was due to the involvement of estrogen, or genes regulated by estrogen, such as interleukin-6. the increasing number of cases in puberty were parallel to the increasing number of exposure to infectious agents in the beginning of school days, and also the increasing hormonal activity in puberty, which worked antagonist to insulin.2 for the fasting and 2 hours post prandial blood glucose levels, which could be seen in table 2 and table 3, there were decreasing trend in the first, second, and third measurements. this meant that subjects had satisfactory control of their blood glucose levels. the hba1c measurement, which could be seen in table 4, showed that there were also a decreasing trend in the first, second, and third measurements. a maintained hba1c levels showed the subjects’ had a satisfactory metabolic control of their disease, and therefore will hopefully also decrease, delay, or table 2 fasting blood glucose levels fasting blood glucose 1st measurement 2nd measurement 3rd measurement n n n <126 mg/dl 5 6 6 126–140 mg/dl 0 0 0 140–180 mg/dl 1 2 1 >180 mg/dl 14 11 13 total 20 20 20 table 3 two hours post prandial blood glucose levels 2hppbg* 1st measurement 2nd measurement 3rd measurement n n n <180 mg/dl 7 9 9 >=180 mg/dl 13 10 9 no results 0 1 2 total 20 20 20 note: *2 hours post prandial blood glucose levels table 4 hba1c levels hba1c* 1st measurement 2nd measurement 3rd measurement n n n <6 % 2 2 1 6–7.9% 7 6 7 8–9.9% 5 7 13 >=10% 14 13 7 total 28 28 28 note: *hemoglobin a1c althea medical journal. 2017;4(2) 220 amj june 2017 even avoid microvascular complications such as retinopathy and nephropathy.2 a continuous blood glucose monitoring could benefit in controlling blood glucose and hba1c levels in dm type 1 patients.10 this monitoring, most importantly and fundamentally, is needed to be done by the subjects and their families. the components that need to be monitored are insulin dose, subjects’ physical activity, and subjects’ diet.2 if there were any discrepancies between the subject’s blood glucose and hba1c levels, the cause should be searched and determined. some causes include patients’ compliance in insulin injection, the manner of insulin injection itself, and subjects’ diet program. there were limitations that might interfere with the results of this study. firstly, the study was done in a very short period of time, making the number of subjects retrieved very limited and maybe not ideal. secondly, errors due to incomplete data and mistakes in data writing made it more difficult analyzing and processing the data. conclusions of this study are most subjects were girls and aged between 11–15 years old. most subjects with uncontrolled blood glucose and hba1c levels decreased in every following measurement. however, most subjects were still in the above normal category. this showed that blood glucose and hba1c control in most subjects were slowly getting satisfactory. recommendations of this study are more proper, organized, complete and maybe computerized data writing could ease the data collecting, and also further study needed to be done to determine the factors influencing the blood glucose and hba1c levels in dm type 1 patients. in addition, subjects are expected to routinely control and monitor their blood glucose and hba1c levels, and giving education to the subjects and their families about their disease how to control their blood glucose might be beneficial. references 1. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047–53. 2. alemzadeh r, ali o. diabetes mellitus. in: kliegman rm, editors. kliegman: nelson textbook of pediatrics. 19th ed. philadelphia: elsevier-saunders; 2011. p. 1968–93. 3. aman pulungan, herqutanto. diabetes melitus tipe 1: “penyakit baru” yang akan makin akrab dengan kita. maj kedokt indon. 2009;59(10):455–458. 4. american diabetes associaton. standards of medical care in diabetes—2014. diabetes care. 2014;37(suppl1):s14–80. 5. american diabetes associaton. diagnosis and classification of diabetes mellitus. diabetes care. 2010;33(suppl1):s62–69. 6. day a. hba1c and diagnosis of diabetes: the test has finally come of age. ann clin biochem. 2012;49(1):7–8. 7. cohen rm, haggerty s, herman wh. hba1c for the diagnosis of diabetes and prediabetes: is it time for a mid-course correction?. j clin endocrinol metab. 2010;95(12):5203–6. 8. alqahtani n, khan wa, alhumaidi mh, ahmed ya. use of glycated hemoglobin in diagnosis of diabetes mellitus and pre-diabetes and role of fasting plasma glucose, oral glucose tolerance test. int j prev med.2013;4(9):1025–9. 9. maahs dm, west na, lawrence jm, mayer-davis ej. epidemiology of type 1 diabetes. endocrinol metab clin north am. 2010;39(3):481–97. 10. battelino t, phillip m, bratina n, nimri r, oskarsson p, bolinder j. effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes. diabetes care. 2011;34(4):795–800. 163 althea medical journal. 2017;4(2) one year data of new secondary glaucoma patients at top referral eye hospital in indonesia elka rifqah,1 elsa gustianty,2 ihrul prianza prajitno3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/national eye center cicendo eye hospital, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: glaucoma is the second most common cause of blindness after cataract in the world and also in indonesia. based on the etiology, glaucoma is classified into primary and secondary glaucoma. secondary glaucoma can cause severe visual function disorders and affect the patient’s quality of life. this study was carried out to indentify the characteristics of new secondary glaucoma patients at cicendo eye hospital from january to december 2013. methods: this descriptive study was carried out at cicendo eye hospital from november to december 2014. secondary data were retrieved from medical records of new secondary glaucoma patients who came to the glaucoma unit from january to december 2013. inclusion criteria were medical records comprising data about age, gender, location of the affected eyes by secondary glaucoma, etiology of secondary glaucoma and value of intraocular pressure. the collected data were recorded and analyzed to illustrate their frequency distribution and proportion. results: out of 63 patients, 42.9% was 40–59 years old and 63.5% was men. most cases were unilateral (82.5%). it was found that 74 eyes (52 unilateral, 11 bilateral), diagnosed as secondary glaucoma, had intraocular pressure ≥30 mmhg which were 54.1%. secondary glaucoma were caused by lens induced (36.5%), inflammation (22.2%), and trauma (9.5%). conclusions: most cases are middle-aged patients and dominated by men. the eye diagnosed as secondary glaucoma occurred more in the unilateral eye which has intraocular pressure ≥30 mmhg and is caused by lens induced and inflammation. keywords: secondary glaucoma, inflammation, lens induced correspondence: elka rifqah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81905501090, email: rifqah.lk@gmail.com introduction visual impairment is one of the health issues of concern around the world. approximately 285 million people are estimated to be visually impaired worldwide, 39 million are blind and 246 have low vision.1 glaucoma is the second leading cause of blindness after cataract in the world.2–4 according to the results of the national survey of health sense in 8 provinces in 1993-1996, the prevalence of blindness in indonesia was 1.5% and from that percentage, 0.2% caused by glaucoma. the results of the survey of blindness and eye health in west java in 2005, showed that the prevalence of glaucoma in the age group above 40 was 1.2% and the prevalence of blindness due to glaucoma was 0.1% from 4.0% of total blindness.5 glaucoma is a chronic optic neuropathy with presence of damage of the optic disc and progressive derivation of visual field. based on the etiology, glaucoma is classified into primary and secondary glaucoma. primary glaucoma is not caused by glaucoma or ocular systemic disorders, while secondary glaucoma results from the manifestation of ocular disorders or systemic disorders.6 cicendo eye hospital is a government, top referral and an academiceye hospital. since 24 april 2010, this hospital has been designated as a national referral eye hospital.7 this study was conducted to investigate the characteristics of secondary glaucoma patients in cicendo eye hospital from january to december 2013. amj. 2017;4(2):163–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1060 althea medical journal. 2017;4(2) 164 amj june 2017 methods a descriptive study was carried out using medical records of secondary glaucoma patients who went to the glaucoma unit of the cicendo eye hospital from january to december 2013. the inclusion criteria were medical records consisting of new secondary glaucoma patients and information about their age, gender, the location of eyes affected by secondary glaucoma, etiology of the secondary glaucoma and value of intraocular pressure. moreover, the exclusion criteria were medical records with incomplete data. the collected data were recorded and analyzed to obtain the frequency distribution and proportion. results a total of 63 medical records of new secondary glaucoma patients were collected from january to december 2013. according to their age, most of the patients were middle-aged (40–59 years) and the number of cases were declined in old age. moreover, this study discovered that men were the most affected by these disorders. according to the location of the eyes affected by these disorders, in most cases, only one eye (unilateral) was affected (table 1). cases of secondary glaucoma in this study were most often caused by lens induced in 23 cases (36.5%), followed by inflammation in 14 cases (22.2%) (table 2). out of 63 cases of secondary glaucoma, 52 cases occurred in one eye (52 eyes) and 11 cases occurred in both eyes (22 eyes), so that the total number of eyes with secondary glaucoma was 74 eyes. this study showed the most common secondary glaucoma had intraocular pressure of ≥30 mmhg. discussion the results of this study showed that cases of secondary glaucoma in the new patient category in 2013 at cicendo eye hospital occurred more in the age range 40-59 years, because the highest etiology (lens induced) caused by senile cataract occurs at the age of 40 years, as described by gupta et al.8 this study showed that secondary glaucoma was more common in men than women; this was unlike the study of sakata, et al.9 which reported more cases of secondary glaucoma in women. the study of sihota et al.10 revealed that the secondary glaucoma due to trauma occurs more in men. although there was a difference between the number of men and women, this difference did not show any relationship between sex and incidence of glaucoma, as described by shen et al.11, and khandekar et al.12 this study showed that secondary glaucoma was more common in the unilateral eye, which is similar to the study conducted by gadia et al.13 a study by bodh et al.14 showed that cases of glaucoma due to inflammation occurs more in bilateral cases. this study discovered that the secondary glaucoma occured due to eye diseases such as lens induced, uveitis, phacomorphic, side effects of corticosteroid, traumatic cataract and other eye diseases. a study by yaakub, et al.15 showed that the secondary glaucoma due to lens-induced glaucoma could occur because of a dislocated lens, lens swelling or inflammation due to phacoanaphilactic and is common in developing countries. some conditions that table 1 patient distribution by gender, age and eyes laterality men women frequency age 14–39 years 12 (19.1%) 5 (7.9%) 17 (27%) 40–59 years 15 (23.8%) 12 (19.1%) 27 (42.9%) ≥60 years 13 (20.6%) 6 (9.5%) 19 (30.2%) total 40 (63.5%) 23 (36.5%) 63 (100%) eye laterality unilateral 32 (50.8%) 20 (31.7%) 52 (82.5%) bilateral 8 (12.7%) 3 (4.8%) 11 (17.5%) total 40 (63.5%) 23 (36.5%) 63 (100%) 165 althea medical journal. 2017;4(2) table 2 characteristic of etiology etiology frequency distribution % lens induced 23 36.5 phacomorphic 6 9.5 immature senile cataract 6 9.5 ectopic lens 1 1.6 phacolytic glaucoma 1 1.6 mature senile cataract 1 1.6 others 8 12.7 inflammation 14 22.2 anterior uveitis 5 7.9 panuveitis 2 3.2 glaucomatous cyclitic crisis 1 1.6 panophtalmitis 1 1.6 bilateral uveitis 1 1.6 others 4 6.3 trauma 6 9.5 hiphema 2 3.2 traumatic cataract 2 3.2 iridoplegi 1 1.6 others 1 1.6 pseudophakia/aphakia 5 7.9 steroid induced 4 6.3 neovascular glaucoma 3 4.8 others 8 12.7 keratopati 3 4.8 ulcus cornea 2 3.2 axenfeld rieger syndrome 1 1.6 absolut glaucoma 1 1.6 suprachoroidal hemorrhage 1 1.6 total 63 100 elka rifqah, elsa gustianty, ihrul prianza prajitno: one year data of new secondary glaucoma patients at top referral eye hospital in indonesia increase the risk of secondary glaucoma caused by corticosteroid is diabetes mellitus, myopia, and rheumatoid arthritis.16 a study by bodh et al.14 revealed that glaucomatocyclitic crisis associated with immunogenetic factor and cause of intraocular pressure rises to 40table 3 distribution of intraocular pressure among secondary glaucoma patients intraocular pressure number of eyes % 21,0 – 29,9 mmhg 19 25.7 ≥30 mmhg 40 54.1 difficult to assess 15 20.3 total 74 100,0 althea medical journal. 2017;4(2) 166 amj june 2017 70 mmhg during acute attack. furthermore, normal intraocular pressure ranges from 11-21 mmhg, although there is no absolute pathological point, 21 mmhg is considered as the upper limit of normal intraocular pressure. in some cases, the manifestation of glaucoma occurs with intraocular pressure less than 21 mmhg. however, in other cases the intraocular pressure rises to 30 mmhg without manifestation of glaucoma.17 this study showed the majority of cases occurred with secondary glaucoma intraocular pressure ≥30 mmhg. a study of yaakub et al.15 showed that the intraocular pressure is between 40-49 mmhg in lens-induced glaucoma patients in malaysia. limitations of this study are the difficulties to access the medical record and limited time. the conclusions of this study are that secondary glaucoma patients occurred more in men than in women, and most are in the age range 40-59 years. the most common etiology of these disorders is lens induced glaucoma. secondary glaucoma is more common in one eye (unilateral) with intraocular pressure ≥30 mmhg. references 1. world health organization. visual impairement and blindness. 2013 [cited 2014 march 11]. available from: http:// www.who.int/mediacentre/factsheets/ fs282/en/. 2. world health organization. glaucoma is second leading cause of blindness globally.2004 [cited 2014 march11]. available from: http://www.who.int/ bulletin/volumes/82/11/feature1104/ en/. 3. quigley ha, broman at. the number of people with glaucoma worldwide in 2010 and 2020. br j ophthalmol. 2006;90(3):262–7. 4. iwase a, araie m, tomidokoro a, yamamoto t, shimizu h, kitazawa y. prevalence and causes of low vision and blindness in a japanese adult population: the tajimi study. ophthalmology. 2006;113(8):1354– 62. 5. kementrian kesehatan republik indonesia. gangguan penglihatan masih menjadi masalah kesehatan 2013 [cited 2014 march 11]. available from: http://www. depkes.go.id/index.php?vw=2&id=845. 6. american academy of ophthalmology. glaucoma. 2011. 7. kementrian kesehatan republik indonesia. menkes resmikan rs mata cicendo sebagai pusat mata nasional.2010 [cited 2014 march 11]. available from: http://www. depkes.go.id/index.php?vw=2&id=1063. 8. gupta p, bhagotra s, prakash s. pattern and visual outcome in lens induced glaucoma. jk science journal of medical education and research. 2012;14(4):181–4. 9. sakata k, sakata lm, sakata vm, santini c, hopker lm, bernardes r, et al. prevalence of glaucoma in a south brazilian population: projeto glaucoma. invest ophthalmol vis sci. 2007;48(11):4974–9. 10. sihota r, kumar s, gupta v, dada t, kashyap s, insan r, et al. early predictors of traumatic glaucoma after closed globe injury: trabecular pigmentation, widened angle recess, and higher baseline intraocular pressure. arch ophthalmol. 2008;126(7):921–6. 11. shen sy, wong ty, foster pj, loo j-l, rosman m, loon s-c, et al. the prevalence and types of glaucoma in malay people: the singapore malay eye study. invest ophthalmol vis sci. 2008;49(9):3846–51. 12. khandekar r, jaffer m, al raisi a, zutshi r, mahabaleshwar m, shah r, et al. oman eye study 2005: prevalence and determinants of glaucoma. east mediterr health j. 2008;14(6):1349–59. 13. gadia r, sihota r, dada t, gupta v. current profile of secondary glaucomas. indian j ophthalmol. 2008;56(4):285–9. 14. bodh sa, kumar v, raina uk, ghosh b, thakar m. inflammatory glaucoma. oman j ophthalmol. 2011;4(1):3–9. 15. yaakub a, abdullah n, siti raihan i, ahmad tajudin l. lens-induced glaucoma in a tertiary centre in northeast of malaysia. malays fam physician. 2014;9(2):48–52. 16. dada t, nair s, dhawan m. steroid-induced glaucoma. journal of current glaucoma practice. 2009;3(2):33–8. 17. kanski jj, bowling b, nischal kk, pearson a. clinical ophthalmology: a systematic approach. 7th ed. edinburgh, new york: elsevier /saunders; 2011. vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 91 correlation between maternal hemoglobin level and birth weight syifa fauziyah safithri,1 nia kania,2 aly diana3 1faculty of medicine universitas padjadjaran, 2department of biomedical sciences faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran correspondence: syifa fauziyah safithri, faculty of medicine universitas padjadjaran, , jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia , email: syifafsafithri@gmail.com introduction pregnant women are susceptible to have anemia. there is 37.1% of pregnant women with anemia, as reported in data of basic health research (riset kesehatan dasar, riskesdas) indonesia 2013.1 during pregnancy, blood volume is increased due to higher plasma volume and erythrocyte numbers. the plasma increase is higher than hemoglobin, leading to a lower hemoglobin concentration. low hemoglobin concentration in pregnant women below 11 g/dl is designated as anemia of pregnant women.2 one of the effects of anemia in pregnant women is a delivered baby with low birth weight.2 this may be to disturbance to nutrition, oxygenation and uteroplacental circulation.3,4 according to the world health organization (who), low birth weight is designated when infant weight is less than 2500 grams (5.5 pounds) at birth.5 infant with low birth weight may have a higher risk of mortality and morbidity, such as the occurrence of growth retardation, delayed cognitive development and the risk of chronic diseases during lifetime.3,5 previous study in india among pregnant women in their third trimester has shown that anemia during pregnancy has a negative effect on the infant birth weight.6 this study aimed to explore the correlation between maternal hemoglobin level and birth weight in a rural area in bandung. methods the study design was a cross-sectional study, conducted from august to september 2014 in a rural area in bandung. a total sample of 95 pregnant women was included from data obtained from medical records of pregnant women from january 2011 until may 2014. the inclusion criteria was pregnant women abstract background: pregnant women are susceptible to have anemia, marked by hemoglobin level <11gr/ dl. maternal hemoglobin levels may influence the nutritional transfer, oxygenation, and uteroplacental circulation of the babies which may affect the infant’s birth weight. this study aimed to explore the correlation between hemoglobin level and birth weight in pregnant women in rural area in bandung. methods: this cross-sectional study was conducted from august to september 2014, recruiting all pregnant women registered in a hospital in a rural areas bandung. hemoglobin level was obtained from the medical records and analyzed to correlate with birth weight (pearson correlation). results: in total, there were 95 pregnant women included. the mean of maternal hemoglobin level was 11.6±1.2gr/dl and birth weight was 2.927±398gram. the proportion of maternal anemia and low birth weights were 30.5% and 15.8%, respectively. pearson correlation test showed r=-0.093 and p=0.369 which was not significant. conclusions: there was no correlation between maternal hemoglobin level and birth weight. other factors for low maternal hemoglobin need to be further explored. keywords: birth weight, hemoglobin, maternal amj. 2019;6(2):91–4 althea medical journal. 2019;6(2) 92 amj june 2019 aged 20–35 years old whereas the exclusion criteria was pregnant women with high parity (more than 4 previous live births), history of abortion, multiple gestation, premature birth, a baby with congenital abnormalities, history of chronic diseases (hypertension, diabetes, asthma, heart disease, tuberculosis, and renal failure) and bleeding during pregnancy (placental abruption and placenta previa). data of third-trimester maternal hemoglobin level and birth weight were obtained from the medical record of pregnant women who gave birth at the amc hospital bandung after getting ethical approval from the ethics committee of the amc hospital bandung. data were collected and analyzed by univariate to find the proportion of each variable, and by bivariate to find the correlation between two variable using pearson correlation test, with a significant value of p<0.05 using statistical software (spss). results of 95 pregnant women included, 44.2% had ever given birth for once (1 parity). the majority were graduated from senior high school (45.3%), and housewife (61.1%) as shown in table 1. the proportion of maternal anemia and low birth weight were 30.5% and 15.8%, respectively (table 2). the mean of maternal hemoglobin level was 11.6±1.2gr/dl and birth weight was 2927±398gram. the linear test was used after normality test. it showed p-value=0.783 (p>0.05), this result indicates that there was a linear table 1 the baseline characteristics of pregnant women characteristics n=95 % parity 0 39 41.1 1 42 44.2 2 10 10.5 3 4 4.2 educational level elementary school 5 5.3 junior high school 21 22.1 senior high school 43 45.3 high education 26 27.3 occupation working 37 38.9 housewife 58 61.1 table 2 hemoglobin maternal level and infant birth weight characteristics n=95 % hemoglobin level <11 gr/dl 29 30.5 11–13 gr/dl 58 61.1 >13 gr/dl 8 8.4 infant birth weight <2500 gram 15 15.8 ≥2500 gram 80 84.2 althea medical journal. 2019;6(2) 93syifa fauziyah safithri et al.: correlation between maternal hemoglobin level and birth weight relationship between maternal hemoglobin level and infant birth weight, as shown in figure 1. furthermore, the pearson correlation test was used to see how close the relationship between the two variables. pearson correlation test showed that the value of the pearson correlation coefficient (r) was -0.093, indicating a very weak correlation with a negative correlation and value of p=0.369 (p>0.05), showing no significant relationship between maternal hemoglobin level and infant birth weight. discussion this study has shown that 30.5% of pregnant women are anemic, and this is slightly lower than the national percentage of 37.1%.1 the characteristics of the respondents are different compared to the national characteristic in general. furthermore, these pregnant women have had a normal delivery. in this study, the results show no significant correlation between hemoglobin level of pregnant women with birth weight (p=0.369), likewise, in a previous study in other parts of indonesia in west sumatra, also has shown no significant correlation between maternal hemoglobin level in the third trimester and infant birth weight.7 many confounding factors cannot be controlled, such as maternal age, parity, nutritional status, chronic disease during pregnancy, genetic factors, characteristics of antenatal care, maternal smoking habits, and socioeconomic condition.7 these factors may have been taken into consideration. in another study conducted in africa has shown a similar result that there is no significant relationship between maternal hemoglobin levels and birth weight.8 there evidence that various factors may influence condition of anemia and birth weight such as low maternal nutrition before and during pregnancy, age less than 20 years old during pregnancy, abortion history, a history of having a baby with low birth weight, parity ≥4 times, women with chronic illness during pregnancy, premature birth, the mother who had multiple gestation, pregnant women that do not consume or low consume of iron tablets, lack of antenatal visits, low maternal education level, and low socioeconomic condition.9-12 in our study, most of these factors have been controlled by exclusion criteria, however, several factors are not examined because of the incomplete data in the medical records. furthermore, several factors that affect birth weight were not studied, such as maternal nutrition before and during pregnancy, intake of iron tablets, antenatal visits during pregnancy, and socioeconomic condition, whereas it may become a confounding factor in this study.7,9-13 of note, maternal nutritional intake figure 1 the linear relationship between maternal hemoglobin level and infant birth weight althea medical journal. 2019;6(2) 94 amj june 2019 before and during pregnancy can affect fetal development. poor nutrition in the mother before and during pregnancy can lead to a lack of nutrients that are transmitted through the placenta to the baby.3 inadequate intake of iron tablets during pregnancy and the lack of antenatal care visits may increase the risk of low birth weight of the baby.9 the intake of iron tablets during pregnancy helps increasing overall maternal nutrition so it may increase the birth weight of the baby.9 in antenatal visits, the risk of low birth weight can be reduced because antenatal visits can improve the mother’s diet during pregnancy, monitor and assist the mother in weight gain during pregnancy.9 socioeconomic conditions have an important role for pregnant women because it affects maternal nutrition before and during pregnancy.7,12 regardless our finding with no association between low hemoglobin during pregnancy and low birth weight, some previous studies have shown otherwise resulting that low hemoglobin level during pregnancy is associated with low birth weight.14,15 interestingly, when the severity of anemia in the third trimester of pregnancy is decreased, the average birth weight is increased.6 limitations of this study were that not all influencing factors can be controlled, such as maternal nutrition before and during pregnancy, intake of iron tablets, antenatal visits during pregnancy, and socioeconomic condition. further study needs to include all of these factors, by doing primary data collection with a prospectively cohort study method and assessing hemoglobin level from first until the third trimester of pregnancy. as for secondary data, in order to control the factors that may affect the results, a good medical record is encouraged, such as data of third trimester hemoglobin level, maternal history of the anc, and keeping medical records in good place, to be used for any later study, and to provide complete information. to conclude, our study shows that there is no correlation between hemoglobin levels of pregnant women with birth weight. other factors for low maternal hemoglobin need to be further explored. references 1. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2013. jakarta: kementerian kesehatan ri; 2013. 2. lee ai, okam mm. anemia in pregnancy. hematol oncol clin n am. 2011;25(2):241– 59. 3. muthayya s. maternal nutrition and low birth weight. indian j med res. 2009;130(5):600–8. 4. cunningham fg, gant nf, leveno kj, gilstrap lc, hauth jc, wenstrom kd. williams obstetrics. 23rded. new york: the mcgraw-hill companies; 2010. 5. united nations children’s fund and world health organization. low birthweight:country, regional and global estimates. new york: unicef; 2004. 6. madaan g, bhardwaj ak, narang s, sharma p. effects of third trimester maternal hemoglobin upon newborn anthropometry. j nepal paediatr soc. 2013;33(3):186–9. 7. setiawan a, lipoeto ni, izzah az. hubungan kadar hemoglobin ibu hamil trimester iii dengan berat bayi lahir di kota pariaman. jurnal kesehatan andalas. 2013;2(1):34– 7. 8. demmouche a, lazrag a, moulessehoul s. prevalence of anemia in pregnant women during the last trimester : consequense for birth weight. eur rev med pharmacol sci. 2011;15(4):436–45. 9. khanal v, zhao y, sauer k. role of antenatal care and iron supplementation during pregnancy in preventing low birth weight in nepal:comparison of national surveys 2006 and 2011. arch public health. 2014;72(1):4–13. 10. kumar sg, kumar hh, jayaram s, kotian m. determinants of low birth weight: a case control study in a district hospital in karnataka. indian j pediatr. 2010;77(1):87–9. 11. nobile cg, raffaele g, altomare c, pavia m. influence of maternal and social factors as predictors of low birth weight in italy. bmc public health. 2007;7(1):192–200. 12. matin a, azimul s, matiur a, shamianaz s, shabnam j, islam t. maternal socioeconomic and nutritional determinants of low birth weight in urban area of bangladesh. j dhaka med coll. 2008;17(2):83–7. 13. dasgupta a, basu r. determinants of low birth weight in a block of hooghly, west bengal. int j biol med res. 2011;2(4):838– 42. 14. francis s, nayak s. maternal haemoglobin level and its association with pregnancy outcome among mothers. nujhs. 2013;3(3):96–100. 15. ahmad mo, kalsoom u, sughra u, hadi u, imran m. effect of maternal anaemia on birth weight. j ayub med coll abbottabad. 2011;23(1):77–9. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 11 motoric clinical symptoms in late onset parkinson’s disease at dr. hasan sadikin general hospital bandung jasvinee sivakurunathan,1 thamrin syamsudin,2 haryono tansah3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry and molecular biology faculty of medicine universitas padjadjaran abstract background: parkinson’s disease (pd) is a progressive neurological that disorder is characterized by a number of motoric symptoms which are resting tremor, bradykinesia, rigidity and postural disturbance. the main aim in carrying out this study was to observe the motoric clinical pattern in patients with late onset parkinson’s disease based on age, gender, and staging of the disease. methods: this was a descriptive retrospective study to 89 medical record of patients with late onset parkinson’s disease from neurology outpatient clinic of dr. hasan sadikin general hospital bandung in the period january 2010 to january 2013. total sampling was used to determine the population sample size the motoric clinical symptoms in patients with late onset parkinson’s disease were classified based on age at diagnosis, gender, and staging of the disease conducted using descriptive retrospective method. besides, staging was made based on hoehn and yarl scale. results: overall, 92% of the patients with late onset parkinson’s disease had resting tremor, and postural instability was less frequently found in 21% of patients. sixty one men suffered from this disease, 43% were from the age group 60–69, and 32% were in stage iii. conclusions: a majority of patients with the late onset parkinson’s disease show resting tremor that has the common motoric clinical pattern, followed by bradykinesia, rigidity, and some show postural instability. [amj.2017;4(1):11–5] keywords: hoehn and yarl scale, hughes criteria, motoric clinical pattern, parkinson’s disease correspondence: jasvinee sivakurunathan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87822005171 email: jasvinee@hotmail.com introduction parkinson’s disease is a progressive neurological disorder characterized by a large number of motoric and non-motoric symptoms that can impact the function with variables degree caused by dopamine deficiency that are a consequences of the substanianigra degeneration.1 the main motoric symptoms of parkinson’s disease consist of resting tremor, bradykinesia, rigidity and postural disturbance.1 the disease is a slow progressive parkinsonian syndrome that begins insidiously and usually affects one side of the body before spreading to involve the other sides.2 james parkinson is the first person to describe parkinson’s disease and it was characterized by “involuntary tremulous motion” with lessened muscular power.3 the etiology of parkinson’s disease still remains unknown but many studies have been supporting that the major risk factors could be from the combination of environmental and genetic factors.4 factors that have been implicated include oxidative stress, inflammation, mitochondrial dysfunction, and signal alteration indicative of apoptosis.3 recent studies have also consistently demonstrated that in some families, the disease is attributable to a mutation in a single gene. the genetic analyses have detected linkage to six chromosomal regions and have identified three causative genes: park1 (alphasynuclein), park2 (parkin), and park7 (dj1).5 besides environment and genetic factors, aging has also been one of the largest risk althea medical journal. 2017;4(1) 12 amj march 2017 factors for the development and progression of parkinson’s disease, in which aging affects many cellular processes that predispose to neuronsdegeneration, and age-related changes in cellular function that predisposes to the pathogenesis of the disease. the accumulation of age-related somatic damage combined with a failure of compensatory mechanisms may lead to an acceleration of parkinson’s disease with age.6 in this study, the main aim was to describe the motoric clinical pattern in patients with late onset parkinson’s disease based on clinical diagnosis criteria. by conducting this study, benefits for general clinician in the diagnostic field will be able to be provided, which may help general clinician in identifying the disease earlier by recognizing the motoric clinical pattern manifest in patients with late onset parkinson’s disease. moreover, by early identification of the motoric clinical pattern in patients with late onset parkinson’s disease, early treatment and management plan can be submitted for the benefits of the patients, especially for those patients with late onset. methods descriptive retrospective method was used to conduct this study by obtaining medical record of patients with late onset parkinson’s disease from neurology outpatient clinic of dr. hasan sadikin general hospital bandung from january 2010 to january 2013. total sampling was used to determine the population sample size. all medical records obtained in this study were approved by the health research ethics committee. motoric clinical pattern in patients with late onset parkinson’s disease was taken based on age at diagnosis, gender, and staging of disease. the diagnosis of the patients on the medical record was taken based on hughes diagnostic clinical criteria while the progression of the parkinson’s disease was taken based on the hoehn and yarl scale. hughes criteria and the hoehn and yarl scale were described as follows: step 1) diagnosis of parkinsonian syndrome: bradykinesia, at least one of the following (muscular rigidity, 4-6 hz rest tremor, postural instability was not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction); step 2) exclusion criteria for parkinson’s disease: history of repeated strokes with stepwise progression of parkinsonian features, history of repeated head injury, history of definite encephalitis, oculogyric crises, neuroleptic treatment at onset of symptoms, more than one affected relative, sustained remission, strictly unilateral features after 3 years, supranuclear gaze palsy, cerebellar signs, early severe autonomic involvement, early severe dementia with disturbances of memory, language, and praxis, babinski sign, presence of cerebral tumor or communication hydrocephalus on imaging study, negative response to large doses of levodopa in absence of malabsorption, mptp exposure; step 3) supportive prospective positive criteria for parkinson’s disease. three or more required for diagnosis of definite parkinson’s disease in combination with step one: unilateral onset, rest tremor present, progressive disorder, persistent asymmetry affecting side of onset most, excellent response (70-100%) to levodopa, severe levodopainduced chorea, levodopa response for 5 years or more, clinical course of ten years or more. the hoehn and yarl scale: 1) only unilateral involvement, usually with minimal or no functional disability, 2) bilateral or midline involvement without impairment of balance, 3) bilateral disease: mild to moderate disability with impaired postural reflexes; physically independent, 4) severely disabling disease; still able to walk or stand unassisted, 5) confinement to bed or wheelchair unless aided. inclusion criteria of the study were all the parkinson’s disease outpatient medical records during study period diagnosed using hughes clinical criteria. exclusion criteria were medical records with uncompleted variable including data that supported hughes clinical criteria and the hoehn and yarl scale. the collected data had been presented in the form of percentage and frequency using microsoft office excel 2007. results total of 151 medical records were obtained within three years with 93 males and 58 females, but only 89 patients’ medical records were included in this study. it was because 62 medical records did not fulfill the inclusion criteria of this study. as shown in table 1, the common motoric pattern shown by patients with late onset parkinson’s disease was resting tremor with the least commonly occurring was postural disturbance. as shown in table 2, parkinson’s disease showed a higher frequency in male compared to female. compared to the motoric clinical pattern based on gender, both male and female showed resting tremor that was the althea medical journal. 2017;4(1) 13jasvinee sivakurunathan, thamrin syamsudin, haryono tansah: motoric clinical symptoms in late onset parkinson’s disease at dr. hasan sadikin general hospital bandung main motoric symptoms commonly found, and less commonly was postural instability. for bradykinesia, female showed a higher frequency compared to rigidity, but in male, bradykinesia and rigidity were equally seen. table 3 shown that resting tremor was the common motoric symptom affecting patients at stage i and stage ii of parkinson’s disease. tremor decreases in frequency had the disease progresses while bradykinesia, rigidity, and postural disturbance increases in frequency had the disease progresses. discussions parkinson’s disease has been a long perceived neurological disease related to aging, with two prominent hypotheses attributing a substantive role to aging in parkinson’s disease pathogenesis, which are accelerated aging and normal aging-related neuronal degeneration affecting the substantia nigra in early or middle adult life.7 in this study, parkinson’s disease showed a higher prevalence at old age group 60–69 with lesser progression of the disease. this result has also been supported by the study conducted by levy7 which discovered that advancing age is associated with a faster rate of motor progression, decreased levodopa responsiveness, more severe gait, and postural impairment.7 from this study, the incidence of parkinson’s disease is higher in male compared to female, similarly with other studies revealing that the prevalence of parkinson’s disease is higher in male than female due to the indolent of table 1 distribution of motoric clinical pattern according to age age category (years) frequency resting tremor (%) bradykinesia (%) rigidity (%) postural disturbance (%) 60–69 39 38(97%) 17(43%) 14(35%) 6(15%) 70–79 37 34(91%) 24(64%) 24(64%) 8(21%) >80 13 10(76%) 10(76%) 9(69%) 5(38%) total 89 82(92%) 51(57%) 47(52%) 19(21%) table 2 distribution of motoric clinical pattern according to gender gender frequency resting tremor (%) bradykinesia (%) rigidity (%) postural disturbance (%) male 55 51(92%) 31(56%) 31(56%) 15(27%) female 34 31(91%) 20(58%) 16(47%) 4(11%) total 89 82(92%) 51(57%) 47(52%) 19(21%) table 3 distribution of motoric clinical pattern according to the staging based on hoehn and yarl scale staging frequency resting tremor (%) bradykinesia (%) rigidity (%) postural disturbance (%) i 25 25(100%) 5(20%) 4(16%) 1(4%) ii 22 22(100%) 10(45%) 11(50%) 2(9%) iii 29 27(93%) 23(79%) 19(69%) 7(24%) iv 12 8(66%) 12(100%) 12(100%) 8(66%) v 1 0 1(100%) 1(100%) 1(100%) total 89 82(92%) 51(57%) 47(52%) 19(21%) althea medical journal. 2017;4(1) 14 amj march 2017 estrogen.8,9 that is why the progression of the disease is commonly more rapid in male than in female. it has been proved and revealed in many studies that estrogen provides neuro protective effects.8 the protective mechanism includes antioxidant agents and up regulation of bcl-2, brain-derived neurotrophic factor, and glial cell-derived neurotrophic factor (gdnf), and it is also achieved through the alterations in dopamine d2 receptors and their associated g protein.8 the cardinal symptoms of parkinson’s disease are resting tremor, bradykinesia, rigidity, and postural disturbance.10 resting tremor is a rhythmic oscillatory movement of a body part, resulting from the contraction of the opposing muscle groups.11 in this study, it can be seen that the resting tremor equally affects both gender, female and male, and it is proven to be the most common motoric manifestation shown by both genders of patients with late onset parkinson’s disease.12 it is often the first symptom of parkinson’s disease with more than 25 percent of elderly patients with parkinson’s disease that have an associated action of resting tremor.12 bradykinesia which indicates slowness of movement is a hallmark of the basal ganglia disorder of the parkinson’s disease.13 as seen in the results in table 2, bradykinesia showed a higher frequency as the disease progresses and it is seen more commonly in male than in female.whereas, the frequency of rigidity varies in age group without any specificity and it is also seen more commonly in male than in female. staging in this study is based on hoehn and yarl scale to indicate the progression of the disease. based on the staging of the disease, the motoric symptom commonly seen was resting tremor, and according to this study, resting tremor was seen at highest frequency in patients classified into stage i, stage ii and stage iii. the frequency of tremor decreases in patients with parkinson’s disease had the severity of the disease progresses. this study found, patients classified into stage iv or v almost showed no evidence of tremor. postural disturbance due to the loss of postural reflexes is generally a manifestation of the late stages of parkinson’s disease and usually occurs after the onset of other clinical features. almost all patients classified into stage i showed no evidence of postural disturbance. postural disturbance increased as the disease progressed where it commonly affected patients classified into stage iv or v. as in the results obtained in table 2, it showed that postural disturbance was commonly seen among male gender compared to female. the limitation encountered while conducting this study was the medical records of the patients with late onset parkinson’s disease, where some of the patient’s data were missing and some could not be included in this study due to incompletion of the patient’s data in the medical records which might decrease the accuracy of this study. lastly, the use of larger samples size might help to increase the chance of significance as in reflecting the population mean accurately. parkinson’s disease consists of a cascade of events that leads to cell death either through physiological aging process or pathological cause. the natural progression of parkinson’s disease is variable but it is usually more common in patients with late onset, and a thorough understanding of the broad spectrum of parkinson’s disease clinical manifestations is essential to the proper diagnosis of the disease, especially for motoric symptoms, early diagnosis has an important role for further parkinson’s disease management. it is an opportunity for general physician to make early diagnosis using motoric clinical pattern in late onset parkinson’s disease. in conclusion, the most common motoric clinical pattern in patients with late onset parkinson’s disease is resting tremor and the less common is postural disturbance. parkinson’s disease in elderly shows a higher prevalence affecting the male patients. references 1. martin w, suchowersky o, burns kk, jonsson e, editors. parkinson disease: a health policy perspective. weinheim: wiley vch; 2010. [cited 2010 march 30]. available from: http://onlinelibrary.wiley. com/book/10.1002/9783527629480 2. fahn s. description of parkinson’s disease as a clinical syndrome. ann n y acad sci. 2003;991(1):1−14. 3. jankovic j, tolosa e. parkinson’s disease and movement disorders. 5th ed. philadelphia, usa: lippincott williams & wilkins; 2007. 4. parkinson disease foundation. understanding parkinson’s: what causes parkinson’s?. [cited 2014 september 20]: available from: http://www.pdf.org/ causes. 5. pankratz n, foroud t. genetics of parkinson disease. neurorx. 2004;1(2):235−42. 6. hindle jv. ageing, neurodegeneration and parkinson’s disease. age ageing. althea medical journal. 2017;4(1) 15 2010;39(2):156−61. 7. levy g. the relationship of parkinson disease with aging. arch neurol. 2007;64(9):1242−6. 8. dluzen de. unconventional effects of estrogen uncovered.trends pharmacol sci. 2005;26(10):485−7. 9. morissette m, sweidi sa, callier s, di paolo t. estrogen and serm neuroprotection in animal models of parkinson’s disease.mol cell endocrinol. 2008;290(1):60−9. 10. coelho m, ferreira jj. late-stage parkinson disease. nat rev neurol. 2012;8(8):435−42. 11. benito-león j, louis ed. clinical update: diagnosis and treatment of essential tremor. the lancet. 2007;369(9568):1152−4. 12. national institute of neurological disorders and stroke. tremor fact sheet. nih publication; 2012:12:4734 [cited 2014 july 20]; available from: http:// www.ninds.nih.gov/disorders/tremor/ detail_tremor.htm. 13. jankovic j. parkinson’s disease: clinical features and diagnosis. j neurol nuerosurg psychiatry. 2008;79(4):368−76. jasvinee sivakurunathan, thamrin syamsudin, haryono tansah: motoric clinical symptoms in late onset parkinson’s disease at dr. hasan sadikin general hospital bandung vol 6 no 2 full text.indd althea medical journal. 2019;6(2) 60 amj june 2019 pharmacological treatment pattern and comorbidities in parkinson’s disease outpatients at dr. hasan sadikin general hospital bandung in 2013–2018 elke feliciana,1 paulus anam ong,2 sobaryati2 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung correspondence: elke feliciana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: elke.feliciana@gmail.com introduction parkinson’s disease (pd) is a neurodegenerative disorder of the central nervous system that affects the motor system and causes motor dysfunction.1,2 the main cause of pd is the decreasing production of dopamine which is caused by the degeneration process of neurons in the substantia nigra.3 prevalence of pd in north america was estimated at around 160 per 100,000 population.3 patients with pd might experience some motoric and non-motoric symptoms. in pd the most common symptoms are tremor, rigidity, and bradykinesia. in this disease there is no curative treatment, most are given to treat the symptoms experienced by patients.4 one of the primary treatment given is the provision of pharmacological therapy. the first-line of pharmacological therapy given to the patients is levodopa with dopa decarboxylase inhibitors such as benserazide, dopamine agonist, anticholinergics and a combination therapy by using anti-parkinson drugs. however, each pharmacological therapy must consider many factors such as age, cost needed, dominant symptoms occurrences, the disease that can be caused by the administration of antiparkinson drugs, and others.5 amj. 2019;6(2):60–4 abstract background: parkinson’s disease (pd) is one of many neurodegenerative diseases with symptomatic management, and with the correct pattern of pharmacological treatment pd may have an improved quality of life for a minimum of three years. this study aimed to illustrate treatment patterns and comorbidities in pd patients at dr. hasan sadikin general hospital, bandung. methods: this study was a cross-sectional descriptive study by using total medical records of the period of 2013 to 2018. pd patients receiving pharmacological treatments such as levodopa, anticholinergics, dopamine agonists, or combined therapy were included. patients with incomplete data and with the previous history of other neurological diseases before pd were excluded from this study. results: in total, there were 57 patients with pd, of whom most of them were males (79%). agewise, pd was most common in 60 to 69-year-olds (32%). the most commonly used treatment pattern was the administration of levodopa (33%). patients aged younger than 30 years were administered anticholinergics, whereas the older patients (>60 years old) mostly were given levodopa. comorbidities after pd diagnosis were mostly stroke, dementia, and epilepsy. conclusions: males are most affected by pd, and the most commonly used treatment pattern is levodopa monotherapy. pd is most commonly found in patients aged 60 to 69 years. patients aged below 30 years are administered anticholinergics. the most common comorbidities found are a stroke, followed by dementia and epilepsy. by recognizing the patterns and comorbidities of this disease, the study may provide some insights into choosing the most effective pharmacological therapy for pd. keywords: comorbidities, parkinson’s disease, pharmacological treatment althea medical journal. 2019;6(2) 61 parkinson’s diseases patients with the right treatment pattern are believed to be able to improve their quality of life for at least three years.6 consequently, this disease needs appropriate treatment. the result of the treatments depends on several factors such as giving the right medication the patient required. the objective of this study was aimed to describe an overview of therapeutic patterns for pd patients in dr. hasan sadikin general hospital bandung. methods a descriptive study was conducted using secondary data from medical records of parkinson’s disease outpatients admitted to dr. hasan sadikin general hospital bandung from january 2013 to june 2018. the inclusion criteria for this study were medical records of patients diagnosed with parkinson’s disease and receiving pharmacological therapy, such as levodopa with dopa decarboxylase inhibitors, dopamine agonists, anticholinergics, or combination therapy. medical records with incomplete data and patients who experienced other neurological disorders before the patients diagnosed with parkinson’s disease were excluded from this study. data were analyzed using microsoft office excel 2010 and presented in percentage. the variables used in this study were age, sex, the given pharmacological therapy, and the patients’ staging. the research ethics committee of universitas padjadjaran has approved this study with ethics number 726/ un6.kep/ec/2018. results during the study period, 78 parkinson’s disease patients were registered in the outpatient at dr. hasan sadikin general hospital bandung. the excluded data were 12 subjects who suffered from other neurological diseases before diagnosed pd and 9 subjects with incomplete medical record data. out of 57 subjects, 47 subjects did not experience other neurological disorders, four subjects had a stroke, three subjects had epilepsy, and three patients had dementia after given pharmacological therapy. based on the characteristics of the study subjects, pd was often experienced by men with a total of 44 (77%) and women as many as 13 (23%). when classified by age, pd most often occurred in the age range of 60–69 years with a total of 18 data (32%), followed by the age range of 70–79 years as many as 16 (28%) and in the age range of 50–59 years as many as 11 (19%). based on the staging, 24 subjects (42%) experienced stage ii and 16 subjects (28%) experienced stage iii (table 1). furthermore, based on the distribution of the most commonly used pharmacological therapy, levodopa as monotherapy was the most commonly administered drug with 19 (33%) data. dopamine agonist was rarely given to the subjects with 1 (2%) data (table 2). table 1 characteristics of study subjects staging i staging ii staging iii staging iv staging v total n=9 n=24 n=16 n=5 n=3 sex male 6 17 15 4 2 44(77%) female 3 7 1 1 1 13(23%) age (years) ≤30 2 1 3 (5%) 30-39 1 3 4 (7%) 40-49 2 2 (4%) 50-59 1 5 4 1 11 (19%) 60-69 3 8 4 1 2 18 (32%) 70-79 2 5 6 3 16 (28%) ≥80 2 1 3 (5%) elke feliciana et al.: pharmacological treatment pattern and comorbidities in parkinson disease outpatients at dr. hasan sadikin general hospital in 2013-2018 althea medical journal. 2019;6(2) 62 amj june 2019 table 2 description of drugs used in study subjects n (%) levodopa + bz* 19 33 dopamine agonist 1 2 anticholinergic 8 14 levodopa + comt 8 14 levodopa+dopamine agonist 4 7 levodopa +anticholinergic 6 11 levodopa+comt+anticholinergic 8 14 levodopa + anticholinergic+ dopamine agonist 3 5 note: *levodopa + benserazide with a ratio of 1:4 table 3 distribution of drugs used by age drugs age (years) ≤30 30–39 40–49 50–59 60–69 70–79 ≥80 n n n n n n n levodopa+bz* 2 6 6 3 2 dopamine agonist 1 anticholinergic 3 2 2 1 levodopa+comt 3 4 1 levodopa+dopamine agonist 1 1 1 1 levodopa+anticholinergic 2 1 2 1 levodopa+comt+ anticholinergic 4 4 levodopa+anticholinergic+ dopamine agonist 1 2 total 3 4 2 11 18 16 3 note: *levodopa + benserazide with a ratio of 1:4 table 4 distribution of drugs used based on staging staging i staging ii staging iii staging iv staging v n n n n n levodopa+bz* 1 10 6 1 1 dopamine agonist 1 anticholinergic 4 3 1 levodopa + comt 1 4 1 2 levodopa+dopamine agonist 1 2 1 levodopa+anticholinergic 6 levodopa+comt +anticholinergic 1 2 3 2 levodopa + anticholinergik+ dopamine agonist 1 1 1 total 9 24 16 5 3 note *levodopa + benserazide with a ratio of 1:4 althea medical journal. 2019;6(2) 63elke feliciana et al.: pharmacological treatment pattern and comorbidities in parkinson disease outpatients at dr. hasan sadikin general hospital in 2013-2018 the administration of drugs based on age showed that at the age of under 30 years, all patients were given anticholinergic monotherapy. in the age range of 40–49 years, all patients were given combination therapy with levodopa and anticholinergics. levodopa was increasingly given along with the patient’s increase in age (table 3). moreover, 4 out of57 subjects (7%) of stage i used anticholinergic therapy. in stage ii, 10 subjects out of 57(18%) used levodopa. in stage iii, as many as 6 subjects out of 57 (11%) used levodopa. in stage iv, as many as 2 subjects (4%) used levodopa+comt+ anticholinergic. in stage v, there were at most 2 subjects (4%) who used levodopa+comt. discussion this study describes an overview of therapeutic patterns for pd patients in dr. hasan sadikin general hospital bandung. the majority of pd patients are male (77%), consistent with another study in china.7 the role of estrogen might support this study result. estrogen has a protective effect against dopaminergic damage and also prevents the deposition of lewy body through specific anti-aggregation activities of alpha-synuclein and destabilization of fibrils.8 the pd mostly occurs predominantly in late age after 50 years old, supported by the previous study in china7and serbia8. our study has shown that as age increases, the risk of getting higher staging is increased. increasing age is one of the risk factors for the development of pd, which increases the risk of a derivative neuron function or often called neurodegenerative. the accumulation of damaged cells might trigger poor regeneration cells and compensation system, it might promote the acceleration of pd progressiveness.9 increasing age also plays a role in decreasing dopamine production, loss and damage of neurons, especially in dopaminergic neurons in substantianigra.10 patients under 30 years in our study are given anticholinergic therapy. dopamine agonist can be an alternative therapy for young aged pd patients.11 there are several consideration for pharmacological therapy for pd patients, such as the predominant symptoms, age, economic burden, and others.12 for young pd patients who have economic problems, anticholinergic therapy might be given.12 however, elderly patients over 60 years in our study are given anticholinergic therapy. based on who, anticholinergic therapy may cause decreased cognitive function, therefore, this therapy is not recommended to be given to patients over 75 years. anticholinergics are not the first-line treatment for pd because of its limited efficacy and side effects on the patient’s neuropsychiatric system.13 nevertheless, anticholinergics could be given to pd patients with dominant tremor and should not experience cognitive impairments.13 besides, levodopa is often given to pd patients aged over 60 years in this study as this is in accordance with the pd management algorithm issued by the indonesian neurological association (perhimpunan dokter spesialis syaraf, perdossi) in 2015. the side effects of levodopa such as dyskinesia potentially occur in young pd patients.14 longterm levodopa therapy can cause unwanted side effects. levodopa therapy might increase the potential to experience side effects such as dyskinesia when it is consumed over 10 years. until now, long-term pharmacological therapy in pd patients has been given, because pd has no curative treatment so that levodopa therapy will be given for a long time to reduce the symptoms.15 the administration of levodopa is given with consideration of functional disorders, dominant symptoms, and age so that the administration of levodopa is mainly given to patients who experienced non-tremor dominant symptoms and aged over 60 years. combination therapy can be given to optimizing the therapy. for example, combination therapy with levodopa and comt inhibitors is to extend the half-life of levodopa levels in the body to stabilize the blood dopamine levels.16 comorbidities for pd in this study are a stroke, epilepsy, and dementia, in which stroke is the most comorbid.9 the degeneration process of dopamine-producing cells in pd can be caused by an oxidative stress process in which it might damage the endothelial cell function and cause atherosclerosis. atherosclerosis may cause chronic hypertension which leads to stroke.12 stroke can also be caused by homocysteine, pd patients treated with levodopa have elevated plasma homocysteine, which can trigger neuroinflammation. the activated microglia and astrocytes release some factors that initiate an inflammatory response and trigger neuronal death. furthermore, homocysteine has prothrombotic and proatherogenic effects so that it may promote the progression of stroke in pd patients.17 this study has several limitations. some of the potential subjects are excluded due to incomplete medical records, especially concerning the patient’s stage. this study althea medical journal. 2019;6(2) 64 amj june 2019 can be developed by increasing the sample and analyzing the correlation of the pharmacological treatment pattern with the patient’s quality of life conducted prospectively. in conclusion, males are most affected by pd, and the most commonly used treatment pattern is levodopa monotherapy. parkonson’s diseases is most commonly found in patients aged 60 to 69 years. patients aged below 30 years are administered anticholinergics. the most common comorbidities found are a stroke, followed by dementia and epilepsy. by recognizing the patterns and comorbidities of this disease, the study may provide some insights into choosing the most effective pharmacological therapy for pd. references 1. standaert d, saint-hilaire m, thomas c, collard r. parkinson’s disease handbook. new york: american parkinson disease association;2014 2. jankovic j. parkinson’s disease: clinical features and diagnosis. j neurol neurosurg psychiatr. 2008;79(4):368–76. 3. colamartino m, padua l, cornetta t, testa a, cozzi r. recent advances in pharmacological therapy of parkinson’s disease: levodopa and carbidopa protective effects against dna oxidative damage. health. 2012;4(11a):1191–9. 4. connolly bs, lang ae. pharmacological treatment of parkinson’s disease. jama. 2014;311(16):1670–83. 5. gray r, ives n, rick c, patel s, gray a, jenkinson c, et al. long-term effectiveness of dopamine agonists and monoamine oxidase b inhibitors compared with levodopa as initial treatment for parkinson’s disease (pd med): a large, open-label, pragmatic randomised trial. lancet. 2014;384(9949):1196–205. 6. brooks dj. optimizing levodopa therapy for parkinson’s disease with levodopa/ carbidopa/entacapone: implications from a clinical and patient perspective. neuropsychiatr dis treat. 2008;4(1):39– 47. 7. wang x, zeng f, jin w, zhu c, wang q, bu x, et al. comorbidity burden of patients with parkinson’s disease and parkinsonism between 2003 and 2012: a multicentre , nationwide, retrospective study in china. sci rep. 2017;7(1):1671. 8. picillo m, nicoletti a, fetoni v, garavaglia b, barone p, pellecchiamt. the relevance of gender in parkinson’s disease: a review. j neurol. 2017;264(8):1583–1607. 9. hindle jv. ageing, neurodegeneration and parkinson’s disease. age ageing. 2010;39(2):156–61. 10. reeve a, simcox e, turnbull d. ageing and parkinson’s disease: why is advancing age the biggest risk facto? ageing res rev. 2014;14:19–30. 11. szczudlik a, rudzinska m. [are dopamine agonists alternative therapy for levodopa in early stage of parkinson’s disease? yes]. neurol neurochir pol. 2007;41(2suppl 1):s6–9 12. chen s, chan p, sun s, chen h, zhang b, le w, et al. the recommendations of chinese parkinson’s disease and movement disorder society consensus on therapeutic management of parkinson’s disease. transl neurodegener. 2016;5;12. 13. worth pf. how to treat parkinson’s disease in 2013. clin med (lond). 2013;13(1):93– 6. 14. matarazzo m, perez-soriano a, stoessl aj. dyskinesias and levodova therapy: whywait? j neural transm (vienna). 2018;125(8):1119–30. 15. huot p, johnston th, koprich jb, fox sh, brotchie jm. the pharmacology of l -dopainduced dyskinesia in parkinson’s disease. pharmacological rev. 2013:65(1):171– 222. 16. stocchi f, vacca l, radicati fg. how to optimize the treatment of early stage parkinson’s disease. transl neurodegener.2015;4:4. 17. doherty gh. homocysteine and parkinson’s disease: a complex relationship. j neurol disord. 2013;1:1. 299 althea medical journal. 2017;4(2) drug allergy clinical characteristics in pediatrics r. devina fathia almira,1 gartika sapartini,2 vycke yunivita kusumah dewi3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: a drug allergy causes a morbidity and a mortality due to its various range of clinical manifestation. unfortunately, a study focusing in pediatric drug allergy is insufficient, especially in bandung. thus, this study is conducted to determine the clinical characteristic of pediatric drug allergy in dr. hasan sadikin general hospital bandung. methods: this study was a retrospective descriptive study using medical records of pediatric drug allergy patients between 2010–2015 in dr. hasan sadikin general hospital bandung taken with total sampling method. the variables were patient age, gender, causative drug, and clinical manifestation. clinical manifestation was then divided into exanthem, urticaria, erythema multiforme, steven-johnson’s syndrome/ toxic epidemiolytic necrosis (sjs/ten), and fixed drug eruption (fde). results: out of 101 patients, only 71 were included in the study due to incomplete medical records of the rest. there were 34 (47.89%) males and 37 (52.11%) females. patients’ age ranged from 1–18 years old with the mean of 7.4 years old. the most common clinical manifestation was sjs/ten with 25 (35.21%) patients, followed by exanthem with 22 (30.98%) patients. the most common suspected causative drug was non-steriodal anti inflammatory drugs (nsaid) (24%), followed with penicillin (21%). conclusions: most common manifestation of pediatric drug allergy in female is sjs/ten, meanwhile in male is exanthema. steven-johnson’s syndrome/toxic epidemiolytic necrosis mostly occurs at the age group of 12–18 years old, and exanthema at the age group of 0–3 years old. this condition is mostly caused by nsaid and penicillin. keywords: clinical manifestation, drug allergy, pediatric correspondence: r. devina fathia almira, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281221112525 email: devinafathia@gmail.com introduction drug allergy is difficult to diagnose most of the time due to the wide variability of symptoms. the diagnosis require a detailed history taking and patient examination to distinguish it from other diseases with the similiar outcome and this often costs in patient’s morbidity or even mortality.1 drug allergy accounts for 3–6% of patient’s admission to hospital and occurs in 10–15% hospitalized patients.1 clinical manifestation of drug allergy can be diverse, from skin rashes such as maculopapular and urticaria, to severe manifestation such as steven-johnson’s syndrome/toxic epidermal necrolytic (sjs/ten) which may cause a death.2 in indonesia, especially bandung, jawa barat, there is an insufficient data of pediatric drug allergy. this study aims to determine the characteristic of pediatric drug allergy that occured in dr. hasan sadikin general hospital bandung. methods this study is a retrospective descriptive study carried out in dr. hasan sadikin general hospital bandung using medical record of pediatrics patients between 2010 to 2015. this study was approved by the health research ethic committee of dr. hasan sadikin general hospital bandung. the population of medical records in pediatrics patients with drug allergy diagnosed between january 2010 to september 2015. total sampling method taken and total of 101 medical records were collected. the inclusion criteria completed the medical records of pediatrics inpatients and outpatients aged 1–18 years old were diagnosed with drug allergy between january 2010 until september 2015. the exclusion criteria included those with congenital amj.2017;4(2):299–303 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1097 althea medical journal. 2017;4(2) 300 amj june 2017 anomaly or comorbidities that could affect the outcome of drug allergy such as known skin or other immunology disease. the data collected in this study consisted of patient gender, clinical manifestation of pediatric drug allergy, and suspected causative drug which used a categorical measurement scale, also a patient age which used a numerical measurement scale. variables were then analyzed using microsoft excel software. results the total subjects were 101 patients, 85 inpatients and 16 outpatients, however patients who met the inclusion criteria were 61 inpatients and 10 outpatients, giving a total of 71 pediatrics patients diagnosed with drug allergy between 2010–2015. other medical records were excluded due to the incomplete of medical records pediatric patients for drug allergy were 34 (47.89%) in males and 37 (52.11%) in females. the patiens’t age were ranged from 1 to 18 years old with the mean age of 7.4 years old. distribution of patient gender on clinical manifestation were shown (table 1). patients in the age group of 12–18 years old have the highest number of sjs/ten, meanwhile age group of 0–3 years old has the highest number of exanthem as clinical manifestation (table 2). > 1 year. suspected causative drug showed no specific distribution on age of patients. however, nsaid showed to be found most on table 1 distribution of gender on clinical manifestation clinical manifestation (n=71) gender (n (%)) female (n=37) male (n=34) sjs/ten 16 (43.2%) 9 (26.4%) exanthem 8 (21.6%) 14 (41.2%) urticaria 6 (16.2%) 4 (11.4%) erythema multiforme 6 (16.2%) 5 (14.7%) fde 1 (2.7%) 2 (5.8%) table 2 distribution of age on clinical manifestation and suspected causative drug age (n (%)) 0–3 years (n=21) 4–6 years (n=12) 7–11 years (n=18) 12–18 years (n=20) clinical manifestation (n=71) sjs/ten 4 (19.1) 4 (33.3) 7 (38.9) 10 (50.0) exanthem 9 (42.8) 2 (16.7) 5 (17.8) 6 (30.0) urticaria 5 (23.8) 0 4 (22.2) 1 (5.0) erythema multiforme 3 (14.2) 4 (33.3) 2 (11.1) 2 (10.0) fde 0 2 (16.7) 0 1 (5.0) suspected causative drug (n=71) nsaid 4 (19.1) 5 (41.7) 5 (17.8) 3 (15.0) penicillin 5 (23.8) 2 (16.7) 4 (22.2) 4 (20.0) cotrimoxazole 1 (4.7) 1 (8.3) 2 (11.1) 3 (15.0) tb drugs 1 (4.7) 0 2 (11.1) 2 (10.0) cephalosporin 3 (14.2) 1 (8.3) 1 (5.6) 4 (20.0) chloramphenicol 1 (4.7) 1 (8.3) 3 (16.7) 1 (5.0) benzodiazepine 1 (4.7) 0 1 (5.6) 2 (10.0) others 5 (23.8) 2 (16.7) 0 1 (5.0) 301 althea medical journal. 2017;4(2) r. devina fathia almira, gartika sapartini, vycke yunivita kusumah dewi: drug allergy clinical characteristics in pediatrics the age group of 4–6 years old and penicillin on the age group of 0–3 years old(table 2). non-steriodal anti inflammatory drugs (nsaid) was found to be the most common suspected drug in causing drug allergy in pediatrics. the percentage of nsaid and other drugs can be seen in the figure. the most common suspected causative drug was nsaid with 17 patients which consist of paracetamol in 12 patients, ibuprofen in 3 patients, diclofenac in 1 patient, and meloxicam in 1 patient. the second most common suspected causative drug was penicillin with 15 patients, consist of ampicillin in 10 patients and amoxicillin in 5 patients. the third was cephalosporin with 9 patients, consist of cefotaxime in 5 patients, cefixime in 3 patients, and ceftriaxone in 1 patient. other drugs found in this study were cotrimoxazole with 6 patients, antituberculosis drugs with 5 patients, benzodiazepine (diazepam) with 4 patients. other drugs included immunos with 2 patients, nevirapine with 2 patients, fradiomycine with 1 patient, leunase with 1 patient, propolis with 1 patient, and vostrin with 1 patient. this study is also attempted to determine the distribution of the suspected causative drug on patients clinical manifestation (table 3). this study is also attempted to determine which suspected causative drug made the drug allergy reaction after the administration of that single drug only, and which did so after the administration with other drugs (table 4). discussion this study reveals that from a total of 71 patients, 34 (47.89%) are male and 37 (52.11%) are female. patients age are ranged from 1–18 old with the mean of 7.4 years old. this finding corresponds with a study that figure suspected causative drug distribution table 3 distribution of suspected causative drug on clinical manifestation clinical manifestation (n=71) suspected causative drug (n (%)) sympto matic causative nsaid (n=17) penicillin (n=15) cotrimoxa zole (n=7) tb drugs (n=5) cephalos porin (n=9) chloram phenicol (n=6) benzo diazepine (n=4) others (n=8) sjs/ten 5 (29.4) 5 (33.3) 4 (57.1) 3 (60.0) 3 (33.3) 3 (50.0) 1 (25.0) 1 (12.5) exanthem 6 (35.2) 3 (20.0) 1 (14.2) 1 (20.0) 3 (33.3) 3 (50.0) 2 (50.0) 3 (37.5) urticaria 1(5.8) 4 (26.7) 2 (28.5) 0 2 (22.2) 0 0 1 (12.5) erythema multiforme 3 (17.6) 3 (20.0) 0 1 (20.0) 1 (11.1) 0 0 3 (37.5) fde 2 (11.7) 0 0 0 0 0 1 (25.0) 0 althea medical journal. 2017;4(2) 302 amj june 2017 prove gender and age do not affect clinical manifestation nor the severity of the reaction.1 several studies also stated that there has not been a proven strong connection between gender and age to drug allergy.3,4 clinical manifestation with most patients is sjs/ten with 25 (35.21%) patients, followed by exanthem with 22 (30.98%) patients, urticaria with 10 (14.08%), and fde with 3 (4.22%) patients. this data is different from the previous studies that stated the most abundant clinical manifestation is exanthem, followed by urticaria and sjs/ten.2,3 this could be due to the fact that dr. hasan sadikin general hospital bandung is a central referral hospital for all hospitals in west java, indonesia. this means that patients with less severe manifestation could have been treated in primary or secondary health care facilities. furthermore, several studies also revealed cutaneous manifestations such as exanthem and erythema multiforme as the most common manifestations of drug allergy, even though it could involve any organ.5–8 this study also showed that sjs/ten followed by urticaria has the highest number in female patients, while exanthem, followed by sjs/ten is the highest in male patients. although there is variation in this study, other previous studies showed that there is no correlation between gender and clinical manifestation of drug allergy in pediatrics.3,4 patients with sjs/ten are mainly from the age group of 12–18 years old, and those with exanthema are mainly from the age group of 0–3 years old. however, there is barely any difference in the distribution of suspected causative drug on the age groups. table 4 distribution of suspected causative drug (single or multi drug usage) on clinical manifestation clinical manifestation (n=71) suspected causative drug (n (%)) nsaid (n=17) penicillin (n=15) cephalosporin (n=9) cotrimoxazole (n=7) single drug (n=12) multi drugs (n=5) single drug (n=9) multi drugs (n=6) single drug (n=6) multi drugs (n=3) single drug (n=6) multi drugs (n=1) sjs/ten 4 (33.3) 1 (20.0) 3 (33.3) 2 (33.3) 2 (33.3) 1 (33.3) 3 (50.0) 1 (100) exanthem 4 (33.3) 2 (40.0) 1 (11.1) 2 (33.3) 2 (33.3) 1 (33.3) 1 (16.7) 0 urticaria 1 (8.3) 0 3 (33.3) 1 (16.7) 1 (16.7) 1 (33.3) 2 (33.3) 0 erythema multiforme 1 (8.3) 2 (40.0) 2 (22.2) 1 (16.7) 1 (16.7) 0 0 0 fde 2 (16.7) 0 0 0 0 0 0 0 suspected causative drug (n (%)) tb drugs (n=5) chloramphenicol (n=6) benzodiaze-pine (n=4) others (n=8) single drug (n=0) multi drugs (n=5) single drug (n=3) multi drugs (n=3) single drug (n=4) multi drugs (n=0) single drug (n=7) multi drugs (n=1) sjs/ten 0 3 (60.0) 1 (33.3) 2 (66.7) 1 (25.0) 0 1 (14.2) 0 exanthem 0 1 (20.0) 2 (66.7) 1 (33.3) 2 (50.0) 0 3 (42.8) 0 urticaria 0 0 0 0 0 0 1 (14.2) 0 erythema multiforme 0 1 (20.0) 0 0 0 0 2 (28.5) 1 (100) fde 0 0 0 0 1 (25.0) 0 0 0 303 althea medical journal. 2017;4(2) this fact is further confirmed by recent studies which showed that generally, there were no definitive proof of age and gender impact in drug allergy.3,4 steven-johnson’s syndrome/toxic epidemiolytic necrosisand exanthema are mainly caused by the suspected drug of nsaid and penicillin. a community study in india also showed that nsaid is the major cause for sjs/ ten and exanthema in drug allergy.9 moreover, noguera-morel et al.10 also showed a similiar result in their study of pediatric drug allergy. nsaid dan penicillin is found as the main suspected causative drug. several studies have discovered that antibiotic and antiinflammatory is the major causative agent in drug allergy.3,8,9 another study in malang, indonesia, also showed that paracetamol and penicillin are the major suspected causative drugs for drug allergy in pediatrics.4 the majority of the suspected causative drugs generates the drug allergy when it is given as a single drug, and not combined with the other drug, except for anti-tuberculosis drugs which is always given as a combination of several different antibiotics. drug allergy that emerged after the administration of several different drug should be further investigated to see the probability of reaction in each drug to another one that affects the drug allergy. this study has several limitations. the first limitation of this study is the usage of patients’ medical records which unfortunately means not all of the patients diagnosed between 2010–2015 can be included in this study due to technical errors such as missing or incomplete medical records. the second limitation is the diagnostic method in the medical records also mainly relied to the clinical diagnostic only, without a proper supportive examination such as ige or a skin prick test, thus the drug variable is only written as a suspected causative drug. furthermore, the percentage of suspected causative drugs in this study were also not a representative of the actual percentage in the community because matching the drugs with drug actual usage percentage in the community was not done. nevertheless, this data is still useful for public to be more aware of the drug mentioned, however the public still have to be alert in drug usage regarding to the kind due to their ability to produce drug allergy. future cohort study in the community are expected in order to find out the true prevalence of drug allergy. in conclusion, the most common manifestation of pediatric drug allergy in female is sjs/ten, meanwhile in male is exanthema. steven-johnson’s syndrome/toxic epidemiolytic necrosis occurs the most at the age group of 12–18 years old, and exanthema at the age group of 0–3 years old, although there is no clinical correlation of age and gender to the clinical manifestation. pediatric drug allergy is mostly caused by nsaid and penicillin. in the future, medical personnels are expected to fill medical records more compeletely, including allergic history of patient and patient’s family, medication history, causative agent of allergic reaction, and also educating patient and patient’s family about allergic condition, drug allergy sign and symptoms, drug allergy first aid, and to quickly take patient to the nearest or appointed medical facility to be further treated to avoid complications. drug allergy diagnosis also will be more solid in the future if a proper supportive examination are implemented. references 1. thong b, tan t. epidemiology and risk factors for drug allergy. br j clin pharmacol. 2011;71(5):684–700. 2. khan d, solensky r. drug allergy. j allergy and clin immunol. 2010;125(2):126–37. 3. heinzerling l, tomsitz d, anliker m. is drug allergy less prevalent than previously assumed? a 5-year analysis. br j dermatol. 2011;166(1):107–14 4. barlianto w. faktor-faktor yang mempengaruhi derajat keparahan erupsi obat pada anak. jurnal kedokteran brawijaya. 2013;26(1):148–53. 5. demoly p, adkinson n, brockow k, castells m, chiriac a, greenberger p et al. international consensus on drug allergy. j allergy. 2014;69(4):420–37. 6. gruchalla r, pirmohamed m. antibiotic allergy. n engl j med. 2006;354(6):601–9. 7. susilawati a, akib aap, satari hi. gambaran klinis fixed drug eruption pada anak di rumah sakit cipto mangunkusumo. sari pediatri. 2014;15(5):269–73 8. warrington r, silviu-dan f. drug allergy. j allergy clin immunol. 2011;7(suppl 1):10–3. 9. raksha m, marfatia y. clinical study of cutaneous drug eruptions in 200 patients. indian j dermatol venereol leprol. 2008;74(1):80–2. 10. noguera-morel l, hernandez-martin a. cutaneous drug reactions in the pediatrics population. pediatr clin na. 2014;61(2):403–26. r. devina fathia almira, gartika sapartini, vycke yunivita kusumah dewi: drug allergy clinical characteristics in pediatrics vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 154 amj september 2019 antituberculosis drug-induced hepatotoxicity in pediatric tuberculosis vycke yunivita,1 muhammad iqbal,2 adi utomo suardi3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: vycke yunivita, department of biomedical sciences, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: v.yunivita@unpad.ac.id introduction indonesia is a country rich in natural resources tuberculosis (tb) remains a major health problem in the world. the world health organization (who) has predicted that there might be 10 million tb cases in 2017 of whom 64% are new cases. more than one million of tbpatients are children and nearly one hundred thousand tb death are among hiv-negative children. indonesia is the ninth country with the largest incident of tb cases in 2017.1 the basic principle in tb therapy is oral antituberculosis (oat) drugs, consisting of four drugs regimen including isoniazid (inh), rifampicin (rif), pyrazinamide (pza) and ethambutol (emb) for positive acid-fast bacilli (afb). for negative afb children in the intensive phase i.e. the first 2 months have been given otherwise three drugs regimen without emb. furthermore, during the maintenance phase or in the next 4 months of tb treatment, two drugs (rif and inh) have been given. morevoer, good nutrition must be monitored and comorbidities need to be checked thoroughly.2 antituberculosis druginduced hepatotoxicity (adih) is the most frequent side effect of oat drugs.3 the mild or moderate clinical symptoms of adih are jaundice and gastrointestinal problems, such as loss of appetite, nausea, confusion, vomiting, and abdominal pain. this side effect may influence patient compliance’s and determine the outcome of therapy.4 many studies have investigated clinical parameters adih in adult subjects.5–7 in contrast, signs or symptoms of adih are often ignored in pediatric tb.8 therefore, it is necessary to identify the incidence and characteristics of oat drugs side amj. 2019;6(3):154–60 abstract background: hepatotoxicity is the most serious side effect caused by using oral antituberculosis (oat) drugs. this study was performed to determine the characteristics of patients who had antituberculosis drug-induced hepatotoxicity (adih) among pediatric inpatient with pulmonary tuberculosis. methods: this was a cross-sectional study with a total sampling of medical records taken from january–december 2012, including pediatric pulmonary tuberculosis inpatients aged <14 years old at the department of child health of dr. hasan sadikin general hospital bandung. the inclusion criteria were children with pulmonary tuberculosis who received oat drugs. patients with liver disease were excluded. data on alanine and aspartate aminotransferase were collected and an increased level of serum aminotransferase was designated as hepatotoxicity. results: in total, 86 medical records were obtained of whom 24 had adih, predominantly occurred in girls (71%), aged 5–9 years old (42%) and in the intensive phase of therapy (58%). elevated serum alanine aminotransferase (58%), aspartate aminotransferase (92%), and bilirubin (0.8%) were found. malnutrition (46%) was common. the difference indeviation of liver function was statistically significant (p<000) between subjects with and without adih. conclusions: hepatotoxicity is most prominent in patients with malnutrition, girls aged 5–9 years old and in the intensive phase of therapy. children with malnutrition during antituberculosis therapy are suggested to have a periodic liver function test monitoring to prevent the development of adih. keywords: antituberculosis, children, hepatotoxicity, tuberculosis althea medical journal. 2019;6(3) 155 effects’ in children. this study intended to find the incidence and characteristic of children with pulmonary tb who had hepatotoxicity due to oat drugs. methods this was an observational analytic study with a cross-sectional approach, conducted in dr. hasan sadikin general hospital bandung. data werecollected from inpatient’s medical records with a total sampling method. the pulmonary tb in children was diagnosed based on the tb scoring system. the inclusion criteria were data of pediatric inpatient aged <14 years old, that was diagnosed to have pulmonary tb and received oat drugs, and that was admitted in the ward during january– december 2012. patients with liver disease were excluded. the data were recorded such as age, gender, phase of tb treatment and other diseases or comorbidities that were existed in those patients. the study was approved by the health research ethics committee, faculty of medicine, universitaspadjadjaran. the adih was marked by the deviation of normal liver function test (lft) including alanine aminotransferase (alt), aspartate aminotransferase (ast), and bilirubin. furthermore, clinical symptoms of liver dysfunction such as jaundice might also be present during antituberculosis treatment.8 grade 1 was designated when alt or ast was increased up to 3 times from upper normal limit or increased 1.5-3 times from baseline if the baseline was abnormal; or when bilirubin was increased up to 1.5 times from upper normal limit or increase 1–1.5 times from baseline if the baseline was abnormal. grade 2 was designated when transferases was increased >3–5 times from upper normal limit or baseline if the baseline was abnormal; or when bilirubin was increased >1.5–3 times from upper normal limit or baseline if the vycke yunivita et al.: antituberculosis drug-induced hepatotoxicity in pediatric tuberculosis table 1 the characteristics of children with pulmonary tuberculosis, admitted in dr. hasan sadikin general hospital from january to december 2012. characteristic with adih % without adih % p (n=24) (n=62) age, years 0.215a 0–4 8 33 36 58 5–9 10 42 17 27 10–14 6 25 9 15 gender 0.221b boys 7 29 27 43 girls 17 71 35 57 number of comorbidities 0.950b 0 1 2 1 8 33 24 39 2 8 33 17 27 3 6 25 11 18 4 2 8 5 8 >4 4 6 phase of tb treatment 0.848b intensive 14 58 36 58 maintenance 9 38 21 34 not identified 1 4 5 8 note: adih=antituberculosis drug-induced hepatotoxicity, aindependent t-test, and bchi-square test, statistically significantlydifferences when p<0.05 althea medical journal. 2019;6(3) 156 amj september 2019 baseline was abnormal. grade 3 was designated when transferases were increased >5–20 times from upper normal limit or baseline if the baseline was abnormal; or when bilirubin was increased >3-10 times from upper normal limit or baseline if the baseline was abnormal. grade 4 was designated when transferases were increased >20 times from upper normal limit or baseline if the baseline was abnormal, or when bilirubin was increased >10 times from upper normal limit or baseline if the baseline was abnormal.9 the data weregrouped into adih cases and control was a group without adih. the characteristic between groups wascompared and analyzed using the independent t-test for variable numerical or independent samples mann-whitney u test when the data werenot normally distributed. as for the categorical variable, the chi-squares test was performed. statistically significant was considered when p<0,05. analysis was conducted using spss version 22 (spss.license.unpad.ac.id). results during january–december 2012, there were 86 children with pulmonary tb were included in this study, of whom only 24 subjects were reported to have adih. most of the children with adih were girls (71%), aged 5–9 years old (42%) with two or three comorbidities (33%), and they were in the intensive phase of therapy (58%), as depicted in table 1. there were no significant statistical differences between the group with adih and without adih. interestingly, the malnutrition was more often in adih cases (46%) compared to those without adih (29%). in a subset of the children (n36) of whom alt, ast and bilirubin were examined; there were 24 (67%) subjects who were indicated table 2 the median concentration and distribution of the liver function test result and clinical symptoms parameter with adih without adih pn (%) n (%) n=24 n=12 alt, u/l; median (range) 49.5 (8–728) 10 (7–24) 0.000a normal 10 (42) 12 (100) grade1 6 (25) grade 2 3 (13) grade 3 5 (21) grade 4 ast, u/l; median (range) 83 (24–997) 28 (16–41) 0.000a normal 2 (8) 12 (100) grade1 16 (67) grade 2 1 (4) grade 3 4 (17) grade 4 1 (4) bilirubin, mg/dl; median (range) na na normal 1 (33) grade1 1 (33) grade 2 grade 3 grade 4 1 (33) note: data are in n (%) or median (range); alt=alanine aminotransferase; ast=aspartate aminotransferase; na=data not available; aindependent-samples mann-whitney u test, significant if p<0,05 althea medical journal. 2019;6(3) 157 adih and 12 (33%) were not adih. grade 4 adih occurred in 2 of 24 cases (8%) from the measurement of ast and bilirubin levels. the alt and ast levels of the subject who had jaundice were in grade 2, respectively. there wasa significant difference (p<0,05) deviation of normal lft based on alt or ast levels between subjects with and without adih. however, only 1 patient had jaundice (table 2). discussions the adih in our study has been found in 28% (24/86) children; however, the laboratory examination was only conducted in 36 children; thus adih with confirmed laboratory test was 67%, suggesting that laboratory examination is needed in pediatric tb. in previous study, adih in hospital has reached 45%, 10 whereas first publication about the disturbance of lft on subjects pulmonary tb who was administered rif and inh just 13/37 (35%) subjects.8 the incidence of adih in children is higher than in adults who received rif and inh. the high frequency of adih in pediatric pulmonary tb has been reported in 25-52% of all patients.11 therefore, laboratory examination for the liver function is necessary to confirm the adih status. interestingly, although there is a state of adih, only 1 child has shown jaundice as a sign of adih with lft elevation. the adih symptoms in the children are less than the adults; it may be due to the incidence of adih in children is less frequent than in adults receiving comparable drug dosages and regimens. study comparing 56 children <19 years of age and 213 adults with oat drugs and liver enzymes measurements that have been taken routinely at two, four, six and eight weeks after treatment start, shows that no children have more than grade 3 of adih and none with signs or symptoms of adih; whereas 20 adults (9.4%) have adih. 8 adih formation has occurred in a complex process that involves a direct pathway, degree of liver injury and its outcome. the key upstream events are triggered by particular drugs or theirmetabolites, which may induce hepatotoxicity. this event is initiated by the increased reactivity of metabolite formation, which is generally a result of phase 1 metabolism, or failure in the metabolic detoxification functions of phase 2. the expression of the enzymes that metabolize the drugs and transporter in the process of excretion and elimination of drugs metabolites (phase 3) have been regulated by transcription factors. genetic and environmental factors that may affect the expressions and activities of proteins in phases 1, 2, 3 of drug metabolism would affect the rate of the formation and accumulation of reactive metabolites. these reactive metabolites would induce an excessive reactive oxygen species (ros) formation that makes lipid peroxidation and cell death, causing hepatocellular damage. this hepatocellular damage causes a release of alt and ast into the bloodstream, resulting in an increased in alt levels. moreover, there is also an elevation of bilirubin levels in hepatocellular damage, making the trias or three measurements of alt, ast, and bilirubin as specific biomarkers to hepatocellular damage induced by oat.12 our study involved forty percent of children aged 5-9 years old with adih. the previous study has found that the majority children with adih are below the age of 5 years old. adih can occur in children at any age, although the risk of complication is increased in the younger age < 4 years of age, however, the incidence of adih is markedly lower in children than in adults.8,10,13 interestingly, our study has shown that the adih waspredominantly in girls, although no association between gender and incidence adih in children.13 in the contrary, female adults are 4-fold more susceptible to adih than males, due to thehigh activity of cyp3a in the female. this enzyme oxidizes toxic isoniazid hydrazine, which is the result of isoniazid hydrolysis to n-hydroxy acetyl hydrazine; before further dehydrated to yield acetyl diazines. acetyl-diazines could be degraded into toxic metabolites or acetyl onium ion, ketene, acetyl radicals that bind covalently to hepatic macromolecules, causing in turn into hepatocellular damage.11 moreover, most of the children with adih in this study were in the intensive phase of therapy (56%). patients who had been received anti-tuberculosis drugs may have increased alt or ast concentration within 12-60 days,5 and the development of adih may start during the first 2 weeks of drug administration.14 the comorbidities in children in our study have been described as bronchopneumonia, malnutrition, sepsis, nephropathy, meningoencephalitis and many others; of which malnutrition (46%) is the most common. malnutrition is associated with a higher incidence of adih,15 and considered as one of the factors contributing to a higher incidence of adih due to inadequate intake of important nutrients in maintaining the integrity of liver metabolism and detoxification of antivycke yunivita et al.: antituberculosis drug-induced hepatotoxicity in pediatric tuberculosis althea medical journal. 2019;6(3) 158 amj september 2019 tuberculosis drug in malnourished states. 11 some limitations encountered in this study were various comorbidities that may influence the patient’s condition and liver function test, leading to eventually confounding results. the deviation of normal lft should be checked for every patient who received antituberculosis drugs to manage pulmonary tb effectively. genetic tests related to susceptibility to druginduced hepatotoxicity might be a topic of interest. in conclusion, antituberculosis druginduced hepatotoxicity (adih) has been diagnosed based on the elevation of alt, ast, and bilirubin; with malnutrition as the most common comorbidities. children with malnutrition during antituberculosis therapy are suggested to have a periodic liver function test monitoring to prevent the development of adih. references 1. world health organization. global tuberculosis report 2018. geneva: world health organization; 2018. 2. direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan republik indonesia. petunjuk teknis manajemen dan tatalaksana tb anak. jakarta: kementerian kesehatan republik indonesia; 2016. p. 1–84. 3. babalik a, arda h, bakirci n, ağca s, oruç k, kiziltaş ş, et al. management of and risk factors related to hepatotoxicity during tuberculosis treatment. tuberk toraks. 2012;60(2):136–44. 4. bagiada im, primasari nlp. faktorfaktor yang mempengaruhi tingkat ketidakpatuhan penderita tuberkulosis dalam berobat di poliklinik dots rsup sanglah denpasar. j peny dalam. 2010;11(3):158–63. 5. faiz sn, chowdhury n, khan mah, parvin r. evaluation of risk factors for hepatotoxicity in patients receiving antitubercular four drugs regimen in initial two months. chattagram maa-o-shishu hosp med coll j. 2015;14(1):15–8. 6. dianwari v, yunivita v, kania n. effect of nti-tuberculosis drugs on liver damage based on alanine aminotransferase level in pulmonary tuberculosis patients. althea medical journal. 2017;4(4):506–11. 7. sun q, zhang q, gu j, sun w, wang p, bai c, et al. prevalence, risk factors, management, and treatment outcomes of first-line antituberculous druginduced liver injury: a prospective cohort study. pharmacoepidemiol drug saf. 2016;25(8):908–17. 8. donald pr. antituberculosis drug-induced hepatotoxicity in children. pediatr rep. 2011;3(2):e16. 9. us department of health and human service. common terminology criteria for adverse events (ctcae) v5.0. washington: national institute of health; 2017. p. 1–152. 10. nataprawira hm, hannah ra, kartika hh. hospitalized pediatric antituberculosis drug induced hepatotoxicity: experience of an indonesian referral hospital. asian pacific j trop dis. 2017;7(5):276–9. 11. ramappa v, aithal gp. hepatotoxicity related to anti-tuberculosis drugs: mechanisms and management. j clin exp hepatol. 2013;3(1):37–49. 12. oh rc, hustead tr. causes and evaluation of mildly elevated liver transaminase levels. am fam physician. 2011;84(9):1003–8. 13. mansukhani s, shah i. hepatic dysfunction in children with tuberculosis on treatment with antituberculous therapy. ann hepatol. 2012;11(1):96–9. 14. singanayagam a, sridhar s, dhariwal j, abdel-aziz d, munro k, connell dw, et al. a comparison between two strategies for monitoring hepatic function during antituberculous therapy. am j respir crit care med. 2012;185(6):653–9. 15. singla r, sharma sk, mohan a, makharia g, sreenivas v, jha b, et al. evaluation of risk factors for antituberculosis treatment induced hepatotoxicity. indian j med res. 2010;132:81–6. althea medical journal. 2019;6(3) 159 index althea medical journal author index althea medical journal. 2019;6(3) 160 amj september 2019 subject index althea medical journal. 2017;4(2) 304 amj june 2017 profile of cardiorespiratory fitness, flexibility and fat percentage of junior high school students in jatinangor gemuruh putra akbar,1 ambrosius purba,2 yenni zuhairini3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: obesity and physical inactivity is a major risk factor for non-communicable disease and global mortality in adolescent. lack of physical activity will lead the condition into poor physical fitness, measured by cardio respiratory fitness (maximum oxygen volume, vo2 max), and other components such as flexibility. the study aimed to describe vo2 max, flexibility and fat percentage among junior high school students in jatinangor. methods: the study was a descriptive observational study using descriptive analysis. vo2 max was assessed using astrand ryhming step test, flexibility was measured using flexometer sit and reach test, and fat percentage was determined using bioelectrical impedance analysis scale. the subjects were junior high school students who were study in 1st, 2nd and 3rd grade in jatinangor junior high school based on stratification sampling method. it was conducted from september–october 2013. results: total subjects were 110 students consisted of male (n=52) and female (n=58). the vo2 max were in good and above category, 57.69% of male (50.37 ± 9.80 ml/kg/min), and 60.34% of female (37.66±7.03 ml/kg/min). the flexibility for both males and females were within excellent category (67.31%, 26.56 ±7.14 cm and 67.24%, 27.29±6.64 cm respectively). the fat percentage in females were within healthy category (67.24%, 25.28 ± 6.85 %), meanwhile male were within underfat category (48.08%, 11.66 ± 5.83 %). conclusions: the majority of vo2 max, and flexibility both in male and female were good. the fat percentages were good in female students, while in male students were under normal range. keywords: adolescent, fat percentage, flexibility, vo2 max, junior high school students correspondence: gemuruh putra akbar, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281573169969 email: gemuruhputraakbar@gmail.com introduction flegal et al.1 stated that overweight and obesity are the risk for global deaths. besides that, the physical inactivity has been identified as one of the leading factor of mortality in the world.2 jatinangor, which is categorized as periurban area because of the population and other facilities, may experience same lifestyle changes as urban does. these changes occur also in children and adolescent, for example junior high school students. changes in lifestyle can lead to changes in nutritional status and physical fitness. obesity is defined as abnormal or excessive fat accumulation.3 one method for measuring nutritional status is fat percentage. measuring fat percentage can be done by several methods such as skin fold calliper, body mass index (bmi), hydrostatic weighing, bod pod, dual energy x-ray absorptiometry (dexa) and bioelectrical impedance analysis (bia). bioelectrical impedance analysis is an accurate, simple, fast, and cheap method to measure fat percentage.4 physical fitness is defined as the capacity to carry out physical activity.5 in relation to physical fitness and health related fitness, there are five components to be measured; (1) cardiorespiratory fitness which can be measured by maximum oxygen volume (vo2 max); (2) muscle strength; (3) muscle endurance; (4) flexibility; and (5) body fat percentage.5 the aim of this study was to describe vo2 max, flexibility, and fat percentage among junior high school students in jatinangor. methods this was a descriptive observational study. the population were junior high school students in amj. 2017;4(2):304–8 305 althea medical journal. 2017;4(2) jatinangor, sumedang, jawa barat. this study was conducted in each related school, the state junior high school (sekolah menengah pertama negeri, smpn 1, 2, and 3 jatinangor and was carried out from september tooctober 2013. the study was approved by the health research ethics committee faculty of medicine universitas padjadjaran and the school committee. sample was taken using a stratified sampling method. the minimum sample of this study based on calculation is 110 people. from total population of 11 junior high schools, 3 schools was taken to be the sample. thirty six students from every school was divided by each degree and gender resulting in minimum 6 male students and 6 female students for each degree in every school. one hundred and ten subjects from 3 schools consisted of 52 male students and 58 female students were given their consent to be part of the study. the physiological physical categories of the subjects consisted of gender, age, weight, height, body mass index, blood pressure and pulse rate were then measured.. subsequently, the students’ vo2 max, flexibility and fat percentage were assessed respectively. astrand ryhming step test was used for measuring vo2 max of the students. students were asked to use polar before measurement. then hey did up and down movement toward bench, different for each gender, for 5 minutes and said the heart rate each minute. the 5th heart rate then were noted and plotted to get vo2 max.6 the flexometer sit and react test was used to measure flexibility. subjects were asked to sit on the floor by extending the legs while tip of the finger touched the edge of flexometer. then students were asked to push the edge of flexometer to their maximal point while the legs were still extended . the result of 2–3 measurements then were divided to find the mean.. bioelectrical impedance analysis scale was calibrated using the subject’s gender, age, and height. subjects with minimal clothes then stood on the scale and the fat percentage result was noted and plotted based on the age. the results were also categorized based on their valid category. these results were then tabulated to show the percentage of each category. results total subjects were 110 students consisted of 52 males and 58 females. the characteristic of the subjects based on the first measurement consisted of age, weight, height, bmi, systolic pressure, diastolic pressure, and pulse rate (table 1). the vo2 max, flexibility, and fat percentage were then measured (table 2), divided into male and female and then categorized (table 3). the vo2 max were categorized into very poor, poor, fair, good, excellent and superior. flexibility were categorized into poor, fair, good, very good and excellent while fat percentage were categorized into underweight, healthy, overweight and obese. the majority of vo2 max in male students was within fair category (38.46%) while female students were within superior category (27.59 %). the total percentage of students with vo2 max within good category and above were 57.69% for male and 60.35% for female (table 2). the flexibility of both male and female were within excellent category as 67.31% and 67.24% respectively (table 2). the majority of fat percentage in female students was table 1 respondents characteristics characteristics male (n=52) female (n=58) mean±sd age (year old) 13.54±0.96 13.38±0.64 weight (kg) 41.99±8.75 42.94±7.41 height (cm) 154.45±7.75 148.52±5.47 body mass index (kg/m2) 17.47±2.73 19.41±2.81 systolic (mmhg) 106.04±12.54 101.53±11.74 diastolic (mmhg) 66.46±13.00 65.57±9.35 pulse rate 90.31±10.21 90.97±9.84 note : sd=standard deviation althea medical journal. 2017;4(2) 306 amj june 2017 within healthy category (67.24%), while male majority were within under the category value (48.08%), even though healthy male were 44.23% (table 2). discussion this study result showed that most of students had good cardiorespiratory fitness. cardiorespiratory fitness is determined by many factors such as age, gender, body composition, and degree of training.5 in this study, the good result in cardio respiratory fitness might be caused by their physical activity and body fat composition. many students must go to school on foot for miles from their house because of their location and socioeconomic status. eventhough jatinangor is a periurban area, there are aspects that do not meet the standard of criteria. one of the aspect is transportation. in jatinangor, the quality of tranportation is below standard, mostly because of the quality of the road. the quality and the amount of land transportation such as public transportation are also contributed to quality of transportation. from this condition, student has no option except walking for miles to their school. walking or cycling to school has been associated with higher daily physical activity and increased daily energy expenditure in children and adolescents compared to those going by car.7 the study in 2006 from danish by cooper et al.7 showed that children and adolescents who actively go to school were five times significantly fitter. socioeconomic status, as mentioned above, also has a strong connection to the cardiorespiratory fitness. in 1998, prista et al.8 conducted a table 2 cardio respiratory fitness, flexibility and fat percentage results variable male female total mean ± sd mean ± sd mean ± sd vo2 max (ml/kg/min) 50,37 ± 9,80 37,66 ± 7,03 43,66 ± 10,56 flexibility (cm) 26,56 ± 7,14 27,29 ± 6,64 26,94 ± 6,86 fat percentage (%) 11,66 ± 5,83 25,28 ± 6,85 18,84 ± 9,33 note : sd = standard deviation table 3 cardio respiratory fitness, flexibility and fat percentage results based on category variable category male female normal value % (n=52) normal value % (n=58) vo2 max very poor <35.0 0.00 <25.0 0.00 (ml/kg/min) poor 35.0–38.3 3.85 25.0–30.9 13.79 fair 38.4–45.1 38.46 31.0–34.9 25.86 good 45.2–50.9 17.31 35.0–38.9 17.24 excellent 51.0–55.9 13.46 39.0–41.9 15.52 superior >55.9 26.92 >41.9 27.59 flexibility poor 1–5 1.92 2–6 0.00 (cm) fair 6–11 0.00 6–11 0.00 good 12–17 9.62 12–18 10.34 very good 18–23 21.15 19–23 22.41 excellent >23 67.31 >23 67.24 fat percentage underweight <12 48.08 <16 8.62 (%) healthy 12–22 44.23 16–29 67.24 overweight 22–27 3.85 29–33 18.97 obese >27 3.85 >33 5.17 307 althea medical journal. 2017;4(2) gemuruh putra akbar, ambrosius purba, yenni zuhairini: profile of cardiorespiratory fitness, flexibility and fat percentage of junior high school students in jatinangor study in mozambique and suggested that socioeconomic status was an important determinant of fitness in mozambique, especially because of influence on body size, composition, and physical activity. there is also a strong relationship between vo2 max and body weight, bmi and body fat composition.9 those who are have normal body weight, bmi, or body fat composition will have higher cardiorespiratory fitness than those who are obese.9 this study is known that body weight, bmi, and body fat of subjects are normal. this result also revealed that most of students had excellent flexibility. the age and their high degree of physical activity may also be the major determinant of this flexibility results.5 there is also an association between students who live in rural area and degree of flexibility. the study from turkey in 2005 by özdirenç et al.10 stated that the children living in the urban areas were more inactive and obese, which resulted in a decrease in their flexibility. this means children in rural area will have higher flexibility. from fat percentage perspective, the research showed that most of female students had healthy fat percentage. in contrast, most male students had under category (48.08%), eventhough there is a little difference from those who were healthy (44.23%). the significant difference between male and female result might caused by gender differences. this condition are caused by the effect of hormones. in males, there are several hormones including testosterone which made the body lean and build more muscle, so there is higher muscle composition. females, in the other hand, have several hormones including estrogen and progresterone which made a deposit of fat in the body instead of muscle, so there are higher fat composition.3 there are many factors that influence fat percentage, such as genetic, age, gender, nutrition, and physical activity.11 increased in physical activity is inversely associated with high fat mass.12 it means high physical activity is associated with lower fat percentage. it was stated in the study from spain that the higher intensity of physical activity from activity such as walking to school for miles can also lower their fat mass.13 in addition, male students tend to be more active than female students. this condition makes even lower fat mass for male students in this study. the area of living and their socioeconomic status might influence the fat percentage results. socioeconomic status will influence their lifestyle and eating behaviour. the study from mozambique8 and turkey10 as mentioned before explained about the correlation between socioeconomic status, area of living and body fat composition. there was also a study from us, conducted by fox et al.14 in 2009, that stated school food environment might influence students bmi and fat mass, eventhough this might be not much related to the study. one of the limitation of this study is in using astrand ryhming step test to measure cardiorespiratory fitness because of malfunction of the heart rate monitor. the short time interval of this study also made the sample limited and some of variable not normally distributed. in conclusion, most of students had good cardiorespiratory fitness and excellent flexibility. from fat percentage prespective, most of female students had healthy fat percentage whereas most male students were within under category. it is recommended that the physical fitness, including cardiorespiratory fitness and flexibility, should be maintained and improved by doing a lot of physical activities. the who recommends children and youth aged 5–17 to accumulate at least 60 minutes of moderate to vigorous intensity physical activity which is equal to 75–85% of maximum heart rate.15 the type of physical activity should be aerobicand activity that strengthen muscle, bone, and flexibility at least 3 times a week.15 there are also other guidelines for maintaining and improving physical fitness. the fat percentage for female students should be also maintained in contrary, for male students, it should be improved because of the importance of fats in the body. vitamins a, d, e, and k are fat-soluble, they can only be digested, absorbed, and transported in conjunction with fats. fats are sources of essential fatty acids, an important dietary requirement and play a vital role in maintaining healthy skin and hair, insulating body organs against shock, maintaining body temperature, and promoting healthy cell function. fats also serve as energy stores for the body and are broken down in the body to release glycerol and free fatty acids. the glycerol can be converted into glucose by the liver and thus used as a source of energy.3 fats, in the form of steroid hormones, are also used in many body function, including testosterone for secondary development in adolescent. although their nutritional status is normal, low fat percentage will lead to health problem. althea medical journal. 2017;4(2) 308 amj june 2017 meal planning is used to improve fat percentage. to increase the fat percentage, a person must take higher intake based on their energy requirement. before conducting meal planning, a person must undergo several steps to determine nutritional status, such as physical exam, anthropometric measurement, and lab examination. after nutritional status known, recommendation of intake must be calculated. the recommendation for adequate intake for children is 80–100 cal/kg bw and 25 % of the total calory intake must be in the form of fat. the meal is then planned based on the type, amount, and time. the type and amount is suited for individual. it is best to have three heavy meals (in the morning, afternoon, and evening) and also two snack times (in the morning and afternoon).11 references 1. flegal km, graubard bi, williamson df, gail mh. excess deaths associated with underweight, overweight, and obesity. jama. 2005;293(15):1861–7. 2. blair sn. physical inactivity: the biggest public health problem of the 21st century. british journal of sports medicine. 2009;43(1):1–2. 3. guyton ac, hall je. textbook of medical physiology. 11th ed. pensylvania: elsevier saunders; 2006. 4. ostojic sm. estimation of body fat in athletes: skinfolds vs bioelectrical impedance. j sports med phys fitness. 2006;46(3):442–6. 5. katch vl, mcardle wd, katch fl. essentials of exercise physiology. 4th ed. philadelphia: lippincott william & wilkins; 2011. 6. jackson as. the evolution and validity of health-related fitness. quest. 2006;58(1):160–75. 7. cooper ar, wedderkopp n, wang h, andersen lb, froberg k, page as. active travel to school and cardiovascular fitness in danish children and adolescents. med sci sports exerc. 2006;38(10):1724–31. 8. prista a, marques at, maia j. relationship between physical activity, socioeconomic status, and physical fitness of 8-15 year old youth from mozambique. am j hum bio. 1998;9(4):449–57. 9. pribis p, burtnack ca, mckenzie so, thayer j. trends in body fat, body mass index and physical fitness among male and female college students. nutrients. 2010;2(10):1075–85. 10. özdirenç m, özcan a, akin f, gelecek n. physical fitness in rural children compared with urban children in turkey. pediatr int. 2005;47(1):26–31. 11. lysen lk, israel da. nutrition in weight management. in: mahan lk, escott-stump y, raymond jl, editors. krause’s food and the nutrition care process. 13th ed. new york: elsevier; 2012. p. 474–7. 12. ness ar, leary sd, mattocks c, blair sn, reilly j, wells j, et al. objectively measured physical activity and fat mass in a large cohort of children. plos med. 2007;4(3):e97. 13. ara i, vicente g, jimenez j, dorado c, serano ja, calbet ja. regular paticipation in sports is associated with enhanced physical fitness and lower fat mass in prepubertal boys. intl j obes relat metab disord. 2004;28(12):1585–93. 14. fox mk, dodd ah, wilson a, gleason pm. association between school food environment and practices and body mass index of us public school children. j am diet assoc. 2009;109(2):108-s17. 15. strong wb, malina rm, blimkie cjr, daniels sr, dishman rk, gutin b, et al. evidence based physical activity for school-age youth. j pediatr. 2005;146(6):732–7. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 444 amj september 2017 geographical factors in diagnostic delay among multidrug resistant tuberculosis patients nunuy nuraeni,1 hendarsyah suryadinata,2 bony wiem lestari3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3 department of public health faculty of medicine, universitas padjadjaran abstract background: diagnostic delay is a factor that can increase the high burden of multi-drug resistant tuberculosis (mdr-tb). xpert mycobacterium tuberculosis/rifampicin known as xpert is a rapid diagnostic test to detect mdr-tb. diagnostic delay defined the duration between a positive result of acid fast bacilli (afb) smear and positive result of mdr-tb by xpert examination. this study aimed to compare the analysis of the geographical factors in the diagnostic delay of mdr-tb patients at dr. hasan sadikin general hospital as the top referral hospital in west java indonesia. methods: this study was conducted in the period july−december 2016 using cross sectional design. a total of 152 mdr-tb patient data were collected from medical records of mdr-tb patients registered in mdr-tb clinic at dr. hasan sadikin general hospital in the period 2015−2016. the socio-demographic characteristics were collected and analyzed descriptively the diagnostic delay among mdr-tb patients was analyzed by mann whitney test. results: diagnostic delay of mdr-tb patients was 15 days in median, with a minimal and maximal delay of 2−140 days. there was a significant difference of diagnostic delay between patients from bandung with a median of 9(2-135) days and patients from outside of bandung with a median of 18(2-140) days, with p<0.01. conclusions: mdr-tb patients from outside bandung have a longer diagnostic delay than patient from bandung . a further expansion of using xpert as a rapid diagnostic test for mdr-tb patient is needed. keywords: diagnostic delay, multi-drug resistant tuberculosis, xpert correspondence: nunuy nuraeni, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: nunuynuraeni49@gmail.com introduction indonesia is one of the high burden countries of tuberculosis cases in the world.1 high burden of tb were added by the existence of multidrug resistant tuberculosis (mdr-tb) and the tb-hiv coinfection.1,2 multidrug resistant tuberculosis cases is still increasing. in 2015, there were 3507 mdr-tb suspect, 504 exposed and 377 cured.3 due to the increasing and development of mdr-tb effective diagnostic tools are needed to diagnose mdr-tb. nucleic acid amplification testing (naat) is a diagnostic method for tb that enables specific and sensitive identification of mutation of mycobacterium tuberculosis (mtb) gene that correlate with drug resistance.1,4 rapid test xpert mtb/rif also known as xpert is one of the examples of rapid diagnostic tools that has been recommended by the world health organization (who) in 2010.1,2,5 the mdr-tb diagnostic in indonesia is detected by a conventional method and rapid test. early examinations have used acid fast bacilli (afb), then used a conventional method such as culture with lowenstein jensen (lj) solid media and mycobacterium growth indicator tube (mgit) liquid media and examination with drug susceptibility test (dst) however, this procedure needs more time than a rapid test such as xpert or line probe assay (a method to examine a sensitivity of rifampicin and isoniazid).2 based on who guidelines about the implementation of xpert shows that xpert has a high accuracy that can diagnose 99% with bta positive patient and 80% with bta negative patient, xpert also can detect a complex mtb dna and rpob genes mutation directly from sputum sample amj. 2017;4(3):444–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1196 althea medical journal. 2017;4(3) 445 less than two hours, therefore this method is recommend as a rapid test to diagnose drug resistant tuberculosis by who.2,6 a study about the implementation of xpert in three indonesian districts, showed that the use of rapid test xpert quickly detects drug resistant tuberculosis and can lower the diagnostic delay from a mean of 75 days becomes 1 day with p<0.001.5 furthermore, factors associated with diagnostic delay are the centralized management of health care and poor health care seeking.7 a study from china showed that more than half of the number of patients have a diagnostic delay of 30 days, the influencing factors are poor knowledge about mdr-tb, low socio-economic conditions, also lack of access to the health care facility and close contact with mdr-tb patients.8,9 this study aimed to analyzed the geographical factors in the diagnostic delay of mdr-tb patients at dr. hasan sadikin general hospital as the top referral hospital in west java indonesia. methods this study was a cross sectional study conducted in the period july−december 2016 using medical records of mdr-tb patients registered in the mdr-tb clinic at dr. hasan sadikin general hospital bandung in the period 2015−2016. data were collected after permission was approved by the health research ethics committee faculty of medicine, universitas padjadjaran with ethical number 508/un6.c1.3.2/kpek/pn/2016. the inclusion criteria were complete medical records of the mdr-tb patients aged ≥ 18 years old. the exclusion criteria were the incomplete or missing medical records of patients. the sample collection used total sampling. a total of 152 medical records were included in the final analysis (figure 1). the variables in this study were the sociodemographic characteristics of the patient (age, gender, residence, occupation, and income) and diagnostic delay. the patient’s residence was divided into 2 locations, namely bandung city (as the capital city of west java and the location of dr. hasan sadikin general hospital), and outside bandung city. diagnostic delay in this study is defined as the duration between positive acid fast bacilli (afb) result and positive rifampicin resistant in xpert examination. furthermore, data analysis was performed using a computer program. the categorical data consisting of gender, residence, and occupation, were analyzed by descriptive statistics and presented by number and percentage. the numerical data consisted of age and diagnostic delay. age was presented by the mean and figure 1 flow diagram of subject inclusion in the study nunuy nuraeni, hendarsyah suryadinata, bony wiem lestari: geographical factors in diagnostic delay among multidrug resistant tuberculosis patients althea medical journal. 2017;4(3) 446 amj september 2017 table 1 socio-demographic characteristic of mdr-tb patient characteristic n(%) gender male 90(59.2) female 62(40.8) age (mean, standard deviation) (39.4; 12.75) residentce bandung city 32(21.1) outside bandung city 120(78.9) occupation unemployed 5(3.3) house wife 29(19.1) employee 12(7.9) laborer 14(9.2) student 8(5.3) entrepreneur 20(13.2) government servant 5(3.3) unknown 59(38.8) standard deviation. diagnostic delay was presented by median and minimal-maximal. the analyzes began from determining the data normality with kolmogorov smirnov test, and mann whitney test was used to compare the diagnostic delay of mdr-tb patients who came from bandung and outside bandung city with 95% confidence interval (ci). for the statistical test, p<0.05 was regarded as statistically significant. results out of 152 patients, most of the participants were male , and the majority of patients’s figure 2 diagnostic delay althea medical journal. 2017;4(3) 447nunuy nuraeni, hendarsyah suryadinata, bony wiem lestari: geographical factors in diagnostic delay among multidrug resistant tuberculosis patients residence were in bandung city (table 1). this study showed that there was a statistical significance of diagnostic delay between patients from bandung with a median delay of 9 days and outside bandung city with a median delay of 18 days with p<0.01 with the total median diagnostic delay of 18 days with minimal and maximal range of 2 to 140 days. while the diagnostic delay of patients from outside bandung was longer than from bandung city (table 2). discussion in this study, the majority of study participants were male respondents. this result is similar with a study from zhang et al.10 in china, which stated that male participants have higher proportion of risk than female participants. this study also supported the study conducted by mekonnen et al.11, most of the study participants are male (64.5%). this finding is due to the environmental exposure by drug resistant tuberculosis strain.10 the study from elmi et al.12 showed that male has a higher risk to mdr-tb due to alcohol abuse, drug abuse dependency by intravenous injection, or status of imprisonment that male often do than female. in contrary, a study conducted by nair sa et al.13 showed, male and female have the same risk for drug resistant tuberculosis. in this study, age of the majority was 39.4 years old, this finding shows the same results as the study in india, however is different with the study by ullah et al.14 in pakistan, which reveals that 10-25 year-olds are at risk to developed mdr-tb due to poor compliance for people in that age group are busy in school or at work. poor treatment of compliance has a bad influence to the outcome because it will increase the transmission of drug resistant bacterial strain.15 furthermore, in occupation, housewife has a high proportion of risk. this might be due to close contacts among family members who had mdr-tb, because the transmission of tuberculosis could occur by person to person through infectious droplets. this was also influenced by the infectious degree and environment conditions. this finding was similar with the study conducted by mulu et al.9 which stated that the second majority of occupation is housewife (24.2%) after farmer (25.5%). moreover, the total diagnostic delay in this study showed that patients with drug resistant tuberculosis have a median diagnostic delay of 15 days with the minimal and maximal range of 2 to 140 days. the median diagnostic delay in this study was lower than the study conducted by li et al.8 in china, where the diagnostic delay is defined as the duration between onset of symptom until true diagnosis, which reaches 30 days of delay. in another study by zhang et al.10 the diagnostic delay is defined as the results of sputum smear and drug susceptibility test (dst), that reach 102 days of delay. the diagnostic delay occurs due to the poor capacity of the laboratory to detect drug resistance.10 in indonesia, laboratories with a diagnostic facility to detect drug resistant tuberculosis still increase. until june 2015, there were 41 xpert, certified culture laboratories and certified dst laboratories spread among the provinces, however, although they were spread in all provinces, the diagnostic delay still occurs.3 in this study, the diagnostic delay of patients from outside bandung reached 18 days in the median, this number was longer than the diagnostic delay of patients from bandung which reached 9 days in the median with p<0.01. this finding was similar with the meta-analysis study from li et al.8 in china that patients in rural areas have a higher susceptibility to develop mdr-tb than patients in the city. this is due to the poor access to health facilities, lack of transportation to reach health facilities, and lack of laboratories with tools to diagnose mdr-tb.7,8 the limitation of this study was, this study did not measure the diagnostic delay received from the laboratory and the patient’s delay as those factors could influence the total diagnostic delay. in conclusion, this study finds that the diagnostic delay of patients from outside table 2 duration of diagnostic delay duration of diagnostic delay median(min-max) p-value* total 15 (2-140) 0.001 bandung city 9 (2-135) outside bandung city 18 (2-140) note: *mann whitney test althea medical journal. 2017;4(3) 448 amj september 2017 bandung is longer than of patients from bandung city. it needs every endeavor to increase an early diagnostic in suspected drug resistant tuberculosis patients in the primary health care, hospital or other health care facility, and one of them is through extension of using xpert in indonesia as rapid diagnostic tools for mdr-tb. references 1. who. global tuberculosis report 2016. geneva: world health organization; 2016. p. 12–4. 2. piatek as, cleeff m, alexander h, coggin wl, rehr m, van kampen s, et al. genexpert for tb diagnosis: planned and purposeful implementation. glob health sci pract. 2013;1(1):18–23. 3. kementerian kesehatan republik indonesia. laporan situasi perkembangan tb mdr di indonesia triwulan ii tahun 2015. jakarta: kemenkes ri; 2016. 4. niemz a, boyle ds. nucleic acid testing for tuberculosis at the point-of-care in highburden countries. expert rev mol diagn. 2012;12(7):687–701. 5. van kampen sc, susanto nh, simon s, astiti sd, chandra r, burhan e, et al. effects of introducing xpert mtb/rif on diagnosis and treatment of drug-resistant tuberculosis patients in indonesia: a pre-post intervention study. plos one. 2015;10(6):1–11. 6. who. xpert mtb/rif implementation manual: technical and operational “howto”; practical considerations. geneva: world health organization press; 2014. p. 1–9. 7. li y, ehiri j, tang s, li d, bian y, lin h, et al. factors associated with patient, and diagnostic delays in chinese tb patients : a systematic review and meta-analysis. bmc med. 2013;11(30):156–61. 8. li y, ehiri j, oren e, hu d, luo x, liu y, et al. are we doing enough to stem the tide of acquired mdr-tb in countries with high tb burden? results of a mixed method study in chongqing, china. plos one. 2014;9(2):1–12. 9. mulu w, mekonnen d, yimer m, admassu a, abera b. risk factors for multidrug resistant tuberculosis patients in amhara national regional state. afr health sci. 2015;15(2):368–77. 10. zhang x, yin j, li h, li s, walley j, zou g, et al. diagnostic and treatment delays of multidrug-resistant tuberculosis before initiating treatment: a crosssectional study. trop med int health. 2015;20(11):1431–37. 11. mekonnen f, tessema b, moges f, gelaw a, eshetie s, kumera g. multidrug resistant tuberculosis: prevalence and risk factors in districts of metema and west armachiho, northwest ethiopia. bmc infect dis. 2015;15(1):461–7. 12. elmi os, hasan h, abdullah s, zuki m, jeab m, alwi z bin, et al. multidrug-resistant tuberculosis and risk factors associated with its development: a retrospective study. j infect dev ctries. 2015;9(10):1076–85. 13. nair sa, raizada n, sachdeva ks. factors associated with tuberculosis and rifampicin-resistant tuberculosis amongst symptomatic patients in india: a retrospective analysis. plos one. 2016;11(2):1–9. 14. ullah i, javaid a, tahir z, ullah o, shah aa. pattern of drug resistance and risk factors associated with development of drug resistant mycobacterium tuberculosis in pakistan. plos one. 2016;11(1):1–7. 15. palomino jc, martin a. drug resistance mechanisms in mycobacterium tuberculosis. antibiotics. 2014;3(3):317– 40. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 506 amj december 2017 effect of anti-tuberculosis drugs on liver damage based on alanine aminotransferase level in pulmonary tuberculosis patients vera dianwari,1 vycke yunivita kusumah dewi,2 nia kania3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: antituberculosis (anti-tb) drugs could cause serious effect such as hepatotoxicity signed by the increase of alanine aminotransferase (alt) level. anti-tb drugs are still needed by tb patients who have hepatotoxicity, although clinicians who manage this condition have not recognize whether the advantage of anti-tb drugs is higher than its adverse effect, and there is no data describing about that issue. this study was conducted to discover the liver damage based on the alt changes before and 12 days after initial antitb treatment. methods: this was a cross-sectional study with total sampling of medical records of pulmonary tuberculosis inpatients from 1st january 2013–31th december 2014 at the department of internal medicine of dr. hasan sadikin.general hospital. from 141 data, only 14 medical records were eligible to be included in this study. the data used were alt level before and after therapy. these data were analyzed using wilcoxon test and considered as significant if p<0.05. results: the median age of the subject study was 48(18-65) years. among 14 patients, 8 were female and 6 were male. five out of fourteen patients developed hepatotoxicity. four out of five developed grade 1 hepatotoxicity and one out of five developed hepatotoxicity grade 4. the analysis of the data showed the differences of alt level before anti-tb therapy (22(4-447)) and 12 days after initial therapy (18.5(4-1206)) was not significant (p=0.660). conclusions: there is no liver damage based on alt changes after anti-tb treatment so the treatment can be continued. keywords: alanine aminotransferase, antituberculosis drugs, hepatotoxicity, tuberculosis correspondence: vera dianwari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west java, indonesia, email: verdian.anwari@gmail.com introduction tuberculosis (tb) is still one of the biggest problems in the world.1,2 the world health organization (who) reported in 2014 that there were approximately 9,6 million new cases of tb, 58% which occurred in south-east asia and western pacific region, including indonesia.2 tuberculosis is actually a disease that can be treated with intensive and comprehensive treatment.3 the challenges from this treatment are that antituberculosis (antitb) drugs could cause multidrug resistance (mdr) and some adverse effects, including hepatotoxicity. hepatotoxicity is one of the anti-tb drugs adverse effects.3,4 it is a liver dysfunction or liver damage that correlates to drug dosage or xenobiotic.5 anti-tb drugs that cause hepatotoxicity include isoniazid, rifampicin, pyrazinamide, and ethambutol.5 hepatotoxicity could be seen by the high level of alanine aminotransferase (alt) especially 12 days after initial treatment.6 this substance is a specific enzyme produced by the liver when the damage occurred.5 patients with hepatotoxicity still need anti-tb drugs, although physicians have not discovered whether the advantages of anti-tb drugs are higher than the disadvantages.4 amj. 2017;4(4):506–11 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1259 althea medical journal. 2017;4(4) 507 until currently, there has not been any study comparing the effect of anti-tb drugs as the agent that cause hepatotoxicity to the changes of alt level in indonesia, especially in dr. hasan sadikin general hospital bandung. these data can help the physician to determine whether the anti-tb drugs treatment should be continued or not when the alt is increasing. this study was conducted to discover liver damage based on alt level changes before and 12 days after initial treatment of anti-tb drugs. methods the study was carried out from septembernovember 2015 at the department of internal medicine and department of clinical pathology in dr. hasan sadikin general hospital bandung. it was an observational analytic study with a cross sectional approach using nonprobability total sampling of pulmonary tb in inpatients’ medical records from 1st january 2013-31th december 2014. this study was approved by the health research ethics committee of dr. hasan sadikin general hospital bandung and all data collection will be concealed. the object of this study was the medical record of pulmonary tb patients who had first line anti-tb drugs treatment in dr. hasan sadikin general hospital bandung. the inclusion criteria were: (1) the patients age were above 18 years, (2) had first line anti-tb drugs treatment, (2) had alt examination at least twice, before the treatment and 12 days after treatment. measurement of alt was carried out using the hitachi 902 machine in the department of clinical pathology and the result was attached in the medical record document. figure flow diagram of all patients diagnosed pulmonary tb in data vera dianwari, vycke yunivita kusumah dewi, nia kania: effect of anti-tuberculosis drugs on liver damage based on alanine aminotransferase level in pulmonary tuberculosis patients althea medical journal. 2017;4(4) 508 amj december 2017 table 1 baseline characteristics of 14 pulmonary tb patients included in the study characteristics n age (years): median(minimum-maximum)) 48(18-65) sex male 6/14 female 8/14 hepatotoxicity grade 1 4/14 grade 2 grade 3 grade 4 1/14 co-morbid of pulmonary tuberculosis patients extrapulmonary tuberculosis 2/14 hematoimmunology disturbances human immunodeficiency virus infection 2/14 systemic lupus erythematosus 1/14 toxic epidermal necrolysis 1/14 thrombocytosis 1/14 anemia inflammation 2/14 hemostasis disturbance hypertension 2/14 pleural effusion 1/14 metabolism disturbance (diabetes mellitus) 2/14 others 10/14 co-medication of pulmonary tuberculosis patients antidepresants 2/14 anticoagulants 1/14 antiretrovirals (arv) 2/14 steroids 4/14 non steroidal anti inflammatory drugs (nsaid) 6/14 the results of alt level measurement in this study were classified into several classes based on common terminology criteria for adverse effect (ctcae) for descriptive purposes. grade 1 was defined as the increasing of alt from the highest normal range of alt until 3 times highest normal level. grade 2 was defined as the increasing of 3-5 times from highest normal range of alt level. grade 3 was defined as the increasing 5-20 times from the highest normal range of alt. grade 4 was defined as increasing more than 20 times from the highest normal range of alt. furthermore, alt level data from the medical record were statistically analyzed using wilcoxon non-parametric test since there were anomalies in the distribution of data. statistically significant was considered when p<0.05. results among 141 patient’s medical records, only 14 met the inclusion criteria and were eligible to be included in this study (figure 1). based on the characteristics of the patients, out of the 14 medical records, 5 developed althea medical journal. 2017;4(4) 509vera dianwari, vycke yunivita kusumah dewi, nia kania: effect of anti-tuberculosis drugs on liver damage based on alanine aminotransferase level in pulmonary tuberculosis patients hepatotoxicity with one of them having severe hepatotoxicity (grade 4). the 14 medical records of pulmonary tuberculosis patients showed that the patients had comorbid disease, the highest co-morbid was hematoimmunology disturbances and the most co-medication used was nsaid (table 1). furthermore, the analysis of pulmonary tb patient’s alt from the measurement before treatment and 12 days after initial treatment used the wilcoxon test as nonparametric test analysis, and showed there was no significant difference (p≥0,05) from the alt measurement before anti-tb drugs treatment and 12 days after initial treatment (table 2). discussions this study showed that the median and mode age of pulmonary tuberculosis patients was 48 and 47 with higher occurrences in female (8/14). this result was similar with another study conducted by qureshi d et al.7, who discovered that the most frequent patients are in the age group of 41-50 years with higher incidence occured in female (71%). this result occurred because the increasing age was associated with the higher incidence of tuberculosis.8 female subjects was higher than male perhaps due to several specific conditions in female, such as malnutrition, pregnancy, breastfeeding baby, and socioeconomic conditions.9 in addition, co-medication recorded along with anti-tb drug in this study was nsaid. eventhough this data was not related to the high event of hepatotoxicity, one study discovered that overdose of nsaid, especially acetaminophen, could cause liver damage. the liver damage is caused by the metabolite (nabqi) of the drug produced by the cytochrome p-450 enzymes in the liver. this metabolite could lead cell death and hepatocelullar necrosis.5 in this study, the range of alt measurement before anti-tb treatment was 4-477 u/l. it was discovered that one of the subjects had a very high alt level (447 u/l). it might occur since the subject had human immunodeficiency virus (hiv) infection and consumed arv drugs. these drugs are one of the most drugs that could cause hepatotoxicity. the mechanism of hepatotoxicity caused by arv can be due to direct toxicity to the hepatocyte, hypersensitivity reaction, or mitochondrial activity.7 the second alt level measurement’s result of this patient revealed the deceasing alt level (60u/l). another result in this study revealed that the range of alt measurement on 12 days after initial therapy was 4-1206 u/l. the subject who had the highest alt measurement in this period only took an anti-tb therapy according to the hospital medical records. the baseline of alt level was normal (26 u/l) and increased 17 days after the initial therapy become 1206 u/l (hepatotoxicity grade 4). this subject could be classifiied as severe hepatotoxicity since the third examination revealed that the alt level decreased although did not reach the normal range. it was similar with the study conducted by gulbay et al.10, who discovered that the incidence of severe hepatotoxicity is 9 (0,8%) out of 1149 subjects. the current study showed, there was no liver damage based on the alt level measurement before the anti-tb treatment and 12 days after the initial treatment of antitb treatment.this study corresponded with a study conducted by nahar.11 it showed that there are also neither alteration of alt before treatment (4.85±2.17) u/l and 12 days after initial treatment (7.50±6.02) u/l nor clinically appreciable.11 however, another study by gulaty et al.12, showed there are alteration of alt before treatment(18.8±3.70) u/l and 12 days after initial treatment (40.6±4.20) u/l.this study conducted by gulaty et al.12 is performed through primary data collection, and the increased frequency as compared to our study could be as a result of complete data information. the changes of alt in the period of 12 days after initial treatment which did not show alteration could occur possibly as hepatocyte is considered similar to other cells in the human body. although, hepatotoxicity occurred in this study, it did not reveal a high result due to the table 2 comparison of median of alt level before and after initial treatment variable type of test n median (minimun-maximum) p alt (u/l) pre-treatment 14 22(4-447) 0.660* post-treatment 14 18.5(4-1206) note: * tested with nonparametric wilcoxon test althea medical journal. 2017;4(4) 510 amj december 2017 regeneration of hepatocyte. the regeneration is initiated by the hepatocyte growth factor (hgf) that is released as response to trauma, either due to physical trauma or chemical trauma. this factor activates the antioxidant signaling pathway and it could prevent oxidative stress enhancement which lead to the increasing of alt. the process of regeneration would start in 5 minutes after trauma and complete the process in 5-7 days.5,13 moreover, alt enhancement is also determined by a genetic factor, although it could not be used as a conclusion since it could not be obtained from medical records. one of the genes responsible for the anti-tb drugs’ metabolism is the n-acetyltransferase-2 (nat2) gene. the anti-tb drug that is metabolized by this gene is isoniazid. besides, the nat-2 gene has a role in the acetylation process of hepatic n-acetyltransferase. polymorphism of the nat-2 gene could be different in patients. there are three kinds of nat-2 genetic variation in humans: slow acetylator, intermediate acetylator, and fast acetylator. these differences include the catalytic activity, stability of enzyme metabolizing by the drug, and the drug affinity. alt would increase in a person who has slow and fast acetylator status.14 the limitation of this study was the missing medical records since the medical record unit did not recorded all the data of inpatient pulmonary tb patients in the internal medicine department of the period 1st january 2013-31th december 2014 which could be analyzed. the remaining medical records also had incomplete information, especially the alt measurement test result and the onset of anti-tb initial treatment. expanding the sample study or homogenizing the sample from other sources could be an option to avoid the missing or incomplete information from medical records and to meet the sample size requirement. besides, the pilot study should be performed to estimate the sample number needed in the study. moreover, a case control study could be the alternative to reveal the effect of hepatotoxicity caused by anti-tb drugs in the future. in conclusion, there are no differences of alt level changes before treatment and 12 days after initial treatment. however, the alt level should still be checked due to the possibility of the occurrence of hepatotoxicity in this study, and to manage and evaluate the symptom that will occur. anti-tuberculosis drugs could be the possible or definitive cause of hepatotoxicity. the reaction after discontinuing the drugs should be observed to discover that anti-tb drugs is the definitive cause of hepatotoxicity. references 1. kementrian kesehatan republik indonesia. pedoman nasional penanggulangan tuberkulosis. jakarta: bakti husada, 2014. 2. world health organization. global tuberculosis report 2014. france: who, 2015. 3. sari id, yuniar y, syaripuddin m. studi monitoring efek samping obat antituberkulosis fdc kategori 1 di provinsi banten dan provinsi jawa barat. media litbang. 2014;24(1):28–35. 4. khoharo hk, ansari s, siddiqui aa, qureshi f. standard antituberculosis drug induced hepatotoxicity : do the risk factors matter. j liaquat univ med heal sci. 2010;09(2):84– 7. 5. singh a, bhat tk, sharma op. clinical biochemistry of hepatotoxicity. j clin toxicol. 2011;1(3):1-19 6. mahmood k, hussain a, jairamani kl. hepatotoxicity with antituberculosis drugs: the risk factors. pak j med sci. 2007;23(1):33–8. 7. núñez m. hepatotoxicity of antiretrovirals: incidence, mechanisms and management. j hepatol. 2006;44(1 suppl):s132–9. 8. wang c-s, chen h-c, yang c-j, tsai j-r, chong i-w, hwang j-j, et al. clinical characteristics of pulmonary tuberculosis patients from a southern taiwan hospitalbased survey. kaohsiung j med sci. 2008;24(1):17–24. 9. abbasi a, moradi a, kabir, mj. characteristic of pulmonary tuberculosis patients in golestan province of iran, 2002-2005. j med sci. 2006;6(4):698-700. 10. gülbay be, gürkan öu, yildiz öa, önen zp, erkekol fo, baççioǧlu a, et al. side effects due to primary antituberculosis drugs during the initial phase of therapy in 1149 hospitalized patients for tuberculosis. respir med. 2006;100(10):1834–42. 11. nahar bl, hossain am, islam mm, saha dr. a comparative study on the adverse effects of two anti-tuberculosis drugs regimen in initial two-month treatment period. bangladesh j pharmacol. 2008;1(2):51–7. 12. gulati k, ray a, vijayan vk. assessment of protective role of polyherbal preparation, livina, against anti-tubercular drug induced liver dysfunction. indian j exp biol. 2010;48(3):318–22. 13. enriquez-cortina c, almonte-becerril m, althea medical journal. 2017;4(4) 511vera dianwari, vycke yunivita kusumah dewi, nia kania: effect of anti-tuberculosis drugs on liver damage based on alanine aminotransferase level in pulmonary tuberculosis patients clavijo-cornejo d, palestino-dominguez m, bello-monroy o, nuno n, et al. hepatocyte growth factor protects against isoniazid/ rifampicin-induced oxidative liver damage. toxicol sci. 2013;135(1):26–36. 14. kumar akh, sudha v, ramachandram g. simple and rapid method for simultaneous determination of isoniazid and acetyl isoniazid in urine by hplc. asian j biomed pharm sci. 2014;4(34):46–50. vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 21 cognitive and functional outcome among hospitalized intracerebral haemorrhage patients in west java’s top referral hospital ilham bagas setyawan,1 paulus anam ong,2 m. zafrullah arifin3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of neurosurgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: stroke is the highest cause of disability in adults. disability and cognitive function impairment cause dependency and decreasing quality of life. the objectives of this study was to describe the outcome of functional and cognitive function among intracerebral haemorrhage patients admitted to dr. hasan sadikin general hospital bandung in 2013. methods: this study was a quantitative descriptive study, conducted from october 2016 to august 2017. data were collected retrospectively with total sampling method from medical records of intracerebral haemorrhage patients admitted to dr. hasan sadikin general hospital in 2013 assessed with the montreal cognitive assessment-indonesian version (moca-ina) and barthel index. patients with incomplete medical records , severe aphasia, severe sensoric-motoric impairment, and decreased consciousness were excluded in this study. data were analyzed using microsoft office excel 2010 and presented in percentage. results: out of the 26 subjects, 11 were men and 15 women , who were in the age range of 45–54 years (42.3%), with low education level (61.5%), and unemployed (61.5%) had the highest prevalence on subjects studied. hypertension was the most common risk factor (78%). most subjects had cognitive function impairment (69.2%) with delayed memory function as the most common impairment domain found (84.6%), followed by visuospatial/executive function (69.2%). most subjects had a high score of dependence according to the barthel test (61.5%). conclusions: two third of intracerebral haemorrhage patients have cognitive function impairment and functional dependence. memory function is the most common impaired cognitive functional domain. keywords: cognitive outcome, functional outcome, haemorrhagic stroke correspondence: ilham bagas setyawan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: bagasetyawan9@gmail.com. introduction according to the world health organization (who), stroke is defined as a clinical manifestation of cerebral dysfunction, either focal or global that occurs rapidly, sustained more than 24 hours or until causing death, without cause other than cerebral vascular origin. meanwhile, according to the american heart association (aha), stroke is defined as an acute neurologic dysfunction caused by ischaemia and haemorrhage, occuring more than 24 hours or until causing death.1 stroke is the most common cause of disability in adults.2 stroke contributes to 43.5 million (3.2%) disability adjusted life years (dalys) annualy worldwide. dalys is defined as the potential number of years lost due to premature death and productive days lost from disability.3 neurologic deficit is the cause of disability in stroke. neurologic deficit that occurs depends on severity and site of lesion,4,5 and may present as cognitive function impairment, sensory impairment, or motor impairment.5 the montreal cognitive assessment (moca) is one of the widely used screening instruments in clinical setting to detect presence of cognitive function in stroke patients.6 this instrument shows high sensitivity to measure cognitive function impairment in mild stroke because it calculates executive functions.7 when cognitive dysfunction is present, rapid detection to prevent cognitive decline by directing treatment into cognitive rehabilitation is needed.6 moreover, during rehabilitation, assessment of functional outcome needs to be carried oout towards stroke patients amj. 2018;5(1):21–5 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1331 althea medical journal. 2018;5(1) 22 amj march 2018 in order to determine improvement for further rehabilitation management.8 the barthel index is an instrument that measures disability degree or functional outcome based on the ability to carry out daily activity independently. barthel index is commonly used because the measurement is simple and does not necessarily need a specially trained observer as it is simply observing the ability to carry out basic daily tasks.9 a study regarding cognitive function of stroke patients using the moca instrument and functional outcome using the barthel index was never performed at dr. hasan sadikin general hospital. moreover, cognitive and functional measurement is vital for further rehabilitation of stroke patients. hence, the study of descriptive cognitive and functional outcome in haemorrhagic stroke patients is needed. the objective of this study was aimed to describe the cognitive and functional outcome among intracerebral haemorrhage patients admitted to dr. hasan sadikin general hospital bandung. methods a descriptive quantitative study was carried out from october 2016 to august 2017 using secondary data from medical records of intracerebral haemorrhage patients admitted to dr. hasan sadikin general hospital bandung from january 2013 to december 2013. the measurements of cognitive and functional outcome were elaborated by using the montreal cognitive assessment-indonesian version (moca-ina), with assessment results categorized as impaired (moca-ina score <26) and normal cognitive function (mocaina score 26-30). moreover, the functional outcome was measured by using the barthel index instrument, and categorized by degree of independence. the study subjects were medical records of intracerebral haemorrhage patients admitted to dr. hasan sadikin general hospital bandung from january 2013 to december 2013, who met the inclusion criteria as patients with the moca-ina and barthel index assessment. medical records with incomplete data, severe aphasia, severe sensory or motor impairment, and decreased consciousness were excluded from this study. this study was approved by the commission of ethics faculty of medicine universitas padjadjaran with number of ethics 354/ un6.c.10/pn/2017. data were analyzed using the microsoft office excel 2010., and were presented in percentage. results during the study period, 68 intracerebral haemorrhage patients were hospitalized at dr. hasan sadikin general hospital bandung, but only 26 patients were eligible for further analysis. the excluded subjects were 29 subjects with decreased consciousness, 9 subjects with severe aphasia, and 4 subjects with incomplete medical record data. female patients were slightly more dominant than males (57.7 vs. 42.3%). more than half of the subjects were of the age range between 45-54 years. subjects with low education level (uneducated, did not finish elementary, and elementary) had the highest prevalence (61.5%). subjects who were unemployed had the highest prevalance with 16 patients (61.5%). subjects with hypertension as the risk factor had the highest prevalence with 19 patients (73.1%) (table 1). moreover, i was obvious that the majority of patients (69.2%) suffered from cognitive function impairment (table 2). furthermore, the affected domain of cognitive function showed that delayed memory was the most common impaired cognitive function domain with 22 patients (84.6%), followed by visuospatial/executive with 18 patients (69.2%), and abstraction with 17 patients (65.4%) (table 3). additionally, assessments of functional outcome were performed by using barthel index assessment for the patient medical records , with assessment results categorized by the degree of independence. based on data of the functional outcome in intracerebral haemorrhage patients, 61.5% patients had higher dependence (moderate, severe, total dependence) (table 4). discussion in this study, intracerebral haemorrhage patients were more prevalent in women. this finding was consistent with a retrospective study conducted by toglia et al.10 however, it was insignificant due to a slight difference in frequency. on the other hand, several other studies found that it was more often found in men.11 the age of study subjects was mostly between 45–54 years, which was comparable to a study by o’donnell et al.12 in 2016, which showed the highest prevalence of stroke is also on a similar age range. based on an observational cohort study althea medical journal. 2018;5(1) 23 table 1 demographic characteristics of study subjects patient characteristics number (n=26) percentage (%) sex male 11 42.3 female 15 57.7 age (years) 15-24 1 3.8 25-34 0 0 35-44 4 15.4 45-54 15 57.7 55-64 5 19.2 ≥ 65 1 3.9 education level uneducated 1 3.9 did not pass elementary 6 23.1 elementary 9 34.6 junior high school 3 11.5 senior high school 7 26.9 diploma/university 118 100 graduate 0 0 occupation unemployed 16 61.5 office worker 2 7.7 entrepreneur/merchant 2 7.7 farmer/fisherman/laborer 4 15.4 others 2 7.7 risk factors hypertension 19 73.1 diabetes melitus 3 11.5 heart disease 1 3.8 dyslipidemia 5 19.2 smoking 7 26.9 recurrent stroke 11 42.3 blood abnormality 2 7.7 blood vessel abnormality 1 3.8 ilham bagas setyawan, paulus anam ong, m. zafrullah arifin: cognitive and functional outcome among hospitalized intracerebral haemorrhage patients in west java’s top referral hospital conducted by the department of neurology dijon university, france,13 during the period of 2010–2012, it found that stroke patients mostly come from a low education level and were unemployed. this study also found that as much as 61.5% of subjects had low education level (uneducated, did not finish elementary, elementary) and were unemployed. results from the basic health research (riskedas)14 in 2013 showed similar results in regard to education level and employment. the cognitive function might be affected by the education althea medical journal. 2018;5(1) 24 amj march 2018 level . thus, when a stroke patient is identified with low education level, one extra point is given in the moca-ina assessment.15 the risk factor has an important role in the disease progression. in this study, 78% of respondents with hypertension as a risk factor had the highest prevalence. this is in line with a stroke epidemiology study conducted by mukherjee et al.3 which showed that hypertension is a risk factor with the highest prevalence in stroke. this study showed that intracerebral haemorrhage at dr. hasan sadikin general hospital mostly resulted in cognitive function impairment with 69.2% of cases. this is consistent with a retrospective study conducted by chan et al.11 regarding a cognitive status with the moca in acute stroke patients in 2013 that most haemorrhagic stroke patients have a cognitive function impairment. a retrospective study performed by toglia et al.10 regarding the mmse and moca showed delayed memory function followed by visuospatial/executive function as the most common impaired cognitive function in stroke patients. a cohort study by jokinen et al.16 also showed memory, visuospatial, and executive functions are the most commonly impaired. it is in line in with this study which showed delayed memory function is the most often impaired domain for as much as 84.6% followed by visuospatial/executive function for as much as 69.2%. a study in china by pei et al.17 which studied factors associated with activities of daily living among the disabled elders with stroke using the barthel index as instrument showed that stroke patients who experienced higher dependence (total, severe, and mild dependence) had higher prevalence. the same finding is also found in this study that haemorrhagic stroke patients who experienced dependence dominates for as much as 61.5%. this study has several limitations. among the 68 potential subjects, only 26 fulfilled table 2 description of cognitive function in study subjects moca-ina score frequency (n=26) percentage (%) score <26 (impaired) 18 69.2 score 26-30 (normal) 8 30.8 total 26 100 table 3 impairment of cognitive function domain in study subjects cognitive function domain frequency (n=26) percentage (%) visuospatial/executive (5) 18 69.2 naming (3) 10 38.5 attention (6) 16 61.5 language (3) 13 50.0 abstraction (2) 17 65.4 delayed memory (5) 22 84.6 orientation (6) 13 50.0 table 4 functional outcome in intracerebral haemorrhage patients barthel index score interpretation frequency (n=26) percentage (%) score 0–20 total dependence 10 38.5 score 25–40 severe dependence 1 3.8 score 45–55 moderate dependence 5 19.2 score 60–95 mild dependence 10 38.5 score 100 independent 0 0 total 26 100 althea medical journal. 2018;5(1) 25 the inclusion criteria. it might be due to the natural history of disease, since most of the intracerebral haemorrhagic stroke patients were admitted with decreased consciusness thus the moca-ina assessment cannot be performed in an acute stroke condition. besides this study was conducted in 2017, on the otherhand the obtained data was from 2013. hence, these conditions might influence the study results. as a conclusion, two third of intracerebral haemorrhage patients who survived in the acute phase have cognitive function impairment. delayed memory function is the most common impaired cognitive function. most of the intracerebral haemorrhage patients experience dependence, where more than half have experienced higher dependence (total, severe, moderate dependence). references 1. sacco rl, kasner se, broderick jp, caplan lr, connors jj, culebras a, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(7):2064–89. 2. mendis s. stroke disability and rehabilitation of stroke: world health organization perspective. int j stroke. 2013;8(1):3–4. 3. mukherjee d, patil cg. epidemiology and the global burden of stroke. world neurosurg. 2011;76(6 suppl):s85–90. 4. gorelick pb, scuteri a, black se, decarli c, greenberg sm, iadecola c, et al. vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. stroke. 2011;42(9):2672–713. 5. corbetta m, ramsey l, callejas a, baldassarre a, hacker cd, siegel js, et al. common behavioral clusters and subcortical anatomy in stroke. neuron. 2015;85(5):927–41. 6. friedman l. evaluating the montreal cognitive assessment (moca) and the mini mental state exam (mmse) for cognitive impairment post stroke: a validation study against the cognistat [thesis]. london, ontario, kanada: the university of western ontario; 2012. 7. stolwyk rj, o’neill mh, mckay aj, wong dk. are cognitive screening tools sensitive and specific enough for use after stroke? stroke. 2014;45(10):3129–34. 8. meyer mj, pereira s, mcclure a, teasell r, thind a, koval j, et al. a systematic review of studies reporting multivariable models to predict functional outcomes after poststroke inpatient rehabilitation. disabil rehabil. 2015;37(15):1316–23. 9. duffy l, gajree s, langhorne p, stott dj, quinn tj. reliability (inter-rater agreement) of the barthel index for assessment of stroke survivors. stroke. 2013;44(2):462–8. 10. toglia j, fitzgerald ka, o’dell mw, mastrogiovanni ar, lin cd. the minimental state examination and montreal cognitive assessment in persons with mild subacute stroke: relationship to functional outcome. arch phys med rehabil. 2011;92(5):792–8. 11. chan e, khan s, oliver r, gill sk, werring dj, cipolotti l. underestimation of cognitive impairments by the montreal cognitive assessment (moca) in an acute stroke unit population. j neurol sci. 2014;343(1– 2):176–9. 12. o’donnell mj, chin sl, rangarajan s, xavier d, liu l, zhang h, et al. global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (interstroke): a case-control study. lancet. 2016;388(10046):761–75. 13. jacquin a, binquet c, rouaud o, graulepetot a, daubail b, osseby g-v, et al. post-stroke cognitive impairment: high prevalence and determining factors in a cohort of mild stroke. j alzheimers dis. 2014;40(4):1029–38. 14. kementrian kesehatan republik indonesia. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan ri; 2013. 15. julayanont p, phillips n, chertkow h, nasreddine zs. montreal cognitive assessment (moca): concept and clinical review. in: larner a (eds). cognitive screening instruments. london: springer; 2013. p. 111–51. 16. jokinen h, melkas s, ylikoski r, pohjasvaara t, kaste m, erkinjuntti t, et al. post-stroke cognitive impairment is common even after successful clinical recovery. eur j neurol. 2015;22(9):1288–94. 17. pei l, zang x-y, wang y, chai q-w, wang j-y, sun c-y, et al. factors associated with activities of daily living among the disabled elders with stroke. international journal of nursing sciences. 2016;3(1):29–34. ilham bagas setyawan, paulus anam ong, m. zafrullah arifin: cognitive and functional outcome among hospitalized intracerebral haemorrhage patients in west java’s top referral hospital althea vol 4 no 1 final 3.indd althea medical journal. 2017;4(1) 20 amj march 2017 severity of allergic rhinitis and body mass index: is there any correlation? gomathi paramasivam,1 fifi veronica,2 yovi yoanita3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: allergic rhinitis is the inflammation of the nasal mucosa. it will be resulting in nasal itching, sneezing, discharge, or blockage which occurs for more than an hour on most days. allergens such as plant pollens, fungi, animal allergens, and dust mites are the factors which initiate allergic rhinitis. there are many risk factors for allergic rhinitis, such as family history of atopic disease, asthma, age, gender and others. besides, overweight is also considered one of the risk factors for developing allergic rhinitis. thus, this study was conducted to investigate the correlation between allergic rhinitis and body mass index. methods: this study involved a cross-sectional analytic study. seventy three respondents both male and female medical students of universitas padjadjaran completed a questionnaire, and had their height and weight measured by a trained researcher. this study was carried out from september to october 2015. statistical analyses were performed included the rank spearman test. results: there was no significant relationship between allergic rhinitis and body mass index. conclusions: there is no correlation between severity of allergic rhinitis and body mass index. [amj.2017;4(1):20–4] keywords: allergic rhinitis, body mass index, severity correspondence: gomathi paramasivam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827997081 email: gomathiparamasivam93@gmail.com introduction allergic rhinitis is the inflammation of the nasal mucosa which is mediated by immunoglobulin e. it is triggered by allergens such as pollen, dust mite, animal dander and mould spores.1 allergic rhinitis occurs when inhaled allergens interact with ige antibodies on cells in the airway which initiate hypersensitivity type 1.2 the symptoms of allergic rhinitis are nasal congestion, rhinorrhea, sneezing, nasal itching, and nasal obstruction.3 it is one of the most common types of rhinitis and effect 10–20% of populations and there are evidence that the prevalence of allergic rhinitis is increasing.4 previously, allergic rhinitis has been categorized as seasonal or perennial but, not all patients fit into this classification. as an example, some allergic triggers, such as pollen, may be seasonal in cooler climates, but perennial in warmer climates. thus, it is classified based on its severity as mild, moderate-severe by allergic rhinitis and its impacts on asthma (aria).5 the aria also classified the allergic rhinitis into intermittent and persistence based on onset of the disease.5 allergic rhinitis is a disease that not only impairs ones quality of life but also disturb sleep and work.6 allergic rhinitis is a burden for both paediatric and adult patients not only because of the physical symptoms but also due to the emotional and social effects.7,8 there are many complications of this disease which effect physically and psychosocially. the comorbidities of this disease are asthma, otitis media with suppurative, rhinosinusitis, and sleep disturbance. allergic rhinitis is not only causing physical problems to nose and lower althea medical journal. 2017;4(1) 21 airway but also causes psychosocial problems including those in learning and cognitive processes and in missing work or school. thus, it is very important to understand the disease and find ways to decrease the occurrence of it.9 there are many risk factors for allergic rhinitis, such as family history of atopic disease, asthma, age, gender and others. besides, overweight is also considered one of the risk factors for developing allergic rhinitis.10,11 according to the who since 2008, more than 1.4 million adults were overweight. the who categorizes a person into underweight, normoweight, overweight and obese based on body mass index (bmi). those who are less than bmi of 17.5 is categorized underweight, those in between bmi of 17.5 to less than 25 is normoweight, those more than or equal to bmi of 25 is considered overweight, while those who are more than or equal to bmi of 30 is considered obese.12 a few studies have been conducted to identify the correlation of atopic disease with bmi. results of the studies prove there are correlations between allergic rhinitis and bmi.10,11 but the studies are conducted overseas such as australia and germany.11 there are no relevant data about the correlation between allergic rhinitis and obesity in asian countries like indonesia. some studies do not find any relevant data regarding the correlation between allergic rhinitis and bmi which are carried out in school-aged children.13 so, this study was aimed to investigate the correlation between allergic rhinitis and bmi among regular medical students of universitas padjadjaran. methods participants of the study were recruited from regular medical students of universitas padjadjaran. to make sure the respondent was eligible to be recruited to the study an inclusion criteria was determined. a total sampling method was used to recruit participants who fulfil the inclusion criteria. the inclusion criteria for this study were the participants must be regular medical students of universitas padjadjaran, can be both male and female, students who had been diagnosed with allergic rhinitis by a physician based on the questionnaire, physical exam and the results of skin prick test, students who presented with or without co-morbidities such as asthma, sinusitis, conjunctivitis, otitis media, atopic dermatitis and other allergies, students who agreed to participate in this study by signing the informed consent form. this study is a cross-sectional analytic study. a self-report questionnaire was completed by each participant, and body weight and height were measured. this study was conducted at universitas padjadjaran from september to october 2015. ethics approval was granted by the health research ethics committee, dr. hasan sadikin general hospital, bandung. furthermore, all participants provided informed consent prior to involvement in the study. questionnaires about the severity of allergic rhinitis based on the american academy of allergy, asthma, and immunology (aaaai), the american college of allergy, asthma, and immunology(acaai), and the joint council of allergy, asthma, and immunology which had been validated were distributed to the respondents . the bmi was calculated by dividing weight in kilograms by the square of height in meters (kg/m2). based on his/her bmi, an individual was classified into normal (bmi ranged from 18.5 to 24.9 kg/m2), overweight (bmi 25-29.9 kg/m2), or obese (bmi >30 kg/m2). the study used the visual analog scale (vas) to measure the severity of allergic rhinitis. the scale consists of 7 numbers and the patient had to decide the number according to their severity. severity of allergic rhinitis can be divided into two, mild and moderate-severe. mild is less than number 4 in vas, while moderate-severe is number 4 or more in vas. the correlation between bmi and severity of allergic rhinitis was analysed after the gomathi paramasivam, fifi veronica, yovi yoanita: severity of allergic rhinitis and body mass index: is there any correlation? table 1 characteristic of respondent based on gender gender percentage% percentage% male 39.73 39.73 female 60.27 60.27 total 100 100 althea medical journal. 2017;4(1) 22 amj march 2017 respondents were divided into groups based on bmi and the level of severity. the cut-off point of bmi used in the analysis was 25 kg/ m2. respondents were categorized into two levels of severity based on the visual analog scales (vas) for the severity of the total symptoms. participants scoring three or less on the vas were categorized as having mild symptoms, while participants scoring more than three were categorized as having nonmild symptoms. data obtained from the vas of global assessment of nasal and non-nasal symptoms were analysed using inferential statistics with the level of significance set at 0.05. the correlation between severity of allergic rhinitis and body mass index was analysed using rank spearman test. results furthermore, the results were analysed through descriptive analysis of characteristics of allergic rhinitis based on gender among regular medical students of universitas padjadjaran which were shown in frequency distribution and association tables. according to the characteristic of respondent based on gender most of the respondent is female. the ratio between female to male is 3:2 (table 1). the majority of respondents as much as 79.45 % had a normal bmi category, the second highest frequency was as much as 15.07% of the students were categorized overweight, and the least students as much as 5.48% were categorized underweight (table2). the majority of the respondents had a mild intermittent allergic rhinitis which was 57.53%, the second highest frequency was severe intermittent allergic rhinitis which was 24.66%, followed by students who had severe continuous allergic rhinitis which was 16.44% table 2 distribution of body mass index (bmi) body mass index (bmi) frequency percentage% underweight 4 5.48 normal 58 79.45 overweight 11 15.07 total 73 100 table 4 relationship between bmi and severity of allergic rhinitis bmi severity of allergic rhinitis total p-valuesevere intermittent mild intermittent severe continuous mild continuous f % f % f % f % f % underweight 1 25.0 3 75.0 0 0.0 0 0.0 4 100 0.051* normal 11 19.0 34 58.6 12 20.7 1 1.7 58 100 overweight 6 54.5 5 45.5 0 0.0 0 0.0 11 100 total 18 24.7 42 57.5 12 16.4 1 1.4 73 100 note: *using rank spearman table 3 severity classification of allergic rhinitis severity of allergic rhinitis frequency percentage % severe intermittent 18 24.66 mild intermittent 42 57.53 severe continuous 12 16.44 mild continuous 1 1.37 total 73 100 althea medical journal. 2017;4(1) 23gomathi paramasivam, fifi veronica, yovi yoanita: severity of allergic rhinitis and body mass index: is there any correlation? and the least students had mild continuous allergic rhinitis which was 1.37% (table 3). moreover, out of 4 students who had a bmi category of underweight mostly had mild intermittent allergic rhinitis which was 75%. out of 58 students who had normal bmi category, mostly as much as 58.6% had mild intermittent allergic rhinitis and among 11 students who had bmi categorized under overweight, mostly as much as 54.5% had severe intermittent allergic rhinitis. the results of correlation analysis, obtained by the p-value of 0.051>0.05, indicated that there was no significant relationship between body mass index and severity of allergic rhinitis among regular medical students of universitas padjadjaran batch 2011. discussion results of the correlation between bmi and severity of allergic rhinitis among regular medical students of universitas padjadjaran can be referred to table 4. from the data analysis using the rank spearman test, the researcher accepted the null hypothesis (p >0.05) and it was now known that basically there was no significant correlation between body mass index and severity of allergic rhinitis among regular medical students of universitas padjadjaran. there were many factors that could contribute to this result. the data for this study was mainly obtained from students who mostly had mild type of allergic rhinitis. therefore, it was hard to see the correlation between the severity of allergic rhinitis and body mass index. besides, most of the respondent was categorized under normal weight. thus, it was hard to see the correlation between the variables. the result was not significant, meaning that basically there was no correlation between body mass index and severity of allergic rhinitis among regular medical students of universitas padjadjaran. hence, based on the hypothesis, it was assumed that there was significant relationship between body mass index and severity allergic rhinitis. according to a study conducted by alrasyid et al.11 there is significant relationship between severity of allergic rhinitis and body mass index. the theory from that study might not be applicable in west java especially in bandung due to some reasons. the previous study was conducted in australia; perhaps th difference in environment and climate between indonesia and australia can cause the difference in the results. besides, the study population in the previous study was patients from the immunology department but in this studythe patients were medical students who were suffering from allergic rhinitis. the diagnosis for the subjects is made from history taking, physical exam and skin prick test which may be less accurate to diagnose those who are not in active phase during the examination. additionally, based on a study by mutious et al.14, there is no significant relation between atopic disease and bmi in children. as the study population was only the regular medical students of universitas padjadjaran, the researcher could only take the number of students who were positive for allergic rhinitis. thus, only 73 students were used in this study which was not sufficient to prove the theory that there was association between severity allergic rhinitis and bmi. besides, the study population was medical students of universitas padjadjaran. most of the student’s age was averaged 19−22 years. therefore, it influenced the severity of allergic rhinitis. this study also needed the respondents to answer the questionnaire which might lead to the recall bias. lastly, the time allocated to carry out this thesis was very limited. based on the data analysis and discussion, the conclusion is that there is no significant relationship between bmi with the severity of allergic rhinitis. references 1. walls rs, heddle rj, tang mlk, basker bj, solley go, yeo gt. optimising the management of allergic rhinitis; an australian perspective. med j aust. 2005;182(1):28−33. 2. plaut m, valentine md. allergic rhinitis. n engl j med. 2005;353(18):1934−44. 3. tran np, vickery j, blaiss ms. management of rhinitis: allergic and non-allergic. allergy asthma immunol res. 2011;3(3):148–56. 4. small p, kim h. allergic rhinitis. allergy asthma clin immunol. 2011:7(suppl 1);s3 5. who. chronic rhinitis and sinusitis: allergic rhinitis and sinusitis. 2014 [cited 2014 may 23]; available from: http:// www.who.int/respiratory/other/rhinitis_ sinusitis/en/. 6. green rj, davis g. the burden of allergic rhinitis. curr allergy clin im. 2005;18(4):176–8. 7. blaiss ms. allergic rhinoconjunctivitis: burden of disease. allergy asthma proc. 2007;28(4):393−7. 8. eichler i, soriano es. close collaboration althea medical journal. 2017;4(1) 24 amj march 2017 between academia, industry and drug regulators is required in the development of allergen products for specific immunotherapy in children. allergy. 2011;66(8):999−1004. 9. bousquet j, khaltaev n, cruz aa, denburg j, fokkens wj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008 update (in collaboration with the world health organization, ga(2)len and allergen). allergy. 2008;63 suppl 86:8−160. 10. van de ven mo, van den eijnden rj, engels rc. atopic diseases and related risk factors among dutch adolescents. eur j public health. 2006;16(5):549−58. 11. alrasyid h, mcmanus a, mallon d, nicholson c. elevated body mass index is associated with severity of allergic rhinitis: results from a cross sectional study. aust med j. 2008;1(2):1–17 12. who. obesity and overweight. 2013[cited 2014 may 23] available from: http:// www.who.int/mediacentre/factsheets/ fs311/en/ 13. sidell d, shapiro nl, bhattacharyya n. obesity and the risk of chronic rhinosinusitis, allergic rhinitis, and acute otitis media in school-age children. laryngoscope. 2013;123(10):2360−3. 14. von mutius e, schwartz j, neas lm, dockery d, weiss st. relation of body mass index to asthma and atopy in children: the national health and nutrition examination study iii. thorax. 2001;56(11):835−8. vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 75 cardiovascular risk profile in health cadres in jatinangor, west java badai bhatara tiksnadi,1 rien afrianti,1 yulia sofiatin,2 arif ridha,1 faris yuflih fihaya,3 rully m. a. roesli,4 muhammad rizki akbar1 1departement of cardiology and vascular medicine faculty of medicine universitas padjadjaran bandung indonesia, 2departement of public health faculty of medicine universitas padjadjaran bandung, indonesia, 3faculty of medicine universitas padjadjaran indonesia, 4departement of internal medicine faculty of medicine universitas padjadjaran bandung, indonesia correspondence: badai bhatara tiksnadi, departement of cardiology and vascular medicine, faculty of medicine, universitas padjadjaran, jalan prof. eijkman no.38, bandung, west java, indonesia email: tiksnadi_badai@yahoo.com introduction cardiovascular disease, especially coronary heart disease (chd), causes a global health problem, including in indonesia. chd is still the number one cause of death in the world.1 cardiovascular disease has very high morbidity and mortality, and is the highest spending funds of the national social insurance administration organization, known as bpjs, in the last 4 years. based on the results of basic health research (riset kesehatan dasar, riskesdas) in 2013, the national prevalence of coronary heart disease is ranging from 0.5% to 1.5%.2 the chd has not only an impact on mortality but also on morbidity and may thus limit the patients’ quality of life. the acute coronary heart disease and cardiocerebrovascular disease often occur suddenly and fatal, therefore, early detection of the risk of cardiovascular disease is needed. through the detection of risk factors and estimating the level of risk, appropriate interventions and monitoring can be optimally given. risk factors in the developing of chd are divided into non-modifiable and modifiable factors.3 the development of this very rapid incidence of chd can be prevented by both primary and secondary preventive measures. primary preventive includes prevention of chd in patients with high risk; whereas amj. 2019;6(2):75–79 abstract background: cardiovascular disease has very high morbidity and mortality, therefore, prevention of this disease becomes a national priority in the health programs. health cadres, as an agent in community primary prevention, should have a good health condition. this study aimed to describe the cardiovascular risk profile in health cadresin jatinangor, west java. methods: this was a cross-sectional study, conducted in cilayung village, jatinangor, in september 2018. consecutive sampling was performed on 20 health cadres aged 25 64 years old who did not have previous cardiovascular events such as coronary heart disease or stroke. clinical data were collected consisting of blood pressure, body mass index (bmi), random blood glucose, history of diabetes mellitus, physical activity and active smoking habits. cardiovascular risk was assessed using jakarta cardiovascular scores and european relative risk score. results: only 17 of 20 health cadres fulfilled the inclusion criteria with a systolic and diastolic blood pressure of 133.5±27.8 mmhg and 81.1±14.8 mmhg, respectively, and bmi of 27.4±5.3 kg/m2.the risk of cardiovascular disease in healthy cadres was at low (47.1%), moderate (41.2%) and high risk (11.7%). the average of the european relative risk score was 1.88±0.9. bmi >30 has a 40% high risk of cardiovascular disease. conclusions: most of the health cadres in jatinangor, west java have a low and moderate risk of cardiovascular disease, even though there is a small percentage that is at a high risk. the awareness for prevention and management programs for risk factors needs to be raised among health cadres. keywords: cardiovascular, health cadre, jatinangor, risk profile althea medical journal. 2019;6(2) 76 amj june 2019 secondary prevention is an effort to prevent recurrent chd in patients who have previously suffered from chd. prevention efforts include minimizing all forms of risk factors. this preventive effort can reduce mortality by 50%, while curative efforts can only reduce by 40%. modification of risk factors has been shown to reduce morbidity and mortality.4 efforts to prevent cardiovascular disease in the last 10 years can be estimated by calculating current cardiovascular scores. the jakarta cardiovascular score is a modification of the framingham score. the jakarta cardiovascular score has a sensitivity of 77.9% and a high specificity of 90%. this score also provides a positive predictive value of 92.2% and a negative predictive value of 72.8%.5 the score is based on gender, age, blood pressure, smoking, diabetes, body mass index, and weekly physical activity. health cadres as a real manifestation of community participation in the health sector play an important role in helping to actualize community health development in the region.6 health cadres are a group in a society that is expected to have the best knowledge about health. to carry out health promotion and primary prevention measures specifically regarding chd in the community, good knowledge and understanding of chd risk factors is needed, which can shape preventive attitudes and behaviors towards the disease. as best as we know, this was the first study aiming to describe the cardiovascular risk profile in health cadres, especially in jatinangor sub-district, west java based on jakarta cardiovascular scores and european relative risk score. methods this was a cross-sectional study, conducted in jatinangor sub-district, sumedang, west java in september 2018. this study was approved by the research ethics committee of universitas padjadjaran no. 1107/un6.kep/ ec/2018. health cadres were recruited by consecutive sampling (n20), all were female, aged 24– 65 years old. only those who completed questionnaires were included. clinical data weretaken, including blood pressure (digital tensiometer abn-100), body mass index (bmi), random blood glucose (digital blood glucose test accu chek active), the history of diabetes mellitus, physical activity and active smoking habits. data were further classified according to the jakarta cardiovascular score and european relative risk score referred to as score.5,7 the distribution of data on gender, age, blood pressure, body mass index, smoking history, diabetes, and physical activity were presented in table forms and graphs, using ibm spss statistics version 20. results of 20 health cadres, only 17 had met the inclusion criteria whereas the three subjects were excluded due to incomplete data. clinical data characteristics of the health cadres were presented in table 1. in this study, all health cadres were women with an average age of 44±8.31 years. the average of systolic and diastolic blood pressure were133.53±27.88 mmhg and 81.19±14.87 mmhg, respectively, and the body mass index was 27.42±5.37 kg/m2. most of them never smoked (94.1%). diabetes mellitus was detected in 2 cadres (11.8%), and all cadres had medium physical activity (table 2). the cardiovascular risk in all women’s health cadres was low (47.1%), moderate (41.2%) and high (11.7%), respectively. according to jakarta cardiovascular score, the risk of cardiovascular disease was low table 1 characteristics of health cadres recruited from jatinangor, west java variable mean (sd) median range age (years) 44.88 (8.31) 45 28–62 blood pressure (mmhg) systole 133.53(27.88) 133 92–186 diastole 81.19 (14.87) 79 60–112 body mass index (kg/m2) 27.42 (5.37) 27.8 14.81–35.7 total cholesterol 210.82 (48.45) 211 146–347 random blood glucose 141.12 (106.90) 104 83–426 althea medical journal. 2019;6(2) 77badai bhatara tiksnadi et al.: cardiovascular risk profile in health cadres in jatinangor, west java (47.1%), moderate (41.2%) and high (11.7%), whereas the average relative risk score based on score relative risk chart was 1.88 ± 0.93. discussion death from cardiovascular disease often occurs due to pathological conditions in blood vessels in the form of atherosclerosis. our study has shown that the proportion of the high risk of cardiovascular disease according to jakarta cardiovascular scores in health cadres in cilayung village, jatinangor sub-district is 11.7%. this result reflects that health cadres table 2 variable cardiovascular risk of jakarta cardiovascular score and european relative risk score variable cardiovascular risk low moderate high n (%) n (%) n (%) age (years) 25–34 2 (11.8) 25–39 2 (11.8) 40–44 3 (17.6) 1 (5.9) 45–49 4 (23.5) 50–54 1 (5.9) 3 (17.6) 55–59 60–64 1 (5.9) blood pressure normal 5 (29.4) 2 (11.8) normal-high 2 (11.8) 3 (17.6) hypertension grade 1 1 (5.9) 1 (5.9) hypertension grade 2 1 (5.9) hypertension grade 3 1 (5.9) 1 (5.9) body mass indexa 13.79–25.99 5 (29.4) 2 (11.8) 26.00–29.99 2 (1.8) 3 (17.6) 30.00–35.58 1 (5.9) 2 (11.8) 2 (11.8) smoking never 8 (47.1) 6 (35.3) 2 (11.8) ex-smoker 1 (5.9) diabetes mellitus yes 1 (5.9) 1 (5.9) no 8 (47.1) 6 (35.3) 1 (5.9) physical activities no. low medium 8 (47.1) 7 (41.2) 3 (11.7) high note: a classification based on jakarta cardiovascular score althea medical journal. 2019;6(2) 78 amj june 2019 in this region may have a risk of experiencing mortality due to cardiovascular disease in the next 10 years.6 the highest relative risk in this study was age 60-64 (4± 0.93) and grade 3 hypertension (3.5 ± 0.71). the aging process is a physiological thing that can cause atherosclerosis. from the results of the study, it appears that the highest frequency with high risk for age variables is in the age range 60-64 years. this study also showed that increased risk of cardiovascular disease in middle age (25% in 40-44 years old at high risk and 100% in 45-49 years old at moderate risk). it caused the proportion of the age group in this study was not equal. another data about the prevalence of cardiovascular disease was increased with age that as increasing age will increase the process of atherosclerosis, causing heart and blood vessel disease.8 the risk of heart and blood vessel disease increases at the age of 55 years and over for men and over 65 years for women.9 based on the results of basic health research (riskesdas 2013), the highest prevalence of coronary heart disease occurred in the age range 65-74 years.2 blood pressure is a modifiable risk factor for heart and blood vessel disease. if blood pressure exceeds more than normal values, it is categorized as hypertension. the risk factor of hypertension are lifestyle changes such as being overweight, excess salt consumption, and excessive alcohol consumption.9 with proper intervention, blood pressure can be controlled and maintain in normal conditions. based on the results of this study, it can be seen that high risk is found in stage 3 hypertension groups. hypertension is a silent factor and a major factor in heart and blood vessel disease. increased blood pressure will increase the risk of heart and blood vessel disease. risk management of heart and blood vessel disease needs to be done to reduce the prevalence of heart and blood vessel disease. obesity is also a risk factor that makes workers more at risk of suffering from heart and blood vessel disease.9 this study showed that the body mass index group of 30.00– 35.58 was 40% at high risk of cardiovascular disease. excess weight is associated with type ii diabetes and the causes of death in patients with diabetes mellitus are mostly caused by coronary heart disease and stroke.10,11 therefore, management to reduce body weight in cadre becomes a priority in primary prevention. unhealthy lifestyles such as smoking and lack of physical activity can accelerate the occurrence of atherosclerosis. nicotine substances in cigarettes cause the production of catecholamines which makes vessels undergo vasoconstriction, increase heart rate, and increase oxygen use. cigarette smoke contains co that can damage blood vessels. when co enters the body, it will bind to hemoglobin in red blood cells, and causes red blood cells to carry less oxygen because the co is transported instead of oxygen. due to the lack of oxygen, the body will compensate by shrinking the blood vessels. if this condition persists, the blood vessels will be damaged and later on, it progresses into atherosclerosis which is the initial stage of heart and blood vessel disease.5 the results of the study found figure 1 total relative risk of cardiovascular disease based on score relative risk chart mean = 1.88 althea medical journal. 2019;6(2) 79badai bhatara tiksnadi et al.: cardiovascular risk profile in health cadres in jatinangor, west java that high risk is experienced by the group who never smoked. this is because the subjects of this study were all women, so the number of the smoker was only 1 person. people who had regular exercise or heavy physical activity have a lower risk of hypertension and coronary artery disease.5 another study showed that only heavy physical activity associated with a reduced risk of premature coronary heart disease.12 physical activity is body movement resulting from musculoskeletal contractions, which increases energy and improves health, encompasses activities outside of routine work such as light exercise, doing work household, going up and down the stairs either at the office or home at least 30 minutes every day. from the results of this study, all cadres had moderate physical activity with various risk of cardiovascular disease. because of a similar level of physical activity in cadres, this study could not determine whether the level of physical activity influenced cardiovascular risk. the limitation of this study is that all respondents are female. our study cannot be compared to another study that also uses jakarta cardiovascular score, showing that male has a greater score.5 the number of respondents in our study is also limited. in conclusion, although most of the health cadres in cilayung village have a low risk of cardiovascular disease, lifetime risk to cardiovascular disease is increasing. prevention and management programs for risk factors still need to be done in health cadres. for further study, it needs to assess awareness of health cadres to their health profile to prevent cardiovascular disease. references 1. ponikowski p, voors aa, anker sd, bueno h, cleland jg, coats aj, et al. 2016 esc guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the european society of cardiology (esc). developed with the special contribution of the heart failure association (hfa) of the esc. eur j heart fail. 2016;18(8):891–975. 2. kementrian kesehatan republik indonesia. riset kesehatan dasar (riskesdas). jakarta: kemenkes ri; 2013. 3. jones ca, ross l, surani n, dharamshi n, karmali k. framingham ten-year general cardiovascular disease risk: agreement between bmi-based and cholesterol-based estimates in a south asian convenience sample. plos one. 2015;10(3):e0119183. 4. world health organization. prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. geneva: who press; 2007. 5. kusmana d. the influence of smoking cessation, regular physical exercise and/ or physical activity on survival: a 13 years cohort study of the indonesian population in jakarta. med j indones. 2002;11(4):230– 41. 6. sofiatin y, roesli r. kesiapan masyarakat dalam melaksanakan dan memanfaatkan posyandu penyakit tidak menular di desa cilayung dan cipacing, kecamatan jatinangor. gmhc. 2017;5(2):123–31. 7. piepoli mf, hoes aw, agewall s, albus c, brotons c, catapano al, et al. 2016 european guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the european society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the european association for cardiovascular prevention & rehabilitation (eacpr). eur heart j. 2016;37(29):2315–81. 8. mozaffarian d, benjamin ej, go as, arnett dk, blaha mj, cushman m, et al. executive summary: heart disease and stroke statistics—2015 update: a report from the american heart association. circulation. 2015;131(4):434–41. 9. lenfant c, chobanian av, jones dw, roccella ej. seventh report of the joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (jnc 7): resetting the hypertension sails. circulation. 2003;107(24):2993–4. 10. lam dw, leroith d. the worldwide diabetes epidemic. curr opin endocrinol diabetes obes. 2012;19(2):93–6. 11. nguyen nt, nguyen xm, lane j, wang p. relationship between obesity and diabetes in a us adult population: findings from the national health and nutrition examination survey, 1999–2006. obes surg. 2011;21(3):351–5. 12. carnethon mr. physical activity and cardiovascular disease: how much is enough? am j lifestyle med. 2009;3(1_ suppl):44s–9s. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 358 amj september 2017 early detection of suspected systemic lupus erythematosus in community-dwellings in west java indonesia nadia gita ghassani,1 soeseno hadi,2 laniyati hamijoyo3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: prevalence of systemic lupus erythematosus (sle) has been known in almost all countries around the world. contrary to this, in indonesia, neither a national epidemiologic study on sle nor any direct study on sle in the general population has been conducted. early detection of sle is needed as a first step to determine prevalence of sle in indonesia as well as to prevent further complications. this study aimed to obtain the prevalence of suspected sle in community-dwellings. methods: this study was conducted in the period september to november 2015 and used the descriptive cross-sectional method. the respondents were people who were at least 18 years old and lived in selected blocks in three different villages in jatinangor, west java. data were obtained from secondary sources of a previous sle screening study that was incorporated in a study on “epidemiology of hypertension and albuminuria in jatinangor” in 2014, using the multistage sampling method. suspected sle was based on the liang screening questionnaire. the collected data were presented in tables. results: there were 72 respondents (8%) suspected to have sle. most of the cases were female (odds ratio:1.47) and 51–60 years old. the most clinical manifestation was painful swollen joints >3 months. conclusions: the existence of suspected sle cases in jatinangor’s population, as an example of indonesian population should be a concern so that examinations could be carried out to make sure that respondents with sle can be provided prompt interventions to prevent further complications. keywords: early detection, liang screening questionnaire, systemic lupus erythematosus correspondence: nadia gita ghassani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: nadiagitag@gmail.com introduction systemic lupus erythematosus (sle) is a chronic multisystem autoimmune disease with broad clinical features, ranged from minor skin manifestation to serious organ damage.1 due to the sle chronic features, the financial burden of sle is expected to increase.2–4 the annual healthcare cost in asia for sle patients without nephritis is estimated to reach us$16,638 per patient/year.4 the prevalence of sle in asia-pacific countries varies between 4.3–45.3 per 100,000 population per year.1 on the other hand, in indonesia, neither an epidemiologic study on sle nor any direct study on sle in the general population has been conducted. the only available data are mostly obtained from local health care centers. for those two reasons, sle screening is needed as a first step to determine the prevalence of sle in indonesia. systemic lupus erythematosus screening is one of the efforts which allows early detection of lupus; hence, immediate intervention of suspected sle patients can be given, so that they will have a better life. a previous multidisciplinary study has been conducted in jatinangor, west java, indonesia to survey the health of communities in jatinangor, including performing sle screening. however, the previous sle screening study has not been published yet. by using data of the mentioned study, this study aimed to obtain the number of people with suspected sle in jatinangor. methods this study used secondary sources obtained from a previous sle screening study amj. 2017;4(3):358–362 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1181 althea medical journal. 2017;4(3) 359 entitled “epidemiology of hypertension and albuminuria in jatinangor” which has been conducted since 2014. this study utilized the previous data using the descriptiveobservational method with a cross-sectional approach and was conducted in the period september to november 2015. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the respondents of both the previous and this current study were the population of jatinangor who lived in three different villages namely, cipacing, hegarmanah and cilayung. the previous study used the multistage sampling technique as study design where samples were taken until the blocks were selected. the minimum sample size was calculated using sample size formula for descriptive categorical study. the assumed prevalence used in the calculation originated from a previous study in birmingham, uk, which was 307 suspected sle patients out of 1153 population (26,6%).6 based on the formula, a minimum of 834 samples should be obtained. the data were selected randomly from the secondary source. the inclusion criteria of this study were (1) all people who were at least 18 years old, lived in the selected blocks, had already participated in the “epidemiology of hypertension and albuminuria in jatinangor” study, and (2) had already signed the informed consent paper. those with incomplete data would be dismissed as an exclusion criteria of this study. the exclusion criteria of this study was based on previous studies in birmingham and israel which included only people who were at least 18 years old.6,7 the total number of respondents of this study was 857 respondents. the collected data on this study consisted of respondent demography (age and gender), and some of the answers toward the questionnaire given in the previous study was consistent with the liang questionnaire. the liang questionnaire comprised 10 questions concerning clinical manifestations of sle which utilized the american rheumatism association preliminary criteria for sle and had been validated as one of the two stages of sle screening study design.5,6 data collection of the study was conducted by medical students as the surveyors who had previously received adequate training and standardized instructions from the experts. furthermore, the respondent demography was described in general, and then categorized into suspected sle and not suspected sle. the operational definition for suspected sle is as follows: if there is a ‘positive’ or ‘yes’ answer on more than 3 questions of the liang questionnaire, then the respondent would be categorized as suspected sle.5 the collected data were then presented in tables. results eight hundred and fifty seven valid data were obtained after the exclusion and inclusion criteria were met. the authors used all the valid data to increase the intensity of this study instead of using only the minimum samples. among the total respondents, 69% were female respondents . the highest number was found in the age group 41–50 years (26%), followed by the age group 31–40 years (23%) (table 1). this study discovered that among the 785 respondents, approximately 8 % (72 cases) were suspected to have sle (table 2). the most common clinical manifestation in suspected sle respondents was pain and swollen joints, which was found in 76% of the respondents. most other clinical manifestations found in this study were changes on finger/toes, pleurisy for a few days and photosensitivity (table 2). the number of females with suspected sle were higher compared to the number of males (55 out of 595 vs 17 out of 262 respondents) with 1.47 as the odds ratio. in addition, the highest number of suspected sle was discoversed in the age group 51–60 years (table 3). nadia gita ghassani, soeseno hadi, laniyati hamijoyo: early detection of suspected systemic lupus erythematosus in community-dwellings in west java indonesia table 1 demography distribution of respondents characteristics frequency (n(%)) gender male 262 (31%) female 595 (69%) age ≤20 25 ( 3%) 21–30 118 (14%) 31–40 201 (23%) 41–50 225 (26%) 51–60 >60 153 (18%) 135 (16%) total 857 althea medical journal. 2017;4(3) 360 amj september 2017 discussions this study discovered that the prevalence of suspected sle in community dwellings using the liang questionnaire was 8%. this is practically lower than the number found in previous studies which also used the liang questionnaire as their screening tool. geva et al.7 reported that among 143 infertile women included in their study in israel, 9.6% of the respondents answered ‘yes’ on more than 3 items in the liang questionnaire. another study conducted in birmingham6, uk, reported that 26.6% of 1153 respondents answered ‘yes’ on more than 3 items in the liang questionnaire. this low prevalence of suspected sle might be due to several reasons. the dissimilarities of sle epidemiology observed across the country might be associated with the differences in the majority of races in certain countries, source of cases and sampling method that were used in this study. furthermore, african-caribbeans or black people has the highest risk of sle compared to white people, asian/pasific and hispanic race.8–12 johnson et al. stated in the study of somers et al.8 that prevalence of sle in birmingham, uk, were much higher among table 3 suspected sle patients according to sex and age distribution sex anf age distribution suspected sle (n) no suspected sle (n) total (n) sex female 55 540 595 male 17 245 262 age ≤20 4 21 25 21-30 11 107 118 31-40 14 187 201 41-50 8 217 225 51-60 24 129 153 >60 11 124 135 total 72 785 857 table 2 clinical manifestations in suspected systemic lupus erythematosus cases clinical manifestations “y ”yes” responses in suspected sle (n(%)) “no” responses in suspected sle (n(%)) painful swollen joints >3 months 55 (76%) 17 (24%) changes on fingers/toes (pallor,numb,uncomfortbale when it is cold) 49 (68%) 23 (32%) mouth ulcers >2 weeks 17 (24%) 55 (76%) low blood counts 25 (35%) 44 (61%) prominent rash on cheeks 10 (14%) 61 (85%) photosensitivity 34 (47%) 37 (51%) pleurisy for a few days 47 (65%) 25 (35%) proteinuria 5 ( 7%) 64 (89%) hair fall 14 (19%) 51 (71%) seizure/convulsion/fit 9 (12%) 63 (88%) note: * sle = systemic lupus erythematosus althea medical journal. 2017;4(3) 361nadia gita ghassani, soeseno hadi, laniyati hamijoyo: early detection of suspected systemic lupus erythematosus in community-dwellings in west java indonesia african-caribbeans compared to the overall population. moreover, methodological differences among studies such as different source of cases (e.g. hospital-based, population survey via mail or telephone, etc.) and sampling method can also create disparity in sle occurences among countries.13 in addition, data of the previous sle screening study conducted in jatinangor was collected by surveyors who were still medical students. although the students were given a standardized instruction previously, there might be still possibilities that the validity of manifestations complained by the respondents could not be confirmed, hence, making the number of suspected sle cases to be less than in the other studies. most of the suspected sle respondents were female. this finding was slightly similar to that reported in previous studies.3,9–11,13 it was stated that sle generally affects females, with a ratio compared to male in the range from 9–14:1.13,14 this high number of female sle patients was suggested by the role of estrogen, progesteron and prolactin hormones as well as x chromosome on the activation of immune system.14,15 the range of age group of suspected sle respondents was more abundant in the range of an older age group. however, this was slightly different from the previous studies. meacock et al.3 and dancheko et al.13 reported that the onset of sle most typically occurs in women of childbearing age. this difference can be caused by the older age group who tends to have degenerative diseases, so the manifestations complained by respondents may represent other diseases rather than sle. furthermore, painful and swollen joints were the most common sle manifestations in this study. somers et al.8 reported that the most common clinical manifestations experienced by sle patients in michigan, us, were positive anti nuclear antibody (ana), followed by arthritis in the second place. the difference of clinical manifestation frequency order from previous studies was related to the absence of ana test performance in this study. the methodology to conduct sle screening study in the population does not necessarily stop by giving the liang or other sle screening questionnaire. the validated sle screening study, currently, consists of a two-stage series design. the first stage is the administration of sle screening questionnaire, the liang questionnaire in this case, and then, it is continued with performing the ana test on respondents who have answered the sle screening questionnaire, previously mentioned, with more than three positive answers. cut-off of three positive answers followed by ana test performance has been proven to yield the best predictive value compared with the other cut-off.5 this two-stage series design fulfills the criteria of a good screening strategy, which is high in sensitivity, specificity, and positive predictive value on the tests that are used as the method for screening.5 administration of sle screening questionnaire before performing ana test will highly help researchers in conducting sle screening study, especially in a large population. executing ana test in a large population will be very expensive and may produce a notable number of false positive results. ana test will be more effective and efficient when it is applied to a smaller population selected by a less expensive screening test, such as the liang questionnaire for example.5 the sampling method is one of the limitations of this study. the obtained samples may not represent the whole population because only the residents of each rt in each neighborhood (rukun warga, rw) of each village were included as respondents. nevertheless, the selected villages in this study were big villages in jatinangor and have a high number of residents compared to the other villages. it can be concluded that the existence of suspected sle cases in the population of jatinangor is an example of the indonesian population and should be a concern of the medical world. this findings should be followed by other studies conducted by other researchers who should perform physical examinations and ana test to ensure that respondents who have sle can be provided early interventions or medication to prevent complications. references 1. jakes rw, bae sc, louthrenoo w, mok cc, navarra sv, kwon n. systematic review of the epidemiology of systemic lupus erythematosus in the asia-pacific region: prevalence, incidence, clinical features, and mortality. arthritis care res. 2012;64(2):159–68. 2. cho j, chang s, shin n, choi b, oh h, yoon m, et al. costs of illness and quality of life in patients with systemic lupus erythematosus in south korea. lupus. 2014;23(9):949–57. althea medical journal. 2017;4(3) 362 amj september 2017 3. meacock r, dale n, harrison mj. the humanistic and economic burden of systemic lupus erythematosus. pharmacoeconomics. 2013;31(1):49–61. 4. mak a. the economic burden of systemic lupus erythematosus in asia: the current state. lupus. 2010;19(12):1442–6. 5. liang mh, meenan rf, cathcart es, schur ph. a screening strategy for population studies in systemic lupus erythematosus. arthritis rheum. 1980;23(2):153–7. 6. johnson a, gordon c, bacon p, hobbs f. undiagnosed systemic lupus erythematosus in the community. the lancet. 1996;347(8998):367–9. 7. geva e, lerner-geva l, burke m, vardinon n, lessing jb, amit a. undiagnosed systemic lupus erythematosus in a cohort of infertile women. am j reprod immunol. 2004;51(5):336–40. 8. somers ec, marder w, cagnoli p, lewis ee, deguire p, gordon c, et al. populationbased incidence and prevalence of systemic lupus erythematosus: the michigan lupus epidemiology and surveillance program. arthritis rheumatol. 2014;66(2):369–78. 9. ferucci ed, johnston jm, gaddy jr, sumner l, posever jo, choromanski tl, et al. prevalence and incidence of systemic lupus erythematosus in a populationbased registry of american indian and alaska native people, 2007–2009. arthritis rheumatol. 2014;66(9):2494–502. 10. feldman ch, hiraki lt, liu j, fischer ma, solomon dh, alarcon gs, et al. epidemiology and sociodemographics of systemic lupus erythematosus and lupus nephritis among us adults with medicaid coverage, 2000–2004. arthritis rheum. 2013;65(3):753–63. 11. lim ss, drenkard c, mccune j, helmick cg, gordon c, deguire p, et al. populationbased lupus registries: advancing our epidemiologic understanding. arthritis rheum. 2009;61(10):1462–6. 12. lim ss, drenkard c. epidemiology of systemic lupus erythematosus: capturing the butterfly. curr rheumatol rep. 2008;10(4):265–72. 13. dancheko n, satia ja, anthony ms. epidemiology of systemic lupus erythematosus: a comparison of worldwide disease burden. lupus. 2006;15(5):308– 18. 14. tan ij, peeva e, zandman-goddard g. hormonal modulation of the immune system-a spotlight on the role of progestogens. autoimmun rev. 2015;14(6):536–42. 15. tsokos gc. mechanisms of disease: systemic lupus erythematosus. n engl j med. 2011;365(22):2110–21. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 73 relationship between socioeconomic demographic characteristics with antibiotic self-medication in community dwelling adults michael aditya,1 istriati,2 aih cahyani3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine, universitas padjadjaran, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: infectious diseases escalation in developing countries especially in indonesia lead to increasing use of antibiotics in the community. self-medication with antibiotics may increase the risk of resistant bacteria and irrational use of antibiotics. this study was conducted to determine the relationship between socioeconomic -demographic characteristics with antibiotic self-medication. methods: an analytical cross sectional study was conducted on people from sayang village in west java indonesia aged over 18 years and had experience in using antibiotics. a total of 146 respondents were selected as the sample of this study. a validated questionnaire was used to collect data. data were analysed by using descriptive statistics and chi-square test to analyze the relationship between socioeconomic demographic characteristics with antibiotic self-medication. results: out of 146 questionnaires that were completed, 111 were female and 35 male respondents, 75 respondents had experience in using antibiotics without prescription. the survey showed significant relation between antibiotics use with monthly income (p=0,031) and source of income (p=0,009). conclusions: the study confirms that there is relation between monthly income and source of income with antibiotic self-medication. [amj.2017;4(1):73–7] keywords: antibiotics, self-medication, socioeconomic -demographic characteristics correspondence: michael aditya l, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 856 917 5300 email: michaeladityalesmana@gmail.com introduction the escalation of infectious diseases is still a major health problem in developing countries especially in indonesia. it reflected the fact based on the indonesian health profile in 2005 that the most common health problem of indonesian people was infectious disease.1 characteristics of the diseases that could be transmitted to the other individual increased the demand of drugs to treat these infectious diseases. antibiotics was already well-known and commonly consumed for treating bacterial infections but the usage is highly restricted and must be taken under prescription since irrational use of antibiotics might build a resistance pattern from bacteria to antibiotics. one of the examples of irrational use of antibiotics that could lead to resistance of bacteria was the development of multidrug-resistant tuberculosis (mdr-tb) and indonesia is classified as a high burden country due to high incidence of mdr-tb (1.9% from new cases and 12% from retreatment cases).2 many factors could affect the behaviour and intention of people in using antibiotics. one of the factors that is related with that behaviour is the socioeconomic-demographic characteristics. this factor could affect the people’s decisions to buy and use antibiotics by himself/herself without prescription and build an assumption that many people will do self-medication3 into diseases that commonly occurred and treated like infectious diseases. this behaviour may increase the demand of antibiotics in the community. studies conducted in many countries like in the united states4, indonesia5,6, greek7, india8-10, nigeria11, jordania12, iran13 and in other countries showed a surprising fact that the use of antibiotics without prescription in those countries was fairly high. a review of literature revealed that similar studies have althea medical journal. 2017;4(1) 74 amj march 2017 already been conducted in many countries including indonesia, specifically in medan but the differences in ethnicity and geographical condition differentiates the other studies with this study despite of similarity of the socioeconomic-demographic characteristics such as sex, age, level of education and monthly income. the purpose of this study was to determine the relationship between socioeconomic-demographic characteristics with antibiotic self-medication in community dwelling adults. methods an analytical cross sectional study was conducted within people in sayang village aged above 18 years and had experience in using antibiotics during the past year. this village is located in sumedang, west java indonesia and is one of the selected places where many studies were conducted by medical students from the faculty of medicine, universitas padjadjaran bandung. consecutive sampling technique was used to select samples and a total of 146 respondents who had experience in using antibiotics during the past year were selected. this study has also already received the ethical approval from the health research ethics committee (no.152/un6.c2.1.2/ kepk/201). a verbal consent was taken after the surveyor explained the aim of the study and if the people agreed to be a respondent they also signed an informed consent. a validated questionnaire from a previous research in medan5 was used to collect antibiotic selfmedication and socioeconomic-demographic data, such as gender, age, level of education, monthly income and source of income. respondents were also asked whether they had used antibiotic without prescription during the past year or not. table 1 characteristics of subjects based on gender, age category, level of education, monthly income, source of income and antibiotic selfmedication variable n % gender female 111 76.0 male 35 24.0 age category <30 years 31 21.2 30 ̶ 39 years 49 33.6 40 ̶ 59 years 36 24.7 >50 years 30 20.5 level of education primary education 24 16.5 secondary education 104 71.2 university graduate 18 12.3 monthly income (rp.) ≤ 1.381.700 75 51.4 > 1.381.700 71 48.6 source of income non fixed income 59 40.4 fixed income 87 59.6 antibiotic self-medication without prescription 75 51.4 with prescription 71 48.6 althea medical journal. 2017;4(1) 75michael aditya l, istriati, aih cahyani: relationship between socioeconomic demographic characteristics with antibiotic self-medication in community dwelling adults descriptive statistic and bivariate analysis was performed sequentially to determine relationship from each of the socioeconomicdemographic variables with antibiotic selfmedication. a descriptive analysis was performed to count every characteristic that would be tested and described every independent and dependent variables using tables of frequency distribution and percentage of each variable. finally, the bivariate analysis was conducted in this study to find any relation between every variable with antibiotic selfmedication by using the chi-square test. the result was considered statistically significant if the variable had a p-value<0.05. results there were 146 respondents involved in this study, with 75 respondents (51.4%) were self-medicating and using antibiotics without prescription. analysis from the questionnaires showed that the highest gender of respondents were female with 111(76.0%) respondents who joined this study with median of age 38 years ranging from the youngest respondent was 18 years old and the oldest respondent was 72 years old. the educational level of respondents was mostly distributed in the secondary education level. the mean of monthly income from the respondents was rp.1.920.890,00 and mostly came from fixed income (table 1). antibiotic self-medication was significantly affected by monthly income (p=0.031) and source of income (p=0.011) but not by age and level of education (table 2). discussions from 146 respondents who were involved in this study 75 respondents (51.4%) were self-medicating and using antibiotics without prescription, 124 respondents (84.9%) had already known that the use of antibiotics must be with a prescription from the physician. the reasons for using antibiotics without prescription were mostly because of economic reason and the previous experience with antibiotics. the previous experience with antibiotics was the main source of information that respondents used when deciding to use that medication again for the second time. most of the respondents (n=67) used antibiotics for a short period of time. they decided to stop the medication with antibiotics after the table 2 bivariate analysis of socioeconomic-demographic characteristics with antibiotic self-medication variables antibiotic self-medication p value with prescription without prescription age category <30 years 18 13 0.810 30 ̶ 39 years 24 25 40 ̶ 59 years 17 19 >50 years 16 14 level of education primary education 11 13 0.639 secondary education 56 48 university graduate 8 10 monthly income (rp.) ≤ 1.381.700 32 43 0.031 > 1.381.700 43 28 source of income non fixed income 38 21 0.009 fixed income 37 50 althea medical journal. 2017;4(1) 76 amj march 2017 symptoms subsided. this could be due to lack of education from the prescribing physician and/or dispensing pharmacist as the patients should be counselled about the treatment regiment. the most respondents in this study were in the age category 30 ̶39 years with 46 respondents (35.4%) in each category. the chi-square test between the variable of age category with antibiotic self-medication showed p-value in the amount of 0.810. the result showed that there was not any significant relation between age category and antibiotic self-medication. this findings was different with previous studies performed in sudan14 and united arab emirates15 that showed a significant relation between age category and antibiotic self-medication. however another study in yogyakarta also showed no relationship between age and antibiotic self-medication.6 further studies and investigation must be performed due to possibilities of people especially who lies in the active age group to have self-medication and tended to have more complaints, for instance, stress of family problems and daily market schedule. on the other hand, the lowest used rate among the younger age group might be caused of some of them may still be in school or learning a trade, usually have less complaint, and low purchasing power.11 the educational level of the population in sayang village was already good enough since 104 respondents (71.2%) graduated from the secondary education grade and not any illiterate individual joined this study. the chi-square test between level of education variable and antibiotic self-medication failed to show any significant relation (p =0.639). the results are similar with studies in medan5 and yogyakarta6 that also could not find any significant relation between level of education with antibiotic self-medication. however, this findings was different with the previous studies in nigeria11, sudan14 and united arab emirates15 which showed a significant relation between level of education with antibiotic selfmedication. this could be due to differences of the educational system in those countries with the educational system in indonesia. although educational level was not showing any relationship with antibiotic self-medication in this study, a further investigation must be conducted due to relation of educational level that could affect people’s insight when accepting a medical information, where people with a higher level of education tend to have a higher knowledge in understanding a medical information.16 people with a higher level of education also feel that a hospital or pharmacy have well-trained personnel rather than a patent medicine dealer in drug dispensing.11 economic considerations were important in this study. from the results of this study, out of 146 respondents, there were 75 respondents (51.5%) who had a monthly income that equalled to rp1.381.700,00 or less and only 87 respondents (59.6%) who had a fixed income. this finding raised a notion that there were a lot of people in sayang village that still had a low monthly income. the result from the chi-square test between monthly income variable and antibiotic self-medication showed that there was a significant relation between monthly income (p=0.031) and source of income (p=0.009). this finding was different with the previous studies conducted in medan5 and yogyakarta6 that could not find any significant relation between monthly income with antibiotic selfmedication. this result can differ due to the differences of culture and ethnicity of people in medan, yogyakarta and in jatinangor which could affect the consumption behaviour of the people. however, this study showed a similar relation with a study in jordania that also showed a significant relation between these two variables.12 the similar result between the study in jordania and jatinangor had an unknown cause. furthermore, this study had limitations. there was a possibility that the collected information was biased. in addition, because the respondents were exposed by the similar economic and environmental conditions, their complaints and responses tended to be similar. the future studies would ideally follow the respondents to gain a deeper insight into the antibiotic self-medication. this study concluded that there is a significant relation between economic characteristics with antibiotic self-medication. references 1. departemen kesehatan ri. profil kesehatan indonesia. jakarta: depkes ri; 2005. 2. world health organization. global tuberculosis report 2013. geneva: who press; 2013. 3. world health organization. who global strategy for containment of amr and implementing it at local and who global strategy for containment of amr. moshi: epn; 2008. 4. larson e, grullon-figueroa l. availability of antibiotics without prescription in new althea medical journal. 2017;4(1) 77 york city. j urban health.2004;81(3):498 ̶ 504. 5. hendriani m. hubungan antara karakteristik masyarakat dengan penggunaan antibiotik yang diperoleh secara bebas di kota medan [thesis]. medan: university of sumatera utara; 2009. 6. widayati a, suryawati s, de crespigny c, hiller je. self medication with antibiotics in yogyakarta city indonesia: a cross sectional population-based survey. bmc res notes.2011;4(1):491. 7. mitsi g, jelastopulu e, basiaris h, skoutelis a, gogos c. patterns of antibiotic use among adults and parents in the community: a questionnaire-based survey in a greek urban population. int j antimicrob agents.2005;25(5):439 ̶ 43. 8. wattal c. development of antibiotic resistance and its audit in our country: how to develop an antibiotic policy. indian j med microbiol.2012;30:381 ̶ 3. 9. jain p, sachan a, singla rk, agrawal p. statistical study on self medication pattern in haryana , india. indo global journal of pharmaceutical sciences.2012;2(1):21 ̶ 35. 10. loharkar n, keche y, yegnanarayan r, dharma m, bhosale a. self-medication use in urban population of pune , maharashtra, india. sch j app med sci.2013;1(6):732 ̶ 8. 11. afolabi a. factors influencing the pattern of self-medication in an adult nigerian population. ann afr med.2008;7(3):120 ̶ 7. 12. al-azzam si, al-husein ba, alzoubi f, masadeh mm, al-horani ma. self medication with antibiotics in jordanian population. int j occup medi environ health.2007;20(4):373 ̶ 80. 13. heidarifar r, koohbor m, mansourabad km, mikaili p, sarahroodi s. self-medication with antibiotics among iranian population in qom state. journal of scientific and innovative research.2013;2(4):785 ̶ 9. 14. awad a ei, matowe l, thalib l. selfmedication with antibiotics and antimalarials in the community of khartoum state, sudan. j pharm pharm sci.2005;8(2):326 ̶ 31. 15. abasaeed a, vlcek j, abuelkhair m, kubena a. self-medication with antibiotics by the community of abu dhabi emirate, united arab emirates. j infect dev ctries.2009;3(7):491 ̶ 7. 16. sariningrum e, irdawati. hubungan tingkat pendidikan, sikap dan pengetahuan orang tua tentang kebersihan gigi dan mulut pada anak balita 3-5 tahun dengan tingkat kejadian karies di paud jatipurno [thesis]. surakarta: muhammadiyah university of surakarta 2009. michael aditya l, istriati, aih cahyani: relationship between socioeconomic demographic characteristics with antibiotic self-medication in community dwelling adults 293 althea medical journal. 2017;4(2) nutritional status of hospitalized stroke patients: assessment by body mass index and subjective global assessment method gloria kartika,1 lisda amalia,2 gaga irawan nugraha3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: stroke is a disease with a high mortality rate and common cause of disability. nutritional factors are strongly associated with this disease. malnutrition in hospitalized patients increases the incidence of complications, prolonged the length of stay and also the cost of hospitalization. furthermore, nutritional status of stroke patients can deteriorate during hospitalization. the prevalence of malnutrition in hospitalized stroke patients is about 6% to 62%. the objective of this study was to identify the nutritional status of hospitalized stroke patient. methods: this was a descriptive cross-sectional study. population of the study was hospitalized stroke patients at neurology ward, kemuning building dr. hasan sadikin general hospital bandung, indonesia from august until october 2014 who meet the inclusion criteria. nutritional status was measured objectively using body mass index (bmi) and subjectively using subjective global assessment (sga) method. the collected data were processed using frequency tabulation and percentage. results: twenty six hospitalized stroke patients were included in this study. the hospitalized patients with normal bmi were about 12 people (46.15%), 8 people were overweight (30.77%), 4 people were undernourished (15.39%) and 2 people (7.69%) were obese. according to sga measurement, approximately 18 people (69.22%) were moderately malnourished, and as much as 4 people (15.39%) were in good nutrition, whereas 4 people (15.39%) were severely malnourished. conclusions: majority of the hospitalized stroke patients has normal bmi and moderately malnourished based on sga. keywords: body mass index, nutritional status, stroke, subjective global assessment correspondence: gloria kartika, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81261715107 email: gloria_kartika@yahoo.com introduction stroke is a disease with high mortality rate and the most frequent cause of disability. stroke was ranked as the third killer disease in the united states of america.1 moreover, the survival rate of this disease is also low. according to statistical data from university hospital network new jersey, only 10% of stroke patients were able to recover completely while 25% had minor disability, 40 had moderate disability while 15% died shortly.2 indonesia has the highest number of death among stroke patients followed by philippines, singapore, brunei, malaysia and thailand.3 the nutritional status of stroke patient tends to decrease during hospitalization. as such, the prevalence of malnutrition among stroke patients is about 6-62%.4 this is not very surprising as the nutritional status of most patients were already bad prior to stroke. increase in both metabolic demands and catabolic stress also tends to deteriorate nutritional status. malnutrition in hospitalized patients leads to many complications such as prolong hospital stay and increased in hospital cost.5,6 one of the best ways to assess nutritional status is by using body mass index (bmi) for objective evaluation of nutritional status and subjective global assessment (sga) for subjective evaluation of nutritional status.6 subjective evaluation of nutritional status by sga is an alternative evaluation that is practical, simple and valid by using clinical amj. 2017;4(2):293–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1090 althea medical journal. 2017;4(2) 294 amj june 2017 evaluation to identify patients with risk of malnutrition or even malnourished patients.5,7 the objective of this study was to identify the nutritional status of hospitalized stroke patients. methods the study was based on observational descriptive with cross-sectional design. this study had been approved by ethical committee of hasan sadikin general hospital, bandung number 8794/diklit/viii/14. the subjects of this study were stroke patients in the neurology ward of kemuning building, dr. hasan sadikin general hospital, bandung, indonesia from august to october 2014. total sampling was used in this study. the inclusion criteria for this study were patients presented with primary or reccurent both infarct stroke and hemorrhagic stroke who were hospitalized at the neurology ward of kemuning building, hasan sadikin general hospital between august and october 2014. patients’ or any family member were asked to sign informed consent prior to participating in this study. on the other hand, stroke patient with diabetes mellitus, aphasia, dementia, decreased consciousness and unstable vital signs were excluded from the study. variables measured was bmi and sga. anthropometry measurement (height and body weight), anamnesis, and physical examination for sga assessment was obtained. body weight measurement for hospitalized patient was conducted using bed scales seca 985 type, meanwhile body height was estimated using recumbent length method and measured using a measure tape abn type. the recumbent length measurement is a common method in measuring bedridden patients and is the most accurate method to estimate the patients’ height.8 bmi then calculated using the formula below: bmi = body weight (kg) / height2 (m) table 1 bmi category category bmi (kg/m2) undernutrition < 18,5 normal 18,524,9 overweight 25 -29.9 obese ≥ 30 table 2 classification of sga category explaination a good nutrition b moderate malnutrition c severe malnutrition bmi obtained was then classified into the following categories based on who. subjective global assessment involved anamnesis about weight loss for the last 6 months expressed in both kilograms and proportionate loss, changes in food intake duration and degree (starvation, hypocaloric liquid, full liquid diet, suboptimal solid diet), gastrointestinal complaints for at least in the last 2 weeks (nausea, vomiting, diarrhea, anorexia), changes in functional capacity (suboptimum, ambulatory or bed rest), primary diagnosis and metabolic demands, physical examinations was conducted to find loss of subcutaneous fat, atrophy of muscles, edema, and ascites.5 loss of subcutaneous fat and atrophy of muscles were evaluated subjectively by the examiner and was categorized as normal, slightly decrease, moderate, severe.7 patients were then categorized according to the degree of nutritional status as follows: patient was categorized as moderate malnutrition when there was a decrease in 5% body weight with no subsequent increase, decreased of food intake, and light loss of subcutaneous tissue. patient was categorized as severe malnutrition when there was a severe loss of subcutaneous tissue, atrophy of muscles and edema.7 results between august to october 2014, 45 stroke patients were hospitalized whereas only 26 patients fulfilled all the inclusion and exclusion criteria. table 3 showed the demographic characteristic of subjects included in this study. the prevalence of female patients with stroke was higher compared to male patients with a ratio of male patients to female patients of 1:1.36 (table 3). most stroke patients were between 43 years old to 78 years old with the average age of 59.8 years old. the patients’ data were collected from day two until the 16th day of hospitalization with an average of 4 days. the difference in nutritional status assessment between patients at the onset of hospitalization was then matched with the 295 althea medical journal. 2017;4(2) table 3 characteristics of subjects total patients (n=26) percentage (%) gender male 11 42.31 female 15 57.69 age group (years old) 40-49 3 11.54 50-59 12 46.15 60-69 7 26.92 ≥70 4 15.39 type of stroke infarct 13 50.00 hemorrhagic 13 50.00 onset stroke first stroke 13 50,00 repeated stroke 13 50.00 onset of hospitalization until measurement (days) 0-5 21 80.77 6-10 4 15.38 >10 1 3.85 gloria kartika, lisda amalia, gaga irawan nugraha: nutritional status of hospitalized stroke patients: assessment by body mass index and subjective global assessment method stability of the patient’s clinical condition at the moment. most of patients can be measured on less than five days of hospitalization. body mass index of the patients showed in table 4. majority of the patient had normal bmi (46.15%) with least obese patients (7.69%) (table 4). in addition, sga method was also used to evaluate the nutritional status of the patients. the characteristics of the parameter for sga evaluation was shown in table 5. based on table 5, it could be concluded that most of the patients experienced loss of body weight. gastrointestinal effect referred to nausea, vomiting, diarrhea, and anorexia. physical examination was carried out to identify any sign of malnutrition such as loss of subcutaneous fat, atrophy of muscles, edema at lower extremities and ascites and this study discovered that most of the patients had not has any physical changes regarding the sga standards. based on the sga evaluation, majority of the patient experienced moderate malnutrition while the percentage number of patients with good nutrition and severe malnutrition were equal. table 4 nutritional status based on bmi total patients (n=26) percentage (%) underweight 4 15.39 normal 12 46.15 overweight 8 30.77 obese 2 7.69 althea medical journal. 2017;4(2) 296 amj june 2017 discussion this study discovered that almost half of the patients had overweight or obese. a study conducted in hospital adam malik showed a strong relationship between obesity and stroke (p<0,013).10 on top of that, it has been shown that increase in bmi during middleage increased the risk of getting total stroke and ischemic stroke but not hemorrhaging stroke.10 the study showed similar result with a study carried out at neurology department of klinikum mannheim and klinikum heidelberg in germany that obesity measured by bmi or waist circumference showed significant relationship towards risk of getting stroke and tia.11 obesity is usually related with hyperlipidemia, hypercholesterolemia and hypertriglyceridemia which lead to atherosclerosis that ultimately result in ischemic stroke. besides that, hypertension in obese people is an important risk factor for hemorrhaging stroke which usually caused by increased in cardiac output and plasma volume.10 based on the nutritional status evaluated by sga, many patients had moderate malnutrition. malnutrition occurs due to various reasons such as increased in metabolism caused by stroke and decreased in gastrointestinal function. on top of that, decreased in gastrointestinal function could be due to disturbances in the oral, pharynx, and esophageal function which often manifested as dysphagia.4 dysphagia is defined as difficulty in swallowing and can be followed by painful swallowing. in a previous study, the prevalence of dysphagia in stroke is as high as 52.6%.9 table 5 characteristics of patients based on sga total patients (n=26) percentage (%) decrease in body weight no 9 34.62 yes 17 65.38 nasogastric tube usage without nasogastric tube 13 50.00 with nasogastric tube 13 50.00 gastrointestinal complaints yes 21 80.77 no 5 19.23 changes in functional capacity no 0 0.00 suboptimal / ambulatory 7 26.92 bedridden 19 73.08 physical examination no changes 19 73.08 there are changes 7 26.92 table 6 nutritional status based on sga total patients (n=26) percentage (%) good nutrition 4 15.39 moderate malnutrition 18 69.22 severe malnutrition 4 15.39 297 althea medical journal. 2017;4(2) dysphagia often leads to aspiration in 20-25% patient and is strongly related with increased in mortally and pneumonia. in addition, there is a significant relationship between dysphagia and malnutrition.13 dysphagia often leads to loss of body weight due to decreased in food intake. besides that, dysphagia often causes discomfort during swallowing which ultimately causes the patient’s to lose his or her appetite which eventually lead to malnutrition in hospitalized patients. to increase the food intake in patient with dysphagia, nasogastric tube is often used. in this study, 13 people or precisely 50% of the patients had dysphagia and used a nasogastric tube for food intake. out of 13 patients, 10 have moderate malnutrition while the other had severe malnutrition. stroke patients also experienced loss of body weight due to loss of appetite caused by depression, cognitive deficit, upper extremities paralysis, visual and cognitive changes like hemianopsia and apraxia.4 in addition, malnutrition in stroke patient usually is caused by the inability of the body of the stroke patient to tolerate enteral nutrition due to decrease in intestinal motility and weak gastrointestinal muscles tones. this condition leads to inadequate food digestion which tend to decrease the gastrointestinal function of the patient. nutritional status evaluation based on bmi showed that most of the patient has normal nutritional status contradictory to sga. as such, bmi only takes into account the energy usage of the patient while sga is more comprehensive in evaluating the patients. bmi measurement does not take into account the loss of body weight, changes in diet, gastrointestinal effects such as nausea, vomiting, diarrhea, anorexia, metabolic stress, changes in functional capacity and changes in the patients physic. planas et al.7 showed anthropometry and sga evaluation were not similar in nature and sga itself was a better method to assess nutritional status. in certain scenario, patients might be categorized as obese and as they progress, they often experienced about 10% of loss in body weight accompanied with gastrointestinal symptoms and present with edema during bmi measurement. this is why it is crucial to have sound understanding in nutritional status of the patient and bmi must be calculated to evaluate the nutritional status and sga comparison.12 there were several limitations in this study such as limited timeframe, which lead to smaller sample size. in addition, there were no earlier study conducted in hasan sadikin general hospital regarding this matter. furthermore, this study did not cover the nutritional status of the patients prior to hospitalization, other diseases present and complications which might affect the nutritional status. in conclusion, most of the hospitalized stroke patients have normal bmi. however, sga evaluation indicates that they have moderate malnutrition. this is an alarming issue as the high prevalence of moderate malnutrition could progress to severe malnutrition. further study is needed to identify the factors that lead to malnutrition. this study can also be used as a reference for further research to determine the relationship between malnutrition and period of hospitalization. besides that, the author also recommends that nutritional assessment should be routinely carried out to evaluate hospitalized patients and to assess patients’ response in term of nutritional status. education about proper nutrition and meal time for stroke patient should be given to the family. this is important to help the patient reaches the ideal bodyweight to prevent comorbidity. on top of that, education about how to prevent recurrent stroke should be given to both patient and the family. finally, nutritional status should be evaluated during follow-up at polyclinic to assess the effectiveness of nutritional therapy for home-care in stroke patient. references 1. yuniadi y. intervensi pada stroke nonhemoragik. karidn. 2010;31(3):153–5. 2. newmark uh. stroke statistic. new jersey. 2013 [cited 2014 march 1]. available from: http://www.uhnj.org/stroke/stats.htm. 3. cintya ys, susila s. gambaran faktor risiko dan tipe stroke pada pasien rawat inap di bagian penyakit dalam rsud kabupaten solok selatan periode 1 januari 2010– 31 juni 2012. jurnal kesehatan andalas. 2013;2(2):57–61. 4. foley n, richardson m, bhogal s, speechley m. nutritional interventions following stroke. ebrsr [evidence-based review of stroke rehabilitation. 2013;16:1–37. 5. keith jn. bedside nutrition assessment past, present, and future: a review of the subjective global assessment. nutr clin pract. 2008;23(4):410–416 6. da silva hv, santos s, silva n, ribeiro f, josua l, moreira a. nutritional assessment associated with length of inpatients hospital stay. nutr hosp. 2012;27(2):542– 7. gloria kartika, lisda amalia, gaga irawan nugraha: nutritional status of hospitalized stroke patients: assessment by body mass index and subjective global assessment method althea medical journal. 2017;4(2) 298 amj june 2017 7. froehlich-grobe k, nary de, van sciver a, lee j, little td. measuring height without a stadiometer empirical investigation of four height estimates among wheelchair users. am j phys med rehabil. 2011;90(8):658– 66. 8. crary ma, carnaby-mann gd, miller l, antonios n, and silliman s. dysphagia and nutritional status at the time of hospital admission for ischemic stroke. j stroke cerebrovas dis. 2006;15(4):164–71. 9. ophine l. hubungan antara obesitas dengan stroke pada pasien rawat inap di bagian ilmu penyakit saraf fk-usu/ rsup h. adam malik medan. medan: universitas sumatera utara; 2010. 10. winter y, linseisen j, lanczik o, ringleb pa, hebebrand j, back t. contribution of obesity and abdominal fat mass to risk of stroke and transient ischemic attacks. j am heart assoc. 2008;39:3145–51. 11. theresia kb, amir a, hendrayati, ayu sd. studi komparasi metode penilaian status gizi indeks massa tubuh dan subjective global assessment (sga) pasien rawat inap di rumah sakit dr wahidin sudirohusodo makassar. j gizi pangan. 2011;11(1):7– 10 12. edmiaston j, connor lt, loehr l, nassief a.. validation of a dysphagia screening tool in acute stroke patients. am j crit care. 2010;19(4):357–6. althea medical journal. 2017;4(2) 234 amj june 2017 environmental factor contributed to the onset of schizophrenia yuleni,1 tuti wahmurti a. sapiie,2 ra. retno ekowati2 1faculty of medicine, universitas padjadjaran, 2departement of psychiatry faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3departement of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: schizophrenia is a severe and chronic mental disorder that needs a long term treatment and social support. this condition may results in burden and disturbance in the family and society a number of studies have investigated some environmental factors that may potentially lead to schizophrenia. one of many suspected environmental factors is place of born or grew up. this study was conducted to investigate association between place of born or grew up and age of onset of schizophrenia. methods: this analytical study using cross-sectional method was conducted by retrieving data from 72 medical records of hospitalized schizophrenic patients in dr. hasan sadikin general hospital from october‒ november 2013. the variables in this study were age of onset and place (urban or rural) where the patients born or grew-up.the collected data were analyzed using chi-square statistical test. results: this study discovered that 75% of subjects were born or grew up in urban area, 68% of subjects had age of onset at 20‒40 years and there was no association between place of born or grew up and age of onset of schizophrenia (p-value was 0.108). conclusions: more than half subjects were born and grew up in urban, who had age of onset of schizophrenia at 20‒40 years and there is no significant association between place of born or grew up and age of onset of schizophrenia. keywords: age of onset, environmental factor, rural, schizophrenia, urban correspondence: yuleni, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85324096266 email: coklatharmoni@gmail.com introduction schizophrenia is a severe mental disorder that influences the cores of human being, which are cognition, emotion, and behavior. the course of schizophrenia is chronic and can be relapsed. based on the data, 90% of schizophrenic patients who undergo treatments are in productive age (15‒55 years old).1-5 schizophrenic patients need long term treatment, continual hospitalization and social support. this condition may results in burden and disturbance in the family and society in some way.1-5 a number of studies have investigated some environmental factors may potentially lead to schizophrenia. one of many suspected environmental factors is place of born or grew up.6-10 based on study conducted by vassos et al.11 and pedersen et al.12 in denmark citizens, it is stated that schizophrenia relative risk (rr) with be born in urban area is 2,4. moreover, from a study conducted by lewis et al.6 it was discovered that the risk of schizophrenia was 1.65 times higher among men who had been grew up in cities, compared to those grew up in rural area.11 around 0.06‒1.7% of the population are suffered from schizophrenia throughout the world. the number of male patients is approximately equal to women.1 the disease can affects human in their early childhood, late teens, or early and middle adulthood. each age group illustrates different pathological component roles in the disease development. thus, age of onset acts as the main character of schizophrenia to determine the ruling etiology.13-15 this study was conducted to investigate the association between place of born or grew up and age of onset of schizophrenia. amj. 2017;4(2):234–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1080 235 althea medical journal. 2017;4(2) methods this studied using cross-sectional method. it was conducted in medical record installation centre and kemuning building of dr. hasan sadikin general hospital from october‒ november 2013. the data used was secondary data obtained from schizophrenic patients who were being hospitalized in department of psychiatric. medical records used were those dated from january 2012‒september 2013, and were selected using total sampling method. data retrieved from patient’s medical records are age of onset which was based on the patient’s history. those who were first diagnosed schizophrenia by physicians and the place where the patients were born and grew up based on the patients’ addresses. permission to use the database was granted by health research ethics committee from dr. hasan sadikin general hospital. from the 230 medical records, 122 patients were age of onset ranging from 12‒40 years old, but 50 patients were excluded because of incomplete or absent medical records. therefore, 72 patients were included in this study. after the data was collected, place of born or grew up were grouped based on the rule of kepala badan pusat statistik nomor 37 tahun 2010 concerning the classification of urban and rural area in indonesia into 2 areas; the urban and rural area. meanwhile, the age of onset was grouped based on human development theory into 2 groups; 12‒19 years and 20‒40 year. finally, the data was analyzed using chi-square analysis. results sixty eight percent of subjects had age of onset at 20‒40 years and 75% of subjects were born or grew up in urban area (table 1). eighty seven percent of subjects of age of onset at 12‒19 years and 69% of subjects of age of onset at 20‒40 years were born or grew up in urban area. this percentage was greater than the percentage of patients who were born or grew up in rural area, both patients who were in the age of onset of 12‒19 years and 20‒40 years (table 2). from the analysis test, it was found that there was not any significant association between born or grew up in urban area with age of onset of schizophrenia p-value is >0.05 (p=0.108) discussion the involvement of environmental factors in schizophrenia such as born or grew up in table 1 characteristics of the subjects frequency percentage age of onset (years) 12‒19 23 32 20‒40 49 68 place of born or grew up urban 54 75 rural 18 25 yuleni, tuti wahmurti a. sapiie, ra. retno ekowati: environmental factor contributed to the onset of schizophrenia table 2 comparison place of birth or grew up based on age of onset of schizophrenia place of born or grew up totalurban rural n % n % age of onset (years) 12‒19 20 87 3 13 23 20‒40 34 69 15 31 49 total 54 18 72 althea medical journal. 2017;4(2) 236 amj june 2017 urban area are inspired by nerve development hypothesis. this hypothesis states that environmental or genetic factors, or more likely their complex interaction, during early periods of brain development, can negatively affect adult mental health and contribute in the increasing of possible onset of schizophrenia in late adolescence (17‒19 years old) and adulthood.6,15-17 since a study conducted by leask9 (1939) in chicago, many studies had reported schizophrenia risk which was higher in urban than in rural. this mental disorder was associated with local population density in urban area.18 one of them was a cohort study on 690,000 swedish citizens. the study emphasized that born in urban was related with schizophrenia risk for late onset (hazard ratio 1.24).7 another study by pedersen et al.12 in denmark citizens stated that schizophrenia relative risk with urban born was 2.4. the higher degrees of urbanization, the higher the risk.11 the urban risk factor had been recently addressed in several large population. cohort studies was investigating place of born, grew up, and residence at onset. the developing line of evidence confirmed an association between place of grew up and risk of schizophrenia and suggested that the urban risk factor influences more in early life.6 from study by brown et al.6 in a study examining 49.191 male swedish conscripts. survey data obtained at conscription were linked to data from the national psychiatric care registry, encompassing 15 years of follow-up”. brown et al.6 found that the risk of schizophrenia was 1.65 times higher among men grew up in cities, compared to those grew up in rural area.11 supported by a study conducted by pedersen, et al.12 reported that an individual, who stay in higher urbanized city for more than 5 years, has 1.4 times higher risk on schizophrenia. an individual living for more than 15 years in the highest urbanized city has 2.75 times higher risk on schizophrenia. they also discovered that moving from rural to urban in childhood and teenager could also increase the risk of schizophrenia. these all demonstrated the relationship existing between urban and schizophrenia. not only it does relate with urban born, but also with duration of continual or repetitive urban grew up and residence.14 however, an observation by zammit et al.17 argued that the low social interaction in urban was the relevant factor in explaining the increase in mental disorders on people growing up in urban area.7,19 apart from urban and rural factors, there were other potential factors. schizophrenia was also suggested to have relation with flu virus (and some other infections, including toxoplasmosis) during pregnancy particularly in the second trimester, malnutrition on mother during the first trimester, obstetrical complication, brain damage, substance misuse (such as nicotine, drugs, and alcohol), psychology were are also play important roles, such as immigration status, minority ethnic, and socio-economic status.8-10, 14 however, in this study, there was no association between place of born or grew up and age of onset of schizophrenia. this finding was different with previous studies confirming an association. this difference may be caused by several factors that could not be explained due to the lack information that stated in the medical records. limitations of this study were, no control group included and participated in this study, other environmental risk factors such as social and culture contribute to the onset of schizophrenia were not examined in this study. based on the results, it can be concluded that more than half subjects were born and grew up in urban, who had age of onset of schizophrenia at 20‒40 years and from the result statistical test showed that there was no significant association between place of born or grew up and age of onset of schizophrenia. references 1. sapiie twa. hubungan reseptor serotonin 5-ht2a trombosit dengan gejala negatif pasien skizofrenia yang mendapat pengobatan kombinasi antipsikotik antagonis d2 dan antidepresan antagonis 5-ht2a [dissertation]. bandung: universitas padjadjaran; 2003. 2. ascher-svanum h, zhu b, faries de, salkever d, slade ep, peng x, et al. the cost of relapse and the predictors of relapse in the treatment of schizophrenia. bmc psychiatry. 2010;10:2. 3. clemmensen l, vernal dl, steinhausen h-c. a systematic review of the long-term outcome of early onset schizophrenia. bmc psychiatry. 2012;12:150. 4. haynes vs, zhu b, stauffer vl, kinon bj, stensland md, xu l, et al. long-term healthcare costs and functional outcomes associated with lack of remission in schizophrenia: a post-hoc analysis of a prospective observational study. bmc psychiatry. 2012;12:222. 237 althea medical journal. 2017;4(2) 5. kurihara t, kato m, reverger r, tirta ig. remission in schizophrenia: a community-based 6-year follow-up study in bali. psychiatry clinical neurosci. 2011;65(5):476‒82. 6. brown as, bresnahan m, susser es. schizophrenia: environmental epidemiology. in: sadock bj, sadock va, editors. kaplan & sadock’s comprehensive textbook of psychiatry. 8th ed. philadelpia: lipincott williams & wilkins; 2005. p. 1371‒5. 7. murray rm, bramon e. developmental model of schizophrenia. in: sadock bj, sadock va, editors. kaplan & sadock’s comprehensive textbook of psychiatry. 8th ed. philadelpia: lippincott williams & wilkins; 2005. p. 1381‒93. 8. dean k, murray rm. environmental risk factors for psychosis. dialogues clin neurosci. 2005;7(1):69‒80. 9. leask sj. environmental influences in schizophrenia: the known and the unknown. adv psychiatr treat. 2004;10(5):323‒30. 10. mcgrath j, saha s, chant d, welham j. schizophrenia: a concise overview of incidence, prevalence, and mortality. epidemiol rev. 2008;30:67‒76. 11. vassos e, pedersen cb, murray rm, collier da, lewis cm. meta-analysis of the association of urbanicity with schizophrenia. schizophr bull. 2012;38(6):1118‒23. 12. pedersen cb, mortesen pb. evidence of a dose-response relationship between urbanicity during upbringing and schizophrenia risk. archiv gen psychiatry. 2001;58(11):1039‒46. 13. delisi le. the significance of age of onset for schizophrenia. schizophr bull. 1992;18(2):209‒15. 14. krabbendam l, os jv. schizophrenia and urbanicity: a major environmental influence-conditional on genetic risk. schizophr bull. 2005;31(4):795‒9. 15. kessler rc, amminger gp, aguilar-gaxiola s, alonso j, lee s, ustun tb. age of onset of mental disorders: a review of recent literature. current opinion in psychiatry. 2007;20(4):359‒64. 16. mcgrath jj, murray rm. environmental risk factors for schizophrenia. in: weinberger dr, harrison p, editors. schizophrenia. 3th ed. new york: john wiley & sons; 2011. 17. zammit s, lewis g, rasbash j, dalman c, gustafsson j-e, allebeck p. individuals, schools, and neighborhood: a multilevel longitudinal study of variation in incidence of psychotic disorders. arch gen psychiatry. 2010;67(9):914‒22. 18. march d, hatch sl, morgan c, kirkbride jb, bresnahan m, fearon p, et al. psychosis and place. epidemiol rev. 2008;30(1):84‒100. 19. allardyce j, boydell j. environment and schizophrenia: review: the wider social environment and schizophrenia. schizophr bull. 2006;32(4):592‒8. yuleni, tuti wahmurti a. sapiie, ra. retno ekowati: environmental factor contributed to the onset of schizophrenia althea medical journal. 2017;4(3) 315 public opinion regarding information on porcine-contained medications anindhita paramita wibowo,1 yoni fuadah syukriani,2 teguh marfen djajakusumah3 1faculty of medicine universitas padjadjaran, 2department of forensic and medicolegal faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: drugs are biological products, a single or combination of active and additives components. some additional components are derived from porcine, a substance that is haraam for muslims. patient’s rights, such as medication information, are substantial in decision-making process. medical decision-making in the eastern culture is not only the patient’s affair, but also family’s interest. this study aimed to determine the public opinion on that matter. methods: this study was conducted in october–november 2014 using qualitative methods. data collection was performed in the district of jatinangor, sumedang regency by using the purposive sampling method. six respondents were selected. data were collected through in-depth interview techniques and were analyzed using content analysis technique. results: there were 3 main responses regarding the respondent’s opinions. first, respondents showed several attitudes toward drugs in general and also several attitudes toward porcine-contained drugs. respondents showed concern for the medications used and wished either to be informed or not about the prohibited substance in the drugs. the decision-making process of respondents was performed by each individual or family, with the guidance of religious scholars. in a doctor-patient relationship, the doctors should be more active in providing information on the medications and the opportunity for patients to choose drugs. respondents also had a high dependency to the physicians in making medical decisions. conclusions: public opinion on patient’s rights regarding porcine-contained drugs shows the people’s attitude towards drugs in general and porcine-contained drugs in particular, the decision-making process and the relationship between physicians and patients. keywords: patient’s rights, drug information, public opinion, porcine correspondence: anindhita paramita wibowo, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: anindhitaparamita@gmail.com introduction drugs are biological products, whether in a single or combination form of several active ingredients and other supplementary materials that function to support the effects of the drug.1 some drugs have additional ingredients derived from porcine.2 on the other hand, indonesia is the largest muslim country in the world with a total of muslim population of about 87% of the overall population.2 muslims are prohibited from consuming products derived from porcine, as stated in the quran.3 religion is one of the basic human rights. mentioning about human rights, the right of health is also included.4 it consists of the right to healthcare and the right to selfdetermination.5 patient’s rights of autonomy are the construct of the right to selfdetermination, including the right of complete explanations of the medical measures that will be undertaken and the right to decide what kind of treatment will be performed, and also the information about the medicine.5 the patient’s medication information would affect the treatment decision-making process, because information is an important weapon in the process.6 a medical decision, in eastern cultures, is not only according to patients’ preferences, but also a common interest of the whole family.7 amj. 2017;4(3):315–20 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1176 althea medical journal. 2017;4(3) 316 amj september 2017 based on the explanation above, a study was conducted to determine the public opinions on patient’s rights regarding the information of porcine-contained medications. methods the study was conducted in october to november 2014 in the district of jatinangor, west java, indonesia using qualitative methods. the study population was the people who lived in the district of jatinangor. sampling was performed using the purposive sampling technique based on the information’s degree of saturation. the selected respondents consisted of six people. those who were willing to participate in the study were 17 years old and above, had a minimum of elementary education, were muslims, were able to communicate well and had adequate language skills. data were collected through in-depth interview using semi-structured technique. observation of the respondents was needed so that the interview and results would be understood in its context. the average duration of the interviews took 15–30 minutes and it was carried out in bahasa indonesia. the interview guide referred to a list of questions prepared according to the four box method, with the advices from assisting researchers. the four box method is a framework made to guide physicians to be able to decide on cases involving ethical issues.7 the topics of interview centered on: 1) the knowledge of information about the drugs in used 2) the attitude of respondents towards porcine-contained drugs 3) matters relating to medical decision-making process. the voice recordings of the interviews were transcribed into verbatim using bahasa indonesia. content analysis was then performed on the transcript by the primary researcher and assisting researcher as peerreview. afterwards, the data reduction was performed, then the withdrawal of pattern in the form of coding was conducted, and lastly, the data were divided into several categories. prior to the interview, the respondents were given a brief explanation of the interview objective, topic of discussion, confidentiality of information and right to refuse to participate in the research. the respondents realized that the interview process was recorded and may refuse to be recorded if not pleased. ethical approval was attained from the health research ethics committee of faculty of medicine universitas padjadjaran and dr. hasan sadikin general hospital bandung. during the presentation of the data, the personal data of the respondents remain anonymous. results according to the information given by the respondents, some important things could be drawn. based on the interviews, the attitude of the respondents towards drugs in general, it revealed that the respondents were concerned about the drugs they were using, including the effects, content, and side effects of the drugs. these answers were attained from the respondents who were pregnant. “kalo dikasih obat baru, apalagi lagi hamil kalo dikasih obat baru sama bidannya aku teh langsung buka google kan, bener ga sih, ya namanya dokter kan sama sama manusia kan, sampe ke isi kandungannya, jadi suka nyari sendiri.” (responden 1) “if i were given a new drug by the midwife, especially when i am pregnant, i will straight search the drug through google, whether it is the right drug or not, as doctors are also l table 1 respondent characteristics respondent characteristics additional info gender age (years old) education occupation n f 27 high school private employee pregnant na m 21 high school college student kp f 20 high school college student sd f 21 high school college student s f 25 high school private employee pregnant y m 20 high school college student althea medical journal. 2017;4(3) 317 table 2 data analysis result category coding attitude toward drugs in general concern for the drugs in use, including information about the content because she is pregnant and to be able to treat themselves not concern for the drugs in use, characterized by directly receiving the drug from the doctors. the information provided are sufficient, as long as the treatment goals are met, the drug information becomes less important toward porcine-contained drugs prefer alternative drugs willing to use porcine-contained drugs if other alternatives are unavailable and in an emergency situation willing to be informed for reasons of respecting one’s religion, different perspectives on porcine, preventing physicians to feel guilty about giving the medication, advancing knowledge and patient’s right to decide unwilling to be informed so that they would not feel guilty decision-making process for themselves without interference medical decisions is in the hand of the family consult to religion scholars doctor-patient relationship expectations for the doctors to be able to be more actively informed about porcine-contained drugs and other treatment information to the patients lack of choices of drugs and the opportunity to choose it independently patient’s trust in doctors is high, the assumption is that the physician are experts anindhita paramita wibowo, yoni fuadah syukriani, teguh marfen djajakusumah: public opinion regarding information on porcine-contained medications human, right? i will search the content also, by myself.” (respondent 1) however, there were also respondents who were not concern about the content of the drug in use. “ga pernah baca baca komposisinya, ga pernah mau tau apa itu obatnya, langsung minum aja.” (responden 2) “i never read the compositions, and never want to know what drug it is either, i just drink it directly.” (respondent 2) the attitude of the respondents to porcinecontained drugs, respondents preferred using alternative medicines than porcine-contained drugs because of religious prohibitions. respondents were also willing to use porcinecontained drugs if there were no other alternatives. “pertimbangan saya yah kalo misalnya saya kan beragama islam sesuai pandangan agama seperti itu pasti ya kalo misalnya tidak ada jalan alternatif lain ya sah sah saja, tetapi ketika ada obat herbal atau seperti apa yang dapat menyembuhkan, kenapa tidak menggunakan obat herbal terlebih dahulu.” (responden 6) “my consideration is my religion, islam, if there is no alternative, than it is legitimate to be consumed, but when there are herbal medicines or anything else available that can cure, why do not use that first.”(repondents 6) respondents wished to be informed about the content of porcine in the drug for the following reasons; respecting one’s religion, different perspectives on porcine, so doctors would not feel guilty for giving the medications, to advance the patient’s knowledge, and the patient’s right to know and to choose whether to use the drug or not. “seharusnya dikasih tau, supaya banyak pengetahuan, kalo dokternya sempet mah buat ngejelasin...” (responden 5) “it should be informed, so that we gain more knowledge, if the doctor have more time also to give explanation...” (respondent 5) “sebaiknya dikasih tau soalnya kan beberapa pandangan orang kan ada yang berbeda beda jadi usahakan untuk tranparanlah terbuka obat ini tuh mengandung apa apa apa biar masyarakat tuh tau ternyata yang dilihat tuh bukan dari hanya pandangan sebelah mata tapi bisa menyembuhkan juga.” (responden 6) “it should inform because of the people’s different perspectives, try to keep the transparency of all the content of the drugs so althea medical journal. 2017;4(3) 318 amj september 2017 that the society would not judge and so they would also benefit for curing.” (respondent 6) “dikasih tau, karna itu hak pasien buat memutuskan, takutnya kalo pasien tau diluar, kan kita gatau dari kalangan mana, tingkat ilmunya sampe mana, mereka kan bisa aja nuntut dokternya, misalnya mereka cuman tau kegunaannya, yang mereka tau kan babi dan hal-hal buruknya.” (responden 4) “it should be informed because it is the patient’s right to decide, we would not want the patient to misunderstand about the porcine itself and eventually, they would sue the doctor for not being truthful.” (respondent 4) “ya kalo ga dikasih tau takutnya dokternya yang merasa berdosa mungkin, sebenernya ya tergantung masing masing, cuman kasih tau mah ya kasih tau aja, soalnya itu kan pilihan si orangnya kalo misalkan ga dikasih tau juga ya gapapa.” (responden 2) “if it was not informed, the doctor might feel guilty, depending on each person because it was their decision, but i think they should be informed.” (respondent 2) “sebenernya mungkin lebih baik dikasih tau, soalnya kan ada beberapa orang yang saklek dengan agamanya, mungkin buat ngehargain agamanya juga, ya lebih baik dikasih tau juga...” (responden 3) “actually, it is best to be informed, also to respect their religion, there may be people who are very strict in their religion .” (respondent 3) respondents would not wish to know the content of porcine-contained drugs, so that respondents would not feel guilty to use the drug. “karena biar ga merasa bersalah aja, yang penting sembuh alhamdulillah, soalnya kalo dikasih tau kan mikir aduh minum ga yah, kalo ga minum ga sembuh, kalo minum ya merasa bersalah sedikit, ya jadi mending gatau jadi minum aja.” (responden 3) “so i would not feel guilty about it, if it cured me alhamdulillah, because if i was informed about the porcine, i would have hesitated to use the drugs.” (respondent 3) the decision making process of the respondents, respondents gave the responsibility of a dilemmatic treatment decision to the family. “...dirundingkan dulu gitu, walaupun udah tau ada babinya haram, tapi kalo kondisi nya urgent bener bener butuh. pokonya konsultasi dulu dirundingkan dulu.” (responden 1) “i would discuss it first, although we already knew about the existence of the porcine, i would consult this matter first.” (respondent 1) respondents chose to decide for themselves regarding the dilemmatic treatment was for figure 1 scheme of research result althea medical journal. 2017;4(3) 319 the respondent’s own interests. “kalo buat hal itu kayanya mutusin diri sendiri aja karena kalo nanya orang apalagi kalo soal masalah babi ini pasti pendapatnya beda beda banget gitu.” (responden 3) “in this case, i would decide it by myself because people’s opinions are various.” (respondent 3) respondents also stated the need to incorporate their own decision with the family decision. “intinya kalo saya sih orgnya menyatukan dulu kesimpulan mana yang baik mana yang benar dan percaya sama keluarga juga.” (responden 6) “i am the kind of person who combines what is good and what is right, and i also trust the family.” (respondent 6) respondents would consult the usage of porcine-contained drugs with the religion scholars. “nanya nanya sih ke ustad, atau cari referensi dari jaman ibnu sina...”(responden 4) “i would ask the ustadz, or look for references from the avicena era.” (respondent 4) the doctor-patient relationship, respondents wished the physician to be more active in providing information on the porcinecontained drugs. “harusnya dikasih tau obat apa, gunanya buat apa, kan kalo praktek dokter katanya ngasih obat paten, jadi kan mahal, jadi lebih baik mungkin tawarin yang generiknya yang lebih murah, terus efek samping, sama cara minum.” (responden 3) “the doctor should inform us about the drug and its functions. in a therapeutic practice, doctors usually give patent drugs that are expensive. maybe it is best to offer generic drugs, the cheaper ones, and inform also about the side effects and instructions of use.” (respondent 3) respondents also stated that the doctor rarely gave choices when prescribing drugs. “jarang ada yang memberi pilihan saat meresepkan, tapi pernah kayanya tp lupa.” (responden 4) “when prescribing drugs, doctors seldom give us the opportunity to choose the drugs , however, it happened once i guess, but i forgot it.” (respondent 4) respondents entrusted entirely their treatment to the physician because physicians were considered to be the expert. “dokternya langsung tulis sendiri kan karena aku engga ngerti, kan dia dokter dia lebih pinter...” (reponden 1) “the doctor prescribed the drugs without asking anything because i would not understand anything; he is the doctor, he must be smarter than i am.”(respondent 1) discussion the respondents’ attitude toward drugs in general, including on information about the content of the drugs were divided into two. respondents who are concerned of the drugs they have been using usually browse for information about the drug via internet, according to the findings of gavgani et al.8 while, respondents who are not concerned about information of the drugs are influenced by the lack of awareness about the importance to obtain full information about treatment. this situation might be due to the lack of understanding about the rights of patients as stated in a study by kagoya et al.9 lack of information can influence the health-seeking behavior of the patients, it can be seen from the statement of the respondents regarding the patients habits of self-treatment.9 speaking of porcine-contained drugs, respondents recognized that the use of porcine in food and medicine are prohibited by their religion. easterbrook et al.3 stated that the use of porcine is allowed for muslims in term of the other alternatives are unavailable and in an emergency situation. according to easterbrook et al.3, religions and beliefs could influence one’s decision making. in addition, the respondents also had the desire to be informed or not about the porcine content in the drug. this is one’s own right as a patient, according to entwistle et al.10 and truog.11 respondents chose to decide for themselves whether they would use the porcine-contained drugs or not. on the other hand, there were respondents who submitted to the family’s decision, which is similar with the findings of letendre et al.7 in contrast to schumann et al.12 findings, family factors have no impact on the respondent’s decision to use porcinecontained drugs, even though, schumann et al.12 stated that family, religion and culture can influence the patient’s medical decision making. furthermore, the experience of the respondents showed that physicians act less actively in helping patients to implement the rights as a patient, such as in the findings of kagoya et al.9 the rights of patients in this case were the information on drugs. the respondents were only concerned about the ability of the drugs to cure their disease. anindhita paramita wibowo, yoni fuadah syukriani, teguh marfen djajakusumah: public opinion regarding information on porcine-contained medications althea medical journal. 2017;4(3) 320 amj september 2017 the right of information is crucial for the implementation of informed consent. moreover, hamammi et al.13 stated that informed consent has a very important role in the medical decision-making process of the patients. according to hargianti dini iswandari5, in a therapeutic relationship between doctor-patient, informed consent serves to protect the patients and the physicians. from the interviews, it appeared that the patient’s trust in physicians remained high because the physicians were considered as the expertise. this relationship is called the paternalistic relationship. nevertheless, truog11 mentions that the relationship between doctor and patient in this current era should be shared-decision making relationship.11 the limitation of this study is the limited research and observation time. the conclusion of this study is the public opinion about the patient’s rights regarding the information on porcine-contained medications includes the public attitudes towards drugs in general, public attitudes towards porcine-contained drugs, the doctorpatient relationship, and one’s decisionmaking process. references 1. badan pengawas obat dan makanan. peraturan kepala badan pengawas obat dan makanan republik indonesia no. hk.00.05.1.23.3516 tentang izin edar produk obat, obat tradisional, kosmetik, suplemen makanan dan makanan yang bersumber, mengandung, dari bahan tertentu dan atau mengandung alkohol. jakarta: bpom;2009. 2. badan pusat statistik. sensus penduduk 2010-penduduk menurut wilayah dan agama yang dianut. jakarta: bps;2010. 3. easterbrook c, maddern g. porcine and bovine surgical products: jewish, muslim, and hindu perspectives. arch surg. 2008;143(4):366–70. 4. hargianti dini iswandari. aspek hukum penyelenggaraan praktik kedokteran: suatu tinjauan berdasarkan undangundang no. 9/2004 tentang praktik kedokteran. jurnal manajemen pelayanan kesehatan. 2006;9(2):52–7. 5. turpin sm, marais ma. decisionmaking: theory and practice. orion. 2004;20(2):143–60. 6. letendre mc, tham lcj. family and healthcare decision making: implications for bioethics in china. stud bioethica. 2011;4(3):25–33. 7. sokol dk. the “four quadrants” approach to clinical ethics case analysis; an application and review. j med ethics. 2008;34(7):513– 6. 8. gavgani vz, qeisari e, jafarabadi ma. health information seeking behavior (hisb): a study of a developing country. library philosophy and practice [e-journal] 2013 [cited 2014 december 17]. available from: http://digitalcommons.unl.edu/ libphilprac/902. 9. kagoya hr, kibuule d, mitonga kh, ekirapa-kiracho e, ssempebwa jc. awareness of responsiveness to and practice of patients’ rights at uganda’s national referral hospital. afr j prm health care fam med. 2013;5(1):1–7. 10. entwistle, vikki a, carter sm, cribb a, mccaffery k. supporting patient autonomy: the importance of clinicianpatient relationships. j gen intern med. 2010;25(7):741–5. 11. truog rd. patients and doctors-the evolution of a relationship. n engl j med. 2012;366(7):581–5. 12. schumann jh, alfandre d. clinical ethical decision making: the four topics approach. semin med pract, 2008;11(1):36–42. 13. hammami mm, al-gaai ea, al-jawarneh y, amer h, hammami mb, eissa a, et al. patients’ perceived purpose of clinical informed consent: mill’s individual autonomy model is preferred. bmc med ethics. 2014;15(1):2–12. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 534 amj december 2017 environmental factors, knowledge, and hygiene behaviour among mothers: a slum area in bandung city, west java, indonesia gusti adintya putri,1 sri yusnita irda sari,2 yoni fuadah syukriani3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran, 3department of forensic and legal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: the increased number of population living in urban areas causes the increase of requirement of basic life needs as well as the increase of household and human excreta waste. if these wastes were not well managed, this situation would contaminate the environment. this study aimed to analyze the relatioship between environmental factors, knowledge and hygiene behavior among mothers who lives in bandung slum area. methods: an analytic cross sectional study was carried out on 132 mothers who lived in tamansari subdistrict in bandung city (rw 06, 07, 15, and 16) from may to october 2014. the primary data were collected using 2 sets of questionnaire and an observation checklist. the environmental factors and knowledge variables were catagorized into good and poor, while hygiene behavior was catagorized into good, moderate, and poor. the collected data were statistically analyzed using chi-square test. results: more than half of the participants had good environmental factors (60.6%), 59 participants (44.6%) had good knowledge about hygiene and 83 participants (62.9%) had good hygiene behavior, 43 participants (32.6%) had a moderate hygiene behavior, and 6 participants (4.5%) bad hygiene behavior. environmental factors was related to hygiene behavior (p=0.002). however, knowledge was not related to hygiene behavior (p=0.539). conclusions: environment is a significant factor to hygiene behavior. keywords: environmental factors, hygiene behavior, knowledge, slum area correspondence: gusti adintya putri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: gustiadintya@yahoo.co.id introduction the trend of human’s habitat has shifted in the last few decades. according to the population division of the united nations, since 2009, the number of people who lived in city areas have exceeded the number of people who lived in rural areas.1 this urbanization phenomenon occurred in every country in the world, including in the developing countries such as indonesia.1 the population growth rate would be parallel with the increasing demand for basic life needs such as living space. more people were likely to live in a poor environmental setting, such as a slum area. moreover, this condition would also affect the increase of house waste and human excreta waste production, which if not well-managed would contaminate the environment. furthermore, the contaminated environment will increase the risk of people getting diseases. hygiene behavior would become one of the key aspects on preventing diseases. according to fishbein, et al.2, there are several aspects such as knowledge and skills, salience of the behavior, intention to perform, environmental factors, and a habit which is known as the determinant of a person to perform a behaviour, as described in the integrated behavioral model (ibm) theory.2 bandung is one of indonesia’s urban areas. the “health profile of bandung” year 2012 reported that the population growth rate was 1.25%.3 bandung also experiences a positive net migration, meaning, a higher number of people migrated to the city.4 tamansari is one of the slum areas with the highest population density in bandung wetan district (9,889/ km2), and located in the centre of the city along cikapundung river.4 the aim of this study was to analyze the relationship between environmental factor, knowledge and hygiene behavior among mothers in tamansari amj. 2017;4(4):534–40 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1264 althea medical journal. 2017;4(4) 535 subdistrict, bandung. methods this was an observational analytic cross sectional study. the study was conducted in tamansari subdistrict, bandung wetan, bandung, from may to october 2014. the sample of the study was mothers who lived in rukun warga (rw) 06, 07, 15, and 16, tamansari subdistrict. the areas were selected because those areas were the most densely populated and closest area to cikapundung river. the minimum sample required in the study was 97 participants. samples were obtained using systematic random sampling. there were 142 home visits but only 132 participants gave complete information, and were included in the data analysis. primary data was collected by using two sets of questionnaire and one observation checklist. the questionnaire about environmental factors which was used in this study were obtained from world health organization-united nation children’s fund (who-unicef ) core question on drinkingwater and sanitation for household survey.5 accounted aspects included: type of toilet used, disposal of diapers, availability of trash, garbage disposal, clean water and drinking water source, waste disposal of human excreta, the availability of a septic tank in the neighborhood, and pets. every aspect was given a score of 1 for improved and 0 for unimproved answers. then the scores were accumulated and categorized either good (>mean) or poor (<mean). the level of knowledge of the participants was assessed by an interview with questions adopted from a publication by stevenson et al.6 the questionnaire consisted of 5 subcategories: general cleanliness (5 questions), household hygiene (2 questions), food hygiene (3 questions), hand hygiene (2 questions), and personal hygiene (3 questions). for each correct answer was given a score of 1 and for every wrong answer or ‘do not know’ was given a score of 0. the scores then were accumulated and categorized either good (>mean) or poor (<mean). it was validated to 26 respondents prior to the study. furthermore, the hygiene behavior of the participants was assessed with the observation of hygiene index, as written by webb et al.7 the subcategories were: drinking water hygiene (3 indicators), food hygiene (3 indicators), personal hygiene (3 indicators), and household hygiene (6 indicators). for every good behavior was given a score of 1 and for any bad behavior was given a score of 0. the scores then were accumulated and categorized as good (10–15), moderate (6– 9), and poor (0–5). the ethical protocol has been approved by the health research ethics committee, faculty of medicine universitas padjadjaran, ethical exemption no. 449/un6. c2.1.2/kek/pn/2014. the data was analyzed using statistical application. then, the chi square method was performed to determine the relationship between each categorical variable. the relationship would be considered significant if p<0.05. results the characteristics distribution of respondents in this study showed that the age of the respondents ranged from 20 years to 77 years with a median age of 42 years. a total of 51 respondents (38.6%) were high school graduates or equivalent, and most respondents had moderate-low income each month, ranging from rp500,001 to rp 1,500,000. the number of people living in one house varied between one and twenty people. the majority of respondents had one to five people who lived in their houses (69.2%) (table 1). based on environmental factors and level of knowledge, this study discovered that more than half of the respondents had good environmental factors, but the majority of the respondents had a poor level of knowledge about hygiene (table 2). moreover, all respondents used an unimproved toilet (100%). a total of 107 (81%) of them had a flush toilet while the other 25 (19%) did not have a flushing toilet. out of 40 respondents who had children under the age of 3 years, 22 of them (55%) disposed of diapers in a way that was considered good. most respondents had a trash bin in the house and most of them (93.1%) collected the trash to a temporary domestic waste disposal nearby. a total of 130 respondents (98.4%) used a clean water source that was considered good, and the same number of respondents used drinking water sources which was categorized as good. no respondents used septic tanks as disposal of human waste, in other words, no septic tank was available in the surrounding area of the survey. a total of 42 respondents (31.8%) had pets in the house and 36 of them (85.7%) used a cage either inside or outside the house. in the observation of water storage, gusti adintya putri, sri yusnita irda sari, yoni fuadah syukriani: environmental factors, knowledge, and hygiene behaviour among mothers: a slum area in bandung city, west java, indonesia althea medical journal. 2017;4(4) 536 amj december 2017 as many as 83 respondents (62.9%) left water in a container or bucket with the risk of contamination, and as many as 76 respondents (57.6%) kept their water storage near the source of pollutants. all respondents learned about the necessity of washing hands after going out and after touching animals (100%). most of the respondents (90.2%) saw the need of washing hands before eating, and a number of 125 respondents (94.7%) knew the need for washing hand after defecation. a total of 127 respondents (96.2%) realised the need to brush their teeth at least twice a day. additionally, in the aspect of household hygiene, most respondents knew that the bathroom and toilet should be cleaned at least once a week (75.8%) and the house needs to be swept at least once a day (76.5%). in the food hygiene aspects, 130 respondents (98.5%) were able answer questions correctly regarding the need to wash hands before making meals, 121 respondents (91.7%) were aware that vegetables should be washed before eating, and 124 respondents (93.9 %) agreed the need of water to be boiled or filtered before drinking. furthermore, most of the respondents were able to answer correctly the question of knowledge on aspects of hand hygiene and table 1 characteristics distribution of the respondents variable frequency (f ) percentage (%) age 20–29 years 12 9.1 30–39 years 38 28.8 40–49 years 37 28 50–59 years 31 23.5 > 60 years 14 10.6 occupation housewife 103 78.2 sales 21 15.9 teacher 3 2.2 employee 2 1.5 pension 3 2.2 education elementary 37 28 junior high 29 21.9 senior high 51 38.6 diploma 6 4.5 bachelor 9 6.8 monthly income (rupiahs) < 500.000 3 2.3 500.001–1.500.000 75 56.8 1.500.001–3.000.000 46 34.8 > 3.000.000 8 6.1 number of people live in the house 1–5 people 92 69.2 6–10 people 35 26.5 11–15 people 3 2.3 16–20 people 2 1.5 althea medical journal. 2017;4(4) 537gusti adintya putri, sri yusnita irda sari, yoni fuadah syukriani: environmental factors, knowledge, and hygiene behaviour among mothers: a slum area in bandung city, west java, indonesia personal hygiene. all respondents knew the correct hand washing must use clean water and soap (n=132, 100%) and as many as 104 respondents (78.8%) realized the need for drying hands after washing. most respondents confirmed the need to shower three times a day. most of the respondents knew that the worn clothes needed to be changed at least once in more than two days and almost all respondents knew that underwear should be changed every day. based on observation of hygiene behavior, more than half of the respondents had a good hygiene behavior (table 3). most respondents stored drinking water in sealed containers (95.5%), clean on the outside (89.4%), and filled with water at the time of observation (94.7%). a total of 56 respondents (42.4%) kept clean dishes covered, 90 respondents (68.2%) kept clean dishes at high altitudes, and as many as 66 respondents (50%) left all the food covered. a total of 47 respondents (36.5%) used footwear, the hands of 110 respondents (83.3%) were table 2 distribution of environmental factors and level of knowledge characteristics environmental factors p value hygiene knowledge p value good (n=80) poor (n=52) good (n=59) poor (n=73) age 0.340 0.522 20–29 years 6 6 5 5 30–39 years 22 16 10 10 40–49 years 25 12 16 16 50–59 years 16 15 9 9 > 60 years 11 3 4 4 occupation 0.121 0.976 housewife 57 46 35 68 sales 17 4 6 15 teacher 2 1 1 2 employee 2 0 1 1 pension 2 1 1 2 education 0.145 0.246 elementary 18 19 10 27 junior high 16 13 9 20 senior high 36 14 16 34 diploma 3 3 4 2 bachelor 7 2 5 4 monthly income 0.910 0.046 < 500.000 2 1 1 2 500.001–1.500.000 45 30 18 57 1.500.001–3.000.000 29 17 20 26 > 3.000.000 4 4 5 3 number of people live in the house 0.390 0.421 1–5 people 55 37 32 60 6–10 people 22 13 11 24 11–15 people 1 2 0 3 16–20 people 2 0 1 1 althea medical journal. 2017;4(4) 538 amj december 2017 clean, and the index finger of 72 children (54.5%) were also clean. in the household hygiene, there were 89 homes of respondents (67.4%) with no garbage scattered outside the home, and 74 homes of the respondents (56.1%) had no garbage strewn in the house. in addition, 106 (80.3%) of respondents did not let animals roam in the house or patio, 72 respondents (54.5%) did not keep a pile of dirty clothes. there were no flies in a significant number of houses (81.1%, and among 88 houses (66.7%) there was not any puddle with no patio or around the house. based on environmental factors and knowledge of the respondents regarding hygiene behavior, there was a significant difference between respondents who had good and bad environmental factors. this study discovered that there was a statistical difference between environmental factors and hygiene behavior (p=0.002). however, there were no statistical differences between respondents with knowledge of good and bad and hygiene behaviour (p=0.539) (table 4). table 3 distribution of hygiene behavior characteristics hygiene behavior p valuegood (n=83) moderate (n=43) poor (n=6) age 0.735 20–29 years 8 3 1 30–39 years 25 12 1 40–49 years 20 14 3 50–59 years 19 11 1 > 60 years 11 3 0 occupation 0.764 housewife 64 35 4 sales 15 4 2 teacher 1 2 0 employee 1 1 0 pension 2 1 0 education 0.432 elementary 22 12 3 junior high 16 11 2 senior high 36 13 1 diploma 3 4 0 bachelor 6 3 0 monthly income 0.562 < 500.000 3 0 0 500.001–1.500.000 47 25 3 1.500.001–3.000.000 29 14 3 > 3.000.000 4 4 0 number of people live in the house 0.787 1–5 people 55 32 5 6–10 people 24 10 1 11–15 people 2 1 0 16–20 people 2 0 0 althea medical journal. 2017;4(4) 539 discussions the rising population living in urban slums was clearly demonstrated in this study, one third of the respondents lived with more than five people in one house. moreover, there were five household with more than ten people in the house. the population density caused by urbanization was also found in several other countries in the world such as in kenya, india, bangladesh, the philippines, and other developing countries.8-11 overly dense residential neighborhoods and inadequate housing conditions can increase the risk factor of some diseases, such as respiratory infectious diseases, diarrhea, cancer, to developmental disorders in children.12-15 thus, the population density in the area is in need of concern of local stakeholders, in order to protect the community health. more than half of the respondents, 83 people (62.8%), had a good level of hygiene behaviors. this could be caused by the educational background of the respondents who were mostly high school graduates. however, on a higher level of knowledge, the majority of the respondents were still on the poor level (55.3%). this was not in line with the study by ahuja et al.16, in mumbai, india, where respondents with higher education were able to answer questions about knowledge better. among all respondents who participated in the study, none of them had a septic tank in the human waste disposal system. absence of septic tanks could also contaminate the water sources in the neighborhood, where 66.7% of respondents used well-water as source of clean water as well as source of drinking water for 46 respondents (34.8%). a study in langa17, a slum area in kenya, discovered that most of the faecal contamination of water sources did not meet the criteria of the who drinking water quality due to sanitation in the environment are inadequate. afurther study must be conducted on the water content in the local area to confirm water quality concerns, as water pollution can cause the transmission of infectious diseases such as fecal-oral cholera, typhoid, hepatitis, polio, and ascariasis.18-19 the management of human sewage in the local area needs to be improved to reduce the risk of disease. furthermore, economic limitations might be another consideration for urban slum communities to choose boiling water for drinking instead of buying bottled water. most respondents had moderate-low incomes per month, rp500,001.00 up to rp1,500,000.00. consistently, more respondents used cooking water from water wells and water taps for drinking water. this was parallel with the study conducted by alam, et al.20 in urban slums in rajshashi, bangladesh. results of this study revealed that some of the respondents were raising pets without cages and some of the respondents let their pets roam in and around the house. on the other hand, pets can be an intermediary source for infection either by bacteria in the body and through the dirt when contaminating water and food consumed.18 the community needs to be educated about the importance of pet hygiene to prevent transmission of disease through vaccination of pets and animals. this study discovered, there was no significant difference of hygiene behavior between respondents who had a good level of knowledge and poor level of knowledge. the results were less in accordance with the theory of ibm, which states that the level of knowledge is a factor that determines the behavior of individual hygiene.2 there were other factors such as intentions, habits, and skills which also determined the behavior of individuals that were not involved in this table 4 environmental factor and hygiene knowledge regarding hygiene behavior variable hygiene behavior total n (%) pgood (n=83) moderate (n=43) poor (n=6) environmental factor good 60(70%) 18(22.5%) 2(2.5%) 114(100%) 0.002 poor 23(44.2%) 25(48.1%) 4(7.7%) 18(100%) knowledge good 36(61%) 19(32.2%) 4(6.8%) 59(100%) 0.539 poor 47(64.4%) 24(32.9%) 2(2.7%) 73(100%) gusti adintya putri, sri yusnita irda sari, yoni fuadah syukriani: environmental factors, knowledge, and hygiene behaviour among mothers: a slum area in bandung city, west java, indonesia althea medical journal. 2017;4(4) 540 amj december 2017 research. in conclusion, environmental factors of the respondents based on hygiene behavior show a significant difference between respondents who have good and poor environmental factors. the findings are consistent with the theory of ibm, which states the environment as a determining factor of individual hygiene behavior.2 the limitation of the study was the absence of age definition of the respondent, which caused a large wide range (20–77 years old). references 1. world urbanization prospects: the 2011 revision. population division of the department of economic and social affairs of the united nations secretariat. [internet database] 2011 [cited 2012 february 8]. available from: http://data.worldbank. org/ 2. glanz k, rimer b, viswanath k, editor. health behavior and health education: theory, research, and practice. 4 ed. san fransisco. ca: jossey-bass; 2008. 3. dinas kesehatan kota bandung. profil kesehatan kota bandung. bandung: dinas kesehatan kota bandung; 2013. 4. puskesmas salam. jumlah penduduk miskin di wilayah kerja upt puskesmas salam. bandung: puskesmas salam; 2012. 5. who. core questions on drinking-water and sanitation for household survey. switzerland: world health organization; 2006. 6. stevenson rj, case ti, hodgson d, porzigdrummond r, barouei j, oaten mj. a scale for measuring hygiene behavior: development, reliability and validity. am j infect control. 2009;37(7):557–64. 7. webb al, stein ad, ramakrishnan u, hertzberg vs, urizar m, martorell r. a simple index to measure hygiene behaviours. int j epidemiol. 2006;35(6):1469–7. 8. cohen b. urbanization in developing countries: current trends, future projections, and key challenges for sustainability. technology in society. 2006;28(1):63–80. 9. agbola t, agunbiande em. urbanization, slum development, and security of tenure: the challenges of meeting millenium development goal (mdg) in 7 metropolitan lagos, nigeria. committee for international cooperation in national research in demography [online journal] 2007 [cited 2014 november 16]. available from http://www.cicred.org/ 10. firdaus g. urbanization, emerging slums and increasing health problems: a challenge before the nation: an empirical study with reference to state of uttar pradesh in india. j environ res develop. 2012;3(9):0146–52. 11. ooi gl, phua kh. urbanization and slum formation. j urban health. 2007;84(1):127–34. 12. breysse p, farr n, galke w, lanphear b, morley r, bergofsky l. the relationship between housing and health: children at risk. environ health perspect. 2004;112(15):1583–8. 13. thomson h, petticrew m. housing and health. bmj. 2007;334(7591):434–5. 14. vlahov d, freudenberg n, proietti f, ompad d, quinn a, nandi v, et al. urban as a determinant of health. j urban health. 2007;84(1):16–26. 15. riley lw, ko ai, unger a, reis mg. slum health: diseases of neglected populations. bmc international health and human rights [online journal] 2007 [cited 2015 january 22]. available from: http://biomedcentral. com/ 16. ahuja s, chakrabakti n. to determine the level of knowledge regarding breast cancer and to increase awareness about breast cancer screening practices among a group of women in a tertiary care hospital in mumbai, india. internet journal of public health. 2010;1(1):1-19 17. kimani-murage ew, ngincu am. quality of water the slum dwellers use: the case of a kenyan slum. j urban health. 2007;84(6):829–38. 18. prüss-ustün abj, clasen t, colford jm jr, cumming o, curtis v, bonjour s, et al. burden of disease from inadequate water, sanitation and hygiene in lowand middleincome settings: a retrospective analysis of data from 145 countries. trop med int health. 2014;19(8):894–905. 19. ziegelbauer k, speich b, mäusezahl d, bos r, keiser j, utzinger j. effect of sanitation on soil-transmitted helminth infection: systematic review and meta-analysis. plos medicine [online journal] 2012 [cited 2015 january 22] avaliable from: http:// journals.plos.org/ 20. alam z, rahman a, firoz aa. water supply and sanitation facilities in urban slums: a case study of rajshahi city corporation slums. american journal of civil engineering and architecture. 2013;1(1):1–6. vol 5 no 2 full text edit.indd althea medical journal. 2018;5(2) 69 young to middle-aged adults and low education: risk factors of spondylitis tuberculosis with neurological deficit and deformity at dr. hasan sadikin general hospital adrian f. ismiarto,1 bambang tiksnadi,2 arifin soenggono3 1faculty of medicine universitas padjadjaran, indonesia, 2department of orthopedics and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia, 3department of basic medicine faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia abstract background: incidence of tuberculosis has risen again, including extrapulmonary tuberculosis. spondilitis tuberculosis is one the most commonly encountered which can cause disability and even death. the aim of this study was to evaluate characteristics of spondilitis tuberculosis patients and probable risk factors. methods: this was a descriptive, cross sectional study from all medical records of spondylitis tuberculosis patients at dr. hasan sadikin general hospital from january 2012 to december 2013. variables evaluated were demographic data, history related to tuberculosis, nutrinutional status, patient’s characteristics, and treatments received. results: spondylitis tuberculosis represented 65.6% of bone and joints tuberculosis. from 78 cases, the male to female ratio was 1.2:1, and mostly found in young and middle-aged adults (79.6%) between 20−64 years old. patients’ level of education were mostly elementary school (30.8%) and unemployed. clinical symptoms were mostly neurological disorders, deformity (kyphotic/gibbus), and tenderness. predilections sites were thoracal and lumbal vertebrae. forty eight percents of cases were also sufferring from tb in other organs. treatments given for these cases were anti tuberculosis drugs (80.8%) and operative procedures (62.8%). conclusions: most common clinical manifestations are neurologial deficit, deformity, and tenderness; mostly have pulmonary tuberculosis as a comorbid disease; probable risk factors are young and middleaged adults, low education level, and unemployment. keywords: deformity, neurological deficit, risk factors, spondylitis tuberculosis correspondence: adrian f. ismiarto, faculty of medicine, universitas padjadjaran. jalan raya bandung-sumedang km. 21, sumedang, indonesia email: no28ro@yahoo.co.id introduction the tuberculosis (tb) incidence in the developed countries shows a decline in the last half of the 20th century. however, in twelve countries, including indonesia, there is approximately 75% of the estimated 2.9 million missed cases which are either not diagnosed or diagnosed but not reported.1 the world heatlh organization (who) data shows the incidence of extrapulmonary tb in indonesia is also escalating, in the year 2000: 833 cases; 2005: 6,142; 2010: 11,659; 2011: 14,054; and 2012: 15,697.1 a study by agrawal et al. 2010, stated that vertebral tb constitutes about 50% of all cases of skeletal tb.2 spondylitis tb is one of the extrapulmonary tb that is commonly encountered and can cause disability and even death. this disease also has socio-economical impacts as occupation and productivity of patients will be hampered. the purpose of this study was to collect data about spondylitis tb patient’s characteristics that was commonly encountered and might have a role in the disease incidence. methods this was a descriptive cross-sectional study. the data were collected from all medical records of spondylitis tb inpatient patients at dr. hasan sadikin general hospital from january 2012 to december 2013. the variables analyzed were demographical data (sex, age, educational amj. 2018;5(2):69–76 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1420 althea medical journal. 2018;5(2) 70 amj june 2018 level, occupation, residence), chief complaint, tb-related history (bcg immunization, tb contact), history of anti tuberculosis drugs, clinical manifestations, nutritional status, predilection based on diagnosis, comorbidity diseases, and management. after approval was given by the ethical committee, data were collected, calculated, analyzed, and then presented in the form of table, diagram, or chart. results one hundred and sixty cases of bone and joint tb were recorded at the inpatient clinic of dr. hasan sadikin general hospital from january 2012 to december 2013. the total of all spondylitis tb patients recorded in the hospital were 105, however, we could only collected 78 medical records. these data showed that 65.6% of bone and joint tb were spondylitis tb. the overall case distribution were 50 cases in 2012 and 55 cases in 2013, however, from 78 medical records, 31 cases (39.7%) occured in 2012 and 47 cases (60.3%) in 2013 based on this study, spondylitis tb cases were a little more prevalent in male. most cases were in the 20−64 years age group. furthermore, based on educational level, table 1 demographical data spondylitis tuberculosis patient in 2012–2013 n n(%) male (%) female (%) age 0−9 4 (5.1) 1 (1.2) 5 (6.3) 10−19 4 (5.1) 2 (2.6) 6 (7.7) 20−64 31 (39.8) 31 (39.8) 62 (79.6) ≥ 65 3 (3.8) 2 (2.6) 5 (6.4) total 42 (53.8) 36 (46.2) 78 (100) educational level primary school 30.8 middle school 11.5 high school 28.2 bachelor degree 6.4 diploma 1.3 no data 21.8 occupation unemployed 43.6 private employee 19.2 freelance 16.7 government employee 6.4 retired 3.8 no data 10.3 residence bandung municipality & regency 56.4 outside of bandung municipality & regency of west java 37.2 outside of west java 1.3 total study subject 100 althea medical journal. 2018;5(2) 71 primary school was the highest, followed by high school and middle school. in terms of occupation, most of the patients were unemployed, followed by private employee, and freelancer. based on residence, most patients lived in bandung municipality & regency, followed by outside of bandung municipality & regency of west java. the results of the study showed that three most common patient’s chief complaints were neurological deficit, followed by pain, and deformity (figure 1). data of tb-related disorders such as bcg immunization, tb contact, and history of anti tuberculosis drugs, were mostly unavailable in the medical records. therefore, these variables could not be analyzed. moreover, the spondylitis tuberculosis patient’s characteristics based on nutritional status and clinical manifestation nutritional status data were mostly unavailable, therefore this variable could not be analyzed. as for the clinical manifestation, data were collected from the result of physical examinations which indicated that 94.9% were found to have neurological deficit (sensoric and motoric), figure 1 spondylitis tuberculosis patient’s characteristics based on chief complaint figure 2 spondylitis tuberculosis patient’s characteristics based on clinical manifestations adrian f. ismiarto, bambang tiksnadi, arifin soenggono: young to middle-aged adults and low education: risk factors of spondylitis tuberculosis with neurological deficit and deformity at dr. hasan sadikin general hospital althea medical journal. 2018;5(2) 72 amj june 2018 followed by 61.5% of deformity (kyphotic/ gibbus) and 53.8% of pain (figure 2). furthermore, from 78 medical records of spondylitis tuberculosis predilection and complication distribution, this study found the highest predilection was in the thoracic vertebrae, followed by lumbar vertebrae, and combined vertebrae column. while complications such as neurological deficit were found in 44.8% cases, and gibbus in 61.5% cases (figure 3). additionally, the result of comorbidity diseases characteristics in spondylitis tuberculosis patients showed that 48.7% (38 cases) of all spondylitis tb also had tb in other organs at the same time. other comorbidites were also found in various organs (figure 4). study results showed that spondylitis tb patients were given anti tuberculosis agents category i and ii and/or operative management (anterior or posterior approach). anti tuberculosis agents were given to the majority figure 3 spondylitis tuberculosis predilection and complication distribution figure 4 comorbidity diseases characteristics in spondylitis tuberculosis patients althea medical journal. 2018;5(2) 73 of cases (80.8%), with some cases undergoing regimen changes. an operative management was given in 62.8% cases (table 2). discussions moreover, the spondylitis tb cases found at dr. hasan sadikin general hospital inpatient clinic were 105 cases (65.6%) which were all bone and joint tb cases. yehya et al.3, also stated that spondylitis tb includes more than 50% of bone and joint tb. the total number of cases in male was 42 cases (53.8%) and in female was 36 cases (46.2%), with a ratio of 1.2:1. this results were similar to a study by alavi et al.4, that stated male to female ratio is 1.5:1. khalequezzaman, et al.5, also stated in his study, that male to female ratio is 2.5:1.5 spondylitis tb is a disease that could affect people in any age groups. middle-aged adults are the most commonly affected age groups.5 this study results showed young and middleaged adults (20−64 years old) were the most commonly affected, with 62 cases (79.6%). these results were similar to a study by alavi et al.4, that stated spondylitis tb in the endemic area of tb is highest in young adults, however, in developed countries, it is more common in older age. it is probably caused by risk factors such as nutrient deficiency, overcrowding, poor environmental hygiene, etc. which are more common in developing countries.4 higher educational level is assumed to have higher knowledge and awareness about healthy behavior and treatment of the disease.6 so far, indonesia only had a free education program up to middle school level (9 years), which caused the majority of less fortunate people could only obtain education as high as that level. additionally, middle school level is still considered as a low educational level. this study also reflected the condition where disease incidences were more common in those with low educational level compared to higher educational level. primary school level was found to be the highest, as much as 30.8%, followed by high school (28.2%) and middle school (11.5%). these results were similar to the case study of lung tb treatment outcome at 10 primary health care table 2 spondylitis tuberculosis patients’ management management total % anti tuberculosis agents category i (rhze) 59 (rh) 1 (hze) 1 category ii (2(hrze)s/(hrze)/5(hr)3e3) 1 anti tuberculosis agents stopped 1 total given anti tuberculosis agents 63 80.8 not given anti tuberculosis agents 15 19.2 operative posterior approach laminectomy withposterior stabilization 22 laminectomy without posterior stabilization 3 anterior approach with posterior stabilization 23 without posterior stabilization 1 anterior & posterior approach 0 total given operative management 49 62.8 not given operative management 26 33.3 total research subjects 78 100 adrian f. ismiarto, bambang tiksnadi, arifin soenggono: young to middle-aged adults and low education: risk factors of spondylitis tuberculosis with neurological deficit and deformity at dr. hasan sadikin general hospital althea medical journal. 2018;5(2) 74 amj june 2018 facilities in jakarta from 1996 to 1999, that stated a low educational level would cause lower awareness in maintaining sanitation and environtmental hygiene, which reflects in the majority of tb patients are still carelessly throwing away their sputum.6 however, results of this study also showed that the total of patients with high school educational level was the second highest. it proved that a lot of other factors not directly related to education might have a role in the disease. the low education might havecorrelations with difficulties to get a job, and lower income, which caused poverty and living in slums. moreover, a tb prevalence survey in 2004 showed that although 76% of families have heard about tb and 85% know tb can be cured, only 26% could mention two main signs and symptoms of tb. tuberculosis modes of transmission are understood by 51% of families and only 19% know there are free anti tuberculosis drugs. this study showed that unemployed people were the most common to catch spondylitis tb, which was consistent with the previous assumption. fourty four (56.5%) spondylitis tb patients lived in bandung municipality & regency. second highest was outside of bandung municipality & regency, with 29 patients (37.2%). patients from other areas in west java were comparatively few. this could be due to the national health coverage program was not yet implemented in the period of 2012–2013, so that a lot of spondylitis tb cases were still treated in the highest referral hospital. dr. hasan sadikin general hospital was one example of this. besides, the uneven distribution of orthopaedics & traumatology specialists in regional hospitals could also be one of the reasons. generally, spondylitis tb patients complained of feeling unwell, prolonged back pain, and in chronic cases, of gibbus deformity. the neurological examination probably showed altered motoric or sensoric functions in the lower extremity. spastic paraparesis is commonly encountered in spondylitis tb adult patients with thoracal predilection.7 results of this study showed that three most common chief complaints were neurological deficit (sensoric and motoric), as much as 47.4%, followed by pain (38.5%), and deformity (14.1%). disease progression of spondylitis tb was slow and insidious. garg et al.8, stated that the disease have variable duration, beginning from months to years, with 4–11 months as the average. usually, patients seek treatment when intense pain, deformity, or neurological deficit already happened.8 it was found similar results in this study: three most common chief complaints were having onset ranging from 2 months to 1 year. data from physical examinations showed the most common clinical manifestation was neurological deficit (sensoric and motoric), as high as 94.9%, 61.5% were deformity (kyphotic/ gibbus), and 53.8% were pain. it is known that one of the spondylitis tb characteristics is destruction of vertebral bodies and disc spaces, which causes anterior wedging and culminate in gibbus formation.8 deformity was the highest clinical manifestation in this study. other than that, garg et al.8, stated that back pain is the most commonly manifestation that emerges from this disease. neurological deficit is also a common occurring manifestation of spondylitis tb involving cervical and thoracic vertebrae. from 78 cases, the highest disease predilection was at the thoracic vertebrae (50%), followed by the lumbar (33.3%). the combination of several vertebrae region were found in 14.1% cases. sixty one point five percent cases were presented with gibbus, and 44.8% with neurological deficit. results found in this study were similar to uduma’s in 2013, which stated that spondylitis tb commonly affects the lower thoracic and upper lumbar vertebrae. as stated in his study, the lower thoracic region is involved in 40–50% of cases, 35–45% cases involve the lumbar region, and 3−9% cases involve the cervival region. thoracolumbar junction is stated as the most common spondylitis tb predilection site.9 various comorbidities with spondylitis tb was found in this study, ranging from tb in other organs to other diseases not related with tb. tb in other organs was found in 38 cases, meanwhile other non-tb diseases were found in 27 cases. lung tb was the most common (35.9%), the rest were extrapulmonary tb other than spondylitis (miliary tb, meningitis tb, scrofuloderma, polyserositis tb, and lymphadenitis tb). miliary tb was occasionally caused by bacillemia from the infected bone and joints in middle-aged or elderly people with bone and joint tb. whereas in cases which comorbid with lung tb, both infections were probably resulted from reactivation caused by decreased systemic immunocompetence.4,10 this study showed that for management of this disease, anti tuberculosis drugs and/ althea medical journal. 2018;5(2) 75 or operative interventions were used. anti tb drugs were given in 63 cases (80.8%), the remaining 19.2% were not given. the anti tb drugs given were category i and ii, with several cases underwent changes of regimen due to drug allergy. anti tb drugs were not given in those cases with an operative intervention, had contraindications, and patient’s decision to go home without consent for release. an operative intervention was given to 49 cases (62.8%), whereas the remaining 26 cases (33.3%) were not operated. as many as 25 cases were operated with the posterior approach technique (22 with and 3 without posterior stabilization), and 24 cases with the anterior approach (23 with and 1 without posterior stabilization). patients who did not undergo operation were those without indication, had financial difficulties, had contraindications, and patient’s decision to go home without consent for release. based on data from this study, it can be concluded that male to female ratio is 1.2:1. young and middle-aged group, ranging from 20–64 years is the most commonly affected. based on educational level, the incidence of this disease is more common in lower educated people. those unemployed are highest on disease incidence. the majority of patients live in bandung municipality and regency, followed by outside of bandung municipality and regency of west java. the three most common chief complaints are neurological deficit, followed by pain and deformity. while data from physical examinations showed, the most commonly clinical manifestations are neurological deficit (sensoric and motoric), followed by deformity (kyphotic/gibbus), and lastly, pain. thoracic vertebrae are the most common predilection sites of the disease, followed by the lumbar and combined vertebrae regions. fourty four point eight percent of cases are with neurological complications, and 61.5% with gibbus. almost half of the total spondylitis tb cases (48.7%) also have tb in other organs at the same time. other comorbidities beside tb also exist. these results might be caused by several factors, such as lack of awareness about the risk of tb and its complications, so patient’s compliance to anti tb drugs given is low. stigma from the community to tb patients might cause them not to seek treatment. a poor immune level caused by lack of nutrients also might have a role in the disease progression. managements given to patients with this disease are anti tuberculosis drugs (category i and ii) and/or an operative intervention (anterior or posterior approach). anti tb drugs are given in majority of cases (80.8%), with several cases undergoing changes in regimen. the operative intervention is given in 62.8% of cases. the limitation of this study is the incomplete data concerning the history of bcg immunizations, tb contact, anti tb drugs before hospitalization, and nutritional status including height and weight of patients in the medical records. thus, these variables cannot be analyzed. therefore, it suggests improving the medical record data completion of each patient, so that it can be used as an accurate research material. furthermore, improving the society’s knowledge about lung tb and extrapulmonary tb (including spondylitis tb), by educating the community regarding modes of transmission, disease progression, and treatment is also important, so patients can be diagnosed and treated as early as possible, minimizing disease transmissions and complications. intensification of the government’s tb treatment programs, improving immunization and nutrition programs at primary health centers in the community are also suggested. references 1. world health organization. global tuberculosis report 2013. geneva: who; 2013. [cited 2014 march 15]. available from: http://apps.who.int/iris/ bitstream/10665/91355/1/9789241564656_ eng.pdf. 2. agrawal v, patgaonkar pr, nagariya sp. tuberculosis of spine. j craniovertebr junction spine. 2010;1(2):74−85. 3. yehya a, mathlom y, hafez a. correlation between clinical, radiological and operative findings in management of tuberculous and pyogenic spondylitis. bull alex fac med. 2010;46(2):177−84. 4. alavi sm, sharifi m. tuberculous spondylitis: risk factors and clinical/paraclinical aspects in the south west of iran. j infect public health. 2010;3(4):196−200. 5. khalequzzaman s, hoque h. tuberculosis of spine magnetic resonance imaging (mri) evaluation of 42 cases. medicine today. 2012;24(2):59−62. 6. ratnasari ny. hubungan dukungan sosial dengan kualitas hidup pada penderita tuberkulosis paru (tb paru) di balai pengobatan penyakit paru (bp4) yogyakarta unit minggiran. j tuberkulosis adrian f. ismiarto, bambang tiksnadi, arifin soenggono: young to middle-aged adults and low education: risk factors of spondylitis tuberculosis with neurological deficit and deformity at dr. hasan sadikin general hospital althea medical journal. 2018;5(2) 76 amj june 2018 indonesia. 2012;8:7−11. 7. solomon l, warwick d, nayagam s. apley’s system of orthopaedics and fractures. 9th ed. boca raton, fl: crc press,taylor & francis; 2010. 8. garg rk, somvanshi ds. spinal tuberculosis: a review. j spinal cord med. 2011;34(5):440−54. 9. uduma fu, emejulu jc, ianafasi eu, igwebuike voi. review of pott’s disease with neurological deficit-radiological algorithm and management. international journal of medical and applied sciences. 2013;2(3):339−46. 10. yagi o, kawabe y, nagayama n, shimada m, kawashima m, kaneko y, et al. bone and joint tuberculosis concurrent with tuberculosis of other organs. kekkaku. 2007;82(6):523−9. 261 althea medical journal. 2017;4(2) level of activity daily living in post stroke patients greesea dinamaria whitiana,1 vitriana,2 aih cahyani3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia , 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: stroke is the leading cause of disability and dependency which directly decrease patient’slife quality . disability caused by stroke can be prevented by holistic and comprehensive management plan of stroke. until now, there was no study conducted to evaluate management for post stroke patients in dr. hasan sadikin general hospital (rshs). therefore, this studyaimed to describe level of activities of daily living (adl) in post stroke patients in neurology unit of rshs as a basic evaluation for a better management hereafter. methods: this descriptive quantitative study participated by 31 post-stroke outpatients in neurology policlinic of rshs was conducted from september to october 2015. interviews were done to assess level of adl by the barthel index score. variables correlated with adl (age, gender, stroke type, stroke occurrence, stroke risk factors and muscle strength) were collected from medical records. collected data was input and presented in tables. results: there were 19 females and 12 males with the age group of 55-64 year old (35.5%). most subjects had first stroke attack (71.0%). the most common type and risk factor were ischemic stroke (83.9%) and hypertension (81%) respectively. patients with a maximum score in the entire extremity muscle strength were in the range of 60-70%. out of the 31 patients, 18 (58.1%) were classified as independent in adl. conclusions: the majority of post stroke patients in the neurology unit of rshs wereindependent in adl. keywords: activities of daily living, disability, post stroke correspondence: greesea dinamaria whitiana, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281314989504 email: greeseadinamaria@yahoo.com introduction stroke is the most common neurological disorder in the aspects of both morbidity and mortality. according to the global burden of disease, injury, and risk factor, stroke is the third leading cause of disability in the world. it is also the second leading cause of death in the world.1 post stroke patients suffer from neurological deficit. such deficits depend on the location and the size of the lesion. post stroke neurological deficits can be motoric and/or non-motoric, however motor deficits are more common than another.2 motor dysfunctions can limit the ability of the patient to perform daily activities and impose on him a state of dependency. further disability will bring patient into decreased social participation/function (handicap). disability does not only affect the patient but also the family. the effects can be felt in different aspects of life, especially the economic and social aspects.3 this may trigger a depression, leading to a decreased patient’s life quality. disability, depression, and decrease in life quality can create a cycle in which the patient only gets worse.4 effective management can decrease the risk of disability and recurrence in post stroke patient. medical rehabilitation aims to restore the patient’s functional abilities.5 intervention must be suited to the patient’s condition and needs while also paying close attention to his safety and comfort in the process. one indicator of poststroke patient’s current condition and his rehabilitative needs is his ability to perform activities of daily living (adl). until now, there is no study conducted to evaluate management for post stroke patients in dr. hasan sadikin general hospital (rshs). therefore, this study was carried out to describe level of adl of post stroke patients in rshs. amj. 2017;4(2):261–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1068 althea medical journal. 2017;4(2) 262 amj june 2017 methods this study took a descriptive quantitative approach. data was collected by total sampling of the study population.the population were all post stroke patients in ambulatory care unit of rshs from september to october 2015. the subjects were ambulatory post stroke patients in the neurology unit of rshs who had a stroke attack at least a week before the visit, had no other neurological conditions causing weakness of the extremities, and had no trauma causing mobilization dysfunction. furthermore, patients with decreased level of consciousness, auditory dysfunction, aphasia, or inability to speak in indonesian had to be accompanied by a family member that could communicate about their condition. based on the criteria, 31 subjects were included in this study by voluntary participation. the data was collected by interviewing the patients or patients’ family members. patients’ age, gender, stroke type, stroke event, risk factors, and muscle strength were collected from the patients’ medical records. based on the previous epidemiological studies on post stroke patients, patients’ age was grouped as the following: ≤44 years, 45–54 years, 55–65 years, 65–74 years, and ≥75 years.6 patients’ gender was grouped into male and female. patients’ type of stroke was classified as ischemic and hemorrhagic. ischemic stroke is caused by thrombotic emboli or hemorrhage that interrupt blood flow while hemorrhagic stroke, is characterized by a bleeding in the brain.7 stroke event was described as first attack stroke, which was occurrence of neurologic deficit in less than 24 hours and sudden for the first time and stroke reccurence if stroke had occured for twice. stroke reccurence was classified as stroke affecting same side (ipsilateral) and stroke affecting different side (contralateral).8 risk factor of stroke was described as hypertension, diabetes and others (smoking, alcohol consumption, obesity, dyslipidemia, and many others).8 patients’ muscle strength was further classified according to the results of their manual muscle testing (mmt): score 0/5 was given when there was no muscle contraction, score 1/5 was given when there was muscle contraction but no movement, score 2/5 was given when there was movement with minimized effect of gravity, score 3/5 was given when there was movement against gravity, score 4/5 was given when the extremity could hold against some resistance, and score 5/5 was given when the extremity could hold against maximum resistance.9 interviews were done to determine barthel index score. the score is for obtaining a description of the patients’ adl. the patients’ barthel index scores were further categorized into independence (score 20), slight dependence (score 12–19), moderate dependence (score 9–11), severe dependence (score 5–8), and total dependence (score 0–4).10 collected data was input and presented in tables and next analyzed. this study had been approved by the health research ethics committee of rshs bandung with ethical clearance number lb.04.01/a05/ec/252/ vii/2015. results the total number of subjects involved in this table 1 distribution of adl based on age and gender independent (n) slight dependence (n) moderate dependence (n) severe dependence (n) total dependence (n) total (n) age <44 4 0 0 0 0 4 45–54 3 2 1 0 0 6 55–64 6 4 0 1 0 11 65–74 5 1 0 1 1 9 ≥75 0 2 0 0 0 2 gender female 12 6 0 0 1 19 male 6 3 1 2 0 12 263 althea medical journal. 2017;4(2) greesea dinamaria whitiana,vitriana, aih cahyani: level of activity daily living in post stroke patients study were 31. the subjects were ambulatory post stroke patients in neurology unit, rshs, bandung from september to october 2015. based on barthel index score, 18 out of 31 patients were independent in adl (table 1). most post stroke patients in this study were female (61.3%) and the largest age group was the 55–64 group (35.5%). ischemic stroke was the most common type of stroke (table 2). most post stroke patients ,whether ischemic or hemorrhagic, were classified as independent in adl. majority of subjects had first stroke attack. the number of dependent patients with recurrent stroke affecting different hemisphere was higher than the number of dependent patients who had first ever stroke attack or recurrent stroke attacks affecting the same side. hypertension was found to be the most prevalent risk factor. other risk factors included dyslipidemia, coronary heart disease, infective endocarditis, post-chemotherapy effect and hyperthyroidism. roughly two-thirds of the patients had good muscle strength on their right arm, left arm, right leg, and left leg. majority patients had maximum mmt score for all extremities (60– 70%), which contributed to the high number of independent patients (table 3). discussion age and gender are non-modifiable stroke risk factors. in this study, the largest age group was the 55–64 year old group. this age group is still considered as a part of the productive age, as such, stroke could limit productive activities due to cognitive problems. those problems lead to decreased executive function or motoric weakness which lead to decreased extremities’ function. from this study, most of the patients were female. previous studies have presented that stroke incidence is lower among females than males in younger age group while it is higher among females than males in older age group. several theories implicate the role of estrogen in preventing stroke in women.11 as female in 55–64 year old age group undergo postmenopause, it could be a reason for more female suffered stroke in this study. other characteristic risk factors among females (preeclampsia, use of oral contraceptives, menopause, hormonal therapies, obesity/ metabolic syndrome, atrial fibrillation, and migraine with aura) may need to be considered in this condition.12 previous studies have also pointed out old age and gender of female to be factors contributing to dependence-inducing disabilities. female patients had more depressive feeling and lower level of memory and concentration than male. these domain play a role in patients’ functional outcome. in older patients, functional recovery lasted quite long. additional disability and comorbidities table 2 distribution of adl based on stroke type, stroke event, and risk factors of stroke independent (n) slight dependence (n) moderate dependence (n) severe dependence (n) total dependence (n) total (n) stroke type ischemic 14 8 1 2 1 26 hemorrhagic 4 1 0 0 0 2 stroke event first time 14 5 1 1 1 22 reccurent contralateral 2 3 0 1 0 6 reccurent ipsilateral 2 1 0 0 0 3 risk factor hypertension 10 5 0 0 0 15 diabetes melitus 2 0 0 0 0 2 hypertension and diabetes melitus 3 3 1 1 1 9 others 3 1 0 1 0 5 althea medical journal. 2017;4(2) 264 amj june 2017 in older patients were also contributed to post stroke functional outcome.13 in this study, the highest number of independent patients came from the 55–64 year old age group. besides, all patients under 44 years old were independent while all patients above 75 years old were dependent. this study revealed that there were more female post stroke patients in the neurology unit of rshs, bandung, who were categorized as independent in adl than male patients. patients’ functional abilities and rate of dependency were not only affected by non-modifiable factors, but also by modifiable factors such as the severity of the stroke, the level of muscle weakness, patients’ motivation, and the effectiveness and efficiency of post stroke management in helping patients performing adl.8,14 the majority of patients in this study had had first stroke attack. control visits are meant to prevent stroke recurrence and other complications. patients with recurrent stroke affecting different sides had a higher rate of dependency compared to those whose recurrent stroke affecting the same side. patients with recurrent stroke had worse functional disabilities compared to those who only had first stroke attack. based on a previous study, patients with recurrent stroke affecting different hemisphere were the least independent in adl since there were impairments in both sides of the body.8 ischemic stroke makes up 85% of all stroke cases in the world. this study correspondingly found more cases of ischemic stroke than hemorrhagic stroke. this may be due to the high mortality rates of hemorrhagic stroke than ischemic stroke shortly after the attack.15 this study discovered 4 out of the 5 hemorrhagic stroke patients were independent (80%) while 14 out of the 26 ischemic stroke patients were independent (54%). previous studies have established that functional recovery in hemorrhagic stroke patients happened faster than in ischemic stroke patients. in the first 3 months after the attack, hemorrhagic stroke patients could achieve a better functional recovery since hemorrhagic stroke’s functional impairments were caused by hematoma and brain edema. after the hematoma and the edema have disappeared, brain tissue will return to its normal state and its functional recovery will occur faster compared to ischemic stroke cases. ischemic stroke carries a higher probability of permanent damage when scar tissue has formed in the brain.16 the different recovery rates and the ability to perform adl are not only influenced by the type of stroke but also by another factor such as the severity, which depends on the size and location of the lesion, and muscle weakness.14 the majority of patients had hypertension table 3 distribution of adl based on muscle strength muscle strength independent (n) slight dependence (n) moderate dependence (n) severe dependence (n) total dependence (n) total (n) right arm 3 0 1 0 1 0 2 4 3 4 1 1 1 10 5 15 4 0 0 0 19 left arm 3 0 1 0 0 0 1 4 4 2 1 1 0 8 5 14 6 0 1 1 22 rigth leg 3 0 1 0 1 0 2 4 2 4 1 1 1 9 5 16 4 0 0 0 20 left leg 4 4 3 1 1 0 9 5 14 6 0 1 1 22 265 althea medical journal. 2017;4(2) as a risk factor of stroke. ten of all subjects even had hypertension and diabetes mellitus concurrently. other risk factors found in this study were dyslipidemia, coronary heart disease, infective endocarditis, post– chemotherapy effect and hyperthyroidism. hypertension was the most common modifiable risk factor found among the ischemic stroke patients even though it had a stronger correlation with hemorrhagic stroke.17 it was also quite prevalent among patients with dependency. high blood pressure was associated with risk of early reccurence in ischemic stroke and also worse intracerebral edema due to hematoma expansion in hemorrhagic stroke which lead to worse outcome.8 consequently, better hypertension management will decrease the incidence of recurrent ischemic stroke and bring patients to a better functional ability. the possible impairments caused by stroke on the upper extremities are muscle weakness, pain, loss of sensation, decreased agility, and decreased coordination. muscle weakness has a stronger correlation to decreased adl performance compared to increased muscle tone, paretic grip strength, and pain. muscle weakness is the most common and the most readily identifiable impairment in stroke patients.18 research has shown that muscle weakness of the lower extremities is related to the walking speed, gait endurance, and balance. muscle weakness in any extremity will affect the patient’s ability to perform adl.19 this study scored muscle strength in a 0 to 5 scale. it was established that the majority of patients had relatively good muscle strength in their extremities with scores ranging from 3 to 5. patients with mmt score of 3–5 could move their arms functionally. the patient was dependent on others because of spasticity, loss of sensation, decreased agility, and decreased coordination should. this study was conducted to also describe patients’ adl without taking into consideration the above-mentioned conditions. according to the previous study, the hemiparetic side was associated with patients’ ability to perform activity daily living. hand dominance is an important aspect since it is habitually crucial in performing daily activities. weakness of the dominant hand will decrease the patient’s ability to perform those activities. however, the need to use the dominant hand will result in that hand being exercised more, it has a faster recovery than the non-dominant hand.20 in this study, there were limitations. the sample was taken from a tertiary health facility; hence the real characteristics of the real population may not be described accurately because severity of stroke in each health facility is varying. the use of other tools beside barthel index should also be considered. using barthel index saved the time efficiently in this research but it did not assign instrumental activity daily living which required more complex function such as cognitive function in post stroke patients. other problems of the extremities such as pain, loss of sensation, spasticity, decreased agility, and decreased coordination also have potential to decrease the patients’ ability in performing adl. location and size of lession, severity of stroke (nihss scale) and depression scale also affect level of activity daily living in post stroke patients. in conclusion, 18 of 31 poststroke patients in neurology unit rshs were independent. thirteen of 31 post stroke patients are dependent.8 majority of post stroke patients in neurology unit rshs have good muscle strength in all extremities, which contributing in patients’ ability to perform adl.8,14 this study might evaluate post stroke management which have been implemented by rshs for a better management of post stroke patients in the future. this study found out 13 of 31 patients (48.9%) of post stroke patients are still in a state of disability. this would be concern for physical medicine and rehabilitation unit of rshs to perform management for those patients. further studies should be done on a wider, larger population in health facilities of different levels and measure other variables that also can affect patients’ ability to perform activity daily living. references 1. feigin vl, forouzanfar mh, krishnamurthi r, mensah ga, connor m, bennett da, et al. global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010. lancet.2014;383(9913):245–54. 2. brewer l, horgan f, hickey a, williams d. stroke rehabilitation: recent advances and future therapies. qjm. 2013;106(1):11–25. 3. di carlo a. human and economic burden of stroke. age ageing. 2009;38(1):4–5. 4. haghgoo ha, pazukies, hosseini as, rassafiani m. depression, activities of daily living and quality of life in patients with stroke. j neurol sci. 2013;328(1):87–91. 5. staines r, mccoy we, brooks d. greesea dinamaria whitiana,vitriana, aih cahyani: level of activity daily living in post stroke patients althea medical journal. 2017;4(2) 266 amj june 2017 functional impairments following stroke: implications for rehabilitation. curr issues cardiac rehab prevent. 2009;17(1):5–8. 6. burke ta, venketasubramanian rn. the epidemiology of stroke in the east asian region: a literaturebased review. int j stroke.2006;1(4):208–15. 7. wang j, an z, li b, yang l, tu j, gu h, et al. increasing stroke incidence and prevalence of risk factors in a low-income chinese population. neurology. 2015;84(4):374– 81. 8. liu x, lv y, wang b, zhao g, yan y, xu d. prediction of functional outcome of ischemic stroke patients in northwest china. clin neurol neurosurg.2007;109(7):571–7. 9. hislop h, avers d, brown m. daniels and worthingham’s muscle testing: techniques of manual examination and performance testing. 9th ed. st. louis: elsevier health sciences; 2014. 10. kwakkel g, veerbeek jm, harmelingvan der wel bc, van wegen e, kollen bj. diagnostic accuracy of the barthel index for measuring activities of daily living outcome after ischemic hemispheric stroke: does early poststroke timing of assessment matter? stroke. 2011;42(2):342–6. 11. lebrasseur nk, sayers sp, ouellette mm, fielding ra. muscle impairments and behavioral factors mediate functional limitations and disability following stroke. phys ther. 2006;86(10):1342–50. 12. reeves mj, bushnell cd, howard g, gargano jw, duncan pw, lynch g, et al. sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. the lancet neurol. 2008;7(10):915–26. 13. bushnell c, mccullough ld, awad ia, chireau mv, fedder wn, furie kl, et al. guidelines for the prevention of stroke in women a statement for healthcare professionals from the american heart association/american stroke association. stroke. 2014;45(5):1545–88. 14. bohannon rw. muscle strength and muscle training after stroke. j rehabil med. 2007;39(1):14–20. 15. chattopadhyay k, douiri a, sheldenkar a. trends in activities of dailyliving among stroke survivors: analysis from the south london stroke register. ijtrr. 2013;2(2):6–21. 16. henriksson km, farahmand b, asberg s, edvardsson n, terent a. comparison of cardiovascular risk factors and survival in patients with ischemic or hemorrhagic stroke. int j stroke. 2012;7(4):276–81. 17. bhalla a, wang y, rudd a, wolfe cd. differences in outcome and predictors between ischemic and intracerebral hemorrhage the south london stroke register. stroke. 2013;44(8):2174–81. 18. harris je, eng jj. paretic upper–limb strength best explains arm activity in people with stroke. phys ther. 2007;87(1):88–97. 19. kluding p, gajewski b. lower-extremity strength differences predict activity limitations in people with chronic stroke. phys ther. 2009;89(1):73–81. 20. harris je, eng jj. individuals with the dominant hand affected following stroke demonstrate less impairment than those with the non-dominant hand affected. neurorehabil neural repair. 2006;20(3):380–9. vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 110 amj september 2019 amj. 2019;6(3):110–4 identification of bacteria from skin swab in pre-operative closed fracture orthopedic surgery patients at dr. hasan sadikin general hospital ghitaa bengtissen,1 sunarjati sudigdoadi,2 yoyos dias ismiarto,3 isa ridwan3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of orthopedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: surgical site infection (ssi) is the most frequent site of health careassociated infections (hais). surgical incision breaks the protective barrier of the skin and causes bacteria to enter; therefore, pre-operative procedure is very important to reduce the risk of ssi. this study aimed to identify any bacteria in skin swab of pre-operative closed fracture during elective orthopedic surgery patients. methods: this was a descriptive laboratory study, conducted in the department of microbiology, faculty of medicine, universitas padjadjaran in october to november 2012. samples were taken from skin swab of patients with closed fracture taken before elective orthopedic surgery. samples were cultured on blood agar, then incubated in an aerobic condition for 24 hours at 37°c. the bacteria were then identified, including the type and the number of the bacteria colonies, using microscopic gram staining and by biochemistry testing using coagulase, novobiocin, and catalase test. the bacteria colonies formed on blood agar were counted using cfu/ml. results: of 24 samples taken, 14 (58.3%) were positive for bacteria, 7 negative and 3 were excluded due to dead bacteria. the bacteria identified in the samples were all staphylococcus species and the colony counting was lower than 10⁵ cfu/ml. conclusions: bacteria staphylococcus are detected from more than half of skin swab during preoperative closed fracture orthopedic surgery patients. thus, it is important to apply a proper antiseptic procedure before making a surgical incision to reduce the risk of ssi. keywords: bacteria, pre-operative patient’s skin, staphylococcus correspondence: ghitaa bengtissen, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang. e-mail: ghitaa_priyanka@yahoo.com introduction according to the centers for disease control and prevention (cdc), the surgical site of infection (ssi) is defined as a proliferation of pathogenic microorganism that develops in an incision site.1 surgical site infections are known as the third most frequent site of health care-associated infections (hais).2 based on surveysin five hospitals in the uk, the national nosocomial infection surveillance (nnis) system reported aprevalence of hospital acquired-infection (hai) relating to surgical wounds as high as 10%. moreover, a prevalence survey that has been conducted suggested that at least 5% of patients who had undergone a surgical procedure were found to have developed ssi. in the other hand, ssi accounts for 14% to 16% of the estimated 2 million nosocomial infections affecting hospitalized patients in the usa.1,3,4 for surgical site infections, the initial exposure of microbial pathogens occurs most often during the surgical procedure that performed in the operating theatre (ot), therefore, we should be aware of the risk of surgical site infections that is influenced by the characteristics of the patient, operation, and health care facility.2 the normal flora of the patient’s skin is althea medical journal. 2019;6(3) 111 the source of pathogens for most surgical site infections. when the physician open or make skin incision, the tissue that is exposed will be at risk for contamination with normal flora.2 the skin always harbors a variety of microorganisms that can be divided into two groups; the resident flora and transient flora.5 the superficial layers of the skin are colonized by transient flora; while the deep layer of the skin are attached by the normal flora resident such as staphylococcus epidermidis.6 other normal bacterial flora in the skin are among others staphylococcus aureus, staphylococcus saprophyticus, diphtheroids, micrococcus species and asmall number of other organisms such as candida species, acinetobacter species, and many others.5 under certain condition, this normal flora may become pathogenic as they enter the blood stream resulting in disease.5 surgical wounds are classified by the degree of bacterial contamination or microbial loads during the time of the procedure. the greater the microbial loads, the higher the risk of infection. the centers for disease control and prevention (cdc), classifies wounds as clean, clean-contaminated, contaminated and dirty wounds.7 orthopedic surgery as general surgery can be divided into 2 groups, elective surgery and emergency surgery. elective surgery is the surgery that is planned in advanced and can safely be delayed for more than 24 hours while emergency surgery is the type of surgery that need to be performed in response to an urgent medical need or lifethreatening within 24 hours.8,9 fracture is defined as a break in the bone, and classified into 2 types; open and closed fracture. open fracture is defined as broken bone that penetrates the skin; whereas closed fracture is a broken bone that does not penetrate the skin.10 according to cdc criteria, a surgical site that is contaminated with >10⁵ microorganisms per gram of tissue, has been shown to have an increased risk of ssi. nevertheless, the contaminating microorganisms concentration is required to cause infection and that is much lower when foreign material is present at the surgical site; for example, 100 staphylococci per gram tissue.2,7,11 thus, pre-operative patients’ skin hygiene is very crucial prior asurgery to prevent post-operative complications. it is not only the responsibility of the physicians to make sure of this, as the patients themselves should take measures to avoid any postoperative infections. therefore, skin care is imperative for pre-operative patients.12 the cdc recommends a patient to take a shower with an antiseptic solution or with a normal bath soap and warm water the night before surgery. this skin microbial colony counts will decrease, but it has not been shown definitively to reduce ssi rates. the cdc notes that the most commonly used skin antiseptic is chlorhexidinegluconate (chg).13-15 another way to prevent infection is by applying antiseptics to the skin of pre-operative patients. the role of an antiseptic is to inhibit the growth or action of microorganisms. it is used for skin before a clinical procedure. the united states food and drug administration (fda) has defined that an antiseptic is an agent that is able to decrease the number of bacteria on the skin. antiseptics that are suggested by cdc for skin preparation are alcohol, chlorhexidinegluconate, and iodine/ iodophors.16 the aim of this study was to identify the presence of bacteria in skin swab, including the type of bacteria and the number of bacteria coloniesformed on blood agar. methods the study method was descriptive laboratory study using skin swabs from previous study. in brief, skin swabs from patients in dr. hasan sadikin hospital in bandung were taken, before an elective orthopedic surgery of closed fracture during the period of february to april 2012.17 the skin swab was taken 30─60 minutes before applying the antiseptic, and stored until used in this current study. sample selection was performed using consecutive sampling method. the inclusion criteria in the previous study was skin swab from preoperative closed fracture orthopedic patients before applying antiseptic. the exclusion criteria were skin swab from pre-operative closed fracture orthopedic surgery patientthat was already infected, or that was cleaned with an antiseptic soap. the identification of the bacteria in this current study was conducted in october–november 2012, thus, bacteria in asample that died due to a longer time of incubation was excluded. in this current study, the swab was cultured using levine technique. the swab collection was placed in a sterile tube containing 1 ml of brain heart infusion (bhi) broth as a transport media, thenspread over the entire blood agar plate, prior incubation in an aerobic condition at 37°c for 24 hours. any presence of bacteria on blood agar was identified, including the type of bacteria and the number of bacteria colonies. colonies from blood agar were taken ghitaa bengtissen et al.: identification of bacteria from skin swab in pre-operative closed fracture orthopedic surgery patients in dr. hasan sadikin general hospital althea medical journal. 2019;6(3) 112 amj september 2019 table 2 the number of bacteria colonies sample colony forming units (cfu/ml) 1 6.0 × 10² 2 1.13 × 10⁴ 3 1.87 × 104 4 2.1 × 103 5 1.0 × 10³ 6 1.0 × 10² 7 3.0 × 10² 8 2.0 × 10² 9 3.0 × 10² 10 2.0 × 10² 11 5.0 × 10² 12 1.1 × 10³ 13 2.0 × 10² 14 1.0 × 10² note: cfu= colony forming units (cfu) for gram staining to identify gram-positive or gram-negative bacteria. gram-positive bacteria retained a purple color of the crystal violet in its cell wall, whereas gram-negative bacteria were stained red with safranin. to differentiate the staphylococcus from streptococcus, catalase test was performed resulting in a positive or negative result, respectively. in brief, one drop of 3% hydrogen peroxide was brought on a slide using a pipette. a colony from blood agar was taken, and the formation of bubbles was observed, indicating the production of oxygen and the catalase test was thus positive.18 to differentiate staphylococcus aureus from other coagulase-negative staphylococci, coagulase test was performed. two test tubes labeled as ‘control’ and ‘test’ was prepared, filled in with 1 ml of 1 in 10 diluted citrated plasma. sterile broth and sample culture of 0.2 ml each was put into the test tubes, prior further incubation at 37°c for four hours. coagulase test was positive when gelling of the plasma remained in place after inverting the tube, indicating s.aureus; whereas coagulase test was negative, indicating s.epidermidis and s.saprophyticus.18 novobiocin test was performed to assess the susceptibility of bacteria to antibiotic. an antibiotic-impregnated disk containing novobiocinwas placed in the center of the agar, prior incubation at 35−37°c for 24 hours, and the bacteria growth on the surface of the plate was observed. a visible zone surrounding the disk was the zone of inhibition, indicating thesusceptibility of bacteria to the antibiotic. when there was no zone present or zone of inhibition was <16 mm, the bacteria was resistant to the antibiotic such as s. saprophyticus. zone of inhibition >16 mm indicated that bacteria was sensitive to novobiocin such as s. epidermidis.19 results this study was to identify the presence of the bacteria in skin swab, including the type of bacteria and the number of bacteria coloniesformed on blood agar. after 24-hour period of time, the presence of bacteria on the blood agar were identified. of 24 samples taken, 14 (58.3%) were positive for bacteria, 7 negative and 3 were excluded due to dead bacteria (table 1). these samples were then viewed under a microscope to identify the type of bacteria. blood agar that contained more than one colony was isolated twice to explore whether there was possibly more than one type of bacteria. of those 14 positive samples, 12 samples had one colony and 2 samples had two colonies, and the number of bacteria colonies were expressed in colony-forming units (cfu) per ml, ranging from 1.0x102 to 1.87x104 cfu/ml (table 2). the type of bacteria present in the skin swab was staphylococcus aureus table 1 the presence of the bacteria in a closed fracture skin swab on blood agar during a pre-operative elective orthopedic surgery presence of bacteria sample percentage (%) positive 14 58.3 negative 7 29.2 excluded* 3 12.5 note: * excluded due to dead bacteria on blood agar althea medical journal. 2019;6(3) 113ghitaa bengtissen et al.: identification of bacteria from skin swab in pre-operative closed fracture orthopedic surgery patients in dr. hasan sadikin general hospital layers of the skin while resident flora attached to deeper layers of the skin. an example oftransient flora is s. aureus, while resident flora is coagulase negative staphylococci such as s. epidermidis and s. saprophyticus.6 in this study, the bacteria that mostly found was s. epidermidis compared to s. aureus. this is because transient flora iseasier to remove compared to resident flora that ismore resistant to removal. even though there is no risk of infections, patients should be aware of their own skin hygiene before they undergo surgery to prevent complications of post-operative. this is because there are other factors that can cause ssi such as the general state of the patient, intraoperative factors like the operating room environment (ventilation and cleanliness), sterilization of instrument, surgical attire like masks, caps, glove and gowns, and postoperative factors like length of stay in hospital after the surgery.11 antiseptic is thus very crucial for pre-operative patients to decrease the risk of surgical site infection, as it can inhibit the growth or action of microorganisms. in conclusion, there is a presence of bacteria from skin swab of pre-operative closed fracture elective orthopedic surgery patients, such as staphylococcus species like s. aureus, s. epidermidis and s. saprophyticus with acceptable colony forming units. therefore, it is important to apply a proper antiseptic procedure before making a surgical incision to reduce the risk of ssi. references 1. bagnall nm, vig s, trivedi p. surgicalsite infection. surgery (oxford). 2009;27(10):426−30. 2. mangram aj, horan tc, pearson ml, silver lc, jarvis wr. guideline for prevention of surgical site infection 1999. center for disease control and prevention (cdc) hospital infection control practices advisory committee. am j infect control. 1999;27(2):97−132. 3. zinn j, jenkins jb, swofford v, harrelson b, mccarter s. intraoperative patient skin preparation agents: is there a difference ? aorn j. 2010;92(6):662−74. 4. afifi ik, baghagho ea. three months study of orthopaedic surgical site infections in an egyptian university hospital. int j infect control. 2010;6(1):1–6. 5. brooks gf, carroll kc, butel js, morse sa. jawetz, melnick, & adelberg’s medical microbiology. 24th ed. michigan us: mc (n=5), staphylococcus epidermidis (n=7), and staphylococcus saprophyticus (n=4). discussion in this study, the type of surgery that has been performed on all patients is an elective surgery for closed fracture, that is a planned surgery. therefore, it is categorized as clean surgery because the wound is clean and there is no acute inflammation that has been encountered.7 however, there are various bacteria growingon blood agar from the skin swab of pre-operative closed fracture elective orthopedic surgery patients; consisting of staphylococcus species such as s. aureus, s. epidermidis, and s. saprophyticus. according to the national nosocomial infections surveillance system (nnis), the pathogens that most commonly isolated from surgical site infections (ssi) are s. aureus (20%) and coagulase-negative staphylococci such as s. epidermidis and s. saprophyticus(14%).13 our study result shows that that the mostly found bacteria is s. epidermidis compared to s. aureus and s. saprophyticus. staphylococcus species are acquired from the patient’s own skin flora. intact skin acts as a very effective barrier and most infections cannot pass through intact skin. a surgical incision will create a break in that protective barrier, causing the bacteria to enter the bloodstream and resulting in diseases. usually, normal flora of the patient’s skinis the source of pathogens for most surgical site infections when the incision is performed. this is because of changing in the environment of normal flora. the precursor of surgical site infection (ssi) is the microbial contamination during a surgical procedure. according to cdc criteria, a surgical site which is contaminated with >10⁵ microorganisms per gram of tissue has been shown to have an increased risk of ssi. thus, the greater the microbial loads, the higher the risk of infection.2,7,11 however, there is no risk of infection because the number of colonies of bacteria is not more than 10⁵.17 this is because all patients that were selected in this study were advised to take a shower with a normal bath soap at least the night before or in the morning of the operative day before they enter the operating room. a preoperative shower can decrease the count of skin microbial colonies but it has not been shown to ease ssi rates. bacteria from the skin can be divided into two categories, namely transient and resident flora. transient flora colonizes 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[cited 2013 january 23]. available from: http://www.surgeons.org/ m e d i a / 3 0 7 1 1 5 / s b m _ 2 0 1 1 0 5 2 4 _ s e p a ra t i n g _ e l e c t ive _ a n d _ e m e r g e n c y _ surgery.pdf. 10. orthoinfo. diseases & condition: open fractures. american academy of the orthopedic surgeons; 2012 [cited 2012 april 2]; available from: http://orthoinfo. aaos.org/topic.cfm?topic=a00582 11. world health organization. who guidelines for safe surgery 2009: safe surgery saves lives. geneva: who press; 2009 [cited 2012 april 20]; available from: https://apps.who.int/iris/bitstream/ handle/10665/44185/9789241598552_ eng.pdf;jsessionid=25ed3f5b06fe8f3c0 e1d8156911cc48f?sequence=1 12. johnson j. pre-operative hygiene. hygieneexpert [online] 2010 [cited 2012 april 3]. available from: http:// www.hygieneexpert.co.uk/preoperativehygiene.html. 13. seal la, paul-cheadle d. a systems approach to preoperative surgical patient skin preparation. am j infect control. 2004;32(2):57–62. 14. rauk pn. educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections. am j infect control. 2010;38(4):319–23. 15. napolitano lm. decolonization of the skin of the patient and surgeon. surgical infections. surgical infections. 2006;7(suppl 3):s3-15. 16. parks pj. patient preoperative skin preparations to reduce surgical site infections. future direction in surgery. 2006;1:84─7 17. ridwan i, ismono d, ismiarto yd, hidajat nn. comparison of effectiveness in decreasing bacterial counts between povidone iodine 10% painted with and without alcohol 70% wiping off preoperative skin preparation in orthopaedic surgery patients [thesis]. bandung: universitas padjadjaran; 2012. 18. virtual amrita laboratories universalizing education. catalase and coagulase test. amrita vishwa vidyapeetham [online] 2011 [cited 2012 april 15]. available from: http://amrita.vlab.co.in/?sub=3&br ch=73&sim=703&cnt=2. 19. hardy diagnostics. novobiocin differentiation disks. santa maria: hardy diagnostic [online article] 1996 [cited 2012 april 15]. available from : https:// catalog.hardydiagnostics.com/cp_prod/ content/hugo/novobiocindiffdisks.htm vol 5 no 2 full text edit.indd althea medical journal. 2018;5(2) 64 amj june 2018 susceptibility to community associated methicillin resistant staphylococcus aureus: a preliminary study gan ee xian,1 imam megantara,2 sharon gondodiputro3 1faculty of medicine universitas padjadjaran, indonesia, 2department of basic medicine faculty of medicine universitas padjadjaran, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia abstract background: the staphylococcus aureus infection is a leading cause of infection around the world. due to the introduction of antibiotics, a strain called methicillin-resistant s. aureus (mrsa) has emerged and occured in hospitalized patients worldwide. however around 1990, this infection had been detected among healthy people in the community without previous health care contact, known as community associated mrsa (ca-mrsa). the objectives of this study was to identify the susceptibility to ca-mrsa among people who came to puskesmas jatinangor, west java, indonesia. methods: a descriptive study using purposive sampling was carried out from september to october 2014 with data obtained through anterior nasal swab of 65 patients from puskesmas jatinangor who fulfilled the exclusion and inclusion criteria. samples were transported to the microbiology lab of faculty of medicine universitas padjadjaran and planted on blood agar for culturing, then identified through gram staining, catalase and coagulase tests. lastly tested for antibiotic resistance and the zone of inhibition measuring ≤21mm were classified as positive mrsa. the collected data were presented using tables. results: out of 65 samples that were collected and tested, 17 samples (26%) were staphylococcus aureus (s. aureus) carriers; 6 samples (9%) were positive with mrsa isolates; 6/17 of the s. aureus are mrsa. conclusions: people who come to puskesmas jatinangor show a significantly high proportion of susceptibility to ca-mrs. keywords: community associated methicillin resistant staphylococcus aureus, community associated methicillin sensitive staphylococcus aureus, nasal swab correspondence: gan ee xian, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: ganeexian@gmail.com introduction staphylococcus aureus (s. aureus) is a wellknown type of bacteria that is a leading cause of infection worldwide.1 hence, these bacteria are also human commensal organisms and are colonized asymptomatically in the anterior nares.1 the manifestation of staphylococcus aureus strain infection, can range from minor skin infection to fatal pneuomonia.1 two years after the introduction of antibiotics to treat penicillin-resistant s. aureus, methicillin-resistant s. aureus (mrsa) was first reported in 1961.1 infection with methicillin resistant staphylococcus aureus (mrsa) typically occurs in hospitalized patients worldwide but around 1990, this infection was detected among healthy people in a community without previous health care contact, known as community associated mrsa (ca-mrsa).1,2 five factors of mrsa transmission have been proposed by the centers for disease control and prevention in atlanta, known as “5 c’s”. the “5 c’s” consist of crowding, frequent skin-to-skin contact, compromised skin integrity, contaminated items and surfaces, and lack of cleanliness.1 one of the subdistricts in west java, known as jatinangor, is a crowded area with 4.346 people/km2. jatinangor is an area where many universities are located, causing huge numbers of students from different parts of the country live in this area. this condition is favourable for spreading of ca=mrsa among the people. the aim of this study was to identify the proportion of susceptibility to ca-mrsa infection in the jatinangor community. methods from september to october 2014, 65 nasal swab samples were taken by purposive sampling with 10-15 nasal swab samples per amj. 2018;5(2):64–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1415 althea medical journal. 2018;5(2) 65 day, collected every tuesday or thursday from the jatinangor primary health care (puskesmas) and the the laboratory testing were acrried out at the microbiology laboratory of faculty of medicine, universitas padjadjaran. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. all samples met the inclusion and exclusion criteria. the inclusion criteria included patients who visited puskesmas jatinangor; had no medical history of recent or current hospitalization, dialysis and surgery; had no permanent indwelling catheters or medical devices that pass through the skin into the body; had not received treatment with intranasal mupirocin or polysporin in the previous 14 days; had no treatment with oral antimicrobials for the purpose of eradicating mrsa colonization within the past 14 days (including oral rifampin therapy for any reason) and had no contraindications to nasal sampling. while the exclusion criteria were the patient who met the inclusion criteria but refused to be a respondent and also the patient who felt uncomfortable with the sample collection of the first sample swab, and refused to proceed with a second sample swab. nasal swabs were performed by asking the patient to attempt to clear the discharge by “blowing” his/her nose into non-scented tissue paper in one attempt. the researcher wore a mask, washed their hands, and wore clean gloves. the amies culture swab seal were peeled open and the swab was removed. then, the swab was inserted approximately 2 cm into the naris and was rotated against the anterior nasal mucosa for at least 5 times. next, the swab was placed back into the transport tube and the end of the swab was firmly pushed to ensure that the swab wass inserted into the end of the transport tube. this was also to ensure that the swab tip was in contact with the moistened pledget, then the transport tube cap was secured. the procedure was repeated with the other naris. the collected samples were transported to the microbiology laboratory within 8 hours and then planted directly on a blood agar plate by using the inoculation loop streak method. cultured after 24 hours at 37ºc, colonization of bacteria was formed. the colony had a diameter about 2-3mm, round, smooth, raised and glistening, colored gray to deep golden yellow and surrounded by β-hemolysis zone that grew on the blood agar. furthermore, for identification of s. aureus the gram staining, catalase and coagulase tests were performed. then, the susceptible bacteria were planted on mueller-hinton agar added with 30µg cefoxitim. gram staining was carried out by first adding a drop of normal saline on the slide then the inoculation loop was heated until red hot to make it aseptic. a small single colony was transferred from the blood agar by the inoculation loop, and then it was left to dry at room temperature. fixation of the dried film was performed by passing it briefly through the bunsen flame two or three times without exposing the dried film directly to the flame. then for staining, first the slide was stained with crystal violet for 1 minute, washed off with distilled water then stained with iodine for 1 minute and similarly washed with distilled water. after that the slide was decolorized with 95% alcohol for 10-15 seconds. stain that comes out is gram negative while stain that stays is gram positive. the gram negative smear is then counterstained with safranin for 1 minute and washed with distilled water.3 lastly, the slide was dried with filter paper and examined under a microscope with highpowered 100x objective lens with a drop of immersion oil. staphylococcus would appear in gram positive pair cocci, tetrads and grapelike clusters. the catalase test was performed by allowing 1-2 drops of the 3% hydrogen peroxide on the glass slide then an inoculation loop was used to take bacteria samples from blood agar. presence (positive result) or absence (negative result) of bubbling or foaming was examined when the bacteria were placed on the slide. finally, the identification test was performed using tube coagulase test. bacteria were inoculated by sterile method into the tube of diluted plasma, then all the tubes were incubated at 37oc and the suspensions were observed at half hourly intervals for a period of four hours. a positive result was indicated by gelling of the plasma, which remained in place even after inverting the tube. the test that remained negative until four hours at 37oc was kept at room temperature for overnight incubation. the susceptibility test was carried out by inoculating the suspected mrsa single colonies to muller–hinton agar containing 30μg cefoxitin. using the kirby-bauer method, bacterial suspension was prepared in sterile aquadest with the haziness suitable according to the 0.5 mcfarland standard, which is equal to 108 colony forming unit (cfu) bacteria in every one millimeter bacterial suspension. the standardized suspension of the bacteria gan ee xian, imam megantara, sharon gondodiputro: susceptibility to community associated methicillin resistant staphylococcus aureus: a preliminary study althea medical journal. 2018;5(2) 66 amj june 2018 was swabbed over the entire surface of the medium. paper discs impregnated with 30μg cefoxitin were placed on the surface of the medium and the plate was incubated for 24 hours at 35oc and diameter zones of inhibition (translucent area) around each disc were measured. a translucent resistance diameter ≤21mm described a positive mrsa result and ≥22mm described a positive methicillin sensitive staphylococcus aureus (mssa) result. the collected data were then plotted in tables and the proportions were calculated in percentage. results this study was performed by selecting 65 samples of people aged 7–68 years who came to puskesmas jatinangor that met the inclusion criteria. this study revealed that one third of the samples were positive for s. aureus and approximately 9.23% from all samples were positive for mrsa (table). discussions this study discovered that susceptibility to camrsa was identified among people who met the inclusion criteria and came to puskesmas jatinangor, west java. this study showed a significantly higher percentage compared to a study carried out in indonesia. a study performed from july 2001 to may 2002 at two university hospitals in indonesia3 included 3,995 inpatients, outpatients and relatives of patients, discovered about 9.1% of individuals are s. aureus nasal carriers, and after further testing with antibiotic resistance, it has found that 2/362 of the s. aureus are mrsa. the s. aureus is a common commensal organism on human skin and mucosa. the anterior nares of the nose are the main ecological niche, while numerous other body sites may also harbor s. aureus including skin, pharynx, perineum and the gastrointestinal tract. approximately 20-40% of healthy individuals carry s. aureus in their anterior nares. although a normal flora, it can cause significant infections ranging from local to deep seated infections.4 staphylococcus aureus proliferates easily and causes infections whenever it is transferred to other areas of the body or if a favorable environment for growth is present. resistance is often acquired by horizontal transfer to genes from outside sources, although chromosomal mutation and antibiotic selection are also important.5 as s. aureus easily adapts to and develops resistance to most antibiotics, hence it is very difficult to treat and will cause severe complications when treatment is delayed as it will cause sepsis when the bacteria enter systemic circulation.5 there are two types of mrsa, namely hospital-associated mrsa (ha-mrsa) and community-associated mrsa (ca-mrsa).5 both types could manifest in hospital or community setting.6 the distinction of hamrsa and ca-mrsa is that almost 100% of ca-mrsa has panton and valentine leukocidin (pvl) toxin gene which releases pv leukotoxin as the main pathogenesis for causing dermonecrotic lesions, also as an important factor in necrotizing skin infections.7 nasal acquisition of ca-mrsa has been associated with a 10-fold increase in risk of developing skin and soft tissue infections (sstis).6 the symptoms of sstis are characterized by the usual red, swollen, painful, warm to the touch, full of pus or other drainage and accompanied by fever. these symptoms are commonly misleadingly referred to as spider or insect bites and treated with normal ointment. hence if the appropriate treatment is delayed, bacteria might enter the bloodstream causing severe bloodstream infections (bsis) which will then cause sepsis. a recent report showsed that 60% mortality for bsis is caused by usa600 strain type.8 the ca-mrsa-associated skin and softtissue infections are treated with oral table percentage of mssa and mrsa detected on the samples isolates n=65 percentage (%) s. aureus + 17 26.15 mssa + 11 16.92 mrsa + 6 9.23 s. aureus ‒ 48 73.85 total 65 100 althea medical journal. 2018;5(2) 67 antibiotics including doxycycline, minocycline, clindamycin, trimethoprim-sulfamethoxazole, rifampicin and fusidic acid. severe ca-mrsa infections and ha-mrsa require intravenous vancomycin therapy. asymptomatic carriers represent an important mrsa reservoir. the transmission of mrsa infections may be limited by universal infection-control measures, patient education, screening and decolonization of asymptomatic mrsa carriers in both health-care and community settings.9 education to the patient includes keeping the skin intact can protect against transmission, and by wearing gloves when performing activities likely cause punctures, scratches, cuts, abrasions or other injuries to the skin will help prevent ca-mrsa from causing skin and soft tissue infections.6 if injury to the skin occurs, the wound should be cleaned immediately with soap and warm water, dried, and then covered with a clean, dry bandage or dressing. other strategies include hand washing with antimicrobial soap or alcohol based sanitizer; laundry (e.g. used clothing, towels, sheets and blankets) should be washed with detergent in water at ≥ 160° f for at least 25 minutes; use an automatic dryer on hot temperature (180ºf) to dry items—do not air dry and items should be used only after they are completely dry, besides that also to clean and disinfect contaminated items and environmental surfaces; family, household members in close contacts to the carrier or patient should perform frequent hand washing with warm water and soap or alcohol-based hand sanitizers; practice good personal hygiene including showering as soon as possible after physical activity, direct contact sports, or working out, make sure to use a clean and dry towel; do not share personal care items (i.e., razors, towels, bar soap, and water bottles), any topical preparations (i.e., ointments, balm, lotions, deodorants, antibiotic creams) and shave body skin for cosmetic or wound care reasons, as shaving can create micro-abrasions that can permit entry of bacteria.6 furthermore, routine screening for camrsa colonization in nares or other site is not recommended in the non-outbreak setting.6 in selected circumstances, screening may be considered, for example if the individual has more than 2 times recurrent s. aureus skin infections within 6 months, family settings where the recurrent skin infection still occurs despite review and re-inforcement of hygiene measures with known high prevalence of camrsa in the community and also to investigate an outbreak.6 decolonization refers to eradication and reducing carriage of a certain organism.6 it can be temporarily achieved but a significant portion of patients and health care workers become re-colonized within a relatively short time. the short-term mupirocin use may help interrupt nosocomial outbreaks, but infection control measures may be equally or more important. it is not recommended for usual management of individual with ca-mrsa infections, endemic infection or outbreak; should be considered only in exceptional circumstances which include cases if a patient develops a recurrent ssti despite optimizing wound care and hygiene measures, ongoing transmission is occurring among household members or other close contacts despite optimizing wound care and hygiene measures.10 decolonization strategies include nasal decolonization with mupirocin twice daily for 5–10 days; nasal decolonization with mupirocin twice daily for 5–10 days and topical body decolonization regimens with a skin antiseptic solution (e.g., chlorhexidine) for 5–14 days or dilute bleach baths. (for dilute bleach baths, 1 teaspoon per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for ~3 months can be considered.).10 as of limitations of this study, the lack of resource might play a definitive role as polymerase chain reaction (pcr) for identification of meca gene presence in the strain is the “golden standard”. there were possibilities of false positive as the culture method for mrsa had a sensitivity of 83.3% and a specificity of 98.2%.14 the sample used was not evenly distributed as it was not randomized with lack of samples collected due to costly culturing methods for detection of mrsa. in conclusion, the proportion of susceptibility to ca-mrsa carriers in people who came to puskesmas jatinangor is 9.23%. references 1. deleo fr, otto m, kreiswirth bn, chambers hf. community-associated meticillinresistant staphylococcus aureus. lancet. 2010;375(9725):1557‒68. 2. otter ja, french gl. community-associated meticillin-resistant staphylococcus aureus strains as a cause of healthcareassociated infection. j hosp infect. 2011;79(3):189‒93. 3. lestari es, severin ja, filius pm, kuntaman k, duerink do, hadi u, et al. antimicrobial gan ee xian, imam megantara, sharon gondodiputro: susceptibility to community associated methicillin resistant staphylococcus aureus: a preliminary study althea medical journal. 2018;5(2) 68 amj june 2018 resistance among commensal isolates of escherichia coli and staphylococcus aureus in the indonesian population inside and outside hospitals. eur j clin microbiol infect dis. 2008;27(1):45‒51. 4. ramana kv, mohanty sk, wilson cg. staphylococcus aureus colonization of anterior nares of school going children. indian j pediatr. 2009;76(8):813‒6. 5. chambers hf, deleo fr. waves of resistance: staphylococcus aureus in the antibiotic era. nat rev microbiol. 2009;7(9):629‒41. 6. barton m, hawkes m, moore d, conly j, nicolle l, allen u, et al. guidelines for the prevention and management of community-associated methicillinresistant staphylococcus aureus: a perspective for canadian health care practitioners. can j microbiol. 2006;17(suppl c):4c‒24c. 7. kuehnert mj, kruszon-moran d, hill ha, mcquillan g, mcallister sk, fosheim g, et al. prevalence of staphylococcus aureus nasal colonization in the united states, 20012002. j infect dis. 2006;193(2):172‒9. 8. donabedian sm, moore cl, perri mb, chua t, zervos mj. do laboratory characteristics predict outcome in methicillin-resistant staphylococcus aureus bacteremia? clin microbiol infect. 2009;15(s4):1860. 9. ray p, gautam v, singh r. methicillinresistant staphylococcus aureus in developed and developing countries: implications and solutions. regional health forum (who/searo). 2011;15:74‒82. 10. liu c, bayer a, cosgrove se, daum rs, fridkin sk, gorwitz rj, et al. clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant staphylococcus aureus infections in adults and children. clin infect dis. 2011;52(3):18‒55. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 100 amj march 2017 treatment failure of ampicillin to children with pneumonia at dr. hasan sadikin general hospital bandung from 2014–2015 kania devi suharno,1 ike rostikawati husen,2 sri sudarwati3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: pneumonia is one of the causes of death in infants in developing countries especially indonesia. appropriate treatment is needed to decrease mortality rate in children due to pneumonia. ampicillin is one of first choices empirical antibiotic to children with severe pneumonia. the study was aimed to determine the failure rate of ampicillin in children with severe pneumonia. methods: this study was a descriptive study which used medical records as source of data. subjects were children aged 2–59 months with world health organization (who) defined with severe pneumonia and treated with intravenous ampicillin during january 2014 to july 2015 at dr. hasan sadikin general hospital bandung. samples were obtained using total sampling method while variables were analyzed using statistics software. results: this study acquired 107 patients who met the inclusion criteria with 23.36% of them aged 2–11 months and 62.21% aged 12–23 months. majority of subjects were male amounted as 63.55% while female occupied 36.45%. treatment failure on the third day was 45.8% while 16.7% on the sixth day of therapy with majority failure due to existence of lower chest indrawing. conclusions: treatment failure on the third and sixth day of therapy still high that is characterized by the existence of lower chest indrawing as its main factor. [amj.2017;4(1):100–6] keywords: ampicillin, pneumonia, treatment failure correspondence: kania devi suharno, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282117797706 email: devi.kania@gmail.com introduction pneumonia is a kind of lung infection characterized by inflammation of the lung parenchyma tissue caused by infection agents such as viruses and bacteria.1,2 in indonesia, pneumonia is a leading cause of death in children less than 5 years old. an increase of period prevalence from 2.1% to 2.7% occurred in 2013.3 most common pathogen in children less than 5 years old are streptococcus pneumoniae and haemophillusinfluenzae.1,4,5 recent studies were conducted in indonesia, as many as 67.8% streptococcus pneumoniae in nasopharyngeal specimens in children aged 2–5 years old with pneumonia.6 death due to pneumonia which is caused by streptococcus pneumoniae and haemophillus influenzae are 32.7% and 15.7% respectively.4 resistance to antibiotics is one of the causes of high mortality rate.7 in asia, 30.1% of streptococcus pneumoniae is resistant to penicillin. effectiveness of ampicillin against haemophillusinfluenzae is 68.7%, therefore the value reflected decreasing ability of ampicillin against haemophillusinfluenzae.8 this should be a concern since streptococcus pneumoniae and haemophillusinfluenzae are the most frequent bacteria causing community acquired pneumonia (cap) in children aged 2–59 months with ampicillin as the first line therapy choice.1,2 different outcome is represented by the study in lombok which showed that serogroup of non-susceptible streptococcus pneumoniae to penicillin could reach 2.2%.6 a study conducted in pakistan9 among children aged 2–59 months with clinical symptoms of pneumonia such as lower chest indrawing and rapid breathing that had treatment failure of intravenous ampicillin althea medical journal. 2017;4(1) 101 was 5.8% on third day and 8.6% on sixth day of therapy.9 the study realized the importance of researching about treatment failure of ampicillin in children with pneumonia due to its increase prevalence, high mortality and the most common etiology such as haemophillusinfluenzae was resistant to ampicillin. in indonesia, treatment failure rate has not been reported; therefore, this study aimed to determine treatment failure of intravenous ampicillin in children with severe pneumonia aged 2–59 months, exclusively patients who were treated in kenanga room at dr. hasan sadikin general hospital bandung from year 2014 to 2015. methods this descriptive study was conducted at dr. hasan sadikin general hospital bandung from 3rd september to 20th november 2015. data used in this study were secondary data from medical records of patients who were treated in kenanga room at dr. hasan sadikin general hospital bandung from january 2014 to july 2015. this study was conducted after obtaining the approval from health research ethics committee of dr. hasan sadikin general hospital bandung, no: lb.04.01/a05/ec/232/vii/2015. method of sampling was conducted by total population method. minimum sample that required in this study were 97 subjects based on sample size calculation for descriptive study with categorical variables. sample criteria were children aged 2–59 months who met the category by world health organization (who) defined with severe pneumonia and treated by intravenous ampicillin. severe pneumonia was categorized for patient with rapid breathing (aged 2–11 months: ≥50 beats/minute, aged 11–59 months: ≥ 40 times /minute) and lower chest indrawing. patients with danger signs of very severe pneumonia such as cyanosis, inability to breastfeeding, vomiting everything, loss of consciousness, convulsions, and severe respiratory distress (aged 2–11 months: ≥60 beats/minute, age 11–59 months: ≥ 50 times / minute) were excluded from this study. patient with malnutrition, congenital heart disease, tuberculosis, and asthma are also excluded. variables observed in this research were age, gender, birth weight, up to date immunization, breast feeding, report of antibiotics use in past 7 days, referral status, treatment failure rate at third and sixth day of treatment, antibiotic therapy, and the duration of hospitalization. immunization status was defined as the conformity between children age and immunization received according to the health ministry program. exclusive breastfeeding was defined as breastfeed for 6 months without other additional food. treatment failure was determined by looking at patient’s clinical symptoms on third and sixth day whether lower chest indrawing, rapid breathing, signs of very severe pneumonia, death, and fever over 38˚c occurred. treatment failure was monitored on third day due to the possibilities of the pathogens which caused pneumonia were susceptible to ampicillin, hence, the clinical symptoms should be improved consequently until the sixth day as the subject recovered. variables were analyzed using statistics software. result total patients with diagnosis of bronchopneumonia with international classification of disease (icd) criteria j.18.0 (bronchopneumonia with unspecified organism) during the period of january 2014 to august 2015 were 616 patients. subjects from january to august 2015 were 191 and 425 subjects from january to december 2014. as of 191 subjects in year 2015, there were 37 subjects met the inclusion criteria, 3 medical records missed, and 151 subjects excluded. from 425 subjects in year 2014, there were 70 subjects met the inclusion criteria, 32 medical records missed, and 323 subjects excluded; therefore, 107 subjects were obtained from january 2014 to august 2015. clinical manifestation of subjects who met inclusion criteria was recorded until subject recovered and dismissed from hospital. based on this study result, median value on the subject aged was 12 months, with minimum aged was 2 months and maximum aged was 48 months. from 15 subjects who have history of antibiotics usage on the previous week, 5 of them were using amoxicillin (table 1). on the third day, subjects who experience treatment failures were about 49 subjects from 107 population subjects; hence, the treatment failure on third day was 45.8% which is figured on table 2. the indicators of treatment failure mostly were marked by the existence of lower chest indrawing on 37 subjects and rapid breathing on 27 subjects. total subjects who have signed of very severe pneumonia were 9 subjects so that they received antibiotics replacement. there were 2 subjects who exceeded normal body temperature (≥ 38˚c) kania devi suharno, ike rostikawati husen, sri sudarwati: treatment failure of ampicillin to children with pneumonia at dr. hasansadikin general hospital bandung from 2014–2015 althea medical journal. 2017;4(1) 102 amj march 2017 and 1 subject passed away on the third day (table 2). there were 9 subjects who experienced treatment failure on the third day due to very severe pneumonia who changed antibiotic and one subject passed away. both of those 10 subjects were excluded thus the number of subject on this study became 97 peoples on the sixth day (table 3). subjects who had duration of hospitalization were less than six days and otherwise cured by doctor, then inserted into group of patients who had success treatment because the patients dismissal from hospital were linked to the absence of lower chest indrawing, no rapid breathing, no fever, and subjects were able to drink and eat. hence, there were 67 patients who underwent treatment success before day 6 (table 4). on the sixth day, total subjects were 97 peoples, 16 subjects had treatment failure, so the treatment failure rate was 16.5%. treatment failure on the sixth day was characterized by the existence of lower chest indrawing, rapid breathing, and sign of very severe pneumonia such as severe respiratory table 1 characteristics of subject characteristics total (%) age (months) 2–11 25 (23.36%) 12–23 67 (62.61%) 24–35 9 (8.41%) 36–47 2 (1.86%) 48–59 4 (3.73%) sex male 68 (63.55%) female 39 (36.45%) birth weight (gram) <2500 7 (6.54%) ≥2500 42 (39.25%) unknown 58 (54.2%) immunization status yes 79 (73.38%) no 19 (17.75%) unknown 9 (8.41%) exclusive breastfeeding yes 72 (67.28%) no 24 (22.42%) unknown 11 (10.28%) report of antibiotic use in past 7 days yes 15 (14%) no 0 unknown 92 (86%) referral yes 55 (51.4%) no 52 (48.6%) althea medical journal. 2017;4(1) 103kania devi suharno, ike rostikawati husen, sri sudarwati: treatment failure of ampicillin to children with pneumonia at dr. hasansadikin general hospital bandung from 2014–2015 distress. most of treatment failure were marked by lower chest indrawing and experienced by 10 subjects. antibiotic replacement was needed for 8 subjects and there were no subjects who had fever. discussion based on this study result, the highest incidence of bronchopneumonia among children occurred from age 12 to 23 months which was occupied by 67 (62.6%) subjects. these findings are in line with the result of national health research (riset kesehatan dasar, riskesdas) which was held by indonesian ministry of health 2013 that showed high occurrence of bronchopneumonia among children happened among children aged 12 to 23 months. nevertheless, this result is slightly different with study conducted in pakistan9 where majority of study subject amounted 64% were aged 3 to 11 months.9 the result presented that based on gender, study subjects were dominated by males as many as 68 subjects (63.55%). analogous with another study among children in pakistan9 with 60.4% subject are males. study conducted in bangladesh10 presented 56.5% subjects are males. although the results acquired more subjects are males, but the different number of subjects was not significant. treatment failure rate on the third day reached 45.8%. this result is much higher than similar study conducted in pakistan9 where treatment failure on third day was 5.8%. study in pakistan9 showed that subject with history of previous antibiotics usage could increase treatment failure rate due to the possibilities of pathogen which were resistant or stronger. subjects on this study who had history of previous antibiotics and experiencing treatment failure on the third table 2 treatment failure on 3rd day treatment failure on 3rd day n lower chest indrawing 13 rapid breathing 10 very severe pneumonia 9 any danger sign existence of: lower chest indrawing and rapid breathing 16 lower chest indrawing and sign of very severe pneumonia 5 lower chest indrawing, rapid breathing, and death 1 lower chest indrawing, sign of very severe pneumonia, and fever 2 total 49 (45.8%) table 3 antibiotic therapy antibiotic n ampicillin 97 changed antibiotic 9 total 106 table 4 length of stay length of stay n <6 days 67 ≥6 days 30 total 97 althea medical journal. 2017;4(1) 104 amj march 2017 day were 5 (33.3%) subjects. high failure treatment rate might be initiated by the change of pathogen that not susceptible to ampicillin. another possibility was etiology of pneumonia caused by serogroup streptococcus pneumoniae that was resistant against ampicillin. dosage of intravenous ampicillin was 25–50mg/kg per injection every 6 hours. accordingly, the minimum inhibitory concentration (mic) for susceptible bacteria reached from peak concentration until the last half life (≥0.12mcg/ml).2,11 the causal factor that induced high treatment failure could not ascertained because subjects did not do lung aspiration and test for antibiotic resistance. on the sixth day of therapy, subjects experienced treatment failure as many as 16 (16.5%) peoples. another study performed in pakistan9 acquired treatment failure in sixth day was 8.6%. the indicators of treatment failure mostly were marked by the existence of lower chest indrawn in 10 (62.5%) subjects. the studies performed in pakistan and other countries had similar results which stated that lower chest indrawing is the indicator of treatment failure.9,12 inflammation of the lung parenchyma in children with pneumonia causes dysfunction in blood oxygen exchange then induces hypoxemia. peripheral chemoreceptor located in the carotid body is very sensitive to changes in blood oxygen levels. when hypoxemia occurs, the carotid body will induce respiratory central controller to increase the rate of breathing. in children, respiratory muscle fibers are composed of many types of 2 muscle fibers which are easily exhausted that will induce use of respiratory accessory muscle. the use of accessory muscle is characterized by clinical sign of lower chest indrawing.1 based on the age, as many as 6 (24%) subjects aged 2–11 months and 9 subjects aged 12–23 (13.4%) months experienced failure treatment on the sixth day. subjects with age less than 12 months had a tendency to experience treatment failure.9,13–15 the reasons of treatment failure in young infant can be caused by smaller airway, more compliant chest wall and poor hypoxic driver. these make young infant become vulnerable to respiratory disease.1 subjects aged less than 24 months and exclusively breastfed failed during treatment on the sixth day as many as 8 (19%) subjects. previous study stated that exclusive breastfeeding could decrease the risk of treatment failure on the sixth day in children aged less than 24 months.9,16,17 this phenomenon happened because the exclusive breastfeeding itself could increase selfimmunity as natural antimicrobial.18 children with exclusive breastfeeding as many as 46 (63.8%) of 72 subjects were hospitalized less than 6 days. previous study conducted at dr. hasan sadikin general hospital bandung to children with severe pneumonia described that children with exclusive breastfeeding had shorter duration of hospitalization.19 exclusive breastfeeding can avoid pneumonia and lower the risk of morbidity or even mortality due to pneumonia among children aged less than 24 months.16,17 exclusive breastfeeding itself has natural antimicrobial effect which can fight against infection caused by streptococcus pneumonia; hence, exclusive breastfeeding is able to improve effectiveness of antibiotics, decrease mic (minimum inhibitory concentration), and also reduce time needed to kill bacteria.18 other study showed that children with severe pneumonia treated with high dose amoxicillin is 80–90 mg/kg per oral every 12 hours had similar failure rate with intravenous ampicillin.9 this is quite interesting considering that 5 subjects in this study had history of amoxicillin oral treatment for three table 5 marked of treatment failure on 6th day treatment failure on 6th day n lower chest indrawing 1 rapid breathing 3 very severe pneumonia 3 any danger sign lower chest indrawing and rapid breathing 4 lower chest indrawing and very severe pneumonia 5 total 16 (16.5%) althea medical journal. 2017;4(1) 105 days, however, the dose given to the patients is unknown. the high failure rate indicated the need for further research in treatment of children with severe pneumonia which considered effective and efficient. study about treatment using combination of antibiotics is considered due to the killing effects of antibiotics that are faster, lowering the cytokines inflammation, and can attack organism with broader spectrum.20 limitations of this study are the data used were secondary data so that some of the data such as report of antibiotic use in past 7 days, birth weight, up to date immunization and breastfeeding that are not listed on the medical record could not be processed. ampicillin still has high failure rate because of the existence of lower chest indrawing during treatment. the failure rate is still high representing lack of effectiveness of treatment intravenous ampicillin in children with severe pneumonia. hence, it requires further research regarding to effective antibiotic for severe pneumonia treatment in children. references 1. kliegman rm, stanton bf, schor nf. community acquired pneumonia (cap). in: gatsch m, dimock k, shreiner j, tannian p, editors. nelson textbook of pediatrics. 20th ed. philadelphia: elsevier; 2015. p. 2089–94. 2. who. pocket book of hospital care for children, guidelines for the management of common illnesses with limited resources. switzerland: who; 2005. p. 72–80. 3. kementerian kesehatan ri. laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2013. jakarta: badan penelitian dan pengembangan kesehatan; 2013. p. 66–8. 4. rudan i, o’brien kl, nair h, liu l, theodoratou e, qazi s, et al. epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. j glob health. 2013;3(1):104– 10. 5. honkinen m, lahti e, osterback r, ruuskanen o, waris m. viruses and bacteria in sputum samples of children with community–acquired pneumonia. clin microbiol infect. 2012;18(3):300–7. 6. bravo l. overview of the disease burden of invasive pneumococcal disease in asia. vaccine. 2009;27(52):7282–91. 7. galli l, montagnani c, chiappini e, de martino m. treating paediatric community–acquired pneumonia in the era of antimicrobial resistance. acta paediatr suppl. 2013;102(465):25–33. 8. tomic v, dowzicky m. regional and global antimicrobial susceptibility among isolates of streptococcus pneumoniae and haemophilusinfluenzae collected as part of the tigecycline evaluation and surveillance trial (t.e.s.t.) from 2009 to 2012 and comparison with previous years of t.e.s.t. (2004–2008). ann clin microbiol antimicrob. 2014;13(1):52–8. 9. hazir t, fox lm, nisar yb, fox mp, ashraf yp, macleod wb, et al. ambulatory short course high dose oral amoxicillin for treatment of severe pneumonia in children: a randomised equivalency trial. lancet. 2008;371(9606):49–56. 10. chisti mj, salam ma, ahmed t, shahid as, shahunja km, faruque asg, et al. lack of bcg vaccination and other risk factors for bacteraemia in severely malnourished children with pneumonia. epidemiol infect. 2015;3(4):799–803. 11. katzung bg, masters sb, trevor aj. beta– lactam and other cell wall– and membrane– active antibiotics. in: akporiaye et, aminoffmj, basbaum ai, editors. basic and clinical pharmacology. 12th ed. san francisco: mcgraw–hill education; 2012. p. 790–808. 12. addo–yobo e, anh dd, el–sayed hf, fox lm, fox mp, macleod w, et al. outpatient treatment of children with severe pneumonia with oral amoxicillin in four countries: the mass study. trop med int health. 2011;16(8):995–1006. 13. jain dl, sarathi v, jawalekar s. predictors of treatment failure in hospitalized children 3–59 months with severe and very severe pneumonia. indian pediatr. 2013;50(8):787–9. 14. agweyu a, kibore m, digolo l, kosgei c, maina v, mugane s, et al. prevalence and correlates of treatment failure among kenyan children hospitalised with severe community–acquired pneumonia: a prospective study of the clinical effectiveness of who pneumonia case management guidelines. trop med int health. 2014;19(11):1310–20. 15. basnet s, sharma a, mathisen m, shrestha ps, ghimire rk, shrestha dm, et al. predictors of duration and treatment failure of severe pneumonia in hospitalized young nepalese children. plos one. kania devi suharno, ike rostikawati husen, sri sudarwati: treatment failure of ampicillin to children with pneumonia at dr. hasansadikin general hospital bandung from 2014–2015 althea medical journal. 2017;4(1) 106 amj march 2017 2015;3(3):1–11. 16. amberti lm z–gi, fischer walker c,l., theodoratou e, nair h, campbell h, et al. breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta–analysis. bmc public health. 2013;13(3):1–8. 17. barsamfjbg, borges gsd, severino aba, mello lmd, silva asd, nunes aa. factors associated with community–acquired pneumonia in hospitalised children and adolescents aged 6 months to 13 years old. eur j pediatr. 2013;172(4):493–39. 18. marks lr ce, hakansson ap. the human milk protein–lipid complex hamlet sensitizes bacterial pathogens to traditional antimicrobial agents. plos one. 2012;7(8):1–7. 19. nataprawira hm, alwi eh, adriani n. faktor risiko morbiditas dan mortalitas pneumonia berat pada anak usia balita. maj kedokt indones. 2010;60(10):443–7. 20. majhi a, kundu k, adhikary r, banerjee m, mahanti s, basu a, et al. combination therapy with ampicillin and azithromycin in an experimental pneumococcal pneumonia is bactericidal and effective in down regulating inflammation in mice. j inflamm (lond). 2014;11(1):5–49. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 382 amj september 2017 three years data of uterine fibroids patient characteristics at west java top referral hospital mutiara azzahra,1 sharon gondodiputro,2 mulyanusa amarullah3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: uterine fibroids are the most common benign tumor in female reproductive system and a major cause in declining their quality of live. patient characteristics has high prevalence in black women, 40s, nulliparous, and early menarche. these characteristics are varied in some areas and considered in treatment decisions. the objectives of this study was to describe the uterine fibroid patient characteristics at dr. hasan sadikin general hospital, bandung from 1 january 2013 to 31 december 2015. methods: a descriptive study was conducted to 255 medical records of patients with uterine fibroids at dr. hasan sadikin general hosiptal, bandung from 1 january 2013 to 31 december 2015. this study was conducted from september to november 2016. the variables were the year of treatment, age, education, occupation, married status, menarche, abortion, parity, type of uterine fibroids, and treatment. the collected data were analyzed and presented using frequency tables and percentages. results: most cases of uterine fibroids were discovered in 2014. the most characteristics with uterine fibroids were pre-menopausal age (41.18%), high school education (55.69%), housewife (63.14%), normal menarche (54.51%), married (92.16%), nulliparous (47.45%), no abortion (76.47%), multiple uterine fibroids (46.67%), and hysterectomy (58.04%). conclusions: the most combination of characteristics of patients with uterine fibroids is nulliparrous women in reproductive and pre-menopausal age with normal menarche. keywords: age, menarche, parity, uterine fibroids correspondence: mutiara azzahra, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: mutiara2021@gmail.com introduction uterine fibroids are benign tumors from smooth muscle of the uterus and most commonly occur in the female reproductive system, especially in the forties.1,2,3 in the united states3, 60% of 35 years old africanamerican women have uterine fibroids. in brazil4, uterine fibroids occur most commonly in the 35-44 years, and among white race l. in ghanaian women, this condition occurred <35 years old and the type was intramural uterine fibroids.5 in indonesia6, this condition ranks second of all gynecological cancer. a study in medan7 in the period 2009–2011, uterine fibroids had high prevalence in the 40–49 years old, high school graduation, work as housewife, married, multiparous and the type was submucosal fibroids. there are several factors suspected to be the cause of uterine fibroids such as socio-demographic, hormones, genetics, and lifestyle factors.8 menarche, parity, age, obesity, smoking, diet, and exercise are several predictors contributing to the development of uterine fibroids.9 these factors can be assessed by identification of the patient characteristics and can be a source of information to consider treatment options.1 dr. hasan sadikin general hospital bandung which is the top referral hospital in west java has not yet published data on uterine fibroids patient characteristics. based on this, the study was conducted to identify the uterine fibroids patient characteristics at dr. hasan sadikin general hospital bandung. methods a descriptive quantitative study was conducted involving medical records of uterine fibroid patients in the department of amj.2017;4(3):382–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1186 althea medical journal. 2017;4(3) 383 obstetrics and gynecology, dr. hasan sadikin general hospital from 1 january 2013 to 31 december 2015 (3 years data). this study was conducted from september to november 2016 and approved by the health research ethics committee of the faculty of medicine of universitas padjadjaran, no 631/un6.c1.3.2/ kepk/pn/2016 and dr. hasan sadikin general hospital bandung, no. 4740 / un6.c1 / pp / 2016. the inclusion criteria for the medical records were medical records consisting of information about the year of treatment, age, education, occupation, menarche, married status, parity, abortion, type of uterine fibroids, and treatment. while exclusion criteria were incomplete medical records according to the variables needed. there were 383 medical records during 3 years, however only 255 medical records met the inclusion criteria. in terms of age, age was divided into four groups according to the women’s uterine development, namely, the reproductive age (15–40 years), pre-menopause (41–46 years), menopause (47–51 years) and postmenopause (≥52 years). the intervals of menarche were divided based on the age of the table 1 distribution uterine fibroids patients characteristics in dr. hasan sadikin general hospital bandung from 2013–2015 variable classification n % years of treatment 2013 68 26.67 2014 94 36.86 2015 93 36.47 age 15–40 years 95 37.25 41–46 years 105 41.18 4–51 years 44 17.25 ≥ 52 years 11 43.1 education elementary school 32 12.55 junior high school 28 10.98 senior high school 142 55.69 college 53 20.78 occupation housewife 161 63.14 entrepreneur 12 4.71 employee 42 16.47 government employee 25 9.80 other 15 5.88 married status unmarried 20 7.84 married 235 92.16 first menstruation, namely, early menarche (<11 years), normal menarche (11–13 years), menarche tarda (14–16 years) and late menarche (≥17 years). moreover, parity was divided into four groups based on the number of delivery, namely nulliparous (null birth), primiparous (first birth), multiparous (2–5 births), and grandemultiparous (> 5 births). the collected data were analyzed using a computer software and were presented by frequency tables and percentages. results this study discovered that women aged 41–46 years had the highest percentage of uterine fibroids, followed by women aged 15–40 years. most of the patients were high school graduates, housewives and married (table 1). in terms of menarche, girls in the age group 11–13 years had the highest percentage of this disease, followed by girls in the age group 14–16 years. the highest percentage of the case was in the never abortus, nulliparous and multiple group. there were some options to treat uterine fibroids. this study discovered mutiara azzahra, sharon gondodiputro, mulyanusa amarullah: three years data of uterine fibroids patient characteristics at west java top referral hospital althea medical journal. 2017;4(3) 384 amj september 2017 that the most common treatment conducted to this condition was hysterectomy (table 2). based on the combination of variables age, menarche, and parity on the incidence of uterine fibroid and treatment options this study discovered that the most cases of uterine fibroids in the reproductive age group had normal menarche (11–13 years) and nulliparous (tables 3,4,5) . in terms of the pre-menopause group, this study discovered a similar result as in the reproductive group. most cases of uterine fibroids were patients who had normal menarche and nulliparous (table 3). compared to other groups, the cases of uterine fibroids in the menopause group had a slightly different result. most cases were still in patients who had normal menarche age but had more than two children (table 4). in this study there were small low cases of uterine fibroids in the post menopause age group. there were only 4.31% cases compared to other groups. hence, most cases had menarche tarda and more than five children (table 5). furthermore, treatment options based on the number of parity was hysterectomy, while based on age was myomectomy. a combination characteristics on hysterectomy was the most widely experienced by pre-menopause (41– 46 years), menarche tarda (14–16 years) and multiparrous (2–5 births), while myomectomy was performed to women who were in the reproductive age (15–40 years), normal menarche (11–13 years), and nulliparous. discussions uterine fibroid is a benign tumor that causes the highest morbidity among women in reproductive age and fewer than in menopause. it consists of many smooth muscle cells and different types of connective tissue. growth of the tumor presses to the multiple networks of myometrium and connective tissue, and causes the formation of pseudo-capsule that consists of lots of collagen fibers and blood vessels.10,11 hormones, gen, and growth factors were factors suspected to contribute to the development of uterine fibroids.12 this study discovered that most cases of uterine fibroids occurred in the premenopouse group. this result was in table 2 distribution of uterine fibroids based on obstetrics and gynecology status of patients in dr. hasan sadikin general hospital bandung from 2013–2015. variable categories n % menarche < 11 years 10 3.92 11–13 years 139 54.51 14–16 years 98 38.43 ≥17 years 8 3.14 abortus 0 195 76.47 1 44 17.25 >1 16 6.27 parity 0 birth 121 47.45 1 birth 38 14.90 2–5 birth 87 34.12 >5 birth 9 3.53 type of uterine fibroid subserous 39 15.29 intramural 79 30.98 submucosa 18 7.06 multiple 119 46.67 treatment medication 10 3.92 myomectomy 97 38.04 hysterectomy 148 58.04 althea medical journal. 2017;4(3) 385mutiara azzahra, sharon gondodiputro, mulyanusa amarullah: three years data of uterine fibroids patient characteristics at west java top referral hospital table 3 combination of age, menarche, parity on treatment option of uterine fibroid based on reproduction age combination n treatment medication myomectomy hysterectomy a1m1 and, p1 4 0 3 1 p2 0 0 0 0 p3 0 0 0 0 p4 0 0 0 0 a1m2 and, p1 38 1 27 10 p2 8 1 6 1 p3 9 0 2 7 p4 0 0 0 0 a1m3 and, p1 17 2 11 4 p2 5 0 3 2 p3 12 0 2 10 p4 0 0 0 0 a1m4 and, p1 2 0 2 0 p2 0 0 0 0 p3 0 0 0 0 p4 0 0 0 0 note: a= age: a1 (15-40 years), a2 (41-46 years), a3 (47-51 years) and a4 (≥52 years), m = menarche: m1 (< 11 years), m2 (11-13 years), m3 (14-16 years) and m4 (≥17 years), p = parity: p1 (0 birth), p2 (1 birth), p3 (2-5 birth), p4 (>5 birth) accordance with a study by ziemerman et al.3 that stated the age group 40-49 years has a high prevalence of uterine fibroids. uterine fibroids occurring in menstruating women, showed the reliance on ovarian steroids, especially estrogen and progesterone that had a role in the development of this disease.10 another study stated that at the premenopause age, increase urine concentration of estrogen and androgen compared to normal women, could be a predictor in the development of uterine fibroids.13 based on the education status, uterine fibroids occur most commonly in women who had already graduated from senior high school and college. the level of education was suspected to increase the stress level of a person.8 this was stated by shen et al.8 that higher level of education was one of the other factors on developing uterine fibroids, due to stress level. stress in a person who had a higher education was related to the changing endocrine system in women via steroid hormone, due to the disturbance of hpa axis responses to stress that result in changes of metabolism steroid hormone, and particularly led to the development of uterine fibroids.8,14 in this study, normal menarche age had the highest frequency of all groups. this result is in accordance with the study of he et al.15 in china which stated that ≤14 years old women have a higher percentage of uterine fibroids compared to 15–16 and ≥17 years old groups.15 it suspected that there are other factors contributing to uterine fibroids, such as smoking, exercise and alcohol consumption. those factors make women more susceptible to develop uterine fibroids.8 althea medical journal. 2017;4(3) 386 amj september 2017 additionally, nulliparous women had the highest frequency of uterine fibroids. uterine fibroids affect fertility due to inflammation of the endometrium, inhibition transport of gamete embryo in the uterus, blood supply and anatomical disorders in the uterine cavity caused by development of the tumor. this condition has a devastating effect on fertility.16,17 childbearing age women preparing for her first pregnancy, and have difficulty getting pregnant should be aware of the possibility of obstetric complication risks caused by uterine fibroids.16 although cases of uterine fibroids in the multiparous group were second rank compared to other groups, this study discovered that this situation existed. this finding was in contradictory with the existing theory. multiparity reduced the risk of uterine fibroid.13 after the delivery myometrium will return to its normal state, such as weight, blood flow, and the size of cells by apoptosis and differentiation through the process of involution reduced blood supply to the myometrium.9 this explanation of uterine fibroids in the multiparous group is still unknown. furthermore, multiple uterine fibroids were the most type in this study. this finding was not similar to a study conducted in surakarta which stated that the highest number of uterine fibroid is intramural, while the multiple is the least of all.17 this result was also different with a study conducted by sarkodie et al.5 in ghana. there was no clear explanation about the differences, whether there was spesific factors in some areas related to the pathogenesis and histologically findings. additionally, the most treatment performed was hysterectomy. this was consistent with a table 4 combination of age, menarche, parity on treatment option of uterine fibroid based on pre-menopause age combination n treatment medication myomectomy hysterectomy a2m1 and, p1 3 1 1 1 p2 1 0 1 0 p3 0 0 0 0 p4 1 0 0 1 a2m2 and, p1 27 1 15 11 p2 11 0 3 8 p3 18 1 1 16 p4 1 0 1 0 a2m3 and, p1 16 1 7 8 p2 7 0 1 6 p3 16 0 3 13 p4 0 0 0 0 a2m4 and, p1 1 0 1 0 p2 1 0 0 1 p3 1 0 0 1 p4 1 0 0 1 note: a= age : a1 (15-40 years), a2 (41-46 years), a3 (47-51 years) and a4 (≥52 years), m = menarche : m1 (< 11 years), m2 (11-13 years), m3 (14-16 years) and m4 (≥17 years), p = parity : p1 (0 birth), p2 (1 birth), p3 (2-5 birth), p4 (>5 birth) althea medical journal. 2017;4(3) 387 previous study in medan.7 hysterectomy is the main therapeutic indication of uterine fibroids in the united states.18 according to the management of the national institute for health and care excellence (nice), hysterectomy may be performed if medication treatment failed and women did not want preserved their fertility.16 this study discovered an interesting result, that in some cases, hysterectomy was performed in women who had never delivered. the reason why this operation was perfomed was unclear. in this case, the most combination of characteristics uterine fibroids was nulliparous. this disease most occurs in nulliparous women with normal reproductive age and normal menarche, followed by nulliparous women with premenopause and normal menarche. this condition becomes a particular concern to nulliparous women to early detect their reproductive system related to uterine fibroids. limitations of this study are the data collection from medical records, which are incomplete since not all patient characteristics related to the risk factor for uterine fibroids are recorded, such as anthropometry, family history, medical history, and lifestyles such as smoking, exercise, medicine. the conclusion of this study, nulliparous in women is the most characteristics in uterine fibroids, which occurred in reproductive and premenopausal age with normal menarche and myomectomy as treatment. references 1. aleksandrovych v, bereza t, sajewicz m, walocha ja, gil k. uterine fibroid : common features of widespread tumor. folia med table 5 combination of age, menarche, parity on treatment option of uterine fibroid based on menopause age combination n treatment medication myomectomy hysterectomy a3m1 and, p1 0 0 0 0 p2 1 1 0 0 p3 0 0 0 0 p4 0 0 0 0 a3m2 and, p1 6 0 2 4 p2 2 0 0 2 p3 15 1 0 14 p4 1 0 0 1 a3m3 and, p1 6 0 1 5 p2 2 0 1 1 p3 8 0 1 7 p4 1 0 1 0 a3m4 and, p1 0 0 0 0 p2 0 0 0 0 p3 1 0 0 1 p4 1 0 0 1 note: a= age: a1 (15-40 years), a2 (41-46 years), a3 (47-51 years) and a4 (≥52 years), m = menarche: m1 (< 11 years), m2 (11-13 years), m3 (14-16 years) and m4 (≥17 years), p = parity: p1 (0 birth), p2 (1 birth), p3 (2-5 birth), p4 (>5 birth) mutiara azzahra, sharon gondodiputro, mulyanusa amarullah: three years data of uterine fibroids patient characteristics at west java top referral hospital althea medical journal. 2017;4(3) 388 amj september 2017 cracov. 2015;55(1):61–75. 2. pérez-lópez fr, ornat l, ceausu i, depypere h, erel ct, lambrinoudaki i, et al. emas position statement: management of uterine fibroids. maturitas. 2014;79(1):106–16. 3. zimmermann a, bernuit d, gerlinger c, schaefers m, geppert k. prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. bmc womens health. 2012;12(6);1–11. 4. boclin kde l, faerstein e. prevalence of self-reported medical diagnosis of uterine leiomyomas in a brazilian population: demographic and socioeconomic patterns in the pro-saúde study. rev bras epidemiol. 2013;16(2):301–13. 5. sarkodie bd, botwe bo, ofori ek. uterine fibroid characteristics and sonographic pattern among ghanaian females undergoing pelvic ultrasound scan: a study at 3-major centres. bmc womens health. 2016;16(10) :1–6. 6. baziad a. endokrinologi ginekologi. 3rd ed. jakarta: media aesculapius fkui. 2008. 7. ginting ly, rasmaliah, jamedi. karakteristik penderita mioma uteri yang dirawat inap di rsud dr. pringadi medan tahun 20092011. jurnal gizi kesehatan reproduksi dan epidemiologi. 2012;1(1):1–9. 8. shen y, xu q, xu j, ren ml, cai yl. environmental exposure and risk of uterine leiomyoma: an epidemiologic survey. eur rev med pharmacol sci. 2013;17(23):3249–56. 9. parker wh. etiology, symptomatology, and diagnosis of uterine myomas. fertil steril. 2007;87(4):725–36. 10. khan at, shehmar m, gupta jk. uterine fibroids : current perspectives. int j womens health. 2014; 29(6):95–114. 11. sparic r, mirkovic l, malvasi a, tinelli a. epidemiology of uterine myomas: a review. int j fertil steril. 2016;9(4): 424–35. 12. ciavattini a, di giuseppe j, stortoni p, montik n, giannubilo sr, litta p, et al. uterine fibroids: pathogenesis and interactions with endometrium and endomyometrial junction. obstetrics and gynecology international. 2013;2013(2013):173184. 13. blake re. leiomyomata uteri: hormonal and molecular determinants of growth. j natl med socc. 2007;99(10):1170–84. 14. wise la, li s, palmer jr, rosenberg l. depressive symptoms and risk of uterine leiyomyomata. am j obstet gynecol. 2015;212(5):617–35. 15. he y, zeng q, dong s, qin l, li g, wang p. associations between uterine fibroids and lifestyles including diet, physical activity and stress: a case-control study in china. asia pac j clin nutr. 2013;22(1):109–17. 16. cook h, ezzati m, segars jh, mccarthy k. the impact of uterine leiyomyomas on reproductive outcomes. minerva ginecol. 2010;62(3):225–36. 17. trivedi p, abreo m. predisposing factors for fibroids and outcome of laparoscopic myomectomy in infertility. j gynecol endosc surg. 2009;1(1):47–56. 18. vannuccini s, clifton vl, fraser is, taylor hs, critchley h, giudice lc, et al. infertility and reproductive disorders: impact of hormonal and inflammatory mechanisms on pregnancy outcome. hum reprod update. 2016;22(1):104–15. 19. kurniasari t. karakteristik mioma uteri di rsud dr. moewardi surakarta periode januari 2009 januari 2010. institutional repository universitas sebelas maret. 2013 [cited 2017 january 6]. available form: https://eprints.uns.ac.id/4595/. 20. baird dd, harmon qe, upson k, moore kr, barker-cummings c, baker s, et al. a prospective, ultrasound-based study to evaluate risk factors for uterine fibroid incidence and growth: methods and results of recruitment. j womens health (larchmt). 2015;24(11):907–15. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 127 knowledge toward drugs resistant tuberculosis in one of the highest burden drug resistant country amalia rizki ramadhani,1 bony wiem lestari,2 hendarsyah suryadinata3 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, bandung, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: drug resistant tuberculosis (dr-tb) is the biggest threat in tb case control worldwide. west java province is one of the three provinces with the most dr-tb burden in indonesia. knowledge level in dr-tb patients influences the perception, health search effort, and patient compliance towards dr-tb treatment. this study was aimed to identify the knowledge level about dr-tb in dr-tb patients at hasan sadikin general hospital. methods: this cross-sectional, descriptive quantitative study used consecutive sampling. in the study 96 patients were included. primary data were collected through interview with questionnaire towards drtb patients at mdr-tb clinic hasan sadikin general hospital during september-november 2016. the questionnaire contained sociodemographic data and knowledge about dr-tb which consisted of definition, transmission, risk factors, resistance types, symptoms, medication, and prevention of dr-tb. the collected data were analyzed using statistical software for descripitive statistical analysis. results: the average age of patients was 38 years (sd±11.7) and mostly ranging from 36–45 years old. male had a higher distribution compared to female (55.2%). analysis results showed 20% patients had “adequate” knowledge level, 34.4% of the patients had “sufficient” knowledge, and 39.6% of the patients had “poor” knowledge about dr-tb. conclusions: dr-tb patients at mdr-tb clinic dr. hasan sadikin general hospital bandung have “poor” knowledge regarding dr-tb. keywords: drug resistant tb, knowledge, patients correspondence: amalia rizki ramadhani, faculty of medicine, universitas padjadjaran. jalan raya bandung-sumedang km. 21, sumedang, indonesia email: amaliarizki202@gmail.com introduction drug resistant tuberculosis (dr-tb) is a type of tuberculosis (tb) caused by tuberculosiscausing bacteria, mycobactrerium tuberculosis (mtb) which have developed resistance to anti tuberculosis drug (atd). this is the greatest threat in tb management in the whole wide world. indonesia is one of the six countries with the highestdr-tb burden in the world with 6800 cases of dr-tb in the year 2014 and the number kept increasing by 1.9% each year.1 the increased number of dr-tb cases in indonesia has caused the government to bear increasing costs to manage and control the drtb cases.2 the dr-tb occurs by two different mechanisms. the first mechanism is a patient infected by mtb is already resistant to drugs. the second mechanism is a patient has an acquired resistance due to inadequate treatment. this cause the previously susceptible mtb to develop genetic mutations which makes it resistant to atds. inadequate treatments include inadequate drugs dosage, inadequate absorption rate of drugs through the gastrointestinal system, inadequate quality of atds, as well as lack of patients’ compliance in continuously consuming atds.3–5 the level of knowledge will greatly affect the behavior, particularly the health behavior.6 the knowledge level of dr-tb patients will affect their perception regarding the disease, their efforts in looking for treatment, and their compliance towards dr-tb treatment regiments. the knowledge level will then have amj. 2018;5(3):127–32 althea medical journal. 2018;5(3) 128 amj september 2018 an important role to minimalize the spread of disease, as part of the efforts to decrease the rate of morbidity and mortality incurred by dr-tb.7–9 west java province is one of the three provinces with the greatest burden of dr-tb in indonesia, does not have sufficient data regarding the knowledge level of patients diagnosed with dr-tb up until presently.10 therefore, this study was aimed to identify the knowledge level regarding dr-tb in patients diagnosed with dr-tb at dr. hasan sadikin general hospital bandung. methods this study was a cross-sectional, quantitative descriptive study. the evaluated data were primary data collected through selfadministered questionnaires at mdr-tb clinic hasan sadikin general hospital. this study was held in september-november 2016. the sample population were patients diagnosed with dr-tb who at the time of the study underwent an intensive period of drtb treatment during september-november 2016. the sampling technique used was consecutive sampling. the inclusion criteria in this study were patients aged ≥18 years and were still undergoing intensive period of dr-tb treatment. patients diagnosed with dr-tb who were hospitalized and had speech impaired were not included in the study. the total number of patients who were undergoing intensive treatment during the period september-november 2016 at mdr-tb clinic hasan sadikin general hospital were 105 patients, however the total number of patients included in this study were 96 patients. the instrument employed in this study was a modified questionnaire which derived from questionnaires used in previous studies.8,11–13 the questionnaire included questions regarding demographic data such as patients’ identity, number of previous tb treatment, and duration of dr-tb treatment at the time of the study, and 20 items on knowledge consisting of true or false questions about definition, etiology, method of transmission, type of resistance, symptoms, treatment, and prevention of dr-tb.8,11–13 the questionnaire used in this study was tested for validity and reliability on 70 patients from may-august 2015. all questions were qualified as valid with alpha cronbach score of 0.78. the collected data were processed and analyzed using statistical software for descriptive statistical analysis and presented in the forms of narratives and figures. numerical variables were presented as mean or median as well as standard deviations (sd) and range. categorical variables were presented as distribution of frequency (n) and percentage (%). normality test of the data of patients’ knowledge level showed that the data were not normally distributed, thus, the grouping of patients’ knowledge level was based on the value of interquartile range. the patients’ knowledge level were classified into three categories, namely “adequate” if the score was ≥15, “sufficient” if the score was in the range table 1 demographic characteristics of dr tb patients on age, sex, patient’s location, marital status, and occupation patient characteristics n (%) age (years old) 18–25 12 (12.5) 26–35 25 (26) 36–45 39 (40.6) 46–55 11 (11.5) 56–65 7 (7.3) >60 2 (2.1) sex male 53 (55.2) female 43 (44.8) patient’s location bandung city 27 (28.1) outside of bandung city 69 (71.9) marital status unmarried 19 (19.8) married 72 (75) divorced with a living spouse 3 (3.1) divorced with a passed-away spouse 2 (2.1) occupation civil servant 8 (8.3) private companies employee 15 (15.6) self-employed 19 (19.8) students 1 (1) housewives 25 (26) retired 0 (0) temporary worker 27 (28.1) unemployed 1 (1) althea medical journal. 2018;5(3) 129 from 12–14, and “poor” if the patient’s score was <12. this study obtained permission from the health research ethical committee of faculty of medicine, universitas padjadjaran num. 505/un.6.c1.3.2/kepk/pn/2016 and the education and research division of dr. hasan sadikin general hospital num. lb.02.01/ c02/8952/vii/2016. results this study showed that male patients had a higher distribution compared to female patients and mean age of dr-tb patients were 38 years (sd±11.7). most patients lived outside the city of bandung (71.9%) and the majority of patients were temporary worker amalia rizki ramadhani, bony wiem lestari, hendarsyah suryadinata: knowledge toward drugs resistant tuberculosis in one of the highest burden drug resistant country table 2 demographic characteristics of dr-tb patients on monthly income, educational status, referral source, history of previous tb treatment, and duration of dr-tb treatment patient characteristic n (%) monthly income (rp.) <1.500.000 54 (56.3) 1.500.000–2.500.000 24 (25) 2.500.000–3.500.000 2 (2.1) >3.500.000 16 (16.7) educational status no formal education 0 (0) elementary school (not graduated) 0 (0) graduated from elementary school 9 (9.4) graduated from junior high school 25 (26) graduated from senior high school 47 (49) diploma/bachelor degree 14 (14.6) magister 1 (1) referral source public health centers 51 (53.1) public hospitals 31 (32.3) private hospitals 12 (12.5) private clinics 1 (1) self-practicing general practitioners 1 (1) history of previous tb treatment (times)* 2(0–5) (median/minimum-maximum) duration of dr-tb treatment (month)** 3(0–18) (median/minimum-maximum) table 3 knowledge level of dr-tb patients knowledge level n (%) adequate 25 (26) sufficient 33 (34.4) poor 38 (39.6) (labor) with the percentage 28.1% (table 1). as many as 51 patients (53.1%) were referred from public health centers (pusat kesehatan masyarakat, puskesmas) (table 2). the majority of dr-tb patients had “poor” knowledge regarding dr-tb (39.6%) and only a few patients (26%) had “adequate” knowledge regarding dr-tb (table 3). as many as 21 people out of 96 patients (21.9%) answered that dr-tb was an althea medical journal. 2018;5(3) 130 amj september 2018 infectious disease caused by bacteria, and 63 people (65.6%) answered correctly that dr-tb was not a genetically inherited disease. only 16 people (16.7%) were aware that dr-tb was caused by the bacteria named mycobacterium tuberculosis (table 4). furthermore, knowledge regarding transmission of dr-tb was quite sufficient. however, there was still a false understanding regarding the transmission of dr-tb. as many as 50 people (52.1%) stated that dr-tb was able to be transmitted through blood products. and 56 people (58.3%) stated that dr-tb could be transmitted through sharing food and drinks with another patient (table 4). moreover, knowledge regarding risk factors of dr-tb was categorized as adequate, as more than 50% patients were able to answer correctly that people with close contact to patients diagnosed with dr-tb (88.5%), patients diagnosed with hiv (50%), and patients with history of previous tb treatment table 3 knowledge level of dr-tb patients variable correct (n, %) wrong (n, %) definition infectious disease caused by bacteria 21 (21.9) 75 (78.1) not genetically inherited 66 (66.6) 33 (34.4) etiology caused by mycobacterium tuberculosis 16 (16.7) 80 (83.3) transmission mucus droplets during sneezing 94 (97.9) 2 (2.1) blood products 46 (47.9) 50 (52.1) physical contact (shaking hands) 83 (86.5) 13 (13.5) food borne 40 (41.7) 56 (58.3) risk factors household contact 85 (88.5) 11 (11.5) hiv* 48 (50) 48 (50) history of previous tb treatment** 88 (91.7) 8 (8.3) resistance type primary resistance 88 (91.7) 8 (8.3) acquired resistance 94 (97.9) 2 (2.1) symptoms sudden loss of body weight 92 (95.8) 4 (4.2) diagnostic test rapid laboratory test (gene xpert) 68 (70.8) 28 (29.2) treatment place of treatment and follow up 47 (49) 49 (51) total duration of dr-tb treatment† 30 (31.3) 66 (69.7) length of intensive phase 76 (75) 24 (25) name of drugs used in dr-tb treatment‡ 28 (29.2) 68 (70.8) prevention sputum disposal 46 (47.9) 50 (52.1) not sharing room with non-dr-tb patients§ 81 (84.4) 15 (15.6) note: * human immunodeficiency virus , ** tuberculosis, †, ‡, § drug resistant tuberculosis althea medical journal. 2018;5(3) 131 (91.7%) were at high risk for contracting drtb. patients also had adequate knowledge regarding the type of resistance, symptoms of dr-tb, and rapid test to diagnosed dr-tb (table 4). on questions regarding the treatment for dr-tb, only 47 people (49%) stated that the main treatment for dr-tb could only be conducted at certain hospitals approved by the government and then referred back to health facilities which were more accessible for patients, such as public health centers or district general hospitals. patients were also aware that the administration of antituberculosis drugs through injections was carried outd during the intensive phase of drtb treatment (75%). on questions regarding the total length of duration for dr-tb treatment only 30 people (31.3%) stated that the total length for dr-tb treatment was >18 months. as many as 68 patients (70.8%) were not aware of the names of anti-tuberculosis drugs provided to them. patients were aware that dr-tb could be prevented by removing their phlegm in places exposed by sun (47.9%) and rooms for dr-tb patients should be separated from other patients (84.4%). discussions this study showed that the distribution of patients diagnosed with dr-tb was higher in males compared to females. this is consistent with the studies by myet et al.9 in myanmar, li et al.11 in china, and mulu et al.14 at amhara, ethiopia, which stated there are more men afflicted with dr-tb than women. different results were obtained from the study by ullah et al.15 in pakistan, and liu et al.16 in china which showed that there are more female patients than male patients, even though there are no clear known relationships between sex and risks of contracting dr-tb yet. from the age factor, it is known that people of productive age are more likely to contract dr-tb than the elderly (≥65 years old), which is similar to the results of the study by nair et al.17 in india. this study found that the mean age of dr-tb patients were 38 years, mostly ranging from 36 to 45 years old, even though there was no fixed limits for the range of age that was more susceptible to dr-tb due to various cut off points for age in each study.15 as many as 72 patients (75%) were married, consistent with the results of the studies by myet et al.9 in myanmar and li et al.11 in china. as much as 27 patients (28.1%) are temporary workers or labor, similar to the result of the study by mulu et al.14 at amhara, ethiopia. this study discovered that most patients had previous tb treatments. previous history of tb treatment is one of the risk factors for dr-tb, as shown in the study by elmi et al.18 in malaysia and the study by liu et al.16 in china which reported that the history of a previous tb treatment is a risk factor for dr-tb which may also indicate patients’ lack of compliance during treatment. another study by daniel et al.19 in nigeria also mentioned that patients with history of a previous tb treatment are more prone to develop dr-tb. this study showed that most of the patients had poor knowledge regarding drtb. different results were found in the study by myet et al.9 in myanmar, and maharaj et al.20 in south africa, which reported that patients have adequate knowledge regarding dr-tb. patients enrolled in this study are mostly still unaware of the exact etiology of dr-tb, either the type or the name of the microorganism which cause dr-tb, risk factor of dr-tb, the transmission of dr-tb and the name of the drugs they received during the treatment period for dr-tb. maharaj et al.20 suggested that by knowing the name of the drugs they received, patients would be more aware of the side effects of the drugs so that they would be more compliant towards the treatment regiments. the limitation of this study was the sample population only consisted of patients who underwent treatment at hasan sadikin general hospital bandung, while there were also patients diagnosed with dr-tb who underwent treatment at the center for lung health community (balai besar kesehatan paru masyarakat, bbkpm) cibadak, and rotinsulu lung hospital bandung. this study also did not discover the association between dr-tb patients’ sociodemographic characteristics and knowledge level regarding dr-tb. in conclusion, dr-tb patients at dr. hasan sadikin general hospital bandung have “poor” knowledge about dr-tb. therefore, it is important for the government and health professionals to increase promotional and educational efforts, such as creating educational media (video, pamphlet, brochures) regarding dr-tb for the community, especially for patients. references 1. world health organization. global tuberculosis report 2013. geneva: who amalia rizki ramadhani, bony wiem lestari, hendarsyah suryadinata: knowledge toward drugs resistant tuberculosis in one of the highest burden drug resistant country althea medical journal. 2018;5(3) 132 amj september 2018 press; 2015. 2. van den hof s, collins d, hafidz f, beyene d, tursynbayeva a, tiemersma e, et al. the socioeconomic impact of multidrug resistant tuberculosis on patients: results from ethiopia, indonesia and kazakhstan. bmc infect dis. bmc infectious diseases; 2016;16(1):470–84. 3. nugroho ra. studi kualitatif faktor yang melatarbelakangi drop out pengobatan tuberkulosis paru. j kesehat masy. 2011;7(1):83–90. 4. oblast a, smith se, ershova j, vlasova n, nikishova e, tarasova i, et al. risk factors for acquisition of drug resistance during multidrug-resistant tuberculosis. emerg infect dis. 2015;21(6):1002–11. 5. kementerian kesehatan ri. petunjuk teknis manajemen terpadu pengendalian tuberkulosis resistan obat. jakarta: kemenkes ri; 2013. 6. manika d, golden ll. advances in prior knowledge conceptualizations: investigating the impact on health behavior. in: plangger k, editor. thriving in a new world economy. 4th ed. london: springer; 2015. p. 319–29. 7. bam k, bhatt lp, thapa r, dossajee hk, angdembe mr. illness perception of tuberculosis (tb) and health seeking practice among urban slum residents of bangladesh: a qualitative study. bmc res notes. 2014;7(1):572–8. 8. fox gj, loan lp, nhung nv, loi nt, sy dn, britton wj, et al. barriers to adherence with tuberculosis contact investigation in six provinces of vietnam: a nested case-control study. bmc infect dis. 2015;15(1):103–11. 9. myet h, maung w, saw s, oo wm. knowledge and practice on mdr-tb disease among mdr-tb patients attending aung san mdrtb clinic (yangon). myanmar heal sci res j. 2015;27(1):77–82. 10. kementerian kesehatan ri. laporan situasi perkembangan tb mdr di indonesia triwulan ii tahun 2015. jakarta: kemenkes ri; 2015. 11. li y, ehiri j, oren e, hu d, luo x, liu y, et al. are we doing enough to stem the tide of acquired mdr-tb in countries with high tb burden? results of a mixed method study in chongqing, china. plos one. 2014;9(2):1–12. 12. tang s, tan s, yao l, li f, li l, guo x, et al. risk factors for poor treatment outcomes in patients with mdr-tb and xdr-tb in china: retrospective multi-center investigation. plos one. 2013;8(12):1–8 13. tupasi te, marie a, garfin cg, kurbatova e v, mangan jm, orillaza-chi r, et al. factors associated with loss to follow-up during treatment for multidrug-resistant tuberculosis, the philippines, 2012–2014. emerg infect dis. 2016;22(3):491–502. 14. mulu w, mekonnen d, yimer m, admassu a, abera b. risk factors for multidrug resistant tuberculosis patients in amhara national regional state. afr health sci. 2015;15(2):368–77. 15. ullah i, javaid a, tahir z, ullah o, shah aa, hasan f, et al. pattern of drug resistance and risk factors associated with development of drug resistant mycobacterium tuberculosis in pakistan. plos one. 2016;11(1):1–7 16. liu q, zhu l, shao y, song h, li g, zhou y, et al. rates and risk factors for drug resistance tuberculosis in northeastern china. biomed cent ltd. 2013;13(1171):1– 7. 17. nair sa, raizada n, sachdeva ks, denkinger c, schumacher s, dewan p, et al. factors associated with tuberculosis and rifampicin-resistant tuberculosis among symptomatic patients in india: a retrospective analysis. plos one. 2016;11(2):1–9. 18. elmi os, hasan h, abdullah s, mat jeab mz, bin alwi z, naing nn. multidrug-resistant tuberculosis and risk factors associated with its development: a retrospective study. j infect dev ctries. 2015;9(10):1076–85. 19. daniel o, osman e. prevalence and risk factors associated with drug resistant tb in south west, nigeria. asian pac j trop med. 2011;4(2):148–51. 20. maharaj j, ross a, maharaj nr, campbell l. multidrug-resistant tuberculosis in kwazulu-natal, south africa: an overview of patients’ reported knowledge and attitudes. african j prim heal care fam med. 2016;8(1):1–6. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 413 prophylactic antibiotic pattern in open reduction internal fixation for closed fractures at dr. hasan sadikin general hospital bandung in 2013 deviana suciani edwiza,1 ike rostikawati husen,2 widya arsa3 1faculty of medicine, universitas padjadjaran, 2departmen of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of orthopaedic and traumatology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: surgical site infection remains a serious complication of a surgery. prophylactic antibiotics should be used in open reduction and internal fixation to prevent surgical site infection. this study aimed to study the pattern of prophylaxis used in internal fixation of closed fractures as this surgery is considered as a high-risk orthopedic procedures. methods: this retrospective-descriptive study was performed from august to october 2014. subject was closed fracture patient who underwent open reduction and internal fixation at dr. hasan sadikin general hospital bandung in 2013. data about characteristics of patients and pattern of the use of prophylactic antibiotics were obtained from patients’ medical record. results: medical records from 76 patients who underwent orif were analyzed. sixty eight patients (68.4%) were given 1 gram cefazolin intravenously as preoperative antibiotic prophylaxis. timing for administration of antibiotics was 30–60 minute preoperatively in 34 (44.2%) patients. all patients were given postoperative prophylaxis for 4.09 ± 1.36 days in average. the antibiotic most commonly used was cefazolin in 51 (63%) patients. all patients were prescribed an oral antibiotic at discharge. cefadroxil was the most common antibiotic prescribed for patients at discharge. conclusions: cefazolin is the most common preoperative prophylactic antibiotic given to patients. all patients are given postoperative prophylaxis and prescribed an antibiotic at discharge. keywords: antibiotic prophylaxis, closed fractures, internal fixation correspondence: deviana suciani edwiza, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west java, indonesia, email: deviedwiza@yahoo.com introduction surgical site infection (ssi) is a serious complication after surgery. the ssi is the most common cause of nosocomial infection and defined as an infection in body cavity, bones, joints, meninges, and other tissues involved in a surgery within 30 days after surgery or within 1 year if the surgery involves an implant. the ssi causes disadvantages to the patient by prolonging postoperative hospital stay, increasing morbidity and mortality, giving additional hospital cost, and reducing productivity and quality of life.1 internal fixation for closed fractures is considered as a high risk orthopedic surgery because it involves implantation of prosthetic materials that can act as a source of infection.2 hence, centers for disease control and prevention (cdc) recommends the use of antibiotic prophylaxis to reduce risk of infection. antibiotic prophylaxis is the use of antibiotics with the goal of reducing intraoperative microbial contamination to prevent harm to patient’s body.1 selection of antibiotics used for surgery prophylaxis is based on the local resistance pattern of antibiotic and pathogens that possibly causes infection in respective operative site.3 dose, timing, and duration of prophylactic administration should be considered, so that the antibiotic can be cost-effective to reduce the risk of infection.1,3 in indonesia, due to the lack of guideline and information about use of surgery prophylaxis, data collection to obtain information about patterns of prophylactic amj. 2017;4(3):413–9 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1191 althea medical journal. 2017;4(3) 414 amj september 2017 antibiotic use is necessary. therefore, this study aimed to study the pattern of prophylaxis used in internal fixation of closed fractures as this surgery considered as a high-risk orthopedic procedures. methods this retrospective-descriptive study was conducted at department of orthopaedics and traumatology, dr. hasan sadikin general hospital (rumah sakit hasan sadikin, rshs) bandung from august to october 2014. the data were collected from patients’ medical records. this study was approved by the health research ethics committee dr. hasan sadikin general hospital. the population of this study was closed fracture patients who underwent open reduction and internal fixation (orif) conducted by department of orthopaedics and traumatology, rshs in 2013. using total sampling method, all patients with closed fractures and underwent orif became the samples of this study. patients with open fractures, infection before surgery, antibiotics administration before surgery, and patients with incomplete or missing medical records were excluded from this study. from each medical record, information about age, sex, location of surgery, duration of surgery, preoperative and postoperative prophylactic antibiotics, length of postoperative hospital stay, and clinical examination on the second postoperative day and time of discharge were collected. the detailed information about antibiotics used including name of drug, regimen dose, time of administration, and duration of administration were also documented. fracture location is the location of bone where the surgery performed. it is anatomically differentiated into the humerus, radius, ulna, and others. the duration of the surgery is a length of time of surgery seen from surgery report. types of antibiotics consist of the name of the antibiotics used both preoperative, postoperative, and at home. regimen dose is a dose of antibiotic administered to the patients and expressed in grams. the route of administration was also documented. time of administration was divided into >60 minutes prior to incision, 30–60 minutes prior to incision, <30 minutes before incision, and after incision. duration of administration was categorized into ≤24 hours,> 24 hours–48 hours,> 48 hours–72 hours, and> 72 hours after the first dose. table 1 characteristics of subject variable (n=76) sex male 68.4% female 31.6% age (mean±sd) 33.75±16.9 fracture location single femur 27.6% clavicle 9.2% radius 7.9% others 18.4% multiple radius and ulna 15.8% fibula and tibia 3.9% others 15.8% surgery duration (minutes) (mean±sd) 162.30±77.039 length of postoperative hospital stay (days) (mean±sd) 3.91±1.277 althea medical journal. 2017;4(3) 415deviana suciani edwiza, ike rostikawati husen, widya arsa: prophylactic antibiotic pattern in open reduction internal fixation for closed fractures at dr. hasan sadikin general hospital bandung in 2013 length of postoperative hospital stay of patients is the duration of hospitalization after surgery until the patients are discharged. the results of clinical examination were all the findings on clinical examination such as fever, hyperemia, swelling, pain, tenderness, and pus obtained from the medical records of patients on the second postoperative day and at the time of discharge. data in the forms of frequency, percentage, mean, and standard deviation were presented in tables. the data were analyzed using microsoft excel 2007 results in 2013, 132 open reduction and internal fixation (orif) procedures were conducted by department of orthopaedics and traumatology, rshs for closed fracture patients. during this study, 76 medical records that met the inclusion criteria became sample of the study and were analyzed. patient characteristics were shown in table 1. the patients included 52 males and 24 females with an average age of 33.75 years old. the most frequent location of the fracture was the femur. all patients underwent surgery in the average duration of 162.70 minutes and underwent postoperative hospital stay in the average duration of 3.91 days. preoperative prophylactic antibiotic usage pattern was shown in table 2, postoperative antibiotic prophylaxis in table 3, and antibiotics at time of discharge in table 4. the table 2 preoperative prophylactic antibiotics variable result (n=76) preoperative antibiotics single cefazolin 68.4% ceftazidime 18.4% others 10.5% combination cefazolin and fosfomycin 1.3% cefazolin and gentamicin 1.3% regimen dose (n=78)* cefazolin 1 gram iv 61.5% 2 gram iv 6.4% 500 mg iv 1.3% ceftazidime 1 gram iv 2.6% 2 gram iv 14.1% 500 mg iv 1.3% others 12.8% time of administration (n=77)* >60 minutes before incission 27.3% 30–60 minutes before incission 44.2% <30 minutes before incission 24.7% after incission 3.9% note: *total exceeded number of samples because some patients received more than 1 kind of antibiotic. althea medical journal. 2017;4(3) 416 amj september 2017 most common antibiotics used as preoperative and postoperative prophylaxis were cefazolin, while the most common antibiotics prescribed at time of discharge were cefadroxil (51.3%) and cefditoren (36.8%). discussion the principle of use of antibiotic prophylaxis is to prevent the surgical site infection (ssi). the selection of types of antibiotics should consider the possible bacteria that could cause infections in the operative site, patterns of bacteria and its sensitivity to antibiotics at hospital.3,4 in orthopedic surgery, most infections are caused by the normal flora of the skin, most often staphylococcus aureus.2,5 staphylococcus aureus is one of bacteria that is often found in body fluid culture including joint fluid and pus in 2012 at rshs.6 in patients who underwent orif at rshs, cefazolin was most commonly used as the preoperative and postoperative prophylactic antibiotic because it was effective against both gram-positive and gram-negative microorganisms. in addition, based on the pattern of bacterial sensitivity to antibiotics at rshs, cefazolin was 100% sensitive to staphylococcus aureus.6 another frequently used antibiotic was ceftazidime (18.4%) which is the third generation cephalosporin. based on a study in india, ceftriaxone which is a third generation cephalosporin, is the most common choice as a preoperative prophylactic antibiotic.7 table 3 postoperative prophylactic antibiotics during hospital stay variable result (n=76) postoperative antibiotics single cefazolin 63.0% ceftazidime 7.4% others 14.8% combination cefazolin and gentamicin 11.1% cefazolin and ceftazidime 2.5% others 1.2% regimen dose (n=81)* cefazolin 2x1 gram iv 66.7% 2x500 mg iv 1.1% ceftazidime 2x1 gram iv 7.5% 2x300 mg iv 1.1% gentamicin 2x80 mg iv 9.7% others 14.1% duration of administration (days) (mean±sd) 4.09±1.368 duration of administration ≤24 hours after preoperative dose 1.3% >24–48 -hours after preoperative dose 6.6% >48–72 hours after preoperative dose 22.4% >72 hours after preoperative dose 69.7% note: *total exceeded number of samples because some patients received more than 1 kind of antibiotic. althea medical journal. 2017;4(3) 417 table 4 postoperative clinical examination result clinical examination day 2 at discharge result (%) result (%) pain 13.1% 11.8% tenderness 7.9% 15.8% swelling 1.3% 0 fever, pain 1.3% 0 pain, tenderness 43.4% 34.2% pain, swelling 1.3% 0 tenderness, swelling 2.6% 1.3% hyperemia, tenderness, swelling 1.3% 0 pain, tenderness, swelling 22.4% 10.5% no finding 5.2% 26.3% however, a survey in canada among orthopedic surgeons proved that cefazolin is used as a first-line prophylaxis.8 the use of cefazolin is still preferred compared to ceftazidime, because cefazolin has better activity against bacteria which often causes postoperative infection, has longer half-life, and is cheaper.9 moreover, cefazolin is bactericidal, safe, and rarely causes fatal side effects compared to aminoglycosides.9 some patients got antibiotics in combination. the purpose of giving antibiotics as a combination was to strengthen the antimicrobial effect. the combination of gentamicin and beta-lactam group can cause a synergistic effect that can strengthen the bactericidal effect.9 however, the use of antibiotics in combination can increase the risk of toxicity and may lead to eradication of the normal flora. thus, a single antibiotic is more commonly used. all patients were given preoperative prophylactic antibiotics intravenously. thus, the medications could reach high concentrations in the tissues within short period.1 this finding was similar to a study in india that showed prophylactic intravenous antibiotics are most commonly used, in as much as 96.4% of the patients.7 patients are mostly often given 1 gram of preoperative antibiotics for cefazolin. this finding was recorded in 66.7% of the patients. this dose, when administered intravenously, is adequate to achieve the minimal inhibitory concentration of the pathogens that may cause infection in a short period.8 exception was done for pediatric patients and patients who were obese. dose adjustments according to patient body weight were required so that the optimal concentration could be achieved in those patients.10 in this study, the antibiotics were most often given in a span of 30–60 minutes prior to surgery in 44.2% of patients. this result was in contrast to a study by mistry, et al.7 in india. mistry et al.7 reported that preoperative prophylaxis is given 12 hours before surgery and during induction anesthesia. administration of antibiotic that is too early or too late will reduce the effectiveness of antibiotics and may increase the risk of infection. hence, the time of administration should be considered in such a way so that the concentration of antibiotics in serum and tissues at incision reaches the minimum inhibitory concentration of bacteria and can be maintained until the end of surgery.3 the most common dose of postoperative prophylactic antibiotic regimen given to patients was 2x1 gram of cefazolin in 62 patients (66.7%). cefazolin was given in the frequency of 2 times a day because it has a long half-life that is enough to be maintained in a minimum inhibitory concentration within 12 hours.8 in addition, cefazolin, as time-dependent antibiotic, should be kept at a constant concentration in order to work optimally. thus, giving 2 doses in a day will be more effective than a single dose.9 postoperative prophylactic antibiotics were most commonly given more than 72 hours after the administration of preoperative antibiotic dose. this was slightly different from the results of study in french that stated postoperative antibiotics are most commonly administered in 24–48 hours after deviana suciani edwiza, ike rostikawati husen, widya arsa: prophylactic antibiotic pattern in open reduction internal fixation for closed fractures at dr. hasan sadikin general hospital bandung in 2013 althea medical journal. 2017;4(3) 418 amj september 2017 preoperative dose. meanwhile, a study in canada showed that most doctors prescribe postoperative antibiotics up to 24 hours after surgery.8,11 average duration of postoperative antibiotics administration is 4.09±1.36 days. this result was slightly different from the study conducted by mistry et al.7 in india which has an administration average duration of 5.05 ± 1.14 days. the most frequent antibiotic given at the time of discharge was oral cefadroxil in a total of 39 (51.3%) patients. cefadroxil can be absorbed well after oral administration.9 thus, it is reasonable to give cefadroxil as an oral prophylaxis. most patients were given antibiotic for 5 days. this was consistent to the results of study in india by mistry et al.7 but the type of antibiotic that is most commonly given is cefixime (55.4%). in this study, patients were hospitalized for 1 until 8 days. the average length of postoperative hospital stay for patients after undergoing surgery was 3.91 days. duration of postoperative hospital stay might be longer if the patients have ssi.1,12 on clinical examination findings in the second postoperative day and at discharge, some patients were found suffering from signs of inflammation such as fever, pain, swelling, tenderness, and redness at surgical wound. there was no patient with pus on physical examination. local inflammation is a common normal tissue healing response to trauma due to fracture and to the additional trauma as a result of a surgery.13 however, if the signs are persistent, the presence of the ssi can be suspected. ssi can be defined as the presence of at least one sign of inflammation accompanied by pus in the surgical wound.14 based on the results of the clinical examination, this study supposed that there was no patient with ssi during hospitalization. however, ssi cannot be diagnosed solely based on clinical findings alone. it requires a combination of clinical examination and laboratory tests to diagnose infections such as c-reactive protein (crp), microbiological tissue culture, and others.2,15 it is possible to get an infection in the next few months although there is no sign of infection during hospitalization. postoperative infection can be obtained exogenously from bacterial contamination at operative site during surgery or hematogenously from distant focus of infection.2 contaminating bacteria during surgery can survive in the host tissue and be attached to the implant material for a long time. this happens because the implant is free from blood circulation that carries antibacterial components such as macrophages and neutrophils and is free from antibiotic distribution. bacteria that have formed inoculum on the implant are able to form biofilms that constantly grow due to their resistance to antibiotic.5 thus, ssi after implantation of implants can occur slowly up to a year.1,2 this study describes the pattern of use of prophylactic antibiotics in open reduction and internal fixation of closed fracture patients. most of the patients are given 1 gram of cefazolin as preoperative prophylactic antibiotics. the most frequent time of administration is 30–60 minutes before incision. all patients are given antibiotics postoperatively with an average duration of 4.09 days. antibiotic for postoperative administration is cefazolin. all patients are given antibiotics at the time of discharge. cefadroxil is the most common antibiotic given at the time of discharge. limited time for research led to difficulty to follow up the patient to monitor healing progression and the risk of infection. further prospective studies should be performed to determine the effectiveness of the use of prophylactic antibiotics. thus, a guideline about the use of antibiotic prophylaxis in accordance with the pattern of bacteria and susceptibility to antibiotics at rshs can be made. this study was conducted only with the data from medical records, so the completeness, accuracy, and systematic recording system can support better study results. references 1. mangram aj, horan tc, pearson ml. guideline for prevention of surgical site infection: centers for disease prevention and control; 1999. 2. trampuz a, widmer af. infections associated with orthopedic implants. curr opin infect dis. 2006;19(4):349–56 3. bratzler dw, dellinger ep, olsen km, perl tm, auwaerter pg, bolon mk, et al. clinical practice guidelines for antimicrobial prophylaxis in surgery. am j health syst pharm. 2013;70(2):195–283. 4. purghel f, badea r, ciuvica r, anastasiu a. the use of antibiotics in traumatology and orthopaedic surgery. maedica a journal of clinical medicine. 2006;1(3):58–65. 5. zimmerli w, moser c. pathogenesis and treatment concepts of orthopaedic biofilm infections. fems immunol med microbiol. 2012;65(2):158–68. althea medical journal. 2017;4(3) 419 6. parwati ida, turbawaty dewi kartika, sugianli adhi kristianto, editors. peta bakteri dan kepekaannya terhadap berbagai antibiotika di rumah sakit umum pusat dr. hasan sadikin bandung semester 1 tahun 2012. bandung: departement of clinical pathology dr. hasan sadikin general hospital; 2012. 7. mistry v, pandya a, chaudhari j, sondarva d, pillai a, hotchandani s. use of antimicrobial prophylaxis in clean elective orthopedic surgical procedures and identifying common infective organisms. int j med sci public health. 2013;2(4):994– 1000. 8. lundine km, nelson s, buckley r, putnis s, duffy pj. adherence to perioperative antibiotic prophylaxis among orthopedic trauma patients. can j surg. 2010;53(6):367–72. 9. petri wa. penicillins, cephalosporins, and other β-lactam antibiotics. in: brunton ll, lazo js, parker kl, editors. goodman and gilman’s the pharmalogical basis of therapeutics. 11st ed. usa: mc graw hill; 2006. p. 1127–52. 10. prokuski l. prophylactic antibiotics in orthopaedic surgery. j am acad orthop surg. 2008;16:283–93. 11. merrer j, girou e, lortat-jacob a, montravers p, lucet jc. surgical site infection after surgery to repair femoral neck fracture: a french multicenter retrospective study. infect control hosp epidemiol. 2007;28(10):1169–74. 12. jodra vm, soler lsdlt, pérez cda, requejo cms, farrás np. excess length of stay attributable to surgical site infection following hip replacement: a nested case-control study. infect control hosp epidemiol. 2006;27(12):1299–303. 13. claes l, recknagel s, ignatius a. fracture healing under healthy and inflammatory conditions. nat rev rheumatol. 2012;8(3):133–43. 14. mathur p, trikha v, farooque k, sharma v, jain n, bhardwaj n, et al. implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries. indian j med res. 2013;137(1):111–6. 15. bauer tw, parvizi j, kobayashi n, krebs v. diagnosis of periprosthetic infection. j bone joint surg am. 2006;88(4):869–82. deviana suciani edwiza, ike rostikawati husen, widya arsa: prophylactic antibiotic pattern in open reduction internal fixation for closed fractures at dr. hasan sadikin general hospital bandung in 2013 vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 35 exclusive and non-exclusive breastfeeding among stunted and normal 6–9 month-old-children in jatinangor subdistrict, indonesia viramitha kusnandi rusmil,1 tri oktaviani prahastuti,2 dimas erlangga luftimas,3 tisnasari hafsah1 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia 2 faculty of medicine universitas padjadjaran, indonesia, 3departement of public health faculty of medicine universitas padjadjaran, indonesia correspondence: viramitha kusnandi rusmil, departmen of child health faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, jalan pasteur 38, bandung, jawa barat, indonesia, email: virmith@yahoo.com introduction stunting is a disruption of growth and development in children caused by malnutrition, recurrent infections, and insufficient psychosocial stimulation.1 children with stunting are identified with short stature who have a height/body length that is not in accordance with their age and sex. a child is designated as stunting when the length-for-age z score (laz) is less than minus-two standard deviation (sd) according to the world health organization (who) child growth standards.1 based on data released by the united nation children’s fund (unicef), the number of children with stunting in the world has decreased every year; in 2010 as many as 169.8 million children were stunted, then this number is decreased to 154.8 million children in 2016 with a prevalence of 22.9%.2 however, in indonesia, there has been an increase in the number of stunted children in recent years. data from national health basic research (riset kesehatan dasar, riskesdas) in 2013 reported that the prevalence of stunting reached 37.2% nationally, and the number is increased compared to 2010 (35.6%) and in 2007 (36.8%).3 stunting problems in indonesia varies in prevalence in each province; in west java province the prevalence of stunting is 35.3%.3 in accordance with who provisions, stunting has become a public health problem in indonesia and west java, especialy because the prevalence exceeds over 20%.3 stunting is influenced by various factors. the disturbing factors of growth and development amj.2019;6(1):35–41 abstract background: stunting has become a public health problem in indonesia, with the prevalence of stunting is 37.2% nationally and 25.6% in west java. one of the causes of stunting is malnutrition that may occur because of not giving exclusive breastfeeding on the first 1000 days of life (fdl). the purpose of this study was to determine whether there was difference between exclusive and non-exclusive breastfeeding among stunted and normal 6–9 month-old-children. methods: this study was conducted using a cross-sectional analytic study during august-october 2018 with consecutive sampling method. this study involved 110 pairs of mothers and children aged 6-9 months who resided in villages which were within the work area of jatinangor public health center. nutritional status was determined based on length-for-age z score according to who. the type of breastfeeding was known based on the questionnaire. data was analyzed by chi square test. result: there were 60 of 110 children (54.5%) who did not receive exclusive breastfeeding. the incidence of stunting in children was 12.7% (14 of 110), of whom 10 children had no exclusive breastfeeding (p>0.05). conclusions: although the incidence of stunting is higher in non-exclusive breastfeeding group, there is no difference in the proportion of stunting in children aged 6–9 months between those who are exclusively breastfed and those who are not, however, exclusive breastfeeding is encouraged. keywords: exclusive breastfeeding, nutritional status, stunting althea medical journal. 2019;6(1) 36 amj march 2019 begin to appear when the child is still in the womb and also after birth. stunting has a lifelong impact.4 in the short term, stunting is associated with infection-related morbidity and mortality.5,6 in the intermediate term stunting can affect children’s development, including cognitive abilities, behavior, and children’s school participation.1,5 in the long run, stunting affects economic achievement and the health later in adult life.4,6 considering the severity of the stunting effect that might occur, it creates an urgency to prevent and treat stunting immediately. this can be done by early detection and ensuring the fulfillment of the needed nutrition. the term first 1000 days of life has been used to define a period of time that begins in the womb until the age of two years.7 during this period there isa very rapid growth and development that does not occur in other age groups, thus, it is considered as a golden period.7 therefore, the adequacy of nutrition during this period greatly determines the growth and development of children in the future. efforts to fulfill nutrition have been initiated by who and unicef since 2009 by issuing recommendations adapted from the global strategy for infant and young child feeding which consists of two main points, namely (1) exclusive breastfeeding until six months of age and (2) providing safe and nutritious complementary food starting at the age of six months while continuing breastfeeding remains until the age of two years or more.8 in fact, exclusive breastfeeding and complementary feeding are still not in accordance with who recommendations, which are estimated to be only 34.8% of babies in the world receive exclusive breastfeeding, while the rest receive food or other fluids at an early age.8 in indonesia the prevalence of exclusive breastfeeding is 54.3% and in west java 33.7%.9 the number of exclusive breastfeeding in west java province is still far below the national exclusive breastfeeding rate and is in the bottom three. the provision of breast milk that is not optimal, one of which the absence of exclusive breastfeeding will affect the adequacy of nutrition, that may cause stunting.1 intervention on stunting has good results if it is carried out during the first 1000 days of life period. this study aimed to determine the differences in the proportion of stunting occurrences in children aged 6–9 months within the work area of public health center (pusat kesehatan masyarakat, puskesmas) jatinangor which is given exclusive and nonexclusive breastfeeding. this study was conducted at a younger age group, so that the information produced can be useful for early detection of stunting events and a preliminary study for prevention and intervention of stunting events in the puskesmas jatinangor work area. methods this study used a cross-sectional analytic study design aimed at a pair of mothers and children aged 6–9 months. the minimum sample size is known by using the cross-sectional study sample formula for the qualitative variable, which is 90 people. the data taken in this study is primary data. data collection was carried out in seven villages included in the work area of puskesmas in jatinangor during august– october 2018 with consecutive sampling method. the inclusion criteria for this study were pairs of mothers and children aged 6–9 months who resided in a village around the work area of puskesmas jatinangor. exclusion criteria were children who had received complementary feeding before the age of 6 months, children with serious illness, and children with a history of premature birth. data was collected by the researcher team, assisted by intergrated service post (pos pelayanan terpadu, posyandu) officers who had been trained before the data collection. after the mothers filled in the informed consent sheets, they were asked to filled in the questionnaires, containing the questions about the characteristics of the mother and the children, and the type of breastfeeding. the body length of children was then measured using infant meter (seca, type 210). nutritional status was determined using data on body length and age of study subjects to calculate the length-for-age z score (laz). interpretation of nutritional status was performed using child growth standards, based on who criteria. furthermore, children were grouped into normal groups if laz ≥ -2 sd and stunted if laz <-2 sd. the type of breastfeeding was determined by summing up the answers of several questions on the questionnaire regarding the history of children when they were 0–6 months old. from these data, children were then grouped into exclusive and non-exclusive breastfeeding groups. bivariate analysis was performed by ibm statistic product and service solution (spss), software version 23 and the significance of the difference was determined using chi-square test. the difference between variables was althea medical journal. 2019;6(1) 37 table 1 characteristics and nutritional status of the children from jatinangor district stunted normal total (n=14; 12.7%) (n=96;87.3%) (n=110; 100%) age 6 months 3 40 43 (39.1) 7 months 7 32 39 (35.5) 8 months 4 24 28 (25.4) sex male 10 51 61 (55.5) female 4 45 49 (44.5) birth order 1 3 38 41 (37.3) 2 7 39 46 (41.8) 3 3 14 17 (15.4) ≥ 4 1 5 6 (5.5) birth method normal (pervaginam) 10 79 89 (80.9) sectio caesarea 3 16 19 (17.3) vakum/forceps 1 1 2 (1.8) birth weight < 2.5 kg 2 1 3 (2.7) 2.5 3.8 kg 11 85 96 (87.3) > 3.8 kg 1 10 11 (10.0) birth gestational age 37–42 weeks 14 90 104 (94.5) >42 weeks 6 6 (5.5) mother's disease throughout pregnancy none 11 81 92 (83.6) hiperemesis gravidarum 1 7 8 (7.3) hypertension 2 4 6 (5.5) diabetes others 4 4 (3.6) anc ever 14 95 109 (99.9) never 1 1 (0.9) birth attendance paraji (traditional birth attendant) midwife 7 67 74 (67.3) medical doctor 2 4 6 (5.4) obstetrician 5 25 30 (27.3) child's basic immunization complete (except measles) 14 88 102 (92.7) incomplete 8 8 (7.3) viramitha kusnandi rusmil, et al: exclusive and non-exclusive breastfeeding among stunted and normal 6–9 month-old-children in jatinangor subdistrict, indonesia althea medical journal. 2019;6(1) 38 amj march 2019 considered significant if the value of p <0.05. the ethical clearance has been obtained from the health research ethics committe of the faculty of medicine, universitas padjadjaran (424/un6.kep/ec/2018). data collection in jatinangor subdistrict has been also obtained by permission from puskesmas jatinangor and sumedang district health office. results this study was succeeded in collecting 170 questionnaire data from mothers, however, only 110 data were met the inclusion criteria. this 110 mothers had children who were categorized in normal and stunted as 87.3% and 12.7%, respectively (table 1). table 1 showed that most children in this study were in the age group of 6 months (39.1%) with boys (55.5%) was more prevalent than girls. the children were mostly the second child in their family (41.8%), and most of the mothers gave birth normally (80.9%) with a normal body weight between 2.5–3.8 kilogram (87.3%). when giving birth, most of the mothers were assisted by midwives (67.3%) with the majority of subjects giving birth at table 2 characteristics of the parents (n=110) of the children recruited from jatinangor district total n (%) father’s occupation unemployed 1 (0.9) laborer 30 (27.3) entrepreneur/merchant 38 (34.6) honorary teacher 4 (3.6) private employee 27 (24.5) civil workers/soldier/police/bumn*/bumd** 10 (9.1) mother's educational level never goes to school 1 (0.9) elementary school 13 (11.8) junior high school 27 (24.6) senior high school 56 (50.9) diploma graduate 2 (1.8) bachelor graduate 8 (7.3) masters graduate 3 (2.7) mother's occupation unemployed 77 (70) laborer 6 (5.5) entrepreneur/merchant 7 (6.4) honorary teacher 12 (10.9) private employee 4 (3.6) civil workers/soldier/police/bumn*/bumd** 4 (3.6) household income < district’s minimum wage 70 (63.6) ≥ district’s minimum wage 40 (36.4) note: *bumn: badan usaha milik negara, **bumd: badan usaha milik daerah althea medical journal. 2019;6(1) 39 a sufficient gestational age between 37–42 weeks (94.5%). most of the mothers did not have any disease during pregnancy (83.6%) and antenatal care (anc) were mostly done by midwives (69.1%). almost all children had undergone basic immunization (92.7%), except for measles that will be given at the age of 9 months (table 1). table 2 showed the characteristics of the parents of the children recruited. father’s job was mostly entrepreneur/merchant (34.6%), whereas most of the mothers did not work (70%) although they had middle education background (50.9%). more than half (63.6%) of the household had monthly household income below the district minimum wage. the number of exclusive breastfeeding and non-exclusive breastfeeding among the children was presented and the nutritional status based on body length over age was compared, resulting in a non significant different between both groups (p=0.248) discussion our study among children in jatinangor, bandung has shown that 12.7% were stunted. this number of stunting events is below 20%, therefore, according to who it is not described as a public health problem. the incidence of stunting in this study is also below the national stunting rate (37.2%) and the province of west java (25.6%), however, this stunting among children requires further good management in nutrition plan and education. furthermore, there is no difference in the proportion of stunting events between children who get exclusive breastfeeding and nonexclusive breastfeeding. study in yogyakarta10 has resulted otherwise, showing a significant relationship between exclusive breastfeeding and the incidence of stunting and children who did not get exclusive breastfeeding had 1.74 times higher chance to be stunting.10 similar result was obtained from a study in surakarta in 2018 in children aged 24–59 months, showing a significant correlation between the incidence of stunting and non-exclusive breastfeeding and exclusive breastfeeding had a protective factor against stunting.11 this difference might occur because the nutritional status of subjects aged 6–23 months and 24–59 months would be more influenced by complementary feeding given. the nutrition of children after the age of 6 months will be fulfilled by giving complementary food. when the complementary food is given, stunting can be prevented. in addition, the influence of factors such as the quality and quantity of breast milk may give different result in stunting. in this study, stunting is more frequent in male. this result is supported by study in malawi, showing that women has a higher average laz compared to men, therefore, boys are more likely to experience stunting.12 according to who stunting is caused by three factors, namely malnutrition, recurrent infections, and insufficient psychosocial stimulation. stunting is also influenced by several factors that can increase the risk of stunting. these factors affect the growth of children from the womb until after birth.4 with the aim of fulfilling the nutritional needs of children for the first 6 months, who recommends exclusive breastfeeding which means breast milk is given for 6 months without other foods or drinks except for drugs and vitamins. when compared with the data on exclusive breastfeeding coverage in sumedang district in 2016 (75.6%), exclusive breastfeeding in this study is still low.13 of the 14 stunting subjects in the study, 10 were included in the non-exclusive breastfeeding group. it can be concluded that 71.4% of stunting patients in this study were given non-exclusive breastfeeding breast milk. if table 3 relation between nutritional status based on body length over age and breastfeedig among children in jatinangor district nutritional status based on body length/age p-valuestunted normal n (%) n (%) breastfeeding exclusive 4 (8.0) 46 (92.0) 0.284 non-exclusive 10 (16.7) 50 (83.3) viramitha kusnandi rusmil, et al: exclusive and non-exclusive breastfeeding among stunted and normal 6–9 month-old-children in jatinangor subdistrict, indonesia althea medical journal. 2019;6(1) 40 amj march 2019 the stunting category is differentiated into stunted and severely stunted, more children with severely stunted nutritional status are given exclusive non-breastfeeding compared to exclusive breastfeeding. apart from being malnourished, stunting can also occur due to recurrent infections. infection will affect nutritional status by reducing appetite, disturbing absorption of nutrients in the digestive tract, increasing catabolism, and diverting the use of nutrients to support the work of the immune system.1 one factor that can increase the risk of infection is poor environmental sanitation. in addition to environmental sanitation, immunization is one of the factors associated with protection against several infectious diseases. in this study, basic immunization is carried out by most children (92.7%) in an effort to prevent infection. the mother formal education and family’s socioeconomic level are also an influential factors on child nutritional status and the risk of infection in children.14 those factors determine the ability of the family to provide nutritional needs and to maintain children’s health. in this study more stunting sufferers came from families with monthly income below the district’s minimum wage. this is in line with research in ecuador15 (2016) stating that the risk of stunting is decreased in families with high socioeconomic levels. the risk of infection also increases when the mother gives birth by a traditional birth attendant (tba), known as paraji in indonesia. there are no children in this study who used paraji assistance for child birth, but delivered labors are assisted by midwives, general practitioners,or obstetrician. even though good immunization and sanitation have been carried out to reduce the risk ofinfection, stunting still occur in this study giving a thought that the incidence of stunting in this study apt to be caused by malnutrition. apart from malnutrition and infection, stunting may be influenced by the condition of the baby at birth. babies born at term and small compared to their age or referred to as small for gestational age is risk factor the number one for the incidence of stunting,16 however, this fact is different from the results in our study, where most stunting sufferers born with a normal body weight and all have been born at normal gestational age. in the prenatal period, genetic factors, health conditions and the adequacy of maternal nutrition determine the growth and development of the child they conceive.17 this is supported the fact that poor diet in pregnant women is associated with poor nutritional status in children, therefore, maternal health and nutrition need to be considered before, during and after pregnancy.18 presence of infections in the pregnant mother can also provide obstacles to the growth of children,19 although in this study most mothers (83.6 %) did not state of the existence of illness during pregnancy. limitations in this study includes that the factors affecting the quality and quantity of breast milk given have not been explored. the relationship or opportunity between various factors that influenced stunting were not conducted, and a case-control study design may provide a better picture of causation compared to a cross-sectional study. however, data from this study can be used as baseline data for further research, specifically related to the intervention of stunting events in the work area of the puskesmas jatinangor. as a conclusion, this study has shown that there is no difference in the proportion of stunting in children aged 6–9 months who are given exclusive breastfeeding or non-exclusive breastfeeding, but the number of stunting events is more common in non-exclusive breastfeeding groups. acknowledgement: this research was funded by the universitas padjadjaran internal grant conflict of interest: the author states that there is no conflict of interest in this study. references 1. de onis m, branca f. childhood stunting: a global perspective. matern child nutr. 2016;12 suppl 1:12–26. 2. unicef. malnutrition unicef data [internet]. 2017[cited 2019 march 7] available from: https://data.unicef.org/ topic/nutrition/malnutrition/ 3. kementerian kesehatan ri. riset kesehatan dasar 2013. jakarta: kementerian kesehatan republik indonesa; 2013. 4. 4. dewey kg, begum k. long-term consequences of stunting in early life. matern child nutr. 2011;7 suppl 3:5–18. 5. who. global nutrition targets 2025: stunting policy brief. geneva: department of nutrition for health and development who; 2014. 6. prendergast aj, humphrey jh. the stunting syndrome in developing countries. paediatr int child health. 2014;34(4):250–65. 7. cusick se, georgieff mk. the role of althea medical journal. 2019;6(1) 41 nutrition in brain development: the golden opportunity of the first 1000 days. j pediatr. 2016;175:16–21. 8. who. infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. geneva: who press; 2009. 9. kementerian kesehatan republik indonesia. situasi dan analisis asi eksklusif. jakarta: kementerian kesehatan republik indonesia; 2014. 10. hidayah f. asi eksklusif sebagai faktor risiko kejadian stunting pada anak usia 6-24 bulan di kota yogyakarta [thesis]. universitas gadjah mada; 2013. 11. lestari ed, hasanah f, nugroho na. correlation between non-exclusive breastfeeding and low birth weight to stunting in children. paediatr indones. 2018;58(3):123–7. 12. kuchenbecker j, jordan i, reinbott a, herrmann j, jeremias t, kennedy g, et al. exclusive breastfeeding and its effect on growth of malawian infants: results from a cross-sectional study. pediatr int child health. 2015;35(1):14–23. 13. dinas kesehatan provinsi jawa barat. profil kesehatan provinsi jawa barat. bandung: dinas kesehatan provinsi jawa barat; 2016. 14. rachmi cn, agho ke, li m, baur la. stunting , underweight and overweight in children aged 2.0 – 4.9 years in indonesia: prevalence trends and associated risk factors. plos one. 2016;11(5):e0154756. 15. roche ml, gyorkos tw, blouin b, marquis gs, sarsoza j, kuhnlein h v. infant and young child feeding practices and stunting in two highland provinces in ecuador. matern child nutr. 2017;13(2). 16. danaei g, andrews kg, sudfeld cr, fink g, mccoy dc, peet e, et al. risk factors for childhood stunting in 137 developing countries: a comparative risk assessment analysis at global, regional, and country levels. plos med. 2016;13(11):e1002164. 17. walker sp, wachs td, granthammcgregor s, black mm, nelson ca, huff sl, et al. inequality in early childhood : risk and protective factors for early child development. lancet. 2011;378:1325–38. 18. tessema m, belachew t, ersino g. feeding patterns and stunting during early childhood in rural communities of sidama, south ethiopia. pan afr med j. 2013;14:75. 19. martorell r, zongrone a. intergenerational influences on child growth and undernutrition. pediatr perinat epidemiol. 2012;26 suppl 1:302–14. viramitha kusnandi rusmil, et al: exclusive and non-exclusive breastfeeding among stunted and normal 6–9 month-old-children in jatinangor subdistrict, indonesia vol 4 no 3 full text final.indd althea medical journal. 2017;4(3) 468 amj september 2017 destructive effect of calcium hypochlorite against pseudomonas aeruginosa biofilm ilma arifani,1 gita widya pradini,2 insi farisa desy arya,3 adi imam cahyadi2 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: pseudomonas aeruginosa is the most common bacteria contaminating the hemodialysis water and has high capability to form a biofilm. the presence of biofilm is hazardous because it becomes a constant source of bacterial and toxin release toward the hemodialysis patient’s blood. calcium hypochlorite (ca(ocl)2) is an easily obtained disinfectant. this study was aimed to detect the destructive effect of ca(ocl)2 against p. aeruginosa biofilm and the optimal disinfectant concentration required to achieve significant effect. methods: this experimental study was conducted in six replicates from september to october 2015 in microbiology laboratory of faculty of medicine universitas padjadjaran bandung. a modified tissue culture plate method was performed to grow p. aeruginosa biofilms which were subsequently treated with ca(ocl)2 in various chlorine concentrations, namely 20, 30, 40, and 500 parts per million (ppm). the data was analyzed using welch analysis of variance (anova) and games-howell post-hoc tests and presented in tables. results: data were obtained from 36 flat-bottomed polystyrene wells. there was a statistically significant mean difference between groups [f(4, 11.92)= 91.198, p<0.001)]. all of the tested chlorine concentrations caused significant decreases in biofilm optical densities (p = 0.027 for 20 ppm and p< 0.001 for 30, 40, and 500 ppm). conclusions: ca(ocl)2 with chlorine concentrations of 20, 30, 40, and 500 ppm have significant destructive effect against p. aeruginosa biofilm. the mean differences among treated groups were not significant. the most optimum concentration is 30 ppm. keywords: biofilm, calcium hypochlorite, pseudomonas aeruginosa introduction in the year of 2012, there were 15,980 patients who required hemodialysis in order to replace the kidney’s function in eliminating the circulating toxins.1 during a hemodialysis session, the patient’s blood is in contact with 80-160 liters of dialysate through the dialysis membrane.2 therefore, adequate cleaning and disinfecting of the dialysate are required in order to protect the patients from blood borne virus and pathogenic bacteria.3 despite the vigorous attempt in purification and disinfection, the bacteria have evidently adapted to low nutrient niches such as the hemodialysis system and produce biofilm in order to survive.4 the presence of biofilm is hazardous because it becomes a constant source of bacterial release toward the patient’s blood and may induce chronic inflammatory reaction in hemodialysis patients.5,6 several studies have concluded that pseudomonas aeruginosa is the most common bacteria contaminating the hemodialysis water samples and has high tendency to form biofilm.5,7 in fact, there was a p. aeruginosa bacteremia outbreak in hemodialysis facility in israel8 in 2013. these facts supports that a careful surveillance of p. aeruginosa biofilm in hemodialysis system is required. a recent study in bandung9 revealed that practice of improper disinfecting of hemodialysis unit is still happening in indonesia. improper disinfecting effort not only causes chronic inflammation to the correspondence: ilma arifani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: iarifani@yahoo.com amj. 2017;4(3):468–73 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1205 althea medical journal. 2017;4(3) 469 patients,5,6 but also increases p. aeruginosa resistance against antibiotics or even increases the biofilm production.4,10 therefore, it is clear that a study needs to be performed in order to help determining the adequate disinfecting process to eliminate p. aeruginosa biofilms. calcium hypochlorite (ca(ocl)2) is a common disinfectant which is cheap and easily obtained. it is relatively steady and has greater available chlorine than sodium hypochlorite (naocl). this study was aimed to detect the destructive effect of ca(ocl)2 against p. aeruginosa biofilm and its maximum concentration to achieve significant effect. methods this experimental study with post-test only control group design was carried out from september–october 2015 in microbiology laboratory of faculty of medicine universitas padjadjaran bandung. it had been approved by the health research ethics committee of faculty of medicine universitas padjadjaran bandung. biofilm detection method using tissue culture plate as described by christensen was used in this study with slight modification, namely addition of glucose11 and prolonged incubation period.12 in addition, the content of the well was increased from 200 µl to 250 µl. the sample size was calculated according formula of federer. for five groups (four different chlorine concentrations and negative control), the minimal number of replication required is five. bacterial preparation was conducted by adding a loopful of p. aeruginosa american type culture collection (atcc) 27853 in lyophilized form to tryptone soy broth (oxoid) mixed with 1% glucose (merck) which was incubated for 18 hours. the resulting broth was then stroken to sheep blood agar to maintain the viability of the bacterial isolate.4,11 the biofilm formation using modified tissue culture plate method11,12 was performed by first adding a loopful of isolates from sheep blood agar which were inoculated to the tryptone soy broth with 1% glucose and incubated for 18 hours at 37oc. then, the broth was diluted with fresh tryptone soy broth 1:100 and poured into the polystyrene 96well flat-bottomed tissue culture plate with lid (iwaki). eight wells for positive controls were filled with 250 µl fresh medium only without bacteria, whereas the remaining eight wells for negative controls and thirty-two wells for treatment were filled with 250 µl aliquots of the diluted broth. next, the edges of the tissue culture plate were covered and sealed using a parafilm to avoid evaporation, and then incubated at 37 oc for 48 hours. the contents of the wells were emptied by pipetting without touching the base. each well then washed with 250 µl of phosphate buffer saline for four times to remove the free floating bacteria.11 the disinfecting process was done by treating the wells with ca(ocl)2 (bratachem) in different chlorine concentrations. previous experiment showed that single-species biofilms could be inactivated by 30 parts per million (ppm) of chlorine,13 and very high concentration of chlorine (>500 ppm) could cause corrosiveness to metals.3 thus, the chlorine concentrations of 20, 30, 40, and 500 ppm were chosen. the chlorine concentrations were obtained by freshly diluting the 60% ca(ocl)2 powder with deionized water according to the world health organization (who)14 fact sheet on environmental sanitation number 2.19. in order to create a 2% (20,000 ppm) ca(ocl)2 solution, 3.33 grams of 60% ca(ocl)2 powder were added to 100 ml of deionized water. the resulting supernatant were diluted in 1:1000, 1:660, 1:500, and 1:4 to yield the desired chlorine concentrations. each concentration was tested on eight individual wells, resulting in 32 treated wells. the disinfecting process was performed by filling the designated wells with 250 µl of ca(ocl)2 and left for 30 minutes. the excess disinfectant was removed by gently tilting and tapping the plate, and washed using tap water. the fixation was achieved by adding sodium acetate 2% to each well for 15 minutes and air-dried. the reading of remaining biofilm optical density on the plate was conducted using microplate photometer (thermoscientific). initial staining process was performed by pipetting crystal violet 0.1% to each well and left for 15 minutes. the remaining stain was removed by washing with tap water. once the plate was dried, isopropyl hydrochloric acid was added to each well. the biofilm optical density was read using microplate photometer at 550 nm wavelength.12 the data were recorded and subsequently analyzed using statistical analysis software. the initial data distribution was not normal, so it was normalized using log10 function. as the levene’s test statistic showed nonhomogeneity in variances (p-value = 0.002), welch analysis of variance (anova) was conducted instead of one-way anova in order to detect significant mean difference between ilma arifani, gita widya pradini, insi farisa desy arya, adi imam cahyadi: destructive effect of calcium hypochlorite against pseudomonas aeruginosa biofilm althea medical journal. 2017;4(3) 470 amj september 2017 groups. games-howell test was carried out as the post-hoc test. the p-values of < 0.05 were considered significant. the results of the analysis were presented in tables. results there were one well for negative control, one well for positive control, and 4 treated wells for each chlorine concentration (20, 30, 40, and 500 ppm). the experiment was originally run in eight replicates with 48 wells in total, but the last two sets were omitted due to presence of content evaporation which could possibly interfered with the analysis, resulting in 36 wells (six replicates) in total (figure 1). the non-treated biofilm in negative control wells had very high optical density compared to the treated wells and the positive control wells (table 1). in general, the mean optical density was decreased in response to the increase of chlorine concentration. however, an exception occurred at the wells treated with chlorine 40 ppm which showed higher optical density compared to those of chlorine 30 ppm. figure 1 tissue culture plate after 48 hours of incubation, showing biofilms growth (green) and positive control (yellow). one of the well at the bottom showed complete evaporation table 1 optical density of pseudomonas aeruginosa biofilm positive control chlorine 20 ppm chlorine 30 ppm chlorine 40 ppm chlorine 500 ppm negative control od550nm 0.107 1.121 0.336 0.267 0.302 2.703 0.117 0.359 0.457 0.571 0.366 2.762 0.107 2.233 0.383 0.476 0.488 2.66 0.121 0.284 0.372 0.364 0.288 2.847 0.121 0.454 0.534 0.531 0.223 3.353 0.113 0.410 0.544 0.569 0.785 2.076 mean od550nm 0.114 0.810 0.438 0.463 0.409 2.734 standard deviation 0.006 0.760 0.088 0.123 0.205 0.409 note: *od550nm: p. aeruginosa biofilm optical density read in microplate photometerat 550nm althea medical journal. 2017;4(3) 471 performed prior to analysis. welch anova result showed a statistically significant mean difference between groups [f(4, 11.92) = 91.198, p < 0.001)]. games-howell post-hoc showed significant difference between non-treated group (negative control) and treated groups ((ca(ocl)2 with chlorine concentrations of 20, 30, 40, and 500 ppm). however, the mean differences among treated groups were not significant (table 2). discussion biofilm needs to be removed because its presence in the hemodialysis system is hazardous to the hemodialysis patients.5,6 several disinfectant containing chlorine and monochloramine have been proved to be effective in inactivating bacterial biofilm.3 the ca(ocl)2 is a chlorine-based disinfectant which is very affordable and widely available for purchase. its use includes industrial sterilization, water purification, and bleaching. when it is freshly diluted in water, the following reaction will occur: ca(ocl)2 + 2 h2o --> 2 hocl + ca(oh)2. 15 the resulting undissociated hypochlorous acid (hocl) is the active disinfecting component which has bactericidal properties.3,16 according to study by tote et al.15 both hydrogen peroxide and hypochlorite solution were active on both the biofilm matrix and the viable mass of p. aeruginosa. although their study used naocl instead of ca(ocl)2, the results might be comparable because the active agent of both biocides is hypochlorous acid. a 1% hypochlorite solution can markedly reduce p. aeruginosa biofilm matrix, reaching a 66% reduction at 1 minute and 91% reduction after 15 minutes of treatment.17 the hocl and its dissociated form, hypochlorite ion (ocl-), exert damaging consequences to the p. aeruginosa’s cell by several mechanisms. first, hocl can cause deleterious effect on dna as it readily reacts with highly nucleophilic sites.18 second, hocl severely repressed several genes involved inprimary metabolic processes, (glucose transport, oxidative phosphorylation, and electron transport) resulting in minimal energy production.19 third, hocl induces active transport of several organic sulfur compounds, possibly in order to manage the sulfur starvation issue (as hocl reacts strongly with sulfhydryl groups in many substrates) and to find alternative carbon source needed for energy production.18,19 finally, hocl stress generate deleterious oxidative species such as superoxide anions (o2-) and hydroxyl radicals (`oh) which can damage cellular components.18,19 in regard to the mean optical density in each treatment groups of this study, it is possible that the destruction of biofilm is concentration-dependant. the higher the chlorine concentration used, the lower the optical density would become. however, an exception occurred in the treatment group with 40 ppm chlorine. instead of a lower optical density, it was actually showing higher optical density (mean 0.463, sd0.123) compared to those treated with 30 ppm chlorine (mean 0.438, sd 0.088). this result was possibly caused by the limitation of this study. according to the statistical analysis, there were significant mean difference between table 2 multiple comparison using games-howell post-hoc test comparison mean difference standard error p-value negative control – chlorine 20 ppm 0.653* 0.144 0.027 negative control – chlorine 30 ppm 0.799* 0.045 < 0.001 negative control – chlorine 40 ppm 0.782* 0.060 < 0.001 negative control – chlorine 500 ppm 0.860* 0.084 < 0.001 chlorine 20 ppm – chlorine 30 ppm 0.146 0.145 0.846 chlorine 20 ppm – chlorine 40 ppm 0.129 0.151 0.904 chlorine 20 ppm – chlorine 500 ppm 0.207 0.162 0.710 chlorine 30 ppm – chlorine 40 ppm -0.165 0.064 0.999 chlorine 30 ppm – chlorine 500 ppm 0.061 0.087 0.948 chlorine 40 ppm – chlorine 500 ppm 0.078 0.096 0.920 note: *significant mean difference ilma arifani, gita widya pradini, insi farisa desy arya, adi imam cahyadi: destructive effect of calcium hypochlorite against pseudomonas aeruginosa biofilm althea medical journal. 2017;4(3) 472 amj september 2017 groups [f(4, 11.92) = 91.198, p < 0.001)]. post-hoc result showed that in comparison to the non-treated group (negative control), all of the tested chlorine concentrations caused significant decreases in mean biofilm optical densities (p = 0.027 for 20 ppm and p < 0.001 for 30, 40, and 500 ppm). the chlorine concentration of 20 ppm yielded significant mean difference, but still the p-value was not as significant as those of 30, 40, and 500 ppm. this result is consistent with the findings of behnke et al.18 which stated that single-species biofilms were readily inactivated with 30 ppm of chlorine with contact time of 30 minutes. however, according to a study by borges et al.19 p. aeruginosa were resistant to hypochlorite solution at a concentration of 500 ppm for 10 minutes contact time. this disinfection routine was used monthly for disinfecting the water distribution system in its local dialysis unit. with such a high chlorine concentration, the possible explanation for the result was that 10 minutes of contact time were not enough to cause sufficient damage against p. aeruginosa.19 in addition, the usage of hypochlorite in high concentrations (> 500 ppm) should be avoided as it can cause corrosiveness to metals.3 at present, there is no specific intervention which is intended to specifically manage the presence of p. aeruginosa and its biofilm in hemodialysis system. however, according to agar et al.20 any water used for hemodialysis should meet the international organization for standardization (iso) guidelines 13959:2014 to ensure the patient’s protection. the current standard for maximum allowable bacteria levels and endotoxin levels are at 100 colony forming unit (cfu)/ml and 0.25 endotoxin unit (eu)/ml, respectively. in addition, agar et al.20 also stated that biofilm prevention should be performed by heat-disinfecting the water distribution system in regular basis to limit bacterial proliferation. hard-to-reach areas within the equipment need to be manually cleaned. in some cases, harsh chemicals (e.g., peracetic acid) is required. finally, it is advised to annually replace the inflow hoses to prevent biofilm formation. the limitation of this study includes an inability to measure the exact chlorine concentration in each ca(ocl)2 solution. the assumed chlorine concentration in this study heavily relied on the manual dilution process which may be subjected to human error. in conclusion, ca(ocl)2 with chlorine concentrations of 20, 30, 40, and 500 ppm have significant destructive effect against p. aeruginosa biofilm. the most optimum chlorine concentration for disinfecting p. aeruginosa biofilm is 30 ppm as the lowest concentration with high significance result. further study using chlorine-based disinfectant should use specific method such as iodometric titration in order to determine the actual chlorine concentration in the disinfecting solution. it should include more variables such as by incorporating more chlorine concentrations with various contact time, adding water shear stress, and testing it to other single-species bacterial biofilm and multi-species bacterial biofilms whose combination includes p. aeruginosa and other bacteria which frequently contaminate the hemodialysis system. if possible, the bacteria should be obtained from an actual hemodialysis water sample. references 1. perkumpulan nefrologi indonesia. 5th report of indonesian renal registry. jakarta: perkumpulan nefrologi indonesia; 2012. 2. kwan bch, chow km, ma tkw, cheng pms, leung cb, li pkt, et al. effect of using ultrapure dialysate for hemodialysis on the level of circulating bacterial fragment in renal failure patients. nephron clin pract. 2013;123(1):246–53. 3. centers for disease control and prevention. guideline for disinfection and sterilization in healthcare facilities. atlanta: centers for disease control and prevention; 2008. 4. suman e, varghese b, joseph n, nisha k, kotian ms. the bacterial biofilms in dialysis water systems and the effect of the sub inhibitory concentrations of chlorine on them. j clin diagn res. 2013;7(5):849– 52. 5. montanari lb, sartori fg, cardoso mj, varo sd, pires rh, leite cq, et al. microbiological contamination of a hemodialysis center water distribution system. rev inst med trop sao paulo. 2009;51(1):37–43. 6. oumokhtar b, lalami aeo, mahmoud m, berrada s, arrayhani m, houssaini ts. prevent infection linked to the dialysis water in a hemodialysis center in fez city (morocco). pan afr med j. 2013;16(1):122– 6. 7. arvanitidou m, vayona a, spanakis n, tsakris a. occurrence and antimicrobial resistance of gram-negative bacteria isolated in haemodialysis water and dialysate of renal units: results of a greek multicentre study. j appl microbiol. althea medical journal. 2017;4(3) 473 2003;95(1):180–5. 8. ciobotaro p, fialko a, nadir e, oved m, bardenstein r, gershkoviz p, et al. p205: an outbreak of polyclonal pseudomonas aeruginosa bacteremia in hemodialysis patients. antimicrob resist infect control. 2013;2(suppl 1):205. 9. al-jailawi mh, ameen rs, al-jeboori mr. effect of disinfectants on antibiotics susceptibility of pseudomonas aeruginosa. j appl biotechnol. 2013;1(1):54–63. 10. hassan a, usman j, kaleem f, omair m, khalid a, iqbal m. evaluation of different detection methods of biofilm formation in the clinical isolates. braz j infect dis. 2011;15(4):305–11. 11. world health organization. fact sheet 2.19: calcium hypochlorite. [cited 2015 december 1]. available from: http:// www.who.int/water_sanitation_health/ hygiene/emergencies/fs2_19.pdf. 12. mathur t, singhal s, khan s, upadhyay dj, fatma t, rattan a. detection of biofilm formation among the clinical isolates of staphylococci: an evaluation of three different screening methods. indian j med microbiol. 2006;24(1):25–9. 13. dutta a, saunders wp. comparative evaluation of calcium hypochlorite and sodium hypochlorite on soft-tissue dissolution. j endod. 2012;38(10):1395–8. 14. wang l, bassiri m, najafi r, najafi k, yang j, khosrovi b, et al. stabilized hypochlorous acid: a component of the inorganic armamentarium of innate immunity. j burns wounds. 2007;6(1):65-79. 15. tote´ k, horemans t, berghe dv, maes l, cos p. inhibitory effect of biocides on the viable masses and matrices of staphylococcus aureus and pseudomonas aeruginosa biofilms. appl environ microbiol. 2010;76(10):3135–42. 16. fukuzaki s. mechanisms of actions of sodium hypochlorite in cleaning and disinfection processes. biocontrol sci. 2006;11(4):147–57. 17. small da, chang w, toghrol f, bentley we. toxicogenomic analysis of sodium hypochlorite antimicrobial mechanisms in pseudomonas aeruginosa. appl microbiol biotechnol. 2007;74(1):176–85. 18. behnke s, parker ae, woodall d, camper ak. comparing the chlorine disinfection of detached biofilm clusters with those of sessile biofilms and planktonic cells in single and dual-species cultures. appl environ microbiol. 2011;77(20):7176–84. 19. borges cr, lascowski km, filho nr, pelayo js. microbiological quality of water and dialysate in a haemodialysis unit in ponta grossa-pr, brazil. j appl microbiol. 2007;103(5):1791–7. 20. agar jw, perkins a, heaf jg. home hemodialysis: infrastructure, water, and machines in the home. hemodial int. 2015;19(suppl 1):s93–111. ilma arifani, gita widya pradini, insi farisa desy arya, adi imam cahyadi: destructive effect of calcium hypochlorite against pseudomonas aeruginosa biofilm althea medical journal. 2019;6(1) 52 amj march 2019 generalized seizure due to acute hyperosmolar hyponatremıa followıng coronary angıography: a lesson learned from a case report mehmet coᶊgun, yilmaz gunes, isa sincer, aslı mansiroglu, oğuz kayabaᶊi department of cardiology, abant izzet baysal unıversity, bolu, turkey correspondence: mehmet coᶊgun, department of cardiology, abant izzet baysal unıversity, bolu, turkey, email: coskun44@gmail.com introduction hyponatremia is a common electrolyte abnormality in hospitalized patients. however, following coronary angiography, it is an uncommon finding. the etiology of most cases of hyponatremia can be deduced from the history, physical examination, and basic laboratory tests. theoretically, contrast medium, like mannitol, may pull osmotically intracellular water into the extracellular space, which dilutes all the extracellular fluid electrolytes, thus resulting in hyponatremia. however, such process is extremely rare. here, we describe a patient with acute severe symptomatic hyponatremia, a rarely seen complication of coronary angiography. case illustration a 69-year-old female was admitted for elective coronary angiography due to exertional chest pain. her height, body weight, and body mass index were 166 cm, 67 kg and 24.3 kg/m2 respectively. she had hypertension and a history of coronary stenting for left anterior descending artery (lad) one year ago. she was under treatment with losartan potassium/hydrochlorothiazide (100/12.5 mg/d), clopidogrel (75 mg/d), metoprolol (25 mg/d) and rosuvastatin (10 mg/d). the blood creatinine was 0.71 mg/dl, the blood urea nitrogen (bun) was 21 mg/dl, the sodium was 132 mmol/l, and the potassium was 3.8 mmol/l. coronary angiography was performed from the left radial artery under local anesthesia, and showed subtotal osteal narrowing of second diagonal osteal artery originating from stented mid lad. after balloon kissing to bifurcation, lesion stent was placed and completed without complications. one hundred and twenty millilitre of iohexol contrast media was used. seven hours later, however, the patient had a headache and temporary mental confusion. her speech was slurring. the neurological examination was without focality and brain diffusion mri was normal. her mental situation was normal thereafter. however, fourteen hours following coronary angiography, she was markedly confused and developed a generalized tonic-type seizure which was relieved after amj. 2019;6(1):52–4 abstract hyponatremia is a common electrolyte disorder, but symptomatic hyponatremia following coronary angiography is rare. although patients with hyponatremia are generally asymptomatic, neurological manifestations may result in lethal complications. here we presented a 69-year-old female, admitted for elective coronary angiography due to exertional chest pain. seven hours later after coronary angiography, however, the patient had a headache, temporary mental confusion and her speech was slurring. a brain magnetic resonance imaging (mri) test, arterial blood gas analysis, and the neurological examination were carried out. the neurological examination showed no focality and brain diffusion mri was normal. arterial blood gas analysis revealed sodium of 110 mmol/l and potassium of2.8 mmol/l. the patient was treated with hypertonic saline (3% nacl) and vasopressin antagonist tolvaptan 15 mg at first and isotonic saline (0,09 nacl) with a gradual normalization of electrolytes. diagnosis of acute hyperosmolar hyponatremia should be considered in patients with developing mental or behavioral abnormalities following coronary angiography. keywords: coronary angiography, hyponatremia, seizure althea medical journal. 2019;6(1) 53 intravenous diazepam. again, the neurological examination was without focality. a repeat diffusion mri (figure 1) was also normal. however, arterial blood gas analysis revealed sodium of 110 mmol/l and potassium of 2.8 mmol/l. with the suspicion of laboratory error, a repeat arterial blood specimen was withdrawn from the femoral artery, but the results were similar. venous biochemistry confirmed that arterial gas analysis, creatinine (0.6 mg/dl) and bun (7.3 mg/dl) were normal. (na:115mmol/l,k:3,0mmol/l,magnesium of 1,34 mmol/l and calcium was7,8 mg/dl). she also had sufficient amount of urination (>2000 ml). therefore we excluded contrast-induced nephropathy. for the differential diagnosis of hypo-osmolar hyponatremia, we measured the serum-free t4, thyroid stimulating hormone and serum cortisollevels, which were normal. the patient was treated with hypertonic saline (3% nacl) at a rate of 2 ml/hr and vasopressin antagonist tolvaptan 15 mg at first and isotonic (0,09 nacl). the patient mental status returned to normal 12 hours later and the serum and urine sodium levels returned to normal 36 hours later. after having her placed to general room from the intensive care unit, she was followed up for 3 days and then discharged. thiazide was stopped and calcium antagonist and angiotensin receptor blocker was prescribed. discussions sodium is an essential electrolyte that maintains the extracellular fluid volume and osmotic equilibrium.1-9 the plasma sodium concentration is maintained in the normal range by water and sodium intake, and the renin-angiotensin system.10,11 patients with hyponatremia are generally asymptomatic. however, it may sometimes be associated with increased mortality and morbidity12-17, especially when it occurs rapidly, as in our case. there may be several mechanisms for hyponatremia. fluid homeostasis impaired with aging and the risk of hyponatremia among elderly people is compounded by chronic diseases and long-term medication use. women are more affected than men as a result of the smaller fluid volume and sex-related hormonal factors. thiazides are known to induce mild hyponatremia. our patient had been taking thiazide for control of blood pressure. her previous sodium levels were ranged between 127-134 mmol/l. it is a routine and advised procedure to increase the amount of oral fluid intake or iv infusion of serum saline for prevention of kidney injury after contrast exposure which may contribute to dilution and decrease in osmolality of intravascular fluid. symptomatic hyponatremia following coronary angiography is rare, especially in a patient without advanced kidney disease. until now, only several cases of contrastinduced hyponatremia have been reported in adult patients. as far as we searched, there are five cases reported a developing of severe symptomatic hyponatremia following coronary angiography or intervention18-20, of which they have used iohexol or urografin. interestingly, mehmet cosgun, et al.: generalızed seızure due to acute hyperosmolar hyponatremıa followıng coronary angıography: a lesson learned from a case report figure brain mri showed no acute infarction althea medical journal. 2019;6(1) 54 amj march 2019 the case we presented had coronary angiography and intervention with the same pharmacologic contrast material content with same density (iohexol 350mg/100ml) one year before without complication,however a different company trademark. previous contrast exposure was not mentioned in other reported cases. because of unfamiliarity with contrast media-related hypo-osmolality and hyponatremia, we have delayed in diagnosis and treatment in our case. first, we suspected anxiety and cerebrovascular complications. an earlier biochemical or arterial blood gas analysis for serum electrolytes would lead us for a prompt diagnosis and treatment. in conclusion, the diagnosis of acute hyperosmolar hyponatremia should be considered in patients developing mental or behavioral abnormalities following coronary angiography. references 1. reddy p, mooradian ad. diagnosis and management of hyponatraemia in hospitalised patients. int j clin pract. 2009;63(10):1494–508. 2. lim gw, lee m, kim hs, hong ym, sohn s. hyponatremia and syndrome of inappropriate antidiuretic hormone secretion in kawasaki disease. korean circ j. 2010;40(10):507–13. 3. heer m, titze j, smith sm, baecker n. nutrition physiology and metabolism in spaceflight and analog studies. 1st ed: springer international publishing; 2015. xiii, p. 69. 4. sterns rh. disorders of plasma sodium-causes, consequences, and correction. n engl j med. 2015;372(1):55–65. 5. titze j. a different view on sodium balance. curr opin nephrol hypertens. 2015;24(1):14–20. 6. begg dp. disturbances of thirst and fluid balance associated with aging. physiol behav. 2017;178:28–34. 7. rundgren m. fluid balance, regulatory mechanisms, and electrolytes. in: svensen ch, prough ds, feldman l, gan tj, editor. fluid therapy for the surgical patient. 1 ed. boca raton, florida:crc press; 2018. p. 15–44. 8. watson f, austin p. physiology of human fluid balance. anaesthesia and intensive care medicine. 2018;19(9):494–501. 9. wiig h, luft fc, titze jm. the interstitium conducts extrarenal storage of sodium and represents a third compartment essential for extracellular volume and blood pressure homeostasis. acta physiol (oxf ). 2018;222(3). 10. reynolds rm, padfield pl, seckl jr. disorders of sodium balance. bmj (clinical research ed). 2006;332(7543):702–5. 11. stanhewicz ae, kenney wl. determinants of water and sodium intake and output. nutr rev. 2015;73(suppl 2):73–82. 12. verbalis jg, goldsmith sr, greenberg a, schrier rw, sterns rh. hyponatremia treatment guidelines 2007: expert panel recommendations. am j med. 2007;120(11 suppl 1):s1–21. 13. liamis g, milionis h, elisaf m. a review of drug-induced hyponatremia. am j kidney dis. 2008;52(1):144–53. 14. funk gc, lindner g, druml w, metnitz b, schwarz c, bauer p, et al. incidence and prognosis of dysnatremias present on icu admission. intensive care med. 2010;36(2):304–11. 15. balling l, schou m, videbaek l, hildebrandt p, wiggers h, gustafsson f. prevalence and prognostic significance of hyponatraemia in outpatients with chronic heart failure. eur j heart fail. 2011;13(9):968–73. 16. kovesdy cp, lott eh, lu jl, malakauskas sm, ma jz, molnar mz, et al. hyponatremia, hypernatremia, and mortality in patients with chronic kidney disease with and without congestive heart failure. circulation. 2012;125(5):677–84. 17. rusinaru d, tribouilloy c, berry c, richards am, whalley ga, earle n, et al. relationship of serum sodium concentration to mortality in a wide spectrum of heart failure patients with preserved and with reduced ejection fraction: an individual patient data metaanalysis(dagger): meta-analysis global group in chronic heart failure (maggic). eur j heart fail. 2012;14(10):1139–46. 18. arieff ai. hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women. n engl j med. 1986;314(24):1529– 35. 19. boulos m, nakhoul f, hir j, markiewicz w. acute symptomatic hyponatremia complicating invasive cardiac procedures: a report of three patients. catheter cardiovasc interv. 2001;53(4):542–5. 20. jung es, kang wc, jang yr, kim s, yang jw, lee k, et al. acute severe symptomatic hyponatremia following coronary angiography. korean circ j. 2011;41(9):552–4. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 16 amj march 2017 analgesic usage in elderly at public health center: a study in west java, indonesias gembong soeyono putro,1 herri s. sastramihardja,2 lazuardhi dwipa3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: various analgesics prescriptions for elderly are not appropriate according to the guideline and can cause the increase of side effects such as gastric problems. puskesmas as a public health center in indonesia has an important role in anticipating this problem. the objectives of this study was to identify the analgesic usage in elderly patients at the public health center. methods: this retrospective descriptive study was conducted for 3 months at tanjungsari public health center, sumedang, west java, indonesia, using total sampling. the data was taken from 417 medical records from 2013. the data taken from medical records were: sex, analgesic drug, diagnosis, and drug for gastric problem. results: from the collected data, the most analgesics prescribed for the elderly patients was paracetamol, followed by piroxicam, mefenamic acid, and ibuprofen. not all of the elderly patients who received nsaids, were given gastric drug. conclusions: the most prescribed analgesic drug given to elderly patients at the public health center is paracetamol. [amj.2017;4(1):16–9] keywords: analgesics, elderly, primary health care, public health center correspondence: gembong soeyono putro, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 91285247252 email: gembongsoeyonoputro@gmail.com introduction indonesia is expected to become a country with aging population in 2050, in which the ratio of older adult (> 60 years) is more than the population aged <15 years. this situation occurs because of the increase of life expectancy.1 doctors often underestimate the analgesic drug administration in older adult patients, whereas the administration of analgesic drugs in older adult patients is different from other age groups. this is due to the increased risk of side effects and decreasing physiological condition of older adult patients.2 analgesic drug administration should be in accordance with the prevailing procedures, which is based on the world health oorganization (who) pain ladder, where the administration of drugs should be started from the bottom of the order to be continued to the next order if the pain is still there or getting worse. analgesic prescription in older adult patient should be accompanied by adjuvant drug, to avoid potential side effects and improving the drug effectiveness.3,4 side effects that usually arise from the administration of analgesic drugs including cardiac and renal dysfunction and toxic effects on the digestive tract and stomach disorders.5,6 the use of nsaid in older adult patients increase the risk of side effects such as gastrointestinal disturbances over as much as 50% and as much as 15% of older adult patients with symptoms of rheumatoid arthritis stop the use of nsaid due to the onset of complaints of stomach ulcers.7 along with the increased likelihood of side effects to occur in older adult patients, it is necessary to administer drugs in a rational way to avoid unwanted side effects. public helath center (pusat kesehatan masyarakat, puskesmas) as the primary health care provider in indonesia has an important role in anticipating this problem, due to ease of access and entry into the indonesian althea medical journal. 2017;4(1) 17 government’s health insurance system the jaminan kesehatan nasional (national health coverage) which requires the patient to go to public health care in advance.8 of all the problems mentioned previously, the objective of this study was to identify the analgesic usage in elderly patients at the public health center. methods the study was conducted from august 2014 to october 2014 at the tanjungsari public health care in sumedang west java. the data used in this study were taken from the medical records of older adult patients (>60 years) who were given analgesics at tanjungsari public health center in 2013. data obtained from the patient’s medical record were: the patient’s age, sex of the patient, patient’s diagnosis, name of the analgesic drug given, and if any provisions of nsaids were also given gastric medication or not. then, the data were processed using computer and presented in tabular form. the data collection used the total sampling method and a total number of 417 patients were obtained which comprised 165 male and 252 female patients. the use of medical records was approved by the health research ethics committee faculty of medicine universitas padjadjaran, sumedang city’s development planning board, and sumedang city health department. results according to collected data, various analgesics were used among elderly. this study discovered that paracetamol was the most used analgesic among elderly patients (315, 68%) compared to other analgesics, followed by piroxicam, mefenamic acid, and ibuprofen. a hundred gembong soeyono putro, herri s. sastramihardja, lazuardhi dwipa: analgesic usage in elderly at public health center: a study in west java, indonesia table 1 amount of analgesic drug use at tanjungsari public health center in older adult patients in 2013 drug name total usage percentage ibuprofen 46 10% paracetamol 315 56% mefenamic acid 46 10% piroxicam 54 12% total 461 100% table 2 diagnosis of elderly with bone, muscle and connective tissue disorders diagnosis total percentage bone, muscle, and connective tissue 57 100% polyarthritis 25 44% myalgia 22 38% rheumatic 9 16% reactive athropathy 1 2% table 3 number of elderly who received nsaids and gastric medication at tanjungsari public health center in 2013 total percentage nsaid with gastric medication 64 33% nsaid without gastric medication 125 67% total 189 100% althea medical journal. 2017;4(1) 18 amj march 2017 four from 417 patients (24.9%) were given more than one kind of analgesic (table 1). out of 417 medical records obtained, only 57 patients were diagnosed with bone, muscle and connective tissue disorders that indicated the prescription of analgesics (table 2). one of the highest side effects of the use of analgesics, especially from the class of nsaids was stomach irritation. gastric drug usage of nsaid prescribed to older adult patients can be seen on table 3. there were 64 patients out of 189 patients who were given gastric drug as adjuvant to nsaid prescription, while the remaining 125 patient did not receive gastric drug as adjuvant to nsaid prescription. discussion this study discovered that there were more female patients attending primary care clinics and given analgesics compared to male patients. this was consistent with a study conducted by miro et al.9 which states that women complain of pain more than men, and the sites of grievances are joint, lower extremities, spine and neck.9 additionally, paracetamol is the most prescribed analgesic in older adult patients at puskesmas tanjungsari in 2013, this is in accordance with a study conducted by won et al.10 which states that of the administration of analgesic drugs, the most common are paracetamol (37.2%), propoxyphene (18.2%), hydrocodone (6.8%), and tramadol (5.4%).10 this is strengthened also by a study conducted by barber et al.11 which states that paracetamol is an analgesic drug that tends safe to be consumed because it has low side effects on gastric and kidneys function.11 according to another study conducted by o’neil et al.12 paracetamol should be the frontline for treating pain symptoms, while the use of nsaid should be considered for short-term used and for moderate to severe pain only, and the usage of opioid analgesic is preferable for older age patients without substance abuse or dependence issues.12 furthermore, for the use of nsaids in older adult patients generally accompanied with gastric medication, this is done to prevent the side effects of gastric irritation.13 according to a study conducted by rahme et al.14 the use of nsaids in the older adult are at greater risk of developing gastrointestinal side effects compared to older adult patients given lowdose paracetamol.14 according to thiéfin et al.15, in france, only half of nsaid users (above 65 years old) receive gastrointestinal protective agents, which is in accordance to this study.15 according to the data of this study, from 313 older adult patients who are prescribed nsaid only 68 patients (32%) are given gastric drug as a companion of nsaid. from these data, it is concluded that gastric drug used as an adjuvant drug of nsaid in older adult patients is still low, while as noted above, the possibility of adverse effects on gastric increase as well as increase of the age. limitations of this study were incomplete filling of medical records. it can be seen from the lack of information on drug dosage, duration of use, and patient’s chief complaints or symptoms. a better record keeping on medical records is needed for completeness of archives and for subsequent studies. in general, it can be concluded that the most used of analgesic drugs at the tanjungsari public health center for older adult patients in 2013 is paracetamol. prescriptions for analgesic in older adult patients in tanjungsari public health center are still not proper, especially in the administration of nsaids; it can be seen from the number of older adult patients who are given nsaids without the accompany of gastric drug, which can cause harmful side effects in the form of gastric disorders. references 1. pusat data dan informasi kementerian kesehatan ri. gambaran kesehatan lanjut usia di indonesia. jakarta: kementerian kesehatan ri; 2013. 2. routledge p, o’mahony m, woodhouse k. adverse drug reactions in elderly patients. br j clin pharmacol. 2004;57(2):121–6. 3. world health organization. who’s pain ladder for adults. geneva: world health organization; 2013. 4. tracy b, sean morrison r. pain management in older adults. clin ther. 2013;35(11):1659–68. 5. cavalieri ta. managing pain in geriatric patients. jaoa: j am osteopath assoc. 2007;107(suppl 4):es10–6. 6. rastogi r, meek bd. management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control. clin interv aging. 2012;8:37–46. 7. pilotto a, sancarlo d, addante f, scarcelli c, franceschi m. non-steroidal antiinflammatory drug use in the elderly. surg oncol. 2010;19(3):167–72. 8. kementerian kesehatan republik indonesia. riset kesehatan dasar. jakarta: althea medical journal. 2017;4(1) 19gembong soeyono putro, herri s. sastramihardja, lazuardhi dwipa: analgesic usage in elderly at public health center: a study in west java, indonesia badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia; 2006. 9. miró j, paredes s, rull m, queral r, miralles r, nieto r, et al. pain in older adults: a prevalence study in the mediterranean region of catalonia. eur j pain. 2007;11(1):83–92. 10. won ab, lapane kl, vallow s, schein j, morris jn, lipsitz la. persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. am j geriatr soc. 2004;52(6):867–74. 11. barber jb, gibson sj. treatment of chronic non-malignant pain in the elderly. drug safety. 2009;32(6):457–74. 12. o’neil ck, hanlon jt, marcum za. adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics. am j geriatr pharmacother. 2012;10(6):331– 42. 13. campanelli cm. american geriatrics society updated beers criteria for potentially inappropriate medication use in older adults: the american geriatrics society 2012 beers criteria update expert panel. j am geriatr soc. 2012;60(4):616– 31. 14. rahme e, barkun a, nedjar h, gaugris s, watson d. hospitalizations for upper and lower gi events associated with traditional nsaids and acetaminophen among the elderly in quebec, canada. am j gastroenterol. 2008;103(4):872–82. 15. thiéfin g, schwalm m-s. underutilization of gastroprotective drugs in patients receiving non-steroidal anti-inflammatory drugs. dig liver dis. 2011;43(3):209–14. althea medical journal. 2017;4(2) 188 amj june 2017 a study of hypoalbuminemia and pleural effusionin pediatric nephrotic syndrome tovan perinandika,1 dedi rachmadi s,2 fenny dwiyatnaningrum,3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, cell biology, and physiology faculty of medicine universitas padjadjaran abstract background: nephrotic syndrome (ns) is a kidney disease that is most often found in children. hypoalbuminemia in ns can cause a decrease in oncotic pressure causing extravasation of fluid into the interstitial space. in conditions of severe hypoalbuminemia, fluid extravasation may cause occurrence of pleural effusion. the objectives of this study was to analyze the correlation between hypoalbuminemia and pleural effusion in children with ns. methods: an analytical study was conducted on 69 medical records of pediatric nephrotic syndrome from 1 january 2008–31 december 2013 in dr. hasan sadikin general hospital. inclusion criteria were pediatric patients between 1-14 years old with ns. exclusion criteria were patients who already had albumin transfusion, malnutrition, patients with chronic disease, and incomplete medical record information. contingency coefficient test was carried out to discover the correlation between variables. results: out of 89 samples, 69 samples were included. characteristics of the included patients are male (n=48), female (n=21), age 1–5 (n=24), 6–10 (n=22), 11–14 (n=23), mild hypoalbuminemia (n=3), moderate hypoalbuminemia (n=27), severe hypoalbuminemia (n=39), patients with pleural effusion (n=23), and nonpleural effusion (n=46). there was a significant correlation between hypoalbuminemia and pleural effusion with p=0.000 (p<0.05) and moderate correlation (r=0.437). conclusions: hypoalbuminemia has correlation with pleural effusion in pediatric nephrotic syndrome. keywords: hypoalbuminemia, pediatric nephrotic syndrome, pleural effusion. correspondence: tovan perinandika, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628122041399 email: p.tovan@yahoo.com introduction nephrotic syndrome (ns) is a kidney disease that is most common in children. nephrotic syndrome is characterized by massive proteinuria (≥40 mg/m2 lpb/h or>50 mg/ kg/24 hours, or the ratio of albumin / creatinine in random urine >2 mg / mg, or dipstick ≥2+), hypoalbuminemia (<2, 5 g/dl), edema, and accompanied by hypercholesterolemia (> 200 mg/dl).1 at the department of child health, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital 241 patients with kidney disease were treated, comprising 129 cases of ns (53.5%) with an average age of 6 years 4 months during january 1995 to june 1999.2 the chief complaint in patients with ns usually is edema. these symptoms appear due to a decrease in the levels of albumin in the blood which has the function to maintain oncotic pressure. when conditions of hypoalbuminemia occurs, oncotic pressure will drop, causing extravasation of fluid into the interstitial space or serousa cavity.3 edema in patients with ns usually happens in the periorbital region, especially in the morning. as the day goes, periorbital edema will be reduced but edema pretibia will occur. if edema is getting worse, it will cause ascites or pleural effusion. for nephrotic syndrome, the most common is transudative pleural effusion.4 pleural effusion can lead to hypoxic conditions so that oxygen carried to the tissues will be reduced. in children with chronic hypoxemia, the child will look small for his/ her age, suffer delayed cognitive and motor amj. 2017;4(2):188–91 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1075 189 althea medical journal. 2017;4(2) development, shortness of breath on exertion, fatigue, and is not able to exercise.5,6 the aim of this study was to analyze the correlation between hypoalbuminemia and pleural effusion in pediatric nephrotic syndrome. methods the study population was children with ns at dr. hasan sadikin general hospital. data were derived from secondary data of medical records at dr. hasan sadikin general hospital from 1 january 2008–31 december 2013. the process of data collection was carried out in october to november 2014 with approval from the medical records departement and the health research ethics committee of the dr. hasan sadikin general hospital . the inclusion criteria of this study were medical records of patients with sn and aged between 1-14 years. the exclusion criteria were medical records of patients which consisted of information that those patients had received an albumin transfusion, had poor nutritional status and suffered from chronic diseases such as pulmonary tuberculosis, malignancy, heart failure, hepatic cirrhosis, and chronic renal failure. in addition, medical records withincomplete data were also excluded. a total of 86 medical records were identified, but 17 samples were excluded so that only 69 medical records were accepted forthis study. the medical records that were excluded consisted of information about pulmonary tuberculosis (n = 13), chronic renal failure (n = 1), and incomplete data (n = 3). furthermore, the age of the patients was categorized in 3 groups, namely aged 1–5 years, 6–10 years and 11–14 years . the degree of hypoalbuminemia value was categorized as mild (2–2.5 g/dl), moderate (2.5> –1.5 g/dl), and severe (<1.5 g/dl). moreover, the existence of pleural effusion was identified from chest x-ray concluded in the medical records. the collected data were statistically analyzed by using the contingency coefficient test. results from 69 children with ns, the number of male patients exceeded female patients. the distribution of ns was similar in every age group. in terms of hypoalbuminemia, the number of patients with severe hypoalbuminemia were higher compared to those with mild hypoalbuminemia. the incidence of pleural effusion was lower compared to patients without pleural effusion. moreover, contingency coefficient test was performed on hypoalbuminemia and pleural effusion. results of the analysis showed that there was a significant correlation (0.437) between the two variables with p = 0.000 (p <0.05). tovan perinandika, dedi rachmadi s, fenny dwiyatnaningrum: a study of hypoalbuminemia and pleural effusionin pediatric nephrotic syndrome table 1 characteristics of pediatric nephrotic syndrome characteristics total (n=69) sex male 48 female 21 age (years old) 1–5 24 6–10 22 11–14 23 hypoalbuminemia severe 39 moderate 27 mild 3 pleural effusion no pleural effusion 46 pleural effusion 23 althea medical journal. 2017;4(2) 190 amj june 2017 discussion this study showed that there was a relationship between hypoalbuminemia and pleural effusion, but the strength of the correlation was moderate. hypoalbuminemia is one of the causes of pleural effusion, especially transudative pleural effusion.7,8 in 1999, alain eid et al.9 conducted a similar study by connecting hypoalbuminemia and pleural effusion. the results showed hypoalbuminemia as a cause of pleural effusion, however it is a rare cause of pleural effusion because all studies with low serum albumin levels have at least one other potential disease in the study. other clinical evaluation is necessary regarding the cause of pleural effusion in people with hypoalbuminemia.9 based on the theory of starling, fluid shifts from the intravascular to the interstitial space is influenced by several things, namely vascular permeability, intravascular hydrostatic pressure, hydrostatic pressure of the interstitial space, intravascular oncotic pressure and oncotic pressure of the interstitial space. thus, hypoalbuminemia is a cause of pleural effusion because it can lower oncotic pressure in the blood so that the intravascular fluid moves into the cavity serosa.3 however, siddall and radhakrishnan3 stated that hypoalbuminemia does not cause edema and extravasation of fluid. hypoalbuminemia conditions in parallel lead to decreasing levels of albumin in the interstitial spaces and interstitial hydrostatic pressure resulting in extravasation of fluid is constant and does not cause edema. another possibility might be due to a disturbance in vascular permeability which causes the extravasation of fluid, but it is still not investigated further.3 results of a study conducted zaffanello and franchini10 showed that chylothorax which is one type of pleural effusion can be caused by nephrotic syndrome, due to coagulation disorders caused by nephrotic syndrome. kerlin et al.11 proved that the nephrotic syndrome is often followed by thromboembolism events. this causes of thromboembolism should always be considered in any event of nephrotic syndrome, associated with complications which is chylothorax .11 further studies should be conducted on the relationship between serum albumin levels and thrombus formation to determine the possible relationship between hypoalbuminemia and chylothorax. limitation of this study is that there is no differentiation type of pleural effusion because pleural effusion caused by nephrotic syndrome is transudative pleural effusion. if there was exudative pleural effusion, the effusion due to other causes could affect the results. it can be concluded that there is a relationship between hypoalbuminemia and pleural effusion in children with nephrotic syndrome. thus, it can also become a factor for clinicians to consider the incidence of pleural effusion in nephrotic syndrome children . references 1. trihono p, alatas h, tambunan t, pardede s. konsensus tata laksana sindrom nefrotik figure 1 percentage of pleural effusion in hypoalbuminemia 191 althea medical journal. 2017;4(2) tovan perinandika, dedi rachmadi s, fenny dwiyatnaningrum: a study of hypoalbuminemia and pleural effusionin pediatric nephrotic syndrome idiopatik pada anak. unit kerja koordinasi nefrologi ikatan dokter anak indonesia jakarta: badan penerbit idai. 2008. 2. ponco e. hubungan kadar kolesterol total darah dengan frekuensi relaps pada anak dengan sindrom nefrotik di bagian/smf ilmu kesehatan anak fkup/rs hasan sadikin kurun waktu 1995-1999 [thesis]. bandung: universitas padjadjaran. 1999. 3. siddall ec, radhakrishnan j. the pathophysiology of edema formation in the nephrotic syndrome. kidney int j. 2012;82(6):635-42. 4. nilawati g. profil sindrom nefrotik pada ruang perawatan anak rsup sanglah denpasar. sari pediatri. 2012;14(4):26972. 5. webster ws, abela d. the effect of hypoxia in development. birth defects res (part c). 2007;81(3):215-28. 6. liu l, cash tp, jones rg, keith b, thompson cb, simon mc. hypoxia-induced energy stress regulates mrna translation and cell growth. mol cell j. 2006;21(4):521-31. 7. mcgrath e, barber c. bilateral pleural effusions. can med assoc j. 2010;182(17):1879-82. 8. rehan m, alam mt, aurangzeb m, imran k, farrukh sz, masroor m. the frequency of various diseases in patients presenting with pleural effusion. gomal j med sci. 2013;11(1):78-83. 9. light rw. the undiagnosed pleural effusion. clin chest med j. 2006;27(2):30919. 10. zaffanello m, franchini m. thromboembolism in childhood nephrotic syndrome: a rare but serious complication. hematology. 2007;12(1):69-73. 11. kerlin ba, blatt nb, fuh b, zhao s, lehman a, blanchong c, et al. epidemiology and risk factors for thromboembolic complications of childhood nephrotic syndrome: a midwest pediatric nephrology consortium (mwpnc) study. j pediatr. 2009;155(1):105-10. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 157 the distribution of meningioma in dr. hasan sadikin general hospital bandung period 2010–2013 stephanie victoria gunadi,1 sri suryanti,2 raden yohana3 1bethesda general hospital serukam west kalimantan, indonesia, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: in neurological diseases, brain tumor is the second leading cause of death after stroke, of which the most common types of brain tumor is meningioma. there are many factors affect the prognosis of meningioma patient, including age, gender, location, and histopathological type of tumor. this study aimed to explore the distribution of meningioma based on age, gender, location of the tumor, and its histopathological type during the period of 2010–2013 in dr. hasan sadikin general hospital bandung. methods: this study was a quantitative descriptive study and data were collected from medical records of department of pathology between january 2010-december 2013. age, gender, location, and histopathological type of meningioma were acquired. results: there were 277 eligible cases of meningioma with an average number of cases per year were 69 cases. the ratio of men to women was 1:6.4. meningioma was most commonly found in the age group 4150 years (38.9%), and mostly located in convexity (55.96%). the most common histopathological type of meningioma was meningotheliomatous meningioma (70%). conclusions: the frequency of meningioma is 6 times higher in women, predominantly around the age of 50 years old. meningioma is most commonly found in convexity, and meningotheliomatous meningioma is the most common histopathological type. keywords: brain tumor, histopathological characteristic, meningioma correspondence: stephanie victoria gunadi, bethesda general hospital serukam west kalimantan, indonesia, email: stephanievictoriagunadi@gmail.com introduction meningioma is an encapsulated tumor in the central nervous system which originates from meningothelial arachnoid cells.1,2 the majority of meningiomas are benign, yet it could be dangerous if the tumor expands and emerging causing an increase of intracranial pressure because of its intracranial location and often leads to headache, nausea, vomit, incoordination, and seizure.3,4 based on who, meningioma can be classified into 3 grades, i.e. benign (grade i), atypical (grade ii), and anaplastic (grade iii).5 women is twice as likely as men to develop meningioma and its incidence increases with age.6,7 intracranial meningioma is more common than spinal meningioma.8 in indonesia9, there are few data about central nervous system tumors, including meningioma. a research in 2009–2013 at rsud abdul moeloek (rsudam) and rs. imanuel bandar lampung showed 55.7% cases of central nervous system tumors were meningiomas. in 1997–2001, the average of meningioma cases in the department of pathology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung is 12 cases per year, and 51 cases per year in 2007–2009.9 prognosis of meningioma is influenced by age, gender, location of tumor, and word healt organization (who) grading of meningioma (grade i iii) which is classified based on type of histopathology.10 location at the convexity of the brain in this study is aimed at frontal, temporal, parietal, and occipital cortex.11 this study aimed to explore the distribution of meningioma based on age, gender, location, and histopathological type. methods this was a quantitative, descriptive study with retrospective data collection, conducted at the amj. 2018;5(3):157–60 althea medical journal. 2018;5(3) 158 amj september 2018 department of pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung in august –october 2014. the total data from 2010 to 2013 of patients with central nervous system tumor who had histopathological examinations at the department of pathology was collected. this study had been approved by the health research ethics committee faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung. the inclusion criteria were patients diagnosed with meningioma based on histopathological examination, with a complete medical record of age, gender, the location of the tumor and the type of histopathological diagnosis. incomplete data was not collected. data was described and presented in table form. results there were 277 cases of meningioma among central nervous system tumor during the table 1 the distribution of central nervous system tumor and meningioma in dr. hasan sadikin general hospital during the period of 2010 –2013 year cns tumor meningioma n n % 2010 85 15 17.65 2011 169 84 49.70 2012 193 92 47.67 2013 199 86 43.22 total 646 277 42.87 note: cns, central nervous system tumour figure microscopic figure of meningotheliomatous meningioma12 grade iii meningioma was 5.04%. discussions this study has explored the distribution of meningioma in dr. hasan sadikin general hospital bandung, during the period 2010– 2013. in this study, there is an increase in the incidence rate of meningioma in almost every year, however, the frequency of meningioma is increased in 2011 and decreased until 2013 because of an increased in the incidence of other cns tumors. the average of meningioma cases was 69 cases per year. this number is higher than the previous study described in 2007 2009 with 51 cases per year. it might occur because people and health providers are period of 2010 2013 of which 11 data were excluded due to incomplete medical records. the highest frequency of meningioma in all central nervous system tumors in this study was in 2011 (49.70%), but the highest incidence of meningioma was in 2012 with 92 cases as shown in table 1. to illlustrate, the nicroscopic figure of meningotheliomatous meningioma diagnosed in departement of pathology was shown in figure 1. in this study, meningioma was commonly found in reproductive age (21–60 years old) and more than 80% of meningioma found in women (table 2). more than half of all meningioma cases were in convexity and most of all were an intracranial meningioma (tabel 3). meningotheliomatous meningioma was the most common type with 194 cases (70.03%) and followed by fibrous meningioma with 21 cases (7.58%). chordoid, secretory, and lymphoplasmocyte-rich meningioma were not found in this study. almost all of the cases were who grade i meningioma (90.22%), who grade ii meningioma was 4.69%, and who althea medical journal. 2018;5(3) 159stephanie victoria gunadi, sri suryanti, raden yohana: the distribution of meningioma in dr. hasan sadikin general hospital bandung period 2010–2013 more concern about health nowadays. people could have better health care because of the development of referring system in indonesia, therefore meningioma can be detected earlier and its cases in dr. hasan sadikin general hospital bandung, as a referring hospital in west java, might increase every year.13 meningioma occurred more frequently in females with 240 cases (87%) than in males with 37 cases (13%). this result is similar to study by shah, et al.6 which showed that table 2 the distribution of meningioma based on age and gender age man woman total 11–20 3 3 6 21–30 9 12 21 31–40 5 86 91 41–50 11 97 108 51–60 8 36 44 61–70 1 4 5 71–80 2 2 total 37 (13.35%) 240 (86.64%) 277 (100%) table 3 the distribution of meningioma based on location location total percentage (%) convexity 156 56.32 sphenoid wing 62 22.38 retroorbital 8 2.89 intraspinal 7 2.53 retro bulbar 6 2.17 olfactory groove 5 1.81 petroclival 5 1.81 intraorbital 5 1.81 cpa 5 1.81 suprasellar 4 1.44 tubercullum 3 1.08 posterior fossa 3 1.08 sellar region 3 1.08 extra cranial 2 0.72 calvarial 1 0.36 parasagittal 1 0.36 cerebellum 1 0.36 meningioma occurred predominantly in women with women and men ratio was 2:1.6 this result might be related with hormonal factors as one of the potential risk factors of meningioma such as estrogen, androgen, and progesterone receptor that are increasingly found in meningioma.7 the incidence rate of meningioma is increasing with age.7 in this study, an increase of meningioma cases has been shown at early 20 years old, especially in women, but decreased after age of 50 years. the frequency of meningioma is increased in productive women when the hormone production is high as shown in this study that the highest rate of meningioma cases is in the age group of 41–50 years and the lowest rate is in the age group of 71–80 years. interestingly, none of the meningioma cases found in the early age group or the eldterly. this may happen because asymptomatic meningioma can be only detected later by the neuroimaging technology such as ct scan and mri.14 the most common type of meningioma in this study was meningotheliomatous meningioma (70.03%), followed by fibrous type (7.58%), and psammomatous type (5.77%), and 90.22% from all cases is categorized as who grade i meningioma. this result was similar as the previous study in which who grade i meningioma is prevalent in more than 90% of all cases, followed by who grade ii, and who grade iii. furthermore, the prevalence of intracranial meningioma is more common than intraspinal meningioma, confirming the study conducted previously.8 convexity, falx and parasagittal, and sphenoid wing are the most common locations for meningioma as shown in this study.15 the limitation of this study is that low meningioma in early years might not reflect the prevalence and incidence. it may be due to althea medical journal. 2018;5(3) 160 amj september 2018 table 4 the distribution of meningioma based on histopathological type histopathological type total percentage meningotheliomatous 194 70.03% fibrous 21 7.58% transitional 5 1.80% psammomatous 16 5.77% angiomatous 9 3.24% microcystic 4 1.44% secretory 0 0% lymphoplasmocyterich 0 0% metaplastic 1 0.36% atypical 10 3.61% chordoid 0 0% clear cell 3 1.08% papillary 1 0.36% rhabdoid 6 2.16% anaplastic 7 2.52% total 277 100% note: *grade i: meningotheliomatous, fibrous, transitional, psammomatous, angiomatous, microcystic, secretory, lymphoplasmocyte-rich, metaplastic; grade ii: chordoid, clear cell, atypical; grade iii: papillary, rhabdoid, anaplastic a lower capacity to diagnose in that period. a better medical record should be implemented. to conclude, meningioma is more common in women and the most common type is meningotheliomatous meningioma with the convexity being the most common location for meningioma. references 1. carlberg m, söderqvist f, mild kh, hardell l. meningioma patients diagnosed 2007– 2009 and the association with use of mobile and cordless phones: a case–control study. environ health.2013;12(1):60. 2. jayasree k, divya k. the cytology of intracranial clear cell meningioma with an unusual scalp presentation. j cytol.2011;28(3):117–20. 3. benign neoplasm of cerebral meninges; cerebral meningioma. capitola: timely data resources, inc.2010 [cited 2014 may 24]. available from: http://search. proquest.com/docview/192471646?acc ountid=48290 4. mack j, squier w, eastman jt. anatomy and development of the meninges: implications for subdural collections and csf circulation. pediatr radiol.2009;39(3):200–10. 5. reszec j, hermanowicz a, kochanowicz j, turek g, mariak z, chyczewski l. mast cells evaluation in meningioma of various grades. folia histochem cytobiol.2012;50(4):542–6. 6. shah s, gonsai rn, makwana r. histopathological study of meningioma in civil hospital, ahmedabad. int j curr res rev.2013;5(3):76. 7. wiemels j, wrensch m, claus eb. epidemiology and etiology of meningioma. j neuro oncol.2010;99(3):307–14. 8. cea-soriano l, blenk t, wallander m-a, rodriguez lag. hormonal therapies and meningioma: is there a link? cancer epidemiol.2012;36(2):198–205. 9. yvs e, indri w, ari w. karakteristik klinik dan histopatologi tumor otak di dua rumah sakit di kota bandar lampung. medical journal of lampung university.2014;3(4):48–56. 10. backer-grondahl t, moen brh, torp sh. the histopathological spectrum of human meningiomas. int j clin exp pathol.2012;5(3):231. 11. baddie b, editor. neuro-oncology: neurosurgical operative atlas. new york: thieme; 2011. p. 115. 12. neuropath [database on the internet]. surgical pathology atlas image database. 2008. [cited 2014 march 4]. available from: http://www.surgicalpathologyatlas.com/ glfusion/search.php?query=meningioma &type=all&mode=search&results=25. 13. hinduan zr, kesumah n, iskandar z, crevel rv, alisjahbana b, hospers hj. characteristics of subjects counseled and tested for hiv in an indonesian hospital; factors associated with hiv-status and cd4 cell-count. acta med indones. 2009;41(suppl1):s12–7. 14. klaeboe l, lonn s, scheie d, auvinen a, christensen h, feychting m, et al. incidence of intracranial meningiomas in denmark, finland, norway, and sweden, 1986-1997. int j cancer.2005;117(6):996–1001. 15. kane aj, sughrue me, rutkowski mj, shangari g, fang s, mcdermott mw, et al. anatomic location is a risk factor for atypical and malignant meningiomas. cancer.2011;117(6):1272–8. althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 138 amj march 2017 validity of immunoglobulin m anti salmonella typhi serologic test in childhood typhoid fever hilda marsela,1 djatnika setiabudi,2 agnes rengga indrati3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: typhoid fever, which mostly affects children, remains a major health problem in developing countries. early diagnosis will help the management and thus, reduce morbidity and mortality. however, a rapid diagnostic test that detects the presence of immunoglobulin m (igm) directed towards salmonella typhi (s. typhi) antigen remains controversial despite its popularity. this study was aimed to assess the validity of igm anti s. typhi serologic test in childhood typhoid fever. methods: this retrospective diagnostic test, used blood culture as gold standard. forty-one typhoid fever children with fever of 1–14 days admitted to dr. hasan sadikin general hospital bandung from 2013 to 2015 were recruited. diagnosis of typhoid fever is made clinically. data were analyzed by receiver operating characteristic (roc) curve and diagnostic test. results: forty one children diagnosed with typhoid fever, 37 were positive for igm anti s. typhi, but only 18 were positive for s. typhi in blood culture. igm anti s. typhi (cut-off ≥4) test had an area under the curve (auc) of 59%, sensitivity of 100% and specificity of 17.39%. igm anti s. typhi with cut-off >8 showed the highest auc with sensitivity of 55.56% and specificity of 73.68%. conclusions: igm anti s. typhi test of cut-off >8 performs better than cut-off ≥4 in terms of auc.. [amj.2017;4(1):138–42] keywords: children, diagnostic test, immunoglobulin m anti salmonella typhi, typhoid fever correspondence: hilda marsela, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281213338130 email: hilda.marsela@gmail.com introduction typhoid fever remains a major global health problem. the endemic population in low and middle-income countries was about 5.6 billion, the risk-adjusted overall incidence was 214 per 100,000 individuals, and the risk-unadjusted overall incidence was 371 per 100,000 individuals in 2010.1 in indonesia, typhoid fever remains endemic. estimated national prevalence is 1.6% (range: 0.3–3%), while west java has a higher rate (2.14%). school-aged children are the most vulnerable group and have the highest prevalence (1.9%).2 a rapid, accurate diagnostic method is crucial for prompt and effective treatment and, moreover, to prevent complications, as complications may occur if disease is not treated immediately.3 furthermore, rapid diagnostic test (rdt), a serologic test which detects the presence of immunoglobulin m (igm) specific to bacterial antigen salmonella typhi (s. typhi), is popular in recent years; however, it remains controversial due to the variability of its performance (sensitivity and specificity) among many studies and countries.4–11 there are no studies about this diagnostic test both in indonesia and children group. hence, this study was conducted to assess the validity of igm anti s. typhi serologic test in childhood typhoid fever. methods the target population of the study was all children diagnosed with typhoid fever. all children aged 1 to 14 years admitted to the department of child health dr. hasan sadikin general hospital bandung, from april 2013 to march 2015 diagnosed with typhoid fever althea medical journal. 2017;4(1) 139 were accessible for the study. inclusion criteria were children with fever of 1-14 days who were clinically diagnosed with typhoid fever, inpatient at the department of child health dr. hasan sadikin general hospital bandung, and tested for both blood culture and igm anti s. typhi. exclusion criteria were children who were diagnosed with typhoid fever and other infectious diseases at the same time, immunocompromise patients, being in immunosuppressant therapy during the disease, or severe malnutrition. ethical approval for the study was granted by the health research ethics committee of dr. hasan sadikin general hospital bandung, no. lb.04.01/a05/ec/236/vii/2015. samples were selected using the total sampling method. a minimum sample of 41 was calculated from sample size formula for diagnostic study. this study was a diagnostic test. data were collected from medical records. furthermore, analysis was performed using roc curve and diagnostic test (2x2 table). the roc curve measured auc, as well as sensitivity, specificity, predictive values and likelihood ratios of corresponding cut-off values of igm anti s. typhi serologic test. diagnostic test (2x2 table) of igm anti s. typhi serologic test, using blood culture as a gold standard, measured sensitivity, specificity, predictive values, likelihood ratios and accuracy of the test. results out of 264 children diagnosed with typhoid fever admitted from april 2013 to march 2015, 152 children met the inclusion criteria; however, 40 did not perform blood culture, 6 did not perform igm anti s. typhi serologic test, and 65 did not perform both tests. thus, the remaining 41 were selected as study subjects. additionally, specimen collection time had a median of day 7 and mode of day 7. characteristics of the study subjects (table 1) demonstrated that the mean age at onset of disease was 7.15 years old and mode 6 years old (middle childhood). antibiotics have been used in 68.3% of study subjects before hospital admission. its proportion is the highest in middle childhood (48.8%). igm anti s. typhi serologic test (median of cut-off >7 and mode of cut-off >10) was positive in 90.2% of cases, the in middle childhood (63.4%) and on day 7 of sample collection (31.7%). blood culture table 1 characteristics of study subjects characteristic n (%) sex male 20 (48.8) female 21 (51.2) age (years) toddler (1–2) 2 (4.9) preschooler (3–5) 10 (24.4) middle childhood (6–11) 27 (65.9) young teen (12–14) 2 (4.9) antibiotics yes 28 (68.3) no 2 (4.9) unidentified 11 (26.8) igm anti s. typhi result (cut-off value) positive (≥4) 37 (90.2) negative (<4) 4 (9.8) blood culture positive 18 (43.9) negative 23 (56.1) hilda marsela, djatnika setiabudi, agnes rengga indrati: validity of immunoglobulin m anti salmonella typhi serologic test in childhood typhoid fever althea medical journal. 2017;4(1) 140 amj march 2017 was positive in 43.9% of cases, the highest in middle childhood (36.6%) and on day 7 of sample collection (24.4%). moreover, igm anti s. typhi serologic test (cut-off ≥4) demonstrated an auc of 0.59 (95% ci, range: 0.42–0.74) when being analyzed by 2x2 table (table 2). the test was calculated to be 100% sensitive (95% ci, range: 81.47–100.00%) and 17.39% specific (95% ci, range: 4.95–38.78%). the positive and negative predictive values were 48.65% (95% ci, range: 31.92–65.6%) and 100% (95% ci, range: 39.76–100.00%), respectively. the positive and negative likelihood ratios were 1.21 (95% ci, range: 1.00–1.46) and 0.00 (95% ci), respectively. the disease prevalence was 43.90% (95% ci, range: 28.47–60.25%), besides, the test had an accuracy of 53.65%. in contrast to 2x2 table, roc curve (figure 1) analysis demonstrated that the auc of igm anti s. typhi serologic test (cut-off ≥4) was 62.9% (95% ci, range: 45.5–78.1%). the cut-off values with their corresponding sensitivity and specificity were compared (table 3). the highest auc was found on cutoff value >8 (95% ci, range: >6 to >9) with sensitivity of 55.56% (95% ci, range: 30.8– 78.5%) and specificity of 73.68% (95% ci, range: 48.8–90.9%). discussion the proportion of disease had no significant difference on the sex group as demonstrated in a prior study.13 however, it is similar to another study,2 which demonstrates that the middle childhood (6–11 years) group has the highest proportion of disease. positivity rates of igm anti s.typhi serological tests were considered good. the highest rate was noted on day 7, presumably because of an increasing igm response, which is similar to previous observations.5,8 positivity rate of blood culture was considered low. in contrast to a previous study which stated that the best period for blood culture is day <7 of disease,14–16 the highest rate was noted on day 7. low positivity rates of blood culture, which figure 1 receiver operating characteristic (roc) curve table 2 diagnostic test (2x2 table) of igm anti s. typhi serologic test gold standard: blood culture total positive negative igm anti s. typhi serologic test positive (≥4) 18 19 37 negative (<4) 0 4 4 total 18 23 41 althea medical journal. 2017;4(1) 141 table 3 comparison of cut-off values with corresponding sensitivity, specificity, positive likelihood ratio and negative likelihood ratio cut-off values sensitivity (%) (95% ci) specificity (%) (95% ci) +lr (95% ci) -lr (95% ci) ≥4 100 (81.5–100.0) 0 (0.0–17.6) 1 (1.0–1.0) >4 83.33 (58.6–96.4) 5.26 (0.1–26.0) 0.88 (0.7–1.1) 3.17 (0.4–27.7) >5 83.33 (58.6–96.4) 15.79 (3.4–39.6) 0.99 (0.7–1.3) 1.06 (0.2–4.6) >6 72.22 (46.5–90.3) 52.63 (28.9–75.6) 1.52 (0.9–2.7) 0.53 (0.2–1.2) >7 55.56 (30.8–78.5) 63.16 (38.4–83.7) 1.51 (0.7–3.1) 0.70 (0.4–1.3) >8 55.56 (30.8–78.5) 73.68 (48.8–90.9) 2.11 (0.9–5.0) 0.60 (0.3–1.1) >9 38.89 (17.3–64.3) 84.21 (60.4–96.6) 2.46 (0.8–8.1) 0.73 (0.5–1.1) >10 0 (0.0–18.5) 100 (82.4–100.0) 1 (1.0–1.0) hilda marsela, djatnika setiabudi, agnes rengga indrati: validity of immunoglobulin m anti salmonella typhi serologic test in childhood typhoid fever was also reported in a previous study, may as well be results from prior antibiotic use.17–18 this study showed that igm anti s. typhi serologic test had a poor auc when cut-off value ≥4 was used, while highest auc was demonstrated on cut-off value >8. sensitivity was found to be good as reported in previous studies in all age groups6 and children group,10,11 reflecting the high number of positive result when the disease is actually present. in contrast, its specificity was considered low; meaning that it would give a low number of negative results when the disease was actually not present. high sensitivity and low specificity of the test were also reported in the childrenpopulated study performed by narayanappa, et al.11 this retrospective study was a hospitalbased study where most patients had previously visited the primary health care. children with 1–14 days of fever were included because the best period of blood culture are the first few days of disease14–16 and the best period of igm anti s. typhi serologic test is the second week of disease.5,8 the facts that antibiotics were widely used prior to the admission of patients could make the number of study subjects even lower and impossible to conduct this study; thus, children with prior antibiotic use were not excluded. the number of bacteria and antibody are influenced by the time of disease. the best period for both blood culture and igm anti s. typhi serologic test is different but specimen was taken only once. perhaps, if specimens were taken twice within a week of interval, the results would differ in some ways. both blood culture and igm anti s. typhi test results are dependent on skills or accuracy of the performing staff as well as laboratory equipment. these might also affect the test results. in conclusion, igm anti s. typhi test of cutoff >8 performs better than cut-off ≥4 in terms of auc. the researcher suggests a further prospective diagnostic study that considers the time of specimen collection and antibiotic usage, perhaps a secondary health care-based study. clinicians should consider the cut-off values when making the diagnosis of typhoid fever in children-populated practical setting. references 1. mogasale v, maskery b, ochiai rl, lee js, mogasale vv, ramani e, et al. burden of typhoid fever in low-income and middleincome countries: a systematic, literaturebased update with risk-factor adjustment. lancet glob health. 2014;2(10):570–80. 2. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2007. jakarta (indonesia): depkes ri; 2008. p. 107–9. 3. bhutta za. salmonella. in: kliegman rm, stanton bf, geme jws, schor nf, behrman althea medical journal. 2017;4(1) 142 amj march 2017 re, editors. nelson textbook of pediatrics. 19th ed. philadelphia: saunders; 2011. p. 948–58. 4. dutta s, sur d, manna b, sen b, deb a, deen j, et al. evaluation of new-generation serologic tests for the diagnosis of typhoid fever: data from a community-based surveillance in calcutta, india. diagn microbiol infect dis. 2006;56(4):359–65. 5. abdoel th, pastoor r, smits hl, hatta m. laboratory evaluation of a simple and rapid latex agglutination assay for the serodiagnosis of typhoid fever. trans r soc trop med hyg. 2007;101(10):1032–8. 6. kawano rl, leano sa, agdamag dma. comparison of serological test kits for diagnosis of typhoid fever in the philippines. j clin microbiol. 2007;45(1):24–7. 7. naheed a, ram pk, brooks wa, mintz ed, hossain ma, parsons mm, et al. clinical value of tubex™ and typhidot® rapid diagnostic tests for typhoid fever in an urban community clinic in bangladesh. diagn microbiol infect dis. 2008;61(4):381–6. 8. pastoor r, hatta m, abdoel th, smits hl. simple, rapid, and affordable pointof-care test for the serodiagnosis of typhoid fever. diagn microbiol infect dis. 2008;61(2):129–34. 9. siba v, horwood pf, vanuga k, wapling j, sehuko r, siba pm, et al. evaluation of serological diagnostic tests for typhoid fever in papua new guinea using a composite reference standard. clin vaccine immunol. 2012;19(11):1833–7. 10. rahman m, siddique ak, tam fc-h, sharmin s, rashid h, iqbal a, et al. rapid detection of early typhoid fever in endemic community children by the tubex® o9antibody test. diagn microbiol infect dis. 2007;58(3):275–81. 11. narayanappa d, sripathi r, jagdishkumar k, rajani hs. comparative study of dot enzyme immunoassay (typhidot-m) and widal test in the diagnosis of typhoid fever. indian pediatric. 2010;47(4):331–3. 12. world health organization. pocket book of hospital care for children: guidelines for the management of common childhood illnesses. geneva: who library cataloguing data; 2013. 13. setiabudi d, madiapermana k. demam tifoid pada anak usia di bawah 5 tahun di bagian ilmu kesehatan anak rs hasan sadikin bandung. sari pediatri. 2005;7(1):9–14. 14. ochoa tj, santisteban-ponce j. salmonella. in: cherry jd, harrison gj, kaplan sl, steinbach wj, hotez pj, editors. feigin and cherry’s textbook of pediatric infectious diseases. 7th ed. usa: elsevier; 2014. p. 1491–509. 15. parry cm, wijedoru l, arjyal a, baker s. the utility of diagnostic tests for enteric fever in endemic locations. expert rev anti infect ther. 2011;9(6):711–25. 16. moore ce, pan-ngum w, wijedoru lpm, sona s, nga tvt, duy pt, et al. evaluation of the diagnostic accuracy of a typhoid igm flow assay for the diagnosis of typhoid fever in cambodian children using a bayesian latent class model assuming an imperfect gold standard. am j trop med hyg. 2014;90(1):114–20. 17. brooks wa, hossain a, goswami d, sharmeen at, nahar k, alam k, et al. bacteremic typhoid fever in children in an urban slum, bangladesh. emerg infect dis. 2005;11(2):326–9. 18. siddiqui fj, rabbani f, hasan r, nizami sq, bhutta za. typhoid fever in children: some epidemiological considerations from karachi, pakistan. int j infect dis. 2006;10(3):215–22. vol 6 no 2 full text.indd althea medical journal. 2019;6(2) 55 serum calcium levels in chronic kidney disease patient stratified by body mass index anthoni,1 rudi supriyadi,2 siti nur fatimah3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitaspadjadjaran correspondence: anthoni, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang. e-mail: anthoni15002@mail.unpad.ac.id introduction chronic kidney disease (ckd) is a chronic inflammatory condition of the kidney that present for more than 3 months and accompanied by structural and functional abnormalities, with implications for health.1,2 estimated prevalence of ckd is 13.4% worldwide and 0.2% in indonesia.3,4 based on global burden of disease 2015, kidney disease ranks 12th as the main cause of death,5 whereas in indonesia, ckd ranks 2nd as the highest expense of indonesia’s badan penyelenggara jaminan sosial (bpjs).3 chronic kidney disease is classified into five stages based on glomerular filtration rate (gfr) and/or on presence or absence of changes of kidney structure, each stage corresponds to the decreased quality of life, morbidity rate, and mortality rate.2,6 kidney has an important role in body fluid, electrolyte regulation, and acid-base balance, hence, ckd can cause complications to heart, lungs, blood vessels, mineral and bone, muscle, nerves, and other organs.6,7 patients with ckd stage or end-stage renal disease (esrd) need kidney replacement therapy.3 patients with ckd experience changes in body mineral level and bone density resulting in metabolic and clinical consequences, including the increase of fibroblast growth amj. 2019;6(2):55–9 abstract background: most of the chronic kidney disease (ckd) patients have low blood calcium levels, yet hypercalcemia has a worse outcome in ckd patients. interestingly, ckd patients with higher body mass index (bmi) have better outcomes. this study aimed to elucidate the difference in blood calcium levels stratified by bmi categories in patients with ckd. methods: the study was conducted using a comparative analytical cross-sectional study design. patients with ckd (n100), aged over 18 years old were included, patients with the following were excluded: the history of hemodialysis, history of antioxidants, calcium and vitamin d supplement consumption, history of infection and malignancy. bmi of patients was categorized into underweight (<18.5 kg/m2), normal (8.5-22.9 kg/m2), and overweight or obese (≥23 kg/m2). data were analyzed to compare blood calcium in different categories of bmi (kruskal-wallis test). results: the age of patients with ckd included in this study had median age of 61 years old, predominantly was men (57%). the blood calcium level of ckd patients was on the lower border of the normal range. median bmi was 23.48 kg/m2, of which 53% was categorized as overweight or obese. there was a trend that overweight/obese patients had higher blood calcium levels than underweight and normal-weight patients, however, no statistically significant difference between the bmi category (p=0.982). conclusions: the blood calcium level in chronic kidney disease varies across the bmi category, however, no correlation with the bmi. keywords: blood calcium, body mass index, chronic kidney disease althea medical journal. 2019;6(2) 56 amj june 2019 factor-23, parathyroid hormone (pth), and blood phosphate; and a decrease of 1.25(oh)2d level and blood calcium level.8 the decrease of blood calcium levels in ckd patients is caused by lower calcium intake, failure of absorption, distribution, and utilization as the consequence of the decrease of vitamin d activities.6,9 interestingly, overweight/obesity serves a one of the risk factors of ckd, and this overweight is related to hemodynamical, physiological, anatomical, and/or pathological changes of the kidney.3,10,11 however, conflicting result occurs, showing that obesity may have a higher survival rate of ckd patient, even though obesity is associated with mortality caused by the increased risk of metabolic syndrome and cardiovascular disease in a non-ckd patient, known as the obesity paradox.10,12-14 another study result has shown that ckd patients with overweight/obese have higher blood calcium levels compared to those with underweight and normal weight.15 blood calcium level higher than normal is correlated with a worse prognosis.16 in light with those contradicting results, this study aimed to explore blood calcium levels in ckd patients stratified based on body mass index (bmi). table 1 clinical characteristics of the chronic kidney disease from bandung characteristic n (%) median (min-max) sex male 57 (57%) 61 (24-78) female 43 (43%) 23.48 (10.54–37.99) age (years) 17.24 (10.5 –18.21) bmi (kg/m2) 21.45 (18.72-22.94) underweight 7 (7%) 26.26 (23.01-37.99) normal 40 (40%) overweight/obese 53 (53%) note: bmi: body mass index; categorized into underweight (<18.5 kg/m2), normal (8.5-22.9 kg/m2), and overweight or obese (≥23 kg/m2). methods this study was conducted using a comparative analytical cross-sectional study design. secondary data from previous study “correlation of total antioxidant capacity, vitamin d, calcium, and sclerostin to body composition of patients with ckd stage 3-5” had been retrieved upon approval of the research ethics committee universitas padjadjaran, bandung, indonesia (794/ u6.kep/ec/2018). data on age, gender, blood calcium level, gfr, and bmi were collected. blood calcium levels were categorized as low (<8.5 mg/dl) and normal (8.5-10.5 mg/dl), and bmi of patients were categorized into underweight (<18.5 kg/m2), normal (8.5-22.9 kg/m2), and overweight or obese (≥23 kg/m2). patients with chronic kidney disease (ckd) stage 3, 4, or 5, aged more than 18 years old were included from three hospitals in bandung; dr. hasan sadikin general hospital bandung, ny. r. a. habibie kidney hospital, and dustira hospital. patients with a history of hemodialysis, use of vitamin d, calcium, and antioxidants (vitamin c and vitamin e) supplements, other chronic diseases, infection, and malignancy were excluded. table 2 blood calcium level among chronic kidney disease calcium level n (%) median (min-max) calcium level (mg/dl) 8.6 (4.2-10.2) low 39 (39%) 7.9 (4.2-8.4) normal 61 (61%) 8.9 (8.5-10.2) note: calcium level was categorized as low (<8.5 mg/dl) and normal (8.5-10.5 mg/dl) althea medical journal. 2019;6(2) 57anthoni et al.: serum calcium levels in chronic kidney disease patient stratified by body mass index comparative analysis between blood calcium level among different bmi was conducted using kruskal-wallis test and posthoc mann-whitney test. a post-hoc test was conducted to elaborate the difference between bmi groups. a significant result was reached when p<0.05 (ibm® spss® statistics 22 program). results in a total sample of a previous study (n=100), there were 57% male cdk patients as shown in table 1. the median age was 61 years old (range 24–78 years old). overweight/obese was observed in 53% of the cases, and 7% was underweight. the characteristic of blood calcium levels in subjects is shown in table 2. median of blood calcium level was 8.6 mg/dl, 61% subject had normal calcium level. the ckd patients were categorized into body mass index (bmi) as followed underweight (bmi<18.5 kg/m2), normal (bmi=18.5-22.9 kg/ m2), and overweight/obese (bmi≥23 kg/m2) (table 3). there was no difference in age and gender group. interestingly, the gfr tended to increase in overweight/obese although the increase was not statistically significant (p 0.509) (table 3). blood calcium levels based on bmi category was shown in table 4. overall, blood calcium levels in ckd patients were at the lower limit of the normal value of blood calcium. statistical test results revealed no difference in blood calcium levels in each bmi category. discussion chronic kidney disease (ckd) affects males predominantly as shown in our study, consisting of a male (57%) and female (43%). table 3 glomerular filtration rate among chronic kidney disease based on body mass index characteristics bmi p-valueunderweight (n=7) normal (n=40) overweight/obese (n=53) gender male(n=57) 2 (28.57%) 22 (55%) 33 (62.26%) 0.226* female(n=43) 5 (71.43%) 18 (45%) 20 (37.74%) age (years) ≤50 years(n=27) 3 (42.86%) 9 (22.50%) 15 (28.30%) 0.509* >50 years(n=73) 4 (57.14%) 31 (77.50%) 38 (71.70%) gfr (ml/min/1,73m2) 10.54 (6.64-42.85) 14.36 (2.38-58.64) 18.81 (1.85-58.01) 0.458** ckd stage 3(30-59) 1 (14.29%) 9 (22.5%) 11 (20.75%) 0.083* ckd stage 4 (15-29) 0 (0%) 11 (27.5%) 23 (43.40%) ckd stage 5 (<15) 6 (85.71%) 20 (50%) 19 (35.85%) note: bmi: body mass index; categorized into underweight (<18.5 kg/m2), normal (8.5-22.9 kg/m2), and overweight or obese (≥23 kg/m2).*chi-square test; **kruskal-wallis test; gfr: glomerular filtration rate; ckd: chronic kidney disease table 4 blood calcium level based on body mass index bmi category n % blood calcium level p-value median (min-max) underweight 7 7% 8.6 (7.1-9.5) 0.982* normal 40 40% 8.6 (5.6-10.2) overweight/obese 53 53% 8.8 (4.2-10.0) note: *kruskal-wallis test; bmi: body mass index althea medical journal. 2019;6(2) 58 amj june 2019 these findings are consistent with other studies in canada and japan.15,16 these studies have also resulted that most of the patients are over 50 years old, confirming that ckd is more frequent to be found in older age, as the glomerular filtration rate (gfr) decreases.2 patients with ckd have decreased kidney function, marked by the declining of gfr.1 decreasing gfr causes phosphate retention which will increase the synthesis of fgf23.17 increased levels of fgf-23 to reduce the function of the enzyme 1-α hydroxylase, therefore, the synthesis of 1.25(oh)2d will decrease.9,17 decreased levels of 1.25(oh)2d results in reduced calcium absorption in the intestine, increased calcium excretion, and decreased calcium resorption from bone, and thus, blood calcium levels will decrease.9,17 this explains the condition of our ckd patients that calcium level, in general, is at the lower limit of the normal value of blood calcium levels. the distribution of blood calcium levels in each bmi group showed that there is a tendency for higher blood calcium levels in the overweight/obese group (table 4). this finding confirms that blood calcium levels are significantly higher in obese groups.18 the abnormal calcium metabolism occurs in the overweight/obese group due to reduced 25 (oh) d levels.18,19 this situation results in reduced calcium absorption in the intestine, reduced bone mineralization process, and increased calcium excretion which causes increased parathyroid hormone (pth), therefore, the blood calcium levels will increase. furthermore, overweight/obese groups tend to have a higher fat mass, and this will indirectly increase the activity of proinflammatory cytokines so that osteoclast activity and bone resorption increase.9,18 this increase causes blood calcium levels in the overweight/obese group to be higher than those with underweight and normal bmi. the overweight/obese group has higher gfr than those with underweight and normal bmi (table 2). the glomerular filtration rate is higher, blood phosphorus and fgf-23 levels are decreased, so that 1.25(oh)2d level increase.16 increased levels of 1.25(oh)2d will cause blood calcium levels to increase,16 resulting in higher calcium levels in the overweight/obese group of ckd patients. the limitation of this study was that this study is not considering other factors that affect blood calcium levels, including the amount of calcium intake, vitamin d levels, pth levels, fgf-23 levels, and phosphate levels.17 to conclude, our study failed to show the difference in blood calcium levels in chronic kidney disease in various body mass indexes. further research that considers the factors that influence blood calcium levels needs to be explored to determine the relationship between calcium levels in patients with chronic kidney disease with various body mass index groups. references 1. kidney disease: improving global outcomes (kdigo) ckd-mbd update work group. kdigo 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (ckd-mbd). kidney int suppl. 2017;7(1):1–59. 2. glassock rj, rule ad. aging and the kidneys: anatomy, physiology, and consequences for defining chronic kidney disease. nephron. 2016;134(1):25–9. 3. pusat data dan informasi kementerian kesehatan ri. situasi penyakit ginjal kronis. jakarta: data dan informasi kementerian kesehatan ri; 2017. 4. kementerian kesehatan ri. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2013. 5. neuen bl, chadban sj, demaio ar,johnson dw, perkovic v. chronic kidney disease and the global ncds agenda. bmj glob health. 2017;2(2):e000380. 6. dhondup t, qian q. electrolyte and acidbase disorders in chronic kidney disease and end-stage kidney failure. blood purif. 2017;43(1–3):179–88. 7. zoccali c, vanholder r, massy za, ortiz a, sarafidis p, dekker fw, et al. the systemic nature of ckd. nat rev nephrol. 2017;13(6):344–58. 8. hill gallant km, spiegel dm. calcium balance in chronic kidney disease. curr osteoporos rep. 2017;15(3):214–21. 9. shanahan cm, crouthamel mh, kapustin a, giachelli cm. arterial calcification in chronic kidney disease: key roles for calcium and phosphate. circ res. 2011;109(6):697–711. 10. kalantar-zadeh k, streja e, kovesdy cp, oreopoulos a, noori n, jing j, et al. the obesity paradox and mortality associated with surrogates of body size and muscle mass in patients receiving hemodialysis. mayo clin proc. 2010;85(11):991–1001. althea medical journal. 2019;6(2) 59 11. kopple jd, feroze u. the effect of obesity on chronic kidney disease. j ren nutr. 2011;21(1):66–71. 12. mafra d, guebre-egziabher f, fouque d. body mass index, muscle and fat in chronic kidney disease: questions about survival. nephrol dial transplant. 2008;23(8):2461–6. 13. bonanni a, mannucci i, verzola d, sofia a, saffioti s, gianetta e, et al. protein-energy wasting and mortality in chronic kidney disease. int j environ res public health. 2011;8(5):1631–54. 14. rahimlu m, shab-bidar s, djafarian k. body mass index and all-cause mortality in chronic kidney disease: a dose-response meta-analysis of observational studies. j ren nutr. 2017;27(4):225–32. 15. garland js, holden rm, hopman wm, gill ss, nolan rl, morton ar. body mass index, coronary artery calcification, and kidney function decline in stage 3 to 5 chronic kidney disease patients. j ren nutr. 2013;23(1):4–11. 16. inaguma d, koide s, takahashi k, hayashi h, hasegawa m, yuzawa y. relationship between serum calcium level at dialysis initiation and subsequent prognosis. ren replace ther. 2017;3:2. 17. blaine j, chonchol m, levi m. renal control of calcium, phosphate, and magnesium homeostasis. clin j am soc nephrol. 2015;10(7):1257–72. 18. dalfardi o, jahandideh d, omrani gh. the correlation of serum calcium level and obesity; is there any explanation?. gmj. 2013;2(1):26–31. 19. rontoyanni vg, avila jc, kaul s, wong r, veeranki sp. association between obesity and serum 25 (oh) d concentrations in older mexican adults. nutrients. 2017;9(2):e97. anthoni et al.: serum calcium levels in chronic kidney disease patient stratified by body mass index vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 26 amj march 2018 perception of universitas padjadjaran students towards psychotic disorders renzavaldy rusly,1 veranita pandia,2 deni kurniadi sunjaya3 1leuwiliang district hospital, west bogor, 2departement of psychiatry faculty of medicine universitas padjadjaran/dr.hasan sadikin general hospital, bandung 3department of public health faculty of medicine universitas padjadjaran bandung, indonesia abstract background: psychotic disorders have a very high incidence in indonesia and arethe first rank in terms of the global burden of disability. students are the frontline in the face of society. the formation of stigma and discrimination is rooted from bad perceptions. the aim of this study was to determine and measure universitas padjadjaran students’ perceptions towards psychotic disorders and find out why these perceptions can be shaped. methods: the design of study was a sequential explanatory mixed method research. the population of this study is glittering universitas padjadjaran students who were in jatinangor between batches 2011 to 2013. samples were taken using cluster and stratified random sampling. quantitative data retrieval was collected by using a self-administered questionnaire. next, there would be focused group discussions and in-depth interviews which discussed the results of the quantitative data collection then interpreted them qualitatively. result: the percentage of students at universitas padjadjaran with perception of psychotic disorders in good category was 19.04%, 80.96% unfavorable category, and bad 0% (n=126). besides various relevant opinion found why these perceptions were formed, such as a lack of education on students towards psychotic disorders, the existence of stigma based on life experience of psychotic patients, the lack of social media and physical campaign towards the psychotic disorders. conclusions: the perception of universitas padjadjaran students towards psychotic disorders is still relatively unfavorable, therefore literation towards psychotic disorders should be provided through education, campaigns, social media utilization by psychiatrists and the government. keywords: perception, psychotic disorders, university students correspondence: renzavaldy rusly, leuwiliang district hospital, west bogor, email: renzavaldyrusly@gmail.com introduction the world health organization1 (who) stated that the number of people with psychotic disorders around the world is 24 million people, and this number is projected to increase rapidly. the psychotic disorder was ranked first in the world burden in terms of disability by 13% of the population. a psychotic disorder was mostly experienced at the age of childbearing. in male it started at the average age of 25.4 years and in female at 27.5 years. according to riset kesehatan dasar2 (rkd)2013, the prevalence of psychotic disorders in indonesia was 1.7 per mile area. west java ranked high among all the provinces in indonesia which is 1.6 per mile area. in sumedang2, the number of psychotic disorders was 0.8 % of the entire population. many recurrences of psychotic disorder were caused by the behavior of the community in the form of stigma and discrimination. it was likely preceded by an initial negative perception towards people with psychotic disorders. the prevalence of psychotic disorder at the high productive age, and the many factors that could lead to the perception of the problem were the main reasons for conducting a study to determine the perception of students at universitas padjadjaran toward psychotic disorder as the agent of change, the guardian of values, and iron stock for this nation so that the problem could be overcame well.3 amj.2018;5(1):26–31 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1332 althea medical journal. 2018;5(1) 27 methods the study design used the sequential explanatory mixed method. the population in this study was students at universitas padjadjaran, with a total number of 126 people. this study was conducted in 2014. inclusion criteria for this study were students at universitas padjadjaran and willing to be the respondent, and were from batch of year 2011 to 2013 who were also actively running the program of undergraduate studies at universitas padjadjaran, jatinangor. the exclusion criteria in this study were those who did not fill out the questionnaire data correctly and completely. this study has received ethical permission from the health research ethics committee of the faculty of medicine, universitas padjadjaran, and got research recommendations from the faculty of medicine universitas padjadjaran. this study began with collecting quantitativedata by using a valid and reliable self-administered questionnaire after it was translated to english. then, the focus group discussions were held along with 2 groups consisting of 6 to 8 people from the same population who discussesed the results of the quantitative data collection. furthermore, after they were carried out, in depth interviews with mental health experts were held as triangulation to explore why the current perception could be formed. the results of the focused group discussion and in-depth interview were then interpreted qualitatively. the sampling technique in this study used cluster sampling on faculties at universitas padjadjaran, and stratified random sampling on each batch in each faculty. then, the study data were analyzed using the univariate analysis. this analysis produced a frequency distribution and percentage of existing variables. formula: p= (∑x)/n x 100% specification: p = percentage of respondents rating x = total value of respondents n = total maximum value of the question the interpretation of the results were using standard of objective criteria for perception, where the result of “good “ was obtained when the p value was more than 75%, the result of “unfavorable” if they were between 50% to 75%, as well as the results of “ bad “ if less than 50%. then, the collected data was analyzed using a computer software. results out of 126 students, about 80.89 % had unfavourable perception towards psychotic disorders, and only a small percentage of students had good perception (table 1). this study discovered that if the students were divided according to the faculty of origin, the percentage of unfavourable perception was lower compared to the total percentage (table 2). furthermore, knowledge, attitude, and understanding of mental health care were the criteria for forming bad perceptions of universitas padjadjaran students towards psychotic disorders. knowledge became the criterion with the lowest percentage, followed by attitude, then understanding of the health care in sequence (tables 3, 4, and 5). in addition, the lack of direct action in the form of campaign by using data and facts of psychotic disorder towards students and the public was the reason that students themselves still lacked insight to psychotic disorders such as diagnosis, treatment, prognosis, and how to overcome the stigma around them. discussion moreover, it could be understood that knowledge, attitude, and understanding of mental health care formed criteria of renzavaldy rusly, veranita pandia, deni kurniadi s: perception of universitas padjadjaran students towards psychotic disorders table 1 perception of universitas padjadjaran students towards psychotic disorders perception category frequency (n=126) percentage good 24 19.05 unfavorable 102 80.89 bad 0 0 total 126 100 althea medical journal. 2018;5(1) 28 amj march 2018 perception.4 knowledge became the main determining factor rather than attitude and understanding of mental health care.5 humans formed perceptions through several processes. initially, when a foreign target was found, we will open ourselves to different information cues and want to learn more about the target. furthermore, we make efforts to gather more information about the target. we found some familiar properties that help us categorize the target.6 we endeavore to look for more cues that confirm categorization table 3 knowledge of universitas padjadjaran students towards psychotic disorders per faculty category faculty percentage knowledge medicine 62.96 mathematics and natural science 62.96 agriculture 62.96 dentistry 66.67 social science and political science 64.40 cultural science 60.74 psychology 57.78 animal husbandry 62.22 communication science 61.48 nursery 66.30 fisheries and marine science 59.63 agriculture industrial technology 67.04 pharmacy 61.85 geological science 64.44 average 62.96 table 2 perception of universitas padjadjaran students towards psychotic disorders per faculty faculty average (%) perception category medicine 65.93 unfavorable mathematics and natural science 67.22 unfavorable agriculture 68.80 unfavorable dentistry 67.87 unfavorable social science and polical science 69.44 unfavorable cultural science 67.41 unfavorable psychology 62.88 unfavorable animal husbandry 64,63 unfavorable communication science 68.15 unfavorable nursery 69.26 unfavorable fisheries and marine science 68.15 unfavorable agriculture industrial technology 68.70 unfavorable pharmacy 66.67 unfavorable geological science 69.26 unfavorable average 67.45 unfavorable althea medical journal. 2018;5(1) 29 of selectively targets. we also actively ignore the nature that violates our initial perception. our perception become more selective and we finally figure a picture that is consistent with the target.7 the shape of perception itself was obtained from a number of factors: the perceiver or people, who are conscious about the suitability to judge, setting or everything which have to do with the environment, the norm around renzavaldy rusly, veranita pandia, deni kurniadi s: perception of universitas padjadjaran students towards psychotic disorders table 4 attitude of universitas padjadjaran students towards psychotic disorders per faculty category faculty percentage attitude medicine 65.18 mathematic and natural science 67.03 agriculture 71.11 dentistry 66.85 social science and political science 69.07 cultural science 68.15 psychology 63.52 animal husbandry 64.07 communication science 71.30 nursery 68.15 fisheries and marine science 69.81 agriculture industrial technology 67.04 pharmacy 66.48 geological science 71.48 average 67.80 table 5 health care understanding of universitas padjadjaran students towards psychotic disorders per faculty category faculty percentage understanding of health care medicine 70.37 mathematic and natural science 71.85 agriculture 70.00 dentistry 71.11 social science and political science 75.18 cultural science 72.59 psychology 66.67 animal husbandry 68.15 communication science 68.52 nursery 71.11 fisheries and marine science 73.33 agriculture industrial technology 73.70 pharmacy 71.85 geological science 69.63 average 71.00 althea medical journal. 2018;5(1) 30 amj march 2018 them, and idealism as well as the perceiver or the target which is something or someone who assessed. it is closely related to the characteristics of a person’s perception, the separation of the individual’s background, size, motion, and others.8 the theory of planned behavior stated that the attitude toward behavior is a subjective norm (perception) with a foundation of knowledge and perceived behavioral control, together are forming intentions of individual behavior.9 as for some of the criteria for the diagnosis of psychotic disorder with signs of delusions, hallucinations, garbled speech, bad behavior, and others could be viewed directly without any treatment or therapy was appropriate and consistent. in prognosis, people who suffer from psychotic disorders could lead a normal life if they get proper treatment and early detection.10 based on a study conducted by domiguez et al.11, it found that the patient’s relapse usually occurs if the family is not ready and lacked adequate information to make adjustments to the presence of large family members who experience psychotic disorder. a study conducted by emsley et al.12 showed that the main cause of relapse in the patient’s treatment is ineffective therapeutic regimen which is 60.8%, although knowledge of psychotic disorder is in the high category, bad family attitude towards patients with serious psychotic disorder is 54.9%. bad behavior towards patients with serious psychotic disorders is 60.8%. at the end, a bad perception of the patient’s psychotic disorder leads to relapse as much as 62.7%. environmental factors are already supporting the patient while in the house supporting the patient is as many as 56.9%, but there are still 43.1% who state that the environment does not support the patient while at home. in a study conducted by corrigan et al.13, the public in general assume that people with psychotic disorders are dangerous individuals and are mainly caused by social factors and environment. subsequently, they are informed about the genetic basis which are also more likely to stigmatize the entire family of the patient. although certain social categories indicate that the stigma may vary from time to time and place, three basic forms of stigma (physical deformity, bad personal traits, and the status of ethnic outgroups) are found in most cultures and eras, leading some researchers hypothesize that the tendency to stigmatize may have a tendency to form little by little on specific things.14 in a similar study conducted in iraq by sadik et al.15, this bad perception is due to the lack of education about psychotic disorders. it could be enhanced with the access of health services to the community of psychotic disorders, with treatment, and good monitoring to people with a psychotic disorder. additionally, perceptions of psychotic disorder may be formed from knowledge, attitude, and understanding of mental health care. the perception of universitas padjadjaran students towards psychotic disorders was unfavorable. this perception could form bad behavioral intentions to psychotic disorders. theseehavioral intentions were not good as they shaped bad behavior to psychotic disorders, such as stigma and discrimination, which will reduce the rate of cure and improve recurrence of the psychotic disorder. the limitation of this study was some of the students when randomly selected as samples were hard to be found, so the randomization of the sample was repeated in order to fulfill the number of samples. it can be concluded that the perception of universitas padjadjaran students towards psychotic disorders is unfavorable. this perception is formed from a lack of education, campaigns, social media utilization, as well as a bad living experience of people with psychotic disorders. this shows that universitas padjadjaran students are illiterate towards psychotic disorders. references 1. who. investing in mental health. geneva: world health organization; 2013. 2. litbangkes ri. riset kesehatan dasar 2013. jakarta: kementerian kesehatan republik indonesia; 2013. 3. dikdik baehaqi arif d. membangun karakter warga negara. jakarta: peran (gerakan) mahasiswa. 2012. 4. angermeyer mc, dietrich s. public beliefs about and attitudes towards people with mental illness: a review of population studies. acta psychiatr scand. 2006;113(3):163–79. 5. gureje o, lasebikan vo, ephraimoluwanuga o, olley bo, kola l. community study of knowledge of and attitude to mental illness in nigeria. br j psychiatry. 2005;186(5):436–41. 6. jorm af, nakane y, christensen h, yoshioka k, griffiths km, wata y. public beliefs about treatment and outcome of mental disorders: a comparison of australia and althea medical journal. 2018;5(1) 31 japan. bmc medicine. 2005;3(1):12. 7. cabeza r, mazuz ys, stokes j, kragel je, woldorff mg, ciaramelli e, et al. overlapping parietal activity in memory and perception: evidence for the attention to memory model. j cogn neuros. 2011;23(11):3209–17. 8. dufner m, denissen j, sedikides c, van zalk m, meeus wh, aken m. are actual and perceived intellectual selfenhancers evaluated differently by social perceiver. european jornal of personality. 2013;27(6):621–33. 9. mceachan rrc, conner m, taylor nj, lawton rj. prospective prediction of health-related behaviours with the theory of planned behaviour: a meta-analysis. health psychol. 2011;5(2):97–144. 10. corcoran cm, first mb, cornblatt b. the psychotic disorders risk syndrome and its proposed inclusion in the dsm-v: a risk–benefit analysis. schizophr res. 2010;120(1):16–22. 11. dominguez m, wichers m, lieb r, wittchen h-u, van os j. evidence that onset of clinical psychotic disorders is an outcome of progressively more persistent subclinical psychotic experiences: an 8-year cohort study. schizophr bull. 2011;37(1):84-93. 12. emsley r, chiliza b, asmal l, harvey bh. the nature of relapse in schizophrenia. bmc psychiatry. 2013;13(1):50. 13. corrigan pw, morris sb, michaels pj, rafacz jd, rüsch n. challenging the public stigma of mental illness: a meta-analysis of outcome studies. psychiatr serv. 2012;63(10):963–73. 14. horsburgh va, schermer ja, veselka l, vernon pa. a behavioural genetic study of mental toughness and personality. pers indiv differ. 2009;46(2):100–5. 15. sadik s, bradley m, al-hasoon s, jenkins r. public perception of mental health in iraq. int j ment health syst. 2010;4:26. renzavaldy rusly, veranita pandia, deni kurniadi s: perception of universitas padjadjaran students towards psychotic disorders vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 1 characteristics of functional constipation among kindergarten students in kecamatan jatinangor, west java, indonesia livia giovanni,1 yudith setiati ermaya,2 tisnasari hafsah2 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr hasan sadikin general hospital bandung indonesia abstract background: functional constipation can occur in children and affect their quality of life, but there is still lack of awareness and inability to provide proper management. therefore, early detection is important. the aim of this study was to identify the prevalence of functional constipation among kindergarten students and its risks. methods: a quantitative descriptive study was conducted from april to may 2017 on kindergarten students in kecamatan jatinangor, west java, indonesia by using questionnaires for their parents. in total, 149 parents joined the study. the questionnaire was made based on the rome iv criteria with additional questions for the student’s characteristics comprised of sex, prematurity, allergy, family history of constipation, dietary fiber consumption, and parents’ education level. descriptive analyses were conducted. results: the prevalence of functional constipation among the students was 8.7% with the most frequent complaints were retentive posturing (76.9%), hard stool consistency (38.5%), and history of obstructing toilet by stool (38.5%). characteristics of children with functional constipation were prematurity (15.4%), history of allergy (15.4%), low dietary fiber intake (from fruits, 69.2%, vegetables 84.6%, seeds 100%), and non-university educated parents (father 76.9%, mother 84.6%). conclusions: constipation among kindergarten students in jatinangor is 8.7%, while the most apparent characteristics in constipated children is low dietary fiber intake. keywords: functional constipation, kindergarten students, prevalence correspondence: livia giovanni, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: livia0697@gmail.com introduction functional constipation commonly occurs in children worldwide (0.7–29.6%).1 a study on kindergarten students in bali2 showed a percentage of 15.1%. patients with functional constipation have various signs and symptoms causing a decrease in quality of life. functional constipation in children can cause learning problems, adaptation difficulty, and minor psychological disorder.3 the early detection of functional constipation is therefore needed. meanwhile, parents rarely bring their children for any possible signs and symptoms of functional constipation to a doctor due to the lack of awareness towards the problem and the importance of proper management. any complaints resembling constipation are usually treated based on local and generational beliefs, as well as self-trial and error with their efficacy unproven. therefore, children are often brought to the hospital in a more serious condition. the aim of this study was to identify the prevalence of functional constipation and its risks. methods a descriptive study was carried out to parents of kindergarten students in jatinangor subdistrict west java, indonesia from april 2017 to may 2017. there were 17 kindergarten schools in jatinangor subdistrict, with the number of students of each school ranging from 16 to 99 students. after considering the location of the school and the number of students in the school, 5 schools were selected. the inclusion criteria of the participants of this study were parents whose children studied in amj. 2018;5(1):1–5 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1128 althea medical journal. 2018;5(1) 2 amj march 2018 those selected kindergarten. the exclusion criteria were parents with children who were under 4 years old, children with neurological, metabolic, or endocrine problems or in treatment phase with opioids, anticonvulsants, antidepressants, or anticholinergic drugs. a total of 220 parents of kindergarten students from those schools were selected to participate in this study. prior to the data collection, the selected parents were given explaination about the study, and those who understood and agreed to join the study were given informed consent form to be signed. every participant was given a set of questionnaire which was divided into 2 parts, that comprised of the student’s general data, to explore the characteristics, and 7 questions as the diagnostic tool for functional constipation. the first part explored the characteristics of the parents and the children, consisted of questions about name, sex, place and date of birth, address, number of children in the family, history of prematurity, allergy, family history of defecation difficulty, dietary fiber consumption, and general data table 1 differentiation characteristics of the subjects characteristics constipated(n=13) unconstipated (n=16) sex male 4 (30.8%) 70 (51.5%) female 9 (69.2%) 66 (48.5%) prematurity preterm 2 (15.4%) 5 (3.7%) term 11 (84.6%) 131 (96.3%) allergy yes 2 (15.4%) 14 (10.3%) no 11 (84.6%) 122 (89.7%) family history of constipation yes 0 (0%) 7 (5.1%) no 13 (100%) 129 (94.9%) dietary fiber consumption fruits not everyday 9 (69.2%) 94 (69.1%) everyday 4 (30.8%) 42 (30.9%) vegetables not everyday 11 (84.6%) 89 (65.4%) everyday 2 (15.4%) 47 (34.6%) seeds not everyday 13 (100%) 120 (88.2%) everyday 0 (0%) 16 (11.8%) paternal last education non-university educated 10 (76.9%) 95 (69.9%) university educated 3 (23.1%) 41 (30.1%) maternal last education non-university educated 11 (84.6%) 87 (63.9%) university educated 2 (15.4%) 49 (36.1%) of the parents, especially the education level. the second part explored their children’s experience in defecation, i.e. the frequency of bowel movements, stool consistency, pain with bowel movements, history of obstructed toilet by stool, retentive posturing, palpable stool in abdomen, and soiling. the second part of the questionnaire was generated from the rome iv diagnostic questionnaire for pediatric functional gastrointestinal disorders for children and adolescents section c that was translated into bahasa indonesia. the students were categorized as constipated if they experienced at least 2 criteria listed in the rome iv criteria in the last one month. a total of 149 from 220 completed questionnaires were eligible to be analyzed. the collected data was expressed in numbers and percentages, and presented in tables. this study was carried out with the permission of the health research ethics committee faculty of medicine universitas padjadjaran with ethical exemption no:459/ un6.c.10/pn/2017. althea medical journal. 2018;5(1) 3livia giovanni, yudith setiati ermaya, tisnasari hafsah: characteristics of functional constipation among kindergarten students in kecamatan jatinangor, west java, indonesia results this study discovered that the prevalence of functional constipation among kindergarten students was 8.7% (13 out of 149 students). based on their characteristics, this study revealed that females, had term birth history, no history of allergy, no family history of constipation, and non-daily dietary fiber consumption (fruits=69.2%, vegetables=84.6%, seeds=100%), were the most frequent who had functional constipation. moreover, the complaints experienced by constipated students showed retentive posturing as the most frequent complaint experienced by 10 out of 13 students (table 2). discussion this study showed constipation among kindergarten students with a prevalence of 8.7%. this prevalence was lower than the percentage of 15.1% from a previous study in bali.2 this result was also in the range of worldwide prevalence of constipation in pediatric population published by the world health organization (who) (0.7–29.6%).1 in the united stated of america (usa)4, 10% prevalence rate has been reported, and studies from europe5 showed prevalence rates ranging from 0.7% to 15%. in taiwan6, functional constipation has been reported in 33.3% of elementary students, 12% to 28% in hong kong7 and south korea8 and 7% to 15% of school children in sri lanka.9 these differences might be due to difference in lifestyle, especially because of the dietary habit, age range of children who was included, duration of study, and the instruments used to detect the symptoms of functional constipation. based on the rome iv diagnostic questionnaire for pediatric functional gastrointestinal disorders for children and adolescents section c, most common complaints experienced by children with functional constipation in this study were retentive posturing (76.9%), compared to hard stool consistency (38.5%), history of obstructed toilet by stool (38.5%), frequency of bowel movements was 2 per week or less (30.8%), painful bowel movements (23.1%), and soiling (30.8%). there was no student with history of palpable stool in abdomen. the percentages presented above were relatively different compared to the previous study performed in pediatric gastroenterology clinics in korea by chang et al.10 which showed hard stool consistency, painful bowel movement, and a history of large stools in the lower abdomen as the most common complaints with the percentage of 60%, 60%, and 68% consecutively. another study from korea which was performed in several daycare centers by park et al.11 showed painful defecation (55.6%) and retentive posturing (50%) as the most common complaints experienced by constipated children, followed by the presence of a large fecal mass in the rectum (44.4%), frequency of bowel movements was 2 per week or less (44.4%), and obstructed toilet by large stool (38.9%), with the least common complaints were soiling once or more per week (27.8%). all these studies showed that one out of three most common experienced complaints in children with functional constipation was hard stool consistency. in exploration of the characteristics, the constipation group was dominated by female. the study by chang et al.10 showed similar result, with 56% of females in the constipation group. this aroused suspicion that there might be correlation between sex and functional constipation. nevertheless, the previous study by park et al.11 did not show any correlation between them. moreover, other factors suspected to have association with functional constipation were table 2 rome iv criteria for children with functional constipation complaints frequency percentage frequency of bowel movements 2 per week or less 4 30.8% stool consistency 5 38.5% pain with bowel movements 3 23.1% history of obstructed toilet by stool 5 38.5% retentive posturing 10 76.9% palpable stool in abdomen 0 0% soiling 4 30.8% althea medical journal. 2018;5(1) 4 amj march 2018 prematurity and allergy. out of the total of 13 students who were detected to have functional constipation, 2 students were born premature. a previous study in turkey12 showed that prematurity was seen more frequently in constipated children compared to unconstipated children, while the other study in korea11 showed no correlations between gestational week and functional constipation. the correlation, if any, might probably be due to the gestational age which is related to the development process of the nervous system in the digestive tract. history of allergy was found in 15.4% of children in the constipated group. rajindrajith et al.13 stated that one of the risk factors for functional constipation in children was cow’s milk protein allergy. the majority of children with functional constipation had parents with nonuniversity based education (father=76.9%, mother=84.6%) this result might suggest that education of parents correlated with functional constipation prevalence. the level of education might probably affect eating habits they applied to their children. currently, a bad eating habit is one of many problems frequently faced by kindergarten students. this study showed that low dietary fiber intake seemed to relate to higher number of constipation cases. in the constipated group, 9 students did not consume fruits daily (69.2%), 13 students did not consume seeds daily (100%) and 11 students did not consume vegetables daily (84.6%). the previous study in korea11 and turkey12 shared similar results. however, there might be a misperception when the respondents were asked about seeds, since seeds are not commonly consumed by indonesians. most of the respondents thought that seeds and nuts were the same but it was actually different. nuts are well-known for its protein, while seeds are well-known for its fiber content. family history as one of the predisposition factors for functional constipation in children had a contradictive result in this study. there was no constipated child with a family history of constipation, while the previous studies showed correlation between family history of constipation and functional constipation in children.2,11,12 this study had several limitations. variables obtained in this study were superficial, for example in the determination of prematurity, history of dietary fiber intake, history of allergy, etc.might cause bias. the other limitation was the minimum amount of samples, which was targeted as many as 197 respondents, was not obtained due to the time of data retrieval. the data was collected near the end of the academic year, when the study process was ineffective; therefore, many students did not attend school. meanwhile, it was difficult to make home visits for obtaining data due to the duration and location access limitations. lastly, this study was a descriptive study, so it could not confirm any correlations between the variables and constipation. therefore, a further analytical study with a larger sample size should be carried out to prove the possible hypotheses mentioned above. in conclusion, the prevalence of constipation among kindergarten students in kecamatan jatinangor is 8.7%, with low dietary fiber intake as the most apparent characteristic. a further analytical study should be performed to find the correlation between the incidence of constipation and the characteristics, so that it may gain more significant information. references 1. mugie sm, benninga ma, di lorenzo c. epidemiology of constipation in children and adults: a systematic review. best pract res clin gastroenterol. 2011;25(1):3–18. 2. eva f. prevalensi konstipasi dan faktor risiko konstipasi pada anak [thesis]. denpasar: universitas udayana; 2015. 3. rajindrajith s, devanarayana nm, crispus perera bj, benninga ma. childhood constipation as an emerging public health problem. world j gastroenterol. 2016;22(30):6864–75. 4. wald er, di lorenzo c, cipriani l, colborn dk, burgers r, wald a. bowel habits and toilet training in a diverse population of children. j pediatr gastroenterol nutr. 2009;48(3):294–8. 5. kiefte-de jong j, escher j, arends l, jaddoe v, hofman a, raat h, et al. infant nutritional factors and functional constipation in childhood: the generation r study. am j gastroenterol. 2010;105(4):940–5. 6. wu t-c, chen l-k, pan w-h, tang r-b, hwang s-j, wu l, et al. constipation in taiwan elementary school students: a nationwide survey. j chin med assoc. 2011;74(2):57–61. 7. tam yh, li am, so hk, shit ky, pang kk, wong ys, et al. socioenvironmental factors associated with constipation in hong kong children and rome iii criteria. j pediatr gastroenterol nutr. 2012;55(1):56–61. 8. lee wt, ip ks, chan js, lui nw, young bw. increased prevalence of constipation althea medical journal. 2018;5(1) 5 in pre-school children is attributable to under-consumption of plant foods: a community-based study. j paediatr child health. 2008;44(4):170–5. 9. rajindrajith s, devanarayana n, adhikari c, pannala w, benninga m. constipation in children: an epidemiological study in sri lanka using rome iii criteria. arch dis child. 2012;97(1):43–5. 10. chang sh, park ky, kang sk, kang ks, na sy, yang hr, et al. prevalence, clinical characteristics, and management of functional constipation at pediatric gastroenterology clinics. j korean med sci. 2013;28(9):1356–61. 11. park m, bang yg, cho ky. risk factors for functional constipation in young children attending daycare centers. j korean med sci. 2016;31(8):1262–5. 12. kocaay p, eğrıtaş o, dalgic b. normal defecation pattern, frequency of constipation and factors related to constipation in turkish children 0-6 years old. turkish j gastroenterol. 2011;22(4):369–75. 13. rajindrajith s, devanarayana nm. constipation in children: novel insight into epidemiology, pathophysiology and management. j neurogastroenterol motil. 2011;17(1):35–47. livia giovanni, yudith setiati ermaya, tisnasari hafsah: characteristics of functional constipation among kindergarten students in kecamatan jatinangor, west java, indonesia althea medical journal. 2017;4(2) 282 amj june 2017 five years study of recurrent febrile seizure risk factors ausi indriani,1 nelly amalia risan,2 titing nurhayati3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, biology cell and physiology faculty of medicine universitas padjadjaran abstract background: nearly one-third of febrile seizure patients suffered recurrent febrile seizures. several risk factors contribute to this recurrence, namely young age, family history of febrile seizures, low body temperature and rapid duration of fever before onset of seizures. recently, the types of seizure and gender have been stated increasing risk of this recurrence. the objectives of this study was to identify the risk factors of recurrent febrile seizures. methods: a descriptive study was carried out by retrieving data from inpatient medical records during the period of january 1st, 2009 to december 31st, 2013 at one of the top referral hospitals in west java, indonesia. variables of this study were the first febrile seizure age, gender, type of febrile seizure, a family history of febrile seizure, a family history of epilepsy, body temperature when febrile seizure occurred and duration of fever before onset of seizure. the collected data were tabulated by frequency and percentage and displayed in tables. results: out of 154 patients with febrile seizures 58 suffered recurrent febrile seizures. forty three percent had a first febrile seizure at the age of under12 months, 72% were male, 46% had fever less than 24 hours before the onset of seizure, 65% had complex febrile seizures, 28% had positive family history of febrile seizures, and 5% had positive family history of epilepsy. conclusions: the risk factors for recurrent febrile seizures are young age, male, rapid duration of fever before onset of seizure and complex febrile seizure. keywords: febrile seizure, recurrent febrile seizure, risk factors correspondence: ausi indriani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281266070152 email: ausi.indriani@gmail.com introduction febrile seizure is one of the most common seizures suffered by children with a total prevalence of 2−5%.1 according to the international league against epilepsy (ilae), febrile seizure is a seizure occurring in association with a febrile illness in the absence of a central nervous system infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures.2 patients with febrile seizures usually have a good prognosis although this condition makes parents worried.3,4 morbidity and mortality rate of febrile seizures are relatively low; nevertheless febrile seizures also have the risk for death.5,6 patients with febrile seizures also have a high risk for recurrent febrile seizures and epilepsy.1,4,7 nearly one-third of febrile seizure patients suffered recurrentfebrile seizures.1,8 theoretically, there are several risk factors for recurrence of febrile seizures; young age, family history of febrile seizure, low body temperature and rapid duration of fever before onset of seizures.8-10 recently, the type of seizure and gender have been stated increasing risk of recurrent febrile seizure.4 the objectives of this study was to identify the risk factors of recurrent febrile seizures. methods data of this descriptive study was retrieved from medical records of recurrent febrile seizure patients who were hospitalized during the period of january 1st, 2009 to december 31st, 2013 at dr. hasan sadikin general hospital (rshs) bandung. the process of collecting medical record data was approved amj. 2017;4(2):282–5 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1086 283 althea medical journal. 2017;4(2) by the ethics committee of rshs. the subjects in this study were all the patients with clinical diagnose of recurrent febrile seizures that met the inclusion criteria, i.e. patients who had seizures accompanied by a rise in body temperature above 38⁰c caused by an extra cranium process, children with an age range 1 month to 7 years and did not have a history of afebrile seizures. the variables of this study were the risk factors for recurrent febrile seizures that consisted of first febrile seizure age, gender, type of febrile seizure, family history of febrile seizure, family history of epilepsy, body temperature when febrile seizures occurred and the duration of fever before onset of seizure. then, data were processed by using statistical software. the data were calculated in the form of frequency and percentage and arranged in tabular form. results from the medical record data of febrile seizure patients at rshs in the period january 1st, 2009 to december 31st, 2013 there were 154 patients with febrile seizures of which 37,6% were with recurrent febrile seizures (58 patients). in this study, patients with first febrile table 1 distribution of risk factors of recurrent febrile seizure variable n = 58 (%) age of first febrile seizure < 12 months, n (%) 25 (43) 12-24 months, n (%) 22 (38) ≥ 24 months, n (%) 5 (9) not identified, n (%) 6 (10) gender male, n (%) 42 (72) female, n (%) 16 (28) duration of fever before onset of seizure < 24 hours, n (%) 27 (46) 24-48 hours, n (%) 18 (31) 49-72 hours, n (%) 5 (9) 73-96 hours, n (%) 1 (2) ≥ 96 hours, n (%) 4 (7) not identified, n (%) 3 (5) type of febrile seizure simple febrile seizure, n (%) 16 (28) complex febrile seizure, n (%) 38 (65) not identified, n (%) 4 (7) family history of febrile seizure positive, n (%) 16 (28) negative, n (%) 33 (57) not identified, n (%) 9 (15) family history of epilepsy positive, n (%) 3 (5) negative, n (%) 55 (95) ausi indriani, nelly amalia risan, titing nurhayati: five years study of recurrent febrile seizure risk factors althea medical journal. 2017;4(2) 284 amj june 2017 seizure under the age of 12 months had the highest percentage. the number of male patients had almost doubled compared with female patients. patients with the duration of febrile seizures less than 24 hours had the highest percentage. the percentage of patients with positive family history of febrile seizures was less than patients with negative family history of febrile seizures. most of the patients had negative family history of epilepsy. discussion in this study out of 154 patients with febrile seizures 58 suffered recurrent febrile seizures. the percentage number of recurrent febrile seizures in this study was more than the percentage number in the study conducted by marudur et al.12 in 2012, which was 28.6%. however, it was less than the study conducted in japan10 which was 45 %. moreover, age is the most consistent risk factor that caused recurrent febrile seizures. the age in this discussion is the age of the patient when the first febrile seizure occurred under 12 months. this is due to febrile seizures have relationships with the maturity level of the brain. in this study, patients with first febrile seizure occurred under 12 months had the highest percentage. this was consistent with studies conducted in yogyakarta and iran who claimed that the age at first febrile seizure under 12 months has relationships with the occurrence of febrile seizures.11,12 based on the results, the number of male patients was almost doubled compared to female patients. this was consistent with the studies conducted by fallah et al.11 (2010), marudur et al.12 (2012), and veisani et al.13 (2013) which stated that male suffered more often from febrile seizures compared to female. according to shinnar1 in swaiman book’s pediatric neurology, gender is not a risk factor for recurrent febrile seizures. this was consistent with the study conducted by marudur et al.12 which state that gender does not have a relationship to an increased risk of febrile seizures. however, this was contrary to mikati’s statement in nelson textbook of pediatrics that male gender, is a risk factor for the occurrence of recurrent febrile seizures.4 in this study, patients with the duration of febrile seizures less than 24 hours had the highest percentage. this was supported by studies conducted by fallah et al.11 (2010) and marudur et al.12 (2012) which stated that the rapid duration of the fever before onset of seizure is a risk factor for the occurrence of recurrent febrile seizures. based on the results, it was discovered that febrile seizures with complex febrile seizure types had the highest percentage. this was contrary to the studies conducted by marudur et al.12 (2012) and veisani et al.13 (2013), which stated febrile seizures with simple febrile seizure types had a greater number than the number of febrile seizures with complex febrile seizure types. in this study, the number of patients who did not have a family history of febrile seizures was higher in percentage than patients who had a positive family history of febrile seizures. this was consistent with studies conducted in iran and turkey, however this result was contrary to studies conducted by fallah et al.11 (2010), marudur, et al.12 (2010), and tosun et al.14 (2010). a family history with febrile seizures was a risk factor for the occurrence of febrile seizures.1,4,9 this was caused by febrile seizures derived through autosomal dominant gene and a variety of single genes associated with febrile seizures.4 the results showed that most children did not have a family history of epilepsy. these results were similar to studies conducted in yogyakarta.12 while the study conducted in iran and turkey had a greater percentage.11, 14 there were limitations to this study regarding the data such as numerous patient medical records were not available, therefore a lot of patient data could not be used in this study. in addition, some medical records did not include the age when the first febrile seizure occurred, duration of the fever to seizure, febrile seizure type and family history of febrile seizures, whereas they were very important to determine the risk of recurrent febrile seizures. furthermore, the medical records contained no data on body temperature during a febrile seizure; it should have been asked to the parents about their children’s body temperature when the seizure occurred. due to the importance of these medical records as a source of a study, the medical record system at rshs should pay attention to the completeness in recording patient’s data. moreover, a study with primary data needs to be conducted so that the data obtained may be more accurate, besides an analytic study related risk factors for recurrent febrile seizures is also needed. the conclusion of this study, the risk groups have a greater percentage when compared to the non-risk group. however, the group with a positive family history of febrile seizures and those with a positive family history of epilepsy 285 althea medical journal. 2017;4(2) ausi indriani, nelly amalia risan, titing nurhayati: five years study of recurrent febrile seizure risk factors have a low percentage compared to the nonrisk group, the group with a negative family history of febrile seizures or epilepsy. references 1. shinnar s. febrile seizures. in: swaiman kf, ashwal s, ferriero dm, schor nf, editors. swaiman’s pediatric neurology, principles and practice. 5th ed. edinburgh: elsevier health sciences; 2012. p. 790−7. 2. kundu gk, rabin f, nandi e, sheikh n, akhter s. etiology and risk factors of febrile seizure an update. bangladesh j child health. 2010;34(3):103−12. 3. kanemura h, sano f, mizorogi s, tando t, sugita k, aihara m. parental thoughts and actions regarding their child’s first febrile seizure. pediatr int. 2013;55(3):315−9. 4. mikati ma. seizures in childhood. in: kliegman r, stanton bf, schor nf, geme iii jws, behrman re, editors. nelson textbook of pediatrics. 19th ed. philadelphia: elsevier/saunders; 2011. p. 2017−18. 5. graves rc, oehler k, tingle le. febrile seizures: risks, evaluation, and prognosis. am fam physician. 2012;85(2):149−53. 6. wolf p, shinar s. febrile seizure. in: maria bl, editor. current management in child neurology. 4th ed. shelton: bc decker; 2009. p. 99−104. 7. syndi seinfeld d, pellock j. recent research on febrile seizures: a review. j neurol neurophysiol. 2013;4(4):165–171. 8. chung s. febrile seizures. korean j pediatr. 2014;57(9):384−95. 9. ukk neurologi idai. kosensus penatalaksanaan kejang demam. in: hardiono dp, dwi pw, sofyan i, editors. 2th ed. jakarta: badan penerbit idai; 2006. p. 6. 10. sugai k. current management of febrile seizures in japan: an overview. brain dev. 2010;32(1):64−70. 11. fallah r, karbasi sa. recurrence of febrile seizure in yazd, iran. turk j pediatr. 2010;52(6):618−22. 12. marudur pt, herini es, satria cd. predictive factors for recurrent febrile seizures in children. paediatr indones. 2012;52(6):317−23. 13. veisani y, delpisheh a, sayemiri k. predictors of recurrent febrile seizures in iranian children. zahedan j res med sci. 2013;15(9):1−5. 14. tosun a, koturoglu g, serdaroglu g, polat m, kurugol z, gokben s, et al. ratios of nine risk factors in children with recurrent febrile seizures. pediatr neurol. 2010;43(3):177−82. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 42 amj march 2017 impact of comorbidity on length of stay of hospitalized pneumonia in children nur mala il a’la,1 adi utomo suardi,2 dewi kartika turbawati3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of clinical pathology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the incidence of pneumonia in children under-five in west java is high. the average length of stay (los) often exceeds the standards set by the indonesia-disease related group (ina-drg) because of the comorbidities. it can cause financial loss for the hospital. this study was conducted to analyze the impact of comorbidity on los. methods: data was collected from medical records of 296 hospitalized pneumonia under-five children in the department of child health dr. hasan sadikin general hospital bandung in the period from january– december 2012 that consisted of patient’s identity, los, primary diagnosis, and comorbid diagnosis. data was selected through inclusion and exclusion criteria and statistically analyzed using the chi-square and spearman correlation test. results: out of 218 subjects, those who had major comorbidities and minor comorbidities was 79 (36.2%) and 39 (17.9%), respectively. the average los of those who had major and minor comorbidities was 8.33±8.252 days and 5.95±3.554 days, respectively. congenital heart disease had the highest and most significant risk ratio (rr) with average los was 8.00±4.889 days with rr: 1.895 (95% ci:1.339–2.682, p=0.001). conclusions: subjects have higher average los than the los set by the ina-drg. congenital heart disease is the most common comorbidity and has the highest and the most significant risk ratio. [amj.2017;4(1):42– 6] keywords: comorbidity, indonesia-disease related group (ina-drg), length of stay (los), pneumonia, under-five children correspondence: nur mala il a’la, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8978311516 email: mala.1612@gmail.com introduction according to the indonesia demographic health survey, the incidence of pneumonia in children under-five in west java in 2009 was entered into the category of red or high (>4%).1 currently, in the implementation of health services with the financing program of jaminan kesehatan masyarakat (jamkesmas) and keluarga miskin daerah (gakinda) from the government, dr. hasan sadikin general hospital (rshs) bandung has sought the implementation of the casemix system with the indonesia-disease related group (ina-drg). the ina-drg is a health care classification system into a certain amount of financing based on diagnosis that consists of health care package rates including diagnosis, length of stay (los), and the cost per diagnosis of disease.2 the real los that occurred in the hospital can be greater than the ina-drg standard and one of the reasons is the presence of the secondary diagnoses or comorbidities. if the real alos of a hospital exceeds the standard of ina-drg, it may lead to higher costs that should be incurred. if this happens continuously, it is assured that the hospital would lose more.3 therefore, based on the above data, this study was conducted to analyze the impact of comorbidity toward the los of under-five year pneumonia patients of jamkesmas or gakinda participants in the inpatient room of the department of child health rshs bandung in the period from january–december 2012. althea medical journal. 2017;4(1) 43 methods this study was an analytic study with a crosssectional design, conducted from october– november 2013. data was obtained with total sampling from 296 medical records of the under-five hospitalized pneumonia jamkesmas or gakinda patients of the department of child health, dr. hasan sadikin general hospital bandung in the period from january– december 2012 . this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. the inclusion criteria were pneumonia patients hospitalized in the pediatric ward in the period from january–december 2012, who were participants of jamkesmas or gakinda, aged between 2 months to 5 years, and were discharged with approval. the exclusion criteria of the study subjects were patients who died during hospitalization. furthermore, comorbidities of pneumonia are anemia, quadriplegia, diarrhea, malnutrition, and congenital heart disease. the severity of pneumonia is classified as severe pneumonia and very severe pneumonia. patients were diagnosed clinically if they had cough or were breathing rapidly. if the child has a lower chest wall indrawing or stridor, the child is diagnosed with severe pneumonia. if the state is added with cyanosis, cannot drink or breast-feed, or there is a change in conciousness, the child is diagnosed with very severe pneumonia.4 the los amounted from the admission of the patient until the discharge of the patient. data were statistically analyzed using the chi-square test for the comparative test and the spearman correlation test to assess the correlation between the variables. it was considered statistically significant when p≤0.05 level. results the number of hospitalized pneumonia underfive children in the child health department of rshs bandung in the period from january– december 2012 amounted to 375 people, but the data that could be retrieved in this study was only of 296 people. out of 218 nur mala il a’la, adi utomo suardi, dewi kartika turbawati: impact of comorbidity on length of stay of hospitalized pneumonia in children table 1 comorbidity and length of stay (los) length of stay ( days ) min* max* mean sd ina-drg without comorbidity 1 20 5.27 3.446 5.5 minor comorbidity 1 20 5.95 3.554 5.6 major comorbidity 1 71 8.33 8.252 7.8 note; * min = minimum, max = maximum table 2 comorbidities that encompass anemia, quadriplegia, diarrhea, and malnutrition and length of stay (los) number length of stay (days) (n) min* max* mean sd ina-drg anemia underlying 34 1 16 6.59 3.491 7.8 fe deficiency 39 1 23 7.18 5.281 5.6 quadriplegia 26 3 71 9.19 13.026 7.8 diarrhea 32 1 13 6.22 3.098 5.5 malnutrition severe 16 3 71 12.94 16.234 7.8 mild-moderate 21 1 17 6.76 3.961 5.6 congenital heart disease 40 1 23 8.00 4.889 5.5 note; * min = minimum, max = maximum althea medical journal. 2017;4(1) 44 amj march 2017 patients who met the inclusion and exclusion criteria, were 100 patients (45.9%) with no comorbidity, 39 patients (17.9%) with minor comorbidities, and 79 patients (36.2%) with major comorbidity. this study showed that minor and major comorbidity had an average los that exceeded the ina-drg standard (table 1). in this study, the most common comorbidities were congenital heart disease. patients with anemia due to fe deficiency, quadriplegia, diarrhea, severe and mildmoderate malnutrition, as well as congenital heart disease had an average los that exceeded the ina-drg standard. patients with severe malnutrition had a higher average length of stay compared to most of the other comorbidities (table 2). this study also showed that congenital heart disease had a very significant risk ratio (rr) to increase the los (table 3). overall malnutrition and congenital heart disease also had a significant correlation with the los (table 4). discussions this study found that the average los was higher than that set by the ina-drg. one of the reasons is the presence of the secondary diagnoses or comorbidity.3 this study was also in line with the result of the study conducted by pichard et al.5 which showed that the length of hospital stay for severely malnourished patients is significantly greater (10.8±26.3 days) than the los for moderately malnourished patients (5.4±8.2 days) or well-nourished patients (3.9±7.8 days), this study also showed that patients with malnutrition have a higher average los (11,320±9:32), (p<0.05). these results indicate that malnutrition has an influence on the increase in the los in pneumonia patients.5 this is caused by malnutrition impaires immune function.6-9 this affects the speed of the patient to recover thus affecting the los. this study was also in line with a study conducted by sadoh et al.10 in 2013 which showed that children with congenital heart disease have a higher average los (11.50±7.03) than patients without congenital heart disease (7.38±5.34, p=0.012). this study also suggested that congenital heart disease had a higher average number of days of hospitalization (8.00±4.889) and increased the los with rr: 1,895 (95% ci:1.339-2.682, p=0.001). additionally, a congenital heart disease may cause a disturbance in sterling forces. increased hydrostatic pressure in the pulmonary capillaries increased driving pressure of the fluid to move out of the capillary. this pressure also damages the integrity of the alveolar-capillary membrane, causing capillary stress fracture. this causes the water to table 3 comorbidity and risk ratio of increasing length of stay (los) rr increasing length of stay (95% ci) p anemia 0.972 (0.644 – 1.467) 0.892 quadriplegia 0.728 (0.376 – 1.408) 0.315 diarrhea 1.215 (0,785 – 1.880) 0.403 malnutrition 1.485 (0.984 – 2.242) 0.078 congenital heart disease 1.895 (1.339 – 2.682) 0.001 table 4 comorbidity and its correlation with increasing length of stay (los) los (days) r p (1-tailed) anemia 6.90 -.009 0.446 quadriplegia 9.19 -.068 0.318 diarrhea 6.22 0.057 0.203 malnutrition 9.43 0.119 0.039 congenital heart disease 8.00 0.220 0.001 althea medical journal. 2017;4(1) 45nur mala il a’la, adi utomo suardi, dewi kartika turbawati: impact of comorbidity on length of stay of hospitalized pneumonia in children accumulate in the interstitial and alveoli which may become the source of lower respiratory tract infections. water that accumulates in the alveoli interstitium can also cause hypoxia due to alveolar collapse, decreased functional residual capacity, and ventilation/perfusion mismatching, thus increasing the work of breathing to maintain adequate ventilation. this will cause tachypnea in patients whose symptoms are also symptoms of pneumonia. this will extend the length of stay.11,12 other comorbidities such as anemia, quadriplegia, and diarrhea did not show rr and significant correlation toward the los . moschovis et al.13 stated that anemia as a comorbidity itself does not increase the risk of treatment failure. this is consistent with the study that the researcher conducted, that anemia did not have a significant rr to increase the los, although the data showed that patients with pneumonia and anemia due to fe deficiency had a higher average los than that set by the ina-drg. in the literature review conducted by krigger14 patients with quadriplegia, for example caused by cerebral palsy, usually have oral malfunction so often associated with aspiration pneumonia due to the esophagus reflux. the collected data showed that patients with quadriplegia had longer average los than that specified in the ina-drg, but quadriplegia did not have a significant rr to increase the los. walker et al.15 showed that diarrhea and alri have a small positive correlation and occurred together more than chance alone (0.15, 95% ci:0.13–0.17). in this study, out of 32 patients suffering from diarrhea, 6 of them had acute dysentry diarrhea, and the rest had non-dysentery, while out of 300 patients, only 12 were cultured and showed positive results. the microorganisms found in the culture results to find the cause of pneumonia in patients included acinetobacter iwofii, burkholderia cepacia, klebsiella pneumoniae, haemophilus influenza type b, pseudomonas aeruginosa, serratia marcescens, staphylococcus hominis, and streptococcus pneumoniae, with staphylococcus hominis which became microorganism that were most frequently found. however, all of the patients who were positive on culture, showed no incidence of diarrhea at all. the main cause was the small number of this culture, while the number of negative culture results might be caused by taking antibiotics prior to culture or was suffering from pneumonia caused by viruses that couldnot grow in culture. diarrhea in patients also may be caused by nosocomial infection. clostridium difficile has been associated with the incidence of diarrhea in hospitalized patients.16,17 in this study, there was not any relationship between diarrhea and the length of stay (los). the limitation of this study was the incomplete medical record documents of hospitalized pneumonia under-five children in the department of child health rshs bandung in the period from january–december 2012 . this study concludes that in general, the average los for either with major or minor comorbidity is higher than it has been defined by the ina-drg so that further studies need to be conducted on the clinical management aspect of under-five pneumonia patients with minor or major comorbidity in order to produce efficient services that will not cause a loss for the hospital. in the ina-drg, congenital heart disease itself is not included in the list of comorbidities, but it is included in the form of heart failure. this study showed that congenital heart disease was the most common comorbidity and had the highest and the most significant risk ratio and correlation with the los even in the absence of heart failure. therefore, it is necessary to conduct further studies and rediscussions concerning the basis of the los set by the government. references 1. pusat data dan surveilans epidemiologi (pusdasure) kementrian kesehatan ri. situasi pneumonia balita di indonesia. jakarta: kementrian kesehatan ri; 2010. 2. departemen kesehatan ri. tarif indonesia diagnosis related group (ina-drg), rumah sakit umum dan khusus. jakarta: departemen kesehatan ri; 2007. 3. nofitasari st, mahawati e. analisis lama perawatan (los) partus seksio caesarea pada pasien jamkesmas rawat inap berdasarkan ina-cbg’s di rumah sakit islam sultan agung semarang tahun 2010. fiki. 2013;1(1):1–18. 4. the united nations children’s fund (unicef)/world health organization (who). pneumonia : the forgotten killer of children. 2006. 5. pichard c, kyle ug, morabia a, perrier a, vermeulen b, unger p. lean body mass depletion at hospital admission is associated with an increased length of stay. am j clin nutr. 2004;79(4):613–8. 6. keusch gt. the history of nutrition: althea medical journal. 2017;4(1) 46 amj march 2017 malnutrition, infection and immunity. j nutr. 2003;133(1):336s–40s. 7. marcos a, nova e, montero a. changes in the immune system are conditioned by nutrition. eur j clin nutr. 2003;57(suppl1):s66–s9. 8. schaible ue, kaufmann she. malnutrition and infection: complex mechanisms and global impacts. plos med. 2007;4(5):e115. 9. cunningham-rundles s, mcneeley df, moon a. mechanisms of nutrient modulation of the immune response. j allergy clin immunol. 2005;115(6):1119– 28. 10. sadoh w, osarogiagbon w. underlying congenital heart disease in nigerian children with pneumonia. afr health sci. 2013;13(3):607–12. 11. sadoh w. natural history of ventricular septal defect in nigerian children. south afr j child hlth. 2010;4:16–9. 12. healy f, hanna b, zinman r. pulmonary complications of congenital heart disease. paediatr respir rev. 2011;13(1):10–5. 13. moschovis pp, banajeh s, macleod wb, saha s, hayden d, christiani dc, et al. childhood anemia at high altitude : risk factors for poor outcomes in severe pneumonia. pediatrics. 2013;132 (5):e1156–62 14. krigger kw. cerebral palsy : an overview. am fam phys. 2006;73(1):91–100. 15. walker cl, perin j, katz j, tielsch jm, black re. diarrhea as a risk factor for acute lower respiratory tract infections among young children in low income settings. j glob health. 2013;3(1):010402. 16. dial s, alrasadi k, manoukian c, huang a, menzies d. risk of clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case–control studies. cmaj. 2004;171(1):33–8. 17. sandokji am, murshid kr, el-badry aa, alali kh, shalaby sa. infectious nosocomial diarrhea in the surgical wards: role of parasites and microbes imply stool analysis. j taibah univ sci. 2009;4(1):73– 81. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 512 amj december 2017 level of knowledge about tuberculosis among type 2 diabetes mellitus patients at the endocrine clinic dr. hasan sadikin general hospital bandung ulfah dwi febriani,1 rovina ruslami,2 bachti alisjahbana3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: diabetes mellitus (dm) is one of the risk factors for tuberculosis (tb). knowledge of tb is essential in prevention control for the person at risk. this study aimed to describe the level of knowledge about tb among dm patients. methods: a cross sectional study was performed involving 72 adult dm patients at the endocrine clinic, dr. hasan sadikin general hospital bandung. the subjects were interviewed using a standardized questionnaire including socio-demographic information and knowledge about tb: manifestation of tb, transmission, treatment, dm-tb co-infections, and status acquiring tb information in the last 12 months. knowledge was categorized as high, moderate and low if total scores were >75, 56–75 and <56 respectively. data were presented descriptively as percentage and mean (sd) after testing for the normality of distribution. results: the mean of age of subjects was 56.6 years, and 55% were female. most were unemployed (72.2%), had an education background lower than high school (75%), and lived in bandung (91.7%). the mean score of knowledge was 54.4. proportion of subjects based on the level of knowledge which is high, moderate and low, were 29.2%, 26.4%, and 44.4% respectively. conclusions: the level of knowledge about tb among type 2 dm patients at the endocrine clinic dr. hasan sadikin general hospital bandung was low. tb education program among dm patients needs to be improved. keywords: diabetes mellitus, knowledge, tuberculosis correspondence: ulfah dwi febriani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: ulfahdwifebriani@gmail.com introduction diabetes mellitus (dm) is one of the risk factors of tuberculosis (tb). increasing dm prevalence is associated with increasing prevalence of tb cases.1,2 increasing dm prevalence occurred significantly in developing countries, including indonesia, where tb is endemic.3,4 in 2010, 285 million adults (aged 20-79 years) in the world were affected by dm and the prevalence was 6.4%. the prevalence will increase to 7.7%, affecting 439 million adult patients in 2030. in developing countries, there will be 69% increase in dm patients in adults.3 the dm patients have two to five times risk toward tb infection compared to non-dm patients.5 increasing dm prevalence is a serious precaution in tb infection control.6 awareness and knowledge of tb is essential in tb control strategies. patients who have satisfactory knowledge of tb are less likely to be delayed in seeking tb care.7 health education program in tb control should increase knowledge about the clinical manifestation, mode of transmission, role of sputum examination, curability of the disease and the availability of diagnostic and tb treatment services in health facilities. awareness about the clinical manifestation of tb, transmission of tb, and misconception may affect population health-care seeking behavior.8 studies about level of knowledge about tb among bandung population are rarely performed. this study was conducted to describe the level of knowledge about tb among dm patients at the endocrine clinic, dr. hasan sadikin general hospital, bandung. methods a cross sectional study was conducted at the amj. 2017;4(3):512–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1260 althea medical journal. 2017;4(4) 513 endocrine clinic, dr. hasan sadikin general hospital bandung between september– november 2015, after obtaining approval from the ethical committee of dr. hasan sadikin general hospital bandung. the subjects were adult type 2 dm patients (aged 18 years or above) treated at the endocrine clinic dr. hasan sadikin general hospital bandung between september–november 2015, and voluntarily joined the study after a written informed consent. diabetic patients who had received tb treatment or were in the tb treatment period were excluded from the study. the minimal number of subject was 49. socio-demographics data and knowledge about tb were obtained by direct interview using a standardized questionnaire consisting of 12 questions. the questionnaire was formed using the frame from the questionnaire of the american international health alliance.9 topics of the questions were clinical manifestation of tb, transmission of tb, treatment of tb, tb-dm co-infection, and status of getting information about tb in the last 12 months. furthermore, the questionnaire was tested for its validity and reliability. the reliability score (chronbach’s alpha) was 0.962. the score was 1 for a correct and 0 for a wrong answer. for multiple-answer questions such as clinical manifestation and transmission of tb, subjects may answer more than one answer, and the answer was correct if subjects mentioned minimal one correct answer. the final score was categorized into high, moderate and low if the total score was >75, 56-75 and <56 respectively according to arikunto’s theory (2006). data were presented descriptively as percentage (%) and central tendency (mean + sd) after testing for normality of distribution using kolmogorovsmirnov. results half of the subjects were male, and the mean age was 56.6 years. the minimum and the maximum age was 31 and 82. three-quarters of them were graduated from high school and lower. most were unemployed while 9 out of 10 subjects lived in bandung (table 1). the mean score of knowledge about tb among dm patients was 54.4; per category it was considered as low. the lowest and highest score was 0 and 100. almost half of the subjects were with low level of knowledge about tb (figure 1). there was similarity in age among the three groups (high, moderate, and low level of knowledge about tb). in the group of dm patients with good level of knowledge of tb, there were more males than females, meanwhile in other groups (moderate and low) they were dominated by females (around 60%). based on educational level, subjects with moderate and low level of knowledge were dominated by groups of high school graduates and below. there were more unemployed subjects in the group of low level of knowledge about tb this study elaborated the detail of knowledge about tb by inquiring about 5 different aspects: knowledge about clinical manifestation of tb, transmission of tb, treatment of tb, tb-dm information, and exposure to tb information in the last 12 months. moreover, more than half of the subjects knew about the clinical manifestation of tb and transmission of tb. three-quarter of the subjects were aware that tb is curable; half of them knew that the treatment of tb will be 6 months, but only one out of 10 of them recognized rifampicin as an anti-tb drug (table 3). regarding tb dm coinfection, half of the subjects knew that persons with low immunity were vulnerable to tb, but only one out of three subjects knew that people with dm were vulnerable to tb. knowledge about routine table 1 characteristics of subjects characteristic n=72 (%) gender, n (%) male 32(44.4) female 40(55.6) age, mean ± sd 56.6± 9.7 educational level, n (%) primary school 16(22.2) junior high school 14(19.5) senior high school 24 (33.3) vocational training 6 (8.3) university 12(16.7) employment, n (%) employed 20(27.8) unemployed 52(72.2) residence, n (%) bandung 66(91.7) outside bandung 6(8.3) ulfah dwi febriani, rovina ruslami, bachti alisjahbana: level of knowledge about tuberculosis among type 2 diabetes mellitus patients at the endocrine clinic dr. hasan sadikin general hospital bandung althea medical journal. 2017;4(4) 514 amj december 2017 table 2 characteristics of subjects and level of knowledge about tuberculosis characteristics level of knowledge about tuberculosis high n (%) moderate n (%) low n (%) gender male 13 (61.9) 8 (42.1) 11 (34.4) female 8 (38.1) 11 (57.9) 21 (65.6) age, mean ± sd 52.7±10.3 58.6±9.5 57.9±8.9 educational level primary school 1 (4.8) 4 (21.1) 11 (34.4) junior high school 3 (14.3) 3 (15.8) 8 (25) senior high school 7 (33.3) 6 (31.6) 11 (34.4) vocational training 1 (4.8) 4 (21.1) 1 (3.1) university 9 (42.8) 2 (10.5) 1 (3.1) employment employed 8 (38.1) 4 (21.1) 8 (25) unemployed 13 (61.9) 15 (78.9) 24 (75) residence bandung 20 (95.2) 16 (84.2) 30 (93.8) outside bandung 1 (4.8) 3 (15.8) 2 (6.3) control and dm treatment could reduce risk of getting infected with tb was known by only half of the subjects. only one-third of the subjects got information about tb in the last 12 months. almost 70% of subjects did not obtain information about tb in the last 12 months (table 3). figure 1 proportion of subjects based on the level of knowledge about tb althea medical journal. 2017;4(4) 515ulfah dwi febriani, rovina ruslami, bachti alisjahbana: level of knowledge about tuberculosis among type 2 diabetes mellitus patients at the endocrine clinic dr. hasan sadikin general hospital bandung table 3 satisfaction distribution based on dimensions of service quality questions answer correct n (%) incorrect n (%) clinical manifestation of tb one main manifestation of tb 41 (56.9) 31 (43.1) transmission of tb tb is infectious 51 (70.8) 21 (29.2) tb is transmitted by droplet/sputum 48 (66.7) 24 (33.3) treatment of tb tb is curable 53 (73.7) 19 (26.3) treatment of tb is minimum 6 months 33 (45.8) 39 (54.2) rifampicin as anti-tb drug 9 (12.5) 63 (87.5) time to stop tb treatment 26 (36.1) 46 (63.9) tb dm co-infection person with low immunity level is vulnerable to tb 41 (56.9) 31 (43.1) control and dm treatment reduces risk of getting tb 37 (51.4) 35 (48.6) dm patients is vulnerable to tb 27 (37.5) 45 (62.5) tb patients with dm is more difficult to recover 26 (36.1) 46 (63.9) acquiring tb information in last 12 months 22 (30.6) 50 (69.4) discussion this study found that dm patients’ level of knowledge about tb was limited. the mean score of knowledge about tb among dm patients was 54.4; per category it was considered as low. the proportion of subjects based on the level of knowledge about tb which was high, moderate and low, were 29.2%, 26.4%, and 44.4% respectively. the fact that only one-third of subjects obtained information about tb in last 12 months, might explain the low level of knowledge about tb in this study. this level of knowledge was comparable to 59% newly-diagnosed pulmonary tb patients in nigeria10, and 64% in sudan11 that have unsatisfactory knowledge of tb. similar to the study in tanzania12, this study showed that the majority (70%) of subjects were with unsatisfactory knowledge of tb.12 the higher level of knowledge of the nigeria10 study could be explained by the higher level of education among the subjects. the correlation further explained in the tanzania study, apparently was not explored in this study. questions about the clinical manifestation of tb and transmission of tb were answered correctly by more than half of the subjects. less than half of the subjects were aware about the duration of treatment, and only onetenth of them knew that rifampicin as an antitb drug. furthermore, only one-third of them knew about the time to stop tb treatment. similar to this findings, subjects of previous study in tanzania12 also responded poorly to questions concerning general management of tb including duration of treatment and drug side effects. regarding the knowledge of tb-dm coinfection, more than half subjects did not know that dm patients were vulnerable to tb. it is contrary to the fact that dm patients have more risk toward tb infection compared to non-dm patients.5 a research in indonesia6 found a strong association between dm and tb in young and non-obese subjects and it was supported by another study in korea.13 almost two-third of dm patients in this study was unable to correctly answer the question that tb patients with dm are more difficult to recover than tb patients without dm. in fact, dm has a negative effect on tb treatment and is associated with lower performance status. 14,15 furthermore, knowledge about the clinical althea medical journal. 2017;4(4) 516 amj december 2017 manifestation, mode of transmission, role of sputum examination, curability of the disease and the availability of diagnostic and tb treatment services in health facility are associated with health seeking behavior.8 patients with lack of knowledge about tb were more likely to be delayed in seeking patients care.7,10 indeed, early diagnosis and effective treatment are the best way to control tb infection. this study found that only one-third of dm patients were being exposed to information about tb in the last 12 months. besides, the tb education program among dm patients should be intensified, especially in indonesia because indonesia is in the top ten for countries in numbers of people with dm.3,16 the tb control program should include educational intervention using alternative media with suitable modification to reach all sectors.17 effectiveness of the tb education program was proven by a study in india17 which explained the information, education and communication (iec) campaign about tb has positive impacts on increasing awareness and improving selfreporting of the general population. this study has several limitations. the subjects of this study were taken only at the endocrine clinic of dr. hasan sadikin general hospital bandung and were not compared to any other place. the phenomenon of differences between the study subjects and general population cannot be captured properly. this study was conducted without considering about factors associating the level of knowledge and the association between knowledge and attitude. further studies are needed to compare the knowledge of tb among diabetic patients treated in hospital and primary health care, to analyze the factors associated with the level of knowledge, and to find the association between knowledge and attitude. in conclusion, the level of knowledge about tb among dm patients at the endocrine clinic of dr. hasan sadikin general hospital bandung is low. almost half of the diabetic patients are with low level of knowledge about tb, one third is high and a quarter of them was moderate. the tb control programs for educating dm patients should be improved. references 1. leung cc, lam th, chan wm, yew ww, ho ks, leung gm, et al. diabetic control and risk of tuberculosis: a cohort study. am j epidemiol. 2008;167(12):1486-94. 2. stevenson cr, forouhi ng, roglic g, williams bg, lauer ja, dye c, et al. diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence. bmc public health. 2007;7(1):234–41. 3. shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes res clin pract. 2010;87(1):4–14. 4. who. global tuberculosis report 2014. geneva: world health organization; 2014. 5. alisjahbana b, crevel rv, sahiratmaja e, heijer md, maya a, istriana e, et al. diabetes mellitus is strongly associated with tuberculosis in indonesia. int j tuberc lung dis. 2006;10(6):696–700. 6. mondal m, nazrul hm, chowdhury m, howard j. socio-demographic factors affecting knowledge level of tuberculosis patients in rajshahi city, bangladesh. afr health sci. 2015;14(4):855–65. 7. suganthi p, chadha v, ahmed j, umadevi g, kumar p, srivastava r, et al. health seeking and knowledge about tuberculosis among persons with pulmonary symptoms and tuberculosis cases in bangalore slums. int j tuberc lung dis. 2008;12(11):1268–73. 8. american international health alliance. strengthening tuberculosis control in moldova. washington dc: usaid; 2007. 9. biya o, gidado s, abraham a, waziri n, nguku p, nsubuga p, et al. knowledge, careseeking behavior, and factors associated with patient delay among newly-diagnosed pulmonary tuberculosis patients, federal capital territory, nigeria, 2010. pan afr med j. 2014;18(suppl 1):6–10. 10. mohammed a, yousif m, ottoa p. knowledge of tuberculosis: a survey among tuberculosis patients in omdurman, sudan. sudanese j public health. 2007;2(1):22–8. 11. wandwalo e, mørkve o. knowledge of disease and treatment among tuberculosis patients in mwanza, tanzania. int j of tuberc lung dis. 2000;4(11):1041–6. 12. koo bk. diabetes mellitus and tuberculosis. diabetes metab j. 2013;37(4):249–51. 13. alisjahbana b, sahiratmadja e, nelwan ej, purwa am, ahmad y, ottenhoff th, et al. the effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. clin infect dis. 2007;45(4):428–35. 14. baker ma, harries ad, jeon cy, hart je, kapur a, lönnroth k, et al. the impact of diabetes on tuberculosis treatment outcomes: a systematic review. bmc med. 2011;9(1):81–95. althea medical journal. 2017;4(4) 517 15. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047–53. 16. sreeramareddy ct, kumar hh, arokiasamy jt. prevalence of self-reported tuberculosis, knowledge about tuberculosis transmission and its determinants among adults in india: results from a nation-wide cross-sectional household survey. bmc infect dis. 2013;13(1):16–24. 17. sharma n, taneja d, pagare d, saha r, vashist r, ingle g. the impact of an iec campaign on tuberculosis awareness and health seeking behaviour in delhi, india. int j tuberc lung dis. 2005;9(11):1259– 65. ulfah dwi febriani, rovina ruslami, bachti alisjahbana: level of knowledge about tuberculosis among type 2 diabetes mellitus patients at the endocrine clinic dr. hasan sadikin general hospital bandung althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 64 amj march 2017 detecting the presence of methicillin-resistant staphylococcus aureus on acne extractor used by some beauty salons in jatinangor ng jo sheng,1 gita indah triyanti rukmana,2 innearline diana3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of dermato-venerology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: over the past few decades, methicillin-resistant staphylococcus aureus (mrsa) has become a major cause of nosocomial infection and has recently emerged in the community. community associated mrsa (ca-mrsa) have grown drastically over the years and have mostly manifested as a form of skin infection. the mrsa infection usually occurs in individuals with skin lesions serving as a site of entry for the bacteria. the aim of this study was to determine if mrsa is presence on the acne extractor used by some beauty salons in jatinangor. methods: a total of 40 samples were taken from 14 beauty salons in jatinangor from september to october 2013. the samples were then cultured on mannitol salt agar. the isolated colonies were then gram stained, followed by catalase and coagulase test. the colonies having positive for staphylococcus aureus (s. aureus) were then tested for cefoxitin susceptibility. results: overall 3 of the isolates were positive for s. aureus and none were positive for mrsa. conclusions: only a small fraction of the isolates are positive for s. aureus and no mrsa is detected.. [amj.2017;4(1):64–8] keywords: acne extractor, beauty salons, community associated mrsa (ca-mrsa) correspondence: ng jo sheng, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285759632537 email: ngjosheng@gmail.com introduction staphylococcus aureus (s. aureus) is part of the staphylococcacceae group, and it is the most frequently seen of the staphylococci strain. the normal habitats of s. aureus are the human skin and mucosal surfaces. over time, the staphylococcal infections have become increasingly difficult to treat. this is due to the s. aureus development of resistance towards antibiotics. one of the most commonly encountered forms of resistant s. aureus is the methicilin-resistant staphylococcus aureus (mrsa).1,2 methicilin-resistant staphylococcus aureus infections are more severe as compared to s. aureus infection, and are highly associated with vulnerable populations. even more recently, community acquired mrsa infections are commonly seen in healthy individuals. these individuals usually present with cutaneous manifestations.3 based on the previous study conducted by center of disease control and prevention (cdc) in year 2005, there was an estimate of 94,000 cases of invasive life-threatening mrsa infection with about 19,000 deaths due to the mrsa infection. a 15-year study conducted by the medical center of san diego from 1990 to 2004 showed that of the 1888 cases collected, 35% were nosocomial acquired mrsa infection while the latter 65% were community acquired mrsa infection.4,5 the transmission of mrsa is usually through direct contact with an infected person, or a carrier and touching mrsa contaminated materials or substance.5-7 according to “outbreak of invasive methicillin-resistant staphylococcus aureus infection associated with acupuncture and joint injection”, data showed that all patients who were in contact with the mrsa colonized needle developed severe invasive mrsa infection. this study has shown that in a community setting, the use of invasive instrument increases the risk of developing althea medical journal. 2017;4(1) 65 mrsa infection.6-9 in jatinangor public health centre (phc), a study was conducted in 2012 whereby mrsa was detected from the isolates of hand swabs of the medical and paramedical staff, proving that there is nosocomial mrsa in phc, jatinangor. a beauty salon is an establishment that provides cosmetic treatment for both men and women. one of the common services offered by the beauty salon is facial treatment which involves the use of an acne extractor. the acne extractor is an invasive instrument, which in practice is used to remove comedones; thus, this serves as a portal of entry for mrsa to infect the individual. the study was conducted to determine if mrsa can be found on the acne extractor from some beauty salons in jatinangor. as the acne extractor may serve as a reservoir for mrsa, there is higher possibility of colonization of mrsa there than any other equipment found in the beauty salons. methods a descriptive laboratory cross-sectional study was conducted from september to october 2013 in jatinangor sub district. samples were obtained prior to cleaning, washing, sterilizing and applying to face from beauty salons which offered facial treatments and willing to participate. the samples were then tested in the microbiology laboratory of faculty of medicine universitas padjadjaran. the study conducted was approved by the health research ethics committee of faculty of medicine universitas padjadjaran. the sample size was calculated using the descriptive study of dichotomous variable formula, and a total of 40 samples were used for the study. the samples were obtained from the acne extractor through convenience sampling technique and were then cultured on mannitol salt agar. after a 24-hour incubation period, the isolated colonies were gram stained. colonies that are gram positive were then further tested for catalase enzyme using hydrogen peroxide (10%), and then tested for coagulase using human plasma. colonies that showed positive reactions were then further tested for cefoxitin (2µg) susceptibility. the diameter of the clear zones around the cefoxitin disc was measured using a ruler. the s. aureus was considered resistant if the clear zone was less than 22mm. the beauticians of the salons were then asked to answer 2 questions about the technique of sterilization used in the salons. the data obtained from the study and the beauticians were then presented descriptively as incidence of mrsa and knowledge and awareness of sterilization protocol. results the total number of beauty salons participated was 14 out of the 16 beauty salons along jatinangor street. isolates are considered s. aureus positive when are proven to be gram positive, with catalase and coagulase positive. the mrsa is considered presence when there is resistance to cefoxitin disc. based on the study, out of the 40 samples collected and tested, only 3 samples were found to be positive for s. aureus. after further microbiological test, none of the samples were positive for mrsa. the awareness and performance was done to assess the ability of the beauticians to sterilize in an acceptable manner. the results showed that more than half of the beauticians were unable to sterilize well although they were aware of the standard sterilization technique (table 1). discussions the study was performed to detect the presence of mrsa on acne extractor used by some beauty salons along jatinangor street. as stated in the previous chapters, the mrsa was detected microbiologically, whereby the specimen collected is cultured, gram stained, tested for catalase and coagulase enzyme, and antibiotic susceptibility. as mrsa is a common bacteria of antibiotic resistance, it is chosen as the subject of the study. besides, many studies conducted have shown that ca-mrsa, have a ng jo sheng, gita indah triyanti rukmana, innearline diana: detecting the presence of methicillin-resistant staphylococcus aureus on acne extractor used by some beauty salons in jatinangor table awareness and performance of proper sterilization technique for the acne extractor standard sterilization technique performed well (n=2) performed poorly (n=12) knows (n=9) 2 7 does not know (n=5) 0 5 althea medical journal. 2017;4(1) 66 amj march 2017 widespread distribution. the sterility of the acne extractor also plays a major role in the presence of the bacteria. a total of 40 samples were used in the study. the samples collected were swabs of the acne extractor from some beauty salons along jatinangor street. as of the 16 beauty salons along jatinangor street, only 14 beauty salons took part in the study. the other 2 beauty salons refused to participate due to worry of losing customers. the participants were given adequate information and procedure about the study before samples were collected. from the 40 samples obtained, no mrsa was found on the surface of the acne extractors. however, the results showed that there were 3 samples positive for s. aureus. in this study, there was no mrsa found; thus, there was no ca-mrsa. therefore, it can be said that the beauty salons along jatinangor street were free of the ca-mrsa. the mrsa is usually transmitted through the direct or indirect contact with either contaminated instruments or infected patients who are involved in the community. hence, there was no risk of mrsa infection for the clients of the beauty salons along jatinangor street. only 2 subjects out of the 14 subjects were able to sterilize the equipment in an acceptable manner. when the participants of the study were asked to demonstrate the technique of sterilization used, none of them used alcohol to sterilize their equipment. the 2 participants who passed this test did so by soaking the acne extractor in hot water. a study conducted shows that after practicing comprehensive infection control measures which involves sterilization and control will improve infection spread.10 community associated mrsa studies conducted in america and switzerland have shown increasing prevalence over the years.11,12 from the similar study conducted in america, community associated mrsa infection accounted for 12% of all the mrsa infection documented during the period of study. the study also shows that the mrsa is detected from the community originated from the healthcare setting.11 the main reason for the widespread of mrsa in the community and healthcare is due to the common use of β-lactam antibiotics prescribed by the primary care doctors.11 as discussed in previous chapters, the common presentation of the mrsa infection is skin and soft tissue infection. besides, ca-mrsa is much more severe compared to nosocomial mrsa as it is resistant to more classes of antibiotics.11 from the results of the study, the acne extractor was contaminated with s. aureus; therefore, it serves as a source of infection. when the contaminated acne extractor is used to remove the comedones on the facial skin, the s. aureus may be able to penetrate the deep skin tissue through the puncture site. this will then develop into a s. aureus infection of the skin. common presentation of the infection is furuncle or also known as a boil. when not treated adequately, the s. aureus can further penetrate the tissue and move deeper increasing the risk of developing invasive s. aureus infection. examples of those diseases are bacteremia, endocarditis, metastatic infections, sepsis and toxic shock syndrome.13 in addition, the patients of s. aureus infection had the risk of 20−50% of developing mrsa infection.14 despite the low percentage of s. aureus found, many other species of bacteria were found to be present on the acne extractor. though the species of the bacteria were not identified, this shows that the acne extractor is not sterilized well. a few of the beauty salons had acne extractors that were already rusty but was still in use. the acne extractors were also not kept well by the beauticians; most of the acne extractor was kept together with hair brushes, hair combs, scissors and the other salon equipment. the beauticians admitted not to frequently clean the extractor and only do so with a wet cloth when it is used. only 2 samples out of the 14 samples were able to sterilize the equipment in an acceptable manner. none of the subjects knew of the use of alcohol as a sterilizing agent. this shows that proper sterilization is not performed in the beauty salons. without proper sterilization, the acne extractor may serve as a breeding ground not only for s. aureus but also other bacteria. when the unsterilized acne extractor is used on clients after clients, the risk of transmission increases; and thus, it increases the risk of clients developing skin lesion infection of s. aureus origin. cross contamination also takes place when the acne extractor is kept in an unhygienic and unsterilized condition. the acne extractor will then harbor many types of bacteria including the s. aureus. as mentioned in the previous chapter, cross contamination serves as a risk of developing much more severe s. aureus infections. all this can be easily prevented by hygienic steps before, during and after the use of acne extractor. previous studies have shown that using alcohol alone is adequate althea medical journal. 2017;4(1) 67ng jo sheng, gita indah triyanti rukmana, innearline diana: detecting the presence of methicillin-resistant staphylococcus aureus on acne extractor used by some beauty salons in jatinangor in killing bacteria and thus sterilizing the acne extractor.15 therefore, it is definitely recommended to use alcohol to sterilize the acne extractor. simple steps like this can ensure that the acne extractor is safe to be used. the knowledge of the beautician on sterilization technique is inadequate as there is no specific course and guideline to be followed by them. the lack of awareness about sterilization puts the clients at risk of developing skin lesions. all this can be prevented easily with knowledge about sterilization and frequent practice of the sterilization technique. methicillin-resistant staphylococcus aureus is an antibiotic resistant form of s. aureus which is much more difficult to treat. although infection brought about by the mrsa is the same as s. aureus, treating the infection is much more difficult due to antibiotic resistance and fear of further antibiotic resistance. from the study, no community associated mrsa was found. this shows that the acne extractors in the salons are still free of the much more severe form of s. aureus. however, if no precaution is taken, the risk of developing mrsa on the acne extractor is high. thus, it is important for the beauticians of the beauty salon to start practicing the standard sterilization protocol that is implemented worldwide, that is by using alcohol to clean all their equipment including the acne extractor. there is no ca-mrsa found in beauty salons along jatinangor street. there is however s. aureus and other species of bacteria found on the acne extractor from the beauty salons. this can all be accounted by the lack of awareness and practice of proper sterilization on the equipments including the acne extractor. throughout the study, there were a few limitations that were met. among them are the changes in behavior of the participants of the study such as increased frequency of washing the instruments and also better hygienic practices. there is also the lack of participation of the beauty salon in the study due to worry of losing their customers. in conclusion, based on the results of the study, it shows that there is no mrsa found on the acne extractor. however, the sterilization of the acne extractor is inadequate, and thus, it accounts for the presence of s. aureus and other unidentified species of bacteria. therefore, it is important for the implementation of standard and proper handling and sterilization of the acne extractor. this also proves that there is no ca-mrsa. for future study, it is needed to do random visitation to the salon and also to give better explanation to the participants to ensure more participation. it is also recommended that a larger sample size needs to obtain for covering the whole of jatinangor sub district. finally, the use of a questionnaire would be helpful in obtaining the beautician’s knowledge on sterilization. references 1. brown df, edwards di, hawkey pm, morrison d, ridgway gl, towner kj, et al. guidelines for the laboratory diagnosis and susceptibility testing of methicillin-resistant staphylococcus aureus (mrsa). j antimicrob chemother. 2005;56(6):1000−18. 2. klevens rm, morrison ma, nadle j, petit s, gershman k, ray s, et al. invasive methicillin-resistant staphylococcus aureus infections in the united states. jama. 2007;298(15):1763−71. 3. boucher hw, corey gr. epidemiology of methicillin-resistant staphylococcus aureus. clin infect dis. 2008;46suppl 5:s344−9. 4. schooneveld t, rupp m. control of grampositive multidrug resistant organism. in: lautenbach e, woeltje kf, malani pn, editors. practical healthcare epidemiology. 3rd ed. london: university of chicago press; 2010. p. 197−204. 5. schwartz b, chambers h. clinical manifestations of community acquired mrsa infections. in: crossley kb, jefferson kk, archer gl, fowler vg, editors. staphylococci in human disease. 2nd ed. west sussex: blackwell publishing; 2009. p. 531. 6. hardy kj, oppenheim ba, gossain s, gao f, hawkey pm. a study of the relationship between environmental contamination with methicillin-resistant staphylococcus aureus (mrsa) and patients’ acquisition of mrsa. infect control hosp epidemiol. 2006;27(2):127−32. 7. al-tawfiq ja. father-to-infant transmission of community-acquired methicillinresistant staphylococcus aureus in a neonatal intensive care unit. infect control hosp epidemiol. 2006;27(6):636−7. 8. murray r, pearson jc, coombs gw, flexman jp, golledge cl, speers dj, et al. outbreak of invasive methicillinresistant staphylococcus aureus infection associated with acupuncture and joint injection. infect control hosp epidemiol. 2008;29(9):859−65. althea medical journal. 2017;4(1) 68 amj march 2017 9. rodriguez d. acne extraction. new york: everyday health media, llc; 2010 [updated 17/02/2010; cited 25 february 2013];available from: http:// www.everydayhealth.com/acne/acneextraction.aspx 10. yokoe ds, classen d. improving patient safety through infection control: a new healthcare imperative. infect control hosp epidemiol. 2008 ;29suppl 1:s3−11. 11. naimi ts, ledell kh, como-sabetti k, borchardt sm, boxrud dj, etienne j, et al. comparison of community-and health care–associated methicillin-resistant staphylococcus aureus infection. jama. 2003;290(22):2976−84. 12. harbarth s, françois p, schrenzel j, fankhauser-rodriguez c, hugonnet s, koessler t, et al. community-associated methicillin-resistant staphylococcus aureus, switzerland. emerg infect dis. 2005;11(6):962−5. 13. liu c, bayer a, cosgrove se, daum rs, fridkin sk, gorwitz rj, et al. clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant staphylococcus aureus infections in adults and children. clin infect dis. 2011;52(3):e18−55. 14. huang ss, platt r. risk of methicillinresistant staphylococcus aureus infection after previous infection or colonization. clin infect dis. 2003;36(3):281−5. 15. rauk pn. educational intervention, revised instrument sterilization methods, and comprehensive preoperative skin preparation protocol reduce cesarean section surgical site infections. am j infect control. 2010;38(4):319−23. vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 129 low knowledge and negative perception about the risks of breast cancer among female high school students sri yusnita irda sari,1 dini desmona,2 teguh marfen djajakusumah3 1department of public health faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: sri yusnita, department of public health faculty of medicine faculty of medicine universitas padjadjaran, jalan prof. eyckman no. 38, bandung, indonesia email: italatif@yahoo.com introduction breast cancer is the most common cancer affecting women from all the races in the world, both in the developed and less developed countries.1,2 breast cancer is also the most frequently diagnosed cancer and the leading cause of death among women in a developing country. the prevalence of breast cancer is 23% of the total cancer cases and 14% of cancer deaths,3 which is higher in developing countries than developed countries, as most of patients seek medical assistance in the latestage.4 early detection of breast cancer such as mammography, ultrasonography (usg), clinical breast examination and self-breast examination might help detect breast cancer at early stage and can reduce the mortality rate.4,5 although breast cancer is more common among women above 35 years old, however, some cases can also be found at a younger age. moreover, breast canceris more aggresive in younger patients, therefore, all women especially at younger age need to understand the importance of early detection of breast cancer.6 however, most the young women have shown a deficit of knowledge and lack of awareness about breast cancer.7-13 age, level of education, employment status and family member living in the same house may affect their knowledge about breast cancer.7,14 in australia, information barrier is one of the most important causes and some have amj. 2019;6(3):129–35 abstract background: breast cancer is one of the leading causes of death among women. the potential risk factor is older age, however, the prevalence at a young age is recently increased. unfortunately, young women show a poor level of knowledge about breast cancer. this study aimed to explore the knowledge and perception among female high school students about the risks of breast cancer. methods: this cross-sectional study was conducted from october to november 2013 in jatinangor. one hundred and eighteen (n118) female students from three senior high schools were included in this study. data on mother’s educational status, family income, family history of breast cancer and number of a family members living in the same house was collected. knowledge and perception toward risks of breast cancer were assessed using a validated questionnaire. results: most of the students (69.5%) had a poor level of knowledge about breast cancer. furthermore, they also had a negative perception (43.2%) toward breast cancer’s risks. factor influencing their perception was family income (p=0.012) and knowledge about breast cancer (p=0.008). conclusions: young female high school students have low knowledge and negative perception about the risks of breast cancer. it is recommended that education about breast care and breast cancer should be given to high school female students to improve their knowledge and to early detect abnormality in their breast. keywords: breast cancer, knowledge, perception, risk althea medical journal. 2019;6(3) 130 amj september 2019 incorrect perception about breast cancer, assuming that breast cancer would not happen to them and only for older women.15 this study was conducted to explore the knowledge and perception about the risks of breast cancer among students from high schools in jatinangor. methods a cross-sectional study was conducted in three senior high schools in jatinangor from october to november in 2013. after calculation, the minimum effective sample size was 110 respondents. the first stage, three of ten senior high schools in the subdistrict of jatinangorwere randomly chosen. in the the second stage, the classes were randomized picked up, and in total, 40 students from each school were randomly chosen as participants. the inclusion criteria were second-grade female students aged 14−19 years old who consented to participate in this study. the exclusion criteria were incomplete data and students who were resigned as the study proceeded. the instrument of the studywas a selfadministered questionnaire about the knowledge and perception of the risks of breast cancer. the questionnaire had been validated beforehand in 21 female students from a high school other than the current study in jatinangor. the questionnaire was developed based on the theory of the risk factors in breast cancer.16 cronbach alpha value was 0.686 for the questionnaire of knowledge and 0.550 forquestionnaire of perception. after signing an informed consent form, respondents had answered the first part of a questionnaire about the characteristic of the respondents, consisting of the educational level of their mother, family income, family history of breast cancer and the number of their family members that lives in the same house. next part, respondents had answered table 1 the characteristics of female senior high school students in jatinangor recruited in the study. variables frequencies (n=118) percentage (%) age (years old) 15 11 9.0 16 81 66.4 17 26 22.0 the educational level of the mother elementary graduated 34 28.8 junior high school graduated 18 15.3 senior high school graduated 34 28.8 diploma/bachelor 32 27.1 family income < rp1.050.000 23 19.5 rp1.050.000 – 2.000.000 41 34.7 rp2.000.000 – 6.000.000 25 21.2 >rp6.000.000 29 24.6 family history of breast cancer no family history 104 88.1 yes, there is a family history 14 11.9 number of a family member that lives in the same house ≤ 5 73 61.9 > 5 45 38.1 althea medical journal. 2019;6(3) 131sri yusnita irda sari et al.: low knowledge and negative perception about the risks of breast cancer among female high school students table 2 knowledge and perception toward the risks of breast cancer among female senior high school students in jatinangor variables frequencies (n) percentage (%) level of knowledge poor 82 69.5 moderate 36 30.5 good perception positive 67 56.8 negative 51 43.2 a 20-questions questionnaire about their knowledge of breast cancer risks. for the last part, respondents had answered a 12-questions questionnaire about their perception of breast cancer risks. for each statement on the knowledge, a correct answer was scored with a value of one, while an incorrect answer or did not know was scored at zero; the maximum score in the knowledge questionnaire was 20, and the minimum was zero. for statements on perception, if it was a positive statement, it was scored four for strongly agree, three for agree, two for disagree, and one for strongly disagree. for negative statements on perception, it was table 3 items measuring the perceptiontoward the risks of breast cancer variables strongly agree (%) agree (%) disagree (%) strongly disagree (%) breast cancer will not happen to young women 6.8 24.6 59.3 9.3 the mother who has breast cancer will not increase the risk of her daughter of getting breast cancer 13.6 42.4 36.4 7.6 women who reach menarche on age younger than 12 years old, has an increased risk of getting breast cancer 3.4 11.9 73.7 11.0 women who experience a first full-term pregnancy at ages older than 35 years old will increase her risk of getting breast cancer 0.8 31.4 58.5 9.3 alcohol makes women immune to breast cancer 6.8 22.9 29.7 40.7 breastfeeding will protect women from getting breast cancer 40.7 47.5 11.9 0.0 using oral or hormonal contraceptives containing estrogen will increase the risk of getting breast cancer 5.1 20.3 66.1 8.5 women should take seriously for any problem concerning their breast condition 64.4 33.1 1.7 0.8 being a woman will increase the risk of getting breast cancer 32.2 47.5 17.8 2.5 indonesian women have risk of getting breast cancer as this country has a high incidence of that cancer 5.1 34.7 38.1 22.0 the polluted environment will not affect women on getting breast cancer 7.6 26.3 53.4 12.7 exposure to radiation will increase the risk of getting breast cancer 21.2 50.0 23.7 5.1 althea medical journal. 2019;6(3) 132 amj september 2019 scored in a reverse way. the maximum score for the perception questionnaire was 48 and the minimum was 12. the level of knowledge was divided into three groups, consisting of poor, moderate and good knowledge; which was <50%, 50−75%, and >75%, respectively. the perception of the respondents was grouped into positive perceptions and negative perceptions. positive perception referred to subject perceived things according to the right knowledge and acceptable reason. the negative perception was arisen due to a lack of knowledge and experience of the subject to the object perceived. the basis for this grouping was the median from all the respondent’s score of questionnaire perception when the distribution was not normal. this study was approved by the health research ethics committee, faculty of medicine universitas padjadjaran. all data were analyzed using the statistical product and service solutions (spss) version 15.0. after a process of scoring, the data distribution of respondents’ characteristics, knowledge and perception were analyzed using the kolmogorov-smirnov method. to assess the relationship between the respondent’s characteristics and knowledge with perception on breast cancer risk, the spearman correlation test had been used because the data was not normally distributed. the level of statistical significance was set at p<0.05. results out of 73 students, mostly were flatfoot (n 40; in total, 120 students were participated, of whom 2 were excluded due to incomplete answers. of these 118 students, the mean age was 16.13 years old (15–17 years old). the education of their mothers was at a good level (55.9%), consisting of senior high school and diploma/bachelor graduated. the family income was higher than the minimum regional payment for sumedang regency which was rp1,381,700,00 in 2013 (table 1). most of the students had a poor level of knowledge toward the risks of breast cancer (table 2), however, most of the students showed positive perception toward breast cancer’s risk, even though there was no significant difference in percentage with respondents who had a negative perception. the overall mean total score of the knowledge table 4 the perception toward the risks of breast cancer among female senior high school students in jatinangor based on their characteristics characteristics perception r p positive (+) negative(-) the educational level of a mother elementary graduated 16 18 0.141 0.127 junior high school graduated 10 8 senior high school graduated 20 14 diploma/bachelor 21 11 family income <rp1,050,000 9 14 0.230 0.012* rp1,050,000 – 2,000,000 20 21 rp2,000,000 – 6,000,000 19 6 >rp6,000,000 19 10 family history of breast cancer yes, there is a family history 8 6 -0.003 0.977 no family history 59 45 number of a family member ≤ 5 39 34 0.086 0.353 >5 28 17 althea medical journal. 2019;6(3) 133 was 8.12±2.55 and for perception was 32.47±3.62. on some statements, respondents had the positive perception (table 3); they had been already aware that breast cancer may also happen to young women, however, 59.3% disagreed with this statement. they also recognized potential risk factors for breast cancer such as being female, alcohol consumption, polluted environment and radiation. a major proportion of respondents agreed that breastfeeding could protect women from getting breast cancer and they knew that any problem about breast was a serious condition. but they still perceived negatively toward other risk factors such as genetics, age at menarche, age at first live birth, estrogen exposure and geographic influence. using the spearman correlation test, from all the characteristics of the students, the only family income had a significant correlation (p 0.012) with perception toward breast cancer risk (table 4). the strength of correlation was weak (r=0.230). there was a significant relationship between the level of knowledge and perception toward breast cancer risk (p<0.008), however, the strength of correlation was weak (r=0.244) (table 5). discussions this study has explored the knowledge and perception about the risks of breast cancer among female senior high school students in jatinangor, and the most of the female students had poor knowledge (69.5%), similar to several other previous studies, that have shown inadequate knowledge about breast cancer.7-15, 17-19 most female students (56.8%) have positive perceptions toward the risks of breast cancer, but, the negative perception is also in a high percentage (43.2%) and no significant difference between those with a positive perception. many participants have already acknowledged the potential risk factors for breast cancer. compared to the previous studies in australia15 and ohio11 it shows that women perceive breast cancer to be a serious illness but they do not think that breast cancer is a threat to them and this disease is rather for older women. the students have very limited knowledge about breast cancer and they have never thought about their perception before this study.15 interestingly, this study revealed that there was a relationship between knowledge and perception of the risks of breast cancer (p<0.008). most of the respondents with moderate knowledge had a positive perception of the risks of breast cancer. this is consistent with the theory of health belief model, stating that knowledge is a modifying factor that affects how someone perceived a disease. a higher level of knowledge means that they know the fact, therefore they perceived breast cancer positively.20 furthermore, there is no relationship between the educational level of the respondents’ mothers with the perception of the respondents on the risks of breast cancer. ideally, when there is a barrier in the information of breast cancer, young women would prefer to obtain information from their mothers.15 therefore, a mother’s knowledge would affect their daughter’s perception of breast cancer and it would be influenced by the educational level of the mother.14 however, our study is unable to prove this because some students do not live with their mothers. further analysis of this data would be interesting to explore. family income showed a significant relationship with respondents’ perception of the risks of breast cancer. respondents from higher family income would have a positive perception,7 and knowledge would affect their perception.20 however, no research available has been identified so far about the relationship of family income directly to perception of the risks of breast cancer. furthermore, a family history of breast cancer might have a relationship with respondents’ perception of table 5 the relationship between the level of knowledge and perception toward the risks of breast cancer among female senior high school students in jatinangor knowledge perception r p positive (+) negative(-) good 0.244 0.008moderate 27 9 poor 40 42 sri yusnita irda sari et al.: low knowledge and negative perception about the risks of breast cancer among female high school students althea medical journal. 2019;6(3) 134 amj september 2019 the risks of breast cancer. women who have a family history of breast cancer might have a significant impact on their perception of breast cancer compared to women without a family history of breast cancer that perceive they are not at risk of developing breast cancer.15 women with a family history of breast cancer have higher knowledge in comparison to the opposite but with no significant difference.14 other predictor is family size staying at the same house. limitation of this study among others is the family size that cannot be explored due to the type of schools; one school is attended by students coming from higher social and economic status than other schools and the other school is a boarding school of which the number of their family member living in the same house, maybe biased, therefore they have less time interacting with their family. further study needs to stratify these factors. furthermore, this study is unable to identify more about respondents’ family history of breast cancer, both first degree (mother, sister, grandmother) and second-degree relatives, as well as their source of information about breast cancer. to conclude, most of the female students of senior high school in jatinangor have poor knowledge and negative perception toward the risks of breast cancer. factors associated with perception are the level of knowledge and socioeconomic family background. young women in high schools should be given a breast cancer education and counseling, therefore, their knowledge andaffect their perception about the risk factors contributing to breast cancer may increase, and they will be more concerned and aware of their health status. acknowledgement we are grateful to the head of public senior high school (sekolah menengah atas negeri, sman) jatinangor, vocational school (sekolah menengah kejuruan, smk) padjadjaran and senior high school (sekolah menengah atas, sma) al-masoem for their permission for this study. references 1. ferlay j, shin h-r, bray f, forman d, mathers c, parkin dm. estimates of worldwide burden of cancer in 2008: globocan 2008. int j cancer. 2010;127(12):2893−917. 2. parkin dm, bray f, ferlay j, pisani p. global cancer statistics, 2002. ca cancer j clin. 2005;55(2):74−108. 3. jemal a, bray f, center mm, ferlay j, ward e, forman d. global cancer statistics. ca cancer j clin. 2011;61(2):69−90. 4. smith ra, caleffi m, albert us, chen th, duffy sw, franceschi d, et al. breast cancer in limited-resource countries: early detection and access to care. breast j. 2006;12(suppl 1):s16−26. 5. smith ra, cokkinides v, eyre hj. american cancer society guidelines for the early detection of cancer, 2006. ca cancer j clin. 2006;56(1):11−25. 6. cancer australia australian government. early detection of breast cancer. 2009 [cited 2013 march 3]: available from: http://canceraustralia.gov.au/about-us/ position-statements/early-detectionbreast-cancer. 7. hadi ma, hassali ma, shafie aa, awaisu a. knowledge and perception of breast cancer among women of various ethnic groups in the state of penang: a cross-sectional survey. med princ pract. 2010;19(1):61−7. 8. hadi ma, hassali ma, shafie aa, awaisu a. evaluation of breast cancer awareness among female university students in malaysia. pharm pract (granada). 2010;8(1):29−34. 9. oluwatosin oa. rural women’s perception of breast cancer and its early-detection measures in ibadan, nigeria. cancer nurs. 2006;29(6):461−6. 10. montazeri a, vahdaninia m, harirchi i, harirchi am, sajadian a, khaleghi f, et al. breast cancer in iran: need for greater women awareness of warning signs and effective screening methods. asia pac fam med. 2008;7(1):6. 11. rahman sm, rahman s. breast cancer perceptions, knowledge and behavioral practices among women living in a rural community. int j canc prev. 2008;2(6):415−25. 12. webster p, austoker j. women’s knowledge about breast cancer risk and their views of the purpose and implications of breast screening-a questionnaire survey. j public health. 2006;28(3):197−202. 13. mafuvadze b, manguvo a, he j, whitney sd, hyder sm. breast cancer knowledge and awareness among high school and college students in mid-western usa. int j sci educ, part b. 2014;3(2):144−58. 14. al-dubai sa, qureshi am, saif-ali r, ganasegeran k, alwan mr, hadi ji. awareness and knowledge of breast cancer and mammography among a group althea medical journal. 2019;6(3) 135 of malaysian women in shah alam. asian pac j cancerprev. 2011;12(10):2531−8. 15. johnson ne. young women’s perception of breast cancer [dissertation]. bendigo: la trobe university; 2006. 16. lester sc. the breast. in: kumar v, abbas ak, fausto n, aster jc, editors. robbins and cotran pathologic basis of disease. 8th ed. philadelphia: saunders elsevier; 2010. p. 1065−93. 17. dandash kf, al-mohaimeed a. knowledge, attitudes, and practices surrounding breast cancer and screening in female teachers of buraidh, saudi arabia. int j health sci. 2007;1(1):61−71. 18. okobia mn, bunker ch, okonofua fe, osime u. knowledge, attitude and practice of nigerian women towards breast cancer: a cross sectional study. world j surg onc. 2006;4:11. 19. parsa p, kandiah m, rahman ha, zulkefli ma. knowledge and behavior regarding breast cancer screening among female teachers in selangor, malaysia. asian pacific j cancer prev. 2008;9:221−8. 20. champion vl, skinner cs. the health belief model. in: glanz k, rimer bk, viswanath k, editors. health behavior and health education: theory, research, and practice. 4th ed. san fransisco: john wiley & sons; 2008. p. 45−50. sri yusnita irda sari et al.: low knowledge and negative perception about the risks of breast cancer among female high school students 267 althea medical journal. 2017;4(2) comparison of post-stroke functional recovery between ischemic and hemorrhagic stroke patients: a prospective cohort study sabrina anggi lubis,1 novitri,2 ahmad rizal3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation/dr. hasan sadikin general hospital bandung, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: stroke is differentiated into two types, hemorrhagic and ischemic stroke. different pathophysiologic mechanism that underlies each stroke type may give different outcome in post-stroke patients. this study aimed to compare the improvement of functional outcome between both types of stroke among stroke patients admitted to dr. hasan sadikin general hospital (rshs). methods: consecutive sampling was carried out on first-ever stroke patients admitted to neurological inpatient unit of rshs from september 2015 to october 2015. functional recovery, measured by subtracting canadian neurological scale (cns) on day-8 and day-1 of admission, was compared among two subgroups and analyzed using mann-whitney u test. baseline characteristics were collected and analyzed. results: total of thirteen stroke patients was included in this study: ten ischemic stroke and three hemorrhagic stroke patients. cns score improvement between ischemic and hemorrhagic stroke patients was not significantly different. however, hemorrhagic stroke had higher score than ischemic stroke with 0.30 cns score difference. conclusions: cns improvement between ischemic and hemorrhagic stroke was not significantly different. keywords: functional recovery, hemorrhagic stroke, ischemic stroke correspondence: sabrina anggi lubis, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85750280918 email: anggisabrina18@gmail.com introduction stroke causes significant health problems in indonesia since its survivors develop disability and indonesia mean age of stroke is 58.8, which is still in productive age.1 there are two main types of stroke: (1) ischemic stroke, which is caused by reduction of cerebral blood flow, eventually leading to cerebral infarction and (2) hemorrhagic stroke, which is caused by rupture of blood vessel in the brain, increasing intracranial pressure.2 there are differences in term of mortality, severity, and prognosis between ischemic and hemorrhagic strokes. hemorrhagic stroke is associated with higher mortality and worse functional impairment after stroke.3-5 in term of recovery, earlier studies have found that after rehabilitation, hemorrhagic stroke is associated with better functional recovery than ischemic stroke.6-8 however, there are many important factors other than stroke type that need to be considered in term of stroke prognosis.2 this study was somewhat different from earlier studies that assessed patient’s capability of recovery within short duration and without rehabilitation exposure. thus, it was expected that this study could compare post-stroke functional recovery between ischemic and hemorrhagic stroke patients without many interfering factors. methods this was a prospective cohort study that consecutively recruited stroke patients in neurological inpatient unit of dr. hasan sadikin general hospital (rshs) from september 2015 to october 2015. patients would be included in this study if they met all the inclusion criteria. inclusion criteria were: first-ever ischemic or hemorrhagic stroke patients confirmed by ct scan, aged ≥18 years old, signed the informed consent, glasgow coma scale (gcs) ≥13, and onset to admission interval ≤48 hours. amj. 2017;4(2):267–70 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1069 althea medical journal. 2017;4(2) 268 amj june 2017 patients who had recurrent stroke attacks or died during the study were excluded. a total of 15 patients were included in this study. this study used the american heart association/american stroke association definition of stroke. ischemic stroke is defined as, ”an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction”, whereas hemorrhagic stroke is defined as, ”a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma”.9 the stroke was classified as ischemic or hemorrhagic using findings on ct scan. baseline characteristics were collected from medical record and tested for normality using shapiro-wilk test. then the baseline characteristics were analyzed using independent t-test and chi square test. functional recovery was measured using canadian neurological scale (cns), a simple and standardized tool to assess neurological status. cns was measured twice, (1) first, at the time of admission in neurological inpatient unit and (2) second, seven days from the first cns measurement. cns improvement was calculated by subtracting first cns score from second cns score. shapiro-wilk test was used to test normality of the data. cns improvement data was analyzed using mann-whitney u test to see the significance of the difference among two subgroups. ethics committee of rshs has reviewed and approved this study through ethical clearance number: lb.04.01/a05/ec/242/vii/2015. results during data collection period, there were 55 stroke patients were admitted to neurological inpatient unit of rshs. forty patients could not be included in the study either because they had recurrent stroke attacks or had gcs score <13. fifteen stroke patients were eligible for the study consisted of ten ischemic stroke patients and five hemorrhagic stroke patients. two hemorrhagic stroke patients were further excluded because they had died during data collection. complete baseline characteristics among two subgroups are presented on table 1. baseline characteristics among two subgroups were not significantly different. data of cns improvement was not normally distributed. from mann-whitney u test result, cns improvement between ischemic and hemorrhagic stroke was not significantly different (table 2). however, hemorrhagic stroke had a higher score with 0.30 cns score improvement difference (table 2). discussion ischemic and hemorrhagic stroke have different mechanism of neuronal injury. in table 2 comparison of cns improvement among two subgroups ischemic stroke hemorrhagic stroke p (n=10) (n=3) cns* score improvement, median (range) 0.70 (-3–4.5) 1.00 (0–1.5) 0.692 note: *cns= canadian neurological scale. table 1 comparison of baseline characteristics among two subgroups ischemic stroke hemorrhagic stroke total p (n=10) (n=3) (n=13) age (year), mean ± sd* 53.70+14.25 58.00+17.06 54.69+14.30 0.668 male, % 70 100 76.92 0.528 cns** score at admission, mean ± sd* 6.75±3.97 6.50±1.80 6.69±3.52 0.920 hypertension, % 80 100 84.62 1.000 heart disease, % 40 0 30.77 0.497 diabetes mellitus, % 10 0 7.69 1.000 note: *sd= standard deviation, ** cns= canadian neurological scale 269 althea medical journal. 2017;4(2) sabrina anggi lubis, novitri, ahmad rizal: comparison of post-stroke functional recovery between ischemic and hemorrhagic stroke patients: a prospective cohort study figure 1 cns scores improvement over time ischemic stroke, neuronal injury is caused by hypo-perfusion to the brain and thus irreversible ischemic necrosis is inevitable, whereas in hemorrhagic stroke, neuronal injury is due to the pressure given by intracranial bleeding. moreover, hematoma that is built in hemorrhagic stroke can cut off connecting pathways in the brain. in ischemic stroke, necrotic neuron persists despite the reperfusion that occurs, but, in hemorrhagic stroke, after blood is drained and intracranial pressure is relieved, neurons may recover.2 therefore, prognosis of hemorrhagic stroke patients is largely influenced by duration of bleeding and size of hematoma.7,10,11 although hemorrhagic stroke has higher mortality and worse functional outcome than ischemic stroke,3-5 hemorrhagic stroke patients who survive have better functional improvement than ischemic stroke.6-8 from the result of this study, hemorrhagic stroke patients tended to be more severe on admission, yet they improved faster and had better final cns scores (figure 1). though there was no significant cns score improvement difference among the two subgroups, this study did found that hemorrhagic stroke patients had higher cns score improvement than ischemic stroke patients. these findings were consistent with earlier reports that have demonstrated that hemorrhagic stroke is worse at first but significantly better in term of functional recovery than ischemic stroke.3,6-8 gender, age, hypertension, diabetes mellitus, and heart disease, which were considered possible confounding factors in this study, had been controlled. patients in this study were not in rehabilitation unit, so it can be assumed that there were no compensatory influences to the patient’s functional improvement. however, there were several limitations in this study. this study was conducted in rshs, which is a tertiary health care facility. thus, patients admitted to this hospital tend to be in severe condition, which was either recurrent stroke patients or stroke patients with gcs score <13. furthermore, this study was conducted only for two months, resulting in small sample size. that sample became the major limitation to this study. due to its higher mortality and lower incidence than ischemic stroke, there was disparity in the number of sample among two subgroups.3,5,12 hemorrhagic stroke patients in this study consisted of only three patients, so those samples might not be representative of total hemorrhagic stroke population. this might be the reasonthis study did not reach significant statistical difference. therefore, this study concludes that cns improvement between ischemic and hemorrhagic stroke was not significantly different. suggestions for future study is to conduct a research in secondary health care facility where stroke patients admitted tend to be in less severe condition. besides, it is also suggested to do a research in a longer time thus the sample size could be bigger. althea medical journal. 2017;4(2) 270 amj june 2017 references 1. kusuma y, venketasubramanian n, kiemas l, misbach j. burden of stroke in indonesia. int j stroke. 2009;4(5):379–80. 2. caplan lr. caplan’s stroke: a clinical approach. 4th ed. philadelphia: elsevier health sciences; 2009. 3. andersen kk, olsen ts, dehlendorff c, kammersgaard lp. hemorrhagic and ischemic strokes compared stroke severity, mortality, and risk factors. stroke. 2009;40(6):2068–72. 4. mcguire aj, raikou m, whittle i, christensen mc. long-term mortality, morbidity and hospital care following intracerebral hemorrhage: an 11-year cohort study. cerebrovasc dis. 2006;23(2– 3):221–8. 5. christensen mc, munro v. ischemic stroke and intracerebral hemorrhage: the latest evidence on mortality, readmissions and hospital costs from scotland. neuroepidemiology. 2008;30(4):239–46. 6. schepers vp, ketelaar m, visser-meily aj, de groot v, twisk jw, lindeman e. functional recovery differs between ischaemic and haemorrhagic stroke patients. j rehabil med. 2008;40(6):487–9. 7. joa k-l, han t-r, pyun s-b, rah u-w, park j-h, kim y-h, et al. inpatient stroke rehabilitation outcomes in korea derived from the korean brain rehabilitation centers’ online database system for the years 2007 to 2011. j korean med sci. 2015;30(5):644–50. 8. bhalla a, wang y, rudd a, wolfe cd. differences in outcome and predictors between ischemic and intracerebral hemorrhage the south london stroke register. stroke. 2013;44(8):2174–81. 9. sacco rl, kasner se, broderick jp, caplan lr, culebras a, elkind ms, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(7):2064–89. 10. mondal rn bs, islam mj, jahan sms, alam abmm, hussain mm, et al. short-term predictors of mortality among patients with hemorrhagic stroke. world heart j. 2014;6(4):273–81. 11. wang c-w, liu y-j, lee y-h, hueng d-y, fan h-c, yang f-c, et al. hematoma shape, hematoma size, glasgow coma scale score and ich score: which predicts the 30day mortality better for intracerebral hematoma? plos one. 2014;9(7):e102326. 12. go as, mozaffarian d, roger vl, benjamin ej, berry jd, borden wb, et al. heart disease and stroke statistics--2013 update: a report from the american heart association. circulation. 2013;127(1):e6– e245. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 78 amj march 2017 characteristics of asthma patients seeking care at west java’s top referral hospital, indonesia juan achmad yudistira,1 emmy hermiyanti pranggono,2 anna tjandrawati,3 primal sudjana2 1faculty of medicine, universitas padjadjaran, 2departement of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3departement of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: the increasing incidence of asthma in many countries in recent decades makes asthma a global health problem. the aim of the study was to determine the characteristics of asthma patients at the respirology outpatient clinic of dr. hasan sadikin general hospital as west java’s top referral hospital. methods: the study used a cross-sectional design. the study population was the medical record data of asthma patients at the respirology outpatient clinic during june 2012–june 2013. there were 1,591 patient’s medical records at the respirology outpatient clinic of dr. hasan sadikin general hospital bandung in that period and 140 medical records were diagnosed with asthma. seventy medical records were excluded because of inadequate data and 70 medical records were the sample of this study. the collected data were presented using percentage. results: seventy percent of the cases were female. from these cases 34% of patients were aged 51–60 years. the partially controlled type was the most frequent type of asthma (62%). the most common sign and symptom was shortness of breath (86%). the most common drug used was beta 2 agonist drugs (90%). conclusions: the characteristic of asthma is that the patients are mostly female. mostly the patients were in the age range of 51–60 years. the partially controlled type is the most frequent type of asthma. shortness of breath is the most common clinical manifestation in asthma. beta 2 agonist is the most used drug for asthma. [amj.2017;4(1):78–82] keywords: asthma, beta 2 agonist, shortness of breath correspondence: juan achmad yudistira, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85222162545 email: juan.achmad@yahoo.com introduction asthma is a chronic disease that is influenced by many factors.1 it is characterized by reversible airway obstruction, inflammation of the respiratory tract, and increased responsiveness of respiratory tract.2 according to the global initiative for asthma (gina), asthma is a chronic inflammatory disease of the airway that includes the involvement of many cells and other cellular elements in it. the chronic inflammation causes recurrent episodes of wheezing, shortness of breath, chest tightness, and cough, especially at night and in the early morning. asthma is associated with reversible airway obstruction which can occur spontaneously or with treatment.2-4 the increasing incidence of asthma in many countries in recent decades, especially in developing countries, makes asthma as a global health problem.3,4 the world health organization (who) estimates that about 235 million people worldwide suffer from asthma.5 over the last thirty years, the prevalence of asthma has been continually increasing.6 according to calculation, the number of people in the world that suffer from asthma in 2025 is expected to increase to 100 million people.7 in indonesia, the prevalence of asthma ranged between 5 to 7% of the total population.1,3 furthermore, factors that influence the prevalence of asthma are patient’s age, gender, race, atopic status, heredity, and environmental factors. the ratio of prevalence between male and female during childhood is 1.5:1 and becomes equal during puberty.1 in adulthood, the ratio is higher in female compared to althea medical journal. 2017;4(1) 79 male.8 however, based on age, the prevalence of asthma in children is higher than in adult.1 the aim of this study was to determine the characteristics of asthma at the respirology outpatient clinic of dr. hasan sadikin general hospital bandung as west java’s top referral hospital, in the period june 2012 to june 2013. methods this study was a descriptive observational study with a cross-sectional approach performed at the respirology outpatient clinic of dr. hasan sadikin general hospital bandung. this study was conducted in october 2013. the sampling method used in this study was total sampling. the main source of the study population was the medical record data of asthma patients who sought treatment at the respirology outpatient clinic during june 2012–june 2013. this study has been approved by the ethical clearance committee of dr. hasan sadikin general hospital. there were 1,591 patient’s medical records at the respirology outpatient clinic of dr. hasan sadikin general hospital bandung in that period. all patients’ data with diagnosis of asthma on medical record at the respirology outpatient clinic of dr. hasan sadikin general hospital bandung were collected. there were 140 medical records of patients who were diagnosed with asthma. the medical records were excluded in this study if age, sex, asthma control type, sign and symptom, and medication data were not available. seventy medical records were excluded because of inadequate data and the other 70 medical records were the sample of this study. the data were analyzed and calculated for the frequency of each variable by using computer. results one hundred and forty from 1,591 patients who sought treatment at the respirology outpatient clinic of dr. hasan sadikin general hospital bandung in the period june 2012 until june 2013 suffered from asthma (9%). the asthma patients were categorized according to sex, age on admission, age of first onset. this study revealed that 70% of the asthma cases were female. thirty four percents of the cases were patients aged 51– 60 years and 54% of the patients were more than 50 years old. nine percent of the patients had the first onset of asthma at18 years of age or older; however 88% of the data was missing because of inadequacy of the data. then, the result of this study was displayed according to the characteristics of the asthma. the results showed the partially controlled type was the most frequent type of asthma, represented by 62% of the total number. the most common clinical manifestation from table 1 characteristics of the asthma patients (n=70) characteristics n (%) sex male 21 (30) female 49 (70) age on admission (years) <21 6 (9) 21–30 7 (10) 31–40 9 (13) 41–50 10 (14) 51–60 24 (34) >60 14 (20) age of onset (years) <18 2 (3) >18 6 (9) missing data 62 (88) juan achmad yudistira, emmy hermiyanti pranggono, anna tjandrawati, primal sudjana: characteristics of asthma patients seeking care at west java’s top referral hospital, indonesia althea medical journal. 2017;4(1) 80 amj march 2017 the asthma patients was shortness of breath with 83%, followed by cough with 44% and wheezing with 31%. according to the medication used in the management of the patients, this study revealed that the most common drug used in asthma patients was beta 2 agonist drug with 90% of the cases, followed by mucolytic drugs with 59% of the cases. discussion there are many statistics about prevalence of asthma from around the world, but only a few from indonesia. this means that prevalence of asthma in indonesia is varied. this could be due to the differences of the methods, ethnics, environmental factor, and social economic status of the patients.9 the distribution of asthma based on sex in this study was higher among females than among males with the rate of 70% and 30% respectively. this result is slightly higher than in a study conducted by priyanto10 that reported 66.7% of asthmatic patients in persahabatan hospital are female. sex hormones also contribute to this phenomenon. female sex hormones such as estrogen and table 2 clinical manifestation and treatment management of asthma patients (n=70) characteristics n (%) asthma control controlled 12 (17) partially controlled 43 (62) uncontrolled 15 (21) clinical manifestation shortness of breath 58 (83) cough 31 (44) wheezing 22 (31) epigastric pain 2 (3) cold 1 (1) fever 1 (1) palpitation 1 (1) throat itch 1 (1) anorexia 1 (1) medication controller glucocorticosteroid 39 (56) theophylline 7 (10) reliever beta 2 agonist 63 (90) anticholinergic 11 (16) others mucolytic 41 (59) expectorant 18 (26) antibiotic 11 (16) antihistamine 6 (9) proton pump inhibitor 4 (6) althea medical journal. 2017;4(1) 81juan achmad yudistira, emmy hermiyanti pranggono, anna tjandrawati, primal sudjana: characteristics of asthma patients seeking care at west java’s top referral hospital, indonesia progesterone have a role in asthma. tam et al.11 showed that female hormones increase the airway inflammation when exposed to the allergen, and the severity also fluctuates over the course of menstrual cycles. estradiol has an important role to up-regulate the pro inflammatory cytokine and down-regulate the anti-inflammatory cytokine. the expression of interleukin (il) like il-10, il1-β, and tumor necrosis factor (tnf)-α will increase by the effect of progesterone.12 female hormones also have an impact on t helper cell.11 females have a better humoral immunity than males, who demonstrate a better cellular immunity.13 those factors may contribute to the higher distribution of female admission to the respirology outpatient clinic. the age of admission at the respirology outpatient clinic showed that most of the asthma patients aged 50 years or over (54%), specifically from patients in the age range 51– 60 years (34%). aging also have an important role because of the changes in anatomy and physiology of the respiratory system.1,14 this may be associated with an increase of burden in morbidity and mortality due to the increasing age. in older patients, distinguishing between asthma and chronic obstructive pulmonary disease (copd) is difficult and can be misrecognized.15 decline in lung function and incomplete lung growth in children make the overlapping of the syndrome in both disease.16 many data from the age of onset was missing on the medical records (88%). nine percent of the sample in this study had the first onset of asthma at the age of 18 years or older. however, this study did not explore the manifestation of other atopic disease so the onset could be younger than 18 years of age. individual with child onset of asthma has an increased risk for irreversible obstructive lung disease later in life.17 antó et al.18 showed that new onset of asthma in adult is related to two factors, host and environmental factors including female gender, lung function, bronchial hyper responsiveness, atopy, nasal allergy, obesity, parental asthma, respiratory infections in early life and high risk occupations. the majority of the patients at the respirology outpatient clinic had the partially controlled type of asthma control (62%). this result differs from the study conducted by bachtiar19 at persahabatan hospital. bachtiar19 showed that the most frequent type of asthma controlled type at the persahabatan hospital is the uncontrolled type with 67% of the cases. the difference in the result can be due to the different study design, sampling method and the research material used in both studies. many factors that contribute to the patients’ behavior related to type of the asthma control. priyanto10 stated that the main reason of the irregularity of asthma patients’ control is unmatched schedule between working hours and clinic hours.10 the other results are the distance of the clinic from their home, the side effect of drugs, the expensive cost of drugs, and the behavior of health care providers towards them. the most common clinical manifestation of the asthma patients at the respirology outpatient clinic was shortness of breath (83%), followed by cough (44%) and wheezing (31%). this is similar with three main characteristics of clinical manifestation in asthma which are wheezing, dyspnea, and coughing.6 moreover, beta 2 agonist is the most common drug used for the treatment of asthma with 90% used for relieving the shortness of breath. rapid-acting inhaled beta agonist is a drug of choice for reducing the bronchoconstriction in adult and children.4 a few example of beta 2 agonist like albuterol and formoterol have a similar safety level and have an effect to reduce asthma symptom.20 this result is relevant with the most common manifestation in asthma that emerge in this study which is shortness of breath, yet this study did not provide the drugs combination. this study is limited due to the use of secondary data, which were the medical record as the research material and the lack of information found in the medical record due to several missing characteristics data. in conclusion, the characteristics of asthma patients in this study are mostly female. the patients’ age is mostly in the range of 51–60 years. the partially controlled type is the most frequent type of asthma. shortness of breath is the most common clinical manifestation in asthma and beta 2 agonist is the most used drug for relieving the shortness of breath in asthma patients. the completeness of the medical record is emphasized and a further study is needed to correct this limitation and broaden the scope of study to yield better comprehension for characteristics of asthma. references 1. sundaru h, sukamto. asma bronkial. in: sudoyo aw, setiyohadi b, alwi i, simadibrata k m, setiadi s, editors. buku ajar ilmu penyakit dalam. 5th ed. jakarta: althea medical journal. 2017;4(1) 82 amj march 2017 interna publishing; 2009. p. 404–14. 2. mathur sk, busse ww. asthma. in: fishman a, elias j, fishman j, grippi m, senior r, pack a, editors. fishman’s pulmonary diseases and disorders. 4th ed. new york: mcgraw-hill companies,incorporated; 2008. p. 773–836. 3. dahlan z. asma bronkiale. in: dahlan z, amin z, soeroto ay, editors. tatalaksana penyakit respirasi & kritis paru. bandung: perpari; 2012. p. 7–26. 4. global initiative for asthma (gina). global strategies for asthma management and prevention. 2012 [cited 2013 march 9]; available from: http://www.ginasthma. org/. 5. world health organization. asthma. 2013 [cited 2013 march 9]; available from: http://www.who.int/mediacentre/ factsheets/fs307/en/index.html. 6. barnes pj. asthma. in: longo d, fauci a, kasper d, hauser s, jameson j, loscalzo j, editors. harrison’s principles of internal medicine. 18th ed. new york: mcgraw-hill education; 2012. p. 2102–15 7. masoli m, fabian d, holt s, beasley r. the global burden of asthma: executive summary of the gina dissemination committee report. allergy. 2004;59(5):469–78. 8. arif aa, delclos gl, lee es, tortolero sr, whitehead lw. prevalence and risk factors of asthma and wheezing among us adults: an analysis of the nhanes iii data. eur respir j. 2003;21(5):827–33. 9. ratnawati. epidemiology of asthma. j respir indones. 2011;31(4):172–5. 10. priyanto h, yunus f, wiyono wh. studi perilaku kontrol asma pada pasien yang tidak teratur di rumah sakit persahabatan. j respir indones. 2011;31(3):138–49. 11. tam a, morrish d, wadsworth s, dorscheid d, man s, sin d. the role of female hormones on lung function in chronic lung diseases. bmc women’s health. 2011;11(1):1–9. 12. de oliveira apl, domingos hv, cavriani g, damazo as, dos santos franco al, oliani sm, et al. cellular recruitment and cytokine generation in a rat model of allergic lung inflammation are differentially modulated by progesterone and estradiol. am j physiol-cell ph. 2007;293(3):c1120–c8. 13. bouman a, heineman mj, faas mm. sex hormones and the immune response in humans. hum reprod update. 2005;11(4):411–23. 14. sharma g, goodwin j. effect of aging on respiratory system physiology and immunology. clin interv aging. 2006;1(3):253–60. 15. sin b, akkoca o, saryal s, oner f, misirligil z. differences between asthma and copd in the elderly. j investig allergol clin immunol. 2006;16(1):44–50. 16. gibson pg, simpson jl. the overlap syndrome of asthma and copd: what are its features and how important is it? .thorax. 2009;64(8):728–35. 17. limb sl, brown kc, wood ra, wise ra, eggleston pa, tonascia j, et al. irreversible lung function deficits in young adults with a history of childhood asthma. j allergy clin immunol. 2005;116(6):1213–9. 18. antó jm, sunyer j, basagaña x, garciaesteban r, cerveri i, de marco r, et al. risk factors of new-onset asthma in adults: a population-based international cohort study. allergy. 2010;65(8):1021–30. 19. bachtiar d, wiyono wh, yunus f. proporsi asma terkontrol di klinik asma rs persahabatan jakarta 2009. j respir indones. 2011;31(2):90–100. 20. pauwels ra, sears mr, campbell m, villasante c, huang s, lindh a, et al. formoterol as relief medication in asthma: a worldwide safety and effectiveness trial. eur respir j. 2003;22(5):787–94. althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 107 skull and posterior rib fractures with respiratory failure caused by child abuse dzulfikar djalil lukmanul hakim, elza noviani department of child health faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung abstract background: presence of multiple fractures suggests child abuse. skull fractures rarely occurred but posterior rib fractures are commonly found and have high specificity as a radiological finding in child abuse. a respiratory failure can occur as a result of the damage to the osseous structure of the thorax that destabilizes the rib cage and impairs spontaneous breathing mechanism. methods: a case report of a 6-month-old boy who presented with respiratory failure, multiple bilateral parietal and occipital bone fractures, and also fractures of right rib 5–8. the patient required ventilatory support for 9 days in the pediatric intensive care unit, dr.hasansadikin general hospital. results: the patient was on ventilatory support for 9 days, and was given antibiotics for 2 weeks. next, the patient was referred to the high care unit (hcu) after the condition was stabilized, and then referred to the ward, for treatment by the social pediatric division. the patient was still having issues about his foster care. conclusions: recognition of presence of fractures is important in early diagnosis and treatment of child abuse. [amj.2017;4(1):107–10] keywords: child abuse, multiple fractures, respiratory failure correspondence: dzulfikar djalil lukmanul hakim, department of child health, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, phone: +62 22 2035957 email: dzulfikar_dlh@yahoo.com introduction skeletal fractures are diagnosed in more than a third of children who have been investigated for physical abuse.1 they occur in infants and toddlers (under three years old) who cannot give a causal explanation about the fracture, and the incidence is around 78%. worlock and colleagues studied children under 12 years old and showed that 80% of all fractures from abuse are seen in children under 18 months, contrary, 85% of fractures not caused by abuse occurred in children over 5 years. the estimated population annual incidence of fracture due to abuse is 4 per 10.000 children under 18 months.1,2 seventy four per cent of abused children had two or more fractures.1 furthermore, chest injuries occur in ~60% of polytrauma cases, hemothorax related to trauma in the united states approaches 300.000 cases per year.3 here in, a case report of a skull fracture and rib fracture in child abuse with ventilation support in the pediatric intensive care unit (picu) in dr. hasan sadikin general hospital, bandung. case a 6-month-old boy was brought to the emergency room with a chief complaint of dyspnea since 2 days before admission, this discomfort was not associated with cyanosis, snoring or wheezing. there was no history of choking. however, the patient’s aunt recognized the history of trauma that his mother had banged the child’s head against the wall, and hugged the chest too tightly. his parents were getting a divorce. besides the mother was not aware about the bumps on the child’s head. furthermore, the patient was admitted to picu with an increase in breathing effort due to respiratory failure, the physical examination revealed dullness at the right intercostal 5. the chest radiograph showed the presence althea medical journal. 2017;4(1) 108 amj march 2017 of right rib 5–8 fractures. schedel radiograph showed multiple fractures of bilateral parietal and occipital bones. blood gas analysis revealed respiratory alkalosis and metabolic acidosis. tapping on the right pleural space resulted in cloudy red fluid, which contained 500 white blood cells; pleural fluid to serum protein ratio of 0.6; and protein of 3 g/dl. the patient was on ventilatory support for 9 days. at the beginning, the ventilator was at pressured controlled mode with fractional concentration of oxygen in inspired air (fio2) 60% and gradually lowered, respiratory rate (rr) was 30x/minute, inspiration (i):expiration (e) =1:2, and inspiratory pressure level (ipl)/ positive end expiratory pressure (peep) =15/5. the next day, he started to breathe spontaneously, then the settings were changed to synchronized intermittent mandatory – pressure support (simv-ps) fio2 40%, rr figure 1 chest radiograph shows posterior right rib 5-8 fractures with right pleural effusion figure 2 schedel radiography shows multiple fractures of bilateral parietal and occipital bones althea medical journal. 2017;4(1) 109dzulfikar djalil lukmanul hakim, elza noviani: skull and posterior rib fractures with respiratory failure caused by child abuse in this case, the patient had respiratory failure without flail chest, and had been intubated with ventilator which was set on pressured control (pc) mode and sedation with midazolam. from another meta-analysis in 2008, 78% studies about child abuse with fracture were performed in the united states.1 this report described a case of multiple fractures that occurred in skull (bilateral parietal and occipital) and rib fracture (right 5-8) due to child abuse, with respiratory failure and requiring ventilatory support. it is important to recognize and distinguish respiratory failure and fracture conditions between abusive and non-abusive children. conventional radiography has historically been and to date has continuously to be the mainstay in radiological imaging of suspected child abuse, both in identifying new cases of possible child abuse,9 but normal initial radiological imaging does not guarantee that there is no fracture. the american association of pediatric (aap) recommends that a followup skeletal survey be obtained for all children < 24 months of age who are strongly suspected to be victims of abuse.10 additionally, retarded parents in this case report schizophrenic parentsbecause of their cognitive limitations were unable to care for their children. these findings point up the need for a mechanism whereby the retarded adult’s right to parent and the child’s right to nurturance and protection may both be preserved. until this dilemma can be resolved, decisions to terminate parental rights in such cases should be made more quickly.11 a meta-analysis by norman et al.12 pointed that there is a causal relationship between child maltreatment and a range of mental and health disturbances. it is needed to establish better identification of child abuse risk and the development of effective interventions to protect children from violence. an interdisciplinary effort is needed among all the institutions sharing responsibility for child protection so that the problem of violence against children can be effectively addressed and the number and severity of cases can be reduced.12,13 references 1. kemp am, dustan f, harrison s, morris s, mann m, rolfe k, et al. patterns of skeletal fractures in child abuse: systematic review. bmj. 2008; 337:a1518. 2. carty mh. fractures caused by child abuse. j bone joint surg br. 1993; 75(6):849–57. gradually decreased to 10x/minute, i:e = 1:2, ipl/peep: 12/5. the ventilator settings was changed to pressure support mode for the next 5 days, until weaning trial can be performed in the following 2 days with minimal ps mode. the patient was given antibiotics for 2 weeks, and then referred to the high care unit (hcu) after his condition was stabilized, and then later referred to the ward, to be treated by the social pediatric division. the patient was still having issues about his foster care. the patient was also consulted to the neurosurgeon for the multiple fractures of bilateral parietal and occipital bones, and to the thoracic surgeon for the rib fractures and they both suggested a conservative treatment. discussion skull fractures had been reported to occur more commonly in non-abusive trauma than in abusive head injury. the most common site of fracture in both abuse and non-abuse group was parietal and the most common fracture type was linear.1 in this case, the skull fractures were quite rare which occurred on both parietal sites. furthermore, a meta-analysis in 2008, stated rib fractures can occur at any location on the rib, they can be unilateral or bilateral. findings on posterior rib fractures were numerous. one of the studies of the american academy of pediatric mentioned that most rib fractures in infants are caused by child abuse.4 a study about specificity of radiological findings discovered that posterior rib fractures have a high specificity value and the fractures are usually multiple.5–7 in this case, rib fractures occurred posteriorly and multiple. moreover, damage to the bony structure of the thorax by the rib fractures destabilizes the rib cage and impairs spontaneous breathing mechanics substantially, which further reduces breathing function. direct traumatic damage to the lung, combined with a concurrent increase in vascular permeability of the lung capillaries of the injured area, leads to extravasation of protein-rich fluid, resulting in respiratory failure. injuries of more than two ribs fractures put the patient at significant risk of complications, such as thorax instability with paradoxical motion, in severe condition, flail chest can also occur. therapeutic aspects for this condition are to optimize ventilation, pneumatic stabilization with noninvasive positive-pressure ventilation (nippv) using mask, or after intubation, using invasive positive pressure ventilation (ippv).8 althea medical journal. 2017;4(1) 110 amj march 2017 3. mowery nt, gunter ol, collier br, diaz jj jr, haut e, hildreth a, et al. practice management guidelines for management of hemothorax and occult pneumothorax. j trauma. 2011;70(2):510–8. 4. bulloch b, schubert cj, brophy pd, johnson n, reed mh, shapiro ra. cause and clinical characteristics of rib fractures in infants. pediatrics. 2000;105(4):e48. 5. kleinman pk. diagnostic imaging in infant abuse. am j roentgenol. 1990;155(4):703– 12. 6. robben s. diagnostic imaging in child abuse non accidental trauma.radiology assistant. 2006 [cited 2014 march 1]. available from: http://www.radiologyassistant.nl/en/ p43c63c41ef 792/diagnostic-imaging-inchild-abuse.html 7. dwek jr. the radiographic approach to child abuse. clin orthop relat res. 2011;469(3):776–89. 8. richter t, ragaller m. ventilation in chest trauma. j emerg trauma shock. 2011;4(2):251–9. 9. van rijn rr, sieswerda-hoogendoorn t.educational paper: imaging child abuse: the bare bones. eur j pediatr. 2012;171(2):215–24. 10. bennett bl, chua ms, care m, kachelmeyer a, mahabee-gittens m. retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. bmc res notes. 2011;4:354. 11. seagull ea, schuerer sl. neglected and abused children of mentally retarded parents. child abuse negl. 1986;10(4):493–500. 12. norman re, byambaa m, de r, butchart a, scott j, vos t. the long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. plos med. 2012;9(11): e1001349. 13. jacobi g, dettmeyer r, banaschak s, brosig b, herrmann b. child abuse and neglect: diagnosis and management. dtsch arztebl int. 2010;107(13): 231–40. althea medical journal. 2017;4(3) 363 response time, decision time, and delivery time in pediatric emergency unit of west java top referral hospital ayu sary oktaviani,1 dzulfikar d. lukmanul hakim,2 suwarman3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the number of visitors at pediatric emergency unit has increased around 25 million per year. this condition caused overcrowded in these units which would disrupt health care process. waiting time is one indicator of health care quality. prolonged waiting times is related to patient’s dissatisfaction and poor outcome. the aim of this study was to identify response time, decision time, and delivery time of pediatric emergency unit in dr. hasan sadikin general hospital. methods: this was a descriptive cross sectional study. data from medical records of pediatric patients who attend pediatric emergency unit, dr. hasan sadikin general hospital from august to september 2015 were collected. the data included sex, age, day of admission, time of admission, insurance status, triage status, disposition of care, response time, decision time, and delivery time. the collected data were analyzed and presented in percentage and peformed in tables. results: a total of 201 data were collected during study period. the geometric mean of total waiting time in pediatric emergency department was 346.65 minutes (5 hours 46 minutes). response time had a geometric mean of 4.07 minutes, meanwhile decision time and delivery time had geometric mean of 46.77 minutes and 181.97 minutes, respectively. conclusions: total waiting times of pediatric emergency department exceeds the standard time (4 hours). meanwhile response time and decision time have already met the standard. keywords: decision time, delivery time, pediatric emergency unit, response time, waiting time correspondence: ayu sary oktaviani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: ayusaryoktaviani@gmail.com introduction the number of visitors at pediatric emergency department increases around 25 million per year.1 globally, there are approximately 30 billion of children under 18 years old visit emergency departments each year, which is equal to 25% of total emergency departments visit.2 high utility of emergency departments make these departments often face problems and pressure, for instance, abundant of the patients and limited of sources than other departments in the hospital.3 overcrowding is the main problem which faced by health care provider recently which would disrupt health care delivery process.4 waiting time is one indicator of health care quality in emergency department that divided into several interval times such as response time, decision time and delivery time. response time is the time needed since the patient arrive in emergency department until triage process is done then patient can meet and examined by physician. decision time is the time needed since patient examined by physician until the physician give the disposition of care. delivery time is the time needed since the disposition of care is made until the patient discharge from emergency department.5 the average waiting time of patient treated by health workers in emergency departments, from 2003 to 2009, increased about 25%, from 46.5 minutes to 58.1 minutes.6 prolonged waiting times have been associated with patient’s dissatisfaction and poor patient’s outcome, for instance increase of mortality and morbidity among emergency department patients and prolong length of stay in hospital.7 in indonesia, unfortunately there is a lack of publication data about waiting time in emergency department, especially pediatric amj. 2017;4(3):363–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1182 althea medical journal. 2017;4(3) 364 amj september 2017 emergency department. therefore, this study was aimed to discover response time, decision time, and delivery time of pediatric emergency department in dr. hasan sadikin general hospital. methods this was a descriptive cross sectional study which has been approved by health research ethics committee faculty of medicine universitas padjadjaran (lb.04.01/a05/ ec/297/vii/2015). the total population of completed medical records of pediatric patients aged under fourteen years old and attended pediatric emergency department at dr. hasan sadikin general hospital from august to september 2015 were included in this study. an exclusion criterion was patients who attended surgery emergency department. data was retrieved from medical record included sex, age, day of admission, time of admission, insurance status, triage status, disposition of care, response time, decision time, and delivery time. table 1 characteristics of patients in pediatric emergency department frequency percentage (%) sex male 121 60.2 female 80 39.8 age toodler (0–5 year) 127 63.2 children (6–11 year) 53 26.4 adolescent (12–14 year) 21 10.4 day of admission weekday 153 76.1 weekend 48 23.9 time of admission morning (7.00-14.00) 48 23.9 afternoon (14.00-21.00) 85 42.3 night (21.00-7.00) 68 33.8 referral status yes 119 59.2 no 82 40.8 insurance government 75 37.3 private 28 13.9 no insurance 98 48.8 triage non-urgent 35 17.4 urgent 136 67.7 emergency 30 14.9 disposition of care discharge 63 31.3 hospitalized 138 68.7 althea medical journal. 2017;4(3) 365ayu sary oktaviani, dzulfikar dlh, suwarman: response time, decision time, and delivery time in pediatric emergency unit of west java top referral hospital the collected data were analyzed using descriptive statistical analysis. mean, standard deviation, frequency distribution and percentage of the mentioned variables were calculated. results during this study period, there were 703 patients admitted in pediatric emergency department. from those all, 502 data were excluded from this study because of uncompleted medical record. of 201 data, 121 medical records were on male patients and 80 were on female patients. toddler was the most frequent visitors in emergency department (63.2%). the majority of patients (69.2%) who visited pediatric emergency department were patients who were referred by other health care facility and around 67.7% patients arrived in urgent triage status (table 1). the emergency department crowding was most seen in the afternoon (table 1), with peak time at 13.42. the geometric mean of waiting time pediatric emergency department was table 2 waiting time in pediatric emergency department (in minutes) geometric mean sd* median range response time 4.07 2.08 4.00 1–34 decision time 46.77 3.89 50 3–734 delivery time 181.97 5.37 232 2–4.333 total 346.65 3.01 355 13-4.357 *sd:standard deviation table 3 pediatric emergency unit waiting time according to day of admission, time of admission , insurance, triage and disposition of care geometric mean(sd*) response time (in minutes) decision time (in minutes) delivery time (in minutes) day of admission weekday 4.35(2.04) 45.56(3.99) 204.55(4.86) weekend 3.37(2.10) 51.92(3.64) 120.03(6.64) time of admission morning 3.69(2.01) 44.84(3.90) 183.82(4.89) afternoon 3.99(2.23) 44.10(4.14) 148.08(5.83) night 4.55(1.91) 52.62(3.64) 226.62(4.98) insurance government 4.11(2.12) 40.95(3.86) 171.83(4.99) private 3.98(2.26) 41.35(4.13) 199.89(2.68) no insurance 4.12(1.99) 54.18(3.90) 181.17(5.86) triage non-urgent 4.96(2.17) 45.12(4.96) 119.97(5.54) urgent 4.26(2.00) 47.69(3.67) 182.47(5.11) emergency 2.73(2.01) 46.13(3.96) 272.58(5.77) disposition of care discharge 4.25(2.1) 70.50(4.21) 84.25(6.40) hospitalized 4.03(2.04) 39.06(3.62) 254.74(4.31) *sd:standard deviation althea medical journal. 2017;4(3) 366 amj september 2017 346.65 minutes with median 355 minutes (5 hours 55 minutes), minimum of waiting time was 13 minutes and maximum of waiting time was 4357 minutes. delivery time contributed the most of emergency department waiting times with the geometric mean of 181.97 minutes (3 hours 1.97 minutes) (table 2). table 3 showed the response time, decision time, and delivery time of patients in pediatric emergency department based on patient’s characteristics. patient who attended emergency department on weekday had prolonged response and decision time. the same thing occurred in patients who visit emergency department at night and without insurance. prolonged delivery time occurred in patient who were hospitalized. meanwhile, patient with emergency status had shorter response time but longer in delivery time. out of 138 patients who suggested by physicians to be hospitalized, only 66.7% entered inpatient ward. meanwhile, 6.5% had approved to discharge by the physician after all, 14.5% were against medical advice (ama), 2.9% were transferred into other health care facility, and the rest (2.9%) died while waiting for inpatient ward. (table 4) discussions according to this study, the emergency department crowding was most seen in the afternoon. this result was in line with other literature which indicated that this crowding is probably due to patient who could not visit outpatient clinic.8 the total of waiting time in pediatric emergency department is longer than other previous study,8,9 and with the 4 hours maximal standard waiting time of emergency department.10,11 total waiting time was determined mostly from delivery time. this study found that delivery time had not meet the 2 hours median recommendation which assigned by council for the accreditation of educator preparation (caep).12 in contrast, response and decision time have been better than previous study and met the standard of good hospital care (5 minutes and 120 minutes).13 however, in reality, there were patients who waited for more than 10 hours to get a disposition of care decision. this matter was caused by multifactorial factors such as prolonged time needed to other supporting examination (laboratory, radiology) and consulted with other specialist.3,12 longer response time is seen on patients who arrived on weekday (monday-friday), likely due to a large number of visitors during that day. this is consistent with other study which stated that an increase in waiting time directly proportional to emergency department volume of visits.6,14 increasing in emergency department visits resulted in unavailability of emergency department resources to take care of patients; therefore, the patients must wait in unreasonable waiting time. american academy emergency declares that emergency physician is required to give health care to 2.5 patients per hours and nurse patient ratio should not excess 1:3.8 whereas in pediatric emergency department of dr. hasan sadikin general hospital, there are 2 doctors and 2 nurses with the average of patient’s visit are 12 patients per day, which is much lower than requirement. in addition, the same result is found in patients who visit during night. meanwhile longer decision times are seen in patient who visited on weekend and night, probably due to time operation of other supporting examination and consultation. patients with hospitalized disposition of care had longer delivery time. lack of inpatient bed capacities is the main cause prolonged of table 4 mode of discharge patient with hospitalized disposition of care n percentage (%) enter inpatient ward 92 66.7 not enter inpatient ward 46 33.3 discharge with doctor’s approval 9 6.5 ama* 20 14.5 death 13 9.4 transfer to other facilities 4 2.9 total 138 100 *ama: against medical advice althea medical journal. 2017;4(3) 367 delivery time.4,11,15 the longer response and decision time also found in uninsured patients (poor patients or patients who do not have insurance). the result is consistent with other study which concluded that insurance status decides the quality of health care in community, include the waiting time in emergency,16 yet contradict with the result of national hospital ambulatory medical care surveys 2005 and 2006 in united states of america.17 patients with non-urgent status have shorter decision time. this result consistent with other studies which related patients with non-urgent status to waiting time in emergency department.18,19 meanwhile, faster response time but longer delivery time are seen in emergency patients. this is consistent with other study which stated that patients with emergency status need more time to health care and treatment of critical condition, that contribute in prolonging delivery time in emergency department, particularly if the patients must wait for full inpatient bed.19 from all patients whom suggested by physician to be hospitalized, there were patients who did not enter in patient bed which in the end would cause prolonged delivery time. this condition caused by some factors such as no patient in bed, no money to pay the hospital fee, and the family of patient refuse patient to enter the inpatient bed.4 this condition can increase patient’s morbidity and mortality since patient must be treated in emergency department with minimal facility. it can be seen from out of 46 patients who did not entered inpatient bed, there were 13 patients deaths (28.3%) who had longer delivery time (701.45 minutes) than patients who still alive (163.90 minutes). meanwhile, transfer process to other health care facility is more difficult because dr. hasan sadikin general hospital, bandung is a tertiary health care facility. dr. hasan sadikin general hospital gets many referred patient from other health care facility in west java which do not have facility or space in inpatient bed, especially for pediatric intensive care unit (picu) and neonatal intensive care unit (nicu).3 based on the observation, dr. hasan sadikin general hospital did not have enough space to accommodate emergency department’s entire patient so that many stretchers had been seen in corridor of emergency department, particularly when there was increasing of volume of patient’s visits at afternoon and night. this finding is similar to condition in other tertiary health care facility.3,20 this condition can be resulted from prolonged delivery time from previous patient due to not enough space in inpatient bed which can block the flow of patients in emergency department and increase waiting time futher.6,11 the limitation of this study is short duration of the study and the data which have been collected were handwritten medical record with less accurate of time documentation. the more collected and the better implementation of medical record writing system will make the data collected in the future more accurate; therefore simplifying policy in hospital could increase the quality of health care delivery. in conclusion, the total waiting times and delivery time of pediatric emergency department exceeds the standard time (4 hours). meanwhile response time and decision time already met the standard. longer waiting times can be seen in patient who attended emergency department on weekday and afternoon until night, uninsured patient, and have been decided to inpatient care. additional inpatient bed in hospital is needed to decrease waiting time, especially delivery time. increasing of emergency department capacities and number of health workers (doctors and nurse) are needed to overcome emergency department overcrowding in particular time (afternoon to night) when there are most emergency visitors. coordination between emergency department, radiology, laboratory, and specialist’s consultation should be improved to decrease decision time. further studies are needed to assess the relationship between variable used in this study with response time, decision time, and delivery time, especially in patients who have national health insurance (badan penyelenggara jaminan sosial, bpjs) or has not have bpjs insurance (private insurance or has no insurance). in addition, the cause of the death of patient who did not enter inpatient bed needs to be more analyzed whether it is resulted from prolong waiting time or patient’s condition itself. references 1. kroner el, hoffmann rg, brousseau dc. emergency department reliance: a discriminatory measure of frequent emergency department users. pediatrics. 2010;125(1):133–8. 2. middleton kr, burt cw. availability of pediatric services and equipment in emergency departments, united states, ayu sary oktaviani, dzulfikar dlh, suwarman: response time, decision time, and delivery time in pediatric emergency unit of west java top referral hospital althea medical journal. 2017;4(3) 368 amj september 2017 2002-03. adv data. 2006;(367):1–16. 3. tiwari y, goel s, singh a. arrival time pattern and waiting time distribution of patients in the emergency outpatient department of a tertiary level health care institution of north india. j emerg trauma shock. 2014;7(3):160–5. 4. harris a, sharma a. access block and overcrowding in emergency departments: an empirical analysis. emerg med j. 2010;27(7):508–11. 5. astle s, banschbach sk, briggs wt, durkin wt, groah lk, guglielmi c, et al. development of consensus statement on defintions for consistent emergency department metrics. j emerg nurs. 2012; 38(3):270–2. 6. hing e, bhuiya f. wait time for treatment in hospital emergency departments: 2009. nchs data brief. 2012;(102):1–8 7. bernstein sl, aronsky d, duseja r, epstein s, handel d, hwang u, et al. the effect of emergency department crowding on clinically oriented outcomes. acad emerg med. 2009;16(1):1–10. 8. ay d, akkas m, sivri b. patient population and factors determining length of stay in adult ed of a turkish university medical center. am j emerg med. 2010;28(3):325– 30. 9. shi p, dai j, ding d, ang j, chou m, jin x, et al. patient flow from emergency department to inpatient wards: empirical observations from a singaporean hospital. 2014. [cited 2016 january 14]. available at ssrn: https://ssrn.com/abstract=2517050 or http://dx.doi.org/10.2139/ssrn.2517050 10. hughes g. four hour target for eds: the uk experience. emerg med australas. 2010;22(5):368–73. 11. di somma s, paladino l, vaughan l, lalle i, magrini l, magnanti m. overcrowding in emergency department: an international issue. intern emerg med. 2015;10(2):171– 5. 12. affleck a, parks p, drummond a, rowe bh, ovens hj. emergency department overcrowding and access block. cjem. 2013;15(6):359–84. 13. sabriyati woni, islam aa, gaus s. faktorfaktor yang berhubungan dengan ketepatan waktutanggap penanganan kasus pada response time i di instalasi gawat darurat bedah dan non-bedah rsup dr. wahidin sudirohusodo [dissertation]. makasar: universitas hasanuddin; 2012. 14. jayaprakash n, o’sullivan r, bey t, ahmed ss, lotfipour s. crowding and delivery of healthcare in emergency departments: the european perspective. west j emerg med. 2009;10(4):233–9. 15. sun y, heng bh, tay sy, seow e. predicting hospital admissions at emergency department triage using routine administrative data. acad emerg med. 2011;18(8):844–50. 16. james ca, bourgeois ft, shannon mw. association of race/ethnicity with emergency department wait times. pediatrics. 2005;115(3):e310-5. 17. park cy, lee ma, epstein aj. variation in emergency department wait times for children by race/ethnicity and payment source. health serv res. 2009;44(6):2022– 39. 18. schull mj, kiss a, szalai jp. the effect of low-complexity patients on emergency department waiting times. ann emerg med. 2007;49(3):257–64, 264.e1. 19. bukhari h, albazli k, almaslmani s, attiah a, bukhary e, najjar f, et al. analysis of waiting time in emergency department of al-noor specialist hospital, makkah, saudi arabia. open journal of emergency medicine. 2014;2(04):67–73. 20. goel s, gupta a, singh a, lenka s. preparations and limitations for prevention of severe acute respiratory syndrome in a tertiary care centre of india. j hosp infect. 2007;66(2):142–7. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 541 etiology of allergic contact dermatitis based on patch test dita maulida anggraini,1 endang sutedja,2 achadiyani3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: allergic contact dermatitis is a type of contact dermatitis, whose prevalence tends to increase every year. patch test is an important diagnostic test to confirm the disease. the result of patch test can help doctors to perform appropriate treatment. the aim of the study was to identify the most frequent allergen causing allergic contact dermatitis based on patch test results. methods: this was a descriptive retrospective study among patients who underwent patch test at the dermatology and venereology clinic in dr.hasan sadikin general hospital bandung, indonesia from august 1st, 2014 to august 31st, 2015. the patch test result was obtained from the patient’s medical record and recapitulation data. the patient’s medical record would be collected based on inclusion and exclusion criteria. this study also collected demographic data of the patients, including age, sex, and occupation.the collected data were presented using tables. results: out of 45 patient’s medical records, 19 patients were male (42.2%) and 26 patients were female (57.8%). nickel sulphate was the most frequent allergen with 17 sensitization. thirteen out of 17 patients who were sensitized by nickel sulphate were females. a great majority of the patients were in the age group of 15–44 years. most of the patients were students (42.2%). allergic contact dermatitis (64.4%) was the main clinical diagnosis among the patients. conclusions: the most frequent allergen causes allergic contact dermatitis is nickel sulphate. keywords: allergic contact dermatitis, nickel sulphate, patch test correspondence: dita maulida anggraini, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: anggrainid17@gmail.com introduction allergic contact dermatitis (acd) is an inflammatory process of the skin caused by a specific allergen. it is included in type-iv hypersensitivity, which the patient has been previously sensitized to the allergens. the north american contact dermatitis group (nacdg) reports from 2009–2010 and 2011– 2012, indicated that the prevalence of acd has increased from 46.3% to 48.0%.1,2 prevalence of acd patients treated at dr. mohammad hoesin general hospital palembang, in 2008 reached 13.42%.3 allergic contact dermatitis can be caused by several factors including genetic, age, gender, occupation, and other comorbidities such as irritant contact dermatitis (icd), atopic dermatitis, and chronic urticaria. clinical manifestations of acd vary from erythematous macules, swelling, papulovesicles, to bullae or ulcer in severe cases. pruritus is the main symptom found in acd patients.4 diagnosis of acd can be performed by anamnesis and physical examination.5 one of the tests used to confirm the diagnosis is the patch test. the test is carried out by attaching chamber/patch which has been given the substances to suspected patient’s skin.6 positive result of the test for at least one allergen confirm the diagnosis. patch test results help doctors in patient education and therapy. in indonesia, studies about the frequency of allergen sensitization have not been much carried out. the aim of the study was to identify the most frequent allergen causing acd based on patch test results methods this was a retrospective, descriptive study of all patients who underwent the patch test amj. 2017;4(4):541–5 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1265 althea medical journal. 2017;4(4) 542 amj december 2017 from august 1st, 2014 to august 31st, 2015 at dr.hasan sadikin general hospital bandung. this study used patient’s medical records and recapitulation data as study tools. fortyfive medical records from patients who had done patch test in the period august 2014 to august 2015 were included based on inclusion criteria: (1) the diagnosis of acd was confirmed (2) positive result for at least one allergen. patch test with an irritant result would be excluded from the samples. the standardized allergen series used at dr. hasan sadikin general hospital were supplied by the department of dermatology and venereology, faculty of medicine, universitas gajah mada. there were 2 versions of standardized allergen series used between 2014–2015: 18-allergens series and 22-allergens series, with the total of both series was 24 allergens. in addition to the patch test results, this study also assessed the clinical diagnosis. the study was conducted at the outpatient clinic of dr. hasan sadikin general hospital bandung from september to november 2015. the collected data would be processed using computer software and presented in tables. the ethical clearance was approved by the health research ethics committee of dr. hasan sadikin general hospital bandung. results clinical diagnosis and demographic data of the patients showed that most of the patients were female and aged between 15 and 44 years. the most frequent clinical diagnosis of the patients was acd (71.1%). the patient’s occupation was mostly student (42.2%); housewife and private employee were similar in frequency (table 1). out of 45 patients tested, 33 patients (73.3%) had at least one positive reaction, and 12 patients had ≥3 positive reactions. the most frequent allergen was nickel sulphate (19.3%), followed by potassium dichromate (10.2%) and cobalt chloride (9.1%). there was an additional allergen, balsam tiger, which was tested only on one patient due to the indication of the substance as causal allergen (table 2). discussions allergic contact dermatitis (acd) is one of the classifications of contact dermatitis. this disease is caused by a hapten complex that penetrates through the skin and sensitizes the body. predisposing factors of acd include genetic, gender, ages, occupational, and environmental factors.7 however, the main factor which affected this disease to be occurred is the exposure to allergen itself. if patients had never been exposed to the allergen, the disease would not likely occur, even if they had a genetic factor. so, exposure to suspected allergen is also important to confirm the diagnosis. an important diagnostic test to confirm allergic contact dermatitis is the patch test. this test is performed to differentiate whether it is an allergy or not. this test uses a set of standardized allergens series and attaches them by using a patch/chamber in the patient’s skin. the diagnosis can be confirmed with only one positive result. this study discovered that the greater predominance of patients with acd was female. a study in a brazilian population group8 and north american contact dermatitis group table 1 distribution of patient’s clinical diagnosis and demographic data variables n(%) gender male 19(42.2) female 26(57.8) age (years-old) <15 2(4.4) 15–44 36(80.0) 45–64 1(2.2) >65 1(2.2) unknown 5(11.1) occupation student 19(42.2) housewife 11(24.4) private employee 11(24.4) government employee 4(8.9) clinical diagnosis allergic contact dermatitis 32(71.1) irritant contact dermatitis 2(4.4) atopic dermatitis 3(6.7) chronic urticaria 3(6.7) pemphigus vulgaris 1(2.2) numular dermatitis 1(2.2) erythema nodosum 1(2.2) other 2(4.4) althea medical journal. 2017;4(4) 543dita maulida anggraini, endang sutedja, achadiyani: etiology of allergic contact dermatitis based on patch test (nacdg) 2 reported a similar result (71.5% and 68.6% female patients respectively). this finding may be related to the high exposure of allergenic substances among females. example of the objects, especially in females, included jewelry (e.g. necklaces, earrings, bracelets, etc.), fragrances, soap, hair dyes, cosmetics, etc. the range of patient’s age found in this study was 11–70 years, in which 5 patients had unknown age. thirty-six patients (80.0%) were from the 15–44 age group. only 2 patients were found in ≥45 age group. furthermore, thaha3 reported that 94.1% of patients in his study are in the adult age group (17–<60). however, this finding was inversely related to other studies. a study in poland9 reported that 55% of people examined are over 40 years old. while adiani and muslimin10 in their study on the characteristics of allergic contact dermatitis reported that 58.6% of patients are in the >30 age group. moreover, the 15–44 age group is a productive age group. this group of people was exposed to many sources of allergen, especially from the occupational environment. they had more opportunities for sensitization in their occupation, such as factory workers (e.g. rubber, metals, textiles), health-care workers (e.g. alcohol, drugs, cleanser), and labourers (e.g. cement, ink, paint). regarding occupation, 19 patients were students (42.2%), making them as the most frequent occupation in this study. this finding table 2 frequency of allergen test allergens test no. of patients tested frequency of sensitization percentage (%) nickel sulphate 5% 45 17 19.3 balsam peru 25% 45 4 4.6 potassium dichromate 0,5% 45 9 10.2 cobalt chloride 1% 45 8 9.1 benzocaine 5% 45 1 1.1 formaldehyde 1% 45 2 2.3 cinnamic aldehyde 1% 36 2 2.3 irgasan 2% 9 0 0.0 paba 10% 45 7 7.9 hidroquinone 1% 45 7 7.9 neomycin sulphate 20% 45 3 3.4 lanolin 45 2 2.3 vaselin 45 3 3.4 benzophenone 3% 45 5 5.7 methyl paraben 5% 45 1 1.1 5-chloro-7-iodo hydroxyquinolone 45 2 2.3 2-mercapto-benzothiazole 2% 45 1 1.1 p-phenilenediamine 0,5% 45 4 4.6 colophony 20% 36 4 11.1 clioquinol 5% 9 0 0.0 quaternium-15 1% 9 1 11.1 tetramethylthiurandisulphate 1% 9 1 11.1 diclofenac sodium salt 1% 9 0 0 ethylenediamine 1% 9 3 33.3 tiger balm 1 1 100.0 althea medical journal. 2017;4(4) 544 amj december 2017 was different from other studies. as explained by thaha3, most of the patients work as government employees (40.0%) and only 15.3% of patients are students. a study in brazil8 found that 22.3% of patients work in commerce. these differences might be related to dr. hasan sadikin general hospital bandung as teaching hospital. in this hospital, many co-assisting medical students were tested as patients due to the indications found in anamnesis and physical examination. thus, the result, showed a higher percentage of students. as explained before, most of the patients were in age group 15–44 years. students might also contribute to higher percentage of this age group. the majority of patients were diagnosed as allergic contact dermatitis (71.1%). diagnosis could be performed by anamnesis and physical examination. the history of exposure, allergy, family with similar sign and symptom, and occupation could be asked in anamnesis to identify the suspected allergen. in addition, physical examination would be focused on characteristics of the lesion (e.g. location, shape, size, colour, pruritic sign, etc.). if there were any indication to contact dermatitis, doctors can perform an additional test such as the patch test. this test helps to differentiate contact dermatitis caused by allergen and irritant. besides, allergic contact dermatitis can also appear as a complication from other skin conditions e.g. atopic dermatitis, nummular dermatitis, chronic urticaria, pemphigus vulgaris, etc. this explained the other diagnoses found among the patients in this study. in this study, the most frequent allergen found was nickel sulphate, followed by potassium dichromate and cobalt chloride. this was similar to the findings from other studies, although some differences were found in the second and third most frequent allergens. a study in palembang3 reported that the 3 most frequent allergens were nickel sulphate, fragrance mix, and 4-phenylenediamine free base. calamita et al.8 reported nickel sulphate, perfume mix, and thimerosal as the most frequent allergens. moreover, the top 3 allergens in this study were metallic allergens. this is similar to the study of bordel-gómez et al.11, with 4 top allergens, nickel sulphate, palladium chloride, cobalt chloride, and potassium dichromate. many metallic products contain 2 or more metallic substances and simultaneous exposure between them can produce co-reactions and aggravate the symptoms.12 moreover, nickel sulphate is one of the most frequent allergens in the world. many reports have ranked this allergen as the top one. the north american contact dermatitis group2 in 2011–2012 also reported nickel sulphate as the most frequent allergen. this finding was similar to nacdg report in 2009–2010.1 many nickel-containing objects are strong sensitizer and soluble in water and sweat.4 contact with the skin, nickel which has been corroded by water or sweat could trigger sensitization. sources for this allergen included jewelry, buttons, watches, coins, etc. out of 17 patients who were sensitized by nickel sulphate, 13 patients were female (76.5%). this also made nickel sulphate as the most common allergen among females. this finding might be related to the high exposure of nickel-containing objects among females. example of the objects, especially in females, included jewelry (e.g. necklaces, earrings, bracelets, etc.), fragrances, soap, hair dyes, cosmetics, cooking pan, etc. sources of allergen could be identified also from the pattern of lesion. for example, if the pattern was a thin and long lesion around the neck, the source of allergen is most likely a necklace. as for male patients, potassium dichromate becomes the most frequent allergen with 6 sensitizations. bordel-gómez et al.11 also reported this allergen as the most common one among males. the sources of allergen are mostly from cement, tattoos, and leather material.12 the difference in standardized allergen series used from august 2014–august 2015 was the major limitation in this study. there were 2 versions of series: 18-allergen series and 22-allergen series. the latter one was used in the 2015 period. cinnamic aldehyde and colophony were not included in this series. new allergens in this series were irgasan, clioquinol, quaternium-15, tetramethylthiuran disulphate, ethylenediamine, and tiger balm (only tested in 1 patient). these differences could cause a decrease in the true frequency of those allergens. furthermore, this study could not sum up the total frequency of sensitization and the percentage would not be exactly in onehundred percent. other limitations are toosmall sample size and incomplete recording process in the patient’s medical record. as the conclusion, the most frequent allergen causing acd based on patch test results is nickel sulphate, which is mostly found in females. allergic contact dermatitis is the most frequent clinical diagnosis among the patients. the great majority of the patients are althea medical journal. 2017;4(4) 545 included in the age group of 15–44 years with student as their major occupation. references 1. warshaw em, belsito dv, taylor js, sasseville d, dekoven jg, zirwas mj, et al. north american contact dermatitis group patch test results: 2009 to 2010. dermatitis. 2013;24(2):50–9. 2. warshaw em, maibach hi, taylor js, sasseville d, dekoven jg, zirwas mj, et al. north american contact dermatitis group patch test results: 2011–2012. dermatitis. 2015;26(1):49–59. 3. thaha ma. uji tempel dengan finn dan iq chambers pada pasien dermatitis kontak alergi di rumah sakit umum pusat dr. mohammad hoesin palembang. majalah kedokteran sriwijaya. 2014;46(2):118– 23. 4. beck mh, wilkinson sm. contact dermatitis: allergic. in: burns t, breathnach s, cox n, griffiths c. rook’s textbook of dermatology. 8th ed. oxford: blackwell publishing; 2010. p. 26.1–26.106. 5. sasseville d. occupational contact dermatitis. allergy asthma clin immunol. 2008;4(2):59–65. 6. lazzarini r, duarte i, ferreira a. patch tests. an bras dermatol. 2013;88(6):879– 88. 7. peiser m, tralau t, heidler j, api a, arts j, basketter d, et al. allergic contact dermatitis: epidemiology, molecular mechanisms, in vitro methods and regulatory aspects. cell mol life sci. 2012;69(5):763–81. 8. calamita z, alonso acr, da costa lco, calamita abp. main allergens observed in patients with contact dermatitis in a brazilian population group. open dermatol j. 2015;9(5):21–4. 9. reduta t, bacharewicz j, pawłoś a. patch test results in patients with allergic contact dermatitis in the podlasie region. postepy dermatol alergol. 2013;30(6):350–7. 10. adiani ad, muslimin m. karakteristik dermatitis kontak alergi (dka) di rsup dr. kariadi. media medika muda. 2014;3(1):1–25 11. bordel-gómez mt, miranda-romero a, castrodeza-sanz j. epidemiology of contact dermatitis: prevalence of sensitization to different allergens and associated factors. actas dermosifiliogr. 2010;101(1):59–75. 12. rietschel r, fowler j, fisher a. fisher’s contact dermatitis. 6th ed. hamilton: bc decker inc; 2008. p. 653–60. dita maulida anggraini, endang sutedja, achadiyani: etiology of allergic contact dermatitis based on patch test althea medical journal. 2017;4(2) 204 amj june 2017 correlation between heredity factor and menarcheal age among adolescent aged 9–15 years old nurul khotimah,1 r.m. ryadi fadil,2 haryono tansah3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry faculty of medicine universitas padjadjaran abstract background: menarche is a sign of maturity of the female reproductive function. it is influenced by many factors, such as heredity, general health status, nutrition, and socioeconomic status. the purpose of this study is to determine the correlation of heredity and menarcheal age. methods:this study was a cross-sectional analytic study conducted from september–october 2014 in bandung using a multi-stage sampling technique and it was conducted in twelve elementary schools and junior high schools. a total of 123 subjects were included in this study. the instrument of this study was questionnaire containing menarcheal age of subject, older sister, biological mother, and maternal grandmother. the data were analyzed using spearman correlation and linear regression test with the level of significance was determined at p<0.05. results: among 123 data, the majority of subjects had experienced menarche at the age of 11 (39%) and 12 years (36.6%) with an average of 11.46 years old. based on the spearman correlation and multiple linear regression tests, there was a correlation between heredity and menarcheal age. (p=0.00). conclusions: there is a correlation between heredity and menarcheal age, with the highest correlation is between subject’s and older sister’s menarcheal age. keywords: adolescent, heredity, menarche correspondence: nurul khotimah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287729166628 email: nlkhotimah@gmail.com introduction in times of growth, human will grow from fetuses, infants, children, and adolescents to adults. the transition from childhood to adulthood is called puberty. one of the changes that will happen is the emergence of signs of sexual maturation and reproductive function, which is marked by menarche or first menstruation. physically, menarche is characterized by bleeding from vagina due to sloughing of the endometrial lining. menarche usually occurs one to two years after the growth spurt.1 the age range of menarche adolescents in indonesia is 9–18 years old.2 factors that influence menarche consist of endogenous and exogenous factors. the examples of endogenous factors are genetics and health status, while the exogenous factors are the nutritional status and socioeconomic condition.3,4 many studies were studying the relationship between exogenous factors and menarche but the study on the relationship between heredity as one of the genetic manifestations and the age of menarche is still rare. on the other hand, in determining a person’s menarcheal age, it is easier to predict from heredity. based on the study in the united kingdom, there is a significant relationship between heredity and menarcheal age. the study involved three generations, the grandmother, mother, and the subject. the results of significance for all three variables are highly significant. however, there is an increase in the average of menarcheal age.5 not only in the united kingdom6, a similar study was also conducted in australia, which the subjects are monozygotic twin, dizygotic twin, and siblings. the most significant result was found in monozygotic twin.7 it is indicated that there is an influence of heredity in the menarcheal age. based on the theoretical facts and the results of previous studies above, the relationship amj. 2017;4(2):204–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1081 205 althea medical journal. 2017;4(2) between heredity and menarcheal age among adolescent aged between 9–15 years old in bandung was interesting to study. selection of subjects due to menarche occurs largely in the age range 9–15 years old.2 methods this study was a cross-sectional study conducted from september–october 2014 in elementary school and junior high school students in bandung, west java, indonesia. a total of 123 data were collected by multistage random sampling technique. first, bandung was divided into six administrative regions. furthermore, the selection of one elementary school and one junior high school was randomly based on the data from the education board of bandung in each region. after that, proportional random sampling was used to select the subject of the 12 selected schools. inclusion criteria for this study were (1) adolescents aged between 9–15 years old in the selected schools who attended and were voluntarily engaged in the study, and (2) older sister, biological mother, and maternal grandmother of the subject who remember their menarcheal age. exclusion criteria were (1) subjects with a chronic disease or hormonal disorders, and (2) subjects taking hormonal drugs. the instrument of this study was a validated questionnaire containing the identity, health status, and menarcheal age of subjects, subjects’ older sister, biological mother, and maternal grandmother. the collected data were entered into the computer using microsoft excel 2007 and spss (version 20) software. furthermore, the data were analyzed using the spearman correlation test, with a significance value at p<0.05. after that, the data were analyzed using multiple linear regression to determine the magnitude of the changes in the subject’s menarcheal age if there is a change in heredity. the test was performed by a model calculation: y = dependent variable a = constant b1, b2, b3 = regression coefficients x1, x2, x3 = independent variables ethical approval was obtained from the health research ethics committee of universitas padjadjaran, bandung . informed consent was also obtained from the national unity and community development of bandung, education board of bandung, and school authorities. results the data were then collected from twelve elementary schools and junior high schools nurul khotimah, r.m. ryadi fadil, haryono tansah: correlation between heredity factor and menarcheal age among adolescent aged 9–15 years old table 1 distribution of subject’s menarcheal age variable subject sister mother grandmother menarcheal age 9 2 (1.6) 5 (4.1) 10 14 (11.4) 28 (22.8) 2 (1.6) 2 (1.6) 11 48 (39) 54 (43.9) 8 (6.5) 4 (3.3) 12 45 (36.6) 33 (26.8) 50 (40.7) 47 (38.2) 13 13 (10.6) 2 (1.6) 44 (35.8) 40 (32.5) 14 1 (0.8) 1 (0.8) 13 (10.6) 22 (17.9) 15 5 (4.1) 7 (5.7) 16 1 (0.8) 17 1 (0.8) total 123 123 123 123 menarcheal age mean 11.46 12.02 12.63 12.83 median 11 12 13 13 minimum-maximum 9-14 10-15 10-16 10-17 althea medical journal. 2017;4(2) 206 amj june 2017 of the six regions of bandung city. the schools were sdn (public elementari school) asmi, sdn banjarsari, sdn cijawura, sdn ciujung, sdn sejahtera, sdn ujung berung, smp negeri (public junior high school) 1, smp negeri 2, smp negeri 8, smp negeri 11, smp negeri 14, and smp negeri 18. from twelve schools, there were 238 children who met the inclusion criteria in this study. a total of 115 children did not fill the questionnaire completely, so only 123 children who wereincluded in this study. the mean of subject’s menarcheal age was earlier than the mean of older sister’s, biological mother’s, and maternal grandmother’s menarcheal age. the earliest of menarcheal age was 9 years old, meanwhile the latest was 17 years old. after that, the data were analyzed using kolmogorov-smirnov and shapiro wilk test to know the distribution of the data. the data were not normally distributed, so they were analyzed using spearman correlation test. the result was shown at table 2. based on spearman test, there was correlation between heredity and menarcheal age. the highest correlation was found between subject’s and older sister’s menarcheal age, while the lowest was found between subject and biological mother. all correlation among variables was positive so if one variable was increasing, the other variables would be increased. to determine the correlation between heredity combinations of older sister’s, biological mother’s, and maternal grandmother’s menarcheal age and subject’s menarcheal age, multiple linear regression was conducted. the result of this correlation was 0.3. the correlation was positive but it had a low correlation. based on data analysis, the data had p value <0.05 so there was a correlation between subject’s menarcheal age and heredity that were taken from older sister’s, biological mother’s, and maternal grandmother’s menarcheal age. to determine the changes in subject’s menarcheal age based on heredity, multiple regression tests were conducted. based on the results of the data analysis, the regression result between heredity and menarcheal age showed was 6.017, b1 was 0.644, and b2 was -0.251. maternal grandmother was not applied to regression model due to level of significance >0.05. therefore, regression model was obtained: subject’s menarcheal age = 6.017+0.644(older sister’s menarcheal age)-0.251(biological mother’s menarcheal age) discussions the mean of menarcheal age in bandung was earlier (11.46) than national indonesian survey conducted in 2010, which was 12.96 years old.2 the mean of menarcheal age in bandung is also lower than the mean of menarcheal age in united kingdom6 (12.7), india8 (12.43), and nepal9 (12.85). the differences among those results are caused by heredity and environment factors.10 the mean of subject’s menarcheal age was lower than older sister’s, biological mother’s, and maternal grandmother’s menarcheal age. the similar result was also found in the study conducted in the united kingdom6 by morris (2011) but the mean difference of menarcheal age in this study was higher than united kingdom. the mean differences of menarcheal age are caused by nutrition intake, physical activity, and psychological state.11 based on spearman correlation and multiple linear regression tests, there was a correlation between heredity and menarcheal age. the similar results were found in the study conducted in australia5, united kingdom6, and iran13. the heredity factor is caused by influence of sterol regulatory element binding protein (srebp), cytochrome p450 family 19 subfamily a polypeptide 1 (cyp19a1), cytochrome p450 family 17 (cyp17), estrogen receptor α (esr α), and gnrh receptor (gnrhr) gene that will affect quantities and activities of steroid hormones, such as gnrh, estrogen, and progesterone that stimulate process of menarche.7,14,15 however, this study table 2 correlation between subject’s menarcheal age and older sister’s, biological mother’s, and maternal grandmother’s menarcheal age correlation older sister’s menarcheal age biologic mother menarcheal age maternal grandmother’s menarcheal age subject’s menarcheal age r: 0,522 r: 0.207 r: 0.216 p: 0.00 p: 0.021 p: 0.017 207 althea medical journal. 2017;4(2) nurul khotimah, r.m. ryadi fadil, haryono tansah: correlation between heredity factor and menarcheal age among adolescent aged 9–15 years old did not discuss about those genes. the highest correlation was found between subject’s and older’s sister menarcheal age. this result revealed that not only heredity could influence menarcheal age, but also other factors, such as nutritional intake and health condition.7 the correlation between subject’s and biological mother’s menarcheal age was the lowest correlation. this result is caused by other factors, such as nutritional intake before puberty, which could affect menarcheal age.16 therefore, heredity is dominant in non-obese children.16 the limitations of this study were limited of time and budget also less of subject’s enthusiasm in some regions. the used study design was not suitable so it could not eliminate the confounding factors, such as nutritional intake and psychological state. this was caused by difficulty to assess those factors and high bias. recall information about menarcheal age could lead to information bias. recommendations based on limitation of this study are increasing size and enthusiasm of subjects, and using prospective cohort design to reduce information bias and eliminate confounding factors. based on data analysis and discussion above, the mean of menarcheal age among adolescent aged 9 – 15 years old in bandung is 11.46 years old. there is a correlation between heredity and menarcheal age, with the highest correlation is between subject’s and older sister’s menarcheal age. references 1. cromer b. menstrual problem. in: kliegman rm, stanton bf, st. geme iii jw, schor nf, behrman re, editors. nelson textbook of pediatrics. 19th ed. philadelphia: elsevier; 2011. p. 1208. 2. jose rl batubara, frida soesanti, van de waal hd. age at menarche in indonesian girls: a national survey. acta med indones. 2010;42(2):78–81. 3. goyal r, mehta p, kaur g. nutritional status and menarche in adolescents of punjab. j life sci. 2012;4(1):63–6. 4. elshiekh m, mohammed ama. influence of socioeconomic status in the age at menarche and duration of menstrual bleeding. mat soc med. 2011;25(4):195–9. 5. anderson ca, duffy dl, martin ng, visscher pm. estimation of variance components for age at menarche in twin families. behav genet. 2007;37:668–77. 6. morris dh, jonesa me, schoemakera mj, ashworthb a, swerdlowa aj. familial concordance for age at menarche: analyses from the breakthrough generations study. paediatr perinat epidemiol. 2011;25(3):306–11. 7. styne dm, grumbach mm. puberty. in: henry m. kronenberg m, shlomo melmed m, kenneth s. polonsky m, p. reed larsen m, facp, frcp, editors. williams textbook of endocrinology. 12th ed. philadelphia: elsevier; 2011. p. 969. 8. khatoon t, verma ak, kumari r, rupani r, singh m, rizvi a. age at menarche and affecting bio-social factors among the girls of lucknow, uttar pradesh. j indian acad forensic med. 2011;33(3):221–3. 9. sunuwar l, saha c, dhungel ku. age at menarche of subpopulation of nepalese girls. nepal med coll j. 2010;12(3):183–6. 10. styne d. puberty. in: gardner dg, shoback d, editors. greenspan’s basic & clinical endocrinology. 9th ed. new york: mc-graw hill; 2011. p. 454. 11. joinson c, heron j, lewis g, croudace t, araya r. timing of menarche and depressive symptoms in adolescent girls from uk cohort. brit j psychiat. 2011;198:17–23. 12. tehrani fr, mirmiran p, zahedi-asl s, nakhoda k, azizi f. menarcheal age of mothers and daughters: tehran lipid and glucose study. east mediterr health j. 2010;16(4):391–5. 13. karapanou o, papadimitriou a. determinants of menarche. reprod bio endocrinol. 2010;8:115–23. 14. dvornyk v, waqar-ul-haq. genetics of age at menarche: a systematic review. hum reprod update. 2012;18(2):198–210. 15. epplein m, novotny r, daida y, vijayadeva v, t. onaka a, marchand l. association of maternal and intrauterine characteristics with age at menarche in a multiethnic population in hawaii. cancer causes control. 2011;21(2):259–268. 16. ersoy b, balkan c, gunay t., egemen a. the factors affecting the relation between the menarcheal age of mother and daughter. child care health dev. 2005;31(3): 303–8. vol 5 no 2 full text edit.indd althea medical journal. 2018;5(2) 77 emotional mental problems among adolescents: urban and semiurban settings meita dhamayanti,1 stanza uga peryoga,1 mohamad rizqy firmansyah2 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia abstract background: emotional mental problems refer to something that complicates someone in an attempt to conform to the environment and experiences. in indonesia the prevalence of emotional mental problems is 6.0%. in west java province as the most populous region in indonesia, the number of prevalence is above the national average of 9.3%. west java province was selected for this study because in addition to being the most densely populated region, it also has urban and semi-urban areas. the purpose of this study was to identify the difference in the prevalence of emotional mental problems of adolescent in urban and semiurban areas. methods: this study used the cross sectional approach method. inclusion criteria were adolescents aged 14-16 years who attended several junior high and senior high schools in cirebon city as an urban area and sumedang regency as a semi-urban area. exclusion criteria were adolescents who filled out the questionnaire incompletely. the study variables consisted of adolescents, urban and semi-urban areas, and emotional mental problems. data were analyzed by using chi square (x2) test. results: out of 1039 respondents, 816 met the inclusion criteria. there were significant differences in emotional mental problems on the aspects of emotional symptoms, behavior, hyperactivity, interpersonal relationships, social behavior, and total value of emotional mental problems with p value <0.05. conclusions: there is a difference in emotional mental problems of adolescents in urban and semi-urban areas. adolescents in urban regions have higher mental-emotional problems than in semi-urban regions. keywords: adolescents, urban, semi-urban, emotional mental problems correspondence: meita dhamayanti, department of child health, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur 38, bandung, indonesia, email: meita.dh@gmail.com introduction mental-emotional problem is a complicated factor in a person’s ability to conform with his/her environment and experiences. mentalemotional problems may arise if there are certain circumstances hampering someone’s ability to conform with their environment and experiences. according to a study by the world health organization (who), as many as 104 of 1000 children aged 4-15 years old have mental-emotional problems.1,2 one of the factors influencing adolescent mentalemotional problems is the demographic status difference.3 indonesia consists of several regions categorized as urban and semi-urban. in indonesia, prevalence of mental-emotional problems is 6% and west java province with the highest population density in indonesia have an incidence rate above the national average as much as 9.3%.4 as the densest region with urban and semi-urban regions, west java province is selected for this study, where the urban region is represented by kota cirebon, and semi-urban is represented by kabupaten sumedang. the aim of this study was to determine the differences in the prevalence of mental-emotional problems among adolescents in urban and semi-urban regions. methods an observational analytic study with cross-sectional approach was carried out using secondary data from the academic leadership grant (alg) study at the faculty of medicine universitas padjadjaran bandung. the inclusion criteria of this study were adolescents aged 14-16 years who were enrolled in several junior high schools and amj. 2018;5(2):77–81 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1416 althea medical journal. 2018;5(2) 78 amj june 2018 senior high schools in kota cirebon as the urban region and kabupaten sumedang as semi-urban region. the exclusion criteria were subjects who did not fill the questionnaire completely. the study variables consisted of adolescents, urban and semi-urban region, and mental-emotional problem. the sample in this study was determined using simple randomized sampling. the sample size acquired with large sample formula for comparing two unpaired independent proportions. out of 1039 subjects, only 816 subjects met the inclusion criteria. the dependent variable in this study was mentalemotional problems in adolescents and independent variables were adolescents in urban and semi-urban regions. data collection and analysis was conducted from march to may 2017. data were collected and analyzed after it was granted ethical exemption from the health research ethics committee faculty of medicine, universitas padjadjaran no: 384/ un6.c.10/pn/2017. furthermore, the dataata were analyzed using the univariate and bivariate method. the univariate analysis is characteristics for scoring of mental-emotional problems in respondents presented in tables. the bivariate analysis was performed in the form of a differential test between two studied groups using chi square (x2). however, if there were cells with expected count value <5, then the alternative test from chi square was used instead, which was the fischer test (2x2 table) or kolmogorov-smirnov test (2xk table). the difference was considered significant if p-value < 0.05. results this study discovered that regarding gender, from 816 subjects there were more males in the urban than in semi-urban areas. regarding ethnicity, in the urban area, there were various ethnic groups compared to the semiurban area. in the urban area, the mother’s and father’s education level of the subjects was higher compared to those in the semi-urban area (table 1). moreover, there were significant differences between urban and semi-urban regions in emotional symptom, behavior problem, hyperactivity level, peer to peer (interpersonal) relationships, social behavior, and mental-emotional problems with p-value<0.05 (figure 1). discussion based on the acquired data, the emotion level of adolescents in the urban region were higher than those in semi-urban region. this finding matches the theory by lazarus in saputra et al.5 that states urban regions have higher population density and may cause more stress to its residents. this stressor may induce intense emotional reaction, anger, criminality, figure 1 difference in prevalence of mental-emotional problems among adolescent in urban and semi-urban regions althea medical journal. 2018;5(2) 79 table 1 general characteristic of subjects general characteristics urban (n=399) semi urban (n=417) p= value gender male 184(55.8%) 146(44.2%) 0.001 female 215(44.2%) 271(55.8%) education level junior high school 218(50.3%) 215(49.7%) 0.379 senior high school 181(47.3%) 202(52.7%) ethnicity melayu/minang 11(73.3%) 4(26.7%) 0.000 batak 12(57.1%) 9(42.9%) sundanese 96(19.8%) 388(80.2%) javanese 269(95.1%) 14(4.9%) batavia 0(0%) 1(100%) balinese 1(100%) 0(0%) makassar 0(0%) 1(100%) madura 1(100%) 0(0%) others 9(100%) 0(0%) religion islam 389(48,7%) 410(51.3%) 0.525 christian 7(53.8%) 6(46.2%) catholic 1(50.0%) 1(50.0%) buddhist 2(100,0%) 0(0,0%) mother’s education level not schooled 13(92.9%) 1(7.1%) 0.000 elementary 97(55.7%) 77(44.3%) junior high school 48(45.7%) 57(54.3%) senior high school 132(44.7%) 163(55.3%) diploma 15(51.7%) 14(48.3%) bachelor’s degree 38(35.5%) 69(64.5%) postgraduate degrees 8(66.7%) 4(33.3%) do not know 48(60.0%) 32(40.0%) father’s education level not schooled 8(88.9%) 1(11.1%) 0.001 elementary 74(49.7%) 75(50.3%) junior high school 45(52.9%) 40(47.1%) senior high school 136(47.4%) 151(52.6%) diploma 18(52.9%) 16(63.4%) bachelor’s degree 48(36.6%) 83(63.4%) postgraduate degree 7(31.8%) 15(68.2%) do not know 63(63.6%) 36(36.4%) meita dhamayanti, stanza uga peryoga, mohamad rizqy firmansyah: emotional mental problems among adolescents: urban and semi-urban settings althea medical journal. 2018;5(2) 80 amj june 2018 and juvenile delinquency. meanwhile, semiurban regions have lower population density thus give off more peaceful surroundings that the residents are less likely to be emotional.5 furthermore, urban regions with competitive surroundings and higher expectations to life can provoke conflict and anger.6 on the other hand, semiurban regions with their mutualism and upholding traditional cultures influence their adolescence to be more sensitive to people around them and stabilize their emotions.7 based on acquired data, behavioral problems among adolescence in the urban region were higher than in semi-urban region. this is in line with a theory by gonzales et al.8 that there are factors influencing behavior in adolescence, such as environment (family, friends, teachers), state of surroundings (density), and individual (genetic and gender) that can influence adolescent behavior, importantly high risk behaviors. in this case, adolescence in urban regions receive more stimuli than those in semi-urban regions, for example in urban regions there are more vehicles and people, dense residence and business places, and movement area at home that are too tight causing adolescents in urban regions to be more likely to moan and complain, bored, wanting to flee from daily hustle, and others that can influence high risk factors in adolescents.9 while in semiurban regions, there are less vehicles and people, more area to play and move thus intersection between one another are relatively small.8,9 from acquired data, the hyperactivity level in adolescents in the urban area was higher than in semi-urban area. this finding aligns with a theory by sobanski that factors playing a role in hyperactivity are family issues, socialeconomic status, large amount of family, parental factors including criminal parent and those with mental illness, and children raised in daycare.10 moreover, from obtained data the level of problems among peers in the urban region were higher than in semi-urban. this is consistent with a theory by brechwald and prinstein11, where explosive emotional reactions can cause adolescents to be more likely to have issues with their peers. the presence of problems among peers could influence negative behavior in adolescents such as smoking, drug consumption, alcohol drinking, violence and criminality, and antisocial behaviors. this matches with a study indicating adolescents in semi-urban region are with higher emotional levels than those in semi-urban region which make those in urban region to have more problems among their peers.11 the summation of scores from emotional symptoms, behavioral problems, hyperactivity, and peer association become the value of the total score in adolescent mental-emotional problems. mental-emotional problems among adolescents in urban region were higher than those in semi-urban region. this may be due to the characteristics in family environment, peers, and society and are relatively different.12 mental-emotional problems may not only be caused by those factors, but also by the interaction of several factors such as genetic, environment, friends, and society.1,13,14 additionally, based on acquired data, the normal social behavior value in the semiurban region is higher than the urban region, which means that those people have protective factors against mental-emotional problems. the social behavior value is equal in meaning with the protective factor, which is a factor that modifies, changes, or forms response of a person to become stronger facing challenges from their environments, and explains that not all adolescents who have risk factors will experience behavioral or emotional problems, neither certain mental problems.1,13,14 meanwhile, social behavior included in the borderline and abnormal category were higher in urban than semi-urban region. the borderline and abnormal categories have weaker protective factors to mental-emotional problems, thus have higher risk to suffer from mental-emotional problems.1,13,14 based on this study, it can be inferred that there are significant differences in mentalemotional problems among adolescents in urban regions and semi-urban regions, where urban regions have higher mental-emotional problems than semi urban regions. the limitation of this study is that it only includes one province, and will be more appropriate with more provinces. furthermore, the characteristic components from respondents need to be added and focused group discussions (fgd) should be conducted to discuss more about this study. this study suggests the need for a form of approach for students with a risk to experience mentalemotional problems, included are students in the borderline category, so it will not develop into mental-emotional problems, involving counseling teachers in schools and parents of corresponding students. moreover, early detection is needed using the sdq questionnaire every 6 months so students althea medical journal. 2018;5(2) 81 having risk factors for mental-emotional problems can be detected. references 1. damayanti m. masalah mental emosional pada remaja: deteksi dan intervensi. sari pediatri. 2011;13(suppl 1):45–51 2. srinath s, kandasamy p, golhar ts. epidemiology of child and adolescent mental health disorders in asia. curr opin psychiatry. 2010;23(4):330–6. 3. departemen kesehatan republik indonesia. riset kesehatan dasar. jakarta. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan ri; 2013. p. 128–9 . 4. badan pusat statistik provinsi jawa barat. angka prevalensi masalah mental emosional pada remaja. bandung; 2017 [cited 2017 february 4]; available from: https://jabar.bps.go.id/linktabelstatis/ view/id/93. 5. saputra f, yunibhand j, sukratul s. relationship between personal, maternal, and familial factors with mental health problems in school-aged children in aceh province, indonesia. asian j psychiatry. 2017;25(1):207–12. 6. adrian m, zeman j, erdley c, lisa l, sim l. emotional dysregulation and interpersonal difficulties as risk factors for nonsuicidal self-injury in adolescent girls. j abnorm child psychol. 2011;39(3):389–400. 7. wiguna t, manengkei psk, pamela c, rheza am, hapsari wa. masalah emosi dan perilaku pada anak dan remaja di poliklinik jiwa anak dan remaja rsupn dr. ciptomangunkusumo (rscm), jakarta. sari pediatri. 2016;12(4):270–7. 8. gonzales na, coxe s, roosa mw, white r, knight gp, zeiders kh, et al. economic hardship, neighborhood context, and parenting: prospective effects on mexican– american adolescent’s mental health. am j community psychol. 2011;47(1–2):98– 113. 9. hunt j, eisenberg d. mental health problems and help-seeking behavior among college students. j adolesc health. 2010;46(1):3–10. 10. sobanski e, banaschewski t, asherson p, buitelaar j, chen w, franke b, et al. emotional lability in children and adolescents with attention deficit/ hyperactivity disorder (adhd): clinical correlates and familial prevalence. j child psychol psychiatry. 2010;51(8):915–23. 11. brechwald wa, prinstein mj. beyond homophily: a decade of advances in understanding peer influence processes. j res adolesc. 2011;21(1):166–79. 12. schonert-reichl ka, lawlor ms. the effects of a mindfulness-based education program on pre-and early adolescents’ well-being and social and emotional competence. mindfulness. 2010;1(3):137–51. 13. mendes av, souza crippa ja, souza rm, loureiro sr. risk factors for mental health problems in school-age children from a community sample. matern child health j. 2013;17(10):1825–34. 14. aebi m, giger j, plattner b, metzke cw, steinhausen h-c. problem coping skills, psychosocial adversities and mental health problems in children and adolescents as predictors of criminal outcomes in young adulthood. eur child adolesc psychiatry. 2014;23(5):283–93. meita dhamayanti, stanza uga peryoga, mohamad rizqy firmansyah: emotional mental problems among adolescents: urban and semi-urban settings vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 449 familial analysis of patients with hypertension in jatinangor, west java, indonesia keumala hayati,1 yulia sofiatin,2 sri endah rahayuningsih,3 rully m.a. roesli4 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital,bandung, 4department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hypertension is a disease that is influenced by genetic factors, although the single gene affecting the occurrence of the disease has not been yet discovered. genetic analysis and familial analysis on hypertension are needed to be done but genetic analysis needs substantial fund, and familial analysis on hypertension has been never done in community. besides sharing the genetic factors, family also shares similar environment and life style. latest study showed that the association between genetic and environmental factors can affect the phenotype of chronic disease suchas hypertension. the study was aimed to explore the family history contribution of patients with hypertension in jatinangor. methods: this was a descriptive-quantitave study. the subjects were 283 hypertensive patients in jatinangor with complete data of family history. the data was retrospectively obtained from secondary data of a previous study conducted in community health and well-ness study center, faculty of medicine, universitas padjadjaran titled epidemiology of hypertension and albuminuria in jatinangor 2014. familial analysis conducted in this study was modified trios analysis. results: in this modified trios analysis, there was only 20% of total patients with hypertension who have history of hypertension in two generations of their family. the proportion of patients with hypertension who have history of hypertension in one generation of their family was greater. more than 45% from the total 283 patients with hypertension analyzed in this study have family history of hypertension. conclusions: familial analysis using modified trios analysis showed similar results with the study conducted using other genetical analysis. keywords: familial analysis, hypertension, modified trios correspondence: keumala hayati, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: hkeumala@outlook.com introduction hypertension is one of the most commonly found disease in the primary health care setting.1 prevalence of hypertension in the age of ≥18 years old is 25.8%.2,3 west java is in the fourth place with the prevalence of 29.4%.3 a study conducted by study center of community health and fitness at faculty of medicine universitas padjadjaran in 2014 which prevailed the prevalence of hypertension and its complications in jatinangor stated that prevalence of hypertension in jatinangor was considered high, which was 38%.2 this national prevalence of hypertension in indonesia is 25.8%. there are risk factors that contribute to the development of hypertension in an individual, they are the genetical and environmental factor.4-6 genetic analysis and familial analysis are conducted to discover the genetic factor. medical history of family members and relatives including the previous illness is needed in order to construct a proper familial analysis. the most common family members chosen as source for familial analysis are parents, siblings, and children.7 familial relationship, or kinship, is a relationship in a family consisted of parents, siblings, and children.3 kinship in a family has a lot of inherited similarity. some of them are genes, environment, and lifestyle.8-10 genetic amj. 2017;4(3):449–55 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1197 althea medical journal. 2017;4(3) 450 amj september 2017 factor is one of the inherited similarities in a kinship which may lead to medical disorders.4,10 recent study stated that combination of genetic factor, environment and lifestyle might influence the fenotypic manifestation in chronic disease such as hypertension.4,6,8 based on the previous analytical study conducted in europe, it was found that fraction of blood pressure influenced by genetic factor and controlled by hereditary mechanism varied among the range of 30─50%, and the risk of developing hypertension in an individual who had hypertensive sibling increased 2.5-3.5 times (relative risk).11 the aim of this study was to find the proportion of hypertensive patients who have family members with hypertension among hypertensive patients in jatinangor. methods a descriptive-quantitative study was conducted with the study population of all hypertensive patients in jatinangor. the data was collected from secondary data obtained previously by the study center of community health and fitness at faculty of medicine universitas padjadjaran in the study entitled “epidemiology of hypertension and albuminuria in jatinangor” in the year of 2014.2 minimum sample size was 97, taken using the sampling method of total sampling technique. the total of all hypertensive respondents in jatinangor was 475, but 30% of these respondents do not have proper familial record so tracing back the familial history was difficult. three hundred thirteen respondents aged ≥18 years were collected and followed by data analysis. from 313 hypertensive respondents, 30 were excluded because of the incomplete familial record, which were only consisted of one generation record. in the end, the total respondents of this study was 283. data collection had been approved by the health research ethics committee of faculty of medicine universitas padjadjaran (1119/ un6.c1.3.2/kepk/pn/2016). analytical method used in this study was familial association study. familial association figure 1 sampling method althea medical journal. 2017;4(3) 451keumala hayati, yulia sofiatin, sri endah rahayuningsih, rully m.a. roesli: familial analysis of patients with hypertension in jatinangor, west java, indonesia study is a method used for examining the existence of hereditary genetic factor in a familial or relative association.7 familial association study could be conducted using various methods, such as analysis of aggregation, heritability, segregation, trios, and sibling-study.7 method of familial analysis used in this study was modified trios method, because epigenetic study approach has never been used in the familial association before. trios method was considered stronger compared to sibling study or twin study because of its three-genotype involvement in the genetic process (genotypes of father, mother, and child) and the two-genotype involvement in the sibling and twin study.7 this study adopted trios method for its emphasize in the family and environment built inside the family. nevertheless, this study was not fully similar with the trios method because this study also analyzed the possibility of association with the family outside the respondent and their parents only, which included association pattern of respondents with their siblings and their children. hypertension was diagnosed based form the result of blood pressure measurement. measurement was conducted two times with the interval of two minutes among each measurements. during the measurement, patient sat upright position, upper arm lied above the table paralleled to the shoulder. the measurement was preceded 5-minutes rest for the patient,do not smoke and/or drink caffeine 30 minutes before the measurement.12 respondent was diagnosed as having hypertension if the systolic blood pressure was ≥140 mmhg and diastolic blood pressure was ≥90 mmhg.5 after that, the respondents were classified as stadium 1 and stadium 2 hypertension based on the classification written in the eighth report of the joint national committee (jnc 8).5 this was applied only for patients aged ≥18years old. record of hypertension in family member was obtained from interview not from direct measurement. respondents were asked whether their family members had hypertension or not. family members who were asked in the interview were parents, siblings, and children (adopted children was not included). if one of the siblings or children was known for having hypertension, then it figure 2 (a) model of trios analysis,7 (b) model of modified trios analysis althea medical journal. 2017;4(3) 452 amj september 2017 was concluded that ‘sibling’ or ‘children’ had the history of hypertension. the answers of respondent consisted of three kinds of answer: ‘yes’, ‘no’, and ‘unknown’. for the purpose of analysis, the ‘unknown’ answer was excluded because the failure might occur if this answer was included. respondents who know the hypertension history only less than 2 family members were also excluded because the criteria for modified trios method would not be met in this condition. results this study, discovered that female with hypertension was more frequent compared to male, while there were only a slight difference between the frequency of patient with stage 1 hypertension (158 patients) compared to patient with stage 2 hypertension (165 patients). from the 3 familial category, which were parents, siblings, and children, it was shown that most of the complete data was regarding the hypertensive history of siblings, followed by parents and children. proportion of ‘unknown’ answer in ‘parents’ category was higher compared to siblings and children, while the proportion of negative answer in the siblings category was found to be the highest among others (figure 3, figure 4). the comparison of proportion between patients with stage 1 and stage 2 hypertension which were previously analyzed using modified trios method showed that the history of hypertension in two related generations only appeared in the pairing of parentssiblings only, while in the data pairing of siblings-children, most of them had no history of hypertension in both data (figure 5). in the stage 1 hypertension group, data table 1 basic characteristic of the data characteristic frequency gender male 86 female 197 age (years old) 18–39 29 40–59 135 ≥60 91 diagnosis stage 1 hypertension 154 stage 2 hypertension 129 figure 3 proportion of family history in respondents with stage 1-hypertension althea medical journal. 2017;4(3) 453 pairing of parents-children showed the highest proportion in the ‘parents-children have no hypertension’ category. on the other hand, in the stage 2 hypertension group, the proportion of ‘one of them have hypertension’ was the highest. there were no respondents having the history of hypertension in three generation for all at once. approximately 10% of the respondents had history of hypertension in two generations. discussion primary hypertension is a multifactorial disease.4 there are a lot of factors other than genetic factors influencing the development figure 4 proportion of family history in respondents with stage 2-hypertension figure 5 comparison between the proportion of family history in respondents with hypertension stage-1 and hypertension stage-2 keumala hayati, yulia sofiatin, sri endah rahayuningsih, rully m.a. roesli: familial analysis of patients with hypertension in jatinangor, west java, indonesia note: p=parents, s=sibling, c=children, (+0)=no positive result in three generations, (+1)=positive result in one generation, (+2)=positive result in two generation, (+3)=positive result in three generation. althea medical journal. 2017;4(3) 454 amj september 2017 of hypertension, and one of them was environmental factor.4,6,10,15 a complex interaction among these factors has given a large influence for the increase in blood pressure.4,14 in this condition, epigenetic has a largeinfluential role. epigenetic is a science of molecular changing in epigenomic level and correlates with fenotypes inherited in the familial relationship, either from mitosis or meiosis.4 epigenom is a chemical compounds and proteins which attached to nucleotide chain and able to alter its fenotype manifestation by altering the end product of protein synthesis in the cell, but not converting the nucleotide chain itself.4 familial association study has strong relationship with epigenetic issue, especially in hypertension disease.4,7 epigenomic changes which induce the appearance of hypertensive fenotype are able to be inherited from the parents to their children.4 this might happen because of the similarity in behavior pattern exemplified by the parents to their children, such as physical activity, diet, and food preferences.9 these behaviors have large influence in epigenomic changes which may induce the fenotype manifestation leading to clinical manifestation of hypertension.4 in other words, if an individual has a family member who developed primary hypertension, then this individual also has possibility of having the same disease.8,9,15 in the study of familial association, the most commonly used method is the trios method,7,16 but this method is unable to be conducted in jatinangor due to the difficulty to conduct genetic examination because most of patients with hypertension were more than 45 years old17-19 died, or live in different place. considering this condition, modified trios method was chosen by converting the dna examination with fenotype (hypertension) examination, and hypertension in family member was based on the history only. limitation of this modified method was overcome by adding the information from the siblings or biological children of the respondents, so the information from 3 generations was obtained. most of the respondents in this study were female. males were excluded because of their different environmental condition. similar with the previous study, it was stated that this might happen because of most of the male residence of jatinangor have their jobs outside the jatinangor area.2 this study presented that 1/3 of the respondents had history of hypertension. only 2% of the respondents with stage 2 hypertension had a hypertensive children. the occurence of hypertension increases in accordance with age,17-19 thus the possibility of having a child with hypertension was low. previous study also stated that 30% of patients with hypertension had parents with hypertension.11 genetical study also reported that the fraction of blood pressure variance influenced by genetic factor was approximately 30─50%.11 approximately 1/3 of the repondents did not know the blood pressure of their parents. most of the respondents who answered ‘unknown’ were elderly. this might be caused by the minimal access to health care facility.. more than 60% of the respondents who had no children aged more than 18 years old were included in this study. in the two generations analysis, it was shown that hypertension in two generations mostly appeared in stage 2 hypertension, which consisted of parents-sibling and children-sibling pairings. this was probably caused by the elderly age of the respondents that lead to more severe disease and have more children, or might be caused by a lot of excluded data because of ‘unknown’ answer. the reason of this phenomena is remained unknown. in the analysis of three generations, there were 20% of respondents who had history of hypertension in two generations, and this finding is smaller than previous studies.11 this is probably caused by the possibility of environmental suppression of the fenotype, or might also be clouded by the number of respondents excluded because of their ‘unknown’ answer. previous study conducted in jatinangor stated that 1/3 of patients with hypertension were not aware of their hypertension disease.20 it was also found in this study that 1/3 of the repondents did not know whether their parents had hypertension or not. there were possibilities that these ‘unknown’ patient were actually had hypertension, and so it might be revealed that the hypertension history in two generations were higher than this finding. limitation of this study was the source of information regarding to hypertension in family member only relying on history taking. although ‘unknown’ choice was given in order to prevent the feeling of obligation in choosing between ‘yes’ or ‘no’, the risk of giving the wrong answer still remained. previous study stated that 36% patients with hypertension were not aware of their disease,20 so they might althea medical journal. 2017;4(3) 455 inform that they were not having hypertension although they were apparently having it. other than that, fenotype was actually a good paramater as a basis for epigenomic study in community setting, but the accuracy of the data is also matters. the conclusion from this familial analysis using modified trios analysis showed that similar results with the study conducted using other genetical analysis. suggestion for the next study is to conduct measurement for all the subjects and is not just rely on history taking. more accurate study is needed to prove the familial association in disease development. medical record might be one of the accurate source of the fenotype data, which is also needed a good access to health facility and a good screening program. analytical study using case-control design has to be encouraged for genetical study on patients with hypertension. references 1. james p, oparil s, carter b, cushman wc, dennison-himmelfarb c, handler j, et al. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the eighth joint national committee (jnc 8). jama. 2014;1097:1– 14. 2. fihaya fy, sofiatin y, ong pa, sukandar h, roesli rma. prevalence of hypertension and its complications in jatinangor 2014. journal of hypertension 2015;33:35-50. 3. kementrian kesehatan ri. riset kesehatan dasar. jakarta: kemenkes ri. 2013:122–4. 4. liang m, cowley aw, mattson dl, kotchen ta, liu y. epigenomics of hypertension. semin nephrol. 2013;33(4):392–9. 5. bell k, twiggs j, olin br. hypertension : the silent killer : updated jnc-8 guideline recommendations. alabama pharmacy association. 2015;1–8. 6. ehret gb. genome-wide association studies: contribution of genomics to understanding blood pressure and essential hypertension. current hypertension rep. 2010;12(1):17–25. 7. laird nm, lange c. the fundamentals of modern statistical genetics. 2011. new york: springer; 2011. 8. garrett jc. why is it important to know my family medical history? [online report] 2016 [cited 2016 march] available from: https://ghr.nlm.nih.gov. 9. welch bm, dere w, schiffman jd. family health history. jama. 2015; 313(17):17112 10. shih pb, connor dto. hereditary determinants of human hypertension: strategies in the setting of genetic complexity. national institutes health. 2008;51(6):1456–64. 11. dominiczak af, munroe pb. genomewide association studies will unlock the genetic basis of hypertension: pro side of the argument. hypertension. 2010;56(6):1017–20. 12. hamied lia, sofiatin y, rakhmilla le, putripratama aa, roesli rma. comparison of mercury, aneroid and digital sphygmomanometer in community setting. j hypertens. 2015;33:33–43. 13. adeyemo a, gerry n, chen g, herbert a, doumatey a, huang h, et al. a genomewide association study of hypertension and blood pressure in african americans. plos genet. 2009;5(7):1–11. 14. chang py, zhao lg, su xl. association of tsc gene variants and hypertension in mongolian and han populations. genet mol res. 2011;10(2):902–9. 15. van der sande ma, walraven ge, milligan pj, banya wa, ceesay sm, nyan oa, et al. family history: an opportunity for early interventions and improved control of hypertension, obesity and diabetes. bull world health organ. 2001;79(4):321–8. 16. hoffmann tj, lange c, vansteelandt s, laird nm. gene-environment interaction tests for dichotomous traits in trios and sibships. genet epidemiol. 2009;33(8):691–9. 17. widjaja ff, santoso la., barus nrv, pradana ga., estetika c. prehypertension and hypertension among young indonesian adults at a primary health care in a rural area. med j indonesia. 2013;22(1):39-45. 18. kamso s, rumawas jsp, lukito w, purwantyastuti. determinants of blood pressure among indonesian elderly individuals who are of normal and overweight: a cross sectional study in an urban population. asia pac j clin nutr. 2007;16(3):546–53. 19. delles c, mcbride mw, graham d, padmanabhan s, dominiczak af. genetics of hypertension: from experimental animals to humans. biochim biophys acta mol basis dis. 2010;1802(12):1299–308. 20. hamzah n, roesli rma, sofiatin y, sukandar h. awareness, treatment, and control of hypertension in jatinangor sub-district between march-november 2014. journal of hypertension. 2015;33:33-47. keumala hayati, yulia sofiatin, sri endah rahayuningsih, rully m.a. roesli: familial analysis of patients with hypertension in jatinangor, west java, indonesia 221 althea medical journal. 2017;4(2) correlation between gross motor function classification system and communication function classification system in children with cerebral palsy vindy margaretha miguna,1 marietta shanti prananta,2 anggraini alam3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cerebral palsy (cp) is a group of movement and posture disorder commonly accompanied by comorbidities such as sensation, cognition, communication abnormalities and many more. this study aimed to identify the correlation between gross motor function(measured by gross motor function classification system, gmfcs) and communication function (measured by communication function classification system, cfcs) in children with cp. methods: thirty six children with cp aged 0–12 years were examined. samples were taken from department of physical medicine and rehabilitation dr. hasan sadikin general hospital bandung on september to october 2015. patients’ descriptive data, levels of gmfcs and cfcs were collected by the researcher and residents previously standardized. kendall’s tau b correlation coefficient was used to analyze the interrelationship between the gmfcs and cfcs. results: levels of gmfcs and cfcs in all samples were moderately correlated (r=0.405; p=0.004). in patients with spastic quadripledic type, correlation were found moderate(r=0.495; p=0.014). no significant correlation was found when cp spastic quadriplegic patients were excluded (r=0.048, p=0.829). conclusions: : levels of gmfcs and cfcs should be described to provide the complete gross motor and communication picture of cp children.gross motor function in a child with spastic quadriplegic cp might be correctly predicted from his/ her communication function and vice versa. keywords: cerebral palsy, children, communication function classification system, gross motor function classification system correspondence: vindy margaretha miguna, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81321198977 email: vindymiguna@gmail.com introduction cerebral palsy (cp) is a group of disorders of movement and posture causing activity limitation that can be attributed to a non progressive lesion on developing brain. the disorder is often accompanied by sensation, cognition, communication, perception, behavior abnormalities, and/or episode(s) of seizure.1 in 2013, 2.11 out of 1000 children worldwide were born with cp.2 some of the disorders can be classified based on world health organization (who) international classification of functioning, disability and health (icf), which categorizes cp patients on the level of participation. four assessment tools are proposed; gross motor function classification system (gmfcs), communication function classification system (cfcs), manual ability classification system (macs), and eating and drinking ability classification system (edacs).3 in this study, gmfcs and cfcs were investigated further. the gmfcs is a method of classification grading functional limitation, use of assitive device, and quality of movement in cp patients.4 this classification method has been commonly used, including in dr. hasan sadikin general hospital bandung, west java, indonesia. meanwhile, cfcs attempts to classify the ability of a cp patient to communicate consistent messages to other individuals.3 amj. 2017;4(2):221–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1092 althea medical journal. 2017;4(2) 222 amj june 2017 developed in 2011, cfcs can be considered as a new assesment tool. it measures 3 aspects; the ability to alternate being a sender and a receiver, pace of communication, and familiarity of partner. the correlation becomes important due to the concurrence of gross motor and communication disorder.1 lesion causing cp can occur in various areas causing different gross motor presentation, sometimes even causing dysarthria.3 lesions in the visual cortex, auditory cortex, and neuronal connections will manifest as lingual, both receptive and expressive, and cognitive disorders. all of these would potentially damage the gross motor and communication functions of a person. from clinical point of view, the correlation identified in this study will provide guidance for professionals to conclude whether or not it is possible to predict a patient’s cfcs level based on his/her gmfcs level and vice versa. previous studies had addressed the issue and findings were variable. in some studies, significant moderate to high correlation was found, another study presented nonsignificant correlation.3,5–7 thus, the aim of this study was to discover the correlation between gmfcs and cfcs with sample taken from dr. hasan sadikin general hospital (rshs) bandung, a tertiary health care facility with a high number of children with cp methods this study was a cross-sectional study analyzing correlation with categoric ordinal scale of measurement. the subject of this study were children aged 0–12 years with cp in department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran, rshs bandung. inclusion criteria were children with cp aged 0–12 visiting for their first examination, control, and/or therapy. any children whose parents refused to give consent were excluded. minimum sample was 36 calculated by the formula: explanation of formula: n is the number of sample needed; type 1 error is 5% and the study was two-sided, zα=1.96; type 2 error is 20%, zβ=0.842; r: minimum valid correlation, determined r=0.47 from previous study with 222 cp patients. every cp patient was examined by residents for gmfcs level, and the result was recorded by the researcher. due to unfamiliarity of researcher to patients’ communication function and the unavailability of indonesian version of cfcs, cfcs measurement were obtained per anamnesis to parents. anamnesis were done by researcher and residents previously standardized by physical medicine and rehabilitation specialist. besides gmfcs and cfcs, data recorded as descriptive data of the patients were age group (0–<2 years, 2–<4 years, 4–<6 years, 6–<12 years), motoric manisfestation (spastic, ataxic, dyskinetic, hypotonic, mixed type), topography of cp (hemiplegic, diplegic, quadriplegic, triplegic, monoplegic, double hemiplegic), and comorbidities (visual, audio, speech, cognitive disturbances, and seizure episode(s)). consecutive sampling was used and data were taken during patients’ visit to hospital. this study was conducted in department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital bandung from september to october 2015. assesment of gmfcs was conducted according to the classification developed by palisano et al.4, while cfcs was according to study by hidecker et al.8 correlation between gmfcs and cfcs was analyzed by kendall’s taub correlation. ethical clearance was approved by the health research ethics committee, dr. hasan sadikin general hospital bandung. before beginning the observation and anamnesis, informed consent were obtained from parents after receiving explanation regarding what would be done. results from 36 cp patients, the largest group of patients were spastic quadriplegic aged 2–<4 years old (table 1). almost all patients experienced comorbidities, with speech and cognitive disturbances being the most common. three patients were without no comorbidities, 5 with 1 comorbidity, 6 with 2 comorbidities, 11 with 3 comorbidities, 7 with 4 comorbidities, and finally 4 with 5 comorbidities. functional assessment of gmfcs and cfcs discovered that patients with equal levels for gmfcs and cfcs were 1 spastic hemiplegic (level ii), 1 spastic monoplegic (level iii), 1 spastic diplegic (level v), and 12 spastic 223 althea medical journal. 2017;4(2) table 1 characteristics of children with cerebral palsy vindy margaretha miguna, marietta shanti prananta, anggraini alam: correlation between gross motor function classification system and communication function classification system in children with cerebral palsy quadriplegic (2 patients with level iv, 10 patients with level v) (figure 1). description of scores stratified by type and topography of cp was shown in figure 2, 3, and 4. level of gmfcs and cfcs were observed to contain some different combinations. some other types of cp samples were 1 spastic monoplegic cp patient with gmfcs level iii cfcs level iii, 1 dyskinetic cp patient with gmfcs level v cfcs level iii, 2 hypotonic cp patients, 1 with gmfcs level iv cfcs level i, 1 with gmfcs level iii cfcs level i, and 1 unspecified cp patient with gmfcs level iii, cfcs level v. correlation between gmfcs and cfcs analyzed by kendall’s tau b was moderate positive and significant (r=0.405; p=0.004). stratified by type, there were also a moderate and significant correlation in cp spastic quadriplegic (r=0.495; p=0.014). in addition to the result, an insignificant correlation (r=0.048, p=0.829) of all other types without cp spastic quadriplegic were present. discussions this study discovered a moderately positive correlation between gmfcs and cfcs. thus, a good performance in gross motor may not significantly indicates good communication function and vice versa. this was also the case if finding was a poor function. result of moderately positive correlation agrees with studies carried out by van der zwart7 and hidecker et al.6 although mean age was lower, cp type distribution was higher in spastic quadriplegia, and no exclusion criteria figure 1 distribution of gross motor function classification system and communication function classification system levels among cerebral palsy sample note: *gmfcs: gross motor function classification system,**cfcs: communication function classification system althea medical journal. 2017;4(2) 224 amj june 2017 was proposed in this present study. a partial similarity was found between this study and a study by compagnone et al.5, which analyzed a slightly stronger correlation between gmfcs and cfcs. possible explanation would be hypoxic–ischemic encepalopathy occuring in extremely diverse region causing distinct presentation or the heterogenous ability of children to cope with their limitations causing different participation function; all explanation results in largely variable findings.9 significant correlation as a conclusion of this study was contrary to a study by killian et al.3 of 49 children with cp recruited from special school for children with complex disability. the past study showed no significant correlation between gmfcs and cfcs.3 disrepancy between results might be due to different settings of study. out of 36 samples, 15 had the same levels on gmfcs and cfcs, 11 of whom were in level v, indicating that cp children with less ability classified in gmfcs were the ones more likely to have the same level of cfcs and vice versa.this finding was different from the observation in studies by hidecker et al.6 and figure 2 distribution of gross motor function classification system and communication function classification system levels among spastic hemiplegic cerebral palsy samples note: *gmfcs: gross motor function classification system,**cfcs: communication function classification system figure 3 distribution of gross motor function classification system and communication function classification system levels among spasticdiplegic cerebral palsy samples note: *gmfcs: gross motor function classification system,**cfcs: communication function classification system 225 althea medical journal. 2017;4(2) van der zwart7 which found same levels to be most prevalent in level i. the explanation for this was that patients who came to a tertiary health care provider would most probably be of poorer function than clinics and rehabilitation centers as in previous studies. several types of cp were observed in this study: spastic quadriplegic, spastic diplegic, spastic hemiplegic, dyskinetic, hypotonic, dan ataxic. spastic quadriplegic cp was discovered the most (21 out of 36 samples). in this type, the correlation was discovered moderately positive and slightly stronger than when all types were included. hidecker et al.6 on the contrary, revealed that spastic quadriplegic cp had lower correlation. explanation for the distinction can be gained through exploration of sample data distribution in this study. ten out of 21 patients with spastic quadriplegic cp were classified as gmfcs level v (transported in a manual wheelchair) and cfcs level v (seldom effectively sends and receives, even with familiar partners). these ten were the ones perfectly correlated, creating higherthan-all-types correlation from the previously nonsignificant negatively correlated data without the ten. the reason that almost half of spastic quadriplegic children had such poor gross motor function were clear; spasticity of the entire limbs would impede sitting and walking.10 communication in this study were also of poor due to: 1) cognitive impairment were present in all spastic quadriplegic sampe. 2) most spastic quadriplegic children fell into younger children category than the previous study. communication typically improves as children grew in age.11 interestingly, it was discovered that the correlation of gmfcs and cfcs; if cp spastic quadriplegic type was excluded, then the finding was insignificant. pathophysiologically speaking, such strong correlation in spastic quadriplegic might be due to severe spasticity in spastic quadriplegic type causing hypoxia leading to worsening of brain functioning. in addition, spasticity occuring not only on the muscles of limbs, but also on the oromotor muscles causes poorer communication function. correlation in each type of cp besides spastic quadriplegic cannot be determined due to inadequacy of samples belonging to those particular types. nevertheless, the distribution of levels in each type is important to be reviewed. in spastic hemiplegic cp, gmfcs levels were distributed in the “highly functioning” group of level i, ii, and iii. this fact was in accordance to a study by himmelman et al.12 stating that hemiplegic patients most likely acquire good motoric function.in spastic diplegic type, the finding was also similar. motoric function were good but observed slightly poorer than hemiplegic patients.this was also noticed on previous research by shevell et al.10 on the contrary, communication were unpredictable in both types, probably owing to the diverse comorbidities suffered as stated in previous studies.13–15 for the remainder cp types, number of samples were limited to one or two. findings of gmfcs and cfcs levels were not able to be generalized. independence of gmfcs and cfcs level in a patient suggested that complete assesment note: *gmfcs: gross motor function classification system,**cfcs: communication function classification system figure 4 distribution of gross motor function classification system and communication function classification system levels among spasticquadriplegic cerebral palsy samples vindy margaretha miguna, marietta shanti prananta, anggraini alam: correlation between gross motor function classification system and communication function classification system in children with cerebral palsy althea medical journal. 2017;4(2) 226 amj june 2017 of both levels in an individual with cp will certainly allow better functional potrayal. besides descriptive purpose, the assessment is also meaningful for patients’ therapy. in order to achieve better results, it is imperative that an active participant is practicing meaningful skills for him/her. hence, the use of functional classifications focusing on participation component such as gmfcs and cfcs as goal setters for therapy is excellent.16 the use of functional classification systems in the field of study is unavoidable. assessment of gmfcs had been used abundantly as an indicator of gross motor ability and cfcs has become increasingly important since it was validated in 2011. studies had used cfcs to select participant for their study , for predicting communication function, and many more.17,18 these evidences provide encouragement for worldwide assesment of gmfcs and cfcs in every cp patients, including in dr. hasan sadikin general hospital. limitation of the study were: 1) hospital setting of the study might have created selection bias. as dr. hasan sadikin general hospital is a tertiary health care service, patients referred to the hospital consists of mostly “low functioning group”. this caused less variability in gmfcs and cfcs combination 2) there was no validated indonesian version of cfcs yet. to overcome this obstacle, researcher applied interview to parents, which may cause information bias. the weakness of parent reported cfcs was bias of the result towards better function.11 3) there was no lower limit for age, while cfcs assesment had only been performed in children as young as 2 years.11 this study performed the assesment on children as young as 1 year old, which may lead children to be seen as having less ability in communication 4) therapy was not considered in this study, therefore, result might not potray pure correlation. in conclusion, child’s functional capacity in gross motor may not be correctly predicted by his/ her communication function and vice versa, as the correlation of gmfcs and cfcs was moderate. the higher correlation in cp spastic quadriplegic compared to other types implies probable correct prediction of cfcs by assessing level of gmfcs and vice versa in this particular type. both assesment of gmfcs and cfcs are proven to be a crucial matter in cp children description. since the use of gmfcs and cfcs as concurrent assessment of cp patients are of great importance in the fields of clinical communication, therapy, and research, further studies should also be directed towards the validation of indonesian-cfcs in order to make it readily available in the country. cohort studies can also be done to discover whether or not age and therapy have any effect on cfcs level in the long run and its possible correlation with gmfcs. references 1. rosenbaum p, paneth n, leviton a, goldstein m, bax m, damiano d, et al. a report: the definition and classification of cerebral palsy april 2006. dev med child neurol suppl. 2007;109(suppl 109):s8– 14. 2. oskoui m, coutinho f, dykeman j, jette n, pringsheim t. an update on the prevalence of cerebral palsy: a systematic review and meta-analysis. dev med child neurol. 2013;55(6):509–19. 3. killian l, bryant e, sellers d. the clinical use of functional classification systems for children and young people with cerebral palsy. dev med child neurol. 2014;56(suppls4):32. 4. palisano r, rosenbaum p, walter s, russell d, wood e, galuppi b. development and reliability of a system to classify gross motor function in children with cerebral palsy. dev med child neurol. 1997;39(4):214–23. 5. compagnone e, maniglio j, camposeo s, vespino t, losito l, de rinaldis m, et al. functional classifications for cerebral palsy: correlations between the gross motor function classification system (gmfcs), the manual ability classification system (macs) and the communication function classification system (cfcs). res div disabil. 2014;35(11):2651–7. 6. hidecker mjc, ho nt, dodge n, hurvitz ea, slaughter j, workinger ms, et al. inter-relationships of functional status in cerebral palsy: analyzing gross motor function, manual ability, and communication function classification systems in children. dev med child neurol. 2012;54(8):737–42. 7. van der zwart k. communication performance of children with cerebral palsy: relation with spoken language comprehensionand contextual factors [thesis]. netherlands: universiteit utrecht; 2012. 8. hidecker mjc, paneth n, rosenbaum p, kent rd, lillie j, eulenberg jb, et al. communication function classification 227 althea medical journal. 2017;4(2) system 2011. [cited 2015 march 31]. available from: http://cfcs.us/. 9. berker n, yalçin s, root l, staheli l. the help guide to cerebral palsy. 2nded. seattle: global help organization; 2010. 10. shevell mi, dagenais l, hall n, the repacq c. the relationship of cerebral palsy subtype and functional motor impairment: a population-based study. dev med child neurol. 2009;51(11):872–7. 11. hidecker mjc, paneth n, rosenbaum pl, kent rd, lillie j, eulenberg jb, et al. developing and validating the communication function classification system for individuals with cerebral palsy. dev med child neurol. 2011;53(8):704– 10. 12. himmelmann k, beckung e, hagberg g, uvebrant p. gross and fine motor function and accompanying impairments in cerebral palsy. dev med child neurol. 2006;48(6):417–23. 13. parkes j, hill nan, platt mj, donnelly c. oromotor dysfunction and communication impairments in children with cerebral palsy: a register study. dev med child neurol. 2010;52(12):1113–9. 14. ghasia f, brunstrom j, gordon m, tychsen l. frequency and severity of visual sensory and motor deficits in children with cerebral palsy: gross motor function classification scale. investophthalmol vissci. 2008;49(2):572–80. 15. pruitt dw, tsai t. common medical comorbidities associated with cerebral palsy. phys med rehabil clin n am. 2009;20(3):453–67. 16. mayston am m. from ‘one size fits all’ to tailor-made physical intervention for cerebral palsy. dev med child neurol. 2011;53(11):969–70. 17. choi y, lee sh, chung cy, park ms, lee km, sung kh, et al. anterior knee pain in patients with cerebral palsy. clin orthop surg. 2014;6(4):426–31. 18. coleman a, weir k, ware rs, boyd r. predicting functional communication ability in children with cerebral palsy at school entry. dev med child neurol. 2015;57(3):279–85. vindy margaretha miguna, marietta shanti prananta, anggraini alam: correlation between gross motor function classification system and communication function classification system in children with cerebral palsy althea medical journal. 2017;4(3) 329 role of satisfaction with health care services in increasing patient loyalty: an ambulatory setting citra restia yusri,1 marlianti hidayat,2 henni djuhaeni3 1faculty of medicine universitas padjadjaran, 2department of oral health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: health care providers must be able to provide services that can satisfy the patient. this encourages patient loyalty so that competitiveness can be preserved. this study aimed to examine the correlation of patients’ satisfaction to their loyalty towards health care facilities. methods: an analytic cross-sectional study was conducted on 50 respondents from anggrek specialist polyclinic at dr. hasan sadikin general hospital bandung (ambulatory setting) who met the inclusion criteria during the period of september to october 2014. questionnaires that had been validated and tested for reliability were used. rank spearman test was used to analyze the correlation between patient satisfaction and patient loyalty. this study used five dimensions of service quality to measure patient satisfaction, i.e. tangibles, reliability, responsiveness, assurance, and empathy. results: the study showed that most (84%) patients felt unsatisfied and only 14% was loyal towards the health care services they received. satisfaction and loyalty showed positive correlation with p=0.001 (p<0.05) and r=0.439, which showed a moderate correlation. conclusions: there is significant correlation between patient satisfaction and loyalty in anggrek specialist polyclinic at dr. hasan sadikin hospital. this study can be an evaluative material for health care providers to encourage improvement of service quality as to increase patient satisfaction and loyalty. keywords: ambulatory, health care service, patient loyalty, patient satisfaction correspondence: citra restia yusri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: citra.restia@gmail.com introduction health care services as public services are highly dynamic in improving services to the response of changing consumers’ demand and tight competition among them.1 in doing so, every health care service institution try to provide quality health services. one of the instruments to measure the quality of health care services commonly used is the service quality (servqual) by parasuraman et al. in fandy tjiptono and gregorius chandra2, the facets of servqual are tangible, reliability, responsiveness, assurance, and empathy. hospitals are one of the health care service providers which has the principle of trust, hence their success is highly depended on the service quality, patient’s satisfaction, and loyalty.3 satisfaction is the feeling which comes after comparing one’s expectations and perceived experience. the measurement of patient’s satisfaction can produce a result that reflects patient’s perception and is a strong basis to improve service quality.4 fandy tjiptono and gregorius chandra2 mentioned that customer satisfaction is correlated positively with their loyalty and can potentially lead to increase income of the hospitals in the long term. this study was carried out to examine the correlation between patient satisfaction and their loyalty towards health care services in an ambulatory setting. methods this was an analytic observational study with a cross-sectional approach. this study had been approved by the health research ethics committee of dr. hasan sadikin general hospital bandung. the population in this study was all patients who visited anggrek specialist amj. 2017;4(3):329–34 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1177 althea medical journal. 2017;4(3) 330 amj september 2017 polyclinic at dr. hasan sadikin hospital bandung. consecutive sampling was used to select 50 respondents during september and october 2014. the respondents who met the criteria were selected until the amount of the sample was fulfilled. the inclusion criteria in this study were: outpatients on the third visit or more to anggrek specialist polyclinic, patients who came for check-up and patients who were older than 18 years old. patients who refused to participate in this study were excluded. the instrument used was a questionnaire which had been tested for its validity and reliability prior to its use. the questionnaire consisted of 25 questions to measure satisfaction: 5 questions for each dimension of service quality. this questionnaire enquired about both the patient’s expectation and perceived experience. while to measure loyalty, there were 4 questions. the questionnaire was designed in the form of likert scale with options: “agree to a large extent”, “agree”, “disagree”, and “disagree to a large extent”. the variables examined in this study were patient satisfaction and loyalty. satisfaction could be measured in the five dimensions of service quality i.e. tangible (physical facility), reliability (ability to provide the promised service), responsiveness (willingness to assist customers), assurance (employees’ knowledge, manner, and trustworthiness), and empathy (care towards the customers). satisfaction was measured by using gap analysis, which means the difference between the expectation score and the perceived experience score.5 the lower the gap, the higher the level of satisfaction is and vice versa. the gap score was categorized into three levels of satisfaction: highly satisfied (gap < 0), satisfied (gap = 0), and dissatisfied (gap > 0). patient’s loyalty was measured by summing up the scores from each question table 1 respondent’s characteristic distribution respondent’s characteristic n % sex male 13 26 female 37 74 age <30 years old 13 26 30–39 years old 11 22 40–49 years old 8 16 >50 years old 18 36 education no formal education 0 0 basic education (elementary, middle school) 5 10 middle-level education (middle school, economic and middle school, school of machinery techniques) 14 28 higher education (diploma, undergraduate) 31 62 occupation housewives 12 24 students 8 16 civil servants/army/police 10 20 employees in private sector 8 16 self-employed 4 8 retirees 4 8 others 3 6 unemployed 1 2 althea medical journal. 2017;4(3) 331citra restia yusri, marlianti hidayat, henni djuhaeni: role of satisfaction with health care services in increasing patient loyalty: an ambulatory setting table 2 respondents distribution based on satisfaction level satisfaction level respondents frequency (f ) percentage (%) highly satisfied 5 10 satisfied 3 6 unsatisfied 42 84 total 50 100 and then categorized into three: loyal (>75%), slightly disloyal (50-75%), and disloyal (<50%). the data was analyzed using computer software. the non-parametric statistical analysis used the rank spearman test since the measured variables were ordinal in nature. this analysis was used to check for any correlation between patient satisfaction and loyalty towards health care services in anggrek specialist polyclinic at dr. hasan sadikin general hospital bandung. the correlation would be considered significant if p<0.05, and r value was used to examine the strength and direction of correlation based on guilford criteria. results the result showed that the majority (74%) of the respondents were female. based on the table 3 satisfaction distribution based on dimensions of service quality dimension of satisfaction respondents frequency (f ) percentage (%) tangibles highly satisfied 2 4 satisfied 10 20 dissatisfied 38 76 reliability highly satisfied 1 2 satisfied 15 30 dissatisfied 34 68 responsiveness highly satisfied 4 8 satisfied 25 50 dissatisfied 21 42 assurance highly satisfied 11 22 satisfied 20 40 dissatisfied 9 38 empathy highly satisfied 4 8 satisfied 33 66 dissatisfied 13 26 althea medical journal. 2017;4(3) 332 amj september 2017 age groups, a large proportion (36%) was in the >50 years age group. most respondents (62%) were with higher education and none of them was without formal education. based on their occupation, the largest proportion was housewife, followed by civil servant, army, and police; there were also some respondents who were unemployed (table 1). about 10% of respondents were highly satisfied over the health care service given by anggrek specialist polyclinic, while the majority (84%) was unsatisfied (table 2). if satisfaction was observed according to the service quality dimensions, empathy and assurance would be the dimensions with the smallest gap between expectation and perceived experience. most respondents (76%) expressed their dissatisfaction with tangibles (table 3). most respondents (86%) were slightly disloyal towards anggrek specialist polyclinic and there were only a few who were loyal (table 4). in overall, the correlation between patient satisfaction and loyalty showed that a large proportion of unsatisfied patients tended to be slightly disloyal. the correlation between satisfaction and loyalty was measured from p-value=0.001 (p<0.05), and correlation coefficient r=0.439 (table 5). the satisfaction dimension with significant correlation to loyalty was responsiveness with p=0.039 (p<0.05) and r=0.292 (weak correlation), while other satisfaction dimensions showed insignificant correlation to loyalty (table 6). discussion patient satisfaction is important and widely used as an indicator of health care services quality.6 satisfaction is the comparison of patient’s expectation and perceived experience of health care services. most patients were unsatisfied and only a few patients were satisfied with the health care services they received. this could occur due to the overly high expectations or perceived experience that failed to fulfill their expectations. furthermore, from the education perspective, high education can also affect their expectations and perceptions towards the health care service they received. bahrampour and zolala7 showed that there is an inverse correlation between education background and level of satisfaction, which means a higher level of satisfaction is found more among respondents with lower levels of education. improvement of service quality is definitely required to achieve a high level of patient satisfaction. asian countries pay their health professional less than other countries, possibly reducing their motivation in providing better services and hence patient’s level of satisfaction.8 the dimensions in which patients showed the highest level of satisfaction were empathy and assurance. this showed that patients were satisfied with the empathy shown by doctors and nurses in the form of care and individual attention towards them. in addition, patients also expressed their satisfaction over assurance which included the doctor’s table 4 respondents distribution based on loyalty loyalty respondents frequency (f ) percentage (%) loyalty 7 14 slightly disloyalty 43 86 disloyalty 0 0 total 50 100 table 5 correlation between satisfaction and loyalty dimension loyalty slightly disloyal disloyal r p (f ) (%) (f ) (%) (f ) (%) highly satisfied 2 40 3 60 0 0 0,439 0,001 satisfied 2 67 1 33 0 0 unsatisfied 3 7 39 93 0 0 althea medical journal. 2017;4(3) 333 knowledge, attitude, and ability to be trusted and believed by patients. the dimension with the poorest level of satisfaction was tangibles. this meant that the patients were unsatisfied by the facilities, equipment, and presentation of health care workers. this was due to the large number of patients complaining about the very poor toilet hygiene. moreover, the patients faced difficulties in finding free parking lots due to the very limited parking area. the considerable number of patients at dr. hasan sadikin general hospital comes from all corners of west java as it is the provincial referral hospital. another factor would be the vehicles of the hospital staff that occupied too much parking space. another dimension with poor level of satisfaction was reliability. one of the indicators was the specialist’s punctuality in managing the patients. the low level of satisfaction in this area could be due to the fact that the specialists in the polyclinic are also the teaching staff in charge of residents and co-assistants. furthermore, some of them have structural positions in the hospital management, restricting them from being punctual due to the teaching obligations or even citosurgeries. this problem forced the patients to unnecessarily wait for the doctors. according to the study by anbori et al.9, empathy and assurance dimensions, which represent the quality of interpersonal communication, have a strong influence on the patient’s motivation to return to the same health care facility. the manager of the health care facility should pay close attention to these dimensions to improve the service quality beside the physical facilities, so that patient’s loyalty towards the health care service can be increased. the analysis of the correlation between patient satisfaction and loyalty in anggrek specialist polyclinic revealed that most unsatisfied patients were slightly disloyal. in general, the correlation was significant with p=0.001 (p<0.05) and a moderate positive table 6 correlation between satisfaction and loyalty based on dimension of service quality dimension loyalty slightly disloyal disloyal r p (f ) (%) (f ) (%) (f ) (%) tangibles highly satisfied 1 50 1 50 0 0 0.064 0.657 satisfied 1 10 9 90 0 0 dissatisfied 5 13 33 87 0 0 reliability highly satisfied 1 100 0 0 0 0 satisfied 3 20 12 80 0 0 0.246 0.085 dissatisfied 3 9 31 91 0 0 responsiveness highly satisfied 2 50 2 50 0 0 satisfied 4 16 21 84 0 0 0.292 0.039 dissatisfied 1 5 20 95 0 0 assurance highly satisfied 3 27 8 73 0 0 satisfied 2 10 18 90 0 0 0.152 0.292 dissatisfied 2 10 17 90 0 0 empathy highly satisfied 1 25 3 75 0 0 satisfied 4 12 29 88 0 0 0.019 0.895 dissatisfied 2 15 11 85 0 0 citra restia yusri, marlianti hidayat, henni djuhaeni: role of satisfaction with health care services in increasing patient loyalty: an ambulatory setting althea medical journal. 2017;4(3) 334 amj september 2017 correlation (r=0.439) according to guilford criteria. this finding is supported by a study by mortazavi et al.10 , which shows that satisfied patients are more likely to be loyal towards the health care service. another study in the field of finance also produced similar results, oladele11 reveals that there is a correlation between customer’s satisfaction and loyalty. in addition, fandy tjiptono and gregorius chandra2 mention that patient satisfaction correlates positively with loyalty; therefore, it can potentially increase future income. moreover, customer’s loyalty is crucial for health care service providers to be able to survive and compete with others because attracting new customers is far more difficult than preserving old customers.1 the correlation between the two variables was positive, meaning that the higher the satisfaction, the higher the patient’s loyalty was. however, the strength of correlation was only moderate. this was also indicated by the relatively large number of highly satisfied patients who were still slightly disloyal. patient satisfaction does not guarantee loyalty, but it encourages loyalty. in some industries, almost 70% customers who have switched to another firm are actually customers who are satisfied by the previous service they received. they switch because of better prices and interesting promotions.12 out of the five service quality dimensions, there was only one with a significant correlation to loyalty, i.e. responsiveness, with p=0.039 and r=0.292 showing a weak positive correlation. in conclusion, there is a significant, positive correlation between patient satisfaction and loyalty in anggrek specialist polyclinic at dr. hasan sadikin general hospital bandung. this study sought to provide some evaluative materials for health care providers so as to keep improving their service quality, thereby increasing patient’s satisfaction and loyalty. the limitations of the study are environmental factors which could affect the patient’s perception of service quality, and hence patient’s loyalty, such as the distance between the patient’s home and hospital, and the patient’s health insurance that requires him/her to seek treatment at certain hospitals only, have not been measured. the author recommends further studies to add to this study and has some expectations for anggrek specialist polyclinic to keep improving its service quality in order to increase patient satisfaction and loyalty, thereby maintaining its competence against other health care service providers. references 1. arab m, tabatabaei sg, rashidian a, forushani ar, zarei e. the effect of service quality on patient loyalty: a study of privete hospitals in tehran, iran. iran j public health. 2012;41(9):71–7. 2. fandy tjiptono, gregorius chandra. service, quality & satisfaction. yogjakarta: andi; 2005. 3. ida ayu werdianingsih kesuma, djumilah hadiwidjojo, ni luh putu wiagustini, fatchur rohman. service quality influence on patient loyalty: customer relationship management as mediation variable int j bus commer. 2013;2(12):01–14. 4. mendoza am. correlation analysis of customer satisfaction and loyalty in carlito pena reyes hospital. apjmr. 2014;2(4):39–45. 5. fredy rangkuti. measuring customer satisfaction. jakarta: pt gramedia pustaka utama; 2006. 6. prakash b. patient satisfaction. j cutan aesthet surg. 2010;3(3):151–5. 7. bahrampour a, zolala f. patient satisfaction and related factors in kerman hospitals. east mediterr health j. 2005;11(5):905– 11. 8. dayasiri, lekamage. predictors of patient satisfaction with quality of health care in asian hospital. med j aust. 2010;3(11):739– 44. 9. anbori a, ghani sn, yadav h, daher am, su tt. patient satisfaction and loyalty to the private hospital in sana’a, yemen. int j qual health c. 2010;22(4):310–5. 10. mortazavi s, kazemi m, shirazi a, azizabadi a. the relationship between patient satisfaction and loyalty in the private hospital industry. iran j public health. 2009;38(3):60–9. 11. oladele po. effect of customer satisfaction on customer loyalty among selected bank customers in ado-ekiti metropolis, niegeria. interdiscip j contemp res bus. 2012;3(11):228–36. 12. mohsan f, nawaz mm, khan ms, shaukat z, aslam n. impact of customer satisfaction on customer loyalty and intentions to swtich: evidence from banking sector of pakistan. int j bus soc sci. 2011;2(16):263–70. vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 115 congenital heart disease characteristics in low birth weight infants at dr. hasan sadikin general hospital in 2010–2014 villia damayantie,1 sri endah rahayuningsih,2 irvan afriandi3 1faculty of medicine universitas padjadjaran, indonesia, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: villia damayantie, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: villia.damayantie@yahoo.co.id introduction congenital heart disease (chd) accounts for nearly one-third of all major congenital anomaly and is known as one of the main causes of death in the first year of life. congenital heart disease is defined as an anomaly in the macroscopic structure of the heart or the large blood vessel, which can cause functional disorders.1 most causes of chd are multi-factorial, which are a combination of genetic predisposition and environmental stimuli. some chd cases are associated with chromosomal abnormality.2 the other risk factors include maternal comorbidities, family history of chd, being born as the first child, medications taken during the pregnancy, and the age of the mother.3 the incidence of chd worldwide varies from year to year, with the estimation of 8 out of 1,000 (0.8%) live births. several studies show that the incidence of chd is more common in infants with low birth weight (lbw) than in the entire neonate population.4–6 low birth weight is defined as birth weight less than 2,500 grams. the incidence of lbw infants is about 20.6 million and it accounted for 15.5% of all births globally and 95.6% has occurred in the developing countries. in indonesia7, the prevalence of lbw infants is 10.2%, and 902 cases are found in bandung, west java. a study conducted in korea5 shows that the highest incidence of chd has been found in a subgroup of infants born with 1,000–2,500 grams of birth weight, which is 9.3%of the entire population. the most common type of lesions is ventricular septal defect (vsd), which comprises 48.9% of the total 7,245 amj. 2019;6(3):115–22 abstract background: congenital heart disease (chd) is a multifactorial disease defined as an anomaly in the macroscopic structure of the heart that may cause functional disorders. the incidence of chd is reported higher in infants with low birth weight (lbw) than the entire population of neonates. this study aimed to describe the characteristics of chd in infants born with lbw. methods: this was a retrospective descriptive study with a cross-sectional design, performed in october–november 2015. data were obtained from medical records of inpatients infants at dr. hasan sadikin general hospital, bandung in the period of 2010–2014. the data presented were the characteristics of chd in lbw infants. results: of 364 lbw infants treated in the hospital within 5 years period, 21 infants (14 girls and 7 boys) were diagnosed as chd, with birth weight group predominantly (n18; 85.7%) in the range of 1,500–2,499 gr. non-cyanosis chd was prevalent in 95.2% (n20),and patent ductus arteriosus (pda) was found in 76.1% (n16). comorbid conditions mostly found in this study were preterm birth (n17), sepsis (n10), and neonatal hyperbilirubinemia (n9). conclusions: the most common type of chd in low birth weight infants in dr. hasan sadikin general hospital is patent ductus arteriosus. the presence of congenital heart disease should be considered in low birth weight infants, thus it is essential to perform screening for early recognition. keywords: congenital heart disease, infants, low birth weight althea medical journal. 2019;6(3) 116 amj september 2019 cases.6 lesions of chd can lead to lbw due to the presence of hemodynamic disorders. moreover, chd in lbw infants may present with other comorbid conditions and could increase infant morbidity and mortality.8–13 in indonesia, there are not many studies describing chd in lbw infants, especially in west java. this study aimed to describe the characteristics of chd in infants born with lbw. methods a descriptive method with cross-sectional research design was conducted. data collections were obtained from medical records of hospitalized patients with chd in infants born with lbw within 5-year, from january 2010 until december 2014. data were taken from october to november 2015 from the medical records installation of the inpatients of the perinatology room at dr. hasan sadikin general hospital. the study was approved by the health research ethics committee of dr. hasan sadikin general hospital. all data of newborn infants aged up to 28 days with lbw who were admitted in the perinatology room at dr. hasan sadikin general hospital were collected (n 364). the inclusion criteria of this study were complete medical records of lbw infants aged 0–28 days with chd diagnosed through an echocardiography examination. the selected data were categorized into four groups consisting of the infant characteristics, mother characteristics, type of chd lesion that was classified into cyanosis and noncyanosis types of lesion, and comorbidity. in the infant characteristic category, the selected data included gender, birth weight, birthplace, and the 10-point apgar score. data on birth weight was categorized based on birth weight group of 1,500–2,499 grams, 1,000–1,499 grams, and <1,000 grams. the apgar score was divided into three categories, with 7–10 points categorized as excellent condition, 4–6 points as moderately depressed, and 1–3 points as severely depressed.12 in the mother characteristic category, the selected data included mother parity, gestational age, no chd diagnosis n=278 chd diagnosis n=86 study population: medical records of lbw infants n=364 no echocardiography n=43 incomplete medical records n=22 complete medical records and echocardiography n=21 suspects of chd incompleteresult: only echocardiography n=1 incomplete result: chest x-ray and echocardiography, no electrocardiography n=11 completed result: chest x-ray, electrocardiography, and echocardiography n=9 figure 1 flowchart data collection althea medical journal. 2019;6(3) 117villia damayantie et al.: congenital heart disease characteristics in low birth weight infants at dr. hasan sadikin general hospital in 2010–2014 frequency of antenatal care (anc) visit, and medication history during the pregnancy. gestational age was divided into pre-term for <37 weeks gestational age, a term for 37–42 weeks gestational age, and post-term for >42 weeks gestational age. the frequency of anc visitwas divided into less than four times, and four times or more. in the type of chd lesion category, the selected data included the type of lesion, both the cyanosis and non-cyanosis, and the presence of supporting exam results including chest x-ray, electrocardiography (ecg), and echocardiography. in the comorbidity condition category, the selected data included other diseases and other congenital abnormalities in the infants. the data were analyzed and presented in tables. results there were 21 data obtained from 364 infants with lbw. other 343 medical record data were excluded consecutively, 278 of them did not contain any chd diagnosis, 22 of them were lost, and 43 of them were excluded because chd was not confirmed through the echocardiography examination step. data were included, only if chd was confirmed by echocardiography (figure 1). in this study, 11 out of 21 samples were born in the hospital and the rest of 10 samples were born assisted by midwives. there were 14 female infants and 7 male infants (table 1). in the birth weight group, the highest frequency was in those born with a birth weight of 1,500–2,499 grams and there was no infant born with a birth weight <1,000 grams found in this study. the results of 1-minute apgar scores in this study were mostly found in the excellent category, however, there were 11 samples whose results of 1-minute apgar scores were not recorded in their medical records (table 2). the results of 5-minute apgarscores in this study were mostly found in the excellent category, yet, there were 12 samples whose results of 5-minute apgar scores were not recorded in their medical records. the results in 10-minute apgar scores in this study were mostly found in the excellent category(three samples). meanwhile, there were 17 samples whose results of 10-minute apgar scores were not recorded in their medical records. as shown in table 3, the highest frequency of parity status was multiparity mothers. most of the mothers delivered the baby in the gestational age of fewer than 37 weeks and most of them had anc visit frequency less than 4 times. unfortunately, only 6 of 21 mothers took vitamins such as iron and calcium tablets given by midwives or doctors at each anc visit. interestingly, only one mother received tt immunization during pregnancy of which there were 6 mothers with the first pregnancy. table 2 distribution of apgar scoresof infants with low birth weight (n=21) apgar scores 1-minute 5-minute 10-minute total (n) total (n) total (n) severely depressed 2 1 moderately depressed 2 2 1 excellent condition 6 6 3 without information 11 12 17 notes: 10-points apgar score designated as severely depressed: 1–3 points; moderately depressed: 4–6 points; excellent condition: 7–10 points table 1 distribution of birth weight groups-for-gender of infants birth weight groups gender total (n)male female 1,500–2,499 grams 6 12 18 1,000–1,499 grams 1 2 3 <1,000 grams total 7 14 21 althea medical journal. 2019;6(3) 118 amj september 2019 however, 12 out of 21 samples did not record the history of medication during pregnancy in their medical records. the highest frequency of chd lesion in this study was non-cyanosis with patent ductus arteriosus (pda) and found in 16 out of 21 samples (table 4). interestingly five out of 21 infants had more than one lesion whichwas pda with a patent foramen ovale (pfo). the number of infants who were born with chd lesion might be comorbid by the presence of other congenital abnormalities, such as down syndrome and labiognatapalatoschizis. however, most of them had no other table 3 the distribution of characteristic from maternal factors maternal factors total (n) parity primiparous 6 multiparous 14 grandmultiparous 1 gestational age preterm birth 17 aterm birth 4 post-term birth frequency of antenatal care visits <4 times 12 ≥4 times 9 medication history during pregnancy herbal medicine supplement 6 drugs for hypertension mother 2 tt immunization 1 without information 12 note: preterm birth: <37 weeks; aterm birth: 37–42 weeks; post-term birth: >42 weeks. tt, tetanus toxoid table 4 the distribution of type lesions of congenital heart disease(chd) type of lesions amount (n) cyanosis chd tga 1 non-cyanosischd asd 2 vsd 3 pda>72 hours 16 multiple lesions asd andvsd 1 pda andpfo 5 vsd andpfo 1 note: asd: atrial septal defect; pda: patent ductusarteriosus; pfo: patent foramen ovale; tga: transposition of great arteries; vsd: ventricular septal defect althea medical journal. 2019;6(3) 119villia damayantie et al.: congenital heart disease characteristics in low birth weight infants at dr. hasan sadikin general hospital in 2010–2014 table 5 distribution of comorbidity comorbidity total (n) other congenital abnormalities down syndrome 2 congenital hypothyroid 1 hirschsprung disease 1 labiognatapalatoschizis 2 without any congenital disorder 16 other diseases/conditions preterm infants 17 sepsis 10 neonatal hyperbilirubinemia 9 omphalitis 5 pneumonia 5 anemia 4 respiratory distress syndrome 4 thrombocytopenia 4 hypoglycemia 3 small gestational age 3 apneu of prematurity 2 asphyxia 2 g6pd deficiency 2 dehydration 2 hypernatremia 2 hyponatremia 2 bacterial infection 2 torch infection 2 feeding problem 2 bilirubin encephalopathy 1 hyperkalemia 1 hypercalcemia 1 iugr 1 conjunctivitis 1 prolonged aptt 1 phlebitis dorsum magnus 1 transient tachypnea of newborn 1 note: g6pd deficiency: glucose-6-phosphate dehydrogenase deficiency; torch infection: toxoplasmosis, other, rubella, cytomegalovirus, and herpes infection; iugr: intrauterine growth restriction; prolonged aptt: prolonged activated-partial thromboplastin time althea medical journal. 2019;6(3) 120 amj september 2019 accompanied congenital abnormalities. the most comorbid condition found in this study was preterm birth (17 out of 21) followed by sepsis and neonatal hyperbilirubinemia (table 5). discussion this study describes an overview of therapeutic congenital heart disease is generally caused by a fetal development disorder or structural failure in the embryogenesis process.14 the incidence of chd worldwide varies from year to year, with the estimation of 8 out of 1,000 (0.8%) live births.1,14 congenital heart disease incidence in infants with lbw is found at a higher rate. several studies have reported that infants with chd are at higher risk of having small gestational age (sga) condition which is closely related to lbw.4,5 this study found that 21 out of 364 lbw infants were born with chd resulting in an incidence of 5.7% (figure 1). the study result showed that the chd cases with lbw were predominantly in female infants (table 1). this is consistent with a study, describing that the frequency of female infants is found higher than the male infants.6 low birth weight defined as an infant with birth weightless than 2,500 grams.15 in indonesia, according to the result of basic health research (riset kesehatan dasar, riskesdas) in 2013, the prevalence of infants born with lbw is 10.2%.7 on the other hand, 902 infants are born with lbw in bandung, west java, while there are 438 infants born with lbw in bandung regency.16 low birth weight is divided into three categories, referred as lbw for a birth weight ranging from 1,500– 2,499 grams, very low birth weight (vlbw) for birth weight ranging from 1,000–1,499 grams, and extremely low birth weight (elbw) for birth weight ranging from less than 1,000 grams. however, in this study, all categories were generally referred to as lbw. the study showed that chd infants were mostly found in the birth weight range of 1,500–2,499 grams, which were 18 out of 21 samples (table 1). a study conducted in korea5 showed that when patients were being categorized based on their birth weight (≥2,500 grams, 1,000– 2,500 grams, and <1,000 grams), the highest chd incidence was found in the birth weight subgroup of 1,000–2,500 grams, comprising of 9.3% (p<0.001), compared to the other two groups, thus the incidenceswere found higher in the lbw group than non-lbw.5 the birth of an infant with lbw occurs in those who are preterm birth or having intrauterine growth restriction.15 this concept is parallel to thestudy result that showedmost of the infants were born at <37 weeks of gestational age (table 3). moreover, the result showed someinfants had intrauterine growth restriction (iugr) as a comorbid condition (table 5). several other factors affecting lbw include maternal factors, infant factors, and socioeconomic conditions. the relationship of mother characteristics and the incidence of lbw indicated significant relationships among pregnancy check-up of anc, the number of parity, the interval between pregnancies of <12 months, mother weight gain, and bad obstetric history.17 our study showed that the highest frequency of chd infants with lbw was found in mothers who had more than one delivery, or multiparity (table 3). although other studies stated that the risk of infants born with lbw is threefold higher in those of primiparity than multiparity mother.17 the result of anc visits in this study was similar compared to other studies, that mothers with less frequency of anc visits have almost six times higher risk of having an lbw baby in comparison to mothers who have 5 or more anc visits. the frequency of anc visits is essential healthcare maintenance for pregnant women. during anc nutritional status of the mother will be assessed, such a condition can also affect fetal nutrition. early detection of congenital anomaly can be assessed through fetal monitoring during anc visits. thus, the less frequent mother received anc, the risk of having infants lbw and/or any other anomaly condition will be higher.17 since chd is a multifactorial disease, a combination of genetic predisposition and exogenous factors such as maternal, gestational, and environmental conditions need to be considered. some of chd cases are also associated with chromosome abnormality, especially trisomy 21, 13, 18, and turner syndrome.2 several studies mentioned that the most common congenital disorder is down syndrome,3,18 in line with the result of this study that the most common comorbid congenital disorder is down syndrome and labiognatapalatoschizis (table 5). however, most of them are not accompanied by other congenital disorder. other risk factors include maternal comorbidities, family history of the disease, being born as the first child, medication taken during pregnancy, age of the mother, and gender of the infant.3 in this study, two mothers took hypertension and heart disease althea medical journal. 2019;6(3) 121 medication during pregnancy (table 3). a study showed that hypertension drugs may increase the risk of preterm birth, sga, and infants suffering from an abnormality of cardiovascular system.19 congenital heart disease is generally divided into two classes, the cyanosis, and noncyanosis. the cyanosis is characterized by the presence of central cyanosis due to the rightto-left shunts. some of the lesions are tetralogy of fallot, transposition of the great arteries (tga), and tricuspid atresia. while noncyanosis chd is characterized by the presence of cardiac septum defect and followed by leftto-right shunts, including vsd, asd, or patency of some blood vessels that are supposed to be closed as in pda. furthermore, non-cyanosis chd can also be found in an obstruction of the outflow tract of the ventricle like aortic valve stenosis, pulmonary valve stenosis, and coarctation of the aorta.2,20 non-cyanosis was the most frequent type of lesion found in this study, in a ratio of 20:1 with the cyanosis one (table 4).the most common lesion found in this study was pda, 16 out of 21 samples, while tga had the lowest frequency because it was only found in one out of 21 samples. some of the previous studies usually excluded the pda lesion due to prematurity which appears during <72 hours in infants who are born preterm. meanwhile, in this study, samples with pda were diagnosed in >72 hours in spite of their prematurity. the diagnosis of congenital heart disease is based on anamnesis to see the risk factors and disease history, physical examination to determine the presence/absence of cyanosis and examination of heart sound and murmurs, and other supporting examinations. basic supporting examinations for chd is chest x-ray to see if there are any enlargement of the heart and vascular marking, electrocardiography (ecg) to see if cardiomegaly or any deviation is found in patients, and routine laboratory tests. further supporting examinations are also conducted in the form of echocardiography and cardiac catheterization to confirm a chd diagnosis. the combination of both examinations allow diagnosis for approaching one hundred percent of accuracy.2 congenital heart disease lesion results in infants born with lbw due to hemodynamic disorders. this hemodynamic disorder can lead to increased metabolism, which consequently increases the energy consumption. a chd infant cannot fulfill this increased energy consumption because he/she suffers from calorie intake impairment. this impairment is presumably caused by the inability of the body to use nutrition for metabolism due to malabsorption and asphyxia. eventually, a manifestation will appear in the form of lbw and other comorbid conditions that contributed to the worsening state of the infants (table 5).8 many infants require corrective or palliative surgery and hospitalization during the first year of life. results of the surgery depend on the complexity of the lesions and infant characteristics such as lung development, prematurity, and body weight.4,13 compared to infants born with normal weight, lbw infants with chd who have undergone surgery are at higher risk of mortality and morbidity.11,13 factors associated with chd infant morbidity include lbw, prematurity and other conditions such as comorbid diseases. this study showed that the most common comorbid condition was preterm birth, followed by neonate sepsis. moreover, there were metabolic disorders found, such as neonate hyperbilirubinemia, followed by pneumonia, umbilical cord infection, respiratory distress syndrome (rds) and abnormality in blood systems such as anemia and thrombocytopenia. the factors affecting mortality include a birth weight that is less than 1,500 grams, the current low body weight before surgery, and the apgar score. generally, the apgar score is used to determine the level of asphyxia or how much apatient can lose the oxygen level in his/her circulation. these factors may determine the prognosis of a baby born with lbw and diagnosed chd.12 the apgar score in this study mostly belonged in a good category (table 2). however, some apgar score data were not recorded in the medical records, as the reasons were stated in the result part. as the apgar score worsens, so did the infant prognosis, and it was marked by the increase in the morbidity and even mortality. this study has several limitations; the study was carried out as a small regional study which may not reflect the actual number of the population. therefore, research with a large number of samples is recommended. there were also missing and incomplete medical records data. due to this, data collection from inpatients that were born or admitted should be more organized. some apgar scores were not recorded in the medical records due to two reasons; first, there were 10 deliveries handled by midwives and they did not perform the apgar test post-delivery to the infants. second, villia damayantie et al.: congenital heart disease characteristics in low birth weight infants at dr. hasan sadikin general hospital in 2010–2014 althea medical journal. 2019;6(3) 122 amj september 2019 several samples already had excellent1-minute apgar score, thus, no further assessment was needed. in conclusion, the most common type of chd in low birth weight infants in dr. hasan sadikin general hospital is patent ductus arteriosus. the presence of congenital heart disease should be considered in low birth weight infants; thus, screening is essential for early recognition. references 1. van der linde d, konings ee, slager ma, witsenburg m, helbing wa, takkenberg jj, et al. birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. j am coll cardiol. 2011;58(21):2241–7. 2. setty hssn, patil ssg, ramegowda rt, vijaykumar, vijayalakshmi ib, manjunath cn. comprehensive approach to congenital heart defects. j cardiovasc disease res. 2017;8(1):1–5. 3. ul haq f, jalil f, hashmi s, jumani mi, imdad a, jabeen m, et al. risk factors predisposing to congenital heart defects. ann pediatr cardiol. 2011;4(2):117–21. 4. malik s, cleves ma, zhao w, correa a, hobbs ca. association between congenital heart defects and small for gestational age. pediatrics. 2007;119(4):e976–82. 5. cho sy, oh j-h, lee jh, lee jy, lee sj, han jw, et al. recent incidence of congenital heart disease in neonatal care unit of secondary medical center: a single center study. korean j pediatr. 2012;55(7):232–7. 6. lindinger a, schwedler g, hense hw. prevalence of congenital heart defects in newborns in germany: results of the first registration year of the pan study (july 2006 to june 2007). klin padiatr. 2010;222(5):321–6. 7. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2013. 8. hagau n, culcitchi c. nutritional support in children with congenital heart disease. nutr ther metabol. 2010;28(4):172–84 9. maramis pp, kaunang ed, rompis j. hubungan penyakit jantung bawaan dengan status gizi pada anak di rsup prof. dr. rd kandou manado tahun 2009–2013. ecl. 2014;2(2):1–8. 10. alam a, sukadi a, risan na, dhamayanti m. preterm and low birth weight as risk factors for infant delayed development. paediatr indones. 2008;48(1):1–4. 11. ades am, dominguez te, nicolson sc, gaynor jw, spray tl, wernovsky g, et al. morbidity and mortality after surgery for congenital cardiac disease in the infant born with low weight. cardiology in the young. 2010;20(1):8–17. 12. dimmick s, walker k, badawi n, halliday r, cooper sg, nicholson ia, et al. outcomes following surgery for congenital heart disease in low-birthweight infants. j paediatr child health. 2007;43(5):370–5. 13. lechner e, wiesinger-eidenberger g, weissensteiner m, hofer a, tulzer g, sames-dolzer e, et al. open-heart surgery in premature and lowbirthweight infants–a single-centre experience. eur j cardiothorac surg. 2009;36(6):986–91. 14. bernier pl, stefanescu a, samoukovic g, tchervenkov ci. the challenge of congenital heart disease worldwide: epidemiologic and demographic facts. semin thorac cardiovasc surg pediatr card surg annu 2010;13(1):26–34. 15. goldenberg rl, culhane jf. low birth weight in the united states. am j clin nutr. 2007;85(2):584s–90s. 16. departemen kesehatan provinsi jawa barat. profil kesehatan provinsi jawa barat tahun 2012. bandung: departemen kesehatan provinsi jawa barat;2012. 17. negi k, kandpal s, kukreti m. epidemiological factors affecting low birth weight. jk science. 2006;8(1):31–4 18. freeman sb, bean lh, allen eg, tinker sw, locke ae, druschel c, et al. ethnicity, sex, and the incidence of congenital heart defects: a report from the national down syndrome project. genet med. 2008;10(3):173–80. 19. lennestål r, olausson po, källén b. maternal use of antihypertensive drugs in early pregnancy and delivery outcome, notably the presence of congenital heart defects in the infants. eur j clin pharmacol. 2009;65(6):615–25. 20. meberg a. congenital heart defects through 30 years. ojped. 2012;2(3):219–227. vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 201 antibacterial effect of human milk against streptococcus pyogenes: an in vitro study novi vicahyani utami,1 nurul nadiya binti abdul razak,2 dzulfikar d. l. hakim3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: novi vicahyani utami, department of biomedical sciences faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia , e-mail: novi.farmakologi@gmail.com introduction infectious disease is one of the major global burden of diseases worldwide.1 infectious diseases or commonly known as communicable diseases are caused by pathogenic microorganisms, such as bacteria, viruses, fungi or parasites. it is easily transmitted from one person to another, either by airborne, blood-borne, food-borne, sexual contact, skin contact and many others.2 various transmission pathways could be the reasons why these diseases are common and cause high mortality and morbidity globally. the global burden of disease 2004 report has shown that infectious and parasitic diseases ranked second as the leading cause of death worldwide. such diseases caused almost 16% of all deaths in women and 17% in men. it is also reported that infections and parasitic diseases are the major causes of death in the low-income countries such as africa and southeast asia with approximately 34% of total deaths.1 among the infectious diseases, bacterial diseases are the major health problems for humans. tuberculosis for example still ranks among the world’s leading causes of death.3 group a streptococcus (gas) disease is another bacterial disease that is reported as a global disease burden in the world health organization (who) report in 2004.; about 18.1 million people had suffered from a serious gas disease at that time, and these diseases are responsible for over 500,000 deaths each year.4 group a streptococcus, also known as streptococcus pyogenes is the common bacterial pathogen that is responsible for a broad spectrum of diseases that range from mild sore throat until life-threatening amj. 2019;6(4):201–4 abstract background: streptococcus pyogenes infection is one of the common upper respiratory infections among children. human milk has antibacterial properties that may play a role against infections. the study was conducted to observe the antibacterial effect of human milk against streptococcus pyogenes. methods: this was an in vitro experimental study conducted on october–november 2012 in microbiology laboratory, faculty of medicine, universitas padjadjaran, bandung, using agar well diffusion method. human milk was collected from eligible donors and tested at concentrations of 70%, 80%, 90%, and 100% dilution with water. inhibition zone formed surrounding the wells were measured after 24 hours of incubation. results: all samples incubated with human mils (in concentration of 70%, 80%, 90% and 100%) inhibited the growth of streptococcus pyogenes, with the inhibition zone mean diameters of 26.33, 28.00, 28.00 and 28.33mm, respectively, compared to the well containing sterile aquadest that did not show any zone of inhibition. conclusions: human milk has an in vitro antibacterial effect against streptococcus pyogenes. giving human milk to babies is important for preventing infectious diseases. keywords: antibacterial, human milk, in vitro, streptococcus pyogenes althea medical journal. 2019;6(4) 202 amj december 2019 illnesses like necrotizing fasciitis.5 this highly transmissible bacterium also a common cause of upper respiratory and skin infections. a study conducted in chennai6 has shown that the prevalence of group a streptococcus was high (36%) compared to other groups of streptococcus among the slum children. many clinicians have to confront this gas infection every day, as this is not only an acute illness for a single individual patient but also as a public health issue related to the highest potential to spread. vaccines to combat these streptococcus pyogenes also are not yet available. penicillin has been used for many years to treat this infection, however, many bacteria are now resistant to penicillin.7 human milk has known worldwide for its beneficial values towards infants. it is a very good source of nutrients, and it has immunological properties. a study in the united state8 has reported that exclusively breastfed babies have a decrease in respiratory tract infections. this might be contributed to the anti-infective properties in the human milk, which cannot be found on other foodstuffs; such as lactoferrin, secretory iga, α-amylase, lysozymes, defensins, cathelicidins and many others that have antimicrobial activity.9-11 therefore, human milk could be used as an alternative to combat infection. many studies confirm that human milk has antimicrobial activity against pathogens, among others in children with diarrhea.12 this study aimed to explore the antimicrobial activity of human milk against streptococcus pyogenes. methods this research was an experimental study, conducted in october–november 2012 in the microbiology laboratory, faculty of medicine, universitas padjadjaran, bandung, indonesia. human milk samples were collected from donors that fulfilled the inclusion criteria after having written informed consent. the inclusion criteria of the donors were healthy nursing mothers beyond four weeks postpartum, delivered to healthy full-term infants, and with no intake of medications within one week before collection day. human milk samples were collected manually into a sterile human milk storage bags and stored in the refrigerator at 4°c until used the next day. for this research, human milk was used as undiluted (100%) and at 70, 80 and 90% dilutions. streptococcus pyogenes were obtained from microbiology laboratory, faculty of medicine, universitas padjadjaran. the bacteria were harvested from a confluent streaked petri dish and suspended in sterile nacl 0.9% to match the 0.5 mcfarland standards. the bacteria suspension was then mixed with muellerhinton broth and 5% sheep blood to make inoculated mueller-hinton blood agar plate. the antibacterial effect of human milk against streptococcus pyogenes was tested using the agar well diffusion method. human milk samples were diluted with sterile aquadest at concentrations of 70%, 80%, 90%, and 100%. the inoculated mueller-hinton blood agar was prepared by making wells on it using a sterile well borer. one hundred and figure zone of inhibition of human milk against streptococcus pyogenes. althea medical journal. 2019;6(4) 203 table diameter of zone of inhibition of human milk against streptococcus pyogenes no. of replication concentrations zone of inhibition diameter (mm) 100% 90% 80% 70% control 1 28.00 28.00 28.00 26.00 0.00 2 28.00 28.00 28.00 27.00 0.00 3 29.00 28.00 28.00 26.00 0.00 x 28.33 28.00 28.00 26.33 0.00 sixty microliters of different concentrations of human milk and sterile aquadest were dispensed into the wells made and incubated at 37°c for 24 hours. the diameter of the inhibition zones formed surrounding the wells were observed and measured in millimeter (mm). the inhibition zones were compared with the inhibition zone of the well containing sterile aquadest that was served as a negative control. the antibacterial test was performed in triplicates. results the inhibition zone was formed surrounding the well that dispensed with human milk samples. the well that contained sterile aquadest did not show any zone of inhibition, as shown in figure. after three times replication of the antibacterial test, the human milk with a dilution of 70%, 80%, 90%, and 100% showed zones of inhibition; whereas the sterile aquadest as a negative control showed no zone of inhibition. the diameters of the inhibition zones were presented in table. the mean diameter of the zone of inhibition formed was slightly different between each dilution used, however, no statistical difference among those dilutions. the 100% of human milk has shown the best antibacterial effect against streptococcus pyogenes of all the concentrations tested with the highest mean diameter of 28.33 mm. discussion the result of this research has proved that human milk can inhibit the growth of the streptococcus pyogenes in vitro. there are many components in human milk that may be responsible for this antibacterial effect. protection from infection by human milk is provided by two mechanisms. first, the production of non-specific protective factors that is independent of exposure to infectious or other foreign agents like lactoferrin, lysozyme, gluco-conjugates, and oligosaccharides. second, the antigen-dependent mechanism which leads to the production of secretory iga antibodies that protect against enteric and respiratory pathogens.9 the secretory iga is believed to be the most influencing factor in human milk which has the antibacterial effect against streptococcus pyogenes. secretory iga is the main immunoglobulin present in human milk. it can attach to the mucosal epithelium of the gut and some parts of the respiratory tract, and it prevents the attachment and invasion of specific infectious agents.10 the secretory iga itself has been proven to have an in vitro antibacterial effect against streptococcus pyogenes.11 the non-specific protective factors may also contribute to the antibacterial effect of human milk. lactoferrin, a protein in human milk can demonstrate a bacteriostatic effect. milk lysozyme which can cleave peptidoglycans of the bacterial cell walls has been known to have a higher concentration in human milk. other factors like oligosaccharides and glycoconjugates have been also known to inhibit the adherence and proliferation of bacteria on the epithelial surfaces.10 all of the non-specific factors have shown in vitro activity against common pathogens like staphylococcus aureus, escherichia coli, vibrio cholera and haemophilus influenzae.11 a previous study using probiotic of the human milk has shown that there is an antibacterial activity against common pediatric communityacquired respiratory pathogens. the probiotic of the human milk can inhibit the growth of streptococcus pneumonia, haemophilus influenzae and staphylococcus aureus tested in this study,13 thus, confirming that the human novi vicahyani putri et al.: antibacterial effect of human milk against streptococcus pyogenes: an in vitro study althea medical journal. 2019;6(4) 204 amj december 2019 milk can prevent the growth of bacteria which causes upper respiratory infections, including the streptococcus pyogenes. there is another study reporting the exclusively breastfed infants who have less hospitalization caused by respiratory tract illness compared to non-breastfed infants.14 the study has portrayed the best of the protective role of human milk, also supported the proposed mechanisms of anti-infective components of the human milk in protecting against pathogens. the result of this research further has proved the protective role of human milk against common respiratory pathogens. the antibacterial effect of the human milk against streptococcus pyogenes is beneficial as some studies have shown that streptococcus pyogenes develop a resistance to some antibiotics. new alternative treatment for streptococcus pyogenes infections is needed especially in children. furthermore, human milk convenient to be used as human milk is a less cost, safe and natural source of treatment options for the community. this study has limitations not to compare the antibacterial effect against streptococcus pyogenes between human milk and formula milk. further study may be of great interest to explore the antibacterial effect of the human milk above the formula milk. in conclusion, human milk has an in vitro antibacterial effect against streptococcus pyogenes. it is thus important to give human milk to the infant for preventing infectious diseases. references 1. world health organization. the global burden of disease: 2004 update. geneva: who press; 2008. 2. lucile packard children’s hospital standford. maternal and fetal infections overview. [online web page] 2010 [cited 2012 april 26]; available from: https:// www.stanfordchildrens.org/en/topic/ default?id=maternal-and-fetal-infectionsoverview-90-p09523&sid=. 3. world health organization. world health statistics 2011. geneva: who press; 2011. 4. world health organization. the current evidence for the burden of group a streptococcal diseases. geneva: who press; 2005. 5. medlineplus. bacterial infections. [online web page] 2019 [cited 2019 october 13]; available at: https://medlineplus.gov/ bacterialinfections.html. 6. kalpana s, sundar js, parameshwari s, kuganantham p, selvam jm, valarmathi ms, et al. isolation and identification of group a streptococcal infection among slum children in the age group of 5–15 years in chennai-one year prospective study. iosrjpbs. 2012;2(1):27–30. 7. pechere jc, kaplan el, editors. streptococcal pharyngitis: optimal management. basel, switzerland: karger medical and scientific publishers; 2004. p. 16–32. 8. chantry cj, howard cr, auinger p. full breastfeeding duration and associated decrease in respiratory tract infection in us children. pediatrics. 2006;117(2):425– 32. 9. goldman as. the immune system in human milk and the developing infant. breastfeed med. 2007;2(4):195–204. 10. lonnerdal b. nutritional and physiologic significance of human milk proteins. am j clin nutr. 2003;77(6):1537s–43s. 11. aldy os, lubis bm, sianturi p, azlin e, tjipta gd. dampak proteksi air susu ibu terhadap infeksi. sari pediatri. 2009;11(3):167–73. 12. chan gm, lee ml, rechtman dj. effects of a human milk-derived human milk fortifier on the antibacterial actions of human milk. breastfeed med. 2007;2(4):205–8. 13. cid src, cruz mc, faustino v, tuazon ao. in vitro study on the antimicrobial activity of probiotic milk against common pediatric community acquired respiratory pathogens. pidsp journal. 2005;9(2):25– 9. 14. bachrach vrg, schwarz e, bachrach lr. breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis. arch pediatr adolesc med. 2003;157(3):237–43. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 420 amj september 2017 nasal endoscopy findings in acute and chronic rhinosinusitis patients stephanie dharmaputri,1 lina lasminingrum,2 yulia sofiatin3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology–head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: according to european position paper on rhinosinusitis and nasal polyps (epos) 2012, rhinosinusitis is diagnosed based on symptoms, nasal endoscopy, and ct scan. the ct scan is the gold standard to diagnose rhinosinusitis, but its high cost and lack of availability become the problems in indonesia. hence, nasal endoscopy is a choice to diagnose rhinosinusitis. this study was aimed to describe the findings of nasal endoscopyin in acute and chronic rhinosinusitis. methods: this cross-sectional descriptive study was performed using medical record of acute and chronic rhinosinusitis patients. the samples were chosen with consecutive sampling. inclusion criteria of this study were patients that underwent nasal endoscopy examination in otorhinolaryngology–head and neck surgery clinic dr. hasan sadikin general hospital bandung in 2014.the collected data were analyzed in the form of tables. results: among 138 patients, the number of female patients (55.1%) was higher than male patients. majority of the patients (37.5%) were 25–44 years old. majority of the chief complaint was nasal obstruction (48.6%). the patients with allergic history (48.6%) were higher than patients without allergic history (19.6%). according to nasal endoscopy results, nasal discharge and edema were found in most of the patients (68.8% and 63.0%), but nasal polyp was only found in 15.9% patients. other findings, such as hypertrophy concha or nasal septum deviation, were also found on 87.7% patients. conclusions: most of the rhinosinusitis patients are found with at least one of the following results of nasal endoscopy, which are nasal discharge, edema, or nasal polyp. keywords: nasal discharge, nasal endoscopy, nasal obstruction, rhinosinusitis. correspondence: stephanie dharmaputri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: stephaniedharmaputri@gmail.com introduction rhinosinusitis, an inflammation of the nose and the paranasal sinuses, is a significant health problem.its incidence and prevalence are growing thus increase the treatment challenge for the clinician.1–3 according to european position paper on rhinosinusitis and nasal polyps (epos) 2012, diagnosis of rhinosinusitis is enforced based on symptoms, nasal endoscopy, and computed tomography (ct). the symptoms are either nasal obstruction or nasal discharge, with or without facial pain and with or without reduction or loss of smell. nasal endoscopy that discovers nasal polyp and/or mucopurulent discharge and/or edema, primarily from middle meatus, and/or result of ct scan that findsmucosal changes within the osteomeatal complex and/or sinuses are results of additional examination that are referred to diagnosis of rhinosinusitis.4 the ct scan is the gold standard for diagnosis of rhinosinusitis, but its high cost and lack of availability become the problems in indonesia.2,5 hence, nasal endoscopy becomes the choice for diagnosing rhinosinusitis. many studies also found that nasal endoscopy is suitable for diagnosing rhinosinusitis. therefore, it is not necessary to reevaluate the findings with ct scan.5,6 besides that, nasal endoscopy also has functions to assess predisposing factors and contributors of rhinosinusitis, such as variations in anatomical structure dan mucosal changes in middle meatus and osteomeatal complex.6 even though studies about nasal endoscopy as diagnostic tool of rhinosinusitis have been amj. 2017;4(3):420–5 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1192 althea medical journal. 2017;4(3) 421 already conducted in many different countries, such as united states, oman, and nepal, the study was still rarely conducted in southeast asia, especially indonesia.5–7 hence, this study was aimed to describe the result of nasal endoscopy in acute and chronic rhinosinusitis. methods this cross-sectional descriptive study was cleared by the health research ethics committee of dr. hasan sadikin general hospital bandung no. lb.04.01/a05/ec/249/vii/2015. data were collected by compiling medical record of acute and chronic rhinosinusitis patients. the minimum sample size needed was 123 subjects. the samples were chosen by consecutive sampling with inclusion criterion, acute and chronic rhinosinusitis patients who underwent nasal endoscopy examination in otorhinolaryngology–head and neck surgery clinics dr. hasan sadikin general hospital table 1 general characteristics of rhinosinusitis patients demographic and clinical characteristics chronic rhinosinusitis acute rhinosinusitis (n=128) (n=10) gender female 71 (55.5%) 5 male 57 (44.5%) 5 age <15 years old 8 (6.3%) 5 15–24 years old 38 (29.7%) 2 25–44 years old 48 (37.5%) 2 45–64 years old 26 (20.3%) 1 >65 years old 8 (6.3%) 0 chief complaint nasal obstruction 63 (49.2%) 4 nasal discharge 19 (14.8%) 2 facial pain 4 (3.1%) 1 reduce/loss of smell 6 (4.7%) 0 others 36 (28.1%) 3 comorbidity none 85 (66.4%) 7 asthma 8 (6.3%) 0 copd* 1 (0.8%) 0 otitis media 6 (4.7%) 0 orbital cellulitis 2 (1.6%) 1 pharyngitis 1 (0.8%) 1 tonsilitis 3 (2.3%) 0 others 34 (26.6%) 2 allergic history no 24 (18.8%) 3 yes 65 (50.8%) 2 unknown 39 (30.5%) 5 note: *copd = chronic obstructive pulmonary disease stephanie dharmaputri, lina lasminingrum, yulia sofiatin: nasal endoscopy findings in acute and chronic rhinosinusitis patients althea medical journal. 2017;4(3) 422 amj september 2017 table 2 nasal endoscopy findings of rhinosinusitis patients nasal endoscopy findings chronic rhinosinusitis acute rhinosinusitis (n = 128) (n = 10) nasal discharge 88 (68.8%) 7 edema 79 (61.7%) 8 nasal polyp 22 (17/2%) 0 other findings none 16 (12.5%) 1 nasal septum deviation 41 (32.0%) 1 processusuncinatus edema 32 (25.0%) 0 concha hypertrophy 94 (73.4%) 9 others 17 (13.3%) 0 bandung from january 1-31 december 2014. if the results of nasal endoscopy did not complete, the patients were excluded from this study. the collected data were analyzed in the form of tables. results among 251 patients who were recorded at outpatients’ medical records, there were only 138 patients who fulfilled the inclusion criteria. there were 128 (92.8%) chronic rhinosinusitis patients and 10 (7.2%) acute rhinosinusitis patients. the age of studied patients were ranged from 3 to 76 years old. majority of the studied patients had chief complaint of nasal obstruction (48.6%). most of the patients did not have comorbidity (66.7%). the patients with allergic history (48.6%) were higher than patients without allergic history (19.6%). based on nasal endoscopy results, there were 10 out of 138 patients (7.2%) that had negative nasal endoscopy result (not found nasal polyp, nasal discharge, or edema). the other findings found in 87.7% patients were nasal septum deviation (30.4%), processusuncinatus edema (23.2%), concha hypertrophy (74.6%), crusting of nasal concha (1.5%), nasal septum spur (8.0%), concha table 3 cross tabulation of age category and nasal endoscopy findings of chronic rhinosinusitis patients age x nasal endoscopy findings <15 years old 15–24 years old 25–44 years old 45–64 years old >64 years old (n = 8) (n = 38) (n = 48) (n = 26) (n = 8) nasal discharge 6 27 38 13 6 edema 4 22 36 16 4 nasal polyp 0 4 9 7 2 other findings none 1 1 4 6 4 nasal septum deviation 2 12 19 8 1 processusuncinatus edema 2 11 13 4 2 concha hypertrophy 6 31 40 17 3 others 0 6 9 2 0 althea medical journal. 2017;4(3) 423stephanie dharmaputri, lina lasminingrum, yulia sofiatin: nasal endoscopy findings in acute and chronic rhinosinusitis patients bullosa (1.5%), and nasal synechiae (1.5%). discussion according to this study, there were only 7.2% acute rhinosinusitis patients. the cause of few numbers of acute rhinosinusitis patients was the symptoms experienced by the patients less than 4 weeks. it caused the patients sought the treatment in primary health care provider, such as health care center or general practitioner, while dr. hasan sadikin general hospital bandung is tertiary health care provider. besides that, the few numbers of acute rhinosinusitis patients in this study made limited discussion of the results. in this study, female with chronic rhinosinusitis was higher than male. this result was similar to studies conducted by tomassen et al.1, kolethekkat et al.6, and hodeson and wise3, they stated that prevalence of rhinosinusitis is two times higher in female (20.9%) than male (11.6%). this result was also in line with epos 2012 that stated the prevalence rate of chronic rhinosinusitis is higher in female than in male.4 majority of patients with chronic rhinosinusitis (37.5%) were aged 25–44 years old. munir8 also discovered that the most common age distribution in chronic maxillary sinusitis is between 35–44 years old. however, 5 out of 10 acute rhinosinusitis patients were less than 15 years old. this result was supported by poachanukoon et al.9 and al-madani et al.10 which found that acute rhinosinusitisis is more common in children than adult due to immature development of sinuses. this study also discovered that the most common chief complaint was nasal obstruction (48.6%) which was same as pokharel et al.7 (85.1%) and munir8 findings (60%). this study also found that loss of smell sensation as chief complaint was only experienced by chronic rhinosinusitis patients that was also found by sánchez-vallecillo et al.11 in argentina. comorbidity is one of the predisposing factors of rhinosinusitis, but this study found that most of the rhinosinusitis patients did not have comorbidity. this result was different from lin et al.12 that found the severity of asthma is associated with rhinosinusitis. tan et al.13 also discovered that adenotonsillitis and otitis media are associated with chronic rhinosinusitis, while upper respiratory tract infections, pneumonia, and bronchitis are associated with chronic rhinosinusitis without nasal polyp. this different result could be caused by incomplete information of the patient’s comorbidity due to under reporting. this study found that the patients with allergic history were slightly higher than patients without allergic history and unknown allergic history patients. this result was concordant with epos 2012 which reported that there are significant association between allergy and rhinosinusitis.4 tan, et al.13 also stated that there is association between chronic rhinosinusitis and one of the allergic condition, allergic rhinitis. according to diagnosis criteria of epos 2012, one of the criteria of a person with table 4 cross tabulation of chief complaint and nasal endoscopy findings of chronic rhinosinusitis patients chief complaint x nasal endoscopy findings nasal obstruction nasal discharge facial pain reduce/ loss of smell others (n = 63) (n = 19) (n = 4) (n = 6) (n = 36) nasal discharge 44 14 2 4 24 edema 35 14 3 4 23 nasal polyp 16 2 0 1 3 other findings none 10 3 0 0 3 nasal septum deviation 16 3 3 5 14 processusuncinatus edema 11 4 1 3 13 concha hypertrophy 48 16 4 4 22 others 9 1 0 1 6 althea medical journal. 2017;4(3) 424 amj september 2017 rhinosinusitis is the finding of nasal polyp and/ or nasal discharge and/or edema, primarily at middle meatus, in the nasal endoscopy.4 if at least one of those criteria was found in nasal endoscopy, the patient had positive nasal endoscopy result. however, this study found 10 patients who had negative nasal endoscopy result. kolethekkat et al.6 also found similar result, 10 of 75 chronic rhinosinusitis patients (13%) had negative nasal endoscopy result. besides those three diagnostic findings, other findings, which are reflecting predisposing factors of rhinosinusitis in the patients, such as anatomical variation and mucosal changes in middle meatus and osteomeatal complex, were found in most of the rhinosinusitis patients (87.7%). the other findingsin most of the patients were concha hypertrophy (74.6%). however, munir8 found a different result that the abnormality of the osteomeatal complex was mostly enlargement of ethmoid bulla (36.2%). this study discovered that more than half of patients from each age group suffered from nasal discharge and mucosal edema, but only those with older age suffered from nasal polyp. it was caused by polyp’s response to chronic inflammation. there was similar finding that nasal septum deviation is also higher along with the patient’s age. ahn et al.14 in korea also discovered that older age is associated with increased risk for chronic rhinosinusitis with nasal polyp and nasal septum deviation. moreover, this study showed that the complaint was not concomitantwith nasal endoscopy findings. among those who complained nasal discharge, about a quarter of them have no nasal discharge during examination. besides that, loss of smell sensation was higher at patients with nasal septum deviation and was followed by nasal discharge, edema, and concha hypertrophy. the similar result was found by sánchezvallecillo, et al.11 that nasal polyp, asthma, septal deviation, concha hypertrophy, and allergic rhinitis are predicting factors of olfactory dysfunction. limited number of samples caused by many unavailable and incomplete medical records is the limitations of this study. since epidemiologic study is an important study to improve the mode of diagnosis and treatment, a high quality of data should be prepared continuously, so then a better method of medical recording is highly recommended. it can be concluded that nasal endoscopy findings, which are found in majority of the rhinosinusitis patients, are nasal discharge, edema, and nasal polyp. besides those diagnostic findings, other findings, such as concha hypertrophy or nasal septum deviation, are also found in rhinosinusitis patients references 1. tomassen p, newson r, hoffmans r, lötvall j, cardell l-o, gunnbjörnsdóttir m, et al. reliability of ep3os symptom criteria and nasal endoscopy in the assessment of chronic rhinosinusitis–a ga2len study. allergy. 2011;66(4):556–61. 2. amodu ej, fasunla aj, akano ao, olusesi ad. chronic rhinosinusitis: correlation of symptoms with computed tomography scan findings. pan afr med j. 2014;18(1):40–5. 3. hoddeson ek, wise sk. acute rhinosinusitis. in: johnson jt, rosen ca, editors. bailey’s head and neck surgery –otolaryngology. 5th ed. philadelphia: lippincott williams & wilkins; 2014. p. 509–24. 4. fokkens wj, lund vj, mullol j, bachert c, alobid i, baroody f, et al. european position paper on rhinosinusitis and nasal polyps 2012. rhinol suppl. 2012(50):1–298. 5. bhattacharyya n, lee ln. evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. otolaryngol head neck surg. 2010;143(1):147–51. 6. kolethekkat aa, paul rr, kurien m, kumar s, al abri r, thomas k. diagnosis of adult chronic rhinosinusitis: can nasal endoscopy predict intrasinus disease? oman med j. 2013;28(6):427–31. 7. pokharel m, karki s, shrestha b, shrestha i, amatya r. correlations between symptoms, nasal endoscopy, computed tomography and surgical findings in patients with chronic rhinosinusitis. kathmandu univ med j. 2013;43(3):201–5. 8. munir d. the clinical features of ostiomeatal complex in chronic maxillary sinusitis by nasoendoscopic examination. majalah kedokteran nusantara. 2006;39(1):6–9. 9. poachanukoon o, nanthapisal s, chaumrattanakul u. pediatric acute and chronic rhinosinusitis: comparison of althea medical journal. 2017;4(3) 425 clinical characteristics and outcome of treatment. asian pac j allergy immunol. 2012;30(2):146–51. 10. al-madani mv, khatatbeh ae, rawashdeh rz, al-khtoum nf, shawagfeh nr. the prevalence of orbital complications among children and adults with acute rhinosinusitis. braz j otorhinolaryngol. 2013;79(6):716–9. 11. sánchez-vallecillo mv, fraire me, baenacagnani c, zernotti me. olfactory dysfunction in patients with chronic rhinosinusitis. int j otolaryngol. 2012;2012(1):1–5. 12. lin dc, chandra rk, tan bk, zirkle w, conley db, grammer lc, et al. association between severity of asthma and degree of chronic rhinosinusitis. am j rhinol allergy. 2011;25(4):205–8. 13. tan bk, chandra rk, pollak j, kato a, conley db, peters at, et al. incidence and associated premorbid diagnoses of patients with chronic rhinosinusitis. j allergy clin immunol. 2013;131(5):1350– 60. 14. ahn j-c, kim j-w, lee ch, rhee c-s. prevalence and risk factors of chronic rhinosinusitus, allergic rhinitis, and nasal septal deviation: results of the korean national health and nutrition survey 20082012. jama otolaryngol head neck surg. 2016;1(1):1–7. stephanie dharmaputri, lina lasminingrum, yulia sofiatin: nasal endoscopy findings in acute and chronic rhinosinusitis patients amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 55 spirometric values of patients with chronic obstructive pulmonary disease in dr. hasan sadikin general hospital bandung christopher rinaldi,1 rudolf andean,2 irma ruslina defi3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: christopher rinaldi, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia , e-mail: chrinaldi93@yahoo.com introduction global initiative for chronic obstructive lung disease (gold) has defined chronic obstructive pulmonary disease (copd) as a chronic, persistent, and progressive airway limitation, that is associated with enhanced inflammatory response and possible excacerbation with exposure to noxious particles or gases.1,2 epidemiological studies have shown that copd has a high burden and the prevalence is relatively increased. prevalence is higher in studies involving older patients over 40 years old (9.0%), smokers (15.4%), males (9.8%), and individuals living in urban areas (10.2%). interestingly, copd is frequently a symptomatic in the early stages. it is shown in the study that reported a much lower estimated prevalence of patient-reported copd (4.9%) compared to copd diagnosed by spirometric criteria (9.2%).3 the disease may cause physical disabilities by reduced activities of daily living (adl), instrumental activities of daily living (iadl), and mobility disability (md). disability aside, copd remains incurable and the best treatments may only be able to inhibit the disease’s progression.4 a survey by the epidemiology and impact of copd (epic) asia, conducted in 2012 in north asia countries (china, hong kong, and taiwan) and southeast asia countries (indonesia, malaysia, the philippines, singapore, thailand, and vietnam) has shown that several southeast asian countries have a worse health condition for patients with copd and a greater rate of underdiagnosis of copd compared to north asian countries.5 the survey result is concurrent with the existing challenges in amj. 2020;7(2):55–60 abstract background: chronic obstructive pulmonary disease (copd) is a frequently underdiagnosed disease. definitive copd has been diagnosed using spirometry to evaluate pulmonary function. this study aimed to explore the spirometric values of copd patients to aid in the diagnosis of copd. methods: a descriptive study was conducted in dr. hasan sadikin general hospital bandung from october to november 2015. data on patients diagnosed with copd, aged 40 to 60 years old, were collected during the year 2014 prior to ethical clearance. spirometry values consisted of forced expiratory volume in one second (fev1), forced vital capacity (fvc), and fev1/fvc ratio were taken from the medical records. results: sixty-eight copd patients, consisting of 48 males and 20 females, were included of with most were classified as moderate copd. the fev1 was 49.72±17.79, whereas the fvc was 55.90 (range 22.80–96.03), and the fev1/fvc ratio was 0.70±0.12. most patients were classified into moderate copd who had fev1 between 50 and 80% of normal as gold 2 standard. conclusions: even though patients seem to have no symptoms, spirometric values may show a silent insufficient lung function affecting patients’ daily life. keywords: chronic obstructive pulmonary disease, copd, fev1, fvc, spirometry https://doi.org/10.15850/amj.v7n2.1687 althea medical journal. 2020;7(2) 56 amj june 2020 diagnosing copd. despite being a possible cause for disabilities and the tendency for rapid progression of the disease’s severity, copd is a frequently underdiagnosed and misdiagnosed condition. therefore, solutions have been aimed at making earlier diagnosis and management to improve the patients’ condition and to delay with the progression of the disease. these efforts may be able to reduce hospitalization and exacerbation rates.6 spirometry is an essential tool, and also serves as a gold standard in diagnosing copd. it contains several pulmonary function values such as forced expiratory volume in one second (fev1) and forced vital capacity (fvc) as main spirometric values that require an assessment to determine the diagnosis and the severity of copd to give an appropriate management plan.7 this study aimed to obtain a description of the spirometric values of patients with copd that may aid the diagnosis of copd. methods this study was conducted from october to november 2015. all data on copd patients during 2014 were collected from medical records, including patients who underwent pulmonary function tests with spirometry in the department of respirology, dr. hasan sadikin general hospital bandung. inclusion criteria were patients diagnosed with copd and the age range of 40 years to 60 years old. exclusion criteria were patients diagnosed with acute exacerbation of copd or diagnosed with other illnesses secondary to copd. the data consisted of basic characteristics consisted of age, sex, height, weight, body mass index (bmi) and disease severity according to the global initiative for chronic obstructive lung disease (gold) system. the gold guideline was used as a combined copd assessment approach to group patients according to symptoms and previous history of exacerbations and the severity of copd was categorized according to gold criteria. a gold criterion was based on spirometry results such as fev1, fvc, and fev1/fvc ratio. the criteria were divided into 4 groups according to percent predicted fev1 with gold1 being the least severe and gold 4 being the most severe. in patients with fev1/fvc <0.70. gold criteria was applied, that were gold 1-mild: fev1≥ 80% predicted, gold 2 moderate: 50% ≤fev1 <80% predicted, gold 3-severe: 30% ≤fev1 <50% predicted, gold 4-very severe: fev1 <30% predicted. the study protocol was granted from the health research ethics committee, dr. hasan sadikin general hospital bandung no. 113/tb/rshs/ nov15. results in total, sixty-eight data on spirometric values and physical profiles of copd patients were collected, including 48 male and 20 female copd patients. the basic characteristic of copd patients was shown in table 1. the majority of patients (44.1%) had been classified as gold 2 or moderate copd (table 1). across all spirometric values, male patients tended to have a higher score compared to female patients. despite the higher predicted and tested spirometric values, the percent predicted spirometric values of male copd patients were lower compared to the percent predicted spirometric values of female copd patients. however, no statistical measurement had been conducted. the mean fev1/fvc ratios were mostly around 0.7 that indicated minimal obstructive respiratory problems despite being diagnosed as copd that required the ratio to be below 0.7. several samples from male and female copd patients were found to have a higher fev1/fvc ratio than 0.7, again no statistical analyses had been performed (table 2). discussion the copd is increasing, predominantly in male as shown in our study. however, in most developed countries, there is a shifting of copd prevalence towards females.8 this occurrence may be attributed to several factors. women are less tolerant to the effects of smoking, and these effects are limited only on lower usage of cigarettes. as for more than 20 cigarettes a day, the dose-response relationship is similar to men.9 another alternative explanation for this proportion is the estimated prevalence of smoking women in indonesia. according to survey data obtained from 1980 to 2012, indonesia has estimated prevalence rates of daily smoking greater than 40% for males and less than 5% for females.10 the difference in prevalence between sexes may justify the view that copd is a predominantly male disease.9 interestingly, survey data and modeling by who conducted in the subregion of southeast asia region b, which is consisted of indonesia, thailand, and sri lanka, has reported an estimated proportion of 56% females that are exposed to second hand smoke, compared to 35% females exposed to second hand smoke althea medical journal. 2020;7(2) 57 table 1 basic characteristic of chronic obstructive pulmonary disease patients at dr. hasan sadikin general hospital 2014 characteristics male (n=48) female (n=20) total (n=68) age (years) 40–45 9 4 13 46–50 5 4 9 51–55 18 6 24 56–60 16 6 22 height (meter) <1.50 3 9 12 1.50–1.60 20 11 31 >1.60 25 25 weight (kilograms) <50 13 10 23 50–59 16 6 22 60–70 13 4 17 >70 6 6 bmi (kilograms/meter2)* ≤18.5 11 6 17 18.5–24.9 26 9 35* 25.0–29.9 7 4 11 ≥30.0 4 1 5 severity gold 1 3 3 6 gold 2 23 7 30* gold 3 13 6 19 gold 4 9 4 13 note. *body mass index was calculated by weight/height2. severity was designated as gold 1 – mild with fev1≥ 80%, gold 2 – moderate with 50% ≤fev1 <80%, gold 3 – severe with 30% ≤fev1 <50% and gold 4 very severe with fev1 <30%. worldwide.11 the combination of earlier described factors may contribute to the development of copd in women, although it is not higher than men, which may indicate the beginning of a shifting paradigm of patients with copd in indonesia. the age range of 40 years to 60 years old included in this study is to minimize the effects of aging and possible undiagnosed comorbidities. the aging process contributes to the reduction of fev1 and fvc in the elderly population and it will increase false positivities that tends to occur from the normal aging process, leading to overdiagnosis of copd in the middle-aged and elderly population. the spirometric values observed in this study have shown a decline in older age groups. this may be caused by the natural decline of lung function and increased bronchial responsiveness. lung function peaks between 20 to 35 years old and follows a steady decline after 35 years. the rate of decline varies individually and it has shown a nonlinear pattern with the estimated rate of decline around 25 ml/year; starting at age 35 to 40 years old and may increase to 60 ml/year after the age of 70 years. such a natural decline of lung function among very old people may be mistaken for copd during spirometry. furthermore, bronchial responsiveness is measured by the dose of christopher rinaldi et al.: spirometric values of patients with chronic obstructive pulmonary disease in dr. hasan sadikin general hospital bandung althea medical journal. 2020;7(2) 58 amj june 2020 methacholine required to cause a significant reduction in fev1, which is about 20% from the baseline. since methacholine can cause bronchospasm, lower doses indicate higher bronchial responsiveness. younger people and older people are much more susceptible to fev1 reduction from methacholine.12–14 bronchial hyper responsiveness may be a confounding factor in copd, especially if the reduction in the flow rate, fev1 specifically, is reversible. therefore, the older age groups on the population might be excluded in this study to minimize the effect of the natural decline in lung function due to aging and bronchial hyperresponsiveness. moreover, copd is uncommon under the age of 40 years old. the predisposition of copd in young adults may be attributable to other causes such as chronic lung disease of prematurity (cldp) and bronchopulmonary dysplasia (bpd). there are individuals who may have a lower fev1/fvc ratio as their normal lung function. young individuals who have developed copd will most likely have cldp as a secondary diagnosis instead of the main issue. issues that occur during growth and development may be recognized as the main issues instead the respiratory disease itself. the hazards include early life viral infection, allergic sensitization, and prematurity. hazards during the developmental period of infants may produce lower lung function in later life, thus, predisposing them to develop an obstructive disease phenotype that may be diagnosed as copd as the main diagnosis.15 amore extensive history taking is required especially history during the younger ages to exclude other differential diagnoses. therefore, the exclusion of younger ages on the population has been made. by definition, copd involves chronic and persistent airway obstruction. the symptoms of copd range from asymptomatic to the ones that may significantly reduce the quality of life. the airway obstruction in copd is mainly diagnosed using spirometers and the most commonly used diagnostic criteria for copd were the gold criteria. measuring the severity of copd using post-bronchodilator with fev1/fvc ratio below 0.7, then continued by the assessment of percent predicted fev1 indicates a partially irreversible airway obstruction.2 the cut off point is not absolute. interestingly, several patients in this study have fev1/fvc above 0.7 and yet, still diagnosed as copd. several alternatives can be used in assessing the lower limit of normal (lln) by using body plethysmography and diffusion capacity tests. a study has compared lln and fixed fev1/ fvc ratio in terms of positive predictive value and negative predictive value, resulting in no significant differences between the two cutoff points.16 reference value for lln is adjusted according to age and defined as the lower fifth percentile of the population in fev1/ fvc ratios as abnormal.17 the lln claims to be able to better diagnose the condition by reducing misdiagnosis of copd, however, the lln has proven to be comparably minimal to the fixed fev1/fvc ratio that gold has proposed.16 moreover, the lln is relatively more difficult to apply in practical situations table 2 spirometric values of chronic obstructive pulmonary disease patients at dr. hasan sadikin general hospital 2014 male female total fev1* predicted (mean±sd)" 2.68+0.34 2.05+0.19 2.49+0.42 result (mean±sd)" 1.33+0.53 1.03+0.47 1.24+0.53 pp** (mean±sd" ) 49.50+18.09 50.26+20.86 49.72+18.79 fvc*** predicted (median; min–max) 3.45; 2.55–4.07 2.48; 1.92–2.67 3.37; 1.92–4.07 result (median; min–max) 1.97; 0.76–2.78 1.22; 0.70–2.42 1.76; 0.70–2.78 pp (median; min–max) 56.20; 22.80–79.20 52.42; 27.89–96.03 55.90; 22.80–96.03 fev1/fvc **** (mean±sd" ) 0.68+0.13 0.73+0.12 0.70+0.12 note: *fev1=forced expiratory volume in one second in liters, ** pp=percent predicted of each values in percentages, *** fvc=forced vital capacity in liters, ****fev1/fvc=forced expiratory volume in one second/forced vital capacity althea medical journal. 2020;7(2) 59 and primary healthcare settings compared to the fixed ratio.16 the findings of copd outside of the currently established reference value may represent the difficulty in establishing the diagnosis of copd, leading to mislabelling of the disease. spirometry can only be described as a tool for diagnosis. the true gold standard for copd diagnosis lies in the diagnostic criteria used to interpret the spirometry results to an accurate clinical diagnosis. so far, spirometry has been used as a gold standard for the diagnosis of copd and many other restrictive or obstructive respiratory disorders. a diagnostic tool, even as a gold standard, will only display desired effectiveness if the operators were competent in its usage. misdiagnosis of copd is not an uncommon occurrence. according to a prospective, controlled, trial study conducted in italy, about 30.1% of patients diagnosed with copd have a normal spirometry result. the definitive diagnosis of copd using spirometry has been found with large variability, ranging from 0 to 100%, with a median of 37%.18 misclassification of copd may result in mismanagement of patients, resulting from further in a faster lung function decline in patients. the limitations of the study include the lack of other variables in medical records, such as smoking history and post-bronchodilator spirometric values. smoking history is one of the most important risk factors in copd development. early identification of copd is important because smoking cessation at an early stage of copd is the only intervention that substantially improves the prognosis by normalizing lung function decline and decreasing morbidity and all-cause mortality. confounding factors of the study include the assessment of spirometry adequacy. the study has not been able to directly evaluate the operators or the physicians in performing the spirometry and also patients’ effort during the spirometry which may influence the diagnosis and the spirometric values recorded by the spirometer. mislabelling of patients without copd in clinical practice is an issue that needs to be addressed. therefore, there are several suggestions in this study aiming to provide possible solutions. training in spirometry usage for physicians and attendants may be beneficial in improving diagnostic accuracy in copd. since spirometry is a tool, it requires calibration to perform optimally. this study has shown that copd in male patients tend to have more severe form compared to women. furthermore, there are still patients diagnosed with copd despite the normal fev1/fvc ratios. copd is an incurable disease and the best way to manage such disease is to prevent the disease from occurring in the first place. to conclude, even though patients seem to have no symptoms, spirometric values may show a silent insufficient lung function affecting patients’ daily life. references 1. viegi g, pistelli f, sherrill dl, maio s, baldacci s, carrozzi l. definition, epidemiology and natural history of copd. eur respir j. 2007;30(5):993–1013. 2. global initiative for chronic obstructive lung disease. global strategy for the diagnosis, management and prevention of copd (updated 2015). fontana: gold [internet] 2015 [cited 2015 october 12]. available from: http://www.goldcopd.org. 3. halbert rj, natoli jl, gano a, badamgarav e, buist as, mannino dm. global burden of copd: systematic review and metaanalysis. eur respir j. 2006;28(3):523–32. 4. rodriguez-rodriguez p, jimenez-garcia r, hernandez-barrera v, carrasco-garrido p, puente-maestu l, miguel-diez jd. prevalence of physical disability in patients with chronic obstructive pulmonary disease and associated risk factors. copd. 2013;10(5):611–7. 5. lim s, lam dc-l, muttalif ar, yunus f, wongtim s, lan ltt, et al. impact of chronic obstructive pulmonary disease (copd) in the asia-pacific region: the epic asia population-based survey. asia pac fam med. 2015;14(1):4. 6. fromer l. diagnosing and treating copd: understanding the challenges and finding solutions. intl j gen med. 2011;4:729–39. 7. bailey kl. the importance of the assessment of pulmonary function in copd. med clin north am. 2012;96(4):745–52. 8. aryal s, diaz-guzman e, mannino dm. copd and gender differences: an update. transl res. 2013;162(4):208–18. 9. sørheim i, johannessen a, gulsvik a, bakke p, silverman e, demeo d. gender differences in copd: are women more susceptible to smoking effects than men?. thorax. 2010;65(6):480–85. 10. ng m, freeman mk, fleming td, robinson m, dwyer-lindgren l, thomson b, et al. smoking prevalence and cigarette consumption in 187 countries, 1980– christopher rinaldi et al.: spirometric values of patients with chronic obstructive pulmonary disease in dr. hasan sadikin general hospital bandung althea medical journal. 2020;7(2) 60 amj june 2020 2012. jama. 2014;311(2):183–92. 11. öberg m, jaakkola ms, woodward a, peruga a, prüss-ustün a. worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. lancet. 2011;377(9760):139–46. 12. schermer trj, smeele ijm, thoonen bpa, lucas aem, grootens jg, van boxem tj, et al. current clinical guideline definitions of airflow obstruction and copd overdiagnosis in primary care. eur respir j. 2008;32(4):945–52. 13. sharma g, goodwin j. effect of aging on respiratory system physiology and immunology. clin interv aging. 2006;1(3): 253–60. 14. jarad n. chronic obstructive pulmonary disease (copd) and old age?. chron respir dis. 2011;8(2):143–51. 15. martinez fd. the origins of asthma and chronic obstructive pulmonary disease in early life. proc am thorac soc. 2009;6(3):272–7. 16. hoesein fam, zanen p, sachs ap, verheij tj, lammers jw, broekhuizen bd. spirometric thresholds for diagnosing copd: 0.70 or lln, preor post-dilator values?. copd. 2012;9(4):338–43. 17. hansen je, sun xg, wasserman k. spirometric criteria for airway obstruction: use percentage of fev1/fvc ratio below the fifth percentile, not <70%. chest. 2007;131(2):349–55. 18. lusuardi m, de benedetto f, paggiaro p, sanguinetti cm, brazzola g, ferri p, et al. a randomized controlled trial on office spirometry in asthma and copd in standard general practice: data from spirometry in asthma and copd: a comparative evaluation italian study. chest. 2006;129(4):844–52. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 133 effects of ageratum conyzoides leaf decoction on glucose absorption in rat’s small intestine siti sakinah,1 diah dhianawaty,2 vita murniati tarawan3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran bandung, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran bandung, indonesia abstract background: obesity is one of the health problems caused by excessive glucose intake which exceeds normal body requirement. to prevent health problems, indonesian natives used traditional herbs, such as ageratum conyzoides (billygoat weeds). the study aimed to discover the effect of ageratum conyzoides leaf decoction on glucose absorption in the small intestine of rats. methods: an experimental study was conducted at the biochemical laboratory of faculty of medicine, universitas padjadjaran. two groups of six rats were given ageratum conyzoides leaf decoction with dosages 0.89 and 1.33 g/kgbw respectively. each rat was given glucose solution as a control, decoction administration along with the glucose solution, and glucose solution again to discover the effect of decoction in the absorption function after the administration of decoction was discontinued. glucose absorbed by the intestine was measured every 15 minutes in 1 hour after the administrationof the solution. results: glucose absorption was impeded in dosage 1 and 2 with a mean of the gap between glucose absorbed concentration before given decoction and after given decoction were 73.97 and 45.09 mg/ dl respectively. analysis using paired t-test resulted in insignificant meaning (p-value of dosage 0.89 g/ kgbw=0.08; p-value of dosage 1.33 g/kgbw=0.06). in the last glucose perfusion, absorption increased in both dosages after administration of decoction was discontinued. conclusions: ageratum conyzoides leaf decoctioncan inhibit the glucose absorption in the small intestine but is not statistically significant. further investigation may be needed by using a higher concentration of ageratum conyzoides and/or other filtration methods. keywords: ageratum conyzoides, glucose absorption, leaves decoction correspondence: siti sakinah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km 21, indonesia, email: sitisakinah1598@yahoo.co.id introduction glucose is a molecule utilized inside the human body as the primary source of energy.1 glucose absorption occurs in the small intestine using secondary active transport via sodium and cotransporter sodium-glucose transporter-1 (sglt-1) and therefore enters the bloodstream via glucose transporter-2 (glut-2) transporter.2 excess of unused glucose is stored in various forms, and one of them is triglyceride.3 further accumulation of triglyceride might cause health problems such as obesity.4,5 obesity may become co-morbid of cardiovascular and metabolic disease.5 the use of herbal medicine is considered common in indonesia. the riset kesehatan dasar (or basic health research) data published in 2013 stated that 49% of indonesian population utilize herbal and traditional medicine (jamu) which are mostly used (52.7%) to maintain health and fitness.6 one of the plants used as medicinal herb is the billygoat weeds (ageratum conyzoides). ageratum conyzoides is originated from the tropical area of america and spread worldwide, in both the subtropics and tropical regions.7 ageratum conyzoides is known for its antihyperglycemic effect in rats by increasing the production of insulin.8 ageratum conyzoides also contains active substrates such as alkaloids, flavonoid, triterpen, volatile, chromen, chromone, etc.9 flavonoid, triterpen and alkaloids are known for their antihyperglycemic effect.10-13 flavonoid impedes glucose absorption by blocking the glut-2 transporter in the small intestine.14 from these active substrate contained inside, it is highly expected that ageratum conyzoides amj. 2018;5(3):133–8 althea medical journal. 2018;5(3) 134 amj september 2018 might impede the absorption of glucose in the small intestine, so that excess glucose stored in the adipocytes might be reduced. this study was conducted to discover the effect of ageratum conyzoides leaf decoction towards glucose absorption in the small intestine of rats and also determine the amount of dosage which brought out the impact if the effect proved to exist. methods a laboratory experimental study was conducted in the biochemical laboratory located at the faculty of medicine, universitas padjadjaran, jatinangor, and used the experimental study design. this study was approved by the health research ethics committee of faculty of medicine, universitas padjadjaran, no: 810/ un6.c1.3.2/kepk/pn/2016. study subjects were 12 homogenous male wistar rats (rattus norvegicus). the number of subjects was calculated using mead resource equation. inclusion criteria for the rats were: in the age of 3–4 months, weighing 250–300 grams, and was considered as healthy (moving actively and did not have any injury). exclusion criteria were rats with deteriorating health status, which was characterized as having reduction in mobility, decreasing bodyweight until m>10%, secretion of porfirin pigment around eyes and nose region appeared as red crust, rats that were unable to adapt, and death. another exclusion criterion was rats that had been used as subject in an earlier project. ageratum conyzoides was collected from solo, central java, indonesia, and then extracted using the decoction method. the process was preceded firstly with the washing and drying process of the ageratum conyzoides leaves before it was powdered. distilled water was added and then it was stirred homogenously. the mixture was then heated for 30 minutes to a temperature of 90oc. after that, the heated mixture was filtered and distilled water was added until it reached the required volume. the study subjects were undergoing the adaptation process for 7 days in the biochemical laboratory at the faculty of medicine, universitas padjadjaran. rats that were unable to adapt were excluded, while rats that were able to adapt for 7 days were enrolled in the study as the study subjects. the study subjects were firstly anesthetized using ketamine with the dosage of 0.13 mg/100 gram per bodyweight. after the anesthetic drug took effect, the rats were fixated on the preparation board. the abdomen of the rat was sliced open starting from the skin, layer by layer, until it reached the small intestine and then it was removed from the body. the cannula from the perfusion set was inserted until it reached ±10 cm beyond the pylorus and 25 cm after. after that, the small intestine was washed using nacl 0.9%. two cannulas tied together on the intestine were connected figure 1 mean of glucose absorbed concentration in group 1 althea medical journal. 2018;5(3) 135 to the perfusion set using a small tube. then, liquid was administered into the small intestine using the perfusion set. the study subjects were classified into two groups with six rats in each group based on different dosages. every subject was given control intervention, which was the administration of 3 mm glucose for 1 hour and sample data collection every 15 minutes from the liquid in the small tube of the perfusion set. the second intervention was given 1 hour after the control intervention, which was the administration of glucose solution with different dosages of the leaves decoction in each group, with the same data collection method as the earlier control intervention. in the last 1 hour, 3 mm glucose solution was again administered as the third intervention to observe the recovery effect of the leaf decoction, and sample data was collected every 15 minutes from the liquid in the small tube of the perfusion set. the first group was given a dosage of 0.89 g/kgbw and the latter was given 1.33 g/kgbw. glucose concentration measurement was conducted by taking 50 μl sample, and then underwent a deproteinization process using 8% tca as much as 500 μl, continued with 3000 rpm centrifugation for 10 minutes. the supernatant was taken as much as 100 μl and then mixed with 1 ml ofreagent. the mixtures were then incubated for 10 minutes in a temperature of 37oc. absorbance was examined using the spectrophotometer with 505 nm wavelength. glucose concentration was measured using the st reagensia formula. the result was then converted into glucose concentration which described the amount absorbed. the data was then analyzed using the shapiro-wilk test for normality test and paired t-test for statistical test. the result was considered as significant if the value of p≤0.05. results the mean of glucose absorbed by rats in the first group with the entire subject of four rats (figure 1). the results were extracted from the measurement of each rat’s sample every 15 minutes for 1 hour after the consecutive administration of three interventions. in the control intervention, the glucose absorption increased in each measurement (in the first 15 minutes until the fourth). glucose accompanied by decoction as much as 0.8928 g/kgbw was administered after 1 hour, and the result showed a decrease in absorption of glucose at the small intestine compared to the control intervention (without decoction administration). it could be determined that the absorption impeded in rats which were given the decoction. lastly, 1 hour after the second intervention, the rats were given the glucose siti sakinah, diah dhianawaty, vita murniati tarawan: effects of ageratum conyzoides leaf decoction on glucose absorption in rat’s small intestine figure 2 mean of glucose absorbed concentration in group 2 althea medical journal. 2018;5(3) 136 amj september 2018 solution as the third intervention to observe the reversible effect of absorption reduction influenced by decoction administration. glucose absorption in the first 15 minutes until the fourth showed a decrease of absorption blockage effect of ageratum conyzoides leaves after the decoction administration was discontinued. the mean of absorbed glucose in the second group of four rats that were given three interventions (figure 2) showed that in the control glucose intervention, there was an increase in glucose absorption in every 15 minutes of measurements. the second intervention was given after 1 hour, which was the mixture of glucose and decoction with a dosage of 1.33 g/kgbw. the measurement for every 15 minutes showed a decreasing trend compared to glucose absorption in the earlier first hour, and so the result revealed that there was an absorption blockage effect after the administration of decoction. lastly, 1 hour after the second intervention, the rats were given the glucose solution again to observe the reversible effect of absorption blockage influenced by decoction administration. the result from the last intervention showed that the absorption blockage effect was reduced after the discontinuation of decoction administration. normality tests and statistical data analysis of the results was conducted four times (table 3 and 4). the normality test showed normal distribution in all data with normal value >0.05. the first and second analyses compared the mean of glucose in the control and glucose+decoction with two different dosages: the first dosage was 0.89 g/kgbw and the second was 1.33 g/kgbw, in order to observe the significance of the blockage effect. the administration of the leaf decoction was found to have an absorption blockage effect, even though it was not statistically significant (p≤0.05). the third and fourth analyses were conducted to find the ratio of glucose absorption in the control intervention and glucose administration after the decoction administration in both groups, group 1 and 2, and the result found was not considered as significant (p≤0.05). this finding could determine that the glucose absorption before and after the administration of the decoction table 1 normality tests (shapiro-wilk) group rats mean of glucose in control intervention for 1 hour in each rats (mg/dl) mean of glucose + decoct for 1 hour in each rats (mg/dl) mean of end last glucose for 1 hour in each rats (mg/dl) normal value 1 a 165.46 9.54 glucose in control = 0.24* glucose+decoct= 0.37* b 47.87 2.65 c 75.00 9.25 d 34.99 5.98 2 e 41.83 3.76 glucose in control = 0.17* glucose + decoct = 0.23* f 94.62 5.13 g 42.80 10.70 h 26.33 5.61 1 a 165.46 48.36 glucose in control = 0.09* last glucose = 0.06* b 47.87 34.98 c 75.00 111.20 d 34.99 41.86 2 e 41.83 55.07 glucose in control = 0,17* last glucose = 0,26* f 94.62 3.59 g 42.80 56.23 h 26.33 20.61 note: * data was normally distributed althea medical journal. 2018;5(3) 137 only showed a slight difference, meaning that glucose absorption returned as being quite high even after the administration of decoction. discussion absorption blockage inflicted by two different dosages of ageratum conyzoides leaf decoction was stated earlier in the previous study, which stated that one of the active substances inside the leaves, flavonoid, had a non-competitive inhibitor role towards glut-2 transporter.14 a similar finding was found in this study, even though the finding was not significant. in this study the mean of the gap between glucose absorbed concentration before given treatment and after given treatment in group 1 and 2 respectively were 73.97 mg/dl and 45.09 mg/dl. the insignificant result might be caused by the inaccuracy of the dosage or limited concentration of the active substance which was able to block glucose absorption contained in the preparation used in this study. an increase in glucose absorption after the cessation of decoction administration in both groups was also found in a previous study, which states that flavonoid is a noncompetitive inhibitor.14 this is one of the reversible inhibitors which is able to retrieve blocked function after the cessation of given inhibitory intervention. this study also has several limitations, including the limitation of time. the limited time for conducting the study caused the inability of examining the samples right after the samples were obtained. during this period, from sample collection until sample measurements, there possibly occurred changes which influenced the glucose concentration or other physical changes which may alter the study. ketamine used in this study is known for having an effect of decreasing the absorption ability of the intestine which may affect the result of the study.15 the contamination of instruments used for sample placements might also influence the measurement results. this limitation was suspected as the cause of ineligibility for the subjects to be enrolled in the study, so that the minimum sample size was not achieved (total subject for two groups had to be 12) since only 8 rats were able to fulfill the criteria because siti sakinah, diah dhianawaty, vita murniati tarawan: effects of ageratum conyzoides leaf decoction on glucose absorption in rat’s small intestine table 2 statistical data analyses group rats mean of glucose in control intervention for 1 hour in each rats (mg/dl) mean of glucose + decoct for 1 hour in each rats (mg/dl) mean of end last glucose for 1 hour in each rats (mg/dl) p value 1 a 165.46 9.54 0.08* b 47.87 2.65 c 75.00 9.25 d 34.99 5.98 2 e 41.83 3.76 0.059* f 94.62 5.13 g 42.80 10.70 h 26.33 5.61 1 a 165.46 48.36 0.479** b 47.87 34.98 c 75.00 111.20 d 34.99 41.86 2 e 41.83 55.07 0.533** f 94.62 3.59 g 42.80 56.23 h 26.33 20.61 note: * data was normally distributed althea medical journal. 2018;5(3) 138 amj september 2018 of this factor. the remaining rats were not included in the equation due to its condition which did not fitt in the glucose absorption theory where it must be in a positive value, while they were in a negative value). it can be concluded that leaves decoction of ageratum conyzoides in the dosage of 0.89 and 1.33 g/kgbw inhibit the glucose absorption in the small intestine of rats, eventhough the finding is not statistically significant (p≤0.05) the suggestion for further studies is to encourage the advance glucose absorption blockade test using ageratum conyzoides extract with other filtration method and/or higher concentration. this plant could be used as herbal medicine to prevent obesity in the further studies. references 1. gailliot mt, baumeister rf, dewall cn, maner jk, plant ea, tice dm, et al. selfcontrol relies on glucose as a limited energy source:willpower is more than a metaphor. j pers soc psychol. 2007;92(2):325–36. 2. sherwood l. human physiology: from cells to systems. 8th ed. pacific grove, california: brooks/cole; 2015. 3. bouret s, levin be, ozanne se. controlling energy and glucose homeostasis and the developmental origins of obesity genetic basis of obesity. am physiol soc. 2015;95(1):47–82. 4. goldberg ij. triglyceride: one molecule at the center of health and disease. bba mol cell biol lipids. 2012;1821(5):719–20. 5. klop b, elte jwf, cabezas mc. dyslipidemia in obesity: mechanisms and potential targets. nutrients. 2013;5(4):1218–40. 6. kementerian kesehatan republik indonesia. riset kesehatan dasar 2013. jakarta: kementerian kesehatan republik indonesia; 2013. 7. nasrin f. antioxidant and cytotoxic activities of ageratum conyzoides stems. int curr pharm j. 2013;2(2):33–7. 8. nyunai n, abdennebi e, bickii j, manguelladicoum ma. subacute antidiabetic properties of ageratum conyzoides leaves in diabetic rats. int j pharm sci res. 2015;6(4):1378–87. 9. pharm ij, res p, shekhar tc, anju g. a comprehensive review on ageratum conyzoides linn.(goat weed). int j pharm phytopharm res. 2012;1(6):391. 10. liu x, zhu l, tan j, zhou x, xiao l, yang x, et al. glucosidase inhibitory activity and antioxidant activity of flavonoid compound and triterpenoid compound from agrimonia pilosa ledeb. bmc complement altern med. 2014;14(1):1-10. 11. singh sb, devi wr, marina a, devi wi, swapana n, singh cb. ethnobotany , phytochemistry and pharmacology of ageratum conyzoides linn ( asteraceae ). j med plants res. 2013;7(8):371–85. 12. mosa r, cele n, mabhida s, shabalala s, penduka d, opoku a. in vivo antihyperglycemic activity of a lanosteryl triterpene from protorhus longifolia. molecules. 2015;20(7):13374–83. 13. babu pva, liu d, gilbert er. recent advances in understanding the antidiabetic actions of dietary flavonoids. j nutr biochem. 24(11):1777–89. 14. kwon o, eck p, chen s, corpe cp, lee j-h, kruhlak m, et al. inhibition of the intestinal glucose transporter glut2 by flavonoids. faseb j. 2007;21(2):366–77. 15. grifiin b, o’driscoll c. drug absorption studies in situ, in vitro and in silico models. in: ehrhardt c, kim k-j, editors. 1st ed. new york: spring; 2008. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 389 description of treatment outcomes among pulmonary tuberculosis patients in bandung city in 2014 syafinaz hamdan,1 enny rohmawaty,2 bony wiem lestari3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: pulmonary tuberculosis (pulmonary tb) is an infectious lung disease which is still a major health problem in the world. in indonesia, pulmonary tb treatment outcomes are monitored and assessed in directly observed treatment short course (dots) as an indicator of national tb control program performance. therefore, the study was conducted to determine the treatment outcomes among pulmonary tb patients in bandung city. methods: this cross-sectional study was conducted using secondary data. the sample sizes were 1,598 pulmonary tb patients taken by total sampling with data collected from tb registration database of bandung city at infectious disease control unit, bandung city health office (unit kontrol penyakit menular, dinas kesehatan kota bandung) from january to december 2014. the treatment outcomes were classified as successful (cured and treatment completed) and unsuccessful (failed, defaulted, and died). results: out of the 1,598 tb patients, most of the respondents were male, aged 15–24 years old and from public health center (pusat kesehatan masyarakat, puskesmas) and hospital. a total of 1,008 treatments (63.08%) were cured, 292 (18.27%) were completed, 47 (2.94%) were failed, 211 (13.21%) were defaulted, and 40 (2.50%) were died. total of transferred outpatients were 134 and not considered as treatment outcome. conclusions: from the results, it can be concluded that 81.35% and 18.65% were considered as successful and unsuccessful outcome respectively, thus, did not achieve who target of 85%. therefore, dots program implemented in bandung city should be reviewed to improve success rate of the treatment outcome. keywords: pulmonary tuberculosis, treatment outcome, type of healthcare correspondence: syafinaz hamdan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: syafinaz1906@gmail.com introduction tuberculosis (tb) is an infectious disease caused by tb bacteria (mycobacterium tuberculosis) which is still a major health problem in the world, estimated 9.6 million new tb cases reported globally in 2014 by world health organization (who).1 according to national tb prevalence survey in indonesia conducted from 2013 to 2014, the burden of tb disease in the country is high which per 100,000 population, an estimated incidence rate and prevalence rate of 403 and 660 has been reported.1 west java meanwhile recorded the highest number of pulmonary tb, comprising 18% compared to other provinces in indonesia. high tb case notification rate is also reported in 2013 by 102 per 100,000 population.2 the directly observed treatment short course (dots) strategy, which allows patients to take its daily drugs under the observation of health professionals, has been adopted by the ministry of health of indonesia since 1995. in its implementation, indicators such as minimum 70% of case detection rate (cdr), minimum 80% of conversion rate, and minimum 85% of cure rate have been set to monitor the achievement of the national tb control program.3 monitoring and evaluation of treatment outcomes of tb patients are an unseparated part of dots strategy in tb control programs. treatment outcomes success rate according to who has been standardized at 85%.1 to date, a few studies from different amj. 2017;4(3):389–95 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1187 althea medical journal. 2017;4(3) 390 amj september 2017 regencies of indonesia have reported the treatment outcomes. however, limited studies have been conducted in details for the treatment outcomes of new positive pulmonary tb patients based on sociodemographic characteristics of the patients and type of health care facilities involved. therefore, specific interest has been taken in count to study the treatment outcomes among pulmonary tb patients of bandung city in 2014 based on gender, age group, and type of health care facilities. methods this cross-sectional study was conducted using secondary data from tb registration database of bandung city from january to december 2014. this study was conducted at infectious disease control unit, bandung city health office (unit kontrol penyakit menular, dinas kesehatan kota bandung). populations in this study were all tb patients registered in tb registration database in bandung city. this study used total sampling technique to select 1,861 new pulmonary tb patients who were treated and registered in the database from january to december 2014. the inclusion criteria were registered tb patients aged ≥ 5 years old diagnosed as having pulmonary tb who got treatment from public health center (pusat kesehatan masyarakat, puskesmas), hospital, and private clinics. the exclusion criteria would be the incomplete records, which were data from community lung health center (balai besar kesehatan paru masyarakat, bbkpm) bandung, correctional facility (lembaga pemasyarakatan, lapas), and detention house (rumah tahanan, rutan). in this study, patients who were not evaluated or out of category in which tb patients without treatment outcomes were assigned as excluded from the treatment outcomes. hence, total sample of 1,598 new pulmonary tb patients were evaluated. figure 1 provided summary for the research subjects selection. variable of this study was the treatment outcomes that were classified into cured, treatment completed, failed, defaulted, and died in accordance with pedoman nasional pengendalian tuberkulosis, kementerian kesehatan republik indonesia, 2014.3 these were analyzed using descriptive analysis. treatment outcomes were further evaluated as categorical data as gender, age group, and type of health care facilities and presented as total number and percentage. gender was categorized as male and female. age group of patients were divided into; 5–14, 15–24, 25– 34, 35– 44, 45–54, 55–65, and ˃65. this study has been approved by health research ethics committee, faculty of medicine, universitas padjadjaran (no: 919/un6.c1.3.2/kepk/ pn/2016). results a total of 1,598 pulmonary tb patients data recorded from january to december 2014 were analyzed. table 1 shows patients characteristics classified into gender, age figure 1 summary of research subjects selection total number of new pulmonary tb patients registered in bandung city incomplete records from bbkpm, lapas & rutan transferred out patients (not evaluated) complete data to be analyzed n = 1861 n = 1,598 althea medical journal. 2017;4(3) 391 table 1 distribution of pulmonary tb patients based on gender, age group, type of health care, and treatment outcomes (n = 1,598) classified by frequency (n) percentage (%) gender male 876 54.82% female 722 45.18% age group 5 – 14 8 0.50% 15 – 24 416 26.03% 25 – 34 407 25.47% 35 – 44 308 19.27% 45 – 54 242 15.14% 55 – 65 158 9.90% > 65 59 3.69% type of health care puskesmas 897 56.13% hospital 697 43.62% private clinics 4 0.25% treatment outcomes cured 1008 63.08% treatment completed 292 18.27% failed 47 2.95% defaulted 211 13.20% died 40 2.50% type of treatment outcomes successful 1300 81.35% unsuccessful 298 18.65% syafinaz hamdan, enny rohmawaty, bony wiem lestari: description of treatment outcomes among pulmonary tuberculosis patients in bandung city in 2014 outcomes. discussions in this study, tb treatment success rate among new positive pulmonary tb patients was 81.35%. this was less than the treatment success rate target set by who.1 in 2014, national tb control program targeted the number of defaulted outcomes to be less than 5%.4 in this study, however, unsuccessful treatment outcomes were mostly from defaulted treatment amounted 211 (13.20%). this is somewhat comparable to the results of studies from cameroon5 (20%), libya6 (28%) and singapore7 (9%). this study also showed defaulted treatment was slightly higher in male, 117 (7.32%) compared to female, 94 group, and type of health care facilities from which they have been getting treatment and treatment outcomes. figure 2 shows tb treatment outcomes based on gender. there were 876 (54.82%) male patients, dominated subjects in this study. figure 3 describes that more than 60% of patients for every age group were fully cured. figure 4 shows the type of health care facilities, puskesmas shows majority in cured outcome which is 72.46% followed by hospitals, 51.22%. table 2 shows the overall pulmonary tb treatment outcomes which is grouped into successful and unsuccessful. a total of 1,300 (81.35%) patients were successfully treated (cured and treatment completed) and 298 (18.65%) were considered as unsuccessful althea medical journal. 2017;4(3) 392 amj september 2017 (5.88%). majority of the patients in this study were male, 876 (54.81%) similar to a study in western ethiopia8 which reported 54.5% of the patients are male. this might be due to men spent more money in accessing care than women which is related to their ability to pay.9 females are described to be less likely to visit health care facilities (health post, clinic, public health center, and hospitals) than males.10 several studies also showed that risk of pulmonary tb is greater in males than in females. this might be due to higher proportion of males carrying out more activities than females, thus, being exposed to the infection area is greater in males.11,12 smoking behavior in males meanwhile could lower the immune system and increase the risk for relapse case of pulmonary tb.13 in this study, treatment success rate for females (81.44%) were slightly figure 2 treatment outcomes based on gender figure 3 treatment outcomes based on age group 70% 60% 50% 40% 30% cured treatment completed failed defaulted died male female 70% 60% 50% 40% 30% 5-14 15 24 25 34 35 44 45 54 55 65 > 65 cured treatment completed failed defaulted died althea medical journal. 2017;4(3) 393 higher than that for males (81.28%). although there is no difference in the result, other studies found that smokers, especially males smokers, are less adherent to anti-tuberculosis treatment, and therefore, at higher risk for poor treatment outcomes.14 likewise, a study in south korean15 (2009) stated that there is an increased risk of tb incident associated with smoking behavior in which male smokers have an approximately 50% increase in risk. in this study, 85.91% of the registered new tb patients were included in the age range of productive age group between 15–54 years as shown in table 1, which is figure 4 treatment outcomes based on type of facilities syafinaz hamdan, enny rohmawaty, bony wiem lestari: description of treatment outcomes among pulmonary tuberculosis patients in bandung city in 2014 70% 60% 50% 40% 30% puskesmas hospital private clinics cured treatment completed failed defaulted died table 2 overall tb treatment outcomes of pulmonary tb (n = 1,598) classified by successful unsuccessful total n % n % gender male 712 81.28% 164 18.72% 876 female 588 81.44% 134 18.56% 722 age group 5 – 14 7 87.50% 1 12.50% 8 15 – 24 339 81.49% 77 18.51% 416 25 – 34 331 81.33% 76 18.67% 407 35 – 44 250 81.17% 58 18.83% 308 45 – 54 197 81.40% 45 18.60% 242 55 – 65 128 81.01% 30 18.99% 158 > 65 48 81.36% 11 18.64% 59 type of health care puskesmas 780 86.96% 117 13.04% 897 hospital 518 74.32% 179 25.68% 697 private clinics 2 50.00% 2 50.00% 4 althea medical journal. 2017;4(3) 394 amj september 2017 similar to studies from southern ethiopia16, malaysia17, and ethiopia.18 non productive age group around above 50 years old is usually more complicated in tb treatment due to medication of other systemic diseases causing increased side effects, increased re-treatment cases, and resistance to anti-tuberculosis drug. this might be due to reduced absorption of drug related with physiological changes in the body as age increases and strength to fight infections decreases.19 this study also revealed the number of registered tb patients based on type of health care facilities consisting of puskesmas, hospitals, and private clinics. more than half of the patients, 897 (56.13%) were getting treatment from puskesmas, followed by hospitals, 697 (43.62%). in indonesia, the government has set the policy for puskesmas to be the primary healthcare service to the society, thus, making it more accessible to every districts and sub-districts and economically affordable.2 table 2 showed that 86.96% of successful treatment was from puskesmas compared to 74.32% recorded from hospitals. also, there were only 13.04% unsuccessful treatment outcomes from puskesmas compared to that from hospital of 25.68%. this clearly showed that tb treatment program in puskesmas was more efficient than that in hospital. national tb control strategy in indonesia 2010–2014 reported that the number of tb drug resistance in patients treated in health care facilities was generally still low. however, most of the data were obtained from puskesmas which implemented proper dots strategy in the last five years. this is because probability of the occurrence of tb drug resistance is higher in hospitals and in private sector who have not been engaged in national tb control programs due to high level of non-compliance and drop out treatment for not implementing the dots strategy.20 it was also reported that about 98% of staff in puskesmas are well-trained with tb control program compared to 24% of hospital staff.4 successful treatment outcomes among pulmonary tb patients in bandung city in 2014 are 81.35%. comparably (78.5%) successful outcomes have been reported from malaysia17 while other studies from addis ababa, ethiopia18 also reported treatment success rate of 82.7%. this is somehow still below the standard set by who which is 85%. the possible reason behind this problem is decentralized health care facilities that negatively affect human resource capacity and development of tb control programs. factors such as limited number of staff, rotation of staff, and continuity between training programs are among the challenges in human resource development. monitoring and evaluation also should be done through supervision activities at various levels. however, due to lack of resources (human resource, finance, and logistic), supervision is not carried out regularly. besides, limitation of access to the quality service of dots are also found especially in population of economically unaffordable society in urban areas.4 the limitation of this study is the limited number of variables obtained from the database. information on other factors such as education level, place of residence, smoking, occupational status, chronic disease, and other sociocultural factors that could also affect the treatment outcome was not available in the register. this study is also dependent on secondary data collected from the database, and any error or incompletion during the data entry process cannot be detected. suggestion for the next study is to explore the factors that can affect the treatment outcomes with a bigger population and a longer study period. this shall yield a better trend of outcomes and shall give more input of the pattern of the tb treatments. by knowing the treatment outcomes, it shows that pulmonary tb is still a serious public health concern that needs to be addressed urgently in bandung city. to improve treatment outcome of tuberculosis patients, improved and systematically implementation of supervision and monitoring the clinical improvement of patients with risk factors should be done to increase the cure rate. similarly, forceful effort in following up the treatment defaulters and transferred out patients should be done and health education are also recommended to reduce unfavorable treatment outcomes. references 1. who. global tuberculosis report 2015. 20th ed. geneva: who press; 2015. 2. kementerian kesehatan republik indonesia. laporan kinerja triwulan iii direktorat jenderal pencegahan dan pengendalian penyakit. jakarta: kementerian kesehatan republik indonesia; 2013. 3. kementerian kesehatan republik indonesia. pedoman nasional pengendalian tuberkulosis. jakarta: althea medical journal. 2017;4(3) 395 direktorat jenderal p2pl (pengendalian penyakit dan penyehatan lingkungan); 2014. 4. kementerian kesehatan republik indonesia. strategi nasional pengendalian tuberkulosis di indonesia 2010-2014. jakarta: direktorat jenderal pengendalian penyakit dan penyehatan lingkunga; 2011. 5. pefura yone ew, kuaban c, kengne ap. hiv testing, hiv status and outcomes of treatment for tuberculosis in a major diagnosis and treatment centre in yaounde, cameroon: a retrospective cohort study. bmc infect dis. 2012;12:190–7. 6. solliman ma, hassali ma, al-haddad ms, sulaiman sas, shafie aa, atif m, et al. treatment outcomes of new smear positive pulmonary tuberculosis patients in north east libya. lat am j pharm. 2012;31(4):567–73. 7. chee cb, wang yt, teleman md, boudville ic, chew sk. treatment outcome of singapore residents with pulmonary tuberculosis in the first year after introduction of a computerised treatment surveillance module. singapore med j. 2006;47(6):529–33. 8. demeke d, legesse m, bati j. trend of tuberculosis and treatment outcomes in gambella region with special emphasize on gambella regional hospital, western ethiopia. j mycobac dis. 2013;3(2):130. 9. aspler a, menzies d, oxlade o, banda j, mwenge l, godfrey-faussett p, et al. cost of tuberculosis diagnosis and treatment from the patient perspective in lusaka, zambia. int j tuberc lung dis, 2008;12(8):928–35. 10. yimer s, holm-hansen c, yimaldu t, bjune g. health care seeking among pulmonary tuberculosis suspects and patients in rural ethiopia: a community-based study. bmc public health,. 2009;9(1):454–63. 11. somma d, thomas be, karim f, kemp j, arias n, auer c, et al. gender and sociocultural determinants of tb-related stigma in bangladesh, india, malawi and colombia. int j tuberc lung dis.2008;12(7):856–66. 12. karim f, ahmed f, begum i, johansson e, diwan vk. female-male differences at various clinical steps of tuberculosis management in rural bangladesh. int j tuberc lung dis. 2008;12(11):1336–9. 13. ng n, padmawati rs, prabandari ys, nichter m. smoking behavior among former tuberculosis patients in indonesia: intervention is needed. int j tuberc lung dis. 2008;12(5):567–72. 14. lavigne m, rocher i, steensma c, brassard p. the impact of smoking on adherence to treatment for latent tuberculosis infection. bmc public health. 2006;6:66. 15. jee sh, golub je, jo j, park is, ohrr h, samet jm. smoking and risk of tuberculosis incidence, mortality, and recurrence in south korean men and women. am j epidemiol. 2009;170(12):1478–85. 16. gebrezgabiher g, romha g, ejeta e, asebe g, zemene e, ameni g. treatment outcome of tuberculosis patients under directly observed treatment short course and factors affecting outcome in southern ethiopia: a five-year retrospective study. plos one. 2016;11(2):e0150560. 17. liew s, khoo e, ho b, lee y, mimi o, fazlina m, et al. tuberculosis in malaysia: predictors of treatment outcomes in a national registry. int j tuberc lung dis. 2015;19(7):764–71. 18. getahun b, amani g, medhin g, biadgilign s. treatment outcome of tuberculosis patients under directly observed treatment in addis ababa, ethiopia. brazilian j infect dis. 2013;17(5):521–8. 19. puspasari n. karakteristik pasien tuberkulosis yang memperoleh pengobatan kategori 2 di up4 provinsi kalimantan barat tahun 2009-2012. jurnal mahasiswa pspd fk universitas tanjungpura. 2014;1(1):1–28. 20. atif m, sulaiman sa, shafie aa, ali i, asif m, babar zu. treatment outcome of new smear positive pulmonary tuberculosis patients in penang, malaysia. bmc infect dis. 2014;14(1):399 syafinaz hamdan, enny rohmawaty, bony wiem lestari: description of treatment outcomes among pulmonary tuberculosis patients in bandung city in 2014 vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 168 amj december 2018 vitamin d levels in chronic kidney disease stage 3, 4, and 5 david kristianus,1 rudi supriyadi,2 siska wiramihardja3 1faculty of medicine universitas padjadjaran, indonesia 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: david kristianus, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: david.kristianus97@gmail.com introduction chronic kidney disease (ckd) is abnormalities of kidney structure or function for more than 3 months.1 about 10% of the world’s population suffer from ckd, and every year there are millions of people die from its complications.2 the results of global burden of disease study in 2010 showed that ckd experienced an increase in the ranking of causes of death in the world, from 27th to 18th in 1990-2010.3 as one of non-communicable diseases, ckd is a health problem that is still increasing in indonesia. based on indonesia basic health research (riset kesehatan dasar) 2013, the prevalence of ckd increased along with increasing life expectancy with a peak at over 75 years of age.4 chronic kidney disease occurs when there is decreased glomerular filtration rate (gfr) for more than 3 months, namely gfr <60 ml/min/1.73m2 which indicates ckd stage 3-5.1 at those stages, the decreased gfr has caused various complications, one of which is hypovitaminosis d which includes vitamin d deficiency (25(oh)d <20 ng/ml) and vitamin d insufficiency (25(oh)d <30 ng/ml).5-7 a decrease in gfr that occurs along with advancing stages of ckd may cause a decrease in vitamin d levels in patients with ckd through/ decreased 25(oh)d (25-hydroxyvitamin d/ calcidiol) supply into the kidney, increased fibroblast growth factor-23 (fgf-23) level, and reduced megalin receptor function inside proximal convoluted tubule (pct).1,6,8 hypovitaminosis d is also common in the general population including indonesia. about 75% of healthy children aged 7 to 12 years in indonesia experience vitamin d insufficiency amj. 2018;5(4):168–74 abstract background: hypovitaminosis d is highly prevalent in chronic kidney disease (ckd). this conditionmay increase ckd progression and cause various complications, since kidney has a pivotal role in metabolizing the vitamin d. the aim of this study was to find the difference in vitamin d levels among ckd stage 3 to 5. methods: a cross-sectional study involving patients aged over 18 years with ckd stage 3 to 5 who visited dr. hasan sadikin general hospital, dustira hospital, and kidney special hospital ny. r.a. habibie in 2017 was conducted. ckd stages were determined based on glomerular filtration rate (gfr). kruskal-wallis test was used to analyzethe difference in vitamin d levels among ckd stage 3 to 5. results: one hundred subjects consisting of 57 men and 43 women met the study criteria. there were 97% of subjects experienced hypovitaminosis d, with 20% having vitamin d insufficiency and 77% having vitamin d deficiency. in subjects with vitamin d insufficiency, a decrease in the mean vitamin d levels was observed along with advancing stages of ckd (p=0.255). no vitamin d level difference was observed among ckd stage 3 to 5 [11.1 (3.8-27.7) ng/ml vs 14.45 (5.10-50.90) ng/ml vs 11.7 (4.238.0) ng/ml, p>0.05]. conclusions: there is no difference in vitamin d levels among ckd stage 3, 4 and 5. keywords: chronic kidney disease, deficiency, vitamin d althea medical journal. 2018;5(4) 169 and 15% experience vitamin d deficiency.9 while in ckd, 70–80% patients experience vitamin d deficiency.10 hypovitaminosis d in ckd may increase ckd progression, as well as morbidity and mortality.6,11 hypovitaminosis d may also cause mineral and bone disorder which leads to osteopenia and osteoporosis that may increase the risk of fracture.12,13 therefore, mineral and bone disorder may cause disability and reduce the quality of life of patients with ckd. kidney disease itself is a disease with the second largest funding from healthcare and social security agency (badan penyelenggara jaminan sosial kesehatan, bpjs kesehatan) after heart disease.4 the mineral and bone disorder will certainly increase the burden of health costs in indonesia. based on above explanation, it is important to know vitamin d levels difference among stages of ckd. this study aimed to determine the vitamin d levels difference among ckd stage 3, 4 and 5, and is expected to add information and data about vitamin d level in ckd so that it canprovide information to help determine cut-off point of vitamin d and proper vitamin d therapy in predialysis ckd. methods this study was a cross-sectional study with comparative analysis conducted in april– august 2018, and carried out using secondary data from previous studies taken from dr. hasan sadikin general hospital, dustira hospital, and kidney special hospital ny. r.a. habibie in 2017. the subjects were patients participated in previous research entitled “correlation of total antioxidant capacity, vitamin d, calcium, and sclerostin to body composition of patients with ckd stage 3-5”. this study was approved by the health research ethics committee universitas padjajaran bandung (no.295/un6.kep/ec/2018). inclusion criteria of this study were all data of patients over the age of 18 who had a diagnosis of ckd stage 3–5. exclusion criteria of this study were patients who had undergone hemodialysis; patients who had a diagnosis of severe diseases, infectious diseases, and malignancy; patients who regularly consumed supplements of antioxidants, vitamin d and calcium; and incomplete patient data, namely data that did not include the variables sought, including vitamin d level and stage of ckd. research variables used in this study include: an independent variable, namely stage of ckd; a dependent variable, namely vitamin d (25(oh)d) level; and confounding variables namely age, gender, and body mass index (bmi). the stage of ckd was determined based on the glomerular filtration rate (gfr) in accordance with kidney disease improving global outcomes (kdigo) 2012 clinical practice guideline for the evaluation and management of chronic kidney disease (stage 3–gfr=30-59 ml/min/1.73m2; stage 4– gfr=15-29 ml/min/1.73m2; stage 5–gfr <15 ml/min/1.73m2).1 the gfr was calculated using the chronic kidney disease epidemiology collaboration (ckd-epi) creatinine equation. vitamin d (25(oh)d) level was measured using chemiluminescent microparticle immunoassay from architect 25-oh vitamin d assay. then, the vitamin d level was categorized as normal (25(oh)d = 30-100 ng/ ml), insufficiency (25(oh)d <30 ng/ml), and deficiency (25(oh)d <20 ng/ml).7 sampling method used in this study was total sampling, in which all samples contained in secondary data were collected. the collected data were then grouped according to stage of ckd. then, to see the difference in vitamin d levels among stages of ckd, kruskalwallis test was performed. hypothesis testing revealed significant results if p <0.05. multiple linear regression analysis was also conducted to control confounding variables (age and bmi). the data were analyzed using ibm spss statistics 25. results the number of subjects who met the criteria of this study was 100 subjects. table 1 shows characteristics of study sample which grouped according to the stages of ckd. most subjects with ckd stage 3, 4 and 5 were found to bemale. subjects with ckd stage 4 were found to have the highest median age of 65 years, while subjects with ckd stage 3 had the lowest median age of 54 years. most patients with ckd stage 3, 4 and 5 had over 50 years of age. there was a significant age difference among ckd stage 3, 4 and 5 (p=0.002) and there was a significant correlation between age and ckd stages (p=0.013). table 2 shows vitamin d levels (25(oh) d) in patients with ckd stages 3, 4, and 5. the overall median of vitamin d level in this study was 12.25 (3.80-50.90) ng/ml. subjects with ckd stage 4 had the highest median vitamin d of 14.45 ng/ml, whereas subjects with ckd stage 3 had the lowest median vitamin d of 11.1 ng/ml. the results david kristianus, rudi supriyadi, siska wiramihardja: vitamin d levels in chronic kidney disease stage 3, 4, and 5 althea medical journal. 2018;5(4) 170 amj december 2018 showed no significant difference in vitamin d (25(oh)d) levels among ckd stage 3, 4, and 5 (p=0.089). most subjects with ckd stage 3, 4, and 5 ckd had vitamin d deficiency, and there were no subjects who had normal vitamin d level in subjects with ckd stage 3. in subjects with vitamin d insufficiency, the highest mean of vitamin d level was found in ckd stage 3, while the lowest mean of vitamin d level was found in ckd stage 5. in subjects with vitamin d deficiency, the highest mean of vitamin d level was found in ckd stage 4, while the lowest mean of vitamin d level was found in ckd stage 3. in those subjects, there was also an increase in the number of subjects with advancing stages of ckd. in subjects with vitamin d insufficiency and deficiency, there were no significant differences in vitamin d levels among ckd stage 3, 4 and 5 (p=0.255 and p=0.596), but in subjects with vitamin d insufficiency there was a decrease in mean vitamin d levels with advancing stages of ckd. figure 1 shows a graph of vitamin d (25(oh)d) levels in ckd stage 3, 4, and 5. in the graph, it was found that most subjects with ckd stage 3, 4, and 5 had vitamin d (25(oh) d) levels below 30 ng/ml, particularly below 20 ng/ml. figure 2 shows a graph of the number of subjects based on hypovitaminosis d category in ckd stage 3, 4, and 5. in the graph, it was found that there was an increase in the number of subjects with vitamin d deficiency along with advancing stages of ckd. table 3 shows the result of multiple linear regression test to control confounding variables. after multivariate test was performed to control confounding variables (bmi and age), the result showed that there was no significant difference in vitamin d levels among ckd stage 3, 4 and 5 (p=0.335 and p=0.736). the classical assumption test showed that there was no multicollinearity and error distribution had not followed table 2 vitamin d (25(oh)d) levels in ckd stage 3, 4, and 5 ckd p value stage 3 stage 4 stage 5 vitamin d levels (ng/ml),median (min-max) 11.1 (3.8-27.7) 14.45 (5.10-50.90) 11.7 (4.2-38.0) 0.089* normal, n(%) 0 (0%) 2 (5.9%) 1 (2.2%) vitamin d levels (ng/ml), x̅±sd 41.75±12.94 38 insufficiency, n(%) 4 (19%) 10 (29.4%) 6 (13.3%) vitamin d levels (ng/nl), x̅±sd 24.38±2.62 23.35±2.48 21.95±1.43 0.255** deficiency, n(%) 17 (81%) 22 (64.7%) 38 (84.4%) vitamin d levels (ng/ml), x̅±sd 10.14±3.99 11.42±3.97 10.62±4.06 0.596** note:*kruskal-wallis test; **one-way anova test; ckd, chronic kidney disease table 1 subject characteristics according to ckd stages characteristics ckd p valuestage 3 (n=21) stage 4 (n=34) stage 5 (n=45) gender, n(%) male 11(52.38%) 21(61.76%) 25(55.56%) 0.765* female 10(47.62%) 13(38.24%) 20(44.44%) age (years),median (min-max) 54 (24-69) 65 (28-77) 59 (33-78) 0.002** >50 year, n(%) 11(52.4%) 30(88.2%) 32 (71.1%) 0.013* ≤50 year, n(%) 10 (47.6%) 4 (11.8%) 13(28.9%) bmi, median (min-max) 23.75(17.65-37.99) 24.39(18.75-36.36) 22.11 (10.54-35.39) 0.067** note:*chi-square test; **kruskal-wallis test; bmi, body mass index; ckd, chronic kidney disease althea medical journal. 2018;5(4) 171 table 3 multiple linear regression analysis with vitamin d level as the dependent variable n=100) predictor variables β value p value confidence interval 95% lower bound upper bound constant 1.835 <0.001 0.939 2.732 stage 3vs4 0.146 0.335 -0.152 0.444 stage 3vs5 -0.047 0.736 -0.321 0.228 bmi -0.002 0.845 -0.026 0.021 age 0.012 0.022 0.002 0.022 note:dependent variable=vitamin d; bmi, body mass index; ckd, chronic kidney disease david kristianus, rudi supriyadi, siska wiramihardja: vitamin d levels in chronic kidney disease stage 3, 4, and 5 normal distribution pattern. transformation of the dependent variable was needed so that the error distribution followed the normal distribution pattern. discussion based on the results of the study, it was known that the general characteristics of the study subjects were predominantly male and most had an age above 50 years (table 1). these results are consistent with the results of research conducted by diniz et al.14 in brazil involving 125 subjects with ckd who had an average age of 57.4 years and 55% of subjects were male. these results are also consistent with the results of research conducted by rozita et al.15 in malaysia involving 50 subjects with ckd who had an average age of 53 years and 58% of the subjects were male. the result of this study also showed a correlation between age and ckd stages. ckd is more common in older age due to decreased renal function with increasing age and the presence of various risk factors for ckd such as diabetes and hypertension in older individuals.16 vitamin d (25(oh)d) level in the body can be classified into 3 categories: normal, insufficiency, and deficiency. vitamin d level is classified as normal if the 25(oh) d concentration in the body is 30–100 ng/ ml. vitamin d insufficiency occurs when 25(oh)d concentration is below 30 ng/ ml, while vitamin d deficiency occurs when 25(oh)d concentration is below 20 ng/ml.7 based on the results of the study, there was no significant difference in vitamin d levels among ckd degrees 3, 4 and 5 (table 3), but the results showed that almost all (97%) study subjects had hypovitaminosis d (table 2). hypovitaminosis d had occurred from ckd stage 3, and most subjects with ckd stage 3, 4, and 5 had vitamin d deficiency. these results are consistent with the research conducted by rozita et al.15 in malaysia involving 50 subjects with ckd stage 2-4 and showed vitamin d deficiency was found in ckd stage 2, 3, and 4 with a mean 25(oh)d levels of 15.7 ng/ml, 16.5 ng/ml, and 15.5 ng/ml, respectively, and also there was no significant difference figure 1 graph of vitamin d (25(oh)d) levels in ckd stage 3, 4, and 5 althea medical journal. 2018;5(4) 172 amj december 2018 in vitamin d levels among ckd stage 2, 3 and 4. these results are also consistent with the results of research conducted by diniz et al.14 in brazil involving 125 subjects with ckd stage 2–5 and showed the majority of subjects had 25(oh)d levels below 30 ng/ml and also there was no significant difference in vitamin d levels among ckd stage 2–5. similar results are also found in children with ckd. study conducted by lee et al.17 in south korea involving 113 children aged 1–18 years with ckd stage 2–5 showed that most subjects had 25(oh)d levels below 30 ng/ml. hypovitaminosis d is a common problem in the general population. the prevalence of vitamin d deficiency in south asia is about 70% or higher, while the prevalence of vitamin d deficiency in southeast asia varies from 6–70%.18 hypovitaminosis d is also quite common in indonesia characterized by 75.8% of healthy children aged 7–12 years old experience vitamin d insufficiency and 15% experience vitamin d deficiency.9 hypovitaminosis d occurs in the general population in indonesia even though indonesia receives a lot of sunlight because it is located in the equatorial region. in addition, ckd can also cause decreased vitamin d level.6 the occurrence of ckd will certainly cause a decrease in vitamin d levels in the community. this is evidenced by the results of research conducted by rozita et al.15 stating that in subjects with vitamin d deficiency, it was found that 25(oh)d levels were significantly lower in the group of subjects with ckd compared to the control group. hypovitaminosis d in ckd may cause worsening renal function, increased ckd progression, and increased morbidity and mortality. this is because vitamin d has renoprotective effects that can reduce inflammation in the kidney, produce antifibrotic and antiapoptotic effects, prevent podocyte damage, and reduce intraglomerular pressure.6,11 based on the results of the study, there was no significant difference in vitamin d levels among ckd stage 3, 4, and 5, but it was found that there was an increase in the number of subjects with vitamin d deficiency along with advancing stages of ckd and a decrease in the mean 25(oh)d levels along with advancing stages of ckd in the group of subjects with vitamin d insufficiency (table 2). increased stages of ckd indicate a decrease in gfr as a marker of renal filtration function.1 a decrease in gfr may cause a decrease in vitamin d level. decreased gfr may cause a decrease in supply of 25(oh)d to proximal convoluted tubule (pct), an increase in fibroblast growth factor-23 (fgf-23) level in the body, and a decrease in megalin receptor function in pct.6,8 a decrease in the supply of 25(oh)d to pct cells may cause a decrease in the synthesis of 1,25(oh)2d (1,25-dihydroxyvitamin d/ calcitriol).8 elevated fgf-23 level may be caused by hyperphosphatemia. this may results from a decrease in renal phosphate excretion which occurs along with decreasing gfr.5 increased level of fgf-23 may cause synthesis of 1,25 (oh)2d decreases due to disruption of 1α-hydroxylase enzyme activity. the increased fgf-23 level may also promote the degradation of vitamin d (25(oh)d and 1,25(oh)2d) due to the figure 2 graph of the number of subjects based on hypovitaminosis d category in ckd stage 3, 4, and 5 althea medical journal. 2018;5(4) 173 increase of 24-hydroxylase enzyme activity.6 megalin receptors require active vitamin d to work properly, so a decrease in 1,25(oh)2d level in the body may reduce the function of the megalin receptor in 25(oh)d tubular reabsorption.6,8 decreased function of megalin receptors may causes loss of 25(oh)d-vitamin d binding protein complex in urine. this leads to a decrease in the levels of 25(oh)d and 1,25(oh)2d in the body.6 based on these mechanisms, it was hypothesized that there was a difference in vitamin d levels among ckd stages. the high prevalence of hypovitaminosis d in the general population in indonesia may cause decreased vitamin d levels that occur in ckd patients does not show a significant difference. in addition, based on the results of the study, there was no decrease in vitamin d levels with advancing stages of ckd, whereas ckd stage 3 had the lowest median of vitamin d and ckd stage 4 had the highest median of vitamin d. this may be caused by factors not measured in this study that may affect vitamin d levels in this study, such as sun exposure, skin pigmentation, and the use of sunscreen.19 hypovitaminosis d may cause mineral and bone disorder in chronic kidney diseasemineral and bone disorder (ckd-mbd), decreased intestinal calcium absorption and renal calcium reabsorption which induce hypocalcemia. hypocalcaemia may promote increased parathyroid hormone production which causes secondary hyperparathyroidism.12 high bone turnover due to secondary hyperparathyroidism leads to high bone resorption (higher than bone formation) that induces hypercalcaemia, hyperphosphatemia, osteopenia and osteoporosis.12,13 cardiovascular disease in form of vascular wall calcifications may occur due to hyperphosphatemia and hypercalcaemia.5 calcification and stiffness of blood vessels may cause increased systolic blood pressure and left ventricular hypertrophy.13 the results of this study indicate that there was hypovitaminosis d starting from ckd stage 3 (table 2). this study did not measure vitamin d levels in ckd stage 1 and 2 because at those stages, there are no signs and symptoms of ckd yet.5 research conducted by diniz et al.14 and rozita et al.15 also showed that hypovitaminosis d had occurred since ckd stage 2. it is important to note that there are no studies that have measured normal value of vitamin d level for indonesians. based on the results of these studies, vitamin d (25(oh)d) testing as well as vitamin d supplementation in patients with ckd can be started from ckd stage 3 or earlier. if hypovitaminosis d is found, it is important to immediately provide vitamin d supplements to reduce ckd progression, prevent mineral and bone disorder, and reduce the risk of all-cause and cardiovascular mortality.14,20 these things can be achieved through several effects of vitamin d, namely reducing the renin-angiotensin system, increasing insulin secretion and sensitivity, preventing proliferation vascular smooth muscle cells proliferation, protecting normal endothelial cells function, controlling inflammatory processes, preventing myocardial cells proliferation and hypertrophy, and inhibiting anticoagulants activity.20 renoprotective activity of vitamin d may also reduce proteinuria and repair kidney damage by decreasing the renin-angiotensin system, decreasing activation of nf-κb (nuclear factorkappab) transcription factors, inhibiting wnt/β-catenin pathway, and maintaining the integrity of slit diaphragm and protecting glomerular filtration membrane.11 the limitation of this study is that the factors that can affect vitamin d levels in patients with ckd were not measured. these factors include factors that can affect vitamin d production in the skin such as sun exposure (can be measured through daily activities or types of clothing that are often used), skin pigmentation/race and sunscreen use. therefore, hypovitaminosis d in the subjects of this study was not solely caused by decreased gfr alone, but there were various other influential factors (confounding factors) that were not measured in this study. substantially based on theory and literature, there is difference in vitamin d levels among ckd stage 3, 4, and 5, but statistically this study showed a conclusion that is not significant to the hypothesis made. based on the results of the study it can be concluded that there is no difference in vitamin d levels among ckd stage 3, 4, and 5, but hypovitaminosis d can be found since ckd stage 3 to 5 so that examination of vitamin d level and vitamin d supplementation are important things to do. various limitations found in this study cause the results of the study could not significantly detect difference in vitamin d levels among stages of ckd. thus, further research is needed by paying attention to and taking into account other factors that can affect vitamin d levels in patients with ckd. david kristianus, rudi supriyadi, siska wiramihardja: vitamin d levels in chronic kidney disease stage 3, 4, and 5 althea medical journal. 2018;5(4) 174 amj december 2018 references 1. eknoyan g, lameire n, eckardt k, kasiske b, wheeler d, levin a, et al. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney int. 2013;3(1):1– 150. 2. world kidney day. world kidney day: chronic kidney disease. 2018. [cited 2018 august 5]. available from: http://www. worldkidneyday.org/faqs/chronic-kidneydisease/. 3. lozano r, naghavi m, foreman k, lim s, shibuya k, aboyans v, et al. global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. lancet. 2012;380(9859):2095–128. 4. kementrian kesehatan republik indonesia. pusat data dan informasi kementrian kesehatan republik indonesia: situasi penyakit ginjal kronis. jakarta: kementrian kesehatan republik indonesia; 2017. 5. bargman jm, skorecki k. chronic kidney disease. in: kasper dl, fauci as, hauser sl, longo dl, jameson jl, loscalzo j, editors. harrison’s principles of internal medicine. 19th ed. new york: mcgraw-hill education; 2015. p. 1811–21. 6. kim cs, kim sw. vitamin d and chronic kidney disease. korean j intern med. 2014;29(4):416–27. 7. holick mf, binkley nc, bischoff-ferrari ha, gordon cm, hanley da, heaney rp, et al. evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. j clin endocrinol metab. 2011;96(7):1911–30. 8. inda filho aj, melamed ml. vitamin d and kidney disease: what we know and what we do not know. j bras nefrol. 2013;35(4):323–31. 9. soesanti f, pulungan a, tridjaja b, batubara jr. vitamin d profile in healthy children aged 7-12 years old in indonesia. int j pediatr endocrinol. 2013;2013(suppl 1):p167. 10. nigwekar su, tamez h, thadhani ri. vitamin d and chronic kidney diseasemineral bone disease (ckd-mbd). bonekey rep. 2014;3:498–503. 11. li yc. vitamin d in chronic kidney disease. contrib nephrol. 2013;180:98–109. 12. mac way f, lessard m, lafage-proust mh. pathophysiology of chronic kidney disease-mineral and bone disorder. joint bone spine. 2012;79(6):544–9. 13. seifert me, hruska ka. the kidneyvascular-bone axis in the chronic kidney disease-mineral bone disorder. transplantation. 2016;100(3):497–505. 14. diniz hf, romao mf, elias rm, romao junior je. vitamin d deficiency and insufficiency in patients with chronic kidney disease. j bras nefrol. 2012;34(1):58–63. 15. rozita m, afidza mn, ruslinda m, cader r, halim ag, kong ctn, et al. serum vitamin d levels in patients with chronic kidney disease. excli j. 2013;12:511–20. 16. prakash s, o’hare am. interaction of aging and chronic kidney disease. semin nephrol. 2009;29(5):497–503. 17. lee k, lee s, cho h. optimal vitamin d levels in children with chronic kidney disease. j nephrol ther. 2015;5(4):207–10. 18. nimitphong h, holick mf. vitamin d status and sun exposure in southeast asia. dermatoendocrinol. 2013;5(1):34–7. 19. tsiaras wg, weinstock ma. factors influencing vitamin d status. acta derm venereol. 2011;91(2):115–24. 20. zheng z, shi h, jia j, li d, lin s. vitamin d supplementation and mortality risk in chronic kidney disease: a meta-analysis of 20 observational studies. bmc nephrol. 2013;14(1):199–211. vol 4 no 3 full text final.indd althea medical journal. 2017;4(3) 474 amj september 2017 characteristics of patients who underwent mastoidectomy: a two years experience ashwini gunasekaran,1 sally mahdiani,2 fifi veronica3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology–head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, physiology and biology cell faculty of medicine universitas padjadjaran abstract background: mastoidectomy is a surgical procedure to remove an infected portion of the bone behind the ear called mastoiditis when medical treatment is not effective. patients with chronic suppurative otitis media (csom) complications mostly need this surgery in order to maintain the normal function of hearing. chronic mastoiditis and cholesteatoma are the most common indications of csom. this study was conducted to identify the characteristics of patients who underwent mastoidectomy at dr. hasan sadikin general hospital, from 2012– 2013. methods: a descriptive study using total sampling method was conducted. data were collected from medical records of 41 patients who underwent mastoidectomy at dr. hasan sadikin general hospital from 2012– 2013. inclusion criteria were medical records of patients who underwent mastoidectomy, and consisted of variables studied, such as age, gender, chief complaint, main etiology, method of surgery, and presence of abnormalities in the structure of middle ear. incomplete medical records were excluded. the collected data were presented using percentage. results: age ranged from 15–64 years (85.37%), male patients were higher (65.9%) compared to female patients (34.1%). otorrhea (70.73%) was the main chief complaint and infection (100%) was the main cause. majority of patients had canal wall down (cwd) surgery (63.41%) and many abnormalities were found in the inner ear structure during the surgery. conclusions: infection is the only cause and otorrhea is the main indication for mastoidectomy. most patients have been operated with cwd technique. keywords: ear infection, inner ear structure abnormalities, mastoidectomy introduction it has been known that chronic otitis media (com) has become one of the most common pediatric infectious diseases in this new era. incidence of chronic suppurative otitis media (csom) is high in developing countries, with the highest prevalence of complications such as deafness and death.1 even though the exact occurrence of csom is still unclear, a previous study states that 25% of patients visiting clinics in indonesia are csom patients.2 according to information taken from patients’ medical records at a public hospital in south sumatera from 2008 to 2009, 7424 patients are with csom.2 according to a study conducted by wisnubroto in harmadji3, approximately 31.2% shows complications of csom seldom occured. even though antibiotics are widely used in order to treat the complications of csom; the number of cases with uncompleted treatment is high. in such situations mastoidectomy is necessary to maintain the normal function of hearing. chronic mastoiditis and cholesteatoma are the two most common indications of csom.3,4 mastoidectomy is a surgical procedure to remove an infected portion of the bone behind the ear when medical treatment is not effective.4this study was conducted to identify the frequency and clinical characteristics of patients who had undergone mastoidectomy at dr. hasan sadikin general hospital bandung from 2012 to2013. correspondence: ashwini gunasekaran, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: winashg@gmail.com amj. 2017;4(3):474–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1206 althea medical journal. 2017;4(3) 475 methods this study used descriptive method and data were collected from medical records of patients who had undergone mastoidectomy at dr. hasan sadikin general hospital bandung from 2012–2013. samples were obtained using the total sampling method. the inclusion criteria were medical records of patients who had undergone mastoidectomy and consisted of variables studied, such as age which was divided into 3 categories: younger age or is not productive (0–14 years), middle age or productive (15–64 years), and older age or non–productive (≥ 65 years), gender, chief complaint (otorrhea, hearing loss, vertigo, facial nerve palsy, otalgia, retroauricular abscess and headache), main etiology, method of surgery such as canal wall down (cwd) or canal wall up (cwu), presence of abnormalities in the structure of middle ear, such as antrum mastoid, tegmen tympani, sigmoid sinus, semicircular canal, facial canal, aditus ad antrum, auditory ossicles, tympanic cavity and canalis acusticus externus (cae). incomplete medical records were excluded. a total of 41 patient’s medical records were obtained. then, the collected data were analyzed using computer software. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran and dr. hasan sadikin general hospital. results the frequency of male patients was 27 (65.9%) and frequency of female patients was 14 (34.1%). this showed, frequency of male patients was much more higher compared to the frequency of female patients (table 1). out of 35 patients who underwent mastoidectomy were from middle age, while only 6 patients were from younger age. there was no patient from older age so far in the past two years (table 2). furthermore, the most common chief complaint was otorrhea which recorded ashwini gunasekaran, sally mahdiani, fifi veronica: characteristics of patients who underwent mastoidectomy: a two years experience table 1 gender distribution sex frequency percentage (%) male (m) 27 65.9 female (f) 14 34.1 total 41 100 table 2 age distribution age frequency percentage (%) younger age (0–14 year) 6 14.63 middle age (15–64 year) 35 85.37 older age (≥ 65 year) 0 0 total 41 100 table 3 chief complaints chief complaints frequency percentage (%) otorrhea 29 70.73 hearing loss 3 7.32 vertigo 2 4.88 otalgia 3 7.32 retroauricular abcess 3 7.32 headache 1 2.43 total 41 100 althea medical journal. 2017;4(3) 476 amj september 2017 29 patients (70.73%), followed by hearing loss, otalgia and retroauricular abscess. the occurrence of symptoms were caused by infections. no other etiology was identify during the period of this 2 years study (table 3). firstly, cwd was performed on 26 patients (63.41%). secondly, cwu was performed together with tympanoplasty on 7 patients (17.07%). thirdly, cwu was performed on 5 patients (12.2%), and finally cwd was performed together with tympanoplasty on 3 patients (7.32%). based on the data, tympanoplasty was not performed on any patient so far in the past two years. mostly, cwd were performed on the patients (table 4). moreover, abnormalities were discovered in the middle ear structures, such as in mastoid antrum in 34 patients (82.97%), tegmen tympani in 2 patients (4.88%), sigmoid sinus in 9 patients (21.95%), semicircular canal in 5 patients (12.2%), facial canal in 6 patients (14.63%), aditus ad antrum in 32 patients (78.05%), auditory ossicles in 29 patients (70.73%), tympanic cavity in 28 patients (68.29%) and cae in 30 patients (73.71%) (table 5). discussion based on sex, the frequency of male patients was higher compared to female patients. based on another study conducted by mustafa et al.11 in kosovo, 91 patients are discovered with csom, and males patients are higher 55 (60.4%) than female patients 36 (39.6%). another study conducted in saudi arabia5 shows that males are highly prominent than females due to the childhood infections caused by major differences based on anatomic, behavioral and socioeconomic factors. data analysis showed highest in patients who underwent mastoidectomy was those aged between 15–64 years (83.37%) or also known as the productive age. a study carried out in palembang2 from 2008 till 2010, states that among 84 patients who have mastoidectomy, mostly are aged between 16–30 years (48.8%), and the youngest is 6 years old while the oldest is 59 years old. otitis media (om) are discovered in children table 4 types of surgery types of surgery frequency percentage (%) cwu 5 12.2 cwd 26 63.41 tympanoplasty 0 0 cwu and tympanoplasty 7 17.07 cwd and tympanoplasty 3 7.32 total 41 100 notes: cwu= canal wall up; cwd= canal wall down table 5 abnormalities findings in the middle ear structure during surgery abnormalities in frequency percentage (%) mastoid antrum 34 82.97 tegmen tympani 2 4.88 sigmoid sinus 9 21.95 semicircular canal 5 12.2 facial canal 6 14.63 aditus ad antrum 32 78.05 auditory ossicles 29 70.73 tympani cavity 28 68.29 canalis acusticus externus (cae) 30 73.17 althea medical journal. 2017;4(3) 477ashwini gunasekaran, sally mahdiani, fifi veronica: characteristics of patients who underwent mastoidectomy: a two years experience and developed as age increases, due to many risk factors such as artificial feeding, low socioeconomic, exposure to smoking, allergic rhinitis, adenoid hypertrophy, chronic tonsillitis, upper respiratory tract infection (urti) and lower respiratory tract infection ( lrti).5 the most common cause of the csom is infection.5 a study conducted by ghonaim5 in saudi arabia proves that bacterium are the major cause of om. out of 110 patients who are taken for bacterial cultures, 68 csom patients have positive results. s.pneumoniae, staph. aureus, proteus and p. aeruginosa are the most common causative agents of acute suppurative otitis media (asom) and csom.5 in addition, there were also other chief complaints, such as trauma and tumor. trauma normally occurs due to the high pressure which can feel inside of the flight while flying over.6 this situation often results in perforation of tympanic membrane. tumor such as cholesteatoma is mostly associated with com. it usually damages bony parts of temporal bone.7 the study in palembang2 states that out of 84 patients with csom, 62 (73.8%) patients are with cholesteatoma and 22 (25.2%) patients without cholesteatoma. this clearly shows csom is mostly associated with cholesteatoma. based on the above results, csom patients often complained about having effusion in the middle ear or in other words otorrhea. besides, patients also came up with many chief complaints, such as otalgia, hearing loss, retroauricular abscess, headache, facial nerve palsy and vertigo. while, otalgia, hearing loss and retroauricular abscess were the second highest chief complaints of patients. vertigo and headache were the least complaints of patients. all these chief complaints indicated the acute otitis media (aom) had become more severe and needed immediate treatment to prevent further complications such as total hearing loss. based on an article in orissa journal of otolaryngology, ear discharge is the main chief complaint, followed by hearing loss, headache, facial palsy, otolgia, and vertigo.8 mastoidectomy is a surgical procedure which is classified into cwu and cwd. both the cwd and cwu can also be performed together with tympanoplasty if necessary. cwd is now conducted worldwide. cwd has become the major type surgery because it is more effective, easy to be done in shorter duration and prevent recurrence and residual rate in those patients with cholesteatoma.12 additionally, cholesteatoma is the major cause of hearing loss. based on a clinical study and management of cavity problems encountered in cwd mastoidectomy in 2009, it state that a retrospective study of 101 patients who have undergone cwd, the anatomic and function of the ears regains to normal.4 a research in palembang2 shows that out of a total of 84 patients with csom, the majority of 61 patients (72.6%) have undergone cwd, 13 patients (15.5%) have undergone cwu and 10 patients (11.9%) have undergone tympanoplasty. another study in india9 shows 600 patients have undergone canal wall down tympanomastoidectomy and 546 patients shows dry and healed cavity with best curative and functional results. in addition, another journal has stated that canal wall down tympanomastoid is performed to those csom patients to eliminate cholesteatoma with extradural granulation.10 intraoperative findings are abnormalities discovered in the anatomic parts of the ear during surgery. based on the data analysis, the most common abnormalities discovered were in antrum mastoid, tegmen tympani, sigmoid sinus, semicircular canal, facial canal, aditus ad antrum, auditory ossicle, tympanic cavity and cae. most commonly, the abnormalities that could be discovered were cholesteatoma, granulation tissue, secretion and many more. the study was conducted using secondary data which were medical records of patients who underwent mastoidectomy at hasan sadikin hospital bandung from 1st january 2012 until 31st december 2013, and the data obtained were 55 samples. out of the 55 samples, only 41 samples could be used as study-subject, whereas the remaining 14 samples were not used as subject because of incomplete information. it can be concluded that the highest frequency is age of 15–64, male, while, otorrhea is the chief complaint of the patients and infection is the main cause. the majority of patients have undergone cwd, and abnormalities are discovered in the middle ear structure during the surgery, such as in mastoid antrum, tegmen tympani, sigmoid sinus, semicircular canal, facial canal, auditory ad antrum, tympanic cavity and cae. references 1. hall-stoodley lh, hu fz, gieseke a, nistico l, nguyen d, hayes j, et al. direct detection of bacterial biofilms on the middle-ear mucosa of children with chronic otitis media. jama. 2006;296(2):202–11. althea medical journal. 2017;4(3) 478 amj september 2017 2. lrwan ag. epidemiology, preoperative evaluations and surgical findings in csom. palembang: department of otorhinolaryngologyhead and neck surgery, medical faculty of sriwijaya university, mohammad hoesin public hospital, palembang; 2010. 3. harmadji s. eradication of cholesteatoma and hearing reconstruction in malignant chronic otitis media. folia medica indonesiana. 2004;40(1):48–50. 4. mohan bs. a clinical study and management of cavity problems encountered in canal wall down mastoidectomy [dissertation]. bangalore: bangalore medical college and research institute; 2009. 5. ghonaim mm, el-edel rh, basiony la, alzahrani ss. risk factors and causative organism of otitis media in children. ibnosina j med bs. 2011;3(5):172–81. 6. pannu kk, chadha s, kumar d, preeti. evaluation of hearing loss in tympanic membrane perforation. indian j otolaryngeal head neck surg. 2011;63(3):208–13. 7. snow jb, wackym pa. ballenger’s otorhinolaryngology: head and neck surgery. 17th ed. new york: pmph–usa; 2008. 8. sahoo gc, deepa ks. a study of complications if chronic suppurative otitis media–a series of 30 cases in rural medical college hospital. orissa journal of otolaringalogy and head & neck surgery. 2007;1(1):36. 9. grewal ds, hathiram bt, saraiya sv. canal wall down tympanomastoidectomy: the ‘on-disease’ approach for retraction pockets and cholesteatoma. j laryngol otol. 2007;121(9):832–9. 10. jang ch, choi yh, jeon es, yang hc, cho yb. extradural granulation complicated by chronic suppurative otitis media with cholesteatoma. in vivo. 2014;28(4):651–5. 11. mustafa a, heta a, kastrati b, dreshaj sh. complications of chronic otitis media with cholesteatoma during a 10–year period in kosovo. eur arch otorhinolaryngol. 2008;265(12): 1477–82. 12. wilson kf, hoggan rn, shelton c. tympanoplasty with intact canal wall mastoidectomy for cholesteatoma: long term surgical outcomes. otolaryngol head neck surg. 2013;149(2):292–5. low socioeconomic, exposure to smoking, allergic rhinitis, adenoid hypertrophy, chronic tonsillitis, upper respiratory tract infection (urti) and lower respiratory tract infection ( lrti).5 vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 18 amj march 2019 alcohol addiction and cognitive function among café visitors at south jakarta andrew suwadi,1 dharmady agus, stefanus lembar3 1faculty of medicine and health sciences, atma jaya catholic university of indonesia, jakarta, indonesia, 2department of psychiatry and behavioral sciences, faculty of medicine and health sciences, atma jaya catholic university of indonesia, jakarta, indonesia, 3department of clinical pathology, faculty of medicine and health sciences, atma jaya catholic university of indonesia, jakarta, indonesia correspondence: andrew suwadi, faculty of medicine and health sciences, atma jaya catholic university of indonesia email: aschipmunk@yahoo.com introduction alcohol is an addictive substance that can cause dependence if consumed continuously within a certain period of time. alcohol is very often consumed in western countries.1 data from national report on basic health research (riset kesehatan dasar, riskesdas) in 2018 has showed that the most consumed types of alcoholic beverages are traditional drinks and the prevalence of alcohol consumption in the capital city of indonesia, jakarta among residents aged 10 years or over is less than 5%. interestingly, some regencies/municipalities have higher alcohol consumption prevalence compared to the daerah khusus ibukota (dki) jakarta province, such as north sulawesi province (16%), followed by east nusa tenggara and bali provinces.2 consuming alcohol continuously can cause someone to be addicted to alcohol. according to the world health organization (who) data in 2010, 1.3% of men and 0.2% of women in indonesia experience alcohol addiction, with an average of 0.7% for both.3 people with alcohol addiction may experience negative health impacts that can be classified as acute and chronic. long-term alcohol consumption with a large volume of alcohol consumed can increase risk factors for various chronic diseases, such as malignant neoplasms, diabetes mellitus, various amj. 2019;6(1):18–23 abstract background: alcohol addiction has an acute and chronic impact, and may cause cognitive function impairment, in the form of interference in decision making and impulse control, as well as impaired motor function. furthermore, research on alcohol addiction and cognitive function has not been widely studied in indonesia. the purpose of this study was to explore the association between alcohol addiction and cognitive function among café visitors at south jakarta. methods: this was a cross sectional study, conducted among cafévisitors at south jakarta in 2018. the respondents of this study were individuals who have consumed alcohol in the last 12 months and not consumed narcotics, psychotropic, and other addictive substances except nicotine and caffeine. alcohol addiction among respondent was assessed by the cage questionnaire and cognitive function was assessed by the moca-ina questionnaire. statistical analysis was determined by chi square test. results: in total, 80 respondents consisting of 57 men and 23 women met the study criteria, 67.5% of respondents have experienced alcohol addiction and 85.2% have experienced poor cognitive function. there was a strong association between alcohol addiction and cognitive function among café visitors (p=0.000; or=44.083). conclusions: individual with alcohol addiction has a poor cognitive function compared with people without alcohol addiction. therefore, awareness of the adverse effects of alcohol addiction on cognitive function among community is needed and thus, people are expected to distance from alcohol addiction. keywords: alcohol addiction, cognitive function, café visitors althea medical journal. 2019;6(1) 19 neuropsychiatric disorders, cardiovascular disease, gastrointestinal disease, and many others.1 furthermore, excessive alcohol consumption can cause cognitive function to be poor, in the form of disturbances in decision making and impulse control, as well as impaired motor function, such as impaired balance and coordination between hands and eyes. memory impairment cases can also occur in 10% of non-binge alcohol drinkers, 27% of occasional alcohol drinkers, and 54% of frequent alcohol drinkers. this event occurs at least once in the past year.4 poor cognitive function will certainly have an impact on health problems and become a burden of health in indonesia. alcohol addiction may thus serve as one of the risk factors associated with poor cognitive function. research on alcohol addiction and cognitive function is very rare in indonesia. the aim of the study was to explore the association between alcohol addiction and cognitive function in individuals who consumed alcohol. methods this study was a cross sectional study, conducted in may–july 2018 and performed among café visitors at south jakarta who met the inclusion criteria, by consecutive sampling technique. the inclusion criteria were café visitors at south jakarta who had consumed alcohol in the last 12 months, aged over 21 years, could speak indonesian, and were willing to become respondents by signing an informed consent. exclusion criteria were visitors who were drunk at the time of the study and had consumed narcotics, psychotropic, and other addictive substances except nicotine and caffeine. alcohol addiction was assessed using the cage questionnaire. two or more “yes” answers indicate positive alcohol addiction.5 montreal cognitive assessment-indonesian version (moca-ina) questionnaire version 7.1 was used to assess cognitive function. the moca-ina questionnaire assessed 7 cognitive domains from 8 existing cognitive domains, namely visuospatial, naming, attention, language, abstraction, delayed recall, and orientation. the total score of mocainaquestionnaire was 30 points. score of >26 indicate good cognitive function.6 this study was approved by the research ethics committee faculty of medicine and health sciences atma jaya catholic university of indonesia (no: 10/12/kep-fkuaj/2017), one-stop permit services board of south jakarta with a recommendation letter for research (no. 937/-082.61), and city health department of south jakarta with data collection agreement (no. 5061/-1.777.22). as for statistical analysis, bivariate analysis was carried out by chi-square test to assess the association between alcohol addiction and the conitive function amongcafé visitorsat south jakarta. significant association was designated when results was p<0.05. the data was analyzed using ibm spss statistics 23. results in total, there were 98 café visitors who took part in this study, however, only 80 respondents who met the criteria and involved in this study. most café visitors were in the age group of 21–30 years (71.25%), male (71.3%), unmarried (65%), had the last education of senior high school (46.25%), and followed by bachelor degree (38.25%). most of them worked as private employees (37.5%) and college students (35%) as shown in table 1. the respondents who experienced alcohol addiction answered questions with the most “yes” answers in question number 1 with the cut down acronym as many as 52 (96.3%) respondents (table 2). this showed that most people who experience alcohol addiction significantly try or feel the need to reduce alcohol consumption, but failed to not consume alcohol again. the respondents who did not experience alcohol addiction had a higher moca-ina score (table 3). furthermore, respondents with alcohol addiction had a mean score below 26 which indicates a decline in cognitive function. table 4 showed mean value of each domain in the moca-ina questionnaire. respondents who experienced alcohol addiction with poor cognitive function had a mean value that was worse in the 7 cognitive domains compared to respondents with good cognitive function. the worst cognitive domain was found in the visuospatial domain with a mean of 2.8 ± 1.258 (56%). meanwhile, the best cognitive domain was found in the orientation domain with the mean was 6±0 (100%). the distribution of alcohol addiction and cognitive function among café visitors was depicted in table 5. the results showed that there were more respondents (67.5%) experienced alcohol addiction than respondents who did not. moreover, most respondents had poor cognitive function andrew suwadi et al.: alcohol addiction and cognitive function among café visitors at south jakarta althea medical journal. 2019;6(1) 20 amj march 2019 table 1 characteristic among café visitors at south jakarta parameters n percentage age 21–30 years 57 71.25 31–40 years 14 17.5 41–50 years 7 8.75 51–60 years 2 2.5 gender male 57 71.3 female 23 28.7 marital status married 28 35 unmarried 52 65 last education junior high school 1 1.25 senior high school 37 46.25 associate degree 9 11.25 bachelor degree 31 38.75 master degree 1 1.25 doctoral degree 1 1.25 occupation private employees 30 37.5 entrepreneur 13 16.25 college student 28 35 unemployed 2 2.5 others 7 8.75 (61.2%). there was a significant association between alcohol addiction and cognitive function among café visitors at south jakarta in 2018 with or=44.083, indicating that individuals with alcohol addiction hada tendency 44 times higher to have poor cognitive function compared to individuals who were not an alcohol addict. discussions alcohol consumption is common in the western countries. currently, alcohol table 2 result of cage questionnaire among café visitors with alcohol addiction alcohol addiction cage questionnaire cut down annoyed guilty eye opener yes 52 (96.3) 20 (37) 46 (85.2) 10 (18.5) n (%) no 2 (3.7) 34 (63) 8 (14.8) 44 (81.5) n (%) althea medical journal. 2019;6(1) 21 consumption prevalence is increasing in the big cities in indonesia, especially among young adult. the who’s study in 2014 showed that the prevalence of alcohol consumption in indonesia is 8%, that is lower compared to other countries in asia.3 report of the national anti-narcotics agency (badan narkotika nasional, bnn) in 2014 estimated that there was 3.2 million people in indonesia (1.5% of the total population) who had a history of drug use and of which there were 4.6% consume alcohol.7 our study shows that young adult in the age group 21–30 years (71.25%) are predominantly often attending café as similarly shown in study in the western country.8 the andrew suwadi et al.: alcohol addiction and cognitive function among café visitors at south jakarta table 3 mean moca-ina questionnaire score among café visitors alcohol addiction moca-ina score (mean ± sd) positive 22.09 ± 2.973 negative 27.69 ± 1.761 table 4 mean cognitive function among café visitors with alcohol addiction using moca ina questionnaire domains of the moca-ina questionnaire, mean ±sd(%)* cognitive function poor x̅±sd (%) good x̅±sd (%) visuospatial 2.8 ± 1.258 (56) 4.5 ± 0.756 (90) naming 2.78 ± 0.554 (92.67) 3 ± 0 (100) attention 4 ± 0.989 (66.67) 5.5 ± 1.069 (91.67) language 1.72 ± 0.455 (57.3) 2.13 ± 0.354 (71) abstraction 1.13 ± 0.542 (56.5) 1.63 ± 0.518 (81.5) delayed recall 2.91 ± 1.029 (58.2) 3.88 ± 0.835 (77.6) orientation 5.74 ± 0.535 (95.67) 6 ± 0 (100) note: *percentage is meanscore in each domain divided with max score in each domain table 5 association between alcohol addiction and cognitive function alcohol addiction* cognitive function** total (%) p odds ratiopoor n(%) good n(%) yes 46 (85.2) 8 (14.8) 54 (67.5) 0.000 44.083 no 3 (11.5) 23 (88.5) 26 (32.5) total (%) 49 (61.2) 31 (38.8) note: * alcohol addiction as assessed by the cage questionnaire, **cognitive function as assessed by montreal cognitive assessment-indonesian version (moca-ina) questionnaire version 7.1 althea medical journal. 2019;6(1) 22 amj march 2019 higher prevalence inmale visitors (71.3%) who consume alcohol is consistent to other studies, however, in russia, the prevalence occurs equally between male and female visitors.9 furthermore, study in malaysia10 shows that unmarried men visit the café more than those who are married, as also shown in this study. interestingly, the café visitors had good education ranging from senior high school to bachelor degree, similar to study conducted in the other city in indonesia.11 in general, the café visitors are young adult who might seek company, or for business conversation or just a lifestyle event in the big cities. based on the results of this study, many the café visitors have poor cognitive function, similar finding as shown in other big city in indonesia, yogyakarta.12 this study also shows a strong association (p=0.000) between alcohol addiction and cognitive function among café visitors in jakarta, which is consistent with the research conducted by sharma et al.13 in 2017 that shows individuals with alcohol addiction with mean moca score 21.50 ±3.33, indicating poor cognitive function (p=0.000). individual who consume large amounts of alcohol (≥36 grams pure alcohol per day) will experience a decline in cognitive function faster in the next 10 years.14 respondents who experience alcohol addiction have the worst mean value in the visuospatial domain (2.8±1.258), followed by the abstraction domain (1.13±0.542). this is in line with the research conducted by alarcon et al.6 by using the moca questionnaire to determine the description of cognitive function in individuals with alcohol addiction. there is thus a decrease in the value of the visuospatial domain, attention (list of digits and substraction), language (fluency), abstraction, and delayed recall. the most significant decrease is found in the domain of abstraction and language (fluency).6 consuming large amounts of alcohol can cause deterioration of cognitive function in the domain of memory, attention, visuospatial, and executive functions. individuals with alcohol addiction will experience changes in gray matter and white matter structures which will cause abnormal brain activity, especially in consuming alcohol since adolescence.15 this occurs because the gray matter of the brain, the cerebral cortex, limbic system, and cerebellum, experiencing significant neurological development in adolescence. these parts of the brain are a vulnerable part of the effects of alcohol consumption.16 alcohol addiction may also cause a decrease in cerebellar volume that can effect a person’s cognitive function and motor functions.17 furthermore, individuals with alcohol addiction also show changes in the integrity of the white matter in some parts of the brain, for example in the cortex and subcortex. a prospective study conducted by bava et al.18 shows that individuals who consume large amounts of alcohol every day will cause a decrease in white matter integrity in the next 1.5 years, which will cause a decrease in speed in processing new information and communication between regions cortex and it will eventually effect and decrease a person’s cognitive function.18 alcohol addiction is a prolonged process consisting of treatment, abstinence, and relapse. treatment that includes continuing care is needed to reduce the possibility of relapse. alcohol addiction must be treated immediately to prevent the negative effects of alcohol consumption, one of which is a decrease in cognitive function. therapy that can be done in initial intensive inpatient or outpatient care based on 12-step principles, followed by continuing care involving self-help groups, 12 step group counseling, or individual therapy.19 in addition, prevention are also needed to avoid alcohol addiction. strategies that can be used are conducting screening and brief counseling about adverse effect of alcohol addiction to people at high risk.20 the limitation of this study is that this study did not measure other factors that can affect cognitive function in alcohol addiction respondents. these factors include factors that can affect cognitive function such as social support, physical function, cigarette smoking, and coffee intake. further research is needed to elaborate the other confounding factors. as a conclusions, our study showed that individual with alcohol addiction has a poor cognitive function. therefore, awareness among young adult in general and café visitors specifically, need to be raised as the adverse effects of alcohol addiction on cognitive function may hamper the life, therefore, it is advisable to distance themselves from alcohol addiction. references 1. shield kd, parry c, rehm j. chronic diseases and conditions related to alcohol use. alcohol res curr rev. 2014;35(2):155–71. 2. kementrian kesehatan republik indonesia. riskesdas 2018. jakarta: kementrian althea medical journal. 2019;6(1) 23 kesehatan republik indonesia; 2018. 3. world health organization. global status report on alcohol and health 2014. geneva: world health organization; 2014. 4. white a, hingson r. the burden of alcohol use. alcohol res curr rev. 2014;35(2):201– 18. 5. williams n. the cage questionnaire. occup med(lond). 2014;64(6):473–4. 6. alarcon r, nalpas b, pelletier s, perney p. moca as a screening tool of neuropsychological deficits in alcoholdependent patients. alcohol clin exp res. 2015;39(6):1042–8. 7. triyono, irdawati, dian nur w. gambaran persepsi peminum alkohol tentang dampak kesehatan pada peminum alkohol di dukuh mendungan. 2014. [cited 2019 march 7]. available from: http://eprints. ums.ac.id/32252/14/2.%20naskah%20 publikasi%20pdf.pdf. 8. kanny d, naimi ts, liu y, lu h, brewer rd. annual total binge drinks consumed by us adults, 2015. am j prev med. 2018;54(4):486–96. 9. zhan w, shaboltas av, skochilov rv, kozlov ap, krasnoselskikh tv, abdala n. gender differences in the relationship between alcohol use and depressive symptoms in st. petersburg, russia. j addict res ther. 2012;3(2):1000124. 10. amit n, hasking p, manderson l. demographic factors associated with alcohol use among young men in rural areas of sarawak. addiction research and theory. 2013;21(5):391–401. 11. maula lk, yuniastuti a. analisis faktor yang mempengaruhi penyalahgunaan dan adiksi alkohol pada remaja di kabupaten pati. public health perspective journal. 2017;2(2):168–74. 12. gofir a, rusdi i, susianti na, wiratama ad, lutfi a. comparison of cognitive function between rural and urban populations in yogyakarta province-indonesia. journal of the neurological sciences. 2017;381(suppl):327–8. 13. sharma d, padam a, gharu y, sharma d, sharma s. assessment of cognitive function in patients with alcohol dependence: a cross-sectional study. nat j physiol pharm pharmacol. 2018;8(3):337–40. 14. sabia s, elbaz a, britton a, bell s, dugravot a, shipley m, et al. alcohol consumption and cognitive decline in early old age. neurology. 2014;82(4):332–9. 15. squeglia lm, jacobus j, tapert sf. the effect of alcohol use on human adolescent brain structures and systems. handb clin neurol. 2014; 125:501–10. 16. squeglia lm, jacobus j, tapert sf. the influence of substance use on adolescent brain development. clin eeg neurosci. 2009;40(1):31-8. 17. lisdahl km, thayer r, squeglia lm, mcqueeny tm, tapert sf. recent binge drinking predicts smaller cerebellar volumes in adolescents. psychiatry res. 2013;211(1):17–23. 18. bava s, jacobus j, thayer re, tapert sf. longitudinal changes in white matter integrity among adolescent substance users. alcohol clin exp res. 2013;37(suppl 1):e181–9. 19. mckay jr, hiller-sturmhöfel s. treating alcoholism as a chronic disease: approaches to long-term continuing care. alcohol res health. 2011;33(4):356–70. 20. willenbring ml. gaps in clinical prevention and treatment for alcohol use disorders: costs, consequences, and strategies. alcohol res. 2014;35(2):238–43. andrew suwadi et al.: alcohol addiction and cognitive function among café visitors at south jakarta vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 214 amj december 2018 is zuspan regimen adequate for preventing eclampsia?: a case report raymond surya, budi iman santoso, surahman hakim department of obstetrics and gynecology, faculty of medicine universitas indonesia dr. cipto mangunkusumo hospital jakarta, indonesia correspondence: raymond surya, department of obstetrics and gynecology, faculty of medicine universitas indonesia/ dr. cipto mangunkusumo hospital jakarta, indonesia, email: raymond_s130291@yahoo.co.id introduction hypertensive disorders of pregnancy are the second leading cause of maternal morbidity (12.9%) and mortality (14%) in both high and middle-low income countries.1 based on the sogc clinical practice guideline, preeclampsia is defined as a gestational hypertension with one or more of the following new proteinuria, with one or more adverse conditions or complications. meanwhile, preeclampsia with severe features means preeclampsia with one or more severe complications. eclampsia is defined as a generalized seizure in a patient with preeclampsia without previous history of epilepsy.2–4 in middle-low income countries, the incidence of eclampsia ranged from 16 to 69 per 10,000, compared with the european countries that is around 2-3 births per 10,000.5 magnesium sulphate (mgso4) is believed to have been used for the treatment of preeclampsia and eclampsia for more than a century, before it became the first anticonvulsant choice to prevent and control eclamptic events.6 in the beginning, the total dose of mg so4 to treat preeclampsia and eclampsia varied from 2 to 5g per 24 hours. studies have shown good control of convulsion for variation in regimen, route of administration, and total dose of mgso4 as both prophylaxis and treatment.7,8 however, the mechanism of action was still poorly understood. currently, two recommended standard regimens such as zuspan and pritchard regimens have been internationally accepted. the zuspan regimen includes a loading dose of 4g iv and maintenance dose of 1g/hour iv, while the pritchard regimen consists of a loading dose of 4g iv and 10g im, followed by a maintenance dose of 5g im per 4 hours. another regimen frequently used is the sibai regimen. the sibai regimen uses 6g loading dose and continued with 2g/hours. although these trials revealed the comparable clinical efficacy form of predominantly intravenous (zuspan or sibai) and intramuscular (pritchard) regimens, the minimum effective dose for magnesium to prevent eclampsia is still questionable.9,10 in indonesia, especially in our centre at department of obstetrics and gynecology, persahabatan hospital/faculty of medicine universitas indonesia, we use the zuspan regimen for severe preeclampsia and eclampsia. this case report presented the application of zuspan regimen in preeclampsia with severe features that became an eclamptic event. case illustration a 41-year-old pregnant woman, was referred to our outpatient clinic at the tertiary hospital due to preeclampsia without severe features, e.g. blood pressure of 140/90 mmhg and +1 proteinuria. in our clinic, the patient was re-assessed as 27 weeks of gestational hypertension and she was advised to antenatal control regularly. due to caesarean amj. 2018;5(4):214–6 abstract magnesium sulphate (mgso4) is believed to treat preeclampsia and eclampsia for more than a century with a total dose of mgso4 varying from 2 to 5g per 24 hours. zuspan and pritchard are two internationally recommended regimens that are accepted as the standard regimen. in this case report, we presented a 41 year old woman with puerperal preeclampsia prescribed with a complete zuspan regimen. she had eclamptic seizure after completing zuspan regimen with mg so4 level of 4.3 mg/dl. in this case, the possibility of eclamptic seizures might be due to a lack of mgso4 dose. the administration of mgso4 for preeclampsia with severe features and prophylactic of eclampsia should be adjusted. keywords: eclampsia, mgso4, pritchard, zuspan althea medical journal. 2018;5(4) 215 section (c-section) in previous deliveries, she planned to terminate her pregnancy at 37 weeks’ gestational age by elective c-section in february 2018. of note, her body mass index before pregnancy was 31.2. the patient was regularly checked for her pregnancy as advised, and no deterioration in her gestational hypertension was found until due. after performing c-section, the blood pressure raised to 190/120 mmhg with +2 proteinuria. we diagnosed as puerperal preeclampsia with severe feature. we administered the loading dose of mgso4 40% 4g continued by 1g per hour as maintenance. anti-hypertension was prescribed to reach the target of blood pressure of less than 160 mmhg for systolic and 110 mmhg for diastolic. after 24 hours of mgso4 40% infusion, we stopped the mgso4 40% and the patient had a seizure 4 hours later. we examined her magnesium level and the result was 4.3 mg/dl. the patient was diagnosed as puerperal eclampsia and she got the repeated dose of mgso4 40% 1g/hour for 24 hours. after that, there was no convulsion anymore and she was discharged six days after the c-section. discussions magnesium sulphate has been proven effective to decrease eclamptic convulsion for almost 50%.11,12 apart from that, magpie trial stated that the use of mgso4 for women with preeclampsia is associated with the 16% decrease risk of death or serious morbidity related to preeclampsia in 2–3 years later. however, this trial did not find any clear difference in relationships including cardiovascular and stroke morbidity and mortality in later life. in fact, intervention to improve outcome following preeclampsia would increase the longer-term outcome for the women.9 based on literature, the validity of therapeutic range is between 4.8-9.6 mg/ dl (2.0-3.95 mmol/l), however, result is debatable. in our case report, the administration of mgso4 based on zuspan regimen showed a magnesium level of 4.3 mg/dl (1.77 mmol/l), which is a little bit under therapeutic level. after administration of mgso4, around 40% of plasma magnesium is protein bound. meanwhile, the unbound magnesium ion will diffuse into the extravascular-extracellular space into the bone, and across the placenta and fetal membrane, into the fetus and amniotic fluid. the level will reach a constant value after three to four hours’ administration i.e. between 0.250 and 0.442 l/kg.12 in a systematic review by okusanya et al.13, the baseline serum magnesium concentration is consistently <1 mmol/l. an intravenous loading dose of 4–6 grams of mgso4 is associated with a rapid doubling of baseline within ½ hour of starting the injection. maintenance of 1 g/hour following a 4 g loading dose resulted ina mean concentration of magnesium between 1–2 mmol/l with fewer fluctuations during the period of administration. several other studies using the sibai regimen showed that the steady state of magnesium after giving 2 g/hour for maintenance is 2–3 mmol/l. in the pritchard regimen, the intermittent bolus injection would result a spike in serum concentration that fell rapidly within 2 hours of injection. therefore, it made more fluctuations compared with the continuous intravenous maintenance regimen. the mean values reached ≥2.00 mmol/l, but it did not reach 3.00 mmol/l. the zuspan regimen which is used in our centre shows the minimum effective serum magnesium concentration is lower than the therapeutic window.9,14 the sibai regimen should become a choice for maintaining the concentration of magnesium appropriate with the therapeutic level. however, the close monitoring of magnesium concentration level should be performed due to the narrow margin of safety between therapeutic and toxic level of magnesium sulphate. the study by rebecca g, et al.15 showed that there is a low rate of complications due to mgso4. maternal respiratory depressions occur in 1.3% of cases (range from 0 to 8.2%), calcium gluconate is used less than 0.2%, and only one maternal death is due to mgso4 (related with a serum level more than 24 meq/l). the mgso4 treatment is influenced by body mass index (bmi) and its failure might be due to high bmi.16,17 the patient in this case had bmi 31.2 kg/m2 before pregnancy, was classified as obesity grade ii based on asia pacific criteria. women with high bmi have lower circulating levels of mg and it remains subtherapeutic up to 18 hours. around 40% of circulating mg is protein bound and the unbound fraction diffuses into extravascularextracellular spaces. in pregnant women, the distribution of mgso4 reaches a plateau value (2.5–4.4 mg/dl) between the third and fourth hours. the doses should be larger for women with bmi exceeding 35 kg/m2, especially in antepartum because it must be distributed into products of conceptus before reaching the equilibrium. they suggested close monitoring raymond surya, budi iman santoso, surahman hakim: is zuspan regimen adequate for preventing eclampsia?: a case report althea medical journal. 2018;5(4) 216 amj december 2018 among the perioperative period due to the high rate of post-cesarean seizures, especially women with high bmi. apart from that, the creatinine level should be considered because urinary excretion of mg is the major route of metabolic clearance. learning from this case, we recommended that the administration of mgso4 should be used along with the sibai regimen for women with high bmi or obese women that consisted of 6g mgso4 loading dose and continued with 2g/hours. in undertaking mgso4 for special population with higher doses, the clinician should pay more attention by checking the mg level to minimize the toxic potency. in conclusion, the eclamptic event in this case is possible due to the suboptimal of mgso4 dose in using the hospital standard of zuspan regimen. administration of mgso4 for preeclampsia with severe feature and prophylactic of eclampsia should be adjusted to the body mass index. references 1. say l, chou d, gemmill a, tunçalp ö, moller a-b, daniels j, et al. global causes of maternal death: a who systematic analysis. lancet glob health. 2014;2(6):e323–33. 2. magee la, pels a, helewa m, rey e, von dadelszen p, canadian hypertensive disorders of pregnancy working group. diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. j obstet gynaecol can jogc j obstet gynecol can jogc. 2014;36(5):416–41. 3. national institute for health and care excellence (nice). hypertension in pregnancy. clinical guideline [cg107]. london: nice; 2010. 4. hypertension in pregnancy: executive summary. obstet gynecol. 2013;122(5):1122. 5. duley l. the global impact of preeclampsia and eclampsia. semin perinatol. 2009;33(3):130–7. 6. who. who recommendations for prevention and treatment of preeclampsia and eclampsia [internet]. who. [cited 2018 aug 27]. available from: http://www.who.int/reproductivehealth/ p u b l i c a t i o n s / m a t e r n a l _ p e r i n a t a l _ health/9789241548335/en/ 7. duley l, gülmezoglu am, hendersonsmart dj, chou d. magnesium sulphate and other anticonvulsants for women with pre-eclampsia. cochrane database syst rev. 2010;(11):cd000025. 8. pratt jj, niedle ps, vogel jp, oladapo ot, bohren m, tunçalp ö, et al. alternative regimens of magnesium sulfate for treatment of preeclampsia and eclampsia: a systematic review of non-randomized studies. acta obstet gynecol scand. 2016;95(2):144–56. 9. magpie trial follow-up study collaborative group. the magpie trial: a randomised trial comparing magnesium sulphate with placebo for pre-eclampsia. outcome for women at 2 years. bjog int j obstet gynaecol. 2007;114(3):300–9. 10. sibai bm, graham jm, mccubbin jh. a comparison of intravenous and intramuscular magnesium sulfate regimens in preeclampsia. am j obstet gynecol. 1984;150(6):728–33. 11. euser ag, cipolla mj. magnesium sulfate treatment for the prevention of eclampsia: a brief review. stroke j cereb circ. 2009;40(4):1169–75. 12. salinger dh, mundle s, regi a, bracken h, winikoff b, vicini p, et al. magnesium sulphate for prevention of eclampsia: are intramuscular and intravenous regimens equivalent? a population pharmacokinetic study. bjog int j obstet gynaecol. 2013;120(7):894–900. 13. okusanya bo, oladapo ot, long q, lumbiganon p, carroli g, qureshi z, et al. clinical pharmacokinetic properties of magnesium sulphate in women with preeclampsia and eclampsia. bjog int j obstet gynaecol. 2016;123(3):356–66. 14. the eclampsia trial collaborative group. which anticonvulsant for women with eclampsia? evidence from the collaborative eclampsia trial. the lancet. 1995;345(8963):1455–63. 15. gordon r, magee la, payne b, firoz t, sawchuck d, tu d, et al. magnesium sulphate for the management of preeclampsia and eclampsia in low and middle income countries: a systematic review of tested dosing regimens. j obstet gynaecol can. 2014;36(2):154–63. 16. dayicioglu v, sahinoglu z, kol e, kucukbas m. the use of standard dose of magnesium sulphate in prophylaxis of eclamptic seizures: do body mass index alterations have any effect on success? hypertens pregnancy. 2003;22(3):257–65. 17. anderson jk, boyd ci. effect of maternal body mass index on serum magnesium levels given for seizure prophylaxis. obstet gynecol. 2013;122(2 part 1):394. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 25 association between patient’s basic characteristic and clark level in cutaneous malignant melanoma egie rahmalaelani,1 hermin aminah usman,2 jono hadi agusni3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of dermato-venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: malignant melanoma is a cancer that begins in the melanocytes. melanoma is commonly happened on older people, male and located on sun exposure body area, such as face, neck and lower limb. melanoma cases occur less than 5% of skin cancer but cause a majority of skin cancer deaths because melanoma has an aggressive behavior. age, sex, location of lesion, and type of melanoma influences the melanoma invasion. the cutaneous melanoma invasion could be assessed with the clark level. this study is aimed to determine the association between patient’s basic characteristic and clark level in cutaneous malignant melanoma. methods: this study used cross sectional analytic design. the medical records and histopathology slide from the department of anatomic pathology dr. hasan sadikin general hospital from 2008−2012 took as a sample. forty one data were meet the inclusion criteria. furthermore, those data were analyzed using chisquare test. result: overall, patient’s characteristic in this study, commonly occurred on female (66%), 50−59 years group age (35%), non-cephalic/acral location (71%), and the level v in clark level (73%). location of lesion showed an association with clark level (p=0.023), whereas, age and sex was not significant (p=0.679 and p=0.389). conclusions: there is an association between location of lesion and clark level [amj.2017;4(1):25–9] keywords: basic characteristic, cutaneous melanoma, clark level, malignant melanoma correspondence: egie rahmalaelani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85720010023 email: egee_rahma@yahoo.com introduction malignant melanoma is a cancer that begins in the melanocytes, which gives tanned skin.1 although primary site of melanoma is skin, but it could occurs on the other part of the body such as eyes, mouth and genital.1 melanoma is commonly happen on older people, but nowadays it is also could occured on younger people. this condition is due to aging condition which reduces skin immunity.2 ultraviolet rays are the main risk factors for malignant melanoma. fair-skinned people had high vulnerability to malignant melanoma, which is 20-fold compared to the dark-skinned people and the most common locations of malignant melanoma are the face, neck, and lower limbs. however, the location of malignant melanoma on dark-skinned people is not on the area that exposed by the sunlight, but the protected areas such as the soles, palms, and nails bed.1,3 in united state, male had a higher rate of melanoma occurrence than female.1 this was due to the most male’s jobs that were exposed by the sun rays which could stimulated melanocytes to grow continuously.4 malignant melanoma rarely occurs compared to basal cell carcinoma and squamous cell carcinoma, but has higher aggressiveness, with its ability to spread to other organs or metastases.1 metastases of malignant melanoma was more common through the lymphatic system and make it as one of the most deadly cancers with threefold mortality rate compared to the other skin cancers.5 depth of invasion is an important althea medical journal. 2017;4(1) 26 amj march 2017 prognostic factor in the evaluation of malignant melanoma.6 patients of melanoma with superficial invasion have higher survival rate than patients with deeper invasion.6 clark level is used to assess the depth of invasion of malignant melanoma on the skin. on level i, the depth of melanoma is still limited in the epidermal layer also called melanoma in situ. level ii, depth reaches a little layer of papillary dermis; level iii, reaches across the papillary layer of the dermis; level iv, reaches the circular layer of the dermis; and level v reaches the subcutaneous layer.6 therefore clark level becomes important in determining the prognosis of malignant melanoma. homsi j et al.7 and filamer et al.8 mentioned that, age, sex, location of lesion and type of malignant melanoma influence melanoma invasion. thus, according to those data, the purpose of this study was to determine the association between patient’s characteristic and clark level in cutaneous malignant melanoma. methods this study used cross-sectional analytic design, and took samples with total sampling method because malignant melanoma case rarely occurred. the study used secondary data, which are medical records and histopathology slides for assessing the clark level. the medical records of patients who were diagnosed malignant melanoma from january 2008−december 2012 in department of anatomical pathology dr. hasan sadikin general hospital bandung, were taken for samples. the inclusion criteria in this study were the patients who were diagnosed cutaneous malignant melanoma complete with histopathology slides or paraffin blocks. the exclusion criteria were cutaneous malignant melanoma patients that were not complete either their data or histopathology slide or paraffin blocks. clark level assessment is conducted by using a light microscope. on level i, the depth of melanoma is still limited in the epidermal layer also called melanoma in situ. level ii, depth reaches a little layer of papillary dermis; level iii, reaches across the papillary layer of the dermis; level iv, reaches the circular layer of the dermis; and level v reaches the subcutaneous layer.6 the data were analyzed using chi-square test, and the hypothesis will be accepted if p <0.05. this whole research process had to get permission from the health research ethics committee of the faculty of medicine universitas padjadjaran and dr. hasan sadikin general hospital bandung results there were 94 cases of malignant melanoma that recorded in dr. hasan sadikin general hospital in 2008−2012. based on inclusion criteria, only 41 data can be analyzed. there were 14 (35%) cases occurred in 50−59 group age with mean age 60.7 years old, and the most occured at female group (66%). the most common location of malignant melanoma was non-cephalic/acral with 29 (71%) cases, and 6 (15%) cases occurred in other locations, such as the back, flank area, rectum, and thorax. thirty (73%) cases categorized into the level v, which is the level that had been reached subcutaneous melanoma and no one at level i (table 1). the association between patient’s characteristic and clark level in cutaneous malignant melanoma which analyzed using chi-square test, showed that, only the location of lesion that had significant (p=0.023) towards clark level, whereas age and sex showed no significant results (p=0.679 and p=0.389). discussion although malignant melanoma is commonly happened on older people but it also can be occurred on the younger people.1 in this study, the mean age is 60.7 years old and the oldest is 90 years old. this indicates that there might be genetic and immunity influences occurrence of malignant melanoma. genetic influences can be caused by mutations in the gene cdkn2a (cycling-dependent kinase inhibitor) and b-raf gene (part of cell signaling and growth).1 whereas immunity influence caused by the immaturity of the children immunity and immunity decreasing while aging, which influence the skin ability to regenerate effectively.2 age is one of prognosis factor in malignant melanoma and invasion of clark level often used as other prognostic factors.3 in this study, the association between age and clark level showed non significant (p=0.679). this is similar with anger et al.9 who mentioned that age does not affect the level of malignant melanoma invasion. more than half of malignant melanoma cases in this study occurred in female, it is similar with anger et al.9 in brazil. in the study by markovic et al.4 it is noted that the increasing of malignant melanoma cases in women althea medical journal. 2017;4(1) 27egie rahmalaelani, hermin aminah usman, jono hadi agusni: association between patient’s basic characteristic and clark level in cutaneous malignant melanoma occurred due to the use of oral contraception (estrogen and progesterone) that can stimulate the proliferation of melanocytes and as well as the lifestyle changes, such as how to dress up daily. however, in these studies, most common of malignant melanoma occurred in male. this was due to the male’s jobs that were exposed to the sun rays which could stimulated melanocytes to grow continuously. the prognosis of malignant melanoma in women is better than men, but actually sex is not the main factor affecting the prognosis of the patients, thus it is necessary to consider the other prognosis factors.3 in this study, the association between sex with clark level showed no significant results (p=0.389) which similar with anger et al.9 in this study, the location of non-cephalic/ acral had higher numbers than the cephalic. study in malaysia, mexico, and brazil (by pailoor et al.10 karam-orantes et al.11 and moris anger et al.9) showed that the most common malignant melanoma is found in the extremities or the acral area. race is one of a risk factors of acral malignant melanoma.12 melanoma from sun-exposed skin showed frequent mutations in either b-raf or nras gene (part of cell signaling and growth). in contrast, melanoma risen from sun-protected area showed a higher degree of chromosomal aberrations, the most common occurred in chromosome 11q13 which contains the cyclin d1 gene. cyclin d1 positively regulates the activity of cycling dependent kinase, table 1 respondents characteristic characteristic n % age (years old) 0−9 0 0 10−19 0 0 20−29 1 2 30−39 1 2 40−49 4 10 50−59 14 35 60−69 11 27 70−79 7 17 80−89 2 5 90−99 1 2 sex male 14 34 female 27 66 location of lesion cephalic * 6 15 non-cephalic/acral** 29 70 others # 6 15 clark level i 0 0 ii 1 2 iii 2 5 iv 8 20 v 30 73 total 41 100 note: *head, face, and neck, **hand, leg, sole, palm, #back, flank area, rectum, and thorax althea medical journal. 2017;4(1) 28 amj march 2017 leading to phosphorylation of retinoblastoma protein promoting entry into mitosis, and acts as an oncogene.13 in fair-skinned people or the caucasian, most location of malignant melanoma occurrences were at the face, neck, and lower limbs, however, in dark-skinned people or non-caucasian, the location of the occurrences were exactly not the same, its occurred on the protected area such as the palm of legs, palm of hands, and nails bed.1,3 melanoma was strongly associated with penetrative injury of the feet or hands. local injury may promote acral melanoma through stimulation of melanocytic cell by fibroblast growth factor abundant in healing wounds.12 in this study, the significant result showed (p=0.023) on the association between the location of the lesion and clark level. this result was similar with anger et al.9 noncephalic/acral locations such as the palms and soles that have thicker skin than other parts of the body skin, they should have a slower level of invasion. acral melanoma becomes invasive when the melanoma cells cross the basement membrane of the epidermis and malignant cells enter the dermis. hyun sun park et al.14 mentioned that acral melanoma has radial growth. histological characterized by proliferation of atypical melanocytes along the basal layer and associated with elongation of rete ridges.15 although malignant melanoma has an aggressive behaviour, early stage treatment probably have fairly good prognosis. in this study, 30 cases were categorized as level v, which was the melanoma that has reached the subcutaneous layer. this result may occurred due to the lack of concerns for the patient’s lesions in acral areas. this condition led to delays diagnosis of malignant melanoma which made the patients came to the doctor in the severe stage. in this study, there were some limitations, including a limited time, the incomplete data, and clark level assessment performed by medical students. however, it can be anticipated by prior training and supervision from the doctor. in this study, it can be concluded that there is association between patient’s characteristic and clark level. age and sex were not associated to clark level. however, the location of the lesion has a significant association with clark level. references table 2 association between respondents characteristic with clark level characteristic clark level p i ii iii iv v age (years old) 0−9 0 0 0 0 0 0.679 10−19 0 0 0 0 0 20−29 0 0 0 1 0 30−39 0 0 0 0 1 40−49 0 0 0 0 4 50−59 0 0 1 3 10 60−69 0 1 0 0 10 70−79 0 0 1 3 3 80−89 0 0 0 1 1 90−99 0 0 0 0 1 sex male 0 0 0 3 10 0.389 female 0 0 2 5 20 location cephalic 0 0 2 1 3 0.023 * non-cephalic/acral 0 1 0 7 21 others 0 0 0 0 6 note: *p value significant (p<0.05) althea medical journal. 2017;4(1) 29egie rahmalaelani, hermin aminah usman, jono hadi agusni: association between patient’s basic characteristic and clark level in cutaneous malignant melanoma 1. american cancer society. melanoma skin cancer. 2012. p. 1−11. [cited 2013 9 february]. available from: https://www. cancer.org. 2. yaar m, gilchrest ba. aging of skin. in: wolff k, goldsmith l, gilchrest b, paller a, leffell d, katz s, et al., editors. fitzpatrick’s dermatology in general medicine. 7th ed. new york: mcgraw-hill; 2008. p. 963−72. 3. world health organization. pathology and genetic of skin tumors: melanocytic tumors. lyon: international agency for research on cancer (iarc); 2006. p. 51−77. 4. markovic sn, erickson la, rao rd, weening rh, pockaj ba, bardia a, et al. malignant melanoma in the 21st century, part 1: epidemiology, risk factors, screening, prevention, and diagnosis. mayo clin proc. 2007;82(3):364−74. 5. buchan j, roberts dl. pocket guide to malignant melanoma. oxford, uk: blackwell science ltd; 2008. p.1−5. 6. markovic sn, erickson la, rao rd, weening rh, pockaj ba, bardia a, et al. malignant melanoma in the 21st century, part 2: staging, prognosis, and treatment. mayo clin proc. 2007;82(4):490−513. 7. homsi j, kashani-sabet m, messina jl, daud a. cutaneous melanoma: prognostic factors. cancer control. 2005;12(4):223−9. 8. kabigting fd, nelson fp, kauffman cl, popoveniuc g, dasanu ca, alexandrescu dt. malignant melanoma in african-americans. dermatol online j. 2009;15(2):3. 9. anger m, friedhoper h, fukutaki mf, ferreira mc, landman g. primary cutaneous melanoma: an 18-year study. clinics (sao paulo). 2010;65(3):257−63. 10. pailoor j, mun ks, leow m. cutaneous malignant melanoma: clinical and histopathological review of cases in a malaysian tertiary referral centre. malays j pathol. 2012;34(2):97−101. 11. káram-orantes m, toussaint-caire s, domínguez-cherit j, veja-memije e. clinical and histopathological characteristics of malignant melanoma cases seen at “dr. manuel gea gonzález” general hospital. gac med mex. 2008;144(3):19−23. 12. roche lm, xiao-cheng w, vivien c, elizabeth hb, frank dg, ahmedin j, et al. cutaneous melanoma incidence and survival among black, asian, pacific islander and white populations in the united state. clinical medicine insights. 2010;(3):15−24. 13. takata m. acral melanoma: clinical, biologic and molecular genetic characteristic. in: murph m, editor. melanoma in the clinicdiagnosis, management and complications of malignancy. rijeka: intech; 2011. p. 3−14. 14. park hs, cho kh. acral lentiginous melanoma in situ: a diagnostic and management challenge. cancers (basel). 2010;(2):642−52. 15. melanoma molecular map project. melanoma: an introduction. [cited 2013 may 15] available from: http://www. mmmp.org. althea medical journal. 2017;4(2) 192 amj june 2017 carpal tunnel syndrome prevalence and characteristics among administrative staff at dr.hasan sadikin general hospital bandung andrian,1 nushrotul lailiyya,2 novitri3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: carpal tunnel syndrome (cts) is a neurologic disease affecting hands, which is closely related to work, and is the most prevalent nerve compression disease. the incidence of cts quite often occur in people working with their hands, for instance the administrative staff, especially in a busy workplace such as dr.hasan sadikin general hospital bandung. cts causes reduction in work productivity, and consequently degrading family welfare and the quality of public service. for that very reason, the prevalence and characteristics of cts among administrative staff at dr.hasansadikin general hospital bandung needed to be revealed. methods: this quantitative descriptive study involved 94 administrative staff in the medical record department of dr. hasan sadikin general hospital using the carpal-tunnel.net questionnaire and further examinations by neurologists. variables involved in this study were the subject characteristics. results: out of the 90 subjects, 22 stated having symptoms related to cts (prevalence, 24.4%). on further clinical examination, 3 were diagnosed of suffering from cts (prevalence, 3.3%). conclusions: carpal tunnel syndrome is found among the administrative staff at dr. hasan sadikin general hospital bandung and the prevalence is lower than in the general population. a further study is required to reveal ther specific division in the hospital with the most prevalent cts case. keywords: administrative staff, carpal tunnel syndrome, hasan sadikin, prevalence correspondence: tara zhafira, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281311349612 email: tarazhafira@yahoo.com introduction carpal tunnel syndrome (cts) is the most prevalent median nerve disease, and also the most prevalent nerve entrapment syndrome, with the estimation that 3.8% of the world population is affected.1 risks for cts are related to work, and cts is often ascribed as an occupational disease.2,3 administrative work, especially in busy workplaces, is one of the jobs with highest cts occurrence, along with other jobs such as secretarial, construction work, and production.4 aside from physical and functional loss, people with cts also suffer financial loss. furthermore, a study in washington state affirmed a significant financial loss is suffered by people with cts each year, and the study underlined the significance of cts prevention in workplace.3,5,6 according to information from the human resources division of dr. hasan sadikin general hospital bandung, currently, there are approximately 3000 administrative staff working every day at dr. hasan sadikin general hospital, and a study stated that 3.8% of the general population are affected by cts, which means, approximately 114 out of 3000 administrative staff have cts and the number will increase if prevention is neglected.1,6 prevention needs to be performed, otherwise cts will cause reduction in the sufferer’s family well-being and downgrade public service efforts.3 nevertheless, not one study has been conducted on cts occurrence and characteristics among the administrative staff at dr. hasan sadikin general hospital bandung. due to those reasons, this study was conducted. methods this study used the quantitative descriptive amj. 2017;4(2):192–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1077 193 althea medical journal. 2017;4(2) method with cross sectional design. this study was approved by dr. hasan sadikin general hospital bandung and the health research ethics committee faculty of medicine, universitas padjadjaran according to ethical clearance letter no. lb.04.01/a05/ ec/263/vii/2015. the study population was all administrative staff working at dr. hasan sadikin general hospital bandung. sample was taken from all administrative staff working in the medical record division, which is one of the busiest hand-involving administrative jobs in the hospital, making it a high risk job for cts. there were 94 workers in the medical record division; however four workers were inaccessible. two of them were taking holiday, one was sick, and the last one was unwilling to participate in this study. this study was conducted at all medical record offices and the department of neurology, dr. hasan sadikin general hospital bandung in september– december 2015. the study was initiated by conducting interviews and educating all medical record administrative staff regarding cts. those who stated having symptoms related to cts during the interview were reffered to a further interviewed using the carpal-tunnel. net questionnaire. the questionnaire was a validated self-administered questionnaire, developed by bland et al.7 to be used by people with hands symptoms that were related to cts. the questionnaire was used as interview material in this study with the author’s consent. the questionnaire contained questions regarding the subject’s characteristics such as gender, age, smoking history, computer use, and handedness. symptom characteristics, such as presence of pain, numbness, tingling, muscle weakness, persistency of symptom, and bilateral symptom are also contained in the questionnaire. the result of the questionnaire was a probability score of the subject having cts. it was suggested by the creator of the questionnaire to use a cut-off point of 20%, instead of 40% which was originally used by the author, in this study, so the subjects who scored over 20% were referred to the department of neurology for further examinations which consisted of history taking and provocative tests. the provocative tests comprised phalen test, tinnel test, carpal compression test, and hand elevation test. the examination was conducted by neurologists and the positive result was established when at least one provocative test was positive. furthermore, phalen test was conducted by asking the subject to bend both wrists so that the dorsal part of the hands were in contact with each other for 60 seconds, positive result was established if the subject experienced tingling or numbness in the part of the hand innervated by the median nerve. tinnel test was conducted by performing percussion over the carpal tunnel. positive result was established if the subject experienced tingling in the part of the hand innervated by the median nerve. carpal compression test was conducted by pressing the part of the hand between thenar and hypothenar eminences of the wrist for 30 seconds. positive result was established if the subject experienced any cts symptoms during the test. the hand elevation test was conducted by requesting the subject to lift both hands upright for 2 minutes. positive result was established if the subject experienced any cts symptoms during the test, which was later analyzed using percentage to discover the prevalence. results out of 94 subjects included in this studyt only 90 subjects were accessible. there was no significant difference in the number of male and female subject in this study, causing the gender variable proportional in number. the numberof male subjects was higher than the female. the higher proportion of medical record administrative staff was less than 40 years old , causing more staff members were not in the high risk age for cts, and this may affect the result of cts prevalence within the staff (table 1). twenty two staff members who stated having hand symptoms were further interviewed using the carpal-tunnel.net questionnaire. the rest of the subjects were andrian, nushrotul lailiyya, novitri: carpal tunnel syndrome prevalence and characteristics among administrative staff at dr.hasan sadikin general hospital bandung table 1 distribution of respondent’s characteristics variable amount of subjectn=90 (%) gender male 46 (51.1) female 44 (48.9) age (years old) < 40 69 (77.7) ≥ 40 21 (22.3) althea medical journal. 2017;4(2) 194 amj june 2017 taken as negative subjects because cts is mainly a symptomatic disease, although a study by naseer et al.8 stated that cts may be asymptomatic. six males and sixteen females stated of having a hand symptom, with fifteen out of the twenty two subjects were below 40 years in age, which is not a high risk age for cts. the bigger proportion of non-high risk age subjects can be resulted from the initial bigger proportion of non-high risk age subjects before the interview was conducted (table 2). most of the subjects experienced bilateral symptoms. nearly all subjects interviewed had intermittent symptoms, leaving only one subject with a persistent symptom. the most prevalent symptoms experienced by the subjects were tingling, pain during the day, muscle weakness, pain during the night, and numbness respectively. those symptoms are consistent with the symptoms described in a previous study by atroshi et al.1 after the second interview, there were only three subjects with cts probability score above 20% and needed to be referred for further examination (table 3). the examination by the neurologist verified the three subjects referred for having cts, and it was concluded that the prevalence of cts at dr. hasan sadikin general hospital bandung was 3.3%. all three subjects were diagnosed as having bilateral cts and had intermittent symptoms, which is indicative for mild cts.9 the main symptom from the three positive subjects was tingling. two females were diagnosed as having cts. the three subjects with positive cts were over 40 years old (table 4). discussions the study discovered that 2 out of 3 subjects table 3 symptom distribution of respondent’s symptoms related to cts variable amount of subject/ frequency bilaterality yes 13 no 9 symptom persistency persistent 1 intermittent 21 symptom description pain during the day only right hand 5 only left hand 2 both hands 2 no pain during the day 13 pain during the night only right hand 5 only left hand 0 both hands 2 no pain during the night 15 numbness only right hand 3 only left hand 2 both hands 1 no numbness 16 tingling only right hand 6 only left hand 1 both hands 12 no tingling 3 muscle weakness only right hand 4 only left hand 1 both hands 2 no muscle weakness 15 table 2 characteristic distribution of respondents with cts-related symptoms variable amount of subject gender male 6 female 16 age (year) < 40 15 ≥ 40 7 with cts were female, although the initial portion of subject’s gender is proportional.1,10 this is consistent with other literatures stating that cts is more prevalent in women.1,6,10, 11 195 althea medical journal. 2017;4(2) andrian, nushrotul lailiyya, novitri: carpal tunnel syndrome prevalence and characteristics among administrative staff at dr.hasan sadikin general hospital bandung ninety four subjects in this study were mostly under 40 years old, which is a non-high risk age for cts. this study discovered that all positive subjects were above 40 years old, although the initial proportion of subject’s age was higher in the age below 40 years . three subjects examined by a neurologist were all diagnosed as having bilateral cts, although one positive subject did not report any symptom on the left hand, supporting the study stating the presence of asymptomatic cts.8 a previous study by atroshi et al.1 stated that bilateral symptom commonly occurs in cts, it was supported by the finding of two out of the three subjects having bilateral symptoms and the diagnosis of all three subjects as bilateral cts in this study.1the most prevalent symptom reported by positive subjects was tingling, and this was consistent with the previous study stated earlier. the results showed the prevalence of cts among administrative staff at dr. hasansadikin general hospital bandung was 3.3% (3 out of 90 subjects) which was close but lower than the general world population prevalence discovered by atroshi et al.1 which is 3.8%. the prevalence in this study may be lower due to many factors. one important factor is age, 77% of all medical record administrative staff were under 40 years old, making most of them excluded from the high risk age for cts. other factors causing difference in the prevalence result may be the number of subject, design, and method. the study conducted by atroshi et al.1 involved 2466 subjects, which was a lot more than this study, causing the study to have a high variation in the subject variable, besides the design of the study conducted by atroshi et al.1 was a case control, giving the study the ability to compare variables (between case and control), identify risk factors, and a giving the study a greater and broader case definition. the study by atroshi et al.1 was conducted by sending mails to the subjects containing inquiries about symptoms. two months later, the responders with and without symptoms (as a control) were clinically examined and underwent nerve conduction studies table 4 distribution of respondent’s characteristic, symptom, & physical exam variable subject 1 subject 2 subject 3 right hand left hand right hand left hand right hand left hand examination tinnel + + + + + + phalen + + + + carpal compression + + + + + hand elevation + + + + + diagnosis bilateral cts bilateral cts bilateral cts symptom description pain during the day + pain during the night + numbness + tingling + + + + + muscle weakness bilateral symptom yes yes no persistency intermittent intermittent intermittent subject characteristics gender female male female age (year) 48 57 53 althea medical journal. 2017;4(2) 196 amj june 2017 (ncs), which is a more sensitive and specific examination for cts than provocative tests. in addition, the two months’ time given to the respondents to fill in the inquiries gave them a longer time for symptoms recall than a direct interview. the limited sample taken only from the medical record division was the limitation of this study, as it might not cover all kinds of administrative work in the hospital. in addition, the amount of time needed to complete the carpal-tunnel.net questionnaire (approximately 30 minutes) might affect the answers of the subjects and bias the result of this study. with the informed limitations of this study, the researcher advises that future studies should cover more or all kinds of administrative work at dr. hasan sadikin general hospital bandung and it recommends that a further study on revealing the administration division with the highest risk for cts should be conducted. if the further study would use the carpal-tunnel. net questionnaire, the interviewer should be confident that the subjects are not answering perfunctorily. this study concluded that cts occurs among dr. hasansadikin general hospital bandung administrative staff, and it amplifies the evidence of other literatures regarding the characteristics and epidemiology of cts. references 1. atroshi i, gummesson c, johnsson r, ornstein e, ranstam j, rosén i. prevalence of carpal tunnel syndrome in a general population. jama. 1999;282(2):153–8. 2. dale amp, harris-adamson cp, rempel dmd, gerr fmd, hegmann kmd, silverstein bp, et al. prevalence and incidence of carpal tunnel syndrome in us working populations: pooled analysis of six prospective studies. scand j work environ health. 2013;39(5):495–505. 3. foley m, silverstein b, polissar n. the economic burden of carpal tunnel syndrome: long-term earnings of cts claimants in washington state. am j ind med. 2007;50(3):155–72. 4. giersiepen k, spallek m. carpal tunnel syndrome as an occupational disease. dtsch arztebl int. 2011;108(14):238–42. 5. roquelaure ymd, ha cmd, fouquet nm, descatha amd, leclerc ap, goldberg mmd, et al. attributable risk of carpal tunnel syndrome in the general population implications for intervention programs in the workplace. scand j work environ health. 2009;35(5):342–8. 6. bardeesi a, al-twair a, al-mubarek a. prevalence of carpal tunnel syndrome (cts) among medical laboratory staff at king saud university hospitals, ksa. bmc proceedings. 2015;9(suppl 1):a55. 7. bland jdp, rudolfer s, weller p. prospective analysis of the accuracy of diagnosis of carpal tunnel syndrome using a web-based questionnaire. bmj open. 2014;4(8):1–6. 8. naseer, sabah a-m, thaier a-r, alhusseiny. electrophysiological changes of ssymptomatic carpal tunnel syndrome in patients with rheumatoid arthritis: frequency distribution and correlation to disease-related factors. med j babylon. 2014;9(2):267–280. 9. gelberman rh, rydevik bl, pess gm, szabo rm, lundborg g. carpal tunnel syndrome. a scientific basis for clinical care. orthop clin north am. 1988;19(1):115–24. 10. harris-adamson c. biomechanical risk factors for carpal tunnel syndrome: a pooled study of 2474 workers. occup environ med. 2014;72(1):33–41. 11. nathan pa, istvan ja, meadows kd. a longitudinal study of predictors of research-defined carpal tunnel syndrome in industrial workers: findings at 17 years. j hand surg br. 2005;30(6):593–8. althea medical journal. 2017;4(2) 242 amj june 2017 nutritional status among elderly in ambulatory care setting karina nurizky,1 putri teesa,2 muhammad apandi3 1faculty of medicine, universitas padjadjaran, 2departmen of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran, 3department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: nutritional status is a final outcome from a balance between food intake and body’s needs of the nutrients. elderly is people whose age more than 60 years old. in indonesia, elderly population has increased. its phenomena is also known as population aging. population aging is related to malnutrition in elderly. malnutrition is defined as the insufficient, excessive or imbalanced consumption of nutrients.the objective of this study was to describe the nutritional status among elderly outpatients in geriatrics clinic of dr. hasan sadikin general hospital bandung. methods: this study was a descriptive cross-sectional study that used primary data in geriatrics clinic dr. hasan sadikin general hospital bandung from september 2013 to october 2013. the sampling method was convenience sampling. this study was done with 43 elderly ( women, n=27 and men, n=16) outpatients.the nutritional status was classified by the questionnaire of mini nutritional assessment into malnourished, risk of malnutrition and without malnutrition (adequate). after collecting the data, it was analyzed by microsoft excel in presenting the proportion of the elderly nutritional status. results: among all the respondents, 27 (63%) respondents had adequate nutrition and 16 (37%) respondents had risk of malnutrition. there was no respondent who had malnutrition (undernutrition). conclusions: majority of elderly outpatients in geriatrics clinic dr. hasan sadikin general hospital had adequate nutrition. keywords: aging, elderly, malnutrition, nutritional status correspondence: karina nurizky, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west java, indonesia, phone: +6281313969390 email: karinanurizky@gmail.com introduction in recent years, the elderly population in the world population has increased rapidly. elderly people means people who grow older, increasing the numbers and proportions of the very old.1 this phenomena happened because of decreasing of the fertility rate, improvement of health status caused by technology and medical research progress, epidemiologic transition from infection disease to degenerative disease, improvement of nutritional status characterized by increasing obesity in elderly, increasing life expectancy, and alteration of lifestyle from urban rural lifestyle to sedentary urban lifestyle.2 the increasing elderly population will affect their life aspects through physical, biological, psychological, and social changes or degenerative disease caused by aging. naturally, increasing age is in line with the decreasing physiologic function in elderly. these physiological changes could cause a decrease in food intake cause the decrease of nutritional status. this problem is one of malnutrition cases.2 malnutrition is a condition of deficiency, overabundance, or imbalance of energy, protein, and other nutrients causing a side effect on body, body function, and disease.3 risk factors of malnutrition are disease, difficulty in eating, teeth loss, economic problems, social isolation, over consumption of drugs and dependence when eating.4 the increasing of elderly population is related to geriatrics syndromes. one of them is malnutrition. malnutrition makes elderly susceptible with infection and diseases. mini nutritional assessment (mna) has been used to identify risk of malnutrition in the elderly. mini nutritional assessment is a amj. 2017;4(2):242–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1087 243 althea medical journal. 2017;4(2) validated tool with positive predictive value 97% to detect undernutrition in elderly. it has 96% sensitivity and 98% specificity.5 the mna is simple, low cost and noninvasive method that can be done at bedside.5 at this period of time, based on former exploring research document, the study about nutritional status of the elderly in dr. hasan sadikin general hospital bandung will be the first academic research, which is able to expanding the knowledge and related information about the elderly problems. thus, this study was conducted to describe the nutritional status among elderly outpatients in geriatrics clinic of dr. hasan sadikin general hospital bandung. methods this study was conducted in september– october 2013 at geriatrics clinic, dr. hasan sadikin general hospital bandung, west java. the subjects were elderly aged more than 60 years old, who visited the clinic, regarding to whether they were newly-coming patients or the patients with follow-up purpose, and ready to participate by filling the informed consent. in this study, with the proportion of 50%, 95% confidence interval, and 15% precision, minimum sample required is 43. from these criteria, 43 elderly participated and selected by convenience sampling. cross sectional descriptive quantitative type of study was conducted since through this type of study.the nutritional status can be obtained in one time visit. the purpose of this study had been approved and legalized by health research ethics committee of dr. hasan sadikin hospital. the patients filled the mna questionnaire that consist of two forms, short form mna for screening and long form mna for assessment. short form mna has 6 questions include declining food intake, weight loss, mobility, psychology stress or acute disease, neuropsychological problems and body mass index. long form mna has 12 questions include independence, drugs consumption, ulcus decubitus, frequency of full meals, protein intake, fruits and vegetables consumption, fluid intake, mode of feeding, self view about their nutritional status, patient’s perspective about their healthy status, mid-arm circumference and calf circumference.6 each question in mna has score that would be calculated and classified. the classifications were malnourished (total score <17), at risk of malnutrition (total score 17–23,5), and without malnutrition or adequate nutrition (total score ≥24). after table 1 general characteristics of the respondents characteristics total (n=43) percentage (%) sex female 27 63 male 16 37 age (years old) 60–64 2 5 65–70 10 23 >70 31 72 education elementary school 4 9 junior high school 4 9 senior high school 25 58 academy / university 10 24 job retirement 25 58 no retirement 4 9 housewife 14 33 karina nurizky, putri teesa, muhammad apandi: nutritional status among elderly in ambulatory care setting althea medical journal. 2017;4(2) 244 amj june 2017 the data were collected, it was analyzed using microsoft excel in presenting the proportion of the elderly nutritional status. results overall, the study was carried out in 43 elderly outpatients of geriatric clinic that fulfill the inclusion criteria. in this study, the subject characteristic was differ in sex, age, education level and job (table 1). out of 43 respondents, 21 (49%) respondents had normal nutrition and did not need to fulfill long form mna, and the rest, 22 (51%) respondents were at risk of malnutrition and need to fulfill long form mna. female elderly had higher risk of malnutrition. people whose age are more than 70 years old had higher risk of malnutrition. elderly with lower education also had higher risk of malnutrition. it showed that housewife had higher risk of malnutrition (table 3). female elderly had higher risk of table 2 elderly distribution based on nutritional status using mini nutritional assessment (mna) , 2013 (n=43) short form (screening) mna long form (assessment) mna frequency percentage (%) normal and do not need to fulfill long form mna 21 49 at risk of malnutrition and need to fulfill long form mna normal 6 14 at risk of malnutrition 16 37 malnutrition 0 0 note: mna = mini nutritional assessment table 3 distribution of elderly nutritional status using short form mini nutritional assessment (mna) screening result normal and do not need to fulfill long form mna at risk of malnutrition and need to fulfill long form mna frequency percentage (%) frequency percentage (%) sex male 10 63 6 37 female 11 41 16 59 age (years old) 60–64 2 100 0 65–70 5 50 5 50 >70 14 45 17 55 education elementary school 0 0 4 100 junior high school 1 25 3 75 senior high school 13 52 12 48 academy/university 7 70 3 30 occupation retirement 12 48 13 52 no retirement 3 75 1 25 housewife 6 43 8 57 245 althea medical journal. 2017;4(2) karina nurizky, putri teesa, muhammad apandi: nutritional status among elderly in ambulatory care setting malnutrition. elderly whose age is more than 70 years old had higher risk of malnutrition. elderly with lower education had higher risk of malnutrition. housewife had higher risk of malnutrition (table 4). most of elderly in geriatrics clinic hasan sadikin general hospital bandung were in adequate nutrition. there were not found malnutrition in this study (table 5). discussion according to this study, majority of the respondents were in normal (adequate) nutrition. study established in 2011 at brazil7 reported that majority of the respondents, 56% respondents were at risk of malnutrition, 36.1% respondents was in adequate nutrition and 8.3% respondents were malnutrition. in other study conducted by oliveira et al.8 in brazil, it presented 37.1% respondents were at risk of malnutrition, 33.8 % respondents had adequate nutrition, and 29.1% respondents were malnourished. in other study conducted in makkah governorate9, it was reported 57.8% were at risk of malnutrition, 22.6% were malnutrition and 19.6% respondents were in adequate nutrition. this difference findings in this studywith former study might be caused by differences in subject of study. this study subjects were elderly outpatients in geriatrics clinic of dr. hasan sadikin general hospital, whereas in other studies, the study subjects were elderly in healthy condition, institutionalized elderly and hospitalized elderly. table 4 distribution of elderly nutritional status using long form mini nutritional assessment (mna characteristics assessment result normal at risk of malnutrition frequency percentage (%) frequency percentage (%) sex male 2 33 4 67 female 4 25 12 75 age (years old) 60–64 0 0 0 0 65–70 3 50 3 50 >70 2 12 14 88 education elementary school 1 25 3 75 junior high school 0 0 3 100 senior high school 4 33 8 67 academy/university 1 33 2 67 occupation retirement 4 31 9 69 no retirement 1 100 0 0 housewife 1 12 7 88 table 5 distribution of elderly nutritional status using full form mini nutritional assessment (mna) nutritional status frequency percentage normal (adequate) 27 63% at risk of malnutrition 16 37% althea medical journal. 2017;4(2) 246 amj june 2017 in this study, it was reported that female elderly were predominantly had the risk of malnutrition, while male elderly predominantly had adequate nutrition. it strengthens the findings in a study conducted in brazil7. it is reported that female elderly have higher tendency to have risk of malnutrition. it might happened because of the subject of this study predominantly were female elderly. according to this study, prevalence of respondents who have risk of malnutrition is higher in elderly age more than 70 years old. it strengthens the study conducted by donini et al.10 that malnutrition associated with increasing age. it might be caused by the changes in the body composition ofelderly that influences the nutritional status.11 it was reported that in the elderly there is declining in food intake and motivation to eat. it might cause more problems associated with the regulation of energy balance and the control of food intake and it would affect the nutritional status.12 in this study, it is reported that there is a tendency for having risk of malnutrition in line with lower education. it strengthens the result in the study conducted by virtuoso et al.12 it is reported that the illiterate elderly women had a higher prevalence of malnutrition compared to those with education. a higher level of education was possibly associated with higher income and better lifestyle, which in turn resulted in a better nutritional status in elderly.12 this study has limitations such as, due to the constraints of time and resources, and the lack of information about nutrition intake per day on respondents, which result in several missing characteristics data. respondents of this study are elderly aged more than 60 years old, and questionnaires were used to collect the data, so there is a tendency for a recall bias. further research is needed to improve this limitation and broaden the scope. in conclusion, most of elderly patients in geriatric clinic hasan sadikin bandung are in adequate nutrition. however, there is still a tendency of the patient to have risk of malnutrition. based on consideration, this case can be mitigated by the family care and social environment. intervention is needed to reduce the risk of malnutrition. one of the intervention is by giving more information about risk of malnutrition and the impacts of malnutrition for patients and family as the caregiver of elderly. references 1. fatmah. gizi usia lanjut. jakarta: erlangga; 2010. 2. united nations population fund (unfpa). aging in the twenty-first century: a celebration and a challenge. new york: unfpa and helpage international; 2012. 3. harris d, haboubi n. malnutrition screening in the elderly population. j r soc med. 2005;98(9):411–4. 4. whitney en, rolfes sr. understanding nutrition. 10th ed. belmont: thomson wadsworth; 2005. 5. drescher t, singler k, ulrich a, koller m, keller u, christ-cralin m, et al. comparison of two malnutrition risk screening methods (mna and nrs 2002) and their association with markers of protein malnutrition in geriatric hospitalized patients. eur j clin nutr. 2010; 64:887–93. 6. guigoz y. the mini nutritional assessment (mna) review of the literature : what does it tell us? j nutr health aging. 2006;10(6):466–85 7. machado rsp, coelho sc. risk of malnutrition among brazilian institutionalized elderly: a study with the mini nutritional assessment (mna) questionnaire. j nutr health aging. 2011;15(7):532–5. 8. oliveira mrm, fogaca kcp, leandro-merhi va. nutritional status and functional capacity of hospitalized elderly. nutrition journal. 2009;8:54. 9. elmadbouly ma, abd elhafez am. assessment of nutritional status of hospitalized elderly patients in makkah governate. pak j nutr. 2012;11(10):886– 92. 10. donini lm, savina c, cannella c. eating habits and appetite control in the elderly: the anorexia of aging. int psychogeriatr. 2003;15(1):73–87. 11. hickson m. malnutrition and ageing. postgrad med j. 2006;82(963):2–8. 12. virtuoso-júnior js, tribess s, romo-perez v, oliveira-guerra r. factors associated to risk of malnutrition amongst elderly women in low-income communities. colombia médica . 2012;43(1):54–620. vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 71 footwear usage in children with flatfoot disorder in sukajadi sub-district, bandung wulan mayasari,1 elta sholihah putri,2 fathurachman3 1department of biomedical science faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran indonesia, 3department of orthopaedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia correspondence: elta sholihah putri, faculty of medicine faculty of medicine universitas padjadjaran, jalan bandungsumedang km 21, jatinangor, sumedang, indonesia email: eltaputris@gmail.com introduction viewed from the standpoint of biomechanics, the foot has a very complex structure with 26 skeletal elements and many ligaments, tendons, intrinsic and extrinsic muscles, as well as functions that are essential for running, giving more power to withstand the weight and do the movements. the foot is a very important part of the body.1 about 90% of the clinical visit has noted that the biggest cause of foot problems is due to flatfoot. flatfoot is a disorder of the lower extremities that often occurs in children.2 a study conducted toward 1158 respondents of all school students from babol shows that 16.1% have flatfoot.3 although flatfoot rarely causes pain, but many parents believe that flatfoot can cause the problem of walking in the future, therefore, the problem of flatfoot is still the focus in most parents.2 flatfoot is a medial longitudinal arch (mla) condition that falls with the entire sole or almost all of it touches the ground.4 if the foot arch does not grow normally it will cause injuries to the feet, knees, and back, balance disorders, unstable, complaint easily of fatigue, and also can cause excessive injury and pain.5,6 according to the effects of flatfoot, it creates a separate paradigm for some work agencies, especially those which are directly related to physical activities. one of the occupations that most often uses physical activities is the army or police. in this group, physical ability is one test that is quite decide whether a person is fit to become a soldier or a police officer. amj. 2019;6(2):71–4 abstract background: flatfoot is a musculoskeletal disorder of the foot where the medial longitudinal arch becomes flatter, resulting in a more foot surface touching the ground compared to the normal foot. one of the risk factors for flatfoot is the rather early footwear usage with a considerably long period of usage with the enclosed footwear type. this may cause weakening of supporting tissues of the foot. this study aimed to describe the use of footwear in children with flatfoot. methods: this study used a descriptive categorical method, conducted from march to june 2017 among students from five elementary schools in sukajadi sub-district, bandung. primary data were obtained by using questionnaires and descriptively presented. results: prevalence of flatfoot among included students (n73) of the elementary school with age range of 6–10 years was 54.8%. all students had their first years of wearing footwear in the age range 0-5 years. the majority (52.5%) of footwear usage duration in flatfoot disorder was ≥8 hours/day, and the footwear type of flatfoot disorder was dominated (65%) by sandals/slippers. conclusions: there is a high number of flatfoot in elementary school, and this needs special attention, especially on how to use the footwear. keywords: flatfoot, footwear, medial longitudinal arch althea medical journal. 2019;6(2) 72 amj june 2019 especially in indonesia, the recruits will be tested for the strength of their hand muscles, abdominal muscles, and the strength of leg muscles to run twelve minutes to depict the distance that can be reached, and a shuttle run which involves running around the shape of the number eight as many as three times that require extra speed. frequently, flatfoot sufferers are disqualified for military service because they are easily tired when walking or running for long periods.7 furthermore, flatfoot is a physiological condition, especially in neonates. in neonates, there is a fat pad under the medial longitudinal arch. as we get older, these fat pads begin to decrease and the prevalence of flatfoot decreases. on the other hand, the number of flatfoot cases is increased in children who have weak ligaments due to the early use of footwear for long-term use, and the type of closed footwear such as shoes. the use of shoes can limit the leg muscles movement resulting in the flattened arches and thus making leg muscles become weak.2,4 sukajadi is one of the urban areas where most of the population wear various types of footwear and duration of usage, the risk factors for the flatfoot. a systematic study conducted in india has shown that the incidence of flatfoot in urban communities is higher, and the footwear use is associated with increased risk of flatfoot. there is a strong tendency between footwear statuses with the number of flatfoot prevalence; therefore this study aimed to describe the use of footwear in children with flatfoot in sukajadi sub-district. methods this study was carried out by using descriptive categorical methods to describe the use of footwear in children with flatfoot. this study was part of previous research in 2017, exploring the prevalence of flat foot in sukajadi sub-district. students from five elementary schools in sukajadi sub-district, bandung aged range 6-10 years old were included. this study was conducted from march to june 2017. to collect data, the research instrument used was the questionnaire, distributed to the selected randomly proportional students to be filled by their parents, prior informed consent. the questionnaire assessed the first age of footwear usage (0-5 years and ≥6 years), the duration of footwear usage (<8 hours and ≥8 hours), and the type of footwear (slippers/ sandals and shoes). students who had an incomplete questionnaire and had burned, fractures in the leg region, as well as congenital deformities were excluded. flatfoot was defined as a musculoskeletal disorder of the foot where the medial longitudinal arch became flatter, resulting in a more foot surface touching the ground compared to the normal foot. the flatfoot was designated when the arch index of footprint analysis was measured by using the foot stamp printed on paper. the result of footprint analysis waw calculated into thearch index ratio. the normal range ratio of the foot arch index is 0.21–0.28; whereas the ratio >0.28 was designated as flatfoot. the data were presented descriptively in the form of tables. this research was approved by the health research ethics committee of faculty of medicine of universitas padjadjaran (no. 376/ un6.c.10/pn/2017) and research permit from dinas pendidikan kota bandung. results out of 73 students, mostly were flatfoot (n 40; 54.8%) of whom flatfoot was predominantly among girls (60.3%). all students had worn footwear at age 0-5years. the majority of the students (52.1%) had worn footwear for ≥8 hours/day. the type of footwear (67.1%) preferred to wear was slippers (table 1). all students had the first age group wearing footwear for flatfoot patients was by the 0-5 age group. however, based on the footwear duration of flatfoot patients, almost 52.5% were wearing footwear for ≥8 hours/day. the type of footwear used by flatfoot children was slippers with a proportion of 65% (table 1). discussions this study was conducted to describe the use of footwear in children with flatfoot in sukajadi sub-district. in this study, the flatfoot prevalence obtained from elementary students in the sukajadi sub-district is 54.8%. this study is in accordance with the study in india that shows flatfoot incidence is higher in the urban community. footwear is often implicated in orthopedic problems which can affect the lower limb and back.8 individuals who are wearing shoes before six years old and with the wearing a duration of more than eight hours per day at an early age have significantly higher flatfoot prevalence compared to the others who are wearing footwear for a shorter duration. this report is same as the data althea medical journal. 2019;6(2) 73 wulan mayasari et al.: footwear usage in children with flatfoot disorder in sukajadi sub-district, bandung table 1 characteristic of the students from elementary schools in sukajadi sub-district, bandung normal foot flatfoot total (n = 33) (n = 40) (n = 73) gender, n (%) boys 12 (36.4) 17 (42.5) 29 (39.7) girls 21 (63.6) 23 (57.5) 44 (60.3) age, n(%) 6 years old 1 (3.0) 1 (1.4) 7 years old 4 (12.1) 6 (15) 10 (13.7) 8 years old 6 (18.2) 9 (22.5) 15 (20.5) 9 years old 10 (30.3) 16 (40) 26 (35.6) 10 years old 9 (27.3) 12 (30) 21 (28.8) the first age group of wearing footwear, n(%) 0–5 years old 33 (100) 40 (100) 100 (100) ≥6 years old footwear duration, n(%) <8 hours/day 16 (48.5) 19 (47.5) 35 (47.9) ≥8 hours/day 17 (51.5) 21 (52.5) 38 (52.1) type of footwear, n(%) sandal/slippers 23 (69.7) 26 (65) 49 (67.1) shoes 10 (30.3) 14 (35) 24 (32.9) obtained in our study. the main function of footwear is to protect the foot from scrapes or injury of harmful objects. along with the times, footwear has been produced in various shapes. the urban area is the area most exposed to new trends, and mode in the shoes industry. this may support the result of our study, showing that all children started to wear footwear for the first time at age 0–5 years, with the wearing duration of ≥ 8 hours.4 in the another study carried out among children in urban and rural communities of southwest nigeria, all children in the urban area have used closed footwear, while most of the children in the rural area (69.5%) have used other forms of footwear.4 interestingly, there is a significant escalation of flatfoot prevalence in children who are wearing shoes and who do not. this indicates that closed footwear can increase flatfoot prevalence. however, our study has shown a different trend, indicating that 65% of children with flatfoot syndrome is dominated by slippers usage. this different in result may probably due to the usage of slippers that is easier to wear and more practical for daily activities. in general, human foot bones have an arch, which can give more power for foot endurance and stability during the movements. there are musculoskeletal disorders on foot among others flatfoot, of which the medial longitudinal arch on foot become flat, resulting in a more surfaces tread of the foot on the floor.9 flatfoot may affect in one foot or both feet, that not only increases the load acting on foot structure, but it also can interfere the normal foot function.10 there are several techniques to evaluate foot structure and to diagnose flatfoot such as clinical diagnosis, x-ray studies, visual observation, footprint analysis that measure the frontal plane heel position and assess the position of the navicular tuberosity. foot radiographs and computed tomography (ct) are the most useful method for analysis of the complex tarsal bones.11-13 the cause of flatfoot includes obesity, posture abnormality, neurology and muscular abnormality, a genetic condition, collagen disorders, and the weakness of supporting tissue.2 the fat pads may resolve between the althea medical journal. 2019;6(2) 74 amj june 2019 ages of 2 and 5 years as the arch of the foot developed.2 by wearing footwear at age under six and with wearing duration more than eight hours per day, especially with the use closed footwear such as shoes, these factors can damage the arch development and will affect the occurrence of flatfoot.4 the limitation of this study was the recall bias of the parent’s memory to remember when their children wearing footwear. moreover, this study only describes the footwear status of flatfoot and its results could not show the effect of footwear usage on the increasing number of flatfoot prevalence. analytical studies on a cohort prospective study should be suitable to identify the correlation between the usage of footwear with the number of flatfoot prevalence by considering various factors that are associated with flatfeet, such as different activities, body mass index, and genetic factors to get more accurate results. in conclusion, the flatfoot prevalence in our study among elementary students aged 6-10 years is approximately 54.8%, of which the first time of footwear usage at age 0-5 years and with duration for ≥8 hours/day, dominated by slippers users. the high number of flatfoot in the elementary school needs special attention, especially on how to use the footwear. references 1. d’aout k, pataky tc, de clercq d, aerts p. the effects of habitual footwear use: foot shape and function in native barefoot walkers. footwear sci. 2009;1(2):81–94. 2. halabchi f, mazaheri r, mirshahi m, abbasian l. pediatric flexible flatfoot; clinical aspects and algorithmic approach. iran j pediatr. 2013;23(3):247–60. 3. pourghasem m, kamali n, farsi m, soltanpour n. prevalence of flatfoot among school students and its relationship with bmi. acta orthop traumatol turc. 2016;50(5):554–7. 4. abolarin t, aiyegbusi a, tella a, akinbo s. predictive factors for flatfoot: the role of age and footwear in children in urban and rural communities in south west nigeria. foot (edinb). 2011;21(4):188–92. 5. tashiro y, fukumoto t, uritani d, matsumoto d, nishiguchi s, fukutani n, et al. children with flat feet have weaker toe grip strength than those having a normal arch. j phys ther sci. 2015;27(11):3533–6. 6. herianto h, aminoto b. analisis pengaruh bentuk telapak kaki terhadap kelelahan fisik. jurnal teknosains. 2013;2(2):71– 158. 7. dinas penerangan tentara nasional indonesia angkatan darat. pembukaan taruna akmil. jakarta pusat: tni angkatan darat; 2014. [cited 2017 october 15]. available from:https://tniad.mil. id/2014/03/pembukaan-taruna-akmil/ 8. kurup hv, clark ci, dega rk. footwear and orthopaedics. foot ankle surg. 2012;18(2):79–83. 9. lendra made dody, santoso totok budi. beda pengaruh kondisi kaki datar dan kaki dengan arkus normal terhadap keseimbangan statis pada anak usia 8-12 tahun di kelurahan karangasem, surakarta. jurnal fisioterapi. 2009;9(2):49–58. 10. bok sk, lee h, kim bo, ahn s, song y, park i. the effect of different foot orthosis inverted angles on plantar pressure in children with flexible flatfeet. plos one. 2016;11(7):e0159831. 11. fernandez sp, martin cg, pillado ts, calvino bl, diaz sp, gil guillen v. validity of footprint analysis to determine flatfoot using clinical diagnosis as the gold standard in a random sample aged 40 years and older. j epidemiol. 2015;25(2):148–54. 12. menz hb, fotoohabadi mr, wee e, spink mj. visual categorisation of the arch index: a simplified measure of foot posture in older people. j foot ankle res. 2012;5;10. 13. kido m, ikoma k, hara y, imai k, maki m, ikeda t, et al. effect of therapeutic insoles on the medial longitudinal arch in patients with flatfoot deformity: a three-dimensional loading computed tomography study. clin biomech (brsitol, avon). 2014;29(10):1095–8. althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 143 undernutrition as risk factor of hydrocephalus prevalence in children with tuberculous meningitis john patria maruli sinaga,1 nelly amalia risan,2 uni gamayani3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of neurology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hydrocephalus is the most frequent neurological complication in children with tuberculous meningitis. tuberculosis infection cannot be separated from nutritional status. children with undernutrition have decreased immunity thus could affect clinical manifestation of tuberculous meningitis. this study was conducted to identify the relationship between undernutrition and the prevalence of hydrocephalus in tuberculous meningitis. methods: an analytic observational study was carried out to 38 medical records of children with tuberculous meningitis in dr. hasan sadikin general hospital from 2007 to 2015. variables that were studied included gender, age, advanced stage of disease, motoric paralysis, history of seizure, nutritional status and hydrocephalus. the collected data were analyzed using chi-square test. results: out of 21 subjects with undernutrition, 11 subjects were found to have hydrocephalus. the analysis using chi-square was statistically significant (p=0.009). prevalence ratio=4.45 (ci 95% 1.14−45.43), meaning tuberculous meningitis children with undernutrition were at risk of hydrocephalus 4.45 times greater than children with normal nutritional status. conclusions: undernutrition may increase the risk of hydrocephalus in children with tuberculous meningitis. [amj.2017;4(1):143–7] keywords: hydrocephalus, nutritional status, tuberculousmeningitis, undernutrition correspondence: john patria maruli sinaga, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8996087277 email: johnpmsinaga@gmail.com introduction tuberculous meningitis is the most severe complication of tuberculosis infection and occurs in 5−10% of tuberculosis cases.1 there are 92 patients with tuberculous meningitis during the period 2000−2005 at dr. hasan sadikin general hospital, bandung.2 the prevalence is higher than the prevalence in developed countries (united states) where there are only 34 cases of tuberculous meningitis in 11.5 years.1 tuberculous meningitis is highly associated with mortality and long-term sequelae. a study reported that the most often neurological complication is hydrocephalus (42%).3 tuberculous meningitis patients with hydrocephalus after ventriculoperitoneal shunt has poor outcome: 42.1% died while the rest ranging from good outcome to moderate disability.4 rautet et al.5 reported that predictor factors of hydrocephalus are advanced stage of disease, severe disability, duration of disease >2 months, seizures, impaired vision, papilledema, cranial nerve palsy (n vi), hemiparesis, cerebrospinal fluid total cell count >100/mm3, cerebrospinal fluid protein >2.5 g/l. tuberculous infections are always associated with nutritional status. children with undernutrition have decreased immunity. decreased immunity can affect course of tuberculous meningitis. in addition, weak immunity supports exudate formation in basilar area.3 this study was conducted to identify the impact of undernutrition to the insidence of hydrocephalus in children with tuberculous meningitis. methods the method used was the unpaired comparative analytical with cross-sectional design. this research was conducted in inpatient ward althea medical journal. 2017;4(1) 144 amj march 2017 of neuropediatric and neurosurgery of dr. hasan sadikin general hospital, bandung during the period 2007−2015. after approval of the health research ethics committee of dr. hasan sadikin general hospital, bandung, subjects of the study were determined by medical record review of children with tuberculous meningitis. the inclusion criteria were the diagnosis of tuberculous meningitis and the age range must be within 1−14 years. meanwhile, the exclusion criteria were medical records that were not accompanied by weight and height data. all medical records of the subject were analyzed and some information was recorded such as identity (name, age, sex), physical examination (weight, height, motoric paralysis), stage of disease, history of seizure and the result of lab investigation (ct scan). personal and clinical manifestation characteristics of the subject such as sex, age, advanced stage of disease, motoric paralysis, and history of seizure were inserted into the subject’s characteristic table. gender was categorized as boy and girl. the age of subjects was grouped into 2: <5 years and ≥5 years. advanced stage of disease, motoric paralysis and history of seizure were categorized into two groups (yes and no) based on the presence of these variables on each subject. the nutritional status was measured by 2 indicators: weight-for-length (weight/ length) was used for children aged ≤5 years and body mass index-for-age (bmi/age) was used for children aged >5 years. weight, height and bmi were then converted into standard deviation score (z score) using the world health organization (who) anthro program. several data such as age, weight and height were inserted into the program and the program automatically counted z score for each indicator. the z scores are categorized into the nutritional status according to the following criteria: based on weight/length or bmi/age: 1) normal (z score ≥-2 to ≤+1) 2) wasted (z score ≥-3 to<-2) 3. severely wasted (z-score <-3).6 the study population was divided into two groups based on nutritional status. the undernutrition group included children with wasted and severely wasted. while the normal nutrition group included children with normal range. sample size was determined by the formula for unpaired categorical comparative analysis with α=5%, β=20%, value of p1=0.407, p2=0.307 and p1-p2=0.1. from the calculation, the estimated minimum sample size (n) was total cases of children with tuberculous meningitis=83 total available data=54 unavailable data=29 data inclusion=38 data exclusion=7 undernutrition group=20 normal nutrition group=18 hydrocephalus without hydrocephalus hydrocephalus without hydrocephalus figure 1 data collection and selection althea medical journal. 2017;4(1) 145 table 1 subject and clinical manifestation characteristics on group with and without hydrocephalus characteristic hydrocephalus(n=13) without hydrocephalus (n=25) p value prevalence ratio (confidence interval 95%) gender 0.728 1.31 (0.49−3.48) boys 9 15 girls 4 10 age 0.575 1.29 (0.52−3.24) <5 years old 8 13 ≥5 years old 5 12 advanced stage of disease 0.004 4.12 (1.34−12.63) yes 10 7 no 3 18 motoric paralysis 0.263 1.75 (0.75−4.106) yes 5 5 no 8 20 history of seizure 1.000 1.04 (0.39−2.70) yes 9 17 no 4 8 john patria maruli sinaga, nelly amalia risan, uni gamayani: undernutrition as risk factor of hydrocephalus prevalence in children with tuberculous meningitis 19 subjects for each group, so the total sample (2n) was 38 subjects. the medical record information system recorded 83 cases of children with tuberculous meningitis at dr. hasan sadikin general hospital, bandung. thirty eight data were taken as study subjects after fulfilling the inclusion criteria, this study had no exclusion criteria. after investigation, there were 20 subjects classified as undernutrition group and 18 subjects classified as normal nutrition group (figure 1). after performing several processes including recording, editing and coding, then data analysis was conducted using a computer statistical program. this study was analyzed by used of chi-square test. the result was significant if the p<0.05. results in this study, the number of boys was more than girls. children with tuberculous meningitis were found more in the category of age less than 5 years. additionally, hydrocephalus was found more in subjects with an advanced stage of disease. the advanced stage of disease showed significant association with hydrocephalus (p value = 0.004) thus further analysis was needed. motoric paralysis and history of seizure did not show statistically significant results (table 1). table 2 relationship between nutritional status of tuberculous meningitis children patients and number of hydrocephalus cases nutritional status hydrocephalus without hydrocephalus p value prevalence ratio (confidence interval 95%) undernutrition 11 10 0.009 4.45 (1.14−45.43) normal nutrition 2 15 althea medical journal. 2017;4(1) 146 amj march 2017 the number of hydrocephalus cases were higher in the undernutrition group (11 subjects) compared to the normal nutrition group (2 subjects). the prevalence of hydrocephalus in the undernutrition group was 52.4%, while the prevalence of hydrocephalus in the normal nutrition group was 11.8%. the analysis is statistically significant with p value = 0.009 (pr = 4.45, ci 95% 1.14−45.43) (table 2). the statistical analysis test between nutritional status and hydrocephalus based on the advanced stage of disease resulted in p=0.003 (pr=9, ci 95% 1.32−61.24). these results indicated that the advanced stage of disease was a confounding variable. discussion the comparison of numbers of subjects by sex was not equal, namely 1.42:1. although the number of boys was larger, there was no significant association between sex and hydrocephalus in the statistical analysis with p=0.728. these results were consistent with a study of van well et al.7 that reports the dominance of boys and there is no statistical significance. in this study, there were more subjects with age less than five years old. this result was consistent with several previous studies conducted by nelly amalia and heda melinda2, van well et al.7, rock rb et al.8 but there was no significance for age (p=0.575). the course disease of tuberculous meningitis was faster in children than adults. clinical manifestation could be different if accompanied by a factor resulting in immunodeficiency state such as undernutrition which is the focus of this study.9-11 furthermore, some clinical conditions of subjects were analyzed in conjunction with hydrocephalus, such as the advanced stage of disease, motoric paralysis and history of seizure. but only the advanced stage of disease was found to be significant. these results were in contrast to the study reported by raut et al.5 in which these three variables are the predictors of hydrocephalus. moreover, this study was in line with the study of anderson et al.3 which found seizure and motoric paralysis only occurred in 28% and 5% of subjects and were not statistically significant. in this study and a study of anderson et al.3, motoric paralysis and history of seizure were assessed from hospital medical records. information on medical records can be erroneously recorded resulting in information bias. this was in contrast to raut’s5 study which used prospective cohort with better level of evidence based medicine. information bias could be the reason why these two conditions were not related to hydrocephalus in this study. at an advanced stage of disease, bloodbrain barrier permeability will continue to rise, causing exudate formation which then causes hydrocephalus, whether communicant or non-communicant.8 cherian and thomas12 also reported that the stage of tuberculous meningitis is the most important factor for assessing prognosis. prevalence of hydrocephalus in children with undernutrition was higher than in children with normal nutrition. tuberculous meningitis children with undernutrition are at risk of hydrocephalus 4.45 times greater than children with normal nutritional status. currently, there is no study about relationship of nutritional status with hydrocephalus specifically. however, this result was supported by a study of cherian and thomas12 which reported undernutrition as the determinant factor of outcome and prognosis patients with tuberculous meningitis. moreover, protein deficiency causes activation of the hypothalamic-pituitaryadrenal axis resulting in increased serum glucocorticoid hormones. high glucocorticoid causes thymocyte cell atrophy (particularly immature cd4+ and cd8+ immature cells), thereby reducing cell proliferation of t lymphocytes. besides, undernutrition also causes changes of fc receptors found on t lymphocytes so that the function of these cells in marking antigen of mycobacterium tuberculosis is disrupted. tuberculosis infection will continue to get worse, while the body’s defenses become weak because of undernutrition. this will affect the clinical manifestation of tuberculous meningitis.9,11 the advanced stage of disease statistically significant affected the relationship between undernutrition and prevalence of hydrocephalus. tuberculous meningitis children with undernutrition and advanced stage of disease have 9 times greater risk to hydrocephalus than children with mild and moderate stage. anderson et al.3 reported an advanced stage of disease is significant to the incidence of stroke with p value <0.001. furthermore, a group of subjects with stroke reported having a higher risk of hydrocephalus. that study showed association among advanced stage of disease, stroke, and hydrocephalus in patients with tuberculous meningitis. althea medical journal. 2017;4(1) 147 additionally, a tuberculous meningitis patient with early stage usually has good outcome and will deteriorate with increasing stage of disease. while a patient with advanced stage of disease has poor outcome, almost 50% died while the rest suffered permanent sequelae such as blindness, deafness, paraplegia, diabetes insipidus, seizures and mental retardation. delayed milestone development in children can occur that later will result in cognition and emotional disorders.3,12 from this study, it can be concluded that undernutrition in children with tuberculous meningitis increases the risk of hydrocephalus. advanced stage of disease is also designated as confounding factor associated with hydrocephalus. this study has some limitations such as the limited number of samples since it has used medical records as secondary data. hospital medical records are generally limited to the last 5-year data, which was 2010−2015. this study uses data from the period 2007−2015 so there are medical records that cannot be taken as study subjects. moreover, because using secondary data, the available information is limited to those recorded in the medical record. several conditions are potential to be confounding variables in this study but cannot be analyzed due to absence of information such as the duration of tuberculosis disease, history of chronic disease (congenital heart disease, asthma, hiv/aids) and drop-out treatment of tuberculosis. thus, the theoretical suggestion of this study is to perform a study similar to this model but with more number of subjects. the practical suggestion from this study is health institutions and health care providers should improve interventions to unresolved children nutritional issues in indonesia to prevent hydrocephalus in children with tuberculous meningitis as early as possible. if hydrocephalus can be prevented by improving the nutritional status, the possibility of poor outcome on indonesian children can be prevented as well. references 1. galimi r. extrapulmonary tuberculosis: tuberculous meningitis new developments. eur rev med pharmacol sci. 2011;15(4):365−86. 2. nelly amalia risan, heda melinda nataprawira. hydrocephalus as a complication of pediatric tuberculous meningitis: clinical features and outcome. mkb. 2005;37(1):13−20. 3. anderson n, somaratne j, mason d, holland d, thomas m. neurological and systemic complications of tuberculous meningitis and its treatment at auckland city hospital, new zealand. j clin neurosci. 2010;17(9):1114−8. 4. rajshekhar v. management of hydrocephalus in patients with tuberculous meningitis. neurol india. 2009;57(4):368−74. 5. raut t, garg rk, jain a, verma r, singh mk, malhotra hs, et al. hydrocephalus in tuberculous meningitis: incidence, its predictive factors and impact on the prognosis. j infect. 2013;66(4):330−7. 6. who. who child growth standards. switzerland: department of nutrition for health and development who; 2006 [cited 2015 15 mei]. available from: http://www.who.int. 7. van well gt, paes bf, terwee cb, springer p, roord jj, donald pr, et al. twenty years of pediatric tuberculous meningitis: a retrospective cohort study in the western cape of south africa. pediatrics. 2009;123(1):e1−8. 8. rock rb, olin m, baker ca, molitor tw, peterson pk. central nervous system tuberculosis: pathogenesis and clinical aspects. clin microbiol rev. 2008;21(2):243−61. 9. cunningham-rundles s, mcneeley df, moon a. mechanisms of nutrient modulation of the immune response. j allergy. 2005;115(6):1119−28. 10. hughes s, kelly p. interactions of malnutrition and immune impairment, with specific reference to immunity against parasites. parasite immunol. 2006;28(11):577−88. 11. savino w, dardenne m, velloso la, dayse silva-barbosa s. the thymus is a common target in malnutrition and infection. br j nutr. 2007;(98 suppl 1):s11−6. 12. cherian a, thomas s. central nervous system tuberculosis. afr health sci. 2011;11(1):116−27. john patria maruli sinaga, nelly amalia risan, uni gamayani: undernutrition as risk factor of hydrocephalus prevalence in children with tuberculous meningitis althea medical journal. 2017;4(2) 252 amj june 2017 balance, general cognition and lower motoric strength in elderly: tai chi versus brisk walking steven kelvin anam,1 yuni s. pratiwi,2 marina a. moelino3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the number of elderly in indonesia continues to increase. a better quality of life can be achieved by preventing reduction of elderly’s cognition, balance and strength of the lower extremities. tai chi has been suggested as one of the sports to maintain cognition, balance and lower extremity strength for elder people. however, there are still few studies that compare tai chi to other exercises. the aim of this study was to compare the effects of practicing tai chi verrsus brisk walking. methods: the study design was observational, cross-sectional. elderly who practiced tai chi and briskwalk in tegalega sport field were chosen as the target population. the respondents must be at least 60 years old, no history of cardiovascular disease in the last 3 months, no musculoskeletal complaints, no obvious signs and symptoms of chronic diseases. afterwards, the respondents were examined using timed up and go (tug) test for balance, montreal cognitive assessment (moca) for cognition and leg dynamometer for the lower extrimities strength. the collected data was analyzed using mann-whitney statistical test and kolmogorov-smirnov test. results: no significant difference was detected among the three parameters between tai chi group (tcg) and brisk walking group (bwg). difference of 0.5 (p=0.314) and 0.6 (p=0.554) was found for tug test and moca test between tcg and bwg using mann whitney. the leg dynamometer was tested using kolmogorovsmirnov (p = 1.00). conclusions: similar result of balance, cognition, and lower motor strength are found between tcg and bwg. keywords: brisk walking, balance, cognition, lower motor strength, tai chi correspondence: steven kelvin anam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628395454808 email: stevenanam1993@gmail.com introduction life expectancy is increasing in indonesia, with the number of elderly people in indonesia is going to reach 11.34% in 2020.1 this increasing number of elderly could lead to an increasing dependency and decreasing quality of life of the population.2 to prevent the decreasing quality of life in elders, there are several factors, known as the geriatric giants that need to be improved. the geriatric giants are factors that can be modified to prevent other disability, among which that the writers choose cognition, postural stability, and risk of fall.3 the improvements of these 3 giants can be achieved by multi-sensorial exercise (including balance, proprioceptive, and position changing) and lower extremity strength.4 one of the sports that is considered fit for the elderly is tai chi. tai chi is a “mind-body” exercise, in which the participants have to do repetitive movements, perform slowly with many postural changes. from several studies, it is known that tai chi increases strength of the lower extremities significantly.5 tai chi also improves the cognitive function.6,7 tai chi improves balance, as shown by the timed up and go (tug) test.8 however, studies that compare tai chi to other moderate exercises are still rare. therefore, the purpose of this study was to compare the balance, cognition, and lower extremities strength between elderly who practice tai chi and elderly who amj. 2017;4(2):252–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1063 253 althea medical journal. 2017;4(2) exercise with brisk walking. methods the study was carried out on august until november 2014 in one of sport centers (tegalega sports center) in bandung, west java, indonesia. the study was approved by the ethical comittee. the study design used was non-experimental, observational, crosssectional. steven kelvin anam, yuni s. pratiwi, marina a. moelino: balance, general cognition and lower motoric strength in elderly: tai chi versus brisk walking table 1 baseline characteristics two groups tai chi, n = 42 brisk walking, n = 47 sex male 10 (24%) 14 (30%) female 32 (76%) 32 (70%) education no education 1 (2%) 0 (0%) sd (elementary school) 8 (19%) 9 (19%) smp (junior high school) 14 (33%) 15 (33%) sma (senior high school) 17 (41%) 17 (37%) d3 1 (2%) 1 (2%) s1 1 (2%) 4 (9%) income level no information 3 (7%) 10 (22%) < rp2.000.000,00 21 (50%) 17 (37%) rp 2.000.000,00rp 4.000.000,00 12 (29%) 11 (24%) > rp4.000.000,00 6 (14%) 8 (17%) other sports no other sports 21 (50%) 28 (61%) light intensity 1 (2%) 0 (0%) medium intensity 12 (29%) 6 (13%) high intensity 8 (19%) 12 (26%) past medical history stroke 1 (2%) 2 (4%) epilepsy 0 (0%) 1 (2%) central nervous system infection 0 (0%) 1 (2%) diabetes 4 (10%) 8 (17%) gout 9 (21%) 9 (20%) hipertension 17 (41%) 18 (39%) chronic obstructive pulmonary disease 1 (2%) 1 (2%) asthma 1 (2%) 1 (2%) angina pectoris 0 (0%) 1 (2%) sprain 5 (12%) 1 (4%) note: * all the diseases happened in the past and were well controlled in the last 3 months, **the disease not writed in the table means both groups’ number is 0 althea medical journal. 2017;4(2) 254 amj june 2017 a hundred and eleven elderly who performed their sport activites in tegalega were recruited. the elders must be practicing either tai chi or brisk walking. the respondents were asked whether they agreed or not to participate in the test and informed consent was given. exclusion, inclusion and various confounding variables (age, sex, years of education, income, the frequency and duration of training, and whether there was other exercise other than tai chi/brisk walking, and history of diseases [stroke, alzheimer, epilepsy, cns infection, diabetes, gout, hypertension, emphysema and chronic obstructive pulmonary disease, asthma, myocardial infarct, angina pectoris, hypertensive heart disease, heart failure, osteoarthritis, rheumatic, myasthenia gravis, myopathy, spraint]) were asked. uncontrolled chronic disease, osteoarthritis, alzheimer and history of hospitalization in the last 3 months were excluded . the minimum duration of tai chi/brisk walking practice must be at least 6 months. the candidates must walk without assistance of walking aids. subjects who had met the criteria were given the tug test, indonesian montreal cognitive assessment (moca) for cognition and leg dynamometer. the outcome of tug test was numerical. tug test time more than 14 seconds was excluded , due to possibility of balance disorders. the indonesian moca test was reliable, with scale from 0-30 as the result.9 the leg dynamometer test was done according to the standard procedure, knee bended to 130 degrees and fixation to ensure that only the legs are used. the result of the leg dynamometer test was divided into 3 categories. the first category was -1 sd of the mean through mean. the second category was mean until +1 sd. the third category was +1 sd until +2 sd from the mean. the data were collected by 13 people, and all had been standardized before the study, with each of the tests was done only using certain people. tug test is accounted to evaluate balance because of its easy to practice, reliability and validity.3,10 moca test as a cognition assesment is usually used because it encompasses a large aspect of cognition, and the test is valid to be use linearly.11 the sample size calculation based on the previous study using analytical, one tailed studies of unpaired-continuous variable sample calculation was 42 per group.12 the final calculation of the sample size was 46 (10% is added). continuous variables were then summarized as mean ± sd. the difference in mean of tug test and moca test was analyzed first using normality test (shapiro-wilk). then tested using mann-whitney test, because the data was not normally distributed. the leg dynamometer measurement was calculated using kolmogorov-smirnov. all the statistics analysis was generated using a statistical table 2 hypothesis testing for tug test and moca test n median p tug test 0.314 tai chi group 42 7.58 (5.06-13.13) briskwalk group 46 7.62 (5.50-11.87) moca test 0.554 tai chi group 42 24 (10-30) briskwalk group 46 23.5 (13-30) table 3 hypothesis testing for leg dynamometer leg dynamometer p-1 sd – mean mean – 1 sd 1 sd – 2 sd n (%) n (%) n (%) tcg 26 (61.9) 12 (28.6) 4 (9.5) 1.000 bwg 31 (67.4) 11 (23.9) 4 (8.7) total 57 (64.8) 23 (26.1) 8 (9.1) 255 althea medical journal. 2017;4(2) steven kelvin anam, yuni s. pratiwi, marina a. moelino: balance, general cognition and lower motoric strength in elderly: tai chi versus brisk walking program. the tested data was not normally distributed. result of 62 people who practiced tai chi (tcg), 11 were excluded because of stopping from the exercise in the last 3 months, 6 were excluded because of certain diseases they had, 2 were dropped due to not being able to finish the tests, 1 was additionally dropped because the data was too extreme, and 42 were included in the study. from 49 people in the brisk walking group (bwg) who agreed to participate, 1 was excluded because of not exercising at the last 3 months, 2 was dropped because the data was too extreme, and 46 were included in the study. mean age was 68.4 ± 5.4 in tcg, 66.1 ± 5.6 in bwg. frequencies of training in hour/week was 319.8 ± 149.8 in tcg, 307.4 ± 149.7 in bwg. the minimum duration for tcg was 11.9 ± 8.5 years of practice, and bwg was 10.8 ± 10.9 years of exercise. the characteristics between the tcg and bwg were not significantly different, except age (z = -2.162, p = 0.031). however, age was confounding only for tug test, because it was only significant when correlated with tug test (0.263, p = 0.013). the significance of tug test, moca test, leg dynamometer were all above 0.05. the regression test was not done because all the p value for all the three dependent variable is above 0.25. discussion there were other studies about tai chi and cognition that contradicts this study. lam et al.6 (2012) found less decreament in cognitive decline in elders. however the control group were given only stretching exercises, with no aerobic exercise.6 tai chi and brisk walking both are moderate intensity aerobic nature, giving the same result in this study. tai chi is also thought to increase cognition because of the crossing the midline movements. there are some support and contradiction of this theory, so that the theory is still debatable, and can not be used reliably.13 one of the contributors to balance is proprioception. tsang and huichan14 found better joint sense and balance in elders practicing tai chi than those practicing golf. however, in another study, tai chi and brisk walking intervention both increase the proprioception of the participants.15 the result is even greater in brisk walking group.15 the increament of balance, if it is based on this previous study, should be similar between the two groups.15 the recent study found no difference in increament of strength between the two groups.16 this study had limitations. the result of tug test in this study was confounded by age, which are not controlled in this study (continuous numerical type of data). the overall mean of the cognition both in tcg or bwg is low (23.77 ± 3.89, even after adjustment with years of education (+1 for 10-12 years of education, +2 for 4-9 years of education).17 this phenomenon can be related with the language used. the majority of the respondents attended primary mandarin school and have very little indonesia language vocabularies, lowering scores on some questions. last, there was only one tai chi teacher for each session which was attended by around 40-50 practitioner. therefore, lack of supervision can be the reason why the results of the exercise, including the lower extremities strength, were not optimal for the tcg. some potentially related variables (other sports, socioeconomstudy method should also be experimental to control the exposure of the exercises. our study conclusion is that tcg have similar cognition, balance, and strength of lower extremities to bwg. references 1. santika a. lanjut usia dalam perspektif hukum dan ham. buletin jendela data dan informasi kesehatan. 2013;1:29–32. 2. pusat data dan informasi kementerian kesehatan republik indonesia. gambaran kesehatan lanjut usia di indonesia. buletin jendela data dan informasi kesehatan. 2013;1:1–18. 3. misiaszek bc. geriatric medicine survival handbook. revised ed. hamilton, ontario: michael g. degroote school of medicine mcmaster university; 2008. p.26. 4. alfieri fm, riberto m, gatz ls, ribeiro cpc, lopes jaf, santarém jm, et al. functional mobility and balance in communitydwelling elderly submitted to multisensory versus strength exercises. clin interv aging. 2010;5:181–5. 5. kuramoto am. therapeutic benefits of tai chi exercise: research review. wis med j. 2006;105(7):40–3. 6. lam lc, chau r, wong bm, fung aw, tam cw, leung gt, et al. a 1-year randomized controlled trial comparing mind body exercise (tai chi) with stretching and toning exercise on cognitive function in older chinese adults at risk of althea medical journal. 2017;4(2) 256 amj june 2017 cognitive decline. j am med dir assoc. 2012;13(6):568.e15-20. 7. kasai jyt, busse al, magaldi rm, soci ma, de moraes rosa p, curiati jae, et al. effects of tai chi chuan on cognition of elderly women with mild cognitive impairment. einstein (são paulo). 2010;8(1):40-5. 8. konig pr, galarza e, goulart nba, lanferdini fj, tiggeman cl, dias cp. effects of tai chi chuan on the elderly balance: a semi-experimental study. rev bras geriatr gerontol. 2014;17(2):373– 81. 9. husein n, lumempouw s, ramli y, hequtanto. uji validitas dan reliabilitas montreal cognitive assessment versi indonesia (moca-ina) untuk skrining gangguan fungsi kognitif. neurona. 2010;27(4):15– 21. 10. herman t, giladi n, hausdorff jm. properties of the ‘timed up and go’test: more than meets the eye. gerontology. 2011;57(3):203–10. 11. koski l, xie h, finch l. measuring cognition in a geriatric outpatient clinic: rasch analysis of the montreal cognitive assessment. j geriatr psychiatry neurol. 2009;22(3):151– 60. 12. li f, harmer p, fisher kj, mcauley e, chaumeton n, eckstrom e, et al. tai chi and fall reductions in older adults: a randomized controlled trial. j gerontol a biol sci med sci. 2005;60(2):187– 94. 13. geake jg. the neurological basis of intelligence: a contrast with ‘brainbased’ education. education-line [online journal] 2006 [cited 2015 jan 14]. available from: http://www.leeds.ac.uk/ educol/documents/156074.htm. 14. tsang ww, hui-chan cw. effects of exercise on joint sense and balance in elderly men: tai chi versus golf. med sci sports exerc. 2004;36(4):658– 67. 15. zhang c, sun w, yu b, song q, mao d. effects of exercise on ankle proprioception in adult women during 16 weeks of training and eight weeks of detraining. res sports med. 2015;23(1):102–13. 16. taylor-piliae re, newell ka, cherin r, lee mj, king ac, haskell wl. effects of tai chi and western exercise on physical and cognitive functioning in healthy community-dwelling older adults. j aging phys act. 2010;18(3):261– 79. 17. doerflinger dmc. mental status assessment in older adults: montreal cognitive assessment: moca version 7.1 (original version). try this: best practices in nursing care to older adults. new york: the hartford institute for geriatric nursing, new york university, college of nursing; 2012. p.1. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 47 clinical characteristics of trigeminal neuralgia patients at dr. hasan sadikin general hospital bandung indonesia in 2010–2012 sri hudaya widihastha,1 henny anggraini sadeli,2 arifin sunggono3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: trigeminal neuralgia is a frequently found craniofacial neuralgia. the clinical characteristics of trigeminal neuralgia patients at dr. hasansadikin general hospital, bandung, indonesia has never been described before. this study conducted an overview of clinical characteristics of trigeminal neuralgia to determine the characteristic features of trigeminal neuralgia. methods: this was a non-experimental study using secondary data with a retrospective descriptive method. data related to medical records of 76 patients with trigeminal neuralgia was collected over a period of 2010 to 2012, treated at dr.hasansadikin general hospital bandung, indonesia. results: mean age was 57.6 years (range 11 to 84 years), no significant difference in gender (male:females 51.3%:48.7%). chewing and swallowing was reported as triggering stimuli to 42 (55%) patients. two patients (2.7%) had suffered pain on bilateral side of the face, 46 (60.5%) patients the right side, and 28 patients (36.8%) on the left side. pain on maxillary nerve division was found in 58 (76.3%) patients. sixty one of the patients (80%) received carbamazepine. conclusions: the peak age was between the fifth and sixth decades of life with equal representation of male to female incidence. right side and the maxillary division was found to be the most frequently site of pain. chewing and swallowing was reported to be the most frequent triggering stimuli and most of patients received carbamazepine as therapy. [amj.2017;4(1):47–51] keywords: clinical characteristic, neuropathic pain, trigeminal neuralgia correspondence: sri hudaya widihastha, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85659966936 email: s.widihastha@gmail.com introduction trigeminal neuralgia is a form of neuropathic pain disorder characterized by episodes of pain in the area which innervated by the trigeminal nerve and characterized as a spontaneous, recurrent, sharp, and paroxysmal pain.1 trigeminal neuralgia is one of craniofacial neuralgia which is known often to be found.1–3 with a prevalence of 0.1–0.2 per thousand and an incidence ranging from about 4-5/100,000/ year up to 20/100,000/year after age 60.4 trigeminal neuralgia has been classified into type 1 and type 2 subtypes. type 1 is characterized by lancinating, intermittent pain present for more than 50% of the time, while type 2 is characterized by a constant pain that is present for more than 50% of the time.5 this study conducted an overview of clinical characteristics of trigeminal neuralgia to determine the characteristic features of trigeminal neuralgia. the results of this study was expected to be useful to improve the knowledge and literature on trigeminal neuralgia, which can be used as references for further research. it is also expected that the results can provide an overview of the characteristics of trigeminal neuralgia, which can be considered for early detection the disease and further management of the patient. methods this was a non-experimental study using secondary data with a retrospective descriptive method. data related to medical records of 76 patients with trigeminal neuralgia in the outpatient clinic of neurology department, dr. hasan sadikin general hospital, bandung althea medical journal. 2017;4(1) 48 amj march 2017 was searched and collected over a period of three years, from 2010 to 2012. all available medical records of patients with trigeminal neuralgia as diagnosis are used, i.e. total sampling method. the inclusion criterion was complete medical record with trigeminal neuralgia as diagnosis, and medical records with incomplete data were excluded. the variables analyzed were age at onset, gender, site of involvement, triggering stimuli, affected divisions of trigeminal nerve, and management therapy given to the patients. data collection approval was obtained from the health research ethics committee of the dr hasan sadikin general hospital. the analysis was performed by using software applications microsoft excel and the results of this study were then evaluated and presented descriptively in table. results the age of patients was ranged between 11 to 84 years old, with a mean age of 57.6 years. the peak incidence was in the fifth and sixth decades of life (table 1). females comprised 51% of the patients, representing a ratio with males of 5.3:5, reflecting that female gender is more common than male with no significance difference between them. table 1 clinical characteristics of trigeminal neuralgia patients characteristics number of patients (n=76) percentage (%) gender male 37 49 female 39 51 age (years old) childhood (0–14) 1 1 adulthood (15–49) 17 23 elderly (>49) 58 76 triggering stimuli chewing and swallowing 42 55 talking 18 24 washing 15 20 tooth brushing 11 15 wind-blowing 4 5 shaving 3 4 touching 3 4 opening mouth 3 4 heat 1 1 management carbamazepine 61 80 amitriptyline 34 45 tramadol 4 5 phenytoin 3 4 baclofen 1 1 gabapentin 1 1 surgical operation 1 1 althea medical journal. 2017;4(1) 49sri hudaya widihastha, henny anggraini sadeli, arifin sunggono: clinical characteristics of trigeminal neuralgia patients at dr. hasan sadikin general hospital bandung indonesia in 2010–2012 chewing and swallowing was reported to be the most frequent triggering stimuli. all of the 76 patients received medical treatment. sixtyone of the patients (80%) received different dosages of carbamazepine and most of cases received more than one medical treatment. there was one case of surgical operation as other forms of modality employed to further ease the pain. two patients had bilateral trigeminal nerve involvement constituting 2% of the series (table 2). of the remaining 74 cases, 46 patients (61%) suffered pain on the right side of the face, and 28(37%) patients on the left side. this finding gave a right site and left site ratio of 1.7:1, confirming a predominance of right side facial affliction. the maxillary division was found to be the most frequently involved branch. twenty-five patients (33%) were reported having neuralgic pain only at the maxillary distribution of the face, fifteen patients (20%) suffered the condition with the additional involvement of the mandibular division on the same side, six patients (8%) suffered the condition with the additional involvement of the ophthalmic division, and twelve patients (16%) were reported having neuralgic pain confined solely at all division of trigeminal nerve distribution of the face. fourteen patients (18%) were reported having neuralgic pain at only the mandibular distribution of the face and the least frequent divisions of trigeminal neuralgia is ophthalmic division (5%). discussions this present study reported that the peak age of the disease was between the fifth and sixth decades of life. similar findings was also reported by previous retrospective studies which reported that the peak age of onset were between the fifth and eighth decades of life.6-9 loh et al.10 stated on his study that this concurrence supports the cardinal rule of subjecting patients under 40 years of age who complain of neuralgia-like pain in the face to a detailed neurological assessment to exclude associated diseases like multiple sclerosis. the causes of trigeminal neuralgia include mechanical suppression by blood vessels, arterial venous malformations surrounding, suppression by lesions or tumors, multiple sclerosis, physical damage of the trigeminal nerve due to surgery or infection, and other unknown factors. therefore, there were unusual patients aged less than 40 years cases reported in this recent study, which needed to be investigated further. katusic et al.6 reported female predominance in the ratio of 5.9:3.4. although other reviewers also reported that the disorder was appeared having a gender inclination, different result was seen in this present study. the result reported that there was more likely an equal representation of male to female incidence, with a ratio of 5.3:5. nayyar et al.9 reported that male predominance, was more likely due to smaller sample size. this finding may be unique to the general populations and, therefore, deserves further study with a larger sample size. the majority of the patients in this study were sensitive to a multitude of triggering stimuli which was varied in both type and intensity. most common triggering stimuli included chewing and swallowing (55%), talking (24%), washing (20%), tooth brushing (15%). those triggering stimulus were also table 2 affected divisions and site of involvement in trigeminal neuralgia patients affected divisions of trigeminal nerve and site of involvement bilateral side of face total right side left side ophthalmic 0 3 1 4 maxillary 1 13 11 25 mandibular 0 8 6 14 ophthalmic, maxillary 0 4 2 6 ophthalmic, mandibular 0 0 0 0 maxillary, mandibular 1 12 2 15 ophthalmic, maxillary, mandibular 0 6 6 12 total 2 46 28 76 althea medical journal. 2017;4(1) 50 amj march 2017 reported in the previous study.10 neto et al.11 stated that in trigeminal neuralgia the right side of the face usually afflict more than the left, since it is known that the foramen rotundum and foramen ovale on the right is narrower. in this study, the right side of the face was also much more involved (ratio 1.7:1). the proportion of bilateral cases in this study (2%) has similar range of percentage with those of previous reports which were stated as less than, or equal to 3 %.6 this study demonstrated about 58 of the patients (76%) in the present series reported affliction of the maxillary division either alone or in combination with the other two divisions. this report made the maxillary branch as the most frequently affected branch of the fifth cranial nerve. reports from other studies stated the similar findings.6,8 loh et al.10 reported that contradictory result, stated mandibular divisions was the most frequently affected branch. however, all support the usual feature of this condition in which the mandibular and maxillary divisions are more commonly involved than the ophthalmic. these presentations emphasized the importance of eliminating potential dental etiology, since the pain may mimic that of toothache because of the maxillary and mandibular site of pain and it is well known that dental extractions have been performed because of wrong diagnosis.10 from this present study, the ophthalmic division involvements to the pain need to be investigated further, because the number of patients (29%) is higher than the studies conducted before hand. since this present study was retrospective, it is needed to consider the limitation of retrospective study and the lack of further examination, for example magnetic resonance imaging (mri) on patients. it was also known that central sensitization of neuropathic pain can affect the distributions of patients’ sensation of pain, especially to the area of ophthalmic division, which is known as a very rare to be affected directly by trigeminal neuralgia. pharmacological treatment of trigeminal neuralgia is usually used as the first option and, in some patients surgical options may be offered.10 carbamazepine is highly effective and specific for this condition.12 carbamazepine is a tricyclic imipramine with mechanism of action related to its ability to block voltage sensitive sodium channels which result in stabilization of the hyper excitable trigeminal neural membranes.13 some previous studies and its subsequent wide-spread use of it in trigeminal neuralgia case made carbamazepine as a drug of choice.14 four placebo-controlled studies totaling 147 patients demonstrated the efficacy of carbamazepine.14 the treatment response in these trials was robust, with 58 to 100% of patients on carbamazepine attaining complete or near complete pain control as compared to 0 to 40% of patients on placebo.14 which makes carbamazepine as the first line drug for medical management of the disease.12,15 carbamazepine reduced both the frequency and intensity of painful paroxysms and was equally efficacious for spontaneous and trigger-evoked attacks.12 this therapeutic response also aided in the diagnostic cconfirmation of the condition in this study.10 on this present study, it was found that carbamazepine and phenytoin can be given as monotheraphy. most of the patients in the present study were treated with carbamazepine, and they responded favourably. possible side effects such as skin rashes, leukopenia, thrombocytopenia, abnormal liver function, and cerebellar dysfunction may occur in 5 to 10% of those patients taking these medications.10 the long term effects of carbamazepine have been evaluated in one study, showing either loss of effect or problem with tolerability in one half patients over 10 years. other treatments were given including tricyclic antidepressant, amitriptyline (45%). this antidepressant treatment was also given to the patients in the study that conducted by loh et al.10 some of the patients also received various medical treatment, such as tramadol (5%), phenytoin (4%), gabapentin (1%), and baclofen (1%). those treatment were useful as an alternative in patients who need add on therapy beside carbamazepine or the given therapy is known to be ineffective.12,16 surgical intervention was employed to relieve the intractablepain of one young-aged patient. however, it is not without risk of morbidity and mortality.10 each surgical technique for treatment of trigeminal neuralgia has merits and limitations and microvasculardecompression was known to provide the highest rate of longterm patient’ satisfaction with the lowest rate of pain recurrence.17 limitation in terms of time and number of samples in this study, making further research deemed necessary. lack of specific clinical or laboratory test exists for the diagnosis of symptomatic trigeminal neuralgia might be also the limitation of this study, since the etiological basis of classic trigeminal neuralgia is unknown but vascular compression of the althea medical journal. 2017;4(1) 51 trigeminal nerve roots has emerged as the likely cause in most cases.19 as a conclusion, this study demonstrated numerous clinical similarities of trigeminal neuralgia afflicting to the previous studies. this present study reported that the peak age was between the fifth and sixth decades of life with equal representation of male to female incidence. right side and the maxillary division were found to be the most frequently site of pain. chewing and swallowing were reported to be the most frequent triggering stimuli and most of patients received carbamazepine as therapy. the sample size could be increased to present clearer data evidence. follow-up studies would be beneficial to establish distinct indonesian patterns in this neurological disorder for further recommendation. references 1. prasad s, galetta s. trigeminal neuralgia: historical notes and current concepts. neurologist. 2009;15(2):87–94. 2. krafft rm. trigeminal neuralgia. am fam physician 2008;77(9):1291–6. 3. hall gc, carroll d, parry d, mcquay hj. epidemiology and treatment of neuropathic pain: the uk primary care perspective. pain. 2006;122(1–2):156–62. 4. manzoni gc, torelli p. epidemiology of typical and atypical craniofacial neuralgias. neurol sci. 2005;26(2):65–7. 5. eller jl, raslan am, burchiel kj. trigeminal neuralgia: definition and classification. neurosurg focus. 2005;18(5):e3. 6. katusic s, beard cm, bergstralh e, kurland lt. incidence and clinical features of trigeminal neuralgia, rochester, minnesota, 1945-1984. ann neurol. 1990;27(1):89–95. 7. jainkittivong a, aneksuk v, langlais rp. trigeminal neuralgia: a retrospective study of 188 thai cases. gerodontology. 2012;29(2):e611–7. 8. siqueira sr, teixeira mj, siqueira jt. clinical characteristics of patients with trigeminal neuralgia referred to neurosurgery. eur j dent. 2009; 3(3):207–212. 9. nayyar as, khan m. trigeminal neuralgia: revisiting clinical characteristics in the indian scenario. jour of med sc & tech. 2012;1(2):9–17. 10. loh hs, ling sy, shanmuhasuntharam p, zain r, yeo jf, khoo sp. trigeminal neuralgia: a retrospective survey of a sample of patients in singapore and malaysia.aust dent j. 1998;43:(3):188–91. 11. neto hs, camilli ja, marques mj. trigeminal neuralgia is caused by maxillary and mandibular nerve entrapment: greater incidence of right-sided facial symptoms is due to the foramen rotundum and foramen ovale being narrower on the right side of the cranium. med hypotheses. 2005;65(6):1179 – 82. 12. gronseth g, cruccu g, alksne j, argoff c, brainin m, burchiel k, et al. practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of thequality standards subcommittee of the american academy ofneurology and the european federation of neurological societies. neurology.2008;71(15):1183–90. 13. mcnamara jo. goodman & gilman’s the pharmacological basis therapeutics. 12th ed. new york. mcgraw hill: 2001. 14. campbell fg, graham jg, zilkha kj. clinical trial of carbamazepine (tegretol) in trigeminal neuralgia. j neurol neurosurg psychiatry. 1966;29(3):265–7. 15. jorns tp, zakrzewska jm. evidence-based approach to the medical management of trigeminal neuralgia. br j neurosurg. 2007;21(3):253 – 61. 16. bennetto l, patel nk, fuller g. trigeminal neuralgia and its management. bmj. 2007;334(586):201–5. 17. tatli m, satici o, kanpolat y, sindou m. various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes. acta neurochirurgica. 2008;150(3):243–255. 18. hasan s, khan ni, sherwani oa, bhatt v, asif s. trigeminal neuralgia: an overview of literature with emphasis medical management. international research journal of pharmacy. 2012;3(11):235–8. 19. thomas kl, vilensky ja. the anatomy of vascular compression in trigeminal neuralgia. clin anat. 2014;27(1):89–93 sri hudaya widihastha, henny anggraini sadeli, arifin sunggono: clinical characteristics of trigeminal neuralgia patients at dr. hasan sadikin general hospital bandung indonesia in 2010–2012 vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 149 profile of nutritional status and nutrient intake among children with cerebral palsy in dr. hasan sadikin general hospital bandung zahra fitrianti,1 ellyana sungkar,2 lola ilona hamied3 1faculty of medicine universitas padjadjaran, indonesia, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: zahra fitrianti, faculty of medicine universitas padjadjaran, , jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, email: zaarafit@gmail.com introduction cerebral palsy is a disorder of movement and posture caused by non-progressive injury or damage in the immature brain.1 cerebral palsy is the most common motoric abnormality in children which is marked by changes in muscle tones and posture whether in resting condition or voluntary contraction.1,2 cerebral palsy can be classified into four types based on an abnormality in muscle tones, namely spastic, dyskinetic, hypotonic, and mixed.1 patients with cerebral palsy also have a problem in growth and nutrition.3-5 the north american cerebral palsy growth project stated that at least 27% of patients with cerebral palsy suffer from malnutrition.1 malnutrition could happen when the nutrient intake can not fulfill one’s metabolic needs. the energy needs of a cerebral palsy patient vary according to the type of cerebral palsy.5 a non-ambulatory spastic quadriplegic cerebral palsy patient will have lower energy expenditure than normal children.2,5 in contrast, an ambulatory cerebral palsy patient will spend more energy than normal children.2,3 motoric abnormalities can cause patients with cerebral palsy to have eating problems and difficulties to get food intake which can supply their energy need.1,5,6 higher energy needs, eating problems, parents’ lack of knowledge and bad eating amj. 2019;6(3):149–53 abstract background: children with cerebral palsy have abnormalities in the motoric function that cause feeding problems and higher energy requirements compared to normal children. these problems put the patients at risk of getting inadequate nutrient intake, leading to malnutrition and thus affecting the health outcomes. this study aimed to explore the nutritional status and nutrient intake among children with cerebral palsy. methods: children with cerebral palsy who came for a rehabilitation program in the department of physical medicine and rehabilitation dr. hasan sadikin general hospital bandung were recruited from september–october 2014. descriptive quantitative study design was performed. nutritional status was determined by body weight and body height or length if the children could not stand upright to calculate z-scorebmi-for-age and length/height-for-age according to who. undernutrition was determined when z-score≤ -2; stunting was designated as height below the average of their age; whereas wasting as a weight. a repeated 24 hours of food recall was used to measure nutrient intake. results: there were 18 children with cerebral palsy, consisting of boys (n=7) and girls (n=11). only 33.3% of patients had good nutritional status, the others (n12; 67.7%) were under nutrition; of whom stunting (n7) was found, followed by wasting (n3) and both stunting and wasting (n2). these under nutrition patients had predominantly a lower energy and carbohydrate intake. conclusions: most of the cerebral palsy children are in under nutrition status due to a low energy and carbohydrate intake, therefore, special attention in mother education for the food pattern of their children needs to be raised. keywords: cerebral palsy, nutrient intake, nutritional status althea medical journal. 2019;6(3) 150 amj september 2019 habits can cause inadequate nutrient intake in patients withcerebral palsy.5,7 inadequate nutrient intake could result in poor nutritional status which can cause growth interference and worsen outcomes for patients with cerebral palsy.4,5,8 the aim of this study was to describe the nutritional status and nutrient intake of patients with cerebral palsy in dr. hasan sadikin general hospital bandung. methods this study had a quantitative descriptive study design. the consecutive sampling was performed on children with cerebral palsy who came for a rehabilitation program in the department of physical medicine and rehabilitation in dr. hasan sadikin general hospital bandung in september to october 2014 was recruited. informed consent was signed by the parents of these children before taking part in this study. the parents were then asked about food and drinks that the patient had consumed in the last 24 hours, using repeated a 24hour food recall method. food recall was conducted three times to assess the eating habit of the children; of which two times in the weekdays and once in the weekend, and the cycle was repeated once. the children cq. the parents who did not come in the designated time were contacted through phone, and they were dropped out from the study when they did not answer the phone. anthropometric measurement was performed, consisting of the body weight and body height; weight measurement was conducted using scales with 0.1 kg accuracy, whereas height measurement conducted using microtoise with 0.1 cm accuracy. the length measurement was performed in the children who could not stand upright using a measuring tape. z-scores for bmi-for-age and length/height-for-age were then calculated using software who anthro for children from 0 to 5 years old and who anthroplus for children from 5 to 19 years old. the nutritional status was classified based on the who recommendation. patients were categorized as undernutrition when z-score≤ -2. nutrient intake was calculated from repeated 24-hour food recall data. the amount of food and drinks consumed by the patients was converted into grams using daftar ukuran rumah tangga (urt). this study had been approved by the ethical committee of dr. hasan sadikin general hospital. results in total, 25 children with cerebral palsy were recruited, however, 5 were dropped out in the middle of the study because they could not be contacted for follow-up food recall and 2 parents decided to resign from the study since they moved out from the treatment program, resulting in 18 children as the respondents of this study, consisting of mostly girls (n 11; 61.1%). these children were from middleclass economic status, and the type of cerebral palsy was predominantly spastic quadriplegia (table 1). as shown in table 2, the median age was table 1 the characteristic of children with cerebral palsy in dr. hasan sadikin general hospital recruited in september–october 2014 characteristic total gender boys 7 girls 11 the economic status of the parents upper class 3 middle class 11 lower class 4 type of cerebral palsy spastic hemiplegia 2 spastic diplegia 5 spastic quadriplegia 11 althea medical journal. 2019;6(3) 151zahra fitrianti et al.: profile of nutritional status and nutrient intake among children with cerebral palsy in dr. hasan sadikin general hospital bandung table 2 the z-score of children with cerebral palsy in dr. hasan sadikin general hospital recruited in september–october 2014 characteristics boys (n=7) girls (n=11) median range median range age (years old) 3.5 11.08 2 9.08 weight (kg) 16 20.1 10.3 12.5 length or height (cm) 94 55 92 56 z-score length or height-for-age -4.14 4.77 -1,13 11.10 bmi-for-age -0.68 7.08 0.12 10.57 3.5 (range 11.08) years old in boys and 2 (range 9.08) years old, with the youngest was 11 months old and the oldest was 12 years old. the nutritional status was classified based on z-score, categorized as undernutrition when z-score for bmi-for-age and/or length or height-for-age≤ -2. the result showed 12 children (66.7%) were undernutrition (table 3), of whom 7 had height below average of children for their age known as stunting, and 3 other had weight below average although the height was normal, known as wasting, and 2 were both stunting and wasting (data not shown). taken together, 10 of 12 children with undernutrition were those with cerebral palsy type spastic quadriplegia, came from lower economy class families (table 4). energy intake in children with cerebral palsy with undernutrition was much less than those who were well-nourished; similar to carbohydrate, fat, and protein intake, in which the well-nourished patients consumed a lot more carbohydrate (table 5). food recall in this study had been performed in patients from different economic status, with different level of knowledge. a lot of patients’ mothers admitted that their children were very difficult to feed. one said that she had to chase her child every time she fed him, and several other mothers admitted that their children only ate 3 until 5 spoons in every meal. mothers who had moderate knowledge about cerebral palsy clearly explained which food their children were allowed to eat and which were not, but even they still had difficulties in feeding their children. in the end, these mothers allowed their children to eat anything they wanted, in the hope for them to still eat and not to starve. the mothers cared less about whether the food had enough nutrition or not. daily meal frequency determined the nutrient intake in patients with cerebral palsy. eight of twelve patients with undernutrition ate less than three times a day. one patient almost always vomited her food, another patient had oromotor impairment; causing him difficulties to eat. another patient was sick when food recall had been asked and the rest were more likely refused to be fed. all of these reasons made mothers less patient and easier to feel tired once they fed their children and decided to only give food two times a day, either morning and noon or morning and night. the economic status of cerebral palsy patients’ family was not the main factor affecting nutrient intake but still playedan important factor. all patients who came from the low economy class family in this study suffered entirely from undernutrition, which they had meals with bad composition, consisting of rice and few side dishes two times a day, with or without a snack in between. the reason was that their family condition had made this impossible to give their children enough nutritious food. one patient with cerebral palsy type spastic quadriplegia from table 3 the distribution of nutritional status based on gender nutritional status male (n=7) female (n=11) total (n=18) undernutrition 5 7 12 well-nourished 2 4 6 althea medical journal. 2019;6(3) 152 amj september 2019 upper economy class family was found to suffer from undernutrition; she had quite a difficulty to eat so the mother admitted feeding her child anything without concerning nutritional composition to keep her child fed. discussion the result of this study has shown that more than half (66.7%) of children with cerebral palsy suffer from undernutrition. patients with cerebral palsy have a high risk of undernutrition due to abnormality in motor function which results in eating problems and higher energy needs than normal kids.3,5 moreover, patient with more severe motor abnormality has a higher risk.3 of our patients with cerebral palsy who was in undernutrition condition, most (58%) of them were stunted, the other (25%) were wasted, and the rest suffer from stunting and wasting, confirming the study results that cerebral palsy patients have lower anthropometric measurement compared to the normal children in their age.6,9 undernutrition in our study is affecting ten of twelve (83%) cerebral palsy patients with spastic quadriplegia type. this result is consistent with study conducted by the north american cerebral palsy growth project; undernutrition is suffered in around one-third of cerebral palsy patients with hemiplegia and diplegia type, and more than two-third patients with quadriplegia type, respectively.1 patients with more severe type of cerebral palsy, commonly spastic quadriplegia type, tend to have difficulty in fulfilling their energy needs and nutrition.5 these patients have more complicated functional and motoric impairments, therefore, it is more difficult to get adequate food intake. moreover, these patients have higher energy needs than normal children due to the greater inefficiency of muscle action.3 the nutritional status of patients with cerebral palsy is associated with the nutrient intake which is obtained from food and drinks and also their eating habits. furthermore, the eating habit of patients with cerebral palsy is influenced by the family factor, the degree of motoric impairment and eating ability of the patients,4,6,8 especially those with more severe motoric impairment, they are depending on their parents to get food.6 the presence of eating problems such as always vomiting food, table 4 the distribution of nutritional status based on the type of cerebral palsy and economic status undernutrition (n=12) well nourished (n=6) total (n=18) type of cerebral palsy spastic hemiplegia 1 1 2 spastic diplegia 1 4 5 spastic quadriplegia 10 1 11 economic status upper class 2 1 3 middle class 6 5 11 lower class 4 0 4 table 5 the nutrient intake profile of children with cerebral palsy in dr. hasan sadikin general hospital recruited in september–october 2014 undernutrition (n=12) well nourished (n=6) median range median range energy intake (kkal) 767.5 951.1 955.5 571.5 protein (gr) 33.2 45.8 36.5 21.4 fat (gr) 26.1 49.2 27.9 18.9 carbohydrate (gr) 116.5 139.8 128 136.6 althea medical journal. 2019;6(3) 153 long eating time, food rejection, etc. can make parents lose their patience and finally give the fewer amount of food than it should be.6 mothers’ knowledge about the disease itself also affects the amount of nutrient intake the patients will get.6 patients with cerebral palsy who suffer from undernutrition have lower energy and carbohydrate intake than those who are well nourished. however, fat intake in cerebral palsy patients with undernutrition does not differ much with cerebral palsy patients who are well-nourished. this is due to the fact that the food consumed by the patients in the undernutrition group is high in fat content.7 patients who suffer from undernutrition are less likely to eat rice and side dishes, thus their mothers allow them to buy outside meals, consistent to study result that shows the diet of patients with cerebral palsy who suffer from undernutrition is high in fat and low in carbohydrate.7 the diet among cerebral palsy patients which has a high content in fat and low in carbohydrate, and additionally with milk and other sweet drinks which is consumed using bottles due to lack of ability to drink, may cause problems to a dental condition, among other dental caries.5 interestingly, this dental problem has not been found in most of the cerebral palsy patients.10 in this study, only two subjects found to suffer from dental caries. nutrient intake and nutritional status of patients with cerebral palsy are also influenced by the eating ability and eating habit. cerebral palsy patients with severe impairments who are fed orally have lower anthropometric measurement than other patients with milder impairments, or with same impairments but fed by gastrostomy tube.9 the limitation of this study is that the eating ability and habit in patients in our study are not explored. all eighteen patients have a variety of eating ability and problems, such as not being able to hold their food, can not eat and drink by themselves, and also difficulty in swallowing. studies in eating ability and habit in patients with cerebral palsy are encouraged. the other limitation is that the measurement for z-score uses the standard charts for normal children; no z score special for patients with cerebral palsy has been developed yet. to conclude, most children with cerebral palsy in our study suffer from undernutrition due to inadequate nutrient intake, predominantly consisting of low energy and carbohydrate intake. education in mothers about the disease itself needs to be raised and psychological family support needs special attention for better food intake and food pattern of their children. references 1. mukherjee s, gaebler-spira dj. cerebral palsy. in: braddom rl, editor. physical medicine and rehabilitation. 4th ed. philadelphia: saunders elsevier ; 2010. p. 1243–61. 2. bell kl, davies ps. energy expenditure and physical activity of ambulatory children with cerebral palsy and of typically developing children. am j clin nutr. 2010;92(2):313–9. 3. andrew mj, sullivan pb. growth in cerebral palsy. nutr clin pract. 2010;25(4):357–61. 4. henderson rc, grossberg ri, matuszewski j, menon n, johnson j, kecskemethy hh, et al. growth and nutritional status in residential center versus home-living children and adolescents with quadriplegic cerebral palsy. j pediatr. 2007;151(2):161– 6. 5. cloud h. medical nutrition therapy for intellectual and developmental disabilities. in: mahan lk, escott-stump s, raymond jl, krause mv, editors. krause’s food & the nutrition care process. 13th ed. philadelphia: elsevier saunders; 2012. p. 1020–40. 6. grammatikopoulou mg, daskalou e, tsigga m. diet, feeding practices, and anthropometry of children and adolescents with cerebral palsy and their siblings. nutrition. 2009;25(6):620–6. 7. lopes pac, amancio oms, araujo rfc, vitalle msds, braga jap. food pattern and nutritional status of children with cerebral palsy. rev paul pediatr. 2013;31(3):344–9. 8. kim js, han za, song dh, oh hm, chung me. characteristics of dysphagia in children with cerebral palsy, related to gross motor function. am j phys med rehabil. 2013;92(10):912–9. 9. day sm, strauss dj, vachon pj, rosenbloom l, shavelle rm, wu yw. growth patterns in a population of children and adolescents with cerebral palsy. dev med child neurol. 2007;49(3):167–71. 10. preetika c, vivek ka. oral status of a group of cerebral palsy children. j dent oral hyg. 2011;3(2):18–21. zahra fitrianti et al.: profile of nutritional status and nutrient intake among children with cerebral palsy in dr. hasan sadikin general hospital bandung amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 11amj. 2020;7(1):11–5 propolis of trigona spp. protects mucosa from aspirin-induced gastric mucosal damage in rats achadiyani,1 anindita laksmi,2 dolvy girawan3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia abstract background: helicobacter pylori and non-steroid anti-inflammatory drugs are the major causes of peptic ulcer in the world. indonesian native stingless bee species, trigona spp., produces propolis that might be effective to protect mucosal damage. the aim of the study was to determine the protective effect of trigona spp. propolis on aspirin-induced gastric mucosal damage in rats. methods: this experimental study was conducted from september–november 2013 at animal laboratory of department of pharmacology and therapy faculty of medicine universitas padjadjaran. healthy male wistar rats (n=24) aged 2–3 months old and weighed 200–250 grams were randomly divided into three groups. the first group was control negative, the second group was given 100 mg/ kg body weight of aspirin, and the third group was given 200 mg/kg body weight of trigona spp. propolis, one hour before administration of 100 mg/kg body weight of aspirin. after two weeks of treatment, rats were sacrificed by laparotomy to obtain gastric tissues, followed by processing for the paraffin section for histopathological analysis. the grade of gastric mucosal damage was determined under a light microscope. data were then compared between groups using the mann-whitney test. results: oral administration of aspirin-induced gastric mucosal damage ranging from grade 0 to grade iv; whereas administration of propolis showed a reduction of gastric mucosal damage’s grade when compared to the aspirin group (p<0.05). conclusions: trigona spp. propolis has a protective effect on aspirin-induced gastric mucosal damage. further study is encouraged to study an optimal dose of aspirin after propolis administration. keywords: aspirin, gastric mucosal damage, propolis, trigona spp correspondence: achadiyani, department of biomedical sciences faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia. e-mail: achadiyani@gmail.com introduction about 10% of the population in western countries are affected by peptic ulcer.1 a peptic ulcer is predominantly caused by helicobacter pylori and non-steroid anti-inflammatory drugs (nsaid).2 aspirin is a member of nsaid that is known as anti-inflammatory, antiplatelet, analgesic, antipyretic, and cardiovascular protection drug. because of the broad use of aspirin, it becomes the most widely used drug.3 however, aspirin causes an imbalance between protective factors and aggressive factors, resulting in gastric mucosal damage.4 there has been a tendency to go back to nature, seeking new treatment for various diseases. in indonesia, various natural products have been used to treat diseases, among others honey and propolis. propolis is a sticky resin substance collected by honeybees from several plants that have been used as one of the natural remedies since thousand years ago. indonesia has a native stingless bee species trigona spp that produces propolis. propolis produced by trigona spp. has a higher flavonoid level than apis mellifera propolis.5 research shows that propolis has antimicrobial activity, antiviral, antifungal, antiprotozoal, antiparasitic, antiinflammatory, and antiulcer.6 the aim of this https://doi.org/10.15850/amj.v7n1.1677 althea medical journal. 2020;7(1) 12 amj march 2020 10% formalin for 24 hours. parrafin sections were prepared and stained with hematoxylin and eosin.9 for each rat, there were 15 fields to examine using a light microscope, thus, per group (n=8) there were 120 fields to examine. these fields were graded using the grading system to evaluate the severity of mucosal damage based on its depth which categorized into grade 0 to grade iv. the grade 0 was normal gastric mucosal; grade i was characterized by a damage of surface mucosal cell on luminal surface and partly exfoliated, but there is no damage to gastric pit cells; grade ii was characterized by an extensive luminal surface cell damage and damage to the cells lining the gastric pits, but there was no damage to gastric gland cells; grade iii was characterized by damage on surface and pit cells, cellular damage in the upper part of the gastric glands (parietal cell area), numerous exfoliated cells and a whole layer of the necrotic superficial epithelium; and grade iv was characterized by severe damage of grade iii and extending into the lower part of the gastric glands (chief cell area), and submucosal edema.9 data were analyzed with statistical product and service solutions (spss) software, and a mann-whitney test was performed. data difference was considered statistically significant if the p-value was less than 0.05. results histological examination revealed that there were various grades of gastric mucosal damage in each group as shown in figure 1. as expected, all rats from the control group had normal tissues (grade 0) as presented in table1. furthermore, aspirin administration had shown higher grades, whereas extra propolis before aspirin administration had shown a shift into lower grades (p<0.05, the mann whitney test), suggesting that propolis trigona spp. had protective effects against aspirin-induced gastric mucosal damage. study was to determine the protective effect of trigona spp. propolis against aspirin-induced gastric mucosal damage in rats. methods this experimental study was conducted from september–november 2013 at the animal laboratory of department of pharmacology and therapy faculty of medicine universitas padjadjaran. all experiments performed in the animal laboratory in this study were approved by the health research ethics committee faculty of medicine universitas padjadjaran. aspirin was purchased from a drugstore. aspirin weighed using digital by the dosage of each treatment group and dissolved in 4 ml of aquadest. trigona spp. propolis was purchased from faculty of agriculture industrial technology universitas padjadjaran jatinangor. in brief, twenty-four healthy male wistar rats aged 2–3 months old and weighed 200–250 grams were placed in a homogenous temperature and dark-light cycle with ad libitum access to food and drink. before initiating treatments, rats were allowed to acclimatize to a new environment conditions for seven days. then, rats were randomly divided into three groups where four rats were placed in one cage. the first group served as a control group that was given only food and drink. the second group was given 100 mg/kg body weight of aspirin, dissolved in 4 ml of distilled water.7 the third group was given a 200 mg/kg body weight of trigona spp. propolis one hour before administration of 100 mg/kg body weight of aspirin.7,8 all treatments were given orally every day for two weeks. in the fifteenth day, rats were sacrificed by using the midline laparotomy method under ketamine anesthesia. the stomach of the rats was cut open along the lesser curvature and gently rinsed with 0.9% nacl solution. gastric tissue samples from each group were fixed in table 1 the distribution of severity grade of gastric mucosal damage group grade total field examined* 0 i ii iii iv control 120 120 aspirin 4 34 60 20 2 120 propolis + aspirin 27 64 25 4 120 note: *there were 15 fields examined each wistar rat (n=8) per group althea medical journal. 2020;7(1) 13 figure 1 grade 0 with normal mucosa appearance (a). exfoliation on surface mucosal cell (s) in grade i (b) and damage extended to cell lining gastric pit in grade ii(c). grade 3 showed damage in surface mucosa cell (s), pit, and parietal cells (p) (d). extensive necrosis and damage were extended to the chief cell (c) in grade iv (e). (h&e, 400x)9 achadiyani et al.: propolis of trigona spp. protects mucosa on aspirin-induced gastric mucosal damage in rats althea medical journal. 2020;7(1) 14 amj march 2020 components that have antioxidant activity and thus can protect gastric from aggressive factors, such as caffeic acid phenethyl ester (cape). in other research, propolis has been reported to be able to reduce gastric juice volume, total acidity, and ph, and to increase antioxidant activity.14,15 another study has reported that 200 mg/kg body weight of indian propolis has protective effects against nsaid-induced gastric ulcers, similar to propolis trigona spp. that has a protective effect against aspirininduced gastric mucosal damage in rats.8 trigona spp. propolis has the same protective effect against aspirin-induced gastric mucosal damage with indian propolis and brazilian propolis, suggesting that protective effect due to phytochemicals.8,16 the limitation of the study is that the dosage given in this study is only one dose. studies with a varying dosage of propolis trigona spp. to determine the optimal dosage for protective effects against aspirin-induced gastric mucosal damage is recommended. in conclusion, trigona spp. propolis has a protective effect against aspirin-induced gastric mucosal damage. further study is needed to explore the effect of propolis administration on the optimal dose of aspirin. references 1. amin d. a textbook of clinical pharmacology and therapeutics. ritter jm, lewis ld, mant tgk, ferro a, editors. a textbook of clinical pharmacology and therapeutics. 5th ed. great britain: hodder arnold; 2008. p. 247. 2. soll ah, graham dy. peptic ulcer disease. yamada t, alpers dh, kalloo an, kaplowitz n, owyang c, powell dw, editors. textbook of gastroenterology. 5th ed. west sussex: wiley blackwell; 2009. p. 936–73. 3. yeomans nd. aspirin: old drug, new uses and challenges. j gastroenterol hepatol. 2010;26(3):426–31. 4. musumba c, pritchard dm, pirmohamed m. review article: cellular and molecular mechanisms of nsaid-induced peptic ulcers. aliment pharmacol ther. 2009;30:517–31. 5. mahani, karim ra, nurjanah n, dahlianti r. keajaiban propolis trigona. 1st ed. jakarta: pustaka bunda; 2011. p. 33–55 6. lotfy m. biological activity of bee propolis in health and disease. asian pacific j cancer prev. 2006;7:22–31. 7. seleem hs. effect of aspirin versus aspirin and vitamin c on gastric mucosa (fundus) discussion aspirin is one of the most widely used drugs. it has been reported that aspirin is associated with gastric mucosal damage. this study has shown that administration of aspirin 100 mg/ kg body weight has induced changes in mucosal gastric; including cellular changes, interstitial hemorrhage and cellular damage in the gastric gland. furthermore, exfoliated cells are frequently noted in gastric lumen. moreover, grade ii is the most frequent in the group with aspirin administration; and this grade has been reduced to grade i by the administration of propolis prior to aspirin (table 1). in grade ii, damage cells are from the luminal surface to cells lining in the gastric pit, whereas the damage only happens in mucosal cells of the luminal surface in grade i.9 this indicates that aspirin might have an impact on local and systemic effects. in an acidic environment, aspirin is dissolved in fat, allowing aspirin to enter mucosa and dissociate inside the gastric mucosa. the dissociation causes uncoupled oxidative phosphorylation and release reactive oxygen species (ros).4,10 aspirin has a systemic effect that contributes to the gastric mucosa damage. aspirin inhibits prostaglandin synthesis through inhibition of cyclooxygenase enzyme. prostaglandin plays an important role as a defensive factor of the gastric mucosa. cyclooxygenase-1 produces prostaglandin that regulates mucus secretion, bicarbonate secretion, and maintains the mucosal blood flow. furthermore, cyclooxygenase-2 produces prostaglandin that regulates the proliferation of epithelial cells and maintains the vascular endothelium to intact by preventing attachment of neutrophil. inhibition of prostaglandin synthesis will disrupt those functions and make gastric mucosa becomes vulnerable to aggressive factor such as acid juice and pepsin.4,10 propolis is believed to have a polyphenol component flavonoids that has many forms; those are flavonol, flavonon, flavon, flavanolol, flavan, and isoflavon. flavonoid acts as an antioxidant, therefore, the decreased grading of gastric mucosal damage in the propolis group may be partially due to its antioxidant activity.11,12 flavonoid level of trigona spp. propolis is 4%, greater than of apis mellifera which is 1.5%.13 next to antioxidant, the flavonoid in propolis is reported to have other gastroprotective effects; those are increasing mucosal blood flow, mucus and amount of prostaglandin in the stomach. beside flavonoid, propolis has other althea medical journal. 2020;7(1) 15achadiyani et al.: propolis of trigona spp. protects mucosa on aspirin-induced gastric mucosal damage in rats of adult male albino rats. histological and morphometric study. egypt j histol. 2010;33(2):313–26. 8. pillai si, kandaswamy m, subramanian s. antiulcerogenic and ulcer healing effects of indian propolis in experimental rat ulcer models. j api prod api med sci. 2010;2(1):21–8. 9. morini g, grandi d. methods to measure gastric mucosal lesion in the rat. curr protoc toxicol. 2010;43:1–15. 10. wallace jl. prostaglandin, nsaid, and gastric mucosal protection : why doesn’t the stomach digest itself. physiol rev. 2008;88(4):1547–65. 11. narayana kr, reddy ms, chaluvadi mr. bioflavonoid classification, pharmacological, biochemical effects and therapeutic potential. indian j pharmacol. 2001;33(1):2–16. 12. mota ks, dias ge, pinto me, luiz-ferreira â, souza-brito ar, hiruma-lima ca, et al. flavonoids with gastroprotective activity. molecules. 2009;14(3):979–1012. 13. siregar hc, fuah am, octavianty y. propolis: madu multikhasiat. 1st ed. jakarta: penerbit swadaya; 2011.p. 35 14. de barrosa mp, sousab jp, bastosb jk, de andradea sf. effect of brazilian green propolis on experimental gastric ulcers in rats. j ethnopharmacol. 2007;110(3):567– 71. 15. mohafez omm, abdel-raheem it, nafady am. antioxidant, lipid peroxidationinhibitory and antiulcer activities of brown propolis. bull pharm sci. 2010;33:169–77. 16. lemos m, de barros mp, sousa jp, da silva filho aa, bastos jk, de andrade sf. baccharis dracunculifolia, the main botanical source of brazilian green propolis, displays antiulcer activity. j pharm pharmacol. 2007;59(4):603–8. vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 179 knowledge, attitude, and behavior regarding homosexualilty among new students in universitas padjadjaran ade nea,1 rudi wisaksana,2 enny rohmawaty3 1faculty of medicine universitas padjadjaran, indonesia, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: ade nea, faculty of medicine, universitas padjadjaran. jalan raya bandung-sumedang km. 21, sumedang, indonesia email: adenea952013@gmail.com introduction homosexuals refer to individuals who are having sex orientation towards same sex.1 homosexual men are termed gays, while homosexual women are called lesbians. issue of homosexuality draws controversy around the globe. several countries accept homosexuality, and still many more reject the concept. in 2013, pew research center reports that 93% of indonesians reject homosexuality.2 homosexuals are rejected by the community as they are regarded as sinful, amoral, and abnormal.3 this negative attitude deters homosexual from access to health care.4 this in turn lead homosexuals to commit high risk sexual behaviors such as unprotected men who have sex with men (msm) and men who have sex with men and woman (msmw).5 highrisk sexual behavior in homosexuals increases the risk of sexually transmitted diseases and human immunodeficiency virus (hiv) in this population.6 homosexuals commit high-risk sexual behavior, which could give rise to health issues. students have been an integral part of the health system and have a role in generate positive impact at community level and as agents of change directly and indirectly.7 their role as agents of change is by influencing knowledge, attitudes, and practices within community.7 new students are needed as the young generation are regarded as agents of change that are responsible in educating the amj. 2018;5(4):179–86 abstract background: homosexualilty has raised a controversy in the society, which commonly has a negative attitude towards homosexual. it is important to develop knowledge and attitude about homosexuality in new students as agents of change. this study aimed to identify the knowledge, attitude, and behavior of new undergraduate students in universitas padjadjaran about homosexual. methods: this was a descriptive quantitative cross-sectional study using primary data obtained from questionnaires, distributed not randomly to new undergraduate students of 2016/2017 academic year in universitas padjadjaran (n=122) from october to november 2016. questions asked were demographic data, knowledge and attitude towards homosexualilty, and homosexual behavior. results: respondents had a good knowledge (18%; n=22), average (66.4%; n=81) and low knowledge (15.6%; n=19) about homosexuality and the majority (55.7%; n=68) of respondents had a negative attitude towards homosexuality. a heterosexual behavior had been showed in 92.6% (n=113) respondents, and 7.4% (n=9) had a heterosexual dominant behavior. conclusions: in our new undergraduate students’ community, the majority has average knowledge, however, with a negative attitude towards about homosexuality. the role of new students as agents of change is to educate the community to prevent potential health issues. the developing of knowledge, attitude, and behavior towards homosexual through a holistic education from health workers should be promoted. keywords: attitude, behavior, homosexual, knowledge althea medical journal. 2018;5(4) 180 amj december 2018 community as a prevention to potential health problems. their knowledge and attitude towards homosexuality are vital in shaping opinions in the community. high population of young people are expected to solve health problems. therefore, studies assessing the knowledge, attitude, and behavior of new students regarding homosexuals are needed. the academic year of 2016/2017 in universitas padjadjaran are attended by 6.148 students.8 the aim of this study was to assess the knowledge, attitude, and behavior of new undergraduate (strata-1) students of universitas padjadjaran from academic year 2016/2017 regarding homosexuals. methods this was a descriptive, quantitative, crosssectional study conducted from october– november 2016 in 16 faculties of universitas padjadjaran. subjects involved in this study were new undergraduate (strata-1) students of universitas padjadjaran from academic year 2016/2017. total final sample used in this study was 122, which was obtained according to minimal total sample proportion from 16 faculties in universitas padjadjaran, utilizing solvin equation.9 this study was not randomized due to time constraints. there were more female subjects than men due to female was a majority population in universitas padjadjaran, but no special treatment in this study. subject that consent to participate signed the consent sheet and filled the questionnaire of the study. if the questionnaire are not completed or not returned, the subject would not be included in this research. questionnaires used in this study were the adaptation from sex education and knowledge about homosexuality (sekh), attitude toward homosexual questionnaire (ahq), and homosexual experience from world health organization year 2005.10,11 sex education and knowledge about homosexuality questionnaire (sekhq) and ahq had been used by dunjić-kostić et al.10 the adapted questionnaire was translated by four oathed and certified linguist from cultural science faculty, universitas padjadjaran, and was validated. validation process in this study was performed in new students of 16 faculties. this process was done three times with different subjects in each process and this study used the last validated questionnaire. subjects who have followed the validation process are not permitted to take part in this study. data collected were analyzed with statistical software. sex education and knowledge about homosexuality questionnaire (sekhq) was a validated 15-questions questionnaire measuring knowledge about homosexual with reliability score of 0.793. respondents answered questions about knowledge with “true,” “false,” or “don’t know”. in data analysis, “false” and “don’t know” answers are given score “0”, while “true” answers are given score “1”. fifteen was the score for all true answers. in the end of the analysis, knowledge scores were categorized as “good”, “average”, and “low”. good knowledge was designated if respondent scored above average score of all respondent. average knowledge was designated if respondent scored in average of all respondent. low knowledge was designated if respondent scored below average score. attitude towards homosexual questionnaire was a validated 12-questions questionnaire measuring attitudes toward homosexual with reliability score of 0,714. attitude questions were composed with 6 positive and 6 negative inquiries utilizing likert scale from 1 (“strongly agree”) to 5 (“strongly disagree”). high score indicated a negative attitude towards homosexual. behavior was measured with homosexual experience, a 9-questions questionnaire which was not validated. it was composed with general questions, questions for male respondents, and questions for female respondents. behaviors was categorized in two groups, heterosexual and dominant heterosexual or sexual orientations other than heterosexual.12 this research was approved by the health researches ethics commitee faculty of medicine universitas padjadjaran (592/ un.c1.3.2/kepk/pn/2016), rector of universitas padjadjaran, and representatives of dean in all faculties in universitas padjadjaran to be conducted on new students from academic year 2016/2017. results all 122 respondents in this study returned the completed questionnaire. the total of respondents was in accordance with the calculated sample size from proportional random sampling calculation in each faculty. the majority of respondents were female, and all respondents declared themselves as heterosexual. the sociodemographic characteristic data of respondents are detailed in table 1. althea medical journal. 2018;5(4) 181 table 1 sociodemographic characteristic of new undergraduate students characteristics total (n) percentage (%) age (years) median 18 minimum 16 maximum 20 sex male 47 38.5 female 75 61.5 faculty law 9 7.4 economy and business 8 6.6 medicine 6 4.9 mathematics and natural sciences 15 12.3 agriculture 8 6.6 dentistry 4 3.3 social and political sciences 12 9.8 cultural sciences 15 12.3 animal husbandry 7 5.7 communication sciences 12 9.8 nursery 3 2.5 fishery and naval sciences 7 5.7 agricultural industry technology 6 4.9 geological engineering 4 3.3. pharmacy 3 2.5 psychology 3 2.5 based on the retrieved data, 18% (n=22) of respondents had a “good” knowledge about homosexual, 66.4% (n=81) had an “average” knowledge, and 15.6% (n=19) had a “low” knowledge. a total of 68% (n=83) respondents answered “true” in the question “in some cultures, same-sex intercourse among boys is a common practice”, meanwhile 95% (n=116) respondents answered “false” in “a majority of homosexuals were seduced when they were teenagers by a person of the same sex, usually a few years older than they were then”. data related to the knowledge of new students regarding homosexuals are reported in figure 1. a total of 55.7% (n=68) respondents show a negative attitude, while 44.3% (n=54) show a positive attitude towards homosexuals. a ade nea, rudi wisaksana, enny rohmawaty: knowledge, attitude, and behavior regarding homosexualilty among new students in universitas padjadjaran total of 71% (n=87) respondents “strongly agree” that “celebrations such as “gay pride day” are stupid because they assume that a person’s sexual orientation is something that they can be proud of ”, and 55% (n=67) respondents “strongly disagree” if same-sex marriage among homosexuals are permitted. most of the respondents disagree with homosexuality. however, most respondents agree with homosexuals having social equality and having equality in job opportunity. data regarding attitudes of new students towards homosexuals are reported in figure 2. from the respondents of this study, 92.6% (n=113) respondents were heterosexual and 7.4% (n=9) was heterosexual dominant. a total of 2% (n=1) of male respondents had been doing same-sex intercourse (msm). data althea medical journal. 2018;5(4) 182 amj december 2018 figure 1 knowledge regarding homosexuals althea medical journal. 2018;5(4) 183 figure 2 attitudes towards homosexuals ade nea, rudi wisaksana, enny rohmawaty: knowledge, attitude, and behavior regarding homosexualilty among new students in universitas padjadjaran althea medical journal. 2018;5(4) 184 amj december 2018 regarding behavior towards homosexual are explained in figure 3. discussions most respondents had an average knowledge regarding homosexuals, and only a few respondents had a good knowledge. this finding is in concordance with previous study in students of medicine in zagreb13, which found that the level of knowledge of most students about homosexuals is inadequate. this study agreed with the previous study that showed having a good level of knowledge about homosexuals in new students is expected to reduce discrimination in health services and to increase awareness in the society about causes and concequences of homosexuals.4,14. this study discovered that negative attitude towards homosexuals was found to be higher than positive. however, although most respondents disagree with homosexuality, they do not prohibit homosexuals from having equal social and occupational rights. this is in concordance with a study by dunjićkostić et al.10 that used same questionnaries which states that generally medical students supported employment equality. many factors could affect the attitude towards homosexuals, one of them is the level of knowledge about homosexuals. previous studies utilizing the same questionnaire with this study showed that the level of knowledge about homosexuals was a strong predictor of attitude expressed to homosexuals, and better knowledge leads to a more positive attitude towards homosexuals.15 sexual orientation could also affect the attitude towards homosexual. teenagers with heterosexual orientation had a more negative attitude towards homosexuals.16 in the previous studies, teenagers that hold the believe to traditional values and gender role show a more negative attitude towards homosexuals.16 in this research, all respondents stated themselves as heterosexuals, however there is a possibility of stigma about homosexual in society affecting respondents, leading to partial disclosure while filling questionnaires, although the name of respondents was not required in the questionnaire.17 study results showed that most respondents had a heterosexual behavior, and interestingly, new students with heterosexual dominant behavior figure 3 behavior regarding homosexualilty among new undergraduate students althea medical journal. 2018;5(4) 185 was detected. students in this group mostly did sexual contact such as hugging with same sex and touching the genitals of their peers. there were several respondents who admit they had been attracted to same sex, and one student had been doing same sex intercourse. this is in concordance with past studies in young adults, which found that most of the respondents were heterosexuals, followed by heterosexual dominant.18 this study discovered that a negative attitude towards homosexuals was found to be higher than positive. although most respondents disagree with homosexuality, they do not prohibit homosexuals from having equal social and occupational rights. this is in concordance with a study conducted by dunjićkostić et al.10 that used same questionnaires which states that generally medical students supported employment equality. many factors could affect the attitude towards homosexual, one of them is the level of knowledge about homosexuals. previous studies utilizing the same questionnaire with this study showed that the level of knowledge about homosexuals was a strong predictor of attitude towards homosexuals and better knowledge leads to a more positive attitude towards homosexuals.15 sexual orientation could also affect the attitude towards homosexuals. teenagers with heterosexual orientation had a more negative attitude towards homosexuals.16 in the previous studies, teenagers that hold the belief to traditional values and gender role shows a more negative attitude towards homosexuals.16 in this study, all respondents stated themselves as heterosexuals, however there is a possibility of stigma about homosexuals in society affecting respondents, leading to partial disclosure while filling questionnaires, although the name of respondents was not required in the questionnaire.17 study results showed that most respondents had a heterosexual behavior and interestingly, some new students with heterosexual dominant behavior was detected. students in this group mostly did sexual contact such as hugging with same sex and touching the genitals of their peers. there were several respondents that admitted that they had been attracted to the same sex and one student had been doing same sex intercourse. this is in concordance with past studies in young adults, which found that most of the respondents were heterosexuals, followed by heterosexual dominant.18 the limitation of this study was the misunderstood question in the questionnaire. respondents that had been experiencing physical contacts such as hugging and touching with their peers did not assume that their peers were homosexuals. in past studies it was shown that physical contacts such as hugging could be done with peers without sexual attraction.19 new students as agents of change that could educate the society in the effort of solving health problem should have a good knowledge, good attitude and good behavior towards homosexual. this study discovered that new students having good knowledge about homosexuals are still a minority, and there are still new students with low level of knowledge. a comprehensive educational effort to new students regarding homosexual is needed, so that there is a similar level of knowledge about homosexual among new students. this study also found a new student that had been doing same sex intercourse. this is expected to be a basis for administering counsel and education by educational institutions and health workers about homosexual, particularly regarding health problems which could rise due to risky sexual behavior. further studies are recommended to identify factors affecting the level of knowledge, attitude and behavior about homosexual. other studies are also expected to find correlation between knowledge, attitude and behavior about homosexual. references 1. sadock bj, sadock va, ruiz p, editors. kaplan & sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. philadephia: lippincott williams & wilkins; 2015. p. 564–72. 2. kohut a. the global divide on homosexuality: greater acceptance in more secular and affluent countries. washington dc: pew res cent; 2013. [cited 2018 november 29] available from: http://www.pewresearch.org/wpcontent/uploads/sites/2/2014/05/pewglobal-attitudes-homosexuality-reportrevised-may-27-2014.pdf 3. mavhandu-mudzusii a, sandy pt. religionrelated stigma and discrimination experienced by lesbian, gay, bisexual and transgender students at a south african rural-based university. cult health sex. 2015;17(8):1049–56. 4. arreola s, santos g-m, beck j, sundararaj m, wilson pa, hebert p, et al. sexual stigma, criminalization, investment, and access ade nea, rudi wisaksana, enny rohmawaty: knowledge, attitude, and behavior regarding homosexualilty among new students in universitas padjadjaran althea medical journal. 2018;5(4) 186 amj december 2018 to hiv services among men who have sex with men worldwide. aids behav. 2015;19(2):227–34. 5. jefferies iv wl, johnson od. homonegative attitudes and risk behaviors for hiv and other sexually transmitted infections among sexually active men in the united states. am j public health. 2015;105(12):2466–72. 6. rice ce, maierhofer c, fields ks, ervin m, lanza st, turner an. beyond anal sex: sexual practices of men who have sex with men and associations with hiv and other sexually transmitted infections. j sex med. 2016;13(3):374–82. 7. kumar s, lensink il, turnbull c. tips for using students during times of change in health care: lessons from the literature and from practice. adv med educ pract. 2017;8:535–40. 8. rektor universitas padjadjaran. daya tampung dan pola penerimaan mahasiswa baru universitas padjadjaran tahun akademik 2016/2017. jatinangor; 2016. p. 1–3. 9. sevilla cg, ochave ja, punsalan tg, regala bp, uriarte gg. an introduction to research methods. manila: rex bookstore; 1984. p. 183. 10. dunjić-kostić b, pantović m, vuković v, randjelović d, totić-poznanović s, damjanović a, et al. knowledge: a possible tool in shaping medical professionals’ attitudes towards homosexuality. psychiatr danub. 2012;24(2):143–51. 11. cleland j, ingham r, stone n. asking young people about sexual and reproductive behaviours: illustrative core instruments. geneva: world health organization; 2005. 12. talley ae, grimaldo g, wilsnack sc, hughes tl, kristjanson af. childhood victimization, internalizing symptoms, and substance use among women who identify as mostly heterosexual. lgbt health. 2016;3(4):266–74. 13. grabovac i, abramović m, komlenović g, milošević m, mustajbegović j. attitudes towards and knowledge about homosexuality among medical students in zagreb. coll antropol. 2014;38(1):39–45. 14. mucherah w, owino e, mccoy k. grappling with the issue of homosexuality: perceptions, attitudes, and beliefs among high school students in kenya. psychol res behav manag. 2016;9:253–62. 15. banwari g, mistry k, soni a, parikh n, gandhi h. medical students and interns′ knowledge about and attitude towards homosexuality. j postgrad med. 2015;61(2):95–100. 16. feng y, lou c, gao e, tu x, cheng y, emerson mr, et al. adolescents’ and young adults’ perception of homosexuality and related factors in three asian cities. j adolesc health. 2012;50(3 suppl):s52-60. 17. pescosolido ba, martin jk. the stigma complex. annu rev sociol. 2015;41:87– 116. 18. savin-williams rc, joyner k, rieger g. prevalence and stability of selfreported sexual orientation identity during young adulthood. arch sex behav. 2012;41(1):103–10. 19. galinsky am, mcclintock mk, waite lj. sexuality and physical contact in national social life, health, and aging project wave 2. j gerontol b psychol sci soc sci. 2014;69 suppl 2:s83-98. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 518 amj december 2017 effectiveness of print and audiovisual media in breast cancer education to high-school students amanda carissa wardhani,1 sri yusnita irda sari,2 dharmayanti francisca badudu3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: breast cancer education could be a non-formal education to achieve a proper understanding about early detection of breast cancer. optimal results need right methods and instruments. recently, technology development can be implemented to support the non-formal education process. the purpose of this study was to determine the effectiveness between print and audiovisual media in health education on prevention and early detection of breast cancer. methods: it was a quasi-experimental study, comparing two intervention and one control groups, which was carried out from august to november 2013. the population was senior high school students in jatinangor subdistrict west java, indonesia. the sample was taken by cluster sampling method; each group consisted of 120 female students. students from sekolah menengah atas negeri jatinangor were given printed media, students from sekolah menengah kejuruan padjadjaran were given audiovisual media and students from pesantren al ma’soem as control group were not given any intervention. the knowledge of respondents was measured with pre-test and post-test questioner. mean scores of knowledge were further analyzed by paired and independent t-test. results: the average of pre-test between intervention and control groups were similar (8.125, 8.725 and 8.450, respectively). the result showed that the average scores of post-test increased compared to pre-test both in the print and audiovisual media group (p=0.001). conclusions: print and audiovisual media can increase the knowledge of respondents on prevention and early detection of breast cancer. however, audiovisual media is more effective as a tool for health education especially among teenagers. keywords: audiovisual, breast cancer education, effectiveness, print media correspondence: amanda carissa wardhani, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: amandacwardhani@gmail.com introduction breast cancer is the most common type of cancer among women worldwide and the global incidence of breast cancer increases annually.1-11 the majority of breast cancer patients come to the hospital in advanced stages, indicating that awareness and knowledge about breast cancer is still low as well as negative social-cultural perception of the disease.4-6,9,11 it is difficult to know the signs and symptoms of breast cancer because it is rarely painful. the easier way of early detection for breast cancer is breast self-examination.3-9,11 early treatment of breast cancer will likely lead to get better prognosis. furthermore, education to society to give better understanding about breast cancer is needed to prevent breast cancer especially to young woman.4-8,11 breast cancer education could be a non-formal education to increase knowledge to achieve a proper understanding toward breast cancer. to get optimal results of breast self-examination, right methods and instruments are needed.10-12 recently, current development of technology can be implemented to support the education process, for instance through media such as leaflets or audiovisual means. the purpose of this study was to get information about differences of breast cancer education effectiveness between the use of print and audiovisual media to high school female students in jatinangor subdistrict, west java, indonesia. amj. 2017;4(4):518–23 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1261 althea medical journal. 2017;4(4) 519 methods a quasi experimental study was conducted for 4 months (august–november 2013). data were collected from female highschool students in jatinangor district. the participants were divided into 3 groups; two groups were experimental groups and one was the control group. participants in the experimental group received breast cancer education, one group received leaflets (print media) as the education material while the other group received education through audiovisual aids. participants assigned to the control group received none. three schools were selected from a total of 10 high-schools in jatinangor using simple random sampling, then 120 second grade students were selected as the study participants which consisted of 40 students of each school. a set of questionnaire was used to assess the knowledge before and after the interventions in both experimental and control groups. before breast cancer education, the experimental group and the control group received a pretest questionnaire. one week after the breast cancer education program, a post-test was applied to the experimental groups. the questionnaire contained definition, risk factor, sign symptom and treatment of breast cancer, and was then validated before the intervention to 21 female students in highschools which were not selected in the study (cronbach’s alpha=0.685). the questionnaire consisted of 20 statements which assessed their knowledge about breast cancer and the common risk factors of breast cancer. a correct answer was assigned one point, whereas a wrong answer was scored zero. the results were calculated as frequencies of the correct answer out of the total answer of the same question and analyzed by paired t-test for each method in pre and post-test results, and independent t-test for post-test both interventions using print and audiovisual media. table 1 data distribution based on respondent’s characteristics variables frequencies (n) percentage (%) age (years old) 15 11 9.0 16 81 66.4 17 26 22.0 total 118 100 level of mother’s education elementary school graduated 34 28.8 junior high school graduated 18 15.3 senior high school graduated 34 28.8 diploma/bachelor 32 27.1 total 118 100 family income (rp) <1,050,000,00 23 19.5 1,050,000,00–2,000,000,00 41 34.7 2,000,000,00–6,000,000,00 25 21.2 >6,000,000,00 29 24.6 total 118 100 family history of breast cancer no 104 88.1 yes 14 11.9 total 118 100 amanda carissa wardhani, sri yusnita irda sari, dharmayanti francisca badudu: effectiveness of print and audiovisual media in breast cancer education to high-school students althea medical journal. 2017;4(4) 520 amj december 2017 the intervention using leaflets was adopted from a leaflet about breast cancer education and prevention which was developed by an oncology team from the department of surgery, dr. hasan sadikin general hospital. furthermore, the intervention using table 2 knowledge score level intervention x ̅ sd leaflet pre-test 8.125 2.681 post-test 14.025 2.674 audiovisual pre-test 8.725 3.273 post-test 15.225 2.177 control 8.450 2.773 note: x ̅ = mean; sd = standard deviation table 3 knowledge score level for correct answer about breast cancer according to leaflet, audiovisual and control group statement leaflet(%) audiovisual(%) control (%) pre post pre post breast cancer is a communicable disease 67.5 82.5 82.5 100 80 breast cancer is all lump found in breast 45 45 40 50 25 breast cancer is not a curse disease 90 80 72.5 72.5 77.5 a woman who get menarche under age 12 has higher risk of breast cancer 5 82.5 5 87.5 0 a woman who has child will have higher risk of breast cancer 42.5 72.5 42.5 72.5 40 a woman who gave birth to her first child after 30 years old will get higher risk of breast cancer 10 15 25 12.5 15 a woman who has never breastfed or breastfeeding her children will get more risk of breast cancer 17.5 80 35 95 50 a woman who has a mother or sister who had breast cancer are more at risk of breast cancer 32.5 82.5 35 95 35 a woman who consumed a low-fat diet is more at risk of breast cancer 22.5 70 47.5 57.5 22.5 smoking increases the risk of breast cancer in women 65 90 55 87.5 67.5 alcohol consumption increases the risk of breast cancer in women 55 87.5 52.5 95 47.5 breast cancer more experienced among women older than 40 years 32.5 50 40 90 17.5 a lump in the breast is one of early symptoms of breast cancer 60 97.5 82.5 100 85 lump caused by breast cancer always feels pain 0 15 7.5 32.5 10 one sign of breast cancer is nipple will be retracted 20 92.5 15 100 22.5 breast cancer can be overcome only by surgical removal of the lump 15 45 17.5 40 10 breast cancer is difficult to cure 27.5 40 40 47.5 25 self-breast examination can detect breast cancer earlier 72.5 100 47.5 95 77.5 self-breast examination require a lot of money to perform 37.5 75 37.5 97.5 47.5 healthy lifestyle can reduce the risk of breast cancer 95 100 92.5 95 90 althea medical journal. 2017;4(4) 521amanda carissa wardhani, sri yusnita irda sari, dharmayanti francisca badudu: effectiveness of print and audiovisual media in breast cancer education to high-school students audiovisual media was developed by the researcher under supervision of an oncologist from dr. hasan sadikin general hospital. informed consent was given to all participants before the interventions and ethical approval from the health research ethics committee, faculty of medicine of universitas padjadjaran was obtained before the study was conducted. results the total number of respondents of this study was 120 respondents; however data of two respondents were missing due to the incomplete questionnaires. consequently, the actual number of respondents in this study was 118 respondents. the youngest age was 15 years while the oldest age was 17 years (mean=16.13 years old), the level of mother’s education was mostly poor; the lowest family income was 19.5% below the regional minimum salary, otherwise, the highest family income was 34.7% above the minimum salary. in addition, 11.9% of the respondents admitted that there was a history of breast cancer in their family (table 1). the average score of post-test after the intervention of breast cancer education using both print and audiovisual media showed an improvement. the average knowledge before the intervention was almost similar among the use of leaflets, audiovisual aids and control group; 8.125, 8.725 and 8.450, respectively (table 2). moreover, breast cancer education using leaflets (print media) or audiovisual aids mostly showed better score in the posttest. the most increasing score rate was on question number 4 which stated that“a woman who gets menarche under age 12 has higher risk of breast cancer”. the correct answers in the pre-test were only 5% both in print media (leaflet) or audiovisual media group, afterward a significant increase by 82.5% was found remarkably at the post-test. on the other hand, there were correct answers in the similar scores between the pre-test and post-test which occurred on question number 2 which stated about “breast cancer is all lump found in breast” (table 3). the average score on the correct answers of the pre-test by use of leaflet (print media) was 8.125 (sd=2.681), and the mean score on the post-test was 14.025 (sd=2.674), also using audiovisual media was 8.725 (sd=3.273), and the mean score on the post-test was 15.25 (sd=2.177). there was a significant increase between the pre and post-test using print (leaflet) and audiovisual media (table 4). a significant difference could be seen from the average of correct answers on the post-test with p=0.031. intervention using audiovisual media provided mean score at 15.225, while intervention using leaflet presented an average of correct answers at 14.025 (table 5) table 4 comparison of level of knowledge between pre-test and post-test intervention (n=40) intervention correct answer t test paired p-valuepre-test post-test x ̅ sd x ̅ sd leaflet 8.125 2.681 14.025 2.674 -12.533 0.001 audiovisual 8.725 3.273 15.225 2.177 -13.722 0.001 note: x ̅ = mean; sd = standard deviation table 5 comparison on level of knowledge after intervention between print and audiovisual media (n=40) leaflet audiovisual t test paired p-valuex ̅ sd x ̅ sd pre-test 8.125 2.681 8.725 3.273 -0.897 0.373 post-test 14.025 2.674 15.225 2.177 -2.200 0.031 note: x ̅ = mean; sd = standard deviation althea medical journal. 2017;4(4) 522 amj december 2017 discussion based on the study among high-school students in jatinangor on health education, prevention and early detection of breast cancer, suggesting that an increase in knowledge was found after interventions both using print and audiovisual media. it showed that knowledge about health can be improved through health education.12 based on the idea that we can increase the public health status, thus promotion activities must be prioritized through health education especially for teenagers, such as on prevention and early detection of breast cancer. the roles of educational method, for instance education by audiovisual aids was more effective than using leaflets. the theory on educational method stated that the more senses involved in receiving something, the more understanding we can gain.12 useful educational method helps to stimulate sensory at the time of the submission of information on the education process, subsequently knowledge can be easily obtained.10 during the educational process, the community can acquire knowledge through a variety of educational tools. proper tools should be selectively chosen to improve knowledge especially about the prevention and early detection of breast cancer for teenagers.10 the results showed the difference in the effectiveness of breast cancer prevention education using leaflets or audiovisual media to high-school students in jatinangor. this difference could be seen from the average response on the post-test, education using leaflets got 14.025 while audiovisual aids got 15.225 (table 4). a leaflet (print media) is likely to provide clear and extensive information; consequently, the readers are able to store information in their memory. an interesting feature on the leaflet will be able to attract the student’s interest. the advantage of the leaflet is that it can stimulate the senses of the eyes at the time of the educational process, besides it is a cost-effective and handy tool which can also be read many times as they wish. moreover, it can be multiplied and distributed to relatives or close friends so that the information will be disseminated. audiovisual aids are proficient to improve the effectiveness in gaining knowledge and information. in addition, audiovisual applications have advantages in displaying real objects that do not exist physically. besides cognitive learning, audiovisual aids will improve student’s memory about materials given during the education process.17-20 the audiovisual media is able to stimulate the senses of vision and hearing at the time of delivery of educational material. furthermore, audiovisual applications also have the ability to combine all the material circumstances, such as text, video, animation, images, graphics, and sound effects. it becomes a unified whole in the presentation. display a fun interactive audiovisual application led to higher student interest rather than view the leaflet.13-16 the limitation of this study was the posttest which was taken only one week after the pre-test, it could be any differential memory in each respondent to remember what they had learned, and in addition the questionnaire was selfadministered therefore recall bias might occur. in conclusion, the audiovisual media is more effective than the print media as a tool for health education especially toward teenagers. each leaflet or audiovisual aids has advantages, consequently a proper method should be chosen according to the time, place and situation of the audience. education of reproductive health is important to be developed as part of the school’s curriculum as a non-formal subject for teenagers. references 1. laveena, karkada s. effectiveness of an informational leaflet on knowledge regarding breast cancer among women of reproductive age. nujhs. 2013;3(3):93–5. 2. ramalingam s, nivedhita s, divya p, madhurima p, poonguzhali r. knowledge and attitude about breast cancer selfexamination among school teacher in an urban area of coimbatore. asian student medical journal. 2012;11(1):1–7. 3. smith ra, caleffi m, albert us, chen th, duffy sw, franceschi d, et al. breast cancer in limited-resource countries: early detection and access to care. breast j. 2006;12 suppl 1:516–26. 4. kanaga kc, nithiya j, shatirah mf. awareness of breast cancer and screening procedure among malaysian women. asian pac j cancer prev. 2011;12(8):1965–7. 5. rasjidi i. deteksi dini & pencegahan kanker pada wanita. jakarta: sagung seto; 2009. 6. radi sm. breast cancer awareness among saudi females in jeddah. asian pac j cancer prev. 2013;14(7):4307–12. 7. akhtari-zavare m, juni mh, manaf ra, ismail iz, said sm. knowledge on breast cancer and practice on breast althea medical journal. 2017;4(4) 523 self examination among selected female university student in malaysia. medical and health science journal. 2011;7:49–56. 8. grunfeld ea, ramirez aj, richards ma. women’s knowledge and belief regarding breast cancer. british journal of cancer. 2002;86(9):1376–7. 9. wang hh, chung yc, sun jl. the effect of education program on knowledge and intention of breast cancer screening in taiwan. asian pac j cancer prev. 2012;13(11):5545–9. 10. khokher s. qureshi w, mahmood s, saleem a, mahmud s. knowledge, attitude and preventive practices of women for breast cancer in the education institutions of lahore, pakistan. asian pac j cancer prev. 2011;12(9):2419–24. 11. al-dubai sa, qureshi am, saif-ali r, ganasegeran k, alwan mr, hadi ji. awareness and knowledge of breast cancer and mammography among a group of malaysian women in shah alam. asian pac j cancer prev. 2011;12(10):2531–2. 12. notoatmodjo s. promosi kesehatan & ilmu perilaku. jakarta: rineka cipta; 2007. 13. parsa p, kandiah m. breast cancer knowledge, perception and breast self examination practices among iranian women. the international medical journal. 2005;4(2):20–3. 14. ng ch, pathy nb, taib na, teh yc, mun ks, amiruddin a, et al. comparison of breast cancer in indonesia and malaysia – a clinico-pathological study between dharmais cancer centre jakarta and university malaya medical centre, kuala lumpur. asian pac j cancer prev. 2011;12(11):2945–6. 15. keegan th, derouen mc, press dj, kurian aw, clarke ca. occurrence of breast cancer subtypes in adolescent and young adult women. breast cancer res. 2012;14(2):r55. 16. handayani s, sudarmiati s. pengetahuan remaja putri tentang cara melakukan sadari. journal nursing studies. 2012;1(1):93–100. 17. pujiyanti a, trapsilowati w, suwasono h. perbandingan dua metode pembelajaran tentang demam berdarah dungue pada guru sekolah dasar. media litbang kesehatan. 2012;22(4):173–80. 18. salimar, mulyati s, agus t, dewi r. peran penyuluhan dengan menggunakan leaflet terhadap perubahan pengetahuan dan sikap ibu balita gizi kurang. pgm. 2009;32(2):122–30. 19. montqomery aa, fahey t, peter tj. a factorial randomised controlled trial of decision analysis and an information video plus leaflet for newly diagnosed hypertensive patient. br j gen pract. 2003;53(491):446–53. 20. zakrzewska jm. research summary: the impact of patient information leaflets. br dent j. 2003;194(12):683–8. amanda carissa wardhani, sri yusnita irda sari, dharmayanti francisca badudu: effectiveness of print and audiovisual media in breast cancer education to high-school students althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 83 fall risk based on timed up and go test in elderly at nursing home in west java, indonesia thiruchelvam selvadurai,1 tertianto prabowo,2 yuni s.pratiwi3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, biology cell and physiology faculty of medicine universitas padjadjaran abstract background: falls are major cause of morbidity and mortality in elderly patients. mobility assessment is important in preventing falls in elderly. this study was conducted to determine the level of fall risk in elderly people at karitas cimahi nursing home, west java, indonesia by using ‘timed up and go test’(tug). methods:this cross-sectional descriptive study was conducted at karitas cimahi nursing home from june– november 2013. the risk of falls was categorized into two; high and low risk of falls. high risk of falls indicated when the participants complete the tug test with time taken >10 seconds, and low risk of falls indicated when the time taken is <10 seconds. to identify the level of fall risk in elderly people the test which is recommended by the american geriatric society was used. the sampling technique used was total sampling. data was analyzed and presented by using frequency tables. results: from a total of 32 elderly population at karitas cimahi nursing home, a total of 20 participated in this study. the ‘timed up and go test’ result for all the participants were >10 seconds. conclusions: the level of fall risk in elderly people at karitas cimahi nursing home based on the test showed that all participants, both male and female, regardless of using assistive device have high level risk of falls. [amj.2017;4(1):83–6] keywords: elderly, risk of falls, ’timed up and go test’ correspondence: thiruchelvam selvadurai, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87827785882 email: thiruchelvam2186@hotmail.com introduction an increasing number of elderly occurred worldwide as a part of health improvement impact. statistics showed that there were estimated 35 million people aged 65 and above in the year 2000. this number is estimated to increase to 70 million in the year 2030. the group of frail elderly people is the most vulnerable and also causes the most expenses for treatment, medication, long term care and medical illness. these are also the main causes which lead many researchers to carry out ample of studies to enhance the quality of healthy life among elderly people.1 the most common reason that causes injury to elderly individuals are falls.2 every year one out of three elderly aged 65 and above falls while elderly above 80 years old falls one out of two.3 furthermore, a frequently used tool is the timed up and go test (tug), which is recommended by the american geriatrics society to do screening for risk of falling.4 a lower cut off point of 10 seconds is the best time which have predictive value of sensitivity 71% and specificity 86%.5 this test has a meaningful information for further care management especially in community dwelling or residential care facilities. the main purpose of this study was to identify the level of fall risk among elderly people at karitas cimahi nursing home based on tug. methods a descriptive cross-sectional study was carried out at karitas cimahi nursing home, indonesia from june–november 2013. primary data collection was done by total sampling from elderly people who lived althea medical journal. 2017;4(1) 84 amj march 2017 there. the total population at karitas cimahi nursing home was 32 participants and out of that only 20 participants could fulfill the inclusion and exclusion criteria of the study. the inclusion criteria of this study was participants regardless of male or female who were 60 years old and above without any physical injuries. the exclusion criteria were any elderly subject who could not respond to verbal instructions or were unable to walk. this study was approved by the health research ethics committee of the faculty of medicine universitas padjadjaran. the participants gave their consent on participation. all subjects were identified by filling an identity form that had their name, age and gender. subjects were given adequate explanation about the test and also demonstration by the researcher by performing the tug test. participants were allowed to wear glasses if they had visual problems. in the tug test, an armchair of standard height was used and a distance of 3 meters was marked with a line of tape on the floor. the starting position was sitting with hands resting on the arms of the chair. the participants crossed the line before turning around and walked back to sit in the chair again. they were instructed to perform the tug test at their normal speed and they performed one trial before they were timed. the timing of the tug test started when the participant got up from the chair and stopped when the participant’s buttocks touch the seat of the chair again. throughout the test, local nurses were required to accompany the participants to prevent any complication of falls. the risk of falls is categorized into high risk of falls which is indicated when the participants complete the test with time taken more than 10 seconds and low risk of falls indicated when the time taken was less than 10 seconds. the data was collected and analysed using appropriate computer software. the results were shown as the frequency of high risk of falls and frequency of low risk of falls among elderly people in the form of table. results the total elderly people population at karitas cimahi nursing home was 32 people; specifically 8 males and 24 females. out of 32 participants only 20 fulfilled the inclusion and exclusion criteria. from these 20 participants, 4 of them were males and 16 were females. table 2 tug test result gender tug score (second) level of risk high risk low risk male 16.61 4 0 female 24.47 16 0 total 20 0 note: tug = timed up and go table 1 characteristic of respondents characteristic n(20) age range age=62 to 93 gender male 4 female 16 table 3 tug test results with and without using assistive device assistive device tug score (seconds) risk fall classification male using=0 high risk not using=4 16.61 female using=2 63.26 high risk not using=14 18.93 note: tug = timed up and go althea medical journal. 2017;4(1) 85thiruchelvam selvadurai, tertianto prabowo, yuni s.pratiwi: fall risk based on timed up and go test in elderly at nursing home in west java, indonesia all participants were found to be having risk of falls with mean tug score >10 seconds regardless of their gender. female participants showed higher risk of falls compared to male (table 2). participants who use an assistive device to walk had a higher risk than those didn’t use the assistive device. there was a prominent difference in the time taken for participants from the same gender but using an assistive device (table 3). discussion the characteristics of the risk of fall in elderly people at karitas cimahi nursing home based on tug test showed that all participants had high risk of falls. there were several factors that might influence this result outcome in karitas cimahi nursing home. firstly, the average age group of elderly who lives here was 75.1. risk of falls increases with increase of aging, thus most of the participants in this study had higher risk of falls. falls is a main problem in elderly people especially in women.6 in this karitas cimahi nursing home most of the elderly were females, thus this age group had higher risk of falls. furthermore, there was lack of physical activities in this nursing home because there was no routine exercise program other than outdoor activities such as sunbathing. most of the time, the elderly people would be doing their routine activities while sitting, not moving around. this showed that most of the elderly here had less mobility, which contributed to higher risk of falls. physical activities will increase the muscle strength which are also important to maintain a proper gait and balance of an individual. reduction in muscle strength will eventually leads to poor daily living activity, decrease physical strength and prominent disturbance of good quality of life of elderly people.7 thus, decreased muscle strength and problem in gait and balance result in high risk of falls. furthermore, disorders of gait and balance contributes about 3 times the risk of falling.8 the time taken to heal from fall related injury is long, especially for elderly people who will experience prolonged immobility.9 nutritional factors also contributes to the high risk of falls here. most of the meals for the elderly here were normal food such as rice, chicken and vegetables. these meals excluded milk or special formulated milk which contains vitamin d or calcium which is essential for strengthening the bone in elderly people’s body. at this nursing home a medical check up was performed every once in a month by local doctors and nurses. the check up only included taking blood pressure, pulse rate, blood sugar level, cholesterol and also dental check ups. special health care checkups namely for falls risk, gait and balance, and muscle strength, were given less priority. for those who were using assistive walking devices, the devices must be bought by some elderly people themselves here and some were sponsored. thus, all these factors contributed to the high risk of falls among elderly people at karitas cimahi nursing home. in this study, it showed that even if the participant was older than the others, his or her tug score did not indicate that the higher the age, the higher the tug score. falls is the main reason for high mortality and morbidity in elderly people.1 a study stated that an enviromental hazard, tripping over an object and fall records the highest cause for falling, followed by slipping.3 the elderly people who are staying at a nursing home have prevalence of falls more than those who are living with communitee.10 in a previous study, it is stated that elderly people staying in residential care facilities are often frail because of multiple causes such as intake of medicines, lack of muscle strength, susceptible to sickness which contributes to unstability and falls.3 although risk of falls increase with age but this statement can be argued because the risk of falls also depends on many other factors for example such as genetic, environment, nutritional status, and many more. overall from this study, all the participants had risk of falls at karitas cimahi nursing home. it is therefore suggested that the management of this nursing home should give more importance in preventing the incidence of falls among the elderly. this nursing home should also make sure that elderly people were given opportunity to do sufficient and pertinent exercise at least for approximately 30 minutes for daily basis. this will increase the muscle strength and increase bone mass thus preventing falls. thorough check up for visual function should also be performed regularly for the elderly at this nursing home. for example, check for the presence of cataract, glaucoma, regular check up with ophtalmologist is essential as it can prevent the incidence of falls. the management of karitas cimahi nursing home should be aware of environmental althea medical journal. 2017;4(1) 86 amj march 2017 hazards. the elderly’s daily living space should be safe. it should have good lighting and substantial grab bars. slippery carpet should be avoided and the bathroom should have nonskid mats and raised toilet seat. this recorded information will be beneficial for the upcoming researchers who will conduct further studies at karitas cimahi nursing home. the limitation of this study is that the population was only from one elderly nursing home, thus it could not represent the total elderly population of indonesia. for further analysis the risk of falls of the individual elderly in this nursing home, upcoming researchers should conduct a cohort study so that the individual at risk of falls can be followed up for a long period of time. this study concludes that all the subjects in karitas cimahi nursing home have high risk of falls so the recommendation is more studies should be conducted at many other nursing homes (panti jompo) so that we can identify the individual with high risk of falls and prevent the incidence of falls. references 1. christine c, rosanne l, harvey c, eric lb, diane me, carol cf, geriatric medicine 4th ed. new york: springer-verlag new york inc; 2003. p. 45 2. nordin e, lindelof n, rosendahl e, jensen j, lillemor ol. prognostic validity of the timed up and go test, a modified getup and go test, staff ’s global judgment and fall history in evaluating fall risk in residential care facilities. age ageing. 2008;37(4):442–8 3. arnold cm, faulkner ra. the history of falls and the association of the timed up and go test to falls and near-falls in older adults with hip osteoarthritis. bmc geriatr. 2007;7:17 4. nordin e, rosendahl e, lundin-olsson l. timed ‘’up and go” test: reliability in focus on cognitive state in older people. phys ther. 2006;86 (5):646–55. 5. whitney jc, lord sr, close jl. streamlining assessment and intervention in a falls clinic using the timed up and go test and physiological profile assessments. age ageing. 2005;34(6):567–71. 6. dennis lk, fauci as, longo dl, braunwald e, hauser sl, jameson jl. harrison internal medicine book. 16th ed. new york: mc graw-hill companies; 2005. p.50 7. yoon je, lee sm, lim hs, kim th, jeon jk, mun mh. the effects of cognitive activity combined with active extremity exercise on balance, walking activity, memory level and quality of life of an older adult sample with dementia. j phys ther sci. 2013;25(12):1601–4. 8. rubenstein lz. falls in elderly people: epidemiology, risk factor and strategic for prevention. age ageing. 2006;35 (suppl 2):ii37–41. 9. delbaere k, bourgois j, noortgate vdn, vanderstraeten g, willems t, cambier d. a home-based multidimensional exercise program reduced physical impairment and fear of falling. acta clin belg. 2006;61(6):340– 50. 10. faisal wa, beattie l, fu h, james k, kalula s, krishnaswamy b, et al. who global report on falls prevention in older age. france: world health organization. 2007. p.1 vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 32 amj march 2018 demographic and risk factors of intracerebral hemorrhage stroke patients in dr. hasan sadikin general hospital bandung in 2007–2016 sabrina putri lofissa,1 paulus anam ong,2 nur atik3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of basic medicine faculty of medicine universitas padjadjaran bandung, indonesia abstract background: intracerebral hemorrhage stroke is a type of stroke which is considered to have a higher mortality risk than ischemic stroke. preventive programs are needed to minimize stroke cases by reducing the risk factors. this study aimed to identify the demographic and risk factors of intracerebral hemorrhage stroke patients in dr. hasan sadikin general hospital bandung in 2007–2016. methods: this was a descriptive cross sectional study. data were obtained from dr. hasan sadikin general hospital medical resume january 2007december 2016 by total sampling. subjects of this study were intracerebral hemorrhage stroke patients hospitalized in dr. hasan sadikin general hospital. the period of study was from august 2016 until may 2017. variables included in this study were gender, occupation, education level, age; risk factors such as hypertension, dyslipidemia, diabetes mellitus, hyperuricemia, and kidney disease. the collected data were presented in percentage. results: the highest demographic prevalence in 10 years was in female, non-occupational person, elementary school graduate, and frequently found in the 50-59 age group. the highest risk factor was hypertension, but it slightly decreased from 78.8% in 2007-2008 to 55.3% in 2015-2016, followed by dyslipidemia, diabetes mellitus, hyperuricemia which increased in 2007-2008 and 2015-2016. (dyslipidemia: from 8.1% to 23.8%; hyperuricemia: from 2.5% to11.2%; diabetes mellitus: from 6.6% to 8.9%). conclusions: the demographic of intracerebral hemorrhage stroke shows a high prevalence found in females, older age, non-occupational persons, and elementary school graduates. among the risk factors, hypertension is most likely to happen in ten years. keywords: demography, intracerebral hemorrhage stroke, risk factors correspondence: sabrina putri lofissa, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: putrilofissa@gmail.com introduction intracerebral hemorrhage stroke is one type of stroke which is considered to have a higher mortality risk than ischemic stroke.1 according to the world health organization (who), stroke was defined as rapidly developed clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death, with no other apparent cause than cerebrovascular disease.2 based on a basic health research (riset kesehatan dasar, riskesdas), the national stroke prevalence showed an increased prevalence from 8.3 per 1000 population in 2007 to 12.1 per 1000 population in 2013.3 according to who, the stroke itself ranks first in the mortality rate in indonesia about 328.000 in 2012.4 west java province has the highest estimated number of stroke patients around 238.001 people (7.4‰) and 533.895 people (16.6‰) based on health personnel (tenaga kesehatan, nakes) or based on diagnosis/symptoms.5 intracerebral hemorrhagic are considered to have a higher mortality than ischemic stroke.1 the risk factors are divided into non-modifiable and modifiable risk factors. some of modifiable risk factors are hypertension, obesity, smoking, diabetes mellitus, hyperuricemia, and heavy alcohol consumption, while the non-modifiable risk factors are age, race, sex, and genetics.6,7 due to the lack of intracerebral hemorrhage stroke data in indonesia, especially in west java amj. 2018;5(1):32–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1333 althea medical journal. 2018;5(1) 33 province which was known to have the most stroke patients in indonesia, this study was carried out to identify the demography and risk factors among intracerebral hemorrhagic patients at dr. hasan sadikin general hospital as a referral hospital in west java. methods the method used in this study was a descriptive cross sectional design which was carried out at the department of neurology, dr. hasan sadikin general hospital from august 2016 to may 2017. the ethics approval has been obtained from dr. hasan sadikin general hospital and the faculty of medicine, universitas padjadjaran health research ethics committee before starting to collect data. the data involved were medical resumes from january 2007 to december 2016 by total sampling with 2259 sample size. the inclusion criteria subjects were intracerebral hemorrhage stroke patients diagnosed in the first admission approved by a computed tomography (ct) scan and hospitalized from 2007 to2016 at dr. hasan sadikin general hospital. incomplete data or missing data of intracerebral hemorrhagic patients’ medical resume were excluded in this study. the variables of demography characteristics included in this study were age, gender, educational level, and occupation. the other variables based on risk factors were hypertension, dyslipidemia, hyperuricemia, diabetes mellitus, and kidney disease. furthermore, data was processed by microsoft office excel 2010 and presented in tables. results among 2259 intracerebral hemorrhagic patients at dr. hasan sadikin general hospital in the period of 2007-2016; only 1168 patients met the inclusion criteria (aged 14-86 years). the total inclusion subjects consisted of 514 male (aged 15-86 years) and 654 female (aged 14-86 years) (table 1). the intracerebral hemorrhagic stroke increases with age. the highest age category was 50-59, while the lowest prevalence occurred at age <40 years with an increase in prevalence from 4% in 2007-2008 to 12.2% in 2015-2016 (table 2). moreover, non-occupation patients had the highest prevalence in 2007-2016. among them were students, housewives, the unemployed and retiree, followed by blue collars and agricultural workers such as farmers, fishermen, and laborers. meanwhile, employee and entrepreneur were the two jobs with the lowest prevalence, with an increased prevalence reaching 18.8% for employee and sabrina putri lofissa, paulus anam ong, nur atik: demographic and risk factors of intracerebral hemorrhage stroke patients in dr. hasan sadikin general hospital bandung in 2007-2016 table 1 demographic characteristic based on gender in 2007-2016 gender 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % male 119 47.0 103 36.3 99 42.7 97 48.0 96 48.7 female 134 53.0 181 63.7 133 57.3 105 52.0 101 51.3 total 253 100 284 100 232 100 202 100 197 100 table 2 demographic characteristic based on age category in 2007-2016 age category (years 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % <40 10 4 11 3.9 25 10.8 14 7 24 12.2 40-49 51 20.2 57 20.1 45 19.3 37 18.3 53 27 50-59 78 30.8 112 39.4 61 26.3 73 36.1 61 30.9 60-69 73 28.8 63 22.2 60 25.9 41 20.3 41 20.8 ≥70 41 16.2 41 14.4 41 17.7 37 18.3 18 9.1 total 253 100 284 100 232 100 202 100 197 100 althea medical journal. 2018;5(1) 34 amj march 2018 14.2% for entrepreneur in 2015-2016 (table 3). based on the difference of educational level; patients who graduated from elementary school or less, were the highest prevalence within 10 years with a declining prevalence in 2015-2016. meanwhile, a decrease in prevalence was shown at the higher educational level among diploma/college/ university graduate patients (table 4). moreover, based on risk factors, the subjects had one or more risk factors. hypertension was the highest risk factor, with the decreasing prevalence from 78.8% in 2007-2008 to 55.3% in 2015-2016, followed by dyslipidemia, diabetes mellitus, and hyperuricemia with an increased prevalence in 2015-2016. meanwhile, there were no significant changes of kidney disease from year to year (table 5). discussion a hospital based study showed that male predominated by 51% between the ages of 2178 and the mean age is 50 years. the female table 3 demographic characteristic based on occupation in 2007-2016 occupation 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % non-occupation 152 60.1 186 65.5 153 65.9 117 57.9 109 55.3 occupation white collar worker employee 39 15.4 19 6.7 10 4.3 17 8.4 37 18.8 entrepreneur 5 2.0 23 8.1 35 15.1 23 11.4 28 14.2 blue collar and agricultural worker 57 22.5 56 19.7 34 14.7 45 22.3 23 11.7 total 253 100.0 284 100.0 232 100.0 202 100.0 197 100.0 table 4 demographic characteristic based on education level in 2007-2016 education level graduates 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % elementary school/ less 187 74 219 77.1 131 56.5 132 65.4 102 51.8 jhs 32 12.6 34 12 68 29.3 35 17.3 33 16.7 shs 33 13.0 29 10.2 31 13.3 33 16.3 51 25.9 d/c/u graduates 1 0.4 2 0.7 2 0.9 2 1 11 5.6 total 253 100 284 100 232 100 202 100 197 100 note: jhs: junior high school, shs: senior high school, d: diploma, c: college, u: university table 5 modifiable risk factors in 2007-2016 modifiable risk factor 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % hypertension 252 78.8 283 65.1 228 71.7 200 62.7 193 55.3 dislipidemia 26 8.1 95 21.8 47 14.8 68 21.3 83 23.8 hyperuricemia 8 2.5 30 6.9 23 7.2 34 10.7 39 11.2 diabetes mellitus 21 6.6 25 5.7 20 6.3 14 4.4 31 8.9 kidney disease 13 4.1 2 0.5 0 0.0 3 0.9 3 0.9 total 320 100.0 435 100.0 318 100.0 319 100.0 349 100.0 althea medical journal. 2018;5(1) 35 is rather older with age ranging from 24-83 years with the mean age of 53 years.6 however, the results of this study showed female were greater in number than male within 10 years. women in pregnancy or postpartum, the longer life expectancy, older age or over 75 years can be considered as the high prevalence found in female.7,8 in this study, the prevalence patient’ age of >70 years were greater in female with 51.1% in the recent two years (2015-2016). stroke incidence increases with age and is expected to double in every decade between the ages of 45 to 85 years. it is most likely to occur between the ages of 55-64 years, while in the age below 40 years is still uncommon.6 the results of this study identified the highest prevalence was found in the age group 55-59 years and an increase of prevalence among age <40 in the last ten years. the increased prevalence among young adults (less than 40) in the recent years is associated with the increasing consumption of junk food and soda or sweet beverages which exceeds the recommended calories per day in young adults. another factor is the prolong inactivity or less frequent physical activity increases the risk of cardiovascular disease.9 based on a study conducted by the korean community health survey10 (kchs) in 2010, 78.8% of the stroke patients are with no occupation. this study revealed those with no occupation within 10 years have the highest prevalence, followed by those who work as blue collar and agricultural workers, and least likely to occur among white collar workers who work as employees or entrepreneurs. the white collar workers tend to get adequate protection, supportive environmental conditions with lower physical demands, and were financially better, while those with no occupation and blue collar and agricultural workers are classified as a low socioeconomic group that have limited access to health facilities and tend to have minimal education. other low socioeconomic groups such as laborers or other blue collar and agricultural workers are frequently affected by physical, chemical, and psychosocial exposure included noise and heat pollution and other environmental factors, thus increase the cardiovascular risk.10,11 however, in this study the low socioeconomic factor is still insufficient to conclude those with no occupation, and blue collar and agricultural workers have a high risk of stroke. the subjects with no occupations in this study were students, housewives, the unemployed and retired. this study showed that the prevalence of age above 50 years was greater than the age below 50, therefore the majority of the subjects might be considered as retired with old age. based on the educational level, the result of this study showed that patients graduated from elementary school or less had the highest prevalence within 10 years and were 51.8% in the last two years, while those graduated from diploma/college/university had the lowest prevalence within 10 years, and were approximately 5.6% in the last two years. in agreement in this study, previous studies reported that educational attainment represents a form of health awareness and socioeconomic status. people with higher education also tend to have an urgency to understand the health consequences, while people with lower educational level are associated with cognitive impairment and unhealthy lifestyles.11,12 based on the interstroke study involving 22 countries reported that hypertension is the highest prevalence among intracerebral hemorrhagic patients with 83% (551/663), and stronger for intracerebral hemorrhagic than ischemic stroke.13 chronic hypertension leads to vascular changes include fibroid necrosis (lipohyalinosis) of penetrating arteries and arterioles supplying the white matters, microaneurysm formation, luminal narrowing and microhemorrhage, all of which are susceptible to rupture.14,15 in this study, hypertension was the highest prevalence among intracerebral hemorrhagic patients and there was a decreasing hypertension prevalence from year to year. an increased awareness of people who have checked into health facilities could be a factor of decreasing hypertension prevalence.3 a study conducted by the chongqin center for disease control and prevention in 2014 showed 37.4% dyslipidemia among stroke patients had hypertriglyceridemia and low high-density lipoprotein (hdl) cholesterol. this phenomenon is likely due to the high carbohydrates intake and high-fat-diets in recent decades, which affects the high serum triglyceride level.16 the result in this study is in agreement with the previous study that people with dyslipidemia were found in intracerebral hemorrhagic patients and 23.8% were in the last two years. hyperuricemia was associated with cardiovascular disease and other risk factors such as hypertension, high triglyceride and cholesterol serum, and metabolic syndrome, though, the mechanism is poorly understood. however, the role of uric acid is sabrina putri lofissa, paulus anam ong, nur atik: demographic and risk factors of intracerebral hemorrhage stroke patients in dr. hasan sadikin general hospital bandung in 2007-2016 althea medical journal. 2018;5(1) 36 amj march 2018 controversial since on the other hand uric acid has neuroprotective effects by acting as a free radical scavenger.17 in this study, the prevalence of hyperuricemia among intracerebral hemorrhagic patients increased from year to year, reaching 11.2% in recent two years. furthermore, interstroke study showed the prevalence of diabetes mellitus among intracerebral hemorrhagic patients were 10%.13 there is not much difference between the previous studies and ours since the recent prevalence in two years in this study were 8.6%. diabetes mellitus is one of the cardiovascular risk that accelerates the atherosclerosis progression and damages microvasculature which leads to hypertension.2,6 in this study, kidney disease was the least likely to occur among intracerebral hemorrhagic patients and had no significant changes from year to year. atherosclerosis risk in communities (aric) reported that a low creatinine clearance among chronic kidney disease (ckd) and anemia were associated with the increase risk for stroke. a study in japan18 revealed that ckd with macroalbuminuria are independent risk factors for stroke. however, a single kidney disease is still insufficient as an independent risk factor for stroke.18 in conclusion, the high prevalence among intracerebral hemorrhage stroke is frequently found in female, older age, nonoccupation and low level of education person. hypertension is the highest risk factor, followed by dyslipidemia, diabetes mellitus, and hyperuricemia with deleterious effect on microvasculature. metabolic syndrome includes high cholesterol and plasma glucose level, high blood pressure, and hyperuricemia is associated with cardiovascular disease and diabetes mellitus type 2 which reflects the stroke patients. a bad lifestyle includes high intake calories from junk food, smoking and less physical activity are enough to explain the reason of increasing prevalence of diabetes mellitus, dyslipidemia, and hyperuricemia in the recent years in this study.17,19 this study had certain limitations. the cross-sectional design of this study was limited in analyzing the correlation between variables of intracerebral hemorrhagic stroke. additionally, the retrospective study using medical resumes was also a limitation in this study since there were many missing data and unspecific information about the variables of this study. the missing data of medical resume might be due to the ten-year-period of this study. based on the policy of the indonesian health minister in 2008 which stated that medical records of more than 5 years would be destroyed, except the return summaries and medical action approvals.20 the suggestion for a further study is a prospective study in order to follow up the progression of risk factors in association to intracerebral hemorrhage stroke. furthermore, this study can be improved by conducting a research using complete or primary medical records. in addition, these results highlight the extensive need for medical checkups, routine screening programs, and appropriate intervention programs in health care instances aimed at lifestyle changes to reduce the intracerebral hemorrhage stroke risk factors. references 1. andersen kk, olsen ts, dehlendorff c, kammersgaard lp. hemorrhagic and ischemic strokes compared: stroke severity, mortality, and risk factors. stroke. 2009;40(6):2068–72. 2. herzig r, vlachová i, mareš j, gabryš m, šaňák d, školoudík d, et al. occurrence of diabetes mellitus in spontaneous intracerebral hemorrhage. acta diabetol. 2007;44(4):201–7. 3. badan penelitian dan pengembangan. riset kesehatan dasar 2013. jakarta: litbangkes; 2013. 4. world health organization. who statistical profile. geneva:who; 2015. 5. kementerian badan litbangkes. pusat data dan informasi kementrian kesehatan ri. jakarta: badan litbangkes; 2014. 6. jahirul ms, choudhury h, chowdhury ti, nayeem a. modifiable and non-modifiable risk factors of stroke : a review update. j natl inst neurosci bangladesh. 2015;1(1):22–6. 7. grysiewicz ra, thomas k, pandey dk. epidemiology of ischemic and hemorrhagic stroke : incidence, prevalence, mortality, and risk factors. neurol clin na. 2008;26(4):871–95. 8. reeves mj, bushnell cd, howard g, gargano jw, duncan pw, lynch g, et al. sex differences in stroke : epidemiology, clinical presentation , medical care , and outcomes. lancet neurol. 2008;7(10):65– 74. 9. sorgi ba, dean sc, meekins k, chen p, ph d, halpern ct, et al. lifestyle and behavior in young adulthood : the national longitudinal study of adolescent to adult althea medical journal. 2018;5(1) 37 health. add healtth. 2015;2(2):1–8. 10. hyun-ju j, kim-ki j, chun-in a, ok-kon m. the relationship between stroke patients ’ socio-economic conditions and their quality of life : the 2010 korean community health survey. j phys ther sci 2015;27(3):2–5. 11. clougherty je, souza k, cullen mr. work and its role in shaping the social gradient in health. ann n y acad sci. 2010;1186(1):102–24. 12. honjo k, iso h, ikeda a, inoue m, tsugane s. education level and physical functional limitations among japanese community residents-gender difference in prognosis from stroke. bmc public health. 2009;9(1):1–8. 13. donnell mjo, xavier d, liu l, zhang h, chin sl, rao-melacini p, et al. risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the interstroke study): a case-control study. lancet. 2010;376(9735):116-23 14. davisson rl. hypertension and cerebrovascular dysfunction. cell metab. 2009;7(6):476–84. 15. caceres ja, goldstein jn. intracranial hemorrhage. emerg med clin north am. 2013;30(3):771–94. 16. qi l, ding x, tang w, li q, mao d, wang y. prevalence and risk factors associated with dyslipidemia in. int j environ res public health. 2015;12(10):13455–65. 17. mehrpour m, khuzan m, najimi n, motamed mr. serum uric acid level in acute stroke patients. mjiri. 2012;26(2):66–72. 18. khella s, bleicher mb. stroke and its prevention in chronic kidney disease. clin j am soc nephrol. 2007;2(6):1343–51. 19. takahashi t, harada m, kikuno t, ujihara m, sadamitsu d, manabe y, et al. prevalence of metabolic syndrome in stroke patients: a prospective multicenter study in japan. acute med surg. 2014;1(1):17–22. 20. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 269/menkes/per/ iii/2008. jakarta: kementrian kesehatan republik indonesia; 2008. sabrina putri lofissa, paulus anam ong, nur atik: demographic and risk factors of intracerebral hemorrhage stroke patients in dr. hasan sadikin general hospital bandung in 2007-2016 vol 4 no 4 final.indd althea medical journal. 2017;4(4) 546 amj december 2017 effects of morinda citrifolia leaf extract on glucose absorption through intestinal epithelial membrane in wistar rat models rikho melga shalim,1 mas rizky a. adipurna syamsunarno,2 muhammad nurhalim shahib2 1faculty of medicine universitas padjadjaran, 2department of biochemistry and molecular biology faculty of medicine universitas padjadjaran abstract background: noni fruit (morinda citrifolia) has been used as herbal medicine by indonesian people. however, the effect of noni leaves as an antihyperglycemic agent is still unknown. this study was conducted to find out the effect of morinda citrifolia leaves on glucose absorption through intestinal epithelial membrane in wistar rat models. methods: the study was conducted in november 2015 at the biochemistry and molecular biology laboratory faculty of medicine, universitas padjadjaran. we used in situ perfusion and rats were divided into 2 groups. the first group used glucose solution as a control. the second group used glucose with extracts. specimens were taken before and after perfusion to check the amount of glucose with spectrophotometer. statistical analysis using t-test was conducted to compare the total absorbed concentration of glucose from each group. results: from calculation we found the kinetic value (km) of glucose absorption without extract (km=17.24) and with extract (km=16.67). statistical test showed there was no significant in results (p>0.05). conclusions: there is no effect of morinda citrifolia leaf extract on glucose absorption. however, kinetics of glucose absorption suggested a non-competitive inhibition by morinda citrifolia leaf extract. keywords: antihyperglycemic, glucose absorption, herbal, morinda citrifolia, transport kinetics correspondence: rikho melga shalim, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: melgaz22_7@ymail.com introduction herbal medicine is a common term for people in indonesia. indonesian people use it for therapy purposes such as heart disease, neuronal problems, and cancer. studies from around the world also succeed to prove the effect of herb.1,2 one of the herbs that is commonly used is noni (morinda citrifolia). it is a plant that grows well in indonesia. this plant has many therapeutical effects to be used in medicating diseases.3 however, for years, the use of noni is more likely from its fruit rather than the other part of it, the leaves. noni leaves contain alkaloids, saponins, tannins, flavonoids, steroids, glycosides, and ascorbic acids.4 some of them known to have effects to inhibit glucose transport in small intestine.5,6 a study was conducted and proved that saponins and flavonoids have effects in glucose transport.7 nevertheless, the mechanism of how these chemical substances work is yet to be known. in 2010, the world health organization (who) found 10% of indonesian people have hyperglycemic condition.8 it is a condition when blood glucose is above the normal range. this condition may cause complications that could endanger the person who bears it. blood glucose rises because of some mechanisms including glucose transport in the small intestine. with intervention to this process, there is a possibility to overcome the hyperglycemic condition. concentration of glucose that will be absorbed is also a decisive factor in glucose absorption. therefore, the kinetics of glucose absorption is related to this study. furthermore, kinetics of glucose absorption can be determined using a lineweaver-burk graph. by use of a millimeter block paper and scale of axis and ordinate, the researcher can calculate the kinetics value or michaelismenten constant (km). the value of km reflects the type of inhibition from the extract.9 the purpose of this study was to find the effects of morinda citrifolia leaves on glucose absorption through intestine and the kinetics of glucose transport in the small intestine of wistar rat. amj. 2017;4(4):546–52 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1266 althea medical journal. 2017;4(4) 547 methods this study was conducted in november 2015 at the biochemistry and molecular biology laboratory, faculty of medicine universitas padjadjaran, jatinangor. morinda citrifolia leaves were purchased and extracted with ethanol at the pharmacy laboratory of institut teknologi bandung (itb). the leaves were picked from the middle part of the tree which was 2–3 years old and grown in coblong, bandung. briefly, they were cut into small pieces and put in the heating and drying oven. then, the dried leaves were mixed with ethanol 70% to undergo the maceration process. twelve rats aged twelve to sixteen weeks old wistar rats with body weight between 200 and 250 grams were adapted for 7 days before experiment. the health research ethics committee faculty of medicine, universitas padjadjaran has agreed and gave permission to conduct this study with concern to the ethical aspects such as 3r and use of the resource equation method to calculate the number of sample needed.10,11 there were conditions to be met before the rats were going to the experiment. these conditions were the inclusion and exclusion criteria. the rats must be in healthy conditions without wounds, and active. there were also some conditions that excluded the rats to be used further such as a dropped in weight more than 10% after the adaptation period and if the rats had been used in an experiment before. the glucose absorption was measured by in situ perfusion technique to make sure every rat in each group was given the same amount of glucose. then, the rats were fasted and anesthetized by ketamine with dosage of 0.13 mg/100 gram body weight. after the anesthesia has worked, the abdomen was opened to install cannulas at 10 cm after pylorus and 25 cm from the first cannula with a marked string to help measure the length of intestine. next step, each cannula was connected with a rubber tube to bath the intestine with solutions. furthermore, the rats were divided into 2 groups. the first group was the control group which was given glucose solution, while the second group was given glucose with morinda citrifolia leaf extract solution. the intestine was perfused with 2.5, 5, and 10 mmol for every 15 minutes with and without leaf extract. pre and post perfused solution were collected at the end of perfusion process. the solutions were mixed with aquadest and trichloroacetic acid (tca) 8% and centrifuged for 10 minutes at 3000 rpm. to obtain the best result, the solutions were incubated in 37oc for 10 minutes or at room temperature for 25 figure 1 rat with perfusion set rikho melga shalim, mas rizky a. adipurna syamsunarno, muhammad nurhalim shahib: effects of morinda citrifolia leaf extract on glucose absorption through intestinal epithelial membrane in wistar rat models althea medical journal. 2017;4(4) 548 amj december 2017 table 1 absorption data of control group solution rat time absorbancy remaining glucose (mg/dl) absorbed glucose (mg/dl) mean ± standard deviation g1 1 before 0.045 35.71 4.76 11.11 ± 4.788 after 0.039 30.95 2 before 0.043 34.13 14.29 after 0.025 19.84 3 before 0.044 34.92 17.46 after 0.022 17.46 4 before 0.044 34.92 7.14 after 0.035 27.78 5 before 0.045 35.71 9.52 after 0.033 26.19 6 before 0.039 30.95 13.49 after 0.022 17.46 g2 1 before 0.130 103.17 46.83 36.77 ± 9.585 after 0.071 56.35 2 before 0.134 106.35 44.44 after 0.078 61.90 3 before 0.133 105.56 44.44 after 0.077 61.11 4 before 0.131 103.97 24.60 after 0.100 79.37 5 before 0.134 106.35 28.57 after 0.098 77.78 6 before 0.131 103.97 31.75 after 0.091 72.22 g3 1 before 0.254 201.59 57.94 56.08 ± 8.364 after 0.181 143.65 2 before 0.254 201.59 64.29 after 0.173 137.30 3 before 0.257 203.97 65.87 after 0.174 138.10 4 before 0.239 189.68 43.65 after 0.184 146.03 5 before 0.240 190.48 53.17 after 0.173 137.30 6 before 0.241 191.27 51.59 after 0.176 139.68 note: solution g1=glucose 2.5 mmol; g2=glucose 5 mmol; g3=glucose 10 mmol althea medical journal. 2017;4(4) 549rikho melga shalim, mas rizky anggun adipurna syamsunarno, muhammad nurhalim shahib: effects of morinda citrifolia leaf extract on glucose absorption through intestinal epithelial membrane in wistar rat models table 2 absorption data of experimental group solution rat time absorbancy remaining glucose (mg/dl) absorbed glucose (mg/dl) mean ± standard deviation m1 1 before 0.045 35.71 17.46 14.02 ± 4.935 after 0.023 18.25 2 before 0.047 37.30 22.22 after 0.019 15.08 3 before 0.046 36.51 11.90 after 0.031 24.60 4 before 0.046 36.51 12.70 after 0.030 23.81 5 before 0.041 32.54 11.11 after 0.027 21.43 6 before 0.037 29.37 8.73 after 0.026 20.63 m2 1 before 0.089 70.63 42.06 21.83 ± 17.072 after 0.036 28.57 2 before 0.092 73.02 43.65 after 0.037 29.37 3 before 0.094 74.60 19.05 after 0.070 55.56 4 before 0.109 86.51 10.32 after 0.096 76.19 5 before 0.092 73.02 12.70 after 0.076 60.32 6 before 0.094 74.60 3.17 after 0.090 71.43 m3 1 before 0.219 173.81 61.90 51.85 ± 9.546 after 0.141 111.90 2 before 0.221 175.40 65.87 after 0.138 109.52 3 before 0.233 184.92 46.83 after 0.174 138.10 4 before 0.235 186.51 46.03 after 0.177 140.48 5 before 0.236 187.30 47.62 after 0.176 139.68 6 before 0.223 176.98 42.86 after 0.169 134.13 note: note: solution m1=glucose 2.5 mmol + morinda citrifolia leaves; m2=glucose 5 mmol + morinda citrifolia leaves; m3=glucose 10 mmol + morinda citrifolia leaves althea medical journal. 2017;4(4) 550 amj december 2017 minutes. the absorbance data were analyzed with the spectrophotometer in 505 nm wave length. next, the data were calculated and analyzed using independent t-test to compare data with and without morinda citrifolia leaf extract solution, with significant values of p<0.05. on the other side, kinetics calculation was not using computerized tools or applications. this study used a millimeter block paper to draw a graph of lineweaver-burk with 1/s (s=concentration of glucose) on axis and 1/v (v=velocity of absorption which was equal to the amount of absorbed glucose). there were 2 lines to be drawn, control (g) and experimental (m). for the axis, 1 smallest square equals to 0.002/mmol, and the ordinate, 1 smallest square equals to 0.0001/mg. then we took the point of both intersections with axis and use it as a value of -1/km. results results from this study showed that in glucose with 2.5 mmol concentration, the addition of morinda citrifolia leaf extract was not providing much difference in the mean of absorbed glucose. in fact, data of the solution with extract had 2.91 mg/dl more higher absorbed glucose than the solution without figure 2 glucose concentration figure 3 graph of lineweaver-burk9 althea medical journal. 2017;4(4) 551 extract (table 1). a difference was found in 5 mmol of glucose concentration. the mean of absorbed glucose in the control group was 14.94 mg/dl much more than in the group with extract. there was also a difference in 10 mmol glucose concentration with extract, since the mean of absorbed glucose was 4.23 mg/dl less than in the control group (table 2). the rise of glucose absorption following the increase of glucose concentration showed the red line, which represented glucose with extract, mostly had a position below the blue one, which represented glucose only solution. there was no significant effects of morinda citrifolia leaf extract in glucose absorption (figure 2). next, we calculated the kinetics of glucose transport with and without morinda citrifolia leaves which showed that the one without additional extract had value of -1/km=-0.058. therefore, the km=17.24. the second, which was glucose with extract, had value of -1/ km=-0.06 and made the km=16.67 (figure 3). discussions moreover, a statistical test was performed and found there was not any significant results in glucose concentration with p value 0.324 (2.5 mmol); 0.091 (5 mmol); and 0.433 (10 mmol). although in two concentrations of glucose showed that there were decreases in glucose absorption,the statistical test gave insignificant results. this may occur with reasons such as the occurrence of a different antihyperglycemic mechanism. a previous study showed morinda leaves have two antihyperglicemic mechanisms, by increasing the production of insulin and increasing the peripheral utilization of glucose.12 there were also limitations in this study. the variety of each rat’s ability to absorb glucose should be considered which took part in varies results. in addition, the insulin also took part in glucose absorption from the cell into bloodstream.13 it can be concluded that there is no effect of morinda citrifolia leaf extract on intestine glucose absorption in wistar rats which is shown by statistical test results with p values >0.05. on the other hand, the kinetic results show a little difference in km values, which mean the inhibitor, is not interfered by the glucose transport in the absorption process. we suspect a non-competitive inhibition of intestine glucose absorption by morinda citrifolia leaf extract.9 we suggest further studies to investigate the effects of morinda citrifolia leaf extract with higher dosage. furthermore, a study to develop the kinetic results of glucose transport still needs to be done. references 1. agromedia r. buku pintar tanaman obat: 431 jenis tanaman penggempur aneka penyakit. jakarta: agromedia pustaka; 2008. 2. surialaga s, dhianawaty d, martiana a. efek antihiperkolesterol jus buah belimbing wuluh (averhoa bilimbi l.) terhadap mencit galur swiss webster hiperkolesterolemia. majalah kedokteran bandung. 2013;45(2):125–9. 3. chan-blanco y, vaillant f, perez am, reynes m, brillouet j-m, brat p. the noni fruit (morinda citrifolia l.): a review of agricultural research, nutritional and therapeutic properties. j food comp anal. 2006;19(6):645–54. 4. wardiny tm, retnani y, sinar tea. penampilan puyuh starter yang diberi ekstrak daun mengkudu sebagai antibakteri salmonella thypimurium. prosiding seminar nasional mipa; 2012. [cited 2016 january 10] available from: https://ejournal.undiksha.ac.id/index. php/semnasmipa/article/view/2786 5. castro ma, angulo c, brauchi s, nualart f, concha, ii. ascorbic acid participates in a general mechanism for concerted glucose transport inhibition and lactate transport stimulation. pflugers arch. 2008;457(2):519–28. 6. el-tantawy w, hassanin l. hypoglycemic and hypolipidemic effects of alcoholic extract of tribulus alatus in streptozotocininduced diabetic rats: a comparative study with t. terrestris (caltrop). indian j exp biol. 2007;45(9):785-90. 7. kwon o, eck p, chen s, corpe cp, lee j-h, kruhlak m, et al. inhibition of the intestinal glucose transporter glut2 by flavonoids. faseb j. 2007;21(2):366–77. 8. soewondo p, pramono la. prevalence, characteristics, and predictors of prediabetes in indonesia. med j indones. 2011;20(4):283-94. 9. shahib mn. biologi molekuler medik. bandung: p.t. alumni; 2012. 10. charan j, kantharia nd. how to calculate sample size in animal studies? j pharmacol pharmacother. 2013;4(4):303–6. 11. festing s, wilkinson r. the ethics of animal research. embo j. 2007;8(6):526–30. rikho melga shalim, mas rizky a. adipurna syamsunarno, muhammad nurhalim shahib: effects of morinda citrifolia leaf extract on glucose absorption through intestinal epithelial membrane in wistar rat models althea medical journal. 2017;4(4) 552 amj december 2017 12. adeneye a, agbaje e. pharmacological evaluation of oral hypoglycemic and antidiabetic effects of fresh leaves ethanol extract of morinda lucida benth. in normal and alloxan-induced diabetic rats. afr j biochem res. 2008;11(1):65–71. 13. kellett gl, brot-laroche e, mace oj, leturque a. sugar absorption in the intestine: the role of glut2. annu rev nutr. 2008;28:35–54. 213 althea medical journal. 2017;4(2) comparison of spatial ability between male and female athletes azkane adilla putri,1 leonardo lubis,2 paulus anam ong3 1faculty of medicine, universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: spatial ability is the ability to understand and memorize spatial relationship beneficial objects. this domain of cognition is crucial in sport activity for deciding strategy. sex is one of the factors that determine spatial ability. this study aimed to determine the comparison of spatial ability between male and female athletes. methods: this cross-sectional study was conducted by non-pairing comparative method. data were taken on september 2015 in indonesian national sport committee (komite olahraga nasional indonesia, koni) sport center, bandung, west java, indonesia. spatial instrument used was spatial ability test 1. subjects were recruited from athletes of koni, west java, aged between 19-27 years old who were being trained for 19th national sports weeks (pekan olahraga nasional, pon xix) 2016. mean value between male and female were compared using studies t-test with significance value (p)<0.05. results: the total samples were 95 subjects, consisting of 44 males and 51 females. results of the mean value in male were 29.16 (± 3.48) and female 28.80 (± 3.74).by using studies t-test, the significance outcome found was p = 0635 (p >0.05). conclusions: there is no spatial ability differencesbetween male and female athletes of koni, west java keywords: athletes, gender, spatial ability correspondence: azkane adilla putri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85720000593 email: azkaneadillap@gmail.com introduction spatial ability defined as ability to visualize and imagine an object into 3-dimensional form and understand the relationship of the surrounding object.1,2 its benefits are seen in daily activities such as reading map, navigating and detecting objects.1,2 it is needed in some parts of mathematics, science, technic, economy, meteorology, architecture, aeronautic and medicine.1,2 spatial ability is also important in sports. athletes need this ability to balance their psychomotor ability and physical fitness in deciding strategy used in a match, in which it is important for their achievements. spatial ability is determined by several factors; one of them is sex, in which determining brain differences in anatomy, and physiology such as hippocampus lateralization, volume of inferior parietal lobe, and androgen hormone level.3–9 these differences are still contradiction. several studies had reported differences and other studies had reported no differences at all.8,10–11 however, it is not known whether occupation or daily activities influence spatial ability, such as what is happened to in athletes. this study was conducted to analyze the comparison of spatial ability between male and female athletes on indonesian national sport committee (komite olahraga nasional indonesia, koni), west java, indonesia. methods this study was a cross sectional study performed using non-pairing comparative method, held on september 2015 in koni sport center, bandung, west java, indonesia. this study had been approved by the health research ethics committee, faculty of medicine, universitas padjadjaran, bandung, no: 519/un6.c1.3.2/kepk/pn/2015. this study was conducted on koni athletes in west java, consisted of 12 sport divisions amj.2017;4(2):213–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1093 althea medical journal. 2017;4(2) 214 amj june 2017 (fencing, athletics, wrestling, judo, kempo, weightlifting, archery, sport climbing, martial arts, gymnastic, taekwondo, and boxing), who were being specially trained for the19th national sports weeks (pekan olahraga nasional, pon xix) 2016. by using comparative analytic unpaired test sample size formula with α = 5% and β = 95%, it was known that minimum sample number were 32 for every sex group. informed consent has been obtained. data taken were further identified based on inclusion criteria such as aged between 19 to 27 years old, had minimum high school level of education or equal and good physical condition prior to the test. athletes who disqualified during the test were excluded from this study. from 200 data taken, finally 95 subjects fulfilled inclusion criteria, consist of 44 males and 51 females. data regarding spatial ability used were primary data acquired by spatial ability test i (newton and bristoll) that had been translated and modified. the validation and reliability (α = 0.704) were performed by 30 subjects which had similar characteristics with samples. instrument was divided into 45 visual questions that had to be done as many as possible within 20 minutes. data used on calculation were male’s and female’s spatial ability score processed by statistic software. data normality test with kolmogorov-smirnov test (n>50) was performed on female group, while shapiro-wilk (n<50) was performed on male group. mean value between male and female were compared using studies t-test in well-distributed data. test result significances were determined by p value (p<0.05). results characteristics of samples found the quantity of female was more than male. based on physical examination performed by koni medical team, the samples had a good condition. results of normality test on both male and female group revealed well-distributed data, thus mean was use as central measurement and standard deviation as distribution measurement. due to well-distributed data, t-test was used to analyze differences spatial ability between male and female. significance outcome developed were p=0.635 (p>0.05) which revealed no spatial ability differences between male and female on athletes of koni, west java. discussions spatial ability is divided into three parts: table 1 characteristics of subjects n (%) mean (±sd) sex male 44 (53.7) female 51 (46.3) body massa index (bmi) 22.35 (±0.82) blood pressure systole 118.75 (±1.85) diastole 72.43 (±1.30) heart rate 65.07 (±3.09) respiratory rate 21.23 (±2.85) table 2 score of spatial ability test spatial ability mean sd male 29,16 3,48 female 28,80 3,74 215 althea medical journal. 2017;4(2) azkane adilla putri, leonardo lubis, paulus anam ong: comparation of spatial ability between male and female athletes spatial visualization, spatial perception, and mental rotation.3 to understand comparison between sex towards spatial ability, we cannot only see one aspect.3 instrument used in this study represents these three aspects generally. on the other hand, there are a lot of instruments that can be used for one or more specific aspects.8–11 spatial ability is specifically recognized by several brain areas. parietal lobe is one of brain areas that plays a role in spatial ability.5 previous study discovered that monkeys with lesions in the parietal lobe had lower spatial ability.5 after controlling brain surface area, males were known to have bigger surface area on parietal lobe compared to females.5 in addition to parietal lobe, hippocampus also has a role in spatial ability.12 other previous study found that hippocampus had greater activity in spatial ability.12 it can be seen using functional magnetic resonance imaging (fmri).12 uniquely, hippocampusis is more connected with parietal lobe on male, and temporal lobe on female.9 androgen hormone is mentioned as one of the important factors affecting spatial ability.3,7–8 androgen plays a role on hippocampus cell formation and development during prenatal period.6 unfairly, androgen effect wismore prominent in the right hemisphere development.4 it is also known that normal androgen level is higher on male than female.3,7–8 this is one of the theories contributing that showed male’s brain is more right hemisphere-lateralized, in which right hemisphere is a functional brain area taking a big role on spatial ability.4,7 based on the factors, there is a possibility that spatial ability on males is higher than females. however, the result of this study does not fit the theories. in addition, this study is not in line with the previous study that was conducted on patrilineal. it might be influenced by education level.10 spatial ability was one aspect of academic, so that higher education level would result in higher spatial ability.10 beside of education level, type of education might also influence spatial ability. it is known that spatial ability correlates more with natural science especially with mathematics.7 in the other studies that performed in three categories of sports, males had better spatial ability on average compared to females in all categories.however, there are different significances on each category.11 there are significant differences between low risk sports activity (running, athletics, and gymnastic) and high risk sports activity (parachuting, scuba diving, skiing, and mountain climbing), while on moderate risk sports activity (football, basketball, and handball), there is no significant difference.11 it might be caused by different characteristics on sport spectrum influencing cognitive functions molecularly, cellularly and behaviorally.13 based on significance of the results, males had higher averages, it was in line with previous studies on volleyball and tennis athletes. there were no significant spatial ability differences between male and female with same performance and training experiences.8 it is assumed that spatial ability might be influenced by sport activity.8 sport activity is considered could increase circulating androgens level and later can shrink sex gap between them.8 increased levels of androgen could improve spatial ability on female, but could inhibit spatial ability on male.6,8 androgen hormone effect is also seen on congenital adrenal hyperplasia (cah) patients, in which adrenal gland produces excess testosterone during prenatal development.6 excess adrenal androgen is provided by cah increases spatial ability on female and reduces spatial ability on male, so it is concluded that moderate androgen level might influence spatial ability optimally.6 this study has limitations. there were confounding factos that contribute to the result of this study. environmental factors are one of the most important factors on cognitive function. biopsychosocial model showed how biology and environment make causative effect.7 for example, differences in brain might alter on how people think and choose their environment, and environment would alter biological development further.7 examples of environmental factors include education level, economical state, culture, use of medication, marital status, and stress.7,10,14 it is recommended to control those factors in further studies. the result of this study shows that there was no spatial ability differences between men and women in athletes of koni, west java. it might be caused by environmental factors influencing, which were not controled in this study. in addition, further studies need to be conducted to know the effect of specific sport on spatial ability. the result of this study can be used as benchmark for athletes to receive specific exercise program in order to improve spatial ability that can increase athletes performance and athletes achievement althea medical journal. 2017;4(2) 216 amj june 2017 references 1. yilmaz hb. on the development and measurement of spatial ability. iejee. 2009;1(2):83–96. 2. ramirez g, gunderson ea, levine sc, beilock sl. spatial anxiety relates to spatial abilities as a function of working memory in children. q j exp psychol (hove). 2012;65(3):474–87. 3. matlin m. cognitive psychology. 7th ed. new jersey: john wiley &sons; 2009. 4. frings l, wagner k, unterrainer j, spreer j, halsband u, schulze-bonhage a. genderrelated differences in lateralization of hippocampal activation and cognitive strategy. neuroreport. 2006;17(4):417– 21. 5. elias lj, saucier dm. neuropsychology: clinical and experimental foundations. new york: pearson; 2006. 6. puts da, mcdaniel ma, jordan cl, breedlove sm. spatial abilty and prenatal androgen: meta-analyses of congenital adrenal hyperplasia and digit ratio (2d:4d) studies. arch sex behav. 2008;37(1):100– 11. 7. miller di, halpern df. the new science of cognitive sex differences. trends cogn sci. 2014;18(1):37–45. 8. notanircola a, maccagnano g, pesce v, tafuri s, novielli g, moretti b. visualspatial capacity: gender and sport differences in young volleyball and tennis athletes and non-athletes. bmc res notes. 2014;7(1):57. 9. persson j, spreng rn, turner g, herlitz a, morell a, stening e,et al. sex differences in volume and structural covariance of the anterior and posterior hippocampus. neuroimage. 2014;99(1)215–25. 10. hoffman m, gneezy u, list ja. nurture affects gender differences in spatial abilities. pnas. 2011;108(36):14786–88. 11. hromatko i, butkovic a. sensation seeking and spatial ability in athletes: an evolutionary account. journal of human kinetics. 2009;21(1):5–13. 12. viard a, doeller cf, hartley t, bird cm, burgess n. anterior hippocampus and goal-directed spatial decision making. j neurosci. 2011; 31(12):4613–21. 13. thomas m. the effect of different movement exercises on cognitive and motor abilities. advance in physical education. 2012;2(4):172–8. 14. weber d, skirbekk v, freund i, herlitz a. the changing face of cognitive gender differences in europe. pnas. 2014;111(32):11673–8 althea medical journal. 2019;6(1) 13 identification of enteric bacterial pathogens in beverages sold by hawkers around jatinangor, bandung teow sheng hao,1 yanti mulyana,2 bachti alisjahbana3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: teow sheng hao, faculty of medicine universitas padjadjaran,jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: oysterteow@hotmail.com introduction water is indisputably essential in life. all of our body systems depend highly on water, such as in carrying nutrients, eliminating toxin from vital organ and for crucial cellular homeostasis.1 nonetheless, it is also considered as a primary medium for the propagation and dissemination of bacteria. therefore, ingestion of water contaminated by opportunistic pathogenic environmental bacteria may ensue in some serious health implications of waterborne disease. reports have shown that the incidence of waterborne diseases caused by microorganisms, including the common diarrhea-caused by enterobacteriaceae, has significantly increased over the past few decades.2 safe drinking water has then become one of our primary fundamental right ever since. thus, the importance of prevention against microbial contamination in drinking water is substantially emphasized.3 a report of who/unicef joint monitoring programme for water supply and sanitation 2012 has been introduced to highlight water supply, sanitation, and hygiene development as its main focuses.4 based on the report, indonesia has over 110 million of the population that has left without proper sanitation and nearly 63 million are still practicing open defecation.5 furthermore, about 43 million of people fending without an access to clean water supplies. consequently, it led to a surge in cases of water-related diseases and worst, some may even result in mortality.6 this study was conducted with the purpose of improving the quality of life and saving lives in the near future. hence, the primary aim of the study was to detect the presence of enteric bacterial pathogens in the beverages sold by hawkers around jatinangor. amj. 2019;6(1):13–7 abstract background: water is essential for life and is considered as a medium for the propagation and dissemination of bacteria. water-borne disease is one of the problems in indonesia, therefore, this study was conducted to explore the presence of enteric bacterial pathogens in the beverages sold by hawkers. methods: a descriptive laboratory method was conducted in september 2015 beverages were collected from hawkers that were randomly chosen around jatinangor using sterile containers, and brought to the laboratory within 1 hour. the beverages were incubated on mueller hinton broth, followed by culturing on macconkey agar. the organisms were identified using gram staining, kliger test, motility-indole-urease test and citrate test. results: out of 30 samples collected, 2 of the samples were tested positive for enteric bacterial pathogen salmonella paratyphi. furthermore, klebsiella pneumoniae (n=12), enterobacterspp (n=10) alcaligenes faecalis (n=3) and pseudomonas spp. (n=3) were detected in the samples. conclusions: the salmonella paratyphi as enteric bacterial pathogen found in the beverages sold by hawkers has potential to cause water-borne disease. education to hawkers need to be enhanced. keywords: beverages, enteric bacterial pathogens, hawkers, salmonella paratyphi althea medical journal. 2019;6(1) 14 amj march 2019 methods this descriptive study was carried out in the microbiology laboratory of faculty of medicine from september to november 2015. a total of 30 samples were collected from randomly chosen hawkers around jatinangor, who did not keep the beverages in the fridge. beverages were defined as drinks made by the hawkersthemshelves. the standard of the beverages was tea with milk, tea with sugar and syrup drink. no ice cubes were present in the drinks. this study protocol was approved by the health research ethics committee, faculty of medicine, universitaspadjadjaran. all the samples were collected in clean containers and were brought to the laboratory within an hour. the samples were incubated in mueller hinton broth at the temperature of 37ºc for 24 hours. followed by culture, the samples were then spread on macconkey agar and incubated in 37ºc for 24 hours. observations were made to detect growing colonies on the macconkey. next, the colonies were collected using a sterile inoculating loop and smeared on the slide for gram staining. these gram staining procedures used crystal violet solution, iodine solution, alcohol 96% and safranin. the suspected colony was first mixed with nacl 0.9%. after it became a dry suspension, the suspected colony was mixed with crystal violet solution for 1 minute to stain the cell purple. the slide was rinsed with tap water and poured with iodine solution for 1 minute to color the cells. subsequently, the slide was rinsed again under tap water and later decolorized by using alcohol 96%. lastly, safranin was added for another 1 minute. the end result would either show a color of pink or red which indicate the presence of gram negative cells. meanwhile, enteropathogenic bacteria in particular were identified under a microscope using high-powered 100x objective lens with a drop of immersed oil. following the gram staining, three more biochemical tests were done using kliger iron agar test (kia), motility indole urease test (miu) and the citrate test. small amount of bacteria colony was streaked in the 3 medium and was incubated in 37ºc for 24 hour. the bacteria were identified by their distinguished appearances according to the specific biochemical test. results furthermore, the presence of several types of bacteria such as klebsiellapneumoniae, enterobacterspp, alcaligenesisfaecalis, salmonella paratyphiand pseudomonas spp, were also successfully identified (table 1). stratification were used to classified bacteria types into pathogenic and non-pathogenic. pathogenic bacteria, in this study was found figure 1 number of cases according to types of bacteria found in beverages althea medical journal. 2019;6(1) 15 table 1 types of bacteria present in beverages sold by hawkers around jatinangor, bandung beverages identification results type of bacteria syrup drinks negative tea with milk negative syrup drinks negative alcaligenesisfaecalis tea with milk negative alcaligenesisfaecalis tea with sugar negative alcaligenesisfaecalis syrup drinks lactose (+) mobility (+) citrate (+) enterobacterspp syrup drinks lactose (+) mobility (+) citrate (+) enterobacterspp syrup drinks lactose (+) mobility (+) citrate (+) enterobacterspp syrup drinks mobility (+) citrate (+) enterobacterspp tea with milk lactose (+) mobility (+) citrate (+) enterobacterspp tea with milk mobility (+) citrate (+) enterobacterspp tea with sugar mobility (+) citrate (+) enterobacterspp tea with sugar lactose (+) mobility (+) citrate (+) enterobacterspp tea with milk (a)mobility (+) citrate (+) (b) lactose (+) citrate (+) enterobacterspp klebsiella pneumoniae tea with sugar (a) mobility (+) citrate (+) (b) lactose (+) citrate (+) enterobacterspp klebsiella pneumoniae syrup drinks lactose (+) citrate (+) klebsiella pneumoniae syrup drinks lactose (+) citrate (+) klebsiella pneumoniae syrup drinks lactose (+) citrate (+) klebsiella pneumoniae tea with milk lactose (+) citrate (+) klebsiella pneumoniae tea with milk lactose (+) citrate (+) klebsiella pneumoniae tea with milk lactose (+) gas (+) citrate (+) klebsiella pneumoniae tea with sugar lactose (+) citrate (+) klebsiella pneumoniae tea with sugar lactose (+) citrate (+) klebsiella pneumoniae tea with sugar lactose (+) gas (+) citrate (+) klebsiella pneumoniae tea with sugar lactose (+) citrate (+) klebsiella pneumoniae syrup drinks mobility (+) citrate (+) pseudomonas spp tea with milk mobility (+) citrate (+) pseudomonas spp tea with milk mobility (+) citrate (+) pseudomonas spp tea with sugar mobility (+) salmonella paratyphi* tea with sugar mobility (+) salmonella paratyphi* note: ** were pathogenic bacteria teow sheng hao et al.: identification of enteric bacterial pathogens in beverages sold by hawkers around jatinangor, bandunga in 2 cases (7.1%) whereas the rest of 26 cases (92.9%) were non-pathogenic bacteria (table 1) . as a result, a crucial pattern on the types of bacteria frequently encountered in the beverages, from the least to the commonest, was able to be deduced (figure 1). the commonest bacteria found were klebsiella pneumoniae (35.7%) followed by enterobacterspp (287%), alcaligenesisfaecalis (10.7%), pseudomonas spp (10.7%) and salmonella paratyphi (7.1%). however, there were also 7.1% of mixed growth between enterobacter spp and klebsiellapneumoniae. althea medical journal. 2019;6(1) 16 amj march 2019 discussions out of 30 beverages samples collected, 28 samples (93.3%) have been contaminated with either pathogen or non-pathogen bacteria. such results may depict that hawkers in jatinangor are majorly serving contaminated beverages to its customers, by change. this intricately reflects that many people havebeen exposed to unwanted, yet serious health implications like waterborne diseases, after ingesting those contaminated drinks.7 similarly, study in pakistan8 has shown that there is a high amount of microbial contamination found in the drinks sold by street hawkers. unhygienic environment and poor handling practices definitely have a strong association to the microbial contamination found in the drinks. these reports also show the possibility of bacteria to be able to survive in drinks especially within the low economic areas. 8 in addition, this study is able to deduce the commonest bacteria found within beverages. klebsiella pneumoniae was the most common bacteria found in baverages (35.7%), despite their non-pathogenic properties in gastrointestinal tract. this may be because of their non-pathogenic character. klebsiella spp can be easily found in the respiratory tract and human feces, but they could only pose threats when they are displaced from their normal habitat. therefore, klebsiella spp plays only a minimal role in causing waterborne disease.9 whilst, the second most enterobacteriaceae that have been isolated from the beverages was enterobacter spp. several enterobacter spp are known as opportunistic pathogens in human that can be found mostly on human skin and in the intestinal tract. this bacteria can barely survive in low ph environment, hence the secretion of gastric acid plays an important role in killing the bacteria.10 thus, enterobacter spp poses even a lower risk to cause harm to humans. intricately, the worst pathogen found within the beverages were salmonella paratyphi, mostly found in animal feces. the bacteria had indeed known to be pathogenic towards human, in which one may suffer severe fever and abdominal pain. salmonella paratyphi possess several unique characteristics that enable them to survive harsh environments, such as the ability to grow at 7–48°c with an optimum growth at human’s body temperature of 37°c and at ph of 4 to 9.5 with an optimal growth at ph 6.5 to 7.5.11 therefore, salmonella spp manage to survive in the stomach through the induction of acid table 2 types of beverages contaminated with various bacteria beverages type of bacteria n syrup drinks none detected 1 alcaligenesisfaecalis 1 enterobacterspp 4 klebsiella pneumoniae 3 pseudomonas spp 1 tea with milk none detected 1 alcaligenesisfaecalis 1 enterobacterspp 2 enterobacterspp 1 klebsiella pneumoniae 3 pseudomonas spp 2 tea with sugar alcaligenesisfaecalis 1 enterobacterspp 2 enterobacterspp 1 klebsiella pneumoniae 4 salmonella paratyphi 2 althea medical journal. 2019;6(1) 17 tolerance response and the ability to undergo an adaptive response to moderately acidic ph.12 the short emptying time after consume beverage could also facilitate salmonella sppsurvival.13 the presence of enteropathogenic bacteria such as salmonella paratyphiis correlated with poor personal hygiene and environmental sanitation, lack of supply of safe water and ignorance of health promotion practices. these may indirectly due to low education status which may lead to outbreaks of infectious diseases among the population. other species of enterobacteriaceae that detected is supporting the idea of contamination of fecal bacteria due to inadequate hand washing of the hawkers. the non-enterobacteriaceae that detected is commonly presence in environment such as soil and water. relatively, indicative of poor hygiene when handling food and beverages. this study was conducted within 3 months, which limited further collection, culturing and analyzing for even bigger sample size. with only 30 samples in total, this study was therefore insufficient to conclude that the enteric bacteria pathogen, especially salmonella paratyphi is commonly present in beverages sold by hawkers, to be said potentially causing waterborne diseases. moreover, the shortage of budget at hand was nearly inadequate to cover the total cost of all the microbiology examinations, especially the agar. despite all the limitations stated, this study is still able to detect numbers of beverages containing pathogenic enteric bacteria. in conclusion, beverages sold by hawkers possess a potential risk to cause serious health implications like waterborne diseases, especially in the presence of salmonella paratyphi. a proper handling during beverages preparation as well as environmental sanitation are the vital factors to help in preventing further risks to consumers, thus, improving the quality of life for humans. references 1. popkin bm, d’anci ke, rosenberg ih. water, hydration, and health. nutr rev. 2010;68(8):439–58. 2. gleeson c, gray n. the coliform index and waterborne disease: problems of microbial drinking water assessment: london; crc press; 2002. 3. matilainen a, vepsäläinen m, sillanpää m. natural organic matter removal by coagulation during drinking water treatment: a review. adv colloid interface sci. 2010;159(2):189–97. 4. unicef, who. progress on drinking-water and sanitation–2012 update. new york: who press; 2012. 5. walters sp, gannon vpj, field kg. detection of bacteroidales fecal indicators and the zoonotic pathogens e. coli o157:h7, salmonella, and campylobacter in river water. environ sci. technol. 2007;41(6):1856–62. 6. madec j-y, lazizzera c, châtre p, meunier d, martin s, lepage g, et al. prevalence of fecal carriage of acquired expandedspectrum cephalosporin resistance in enterobacteriaceae strains from cattle in france. j clin microbiol. 2008;46(4):1566– 7. 7. mercado-blanco j, bakker pa. interactions between plants and beneficial pseudomonas spp.: exploiting bacterial traits for crop protection. antonie van leeuwenhoek. 2007;92(4):367–89. 8. akhtar s, riaz m, ismail t, farooq u. microbiological safety of street vended fresh fruit juices, drinks and conventional blends in multan-pakistan. pak j agri sci. 2013;50(2):255–60. 9. had s, amer, ustovi, smajlovi j, ahmetagi s. distribution of nosocomial infections caused by klebsiella pneumoniae esbl strain. j environ occup sci. 2012;1(3):141– 6. 10. zhu h, hart ca, sales d, roberts nb. bacterial killing in gastric juice – effect of ph and pepsin on escherichia coli and helicobacter pylori. j med microbiol. 2006;55(pt9):1265–70. 11. semenov av, van bruggen ahc, van overbeek l, termorshuizen aj, semenov am. influence of temperature fluctuations on escherichia coli o157:h7 and salmonella enterica serovar typhimurium in cow manure. fems microbiol ecol. 2007;60(3):419–28. 12. alvarez-ordóñez a, begley m, prieto m, messens w, lópez m, bernardo a, et al. salmonella spp. survival strategies within the host gastrointestinal tract. microbiology. 2011;157(pt 12):3268–81. 13. momtaz h, dehkordi fs, rahimi e, asgarifar a. detection of escherichia coli, salmonella species, and vibrio cholerae in tap water and bottled drinking water in isfahan, iran. bmc public health. 2013;13:556. teow sheng hao et al.: identification of enteric bacterial pathogens in beverages sold by hawkers around jatinangor, bandunga althea medical journal. 2017;4(3) 340 amj september 2017 visual impairment screening in cibeusi elementary school students dea aprilianti permana,1 feti karfiati memed,2 putri teesa radhiyanti santoso3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/cicendo eye hospital, 3department of anatomy, physiology and biology cell faculty of medicine universitas padjadjaran abstract background: the world health organization (who) shows that there are around 153 million people with visual impairment due to uncorrected refractive error, mostly in 8–10 years. screening of visual function in earlier age is important, because it is treatable. correction of refractive error by using eye-glasses is the easiest and the cheapest way. this study aimed to identify the frequency of visual impairment and eyeglasses-used in children aged eight to ten in cibeusi elementary school. methods: a descriptive study was conducted. this study was held in august 2014. data were obtained from cibeusi elementary school in jatinangor; simple random sampling technique was used to select 8–10 years old students. the total number of respondent was 101 students. screening for visual impairment was performed using e-chart. result: eleven eyes (5.44%) from a total of 202 eyes had visual impairment. six (5.94%) students had visual impairment, whereas only 1 (1%) student used eye-glasses for improving his visual function. visual impairment was considerably high in boy-students aged 8 years and was most prevalence in 3rd grade students. conclusions: there are visual impairments which are not corrected with sunglasses. keywords: children, corrected refractive error, eye-glasses-used, visual impairment screening correspondence: dea aprilianti permana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81809869488 email: deaaprilianti@gmail.com introduction visual impairment is one of the health problems which has a long-term effect and has not been solved completely by the government and health care providers. based on the world health organization (who) in 2006, 153 million people had visual impairment due to uncorrected refractive error. thirteen million of them were 5–15 years old.1 based on basic health research (riset kesehatan dasar, riskesdas) in 2013, the prevalence of visual impairment in ≥6 years old was 0.9% in indonesia. lampung had the highest prevalence of visual impairment (1.7%), on the other hand, the lowest prevalence was in yogyakarta (0.3%). in west java, the prevalence of visual impairment was 0.8%.2 a study conducted in nigeria shows that in the 5–15 years old age group, 8–10 years old (40.7%) children had the greatest number of visual impairment.3 uncorrected refractive error causes visual impairment, affects communication and learning, loss of productivity causing poverty and even quality of life.4 correction of refractive error by using eye-glasses is the easiest and the cheapest way than using contact lenses or performing an operation. it should be easily accessed by the community. in fact, there are limitations for perfoming that strategy especially in developing countries which are lack of infrastructure of eye-glasses providers, lack of training for eye-care givers, and lack of education for both parents and teachers about the importance of doing correction of refractive error. india was one of the countries that have conducted the eye examination for school-children and provided eye-glasses for children who have visual impairment as the way to decrease the number of avoidable blindness.1,5,6 furthermore, to find out whether schoolaged children have visual impairment or not, the visual function screening program is held to support vision 2020 by who.1 the awareness of parents, teachers, and community to avoid blindness in their children especially caused by refractive error is poor. since refractive amj.2017;4(3):340–4 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1178 althea medical journal. 2017;4(3) 341 error does not show specific symptoms, this screening program is important to be carried out.1,6 training for teachers to screen visual function in school should be developed to detect visual impairment in early age. this study aimed to recognize the frequency of visual impairment and eye-glasses-used in students aged 8–10 years at cibeusi elementary school in jatinangor, in 2014. methods this descriptive study was conducted at cibeusi elementary school jatinangor in august 2014 and. this study was approved by the health research ethic committee faculty of medicine, universitas padjadjaran. students aged 8–10 years were selected by using simple random sampling, and 101 students met the inclusion criteria. the age of the 8–10 years students were calculated from their last birthday to the date of examination held. the students were permitted by their parents to be involved in this study after signing informed consent letter. on the other hand, students who were having a red eye were excluded from this study. the researcher did the visual impairment screening by using the e-chart on a distance of 3m; each eye separated starting from the right eye. students with eye-glasses still used eye-glasses when screening was performed. students had to adjust four large e-letters and four small e-letters with different directions. those who were able to adjust at least three small e-letters were categorized as having normal eyes. while those who were able to adjust two or less small e-letters were categorized as having visual impairment. data obtained in this study were input to statistics software. moreover, this study was conducted based on ethical aspects. this study may benefit to screen visual impairment, so both parents and teachers could give interventions, for example correction by using eye-glasses. additionally, this study did not harm the students and they were all treated with similar manners. the involvement of the students in this study was voluntary. results a total of 101 students consisting of 49 (48.5%) boys and 52 (51.5%) girls were included in this study. students were of 3rd to 5th grade. those who were 8 years old (39.6%) were the most common in this study. only 1 (1%) student table 1 clinical eye examination based on student’s characteristics characteristic n (%) eye examination normal n(%) visual impairment n(%) gender boys 49 (48.5) 87 (43.1) 11 (5.4) girls 52 (51.5) 104 (51.5) 0 (0) age (years old) 8 40 (39.6) 74 (36.6) 6 (3.0) 9 38 (37.6) 72 (35.6) 4 (2.0) 10 23 (22.8) 45 (22.3) 1 (0.5) grade 3rd 47 (46.5) 86 (42.6) 8 (3.9) 4th 29 (28.7) 55 (27.2) 3 (1.5) 5th 25 (24.8) 50 (24.8) 0 (0) eyeglasses-used yes 1 (1%) no 100 (99%) total 101 (100.0) 191 (94.6) 11 (5.4) dea aprilianti permana, feti karfiati memed, putri teesa radhiyanti santoso: visual impairment screening in cibeusi elementary school students althea medical journal. 2017;4(3) 342 amj september 2017 already used eye-glasses during screening. by using e chart as a screening tool, out of a total of 202 eyes, 191 (94.55%) eyes had normal visual function whereas 11 (5.44%) eyes had visual impairment. the data showed that boys (5.94%) had greater number of visual impairment than girls. students with visual impairment were considerable high in 8 years old students (3.0%) and were of 3rd grade (3.9%). frequency of students with visual impairment was not similar with frequency of eye-glasses-used students (table 1). results of clinical eye examinations showed that there were small differences of right and left eye with visual impairment. five students had visual impairment in their both eyes and one student had one eye with visual impairment (tabel 2). discussion eye examination in infant and children is conducted by eye-care providers in the eye hospital by using pictures, and one of them is e-chart. it is similar with the tool used in this study to screen visual impairment. e-chart is used to assess the visual function in four years old and older verbal children.2,7 prevalence of school-aged children in the age group 6-14 years with visual impairment is 0.03% in a study conducted by riskesdas 2013. the study by teerawattananon et al.8 in thailand (2014) has showed that 6.6% students have visual impairment. an other study held in ethiopia by sewunet et al.9 shows that 11.6% schoolaged children have visual impairment. in this studythe frequency of visual impairment among students was 5.94%. the variations of result in several studies can be due to different sampling technique methods, size of population screened, and geographical area.10 furthermore, boys (5.94%) with visual impairment were in greater number than girls (table 1). this is similar with the study conducted by opubiri et al.3 in nigeria (2013), which shows visual impairment is the most common problem in age group 8˗10 years , and 7 from 11 children were boys. in contrast, a study conducted in saudi arabia proves that refractive error occurs more in girls (12%) than boys (7.7%).10,11 while a study conducted by teerawattananon et al.8 in thailand (2014) has concluded that there is no significant difference of occurrence of visual impairment in boys (51%) and girls (49%). there is no difference of eye development both in preschool-age and school-age children based on their gender.7 according to who that proved that most children affected by visual impairment due to refractive error were in age group 5–15 years, this study focused on students aged 8–10 years. moreover, 8 years old students had the greatest number of visual impairment and students were of 3rd grade (table 1). this data is similar with a study conducted in saudi arabia11 which shows visual impairment is most common in students aged 7–8 years and were of 3rd to 4th grade. one of the reason is students are actively growing in that age group.11 the study conducted by opubiri et al.3 in nigeria (2013) also shows that visual impairment is considerably high in age group 8–10 years (40.7%). a study in thailand8(2014) reports that screening program has already been conducted in pre-school and primary elementary school children. the teachers get difficulties during the screening process that is performed in pre-school children, due to lack of cooperative and lack of knowledge of the children.8 eye examination in early age needs parents participation to get children focus while doing the examination.7 so that children aged 8˗10 years old were involved in this study. the alteration of eye diameter and its curvature affects the clearance of image captured by the retina. the changes of axial length occur faster in the first three years of life, after that the changes occur slowly. in the second decade of life, the cornea will be flattened, keratinocyte will be thinner, and the endothelial cell will be changed. lens crystalline affecting lens capability in refraction also changes in the second decade of life. lens fiber will be produced along the table 2 clinical eye examination characteristic right eye n (%) left eye n (%) eye examination normal 95 (94.1) 96 (95.0) visual impairment 6 (5.9) 5 (5.0) total 101 (100) 101 (100) althea medical journal. 2017;4(3) 343 life, so it becomes thicker in older age.7 moreover, data showed 1 (1%) student used eye-glasses during screening, in contrast to 6 students with visual impairment (table 1). the study conducted by riskesdas indonesia in 2013 in age group 6-14 years, shows that there are 1% cases of corrected refractive error.2 the study conducted in 2012 by ghosh et al.12 in kolkata, india, shows that 4 (1.46%) students from the total of 273 students with visual impairment already used eye glasses. three other studies conducted in saudi arabia11 that have a similar purpose with this study shows three different results. first, from 18.6% students with refractive error, 16.3% students have uncorrected refractive error.11 econd, in 2012, according to a study conducted by al wadaani et al.10 in al hassa, saudi arabia, 9.4% students with refractive error have used eye-glasses to avoid early blindness. data in the study of compliance of eye-glasses-used in primary school children by aldebasi13 shows that boys (30.87%) have poor compliance than girls (35.97%). another study conducted in ethiopia9 reports that 9.3% students with refractive error have used eye-glasses. there are several factors affecting the differences in number of eye-glasses-used in students with visual impairment. it depends on the education level and the age of people.2 besides, there is underestimation from the eye care provider in health care facilities and policy maker in the government about the importance of using eye-glasses for visual impaired children. the other factor is people of low socioeconomic level have difficulties in getting health care facilities from the eye care provider.14 this study concludes that frequency of visual impairment and eye-glasses-used students at cibeusi elementary school is considerably different. there are some limitations in this study. e-chart used as a tool in screening of visual impairment does not give information about the visual acuity. this screening program provides information whether the students has visual impairment or not. data were obtained during school time so that the number of students involved in this study was limited. there is no analysis about factors affecting visual impairment in aged 8–10 years . the frequency of visual impairment was not similar with the frequency of eye-glassesused in this study, so there should be an approach not only to the health and education department but also to both teachers and parents to make visual screening as a school program to support vision 2020 of who. it may also decrease the number of avoidable blindness in early age. education is important to increase the awareness of teachers and parents that visual impairment can affect learning, communication, productivity, and quality of life. next study should be conducted to analyze whether there is an association of student’s characteristics and visual impairment or not, and factors affecting visual impairment. references 1. world health organization. global initiative for the elimination of avoidable blindness: action plan 2006-2011. geneva: world health organization. 2007:1–25. 2. kementerian kesehatan republik indonesia. pokok-pokok hasil riskesdas 2013. jakarta: kemenkes ri. 2013: 270–7. 3. opubiri i, pedro-egbe c. screening for refractive error among primary school children in bayelsa state, nigeria. pan afr med j. 2013;14(1):74. 4. pi l-h, chen l, liu q, ke n, fang j, zhang s, et al. prevalence of eye diseases and causes of visual impairment in school-aged children in western china. j epidemiol. 2011;22(1):37–44. 5. smith t, frick k, holden b, fricke t, naidoo k. potential lost productivity resulting from the global burden of uncorrected refractive error. bull world health organ. 2009;87(6):431–7. 6. padhye as, khandekar r, dharmadhikari s, dole k, gogate p, deshpande m. prevalence of uncorrected refractive error and other eye problems among urban and rural school children. middle east afr j ophthalmol. 2009;16(2):69–74. 7. harley rd, nelson lb, olitsky se. harley’s pediatric ophthalmology. philadelphia: lippincott williams & wilkins; 2005. 8. teerawattananon k, myint c-y, wongkittirux k, teerawattananon y, chinkulkitnivat b, orprayoon s, et al. assessing the accuracy and feasibility of a refractive error screening program conducted by school teachers in preprimary and primary schools in thailand. plos one. 2014;9(6):1–8. 9. sewunet sa, aredo kk, gedefew m. uncorrected refractive error and associated factors among primary school children in debre markos district, northwest ethiopia. bmc ophthalmol. 2014;14(1):95. 10. al wadaani fa, amin tt, ali a, khan dea aprilianti permana, feti karfiati memed, putri teesa radhiyanti santoso: visual impairment screening in cibeusi elementary school students althea medical journal. 2017;4(3) 344 amj september 2017 ar. prevalence and pattern of refractive errors among primary school children in al hassa, saudi arabia. glob j health sci. 2012;5(1):125–34. 11. aldebasi yh. prevalence of correctable visual impairment in primary school children in qassim province, saudi arabia. j optom. 2014;7(3):168–76. 12. ghosh s, mukhopadhyay u, maji d, bhaduri g. visual impairment in urban school children of low-income families in kolkata, india. indian j public health. 2012;56(2):163–7. 13. aldebasi yh. a descriptive study on compliance of spectacle-wear in children of primary schools at qassim province, saudi arabia. int j health sci (qassim). 2013;7(3):291–9. 14. mcclure tm, choi d, wooten k, nield c, becker tm, mansberger sl. the impact of eyeglasses on vision-related quality of life in american indian/alaska natives. am j ophthalmol. 2011;151(1):175–82. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 456 amj september 2017 relationship between knowledge, attitude and practice of student’s personal hygiene with scabies incidence in pesantren darul fatwa, jatinangor, west java, indonesia karinna dwi purnama,1 dedi rachmadi sjambas,2 oki suwarsa3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of dermatovenerology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: scabies is a parasitic infection caused by sarcoptesscabiei hominis varian and acarina order. sarcoptes scabiei infects both male and female in any age groups, ethnics, and socio-economic levels. transmission of scabies can pass through by a direct contact from skin-to-skin or indirect contact through sharing bed, clothes, and towels. pesantren as an educational institution supplies facilities that are shared thus making students susceptible to scabies infection. this study was conducted to discoverrelationshipbetween knowledge, attitude, and practice of student’s personal hygiene with scabies incidence. methods: an analytic observational study was conducted from october to november 2015 in pesantren darul fatwa, jatinangor. study was conducted with cross-sectional design and total sampling for the sample size. total of 37 students whoparticipated in this study were 22 malesand 15 females. this study was begun with a stand alone-questionnaire, fill out on knowledge, attitude, and practice of personal hygiene that was supervised by researcher, and physical examination for scabies diagnosis that was performed by doctors. results: based on history taking and physical examination, 15 out of 37 students were diagnosed with scabies positive. all of them were males, dominated by 13 year old students, 1st and 2nd junior high school students. statistical analysis with chi-square test showed that there were no relationship between knowledge, attitude and practice of student’s personal hygiene with scabies incidence. conclusions: there is no relationship between knowledge, attitude and practice of student’s personal hygiene with scabies incidence in pesantren. keywords: attitude, hygiene, knowledge, practice, scabies correspondence: karinna dwi purnama, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: karinnarinn@gmail.com introduction scabies prevalences around the world exceed 300 million people.1-3 scabies is caused by sarcoptesscabiei which lives on stratum corneum layer of the human skin. lesion characteristic caused by this infection is pruritic papular eruption.4 an epidemiological study showed that scabies incidences in developing countries in asia are high, about 17% in schools in timor leste and 31% in orphanages in malaysia.5 sarcoptesscabiei migrates from the infected body to the new host by odour and body heat stimulation. in order to have enough stimulation, a person must live in a place that has very close skin-to-skin contact, such as a crowded pesantren.6,7 pesantren is an institution that provides some facilities that are shared together as the student’s types of personal hygiene varies. this makes them susceptible to be infected with scabies.8 a study showed that sarcoptesscabiei infected about 10% of general population and 59% children on rural community.9 a study conducted at madrasah in dhaka city, bangladesh also reported that in 2011, scabies is hyper endemic at the madrasah, 98% of 492 students at madrasah are diagnosed with scabies positive.10 thus, this researcher was attracted to conduct a study about relationship between knowledge, attitude, and practice of student’s personal hygiene with scabies incidence in pesantren. amj. 2017;4(3):456–60 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1198 althea medical journal. 2017;4(3) 457 methods this study was carried out from october to november 2015 in pesantren darul fatwa jatinangor. the type of study was analytic observational with cross-sectional design. sampling method used was total sampling method, which 37 students participated in this study (15 females and 22 males). every student was needed to be in the inclusion and exclusion criteria parameters to participate the study. inclusion criteria in this study were both male and female students in junior high school who lived at pesantren darul fatwa jatinangor. students were obligated to fill the inform consent form as an agreement to participate in this study. students who had mental disorder were included into exclusion criteria because they disturbed communication process. the method of this study was unpaired categorical comparative analytic. this study was approved by health research ethics commitee faculty of medicine universitas padjadjaran no.538/ un6.c1.3.2/kepk/pn/2015. tested variables were knowledge, attitude, and practice of student’s personal hygiene as the independent variables, and scabies incidence as the dependent variable. data collection was begun from study instruments preparation, such as questionnaire and physical examination tools. questionnaire used as a tool was validated in a pesantren in jatinangor that had similar characteristics with this research location. the alpha-cronbach’s scores were: α=0.733 for personal hygiene knowledge, α=0.716 for personal hygiene attitude, and α=0.701 for personal hygiene practice. scoring criteria division for each knowledge, attitude, and practice were divided into three categories, which were good (respondent’s answer percentage was 76%–100% from total score), moderate (respondent’s answer percentage was 56%–75% from total score), and poor (respondent’s answer percentage was <56% from total score).11 subjects who were eligible to participate the study were given inform consent first, and then filled the questionnaire autonomously as the researcher supervised fulfillment process. next step, the respondents were interviewed and examined by doctors. the doctors who examined the students were from department of dermato-venerology of dr. hasan sadikin general hospital bandung. they have been standarized and were competent for this study. physical examination was conducted by male doctor who examined male students, and female doctor who examined female students. history taking and physical examination were conducted to diagnose scabies infection on students, determine lesion efflorescence, and microscopic examination of sarcoptes scabiei with cellophane tape method. the data were not normally distributed after table 1 respondent’s general characteristics characteristics scabies total yes no gender male 15 7 22 female 0 15 15 age (year) 11 0 1 1 12 2 2 4 13 7 1 8 14 3 5 8 15 3 12 15 17 0 1 1 grade in junior high school 1st 6 5 11 2nd 6 13 19 3rd 3 4 7 karinna dwi purnama, dedi rachmadi sjambas, oki suwarsa: relationship between knowledge, attitude and practice of student’s personal hygiene with scabies incidence in pesantren darul fatwa, jatinangor althea medical journal. 2017;4(3) 458 amj september 2017 running a normality test, saphiro-wilk, so chisquare and fisher test on statistical program that were used to test relationship among two categorical variables. confidence interval value was 95% with mean determined by p value, in which p value <0.05 showed that the result had a meaning or there was an relationship among two tested variables. results thirty seven data were collected from this study, 15 students were diagnosed with scabies. respondents of this study were table 2 distribution of lesion efflorescence on scabies sufferers type of lesion number of scabies sufferers excoriation 13 erosion 2 hiper pigmentation 7 crust 14 papule 15 table 3 distribution of lesion location on scabies sufferers type of lesion number of scabies sufferers finger webs of hand 15 volar of lower arm 11 abdomen 9 genital 9 table 4 analysis of relationship between knowledge, attitude, and practice of student’s personal hygiene with scabies incidence in pesantren independent variables scabies (n=37) total p value yes no knowledge of personal hygiene p=0.708 good 17 10 27 moderate 5 5 10 poor 0 0 0 total 22 15 37 attitude of personal hygiene p=1.000 good 18 12 30 moderate 4 2 6 poor 0 1 1 total 22 15 37 practice of personal hygiene p=1.000 good 2 2 4 moderate 17 11 28 poor 3 2 5 total 22 15 37 althea medical journal. 2017;4(3) 459karinna dwi purnama, dedi rachmadi sjambas, oki suwarsa: relationship between knowledge, attitude and practice of student’s personal hygiene with scabies incidence in pesantren darul fatwa, jatinangor dominated by male students. all of scabies sufferers were males, dominated by 13 years old students, 1st and 2nd junior high school students (table 1). statistical differences between knowledge, attitude, and practice of student’s personal hygiene with scabies incidence resulted p value>0.05 . this result showed that there was no relationship between knowledge, attitude, and practice of student’s personal hygiene with scabies incidence. discussion this study discovered that more than 50% students were diagnosed with positive scabies. this result was similar with the epidemiological study in 2013 which showed that scabies incidence in developing countries in asia was high, about 17% in schools in timor leste and 31% in orphanage in malaysia.5 it was reported that high number of scabies sufferers lived in an institution that accomodated many people in one place (pesantren, orphanage), were high for scabies transmission because there were so many people living in the same place. due to the phenomena, direct contact from skin to skin can be easily established and often occured. this study showed that scabies sufferers efflorescence distribution and lesion location are appropriate with the given theories. a study reported that lesion efflorescence scabies sufferers are pruritic papule, pustule, vesicle, nodul, excoriation, and crust.12 characteristics of lesion distribution are on predilection area of the body, which are finger webs, dorsum and palm, axilla, periumbilicus, genital, and sole.12 this study discovered that most of personal hygiene knowledge and attitude degree of respondents were good. in contrast, most of personal hygiene practice degree were at moderate level. there were 27 out of 37 respondents having good knowledge, 30 out of 37 having good attitude, while 28 out of 37 having moderate practice. these results are similar to other studies conducted in 2012 about the characteristics of knowledge, attitude, and practice in preventing transmission of scabies in pesantren.13 based on this study analysis of pesantren situation and questionnaire result, respondents’ knowledge, attitude, and practice of personal hygiene are good because most students understand about personal hygiene itself. however, most of the practice of personal hygiene was at moderate level. these results might be as a consequence of the minimal facilities in pesantren. pesantren does not have laundry service so every student must wash their own clothes. there is also no health facility, thus sick students seldom get cure and has minimum knowledge about prevention strategies of scabies. in addition, students also sleep together in their room, share towels and clothes each other. students who live together in a room can be influenced by personal hygiene practice of other students. however, this study discovered that there was no relationship between knowledge, attitude, and practice of students’ personal hygiene with scabies incidence in pesantren. this result was contradicted with theory that stated scabies can transmit if students do not understand about personal hygiene.14 another theory claimed that students are vulnerable to get scabies because of students’ personal hygiene varieties.8 a study reported that the poor knowledge of student’s personal hygiene can increase scabies incidence which contradicts with this study.15 in this study, the causes of scabies incidence might be caused by the students who live together with other friends in one crowded room (close contact), so that the students with good knowledge, attitude, and practice of personal hygiene can be transmitted by the students with moderate and poor knowledge, attitude, and practice of personal hygiene. the limitations of this study are small sample size and less detail questionnaire. the study hereafter needs to consider the sample size, elaborate, and develop the questionnaire, and focus on the preventive and management strategies of scabies. the conclusion of this sudy is the tested hypothesis which is rejected. it means there is no relationship between knowledge, attitude and practice of student’s personal hygiene with scabies incidence at pesantren darul fatwa, jatinangor. references 1. chosidow o. scabies. n engl j med. 2006;354(16):1718–27. 2. capobussi m, sabatino g, donadini a, tersalvi ca, castaldi s. control of scabies outbreaks in an italian hospital: an information-centered management strategy. am j infect control. 2014;42(1):316–20. 3. ly f, caumes e, ndaw cat, ndiaye b, mahe a. ivermectin versus benzyl benzoate applied once or twice to treat human scabies in dakar, senegal: a randomized althea medical journal. 2017;4(3) 460 amj september 2017 controlled trial. bull world health organ. 2009;87(1):424–30. 4. aboud ka, aboud da. multiple lesions of granuloma annulare on the hand in a patient with scabies. clinical cosmetic and investigational dermatology. 2011;4(1):131–2. 5. mounsey ke, mccarthy js, walton sf. scratching the itch: new tools to advance understanding of scabies. trends in parasitology. 2013;29(1):35–42. 6. heukelbach j, feldmeier h. scabies. j lancet. 2006;367(3):1767–74. 7. wolf r, davidovici b. treatment of scabies and pediculosis: facts and controversies. clin dermatol. 2010;28(1):511–8. 8. ratna aryani. kesehatan remaja problem dan solusinya. jakarta: salemba medika; 2010. 9. feldmeier h, jackson a, ariza l, maria c, lima vd, oliveira fa. the epidemiology of scabies in an impoverished community in rural brazil: presence and severity of disease are associated with poor living conditions and illiteracy. j am acad dermatol. 2008;60(3):436–43. 10. talukder k, talukder m, farooque m, khairul m, sharmin f, jerin i, et al. controlling scabies in madrasahs (islamic religious schools) in bangladesh. public health. 2013;127(1):83–91. 11. wawan, dewi.teori dan pengukuran pengetahuan, sikap, dan perilaku manusia. yogyakarta: nuha medika; 2010. 12. gunning k, pippitt k, kiraly b, sayler m. pediculosis and scabies: a treatment update. am fam physician. 2012;86(6):535–41. 13. mohd yusuf mb, fitri rs, damopolii y. a study on knowledge, attitude, and practice in preventing transmission of scabies in pesantren darul fatwa, jatinangor. amj. 2015;2(1):131–7. 14. marwali harahap. ilmu penyakit kulit. jakarta: gramedia; 2008. 15. ciftci ih, karaca s, dogru o, cetinkaya z, kulac m. prevalence of pediculosis and scabies in preschool nursery children of afyon, turkey. korean j parasitol. 2006;44(1):95–8. althea medical journal. 2018;5(2) 105 elderly profile of quality of life using whoqol-bref indonesian version: a community-dwelling aghnia rizki hidayati,1 sharon gondodiputro,2 lina rahmiati2 1diploma 4 of midwifery program faculty of medicine universitas padjadjaran, indonesia 2department of public health faculty of medicine universitas padjadjaran, indonesia abstract background: indonesia as one of the developing countries is facing a demographic transition. the proportion of under-five children is decreasing while the proportion of elderly is rising. this situation is followed by the increase of noncommunicable/degenerative diseases. however, this situation is not a constraint for the elderly to have a better life. the whoqol group had developed a questionnaire to measure the elderly’s quality of life. the aim of this study was to describe the quality of life (qol) of a community-dwelling elderly by using the whoqol-bref questionnaire indonesian version. methods: eighty eight elderly from 6 villages in jatinangor, west java, indonesia were involved in a descriptive study relating to qol by using the whoqol-bref questionnaire indonesian version. the inclusion criteria were men and women, aged ≥60 years, could communicate effectively, and had mini mental state examination score ≥>23. the variables in the study were physical, psychological, social and environmental domains and facets in the qol questionnaire. the collected data in the study were analyzed using the central tendency items. results: most respondents had low qol scores (≤60). this study discovered that some facets of every domain in the whoqol-bref had low scores, namely adequate energy, ability to perform daily living activities, satisfaction with work capacity, ability to concentrate, acceptance of physical appearance, satisfaction of sex life, financial fulfillment, availibility of information, opportunity for leisure activities and transport. conclusions: most of the elderly have low qol scores in some facets of every domain in the whoqol-bref questionnaire. keywords: elderly, environment domain, physical domain, psychological domain, social domain correspondence: aghnia rizki hidayati, diploma 4 of midwifery program faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: bidunpad.2014.021@gmail.com introduction indonesia, as a developing country, is facing a demographic transition. the demographic transition leads to decrease the under-five children proportion and raise the 60-andabove elderly proportion. accordingly, this condition causes the proportion of the elderly population will be higher than the under-five children population. this condition is caused by the decrease of total fertility rate (tfr) and the raise of life expectancy.1 based on the united nations population fund (unfpa) indonesia, in 1971 the tfr in indonesia was 5.6 and in 2035 the tfr will be decreasing to 1.9.1 in 1971, the life expectancy was 45.7 but it will be rising to approximately 72.4 in 2035.1 the rising of elderly population also generates changes in the population structure. the proportion of elderly aged 60–74 years tends to decrease while the proportion of elderly aged above 75 years tends to rise.1 elderly population aged above 75 years will be approximately 21% among the total population in 2035.1 furthermore, demographic transition can cause epidemiological transition. noncommunicable/degenerative diseases will mostly occur when compared to acute infectious diseases.2 hence, this situation does not cause problems for the elderly to perform daily activities or to have a better life. based on the world health organization (who), quality of life (qol) is defined as “an individual’s perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”.3 quality of life is considered as an individual’s subjective perceptions to their position in life which is not only associated with disease symptoms or diseases but also measurement amj. 2018;5(2):105–10 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1417 althea medical journal. 2018;5(2) 106 amj june 2018 of disease impacts towards their qol in daily activities.3 quality of life (whoqol-100 and whoqol-bref) questionnaires had been provided by the whoqol group in 1995.3 the questionnaires were translated into indonesian in 2004 by experts, namely ratna mardiati, satya joewana, hartati kurniadi, isfandari, and riza sarasvita. additionally, the questionnaires had been revised twice (in 2014 and 2016) by fredrick dermawan purba. the whoqol-bref questionnaire includes 4 domains, namely physical, psychologycal, social relationships, and environment, consisting of 24 facets.3 a previous study by salim et al.4 observed the whoqol-bref validity and reliability for elderly in indonesia. the measurement of qol has not been widely studied in indonesia. the purpose of this study was to describe qol in elderly using the indonesian version of the whoqol-bref questionnaire. methods a descriptive study was carried out to 88 out of 97 elderly. the study was conducted in a suburb area near bandung in june 2017. located in jatinangor, it is one of the sub-districts in kabupaten sumedang, west java, indonesia. the inclusion criteria were the elderly aged above 60 years, could communicate effectively, and did not have dementia through a measurement using the mini mental state examination (mmse) questionnaire scored ≥23. the exclusion criterion in the study was the elderly who was absent during the study. the study used multistage random sampling as the sampling method. among 12 villages, 6 villages in jatinangor sub-district were selected. the samples of each village were calculated based on the number of elderly in order to obtain the proportional total samples. afterwards, one rw (rukun warga) of each village was selected by using the simple random sampling method. the respondents’ selection was then performed by using consecutive sampling method. the study commenced by describing the objectives of the study to the respondents. the respondents who agreed were asked to fill and sign the informed consent. furthermore, the mmse questionnaire test was carried out. if the mmse score was ≥23, the measurement of qol would be performed by using the whoqol-bref in indonesian version.3 the questionnaire consisted of 26 questions which included 2 general questions relating to the respondents’ perceptions to their qol, satisfaction in life, and health condition; 4 domains such as the physical domain consists of 7 questions, psychologycal domain consists of 6 questions, social relationships domain consists of 3 questions, and environment domain consists of 8 questions.3 every question scores from 1 to 5.3 the total score of every domain was calculated, and transformed by using the transformation table with a scale 0–100.3 the total score of every domain was examined by using the kosmogorov-smirnov normality test. since the data found in the study were not normally distributed (p<0.05), the presented results were in the forms of median, mean, minimum, and maximum scores. the respondents’ characteristics were age, gender, marital status, and education level. the age characteristic was divided into two categories which were 60–69 years and ≥70 years. gender was classified into man and woman, while marital status was divided into married and divorced/widower/widow. the education level was classified into 4 categories i.e. no education, primary school, junior school, and senior high school. the qol level was classified into two categories which were good qol scored ≥60 and poor qol scored ˂60.5 the collected data in the study were presented in tables. moreover, this study was approved by the health research ethic committee, faculty of medicine, universitas padjadjaran with the ethical number 779/ un6.c.10/pn/2017. results among 88 respondents, the major respondents were those aged 60–69 years. the proportion between male and female respondents based on gender was slightly similar. based on marital status, proportion of the respondents who were with or without spouses was slightly similar as well. the majority of the respondents showed lower education level but several of them were senior high school graduates (table 1). the study discovered that the qol domains such as physical, psychologycal, social relationships, and environmental domains showed low scores (<60). the results determined 100% of respondents had low physical domain score, 98.9% respondents had low psychological domain score, 96.6% respondents had low social relationship domain score, and 89.8% respondents had althea medical journal. 2018;5(2) 107 low environmental domain score. the study also revealed that overall, the respondents perceived mediocre qol. however, the respondents were satisfied with their health condition (table 2). based on the physical domain, most respondents revealed that they did not obtain satisfaction in their vitality (enough energy everyday), ability to perform daily living activities and their capacity to work. based on the psychological domain, most respondents complained about the ability to concentrate and physical appearance. based on social relationship domain, sex life was among the facets frequently complained by the respondents. based on the environmental domain, financial fulfillment, availibility of information, opportunity for leisure activities and transport were the facets which mostly were complained by the respondents (table 2). discussions aging is a multidimensional process of many changes6 related to cells and tissues generally caused by increased age. this condition leads to the increased risks of diseases and in many cases it can cause deaths.6 nevertheless, aging is not a major problem for the elderly to improve their qol. this study discovered that the respondents’ qol was low particularly the physical domain score. this study revealed that most respondents were not satisfied with their physical performances such as did not have sufficient energy to perform daily activities (vitality), ability to perform daily living activities, and capacity to work. lower vitality, daily living activity disturbances, and lower working capacity are several symptoms of fragility syndrome frequently found in elderly.7 according to chen et al.7 fragility in elderly is the condition of the decreases of both physiological reserves and multiorgan system functions leading to increased vulnerability for adverse health outcomes. a previous study by moreh et al.8 stated that fragility in elderly is commonly associated with immediate fatigue. fatigue can increase along with increased age. some factors which can influence fatigue are loneliness, depression, lower daily and physical activities, joint and back pains, lower sleep satisfaction, hypertension, and ischemic heart disease.8 another study by witard et al.9 reported that decreased muscular mass and strength are among several factors which can contribute to vitality in elderly. furthermore, cognitive impairments frequently occur in elderly which can influence daily functions.10 this study revealed that most respondents had concentration disturbances. mild cognitive impairments often occur in elderly before having dementia although this condition may not disturb their daily living activities.11 mild cognitive impairments if left table 1 respondents’ characteristics distribution based on age, gender, marital status, and education level characteristics frequency (n=88) percentage (%) age 60–69 years 64 72.7 ≥70 years 24 27.3 gender men 39 44.3 women 49 55.7 marital status divorced/widowed 43 48.9 married/spouses 45 51.1 education level no education 22 25 primary school 45 51.1 junior school 16 18.2 senior high school 5 5.7 aghnia rizki hidayati, sharon gondodiputro, lina rahmiati: elderly profile of quality of life using whoqol-bref indonesian version: a community-dwelling althea medical journal. 2018;5(2) 108 amj june 2018 table 2 scores of each facet and domain no domains facets score median mode minimum maximum 1 how would you rate your quality of life? 3 3 2 5 2 how satisfied are you with your health? 3 3 2 4 3 physical to what extent do you feel that physical pain prevents you from doing what you need to do? 3 3 2 5 4 how much do you need any medical treatment to function in your daily life? 3 3 2 4 5 do you have enough energy for everyday life? 2 2 1 4 6 how well are you able to get around? 3 3 2 4 7 how satisfied are you with your sleep? 3 3 1 4 8 how satisfied are you with your ability to perform your daily living activities? 2 2 1 4 9 how satisfied are you with your capacity for work? 2 2 1 4 10 psychological how much do you enjoy life? 3 3 2 4 11 to what extent do you feel your life to be meaningful? 3 3 2 5 12 how well are you able to concentrate? 2 2 1 4 13 are you able to accept your physical appearance? 2 2 1 5 14 how satisfied are you with yourself ? 3 3 2 5 15 how often do you have negative feelings such as blue mood, despair, anxiety, depression? 4 4 2 5 16 social relationship how satisfied are you with your personal relationships? 3 3 2 4 17 how satisfied are you with your sex life? 2 2 1 4 18 how satisfied are you with the support you get from your friends? 3 3 2 4 19 environment how safe do you feel in your daily life? 3 3 2 5 20 how healthy is your physical environment? 3 3 1 4 21 have you enough money to meet your needs? 2 2 1 4 22 how is the availability of information that you need in your day-to-day life? 2 2 1 4 23 to what extent do you have the opportunity for leisure activities? 2 2 1 4 24 how satisfied are you with the conditions of your living place? 3 2 2 4 25 how satisfied are you with your access to health services? 3 3 1 5 26 how satisfied are you with your transport? 2 2 1 5 althea medical journal. 2018;5(2) 109aghnia rizki hidayati, sharon gondodiputro, lina rahmiati: elderly profile of quality of life using whoqol-bref indonesian version: a community-dwelling untreated, will be a public health problem in the future.11 moreover, this study discovered a unique finding that most respondents did not accept physical appearance changes. a previous study explained that physical appearances are related to self-esteem although there may be differences based on age and gender.12 selfesteem in elderly men is influenced by general physical appearances which they cannot reach. meanwhile, the major predictor of self-esteem in elderly women is overweight.12 a study by tavarez et al.13 reported that lower self-esteem can contribute to physical conditions and lower social participations. according to ambler et al.14 sex life in elderly men and women becomes a main component of psychological and physical intimacy. increased age does not mean sex life is not important. desire to be close with someone and sexual contacts occur in lifetime.15,16 generally, elderly are unwilling to complain about sex life.16 this condition leads to undetected and unreported sexual problems.16 elderly patients did not always complain relating to sexual dysfunctions to the doctors.16 approximately 92% men and 96% women, who had at least one sexual complaint, did not seek treatment. this study discovered that sex life was mostly complained by the respondents. this condition occurred because there were respondents who did not have a spouse, and those who had a spouse potentially felt ashamed to express satisfaction or dissatisfaction regarding their sex life. additionally, this study discovered that most respondents had financial problems. a study revealed that indonesia as a developing country is not widely establishing old-age insurance leading to the condition that most elderly lived depending on their families.2 the indonesian central statistics agency reported, the number of elderly dependent on their families were rising for years, particularly in the rural areas.17 in 2012, the number of elderly dependent on their families in rural area was 14.09% which increased continuously to 15.04% in 2016.17 afterwards, 44.59% of elderly were included in the category of 40% of the population with low economic status; the percentage of elderly women was higher than elderly men (46.04% compared to 42.97%).17 this condition determines that elderly women are vulnerable to have financial problems when compared to elderly men. everybody needs information in their lives, including the elderly. this study discovered that some elderly complained about the availability of information relating to daily living. however, investigation regarding to information necessity in elderly has not been widely studied. hence, a study conducted in nigeria by edewor et al.18 discovered some respondents need information relating to their health and financial/pension conditions. furthermore, this study discovered less opportunity for leisure activities in elderly. recreation activities play an important role to improve qol in elderly. a study reported that the elderly who usually do recreation activities have better mental health because recreation activities can also decrease stress, depression, anxiety and improve health and fitness.19 recreation activities increase social participation for elderly in the society leading to positive effects for health.2,19 according to villar20 , the elderly who succeed in living are influenced by two components i.e. the opportunity to participate in the society (social participations) and ability to participate. recreation activities are positive efforts for elderly to reach successful aging. there were several limitations in this study as most respondents had lower education level which caused the respondents did not properly comprehend the questions. moreover, the study only described elderly’ perceptions to the questions included in the whoqolbref questionnaire which should be explored further regarding the reasons for choosing a certain score on the questions. this should be performed in order to discover detailed descriptions relating to qol in elderly. the study concluded that the qol in elderly is low. the most caused facets of dissatisfactions in elderly were vitality, ability to do daily living activities, capacity of working, ability to concentrate, acceptance of physical appearances, sex life, financial fulfillment, information availibility, opportunity for leisure activities, and transportation. references 1. unfpa indonesia. indonesia on the threshold of population ageing. 1st ed. jakarta: unfpa indonesia; 2014. 2. cao j, rammohan a. social capital and healthy ageing in indonesia. bmc public health. 2016;16(631):1–14. 3. world health oranization. whoqol-bref, introduction, administration, scoring and generic version of the assessment. 1st ed. geneva: who; 1996. 4. salim oc, sudharma ni, kusumaratna rk, hidayat a. validitas dan reliabilitas world althea medical journal. 2018;5(2) 110 amj june 2018 health organization quality of life-bref untuk mengukur qol lanjut usia. universa medicina. 2007;26(1):27–38. 5. silva pab, soares sm, santos jfg, silva lb. cut-off point for whoqol-bref as a measure of quality of life of older adults. rev saúde pública. 2014;48(3):390–7. 6. amarya s, singh k, sabharwal m.changes during aging and their association with malnutrition. journal of clinical gerontology & geriatrics.2015;6():78–84. 7. chen x, mao g, leng sx. frailty syndrome: an overview. clin interv aging. 2014;9(3):433–41. 8. moreh e, jacob jm, stessman j. fatigue, function, and mortality in older adults. j gerontol a biol sci med sci. 2010;65(8):887–95. 9. witard oc, mcglory c, hamilton dl, phillips,sm. growing older with health and vitality: a nexus of physical activity, exercise and nutrition. biogerontol. 2016;17(5):529–46. 10. dregan a, stewart r, gulliford mc. cardiovascular risk factors and cognitive decline in adults aged 50 and over: a population-based cohort study. age and ageing. 2013;42(3):338–45. 11. geda ye. mild cognitive impairment in older adults. curr psychiatry rep. 2012; 14(4):320–27. 12. baker l, gringar e. body image and selfesteem in older adulthood. ageing and society. 2009;29(7):977–95. 13. tavares dmds, matias tgc, ferreira, pcds, pegorari ms, nasciment js, de paiva mm. quality of life and self-esteem among the elderly in the community. ciencia & saude coletiva. 2016;21(11):3557–64. 14. ambler dr, bieber ej, diamond mp. sexual function in elderly women: a review of current literature. rev obstet gynecol. 2012;5(1):16–27. 15. rheaume c, mitty e. sexuality and intimacy in older adults. geriatric nursing. 2008;29(5):342–9. 16. omole f, fresh em, sow c, lin j, taiwo b, nichols m. how to discuss sex with elderly patients. the journal of family practice. 2014;63(4):e1-4. 17. badan pusat statistik. statistik penduduk lanjut usia. jakarta: bps; 2016. 18. edewor n, ijiekhuamhen op, emekaukwu up. elderly people and their information needs. library philosophy and practice (e-journal) [serial on the internet]. 2016 feb [cited 2017 dec 20];2016(1332):[about 16p.]. available from: http://digitalcommons.unl.edu/ libphilprac/1332. 19. singh b, kir uv. recreational activities for senior citizens. iosr j human soc sci. 2014;19(4):24–30. 20. villar f. successful ageing and development: the contribution of generativity in older age. ageing soc. 2012;32(7):1087–105. althea medical journal. 2017;4(2) 178 amj june 2017 prevalence of urinary incontinence in women aged 20–59 years in community dwellings ratuafni sharfina,1 tina dewi judistiani,2 amillia siddiq3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: urinary incontinene (ui) is the symptomof involuntary leakage of urine. three types of urinary incontinence are stress ui, urge ui, and mixed ui. this study was aimed to determine the prevalence of urinary ui in women and to identify the most common type of ui. methods: a descriptive study was conducted to 191 women age 20–59 in two villages in west java, indonesia. subjects were visited door-to-door and interviewed using a standardized questionnaire for data collection. the study was conducted in february 2014. the variables of this study were age, parity, and the prevalence of urinary incontinence. the collected data were presented using frequency tabulation and percentage. results: from 191 respondents, thirty eight subjects had ui. the prevalence of urinary incontinence was 19.90% which consisted of prevalence of stress ui (7.33%), urgency ui (9.43%), and mixed ui (3.14%). the prevalence of ui in 20–29 year age group was 3.23%, 30–39 year age group was 9.72%, 40–49 year age group was 27.69%, and 50–59 year age group was 52.17%. prevalence of ui in nulliparous women was 5%, primiparous was 10.25%, multiparous with 2 childbirths was 23.61%, and multiparous with 3 childbirths or more was 26.67%. conclusions: prevalence of ui in women in community dwelling is 19.90%, which is higher than previous study from indonesia and other asian countries. urgency ui is the most common type of ui. prevalence of ui increases with age and parity. keywords: community dwellings, prevalence, urinary incontinence, women. correspondence: ratuafni sharfina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: :+6281908428625 email: ratuafnisharfina@yahoo.com introduction international continence society (ics) is defined urinary incontinence (ui) as symptomatic complaint of urinary leakage.1 urinary incontinence is not a disease, but rather a symptom resulting from impairment of the bladder or of the sphincter.2 in western societies, epidemiologic studies indicate a prevalence of urinary incontinence of 15 to 55 percent. this wide range is attributed to variations in research methodologies, population characteristics, and definitions of incontinence.3 according to the asia pacific continence board (apcb), ui prevalence is 20.9–35% where ui is more prevalent in women (15.1%) compared to men (5.8%). from those women with ui, 24.9% have stress ui, 10.5% have urgency ui, and 5%.4 overall prevalence of ui in indonesia5 is 13% and it increases with age.2,6 stress ui is the most common type ui in women, meanwhile urgency ui is more common in older women.1 the ui can significantly impair women’s quality of life, leading to disrupted social relationships, psychological distress from embarrassment and frustration, hospitalizations due to skin breakdown and urinary tract infection, and sleep disorder.3,6 women with stress ui find a way to cope with incontinence by limiting their daily activities. limiting their activities may eliminate the incontinence problem, but it does so at a certain cost to their quality of life.1 this study was conducted to determine the prevalence of ui and to identify the most common type of ui in women aged 20–59 years in community dwellings. amj. 2017;4(2):178–83 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1070 179 althea medical journal. 2017;4(2) methods this descriptive study was conducted in february 2014 to women who lived in two villages (mekargalih and cipacing) in jatinangor, west java, indonesia. this study was part of the study project by midwifery program, faculty of medicine, universitas padjadjaran. inclusion criteria were women aged 20–59 years old and registered as a resident in mekargalih or cipacing village during data collection. exclusion criteria included women who were pregnant, women who could not speak, women who could not speak indonesian, women with dementia and/ or women who had a mental disorder. after given some explanation about this study, the respondents who were willing to participate in this study were asked to sign a written consent form. sample size was calculated using descriptive study formula7 which was valid where n is the sample size, zα was the abscissa of the normal curve that cut off an area at the tail (1.96), p was the estimated propotion of an attributed that presented in the population (13%), and e was the desired level of precision (5%). the number of sample was 174 respondents. respondents were selected by simple random sampling of mekargalih village and cipacing village family cards data. the visits were conducted with door-to-door method in accordance with the list of respondents and then, the guided interviews with respondents who were eligible to use quid (questionnaire for urinary incontinence diagnosis)8 were conducted. urinary incontinence (ui) defined as urinary complaints that happened accidentally or involuntarily for 7 days was divided into 3 types, which were stress, urgency, and mixed.3,6 stress ui is the process of involuntary urination during coughing, sneezing, or other physical activities that increase intra-abdominal pressure. urgency ui is characterized by involuntary urination which is preceded by a strong desire to urinate/ urgency. mixed ui is the simultaneous presence of stress ui and urgency ui complaints.1,3,6 the quid is a short valid and responsive instrument that can serve as a diagnostic tool to determine ui type and also as a mesure of stress & urgency ui. there were 6 questions, the first 3 items focused on stress ui symptoms and other 3 items focused on urgency ui symptoms. first 3 items in the questionnaire asked if the respondents experienced incontinence when coughing/ sneezing, bending down/lifting something up, and walking quickly/jogging/exercising. the rest of the items asked if the respondents experienced incontinence when undressing in order to go to toilet, having a strong and uncomfortable need to urinate that the urine leaked before reaching to the toilet, and having to rush to the bathroom because of a sudden and strong need to urinate. each question had 6 response options ranging from none of the time (score 0 point), rarely (score 1 point), once in a while (score 2 points), often (score 3 points), most of the time (score 4 points), all of the time (score 5 points). permission to conduct this study was given by the health research ethics committee of the faculty of medicine, universitas padjadjaran, bappeda sumedang and jatinangor subdistrict office. the data were then analyzed using statistics program. results there were 191 respondents who met the inclusion criteria and were willing to answer the questionnaire in the interview. the majority were between 30–39 years old (37.70%). the majority of the respondents were multiparous which were 37.70% who had given birth twice and 31.41% who had given birth ≥3 times. table 3 describes the prevalence of ui. among 191 respondents, there were 38 respondents who had ui. the prevalence of all types of ui was 19.90%. the prevalence of stress ui was 7.33% (14 respondents), urgency ui was 9.43% (18 respondents) and mixed ui was 3.14% (6 respondents). the percentage of ui tends to be higher with higher age category. the lowest prevalence was the age category of 20–29 years old. the highest prevalence was the age category of 50–59 years old which was 52.17% and 34.78% of who were suffering from urgency ui. the prevalence of stress ui increased with age while the prevalence of mixed ui did not increase with age. among the respondents who were nullipara, only 5% of them had ui. however, among primiparous respondents, the prevalence of ui was two-fold, which was 10.25%. multiparous was divided into who had given birth twice and more than or equal to 3 times. the prevalence ratuafni sharfina, tina dewi judistiani, amillia siddiq: prevalence of urinary incontinence in women aged 20–59 years in community dwellings althea medical journal. 2017;4(2) 180 amj june 2017 on respondents who had given birth twice reached 23.61% with stress, urgency, and combination ui respectively, 9.72%, 11.11%, and 2.78%. the prevalence on respondents who had given birth more than or equal to 3 times was 26.67%. discussion overall, the prevalence of ui in this study was 19.90%, higher than previous hospital based-study in indonesia by sumardi et al.5 that is 13%. yet, ui prevalence in this study was similar to previous community dwelling study about prevalence of ui in women aged 20–59 years in taiwan9 (18.7%). this difference could be caused by variation in population characteristic, tool for data collection, or research methodologies. the community dwelling study showed a higher prevalence than the hospital based-study. as the developing country where poverty is still a main problem, quality of life is not a concern for most indonesian people. in addition, from the patient’s point of view, ui remains a taboo subject.10 study in taiwan11 found that the main reason women do not seek a medical treatment for ui is shyness. this may explain its higher prevalence of ui in population-based study than in the hospital-based study. in this study, the most prevalent type of ui was the urgency type. this result was different with findings from western countries and the asia pacific continense board (apcb) stating that stress ui is the most prevalent.4the prevalence of urgency ui in this study was 9.43%, similar to study conducted by milsom etc in 2013 that found the prevalence of urgency ui in indonesia was 8%.12 the prevalence of stress ui and mixed ui in this study was 7.33% and 3.14%, respectively, similar to the prevalence of stress ui and mixed ui in indonesia which is 5.1% and 1.6%, respectively.5 very few studies and data were available about urgency ui in indonesia. meanwhile, the prevalence of urgency iu was predicted table 2 classification of urinary incontinence (ui) types of urinary incontinence f % stress ui quid score stress≥4 14 7.33 urgency ui quid score urgency ≥6 18 9.43 mixed ui quid score stress ≥4 & quid score urgency ≥6 6 3.14 overall prevalence of ui 38 19.90 table 1 characteristics of respondents based on age and parity characteristic frequency % age (years) 20–29 31 16.23 30–39 72 37.70 40–49 65 34.03 50–59 23 12.04 parity 0 20 10.47 1 39 20.42 2 72 37.70 ≥3 60 31.41 181 althea medical journal. 2017;4(2) table 4 prevalence of urinary incontinence (ui) based on parity parity n (%) incontinence n(%) types n (%) stress urgency mixed 0 20 (10.47%) 1 (5%) 0 (0%) 1 (5%) 0 (0%) 1 39 (20.42%) 4 (10.25%) 2 (5.13%) 2 (5.13%) 0 (0%) 2 72 (37.70%) 17 (23.61%) 7 (9.72%) 8 (11.11%) 2 (2.78%) ≥3 60 (31.41%) 16 (26.67%) 5 (8.33%) 7 (11.67%) 4 (6.67%) table 3 prevalence of urinary incontinence (ui) by age category age category (years old) n (%) ui n(%) types n(%) stress urgency mixed 20–29 31 (16.23%) 1(3.23%) 0(0%) 1 (3.23%) 0 (0%) 30–39 72 (37.70%) 7 (9.72%) 4 (5.56%) 3 (4.17%) 0 (0%) 40–49 65 (34.03%) 18 (27.69%) 7 (10.77%) 6 (9.23%) 5 (7.69%) 50–59 23 (12.04%) 12 (52.17%) 3 (13.04%) 8 (34.78%) 1 (6.78%) to increase to 25% in the next decade due to the aging population. increased prevalence of urgency iu and its morbidity became an economic burden to society and personal burden for the patient as an individual. additional costs included cost for laundry, panty liner/pad, and the cost for treatment due to comorbidity of ui like urinary tract infection.12 lack of awareness of ui patients in indonesia caused comorbidity sufferred becomes more likely and bigger economic burden. public health programs and clinical management of patients are needed to raise the awareness of ui patients and health workers. based on age, the prevalence of ui increases with age. the prevalence of ui in the respondents aged 40–49 years was 27.69%. the highest prevalence was 52.17% in respondents aged 50–59 years. these results were consistent with findings by hannestad3, which the prevalence of ui in women aged 30–39 years ranges between 18.2–21.2%. this result was not similar to findings by ghafouri et al.13 in qatar that found the highest prevalence of ui in women aged 40–49 years old, which is 29.2% and prevalence of ui in women aged 50–59 years old decrease to 21.9%. in this study, prevalence of stress ui and urgency ui in women aged 30–39 years old were 5.56% and 4.17%, respectively. the prevalence of stress ui was 10.77%, urgency ui was 9.23%, and mixed ui was 7.69% in women aged 40–49 years old. the prevalence of stress ui was 13.04%, urgency ui was 34.78%, and mixed ui was 6.78% in women aged 50–59 years old. these findings were consistent with available evidence that indicates urgency ui is a highly prevalent condition among men and women worldwide, particularly those aged ≥40 years old.12 this study found an increase prevalence of stress and urgency ui with age, particularly urgency ui and decrease prevalence of mixed ui with age. similar results were also found by botlero et al.14 who found that the increasing age is significantly associated with urgency ui but not with stress and mixed ui. table 4 showed an overall prevalence of ui and its type based on parity. the parity was defined as 0, 1, 2, and ≥3. overall, the prevalence of ui increased with parity. the prevalence of ui was 5% in nulliparous women, 10.25% in primiparous women, 23.61% in multiparous women with 2 childbirths, and 26.67% in multiparous women with 3 childbirths or more. this is consistent with many studies that suggest that prevalence of ui is higher in multiparous women compare to nulliparous women. the effects of childbirth on incontinence may result from direct trauma to the pelvic muscles and connective tissue of the pelvic floor. approximately 20% of women who had a vaginal deliveryshows a visible defect on levator ani muscle.1,3 prevalence of stress ui in this study increases with parity, similar results were also found by botlero et al.14. prevalence of stress ui in primiparous women was 5.13%, then increases to 9.72% in multiparous women ratuafni sharfina, tina dewi judistiani, amillia siddiq: prevalence of urinary incontinence in women aged 20–59 years in community dwellings althea medical journal. 2017;4(2) 182 amj june 2017 with 2 childbirths. the prevalence of stress ui in multiparous women with 3 childbirths or more was 8.33%. this results were similar to findings by danforth et al.15 who found that the first 2 births account for most of the effects. the prevalence of urgency ui increased with parity that contradicted the findings by botlero et al.14 i.e parity is not associated with urgency ui. it could be explained by the characteristics of the most multiparous women in this study which were particularly those with 3 childbirths or more, older than nulliparous women. the prevalence of mixed ui increased in multiparous women, which was 2.78% in women with 2 childbirths and 6.67% in women with 3 childbirths or more. similar results were also found in china16. in this study, the prevalence of ui in nulliparous women was 5% and all of them were women with urgency ui. the prevalence of ui in women aged 20–29 years old was 3.23% and all of them were women with urgency ui. urge incontinence not infrequently occurs with acute cystitis, particularly in women.17 urinary tract infection also may exacerbate symptom of incontinence.1 further anamnesises are needed to identify other symptoms of urinary tarct infection (frequency and dysuria). the diagnosis of urinary tract infection relies on urinalysis and urine culture. the urine is evaluated for leukocyte esterase by a urine dipstick and microscopic examination for wbcs and bacteria.18 routine microscopic examination is available in jatinangor primary health care, but urinalysis to evaluate leukocyte esterase is not yet available. from public health’s point of view, it is important to identify risk factors for ui. identification of risk factors will help in lifestyle behavior modification of women at risk, which will be important for prevention of ui.19 conservative therapy pelvic muscle floor training (kegel exercise) is a reasonable initial approach to most patients with urinary incontinence.3 it is easy and very likely to be held in primary health care. the cochrane incontinence group concluded that pelvic floor muscle training is consistently better than no treatment or placebo treatment for stress incontinence and should be offered as first-line conservative management to women. medical evidence from welldesigned randomized clinical trials shows that supervised kegel exercise is an effective treatment for stress ui.1 studies have shown up to 70% improvement in symptoms of stress ui following appropriately pelvic floor muscle exercises. this improvement is the evident across all age groups.20 for urge urinary incontinence, it improves pelvic floor muscle contractions strength to provide temporary continence during waves of bladder detrusor contraction.3 subspeciality urogynecology in department of obstetric and gynecology at dr. hasan sadikin general hospital bandung provides a comprehensive management for ui. there were some limitations in this study. this study was conducted using descriptive design making this study could not analyze the cause and effect relationship between age, parity, and prevalence of ui. in conclusion, overall prevalence of ui in women in jatinangor subdistrict is 19.90%, higher than previous study in indonesia and other asian countries. of 19.90% women with ui, 9.43% have urgency ui, 7.33% have stress ui,and 3.14% have mixed ui. these findings may increase the awareness of ui and its burden in population. further identifications of risk factors and measurement of public health burden are needed to determine the appropriate public health and clinical management program. the prevalence of ui increases with age, particularly urgency ui, while the prevalence of ui increases with parity. references 1. nygaard i, menefee sa, wall ll. lower urinary tract disorder. berek & novak’s gynecology. philadelphia: lippincott williams & wilkins; 2007. p. 849–96. 2. kwon be, kim gy, son yj, roh ys, you ma. quality of life of women with urinary incontinence : a systematic literature review. int neurourol j. 2010;14(3):133–8. 3. hoffman b, schorge j, schaffer j, halvorson l, bradshaw k, cunningham f. urinary incontinence. williams gynecology. 2nd ed. dallas: the mcgraw-hill companies, inc.; 2012. p. 606–30. 4. suparman e, rompas j. urinary incontinence in postmenopausal women. maj obstet ginekol indones. 2011;32(1):48–54. 5. sumardi r, mochtar ca, junizaf, santoso bi, setiati s, nuhonni sa, et al. prevalence of urinary incontinence, risk factors and its impact: multivariate analysis from indonesian nationwide survey. acta med indones. 2014;46(3):175–82. 6. santoso bi. urinary incontinence in female patients. maj kedokt indon. 2011;58(07):258–64. 7. kasiulevičius v, šapoka v, filipavičiūtė r. 183 althea medical journal. 2017;4(2) sample size calculation in epidemiological studies. gerontologija. 2006;7(4):225–31. 8. bradley cs, rahn dd, nygaard ie, barber md, nager cw, kenton ks, et al. the questionnaire for urinary incontinence diagnosis (quid): validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence. neurourol urodyn. 2010;29(5):727–34. 9. hsieh c-h, su t-h, chang s-t. prevalence of and attitude toward urinary incontinence in taiwanese women. int j gynaecol obstet. 2005;88(2):152–3. 10. cornu j. urinary incontinence symptoms stratification: the devil is in the details. eur urol. 2012;61(1):96–7. 11. hsieh c-h, su t-h, chang s-t, lin s-h, lee m-c, lee my. prevalence of and attitude toward urinary incontinence in postmenopausal women. int j gynaecol obstet. 2008;100(2):171–4. 12. milsom i, coyne ks, nicholson s, kvasz m, chen c-i, wein aj. global prevalence and economic burden of urgency urinary incontinence: a systematic review. eur urol. 2014;65(1):79–95. 13. ghafouri a, alnaimi ar, alhothi hm, alroubi i, alrayashi m, molhim na, et al. urinary incontinence in qatar: a study of the prevalence, risk factors and impact on quality of life. arab j urol. 2014;12(4):269– 74. 14. botlero r, davis sr, urquhartb dm, shortreedb s, bell rj. age-specific prevalence of, and factors associated with, different types of urinary incontinence in community-dwelling australian women assessed with a validated questionnaire. maturitas. 2009;62(2):134–9. 15. danforth k, townsend m, lifford k, curhan g, resnick n, grodstein f. risk factors for urinary incontinence among middle-aged women. am j obstet gynecol. 2006;194(2):339–45. 16. zhu l, li l, lang j, xu t, wong f. epidemiology of mixed urinary incontinence in china. int j gynaecol obstet. 2010;109(1):55–8. 17. mcaninch j. symptom of disorders of genitourinary tract. smith’s general urology. 17 ed. california: the mcgrawhill companies, inc; 2008. p. 30–8. 18. nguyen h. bacterial infections of the genitourinary tract. smith’s general urology. 17th ed. california: the mcgrawhill companies, inc; 2008. p. 193–218. 19. hsieh c-h, lee m-s, lee m-c, kuo t-c, hsu c-s, chang s-t. risk s for urinary incontinence in taiwanese women aged 20-59 years. taiwan j obstet gynecol. 2008;47(2):197–202. 20. price n, dawood r, jackson sr. pelvic floor exercise for urinary incontinence: a systematic literature review. maturitas. 2010;67(4):309–15. ratuafni sharfina, tina dewi judistiani, amillia siddiq: prevalence of urinary incontinence in women aged 20–59 years in community dwellings althea medical journal. 2017;4(3) 369 treatment seeking patterns among dengue fever patients: a qualitative study tharani krisnian,1 bachti alisjahbana,2 irvan afriandi3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: incidence of dengue fever is increasing drastically and has become a major public health problem globally. the reason patients are late in seeking medical treatment should be identified in order to prevent complications which can be avoided to produce a good prognosis. this study was conducted to find the pattern of treatment seeking behaviour among dengue fever patients and their influencing factors using a health utilisation model. methods: data on health seeking behaviour were collected among the dengue fever patients who were admitted to dr. hasan sadikin general hospital bandung from september–october 2014. the data were collected through in-depth interview with patients who were diagnosed with dengue fever and dengue haemorrhagic fever. all the interviews were recorded using an audio recorder. the recordings were transcribed and then translated into english and analyzed using thematic analysis. results: nine patients were interviewed. the age of the patients ranged between 17 to 46 years. altogether 7 patterns were identified with patients treatment seeking behavior. most of them took longer steps to reach adequate care with blood examination. these longer steps, caused by lack of facilities to perform blood test in primary health care facilities, no bed for admission and also low skills of health care providers in diagnosing patients. the primary health care facility played an important role in the delay of patients acquiring definite care for their dengue fever. conclusions: health care seeking behavior is hampered by the inadequacy of primary health care facilities to provide adequate services to dengue patients. ] keywords: dengue fever, dengue haemorrgic fever, treatment seeking pattern correspondence: tharani krisnian, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: tharukrish3110@gmail.com introduction dengue fever (df) or dengue hemorrhagic fever (dhf) is caused by one of four virus serotypes (den–1, den–2, den–3 and den– 4).1 according to the world health organization (who), the number of incidence of df are increasing drastically and have become a major public health problem globally.2 there are about 50 million of dengue cases reported every year that was estimated by who.2 about 500,000 are admitted in hospital due to df.2 the incidence and geographical distribution have increased in recent years because there is increase in the spread of the vector throughout tropic and subtropics, and become more exposed to dengue viruses transmitted through infected human.3 the incidence rate of df in west java is 18 cases per 1000 and mild infection is 56 cases per 1000.4 there were 150,000 cases reported in 2007 and 25,000 of the cases are from jakarta and west java as mentioned by who.2 the fatality of the case was 1% approximately.4 the reason why patients are late in seeking medical treatment should be identified in order to prevent complications which can be avoided to produce a good prognosis. treatment seeking behaviour among dengue fever patients affects the prognosis of the disease. if the patients seek the treatment as soon as they have the symptoms, then the prognosis of the patients are good and further complications from the dengue fever such as dengue haemorrhagic fever can be prevented.3 there are several factors which amj. 2017;4(3):369–74 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1183 althea medical journal. 2017;4(3) 370 amj september 2017 affect the treatment seeking behaviour among the patients such as the perception of the person who thinks that the fever might be a mild fever and not dengue fever and health care facilities that are not ready to conduct early detection.5 moreover, demographic and socioeconomic factors also play an important role in treatment seeking behaviour among dengue patients.5 the aim of this study was to explore the treatment seeking patterns among df patients. methods this study was conducted at dr. hasan sadikin general hospital which is located in bandung, indonesia, from september–october 2014. this study was approved by the health research ethics committee of dr. hasan sadikin general hospital. the samples were collected using purposive sampling method. the study design used was explorative qualitative. the inclusion criteria were the patients who were admitted (inpatient) to the hospital and confirmed with dengue fever. the exclusion criteria were the patients who were only suspected with dengue fever and who disagreed to be interviewed. the data was collected through key informant interviews and indepth interviews which was performed to the patient who was diagnosed with df and dhf based on the who diagnostic criteria. the interview was conducted on 9 patients who were admitted to dr. hasan sadikin general hospital. information about the pattern of treatment seeking behavior was from the day 1 they had symptoms until the day they went to seek for help was gathered. furthermore, questions about the steps they took to overcome the sickness were also asked. moreover, interviewer also gathered information about their attitude, knowledge, access in seeking treatment and also about primary health care facility services from the informants. all the interviews were recorded using an audio recorder. the recordings were transcribed, and then translated into english and analyzed using thematic analysis. results there were 9 patients interviewed consisting of 7 males and 2 females. their age ranged from 17–46 years. most respondents completed their senior high school (sekolah menengah atas, sma). there were 6 patients who were working and their monthly salary ranged from rp800,000 to rp1,3 million. there were 7 patients who were diagnosed as dhf and 2 patients as df. the most common symptom reported by the dengue patients was continuous fever. other symptoms that appeared differently according to the individuals was nausea, figure pattern of treatment seeking in dengue fever patients6 althea medical journal. 2017;4(3) 371tharani krisnian, bachti alisjahbana, irvan afriandi: treatment seeking patterns among dengue fever patients: a qualitative study table favorable and less favorable condition and practices in seeking treatment for dengue fever patient patient/health care provider favorable practice less favorable practice healthcare provider blood test was done ≤ 3 days of being sick. primary health care that has facility for blood test. blood test that done > 3 days of being sick. primary healthcare and district hospital that does not have facility to perform blood test. district hospital full (no bed) to treat the patient. referral hospital that is far. skills of healthcare provider in diagnosing patient. patient seek for medical care ≤ 3 days. persistent in seeking treatment if symptoms present seeking medical treatment > 3 days of being sick. dizziness, vomiting, nose bleeding, body ache, cough and joint pain. there were 8 patients who took obat warung (over-the-counter drugs) as their first step in curing the illness. they bought the drugs that were available in an ordinary shop that was nearer to their house, or took the drugs that were already available in the house from a previous purchase. it was their habit to consume over-the-counter drugs to see whether the symptoms were reducing or not. there was 1 patient who does not consume over-the-counter drugs and always will go to the primary health care facility to seek treatment despite severity of the illness. when there was no any improvement, they would decide to go to the clinic or other primary health care facilities. most of the patients chose a private clinic or public health center (pusat kesehatan masyarakat, puskesmas) as their first aid to seek treatment if over-the-counter drugs did not give any effect. the reason for them to choose a private clinic or puskesmas was, most of them claimed, that it was nearer to their house. some of them even considered that the illness was still mild. there were 2 patients who chose the district hospital as their first place to seek treatment. this was due to their habit of going to hospital for seeking treatment and they did not have to pay much because of the health insurance (badan penyelenggara jaminan sosial, bpjs). another patient went to hospital because he was triggered by the symptom he had (nose bleeding). when the patients failed to respond to the treatment that was given by a private practitioner or puskesmas (first aid), then they would go to the district hospital as their next place to seek treatment. the reasons that made them go and seek for second aid was their symptoms did not get resolved and got worsened. most the patients were diagnosed with dengue fever when they were in the district hospital when the blood test was carried out. finally, all the patients were admitted to dr. hasan sadikin general hospital (rshs). this was due to the district hospital was filled to capacity. there was no more bed to treat those patients, thus they had to refer them to rshs. there was 1 patient who never seeked treatment to the district hospital, in addition came to rshs as second place to seek treatment because he was a staff who was working at rshs. the way the patients are seeking treatment is usually step by step which means if the previous step did not work, then they choose to go and seek treatment in a more higher health care facility such as a private or government hospital. (figure) furthermore, healthcare practice can be divided into 2 major groups: favorable healthcare practice and less favorable healthcare practice (table). out of 9 patients, 3 patients’ knowledge was bad because they did not know anything about dengue fever including the cause. one patient mentioned that it was caused by dust, and the rest said it was caused by mosquitoes which transmitted the disease from an infected person to another. since his knowledge was bad so his health care practice was also not favorable because he went to seek treatment only on the fourth day. when the patients were asked about the treatment for df, and the need for hospitalization; 6 patients mentioned that hospitalization was necessary for df, 3 patients said there was no need of hospitalization althea medical journal. 2017;4(3) 372 amj september 2017 as long as the patient was not severely dehydrated and controlled for thrombocyte count. they obtained this information from a healthcare provider. however, since they had no knowledge about the severity of the illness, they did not try to seek for appropriate professional care. the patients’ attitude towards the df varied from good to bad attitude. there were 4 patients who were ignorant towards the disease because they did not really care about being sick. some of them even thought that it was just a normal fever of which they would recover eventually. thus, they did not take serious actions to cure the disease such as seeking treatment on the first day the symptom appeared. however, one of the patients had a good attitude because she sought help on the first day the symptom appeared. she did not have the habit of purchasing over-the-counter drugs and would always go to the healthcare provider whenever she got sick, which enabled her for having a good healthcare practice. another patient’s attitude was also good because he planned to go and seek treatment on the first day the symptom appeared however, it was on the weekend and the nearest primary health care facility was closed. there was 1 patient who was embarrassed; whenever, he was sick it was very hard for him to go and seek treatment to the primary health care facility. his attitude made him to have less favorable practices. most of the patients also claimed that they had no prior experience regarding df. they did not get infected by df before and neither did their family members. on the one hand, they thought that it was just a normal fever and did not care much but on the other, some of the patients were aware that something was wrong although, they did not have prior experience of having df. they felt this because the symptom such as nose bleeding and the condition of the sick got worse and did not get cured at all. however, there was one patient who did not care at all about the illness he suffered from. he did not seek treatment on his own initiative and was forced by his wife. this was a less favorable practice from the patient. the access to primary health care facilities is the distance from the patient’s residence to the nearest primary health care facility. all the patients did not have problems with healthcare access because it only took about 7 to 15 minutes by vehicle to reach the nearest primary health care facility. however, some of the patients had problems in reaching rshs due to the far distance from their house to the primary health care facility; however they had no choice and had to seek treatment. the direct impact of the distance for the patient was the travel-costs. some of the patients had difficulties to purchase petrol as it cost a lot of money but they had no choice because health was more important. most of the patients had their own car to travel and did not have financial problems. one of the patients used the public car that was already available at the puskesmas. some of them used a rented car borrowed from neighbors and their friends. so, good access to the primary health care facility made the patients had favorable healthcare practices. all the patients were satisfied with the service provided by rshs, according to them, the health care providers at rshs took the blood test and sent them to the ultrasonografi (usg) to check whether there was any complication. moreover, most of the patients were unsatisfied with the treatment at the district hospital. the facilities were insufficient for performing blood test to the patient and there was a delay of treatment since they were not able to diagnose the patient. most of the patients were referred to rshs not because of the medical indication but because of insufficient treatment capacity at the district hospital; there was no bed to treat the patient. due to this situation, the patient had to travel all the way to the referral hospital which cost a lot of money. furthermore, when the patient went to a private clinic or puskesmas as the first aid or first place for seeking treatment, the health care provider might wrongly diagnose them. they might tell the patient that it was just a normal fever and gave paracetamol and antibiotics as the medication. they did not ask the patient to perform a blood test nor refer them to another place or primary health care facility to perform a blood test. this was a less favorable practice from the health care providers as they could perform the blood test on the third day since the day the symptoms appeared or at least referred them to better primary health care facility if they did not have the facility for performing a blood test. there were 2 healthcare providers who referred patients to the district hospital to perform a blood test. discussion the benefit of knowing the pattern of treatment seeking behavior is to understand how and why the patients react when they althea medical journal. 2017;4(3) 373 are ill. most of the patients used over-thecounter drugs as their first step in curing their illness which is supported by the study that was conducted by khun and manderson6 in cambodia. moreover a study about health seeking behavior in guatemala by goldman and heuveline7 also state that they choose a pharmacist over a doctor to seek treatment. furthermore, most of the patients choose a private practice as their first place to seek treatment. the same findings are identified in india8 and pakistan9, this study reveals that there are 2 types of health practices, which are favorable and less favorable practice that come from both the sides, including patients and also health care providers. in df or dhf, the health seeking behavior is mainly affected by the patients who select the methods and primary health care facility based on their knowledge and attitude as well. most of the patients were knowledgeable about the cause of df. they knew that it is caused by mosquitoes and cannot be transmitted from person to person from direct contact. it was notable that one of the patients had a misconception about the cause, i.e. caused by dust. this reason affected the patient’s health seeking behavior. chibwana et al.10 also state that knowledge about the cause of the disease affects the treatment seeking behavior in the study conducted by them. gender, rural or urban areas, income and educational level do not really seem to affect the treatment seeking behavior. this study also revealed that there was no evidence that educational level influenced the treatment seeking behavior. the patient’s attitude towards df also influenced the treatment seeking pattern. their prior experience of not having df led to the delay of health seeking behavior as they deemed it was just a normal fever. their attitude varied from good to bad. in the study that was conducted by khun and manderson6, they state that costs and access to the primary health care facility influence the most in the delay of treatment seeking in cambodia. this however, contradicts the current study because patients in indonesia are already under universal insurance coverage or bpjs. so they do not need to spend money regarding treatment at the primary health care facility. the access to the nearest primary health care facility was also good. khun and manderson6 also mention that women in cambodia do not trust the public sector and choose the private sector to bring their child in seeking treatment although they are financially restricted. furthermore, a study carried out in pakistan9 and malawi10 reveal that access and costs influenced the most in patient’s treatment seeking behavior. healthcare providers seem to contribute to overall delay in treatment seeking in df patients. the common mistakes that were performed by the health care providers in this study were wrong diagnosis and delay in performing blood test. the study conducted in malawi10, also state that healthcare service plays an important role in treatment seeking behavior of malaria patients. they prefer private practitioners over government hospitals because of poor healthcare services of government healthcare providers.10 there is also gender discrimination that leads to delay in treatment seeking in pakistan9 because men is the only one who decides in treatment seeking for their woman and also family, which did not influence this current study. thus, interventions to ensure more proper implementation of who guidelines in health facilities might be needed. although this finding was only bound to one particular setting, they might be relevant and applicable to other parts of indonesia with similar socioeconomics, epidemiological and health system characteristics. limitation of this study is the biased selection because the patients who are included in the study are only those who are admitted at the tertiary hospital. in conclusion, there are altogether 7 patterns in the treatment seeking behavior by dengue fever patients. the most influenced factor in the treatment seeking behavior is healthcare service itself by the delay in performing blood examination, bed unavailability for the hospitalized and also the low skills of health care providers in diagnosing the patients. there should be more campaign or effective programs conducted by government to create more awareness of df, and improvement of the healthcare system for the primary health care facility for early diagnosis. district hospitals should have more treatment capacity to support the increase of number of admitted patients. references 1. karper dl, fausi as, longo dl, braunwald e, hauser sl, jameson jl. infections caused by arthropod– and rodent–borne virues in: peters cj editor. harrison’s principle of internal medicine. 16th ed. new york: mcgraw–hill companies; 2005. p. 1173. tharani krisnian, bachti alisjahbana, irvan afriandi: treatment seeking patterns among dengue fever patients: a qualitative study althea medical journal. 2017;4(3) 374 amj september 2017 2. who. comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. world health organization; 2011 [cited 2014 may 14]: available from: http://apps.searo.who. int/pds. 3. guha-sapir d, schimmer b. dengue fever: new paradigms for a changing epidemiology. emerg themes epidemiol. 2005;2(1):1–10. 4. porter kr, beckett cg, herman kosasih, ratna irsiana tan, bachti alisjahbana, pandji irani fianza rudiman, et al. epidemiology of dengue and dengue hemorrhagic fever in a cohort of adults living in bandung, west java, indonesia. mclean va. 2005;72(1):60–6. 5. chuma j, gilson l, molyneux c. treatmentseeking behaviour, cost burdens and coping strategies among rural and urban households in coastal kenya: an equity analysis. oxford. 2007;12(5):673–86. 6. khun s, manderson l. health seeking and access to care for children with suspected dengue in cambodia: an ethnographic study. bmc public health. 2007;7(1):262– 72. 7. goldman n, heuveline p. health-seeking behaviour for child illness in guatemala. family med prim care. 2000;5(2):145–55. 8. banerjee a, bhawalkar j, jadhav s, rathod h, khedkar d. access to health services among slum dwellers in an industrial township and surrounding rural areas: a rapid epidemiological assessment. basingstoke. 2012;1(1):20–6. 9. shaikh bt, hatcher j. health seeking behaviour and health service utilization in pakistan: challenging the policy makers. j public health (oxf ). 2005;27(1):49–54. 10. chibwana ai, mathanga dp, chinkhumba j, campbell ch. socio-cultural predictors of health seeking behaviour for febrile underfive children in mwanza-neno district, malawi. malar j. 2009;8(1):219–27. 271 althea medical journal. 2017;4(2) knowledge, attitude and behavior related to antibiotic use in community dwellings rocci jack parse,1 eva mardiana hidayat,2 bachti alisjahbana3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine, universitas padjadjaran, 3 department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: irrational antibiotic use is the major reason for insidence of antibiotic resistance. antibiotic misuse in community is influenced by environmental and behavioral factors. environment included community preference for purchasing antibiotics, lack of health care infrastructure, lack of general practitioner and policy in regulating antibiotic use. behavior is influenced by lack of information in antibiotic use and unawareness of antibiotic resistancy. the aim of the study was to assess the level of knowledge, attitude and behavior regarding antibiotic use in community dwellings. methods: a cross sectional descriptive study was carried out to 96 respondents who were selected by a rapid survey sampling method in cileles village jatinangor, sumedang, west java, indonesia in august 2013. data were collected using questionnaires. the data was analyzed in the form of frequency and percentage. results: out of 96 respondents, only 40.6% had good knowledge regarding antibiotic use, 12.5% of respondents were prescribed antibiotics, but in the last course did not purchased all the antibiotics prescribed by the clinician and 55.2% of respondents did not complete their treatment course. conclusions: most of the community still have poor knowledge regarding antibiotic use and its consequences such as allergy, and resistancy based on the knowledge questions has a total score ≤6. their attitude and behavior regarding antibiotic use are still poor which is also based on incompletion of the antibiotic treatment and irregular use. keywords: antibiotic, attitude, behavior, knowledge correspondence: rocci jack parse, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285263138760 email: ciciho.roromo@gmail.com introduction antibiotic is the most used drug in the treatment of infections caused by bacteria. high intensity in antibiotic prescription causes worldwide problem in antibiotic resistance. besides mortality and morbidity, antibiotic resistance also causes economic and social effects.1 resistance to antibiotic use causes pathogens cannot be cured by the same antibiotic and needs a different class of antibiotic, whereas development of new antibiotic drugs has slowed. microorganism that is resistant in the first line drug, should use second line or third line antibiotic which inflicts financial loss to the patient because second line and third line antibiotic drug is expensive.2 furthermore, antibiotic misuse in the community is influenced by environmental and behavioral factors. environmental factors included community preference for purchasing antibiotics, lack of health care infrastructures, lack of general practitioners and policy in regulating the antibiotic use. while behavioral factors are influenced by lack of information in antibiotic use and unawareness in antibiotic resistance.3 in indonesia,4 antibiotic drugs can be purchased over the counter (otc) or at the kiosk, whereas the indonesian government regulation restricts antibiotic availability so that antibiotic drugs can only be prescribed by doctors. the use of antibiotic drugs without prescription causes some problems in the community’s behavior and attittude toward antibiotic use which are the use of inappropriate dosage and duration along with the use of left-over antibiotic.5 the aim of this study was to assess the level of knowledge, attitude and behavior regarding antibiotic use in community dwellings. amj. 2017;4(2):271–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1082 althea medical journal. 2017;4(2) 272 amj june 2017 methods a cross sectional descriptive study was carried out during august 2013. the study population was the community that lived in one of the villages in jatinangor, sumedang, west java, indonesia, namely cileles. the respondents were selected from 4 locations (rw 3, rw 5, rw 7 and rw 8) and 24 respondents were selected in each location using the rapid survey method. the inclusion criteria were people living in cileles village and able to communicate with the indonesian language. the exclusion criteria were people who did not want to participate in this study. a structured questionnaire was developed by reviewing relevant literatures and questionnaires used previously in similar studies with several modification.6,7 the questionnaire comprised a total of 32 questions divided into four sections. the first section covered the participants demographic data such as age, address, sex, occupation, and education. the second section assessed community knowledge on the purpose of using antibiotics, antibiotic efficacy, safety and reasons leading to antibiotic resistance. the third section examined community attitude regarding antibiotic use, and the last section assessed community behavior regarding antibiotic use. the questionnaire was validified in another village of jatinagor, namely hegarmanah village which had the same characteristics as cileles village. thirty respondents participated in this process. each question was assigned as valid if the significance (p-value) of the question was higher than 0.44 and reliable if the cronbach’s alpha value (a) was higher than 0.60. the result was all the questions were valid and reliable. knowledge is the results from knowing something which occurs after having sensed the object; it could be a visual sense, tactile sense or smell. attitude is a closed response against stimulus or object; it could be someone’s perception or emotion. behavior is the activity of someone or an open response against stimuli.8 moreover, questions to determine the level of knowledge (n=12) were stated as “agree”, “disagree” or “i do not know”. each correct answer would be given one point while the zero point was given to a wrong or “i do not know” answer. whereas, questions on the participant’s attitude were stated as “agree”, “sometimes”, “best not” and “disagree” with a range point from 1 to 4. questions on the participant’s behavior were stated as “yes” and “no” questions. next, all data were coded, entered and analyzed using computer, for each correct answer, one point was given, whereas a wrong answer and “i do not know” answer did not affect the grade. respondents with a total score of 7 or above were considered to have good knowledge, while those with a total score of 6 or below were considered to have poor knowledge. the analysis of answers of other questions was performed in descriptive quantitative statistics e.g. frequency and percentage. the respondents were informed about the study and were requested to complete an approval page. the identity of the respondents was kept confidential. this study was performed after it was approved by the health research ethics committee of the faculty of medicine, universitas padjadjaran, number 209/un6.c2.1.2/kepk/2013. results the majority of respondents (35.4%) were 36─45 years old comprising 66.7% of female respondents and 47.9% of these respondents were housewives, while 40.6% of the respondents’ education was elementary school (table 1). the level of knowledge about the use, effectiveness, resistance and safety of antibiotic was evaluated using statements . more than half of the respondents (80.2%) knew that antibiotics were indicated to treat bacterial infections and 87.5% of respondents knew that antibiotics were indicated to treat swelling caused by infection. additionally, 17.7% of respondents incorrectly believed that antibiotics could be used for viral infections, whereas, 39.6% of respondents believed that antibiotics could be used for common cold, 30.2% of respondents agreed that antibiotics were always used to treat fever and 50% of respondents agreed that antibiotics were always used to treat stomachache and diarrhea. when asked about antibiotic resistance, the majority of respondents (77.1%) knew that antibiotic resistance was caused by not following the clinical instructions, and less than one third of respondents (22.9%) agreed that antibiotic effectiveness would not be affected by antibiotic misuse, 16.7% of respondents still believed that by changing the antibiotic brand would cause resistance, and 39.6% of respondents believed antibiotics would always be effective in the treatment of 273 althea medical journal. 2017;4(2) table 1 subject characteristics n % age(years old) 17−25 6 6.2 26−35 20 20.8 36−45 34 35.4 46−55 17 17.7 56−65 10 10.4 >65 9 9.3 occupation housewife 46 47.9 labor 17 17.7 private sector employees 5 5.2 students 4 4.2 civil servant 7 7.3 enterpreneur 17 17.7 education elementary school 39 40.6 junior high school 23 24 senior high school 29 30.2 d1 1 1 d3 1 1 s1 3 3.1 sex male 32 33.3 female 64 66.7 rocci jack parse, eva mardiana hidayat, bachti alisjahbana: knowledge, attitude and behavior related to antibiotic use in community dwellings similar infections in the future. respondent awareness about antibiotics possible adverse effect was quite high, 62.5% of respondents were aware of the harmful effect due to antibiotic allergy (table 2). by adding the total score of knowledge regarding antibiotic use, only 40.6% of the respondents had good knowledge and the majority of respondents (59.4%) had poor knowledge regarding antibiotic use. furthermore, inconsistency in antibiotic use was also revealed in this study. even though clinicians told the majority of respondents (70.8%) how to use antibiotics, 45.3% of respondents did not take their antibiotics regularly. there was 5.2% of respondents who purchased antibiotic without consulting clinicians. almost half of the respondents (45.6%) agreed to stop antibiotic treatment after feeling better without consulting their physician first, while the majority of the participants were still unaware of the effect of antibiotic misuse, and 47% of the respondents agreed that they did not complete their antibiotic treatment (table 3). incompleteness in antibiotic use was one of the major concern in this study, 12.5% of respondents who got a prescription for an antibiotic in the last course did not purchase all the antibiotics prescribed by the clinician, and 55.2% of respondents did not complete their treatment course. the reasons for this were various, 46 respondents were feeling better, 33 respondents who did not complete their treatment course threw the leftover antibiotic, and 3 respondents used the leftover antibiotic for another infection. more than half of the respondents (71.8%) used antibiotics in althea medical journal. 2017;4(2) 274 amj june 2017 2013 so they still remembered their behavior regarding antibiotic use. while 84.2% of the respondents knew the kind of antibiotic prescribed so they knew which drug should be completed (table 4). discussion a majority of the respondents knew that antimicrobial is used against bacterial infections. a number of respondents still table 2 knowledge of respondent regarding antibiotic use questions yes no i do not know n (%) n (%) n (%) antimicrobial drug is used for: illness caused by bacteria1 77(80.2 ) 3(3.1) 16(16.7) illness caused by viral2 17(17.7) 57(59.4) 22(22.9) common cold2 38(39.6) 52(54.2) 6(6.2) fever 2 29(30.2) 56(58.3) 11(11.5) skin infection1 84(87.5) 5(5.2) 7(7.3) stomach ache and diarrhea2 48(50) 31(32.3) 17(17.7) antibiotic resistance due to: using antibiotic without clinical instruction1 74(77.1) 10(10.4) 12(12.5) not completing the full course of antibiotic1 47(49) 37(38.5) 12(12.5) using the same antibiotic with different brand2 16(16.7) 54(56.2) 26(27.1) using antibiotic when not necessary will increase body immune2 53(55.2) 22(22.9) 21(21.9) an antibiotic will always be effective in the treatment of the same infection in the future2 38(39.6) 35(36.5) 23(24) antibiotic might develop dangerous allergy in sensitive person1 60(62.5) 21(21.9) 15(15.6) note: 1statements awarded respondents one point in scoring the level of knowledge upon agreement; 2statements give respondent zero point in scoring the level of knowledge upon agreement table 3 attitude of respondent regarding antibiotic use attitude agree sometimes best not disagree n(%) n(%) n(%) n(%) respondent use antibiotic without clinical prescription when get illness2 14 (14.6) 24 (25) 9 (9.4) 49 (51) respondent follow clinical instruction when prescribed antibiotic1 68 (70.8) 27 (28.1) 1 (1) 0 (0) respondent stop antibiotic use without consulting their physician when the symptoms reduced2 44 (45.8) 24 (25) 5 (5.2) 23 (24) respondent use antibiotic when get ill and stop antibiotic use when feel better2 44 (45.8) 26 (27.1) 10 (10.4) 16 (16.7) respondent always complete their antibiotic use when prescribed1 4 (47.9) 14 (14.6) 14 (14.6) 22 (22.9) note: 1the respondent was given four points when answered “agree” statements, three points when answered “sometimes”, two points when answered “best not”, and one point when answered “disagree”;2 the respondent was given one point when answered “agree” statements, two points when answered “sometimes”, three points when answered “best not”, and four points when answered “disagree” 275 althea medical journal. 2017;4(2) rocci jack parse, eva mardiana hidayat, bachti alisjahbana: knowledge, attitude and behavior related to antibiotic use in community dwellings table 4 behavior of respondent regarding antibiotic use (1) behavior n percent (%) 1. symptoms/illness urti 29 30.2 diarrhea 9 9.4 fever 22 22.9 typhoid 9 9.4 teeth problem 9 9.4 etc 18 18.7 2. source of the drug puskesmas 42 43.8 pharmacy 38 39.6 drug store 4 4.2 otc drug/kiosk 5 5.2 etc 7 5.2 3. the clinician told respondent that antibiotics were prescribed yes 74 77.1 no 17 17.7 4. the prescriber told how to use antibiotics : yes 68 70.8 no 23 24 5. knew which one is antibiotic drug yes 77 80.2 no 14 14.6 6. duration in antibiotic use 3 63 65.6 4 5 5.2 5 9 9.4 7 12 12.5 etc 7 7.2 7. did you buy all the drugs that has been prescribed: yes 79 82.3 no 12 12.5 8. total duration in antibiotic use 2 days 6 6.25 3 days 5 5.12 10 days 1 1.04 not change 84 87.5 9. complete last course of antibiotics yes 43 44.8 no 53 55.2 althea medical journal. 2017;4(2) 276 amj june 2017 believed that antibiotic was used against viral infection and some believed that antibiotic worked against both bacteria and virus. this confusion was due to some respondents believed that antibiotics could be used for all kinds of illness but actually antibiotic is only effective for bacteria and illnesses caused by bacteria.2 most of them were still unaware about antimicrobial resistance and considered that antibiotic resistance was not a problem since only 49% respondents answered that antibiotic resistance was due to incompleted antibiotic treatment. the fact is irrational use of antibiotic could lead to serious problems with the emergence and prevalence of resistant microbial strains, which have become a worldwide problem.9,10 whereas this perception is wrong and causes antibiotic resistance is still high.2 such wrong belief could cause wrong attitude and behavior against antimicrobial treatment.8 besides resistance, antibiotic use without caution could lead to allergy and the most severe case is death.11 when asked about antibiotic allergy, 62.5% respondents knew that antibiotic could lead to allergy in sensitive persons. remarkably in this study, the poor respondent knowledge about antibiotic was obvious since 59.4% of the participants total score illustrated <6 point, which was similar to a r study conducted at the jordan university.6 the attitude and behavior of study participants with regards to antibiotic use and resistance was not good. more than half of the respondents did not finish the antibiotic treatment, and this attitude and behavior is similar to a study in india that has the same characteristics with indonesia.3 the respondent’s reason for this behaviour was they felt much better and one respondent forgot to took the antibiotic. this phenomenon became a bigger problem, time after time because people were still unaware of the effect of antibiotic, they did not know how antibiotic worked against microbacteria and thought that after the symptoms disappeared, they could stop taking antibiotic pills. actually, the real effect of antibiotics is after the symptoms disappear because if the bacteria are not eradicated completely, the illness will return again with stronger bacteria. these strong bacteria could not be treated by the first line of antibiotic again or by an antibiotic that is resistant against it. so, the second line or third line of antibiotic should be used, even though the price of the antibiotic is much higher. the real problem is what should the physician do if the second or third line of antibiotic become resistant because the development of antibiotic drugs is still slow, and it needs much money and experimental studies.2 fourteen percent of the respondents purchased antibiotics without a prescription at otc or kiosk. this corresponded with hadi et al.4 (2010) findings; this could occur because the regulations for antibiotic selling is not strong enough and there is no strong punishment for otc or pharmacies selling the drug without prescription.1 this study has certain limitations that merit discussion. the sample of the study were majority female and housewives, this was due to handling the questionnaire to respondents during day time when presence of housewives was higher, while the husbands were gone to work. moreover, a f future study should use a larger number of sample and longer period. table 4 behavior of respondent regarding antibiotic use (2) behavior n percent (%) 10. reasons stated by respondent for not completing their last course of antibiotics felt better 46 47.9 forgot 1 1 side effect/antibiotics made me feel unwell 3 3.1 etc 3 3.1 11. respondent who kept the leftover antibiotic use for another illness 3 3.1 just kept the antibiotic 17 17.7 etc 33 34.4 277 althea medical journal. 2017;4(2) physician and health care workers should work together to explain that antimicrobial resistance is a serious problem worldwide and could be prevented by a simple action such as following the clinical instructions. it can be concluded that the knowleedge, attitude and behaviour of the community are still poor regarding antibiotic use. references 1. sedyaningsih er. peraturan menteri kesehatan republik indonesia nomor 2406/menkes/per/xii/2011. jakarta. 2011. 2. brunton l, blumenthal d, buxton i, parker k. goodman and gilman’s manual of pharmacology and therapeutics. 11th ed. united states of america. mcgraw-hill. 2007. p. 950−70. 3. sahoo k c, tamhankar a j, johansson e, lundborg c s. antibiotic use, resistance development and environmental factors: a qualitative study among healthcare professionals in orissa, india. bmc public health. 2010;1:1−10. 4. hadi u, broek pvd, kolopaking ep, zairina n, gardjito w, gyssens ic. cross-sectional study of availability and pharmaceutical quality of antibiotics requested with or without prescription (over the counter) in surabaya, indonesia. bmc infectious diseases. 2010; 10:203. 5. foster sp, boyd sm, edgar tp. patient behaviors and beliefs regarding antibiotic use. alliance for the prudent use of antibiotics 2010;1:1−3. 6. shehadeh m, suaifan g, darwish m, wazaify m, zaru l, alja’fari s. knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of jordan. a pilot study. saudi pharm j. 2012;20(2):125−33. 7. buke c, hosgor-limoncu m, ermertcan s, ciceklioglu m, tuncel m, köse t, et al. irrational use of antibiotics among university students. j infect. 2005;51(2):135−9. 8. notoatmodjo s. promosi kesehatan dan ilmu perilaku. pt.rineka cipta: jakarta. 2010. 9. spellberg b, bartlett jg, gilbert dn. the future of antibiotics and resistance. n engl j med. 2013;368(4):299−302. 10. maryandi d. gunakan antibiotik secara tepat untuk mencegah ke kebalan kuman, peringatan hari kesehatan sedunia. jakarta. 2011. p. 3. 11. gruchalla rs, pirmohamed m. antibiotic allergy. n engl j med. 2006;354(6):601−9. rocci jack parse, eva mardiana hidayat, bachti alisjahbana: knowledge, attitude and behavior related to antibiotic use in community dwellings althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 118 amj march 2017 clinical profile and outcome of myocarditis in children at dr. hasan sadikin general hospital bandung from 2008 to 2012 erza nurtriandari,1 rahmat budi,2 r.b. soeherman3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, biology cell and physiology faculty of medicine universitas padjadjaran abstract background: diagnosis of myocarditis in children is still challenging due to its inconsistent and wide spectrum of clinical manifestations. there is no specific laboratory test available. this may obscure the true incidence of myocarditis. the purpose of this study was to describe clinical profile and outcome of myocarditis in children. methods: a descriptive study was performed using 80 medical records of hospitalized pediatrics patients with myocarditis in dr. hasan sadikin general hospital bandung from january 2008 to december 2012. the obtained data were age, gender, nutritional status, etiology, chief complaint, physical examination, laboratory findings, other examinations and outcome of the disease. the collected data were analyzed and presented in the form of frequency distribution. results: the mean age of the patients was 91.46 (45.93) months old, predominantly male. the most etiology was dengue infections (61%). high fever was found as the most common chief complaint (38%) and the most common found in physical examinations were tachypnea (65%) and hepatomegaly (55%). electrocardiography (ecg) showed the first degree atrioventricular block (av block) (35%), aspartate aminotransferase (ast) and creatine kinase myocardial band (ckmb) was increased in more than 80% of patients. the majority of patient was improved. shock was the common complication. conclusions: dengue is the most etiology of myocarditis etiology. tachypnea, hepatomegaly, the first degree av block in ecg, elevated ast and ckmb were the most common presentations. most of the patients were improved during treatment. [amj.2017;4(1):118–24 keywords: children, dengue, hepatomegali, myocarditis, tachypneu correspondence: erza nurtriandari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81285326800 email: erzanurtriandari@gmail.com introduction myocarditis is an insidious disease with a variety of signs and symptoms which cause difficulty in diagnosis.1,2 this disease has many etiologies, pathophysiology, diagnostic ways, and therapies.3 the incidence of myocarditis remains obscure due to difficulties in diagnosing this disease because of its inconsistency of clinical manifestation in pediatric population and assuredly underdiagnosed.1,3 children may present with nausea and vomit that may be mistakenly diagnosed of having gastroenteritis or present with tachypnea, which may lead to asthma.4 in addition to the clinical presentations, the diagnosis can also be made based on noninvasive imaging findings, namely chest radiography, electrocardiography (ecg), and echocardiography.1,4,5,6 laboratory test usage in diagnosing myocarditis is limited, but freedman et al.2 demonstrated that aspartate aminotransferase (ast) is a sensitive test, its rise in 85% case of myocarditis.1,2 cardiac enzymes, troponin t, creatine kinase (ck) and creatine kinase myocardial band (ckmb), may provide additional information in the evaluation of children with suspected viral myocarditis.3,7 diagnosing myocarditis in children is a clinical challenge because the clinical scenario and findings from diagnostic tools vary greatly.8 however, this disease may proceed to dilated cardiomyopathy which will need longalthea medical journal. 2017;4(1) 119 term therapy, even a heart transplant, and may be an important cause of sudden death in the pediatric population.1 the aim of this study was to describe clinical profile and outcome of myocarditis in children. methods the design of this study was descriptive from secondary data. data were obtained from total population of inpatients medical record of children with myocarditis in dr. hasan sadikin general hospital bandung, indonesia between january 2008 and december 2012. all pediatric patients ≤14 years old were included. the data was excluded if the recording was incomplete, including lost of pages, uncontained ecg, echocardiography, chest x-ray, and laboratory examinations (ast, ck, and ckmb). this study has been approved by the health research ethics committee. the obtaining data was included: the age of the patients, gender, nutritional status, etiology of myocarditis based on the diagnoses at admission, chief complaint, physical examination including general appearance, vital signs (blood pressure, pulse rate, respiratory rate, temperature), body weight, height, capillary refill time, heart sounds, hepatomegaly, splenomegaly and edema, laboratorial examinations including cardiac enzymes (ast, ck, ckmb), other examinations including ecg, echocardiography, chest x-ray, and also outcome. echocardiography, ecg, chest x-ray, ast, ck, and ckmb examinations were expertised by consultant physicians. the collected data were analyzed and presented in the form of frequency distribution. results there were 107 cases were diagnosed as myocarditis from 31,546 hospitalized at dr. hasan sadikin general hospital bandung from january 2008 to december 2012. therefore, the frequency of children presenting with myocarditis was 0.34%. twenty seven cases were excluded because the medical records were not available or the data were incomplete; due to lack of laboratory examination or ecg, echocardiography, or chest radiography. the mean of age was 91.46 ± 45.93 months old (table 1) and 51 of them (64%) were male. many patients (61%) had dengue infection as their etiology (table 2), with 1 of them (2%) was dengue encephalopathy, 7 of them (14%) were dengue fever, 17 of the patients (35%) were dengue hemorrhagic fever, and 24 of them (49%) were dengue shock syndrome. sixty-eight patients (85%) were fully alert and 56 patients had normal nutritional status (table 3). there were 63 data of blood erza nurtriandari, rahmat budi k., r.b. soeherman: clinical profile and outcome of myocarditis in children at dr. hasan sadikin general hospital bandung from 2008 to 2012 figure 1 flow of the study inpatients medical records of children with myocarditis (n=107) inclusion’s and exclusion’s criteria the amount of population study (n=80) clinical profile ecg, echo, chest x-ray, and lab exam outcome althea medical journal. 2017;4(1) 120 amj march 2017 seventy patients (89%) had normal first (s1) and second (s2) regular heart sounds, 5 patients (6%) had normal s1 and s2 followed by gallop and/or murmur, and 4 patients (5%) had abnormal s1 and s2 followed by gallop and/or murmur. thirty patients (38%) came to the hospital with high fever, 21 patients (26%) came with cold body or extremities, and the other patients have edema face/body, heart throbbing, seizure, erythematous whole body, fatigue, chest pain, low fever, lost of consciousness, breathlessness, and regular check up for heart problem as their chief complaint. from the history, 59 patients (74%) had nausea, vomit, epigastric pain, abdominal pain, fatigue, bleeding, cough, flu, headache, or diarrhea, pressure that were available. the others 17 data were incomplete for body height or blood pressure, which made it difficult to categories the blood pressure. forty-four patients (70%) had normal blood pressure for age, 51 patients (64%) had normal pulse rate, but 16 of them (31%) had irregular pulse rate, and 62 patients (79%) had normal temperature. fifty-two patients (65%) had tachypnea with median 26 per minute (table 2). seventy-six patients (95%) had ≤ 2 second for capillary refill, 44 patients (55%) had hepatomegaly, 5 patients (6%) positive for splenomegaly and 15 (19%) were positive for edema. there were 79 data available for temperature, heart sounds, splenomegaly, and edema, due to lack of data. table 2 etiologies of patients myocarditis etiology n % dengue infections* 49 61 pneumonia* 5 6 sepsis* 5 6 typhoid fever 3 4 meningitis * 3 4 nephrotic syndrome 2 3 rheumatic fever 1 1 steven johnson syndrome 1 1 tuberculosis 1 1 others 10 13 total 80 100 note: * some of the patients also followed by anemic, malnutrition, hiv infection, thalassemia, mitral regurgitations, epilepsy, myocardial ischemia, intracranial high pressure, or empyema. table 1 clinical profile myocarditis in children clinical profile mean (sd)/median (min-max) age (months) 91.46 (45.93) blood pressure sistole (mmhg) 10(13.41) diastole (mmhg) 66 (palpated – 100) pulse rate 76 (40−160) respiratory rate 26 (18−60) temperature (0c) 37 (35−39) body weight (kg) 21 (3−52) body height (cm) 119 (49−153) head circumference (cm) 38.5 (35−44) note: data presented are mean value (sd) or median (range) althea medical journal. 2017;4(1) 121 table 3 distribution of patient’s physical examinations(1) categories n % nutritional status: (n= 80) 100 normal 56 70 wasted 6 8 severely wasted 4 5 possible risk of overweight 1 1 overweight 4 5 obese 2 3 undefined* 7 9 level of consciousness (n= 80) 100 fully alert 68 85 lethargic 4 5 somnolent 4 5 stupor 4 5 blood pressure (n= 63) 100 normal 44 70 low 4 6 prehypertension 4 6 hypertension type i 7 11 hypertension type ii 4 6 pulse rate (n= 80) 100 normal 51 64 low 22 28 high 7 9 respiratory rate (n= 80) 100 normal 27 34 slow 1 1 fast 52 65 temperature (n= 79) 100 normal 62 79 low 2 3 high 15 19 capillary refill (n= 80) 100 ≤ 2 second 76 95 > 2 second 4 5 heart sounds (n= 79) 100 normal 70 89 abnormal 9 11 hepatomegaly (n= 80) 100 negative 36 45 positive 44 55 erza nurtriandari, rahmat budi, r.b. soeherman: clinical profile and outcome of myocarditis in children at dr. hasan sadikin general hospital bandung from 2008 to 2012 althea medical journal. 2017;4(1) 122 amj march 2017 with 23 of them followed by fever and the rest of them had edema in palpebral/ face/ extremities/ body, preceded by sudden high fever, chest pain, breathlessness, and no other complains. history was taken during patients admitted to the hospital. the data for ecg available in 60 patients, echocardiography in 17 patients, and chest x-ray in 39 patients. in 21 patients (35%), the ecg showed first degree atrioventricular block (av block), 9 patients (15%) sinus bradycardia, and the others abnormalities were (43%), sinus tachycardia, qrs wave low voltage, left and/or right ventricular hypertrophy, prolonged qt wave interval, left and/or right atrial hypertrophy, prolonged qrs interval. only 4 patients (7%) had normal ecg, one patient with total av block who required temporary pace maker. in 6 patients (35%) the echocardiography showed normal intracardiac, 6 patients (35%) had mitral regurgitation, 2 patients (12%) had left ventricular dysfunction, and the others (18%) with pulmonary hypertension, dilated all chambers, and patent ductus arteriosus were report in 1 person each. twenty-five patients (66%) had normal cardiac size with lung infiltrate pleural effusion in 12 patients on their chest x-ray examination. the laboratory result showed elevated ast in 19 (83%) of 23 patients, normal ck in 21/38 patients (55%) and elevated ckmb in 41/51 patients (80%) (table 4). sixty-four (80%) patients had satisfactory result with improvement as their outcome, 2 (3%) patients were not improved, and one patient died due to severe sepsis. thirteen (16%) patients had unknown outcome due to unavailable of information in the records. the median length of stay was 5 (range: 1-31) days. table 3 distribution of patient’s physical examinations (2) categories n % spleen enlargement (n= 79) 100 negative 74 94 positive 5 6 edema (n= 79) 100 negative edema 64 81 positive edema 15 19 note: * data were not available for body height or weight table 4 distribution of patient’s laboratory examinations categories n % ast (n=23) 100 normal 4 17 elevated 19 83 median (range) 100 (25−1125) ck (n= 38) 100 normal 21 55 low 7 18 high 10 13 median (range) 98.5 (5−3613) ckmb (n= 51) 100 normal 10 20 high 41 80 median (range) 35 (16−348) note: data presented are median (range) or number of patients. ast = aspartate aminotransferase; ck = creatine kinase; ckmb = creatine kinase myocardial band althea medical journal. 2017;4(1) 123 discussion this study examined 80 medical records of pediatric patients who were diagnosed with myocarditis at dr. hasan sadikin general hospital bandung from january 2008 to december 2012. pediatric myocarditis represented 0.34% of 31,546 hospitalized pediatric patients at that period. in other studies, autopsy reports have revealed varying estimations of the incidence of myocarditis, ranging from 0.12% to 12%.5,9 this different finding might be caused by different kinds of approach of studied. the incidence of myocarditis has been difficult to be studied because the clinical presentations vary widely and myocarditis is commonly found as a mild or subclinical disease.5,9 many of the children were not diagnosed with myocarditis at first presentation because the subclinical presentation and the underlying infection was the established diagnosis at admission.2 most of the patients had dengue infection, especially dengue shock syndrome, as the etiology. another study in sri lanka has shown that myocarditis was present in 24% of patients with dengue infection in 2002−2003 and 27% of patients with dengue infection in 2009.10,11 it might be caused directly by the effect of the dengue virus or due to cytokine mediators and/or cellular components of the immune response.10 however, there were only 49 cases of dengue infections reported in this study. it is important to note due to dengue being epidemic in indonesia12 and dr. hasan sadikin general hospital received hundreds of dengue patients each year. the other etiologies predominantly were infectious disease. ten patients had others etiology that was not defined. these patients came to the hospital with some chief complaints. they are chest pain, breathlessness, heart throbbing, or regular check up. this finding shows that myocarditis could be also considered as a complication of other diseases. the most common chief complaint and symptoms at the time of admission were high fever and nausea, vomit, epigastric pain, fatigue, cough, flu, headache, diarrhea, abdominal pain, and bleeding. these symptoms are commonly caused by infection. it is important to highlight that these are results of anamnesis at time of admission and are not at the time when myocarditis is suspected. the most common physical examination finding when the patients are suspected of having myocarditis were elevated respiratory rate and hepatomegaly. respiratory distress, tachypnea, and abnormality respiration examination are common in pediatric patients, it is the reason for consideration of asthma and pneumonia at initial diagnosis.4 hepatomegaly are also common, but not essential.15 chest radiography and ecg can be used as the first line diagnostic tools.1 in our cases, chest x-ray was available in 39 patients and the most common finding was normal heart size (25 patients). the chest radiographies were not sensitive enough to diagnose myocarditis.2 even though the most common ecg changes in myocarditis are sinus tachycardia, axis deviation, ventricular hypertrophy, st-t waves changes, low voltage qrs complex, or inverted t wave.4 from our 60 patients that had ecg , the most common finding was first degree av block (35%). sinus bradycardia was found in 15% of patients and sinus tachycardia in 10% of patients. six of our patients in their echocardiography showed normal intracardia and mitral regurgitations found in five. the echocardiography allowed the evaluation of cardiac chamber sizes, walls thickness, and cardiac function6,14, but in our cases the finding were mostly normal. in patients with myocarditis, ckmb is elevated in the acute stage of the disease but return to normal after recovery.15 in this study, 38 patients were tested for ck and most of them (21 patients) were within normal range, but for ckmb, from 51 patients that were tested, 41 of them (80%) had increased level of ckmb. the ast level was the most sensitive marker for myocarditis, as it was frequently found to be elevated.4 in 23 patients that were tested for ast, 19 patients (83%) had elevated level. it was found that laboratory test for cardiac enzymes, especially ck-mb and ast, had a tendency to rise in myocarditis. in other studies reported that death or heart transplantation were high in patients at 6 years old.16 in contrary, many with myocarditis children in other studies were found recovered without emergencies.13 this study was a retrospective approach, it is our limitation to have the patients followed up information. however, in our cases, the most common complication in patients was shock due to the most etiology was dengue infections, especially dengue shock syndrome. the patients’ outcome showed most of them had improvement (80%) with 29 of them full recovery and 35 of them need to be followed up, and mortality found in only one case. the cause of mortality was sepsis shock and empyema. two patients refused to get further treatment and went home with no improvement. this erza nurtriandari, rahmat budi k., r.b. soeherman: clinical profile and outcome of myocarditis in children at dr. hasan sadikin general hospital bandung from 2008 to 2012 althea medical journal. 2017;4(1) 124 amj march 2017 finding showed that myocarditis was not life threatening. the limitation of this study was retrospective study that used medical record. the data that we received based on what were in the medical record were incomplete data, non-standardized data obtained, no further information about follow up patients. they were our limitation. from this study, it can be concluded that myocarditis appeared with low frequency (0.34%) in pediatric patients at dr. hasan sadikin general hospital bandung from january 2008 to december 2012. this might be caused by underdiagnosed or misdiagnosed. dengue infections appeared to be the most etiology of myocarditis. from the clinical profile, elevated respiratory rate and hepatomegaly are the most common presentations in our myocarditis patients. the finding showed most of the patients had the first degree av block in their ecg. however, there were no specific diagnostic tools that could be exactly diagnosed myocarditis, with the additional laboratory examinations for ast and ck-mb, it would help to confirm the diagnosis. the ast and ck-mb levels were elevated in our myocarditis patients. the outcomes of the patients were satisfying. most of the patients were improved. the next study better uses prospective study method to reach the validity of frequency, seeks a complete progress of clinical profile and outcome in patients, starts observing from patients admission to the hospital to the patients discharge, with complete non invasive imaging examination, which are ecg, echocardiography, and chest x-ray, and the cardiac enzymes examinations, including ast, troponin t, ck, and ckmb. in addition, the medical records should be registered appropriately. physician should be aware of myocarditis especially if facing infection cases. references 1. tavli v, guven b. myocarditis in childhood: an update on etiology, diagnosis and management. in: cihakova d, editor. myocarditis [internet]. intech; 2011. p. 39–68. [cited 2013 february 17] available from: http://www.intechopen. com/books/myocarditis/myocarditisi n c h i l d h o o d a n u p d a te o n e t i o l o g ydiagnosis-and-management 2. feldman am, mcnamara d. myocarditis. n engl j med. 2000;343(19):1388–98. 3. wheeler ds, kooy nw. a formidable challenge the diagnosis and treatment of viral myocarditis in children. crit care clin. 2003;19(3):365–91. 4. freedman sb, haladyn jk, floh a, kirsh ja, taylor g, thull-freedman j. pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. pediatrics. 2007;120(6):1278–853. 5. blauwet la, cooper lt. myocarditis. prog cardiovasc dis. 2010;52(4):274–88. 6. kindermann i, barth c, mahfoud f, ukena c, lenski m, ylimaz a, et al. update on myocarditis. j am coll cardiol. 2012;59(9):779–92. 7. levine mc, klugman d, teach sj. update on myocarditis in children. curr opin pediatr. 2010;22(3):278–83. 8. magnani jw, dec gw. myocarditis: current trends in diagnosis and treatment. circulation. 2006;113(6):876–90. 9. kytӧ v, saraste a, voipio-pulkki lm, saukko p. incidence of fatal myocarditis: a population-based study in finland. am j epidemiol. 2007;165(5):570–4. 10. satarasinghe rl, arultnithy k, amerasena nl, bulugahapitiya u, sahayam dv. asymptomatic myocardial involvement in acute dengue virus infection in a cohort of adult sri lankans admitted to a tertiary referral centre. br j cardiol. 2007;14(3):171–3. 11. weerakoon kg, kularatne sa, edussuriya dh, kodikara sk, gunatilake lp, pinto vg, et al. histopathological diagnosis of myocarditis in a dengue outbreak in sri lanka, 2009. bmc res notes. 2011;4:268 12. who, the special programme for research and trianing in ttopical diseases (tdr). dengue guidelines for diagnosis, treatment, prevention, and control. new edition. france: who press; 2009. 13. uhl tl. viral myocarditis in children. crit care nurse. 2008;28(1):42–63. 14. skouri hn, dec gw, friedrich mg, cooper lt. noninvasive imaging in myocarditis. j am coll cardiol. 2006;48(10):2085–93. 15. wang h, liu s, xing yl, chen r, yu xy. the limitation of mb isoenzyme of creatine kinase mass in assess myocardial injury in muscular disease. zhongguo wei zhong bing ji jiu yi xue. 2011;23:723–6. 16. caforio al, calabrese f, angelini a, tona f, vinci a, bottaro s, et al. a prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis. eur hear j. 2007;28(11):1326–33 vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 205 factors affecting nutritional status among children aged 12–23 months tisnasari hafsah,1 lina shabrina qorib sudaryo,2 yovi yoanita3 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: tisnasari hafsah, department of child health, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital, jalan pasteur no. 38 bandung, indonesia, email: tisnasari_hafsah@yahoo.com introduction nutrition is a key component of development in children. fulfillment of adequate nutrition will help children to survive, to grow healthy, to avoid illness, and to develop excellent intellectual, emotions, and behavior.1,2 most optimal growth in children occurs between the beginning of pregnancy and the first two years of life, which period is called the window of opportunity or a critical window.3 malnutrition during this period may cause a serious impact on growth and development in children, which is harder to restore when given a late intervention.1,4 many factors are thought to affect the nutritional status of children. the previous study has shown that the important determinants of the incidence of child malnutrition are infant feeding practice, immunization status, growth monitoring, birth weight, and maternal education.5 micronutrient deficiency especially in children may also increase the risk of infectious diseases.6 stimulation of the immune response when exposed to infection may increase energy requirements affecting nutritional status in children.6 there is abundant data collected from riset kesehatan dasar (riskesdas) 2010, which amj. 2019;6(4):205–10 abstract background: in indonesia about 18% of children, mostly in the first two years of life, are malnourished, causing a serious impact. many factors are thought to affect nutritional status among young children. this study was conducted to determine factors affecting the nutritional status of children aged 12–23 months in west java, indonesia. methods: this cross-sectional study used secondary data obtained from a basic health research (riset kesehatan dasar, riskesdas) 2010, conducted by badan penelitian dan pengembangan kesehatan (balitbangkes) ministry of health republic of indonesia. all of the data among children aged 12–23 months in west java province was obtained. statistical relationships between predisposing factors and nutritional status i.e. weight for height were analyzed using the chi-square test. results: in total, 730 data were obtained, of which 567 data met the inclusion criteria. malnutrition was detected in 101 (17.8%) children. there was a significant relationship (p=0.017, or=2.6, 95% ci 1.1–5.8) between low birth weight and nutritional status. nevertheless, no significant relationship was found between nutritional status and history of exclusive breastfeeding (p=0.629), complimentary feeding (p=0.949), vitamin a (p=0.209), infectious diseases (p=0.266), complete immunization status (p=0.420), and mother education level (p=0.251). conclusions: the low birth weight is the only significant factor associated with the nutritional status among children less than 2 years old; resulting in that low birth weight had a 2.6 higher chance of malnutrition in the early years. other factors are unexpectedly not significant in this study. there is thus a need to improve the quality of programs, focusing on childbearing mothers, during antenatal control. keywords: low birth weight, nutritional status, malnutrition, riskesdas 2010, west java althea medical journal. 2019;6(4) 206 amj december 2019 can be studied thoroughly. in this survey, it has been shown that 17.9% of infants in indonesia are still malnourished.7 therefore, we were intrigued to study further to determine the factors that may affect the nutritional status among children under 2 years old, especially children in west java province. methods the initial data was from a national basic health research or riskesdas 2010, a national basic health survey conducted by badan penelitian dan pengembangan kesehatan (balitbangkes), institution of health research and development, under the ministry of health of the republic of indonesia. after obtaining permission and approval from the ministry of health, we analyzed the data from west java province. this secondary data was further analyzed to answer our research questions, to determine the factors that affected the nutritional status among children under 2 years old, especially children in west java province. data collection of riskesdas 2010 itself started in may 2010 to august 2010. in brief, this national survey employed two-stage cluster random sampling to select representative samples. the first phase was the selection of census blocks group (bg), and the second stage was the selection of households. each census block consisted of 25 households. from each province in indonesia, several bgs were taken to represent household and household members in the area. the instrument for collecting household and individual data was questionnaires of rkd10.rt and rkd10.ind, which were filled out by trained and skillful interviewers, based on clear questionnaire guidelines. for our study purpose, all of the data among children aged 12–23 months in west java province was obtained. the dependent variable in this study was the nutritional status measured by the weight-for-height category. the status was further grouped into wasting nutritional status (z-score<-2.0) and normal nutritional status (z-sore ≥ -2.0 to ≤ 2.0). data on overweight nutritional status (z-score>2.0) was further excluded. the independent variables of this study were history of exclusive breastfeeding, complimentary feeding, administration of vitamin a, low birth weight (lbw), history of infectious diseases, complete immunization status, the frequency of weighing in the last six months, and the education of the mothers. in accordance with the riskesdas 2010 survey, our study also used a cross-sectional design that observed and measured several risk factors as independent variables and particular outcomes as dependent variables. the statistical association between variables was analyzed using the chi-square test. p values < 0.05 were considered significant. results from the original riskesdas data, data of 730 children aged 12–23 months in west java were obtained from whom data of 163 children with overweight nutritional status (z-score > 2.0) were excluded. the remaining data of 567 data of children aged below 2 years old in west java had shown that the prevalence rate of malnutrition among boys (9.5%) was similar to the corresponding prevalence among girls (table 1). in total, 101 children (17.8%) were table 1 the nutritional status among children aged 12–23 months old from west java province based on gender and place of origin. sample distribution nutritional status total nmalnutrition normal n (%) n (%) gender male 54 (9.5%) 249 (43.9%) 303 female 47 (8.3%) 217 (38.3%) 264 place of origin rural area 32(5.6%) 186 (32.8%) 218 urban area 69 (12.2%) 280 (49.4%) 349 althea medical journal. 2019;6(4) 207 malnourished. based on the distribution of place of origin, as many as 218 children (38.4%) were living in rural areas of which 32 children (5.6%) had malnutrition. this percentage of malnutrition was lower than the proportion of children in urban areas (12.2%). however, the place of origin only tended to show a significant difference (p>0.05). furthermore, 23 children (20.0%) did not receive exclusive breastfeeding and 251 children (44.3%) already started to consume complimentary food before the age of six months. there were still 63 children (23.7%) who did not complete their immunizations. maternal education level in west java was low, with only 31 mothers (6.7%) received a high education level which was high school and above) (table 2). moreover, the only statistically significant risk factor of malnutrition was the low birth weight (lbw), with p=0.017 or 2.6 (95% ci 1.1–5.8), suggesting that low birth weight had 2.6 higher chance of malnutrition. as much as 35.7% of infants born weighing less than 2500 grams suffered from malnutrition. lbw infants were 2.6 times at higher risk to have malnutrition as compared to infants with normal weight (table 3). discussions the majority of infants with low birth weight (lbw) have poor growth in the first few days to weeks of their lives. hence, when the normal table 2 the distributions of risk or predisposing factors among children aged 12–23 months in west java variables total (n) percentage (%) exclusive breastfeeding no 23 20.0 yes 92 80.0 complimentary food <6 months 251 44.3 ≥6 months 316 55.7 received vitamin a no 140 24.7 yes 427 75.3 birth weight <2,500 gr or low birth weight 28 5.5 ≥2,500 gr or normal 477 94.5 history of infections yes 56 9.9 no 511 90.1 immunization status not complete 63 23.7 complete 203 76.3 frequency of weighing in the last 6 months not regular (1–3 times) 169 29.8 regular (4–6 times) 398 70.2 education of mothers low 430 93.3 high* 31 6.7 note: * high education was high school and above tisnasari hafsah et al.: factors affecting nutritional status among children aged 12–23 months althea medical journal. 2019;6(4) 208 amj december 2019 infant starts to grow, they are left behind and have difficulty catching up as they do not get enough nutrition to produce adequate growth rates.8 infants with a history of lbw require more nutrition for their growth. although lbw infants are breast-fed or given formula milk, the total protein intake is often still not sufficient to lead them to the normal growth rate.9 sometimes, even when the total protein intake is sufficient, a particular amino acid component could still be lacking and disrupt the protein balance.10 additional supplements consisting of protein, fat, glucose, and zinc should be given in order to achieve optimum growth.8 the fact that infants with a history of lbw burn more energy than babies, in general, it complicates the situation. they need more energy to grow and to synthesize new tissue. the degree of heat exchange and evaporation on the skin of lbw infants are also higher. quite often, these babies suffer from respiratory problems and infections or these babies are required to take certain drugs. for compensation, more intake is needed to produce more energy.11,12 impaired growth in lbw infants may provide long-term effects that are not desirable. the children might be shorter than children in general and the history of malnutrition during table 3 associations between risk or predisposing factors and nutritional status of children aged 12–23 months in west java predisposing factors nutritional status p-value odds ratio (or) 95% confidence interval (ci) malnutrition normal n(%) n(%) exclusive breastfeeding no 5 (21.7) 18 (78.3) 0.629 nd nd yes 16 (17.4%) 76 (82.6%) complimentary food <6 months 45 (17.9) 206 (82.1) 0.949 nd nd ≥6 months 56 (17.7) 260 (82.3) received vitamin a no 20 (14.3) 120 (85.7) 0.209 nd nd yes 81 (19.0) 346 (81.0) birth weight <2,500 gr or low birth weight 10 (35.7) 18 (64.3) 0.017 nd nd ≥2,500 gr or normal 84 (17.6) 393 (82.4) history of infection yes 13 (23.2) 43 (76.8) 0.266 nd nd no 88 (17.2) 423 (82.8) immunization status not complete 13 (20.6) 50 (79.4) 0.604 nd nd complete 36 (17.7) 167 (82.3) frequency of weighing in the last 6 months not regular (1–3 times) 30 (17.8) 139 (82.2) 0.980 nd nd regular (4–6 times) 71 (17.8) 327 (82.2) education of mothers low 40 (17.9) 183 (82.1) 0.251 nd nd high* 3 (9.7) 28 (90.3) note: nd was designated as not determined since p-value was not a significant difference (p>0.05; chi-square test). * high education was high school and above althea medical journal. 2019;6(4) 209 the period of brain development can result in a decreasing number of brain cells as well as deficiencies in the behavior, the learning ability, and an impaired memory.8,13-16 prevention efforts should be carried out to reduce the incidence of lbw. it certainly can be done by improving prenatal care.17 besides maintaining the nutritional intake, the mothers in childbearing age should avoid an unhealthy lifestyle, such as smoking, taking drugs, and alcohol. interestingly, consuming progesterone hormone during pregnancy is proven to be effective in reducing the risk of delivering a pre-term baby in a woman with history premature birth.18,19 a workshop has been conducted by the usa national institute of child health and human development to answer questions about the nutritional needs of infants with a history of low birth weight and whether an earlier aggressive intake would help the baby to catch up. an early aggressive feeding has been suspected to bring a bad impact and instead would give a toxic effect on the baby’s organs. however, the idea of supplementing the additional intake of macronutrients such as amino acids, glucose, and lipids as well as specific essential or nonessential amino acids such as insoles, choline, nucleotides is substantial to support an optimum growth.8 this study is lacking some aspects as this study has used secondary data, thus, missing data cannot be back-traced which reduce the number of data collected. furthermore, several types of bias, such as information bias and confounding may also take part in this unexpected result.20 to conclude, our study has only shown that low birth weight is associated with the nutritional status among children aged 12–23 months in west java province, resulting in that low birth weight has a 2.6 higher chance of malnutrition. there is thus a need to improve the quality of programs during antenatal control to raise awareness and knowledge about the pregnancy and early life of children. references 1. unicef. why early childhood development?. 2013. 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plos med. 2007;4(5):e115. 7. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. laporan nasional riset kesehatan dasar (riskesdas) tahun 2010. jakarta: badan penelitian dan pengembangan kesehatan. 2010. 8. hay ww jr, lucas a, heird wc, ziegler e, levin e, grave gd, et al. workshop summary: nutrition of the extremely low birth weight infant. pediatrics. 1999;104(6):1360–8. 9. ziegler ee. protein in premature feeding. nutrition. 1994;10(1):69–71. 10. rassin dk. essential and non-essential amino acids in neonatal nutrition. in: räihä ncr, editor. protein metabolism during infancy. new york: raven press ltd; 1994. p. 183–95. 11. kalhan sc, denne sc. energy consumption in infants with bronchopulmonary dysplasia. j pediatr. 1990;116(4):662–4. 12. wahlig tm, gatto cw, boros sj, mammel mc, mills mm, georgieff mk. metabolic response of preterm infants to variable degrees of respiratory illness. j pediatr. 1994;124(2):283–8. 13. hack m, schluchter m, cartar l, rahman m, cuttler l, borawski e. growth of very low birth weight infants to age 20 years. pediatrics. 2003;112(1 pt 1):e30–8. 14. binkin nj, yip r, fleshood l, trowbridge fl. birth weight and childhood growth. pediatrics. 1988;82(6):828–34. 15. hayakawa m, okumura a, hayakawa f, kato y, ohshiro m, tauchi n, et al. nutritional state and growth and functional maturation of the brain in extremely low birth weight infants. pediatrics. 2003;111(5 pt 1):991– 5. tisnasari hafsah et al.: factors affecting nutritional status among children aged 12–23 months althea medical journal. 2019;6(4) 210 amj december 2019 16. casey ph, whiteside-mansell l, barrett k, bradley rh, gargus r. impact of prenatal and/or postnatal growth problems in low birth weight preterm infants on schoolage outcomes: an 8-year longitudinal evaluation. pediarics. 2006;118(3):1078– 86. 17. goldenberg rl, culhane jf. low birth weight in the united states. am j clin nutr. 2007;85(2):584s–90s. 18. da fonseca eb, bittar re, carvalho m, zugaib m. prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased risk: a randomized placebo-controlled double-blind study. am j obstet gynecol. 2003;188(2):419–24. 19. meis pj, klebanoff m, thom e, dombrowski mp, sibai b, moawad ah, et al. prevention of recurrent preterm delivery by 17 alphahydroxyprogesterone caproate. n engl j med. 2003;348(24):2379–85. 20. jones s, carley s, harrison m. an introduction to power and sample size estimation. emerg med j. 2003;20(5):453– 8. vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 176 amj december 2019 neutrophil to lymphocyte ratio within clinical staging of head and neck squamous cell carcinoma orlena dharmantary kartika, bambang purwanto, yussy afriani dewi department of otorhinolaryngology-head & neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: orlena dharmantary kartika, department of otorhinolaryngology-head & neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, indonesia, e-mail: dr.orlena@gmail.com introduction head and neck squamous cell carcinoma (hnscc) is the most common type of the entire head and neck cancers, involving 90% of the total cases. every year, there are more than 500,000 new cases of hnscc worldwide, with 40,000 new cases and 7,890 deaths reported annually in the united states.1,2 indonesian national cancer registry places the head and neck carcinoma on the fourth position among the top ten malignancies.3 the prevalence of patients with hnscc in dr. hasan sadikin general hospital, bandung in 2010–2014 is 22.3%.4 the inflammatory response has an important role in the development and progression of cancer, and inflammatory indicators may have prognostic means for different types of cancer. the neutrophil-to-lymphocyte ratio (nlr) acts as a free prognostic factor for patients with various types of cancer. an increase in nlr is associated with a decline in overall survival (os) of several solid tumors, including hnscc.5 an increase in nlr indicates an ongoing inflammatory process. the nlr presents the activity index of protumor and antitumor which is easy to do because it is a routine examination in the daily clinical practice, obtained through the peripheral blood examination.6 the nlr is easily to perform in daily clinical practice. the aim of this study was to assess the prognostic value of nlr in hnscc patients, associated with the clinical staging. methods this study was an analytical research design to assess the nlr as a prognostic factor in hnscc patients. the inclusion criteria were early and late stage of hnscc patients with histopathology result was scc and had never amj. 2019;6(4):176–80 abstract background: neutrophil to lymphocyte ratio (nlr) is one of the inflammatory markers, associated with malignancies progression and metastasis, including head and neck squamous cell carcinoma (hnscc). neutrophil to lymphocyte ratio is presenting the activity index of protumor and antitumor. it is easy to perform in daily clinical practice, obtained from blood examination. the aim of this study was to assess the prognostic value of nlr in hnscc patients, associated with the clinical staging. methods: this study was an analytic design to explore the relationship between nlr and clinical staging. the sample was collected from pre-treatment hnscc patients who came to the head and neck oncology clinic, dr. hasan sadikin general hospital. the data consisted of disease history, ent examination, staging determination, and blood sample examination for nlr count. results: in total, data on 92 hnscc patients were collected. there was a statistically significant association between nlr with clinical staging in hnscc (p<0.001). the higher the nlr, the higher the clinical stage, whereas the lower the nlr, (or14.1; 95% ci 3.4–59.0). conclusions: there is a significant association between nlr with clinical staging in hnscc. further study is needed to explore nlr as a prognostic marker in hnscc patients keywords: clinical staging, head and neck squamous cell carcinoma, neutrophil to lymphocyte ratio althea medical journal. 2019;6(4) 177 been given therapy. the exclusion criteria were multiple carcinoma and residual or recurrent hnscc patients. a cross-sectional study was conducted to include the data from the medical record, involving hnscc patients.7,8 data on history taking, physical examination, and biopsy were collected. after the positive scc biopsy results were obtained, other data involving supporting examination were collected, such as computed tomography scan (ct scan), chest x-ray, and abdominal ultra sonography (usg) by the standard operating procedures (sop). furthermore, laboratory data were collected from the clinical pathology laboratory for complete blood count (sysmex automatic hematology xt 2000i analyzer, usa). neutrophil to lymphocyte ratio (nlr) was used as a marker of subclinical inflammation, and it also presented the activity index of protumor and antitumor. the nlr was calculated by dividing the number of neutrophils percentage over the number of lymphocytes percentage. this study protocol was accepted by the ethical committee number is lb.04.01/a05/ec/130/ iv/2018. the chi-square test was used for the statistical analysis and the fisher exact test was used for the 2x2 table. a receiver operating characteristic (roc) analysis table 1 characteristics of head and neck squamous cell carcinoma patients form dr. hasan sadikin general hospital subject characteristics total clinical stage p-valueearly (i-ii) n=12 advanced (iii-iv) n=80 gender male 81 (88.0) 10 (83.3) 71 (88.8) 0.632a female 11 (12.0) 2 (16.7) 9 (11.3) age mean ± sd 58 ± 13 59 ± 17 58 ± 13 0.819b carcinoma location larynx 61 (66.3) 9 (75.0) 52 (65.0) 0.937c tongue 15 (16.3) 1 (8.3) 14 (17.5) sinonasal 8 (8.7) 1 (8.3) 7 (8.8) nasopharynx 4 (4.3) 1 (8.3) 3 (3.8) tonsil 2 (2.2) 0 (0.0) 2 (2.5) oropharynx 1 (1.1) 0 (0.0) 1 (1.3) esophagus 1 (1.1) 0 (0.0) 1 (1.3) histopathology moderately differentiated 44 (47.8) 5 (41.7) 39 (48.8) 0.757c well-differentiated 29 (31.5) 5 (41.7) 24 (30.0) poorly differentiated 9 (9.8) 1 (8.3) 8 (10.0) non keratinizing 2 (2.2) 0 (0.0) 2 (2.5) basaloid scc 3 (3.3) 0 (0.0) 3 (3.8) non keratinizing moderately differentiated 2 (2.2) 0 (0.0) 2 (2.5) non-keratinizing poorly differentiated 2 (2.2) 1 (8.3) 1 (1.3) carsinoma in situ 1 (1.1) 0 (0.0) 1 (1.3) note: the chi-square test was used for the statistical analysis of this study. the analysis was used afisher exact test, bunpaired t-test, cchi square test, *significant at p<0,05 orlena dharmantary kartika et al.: neutrophil to lymphocyte ratio within clinical staging of head and neck squamous cell carcinoma althea medical journal. 2019;6(4) 178 amj december 2019 was performed before the chi-square test was done to find an optimal cut off point of the nlr. the significance criteria used was when p-values<0.05. the data obtained were recorded and then processed through the statistical package for the social sciences (spss) version 21.0 program for windows. results in total, 92 data of hnscc patients were collected, consisting of hnscc in the early clinical stage (n=12) and in advanced clinical stage (n=80). the majority of hnss patients were males (88.0%). the overall characteristics of the patients in this study were shown in table 1. the value of the nlr was determined based on literature, while the cutoff point of the nlr was obtained through the roc curve analysis. nlr cutoff points based on the roc curve analysis were 3.2 with area under the curve (auc) value of 0.784, a sensitivity of 82.5% and specificity of 75.0% (figure). based on the cutoff point value, nlr was categorized as low if nlr was<3.2 and high if nlr was >3.2. there was a significant difference between nlr and clinical stages in hnscc patients (p <0.001). the direction of the relationship shown was positive, meaning that the higher the nlr, the higher the clinical stage in patients with hnscc; whereas the lower the nlr, the lower the clinical stage. the odds figure the nlr cut off point based on roc curve analysis table 2 the relationship between nlr and clinical staging variable total clinical stage p-value or (95%ci)early (i-ii) n=12 advanced (iii-iv) n=80 nlr low 23 (25.0) 9 (75.0) 14 (17.5) <0.001 14.1 (3.4 – 59.0) high 69 (75.0) 3 (25.0) 66 (82.5) note: low nlr was <3.2 and high nlr was >3.2 althea medical journal. 2019;6(4) 179 ratio (or) of this study was 14.1, meaning that patients who had a high nlr in hnscc had a 14.1 higher risk in being in the advanced clinical stage compared to patients with a low nlr ratio. discussions this study has explored the nlr as a prognostic marker in hnscc patients. most of our patients were males (88%), similar to study in bulgaria11 with male and female ratio of 3.23:1. another study in india12 also reports that hnscc is more common in males than females, with an oral scc and oropharyngeal scc ratio based on gender about 1.5:1 and 2.8: 1, respectively. moreover, a study in pakistan12 shows head and neck carcinoma happens in 21% of males and 11% of females. this is in line with research in other places in indonesia4,13, reporting that most of hnscc patients are males. the risks of head and neck carcinoma increase with age, and the majority occur at the age of 50 or older. our study has shown that the age of hncss patients in early is 59+17 compared to the advanced stage which is 58 +13. although the difference in both clinicalstage is not significantly different, there is a trend that in the advanced stage hncss is younger, similar to study that shows more than 50% cases of head and neck carcinoma occur at the age of >60, and 28% occurs at the age of >70. head and neck carcinoma also occur in middle-aged patients (aged 46–55).4 interestingly, most carcinomas in this study (66.3%) are located in the larynx, and those have come at an advanced stage. this was in accordance with the result of other studies.11 the most histopathological findings in our study were moderate differentiation (47.8%), whereas carcinoma in situ is the least histopathological finding. this contrasts with the results of a study conducted in other places in indonesia, that most of the hnscc patients came with a high differentiation grade or in bad differentiation),14 or in opposite with the result in the national referral cancer hospital13, that the most differentiation from hnscc patients admitted in the hospital is the good differentiation.13 the difference in histopathological findings may very much depend on the various factors and need to be further explored. meaningful results between nlr and clinical stage of hnscc (p <0.001) in our study shows that there is a positive relationship between nlr and clinical stage of the disease; the higher the nlr, the higher the clinical stage of hnscc, whereas the lower the nlr, the lower the clinical stage of hnscc. the odds ratio (or) in this study is 14.1; the patients with a high nlr who is suffering from hnscc have a 14.1 times possible to have an advanced clinical stage compared to patients with a low nlr. a systematic review by guthrie et al.15 have shown that the neutrophil-lymphocyte ratio has an independent prognostic value on tumor clinical staging. the limitations of this study are that the data on co-morbidity in hnscc patients such as other metabolic diseases or chronic inflammation is lacking, as this condition may have a high value of nlr, so the confounding factor that may present could not be further assessed. therefore, further study is needed to compare nlr in hnscc patients with or without morbidity and prospective follow-up design study is needed to compare the nlr value pre and post-therapy among hnscc patients. as a conclusion, nlr can be used as the prognostic marker for the clinical stage in hnscc patients; the higher the nlr, the higher the clinical stage, with higher values is correlated with poor outcomes. references 1. timmerman a. neck ultrasound as a diagnostic method of cervical lymph node metastasis in patients with head and neck squamous cell carcinoma [thesis]. orebro, sweden: school of health and medical sciences department of clinical medicine orebro universitet; 2017. 2. marur s, forastiere aa. head and neck squamous cell carcinoma: update on epidemiology, diagnosis, and treatment. mayo clinic proc. 2016;91(3):386–96. 3. arifianto a. hubungan ekspresi epidermal growth factor receptor dengan stadium klinis karsinoma sel skuamosa kepala leher [thesis]. bandung: universitas padjadjaran; 2015. 4. sabirin msm, permana ad, soeseno b. epidemiologi penderita tumor ganas kepala leher di departemen telinga hidung tenggorokan-kepala leher rumah sakit dr. hasan sadikin bandung indonesia, periode 2010-2014. tunas medika jurnal kedokteran & kesehatan. 2016;3(1):1–6. 5. salim dk, mutlu h, eryilmaz mk, salim o, musri fy, tural d, et al. neutrophil to lymphocyte ratio is an independent prognostic factor in patients with recurrent orlena dharmantary kartika et al.: neutrophil to lymphocyte ratio within clinical staging of head and neck squamous cell carcinoma althea medical journal. 2019;6(4) 180 amj december 2019 or metastatic head and neck squamous cell cancer. mol clin oncol. 2015;3(4):839–42. 6. yu b, li z, zheng q, luo z, li j, zhou y, wang l, he c, shi f, wang r. prognostic value of neutrophil to lymphocyte ratio in patients with nasopharyngeal carcinoma: a metaanalysis. biomed res. 2017;28(3):1378– 82. 7. agresti a. an introduction to categorical data analysis. 3rd ed. new jersey: john wiley and sons; 2018. p. 207-45. 8. sastroasmoro s, ismael s. dasar-dasar metodologi penelitian klinis. 5th ed. jakarta: sagung seto; 2014. p. 130-43, 366. 9. field ap. discovering statistics using spss: (and sex and drugs and rock ‘n’ roll). 3rd ed. london: sage publication ltd; 2011. p. 128-34. 10. levy ps, lemeshow s. sampling of population, methods, and application. 4th ed. new york: john wiley and sons; 2011. p. 291-308. 11. stoyanov gs, kitanova m, dzhenkov dl, ghenev p, sapundzhiev n. demographics of head and neck cancer patients: a single institution experience. cureus. 2017;9(7):e1418. 12. joshi p, dutta s, chaturvedi p, nair s. head and neck cancers in developing countries. rambam maimonides med j. 2014;5(2):e0009. 13. to’bungan n, a’liyah sh, wijayanti n, fachiroh j. epidemiologi, stadium, dan derajat diferensiasi kanker kepala dan leher. biogenesis. 2015;3(1):47–52. 14. ayuni l. profil penderita karsinoma sel skuamosa kepala dan leher (ksskl) di rsup haji adam malik tahun 20122016 [minor thesis]. medan: universitas sumatera utara; 2017. 15. guthrie gj, charles ka, roxburgh cs, horgan pg, mcmillan dc, clarke sj. the systemic inflammation-based neutrophil– lymphocyte ratio: experience in patients with cancer. crit rev oncol hematol. 2013;88(1):218–30. vol 5 no 2 full text edit.indd althea medical journal. 2018;5(2) 53 knowledge and attitude of women of reproductive age toward clubfoot: a rural community dwelling f. m. dicky fitraendi,1 fathurachman,2 nugroho harry susanto3 1faculty of medicine universitas padjadjaran, 2department of orthopaedics and traumatology faculty of medicine universitas padjadjaran/dr hasan sadikin general hospital bandung indonesia, 3departement of public health faculty of medicine universitas padjadjaran abstract background: clubfoot is a congenital anomaly in which the ankle is twisted outward from the normal position. clubfoot is one of the most common birth defect in the world that can cause disability. approximately 150.000 – 200.000 babies are born with clubfoot every year. clubfoot is a neglected disease. immediate intervention is needed to treat the patient with clubfoot. one of the most common barriers of the treatment is the knowledge and attitude of the society about clubfoot. this study aimed to identify the knowledge and attitude of the society especially women of reproductive age toward clubfoot in cikeruh village jatinangor sub−district in 2014. methods: this study was conducted to 100 women of reproductive age with age interval 15−49 years obtained by using the purposive sampling method, and who live in cikeruh village jatinangor. a questionnaire was used as instrument to collect data which was later categorized as good, fair, and low for the knowledge and positive and negative for attitude. results: out of 100 samples of women of reproductive age in cikeruh village, who were asked about clubfoot, 39% had a good knowledge and 61% had a fair knowledge. there were 42% of respondent who had a negative attitude toward clubfoot and 58% had positive attitude. conclusions: the majority sample of women of reproductive age in cikeruh village in 2014 have a fair knowledge about clubfoot. the ratio between positive and negative attitude toward clubfoot is almost 1:1. keywords: attitude, clubfoot, knowledge correspondence: f. m. dicky fitraendi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: fitraendifm@yahoo.co.id introduction clubfoot or congenital talipes equinovarus is one of the most common serious birth defects− caused by congenital anomaly which is likely to occur in the world.1 at least 150.000– 200.000 babies are born with clubfoot every year. approximately 80% of the cases occur in developing countries.2 in indonesia the frequency of congenital clubfoot is 1 in 1000 births. amniocentesis process and smoking habit on childbearing women can increase the ratio of giving birth child with clubfoot. some studies showed that variation on pitx1– pitx4 gen has a major role in mechanism of clubfoot.3−5 congenital anomaly like clubfoot is an abnormality that should be treated at an earlier age. however, clubfoot is still categorized as a neglected disease nowadays.6 some of the barriers on treating congenital anomaly like clubfoot are knowledge and attitude of the society toward clubfoot itself. bedford in his study stated that there are four main barriers in society in treating clubfoot: knowledge on the condition of his body related to disease and how to treat it, attitude of the family, way of thinking, and socio−cultural stress.7 therefore, the purpose of this study was to identify the knowledge and attitude toward clubfoot among women in their reproductive age who would bear a child in the rural area. methods this descriptive study was conducted in july− november in cikeruh village, jatinangor sub− district as one of the rural areas in west java, amj. 2018;5(2):53–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1413 althea medical journal. 2018;5(2) 54 amj june 2018 indonesia. this study was approved by the health research ethics committe, faculty of medicine, universitas padjadjaran. this study used the purposive sampling method. there were 100 women of reproductive age between 15 to 49 years who lived in cikeruh village. in order to measure the knowledge and attitude of the respondent toward the clubfoot, this study used the questionnaire which had been through validity and reliability process. the collected data were then processed and grouped based on percentage of the total score from the respondent answer. knowledge was categorized into 3 groups: good (≥76%), fair (56%−75%), and low (≤55%). the category of attitude was grouped based on the position of the total score toward the median result from scores that were obtained from every respondent. the group obtaining results more than or the same as the median was categorized as having a positive attitude. the group which had results below the median was categorized as having a negative attitude. results this study discovered that there was no woman under 19 years of age. most of the respondents were 30–34 years old and had table 1 characteristic of sample women with reproductive age in cikeruh village, jatinangor sub−district toward clubfoot in 2014 frequency percentage age 15−19 0 0% 20−24 13 13% 25−29 19 19% 30−34 22 22% 35−39 18 18% 40−44 13 13% 45−49 15 15% marriage yes 99 99% no 1 1% education level elementary school 20 20% junior high school 36 36% senior high school 40 40% college 4 4% willing to have a child or more children yes 45 45% no 55 55% table 2 distribution of knowledge level of women of reproductive age in cikeruh village jatinangor sub−district toward clubfoot in 2014 knowledge level category of score frequency n=100 percentage good ≥76% 39 39% fair 56%−75% 61 61% low ≤55% 0 0 althea medical journal. 2018;5(2) 55f. m. dicky fitraendi, fathurachman, nugroho harry susanto: knowledge and attitude of women of reproductive age toward clubfoot: a rural community dwelling a low level of education. regarding marital status, only one respondent was single. the number of respondents who would have more children was less compared to respondents who would have a child or more children. based on the distribution of knowledge level of women of reproductive age, 61% of sample had fair knowledge about clubfoot. the rest or 39% of sample had good knowledge. (table 2) furthermore, this study discovered that more than half of the respondents or 58% had positive knowledge toward clubfoot.(table 3) discussion as much as 61% reproductive-age women who were interviewed had fair knowledge toward clubfoot. this finding differed from the results stated by aziza et al. in her study about knowledge of the family with clubfoot toward clubfoot in karachi, pakistan8 which indicated that the majority of the respondent have low knowledge toward it. some respondents even believe that a child with clubfoot would maintain their condition live long that way. the minimum level of knowledge of course will impact to the treatment−seeking behavior. boardman et al.1 in his study stated that the minimum level of knowledge will delay the treatment.1,9 most of the respondents had a positive attitude toward clubfoot. this findings was different from research findings which is claimed by lemacks et al.10 that parents of the child with congenital anomaly tend to get negative implication physically and mentally. it certainly can have a negative influence on the attitude of society, especially in women of reproductive age. furthermore, lemacks et al. 10 revealed that parents who have children with congenital abnormalities tend to close themselves off from social life which is likely to exacerbate the stress levels of parents. the stress level is an indicator of a negative attitude.10 the limitation of this study was that not every hamlet in cikeruh village was represented since not all population members had the same opportunity to be the sample of this study as it used the purposive sampling. it can be concluded that the majority of women of reproductive age have fair knowledge (61%) toward clubfoot in cikeruh village in 2014. the majority of respondents (58%) have positive attitude toward clubfoot. it is quite surprising that there are no single respondent who have low knowledge about clubfoot. references 1. boardman a, jayawardena a, oprescu f, cook t, morcuende ja. the ponseti method in latin america: initial impact and barriers to its diffusion and implementation. iowa orthop j. 2011;31:30–5. 2. lourenço a, morcuende j. correction of neglected idiopathic club foot by the ponseti method. j bone joint surg br. 2007;89(3):378−81. 3. ester ar, weymouth ks, burt a, wise ca, scott a, gurnett ca, et al. altered transmission of hox and apoptotic snps identify a potential common pathway for clubfoot. am j med genet. 2009;149(12):2745−52. 4. honein ma, paulozzi lj, moore ca. family history, maternal smoking, and clubfoot: an indication of a gene− environment interaction. am j epidemiol. 2000;152(7):658−65. 5. dobbs mb, gurnett ca. genetics of clubfoot. j pediatr orthop b. 2012;21(1):7–9. 6. penny jn. the neglected clubfoot. tech orthop. 2005;20(2):153−66. 7. bedford kja, chidothi p, sakala h, cashman j, lavy c. clubfoot in malawi: treatment−seeking behaviour. trop doc. 2011;41(4):211−4. 8. burfat a, mohammed s, siddiqi o, samad l, mansoor ak, amin cm. understanding the knowledge and perceptions about clubfoot in karachi, pakistan: a qualitative exploration. iowa orthop j. 2013;33:149−52. 9. kazibwe h, struthers p. barriers experienced by parents of children table 3 distribution of attitude level of women with reproductive age in cikeruh village jatinangor sub−district toward clubfoot in 2014 attitude category of score frequency percentage positive ≥median 58 58% negative < median 42 42% althea medical journal. 2018;5(2) 56 amj june 2018 with clubfoot deformity attending specialised clinics in uganda. trop doc. 2009;39(1):15−8. 10. lemacks j, fowles k, mateus a, thomas k. insights from parents about caring for a child with birth defects. int j environ res publ health. 2013;10(8):3465−82. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 426 amj september 2017 characteristics of hypertension in children at dr. hasan sadikin general hospital bandung in january to december 2014 meilani,1 nanan sekarwana,2 yuni susanti pratiwi3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: hypertension is often found in children. it could cause serious complications and added risk of hypertension in adulthood. hypertension in children is likely secondary type and some of them might be severe. the aim of this study was to determine the demographic and clinical characteristics of hypertension in children admitted to dr. hasan sadikin general hospital bandung in january to december 2014. methods: the study design used was a quantitative, descriptive cross-sectional study. data were obtained from medical records retrospectively of inpatient children from the period january to december 2014. data were collected from the period september to november 2015 based on age and gender as a demographic characteristics and stage of hypertension, etiology of hypertension, and emerge of hypertensioncomplication as a clinical characteristics. results: ninety(1.9%)children with hypertension were found from 4,681 of total inpatient children consisting of 58 males and 32 females with median of age 8 (0−13) years old.the main stage of hypertension was hypertension stage 2 with 55 cases and nephrotic syndrome as the most common causes with 43 cases. the complications were present in hypertension stage 2 with 3 cases and hypertensive crisis with 2 cases. conclusions: children with hypertension are most commonly males and median of age was 8 years old. hypertension is characterized by hypertension stage 2 and nephrotic syndrome as the most common etiology. complications of hypertension appear in severe hypertension. keywords: nephrotic syndrome, pediatric hypertension, secondary hypertension correspondence: meilani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: akumeilani@gmail.com introduction hypertension is a disease that is more common in adults. the prevalence of hypertension in adults in indonesia is very high reaching 26.5% of the total population.1 the high percentage of that prevalence is indirectly caused by the increasing number of hypertension in children.2 this is due to the tracking of hypertension from childhood to adulthood.3 furthermore, hypertension in children might cause serious complications such as left ventricular hypertrophy (lvh) and chronic kidney disease(ckd).2 estimated prevalence of hypertension in children is 1%.4 the diagnosis of hypertension in children is different from adults because the blood pressure in children is influenced by age, gender, and height.2 hypertension in children can be divided into two categories based on its etiology; which are primary hypertension and secondary hypertension. secondary hypertension is more prevalent in children.5 the most common causes of secondary hypertension in children are kidney and renovascular diseases.2 secondary hypertension in children is likely severe and requires accurate evaluation and treatment.6 dr. hasan sadikin general hospital bandung is a referral hospital in the province of west java but there has not been any reports on the incidence of hypertension in there. thus, the author was interested in determining characteristics of hypertension in children in dr. hasan sadikin general hospital bandung, therefore it might be helpful in evaluating the incidence of hypertension in children. amj. 2017;4(3):426–30 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1193 althea medical journal. 2017;4(3) 427 methods the study design used was a quantitative, descriptive cross-sectional study which was approved by the ethical committee of dr. hasan sadikin general hospital bandung, number lb.02.01/c02/x/2015. the population in this study included the entire medical record ofpatients with hypertension who were admitted to the inpatient child health department at dr. hasan sadikin general hospital bandung from the period january to december 2014. data were collected from the period september to november 2015. subjects selected fulfilled the inclusion criteria. in this study, the inclusion criteria were the entire medical records of patients with hypertension who were admitted to the inpatient child health department at dr. hasan sadikin general hospital bandung from the period january to december 2014 with completed and reliable data. hypertension were diagnosed according to national high blood pressure education program working group on high blood pressure in children and adolescent.2 secondary data from medical records were collected based on age and gender as demographic characteristics and astage of hypertension, etiology of hypertension, and emerge of its complications as clinical characteristics. total sampling method was used during sampling. height percentile data according to center fo disease control growth charts was included on measurement of hypertension in children. persentil of systolic blood pressure (sbp) and diastolic blood pressure (dbp) were determined by age, gender, and height percentile. systolic blood pressure and dbp were taken from physical examination data from medical records. the diagnosis of hypertension was made when the average systolic blood pressure or diastolic blood pressure ≥95th percentile, assessed ≥3 times on different occasions. hypertension was confirmed within the next two visits. standards for sbp and dbp for infants younger than 1 year are available. in children younger than 1 year, sbp has been used to define hypertension.2 in this study, hypertension was divided into three categories, consisting of hypertension stage 1, hypertension stage 2, and hypertensive crisis. the hypertension stage 1 was characterized by blood pressure from the 95th percentile to the 99th percentile plus 5 mmhg. the hypertension stage 2 was characterized by blood pressure more than the 99th percentile plus 5 mmhg. meanwhile, hypertensive crisis was characterized by systolic blood pressure >180mmhg or diastolic >120mmhg or any stage of hypertension complicated by hypertensive encephalopathy, heart failure, meilani, nanan sekarwana, yuni susanti pratiwi: characteristics of hypertension in children at dr. hasan sadikin general hospital bandung in january to december 2014 table 1 distribution of patients with hypertension based on age and gender age male n = 58 female n = 32 total 0 0 1 1 1 0 1 1 2 3 2 5 3 5 1 6 4 3 1 4 5 3 0 3 6 7 4 11 7 8 4 12 8 3 0 3 9 5 5 10 10 6 5 11 11 6 1 7 12 4 2 6 13 5 5 10 median(min-max) 7.5 (2-13) 9 (0-13) 8 (0-13) althea medical journal. 2017;4(3) 428 amj september 2017 or papilledema.2 in this study, complications of hypertension in children were seen in the emerged of heart disease resulting from hypertension. cardiorenal type iv were used as an indication for complications of hypertension. the collected data were then categorized into appropriate categories. subsequently, the collected data were tabulated to display the frequency of each category using a statistical program. result in the period january to december 2014, there were 4,681 patients admitted to inpatient child health departmentat dr. hasan sadikin general hospital bandung, out of which 90 (1.9%) children were found to be suffering from hypertension consisting of 58 males and 32 females. the median was used as the nonnormal distribution of age in this study. the median (min−max) of age in this study was 8 (0−13) years (table 1). the hypertension group most commonly found were 55 cases of hypertension stage 2, followed by 28 cases of hypertension stage 1 and 7 cases of hypertensive crisis. this study also summed up the etiology of hypertension, such as 43 cases of nephrotic syndrome, 20 cases of nephritic syndrome, 19 cases of ckd, 3 cases of acute kidney injury (aki), and 5 cases of other diseases. other diseases include acute lymphoblastic leukemia (all), coarctation aorta and primary hypertension of unknown cause. the result of this study also showed that there were other diseases along with nephrotic syndrome which may have caused hypertension, such as 11 cases of nephrotic syndrome with ckd, 2 cases of nephrotic syndrome with aki, and 3 cases of nephrotic table 2 distribution of patients with hypertension based on etiology and stage of hypertension hypertension etiology hypertension i (n=28) hyperten-sion ii ( n=55) hypertensive crisis (n=7) total (n=90) nephrotic syndrome nephrotic syndrome 13 14 0 27 nephrotic syndrome with ckd 3 7 1 11 nephrotic syndrome with aki 1 1 0 2 nephrotic syndrome with obesity 0 3 0 3 total 17 24 1 43 nephritic syndrome nephritic syndrome 4 11 1 16 nephritic syndrome with ckd 1 0 0 1 nephritic syndrome with aki 0 2 1 3 total 5 13 2 20 ckd 2 14 3 19 aki 0 2 1 3 others 4 1 0 5 note: *chronic kidney disease (ckd), acute kidney injury (aki table 3 distribution of patients with hypertension based on complications complication hypertension i hypertension ii hypertensive crisis yes 0 3 2 no 28 52 5 althea medical journal. 2017;4(3) 429meilani, nanan sekarwana, yuni susanti pratiwi: characteristics of hypertension in children at dr. hasan sadikin general hospital bandung in january to december 2014 syndrome with obesity. similarly, there were other diseases along with nephritic syndrome which may have caused hypertension, such as 1 case of nephritic syndrome with ckd and 3 cases of nephritic syndrome with aki(table 2). based on complication of hypertension, there were 5 cases of hypertension complications, 3 of which were from hypertension stage 1 and 2 were from hypertensive crisis (table 3). discussion other studies that indicated incidence rate of pediatric hypertension in indonesia were zainoel abidin general district hospital, banda aceh7 (0.87%) and dr. sardjito general hospital, yogyakarta8 (1.3%) with the respective period of research are five years. meanwhile, in this study, there were 1.9% children suffering from hypertension. this increase may be due to the high incidence of obesity in children.9 blood pressure measurement in children are given slight importance by doctors. for instance, in this study, there were medical records that did not register blood pressure measurements of pediatric patients routinely. some study showed about 71 % of doctors only measure blood pressure in children if the child is at risk to suffer from hypertension.10 furthermore, an increase in blood pressure in children is a risk of hypertension.2 this makes hypertension in children underdiagnosed which in turn increases the occurrence in the future. based on gender, male patients (58) have higher incidence rate compared to female patients (32). this pattern is similar to the study done in zainoel abidin general district hospital,banda aceh7 and dr. sardjito general hospital, yogyakarta.8 other studies have also shown that hypertension is more prevalent in males compared to females.11 the median of age in this study was 8 years old. the study done in zainoel abidin general district hospital, banda aceh7 used modus as a data centralization with age of 10−11 years old. in this study, hypertension was divided into three categories, consisting of hypertension stage 1, hypertension stage 2 and hypertensive crisis, defined by national high blood pressure education program working group on high blood pressure in children and adolescent.2 there were more children suffering from hypertension stage 2 compared to hypertension stage 1, where there were 55 and 28 cases respectively. this result is consistent with the study conducted in zainoel abidin general district hospital,banda aceh.7 the emergence of hypertension stage 2 in children is associated with the incidence of secondary hypertension, whereas the hypertension stage 1 is associated with the incidence of primary hypertension.2 this explains the high prevalence of hypertension stage 2 in children. meanwhile, there were only 7 cases of hypertensive crisis in this study. this is in contrast to the study conducted in zainoelabidin general district hospital, banda aceh7 that showed hypertensive crisis was the most prevalent. other studies mention that hypertensive crisis occur more frequently in children aged >6 years, ranging from 1−18 years old.12 therefore, hypertensive crisis cases are rarely found in this study because of the limited age range. this study indicated the severity of hypertension in children, as well as the importance of blood pressure measurement and the necessity of immediate treatment. this study also summed up the common causes of hypertension, consisting of nephrotic syndrome with 42 cases, nephritic syndrome with 20 cases, ckd with 19 cases, aki with 3 cases, and other diseases with 5 cases. the number of cases is quite different from the results found in zainoel abidin general district hospital, banda aceh7, where acute glomerulonephritis was the most common cause of hypertension. however, in those studies, the number of cases obtained for acute glomerulonephritisand nephrotic syndrome were similar, which were 16 cases and 13 cases respectively.7 acute glomerulonephritis is included in nephritic syndrome group in this study as it is considered as most of the acute symptoms of nephritic syndrome.13 nephrotic syndrome is a kidney disease that is most often found in the inpatient department of child health at dr. hasan sadikin general hospital in january to december 2014. in addition, this study included children treated with cyclophosphamide therapy which is an indicator for the treatment of nephrotic syndrome. this may be explained that the nephrotic syndrome as the most etiology of hypertension in this study. nephrotic syndrome is also found with other diseases that can also cause hypertension, such as ckd, aki and obesity. besides, nephrotic syndrome may occur with aki since aki is known to be a common complication of nephrotic syndrome.14in this study, ckd was identified as the third most common cause of hypertension. other studies mention that hypertension is a symptom that occurs in 70.2 % of cases of ckd.15 drug-induced hypertension must althea medical journal. 2017;4(3) 430 amj september 2017 always be considered. drugs that can raise bp include oral contraceptive, steroids, non-steroidal anti-inflammatory drugs, cocaine, amphetamines, erythropoietin and cyclosporins. glucocorticoids were among the first drugs used in the treatment of all. some studies mention that the incidence of hypertension in all patients was 14%.16 children with hypertension are most commonly males and median of age was 8 years. hypertension is characterized by hypertension stage 2 and nephrotic syndrome as the most common etiology. complications of hypertension appeared in severe hypertension. these information can help doctors to evaluate the incidence of hypertension in children, so complications of hypertension can be avoided. furthermore, it can enhance doctor’s attention to measure blood pressure in children as vital component of the routine pediatric physical examination. limitation of this study included the short duration of the study which is of the period of 1 year. hence, information regarding the incidence of hypertension in children at dr. hasan sadikin general hospital could not be described in more details. this is due to the lack of time that was allocated to the researcher for data collection. besides, incompleted and misplaced medical records were one of the causes this study slightly less descriptive. references 1. kementerian kesehatan ri. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri;2013. 2. national high blood pressure education program working group on high blood pressure in children and adolescent. the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescent. pediatrics; 2004. p. 555−76. 3. chen x, wang y. tracking of blood pressure from childhood to adulthood: a systematic review and meta–regression analysis. circulation. 2008;117(25):3171−80. 4. lo jc, sinaiko a, chandra m, daley mf, greenspan lc, parker ed, et al. prehypertension and hypertension in community-based pediatric practice. pediatrics. 2013;131(2):415−24. 5. gomes r, quirino i, pereira r, vitor b, leite a, oliveira e, et al. primary versus secondary hypertension in children followed up at an outpatient tertiary unit. pediatr nephrol. 2011;26(3):441−7. 6. bajracharya p, olivera m, kapur g. epidemiology of secondary hypertension in children. current cardiovascular risk reports. 2014;8(7):1−9. 7. haris syafruddin, dimiati herlina, anwar m.sidqi. profil hipertensi pada anak di rsud dr. zainoel abidin banda aceh. sari pediatri. 2013;15(2):105−10. 8. pungky ak, damanik mp. hipertensi pada anak di rs dr. sardjito yogyakarta. berita kedokteran masyarakat. 2006;22(3):124−7. 9. ng m, fleming t, robinson m, thomson b, graetz n, margono c et al. global, regional and national prevalence of overweight and obesity in children and adults 1980−2013: a systematic analysis. lancet. 2014;384(9945):766−81. 10. bijlsma mw, blufpand hn, kaspers gjl, bökenkamp a. why pediatricians fail to diagnose hypertension: amulticenter survey. the journal of pediatrics. 2014;164(1):173−7.e7. 11. tran cl, ehrmann bj, messer kl, herreshoff e, kroeker a, wickman l, et al. recent trends in healthcare utilization among children and adolescents with hypertension in the united states. hypertension. 2012;60(2):296−302. 12. yang w-c, wu h-p. clinical analysis of hypertension in children admitted to the emergency department. pediatrics & neonatology. 2010;51(1):44−51. 13. kanjanabuch t, kittikowit w, eiam-ong s. an update on acute postinfectious glomerulonephritis worldwide. nat rev nephrol. 2009;5(5):259−69. 14. mong hiep t, ismaili k, collart f, van damme-lombaerts r, godefroid n, ghuysen ms, et al. clinical characteristics and outcomes of children with stage 3–5 chronic kidney disease. pediatr nephrol. 2010;25(5):935−40. 15. wong h, mylrea k, feber j, drukker a, filler g. prevalence of complications in children with chronic kidney disease according to kdoqi. kidney int. 2006;70(3):585−90. 16. juliansen andry, andriastuti murti, pardede sudung o, sekartini rini. hypertension, high-dose corticosteroids, and renal infiltration in children with acute lymphoblastic leukemia. paediatr indones. 2014;54(6):372−6. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 111 short-term memory comparison between stunted and non-stunted groups irma suwandi sadikin,1 leonardo lubis,2 julistio t. b. djais3 1kebayoran lama general hospital south jakarta, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran bandung, indonesia, 3departement of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: long-term insufficient nutritional needs will directly impact on the development and maturation of brain function. disruption of development and maturation process in the brain is associated with decreased cognitive abilities. frequently, the effect of long-term nutritional insufficiency has also height deficits called stunting.this study aimed to compare the short-term memory between stunted and non-stunted groups. methods: a comparative study was conducted on 30 children in a non stunted group and 30 children in a stunted group. children in both groups were selected from one of the elementary schools in jatinangor using the simple random sampling method toward 3–5 for grade and 8–10 for age groups. the measurement of memory aspects for short-term memory used the digit span test (forward and backward) and simbol modality test. results: the collected data were in normal and not normal distribution because the statistical test used the independent-t test and mann-whitney. the mean memory score comparison between group 1 and group 2 on digit span test forward was 5.33:5.33 (p=0.994), digit span test backward was 2.73:2.60 (p=0.440), and symbol modality test was 20.90:19.60 (p=0.347). conclusions: there is no significant difference in short-term memory between stunted and non– stunted groups, due to some confounding factors such as, environmental aspect, parent’s education level, socioeconomic, and genetic factors. keywords: cognitive development, short-term memory, stunted correspondence: irma suwandi sadikin, kebayoran lama general hospital, south jakarta, indonesia, email: irmaswans@gmail.com introduction malnutrition is a manifestation of insufficient intake of nutrition. malnutrition is a common problem in developing countries even in the world. children with severe malnutrition have more than an eight-fold greater risk of mortality and also gives long-term effects on cognitive and social development, physical work capacity, productivity and economic growth.1 survivors of chilhood undernutrition frequently have deficits in height and weight that persist beyond adolescence into adulthood.1 one of the manifestations of chronic malnutrition is stunting. stunting is low height for age proportion and based on growth chart is <-2sd.1 according to riset kesehatan dasar (riskesdas) in 2010, the sites of the ministry of health in indonesia show that 35.6% of children under five are stunted and it is still a major problem in indonesia.2 stunting is associated with reduction of cognitive abilities in children. long-term insufficienct nutritional intake will directly impact on the development and maturation of brain function. disruption of development and maturation of the brain is associated with decreasing in cognitive abilities.3 decreasing in cognitive abilities will impact on the child’s learning process. short-term memory is important for the learning process and formation of long-term memory.4 therefore, the author is interested in examining the comparison of cognitive aspects especially for short-term memory between amj. 2018;5(3):111–5 althea medical journal. 2018;5(3) 112 amj september 2018 stunted and nonstunted groups in children aged 8–10 years. methods the method used in this study was comparative study. this study was conducted in september 2015 and was approved by the health research ethics committee faculty of medicine, universitas padjadjaran. all participants were students from karangmulya elementary school in jatinangor, sumedang district, west java province, indonesia. a total of 103 students from grade 3-5 were selected using the simple random sampling. the 103 students were then measured for their height. based on the height measurement result, the total subjects obtained were 60 students. next, they were divided into two groups, 30 students for the normal group and 30 students for the stunted group. the eligible participants ranged from 8 to 10 years of age, and were free from the exclusion criteria, such as children who had spinal abnormalities (such as scoliosis, kyphosis, lordosis), and children who slept less prior to the study;5 children who consumed foods, beverages, and medications that contained caffeine infortyeight hours prior to the study (such as: tea, coffee, chocolate, energy drinks);6 children who were diagnosed with thyroid disease;7 children who had experienced anxiety that couldnot be appeased , and children who were diagnosed with impaired vision, hearing, and extremely impaired motor function that could interfere the measurement process. prior to the beginning of this study, parents were invited to attend the meeting in which the study procedures were explained thoroughly and informed written consent was obtained. f u r t h e r m o r e , a n t h r o p o m e t r i c measurements were performed to measure height, and adjust weight based on the age of the study subjects. weight was recorded by using stepped measuring to the nearest 0.1 table 1 characteristics of non-stunted/normal group mean interval standard deviation age 115 months 98–127 months 9 weight 26.17 20–40 4.549 height 128.99 119–145.6 6.523 bmi 15.34 13–25 2.712 z score height for age -1.17 (-1.98)–0.8 0.719 kg on the weighing scale. height was recorded by using microtoise measuring to the nearest 0.1 cm. anthropometric data were used to calculate a height for-age z-score (haz) by using the world health organization (who) growth reference data. children with a haz <-2 sd from the reference median were classified as stunted. in order to assess short-term memory, the digit span test forward, backward digit span test, and symbol digit modalities test were used. the tests are components of the wechsler memory scale (wms) and the wechsler intelligence scale which focused on working memory and selective attention. digit span forward is considered to measure the atention aspect, digit span backward is considered to measure the working memory/short-term memory. span refers to the ability in holding an adequate amount of information in working memory. it refers to how much information can be held after a single presentation in correct serial order also required the additional processing components of mental manipulation numbers, internal visual scanning, and/or visuospatial processing.8 numeric data were summarized from the score of short-term memory test (digit span test forward, backward digit span test, and symbol digit modalities test) and categorical data were from each group (group 1 for normal and group 2 for stunted). differences in cognition scores across the stunted and normal groups were compared by using independent sample t-tests for normal distribution data. the mann-whitney test for not normal distribution was α<0.05 which was considered statistically significant. all analyses were performed by using statistic software. results furthermore, the characteristics of both groups showed, the mean of z-score for nonalthea medical journal. 2018;5(3) 113irma suwandi sadikin, leonardo lubis, julistio t. b. djais: short-term memory comparison between stunted and non-stunted groups stunted group was -1.17 and mean of z-score for stunted group was -2.54 (table 1 and 2). moreover, results of the tests showed the mean memory score comparison between group 1 and group 2 on digit span test forward (p=0.994), digit span test backward (p=0.440), and symbol modality test (p=0.347) there was no significant difference in short-term memory scores by examination with the digit span test forward, backward and symbol modality test between the two groups (figure 1). discussion measurement in this study refers to an examination that focuses on attention of examining the cognitive form. attention is the taking possession of the mind, in clear and vivid form, of one out of what seem several simultaneously possible objects or trains thoughts.9 it implies withdrawal from some things in order to deal effectively with others.9 heightened attention also paves the way for memory processes. areas of the brain such as the posterior parietal neuron, limbic area, ascending reticular activating system (aras) and prefrontal area have an important role for these process.9 the symbol digit modalities test performance is associated with increasing of brain activity in frontal and parietal areas involves in selective attention and working memory functions.10 attention is divided into four categories such as focused attention, selective attention, sustained attention, switching or mental set shifting, and divided attention. the three examinations in this study included the examination of the type of selective attention. selective attention refers to vigilance in monitoring information or ability table 2 characteristics of stunted group mean interval standard deviation age 110 months 96–126 months 12 weight 21.77 17–27 2.424 height 118.27 108–126.9 2.208 bmi 15.52 12.9–17.8 1.135 z score height for age -2.54 (-3.66)–(-2.02) 0.389 figure 1 comparison of short-term memory between stunted and non stunted groups *p –value >0.05 (no significant difference) althea medical journal. 2018;5(3) 114 amj september 2018 to maintain a cognitive set in the presence of background “noise” or distraction.9 this test can be influenced by several factors such as context, content and culture, and the linguistic factor also contributes to the result of the test. therefore, this study was related to technical errors so that it showed no significant result. cognitive development is influenced by genectic, environment and nutrition in general.1 long-term nutritional insufficiency can give impact on brain development especially on the cognitive aspect. however, the impact is not only on brain development but also on height deficits which can cause stunting. therefore, stunting is associated with decreasing of cognitive development. the statement mentioned above is supported by a previous study, which stated that stunted children and children with chronic malnutrition are associated with decreasing of cognitive ability. another previous study also stated that stunted children and children with chronic malnutrition are associated with decreasing of cognitive ability based on short-term memory test, retrieval ability, verbal fluency, selective attention, visuospatial abilities, verbal learning and memory.3,11,12 another study stated about the effect of undernutrion to cognitive ability using intelligence quotient (iq). the result showed that undernourished children have low cognitive ability especially for the attention aspect, executive function, calculation, visuoperceptual ability, long term learning, and memory and intelligence.13 these statements supported the hypothesis of this study. furthermore, the result of this study was different from another study. this study result showed, stunted children and non-stunted children did not have a signifficant difference on cognitive ability especially for short-term memory. this difference could be due to other factors that could influence this result. factors like mental ability from parents, education of parents, socioeconomic and environment can affect the cognitive development and nutritional status of children.14–17 there also will be a risk factor for occurence of malnutrition in children. these factors could possibly be non significant for the result, due to the characteristic of most subjects were low level of education and elementary and junior high school graduates, who live in rural areas. moreover, the genetic factor also can contribute to the cognitive development and languange ability of someone.18–20 generally, these factors will affect a child’s growth and development process. however, it depends on the different stimulation and response which can affect a child’s growth and development process. based on the statements above, the author has found facts which differ from the existing theories that there is no difference in shortterm memory between stunted children and non-stunted children. nevertheless, there are many factors which can influence the cognitive and nutrional status of children such as, culture, mental ability of parents, child guidance, genetic variation, and past nutritional status (birth weight). in this study the environment al factor is not considered. references 1. kliegman rm, behrman re, jenson hb. nelson textbook of pediatric. 18th ed. philadelphia: elsevier; 2007. p. 22–53. 2. depkes. stop generasi stunting di indonesia : kementrian esehatan ri; 2011 [cited 2014 15 february]. available from: http://gizi.depkes.go.id/stop-generasistunting-di-indonesia. 3. kar br, rao sl, chandramouli ba. cognitive development in children with chronic protein energy malnutrition. behav brain funct. 2008;4(1):31–43. 4. papalia de, olds sw, feldman rd. human development. 10th ed. new york: mcgrawhill companies; 2006. p. 5–522 5. alhola p, polo-kantola p. sleep deprivation: impact on cognitive performance. neuropsychiatr dis treat. 2007;3(5):553– 67. 6. nobre ac, rao a, owen gn. l-theanine, a natural constituent in tea, and its effect on mental state. asia pac j clin nutr. 2008;17(1):167–68. 7. wheeler sm, willoughby ka, mcandrews mp, rovet jf. hippocampal size and memory functioning in children and adolescents with congenital hypothyroidism. j clin endocrinol metab 2011;96(9):1427–34. 8. woods dl, kishiyama mm, yund ew, herron tj, edwards b, poliva o, et al. improving digit span assessment of short-term verbal memory. j clin exp neuropsychol. 2011;33(1):101–11. 9. baron is. neuropsychological evaluation of the child. new york: oxford university press; 2004. p. 215–27. 10. forn c, belloch v, bustamante jc, garbin g, parcet-ibars ma, sanjuan a, et al. a symbol digit modalities test version vuitable for functional mri studies. neurosci lett. 2009;456(1):11–4. althea medical journal. 2018;5(3) 115 11. crookston bt, dearden ka, alder sc, porucznik ca, stanford jb, merrill rm, et al. impact of early and concurrent stunting on cognition. matern child nutr. 2011;7(4):397–409. 12. sokolovic n, selvam s, srinivasan k, thankachan p, kurpad2 a, thomas t. catch-up growth does not associate with cognitive development in indian school-age children. eur j clin nutr. 2014;68(1):14–8. 13. kesari kk, handa r, prasad r. effect of undernutrition on cognitive development of children. int j food sci nutr. 2010;3(2):133–48. 14. walker sp, chang sm, powell ca, simonoff e. early childhood stunting is associated with poor psychological functioning in late adolescence and effect are reduces by psychosocial stimulation. j nutr. 2015;22(1):2464–79 15. azis nra, muzakkir h. faktor risiko gizi buruk pada anak balita. journal of pediatr. nurs. 2014;1(2):63–9. 16. puspitasari fd, sudargo t, gamayanti il. hubungan antara status gizi dan faktor sosiodemografi dengan kemampuan kognitif anak sekolah dasar di daerah endemis gaki. jgi. 2011;1(34):52–60. 17. warsito o, khomsan a, hernawati n, anwar f. relationship between nutritional status, psychosocial stimulation, and cognitive development in preschool children in indonesia. nutr res pract. 2012;6(5):451– 7. 18. tucker-drob em, briley da. continuity of genetic and environmental influences on cognition across the life span: a metaanalysis of longitudinal twin and adoption studies. psychol bull. 2014;140(4):949– 79. 19. schady n. parents’ education, mothers’ vocabulary, and cognitive development in early childhood: longitudinal evidence from ecuador. am j public health. 2011;101(12):2299–307. 20. byrne b, coventry wl, olson rk, samuelsson s, corley r, willcutt eg, et al. genetic and environmental influences on aspects of literacy and language in early childhood: continuity and change from preschool to grade 2. j neurolinguistics. 2009;22(3):219–36. irma suwandi sadikin, leonardo lubis, julistio t. b. djais: short-term memory comparison between stunted and non-stunted groups vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 396 amj september 2017 concentration level differences between athletes of body contact and non-body contact sports nisrina tache,1 leonardo lubis,2 lucky saputra3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine, universitas padjadjaran, 3department of psychiatry faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: concentration is one of the components of cognitive function, which is important for athletes in all sport branches. every branch of sports has their own different characteristics, body contact or nonbody contact, seen from the aspects of game activity that have direct or indirect physical contact, rules of the sports, behavior of the athlete and psychological demands. basically, both sports branches need good level of concentration in order to display their best performance. the study aimed to determine the difference of concentration level between athletes of body contact and non-body contact sports. methods: this study was an analytic observational study with cross-sectional design, conducted in the indonesian national sport committee (komite olahraga nasional indonesia, koni) secretary office in september 2015. primary data were taken using the instrumental concentration test namely grid concentration test. one hundred ninety three athletes were obtained and grouped in body contact (111 athletes) and non-body contact sports (82 athletes). statistical analysis was performed using the nonparametric test of mann-whitney. results: the result showed that the difference in the athlete’s concentration level between body contact and non-body contact sports was not significant (p=0.151). nevertheless, the data collection of this study showed that body contact sports had a better concentration level than non-body contact sports however the data was not statistically significant. conclusions: there is no significant difference in concentration level between athletes of body contact and non-body contact sports. keywords: athlete, concentration level, body contact, non-body contact correspondence: nisrina tache, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: nisrinatachee@gmail.com introduction indonesia has shown glorious achievements in asia and the world level. however, in the last few years, the athlete’s performance in indonesia is far behind the previous achievements, including badminton.1 in past events, indonesia managed to win medals at the singapore and malaysia open. on the other hand, indonesia could not win medals at the indonesia open. it seems ironic, if the country itself does not reach the target. it does not rule out that the possibility of this incident occurred due to factors that disrupted the athlete’s concentration during a match, such as the excessive cheering crowd since the match is held in their own country. it certainly led to the disruption of the athlete’s concentration, resulting in the inability to achieve their best performance. thus, it can be said that concentration may have been one of the factors that influences succession of achievement.2 concentration is the component of cognitive function, which is important for athletes in every sports branch.2 every branch of sports has its own different characteristic, body contact or non-body contact, based on the aspect of game activity that have direct or indirect physical contact, rules of the sports, behavior of the athlete, and psychological demands.3 basically, both sport branches need a good concentration ability to display their best performance.2 yet, until currently, there are no studies on the level of concentration in both sports, even by the indonesian national sport committee (komite olahraga nasional amj. 2017;4(3):396–401 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1188 althea medical journal. 2017;4(3) 397 indonesia, koni). therefore, this study aimed to observe the difference of concentration level between body contact and non-body contact sports among koni west java’s athletes. methods this study was an unpaired analytic comparative categorical study with a crosssectional study design, and was conducted in september 2015 at koni sport center. the study was previously approved by the health research ethics committee, faculty of medicine, universitas padjadjaran, bandung. primary data were collected using the instrumental concentration test namely grid concentration test. population of this study were koni west java’s athletes who lived and practiced in koni west java’s training center for the national sports week (pekan olahraga nasional, pon) xix championship 2016 in bandung. the population sample was 200 athletes. the inclusion criteria were met by 193 athletes who were in good physical condition, based on the examination conducted by koni. meanwhile, 7 athletes who did not pay attention during the test, and did not follow instructions given for the test were excluded from the study. the 193 athletes were grouped in body contact (111 athletes) and non-body contact sports (82 athletes). the sample exceeded the minimum sample of 49 athletes for each group through the unpaired analytic comparative categorical measurement. furthermore, data on sex, age, sports group, and level of concentration of athletes were put into characteristics of subject in this study. sex was categorized as male and female, while age of respondents was divided into groups of teenager aged 12–25 and adult aged 26–45. then, the sports groups were divided into 2 groups: sports with body contact and non-body contact. additionally, concentration levels were divided into 5 groups: excellent (>21), good (16–20), sufficient (11–15), less (6–10), and poor (<5). the variables in this study consisted of body contact and non-body contact sports as independent variables with nominal scale and concentration level as dependent variable with ordinal scale. the instrument used to measure the level of concentration among athletes was grid concentration test adopted from harris and harris5 which had been tested for validity and reliability. the grid concentration test is a measurement tool for testing concentration in the form of tables containing numbers 00–99 randomly. respondents were asked to connect the numbers with a line starting from the smallest number to the next larger number in one minute. an assessment was conducted by calculating the highest score. the score obtained from this test was then categorized. the data used in the calculation of this study were categories of concentration levels between body contact and non-body contact sports. since the data was ordinal scale and the data distribution was not normal, nonparametric mann-whitney hypothesis testing was conducted to compare the unpaired groups. significance of the result was based on the value of p, where p<0.05 indicated significant difference between the two variables. results according to the subject characteristic distributions on sports branches, female dominated with 51% in body contact and 52% in non-body contact sports. furthermore, in terms of age, the two sports branches were dominated by adult 73% in body contact sports and 82% in non-body contact sports. moreover, the level of concentration of both sports branches was dominated by the group of athletes with a level of concentration that fell into the less category, 63% in body contact sports and 60% in non-body contact sports (table 1). the subject characteristic distributions on concentration level showed that all variables, teenager or adult, male or female, as well as body contact and non-body contact sports, dominated the category of less the concentration level. the acquisitions of a good level of concentration are all on the body contact sports with a total of 4 athletes, i.e. in judo and martial arts with 2 athletes each. while in non-body contact sports, there was not one athlete who had good concentration level. in addition, the poor category of concentration level was more in athletes of non-body contact sports as much as 15%, while in athletes of body contact sports was only 6% (table 2). the result of subject characteristic distributions on concentration level showed the difference of concentration level between body contact and non-body contact sports, where sports with body contact was slightly higher than the non-body contact with an average difference (0.49). therefore, due nisrina tache, leonardo lubis, lucky saputra: concentration level differences between athletes of body contact and non-body contact sports althea medical journal. 2017;4(3) 398 amj september 2017 to the value of p>0.05, it can be concluded that there is no significant difference in concentration level between athletes of body contact and non-body contact sports (table 3). discussions sports play a role in maintaining the brain function, increasing brain plasticity and even accelerating their cognitive function.6 it is strengthened by many studies that examined the relationship between sports and cognitive function. most of the studies report positive results between the effect of exercise with cognitive function, either in molecular, cellular, and behavioral.6-8 concentration is defined as focusing on the relevant cues in the environment, maintaining that attention al focus over time, having awareness of the situation and performance errors.2 therefore, concentration is part of the cognitive function and a necessity that every athlete should have. if athletes have a good concentration, the optimal accomplishment will be easily achieved.2 however, result of this study showed that more than half of the sample population consisting of 101 athletes (59%) fell into the less category of concentration level, while athletes who showed good category in concentration level consisted only of 4 athletes (2%). when compared with the non-athlete subjects, it was still higher than the athlete’s. the study conducted by nurcahyono9 in indonesia shows the measurement for concentration ability among 43 vocational school students has a mean of 14.91 that is higher than the athletes in this study (8.18). in fact, the contribution of concentration is significantly affecting the athlete’s performance. a study conducted by mashuda10 on softball athletes in indonesia states that concentration has the highest contribution compared to muscle strength. therefore, it could be concluded that a good concentration is an important factor that every athlete in every sports branch should have.10 according to the type of sports, it is grouped into 2 categories, body contact and non-body contact.11 basically, both sports need a good level of concentration in order to achieve optimal performance.2 however, statistical test results conducted in both categories show the same result of less category level of concentration. even in the non-body contact sports there were none with a good category result, whereas in the body contact sports there were only 4 athletes. moreover, the poor category of concentration level was more in athletes with non-body contact as much as 15%, while the athletes with body contact was only 6%. besides, if viewed from the mean value of concentration level, it indicated that body contact (8.39) had higher result than nonbody contact sports (7.90). based on that, table 1 subject characteristic distributions on sports branch characteristic sports branch body contact (n=111) non-body contact (n=82) age (years) teenager (16 – 25) 30 (27)* 15 (18) adult (26 – 45) 81 (73) 67 (82) sex male 54 (49) 39 (35) female 57 (51) 72 (65) concentration level excellent (>21) 0 (0) 0 (0) good (16-20) 4 (4) 0 (0) sufficient (11-15) 30 (27) 21 (25) less (6-10) 69 (63) 49 (60) poor (<5) 8 (6) 12 (15) note: *) number and percentage althea medical journal. 2017;4(3) 399nisrina tache, leonardo lubis, lucky saputra: concentration level differences between athletes of body contact and non-body contact sports it could be concluded that sports with body contact showed a higher level of concentration compared to sports with non-body contact but the data was not statistically significant. these result contradicted with the theory suggesting there are differences between the two sports level of concentration, whereas the sports with non-body contact showed a higher level of concentration compared to body contact. this was due to the need for a sharper and focused concentration to achieve better results of the target, since the characteristic of this sport is demanding the aspects of precision, accuracy, consistency, and high level of concentration, while body contact sports uses strategies, tactics, aggressiveness, and high courage.3 apart from the characteristics, the nature of the individual or team sports might also affect the ability of the athlete’s concentration. especially in sports with body contact which are usually in teams, and able to mobilize the crowd such as, in football or in basketball. since the number of supporters may cause the atmosphere of the game to become loud and noisy hence disrupt the players to remain concentrated. while non-body contact sports are generally individual sports, which are not drawing much crowd. they have a calmer atmosphere so that the athletes can mentally minimize table 2 subject characteristic distributions on concentration level variable concentration level n good sufficient less poor age (years) teenager (16-25) 45 0(0%) 16 (35.6%) 27 (60%) 2 (4.4%) adult (26-45) 148 4 (2.7%) 35 (23.6%) 91 (61.5%) 18 (12.2%) total 193 4 (2.1%) 51 (26.4%) 118 (61.1%) 20 (10.4%) sex male 93 3 (3.2%) 17 (18.3%) 61 (65.6%) 12 (12.9%) female 100 1 (1%) 34 (34%) 57 (57%) 8 (8%) total 193 4 (2.1%) 51 (26.4%) 118 (61.1%) 20 (10.4%) sports branch body contact judo 20 2 (10%) 8 ( 40% ) 10 (50%) 0 (0%) martial arts 22 2 (9%) 5 (23%) 15 (68%) 0 (0%) taekwondo 14 0 (0%) 4 (29%) 9 (64%) 1 (7%) kempo 31 0 (0%) 10 (32%) 18 (58%) 3(10%) fencing 14 0 (0%) 3 (21.4%) 8 (57.1%) 3 (21.4%) wrestling 4 0 (0%) 0 (0%) 4 (100%) 0 (0%) boxing 6 0 (0%) 0 (0%) 5 (83%) 1 (17%) total 111 4 (4%) 30 (27%) 69 (63%) 8 (6%) non-body contact sports climbing 27 0 (0%) 9 (33%) 13 (48%) 5(19%) athletics 15 0 (0%) 5 (33%) 9 (60%) 1 (7%) gymnastics 15 0 (0%) 4 (25%) 10 (63%) 1 (12%) archery 13 0 (0%) 0 (0%) 13 (100%) 0 (0%) weightlifting and body building 12 0 (0%) 3 (24%) 4 (34%) 5 (42%) total 82 0 (0%) 21 (25%) 49 (60%) 12 (15%) althea medical journal. 2017;4(3) 400 amj september 2017 the dispersion of their concentration.12 moreover, in individual sports; the athlete obtains feedback individually most of the time as opposed to the team sports, in which feedback is mostly presented to the team as a whole. the provided feedback will help boost their confidence which will increase the performance of the athletes. this is discovered in a study conducted by elferink-gemser et al.12 in groningen, who stated the level of concentration in individual sports is higher than in group sports. furthermore, emotion is one of the factors that affect concentration, when emotion goes out of control surely it will interfere the athletes in maintaining their concentration.2,12 the study conducted by sukadiyanto11 in indonesia showed that the emotional reaction for sports with body contact are higher than non-body contact. since in body contact sports athletes are constantly in direct contact with the opponent, resulting in a surge of emotional outburst and preventing athletes for maintaining their concentration. unlike sports with non-body contact, where there is a separator so that there is no direct physical contact with the opponent and if a player violates the separator, it will be counted as a violation. these conditions minimize the appearance of emotional outburst of athletes in non-body contact sports, thus the athletes can fully maintain their concentration without disruption. moreover, the contrary result by the above theory was influenced by several factors such as emotion, physical condition, gender, age, experience and knowledge, including educational level. there are two kinds of emotion, positive and negative. positive emotion includes feelings of pleasure, joy, and passion, while negative emotion includes feelings such as anger, anxiety, and boredom.11 the negative emotion can prevent athletes from maintaining their concentration.2 furthermore, in this study psychological examination was not conducted to assess the psychological state of the athletes whether it is good or bad. second, regarding the physical condition of each individual, who has a different ability of brain function in selecting a number of available information so this affect the ability of individuals for focusing their attention.13 a physically exhausted condition also affects concentration. the study conducted by faber et al.14 founded the effect of fatigue with visual selective attention. the third factor is gender. the study conducted by elferink-gemser et al.12, showed that male has a higher level of concentration than female. while in this study, both sports branches are dominated by female as much as 51.5%. then, the fourth factor is age. in addition, the increase in someone’s age will be followed by growth of the brain, therefore increasing the capability of brain to process information.13 knowledge and experience factors also contribute in the effort of focusing the attention toward unidentified patterns, thus it can be concluded that individual knowledge and experience make athletes easier to maintain their concentration.13 the last factor is the level of education. the higher educational level, the easier for someone to concentrate well.15 therefore, the possibility of negative emotional factor, exhaustion experienced by athletes, such as after physical activities or strenuous physical training, the population is dominated by female, and lack of knowledge and experiences, also low educational level will table 3 descriptive data analysis concentration level sports branch body contact (n=111) non-body contact (n=82) total p-value mean (sd)* 8.39 (3.65) 7.90 (3.41) 8.19 (3.56) 0.151 median 7 7 7 interval (min-max) 15 (3–18) 12 (3–15) 15(3–18) excellent (>21) 0 (0%) 0 (0%) 0(0%) good (16–20) 4 (4%) 0 (0%) 4 (2.1%) sufficient (11–15) 30 (27%) 21 (25%) 51 (26.4%) less (6–10) 69 (63%) 49 (60%) 118 (61.1%) poor (<5) 8 (6%) 12 (15%) 20 (10.4%) notes:*) standard deviation althea medical journal. 2017;4(3) 401 reduce the concentration ability of athletes at the time of the concentration test. however, all these factors have not been explored in more depth. the limitations of this study are the cross-sectional method that only describes the level of concentration at that moment, and the data retrieval time is not homogeneous for each sports branch as it is also taken in the middle of exercise time, ideally, the concentration test should be conducted after one day of free practice. this study concludes that there is no significant difference in the level of concentration between sports with body contact and non-body contact, and shows the state of sufficient and less concentration level in most athletes is extremely concerning. this becomes a specific issue that must be considered, hence, it is worth exploring what causes this condition as well as the solution, and what interventions can solve the problem, because if the concentration is not good it will have an impact on the performance of athletes and may interfere succession of the achievement. moreover, koni have to provide training programs to increase the concentration level among athletes. for further studies, it is necessary to analyze the correlation or interaction between sports types with the ability of concentration, to find out whether body contact and non-body contact sports affect the concentration ability of athletes or not as well as the effect of the level of concentration on the performance of athletes. references 1. sholichah if. pengaruh pelatihan quiet eye training terhadap peningkatan konsentrasi pada atlet bulutangkis. character: jurnal penelitian psikologi.2015;03(3):1–5. 2. karageorghis ci, terry pc. inside sport psychology. 1sted. united states of america: human kinetics publishers; 2011. p.143–168. 3. hermawati, rizki l. profil perilaku sosial atlet cabang olahraga bela diri, cabang olahraga permainan dan cabang olahraga konsentrasi [dissertation]. bandung: universitas pendidikan indonesia; 2014. 4. depkes ri. klasifikasi umur menurut kategori. jakarta: ditjen yankes; 2009. 5. supriyanto a, lismadiana. penggunaan metode hypnotherapi untuk meningkatkan konsentrasi saat start dalam renang. jurnal iptek olahraga. 2013;15(2):111–24. 6. mcmorris t, hale bj. is there an acute exercise-induced physiological/ biochemical threshold which triggers increased speed of cognitive functioning? a meta-analytic investigation. j sport health sci. 2015;4(1):4–13. 7. thomas m. the effect of different movement exercises on cognitive and motor abilities. adv physic educ. 2012;2(4):172–8. 8. hillman ch, erickson ki, kramer af. be smart, exercise your heart: exercise effects on brain and cognition. nat rev neurosci. 2008;9(1):58–65. 9. nurcahyono fh. hubungan antara konsentrasi siswa dengan ketepatan passing bawah dalam permainan bola voli (studi pada siswa kelas x jurusan administrasi perkantoran smk negeri 1 boyolangu tulungagung tahun ajaran 2012/2013). jurnal pendidikan olahraga dan kesehatan. 2014;2(1):259–61. 10. mashuda i, purnomo m. the contribution of concentration, arms muscle strenght, legs muscle strenght and back flexibility in outfield hitting in softball. jurnal prestasi olahraga. 2013;1(1):1–8. 11. sukadiyanto. perbedaan reaksi emosional antara olahragawan body contact dan non-body contact. jurnal psikologi. 2006;33(1):50–62. 12. elferink-gemser mt, visscher c, lemmink kapm. psychological characteristics of talented youth athletes in field hockey, basketball, volleyball, speed skating, and swimming. in: gemser j, gemser pj. today’s talented youth field hockey players, the stars of tomorrow?: a study on talent development in field hockey. groningen: university of groningen; 2005. p. 87–101. 13. wicaksono p. kontribusi konsentrasi terhadap hasil shooting under basket (studi pada atlet putra klub bola basket guardians tuban). jurnal kesehatan olahraga. 2014;2(1):43–50. 14. faber lg, maurits nm, lorist mm. mental fatigue affects visual selective attention. plos one. 2012;7(10):e48073. 15. farooq ms, chaudhry ah, shafiq m, berhanu g. factors affecting student’s quality of academic performance: a case of secondary school level. journal of qualty and technology management. 2011;7(2):01–14. nisrina tache, leonardo lubis, lucky saputra: concentration level differences between athletes of body contact and non-body contact sports althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 148 amj march 2017 characteristics of malignant eyelid basal cell carcinoma in cicendo eye hospital bandung from 2013 to 2015 yee she hui,1 raden angga kartiwa,2 resti gradia dwiwina3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine, universitas padjadjaran/cicendo eye hospital bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: basal cell carcinoma (bcc) has been proved to have the highest incidence among eyelid malignancies. basal cell carcinoma is the most common invasive cancer in humans. it is capable of causing extensive tissue destruction. the aim of the study was to identify the characteristics of adult patients with malignant eyelid bcc in cicendo eye hospital bandung. methods: a descriptive retrospective study was conducted to determine the characteristics of adult patients with malignant eyelid bcc in cicendo eye hospital bandung from march 2013 to october 2015. age and sex distribution of the lesions, location and histopathological results of the tumors were stratified as variables. the inclusion criteria were patients over age of 20, histopathologically diagnosed with periocular bcc. results: a total of 37 cases histopathologically diagnosed with periocular bcc were evaluated. females had a slight predominance. the mean age was 61.7 years. the most common site was on the lower lid. the tumors occurred more on the left side. the most common histological subtype was represented by solid growth pattern. conclusions: the majority of periocular bcc cases occur in females and elderly. most tumors develop on the lower lid with a left-side preference and have a solid growth pattern histologically. [amj.2017;4(1):148– 51] keywords: basal cell carcinoma, characteristics, malignant eyelid tumor correspondence: yee she hui, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281802264493 email: yeeshehui@gmail.com introduction incidence rates of skin cancer have risen dramatically over the last decade. the incidence has increased with decreased latitude and most tumors develop on sun exposed areas of the head and neck. as the earth’s protective ozone shield continues to thin, further increases in the incidence of skin cancer can be predicted.1 approximately 90 percent of skin cancers arise to head and neck and 10 percent from them occur in the eyelids.2 histopathological diagnosis and clinical correlation have been examined in published case reviews. many studies overseas have shown that basal cell carcinoma (bcc) represents the most common malignant eyelid tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma and/or malignant melanoma.2-7 basal cell carcinoma is the most common invasive cancer in humans. it is a slowly enlarging, locally invasive neoplasm arising from epidermal basal cells and is capable of extensive tissue destruction.1,4 therefore, the ability to identify characteristics of the tumor is extremely important. this study focused solely on malignant eyelid bcc in cicendo eye hospital bandung in the period of march 2013 to october 2015. in addition, age and sex distribution of the lesions, location and histopathological results of the tumors were evaluated. methods this study was conducted from october to this study retrospectively reviewed the medical records specific to periocular bcc from march 2013 to october 2015 in cicendo eye hospital bandung. a total sampling method was used for data collection. eligible were patients over althea medical journal. 2017;4(1) 149 20 years of age, histopathologically diagnosed with periocular bcc. exclusion criteria were medical records without histopathological confirmation. patients’ demographics, location and histopathological results of the tumors were collected and recorded. age and sex distribution of the lesions, location and histopathological results of the tumors were then analyzed and tabulated. this study received approval from the health research ethics committee of cicendo eye hospital bandung. results a total of 37 adult patients with periocular bcc histopathologically diagnosed from march 2013 to october 2015 were identified. the distribution related to patients’ characteristics was presented (table 1). related to gender, 19 cases were female and 18 cases were male patients. it was a little preponderance for the female patients. the most common age group affected was between 51–60 years. the mean age of patients group was 61.7 years with range between 26–90-year-old. the distribution related to tumors’ characteristics was presented (table 2). table 1 distribution related to patients’ characteristics patients’ characteristics frequency gender male 18 female 19 age group (years) 21–30 1 31–40 2 41–50 3 51–60 12 61–70 7 71–80 9 81+ 3 table 2 distribution related to tumors’ characteristics tumors’ characteristics frequency periocular region lower lid 18 upper lid 8 medial canthus 0 lateral canthus 1 combined* 4 unspecified 6 side right 7 left 23 unspecified 7 subtype solid 16 pigmented 5 nodular 1 basosquamous 3 combined** 4 unspecified 8 note: * the combined involvements contained two simultaneous involvements of upper and lower lid; simultaneous involvement of upper lid, lower lid, and medial canthus; and simultaneous involvement of lateral canthus and lower lid, ** the combined involvements were all simultaneous involvements of solid and pigmented subtypes. yee she hui, raden angga kartiwa, resti gradia dwiwina: characteristics of malignant eyelid basal cell carcinoma in cicendo eye hospital bandung from 2013 to 2015 althea medical journal. 2017;4(1) 150 amj march 2017 regarding the site of tumors, 18 cases of the tumors were located on the lower lid, followed by 8 cases on the upper lid, and only 1 case on the lateral canthus. there were 4 cases involved more than one region. of the cases, periocular bcc occurred less on the right side and more on the left. the most common histological subtype was represented by solid growth pattern, accounting for 16 cases. pigmented bcc was identified in 5 cases, followed by basosquamous with 3 cases and nodular with only 1 case. there were 4 cases consisting of more than one subtype. discussion there is a significant consideration in this study in which data are retrieved from the pathology logs of cicendo eye hospital bandung due to limitations in medical records of bcc. nevertheless, this study still shows a compelling overview of data that is important for ophthalmologist and other physicians. in this study, the incidence of bcc is more predominant in females than males. this finding is in contrast to other studies which have been conducted in other countries.2,5 for example, in a retrospective study carried out in san francisco, the data demonstrated a significant difference in number of men diagnosed over women with bcc.5 in addition, in another study carried out in oradea, demonstrated an equal male over female distribution.2 solid reasons for bcc having slight predominance for the females are unable to be predicted. this may be associated with the higher use of sunscreen by women in developed countries comparing to women in developing countries, which resulting in this dissimilarity finding. however, both of these studies had a patient’s mean age of over 60, which were highly consistent with the mean age of 61.7 years in our study.2,5 thus, we can conclude that, an older age can be a solid contributing factor to the development of bcc of the eyelids. in agreement with other studies, the majority of bcc are located on the lower lid.6,8 this statement can be affirmed in accordance with a retrospective study carried out in australia for a period of seven years (2006 to 2012) which have discovered bcc occurring more frequently on the lower lid.6 an early study in central india also demonstrated similar finding.8 while studies reported from australia and israel revealed bcc tend to have leftor right-side preferences due to greater sun exposure on that side during driving, our study has shown an inconsistent outcome.6,9 this phenomenon may be explained by the vehicle composition in indonesian cities with a threefold proportion of motorcycles than cars.10 histologically, the most common subtype is represented by solid growth pattern. this finding is particularly constant with previous study in oradea while interestingly, most other studies describing nodular bcc as the most common histological type.2,6,9,11 there are limitations in this study where this study may not represent the entire bandung population. nonetheless, this study provides a compelling overview of bcc as a basis of upcoming research and essential information for physicians and the community. in conclusion, there is slight preponderance for the females in periocular bcc. most of the patients are older. additionally, the most common site of tumors is on the lower lid. the tumors show left-side preference. lastly, the most common bcc histological subtype occurring in the periocular region is represented by solid growth pattern. this study may increase the awareness of periocular bcc among medical professionals and the community and aids in early diagnosis which favors a better prognosis. references 1. longo d, fauci a, kasper d, hauser s, editors. harrison’s principles of internal medicine. 18thed. new york: mcgraw-hill professional; 2011. 2. coroi mc, roşca e, muţiu g, coroi t, bonta m. eyelid tumors: histopathological and clinical study performed in county hospital of oradea between 2000–2007. rom j morpholembryol. 2010;51(1):111– 5. 3. bagheri a, tavakoli m, kanaani a, zavareh rb, esfandiari h, aletaha m, et al. eyelid masses: a 10-year survey from a tertiary eye hospital in tehran. middle east afr jophthalmol. 2013;20(3):187–92. 4. hussain i, khan fm, alam m, khan bs. clinicopathological analysis of malignant eyelid tumours in north-west pakistan. j pak med assoc. 2013;63(1):25–7. 5. paul s, vo dt, silkiss rz. malignant and benign eyelid lesions in san francisco: study of a diverse urban population. am j clin med. 2011;8(1):40–6. 6. wu a, sun mt, huilgol sc, madge s, selva d. histological subtypes of periocular basal cell carcinoma. j clin exp ophthalmol. 2014;42(7):603–7. althea medical journal. 2017;4(1) 151yee she hui, raden angga kartiwa, resti gradia dwiwina: characteristics of malignant eyelid basal cell carcinoma in cicendo eye hospital bandung from 2013 to 2015 7. pombejara fn, tulvatana w, pungpapong k. malignant tumors of the eye and ocular adnexa in thailand: a six-year review at king chulalongkorn memorial hospital. asian biomed (res rev news). 2010;3(5):551–5. 8. jahagirdar ss, thakre tp, kale sm, kulkarni h, mamtani m. a clinicopathological study of eyelid malignancies from central india. indian j ophthalmol. 2007;55(2):109–12. 9. ben simon gj, lukovetsky s, lavinsky f, rosen n, rosner m. histological and clinical features of primary and recurrent periocular basal cell carcinoma. isrn ophthalmol. 2012;2012:1–5. 10. putranto ls, prasetijo j, eka nlps, editors. vehicle composition in indonesia and malaysia. proceedings of the eastern asia society for transportation studies. 2013;9. 11. ho s, brown l, bamford m, sampath r, burns j. 5 years review of periocular basal cell carcinoma and proposed follow-up protocol. eye. 2013;27(1):78–83. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 30 amj march 2017 comorbidities of chronic obstructive pulmonary disease patients at respirology and critical care outpatient clinic dr. hasan sadikin general hospital, bandung, indonesia adrian sebastian suhendro,1 prayudi santoso,2 silvita fitri riswari,3 primal sudjana2 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of microbiology and parasitology faculty of medicine universitas padjadjaran abstract background: chronic obstructive pulmonary disease (copd) is a chronic disease that becomes one of the leading causes of death in the world. the copd is usually accompanied by comorbidities that impact prognosis and increase patients’ expenses. however, the comorbidities of copd patients have not yet to be known in dr. hasan sadikin general hospital, bandung, indonesia. this study was aimed to determine the frequency, type and number of comorbidities accompanying copd. methods: this study was a retrospective, cross-sectional study at the respirology and critical care outpatient clinic of dr. hasan sadikin general hospital, bandung, indonesia in 2012. data were obtained from medical records of patients diagnosed with copd and had an obstructive pulmonary function test result. sampling technique in this study was total sampling. data were classified by age, gender, smoking history and severity of disease and were analyzed to determine the frequency, type and number of comorbidities accompanying copd. results: thirty eight copd patients with obstructive pulmonary function test results were analyzed. it consists of 31 males and 7 females with age ranged between 43–82 years and median age of 64 years. severe obstruction was found in 15 of 38 patients. comorbidities were found in 26 patients, and 2 patients had up to four comorbidities. the most common comorbidity was hypertension (9 of 38). conclusions: the majority of copd patients had comorbidities and the most frequent comorbidity was hypertension. [amj. 2017;4(1):30–5] keywords: chronic disease, chronic obstructive pulmonary disease (copd), comorbidities correspondence: adrian sebastian suhendro, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281321119225 email: adriansebastiansuhendro@gmail.com introduction chronic obstructive pulmonary disease (copd) is a chronic disease that is characterized by persistent airway limitation due to chronic inflammatory response in airway and lungs caused by hazardous particle or gas.1 diagnosis of copd is usually made on the basis of medical history taking, physical examination, and results from pulmonary function test.2 worldwide, the prevalence of copd is 4–10% of all population.3,4 the world health organization (who) has ranked copd as the fourth leading cause of death.5 the prevalence of copd in asia pacific is estimated about 6.3% of all population.6 the copd is mostly accompanied by comorbidities that can impact patients’ prognosis, change the effectiveness of copd therapy, cause potentially dangerous therapeutic interactions and increase patients’ expenses in treating the disease.2,7-9 the definition of comorbidity is the presence of one or more diseases or health conditions in an individual at a given time.10 comorbidity is different from complication. comorbidity can occur regardless of copd, having the same cause(s), or sharing the same risk factors.7,8 it has been shown that 96.4% copd patients had one or more comorbidities.9 cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression and lung cancer are the most common comorbidities in althea medical journal. 2017;4(1) 31 copd patients.7 the exact mechanism linking copd and comorbidities is not yet known.11 a study by barnes11 and boschetto et al.12 suggested systemic inflammation as the linking mechanism. patients with copd have a peripheral lung inflammation which may ‘spill over’ to systemic circulation and cause an increase of acute-phase proteins (c-reactive protein and serum amyloid a (saa)) and circulating cytokines (interleukin (il)-1β, il6, il-18, and tumor necrosis factor (tnf)-α). smoking is the most important risk factor of copd.7 according to who, indonesia is ranked fourth in the total number of smokers in the world, third in total number of men smokers and seventeenth for women smokers.13 according to the national basic health research 2010 (riset kesehatan dasar/riskesdas 2010), the percentage of population aged >15 years who smoke every day was 28.2%.14 west java ranked twelfth for the prevalence of smokers in indonesia.14 dr. hasan sadikin general hospital is the provincial referral hospital of west java and it manages a large amount of copd patients. however, the comorbidities of copd patients in this hospital have not yet to be known. this study aimed to determine the frequency, type and number of comorbidities accompanied in copd patients. methods the study was a retrospective, cross-sectional study carried out in the respirology and critical care outpatient clinic of dr. hasan sadikin general hospital, bandung, indonesia. the total sampling method was done to copd patients’ medical records at respirology and critical care outpatient clinic of dr. hasan sadikin general hospital in january–december 2012. patients with obstructive pulmonary function test results in the medical record were included in this study while patients with no pulmonary function test result or test result stated the pulmonary function as ‘restrictive’ or ‘normal’ were excluded. this study was approved by health research ethics committee of the faculty of medicine, adrian sebastian suhendro, prayudi santoso, silvita fitri riswari, primal sudjana: comorbidities of chronic obstructive pulmonary disease patients at respirology and critical care outpatient clinic dr. hasan sadikin general hospital, bandung, indonesia table 1 respondents characteristic variable copd with comorbidities (n=26) copd without comorbidities (n=12) total (n=38) sex male 22 9 31 female 4 3 7 age (median(range)) 64 (43–82) 59 (43–82) 67 (43–77) age (years old) ≤60 13 2 15 61–70 4 6 10 71–80 6 4 10 ≥81 3 0 3 smoking history smokers 8 4 12 non smokers 0 0 0 unknown 18 8 26 severity of disease gold 1 1 1 2 gold 2 10 4 14 gold 3 11 4 15 gold 4 4 3 7 althea medical journal. 2017;4(1) 32 amj march 2017 universitas padjadjaran and dr. hasan sadikin general hospital, bandung, indonesia. data were analyzed using microsoft office excel 2010. data were classified by age, gender, smoking history and severity of disease. severity of disease was determined by using global initiative for chronic obstructive lung disease (gold) classification.7 comorbidity was defined as other medical conditions occurred in subjects except pulmonary hypertension as a complication of copd. we described the frequency of comorbidities in copd cases, as well as the type and number of comorbidities accompanying copd in each subject. results thirty eight copd patients with obstructive pulmonary function test results were analyzed (table 1). they consist of 31 males and 7 females, with age ranged between 43–82 years and median age of 64 years. severe obstruction is the most common pulmonary function test results found in subjects (15 subjects). twelve patients have a history of cigarette smoking while smoking history is unknown in 26 remaining subjects. of all copd patients, 26 had at least one comorbidity (table 2) while two of them have four comorbidities. comorbidities that frequently occurred among copd patients were hypertension (9 of 38), coronary artery disease (5 of 38), heart failure (5 of 38), anemia (4 of 38) and benign prostate hyperplasia (3 of 38) (table 3). discussion this study found 26 of 38 copd patients at a referral hospital having comorbidities, lower than the ones that found in family practice obtained from cross-sectional study using data from national health and nutrition examination survey of usa in 1999–2008 (96.4%) or a study by fumagalli et al.15 (94.1%).8,9 apart from the differences in study location and potential risk factors, our small simple size may explain this difference. this study found more male copd patients (31 of 38 subjects). this is similar to the national survey which found copd prevalence in male (5.3%) to be greater than female (1.4%).8 same results are shown in the studies by almagro et al.16 (353 of 398 subjects) and yamasaki et al.4 (462 of 608 subjects). one explanation may be that cigarette smoking as a risk factor of copd is more common in male than female. according to who, 67.4% men and 4.5% women in indonesia are active smokers.13 most copd patients found in our study aged 60 or younger. it is younger than that found by almagro et al.16 where the copd patients aged between 70–80 years old. it might be due to the fact that we recruited patients’ medical records at an outpatient while the other study at an inpatient clinic. despite the age difference, the severity of pulmonary obstruction found in our study is similar to that of the study by almagro et al.16 at gold 3. while a study by yamasaki et al.4 at the tottori university hospital, japan, had copd patients with gold 1 as the most frequent patients’ severity. obstruction in copd patient can be caused by ‘small airway disease’ such as airway inflammation, airway fibrosis, luminal plugs, or increased airway resistance, and parenchymal destruction, such as loss of alveolar attachments or decrease of elastic recoil.7 copd exacerbation can also affect the severity of illness by decelerating the rate of lung function.7 the type of comorbidities that frequently occurred in this study was hypertension, as corroborated by other studies except a study by ekstrom et al.17 in sweden where heart failure is the most common comorbidity.8,9,15,16 contractively, the swedish national oxygen register, as explained in their paper, found a high table 2 number of comorbidities suffered by one subject comorbidity n copd only (or ‘none’) 12 copd + 1 or more 26 copd + 2 or more 18 copd + 3 or more 10 copd + 4 2 althea medical journal. 2017;4(1) 33adrian sebastian suhendro, prayudi santoso, silvita fitri riswari, primal sudjana: comorbidities of chronic obstructive pulmonary disease patients at respirology and critical care outpatient clinic dr. hasan sadikin general hospital, bandung, indonesia sensitivity and specificity for cardiovascular disease but low sensitivity for less serious and less acute condition such as hypertension.17 the exact mechanism linking hypertension and copd has not yet known. hypertension in copd is probably due to smoking and old age as the sharing risk factor.8,12,15 also, hypertension could happen because of increased arterial stiffness.15 another study said that arterial stiffness occur frequently in copd patients due to systemic inflammation.10 furthermore, hypertension could happened because of insulin resistance which related with chronic systemic inflammation.18 almagro et al.16 in his study once said that there was a different distribution of comorbidities in male and female copd patients. in this study, hypertension is commonly found in male subjects. it is contrary to garcia-olmos et al.8, almagro et al.16, and ekstrom et al.17 study which said that hypertension as the comorbidity of copd is table 3 type of comorbidities comorbidities male female total (n= 31) (n=7) hypertension 8 1 9 coronary artery disease 5 0 5 heart failure 5 0 5 anemia 3 1 4 benign prostate hyperplasia 3 0 3 diabetes mellitus 2 0 2 diabetes mellitus with diabetic neuropathy 2 0 2 hypertensive heart disease 2 0 2 inguinal hernia 2 0 2 pulmonary tuberculosis 2 0 2 asthma 0 1 1 breast cancer 0 1 1 bronchiectasis 1 0 1 cirrhosis 1 0 1 community acquired pneumonia 0 1 1 dilated cardiomyopathy 0 1 1 diverticulitis 1 0 1 dyspepsia 1 0 1 epulis fibromatosa 1 0 1 grave’s disease with thyrotoxicosis 1 0 1 hospital-community acquired pneumonia 1 0 1 hemorrhoid 1 0 1 liver cancer 1 0 1 peptic ulcer 0 1 1 rectal cancer 0 1 1 stroke sequelle 1 0 1 thyroid heart disease 1 0 1 vesiculolithiasis 1 0 1 althea medical journal. 2017;4(1) 34 amj march 2017 commonly occurred in female. this might be related to tobacco smoking, as the sharing risk factor of copd and hypertension, which more frequent in male than female in indonesia.13 this difference of study result might happen due to different location of study which influences different culture and smoking behavior, particularly in female. according to who, prevalence of female smoker in developed country (22%) are more than prevalence of female smoker in developing country (9%). few cases of diabetes mellitus were found in this study (5.26%). in addition, we could not found skeletal muscle dysfunction, osteoporosis, depression, and lung cancer as comorbidities in copd patients. it is contrary to gold publication and boschetto et al.12 study which said that besides cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome osteoporosis, depression, and lung cancer are the most common comorbidities found in copd patients.7 this might be happened because copd patients that came to respirology and critical care outpatient clinic of dr. hasan sadikin general hospital did not get bone mass density (bmd) test as osteoporosis marker and mental health detection to screen depression. patients with lung cancer may found in inpatient instead of outpatient facilities. this study constraint is time and resources, the lack of information found in medical records, which resulted in several missing characteristics data. furthermore, the onset of comorbidity in copd patients is unknown in conclusions, our study revealed high frequency of comorbidities in copd patients and gives information that hypertension, coronary artery disease, and heart failure were the most frequent comorbidities which are found in copd patients admitted to respirology and critical care outpatient clinic of dr. hasan sadikin general hospital in 2012. in addition, due to the comorbidity which often occurs on the copd patients, it is suggested that physician examine the comorbidity, primarily the most often occurred one, such as hypertension, coronary artery disease, and heart failure, to enhance the quality of health services. references 1. soeroto ay. penyakit paru obstruktif kronis. in: dahlan z, amin z, soeroto ay, editors. kompendium tatalaksana penyakit respirasi & kritis paru: perhimpunan respirologi indonesia; 2012. p. 31–42. 2. menzin j, boulanger l, marton j, guadagno l, dastani h, dirani r, et al. the economic burden of chronic obstructive pulmonary disease (copd) in a u.s. medicare population. respir med. 2008;102(9):1248–56. 3. senior r, atkinson j. chronic obstructive pulmonary disease: epidemiology, pathophysiology, and pathogenesis. in: fishman a, elias j, fishman j, grippi m, senior r, pack a, editors. fishman’s pulmonary diseases and disorders. 4th ed. new york: mcgraw-hill education; 2008. p. 707–27. 4. yamasaki a, hashimoto k, hasegawa y, okazaki r, yamamura m, harada t. copd is frequent in conditions of comorbidity in patients treated with various diseases in a university hospital. int j chron obstruct pulmon dis. 2010;5:351–5. 5. salvi ss, manap r, beasley r. understanding the true burden of copd: the epidemiological challenges. prim care respir j. 2012;21(3):249–51. 6. tan wc, ng tp. copd in asia: where east meets west. chest. 2008;133(2):517–27. 7. global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, global initiative for chronic obstructive lung disease (gold). 2013 [cited 2013 september 25]. available from: http:// www.goldcopd.org/. 8. garcia-olmos l, alberquilla a, ayala v, garcia-sagredo p, morales l, carmona m, et al. comorbidity in patients with chronic obstructive pulmonary disease in family practice: a cross sectional study. bmc fam pract. 2013;14:11. 9. schnell k, weiss co, lee t, krishnan ja, leff b, wolff jl, et al. the prevalence of clinically-relevant comorbid conditions in patients with physician-diagnosed copd: a cross-sectional study using data from nhanes 1999–2008. bmc pulm med. 2012;12:26. 10. wouters efm, celis mpm, breyer mk, rutten epa, graat-verboom l, spruit ma. co-morbid manifestation in copd. respir med: copd update. 2007;3(4):135–51. 11. barnes pj. chronic obstructive pulmonary disease: effects beyond the lungs. plos medicine. 2010;7(3):e1000220. 12. boschetto p, beghe b, fabbri lm, ceconi c. link between chronic obstructive pulmonary disease and coronary artery althea medical journal. 2017;4(1) 35 disease: implication for clinical practice. respirology. 2012;17(3):422–31. 13. who. global adult tobacco survey: indonesian report 2011[cited 2014 january 7]. available from: www.searo. w h o . i n t / e n t i t y / t o b a c c o / d a t a / g a t s _ indonesia_2011.pdf. 14. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar (riskesdas 2010). 2010 [cited 2013 november 14]. available from: http://www.litbang.depkes.go.id/ sites/download/buku_laporan/lapnas_ riskesdas2010/laporan_riskesdas_2010. pdf. 15. fumagalli g, fabiani f, forte s, napolitano m, marinelli p, palange p, et al. indaco project: a pilot study on incidence of comorbidities in copd patients referred to pneumology units. multidiscip respir med. 2013;8(1):28. 16. almagro p, lopez garcia f, cabrera f, montero l, morchon d, diez j, et al. comorbidity and gender-related differences in patients hospitalized for copd. the ecco study. respir med. 2010;104(2):253–9. 17. ekstrom mp, jogreus c, strom ke. comorbidity and sex-related differences in mortality in oxygen-dependent chronic obstructive pulmonary disease. plos one. 2012;7(4):e35806. 18. fabbri lm, luppi f, beghe b, rabe kf. complex chronic comorbidities of copd. eur respir j. 2008;31(1):204–12. adrian sebastian suhendro, prayudi santoso, silvita fitri riswari, primal sudjana: comorbidities of chronic obstructive pulmonary disease patients at respirology and critical care outpatient clinic dr. hasan sadikin general hospital, bandung, indonesia vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 107 the impact of nutritional counseling to nutritional knowledge and energy intake among obese children in junior high school lastri asmuniati,1 dewi marhaeni diah herawati,2 julistio t. b. djais3 1faculty of medicine universitas padjadjaran, indonesia,2department of public health faculty of medicine universitas padjadjaran, indonesia, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: lastri asmuniati, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang. e-mail: asmuniatilastri@gmail.com amj. 2019;6(3):107–9 abstract background: obesity has a serious impact on health, leading to not only premature mortality but also to long-term morbidity. factors that contribute to obesity are genetic and lifestyle. this study aimed to analyze the impact of nutritional counseling on nutritional knowledge and energy intake among obese children in junior high school. methods: this quasi-experimental study was conducted in jatinangor in september–november 2014 using a consecutive sampling until 25 students had reached. the inclusion criteria were junior high school students with bmi z-score per age >2 obese categories. nutritional knowledge and energy intake were measured using a 24-hour recall test, conducted before and after 2 weeks of nutritional counseling. data were analyzed using a paired t-test. results: the average of nutritional knowledge before counseling was 46.72±2.63 and after counseling was 65.92±2.92 (p<0.001), whereas the average in energy intake before counseling was 1769.68±113.32 and after counseling was 1397.52±114.31 (p=0.006). conclusions: there is an increase knowledge and decrease energy intake among obese children in junior high school students in jatinangor subdistrict after nutritional counseling. a better understanding among obese children needs to be highlighted and nutrition education and counseling should be given in schools. keywords: energy intake, counseling, nutrition, obesity introduction obesity is an excess of adipose tissue mass fat in the body, leading to health impairment.1 obesity is a global problem that occurs in all age including childhood, adolescence, or adulthood. this condition has a serious impact on health, leading to not only premature mortality but may cause long-term morbidity such as diabetes, ischemic heart disease, cancer, and psychological problem.2 obesity might be caused by an excess energy intake or a lack of energy expenditure or both; and influenced by genetic factor and environmental factors such as lifestyle, physical activity, nutrition, and socioeconomic factor.1 for the last thirty years, the prevalence of obesity is increased gradually. it is estimated that more than 170 million children are obese globally.2 the prevalence of obesity in indonesia in 2007 is 12%, and increased to 14% in 2010.3 national data shows that the highest prevalence of obesity is in children of age category of 6–12 years old, followed by age category of 13–15 years old.3 in our region jatinangor, there is a shift from rural to urban; from the agricultural sector to the university area.4 this shift has led to a change of lifestyle in the communities that may play a role in obesity, including a changing in food intake in children in general and in obese children in particular, leading to an increased prevalence of obesity in the area. therefore, we were interested in researching the impact of nutritional counseling on nutritional knowledge and the energy intake in obese althea medical journal. 2019;6(3) 108 amj september 2019 children junior high school in the area of the jatinangor subdistrict. methods this was a quasi-experimental study, involving students from 4 junior high schools in jatinangor subdistrict. this study was conducted from september to november 2014. participants were selected by consecutive probability sampling, with a total of 25 participants. the inclusion criteria were obese students with z-score who bmi per age >2 obese categories who were not on diet restriction program, healthy, willing to participate in the study and signing in the informed consent form. the weight and height were measured and described in the z-score who bmi per age. the score of >2 to 3 was designated as obese, and >3 as very obese. the nutritional knowledge and 24-hour recall for energy intake questionnaires were asked before and after nutritional counseling, using an instrument. the post-test was performed 2 weeks after nutritional counseling. data were collected and analyzed statistically using paired t-test (spss 15.0), comparing the result of nutritional knowledge and energy intake before and after nutritional counseling. the result of the study was statistically significant if the p-value <0.05. results of twenty-five students aged 12–15 years old with obese included, girls were predominant (15 of 25; 60%) in the study. the distribution of students with obesity in this study was depicted in table 1, based on gender and obesity categories. the mean of nutritional knowledge was 46.72±2.63 and 69.92±2.92 before and after nutritional counseling, respectively, showed that there was a significant increased (p<0.001) in knowledge after a session of nutritional counseling. similarly, the energy intake before counseling was 1769.68±113.32 and after table 1 the distribution of students with obesity based on gender and obesity category variable total (n=25) gender male 10 female 15 obesity category obese (>2 to 3) 11 very obese (>3) 14 note: the obesity category according to z-score who bmi per age table 2 the nutritional knowledge and the energy intake before and after nutritional counseling nutritional counseling p-value before after knowledge 46.72±2.63 65.92±2.92 <0.001 energy intake 1769.68±113.32 1397.52±114.31 0.006 was 1397.52±114.31 which was significantly decreased (p<0.006) after counseling. discussion children with obesity have a serious impact on health in a medium-term and also in the long term, resulting in a greater risk factor for the occurrence of cardiovascular disease for about 70 percent. obese children are more likely to have pre-diabetes, the problem in bones and joints, shortness of breath during sleep, social and psychological problems, such as stigmatization and declining selfconfidence.5,6,7 moreover, in the long term, these obese children are most likely will later become obese in adulthood and also have a higher risk factor for the occurrence of cancer.8,9 prevention of obesity complications requires behavioral changes especially food intake and physical activity. in this study, we provided data about the effect of counseling to change the energy intake in lifestyle and nutritional knowledge. counseling could develop trust and build a good relationship between respondents of clients and counselor as such a study requires a considerable time and high intensity of conversation with the clients. althea medical journal. 2019;6(3) 109 our result has shown that nutritional counseling has increased the nutritional knowledge (p<0.001), confirming that nutritional counseling has a good impact on knowledge as shown in a study conducted in finlandia.10 as for the energy intake after nutritional counseling, there is a reduced intake (p<0.006) showing that not only knowledge is increased but the intake is reduced conforming to the action of awareness and knowledge. lower energy intake may in turn continually decrease bmi in obese children, as reported in a study showing an impact in decreasing bmi in obese individuals.11 as reported, most obese children is in girls similar to our study. interestingly, a study in italy has observed a change of knowledge after nutritional education with kalèdo’s game methods in junior high school for 24 weeks.12 study on younger students has been successfully achieved in finland including children aged 7 to 9 years old,10 making that such a study might be double in indonesia. the limitation of this study was a time limit to observe changes energy intake in students after counseling. ideally, the measurement of dietary intake changes may take place a minimal 12 weeks after intervention.13 however, in only 2 weeks, there is already increasing in the energy intake that may, in turn, become a habit to lower the intake due to higher nutritional knowledge. to conclude, after nutritional counseling there is an increased knowledge and decrease energy intake among obese children in junior high school students in the jatinangor subdistrict. a better understanding among obese children starting at young age needs to be highlighted and nutrition education and counseling should be given in schools. references 1. spruitz-metz d. etiology, treatment and prevention of obesity in childhood and adolescence: a decade in review. j res adolesc. 2011; 21(1):129−52 2. who. population-based approaches to childhood obesity prevention. geneva: who press; 2012. 3. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar nasional. jakarta : kementerian kesehatan republik indonesia; 2010. 4. bappeda kabupaten sumedang. laporan akhir studi kelayakan kawasan jatinangor sebagai kawasan perkotaan. sumedang: bappeda kabupaten sumedang; 2009. 5. freedman ds, mei z, srinivasan sr, berenson gs, dietz wh. cardiovascular risk factors and excess adiposity among overweight children and adolescents: the bogalusa heart study. j pediatr. 2007;150(1):12−7. 6. daniels sr, arnett dk, eckel rh, gidding ss, hayman ll, kumanyika s, et al. overweight in children and adolescents: p a t h o p h y s i o l o g y , c o n s e q u e n c e s , prevention, and treatment. circulation. 2005;111(15):1999−2012. 7. li c, ford es, zhao g, mokdad ah. prevalence of pre-diabetes and its association with clustering of cardiometabolic risk factors and hyperinsulinemia among u.s. adolescents. diabetes care. 2009;32(2):342−7. 8. freedman ds, khan lk, serdula mk, dietz wh, srinivasan sr, berenson gs. the relation of childhood bmi to adult adiposity: the bogalusa heart study. pediatrics. 2005;115(1):22−7. 9. kushi lh, doyle c, mccullough m, rock cl, demark-wahnefried w, bandera ev, et al. american cancer society guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. ca cancer j clin. 2012;62(1):30−67. 10. rasanen m, niinikoski h, keskinen s, heino t, lagstrom h, simell o, et al. impact of nutrition counselling on nutrition knowledge and nutrient intake of 7to 9-y-old children in an atherosclerosis prevention project. eur j clin nutr. 2004;58(1):162−72. 11. cassani rsl cunha sfc, freitas alg, nonino cb, marchini js. effects of nutritional counseling on the anthropometric and biochemical nutritional data of obese workers: a randomized blind study. universal journal of clinical medicine. 2013;1(1):6−12. 12. amaro s, viggiano a, di costanzo a, madeo i, viggiano a, baccari me, et al. kalèdo, a new educational board-game, gives nutritional rudiments and encourages healthy eating in children: a pilot cluster randomized trial. eur j pediatr. 2006;165(9):630−5. 13. brown t, summerbell c. systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity. the national institute for health and clinical excellence. 2009;10(1):110−41. lastri asmuniati et al.: the impact of nutritional counseling to nutritional knowledge and energy intake among obese children in junior high school vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 161 relationship between diet, cosmetics and degree of acne vulgaris in dermatovenereology outpatients at dr. soetomo general hospital, surabaya mah zhook yueng,1 diah mira indramaya,2 arifa mustika3 1faculty of medicine universitas airlangga surabaya, indonesia, 2department of dermatology and venereology faculty of medicine universitas airlangga/dr. soetomo general hospital surabaya, indonesia, 3department of pharmacology faculty of medicine universitas airlangga surabaya, indonesia correspondence: mah zhook yueng, faculty of medicine universitas airlangga, jl. professor dr. mustopo no.47, pacar kembang, jawa timur, indonesia, email: zhookyueng_1995@hotmail.com introduction acne vulgaris (av) is a chronic obstructive and inflammatory dermatoses, seen mainly in adolescent and involves the sebaceous follicle. scarring and pigmentation might be caused by the characteristic lesions such as open (black) and closed (white) comedones, inflammatory papules, pustules, nodules and cysts.1 acne vulgaris is a condition which is caused by multiple factors. however, the pathogenic factors involved are revolved around the interaction between follicular hyperkeratinisation, colonization of p. acnes, increased sebum production and inflammation. the factors that will cause acne vulgaris includes, hormonal, genetics, diet, stress, cosmetics etc.1 lately, dietary factors such as insulin resistance and dietary carbohydrates have been associated with the etiology of acne. some people believe chocolate and oily foods are the culprit of getting acne. milk is also commonly associated with the occurrence of acne. many recent studies investigate the role of diet as the cause of acne vulgaris. a few studies were carried out to support the hypothesis that high glycemic index (gi) diet and dairy products are related to this skin condition. however, the effects of diet on acne are still controversial. other than diet, cosmetics which is widely used especially among generation y and z is also one of the factors that will influence the occurrence of acne vulgaris. some cosmetic products that increase the risk of whiteheads amj. 2018;5(4):161–7 abstract background: acne vulgaris (av) is a chronic inflammatory multifactorial disease that involves the pilosebaceous unit. the lesions of acne may be either non-inflammatory (comedones, which are blackheads or whiteheads) or inflammatory lesions (papules, nodules or pustules). the effects of diet and cosmetics on acne are still inconclusive. the objective of this study was to analyse the relationship between diet, cosmetics and the degree of av. methods: this was a hospital-based, analytic observational study with cross-sectional design. the subjects were patients from the outpatient clinic of dermatovenereology department of dr. soetomo general hospital. the questionnaire was filled by the respondents and the degree of av was graded by the specialist. results: among the types of diet, white bread (p=0.039), chocolate (p=0.044) and oily food (p=0.013) are significantly associated with the degree of av. however, white rice, potatoes and milk were insignificantly related to degree of av (p>0.05). no significant association was found in cosmetics (cleanser, moisturizer, facial protection, exfoliators and decorative cosmetics) with the degree of av (p>0.05). conclusions: the factors that have an influence on the degree of av are white bread, chocolate and oily food intake. keywords: acne vulgaris, cosmetics, degree of acne, diet, multifactorial disease althea medical journal. 2018;5(4) 162 amj december 2018 and blackheads occurrences are known as comedogenic. when the inducing ingredient gets into the hair follicles and pores, it will clog them up and leads to sebaceous gland blockage due to the excess oil within the content of the product.2 yet, usage of oil-free concealers, noncomedogenic makeup can enhance the quality of life of individuals and does not make the condition worse.3 removing excessive oil or dirt from the face can be done by cleansing the face. nevertheless, washing frequently to remove excessive oil is ineffective as it aggravates the sebaceous gland and causes oiliness to rebound. moreover, using exfoliators and scrubbing can also irritate the sebaceous gland and leads to trauma which worsens the condition of acne.4 information on diet and cosmetics influence the degree of acne vulgaris which is important for the management of the skin condition and education for the community to prevent and recover from the acne condition. hence, this table 1 characteristics of respondents characteristics of respondents no. of respondents % age (years) ≤16 (early adolescent) 6 14.3 17-25 (late adolescent) 31 73.8 26-35 (early adult) 3 7.1 36-45 (late adult) 2 4.8 sex female 38 90.5 male 4 9.5 marital status not married 36 85.7 married 6 14.3 educational status junior high school 6 14.3 senior high school 17 40.5 university 19 45.2 occupation student 27 64.3 housewife 3 7.1 private sector 8 19.0 others 4 9.5 total 42 100 study was aimed to analyse the relationship between diet, cosmetics and the degree of acne vulgaris. methods this study was an analytic observational, cross-sectional study carried out at the dermatovenereology outpatient clinic of dr. soetomo general hospital, surabaya during march–july 2018. the ethical clearance of this study was issued by the health research ethics committee of dr. soetomo general hospital, surabaya. respondents were selected using the random sampling method and 42 respondents were included in this study. the respondents were interviewed using a structured questionnaire after obtaining their informed consent. the types of food investigated were white bread, white rice, potatoes, chocolate, oily food and milk. the frequency of food consumption was recorded althea medical journal. 2018;5(4) 163mah zhook yueng, diah mira indramaya, arifa mustika: relationship between diet, cosmetics and degree of acne vulgaris in dermatovenereology outpatients at dr. soetomo general hospital, surabaya after being divided into five categories, namely ‘none’, ‘less than 4 times/month’, ‘1 time/ week’, ‘2-4 times/week’ and ‘5-7 times/week’. cosmetics were categorized as cleansers, moisturizers, facial protection, exfoliators and decorative cosmetics. usage of all five types of cosmetics were recorded in this study, respondents answered ‘yes’ if they use the products and answered ‘no’ if they do not use it. frequency of face wash was recorded after being grouped into ‘none’, ‘1-2 times/day’ and ‘more than 3 times/day’. frequency of applying decorative cosmetics was recorded after being classified into 5 groups, which is ‘none’, ‘only on special occasions’, ‘1 time/week’, ‘2-4 times/week’ and ‘5-7 times/week’. the type of cleansers, moisturizers, and decorative cosmetics were also recorded in this study. part one and part two of baumann skin type indicator had been translated into the indonesian language and were included in the questionnaire to study the relation of skin type and skin sensitivity with degree of acne. other factors such as hormonal, genetics, stress, infection and trauma were also included in the questionnaire. the established face validity method is used to validate the questionnaire. the diagnosis of the degree of acne was carried out by the specialist of the dermatovenereology outpatient clinic at dr. table 2 distribution of degree of acne vulgaris degree of av no. of respondents % mild 27 64.3 moderate 11 26.2 severe 4 9.5 total 42 100 table 3 relationship between diet and degree of acne vulgaris diet p-value white bread 0.039* white rice 0.293 potatoes 0.511 chocolate 0.044* oily food 0.013* milk 0.416 note. * significantly significant p < 0.05 soetomo general hospital, surabaya using the lehmann grading system. the number of comedones, inflammatory lesions and total lesion counts were noted to classify the degree of acne into mild, moderate and severe. data analysis was performed using the chi-square test with the statistical package for social sciences (spss), version 21. results among 42 respondents, 38 respondents (90.5%) were females and 4 respondents (9.5%) were males. the majority of the respondents (73.8%) were between 17– 25 years old with a mean age of 21.90±6.5 years old. the characteristics of most of the respondents were unmarried (85.7%); with a university degree (45.2%); currently still a student (64.3%). acne patients were divided into 3 groups according to the number of comedones, inflammatory and total lesion count by using the lehmann grading system. it was found that the majority of the respondents hadmild acne (64.3%). based on the study on dietary factors, only white bread, chocolate and oily food influenced the degree of acne vulgaris (table 1). using the chi-square test, the degree of acne was not influenced by cosmetics products (table 4). of the seven other acne aggravators included in the questionnaire, none of them influenced the degree of acne (table 5). discussion among the different diets studied in this research, white bread, chocolate, and oily food had a significant positive relationship with the degree of acne vulgaris whereas white rice, potatoes and milk did not have any significant relation with the degree of acne vulgaris. according to atkinson et al.5, white bread, white rice and potatoes are foods with high gi. among the foods with high gi studied in this althea medical journal. 2018;5(4) 164 amj december 2018 study, only white bread was associated with the degree of acne vulgaris whereas white rice and potatoes had no relation with the degree of acne vulgaris. in contrast to this study, di landro et al.6 states that the intake of bread has no relation with the risk of acne (or 1.39, 95% ci 0.65–2.98). a study in new york7, compared the dietary gi among participants with no acne, mild acne and moderate to severe acne. the study shows that the group with moderate to severe acne (51.8±3.0) have a higher dietary gi than the group with no acne (48.9±4.6) and mild acne (49.6±3.9). the study also suggests that dietary gi could affect or aggravate acne development (p<0.001).7 dietary factors particularly high glycemic load diets are also proven to have an association with the development of av, as shown in a casecontrol study conducted in malaysia8. patients with av have a significantly higher dietary glycemic load (175±35) compared to controls (122±28) (p<0.001).8 the gi of meals and insulin response have a direct correlation; high gi diets have been shown to increase insulin resistance. the increased proliferation of basal keratinocytes due to high insulin concentration in the fasting and/or post prandial state may exacerbate acne. the synthesis of androgens is also stimulated by insulin, which leads to high sebum production, a recognized correlate table 4 relationship between cosmetics and degree of acne vulgaris cosmetics p-value cleansers usage of cleansers 0.287 frequency of face wash 0.744 types of cleansers cleansing cream 1.000 cleansing milk 0.686 face tonic 1.000 skin freshener 0.739 facial mask 0.330 moisturizers usage of moisturizers 0.242 types of moisturizers morning cream 1.000 night cream 1.000 moisturizing cream 0.639 facial protection usage of facial protection (sunblock) 1.000 exfoliators usage of exfoliators 0.686 decorative cosmetics usage of decorative cosmetics 1.000 frequency of applying decorative cosmetics 0.761 types of decorative cosmetics make up base 0.273 make up foundation 0.750 primer 0.451 blusher 1.000 althea medical journal. 2018;5(4) 165 of acne severity. inflammatory responses enclosed and adjacent to the comedone could be increase due to insulin resistance. the significant relation between chocolate and oily food provides further support to a cross-sectional study which shows that sweet and oily food are an aggravating factor for moderate to severe acne (p=0.03, x2 test).9 in another prospective, a placebo-controlled study states that there is a significant increase of total acneiform lesions (comedones, papules, pustules, nodules) and noninflammatory lesion on day 4 (p=0.006, p=0.009 respectively) and day 7 (p=0.043, p=0.042 respectively) after consuming chocolate.11 both studies showed that consumption of chocolate correlates to an increase in the exacerbation of acne. however, in contrast with the high prevalence of belief, adebamowo et al.12 conducted a study with more than 4000 boys, the study shows no associations between acne and intakes of chocolate and french fries. currently, there are not many studies that conclude chocolate or any specific fatty foods will cause acne, but it is clear that sebum production will increase as we consumed high-sugar/high-fat diet. thus, promote inflammatory responses in the body.10 this study is in line with a study by çerman et al.13 which shows no significant difference between milk and acne vulgaris subgroups (mild acne, moderate acne and severe acne) (p=0.596, p>0.05). besides, the study also shows no significant association between dairy product consumption among acne vulgaris and control groups (p=0.911, p>0.05). yet, the data of this study only covers the milk consumption in the previous 7 days of the study, this result may not reflect the long-term consumption habits.13 in contrast with this study and the above study, a case-control study by di landro et al.6 states that a diet with higher milk consumption influenced the risk of moderate to severe acne regardless of the family history and bmi. skim milk (or 2.20, 95% ci 1.18– 4.10) has a more prominent association with the risk of moderate to severe acne than whole milk (or 1.64, 95% ci 0.81–3.33) although the difference does not reach any statistical significance.7 a study performed by adebamowo et al.12 which includes more than 4000 boys also shows a positive correlation between consumption of skim milk and acne vulgaris (p=0.02, p<0.05). thus far, there has been no conclusive evidence that milk and dairy products have comedogenic effects. cosmetics are categorized into cleanser, moisturizer, facial protection, exfoliators and decorative cosmetics. there was no significant relation between frequency of face wash and degree of acne vulgaris in this study. it is believed that exacerbation of the condition occurs when excessive washing of acne afflicted area occurs.4 a study conducted by rahmawati et al.14 in semarang, indonesia, reports that there is no relation between frequency of face wash with the occurrence of mild-moderate and severe acne. the study also suggested the ideal face wash frequency is insufficient; the correct face wash technique such as being gentle is also important to obtain the best result.14 in this research, the majority of respondents used moisturizers. however, there was no relation between usage of moisturizers and type of moisturizers with the degree of acne table 5 relationship between other factors and degree of acne vulgaris factors p-value skin type 0.638 skin sensitivity 0.689 hormonal male 1.000 female 0.689 genetics 0.734 stress 0.730 infection and trauma habit of scraping, scratching, picking or digging the skin 0.089 habit of shaving, waxing, threading or performing laser hair removal 0.287 mah zhook yueng, diah mira indramaya, arifa mustika: relationship between diet, cosmetics and degree of acne vulgaris in dermatovenereology outpatients at dr. soetomo general hospital, surabaya althea medical journal. 2018;5(4) 166 amj december 2018 vulgaris. this result is in line with the study by rahmawati et al.14, which also shows no significant relation between the use of moisturizers and acne vulgaris (p=0.520). the absence of a significant association could be due to the type of moisturizer used did not contain oil and comedogenic products. frequently, moisturizers were suggested by some clinician to patients as adjuvant care of acne when benzoyl peroxide or retinoid was used in the topical treatment. a study shows when moisturizer is used with adapalene (topical steroids), there is no effect on its therapeutic effect. despite that, it helps to improve adherence to therapy with adapalene by decreasing the risk of experiencing uncomfortable skin symptoms such as dry skin conditions.15 at present, numerous moisturizers claim to be appropriate for acne care by functioning independently in preventing worsening of acne. furthermore, 92% out of 52 moisturizers had antiinflammatory properties apart from occlusive, humectant and emollient effect when its active ingredients and properties were examined. moisturizers that have anti-inflammatory properties contain anti-acne medication such as salicylic acid (35%), benzoyl peroxide (10%) and retinol (8%).16 in this study, there was no association between the usage of sunblock as facial protection and degree of acne vulgaris. yet, according to theory, the presence of physical blockers (zno and tio2) in sunscreen could cause exacerbation of acne. due to the its greasy property and large particle sizes, these physical blockers will block skin pores. oily skin and acne skin are suggested to use spray or gel-based sunscreens. the contrast of the result from this study and theory could be due to the type of sunblock used were sunblock with microfine particles, which were recommended to be safe and effective for acne patients. the usage of sunblock is important as the chance of photosensitivity increases with the usage of topical retinoids (topical medication for acne patient). thus, it is used to decrease the risk of sunburn. the absence of a significant association could also be due to the frequency of applying the facial protection.17 a further study regarding correlation between frequency of applying sunblock and degree of acne can be performed by another researcher. the usage of exfoliators is not related with the degree of acne vulgaris in this study. according to theoretical expectation which states appropriate usage of exfoliators helps to get rid of excess skin cells and clogging up acne pores. this is because exfoliation fastens skin cell regeneration and reduces comedones. this could be the reason of the absence of the significant association. however, kubba et al.4 states that excessive usage of exfoliators especially on acne lesions will cause trauma and worsen the condition. a study regarding the frequency of using exfoliators and the degree of acne vulgaris or occurrence of acne vulgaris should be done for a better understanding of the relation of exfoliator and acne vulgaris.4 in this study, most of the respondents tended to avoid the frequent usage of decorative cosmetics as they only used decorative cosmetics on special occasions. this could be due to the common belief that decorative cosmetics are occlusive and can lead to cosmetic acne.18 however, there is no association between the frequency of applying decorative cosmetics and degree of acne vulgaris. a case control study also suggests that overall cosmetic use is negatively linked with post-adolescent acne, but the use of some individual cosmetics have a positive effect with it, not all cosmetics causes acne.19 no significant association between the type of decorative cosmetics and degree of acne vulgaris was found in this study too. however, the study showed make up foundation was the most frequently used decorative cosmetics. it could be used to cover flaws such as acne scar. usages of oil-free concealers, noncomedogenic makeup were reported to enhance the quality of life of individuals. some foundations can also function as a moisturizer and sunscreen.3 many other factors were found to be linked with the degree of acne vulgaris including skin type, skin sensitivity, hormonal, genetic, stress, infection and trauma. these factors were known to cause acne exacerbation. yet, none of these factors were significantly associated with the degree of acne vulgaris in this study. the number of populations in this study was small; this could be one of the factors that caused most of the variable to have a different result compared with other studies. the population of patients with moderate acne and severe acne was also limited in this study, as the majority of patients at the outpatient clinic were patients with mild acne. hence, a further investigation should increase the total sample size in order to overcome this problem. due to the nature of this study, the cause and effect of diet and cosmetic on acne vulgaris could not be determined. a further research should use a better study design such as casecontrol, cohort etc. also, the diet tracking was althea medical journal. 2018;5(4) 167 limited to a few types of foods. therefore, further research should include a long-term diet tracking using food diary to have a better understanding on the effect of diets. in this study, it is concluded that white rice, chocolate and oily food are associated with the degree of acne vulgaris. however, diet such as white rice, potatoes and milk have no influence on the degree of acne vulgaris. moreover, cosmetics including moisturizer, cleansers, exfoliators, facial protection and decorative cosmetics are also not associated with the degree of acne vulgaris. other than topical and oral medication for acne vulgaris, physicians should explore the factors that cause acne on different individuals to provide a more suitable treatment plan. physicians should also educate patients the importance of avoiding certain diet and usage of cosmetic products that will cause an aggravation to the condition to speed up the healing process of the acne condition. references 1. goldsmith li, gilchrest ba, paller as, leffell dj, wolff k. fitzpatrick’s dermatology in general medicine. 8th ed. new york: mcgraw-hill; 2012. 2. sajayan j, mohan a. acne cosmetica– current burning issue. int ayurvedic med j. 2015;3(4):1195–8. 3. eichenfield lf, krakowski ac, piggott c, del rosso j, baldwin h, friedlander sf, et al. evidence-based recommendations for the diagnosis and treatment of pediatric acne. pediatrics. 2013;131 suppl 3:s163– 86. 4. kubba r, bajaj a, thappa d, sharma r. cosmetics and skin care in acne. indian j dermatology venereol leprol. 2009;75(7):s55–6. 5. atkinson fs, foster-powell k, brand-miller jc. international tables of glycemic index and glycemic load values: 2008. diabetes care. 2008;31(12):2281–3. 6. di landro a, cazzaniga s, parazzini f, ingordo v, cusano f, atzori l, et al. family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults. j am acad dermatol. 2012;67(6):1129–35. 7. burris j, rietkerk w, woolf k. relationships of self-reported dietary factors and perceived acne severity in a cohort of new york young adults. j acad nutr diet. elsevier inc; 2014;114(3):384–92. 8. ismail nh, abdul manaf z, azizan nz. high glycemic load, milk and ice cream consumption are related to acne vulgaris in malaysian young adults: a case control study. bmc dermatol. 2012;12(1):13. 9. ghodsi sz, orawa h, zouboulis cc. prevalence, severity, and severity risk factors of acne in high school pupils: a community-based study. j invest dermatol. 2009;129(9):2136–41. 10. reynolds rc, lee s, choi jyj, atkinson fs, stockmann ks, petocz p, et al. effect of the glycemic index of carbohydrates on acne vulgaris. nutrients. 2010;2(10):1060–72. 11. caperton c, block s, viera m, keri j, berman b. double-blind, placebo-controlled study assessing the effect of chocolate consumption in subjects with a history of acne vulgaris. j clin aesthet dermatol. 2014;7(5):19–23. 12. adebamowo ca, spiegelman d, berkey cs, danby fw, rockett hh, colditz ga, et al. milk consumption and acne in teenaged boys. j am acad dermatol. 2008;58(5):787–93. 13. çerman aa, aktaş e, altunay ik, arici je, tulunay a, ozturk fy. dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris. j am acad dermatol. 2016;75(1):155–62. 14. rahmawati d, widayati ri, sudaryanto s. hubungan perawatan kulit wajah dengan timbulnya akne vulgaris pada siswi sma/ ma/smk yang menderita akne vulgaris. jurnal media medika muda. 2012;1(1):1– 17. 15. hayashi n, kawashima m. study of the usefulness of moisturizers on adherence of acne patients treated with adapalene. j dermatol. 2014;41(7):1–6. 16. chularojanamontri l, tuchinda p, kulthanan k, pongparit k. moisturizers for acne: what are their constituents? j clin aesthet dermatol. 2014;7(5):36–44. 17. latha ms, martis j, shobha v, shinde rs, bangera s, krishnankutty b, et al. sunscreening agents: a review. j clin aesthet dermatol. 2013;6(1):16–26. 18. tahir cm, ansari r. beliefs, perceptions and expectations among acne patients. j pakistan assoc dermatologists. 2012;22:98–104. 19. singh s, mann bk, tiwary nk. acne cosmetica revisited: a case-control study shows a dose-dependent inverse association between overall cosmetic use and post-adolescent acne. dermatology. 2013;226(4):337–41. mah zhook yueng, diah mira indramaya, arifa mustika: relationship between diet, cosmetics and degree of acne vulgaris in dermatovenereology outpatients at dr. soetomo general hospital, surabaya vol 4 no 3 full text final.indd althea medical journal. 2017;4(3) 479 effect of short term cardiac rehabilitation program on quality of life in patients with coronary artery disease ina marita,1 sunaryo b. sastradimaja,2 badai bhatara tiksnadi3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cardiac rehabilitation (cr) programs are known to be one of the effective managements which aim to improve the quality of life (qol) in coronary artery disease (cad). however, there is still controversy about the effect on qol dimension. the purpose of this study is to determine the effect of short term cardiac rehabilitation program on quality of life in patients with coronary artery disease. methods: the study design used was a quasi experimental study with repeated measurements in consecutive sampling involving 11 subjects with cad from september–november 2015 in cardiorespiratory clinic and gymnasium of physical medicine and rehabilitation and cardiac unit services, dr. hasan sadikin general hospital bandung. the cardiac rehabilitation program was performed for 4 weeks. the quality of life was scored using medical outcomes study short form 36 (sf-36) questionnaire before and after cr program. statistics obtained in this study were analyzed using paired t-test and wilcoxon test. results: this study involved 11 male patients with cad with an average age of 58 (11) years old with the diagnosis of cad post cabg (n=6), cad post pci (n=4), and cad unrevascularized (n=1). the average total score of quality of life questionnaire sf-36 demonstrated a significant increase (p<0.001) after cr program 87.27(8.5) as compared to before cr program 49.09(8.4). this improvement occurred in all qol dimensions. conclusions: short term cardiac rehabilitation program can improve the quality of life in patients with coronary artery disease. keywords: cardiac rehabilitation, coronary artery disease, quality of life introduction based on the world health organization (who) in 2012, cardiovascular disease is the leading cause of death, representing 31% of total deaths worldwide. of these deaths, the highest rate is due to coronary artery disease (cad) that has high mortality and morbidity rate.1,2 management of cad has been progressing rapidly either by medication or surgical intervention. nevertheless, cardiac rehabilitation (cr) has an important role in the management of cad as it has been proven to be effective in reducing mortality and morbidity rate, reducing health care cost, significantly increasing patient’s functional capacity and quality of life, especially in women.3 this program can be performed both in health care facility and at home with the same effectivity rate.4 quality of life (qol) has been widely used as a criteria in assessing the outcomes of treatment and intervention given to the patients.5 quality of life can be defined as a complex, subjective, and multidimensional concept which represents a patient’s perception or subjective evaluation of the impact of disease on their functional status and well being.6 various studies have been conducted to observe the effectiveness of cardiac rehabilitation program on qol in various time periods. however, there is still controversy about the effect on qol dimension. nonetheless, studies about the effect of cardiac rehabilitation programs on the quality of life in shorter periods are correspondence: ina marita, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: inamarita53@gmail.com amj. 2017;4(3):479-85 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1207 althea medical journal. 2017;4(3) 480 amj september 2017 still limited in indonesia. the aim of this study was to observe the effect of short term cardiac rehabilitation program on quality of life in patients with coronary artery disease. methods this quasi experimental study without control group was conducted from september– november 2015. the population of this study included all cad patients in cardiorespiratory clinic and gymnasium of physical medicine and rehabilitation and cardiac unit services, dr. hasan sadikin general hospital bandung. minimum samples needed for this study were 11 subjects. the samples were taken with consecutive sampling method. the subjects were given an informed consent form as a proof of agreement to participate in this study. this study had received ethical approval from health research ethics committee faculty of medicine universitas padjadjaran. the subject inclusion criteria were patients with cad who agreed to participate as study subjects and were cooperative in answering questions throughout an interview session. meanwhile, patients with unstable angina, uncontrolled risk factors, neuro-orthopedic pathological conditions that may affect exercise capacity, and who recently (<2 weeks) underwent surgical interventions such as percutaneous coronary intervention (pci)/ coronary artery bypass graft (cabg) were excluded from this study. drop out criteria were patients who did not return for final evaluation, did not finish exercise phases for 4 weeks, only performed exercise <4 times out of total hospital visits, <8 times out of total home exercise, and did not perform any exercise 5 times in a row. before the rehabilitation program, vital signs were measured and submaximal exercise test was performed to determine subject’s basic exercise capacity using a 6-minute walking test. all subjects who underwent the cardiac rehabilitation program were given an aerobic exercise modality by using a treadmill under doctor’s supervision in the hospital as well as walking at home with a frequency of 3–5 times per week (2 times in the hospital and 3 times at home). each exercise modality duration was ≥ 30 minutes which consisted of ≥5 minutes warm-up, ≥20 minutes aerobic exercise, and ≥5 minutes cool-down, and intensity exercise in the hospital was 60–70% of the vo2 max or 70–85% of maximum heart rate, while the home exercises were 60–75% of maximum heart rate. this cr program was performed for 4 weeks. in every hospital visit, the subjects were given education and counselling about risk factor modifications and stress management. during home exercise, subjects were asked to walk on a flat surface around the patient’s home at a pace that had been adapted to the patient’s condition. the exercise distance was specified by the doctor. subject’s quality of life was measured by medical outcomes study short form 36 (sf36) questionnaire which has been widely used in indonesia as well as other countries. the indonesian version of the questionnaire had been validated and was used for outcome measurement in this study. the questionnaire was composed of 36 questions assessing physical and mental health components. physical health component included 4 dimensions: physical function (pf), physical limitation (pl), body pain (bp), and vitality (v). the dimension that reflected mental health components were social function (sf), emotional limitation (el), mental health (mh), and general health (gh). each question was scored on a scale from 0 (maximal limitation) to 100 (no limitation). every score from those questions that addressed each specific dimension were than averaged together, resulting in a final score within each of the 8 dimensions.7 the data were analyzed with statistical computer software. bivariate analysis was performed to observe the correlation between the dependent and independent variables. normality test using shapiro-wilk was performed to assess data distribution. data with normal distribution were assessed with paired t-test, while data with abnormal distribution were assessed with wilcoxon test. the confidence interval (ci) used in this study was 95%. results the subjects were recruited using consecutive sampling. subjects included 11 patients with coronary artery disease. all subjects were males with an average age of 58 years old. most subjects had undergone revascularization in the form of cabg (table 1). descriptive statistical analysis was performed on the data collected to obtain the average total score and the average score of each dimension of qol. then, the data collected were analyzed statistically. the data for normality test using saphiro-wilk were obtained to determine the total score of qol, althea medical journal. 2017;4(3) 481ina marita, sunaryo b. sastradimaja, badai bhatara tiksnadi: effect of short term cardiac rehabilitation program on quality of life in patients with coronary artery disease physical and mental component, dimension of physical functionality, vitality, mental health, and social functions which had normal data distribution. thus, the data were interpreted using a parametric test, paired t-test. meanwhile, the score of dimensions in physical limitations, emotional limitations, bodily pain, and general health had anabnormal data distribution, so the alternative nonparametric wilcoxon test was used. there were significant differences between the mean score of qol before and after cr program (table 2). based on the sf-36 questionnaire, qol can be divided into two large components consisting of physical and mental health components. the result shows significant differences between the average scores on the physical and mental health components of the patients before and after cr program (table 2). additionally, the questionnaire can also be divided into eight dimensions: physical function, physical limitation, emotional limitation, vitality, mental health, social function, body pain, and general health. based on the p-values in table 3, there were significant differences between the qol of patients before and after cr program in all qol dimensions. discussion coronary artery disease (cad) is the leading cause of death in the world with high mortality and morbidity rate.1,2 cardiac rehabilitation program has largely demonstrated their long-term efficacy in reducing mortality and morbidity rate, increasing patient’s functional table 1 characteristics of subject variable (n=11) mean(sd) n age (year) 58 (11) weight (kg) 65.18 (6.9) height (m) 1.63 (0.1) bmi (kg/m2) 24.5 (2.5) diagnosis cad unrevascularized 1 cad post cabg 6 cad post pci 4 gender male 11 female 0 education elementary school 3 junior high school 1 senior high school 3 college 4 marital status married 10 single 1 occupation working 8 not working 3 note : bmi= body mass index; cad= coronary artery disease; cabg= coronary artery bypass graft; pci= percutaneous coronary intervention; age, weight, height and bmi are presented as mean (standard deviation) althea medical journal. 2017;4(3) 482 amj september 2017 capacity and quality of life, and reducing risks that can arise from cad and its complications.8 in this study, 11 people with cad participated in cardiac rehabilitation program for 4 weeks. based on the total study subjects, it can be said that the participation of the patient in cardiac rehabilitation is still quite low. this is supported by a study of karam et al.9 showing that the level of patient participation in cardiac rehabilitation is <50% in most countries, with the drop-out rate reaching 56% in high-income countries and 82% in middle-income countries. all study subjects in this study were male. the low participation of females in this program is supported by a study from samayoa et al.10 showing that women’s participation in cr program is significantly lower compared to men, women (36%) are less likely to enroll in cr programs. results of this study showed that there was an increase in average scores in all dimensions of quality of life significantly after cardiac rehabilitation program for 4 weeks. this study showed that the effect of a shorter but optimal cardiac rehabilitation conducted for 4 weeks with consistent surveillance can increase the quality of life of the patient mentally dan physically as good as a cardiac rehabilitation process conducted for a longer period of time. the results were consistent with the findings of several studies that have been done before. a study conducted by saedi et al.3 showed that qol in 100 patients with cad who followed cardiac rehabilitation for 8 weeks improve significantly. freitas et al.11 showed that patients’ physical and mental health component of qol improve significantly after 4-week cardiac rehabilitation program. the same findings were obtained from the study of lee et al.12 after undergoing cardiac rehabilitation within 12 weeks. a study conducted by tavella et al.13 on cad patients who followed a cr program for 6 weeks showed that qol is improved even for 6 months after the program. however, when compared with the control, there was no table 2 quality of life score differences based on physical and mental components in patients with coronary artery disease before and after cardiac rehabilitation program scale cr program p valuebefore (mean, sd) after (mean, sd) physical health component 34.04 (5.7) 87.16 (10.9) <0.001 mental health component 63.93 (15.4) 87.29 (8.8) <0.001 quality of life score 49.09 (8.4) 87.27 (8.5) <0.001 note : sd= standard deviation table 3 dimensional scores differences of quality of life in patients with coronary artery disease before and after cardiac rehabilitation program scale cr program p value before after physical function* 35.45 (9.1) 89.36 (8.5) <0.001 physical limitation** 0.00 (0-25) 100 (50-100) 0.003 emotional limitation** 67 (0-100) 100 (67-100) 0.027 vitality* 64.09 (14.6) 80.45 (12.1) <0.001 mental health* 82.55 (10.3) 88.00 (6.7) <0.001 social function* 48.55 (12.3) 83.73 (15) <0.001 body pain** 22 (0-55) 100 (68-100) 0.003 general health** 70 (45-75) 80 (75-100) 0.003 note: *: paired t-test (if normal distribution). data were presented in mean and standard deviation, **: wilcoxon test (if abnormal distribution). data were presented in median, minimum value and maximum value althea medical journal. 2017;4(3) 483 significant difference.13 quality of life can be divided into two major components, which are physical and mental health components. in the present study, physical health component score increased significantly after cr in total population. it can be explained as follows: the primary effect of aerobic exercise training is to increase maximal stroke volume (sv) and maximal arterial-venous o2 difference (a-v o2 δ), resulting in an increase of maximal exercise capacity (vo2max). there are multiple factors that can influence improvement in vo2max, including age, baseline exercise capacity, characteristics of the training regimen, and genetic factors. exercise-based rehabilitation increases the body’s oxygen demand measured as the ventilatory oxygen uptake (v̇o2). rearranging the fick equation, v̇o2 is determined by the product of (cardiac output) and a-v o2. increasing either heart rate (hr) or stroke volume (sv) increases q. whereas q is determined by the absolute v̇o2; hr and systolic blood pressure (sbp) response, an index of myocardial oxygen requirements (mo2), or internal work rate are determined by the v̇o2 requirements of a physical task relative to maximal capacity or the percent v̇o2max. exercise training raises the ventilatory threshold (vt) which indicates the maximal steady state or work rate that can be maintained during submaximal exercise and increased endurance capacity in cardiac patients. in conclusion, the increase in v̇o2max means that any submaximal physical task represents a smaller percent v̇o2max, produces a slower hr and lower sbp, raises the vt, and therefore, requires a lower mo2. 14 in this study, the average mental health component scores increased significantly after the cr program. these results are comparable to the study of freitas et al.11 that showed patient’s psychological parameters such as anxiety and depression were improved after cr for 4 weeks. poortaghi et al.15 compared a group which received routine centre-based cr programs combined with home visits of a community health nurse throughout the followup period with centre-based cr programs alone. improvements inpatient’s self efficacy showed statistically significant differences between two studied groups.15 the findings of that study were the same as the results of the study by lee et al.16 in 2013. an investigation by sharif et al.17 on cad patients undergoing cabg showed that cardiac rehabilitation is effective in reducing depression for almost 2 months after surgery. in addition, the decrease in anxiety is not statistically significant.17 however, there are some investigations with different findings; the study conducted by weberg et al.18 on 89 cardiac patients showed that all macnew heart disease health-related quality of life questionnaire (macnew) and sf36 domains show significant improvements except the sf-36 domain for emotional limitation. moholdt el at.19 compared 4 weeks of residential with home-based cr program. figure average score of qol dimensions in 11 patients with coronary artery disease ina marita, sunaryo b. sastradimaja, badai bhatara tiksnadi: effect of short term cardiac rehabilitation program on quality of life in patients with coronary artery disease althea medical journal. 2017;4(3) 484 amj september 2017 they found that there is a significant increase in social and physical domains of the macnew questionnaire in both groups, but not the emotional domain.19 possible explanations of qol improvement in the cr program are that the program may ameliorate subject’s risk factors and lifestyle by education and also increase in exercise capacity by gradual exercise loading, resulting in improvement of their performance and a better qol.12 improved physical status of patients also influences on their psychological condition and increases participation in social activities along with an improved well being throughout.3 recent studies showed that homeand supervised -based cardiac rehabilitation have the same effectiveness in improving the qol in patients with cad, myocardial infarction, and patients who underwent revascularization.4,20 in this study, cardiac rehabilitation was performed in a short period of time, but the subjects were not only encouraged to undergo supervised cardiac rehabilitation at the hospital twice a week, but also underwent home-based cardiac rehabilitation three times a week. thus, if the patient underwent cr program regularly, it may have a major impact in improving the patient’s qol. in addition, cr programs held at dr. hasan sadikin general hospital already has a good multidiciplinary team coordination whereby the outcome of rehabilitation programs is fairly outstanding. limitation of this study is that the absence of female study subjects which results in the findings of this study cannot be used to describe the effects of cardiac rehabilitation on quality of life in the whole population. based on the results of this study, it can be deduced that short term cardiac rehabilitation program can improve physical and mental health components in patients with coronary artery disease. this study is expected to be able to enhance the active participation of physicians and other health providers to motivate patients to undergo cardiac rehabilitation in accordance with the gold standards to increase the cad patient’s participation. we also hope this study will be a guide that optimal result can be obtained with cardiac rehabilitation program within a shorter period, however, patients must be observed that they did a proper and regular rehabilitation in hospital as well as at their home. to get better study results in future studies, using specific quality of life questionnaire for heart disease is recommended, such as the seattle angina questionnaire (saq), along with a generic questionnaire. routine follow ups with a longer period of time can also be performed to determine long-term effects of cardiac rehabilitation on quality of life. moreover, further studies should be conducted not only to assess the subjective quality of life but also the objectivity by measuring the capacity of exercises. references 1. who. global status report on noncommunicable diseases 2014. geneva: world health organization; 2014. 2. hamm cw, bassand j-p, agewall s, bax j, boersma e, bueno h, et al. esc guidelines for the management of acute coronary syndromes in patients presenting without persistent st-segment elevation. eur heart j. 2011;32(23):2999–3054. 3. saeidi m, mostafavi s. gw24-e3978 effects of a comprehensive cardiac rehabilitation program on quality of life in patients with coronary artery disease. heart. 2013;99(suppl 3):a140–1. 4. taylor rs, dalal h, jolly k, moxham t, zawada a. home-based versus centrebased cardiac rehabilitation. cochrane database syst rev. 2010;1(1):5631–45. 5. dyer mt, goldsmith ka, sharples ls, buxton mj. a review of health utilities using the eq-5d in studies of cardiovascular disease. health qual life outcomes. 2010;8(13):1– 12. 6. shepherd cw, while ae. cardiac rehabilitation and quality of life: a systematic review. int j nurs stud. 2012;49(6):755–71. 7. rand health. scoring instructions for the 36-item short form survey (sf-36). rand; 2009 [cited 2016 january 14] available from: http://www.rand.org/health/ surveys_tools/mos/mos_core_36item. html. 8. jenni j, buckley j, furze g, doherty p, speck l, connolly s, et al. the bacpr standards and core components for cardiovascular prevention and rehabilitation 2012. 2nd ed. london: bacpr; 2012. 9. turk-adawi ki, grace sl. narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middleand low-income countries. heart lung circ. 2015;24(5):510–20. 10. samayoa l, grace sl, gravely s, scott lb, marzolini s, colella tj. sex differences in cardiac rehabilitation enrollment: a metaanalysis. can j cardiol. 2014;30(7):793– althea medical journal. 2017;4(3) 485 800. 11. freitas pd, haida a, bousquet m, richard l, mauriège p, guiraud t. short-term impact of a 4-week intensive cardiac rehabilitation program on quality of life and anxiety-depression. ann phys rehabil med. 2011;54(3):132–43. 12. lee yh, hur sh, sohn j, lee hm, park nh, cho yk, et al. impact of home-based exercise training with wireless monitoring on patients with acute coronary syndrome undergoing percutaneous coronary intervention. j korean med sci. 2013;28(4):564–8. 13. tavella r, beltrame jf. cardiac rehabilitation may not provide a quality of life benefit in coronary artery disease patients. bmc health serv res. 2012;12(1):406–14. 14. fletcher gf, ades pa, kligfield p, arena r, balady gj, bittner va, et al. exercise standards for testing and training. circulation. 2013;128(8):873–934. 15. poortaghi s, baghernia a, golzari se, safayian a, atri sb. the effect of homebased cardiac rehabilitation program on self efficacy of patients referred to cardiac rehabilitation center. bmc res notes. 2013;6(1):287–90. 16. hazavei smm, sabzmakan l, hasanzadeh a, rabiei k, roohafza h. the effects of an educational program based on precede model on depression levels in patients with coronary artery bypass grafting. arya atheroscler. 2012;8(1):36–42. 17. sharif f, shoul a, janati m, kojuri j, zare n. the effect of cardiac rehabilitation on anxiety and depression in patients undergoing cardiac bypass graft surgery in iran. bmc cardiovasc disord. 2012;12(1):40–6. 18. weberg m, hjermstad m, hilmarsen c, oldervoll l. inpatient cardiac rehabilitation and changes in self-reported health related quality of life–a pilot study. ann phys rehabil med. 2013;56(5):342–55. 19. moholdt t, bekken vold m, grimsmo j, slordahl sa, wisloff u. home-based aerobic interval training improves peak oxygen uptake equal to residential cardiac rehabilitation: a randomized, controlled trial. plos one. 2012;7(7):e41199–203. 20. oerkild b, frederiksen m, hansen jf, simonsen l, skovgaard lt, prescott e. home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial. age ageing. 2011;40(1):78– 85. ina marita, sunaryo b. sastradimaja, badai bhatara tiksnadi: effect of short term cardiac rehabilitation program on quality of life in patients with coronary artery disease vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 123 comparison of intelligence based on short-term memory test between urban and rural children amira addiniya,1 leonardo lubis,2 marietta shanti prananta3 1regional public hospital (rsud) bandung, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: amira addiniya, regional public hospital (rsud) bandung, jl. rumah sakit no. 22, ujung berung, bandung, indonesia, email: amiraaddiniya@yahoo.com introduction intelligence in children is highly associated with cognitive development.1 based on piaget’s theory, there are four stages of cognitive development in children, leading to the capacity of adult thought. the rate at which children move through different stages not only depends on genetics but also depends on environmental factors.2 during the interactions with their environment, there will be a modification of the brain of the children.3 the environment is classified into urban and rural areas, with many distinctions between them and can affect the cognitive of the children differently. due to a lower socioeconomic level in a rural area, it can cause chronic stress and inadequate nutritional intake that affects the development of brain cells and decreased number of brain cells.4-6 the less advanced technology in a rural area can cause a decreased verbal and visual stimulation for the cognitive.4 furthermore, the low education level of parents in a rural area may also affect the parents’ perspective to raise their children. they tend to be less involved in the learning process of their children.7 hence, it is important to consider the difference in cognitive level between urban and rural children. among all cognitive components, working memory is believed to be a critical contributor to cognitive functions. in children, working memory plays a major role in language comprehension, learning process, planning, reasoning, and problem-solving. working amj. 2019;6(3):123–8 abstract background: cognitive development occurs during childhood and this development is influenced by various environmental factors such as urban and rural environments which can affect child cognitive development. short-term memory is very important as the first step in processing new information to do cognitive tasks. the aim of this study was to compare the short-term memory of children coming from an urban and rural area. methods: a cross-sectional design was performed in this observational analytical study, conducted from september to october 2014 in jatinangor. students from elementary school students in an urban and rural area in jatinangor were selected, using a stratified random sampling method. the digit span forward, backward, and symbol digit modality test (sdmt) were used to measure short-term memory. mann-whitney test and independent t-test were used in this research. results: there was no significant difference in digit span forward score between urban and rural boys (p=0.564); and girls group (p=0.982). on the contrary, digit span backward score among urban boys (p=0.007) and urban girls (p=0.006) was significantly higher compared to those living in the rural areas. similarly, a significantly higher score of sdmt in the urban areas was found compared to rural for boys (p=0.011) and girls (p=0.026). conclusions: intelligence based on a short-term memory test, consisting of digit span backward and symbol digit modality test, is higher in urban children compared to children in the rural areas. keywords: rural, short-term memory, urban althea medical journal. 2019;6(3) 124 amj september 2019 memory is the ability to manipulate or to transform the information that temporarily stored in short-term memory to be applied in cognitive tasks.8-10 therefore, short-term memory is very important as the first step in processing new information to do cognitive tasks.11 the aim of this study was to compare the short-term memory level between children in the urban and rural areas. methods students from elementary schools in an urban and rural area in jatinangor were recruited by a stratified random sampling method. the elementary schools representing schools in urban areas were taken from cibeusi elementary school, cibeusi village, jatinangor district; whereas the elementary schools representing rural areas were taken from karangmulya elementary school, cilayung village, jatinangor district. this study was conducted from september until october 2014. the method of this study had been approved by the health research ethics committee faculty of medicine, universitas padjadjaran, bandung with the ethical approval number 473/un6.c2.1.2/kepk/pn/2014. the inclusion criteria for this study were students aged 8–10 years old from elementary school students and had lived in a house located in the same village with the school. consent to participate in this study was signed by the parents. exclusion criteria were vision and hearing abnormalities, motoric function disorders, metabolic or structural thyroid disease, a state of anxiety and unhealthy when the test was performed, a history of head trauma, consuming any caffeinated drinks such as tea, coffee, carbonated drinks, and energy drinks in 48 hours before the tests were performed, and sleep deprivation for less than 8 hours at the night before the tests performed. the tools used to measure the short-term memory level in children were (i) digit span forward, (ii) digit span backward, and (iii) symbol digit modalities test (sdmt). in digit span forward, the students were asked to immediately repeat the digit sequence presented by the examiner in the forwarding sequence. the digit sequences were presented with the speed of one digit per second. initially, the test began with a length of 2 digits. when the students repeated the whole sequence correctly, the examiner would present the next sequence with one digit longer. for the subjects who failed to repeat the digit sequence correctly, the examiner would present the next sequence with the same length as another chance. the test was halted if the subjects failed for the second time to repeat the digit sequence with the same length. the digit span backward was performed with a similar procedure as the digit span forward, but the students were asked to repeat the digit presented by the examiner in the reversed sequence. when the number of digits in the last sequence correctly were repeated, it showed the score of the digit span test.12 on the other hand, sdmt consists of a sheet of paper with a sequence of nine numbers (1–9) and nine corresponding symbols at the top of the paper. the task sequence consists of a series of random numbers, each with a blank space underneath. within 90 seconds, the students were required to fill the blank spaces with the matched symbol. the number of the blank spaces filled correctly with the matched symbol was the score of the sdmt.13 the result of this study was analyzed using ibm spss statistics version 22. shapiro-wilk was used to test the normality of the data. when the data were not normally distributed, the mann-whitney test was used to compare the score of digit span forward and backward test between children in the urban and rural areas. for sdmt, the independent t-test was used to compare the score of children an urban and rural area, when the data was normally distributed. results in total, 60 students from the elementary schools were included, who were living in an urban (n 30) and rural (n 30) area, consisting of 16 boys and 14 girls each area. the comparison of short-term memory test scores between boys from an urban and rural areas in jatinangor had been shown in table 1. table 1 showed that the mean of digit span forward, digit span backward and sdmt scores were higher in urban boys than in rural boys. but the difference of digit span forward score between urban and rural areas was not statistically significant because the p-value was 0.564 (p>0.05). unlike the digit span forward, the difference between digit span backward score in the urban and the rural area was statistically significant with the p-value was 0.007 (p<0.05). furthermore, the sdmt score in urban and rural areas also showed that the difference was statistically significant with the p-value was 0.011 (p<0.05). similar results were also found in the althea medical journal. 2019;6(3) 125 table 1 comparison of short-term memory test scores between boys in urban (n16) and rural (n16) are in jatinangor short-term memory test living place mean ± sd median (minimum–maximum) p digit span forward urban 4.75±0.77 5.0 (4.0–6.0) 0.564** rural 4.56±0.63 4.5 (4.0–6.0) digit span backward urban 3.13±0.81 3.0 (2.0–4.0) 0.007** rural 2.31±0.48 2.0 (2.0–3.0) sdmi urban 22.25±4.93 0.011* rural 18.38±2.63 note. sdmi, symbol digit modalities test. * independent t-test, ** mann whitney test amira addiniya et al.: comparison of intelligence based on short-term memory test between urban and rural children girls’ groups. the table below showed the comparison of short-term memory test scores between urban and rural girls in jatinangor. the mean of digit span forward, digit span backward and sdmt scores were higher in urban girls compared to those in a rural area, however, the difference of digit span forward score between urban and rural area was not statistical significant (p=0.982). in the contrary, there was a statistically difference between digit span backward score among girls in the urban and rural areas (p=0.006). furthermore, the sdmt score in urban and rural areas also showed a statistically higher score among girls in the urban area (p=0.026). discussions short-term memory is the ability to store and manipulate the information in the brain for a brief period.14 based on experiments conducted using the brown-peterson task, the duration of short-term memory is expected to be 0–18 seconds. when shortterm memory is functionally used to perform daily activities, the concept of short-term memory has developed into working memory. other cognitive component called attention is needed and plays a major role in establishing the working memory. working memory system itself consists of four subsystems; (i) a phonological loop which serves to process verbal information, (ii) a visuospatial sketchpad which has a function to process visual and spatial information, (iii) an episodic buffer which combines all information from various modalities, and (iv) the central executive system, a system that controls attention in regulating and coordinating other subsystems.14,15 the phonological loop is then divided into two subsystems, phonological store, and subvocal rehearsal system. the phonological store is the storage information in the form of primary memory or immediate memory in which the trace memory and storage capacity are limited. the information will be stored in the brain only for a few seconds before the information is lost. anterior superior temporal gyrus (stg) is an area of the brain that is responsible for phonological store systems. table 2 comparison of short-term memory test scores between girls in urban (n14) and rural (n14) area in jatinangor short-term memory test living place mean ± sd median (minimum–maximum) p digit span forward urban 5.93±1.69 6.0 (4.0–10.0) 0.982** rural 5.36±0.61 6.0 (5.0–7.0) digit span backward urban 3.71±0.73 4.0 (3.0–5.0) 0.006** rural 2.79±0.61 3.0 (2.0–4.0) sdmi urban 28.50±5.13 0.026* rural 23.57±5.91 note: sdmi= symbol digit modalities test. * independent t-test, ** mann whitney test althea medical journal. 2019;6(3) 126 amj september 2019 meanwhile, the subvocal rehearsal system is the process of strengthening the information by giving more attention in the form and meaning of information, as well as the process of repetition of the given information. the function of this rehearsal system is increasing the memory trace and preventing decay of the information. the left inferior frontal gyrus or broca’s area and the rolandic operculum are brain areas that are responsible for managing this subvocal rehearsal system.14,15 digit span test is a subtest of the wechsler intelligence scale for children (wisc) that can be used to measure verbal working memory or phonological loop subsystem. digit span test consists of two types of tests, namely digit span forward and digit span backward. digit span forward is the test that can be used to measure the phonological store, which is the subsystem of the phonological loop. this type of test uses the phonological store only without entering the rehearsal process system. on the other hand, the digit span backward is the test that should involve the rehearsal process system. the rehearsal process is done by calling the numbers repeatedly or imagining the sequence of the digit.14,15 this study has shown that the mean of digit span forward scores, both in boys and girls groups, are higher in an urban area than in a rural area, however, the differences were not statistically significant. on the contrary, the differences between boys and girls digit span backward scores between urban and rural areas are statistically significant. it may due to the subvocal rehearsal process system that must be done when the digit span backward test is performed. at the time of the rehearsal process, the respondent should imagine the sequence of digit presented by the examiner. by this strategy, the respondent can transform the digit into a new reversed sequence. the process of imagining is called visual processing and this process is one of the strategies that should be done in the digit span backward and rarely used in digit span forward.16 besides, the digit span backward requires better attention to help the process of rehearsal. attention is controlled by a subsystem of working memory in the central executive system. this is confirmed by a study conducted in japan that measured the concentration of oxygenated and deoxygenated hemoglobin by using near-infrared spectroscopy (nirs). the measurement was conducted in the prefrontal cortex, which is the center of the central executive system. hemoglobin concentration measurements have been performed both at rest, which is used as a baseline and when the digit span tests are performed. when using nirs measurement, the activation of neurons would be expressed by an increase in the concentration of the oxygenated hemoglobin and a decrease in the concentration of deoxygenated hemoglobin. as a digit span test backward has been performed, the concentration of oxygenated blood in the prefrontal cortex is significantly higher compared to the baseline; while the deoxygenated hemoglobin is significantly decreased. on the contrary, when digit span test forward is performed, the oxygenated and deoxygenated hemoglobin concentrations in the prefrontal cortex are not significantly different from the baseline. the digit span test backward test requires more neuron activations in the prefrontal cortex compared to digit span test forward because the central executive system is needed more on the digit span backward.17 in brief, digit span backward not only involves the phonological store and subvocal rehearsal system but also the visual processing and central executive system, therefore the digit span backward requires more efforts than the digit span forward. digit span backward is also more sensitive to measure working memory. digit span forward, which only measures the phonological store, has a low level of difficulty and can be easily done by the elementary school students both in the urban and rural areas. therefore, the difference of digit span forward scores between boys and girls in the urban and rural area is not statistically significant. furthermore, the results of the digit span backward in this study which is significantly different between urban and rural area is in contrary to another study that shows the ability of verbal working memory in children of a rural area is better than in an urban area.4 the urban area has more noise pollution compared to the rural area. chronic exposure to noise pollution harms verbal memory. moreover, the urban school participated in this study is located close to the airport, allowing the children in the urban area to have decreased verbal memory because of the chronic exposure of noise pollutant.4 verbal information received by children will be processed into memory through several strategies, such as rehearsal, organization, and elaboration. these processes require another cognitive component, known as attention. the presence of chronic exposure to noise pollution causes the process of information althea medical journal. 2019;6(3) 127 storage to be interrupted because attention is distracted by unwanted noise in children. as a result, the information obtained will be hard to be remembered by the children and the verbal memory will be decreased.18 in our study, it seems likely that exposure to noise pollution is not much difference between children in an urban and rural areas in jatinangor. furthermore, our study measured not only verbal memory but also the visuospatial memory, tested by sdmt. the sdmt score of children living in an urban areas was higher and the difference was statistically significant. this result was similar to another study; children who live in rural areas have a weakness for visuospatial memory. this can occur due to the environmental differences between urban and rural areas. the daily visual stimulations in a rural areas are lower than in urban areas. in an urban area, the crowd of the city, office buildings, residential and industrial buildings, as well as advertisement boards and posters can provide visual stimulation to children.4 these stimulations can give pleasant stimulation and affect cognitive functions, such as attention and memory. the scores of memory in respondents exposed with a pleasant visual stimulus is higher than in respondents exposed with no visual stimulus or neutral visual stimulus, due to the positive emotions involved in these visual stimulations. there is an increased release of dopamine when positive emotions are induced and this neurotransmitter has a role in the formations of memory. moreover, positive emotions will also activate the amygdala and when activated, the amygdala will mediate connections with the cortex and facilitate the processes of memory formation such as encoding, recalling, and recognition.19 on the contrary, if the aversive visual stimulations are exposed, high levels of anxiety are presented and there will be a decline in working memory and attention.20 also, less technological advances in a rural areas, such as internet access or ownership of computers which also provide visual stimulation would make the children in rural areas to not use visuospatial memory as often as children in the urban areas.4 children who have access to a computer may perform better in cognitive development. computer applications such as computer games can increase some cognitive skills, such as visual intelligence skills, spatial skills, and visual attention skills. therefore, children in rural area can experience a delay in visuospatial memory development. there are some limitations encountered that may affect the results of this study. the room used for the test performed is not soundproof, thus, the sound from the outside of the room can interfere child’s concentration and affect the results of the tests. it is therefore recommended that soundproof room or other places that can minimize all types of distractions is needed for future study. besides several confounding factors may also affect the result of this study such as the nutritional status, the activity, the emotion and the motivation of the children during the test, as well as the parenting patterns. future studies are expected to overcome these confounding factors and to find the association of these factors with child intelligence. in summary, the intelligence of the children based on short-term memory tests consisting of digit span backward and symbol digit modalities test is higher in an urban areas compared to a rural areas in jatinangor. improving the quality of teaching methods in educational institutions is needed to enhance the intelligence of students in rural area. parents are also needed to pay more attention to the environment around the children to provide a good stimulus for the cognitive and to eventually improve cognitive abilities in their children. references 1. ropper ah, brown rh. adams and victor’s principles of neurology. eigth edition ed. new york: mcgraw-hill professional; 2005. 2. sadock bj, sadock va. kaplan & sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 10th ed. philadelphia: lippincott williams & wilkins; 2007. 3. santos mm, corsi c, marques la, rocha na. comparison of motor and cognitive performance of 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the environmental, not genetic, effect on iq. plos one. 2012;7(2):e30320. 8. postle br, pasternak t. short term and working memory. in: squire lr, editor. encyclopedia of neuroscience. san diego, ca: elsevier; 2009. p. 783–9. 9. fornasari rdccv, de lima tf, ciasca sm. profile performance of working memory in children of elementary schools. psychology. 2013;4(10):42–7. 10. rodrigues a, befi-lopes dm. shortterm phonological memory in preschool children. codas. 2013;25(5):422–8. 11. majerus s, van der linden m. memory disorders in children. in: dulac o, lassone m, sarnat hb, editors. handbook of clinical neurology. vol 111. amsterdam: elsevier; 2013. p. 251–5. 12. woods dl, kishiyama mm, yund ew, herron tj, edwards b, poliva o, et al. improving dgit span assessment of short-term verbal memory. j clin exp neuropsychol. 2011;33(1):101–11. 13. forn c, belloch v, bustamante jc, garbin g, parcet-ibars ma, sanjuan a, et al. a symbol digit modalities test version suitable for functional mri studies. neurosci lett. 2009;456(1):11–4. 14. li r, qin w, zhang y, jiang t, yu c. the neuronal correlates of digits backward are revealed by voxel-based morphometry and resting-state functional connectivity analyses. plos one. 2012;7(2):e31877. 15. baron is. neuropsychological evaluation of the child. new york: oxford university press; 2004. 16. st clair-thompson hl, allen rj. are forward and backward recall the same? a dual-task study of digit recall. mem cognit. 2013;41(4):519–32. 17. kaneko h, yoshikawa t, nomura k, ito h, yamauchi h, ogura m, et al. hemodynamic changes in the prefrontal cortex during digit span task: a near-infrared spectroscopy study. neuropsychobiology. 2011;63(2):59–65. 18. stansfeld sa, berglund b, clark c, lopezbarrio i, fischer p, ohrstrom e, et al. aircraft and road traffic noise and children’s cognition and health: a cross-national study. lancet. 2005;365(9475):1942–9. 19. gago d, de almeida rmm. effects of pleasant visual stimulation on attention, working memory, and anxiety in college students. psychol neurosci. 2013;6(3):351–5. 20. giron pr, de almeida rmm. influence of aversive visual stimulation on attention, working memory, and anxiety in university students. psychol neurosci. 2010;3(1):109–15. amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 16 amj march 2020 lipid level of street food at cibeusi elementary school in jatinangor subdistrict, west java, indonesia siti nur fatimah,1 indri nurul hayyi,2 adria adnan3 1department of public health faculty of medicine universitas padjadjaran, 2faculty of medicine universitas padjadjaran, 3department of biomedical sciences faculty of medicine universitas padjadjaran correspondence: siti nur fatimah, department of public health, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, e-mail: st_nurf@yahoo.com introduction school-aged children have quite high energy consumption demand as well as their need for food because they are growing and active physically.1,2 children tend to eat small amounts of food frequently throughout the day because the stomach capacity is small. to overcome the high total calorie requirements, they should have more meal servings, therefore, additional food or snacks are considered necessary. additional food or snacks provide additional energy in 2 hours after a meal, so their body can remain fulfilling the nutritional requirements. it is good to give the schoolaged children additional food or snacks twice a day between the main meal, in mid-morning and mid-afternoon.3,4 street foods are readyto-eat food and beverages prepared and/or sold by vendors and hawkers especially in the streets or other similar public places.5 children have different nutrition necessities based on age and gender. seven to nine years old children need 45 gram protein and 1800 kcal energy per day. ten to twelve years old children need 50 gram protein and 2050 kcal energy per day.6 the emphasized snacks are foods which contain 300 kcal energy and 5 gram protein or provide 10–̶ 20% energy and protein for everyone in a day.7,8 additional food or snack consumption would meet 23%, 21.7%, and 30% of total daily energy, protein, and fat requirements, respectively.9 those are considered higher than the total daily requirements themselves, especially in fat consumption. in indonesia, it is common that school-aged children frequently consume additional food or snacks from street food vendors around their schools. this study aimed to reveal the lipid level of street food in an elementary school, jatinangor subdistrict, sumedang, west java, indonesia. amj. 2020;7(1):16–9 abstract background: school-aged children have quite high energy consumption demand because they are growing and physically active. in indonesia, school-aged children frequently consume their additional foods/snacks from street food vendors around their schools. this study aimed to reveal the lipid level of street food in elementary schools, in jatinangor subdistrict, west java, indonesia. methods: this study was an observational descriptive study. elementary schools in jatinangor subdistrict were selected using a random sampling method. four frequent street foods were fried meatball (in indonesian: bakso goreng (basreng)), batagor (bakso tahu goreng), crepes, and egg roll were then taken, and lipid level was measured twice using soxhlet extraction method. results: fried meatball contained 22.10% (±0.23%) or 2.78 gram lipid, batagor 30.091% (±4.14%) or 12.49 gram lipid, crepes 7.14% (± 0.12%) or 0.66 gram lipid, and egg roll 13.66% (±1.63%) or 1.28 gram lipid. conclusions: only the batagor fulfilled the lipid demand in one snack time. it is recommended to minimize the intake of batagor as a between-meal snack for a balanced nutrient intake control. keywords: lipid level, soxhlet extraction, street food https://doi.org/10.15850/amj.v7n1.1684 althea medical journal. 2020;7(1) 17 methods this descriptive observational study was conducted by taking some samples of street food from elementary school in the jatinangor subdistrict, sumedang regency, west java province, indonesia in september 2013. the school was selected by using a random sampling method. a preliminary survey was implemented by using an interview approach to reveal the most commonly consumed type of foods in that school. of each sample, the lipid level was measured in duplo directly by the soxhlet extraction method. lipid was extracted from an organic solvent, diethyl eter, by refluxing at a temperature that was suitable with the boiling point of the solvent used. in brief, the chosen snack had been dried and refined, before encased with filter paper. the filter paper that contained the sample was inserted into the soxhlet equipment. on top of it, condenser had been installed and on the bottom of it, a flask was placed, which contained solvent. reflux was then conducted for five hours until the solvent descended back into a flask. during reflux, the solvent would evaporate and dissolve fat in the sample. furthermore, the fat would enter into a flask. the flask containing the fat of extraction result was heated in the oven at 1500c, until its weight was constant. after the flask was cooled, the fat weight was weighted. some factors such as particle size, type of solvent, duration of extraction, and temperature of extraction could influence the soxhlet method analysis result. the smaller particle size resulted in greater total particle surface that exposed to the solvent, the faster and more efficient the extraction process could occur. the lipophylic solvent was the best type of solvent because of its compatibility with the sample’s lipid component and thus produced a better extraction result. the longer the duration of extraction, the more soluted lipid the soxhlet extraction could produce, so there was nearly no residual sample to be found. this process of extraction must be performed at a suitable temperature that was compatible with the solvent evaporating point.10 after conducting soxhlet extraction, lipid level of the foods was calculated by using this formula: wc–wa wb note: wc=pre-distilled flask weight, wa=distilled flask weight, wb=sample weight results before the study started, a survey was established to explore the most commonly consumed type of food. from fourteen that were available and sold in the school, five foods were listed as the most consumed type of food, including fried meatballs (in indonesian: bakso goreng (basreng), batagor (bakso tahu goreng), crepes, egg roll, and sandwich. only basreng, batagor, crepes and egg roll were further included in this study since the sandwich vendor did not appear during the sampling. of the four types of street food that were the most frequently eaten by the school children in elementary school in jatinangor subdistrict, batagor had the highest lipid level compared to other street food which was 30.091 percent (±4.14%) or 12.49 gram lipid (table 1). discussion soxhlet extraction is a lipid-level measurement for solid material, including a solid food sample that uses lipid soluting phenomenon table 1 lipid level of street food at cibeusi elementary school street food sample weight (gram) lipid level (%) sample weight per portion (gram) lipid weight per portion (gram) basreng 2.96 22.10 37.35 2.78 batagor 2.65 30.91 107.25 12.49 crepes 2.81 7.14 25.95 0.66 egg roll 2.87 13.66 26.90 1.28 average 18.89 49.36 4.30 note: fried meatball or bakso goreng (basreng); batagor (bakso tahu goreng). the lipid level was average of duplo measurement % lipid= x 100 wc–wa% lipid= x 100 wc–wa wc–wa wb% lipid= x 100 wb wb% lipid= x 100% lipid= x 100 siti nur fatimah et al.: lipid level of street food at cibeusi elementary school in jatinangor subdistrict althea medical journal. 2020;7(1) 18 amj march 2020 by evaporating solvent. there are some solvent for soxhlet extraction that can be used, for example, hexane and diethyl ether. our study has used hexane as a solvent because of its non-flammable property and cheapness.10 the duplo process, in which lipid level measurement was performed twice, was conducted in each of the samples. the measurement had two different results. as had been explained before, there were some factors such as particle size, type of solvent, duration of extraction, and temperature of extraction that could influence soxhlet method analysis result.10 this study revealed that batagor had the highest result with 30.91% average and crepes had the lowest one, 7.14% average. these two foods differed in their ingredients and processing. one portion of basreng contained 2.78 grams of lipid, batagor contained 12.49 gram of lipid, crepes contained 0.66 grams of lipid, and egg roll contained 1.28 grams of lipid. the results can be compared to the guidance on additional food for school-aged children serving in 2012 (in indonesian: pedoman penyediaan makanan tambahan anak sekolah 2012), which suggested that each child should consume additional food or snacks containing 300 kcal of energy and 5 grams of protein distributed in two snack times. lipid and carbohydrate should contain 75 kcal and 180 kcal of energy every day. in one snack time, the snack should contain 37.5 kcal of energy from lipid or equals to 4.16 grams of lipid.11 daily lipid dietary consumption should not comprise over 25 percent of total daily energy needs.12 excessive lipid consumption can lead to obesity and increase the risk of vascular and heart disease in the future. however, insufficient daily lipid consumption can also give rise to health problems, for example, failure to thrive, vitamin and mineral absorption disorder, and immune disorder.13,14 a study conducted in on 4th and 5th graders elementary school in bogor has revealed that additional food or snack consumption in school-aged children exceeded daily nutritional needs.9 this study has shown that about 23% of energy needs 21.7% of total protein need, and 30% of total fat need have to be fulfilled by consuming the additional food or/snacks alone. some factors would be considered as limitations of this study. the soxhlet extractor apparatus used in this study could not interpret the sensitivity and specificity values because it has measured processed food instead of pure lipid solution. human error such as non-homogenous sample because unevenly mashed and unclean flask contaminated by human skin fat may also interfere with the result of lipid level measurement. this study concluded that the lipid level in a portion of batagor fulfilled the lipid demand in one snack time. education for the students needs to be given on how to select safe street foods. furthermore, healthy canteens at school need to be considered to provide more healthy food. acknowledgment we are grateful to elementary school in cibeusi elementary school for collaboration in this study. references 1. kusmandayu t, muniroh l. relationship between the level of knowledge and street food consumption patterns with nutritional status of children. international proceedings of chemical, biological and environmental engineering. 2012;39:30– 4. 2. hariyadi d, damanik mr, ekayanti i. analisis hubungan penerapan pesan gizi seimbang keluarga dan perilaku keluarga sadar gizi dengan status gizi balita di provinsi kalimantan barat. jurnal gizi dan pangan. 2010;5(1):61–8. 3. soetrisno us, almasyhuri, karyadi l. pengaruh makanan tambahan glikemik tinggi terhadap peningkatan konsentrasi belajar siswa sekolah dasar. penel gizi makan. 2005;28(2):83–91. 4. loubna b, nacer aa. food and nutrition education; elaboration of a guide for children of 6 to 12 years. int j nutr metab. 2012;4(1):1–10. 5. khairuzzaman m, chowdhury fm, zaman s, al mamun a, bari ml. food safety challenges towards safe, healthy, and nutritious street foods in bangladesh. int j food sci. 2014;2014:483519. 6. menteri kesehatan republik indonesia. keputusan menteri kesahtan republik indonesia nomor 1593/menkes/sk/ xi/2005 tentang angka kecukupan gizi yang dianjurkan bagi orang indonesia. jakarta: kementerian kesehatan republik indonesia; 2005. 7. temple jl, bulkley am, badawy rl, krause n, mccann s, epstein lh. differential effects of daily snack food intake on the reinforcing value of food in obese and nonobese women. am j clin nutr. althea medical journal. 2020;7(1) 19 2009;90(2):304–13. 8. lachat c, khanh lnb, khan nc, dung nq, anh ndv, roberfroid d, et al. eating out of home in vietnamese adolescents: socioeconomic factors and dietary associations. am j clin nutr. 2009;90(6):1648–55. 9. syafitri y, syarief h, baliwati yf. kebiasaan jajan siswa sekolah dasar (studi kasus di sdn lawanggintung 01 kota bogor). jurnal gizi dan pangan. 2009;4(3):167–75. 10. blum-fretz c, baumann a, feifel s. fat determination: comparison between soxhlet and hot extraction using the extraction units e-812/e-816. best@ buchi: information bulletin: 2007;47:1-8. 11. direktorat pendidikan madrasah ditjen pendidikan islam. pedoman pelaksanaan penyediaan makanan tambahan anak sekolah (pmt-as) bagi siswa ra dan mi tahun 2012. jakarta: kementerian agama republik indonesia; 2012 12. zhang j, hebert jr, muldoon mf. dietary fat intake is associated with psychosocial and cognitive functioning of schoolaged children in the united states. j nutr. 2005;135(8):1967–73. 13. hendriksen ma, boer jm, du h, feskens ej, van der a dl. no consistent association between consumption of energy-dense snack foods and annual weight and waist circumference changes in dutch adults. am j clin nutr. 2011;94(1):19–25. 14. st-onge mp, aban i, bosarge a, gower b, hecker kd, allison db. snack chips fried in corn oil alleviate cardiovascular disease risk factors when substituted for low-fat or high-fat snacks. am j clin nutr. 2007;85(6):1503–10. siti nur fatimah et al.: lipid level of street food at cibeusi elementary school in jatinangor subdistrict vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 7 malnutrition in non-hodgkin lymphoma patients at dr. hasan sadikin general hospital bandung azizah puspitasari ardinal,1 siska wiramihardja,2 indra wijaya3 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia,3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: azizah puspitasari ardinal, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: azizahardinal40@gmail.com introduction non-hodgkin lymphoma (nhl) is a malignancy derived primarily from lymphocytes, mostly from b and t cells.1 the prevalence of nhl is the highest among all hematologic malignancies with the incidence is 2.8% among all cancers. in indonesia, nhl is the seventh most frequently diagnosed cases among all cancers with 4.1% incidence. malnutrition in cancer patients is usually caused by chronic inflammation. but in hematological malignancies, the high dose of chemotherapy may worsen the nutritional status. nhl patients’ nutritional status may affect the patients’ respond to therapy and prognosis.2 there are several screening tools available to be used as a nutritional assessment in cancer patients. previous studies had shown various malnutrition among cancer patients, for example nrs 2002 has been used as the screening tool and it is common among oncology patients to have a higher risk of malnutrition.3 another study has used nri as screening tools, resulted that around 40% of cancer patients were malnourished.4 recently, american society for parenteral and enteral nutrition (aspen) recommends subjective global assessment (sga) as a nutritional screening tool.5 a study conducted in china has shown that the clinical application of sga in gastrointestinal cancer is a safe, cheap, and reliable method to screen patients’ nutritional status.6 nutrition is an important aspect in cancer patients. study about nutritional status of cancer patients has been conducted in medan,7 amj. 2019;6(1):7–12 abstract background: non-hodgkin lymphoma (nhl) has the highest prevalence among hematologic malignancies. the prognosis and response to therapy in nhl patients may worsen in the presence of malnutrition. the aim of the study was to describe the malnutrition status in nhl patients. methods: this was a cross-sectional descriptive study. nutritional status was assessed using subjective global assessment (sga) obtained from the medical records of all nhl patients at dr. hasan sadikin general hospital registered in 2017. results: in total, there were 78 medical records of nhl patients that fulfilled the inclusion criteria. all nhl patients had experienced malnutrition, categorized as mild-moderate malnutrition (70.5%) and severe malnutrition (29.5%). in nhl patients with mild-moderate malnutrition, 29% had 5–10% weight loss; 60% had suboptimal solid diet; 56.4% experienced anorexia; and 50.9% had subcutaneous fat loss. in nhl patients with severe malnutrition, 78.3% had more than 10% weight loss; 73.9% had suboptimal solid diet; 78.3% experienced anorexia; and 100% had subcutaneous fat loss. conclusions: based on subjective assessment, all nhl patients were malnourished and experienced change of food intake and loss of subcutaneous fat, therefore, a better nutritional support scheme are crucial for nhl patients. keywords: non-hodgkin lymphoma, malnutrition, subjective global assessment althea medical journal. 2019;6(1) 8 amj march 2019 however, sga as a tool in assessing nutritional status among nhl patients has not been explored. the aim of the study was to describe the nutrition status among nhl patients at dr. hasan sadikin general hospital, registered in 2017. methods this study was a descriptive cross-sectional study. study protocol had been approved by the health research ethics committee, faculty of medicine, universitas padjadjaran number 376/un6.kep/ec/2018. data were collected from the medical records of all nhl patients registered in 2017. the inclusion criteria were nhl patients aged 18 years old or older. incomplete medical records were excluded. nutritional status of the patients were obtained from the sga form that were included in the patients medical record. generally, sga has been considered as gold standard to detect malnutrition as recommended by american society for parenteal and enteral nutrition (aspen). points assessed by sga were recent weight loss, gastrointestinal changes (nausea, vomit, diarrheae, anorexia), changes in functional capacity, and physical changes (muscle atrophy, subcutaneous fat loss, edema and ascites). sga was then categorized into sga-a, sga-b, and sga-c for well-nourished, mild to moderately malnourished, and severely malnourished, respectively. sga-a was designated when the patient had no weight loss, no gastrointestinal symptoms, no change of food intake, no subcutaneous fat loss, no muscle wasting, and no ankle edema; sga-b when the patient had marked changes in food intake and 5-10% weight loss with mild to moderate condition in other variables; sga-c when the patient had severe change of food intake or starvation, more than 10% weight loss, and severe condition in other variables.6 the data was analyzed using ibm spss statistic version 22.0. results out of 116 nhl adult patients registered during 2017, complete data were collected from 78 patients. all patients were malnourished; 70.5% had mild-moderate malnutrition and 29.5% had severe malnutrition. due to the significant differences in the number of patients among the two groups, this study only described the characteristics within each group. the patients’ characteristic showed that most of the malnourished patients in both degree of malnutrition were males. the age group that had the highest incidence was 61 to 70 years old (25.5%) in mild-moderate malnutrition and 51 to 60 years old (30.4%) in severe malnutrition. the majority of patients with mild-moderate malnutrition (50.9%) and severe malnutrition (56.5%) were senior high school graduates. more than half of patients with mild-moderate malnutrition was still ambulatory (65.5%). meanwhile in patients with severe malnutrition, the number of patients who was immobile was slightly higher than those who were not (52.2%). nearly half of patients with mild-moderate malnutrition had normal bmi (49.1%). almost all severely malnourished patients were underweight according to the bmi (91.3%) (table 1). weight loss in patients with mild-moderate malnutrition were varied with most frequent loss between 5–10% (29.1%). most of patients with severe malnutrition experienced more than 10% weight loss (78.3%). suboptimal solid diet was the most common form of dietary intake change in both degree of malnutrition (60% and 73.9%). while the most common type of gastrointestinal change experienced by patients from both degree of malnutrition was anorexia (56.4% and 78.3%). half of the patients with mild-moderate malnutrition (50.9%) and all of the patients with severe malnutrition (100%) experienced subcutaneous fat loss (table 2). discussion our study has shown that all nhl patients experienced malnutrition with mild-moderate malnutrition in larger proportion compared to severe malnutrition. this finding is consistent in other study showing that nhl patients had more mild-moderate malnutrition than severe malnutrition.7 malnutrition is the most often comorbidity found in cancer patients, known as chronic disease-related malnutrition.8 the protein, carbohydrate, and fat metabolism are all affected by chronic systemic inflammation due to the presence of malignancy which causes a hyper catabolic condition.9 there are more malnourished patients detected by sga than bmi in this study. nutritional status could not be concluded by the measurement of current anthropometry only. it is important to consider the use of screening tools that assess other factors such as weight loss, anorexia, muscle atrophy, and subcutaneous fat loss. this finding is althea medical journal. 2019;6(1) 9azizah puspitasari ardinal et al: malnutrition in non-hodgkin lymphoma patients at dr. hasan sadikin general hospital bandung consistent, showing that malnutrition is more identified by sga rather than than bmi.6 interestingly, nearly half of the mild to moderately malnourished patient have normal bmi. moreover, male has experienced mild-moderate malnutrition and severe malnutrition. this finding might be due to the higher incidence of nhl in male population than female population in indonesia2 and this similar result has been showed that there is higher incidence of malnutrition in male population.7 the incidence of malnutrition among patients’ age group in this study is equally distributed. this finding is not in accordance with the study, resulting that the risk of malnutrition in hospitalized oncology patients is increased in elderly.3 however, age is not the only factor that contributes to the incidence of malnutrition. the other factors that may be related to malnutrition are among others smoking, reduced functional capacity, and low socio-economic status.10 furthermore, anorexia is the most common form of gastrointestinal changes that is experienced by nhl patients in this study (62.8%). this condition decreases patients’ food intake that may cause nutrient deficiencies. this finding is in corcordance with the fact that anorexia is the most common cause of decreased food intake in cancer patients (62.5%).4 the occurrence of anorexia in cancer patients might be due to chronic inflammation which releases some cytokines, affecting the appetite regulator in the hypothalamus are tnf-α and il-6. tnf-α may also increase gluconeogenesis, lipolysis, and proteolysis. serotonin release from table 1 characteristics of non hodkin lymphoma (nhl) patients and nutritional status according to subjective global assessment malnutrition mild-moderate (sga-b) severe (sga-c) n (%) n (%) gender male 32 (58.2) 15 (65.2) female 23 (41.8) 8 (34.8) age (years) 18-30 6 (10.9) 5 (21.7) 31-40 12 (21.8) 3 (13) 41-50 11 (20) 3 (13) 51-60 9 (16.4) 7 (30.4) 61-70 14 (25.5) 4 (17.4) ≥71 3 (5.5) 1 (4.3) education level not finished elementary school 2 (3.6) 1 (4.3) elementary school 10 (18.2) 2 (8.7) junior high school 5 (9.1) 6 (26.1) senior high school 28 (50.9) 13 (56.5) bachelor 10 (18.2) 1 (4.3) body mass index (kg/m2) <18.5 16 (29.1) 21 (91.3) 18.5-22.9 27 (49.1) 1 (4.3) 23-24.9 5 (9.1) 1 (4.3) ≥25 7 (12.7) althea medical journal. 2019;6(1) 10 amj march 2019 hypothalamus that is triggered by il-1 may also cause anorexia.9 decreased food intake can cause the body to undergo compensation to fulfill patients energy need.11 increased release of cytokines and body compensation toward energy imbalance may cause muscle atrophy and subcutaneous fat loss.11 in this study, physical changes such as muscle atrophy of the arm and subcutaneous fat loss is more prevalent in severely malnourished patients (87% and 100%) compared to the mild to moderately malnourished patients table 2 nutritional characteristics of non hodkin lymphoma (nhl) patients according to subjective global assessment malnutrition mild-moderate (sga-b) severe (sga-c) n (%) n (%) weight loss no 14 (25.5) 1 (4.3) yes 0–5% 13 (23.6) 2 (8.7) 5–10% 16 (29.1) 2 (8.7) >10% 12 (21.8) 18 (78.3) intake changes no 11 (20) yes suboptimal solid 33 (60) 17 (73.9) liquid 9 (16.4) 4 (17.4) hypocaloric liquid 3 (13) starvation 3 (5.5) gastrointestinal changes no 18 (32.7) 2 (8.7) yes nausea 9 (16.4) 7 (30.4) vomit 5 (9.1) 4 (17.4) diarrhea 1 (1.8) anorexia 31 (56.4) 18 (78.3) physical changes no 20 (36.4) yes muscle atrophy of arm 14 (25.5) 20 (87) subcutaeous fat loss 28 (50.9) 23 (100) foot edema 9 (16.4) 5 (21.7) sacral edema 1 (1.8) ascites 5 (9.1) 3 (13) functional capacity limitation immobility 19 (34.5) 12 (52.2) althea medical journal. 2019;6(1) 11 (25.5% and 50.9%). a decrease in the average value of mid-upper arm muscle circumference (mamc) and triceps skinfold (tsf) in mildly to moderately malnourished patients to severely malnourished patients might occured.6 muscle atrophy and subcutaneous fat loss are signs of cancer cachexia.9 the diagnostic criteria for cachexia is weight loss more than 5% or more than 2% in patients with bmi less than 20kg/ m2. patients in this study that met the weight loss criteria of cachexia are 50.9% in mildmoderate malnutrition and 87% in severe malnutrition. about half of severely malnourished patients in this study is immobile (52.2%) and this finding is not much of a difference to other study showing that immobile patients with cancer had severe malnutrition.13 the risk of malnutrition in hospitalized patients would increase when the patient is on bed rest.12 all patients with severe malnutrition in this study have experienced change of food intake. most patients with mild-moderate malnutrition and severe malnutrition had suboptimal solid diet (60% and 73.9%), suggesting that the majority of the patients are still able to eat but the intake is less than their nutritional needs. therefore, it should be considered to give nutritional support to these patients. in general, oral nutritional supplement (ons), enteral nutrition (en), or parenteral nutrition (pn) according to their condition can be given.14 mild to moderately malnourished and severely malnourished onco-hematological patients undergo antineoplastic therapy should be given ons. when mucositis is present, then en and ons should be given to those with moderate mucositis; en and pn should be given to severe mucositis.15 the limitation of the study is that this study only relying on a subjective nutritional assessment. a nutritional assessment should also be performed objectively, and thus, to have a comprehensive nutritional assessment. the sga form is often missing in medical record, therefore, a good systematic nutritional assessment should be conducted accordingly. to conclude, all nhl patients have experienced malnutrition assessed by a subjective global assessment with the majority had mild-moderate malnutrition; while most of severely malnourished patients have experienced change of food intake and loss of subcutaneous fat. a better macro and micronutrients for nutritional support scheme is crucial for nhl patients. references 1. reksodiputro ah, irawan c. limfoma nonhodgkin (lnh). in: setiati s, alwi i, sudoyo aw, simadibrata km, setiyohadi b, syam af, editors. buku ajar ilmu penyakit dalam jilid 3. 6th ed. jakarta: interna publishing; 2014. p. 2977-93. 2. international association of cancer registries, world health organization. global cancer observatory: cancer today. lyon, france: international agency for research on cancer (iarc); 2018. 3. planas m, alvarez-hernandez j, leonsanz m, celaya-perz s, araujo k, harcia de lorenzo. prevalence of hospital malnutrition in cancer patients: a subanalysis of the predyces® study. support care cancer. 2016;24(1):429–35. 4. hebuterne x, lemarie e, michallet m, montreuil cbd, schneider sm, goldwasser f. prevalence of malnutrition and current use of nutrition support in patients with cancer. jpen j parenter enteral nutr. 2014;38(2):196–204. 5. correia mitd. nutrition screening vs nutrition assessment: what’s the difference? nutr clin pract. 2017;33(1). 6. wu b-w, yin t, cao w-x, gu z-d, wang x-j, yan m, et al. clinical application of subjective global assessment in chinese patients with gastrointestinal cancer. world j gastrointest oncol. 2009;15(28):3542–9. 7. siregar bm. gambaran status nutrisi pada pasien kanker di poli penyakit dalam divisi hemato-onkologi medik rsup h. adam malik pada bulan september–november 2014 [minor thesis]. medan: universitas sumatera utara; 2014. 8. kumar n. assessment of malnutrition and nutritional therapy approaches in cancer patients. in: kumar n, editor. nutritional management of cancer treatment effects. berlin, heidelberg: springer; 2012. p. 7–41. 9. aoyagi t, terracina kp, raza a, matsubara h, takabe k. cancer cachexia, mechanism and treatment. world j gastrointest oncol. 2015;7(4):17–29. 10. silva fr, de oliveira mg, souza as, figueroa jn, santos cs. factors associated with malnutrition in hospitalized cancer patients: a croos-sectional study. nutr j. 2015;14;123. 11. aapro m, arends j, bozzetti f, fearon k, grunberg s, herrstedt j, et al. early recognition of malnutrition and cachexia in the cancer patient: a position paper of azizah puspitasari ardinal et al: malnutrition in non-hodgkin lymphoma patients at dr. hasan sadikin general hospital bandung althea medical journal. 2019;6(1) 12 amj march 2019 a european school of oncology task force. ann oncol. 2014;25(8):1492–9. 12. konturek pc, herrmann hj, schink k, neurath mf, zopf y. malnutrition in hospitals: it was, is now, and must not remain a problem! med sci monit. 2015;21:2969–75. 13. nouh f, omar m, alshukri a, younis m, elmabsout a, salem m, et al. nutritional status of female breast cancer patients in benghazi city of libya. sch j app med sci. 2017;5(6b):2179–87. 14. arends j, baracos v, bertz h, bozzetti f, calder pc, deutz nep, et al. espen expert group recommendations for action against cancer-related malnutrition. clin nutr. 2017(36):1187–96. 15. gómez-candela c, albendea mac, milla sp, arias rdp, gómez jd, rodríguezdurán d, et al. nutritional intervention in oncohematological patient. nutr hosp. 2012;27(3):669–80. althea medical journal. 2017;4(2) 228 amj june 2017 effect of sappan wood ethanol extracts (caesalpinia sappan. l) to the sperm motility, viability, and concentration of male wistar rats nadiyah,1 andri rezano,2 sunarjati sudigdoadi3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine, universitas padjadjaran, 3department of microbiology and parasitology faculty of medicine universitas padjadjaran abstract background: idiopathic male infertility becomes an issue because of the limited management options and increasing number of infertile couples. sappan wood (caesalpinia sappan. l) is an herbal plant predicted to have fertility and spermatogenesis enhancing effects through antioxidant properties. this study aimed to observe the effects of sappan wood ethanol extract in improving sperm quality of male wistar rat based on sperm motility, viability, and concentration. methods: this was an experimental laboratory study by using sappan wood ethanol extracts as material and male wistar rat as the experimental animal. twenty-four adult male wistar rats were divided into 4 groups including rats which were treated with aquades, 30, 60, and 120 mg/kg/day/orally of ethanol extract of sappan wood, respectively, during 35 days. after this period, the animals were sacrificed. then the epididymis were taken for samples to calculate sperm motility percentage, sperm viability percentage and sperm concentration. comparison between control group and the treated group was analyzed by one-way annova. results: there were significant differences between the control group and the group with 120 mg/kg of sappan wood ethanol extracts in the percentage of motility (36.39% and 51.75%; p-value 0.001), viability percentage (55.36% and 66.63%, p-value 0.031), and sperm concentration (54.47 million/ml and 47.79 million/ml; p-value 0.001). conclusions: the ethanol extract of sappan wood with a dose of 120 mg/kg for 35 days is able to improve sperm motility percentage, sperm viability percentage, and sperm concentration of male wistar rat. keywords: antioxidant, caesalpinia sappan. l, infertility correspondence: nadiyah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85782318569 email: nadiyah.96.28@gmail.com introduction infertility is a global health problem affect 15% couples worldwide.1 approximately 50 million couples suffered from infertility by year 2010 compared to 42 million couples suffered from infertility by year 1990. the highest prevalence of infertility occurs in south asia, sub-saharan africa, north africa, middle east, central europe, eastern europe, and central asia.2 infertility has become an issue for its impact to the quality of life of married couples. infertile couples have had to undergo a lengthy treatment and management regimen that may place burdens on their life. the lengthy treatment has affected psychological problems of infertile couple and also there were embarrassment and social stigma felt by childless couple.3 infertility can be found in either males or females. approximately 40% of infertility cases are caused by male infertility. in male infertility cases, approximately 30 to 45% of the cases have unknown causes or is defined as idiopathic male infertility.1 the etiology and pathophysiology of idiopathic male infertility are still unknown. the existing treatment and management for idiopathic male infertility are still very limited and lacking in efficacy.4 empirical therapies to treat idiopathic male infertility are antioxidant supplements. several studies stated that combination of antioxidant supplements, such as vitamin c, vitamin e, zinc, selenium, l-carnitine, and coenzyme q10, taken orally may increase sperm quality based on sperm concentration, amount, and motility. amj. 2017;4(2):228–33 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1078 229 althea medical journal. 2017;4(2) antioxidants may increase sperm quality by preventing sperm damage caused by oxidative stress that may occur in male infertility.5 sappan wood (caesalpnia sappan. l) is a species of flowering tree in the legume family, fabaceae, that is native to southeast asia and commonly found in indonesia. the main component of sappan wood that act as an antioxidant is brazilin. the structure of hydroxyl chain in brazilin contains phenolic compound that inhibit free radicals or reactive oxygen species (ros) production.6 regulation of ros plays an important part in normal spermatogenesis and sperm production.7 therefore, sappan wood may affect in improving sperm quality. this study aimed to observe the effects of sappan wood ethanol extract on sperm quality parameters based on sperm motility percentage, sperm viability percentage, and sperm concentration of male wistar rat. methods this was an experimental study which conducted in laboratory of natural products, faculty of pharmacy, universitas padjadjaran for the extraction of the sappan wood; laboratory of pharmacology and therapeutics, faculty of medicine, universitas padjadjaran for animal experiments, and the laboratory of anatomy and cell biology, faculty of medicine, universitas padjadjaran for the semen analysis in male rat, from september to december 2015. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the object of the study were male wistar rats. sappan wood used in the study was obtained from the research institute of medicinal and aromatic plants, bogor and was determined in herbarium bogoriense institute, lembaga ilmu pengetahuan indonesia (lipi). sappan wood ethanol extract was processed in laboratory of nature materials, faculty of pharmacy, universitas padjadjaran. the extraction process started with pulverizing the sappan wood. shaved sappan wood firstly washed and thinly sliced, and then dried at room temperature until the water content reduce. the extract was processed by maceration technics, using ethanol 70% for 24 hours in macerator. macerate was separated by filtration using a buchner funnel which connected to a vacuum. the filtering process was needed to be completed at least twice by using the same type and amount of solvent. then, all macerate was collected and evaporated using a rotary evaporator to obtain a yellow-brown viscous extract.8 sappan wood ethanol extract formed into suspension with 100 ml of sodium carboxyl methyl cellulose (cmc na) 0.5%. by using the frederer’s formula, the total sampel obtained were 24 rats. twenty-four male wistar rats (rattus norvegicus) were treated for 3 dose variation of sappan wood. rats were obtained from the inter-university laboratory of biological sciences institute of technology bandung with average age and weight 2–3 months old and 180–200 gr, respectively. rats were acclimatized beforehand with the atmosphere of a research laboratory for 7 days. the inclusion criterion were all rats which had constant body weight between 180–200 grams during the adaptation period. exclusion criterion were rats which had weight loss >10% during the adaptation period. the maintenance was done under lighting process contained 12 hours of darkness and 12 hours of light with room temperature 26˚c and humidity of 60%. diet for rats was in the form of small pellets and water administered daily and ad libitum to all rat. this study divided the objects into 4 groups, 1) the control group (n=6), only given aquades, 2) group i, given a suspension of sappan wood ethanol extract 30 mg/kg body weight/day of dose, orally, 3) group ii, given a suspension of the sappan wood ethanol extract with 60 mg/kg body weight/ day of dose, orally, and 4) group iii, given suspension of sappan wood ethanol extract with 120 mg/kg body weight/day of dose, orally. the sappan wood ethanol extract was given for 35 days by oral gavage. on the 36th day, the rat was anaesthetized using ketamine (70 mg/body weight) and xylazine (10 mg/body weight) and then killed by cervical dislocation. the posterior part of the dextra and sinistra distal cauda epididymis, to the ends of the ductus deferens were isolated and placed in 0,25 ml nacl 0.9% in petri dish. sperm released by clamping the end of the epididymis and then pressed in the same direction and clamping the other end of the epididymis and also pressed in the same direction. the process was carried out several times and then stirred until homogeneous suspension obtained. calculation of sperm motility percentage, sperm viability percentage and amount or concentration of sperm was done afterwards. the percentage of sperm motility and sperm viability were calculated by evaluating nadiyah, andri rezano, sunarjati sudigdoadi: effect of sappan wood ethanol extracts (caesalpinia sappan. l) to the sperm motility, viability, and concentration of male wistar rats althea medical journal. 2017;4(2) 230 amj june 2017 the minimum of 200 sperm in 5 visual fields under a light microscope with a magnification of 400 times. sperm were then classified based on the type of movement, progressive moving sperm, non-progressive, and not-moving sperm (immotile). the viability percentage was calculated by evaluating the viability of 200 sperm by staining using eosin-y 0.5% under a microscope with a magnification of 400 times. viable sperm categorized as sperm which had white or pink head color while unviable sperm had red or dark pink of head color. the calculation of the sperm concentration was done by using the counting chamber (improved neubauer hemocytometer) which was calculated on the central grid.9 comparison of the values of control and treated groups was carried out by statistical analysis of variance (anova), followed by tukey’s test. this study used a confidence interval of 95% and the result stated to be statistically significant if the p-value <0.05. the normality of obtained data was tested using the shapiro-wilk test, due to the total number sample was ≤50 and data homogeneity test was using levene test. if the data were not normally distributed and the variance of the data was not homogeneous, then kruskal wallis non parametric test was performed. if the result was significant, post hoc test would be performed later. results the results of sperm motility percentage, sperm viability percentage and sperm concentration calculation were shown in figure 1 and figure 2. anova test results on motile sperm percentage showed a significant difference between the treatment groups with p-value 0.005 (table 1). post hoc test was conducted to determine which group had significant percentage motility. post hoc results showed there were significant differences between the control group and group iii (p value 0.001), between group i and group iii (p value 0.011), and between group ii and group iii (p value 0.005). the anova test results on viable sperm percentage showed significant differences between three groups; with p-value 0.002 (table 1). post hoc test showed significant difference between the control group with group iii (p value 0.031), between group i and group ii (p value 0.001), and between group i and group iii (p value 0.001). anova test results on the amount/ concentration of sperm showed a significant difference between the three groups with p-value 0.001 (table 1). results of post hoc test showed a significant difference between the control group and group iii (p value 0.001), between group i and group iii (p value 0.001), between group ii and group iii (p value 0.001). discussions this study discovered that there was significant difference in sperm quality figure 1 mean data of sperm motility percentage and sperm viability percentage note: * there was significance difference compared to control group. p-value < 0.05 error bar indicate standard deviation 231 althea medical journal. 2017;4(2) nadiyah, andri rezano, sunarjati sudigdoadi: effect of sappan wood ethanol extracts (caesalpinia sappan. l) to the sperm motility, viability, and concentration of male wistar rats between the group iii (suspension of 120 mg/ kg sappan wood ethanol extract) and control group. it is proven that the ethanol extract of the sappan wood with a dose of 120 mg/kg body weight had the effect of improving the quality of sperm including the percentage of progressively moveable sperm, the percentage of viable sperm and sperm concentration. sappan wood (caesalpinia sappan. l) contains phenolic compounds which have four main components: (1) brazilin, (2) chalcone, (3) protosappanin, and (4) homoisoflavonoid. brazilin, the main compound in the sappan wood, has a variety of biological effects among them as antioxidant, antibacterial, anti-inflammatory, anti-hepatotoxity, and antiplatelet activity.6,10 as an antioxidant, brazilin may have an effect on spermatogenesis. brazilin inhibits the production of nitrite oxide (no) which acts as a mediator in the inflammatory reaction. nitrite oxide produced by inducible nitrite oxide synthase (inos) may react with reactive oxygen species (ros) and produces nitrate species that can cause dna damage and gene mutations. in addition, the structure of the hydroxyl groups contained in brazilin which is a phenol plays a role as a major determinant in the free radical scavenging activity. the number and position of hydroxyl groups in carboxyl functional groups determines the antioxidant activity of brazilin.11,12,13 reactive oxygen species is included in the oxidation process. the oxidation refers to a series of enzymatic reactions that normally occurs in the extracellular and intracellular signaling mechanisms.14 the main source of ros derived from cell activities that require more oxygen, namely the mechanism of electron transport in the mitochondria. regulation of ros production and oxidationreduction reactions play an important role note: * there was significance difference compared to control group. p-value < 0.05 error bar indicate standard deviation figure 2 mean data of sperm concentration table 1 mean data of sperm motility percentage, sperm viability percentage and sperm concentration parameter treatment group p value control group group i group ii group iii motility (%,sd) 36.39(3.28) 40.67(4.69)** 39.43(7.86)** 51.75(9.63)* 0.005 viability (%,sd) 55.36(9.28) 47.69(7.95)** 65.44(9.15)# 66.63(6.07)* 0.002 concentration (million/ ml,sd) 40.79(3.59)** 44.85(2.80)** 42.30(2.43)** 54.47(5.81)* 0.001 note: the data are expressed as the mean±sd; *significantly different with the control group; **significantly different with group iii; #significantly different with group i althea medical journal. 2017;4(2) 232 amj june 2017 in normal spermatogenesis and sperm production.7 in semen, there are two main sources of ros, leukositospermia and sperm. most of the cemen contains leukocytes which were dominated by neutrophils. reactive oxygen species is a byproduct of neutrophils-destroypathogenic mechanisms.15 several preliminary studies showed a correlation between a decrease in sperm function with high levels of ros and pro inflammatory mediators (il-6, il-8, and tnf-α).7,14,15 increased inflammatory mediators may cause injury to the sperm and the occurrence of lipid peroxidation in cell membranes of sperm. besides leukocytes, sperm can also generate ros.7 the ability of the sperm produces ros related to the level of sperm maturation. in the process of sperm maturation, cytoplasmic residues normally removed before the sperm is released from the germinal epithelium. if there is a disruption in the maturation of sperm, there will be a build up of residual cytoplasm. cytoplasmic residues are rich of glucose-6phosphatase dehydorgenase that will produce nicotinamide adenine dinucleotide phosphate (nadph). nicotinamide adenine dinucleotide phosphate will generate ros through the action of the enzyme nadph oxidase. increased ros will eventually causes damage to sperm cells.7,14 reactive oxygen species which derived from leukocytes known as external ros, whereas ros generated from the sperm itself is referred to internal ros. the composition of the external and internal ros affects the quality of sperm, both in dna fragmentation, sperm motility, sperm concentration, and sperm morphology. increased external ros production associated with decreased sperm motility, sperm concentration and sperm morphology. the increase in internal ros production associated with increased dna fragmentation.7 the imbalance between the production of ros as pro-oxidants and antioxidants can cause oxidative damage to cells which eventually led to the destruction of the quality of sperm. brazilin as an antioxidant thought to have the ability to improve sperm quality by preventing oxidative stress that can be caused by exposure to the environment or produced by the sperm cell itself.7,15 this result showed that that group i and group ii, which were given sappan wood ethanol extract at a dose of 30 mg/kg bw and 60 mg/kg bw, respectively, showed results of sperm concentration and sperm motility percentage which was more than the control group. however, the difference between these groups was not significant, reveals that the ethanol extract of the sappan wood with dose of 30 mg/kg bw and 60 mg/kg bw had no effect on sperm quality of male rats. the optimum dose that affect to the improving sperm quality based on sperm motility percentage, sperm viability percentage, and sperm count of male wistar rat is 120 mg/kg bw of ethanol extracts of sappan wood. this study had limitation. it was suspected that the parameter of sperm quality measurement could create a bias . in can be concluded that ethanol extract of sappan wood with a dose of 120 mg/kg for 35 days is able to improve sperm motility percentage, sperm viability percentage, and sperm concentration. references 1. jungwirth a, giwercman a, tournaye h, diemer t, kopa z, dohle g, et al. european association of urology guidelines on male infertility: the 2012 update. eur urol. 2012;62(2):324–32. 2. mascarenhas mn, flaxman sr, boerma t, vanderpoel s, stevens ga. national, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. plos med. 2012;9(12):e1001356. 3. hasanpoor-azghdy sb, simbar m, vedadhir a. the emotional-psychological consequences of infertility among infertile women seeking treatment : a result of qualitative study. iran j reprod med. 2014;12(2):131–8. 4. kim sj, kim mr, hwang sy, bae wj, kim s, hong sh, et al. preliminary report on the safety of a new herbal formula and its effect on sperm quality. world j mens health. 2013;31(3):254–61. 5. imamovic kumalic s, pinter b. review of clinical trials on effects of oral antioxidants on basic semen and other parameters in idiopathic oligoasthenoteratozoospermia. biomed res int. 2014;21(2):190–5. 6. nirmal np, rajput ms, prasad rg, ahmad m. brazilin from caesalpinia sappan heartwood and its pharmacological activities: a review. asian pac j tropmed. 2015;8(6):421–30. 7. fujii j, tsunoda s. redox regulation of fertilisation and the spermatogenic process. asian j androl. 2011;13(3):420– 3. 8. kementrian kesehatan republik indonesia. suplemen i farmakope herbal 233 althea medical journal. 2017;4(2) indonesia. jakarta: kementrian kesehatan republik indonesia; 2010. 9. who. who laboratory manual for the examination and processing of human semen [internet]. 2010 [cited 12 mei 2015]. available from : http://www.who. int/reproductivehealth/publications/ infertility/9789241547789/ 10. min bs, cuong td, hung tm, min bk, shin bs, woo mh. compounds from the heartwood of caesalpinia sappan and their anti-inflammatory activity. bioorg med chem lett. 2012;22(24):7436–9 . 11. bae i-k, min h-y, han a-r, seo e-k, lee sk. suppression of lipopoly saccharideinduced expression of inducible nitric oxide synthase by brazilin in raw 264.7 macrophage cells. eur j pharmacol. 2005;513(3):237– 42. 12. sasaki y, hosokawa t, nagai m, nagumo s. in vitro study for inhibition of no production about constituents of sappan lignum. biol pharm bull. 2007;30(1):193–6. 13. balasundram n, sundram k, samman s. phenolic compounds in plants and agri-industrial by-products: antioxidant activity, occurrence, and potential uses. food chem. 2006;99(1):191–203 . 14. tremellen k. oxidative stress and male infertility––a clinical perspective. hum reprod update. 2008;14(3):243–58. 15. kefer jc, agarwal a, sabanegh e. role of antioxidants in the treatment of male infertility. int j urol. 2009;16(5):449–57 nadiyah, andri rezano, sunarjati sudigdoadi: effect of sappan wood ethanol extracts (caesalpinia sappan. l) to the sperm motility, viability, and concentration of male wistar rats althea medical journal. 2018;5(2) 82 amj june 2018 cognitive and functional outcome of patients with ischemic stroke at dr. hasan sadikin hospital bandung najmia shabrina nahrowi,1 paulus anam ong,2 achmad adam3 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of neurosurgery faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia abstract background: stroke is the second leading cause of death and adult disability throughout the world in which the risk of cognitive impairment tripled after stroke. approximately 30% of the patients experience residual disabilities and over half of patients remain physically dependent following a stroke. this study aimed to describe cognitive and functional outcome of patients with ischemic stroke at dr. hasan sadikin hospital bandung. methods: this retrospective descriptive study used secondary data from medical records (januarydecember 2013) of patients with ischemic stroke at dr. hasan sadikin hospital, bandung, and was conducted from june–september 2017. cognitive outcome was determined by the final score of the indonesia version of moca (moca-ina), classified into impaired if the score was <26 and normal if the score was >26.whereas functional outcome was determined by degradation of barthel index (bi), from complete dependence to independence. data were analyzed, presented in the form of tables. results: out of a total of 91 subjects consisting of 46 female (50.55%) and 45 male (49.45%), the result showed 55 subjects (60.44%) had cognitive impairment with memory (75.82%) as the highest prevalence of impaired cognitive domain. the functional outcome was 34 patients (37.37%) had moderate to complete dependence whereas only 13 patients (14.29%) were independent. conclusions: cognitive impairment occurs in more than 75% ischemic stroke patients with memory as the most commonly impaired domain and more than one third of ischemic stroke patients still have moderate to complete dependence in activities of daily living (adl). keywords: cognitive outcome, functional outcome, ischemic correspondence: najmia shabrina nahrowi, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: najmiashabrina@gmail.com introduction according to who, stroke is a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin.1 stroke is the second leading cause of death after ischemic heart disease.2 the results of the basic health research 2013, (riset kesehatan dasar, riskesdas) shows that stroke is the leading cause of death in indonesia. the prevalence of stroke increases from 8.2 per 1000 (2007) to 12.1 per 1,000 (2013).3 the incidence of stroke tripled the risk of cognitive impairment and 30% of the patients experience residual disabilities, over half of patients remaining physically dependent following a stroke and approximately two-thirds having some form of neurological impairment at five years poststroke.2,4 the montreal cognitive assessment (moca) is a screening tool used to detect mild cognitive impairment. moca has a maximum score of 30; a score less than 26 indicate the presence of cognitive impairment. moca could be used to detect the mild form of cognitive impairment despite normal result of the minimental state examination (mmse). moca has higher sensitivity than mmse because moca evaluates the executive function, a cognition domain that often get impaired on stroke patients, moreover moca score could be adjusted with education level.5,6 the barthel index (bi), originally described in 1955 by dr. florence mahoney and dorothea barthel, is a ten-item measure of activities of daily living amj. 2018;5(2):82–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1173 althea medical journal. 2018;5(2) 83 (adl). in stroke medicine, bi is used in clinical practice to assess baseline abilities, to quantify functional change after rehabilitation and to inform discharge planning.7 previous studies show a rather vast variation of cognitive and functional outcomes due to multiple factors. the aim of this study was to recognize the cognitive and functional outcomes of ischemic stroke patients in bandung. methods this was a retrospective descriptive study conducted from june to september 2017. the population in this study was medical records of ischemic stroke patients registered at dr. hasan sadikin hospital bandung (period january–december 2013). the inclusion criteria specified in this study were ischemic stroke patients, had medical resume consisting of patient’s demography (name, age, sex, education, occupation), risk factors (diabetes mellitus, hypertension, dyslipidemia and smoking) and a completely filled bi and moca–indonesian version (moca-ina). the exclusion criteria in this study were the data found had an incomplete medical resume, the patient had aphasia, prestroke cognitive impairment, major psychiatric conditions and acute confusional state/delirium when going home. table 1 basic demographic and clinical data variable frequency (n=91) percentage (%) age (years) 20–29 1 1.10 30–39 3 3.30 40–49 20 21.98 50–59 35 38.46 60–69 22 24.18 >70 10 10.99 gender male 45 49.45 female 46 50.55 education uneducated 18 19.78 elementary school 37 40.66 junior high school 11 12.09 senior high school 18 19.78 college 7 7.69 occupation not working 47 51.65 employee 6 6.59 entrepreneur 15 16.48 farmer/fisherman/labor 16 17.58 others 7 7.69 modifiable risk factor hypertension 70 76.92 dyslipidemia 15 16.48 smoking 29 31.87 diabetes mellitus 12 13.19 najmia shabrina nahrowi, paulus anam ong , achmad adam: cognitive and functional outcome of patients with ischemic stroke at dr. hasan sadikin hospital bandung althea medical journal. 2018;5(2) 84 amj june 2018 cognitive impairment was determined if the moca-ina score was less than 26, whereas functional outcome was determined by the degradation of barthel index. this study had been approved previously by the health research ethic committee of the faculty of medicine, universitas padjadjaran with registration number 41/un6.c.10/pn/2017. all collected data were then analyzed using computer. furthermore, the results of data analysis were displayed in the form of tables and graphs. results the results of the subject sampling showed, out of 185 ischemic stroke patients, 94 patients did not meet the inclusion criteria due to aphasia and incomplete moca-ina and barthel index. thus, the total subjects of the study were 91 patients. from the total of 91 samples, the incidence of ischemic stroke was more common in the age group 50-59 (38.46%) and least common in the younger age group. the incidence rate was slightly higher in women (50.55%) than in men (49.45%) by a very close difference. ischemic stroke was most common in patients with elementary school education (40.66%) and least common in college level patients (7.69%). not working patients were more likely to have ischemic stroke compared to working patients; with the highest incidence of 51.65% in the not working group and the lowest incidence of 6.59% in patients who worked as employee. the most common risk factor in patients with ischemic stroke was hypertension with 76.92%, and the least common was diabetes mellitus with 13.19% (table 1). furthermore, out of the total of 91 poststroke patients, 55 patients (60.44%) had cognitive impairment whereas 36 patients (39.56%) had normal cognitive function. the highest prevalence of impaired cognitive domain was delayed recall (75.82%), followed by attention (64.84%), language (58.24%), visuospatial / executive (57.14%), abstraction (52.57%), and the lowest was orientation (43.96%) (table 2). moreover, i was found that the prevalence of subjects with moderate to complete dependence was 37.37%, and only 14.29% was with independent subjects (table 3). table 2 prevalence of cognitive impairment of patient with ischemic stroke cognitive impairment frequency (n=91) percentage (%) normal (moca-ina >26) 36 39.56 impaired (moca-ina <26) 55 60.44 visuospatial/executive 52 57.14 attention 59 64.84 language 53 58.24 abstraction 48 52.75 delayed recall 69 75.82 orientation 40 43.96 note: moca-ina, montreal cognitive assessment indonesian version table 3 prevalence of functional outcome using barthel index score score interpretation n % 0–20 complete dependency 13 14.29 25–40 severe dependency 8 8.79 45–55 moderate dependency 13 14.29 60–95 mild dependency 44 48.35 100 independent 13 14.29 total 91 100 althea medical journal. 2018;5(2) 85 discussion the basic demographic and clinical data in this study included age, sex, education level, occupation and modifiable risk factors such as hypertension, diabetes mellitus, dyslipidemia, and smoking. ischemic stroke was found most commonly in the 50-59 age group. this is consistent with a number of recent epidemiological studies that remarkably show the incidence of ischemic stroke at younger ages has been increasing since 1980s to present.8 the incidence of stroke increases with aging, however there is a shift of stroke trend in younger patients. a prospective population based study conducted for 16 years reveals an increase of stroke incidence in those who are aged 45 to 59 years. it could be due to the rise in classical cardiovascular risk factors such as diabetes mellitus, obesity and high cholesterol level.9 ischemic stroke is only slightly more common in female than male (50.55% vs. 49.45%). another retrospective hospitalbased study by farhoudi et al.10 in iran reveals a similar result in male (50.6%) and female (49.4%). moreover, the basic health research (riskesdas) 2013 result shows that stroke prevalence is similar in male and female.3 the prevalence of ischemic stroke is highest in patients with elementary school education and is less compared to those with higher education level, with the highest incidence of 40.66% at elementary school level and the lowest incidence of 7.69% at college level. this is probably due to the low knowledge of healthy lifestyle, namely maintaining food and exercise regularly.11 this study showed that the prevalence of ischemic stroke was greater in those who did not work with a percentage of 51.65%. this result is due to the influence of socioeconomic, educational and knowledge levels.12 the risk factor of subjects with hypertension as the highest prevalence is 76.92%, likewise to another epidemiologic study. the second highest was smoking with 31.87%. the association between smoking and ischemic stroke is well known and can be attributed to large-vessel atherosclerosis with stenosis.10 it was followed by dyslipidemia with 16.48%. this occurs probably due to increased intake of high carbohydrate and high fat diet that in decade can affect the high serum triglyceride.12 the lowest prevalence was diabetes mellitus, as much as 13.19%. moreover, in this study, the overall prevalence of post-stroke cognitive impairment (psci) was 60.44%. in other studies of psci in indonesia, a hospital-based, cross sectional study by hanas et al.13 reveals the incidence of psci is 92.68%. in comparison, the prevalence of psci in previously reported studies in a number of countries varies from 17% to 92%. this vast variation can be associated mainly to diversities in study site-areas, time since stroke onset, stroke type, assessment methods and diagnostic criteria.14 at three months post-stroke, approximately 60% of patients were estimated to suffer from major or residual deficits in at least one cognitive domain. the most commonly impaired cognitive domain in this study was memory (75.82%), followed by attention (64.84%), language (58.24%), visuospatial/ executive (57.14%), abstraction (52.57%), and the lowest was orientation (43.96%). this is consistent with the result of a review conducted by mohd zulkifly et al.15 which states, the most common cognitive impairments among stroke survivors are memory, orientation, language and attention, executive dysfunction (initiation inhibition, mental flexibility) and aphasia. infarctions are bound by vascular territory, thus damage is hardly limited to regions purely sub serving memory formation.16 depending on adjacent regions involved, strokes causing memory problems commonly co-occur with language and visuospatial/executive deficits.16 however, individuals with stroke often have other comorbidities, so the manifestation of cognitive symptoms after stroke is not always as expected from the location of the lesion or even the area of hypoperfusion. demographic (age and sex) and medical factors (fever, hyperglycaemia, seizures, previous history of stroke, cognitive difficulties before the onset of stroke, and medications) appeared to have some influences to which cognitive deficits after stroke are present.17 in this study, the prevalence of subjects with moderate to complete dependency was 37.37%, distinctively only 14.29% of subjects were independent. this result is consistent with that of the american heart association,18 which states that 14% of stroke survivors will achieve full recovery in their basic adls, between 25-50% require at least some assistance, and approximately half of them experience severe long-term dependency. the independence of adls is affected by various factors, stroke patients at older age, recurrent strokes, hemorrhagic stroke, dependent financial resources and risk of malnourishment have poorer adl.19 the limitation of this study is data are obtained from the medical resume of patients najmia shabrina nahrowi, paulus anam ong , achmad adam: cognitive and functional outcome of patients with ischemic stroke at dr. hasan sadikin hospital bandung althea medical journal. 2018;5(2) 86 amj june 2018 whose completeness is lower than that of the primary medical records. in addition, for a further study medical resume improvements are required. as a conclusion, more than 75% of the ischemic stroke patients experience cognitive impairment and the most commonly impaired domain is memory. approximately one third of the ischemic stroke patients experience moderate to complete dependency in activities of daily living while only less than 15% patients are independent. references 1. sacco rl, kasner se, broderick jp, caplan lr, connors jj, culebras a, et al. an updated definition of stroke for the 21st century. stroke. 2013;44(7):2064–89. 2. mellon l, brewer l, hall p, horgan f, williams d, hickey a. cognitive impairment six months after ischaemic stroke: a profile from the aspire-s study. bmc neurology. 2015;15(1):31. 3. kementrian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan; 2013. 4. danovska m, peychinska d. post-stroke cognitive impairment – phenomenology and prognostic factors. j of imab. 2012;18(3):290–7. 5. stolwyk rj, o’neill mh, mckay ajd, wong dk. are cognitive screening tools sensitive and specific enough for use after stroke? a systematic literature review. stroke. 2014;45(10):3129–34. 6. teasell r, hussein n. rehabilitation of cognitive impairment post stroke. in: teasell r, hussein n, viana r, madady m, donaldson s, mcclure a, et al. stroke rehabilitation clinician handbook. london: department of physical medicine and rehabilitation western university; 2014. 7. duffy l, gajree s, langhorne p, stott dj, quinn tj. reliability (inter-rater agreement) of the barthel index for assessment of stroke survivors. stroke. 2013;44(2):462–8. 8. putaala j. ischemic stroke in the young: current perspectives on incidence, risk factors, and cardiovascular prognosis. european stroke journal. 2016;1(1):28– 40. 9. wang y, rudd ag, wolfe cd. age and ethnic disparities in incidence of stroke over time. stroke. 2013;44(12):3298–304. 10. farhoudi m, mehrvar k, sadeghi-bazargani h, hashemilar m, seyedi-vafaee m, sadeghihokmabad e, et al. stroke subtypes, risk factors and mortality rate in northwest of iran. iran j neurol. 2017;16(3):112–7. 11. adams hp, jr., biller j. classification of subtypes of ischemic stroke: history of the trial of org 10172 in acute stroke treatment classification. stroke. 2015;46(5):e114–7. 12. romero jr, morris j, pikula a. review: stroke prevention: modifying risk factors. ther adv cardiovasc dis. 2008;2(4):287– 303. 13. hanas m, lestari e, asni ek. gambaran fungsi kognitif pada pasien pasca stroke di poliklinik saraf rsud arifin achmad provinsi riau. jurnal online mahasiswa (jom) fakultas kedokteran universitas riau. 2016;3(1):1–12. 14. qu y, zhuo l, li n, hu y, chen w, zhou y, et al. prevalence of post-stroke cognitive impairment in china: a communitybased, cross-sectional study. plos one. 2015;10(4):e0122864. 15. mohd zulkifly mf, ghazali se, che din n, singh dka, subramaniam p. a review of risk factors for cognitive impairment in stroke survivors. the scientific world journal. 2016;2016(1):1–16. 16. godefroy o. the behavioral and cognitive neurology of stroke. 2nd. cambrigde, uk: cambridge university press; 2014. 17. gottesman rf, hillis ae. predictors and assessment of cognitive dysfunction resulting from ischaemic stroke. lancet neurol. 2010;9(9):895–905. 18. kwakkel g, veerbeek jm, harmelingvan der wel bc, van wegen e, kollen bj. diagnostic accuracy of the barthel index for measuring activities of daily living outcome after ischemic hemispheric stroke. stroke. 2011;42(2):342–6. 19. pei l, zang x-y, wang y, chai q-w, wang j-y, sun c-y, et al. factors associated with activities of daily living among the disabled elders with stroke. international journal of nursing sciences. 2016;3(1):29–34. 167 althea medical journal. 2017;4(2) characteristics of neonatal hyperbilirubinemia at west java’s top referral hospital, indonesia nurain yahya,1 tetty yuniati,2 leonardo lubis3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: neonatal hyperbilirubinemia or neonatal jaundice is a common disorder and considered as one of the main problems in neonatal period worldwide with high incidence, especially in asia and southeast asia region. this study was conducted to determine the characteristics of neonatal hyperbilirubinemia including the prevalence and frequency of neonatal hyperbilirubinemia causes at dr. hasan sadikin general hospital in 2012. methods: this descriptive study was conducted at dr. hasan sadikin general hospital using the crosssectional method. four hundred and twenty five cases of neonatal hyperbilirubinemia in hospitalized and outpatients, from 1 january to 31 december 2012 were included in this descriptive study. results: the prevalence of neonatal hyperbilirubinemia was about 4.08%. causes were identified in 95 cases and the most common cause of neonatal hyperbilirubinemia during this period of time was physiological causes (23.2%). other causes included neonatal hepatitis (14.7%), other hemolytic causes (13.7%), infection (12.6%), abo incompatibility (11.6%) and breastfeeding (11.6%). conclusions: neonatal hyperbilirubinemia cases are common and remain as one of the neonatal problems in dr. hasan sadikin general hospital, thus prevention and proper management of neonatal hyperbilirubinemia should be implemented. keywords: neonatal hyperbilirubinemia, neonatal jaundice, prevalence correspondence: nurain yahya, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 857 221 43865 email: escape_k@yahoo.com introduction neonatal hyperbilirubinemia or neonatal jaundice is a condition cause by an elevation of the serum bilirubin level.1-3 it is common and considered as one of the main problems in neonatal period worldwide with high incidence, especially in asia and southeast asia region.3,4 in the course of this disorder, severe neonatal hyperbilirubinemia can cause acute bilirubin encephalopathy, with deafness and other permanent neurodevelopmental abnormalities due to brain toxicity of bilirubin occurrence.5,6 neonatal hyperbilirubinemia can be classified into physiologic jaundice and pathologic cause of jaundice.7 determination of pathologic causes is pursued when the time and course of jaundice are significantly different from that of physiologic jaundice, by using laboratory tests.3 the number of neonatal hyperbilirubinemia cases is much lower in developed countries than in the developing countries.7,8 there were a few studies conducted in indonesia recently to determine the prevalence of neonatal hyperbilirubinemia, as well as the frequency of causes. data from the perinatalogy ward at dr. hasan sadikin general hospital9 reported the prevalence of neonatal hyperbilirubinemia among full term neonates in 2008 was approximately 17.53%. another study conducted at dr. soetomo general hospital10 in 2000, showed that the prevalence of neonatal hyperbilirubinemia was 13%. studies about determining the frequency of causes of neonatal hyperbilirubinemia were not extensive due to resource limitations and reported majority of the causes were amj. 2017;4(2):167–72 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1065 althea medical journal. 2017;4(2) 168 amj june 2017 unidentified.11 this study was conducted to determine the characteristics of neonatal hyperbilirubinemia including the prevalence and the frequency of causes of neonatal hyperbilirubinemia at dr. hasan sadikin general hospital in 2012. methods the study was conducted at dr. hasan sadikin general hospital, using the crosssectional method with purposive sampling. the subjects were enlisted from hospitalized neonatal hyperbilirubinemia patients and the neonates born from 1 january 2012 to 31 december 2012 at dr. hasan sadikin general hospital. a total of 425 neonates diagnosed with neonatal hyperbilirubinemia were involved in this descriptive study. neonatal hyperbilirubinemia refers to the presence of yellowish discoloration of the skin and sclera, associated with an increase level of serum bilirubin.3 some of the babies were excluded if they had multiple congenital abnormalities. the prevalence was calculated by using the prevalence formula. the total number of neonatal hyperbilirubinemia cases was obtained from hospitalized patients and newborns. the denominator of the prevalence formula included the number of live births and the total number of pediatric patients who came to the pediatric clin in 2012. the list of identified causes of neonatal hyperbilirubinemia from these patients was collected from medical records and the frequency of causes was determined. the characteristics of the subject population were summarized using descriptive statistics. approval from the health research ethics committee was acquired before the collection of data. table 1 characteristics of study population characteristics number of patients* (n=425) percentage (%) sex male 250 58.8 female 175 41.2 birth term infant (≥ 37 weeks) 303 71.3 preterm infant (< 37 weeks) 122 28.7 type of delivery caesarean section 245 57.6 spontaneous 156 36.7 vacuum extraction 13 3.1 forceps delivery 11 2.6 birth weight, low birth weight (< 2500) 159 37.4 normal birth weight ( ≥ 2500) 266 62.6 size for gestational age appropriate for gestational age 368 86.6 small for gestational age 42 9.9 large for gestational age 15 3.5 death less than 48 hours 2 0.5 more than 48 hours 10 2.4 no 413 97.2 note: sd = standard deviation * unless stated otherwise 169 althea medical journal. 2017;4(2) nurain yahya, tetty yuniati, leonardo lubis: characteristics of neonatal hyperbilirubinemia at west java’s top referral hospital, indonesia results the study was conducted at dr. hasan sadikin general hospital, and data was collected from medical records of patients diagnosed with neonatal hyperbilirubinemia in the period between 1 january and 31 december 2012. a higher number of male patients constituted the total number of neonatal hyperbilirubinemia cases. most of the infants were term infants and had appropriate size for gestational age. those delivered through caesarean section constituted a higher proportion of the total number of neonatal hyperbilirubinemia patients, compared to those through other types of vaginal deliveries (table 1). the prevalence of neonatal hyperbilirubinemia at dr. hasan sadikin general hospital in 2012 was about 4.08%. hospitalized neonatal hyperbilirubinemia patients contributed greater proportion of the total number of neonatal hyperbilirubinemia patients than neonatal hyperbilirubinemia patients among neonates born at dr. hasan sadikin general hospital (table 2). furthermore, several causes for neonatal hyperbilirubinemia were obtained from medical records in 95 cases (22.4%). however, no cause was identified in the remaining cases (77.6%), which represented the majority. the frequency of identified causes leading to presence of neonatal hyperbilirubinemia conditions showed that the main cause of neonatal hyperbilirubinemia was due to physiological causes. the second most common cause was neonatal hepatitis, followed by other hemolytic causes and infection (figure 1). patients with complications of severe neonatal hyperbilirubinemia included 4 neonates with bilirubin encephalopathy and a neonate with kernicterus (chronic bilirubin encephalopathy). however, only the kernicterus patient died before 48 hours after birth with neonatal sepsis as the cause table 2 distribution of neonatal hyperbilirubinemia patients neonatal hyperbilirubinemia patients frequency (n) percentage (%) inpatients 171 40.24 newborns 254 59.76 total 425 100.00 figure 1 frequency and causes of neonatal hyperbilirubinemia althea medical journal. 2017;4(2) 170 amj june 2017 of death. additionally, 12 neonates died and the causes of death were mainly sepsis and neonatal hepatitis. moreover, according to history acquired from mothers of 171 hospitalized patients reported information related with the risk factors of neonatal hyperbilirubinemia such as any maternal illness during pregnancy, any previous sibling with jaundice and breastfeeding. exclusive breastfeeding was the most favorable diet given by the mothers of neonatal hyperbilirubinemia infants, followed by mixed feeding (breastfeeding and formula milk) and formula milk (table 3). four hospitalized patients had history of the first sibling with jaundice. however, no cause was known and no further information if any sibling required phototherapy for neonatal jaundice. the number of cases was 3, 4 and 1 related cases in mother with history of infection or illness during pregnancy, hypertension and diabetes mellitus, respectively. only 7 mothers aged older than 25 years were reported among the hospitalized patients. re-admission of discharged patients occurred with a chief complaint of jaundice accounted for 7 patients with mean peak total bilirubin of 15.68 mg/dl (standard deviation 5.70mg/dl). all these patients received phototherapy as the treatment. a total of 137 neonates from hospitalized neonatal hyperbilirubinemia received phototherapy and of these, only 4 neonates needed to undergo exchange transfusion. there were 5 neonates from hospitalized neonatal hyperbilirubinemia who required exchange transfusion. discussions the study showed that the prevalence of neonatal hyperbilirubinemia at dr. hasan sadikin general hospital in 2012 was 4.08%. the prevalence was lower than the prevalence of neonatal hyperbilirubinemia in the same location in 2008, which was reported as 17.53%.9 the previous study included full term infants as the subject population, while in this study both full term and preterm infants were included. descending prevalence may be due to many neonatal hyperbilirubin patients were actually managed by other health workers before coming to hospital, as the more severe conditions of neonatal hyperbilirubinemia were referred to the hospital, thus reducing the number of neonatal hyperbilirubinemia at dr. hasan sadikin general hospital. otherwise, it could be a sign assuming that proper prevention of neonatal hyperbilirubinemia guidelines published by american academy of pediatrics (aap) was implemented and improved.12 it is essential for physicians to distinguish whether the jaundice is physiologic or pathologic. benign physiologic jaundice is caused by increased production of bilirubin and immature liver function for bilirubin clearance.3 increased bilirubin production is caused by increased of ineffective erythropoiesis, increased of volume and decreased survival of red blood cells in infants.13 undetermined causes of neonatal hyperbilirubinemia constituted majority of cases in this study was similar to studies conducted in canada8 and pakistan11. many cases without reported causes in the medical records contributed to limitations in this study. economical constraints caused many patients were unable to afford to undergo several diagnostic tests; the patients’ family had to ask for early discharge from the hospital without determining the cause of neonatal hyperbilirubinemia. early onset of jaundice (less than 24 hours) is pathologic and can be caused by infection, spherocytosis, or hemolytic disease. hemolytic diseases due to abo incompatibility and glucose-6-phosphate dehydrogenase (g6pd) deficiency lead to overproduction of bilirubin.13 eleven cases of neonatal hyperbilirubinemia with abo incompatibility were reported in the study, compared to a study conducted in canada8 which presented abo incompatibility as the most common cause of severe neonatal hyperbilirubinemia, followed by g6pd deficiency. however, no g6pd deficiency cause was found in this study because g6pd enzyme test was not performed, perhaps due table 3 feeding history of hospitalized neonatal hyperbilirubinemia patients feeding type frequency (n=171) percentage (%) exclusive breastfeeding 135 78.9 mixed 31 18.1 formula milk 5 2.9 171 althea medical journal. 2017;4(2) to economical and resource constraints. other pathologic causes such as neonatal hepatitis, infections, biliary atresia and sepsis were identified from the cases in this study. neonatal hepatitis was the second most common cause and the examples of the etiologies reported were cytomegalovirus (cmv) and toxoplasmosis, other (syphilis, varicella-zoster, parvovirus b19), rubella, cytomegalovirus, and herpes (torch) infections. additionally, sepsis condition leads to mixed overproduction and under-secretion of bilirubin.13 biliary atresia was reported in one case diagnosed with cholestasis jaundice causing presentation of hyperbilirubinemia through mechanism of biliary obstruction leading to unsecretion of bilirubin.13 moreover, risk factors for development of severe hyperbilirubinemia included male sex, mothers older than 25 years, poorly established exclusive breastfeeding, sibling had jaundice and any sibling required phototherapy for neonatal jaundice.12 the higher number of male patients than female patients in this study corresponded with one of the risk factors. mothers older than 25 years of age have higher risk of pregnancy complications, such as hypertension and diabetes.14 infants of diabetic mothers are at risk of hyperbilirubinemia due to larger red cell mass, inefficient conjugation by the relative immature hepatic enzyme system and ineffective erythropoiesis, leading to increased serum level of unconjugated bilirubin.15 furthermore, breastfeeding jaundice was reported in 11 patients. these patients presented with mild dehydration and the mother mentioned that their babies did not want or were lazy to be breastfed. breastfeeding jaundice may occur due to inadequate intake and ineffective breastfeeding, thus resulting in increased enterohepatic circulation and delayed bilirubin elimination.13 one of the major risk factor for developing severe hyperbilirubinemia is cephalohematoma or any significant bruising.12 in this study, 4 neonates had cephalohematoma, which led to overproduction of bilirubin due to breakdown of extravascular blood.13 besides cephalohematoma can be caused by laceration during delivery due to the use of vacuum extraction, and traumatic injury in macrosomia babies.16 furthermore, a kernicterus (chronic bilirubin encephalopathy) case was found in this study; even it is rare since the implementation of phototherapy and exchange transfusion.6,17,18 the patient presented with apnea, which was the late effect of bilirubin toxicity. however, both the developed and developing countries are still reporting the occurrence of kernicterus, which can be prevented through proper identification and management of progression of severe neonatal hyperbilirubinemia.6,18,19 there were several limitations in this study. a number of medical records were missing and could not be tracked. more efficient administration process of getting approval letter and proper management of the medical records in the future could minimize the problems. in conclusion, the prevalence of neonatal hyperbilirubinemia in this study is 4.08 %. the most common causes are physiological causes, followed by neonatal hepatitis, other hemolytic causes, infections, abo incompatibility, breastfeeding jaundice, sepsis, cephalohematoma, other nonhemolytic causes, drug-induced hepatitis and billiary atresia. the high number of neonatal hyperbilirubinemia cases indicates that neonatal hyperbilirubinemia cases are common and remain as one of the neonatal problems at dr. hasan sadikin general hospital. therefore, proper management of neonatal hyperbilirubinemia cases by health care practitioners should be improved. prevention of severe neonatal hyperbilirubinemia should be implemented by members of the society. references 1. taeusch hw, ballard ra, gleason ca, avery me. avery’s diseases of the newborn. 9th ed. philadelphia: elsevier saunders; 2012. p. 1129–1148. 2. brown ak. kernicterus: past, present, and future. pediatrics. 2003;4(2):e33–40. 3. kliegman rm, stanton bmd, geme js, schor nf, behrman re. nelson textbook of pediatrics: expert consult. 19th ed. philadelphia: elsevier health sciences; 2011. p. 603–8. 4. setia s, villaveces a, dhillon p, mueller ba. neonatal jaundice in asian, white, and mixed-race infants. arch pediatr adolesc med. 2002;156(3):276–9. 5. du l, ma x. international perspectives: hyperbilirubinemia and kernicterus in neonates in china. neoreviews. 2012;13(3):e141–4. 6. maisels mj. neonatal jaundice. pediatr rev. 2006;27(12):443–54. 7. national institute for health and care excellence. neonatal jaundice: nice clinical guideline 98. manchester: nurain yahya, tetty yuniati, leonardo lubis: characteristics of neonatal hyperbilirubinemia at west java’s top referral hospital, indonesia althea medical journal. 2017;4(2) 172 amj june 2017 national institute for health and clinical excellence. 2010 [cited 2013 march 21]: available from: http://www.nice.org.uk/ nicemedia/live/12986/48678/48678.pdf. 8. sgro m, campbell d, shah v. incidence and causes of severe neonatal hyperbilirubinemia in canada. cmaj. 2006;175(6):587–90. 9. widiasta a, reniarti l, sukadi a. incidence of neonatal hyperbilirubinemia in low, intermediate-low, and intermediate-high risk group infants. paediatr indones. 2010;50(6):351–4. 10. indriyani sak, retayasa iw, surjono a, suryantoro p. percentage birth weight loss and hyperbilirubinemia during the first week of life in term newborns. paediatr indones. 2009;49(3):149–54. 11. tikmani ss, warraich hj, abbasi f, rizvi a, darmstadt gl, zaidi ak. incidence of neonatal hyperbilirubinemia: a populationbased prospective study in pakistan. trop med int health. 2010;15(5):502–7. 12. moerschel sk, cianciaruso lb, tracy lr. a practical approach to neonatal jaundice. am fam physician. 2008;77(9):1255–62. 13. cloherty jp, eichenwald ec, hansen ar, stark ar. manual of neonatal care. 7th ed. philadelphia: wolters kluwer health; 2012. p. 304–39 14. lazarus c, avchen rn. neonatal hyperbilirubinemia management: a model for change. j perinatol. 2009;29(suppl 1):s58–60. 15. nold jl, georgieff mk. infants of diabetic mothers. pediatr clin north am. 2004;51(3):619–37, viii. 16. gudmundsson s, henningsson ac, lindqvist p. correlation of birth injury with maternal height and birthweight. bjog. 2005;112(6):764–7. 17. aap subcommittee on neonatal hyperbilirubinemia. neonatal jaundice and kernicterus. pediatrics. 2001;108(3):763– 5. 18. maisels mj. neonatal hyperbilirubinemia and kernicterus-not gone but sometimes forgotten. early hum dev. 2009;85(11):727–32. 19. manning d, todd p, maxwell m, platt mj. prospective surveillance study of severe hyperbilirubinaemia in the newborn in the uk and ireland. arch dis child fetal neonatal ed. 2007;92(5):f342–6 althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 52 amj march 2017 bacterial and antibiotic susceptibility patterns in patient with pediatric urinary tract infection at dr. hasan sadikin general hospital muhammad ilham muttaqin,1 dany hilmanto,2 neneng syarifah syafei3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of microbiology and parasitology faculty of medicine universitas padjadjaran abstract background: pediatric urinary tract infection (uti) should become attention due to high prevalence, severe complication, and high cost treatment. bacterial pattern and its susceptibility are different in every region.the objective of this study was to discover pattern of bacteria causing uti and their susceptibility to antibiotics. methods: this study was an observational descriptive study. the data was obtained from medical records and susceptibility testing results of pediatric uti in department of child health at dr. hasan sadikin general hospital in period of 2014. data taken was presented in table. results: there were 26 cultures which had microbiological findings among 79 cultures taken from 106 patients with uti. the majority of findings were escherichia coli (10 cases), pseudomonas aeruginosa (4 cases), and klebsiella pneumoniae (4 cases). antibiotic classes with high susceptibility level were aminoglycoside, sulfonamide, and fluoroquinolone. resistance level were higher in cephalosporin class than others. conclusions: most common bacterial found are escherichia coli, pseudomonas aeruginosa, and klebsiellapneumoniae. the result of susceptibility testing for cultures shows variance of susceptibility pattern to antibiotics in pediatric patients with uti at department of child health dr. hasansadikin general hospital. [amj.2017;4(1):52–7] keywords: antibiotic susceptibility, bacteria, pediatric urinary tract infection correspondence: muhammad ilham muttaqin, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85721383075 email: m.ilhamuttaqin@gmail.com introduction attention should be focused on pediatric urinary tract infection (uti) due to high prevalence, severe complication, and high cost treatment. urinary tract infection is one of the most bacterial infection in children. urinary tract infection prevalence is higher in boys than in girls, 2.7% and 0.7%, respectively.1 besides of high prevalence, uti causes several complications, such as renal scars, hypertension, and end-stage renal disease.2 expense on uti treatment creates another burden. uti treatment costs are more than total ≥180$ million per year in united states.3 urinary tract infection in pediatric patients should be treated with antibiotics as soon as possible. most cases need antibiotic therapy before the culture and susceptibility testing are done. antibiotic therapy is started with empirical therapy, then matched with susceptibility testing result. the selection of antibiotics depends on the most frequent pathogen causing uti in previous cases.4 since the bacteria and antibiotic susceptibility patterns are different in each region, knowledge of these pattern in each region is essential to provide clinically appropriate therapy.5 incorrect antibiotic empirical therapy, such as overuse, misuse, or underuse, may increase bacterial resistance to antibiotic.6,7 the objective of this study was to investigate bacterial pattern and antibiotics susceptibility in pediatric patients with uti. methods the descriptive observational design was used in this study. this study was performed at department of child health at dr. hasan althea medical journal. 2017;4(1) 53 sadikin general hospital bandung from september to november 2015. the population in this study was all taken from medical records and laboratory exam results of pediatric patients which diagnosed as uti and admitted to hospital in 2014. this study was approved by the ethical standard approval from faculty of medicine of universitas padjadjaran and health research ethics committee dr. hasan sadikin general hospital bandung, no. lb.04.01/a05/ec/307/vii/2015. the inclusion criterion of this study was all the medical records and laboratory exam results of pediatric patients who were admitted to dr. hasan sadikin hospital bandung and diagnosed as uti, either as primary diagnosis or additional diagnosis. the exclusion criteria were uti pediatric patients without complete or available antimicrobial susceptibility test results. samples were collected through total sampling. urine samples were collected from midstream urine or catheter. this study required access to obtain database of clinical pathology laboratory of dr. hasan sadikin general hospital to observe microbiological cultures and antibiotics susceptibility testing results. susceptibility testing results were interpreted with clinical & laboratory standard institute. results there were 106 pediatric patients with uti in dr. hasan sadikin general hospital in period of 2014. there were 79 urine cultures to be examined taken from patients with diagnosis of uti. there were 26 urine cultures from which were found microorganisms tested for its susceptibility to antibiotics later on. the results showed that three most frequent bacteria causing uti in pediatric patient were escherichia coli, klebsiellapneumoniae, and pseudomonasaeruginosa (table 1). urine cultures with positive bacterial colonization were tested for their susceptibility to antibiotics and classified according to criteria from clsi. susceptibility testing results showed variance of susceptibility level (table 2). aminoglycoside and fluoroquinolone had high susceptibility to bacteria causing uti, while the findings of cephalosporin showed high level of resistance to bacteria causing uti (table 2). the data which became the most common pathogen (escherichia coli, klebsiellapneumoniae, and pseudomonas aeruginosa) were presented in detail result (table 3). escherichia coli fndings was known to be susceptible more than 50% to amikacin, piperacillintazobactam, ertapenem, meropenem, levofloxacin, cotrimoxazole, and tigecycli, while the cephalosporin class have low susceptibility, such as cefadroxil, cefmetazon, cefotaxime, cefazolin, ceftriaxone, and cefepime. klebsiellapneumoniae was fully resistant to cephalosporin class antibiotic, such as cefazolin, cefmetazon, ceftazidime, ceftriaxone, andcefepime. while klebsiellapneumoniae was susceptible to amikacin, meropenem, ciprofloxacin, levofloxacin, cotrimoxazole, and tigecyclin. pseudomonas aeruginosa were susceptible to amikacin, piperacillintazobactam, ciprofloxacin, and levofloxacin. while pseudomonas aeruginosa was fully resistant to ampicillin sulbactam, cefazolin, ceftriaxone, cotrimoxazole, and tigecyclin. discussion this study discovers the most common bacteria causing uti in pediatric patient at department of child health was escherichia coli, followed by klebsiellapneumoniae and pseudomonas aeruginosa. this result was similar to the recent study by edlin et al.8 and garout et al.9 which showed that the most common uropathogen was escherichia coli. these findings were different from the study conducted by rezaeet al.5 and waadallah et al.10 which showed that klebsiellapneumoniae and enterococcus spp were the second and third most common uropathogen, respectively. it might be due to pseudomonas table 1 bacterial pattern from urine cultures of pediatric patients with diagnosis of uti bacteria number of findings (n=26) acinetobacterbaumanii 1 acinetobacteriwoffii 1 escherichia coli 10 klebsiellapneumoniae 4 pseudomonas aeruginosa 4 enterococcus faecalis 3 micrococcus spp. 1 staphylococcus haemolyticus 2 muhammad ilham muttaqin, dany hilmanto, neneng syarifah syafei: bacterial and antibiotic susceptibility patterns in patient with pediatric urinary tract infection at dr. hasan sadikin general hospital althea medical journal. 2017;4(1) 54 amj march 2017 table 2 susceptibility patterns of bacteria to antibiotics from urine culture of patients with diagnosis of uti acinetobacter baumanii (n=1) acinetobacter iwoffii (n=1) eschericia coli (n=10) klebsiella pneumoniae (n=4) pseudomonas aeruginos (n=4) enterococcus faecalis (n=3) streptococcus haemolyticus (n=2) micrococcus (n=1) total susceptible (persentase) aminoglycoside amikacin 1 (100) 1 (100) 7 (70) 2 (50) 4 (100) gentamycin 1 (100) 0 (0) 5 (50) 0 (0) 2 (50) 2 (100) 1 (50) 0 (0) netilmycin 1 (100) 0 (0) 0 (0) β-lactam/ with adjuvant ampicillin sulbactam 0 (0) 1 (100) 3 (33,3) 0 (0) 0 (0) 3(100) piperacillintazobactam 1 (100) 1 (100) 6 (60) 0 (0) 2 (5) amoxycillin-clav 0 (0) 0 (0) 3(100) carbapenems ertapenem 1 (100) 0 (0) imipenem 2 (100) 0 (0) meropenem 1 (100) 1 (100) 7 (77,7) 3 (75) 2 (50) 0 (0) cephalosporins cephadroxil 0 (0) 0 (0) 0 (0) 0 (0) cefoxitin 0 (0) cefazolin 0 (0) 0 (0) 3 (30) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) cefmetazon 0 (0) 0 (0) 0 (0) cefuroxime 0 (0) 0 (0) ceftazidime 1 (100) 0 (0) 4 (40) 0 (0) 1 (25) 0 (0) 0 (0) 0 (0) cefixime 0 (0) 0 (0) cefotaxime 0 (0) 0 (0) 0 (0) 0 (0) cefoperazone 0 (0) 0 (0) ceftriaxone 0 (0) 4 (40) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) cefepime 1 (100) 1 (100) 4 (40) 0 (0) 1 (25) 0 (0) 0 (0) fluoroquinolones ciprofloxacin 1 (100) 0 (0) 5 (55,5) 1 (25) 3 (75) 1 (50) 0 (0) levofloxacin 1 (100) 5 (83,3) 1 (50) 3 (75) 3 (100) 1 (50) 0 (0) moxifloxacin 2 (100) macrolides erythromycin 1(33,3) 0 (0) 0 (0) monobactams aztreonam 1 (100) 4 (44,4) 0 (0) 2 (67) penicillins ampicillin 0 (0) 0 (0) 0 (0) sulfonamide cotrimoxazole 1 (100) 0 (0) 6 (60) 2 (50) 0 (0) 1 (50) 1(100) tetracycline tigecyclin 1 (100) 9 (100) 3 (75) 0 (0) 3 (100) 2(100) chloramphenicol 0 (0) 0 (0) 1(100) linezolid 3 (100) 1 (100) vancomycin 3 (100) 2 (100) althea medical journal. 2017;4(1) 55muhammad ilham muttaqin, dany hilmanto, neneng syarifah syafei: bacterial and antibiotic susceptibility patterns in patient with pediatric urinary tract infection at dr. hasan sadikin general hospital aeruginosa which had been colonizing at the hospital which causing nosocomial infection or previous antibiotic therapy in pediatric patients.11 escherichia coliis is susceptible to amikacin (70%), piperacillintazobactam (60%), levofloxacin (83.3%), and cotrimoxazole (60%). e. coli is susceptibility to amikacinin. this study is similar to the rates observed by reeza et al.5 (70.3%) comparable figures of escherichia coli susceptibility to piperacillintazobactam, levofloxacin, cotrimoxazolewere found by magliano et al.12 (95.4%; 77.1%; 72.9%, respectively). amikacin, piperacillin tazobactam, and cotrimoxazole usage should be considered in pediatric patient with uti management.13 escherichia coli had low level of susceptibility to cephalosporin class, such as cefadroxil (0%), cefazolin (30%), ceftazidime (40%), ceftriaxone (40%), table 3 result of antibiotic susceptibility testing in 3 most common bacteria causing uti in pediatric patient escherichia coli (n=10) total susceptible (%) klebsiella pneumoniae (n=4) total susceptible (%) pseudomonas aeruginosa (n=8) total susceptible (%) r i s r i s r i s aminoglycoside amikacin 2 1 7 7 (70) 2 0 2 2 (50) 0 1 4 4 (100) gentamycin 5 0 5 5 (50) 4 0 0 0 (0) 1 1 2 2 (50) netilmicin 1 0 0 0 (0) β-lactam/ with adjuvant ampicillin sulbactam 5 1 3 3 (33,3) 4 0 0 0 (0) 1 0 0 0 (0) piperacillintazobactam 4 0 6 6 (60) 2 2 0 0 (0) 2 0 2 2 (50) amoxycillin-clav 1 0 0 0 (0) carbapenem meropenem 2 0 7 7 (77,7) 1 0 3 3 (75) 1 1 2 2 (50) ertapenem 0 0 1 1 (100) 1 0 0 0 (0) cephalosporins cefadroxil 1 0 0 0 (0) cefazolin 6 1 3 3 (30) 4 0 0 0 (0) 4 0 0 0 (0) cefmetazon 0 1 0 0 (0) 1 0 0 0 (0) ceftazidime 6 0 4 4 (40) 4 0 0 0 (0) 3 0 1 1 (25) cefotaxime 1 0 0 0 (0) ceftriaxone 6 0 4 4 (40) 4 0 0 0 (0) 4 0 0 0 (0) cefepime 6 0 4 4 (40) 4 0 0 0 (0) 3 0 1 1 (25) fluoroquinolones ciprofloxacin 4 0 5 5 (55,5) 1 2 1 1 (25) 1 0 3 3 (75) levofloxacin 1 0 5 5 (83,3) 1 0 1 1 (50) 1 0 3 3 (75) monobactams aztreonam 5 0 4 4 (44,4) 4 0 0 0 (0) 1 0 2 2 (67) penicillins ampicillin 1 0 0 0 (0) 1 0 0 0 (0) sulfonamide cotrimoxazole 4 0 6 6 (60) 2 0 2 2 (50) 4 0 0 0 (0) tetracycline tigecyclin 0 0 9 9 (100) 0 1 3 3 (75) 4 0 0 0 (0) chloramphenicol 1 0 0 0 (0) note: r: resistant; i: intermediate; s: susceptible althea medical journal. 2017;4(1) 56 amj march 2017 and cefepime (40%). mirsoleymani et al.14 reported higher susceptibility percentage of escherichia coli to ceftriaxone (52.2%). high resistance to ceftazidime and ceftriaxone was supported by the study by haris et al.15 high level susceptibility to amikacin (50%), levofloxacin (50%), and cotrimoxazole (50%) was found on klebsiellapneumoniae isolates. in comparison, the study by waadallah et al.10 showed klebsiellapneumoniae was susceptible to amikacin (100%) and cotrimoxazole (80%). other studies conducted by magliano et al.12 discovered 93.0% of klebsiellapneumoniae was susceptible to levofloxacin. klebsiellapneumoniae was fully resistant to cephalosporin antibiotic class, such as cefazolin, cefmetazon, ceftazidime, ceftriaxone, and cefepime.on the other hand, study by gracia et al.16 showed that 0% was resistant to cefepime and 26% was resistant to ceftazidime on klebsiellapneumoniae isolates. the study by waadallah et al.10 showed that 93% of klebsiellapneumoniae was susceptible to ceftriaxone. there were 2 isolates which were classified as esblproducing klebsiellapneumoniae. the study by maslikowska et al.17 showed that there were esbl-producing k. pneumonia causing uti. pediatric patients with diagnosed of uti which caused by esbl-producing klebsiellapneumoniae had high risk mortality and severe clinical outcomes with high cost of treatment for uti.17 pseudomonas aeruginosais considered to be fully resistant to ampicillin sulbactam, cefazolin, ceftriaxone, cotrimoxazole, and tigecyclin. pseudomonas aeruginosa were found naturally resistant to cotrimoxazoleand cephalosporin antibiotic, including ceftazidime.11,18 antibiotics susceptible to pseudomonas aeruginosa isolates are ciprofloxacin (75%)and levofloxacin (75%). these findings are supported by the study conducted by pobiega et al.19 showed that most of pseudomonasaeruginosa are susceptible to fluoroquinolone, such as ciprofloxacin (80.8%) and levofloxacin (77%).this study discovered amikacin (100%) and piperacillintazobactam (50%) are susceptible on pseudomonas aeruginosa cultures. this study is similar with a study by rezaee et al.5 which found pseudomonas aeruginosais susceptible to amikacin (100%). the study by maglianoet al.12 found similar result that pseudomonas aeruginosa was susceptible to piperacillin tazobactam (88%). the limitations of this study are the small range of population involved and short research period. other important things to notice are the physician should neatly write the medical record and the hospital should collect the data completely. this study recommends the next study to obtain larger scale of population and to spend longer research period in order to reach more accurate and reliable result to represent present circumstances. the possibility colonization of bacteria causing uti should increase health care worker awareness to prevent nosocomial infection (now it is known as health care related infection). aseptic and antiseptic procedures should be done according tostandard procedures. high susceptibility level on amikacin, cotrimoxazole, ciprofloxacin, and levofloxacin become evidence that these antibiotics should be considered as antibiotic empirical therapy for uti in pediatric patients. this study recommends the antibiotic empirical therapy to be given after the sample is taken for culture test, and matched with the culture and susceptibility result. in conclusion, microorganisms causing urinary tract infection are mostly escherichia coli, pseudomonas aeruginosa, and klebsiellapneumoniae at department of child health, dr. hasan sadikin general hospital, bandung. the susceptibility level of aminoglycoside, sulfonamide, and fluoroquinolone are high on most microorganisms. meanwhile, the resistance level of microorganisms is high on cephalosporin class. these susceptibility and resistance level should be considered in pediatric patient with uti therapy. the findings showed diverse susceptibility to antibiotics in pediatric patients with diagnosis of uti. the culture and susceptibility test are important to do in pediatric patients with uti management to prevent antibiotic resistant development. references 1. who. urinary tract infections in infants and children in developing countries in the context of imci.geneva: world health organization; 2005. 2. chang sl, shortliffe ld. pediatric urinary tract infections. pediatr clin north am. 2006;53(3):379–400. 3. sood a, penna fj, eleswarapu s. incidence, admission rates and economic burden of pediatric emergency department visits for urinary tract infection: data from the nationwide emergency department sample, 2006 to 2011. j pediatr urol. althea medical journal. 2017;4(1) 57 2015;10(5):1–12. 4. beetz r, westenfelder m. antimicrobial therapy of urinary tract infections in children. int j antimicrob agents. 2011;38(1):42–50. 5. rezaee ma, abdinia b. etiology and antimicrobial susceptibility pattern of pathogenic bacteria in children subjected to uti: a referral hospitalbased study in northwest of iran. medicine.2015;94(39):1–4. 6. theuretzbacher u. global antibacterial resistance: the never-ending story. j glob antimicrob resist. 2013;1(2):63–69. 7. cantón r, horcajada jp, oliver a, garbajosa pr, vila j. inappropriate use of antibiotics in hospitals: the complex relationship between antibiotic use and antimicrobial resistance. enferm infecc microbiol clin. 2013;31(4):3–11. 8. edlin rs, shapiro dj, hersh al, copp hl. antibiotic resistance patterns of outpatient pediatric urinary tract infections. juro. 2013;190(1):222–227. 9. garout w, kurdi h, shilli a, kari j. urinary tract infection in children younger than 5 years: etiology and associated urological anomalies. saudi med j. 2015;36(4):497– 501. 10. waadallah s, el-naggari m, al-nabhani d. incidence of antibiotics resistance among uropathogens in omani children presenting with a single episode. j infect public health. 2015;1(5):1–8. 11. bitsori m, maraki s, koukouraki s, galanakis e. pseudomonas aeruginosa urinary tract infection in children: risk factors and outcomes. juro. 2012;187(1):260–264. 12. magliano e, grazioli v, deflorio l, leuci ai, mattina r, romano p, et al. gender and age-dependent etiology of communityacquired urinary tract infections. scientific world j. 2012;2012(1):3–5. 13. stein r, dogan hs, hoebeke p, kočvara r, nijman rjm, radmayr c, et al. urinary tract infections in children: eau/espu guidelines. eur urol. 2015;67(3):546–558. 14. mirsoleymani sr, salimi m, brojeni ms, ranjbar m, mehtarpoor m. bacterial pathogens and antimicrobial resistance patterns in pediatric urinary tract infections: a four-year surveillance study (2009 –2012). int j pediatr. 2014;2014(1):3–6. 15. syafruddin haris, anisah sarindah. kejadian infeksi saluran kemih di ruang rawat inap anak rsud dr. zainoel abidin banda aceh. sari pediatri. 2012;14(4):235– 240. 16. arredondo-garcía jl, soriano-becerril d, solórzano-santos f, arbo-sosa a. resistance of uropathogenic bacteria to first-line antibiotics in mexico city : a multicenter susceptibility analysis.j pediatr urol. 2007;68(2):120–126. 17. maslikowska ja, walker san, elligsen m, mittmann n. impact of infection with extended-spectrum β-lactamaseproducing escherichia coli or klebsiella species on outcome and hospitalization costs. j hosp infect. 2016;92(1):33–41. 18. hemalatha, dhasarathan p. multi-drug resistant capability of pseudomonas aeruginosa isolates from nasocomal and non-nasacomal sources. j biomed sci. 2010;2(4):236–239. 19. pobiega m, maciag j, chmielarczyk a, romaniszyn d, ziolkowski g, heczko pb, et al. urinary tract infections caused by pseudomonas aeruginosa among children in southern poland: virulence factors and antibiotic resistance. j pediatr urol. 2015;5(34):1–14. muhammad ilham muttaqin, dany hilmanto, neneng syarifah syafei: bacterial and antibiotic susceptibility patterns in patient with pediatric urinary tract infection at dr. hasan sadikin general hospital althea medical journal. 2017;4(2) 286 amj june 2017 quality assesment of antibiotic prescription for sepsis treatment in intensive care unit at top referral hospital in west java, indonesia shadrina dinan adani,1ardi zulfariansyah,2 putri teesa3 1faculty of medicine universitas padjadjaran, 2department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, biology cell and physiology faculty of medicine universitas padjadjaran abstract background: sepsis is a common disease in intensive care unit (icu) with high mortality rate. administration of antibiotic has an important role to determine the outcome of sepsis patient. this study aimed to evaluate the quality of antibiotic prescription for sepsis treatment in intensive care unit (icu). methods: this descriptive study was conducted by retrieving data from 48 medical records of patients with sepsis, severe sepsis, and septic shock admitted to icu dr. hasan sadikin general hospital (rshs) in 2013. the study was conducted from august to october 2014. empiric therapy in the icuat rshs and surviving sepsis campaign (ssc) guidelines in 2012 were used as a standard for antibiotic prescription. the quality of antibiotic prescription was assessed then categorized based on gyssens criteria. the collected data were analyzed in the form of frequency and percentage and presented in tables. results: this study discovered that most of the patients had severe sepsis and septic shock. based on gyssens criteria, 35% antibiotic uses were included into category 0 (proper); 1.4% category i (improper timing); 10.5% category iia (improper dosage); 9.1% category iib (improper interval); 3.5% category iic (improper route); 12.6% category iiia (improper duration; too long); 1.4% category iiib (improper duration; too short); 16.8% category iva (improper; other antibiotics were more effective); 4.2% category ivd (improper; other antibiotics had narrower spectrum); and 5.6% category v (improper; no indication). conclusions: there are still improper uses of antibiotic for sepsis, severe sepsis, and septic shock patients in the icu. keywords: antibiotic, glyssens criteria, sepsis, septic shock, severe sepsis correspondence: shadrina dinan adani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8561101115 email: dinanshadrina@yahoo.com introduction sepsis is a systemic response to infection that can result to severe sepsis (acute organ dysfunction caused by an infection that is already known in advance) and septic shock (severe sepsis plus hypotension that is not improved after fluid resuscitation).1 sepsis is a common disease in intensive care unit (icu), in which 6–30% patients treated have sepsis.2 a study in spain reported the mortality of sepsis patients admitted to hospital; patients with sepsis are 12.8%; patients with severe sepsis are 20.7%; while patients with septic shock are 45.7%.3 in addition, another study in spain reported that sepsis is the second largest cause of death in icu with mortality in the first 48 hours of admission is 14.8%.4 surviving sepsis campaign (ssc) guidelines in 2012 discussed about the management of severe sepsis and septic shock with the aim to improve the outcome of treatment, so that the incidence and mortality of sepsis will decrease.1 however, based on studies regarding treatment of patient with sepsis, it turns out that there are still treatments or actions that are not according to ssc guidelines, thus, morbidity and mortality increase.5 one of the treatments that is still not appropriate according to ssc guidelines is antibiotic treatment. because there is no study data regarding antibiotic uses in the icu at dr. hasan sadikin general hospital (rshs) bandung, especially in patients with sepsis, severe sepsis, and septic shock, this study was conducted to assess the quality of antibiotic amj. 2017;4(2):286–92 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1088 287 althea medical journal. 2017;4(2) prescription in patients with sepsis, severe sepsis, and septic shock in the icu at rshs bandung in 2013. methods the study was conducted from august to october 2014 using quantitative descriptive study method. the study was approved by the health research ethics committee rshs bandung. the data were collected retrospectively using secondary data recorded in the medical record installation rshs. samples were then determined by total sampling technique including patients with sepsis, severe sepsis, and septic shock admitted to icu in 2013. the data collected from medical records were patient demographics (name, age, and gender), indication (diagnosis and results of culture examination with its resistance to antibiotic), name of administered shadrina dinan adani, ardi zulfariansyah, putri teesa: quality assesment of antibiotic prescription for sepsis treatment in intensive care unit at top referral hospital in west java, indonesia figure 1 flow chart for evaluation of antibiotic prescription source: gyssens et al.6 althea medical journal. 2017;4(2) 288 amj june 2017 antibiotic, dose, timing, route, frequency, and its duration of administration; also mortality. the antibiotic prescriptions in the icu at rshs were adjusted to the standard of empiric therapy (guidelines of antibiotic use that have been agreed and should be applied in the icu at rshs) and also prescription uses were then assessed using flow chart of gyssens criteria 2001 (figure 1) that was divided into 0–vi category, namely proper use of antibiotic table 1 distribution of the number of sepsis, severe sepsis, and septic shock cases based on the characteristics of the patients variable sepsis n(%) severe sepsis n(%) septic shock n(%) total n(%) age 17–50 years old 4 (26.7) 4 (30.8) 9 (45) 17 (35.4) 51–87years old 11 (73.3) 9 (69.2) 11 (55) 31 (64.6) gender female 7 (46.7) 8 (40) 6 (46.2) 21 (43.8) male 8 (53.3) 12 (60) 7 (53.8) 27 (56.3) total 15 20 13 48 table 2 distribution of quality of antibiotic uses based on the severity of sepsis variable sepsis n(%) severe sepsis n(%) septic shock n(%) total n (%) indication proper indication 33 (97) 43 (87.8) 34 (97.1) 110 (93.2) improper indication 1 (3) 6 (12.2) 1 (2.9) 8 (6.8) antibiotic proper antibiotic 25 (75.8) 29 (67,4) 26 (76.5) 80 (72.7) improper antibiotic 8 (24.2) 14 (32.6) 8 (23.5) 30 (27.3) timing proper timing 33 (100) 41 (95.3) 34 (100) 108 (98.2) improper timing 0 (0) 2 (4.7) 0 (0) 2 (1.8) dose proper dose 29 (87.9) 40 (93) 26 (76.5) 95 (86.4) improper dose 4 (12.1) 3 (7) 8 (23.5) 15 (13.6) route proper route 30 (90.9) 41 (95.3) 34 (100) 105 (95.5) improper route 3 (9.1) 2 (4.7) 0 (0) 5 (4.5) interval proper interval 28 (84.8) 39 (90.7) 30 (88.2) 97 (88.2) improper interval 5 (15.2) 4 (9.3) 4 (11.8) 13 (11.8) duration proper duration 22 (66.7) 36 (83.7) 32 (94.1) 90 (81.8) too long 10 (30.3) 6 (14) 2 (5.9) 18 (16.4) too short 1 (3) 1 (2.3) 0 (0) 2 (1.8) 289 althea medical journal. 2017;4(2) (0); improper timing of administration (i); improper dose of administration (iia); improper interval of administration (iib); improper route of administration (iic); improper duration of administration due to long administration (iiia) and very short administration (iiib); improper type of antibiotic due to other more effective antibiotics (iva), other safer antibiotics with low toxicity (ivb), other cheaper antibiotics (ivc), other narrower spectrum antibiotics (ivd); improper indication (v); and the data in medical record were incomplete as well that could not be evaluated (vi).6 the data were analyzed descriptively with quantitative approach in the form of frequencies and percentages presented in tables. results there were 48 sepsis cases admitted to icu in 2013, including 31.2% sepsis, 41.7% severe sepsis, and 27.1% septic shock. most of the cases were found in males and in patients above 50 years old (table 1). there were 118 antibotic uses including 86 empiric therapies and 32 definitive therapies in 48 patients with sepsis, severe sepsis, and septic shock in the icu. improper uses of antibiotic were mostly due to incompatibility in the type of antibiotic and administration duration (table 2). the quality assessment of antibiotic prescription based on flow chart of gyssens criteria were conducted in all administered antibiotics and obtained 143 units of analysis in 118 uses of antibiotics. the results of quality of antibiotic prescription in treatment of sepsis, severe sepsis, and septic shock in the icu (category 0 gyssens criteria) were found to be proper in 35% of the antibiotic prescription (table 3). the incidence of mortality based on the severity of sepsis was found mostly prescription, mortality occurred more frequently in patients who received antibiotics improperly (56.3%) (table 4). discussion based on the study, incidence of sepsis, severe sepsis, and septic shock occurred more frequently in elderly patients (>50 years old) table 3 distribution of quality of antibiotic uses based on gyssens criteria gyssens criteria amount (n) percentage (%) category 0 50 35 % category i 2 1.4 % category iia 15 10.5 % category iib 13 9.1 % category iic 5 3.5% category iiia 18 12.6 % category iiib 2 1.4 % category iva 24 16.8 % category ivd 6 4.2 % category v 8 5.6 % total 143 100 % table 4 incidence of mortality based on the quality of antibiotic prescription and severity of sepsis mortality sepsis n(%) severe sepsis n(%) septic shock n(%) total n(%) category 0 3 (23) 4 (26.7) 5 (45.5) 12 (25) category i-v 10 (77) 11 (73.3) 6 (54.5) 27 (56.3) total 13 (33.3) 15 (38.5) 11 (28.2) 39 (81.3) shadrina dinan adani, ardi zulfariansyah, putri teesa: quality assesment of antibiotic prescription for sepsis treatment in intensive care unit at top referral hospital in west java, indonesia althea medical journal. 2017;4(2) 290 amj june 2017 and male patients. this is in accordance with a study conducted by martin et al.7 which found the incidence of sepsis increases by 20.4% in patients older than 60 years old and the possibility for male patients suffering from sepsis is higher than female patients. old age is a risk factor for infection. the elderlies are vulnerable because their immune systems may not be able to fight infection. in general, elderly patients with chronic diseases may spend time in hospital much longer so that they become susceptible to the cause of infection. in addition, the use of medical devices such as catheters to the elderly patients also increases the risk of infection.8 besides age, gender also affects the immune system. a study conducted by aulock et al.9 in 2006 found differences in the immune defense capabilities between men and women. when there is an infection, blood in males produce more cytokines such as tumor necrosis factor-alpha (tnf-α), interleukin-1β (il-1β), il-6, and il-8 in response to the high concentration of lipopolysaccharide (lps) endotoxins from gram negative bacteria or lipoteichoic exotoxins from gram positive bacteria. if the inflammatory response is widespread and unregulated, it will cause men to be more susceptible to infection and sepsis.9 the quality of antibiotic prescription in patients with sepsis in the icu was assessed using gyssens criteria flow, including the indication of antibiotic, the type of administered antibiotic, the dose and route of administration, also the interval and duration of administration.6 this study discovered improper antibiotic prscription in all variables of those gyssens criteria. a total of 110 administered antibiotics were given with a proper indication, while 8 other administered antibiotics not proper with the source of infection. improper use of antibiotics most commonly found was choosing the type of antibiotics. based on gyssens criteria, selection of the type of antibiotic was considered proper if there is no other antibiotic which is more effective, with lower toxicity, or with narrower spectrum.6 based on ssc guidelines, the choice of empirical antibiotic therapy should depend on sensitivity of pathogens that cause infections in hospital and patients clinical conditions such as drug intolerances, underlying disease, and clinical syndrome. administered empirical antibiotic must be able to cover all possible pathogens that cause infections. after 3–5 days of empirical antibiotic administration, the management of sepsis patient continued with definitive treatment as soon as the susceptibility profile is known.1 this study discovered some selection of the type of empirical antibiotic combination that was less effective because it was not in accordance with the list of bacteria and its sensitivity to antibiotics at dr. hasan sadikin general hospital bandung in 2013. besides that, in some cases, even combination therapies were not given. this contrasts with the ssc guidelines which recommend the administration of combination therapy for patient with respiratory failure, septic shock, and infections due to multidrug-resistant (mdr) microbes.1 after the laboratory results of bacterial culture are obtained, if the sensitivity results are different with previous empiric therapy that was already given, empiric therapy is replaced with definitive therapy according to laboratory result. however, in some patients, there were still also found some resistant definitive antibiotic uses, which were not in accordance with culture result and its resistance from laboratory, such as ceftriaxone, ceftazidime, ciprofloxacin, and meropenem. the second highest improper use of antibiotic was found in the duration of antibiotic treatment (table 2). based on ssc guidelines, empirical antibiotic combinations should not be used more than 3–5 days. initiation of empiric antibiotic treatment should be evaluated periodically after 48–72 hours based on the causal microbes and also the clinical condition of patient in order to give the narrower spectrum of antibiotic. if the test results of the sensitivity of bacteria have been known, definitive therapy should be given immediately.1 this study found a total of 18 empiric antibiotic treatments that are not in accordance with ssc guidelines because the treatment was given more than 5 days even more than 2 weeks. this is due to the culture results and resistances of bacteria that cause the infection was not obtained on time from laboratory, so the definitive therapy could not be administered. in this study, there were still many culture results and bacterial resistances obtained from laboratory for more than 5 days. in some cases, the culture and resistance examination were not even done. excessive antibiotic treatment was not only detrimental to the patient in terms of cost, but also could cause bacteria to become resistant and increase in complication. administered antibiotic for long time can cause side effects such as allergic reactions, antibiotic-associated colitis, and even death due to mdr.10 bacterial resistance to antibiotics occurs through the changes of bacterial genetic structure such as 291 althea medical journal. 2017;4(2) gene mutation. genetic materials are capable of making the bacteria resistant through three main mechanisms, such as producing enzymes that inactivate or destroy antibiotics, changing the antibiotic target binding to the bacteria, and preventing access to the target itself.11 improper use of antibiotic was also found in the dose of administration. in general, the maximum dose of antibiotic given to sepsis patients in this study was already proper; however, in some patients with kidney disorders such as acute kidney injury (aki) in advanced stage, chronic kidney disease (ckd), and end stage renal disease (esrd), there was still found antibiotic treatment with high dosage. kidney failure can be triggered by nephrotoxic drugs such as antibiotics vancomycin, aminoglycosides, and betalactam group. most of the classes of those antibiotics are excreted through the kidneys so that in patients with renal impairment, the dose given shoud be lower than the standard usually applied.12 moreover, this study discovered that only 35% of antibiotic prescription for sepsis patients in the icu at rshs bandung that was proper in accordance with the indication, type of antibiotic, timing, dose, route, interval, and duration (category 0 gyssens criteria). mortality rate was still considerably high (81.3%). the high incidence of mortality in sepsis patients can be caused by various factors, one of which is initiation of improper antibiotic treatment. initial empiric antibiotic treatment that is adequate and continued with antibiotic treatment which is specific based on culture and its resistance result for sepsis patient treated in icu is instrumental in determining outcome.13 improper empiric and definitive antibiotic therapy effect on the outcome in this study, shown by incidence of mortality was more common in sepsis patient who received improper antibiotic treatment (56.3%), while in sepsis patient who received proper antibiotic treatment, incidence of mortality were only 25% (table 4). this result is suitable with previous study in the united states. the study reported the percentage of survival rates of septic shock patients who received proper antibiotic treatment are 52%, while survival rates in patients who received improper antibiotic treatment are only 10.3%.14 limitations of this study were incomplete data in medical records so that the quality of antibiotic prescription could not be evaluated maximally. given the importance of proper antibiotic use in order to achieve better outcomes for sepsis patient in icu, further study needs to be conducted qualitatively to determine the factors that can influence the quality of improper antibiotic use in patients with sepsis, severe sepsis, and septic shock in icu. based on the result of this study, it can be concluded that there are still a lot of improper uses of antibiotics prescription in patients with sepsis, severe sepsis, and septic shock in the icu at rshs bandung. references 1. dellinger rp, levy mm, rhodes a, annane d, gerlach h, opal sm, et al. surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. crit care med. 2013;41(2):580–635. 2. vincent jl, sakr y, sprung cl, et al. sepsis in european intensive care units: results of the soap study. crit care med. 2006;34(2):344–353. 3. esteban a, frutos-vivar f, ferguson n, penuelas o, lorente ja, gordo f, et al. sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward*. crit care med. 2007;35(5):1284–9. 4. blanco j, muriel-bombin a, sagredo v, taboada f, gandia f, tamayo l, et al. incidence, organ dysfunction and mortality in severe sepsis: a spanish multicentre study. crit care. 2008;12(6):r158. 5. herald napitupulu. sepsis. the indonesian j anesth crit care. 2011;28(3):207–15. 6. van der meer jwm, gyssens ic. quality of antimicrobial drug prescription in hospital. clin microbiol infect. 2001;7(6):12–15. 7. martin gs, mannino dm, moss m. the effect of age on the development and outcome of adult sepsis. crit care med. 2006;34(1):15–21. 8. nhmrc.prevention and control of infection in residential and community aged care.canberra: department of health and ageing; 2013. 9. aulock sv, deininger s, draing c, gueinzius k, dehus o, hermann c. gender difference in cytokine secretion on immune stimulation with lps and lta. j interferoncytokine res. 2006;26(12):887–92. 10. hochreiter m, köhler t, schweiger am, keck fs, bein b, von spiegel, et al. procalcitonin to guide duration of antibiotic therapy in intensive care patients: a randomized prospective controlled trial. crit care. 2009;13(3):r83. shadrina dinan adani, ardi zulfariansyah, putri teesa: quality assesment of antibiotic prescription for sepsis treatment in intensive care unit at top referral hospital in west java, indonesia althea medical journal. 2017;4(2) 292 amj june 2017 11. iwan dwiprahasto. kebijakan untuk meminimalkan risiko terjadinya resistensi bakteri di unit perawatan intensif rumah sakit. jurnal manajemen pelayanan kesehatan. 2005;8(4):177–81. 12. pea f, viale p. bench-to-bedside review: appropriate antibiotic therapy in severe sepsis and septic shock does the dose matter. crit care. 2009;13(3):r214. 13. garnacho-montero j, garcia-garmendia jl, barrero-almodovar a, jimenez-jimenez fj, perez-paredes c, ortiz-leyba c. impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis. crit care med. 2003;31(12):2742–51 14. kumar a, ellis p, arabi y, roberts d, light b, parrillo je, et al. initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. chest j. 2009;136(5):1237–48. vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 38 amj march 2018 knowledge, attitude, and behavior level of women of reproductive age toward calcium intake kartika ratna dewi,1 eva m hidayat,2 anita rachmawati3 1faculty of medicine universitas padjadjaran, 2department of basic medicine faculty of medicine, universitas padjadjaran, 3department of obstetric and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: women have a higher risk of developing osteoporosis compared to men. calcium intake is one of the determinant factor which can be modified to prevent osteoporosis. knowledge, attitude and behaviour are important factors to fulfill the needs of calcium intake. this study aimed to describe knowledge, attitude, and behavior toward calcium intake of woman of reproductive age. methods: this descriptive study recruited 100 women (aged 20–30 years) in jatinangor, west java and was conducted from september to november 2014. knowledge and attitude measurements used a validated questionnaire consisting of 10 and 9 closed questions respectively. behavioral aspect was assessed using semi-quantitative food frequency questionnaire (ffq). knowledge was classified as high, moderate, and low based on questionnaire scoring results, >75%, 60–75%, and <60% respectively. attitude was categorized in two: positive and negative. behaviour category used recommended dietary allowances (rda) as the cutoff point. if the daily calcium intake is below the rda it is categorized less and if the daily calcium intake equals to or exceeds the rda it is categorized sufficient. the collected data were presented in frequency tabulation and percentage. results: the majority of subjects showed low to moderate level of knowledge toward calcium intake, 66% of subjects showed negative attitude towards calcium intake, and 98% showed calcium intake below the rda. conclusions: subjects of this study have low to moderate level of knowledge, negative attitude toward calcium intake, and low level of behavior toward calcium intake. keywords: attitude, behavior, calcium intake, knowledge correspondence: kartika ratna dewi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: kartika_rtndewi@yahoo.com introduction the bone has a remodeling process, that is the process of solving existing bones which will be replaced by new bone components, and this process occurs throughout life.1 bones will reach peak bone mass at around the age of 30 years.2 then, starting from 30 to 40 years old, there will be an increase of releasing bone minerals that exceeds its formation, mainly in women.1,3 when peak bone density is optimally reached, it can prevent and reduce an osteoporosis risk.3 the risk of osteoporosis is still high in indonesia, 2 in 5 indonesian population are at risk for osteoporosis.4 furthermore, osteoporosis is called a silent disease because of a decrease in bone density without causing symptoms until a fracture occurs.5 although it is called as a silent disease, osteoporosis is a disease that can be prevented.6 in the prevention of osteoporosis, the peak bone mass needs to be considered as a determinant of bone health, thus optimizing on bone mineral accretion is important.7 the main factors that affect bone density are the calcium intake in childhood, adolescence and early adulthood.8 however, the average calcium intake of the indonesian society is still low, for example 254 mg/day (only a quarter of the international standard, that is 1000 to 1200 mg/day for adults).4 one of the important factors related to the level of calcium intake in women is knowledge.9 moreover, the primary domain of human behavior in the form of operations consists of knowledge, attitude, and actions.10 therefore, this study aimed to describe the level of knowledge, attitude and behavior of women of reproductive age toward calcium intake to prevent osteoporosis. amj. 2018;5(1):38–42 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1334 althea medical journal. 2018;5(1) 39 methods this study used a quantitative descriptive method with a cross-sectional design and was conducted during the period of september to november 2014 in jatinangor, sumedang, west java province. the data collection process was approved by the health research ethics committee of faculty of medicine universitas padjadjaran and the government of sumedang district. the study population was all women of reproductive age in jatinangor subdistrict. sample of this study was women of reproductive age between 20 to 30 years who live in the cipacing, hegarmanah, and cikeruh villages, jatinangor. the purposive sampling technique was used for selecting the villages. villages which had the highest number of women of reproductive age were selected. then, the sample was collected by visiting and tracing the villages to meet women of reproductive age who met the appropriate inclusion criteria. the minimum sample in this study was calculated by a descriptive categorical formula, and the result was 97 people. those included in the study were women of reproductive age between 20 to 30 years, willing to be the respondent and ever heard about calcium. while excluded from the sample were women of reproductive age who did not complete the questionnaire. the variables of this study were knowledge, attitude, and behavior of women of reproductive age toward calcium intake to prevent osteoporosis. knowledge and attitude masurements used validated questionnaires consisting of 10 and 9 closed questions respectively. first, it was the predefined variables that we identified and constructed questions of the appropriate variables. after the questionnaire was constructed, it was tested to 30 respondents and processed for validity and reliability. meanwhile, the behavioral aspect was assessed using the semi-quantitative food frequency questionnaire (ffq). the ffq questionnaire started with a list of foods containing calcium, and then continued with a pre-elimination study to adapt to the types of food around the sample. data was clarified to determine what foods would be incorporated or removed from the questionnaire. prior to its use, the questionnaire was consulted to a nutritionist. furthermore, the guttman scale was used to query knowledge. the likert scale with 4 scales was used to measure attitude. all obtained data were incorporated into microsoft excel 2007. knowledge was classified as high, moderate, or low based on questionnaire scoring results, >75%, 60–75%, and <60% respectively. attitude was categorized using kartika ratna dewi, eva m hidayat, anita rachmawati: knowledge, attitude, and behavior level of women of reproductive age toward calcium intake table 1 characteristics of respondent characteristics of respondent frequency (n=100) percentage (%) level of education elementary school 1 1% junior high school 30 30% senior high school 53 53% college 16 16% occupation housewife 67 67% teacher 4 4% seller 3 3% labor 8 8% employee of company 10 10% collegian 6 6% others 2 2% income per month less than regional minimum wage 27 27% same or more than regional minimum wage 73 73% althea medical journal. 2018;5(1) 40 amj march 2018 the median attitude resulting in two categories: positive and negative. the behavior category of calcium intake used the recommended dietary allowances (rda) as the cut-off point, so if the amount of daily calcium intake was below the rda it was categorized less and if the amount of daily calcium intake equals to or exceeds the rda it was categorized sufficient. results after the distribution of 107 questionnaires to reproductive-aged women in cipacing, hegarmanah, and cikeruh, there were 100 respondents included in this study. out of 100 respondents, most of them had completed senior high school (53%), worked as housewife (67%), and had a monthly income which was similar to or more than the regional minimum wage in sumedang district (73%). furthermore,most of the respondents had a moderate level of knowledge about calcium intake (40%), negative attitude toward calcium intake (66%), and less than rda for behavior toward calcium intake (98%) (table 2, 3, and 4). based on a normality test, data from this study was normally distributed with the daily calcium intake of 410.1955±206.385 mg. discussions this study discovered that the majority of the respondents had a low to moderate level of knowledge about calcium intake. this result was consistent with a study conducted by von hurst and wham11 on 622 women aged 20–49 years in auckland, new zealand. the study measured the level of knowledge about osteoporosis risk factors, including calcium intake.11 additionally, rafraf et al.12 found the same results in 399 fertile women in tabriz, iran which was in line with a study conducted in egypt.13 the level of knowledge was defined as moderate, and might be caused by the knowledge of osteoporosis that have not been internalized among women, including educated women in this study.12 there were some differences according to the study conducted by wahba, et al.14 in cairo in 494 women aged 16–24. the study stated that the respondent’s knowledge about the intake of calcium to prevent osteoporosis is still very poor and limited. the difference in results may be due to the respondent’s age difference. the age of respondents in cairo14 was younger than those in this study. an increase in age will be followed by an increase in knowledge table 2 level of knowlegde about calcium intake to prevent osteoporosis knowlegde frequency (n) percentage (%) high 28 28% moderate 40 40% low 32 32% total 100 100% table 3 attitude toward calcium intake to prevent osteoporosis attitude median frequency (n) percentage (%) positive >75 34 34% negative <75 66 66% total 100 100% table 4 behavior toward calcium intake to prevent osteoporosis behavior frequency (n) percentage (%) fulfill rda 2 2% less than rda 98 98% total 100 100% althea medical journal. 2018;5(1) 41kartika ratna dewi, eva m hidayat, anita rachmawati: knowledge, attitude, and behavior level of women of reproductive age toward calcium intake about osteoporosis. apparently, the increased age of a woman, specifically which is closer to menopause, would raise the concern of women to the risk of osteoporosis.11 in this study, the majority of respondents, as many as 66 people (66%) had negative attitudes. the result was contrary to the study conducted by hussein, et al.13 in egypt involving 400 women aged 18–28 years and sriring, et al.15 in thailand involving 1475 adults aged 20 years and above. both studies indicated that overall respondents have positive attitudes. the difference in the results of these studies may be due to differences in the components of attitude of the respondents in this study compared to other studies, both of emotion involved (such as experience) as well as the confidence of the self respondent.10 the result of calcium intake in this study showed that the average calcium intake per day of the respondents in cipacing, hegarmanah, and cikeruh was 410.1955(206.385) mg/ day. this result implied that most of the respondents did not meet the rda (1100 mg/ day for people aged 19–29 years and 1000 mg/day for people aged 30 years).16 ninety eight percent of the respondents had a daily calcium intake below the rda. this result was in line with a study by rafraf, et al.12 the result of calcium intake in the study indicated that most women of reproductive age do not fulfill the recommended daily calcium needs. the average daily calcium intake of the respondents is 689.08(393.15) mg/day and most of the women who were interviewed (50.7%) consumed the daily calcium needs less than 60% of the recommended amount.12 the study in cairo, egypt14 also showed a similar result, with an average calcium intake of the respondents 470(311.5) mg/day and 86.5% of respondents consumed calcium below the recommended amount. another study conducted in taipei, taiwan9 also showed that the average calcium intake in young women do not fulfill the needs, that is equal to 454 mg/day. the average calcium intake of the indonesian society is still low, i.e. 254 mg/day.4 the average of calcium intake in this study was much lower than the rda. it might be caused by the lack of knowledge about the types of food source containing calcium, especially aside from milk and other dairy products, such as vegetables, and fish.11 there were 51% respondents who provided the right answer in the knowledge part about food sources of calcium.therefore, it could be inferred that only half of the respondents were aware of the calcium food source aside from milk and dairy products. in fact, there are other food sources containing high calcium, such as anchovy and rebon.4 besides low calcium intake can be also caused by the lack of knowledge of the respondent about the rda of calcium.11 based on the answers regarding the need for daily calcium intake, 90% of respondents in this study chosed the wrong answer. on further review of the frequency, amount and type of food consumed by the respondents, it seemed that the frequency of milk consumption and other dairy products, like milk, cheese, yogurt, ice cream, was still fairly low. out of 100 respondents, 9 respondents consumed milk every day. in fact, milk and other dairy products have a very high calcium content.3 the respondent, who had the highest daily calcium intake, can be detected from the higher frequency in milk consumption, i.e. three times a day plus the consumption of cereals and processed soybean, such as tofu and tempe, as well as green vegetables, such as beans, spinach, and water spinach. it seemed that there was no intake of milk and dairy products in the low calcium intake group. other foods known as a source of calcium are cassava leaves, beans, tofu, but the content of calcium inside them still is less than those in milk.3 this study revealed that the knowledge level of the majority of respondents was categorized as moderate. knowledge, thoughts, beliefs, and emotions play an important role in determining the whole attitude.10 the respondent’s behavior belongs to less category from rda, and this relates to the statement that the attitude is not necessarily manifested in action because action needs other factors, among others, the facilities and infrastucture.10 in this study, the less action can be caused by the unavailability of sufficient calcium food in each household. in the study conducted in tabriz, iran,12 it was stated that the adequate knowledge is often not accompanied by the application of lifesyle. the limitation in this study was the use of the non-probability or non-random sampling technique, while the technique that really could represent the population was a random technique, so, the samples of this study were less representative to the population. during the interview process, it was possible that the respondent forgot to mention the type and amount of food consumed, and there was still a possibility that the calculation of calcium intake was less meticulous. however, due to the limited time and experience in conducting this study, the study method was considered to althea medical journal. 2018;5(1) 42 amj march 2018 be the most likely to be carried out. based on the data processing result, it can be concluded that the majority of respondents have low to moderate knowledge about calcium intake to prevent osteoporosis in jatinangor sub-district. the majority of respondents have a negative attitude toward calcium intake to prevent osteoporosis in jatinangor sub-district. almost all respondents have less behavior in fulfilling calcium intake toward preventing osteoporosis in jatinangor sub-district. references 1. brandi ml. microarchitecture, the key to bone quality. rheumatology (oxford). 2009;48(suppl4):iv3–8. 2. sasson h cc. achievement of peak bone mass in women is critically dependent on adolescent calcium intake. oa sports med. 2013;1(2):16. 3. whitney e, rolfes sr. understanding nutrition. 12th ed. wadsworth: cengage learning; 2011. 4. menteri kesehatan republik indonesia. kepmenkes no.1142/menkes/sk/ xii/2008 tentang pedoman pengendalian osteoporosis. jakarta: kementerian kesehatan republik indonesia; 2008. 5. agrawal v, gupta d. recent update on osteoporosis. int j med sci public health. 2013;2(2):164–8. 6. puttapitakpong p, chaikittisilpa s, panyakhamlerd k, nimnuan c, jaisamrarn u, taechakraichana n. inter-correlation of knowledge, attitude, and osteoporosis preventive behaviors in women around the age of peak bone mass. bmc womens health. 2014;14(1):35. 7. baxter-jones adg, faulkner ra, forwood mr, mirwald rl, bailey da. bone mineral accrual from 8 to 30 years of age: an estimation of peak bone mass. j bone miner res. 2011;26(8):1729–39. 8. poslušná k, matějová h, březková v. risk factors of osteoporosis knowledge and practices among adolescent females. school and health. 2008;21(3):211–20. 9. chang sf. a cross-sectional survey of calcium intake in relation to knowledge of osteoporosis and beliefs in young adult women. int j nurs pract. 2006;12(1):21–7. 10. soekidjo notoatmodjo. ilmu perilaku kesehatan. jakarta: rineka cipta; 2010. 11. von hurst pr, wham ca. attitudes and knowledge about osteoporosis risk prevention: a survey of new zealand women. public health nutr. 2007;10(7):747–53. 12. rafraf m, bazyun b, afsharnia f. osteoporosis-related life habits and knowledge about osteoporosis among women in tabriz, iran. imj. 2009;8(2):17– 20. 13. hussein raeh, ashqan bs, jamalallail rh, alafeef as. knowledge, attitude, and behavior of young women towards dietary calcium intake. life science journal. 2013;10(3):2491–6 14. wahba sa, el-shaheed aa, tawheed ms, mekkawy aa, arrafa am. osteoporosis knowledge, beliefs, and behaviors among egyption female students. jasmr. 2010;5(2):173–80. 15. sriring p, krass i, kanjanarach t. calcium consumption for osteoporosis prevention: knowledge, attitudes and behavior in the northeastern region, thailand. j med assoc thai. 2014;97(2):232–40. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 87 perception of mothers on adequate nutrition darshini valoo,1 aly diana,2 sharon gondodiputro3 1faculty of medicine, universitas padjadjaran, 2departmen of public health faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: malnutrition in children less than 5 years old persists around the world. in west java and one of the districts of west java (sumedang), the prevalence of malnutrition is about 18.5% and 15.8% respectively. numerous factors can lead to child malnutrition. difficulties in availability, accessibility, acceptability and quality of food can be contributing factors. a good perception of mother on adequate nutrition can improve children’s nutritional status. this study was conducted to study the perception of mothers with children 2 to 5 years old on adequate nutrition. methods: most of the respondents had good perception on the aspect of adequate nutrition. results showed perception on availability was 83.8%, physical accessibility was 97.1%, economical accessibility was 98.6%, information accessibility was 84.8% and acceptability was 81.0%. however, perception of respondents on good quality nutrition for the main meal and additional food was still poor. moreover, there are taboos for eating shrimp and watermelon. additionally, children were given snacks in large amount. results: there was a strong correlation between mid-upper arm muscle area/size and muscular strength (correlation cooefficient 0.746). moreover, the higher the body mass index, the stronger the muscle strength was to some point. if the bmi was more than 25 kg/m2, this findings did not occurred. conclusions: this study reveals that the perception of mothers on good quality food is poor regardless the good results on availibility, accesibility and acceptability. [amj.2017;4(1):87–93] keywords: acceptability, accessibility, availability, nutrition correspondence: darshini valoo, hospital sultan haji ahmad shah, temerloh,pahang, malaysia, phone: +628170207331 email: bablooshini@gmail.com introduction the deaths of children under 5 years old due to malnutrition still persist.1 malnutrition is a life-threatening condition that needs special attention. in indonesia, the prevalence rate of malnutrition in children under five years old is 22.7% and in west java about 18.5%. sumedang, a district in west java where the study was carried out, the percentage of malnutrition is 15.8%.2 in another way, adequate nutrition is very crucial for children in particular for the under five years old children for early brain development.3 inadequate nutrition can affect the overall health of a child including the intellectual development as well as the rate of motor development and rate of physical growth. isabelle4 highlighted that undernutrition children in indonesia are the major contributing factor that affects the growth and development.4 an inadequate nutrition may be a result of less food stock availability and accessibility of nutrition due to the economic status of the family. based on a study, most of the children from low income families in developing country are the victim of malnutrition.5 besides, lack of knowledge of rights on nutrition due to improper information delivery to mothers can be another factor lead to malnutrition.6 education is one of the most important resources that enable women to provide appropriate care for their children, which is a critical determinant of children’s growth and development.6 moreover, the available food source should be acceptable in the cultural traditions of the family and be of high quality so that the consumer can get good and satisfying food.7 althea medical journal. 2017;4(1) 88 amj march 2017 the responsibility of children in malnutrition condition usually goes to the family, especially to the caregiver and to the community. the objectives of this study was to identify the perception of mothers with children 2 to 5 years old on adequate nutrition. methods this study was carried out in jatinangor, sumedang west java from october to november 2013. the rapid survey was performed on mothers with children 2 to 5 years old in 30 posyandu around jatinangor. cluster sampling was used to select 30 posyandu from 3 villages. the mothers who were willing to participate in the study were selected as the research subjects. in every posyandu, seven respondents were chosen which summed up to 210 respondents in total from 30 posyandu. the respondents were informed consent on the procedure of the study. the questionnaire on rights to optimal nutrition consisted of four main criteria; availability, accessibility, acceptability and quality.8 components of availibility were the overall availibility of source of food, source of carbohydrate, protein, fat, vitamins and minerals. components of accesibility were the physical/geographical, economical (affordability) and information availibility. moreover, acceptability was defined as there were taboos or no taboos on certain food. quality was determined by some components, namely the source of children’s meal, frequency of main and additional meals per day, frequency of snacks per day, and calorie consumption per day according to angka kecakupan gizi orang indonesia. the answering of the questionnaire was carried out by interview method. the data collected was analyzed using computer software. the results were performed using tables. table 1 characteristics of respondents variable n (%) mother’s education status elementary 43(20.5) junior high school 82(39.0) senior high school 78(37.1) diploma 2(1.0) bachelor 4(1.9) master 1(0.5) father’s occupation government worker 1(0.5) labor 95(45.2) security 2(1.0) driver 2(1.0) private 40(19.0) business 65(31.0) civil servant 5(2.4) mother’s occupation labor 6(2.9) civil servant 3(1.4) private 18(8.6) business 12(5.7) housewife 171(81.4) althea medical journal. 2017;4(1) 89darshini valoo, aly diana, sharon gondodiputro: perception of mothers on adequate nutrition results the subjects were apparently healthy men the minimum level of education of the subjects was elementary school and maximum level was of masters. the occupational background showed various jobs listed such as labor, civil servant, private, and business; in addition the majority of the respondents were housewives (table 1). there were all kinds of nutrient from carbohydrate, protein, fat, vitamin and minerals. there were varieties of food from every food class as mentioned in table 2. most of the sources of carbohydrate were from rice and potato. in terms of protein, most of its sources were tempe, tofu, eggs and chicken. the source of fat was from oil and most of the source of vitamins and minerals was from vegetables. furthermore, one of the components of adequate nutrition according to the right to health was accesibility of the source of food, which consisted of physical/geographical, economical and information accesibility. this study discovered that most of the mothers did not have any difficulties to access the source of food to fulfill their children’s nutrition, except for buying beef (table 3). in terms of nutrition information, most of the place where mothers could gain its information was posyandu, followed by puskesmas. regarding perception of taboo on food, there were 7 respondents who answered there were special taboos like taboos on consuming table 2 availability and types of food variable n (%) availability of all kinds of food yes 176(83.8) no 34(16.2) types of food source available carbohydrate rice 120(57.1) noodle 67(31.9) bread 55(26.2) potato 89(42.4) protein chicken 120(57.1) beef 56(26.7) fish 35(16.7) egg 135(64.3) tofu 130(61.9) tempe 156(74.3) milk 70(33.3) fat oil 113(53.8) sausage 89(42.4) cheese 34(16.2) vitamins and mineral vegetables 108(51.4) fruits 87(41.4) althea medical journal. 2017;4(1) 90 amj march 2017 watermelon (6 respondents) and shrimp (1 respondent) (table 4). however, another 33 respondents had perceptions that there were taboos on food such as spicy food, chocolate, cold water and sweet. it could be said that the result was contradictory since it was only a belief by their family and it was not culturally inherited. the food given to children from 2 to 5 years old were poor in quality (table 5). this was because 175 respondents out of 210 respondents gave snacks to their children, and the frequency of two times and more of snacks per day was about 83.2% which was quite high. moreover, after the calculation of calorie consumption per day according to the angka kecakupan gizi orang indonesia , almost all of the children had not have the standard calorie intake as it should be according to indonesian standard. discussion based on the study conducted in 3 villages in table 3 accessibility of food variables n (%) perception on physical/geographical accessibility yes 204(97.1) no 6(2.9) distance of food source from house ≤ 1 km 183(87.1) >1km 27(12.9) transportation to reach food source walk 146(69.5) vehicles 43(20.5) both (walk and vehicle) 21(10.0) perception on economical accessibility yes 207(98.6) no 3(1.4) food that cannot be afforded beef 170(81.0) chicken 21(10.0) milk 59(75.7) information accessibility yes 178(84.8) no 32(15.2) types of information nutrition 103(57.9) health 75(42.1) source of information posyandu 81(47.2) midwife 19(10.7) puskesmas 29(16.3) internet 3(1.7) althea medical journal. 2017;4(1) 91 jatinangor, sumedang the result showed that mothers were having a good perception on availability, physical accessibility, information accessibility and acceptability of food for their children. availability is sufficient quantity of goods or services. food is considered as available when there is an existence of all classes of food such as carbohydrate, protein, fat, vitamin and mineral. in this study, the type table 4 acceptability of food variable n (%) food taboo yes 40(19.0) no 170(81.0) types of food taboo shrimp 1(14.3) watermelon 6(85.7) darshini valoo, aly diana, sharon gondodiputro: perception of mothers on adequate nutrition table 5 quality of food variable n (%) source of meal cooked by mothers 201(95.7) food stall/warung 9(4.3) frequency of main meal per day once 1(0.5) twice 54(25.7) three times 155(73.8) frequency of additional food per day once 70(35.7) twice 92(46.9) three times 42(21.4) four times 3(1.5) five times 3(1.5) frequency of snack per day once 26(14.5) twice 62(34.6) three times 58(32.4) four times 7(3.9) five times 16(8.9) six times 6(3.4) calorie consumption per day (main meal and additional food according to the age and average value from angka kecakupan gizi orang indonesia9 poor 108(94.3) normal 12(5.7) althea medical journal. 2017;4(1) 92 amj march 2017 of food in indonesia was listed according to the classes and the percentage of availability was calculated. results showed there was availability of food source since at least one kind of food was available from each class of food. about 83.8% of respondents were having a good perception on availability. accessibility can be defined as the ability to reach or all kinds of services and products.8 the second variable studied was perception on accessibility of food source. the distance of food source from the house of the respondent ranged between less than or equal to 1km and more than 1km. the result obtained was 87.1% of respondents were having food source less than or 1km away from their house, and only 12.9% was more than 1km.2 accessible distance according to riset kesehatan dasar (riskesdas) is less than or equal to one km. perception of respondents on physical accessibility could be concluded as good since approximately 97.1% of respondents stated that according to their understanding it was easy to access the food source.2 economic accessibility is a condition where respondents are able to purchase food stuff from all classes of food even though there are certain food such as beef, chicken or fruits which they cannot often purchase since the price is beyond their affordability. the socioeconomic status of the family does affect the nutritional status of the children.10 in general, the respondents had a good perception on economic accessibility since approximately 98.6% of respondents stated that they could afford to buy the majority of the food. information accessibility is achieved when respondents have or get knowledge on adequate nutrition for their children. good quality food contains nutritious food which is equivalent to the need of the person according to the body weight or an average value as available in angka kecakupan gizi 2004 bagi orang indonesia. for children from 2 to 5 years old the average amount of calorie needed is 1000 to 1550 kcal per day. approximately 84.8% respondents got information for nutrition and only 15.2% did not get any information for adequate nutrition. lack in accessibility to information on adequate nutrition can be a factor for undernourishment or over nourishment in children. in addition, for acceptability of food 81.0% had the perception that there was no taboo and only 19.0% had taboo. approximately 7 respondents stated that there are taboo to watermelon and shrimp. based on previous studies , there is existence of taboo on pregnant mothers and there is no information on food taboo for children.11 good quality of food composed of an adequate and a well-balanced diet containing the needed nutrients in the correct amount and number of serving according to the age. furthermore, the frequency of main meals suggested to be given to children 2 to 5 years old is 3 times daily and additional food twice daily. in this research the frequency of 3 times of main meal was 73.8% and for additional food with frequency of 2 until 5 times was 66.7%. another aspect studied was the consumption of snacks among children 2 to 5 years old. from the total of 210 respondents, 85.2% respondents stated that they gave snacks to their children. even though snack is poor in nutrition but the amount of calorie in it is sufficient for the daily need of the children. this result provided information that even though the calorie from the main meal and additional food were insufficient but snacks could provide and fulfill the daily calorie requirement in these children. the limitation of this study is the nutritional status of the children was not studied. only observation and verbal evidence from health care workers in the posyandu were obtained for nutritional status. the researcher did not measure the nutritional status of the children due to restriction of time and the large sample size. lack of information on nutritional status caused the researcher was unable to correlate the relationship between under-nutrition and aspects of rights to health. the conclusion of the study from the 4 aspects studied on rights to health for adequate nutrition, the perception of respondents are overall good. the respondents have achieved good perception on availability, physical accessibility, economic accessibility, information accessibility and acceptability of food. however, for good quality of food the respondent’s perception is considered poor. this can be due to lack of exposure on the disadvantage of consuming snacks. a further study is suggested to be conducted to assess the relationship between the nutritional status of children 2 to 5 years old and aspect of rights to adequate nutrition. references 1. grantham-mcgregor s, cheung yb, cueto s, glewwe p, richter l, strupp b. developmental potential in the first 5 years for children in developing countries. lancet. 2007; 369(9555):60−70. althea medical journal. 2017;4(1) 93 2. departemen kesehatan republik indonesia. laporan nasional riset kesehatan dasar (riskesdas) 2007. jakarta: departemen kesehatan republik indonesia; 2008. 3. rosales fj, reznick js, zeisel sh. understanding the role of nutrition in the brain & behavioral development of toddlers and preschool children: identifying and overcoming methodological barriers. nutr neurosci. 2009; 12(5):190−202. 4. isabelle m, chan p. seminar on young child nutrition: improving nutrition and health status of young children in indonesia. asia pac j clin nutr. 2011; 20(1):141−7. 5. van de poel e, hosseinpoor ar, speybroeck n, van ourti t, vega j. socioeconomic inequality in malnutrition in developing countries. bull world health organ. 2008; 86(4):282−91. 6. barros fc, victora cg, scherpbier rw, gwatkin d. health and nutrition of children: equity and social determinants. in: blas e, kurup as, editors. equity, social determinants and public health programmes. switzerland: who library cataloguing in publication data; 2010. p. 49−75 7. drewnowski a. concept of a nutritious food: toward a nutrient density score. am j clin nutr. 2005; 82(4):721−32. 8. who. 25 questions and answers on health and human rights: health and human rights publication series: geneva: world health organization; 2002. 9. kementerian kesehatan republik indonesia. peraturan menteri kesehatan nomor 75 tahun 2013 tentang angka kecukupan gizi yang dianjurkan bagi bangsa indonesia. jakarta: kementerian kesehatan republik indonesia; 2013. 10. hulshof kf, brussaard jh, kruizinga ag, telman j, löwik m. socio-economic status, dietary intake and 10 y trends: the dutch national food consumption survey. eur j clin nutr. 2003; 57(1):128−37. 11. hartini tn, padmawati rs, lindholm l, surjono a, winkvist a. the importance of eating rice: changing food habits among pregnant indonesian women during the economic crisis. soc sci med. 2005; 61(1):199−210. darshini valoo, aly diana, sharon gondodiputro: perception of mothers on adequate nutrition althea medical journal. 2018;5(2) 93 foot anthropometric profile of high school students in bandung imam ramdhani abdurrahman, 1 alwin tahid,2 fathurachman3 1faculty of medicine universitas padjadjaran, indonesia, 2department of basic medicine faculty of medicine universitas padjadjaran, indoneseia 3department of orthopaedics and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: during the process of walking, the foot plays a role in supporting the body weight. due to continously with stand weight, a person will experience foot pain aggravated by the use of improper shoe size. foot anthropometric data acts as reference in the manufacture of orthotics and shoes with appropriate size, while indonesia still does not have foot anthropometric data. the purpose of this study was to describe foot anthropometric data of high school students in bandung in order to obtain good fitting shoes. methods: the study was performed using observational descriptive method on 81 students aged 16–18 years from three different senior high schools in different regions of bandung in november 2014. results: the mean of foot and ankle anthropometry of senior high school students were 25.75 cm for foot length, 18.82 cm for ball of foot length, 21.57 cm for outside ball of foot length, 9.70 cm for foot breadth diagonal, 5.43 for heel breadth, 6.00 cm navicular height, 6.62 cm for instep height and 5.06 for heel to lateral malleolus. conclusions: the anthropometric data help the footwear industry to determine the design and size for shoes in indonesia. keywords: anthropometry, ankle anthropometry, foot anthropometry, foot. correspondence: imam ramdhani abdurrahman, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: imam.ramdhani93@yahoo.co.id introduction foot is the first structure of the musculoskeletal system that begin to grow at puberty.1 the human foot is composed of 26 bones and more than 30 synovial articulation.2 during walking, the foot supports the body to hold the weight of the body so, it can cause someone to feel pain in his feet due to that mechanism and exacerbated by using ill–fitting shoes.3 the use of narrow shoes is associated with the occurrence of corn on the finger–toe, bunion, and leg pain, while the use of shoes which is shorter than the foot is associated with deformities of toes.4 comfortable shoes require the dimensions of the foot for the shoe by measuring the length, width and height of the foot.3 for example, japan has its own standards to determine the size of the shoe by measuring foot length, girth, and width of the foot joint.5 however, indonesia still does not yet have a foot anthropometric database to be used as reference in the development of footwear products. moreover, the proper fit of shoes is important for diabetes patient to prevent complications.6 due to its role in product development, each region should have an anthropometric database of its population as the anthropometric data of each area is different. therefore, it is very important for a population to have their own anthropometric data in designing shoes to prevent incompatibility with users.7 in addition, the different anthropometric dimension of each population is influenced by age, race, region, and work that should be a reference in the provision of anthropometric data.8 methods this study was conducted using the observational descriptive method. data were amj. 2018;5(2):93–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1418 althea medical journal. 2018;5(2) 94 amj june 2018 collected in november 2014 from three senior high schools in bandung. the anthropometric data collection performed in this study was approved by the health research ethic committee, faculty of medicine, universitas padjadjaran. samples were male senior high school students spread over three regions that were randomly selected from six regions in bandung. the sample size was 81 people,s obtained by quantitative descriptive study formula with a precision value of 0.3 cm. samples included in the study were male students who met the inclusion criteria, aged 16–18 years and did not have a foot deformity. furthermore, anthropometric measurements of the selected students were performed in a separate place from the classroom. after filling out the consent form, the students were instructed to sit with legs parallel to the floor then anthropometric measurements of foot and ankle were carried out. the measurement method used in this study was similar to previous studies.3,9 eight dimensions of foot and ankle were measured comprising foot length, ball of foot length, outside ball of foot length, foot table 1 age distribution of subjects (n = 81) age group (years) percentage total 16 13.6 11 17 72.8 59 18 13.6 11 total 100 81 figure 1 eight dimensions of foot and ankle table 2 foot length distribution by age age (years) foot length group (cm) total 23–24 24–25 25–26 26–27 27–28 28–29 29–30 16 1 1 0 4 3 1 1 11 17 9 14 17 6 11 2 0 59 18 0 2 5 4 0 0 0 11 total 10 17 22 14 14 3 1 81 althea medical journal. 2018;5(2) 95 breadth diagonal, heel breadth, navicular height, instep height and heel to lateral malleolus. then those measurements were processed with a statistical software to find the mean, standard deviation, minimum and maximum values, the 5th percentile, 50th and 95th. results among 2259 intracerebral hemorrhagic the age distribution of the sample included subjects from 16–18 years (table 1). in this study a 16–years–old student was included in the longest foot length group (table 2). while based on the region, one male student in b senior high school was included in the longest foot length group (table 3). the mean of foot and ankle anthropometry of senior high school students were 25.75 cm for foot length, 18.82 cm for ball of foot length, 21.57 cm for outside ball of foot table 4 mean (m), standard deviation (sd), minimum (min) and maximum (max) for anthropometric dimensions of the foot and ankle (n = 81), values in cm foot dimensions m sd min max foot length 25.75 1.42 23.1 29.3 ball of foot length 18.82 1.14 17 22.7 outside ball of foot length 21.57 1.13 19 23.7 foot breadth diagonal 9.70 0.58 8.4 10.9 heel breadth 5.43 0.55 4.5 8.1 navicular height 6.00 0.58 4.8 7.7 instep height 6.62 0.51 5.4 8.5 heel to lateral malleolus 5.06 0.65 3.5 6.7 table 3 foot length distribution by school senior high school foot length group (cm) total 23–24 24–25 25–26 26–27 27–28 28–29 29–30 a 1 4 7 7 2 2 0 11 b 3 4 7 2 10 1 1 59 c 6 9 8 5 2 0 0 11 total 10 17 22 14 14 3 1 81 table 5 percentile for anthropometric dimensions of foot and ankle (n = 81), values in cm foot dimensions 5th percentile 50th percentile 95th percentile foot length 23.60 25.70 28.25 ball of foot length 17.20 18.80 20.40 outside ball of foot length 19.42 21.70 23.29 foot breadth diagonal 8.70 9.60 10.50 heel breadth 4.61 5.40 6.29 navicular height 5.21 5.90 7.18 instep height 5.81 6.60 7.78 heel to lateral malleolus 4.21 5.00 6.30 imam ramdhani abdurrahman, alwin tahid, fathurachman: foot anthropometric profile of high school students in bandung althea medical journal. 2018;5(2) 96 amj june 2018 length, 9.70 cm for foot breadth diagonal, 5.43 for heel breadth, 6.00 cm navicular height, 6.62 cm for instep height and 5.06 for heel to lateral malleolus (table 4 and table 5). discussion the results were displayed based on anthropometric measurements of foot and ankle in 81 senior high school students who met the inclusion criteria and were selected from several areas in bandung. the result showed a 16–years–old student with the longest foot length was included in the longest foot length group, and there was also one student at sman b who had the longest foot length in the group based on the region. it could be attributed to the differences in physical activities or nutritional factors such as in the anthropometric study conducted in india10 which shows that anthropometric differences could be due to regional differences. moreover, the foot length has an average value±sd 25.75±1.42 with minimum and maximum values 23.1 and 29.3 (table 4). in a study of 160 male students in iran with ages ranging from 18 to 25 years, mean±sd values for the foot length are 26.5±1.31 with a maximum value 30.5 and a minimum value of 23.1.3 there is a difference in the value of foot length between iran and indonesia, 26.5 and 25.75. in his study, kanaani et al.3 states that the difference occurs due to the number of subjects with different ages and the use of different methods, besides using a ruler it is also coupled with a digital camera. for mean±sd values of the width of the foot is 9.70±0.58 and minimum and maximum values of 8.4 and 10.9 (table 4). in a study of 26 men with an age from 19–24 years in hong kong11, the foot width value for mean±sd is 9.67±0.55 and minimum and maximum values are 8.7 and 10.6. the value obtained by the study was not too much different, 9.70 to 9.67. anthropometric values are useful in many ways, such as in product development of fitting shoes. however, basically these anthropometric measurements are limited to foot measuring hence the development of products of fitted the shoes must also consider several factors, such as the design of the shoes. hopefully, the results of this study would encourage other researchers to conduct this kind of research because indonesia does not have a national standardization yet. daily activities, age, and gender also need to be considered in further studies since those factors influence the variation in the dimensions of the foot based on studies conducted in other countries. the limitation of this study was the use of a simple measuring instrument i.e. a ruler. other instruments that can be used in the foot measurement are a digital caliper, digital gauges and first metatarsophalangeal joint indicators.12 for a further study, it is recommended to pay attention to several factors, such as age, gender, and physical activities. references 1. dimeglio a. growth in pediatric orthopaedics. in: lovell ww, winter rb, morrissy rt, weinstein sl. lovell and winter’s pediatric orthopaedics. 6th ed. philadelphia: lippincott williams & wilkins; 2006. p. 59. 2. oladipo g, bob–manuel i, ezenatein g. quantitative comparison of foot anthropometry under different weight bearing conditions amongst nigerians. internet j bio anthrop [online journal] 2009 [cited in 2014 june 21]. available from: http://www.ispub.com. 3. kanaani jm, mortazavi sb, khavanin a, mirzai r, rasulzadeh y, mansurizadeh m. foot anthropometry of 18–25 years old iranian male students. asian j sci res. 2010;3(1):62–9. 4. kurup h, clark c, dega r. footwear and orthopaedics. j foot ankle surg. 2012;18(2):79–83. 5. agić a, nikolić v, mijović b. foot anthropometry and morphology phenomena. colleg antropol. 2006;30(4):815–21. 6. schwarzkopf r, perretta dj, russell ta, sheskier sc. foot and shoe size mismatch in three different new york city populations. j foot ankle surg. 2011;50(4):391–4. 7. ismaila s. anthropometric data of hand, foot, ear of university students in nigeria. leonardo j sci. 2009;15(8):15–20. 8. luximon a, luximon y, chao h. a human surface prediction model based on linear anthropometry. int j adv intell sys. 2013;6(3):213–22. 9. chaiwanichsiri d, tantisiriwat n, janchai s. proper shoe sizes for thai elderly. foot. 2008;18(4):186–91. 10. dewangan k, prasanna kumar g, suja p, choudhury m. anthropometric dimensions of farm youth of the north eastern region of india. int j ind ergonom. 2005;35(11):979–89. 11. xiong s, goonetilleke rs, witana cp, lee au ey. modelling foot height and foot shape–related dimensions. ergonomics. althea medical journal. 2018;5(2) 97 2008;51(8):1272–89. 12. mcpoil tg, vicenzino b, cornwall mw, collins n. can foot anthropometric measurements predict dynamic plantar surface contact area. j foot ankle res. 2009;2(1):28. imam ramdhani abdurrahman, alwin tahid, fathurachman: foot anthropometric profile of high school students in bandung vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 12 amj march 2018 superior vena cava syndrome and multiple venous thrombosis in a patient with b cell lymphoma mehmet zahid kocak, gulali aktas, edip erkus, burcin atak, tuba duman, haluk savli abant izzet baysal university hospital, department of internal medicine, bolu, turkey abstract background: superior vena cava syndrome (svcs) develops due to external mechanical pressure of superior vena cava (svc) by a mass lesion or by an enlarged lymph node, tumor invasion of the vessel wall, or venous thrombosis resulting in intraluminal obstruction. approximately 3,9% of lymphomas are complicated with svcs. this rate reaches to 7% in diffuse large b cell lymphoma. the objective of this article was to describe a case report of a young woman with a diffuse large b cell lymphoma, complicated with pericardial-pleural effusion and svcs. methods: a 25 year old woman referred to the internal medicine clinic of abant izzet baysal university hospital with complaints of bloating in the neck and both arms. she had chest pain, dyspnea, cough, and epigastric discomfort for 10 days. a thoracic magnetic resonance imaging (mri) test and pathological assessment were carried out. results: a mediastinal mass 64x112x82 mm in size, displaced the heart and main mediastinal structures to posterior, was detected by thoracic magnetic resonance imaging (mri) test. the result of the pathological assessment of the biopsy specimen revealed large b cell lymphoma, stained strongly and diffusely with cd20 and bcl-2. she was referred to the hematology unit and doing well after a chemotherapy. conclusions: diagnosis of svcs requires high level of clinical suspicion, detailed and complete physical examination. moreover, svcs should be kept in mind in the differential diagnosis of patients presented with edema in the neck and upper extremities. keywords: lymphoma, mediastinal mass, superior vena cava syndrome correspondence: gulali aktas m.d, abant izzet baysal university hospital, department of internal medicine, golkoy, 14280, bolu, turkey. email: draliaktas@yahoo.com introduction superior vena cava syndrome (svcs) develops due to external mechanical pressure of superior vena cava (svc) by a mass lesion or by an enlarged lymph node, tumor invasion of the vessel wall, or venous thrombosis resulting in intraluminal obstruction.1,2 despite symptomatic relief is the rule in treatment of the patients with svcs3, cerebral edema may develop.4 the underlying etiologic cause is malignancy in about 60–90% of svcs cases. bronchogenic carcinoma remains the most common malignant etiology in svcs, but lymphoma and germ cell tumors follow that clinical entity.1 on the other hand, iatrogenic causes may also promote superior vena cava syndrome.5 generally, 3.9% of lymphomas complicate with svcs. this rate reaches to 7% in diffuse large b cell lymphoma and 21% in lymphoblastic lymphoma.6 this article decribed a case report of a 25-year-old woman with a diffuse large b cell lymphoma, complicated with pericardialpleural effusion and svcs. case a 25-year-old woman referred to the internal medicine clinic of abant izzet baysal university hospital with complaints of bloating in the neck and both arms, recently. she also had chest pain, dyspnea, cough, and amj. 2018;5(1):12–5case report issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1202 althea medical journal. 2018;5(1) 13 epigastric discomfort for 10 days. although she had a history of cholecystectomy due to cholelithiasis a month ago, she did not complain of night sweats and 35 kg weight loss within two years. additionally, she was not using medications regularly. the progressive dyspnea and edema in neck and arms lead to a preliminary diagnosis of svcs. a physical examination revealed the patient’s arterial blood pressure was 120/90 mmhg, heart rate was 115 beats per minute, body temperature was 36.9o celsius and respiratory rate was 20 per minute. the patient was comfortable only at sitting position. moreover, her face was plethoric and the enlarged neck veins were notable along with the diffuse bulging in the neck and edema in both arms. however, lymphadenopathy and splenomegaly were not detected. furthermore, blood test results were as follows: hemoglobin: 10.2g/dl, hematocrit: 32%, white blood cell count: 9,850/mm3, platelet count: 412,000/mm3, erythrocyte sedimentation rate: 69mm/hour, lactate dehydrogenase: 911 u/l, uric acid: 4.8mg/ dl. the rest of the serum biochemistry was normal. viral serology, including ebstein-barr virus, was negative. furthermore, multiple lymphadenopathies of which the largest sized was 6mm and sub-acute thrombi in left jugular vein were detected in the neck sonography. the doppler ultrasonography of upper extremities revealed sub-acute thrombi at the left axillary, brachial and cephalic veins. moreover, a portable echocardiogram revealed a pericardial effusion and a chest x-ray signed enlarged mediastinum. besides bilateral pleural and pericardial effusions, a heterogeneous malignant mass at the anterior mediastinum, 64x112x82 mm in size, displaced the heart and main mediastinal structures to posterior was detected by the thoracic magnetic resonance imaging (mri) test. the mass surrounded the circumference of ascending aorta by 270 degrees, pulmonary trunk and its branches by 180 degrees, and completely surrounded the circumferences of bilateral brachiocephalic veins and superior vena cava (figure 1). then, a transthoracic biopsy was performed. additionally, aortocaval and para-aortic lymph nodes, of which the largest was 7.1mm were visualized by the abdominal tomography. no hepatomegaly or splenomegaly was noted. based on these, enoxaparin 60 mg twice a day was prescribed. dexamethasone 4mg four times a day was initiated due to progressive dyspnea and upper extremity edema. dyspnea and cough were ameliorated at the 2nd day of the treatment. while, pathological assessment of the biopsy specimen revealed a large b cell lymphoma, stained strongly and diffusely with cd20 and bcl-2. on the 5th day of treatment, the patient was doing well; her clinical signs and symptoms were improved. so she was referred to a hematology center for appropriate chemotherapy treatment. discussions the main finding of the present report was that superior vena cava syndrome could be mehmet zahid kocak, gulali aktas, edip erkus, burcin atak, tuba duman, haluk savli: superior vena cava syndrome and multiple venous thrombosis in a patient with b cell lymphoma figure 1 mediastinal lymphadenopathy in magnetic resonance imaging althea medical journal. 2018;5(1) 14 amj march 2018 caused by lymphoma in young age despite the lack of palpable lymphadenopathies. careful history review, physical examination and imaging studies were needed to establish the underlying etiology in this syndrome. the superior vena cava syndrome was first described by william hunter in 1757.7 it often poses medical emergency. approximately 60– 90% of svcs cases are caused by malignancy, which increases the incidence of thrombosisassociated svcs due to increased venous thrombosis in malignancies.1 patients with svcs usually complain of cough, shortness of breath, voice disturbance and stridor.8,9 severity of the symptoms in svcs is depended on the rate of progression, the degree of obstruction, and the association between congestion and azygos vein.1 in this case report, the patient was presented with chest pain, dyspnea, cough, facial plethora and edema in both upper extremities and in the neck. in addition to these findings, bilateral pleural and pericardial effusions were detected in our patient. the enlarged paratracheal lymph nodes, lymphomas and thymomas located in the mediastinum or anterior mediastinum caused svcs via the external compression of the superior vena cava. however, bronchogenic carcinoma has the highest association with svcs development.8,9 yu et al.10 classified svcs as asymptomatic, mild, moderate, serious, life-threatening, and fatal according to the symptoms and findings of patients and concluded that the most common form of svcs is moderate svcs (50%) and least common is fatal svcs (<1%). according to this classification, our phenomenon is in accordance with the moderate class svcs. the contrast-enhanced thoracic computed tomography is the most useful diagnostic method for evaluating.1 in patients with contrast allergy, thoracic mri is a good alternative with an equal sensitivity.1 biopsy is needed to confirm the underlying cause of svcs in patients presented with undiagnosed mass. although the younger age of the patient along with pericardial and pleural effusions and multiple sub-acute venous thrombi suggested the possibility of mediastinal large b cell lymphoma, we detected diffuse b cell lymphoma in our case. according to the world health organization (who) classification, mbbhl (mature large b cell lymphoma) is classified under the title of diffuse large b-cell lymphoma (dbbhl) and the average age of onset is between 35-40 years. the mbbhl is differentiated from dbbhl at the molecular level by the absence of bcl-2.11 on the other hand, presentation with svcs is a rare condition in lymphomas, advanced cases may present this syndrome as seen in our patient. the svcs treatment is largely dependent on the underlying cause. supportive and symptomatic treatments include corticosteroids, diuretics and elevation of head of the bed. however, there is no evidencebased validation for any of these approaches that they are curative.2 since lymphomas are steroid-sensitive malignancies, the steroid therapy provided symptomatic relief in the present case. the present patient responded well to the standard chemotherapy for diffuse large b cell lymphoma. in conclusion, diagnosis of svcs requires high level of clinical suspicion, detailed and complete physical examination. svcs should be kept in mind in the differential diagnosis of the patient whom is presented with edema in neck and upper extremities. references 1. owens cd, rapp jh, gasper wj, johnson md. superior vena caval obstruction. blood vessels and lymphatic disorders. in: papadakis ma, mcphee sj, editors. current medical diagnosis and treatment (lange). 54th ed. san fransisco: mcgraw hill education; 2015. p. 481–2. 2. shenoy s, shetty s, lankala s, anwer f, yeager a, adigopula s. cardiovascular oncologic emergencies. cardiology. 2017;138(3):147–58. 3. friedman t, quencer kb, kishore sa, winokur rs, madoff dc. malignant venous obstruction: superior vena cava syndrome and beyond. semin intervent radiol. 2017;34(4):398–408 . 4. talapatra k, panda s, goyle s, bhadra k, mistry r. superior vena cava syndrome: a radiation oncologist’s perspective. j can res ther. 2016;12(2):515–9. 5. thapa s, terry pb, kamdar bb. hemodialysis catheter-associated superior vena cava syndrome and pulmonary embolism: a case report and review of the literature. bmc res notes. 2016;9:233. 6. ferhanoğlu b. diffuse large b cell lymphomasclinical findings and treatment. 2006. [cited 2018 january 28]. available from: http://www.thd.org.tr/ thddata/userfiles/file/diffuz_buyuk_b. pdf.) 7. stajnic m, canji t, panić g, tomić n, jelkić althea medical journal. 2018;5(1) 15mehmet zahid kocak, gulali aktas, edip erkus, burcin atak, tuba duman, haluk savli: superior vena cava syndrome and multiple venous thrombosis in a patient with b cell lymphoma n, kovacević b. the superior vena cava syndrome as a manifestation of dissection of the ascending aorta. med pregl. 2001;54(7–8):380–2. 8. lepper pm, ott sr, hoppe h, schumann c, stammberger u, bugalho a, et al. superior vena cava syndrome in thoracic malignancies. respir care. 2011;56(5):653–66. 9. wan jf, bezjak a. superior vena cava syndrome. emerg med clin north am. 2009;27(2):243–55. 10. yu jb, wilson ld, detterbeck fc. superior vena cava syndrome—a proposed classification system and algorithm for management. j thorac oncol. 2008;3(8):811–4. 11. arlindo em, marcondes na, fernandes fb, faulhaber gam. quantitative flow cytometric evaluation of cd200, cd123, cd43 and cd52 as a tool for the differential diagnosis of mature b-cell neoplasms. rev bras hematol hemoter. 2017;39(3):252–8. vol 4 no 4 final.indd althea medical journal. 2017;4(4) 524 amj december 2017 perception of men who have sex with men about the test and treat strategy of human immunodeficiency virus in bandung city ayesha nadiatama saifuddin,1 nita arisanti,2 bony wiem lestari2 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran abstract background: human immunodeficiency virus (hiv) infection in indonesia has shifted from injecting drug use to sexual transmission. one of the ways to prevent hiv transmission is by using early antiretroviral therapy (art) or known as test and treat. test and treat is recommended by the world health organization (who) in 2013. this study aimed to explore the perception of men who have sex with men (msm) about hiv test and treat strategy. methods: this quantitative observational study used a cross-sectional design. primary data were collected from questionnaires filled in by 58 msm diagnosed as hiv positive at mawar clinic, pasundan and ibrahim adjie public health centers in september–december 2016. sampling was performed using total sampling method which was bounded by time period. the questionnaire contained data of respondents’ characteristics and perceptions of hiv test and treat strategy. data analysis was presented in tables. result: respondents were mostly 20–24 years old (48%), 55% were senior high school graduates, 98% were unmarried, 58% worked as employees, and 21% earned 2–2.5 million rupiahs per month. forty eight percent of the respondents had negative perception of the test and treat strategy, and 52% of the respondents had positive perception of the strategy. conclusions: most of the msm population have a negative perception of hiv test and treat strategy. it is important for the key populations especially the msm to obtain education related to hiv treatments and strategy. keywords: human immunodeficiency virus, men who have sex with men, perception, test and treat correspondence: ayesha nadiatama saifuddin, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: ayeshanadiatamas@gmail.com introduction according to data from the world health organization (who) in 2014, there were 36.9 million of people in the world who lived with human immunodeficiency virus (hiv), out of which 34.3 million of them were adults, 17.4 million were women, and 2.6 million were children under 15 years of age.1 in indonesia2, according to data from the indonesian ministry of health from 1987 until december 2015, there were 191.073 people in hiv infection cases. if the people with hiv infection were classified based on provinces, west java ranked in the fourth position with 17.679 people. if the people with hiv infection were grouped based on the risk factors, the most is heterosexuals, followed by others, then followed by men who have sex with men (msm) with the percentage of 21.6%, and the last is injecting drug users with 4.1%.2 from 2010 until 2015, the order of the most risk factors had been shifting from injecting drug use to sexual transmission especially in msm which has increased by 28.1%.2 men who have sex with men is a risk behavior and a precarious group towards hiv transmission sexually.3 one of the ways to prevent hiv transmission sexually is by giving antiretroviral (arv) which was recommended by who in 2013.4 in accordance with the research of hiv prevention trials network (hptn) 052, providing an early art reduce the risk of hiv sexual transmission to 96%. the prevention of hiv transmission by providing art is also called test and treat.5 sexual transmission of hiv can also be prevented through the use of condoms; this can be seen from the research by liu et al.6 regarding the effectiveness of wearing condoms to prevent hiv sexual transmission amj. 2017;4(4):524–9 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n4.1262 althea medical journal. 2017;4(4) 525 within serodiscordant couples that couples who joined the antiretroviral therapy (art) program have a declining risk of transmitting hiv for 67% and who joined the hiv program as well as wear condoms regularly can increase the protection level up to 99%. in indonesia, the strategy of test and treat has not been implemented yet by healthcare facilities. according to the policy of the indonesian ministry of health regulation no. 21 year 2013 about hiv/ acquired immunodeficiency syndrome (aids) prevention and policy no. 87 year 2014 about the arv medication guidance, art will be given if the cluster of differentiation 4 (cd4) is less than or equal to 350 cell/ mm3.7 meanwhile, based on the who recommendation, the test and treat strategy has been applied in several countries as part of hiv transmission prevention.4 due to the hiv sexual transmission increases for years and recently msm is also a high risk factor, thus, this study aimed to identify the perception of the test and treat strategy on msm population to give description in initiating the test and treat strategy in indonesia. methods this study was an observational quantitative study using cross-sectional design. the population of the study was men having sex with men (msm) who lived in the city of bandung. the subjects were msm who were diagnosed hiv positive at mawar clinic, pasundan and ibrahim adjie public health centers with the support and assistance of abiasa non-governmental organization (ngo) in bandung. the inclusion criterion of this study was msm who were diagnosed with hiv, meanwhile, the exclusion criteria were msm with severe illness, unwilling to participate in the study, and had the history of arv (antiretroviral) medication. the subjects were selected using the total sampling method that was bounded by time in the period of september–december 2016. the data were collected by distributions of questionnaires with a structured interview. the questionnaire reference used was a questionnaire for doctors/physician in massachusetts8 which had been modified and validated with cronbach’s alpha of 0.867. the total of questions in the questionnaire was 51 points, in which five points were about the respondents’ characteristics and the other 46 points were questions about perceptions using likert scale answer choices (strongly agree, agree, quite agree, quite disagree, disagree, and strongly disagree). the questions in the questionnaire were recited after gaining permission from the respondents. the respondents were introduced by the counselor and the workers at abiasa ngo. data collection was conducted from september– december 2016 and was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran with the letter no:518/un6.c1.3.2/kepk/pn/2016. the obtained data were then processed and analyzed using data processing software. the perception towards hiv test and treat strategy was categorized as positive by using data distribution test if the score result was >160.2, and if the score result was <160.2 then the perception of the respondents was categorized as negative. results the number of respondents in this study was 58. the respondents were characterized in accordance with the age, the latest level of education, marital status, profession, and monthly income (table 1). in this study, the respondent’s youngest age was 18 years and the oldest age was 46 years. the majority, 55% (n=32) of the respondents’ level of education was senior high school graduates, 98% (n=57) of the respondents were unmarried, 58% (n = 34) worked as an employee and 21% (n=12) earned rp2–2.5 million per month (table 1). respondents who had positive perception towards hiv test and treat strategy were lower in percentage than respondents who had negative perception. the negative perception was higher by 4% (table 2). discussion this study discovered that the majority of respondents were 20–24 years old (48%). the median of the age in this study was 24 years. the highest number of respondents’ level of education was senior high school (55%). the majority of the respondents were unmarried (98%). the majority of the respondents worked as employees (58%). similar findings can also be seen in a study conducted by guadamuz, et al.9 about the characteristics of msm who had not checked on hiv themselves yet, in the association of south east asian nations (asean); the majority of the respondents’ age was 23–28 years and >28 years or categorized ayesha nadiatama saifuddin, nita arisanti, bony wiem lestari: perception of men who have sex with men about the test and treat strategy of human immunodeficiency virus in bandung city althea medical journal. 2017;4(4) 526 amj december 2017 in the productive period. while the majority of respondents had higher education and were university graduates. in addition, the majority of the respondents were unmarried, and had full-time jobs. the results of the study revealed that the perception towards hiv test and treat strategy was slightly negative (52%) compared to the positive perception. however, most participants (95%) responded that the information gained was adequate regarding the program. however, there were some respondents (5%) who felt that information of the program regarding the objectives, benefits, table 1 general characteristics of respondents characteristics frequency (n) percentage (%) age 15–19 years 6 10 20–24 years 28 48 25–49 years 24 42% level of education never get formal education 0 0 primary school 0 0 junior high school 6 10 senior high school 32 55 academy/university 20 35 no response 0 0 marital status unmarried 57 98 married 0 0 divorced 1 2 divorced (because of death) 0 0 occupation employee 34 58 freelancer 2 4 student/college student 10 17 unemployed 0 0 no response 1 2 others 11 19 monthly income no income 6 10 <rp500.000 4 7 rp500.000–1 million 9 16 rp1 million–1.5 million 6 10 rp1.5 million–2 million 5 9 rp2 million–2.5 million 12 21 rp2.5 million–3 million 2 3 >rp3 million 8 14 do not know 2 3 no response 4 7 althea medical journal. 2017;4(4) 527 table 2 perception towards hiv test and treat strategy perception frequency (n) percentage (%) positive 28 48 negative 30 52 procedures, and advantages and disadvantages of the program was inadequate. all respondents were willing to join the program and acknowledged that the side effects of the medicines were really important to have prior discussions and to identify the opportunistic infections related to hiv. the majority of the respondents (97%) considered the hiv test and treat program was positive and should be implemented in public health centers. this was shown in the study by stringer, et al.10 about providing art at primary services in zambia, that the hiv aids services and providing art at primary services could be implemented with good clinical results. some of the respondents (36%) still wanted to try traditional medication, this showed that the respondents still lacked knowledge regarding arv medicines and hiv. this finding was in line with the study by tabi, et al.11 about the use of traditional and modern medications in ghana, that to choose between tradition or modern medications was really influenced by the level of education, family, friends, faith and religion. this was also possibly caused by the time limitation of counselors to educate patients, due to the large number of patients and lacked of staff at the public health center. almost a half of the respondents (47%) were anxious about the side effects management if arv medicines were provided in public health centers, and considered that the side effects management had to be provided in hospitals. some respondents were also anxious about their obedience if arv was given in public health centers, and 97% of the respondents thought that it would be better that every arv taken in all hiv/aids services had to include the counseling process of compliance. meanwhile, in the study conducted in swaziland by humphreys, et al.12 regarding art given in the primary service and hospitals, it figured out that people who took art in hospitals had more opportunities to skip an appointment with the therapist than those who took art in the primary service. the majority (86%) of the respondents was anxious about the interaction of arv medicines with other medicines or alcohol; this is contrary to the study conducted by shuaib, et al.13 regarding a survey towards patients who obtained warfarin therapy, about the medicine regiment knowledge, reveals that 56% do not acknowledge the interaction between medicines. more than a half of the respondents (69%) were also anxious about being unable to take arv medicines easily and regularly. most respondents (62%) were anxious about their status if taking arv medications at the public health center, and some respondents (22%) were reluctant to take arv at the public health center since they were afraid that their status would be noticed by people around them and thought that it would be better if arv services were given in hospitals or special clinics. there were several respondents (45%) who still felt that the stigma towards hiv is not decreasing. the findings in the study by waluyo, et al.14 discovered that the stigma is still an issue in the society and this stigma is related to the level of information that the society have towards hiv/aids. the stigma influences one’s optimum ability towards arv therapy and the willingness to take the hiv test. therefore, educating the society about hiv/ aids is very important to reduce the spread of stigma. almost all respondents (83%) were anxious that their status would be noticed by family, friends, or others in the community; meanwhile, the majority of the respondents (78%) felt that the family’s support was very important to encourage them to join the program. according to the study conducted by shaluhiyah, et al.15 the stigma towards people with hiv/aids (pwha) started from the family. the family who have negative perspectives towards pwha will have greater probability to give stigma. stigma towards pwha will cause people with hiv feel alienated. the majority of the respondents (95%) decided to start taking arv medications and considered starting arv medication in the near future. a rise in the willingness to undergo arv treatment is a good thing, but the education about protected sex should be given. a study by phillips an, et al.16 discovered that there is a rise in art but the number of unprotected sex has also increased. several respondents (33%) were unwilling to consume arv since they still did not accept the fact that they were infected by hiv, meanwhile, those who did not yet start the ayesha nadiatama saifuddin, nita arisanti, bony wiem lestari: perception of men who have sex with men about the test and treat strategy of human immunodeficiency virus in bandung city althea medical journal. 2017;4(4) 528 amj december 2017 arv medication due to the anxiety of the side effects were around 31% out of the total of the respondents. in addition, some respondents (62%) were anxious about the examination cost of viral load and cd4 which became the constraint to get arv. some respondents (59%) also addressed that the scheduled limitation of arv taking at hiv/aids services which they visited would cause problems to obtain the medicines. several respondents (12%) felt healthy and did not need medication. moreover, 65% of the respondents were anxious about the side effects of the medicines, and 64% were anxious that they could not work during arv medication. additionally, several respondents (5%) were uncertain about the advantages of hiv medication, and 26% of the respondents did not want to consume the pills every day. those findings could influence an individual to start arv medication. a study about art and reasons of not consuming it in msm population in europe conducted by marcus, et al.17 revealed that the common reasons (88.8% out of 3259 respondents) for a person to stop consuming arv and not to start arv are that the person does not need the program, then followed by the fear of its consequences (11.7%), and inability to access art (2.3%). based on the theory of health belief model (hbm), behavior can change based on perception. a perception towards a disease can change someone’s behavior if the performed behavior affects the health.18 in relation to it, then, somebody’s perception is important to reduce risky behaviors to prevent hiv transmission. this is in line with the study by mimiaga, et al.19, if someone is not precarious or exposed, they will not do screening. therefore, education, information, and perception of somebody are important to reduce the hiv epidemic in indonesia. the meta-analysis study by crepaz, et al.20 revealed that most people with hiv positive is having a protected anal sex to protect partners. this behavioral change is possibly affected by the perception towards hiv. this study has limitation of insufficient research time. men who have sex with men is also a hidden population which made it difficult to get respondents, and the stigma towards hiv and msm in society caused many respondents were not open with their status and were unwilling to be interviewed. the psychological condition of the respondents who only recently knew that they were hiv infected caused some respondents were unwilling to be interviewed since they were still shocked and were in the denial phase. generally, this study discovers that the perception of msm population towards the strategic program of hiv test and treat is negative, especially regarding the statement of respondents’ anxiety towards their hiv status which may be noticed by family, friends, or people in the community. references 1. world health organization. hiv/aids data and statistics; [cited in 1 may 2016]; available from: http://www.who.int/hiv/ data/en/ 2. kementrian kesehatan republik indonesia. laporan pengembangan hiv aids triwulan i–iv. jakarta: pusat data dan informasi kementrian kesehatan republik indonesia; 2015. 3. kaufman mr, cornish f, zimmerman rs, johnson bt. health behavior change models for hiv prevention and aids care: practical recommendations for a multi-level approach. j acquir immune deficiency syndrome. 2014;66(3):250–8. 4. world health organization. guidelines guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for hiv. geneva;who library cataloguingin-publication data: 2015. 5. hosseinipour mc, kumarasamy n, hakim jg, mehendale s, chariyalertsak s, santos br, et al. prevention of hiv-1 infection with early antiretroviral therapy. n engl j med. 2011;365(6):493–505. 6. liu h, su y, zhu l, xing j, wu j, wang n. effectiveness of art and condom use for prevention of sexual hiv transmission in serodiscordant couples: a systematic review and meta-analysis. plos one. 2014;9(11):1–7. 7. kementrian kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia tentang penanggulangan hiv dan aids. jakarta: peraturan menteri kementrian kesehatan ri; 2013. 8. white jm, mimiaga mj, krakower ds, mayer kh. evolution of massachusetts physician attitudes , knowledge , and experience regarding the use of antiretrovirals for hiv prevention. aids patient care stds. 2012;26(7):395–405. 9. guadamuz te, cheung dh, wei c, koe s, lim sh. young, online and in the dark: scaling up hiv testing among msm in asean. plos one. 2015;10(5):1–12. 10. stringer jsa, zulu i, levy j, stringer em, mwango a, chi bh, et al. rapid scalealthea medical journal. 2017;4(4) 529 up of antiretroviral therapy at primary care sites in zambia: feasibility and early outcomes. jama. 2006;296(7):782–93. 11. tabi mm, powell m, hodnicki d. use of traditional healers and modern medicine in ghana. int nurs rev. 2006;53(1):52–8. 12. humphreys cp,wright j, walley j, mamvura ct, bailey ka, ntshalintshali sn, et al. nurse led, primary care based antiretroviral treatment versus hospital care: a controlled prospective study in swaziland. bmc health serv res. 2010;10(229):1–7. 13. shuaib w, iftikhar h, alweis r, shahid h. warfarin therapy: survey of patients’ knowledge of their drug regimen. malays j med sci. 2014;21(4):37–41. 14. waluyo a, sukmarini l, rosakawati r. persepsi pasien hiv/aids dan keluarganya tentang hiv/aids dan stigma masyarakat terhadapnya. jurnal keperawatan indonesia. 2006;10(1):16–23. 15. shaluhiyah z, musthofa sb, widjanarko b. stigma masyarakat terhadap orang dengan hiv/aids. jurnal kesmas nasional. 2015;09(4):333–9. 16. phillips an, cambiano v, nakagawa f, brown ae, lampe f, rodger a, et al. increased hiv incidence in men who have sex with men despite high levels of artinduced viral suppression: analysis of an extensively documented epidemic. plos one. 2013;8(2):1–8. 17. marcus u, hickson f, weatherburn p, furegato m, breveglieri m, berg rc, et al. antiretroviral therapy and reasons for not taking it among men having sex with men (msm)-results from the europian msm internet survey (emis). plos one. 2015;10(3):1–13. 18. baghianimoghaddam mh, forghani h, zolghadr r, rahaii z kp. health belief model and hiv/aids among high school female students in yazd, iran. j res med sci. 2010;15(3):189–90. 19. mimiaga mj, goldhammer h, belanoff c, tetu am, mayer kh. men who have sex with men: perceptions about sexual risk, hiv and sexually transmitted disease testing, and provider communication. sex transm dis. 2007;34(2):113–9. 20. crepaz n, marks g, liau a, mullins mm, aupont lw, marshall kj, et al. prevalence of unprotected anal intercourse among hiv-diagnosed msm in the united states: a meta-analysis. aids. 2009; 23(13):1617– 29. ayesha nadiatama saifuddin, nita arisanti, bony wiem lestari: perception of men who have sex with men about the test and treat strategy of human immunodeficiency virus in bandung city althea medical journal. 2017;4(2) 184 amj june 2017 antimicrobial sensitivity of neonatal bacterial sepsis nadya iswandari,1 aris primadi,2 sunarjati sudigdoadi3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of microbiology and parasitology faculty of medicine universitas padjadjaran abstract background: appropriate treatment on neonatal bacterial sepsis is important based on the exact etiology to prevent bacterial resistance, but bacterial identification using blood cultures requires a considerable time. the newest data of various bacteria and their sensitivity can be used to assist empirical antibiotics usage. this study was conducted to identify bacterial profile that caused neonatal sepsis and their sensitivity to antibiotics at dr. hasan sadikin general hospital bandung.. methods: a total of 275 neonatal sepsis cases and 288 blood cultures results were collected from a database provided by dr. hasan sadikin general hospital bandung during the period of july 2011 todecember 2012 (three semesters). etiology of the bacteria and antimicrobial sensitivity profile data were taken from positive bacteria results. then, these variables were processed using the descriptive method and classified by semester result: the most common bacteria that caused neonatal sepsis in the second semester 2011 is serratia marescens, the first semester 2012 was enterobacter aerogenes and in the second semester 2012 was burkholderia cepacia. the most sensitive antibiotics were piperacillin tazobactam, cefepime, meropenem and amikacin in all three semesters, gentamycin in the second semester 2011 and 2012, and amoxicillin clavulanic in the second semester 2012. conclusions: bacterial and antimicrobial sensitivity profile is varied in every semester. keywords: antimicrobial sensitivity profile, bacterial profile, neonatal sepsis correspondence: nadya iswandari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81280282436 email: nadiswandari@gmail.com introduction most of neonatal deaths in indonesia are caused by sepsis.1 treatment of neonatal sepsis is prescribed based on the bacterial profile sensitivity to antimicrobial. however, both bacterial and sensitivity profile tend to be varied at different times and in different places. in indonesia, a study conducted at dr. cipto mangunksumo hospital in 2008, revealed that acinetobacter calcoaceticus, staphylococcus epidermidis, enterobacter aerogenes and pseudomonas sp., were the most common bacteria in neonatal sepsis.2 in developing countries, the most frequent etiologies for neonatal sepsis were staphylococcus aureus, escherichia coli and klebsiella sp.3 in developed countries, early onset neonatal sepsis is mostly caused by group b streptococcus.4 an appropriate treatment is important based on the exact etiology, but bacterial identification using blood cultures requires a considerable time. on the other hand, the usage of broad spectrum antibiotics could increase risk of loss of bacterial sensitivity to antibiotics given, resulting in bacterial resistance.5 to solve this situation, the newest data of bacteria that commonly caused neonatal sepsis was needed to assist empirical antibiotics usage. at dr. hasan sadikin general hospital, bacterial profile is routinely studied in the department of clinical pathology every semester. yet, bacterial and antimicrobial sensitivity profile in infants born at dr. hasan sadikin general hospital were scarce. moreover, decision in using a certain antibiotic depends on the variety of antibiotics provided by the government health insurance (jaminan persalinan/jampersal) such as ampicillin, gentamycin, and cefotaxime. this study was conducted to identify the bacterial and sensitivity profile to antibiotics amj.2017;4(2):184–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1072 185 althea medical journal. 2017;4(2) that cause neonatal sepsis at dr. hasan sadikin general hospital. methods data base of all neonatal sepsis patients were collected from the second semester of 2011 and two semesters of 2012 at dr. hasan sadikin general hospital bandung. the inclusion criteria in this study was neonatal sepsis patients. incomplete data and non‒bacterial neonatal sepsis were excluded in this study. then a total of 275 neonatal sepsis cases and 288 blood cultures results were identified. the incompatibility of the number of samples between the patients and the blood cultures occurred because one patient might have his/her blood culture examined more than once. the variables in this study were bacterial and sensitivity profile data. then, the data was processed using the descriptive method and the results were classified in semester to describe the pattern of culture results, bacterial profile in frequency and antimicrobial sensitivity in percentage. this study was approved by the health research ethics committee at dr. hasan sadikin general hospital bandung. results from the total of 288 blood cultures in three semesters, the distribution of the presence of bacteria was slightly higher than the distribution of sterile specimen in their blood cultures (table 1). the most common bacteria that causes neonatal sepsis was varied. in the second semester of 2011 were serratia marescens, klebsiella pneumoniae and staphylococcus haemolyticus, in the first semester of 2012 the most common bacteria that caused neonatal sepsis were enterobacter aerogenes, staphylococcus haemolyticus, and klebsiella pneumoniae. in the second semester of 2012 were burkholderia cepacia, staphylococcus haemolyticus and enterobacter cloacae. the most sensitive antibiotics in the second semester of 2011 were piperacillin tazobactam, cefepime, meropenem, amikacin and gentamycin. in the first semester of 2012 were piperacillin tazobactam, cefepime, meropenem and amikacin. in the second semester of 2012 were piperacillin tazobactam, amoxicillin clavulanic, cefepime, amikacin and gentamycin. discussion culture results revealed positive results were slightly higher than sterile results. these results were similar to a study conducted at dr. cipto mangunkusumo hospital.2 in routine clinical practice, negative culture results are almost inevitable in many cases caused by inadequate blood sample volume.6 in this study, bacteria that were considered as contaminant bacteria such as coagulase negative staphylococci, corynebacterium, bacillus and micrococcus are excluded from results.7 based on the results, there was causative diversity in neonatal sepsis cases. in the second semester of 2011 bacteria that mostly caused neonatal sepsis are serratia marcescens, klebsiella pneumoniae, staphylococcus haemolyticus and staphylococcus aureus. a similar study in yale8 also concluded that the causative pathogen of neonatal sepsis continue to change. serratia marcescens is normal flora in gastrointestinal tract and opportunis pathogen. it commonly caused infection in hospital setting especially patients with venous catheter.9 in the first semester of 2012 bacteria that mostly caused neonatal sepsis are enterobacter aerogenes, staphylococcus haemolyticus and klebsiella pneumoniae whereas serratia marcescens only 2 cases occurred in this period. enterobacter aerogenes is a free living bacteria and normal flora in gastrointestinal tract.9 in the second semester of 2012 bacteria that mostly caused neonatal sepsis are burkholderia cepacia, staphylococcus haemolyticus and enterobacter cloacae whereas enterobacter aerogenes was not found in this period. burholderia table 1 culture results of neonatal sepsis patients presence of bacteria second semester 2011 first semester 2012 second semester 2012 n n n bacteria 30 45 53 steril 34 51 51 nadya iswandari, aris primadi, sunarjati sudigdoadi: antimicrobial sensitivity of neonatal bacterial sepsis althea medical journal. 2017;4(2) 186 amj june 2017 cepacia is commonly found in water and environment. in hospital setting this bacteria transmit between patients, and often infect infants.9 this result proved bacterial profile that caused neonatal sepsis was varied. based on literature, staphylococcus can be acquired from primary sepsis or nosocomial. klebsiella and serratia commonly caused nosocomial sepsis.10 enterobacter is an enterobactericeae family, similar as escherichia coli which is primary sepsis etiology. however, klebsiella pneumoniae and serratia marcescens were one of the most common bacterial cause of early onset neonatal sepsis, so nosocomial infection was unlikely. staphylococcus haemolyticus was the most frequent bacterial cause of early onset neonatal sepsis, then based on literature those cases were primary sepsis.10 in asimilar study conducted in dr. cipto mangunkusumo hospital2, another state hospital, there was a significant difference between causative bacteria in neonatal sepsis. the most common bacteria that caused neonatal sepsis in dr. cipto mangunkusumo hospital are acinetobacter calcoaceticus, followed by enterobacter aerogenes, pseudomonas, escherichia coli and klebsiella pneumoniae. except enterobacter aerogenes and klebsiella pneumoniae, these bacteria also caused neonatal sepsis in dr. hasan sadikin general hospital, but in much lower cases. in other developing country, the most bacteria caused neonatal sepsis are staphylococcus aureus, escherichia coli, and klebsiella.3 except for escherichia coli, these bacteria also caused neonatal sepsis in dr. hasan sadikin general hospital in high number. a study conducted in india11 also reveal causative bacteria variability at different times. furthermore, klebsiella pneumoniae and enterobacter aerogenes found decreased in incidence and staphylococcus aureus increased in incidence. in this study klebsiella pneumoniae and enterobacter aerogenes were found in high number. in developed countries, the most bacteria caused neonatal sepsis are group b streptococci. in dr. hasan sadikin general hospital, there were no group b streptococci positive culture results found.12 in this study the most sensitive antibiotics in the second semester of 2011 were piperacillin tazobactam, cefepime, meropenem, amikacin and gentamycin, in the first semester of 2012 were piperacillin tazobactam, cefepime, meropenem and amikacin, in the second semester of 2012 were piperacillin tazobactam, amoxicillin–clav, cefepime, amikacin and gentamycin. cefotaxime and ceftazidime also had high sensitivity percentage in the second semester of 2011 and 2012. this result was similar to a study conducted in dr. cipto mangunkusumo hospital2, which reported meropenem has high sensitivity level. this was different with literature that suggest to use ampicillin to treat early onset neonatal sepsis.10 ampicillin was only tested in 4 cases and only 25% had sensitivity level. ampicillin and gentamicin was preferably recommended in developed countries but not in dr. hasan sadikin general hospital, due to causative bacteria difference as described above.12 in nosocomial sepsis, literature suggest to use vancomycin, and based on result vancomycin has high sensivitity level but only tested in 36 cases.10 antibiotics that used for gram negative bacteria, in this study amikacin and gentamicin, has lower sensitivity level than meropenem. antibiotics is used for gram positive bacteria, in this study linezolid and vancomycin, had high sensitivity level, but gram positive bacteria cases were much lower than gram negative bacteria cases, then broad spectrum antibiotics, meropenem, cefepime, piperacillin, ceftazidime and cefotaxime gave more gram positive and negative bacteria coverage. on the one hand, amikacin also had high sensitivity level. apart from sensitivity level, the antibiotic selection also had to consider the price of antibiotics itself. most of dr. hasan sadikin general hospital patients were insured by jampersal coverage. antibiotics available for this insurance were ampicillin, gentamycin and cefotaxime. ampicilin has low sensitivity level as described above, and gentamycin also has lower sensitivity than other aminoglycoside antibiotic, amikacin. cefotaxime, still has high sensitivity level. on the other hand, another study found that concurrent use of cefotaxime during the first 3 days after birth associated with an increased risk of death, compared with the concurrent use of gentamycin.13 in addition, this study could be an evidence based study to recommend other sensitive antibiotics to be borne by government in upcoming jaminan kesehatan nasional programme, and included in formularium. limitation of this study was lack of data between january–june 2011. this study needs periodic study to describe etiology and antimicrobial sensitivity profile due its variability. references 1. departemen kesehatan republik indonesia. ibu selamat, bayi sehat, suami 187 althea medical journal. 2017;4(2) nadya iswandari, aris primadi, sunarjati sudigdoadi: antimicrobial sensitivity of neonatal bacterial sepsis siaga. 2010. [cited 13 february 2013]; available from: http://www.depkes.go.id/ index.php/berita/press-release/790-ibuselamat-bayi-sehat-suami-siaga.html. 2. juniatiningsih a, aminullah a, firmansyah a. profil mikroorganisme penyebab sepsis neonatorum di departemen ilmu kesehatan anak rumah sakit cipto mangunkusumo jakarta. sari pediatri. 2008;10(1):60‒5. 3. waters d, jawad i, ahmad a, luksic i, nair h, zgaga l, et al. aetiology of community‒ acquired neonatal sepsis in low and middle income countries. j glob health. 2011;1(2):154‒70. 4. stoll bj, hansen ni, sánchez pj, faix rg, poindexter bb, van meurs kp, et al. early onset neonatal sepsis: the burden of group b streptococcal and e. coli disease continues. pediatrics. 2011;127(5):817‒26. 5. tenover fc. mechanisms of antimicrobial resistance in bacteria. am j infect control. 2006;34(5 suppl 1):s3‒10;discussion s64‒73. 6. connell tg, rele m, cowley d, buttery jp, curtis n. how reliable is a negative blood culture result? volume of blood submitted for culture in routine practice in a children’s hospital. pediatrics. 2007;119(5):891‒6. 7. hall kk, lyman ja. updated review of blood culture contamination. clin microbiol rev. 2006;19(4):788‒802. 8. bizzarro mj, raskind c, baltimore rs, gallagher pg. seventy‒five years of neonatal sepsis at yale: 1928‒2003. pediatrics. 2005;116(3):595‒602. 9. brooks g, carroll kc, butel j, morse s. jawetz, melnick, & adelberg’s medical microbiology, 25th ed: new york: mcgraw‒ hill companies, incorporated; 2007. 10. sundaram v, kumar p, dutta s, mukhopadhyay k, ray p, gautam v, et al. blood culture confirmed bacterial sepsis in neonates in a north indian tertiary care center: changes over the last decade. jpn j infect dis. 2009;62(1):46‒50. 11. polin ra. management of neonates with suspected or proven early‒onset bacterial sepsis. pediatrics. 2012: 129(5): 1006‒15. 12. clark rh, bloom bt, spitzer ar, gerstmann dr. empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamicin, for neonates at risk for sepsis is associated with an increased risk of neonatal death. pediatrics. 2006;117(1): 67‒74. vol 5 no 1 full text edit.indd althea medical journal. 2018;5(1) 6 amj march 2018 congenital heart disease among down syndrome children at dr. hasan sadikin general hospital from 2008 to 2013 thyviyaa rajamany,¹ rahmat budi kuswiyanto,² leonardo lubis3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia, 3department of physiology faculty of medicine universitas padjadjaran bandung, indonesia abstract background: children with down syndrome are more prone to congenital heart disease due to the consequences of trisomy chromosomal 21 on gene expression. the aim of this study was to determine the pattern of congenital heart disease in children with down syndrome. methods: this was a retrospective study of reviewed children with down syndrome from january 2008 to january 2013 at dr. hasan sadikin general hospital, bandung, indonesia. this study was conducted from august until october 2014. patients under the age of 15 years and diagnosed having congenital heart disease from 2008 to 2013 were enrolled in this study by using the total sampling method. incomplete medical records and children who had not performed an echocardiogram were excluded. sex, age at diagnosis for congenital heart disease, nutritional status and other comorbidities were also examined. results: congenital heart disease occurred in 28 children with down syndrome. patent ductus arteriosus (pda) was the most common and found in 11 patients followed by a combination of congenital heart diseases in 5 patients. other 3 patients had atrioventricular septal defect (avsd), and tetralogy of fallot (tof) was found in 3 patients, 2 patients had atrial septal defect (asd) and 1 patient had miscellaneous cardiac defect. conclusions: the most common chd in down syndrome is pda. keywords: children, congenital heart disease, down syndrome correspondence: thyviyaa rajamany, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: thyviyaarajamany@gmail.com introduction the world health organization (who) confirmed that children with down syndrome were more prone to get congenital heart disease and other diseases.1 incidence of congenital heart defect is higher among down syndrome children, approximately 50% as suggested by several studies and this is associated with abnormality in genes of the children with down syndrome.2 previous studies in the north east of england and turkey showed that the most common single defect of congenital heart disease is an atrioventricular septal defect.3,4 several studies were also conducted to determine the pattern of congenital heart disease and they concluded that the most common types of congenital heart disease are atrioventricular septal defect (avsd), ventricular septal defect(vsd), atrial septal defect(asd) and tetralogy of fallot (tof).5 trisomy of hsa21 which occurs in children with down syndrome is associated with congenital heart defects. however, not one study has proven yet that chromosome 21 is the exact chromosome responsible for the cardiac anomaly in down syndrome. thus, the presence of specific gene variants such as trisomy 21 can further increase susceptibility for cardiac defects in down syndrome.6 the variation in folate pathway genes plays an important role in forming the congenital heart disease in down syndrome. in this metabolic pathway, the methylenetetrahydrofolate reductase (mthfr) undergoes polymorphism which causes decrease in availability of 5-methylthf for methylation, and then leads to reduction of global dna methylation. inhibition of dna methylation can cause decrease in s-adenosylmethionine/sadenosylhomocysteine ratio which results in cranial defects.7 the objective of this study was amj. 2017;5(1):6–11 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1328 althea medical journal. 2018;5(1) 7 to determine the pattern of congenital heart disease in children with down syndrome. methods this study was conducted from august to october 2014 as a descriptive retrospective study, and medical records were used as the source of data. data collection using medical records has been approved by the health research ethics committee at dr. hasan sadikin general hospital. the target population in this study were all children with down syndrome and the samples for this study were children with down syndrome who were diagnosed with congenital heart disease in the department of child health, dr. hasan sadikin general hospital. the total sampling method was used in this study. medical records and echocardiogram reports were evaluated which included gender, height, and weight for nutritional assessment, age at diagnosis, types of congenital heart disease, and other non-cardiac diseases. data of patients were considered eligible if the patient was under the age of 15 years and had been diagnosed with congenital heart disease from 2008 to 2013. incomplete medical records and children who had not performed the echocardiogram were excluded. in this study, the children’s standard age was under the age of 15 years, and age was recorded in months and years. age at diagnosis was calculated by deducting the age of children when first diagnosed having a congenital figure 1 flow chart of data collection thyviyaa rajamany, rahmat budi kuswiyanto, leonardo lubis: congenital heart disease among down syndrome children at dr. hasan sadikin general hospital from 2008 to 2013 althea medical journal. 2018;5(1) 8 amj march 2018 heart disease with date of birth of that child. moreover, age group were classified according to nelson’s paediatric age classification which was neonates (less than 1 month), infant (1 month to 2 years), pre-school children (2 to 5 years), middle childhood (6 to 11 years) and early to middle adolescents (12 to 14 years).8 types of congenital heart disease were diagnosed using the echocardiogram and it was classified according to icd-10. the nutritional status was measured according to who child growth assessment. children under the age of 6 years were measured for their weight for length or weight for age. the nutritional status in children more than 6 years old was calculated by bmi. this was done to determine the height and weight appropriate to children’s age. for the interpretation, z-score classification system is used. children are considered obese if the z-score is above 3, overweight if the z-score is above 2, possible risk of overweight if the children have a z-score above 1. z-score 0 to -1 are considered normal weight and z-score below -2 indicates that the children are wasted and z-score -3 means the children are severely wasted.9 results of the study were arranged in frequency tables and graphics charts to evaluate the pattern of congenital heart disease in down syndrome children according to sex, age when diagnosed having congenital heart disease, types of congenital heart disease and other comorbidities. the results were then analysed and explained descriptively by using the microsoft office excel 2011®. results furthermore, a total of 179 cases of congenital heart disease among children with down syndrome was reported from january 2008 to january 2013. however, about 84 medical records were lost, and out of the remaining 95 medical records, 57 patients did not have a congenital heart disease, 10 patients did not perform the echocardiogram, so 28 samples (33%) were selected according to the inclusion criteria. moreover, the highest number of cases were reported in 2013 which were 11 cases among 28 cases. overall, it showed the distribution of patients increased about 32.8% from 2008 to 2013, as 2 cases were reported in 2008 and another 2 cases were reported in 2009. in 2010, 5 down syndrome patients were reported having a congenital heart disease and 4 people came in 2011 and 2012. the number ofemale patient was 18 patients table 1 characteristics of down syndrome patient with congenital heart disease data characteristics frequency (n=28) sex male 8 female 15 age group ≤ 1 month 1 1 month – 2 years 22 2 – 5 years 4 6 – 11 years 0 12 – 14 years 1 nutritional status obese 0 overweight 1 possible risk of overweight 0 normal 13 wasted 8 severly wasted 6 althea medical journal. 2018;5(1) 9 table 2 type of congenital heart disease among children with down syndrome type of congenital heart disease frequency (n=28) asd 2 vsd 3 avsd 3 pda 11 tof 3 combined 5 unspecific 1 notes: asd=atrial septal defect; vsd= ventricular septal defect; avsd= atrio ventricular septal defect; pda= patent ductus arteriosus; tof= tetralogy of fallot thyviyaa rajamany, rahmat budi kuswiyanto, leonardo lubis: congenital heart disease among down syndrome children at dr. hasan sadikin general hospital from 2008 to 2013 while male patients were 10. consequently, the dominated gender among the patients was female. the samples for the study were divided into five categories according to their age. the majority of patients were one month until 2 years old. whereas 13 patients were found to be in the normal category but about 50% of patients were in the abnormal category where 8 patients were wasted, and 6 patients were severely wasted. these provided indications of malnutrition occurrences in half of the patients. the most common type of congenital heart disease among down syndrome patients was pda which accounted for 11 patients, followed by multiple type of congenital heart disease with 5 patients. among the 5 patients who had multiple type of congenital heart disease, 4 patients were diagnosed with pda+asd while the remaining 1 patient had avsd+tof. moreover, pda associated lesions were the most common in combined lesions. the unspecific lesion or miscellaneous cardiac defect was found in 1 patient where the diagnosis was stated as icd q 24.9. furthermore, congenital hypothyroid was the highest defect in down syndrome patients with congenital heart disease followed by bronchopneumonia. discussion a number of researchers from previous studies stated that half of the children with down syndrome had a congenital heart disease. in this study, the total frequency of down syndrome children with a congenital heart disease was 33.3% which was less than previously estimated. many factors might affect the results, firstly, it could be due to health care systems aspects. a huge number of medical records were missing which could cause big changes in the data. the use of echocardiogram and routine screening for congenital heart disease was not really practiced to all the children. approximately 15 samples were excluded due to this factor. secondly, the lower frequency in samples could be due to ethnic or race factors. previous studies proved that less asian people with down syndrome had table 3 other non-cardiac diseases in down syndrome patient with congenital heart disease other defects frequency total 28 congenital hypothyroid 10 bronchopneumonia 8 pulmonary hypertension 3 sepsis 3 failure to thrive 2 respiratory failure 2 althea medical journal. 2018;5(1) 10 amj march 2018 a congenital heart disease. a study that was carried out by the atlanta down syndrome project, showed that only 13 asian people with down syndrome had cardiac defect among 243 people.2 another study also stated that among 487 patients with down syndrome only 20 asian people had congenital heart disease. thus, this could be the corresponding reason for the lower frequency number in the present study.10 according to this study, the common type of congenital heart disease in children with down syndrome was pda. from previous studies, pda is one of the common congenital heart disease in down syndrome. however, many studies indicated the avsd and vsd as the common type of congenital heart disease among children with down syndrome. several studies suggested that factors like ethnic and geographic differences such as high altitude with lower partial pressures of oxygen may contribute to a higher frequency of pda. at a high altitude, arterial oxygen desaturation can occur. the usual left-to-right shunting of blood reverses will cause right-sided pressures to increase.11 however, these hypotheses need to be tested by further large-scale multinational collaborative studies. the congenital heart disease was higher in female compared to male and this result corresponds with previous studies. according to a study carried out by the national down syndrome project (ndsp), it was proven that the incidence of atrioventricular septal defect (avsd) in down syndrome are about two times greater in female than male.2 in this study, the age group of 1 month until 2 years showed the highest frequency of congenital heart disease among down syndrome children. this might be due to the improved medical facilities and interventions in early detection of congenital heart disease. based on a study, it stated that early diagnosis of heart disease in down’s syndrome is important in order to initiate a timely referral to the concerned specialties and to educate the parents regarding the early and late complications of down syndrome.12 the researcher also studied the nutritional status of children with down syndrome with congenital heart disease. although characteristics of down syndrome patients with congenital heart disease showed the highest frequency in normal nutritional status however 50% of children were wasted and severely wasted (table 1). many studies looked for the relationship of congenital heart disease with nutritional status; the researchers found out that it is common for children with congenital heart disease to have malnutrition due to multifactorial issues which include inadequate nutritional intake due to difficulties in feeding, malabsorption, and increased energy requirements caused by increased metabolism.13 inadequate feeding capabilities in neonates with congenital heart disease are usually due to respiratory compromise or vocal cord paralysis or because of underlying neurological consequences which lead to growth failure if untreated.14 however, one patient was overweight in this study. the american heart association guidelines indicate that children with chd are less likely to meet physical activity recommendations due to self-esteem and physical self-concept which may lead to overweight or obesity.15 moreover, other defects were evaluated in this study. the congenital hypothyroid showed the highest frequency which was 35.7% compared to other defects such as bronchopneumonia, pulmonary hypertension, sepsis, failure to thrive and respiratory failure. based on a previous study, the abnormalities in thyroid are due to slow maturation of negative feedback control systems in the hypothalamopituitary axis in down syndrome which lead to the production of a less active form of tsh, or tsh insensitivity in the thyroid gland.16 in a study, it was stated that the thyroid hormone deficiency may cause abnormalities in the cardiovascular function such as an impaired cardiac contractility and diastolic function, increased systemic vascular resistance, decreased endothelial derived relaxation factor, increased serum cholesterol, increased c-reactive protein, and increased homocysteine where this conditions will enhance the severity of the heart disease.17 additionally, murine nkx-2.5, is a gene which is expressed in the early embryogenesis of thyroid and myocardium, thus patients with congenital hypothyroid are associated with cardiac defects.18 pulmonary hypertension which showed remarkable occurrences in previous studies was less in the present study because it is more associated with the avsd type of congenital heart disease. this is due to the uncorrected left-to-right shunt increases the pulmonary pressure that eventually leads to vascular remodelling and dysfunction. thus, the progressive rise in pulmonary vascular resistance and increased pressures in the right heart occurred as a result.19 there were certain limitations in this study. firstly, it was due to the loss of some medical records. this factor could influence the results of the study due to the small sample size. if althea medical journal. 2018;5(1) 11 there was a more systematic way and the number of medical records were complete , the results would be more accurate. besides, many patients did not perform the echocardiogram test. this could be due to several factors. first, many children were not followed up until the echocardiogram results or the patients wanted to be referred to another hospital which was nearer. not many down syndrome patients visited or were being referred here. it was either they did not visit the primary care physician or the parents’ socioeconomic status did not allow them to visit the general hospital in bandung from their remote hometown or they died prior to the diagnosis, since the survival rate of down syndrome with congenital heart disease is usually low. in conclusion, the most common congenital heart disease in children with down syndrome is pda. references 1. who. genes and human disease.2013. [cited 2014 november 10] available from: http://www.who.int/genomics/public/ geneticdiseases/en/index.html. 2. freeman sb, bean lh, allen eg, tinker sw, locke ae, druschel c, et al. ethnicity, sex, and the incidence of congenital heart defects: a report from the national down syndrome project. genet med. 2008;10(3):173–80. 3. nisli k, oner n, candan s, kayserili h, tansel t, tireli e, et al. congenital heart disease in children with down’s syndrome: turkish experience of 13 years. acta cardiol. 2008;63(5):585–9. 4. irving ca, chaudhari mp. cardiovascular abnormalities in down’s syndrome: spectrum, management and survival over 22 years. arch dis child. 2012;97(4):326– 30. 5. wiseman fk, alford ka, tybulewicz vl, fisher em. down syndrome–recent progress and future prospects. hum mol genet. 2009;18(r1):r75–r83. 6. joziasse ic, smith ka, chocron s, van dinther m, guryev v, van de smagt jj, et al. alk2 mutation in a patient with down’s syndrome and a congenital heart defect. eur j hum genet. 2011;19(4):389–93. 7. blom hj, smulders y. overview of homocysteine and folate metabolism. with special references to cardiovascular disease and neural tube defects. j inherit metab dis. 2011;34(1):75–81. 8. stanton b, berhman k, stanton j. nelson textbook of pediatrics. 19th ed. philadelphia: elsevier, pg; 2007. p. 29–39. 9. de onis m, mercedes, who. who child growth standards: length/height–for– age, weight–for–age, weight–for–length, weight–for–height and body mass index– for–age: methods and development. geneva: who; 2006 [cited 2014 november 3]. available from: http://apps.who.int/ iris/handle/10665/43413 10. mogra r, zidere v, allan l. prenatally detectable congenital heart defects in fetuses with down syndrome. ultrasound obstet gynecol. 2011;38(3):320–4. 11. forsey jt, elmasry oa, martin rp. patent arterial duct. orphanet j rare dis. 2009;4(1):17. 12. abbag fi. congenital heart diseases and other major anomalies in patients with down syndrome. saudi med j. 2006;27(2):219–22. 13. okoromah ca, ekure en, lesi fe, okunowo wo, tijani bo, okeiyi jc. prevalence, profile and predictors of malnutrition in children with congenital heart defects: a case–control observational study. arch dis child. 2011; 96(4):354-60 14. jadcherla s, vijayapal a, leuthner s. feeding abilities in neonates with congenital heart disease: a retrospective study. j perinatol. 2008;29(2):112–8. 15. pemberton vl, mccrindle bw, barkin s, daniels sr, barlow se, binns hj, et al. report of the national heart, lung, and blood institute’s working group on obesity and other cardiovascular risk factors in congenital heart disease. circulation. 2010;121(9):1153–9. 16. gibson p, newton r, selby k, price d, leyland k, addison g. longitudinal study of thyroid function in down’s syndrome in the first two decades. arch dis child. 2005;90(6):574–8. 17. klein i, danzi s. thyroid disease and the heart. circulation. 2007;116(15):1725–35. 18. park s, chatterjee v. genetics of congenital hypothyroidism. j med genet. 2005;42(5):379–89. 19. d’alto m, mahadevan vs. pulmonary arterial hypertension associated with congenital heart disease. eur respir rev. 2012;21(126):328–37. thyviyaa rajamany, rahmat budi kuswiyanto, leonardo lubis: congenital heart disease among down syndrome children at dr. hasan sadikin general hospital from 2008 to 2013 vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 46 amj march 2019 etiology of symptomatic focal epilepsy based on neuroimaging result in neurology outpatient clinic of dr. hasan sadikin general hospital agastya prabhaswara,1 suryani gunadharma,2 uni gamayani2 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: agastya prabhaswara, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: agastyapp@gmail.com introduction epilepsy is estimated to occur in 50 million people worldwide.1 more than 80% people with epilepsy come from middle-income countries and tropical areas, such as indonesia.2 it is estimated that there are 1–2 million people with epilepsy in indonesia, although there is no exact data yet.3 epilepsy is a brain disorder with predisposition to generate at least one epileptic seizure, which affects neurobiological, cognitive, psychological, and social aspects of an individual. epileptic seizure is a symptom that occurs momentarily due to abnormal neuronal activity in the brain.4 forty percent of epilepsy cases are caused by symptomatic etiology, meaning epilepsy with structural brain lesions. most of them begin in one hemisphere of the brain, or known as focal epilepsy.5 structural lesions that are the etiology of epilepsy can be seen from neuroimaging, such as computed tomography scan (ct scan) and magnetic resonance imaging (mri). ct scans use ionizing radiation technology that is able to generate brain images withexcellent hard tissue imaging and moderately good soft tissue imaging. mri uses a magnetic field that can produce clear imaging of the brain so that it can be used to determine the characteristics and progression of lesions that are the etiology of epilepsy.6 based on the explanation above, it can be concluded that brain imaging is an important tool in epilepsy, especially focal epilepsy, which generally caused by structural abnormalities (symptomatic) that could be seen from neuroimaging results. in indonesia, there are no data on the etiological distribution amj. 2019;6(1):46–51 abstract background: focal epilepsy is the most common type of epilepsy that can be caused by structural lesions. images from neuroimaging can show those structural lesions that may point to the etiology of epilepsy and would affect the management of epilepsy. the aim of the study was to explore the possible etiology of symptomatic focal epilepsy from neuroimaging result at the neurology outpatient clinic in dr. hasan sadikin general hospital. methods: this study was a cross-sectional descriptive study. the medical records that fulfilled the inclusion criteria were collected at the neurology outpatient clinic of dr. hasan sadikin general hospital from the year 2017. the inclusion criteria were symptomatic focal epilepsy patients that had abnormal neuroimaging result. results: in total, there were 71 medical records collected of which eight etiologies of symptomatic focal epilepsy were found, that were vascular disorder caused by strokes (33%), tumors (21%), hippocampal sclerosis (20%), infections (11%), head trauma (6%), malformations of cortical development (4%), vascular malformations (3%), and phakomatosis (1%). vascular disorder was the most abundant etiology found in all brain lobes, except in temporal and frontal lobes, which also most often caused by hippocampal sclerosis and tumors, respectively. conclusions: vascular disorders due to stroke, is the most abundant etiology found in symptomatic focal epilepsy, therefore, stroke patients need to be informed about the possibility of having epilepsy later on. keywords: epilepsy etiology, neuroimaging, symptomatic focal epilepsy althea medical journal. 2019;6(1) 47 of symptomatic focal epilepsy that causes epilepsy, which will affect the further management of epilepsy. the aim of this study was to explore the possible etiology of symptomatic focal epilepsy from neuroimaging result at the neurology outpatient clinic in dr. hasan sadikin general hospital bandung. methods this study used a cross-sectional descriptive design with total sampling and conducted at the neurology outpatient clinic of dr. hasan sadikin general hospital bandung. this study had been approved by the health research ethics committee of faculty of medicine, universitas padjadjaran with ethical exemption number 814/un6.kep/ec/2018. subjects of the study were 368 medical records of symptomatic focal epilepsy patients at the neurology outpatient clinic of dr. hasan sadikin general hospital in january–december 2017. data was taken at the neurology outpatient clinic of dr. hasan sadikin general hospital in september–october 2018. sample of the study was obtained by selecting the subject with inclusion and exclusion criteria. the inclusion criteria in this study were symptomatic focal epilepsy patients at the neurology outpatient clinic of dr. hasan sadikin hospital in 2017 with abnormal neuroimaging results, either from ct scan or mri. the exclusion criteria wereincomplete medical records of patients, such as the absence of electroencephalography (eeg) results or information regarding the epilepsy lobe. in total, there were 71 samples obtained that fulfilled the inclusion criteria. the demographic data assessed were gender and age. age was grouped into several groups, with a division per 10 years. the clinical data assessed were epilepsy lobe type. types of epilepsy lobe are categorized as frontal lobe epilepsy (fle), occipital lobe epilepsy (ole), parietal lobe epilepsy (ple), and temporal lobe epilepsy (tle). the etiological data was obtained from neuroimaging results and will be grouped according to the findings. etiology data of symptomatic focal epilepsy based on epilepsy lobe was presented in frequency agastya prabhaswara, et al.: etiology of symptomatic focal epilepsy based on neuroimaging result in neurology outpatient clinic of dr. hasan sadikin general hospital table 1 characteristic of subjects n (%) gender male 33 (46) female 38 (54) age (years), mean (sd) 39.66 (17.32) 10–19 years 10 (14) 20–29 years 13 (18) 30–39 years 15 (21) 40–49 years 14 (20) 50–59 years 7 (10) 60–69 years 8 (11) 70–79 years 4 (6) clinical epilepsy lobe temporal lobe epilepsy (tle) 51 (72) frontal lobe epilepsy (fle) 10 (14) parietal lobe epilepsy (ple) 6 (8) occipital lobe epilepsy (ole) 4 (6) neuroimaging ct scan 38 (54) mri 33 (46) total 71 (100) althea medical journal. 2019;6(1) 48 amj march 2019 results the number of epilepsy patients in the neurology outpatient clinic of dr. hasan sadikin hospital was 368 patients, in which 231 patients with focal epilepsy, and only 113 patients had neuroimaging, either ct scan or mri. from the neuroimaging results, only 71 patients had an abnormal brain imaging as shown in table 1. the data showed that there were 38 (54%) females and 33 (46%) males. the majority of epilepsy patients (n=42; 59%) were aged 20–49 years with the mean age was 39.6 (range 14–79 years old). the most common type of epilepsy lobe was temporal lobe epilepsy (n=51;72%) . neuroimaging in the form of ct scan was carried out in 38(54%) subjects and mri was performed on 33(46%) subjects. the most abundant etiology was vascular disorders, accounting for 24 (33%) patients. the vascular disorders found in this study were caused by two things; ischemic stroke (n 22; 30%) and hemorrhagic stroke in ( n=2;3%) subjects. the etiology of symptomatic focal epilepsy obtained from neuroimaging results was listed in table 2. the symptomatic etiology of focal epilepsy was based on epileptic lobes (table 3). in temporal lobe epilepsy, the most abundant etiology found was vascular disorders and hippocampal sclerosis, both were in similar perccentage (n=14; 27%). vascular disorders were most often caused by ischemic stroke, occurring in 13 (26%) patients. in frontal lobe epilepsy, the most abundant etiology found table 2 etiology of symptomatic focal epilepsy at the neurology outpatient clinic dr. hasan sadikin general hospital in january–december 2017 neuroimaging n = 71 (% per total)ct scan mri n (%) n (%) vascular disorders 24 (33) ischemic stroke 15 (21) 7 (9) hemorrhagic stroke 2 (3) tumors 15 (21) low-grade glioma 4 (6) high-grade glioma 2 (3) arachnoid cyst 1 (1) 5 (7) meningioma 1 (1) cancer metastasis 1 (1) 1 (1) hippocampal sclerosis 3 (4) 11 (15) 14 (20) infections 8 (11) tuberculoma 6 (8) 1 (1) toxoplasma 1 (1) head trauma 3 (4) (1) 4 (6) malformations of cortical development 3 (4) focal cortical dysplasia 3 (4) vascular malformations 2 (3) cavernosum malfomation 1 (1) arteriovenous malformation 0 (0) 1 (1) phakomatosis 1 (1) sturge-weber syndrome 1 (1) althea medical journal. 2019;6(1) 49agastya prabhaswara, et al.: etiology of symptomatic focal epilepsy based on neuroimaging result in neurology outpatient clinic of dr. hasan sadikin general hospital table 3 etiology of epilepsy based on epilepsy lobes neuroimaging total n (%)ct mri n (%) n (%) temporal lobe epilepsy (n=51) vascular disorders 14 (27) ischemic stroke 8 (16) 5 (10) hemorrhagic stroke 1 (2) hippocampal sclerosis 3 (6) 11 (21) 14 (27) tumors 10 (20) low-grade glioma 3 (6) high-grade glioma 1 (2) arachnoid cyst 3 (6) meningioma 1 (2) cancer metastasis 1 (2) 1 (2) infections 4 (8) tuberculoma 3 (6) toxoplasma 1 (2) malformations of cortical development 3 (6) focal cortical dysplasia 3 (6) head trauma 2 (4) 1 (2) 3 (6) vascular malformations 2 (4) cavernosum malformation 1 (2) arteriovenous malformation 1 (2) phakomatosis 1(2) sturge-weber syndrome 1 (2) frontal lobe epilepsy (n=10) vascular disorders 4(40) ischemic stroke 2 (20) 1 (10) hemorrhagic stroke 1 (10) tumors 4(40) low-grade glioma 1 (10) high-grade glioma 1 (10) arachnoid cyst 1 (10) 1 (10) infections 1(10) tuberculoma 1 (10) head trauma 1 (10) 1(10) parietal lobe epilepsy (n=6) vascular disorders 3(50) ischemic stroke 2 (33) 1 (17) tumors 1(17) arachnoid cyst 1 (17) infections 2 (33) tuberculoma 1 (17) 1 (17) occipital lobe epilepsy (n=4) vascular disorders 3(75) ischemic stroke 3 (75) infection 1(25) tuberculoma 1 (25) althea medical journal. 2019;6(1) 50 amj march 2019 was vascular disorders and tumors (n=4; 40%). vascular disorders were most often caused by ischemic strokes in 3 (30%) patientss and the most common tumor found was arachnoid cyst, found in 2 (20%) patients. in parietal and occipital lobe epilepsy, the most abundant etiology found was vascular disorders in the form of ischemic stroke, occurring in 3(50%) patients and 3(75%) patients, respectively. discussions focal epilepsy is the most common type of epilepsy, caused by structural lesions there are eight etiologies found in this study, which are vascular disorders, tumors, hippocampal sclerosis, infections, and malformations of cortical development, head trauma, vascular malformations, and phakomatosis. the most abundant etiology found in this study is vascular disorders (33%) consisting of ischemic stroke (30%) and hemorrhagic stroke (3%). this result is similar to several other studies in india2 and hongkong7, showing that cerebrovascular disease, such as stroke, is the most abundant etiology in epilepsy. about 30–50% of patients with brain tumors experience seizures.8 the brain tumors in our study consist of high-grade and lowgrade gliomas, arachnoid cysts, meningioma, and cancer metastasis. furthermore, our study, hippocampal sclerosis occurres only ini 20%, making it the third most abundant etiology, however, hippocampal sclerosis occurreds in slightly lower (10%) in chinas.7 tuberculomas and toxoplasmosis infections occurre a small portion (11%) in our study, similar to study in china7 including tuberculomas (4.3%) and other infection (11.9%). interestingly, in sub-sahara africa9 region, epilepsy cases in adults can be caused by a parasitic infection, including toxoplasmosis. as for the incidence of epilepsy might be occurred after head trauma over 15 years, mild trauma (3.5%) and severe trauma (12.2%).10 malformations of cortical development in the form of focal cortical dysplasia might be also occured. focal cortical dysplasia is the most common cause of refractory epilepsy in children and the second most common etiology of intractable seizure in adults.11 vascular malformations can be caused by cavernous malformations or arteriovenous malformations. the risk of first seizure occurrence is about 2.4% person per year in people with cavernous malformation and 1.1% per year in people with arteriovenous malformation.12 the sturge-weber syndrome (sws), as one of the most common forms of phakomatosis, is a segmental neurocutaneous vascular disorder associated with port-wine stains, ocular vascular abnormalities-associated glaucoma, and leptomeningeal capillary-venous type malformation. seizures in sws occur in 7580% of all kind of sws and more than 90% in patients with bilateral involvement.13 in this study, phakomatosis in the form of sturgeweber syndrome is only found in 1% patients. the limitation of this study is that this study has been conducted for a short period at only one hospital in bandung, thus, it could not describe the etiology of symptomatic focal epilepsy in indonesia as a whole. in conclusion, vascular disorders, i.e. stroke, are the most abundant etiology of symptomatic focal epilepsy found in the neurology outpatient clinic of dr. hasan sadikin general hospital. other etiologies found in this study are tumors, hippocampal sclerosis, infections, malformations of cortical development, head traumas, vascular malformations, and phakomatosis. therefore, stroke patients need to be informed about the possibility of experiencing epilepsy in the future. references 1. who epilepsy internet. 2019. [cited 2019 march 15] available from: http://www. who.int/mediacentre/factsheets/fs999/ en/ 2. sheikh na, shabnum n, bhat ga, kawoosa a, mushtaq m, wani ma. etiological profile of adult onset seizures : a hospital based prospective study from kashmir, india. int j adv med. 2017;4(3):793–8. 3. tendean pg, karema w, mawuntu a. gambaran penyandang epilepsi berdasarkan ilae 1989 di poliklinik saraf rsup prof. dr. r. d. kandou manado tahun 2014. jurnal e-clinic (ecl). 2016;4(1):4. 4. fisher rs, acevedo c, arzimanoglou a, bogacz a, cross jh, elger ce, et al. ilae official report: a practical clinical definition of epilepsy. epilepsia. 2014;55(4):475–82. 5. hui yin y, ahmad n, makmor-bakry m. pathogenesis of epilepsy: challenges in animal models. iranj basic med sci. 2013;16(11):1119–32. 6. roy t, pandit a. neuroimaging in epilepsy. ann indian acad neurol. 2011;14(2):78– 80. 7. si y, liu l, hu j, mu j, fang jj, an dm, et al. etiologic features of newly diagnosed althea medical journal. 2019;6(1) 51 epilepsy : hospital-based study of 892 consecutive patients in west china. seizure. 2012;21(1):40–4. 8. you g, sha z, jiang t. the pathogenesis of tumor-related epilepsy and its implications for clinical treatment. seizure. 2012;21(3):153–9. 9. kamuyu g, bottomley c, mageto j, lowe b, wilkins pp, noh jc, et al. exposure to multiple parasites is associated with the prevalence of active convulsive epilepsy in sub-saharan africa. plos negl trop dis. 2014;8(5):e2908. 10. lamar cd, hurley ra, rowland ja, taber kh. post-traumatic eeilepsy: review of risks, pathophysiology, and potential biomarkers. j neuropsychiatry clin neurosci. 2014;26(2):iv–113. 11. josephen cb, leach jp, duncan r, roberts rc, counsell ce, al-shahi salman r. seizure risk from cavernous or arteriovenous malformations. neurology. 2011;76(18):1548–54. 12. lv x, li y, jiang c, yang x, wu z. brain arteriovenous malformations and endovascular treatment : effect on seizures. interv neuroradiol. 2010;16(1):39–45. 13. pinto a, sahin m, pearl pl. epileptogenesis in neurocutaneous disorders with focus in sturge weber syndrome. f1000research. 2016;5(f1000 faculty rev):370. agastya prabhaswara et al.: etiology of symptomatic focal epilepsy based on neuroimaging result in neurology outpatient clinic of dr. hasan sadikin general hospital 157 althea medical journal. 2017;4(2) two years profile of anemia in systemic lupus erythematosus patients at west java’s top referral hospital, indonesia stefanie yuliana usman,1 laniyati hamijoyo,2 anna tjandrawati3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: anemia is a common clinical manifestation in systemic lupus erythematosus (sle) patients. anemia can be caused by an ineffective hematopoietic process or excessive red blood cell destruction. the aim of this study was to classify and characterize anemia in sle patients. methods: this study involved 97 outpatients visiting the rheumatology clinic of dr. hasan sadikin general hospital bandung, from january 2013 to september 2014. patient data was collected from medical records and study subjects were selected according to the american college of rheumatology 1997 criteria for sle, and the characteristic of anemia among outpatients were described according to the world health organization criteria. results: the characteristics among 97 respondents showed 95 (98%) were female; 32 (33%) were 21–30 years old; and 49 (51%) had sle for 1–5 years. the characteristics and classification of anemia, 57 (59%) had normocytic normochromic, and 33 (34%) had microcytic hypochromic anemia. according to the severity classification, 48 (50 %) had moderate anemia, only 8 (8%) had severe anemia. four (4%) subjects had anemic conjunctiva, 45 (46%) had fatigue and 48 (50%) had no clinical manifestations of anemic conjunctiva and fatigue. conclusions: moderate anemia, normocytic normochromic anemia are the most prevalent among the subjects. half of the anemic sle patient has no clinical manifestation of anemic conjunctiva and fatigue. keywords: anemia, anemic conjuctivasystemic lupus erythematosus, fatigue correspondence: stefanie yuliana usman, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281220828205 email: stefanie_yuliana@yahoo.com introduction systemic lupus erythematosus (sle) is an autoimmune disease involving multi-organ systems, with cases including females who outnumbered their male counterparts by 9–15:1.1,2 a study of lupus patients in asian populations in 2010 reported that the prevalence of this disease was 30–50/100,000 population.3 at the rheumatology clinic of dr. hasan sadikin general hospital bandung as the top referral hospital in west java, lupus patients accounted for 291 patients or about 10.5% from all outpatients in 2010 and 366 patients or about 9.07% from all outpatients (4,037 patients) in 2011.4 clinical manifestations of sle vary among individuals, but the most common manifestation is anemia, found in 50% of sle patients.5 anemia is a condition in which an insufficient number of red blood cells is present to meet the body’s physiological needs for tissue metabolism.6 anemia can be classified based on the world health organization (who) criteria according to its severity using hemoglobin level or red blood cell morphology as determined by red cell indices such as mean cell volume (mcv), and mean corpuscular hemoglobin (mch).6,7 the most common causes of anemia in sle are anemia in chronic disease (acd), irondeficiency anemia (ida), and autoimmune hemolytic anemia (aiha), while drug-induced anemia and renal failure anemia are not uncommon.8 a study in malang, indonesia9 reported that anemia was found in 71.4% of all amj. 2017;4(2):157–62 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1094 althea medical journal. 2017;4(2) 158 amj june 2017 sle patients, yet such data was not available at hasan sadikin general hospital bandung which is the primary/top referral hospital for sle cases in west java. the aim of this study was to describe the characteristics and classification of anemia based on its severity and manifestations. methods this observational descriptive study utilized a cross-sectional approach and was carried out at the rheumatology clinic of dr. hasan sadikin general hospital bandung from january 2013 to september 2014. the object of this study was medical records of all sle outpatients with manifestations of anemia. the aim and the method of the study were approved by the health research ethics committee, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital bandung. data collection was conducted using nonprobability quota sampling with 10% precision. a minimum of 79 samples was required. furthermore, sle outpatients were evaluated according to the american college of rheumatology criteria which define systemic lupus erythematosus patients as having at least 4 of 11 sle diagnostic criteria such as, butterfly/malar rash, discoid rash, oral ulcers, photosensitivity, arthritis, serositis, hematologic disorder, neurologic disorder, immunologic disorder, renal disorder and positive antinuclear antibody (ana). patients should have fulfilled the acr 1997 criteria to be included in this study. patients with incomplete medical record were excluded from the study. anemia was classified based on the who criteria according to its severity using hemoglobin level (table 1).6 using the red cell indices (mcv, mch and mchc), the anemia was then classified as normocytic normochromic anemia, microcytic hypochromic anemia, or macrocytic anemia. mcv was used to determine the red blood cell’s size, normal range for mcv is 80–100 fl. this mcv measurement can classify anemia into microcytic anemia (mcv below normal range) which can be found in anemia due to iron deficiency, normocytic anemia (mcv within normal range) which can be found in anemia chronic disease, and macrocytic anemia (mcv above normal range) which can be found in hemolytic anemia, nutritional anemia and pernicious anemia. mch and mchc reflect the hemoglobin content of erythrocytes. the normal range for mch is 27–31pg and normal range for mchc is 32–36%. anemia can be classified as normochromic anemia (mch within normal range) and hypochromic anemia (mch below normal range). mch only increases in case of spherocytosis anemia or hemolytic anemia.7 the presence of a renal disorder in patients and henceforth, its severity (ckd stage) were determined accordingly using creatinine and ureum measurements. all of these tests were taken from the patient’s final laboratory workup. the patient’s characteristics such as sex, age, date of diagnosis, renal disorder and ckd stage, type and amount of drugs consumed were collected from the patient’s medical record. outpatients with any missing data were excluded from this study. ninetyseven outpatients with anemia from january 2013–september 2014 were included in the study; all of them met the inclusion criteria. the collected data were analyzed and presented using frequency tabulation in tables. results the demographics of the study population showed that out of 97 patients, 95 (98%) were female. the study subjects’ age were between 15–55 years which is the reproductive active age. patients aged between 21–30 (33%) were table 1 who classification of anemia female (>15 years old) male (>15 years old) non pregnant pregnant non-anemia ≥12 g/dl ≤11 g/dl ≥13 g/dl mild anemia 11–11.9 g/dl 10–10.9 g/dl 11–12.9 g/dl moderate anemia 8–10.9 g/dl 7–9.9 g/dl 8–10.9 g/dl severe anemia <8 g/dl <7 g/dl <8 g/dl 159 althea medical journal. 2017;4(2) stefanie yuliana usman, laniyati hamijoyo, anna tjandrawati: two years profile of anemia in systemic lupus erythematosus patients at west java’s top referral hospital, indonesia table 2 systemic lupus erythematosus with anemia patient demography characteristics frequency (n) percentage (%) sex (n=97) female 95 98 male 2 2 age (years old) (n=97) 15–20 15 15 21–30 32 33 31–40 28 29 41–50 18 19 51–55 3 3 > 55 1 1 date of diagnosis (years) (n=97) < 1 2 2 1–5 49 51 ≥5–10 36 37 ≥ 10 10 10 renal disorder (n=97) yes 57 59 no 40 41 stage of ckd (n=57) stage 1 25 44 stage 2 12 21 stage 3 13 23 stage 4 2 3 stage 5/ esrd 5 9 drugs consumed (n=97) steroid methylprednisolone 91 94 non steroid azathioprine 28 29 chloroquine 42 43 cyclophosphamide 5 5 methrotrexate 4 4 no drugs consumed 5 5 type of drugs consumed (n=92) steroid 32 33 non steroid 1 1 steroid and non steroid 59 61 type of anemia (n=97) normocytic hypochromic 3 3 microcytic hypochromic 33 34 macrocytic 4 4 normocytic normochromic 57 59 althea medical journal. 2017;4(2) 160 amj june 2017 largest in number, followed by those aged between 31–40 (29%) (table 2). each subject had a different disease chronicity that could be seen from the date of diagnosis. more than half of the patients (51%) had been diagnosed with sle from 1–5 years. renal disorder was encountered in more than half of the subjects (59%). from data collected, some patients with renal disorder (44%) had ckd stage 1. most of study subjects (95 %) received drugs therapy and only 5 subjects were not taking any drugs. methylprednisolone, the first-choice drug for sle therapy, was consumed by more than 90% of subjects. in general, subjects received steroid and non steroid drugs. fifty-nine subjects (61%) took two types of drugs. additionally, normocytic normochromic anemia was found in 59% of subjects, followed by microcytic hipochromic anemia in 34% of subjects. hemoglobin levels were used to assess the severity of anemia as stated by the who criteria (table 1). moderate anemia was found in half of the subjects, closely followed by mild anemia (42%). therefore, the majority of sle patients at hasan sadikin general hospital bandung exhibited mild to moderate anemia. based on physical examination results of the medical records, a few subjects presented anemic conjunctiva (table 3). complaints of being “easily fatigued” were found in less than half of the subjects (table 4). discussion the distribution of clinical manifestations of sle in anemia patients clearly demonstrated that the majority of sle patients with anemia were female between 21–30 years old, right at the peak of her reproductive age (table 1). furthermore, female to male ratio was 47.5:1. such results corresponded relatively well with other studies which stated that the majority of sle patients were female, the female to male ratio was 9–14:1, but lopez et al.10 reported female to male ratio was up to 50:1 in spain. the majority of sle patients were female, this was well suited with the study that stated the effect from reproductive hormone endogenous activity on immune system.11 also, sle patients were in productive age with their average age was 28–43 years.8,11 more than fifty percent of the subjects had been diagnosed with sle for 1–5 years and more than thirty percent for 5–10 years. thus, it is no surprise that the majority of sle patients had anemia due to chronic disease.5,8 moreover, renal disorders were found in more than half of the subjects (59 %), in the long run wouldl aid in the precipitation of anemia. the anemia manifests as the kidney’s ability to produce erythropoietin, a hormone crucial for red blood cell formation, is severely hampered.12 interestingly, this study demonstrated that most subjects with a renal disorder were at ckd stage 1, which could have been explained by the timely administration of pharmacotherapy. in general, most subjects were given a steroid and an immunosuppressant drug. the co-administration of multiple drugs was appropriate as it follows the recommendations for therapy concerning sle patients, in which steroid as the first-line drug should be administered with complementary drugs (azathiophrine, cloroquine, cyclophosphamide, and methrotrexate) in order to minimize the table 3 classification of anemia based on its severity severity of anemia frequency (n) percentage (%) mild anemia 41 42 moderate anemia 48 50 severe anemia 8 8 total 97 100 table 4 distribution of clinical manifestation of sle in anemia patients clinical manifestation frequency (n) percentage (%) anemic conjunctiva 4 4 easily fatigue 45 46 161 althea medical journal. 2017;4(2) side effects of steroid use.4 a majority of subjects exhibited normocytic normochromic anemia (59%) and such observation is suggestively due to anemia of a chronic disease. a smaller proportion of subjects (34%) exhibited a different type of anemia (microcytic hypochromic anemia) and such finding is most likely due to irondeficiency. portillo et al.13 reported most patients with chronic disease in spain have normocytic normochromic anemia, while thomas et al.14 stated that iron deficiency causes microcytic hypochromic anemia to patients in germany.13,14 nevertheless, it is not uncommon for anemia in sle to manifest due to both chronic disease and ida simultaneously.5 this study also revealed that most subjects had either moderate anemia (50%) or mild anemia (42%). this corresponds well to other studies which often report mild–moderate anemia in sle patients.15 however, the findings of moderate anemia is also justified, taking into account the concurrence of both anemia due to chronic disease and irondeficiency.5 besides anemia chronic disease is caused by several mechanisms, such as iron homeostasis disorder due to cytokines and reticuloendothelial system cells, decrease erythropoietin production due to renal injury or antiproliferative effect from uremic toxin deposition.16 moreover, only 4 (4%) sle patients had clinical manifestations of anemic conjunctiva, while 45 (46%) patients complained of fatigue (table 3). clinical manifestations of anemia cannot be used to pin point the specific condition of anemia, anemic conjunctiva cannot describe the patient’s condition and severity of anemia spesifically because anemic conjunctiva is more obvious in severe anemia patient.17 fatigue is a symptom of several diseases. while anemia is a common cause of fatigue, however fatigue does not reflect severity of the patient’s anemia. fatigue can be caused by psychological factors.18,19 however, the study is not without limitations. the medical record only contained information pertaining to the severity of anemia as determined by the rbc indices and there was no record of patients having received coombs test, reticulocyte count or peripheral blood count. thus, the information on the possibilty of hemolytic anemia was lacking.20 hence, determining whether the patients were in remission or had had flares was not feasible. furthermore, the medical record was lacking in the description of anemia-related clinical manifestations other than anemic conjunctiva and fatigue. for further studies, the authors suggest the need for special attention to patients with chronic sle or with impaired renal function about the patient’s anemia with recorded clinical manifestations of anemia in patients and routine laboratory tests. education of patients for a routine control about the condition of the disease is also important so that patients can avoid the possible occurrence of complications. as conclusion, the characteristics of majority of sle patients are female (98%), between 21–30 years old (33%), have been diagnosed with sle for 1–5 years (51%), exhibited normocytic normochromic anemia (59%), and had moderate anemia (50%). other characteristics are found such as patients have renal disorder (59%), and have been given steroid drugs (94%). half of the patients have no clinical manifestations of anemic conjunctiva and fatigue. references 1. tsokos gc. systemic lupus erythematosus. n engl j med. 2011;365(2):2110–21. 2. xiong w, lahita rg. pragmatic approaches to therapy for systemic lupus erythematosus. nat rev rheumatol. 2014;10(2):97–107. 3. salido o, reyes m. epidemiology of systemic lupus erythematosus in asia. lupus. 2010;19(12):1365–73. 4. yoga k i, kusworini h, linda kw, laniyati h, zuljasri a, handono k, hermansyah, et al. rekomendasi perhimpunan reumatologi indonesia untuk diagnosis dan pengelolaan lupus eritematosus sistemik. perhimpunan reumatologi indonesia; 2011. 5. karpouzas ga. hematologic and lymphoid abnormalities in sle. in: wallace dj, hahn bevra h, isernberg d, shen n, vollenhoven rf, weisman mh, et al, editors. dubois’ lupus erythematosus and related syndromes. 8th ed. philadelphia: saunders elsevier; 2013. p. 426–9. 6. who. haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. 2011 [cited 2014 februari 09]. available from: http://www.who. int/vmnis/indicators/haemoglobin/en/ index.html. 7. sultan ah. anemia among female college students attending the university of sharjah, uae: prevalence and classification. j egypt public health assoc. 2007;82(3– 4):261–71. stefanie yuliana usman, laniyati hamijoyo, anna tjandrawati: two years profile of anemia in systemic lupus erythematosus patients at west java’s top referral hospital, indonesia althea medical journal. 2017;4(2) 162 amj june 2017 8. giannouli s, voulgarelis m, ziakas pd, tzioufas ag. anaemia in systemic lupus erythematosus: from pathophysiology to clinical assessment. ann rheum dis. 2006;65(2):144–8. 9. kusworini h, leny p, achmad r, singgih w, handono k. vitamin d serum level and disease activity in patients with systemic lupus erythematosus. int j pharm sci invent. 2013;2(2):35–40. 10. lopez p, mozo l, gutierrez c, suarez a. epidemiology of systemic lupus erythematosus in a northern spanish population: gender and age influence on immunological features. lupus. 2003;12(11):860–5. 11. murphy g, isenberg d. effect of gender on clinical presentation in systemic lupus erythematosus. rheumatology. 2013;52(12):2108–15. 12. jelkmann w. regulation of erythropoietin production. j physiol. 2011;589(pt 6):1251–8. 13. portillo k, belda j, anton p, casan p. high frequency of anemia in copd patients admitted in a tertiary hospital. rev clin esp. 2007;207(8):383–7. 14. thomas c, thomas l. anemia of chronic disease: pathophysiology and laboratory diagnosis. lab hematology. 2005;11(1):14–23. 15. zarychanski r, houston ds. anemia of chronic disease: a harmful disorder or an adaptive, beneficial response? can med assoc j. 2008;179(4):333–7. 16. weiss g, goodnough lt. anemia of chronic disease. n engl j med. 2005;352(10):1011– 23. 17. butt z, ashfaq u, sherazi sfh, jan nu, shahbaz u. diagnostic accuracy of “pallor” for detecting mild and severe anaemia in hospitalized patients. j pak med assoc. 2010;60(9):762–65. 18. patel v, kirkwood b, weiss h, pednekar s, fernandes j, pereira b. chronic fatigue in developing countries: population based survey ofwomen in india. bmj. 2005;330(7501):1190–97. 19. gasche c, lomer mce, cavill i, weiss g. iron, anaemia, and inflammatory bowel diseases. gut. 2004;53(8):1190–97. 20. dhaliwal g, cornett pa, tierney jrlm. hemolytic anemia. am fam phys. 2004;69(11):2599–606. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 431 incidence of neonatal hyperbilirubinemia based on their characteristics at dr. hasan sadikin general hospital bandung indonesia namira bening nurani,1 fiva aprillia kadi,2 tiene rostini³ 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 1department of clinical patologyfaculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hyperbilirubinemia is the most frequent clinical condition that occurs in neonates identified by yellow discoloration of the skin and other tissues. it is caused by elevations of bilirubin level as the effect of increased breakdown of red blood cells, impaired conjugation of indirect bilirubin, and incomplete bilirubin excretion. this study was conducted to discribe the characteristics of neonates with hyperbilirubinemia. methods: this study used descriptive quantitative method which took retrospective data from medical record of neonates with hiperbilirubinemia in 2014. the population of this study was neonates which were born in the perinatology division at dr. hasan sadikin general hospital, bandung. the variables collected were gender, gestational age, weight birth, general condition ad treatment options. the collected data were tabulated and presented by percentage and in the form of a table. results: one hundred and seventy four of 230 medical records of neonates with hyperbilirubinemia were collected based on the inclusion criteria. the results showed that 8.04% of 2,531 neonates born at dr. hasan sadikin general hospital in 2014 suffered from hyperbilirubinemia. males (56.9%) were higher than females to have hyperbilirubinemia. neonates born at term gestational age (55.2%) were more likely to have hyperbilirubinemia with low birth weight category (51.7%), healthy general condition (60.4%). the most treatment option was phototherapy (54.6%). conclusions: most neonates with hyperbilirubinemia are males, who were born at aterm gestational age, with low birth weight. most of the neonates are in healthy general condition and the most common treatment given to neonates is phototherapy. keywords: hyperbilirubinemia, neonates, phototherapy correspondence: namira bening nurani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, email: beningnamira@yahoo.co.id introduction hyperbilirubinemia is a term of increased bilirubin serum levels based on the laboratory examination.1 every year, 65% of the 4 million neonates in the united states suffer from hyperbilirubinemia in the first week of their lifes.2 in malaysia3, 75% of the neonates suffer from hyperbilirubinemia in 1998. in indonesia4, in 2007, incidence of neonatal hyperbilirubinemiavaries among several teaching hospitals at dr. cipto mangunkusumo general hospital, jakarta reported that there are 58% of hyperbilirubinemia cases from all neonates. dr. sardjito general hospital, yogyakarta, central java revealed that 38% of newborn neonates suffer from hyperbilirubinemia. dr. kariadi general hospital in semarang with 22.8% of neonates suffer from hyperbilirubinemia, and dr. sutomo general hospital in surabaya with 33% of neonates suffer from hyperbilirubinemia.4 most neonates experience increased levels of bilirubin at the first days of life due to a physiological process.5 this process is influenced by high erythrocytes number, short life of erythrocytes (80–90 days), and immature development of liver during neonatal period.6,7 increased levels of indirect bilirubin in neonates cause damage to brain cells and lead to death.8 some studies showed that the risk factors of hyperbilirubinemia are maternal gestational amj. 2017;4(3):431–4 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1195 althea medical journal. 2017;4(3) 432 amj september 2017 age, sex, and comorbid diseases including sepsis and asphyxia.9 hyperbilirubinemia harms the neonatal condition and causes complications if untreated. phototherapy, exchange transfusion, and pharmacological therapy are the treatments for neonates with hyperbilirubinemia.10 the treatments are determined based on the age of the mother’s gestation but there are some guidelines for hyperbilirubinemia treatment considering treatment from birth weight.11 the aim of the study was to describe the proportions and characteristics of neonates with hyperbilirubinemia at dr. hasan sadikin general bandung as the west java top refferal and teaching hospital. methods this study used descriptive quantitative method and was conducted in october 2015. the data of the neonates with hyperbilirubinemia wereobtained through the medical record retrospectively. population in this study was all neonates with hyperbilirubinemia and hospitalized in perinatology division at department of child health, dr. hasan sadikin general hospital in the period of january to desember 2014. this study used total sampling methods. inclusion criteria for this study were all neonates with hyperbilirubinemia with bilirubin levels >5 mg/dl, born in >32 weeks, and had complete medical record data. exclusion criterion of this study was patients with incomplete medical record data. the variable in this study were neonates which had bilirubin levels >5 mg/ dl, sex, gestational age, birth weight, general condition, and treatment options. this study was approved by the health research ethics committee of dr. hasan sadikin general hospital bandung number lb.04.01/a05/ec/283/vii/2015. the collected data were presented in percentage and in the form of a table. table characteristic of neonates with hyperbilirubinemia characteristics neonates with hyperbilirubinemia (n) (%) gender male 99 56.9 female 75 43.1 gestational age near-term (34–36 weeks) 38 21.8 preterm (<37 weeks) 40 23 aterm(37–41 weeks) 96 55.2 birth weight high birth weight (>4000 gr) 2 1.1 normal birth weight (2500–4000 gr) 83 47.7 low birth weight (<2500 gr) 90 51.7 very low birth weight (≤1000 gr) 1 0.6 general condition healthy 105 60.4 unhealthy 69 39.6 management phototherapy 95 54.6 exchange transfusion 0 0 pharmacology 0 0 observation 79 45.4 althea medical journal. 2017;4(3) 433namira bening nurani, fiva aprillia kadi, tiene rostini: incidence of neonatal hyperbilirubinemia based on their characteristics at dr. hasan sadikin general hospital bandung indonesia already taken home by their parents and did not undergo the examination at the time of routine control in the hospital where the neonates were born.17 birth weight is one of the characteristics that affect hyperbilirubinemia. in this study, low birth weight neonates placed the highest proportion compared to other groups. this finding was in accordance with a study conducted by ben et al.2 the study mentioned that neonates born with weight less than 2,500 grams mighthave higher bilirubin levels because the liver organs are not mature enough and metabolic enzymes have not worked properly so the bilirubin level wilincrease.2 general condition of neonates with hyperbilirubinemia in this study was healthy. the results of this study was relevant with the study conducted by han et al.18 in china in 2015. it discovered that 80% of neonates with hyperbilirubinemia are without any comorbid disease.18 treatment given to neonates with hyperbilirubinemia at dr. hasan sadikin general hospital is phototherapy. observation for general condition of neonates was performed in most neonates with hyperbilirubinemia. the exchange transfusion or pharmacological therapy was not implemented in the neonates. the study conducted by vanborgg et al.19 stated that phototherapy becomes the general treatment for neonates with hyperbilirubinemia because phototherapy is safer and more effective than the exchange transfusion. observation of vital sign and bilirubin serum level is performed on neonates who do not have risk factors from hyperbilirubinemia, such as low birth weight or premature gestational age. 20 limitations of this study are the presence of incomplete medical records. some medical records were not available due to inappropriate storage of the medical records. this study concluded that the proportion of neonates with hyperbilirubinemia at dr. hasan sadikin general hospital is 8.04%. most neonates with hyperbilirubinemia are males, a term, low birth weight, in a healthy condition, and given phototherapy management. references 1. sgro m, campbell d, shah v. incidence and causes of severe neonatal hyperbilirubinemia in canada. can med assoc j. 2006;175(6):587–90. 2. ben md, gazzin s, tiribelli c. neonatal hyperbilirubinemia. ital j ped. results the population in this study was 230 neonates, where 174 neonates met the inclusion criteria for this study. the proportion of neonates with hyperbilirubinemia at department of child health, dr. hasan sadikin general hospital in 2014 was 8.04% in the period of january 2014 to december 2014. the characteristics of neonates with hyperbilirubinemia were described in table 1. this study discovered that most of the patients were males. based on the gestational age, 55,2% nenonates were in their normal gestational age, but with low birth weight. most of the patients were in their healthy condition. regarding the treatment, most of the patients underwent phototherapy. discussion the highest number of congenital anomaly the proportion of neonates with hyperbilirubinemia at dr. hasan sadikin general hospital in 2014 is 8.04%. this proportion is lower than in 2010.12 decreasing number of neonatal hyperbilirubinemia was suspected because of the good implementation of hyperbilirubinemia prevention, such as the breast feeding method for all the neonates and screening of neonates with risk of hyperbilirubinemia in accordance with the guideline published by the american academy of pediatrics (aap).13 this study showed that male neonates were more dominant than female neonates. gender is one of the risk factor in neonatal hyperbilirubinemia.2 this result was relevant with the study conducted by onwuanaku ca et al.14 in nigeria. a study in the united kingdom by tioseco et al.15, stated the y chromosome increases the risk of bilirubin metabolism disorder and damage to enzymes that roles the formation of bilirubin. gestational age is one of the risk factors that influence the numbers of hipebilirubinemia in neonates, hence, this study showed that the incidences of neonates with hyperbilirubinemia were most discovered in born with aterm gestational age. a study by bhutani et al.16 in 2014 mentioned that the newborns with preterm gestational age suffer from hyperbilirubinemiacompared to neonates that have term gestational age.16 this contracdictory situation might be explained that the onset of hyperbilirubinemia on premature newborns are more slowly than aterm neonates. the preterm neonates had althea medical journal. 2017;4(3) 434 amj september 2017 2014;40(1):10–5 3. wong rj, stevenson dk, ahlfors ce, vreman hj. neonatal jaundice bilirubin physiology and clinical chemistry. neoreviews. 2007;8(2):58–67. 4. juffrie m, arief s, rosalina i. buku ajar gastroenterologi-hepatologi. jakarta: badan penerbit idai; 2010. p.263–84. 5. maisels mj. what’s in a name? physiologic and pathologic jaundice: the conundrum of defining normal bilirubin levels in the newborn. pediatrics. 2006;118(2):805–7. 6. cohen rs, wong rj, stevenson dk. understanding neonatal jaundice: a perspective on causation. pediatrics & neonatology. 2010;51(3):143–8. 7. wang x, chowdhury jr, chowdhury nr. bilirubin metabolism: applied physiology. current ped. 2006;16(1):70–4. 8. croen la, yoshida ck, odouli r, newman tb. neonatal hyperbilirubinemia and risk of autism spectrum disorders. pediatrics. 2005;115(2):135–8. 9. scrafford cg, mullany lc, katz j, khatry sk, leclerq sc, darmstadt gl, et al. incidence of and risk factors for neonatal jaundice among newborns in southern nepal. trop med int health. 2013;18(11):1317–28. 10. petrova a, mehta r, birchwood g, ostfeld b, hegyi t. management of neonatal hyperbilirubinemia: pediatricians’ practices and educational needs. bmc pediatrics. 2006;6(1):6–15 11. martin rj, fanaroff aa, walsh mc. fanaroff and martin’s neonatal-perinatal medicine. philadelphia: mosby;2011. 12. widiasta a, reniarti l, sukadi a. incidence of neonatal hyperbilirubinemia in low, intermediate-low, and intermediate-high risk group infants. paediatr indones; 2010;50(6):351–4 13. maisels mj, bhutani vk, bogen d, newman tb, stark ar, watchko jf. hyperbilirubinemia in the newborn infant ≥35 weeks’ gestation: an update with clarifications. pediatrics. 2009;124(4):1193–8. 14. onwuanaku ca, okolo sn, ige ko, okpe se, toma bo. the effects of birth weight and gender on neonatal mortality in north central nigeria. bmc study notes. 2011;4(1):562. 15. tioseco ja, milner, patel k, mohandes aae. does gender affect neonatal hyperbilirubinemia in infants? pediatric crit care med. 2011:6(2): 171–4. 16. bhutani vk. late preterm births: major cause of prematurity and adverse outcomes of neonatal hyperbilirubinemia. indian pediatrics. 2012;49(9):704–5. 17. maisels mj, kring e. length of stay, jaundice, and hospital readmission. pediatrics. 2008;101(6):995–8. 18. han s, yu z, liu l, wang j, wei q, jiang c, et al. a model for predicting significant hyperbilirubinemia in neonates from china. pediatrics. 2015;136(4):896–905. 19. vandborg pk, hansen bm, greisen g, ebbesen f. dose-response relationship of phototherapy for hyperbilirubinemia. pediatrics. 2012;130(2):352–7. 20. smitherman h, stark ar, bhutan vk, editors. early recognition of neonatal hyperbilirubinemia and its emergent management. seminars in fetal and neonatal medicine. amsterdam: elsevier;2006. amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 20 amj march 2020 the characteristics, knowledge, and attitude of pregnant women regarding early breastfeeding initiation on the fourth antenatal care visit elsa pudji setiawati,1 cindy regina putri,2 tisnasari hafsah3 1department of public health faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: elsa pudji setiawati, department of public health faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: elsapudji@gmail.com introduction early breastfeeding initiation within one hour after birth has a specific role to reduce the infant mortality rate.1,2 furthermore, early skin-to-skin contact between mother and infant may give benefit to infant health.3,4 the world health organization (who) has recommended the breastfeeding within one hour after childbirth to ensure that the infant receives the colostrums that contain many antibodies to increase the immunity of the newborn.5 the implementation of breastfeeding initiation within one hour after giving birth in indonesia was very low, which is only 29.3%.6 implementation of early breastfeeding initiation is influenced by the mother’s knowledge and attitude about its benefits and risk associated with not breastfeeding.7 information regarding early breastfeeding initiation has given to pregnant women through the third (k3) and fourth (k4) antenatal care (anc) visit.8 however, there is a considerable gap between the coverage of the fourth antenatal care (anc) visit (k4) with the implementation of early breastfeeding initiation.6 behavior is influenced by knowledge and attitude.9 it shows that successful breastfeeding was determined by the knowledge and attitude of the pregnant women.10,11 knowledge and attitude are influenced by various factors, including age, education, environment, experience, facilities, and socio-cultural.9,12 the aim of this study was to analyze the relationship among characteristics of a pregnant women during the fourth anc visit amj. 2020;7(1):20–4 abstract background: early breastfeeding initiation within one hour after birth can reduce maternal and neonatal mortality. one of the interventions given on the fourth antenatal care (anc) visit is providing information regarding breastfeeding initiation, however, the implementation is low. many factors may influence breastfeeding initiation, including knowledge and attitude. the aim of this study was to analyze the relationship among the characteristics, knowledge, and attitude of the pregnant women on the fourth anc visit regarding early breastfeeding initiation in jatinangor. methods: an analytic cross-sectional study was conducted in september 2013. a total of 61 pregnant women registered for the fourth anc visit (k4) in jatinangor public health center were involved in this study. data were collected from questionnaires. data on the number of gestation, level of education, source of information regarding breastfeeding initiation, knowledge and attitude about early breastfeeding initiation were collected and analyzed using chi-square. results: there was a significant relationship between a number of gestation, level of education, source of information and knowledge also attitude, as well as between age and attitude (p<0.05). however, there was no significant association between age and knowledge (p>0.05). conclusions: number of gestation, level of education, and source of information have a significant relationship with both knowledge and attitudes about early breastfeeding initiation. keywords: antenatal care visit, attitude, breastfeeding initiation, knowledge https://doi.org/10.15850/amj.v7n1.1710 althea medical journal. 2020;7(1) 21 (k4) with knowledge and attitudes regarding early breastfeeding initiation methods an analytical cross-sectional study was conducted in september 2013. the sample data was obtained from the public health center (pusat kesehatan masyarakat, puskesmas) jatinangor, sumedang district, west java. all pregnant women who registered for the fourth antenatal care (anc) visit (k4) at puskesmas jatinangor during september 2013 and had consented to participate by filling the informed consent form were selected to be a participant. from these criteria, 61 pregnant women were participated and selected by consecutive sampling. this study was approved by the health research ethics committee, faculty of medicine universitas padjadjaran, with ethical clearance no. 34/un6.c2.1.2/kepk/2013. participant’s characteristics in this study were age, categorized into age above the median and below the median. the number of gestation was categorized into primigravid (first pregnancy) and multigravid (number of gestation ≥2). level of education was categorized into high and low. high education including senior high school or college, low education primary high school, junior high school, or did not attend school. source of information about early breastfeeding initiation was categorized into information from health care service and not from health care service. this study used primary data. the participants were asked to fill the informed consent form and questionnaire. the questionnaires were explored about knowledge and attitude about early breastfeeding initiation. the scoring of good knowledge was more than 75, moderate was 50–<75 and low was less than 50. the attitude was categorized positive when the score is ≥the median and negative attitude when the score <median. the data collected were analyzed through statistical product and service solutions (spss). bivariate analysis was conducted to assess the relationship of characteristics with knowledge and attitude regarding early breastfeeding initiation. the chi-square test and kolmogorov-smirnov test were used to measure the bivariate relationship of two categorical data. if the p-value <0.05, it showed that there was a significant relationship between those variables tested. results the median age in this study was 28. most of the respondent had age above the median (59%), multigravid (56%), high level of education (62%), and health care service as a source of information regarding early breastfeeding initiation (72%) (table 1). most of the respondents received information regarding breastfeeding initiation from primary health care and midwives. a total of 34 respondents (56%) graduate from senior high school. most the respondents had a moderate level of knowledge. most of the respondents who had a good knowledge were within age group above the median, a multiple numbers of gestation (g≥2), high level of education, and health service as a source of information (table 2). table 1 characteristics of pregnant women during the fourth antenatal care visit. variables category participants (n=61) n % age (years old) above the median 36 59 below the median 25 41 number of gestation primigravida (g1) 27 44 multigravida (g ≥ 2) 34 56 level of education high 38 62 low 23 38 source of information from health care service 44 72 not from health care service 17 28 note: g1= the first gestation; g≥2= the second gestation or more elsa pudji setiawati et al.: the characteristics, knowledge, and attitude of pregnant women regarding early breastfeeding initiation on the fourth antenatal care visit althea medical journal. 2020;7(1) 22 amj march 2020 most of the respondents (44 respondents or 72%) had a positive attitude regarding early breastfeeding initiation. all respondent’s characteristics had a significant relationship (p<0.005) with the attitude of early breastfeeding initiation as shown in table 3. discussions our study result has shown that pregnant women (k4) mostly had good knowledge regarding early breastfeeding initiation, including 34.4% with good knowledge and table 2 relationship between characteristics of pregnant women and knowledge regarding early breastfeeding initiation variable knowledge total (n=61) p-valuegood (n=21) moderate (n=23) low (n=17) age (years old) above the median 16 13 7 36 0.088 below the median 5 10 10 25 number of gestation g1 5 10 12 27 0.015* ≥g2 16 13 5 34 level of education low 3 9 11 23 0.006* high 18 14 6 38 source of information from health care service 20 17 7 44 0.022* not from health care service 1 6 10 17 note: median of age= 28 years old; g1= the first gestation; g2= the second gestation or more, *significant p<0.05 table 3 relationship between characteristics of pregnant women and attitude regarding early breastfeeding initiation variable attitude total (n=61) p-valuepositive (n =44) negative (n=17) age (years old) above the median 30 11 36 0.019 below the median 14 11 25 number of gestation g1 13 14 27 0.000* ≥g2 31 3 34 level of education low 12 11 23 0.007* high 32 6 38 source of information from health care service 38 6 44 0.003* not from health care service 6 11 17 note: median of age= 28 years old; g1= the first gestation; g2= the second gestation or more, *significant p<0.05 althea medical journal. 2020;7(1) 23elsa pudji setiawati et al.: the characteristics, knowledge, and attitude of pregnant women regarding early breastfeeding initiation on the fourth antenatal care visit 37.7% with a moderate knowledge. one of intervention given in the fourth antenatal care visit (k4) was providing information regarding early breastfeeding.8 thus, the knowledge of pregnant women k4 can be obtained from counseling on antenatal care. however, there were 17 subjects (27.8%) who had low knowledge. the results suggest that information regarding early breastfeeding initiation through antenatal care was not optimal, proven by a total of 11 respondents (27.9%) who did not get the information from the health caregiver. a significant relationship has been found between the number of gestation, level of education, source of information and knowledge regarding early breastfeeding initiation. the relationship between age and knowledge regarding early breastfeeding initiation was not significant. the number of gestations has a significant association with knowledge. knowledge is influenced by sensing and intensity of attention.9 number of gestation related to childbirth experience. this experience affects knowledge regarding early breastfeeding initiation. a study by narayan et al.13 showed that primigravida adversely affects breastfeeding. education is one of the factors that affect knowledge. education is needed to get information. the higher level of education, the easier to receive the information,12 therefore, the level of education of pregnant women determines knowledge regarding early breastfeeding initiation. the source of information had a significant association with knowledge regarding early breastfeeding initiation. it was related to the counseling given by health care to pregnant women who visit antenatal care. some studies discovered that knowledge and awareness related to breastfeeding was better after counseling.14,15 the age of the pregnant women did not have a significant relationship with their knowledge. the older person’s age, the better able to work and think, the experience was one of the factors.12 however, older age does not always create better knowledge. younger mothers are less likely to do breastfeeding initiation compared with older mothers. this is due to the lack of social support and mother misperception about breastfeed.16 it shows that age does not become an absolute factor that determines the knowledge level of a pregnant women. most of the respondents (72.1%) have a positive attitude regarding early breastfeeding initiation, confirming the theory by newcomn that attitude is a readiness to take action.9 that means the subjects mostly ready and agreed to do early breastfeeding initiation. based on the analysis of each characteristics with attitude, all of characteristic of pregnant women, that is age, a number of gestation, level of education, and source of information regarding early breastfeeding initiation have a significant association with attitude.9 factors that influence attitude is experience, facilities, and socio-cultural. experience related to age and number of gestation, facility related to promote and support breastfeeding provided by health care service and one of socio-cultural factors is the level of education.17 through one of the questions about attitudes on the questionnaire, most of the respondents (92%) agreed to do early breastfeeding initiation after childbirth. the result contradicts the fact that there was the low implementation of early breastfeeding initiation. it may relate to other factors, including health care service factors. 17 this study had some limitations. not all the questionnaires were administered directly by the author and the sampling used in this study was consecutive sampling, therefore this study tends to less reflecting the jatinangor subdistrict. in conclusion, most of the characteristics of pregnant women have a significant association with knowledge and attitude. age did not have a significant association with knowledge. the suggestion for health care services is to improve antenatal care service, particularly in providing information regarding early initiation of breastfeeding and further research is needed to follow up on the implementation of early breastfeeding initiation among respondents references 1. smith er, hurt l, chowdhury r, sinha b, fawzi w, edmon km. delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis. plos one; 2017;12(7):e0180722 2. rao mvr, fathima n. a critical analysis of factors for delayed initiation of breast feeding in a district level hospital. int j reprod contracept obstet gynecol. 2018;7(12):4840-4. 3. debes ak, kohli a, walker n, edmond k, mullany lc. time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. bmc althea medical journal. 2020;7(1) 24 amj march 2020 public health. 2013;13 suppl 3:s19. 4. moore er, anderson gc, bergman n, dowswell t. early skin-to-skin contact for mothers and their healthy newborn infants. cochrane database syst rev. 2012;5:cd003519.. 5. inayati da, scherbaum v, purwestri rc, hormann e, wirawan nn, suryantan j, et al. infant feeding practices among mildly wasted children: a retrospestive study on nias island, indonesia. int breastfeed j. 2012;7(1):3. 6. badan penelitian dan pengembangan kesehatan. pola pemberian asi. in: riset kesehatan dasar. jakarta: departemen kesehatan ri; 2010. 7. mohamed mj, ochola s, owino vo, comparison of knowledge, attitude and practise on exclusive breastfeeding between primparous and multiparous mothers attending wajir district hospital, wajir county, kenya: a crosssectional analytical study. int breastfeed j. 2018;13:11. 8. departemen kesehatan. pedoman pelayanan antenatal. jakarta: departemen kesehatan ri; 2007. 9. notoatmodjo s. ilmu perilaku kesehatan. jakarta: rineka cipta; 2010. p. 27 ̶ 33 10. 10. tan ae, choong wk, leong py, ng wm, yong sl. knowledge, attitude and sources of information on breastfeeding among pregnant mothers. med & health. 2008;3(1):30 ̶ 7. 11. james dc, lessen r. position of the american dietetic association: promoting and supporting breastfeeding. j am diet assoc. 2009;109(11): 1926 ̶ 42. 12. wawan a, dewi m. teori dan pengukuran pengetahuan, sikap, dan perilaku manusia. yogyakarta: nuha medika; 2010. 13. narayan s, natarajan n, bawa k. maternal and neonatal factors adversely affecting breastfeeding in the perinatal period. med j armed forces india. 2005;61(3):216 ̶ 9. 14. sungkar s, winita r, kurniawan a. pengaruh penyuluhan terhadap tingkat pengetahuan masyarakat dan kepadatan aedes aegypti di kecamatan bayah, provinsi banten. makara kesehatan. 2010;14(2):81 ̶ 5. 15. dhandapany g, bethou a, arunagirinathan a, ananthakrishnan s. antenatal counseling on breastfeeding is it adequate? a descriptive study from pondicherry, india. int breastfeed j. 2008;3:5. 16. apostolakis-kyrus k, valentine c, defranco e. factors associated with breastfeeding initiation in adolescent mothers. j pediatr. 2013;163(5):1489–94. 17. burgio ma, lagana as, sicilia a, prosperi porta r, porpora mg, frangez hb, etal. breastfeeding education; where are we going? a systmatic review article. iran j public health. 2016; 45(8):970–7. althea vol 4 no 1 final.indd althea medical journal. 2017;4(1) 125 relationship between drugs use and sexual risk behaviors among senior high school students yola yuniaarti herijanto,1 lucky saputra,2 meita dhamayanti3 1faculty of medicine universitas padjadjaran, 2department of psychiatry faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3 department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: drugs use and risky sexual behavior among teenager are some of crucial problems arising in indonesia. statistic showed that there is an increasing prevalence in drugs use and risky sexual behavior among teenagers. this study was conducted to analyze the relationship between drugs use and risky sexual behaviors among high school students. methods: an analytic study involving 432 students in 5 state high schools located in kerees region bandung, west java, indonesia, was carried out in 2013. the region was chosen due the high prevalence of substance abuse. the inclusion criteria were every high school students in the karees region. the exclusion criteria were the students who refused to participate in the study, did not come when the sample was taken, and did not fill the questionnaire completely. the instruments used for the study were questionnaires with crosssectional technique. furthermore, the questionnaire used for analyzing drugs use was addiction severity index-lite version (asi-lite) questionnaire; with additional questionnaire to analyze risky sexual behaviors. results: out of 432 students, 23.8% students already engaged to one or more risky sexual behavior. among all respondents, the prevalence of students who had already done kissing was 22.7%, necking 9.3%, petting 7.2% and sexual intercourse 1.2%. illegal drugs had been used at least once by 21.8% students. according to chi-square test, drugs use and risky sexual behavior were related. conclusions:the prevalence of both drugs use and risky sexual behaviors are high and students who use drugs are more prone to do risky sexual behavior. [amj.2017;4(1):125–8] keywords: drugs use, high school, sexual risk behavior correspondence: yolayuniaarti herijanto, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281294059673 email: yolayuniaartiherijanto@gmail.com introduction senior high school is a formal education for teenagers between the ages of 14 to 18.1 there are changes in many areas of life in a teenagers including physical, mental, emotional and social. research showed that adolescences tend to use their emotional pathway rather than their cognitive pathway regarding to risk taking decision which lead them to do risky behavior.2 drug is any substance that has the ability to enhance physical or mental welfare.3 drugs use among teenagers is one of the significant public health concerns.4 a survey conducted at minnesota5 in 2011 showed that most of drugs users were 11–12 graders. ricardo6 stated that the number of drug users was increasing. many factors influenced drugs use, including family and peer pressure.4 a research conducted in 2012 showed that men with low education tend to be reported with negative alcohol abuse.7 according to the survey conducted on 2012,8 for the last 5 years there was an increase of drugs use in teenagers less than 16 years old. prevalence of risky sexual behavior has also increased. a survey conducted in ghana8 stated that 25% teenagers admitted that they had done sexual intercourse, where males were at higher prevalence than females. according to the survey conducted by survei kesehatan reproduksi remaja indonesia (skrri) on 2007,9 the number of risky sexual behaviors committed by teenager was increasing. the term risky sexual behavior refers to any sexual behaviors that increase the risk of negative sexual consequences.10 drugs use is believed to have an influence to the higher incidence of sexual risk behavior.11 baldwin et al.12 stated althea medical journal. 2017;4(1) 126 amj march 2017 that alcohol consumption, cigarette smoking and illicit substance usage had an association with early sexual initiation.12 an analysis conducted by ritchwood et al.13 stated that there was a positive association between drug use and risky sexual behaviors. considering the relationship between drugs use and risky sexual behavior among teenagers in bandung city, it is likely to figure out the appropriate intervention to prevent a higher prevalence in the future. the aim of this study was to analyze the relationship between risky sexual behavior and substance abuse. methods the survey was taken from october until november 2013. the participants involved in this survey were 453 senior high school students in bandung city, west java, indonesia, located in karees region. karees region was chosen because of its high prevalence of substance abuse based on data from grapiks, a non-government organization. this study used the non-paired categorical data analysis formula to obtain the minimal sample size. the minimal sample size of this study was 100 subjects. the inclusion criteria were every high school student in the karees region who agreed to fill the questionnaire and presented at the data collection’s day whereas, the exclusion criteria were students who refused to take part of the study, the students who did not come when the survey was taken, and the student who did not fill the questionnaire completely. there were 453 students who came when the survey was taken. of the 453 students, 21 students did not fill the questionnaire completely, therefore, they were excluded in the study. the questionnaire used in the study consisted of three parts: identity, sexual risk behaviors and substance-use. the prevalence of risky sexual behaviors was analyzed using questionnaire-containing questions to explore what kind of risky sexual behaviors done by the students. the addiction severity index lite version (asi lite version) was used to identify the prevalence of substance use among the respondents. the asi-lite is a shortened version of the addiction severity index (asi), an instrument used to analyze problem behaviors. the asi-lite is a validated questionnaire which can be used to assess substances use and associated psychosocial impairment.14 after permitted by health research ethics committee of faculty of medicine, bandung municipal government and bandung municipal education department, the questionnaires were administered to the schools. the questionnaires were administered to the selected schools. before the questionnaires were administered to participants, the participants signed the inform consent and were given explanation to ensure the privacy of their identity and to explain the purpose of these questionnaires. the data were analyzed by statistical analysis. there were 2 variables that were analyzed, table 1 respondent characteristics sexual risk behavior* n(%) drugs use** n(%) both n(%) not at risk total age (years) 14 0(0) 0(0) 0(0) 8(100) 8 15 15(15.6) 15(15.6) 9(9.4) 75(78.1) 96 16 34(20.2) 33(19.6) 13(7.7) 114(67.9) 168 17 52(34.2) 44(28.9) 26(17.1) 82(53.9) 152 18 2(25.0) 2(25.0) 2(25) 6(75.0) 8 gender male 53(29.3) 77(42.5) 38(20.9) 89(49.2) 181 female 50(19.9) 17(6.8) 12(4.8) 196(78.1) 251 total 103(23.8) 94(21.8) 50(11.6) 285(65.9) 432 note: *everyone except determined as “not having sexual risk behavior” by questionnaire, ** every drugs use regardless its substances althea medical journal. 2017;4(1) 127yolayuniaarti herijanto, lucky saputra, meita dhamayanti: relationship between drugs use and sexual risk behaviors among senior high school students and both of them were ordinal categorical variable. the independent variable was drugs use and the dependent variable was sexual risk behavior. chi square test was used to analyze the variables. to analyze whether the association was statistically significant, p value was calculated. results from all respondents, 329 students (76.2%) did not have any risky sexual behaviors and 103 students (23.8%) did at least one risky sexual behavior. furthermore, male students have higher risk (51.5%) than females (48.5%). students who had the highest risk of doing risky sexual behaviors were 12nd grade students (53.4%), followed by 11st grade students (31.1%), and 10th grade students (15.5%). from all respondents, 22.7% students admitted that they had done kissing, 9.3% had done necking, 7.2% had done petting and 1.2% had done sexual intercourse. the youngest age of those students who had done kissing were less than 11 years old, necking were 13 years old, petting were 13 years old and sexual intercourse were 14 years old. among all respondents, 94 students (21.8%) admitted that they had used drugs at least once; with the percentage of male students who used drugs which was much higher (81.9%) than female (18.1%). the most common type of drugs that were used by the students were nicotine (66.2%), alcohol (23.3%), marijuana (5.3%) and methamphetamine (1.5%). barbiturate (0.8%), cocaine (0.8%), amphetamine (0.8%), hallucinogens (0.8%) and other drugs such as mushrooms (0.8%) were the least drugs that were used by the students. the use of methadone and heroin were not found. the youngest age of nicotine user was 9 years old, alcohol user was 12 years old, marijuana user was 14 years old, methamphetamine user was 15 years old, barbiturate user was 14 years old, and amphetamine user was 13 years old. (table 2). chi-square test was used to determine the relationship between drugs use and risky sexual behavior. based on chi-square test, it can be concluded that there was an association between drugs use and risky sexual behavior, with p = 0.001, or = 6.111 and rr = 3.392 (table 3). discussion the prevalence of risky sexual behaviors was much higher than the result obtained by survei kesehatan reproduksi remaja indonesia (skrri) in 33 provinces of indonesia on 2007 (4.1%).9 the incidence of drugs use was also higher than the incidence of drugs use in a study conducted by skrri on 2007(3.4%).6 this was caused by the sample size used in the survey was much bigger than the sample size used in this study. the higher prevalence of risky sexual behaviors was also resulted from the different classification that the author used, where kissing, necking and petting were included to risky sexual behaviors category.10 the higher prevalence of drugs use may be caused by the difference of classification used by the author, in which nicotine (cigarette) and alcohol was included to addictive substances.3 the relationship between drugs use and high-risk sexual behaviors among teenager table 2 the prevalence of drugs use frequency percent (%) never use drugs 338 78.2 use drugs at least once 94 21.8 total 432 100.0 table 3 cross tabulation between drugs use and risky sexual behaviors risky sexual behaviors not risky sexual behaviors total use drugs 50 44 94 never use drugs 53 285 338 total 103 329 432 althea medical journal. 2017;4(1) 128 amj march 2017 was in line to those reported by doku in ghanaian youth8 who stated that teenagers who used tobacco, alcohol and other drugs were found to increase the likelihood of doing risky sexual behaviors. an analysis conducted by ritchwood et al.13 stated that there was a positive association between substance use and risky sexual behavior. hipwell15 also stated that alcohol use increased the number of risky sexual behaviors among adolescents. this relationship can be explained as follows: drugs use can disturb brain development in teenagers which cause dysfunctions in cognitive and behavioral aspects. this dysfunctions will promote teenagers to do risk taking behaviors.12 the limitations of the study were the limited time for the author to conduct this study so that the data presented in this study was not normally distributed. many factors that influenced of drugs use and risky sexual behaviors such as peer pressure and family influence4 were not analyzed, which could be confounding factors in this study. the honesty of the respondents might be one of bias that could be found in this study, although the author had tried to minimize it by assuring the respondents of their secrecy. the author suggested the usage of interview as an instrument rather than questionnaire to guarantee the honesty of the respondents. other variables such as peer pressure, family and emotional condition can be analyzed to prevent confounding factors. the author also suggested using more samples in order to obtain the more significant result. as a conclusion, the prevalence of risky sexual behaviors and drugs use among the high school students was high, and there was a significant association between drug use and risky sexual behaviors. references 1. whitelock p, heuboeck a. oxford dictionary. oxford: oxford university press; 2013. 2. smith ar, chein j, steinberg l. impact of socio-emotional context, brain development, and pubertal maturation on adolescent risk taking. horm behav. 2013;64(2):323–332 3. who. lexicon of alcohol and drug terms. geneva: who; 1994 [cited: 2014 february 10]. available from: http://apps.who.int/iris/ itstream/10665/39461/1/9241544686_ eng.pdf. 4. branstetter sa, low s, furman w. the influence of parents and friends on adolescent substance use: a multidimensional approach. j subst use. 2011;16(2):150–60. 5. arcan c, kubik my, fulkerson ja, hannan pj, story m. substance use and dietary practices among students attending alternative high schools: result from a pilot study. bmc public health. 2011;11:263–72 6. ricardo p. upaya penanggulangan penyalahgunaan narkoba oleh kepolisian (studi kasus satuan narkoba polres metro bekasi). jurnal kriminologi indonesia. 2010;6(3):232–45. 7. grittner u, kuntsche s, graham k, bloomfield k. epidemiology social inequalities and gender differences in the experience of alcohol-related problems. alcohol alcohol. 2012;47(5):597–605. 8. doku d. substance use and risky sexual behaviours among sexually experienced ghanaian youth. bmc public health. 2012;12(1):571–8. 9. lestary h, sugiharti. young adults risk behavior by indonesia young adult reproductive health survey in 2007. jurnal kesehatan reproduksi. 2011;1(3):136–44 10. musthofa sb, winarti p. the influencing factors of a pre-marital sexual behavior among college students in pekalongan. jurnal kesehatan reproduksi. 2010;1(1):33–41 11. turner ak, latkin c, sonenstein f, tandon sd. psychiatric disorder symptoms, substance use, and sexual behavior among african-american out of school youth. drug alcohol depend. 2011;115(1–2):67–73. 12. baldwin p, shrestha r, potrepka j, copenhaver m. review article the age of initiation of drug use and sexual behavior may influence subsequent hiv risk behavior: a systematic review. isrn aids. 2013;2013:976035. 13. ritchwood td, ford h, decoster j, sutton m, lochman je. risky sexual behavior and substance use among adolescents: a meta-analysis. child youth serv rev. 2015;52:74–88. 14. fiellin da, weiss l, botsko m, egan je, altice fl, bazerman lb, et al. drug treatment outcomes among hiv-infected opioid dependent patients receiving buphrenorphine/naloxone. j acquir immune defic syndr. 2011; 56(01):1–13. 15. hipweel a, stepp s, chung t, durand v, keenan k. growth in alcohol use as a developmental predictior of adolescent girls’ sexual risk-taking. prev sci. 2012;13(2):118–28. vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 172 amj december 2019 the effect of leunca fruit (solanum nigrum linn) infusion in inhibiting the increase of serum glutamate pyruvate transaminase level in ccl4 induced hepatitis wistar rats kuswinarti,1 syifa karmani,2 coriejati rita3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: kuswinarti, department of biomedical sciences, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, e-mail: wiwinsumarlan@yahoo.com introduction hepatitis is caused by an inflammation in the hepatic cells which can damage both hepatocytes or hepatic mesenchymal tissue, leading to its function disruption.1 hepatitis has become the attention of the medical world due to high prevalence in the world and also in indonesia. according to the world health organization (who), the frequency of hepatitis b virus that infects the global population is about 2 billion; whereas hepatitis c infects 130−170 millions of population.2 in indonesia3,4, the hepatitis b affects 13 million individuals while hepatitis c affects 7 million individuals. there are various types of hepatitis treatment, however, it also induce several adverse effects such as hypersensitivity reaction and cardiovascular disturbance. therefore, herbal medicines become alternative treatments chosen by the indonesians because of its natural materials, relatively easy to obtain and process, affordability, and less adverse effects.5 solanum nigrum linn have many chemical contents such as solanine, solamargine, solasodine, solanidine, solasonine, vitamin e, vitamin c, and flavonoid, useful to prevent many diseases like cancer for examples on cervical, breast, hepatic, and lung cancer; moreover, urinary tract infection, hypertension, amj. 2019;6(4):172–5 abstract background: hepatitis may cause liver cell damage due to the oxidation processes and can be inhibited by antioxidant components. antioxidant acts as hepatoprotector by slowing down the oxidation process. leunca fruits (solanum nigrum linn) contain antioxidants such as vitamin c and flavonoid. this study aimed to explore the effect of leunca fruit infusion to inhibit the increase of serum glutamate pyruvate transaminase (sgpt) level in wistar rats’ blood. methods: this was an experimental study using male wistar rats, conducted in the animal laboratory, department of pharmacology and therapy, faculty of medicine, universitas padjadjaran between september−october 2012. the hepatitis rats model was induced with carbon tetrachloride (ccl4) in 10% paraffin intraperitoneally as much as 8 ml/kgbw on day 8th. a 3 ml of leunca fruit infusion was given with a concentration of 22.5 g, 45 g, and 90 g per 100 ml, respectively. on the 10th day, serum was taken and sgpt was examined. only food and distilled water were given to the negative control group. the result was analyzed by using a kruskal-wallis non-parametric test, followed by mann-whitney post hoc. results: there was a significant difference between the negative control and hepatitis positive control group (p=0.009), indicating that the induction was successful. the dose 90 g/100 ml leunca had a significant different in sgpt concentration (p=0.047), suggesting that leunca fruit infusion had a significant effect on reduced sgpt level. conclusions: leunca fruit infusion has a hepatoprotective effect by inhibiting the increase of the sgpt level in ccl4 induced rats. studies on the leunca effectiveness in human hepatitis need further exploration. keywords: ccl4, hepatoprotective, leunca, sgpt althea medical journal. 2019;6(4) 173 hepatitis can make use of this component.6 vitamin e, vitamin c, and flavonoids are known antioxidants that protect cells from the negative effects of free radicals by bonding and stabilizes free radicals and by preventing, inhibiting, and slowing the oxidation process.7,8 interestingly, study on leunca fruit extract has shown to have a significant hepatoprotective effect in rats.9,10 carbon tetrachloride (ccl4) is one of the hepatotoxins that is metabolized by the cytochrome enzyme p450. ccl4 will form trichloromethyl, a free radical which oxidizes the fatty acid polyenoic on cell membranes and forms radical lipid.11,12 cell membrane damage causes a leak of intracellular enzymes such as serum glutamate pyruvate transaminase (sgpt) that can be detected in blood and may serve as a marker on hepatocytes damage.11 this study aimed to explore the effects of leunca fruit infusion on the sgpt level of wistar rats after being induced with ccl4. methods this study was conducted in the animal laboratory, department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, and clinical pathology laboratory of the open treatment unit, universitas padjadjaran, in the period of septemberoctober 2012 using a laboratory experimental study designs with total random sampling. the leunca fruit (solanum nigrum linn) was obtained from manoko, lembang, bandung, west java, and processed in the herbarium of jatinangor, plantation taxonomy laboratory, department of biology, faculty of mathematics and natural sciences, universitas padjadjaran. in brief, leunca fruit was cleansed, cut and weighed according to the used concentration. the infusion was made by adding 100 ml water on the simplicia, which was heated (90oc) for 15 minutes and stirred once every 5 minutes. the infusion was let to cool in ambient temperature and filtered using flannel; hot figure 1 flow of research study rats adaptation, 7 days selection inclusion and exclusion criteria group i (negative control) 10 d. water + standard feeding group ii (positive control) 10 d. water + standard feeding group iii 10 d. water + standard feeding + infuse of fruit leunca dose 1 22.5g/100ml group iv 0 d. water + standard feeding + infuse of fruit leunca dose 1 45g/100ml group v 0 d. water + standard feeding + infuse of fruit leunca dose 1 90g/100ml days 8: ccl4 8 ml/kg bw, i.p. days 10: sgpt measurement kuswinarti et al.: the effect of leunca fruit infusion in inhibiting the increase of serum glutamate pyruvate transaminase level in ccl4 induced hepatitis wistar rats althea medical journal. 2019;6(4) 174 amj december 2019 water was added to the resulting base in the pot as much as the water lost in evaporation and filtering. male rats of wistar strain aged 8−12 weeks weighted 180−200 g were retrieved from the inter university central laboratory of life sciences (pau), institute of technology bandung and adapted for 7 days with a standard environmental condition of the animal laboratory, department of pharmacology and therapy, faculty of medicine, universitas padjadjaran. rats were given standard feeding and drinking, according to the ethical principle including reduction, refinement, and replacement on experimental animals.13 furthermore, rats were randomly assigned into 5 groups, each of 5 rats as shown in figure 1. group 1 was a negative control, whereas group 2 was a control positive and together with group 3, 4, and 5 were given an infusion of leunca fruit orally between the 1st to 8th day of experiment, with a volume of 3 ml in concentration of 22.5 gram/100ml, 45 gram/100 ml, and 90 gram/100 ml, respectively. on the 8th day, rats were injected intraperitoneal with ccl4, (merck, indonesia) 10% within liquid paraffin at 8 ml/kgbw. on day 10th, all rats have fasted before measurement for the sgpt level. rats have undergone an anasthesic procedure with ketamine, then blood was taken from the tail of the rats as much as 3 cc without anticoagulants. blood was then centrifugated with a speed of 1000 rpm for 10 minutes before sgpt measurement using a spectrophotometer. data were tested for normality test (saphirowilk) and homogeneity test (levene) ensued. if the data were normally distributed and homogenous, analysis was continued with one way analysis of variance (anova) test. if the analyzed was significantly different, then the tukey test with a confidence interval of 95% was performed; otherwise, if the data was not normally distributed and heterogeneous, then analysis was performed using non-parametric test. the result was considered as significant if p≤0.05. the average of sgpt level obtained from 25 rats in the 10th day is presented in figure 1. the largest average was obtained from group ii as positive control and the smallest in group i as negative control. results after testing the normality of the data (saphiro-wilk test), it was shown that the data was not normally distributed. the variance homogeneity test using the levene method gave a p-value of 0.001 (p<0.05) which showed heterogeneous data variance. data that was not normally distributed and heterogeneous was tested with non-parametric test kruskalwallis, resulting in a p-value of 0.006 (p<0.05) and thus there were significant differences between the tested groups. to know which group gave the most significant difference, an analytic test post hoc mann-whitney was performed, resulting in a statistically significant difference between the negative control and hepatitis positive control group (p=0.009) indicating that the induction of ccl4 was successful (table). furthermore, the dose 90 g/100 ml leunca had a significant difference in sgpt concentration (p=0.047) suggesting that leunca fruit infusion had a lowering effect of sgpt level. discussion this study was successful to make an animal model, in this case, wistar rats, to have inflammatory hepatitis induced by ccl4, and this hepatitis model was confirmed by an increase of sgpt level. the induction of ccl4 as a hepatotoxin caused damage to the table the level of serum glutamate pyruvate transaminase of wistar rats induced with ccl4 after leunca fruit infusion treatment rats no. negative control positive control leunca infusion 22.5 g/100 ml leunca infusion 45 g/100 ml leunca infusion 90 g/100 ml 1 83 1766 1139 952 534 2 103 695 109 86 94 3 83 1533 421 460 592 4 77 1732 535 172 609 5 85 483 529 994 121 mean 86.2 1241.8 546.6 532.8 390 note: the level of serum glutamate pyruvate transaminase (sgpt) was in presented in iu/l althea medical journal. 2019;6(4) 175kuswinarti et al.: the effect of leunca fruit infusion in inhibiting the increase of serum glutamate pyruvate transaminase level in ccl4 induced hepatitis wistar rats hepatic cells by forming trichloromethyl (ccl3-) which was a reactive free radical after being activated by p450 of hepatic cells.9 trichloromethyl initiated a lipid oxidation process on phospholipids, resulting in aldehyde which was toxic to cells. both factors could cause damage on hepatic cell membrane and increase the activity of its intracellular enzymes such as sgpt. serum glutamate pyruvate transaminase (sgpt) detected in serum can be used as a sensitive indicator for hepatic damage, leading to a significant sgpt level rise in positive control group.10 some concentration leunca fruit infusion has been tested, all have a decreasing effect of sgpt level, hence, no significant difference of leunca fruit infusion concentration for 22.5 g/100 ml and 45 g/100 ml, respectively. however, with a concentration of 90 g/100 ml, it has a significant effect on the decrease of sgpt. leunca fruit has antioxidant substances, such as vitamin c and flavonoid which are known to be hepatoprotective. flavonoid is an antioxidant that can prevent hepatic damage caused by the oxidation process.7,8 vitamin c and flavonoid are of the group primary antioxidant which will react and change radical lipids into a stable products that can oxidize the fat of phospholipids in cellular membranes and organelles.7,8,12 this causes sgpt to leak into the sinusoid and cause inhibition on the rise of sgpt in serum which indirectly demonstrated that leunca fruit infusion has a hepatoprotective active compound, suggesting that leunca fruit extract have a hepatoprotective effect by inhibiting the rise of sgpt on ccl4 induced rats. 14 similarly, our previous study using annona muricata linn. the leaf has also an effect in inhibitory sgpt elevation.15 the limitation of this study is that this study only has three concentrations of infusion. to conclude, the administration of leunca fruit infusion (solanum nigrum linn.) with a dose of 90 grams/100 ml on wistar rats can inhibit the rise of sgpt significantly. further research is needed to explore the optimal dose and the toxicity concentration of leunca fruit infusion, to make possible for leunca fruit to be regarded as phytopharmaca. references 1. robbins sl, kumar v, abbas ak, cotran rs, fausto n. robbins and cotran pathologic basis of disease. 8th ed. philadelphia: saunders/elsevier; 2010. 2. world health organization. viral hepatitis. geneva: world health organization; 2010 3. kementrian kesehatan republik indonesia. lembar fakta hepatitis. 2010 [cited 2012 march 14]; available from: http:// www.depkes.go.id/hepatitis/index.php/ component/content/article/34-pressrelease/799-lembar-fakta-hepatitis.html. 4. kementrian kesehatan republik indonesia. saatnya lawan hepatitis. 2010. [cited 2012 march 23]; available from: http://www. d e p ke s . g o . i d / i n d ex . p h p / c o m p o n e n t / content/article/43-newsslider/1557saatnya-lawan-hepatitis.html. 5. govind p. medicinal plants against liver diseases. irjp. 2011;2(5):115–21. 6. hartati k, ruslan k, fidrianny i. telaah kandungan kimia buah leunca (solanum nigrum l.). [thesis]. bandung: institut teknologi bandung; 2005. 7. hamid aa, aiyelaagbe oo, usman la, ameen om, lawal a. antioxidants: its medicinal and pharmacological applications. afr j pure appl chem. 2010;4(8):142–51. 8. mohy-ud-din a, khan zud, ahmad m, kashmiri ma. chemotaxonomic value of alkaloids in solanum nigrum complex. pak j bot. 2010;42(1):653–60. 9. zulaikhah st. the role of antioxidant to prevent free radicals in the body. sains medika. 2017; 8(1):39–45 10. elhag ram, el badwi smae, bakhiet ao, galal m. hepatoprotective activity of solanum nigrum extracts on chemically induced liver damage in rats. j vet med anim health. 2011;3(4):45–50 11. sahreen s, khan mr, khan ra. hepatoprotective effects of methanol extract of carissa opaca leaves on ccl4induced damaged in rat. bmc complement altern med. 2011;11:48. 12. panjaitan rgp, handharyani e, chairul, masriani, zakiah z, manalu w. pengaruh pemberian karbon tetraklorida terhadap fungsi hati dan ginjal tikus. makara, kesehatan. 2007;11(1):11–6. 13. buchanan-smith h, rennie ae, vitale a, pollo s, prescott mj, morton db. harmonising the definition of refinement. animal welfare. 2005;14:379-84. 14. raju k, anbuganapathi g, gokulakrishnan v, rajkapoor b, jayakar b, manian s. effect of dried fruits of solanum nigrum linn against ccl4-induced hepatic damage in rats. biol pharm bull. 2003;26(11):16189. 15. tanaya g, kuswinarti, dewi ns. annona muricata linn. leaf effect in inhibitory sgpt elevation. amj. 2015; 2(1):86–9. althea medical journal. 2017;4(2) 208 amj june 2017 comparison of shoulder strength in routinely trained badminton players and non-badminton players wong zhen feng,1 hermawan nagar rasyid,2 juliati3 1faculty of medicine universitas padjadjaran, 2department of orthopedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: : shoulder pain is a common reason for patients to seek medical help in any healthcare center. shoulder pain is influenced by a few factors such as gender, posture during daily activities, aging and psychological factors. based on the study of epidemiology of injuries and prevention strategies in competitive swimmers, shoulder pain due to shoulder injuries can be reduced by strengthening the shoulder muscle. badminton has become one of the most popular sports in asia, especially in indonesia. this study was conducted to determine if badminton is able to strengthen the shoulder muscle group. methods: a cross-sectional analytic experimental study was conducted on september 2015 at lodaya badminton training center and bale padjadjaran of universitas padjadjaran. subjects were 30 healthy male routinely trained badminton players and 30 non-badminton players who voluntarily follow the rstudy procedures. strength measurement procedures were provided to the subjects after getting informed consent. data analysis was performed using t-test. results: the shoulder strength in routinely trained badminton players was significantly different from non-badminton players (p<0.05). conclusions: shoulder strength can be improved through routine training of badminton to reduce risk of shoulder injury. ] keywords: badminton players, shoulder pain, shoulder strength correspondence: wong zhen feng, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287726068299 email: wongzhenfeng26@gmail.com introduction the shoulder joint is a joint with the most mobility in our body at the cost of its stability.1 the bony structure of the shoulder joint is often described as the golf ball and tee structure.2 the humeral is the golf ball and it is four times bigger than the tee, which is the glenoid, and hence, possesses a higher risk of injury. according to the study conducted by schwarzkopf3 shoulder pain due to shoulder injuries has become a common complaint in healthcare centers. based on an article by hermoso4 there are a few factors that can cause shoulder pain: aging which causes muscle degeneration, gender as females are usually more prone to shoulder pain, and daily work posture. therefore, prevention of shoulder pain by strengthening the shoulder muscle is necessary for the population with high risk of shoulder pain. shoulder muscle strength training can improve shoulder health and reduce the risk of shoulder injury or shoulder pain.5 an article written by labriola6 reported that stronger shoulder muscles helps in maintaining the shoulder stability as the rotator cuff muscle group can help maintaining the stability of the glenohumeral joint. however, due to the improvement of technology, the younger generation prefer a more sedentary lifestyle. badminton is one of the most popular sports in asia, especially in indonesia. there are many reasons why badminton is popular, for example, it can improve physical and mental health, it has fairly low injury risks, it is easy to play, racquet used is very durable and most importantly, all ages can play this sport. badminton is a sport that requires high functionality of the shoulder, especially the movement and strength of the shoulder. this study was aimed to discover if playing amj. 2017;4(2):208–12 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n2.1083 209 althea medical journal. 2017;4(2) badminton can improve shoulder strength. methods this study was a cross sectional analytic experimental study with paired observation and was conducted in september 2015 at lodaya badminton training center and bale padjadjaran of universitas padjadjaran. the sampling technique used in this study was consecutive random sampling and the calculation used the analytical study of paired continuous variables (one sided). by using z-score of 1.96 and power of 1.00, the minimal sample required for this study was 60 subjects. the data was collected from two groups of participants. the first group was routinely trained badminton players with at least two times of badminton training sessions in a week from lodaya badminton training center, while the second group was nonbadminton players from bale padjadjaran of universitaspadjadjaran. the study was conducted after obtaining ethical clearance from the health reserach ethics committee faculty of medicine universitas padjadjaran according to clearance letter number 3003/ un6.c.c1/pp/2015. this study was performed to determine the difference of shoulder strength between routinely trained badminton players and nonbadminton players. furthermore, shoulder strength measurement procedure was explained to the subjects after getting inform consent agreement from the participants. the subjects were male because shoulder strength can differ in gender based on the study conducted by katolik.7 the subject’s age was ranged from 18–59 because the normal constant score were not significantly different among these age groups.7 the researcher also wanted to determine whether badminton exercises can decrease the speed of shoulder muscle strength degeneration in older people. then, subjects were chosen according to the inclusion and exclusion criteria. this study was a preliminary study; hence some criteria and methods in data collection were decided by the author based on his own experience in badminton. the inclusion criteria for this study were male badminton players of age range 18–59 years, routinely trained, and male individual with less than two times of badminton training sessions in a week. subjects from both groups should not be affected by current or previous shoulder injuries, and no current use of medication which t could influence the muscles strength. the exclusion criteria were female, physically and mentally dysfunction, had an upper limb injury such as carpaltunnel or tennis elbow injury, subjects were actively involved in overhead exercise such as baseball, tennis and handball and occupations that required heavy lifting. the apparatus used in the shoulder measurement was the baseline pull and push dynamometer, which can measure the muscle strength in kilograms or pounds. it has 2 ends, one side is push and one side is pull.8 to measure shoulder strength, subjects were asked to raise their dominant hand to 90 degree and the examiner used the baseline push and pull dynamometer to give pressure on the shoulder. subjects were asked to resist the force. the resistant of each subject was recorded based on the dynamometer reading as pounds. the sample size of this study was 30 routinely trained badminton players and 30 non-badminton players who voluntarily followed the study procedures. all the subjects met the inclusive and exclusive criteria before the selection. the mann-whitney test was conducted to check whether the age in these groups were normally distributed. next, independent t-test was performed to calculate the mean and standard deviation of shoulder strength between these groups. lastly, the regression test was conducted to determine whether there was a difference in shoulder strength between routinely trained badminton players and non-badminton players using the statistical package for social sciences. statistically significant result was considered when p<0.05. results there were 30 male routinely trained badminton players and 30 non-badminton players included in the study to determine whether there was a different of shoulder strength between these two groups. the p-value found using the mann-whitney test showed the age was not normally distributed. hence, age difference between these groups need to be controlled using regression test (table 1). the mean shoulder strength of routinely trained badminton players was higher than the mean shoulder strength of non-badminton players. the p-value for the difference of shoulder strength between routinely trained badminton players and non-badminton players was <5%, so the null hypothesis was rejected. however, the researcher found that wong zhen feng, hermawan nagar rasyid, juliati: comparison of shoulder strength in routinely trained badminton players and non-badminton players althea medical journal. 2017;4(2) 210 amj june 2017 table 1 total number and median (interquatile range) of age of routinely trained badminton players and non-badminton players group routinely trained badminton players non-badminton players p-value* number of subjects n=30 n=30 median (iqr)** age 45(13) 18(2) <0.001 note: *p value is found using mann-whitney test, **iqr is interquatile range table 2 comparison of shoulder strength in mean±standard deviation on routinely trained badminton players and non-badminton players routinely trained badminton players non-badminton players p-value* mean δ±sd** 56.65±6.78 44.29±4.82 0.011 note: *p value is found using independent t-test, **sd is standard deviation it was necessary to control the age since the age variance between these groups was large. hence, linear multiple regression test was performed to control the age difference between these groups (table 2). moreover, after controlling the age difference using multiple linear regression test, the strength difference between these groups was 11.45lbs and the p-value for the difference of shoulder strength between the routinely trained badminton players and non-badminton players was <5%, so null hypothesis was rejected (table 3). after controlling the age difference using the multiple linear regression test, the strength difference between these groups was 11.45lbs and the p value for the difference of shoulder strength between the routinely trained badminton players and non-badminton players was <5%, so null hypothesis was rejected. discussion shoulder pain is the third most common reason for the patient to seek for medical musculoskeletal consultation.9 shoulder pain can affect the ability of an individual to carry out daily activities. the quality of life will be significantly affected if an individual is unable to perform normal daily activities. thus, an individual is encouraged to carry out some prevention program such as shoulder strengthening exercises to increase their shoulder health. according to the study of ronai10 if a patient undergoes some conditioning programs that focus on the restoration of shoulder strength and flexibility of shoulder structure, it can enhance the shoulder function and health. the strengthening of core muscles table 3 comparison of shoulder strength between routinely trained badminton players and non-badminton players model unstandardized coefficients t p-value* 95 % confidence interval for b b std.error** lower bound upper bound (constant) 43.59 shoulder** strength 11.45 age 0.04 note: *p value is found using linear multiple regression test, **std.error is standard error, ***shoulder strength use pounds as unit 211 althea medical journal. 2017;4(2) wong zhen feng, hermawan nagar rasyid, juliati: comparison of shoulder strength in routinely trained badminton players and non-badminton players is an essential component in any injury prevention program.11 therefore, the shoulder strengthening exercise is an important factor for the subject to maintain healthy shoulders and reduce the risk of shoulder injuries. for example, the overhead barbell press exercises can be used to enhance shoulder function and stability.12 badminton is one of the commonly played sports in the community and it uses a lot of overhead movements of the upper limb. it is considered as an endurance training to improve the cardiovascular system health. a study performed by silvennoinen13 stated that endurance exercises can increase the muscular strength by promoting the release of pgc-1 alpha. pgc-1 alpha is used as a marker for mitochondria biogenesis after exercise. therefore, badminton is suitable for an individual to improve shoulder strength. the results showed that there were significant differences between the routinely trained badminton players and nonbadminton players. the null hypothesis of routinely trained badminton players had the same shoulder strength with non-badminton players was rejected as the p value <0.05. furthermore, the median age of the routinely trained badminton players was significantly higher than the non-badminton players. based on this, the examiner found that although the median age of the routinely trained badminton players was older than of the non-badminton players, the result of strength measurement was still higher in the routinely trained badminton players (table 1). thus, badminton exercises can strengthen shoulder muscles inspite of aging, where muscle function is greatly decreased.14 the non-badminton players median age was 18 years old and yet their shoulder strength was lower than the active routinely trained badminton players, hence possessing a higher risk of injury since their shoulder strength was lower than the routinely trained badminton players. additionally, the mean shoulder strength of routinely trained badminton players was higher than the shoulder strength of nonbadminton players. however, even though the results was significant when p<0.05, however, the researcher refused to analyze the data in the table since the age was not yet a control factor (table 2). moreover, this study found that badminton exercises were able to strengthen the shoulder muscle and therefore, could maintain healthy shoulders. based on a research by labriola6 it showed that shoulder muscle strength can help to maintain the stability of shoulder joint especially the rotator cuff muscle group, which is an effective compressor of glenohumeral joint. thus, the results showed clearly that routinely trained badminton group had a healthier shoulder muscle group. there are two limitations in the study. firstly, this study only measured the dominant hand of the subjects as it was commonly used in routinely trained badminton players. however, it was tried to exclude all possible confounding factors such as heavy lifting, hence ensuring that increase in muscle strength was only due to badminton training. secondly, the study only tested male subjects. further studies should be conducted to test whether other overhead exercises such as tennis and baseball can strengthen the shoulder muscle. in conclusion, even though badminton can improve shoulder strength; over-practicing the sports can cause injuries, such as microtrauma stress instead.15 hence, with proper amount and duration of badminton training, a person’s shoulder strength can be improved and risk of shoulder injury can be reduced. thus, with these positive results, we can suggest the community to join badminton activities since it can help maintain shoulder health and reduce the risk of shoulder injury. references 1. wilk ke, macrina lc, reinold mm. nonoperative rehabilitation for traumatic and atraumatic glenohumeral instability. n am j sports phys ther. 2006;1(1):16–31. 2. dumont gd, russell rd, robertson wj. anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. curr rev musculoskelet med. 2011;4(4):200–7. 3. schwarzkopf r, oron a, loebenberg m. [shoulder pain: assessment, diagnosis and treatment of common problems]. harefuah. 2008;147(1):71–6, 93. 4. hermoso fe, calvo e. shoulder pain in the elderly. aging health. 2009;5(5):711–8. 5. niederbracht y, shim al, sloniger ma, paternostro-bayles m, short th. effects of a shoulder injury prevention strength training program on eccentric external rotator muscle strength and glenohumeral joint imbalance in female overhead activity athletes. j strength cond res. 2008;22(1):140–5. 6. labriola je, lee tq, debski re, mcmahon pj. stability and instability of the glenohumeral joint: the role of althea medical journal. 2017;4(2) 212 amj june 2017 shoulder muscles. j shoulder elbow surg. 2005;14(1):s32–8. 7. katolik li, romeo aa, cole bj, verma nn, hayden jk, bach br. normalization of the constant score. j shoulder elbow surg. 2005;14(3):279–85. 8. maayah mf, al-jarrah md, el zahrani ss, alzahrani ah, ahmedv et, abdel-aziem aa, et al. test-retest strength reliability of the electronic push/pull dynamometer (eppd) in the measurement of the quadriceps and hamstring muscles on a new chair. open journal of internal medicine. 2012;2(2):123–8. 9. mitchell c, adebajo a, hay e, carr a. shoulder pain: diagnosis and management in primary care. bmj. 2005;331(7525):1124–8. 10. ronai p. exercise modifications and strategies to enhance shoulder function. strength and conditioning journal. 2005;27(4):36–45. 11. wanivenhaus f, fox ajs, chaudhury s, rodeo sa. epidemiology of injuries and prevention strategies in competitive swimmers. sports health. 2012;4(3):246– 51. 12. mckean mr, burkett bj. overhead shoulder press – in-front of the head or behind the head?. journal of sport and health science. 2015;4(3):250–7. 13. silvennoinen m, ahtiainen jp, hulmi jj, pekkala s, taipale rs, nindl bc, et al. pgc-1 isoforms and their target genes are expressed differently in human skeletal muscle following resistance and endurance exercise. physiological reports. 2015;3(10):e12563. 14. eibich p, buchmann n, kroh m, wagner gg, steinhagen-thiessen e, demuth i, et al. exercise at different ages and appendicular lean mass and strength in later life: results from the berlin aging study ii. j gerontol a biol sci med sc. 2015;00(00):6. 15. reinold mm, curtis as. microinstability of the shoulder in the overhead athlete. int j sports phys ther. 2013;8(5):601–16. althea medical journal. 2017;4(3) 345 characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital oldi caesario,1 shinta fitri boesoirie,2 alwin tahid3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: maxillofacial fracture is a serious injury in the head region which is frequently found in the emergency room. in indonesia, the road traffic accident is the main etiology. epidemiological assessments are important to assess trends and set the priorities for treatment and prevention of the injury. this study was conducted to identify the characteristics of maxillofacial fracture resulting from road traffic accidents. methods: this descriptive retrospective study involved hospitalized patients with maxillofacial fracture resulting from road traffic accidents at dr. hasan sadikin general hospital in 2011–2013 using the total sampling technique. data were collected in the period august–october 2014 which included patient demographics, detailed description of the accident and the fracture. results: a total of 187 patients with male/female ratio of 5:1 and a mean age of 26.78 year. the majority of patients were motorcyclists (92%) with most of them were not wearing safety equipment. most of the accidents took place in 2011 in bandung. mandible was the most common site of injury followed by the maxilla and nasal bone. open reduction was performed in 69.52% patients). conclusions: maxillofacial fracture is more common in men with the mean age of 26.78 years. the majority of patients are motorcyclists. most of them are not using safety equipment. most of the accidents occurred in bandung in 2011. mandible is the most common site of fracture. open reduction is the most commonly performed treatment. keywords: head injury, maxillofacial fracture, road traffic accident. correspondence: oldi caesario, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: oldi.caesario@gmail.com introduction maxillofacial fracture is a serious injury in the head region which is frequently found in the emergency room.1 the maxillofacial region is more vulnerable to fractures because it is the most exposed part of the body.1 besides maxillofacial fracture still becomes a serious clinical problem because of its specific anatomical area, where the important organs such as respiratory, neurologic, and digestive system are located.2 a study in uganda2 stated that 20% of maxillofacial fracture patients have cranio-cerebral injury. it also can affect the patient’s quality of life, such as the psychological and esthetical aspect.2 the etiology of maxillofacial fractures are road traffic accident, assault, fall, sport injury, domestic violence, and other.1,3,4 in developing countries, road traffic accident is still the main etiologic factor of maxillofacial fractures. in indonesia5 especially west java, 84.2% cases of maxillofacial fracture are caused by road traffic accidents. a road traffic accident is caused by many factors. human factor is one of the main reasons for traffic accidents. driving while sleepy, fatigue, at inappropriate speed, or without using protective gears (such as helmet and safety belts) and poor compliance to traffic laws are examples of human factors contributing to road traffic accidents. the development of roads and other transport infrastructures which did not keep up with the rapid pace of increase in the number of vehicles also contributes to road traffic accidents.6 amj. 2017;4(3):345–52 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1179 althea medical journal. 2017;4(3) 346 amj september 2017 epidemiological assessments are important to assess trends and set the priorities of treatment protocols and prevention programs against the injury.7 the aim of this study was to identify the frequency and characteristics of patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital. methods population of the study were patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital. the subjects of the study were hospitalized patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital in the period 2011–2013. the inclusion criteria were hospitalized patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital in the period 2011–2013. this study excluded patients whose detailed data were not completed in the medical record such as identity, type of fracture and the treatment. this study used total sampling as data collection method. this descriptive retrospective study was using the cross-sectional method. this study was conducted by using data in medical records of hospitalized patients with maxillofacial fractures resulting from road traffic accidents treated in otorhinolaryngology-head and neck surgery department, oral and maxillofacial surgery department, plastic surgery department and neurosurgery department at dr. hasan sadikin general hospital in the period 2011–2013. data were collected between august and october 2014. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran and dr. hasan sadikin general hospital, bandung. the collected data included patient’s identification and demographic features, detailed description of the accident (time and location of accident, role of patient in vehicle, the vehicle and safety equipment used), detailed description of the injury (type of fracture, treatment of the fracture and location of concomitant injury). information of patient identification and demographic features were obtained from the identity form of the patient’s medical record. detailed data descriptions of the accident were obtained from the anamnesis written in the medical record. while data regarding the detailed description of the injury (type of fracture and location of concomitant injury) were obtained from the anamnesis, physical examination, and supportive examination written in the medical record. data concerning the treatment of the patient were collected from the information written in the medical record. the etiology of maxillofacial fractures was grouped into road traffic accidents and other causes. the time of accidents were grouped into year 2011, 2012 and 2013. the locations of accidents were grouped into bandung and outside bandung region. bandung region included bandung city, kabupaten bandung and kabupaten bandung barat (regencies), other than that was outside bandung region. the type of vehicles used by patients were grouped into pedicab, bus, car, bicycle, motorcycle, and truck. patients who did not have a description about the location of accident and type of vehicle were included into the no-details group. the roles of patient who used vehicles were grouped into driver and passenger. the safety equipments used by the patient at the time of accident were classified into using the safety equipment, were not using the safety equipment and have no-details group. the injuries which patients suffered were grouped into maxillary fracture, mandible fracture, nasal fracture, orbital fracture, frontal sinus fracture, zygoma fracture, and multiple maxillofacial fractures. the mandibular fractures were grouped by their anatomical location into angular, condyle, coronoid, corpus, parasymphysis, ramus, symphysis, and subcondyle. the maxilla fractures were grouped into unilateral fracture and le fort classification. in addition patients having a combination of more than one type of isolated maxillofacial fractures were grouped into multiple maxillofacial fractures. the treatment of fractures were classified into open reduction, closed reduction, conservation, and refused treatment. all data obtained were input using the microsoft excel 2007 program. the data analysis was conducted using descriptive statistics, while statistical software was used for statistical analysis. results the total data obtained in this study was 368, but only 211 cases with maxillofacial fractures were treated at dr. hasan sadikin general hospital bandung, in the period january 2011 althea medical journal. 2017;4(3) 347oldi caesario, shinta fitri boesoirie, alwin tahid: characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital table 1 demographic characteristics of maxillofacial fracture characteristics frequency percentage (%) etiology 211 road traffic accident 187 88.63 other 24 11.37 sex 187 male 156 83.4 female 31 16.6 age mean+sd = 26.78+11.64years median = 24 years mode = 17 years range = 5–70 years time of accident 187 2011 88 47.1 2012 55 29.4 2013 44 23.5 location of accident 187 bandung region 110 58.8 outside bandung region 72 38.5 no details 5 2.7 type of vehicle used 187 pedicab 0 0 bus 2 1.1 car 5 2.7 bicycle 1 0.5 motorcycle 172 92 pedestrian 6 3.2 truck 0 0 no details 1 0.5 role of patient 180 driver 158 92.94 bicycle 1 bus 0 car 4 motorcycle 153 passenger 22 7.06 bicycle 0 bus 2 car 1 motorcycle 19 althea medical journal. 2017;4(3) 348 amj september 2017 to december 2013. out of the 211 cases, only 187 cases (88.63%) met the inclusion criteria and 24 cases (11.37%) resulted from other causes such as interpersonal violence, sport injury, work injury, falls, etc. there were 156 (83.4%) males and 31 (16.6%) females, causing a male to female ratio of approximately 5:1 and an age range from 5–70 years (mean = 26.78 years; sd = 11.64 years) (table 1). the distribution of patients with maxillofacial fractures resulting from traffic accidents according to the time of accident revealed that most accidents occurred in 2011 (88 patients, 47.1%) and least in 2013 (44 patients, 23.5%). the distribution according to the location of the accidents revealed that most accidents occurred in bandung region (110 patients, 58.8%). based on the statistics of patients with the type of vehicle used showed most of the patients were using a motorcycle at the time of the traffic accident, causing maxillofacial fractures (172 patients, 92%). while other patients were using car, bus, bicycle, or were table 2 distribution of the type of vehicle and the safety equipment used type of vehicle safety equipment used totalusing not using no details f % f % f % car 0 0 4 80 1 20 5 motorcycle 84 48.8 81 47.1 7 4.1 172 total 84 47.5 85 48 8 4.5 177 table 3 types of maxillofacial fracture type of fracture frequency percentage (%) maxillary 21 11.2 unilateral 7 33.3 le fort i 5 23.8 le fort ii 7 33.3 le fort iii 2 9.5 mandibular* 89 47.6 angular 20 16.95 condyle 11 9.32 coronoid 1 0.85 corpus 17 14.41 parasymphysis 48 40.68 ramus 2 1.7 symphysis 15 12.71 subcondyle 4 3.39 nasal bone 15 8 orbital 4 2.1 frontal sinus 4 2.1 zygoma 8 4.3 multiple fracture 46 24.6 total 187 100 note: * more than one type can be present for each patient althea medical journal. 2017;4(3) 349 pedestrians. furthermore, the statistics of patients with reference to their role in using a vehicle revealed that the majority of patients were motorcycle drivers (153 patients), followed by motorcycle passengers (19 patients), and car drivers (4 patients) (table 1). the distribution of type of vehicle according to the safety equipment used by maxillofacial fracture patients revealed, most of the patients who used a motorcycle at the time of accident were not wearing safety equipment (85 patients, 48%). there were no data available in the patient’s medical record regarding the safety equipment worn by patients who were using a bycicle and bus (table 2). the distribution of patients with maxillofacial fracture resulting from road traffic accidents according to the type of fracture showed that the multiple maxillofacial fracture is the combination of more than one type of isolated maxillofacial fractures. the most common site of fractures were mandible (89 patients–47.6%), maxilla (21 patients–11.2%), and nasal (15 patients–8%) (table 3). the distribution of the type of maxillofacial fracture in multiple maxillofacial fracture patients revealed that the common sites of fractures were mandible, maxilla, nasal and zygoma (table 4). the statistics of patients in relation to the treatment of maxillofacial fractures showed that open reduction was performed in 69.52% of patients, while 10.6% of patients had close reduction (table 5). discussion in this study, road traffic accident was the main etiology of maxillofacial fractures compared to other factors. this result was in accordance with the study conducted by adeyemo et al.1 in nigeria and leles et al.7 in brazil which showed most patients with maxillofacial fractures resulted from road traffic accidents, however it was inconsistent with a similar study conducted by pham-dang et al.4 in france that showed interpersonal violence as the main cause of maxillofacial fracture. the study conducted in azerbaijan8 stated that the road traffic accident is still the main reason for maxillofacial fractures ,due to the rapid increase in the number and type of vehicle and table 4 distribution of multiple maxillofacial fractures type of fracture* frequency maxillary 24 unilateral 11 le fort i 3 le fort ii 9 le fort iii 6 mandibular 25 angular 1 condyle 4 coronoid 0 corpus 3 parasymphysis 13 ramus 1 symphysis 6 subcondyle 1 nasal bone 20 orbital 16 frontal 12 zygoma 20 note: * more than one type can be present for each patient oldi caesario, shinta fitri boesoirie, alwin tahid: characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital althea medical journal. 2017;4(3) 350 amj september 2017 along with poor driver’s compliance with the traffic law. this study exhibited that most of the patients were males. more males were involved in maxillofacial fractures than females which were in accordance with other previous international studies.3,7,9,10 the predominance of male patients could be due to the fact that males are the breadwinner of the family and mostly work outdoors, consequently have a high risk to road traffic accidents. even though in past decades, there is an increase in the prevalence of female patients especially of those aged below 40 years due to changes in their social behavior, for example their participation in non-domestic work. cultural and socioeconomic factors of certain regions determine the prevalence of male to female ratio of maxillofacial fracture patients.7 in countries where women are extensively active in social activities such as in brazil7, the male to female ratio is 3:1. on the other hand, in the united arab emirates10 the male to female ratio is 7:1, due to the fact that mostly men are working outdoors and few women are driving vehicles. the mean age of the subjects in this study was 26.78 year with most cases below the age of 24 years. these results are consistent with the study conducted by leles et al.7 in the brazil which showed that 32.3% of the patients are in the age group of 21–30 years. other international studies also had similar results with this study. this was possibly due to their behavioral changes into independent individuals, high mobility, careless driving on the roads and economically active segment of society. on the other hand, in this age group, their compliance to the traffic law is poor and their inexperience in driving.1,2,7,9-11 the frequency of maxillofacial fracture resulting from road traffic accidents in this study steadily decreased from year to year. whilst a study conducted in kenya11 had similar results. there is a decrease in the number of maxillofacial trauma resulting from road traffic accidents in 2004 compared to 2003. it might be due to an increase of awareness among the road users about the importance of compliance to the traffic law including wearing safety equipment while driving. according to the location of the traffic accident, more traffic accidents occurred in bandung region than outside bandung region. nevertheless, there was no other study concerning the location of road traffic accidents which caused maxillofacial fractures in west java. our results demonstrated that the maxillofacial fractures resulting from traffic accidents were most common in the group of patients who were using motorcycle as their table 5 distribution of treatment of fractures characteristics frequency percentage (%) concomitant injury 187 upper extremity injury 4 2.1 lower extremity injury 6 3.2 ocular injury 1 0.5 mild head injury 59 31.6 moderate head injury 7 3.7 severe head injury 0 0 thorax injury 3 1.6 abdominal injury 0 0 multiple injury 7 3.7 without injury 100 53.5 treatment of fracture 187 open reduction 130 69.52 close reduction 20 10.7 conservative 7 3.74 refuse treatment 30 16.04 althea medical journal. 2017;4(3) 351 vehicle when the accident occurred. based on the role of the patients with vehicles, most of the subjects were motorcycle drivers followed by motorcycle passengers and next, car drivers. it is in accordance with the study conducted by leles et al.7 in brazil which showed 41.32% of patients are motorcyclist. it can be explained by the fact that in indonesia, the prevalent number of people is using a motorcycle as means of transport. it was proven by data from statistic indonesia (badan pusat statistik, bps) that showed in 2012 motorcycle is the most common used vehicle in indonesia.13 it occupied 80.95% of all vehicle transport in indonesia; however, this result was different with the study conducted by akama et al.11 in kenya that showed most of the subjects are 72.5% pedestrians. furthermore, most of the maxillofacial fracture patients in this study were not wearing safety equipment such as safety belts and helmets. however the number was not significantly different with the subjects who were wearing safety equipment, indicating that the compliance of road users for wearing safety equipment was still low. this study result is lower than another study result in malaysia12, which reported 60% of motorcyclist are wearing helmets. however, it is higher than in the study conducted by oginni et al.14 which showed only 3% patients are wearing helmets. the application of safety equipment by the vehicle users was important. data showed that there was a significant decrease in the occurrence of road traffic accidents in developed countries after the enforcement of the traffic law. the best protection against injuries as indicated by vehicle accident statistics includes safety awareness and a personal commitment to ride safely all the time. another study showed that the usage of safety belts can reduce 42% of fatalities, while the motorcyclist who are not wearing helmets are five times more likely to have severe head injury.7,11 in this study, mandible fracture was the most common type of maxillofacial fracture. this agrees with the result of a study from al khateeb10 in united arab emirates (uae). the locations of mandible fractures in this study were more common in the parasymphysis and corpus region. the study conducted by leles et al.7 in brazil revealed that the most common affected region was condyle of the mandible. the tendency is due to the prominence of mandible and is the only movable bone in the maxillofacial region.9 whilst a different study revealed that the most affected region of maxillofacial fractures are nasal and zygomatic-orbital complex.7 this study showed that more patients received open reduction as their fracture treatment than others, which was also reported elsewhere.4 contrary, this study results was different with the study conducted by adriane2 in uganda which showed that most of the fracture patients are performed by closed reduction. in uganda2, it is due to the cost of open reduction and the scarce of plates and theater space to perform the procedure. this study concluded that maxillofacial fractures resulting from road traffic accidents are more common in male than in female patients. the mean age of the patient is 26.78 years. the highest prevalence of fracture occurs in the bandung region, in 2011. the majority of patients are motorcycle drivers, followed by motorcycle passengers, pedestrians, car drivers, and car passengers, respectively and most of them are not wearing protective equipment. the frequent type of maxillofacial fracture resulting from road traffic accidents includes mandibular fracture, maxillary fracture, and nasal bone fracture. open reductions are more frequently performed than close reductions or conservative methods. the limitations of study are mainly caused by the high number of incomplete data on the patient medical records regarding to the variable seek in this study. improvements of the medical record system including the registry and storage system are highly recommended. references 1. adeyemo wl, ladeinde al, ogunlewe mo, james o. trends and characteristics of oral and maxillofacial injuries in nigeria: a review of the literature. head face med. 2005;1:7. 2. kamulegeya a, lakor f, kabenge k. oral maxillofacial fractures seen at a ugandan tertiary hospital: a six-month prospective study. clinics (sao paulo, brazil). 2009;64(9):843–8. 3. alves ls, aragao i, sousa mj, gomes e. pattern of maxillofacial fractures in severe multiple trauma patients: a 7-year prospective study. braz dent j. 2014;25(6):561–4. 4. pham-dang n, barthelemy i, orliaguet t, artola a, mondie jm, dallel r. etiology, distribution, treatment modalities and complications of maxillofacial fractures. med oral patol oral cir bucal. 2014;19(3):e261–9. oldi caesario, shinta fitri boesoirie, alwin tahid: characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital althea medical journal. 2017;4(3) 352 amj september 2017 5. daniel angel laura, syamsudin endang, fathurrahman. characteristics of maxillofacial fractures in hasan sadikin hospital within period 2009–2011. proceeding of the international symposium on oral and dental sciences; 2012 march 1–3; yogyakarta. yogyakarta: faculty of dentistry universitas gajah mada; 2013. 6. peden m, scurfield r, sleet d, mohan d, hyder aa, jarawan e, et al., editors. world report on road traffic injury prevention. geneva: world health organization; 2004. 7. leles jl, dos santos ej, jorge fd, da silva et, leles cr. risk factors for maxillofacial injuries in a brazilian emergency hospital sample. j appl oral sci. 2010;18(1):23–9. 8. hasanova gf. maxillofacial injuries resulting from road traffic accidents. ліки україни. 2014;2(178):22–3. 9. maliska mcd, marcia b, luciana a, de moraes m, moreira rwf. oral and maxillofacial surgery-helmet and maxillofacial trauma: a 10-year retrospective study. braz j oral sci. 2012;11(2):125–9. 10. al-khateeb t, abdullah fm. craniomaxillofacial injuries in the united arab emirates: a retrospective study. j oral maxillofac surg. 2007;65(6):1094–101. 11. akama mk, chindia ml, macigo fg, guthua sw. pattern of maxillofacial and associated injuries in road traffic accidents. east afr med j. 2007;84(6):287–95. 12. ramli r, abdul rahman r, abdul rahman n, abdul karim f, krsna rajandram r, mohamad ms, et al. pattern of maxillofacial injuries in motorcyclists in malaysia. j craniof surg. 2008;19(2):316–21. 13. badan pusat statistik indonesia. produksi kendaraan bermotor dalam negeri (unit), 2008-2013. jakarta: badan pusat statistik indonesia; 2015. 14. oginni fo, ajike so, obuekwe on, fasola o. a prospective multicenter study of injury profile, severity and risk factors in 221 motorcycle-injured nigerian maxillofacial patients. traffic inj prev. 2009;10(1):70–5. althea medical journal. 2017;4(3) 375 knowledge, attitude and practice towards human immunodeficiency virus infection among university freshmen students year 2016/2017 hervina agustinawaty,1 bony wiem lestari,2 rudi wisaksana3 1faculty of medicine, universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: human immunodeficiency virus (hiv) infection is one of the most serious public health and social problems in the world. transmission of hiv occurs in the age group of 20 years or below. one of the ways to prevent hiv transmission is to improve the knowledge so the attitude and practice can be changed. the objectives of this study was to identify the knowledge, attitude, and practice of hiv infection among university freshmen students year 2016/2017. methods: this was a descriptive cross sectional quantitative study. samples were selected using proportional random sampling and primary data were collected using questionnaires which were self-completed by 122 universitas padjadjaran freshmen students year 2016/2017 in november 2016. questionnaire consisted of sociodemographic, knowledge, attitude, and practice data regarding to hiv infection. the collected data was analyzed dan presented in the form of tables and figure. results: respondents had a median age criterion of 18 years, 52.5% were female, 73.8% high school originated outside bandung and 19.4% knew information about hiv/aids through the internet. there were 18.9% of the respondents classified as having “good” knowledge, 63.9% classified as “satisfactory” and the other 17.2% were classified as having “poor” knowledge of hiv. there were 52.5% respondents who had negative attitude towards hiv discussion and 96.7% of the respondents had good practice. conclusions: lack of knowledge and negative attitude towards hiv infection and the presence of high risk practice for hiv infection demanded that students should receive reproduction health education to support the prevention of hiv infection. keywords: attitude, hiv, knowledge, practice correspondence: hervina agustinawaty, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: hervinaagustinawaty@gmail.com introduction human immunodeficiency virus (hiv) infection continues to be a major global public health issue.1 according to the united nations program on hiv/aids (unaids), there were approximately 36.7 million people living with hiv at the end of 2016 with 1.8 million people becoming newly infected in 2016 globally.1 in indonesia, based on progress report of hiv-aids quarter 4 of 2015 by directorate general of disease control and environmental health, hiv infection and aids have spread in 407 out of 507 districts/cities in all provinces with a total of 30,935 cases and west java ranked fourth with most hiv cases among all provinces.2 acquired immune deficiency syndrome (aids) is most frequently found on people from age group 20-29 years with incidence rate of 31.8%; this result showed that hiv transmission most frequently occur on age group of <20 years.2 lack of correct health information and limited access to reproductive health service cause adolescents to be very prone towards hiv infection.3 preventive approaches become very important, especially through health education and health upgrading about hiv among young adults. with adequate knowledge and attitude, someone will behave well, hence avoid behavior that increase the risk of hiv/aids.4 based on these elaborations, the objectives of this study was to identify the knowledge, attitude and practice towards hiv amj.2017;4(3):374–81 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1184 althea medical journal. 2017;4(3) 376 amj september 2017 infection among university freshmen students of universitas padjadjaran (unpad) year 2016/2017. methods this was a descriptive cross-sectional study. this study had been permitted by health research ethics committee faculty of medicine universitas padjadjaran with letter number 651/un6.c1.3.2/kepk/pn/2016 and by rectorate of universitas padjadjaran with letter number 654/un6.baa/pp/2016. the study populations were students of universitas padjadjaran with estimated 27,983 students. the subjects in this study were freshmen students of universitas padjadjaran year 2016/2017 with estimated 6,148 students. samples were selected using proportional random sampling and sample size was determined using slovin formula with subject of 6,148 people and study precision of 9%, hence the required sample was 122. data collection was conducted on november 1–8, 2016 at jatinangor campus, universitas padjadjaran. inclusion criteria of this study were enrolled as new unpad student year 2016/2017, fluent in indonesian, and had agreed to sign informed consent form. exclusion criterion of this study was students who did not fill questionnaire completely. instrument used in this study was questionnaire that had been modified and revalidated from a previous study conducted in 2011 at ethiopia by shiferaw et al.5 alpha cronbach value from knowledge questionnaire validation result was 0.84 and 0.56 for attitude questions. questionnaire validation test was conducted on 30 freshmen students of universitas padjadjran year 2016/2017. study data used in this study were primary data collected by self-administered questionnaire by respondents. this questionnaire contained sociodemographic data of freshmen students including age, sex, high school origin, faculty and source of information about hiv/aids. knowledge questionnaire consisted of 20 questions with right or false options; aspect included knowledge about etiology, hiv transmission and early hiv symptoms. attitude questionnaire consisted of 10 questions with likert scale option (strongly agree, agree, doubtful, disagree, and strongly disagree); aspect included attitude of freshmen towards hiv transmission, attitude towards people with hiv infection and the need of program about prevention of hiv infection. practice questionnaire consisted of 5 questions with yes or no option; aspect included high risk behavior for hiv transmission. the collected data were processed and analyzed using computer statistic software, then presented in terms of tables and figures. numerical variables were presented in form of median data and minimum-maximum value. categorical variables were presented in distribution of frequency (n) and percentage (%). knowledge level of this study referred to interquartile range value; result score of >13 was classified as “good”, score of 7 – 13 was classified as “satisfactory” and score <7 was classified as “poor”. attitude of freshmen was classified as positive or negative attitude; if result score ≥ median score, respondents were considered having positive attitude and if result score < median, respondents were considered having negative attitude. practice was classified into good or bad behavior; if respondent answered yes to at least 1 question, the practice was considered bad. results the median age of the 122 respondents in this study was 18 years with 16 years the youngest and 20 years the oldest. there were 52.5% female respondents and 47.5% male, high school origin was mostly (73.8%) from outside bandung and 26.2% from bandung. all students had heard about hiv infection, 19.4% respondents had information about hiv infection from the internet and ranked second was teachers (18%) (table 1). the study discovered that 63.9% categorized into having “satisfactory” knowledge (table 2). almost all study respondents (99%) were able to answer correctly the cause of hiv. regarding the transmission of hiv, 87% answered that it can be transmitted through vaginal discharged and 69% through breast milk. less than half of study respondent were able to identify symptoms of hiv. all other aspects related to knowledge about hiv are presented in table 3. study result showed that more than half of the respondents had negative attitude (52.5%) towards hiv infection (table 2). the aspect attitude of respondents shown that 98.4% respondents agreed that promiscuity could increase the risk of contracting hiv/ aids. almost all respondents (98.4%) stated that they agreed that injected drug usage could increase risk of contracting hiv/aids. more than half of respondents (66.4%) agreed that students who were infected with hiv/ aids should continue their studies and 78.7% respondents would still be friends with hiv/ althea medical journal. 2017;4(3) 377 table 1 sociodemographic characteristic of unpad freshmen students year 2016/2017 subject characteristics frequency (n) percentage (%) age median, min-max (18, 16-20) years sex male 58 47.5 female 64 52.5 high school origin bandung 32 26.2 outside bandung 90 73.8 faculty law 9 7.4 economics and business 8 6.6 medicine 6 4.9 mathematics and natural sciences 15 12.3 agriculture 8 6.6 dentistry 4 3.3 social and political sciences 12 9.8 arts 15 12.3 psychology 3 2.5 animal husbandry 7 5.7 communication sciences 12 9.8 nursing 3 2.5 fishery and marine science 7 5.7 agricultural industrial technology 6 4.9 pharmacy 3 2.5 geological engineering 4 3.3 source of hiv/aids information teacher 90 18 parents 40 8 medical professionals 57 11.4 friends 65 13 newspaper 35 7 magazine 30 6 television 73 14.6 radio 13 2.6 internet 96 19.4 hervina agustinawaty, bony wiem lestari, rudi wisaksana: knowledge, attitude and practice towards human immunodeficiency virus infection among university freshmen students year 2016/2017 aids patients even it was their own close friend (figure). most respondents (96.7%) had good behavior and the rest (3.3%) stated that they had had sexual intercourse before wither with friend or date (table 2). no respondents stated that they had sexual intercourse with commercial sex workers, had same sex althea medical journal. 2017;4(3) 378 amj september 2017 intercourse and were injected-drug user. discussions this study revealed that the median age of freshmen is 18 years, this result is similar to a previous study in 2008 at africa-america by rose6 which stated that the mean age of freshmen students was 18 years. it is known from this study that the distribution of students showed that there were more female than male students. this could also be observed on a study in 2011 at gondar by shiferaw et al.5 most of study participants accessed information about hiv through the internet, just as shown on a study conducted in 2011 at china by tung et al.7 this result could be a consideration in choosing the suitable media to spread information about hiv. majority of the respondents had satisfactory knowledge which was similar satisfactory knowledge level was also shown on a study in 2016 at united arab emirates which described table 2 knowledge, attitude, and practice of unpad freshmen year 2016/2017 subject characteristics frequency (n) percentage (%) knowledge good 23 18.9 satisfactory 78 63.9 poor 21 17.2 attitude positive 58 47.5 negative 64 52.5 practice good 118 96.7 bad 4 3.3 figure attitude of unpad freshmen towards hiv year 2016/2017 althea medical journal. 2017;4(3) 379 that the knowledge level about hiv in students were below good.8 most freshmen had known that hiv was the cause of aids; more than half of the respondents had known that hiv could be found on breast milk and vaginal discharge, however, poor knowledge of the respondents thought that hiv was present on urine, saliva and feces. in terms of hiv transmission, not many of respondents had known that hiv was not transmitted via mosquito bite, just as found on a study conducted in 2008 at kazakhstan by hansson et al.9 that more than half of the study respondents had known this fact. inadequate understanding about early symptoms of hiv could be assessed from 9 questions, more than half of respondents were correct only on the question which stated that easy fatigability was one of the early symptoms of hiv, this result was similar with a previous study in 2011 at ethiopia by shiferaw et al.5 this result should attract attention; considering that most freshmen got information about hiv from the internet, it could be assumed that the truthfulness about information from the internet was doubtful. knowledge would affect the attitude of someone. this study revealed that more than half of the respondents stated negative attitude towards hiv. this result reflected previous study in 2016 at united arab emirates by haroun et al.8 stated that most of students had negative attitude towards hiv especially stigmatization towards people living with hiv/aids (plha). there were not many respondents who disagree that sexual intercourse using condom could prevent transmission of hiv/aids. this result is similar to a study in 2015 at ethiopia by kejela et al.10 which stated that there were respondents who disagree that condom could transmit hiv. most respondent had positive opinion that the transmission of hiv is not only occurred via sexual intercourse, but also by having sexual intercourse with multiple table 3 knowledge about hiv knowledge about hiv frequency n (%) hiv is caused by immunodeficiency virus 121 (99%) transmission of hiv urine 34 (28%) saliva 50 (41%) feces 57 (47%) tears 77 (64%) sweat 72 (59 %) vaginal discharge 106 (87%) breast milk 84 (69%) mosquito bite 75 (62) swimming together with hiv patiets 83 (68%) sneezing/coughing 71 (58%) symptoms of hiv flu symptoms for 3-6 weeks 45 (37%) chronic diarrhea 35 (29%) fever for 10 days 54 (44%) fungal infection/ candidiasi on oral cavity, throat, or genital 60 (49%) furuncles with red rash 29 (24%) frequent headache 35 (29%) purplish spots on skin that did not disappear 17 (14%) shortness of breath 27 (22%) always feel tired 80 (66%) hervina agustinawaty, bony wiem lestari, rudi wisaksana: knowledge, attitude and practice towards human immunodeficiency virus infection among university freshmen students year 2016/2017 althea medical journal. 2017;4(3) 380 amj september 2017 partners and injecting drug. however, more than half of respondents had positive opinion that students with hiv/aids infection could continue their education, not to be picked on and would stay friends with them. this result corresponded with a previous study conducted in 2014 at libreville by christiane et al.11 which stated that up to half of the respondents would stay friends with hiv patients and stated that hiv patients could continue their studies. some of the students stated that they had sexual intercourse with friend or date; similar to a research conducted in 2007 at china by tan et al.12 which stated that 37.2% of students had dates and had sex for the first time with their dates. the proportion of male who had sexual intercourse was bigger than female with percentage of 75% and 25% respectively. this pattern could also be found on a study conducted in 2013 at lao by thanavanh et al.13 which stated that this pattern could occurred because male played a more dominant role in terms of sexual activity. most of those students who had sexual intercourse before were freshmen from high school originated outside bandung. as found on a study in 2010 at china by cai et al.14 which stated that young people who lived far from their family had a big possibility to be free in having sexual intercourse. however, neither of the respondents admitted having sexual intercourse with commercial sex worker, same sex intercourse or people who inject drugs. the fact that neither of the students admitted the use of injected drug should be noticed in detail because this fact was probably due to the fear of students to be expelled from the university if they answered the question honestly even though data collection were emphasized to be anonymous and students had been assured that only the authors were the sole people who had access to this study. in terms of methodology, the sample size of this study only represents 2% of total population due to the short time span for the authors to collect data; this was the limitation of this study because probably on the population not present on this data could be a variation that might affect the result of this study considering the minimum sample size for a survey should be 20%. technically, there were some questions which were considered sensitive, hence it was considered to be ineffective if questionnaire-filling were conducted directly face-to-face with respondents; there could be a higher chance that the respondents would respond honestly if the questionnaires were to be filled online. it can be concluded that most students have satisfactory knowledge, but still lack of knowledge about hiv transmission and early hiv symptoms; this could affect the attitude of freshmen who mostly have negative attitude towards hiv, how the freshmen should behave to prevent high risk behavior for hiv transmission and stigmatization towards plha. it demands an upgrade in knowledge of freshmen about transmission of hiv and the proper behavior to prevent hiv infection and transmission. this preventive measure should have been applied even before continuing higher education in university, i.e. during middle school and high school to reduce the number of hiv cases which are currently increasing. a human touch could be added to support shift of stigmatization towards plha. references 1. who. fact sheets: hiv/aids. geneva: world health organization; 2016. [cited 2016 november 9]. available from: http:// www.who.int/mediacentre/factsheets/ fs360/en/ 2. kementrian kesehatan republik indonesia. final laporan perkembangan hiv aids triwulan 4. jakarta: pusat data dan informasi kementrian kesehatan republik indonesia; 2015. 3. chen pf. hiv/aids prevention among young people in east and south-east asia in the context of reproductive and sexual health. asia-pac popul j. 2008;23(1):7–28 . 4. barss p, grivna m, ganczak m, bernsen r, al-maskari f, agab h el, et al. effects of a rapid peer-based hiv/aids educational intervention on knowledge and attitudes of high school students in a high-income arab country. j acquir immune defic syndr. 2009;52(1):86–98. 5. shiferaw y, alemu a, girma a, getahun a, kassa a, gashaw a, et al. assessment of knowledge, attitude and risk behaviors towards hiv/aids and other sexual transmitted infection among preparatory students of gondar town, north west ethiopia. bmc res notes. 2011;4(1):505– 12. 6. rose ms. african american college freshman students’ knowledge, attitudes, beliefs, and behaviors related to hiv: a preliminary investigation. internet j allied health sci pract. 2008;6(3):1540–80. 7. tung w, hu j, thomas j, yu l, su w. hiv-related knowledge, attitudes and behaviours among college students althea medical journal. 2017;4(3) 381 in china. j assoc nurses aids care. 2011;71(5):606–16. 8. haroun d, el saleh o, wood l, mechli r, al marzouqi n, anouti s. assessing knowledge of, and attitudes to, hiv/aids among university students in the united arab emirates. plos one. 2016;11(2):1– 11. 9. hansson m, stockfelt l, urazalin m, ahlm c. hiv/aids awareness and risk behavior among students in semey, kazakhstan: a cross-sectional survey. bmc int health hum rights. 2008;8(14):1–10. 10. kejela g, soboka b. assessment of knowledge, attitude and preventive practices towards sexually transmitted infections among preparatory school students in shone town. j health med inform. 2015;6(1):1–6. 11. christiane na, roger zm, masika j, zhang y. hiv/aids prevalence, knowledge, attitudes and related behaviors among young people in libreville, gabon. iosr j hum soc sci. 2014;19(1):59–65. 12. tan x, pan j, zhou d, wang c, xie c. hiv/ aids knowledge, attitudes and behaviors assessment of chinese students: a questionnaire study. int j environ res public health. 2007;4(3):248–53. 13. thanavanh b, kasuya h, sakamoto j. knowledge, attitudes, and practices regarding hiv/aids among male high school students in lao people’s democratic republic. j int aids soc. 2013;16(1):1–7. 14. cai y, shi r, shen t, pei b, jiang x, ye x, et al. a study of hiv/aids related knowledge, attitude, and behaviors among female sex workers in shanghai china. bmc public health. 2010;10(1):377–84 hervina agustinawaty, bony wiem lestari, rudi wisaksana: knowledge, attitude and practice towards human immunodeficiency virus infection among university freshmen students year 2016/2017 vol 5 no 3 final.indd althea medical journal. 2018;5(3) 116 amj september 2018 visual acuity of four-wheeled public transport drivers in jatinangor feranika,1 reni farenia,2 nina ratnaningsih3 1faculty of medicine universitas padjadjaran bandung, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran bandung, indonesia, 3department of ophthalmology faculty of medicine universitas padjadjaran/cicendo eye hospital bandung, indonesia abstract background: the number of motor vehicles usage is increasing every year, along with the increasing prevalence of motor vehicle accidents, and mortality due to traffic accidents in 2010. the driver’s visual impairment is one factor that affects this phenomenon. in indonesia there are regulations regarding the minimum requirements for visual acuity in order to get a driving license. however, data of driver’s visual acuity have not been obtained yet. this study aimed to assess the public transport (angkot) driver’s visual acuity. thus, the regulation and evaluation of the minimum requirements for a driver’s visual acuity can be applied optimally. methods: this study used the categorical descriptive method with cross sectional design to assess visual acuity for four-wheeled motor vehicle (angkot) drivers in jatinangor using raab e chart and pinhole. the variable that was described in this study was the visual acuity of 4-wheeled motor vehicle drivers in jatinangor. results:results showed 86.5% of drivers fulfilled the minimum requirements of visual acuity for driving. meanwhile, the rest did not fulfill the minimum requirements of visual acuity for driving. conclusions: most of the public transport drivers have already fulfilled the minimum requirement of visual acuity for driving. however the minimum requirement of visual acuity for drivers has not been implemented optimally since there were drivers who have not performed an eye examination when taking and extending their driving license. keywords: drivers, visual acuity, visual impairment correspondence: feranika, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: feranikafe@gmail.com introduction the number of motor vehicle usage in indonesia each year continues to rise followed by the increasing prevalence of traffic accidents in indonesia that reached 27.2% in year 2008.1 one of the influential factors in this phenomenon was the driver’s visual acuity which is not suitable for driving. the term’s application of visual acuity of the driver was an appropriate measure to resolve traffic problems caused by the condition of the driver’s eye health. this was reaffirmed by the chief of police of the republic of indonesia, and stated in terms of obtaining a driver’s license, number 9 in section 4 in 2012, which mentioned that health requirements are needed to get a driver’s license including physical and spiritual health. as for physical health, this meant including physical health or stature, hearing and vision. driver’s visual acuity was measured through visual acuity tests, color test, as well as visual fields.2 this study examined the visual acuity of four-wheeled public transport drivers in jatinangor. this study aimed to analyze the visual acuity of four-wheeled public transport drivers as one of the evaluation of the minimum requirement of visual acuity for drivers. methods this study used the descriptive method with cross sectional design, and was carried out on monday–tuesday, 28–29 october 2014 among four-wheeled public transport drivers at the padjadjaran clinic and shuttle bus station. this study was using primary data by performing amj. 2018;5(3):116–20 althea medical journal. 2018;5(3) 117 visual acuity examinations directly to drivers after obtaining approval from the concerned respondents, and data from questionnaires filled in by the respondents. the inclusion criteria in this study were the driver of a public transport vehicle for the routes of the terminal ranca mulya–tanjung sari–cileunyi. meanwhile, the exclusion criteria were the driver who had no driving license, with age less than 17 years or over 50 years, and who at the time of the examination was in an impaired consciousness condition and or suffered eyes’ inflammation liked red eyes and infection. samples were obtained by using the consecutive sampling method. the total number of samples that must be met was based on the formula for minimum descriptive categorical sample, enrolled in this study were 97 persons. the variables included in this study were visual acuity, age, gender, status of the eye examination when the driver’s license was taken and extended, the status for the use of glasses and eye complaints. the visual acuity examination was conducted by a staff member of ophthalmology and an eye specialist from cicendo eye hospital. the driver’s visual acuity in this study used the world health organization (who) categorization, namely normal vision, and impaired vision including mild, moderate, severe, and blindness. furthermore, the causes of visual impairment will be classified into refraction abnormalities and non-refraction abnormalities. this study was approved by the health research ethics committee of faculty of medicine, universitas padjadjaran. in order to appreciate the aspects of autonomy, the respondents would be provided information about the examination to be performed and were asked to fill out the sheet of informed consent in advance. after the eye examination was performed, the data would be concealed to ensure the privacy of the respondents. regarding the aspect of beneficence, the respondents would get benefits because they would know their visual acuity conditions, get a prescription for glasses when there was impairment due to refraction disorders and be given the facility to purchase glasses at a low table 1 characteristics of respondents variables number (n=52) percentage (%) gender male 52 100 female 0 0 age 17–39 years 28 53.8 40–50 years 24 46.2 status of eyeglasses yes 2 3.8 no 50 96.2 eye status examination when driver takes and extends the driving license yes 37 71.2 no 15 28.8 complaints of eye yes 16 30.7 tenderness 9 17.3 itchy 4 7.7 blurred away 2 3.8 watery eyes 1 1.9 no 36 69.3 feranika, reni farenia, nina ratnaningsih: visual acuity of four-wheeled public transport drivers in jatinangor althea medical journal. 2018;5(3) 118 amj september 2018 price from cicendo eye hospital. regarding the aspect of non-maleficence, visual acuity screening was carried out as best as possible by a standardized person, and respondents also would earn money for their time. regarding the aspect of justice, each of the respondents would get the same treatment by following the appropriate research procedures. results this study used primary data obtained by performing direct visual acuity examinations and interviewing respondents with questionnaires regarding their characteristics. moreover, visual acuity data were obtained from 52 samples. the majority of the respondents (86.5%) had normal visual acuity on the best eye which meant, they met the minimum requirement of visual acuity for driving. the rest had impaired visual acuity including mild and moderate visual impairment (table 2). furthermore, the percentage of normal eyes were 84.6% for the right eye and 86,5% for the left eye. the data showed, there were 8 right eyes and 7 left eyes with visual impairment (table 3). the results showed 8 drivers experienced visual impairment and after performing correction of the lens by using a pinhole. moreover, the eyes of 7 drivers increased to normal and the eye of one driver was in a blind condition (figure 1). regarding the left eye, all of the visual acuity increased to a normal vision after the correction was performed by using a pinhole. most of the respondents (87.5%) had visual impairment caused by refraction abnormalities such as myopia, combination of myopia and presbyopia and aphakia (table 4), and the rest were caused by traumatic cataract, which is a non-refractive error abnormality. discussion the result of this study showed that 100% of four-wheeled public transport drivers were men, which was similar to a study conducted by oladehinde et al.3 that the drivers of public transport are male. the results of this study showed the majority of public transport drivers were aged less than 40 years, comprising 28 people with a percentage of 53.8%. the data was different from the study conducted by ayanniyi et al.4, where the majority of driversare aged between 40–44 years. people 40 years of age and over need table 2 visual acuity of public transport drivers in jatinangor categories of visual acuity of the best eye with available correction (who) basic visual acuity number (n=52) percentage (%) normal 45 86.5 mild visual impairment 3 5.8 moderate visual impairment 4 7.7 severe visual impairment 0 0.0 blindness 0 0.0 table 3 visual acuity of each driver’s eye categories of visual acuity of each eye number right eye (%) left eye (%) normal 44 (84.6) 45 (86.5) mild visual impairment 3 (5.8) 3 (5.8) moderate visual impairment 4 (7.7) 1 (1.9) severe visual impairment 0 (0.0) 2 (3.9) blindness 1 (1.9) 1 (1.9) althea medical journal. 2018;5(3) 119feranika, reni farenia, nina ratnaningsih: visual acuity of four-wheeled public transport drivers in jatinangor the screening of eye condition because the cases of glaucoma, cataracts and age-related macular degeneration are frequent in this age.4 results of this study found that only 2 people were using eyeglasses. however, further examinations showed there were actually 8 persons who experienced visual impairment of whom 2 persons were using glasses but were not included among the drivers who were having visual impairment. furthermore, there were 16 people (30.7%) who had eye complaints including blurred vision when see from far distance, tender eyes, itchy eyes, and watery eyes. however, after the examinations, only 8 people had visual impairment and only 4 people among them had eye complaints. an overview of this study revealed that the application of the minimum requirement regulation of visual acuity for the driver has not yet been implemented optimally. there was still as many as 28.8% of drivers who did not perform the eye examination when they took and extended their driving license. this is similar to a study conducted in nigeria by oladehinde et al.3 where the majority of motor vehicle drivers (83.6%) never perform eye examinations when making a license. moreover, this study showed that there were still 13.5% of four-wheeled public transport drivers who did not fulfill the minimum requirements of visual acuity for driving. the driver’s visual impairment in this study was mostly caused by refraction abnormalities. refraction abnormalities occurring in this study were myopia, combination of myopia and presbyopia, and aphakia as might be seen from the increase of visual acuity after correction by using a pinhole. according to resnikoff et al.5, the global prevalence of refraction right eye left eye figure 1 visual acuity of drivers with visual impairment in each eye table 4 causes of visual impairment of drivers diagnosis number (n=8) percentage (%) refractive errors myopia 5 62.5 myopia & presbyopia combination 1 12.5 aphakia 1 12.5 non-refractive errors traumatic cataract 1 12.5 althea medical journal. 2018;5(3) 120 amj september 2018 abnormalities reached 1.1% at the age of 16–39 years. it was different from studies that included presbyopia in refractive errors while presbyopia, hyperopia and myopia were the most common ocular conditions found among the drivers. the uncorrected refractive error is a known cause of visual impairment and blindness, and can limit ability to drive.6-9 another study by schellini et al.10 also showed the main causes of low vision and blindness are uncorrected refractive errors, cataract, and retinal diseases. in addition, the impaired vision may also be due to a non-refractive cause, such as by traumatic cataract conditions that occurred in this study. refractive errors and cataract contributed to over 85% of presenting visual impairment and over 60% of who-defined visual impairment.11 in conclusion, there are still 13.5% of drivers who do not fulfill the minimum requirement of visual acuity for driving. the minimum requirement regulation of visual acuity for drivers has not been carried out with maximum effort because there were still 28.8% of drivers who have not taken the eye examination when they take and extend their driving license. limitations of this study were the unavailability of studies about the factors affecting the driver’s visual impairment. it can be suggested to the relevant institutions, like the indonesian national police and the department of transportation in indonesia to enhance implementation of the minimum visual acuity requirements. moreover, a further study should be conducted to another kind of driver with high risks such as the truck driver. references 1. badan pusat statistik. jumlah kecelakaan, korban mati, luka berat, luka ringan, dan kerugian materi yang diderita tahun 19922012. [2014 february 20]; available from: www.bps.go.id. 2. kepolisian negara republik indonesia. peraturan kepala kepolisian negara republik indonesia nomor 9 tahun 2012 tentang surat izin mengemudi; 2012. 3. oladehinde mk, adeoye ao, adegbehingbe bo, onakoya ao. visual functions of commercial drivers in relation to road accidents in nigeria. indian j occup environ med. 2007;11(2):71–5. 4. ayanniyi aa, chikwe ac. eye screening for automobile drivers: the need to make it mandatory eye test among automobile drivers. sudanese j public health. 2012;7(2):41–6. 5. resnikoff s, pascolini d, mariotti sp, pokharel gp. global magnitude of visual impairment caused by uncorrected refractive errors in 2004. bulletin of the world health organization; 2008;86(1):63–70. 6. ayanniyi aa, folorunso fn, adepoju fg. refractive ocular conditions and reasons for spectacles renewal in a resource-limited economy. biomed central ophthalmol. 2010;10(12):1–7. 7. patel i, west sk. presbyopia: prevalence, impact, and interventions. community eye health. 2007;20(63):40–1. 8. ayanniyi aa, adepoju fg, ayanniyi ro, morgan re. challenges, attitudes and practices of the spectacle wearers in a resource-limited economy. middle east afr j ophthalmol. 2010;17(1):83–7. 9. ayanniyi aa, fadamiro co. opinion of the patients on the free eye care intervention in a resource limited economy. asian j ophthalmol. 2009;11(2):91–5. 10. schellini sa, durkin sr, hoyama e, hirai f, cordeiro r, casson rj. et. al. prevalence and causes of visual impairment in a brazilian population: the botucatu eye study. biomed central ophthalmol. 2009;9(8):1–9. 11. onakpoya oh, adeoye ao, akinsola fb, adegbehingbe bo. prevalence of blindness and visual impairment in atakunmosa west local government area of southwestern nigeria. tanzan health res bull. 2007;9(2):126–31. vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 100 amj june 2019 quality of life of laryngeal carcinoma patients after total laryngectomy achmad prihadianto, yussy afriani dewi, agung dinasti permana department of otorhinolaryngology-head & neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia correspondence: achmad prihadianto, department of otorhinolaryngology-head & neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jl. pasteur 38 bandung, email: akmaleb20@gmail.com introduction laryngeal carcinoma is a malignancy in the larynx which affects the supraglottic, glottic, and subglottic regions.1 the therapeutic modalities of laryngeal carcinoma have developed, for example by surgery, radiation, chemotherapy, or a combination there of. in patients who have had total laryngectomy procedure, the ability of the larynx to produce sound will disappear, and adaptation to this situation is needed. on the other hand, swallowing and breathing process are also affected. therefore, treatment of laryngeal carcinoma has a major impact on physical, social, and physiological health that may change the quality of life.2 quality of life is one of the main concerns in the head and neck cancer treatment.3 it is important to evaluate the quality of life in patients who have total laryngectomy. quality of life is one of the main concerns of head and neck oncology. there are several questionnaires to assess the quality of life among patients after having surgery of the larynx, known as post laringectomy. short form 36 (sf-36) study questionnaire is used as a measurement tool to assess the quality of life of patients in general, whereas the european organization for research and treatment of cancer head and neck cancer quality of life questionnaire (eortc qlq-h & n35) measure a specific questionnaire to assess aspects of quality of life in patients with head and neck cancer. the combination of the two questionnaires is expected to better illustrate the quality of life in patients with head and neck cancer, especially can add more specific components of quality of life that are not found in the general questionnaire.5,6 this study aimed to determine the quality of life of laryngeal carcinoma patients after total laryngectomy, including all aspects related to laryngeal function in patients with laryngeal carcinoma. amj. 2019;6(2):100–6 abstract background: management of laryngeal carcinoma has been widely developed, either by surgery, radiotherapy, and/or chemotherapy. the treatment has a major impact on physical, social, and psychological health that can change the quality of life of patients. this study aimed to determine the quality of life of laryngeal carcinoma patients after total laryngectomy. methods: this descriptive study was conducted from may to august 2018. patients with post total laryngectomy at the division of ear, nose, throat, head and neck surgery, dr. hasan sadikin general hospital, bandung were recruited. short form 36 (sf-36) study questionnaire and the european organization for research and treatment of cancer head and neck cancer quality of life questionnaire (eortc qlq-h & n35) were used, and data were presented in the form of descriptive narratives and tables. results: in total, 23 patients were included consisting of 19 men (82.61%) and women (17.39%), aged 56-65 years old. the mean score of quality of life in physical components of sf-36 was 87.55 ± 2.35 and in mental components was 85.35 ± 3.92. the highest score of quality of life of eortc qlq-h & n35 on the speech problem scale was 51.69 ± 6.36. conclusion: the quality of life of laryngeal carcinoma patients after total laryngectomy is generally good, however, speech is the main problem and needs to be further elaborated to enhance the quality of life. keywords: laryngeal carcinoma, total laryngectomy, quality of life althea medical journal. 2019;6(2) 101 methods this descriptive study was conducted from mei to agustus 2018. all patients in that period with post total laryngectomy in the department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital, bandung were included. the inclusion criteria were patients with total laryngectomy within 3 months or more after radiotherapy without any other complications and comorbidities. ethical clearance was obtained from the ethical committee of dr. hasan sadikin general hospital. in brief, data was taken through the interviewing process using short form 36 (sf36) study questionnaire and the european organization for research and treatment of cancer head and neck cancer quality of life questionnaire (eortc qlq-h & n35). sf36 questionnaire consisted of 36 questions consisting of two major components, physical and mental components. physical components consist of physical health, activity restrictions due to physical health, body pain, and perceptions of general health. the mental componentconsists of activity restrictions due to emotional problems, vitality, mental health, and social function. the score of each question was numerical with a scale of 0-100. a score of 0 indicated a low health level and a score of 100 indicates the healthiest level. the scores were further averaged from the question that has the same dimensions.4,5 eortc qlq-h & n35 consists of 35 questions; divided into 7 major scales including pain, swallowing problems, sensory problems, speech problems, eating problem, social interaction, and sexual problems and 11 minor scales consisting of dental problems, mouth opening problems, dry mouth thick spit, cough, feeling sick, use of pain killer, use of nutritional supplements, use of nasogastric tube, weight loss, weight gain. the first questions were assessed on a 4 likert scale (never, rarely, enough, often) while the remaining 5 questions were assessed by a dichotomous scale (yes, no). the final score was interpreted in range of values from 0 to 100. the higher results indicated the increase in health problems and the decrease in the quality of life.6 the collected data were processed with a scoring system and analyzed through the statistical package for social sciences (spss) table 1 characteristics of research subjects variable amount (n=23) percentage (%) stage stage i stage ii stage iii 9 39.13 stage iv 14 60.86 gender male 19 82.61 female 4 17.39 age ≤ 45 years 1 4.35 46 – 55 years 3 13.04 56 – 65 years 15 65.22 ≥66 years 4 17.39 last education elementary school 1 4.35 junior high school 4 17.39 senior high school 16 69.57 university 2 8.70 achmad prihadianto et al.: quality of life of laryngeal carcinoma patients after total laryngectomy althea medical journal. 2019;6(2) 102 amj june 2019 program version 23.0. to assess the normality of the data, this study used shapiro-wilktest. univariate data analysis on categorical variables were used to see the proportion of each variable that would be presented descriptively, while the numeric variables were represented by mean, standard deviation, and median. data were presented in the form of descriptive narratives with tables and/or graphs. results in total, 23 post laryngectomy patients were included, consisting of patients with laryngeal carcinoma of stage iii (n 9; 39.13%) and stage iv (n 14; 60.86%) and the clinical characteristics of those patients were presented in table1. most of the patients were male (n 19; 82.61%), predominantly in the range age of 56-65 years old. the total score of the sf-36 questionnaire showed good result, consisting of a physical component with a mean score of 87.55+2.35 and mental component with a mean score of 85.35+3.92. scoring on the eortc qlq-h & n35 questionnaire had a range of values from 0 to 100. the higher results explained the increasing number of health problems and the quality of life of patients decrease. the highest scoring score was found in the speech problems, weight gain, use of nutritional supplements, use of painkiller, and coughing. a low score was observed on the scale of pain, swallowing problems, sensory problems, eating problems, social interactions, sexual problems, dental problems, problems with opening wide mouths, dry mouth, thick spit, use of the nasogastric tube and weight loss. the pain scale was lower but the pain killer consumption was quite high, possibly because patients used drug stalls. the average value of weight gain in patients with post laringectomy and radiotherapy interviewed using a questionnaire was 47.83 because no swallowing problem was observed in the patients. the average value of nutritional supplement use in patients interviewed used a questionnaire of 34.78 because patients were still taking nutritional supplements given by their closest family in hopes of better health. none of the patients had used the gastric tube. discussions this study was involving patients who underwent a total laryngectomy because of laryngeal carcinoma stage iii and iv. dr. hasan sadikin hospital is a level iii referral hospital, thus, the patients who come are mostly at an advanced stage. the definitive therapy for advanced cancer is a combination therapy of surgery with radiotherapy or chemoradiotherapy. the surgical options that can be done are transoral resection using a laser, partial laryngectomy, and total table 2 mean values of sf-36 components in patients with laryngeal carcinoma post total laryngectomy component mean±standard deviation physical component physical health 92.17±6.25 activity restrictions due to physical health 95.65±3.55 body pain 84.13±7.07 perceptions of general health 78.26±9.22 total score in the physical component 87.55±2.35 mental component activity restrictions due to emotional problems 86.96±11.50 vitality 81.52±2.50 mental health 84.87±7.69 social function 88.04±4.61 total score in the mental component 85.35±3.92 total score 86.5±2.99 althea medical journal. 2019;6(2) 103 laryngectomy. but in advanced stages, the only treatment is total laryngectomy. total laryngectomy is the gold standard for the treatment of advanced laryngeal cancer with large cartilage destruction, extra laryngeal extension, and treatment of recurrent laryngeal cancer after primary non-surgical treatment.7 conform another study, our study shows that the number of men is more than women.8 men are susceptible to laryngeal carcinoma due to several factors such as higher smoking habits and alcohol consumption.9 smoking is known as the highest risk factor (99%) occurrence of laryngeal carcinoma. smoking components, especially nitrosamines and polycyclic aromatic hydrocarbons act as carcinogens in the laryngeal epithelium, these components specifically cause mutations in dna and interfere with the normal cell division and proliferation process that triggers the mechanism of carcinogenesis. in addition to cigarettes, alcohol is also an important risk factor in the pathogenesis of laryngeal cancer. chronic inflammation of the laryngeal layer of ethanol can cause a series of mutations at the gene level that interferes with cell proliferation and increase carcinogenesis.10 older age is also a risk factor as confirmed in our study which is in the range of 56-65 years old. these results are in accordance with the study conducted elsewhere.12 the high number of malignancies in the elderly is caused by mutations that accumulate in the body resulting in less efficient deoxyribonucleic acid repair and reduced immune system that decreases defense against cancer cells. in the elderly, there is also the accumulation of cells undergoing the aging process and supporting the microenvironment of the development of cancer cells.12 furthermore, the education level of the study subjects varied from elementary school to university with the highest level of education being senior high school. the level of education can be used as an indicator of the patient’s socio-economic status. the majority of patients with laryngeal cancer are unemployed or unskilled workers. people with low socioeconomic levels tend to be more smoking and alcohol consumption, poor diet, lack of prevention strategies and poor table 3 mean values of eortc qlq-h & n35 in patients with laryngeal carcinoma after total laryngectomy scale mean standard deviation pain 5.43 9.27 swallowing problems 3.99 7.48 sensory problems 2.17 5.74 speech problems 51.69 6.36 eating problem 4.71 7.46 social interaction 9.28 11.50 sexual problems 0.72 3.48 dental problems 2.90 9.60 mouth opening problems 7.25 14.06 dry mouth 2.90 9.60 thick spit 7.25 14.06 cough 26.09 14.06 feeling sick 10.14 15.68 use of pain killer 26.09 44.90 use of nutritional supplements 34.78 48.70 use of nasogastric tube weight loss 8.70 28.81 weight gain 47.83 51.08 total score 13.99 15.72 achmad prihadianto et al.: quality of life of laryngeal carcinoma patients after total laryngectomy althea medical journal. 2019;6(2) 104 amj june 2019 sanitation and support high rates of laryngeal cancer in this population.13 based on the sf-36 questionnaire, our study shows that the quality of life of patients with laryngeal cancer who have undergone total laryngectomy is generally good, which includes the physical and mental components. this result confirms, that the sf-36 quality of life scores is generally good on all scales (> 60.5). the lowest average score on the sf-36 questionnaire is on the scale of perception of general health and the vitality scale. the quality of life, in general, is also affected by the quality of life of patients based on the functional capacity that changes due to illness. functionally, there are speech disorders, such as difficulty speaking, changes in sound quality, speechlessness, delay in the sound coming out and a hoarse voice when speaking. there are other physical symptoms, such as phlegm, difficulty swallowing, eating difficulties, neck muscle weakness, and fungal infections. psychologically, depression and regret can be found in patients undergoing laryngectomy.14 interestingly, the pain scale score in eortc qlq-h & n3 is low, which shows that most respondents do not complain of pain. to minimize bias, it is also necessary to pay attention to the scale of the use of the pain killer. in this study, the use of a pain killer is only found in a small portion (6 of 23 patients) which indicates that the possibility of postpain 3 months after surgery is no longer felt. the component that also affects the quality of life of patients after laryngectomy is sound. sound is one of the important components in communication which is the basic need of every human being in carrying out his life. communication has an important role so it must be considered to be one of the important things in managing patients.2 the largest average value is found on the scale of speech problems represented by three questions, such as hoarseness, whether there are difficulties in talking to other people, and whether there are difficulties in talking on the telephone. the results of this study are in line with the study conducted by akil et al.15 and dinescu et al.16 there is a significant change in voice after total laryngectomy, and patients may experience difficulties in speech problems because the laryngeal function of speech is completely lost. in post laringectomy patients have difficulty to communicate. medical rehabilitation therapy has been done and patients are expected to speak again even without the vocal cords. tracheo esophageal prosthesis (tep) is the most common way to restore speech after laryngectomy. sound prostheses are valves that make it possible to make sound by pushing air from the lungs through the valve and up to the mouth, using sound prostheses requires training and therapists.8 tracheo esophageal prosthesis cannot be used optimally in countries with low socioeconomic status due to the difficulty of accessing health services that can carry out periodic prosthesis changes. esophageal speech therapy (est) is a natural, reliable and cost-effective method that can be applied without other devices or prosthesis. esophageal speech therapy is a sound production method that involves esophageal oscillations, this is different from the production of sound in normal people who use vocal oscillations. the way to do est is to swallow air into the esophagus which causes the esophagus to vibrate and then release it by controlling it to create a sound that is used to produce speech.17 larynx plays a role in the process of swallowing so that the total laryngectomy procedure performed in patients with laryngeal carcinoma can also affect the ability to swallow. the radiation effect as adjuvant therapy can also contribute to the occurrence of dysphagia, dry mouth, and thick saliva. however, our study shows not many problems with swallowing, eating problems, problems opening wide mouths, dry mouth, and thick split. this is in line with the scale of using a feeding hose that no patient uses a feeding hose at all which shows the ability to swallow is still good, and thus it is estimated that food intake through the mouth is maintained well and no weight loss occurs. this result is also offset by an increase in body weight felt by some patients, in line with the study conducted by akil et al.15, showing that the scale of dry mouth and thick spit has a small score that indicates the small problem on that scale. radiation therapy triggered xerostomia. functional cells of the salivary gland such as excretory cells and acinar cells respond acutely to radiation. tissues with low mitotic speeds should not be sensitive to radiation. the granulation hypothesis states that secretory granule membranes in acinar cells undergo lipid peroxidation damage triggered by radiation, and as a result, proteolytic enzymes begin to leak causing cell lysis. another hypothesis states that at the beginning of radiation there is a disruption in cellular function due to damage to the selective membrane, disrupting signals that regulate water excretion, without being accompanied by cell death, while further damage is experienced due to the death of althea medical journal. 2019;6(2) 105achmad prihadianto et al.: quality of life of laryngeal carcinoma patients after total laryngectomy progenitor cells and stem cells. saliva function will continue to be disturbed for several months after radiotherapy. all patients should be encouraged to take an active role in the management of their xerostomia; so a daily mouth examination, checking for red, white, or dark patches, ulcers, or tooth decay, is highly recommended.19 dental problems are known to be a problem in patients with total laryngectomy.15 however, there is no dental problem found in the study or wide mouth opening problems, which are in accordance with other studies.16 the presence of sexual problems in laryngeal cancer patients after total laryngectomy occurs,15 due to decreased libido and due to decreased self-confidence, especially in women, however, some other studies show no sexuality problems.16,18 cough problem showed a good quality of life and showed no significant coughing problems. these results are also supported by studies conducted by akil et al.15 and dinescu et al.16 also reported the existence of cough problems experienced by patients after laryngectomy. the limitation of this study was there was no assessment of the quality of life before total laryngectomy was performed so that there was no known improvement in the quality of life before and after treatment in the form of total laryngectomy. as a conclusion, the quality of life in patients with laryngeal carcinoma after total laryngectomy in dr. hasan sadikin general hospital bandung is generally good based on the sf-36 generic questionnaire and eortc qlq-h & n35specific questionnaire for head and neck cancer. speech is the main problem and needs to be further elaborated to enhance the quality of life. references 1. kolegium ilmu kesehatan telinga hidung tenggorokan bedah kepala leher. modul utama onkologi kepala leher.: neoplasma laring, ii ed. jakarta: kolegium ilmu kesehatan telinga hidung tenggorokan bedah kepala leher;2015. 2. badwal js. quality of life following voice restoration with tracheoesophageal prosthesis after total laryngectomy. world journal of pharmaceutical and medical research. 2016;2(6):191–4. 3. mansour mmh, abdel-aziz m, saafan me, al-afandi hrm, darweesh m. voice, swallowing, and quality of life after management of laryngeal cancer with different treatment modalities. the egyptian journal of otolaryngology. 2016;32(1):37–44. 4. perwitasari da. development the validation of indonesian version of sf36 questionnaire in cancer disease. indonesian j pharm. 2012;23(4):248–53. 5. rand corporation. 36-item short form survey (sf-36) scoring instructions. california: rand corporation; 2009. 6. bjordal k, de graeff a, fayers pm, hammerlid e, van pottelsberghe c, curran d, et al. a 12 country field study of the eortc qlq-c30 (version 3.0) and the head and neck cancer specific module (eortc qlq-h&n35) in head and neck patients. eortc quality of life group. eurj cancer. 2000;36(14):1796–807. 7. sheahan p. management of advanced laryngeal cancer. rambam maimonides med j. 2014;5(2):e0015. 8. rossi vc, fernandes fl, ferreira ma, bento lr, pereira ps, chone ct. larynx cancer: quality of life and voice after treatment. braz j otorhinolaryngol. 2014;80(5):403– 8. 9. tawab hma, abd elmessih mw, alnaggar na, el sharkawy ls, . study of the epidemiology and management of laryngeal cancer in kasr al-aini hospital. the egyptian journal of otolaryngology. 2014;30(3):208–14. 10. cahyadi i, permana ad, dewi ya, aroeman na. karakteristik penderita karsinoma laring di departemen ilmu kesehatan telinga hidung tenggorok bedah kepala leher rumah sakit dr hasan sadikin bandung periode januari 2013–juli 2015. tunas medika jurnal kedokteran & kesehatan. 2016;3(1):39–42. 11. rahmaeni, kuhuwael f, rahardjo sp. validitas dan reliabilitas eortc qlqh&n35 sebagai alat ukur kualitas hidup penderita kanker kepala leher. orli. 2015;45(2):142–50. 12. putri sa, dewi ya, dewayani bm. risk factors of laryngeal carcinoma in otorhinolaryngology-head and neck division of dr. hasan sadikin hospital bandung. journal of medicine and health. 2018;2(2):715–21. 13. markou k, christoforidou a, karasmanis i, tsiropoulos g, triaridis s, constantinidis i, et al. laryngeal cancer: epidemiological data from νorthern greece and review of the literature. hippokratia. 2013;17(4): 313–8. 14. noonan bj, hegarty j. the impact of total althea medical journal. 2019;6(2) 106 amj june 2019 laryngectomy: the patient’s perspective. oncol nurs forum. 2010;37(3):293–301. 15. akil f, yollu u, toprak sf, ayral m. laryngectomy: what is the impact of the type of surgery on life quality and sexual function? acta otorhinolaringol ital. 2017;37(4):276–80. 16. dinescu fv, tiple c, chirila m, muresan r, drugan t, cosgarea m. evaluation of health-related quality of life with eortc qlq-30 and qlq-h&n35 in romanian laryngeal cancer patients. eur arch othorhinolaryngol. 2016;273(9):2735– 40. 17. sahin m, ogut mf, vardar r, kirazli t, engin ez, bor s. novel esophageal speech therapy method in total laryngectomized patients: biofeedback by intraesophageal impedance. dis esophagus. 2016;29(1):417. 18. akduman d, karaman m, uslu c, bilac o, turk o, deniz m, et al. larynx cancer treatment results: survive and quality of life assessment. kulak burun bogaz ihtis derg. 2010;20(1):25–32. 19. pinna r, campus g, cumbo e, mura i, milia e. xerostomia induced by radiotherapy: an overview of the physiopathology, clinical evidence, and management of the oral damage. ther clin risk manag. 2015;11:171–88. amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 31 significant relationship between overweight and hypertension in the elderly suwanda wahyudin,1 rudolf andean,2 lilik sukesi3 1faculty of medicine universitas padjadjaran, indonesia, 2departement of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: suwanda wahyudin, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, e-mail: suwandafkup2010@gmail.com introduction the prevalence of hypertension in indonesia is reported around 50% for the age group of 45−64 years old and 65% age group of above 65 years old.1 the primary hypertension cases are predominantly about 90−95% in the elderly, however, the etiology is still unknown.2 untreated hypertension may cause complications, including congestive heart failure, angina pectoris, encephalopathy, stroke, proteinuria, and renal impairment.3 one of the risk factors for hypertension is overweight.4 overweight is an excessive accumulation of fat in adipose tissue. the risk of hypertension in indonesia is increased by 2.15 fold in the overweight group compared with the underweight group.4 individuals who have a 20% increased of normal weight have a risk of hypertension 3−8 times higher compared to individuals with normal weight.5 the aim of this study was to investigate the relationship between overweight and hypertension in the elderly living in hegarmanah village. methods the study design was an analytic study with a cross-sectional approach, conducted from september to november 2013 in hegarmanah village, jatinangor, sumedang. the study included 100 elderly above 60 years old, selected by cluster sample technique. the exclusion criteria were elderly who could not sit on a chair and/or stood up when the examination was performed. after approving informed consent, body weight, height, and blood pressure were measured. the measurement of body weight was performed with a calibrated scale with a amj. 2020;7(1):31–4 abstract background: hypertension is one of the degenerative diseases that commonly occurs in the elderly, however, the etiology is still unclear. one of the risk factors is overweight. this study aimed to investigate the relationship between overweight and hypertension in the elderly living in hegarmanah village. methods: a cross-sectional analytic study was conducted from september to november 2013, including 100 elderly in hegarmanah village jatinangor, sumedang, using a cluster sample technique. the data of body weight, height, and blood pressure were obtained after informed consent. results: in total, 58 females and 42 males were included. the nutritional status was underweight (9%), normal (45%), overweight (31%), and obese (15%). hypertension among the elderly was normal (4%), prehypertension stage 1 (18%), hypertension stage ii (24%), and hypertension stage iii (54%). the hypertension was occurred in 43.6% non-overweight group and 56.4% in the overweight group, resulting in a significant relationship between overweight and hypertension in the elderly (p=0.001). conclusions: the high prevalence of hypertension among the elderly who were overweight suggests a better promotion in lifestyle control, a particularly nutritional program for the elderly to manage hypertension and its complication. keywords: elderly, hypertension, lifestyle, overweight https://doi.org/10.15850/amj.v7n1.1727 althea medical journal. 2020;7(1) 32 amj march 2020 capacity of 120 kg and an accuracy rate of 0.5 kg. height measurement was performed with a calibrated microtoise with the maximal length was 200 cm and the accuracy rate was 0.5 cm. body mass index (bmi) was calculated by dividing body weight (kg) by squared height (m2). the bmi was designated as underweight (<18.5), normal (18.5-24.9), overweight (2529.9) and obesity (>30). blood pressure measurement was performed by using a sphygmomanometer (mmhg) and a stethoscope. the respondents were asked to sit on a chair and relaxed before blood pressure measurement was taken twice. the second measurement was performed to finalize the result of blood pressure. there were four stages of high blood pressure or hypertension: stage i or prehypertension was 120/80 to 139/89; stage ii or mild hypertension was 140/90 to 159/99 and stage iii or moderate hypertension was 160/100 to 179/109. this study was approved by the health research ethics committee faculty of medicine, universitas padjadjaran. analysis of data was performed using a chi-square test. the results of p-value showed statistically significant if less than 0.05 (p <0.05), using software statistical product and service solution (spss) v. 15.0 results in total, females (58%) had participated in the study and most of them (87%) were in 60−74 age groups. the overweight elderly groups (bmi≥25 kg/m) were found in 46% of subjects, including obese (15%) and overweight (31%). hypertension cases were detected 78%, including hypertension stage 2 or mild hypertension (24%) and hypertension stage 3 or moderate hypertension (54%) as shown in table 1. in the non-overweight elderly group, 43.6% of hypertension cases were found. the chi-square test showed that there was a significant relationship between overweight and hypertension (p=0.001) with or 12 (table 2). table 1 characteristics of elderly living in hegarmanah, bandung variable n percentage (%) age; years old 60–74 87 87 75–89 11 11 ≥90 2 2 gender female 58 58 male 42 42 nutritional status underweight 9 9 normal 45 45 overweight 31 31 obese 15 15 hypertension normal 4 4 stage i prehypertension 18 18 stage ii mild hypertension 24 24 stage iii moderate hypertension 54 54 note: the nutritional status was designated as underweight (bmi <18.5), normal (bmi 18.5-24.9), overweight (bmi 25–29.9) and obesity (bmi >30). the hypertension was classified as stage 1 or prehypertension (120/80 to 139/89); stage 2 or mild hypertension (140/90 to 159/99) and stage 3 or moderate hypertension (160/100 to 179/109). althea medical journal. 2020;7(1) 33suwanda wahyudin et al.: significant relationship between overweight and hypertension in the elderly discussion in this study, most of the elderly livings in hegarmanah village have been found to have hypertension; with hypertension stage iii is being the most prevalent. previous studies have shown that the prevalence of hypertension in indonesia is 32.2% and particularly in west java is 29.4%, although in the general population of indonesia 76% is undiagnosed.4 the result in this study has detected higher hypertension cases in hegarmanah elderly. it might occur because of undiagnosed hypertension which is not reported to jatinangor primary health care center or puskesmas. the aging itself contribute to hypertension state which is caused by blood vessel damage, increasing smooth muscle cells, collagen deposit, and decreasing elastin, causing narrowed lumen and rigid blood vessel.6 in our study, 43.6% of hypertension cases are found in the non-overweight elderly group. this phenomenon could be explained by factors of blood pressure in the normal weight elderly, including monounsaturated fatty acid, saturated fatty acid, sodium intake, plasma total cholesterol level, the ratio of total cholesterol to high dense lipoprotein (hdl)-cholesterol and a sports index.7 in the other hand, the hypertension cases in the overweight elderly group could be influenced by some factors, including potassium intake, calcium intake, bmi score. furthermore, there are other risk factors of hypertension such as age, sex, family history, sodium intake, diabetes mellitus, obesity, smoking habit, alcohol and caffeine consumption, potassium intake, calcium intake, low magnesium, and stress.4 all of these risk factors may play a significant role as confounding factors that should be evaluated further. the pathophysiology of overweight related to hypertension might be due to the role of leptin, produced by adipose tissue. leptin increases the production of catecholamine to table 2 the relationship between overweight and hypertension nutritional status blood pressure p-valuenon-hypertension hypertension n % n % non-overweight (bmi<25) 20 90.9 34 43.6 0.001 overweight (bmi≥25) 2 9.1 44 56.4 total 22 100 78 100 note: non-hypertension designated as normal & prehypertension or stage i; hypertension designated as stage ii & iii stimulate a sympathetic nerve in the blood vessels, causing an increased total peripheral resistance (tpr). leptin indirectly increases cardiac output (co), and both play an important role in blood pressure. therefore, leptin, which is over secreted in adipose tissue of overweight individuals could elevate arterial blood pressure.8,9 our study has shown a significant relationship between bmi and blood pressure. bmi ≥22 kg/m2 may increase the risk of hypertension. the optimal bmi for a female is 24.1 kg/m2 and for a male is 23.8 kg/m2. the risk of hypertension in individuals of normaltension increased with an increase in body weight.10 limitation of the study is that data of risk factors that may play a significant role in hypertension and serve as confounding factors such as family history, sodium intake, history of diabetes mellitus, smoking habit, alcohol and caffeine consumption, potassium intake, calcium intake, low magnesium, and stress events are not collected. further study is needed to evaluate these factors thoroughly. in conclusion, this study has shown a significant relationship between overweight and hypertension in the elderly living in hegarmanah. nutritional status maintenance is needed to control of hypertension through health promotion. therefore, blood pressure measurement, bodyweight measurement, and regular hypertension therapy are necessary for the elderly. references 1. setiawan z. prevalensi dan determinan hipertensi di pulau jawa tahun 2004. kesmas. 2006;1(2):57−62. 2. mccance k,l huether se, brashers vl, rote ns.. pathophysiology: the biologic basis for disease in adults and children. 6thed . maryland heights: mosby elsevier; 2010. p. 1149−50. althea medical journal. 2020;7(1) 34 amj march 2020 3. williams b, poulter nr, brown mj, davis m, mcinnes gt, potter jf, et al. british hypertension society guidelines for hypertension management 2004 (bhs-iv): summary. bmj. 2004;328(7440):634−40. 4. rahajeng e, tuminah s. prevalensi hipertensi dan determinannya di indonesia. maj kedokt indon. 2009;59(12):580−7. 5. pratiwi vr, tala zz. gambaran status gizi pasien hipertensi lansia di rsup h.adam malik medan. e-jurnal fk usu. 2013;1(1):1−5. 6. mitchell gf, parise h, benjamin ej, larson mg, keyes mj, vita ja, et al. changes in arterial stiffness and wave reflection with advancing age in healthy men and women: the framingham heart study. hypertension. 2004;43(6):1239−45. 7. kamso s, rumawas js, lukito w, purwantyastuti. determinants of blood pressure among indonesian elderly individuals who are of normal and overweight: a cross sectional study in an urban population. asia pac j clin nutr. 2007;16(3):546−53. 8. aizawa-abe m, ogawa y, masuzaki h, ebihara k, satoh n, iwai h, et al. pathophysiological role of leptin in obesity-related hypertension. j clin invest. 2000;105(9):1243−52. 9. beltowski j. role of leptin in blood pressure regulation and arterial hypertension. j hypertens. 2006;24(5):789−801. 10. wen cp, david cheng ty, tsai sp, chan ht, hsu hl, hsu cc, et al. are asians at greater mortality risks for being overweight than aucasians? redefining obesity for asians. public health nutr. 2009;12(4):497−506. amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 35 larvicidal activity of citrus aurantifolia decoction against aedes aegypti larvae priyanka devi muniandy,1 silvita fitri riswari,2 kartika ruchiatan3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of dermatovenerology faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: priyanka devi muniandy, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: priyankadevi27@yahoo.com introduction dengue fever is transmitted through a bite of infected female aedes mosquito, the aedes aegypti. this mosquito is the primary transmission vector for dengue virus infection.1 the aedes mosquito is also the main vector for several other diseases such as yellow fever and chikungunya.2 in year 2006, indonesia reported quite a number of dengue cases in south east asian region, with 57% contributing to the southern hemisphere countries.3 due to the increasing incidence rate of dengue, the indonesian government has focused on vector controlling which can be directed by biological, chemical or environmental management with the usage of larvicides as a complementary way in eradicating dengue vector development according to the world health organization (who) guideline. one percent has been used for resistance management tool in mosquito abatement programs. however, it also causes toxicity in higher dosage due to overstimulation of the nervous system in humans.1,4 thus, alternative natural phytochemicals are preferred to encounter toxicity problems. the previous study on citrus-derived essential oils has proved that citrus has natural elements effective against aedes mosquito as larvicides.5 citrus aurantifolia is a citrus genus consisting of chemical coumarins such as phenolics, scopoletin, flavonoids and limonin, which are favorable as phytochemical amj. 2020;7(1):35–9 abstract background: infected female aedes mosquito is the primary vector of virus transmission for dengue hemorrhagic fever (dhf). natural phytochemical larvicide is becoming a complementary way for vector control management. the citrus plant extract has natural chemical reactions against mosquito larvae. this study aimed to identify the larvicidal activity of citrus aurantifolia leaves decoction against larvae of aedes aegypti as an effort to discover natural phytochemical repellant. methods: this was an analytic experimental study using twenty-five aedes aegypti larvae. the larvae were placed in translucent cups containing different concentrations of c. aurantifolia leaves decoction. the cups were filled with abate as positive controls and water as negative controls. the experiment was repeated for three consecutive days, and the mortality of larvae was monitored for 48 hours as described in the world health organization (who) guidelines for laboratory and field testing for mosquito larvicides (whopes). results: c.aurantifolia decoction significantly decreased the number of larvae. the highest mortality was shown in 30% concentration with a total of 224 dead larvae. probit analysis showed lc50 was 38.5% and 6.6% at 24 and 48 hours, respectively. the highest rate of killing the larvae was taken at lc60 with 91.6% for 24 hours and lc65 64.4% for the 48 hours; thus lc90 could not be determined. the significance of the decoction concentration was analyzed by one way anova preceded with posthoc test (p-values 0.000). conclusions: decoction of c.aurantifolia leaves has proved to have larvicidal activity against larvae of aedes aegypti and could be used as phytochemical larvicides in controlling vector of dhf. keywords: aedes aegypti, larvae, citrus aurantifolia, dengue, fever https://doi.org/10.15850/amj.v7n1.1814 althea medical journal. 2020;7(1) 36 amj march 2020 larvicides.6,7 research in thailand8 has shown that citrus hystrix’s fruit peel has higher mortality compared to the plant against aedes aegypti larvae. by using the decoction process, the extracted herbs which are boiled at 900c with a specific volume of water in 30 minutes is convenient for extracting heat-stable and water-soluble ingredients.9 this procedure is the inexpensive and can be easily performed. however, citrus-derived leaves have not been proved to have higher mortality on aedes larvae. this study aimed to identify the effectiveness of citrus aurantifolia leaves in decoction form against larvae of aedes aegypti and to determine the lethal concentration at 50% (lc50) and 90% (lc90) mortality as an effort to promote natural phytochemicals to eradicate dengue vector transmission. methods this research was an analytic experimental study in accordance as described by who guidelines for laboratory and field testing of mosquito larvicides.10 this study was conducted in the parasitology laboratory, faculty of medicine, universitas padjadjaran in october to november 2012. leaves of key lime (citrus aurantifolia) were collected from the tanjung sari market, sumedang and identified at the biology herbarium, universitas padjadjaran. leaves were weighed for 400g for each time repetition. aedes aegypti larvae were obtained from the department of biology, institute of technology bandung and were further identified at the parasitology laboratory, faculty of medicine, universitas padjadjaran. the larvae eggs were bred until becoming instar iii or iv, and the larvae were fed with fish powder as its food source. for the decoction process, fresh citrus aurantifolia leaves (400g) was mixed with 400 ml water into the decoction equipment, designated as 100% concentration. the mixture was heated at 90oc for 30 minutes, on an electric stove and stirred occasionally. then, the solution was filtered and a certain amount of hot water was added until the final volume of 400 ml. this mixture was further diluted using distilled water. concentrations were made for 15%, 30%, 45%, 60%, 75%, and 90%. for example, 15 ml of the prepared 100% concentration of decocting citrus aurantifolia was mixed with 85 ml of distilled water to obtain 15% of concentration with 100 ml in total for each concentration. abate (temephos 1%) was used as the control positive in this experiment and a solution of 100 ml abate was prepared according to the abate sachet procedure. as a control negative, 100 ml distilled water was used. four replicates were prepared in containers for each concentration. twentyfive actively motile larvae were inserted into each container and the mortality rate of larvae was recorded at an interval of 24 hours and 48 hours. the experiment was repeated in three different days with a minimal interval of one day. room temperature was recorded as a control variable that might influence the experiment from the beginning until the end. the significant difference of the citrus aurantifolia leaves decocts concentrations were statistically analyzed by one-way analysis of variance (anova) which was a parametric method for numerical unpaired observation. the test was followed with a post-hoc test. the statistical analysis was conducted using statistical product and service solutions (spss) for windows (version 15.0). the lc50 and lc90 values were determined using probit analysis. table 1 cumulative frequency and percentage of the mortality rate of aedes aegypti larvae in different concentrations of citrus aurantifolia decoct at 48 hour observation replicate control negative concentration of c.auratifolia control positive15% 30% 45% 60% 75% 90% cumulative frequency 1 1 45 61 44 44 51 50 75 2 35 59 41 48 47 51 75 3 1 38 52 42 45 47 59 75 4 33 52 45 37 48 54 75 % mortality rate 0.6 50.3 74.6 57.3 58.0 64.3 71.3 100 note. the number of dead larvae althea medical journal. 2020;7(1) 37priyanka devi muniandy et al.: larvicidal activity of citrus aurantifolia decoction against aedes aegypti larvae results the highest mortality rate was shown at the concentration of 30% with a total of 224 dead larvae; while control negative had shown 2 dead larvae and control positive with complete 100% mortality rate with a total of 300 dead larvae (table 1). the highest mortality rate of aedes aegypti larvae of the citrus aurantifolia leaves decoction concentrations was shown the highest rate at 30% with 65.6% on the 24 hours of observation and 74.6% on the 48 hours of observation; whereas the lowest mortality rate was shown by 15% concentration of citrus aurantifolia with 34.3% at 24 hours of observation and 50.3% on the 48 hours of observation. distilled water has 0.6% and abate with 100% mortality. the higher killing power was shown by decocts of citrus aurantifolia at 30% concentration, and there was no difference mortality rate that was observed in 24 hours or 48 hours (figure 1). anova and post-hoc tests were exerted to identify the effect of citrus aurantifolia leaves decoction at various concentrations with the mortality of aedes aegypti larvae. when comparing the number of dead larvae’s in various concentrations of citrus aurantifolia leaves and distilled water, it showed that even concentration of 15% had a significantly high number of dead larvae (p-value 0.000), suggesting that decoction of citrus aurantifolia leaves has good larvicidal activity on aedes aegypti larvae. table 2 the comparison between the various concentration of citrus aurantifolia and distilled water concentration no. dead larvae (n=300) p-value† distilled water* 0.5±0.57 15% 37.75±6.95 0.000 30% 56±2.94 0.000 45% 43±2.00 0.000 60% 43.5±6.76 0.000 75% 48.25±2.50 0.000 90% 53.5±4.20 0.000 abate ** 75 note: * negative control ** positive control †one way anova, post-hoc test compared to distilled water as well as abate figure 1 percentage of mortality rates of aedes aegypti at 24 hours and 48 hours of observation 120% 100% 80% 60% 40% 20% 0% althea medical journal. 2020;7(1) 38 amj march 2020 the same result was shown when the various concentrations of citrus aurantifolia leaves were compared to positive controls; there were statistically significant differences in the effectiveness of decoction of citrus aurantifolia leaves and abate. the median differences between citrus aurantifolia decoction and abate showed that abate had a higher median. it indicated that abate was the most effective in killing aedes aegypti larvae. this study also revealed larvicidal activity of decoction form of citrus aurantifolia leaves against larvae of aedes aegypti within 48 hours observation. based on probit analysis the chances of killing 50% of aedes aegypti larvae were achieved at a concentration of 38.5% for 24 hours and 6.6% for the 48 hours of observation. however, the lc90 could not be defined. this was probably due to the highest lethal concentration taken by decoct form of citrus aurantifolia leaves in killing aedes aegypti larvae was at lc60 with 91.6% and at lc65 was 64.4% for 24 hours and 48 hours of observation, respectively (table 3). discussion this study has identified the larvicidal activity of citrus aurantifolia leaves decoction against larvae of aedes aegypti as an effort to discover natural phytochemicals. the results showed that c.aurantifolia decoction significantly decreased the number of larvae. the highest mortality has proved that 30% concentration of citrus aurantifolia decoction was effective in killing almost 75% of the larvae as also shown with the 90% concentration. according to a study done in india11, the higher the concentration, the higher the mortality rate achieved by citrus sinensis, a species of genus citrus. however, our result did not show the linear similarities by citrus aurantifolia, indicating that there might be other factors that could have influenced the result of the experiment. minor trauma would have occurred while handling the transfer of actively motile aedes aegypti larvae into containers, or there might be changes of the chemical mixture while preparing the needed concentrations. other possible contributing factors could be due to the lack of photo period of 12 hours light and 12 hours dark as recommended by who guidelines.10 table 1 has shown 0.6% mortality in the negative control, which is still acceptable according to whopes guidelines of less than 5% mortality, lc50 have shown 38.5% which is 385,470 ppm at 24-hour observation and 6.6% which is 66,130 ppm. furthermore, lc90 could not be defined due to the highest killing effect of citrus aurantifolia decoction, therefore, lc60 has been taken with 91.6% which is 916,170 ppm for 24 hours and lc65 table 3 probit analysis result at 24 hour and 48 hour for each concentration lethal concentration (lc) percentage (%) 24 h 48 h 0.01 .014 .000 0.05 .140 .000 0.1 .483 .003 0.2 2.173 .046 0.3 6.423 .299 0.4 16.219 1.483 0.5 38.547 6.613 0.6 91.617 29.494 0.65 143.824 64.269 0.7 231.330 146.043 0.8 683.921 949.644 0.9 3075.295 12739.750 0.95 10642.584 1.087e5 0.99 1.093e5 6.069e6 althea medical journal. 2020;7(1) 39 64.4% which is 644,940 ppm at 48 hours. study in nigeria12 has proved that citrus species, citrus sinensis has lower ppm with lc50 0.4 ppm and lc90 with 0.9 ppm using ethanolic extraction method against aedes aegypti larvae. another study showed that citrus limonia and citrus sinensis fruit peels essential oils have high mortality against aedes aegypti larvae with lower ppm, suggested that alcohol extract of used herbs contained more chemical components compared with decoction method.13,14 in line to those studies, the chemical content of citrus-derived plant is better in killing the aedes larvae by the ethanolic extraction method compared to the decoction method as the decoction method has weakness in extracting chemical constituent of ingredients or herbs being used. in conclusion, citrus aurantifolia leaves have larvicidal activity against aedes aegypti larvae. further study should be conducted in the narrower range to determine larvae mortality at lc90. government and health authorities should encourage the usage of citrus aurantifolia leaves as a bio-insecticide for vector controlling against dengue hemorrhagic fever. further research is suggested on ethanolic extractions or essential derived oil from citrus aurantifolia leaves against aedes aegypti as larvicides or mosquito repellent. references 1. world health organization, special programme for research and training in tropical diseases (tdr). dengue: guidelines for diagnosis, treatment, prevention, and control. geneva: who library cataloging data; 2009. p.14−65. 2. wertheim hfl, horby p, woodall jp. emerging infectious diseases. in: wertheim hfl, horby p, woodall jp. atlas of human infectious diseases. 1st ed. oxford, uk: wiley-blackwell; 2012. p. 1-39. 3. world health organization. dengue/dhf: trend of dengue case and cfr in sear countries. 2007. [cited 2012 september 15]. available from: http://www.searo.who.int/ en/ section10/section332/ section2277_11 960.htm last update: 06 july 2007 4. united states environmental protection agency. temephos facts: epa document 738-f-00-018 july 2001. washington, usa: united states environmental protection agency; 2001 [cited 2012 november 29] available from: https://nepis.epa.gov/ exe/tiff2png.cgi/200005e5.png?-r+75+g+7+d%3a%5czyfiles%5cindex%20dat a%5c00thru05%5ctiff%5c00000039% 5c200005e5.tif. 5. sadr ud din, akram w, khan ha, hussain a, hafeez f . citrus waste-derived essential oils: alternative larvicides for dengue fever mosquito, aedes albopictus (skuse) (culicidae: diptera). pakistan j zool. 2011;43(2):367−72. 6. daniel m. medicinal plants: chemistry and properties. 1st ed. enfield, new hampshire, usa: science publishers; 2006. p.208−209. 7. effiom, avoaja da, ohaeri cc. mosquito repellent activity of phytochemical extracts from peels of citrus fruit species. global j sci frontier res. 2012;12(1):4−8. 8. sutthanont n, choochote w, tuetun b, junkum a, jitpakdi a, chaithong u et al. chemical composition and larvicidal activity of edible plant-derived essential oils against the pyrethroid-susceptible and resistant strains of aedes aegypti (diptera: culicidae). j vector ecol. 2010;35(1):106−15. 9. handa ss, khanuja sps, longo g, rakesh dd, editors. extraction technologies for medicinal and aromatic plants. trieste, italy: ics-unido; 2008.p.28−30 10. world health organization. guidelines for laboratory and field testing of mosquito larvicides. geneva, switzerland; 2005. [cited 2019 september 15]. available from: https://apps.who.int/iris/ handle/10665/69101. 11. murugan k, mahesh kumar p, kovendan k, amerasan d, subrmaniam j, hwang js. larvicidal, pupicidal, repellent and adulticidal activity of citrus sinensis orange peel extract against anopheles stephensi, aedes aegypti and culex quinquefasciatus (diptera: culicidae). parasitol res. 2012;111(4):1757−69. 12. amusan aa, idowu ab, arowolo fs. comparative toxicity effect of bush tea leaves (hyptis suaveolens) and orange peel (citrus sinensis) oil extract on larvae of the yellow fever mosquito aedes aegypti. tanzan health res bull. 2005;7(3):174−8. 13. cavalcanti esb, morais smd, lima maa, santana ewp. larvicidal activity of essential oils from brazilian plants against aedes aegypti l. mem inst oswaldo cruz. 2004;99(5):541−4. 14. shang e, zhu z, liu l,tang y, duan ja. uplcqtof-ms with chemical profiling approach for rapidly evaluating chemical consistency between traditional and dispensing granule decoctions of tao-hong-si-wu decoction. chem cent j. 2012;6(1):143. priyanka devi muniandy et al.: larvicidal activity of citrus aurantifolia decoction against aedes aegypti larvae vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 196 amj december 2019 smoking behavior among undergraduate female students in universitas padjadjaran bandung rafsae iqbal akbar,1 arifah nur istiqomah,2 irvan afriandi3 1faculty of medicine universitas padjadjaran, indonesia, 2department of psychiatry faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: rafsae iqbal akbar, faculty of medicine, universitas padjadjaran jalan raya bandung-sumedang km 21, jatinangor, sumedang, jawa barat, indonesia, email: rafsae.iqbal@gmail.com. introduction smoking is an addictive habit, contributed as one of the risk factors in the human lifestyle affecting health in the past four centuries.1 there are more than one billion smokers around the world, and smoking behavior has increased significantly especially in women. estimated, 47.5% of men and 10.3% of women world population is active smokers. interestingly, three out of ten students (30.9%) have been found to smoke for the first time before they reach the age of 10 years. among students who smoke, 3.2% have addictions with the desired indicator first thing in the morning is a cigarette.2 girls start smoking when they reach puberty. they start smoking as a response to peer pressure and misperception that consider smoking as something ‘cool’ to increase their popularity. some teenage girls start smoking or continue smoking because they believe that smoking can help them lose weight, especially, those who are living in a culture whose concept of ideal body proportions is not realistic. cigarette company directly promotes cigarettes to women and makes the relationship between smoking behavior and gender equality.3 indonesian society considers smoking behavior in women as a deviant behavior, however, evidence show that smoking habit among teenage girls continues to increase especially in urban society.4 based on survei sosial ekonomi nasional (susenas), the prevalence of adult smoking women is increased four times from 1.3% into 5.2% in 2007.5 this study was conducted to describe the smoking behavior among undergraduate female students in universitas padjadjaran, bandung. amj. 2019;6(4):196–200 abstract background: smoking is an addictive habit of affecting human behavior. global data has shown that 47.5% of men and 10.3% of women are active smokers. based on survei sosial ekonomi nasional in 2007, the prevalence of women smokers in indonesia is increased from 1.3% to 5.2%. this study was conducted to describe the smoking behavior among undergraduate female students in universitas padjadjaran, bandung. methods: this was a descriptive cross-sectional study, including female students from 9 faculties in universitas padjadjaran, using a snowball sampling technique. a self-administered questionnaire was distributed, consisting of questions about when students smoked for the first time, level of addiction, smoking intensity, smoking location, and the affecting mood. result: of 99 female students, 40.40% have started smoking in high school, 31.32% in the university, and 25.25% in junior high school. the smoking intensity was moderate (45.45%), but some were high (29.30%). the location preference for smoking was both in private and public places (88.89%), driven by both positive and negative moods (88.89%). interestingly, the most addiction level was situational (34.34%) or intensive (34.34%). conclusions: since most of the female students have started smoking before enrolling in the university, smoking education and cessation in junior high school need to be strengthened. keywords: addiction, behavior, cessation, smoking althea medical journal. 2019;6(4) 197 methods this cross-sectional study was conducted in universitas padjadjaran from 2013 to 2014. respondents of this study were undergraduate female students in universitas padjadjaran who had smoked for at least one month. respondents were voluntarily involved in this study after submitted informed consent. the respondents were chosen using snowball sampling. in brief, the first respondent selected through inclusion and exclusion criteria was chosen to be a ‘seed’ or ‘source’ for the next respondent sampling. the following table 1 the distribution of the first time smoking and smoking intensity among female students from universitas padjadjaran variable number of respondentn=99 percentage (%) age (years old) (n=58)* 17 2 3.45 18 1 1.72 19 7 12.07 20 18 31.03 21 12 20.70 22 10 17.24 23 3 5.17 24 4 6.90 25 1 1.72 faculty (n=49)* medicine 2 4.08 cultural study 13 26.53 dentistry 2 4.08 communication science 14 28.57 nursing 2 4.08 psychology 2 4.08 social & political science 12 24.49 mathematics & natural science 1 2.04 law 1 2.04 first time smoking(n=99) elementary school 3 3.03 junior high school 25 25.25 high school 40 40.40 university 31 31.32 smoking intensity(n=99) low 25 25.25 moderate 45 45.45 high 29 29.30 note: the smoking intensity was designated as low (1–4 cigarettes), moderate (5–14 cigarettes), and high (>15 cigarettes). *the number of respondents was not the same as total numbers since not all respondents acknowledge their age and faculty. rafsae iqbal akbar et al.: smoking behavior among undergraduate female students in universitas padjadjaran bandung althea medical journal. 2019;6(4) 198 amj december 2019 respondents were asked to bring back two other respondents that had similar criteria and so on. this study had been approved by the health research ethics committee no. 468/un6.c2.1.2/kepk/2013. after consent, a validated self-administered questionnaire was distributed, which consisted of 32 questions exploring the respondent smoking behavior characteristics. the questions included the first time when the respondent had started smoking (elementary school, junior high school, high school) and smoking intensity (low, 1–4 cigarettes; moderate, 5–14 cigarettes; and high,>15 cigarettes), that had been asked in 1 question each; followed by 16 questions in likert–scale type statements to assess respondent addiction (experimental, recreational, situational, intensive, compulsive). furthermore, there were 8 questions about the preference of place or location for smoking (private place, public place, both places), and 6 questions about mood aspect that affected them to smoke (positive, negative, both moods. data was organized and presented using microsoft excel 2013. results ninety-nine female students from 9 faculties had participated in this study. the number of respondents who acknowledge their age and faculty was not the same as the total numbers, however, the average age of the respondents was 20 years old and most of the respondents studied at faculty of communication science (28.57%). the female students started smoking in high school (40.40%) and smoked in moderate-intensity (45.45%) as shown in table1. most of respondents’ favorable place to smoke was in a restaurant or canteen (79.80%) table 2 the distribution of location of preference for smoking among female students (n=99) from universitas padjadjaran variable number of respondent percentage (%) private place private vehicle 73 73.74 private room 74 74.75 restroom 65 65.66 public place campus 69 69.70 smoking area 76 76.77 public transport 14 14.14 restaurant/canteen 79 79.80 wherever i want 32 32.32 table 3 the mood affecting among female students (n=99) from universitas padjadjaran. variable number of respondent percentage (%) positive pleasure 61 61.62 after meal 80 80.81 complementary cigarette 62 62.63 negative while working/studying 63 63.64 anger 62 62.63 anxious 71 71.72 althea medical journal. 2019;6(4) 199 as shown in table 2. furthermore, our results showed that a small proportion of respondents preferred to smoke only in private places (10.10%) and only in public places (1.01%), and most of them in both places (88.89%). most of the respondents smoked after a meal (80.81%) or when they felt anxious (71.72%) as shown in table 3. moreover, 8.08% of respondents affected only by positive moods, 3.03% only by negative moods, and 88.89% by both moods. the respondents admitted to smoke as experimental (10.10%), as recreational (16.17%), situational (34.34%), intensive (34.34%), and compulsive (5.05%). discussion respondents of this study have started smoking since high school, similar to a various studies in usa,6 and new zealand,7 that also shows that there is a low level of initiation table 4 the level addiction among female students from universitas padjadjaran. variable number of respondent (n=99) strongly agree/ agree* neutral disagree/ strongly disagree** experimental for the past week i only try smoke for the experience 10 10 79 recreational i only smoke while hangout with my close friend 42 11 46 i only smoke while hangout with my smoking friend 45 15 39 situational i smoke when feeling cold 56 19 24 i smoke when having exams 42 20 37 i smoke when having problems with family, friends, or girlfriend 64 13 22 i smoke if have a bad grade or bad review 47 17 35 intensive i smoke whenever i want 71 15 13 i smoke everyday 68 13 18 i keep smoking even when i’m with my parents 11 8 80 i keep smoking even when i’m with my siblings or other relatives 29 16 54 compulsive i can quit smoking whenever i want to 54 25 20 i will feel unease if i’m not smoking for a week 46 27 26 i will feel physically uncomfortable if i’m not smoking for a week 38 23 38 i will feel mentally uncomfortable if i’m not smoking for a week 38 28 33 every day i am more and more frequent smoking 30 24 45 note: the following answers were grouped into one category; *strongly agree and agree, and **disagree and strongly disagree rafsae iqbal akbar et al.: smoking behavior among undergraduate female students in universitas padjadjaran bandung althea medical journal. 2019;6(4) 200 amj december 2019 on older age.7 the fact that the majority of smokers start smoking in high school, it might be due to the teenager rebellious phase that starts in the period of high school. in the case of smoking intensity, our respondents are moderate-intensity smokers (45.45%). in a similar study conducted in medan8, 89.43% are of low-intensity smokers.8 it seems that female students from bandung smoke more often and have a higher cigarette/day ratio compared to students from medan. compared to study in the us, our respondent also have a similar distribution of high-intensity smokers, which is around 25%.9 female students in our study tend to smoke in their private place (house, room, and vehicle) and also in public place (campus, restaurant). however, data show that public place as the less favorable place to smoke. again in comparison to a similar study in medan8 that shows 33.33% prefer to smoke in their house (private place) and 48.78% prefer to smoke in public place, in bandung the respondents are braver in expressing their smoking behavior in both places (88.89%). female students start smoking not only because positive feelings they have, but also when they have a negative feeling. a similar study in arizona-us10 shows that 49% of respondents smoke because of stress, while 47% because of relaxing feeling when smoking. it shows that not only negative feelings (stress, anger, anxiety) that affect people to smoke but also positive feeling (relaxation, successes). the respondents’ addictions to cigarettes are situational, intensive stage but it is still controllable. it is because they only smoke in certain situations. the parenting control affects their smoking behavior because the presence of parents or other siblings might prevent most of them to smoke. furthermore, the respondent could quit smoking whenever they want, and they still do not feel any disturbance physically and mentally when they do not smoke. this study has encountered several limitations. inequality happens because there are some questions which are incomplete or incorrectly filled, and most of the respondent only keeps their smoking habit and behavior to themselves. even though this study has used snowball sampling, it is hard to find respondents since each of the respondents usually does not know other women who smoke except their close friend. in conclusion, most female students in our study have started smoking from high school with moderate intensity. they are intensive and situational smokers with no location preference, thus, both in private and public places. they are affected by both positive and negative moods to smoke. since most of the female students have started smoking before enrolling in the university, smoking education and cessation in junior high school need to be strengthened. references 1. yanbaeva dg, dentener ma, creutzberg ec, wesseling g, wouters efm. systemic effects of smoking. chest. 2007;131(5):1557–66. 2. edwards r. abc of smoking cessation: the problem of tobacco smoking. bmj. 2004;328(7433):217–9. 3. glynn t, seffrin jr, brawley ow, grey n, ross h. the globalization of tobacco use: 21 challenges for the 21st century. ca cancer j clin. 2010;60(1):50–61. 4. nichter m, padmawati s, danardono m, ng n, prabandari y, nichter m. reading culture from tobacco advertisements in indonesia. tob control. 2009;18(2):98–107. 5. litbang depkes. konsumsi rokok dan prevalensi merokok. jakarta: litbang depkes ri; 2010. 6. jordan jn, mcelroy ja, everett kd. smoking initiation, tobacco product use, and secondhand smoke exposure among general population and sexual minority youth, missouri, 2011–2012. prev chronic dis. 2014;11:e113. 7. edwards r, carter k, peace j, blakely t. an examination of smoking initiation rates by age: results from a large longitudinal study in new zealand. aust n z j public health. 2013;37(6):516–9. 8. alamsyah rm. faktor-faktor yang mempengaruhi kebiasaan merokok dan hubungannya dengan status penyakit periodontal remaja di kota medan tahun 2007 [thesis]. medan: universitas sumatera utara; 2009. 9. centers for disease control and prevention (cdc). vital signs: current cigarette smoking among adults aged ≥18 years– united states, 2005-2010. mmwr morb mortal wkly rep. 2011;60(35):1207– 1212. 10. shiffman s, paty j. smoking patterns and dependence: contrasting chippers and heavy smokers. j abnorm psychol. 2006;115(3):509–23. vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 95 antibacterial effect of jatropha multifida l. leaf infusion towards staphylococcus aureus and pseudomonas aeruginosa ivan,1 sunarjati sudigdoadi,2 achmad hussein s. kartamihardja3 1faculty of medicine universitas padjadjaran, 2department of biomedical sciences faculty of medicine universitas padjadjaran, 3department of nuclear medicine and molecular imaging, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: ivan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: ucokzzmail@gmail.com introduction indonesia is a country rich in natural resources and biological diversity, one of which is found in medicinal plants. since historical times, indonesians have been using various types of traditional medicinal plants to cure various ailments, one of which is coral plants or jatropha multifida linn (j. multifida).1 benefits of j. multifida have not been well known to common indonesian. the parts of this plant that can be used are its leaves, sap, and seeds oil, which have been utilized to treat helminthiasis, infections in open wounds, and various inflammatory conditions of the skin.2 generally, an extract of the parts of a particular plant is used to test the plant’s potential effects and therapeutic benefits. one of the more readily made extracts is a liquid extract, which is produced by using solvents as extractors. solvents that are commonly used are water and ethanol 95%. the most frequently used methods to create liquid extracts are by dedoctum and infusum, which utilize water as the solvent.3 in this study, the infusum method was used because it is cheaper, faster, and simpler, which makes it more available to common people. open wounds happen when the skin or the mucosal surface experiences destruction. this destruction causes increased exposure to infectious agents, one of which is bacteria. one of the bacteria that commonly infect open wounds is staphylococcus aureus.4 beside s. aureus, pseudomonas aeruginosa is another bacteria that commonly cause open wound infection and also nosocomial infection.5 based on these facts, the author is interested to study the antibacterial effect of j. multifida leaves, in the form of an infusion, against s. aureus, which represents gramamj. 2019;6(2):95–9 abstract background: jatropha multifida is one of the medicinal plants commonly found in indonesia. this plant is used in the community to heal open wounds, however, scientific evidence is lacking. the two most common bacteria which often cause infection in open wounds are staphylococcus aureus and pseudomonas aeruginosa. this study aimed to determine the antibacterial effect of j. multifida leaf infusion towards s. aureus and p. aeruginosa in vitro. methods: this was an experimental laboratory study conducted at the microbiology laboratory, faculty of medicine, universitas padjadjaran in 2014. the modified kirby-bauer antimicrobial diffusion procedure on mueller-hinton agar was applied to determine the inhibitory zone. in determining the minimum inhibitory concentration (mic) and the minimum bactericidal concentration (mbc), the modified technique of tube dilution was used. results: the results of this research showed that the infusion of j. multifida leaves had inhibitory effects on the growth of s. aureus dan p. aeruginosa at the concentration of 100% and 75%. the minimum inhibition concentration and minimum bactericidal concentration could not be determined. conclusions: there is evidence confirming the bacteriostatic antibacterial effect of j. multifida leaves which inhibits the growth of s. aureus and p. aeruginosa. further study is needed to explore j. multifida leaves. keywords: antibacterial effect, infusion, jatropha multifida leaf, p. aeruginosa, s. aureus althea medical journal. 2019;6(2) 96 amj june 2019 positive bacteria, and p. aeruginosa, which represents gram negative bacteria, as bacteria that commonly cause open wound infection. methods this was an experimental laboratory study, approved by the research ethics committee universitas padjadjaran. the study was carried out in the microbiological laboratory faculty of medicine universitas padjadjaran in jatinangor in october 2014. the study comprised of four stages: (i) making of j .multifida leaf infusion, (ii) making of bacterial suspension, (iii) determination of antibacterial effect with antimicrobial infusion method of kirby bauer that had been modified on mueller hinton agar, and (iv) determination of minimum inhibitory concentration (mic) and minimum bactericidal concentration (mbc) with modified tube dilution method. on the first stage, j. multifida leaf infusion was made. j. multifida leaves were washed, and then dried and finely cut. 100% concentration was achieved by putting 20 g of leaves into 20 g of water. it was heated at 90oc for 15 minutes and stirred every 5 minutes. after cooling it down, the mixture was filtered using sterile gauze until no more water was left. the 100% infusion was diluted to make 75%, 50%, and 25% infusions. on the second stage, bacterial suspension was made. the bacterial colony was grown on mueller hinton agar in a petri dish and incubated for 24 hours at 37oc. after incubation, bacteria were taken using an inoculating loop for 4–5 times and then inserted into a reaction tube filled with distilled water to produce a suspension until the turbidity achieved mcfarland standard 0.5.6 this suspension was equivalent to 1.5 x 108 cfu/ml. in the third stage, the antibacterial effect was determined. a milliliter of bacterial suspension was added into a petri dish, then the dish was filled with 24 ml mueller hinton agar at 40– 50oc. it was then homogenized and let to cool down until it solidified with ± 4 mm thickness. five holes with 10 mm diameter and 4 mm depth were made on the solidified agar. four holes were filled with 0.3 ml of j. multifida leaf infusion with different concentrations: 100%, 75%, 50%, and 25%. the fifth hole was filled with distilled water as a positive control. the dish was then incubated for 24 hours at 37oc in the incubator. after 24 hours, the diameter of bacterial growth inhibition zones at each hole was measured. these zones appeared as clear areas surrounding each hole. on the fourth stage, mic and mbc were determined. to determine mic, ten reaction tubes and j. multifida infusions with different concentrations: 100%, 50%, 25%, 12.5%, 6.25%, 3.13%, 1.56%, and 0.78%. the first to the eight tubes were filled 1 ml of infusion, each one with a different concentration. a milliliter liquid mueller hinton agar that had been added with bacterial suspension (0.5 mcfarland turbidity) was added to the eight tubes that contained infusion, and then the tubes were shaken for homogenization. the end concentrations would be the following: 50%, 25%, 12.5%, 6.25%, 3.13%, 1.56%, 0.78%, and 0.39%. the ninth reaction tube was filled with the same liquid mueller hinton agar (with bacterial suspension) as positive control and the tenth tube was filled table 1 diameter of inhibitory zones of s. aureus and p. aeruginosa with different concentrations of j. multifida leaf infusion bacteria concentration (%) diameter of inhibitory zone (mm) average (mm)i ii iii s. aureus 100 25 22 17 21.3 75 20 19 13 17.3 50 25 p. aeruginosa 100 20 18 18 18.7 75 14 15 14 14.3 50 25 althea medical journal. 2019;6(2) 97 with liquid mueller hinton agar and 100% j. multifida infusion as a negative control. next, all ten reaction tubes were put into the incubator for 24 hours at 37oc. after incubation, the turbidity of each tube was observed to examine the mic. tubes that were clearer than the negative control indicated the presence of an antibacterial effect. to determine mbc, as much as 1 inoculating loop of the mixture from each tube was taken and smeared on mueller hinton agar. it was next incubated for 24 hours at 37oc for observation. the above procedure was repeated for 3 times with new infusion but identical treatment. results determination of the antibacterial effect of j. multifida leaf infusion against s. aureus and p. aeruginosa was done by measuring the diameter of the inhibitory zones. table 1 shows that at 100% and 75% concentrations, j. multifida leaf infusion has an antibacterial effect against s. aureus and p. aeruginosa. the antibacterial effect was bacteriostatic because there was still bacterial growth in the inhibitory zones. the growths were observed through gram staining. after mic test observation for 24 hours with the tube dilution method, it was concluded that mic of j. multifida leaf infusion against s. aureus and p. aeruginosa could not be determined because there were still visual observations of turbidity in every tube, indicating bacterial growth (table 2). from mbc test observation for 24 hours, using the culture from the previous mic test, it was concluded that the mbc of j. multifida leaf infusion against s. aureus and p. aeruginosa could not be determined because there was still bacterial colony growth in mh agar regardless of the concentration of the infusion added (table 3). discussions this study has shown that inhibitory zones table 2 bacterial growth after mic test against s. aureus and p. aeruginosa by j. multifida leaf infusion at different concentrations bacteria concentration (%) control 50 25 12.5 6.25 3.13 1.56 0.78 0.39 c(-) c(+) s. aureus + + + + + + + + + + + + + + + + + + + + + + + + + + + p. aeruginosa + + + + + + + + + + + + + + + + + + + + + + + + + + + note: + : bacterial colonies were present, : bacterial colonies were absent, (+): mh broth with tested bacteria suspension, (-) : 100% j. multifida leaf infusion with mh broth table 3 bacterial growth in mbc test against s. aureus and p. aeruginosa by j. multifida leaf infusion at different concentrations. bacteria concentration (%) control 50 25 12.5 6.25 3.13 1.56 0.78 0.39 c(-) c(+) s. aureus + + + + + + + + + + + + + + + + + + + + + + + + + + + p. aeruginosa + + + + + + + + + + + + + + + + + + + + + + + + + + + note: + : bacterial colonies were present, : bacterial colonies were absent, (+): mh broth with tested bacteria suspension, (-) : 100% j. multifida leaf infusion with mh broth ivan et al.: etiology of symptomatic focal epilepsy based on neuroimaging result in neurology outpatient clinic of dr. hasan sadikin general hospital althea medical journal. 2019;6(2) 98 amj june 2019 have been produced surrounding the infusion holes with 100% and 75% infusion concentrations, however, bacterial growth still exists in the hole after examination with gram staining. it is possible that the antibacterial contents in the infusion are not enough to kill the bacteria, as such only the bacteriostatic effect is observed. the bacteriostatic effect is not observed in the mic and mbc test. it is shown by the presence of bacterial growth in all of the tubes except in the negative control tube. this could be due to the concentration of the infusion. even though the infusion with the highest concentration (100%) has been used, the concentration becomes only 50% after the mixing with mueller hinton broth. on the other hand, 50% infusion is failed to produce any inhibitory zones surrounding the holes in the antibacterial effect test. several studies have been done to examine the antibacterial effect of the different parts of j. multifida such as the leaves, barks, and sap. j. multifida leaf extract can inhibit the growth of m. tuberculosis at the concentration of 128 µg/ml.1 interestingly, the bark extract of j. multifida has an inhibitory effect against several types of fungi and bacteria and has the potential to be an antimalarial drug.7 the sap of j. multifida can inhibit the growth of various bacteria.8 in other studies, the cream made of j. multifida sap can help the healing process of s. aureus infection on the external wounds on rats.4 there is a difference between this study and the previous studies in the form of the sample used. this study has used an infusion with water as its solvent, while other studies have made extracts with organic solvents such as ethanol. the advantages of using the infusion method are cheaper, faster, and simpler in terms of procedures and tools needed; meanwhile, extraction process requires prior knowledge about the contents of the plant and their respective suitable solvent. suitable solvents are used to separate the active substances from the plant and dissolve them. after that, the separation of the active substances from the solvent is relatively easier to do to achieve a pure extract. this shows that extract production is more complicated and expensive than the infusion method and hence more difficult to be adopted by the common people. however, the infusion method also has some limitations, one of them being that the amount of the active substance extracted from the plants is less if compared to extract. several studies have shown that the active substances that have ann antibacterial effect in j. multifida leaves are flavonoid, saponin, and tannin.1,9,10 flavonoid and tannin could dissolve in water and hence they are extractable by infusion,11 however, the extracted amount is still much smaller than if ethanol 96% is used. the use of ethanol 96% as the solvent can extract flavonoids and tannin twenty-five times more than when water is used.11 this study has some limitations. there are difficulties in producing infusion concentration higher than 100% because not all the leaves can be submerged in the water. the study could not use dried leaves because the storage was prone to contamination. further studies to compare the antibacterial effect between j. multifida leaf infusion and its extract are interested to be explored. to conclude, j. multifida leaf infusion has an antibacterial effect, which is bacteriostatic against s. aureus and p. aeruginosa. references 1. mina ec, ibarra mr, franzblau sg, aguinaldo am. chemical and antitubercular screening on the leaves of jatropha multifida linn. pure appl bio. 2014;2(1):32–6. 2. falodun a, igbe i, erharuyi oy, agbanyim oj. chemical characterization, antiinflammatory and analgesic properties of jatropha multifida root bark. j appl sci environ manag. 2013;17(3):357–62. 3. agoes goeswin. teknologi bahan alam. bandung: penerbit itb; 2007. p.10–24. 4. muntiaha mc, yamlean pvy, lolo wa. uji efektivitas sediaan krim getah jarak cina (jatropha multifida l.) untuk pengobatan luka sayat yang terinfeksi bakteri staphylococcus aureus pada kelinci (orytolagus cuniculus). pharmacon. 2014;3(3):294–302. 5. dwiprahasto i. kebijakan untuk meminimalkan risiko terjadinya resistensi bakteri di unit perawatan intensif rumah sakit. jmpk. 2005;8(4):177–81. 6. mahon cr, lehman dc, manuselis g. textbook of diagnostic microbiology. 4th ed. usa: saunders elsevier; 2011. p.280–1. 7. falodun a, imieje v, erharuyi o, joy a, langer p, jacob m, et al. isolation of antileishmanial, antimalarial and antimicrobial metabolites from jatropha multifida. asian pac j trop biomed. 2014;4(5):374–8. 8. aransiola mn, ehikhase c, mmegwa jc, wahab io. antibacterial and antifungal althea medical journal. 2019;6(2) 99 activities of jatropha multifida (ogege) sap against some pathogens. iosr j pharm biol sci. 2014;9(4):53–7. 9. nuria mc, faizatun a, sumantri. uji aktivitas antibakteri ekstrak etanol daun jarak pagar (jatropha curcas l) terhadap bakteri staphylococcus aureus atcc 25923, escheria coli atcc 25922, dan salmonella typhi atcc 1408. mediagro. 2009;5(2):26–37. 10. fahriya ps, shofi ms. ekstraksi zat aktif antimikroba dari tanaman yodium (jatropha multifida l) sebagai bahan baku alternatif antibiotik alami. jtki. 2011:1–7. 11. agustiningsih, wildan a, mindaningsih. optimasi cairan penyari pada pembuatan ekstrak daun pandan wangi (pandanus amaryllifous r) secara maserasi terhadap kadar fenolik dan flavonoid total. momentum. 2010;6(2):36–41. ivan et al.: etiology of symptomatic focal epilepsy based on neuroimaging result in neurology outpatient clinic of dr. hasan sadikin general hospital vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 30 amj march 2019 muscle mass difference among patients with chronic kidney disease stage 3 to stage 5 ivena,1 rudi supriyadi,2 setiawan3 1faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: ivena, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: ivena15001@mail.unpad.ac.id introduction chronic kidney disease (ckd) is defined as abnormalities of kidney structure or function for 3 months or more.1 ckd has a high and consistent global prevalence.2,3 it is estimated that the prevalence of ckd is between 11 to 13% with the majority ckd is in stage 3. millions of people have died from its complications each year.2,3 it is also ranked as the 17th leading cause of global years of life lost, and the third largest increase of any major cause of death.4 based on national basic health research (riset kesehatan dasar, riskesdas) 2013, the prevalence of ckd in indonesia has increased with age, with a peak in the age above 75 years old.5 generally, ckd stage 1 and 2 show no clinical signs and symptoms, although a decrease in gfr has occurred.6 in advanced stage of ckd, clinical signs and symptoms may appear as a manifestation of declined filtration function. this may also cause some complications.1,6 one of its complications is a decrease in muscle mass that occurs along with advancing stage of ckd.6 low muscle mass can occur due to metabolic acidosis, insulin resistance, inflammation, and increased glucocorticoid production and angiotensin ii in ckd patients. these conditions can activate catabolic pathways such as ubiquitin–proteasome system (ups), caspase-3, lysosomes, and myostatin in protein degradation.7,8 decrease muscle mass and muscle streng this associated with high risk of heart failure, fractures, infections, frailty, and insulin resistance.9 the reduction in muscle mass shows a higher risk of death.10 disability, morbidity and even mortality can occur as a manifestation of comorbid complications of low muscle mass and muscle strength.9 the healthcare and social security agency (badan penyelenggara jaminan sosial kesehatan, bpjs) in indonesia shows that ckd treatment costs is placed second for health funding after heart disease,1 therefore, from an economic and clinical amj. 2019;6(1):30–4 abstract background: low muscle mass is one of the complications of chronic kidney disease (ckd), that may occur due to the accumulation of uremic toxins and other mechanisms related to ckd. the aim of this study was to explore the difference of muscle mass among ckd patients stage 3 to stage 5. methods: a cross-sectional study was conducted with comparative analysis, using secondary data collected during the year 2017 by total sampling method. subjects were patients aged over 18 years with ckd stage 3 to stage 5 from three hospitals in bandung. chronic kidney disease stages were determined based on glomerular filtration rate. muscle mass data was determined using bioelectrical impedance analysis, collected from previous research. data were analyzed usingone-way anova or kruskal-wallis test. results: one hundred subjects consisting of 57 men and 43 women were included in in this study with the mean muscle mass was 26.29%±4.86, of whom 67% of the patients had low muscle mass. there was no difference between male (27.21%±3.82) and female (28.36%±4.67). the muscle mass among patients withckd stage 3 to stage 5 showed no significant results (p>0.05). conclusions: there is no difference in muscle mass among ckd stage 3 to stage 5. keywords: chronic kidney disease, glomerular filtration rate, muscle mass althea medical journal. 2019;6(1) 31 perspective, prevention on ckd progression is required for further complications.12 research on ckd and muscle atrophy has been widely carried out, however, no studies have discussed about differences in muscle mass for each stage of ckd. this study aimed to explore the muscle mass differences among ckd stages. methods the design of this study was a cross-sectional with comparative analysis, conducted from april to august 2018 using secondary data from previous studyin 2017. data were collected from three hospitals in bandung, that were in dr. hasan sadikin general hospital, dustira hospital, and kidney special hospitals ny. r.a. habibie. this study had been approved by the health research ethics committee universitas padjajaran bandung (no.294/ un6.kep/ec/2018). in brief, data from all patients aged over 18 years with ckd stage 3 to stage 5 who had not undergone hemodialysis were collected. data of patients with malignancy, infectious diseases, severe diseases or patients who routinely consumed antioxidants, and patients with incomplete data that did not include the variables sought including muscle mass and gfr, were excluded. the collected data were grouped according to the stages of ckd i.e. stage 3, stage 4, and stage 5, based on the gfr in accordance with kdigo 2012 clinical practice guidelines for evaluation and management of chronic kidney disease.1 skeletal muscle mass were measured using bioelectrical impedance analysis (bia). measurements of muscle mass were performed in various body regions, namely trunk, upper limb, lower limb, and the whole body. muscle mass data were also grouped into 4 categories: low, normal, high, and very high,13 and compared between age group and gender. muscle mass were expressed in terms ofa ratio between muscle mass and body weight.13 one-way anova statistical test was conducted to explore the differences in muscle mass among ckd stages when the data were normally distributed or otherwise kruskal-wallis statistic test when the data was not normally distributed. furthermore, post-hoc analysis was performed to assess the comparison between groups. hypothesis tests were considered significant if the value of p<0.05. multiple linear regression analysis was also conducted to control confounding variables. data analysis was conducted using ibm spss statistics v.23. results in total, 100 data of ckd patients that was met the criteria was collected. the characteristics of the ckd patients were grouped according to the stage of ckd (table 1). most of patients were found to be male; however, there was no significant correlation between gender and ckd stages (p=0.765). as for age, stage 4 ckd patients were found to be older compared to ckd stage 3, in which it had the lowest median age of 54 years, and there was a significant age difference among ckd stage 3-5 (p=0.002). furthermore, no significant difference in bmi among ckd stage 3-5 (p=0.067). the muscle mass in patients with ckd stage 3 to stage 5 was presented in table 2. measurements of muscle mass were performed in various body regions. overall, there was an increase in muscle mass with the stage of ckd, table 1 the characteristicsof chronic kidney disease patients based on stages chronic kidney disease p valuestage 3 (n=21) stage 4 (n=34) stage 5 (n=45) gender, n (%) male 11 (52.38) 21 (61.76) 25 (55.56) 0.765 female 10 (47.62) 13 (38.24) 20 (44.44) age (years), median (min-max) 54 (24-69) 65 (28-77) 59 (33-78) 0.002* bmi (kg/m2),median (min-max) 23.75 (17.65–37.99) 24.39 (18.75-36.36) 22.11 (10.54-35.39) 0.067 note: bmi= body mass index ivena et al.: muscle mass difference among patients with chronic kidney disease stage 3 to stage 5 althea medical journal. 2019;6(1) 32 amj march 2019 although the difference was not significant, except in the upper limb as shown in table 2. interestingly, not only the whole body’smuscle mass in female showed a significant increase with the stages (p=0.046),but also in the upper limb’s muscle mass (p=0.027). the result of the multiple linear regression tests to control confounding variables was shown in table 3. after the multivariate test was performed to control confounding variables (bmi and age), the result showed similar results; there was no significant difference in muscle mass among male subjects with ckd stage 3 to stage 5 (p=0.565 and p=0.422). interestingly, there was a significant difference (p=0.032 and p=0.021)in female subjects. the classical assumption test showed that there was no multicolinearity and error distribution and this had not followed normal distribution pattern. transformation of the dependent variable was needed, so the error distribution followed the normal distribution pattern. discussion chronic kidney disease is predominantly in male, and in our study, aged above 50 years. it is more common in older age due to a decline in renal function with increasing age and due to the presence of various risk factors of ckd in older individuals such as diabetes and table 2 muscle mass in chronic kidney disease stage 3–5 based on gender muscle mass (%) chronic kidney disease p value stage 3 stage 4 stage 5 whole body 26.29±4.86 27.21±3.82 28.3±4.67 0.188 male 28.5 (21.8–35.1) 28.3 (18.3–37.8) 29.5 (16.0–39.2) 0.598 female 23.19±2.82 25.25±2.99 26.99±4.67 0.046* trunk 18.9 (13.6–30) 20.5 (12.5-33.6) 23.6 (10.8–34.4) 0.071 male 23.7 (13.6–30) 21.9 (17.2-33.6) 23.8 (17.9–34.4) 0.553 female 17.53±2.60 18.72±3.01 21.16±5.04 0.055 upper limb 30.4 (20.5-39.9) 33.8 (13.5-41.3) 34.9(18.7–48.5) 0.037* male 35.0 (21.0-39.9) 34.4 (19.9-41.3) 36.3(30.4–42.9) 0.591 female 25.66±3.96 27.25±5.59 31.86±7.52 0.027* lower limb 40.9 (30.1–52.3) 44.15 (34.5-54.9) 45.1(25.0-77.3) 0.245 male 45.9(36.4-52.3) 45.80 (34.8-54.9) 46.9(42.4-77.3) 0.376 female 35.78±3.77 39.19±3.6 39.44±6.86 0.203 note: ckd=chronic kidney disease. *p value <0.05 considered to be significant different among the groups table 3 multiple linear regression analysis with muscle mass as the dependent variable predictor variables male female β value p value confidence interval 95.0 % β value p value confidence interval 95.0 % minimum maximum minimum maximum constant 3.545 0.000 3.091 3.999 3.723 0.000 3.400 4.046 stage 4vs. 3 0.040 0.565 -0.097 0.176 0.119 0.032* 0.011 0.228 stage 5vs. 3 0.049 0.422 -0.072 0.170 0.119 0.021* 0.019 0.219 age 0.004 0.129 -0.009 0.001 -0.006 0.002* -0.009 -0.002 bmi 0.001 0.820 -0.009 0.011 -0.011 0.025* -0.021 -0.002 note: dependent variable = muscle mass (whole body); bmi=body mass index althea medical journal. 2019;6(1) 33 hypertension.14 after stratifying the data into male and female, the result shows that there is no significant difference in whole body’s muscle mass on male subjects; whereas in female subjects there is a significant difference in whole body’s muscle mass. no differences in male subjects may occur due to almost all male subjects who have low muscle mass since stage 3 ckd. the difference in whole body’s muscle mass has been shown in female subjects with stage 3 and stage 5 ckd. statistically, a significant difference in muscle mass of female subjects does not correlate with clinical sign due to a high number of female subjects with low muscle mass. several other factors such as physical activity, nutritional intake, hormonal status, and menopausal status may cause differences in subjects’ muscle mass. this may be due to more daily activities involving the upper and lower extremities. the whole body’s muscle mass may also be affected by low muscle mass in the trunk region. a significant difference in muscle mass has also been found in the female’s upper limb area (p=0.027), next to an increase in muscle mass with increasing stage of ckd. this phenomenon has not been clearly explored and need further study. a decrease in muscle mass can occur along with a declinein kidney function, as confirmed this study.10 as the ckd stage increases, kidney filtration function will decline.1 this condition may cause accumulation of substances that should be excreted through the kidneys. accumulation of uremic toxins may lead to a variety of clinical symptoms and complications.6,15 complications that may arise from the accumulation of uremic toxins include the degradation of muscle protein. this may happen due to the increase of ubiquitin and proteasome transcription, resulting in an increase in protein degradation that may cause loss of muscle protein in ckd patients.16,17 chronic kidney disease stage was also classified based on kidney ability to filter various toxins, the lower the kidney filtration function (higher ckd stage), the higher the amount of toxins that involved in activation of muscle protein degradation process.1,6 muscle protein degradation was a resultof various mechanisms involving uremic toxins such as metabolic acidosis, insulin/igf-1 signaling, inflammation, decreased hypothalamic function in regulating appetite, and micro rna deregulation. all of these conditions may lead to the activation of ups, caspase-3, lysosome and myostatin pathways in muscle protein catabolism.16 these conditions may cause an imbalance between protein synthesis and protein degradation, so that there may be a decrease in muscle mass and muscle strength. loss of appetite may also be caused by a decrease in hypothalamic function. this may also trigger a decrease in muscle mass due to reduced protein intake. disability, mortality and even mortality may occur as a manifestation of comorbid complications of lowmuscle mass and muscle strength.9 this study showed that low muscle mass had been found from stage 3 ckd, however, this study did not measure muscle mass in stage 1 and stage 2 since no clinical signs and symptoms can be observed, even though there is a decrease in gfr.6 prevention of low muscle mass in ckd patients could be done by among others giving supplementation in the form of essential keto acids and amino acids that are safe for the kidneys to prevent further decline in muscle mass, regulation of nutritional intake with a low protein diet that is appropriate for the needs of each ckd stage,9,18 and examination of muscle mass and body composition and doing routine and controlled physical activity are also recommended to prevent ckd progression even to reduce the risk of death due to loss of muscle mass.9 by preventing a decrease in muscle mass and strength in ckd patients, the progression of ckd canbe prevented. if these things weredone,the risk of heart failure, fractures, infections, muscle weakness, and insulin resistance can also be prevented.9 furthermore, the high number of ckd patients with low muscle mass suggests that physical activity is needed. we here to recommend exercise in ckd patients as a structured activity that includes aerobic exercise, which uses large amounts of oxygen for example strength training, which involves using a large amount of muscle; and flexibility training, which involves joint activity. 19 the limitations of this study are unmeasured factors that may affect muscle mass. these factors include data on nutritional intake, hormonal status, menopausal status, and physical activity. confounding variables in this study are controlled through data analysis and data stratification only. another limitation of this study is that the data cannot be excluded from chronic diseases that may have been preceded ckd. one chronic disease that may become the etiology of ckd is diabetes mellitus. diabetes mellitus may affect muscle mass variables in the study subjects. thus, further research is needed by paying attention ivena et al.: muscle mass difference among patients with chronic kidney disease stage 3 to stage 5 althea medical journal. 2019;6(1) 34 amj march 2019 to and taking into account other factors that can affect muscle mass in ckd patients. to conclude, no difference in the whole body’s muscle mass in male patients with chronic kidney disease stage 3 to stage 5; in opposite, female patients subjects with stage 3 to stage 5 ckd. the low muscle mass found since stage 3ckd indicates that the examination of muscle mass, regulation of protein intake and supplementation of nutrients according to patient’s needsare important. references 1. eknoyan g, lameire n, eckardt k, kasiske b, wheeler d, levin a, et al. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney int suppl. 2013;3(1):1–150. 2. hill nr, fatoba st, oke jl, hirst ja, o’callaghan ca, lasserson ds, et al. global prevalence of chronic kidney disease a systematic review and meta-analysis. plos one. 2016;11(7):e0158765. 3. world kidney day. chronic kidney disease. 2018. [cited 2018 august 5]. available from: http://www.worldkidneyday.org/ faqs/chronic-kidney-disease/. 4. gbd 2015 mortality and causes of death collaborators. global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the global burden of disease study 2015. lancet. 2016;388(10053):1459–544. 5. kementrian kesehatan republik indonesi. pusat data dan informasi kementrian kesehatan republik indonesia: situasi penyakit ginjal kronis. jakarta: kementrian kesehatan republik indonesia; 2017. 6. kasper dl, fauci as, hauser sl, longo dl, jameson jl, loscalzo j. harrison’s principles of internal medicine. 19th ed. new york: mcgraw hill education; 2015. 7. wang xh, mitch we. muscle wasting from kidney failure-a model for catabolic conditions. int j biochem cell biol. 2013;45(10):2230–8. 8. wang dt, yang yj, huang rh, zhang zh, lin x. myostatin activates the ubiquitinproteasome and autophagy-lysosome systems contributing to muscle wasting in chronic kidney disease. oxid med cell longev. 2015;2015:684965. 9. stenvinkel p, carrero jj, von walden f, ikizler ta, nader ga. muscle wasting in end-stage renal disease promulgates premature death: established, emerging and potential novel treatment strategies. nephrol dial transplant. 2016;31(7):1070–7. 10. oliveira ea, cheung ww, toma kg, mak rh. muscle wasting in chronic kidney disease. pediatr nephrol. 2018;33(5):789–98. 11. couser wg, remuzzi g, mendis s, tonelli m. the contribution of chronic kidney disease to the global burden of major noncommunicable diseases. kidney int. 2011;80(12):1258–70. 12. olivier j. wouters, donal j. o’donoghue, james ritchie, panos g. kanavos, narva as. early chronic kidney disease: diagnosis, management and models of care. nat rev nephrol. 2015;11(8):491–502. 13. omron healthcare. instruction manual: body composition monitor hbf-375. kyoto, japan: omron healthcare co.,ltd; 2012. 14. prakash s, o’hare am. interaction of aging and chronic kidney disease. semin nephrol. 2009;29(5):497–503. 15. mccance kl, huether se. pathophysiology: the biologic basis for disease in adults and children. 7th ed. st. louis, missouri: elsevier; 2013. 16. wang xh, mitch we. mechanisms of muscle wasting in chronic kidney disease. nat rev nephrol. 2014;10(9):504–16. 17. rajan vr, mitch we. muscle wasting in chronic kidney disease: the role of the ubiquitin proteasome system and its clinical impact. pediatr nephrol. 2008;23(4):527–35. 18. mitch we, remuzzi g. diets for patients with chronic kidney disease, should we reconsider? bmc nephrol. 2016;17(1):80. 19. milam rh. exercise guidelines for chronic kidney disease patients. j ren nutr. 2016;26(4):e23–5. amj vol 7 no 2 2020_200805 final.indd althea medical journal. 2020;7(2) 95 bleeding patterns among severe hemophilia a and b patients in west java muhammad mufakkirul islam,1 susi susanah,2 amaylia oehadian3 1faculty of medicine universitas padjadjaran, indonesia, 2departement of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: muhammad mufakkirul islam, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km. 21, jatinangor, sumedang, indonesia, e-mail: mufakkiruli@gmail.com introduction hemophilia is a genetic disease that is inherited by x-linked recessively. hemophilia is characterized by bleeding abnormalities due to lack of factor viii or factor ix.1–4 when part of the body is injured, the hemostatic process is immediately initiated to protect the integrity of the body and to prevent further bleeding.5,6 platelet activation at the site of injury is followed by sequential activation of clotting factors and fibrin formation.7 factor viii and factor ix are essential for thrombin generation and fibrin spread. circulating factor viii is bound to von willebrand factor (vwf) to protect from proteolytic degradation. both factor viii and factor ix are encoded by genes located in the long arm of the x chromosome. when the gene sequence f8 or f9 is interrupted, synthesis of factor viii/factor ix is reduced or absent, or a less functionally active form is produced.8 some studies have reported that clinical manifestations between hemophilia a (ha) and hemophilia b (hb) do not differ, however, conflicting results might occur such as in bleeding frequency, clinical scores, the need for prophylaxis and the need for joint replacement.9hemophilia b tends to have milder symptoms than those with hemophilia a, especially in young patients.10 an epidemiological study in scotland has shown that hb patients have a hospital admission amj. 2020;7(2):95–8 abstract background: the clinical manifestations of hemophilia a (ha) and hemophilia b (hb)are quite similar; however, the bleeding characteristics of these two hemophilia types have been reported to be different. this study aimed to explore the bleeding patterns among patients with severe ha and severe hb. methods: a cross-sectional study was conducted among patients with severe ha and hb registered at the west java indonesian hemophilia society. the inclusion criteria were patients with severe hemophilia diagnosed for at least one year. the bleeding patterns included bleeding episodes and bleeding types. the mann-whitney test was used to compare bleeding episodes and a chi-square test for bleeding types. results: in total, 158 severe ha patients and 21 severe hb patients were included with a median bleeding frequency per patient per year for ha and hb was 24 (range 0–48) and 24 (range 5–48), respectively. the bleeding types in ha and hb were ecchymosis (69% vs. 66.7%), hematoma (62.7% vs. 61.9%), hemarthrosis (99.4% vs. 100%), epistaxis (46.8% vs. 38.1%), gum bleeding (87.3% vs. 95.2%), intracranial hemorrhage (15.2% vs. 9.5%), multiple hematomas (36.7% vs. 47.6%), hemarthrosishematoma (61.4% vs. 61.9%), and hemarthrosis-ecchymosis (69% vs. 61.9%). however, there was no significant difference in all types of bleeding between ha and hb. conclusions: there is no difference in the pattern of hemorrhage between severe ha and severe hb in west java. however, the bleeding phenotypes in hemophilia has considerable implications in the therapeutic process. further research is needed to optimize the treatment regimens. keywords: bleeding episodes, bleeding types, hemophilia a, hemophilia b https://doi.org/10.15850/amj.v7n2.1941 althea medical journal. 2020;7(2) 96 amj june 2020 rate of 2 to 3 times lower compared to ha.9 in contrast, another study has described that ha has more frequent bleeding frequency compared to hb that is 14.4 times compared to 8.63 bleeding time per patient per year.11 the difference in various bleeding phenotypes in hemophilia has considerable implications in the therapeutic process, thus, further research in this area is needed to optimize treatment regimens.9 there are around two thousand ha patients registered in the indonesian hemophilia society association at the end of 2017, of whom this number is only 10% of the estimated individuals with hemophilia.12 the purpose of this study was to explore the bleeding pattern such as bleeding episodes and bleeding types among patients with severe ha and severe hb in west java. methods this study was a cross-sectional study using comparative analytical methods. a list of hemophilia patients with severe ha and hb in west java was taken from the indonesian hemophilia society in the period july 2018– june 2019. the hemophilia patients must have been diagnosed for at least one year. the data of bleeding episodes when patients had experienced in the last year was collected by calling the patients via mobile phone or by interviewing the patient directly when the patient visited the hospital for control. further confirmation was asked to assess the type of bleeding experienced such as ecchymosis, hematoma, hemarthrosis, epistaxis, gum bleeding, and intracranial hemorrhage. the interview format from the indonesian hemophilia society west java was used when calling or interviewing the patients. the ethics committee of universitas padjadjaran had approved study no. 1248 / un6.kep/ec/2019. the normality test was used to test thedata distribution for age, initial age of diagnosis, and bleeding episodes. the episodes of bleeding were compared using the mann whitney test; whereas the type of bleeding between hemophilia a and b was compared using chisquare. results in total, there were 338 hemophilia patients registered in the west java indonesian hemophilia society, consisted of 252 severe hemophilia and 86 mild-moderate hemophilia. of severe hemophilia patients, only 179 were willing to participate, consisting of 158 ha and 21 hb; while others were excluded due to inactive mobile phone, death, or relocation of domiciles outside of west java. the normality test (kolmogorov-smirnov test) showed that the distribution of age and age of diagnosis were not normal distributed, thus median value was used. furthermore, the data of bleeding episodes among ha and hb was also not normal distributed, thus, the mann whitney test was used as shown in table 1. there was no difference in age between ha and hb (median 14 vs 14 years old; p 0.959). the age of diagnosis in ha was lower than that of hb, however, no statistical difference between ha and hb (median 1.75 vs 3 years old; p 0.204). there were no differences in bleeding episodes between severe ha and hb (median 24 vs 24; p 0.066). the types of bleeding were presented, and no statistically significant differences in distribution and prevalence among ha and hb (table 3). discussion this study is exploring the bleeding pattern such as bleeding episodes and bleeding types table 1 characteristics and bleeding episodes of hemophilia patients in dr. hasan sadikin general hospital, west java, indonesia type of hemophilia hemophilia a hemophilia b p-value age; years median (min-max) 14 (2–44) 14 (3–50) 0.959 age of diagnosis; years median (min-max) 1.75(0–22) 3(0–40) 0.204 bleeding episodesper year median (min-max) 24 (0–48) 24 (5–48) 0.066 althea medical journal. 2020;7(2) 97 among patients with severe ha and severe hb in west java. the bleeding patterns in hemophilia have considerable implications in the therapeutic process.9 the median age of patients with both severe ha and hb in west java registered in the indonesian hemophilia association is 14 years old. these results are different when compared with the median age in other studies, of whom for ha and hb is 23 years old and 28 years old, respectively.11 it seems that ha is younger and hb; whereas in our study the median age of the patients is very young. furthermore, there is no difference in bleeding episodes. in a study published earlier, within a period of 36 months, hemophilia a patients might have 2,800 hemorrhage episodes, whereas hemophilia b has 502 hemorrhage episodes. beside, severe ha has 1,491 joint hemorrhages, and in severe hb has 332 joint bleeding. this study also shows that bleeding episodes in hemophilia a are more than hemophilia b, which is 14.4 vs 8.63 bleeding/patient/year, respectively.11 the differences in the results in our study on the median age and bleeding episodes might be due to the effect of prophylactic administration table 2 distribution and prevalence of bleeding types among patients with severe hemophilia a and severe hemophilia b type of bleeding ha hb total p-value ecchymosis yes 109 (69) 14 (66.7) 123 (68.7) 0.829 no 49(31) 7 (33.3) 56 (31.3) hematoma yes 99 (62.7) 13 (61.9) 112 (62.6) 0.947 no 59 (37.3) 8 (38.1) 67 (37.4) hemarthrosis yes 157 (99.4) 21 (100) 178 (99.4) 0.715 no 1 (0.6) 1 (0.6) epistaxis yes 74 (46.8) 8 (38.1) 82 (45.8) 0.450 no 84 (53.2) 13 (61.9) 97 (54.2) gum bleeding yes 138 (87.3) 20(95.2) 158 (88.3) 0.291 no 20 (12.7) 1 (4.8) 21 (11.7) intracranial bleeding yes 24 (15.2) 2 (9.5) 26 (14.5) 0.489 no 134 (84.8) 19(90.5) 153 (85.5) hematoma multiple yes 58 (36.7) 10 (47.6) 68 (38) 0.333 no 100 (63.3) 11 (52.4) 111 (62) hemarthrosis-hematoma yes 97 (61.4) 13(61.9) 110(61.5) 0.964 no 61 (38.6) 8(38.1) hemarthrosis-ecchymosis yes 109 (69) 13(61.9) 69(38.5) 0.513 no 49 (31) 8(38.1) 57(31.8) muhammad mufakkirul islam et al.: bleeding patterns among severe hemophilia a and b patients in west java althea medical journal. 2020;7(2) 98 amj june 2020 and more equitable replacement factors in the developed countries. in addition, factors that can affect the number of episodes of bleeding in patients including nutritional status,13 the severity of coagulation factor deficiency, genetic factors, and the formation of inhibitors.14 further research on differences in bleeding patterns by considering those confounding factors need to be done. the limitation of this study is the recall bias that may occur in patients or the family members interviewed. furthermore, there are no significant differences in the clinical manifestations of the bleeding episode and bleeding type between severe hemophilia a and b patients in west java. a previous study has shown the same result.15 however, intracranial hemorrhage as a manifestation of the bleeding type which is quite severe and the biggest cause of death in people with severe hemophilia has a percentage of events almost 2-fold greater in hemophilia a when compared with hemophilia b (15.2% vs 9.5%).16 in conclusion, there is no difference in the pattern of hemorrhage between severe ha and severe hb in west java, however, the bleeding phenotypes in hemophilia have considerable implications in the therapeutic process. further research is needed to optimize treatment regimens. references 1. srivastava a, brewer ak, mauserbunschiten ep, key ns, kitchen a, llinas a, et al. guidelines for the management of hemophilia. haemophilia. 2013;19(1):e1– 47. 2. rambe ik, sungkar e, moeliono ma, astini s. prediction of hemophilia joint health score based on age and disease severity of hemophilia a and b with on demand therapy in west java. malays j paediatr child health. 2018;24(2):1–10. 3. berntorp e, shapiro ad. modern haemophilia care. lancet. 2012;379(9824): 1447–56. 4. potgieter jj, damgaard m, hillarp a. one-stage vs. chromogenic assays in haemophilia a. eur j haematol. 2015; 94(suppl 77):38–44. 5. gale aj. continuing education course #2: current understanding of hemostasis. toxicol pathol. 2011;39(1):273–80. 6. versteeg hh, heemskerk jwm, levi m, reitsma ph. new fundamentals in hemostasis. physiol rev. 2013;93(1):327– 58. 7. periayah mh, halim as, saad azm. mechanism action of platelets and crucial blood coagulation pathways in hemostasis. int j hematol oncol stem cell res. 2017;11(4):319–27. 8. fijnvandraat k, cnossen mh, leebeek fwg, peters m. diagnosis and management of haemophilia. bmj. 2012;344:e2707 9. santagostino e, fasulo mr. hemophilia a and hemophilia b: different types of diseases? semin thromb hemost. 2013; 39(7):697–701. 10. mannucci pm, franchini m. is haemophilia b less severe than haemophilia a? haemophilia. 2013;19(4):499–502. 11. nagel k, walker i, decker k, chan akc, pai mk. comparing bleed frequency and factor concentrate use between haemophilia a and b patients. haemophilia. 2011;17(6): 872–4. 12. world federation of hemophilia. annual global survery 2017. canada: world federation of hemophilia; 2018. 13. biere-rafi s, haak bw, gerdes vea, büller hr, kamphuisen pw. the impairment in daily life of obese haemophiliacs. haemophilia. 2011;17(2):204–8. 14. peyvandi f, garagiola i, young g. the past and future of haemophilia: diagnosis, treatments, and its complications. lancet. 2016;388(10040):187–97. 15. longo dl, fauci as, kasper dl, hauser sl, jameson jl, loscalzo j, editors. harrison´s principles of internal medicine. 18th ed. new york: mcgraw-hill professional; 2012. 16. escobar m, sallah s. hemophilia a and hemophilia b: focus on arthropathy and variables affecting bleeding severity and prophylaxis. j thromb haemost. 2013;11(8):1449–53. althea medical journal. 2018;5(2) 87 factors influencing outcomes of children hospitalized with acute severe malnutrition viramitha kusnandi,1 siska wiramihardja,2 adhitya ap,1 dida a gurnida1 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2departement of public helath faculty of medicine universitas padjadjaran, indonesia abstract background: nutrition is still a global health issue, and improving nutrition is among the targets of the sustainable developmental goals (sdgs). one of indonesia’s sdgs indicators is to reduce prevalence of malnutrition in children. indonesia, as a developing country, implements a comprehensive malnutrition treatment program for children, including various aspects related to management of children with acute malnutrition. the purpose of this study was to identify factors associated with the outcome of children hospitalized with acute severe malnutrition. methods: this cross sectional study enrolled 195 children with severe acute malnutrition, admitted to hospital from november 2016 to august 2017. statistical analysis was conducted using multivariable logistic regression to identify factors associated with the outcome. adjusted ratio with confident interval 95% and the value of p <0 .05 was considered significant. result: a total of 195 children were diagnosed havings acute severe malnutrition. a history of complete immunization status (p value <0.001) was proved to be directly proportional to the recovery rate of patients with acute severe malnutrition. provision of other types of antibiotic (p value 0.001) showed to increase recovery rates of patients with acute severe malnutrition. several comorbid diseases reduced recovery rates such as pneumonia (crude or 0.619) tuberculosis (crude or 0.606) and hiv (p value 0.08). conclusions: this study shows that although the provided treatments are appropriate with the standard treatment for severe malnutrition, they still encounter high levels of morbidity. further large-scale studies should be conducted to develop better interventions and management of acute severe malnutrition, in order to achieve better outcome. keywords: children, related factors, outcome, severe acute malnutrition correspondence: viramitha kusnandi, department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, email: virmith@yahoo.com introduction adequate nutrition is a fundamental human right and is a prerequisite for good health. malnutrition is still one of the most common causes of morbidity and mortality among children worldwide, especially in the regions of sub-saharan africa and asia. severe acute malnutrition (sam) causes approximately 1–2 million deaths each year, with 20 million living in a state of severe acute malnutrition.1,2 malnutrition is associated with > 50% mortality in developing countries due to underlying infectious diseases.3 several diseases that often accompanies children with malnutrition and increase mortality are: diarrhea 60.7%, pneumonia 52,%, measles 44.8% and malaria 57.3%.3,4 approximately 2% of children in developing countries suffer from sam, especially in south asian countries and sub-saharan africa. acute severe malnutrition is a common comorbid of children admitted to the hospital.5-7 this underlying condition may cause death up to 25 to 30% of children in many poor countries.6 previous studies suggest that approximately 12 million children under the age of five die every year in developing countries, in which 60% was associated with malnutrition.8 despite good progression in child health, severe acute malnutrition remains the leading cause of death in children under the age of five.7 sam high mortality rate had remained a problem for the past few years. several countries with issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n2.1246 amj.2018;5(2):87–92 althea medical journal. 2018;5(2) 88 amj june 2018 high sam prevalence have developed specific national policies in order to to formulate the strategies to solve malnutrition problem comprehensively.9 currently, there are limited information on treatment outcome and clinical characteristics associated with mortality aiming to improve inpatient care of sam.10 therefore, this study aims to assess outcome status and factors influencing outcome in children with sam admitted to the department of child health hasan sadikin hospital.4 methods this study was conducted in bandung city, ±150 km from indonesia’s capital, jakarta, and is the largest city in west java province with an estimated population of 2,500,000 inhabitants. this study was conducted at dr. hasan sadikin hospital, which is a provincial reference hospital that has a pediatric intraining study program. data was obtained from patient’s medical records with prior approval from the helath research ethics committee and medical record installation of dr. hasan sadikin general hospital. the inclusion criteria were based on who child growth standard curve <-3 z-score or if the patient had bilateral pitting edema or arm circumference <-3 z-score. criteria for improvements were based on the sphere international criteria, in which children returning from hospital present no symptoms of disease and are able to maintain or increase bodyweight (measured within 2 weighing times).4 this cross sectional study enrolled 195 children with acute severe malnutrition treated at the department of child health, dr. hasan sadikin general hospital, since november 2016 to august 2017. analysis using multivariable logistic regression was used to identify the factors associated with outcomes. adjusted ratio with 95% ci and p-values less than 0.05 was considered significant. all data obtained were processed and analyzed using spss software version 16. results the result of this study showed no association between gender, age, place of residence and exclusive breastfeeding with patient outcome (p> 0.05). interestingly, a significant positive correlation was observed between immunization and patient recovery. a total of 96 out of 152 recovered subjects had complete records and 33 out of 43 patients who did not recovered had complete records. complete immunization status in the recovery group was 44.8%, which was higher than the nonrecovered group (12.1%) (table 1). furthermore, in the non-recovered group, the most common comorbidities were pneumonia 44.2%, anemia 32.6%, and tuberculosis 20.9%. from 152 recovered subjects 28.9% were given other antibiotics, while from 43 non recovered subjects, only 4.2% were given other antibiotics. in the nonrecovered group, 72.1% received folic acid supplementation and 58.1% received fe which were significantly higher than the recovered group (52.6% folic acid (p 0.023) and 28.3% fe supplementation (p <0.001), respectively (table 1). moreover, the bivariate analysis indicated that sex, age and residency did not show significant correlation with patient’s outcome. however, the result implied that female, age <2 years and urban residence tend to have a higher chance of recovery. this study revealed that complete immunization status had a 2-fold tendency to recover among children with acute severe malnutrition. comorbid such as tuberculosis, pneumonia, anemia and sepsis showed an or <1, suggesting reduced chance of recovery, but the results were not significant. provision of other antibiotics influenced recovery 8-fold and was statistically significant. multivitamin, folate and fe supplementation results had or<1, meaning that it reduced the chances of recovery, especially folate and fe which was significant. discussion this study included 195 children treated in the pediatric ward of dr. hasan sadikin hospital bandung. this study showed no significant differences in sex among all patients with acute severe malnutrition. the ratio of male and female is 115 to 80. most of the patients were above 5 years old, comprising almost half of the study subjects. a number of research and management in the field of healthcare has continued to increase, aiming to improve recovery rate. malnutrition in children leads to weakened immunity and plays a large role in the high mortality rates observed among children in sub-saharan africa and south asia.11,12 acute severe malnutrition is a global problem especially in developing countries such as indonesia. althea medical journal. 2018;5(2) 89 table 1 basic characteristics of subject total n=195 recovered n=152 not recovered n=43 p-value gender male 115 (59.0) 89 (58.6) 26 (60.5) 0.822 female 80 (41.0) 63 (41.4) 17 (39.5) age < 2 years old 59 (30.3) 46 (30.3) 13 (30.2) 0.255 2–5 years old 54 (27.7) 46 (30.3) 8 (18,.) >5 years old. 82 (42.1) 60 (39.4) 22 (51.2) residence rural 99 (50.8) 74 (48.7) 25 (58.1) 0.274 urban 96 (49.2) 78 (51.3) 18 (41.9) exclusive breastfeeding n=9 n=9 not breastfeeded 3 (33.3) 3 (33.3) 6 months 4 (44.4) 4 (44.4) 2 years 2 (22.2) 2 (22.2) immunization status n=129 n=96 n=33 measles 63 (48.8) 37 (38.5) 26 (78.8) <0.001* complete 47 (36.4) 43 (44.8) 4 (12.1) incomplete 19 (14.7) 16 (16.7) 3 (9.1) comorbid diarrhea 18 (9.2) 16 (10.5) 2 (4.7) 0.372 tbc 30 (15.4) 21 (13.8) 9 (20.9) 0.254 hiv 2 (1.0) 0 (0.0) 2 (4.7) 0.048* pneumonia 69 (35.4) 50 (32.9) 19 (44.2) 0.172 anemia 61 (31.3) 47 (30.9) 14 (32.6) 0.838 chf 8 (4.1) 7 (4.6) 1 (2.3) 0.688 sepsis 22 (11.3) 16 (10.5) 6 (14.0) 0.586 head circumference n=64 n=49 n=15 normosefal 24 (37.5) 19 (38.8) 5 (33.3) 0.930 mikrosefal 36 (56.3) 27 (55.1) 9 (60.0) makrosefal 4 (6.3) 3 (6.1) 1 (6.7) treatment amoxicillin 10 (5.1) 10 (6.6) 0 (0.0) 0.121 ampicillin-gentamisin 99 (50.8) 72 (47.4) 27 (62.8) 0.074 other antibiotics 46 (23.6) 44 (28.9) 2 (4.7) 0.001* supplements multivitamin 93 (47.7) 69 (45.4) 24 (55.8) 0.227 folat 111 (56.9) 80 (52.6) 31 (72.1) 0.023* fe 68 (34.9) 43 (28.3) 25 (58.1) <0.001* viramitha kusnandi, siska wiramihardja, adhitya ap, dida a gurnida: factors influencing outcomes of children hospitalized with acute severe malnutrition althea medical journal. 2018;5(2) 90 amj june 2018 table 2 bivariate analysis of logistic regression factors affecting the output crude or (95% ci) p-value gender male 1 female 1.083 (0.542 – 2.161) 0.822 age < 2 years old 1 2–5 years old 1.297 (0.591 – 2.847) 0.516 >5 years old 2.108 (0.861 – 5.164) 0.103 residence rural 1 urban 1.464 (0.739 – 2.902) 0.275 immunization status measles 1 complete 0.267 (0.070 – 1.010) 0.052 incomplete 2.016 (0.406 – 10.016) 0.391 comorbid diarrhea 2.412 (0.532 – 10.972) 0.253 tbc 0.606 (0.254 – 1.441) 0.257 hiv pneumonia 0.619 (0.310 – 1.235) 0.174 anemia 0.927 (0.449 – 1.914) 0.838 chf 2.028 (0.243 – 16.947) 0.514 sepsis 0.725 (0.265 – 1.984) 0.532 treatment amoxicillin ampicillin-gentamisin 0.533 (0.266 – 1.069) 0.076 other antibiotics 8.352 (1.936 – 36.033) 0.004* supplements multivitamin 0.658 (0.333 – 1.301) 0.229 folat 0.430 (0.206 – 0.900) 0.025* fe 0.284 (0.141 – 0.573) <0.001* this study showed a recovery rate of 77.9%, slightly exceeding the minimum value of international standards to monitor recovery rates which is more than 75%.4,13 these results are similar with results obtained by jimma university, which show a result of 77.8%.4 these results provide notice that the recovery rate of children with acute severe malnutrition is still low, therefore an intervention program is needed to improve welfare and health of the child in the future.14 the differences in recovery outcomes may be influenced by socioeconomic status, quality of treatment, clean and healthy life behavior, access to supplementary food and health services, and finally the difference in malnutrition management guidelines in each area. the study in africa conducted by grebemichael et al.10 shows similar results. the study reported that socio-demographic factors althea medical journal. 2018;5(2) 91 such as age and residence are not associated with recovery rates, however immunization status is proportionally correlated with severe acute malnutrition in children.14 furthermore, pneumonia occurred in 35% of sam patients, pneumonia is the most frequent comorbid disease suffered by the subjects. the incidence of pneumonia is still high in indonesia, data from a study conducted by rudan et al. in tan et.al15 showed that 450.611 episodes of lower respiratory tract infection in children <5 years old are caused by streptococcus infection pneumonia. rudan et al. in tan et al.15 also showed that in surabaya and denpasar are 283 cases/100,000 children and 347 cases/100,000 children. the low recovery rate obtained in this study might be due to the lack of data and limited amount of subjects. in addition, low immunization coverage also contributes to the recovery rate of children with severe acute malnutrition. the study was conducted at a tertiary referral hospital, therefore many patients had a severe comorbid such as tuberculosis, congenital heart disease, hemato-oncology and hiv malignancies, all which have an effect on the recovery rate of hospitalized patients. similar outcomes was reported by a retrospective cohort study conducted in southern africa, in which socio-demographic characteristics such as age, place of residence, and breastfeeding status are not statistically associated with recovery rates. however, immunization status and use of other antibiotics are statistically correlated.10 moreover, the probability of recovery rate of patients with comorbid decreases, that was also found in studies conducted at jimma university, which reported low recovery rate and increase chance of mortality among patients with comorbid.16 the reason behind this might be due to longer admission period, severe decline of nutrition status, and higher demand for nutrition. however, intake, absorption, and utilization remains low.10,16 other comorbid studies are patients with hiv / aids and tb who have a lower recovery rates than patients without hiv / aids and tb. the percentage of people with hiv and tb in this study are 1% and 15.4% respectively. this study has similar results as those done by collins et al.17 the limitations of this study are the lack of comparison with other studies conducted in other health facilities within the same area; lack of information on the study subject because the study relied on medical record records; and the lack of appropriate statistical method to use in a small sample.4 it can be concluded that there is an association of factors that alleviate and increase the morbidity and mortality of acute severe malnutrition in children. based on this research, the patient’s complete immunization status and measles immunization was found to correlate with better recovery rates, while the provision of multivitamin, folic acid and fe supplements reduces the chance of recovery. the use of other choices of antibiotics is also a factor that may have more influence on the recovery rate than the provision of ampicillin and gentamicin and when not given antibiotics. additionally, hiv infection, pneumonia and tuberculosis are comorbid factors that exacerbate acute severe malnutrition. references 1. jarso h, workicho a, alemseged f. survival status and predictors of mortality in severely malnourished children admitted to jimma university specialized hospital from 2010 to 2012, jimma, ethiopia: a retrospective longitudinal study. bmc pediatr. 2015;15(1):76. 2. mekuria g, derese t, hailu g. treatment outcome and associated factors of severe acute malnutrition among 6–59 months old children in debre markos and finote selam hospitals, northwest ethiopia: a retrospective cohort study. bmc nutrition. 2017;3(1):42. 3. berti a, bregani er, manenti f, pizzi c. outcome of severely malnourished children treated according to unicef 2004 guidelines: a one-year experience in a zone hospital in rural ethiopia. trans r soc trop med hyg. 2008;102(9):939–44. 4. desyibelew hd, fekadu a, woldie h. recovery rate and associated factors of children age 6 to 59 months admitted with severe acute malnutrition at inpatient unit of bahir dar felege hiwot referral hospital therapeutic feeding unite, northwest ethiopia. plos one. 2017;12(2):e0171020. 5. dereje n. determinants of severe acute malnutrition among under five children in shashogo woreda, southern ethiopia: a community based matched case control study. j nutr food sci. 2014;4(5):300 6. shanka n, lemma s, abyu d. recovery rate and determinants in treatment of children with severe acute malnutrition using outpatient therapeutic feeding program in kamba district, south west ethiopia. j viramitha kusnandi, siska wiramihardja, adhitya ap, dida a gurnida: factors influencing outcomes of children hospitalized with acute severe malnutrition althea medical journal. 2018;5(2) 92 amj june 2018 nutr disorders ther. 2015;5(2):155 7. lijalem m, ahmed a, mulate a, asmare a, bahiru k. severity of malnutrition and treatment responses in under five children in bahir dar felege hiwot referral hospital, northwest ethiopia. j food nutr sci. 2014;2(3):93–8. 8. chane t, oljira l, atomesa ge, agedew e. treatment outcome and associated factors among under-five children with severe acute malnutrition admitted to therapeutic feeding unit in woldia hospital, north ethiopia. j nutr food sci. 2014;4(6):329. 9. ahmed s, ejaz k, mehnaz a, adil f. implementing who feeding guidelines for inpatient management of malnourished children. j college physicians surg pak. 2014;24(7):493–7. 10. gebremichael dy. predictors of nutritional recovery time and survival status among children with severe acute malnutrition who have been managed in therapeutic feeding centers, southern ethiopia: retrospective cohort study. bmc public health. 2015;15(1):1267. 11. black re, morris ss, bryce j. where and why are 10 million children dying every year? lancet. 2003;361(9376):2226–34. 12. munthali t, jacobs c, sitali l, dambe r, michelo c. mortality and morbidity patterns in under-five children with severe acute malnutrition (sam) in zambia: a five-year retrospective review of hospitalbased records (2009–2013). arch public health. 2015;73(1):23. 13. van zutphen t. sphere project: humanitarian charter and minimum standards in humanitarian response. rugby,warwickshire, uk: practical action publishing; 2011. 14. mbaya d, bitok lk, karani ak, osano b, habtu m. outcomes of severely malnourished children aged 6-59 months on outpatient management program in kitui county hospital, kenya. open journal of child health. 2015;5(04):326–33. 15. tan kk, dang da, kim kh, kartasasmita c, kim hm, zhang x-h, et al. burden of hospitalized childhood communityacquired pneumonia: a retrospective cross-sectional study in vietnam, malaysia, indonesia and the republic of korea. hum vaccine immunother. 2018:14(1):95–105. 16. singh k, badgaiyan n, ranjan a, dixit h, kaushik a, kushwaha k, et al. management of children with severe acute malnutrition: experience of nutrition rehabilitation centers in uttar pradesh, india. indian pediatr. 2014;51(1):21–5. 17. collins s, dent n, binns p, bahwere p, sadler k, hallam a. management of severe acute malnutrition in children. lancet. 2006;368(9551):1992–2000. amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 83 correlation between cognitive function and physical performance in community-dwelling older adults amanda risviandari,1 rensa2 1school of medicine and health sciences atma jaya catholic university of indonesia, indonesia, 2department of internal medicine school of medicine and health sciences atma jaya catholic university of indonesia, indonesia correspondence: amanda risviandari, school of medicine and health sciences atma jaya catholic university of indonesia, jalan pluit raya no.2, penjaringan, jakarta utara, indonesia, email: amandarsvdr@gmail.com introduction the older adult is those who have reached the age of 60 years or older.1 the proportion of the elderly population over 60 in indonesia exceeds 7% of the total population, hence indonesia is transitioning towards an aging population.2 the number of older adults in indonesia in 2019 was 25.9 million (9.7%) and is expected to continue to increase to 48.2 million in 2035.2 one of the health problems commonly found in an older adult is an impaired cognitive function. this cognitive impairment is in the form of difficulty remembering, recognizing, and thinking, affecting everyday life.3 the prevalence of people with cognitive impairments in indonesia is about 2.2 million of total of 220 million people.4 older adults with cognitive impairment will undoubtedly find it difficult to carry out daily activities. thus, it can cause a significant decrease in functional status.5 the ability of an individual to carry out daily activities is determined by an understanding of physical performance.6 several components of a cognitive function affect a person’s physical performance, including attention and executive function. attention is the ability to focus on a specific stimulus, whereas executive function is the ability to perform complex motor functions.7 if these two components decrease in function, it may cause a mobility impairment in older adults.8 older adults with low mobility will have a poor quality of life, encounter social isolation, and also become dependent on others’ help because they cannot do it independently.9 this study aimed to determine the correlation between cognitive function and physical performance in community-dwelling older adults. by understanding the correlation, the number of older adults who experience amj. 2021;8(2):83–6 abstract background: one of the health problems often found among older adults in indonesia is cognitive impairment, resulting in difficulties daily life and a significant decrease in functional status. this study aimed to determine the correlation between cognitive function and physical performance in community-dwelling older adults. methods: this was a cross-sectional study conducted from october–november 2019. samples were collected from north jakarta through consecutive sampling (n=38). cognitive function was measured using the mini-mental state examination (mmse) and the physical performance was measured using the timed up and go test (tug) method. the statistical test applied in this study was spearman’s rank correlation (p<0.05). results: the majority of the subjects in this study were mostly female young older adults with the most received ≥12 years of education. the results for both mmse and tug were normal. there was a negative correlation between mmse and tug scores (r= -0.357, p=0.028). conclusions: there is a weak but significant correlation between cognitive function and physical performance in community-dwelling older adults. a further study exploring cognitive dysfunction and physical performance in older adults is needed. keywords: cognitive function, elderly, physical performance https://doi.org/10.15850/amj.v8n2.2145 althea medical journal. 2021;8(2) 84 althea medical journal june 2021 physical performance impairment due to cognitive function impairment can be reduced. methods this study was conducted from october to november 2019 with a cross-sectional study design. the study protocol had been approved by the ethical committee of school of medicine and health sciences atma jaya catholic university of indonesia no. 33/11/ kep-fkuaj/2019. samples were collected from the santo lukas sunter catholic church, north jakarta, dki jakarta through consecutive sampling. this place had a community of older adults who were active in carrying out daily activities. the number of samples needed was calculated by the sample size formula used for correlative analytical research. respondents were approached and being informed about the study, and those who consented were then evaluated for eligibility.10 the inclusion criteria were those aged ≥60 years old that were still able to walk, either with or without aid tools (canes, walkers), and who were willing to participate after giving consent. the exclusion criteria were those who had a habit of consuming alcohol, had experienced acute illness (respiratory infections, arthritis, and others), and had a history of orthostatic hypotension, hemiparesis, fractures, or illiteracy. cognitive function was measured using the mini-mental state examination (mmse) questionnaire, which contains five cognitive domains (orientation, registration, attention and calculation, recall, and language)11 and was obtained through interviews. the cut-off point for the mmse score based on education level was 22 for the 1–5 years of education, 23 for the 6–11 years of education, and 24 for the ≥12 years of education.12 physical performance was measured using the timed up and go test (tug) method and a stopwatch was used to measure the time. the score was normal if <10 seconds, moderate impairment if 10–20 seconds, and severe impairment if >20 seconds.13 spearman’s rank correlation test was used as the statistical test considering the data to be tested was in the data was a categorical scale. results in total, 38 older adults were participated, predominantly (n=28) those in the young-old category of 60–69 years. the respondents were mostly females (34 of 38), and the highest education level was ≥12 years (29 of 38). since the respondents were limited, the frequency in percentage was not calculated. the mmse and tug results were mostly normal, with a median score of mmse was 28 and tug was 7.35 seconds as shown in table 1. based on the age category in this study, those in the middle old category (70–79 years old) had more impaired cognitive function and moderate impairment of physical performance as depicted in table 2. the normality test was performed using the shapiro-wilk test, showing that the data distribution for the variable mmse score table 1 general characteristics of respondents (n=38) characteristics mean (sd) or median (min–max) n age (years) young old (60–69) middle old (70–79) 65.89 (5.402) 28 10 gender male female 4 34 education (years) 6–11 ≥12 12.26 (2.648) 9 29 cognitive function normal impaired 28 (18–30) 29 9 physical performance (tug score) normal (<10) moderate impairment (≥10) 7.35 (5.95–14.93) 31 7 note: tug= timed up and go test; sd= standard deviation althea medical journal. 2021;8(2) 85amanda risviandari et al.: correlation between cognitive function and physical performance in community-dwelling older adults and tug score was not normal (p=0.000; α=0.05; p<α). furthermore, there was a weak and negative correlation between cognitive function and physical performance (r= –0.357). the correlation between cognitive function and physical performance in communitydwelling older adults was shown in table 3. discussions this study describes community-dwelling older adults who are mostly females and in young-old category (60–69 years old). in general, the status of cognitive function and physical performance of these elderly are normal. furthermore, the middle old category (70–79 years old) has more impaired cognitive function as well as a moderate impairment of physical performance. our study has shown a significant correlation between cognitive function and physical performance. cognitive impairment begins at the age of 50, and it gets more severe at the age of ≥70. each component of cognitive function starts declining at a different age. for example, intellectual ability begins to decline at the age of 80 and executive function declines at age 70. interestingly, attention begins to decline at the age of 20, and visuospatial declines at age 60. cognitive function impairment occurs as a result of the aging process, of which brain structure in the frontal cortex has significantly changed. there is a decrease in the volume of the gray matter and the white matter. by the age of 70, the gray matter decreases by 6.14%, while the white matter decreases by 16–20%.14 this study has shown that an increase in the mmse score correlates with the decrease of the tug score. the higher mmse score means better cognitive function; whereas the lower tug score means better physical performance. prior research showed that 11.3% of the elderly aged 45 to 64 years and 31.7% of the elderly aged ≥65 years experience difficulty in moving.15 the decline in physical performance among older adults can be caused by decreased muscle mass and muscle strength with age, which begins at 50 years.16 furthermore, there is a strong and negative correlation between dementia and functional ability. it also shows that the mmse score is dominated by mild cognitive impairment (56.25%).17 a study among older adults aged 69–80 years in malaysia also shows that there is a weak and negative correlation between cognitive function and physical performance.18 the cognitive abilities will decrease as aging occurs, so that the ability to learn new things, carry out orders, and good coordination between understanding, attention, and a person’s motor skills to perform activities are also declined.7 there are several limitations in this study, one of which is the possibility that some of the information given during the interview is not easily understood by the elderly. the design of this study, which is cross-sectional, can only show things that are happening at present moment, thus, any clausal relation cannot table 2 cognitive function and physical performance based on age category young old (60–69 years old) middle old (70–79 years old) cognitive function normal impaired 26 2 3 7 physical performance normal moderate impaired 27 1 4 6 note: tug= timed up and go test; sd= standard deviation table 2 cognitive function and physical performance based on age category cognitive function physical performance (tug score) pnormal (<10) moderate impairment (≥10) normal impaired 26 5 3 4 0.028 note: tug= timed up and go test; althea medical journal. 2021;8(2) 86 althea medical journal june 2021 be described. the respondents in this study are limited, thus further study is interesting to explore this correlation in broader multi variables. in conclusion, there is a statistically significant correlation, hence a weak and negative correlation, between cognitive function and physical performance in community-dwelling older adults. further study is imperative, to prevent an increasing number of cognitive impairment and physical performance impairment in older adults. references 1. jaul e, barron j. age-related diseases and clinical and public health implications for the 85 years old and over population. front public health. 2017;5:335. 2. soulissa ag. a review of the factors associated with periodontal disease in the elderly. journal of indonesian dental association. 2020;3(1):47–53. 3. dini aa. sindrom geriatri (imobilitas, instabilitas, gangguan intelektual, inkontinensia, infeksi, malnutrisi, gangguan pendengaran). medula. 2013;1(3):117–25. 4. sengkey ah, mulyadi m, bawotong j. hubungan depresi dengan interaksi sosial lanjut usia di desa tombasian atas kecamatan kawangkoan barat. e-journal keperawatan. 2017;5(1):15948. 5. mongisidi r, tumewah r, kembuan mahn. profil penurunan fungsi kognitif pada lansia di yayasan-yayasan manula di kecamatan kawangkoan. jurnal e-clinic. 2013;1(1):1–10. 6. van lummel rc, walgaard s, pijnappels m, elders pjm, garcia-aymerich j, van dieën jh, et al. physical performance and physical activity in older adults: associated but separate domains of physical function in old age. plos one. 2015;10(12):e0144048. 7. harada cn, natelson love mc, triebel kl. normal cognitive aging. clin geriatr med. 2013;29(4):737–52. 8. ferrucci l, cooper r, shardell m, simonsick em, schrack ja, kuh d. age-related change in mobility: perspectives from life course epidemiology and geroscience. j gerontol a biol sci med sci. 2016;71(9):1184–94. 9. manini tm. mobility decline in old age: a time to intervene. exerc sport sci rev. 2013;41(1):2. 10. setia ms. methodology series module 5: sampling strategies. indian j dermatol. 2016;61(5):505–9. 11. prakoso k, vitriana, ong a. correlation between cognitive functions and activity of daily living among post-stroke patients. althea medical journal. 2016;3(3):329–33. 12. kochhann r, varela js, de macedo lisboa cs, chaves mlf. the mini mental state examination: review of cut off points adjusted for schooling in a large southern brazilian sample. dement neuropsychol. 2010;4(1):35–41. 13. nurmalasari m, widajanti n, dharmanta rs. hubungan riwayat jatuh dan timed up and go test pada pasien geriatri. jurnal penyakit dalam indonesia. 2018;5(4):164– 8. 14. laksmidewi aaap. cognitive changes associated with normal aging. in: laksmidewi aaap, adnyana imo, meidiary aaa, susilawathi nm, witari np, yuliani d, et al., editors. proceeding the 4th bali neurology update; 2016 july 22–24. denpasar: udayana university press; 2016. 15. satariano wa, guralnik jm, jackson rj, marottoli ra, phelan ea, prohaska tr. mobility and aging: new directions for public health action. am j public health. 2012;102(8):1508–15. 16. norheim kl, hjort bønløkke j, samani a, omland ø, madeleine p. the effect of aging on physical performance among elderly manual workers: protocol of a cross-sectional study. jmir res protoc. 2017;6(11):e226. 17. suwarni s, setiawan s, syatibi mm. hubungan usia demensia dan kemampuan fungsional pada lansia. jurnal keterapian fis. 2017;2(1):34–41. 18. won h, singh dka, che din n, badrasawi m, manaf za, tan st, et al. relationship between physical performance and cognitive performance measures among community-dwelling older adults. clin epidemiol. 2014;6:343–50. vol 4 no 3 full text final.indd althea medical journal. 2017;4(3) 402 amj september 2017 pulmonary function of tuberculosis patients in medication at dr. hasan sadikin general hospital bandung 2013–2014 shalahuddin galih pradipta,1 hendarsyah suryadinata,2 setiawan3 1faculty of medicine, universitas padjadjaran, 2departement of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3departement of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: tuberculosis (tb) is a dangerous global disease that already affects millions of people in the world and acts as the second most frequent cause of death in infectious diseases. tuberculosis mostly attacks the lung and the inflammation process causes lung damage. the lung damage causes a decrease in pulmonary function. there has been no study about tuberculosis patient lung function in the advanced stage of medication. methods: this study was conducted from august–october 2014 at dots policlinic of dr. hasan sadikin general hospital bandung. the study population was lung tb patients. the inclusion criteria were 1st category lung tb patients with anti-tb drug treatment on intensive phase. the exclusion criteria were extrapulmonary tb patients, patients with lung surgery history, and patients with asthma or chronic obstructive pulmonary disease (copd). this study used purposive sampling. the subjects were given a spirometry test where the forced expiratory volume 1 second (fev1), forced vital capacity (fvc), and their ratio were collected and then interpreted. results: among the 60 subjects included in this study, the data showed that 83.4% of the subjects had a decreased pulmonary function consisting of obstructive (6.7%) and restrictive patterns (76.7%). conclusions: the majority of pulmonary tb patients treated with 1st category anti-tb drugs during intensive phase have a decrease in pulmonary function and most of them have restrictive pattern of pulmonary function. keywords: lung, restrictive, spirometry, tuberculosis correspondence: shalahuddin galih pradipta, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: pradipta.galih@yahoo.com introduction tuberculosis is a dangerous global disease that has infected millions of people. it is the second most frequent death cause by infectious diseases. the world health organization (who)1 2013 report stated that globally, there are 8.6 millions new cases of tb and 1.3 millions of death because of tb during 2012. based on who1 data, indonesia is at the 4th position among 5 countries with the highest tb incidence. the data stated that there are 0.4–0.5 millions tb cases in 2012 in indonesia.1 indonesia basic health research in 2010 showed that indonesia has the prevalence of tb as much as 0.725% and tb suspects as much as 2.728%. java island is one of the regions with the most prevalent tb rate in indonesia.2 this shows that tb is the main problem in indonesia. tuberculosis attacks various human organs and tissues. an organ that is most frequently attacked by tb is lung. pulmonary infection by m. tuberculosis causes inflammation that will eventually destroy lung tissues.3 this condition is shown by a decrease in force expiration volume in 1 second (fev1), forced vital capacity (fvc), and the ratio of fev1/fvc. according to some studies regarding decrease in pulmonary function due to tb, it is found that the decrease of pulmonary function can be caused by obstructive, restrictive, or mixed lung disorders.4-6 based on previous studies, there has been no study conducted regarding lung function of pulmonary tb patients in intensive phase of treatment. methods this study was conducted from august− amj. 2017;4(3):402–6 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1189 althea medical journal. 2017;4(3) 403 october of 2014 at dots policlinic of dr. hasan sadikin general hospital bandung. the study population was new pulmonary tb patients in dots policlinic. the inclusion criterion for this study was tb patient treated with 1st category anti-tb drugs during intensive phase of treatment. the exclusion criteria for this study were extrapulmonary tb patients, patients with lung surgery history, patients who smoke cigarettes, and patients with asthma or chronic obstructive pulmonary disease (copd). this study used purposive sampling and involved 62 subjects. two subjects were excluded from this study for having asthma history since it could affect spirometry interpretation. the final number of subjects involved in this study were 60 subjects. the data were collected using spirometry test. then, the values of %fev1, %fvc, and the ratio of fev1/fvc were calculated and interpreted to determine subject’s pulmonary function. the tendency of the values of %fev1, %fvc, and the ratio of fev1/fvc towards age and sex characteristics were assessed. the data were collected by the permission of health research ethics committee of dr. hasan sadikin general hospital. the data were then processed using statistical software. results the subjects were classified based on the general characteristics consisting of age group and sex. table 1 shows general characteristics of the subjects. the subjects were mostly in 15–24 year old and 45–54 year old age groups table 1 general characteristics characteristics n=60 (%) age age groups (years old) 15–24 14 (23.3) 25–34 12 (20) 35–44 10 (16.7) 45–54 14 (23.3) 54–65 7 (11.7) >65 3 (5) mean ± sd 39.18 ± 16.28 sex male 32 (53.3) female 28 (46.7) shalahuddin galih pradipta, hendarsyah suryadinata, setiawan: pulmonary function of tuberculosis patients in medication at dr. hasan sadikin general hospital bandung 2013–2014 table 2 general characteristics of fev1, fvc, and the ratio of fev1/fvc variables n=60 (%) %fev1 0–39 9 (15) 40–49 5 (8.3) 50–59 12 (20) 60–69 15 (25) 70–79 8 (13.3) >80 11 (18.3) mean ± sd 62.03 ± 19.5 %fvc 0–39 6 (10) 40–49 10 (16.7) 50–59 15 (25) 60–69 10 (16.7) 70–79 9 (15) >80 10 (16.7) mean ± sd 61.7 ±17.95 fev1/fvc 0–0.39 0 (0) 0.40–0.49 1 (1.7) 0.50–0.59 2 (3.3) 0.60–0.69 0 (0) >0.70 57 (95) mean ± sd 0.88 ± 0.10 note: *fev1: forced expiratory volume 1 second, **fvc: forced vital capacity with the mean age of 39.18 years old. male subjects were more than female subjects. the subjects were classified based on their fev1, fvc, and fev1/fvc value. table 2 shows the overview of subjects’ %fev1, %fvc, and the ratio of fev1/fvc. most of the subjects had decreased values of fev1 and fvc with normal value of fev1/fvc ratio. the subjects’ fev1, fvc, and the ratio of fev1/fvc were classified based on age and sex. table 3 shows the overview of %fev1, %fvc and the ratio of fev1/fvc based on subjects’ age and sex. all age groups underwent a decrease in the mean values of fev1 and fvc. however, the ratio of fev1/fvc remained normal. male subjects’ %fev1 and %fvc values were lower than female subjects’. the subjects’ pulmonary functions were althea medical journal. 2017;4(3) 404 amj september 2017 classified into normal, obstructive lung disorder, and restrictive lung disorder. table 4 shows the overview of subjects’ pulmonary function. most subjects had table 3 overview of subjects’ %fev1, %fvc and ratio of fev1/fvc based on age and sex characteristics mean ± sd age groups 15–24 years old %fev1 62.71 ± 21.84 %fvc 68.36 ± 20.89 fev1/fvc 0.89 ± 0.13 25–34 years old %fev1 55.17 ± 21.49 %fvc 57 ± 19.42 fev1/fvc 0.89 ± 0.12 35–44 years old %fev1 61.7 ± 25.2 %fvc 62.2 ± 22.39 fev1/fvc 0.85 ± 0.12 45–54 years old %fev1 61.36 ± 14.69 %fvc 57.64 ± 11.29 fev1/fvc 0.88 ± 0.07 55–64 years old %fev1 75.43 ± 11.16 %fvc 67.29 ± 15.3 fev1/fvc 0.90 ± 0.07 >65 years old %fev1 59.33 ± 4.72 %fvc 53.67 ± 6.42 fev1/fvc 0.81 ± 0.08 sex male %fev1 61.66 ± 20.74 %fvc 60.44 ± 19.23 fev1/fvc 0.87 ± 0.1 female %fev1 62.46 ± 18.36 %fvc 63.14 ± 16.59 fev1/fvc 0.88 ± 0.1 note: *fev1: forced expiratory volume 1 second, **fvc: forced vital capacity restrictive lung disorder. the subjects’ pulmonary function classification was classified based on the age group. table 5 shows the overview of pulmonary function based on subjects’ age. obstructive lung disorder was mostly found in subjects aged 55−64 years old while restrictive lung disorder was most likely found in subjects aged 45–54 years old. the subjects’ pulmonary function classification was classified based on sex. table 6 shows the overview of subjects’ pulmonary function based on sex. based on subjects’ sex, the results were most likely the same. discussion subjects were mostly in 15–24 and 45–54 age groups with the mean age of 39.18 years old. this result was consistent with studies conducted by wu et al.7 and abioye et al.8 wu’s7 study was a cohort analytical study regarding age period of tuberculosis notifications in hongkong from 1961–2005. wu et al.7 stated that people aged 20–24 years old have higher risk of suffering tb. the study conducted by abioye et al.8 was a cross-sectional study involving tb patients in nigeria. abioye et al.8 stated that the mean age of tb patients is 32.9 years old and they are mostly 21–30 years old. most subjects in this study were male. this result was similar to the study conducted by neyrolles et al.9 in france. neyrolles’9 study compared tb incidence with previous studies. neyrolles et al.9 stated that tb rate is higher in males than in females with various ratio in each region. most subjects had %fev1 at the range of 60−90, %fvc at the range of 40–49 and 60–69, and the ratio of fev1/fvc at approximately above 0.7. this result was consistent with a comparison study conducted by paspinodya et al.5 paspinodya et al.5 conducted a study regarding pulmonary function of pulmonary tb patients who have undergone treatment table 4 overview of subjects’ pulmonary function category amount (%) normal pulmonary function 10 (16.7) obstructive lung disorder 4 (6.7) restrictive lung disorder 46 (76.7) total 60 (100) althea medical journal. 2017;4(3) 405 for 20 weeks compared to latent tb patients. paspinodya’s5 study stated that most of the subjects have %fev1 at the range of 60−90, %fvc at the range of 40–49 and 60–69, and the ratio of fev1/fvc at approximately above 0.7. all age groups in this study underwent a decrease of %fev1and %fvc. this result was consistent with the study conducted by paspinodya et al.5 paspinodya et al.5 stated that pulmonary tb patients who have undergone treatment for 20 weeks have a decrease in pulmonary function in all age groups with mean %fev1of 77.77 and %fvc of 76.07. this study did not show any decrease of pulmonary function in patients with latent tb.5 among subjects who had decreased %fev1 and %fvc values, male subjects had higher %fev1and %fvc values. this finding was similar to a study done by pereira et al.10 regarding reference value of pulmonary function between male and female in brazil. pereira et al.10 stated that %fev1 and %fvc values and ratio of fev1/fvc of male subjects are higher than of females. most subjects had restrictive lung disorder, similar to study conducted by paspinodya et al.5 this study showed that restrictive lung disorder was the most common finding in pulmonary tb patients who have undergone treatment for 20 weeks or more.5 this finding was also similar to a study conducted by dheda et al.11 dheda et al.11 stated that lesion healing post-tb will cause restrictive lung disorder characteristic findings in spirometry test. some differences were found by menezes et al.4 in a study conducted in some big cities in latin america. menezes et al.4 stated that obstructive lung disorder is the most common finding in patients with pulmonary tb history. the result of menezes’4 study was supported by a study conducted by baig et al.12 in pakistan. baig et al.12 conducted a study regarding pulmonary function of people with cured tb and found out that most subjects have obstructive lung disorder. a study conducted by ramos et al.13 regarding the sequela of pulmonary tb showed different results with menezes et al.4 and baig’s12 studies. ramos’13 study found that most pulmonary tb patients have mixed lung disorder. obstructive lung disorder was mostly found in patients aged 55–64 years old. meanwhile, restrictive lung disorder was mostly found in patients aged 45–54 years old. a study by lamprecht et al.14 showed similar result. lamprecht stated that the age group of 60–69 years old is one of the most prevalent age groups suffering from obstructive lung disorder. a study conducted by paspinodya et al.5 showed that the mean age of subjects with obstructive lung disorder is 47 years old. most subjects had restrictive lung disorder. this result was similar yet different with a study conducted by manino et al.15 mannino et al.15 stated that obstructive lung disorder is mostly found in males while restrictive lung disorder is mostly found in females. the high number of restrictive lung disorder in this study was most likely affected by some factors such as nutrition and treatment. a study conducted by pakasi et al.16 in nusa shalahuddin galih pradipta, hendarsyah suryadinata, setiawan: pulmonary function of tuberculosis patients in medication at dr. hasan sadikin general hospital bandung 2013–2014 table 5 overview of subjects’ pulmonary function based on age pulmonary function age group (years old) 15–24 (n=14)(%) 25–34 (n=12) (%) 35–44 (n=10) (%) 45–54 (n=14) (%) 55–64 (n=7) (%) >65 (n=3) (%) normal 4(28.6) 2(16.7) 2(20) 1(7.1) 1(14.3) 0(0) obstructive lung disorder 1(7.1) 1(8.3) 1(10) 0(0) 1(14.3) 0(0) restrictive lung disorder 9(64.3) 9(75) 7(70) 13(92.9) 5(71.4) 3(100) table 6 overview of subjects’ pulmonary function based on sex pulmonary function sex male (n=32) (%) female (n=28); (%) normal 6(18.8) 4(14.3) obstructive lung disorder 3(9.4) 1(3.6) restrictive lung disorder 23(71.9) 23(82.1) althea medical journal. 2017;4(3) 406 amj september 2017 tenggara found that nutrition is an important factor in tb natural history. this result stated that severe deficiency of vitamin a is associated with severe tb.16 a study conducted by menzies et al.17 regarding the effectivity of tb treatment stated that treatment using rifampin in short duration or intermittently will produce worse outcome of tb treatment. both studies showed that restrictive lung disorder is most likely caused by a longer duration of inflammation. moreover, it is also affected by nutrition and tb treatment. the conclusion of this study is the majority of pulmonary tb patients treated with 1st category anti-tb drugs during intensive phase undergo a decreased pulmonary function and restrictive lung disorder. this study has some limitations. data homogenization cannot be done due to limited time and cost. it is suggested for further studies to provide larger sample size and comparison of pulmonary function of patients in treatment and cured pulmonary tb patients. it is also suggested to do a routine pulmonary function examination and specialized treatment to minimize the decrease of pulmonary function of pulmonary tb patients. references 1. who. global tuberculosis report 2013. who; 2013. 2. trihono. riset kesehatan dasar 2010. jakarta: departemen kesehatan republik indonesia; 2010. 3. fishman ap, elias ja, fishman ja, grippi ma, kaiser lr, senior rm. fishman’s manual of pulmonary diseases and disorders. 3th ed. senior rm, pack ai, editors. new york: mcgraw-hill; 2008. p. 2734. 4. menezes amb, hallal pc, perez-padilla r, jardim jrb, muino a, lopez mv, et al. tuberculosis and airflow obstruction: evidence from the platino study in latin america. eur respir j. 2007;30(6):1180–5. 5. paspinodya jg, miller tl, vecino m, munguia g, garmon r, bae s, et al. pulmonary impairment after tuberculosis. chest. 2007;131(6):1817–24. 6. chung k, chen j, lee c, wu h, wang j, lee l, et al. trends and predictors of changes in pulmonary function after treatment for pulmonary tuberculosis. clinics (sao paulo). 2011;66(4):549–56. 7. wu p, cowling bj, schooling cm, wong iol, johnston jm, leung cc, et al. ageperiod-cohort analysis of tuberculosis notifications in hong kong from 1961 to 2005. thorax. 2008;63(4):312–6. 8. abioye la, omotayo mo, alakija w. socio-demographic determinants of stigma among patients with pulmonary tuberculosis in lagos, nigeria. afr health sci. 2011;11(suppl 1):s100–4. 9. neyrolles o, murci lq. sex inequality in tuberculosis. plos medicine. 2009;6(12):1–5. 10. pereira cadc, sato t, rodrigues sc. new reference values for forced spirometry in white adults in brazil. j bras pneumol. 2007;33(4):397–406. 11. dheda k, booth h, hugget jf, johnson ma, zumla a, rook ga. lung remodeling in pulmonary tuberculosis. j infect dis. 2005;192(7):1201–9. 12. baig im, saeed w, khalil kf. posttuberculous chronic obstructive pulmonary disease. j coll physicians surg pak. 2010;20(8):542–4. 13. ramos lmm, sulmonett n, ferreira cs, henriques jf, miranda ssd. functional profile of patients with tuberculosis sequelae in a university hospital. j bras pneumol. 2006;32(1):43–7. 14. lamprecht b, mcburnie ma, vollmer wm, gudmundsson g, welte t, nizankowskamogilnicka e, et al. copd in never smokers: results from the population-based burden of obstructive lung disease study. chest. 2011;139(4):752–63. 15. mannino dm, mcburnie ma, tan w, kocabas a, anto j, vollmer wm, et al. restricted spirometry in the burden of lung disease study. int j tuberc lung dis. 2012;16(10):1405–11. 16. pakasi t, karyadi e, wibowo y, simanjuntak y, suratih n, salean m, et al. vitamin a deficiency and other factors associated with severe tuberculosis in timor and rote islands, east nusa tenggara province, indonesia. eur j clin nutr. 2009;63(9):1130–5. 17. menzies d, benedetti a, paydar a, martin i, royce s, pai m, et al. effect of duration and intermittency of rifampin on tuberculosis treatment outcomes: a systematic review and meta-analysis. plos med. 2009;6(9):1–18. althea medical journal. 2017;4(3) 407 five years data of vaginal swab examination on sexual assault cases inwest java top referral hospital, indonesia machrani febriastry,1 chevi sayusman,2 zulvayanti3 1faculty of medicine universitas padjadjaran, 2department of legal and forensic medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: vaginal swab test is one of the way to prove that penile penetration has occurred by detection of spermatozoa or seminal fluid components in vaginal fluid of sexual assault victims. it is also used for detecting sexually transmitted infection (sti) in thevictims and identifying perpetrators’ dna. the objective of this study was to describe vaginal swab examination result on sexual assault cases in dr. hasan sadikin general hospital, bandung so it can be used as an evaluation material for the management of sexual assault cases and a reference for subsequent researches related to sexual assault. methods: descriptive study was carried out using medical records and visumetrepertum of sexual assault victims who underwent vaginal swab examination at dr. hasansadikin general hospital, bandung from2010 to2014. of 62 medical records which met the inclusion criteria, 3 were excluded. a total of 59 medical records were included as study subjects. data taken were victims’ age, sexual assault’s time, examination time, penile penetration and intra-vaginal ejaculation history, also vaginal swab and sti examination result. the data were processed and presented using a frequency distribution table. results: spermatozoa were found in 13 cases (22.03%). spermatozoa were found at latest 96 hours since assault. none of the victims was detected with sti. conclusions: the successful rate of spermatozoa detection by conducting vaginal swab in dr. hasansadikin general hospital, bandung is 22.03%. spermatozoa can be detected even 72 hours post assault. keywords: seminal fluid, sexual assault, spermatozoa, vaginal smear, vaginal swab correspondence: machrani febriastry, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: machrani_febriastry@yahoo.com introduction sexual assault is all forms of action or words with unwanted sexual connotations or the forcing of an individual to partake in any activity that goes against their sexuality.1 according to the data from indonesia’s national commission on violence against women (komisi nasional anti kekerasan terhadap perempuan, komnas perempuan) in 2013, there were 5,626 sexual assault cases on indonesian women. these figures have not been yet an accurate depiction of the real total of occurrences due to high number of underreported cases.2 in reported sexual assault cases, forensic examination will be conducted to gather evidence that can be used in the court, either to support or to overrule the allegations of sexual assault.3 one of forensic examination’s components is vaginal swab examination aimed to prove that penile penetration has occurred by detecting the perpetrators’ spermatozoa or seminal fluid components in victim’s vagina. vaginal swab is also taken for identifying perpetrator and detecting sexually transmitted infection (sti) on the victims.1 vaginal swab examination usually consists of microscopic observation accompanied by acid phosphatase (ap) test. more advanced testing involves prostate-specific antigen (psa) or semenogelin (sg) assay.1,3 deoxyribonucleic acid (dna) testing is done for perpetrators’ identification purpose.4 sexually transmitted infection examinations are done to detect trichomonasvaginalis, chlamydia trachomatis, and neisseria gonorrhea.1,3 in dr. hasan sadikin general hospital bandung, as one amj. 2017;4(3):407–12 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1190 amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 206 amj december 2020 proportion of tlr-9 gene polymorphisms at rs352139 (g1174a) in human immunodeficiency virus/acquired immunodeficiency syndrome patients in west java, indonesia yehezkiel yonathan,1 edhyana sahiratmadja,2 agnes rengga indrati3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: edhyana k. sahiratmadja, department of biomedical sciences faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: e.sahiratmadja@unpad.ac.id introduction human immunodeficiency virus (hiv) infection is the main cause of getting immunodeficiency syndrome (aids).1 indonesia has 48,000 new hiv infections and 38,000 aids-related deaths in 2016, and hiv became thus a problem due to increased cases in the population. since 2010, new hiv infections is increased by 68%.2 in west java the number of people with hiv in 2014 reach 13,507 individuals.3 it is well known, that individual infected with hiv has a relatively long latent period with an average of 10 years until symptoms appear.4 the mortality of hiv/aids until today is around 90% and the average time from infection to death is approximately 8–10 years. if the hiv infection is continued to aids, the life expectancy of the patient is only up to two years.5 therefore, better knowledge is required to fight this chronic disease.6 the only way to avoid patients from mortality at this moment is to control viral load and the cluster od differentiation 4+ (cd4+) levels increase.7 hence, factors that affect the viral load and cd4+ on the disease should be well explored. toll-like receptors (tlr), encoded by the tlr gene, might play a role as a pattern recognition receptor (prr).8 the tlr-9 which is located in the endosome recognizes nucleic acids, including the genome of hiv.9 tlr-9 gene is located on chromosome 3p21.3, and especially the polymorphism at g1174a has been widely investigated concerning hiv/aids.10,11 hiv patients with amj. 2020;7(4):206–10 abstract background: human immunodeficiency virus (hiv) infection is the main cause of the immunodeficiency syndrome (aids). tlr-9 gene encodes a toll-like receptor-9 that plays a key role in innate immunity. this study aimed to describe the proportion of tlr-9 polymorphisms at rs352139 in patients with human immunodeficiency virus (hiv) and acquired immunodeficiency syndrome (aids) in bandung, west java, indonesia. methods: this was a descriptive study involving a total of 96 patients with hiv/aids treated in a tertiary hospital in bandung, west java, indonesia in 2013. tlr-9 gene polymorphisms atrs 352139 were examined using a mass screening platform and the genotypes proportion was presented in percentage and compared with other populations. results: the average age of the hiv/aids patients recruited was 30 years(sd+6.1) and the baseline mean of cd4+ count was 318.02 mm3(normal was 1,500 mm3) (sd+273.1). the proportion of polymorphisms at rs352139or g1174a presented a wild type genotype gg (42.7%), ga (44.9%), and aa (12.4%), resulting in a total proportion nucleotide change of 57.3%. conclusions: a total proportion of nucleotide change or polymorphism is higher than the wild type. a further cohort study is of great interest to associate the rs352139 polymorphisms with a decrease in cd4+cells in hiv/aids patients, confirming a rapid disease progression. keywords: cd4+, hiv/aids, polymorphisms, rapid progression, tlr-9, west java https://doi.org/10.15850/amj.v7n4.2014 althea medical journal. 2020;7(4) 207 tlr-9 gene polymorphisms have an increase in viral load and a decrease in cd4+.10 this study aimed to explore the proportion of the tlr-9 gene polymorphisms at rs352139 among hiv/aids patients. methods the design of this study was a retrospective descriptive cross-sectional study. a total of 96 hiv/aids patients were recruited from west java in 2013 of whom the injecting drug use (idu) community was involved from garut, bogor, tangerang, depok, sukabumi, cianjur, and bandung. blood from the vein was collected in 3 ml edta tubes and stored in cold conditions (+4) before being sent to bandung, west java, indonesia, where dna was isolated according to the manufacturer’s protocol (qiaamp dna blood mini kit, cat no.51104, qiagen). polymorphisms in the tlr-9 gene at rs352139 (g1174a) were examined by the golden gate® genotyping assay for veracode®/ beadxpressillumina®. the machine used in this study screened 96 participants in each table 1 clinical characteristic of hiv/aids patients in west java total (n=87) proportion (%) gender ( n= 87) male 73 83.9 female 14 16.1 injected drug users (idu) (n=87) idu 53 60.9 non-idu 34 39.1 tuberculosis (n=85) tuberculosis 4 4.7 non-tuberculosis 81 95.3 figure 1 proportion of polymorphisms tlr 9 rs352139 in west java using illumina’s genomestudio® yehezkiel yonathan et al.: proportion of tlr-9 gene polymorphisms at rs352139 (g1174a) in human immunodeficiency virus/acquired immunodeficiency syndrome patients in west java, indonesia note: each dot represents individual genotypes in one plate for 96 people. the pink area is designated as gg genotype (wild type), the purple area is ga, the blue area is gg, respectively althea medical journal. 2020;7(4) 208 amj december 2020 plate and detect up to 48 snps. in short, dna was activated to bind paramagnetic samples, and hybridization was followed according to the manufacturer’s protocol. the microbead code was identified and a fluorescent signal was detected (beadxpress® reader). during the scan, the laser beam penetrated the digital writing to produce unique codes. data were generated and analyzed (illumina’s genomestudio®). the distribution of each allele and genotype of each number was counted for frequency and compared with published global frequencies. the study protocol was approved by the research ethics committee of universitas padjadjaran, bandung, indonesia (no. 949/ un6.kep/ec/2018). the data was presented in proportion. results in total, 96 participants of iduers from the west java area were included in this study. however, only 89 participants had complete data of genotyping, and only 87 participants had complete clinical data, consisting of 73 males (83.9%) and 14 females (16.1%). among them, there were 53 participants (60.9%) who regularly used injected drugs and 4 participants (4.7%) who had tuberculosis (table 1). the mean age among hiv patients was 30 years old (sd +/6.1 years). as expected, the mean cd4+ count among hiv patients was low which was 318.02 mm3 (sd ± 273.1). the normal cd4+ count was 1500 mm3. the proportion of rs352139 showed the genotype frequency of gg, ga, and aa as 42.7%, 44.9%, and 12.4%, resulting in a total proportion nucleotide change of 57.3% (figure 1). the allele proportion of g was 65.2% and for a was 34.8%. discussion aids is an immunosuppressive condition caused by hiv. the hiv/aids is closely related to various opportunistic infections, secondary neoplasms, and certain neurologic manifestations due to hiv infection. the virus targets cd4+ cells and thus cd4+ levels below 200 cells/ul are associated with hiv infection that later develops into aids.15 the tlr-9 is a pattern-recognition receptor (prrs) which is innate immune response that play a role in the first defense against the virus.9 polymorphisms in tlr-9 have an important role in the progression of hiv/ aids; it increases the clinical progression of the disease.10 to better knowledge of tlr-9 polymorphisms, the proportion of the tlr9 gene among hiv/ aids patients should be revealed. a study by skevakiet al.10 has shown that there are two snps in the tlr-9 gene that play a key role in nucleotide change at rs352140 or a1635g, and at rs352139 g1174a, as those polymorphisms have a role in hiv/aids clinical progression.10 since only one polymorphisms data available in our study, we can only describe the proportion of tlr-9 rs352139 gene among hiv/aids patient in west java, indonesia the proportion tlr-9 rs352139 gene polymorphisms among hiv/aids patient has not been reported in many studies, table 2 comparative frequency distribution of tlr-9 rs352139 genotype in different populations population genotype (%) allele (%) study on disease p-value *p-value reference gg ga aa g a west java 42.7 44.9 12.4 65.2 34.8 hiv/aids present study indonesia 11 52 37 37 63 tuberculosis vs control gg (0.00222) 0.17 kobayashi k, et al.12 12.1 41.6 46.3 32.9 67.1 g(0.0489) vietnam 10.1 45.3 44.6 32.8 67.2 tuberculosis vs control gg (0.239) 0.65 kobayashi k, et al.12 8.8 40.2 51 28.9 71.1 g(0.127) china 20.5 35 35 44.5 65 tuberculosis vs control 0.98 yang y, et al.13 12.2 53.8 34 41.1 58.9 mexico 21.1 53.3 25.6 47.8 52.2 tuberculosis vs control gg (0.01) 0.73 torres-garcía d, et al.14 althea medical journal. 2020;7(4) 209yehezkiel yonathan et al.: proportion of tlr-9 gene polymorphisms at rs352139 (g1174a) in human immunodeficiency virus/acquired immunodeficiency syndrome patients in west java, indonesia only one data from the previous study that represent the frequency of this gene. however, studies on tuberculosis exploring tlr-9 rs352139 gene polymorphisms have shown genotype frequency variation in different populations as shown in table 2. the total proportion of polymorphisms in our study has shown a similar result from published data (46.42%)10, suggesting that tlr-9 rs352139 polymorphisms might have a role in hiv/aids rapid progression. however, the prevalence of the tlr-9 rs352139 gene has been shown differently with several tuberculosis studies in vietnam, china, and indonesia, and mexico (table 2). tlr-9 single nucleotide polymorphism (snp) at rs352139 is located in the intronic region of tlr-9. introns do not play a role in dna synthesis. interestingly, in tlr-9 polymorphisms, the intron region might influence the hiv/aids disease. the presence of g and c alleles is associated with the down regulation of tlr-9 expression at the transcription level. conversely, the presence of allele a induces tlr-9 regulation.14 the mechanism of the interaction between hiv1 and tlr-9 polymorphisms remained poorly understood. several hypotheses have been described; one of the hypotheses is when the reverse transcription phase in viral replication, hiv-1 producing dsdna containing cpg motives. this is transferred from the cytoplasm to the nucleus and integrated into the host cell genome. since tlr-9 is located in endosomal cells, debris that is phagocyted from hiv-1 cells, contain pro-viral dna that activates macrophages through tlr-9. the activated tlr induces the production of proinflammatory cytokines and modulates viral dna who integrated into the cells genome to replicate. this process causes hiv replication to increase and will decrease in cd4 + levels. tlr-9 stimulation via cpg also induces ip10 production from plasmacytoid dendritic cells, monocytes, and b cells. ip10 is elevated in hiv infections and associated with immune activation, plasma viral load, and cd4 decline.16,17 tlr-9 can also be stimulated by cpg dna from bacteria and microbial translocation and plasma levels from bacterial dna both increase in hiv patients and correlate with immune activation.17 the cpg genome of hiv plays a role in the latency of the disease.18 normally, without polymorphisms, tlr-9 will recognize and or target the cpg genome of hiv, thereby reducing the level of cpg, but on the polymorphisms of tlr-9, this doesnot happen.19 from the hypothesis, these polymorphisms will make a rapid clinical progression of the disease. the study was only able to detect one type of polymorphism, which is rs352139. the complete data of tlr-9 polymorphisms and correlation study between the tlr-9 rs352139 gene and hiv/aids is needed in the future study. the distribution of tlr-9 polymorphisms in the larger population in west java has not been conducted. therefore, further studies need to include a control group. in conclusion, total polymorphisms in our study are higher than the wild type and shows similar results from the previous study in mexico and ncbi gene bank. however, the proportion is different from other study in indonesia, vietnam, and china. a further cohort study is of great interest to associate the rs352139 polymorphisms with a decrease of cd4+cells in hiv/aids patients, confirming a rapid disease progression. references 1. sharp pm, hahn bh. origins of hiv and the aids pandemic. cold spring harb perspect med. 2011;1(1):a006841. 2. unaids. unaids data 2017. 2017 [cited 2018 august 29] available from https:// w w w. u n a i d s . o rg / s i te s / d e fa u l t / f i l e s / media_asset/20170720_data_book_2017_ en.pdf 3. pusat data dan informasi kementrian kesehatan ri. infodatin: situasi dan analisis hiv aids. jakarta: pusat data dan informasi kementerian kesehatan ri; 2014 4. siliciano rf, greene wc. hiv latency. cold spring harb perspect med. 2011;1(1):a007096. 5. nicholas jb, shelley ag, michael sb, aaron g, mary lwp. hiv infection and aids workup. new york: medscape; 2017 [cited 2018 august 29] available from: https://emedicine.medscape.com/ article/211316-work. 6. deeks sg, lewin sr, havlir dv. the end of aids: hiv infection as a chronic disease. lancet. 2013;382(9903):1525–33. 7. maartens g, celum c, lewin sr. hiv infection: epidemiology, pathogenesis, treatment, and prevention. lancet. 2014;384(9939):258–71. 8. mackelprang rd, bigham aw, celum c, debruyn g, beima-sofie k, john-stewart g, et al. toll-like receptor polymorphism associations with hiv-1 outcomes among sub-saharan africans. j infect dis. althea medical journal. 2020;7(4) 210 amj december 2020 2014;209(10):1623–7. 9. hajishengallis g, lambris jd. more than complementing tolls: complement–tolllike receptor synergy and crosstalk in innate immunity and inflammation. immunol rev. 2016;274(1):233–44. 10. skevaki c, pararas m, kostelidou k, tsakris a, routsias jg. single nucleotide polymorphisms of toll-like receptors and susceptibility to infectious diseases. clin exp immunol. 2015;180(2):165–77. 11. willie b, hall nb, stein cm, jurevic rj, weinberg a, mehlotra rk, et al. association of toll-like receptor polymorphisms with hiv status in north americans. genes immun. 2014;15(8):569–77. 12. kobayashi k, yuliwulandari r, yanai h, naka i, lien lt, hang nt, et al. association of tlr polymorphisms with development of tuberculosis in indonesian females. tissue antigens. 2012;79(3):190–7. 13. yang y, li x, cui w, guan l, shen f, xu j, et al. potential association of pulmonary tuberculosis with genetic polymorphisms of toll-like receptor 9 and interferongamma in a chinese population. bmc infect dis. 2013;13:511. 14. torres-garcia d, cruz-lagunas a, garciasancho fmc, fernandez-plata r, baezsaldana r, mendoza-milla c, et al. variants in toll-like receptor 9 gene influence susceptibility to tuberculosis in a mexican population. j transl med. 2013;11:220. 15. direktorat jenderal pengendalian penyakit dan penyehatan lingkungan kementerian kesehatan republik indonesia. pedoman nasional tatalaksana klinis infeksi hiv dan terapi antiretroviral pada orang dewasa. jakarta: direktorat jenderal pengendalian penyakit dan penyehatan lingkungan kementerian kesehatan republik indonesia;2011 16. liovat as, rey-cuillé ma, lécuroux c, jacquelin b, girault i, petitjean g, et al. acute plasma biomarkers of t cell activation set-point levels and of disease progression in hiv-1 infection. plos one. 2012;7(10):e46143. 17. joshi a, punke eb, mehmetoglu-gurbuz t, peralta dp, garg h. tlr9 polymorphism correlates with immune activation, cd4 decline, and plasma ip10 levels in hiv patients. bmc infect dis. 2019;19(1):56. 18. blazkova j, murray d, justement js, funk ek, nelson ak, moir s, et al. paucity of hiv dna methylation in latentlyinfected, resting cd4(+) t cells from infected individuals receiving antiretroviral therapy. j virol.2012; 86(9):5390–2. 19. alinejad-rokny h, anwar f, waters sa, davenport mp, ebrahimi d. source of cpg depletion in the hiv-1 genome. mol biol evol. 2016; 33(12): 3205–12. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 175althea medical journal. 2021;8(4):175–180 coping stress of the covid-19 pandemic among medical and non-medical undergraduate students at universitas padjadjaran, bandung, indonesia wulan mayasari,1 devia oktaviandra,2 fathurachman3 1department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of orthopaedic and traumatology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: coping stress is an act of dealing with stress by adapting to the problems of the thought process. the ‘distance learning’ policy is a stress factor during the covid-19 pandemic which may have an impact on psychological conditions and coping stress. this study aimed to determine differences in stress levels and coping stress among medical and non-medical undergraduate students against the global covid-19 pandemic. methods: cross-sectional analytical methods were used. stratified random sampling recruiting undergraduate students, including from medical students (n=80) and non-medical students (n=84) at universitas padjadjaran class 2017–2019. the distributed questionnaire contained 25 questions adapted from the depression anxiety stress scale (dass 42) and the cope inventory. validity and reliability tests were carried out previously, and statistical analysis was performed using spss v.26. results: the median age of both groups was 21 years and most of the respondents were female. there was no significant difference in stress and coping stress. at the time of coping, the medical students focused more on emotions and the non-medical students focused more on the problems. conclusion: there is no difference in the levels of stress and coping stress with emotional and problems focus in the medical and non-medical students. keywords: coping stress, covid-19, epidemiology, medical students, non medical students correspondence: wulan mayasari, dr., mh.kes., aifo-k, department of biomedical sciences, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: wulan.mayasari@unpad.ac.id introduction coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome-coronavirus-2 (sarscov-2) which does not always cause any symptoms such as fever, dry cough, difficulty breathing, and fatigue. however, it has specific symptoms such as anosmia, which is a lack of smell, and ageusia, which is a lack of taste.1–3 in severe cases of covid-19 it can cause pneumonia, acute respiratory syndrome, kidney failure, and even death.1 in 2020, covid-19 has designated as pandemic disease. the number of cases has increased rapidly and spread to various countries in a short time.1 in indonesia, within 4 months of the first case, 70,736 confirmed cases of covid-19 were reported with 3,417 deaths of which the case fatality rate (cfr) is 4.8%.1 the covid-19 pandemic has had psychological and social impact on society as well as on students. the psychological impacts found are anxiety, depression, stress, posttraumatic stress syndrome, and post-traumatic growth.4 similar to the outbreak of influenza a (h1n1) in 2009 and ebola virus disease oubreak in sierra leone during 2014–2015, the most common diagnostic category was mild distress or depression, anxiety disorders, and grief, or social problems.5 state anxiety was found to be high in respondents who felt the vaccine was unsafe.6 in china, during the epidemic of covid-19, the anxiety and https://doi.org/10.15850/amj.v8n4.2242 althea medical journal. 2021;8(4) 176 depression level of college students increased significantly, which was also related to multiple factors.7 the students have increased levels of anxiety, depression, and overreaction to fear of infection due to the emergence of a virus of unknown cause illness or death. factors that influence the psychological state of a pandemic, including attitude to take preventive action, symptoms that appear, social responsibility, personal priority over others, level of knowledge and information obtained about the disease.7 in preventing covid-19, the indonesian government has implemented a large-scale social restrictions, stipulated by the minister of health no. 9/2020. particularly in the field of education, there are distance learning policies to reduce direct interaction. when the individual cannot adapt to the situation for a prolonged period, it can lead to increased stress and anxiety, leading to a state of depression,8 especially among students as they need to adapt to develop in learning. groups of students are under pressure in all aspects of daily life, such as learning, emotion, social interaction, including adapting to conditions of emotional stability, psychological and psychosocial conflicts, therefore, they have to cope with stress during the covid-19 pandemic.7 coping stress is an act to cope with stress which is an adaptation to the problems faced in the thinking process.9 coping with stressors, such as obtaining information related to covid-19, will have an impact on psychological conditions.10 high stress levels will increase the abililty to cope with stress better. medical students have higher stress level than nonmedical students,11 thus, the possibility of coping with stress in medical students tend to be better. the covid-19 pandemic has prompted researchers to study coping stress during the covid-19 pandemic period. this study aimed to compare coping stress during the covid-19 pandemic period among medical and non-medical undergraduate students. methods this study was a cross-sectional analytic study, conducted in september–november 2020 using primary data with a stratified random sampling method. respondents were active students of undergraduate medical and non-medical programs class 2017–2019 at universitas padjadjaran, bandung. this research has obtained permission from the research ethics committee of universitas padjadjaran with no. 826/un6.kep/ec/2020. an online questionnaire adapted from the depression anxiety stress scale (dass 42) and the cope inventory, containing 25 questions was distributed to the respondents. stress level was measured by 14 questions whereas coping stress was measured by 11 questions, especially about the emotional and problemfocused aspects with 8 nad 3 questions, respectively. the answers to each question were assessed using a likert scale of 0 to 3 to represent never (scale 0), sometimes (scale 1), often (scale 2), and always (scale 3). the results of the coping stress were divided into coping focused on emotions or problems. the validity and reliability test of the questionnaire (n=30 questions) were carried out in september 2020 on 30 respondents, who were active students from other universities. only questions with a cronbach’s alpha coefficient >0.7 were included in the quesationnaire. validity was calculated using the pearson’s correlation. in total, 25 questions were eligible for the current questionnaire. valid and reliable questionnaires were then distributed to respondents according to the inclusion criteria through the google form link (online) to avoid direct contact between researcher and the respondents due to the covid-19 pandemic. statistical analysis was processed using microsoft office excel and ibm spss statistics v.26. the normality test was conducted to determine the distribution of the data and data were analyzed using parametric and nonparametric tests (mann whitney t-test). results in total, 164 respondents were included, consisting of 80 medical students and 84 nonmedical students, with the median age of both groups was 21 years old, and predominantly females. the frequency of coping stress between medical students and non-medical students was shown in table 1. the coping stress score had a data distribution normality of p <0.05, thus the data distribution was not normal. the coping stress score in the medical and non-medical groups were 76.02 and 88.67, respectively, and there was no significant difference between both groups (figure). furthermore, there was no significant difference in the comparison of the average value of emotion focused and problem focused between the two groups as shown in table 2. although not significant, the medical students althea medical journal december 2021 althea medical journal. 2021;8(4) 177wulan mayasari et al.: coping stress of the covid-19 pandemic among medical and non-medical undergraduate students at universitas padjadjaran, bandung, indonesia table 1 frequency of coping stress based on emotional and problem focused among medical and non-medical undergraduate students at universitas padjadjaran coping stress never sometimes often always ms n (%) non-ms n (%) ms n (%) non-ms n (%) ms n (%) non-ms n (%) ms n (%) non-ms n (%) emotional focused i try to see the covid-19 pandemic in a positive light from the information circulating. 1 (1.3) 1 (1.2) 26 (32.5) 30 (35.7) 41 (51.3) 37 (44) 12 (15) 16 (19) i share my complaints and boredom regarding the covid-19 pandemic with others or write links on social media. 18 (22.5) 21 (25) 47 (58.8) 36 (42.9) 13 (16.3) 24 (28.6) 2 (2.5) 3 (3.6) i have a lot of ideas that can be put in writing or pictures because there is a lot of free time during distance learning during the covid-19 pandemic. 20 (25) 23 (27.4) 45 (56.3) 40 (47.6) 13 (16.3) 16 (19) 2 (2.5) 5 (6) i tend to postpone work because i feel i have a lot of free time during distance learning during the covid-19 pandemic. 14 (17.5) 12 (14.3) 45 (56.3) 36 (42.9) 20 (25) 28 (33.3) 1 (1.3) 8 (9.5) i vent my emotions by being angry with those around me (eg friends, family) since the covid-19 pandemic. 44 (55) 48 (57.1) 30 (37.5) 26 (31) 6 (7.5) 8 (9.5) 2 (2.4) i am excited when i will meet virtually with relatives. 2 (2.5) 13 (15.5) 31 (38.8) 35 (41.7) 37 (46.3) 29 (34.5) 10 (12.5) 7 (8.3) i seek god's help by praying and praying more often than usual during the covid-19 pandemic. 2 (2.5) 3 (3.6) 28 (35) 18 (21.4) 33 (41.3) 41 (48.8) 17 (21.3) 22 (26.2) i accept the fact that the covid-19 pandemic is happening without us expecting it. 2 (2.5) 10 (12.5) 7 (8.3) 28 (35) 28 (33.3) 40 (50) 49 (58.3) problem focused i try to read the information about covid-19 carefully. 1 (1.3) 21 (26.3) 25 (29.8) 40 (50) 35 (41.7) 18 (22.5) 24 (28.6) during the covid-19 pandemic, i took my mind off boredom during distance learning by doing other activities (for example: watching movies, studying, creating work, exercising at home). 1 (1.2) 12 (15) 15 (17.9) 42 (52.5) 35 (41.7) 26 (32.5) 33 (39.3) i thought about the best way to prevent the spread of covid-19 within my family first by implementing health protocols. 1 (1.2) 10 (12.5) 10 (11.9) 34 (42.5) 30 (35.7) 36 (45) 43 (51.2) note: ms= medical student; non-ms=non-medical student althea medical journal. 2021;8(4) 178 table 2 emotion focused and problem focused coping among medical and non-medical students group mean standard deviation p-value significance* emotion focused medical non-medical 11.74 11.20 2.489 2.477 0.067 0.797 problem focused medical non-medical 6.44 6.55 1.358 1.710 0.652 0.032 were tended to focus more on the emotion and the non-medical students more on the problems. discussion this study shows that there is no difference regarding the level of stress between groups of medical and non-medical students. this is different from a research conducted in saudi arabia,11 resulting that stress levels in medical students are higher than non-medical students. in wuhan, china,7 college students have high levels of stress, anxiety, and depression during the covid-19 pandemic. stress levels may decrease during the covid-19 pandemic because, during the pandemic, everyone is forcing themselves to stay at home and spend a long time with family. increased interaction may improve the quality of life and reduce stress due to the intimacy of social interactions, support from family or people around them, and the gift of love from parents will create resilience and increase better coping and reduce stress levels.12,14 in addition, the same level of stress in medical and non-medical students in saudi arabia is due to differences in several situations figure total score of coping stress among medical and non-medical students note: cs=coping stress althea medical journal december 2021 althea medical journal. 2021;8(4) 179wulan mayasari et al.: coping stress of the covid-19 pandemic among medical and non-medical undergraduate students at universitas padjadjaran, bandung, indonesia and conditions. our study was conducted a few months after the covid-19 pandemic emerged in indonesia, and also when the covid-19 pandemic was still occurring. at that time the distance learning system was in progress, so students from the two groups studied were used to coping well and could adapt to the environment.15 in the comparison of the mean value of coping stress in the two groups, there was no difference. these results are in accordance with the theory of lazarus and folkman, 1984, showing that coping stress is determined by the level of stress. in our study, the results of the stress level of the two groups were not significant and this is in line with the results of the average stress coping score, in which there was no significant difference.16 a particular focus makes a difference in dealing with one’s coping stress. from the results of our study, there was no significant difference in the mean value of the two aspects of emotion-focused and problem-focused between the medical and non-medical groups. however, the results of the study showed that the value of coping aspects that focused on emotions was more diverse in medical students. coping stress that focuses on emotions will reduce individual stress level.17 this can be collaborated with the results of research on stress levels in medical students, which might be higher than non-medical students.11 the medical students have lower stress levels because they do coping stress focuses on emotions. compared with the non-medical group, the scores were more or less diverse on problem-focused coping. the limitation of this study is that there is the lack of research data on coping stress regarding pandemic situation among college students, as this covid-19 pandemic is a new life experience since previous pandemic in century. to conclude, there is no significant difference in stress levels between the medical and non-medical groups. alignment or the absence of differences in stress levels of the two groups result in no differenct of coping stress score. the dominant medical students have emotional-focused coping, and the nonmedical students in problem-focused coping. the result of this study is different from other studies because it is unique since this study has been carried out during the covid-19 pandemic. references 1. kementerian kesehatan republik indonesia. pedoman pencegahan dan pengendalian coronavirus disease (covid-19). jakarta: kementerian kesehatan ri; 2020. 2. rothan ha, byrareddy sn. the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak. j autoimmun. 2020;109:102433. 3. who. episode #59 flu & covid-19 [internet] 2021 [cited 2021 october 30]. available from: https://www. who.int/emergencies/diseases/novelc o ro n av i r u s 2 0 1 9 / m e d i a re s o u rc e s / science-in-5/episode-59---flu-covid-19?gc lid=cjwkcaia4vembhameiwau4xrrznlb 47dwmceezp7fg8txzvp1y9xwsor974cy 0qmbufd5-gbuizsjhocthgqavd_bwe. 4. ratunuman ra, david lev, opod h. dampak psikologis pandemi covid-19 pada mahasiswa. jurnal biomedik. 2021;13(2):227–32. 5. kamara s, walder a, duncan j, kabbedijk a, huges p, muana a. mental health care during the ebola virus disease outbreak in sierra leone. bull world health organ. 2017;95(12):842–7. 6. savas e, tanriverdi d. knowledge, attitudes and anxiety towards influenza a/h1n1 vaccination of healthcare workers in turkey. bmc infect dis. 2010;10:281. 7. liu x, liu j, zhong x. psychological state of college students during covid-19 epidemic. 2020 [cited 2020 december 18]. available from: ssrn: https://ssrn. com/abstract=3552814 or http://dx.doi. org/10.2139/ssrn.3552814. 8. nurkholis n. dampak pandemi novelcorona virus disiase (covid-19) terhadap psikologi dan pendidikan serta kebijakan pemerintah. jurnal pgsd. 2020;6(1):39– 49. 9. gustems-carnicer j, calderón c, calderóngarrido d. stress, coping strategies and academic achievement in teacher education students. eur j teach educ. 2019;42(3): 375–90. 10. gaol ntl. teori stres: stimulus, respons, dan transaksional. buletin psikologi. 2016;24(1):1–11. 11. al-dabal bk, koura mr, rasheed p, alsowielem l, makki sm. a comparative study of perceived stress among female medical and non-medical university students in dammam, saudi arabia. sultan qaboos univ med j. 2010;10(2):231–40. althea medical journal. 2021;8(4) 180 12. polizzi c, lynn sj, perry a. stress and coping in the time of covid-19: pathways to resilience and recovery. clin neuropsychiatry. 2020;17(2):59–62. 13. brown sm, doom jr, lechuga-peña s, watamura se, koppels t. stress and parenting during the global covid-19 pandemic. child abus negl. 2020;110(2):104699. 14. mari e, fraschetti a, lausi g, pizzo a, baldi m, paoli e, et al. forced cohabitation during coronavirus lockdown in italy: a study on coping, stress and emotions among different family patterns. j clin med. 2020;9(12):3906. 15. mazo gn. causes, effects of stress and the coping mechanism of the bachelor of science in information technology students in a philippine university. j educ learn. 2015;9(1):71–8. 16. ryan k. how problem focused and emotion focused coping affects college students’ perceived stress and life satisfaction [bachelor thesis]. dublin: dbs school of arts; 2013. 17. gurvich c, thomas n, thomas ehx, hudaib ar, sood l, fabiatos k, et al. coping styles and mental health in response to societal changes during the covid-19 pandemic. int j soc psychiatry. 2020;20764020961790. doi: 10.1177/0020764020961790. althea medical journal december 2021 amj vol 8 no 1 march 2021.indd althea medical journal. 2021;8(1) 18 althea medical journal march 2021 readiness of health workers to provide pregnancy planning program for women infected with human immunodeficiency virus: a case study in surabaya, east java, indonesia made chindy dwiyanti marheni putri,1 pudji lestari,2 muhammad ilham aldika akbar3 1faculty of medicine universitas airlangga, indonesia, 2department of public health faculty of medicine universitas airlangga, indonesia, 3department of obstetrics and gynecology faculty of medicine universitas airlangga/dr. soetomo general hospital surabaya, indonesia correspondence: made chindy dwiyanti marheni putri, faculty of medicine, universitas airlangga, jalan mayjen prof. dr. moestopo no.47, surabaya, indonesia, email: made.chindy.dwiyanti-2017@fk.unair.ac.id introduction the ministry of health republic of indonesia has stated that the human immunodeficiency virus (hiv) epidemic in the world has made it a problem that goes global. within the scope of the asian continent, the fastest spread of this disease happens in indonesia. the ranking of people living with hiv in east java is currently the second-highest in indonesia and the highest prevalence is in reproductive age. therefore, the high number of hiv in reproductive women has a bigger chance of the increased number of hiv in pregnancy. in fact, the prevalence of vertical transmission in indonesia is approximately more than 90%.1-2 not only making a bad impact on the mother, namely the higher pregnancy, labor, and puerperium risk, hiv transmission also will affect the baby growth and development.3 proper pregnancy planning is needed, in hope; it will decrease the risk of transmission from mother to child. based on the regulation of ministry of health no. 21 the year 2013, health professionals are needed to help to handle hiv transmission from mother to child.4 the ministry of health in 2015 issued a guideline that strongly demands the competence of doctors in pregnancy planning, including the knowledge that doctors must know and be able amj. 2021;8(1):18–23 abstract background: the prevalence of human immunodeficiency virus (hiv) mother-to-child infection or vertical transmission of hiv, in indonesia is about 90%. ministry of health of the republic of indonesia regulation no. 21 of 2013 stated that hiv infection in sexual productive age needs integrative professional help to lower the transmissions, including voluntary counseling and testing for pregnant women as well as all people at risk. this study aimed to determine the readiness of health workers to provide pregnancy planning program service for women with hiv. methods: this study was a descriptive study involving 30 obstetricians and 30 residents of obstetrics and gynecology specialist education in surabaya, indonesia. the respondents’ knowledge on pregnancy planning for hiv-infected women based on based on guidance released by the ministry of health of indonesia in 2017 and regulation of ministry of health no. 52 the year 2017, as well as their attitude and readiness to provide pregnancy planning services, was explored. questionnaires were distributed from august to december 2019 and the data collected were analyzed using statistical package for the social science (spss) version 17.0 and results were described in percentage. results: most health workers (80%) had good knowledge on providing pregnancy planning program for hiv positive women; however, only 63.3% had good attitude towards it. the majority of respondents (90%) were ready to help hiv patients in planning their pregnancy. conclusions: health workers in surabaya are ready to provide services related to pregnancy planning for women infected with hiv. keywords: human immunodeficiency virus, hiv transmission, pregnancy, readiness https://doi.org/10.15850/amj.v8n1.2087 althea medical journal. 2021;8(1) 19 to educate pregnancy requirements on people living with hiv/aids (plwha). for instance, the cd4 levels, viral load, and the use of contraception in plwha. doctors must possess a good attitude toward plwha patients. attitude concerning the absence of stigma and discrimination is needed to support the course of pregnancy planning.5 this research must be carried out because most studies about this field only focusing on the impact of patients but not the doctors’ readiness. by knowing the doctors’ readiness, it is expected that it can be a tool by doctors to evaluate themselves and give information to people, the hope they will know how our doctors are and may make good decisions whenever they want to consult the doctors. therefore, it can help to make a better service and a better relation between doctors table 1 knowledge of obstetricians and the residents towards readiness in pregnancy planning for hiv-infected women knowledge correct answer n % early detection of the risk of hiv infection, syphilis, and hepatitis b is done through blood tests at least one time during pregnancy 30 100 term of eligibility for pregnancy is healthy in general that is examined by anamnesis and physical examination while laboratory verification is not needed 26 86.7 to diagnose hiv, we need to test the cd4 and viral load 25 83.3 term of eligibility for pregnancy on plwha is already consumed arv in 6 months, healthy in general, and declared fit to be pregnant by a doctor 22 73.3 suppressed viral load is a term of eligibility for pregnancy 26 86.7 plwha who infected by tb is still allowed to be pregnant 24 80 hiv, syphilis, and hepatitis b early detection is held by the rapid diagnostic test 29 96.7 one of the risks of unplanned pregnancy is having a low birth baby 27 90 hiv, syphilis, and hepatitis b early detection in pregnancy may be repeated by the couple minimum in the next 3 months or ahead of pregnancy, or if the indication is founded 23 76.7 babies should not receive breast milk from hiv-infected mothers 15 50 plwha are allowed to do a vaginal delivery 26 86.7 hiv detection is done with pcr dna qualitative examination using blood and dried blood spot on 6-weeks(or more) baby 26 86.7 one condition that will produce a healthy pregnancy in plwha couple is having 1 or 2 hiv stage 20 66.7 plwha should consume arv in a lifetime to reduce transmission risk to the baby 27 90 plwha are allowed to have more than one child if already followed the pregnancy planning program correctly 21 70 plwha that are infected by malaria are eligible to be pregnant 19 63.3 100% of the baby from hiv mother should get arv and cotrimoxazole prophylaxis 21 70 unplanned pregnancy risk for mother could be in the form of anemia and infection 26 86.7 using condom as a contraception is enough for plwha couple 20 66.7 plwha have to stop consuming arv 6 weeks after the childbirth 27 90 made chindy dwiyanti marheni putri et al.: readiness of health workers to provide pregnancy planning program for women infected with human immunodeficiency virus: a case study in surabaya, east java, indonesia althea medical journal. 2021;8(1) 20 althea medical journal march 2021 and patients so that it can help to overcome a very crucial problem in this country, namely hiv. this research aimed to determine the readiness of health workers in pregnancy planning programs for women with hiv methods this research was a descriptive observational study, conducted from august to december 2019 after obtaining approval from the research ethics committee of universitas airlangga hospital no. 167/kep/2019. the sampling was performed using random sampling techniques, with sampling frames obtained from a member list of perkumpulan obstetri dan ginekologi indonesia (pogi) surabaya and idi surabaya, including the obstetricians and the residents of the obstetrics and gynecology department who were actively working on the implementation of pregnancy services at public and private hospitals surabaya. the sample was calculated using the z1-α/22p(1-p):d2 formula with 0.1 limit error and 0.07 in a previously expected proportion, resulting in a minimum sample of 25 respondents. a self-made questionnaire was distributed, table 2 attitude of obstetricians and the residents towards readiness in pregnancy planning for hiv-infected women attitude frequency agree doubtful disagree i will not use handschoen if i do the leopold test on a mother that is known to have hiv 9 3 18 in my opinion, women who are infected with hiv will greatly affect the baby they are carrying, so they must be immediately treated 30 0 0 i do believe with the existence of pregnancy planning program on plwha will decrease the number of a baby born with hiv 27 1 2 if there is hiv-infected woman come to my private practice, i will still give her arv 24 2 4 as a doctor, i am aware of the chance to be infected by hiv 30 0 0 when giving counseling to pregnant women with hiv status that is known to be positive, i consider there is no need to use protective barriers 15 1 14 pregnancy planning program on plwha must be implemented 28 0 2 i am not afraid to make contact or provide services to plwha even though there is the possibility of contracting it 24 2 3 i do not hesitate to use a thing that is already touched by an hiv patient 16 5 9 i am ready to give counseling to hiv patient for a long duration if needed 29 1 0 i will decide the eligibility of pregnancy for plwha if they have already done the test related to hiv stage, cd4, viral load, and the other infections 26 2 2 i will allow plwha that want to be pregnant and do vaginal delivery with terms 7 11 12 in my opinion, plwha are allowed to deliver more than 1 children 16 7 7 in my opinion, plwha are allowed to breastfeed the baby with terms 12 3 15 althea medical journal. 2021;8(1) 21made chindy dwiyanti marheni putri et al.: readiness of health workers to provide pregnancy planning program for women infected with human immunodeficiency virus: a case study in surabaya, east java, indonesia based on guidance released by the ministry of health of indonesia in 2017 and regulation of ministry of health no. 52 the year 2017 to assess knowledge, attitude, and readiness of doctors towards pregnancy planning program. the validity and reliability test were conducted by testing the questions to other 25 doctors not including in this research criteria, resulting in 20 questions for knowledge and 14 questions for the attitude. the knowledge was answered with correct or incorrect, whereas the attitude with agree, disagree, or doubtful. after a brief explanation of the purpose of this study, the informed consent form was signed before answering the questions. the result was classified as ready and not ready. ready was designated if the respondent had good knowledge and attitude, or good knowledge with fair attitude, or fair knowledge with a good attitude. not ready was designated if the respondents had poor knowledge and attitude, or fair knowledge and attitude. the answer above 75% was scored as good knowledge and good attitude; the correct answers 50–74% were scored as fair and below 50% as poor. data were analyzed using spss statistics 17.0. results in total, 30 respondents were included consisting of 13 (43%) residents and 17 (47%) obstetricians of whom most of them (70%) worked in public hospitals, male (63%), and aged over 40 years old (48%). the questionnaire and its result about knowledge and attitude were shown in table 1 and table 2, respectively. the majority of the respondents’ knowledge about hiv / aids and pregnancy was good (80%), whereas the attitudes were good in 63.3% as shown in table 3. the readiness of the physician showed that 46.67% (n=14) respondents had good knowledge and attitude, 26.67% (n=8) had good knowledge and fair attitude, and 16.67% (n=5) had fair knowledge and a good attitude, resulting in a total of 90% readiness of the physicians towards pregnancy planning for hiv-infected women. discussions pregnancy planning is a program implemented by doctors to realize a healthy pregnancy, good parturition, and healthy baby. it is interesting to note that there are some of the characteristics that give no impact on the result, namely age and knowledge. other studies supporting our result on factors related to the level of knowledge of health professionals, as well as on the relation of education level, age, and years of service to oral and dental health knowledge.6–7 specialists have more extensive experiences in the field of handling pregnant women compared to doctors trainee who are still in the education since experiences influence the knowledge.8 in order to lower the risk of transmission, the indonesian government has targeted pregnant woman to be tested for hiv.6 question no. 1 regarding early detection of hiv has been answered correctly in 100%, and this proves that respondents already have knowledge of what should be done to eliminate hiv transmission from mother to child by government regulations. there are many advantages for babies who receive breast milk from their mothers to fulfill nutrients, to protect babies from infections, to give a good impact on long-term health, and to reduce the risk of obesity and allergies. however, breastfeeding by mothers with hiv can increase the risk of transmission. without hiv treatment, the risk of transmission is ranging from 5–20%. to reduce this risk, the mother must continue taking arvs, and their infants should also be given prophylaxis. the breastfeeding and replacement of breast milk should not be given simultaneously because it will cause injury to the baby’s intestines and can increase the risk of hiv transmission to infants.3 table 3 category of knowledge and attitude of obstetricians and the residents towards readiness in pregnancy planning for hiv infected women value knowledge attitude n % n % poor 1 3 1 3.4 fair 5 17 10 33.3 good 24 80 19 63.3 althea medical journal. 2021;8(1) 22 althea medical journal march 2021 half of respondents agree that it is a dilemma for doctors whether to prohibit or allow breastfeeding in hiv. breastfeeding has a beneficial effect but also has a high risk for hiv transmission to the baby. to answer the dilemma, who has researched from 2011 to 2014 in various countries, including south africa, malawi, tanzania, uganda, zambia, zimbabwe, and india. in brief, 2431 pairs of mothers with hiv and their babies have been included, resulting in that almost 99% of these babies can live and reach their first birthday. in developing countries where adequate coverage of breast milk substitution is still challenging to obtain, the choice to breastfeed by hiv-positive mothers is a very safe choice for their babies.9 the effect that will arise in infants conceived by hiv-infected women is when a baby is born, and the risk of transmission is very high. infants who are infected with hiv will experience a disruption in their growth and development. in the first few months, the mortality risk remains high if they are not given any treatments.10 the risk of transmission from mothers with hiv if left untreated is 15–45%. however, given appropriate interventions during pregnancy, childbirth, and breastfeeding, the risk can be reduced to below 2%.11 interventions that can be performed by obstetricians when faced with women with hiv who are pregnant are by providing universal counseling, hiv monitoring, prophylactic administration of arvs, and knowing the indications of assisting with proper cesarean delivery.12 all respondents agreed to the statement “in my opinion, women who are infected with hiv will greatly affect the baby they are carrying, so they must be immediately treated”, concluding that all respondents had the right attitude when confronted with hiv women who were pregnant, namely providing immediate treatment in the hope of helping to reduce the risk that the baby could suffer. handling is based on a good understanding of the prevention of motherto-child transmission (pmtct). medical staffs, especially obstetricians, need to understand and implement pmtct well.13 standard precaution is an effort to minimize the transmission of infectious diseases to health workers and it is recommended to avoid direct or indirect contact with blood, body fluids, and skin that is not intact.14 protective barriers are not needed in conducting counseling activities. a balanced response between agreeing and disagreeing as well as hesitancy also shows that there is still uncertainty in the use of protective barriers. this finding suggests that doctors’ understanding of hiv transmission still needs to be improved. there is one respondent who scores low on knowledge and attitude. the factors that can influence the process of data retrieval including the psychological state of the respondent at the time the data was collected. when answering the questionnaire, the researcher observed that the respondent seemed to be in a hurry, and it was proven that the time in answering questions was less than 20 minutes. the state of mind at that particular time is very influential on how a person makes decisions, one of which is when answering statements in the questionnaire.15 this study certainly has limitations that the data is only given by respondents while the researchers did not directly observe when respondents were dealing with hiv patients. to conclude, doctors are ready to plan the pregnancy on a woman with hiv. this readiness of obstetricians will give benefits to make the best action to reduce the mother to child hiv transmission. therefore, the mother has the right prevention and treatment regarding to hiv and pregnancy. acknowledgements we would like to thank the doctors in dr. soetomo hospital, airlangga university hospital, siloam hospital, husada utama hospital who participated in this study. references 1. lie h, marianto m. infeksi human immunofediciency virus (hiv) dalam kehamilan. cdk-276. 2019; 46(5):346–51 2. tumangke h, tappy m, kendek r. faktorfaktor yang mempengaruhi efektivitas pencegahan penularan hiv dari ibu ke anak (ppia) di kota jayapura. unnes journal of public health. 2017; 6(4):261–5 3. kementerian kesehatan republik indonesia. lembar balik perencanaan kehamilan bagi pasangan orang dengan hiv aids (odha) jakarta: kementerian kesehatan ri; 2017 [cited 2 july 2020]. available from: https://kesga. ke m ke s . g o . i d / a s s e t s / f i l e / p e d o m a n / lembar%20balik%20perencanaan%20 kehamilan%20bagi%20pasangan%20 odha.pdf 4. mujiati m, lestary h, sugiharti s. kecukupan tenaga kesehatan dan permasalahannya dalam pelayanan kesehatan anak dengan althea medical journal. 2021;8(1) 23 hiv-aids di rumah sakit pada sepuluh kabupaten/kota, indonesia. media litbangkes. 2017;27(1):1–8 5. kementerian kesehatan republik indonesia. pedoman pelaksanaan pencegahan penularan hiv dan sifilis dari ibu ke anak. jakarta: kementerian kesehatan ri; 2015 [cited 2 july 2020] available from: https://siha.kemkes. g o . i d / p o r t a l / f i l e s _ u p l o a d / pe d o m a n _ manajemen_ppiapdf.pdf 6. wardani nii, rejeki dss, masfiah s. faktorfaktor yang berhubungan dengan tingkat pengetahuan kader kesehatan tentang thalassemia di kecamatan sumbang kabupaten banyumas. kesmasindo. 2014;6(3):194–206 7. dharmawati igaa, wirata in. hubungan tingkat pendidikan, umur, dan masa kerja dengan tingkat pengetahuan kesehatan gigi dan mulut pada guru penjaskes sd di kecamatan tampak siring gianyar. jurnal kesehatan gigi. 2016; 4(1):1–5 8. cahyaningrum e, siwi as. faktor-faktor yang berhubungan dengan tingkat pengetahuan ibu dalam penanganan demam pada anak di puskesmas i kembaran kabupaten banyumas. bidan prada: jurnal publikasi kebidanan. 2018;9(2):1–13 9. flynn pm, taha te, cababasay m, fowler mg, mofenson lm, owor m, et al. prevention of hiv-1 transmission through breastfeeding: efficacy and safety of maternal antiretroviral therapy versus infant nevirapine prophylaxis for duration of breastfeeding in hiv-1-infected women with high cd4 cell count (impaact promise): a randomized, open-label, clinical trial. j acquir immune defic syndr. 2018; 77(4): 383–92 10. davies ma, gibb d, turkova a. survival of hiv-1 vertically infected children. curr opin hiv aids. 2016; 11(5):455–64 11. barral mfm, de oliveira gr, lobato rc, mendza-sassi ra, martínez amb, gonçalves cv. risk factor of hiv-1 vertical transmission (vt) and the influence of antiretroviral therapy (art) in pregnancy outcome. rev inst med trop sao paulo. 2014; 56(2):133–8 12. hardy e, co-uvin s. care of the hiv-infected pregnant woman in the developed world. obstet med. 2015;8(1):13–7 13. erliana n, suryoputro a, mustofa sb. gambaran pelaksanaan prevention mother to child transmission di rsud kelas b dr. r. sosodoro djatikoesoemo kabupaten bojonegoro. jurnal promosi kesehatan indonesia. 2016;11(2):1–17 14. masyhuri i, utari tr, kusbaryanto k. implementation standard precaution of risky dental treatments on patient with hiv-aids in x public health center yogyakarta. jurnal medicoeticolegal dan manajemen rumah sakit. 2019;8(2):77– 89 15. johanes j, daya t. peran faktor psikologis terhadap keputusan investasi produk mulia pada pt. pegadaian (persero) di kota jambi. digest marketing. 2017;2(1):210– 21. made chindy dwiyanti marheni putri et al.: readiness of health workers to provide pregnancy planning program for women infected with human immunodeficiency virus: a case study in surabaya, east java, indonesia amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 99 characteristics of in-hospital mortality among patients with acute coronary syndrome: a single-center study in west java, indonesia dennis bonang tessy,1 miftah pramudyo,2 charlotte johanna cool2 1faculty of medicine universitas padjadjaran, indonesia 2department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: dennis bonang tessy, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, e-mail: dennistessy2@gmail.com introduction acute coronary syndrome (acs) is a severe, potentially life-threatening manifestation of coronary artery disease (cad), consists of a spectrum of disorders that are classified into unstable angina (ua), non-st-segment elevation myocardial infarction (nstemi), and st-segment elevation myocardial infarction (stemi).1 cardiovascular diseases (cvds) are the leading cause of death globally, accounting for 17.9 million deaths worldwide in 2016, which represents 31% of all global deaths. both cad and acs constitute approximately 7 million deaths per year.2 in indonesia, epidemiological studies on acs are still limited. based on the basic health research report published by the indonesian ministry of health in 2019, the prevalence of heart disease in indonesia varies between provinces, with the prevalence in west java is 1.62%.3 the mortality risk scoring systems that are commonly used in clinical practice are killip classification, thrombolysis in myocardial infarction (timi) score, and global registry of acute coronary event (grace) risk score system.4 the grace risk score system is a risk stratification system for acs patients that is constructed based on acs registry data, collected from various geographical locations. the system considers various variables to measure acs patients’ risk of mortality, including age, pulse rate, systolic blood pressure, killip class, cardiac arrest, stsegment deviation, serum creatinine levels, and early status cardiac biomarkers.5 amj. 2021;8(2):99–103 abstract background: acute coronary syndrome (acs) is a severe manifestation of coronary artery disease, classified into unstable angina (ua), non-st-segment elevation myocardial infarction (nstemi), and st-segment elevation myocardial infarction (stemi). in-hospital mortality in patients with acs remains high despite the advancement of therapy. this study aimed to evaluate the characteristics of in-hospital mortality among acs patients in west java, indonesia. methods: this descriptive cross-sectional study analyzed retrospective secondary data of acs patients who died during hospitalization in the period of july 2018 to june 2019 that were recorded in the acs registry. results: a total of 17 patients died during hospitalization in the study period. the mean age was 64.1 years, predominantly female (n=10). the prevalent diagnoses were stemi (n=11) and nstemi (n=6). interestingly, no patients had died from ua. hypertension was the most frequent risk factor (11 of 17). mortality among killip class i, ii, iii, and iv were 7, 5, 1, and 4 patients, respectively. the number of patients who died after underwent percutaneous coronary intervention (pci) was lower (n=6) than those who did not undergo pci or those without revascularization (n=11). conclusions: the incidence of in-hospital mortality with acute coronary syndrome is high in females, stemi diagnosis, killip class i, and no revascularization. keywords: acute coronary syndrome, characteristics, in-hospital mortality https://doi.org/10.15850/amj.v8n2.2281 althea medical journal. 2021;8(2) 100 althea medical journal june 2021 the challenge of using the grace risk score system to estimate the risk of mortality for acs patients in indonesia is the possibility for geographical variation to influence the outcome of patient risk stratification. the predictors of in-hospital mortality for stemi patients have been reported such as killip class 3 and 4, anterior stemi, tachycardia, arrhythmias, diabetes, late-onset, and without fibrinolysis.6 the aim of this study was to determine the in-hospital mortality characteristics of acs patients treated in dr. hasan sadikin general hospital bandung. methods this descriptive cross-sectional study analyzed retrospective secondary data of acs patients who died during hospitalization in the period of july 2018 to june 2019 that were recorded in the acs registry. the study was conducted at dr. hasan sadikin general hospital bandung from march 2020 to november 2020. the inclusion criteria for this study were adult acs patients (≥18 years) treated in dr. hasan sadikin general hospital bandung from july 2018 to june 2019 who died from any cause (all-cause mortality) during treatment. the exclusion criteria were inaccessible, unreadable, and incomplete or lost patient medical record data. this study used the total sampling method. the data for this study were retrieved following approval from the research ethics committee of universitas padjadjaran no. 831/un6.kep/ec/202 and a research permit from the health research ethics committee of dr. hasan sadikin general hospital bandung no. lb.02.01/x.6.5/3/2019. the variables used in this study were diagnosis, age, gender, medical history (smoking history, diabetes mellitus, table in–hospital mortality of acute coronary syndrome patients in dr. hasan sadikin general hospital bandung from july 2018 to june 2019 frequency (n=17) average (min–max) acute coronary syndrome stemi nstemi 11 6 characteristics age (mean, years) 64.1 (48–82) gender male female 7 10 risk factor hypertension diabetes mellitus smoking habit (active) smoking habit (ex-smoker) dyslipidemia previous ami multiple risk factors 10 4 4 1 4 1 9 killip class i ii iii iv 7 5 1 4 systolic bp (mean, mmhg) 106.8 (60–160) pulse rate (mean, beats/m) 87 (28–134) hemoglobin (mean, g/dl) 13 (4.4–18.7) leukocytes (mean, cells/μl) 16,387 (5,100–36,840) pci pci non–pci 6 11 note: ami=acute myocardial infarction; pci=percutaneous coronary intervention; stemi=st–segment elevation myocardial infarction; nstemi=non–st–segment elevation myocardial infarction althea medical journal. 2021;8(2) 101dennis bonang tessy et al.: characteristics of in-hospital mortality among patients with acute coronary syndrome: a single-center study in west java, indonesia hypertension, dyslipidemia, and previous acute myocardial infarction), clinical presentation (killip class, blood pressure, and pulse rate), laboratory results (hemoglobin level and a number of leukocytes), and reperfusion therapy. the variables were presented as the frequency in percentage and mean. the percentage of findings in this study was based only on acs patients that died and not acs patients in general. subgroup analysis was performed to observe the trend of in-hospital mortality characteristics according to gender, diagnosis, and killip class. all collected data were performed using microsoft office excel 2016. results during the study, there were 365 acs patient data found in icd i21. among those data, there were only 24 data that fulfill the inclusion criteria, and out of those 24 data, seven data were excluded because they were not found in the online registry. among a total of 17 acs death cases, stemi (11 of 17) was more in-hospital mortality compared to nstemi as shown in table 1. in-hospital mortality characteristics of acs patients that died during treatment were predominantly female (n=10) with an average age of 64.1 years. the most common risk factor found among the patients was a history of hypertension, followed by smoking habits (n=5). however, more than half of the subjects were observed to have multiple risk factors (n=9). there were more subjects found in killip class i than those in killip classes ii, iii, and iv. most of the subjects did not undergo percutaneous coronary intervention (pci) (11 of 17). based on gender, female patients were found to be older and had more stemi diagnosis, a more frequent history of hypertension and dyslipidemia, and a higher mean systolic bp compared to male subjects. based on the diagnosis, stemi patients were older, had a more frequent history of hypertension, dyslipidemia, and previous ami, more prevalent in killip class iii and iv groups, and had a higher mean leukocyte count. based on killip class groups, killip class iv had the highest mean age, hemoglobin levels, and leukocyte count, and the lowest mean systolic bp (data not shown). discussions this study has explored the characteristic of patients who have died from acs during hospitalization in dr. hasan sadikin general hospital bandung. stemi diagnosis has higher in-hospital mortality compared with nstemi, in accordance with a study result in another indonesian city.6 this is likely due to the severe nature of stemi. female is predominantly prevalent with a mean age of 64.1 years old. there is an increased risk of comorbidities found in the elderly population and the relatively high life expectancy in the area. the life expectancy in bandung, west java is 74.14 years, as reported by the national central agency of statistics.8 however, other studies in indonesia show different results which found predominantly male subjects with cardiac arrest or inhospital mortality.6,7 furthermore, a study on gender associated with hospitalization outcomes in acs patients shows that women have significantly worse outcomes and higher in-hospital mortality. the majority of female acs patients are in the older age group with more comorbidities and received less frequent acute treatments and medical therapy for secondary prevention compared to their male counterparts.9,10 in a 2-year follow-up study on acs patients in dr. hasan sadikin general hospital bandung has found that in-hospital mortality is higher in female acs patients, but the sex difference is no longer significant following clinical adjustment.11 in this study, a history of hypertension occurs in more than half of the cases, while a history of smoking, diabetes mellitus (dm), dyslipidemia, and previous acute myocardial infarction (ami) are only found in less than half of the cases, similar with several other studies.7,12 the findings in this study are likely due to a high prevalence of chronic diseases among the elderly population. the most prevalent chronic disease found among the elderly is hypertension, followed by diabetes, heart disease, asthma, ulcer, and cancer.13 killip classification is a clinical tool to identify heart failure in acs patients. class i is designated for those with no evidence of heart failure and killip class ii, iii, and iv for those showing signs of heart failure.14 surprisingly in this study, the majority of the subjects has been found in killip class i, whereas the previous study shows the association of killip class with higher mortality.6 interestingly, the 2-year follow-up study conducted by nastiti11 found that the total deaths for patients in killip class i were similar to that in killip class iv. the high mortality found in the killip class i group is likely due to a high rate of althea medical journal. 2021;8(2) 102 althea medical journal june 2021 patient admissions in the group. however, the proportion of mortality found when compared to the total patients in their corresponding killip classes is still consistent with previous studies, where a high percentage of mortality can be seen in higher killip classes (killip class ≥ii). pulse rate and systolic blood pressure (bp) can be used to assess the hemodynamic state of the patient.7 vital signs measurements in this study reveal an average systolic bp of 106.8 mmhg (60–160 mmhg) and an average pulse rate of 87 beats/min (28–134 beats/ min). this finding was slightly lower than the results found the emergency department.7 this was likely due to the delayed presentation found among the subjects in this study. the hematologic examination has been proven to have diagnostic and prognostic value in cardiovascular diseases. their relatively inexpensive cost and wide availability in daily clinical practice made them a potentially advantageous determinant in acs patient risk stratification.15 an elevated wbc count (wbc >10,000) is related to a more advanced cad and increased mortality among ami and ua patients.15 furthermore, anemia (hb <12 g/ dl) on admission is associated with increased mortality in acs patients.16,17 however, the mean hb concentration found in this study is in the normal range. in this study, the mortality in cases that did not undergo pci was significantly higher than those who did. this result is in accordance with the data found in jakarta acute coronary syndrome (jacs) registry where the highest in-hospital mortality was found among non-reperfused patients.18 the reason for this failure to initiate reperfusion therapy is likely because the patient has died before therapy initiation, contraindications to initiating therapy, ineligibility for reperfusion therapy (onset >12 hours), or refusal to do the procedure. this study also found that more patients in killip class i were treated with pci, in contrast with those in more severe killip classes (killip class ≥ii). the severity and nature of the killip classes likely influenced the decision to initiate pci. the patients have shown progressively worsening hemodynamic status with higher killip classification. hence, in this study, the subjects in killip class i were likely stable enough to initiate reperfusion therapy, while those in killip class iv most likely died prior to undergoing pci. the relatively few samples have limited this study, thus, this study has not reflected the inhospital mortality characteristics of all acs patients in dr. hasan sadikin general hospital bandung. moreover, there were no further laboratory examinations that can be used to evaluate other potential determinants in acs patient mortality, hence, some findings have a trend result by previous literature. to conclude, the in-hospital mortality in patients with acute coronary syndrome treated in dr. hasan sadikin general hospital bandung are mostly diagnosed with stemi, female >60 years old, with hypertension, killip class i and do not undergo pci or no revascularization intervention. references 1. reed gw, rossi je, cannon cp. acute myocardial infarction. lancet. 2017;389(10065):197–210. 2. world health organization. about cardiovascular diseases [internet]. 2020 [cited 2020 jun 23]. available from: https://www.who.int/cardiovascular_ diseases/about_cvd/en/ 3. badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2018. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia; 2019. 4. anggraini r, wihastuti ta, ningsih dk. the differences of correlation of the timi, grace, and killip risk scores as predictor prognosis patients with non st-elevation myocard infarction acute coronary syndrome in iccu rsud dr. iskak tulungagung. jurnal ilmu keperawatan. 2018;6(1):79–87. 5. everett cc, fox kaa, reynolds c, fernandez c, sharples l, stocken dd, et al. evaluation of the impact of the grace risk score on the management and outcome of patients hospitalised with non-st elevation acute coronary syndrome in the uk: protocol of the ukgris cluster-randomised registrybased trial. bmj open. 2019;9(9):e032165. 6. gayatri ni, firmansyah s, hidayat s, rudiktyo e. prediktor mortalitas dalamrumah-sakit pasien infark miokard st elevasi (stemi) akut di rsud dr. dradjat prawiranegara serang, indonesia. cdk. 2016;43(3):171–4. 7. ray m, ruthazer r, beshansky jr, kent dm, mukherjee jt, alkofide h, et al. a predictive model to identify patients with suspected acute coronary syndromes at high risk of cardiac arrest or in-hospital mortality: an althea medical journal. 2021;8(2) 103 immediate trial sub-study. int j cardiol heart vasc. 2015;9:37–42. 8. badan pusat statistika. data kota bandung 2018: indeks pembangunan manusia [internet] [cited 2020 nov 23]. available from: https://ipm.bps.go.id/data/kabkot/ metode/baru/3273 9. hao y, liu j, liu j, yang n, smith jr sc, huo y, et al. sex differences in in-hospital management and outcomes of patients with acute coronary syndrome. circulation. 2019;139(15):1776–85. 10. gong iy, goodman sg, brieger d, gale cp, chew dp, welsh rc, et al. grace risk score: sex-based validity of in-hospital mortality prediction in canadian patients with acute coronary syndrome. int j cardiol. 2017;244:24–9. 11. nastiti g. prediktor kematian dalam perawatan rumah sakit pada pasien sindrom koroner akut di rsup dr. hasan sadikin bandung [dissertation]. bandung: universitas padjadjaran; 2020. 12. singh s, paul s, pal r, thatkar p. acute coronary syndrome-related mortality audit in a teaching hospital at port blair, india. j family med prim care. 2017;6(3):502–8. 13. saquib n, saquib j, alhadlag a, albakour ma, aljumah b, sughayyir m, et al. chronic disease prevalence among elderly saudi men. int j health sci (qassim). 2017;11(5):11–6. 14. el-menyar a, zubaid m, almahmeed w, sulaiman k, alnabti a, singh r, et al. killip classification in patients with acute coronary syndrome: insight from a multicenter registry. am j emerg med. 2012;30(1):97–103. 15. budzianowski j, pieszko k, burchardt p, rzeźniczak j, hiczkiewicz j. the role of hematological indices in patients with acute coronary syndrome. dis markers. 2017;2017:3041565. 16. mamas ma, kwok cs, kontopantelis e, fryer aa, buchan i, bachmann mo, et al. relationship between anemia and mortality outcomes in a national acute coronary syndrome cohort: insights from the uk myocardial ischemia national audit project registry. j am heart assoc. 2016;5(11):e003348. 17. moady g, iakobishvili z, beigel r, shlomo n, matetzky s, zahger d, et al. the predictive value of low admission hemoglobin over the grace score in patients with acute coronary syndrome. j cardiol. 2019;73(4):271–5. 18. dharma s, andriantoro h, purnawan i, dakota i, basalamah f, hartono b, et al. characteristics, treatment and in-hospital outcomes of patients with stemi in a metropolitan area of a developing country: an initial report of the extended jakarta acute coronary syndrome registry. bmj open. 2016;6(8):e012193. dennis bonang tessy et al.: characteristics of in-hospital mortality among patients with acute coronary syndrome: a single-center study in west java, indonesia amj vol 7 no 3 september2.indd althea medical journal. 2020;7(3) 122 amj september 2020 vitamin d serum level in patients with schizophrenia in west java, indonesia nofan pratama maulana,1 tuti kurnianingsih,2 sumartini dewi3 1faculty of medicine universitas padjadjaran, indonesia, 2department of phsyciatry faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2department of internal medicine faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: nofan pratama maulana, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, email: nofanpratama@gmail.com introduction schizophrenia is a psychiatric disorder that affects thought processes and causes mental and social function disorders. characteristics of schizophrenia symptoms are divided into three groups, including positive symptoms such as delusions and hallucinations; negative symptoms such as blunted affect and apathetic; and cognitive symptoms such as attention and memory disorders.1 the world health organization (who) data shows the range of schizophrenic patients in the world is 21 million people,2 and the basic health research (riset kesehatan dasar, riskesdas) data shows the proportion of households with schizophrenia or psychosis in indonesia is about seven per 1000 population.3 the etiology of schizophrenia is still unknown. the current hypothesis explains that the manifestations of schizophrenia occur due to abnormalities or pathophysiological changes in the transmission of neurotransmitters, such as dopamine and glutamate, in the central nervous system. mesolimbic and mesocortical dopaminergic pathways are responsible for manifesting positive symptoms, negative symptoms, and cognitive symptoms. the rate of glutamate release can affect the dopaminergic pathways through the cortico-brainstem glutamate pathways. increased glutamate release influences the rate of dopamine release which can trigger the clinical symptoms of schizophrenia.4 glutamate transmission can amj. 2020;7(3):122–7 abstract background: vitamin d is an immune-regulator that influences the neuro-inflammation process in schizophrenia. the study aimed to explore the vitamin d serum level in schizophrenic patients at the outpatient clinic of the provincial mental hospital, west java, indonesia. methods: a quantitative descriptive study was conducted in november–december 2019 using secondary data of all-male schizophrenic patients at the provincial mental hospital. data collected were demographic characteristics, clinical characteristics, and vitamin d level. scoring was then performed using positive and negative syndrome scale (panss) and montreal cognitive assessment (moca) to assess the positive and negative symptoms as well as the cognitive symptoms based on the serum vitamin d levels. results: all male schizophrenic patients had a low serum vitamin d level (mean16.67±5.6ng/ml) with 64.52% of them had vitamin d deficiency (<20 ng/ml). interestingly, patients with vitamin d deficiency had a negative symptom (mean22.1±5.6ng/ml) whereas those with vitamin d insufficiency (20-29 ng/ ml) had a positive symptom (mean 18.55±5.6ng/ml). furthermore, patients with vitamin d deficiency had a lower impaired cognitive function value (mean 19.7±3.4ng/ml) compared to those with vitamin d insufficiency. conclusions: a low vitamin d serum level in schizophrenic patients may play a role in the pathogenesis of this disorder. further studies are needed to confirm this finding. keywords: montreal cognitive assessment, positive and negative syndrome scale, schizophrenia, vitamin d https://doi.org/10.15850/amj.v7n3.1897 althea medical journal. 2020;7(3) 123 be influenced by several things, one of which is nmda receptor hypofunction caused by the neuroinflammation process.5 vitamin d which functions as an immune-regulator is thought influence the neuroinflammation process in schizophrenia.6 risk factors for vitamin d deficiency such as geographic location, bmi, age, and prenatal infections were also found to be related to the risk of developing schizophrenia.7 vitamin d is a fat-soluble steroid hormone obtained from the synthesis of pro-vitamin d in the skin with the help of exposure to ultraviolet light and food intake. vitamin d has two forms according to the source, namely vitamin d3 and vitamin d2. both forms must undergo two hydroxylation processes to become active form 1.25(oh)2d.8 besides having a role in bone metabolism and calcium homeostasis, vitamin d also plays a role in the function and development of the brain and immune system. researchers have found that the central nervous system can synthesize and metabolize vitamin d. vitamin d receptors and enzymes that play a role in vitamin d metabolism are found scattered in various regions of the brain such as the hippocampus, cortex, and limbic system.9 there are various psychiatric disorders, such as alzheimer’s, mood disorders, major depression, and psychosis or schizophrenia reported to have involvement with vitamin d.10 research conducted in europe in schizophrenia patients with the first psychosis episode showed that all patients had lower vitamin d levels than controls.11 another study in medan, north sumatra found a lower mean serum vitamin d level than normal levels among schizophrenia patients from the batak tribe.12 various studies have found a decrease in vitamin d levels in schizophrenic patients, but no similar studies yet in west java. therefore, this study aimed to explore the vitamin d levels in schizophrenia patients in west java province. methods this was quantitative descriptive research conducted in november-december 2019. in total, 31 schizophrenic patients data who met the inclusion criteria were collected, such as age 18−45 years, male, used atypical antipsychotic drugs, could speak indonesian, and both patients and families signed a written consent letter to participate in the table 1 demographic characteristic of subjects characteristics subjects (n=31)n(%) age (years) mean± sd 35.23 ± 6.8 median 36 range 24−45 education elementary school 6 (19.35) junior high school 3 (9.68) senior high school/vocational high school 20 (64.52) college 2 (6.45) marital status not married 22 (71.97) married 8 (25.8) divorced 1 (3.22) occupation working 19 (61.29) unemployed 12 (38.71) notes: n=frequency, sd=standard deviation nofan pratama maulana et al.: vitamin d serum level in patients with schizophrenia in west java, indonesia althea medical journal. 2020;7(3) 124 amj september 2020 study. the exclusion criteria were intellectual disability, anxiety and uncooperative, and the use of psychotropic drugs other than a typical antipshychotics. the study protocol was granted by the research ethics committee universitas padjadjaran, number 1350/un6. kep/ec/2019. the vitamin d 25(oh)d serum levels were measured using an electro chemiluminescence immunoassay analyzer (eclia) and classified into normal (>30 ng/ml), insufficiency (20–29 ng/ml), and the deficiency (<20 ng/ml). the assessment of positive and negative symptoms was carried out based on the positive and negative syndrome scale (panss) to assess the severity of seven domains of each symptom. a value of one indicated no symptoms and a value of seven indicated extreme symptoms. domain with a value of three or greater indicated symptom manifestations. cognitive function disorders were classified based on the total score from the montreal cognitive assessment (moca) with a score of >26 indicated no cognitive impairment, and a score of <26 indicated a cognitive impairment. the scores then adjusted to the patient’s educational history by adding a value of one to patients with an education of less than four years. the data was presented in the form of tables that were valued for frequency and percentage (ibm spss statistics software). results of 31 schizophrenic patients, the mean age was 35.23 (sd + 6.82; range 24−45 years). the last educational history was predominantly high school or equivalent (64.52%), already had a table 2 clinical characteristics of subjects characteristics subjects (n=31)n(%) age of onset (years) mean±sd 24.87±6.5 median 23 range 8−41 body mass index (kg/m2) mean± sd 22.56±3.3 <18.5 (underweight) 3 (9.68) 18.5–24.9 (normal) 23 (74.19) 25.5–29.9 (overweight) 4 (12.9) ≥30.0 (obese) 1 (3.22) antipsychotics used clozapine, risperidone, trihexyphenidyl 22 (70.94) risperidone, trihexyphenidyl 9 (29.03) serum vitamin d levels (ng/ml) mean±sd 16.67±5.6 median 16.76 range 8.02−27.75 panss positive symptoms mean±sd 17±6 panss negative symptoms mean±sd 21±6 mocacognitive symptoms mean±sd 20±4 notes: panss=positive and negative syndrome scale, n=frequency, sd=standard deviation althea medical journal. 2020;7(3) 125nofan pratama maulana et al.: vitamin d serum level in patients with schizophrenia in west java, indonesia job (61.29%), but not married yet (71.92%) (table 1). the age of onset of the subjects was found to be quite young (mean 24.87+6.5 years). most subjects had a normal body mass index (74.19%) and used clozapine, risperidone, and trihexyphenidyl (70.94%) as the antipsychotics. mean serum vitamin d levels showed decreased levels compared to normal (16.67±5.6). the average value of panss and moca showed that almost all subjects had a mean positive symptoms value of 17±6, mean negative symptoms value of 21±6, and mean cognitive symptoms of 20±4 (table 2). serum vitamin d levels of all of the subjects were found to be lower than normal levels and most had vitamin d deficiency (64.52%) as depicted in table 3. in table 4, the subjects with vitamin d deficiency hade higher negative symptom (22.1±5.6) and lower cognitive impairment values (19.7±3.4), while subjects with vitamin d insufficiency had a higher positive symptom value (18.55±5.6). discussions in this study, all schizophrenia patients have low serum vitamin d levels, similar to research conducted in the united kingdom, showing that schizophrenia patients have a low serum vitamin d level.11,13 this result is also similar in other parts of indonesia, in medan and surabaya.12,14 the decrease of serum vitamin d levels in the study might be caused by several factors such as lack of sun exposure, lack of intake of foods containing vitamin d, the presence of genetic factors that affect vitamin d metabolism, and possible drug interactions.15 the findings regarding low vitamin d levels support the hypothesis of the role of vitamin d in the pathogenesis of schizophrenia. vitamin d has a function in the immune system and inflammation as a regulator of activation, proliferation, and differentiation of immune and inflammatory cells. this function enables vitamin d to reduce the production of type 1 pro-inflammatory cytokines and increase the production of type 2 anti-inflammatory cytokines. in vitamin d deficiency, regulation of the immune and inflammatory systems mediated by vitamin d is disrupted, causing an imbalance in inflammatory cytokine levels and increasing pro-inflammatory cytokines.6 type 2 immune responses initiated by inflammatory cytokines can inhibit indoleamine 2,3-dioxygenase (ido) enzyme from the metabolism of tryptophan/kynurenine. the ido enzyme functions as a regulator of tryptophan/ kynurenine metabolism by converting tryptophan to kynurenine, then kynurenine can produce neuroactive metabolites of kynurenic acid with the help of the enzyme kynurenine aminotransferase. kynurenic acid is a natural antagonist for n-methyl-d-aspartate (nmda) receptors. the nmda receptor is one of the ionotropic receptors used by glutamate. increased nmda receptor antagonisms cause hypofunction of the receptor, leading table 3 serum vitamin d levels serum vitamin d levels(ng/ml) subjects (n = 31)n(%) insufficiency 11 (35.48) deficiency 20 (64.52) table 4 panss and moca scoring based on serum vitamin d levels panss and moca scoring serum vitamin d levels insufficiency (n=11) deficiency (n=20) panss positive symptoms 18.55±5.6 15.95±6.6 negative symptoms 19.55±5.7 22.1±5.6 moca cognitive symptoms 20.45±3.9 19.7±3.4 note: panss=positive and negative syndrome scale;moca, montreal cognitive assessment;sd, standard deviation althea medical journal. 2020;7(3) 126 amj september 2020 to increased glutamate release. the excess release of glutamate can affect the activity of the dopaminergic pathway and the release of dopamine.5 physiologically, dopamine works through several dopaminergic pathways. pathways that play a role in the pathogenesis of schizophrenia are mesolimbic and mesocortical pathways. in the mesolimbic pathway, dopamine is sent from the ventral tegmental area to the nucleus accumbens, which functions in the regulation of emotional behavior. in the mesocortical pathway, dopamine sent from the ventral tegmental area to the prefrontal cortex, especially in the dorsolateral region. high glutamate release in the ventral tegmental area results in the increased mesolimbic pathway and decreased mesocortical pathway activity. increased mesolimbic activity is thought to cause positive symptoms such as delusions and hallucinations, whereas decreased dopamine release in the mesocortical pathway is thought to cause negative symptoms and cognitive symptoms.4 in this study, the panss value of negative symptoms was higher in patients with vitamin d deficiency. this is in accordance with a study in turkey that found patients with vitamin d deficiency had higher negative symptom values than patients with vitamin d insufficiency.7 this study also found subjects with vitamin d deficiency experience impaired cognitive function with a low moca value. this finding is in accordance with a study in norway which found schizophrenia patients with vitamin d deficiency had cognitive impairment.16 excessive reduction of serum vitamin d levels in vitamin d deficiency increased the release of excess glutamate and dopamine. these conditions further reduce the release of dopamine into the prefrontal cortex, thereby increasing the severity of negative and cognitive symptoms in patients. the panss value of positive symptoms in this study was found to be higher in patients with vitamin d insufficiency. however, our result is not in accordance with research conducted in turkey7 which found that the value of positive symptoms (saps) was higher in patients with vitamin d deficiency. our study is an outpatient schizophrenic patient who has received atypical antipsychotic therapy so that the patient has experienced a decrease in positive symptoms. a typical antipsychotic therapy has dopamine receptor antagonistic properties so it works by reducing the level of dopamine release in the brain. the effects of antipsychotic therapy are more effective in dealing with positive symptoms than negative and cognitive symptoms. antipsychotic therapy can also affect the body’s metabolism, but no findings of the interactions between antipsychotic drugs and serum vitamin d levels. the limitation of this study is that our patients are outpatients who have received atypical antipsychotic therapy and some of them get additional clozapine therapy. further research is needed with data that are more complete to eliminate confounding factors for serum vitamin d levels. to conclude, all schizophrenic patients have low serum vitamin d levels. schizophrenic patients with vitamin d deficiency have higher negative symptom values and lower cognitive impairment values, whereas schizophrenia patients with vitamin d insufficiency have higher positive symptom values. references 1. patel kr, cherian j, gohil k, atkinson d. schizophrenia: overview and treatment options. p t. 2014;39(9):638–45. 2. world health organization (who). fact sheets: schizophrenia. geneva: world health organization; 2018. 3. kementrian kesehatan republik indonesia. penyakit tidak menular dan kesehatan jiwa. hasil utama riskesdas. jakarta: badan penelitian dan pengembangan kesehatan; 2018. p.78–80. 4. stahl sm. stahl’s essential psychopharmacology: neuroscientific basis and practical applications. 4th ed. new york, uk: cambridge university press; 2013. p. 79–128. 5. müller n. inflammation in schizophrenia: pathogenetic aspects and therapeutic considerations. schizophr bull. 2018;44(5):973–82. 6. colotta f, jansson b, bonelli f. modulation of inflammatory and immune responses by vitamin d. j autoimmun. 2017;85:78–97. 7. bulut sd, bulut s, atalan dg, berkol t, gürçay e, türker t, et al. the relationship between symptom severity and low vitamin d levels in patients with schizophrenia. plos one. 2016;11(10):e0165284. 8. nair r, maseeh a. vitamin d: the “sunshine” vitamin. j pharmacol pharmacother. 2012;3(2):118–26. 9. cui x, gooch h, petty a, mcgrath jj, eyles d. vitamin d and the brain: genomic and non-genomic actions. mol cell endocrinol. 2017;453:131–43. althea medical journal. 2020;7(3) 127 10. graham ka, keefe rs, lieberman ja, calikoglu as, lansing km, perkins do. relationship of low vitamin d status with positive, negative and cognitive symptom domains in people with first-episode schizophrenia. early interv psychiatry. 2015;9(5):397–405. 11. salavert j, grados d, ramiro n, carrión mi, fadeuilhe c, palma f, et al. association between vitamin d status and schizophrenia: a first psychotic episode study. j nerv ment dis. 2017;205(5):409– 12. 12. prasanty n, amin mm, effendy e, simbolon j. low vitamin d serum level increases severity symptoms in schizophrenic patients measured by positive and negative symptoms scale (panss) in batak tribe sumatera utara, medan-indonesia. bali med j. 2018;7(1):249–54. 13. crews m, lally j, gardner-sood p, howes o, bonaccorso s, smith s, et al. vitamin d deficiency in first episode psychosis: a case-control study. schizophr res. 2013;150(2–3):533–7. 14. simangunsong ad, karimah a, marpaung fr. correlation between serum vitamin d levels and severity of schizophrenia patients in the dr. soetomo hospital. indonesian journal of clinical pathology and medical laboratory. 2019;25(3):250– 6. 15. akinlade ks, olaniyan oa, lasebikan vo, rahamon sk. vitamin d levels in different severity groups of schizophrenia. front psychiatry. 2017;8:105. 16. nerhus m, berg ao, simonsen c, haram m, haatveit b, dahl sr, et al. vitamin d deficiency associated with cognitive functioning in psychotic disorders. j clin psychiatry. 2017;78(7):e750–7. nofan pratama maulana et al.: vitamin d serum level in patients with schizophrenia in west java, indonesia amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 72 amj june 2020 daily living performance in schizophrenic patients in correlation with positive and negative symptoms nurul amelia rahayu putri,1 tuti kurnianingsih,2 santi andayani2 1faculty of medicine universitas padjadjaran, indonesia, 2department of psychiatry faculty of medicine universitas padjadjaran/dr hasan sadikin general hospital bandung, indonesia correspondence: nurul amelia rahayu putri, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, e-mail: nurul16006@mail.unpad.ac.id introduction schizophrenia is a global mental health problem with high costs and needs for care.1 according to national health basic research (riset kesehatan dasar, riskesdas) year 2013, the prevalence of psychotic disorders in indonesia has reached 1.7 per mile area. west java is ranked 11th among the provinces in indonesia with prevalence as high as 1.6 per mile area.2 the prevalence of schizophrenia has its peak at around 40 years of age, with a decline in the older age group, whereas the incidence is higher among males.3,4 disability adjusted life year (daly) has been used to measure disease burden, based on the definition of global burden of disease.3 the daly is calculated by summing years of life lived with disability (ylds) and years of life lost (ylls) to premature mortality for a disease. schizophrenia is being the most disabling disorder in 12th rank among 310 diseases and injuries globally.3 positive symptoms are a distinctive fundamental distortion of thoughts and perception, including hallucinations and delusions. negative symptoms are deficits or loss of normal function and behavior, such as anhedonia, avolition, asocial, blunt affect, alogia. both symptoms are distinctive characteristics of schizophrenia that are absent in normal individuals. along with it, schizophrenic patients experience disturbances on activities of daily living (adls) and instrumental activities of daily living (iadls).5,6 activities of daily living (adls) are activities to fulfill amj. 2020;7(2):72–8 abstract background: schizophrenia is a global mental health problem. patients experience problems in their daily-living performance. positive and negative symptoms have been part of characteristics of schizophrenia that are absent in normal individuals, which include a distinctive fundamental distortion of thoughts and perception (positive symptoms) and loss of normal function and behavior (negative symptoms). this study aimed to explore the correlation between positive and negative symptoms and daily-living performance in schizophrenia. methods: a correlative analytical study with a cross-sectional approach was conducted using secondary data from the outpatient clinic of the mental hospital of west java province. data on socio-demographic characteristics were collected and positive and negative symptoms as assessed by positive and negative syndrome scale or subscales (panss) were correlated with the activities of daily living (adls) and instrumental activities of daily living (iadls), which were further analyzed by spearman’s correlation test. results: in total, 31 male schizophrenic patients aged between 24-45 years old. there was no significant correlation between adls dependency levels and both positive and negative symptoms. however, there was a significant correlation between iadls function and positive symptoms and not with negative symptoms. conclusions: even though no correlation was identified between adls dependency levels with positive and negative symptoms, the adls and iadls assessments should be considered as important tools for schizophrenic patients for rehabilitation to improve daily-living functioning. keywords: barthel index, lawton-brody scale, negative syndrome scale, positive syndrome scale https://doi.org/10.15850/amj.v7n2.1870 althea medical journal. 2020;7(2) 73 physical needs, including grooming, clothing, urinating/defecating, walking, and feeding.7 instrumental activities of daily living comprise of more complex activities for independent living, such as managing finances and medication.7 moreover, the absence of similar studies in indonesia, and inconsistent results from previous studies require further research to correlate the positive and negative symptoms with daily-living performance, specifically adls and iadls.8–10 therefore, this study aimed to explore the correlation between positive and negative symptoms and daily-living performance in schizophrenia. methods this study was a correlative analytical study with a cross-sectional approach, conducted at the outpatient clinic of psychiatry in mental hospital of west java province. this study used secondary data from the previous study “correlation between vitamin d serum in schizophrenic patients and positive and negative symptoms subscale”. this study had ethical clearance exemption from the research ethics committee, universitas padjadjaran no. 1211/un6.kep/ec/2019. in brief, data were collected from patients who came for control treatment from december 2018 to february 2019. in order to calculate the sample size, the formula for finding a correlation between positive and negative symptoms and adls, as well as iadls, was employed using error percentage of 5%, test strength of 90%, an expected minimum correlation coefficient of 0.55.8 the estimated sample size was 31 samples. patients were included based on the gender which was male. the patients need to be calm and cooperative, justified by panss-ec score<25. the exclusion criteria were patients with physical disabilities, including neuromuscular diseases, paralysis, deformity on limbs, disfigurements, blindness and deafness, and incomplete data. data on positive and negative symptoms of psychopathology were collected. the positive and negative symptoms of psychopathology were assessed using the positive and negative syndrome scale or subscales (panss), administered by trained raters, as published earlier. the scale had good and strong psychometric properties in terms of reliability, validity, and sensitivity.11 the single items of the panss were rated on a 7-point scale (1=absent, 2=minimal, 3=mild, 4=moderate, 5=moderatesevere, 6=severe, and 7=extreme).12 the scoring of panss was performed by adding every item of each subscale with a potential range of 7–49. the daily living performance was measured using the barthel adl index and the lawtonbrody iadl scale. barthel adl index assessed the mobility function, continence, and selfcare such as eating, bathing, and dressing, whereas the lawton-brody iadl scale assessed the ability to use tools or interaction with other people or the environment, such as preparing the meal, using the telephone, shopping, and housekeeping. the potential range for both the barthel adl index and the lawton-brody iadl scale for males was 0 to 20 and 0 to 5, respectively. based on barthel adl index, activities of daily living (adls) performance was classified into five levels of adls dependency, comprised of independency (20); mild dependency (12–19); moderate dependency (9–11); severe dependency (5– 8); and total dependency (0-4). lawton-brody iadl scale classifies iadls performance for men into 2 categories: high function or independency (5), and low function or dependency (0–4).12 statistical analysis was executed using a computed statistical program (spss v. 22, licensed to universitas padjadjaran). sociodemographic characteristics were analyzed using descriptive statistics. correlation between positive and negative symptoms and adls were analysed with spearman’s correlation test and p<0.05 considered as statistically significant. correlation between positive and negative symptoms and iadls were analyzed with spearman’s correlation test and p<0.05 considered as statistically significant, after analysis of the distribution of data with the shapiro-wilk test. results in total, data of 31 male schizophrenic patients aged between 24 to 45 years old were collected with a mean age of 35.2 years old (s.d. 6.7 years). most of them were unmarried (22/31), employed (17/31), and had high school education (20/31) at the time of the study. these patients had never been admitted to the hospital (11/31) and almost half of them were admitted more than once (13/31). more than half of the patients experienced chronicity of the illness (19/31). moreover, patients demonstrated independency (21/31) and the rest revealed mild dependency (10/31). the patients showed high iadls function (21/31), and only some were low (10/31) as shown in table 1. nurul amelia rahayu putri et al.: daily living performance in schizophrenic patients in correlation with positive and negative symptoms althea medical journal. 2020;7(2) 74 amj june 2020 the panss-positive subscale subdomains score in the samples revealed a median of 3, except for subdomain excitement and grandiosity, both had 1 as the median. the panss-negative subscale subdomains score in the samples also revealed the median of 3, with the exception of subdomain stereotyped thinking, with 2 as its median (table 2). before statistical correlation analyses, the shapiro-wilk test was used to test the normality of numeric data distribution. both panss-positive subscale and panss–negative subscale had normal data distribution (p-value =0.350, and p-value=0.759, respectively); whereas, liadl did not demonstrate normal data even with data transformation (p-value=0.00). linearity test was conducted between barthel adl index (bai) and pansspositive subscale, and panss-negative subscale, resulting in the linear relationship (p-value=0.425, and p-value=0.809, respectively). linearity test was also operated between liadl and panss-positive subscale, and panss-negative subscale, and showed a linear relationship (p-value=0.512, and p-value= table 1 socio-demographic and clinical characteristics of male schizophrenic patients (n=31) at the outpatient clinic of psychiatry in mental hospital of west java province, recruited from december 2018–february 2019 characteristics n (%) marital status married 8 (26) unmarried 22 (71) divorced 1 (3) occupational status employed 17 (55) unemployed 14 (45) education level no education 2 (6) primary school 4 (13) secondary/middle school 3 (10) high school 20 (65) college/university 2 (6) history of hospitalization never 11 (35) once (1 admission) 7 (23) more than once (> 1 admission) 13 (42) duration of illness 2–5 years 12 (39) > 5 years 19 (61) bai mild dependency 10 (32) independency 21 (68) liadl low function (dependency) 10 (32) high function (independency) 21 (68) note: bai=barthel activity of daily living index; liadl=lawton-brody instrumental activities of daily living scalet althea medical journal. 2020;7(2) 75 0.496, respectively). a spearman’s correlation was run to determine the relationship between bai and panss–positive subscale. there was no correlation between adls dependency levels and positive symptoms (rs=0.039; p>0.05); furthermore, there was no correlation between adls dependency levels and negative symptoms (rs=0.228; p>0.05) (table 3). a spearman’s correlation was run to determine the relationship between liadl and panss-positive subscale. there was a correlation between iadls function and positive symptoms (rs=-0.386; p<0.05); and there was no correlation between liadl and negative symptoms (rs=-0.169; p>0.05). (table 4). discussion this study has correlated positive and negative symptoms with daily-living performance in schizophrenia. most of the patients are unmarried and employed, similar to a study in india,9 but different from a study in israel8, of whom the majority was single (74%) and unemployed (65.4%), even though the patients have had high school education of 4 to 17 years of education (m=11.41, sd=2.48).8 on the contrary, the study in india9 has a lower education level, which is a secondary school, suggesting that unemployment has no correlation with the education but rather to the severity of the disease itself. more than one-fourth of the patients in our study have never been admitted to the hospital (11/31), while almost the same percentage has been admitted more than once (13/31). most of the patients are hospitalized about 5 times.14 more than half of the patients experienced chronicity of illness (19/31), similar to a study in australia.13 most of them show independency,10 with high iadls function, although another study shows conflicting result.9 our study has revealed that the pansspositive subscale score (mean 16.7, sd = 6.1) as well as panss–negative subscale score (mean=20.8, sd=5.9) are not similar with the previous study conducted in india.9 the table 2 panss–positive subscale and panss–negative subscale of male schizophrenic patients (n=31) at the outpatient clinic of psychiatry in mental hospital of west java province recruited during december 2018–february 2019. subdomains median (min–max) panss–positive subscale delusions 3 (1 –6) conceptual disorganization 3 (1–6) hallucinatory behavior 3 (1–5) excitement 1 (1–2) grandiosity 1 (1–5) suspiciousness 3 (1–5) hostility 3 (1–4) subscale total, m (sd) 16.7 (6.1) panss–negative subscale, median (min–max) blunted affect 3 (2–6) emotional withdrawal 3 (1–5) poor rapport 3 (1–5) passive–apathetic social withdrawal 3 (1–5) difficulty in abstract thinking 3 (1–7) lack of spontaneity and flow of conversation 3 (1–6) stereotyped thinking 2 (1–5) subscale total, m (sd) 20.8 (5.9) note: panss=positive and negative syndrome scale; min=minimum; max=maximum; m=mean; sd=standard deviation nurul amelia rahayu putri et al.: daily living performance in schizophrenic patients in correlation with positive and negative symptoms althea medical journal. 2020;7(2) 76 amj june 2020 panss–negative subscale score correspond to between mildly ill to moderately ill when compared with the clinical global impressions scale.11 although most previous studies find a correlation between positive symptoms and adl functioning,10,13 our study shows no significant correlation between adls dependency level and positive symptoms, suggesting that schizophrenic patients with persistent psychosis may be able to retain independence in adls, partly due to the consistent finding that cognitive impairments are also not severely associated with the current presence of psychosis and functional capacity performance.15 interestingly, our study result shows no significant correlation between adls dependency level and negative symptoms, in contradictory to most former studies.10,16 low adls functioning is correlated with apathy subscales of brief psychiatric rating scale–expanded (bprs-e), including emotional withdrawal and blunted affect.10 in a present study, the correlation has been demonstrated between iadls function and positive symptoms, and again this result is conflicting with most of the previous studies,9,17 in which the correlation between total liadl score and the positive subscales of panss do not show statistical significance. most former studies also revealed a correlation between iadl’s function and negative symptoms.15,18 negative symptoms have predicted functioning in iadl.8 it implies that the severity of these symptoms are associated with daily-living performance.8 however, the present study did not demonstrate a correlation between iadl’s function and negative symptoms. despite these results, adls and iadl’s assessments should be considered as important tools to assess proper rehabilitation program for schizophrenic patients to improve their dailyliving functioning. all contradictory results may be attributed to the diversity of the patients or differences in methods of adls as well as iadls evaluation in the former studies. a previous study in israel8 has measured iadls with a performancebased evaluation tool the revised observed tasks of daily living (otdl-r), whereas in sri lanka10 used self-report and caregiver-report evaluation tool activities of daily living scale (adls) to measure adls. however, combining both self-reported and performance-based measures of daily-living performance may be the best way to fully represent an individual’s disability.7 the ability to perform adls and iadls are dependent upon cognitive and motor abilities. capability to perform adequate muscular work, or physical performance, is the strongest predictor of adl limitations.16 physical performance factors include poor physical health status, represented by rates of obesity and related metabolic comorbidities; socioeconomic challenges; and antipsychotic table 3 correlation between barthel adl index with panss-positive and negative subscale of male schizophrenic patients (n=31) bivariate statistics (spearman’s correlation test) rs p-value panss–positive subscale 0.039 0.836 panss–negative subscale 0.228 0.217 note: panss – positive and negative syndrome scale, rs = spearman’s correlation coefficient table 4 correlation between total lawton-brody iadl scale score with panss-positive and negative subscale of male schizophrenic patients (n=31) bivariate statistics (spearman’s correlation test) rs p-value panss–positive subscale -0.386^ 0.032 panss–negative subscale -0.169 0.365 note: correlation was significant at the 0.05 level (2-tailed), panss=positive and negative syndrome scale; iadl= instrumental activities of daily living scale, rs=spearman’s correlation coefficient althea medical journal. 2020;7(2) 77 medications use.16 other confounding factors that also influence adls ability are age,5 age of onset,19 histories of hospitalization, and duration of illness.14 instrumental activities of daily living ability worsen with cognitive impairment, as do motor skills, reducing the capability to perform adequate muscular work.16 other confounding factors that influence iadls function, including age, employment, and marital status,9 level of education,8 age of onset,19 histories of hospitalization, and duration of illness.14 further studies focusing on the impact of daily-living performance should be reattempted by using both self-reported and performance-based evaluation tools and thoroughly control confounding factors, i.e. cognitive abilities that may influence the results. as a conclusion, there is no significant correlation between adls dependency levels and positive symptoms, neither with negative symptoms. however, there is a correlation between iadls function and positive symptoms but not with negative symptoms. the adls and iadls assessments should be considered as important tools for schizophrenic patients for rehabilitation to improve daily-living functioning. references 1. charlson fj, ferrari aj, santomauro df, diminic s, stockings e, scott jg, et al. global epidemiology and burden of schizophrenia: findings from the global burden of disease study 2016. schizophr bull. 2018;44(6):1195–203. 2. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri; 2013. 3. vos t, barber rm, bell b, bertozzi-villa a, biryukov s, bolliger i, et al. global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the global burden of disease study 2013. lancet. 2015;386(9995):743– 800. 4. maisyarah ta, nugraha gi, lidyana l. nutritional status of schizophrenic patients at department of psychiatry in dr. hasan sadikin general hospital. althea medical journal. 2014;1(1):40–7. 5. viertiö s, tuulio-henriksson a, perälä j, saarni si, koskinen s, sihvonen m, et al. activities of daily living, social functioning and their determinants in persons with psychotic disorder. eur psychiatry. 2012;27(6):409–15. 6. carter jw, parnas j, urfer-parnas a, watson j, mednick sa. intellectual functioning and the long-term course of schizophrenia-spectrum illness. psychol med. 2011;41(6):1223–37. 7. mlinac me, feng mc. assessment of activities of daily living, self-care, and independence. arch clin neuropsychol. 2016;31(6):506–16. 8. lipskaya l, jarus t, kotler m. influence of cognition and symptoms of schizophrenia on iadl performance. scand j occup ther. 2011;18(3):180–7. 9. samuel r, thomas e, jacob ks. instrumental activities of daily living dysfunction among people with schizophrenia. indian j psychol med. 2018;40(2):134–8. 10. wijesundara h, dayabandara m, ellepola a, hanwella r. psychopathology in patients with schizophrenia attending a psychiatry outpatient clinic at a tertiary care hospital. sri lanka j psychiatry. 2011;2(1). 11. leucht s, barabássy á, laszlovszky i, szatmári b, acsai k, szalai e, et al. linking panss negative symptom scores with the clinical global impressions scale: understanding negative symptom scores in schizophrenia. neuropsychopharmacology. 2019;44(9):1589–96. 12. dolai mc, chakrabarty f. functional status of the elderly santal people. indian j gerontol. 2013;27(4):610–20. 13. ayres h, ngo h, john ap. limited changes in activities of daily life performance ability among people with schizophrenia at clinical settings and the factors moderating the changes. schizophr res cogn. 2019;16:29–35. 14. reichenberg a, feo c, prestia d, bowie cr, patterson tl, harvey pd. the course and correlates of everyday functioning in schizophrenia. schizophr res cogn. 2014;1(1):e47–52. 15. harvey pd, strassnig m. predicting the severity of everyday functional disability in people with schizophrenia: cognitive deficits, functional capacity, symptoms, and health status. world psychiatry. 2012;11(2):73–9. 16. strassnig m, signorile j, gonzalez c, harvey pd. physical performance and disability in schizophrenia. schizophr res cogn. nurul amelia rahayu putri et al.: daily living performance in schizophrenic patients in correlation with positive and negative symptoms althea medical journal. 2020;7(2) 78 amj june 2020 2014;1(2):112–21. 17. aubin g, chapparo c, rainville c, gélinas i, stip e. daily activities, cognition and community functioning in persons with schizophrenia. schizophr res. 2009;107 (2–3):313–8. 18. leifker fr, bowie cr, harvey pd. determinants of everyday outcomes in schizophrenia: the influences of cognitive impairment, functional capacity, and symptoms. schizophr res. 2009;115(1): 82–7. 19. bechi m, bosia m, spangaro m, buonocore m, cavedoni s, agostoni g, et al. exploring functioning in schizophrenia: predictors of functional capacity and real-world behaviour. psychiatry res. 2017;251:118–24. amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 19 body mass index, a body shape index, and waist-to-height ratio in predicting elevated blood pressure bryan junius winata,1 veronika m. sidharta,2 linawati hananta,3 vetinly,4 nawanto a. prastowo5 1school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia, 2department of histology, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia, 3department of pharmacology and pharmacy, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia, 4department of public health and nutrition, atma jaya catholic university of indonesia, indonesia, 5department of physiology, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia correspondence: dr. dr. veronika m. sidharta, m. biomed, department of histology, school of medicine and health sciences, atma jaya catholic university of indonesia, jalan pluit raya no. 2, north jakarta, indonesia, e-mail: veronika.maria@atmajaya.ac.id introduction obesity is a condition caused by an increase in the size and number of fat cells in the body.1 one type of obesity that causes health problems and premature death is central obesity. central obesity is a condition of accumulation of fat cells in the abdominal area. a study revealed that people who have a distended stomach have a higher risk of death than those who are obese but not distended stomach.1 in addition, central obesity can trigger inflammation or inflammation of the internal organs by releasing cytokine compounds. intra-abdominal fat has a higher lipogenic activity so that it is metabolically very active releasing free fatty acids into the portal circulation which travels directly to the liver. excessive free fatty acids can trigger an increase in fat biosynthesis in the liver, causing insulin resistance, hyperlipidemia, glucose intolerance, increased blood pressure, and atherosclerosis.1 the prevalence of indonesian adult population (aged over 18 years) with central obesity is 26.6 percent in 2013. this prevalence is higher than in 2007 (18.8%).2 this increase in cases if ignored could cause problems in the future. the best method for assessing body fat distribution is by using computed tomography. however, the use of this tool is impractical because it requires high costs and radiation althea medical journal. 2022;9(1):19–23 abstract background: one of the complications of obesity is an elevation in blood pressure which can increase the risk of hypertension. this study aimed to explore body mass index (bmi), a body shape index (absi), and waist-to-height ratio (whtr) in predicting elevated blood pressure (bp). methods: this study was conducted in a cross-sectional design on 215 medical students from october 2019 to september 2020. respondents measured their own weight, height, waist circumference and bp. receiver operating characteristics (roc) curve were analyzed using ibm spss v.23. results: of the 215 medical students who participated in this study, only 102 met the inclusion criteria. the majority of the students were female (n=71, 69.6%) with a mean age of 19.37 years, and normal blood pressure (n=90, 88.2%). area under the roc curve (auc) of whtr and absi were 0.774 (p-value= 0.002) and 0.766 (p-value= 0.003) respectively, which were still acceptable. however, the auc of bmi (p-value=0.589) was 0.11, which was considered poor. conclusion: the indicators of obesity can be used as a screening value for increased blood pressure in adults, with bmi being the weakest indicator compared to absi and whtr. further research is needed to examine absi and whtr indicators as predictor of increased blood pressure in adults. keywords: absi, blood pressure, bmi, obesity, whtr https://doi.org/10.15850/amj.v9n1.2291 althea medical journal. 2022;9(1) 20 exposure. therefore, anthropometric measurement can be used as another option because it is easier to apply and does not cost a lot of money.3 previously, body mass index (bmi) was a fairly effective measuring tool, which was to measure the average obesity in a population. the benefits of the body mass index method are simple formula, cheap, and relatively precise results. however, the disadvantage of body mass index is the disability to differentiate between overweight due to fat or muscle. in addition, the body mass index cannot precisely determine the location of fat deposits in the body.4 the current effort to overcome the weakness of bmi is to create measurements with a body shape index (absi) and waist-to-height ratio (whtr). absi is an indicator of obesity that can predict risk factors for premature death in the general population. meanwhile, whtr was reported to be a better predictor of increased blood pressure than bmi.5 hypertension is one of the important factors triggering non-communicable diseases such as stroke, ischemic heart disease, and others. currently, cardiovascular disease is the number one cause of death in the world.6 based on study results from the research and development agency of the ministry of health in 15 districts/cities in indonesia, 17.7% of deaths were caused by strokes and 10% of deaths were caused by ischemic heart disease (ihd).7 the risk factor for both diseases is hypertension. the interesting fact is that more deaths from stroke and ihd were at home than in hospitals. thus, it can be said that hypertension is a silent killer.7,8 although various obesity indexes have been developed, the best obesity index in predicting elevated blood pressure/prehypertension is controversial. prehypertension has a high risk of developing hypertension.9 several studies found that there is a trend of increasing cases of increased blood pressure in adults due to obesity. obese adults are 4–10 times more likely to develop hypertension.10 unpreventable increases in blood pressure may increase the likelihood of severe cardiovascular disorders. therefore, aim of this study was to compare several obesity indices in predicting prehypertension. thus, this study can determine early and accurate prehypertension screening to prevent the progression of prehypertension to hypertension. methods the research design used in this study was a cross-sectional study. the study included 215 medical students at the atma jaya catholic university of indonesia. exclusion criteria were those who had a history of medication for hypertension, diabetes mellitus or kidney disorders, consumed caffeine within six hours prior to blood pressure measurement, had a habit of smoking or drinking alcohol, and did not have a blood pressure measuring device. this study has been approved by the research ethics board, school of medicine and health sciences atma jaya catholic university of indonesia (no: 04/04/kep-fkuaj/2020). subjects were asked to complete an electronic form created by google forms inquiring blood pressure and anthropometric data, including their weight, waist circumference and height. the data were than calculated for the bmi, absi, and whtr formulas.4,5,11 bmi = weight (kg) height2 (meter2) whtr = waist circumference height absi = waist circumference (meter) althea medical journal march 2022 table 1 respondents characteristics (n=102) characteristics n % gender male female 31 71 30.4 69.6 blood pressure normal elevated 90 12 88.2 11.8 althea medical journal. 2022;9(1) 21bryan junius winata et al.: body mass index, a body shape index, and waist-to-height ratio in predicting elevated blood pressure blood pressure data was collected independently using their pre-owned device. concise blood pressure measurement instructions following current guideline from the american college of cardiology/american heart association (acc/aha) were given to each individual. blood pressure was measured 3 times; upon waking up, in the afternoon, and before going to bed. measurements were averaged and categorized as normal (systolic blood pressure ≤120 and diastolic blood pressure ≤80 mmhg), or elevated (systolic blood pressure >120 and diastolic blood pressure >80 mmhg). the analysis used was the receiver operating characteristics (roc) curve to compare the predictive power of each indicator in predicting the increase in blood pressure in respondents. area under the roc curve (auc) in this study was used to conclude the ability of each indicator in predicting an increase in blood pressure. auc of 1 was designated as perfect predictive ability; 0.5 indicated that the indicator did not have the ability to predict an increase in blood pressure; auc of 0.7–0.8 indicated that the indicator was still acceptable; 0.8–0.9 was good; and >0.9 was excellent.12 the optimal cut-off values of the anthropometric indices to predict the elevated blood pressure were estimated based on the largest value of the youden index (j=sensitivity+ specificity–1).13 analysis was performed using ibm spss statistics for windows version 23 (spss inc., chicago, il, usa) with roc curve analysis. data were presented in table and figure. results of the 215 medical students who participated in this study, only 102 met the inclusion criteria. the majority of the students were female (n=71, 69.6%), with a mean age of 19.37 years, and normal blood pressure (n=90, 88.2%) (table 1). regarding the discriminatory power of obesity indices based on roc curve analysis, it could be seen that the whtr line was closest to the y line (0,1), followed by the absi line in second place, whereas the bmi line was farthest from the y line. the y line was called a perfect classification. the closer the line was to the y line, the better the obesity index predicted an elevation in blood pressure (figure). in table 2, it showed that the auc of whtr and absi scores were higher than bmi. the auc of whtr and absi were 0.774 (p-value=0.002) and 0.766 (p-value=0.003) respectively, which were still acceptable. however, the auc of bmi (p-value=0.589) was 0.11, which was considered poor. after determining the highest youden index for each indice, the optimum cut-offs of whtr, absi, and bmi in predicting the elevation of blood pressure were 0.49, 0.08, and 28.2, consecutively. based on roc analysis, the sensitivity of whtr, absi, and bmi were 91.67%, 83.33%, and 25% consecutively. meanwhile, the specificity of whtr, absi, figure discriminatory power of obesity indices based on roc curve analysis se ns it iv it y diagonal segments are produced by ties 1-specificity roc curve source of the curve 1.0 1.00.80.60.40.20.0 0.0 0.2 0.4 0.6 0.8 bmi absi whtr reference line absi whtr reference line althea medical journal. 2022;9(1) 22 and bmi were 68.89%, 67.78%, and 85.56% respectively. discussion easy-to-use screening tools are essential in detecting the risk of prehypertension for early intervention. this is because the prevalence of prehypertensive people who are obese is increasing.14 this study provides information about the optimal cutoff and compares three indicators of obesity (bmi, absi, and whtr) in predicting increased blood pressure. bmi is a poor indicator of predicting increased blood pressure. this is indicated by the very low auc results (auc=0.452) and p-value >0.05 (p=0.589). among all the indicators tested in this study, the roc bmi curve is the farthest from the y line (0.1). this is because bmi is not able to measure fat distribution. in addition, bmi cannot differentiate between fat tissue and muscle mass in a person’s body so that many individuals with high body fat composition are not detected based solely on bmi measurements. therefore, the use of a bmi indicator in predicting elevated blood pressure is not recommended.15,20 indicators that show central obesity such as whtr can predict cardiometabolic risk better than bmi. this is indicated by the high auc results (auc=0.774) and p-value <0.05 (p=0.02). among all the indicators tested in this study, the whtr roc curve is closest to the y line (0.1) so it can be concluded that the whtr indicator has a reliable ability to predict an increase in blood pressure in respondents. the cut off value of whtr that has the highest sensitivity and specificity based on youden index in predicting elevated blood pressure is 0.49. the whtr cutoff in predicting increased blood pressure was only slightly lower than the cutoff for obesity (whtr> 0.5). cut-off whtr> 0.5 has a sensitivity and specificity that can still be relied upon in predicting elevated blood pressure above normal (sensitivity=83.3%, specificity=72.2%). however, for screening needs it is recommended to use a cut-off that has a higher sensitivity. so, whtr cut-off> 0.49 is more recommended in predicting an increase in blood pressure. this study is consistent with the results of a meta-analysis study conducted by tee et al.5 which examined more than 513 adolescents from malaysia. whtr is the best indicator as an initial screening for prehypertension, while bmi is the worst indicator as an initial screening for prehypertension.6,19 the absi indicator was good at predicting an increase in blood pressure in respondents. the auc absi score was only slightly lower than the whtr (auc=0.766). the absi cutoff value in predicting an increase in blood pressure is 0.08. the results of this study are not so surprising given that a high absi score has a strong correlation with the visceral fat fraction, which has metabolic effects that are harmful to health.16–18 limitation of this study is that it was a cross-sectional study. cross-sectional design can explain the relationship between the two variables, but this study cannot show the direction of the causal relationship between the two observed variables. besides, anthropometric measurements such as weight, height, waist circumference and blood pressure were measured independently by the respondents using the tools they had. due to covid-19 pandemic, researchers must implement health protocol by limiting social gathering so that measurements carried out by respondents independently cannot rule out human error in the data collection process. to conclude, indicators of obesity can be used as a screening for increased blood pressure in adults. however, bmi is the weakest indicator compared to absi and whtr. therefore, bmi is not recommended as an initial screening for elevated blood pressure. whtr and absi can be considered as althea medical journal march 2022 table 2 optimal cut-off values, sensitivities, specificities, youden index, and auc of anthropometric indices in predicting elevate anthropometric indices cut-off sensitivity (%) specificity (%) youden index auc p-value (95% ci) (95% ci) (95% ci) bmi 28.20 25.00 85.56 0.11 0.452 0.589 absi 0.08 83.33 67.78 0.51 0.766 0.003 whtr 0.49 91.67 68.89 0.61 0.774 0.002 note: bmi=body mass index, absi=a body shape index, whtr=waist-to-height ratio, auc=area under the roc curve althea medical journal. 2022;9(1) 23 a good predictors of elevated blood pressure in adults. further research is needed to examine whtr and absi as predictors of increased blood pressure in adults. references 1. fruh sm. obesity: risk factors, complications, and strategies for sustainable long-term weight management. j am assoc nurse pract. 2017;29(s1):s3–14. 2. badan penelitian dan pengembangan kesehatan kemenkes ri. laporan hasil riset kesehatan dasar 2013. jakarta: badan penelitian dan pengembangan kesehatan kemenkes ri; 2013. 3. karakaș pi, bozkir mg. anthropometric indices in relation to overweight and obesity among turkish medical students. arch med sci. 2012;8(2):209–13. 4. nuttall fq. body mass index: obesity, bmi, and health: a critical review. nutr today. 2015;50(3):117–28. 5. tee jyh, gan wy, lim py. comparisons of body mass index, waist circumference, waist-to-height ratio and a body shape index (absi) in predicting high blood pressure among malaysian adolescents: a cross-sectional study. bmj open. 2020;10(1):e032874. 6. mc namara k, alzubaidi h, jackson jk. cardiovascular disease as a leading cause of death: how are pharmacists getting involved? integr pharm res pract. 2019;8:1–11. 7. pusat data dan informasi kementerian kesehatan republik indonesia. hipertensi the silent killer. jakarta: pusat data dan informasi, kementerian kesehatan republik indonesia; 2015. 8. sawicka k, szczyrek m, jastrzębska i, prasał m, zwolak a, daniluk j. hypertension –the silent killer. j pre clin clin res. 2011;5(2):43–6. 9. booth jn, li j, zhang l, chen l, muntner p, egan b. trends in prehypertension and hypertension risk factors in us adults: 1999–2012. hypertension. 2017;70(2):275–84. 10. churniawati l, martini s, wahyuni cu. prehipertensi pada obesitas abdominal. kesmas. 2015;9(4):293–9. 11. krakauer ny, krakauer jc. a new body shape index predicts mortality hazard independently of body mass index. plos one. 2012;7(7):e39504. 12. hosmer jr. dw, lemeshow s, sturdivant r. applied logistic regression. 3rd ed. hoboken, new jersey: john wiley & sons; 2013. 13. martínez-camblor p, pardo-fernández jc. the youden index in the generalized receiver operating characteristic curve context. int j biostat. 2019;15(1):20180060. 14. kelly rk, magnussen cg, sabin ma, cheung m, juonala m. development of hypertension in overweight adolescents: a review. adolesc health med ther. 2015;6:171–87. 15. carpenter cl, yan e, chen s, hong k, arechiga a, kim ws, et al. body fat and body mass index among a multiethnic sample of college-age men and women. j obes. 2013;2013:790654. 16. duncan mj, mota j, vale s, santos mp, ribeiro jc. associations between body mass index, waist circumference and body shape index with resting blood pressure in portuguese adolescents. ann hum biol. 2013;40(2):163–7. 17. christakoudi s, tsilidis kk, muller dc, freisling h, weiderpass e, overvad k, et al. a body shape index (absi) achieves better mortality risk stratification than alternative indices of abdominal obesity: results from a large european cohort. sci rep. 2020;10(1):14541. 18. bouchi r, asakawa m, ohara n, nakano y, takeuchi t, murakami m, et al. indirect measure of visceral adiposity ‘a body shape index’ (absi) is associated with arterial stiffness in patients with type 2 diabetes. bmj open diabetes res care. 2016;4(1):e000188. 19. aguirre pf, coca a, aguirre mf, celis g. waist-to-height ratio and sedentary lifestyle as predictors of metabolic syndrome in children in ecuador. hipertens riesgo vasc. 2018;35(3):101–9. 20. vanderwall c, randall clark r, eickhoff j, carrel al. bmi is a poor predictor of adiposity in young overweight and obese children. bmc pediatr. 2017;17(1):135. bryan junius winata et al.: body mass index, a body shape index, and waist-to-height ratio in predicting elevated blood pressure amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 149 pathological findings of the lung at neonatal autopsy in dr. hasan sadikin general hospital bandung period 2016–2019 rania azzahra salsazayasya parikesit,1 nita novita,2 hermin aminah3 1faculty of medicine, universitas padjadjaran, indonesia, 2department of forensics and medicolegal faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: rania azzahra salsazayasya parikesit, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: raniaparikesit82@gmail.com introduction the term infanticide has a specific meaning in each country based on the legislation. in general, infanticide is a criminal act when a mother kills her child soon after birth or until the baby is twelve months old.1 in indonesia, based on the indonesian penal code book ii chapter xix article 341, infanticide is a crime committed by a mother who, driven by fear of the discovery of her confinement with deliberate intent takes the life of her child at or soon after its birth.2 the mother shall be punished by a maximum imprisonment of seven years.2 in addition, article 342 of the penal code states that the mother who, for the execution of a decision driven by fear of the discovery of her forthcoming confinement, with deliberate intent takes the life of her child at or soon after its birth, shall, being guilty of infanticide, be punished by a maximum imprisonment of nine years.2 to consider whether a case is decided as infanticide, it is necessary to determine whether a child was born alive or not.3 to determine it, signs of breathing or other signs of life, such as the condition of umbilical cord, pulse and food in the stomach need to be shown from the infant. in this case, breath signs are the the most widely used indicators.4 the hydrostatic test (floatation) became one of the examination approaches used for 300 hundred years by pathologists to find this sign. however, recently the reliability of the test has amj. 2021;8(3):149–54 abstract background: infanticide is a criminal act when a mother kills her child at or soon after birth. considering whether a case has been decided as infanticide, determination of the life of the neonate at birth is imperative. breath signs from macroscopic and microscopic approacesh and hydrostatic test are useful indicators. this study aimed to explore the lungs pathological findings at autopsy of neonates. methods: this study was a retrospective descriptive observational study, using medical records of neonatal deaths in the department of forensics and medicolegal dr. hasan sadikin general hospital, bandung for the period 2016–2019. total sampling method was used. inclusion criteria were neonatal death with presumptive infanticide, had autopsied and microscopic examination as well as neonatal death without putrefaction. data on macroscopic and microscopic findings as well as the hydrostatic test were presented. results: in total, 12 of the 42 medical records with data on presumptive infanticide met the inclusion criteria. for macroscopic findings, 7 of the 12 samples had positive results, meaning the lungs had sign of breath. meanwhile, in microscopic findings 8 of the 12 samples had positive results. for the hydrostatic test, 8 out of 12 samples had positive results. of the 12 samples, there were four samples that had different results, at least on one variable. conclusions: most of the cases match the macroscopic, microscopic, and hydrostatic tests, but some unmatched data are also found. in order to improve reliability, especially for legal purposes in infanticide, it is necessary to conduct all the examinations. keywords: hydrostatic test, infanticide, macroscopic finding, microscopic finding https://doi.org/10.15850/amj.v8n3.2337 althea medical journal. 2021;8(3) 150 althea medical journal september 2021 begun to be questioned by pathologists.3 falsepositive and false-negative are the reason why the hydrostatic test results are not completely reliable. there are well-known influences that may affect the results. one of the reasons for a false-positive result is gas due to putrefaction, and that will cause the lungs to float and give a different meaning to the test. while, the false-negative results can occur if a person can kill the newborn before the first birth or the fluid in the newborn’s lungs. for that reason, if hydrostatic test results are submitted during a trial, then both false-positive and false-negative consequences could have farreaching consequences.5 the hydrostatic test is not recommended as the only examination approach for finding breath signs in newborns, especially if the test results are used as evidence in court. microscopic and macroscopic examination of the infant’s lungs is another approache to examine the newborn’s breath signs.3 based on these reasons, this study aimed to assess lung pathological findings in neonatal autopsy cases. this study is needed to help pathologists identify whether newborns are categorized as live or stillborn. hopefully, this study can help the court to decide whether the alleged perpetrator, mostly mothers, are guilty. methods this study was a retrospective descriptive observational study, using medical records data retrieved from the department of forensics and medicolegal of dr. hasan sadikin general hospital, bandung. this study consisted of autopsy data on neonatal deaths during 2016–2019. a total sampling method was employed. the inclusion criteria for this study were neonatal deaths with presumptive of infanticide, had an autopsy and microscopic examination as well as neonatal deaths without putrefaction. neonatal deaths that had been reported to had died due to medical conditions or other causes of death and decomposition found were excluded from this study. of the 42 medical records of neonatal deaths with presumptive infanticide, 13 met the inclusion criteria. this study analyzed macroscopic and microscopic findings as well as the results of the hydrostatic examination in accordance with the collected data. macroscopic findings such as lungs’ color, weight, structure, and border features of the lungs were assessed as characteristics to determine the live births. positive results on macroscopic findings were characterized by the presence of signs of breath, the color of the lungs was pink or light red, and rounded lung edges. for microscopic findings, alveolar expansion was observed. if an alveolar expansion was found, it was categorized as positive findings on microscopic findings. meanwhile, the lungs sink or float after being placed on the water observed in the hydrostatic test. the result was positive when the lungs were respired, which gave a positive breath sign and indicated that the lungs floated after being placed on water; whereas a negative result was indicated when the lungs were unrespired, which gave a negative breath sign it was shown by the sinking of the lungs after being placed on the water. the collected data were then presented in tables for each variable to represent the lung findings in neonatal deaths autopsies. the table 1 frequency of lung pathology findings from autopsy data on neonatal deaths registered at dr. hasan sadikin general hospital 2016–2019 variable n gender female male 7 5 macroscopic finding positive negative 7 5 microscopic finding positive negative 8 4 hydrostatic test positive negative 8 4 althea medical journal. 2021;8(3) 151rania azzahra salsazayasya parikesit et al.: pathological findings of the lung at neonatal autopsy in dr. hasan sadikin general hospital bandung period 2016–2019 study was approved by the health research ethics committee of dr. hasan sadikin general hospital no. lb.02.01/x.2.2.1/19925/2020. results in total, only 12 of 42 retrieved medical records were included. most of the cases excluded were due to decomposition in almost the entire body of the infant, thus making it difficult to analyze, and incomplete medical record data as other reasons. most of the samples included were female neonates. the macroscopic findings of the lungs at autopsy of the neonate cases were predominantly positive result (n=7), indicating that the lungs were brighter red than the negative results and the edges were rounder (figure 1). similar to the microscopic finding, a primarily positive result was found (n=8), as shown in figure 2. for the hydrostatic test, a positive result (n=8) was mainly found. as shown in figure 3, the lungs floated on the water, indicating that the lungs had a positive result. for negative results, the lungs sank. in this study, 4 of the 12 samples had different results for each variable. discussions newborn autopsies provide important information, such as the cause of death and the accuracy of pre-death clinical information.6 associated with infanticide, the forensic pathologist needs to determine stillbirth or live birth as well as to determine the cause and manner of death.7 the breath sign is one of the indicators to prove that the newborn was born alive. the hydrostatic test or floatation test has used to be the definitive test to determine a newborn’s breath sign.1 in addition to hydrostatic test, macroscopic table 2 conformity of lung pathological findings from neonatal death autopsy data registered at dr. hasan sadikin hospital 2016–2019 macroscopic finding microscopic findings hydrostatic test n + + + 5 + + 1 + + 1 + + 2 3 case 1 case 2 figure 1 lung macroscopic findings in neonatal deaths as shown during the autopsy note: case 1 positive result; case 2 negative result althea medical journal. 2021;8(3) 152 althea medical journal september 2021 and microscopic evaluation of the lungs have been included as a post-mortem examination to determine whether the newborn was born alive or stillbirth. this study shows a positive or negative signs of breath in macroscopic findings, especially by the lungs’ color. the bright red color of the lungs is categorized as respired lungs or has a positive breath sign. the bright red color of the lungs occur due to increased blood flow to the pulmonary circulation after breathing and the low resistance placenta figure 2 microscopic finding of the lung with positive results case 1 case 2 figure 3 hydrostatic test note: case 1 sample with a positive result; case 2 sample with a negative result althea medical journal. 2021;8(3) 153rania azzahra salsazayasya parikesit et al.: pathological findings of the lung at neonatal autopsy in dr. hasan sadikin general hospital bandung period 2016–2019 removal.8 mechanical forces in the lungs can directly influence physiological functions such as during lung development, surfactant release by alveolar epithelial cells, contraction of airway smooth muscle, and tissue remodeling through cellular signaling. subsequently, these physiological changes provide features of macroscopic findings.9 therefore, lung’s weight, texture, and border features have been used in macroscopic findings for additional characteristics. for the microscopic findings, the lungs as a respired and unrespired lungs were categorized based on the expansion of the alveolus. initiation of breath during the delivery process increases the secretion of surfactant into the fetal lungs, allowing the alveolar to stretch. surfactant has the function of lowering the surface tension in the lungs, thus allowing inflation at lower pressures.10 the hydrostatic test is a method for assessing lung aeration by the lung floatation technique. if an infant is breathing or born alive, the alveolus will be filled with air, and the lungs will float when placed into water.11 this sign is categorized as a lung that has positive sign of breath. meanwhile, if the lung sink when put in water, it is categorized as a negative breath sign. based on the medical record data in our study, some samples were found to have a bright red color, and some samples also had a soft texture, and features a rounded border. this finding has been categorized as respired lungs, which gives a positive breath sign.12 another finding is the appearance like marbles in some respired lung. this marblelike appearance or mottled also proves that the lungs have a positive sign of breath. furthermore, a mosaic appearance has been found in some samples.13–15 some samples have shown a dark red color, solid texture, and a sharp margins. its appearance is similar to that of the liver, showing an unrespired lung as a negative sign of breath.12,13 moreover, lungs weighing >40g are designated as respired lung, and <40 g are considered unrespired lungs.16 in this study, the alveolus was mainly expanded in microscopic finding, indicating that the alveoli have been aerated and therefore, it had a positive sign of breath. on the other hand, the alveoli found to be uniformly unaerated had a negative sign of breath.12,13 as for the hydrostatic test, some samples showed positive result in the hydrostatic test. the lungs float when placed in water, indicating that the infant has been born alive with aerated and expanded alveoli. on the contrary, the lungs sink when placed in water, indicating a stillbirth infant with a negative sign of breath.13 interestingly, some samples had different results in each test; macroscopic, microscopic, and hydrostatic tests. positive and negative breath signs for macroscopic findings are showed mainly by their color. this can give a false-positive and false-negative result because there is no standard color and the result can be influenced by a personal judgment in determining the color of lung, whether it is dark red or bright red. indeed, in some medical records, they just mentioned one primary color: “red”, which could cause live births interpreted differently. a study of the interrater reliability of vehicle color perception for forensic intelligence has discussed similar problems regarding variations in color perception by individuals with normal vision, leading to incorrect determinations.17 macroscopic findings will be more reliable if supported by other characteristic, such as lung weight, texture, and topography. in the medical records used for this study, not every sample included all macroscopic characteristics other than color, which limits our study to interpreting macroscopic finding to decide whether the infant was born alive or stillbirth. although the microscopic approach has been considered the most reliable approach, false-negative results might occur due to possible atelectasis in the neonates’ lungs indicating stillbirth. for example, the sample used for the microscopic test is from the part of the lung that has not been aerated, while the other part is aerated, as noted in study by philip et al.13 microscopic assessment should not be used as the definitive test to determine the neonates’ live birth,13 contrary to the study of milroy et al.3 which stated that microscopic examination of the lungs has greater value in determining fetal age or maturity than in determining live birth.3,13 interestingly, the value of the hydrostatic test and its reliability were questioned to determine whether the infant was born alive or stillbirth. due to decomposition, the development of gases for ventilation of a lifeless neonate by the mother or a third person, or the possibility of the neonate breathing before delivery, will give a false-positive result on a hydrostatic test. meanwhile, a false-negative result could happen if the newborn’s lungs are filled with fluid after a water birth. another possibility if someone could kill the neonate althea medical journal. 2021;8(3) 154 althea medical journal september 2021 before the newborn takes its first breath or the air is absorbed by the surrounding tissues from the post-mortem if breathing is insufficient.3,5 this study has several limitations. first, the low number of microscopic examinations performed on autopsy cases of neonates with presumptive infanticide. second, not every sample includes all macroscopic characteristics other than color, especially the topographic characteristics. as mentioned earlier, the color red in the medical record can provide different interpretations and variations in color perception can lead to incorrect determinations. in conclusion, most of the cases have matched macroscopic, microscopic, and hydrostatic tests. however, some unmatched results have been found, so a comprehensive examination is necessary to decide whether an infant was born alive or stillbirth to avoid mistakes. this approach could also provide more practical results, primarily if these results are used for jurisprudential interest in infanticide cases. references 1. payne-james j, jones r, karch sb, manlove j. deaths and injury in infancy. in: paynejames j, jones r, karch sb, manlove j. simpson’s forensic medicine. 13th ed. london: hodder education publisher; 2011. p.65–75 2. directorat general of law and legislation ministry of justice republic of indonesia. penal code of indonesia book ii chapter xix: crimes against life-article no. 341 and 342. jakarta: republic of indonesia; 1982. p. 81 3. milroy c. neonatal deaths, infanticide, and the hydrostatic (floatation) test: historical perspectives. acad forensic pathol. 2012;3(4):338–45. 4. amelinda a, hoediyanto h, kalanjati vp. profil kasus pembunuhan anak di departemen ilmu kedokteran forensik dan medikolegal rsud dr. soetomo. ejki. 2018;6(1):50–2. 5. große ostendorf al, rothschild ma, müller am, banaschak s. is the lung floating test a valuable tool or obsolete? a prospective autopsy study. int j legal med. 2013;127(2):447–51. 6. de sévaux jlh, nikkels pgj, lequin mh, groenendaal f. the value of autopsy in neonates in the 21st century. neonatology. 2019;115(1):89–93. 7. haridas s v, patekar mb, ninal ns, zine ku. newborn infanticide within hospital premise an unusual case report. journal of indian academy of forensic medicine. 2014;36(2):220–2. 8. hillman nh, kallapur sg, jobe ah. physiology of transition from intrauterine to extrauterine life. clin perinatol. 2012;39(4):769–83. 9. suki b, stamenović d, hubmayr r. lung parenchymal mechanics. compr physiol. 2011;1(3):1317–51. 10. morton su, brodsky d. fetal physiology and the transition to extrauterine life. clin perinatol. 2016;43(3):395–407. 11. barber jl, sebire nj, chitty ls, taylor am, arthurs oj. lung aeration on post-mortem magnetic resonance imaging is a useful marker of live birth versus stillbirth. int j legal med. 2015;129(3):531–6. 12. turan n, pakis i, yilmaz r, gunce e. macroscopic and microscopic findings of infant lung in case of live or still birth. sci res essays. 2013;8(21):867–74. 13. phillips b, ong bb. “was the infant born alive?” a review of postmortem techniques used to determine live birth in cases of suspected neonaticide. acad forensic pathol. 2018;8(4):874–93. 14. karmakar rn, editor. j.b. mukherjee’s forensic medicine and toxicology. 5th ed.. kolkata, west bengal, india: academic publisher; 2018. p.1068 15. aldila ba, alit ibp. studi deskriptif terhadap ciri-ciri korban infantisida di bali, tahun 2012 sampai 2014. medika udayana. 2015;4(6):13834. 16. d’angelis ca, coalson jj, ryan rm. structure of the respiratory system: lower respiratory tract. in: fuhrman bp, zimmerman jj, editors. pediatric critical care. 4th ed. philadelphia: elsevier saunders; 2011. p. 490–8. 17. lee k, abdul fatah aa, norizan nm, jefrey z, md nawi fh, wan nor wfk, et al. interrater reliability of vehicle color perception for forensic intelligence. plos one. 2019;14(6):e0218428. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 204 characteristics of brain imaging in intracranial tumor patients at neurology ward dr. hasan sadikin general hospital bandung 2017–2019 putri nur amalia dewi,1 asep nugraha hermawan,2 cep juli,2 paulus anam ong,2 sofiati dian2 1faculty of medicine, universitas padjadjaran, indonesia, 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: putri nur amalia dewi, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: putri17031@mail.unpad.ac.id introduction intracranial tumors or brain tumors are neoplastic lesions inside the cranium due to uncontrolled and progressive cell growth or space-occupying lesions (sol) in terms of imaging.1 according to data from the global cancer observatory, the incidence of intracranial tumors ranks 15th of all tumor diseases with an incidence of 1.5% worldwide.1 intracranial tumors are the 13th cause of death of all tumor/cancer cases in indonesia.1 this is largely due to delays in diagnosis and treatment. if detected at an early stage, appropriate treatment can be done earlier to improve the prognosis. those can be pursued through selecting the appropriate imaging method. intracranial imaging is useful to help in diagnosing intracranial tumors, to determine management and to monitor the therapy process.2 therefore, knowledge of the characteristics of imaging is important in managing intracranial tumor patients. dr. hasan sadikin general hospital is a national referral hospital and cases of tumors or cancers including intracranial tumors are referred from various regions in west java, indonesia. many imaging modalities are available and have an important role in the diagnosis and management of intracranial tumor cases. this study aimed to describe the use of imaging modalities and the characteristics of imaging findings in diagnosing intracranial tumor patients. althea medical journal. 2021;8(4):204–209 abstract background: brain imaging is the main modality in establishing the diagnosis of intracranial tumors. therefore, by using appropriate imaging modalities, lesions can be identified and this is useful in determining management and monitoring of the therapeutic process. this study aimed to describe the use of imaging modalities and the characteristics of imaging findings in diagnosing intracranial tumor patients. methods: this cross-sectional descriptive study obtained data from medical resumes at the neurology ward of dr. hasan sadikin general hospital bandung, collected by total sampling method. data on patients with intracranial tumors who underwent imaging examinations in january 2017–december 2019 were taken, including demographical and imaging characteristics data, divided by tumor type. results: of 206 data, the imaging modalities used were contrast ct scan (45.6%), non-contrast ct scan (34.5%), multimodality imaging (13.6%), contrast magnetic resonance imaging (mri) (3.9%), non-contrast mri (2.4%), and magnetic resonance spectroscopy (mrs) (0.5%). the most common primary tumor was a solitary lesion (89.4%) located in the right hemisphere in 38.1% of subjects. metastatic tumors were found mostly as multiple lesions (63.4%) located in both supratentorial and infratentorial in 25.8% of the subjects. perifocal edema was found in 75% of patients in both tumor types. conclusions: contrast ct scan is the most frequently used imaging modality. the most common radiological finding is perifocal edema. primary tumors are commonly found in solitary numbers, and are located in supratentorial on the right hemisphere. metastatic tumors are commonly found in multiple numbers and are located both in supratentorial and infratentorial. keywords: brain imaging, imaging modality, intracranial tumor https://doi.org/10.15850/amj.v8n4.2361 althea medical journal. 2021;8(4) 205 methods this was a descriptive study with a crosssectional design. the subjects were patients aged >18 years between january 2017– december 2019, presented in neurology ward dr. hasan sadikin general hospital bandung, who had a final diagnosis of intracranial tumors and brain imaging has been performed. data were collected from medical resumes in the department of neurology by the total sampling method. the study has been approved by the research ethics committee of universitas padjadjaran with ethical clearance number 791/un6.kep/ec/2020. patients with missing medical resume data, incomplete or missing head imaging results, inaccessible, or duplicate data were excluded. demographic data and imaging characteristics from radiological experts were analyzed and divided into primary and metastases intracranial tumors. results during the study period, 275 cases were presented, but only 206 subjects had complete data. patients who were admitted to the hospital had a mean age of 50.06 (± sd 12.62) with a greater proportion of female patients (55.3%). the general characteristics of the age and sex of subjects were listed in table 1. of all the subjects, it was found that primary intracranial tumors (54.9%) were more prevalent than metastatic tumors (45.1%) based on the final clinical diagnosis. contrast ct scan was the most often used modality in both groups, followed by noncontrast ct (table 2). it was also the most widely used modality of choice in identifying lesions in any location (table 3). in the use of multimodality imaging, there was a difference in the preference for using a combination of modalities between the primary and metastatic group. the first two most common radiological findings in both groups were similar, perifocal edema and midline shift, followed by other findings as described in table 2. however, the number of lesions and the location found had differences in the primary and metastatic groups. discussions this study has found that female patients are predominant, in both the primary intracranial tumor (54%) and metastatic (57%) groups, conforming to the central brain tumor registry of the united states (cbtrus) data from 2013–2017.3 meningioma lesions have the potential to significantly influence growth in women due to progesteron receptor expression.3 however, this study was limited to showing the number of meningioma cases from all primary tumors, thus, the proportion of incidence cannot be confirmed. the high incidence of metastatic brain tumors in women might be caused by the high incidence of breast cancer in indonesia.1 in this study, 24 of 93 metastatic intracranial tumor patients were breast cancer patients. a literature study showed that intracranial metastases can occur in 16–30% due to overexpression of her2.4 within each modality, there are advantages as well as limitations in identifying lesions in a particular location. in this research, contrast ct-scan (45.6%) was the most widely used table 1 characteristics of intracranial tumor patients at dr. hasan sadikin general hospital 2017–2019 characteristic subject (n=206) age, mean±sd 50.06±12.62 gender, n(%) male female 92 (44.7) 114 (55.3) imaging modality, n (%) non-contrast ct contrast ct non-contrast mri contrast mri mrs multimodality 71 (34.5) 94 (45.6) 5 (2.4) 8 (3.9) 1 (0.5) 28 (13.6) notes: ct= computed tomography, mri= magnetic resonance imaging, mrs= magnetic resonance spectroscopy putri nur amalia dewi et al.: characteristics of brain imaging in intracranial tumor patients at neurology ward dr. hasan sadikin general hospital bandung 2017–2019 althea medical journal. 2021;8(4) 206 modality in imaging studies for both primary (39.8%) and metastatic (52.7%) tumor types as well as for lesions located in supratentorial (46.2%), infratentorial (44.4%), or both (42.3%). using a contrast ct scan is more advantageous than a single ct scan without contrast. based on a retrospective study conducted in south africa,5 there is 3.28% of intracranial pathology that failed to be detected on the use of non-contrast ct without being followed by a contrast ct scan, for example, if there is blood-brain barrier damage.5 although a non-contrast ct scan can reduce operational costs, risk of allergic reactions, and risk of contrast-induced acute kidney injury, it requires careful assessment of the history of the disease.5 magnetic resonance imaging (mri) is rated as the modality of choice with high table 2 imaging characteristics of intracranial tumor patients characteristics primary tumors (n=113) metastatic tumors (n=93) imaging modality, n (%) non-contrast ct contrast ct non-contrast mri contrast mri mrs multimodality non-contrast ct and mrs non-contrast ct and contrast mri non-contrast ct and non-contrast mri contrast ct and mrs contrast ct and non-contrast mrii contrast ct and contrast mri contrast mri and mrs 38 (33.6) 45 (39.8) 5 (4.4) 6 (5.3) 1 (0.9) 19 (15.9) 8 (7.1) 6 (5.3) 1 (0.9) 2 (1.8) 33 (35.5) 49 (52.7) 3 (3.2) 8 (8.6) 1 (1.1) 1 (1.1) 3 (3.2) 2 (2.2) 1 (1.1) 1 (1.1) location, n (%) supratentorial right hemisphere left hemisphere bilateral others infratentorial supratentorial and infratentorial 105 (92.9) 43 (38.1) 34 (30.1) 7 (6.2) 21 (18.6) 6 (5.3) 2 (1.8) 66 (71) 21 (22.6) 21 (22.6) 20 (21.5) 4 (4.3) 3 (3.2) 24 (25.8) number, n (%) solitary multiple 101 (89.4) 12 (10.6) 34 (36.6) 59 (63.4) radiological findings,n (%) perifocal edema midline shift non-communicating hydrocephalus intracranial hemorrhage calcification ring enhancement communicating hydrocephalus intratumoralhemorrhage meningeal enhancement hyperostosis septal enhancement 85 (75.2) 62 (54.9) 23 (20.4) 16 (14.2) 12 (10.6) 5 (4.4) 5 (4.4) 3 (2.7) 2 (1.8) 2 (1.8) 2 (1.8) 70 (75.3) 31 (33.3) 8 (8.6) 12 (12.9) 5 (5.4) 9 (9.7) 2 (2.2) 0 (0) 1 (1.1) notes: ct= computed tomography, mri= magnetic resonance imaging, mrs=magnetic resonance spectroscopy althea medical journal december 2021 althea medical journal. 2021;8(4) 207putri nur amalia dewi et al.: characteristics of brain imaging in intracranial tumor patients at neurology ward dr. hasan sadikin general hospital bandung 2017–2019 contrast and spatial resolution for delineating intracranial tumor lesions compared to ct.6 this is due to the working principle of mri which utilizes electromagnetic signal emission at the level of the hydrogen atom nucleus in the human body.6 according to the panduan penatalaksanaan kanker otak tahun 2016 from the ministry of health of the republic of indonesia,2 mri should be the right method of choice to provide a good picture, especially for infratentorial lesions. this is contrary to this study in which the identification of infratentorial lesions is still dominated by the use of contrast ct scan. ct scan is still the standard radiological examination and as an initial screening tool due to its availability and relatively low operating costs compared to mri.2,6 magnetic resonance spectroscopy (mrs) can also be the modality of choice that serves to measure the metabolites of tumor tissue so that anatomical, physiological, and metabolic information is obtained at one time.7 it has the same working principle as mri so that it will produce mri and mrs images on examination. in this study, the use of mrs appeared to be combined with the use of ct scans. another advantage, mrs is a non-invasive modality.8 as with mri, the availability of mrs is limited in hospitals in indonesia and cannot be performed on patients with metal implants, so its use is limited.8 imaging studies can provide characteristic information such as location, number of lesions, and radiological findings, so that tumor lesions can be identified. in primary intracranial tumors, this study shows that tumor lesions have been found in a solitary form (89.4%) and located in the right hemisphere (38.1%), whereas in metastatic intracranial tumors, the lesions are more frequent in multiple forms (63.4%), located in both supratentorial and infratentorial (25.8%). the location varies depending on histopathological type of the primary tumor. in general, many primary tumors are supratentorial.6 for example, glioma is often found in the cerebral hemispheres (frontal and temporal lobe) and meningioma is most common in supratentorial parasagittal.6 almost all primary tumor lesions are found in solitary numbers, multiple lesions are a very rare condition.10 it is thought that multiple lesions that occur sequentially are caused by irritation by the perifocal edema of the first lesion, leading to proliferation of neoplastic cells in astrocytes or arachnoid cells.10 metastatic lesion are formed due to neoplastic cells that spread hematogenously and extravasates in the perivascular space or brain parenchyma.11 this mechanism allows the formation of metastatic tumors tend to produce multiple lesions, as many as 70– 80% of patients with metastatic intracranial tumors have multiple lesions.11 however, metastatic lesions have a predilection location intracranial depending on the primary tumor type.12 breast cancer has a predilection location in the posterior fossa whereas lung cancer tends to be scattered throughout the intracranial area.12 so far, there have been no studies that have proven significantly the predilection location of intracranial metastatic tumors.12 the results of this study indicate that the appearance of perifocal edema is the most common feature found on imaging examinations of patients with intracranial tumors, followed by midline shift, and noncommunicating hydrocephalus. perifocal edema can be found in both primary and metastatic intracranial tumors, and in this study, almost the same frequency was found, 75.2% and 75.3%, respectively. the table 3 distribution of imaging modality based on location imaging modality supra-tentorial (n=171) infra-tentorial (n=9) supratentorial and infratentorial (n=26) non-contrast ct, n (%) contrast ct, n (%) non-contrast mri, n (%) contrast mri, n (%) mrs, n (%) multimodality, n (%) 62 (36.3) 79 (46.2) 2 (1.2) 6 (3.5) 1 (0.6) 21 (12.3) 1 (11.1) 4 (44.4) 3 (33.3) 1 (11.1) 8 (30.8) 11 (42.3) 3 (11.5) 4 (15.4) notes: ct= computed tomography, mri= magnetic resonance imaging, mrs= magnetic resonance spectroscopy althea medical journal. 2021;8(4) 208 pathophysiology of perifocal edema in primary and metastatic intracranial tumors has different characteristics. perifocal edema in metastasis cases is vasogenic edema, which is formed by increased production of factors that increase blood vessel permeability, such as vascular endothelial growth factor (vegf).13 in primary tumors, perifocal edema is not only caused by vasogenic mechanisms but is also characterized by extensive infiltration of surrounding tumor cells.13 the midline shift image in primary intracranial tumors was found to be more (54.9%) than in metastatic tumors (33.3%). this is due to the location of the tumor. besides, the study found that the mean and median tumor volume and peritumoral edema volume in primary intracranial tumors were greater than in metastatic tumors.14 there is a strong correlation between volume and length of the shift in primary intracranial tumors, so that the midline shift will be significantly greater than in metastatic tumors.13 non-communicating hydrocephalus was more common in primary tumors (20.4%) than metastases (8.6%). non-communicating hydrocephalus results from obstruction along the cerebrospinal fluid (csf) pathway between the lateral ventricles and the outlet of the fourth ventricle; whereas communicating hydrocephalus results from a disruption of csf absorption, which causes accumulation of csf throughout the ventricular system.15 intracranial tumor lesions located near the posterior fossa area can cause obstruction in the fourth ventricle area so that the appearance of non-communicating hydrocephalus is more common.15 however, the mechanism of hydrocephalus is not always caused by a brain tumor. therefore, information about co-morbidities and other medical conditions is needed so that the relationship between lesions and the incidence of hydrocephalus can produce accurate data. the limitations of the study are the incomplete data available, especially on radiological expertise and patient-specific tumor types according to the world health organization (who). further research on imaging characteristics, such as radiological findings based on age, location of the lesion, and type of intracranial tumor can be developed with more complete and accurate data considering the lack of research on these variables. in conclusion, ct scan is still the modality of choice for imaging brain tumors at dr. hasan sadikin general hospital during the 2017– 2019 period. the most common radiological finding is perifocal edema. based on the group of tumor types, primary tumor lesions have been found in solitary numbers and located in the right hemisphere, whereas metastatic intracranial tumors have been found in multiple numbers, located both supratentorial and infratentorial. references 1. international agency for research on cancer (iarc). globocan 2020: indonesia [internet]. 2020 [cited 2021 january 15]. available from: https://gco.iarc.fr/ today/data/factsheets/populations/360indonesia-fact-sheets.pdf 2. komite penanggulangan kanker nasional kementerian kesehatan republik indonesia. panduan penatalaksanaan tumor otak. jakarta: kementerian kesehatan republik indonesia; 2016 [cited 2021 january 15]. available from: http://kanker.kemkes.go.id/guidelines/ ppkotak.pdf 3. ostrom qt, patil n, cioffi g, waite k, kruchko c, barnholtz-sloan js. cbtrus statistical report: primary brain and other central nervous system tumors diagnosed in the united states in 2013–2017. neuro oncol. 2020;22(12 suppl 2):iv1–96. 4. tabouret e, chinot o, metellus p, tallet a, viens p, gonçalves a. recent trends in epidemiology of brain metastases: an overview. anticancer res. 2012;32(11):4655–62. 5. minné c, kisansa me, ebrahim n, suleman fe, makhanya nz. the prevalence of undiagnosed abnormalities on noncontrast-enhanced computed tomography compared to contrast-enhanced computed tomography of the brain. s afr j rad. 2014;8(1):598. 6. gunderman rb. radiology 101: water. acad radiol. 2014;21(7):945–6. 7. serkova nj, brown ms. quantitative analysis in magnetic resonance spectroscopy: from metabolic profiling to in vivo biomarkers. bioanalysis. 2012;4(3):321–41. 8. hulmansyah d. prosedur pemeriksaan magnetic resonance spectroscopy (mrs) kepala pada kasus tumor otak di instalasi radiologi rs awal bros pekanbaru. journal of stikes awal bros pekanbaru. 2020;1(1):21–30. 9. luo q, li y, luo l, diao w. comparisons of the accuracy of radiation diagnostic modalities in brain tumor: a althea medical journal december 2021 althea medical journal. 2021;8(4) 209putri nur amalia dewi et al.: characteristics of brain imaging in intracranial tumor patients at neurology ward dr. hasan sadikin general hospital bandung 2017–2019 nonrandomized, nonexperimental, crosssectional trial. medicine (baltimore). 2018;97(31):e11256. 10. tunthanathip t, kanjanapradit k, ratanalert s, phuenpathom n, oearsakul t, kaewborisutsakul a. multiple, primary brain tumors with diverse origins and different localizations: case series and review of the literature. j neurosci rural pract. 2018;9(4):593–607. 11. svokos ka, salhia b, toms sa. molecular biology of brain metastasis. int j mol sci. 2014;15(6):9519–30. 12. loeffler js. epidemiology, clinical manifestations, and diagnosis of brain metastases. uptodate [internet] 2020 [cited 2021 january 15]. available from: https://www.uptodate.com/contents/ epidemiology-clinical-manifestationsand-diagnosis-of-brain-metastases. 13. baris mm, celik ao, gezer ns, ada e. role of mass effect, tumor volume and peritumoral edema volume in the differential diagnosis of primary brain tumor and metastasis. clin neurol neurosurg. 2016;148:67–71. 14. hanum a, achmad bna, yueniwati y, retnani dp, setjowati n. measurement of the peritumoral edema and tumor volume ratio in differentiating malignant primary and metastatic brain tumor. gsc biol pharm sci. 2020;13(2):055–61. 15. ledezma cj, wintermark m. modern neuroradiology relevant to anesthetic and perioperative management. in: cottrell je, young wl, editors. cottrell and young’s neuroanesthesia. 5th ed. philadelphia: mosby; 2010. p. 95–114. amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 86 dietary intake, nutritional status, and quality of life in patients with thalassemia major steven yulius usman,1 salvabilla azheema rahmat,1 vetinly,2 felicia kurniawan2 1school of medicine and health sciences, atma jaya catholic university of indonesia, 2department of public health and nutrition, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia correspondence: steven yulius usman, school of medicine and health sciences, atma jaya catholic university of indonesia, jalan pluit raya no. 2, penjaringan, jakarta utara, indonesia, e-mail: steven.201706000061@student.atmajaya.ac.id introduction thalassemia is a genetic red blood cells disorder that interferes with the synthesis of a specific globin chain and makes the age of red blood cells shorter than normal.1 the highest incidence rate is in asia, which reaches 40%. in indonesia, the number of patients is over 15,000 thalassemia major patients, with the second-highest prevalence (12.3%) in jakarta after west java.2 thalassemia patients experience impaired growth caused by decreased appetite due to anemia.1 recommendations for nutritional intake for thalassemia patients are high in protein, potassium, zinc, and b vitamins. it is recommended to reduce iron and vitamin c. unbalanced nutritional adequacy can affect the nutritional status.3 most thalassemia patients have malnutrition.4,5 however, another study reported otherwise; most patients have normal nutritional status even though they have less dietary intake than recommended daily allowance (rda).6 some factors can influence diary intake and nutritional status, such as education, knowledge, eating habits, socioeconomic status, age, gender, height, weight and psychiatric problems.4,6 prolonged medication treatments, various psychiatric pressures from the community, and difficulties in socio-educational activities can severely affect their general health, psychological health and quality of life.7 a study in iran7 showed that quality of life is standard in physical health, psychological health, and environmental health, but less in the social relationship dimension. this study aimed to determine and examine the relationship between dietary intake, nutritional status, and quality of life in thalassemia major patients. althea medical journal. 2022;9(2):86–92 abstract background: impaired growth and inadequacy of dietary intake in thalassemia patients may affect the quality of life. this study aimed to determine and examine the relationship between dietary intake, nutritional status, and quality of life in in patients with thalassemia major. methods: this study was a cross-sectional descriptive study conducted from february to october 2020. twelve respondents who were registered at the yayasan thalassemia indonesia and the blood transfusion unit at fatmawati hospital participated. this study conducted a physical examination and distributed food record questionnaires and whoqol-bref. data analysis was performed using nutrisurvey 2007 and fisher’s exact test. results: the majority of the respondent were male (58.3%), categorized in the age group 5–18 years (58.3%), had normal nutritional status (50%) and quality of life. interestingly, the respondents had an excess intake of protein and fats, while the intake of energy and carbohydrates was normal. respondents had less intakes of all micronutrients. conclusion: the majority of respondents have normal nutritional status and quality of life but have a low intake of micronutrients. both patients and parents need to be further educated on dietary intake to meet their nutritional needs. keywords: dietary intake, impaired growth, thalassemia, quality of life https://doi.org/10.15850/amj.v9n2.2301 althea medical journal. 2022;9(2) 87 methods this study was a cross-sectional descriptive study conducted in february 2020. thalassemia patients from the blood transfusion unit at fatmawati hospital and registered at the yayasan thalassemia indonesia were invited to the we act ‘atma jaya care for thalassemia’ activity. the thalassemia patients were informed about the study, followed by an online procedure via chat messenger and sending the food record questionnaire to respondents to fill out. the respondents themselves signed informed consent, and those less than 18 years old signed by their mothers who came along in the event. ethical clearance was granted by the committee of research ethics commission, faculty of medicine atma jaya no. 44/11/kepfkuaj/2019. samples were obtained by total sampling and passed the inclusion and exclusion criteria. the inclusion criteria were subjects registered at the indonesian thalassemia foundation who agreed to participate in this study. the exclusion criteria were subjects with comorbidities such as digestive, cardiovascular, respiratory, and psychological disorder. the total sample who participated in this study was 12 patients. data collection of thalassemia major patients included gender, age, and last education, while physical examinations such as weight and height were measured to determine nutritional status. furthermore, the food record questionnaire about the intake of macronutrients (carbohydrate, protein, fats, and energy/calories) and micronutrients (calcium, potassium, zinc, iron, vitamin a, vitamin b1, vitamin b2, vitamin b6, vitamin b9, vitamin c, vitamin e.) as well as the whoqolbref questionnaire on quality of life based on four domains (physique, psychosocial, social relation and environment) was distributed in g-form, filled out via mobile phones due to the covid-19 restrictions. in brief, the food record questionnaires were collected from 3 different days (2 weekdays and 1 weekend) and was supported by photos of food that the respondents sent when filling the questionnaires. then, the data from the questionnaires were calculated using the nutrisurvey 2007 according to the recommended daily allowance (rda), and further analyzed using spss version 25.0. the whoqol-bref questionnaire was used to measure the patients’ quality of life based on four domains (physique, psychosocial, social relation, and environment).8 individuals steven yulius usman et al.: dietary intake, nutritional status, and quality of life in patients with thalassemia major with a score above 50 were defined as having a standard quality of life. fisher’s exact test was used to analyze the relationship between adequate food intake, nutritional status, and quality of life. the nutritional status category was merged into less categories (less and very less) and normal categories. therefore, the categories of nutritional intake variables were also merged into normal (normal, excess) and less (mild, severe) categories. the nutritional status variable referred to the body mass index based on the regulations of the ministry of health of the republic of indonesia in 2013, for respondents aged over 18 years,9 or the z-score weight for the height index of respondents under 18 years.10 it aimed to simplify the explanation of procedures and data collection due to the online procedures. results in total, 12 thalassemia major patients were included in this study, with a mean age of 16.63 years (sd=4.48), and distributed normally using the shapiro wilk test with a significant result above 0.05 (table 1). data on macronutrient and micronutrient intake in thalassemia major patients were distributed normally using the shapiro wilk test showed a significant result above 0.05. overall, the average dietary intake of energy and carbohydrates was normal, while the average dietary intake of protein and fats was in the excess category. the average intake of all the micronutrients was in the deficiency category (table 2). the nutritional status data in thalassemia major patients were distributed normally using the shapiro wilk test, which showed a significant result above 0.05. furthermore, from the relationship between dietary intakes (macro-micronutrient) and table 1 distribution of thalassemia major patients’ characteristics in jakarta (n=12) characteristics n gender male female 7 5 age 5–18 years old >18 years old 7 5 last education elementary school junior high school senior high school 4 6 2 althea medical journal. 2022;9(2) 88 althea medical journal june 2022 nutritional status of thalassemia major patients, it was found that there was no significant relationship between energy intake, carbohydrate, protein, potassium, zinc, vitamin a, and vitamin b6 on nutritional status in thalassemia major patients. several variables such as fat intake, calcium, iron, vitamin b1, vitamin b2, vitamin b9, vitamin c, and vitamin e were not obtained in the calculation due to the constant data (table 4). most respondents had a normal quality of life based on four domains including physique, psychology, social relation, and environment. all domains had a mean score above 50, which was categorized as a normal quality of life. it found that there was no significant relationship between nutritional status and each domain on quality of life. discussion the result regarding the macronutrients intake was consistent with the study that states an increase in calorie intake. the recommendation for nutritional intake is to consume high protein.4,6 thalassemia patients have ineffective erythropoiesis, which tends to consume more than normal people to compensate for excessive energy expenditure; therefore, patients tend to consume more calories to compensate.3,11 a high protein intake can help regenerate and repair cells in the body due to red blood cells’ destruction.11 thalassemia major patients have a lower micronutrients intake; this is in line with previous studies.4,6 recommendations for nutritional intake are to reduce vitamin table 2 macro and micronutrient intake in thalassemia major patients based on recommended daily allowance (n=12) intake mean total rda sd mean % rda sd category n energy (kcal) 2159.84 265.54 103.25* 1.28* normal excess 5 7 carbohydrate(g) 211.81 24.80 106.28 28.00 less normal excess 5 5 2 protein (g) 64.60 10.77 156.48 44,44 normal excess 4 8 fats (g) 119.15 23.30 241.88* 1.41* normal excess 12 potassium (mg) 1189.94 350.62 41.30* 1.66* less normal 11 1 calcium (mg) 257.41 142.39 24.55 14.17 less 12 iron (mg) 6.23* 1.27* 54.41 17.01 less 12 zinc (mg) 5.98* 1.22* 75.78 26.87 less normal 9 3 vitamin a (mg) 487.60 218.67 54.08 28.77 less normal 11 1 vitamin b1 (mg) 0.48* 1.2* 42.26 12.60 less 12 vitamin b2 (mg) 0.73 0.21 58.63 21.06 less 12 vitamin b6 (mg) 0.89* 1.26 * 76.90 32.65 less normal excess 8 3 1 vitamin b9 (µg) 97.98 30.65 26.03 9.15 less 12 vitamin c (mg) 14.55* 2.32* 15.10* 2.32* less 12 vitamin e (mg) 3.95 1.54 31.37 13.57 less 12 note: rda= recommended daily allowance, * geometric mean value althea medical journal. 2022;9(2) 89 table 3 nutritional status of thalassemia major patients (n=12) nutritional status mean sd n weight (w; kilogram) 34.12 8.90 stature (s; centimetre) 140 13.05 category* severe malnutrition mild malnutrition normal 2 2 8 note: * category designated as body mass index (w/(s2.100)) for patients >18 years old, and z-score (w/s) for patients 5-18 years old c and iron consumption, and increase the consumption of zinc and vitamin b.3 patients’ knowledge about iron intake was good. most thalassemia patients avoid iron consumption because the iron accumulation of iron consumption can lead to zinc reduction.11 severe zinc deficiency can lead to impaired growth, inhibition of sexual maturation, immune deficiency, and impaired wound healing.5,12 folic acid (vitamin b9) and cobalamin (b12) play roles in erythropoiesis and maintaining the function of peripheral table 4 relationship between macro-micronutrients’ intake and nutritional status of thalassemia major patients (n=12) nutrient intake rda category nutritional status p-valueless n normal n energy (kcal) normal excess 2 2 3 5 1.00 carbohydrate(g) less normal 1 3 4 4 0.576 protein (g) less normal 3 1 1 7 0.067 fats (g) excess 4 8 potassium (mg) less normal 4 7 1 1.00 calcium (mg) less 4 8 iron (mg) less 4 8 zinc (mg) less normal 3 1 6 2 1.00 vitamin a (mg) less normal 4 7 1 1.00 vitamin b1 (mg) less 4 8 vitamin b2 (mg) less 4 8 vitamin b6 (mg) less normal 3 1 5 3 1.00 vitamin b9 (µg) less 4 8 vitamin c (mg) less 4 8 vitamin e (mg) less 4 8 note: *p-value for combined category for 2x2 fisher test, (normal + excess) vs less steven yulius usman et al.: dietary intake, nutritional status, and quality of life in patients with thalassemia major althea medical journal. 2022;9(2) 90 nerves. therefore, these deficiencies may create a risk for peripheral neuropathy in beta-thalassemia major patients.13 effective delivery of dietary information to patients and caregivers is essential to choosing a healthy diet for their condition.14 there was no significant relation between macro and micronutrient intake on nutritional status. the nutritional status was normal but patients had inadequate micronutrients intake, which is in line with the previous study.6 it is influenced by several factors such as dietary restrictions on certain foods (iron and vitamin c), insufficient consumption of additional supplements, knowledge, eating habits, socioeconomic status and ecological factors.6,15,16 nutritional status assesses a person’s body condition by comparing weight, height, and age. still, it does not look at the nutritional adequacy of daily food intake, so it is possible to have differences in nutritional status and nutritional intake adequacy, especially in thalassemia patients who have specific nutritional intake recommendations.3,17 respondents had a normal quality of life, which contradicts previous studies in iran and qatar.7,18,19 based on four domains, the result showed no significant relationship between nutritional status and quality of life. in general, thalassemia patients have various psychiatric pressure from the community, such as depression, anxiety, psychosocial disorder, and impaired school functioning. thalassemia patients require long and frequent home care treatment that can affect their general health, and psychological health, which is expected to have a negative impact on the patients’ quality of life.7,18,20 screening for psychiatric disorders, facilitated access to oral iron chelators, and regular monitoring of complications especially cardiac disease and hepatitis along with strict quality control of blood products were also mandatory to improve quality of life.18 overall, this study has several limitations due to the covid-19 pandemic, which has caused various problems , especially in terms of time and communication. the sample did althea medical journal june 2022 table 5 quality of life in thalassemia major patients (n=12) quality of life mean sd category n physique 56.83 10.74 less normal 2 10 psychology 51.75 17.49 less normal 2 10 social relation 56.25 12.02 less normal 2 10 environment 56.75 13.97 less normal 4 8 table 6 relationship between nutritional status and quality of life in thalassemia major patients (n=12) quality of life nutritional status p-valueless normal n n physique less normal 2 2 8 0.091 psychology less normal 3 1 1 7 1.00 social relation less normal 2 2 8 0.091 environment less normal 1 3 1 7 0.067 althea medical journal. 2022;9(2) 91 not reach the required minimum number, so it might not provide an optimal description. this study used body mass index to simplify the procedure and data collection due to the online procedure. however, it was not an option for people with organomegaly, such as thalassemia patients.10 this research is a preliminary study; if a similar study will be carried out, it requires further analysis with a much larger sample of respondents and select other methods in collecting the data, especially in nutritional status, to reduce bias from self-report. further study is needed to determine the risk of malnutrition despite normal nutritional status and monitor psychological problems due to the covid-19 pandemic. in conclusion, thalassemia patients tend to have normal nutritional status, quality of life, and low intake of micronutrients. several factors such as education, knowledge, environment, and socioeconomic status may affect the results. thalassemia patients and their families require monitoring and education on dietary intake to control the daily nutrient intake, fulfil the nutrition needs based on recommended daily allowance, and increase the quality of life. acknowledgement we would like to thank the late dr. stefanus lembar, sp.pk for his dedication as one of the founders of we act “atma jaya care for thalassemia”. we also thank the indonesian thalassemia foundation (yayasan thalassaemia indonesia/persatuan orang tua penderita thalassemia indonesia, yti/popti), mr. ruswandi, mr. eddy, and the thaller mr. bangkit prayoga, as well as edhyana sahiratmadja for their cooperation in this research. references 1. higgs dr, engel jd, stamatoyannopoulus g. thalassemia. lancet. 2012;379(9813):373– 83. 2. menteri kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor hk.01.07/ menkes/i/2018 tentang pedoman nasional pelayanan kedokteran tata laksana thalassemia. jakarta: kementerian kesehatan republik indonesia; 2018. [cited 2021 february 5] available from: https://persi.or.id/wp-content/ uploads/2020/11/kmk12018.pdf. 3. robbiyah n, hakimi, deliana m, mayasari s. gangguan pertumbuhan sebagai komplikasi talasemia mayor. majalah kedokteran nusantara. 2014; 47(1):44– 50. 4. fung eb, xu y, trachtenberg f, odame i, kwiatkowski jl, neufeld ej, et al. inadequate dietary intake in patients with thalassemia. j acad nutr diet. 2012;112(7):980–90. 5. isworo a, setiowati d, taufik a. kadar hemoglobin, status gizi, pola konsumsi makanan dan kualitas hidup pasien talasemia. jurnal keperawatan soedirman. 2012;7(3):183-9. 6. kusumawati e, proverawati a, purnamasari d, rahardjo s. tingkat asupan zat gizi dan status gizi penderita talasemia di kabupaten banyumas. jurnal kesmasindo. 2015;7(2):153–66. 7. kaheni s, yaghobian m, sharefzadah gh, vahidi a, ghorbani h, et.al. quality of life in children with b-thalassemia major at center for special diseases. iran j ped hematol oncol. 2013;3(3):108–13. 8. hidayati ar, gondodiputro s, rahmiati l. elderly profile of quality of life using whoqol-bref indonesian version: a community-dwelling. althea medical journal. 2018;5(2):105–10 9. menteri kesehatan republik indonesia. tabel batas ambang indeks massa tubuh (imt). jakarta: kementerian kesehatan republik indonesia; 2013 [cited 2021 february 5] (available from: http:// p2ptm.kemkes.go.id/infographic-p2ptm/ obesitas/tabel-batas-ambang-indeksmassa-tubuh-imt, 10. menteri kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor no 2 tahun 2020 tentang. standar antropometri anak. jakarta: kementerian kesehatan republik indonesia;2020. [cited 2021 february 5] available from: https://dinkes.kedirikab. g o . i d / k o n t e n / u u / 8 9 0 1 8 p m kn o 2 tahun-2020-ttg-standar-antropometrianak.pdf. 11. rahman hd. asupan protein dan vitamin e berhubungan dengan kadar haemoglobin pasien talasemia di rsu kabupaten tangerang. argipa. 2020:5(1):18–26. 12. goldberg ek, neogi s, lal a, higa a, fung e. nutritional deficiencies are common in patients with transfusion-dependent thalassemia and associated with iron overload. j food nutr res (newark). 2018;6(10):674–81. steven yulius usman et al.: dietary intake, nutritional status, and quality of life in patients with thalassemia major althea medical journal. 2022;9(2) 92 13. bayhan t, ünal ş, konuşkan b, erdem o, karabulut e, gümrük f. assessment of peripheral neuropathy in patients with β-thalassemia via electrophysiological study: reevaluation in the era of iron chelators. hemoglobin. 2018;42(2):113–6. 14. chin dm, kader maideen sf, rashid a. knowledge, attitude and practice towards dietary iron among patients with thalassemia and their caregivers in peninsular malaysia. med j malaysia. 2019;74(5):365–71. 15. putri rf, sulastri d, lestari y. faktor-faktor yang berhubungan dengan status gizi anak balita di wilayah kerja puskesmas nanggalo padang. jurnal kesehatan andalas. 2015;4(1):254-61. 16. rejeki dsr, nurhayati n, supriyanto, kartikasari e. studi epidemiologi deskriptif talasemia. kesmas. 2012;7(3):139–44. 17. regar e, sekartini r. hubungan kecukupan asupan energi dan makronutrien dengan status gizi anak usia 5–7 tahun di kelurahan kampung melayu, jakarta timur tahun 2012. ejki. 2013;1(3):184–9. 18. ansari sh, baghersalimi a, azarkeivan a, nojomi m, hassanzadeh. quality of life in patients with thalassemia major. iran j pediatr hematol oncol. 2014;4(2):57–63. 19. nashwan aj, yassin ma, babu gdj, nair sl, libo-on il, hijazi ha, et al. quality of life among adolescents aged 14 to 18 years with beta-thalassemia major (tm) in qatar. acta biomed. 2018; 89(2-s):16–26. 20. mettananda s, pathiraja h, peiris r, bandara d, de silva u, mettananda c, et al. health related quality of life among children with transfusion dependent β-thalassaemia major and haemoglobin e β-thalassaemia in sri lanka: a case control study. health qual life outcomes. 2019; 17(1):137. althea medical journal june 2022 amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 70 association of maternal obesity and pregnancy outcomes timoty krisna sukoco,1 dini hidayat,2 raden tina dewi judistiani3 1faculty of medicine universitas padjadjaran, indonesia, 2department of obstetrics and gynecology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: timoty krisna sukoco, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: timoty18002@mail.unpad.ac.id introduction obesity is excessive body fat accumulation which has been a major global health problem.1 the world health organization (who) defines obesity as when a person has a body mass index (bmi) of 30 kg/m2 or greater, calculated by dividing a person’s weight by the square of their height.2 the prevalence of obesity is escalating worldwide.3 in indonesia, 21.8% of adults are considered obese as reported in the basic health research (riset kesehatan dasar, riskesdas) by the ministry of health.4 obesity is linked to various disorders and complications.5 studies have shown that obesity in pregnant mothers may increase the risk of unfavorable maternal outcomes such as preeclampsia, gestational diabetes, caesarean section, hemorrhage, and death.6–8 offspring of obese mothers may also be at greater risk of perinatal outcomes such as large birth weight, prematurity, low apgar score, and stillbirth.6–8 obese pregnant women become a global health burden.9 with a prevalence of 32.2% of obese adult women in west java, the obstetrical concern might be significant.4 however, local studies and information about the impact of obesity on maternal and perinatal morbidity and mortality are deficient. the morbidity and mortality are pregnancy outcomes potentially affected by maternal obesity. therefore, this study was accomplished to evaluate the association between maternal obesity and pregnancy outcomes. methods this retrospective cohort study was part of a althea medical journal. 2022;9(2):70–73 abstract background: the prevalence of obesity is increasing globally, causing various possible disorders and complications. maternal and perinatal morbidity and mortality might potentially be affected by maternal obesity. this study aimed to evaluate the association between maternal obesity and pregnancy outcomes. methods: this retrospective cohort study was part of a larger cohort study performed from july 2016 to july 2017 in west java, including 223 pregnant women with normal fetuses, who were obese or nonobese pre-pregnancy. underweight women were excluded. data on pregnancy outcomes consisting of caesarean section, preeclampsia, premature rupture of membrane (prom), preterm birth, post-term birth, small for gestational age (sga), and large for gestational age (lga) were collected. the association with maternal obesity was analyzed using the fisher’s exact test to determine the association with a 95% confidence interval, and a p-value <0.05 was considered significant. results: there was an association between maternal obesity and caesarean section, with an increased risk in obese mothers compared to non-obese mothers (rr 2.398 ci 1.328–4.329). there was no significant association between maternal obesity and preeclampsia, prom, preterm birth, post-term birth, sga, and lga. conclusion: maternal obesity is associated with caesarean section. a more comprehensive approach is essential for obese pregnant women to ensure the health of both the mother and the infant. keywords: obesity, pregnancy, pregnancy outcomes https://doi.org/10.15850/amj.v9n2.2632 althea medical journal. 2022;9(2) 71 larger cohort study by judistiani et al.10 which was performed from july 2016 to july 2017 in bandung, cimahi, sukabumi, and waled, west java, indonesia. subjects of the original study were pregnant women with a normal fetus aged 10–14 weeks upon recruitment. bmi was calculated from self-reported prepregnancy weight and measured height upon recruitment. women with obese prepregnancy bmi (≥30 kg/m2) were included in this study while women within the non-obese range were included in the control group. this study excluded women with underweight bmi (<18.5 kg/m2) and those with inaccessible or incomplete data. the total sampling method was used. the data for this study were acquired following approval from the research ethics committee of universitas padjadjaran no. 589/un6.kep/ec/2021. the variables used in this study for maternal outcomes were caesarean section, preeclampsia, and premature rupture of membrane (prom), while the variables for perinatal outcomes were preterm delivery, post-term delivery, small for gestational age (sga), and large for gestational age (lga). maternal characteristics including age, parity, and education level were also observed. statistical analysis was performed using statistical package for social scientists (spss version 25). fisher’s exact test was used to determine the association with a 95% confidence interval considering a p-value <0.05 as significant. results from the larger study, this study included 223 eligible subjects consisting of 18 mothers with obese pre-pregnancy bmi (≥30 kg/m2) and 205 mothers with non-obese pre-pregnancy bmi (18.5–29.9 kg/m2). the bmi was categorized according to the classification by the who. characteristics of the subjects were presented in table 1. subjects were mainly aged under 35 years old with varying parity. most subjects achieved secondary education. there were no difference in age, parity, and education level proportions between the obese and non-obese groups. maternal outcomes in both groups are displayed in table 2. the risk of caesarean delivery was significantly increased in obese mothers compared to non-obese mothers (rr 2.398 ci 1.328–4.329) (table 2). there was no significant association between maternal obesity and preeclampsia (p=0.239) and prom (p=1.000). the association of maternal obesity and perinatal outcomes including preterm delivery, posttimoty krisna sukoco et al.: association of maternal obesity and pregnancy outcomes table 1 characteristics of the subjects characteristic obese non obese p-value n % n % age (years) <35 ≥35 14 4 78 22 160 45 78 22 1.000 parity 0 1 ≥2 6 10 2 33 56 11 74 66 65 36 32 33 0.081 level of education primary education secondary education higher education 3 9 6 17 50 33 27 139 39 13 68 19 0.270 table 2 maternal outcomes maternal outcome obese non obese rr [95% ci] p-value caesarean section preeclampsia prom 8 (44%) 4 (22%) 3 (17%) 38 (42%) 22 (11%) 36 (18%) 2.398 [1.328-4.329] 0.015* 0.239 1.000 note: *p-value <0.05 considered as significant, all variables were analyzed using fisher’s exact test, prom= premature rupture of membrane althea medical journal. 2022;9(2) 72 term delivery, sga, and lga was also not significant (data not shown). discussion this study shows an association between maternal obesity and the risk of caesarean section. this finding corresponds with a study in iraq11 and another similar study in malawi.12 the latter suggested that women with large body volumes may need extra time to achieve the level of oxytocin needed for labor. the presence of excess intraabdominal fat may also obstruct labor progression and compromise fetoplacental circulation.12 these factors likely prompt the necessity of caesarean birth in obese mothers. our study found no significant association between maternal obesity and other measured outcomes despite reports of increased risk of preeclampsia in multiple studies.13,14 the higher risk of preeclampsia involves reduction of placental perfusion, a rise of soluble factor release, and increased sensitivity of maternal vasculature caused by metabolic factors in obese women.15 insulin resistance that results from maternal obesity is also related to a reduced cytotrophoblast migration and remodeling of the uterine spiral artery.16 a systematic review and meta-analysis found a higher risk of preterm birth in obese women.17 this was consistent with a large cohort study in sweden18 which stated inflammatory up-regulation in obesity might play an important role. conversely, a study in the united kingdom19 found that postterm birth increases with increasing bmi. it is presumed that high lipid profiles correlate with decreased uterine contractility while leptin inhibits oxytocin-induced uterine activity, leading to prolonged pregnancy in obese women.20 research on the relationship between maternal obesity and prom also have conflicted. some have found that high prepregnancy bmi is linked with an increased risk of prom.21,22 obesity is suspected to induce inflammation and harmful effects on the placenta.23 other studies found a lower rate of prom in obese mothers, pointing to nutritional reasons. this inconsistency may be explained by the heterogeneity of prom and the ethnic differences in study populations.23 previous studies stated maternal obesity is strongly associated with infant birth weight.24,25 high birth weight increases with pre-pregnancy obesity.24 there is also a protective effect of pre-pregnancy obesity against low birth weight.25 contrary to these findings, our study has shown no significant association between maternal obesity and offspring birth weight. this study is subject to several limitations. this study utilized secondary retrospective data with a very small number of subjects, lower than the calculated minimum size of 147. the low sample size was expected due to the time and geographical constraints. moreover, the variables were not documented in every subject, leading to the exclusion of subjects. this study did not account for potential confounding factors since only basic information was available. further study with a more appropriate size and method will demonstrate the situation more precisely. evaluation of other maternal and perinatal outcomes will also be beneficial. in conclusion, maternal obesity is associated with caesarean section occurrence. obese mothers have a greater risk of undergoing caesarean section delivery compared to nonobese mothers with a relative risk of 2.398. a more comprehensive approach is essential for obese pregnant women to ensure the health of both the mothers and the infants. strategies need to be implemented to reduce the risks of possible unfavorable pregnancy outcomes in women with obesity. references 1. lin x, li h. obesity: epidemiology, pathophysiology, and therapeutics. front endocrinol (lausanne). 2021;12:706978. 2. who consultation on obesity. obesity: preventing and managing the global epidemic. report of a who consultation. world health organ tech rep ser. 2000;894:i–xii, 1–253. 3. orukwowu u. epidemiology of adult obesity, measurements, global prevalence, and risk factors. ips intelligentsia multidiscip j. 2022;1(1):1–6. 4. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. laporan nasional riskesdas 2018. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan; 2019. 5. kinlen d, cody d, o’shea d. complications of obesity. qjm. 2018;111(7):437–43. 6. sinha k, pandey s, das cr. impact of maternal obesity on pregnancy outcome. j nepalgunj med coll. 2016;14(2):18–22. 7. stubert j, reister f, hartmann s, janni w. the risks sssociated with obesity in pregnancy. dtsch arztebl int. 2018;115(16):276–83. althea medical journal june 2022 althea medical journal. 2022;9(2) 73 8. gonzález-plaza e, bellart j, martínezverdú má, arranz á, luján-barroso l, seguranyes g. pre-pregnancy overweight and obesity prevalence and relation to maternal and perinatal outcomes. enferm clin. 2021;s1130-8621(21)00081-4. 9. chen c, xu x, yan y. estimated global overweight and obesity burden in pregnant women based on panel data model. plos one. 2018;13(8):e0202183. 10. judistiani rtd, gumilang l, nirmala sa, irianti s, wirhana d, permana i, et al. association of colecalciferol, ferritin, and anemia among pregnant women: result from cohort study on vitamin d status and its impact during pregnancy and childhood in indonesia. anemia. 2018;2018:2047981. 11. al-kubaisy w, al-rubaey m, al-naggar ra, karim b, mohd noor na. maternal obesity and its relation with the cesarean section: a hospital based cross sectional study in iraq. bmc pregnancy childbirth. 2014;14(1):235. 12. nkoka o, ntenda pam, senghore t, bass p. maternal overweight and obesity and the risk of caesarean birth in malawi. reprod health. 2019;16(1):40. 13. melchor i, burgos j, del campo a, aiartzaguena a, gutiérrez j, melchor jc. effect of maternal obesity on pregnancy outcomes in women delivering singleton babies: a historical cohort study. j perinat med. 2019;47(6):625–30. 14. mohammadi m, maroufizadeh s, omanisamani r, almasi-hashiani a, amini p. the effect of prepregnancy body mass index on birth weight, preterm birth, cesarean section, and preeclampsia in pregnant women. j matern neonatal med. 2018;32(22):3818–23. 15. spradley ft, palei ac, granger jp. increased risk for the development of preeclampsia in obese pregnancies: weighing in on the mechanisms. am j physiol regul integr comp physiol. 2015;309(11):r1326–43. 16. lopez-jaramillo p, barajas j, ruedaquijano sm, lopez-lopez c, felix c. obesity and preeclampsia: common pathophysiological mechanisms. front physiol. 2018;9:1838. 17. mcdonald sd, han z, mulla s, beyene j; knowledge synthesis group. overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and meta-analyses. bmj. 2010;341:c3428. 18. cnattingius s, villamor e, johansson s, bonamy a-ke, persson m, wikström a-k, et al. maternal obesity and risk of preterm delivery. jama. 2013;309(22):2362–70. 19. heslehurst n, vieira r, hayes l, crowe l, jones d, robalino s, et al. maternal body mass index and post-term birth: a systematic review and meta-analysis. obes rev. 2017;18(3):293–308. 20. bogaerts a, witters i, van den bergh brh, jans g, devlieger r. obesity in pregnancy: altered onset and progression of labour. midwifery. 2013;29(12):1303–13. 21. tabatabaei m. gestational weight gain, prepregnancy body mass index related to pregnancy outcomes in kazerun, fars, iran. j prenat med. 2011;5(2):35–40. 22. liu l, hong z, zhang l. associations of prepregnancy body mass index and gestational weight gain with pregnancy outcomes in nulliparous women delivering single live babies. sci rep. 2015;5:12863. 23. lim j, han k, kim sy, cho yh, yoon ys, park hs, et al. effects of central obesity on maternal complications in korean women of reproductive age. obes res clin pract. 2019;13(2):156–63. 24. yu z, han s, zhu j, sun x, ji c, guo x. prepregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis. plos one. 2013;8(4):e61627. 25. averett sl, fletcher ek. prepregnancy obesity and birth outcomes. matern child health j. 2016;20(3):655–64. timoty krisna sukoco et al.: association of maternal obesity and pregnancy outcomes amj vol 7 no 3 september2.indd althea medical journal. 2020;7(3) 105amj. 2020;7(3):105–10 semi-quantitative digital analysis for human papillomavirus detection from environmental specimens adelina siagian,1 dicky bagus pratama,1 fahmy fathurrohman,1 lia faridah,2 savira ekawardhani,2,3 1faculty of medicine universitas padjadjaran, indonesia 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3oncology and stem cell research centre faculty of medicine universitas padjadjaran, indonesia abstract background: recently, human papillomavirus (hpv) deoxyribonucleic acid (dna) has been detected in urban wastewater, indicating that the virus can reach the sewer and, eventually, other water environments. this study aimed to develop a semi-quantitative assay for hpv dna detection from environmental specimens using the pcr gel electrophoresis method. methods: this was an experimental descriptive qualitative study conducted from july to november 2019 in a standard molecular laboratory and non-laboratory administration room without air conditioner. three brands of pcr reagents and different annealing temperatures were compared to identify the best condition for conventional pcr of plasmid dna containing the hpv l1 gene. the semi-quantitative data were obtained from densitometry digital analysis using an imaging software. the optimized protocol was then applied on dna serial dilutions to seek for the lower limit of detection (llod) value and the linear range of the assay. to evaluate the robustness of the assay, the protocol was further applied to spiked specimens of wastewater. finally, several wastewater samples were tested for the presence of hpv dna using this protocol. results: a broad linear range and hpv l1 gene detection ability were observed with an llod of less than 2pg plasmid dna in field condition. although the assay successfully detected hpv dna from several spiked wastewater samples, certain wastewater could interfere with the assay and gave false negative result. conclusions: a semi-quantitative conventional pcr method to detect hpvdna from environmental samples has been established and proven to be robust in field condition with non-optimum cold chain. keywords: environmental specimens, human papillomavirus, pcr, semi-quantitative correspondence: adelina siagian , faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia. e-mail: siagianadelin2711@gmail.com introduction human papillomavirus (hpv) is a virus from the papillomaviridae family with the doublestranded deoxyribonucleic acid (dsdna) genome.1 the most known high-risk hpv infection can cause cervical cancer, where transmission occurs through sexual contact. a recent study has reported that hpv can remain reactive outside stem cells, and thus there is a possibility of transmission of hpv non-sexually. the ability of hpv can remain reactive outside of host cells because of its characteristics, which are very stable and resistant from environmental conditions.2 various types of hpvs have been found from river water samples, especially rivers for waste disposal.3 some countries have also recognized the presence of hpvs in water and have been used as an indicator of polluted water.4 the hpv detection is most often performed using a pcr detection tool. the latest development of pcr is a portable pcr.5 the emergence of a portable pcr is one of the solutions to overcome the constraints of pcr, which usually can only be used in laboratories, and it causes the pcr process to be longer. furthermore, it costs money to transport environmental samples to the laboratory. the amplification process using a portable pcr allows researchers to perform pcr in remote areas, where environmental samples are taken.6,7 https://doi.org/10.15850/amj.v7n3.1918 althea medical journal. 2020;7(3) 106 amj september 2020 points in bandung city areas; namely, samples a, b, c, d, and e. sample a was river water from the taman hewan area, sample b was the open sewage water from the sukasari area, sample c was the open sewage water from sadang serang area, sample d was river water from sederhana market area and sample e was the tap water from pelesiran area. spiking samples were then made by adding a certain amount of hpv dna to those water samples. the purpose of making spiking samples in this study was as a simulation for the detection of hpv from water samples in the environment. in parallel, other water samples referred as original water samples were prepared by using those a to e samples as they were in the pcr. this study used a portable pcr machine (minipcrtm) in optimizing the protocol for hpv dna detection in the field and the eppendorf gradient cycler (eppendorf, germany) for the standard pcr procedure in the lab. the protocol tested three pcr kits [kitp (promega), kitb (biosystem), and kitm (minipcr)] and three different annealing temperatures (50°c, 55°c, and 58°c), in the field condition. the p and b reagents were usually used in pcr for hpv dna detection in our laboratory, while m kit was the original kit for the portable machine and being used at room temperature, without cooling in ice. three pcr protocols were derived from the original pcr protocol of hpv dna detection, varied in the annealing temperatures. the hpv plasmid (514 ng/µl) diluted with nuclease free water at 1000x dilution served as the positive control, and nuclease free water served as the negative control. we used my09/my11 primers, one of the primers mostly used for the l1 gene amplification of hpv that would give a 450 bp amplicon. the purpose of this study was to develop a semi-quantitative assay for electrophoresis gel of hpv dna detection from environmental specimens, such as wastewater. furthermore, this study aimed to validate the protocol for detecting hpv dna from environmental samples using a portable pcr machine with the less cold-chain condition. methods this research was an experimental study with a descriptive qualitative research design. the research process was carried out from july to november 2019 in the standard molecular laboratory and the administration room which was a non-laboratory room without an air conditioner. all reagents were put in the cooler box with ice-gel, and the pipetting was done on the bench at room temperature, after cleaning the surface using household ethanol. this research activity had a research permit from the research ethics committee universitas padjadjaran with the number 1350/un6.kep/ ec/2019. the hpv dna plasmid already containing the hpv 52 l1 gene was obtained from the laboratory of genetics and molecular biotechnology, institute of technology bandung.8 the l1 gene in the plasmid was the result of cloning from a biopsy sample of a patient with cervical cancer obtained from dr. hasan sadikin hospital, bandung.9 upon arrival, the plasmid was sequenced with primer my09 and my11 to confirm the presence of the hpv52 l1 gene in the plasmid. in this study, water samples from the environment were directly used as templates in the pcr or were first spiked with the hpv plasmid followed by the dna extraction process. water samples were taken from five table 1 pcr conditions step temperature duration cycle early denaturation 95°c 60 seconds hold denaturation 95°c 30 seconds 35 cyclesannealing 50°c 30 seconds 55°c 30 seconds 58°c 30 seconds extension 72°c 60 seconds final extension 72°c 5 minutes 1 cycle althea medical journal. 2020;7(3) 107adelina siagian et al.: semi-quantitative digital analysis for human papillomavirus detection from environmental specimens figure 1 pcr reaction results in the optimization process. (a) pcr reaction in the first laboratory experiment: 1. sample with p reagent at an annealing temperature of 50°c; 2. samples with reagent b at an annealing temperature of 50°c; 3. samples with reagent b at annealing temperature of 55°c. (b) pcr reaction outside the laboratory on spiking samples (a, b, c, d, e) and positive control of dilution results 1x, 2x, 4x, 8x with m reagents, and annealing temperature of 55°c. (c) pcr reaction in spiking samples with reagent b and annealing temperature of 50°c. figure 2 standard curves of hpv dna plasmid dilution samples. (a) pcr reaction with m reagents and annealing temperature of 55°c resulted in amplicons with the concentration at dilution 1x = 193.64 ng/µl; 2x = 108.82 ng/µl; 4x = 29.59 ng/µl; 8x= 18,38 ng/µl. (b) pcr reaction with reagent b and annealing temperature of 50 °c resulted in the amplicons with the concentration of t 8x dilution=228.75 ng/µl; 80x=191.78 ng/µl; 800x=47.38 ng/µl; 8000x=11.48 ng/µl. a b althea medical journal. 2020;7(3) 108 amj september 2020 and initial spiked sample with my09/my11 primers was confirmed as the hpv52 l1 gene as expected. genotype 52 hpv is one of the most common types of hpv, causing multiple infections in cervical cancer patients in bandung, indonesia.12,13 this plasmid sample has been detected for the pcr optimization process and through the spiking experiments using optimal protocols with b reagents and annealing temperature of 50°c. the optimal protocol that has been obtained has been further developed for the field condition. the parameters specified in the development process are llod (2.66638x10-5ng), ulod (2.1331x10-1ng), and reproducibility/robustness of the system. dna quantification in this system also shows an accurate efficiency seen from the value of r2 = 1 and two standard curves that show the same slope value. the amplification in a pcr reaction is greatly influenced by many factors, such as the annealing temperature, reagent component such as enzymes, dntps, mgcl, and primers as well as the number of pcr cycles, and also the skill of the operator.14 in this study, we have considered the annealing temperature factor and reagents used. the optimal annealing temperature for a pcr reaction can be determined by knowing the melting temperature (tm) of the primer used.14 the formula commonly used to calculate tm is 4°c (g+c) + 2°c (a+t). from the calculation, the forwarding primary tm is 50°c and the reverse primary tm is 52°c. the optimal annealing temperature range based on tm is tm-5°c to tm+2°c which results in annealing temperature 45°c 54°c. our study shows that the optimal temperature in this experiment is at 50°c. a comparison of three different reagents shows that the reagent p is the first reagent to be excluded. in the initial experiments, the p reagent is only able to detect dna at 50°c, whereas the reaction with reagent b is able todetect up to 55°c annealing temperature. the optimal temperature would show a higher band intensity on the agarose. for b and m reagents at an annealing temperature of 55°c, the pcr worked well for pure plasmid dna. however, in the spiked samples of wastewater, m reagent did not give amplicon. for reagent b, four out of five spiked samples gave positive results. this result shows that the pcr kit is one of the essential elements that would influence the results, especially in the field condition.14 based on the results of the pcr on spiked samples with reagent b, it could be seen these primers could be used at relatively high annealing temperatures.10 the sequences were 5’-cgtccmarrggawactgatc-3’ for the forward primer and 5’-gcmcagggwcataayaatgg-3’ for the reverse primer.11 pcr master mixes was made according to the manufacturer’s instructions. the pcr profiles were shown in table 1. the pcr reaction was carried out three times with three different annealing temperatures to see the most stable conditions. pcr amplicons were stored at -20°c. the amplicons from the pcr reaction at this initial stage were sequenced to confirm the correct target by using the basic local alignment search tool (blast) program, which was accessed through the ncbi website (https:// blast.ncbi.nlm.nih.gov/blast.cgi). the process of developing the assay was done through serial dilution of hpv dna plasmid samples. serial dilutions started from 1x, 2x, 4x, 8x, 80x, 800x, 8000x dilutions. the diluted samples were amplified using the optimized pcr protocol. the image of amplicons resulted from this pcr were analyzed with a densitometric procedure using the image j application software, and the data obtained were further processed in microsoft excel software. results the blast result on the sequenced amplicon of the first spiked sample showed that the sample was, indeed, containing the l1 gene from hpv type 52 with 100% identity as expected. the standard pcr optimization procedure in the lab was applied initially on the hpv dna samples using three kinds of reagents and three different annealing temperatures. the most optimal protocol obtained in the pcr process was reagent b and annealing temperature of 50°c (figure 1). the results of densitometry on the agarose gel picture showed that there was a decreasing intensity of the band signal (auc) along with the increasing number of dilutions for each pcr reaction given to the sample. the linear curve shows that curve a and curve b had the same slope value at 0.0089. with the optimal pcr reaction, the amplification process in this study detected samples up to 2.7x10-5ng template dna, which produced 11.47857037 ng amplicon dna with 35 pcr reaction cycles (figure 2). discussion the sequencing result from the plasmid althea medical journal. 2020;7(3) 109 that the pcr reaction was influenced by water quality, even after the dna extraction process. the possibility of dna disrupting substances contained in the wastewater sample c which is open sewage water may cause this sample to be the only false negative among the four spiked samples that gave positive signals. the pcr reaction to the results of dilution of hpv dna plasmids is an assay development process carried out to determine the llod, ulod, and reproducibility or robustness of the hpv dna detection system using a portable pcr in the field condition. reproducibility means that the detection system is precise or has the smallest variation possible when repeated, while robustness means that the testing system is not too affected by changes in sample preparation and handling.15 based on data obtained from the plasmid dilution process, we found that the llod value in this study was below 2 pg dna templates, and the value for ulod was higher than 0.21 ng dna templates. llod values from this optimized protocol could be further tested to find new lower values. the reproducibility parameters of the optimal protocol in this study were fulfilled by the positive results on repeated pcr experiments. the robustness parameter met with the discovery of positive results by showing that the protocol could be applied on extracted and non-extracted samples, also when it was performed in the field condition outside the laboratory with almost no cold-chain condition. on the linear curve, curve a and curve b have the same slope value and the value r2= 1. the value of slope and r2= 1 showed the dna quantification with densitometry to be quite accurate. through these standard curves, it could be concluded that if the number of templates of a water sample within the linear range of the assay, then the quantification of the sample with digital densitometry using imagej could be also accurate (figure 2). the limitation of this study is that the protocol has only been applied to spiking experiments of plasmid dna. further testing and validation are needed on raw samples known to be containing dna of hpv, such as wastewater containing the faecal specimen from the hpv positive-patients. to conclude, a semi-quantitative conventional pcr method for the detection of hpv dna in environmental samples such as wastewater has been established and proofed to be robust, showing a stable performance when conducted in the field condition, outside the conventional laboratory. acknowledgment we thank dr. azzania fibriani for the generous gift of hpv l1 plasmid dna, and ms. annisa r arimdayu for her experimental assistance. this research is partly supported by the internal grant of universitas padjadjaran (rkdu) year 2019. references 1. bernard h, burk rd, chen z, doorslaer k van, villiers e de. classification of papillomaviruses (pvs) based on 189 pv types and proposal of taxonomic amendments. virology. 2010;401(1):70–9. 2. ryndock ej, meyers c. a risk for non-sexual transmission of human papillomavirus? expert rev anti infect ther. 2014;12(10):1165–70. 3. iaconelli m, petricca s, libera s della, di bonito p, la rosa g. first detection of human papillomaviruses and human polyomaviruses in river waters in italy. food environ virol. 2015;7(4):309–15. 4. la rosa g. papillomavirus. in: rose jb, jiménez-cisneros b, (eds) global water pathogen project part 3. [cited 2020 january 6] available from: https:// w w w . w a t e r p a t h o g e n s . o r g / b o o k / papillomavirus 5. abreu alp, souza rp, gimenes f, consolaro mel. a review of methods for detect human papillomavirus infection. virol j. 2012;9:262. 6. guevara ee, frankel dc, ranaivonasy j, richard af, ratsirarson j, lawler rr, et al.. a simple , economical protocol for dna extraction and amplification where there is no lab. conservation genet resour. 2017;10(1):119–25. 7. boguraev a, christensen hc, bonneau ar, pezza ja, nichols nm, giraldez aj, et al. successful ampli fi cation of dna aboard the international space station. npj microgravity. 2017;3:26. 8. hanifa vr. construction of l1 hpv 52 gene on ppicza and ppiczα for expression of virus -like partices (vlp) protein on pichia pastorisgs115. 2014. [cited 2020 january 6] available from: http://repositori.sith.itb.ac.id/download. php?iden=nvp76y8wze. 9. suhandono s, kencana ungu da, kristianti t, sahiratmadja e, susanto h. cloning, expression and bioinformatic analysis of human papillomavirus type 52 l1 capsid gene from indonesian patient. microbiol indones. 2014;8(3):94–102. adelina siagian et al.: semi-quantitative digital analysis for human papillomavirus detection from environmental specimens althea medical journal. 2020;7(3) 110 amj september 2020 10. venceslau em, bezerra mm, lopes acm, souza év, onofre asc, de melo cm, et al. hpv detection using primers my09/my11 and gp5+/gp6+ in patients with cytologic and/or colposcopic changes. j bras patol med lab. 2014;50(4):280–5. 11. manos mm, waldman j, zhang ty, greer ce, eichinger g, schiffman mh, et al. epidemiology and partial nucleotide sequence of four novel genital human papillomaviruses. j infect dis. 1994;170(5):1096–9. 12. sahiratmadja e, tobing mdl, dewayani bm, hernowo bs, susanto h. multiple human papilloma virus infections predominant in squamous cell cervical carcinoma in bandung. univ med. 2014;33(1):58–64. 13. panigoro r, susanto h, novel ss, hartini s, sahiratmadja e. hpv genotyping linear assay test comparison in cervical cancer patients: implications for hpv prevalence and molecular epidemiology in a limitedresource area in bandung, indonesia. asian pac j cancer prev. 2013;14(10):5843–7. 14. lorenz tc. polymerase chain reaction: basic protocol plus troubleshooting and optimization strategies. j vis exp. 2012;63:e3998. 15. broadway n. assay development: 5 considerations and 8 fundamentals. mater methods. 2012;2:121. amj vol 9 no 3 september 2022 (3).indd althea medical journal. 2022;9(3) 174 cognitive outcome of intracerebral hemorrhage patients with and without pneumonia carissa vania pratama,1, cep juli,2 chandra calista,2 suryani gunadharma,2 yusuf wibisono,2 paulus anam ong2 1faculty of medicine universitas padjadjaran, 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: carissa vania pratama, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: carissa17001@mail.unpad.ac.id introduction according to the definition by the american heart association/american stroke association, intracerebral hemorrhage (ich) is a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma.1 the ich is one of the mechanisms of stroke that is rapidly developing clinical signs of neurological dysfunction that lasts more than 24 hours or even leads to death.1 stroke itself is the second leading global cause of death, with hemorrhagic stroke as a significant source of mortality and disability despite its prevalence is lower than ischemic stroke.2 patients may develop infections after the onset of stroke. one of the causes of primary infectious complications in ich is a respiratory infection with a prevalence of 17%.3 the ich itself is also known to be a predictor of pneumonia development.4 complications of infection, especially respiratory infection, may lead to worse functional outcomes in patients.3,5 cognitive impairment is one of the neurological manifestations in stroke patients. post-stroke cognitive impairment (psci) occurs in over 20% of patients 3 months after the first stroke.6 in the acute phase of ich, psci occurs in 27–84% of patients.7 this manifestation indicates worse long-term mortality and functional outcome, and is associates with lower long-term quality of life in stroke patients.6,8 therefore, it is crucial to run an early screening assessment of cognitive functioning in stroke patients in order to preserve the later outcome. mini-mental state examination (mmse) is a widely used althea medical journal. 2022;9(3):174–179 abstract background: there is high prevalence of cognitive impairment in patients with intracerebral hemorrhage (ich) that may worsen the patients’ outcomes. pneumonia, as the significant infection complication in stroke patients, may aggravate the decline in the cognitive outcome of patients. this study aimed to explore the cognitive outcomes among patients with or without pneumonia among patients with intracerebral hemorrhage. methods: a cross-sectional retrospective analytical comparative numeric study was conducted from september 2020 to february 2021, using secondary data of patients with intracerebral hemorrhage admitted to the department of neurology dr. hasan sadikin general hospital in the year 2019. a total sampling method was employed. data on pneumonia in stroke patients was retrieved, consisting of patients with pneumonia and without pneumonia. data on mini-mental state examination (mmse) scores as the measures of cognitive outcomes were compared using the mann-whitney u test. results: there were 108 patients with intracerebral hemorrhage included. there was a statistically significant difference (p-value=0.049) in mmse scores with median mmse score for pneumonia patients (n=27) and non-pneumonia patients (n=81) were 21 and 25, respectively. conclusion: cognitive outcome is worse in patients with pneumonia than those without pneumonia. early intervention is needed for intracerebral hemorrhage patients who develop pneumonia as a complication to improve the cognitive outcome. keywords: cognition, intracerebral hemorrhage, mmse, pneumonia https://doi.org/10.15850/amj.v9n3.2320 althea medical journal. 2022;9(3) 175 screening tool to assess a patient’s cognitive function. this test has an 82% sensitivity and 76% specificity on the cut-off value <27 from a maximum score of 30 for the cognitive impairment.9 thus, mmse is considered to be a valid assessment tool for cognitive outcomes. the previous study has shown that patients’ hospitalization due to pneumonia is associated with an increased probability of developing cognitive decline and dementia.10 this indicates that the presence of pneumonia complications may also worsen ich patients’ cognitive outcomes. hence, this study aimed to explore the difference in the cognitive outcomes of ich patients with or without pneumonia complications by comparing the mmse score. knowing the impact of such complications, preventive efforts to improve patients’ outcomes are imperative. methods a retrospective analytical study using a comparative numeric method for two independent groups was conducted. secondary data from the medical resume of all ich patients admitted to the department of neurology dr. hasan sadikin general hospital bandung in 2019 were retrieved. the data collection was conducted from september 2020 to february 2021 using a cross-sectional method. this study had been approved by the research ethics committee universitas padjadjaran bandung with ethical clearance no.026/un6.kep/ec/2021. the inclusion criteria were those who had mmse score data at discharge. mmse score was used as the measurement of cognitive outcome. patients without mmse scores, those who were deceased, were illiterate, and had an unimproved consciousness until discharge time were excluded. furthermore, the data on demographic, level of consciousness on admission, vascular risk factors, location of ich, national institute of health stroke severity (nihss) score, and volume of ich (cm3), if any, were also collected. the data were grouped into patients with a presence or absence of pneumonia, of which the diagnosis of pneumonia was determined by chest x-ray results and/or final diagnosis in the medical resume. both categoric and numeric data of patients’ characteristics were analyzed using descriptive and analytical statistics. the comparison between categorical data was conducted using the chi-square test and fisher’s exact test. the numerical data were compared using the independent t-test or mann-whitney u test according to the normality of the data. to compare cognitive outcome, the normality distribution of mmse score for groups with pneumonia or without pneumonia were analyzed first using the kolmogorov-smirnov test and shapiro-wilk test, before assessing by the mann-whitney u test. the significance of (p-value) <0.05 was considered statistically significant. results from 267 data of ich patients admitted to dr. hasan sadikin general hospital in 2019, 159 (59.5%) were excluded, due to lack of mmse examination results (n=108; 40.4%) and deceased (n=51; 19.1%). the lack of mmse result was due to incomplete medical resume data for mmse score (n=45; 16.8%), aphasia (n=23; 8.6%), decreased consciousness (n=39; 14.6%) and illiteracy (n=1; 0.4%). of the remaining 108 data that met the inclusion criteria of this study, 27 had pneumonia and 81 had no pneumonia. the patients’ characteristics were presented in table 1. the majority of patients in this study were female (53.7%), unemployed (46.3%), had somnolent consciousness (28.1%), had hypertension as vascular risk factor (91.7%), experienced first stroke attack (75.9%), and had deep ich location (62%). although there were some slight differences, the pattern of subjects’ demographics and clinical characteristics in both groups were relatively the same. analytical statistics results of cognitive outcome comparison between those with pneumonia or without pneumonia patients can be seen in table 2. shapiro-wilk test showed that the data in the pneumonia group were normally distributed (p=0.646). however, in the non-pneumonia group, the kolmogorovsmirnov test did not show that the data were normally distributed (p<0.0001). therefore, the mann-whitney u test was used to make a comparison between the two groups, resulting in a significance value (p-value) of 0.049. discussion other than the acute expansion of hemorrhagic lesions, cognitive decline in ich patients may occur due to deterioration of underlying neurodegenerative processes or cerebral small vessel disease (csvd) which are also associated with the mechanism of ich.7,11 some vascular risk factors such as carissa vania pratama et al.: cognitive outcome of intracerebral hemorrhage patients with and without pneumonia althea medical journal. 2022;9(3) 176 table 2 comparison of cognitive outcome in intracerebral hemorrhage patients with or without pneumonia mmse score p-value* n mean rank median iqr pneumonia 27 44.24 21 17–24 0.049 no pneumonia 81 57.92 25 19.5–27.5 note: *mann-whitney u test, iqr, interquartile range; mmse, mini-mental state examination althea medical journal september 2022 table 1 demographics and characteristics of study subjects variables (n=108) pneumonia (n= 27) no pneumonia (n= 81) p-value age, median (iqr) years of education, median (iqr) nihss, mean ± sd ich volume (cm3), median (iqr) 108 92ϯ 95 55 ϯ 53 (49–59) 12 (6–12) 12.08 ± 4.872 9.7 (3.5–39.7) 55 (46–60) 12 (9–12) 10.89 ± 4.783 14.6 (5.3–21.4) 0.670* 0.157* 0.279** 0.870* sex, n (%) male female 50 (46.3) 58 (53.7) 12 (44.4) 15 (55.6) 38 (46.9) 43 (53.1) 0.824*** occupation, n (%) unemployed office worker entrepreneur farmer/fisherman/laborer others 50 (46.3) 28 (25.9) 6 (5.6) 9 (8.3) 15 (13.9) 14 (51.9) 6 (22.2) 2 (7.4) 2 (7.4) 3 (11.1) 36 (44.4) 22 (27.2) 4 (4.9) 7 (8.6) 12 (14.8) 0.926*** consciousness on admission, n (%) compos mentis conscious, inadequate contact conscious, aphasic somnolent sopor coma 38 (35.2) 10 (9.3) 6 (5.6) 52 (48.1) 2 (1.9) 8 (29.6) 3 (11.1) 1 (3.7) 14 (51.9) 1 (3.7) 30 (37.0) 7 (8.6) 5 (6.2) 38 (46.9) 1 (1.2) 0.837*** vascular risk factors, n (%) hypertension dyslipidemia diabetes mellitus atrial fibrillation ischemic heart disease no vascular risk factors 99 (91.7) 33 (30.6) 5 (4.6) 2 (1.9) 1 (0.9) 8 (7.4) 26 (96.3) 10 (37.0) 1 (3.7) 1 (3.7) 0 (0.0) 0 (0.0) 73 (90.1) 23 (28.4) 4 (4.9) 1 (1.2) 1 (1.2) 8 (9.8) 0.315*** 0.399*** 1.000**** 0.439**** history of stroke, n (%) first time recurrent 82 (75.9) 26 (24.1) 19 (70.4) 8 (29.6) 63 (77.8) 18 (22.2) 0.436*** location of ich, n (%) lobar deep mixed/multiple 17 (15.7) 67 (62) 11 (10.1) 1 (4.3) 18 (78.3) 4 (17.4) 16 (22.2) 49 (68) 7 (9.8) 0.119*** note: *mann-whitney u test, **independent t-test, ***chi-square test, ****fisher’s exact test, ich, intracerebral hemorrhage; iqr, interquartile range; mmse, mini-mental state examination; nihss, national institute of health stroke scale; sd, standard deviation, ϯ the number of patients as stated althea medical journal. 2022;9(3) 177carissa vania pratama et al.: cognitive outcome of intracerebral hemorrhage patients with and without pneumonia hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, and ischemic heart disease are known to be associated with the event of csvd in patients as well as vascular cognitive impairment.12,13 the medical history of hypertension may lead to the development of white matter lesions, which is also a predictor for cognitive decline. in diabetes patients, the accumulation of proinflammatory cytokines and adhesion molecules is related to csvd.12 meanwhile the neurodegenerative process is mostly related to the lobar location of ich, csvd is mostly related to the deep location of ich.7 both neurodegenerative process and csvd are potentially associated with preich, acute-phase ich, and long-term post-ich cognitive decline.11 this study unfortunately was only able to seek the cognitive outcome of acute-phase ich patients. a single-center study of cognitive outcomes in ich patients found that the cognitive outcomes of patients in pneumonia and nonpneumonia groups were below the optimal cut-off of mmse (<27), indicating that ich patients as general had a poor cognitive outcome in the acute phase of the disease. in addition, a statistically significant difference was found when the cognitive outcome of ich patients in both groups was compared. the mmse median of the pneumonia group is lower than the non-pneumonia group, which denotes that the distribution of their cognitive outcome is lower than the non-pneumonia group. this result is parallel to the previous study which also reported worse functional outcomes in stroke patients with pneumonia complications at discharge.5 other studies also reported that the presence of infection in ich patients lead to worse functional outcomes after 3 months, and the impact was greater in respiratory infection compared to urinary tract infection.3 particularly in cognitive functioning, pneumonia is related to a decline in cognition.10 stroke patients with pneumonia may have worse cognitive outcomes due to infection-induced inflammatory response, which is associated with the later occurrence of cognitive decline.14 other to inflammatory cascades, pneumonia patients may also experience hypoxia, which can disrupt neuronal physiology and lead to an increase in cell death numbers in the underlying stroke lesion. the presence of hypoxia is known to be associated with cognitive decline in patients.15 however, this study did not observe the impact of such manifestation, and thus the exact consequences of hypoxia in ich patients with pneumonia cannot be investigated. demographically, the gender distribution of the two groups showed that most of the subjects were female.5 the slightly higher proportion of female patients in this study was a perchance due to the high exclusion number of male patients. however, this slight difference was found to be statistically insignificant. moreover, the age distribution of included subjects in this study is lower in the pneumonia group, which is similar to the previous study conducted in new york, but different from the study conducted in england.3,5 although there was no statistically significant difference between both groups, this slight difference may occur due to the high number of exclusions for older patients in this study, especially in patients with pneumonia as a complication. other characteristics such as level of consciousness or gcs on admission, vascular risk factors, history of stroke, location of ich, stroke severity, and ich volume were also taken as these covariates may interfere with patients’ outcomes.3,16–19 in summary, patients with pneumonia had a slightly lower level of consciousness on admission, had a higher proportion of hypertension and dyslipidemia, had higher proportion of recurrent stroke, had a higher proportion of deep ich location, had a higher nihss mean, and had lower ich volume median, however, these differences were not statistically significant, similar to various studies.3,4,17 in contrast, lower ich volume in patient with pneumonia was in contrary to the result of the previous multicenter case-control study.3 interestingly, of 108 patients in this study, 25% had developed pneumonia during ich hospitalization, which is higher than in previous studies.3,5,17,20 although there were not statistically significant, overall slight proportion differences from patients’ characteristics in this study support the high proportion of pneumonia in this study by providing the data of predictors and risk factors for pneumonia such as lower level of consciousness on admission, a higher proportion of deep ich location, and higher nihss score in pneumonia group subjects.3,17 moreover, the higher proportion of recurrent stroke and higher stroke severity found in patients with pneumonia are also known as predictors for cognitive decline in ich patients.16,19 other known predictors and risk factors for the development of cognitive decline in ich patients such as older age, lobar ich location, and ich volume are found to be higher in patients without pneumonia.16,18 althea medical journal. 2022;9(3) 178 this study has several limitations, among others the feasibility of running the mmse test at discharge that was limited to the patients’ ability. therefore, the measurement of cognitive outcome in patients with severe disability, low level of consciousness at discharge time, and older age tend to be difficult. also, this study fails to exclude previous cognitive impairment before stroke onset due to a lack of available data. other potential confounders to cognitive outcomes such as the presence of seizure, the degree of oxygen saturation, and other complications were also overlooked in this study.13,15 to conclude, ich patients with pneumonia develop worse cognitive outcomes than patients without pneumonia. the worse cognitive outcome of patients within the pneumonia group tends to occur as the effect of the presence of pneumonia alone since the other characteristics between both groups showed no statistically significant difference. therefore, more attention to preventive and curative measures for pneumonia in ich patients is essential to improve patients’ outcomes. a better understanding of the mechanism of cognitive decline in ich patients with pneumonia is also substantial to maximize these efforts. references 1. sacco rl, kasner se, broderick jp, caplan lr, connors jjb, culebras a, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/american stroke association. stroke. 2013;44(7):2064–89. 2. gbd 2016 stroke collaborators. global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the global burden of disease study 2016. lancet neurol. 2019;18(5):439–58. 3. lord as, langefeld cd, sekar p, moomaw cj, badjatia n, vashkevich a, et al. infection after intracerebral hemorrhage: risk factors and association with outcomes in the ethnic/racial variations of intracerebral hemorrhage study. stroke. 2014;45(12):3535–42. 4. de castillo llc, sumalapao dep, pascual jlr. risk factors for pneumonia in acute stroke patients admitted to the emergency department of a tertiary government hospital. natl j physiol pharm pharmacol. 2017;7(8):855–9. 5. teh wh, smith cj, barlas rs, wood ad, bettencourt-silva jh, clark ab, et al. impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome. acta neurol scand. 2018;138(4):293–300. 6. douiri a, rudd ag, wolfe cda. prevalence of poststroke cognitive impairment: south london stroke register 1995-2010. stroke. 2013;44(1):138–45. 7. donnellan c, werring d. cognitive impairment before and after intracerebral haemorrhage: a systematic review. neurol sci. 2020;41(3):509–27. 8. cumming tb, brodtmann a, darby d, bernhardt j. the importance of cognition to quality of life after stroke. j psychosom res. 2014;77(5):374–9. 9. cumming tb, churilov l, linden t, bernhardt j. montreal cognitive assessment and mini-mental state examination are both valid cognitive tools in stroke. acta neurol scand. 2013;128(2):122–9. 10. shah fa, pike f, alvarez k, angus d, newman ab, lopez o, et al. bidirectional relationship between cognitive function and pneumonia. am j respir crit care med. 2013;188(5):586–92. 11. xiong l, reijmer yd, charidimou a, cordonnier c, viswanathan a. intracerebral hemorrhage and cognitive impairment. biochim biophys acta. 2016;1862(5):939–44. 12. hakim am. small vessel disease. front neurol. 2019;10:1020. 13. dichgans m, leys d. vascular cognitive impairment. circ res. 2017;120(3):573–91. 14. elkind msv, boehme ak, smith cj, meisel a, buckwalter ms. infection as a stroke risk factor and determinant of outcome after stroke. stroke. 2020;51(10):3156–68. 15. ferdinand p, roffe c. hypoxia after stroke: a review of experimental and clinical evidence. exp transl stroke med. 2016;8:9. 16. biffi a, bailey d, anderson cd, ayres am, gurol em, greenberg sm, et al. risk factors associated with early vs delayed dementia after intracerebral hemorrhage. jama neurol. 2016;73(8):969–76. 17. quyet d, hien nm, khan mx, dai pd, thuan dd, duc dm, et al. risk factors for stroke associated pneumonia. open access maced j med sci. 2019;7(24):4416–9. 18. garcia py, roussel m, bugnicourt jm, lamy c, canaple s, peltier j, et al. cognitive impairment and dementia after intracerebral hemorrhage: a crosssectional study of a hospital-based series. j stroke cerebrovasc dis. 2013;22(1):80–6. 19. benedictus mr, hochart a, rossi c, althea medical journal september 2022 althea medical journal. 2022;9(3) 179 boulouis g, hénon h, van der flier wm, et al. prognostic factors for cognitive decline after intracerebral hemorrhage. stroke. 2015;46(10):2773–8. 20. alsumrain m, melillo n, debari va, kirmani j, moussavi m, doraiswamy v, et al. predictors and outcomes of pneumonia in patients with spontaneous intracerebral hemorrhage. j intensive care med. 2013;28(2):118–23. carissa vania pratama et al.: cognitive outcome of intracerebral hemorrhage patients with and without pneumonia althea medical journal. 2021;8(3) 170 althea medical journal september 2021 psychosocial burden due to acne vulgaris affects treatment-seeking behavior in medical students in jakarta, indonesia franklind matthew,1 regina,2 inneke jane hidajat,2 melyawati2 1school of medicine and health sciences, atma jaya catholic university of indonesia, 2department of dermatology and venereology school of medicine and health sciences, atma jaya catholic university of indonesia correspondence: dr. regina, sp.kk, department of dermatology and venereology, school of medicine and health sciences, atma jaya catholic university of indonesia-atma jaya hospital, jalan pluit raya no. 2 north jakarta, indonesia, email: regina@atmajaya.ac.id introduction acne vulgaris (av) is a chronic inflammation of the pilosebaceous unit that occurrs in 85% of adolescents and can continue into adulthood.1 the prevalence of av in the united states2 is 85% in the age group 12–24 years, mainly due to hormonal changes. many factors affect the av prevalence, such as race, age, and gender. at the age of 18–22 years, more men were found to experience av than women, but starting at the age of 23 years, the prevalence of av in the female group was considerably higher. some typical av skin lesions include blackheads, papules, pustules, nodules, and cysts. severe av conditions can cause scarring and psychosocial stress.3 the skin, especially the face, has a vital role in socializing. acne can cause disturbances in social functioning, such as decreased self-confidence, academic performance, and contribute to psychological burdens, especially in adolescents and young adults. associated conditions include increased anxiety, depression, and frustration, which in turn affects their quality of life.4,5 although av affect increased of psychosocial burden, several studies reported that only less than 20% of adolescents with av in the united states and less than 51% of young adults in jordan sought treatment from medical doctors.3,6 many cases have experienced av amj. 2021;8(3):170–4 abstract background: acne vulgaris (av) is a chronic inflammation of the pilosebaceous unit of the skin that occurs in 85% of adolescents and can continue into adulthood. the skin of the facial area has an essential role in socializing, therefore, facial av can contribute to the accumulation of psychosocial stress. the prevalence of individuals with av seeking treatments is low in some countries. this study aimed to determine the association between psychosocial burdens due to av and medical treatment-seeking behavior in young adults. methods: a cross-sectional study was conducted in february 2020 among 100 medical students with av. the asean lehmann criteria were used to objectively assessed av. psychosocial burden was determined by the cardiff acne disability index (cadi) questionnaire and then classified into unaffected (score 0), mild (score 1–5), moderate (6–10), and severe (11–15). history-related av was obtained through a questionnaire. the analysis was performed using the chi-square test. results: of the 100 medical students with av, 82% had suffered from mild to severe psychosocial burdens. the mean score of the cadi was 4.03. however, only 44% of students sought treatment from doctors for their av. there was a significant association between psychosocial burden and medical treatment-seeking behavior (p=0.014). conclusions: the psychosocial burden of acne vulgaris in young adults is high, however, medical treatment-seeking behavior is low. therefore, psychosocial management is an essential aspect in treating patients with av. keywords: acne vulgaris, cadi, psychosocial burden, treatment-seeking behavior https://doi.org/10.15850/amj.v8n3.2179 althea medical journal. 2021;8(3) 171 for years before seeking treatments. some of the reasons are embarrassment, unsuitable schedules, or self-medication with over the counter (otc) products. many otc products for av treatment are widely available due to lower cost, convenience, and increasing usage trend in society.6 the proportion of the young adults in indonesia who seek av treatment from doctors, either a dermatologist or a general practitioner, is not widely known. this study was conducted to determine the severity of av, the psychosocial burden it incurred, and the relationship between this burden and treatment-seeking behavior among young adults. methods a cross-sectional study was conducted in february 2020, conducted at the school of medicine and health sciences, atma jaya catholic university of indonesia. the minimum sample size was 61 respondents considering the 80% av prevalence, a confidence level of 95%, and a degree of deviation of 10%. the inclusion criteria for this study were medical students who suffered from acne vulgaris and willing to participate in this study by signing an informed consent. exclusion criteria were students with hormonal disorders such as polycystic ovarian syndrome (pcos), cushing’s syndrome, and others. the questionnaire was distributed and filled out by each respondent, consisting of three parts. the first part contained demographical data, and the second part consisted of questions regarding acne treatment behavior. the third part referred to the psychosocial burden due to av, which was assessed using the cardiff acne disability index (cadi) questionnaire. the classification of the psychosocial burden was divided into unaffected (score 0), mild (score 1–5), moderate (6–10), and severe (11–15).7,8 then, the dermatologist assessed the av degree according to the asean lehmann classification; mild designated as <20 comedones, <15 papules or pustules, without nodule; moderate for 20–100 comedones, 1550 papules or pustules, <5 nodules; and severe for >100 comedones, >50 papules or pustules, >5 nodules. the ethical clearance was obtained from the ethics committee of the school of medicine and health sciences, atma jaya catholic university of indonesia with the number: 12/01/kepfkuaj/2020. univariate data analysis used descriptive statistics. bivariate analysis was performed using the chi-square test to determine the relationship between the psychosocial burden of av and medical treatment-seeking behavior. the relationship was declared significant if the p-value is <0.05. statistical analysis using the spss version 25.0. results demographic characteristic showed that out of 100 study participants, there were more women (65%) than men, with an age range of 19–22 years old and a mean age of 20.3+0.77 years (table 1). most of the students suffered from av for about 5 to 9 years (57%), with a period of suffering of at least ≥10 years (3%). the degree of av severity on the face was assessed by dermatologists using the asean lehmann classification with most students had a mild classification (74%) and the least students suffering from severe av (3%). interestingly, only 44% of the students went to a medical doctor, either a general practitioner or a dermatologist, to treat their av. based on currently used av therapies, 59% of students used otc products, 4% used medications prescribed by doctors, and the rest combined both categories (table 2). table 1 demographic characteristic of study participants (n=100) demographic characteristic n % age (years) 19 20 21 22 8 54 30 8 8 54 30 8 gender men women 35 65 35 65 franklind matthew et al.: psychosocial burden due to acne vulgaris affects treatment-seeking behavior in medical students in jakarta, indonesia althea medical journal. 2021;8(3) 172 althea medical journal september 2021 several subjects used other otc products (table 3), with the most widely used otc products for treating av was facial soap (n=89), followed by acne spot drugs (n=52), and sheet masks (n=46). furthermore, data on the psychosocial burden of av and medical treatment-seeking behavior clarified two points. first, students who had a psychosocial burden due to av suffered the most most mild burden (60%) and severe burden (9%). the mean value of psychosocial burden obtained based on the cadi score was 4.03. second, there was a relationship between the psychosocial burden due to av and medical treatment-seeking behavior (p=0.014) (table 4). discussion this study found that most (82%) students aged 19–22 years old suffered from mild to severe psychosocial burdens due to acne vulgaris, with a mean cadi score of 4.03. there were 44% of students who sought treatment to a doctor for their av. there is a statistically significant relationship between psychosocial burden and medical treatmentseeking behavior (p=0.014). most of the students (57%) had suffered from av for 5–9 years. this result is similar to a previous study in europe which showed that the mean av onset has occurred at the age of 14±1.9 years (range 10–24 years).9 the table 2 characteristic of acne vulgaris among students aged 19–22 years av–related data n % duration of suffering from av < 5 years 5–9 years ≥10 years 40 57 3 40 57 3 av degree mild moderate severe 74 23 3 74 23 3 treatment to doctor yes no 44 56 44 56 current medication used medications from doctor otc products combination 4 56 40 4 59 37 total 100 100 note: av= acne vulgaris, otc= over the counter table 3 over the counter products used by students otc products n facial soap 89 acne spot drugs 52 sheet masks 46 night creams 40 serums 32 face masks 32 cleansing oils 29 scrubs 26 others (moisturizer, toner, etc.) 17 note: otc= over the counter althea medical journal. 2021;8(3) 173franklind matthew et al.: psychosocial burden due to acne vulgaris affects treatment-seeking behavior in medical students in jakarta, indonesia occurrence of av in adolescence is associated with increased sebum production in the pilosebaceous unit related to androgenous hormones. although it affects about 85% of adolescents, av can also occur before or after adolescence due to its multifactorial pathogenesis.10 most (74%) students had mild av, and only 3% had severe av, similar to another study showing about 70% mild av.1 in choosing av therapy, only half of the students (44%) went to a doctor to treat their av. the rate of visits to the doctor due to av is low, some of which are the feeling that the av condition is not too severe, busy schedule, and shyness to consult.11 another similar study in pakistan also showed about 55% of students seeking help from a doctor for their av problems.12 however, this study did not investigate why the study subjects did not consult their av problems with their doctor. self-medication with otc products was found in 56% of students, and 44% had used a combination of prescription drugs with otc products. some of the reasons for selfmedication include mild av degrees, available otc products, lack of time to see a doctor, and knowledge of pharmacology as a medical student.12 sources of information related to av treatment were mostly obtained through friends or seniors in medical school and family members who are doctors. these results are similar to several previous studies in jordania3 and saudi arabia.6 the most widely used otc products by students include facial soaps and topical therapies, such as acne spots, night creams, masks, and serums. the severity of the psychosocial burden due to av was mostly mild, with an average cadi score of 4.03. several other studies have also revealed similar results.11,13 thus, there is thus a significant relationship between psychosocial burden due to av and medical treatmentseeking behavior (p<0.05), although another study showed a different result.11 interestingly, a study among 852 french adolescents found that nearly two-thirds wanted more information about acne and 38.6% had never consulted a physician. more than half of the respondents felt ashamed of their skin condition and almost a third felt that av interfered with their social and leisure activities. with society becoming increasingly beauty-conscious, there may be additional pressure on young adults to achieve “flawless” skin. as expected, the more severe the acne degree, the more likely a person is to seek medical treatment.14 moreover, 58.9% of participants who had received medical treatment would rate their acne as “excellent”, “very good” or “good” compared to up to 41.3% of participants seeking non-medical treatment.15 acne has been known to have a significant impact on psychological and social life. the cadi questionnaire used in this study is a specific questionnaire for av sufferers describing feelings of shame, frustration, aggression, disturbances in social life, or relationships with the opposite gender, public avoidance behavior, concerns about skin appearance, and self-perception problems about av.5 our results indicate that there is a psychosocial burden due to acne, therefore, psychosocial factors also need to be considered when treating av patients. the strength of this study is the use of a special cadi questionnaire to assess the psychosocial burden of av. moreover, an objective assessment of the degree of acne has been performed by a dermatologist. the weakness of this study is that there is no further exploration of why the participants choose to seek a doctor or not. in conclusion, this study concludes that there is a significant association between psychosocial burdens caused by acne vulgaris and medical treatment-seeking behavior. table 4 association between psychosocial burden due to acne vulgaris and medical treatment-seeking behavior among students aged 19–22 years old total treatment from doctor p-valueyes no n % n % psychosocial burden unaffected mild moderate severe 13 60 18 9 5 20 13 6 11.4 45.4 29.5 13.7 8 40 5 3 14.3 71.4 8.9 5.4 0.014 althea medical journal. 2021;8(3) 174 althea medical journal september 2021 these results are expected to assist doctors in carrying out av management holistically by considering the psychological factors of the patients. references 1. zari s, turkistani a. acne vulgaris in jeddah medical students: prevalence, severity, selfreport, and treatment practices. journal of cosmetics, dermatological sciences and application. 2017;7(1):67–76. 2. raikar dr, manthale ns. a cross sectional study of self-medication for acne among undergraduate medical students. int j res dermatol. 2018. 25;4(2):211–4. 3. jaber rm, alnshash bm, mousa sn, fayoumi hs, al-qaderi lm, zant am. the epidemiology of acne vulgaris among adolescents and young adults in jordan university hospital. open journal of nursing. 2020;10(4):353–66. 4. hosthota a, bondade s, basavaraja v. impact of acne vulgaris on quality of life and self-esteem. cutis. 2016;98(2):121–4. 5. kumar s, singh r, kaur s, mahajan bb. psychosocial impact of acne on quality of life in north india: a hospitalbased cross-sectional study. journal of pakistan association of dermatologists. 2016;26(1):35–9. 6. alshehri m, almutairi a, alomran a, alrashed b, kaliyadan f. over-the-counter and prescription medications for acne: a cross-sectional survey in a sample of university students in saudi arabia. indian dermatol online j. 2017;8(2):120–3. 7. abdelrazik yt, ali fm, salek ms, finlay ay. clinical experience and psychometric properties of the cardiff acne disability index (cadi). br j dermatol. 2021. doi:10.1111/bjd.20391. 8. tayel k, attia m, agamia n, fadl n. acne vulgaris: prevalence, severity, and impact on quality of life and self-esteem among egyptian adolescents. j egypt public health assoc. 2020;95(1):30. 9. szepietowski jc, wolkenstein p, veraldi s, tennstedt d, machovcová a, delarue a. acne across europe: an online survey on perceptions and management of acne. j eur acad dermatol venereol. 2018;32(3):463– 6. 10. picardo m, eichenfield lf, tan j. acne and rosacea. dermatol ther (heidelb). 2017;7(suppl 1):43–52. 11. desai kp, martyn-simmons c, viner r, segal t. help-seeking behaviours, opportunistic treatment and psychological implications of adolescent acne: crosssectional studies in schools and hospital outpatient departments in the uk. bmj open. 2017;7(9):e016964. 12. tameez-ud-din a, malik ij, bhatti aa, tameezud din a, sadiq a, khan mt, et al. assessment of knowledge, attitude, and practices regarding self-medication for acne among medical students. cureus. 2019;11(8): e5510. 13. bajawi s, salih s, mahfouz ms, bajawi n, asiri b. acne vulgaris awareness and impact on quality of life and psychological status of adolescent school children in jazan, saudi arabia. international journal of sciences: basic and applied research. 2016;25(2):374–84. 14. de vries f, tjin e, driessen r, vehof h, van de kerkhof p. exploring patient journeys through acne healthcare: a patient perspective. j dermatolog treat. 2021;1–8. doi: 10.1080/09546634.2021.1940808 15. su p, chen wee aw d, lee sh, han sim toh mp. beliefs, perceptions and psychosocial impact of acne amongst singaporean students in tertiary institutions. j deutsch dermatol ges. 2015;13(3):227–33. amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 51 characteristics of nasal foreign body cases in dr. hasan sadikin general hospital bandung henzen ghesan hampry,1 sinta sari ratunanda,2 melati sudiro,2 wijana,2 raden ayu hardianti saputri2 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology-head and neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: henzen ghesan hampry, faculty of medicine universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, e-mail: henzen18001@mail.unpad.ac.id introduction corpus alienum or foreign body is defined as an object originating from outside body, which enters and settles inside the body. nasal foreign body refers to a foreign body located inside the nasal cavity. it can happen through a couple of mechanisms. these foreign bodies can enter through the natural body orifice (nares or choanae), then through the wound in the facial area. another mechanism is that a foreign body can also be caused by an undesirable error during a medical examination or treatment.1,2 foreign body cases comprise 30% of ear, nose, and throat (ent) emergencies incidents, of which 19% of cases are nasal foreign bodies.3 generally, nasal foreign bodies are more common in children under five years (84%), of which 73% of cases occur in children under three years.4 nasal foreign bodies can be categorized as an ent emergency. not only are these cases common in toddlers, but the complications can be life threatening if not treated immediately and properly. nasal foreign bodies complications are determined by two main factors, namely the duration of the foreign body is in the nasal cavity and the characteristics of the object. the most common complications that can occur are epistaxis, mucosa ulceration, and rhinosinusitis.5 some severe complications that could occur are septum perforation, especially in the case of watch batteries and aspiration of foreign bodies that may obstruct the airway, which can lead to death from suffocation.2,3,6,7 given the magnitude of the incidents and the severity of the morbidity that can occur if cases of nasal foreign bodies are not handled immediately and properly, this study was conducted to evaluate the characteristics of althea medical journal. 2023;10(1):51–55 abstract background: nasal foreign bodies are caused by the insertion of an extraneous substance into the nasal cavity. these cases frequently occur in children. nasal foreign bodies are easily diagnosed, yet the treatment may be burdensome with possible complications and costly management. the study aimed to evaluate the characteristics of nasal foreign body cases. methods: the study was descriptive and cross-sectional, using secondary data taken from all medical records of the emergency room in dr. hasan sadikin general hospital, bandung, from 2018 to 2021. data were presented in tables. results: of the 57 cases, most of the patients (64.9%) were aged 3-5 years, with boys as the most prevalent cases (59.7%) and the most common complaint was pain (31.7%). inorganic foreign bodies (61.4%) were more commonly found, and being frequently found in the right nasal cavity (49.1%). the duration of the foreign body in the nasal cavity and the treatment conducted on the patients were mostly not written in the medical records, however, no complications were found. conclusions: a higher incidence of nasal foreign bodies can be found in boys aged 3-5 years. inorganic objects and pain are the most common manifestations, although the condition of all patients has been improved. raising awareness about foreign body cases to the community, especially the parents, is the key to preventing these cases from occurring. keywords: characteristics, foreign bodies, nasal https://doi.org/10.15850/amj.v10n1.2702 althea medical journal. 2023;10(1) 52 nasal foreign body cases in dr. hasan sadikin general hospital bandung. methods this study design was descriptive and crosssectional. the population of this study were ent patients who sought the treatment at the emergency room in dr. hasan sadikin general hospital bandung. the inclusion criteria for this study were patients with a diagnosis of nasal foreign bodies who were observed from medical records from july 2018 to december 2021. exclusion criteria were medical records that were inaccessible and unreadable. data were collected using the total sampling method, including the characteristics of nasal foreign body cases, such as age of the patients, gender, clinical manifestations, characteristics of the foreign bodies, treatment, and outcome of the cases. the collected samples were presented in the form of table. this study was approved by the research ethics committee of universitas padjadjaran with ethical clearance number 940/un6.kep/ ec/2021. results in total, there were 63 cases, however, only 57 data were available. as shown in table 1, the age of patients who sought treatment in the emergency room ranged from 2 to 65 years old, with preschool age (3 to 5 years old) predominant (mean age 5 years old). the male was slightly higher in proportion than female patients. among the patients, there was an interesting case namely a suspected mental retardation case (11 years old). the pain was the most common clinical manifestation, which was graded from pain numerical rating scales (table 2). inorganic foreign bodies were found, to be more prevalent compared to organic foreign bodies. however, some types were not written in the medical records. the duration of the foreign body in the nasal cavity were also unknown. in known cases, most foreign bodies were diagnosed and treated promptly. however, there were few cases of foreign bodies that had stayed longer in nasal cavities, for example, about a week. in other cases (n=2), foreign bodies were left untreated for nine to twelve months. the treatment type conducted were mostly unknown, however, suctioning was mentioned in the medical record. all patients’ condition improved, and no complication was observed after the treatment. most foreign bodies were found in the right nasal cavity and no bilateral cases were found. discussion most of the patients found in this study were between three to five years old. these findings are consistent with many previous studies about the age of patients with nasal foreign bodies. a study in turkey has found that the age found is four years old, with the highest cases (36.1%) occurring in children aged two to five years,6 whereas another study found a similar result, which is the three years age group (48.8%).8 these findings correspond with a study about motoric development, in which children in this age group (3 to 5 years old) begin to explore their control and power over their surroundings and also their bodies. they can actively grasp any items while playing and have a particular interest in inserting them into their body cavities, including the nares.8–10 male patients are usually more commonly found than female patients. a study in nigeria table 1 characteristic of patients with nasal foreign body (n=57) variable n % age (years) < 3 3-5 6-12 12-18 19-40 40-60 >60 9 37 9 1 1 15.8 64.9 15.8 1.75 1.75 gender male female 34 23 59.6 40.4 althea medical journal march 2023 althea medical journal. 2023;10(1) 53henzen ghesan hampry et al.: characteristics of nasal foreign body cases in dr. hasan sadikin general hospital bandung has shown that male patients are slightly more prevalent (50.6%).2,6 these findings are explained by a study that compared motoric activity between genders. most of the male respondents were more active in grasping, playing, and manipulating toys or items around them, compared to female respondents.11 this study shows that the prevailing clinical manifestation is pain, followed by asymptomatic, nasal discharge, edema, hyperemic mucosa, foul smelling, and epistaxis, sequentially. a previous study has found that the most prevalent clinical manifestations found are asymptomatic or foul-smelling nasal discharge, followed by nasal discharge. in contrast, other symptoms like bleeding and nasal discomfort are the least common.8 purulent rhinorrhea with foul smell and bleeding are also common.12 several factors might be the causes of clinical manifestation. most of the patients were under or equal to 5 years of age, and they were easily irritated, especially in a foreign and hustling setting such as the emergency room, being surrounded by strangers examining them.13 the doctor might misinterpret this and conclude that the patient is in pain. these might be the reason why pain became the most common clinical manifestation found in this study. in addition, pain can be marked on a numerical rating scale of pain. inorganic and organic foreign bodies have been found in this study; inorganic objects such as small toys, beads, button batteries, and styrofoam, whereas organic substances such as rice, seed, bean, and paper. the previous table 2 clinical manifestation and other factors about foreign bodies in patients with nasal foreign body (n=57) n % clinical manifestation (n=41) foul-smelling epistaxis nasal discharge hyperemic mucosa edema unilateral pain asymptomatic 2 2 8 3 4 13 9 4.9 4.9 19.5 7.3 9.8 31.7 21.9 type of foreign bodies (n=57) organic inorganic unknown 7 35 15 12.3 61.4 26.3 duration of foreign bodies in nasal cavity (n=57) <24 hours 1–7 days 8–30 days >30 days not written in the medical records 13 1 0 2 41 22.8 1.8 0 3.5 71.9 treatment (n=57) tweezers or forceps medical instrument with a hook catheter suction not written in the medical records 0 0 0 3 54 0 0 0 5.3 94.7 outcome (n=57) improvement complication 57 0 100 0 nasal cavity (n=57) right left bilateral not written in the medical records 28 17 0 12 49.1 29.8 0 21.1 althea medical journal. 2023;10(1) 54 study found that foreign bodies extracted were also comprised of both inorganic and organic objects. inorganic objects, such as beads, stones, toys, erasers, and others, were found in 74% of cases, while organic objects were found in 25% of cases.2 these findings were in accordance with another study conducted in turkey, that inorganic were more commonly found.14 availability of the objects may be the reason why inorganic matter was more commonly found.15 as toddlers begin to explore their surroundings, they start to grasp easily accessible items around them, such as small toys, beads, button battery, and others, which they have a particular interest in putting such objects in their nose or mouth.11,16,17 the duration of the foreign body in each patient mostly was not written in the medical records. from the cases known for their duration, most of the patients were diagnosed and treated in less than twenty-four hours. these results are slightly different from data obtained in malaysia, most of the patients did not seek medical help within 24 hours after the entrance of the foreign body, yet the majority of the cases received medical attention within the first week.8 after the treatment, no complication was found in this study, and patients’ conditions were improved after treatment. a previous study has found that hook, forceps, and suctioning predominantly treated cases. few complications (7%) were found, such as rhinosinusitis, epistaxis, laceration, rhinolith formation, and ulceration of nasal septum.3 another study has shown that foreign bodies were extracted using micro-instruments such as forceps or micro-hook. the outcome was mostly favorable, with only slight epistaxis and septal perforation.12 the outcome of these cases is not fully determined by the method of extraction. more than 20 foreign body treatments are defined in many kinds of literature, yet the outcome may vary, influenced by many other factors such as patients’ age, compliance, duration of the foreign body in the nasal cavity, and even physician’s skillfulness.14,18 foreign bodies were more commonly found in right nasal cavity than the left nasal cavity, however, left or bilateral cavities may exist.3 interestingly, infants began to develop a preference for using one particular hand in the first two years of life.19 this unilateral handedness would influence how children interact with their environment, especially in exploring, grasping, and playing with objects around them. many studies found that righthandedness predominates in infants, even similarly to adults across the globe. this might be why foreign bodies were more commonly found in the right nasal cavity.16,20 this study has several limitations. the lack of completeness of medical records makes the availability of data less and less. in addition, most medical records were handwritten, and many were difficult to read. there are also quite a lot of incomplete medical records, resulting some variables could not be measured precisely, such as treatment and duration of the foreign body in the nasal cavity. in the era of digital platforms in the hospitals, data acquisition would be better for exploring important and interesting cases. in conclusion, nasal foreign body cases are predominantly prevalent in young age, with the majority between 3 to 5 years old and male. clinical manifestations are generally mild, with pain being the most common complaint. the foreign bodies are mostly inorganic material. the outcomes are favorable, and no complications are found after the treatment. raising awareness about foreign body cases to the community, especially parents of young children, is the main key in preventing and treating these cases. references 1. constantine s, buckley j. corpus alienum. european society of radiology [internet] 2017 [cited 2021 sept 6]. available from: h t t p s : / / e p o s . mye s r. o r g / p o s t e r / e s r / ranzcr2017/r-0030. 2. ogah sa, odenkunle rr. nasal foreign bodies: a retrospective study. nigerian j otorhinolaryngol. 2018;15(5):36–8. 3. awad ah, eltaher m. ent foreign bodies: an experience. int arch otorhinolaryngol. 2018;22(2):146–150. 4. yunker wk, friedman em. ingestion injuries and foreign bodies in the aerodigestive tract. in: johnson jt, rosen ca, editors. bailey’s head and neck surgery otolaryngology. 5th ed. philadelphia: lippincott williams & wilkins; 2014. p. 1399–408. 5. lee kj. pediatric otolaryngology. in: lee kj, editors. essential otolaryngology head and neck surgery. 10th ed. new york: mc grawhill; 2012. p. 776–826. 6. hira i̇, tofar m, bayram a, yaşar m, mutlu c, özcan i̇. childhood nasal foreign bodies: analysis of 1724 cases. turk arch otorhinolaryngol. 2019;57(4):187–90. 7. onal m, ovet g, alatas n. an asymptomatic althea medical journal march 2023 althea medical journal. 2023;10(1) 55henzen ghesan hampry et al.: characteristics of nasal foreign body cases in dr. hasan sadikin general hospital bandung foreign body in the nose in an eighteenyear-old patient: button battery. case rep surg. 2015;2015:129851. 8. yaroko aa, baharudin a. patterns of nasal foreign body in northeast malaysia: a fiveyear experience. eur ann otorhinolaryngol head neck dis. 2015;132(5):257–9. 9. kesavelu d, sheela k, abraham p. stages of psychological development of child-an overview. int j curr res rev. 2021;13(13):74–8. 10. scharf rj, scharf gj, stroustrup a. developmental milestones. pediatr rev. 2016;37(1):25–38. 11. dinkel d, snyder k. exploring gender differences in infant motor development related to parent’s promotion of play. infant behav dev. 2020;59:101440. 12. abou-elfadl m, horra a, abada rl, mahtar m, roubal m, kadiri f. nasal foreign bodies: results of a study of 260 cases. eur ann otorhinolaryngol head neck dis. 2015;132(6):343-6. 13. brotman ma, kircanski k, leibenluft e. irritability in children and adolescents. annu rev clin psychol. 2017;13:317–41. 14. çelik m. evaluation of patients with nasal foreign body. haydarpasa numune med j. 2018;58(2):79–84. 15. libertus k, gibson j, hidayatallah nz, hirtle j, adcock ra, needham a. size matters: how age and reaching experiences shape infants’ preferences for different sized objects. infant behav dev. 2013;36(2):189– 98. 16. michel gf, campbell jm, marcinowski ec, nelson el, babik i. infant hand preference and the development of cognitive abilities. front psychol. 2016;7:410. 17. cetinkaya ea, arslan ib, cukurova i. nasal foreign bodies in children: types, locations, complications and removal. int j pediatr otorhinolaryngol. 2015;79(11):1881–5 18. lou zc. analysis of nasal foreign bodies in 341 children. j laryngol otol. 2019;133(10):908–12. 19. campbell jm, marcinowski ec, babik i, michel gf. the influence of a hand preference for acquiring objects on the development of a hand preference for unimanual manipulation from 6 to 14 months. infant behav dev. 2015;39(5):107–17. 20. fagard j. the nature and nurture of human infant hand preference. ann n y acad sci. 2013;1288(1):114–23. amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 212 relationship between the risk of eating disorders and the concentration capacity of high school students samantha shania,1 felicia kurniawan3 1school of medicine and health sciences atma jaya catholic university of indonesia, indonesia, 2department of health sciences, school of medicine and health sciences atma jaya catholic university of indonesia, indonesia correspondence: samantha shania, s.ked, school of medicine and health sciences atma jaya catholic university of indonesia, jalan pluit raya no. 2, north jakarta, indonesia, e-mail: sam.shania@gmail.com introduction changes in eating behaviors and dietary habits are very common in the general global population. unhealthy eating behavior may affect daily activities and cause vulnerability to various diseases, known as eating disorders.1 eating disorders are a group of serious mental disorders, generally leading to fatal consequences that cause people to become obsessed with weight and body shape.2 the disorder is a comprehensive spectrum disorder, which is further classified into anorexia nervosa (an), bulimia nervosa (bn), binge-eating disorder (bed), avoidant/ restrictive food intake disorder (arfid), and pica. those with an eating disorder who do not meet the full criteria for any of the disorders above falls into ‘other specified feeding and eating disorder’ (osfed) or ‘unspecified eating disorder’ (ufed).3,4 changes in individual eating behavior are designated as unhealthy if the effects of these changes result in an excessive or inadequate energy intake. three of the most common eating disorders are anorexia nervosa (an), bulimia nervosa (bn), and bed.1 eating disorders are most commonly found in women between the ages of 12–35 years, although they can also be found in all types of individuals.5 another study has shown that this disorder is found primarily in adolescents, mainly at 16–24 years old.6 unhealthy eating behavior can be experienced by everyone, although it is more commonly found in women from adolescence to young adulthood.1,7 in althea medical journal. 2022;9(4):212–217 abstract background: eating disorder is a change in eating behaviour that affects daily activities, resulting in a vulnerability towards diseases that have several effects on the organ systems, including the neurological system. in teenagers, these disturbances, including a decline in memory, cognitive function, and concentration, will significantly affect daily activities, especially in their studies. the objective of this study was to determine the relationship between the risk of eating disorders and the concentration capacity of high school students aged 12–19 years old. methods: this study was an observational analytic study conducted cross-sectionally among high school students. data were collected from september to october 2019. data were taken using eating disorder examination (ede) questionnaire filled out by the respondents, followed by a stroop test. data analysis was performed by the chi-square test. results: of 294 students, 56.5% had a risk of eating disorder, of whom 66.7% did eating restrain. of all respondents, 54.8% had poor concentration capacity. there was a relationship between the risk of eating disorder and concentration capacity (p=0.002). conclusion: the risk of eating disorders has a significant relationship with concentration capacity. an urgent measurement is needed to promote an eating behaviour among adolescents to increase good and productive daily activity. keywords: concentration capacity, eating disorders, ede-q, stroop test https://doi.org/10.15850/amj.v9n4.2530 althea medical journal. 2022;9(4) 213 indonesia, 12–22% of women aged 15–29 years suffer from chronic energy deficiency with a body mass index of <18.5, however, it has not been confirmed yet due to a lack of prevalence studies conducted.8 moreover, eating disorders prevalence is relatively high in adolescents under 18 years old, and the prevalence is high in asia and other developing countries.9 this high prevalence of eating disorders among adolescents might be correlated with the effect of negative body image distortion.10 next to serious mental illness, eating disorders affect various organ systems in the body, among others cardiovascular, gastrointestinal, endocrine, and neurology system.11 food restriction, nutritional deficiency, and in other ends also, excessive energy intake can cause an individual to experience several disruptions in the activities of daily living. in adolescents, neurological disruption will significantly affect daily activities, especially in the study.11 these neurological disruptions include dull memory, decreased cognitive function that is associated with cognitive inflexibility, which is considered one factor that worsens prognosis, which will be more likely to present resistance to therapy,12 and problems with concentration or inattention due to alterations of the neurotransmission of the brain.11 an individual is described as inattentive if he/she has poor concentration capacity, a short attention span, and is easily distracted.13 several studies have found evidence showing a relationship between eating disorders and neurological disruption.13 this relationship is associated with neurological disruption due to either inadequate nutrition intake for the body or excessive food intake, which are both caused by disordered eating.11 this study focuses on concentration problems as one of the consequences of an eating disorder due to the high demands for good concentration in high school students and the high prevalence of eating disorders in adolescents in the high school age range. therefore, this study aimed to determine the relationship between eating disorders in adolescents aged 12–19 years in west jakarta and their impacts on concentration capacity. methods this study was a cross-sectional analytic observational study conducted from september to october 2019. the sample was collected by total sampling. the respondents were all junior and senior high school students at an international school in west jakarta, indonesia who met the inclusion criteria. inclusion criteria were students aged 12–19 years had never done the stroop test and were willing to become respondents by signing informed consent. since they were underage, informed consent was signed by their parents/guardian and they were asked for posible exclusion criteria. exclusion criteria were respondents who were color blind, had dyslexia, and had attention-deficit/ hyperactivity disorder (adhd). furthermore, respondents who experienced non-optimal physical conditions that could interfere with concentration, such as headache, body aches, fatigue due to physical activity, chills, fever, cough, and runny nose, were excluded. respondents who were taking drugs that stimulated drowsiness were also excluded as well as those who were not present on the day of data collection. ethical clearance was obtained from the research ethics committee school of medicine and health sciences atma jaya catholic university of indonesia with a number 02/09/kep-fkuaj/2019. data were collected using the ede-q questionnaire to obtain data on the risk of eating disorder and the stroop test to determine the concentration capacity. the ede-q questionnaire was used to screen respondents for eating disorders. the results of the questionnaire were divided into 4 subscales, including restrain, eating concern, shape concern, and weight concern. the 4 subscales were then subdivided to obtain the average value or the global score of each respondent’s ede-q. the stroop test used was the stroop color and word test (scwt). in the stroop test, respondents were asked to read a board containing the name of the color (w) printed in different ink from the writing (c). for example, the word “blue” in red ink. this condition will cause the participant’s attention to be more divided, where tasks that can usually be done more automatically, such as reading the color of the writing, become obstructed due to the respondents being required to name the color of the ink instead of reading the word.14 the concentration capacity tested by the stroop test was divided into two parts. initially, the respondents will be asked to read aloud the words written on the card while ignoring the color of the ink printed on the word. then in the next section, the respondent will be asked to name the color of ink used for the word, regardless of the word printed on samantha shania and felicia kurniawan: relationship between the risk of eating disorders and the concentration capacity of high school students althea medical journal. 2022;9(4) 214 the card. the respondent’s reading time (in seconds) was recorded in both steps. then the researcher calculated the interference score between these two steps by reducing the time recorded in the first step with the time recorded in the second step. if the interference score was less than 13, the concentration of the respondent was categorized as good. if the interference score was more than or equal to 13, the concentration of the respondent was considered poor.15 the data were analyzed by univariate analysis for the demographic characteristics, risk of eating disorders, and concentration capacity of the junior and high school students. bivariate analysis was then performed with the chi-square test for the relationship between the effects of risk of eating disorder and concentration capacity. results this study included 294 junior and high school students. the distribution of respondents by gender was 179 female (60.9%), and 115 male (39.1%). distribution of respondents who had a risk of eating disorders was 56.5%, while 43.5% did not. the results also showed that there were 54.8% with impaired concentration capacity, while 45.2% did not (table 1). hence, the risk of eating disorders and impaired concentration capacity dominates all respondents. females (60.9%) had more risk of eating disorders compared to males (49.6%) (table 2). however, there was no significant relationship between gender and risk of eating disorder (p=0.056). interestingly, there was a significant relationship between gender and concentration disruption (p=0.000). althea medical journal december 2022 table 1 demographic characteristics, eating disorders, and concentration capacity of junior and high school students (n=294) variable distribution n % class level grade 7 grade 8* grade 9 grade 10 grade 11 grade 12 53 63 62 58 37 21 18.0 21.4 21.1 19.7 12.6 7.1 gender female* male 179 115 60.9 39.1 eating disorder risk of eating disorder* no risk 166 128 56.5 43.5 concentration capacity impaired* normal 161 133 54.8 45.2 note: *highest percentage table 2 normality test gender eating disorders concentration capacity risk no risk impaired normal n (%) n (%) n (%) n (%) female 109 (60.9) 70 (39.1) 59 (33.0) 120 (67.0) male 57 (49.6) 58 (50.4) 102 (88.7) 13 (11.3) althea medical journal. 2022;9(4) 215samantha shania and felicia kurniawan: relationship between the risk of eating disorders and the concentration capacity of high school students in the interpretation results on the ede-q questionnaire, which were divided into 4 subscales, it was found that 66.7% had the restrain subscale, 69.1% had the eating concern subscale, 60.2% had the shape concern subscale, and 56.5% had the weight concern subscale (table 3). there was a significant relationship between the risk of eating disorders and impaired concentration (p=0.002), and there was a significant relationship between eating restrictions and the risk of eating disorders (p=0.000) (table 4). discussion the results showed that females had a higher risk of eating disorders compared to male, as depicted in table 2. however, the relationship between gender and risk of eating disorders is not significant (p=0.056). this result is in accordance with a study on the risk of eating disorders in more respondents, including 6,140 adolescents. there is a higher number of body dissatisfaction in girls compared to boys in their adolescence period. however, gender as a risk factor for the eating disorders could not be determined.16 the results of this study are also supported by a meta-regression analytical study that refutes gender role as a risk of developing an eating disorder. although gender may play a role, it needs to be in correlation with other risk factors in determining a person’s risk for eating disorders.17 our study also showed that male students had more experienced concentration problems compared to female students. gender seems to have a role in impaired concentration. similar to another study, the stroop test is different between genders. the response speed in women is faster than in men. therefore, the performance of the stroop test in men has worse results.18 there is a significant relationship between the risk of eating disorders and the concentration capacity of these junior and high school students (p=0.002). this result is consistent with a study about the physiological consequences of eating disorders. nutritional deficits in eating disorders can cause sufferers to become weak and tired easily.11 eating disorder risks in this study were determined by disordered eating and dissatisfaction with self-perception at least in the last 28 days. it shows that respondents who have been determined to have an eating disorder risk changed to abnormal eating patterns. this nutritional deficit behavior can cause cognitive development disorders, and one of the components of cognitive function is concentration.10 furthermore, other studies table 3 eating disorder examination questionnaire (ede-q) interpretation subscale mean impairedn (%) normal n (%) restrain 1.625 196 (66.7) 98 (33.3) eating concern 1.256 203 (69.1) 91 (30.9) shape concern 2.258 177 (60.2) 117 (39.8) weight concern 1.780 161 (54.8) 133 (45.2) global score 1.730 166 (56.5) 128 (43.5) table 4 relationship between eating disorders risk and concentration capacity of high school students eating disorders risk concentration capacity total n (%) p-value*impaired n (%) normal n (%) risk 104 (35.4) 57 (19.4) 166 (56.5) 0.002 no risk 62 (21.1) 71 (24.1) 128 (43.5) total 161 (54.8) 133 (45.2) 294 (100.0) althea medical journal. 2022;9(4) 216 also state the existence of neurological susceptibility in nutritionally restricted individuals.19 there is a close relationship between impaired concentration/attention and restrictive eating patterns.20 individuals with eating disorders have worse performance in completing cognitive tasks, inhibitory function, planning performances, and worse working memory tasks.21 a significant relationship between restrictive eating behavior and the risk of eating disorders. in our study also shows that there is a relationship between restrictive eating behavior on concentration capacity. this finding supports the theory that restrictive eating behavior may cause nutritional deficiencies and thus can interfere with concentration capacity.11 these results are consistent with a study that assessed the relationship of cognitive function with restrictive eating behavior such as skipping meals. skipping meals and cognitive function has a significant interaction, in which dietary restriction impairs the ability to learn and encode new information.22 this study has several limitations and shortcomings. one of the limitations encountered in this study was the location where respondents were collected, which was only from one school. therefore, the data obtained only describes the results of the risk of eating disorders in high school students where the majority are from the middle and upper socioeconomic status with a tiong hoa ethnic background. data collection for concentration power also does not exclude confounding factors, such as preoccupation with gaming addictions, which also have a high prevalence in adolescents. in conclusion, the risk of eating disorders has dominated junior and senior high school students with the concentration capacity mostly disrupted. counseling about the effects of eating disorders and the ease of individuals to have the risk of eating disorders is highly needed, to reduce the number of students who have the risk of eating disorders and to reduce individuals who receive the effects of unhealthy eating habits. references 1. neale j, hudson ld. anorexia nervosa in adolescents. br j hosp med (lond). 2020;81(6):1–8. 2. national institute of mental health. eating disorders [internet]. bethesda, maryland: national institute of mental health; 2016. [cited 2021 november 28]. available from: https://www.nimh.nih.gov/health/topics/ eating-disorders/index.shtml. 3. qian j, wu y, liu f, zhu y, jin h, zhang h, et al. an update on the prevalence of eating disorders in the general population: a systematic review and meta-analysis. eat weight disord . 2022;27(2):415–28. 4. hay p. current approach to eating disorders: a clinical update. intern med j. 2020;50(1):24–9. 5. zipfel s, giel ke, bulik cm, hay p, schmidt u. anorexia nervosa: aetiology, assessment, and treatment. lancet psychiatry. 2015;2(12):1099–111. 6. solmi f, hatch sl, hotopf m, treasure j, micali n. prevalence and correlates of disordered eating in a general population sample: the south east london community health (selcoh) study. soc psychiatry pyschiatr epidemiol. 2014;49(8):1335–46. 7. mcbride o, mcmanus s, thompson j, palmer rl, brugha t. profiling disordered eating patterns and body mass index (bmi) in the english general population. soc psychiatry psychiatr epidemiol. 2013;48(5):783–93. 8. krisnani h, santoso mb, putri d. gangguan makan anorexia nervosa dan bulimia nervosa pada remaja. prosiding penelitian dan pengabdian kepada masyarakat. 2017;4(3):399–447. 9. galmiche m, déchelotte p, lambert g, tavolacci m-p. prevalence of eating disorders over the 2000–2018 period: a systematic literature review. am j clin nutr. 2019;109:1402–13. 10. azrimaidaliza a, helmizar h, yollanda f. meta analysis study of factors relates eating disorders on adolescents. j aisyah. 2021;6(1):17–22. 11. sidiropoulos m. anorexia nervosa: the physiological consequences of starvation and the need for primary prevention efforts. mcgill j med. 2007;10(1):20–5. 12. grau a, magallón-neri e, faus g, feixas g. cognitive impairment in eating disorder patients of short and long-term duration: a case–control study. neuropsychiatr dis treat. 2019;15:1329–41. 13. ptacek r, stefano gb, weissenberger s, akotia d, raboch j, papezova h, et al. attention deficit hyperactivity disorder and disordered eating behaviors: links, risks, and challenges faced. neuropsychiatr dis treat. 2016;12:571–9. 14. donnelly b, touyz s, hay p, burton a, russell j, caterson i. neuroimaging in bulimia nervosa and binge eating disorder: althea medical journal december 2022 althea medical journal. 2022;9(4) 217 a systematic review. j eat disord. 2018;6:3. 15. sardiman am. interaksi & motivasi belajar mengajar. jakarta: pt raja grafindo persada; 2020. 16. micali n, de stavola b, ploubidis g, simonoff e, treasure j, field ae. adolescent eating disorder behaviours and cognitions: gender-specific effects of child, maternal and family risk factors. br j psychiatry. 2015;207(4):320–7. 17. jahrami h, saif z, faris me, levine mp. the relationship between risk of eating disorders, age, gender and body mass index in medical students: a meta-regression. eat weight disord. 2019;24(2):169–77. 18. baroun k, alansari b. gender differences in performance on the stroop test.. soc behav personal. 2006;34(3):309–18. 19. weir k. new insights on eating disorder. am psychol assoc. 2016;47(4):36. 20. kaisari p, dourish ct, rotshtein p, higgs s. associations between core symptoms of attention deficit hyperactivity disorder and both binge and restrictive eating. front psychiatry. 2018;9:103. 21. iceta s, rodrigue c, legendre m, daoust j, flaudias v, michaud a, et al. cognitive function in binge eating disorder and food addiction: a systematic review and three-level meta-analysis. prog neuropsychopharmacol biol psychiatry. 2021;111:110400. 22. datta n, bidopia t, datta s, mittal g, alphin f, marsh ej, et al. meal skipping and cognition along a spectrum of restrictive eating. eat behav. 2020;39:101431. samantha shania and felicia kurniawan: relationship between the risk of eating disorders and the concentration capacity of high school students amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 6 snakebites and the effect of serum anti bisa ular (sabu) antivenom at dr. hasan sadikin general hospital bandung, indonesia: an overview period 2015–2019 sharon noor alya,1 ennyrohmawaty,2 achadiyani,2 muhammad hasan bashari,2 hardisiswo soedjana3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: sharon noor alya, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: sharcademics@gmail.com introduction snakebite is considered a global health issue, although globally there is a lack of data on the total number of the venomous snakebite.1,2 annually in the united states, there are 7,000 to 8,000 venomous snakebites with reported deaths of five to ten cases per year.3,4 the incidence rate of venomous snakebites in southeast asia reaches 1.2 to 5.5 million per year, which is capable of causing 125,000 deaths and tens of thousands of chronic disabilities.5 as one of the largest tropical countries in the world, indonesia has a fairly large potential for snakebite cases.6 as part of the southeast asia region, indonesia has been reported to have 12,739–214,883 cases of snakebite causing up to 11,581 deaths in 2007.7 in indonesia, there were approximately 135,000 cases of snakebite that occurred in 2017.8 the snakebite incidence rate in west java province is considerably high. various snakebite cases were reported in the emergency room (er) of dr. hasan sadikin general hospital with different clinical manifestations, from mild to quite severe to even cause death. literature records reveal that more than 100 species of snakes have been reported from java.9,10 snakebite is a type of case that could evoke plenty of complications hence elevating the althea medical journal. 2022;9(1):6–11 abstract background: snakebite is considered a global health issue, especially in the southeast asian region. however, data regarding snakebite cases in indonesia are still very limited. this study aimed to explore the venomous snakebite cases and the serum anti bisa ular (sabu) antivenom effect in treating venomous snakebite caused by other than the snake species indicated in currently available sabu antivenom formulas. methods: the analytical descriptive method with a cross-sectional study design was conducted in 2021 using a total sampling from the medical records of 63 patients diagnosed with snakebite at dr. hasan sadikin general hospital bandung from 2015 to 2019. characteristics of patients, clinical manifestation, and correlation between snakes species and outcomes after treatment with or without administration of sabu antivenom were collected. results: out of 63 patients, males (79%) were predominant with an average age of 39 years. fifty-six patients arrived at the emergency room less than 24 hours after the occurrence (89%). most cases were categorized as grade 2 (41.%) where the upper extremities were commonly bitten the body area (64%). edema (83%) was the most common manifestation. there was no correlation between snake antivenom administered to a specific snake species and the stated outcome (p=0.053), meaning that sabu antivenom might be an effective alternative to treat more types of snakebites. conclusions: snakebites are most common in males, attack the upper extremities, categorized as grade 2 with edema. administration of sabu antivenom provides the similar outcome compared to the group caused by the javan spitting cobra, banded krait, and malayan pit viper. keywords: sabu, snake antivenom, snakebite https://doi.org/10.15850/amj.v9n1.2392 althea medical journal. 2022;9(1) 7 mortality rate.11 snake venom produces a toxic effect on the body and further complicates the victim’s body from the inflammatory response.12 precise identification, management, and rational usage of antivenom are expected to substantially reduce the mortality and morbidity rate of snakebites.13 antivenom should be administered to all patients with apparent systemic signs and symptoms, including hemostatic disorders, neurotoxic signs, cardiovascular abnormalities, acute kidney failure and/or local chronic symptoms such as progressive and immediate swelling involving more than half of the body part bitten within 48 hours after snakebite occurred.14 the clinical presentations of snakebite victims vary according to the snake species, the number and location of the bites, quantity and toxicity of the venom, as well as the patient’s age and body size. the bigger the size of the patient, the better the outcome due to the less amount of toxin per kilogram of body weight.12 most snakebite patients are men, related to their occupations, there are farmers or those who work in open area, there are also herpeto culture hobbyists and reptile keepers. thus far, all snakebite patients who came to dr. hasan sadikin general hospital, bandung, indonesia were given sabu antivenom, because it is the only type of antivenom available in indonesia, specifically in western indonesia. sabu antivenom is indicated for snakebites by three most common types of venomous snakes namely javan spitting cobra, banded krait, and malayan pit viper (polyvalent). aside from these three snakes, indonesia has not yet produced antivenoms that are more specific for other types of venomous snakes.15 several countries in southeast asia such as thailand12 and the philipines16 are known to produce their snake antivenoms but with a slightly different set of snake species. according to the world health organization (who),5 snakebite is suggested to be made a certain case that must be reported in all regions of southeast asia, because more than 95% of snakebite cases occur in tropical and/or developing countries. since 2017, snakebite has been categorized as a neglected tropical disease category a. however, in indonesia there has not been a proper national epidemiological reports. there is almost no epidemiological data for snakebites and the data obtained are only hospital-based case reports. many factors could determine the accuracy of information from the reported cases, such as the number of snakebite cases occurring in rural areas, traditional medicine practice, or some patients who never come to the hospital. as a result, the real issue of snakebites might be bigger than expected.17–19 this study aimed to acknowledge the overview of venomous snakebite cases and the effect of the serum anti bisa ular (sabu) antivenom in treating venomous snakebite other than the snake species indicated in the sabu formula available. methods this research used descriptive-analytical method with cross-sectional study design. total data were collected from the medical records of patients diagnosed with snakebite at dr. hasan sadikin general hospital in the 2015–2019 period using the international classification of diseases (icd) 10 code t63. only complete data were included, meaning that information such as age, gender, complaints, type of snake, prehospital time, grade of severity, area of body bitten, administration of sabu antivenom, and outcome should be clearly mentioned in the medical records. the grade of severity used was based on the snakebite severity score (sss) which was divided into 4 grades.20,21 grade 1 (minor) indicated no occurrence of symptoms. in this condition, snakebite wound usually did not cause local or systemic reactions. grade 2 (moderate) indicated local symptoms of mild envenomation such as bite marks, moderate pain, mild local edema with a diameter of 0–15 cm, redness, ecchymosis, and no systemic reaction. grade 3 (severe) progressed further to cause regional symptoms including bite marks, severe pain, moderate local edema with a diameter of 15–30 cm, redness, ecchymosis, systemic weakness, sweating, syncope, nauseous, vomiting, anemia or thrombocytopenia. whereas grade 4 (major) was indicated by bite marks, severe pain, severe local edema (>30 cm), redness, ecchymosis, hypotension, paresthesia, coma, lung edema, and respiratory failure. several factors might affect the grading of severity and outcome of snake envenomation such as the size of patient’s body, comorbidities, body area bitten, physical training, individual sensitivity, type of snake, secondary infection, and treatment administered.12 out of all snakebite patients who were included in the study, there were 63 distinguished patients with the complete records. the correlation between snakebite of particular types of snake administered antivenom and patients outcomes was sharon noor alya et al.: snakebites and the effect of serum anti bisa ular (sabu) antivenom at dr. hasan sadikin general hospital bandung, indonesia: an overview period 2015–2019 althea medical journal. 2022;9(1) 8 table 1 characteristics of snakebite patients characteristic n=63 n % age, average (year) 39.27 gender male female 50 13 79 21 prehospital time <6 hours 6–24 hours >24 hours 29 27 7 46 43 11 grade of severity 0 1 2 3 4 4 6 26 24 3 6 10 41 38 5 area of body bitten upper extremities lower extremities other 40 21 2 64 33 3 conducted using the chi-square method. the study has been approved by the ethics committee of dr. hasan sadikin general hospital with a number of approval 1191/ un6.kep/ec/2020. results from 2015 to 2019, 66 medical records of snakebite patients were obtained at dr. hasan sadikin general hospital. out of 66, only 63 records were completed with information on the type of snake that caused the bite. in the following study, the average age of snakebite patients was 39 years. a total of 50 patients were male (79%). more than 50% of patients arrived at the emergency room of dr. hasan sadikin general hospital in less than 24 hours, collectively 56 patients (89%). the most common grade of severity found was grade 2 as many as 26 cases (41%) with the most common body area bitten occurring in the upper extremities (64%). data explanation regarding the characteristics of snakebite patients was presented in table 1. the percentage of each clinical manifestation that occurred in the snakebite patients was shown in table 2. each subject might have multiple complaints. the most often clinical manifestation was edema with a total of 52 patients (83%). number of patients who were given the sabu antivenom and those who were not, based on the type of snake that caused the table 2 clinical manifestations in snakebite patients complaints n % edema headache nausea sensory disturbance hemorrhage vision impairment loss of consciousness shortness of breath 52 18 17 12 11 7 6 5 83 29 27 19 18 11 10 8 althea medical journal march 2022 althea medical journal. 2022;9(1) 9sharon noor alya et al.: snakebites and the effect of serum anti bisa ular (sabu) antivenom at dr. hasan sadikin general hospital bandung, indonesia: an overview period 2015–2019 bite was depicted in table 3. there were 36 patients who were bitten by snakes that had no indication of antivenom, and were given the antivenom. the outcome of snakebite patients who were given sabu was shown in table 4. as many as 36 snakebite patients who were bitten by other than the three snakes indicated an outcome of recovery or improvement. there was no correlation between the administration of sabu antivenom and the type of snake (p= 0.053). discussion this study has shown that the snakebite occurred most commonly in male of average age in the workingclass population. the average patients arriving at the hospital is less than 24 hours. administration of sabu antivenom to snakebites caused by other than the javan spitting cobra, banded krait, and malayan pit viper was able to provide the same outcome as the three main indicated snakes. presuming that a wider scope of data collection on snakebite cases will be done, thus the distribution of antivenom in indonesia could be further acknowledged for more immediate and effective management. in this study, the age of patients ranged from one to ninety years with an average of 39.27 years. in addition, snakebites are often experienced by men. this could be because the majority of the patients were bitten while they were in the rice fields or doing activities, so that more than 50% of the patients were working age population. snakebites in indonesia often occur in plant farmers in plantations or rice farmers in rice fields.15 in this study, most of the adult patients were attacked at work, students got struck while playing on the farm, and some patients confessed to keeping snakes as pets and were bitten while playing or participating in snake contests. this activity also explains why most bites are found in the upper extremities. collectively, 89% of patients were brought to the er in less than 24 hours. public awareness towards the emergency of snakebite is adequate, although sometimes traditional medicine is still carried out before being taking to the hospital. patients who come more than 6 hours after being bitten might be because the incident was far from bandung city, for example in west bandung regency. treatments include tying knots over the the bitten body area, sucking the blood out, covering the wound with certain leaves or herb, and even incising the bite wound area. the management of first aid that is most often carried out by patients is the use of tourniquet, even though it is not accordance with the who guidelines.5 in the data collection process, it is rather difficult to ruling out the exact type of snake that caused the bite based on the anamnesis, hence it is decided only by looking at the snake color. however, some data from medical records show some non-specific characteristics of snake. nevertheless, it could be roughly pinpointed that the green-colored snake in indonesia is most likely a green pit viper (trimeresurusalbolabris), a black snake is referred to as the cobras (naja sumatrana and naja sputatrix), and the brown striped or brown-colored snakes might be the pit viper (calloselasmarhodostoma). based on the data collected, almost table 3 total of patients treated with and without sabu antivenom type of snake sabu without sabu total javan spitting cobra, banded krait, malayan pit viper other snakes total 20 36 56 4 3 7 24 39 63 table 4 correlation between the type of snakes and the outcome type of snake recovery/improvement deceased total p-value javan spitting cobra, banded krait, malayan pit viper other snakes total 18 36 54 2 0 2 20 36 56 0.053 althea medical journal. 2022;9(1) 10 every snakebite with the grade of severity above 1 was given the sabu antivenom regardless of the type of snakes. indications for administration of antivenom such as hemostatic disorders, neurotoxic signs, cardiovascular abnormalities, acute kidney failure, hemoglobinuria, myoglobinuria, local swelling of more than half of the body area bitten within 48 hours after the occurrence, progressive swelling immediately, and enlarged lymph nodes. a total of 54 patients recovered or improved after being given the antivenom. the correlation between the outcome of antivenom administration and snakebite with certain types of snakes is not significant (p=0.053). sabu available in indonesia is only indicated to neutralize the neurotoxins produced by naja sputatrix, bungarusfasciatus, and hemotoxins produced by agkistrodonrhodostoma, however the same outcome was acquired in snakebites caused by the type of snakes that was not indicated in the antivenom formula. previous related studies stated that the sabu antivenom was not effective in neutralizing the venoms produced by snake species inhabiting eastern indonesia area such as acanthopisantarticus, xyuranusscuttelatus, pseudechispapuanus, and enhydrinacystsa.8 the limitation of this study is secondary data, so that a clear overview of the anamnesis, especially the type of snake could not be obtained. low prevalence due to limited cases, as there are not many documented. however, this is an overview of the referral hospital showing the result of antivenom management. for further research, it is better to obtain more complete data by looking for newer cases or maintaining the quality of completeness of medical records document. to conclude, snakebite most commonly occur in men with ann average age of workingclass population who arrived at the hospital less than 24 hours. administration of sabu antivenom for snakebites caused by other than javan spitting cobra, banded krait and malayan pit viper is able to provide the similar outcome to the three main indicated snakes, suggesting that antivenom in indonesia could be further acknowledged for faster and effective management. references 1. nikapitiya b, maduwage k. pharmacodynamics and pharmacokinetics of snake antivenom. sri lanka j med. 2018;27(1):54–65. 2. meyers se, tadi p. snake toxicity [updated 2021 jan 31]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2021. [cited 2021 may 17]. available from: https://www.ncbi.nlm.nih. gov/books/nbk557565/ 3. warrell da. venomous bites, stings, and poisoning: an update. infect dis clin north am. 2019;33(1):17–38. 4. bawaskar hs, bawaskar ph. snakebite envenoming. lancet. 2019;393(10167):131. 5. world health organization regional office for south-east asia. guidelines for the management of snake-bites. 2nd ed. new delhi: world health organization, regional office for south-east asia; 2016. 6. silva a, marikar f, murugananthan a, agampodi s. awareness and perceptions on prevention, first aid and treatment of snakebites among sri lankan farmers: a knowledge practice mismatch? j occup med toxicol. 2014;9:20. 7. sharma sk, chappuis f, jha n, bovier pa, loutan l, koirala s. impact of snake bites and determinants of fatal outcomes in southeastern nepal. am j trop med hyg. 2004;71(2):234–8. 8. adiwinata r, nelwan ej. snakebite in indonesia. acta med indones. 2015;47(4):358–65. 9. uetz p, freed p, aguilar r, hošek j, editor. the reptile database [internet]. 2021. [cited 2022 march 6]. available from: http://www.reptile-database.org. 10. kurniawan n, fathoni m, fatchiyah f, aulani a, septiadi l, smith en. composition, distribution, and habitat type of snakes in java, with discussion on the impact of human-snake interactions during 2013– 2019. herpetology notes. 2021;14:691– 711. 11. roberts n, johnson e, zeng s, hamilton e, abdoli a, alahdab f, et al. mortality from snakebite envenomation: an analysis from the global burden of disease study 2019. research square. 2021. [cited 2022 march 6]. available from: https://www. researchsquare.com/article/rs-1021472/ v1. 12. ahmed sm, ahmed m, nadeem a, mahajan j, choudhary a, pal j. emergency treatment of a snake bite: pearls from literature. j emerg trauma shock. 2008;1(2):97–105. 13. kasturiratne a, wickremasinghe ar, de silva n, gunawardena nk, pathmeswaran a, premaratna r, et al. the global burden of snakebite: a literature analysis and althea medical journal march 2022 althea medical journal. 2022;9(1) 11 modelling based on regional estimates of envenoming and deaths. plos med. 2008;5(11):e218. 14. rojnuckarin p, suteparak s, sibunruang s. diagnosis and management of venomous snakebites in southeast asia. asian biomed. 2012;6(6):795–805. 15. kumar mr, veeraprasad m, babu pr, kumar ss, subrahmanyam b, rammohan p, et al. a retrospective review of snake bite victims admitted in a tertiary level teaching institute. ann afr med. 2014;13(2):76–80. 16. tan ch, palasuberniam p, blanco fb, tan ky. immunoreactivity and neutralization capacity of philippine cobra antivenom against naja philippinensis and naja samarensis venoms. trans r soc trop med hyg. 2021;115(1):78–84. 17. tan ch, liew jl, tan ky, tan nh. assessing sabu (serum anti bisa ular), the sole indonesian antivenom: a proteomic analysis and neutralization efficacy study. sci rep. 2016;6:37299. 18. chippaux j-p. snakebite envenomation turns again into a neglected tropical disease! j venom anim toxins incl trop dis. 2017;23:38. 19. bagcchi s. experts call for snakebite to be re-established as a neglected tropical disease. bmj. 2015;351:h5313. 20. peterson n. venomous snake bites. in: bruyette ds, bexfield n, chretin jd, kube s, owen tj, peterson n, et al, editors. clinical small animal internal medicine. hoboken: john wiley & sons; 2020. p. 459–65. 21. afni acn, sani fn. pertolongan pertama dan penilaian keparahan envenomasi pada pasien gigitan ular. j kesehat kusuma husada. 2020;11(1):91–8. sharon noor alya et al.: snakebites and the effect of serum anti bisa ular (sabu) antivenom at dr. hasan sadikin general hospital bandung, indonesia: an overview period 2015–2019 amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 49 lung abnormalities in systemic sclerosis patients through spirometry, chest x-ray, and high-resolution computed tomography scan sumartini dewi,1,3 waliyyuddin robbani,2 iceu dimas kulsum1 1department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3immunology study center, faculty of medicine universitas padjadjaran, indonesia correspondence: dr. sumartini dewi, dr., sp.pd-kr., m.kes, department of internal medicine, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur no. 38, bandung, indonesia, e-mail: sumartini.dewi@unpad.ac.id introduction systemic sclerosis (ssc) is a chronic progressive multisystem autoimmune disease with heterogenous clinical manifestations.1,2 the etiologies are multifactorial, including genetic and environmental.3 the pathophysiological processes that occur are endothelial dysfunction, autoimmunity and the fibrosis process.4,5 based on skin involvement, clinical manifestations, and laboratory examination results, ssc is divided into two subtypes: diffuse cutaneous ssc (dcssc) and limited cutaneous ssc (lcssc).1 ssc can affect all system organs in the body.6 pulmonary organ manifestations frequently occur, but the symptoms are non-specific. symptoms can be fatigue, dry cough, or shortness of breath.7,8 early detection of organ involvement in ssc is essential.9 patients diagnosed early and receiving prompt therapy can minimize the possibility of irreversible organ damage.6 in a study conducted on 953 systemic sclerosis patients, subjects with severe interstitial lung disease (ild) have a poor prognosis.8 another study has shown that one of two main leading causes of death in ssc patients are ild.10 radiological examination and pulmonary function tests (spirometry) are needed to detect lung abnormalities in ssc patients.11 spirometry is more affordable than other modalities because the tools are widely available; however, the obtained results cannot rule out extrapulmonary abnormalities such as skin disorders.12 a tuberculosis-like appearance often appears on chest x-ray althea medical journal. 2022;9(1):49–54 abstract background: systemic sclerosis (ssc) is a multisystem autoimmune illness with a wide range of clinical symptoms. the pulmonary organ manifestations frequently occur, but the symptoms are nonspecific. radiological examination and pulmonary function tests (spirometry) are needed to detect lung abnormalities in ssc patients. this study aimed to obtain information about the overview of lung abnormalities in ssc patients through spirometry, chest x-ray, and high-resolution computed tomography (hrct) scan examination. methods: a descriptive qualitative study was conducted on 75 ssc patients registered in dr. hasan sadikin general hospital bandung from january 2019 to december 2020. data were collected with a total sampling method and presented in proportions and percentages. results: the majority of subjects were affected by cutaneous 73 (97%), pulmonary 29 (39%), and musculoskeletal 17 (23%) involvement. spirometry revealed that 43 subjects (57%) had restrictive lung disease, with one false-positive case and two false-negative cases. on a chest x-ray, 45 (60%) of subjects had abnormalities. the majority of subjects were found to have ground-glass opacities on hrct scans. ground-glass opacities were discovered in 46 subjects (82%) and 27 subjects (60%) were identified as having severe fibrosis scores. conclusion: according to spirometry results and abnormalities on chest x-ray and hrct scans, the majority of ssc patients have restrictive lung disease. keywords: chest x-ray, hrct scan, interstitial lung disease, sclerosis systemic, spirometry https://doi.org/10.15850/amj.v9n1.2509 althea medical journal. 2022;9(1) 50 examination resulting in misdiagnosis.13 chest x-rays also cannot detect early ild.14 highresolution computed tomography (hrct) scan requires sophisticated equipment and is limited only to a few large hospitals; however, it should still be performed because it is the gold standard for detecting ild disorders.15–16 research on overview of lung abnormalities on systemic sclerosis patients through spirometry, chest x-ray, and high-resolution computed tomography scan has not been widely studied in indonesia. this study is expected to add information about the overview of lung abnormalities in ssc patients. the study results are expected to form the basis of future studies and help clinicians be aware of ild incidence. this study aimed to obtain information about the overview of lung abnormalities in ssc patients through spirometry, chest x-ray, and hrct scan examination. methods a descriptive qualitative study was conducted on 75 ssc patients obtained from the patient registry in dr. hasan sadikin general hospital bandung from january 2019 to december 2020. data were collected with a total sampling method; proportions and percentages were presented in tables. the inclusion criteria were spirometry examination, chest x-ray, and hrct scan data in the systemic sclerosis patient registry. exclusion criteria were intrapulmonary and extrapulmonary conditions that were not caused by ssc, such as pulmonary tuberculosis or lung tumors and other lung infections. variables used in this study were clinical characteristic (age, sex, modified rodnan skin score, ssc subtype and clinical manifestation) and examination result (spirometry, chest x-ray and hrct scan). age used in this study was the age of subjects when they were admitted to the rheumatology clinic dr. hasan sadikin general hospital, bandung. sex consisted of male and female. the modified rodnan skin score (mrss) used in this study was the mrss of subjects when they were admitted to the rheumatology clinic dr. hasan sadikin general hospital, bandung. ssc subtype consisted of a diffuse and limited type. clinical manifestations consisted of skin, respiration, musculoskeletal, gastrointestinal, and cardiovascular. spirometry examination results consisted of restrictive lung disease and were graded based on severity. chest x-ray consisted of normal and abnormal based althea medical journal march 2022 on radiologist expertise. likewise, hrct scan consisted of normal and abnormal based on radiologist expertise. this study was approved by the ethics committee of universitas padjadjaran bandung, indonesia (no. 928/un6.kep/ ec/2020) and obtained the research licensing letter issued by the research ethics committee of dr. hasan sadikin general hospital bandung (no. lb.02.01/x.2.2.1/2271/2021). results the study result showed that the majority of subjects were female (97%). the mean age of the subjects was 39.08±13.52 years. furthermore, the median mrss score of the subjects was 15 (0–39). most of the subjects had a diffuse type of ssc of 63%. the most common clinical manifestations were skin disorders 97%, respiratory disorders 39%, and musculoskeletal disorders 23% (table 1). the spirometry examination showed that most subjects had restrictive lung disease (57%) (table 2). from chest x-ray examinations, 30 subjects (40%) had normal results and 45 (60%) had abnormal results (table 3). there were 19 subjects (25%) of the 75 subjects who did not undergo an hrct scan. only 56 subjects (75%) underwent hrct scan examination. the most common lung abnormality based on hrct scan was groundglass opacities (ggo) in 46 subjects (82%) (table 4). there were 30 subjects (40%) with fibrosis scores that were not calculated, while most of the subjects with a score that was calculated (27 subjects, 60%) had severe pulmonary fibrosis (table 5). discussion this study showed a significant difference in gender among all patients at the rheumatology clinic dr. hasan sadikin general hospital, bandung. the ratio of male and female was 73 and 2. this is consistent with a cohort study conducted by eular scleroderma trials and research (eustar) in 2011 in europe, where the incidence of ssc in women was greater than that of men.17 based on the subtype, diffuse ssc is the most common, this finding is appropriate with literature that states the diffuse type of ssc is the most common subtype of ssc.5 there were 73 subjects (97%) who had skin disorders, 29 subjects (39%) with respiratory althea medical journal. 2022;9(1) 51sumartini dewi et al.: lung abnormalities in systemic sclerosis patients through spirometry, chest x-ray, and high-resolution computed tomography scan table 1 clinical characteristic of systemic sclerosis patients characteristics total (n=75) n (%) age on average (years) 39.08±13.52 gender female male 73 (97) 2 (3) mrss score median 15 (0–39) ssc subtype diffuse limited 47 (63) 28 (37) clinical manifestation skin skin stiffness raynaud’s phenomenon sclerodactyly fish mouth salt and pepper appearance digital scar telangiectasia sausage fingers ulkus digity post inflammation hyperpigmentation 73 (97) 67 (89) 62 (83) 60 (80) 44 (59) 35 (47) 33 (44) 29 (39) 25 (33) 23 (31) 6 (8) respiration interstitial lung disease dyspnea dry cough pulmonary hypertension pleural effusion 29 (39) 20 (27) 18 (24) 11 (15) 7 (9) 1 (1) musculoskeletal arthralgia joint stiffness myopathy 17 (23) 15 (20) 5 (7) 1 (1) gastrointestinal dry mouth nausea decreased body weight bloating vomiting esophageal dysmotility 7 (9) 4 (5) 2 (3) 2 (3) 2 (3) 1 (1) 1 (1) cardiovascular chest pain palpitation constrictive pericarditis congestive heart failure 4 (5) 1 (1) 1 (1) 1 (1) 1 (1) n/a 2 (3) note: most of the subjects had overlapping clinical examinations, mrss=modified rodnan skin score disorders, and 17 subjects (23%) with musculoskeletal disorders. this is appropriate with the literature that states skin disorders, respiratory disorders, and musculoskeletal disorders are the most common manifestations in ssc subjects.6 based on pulmonary function tests (spirometry), 43 subjects (57%) had restrictive lung abnormalities. one subject had normal spirometry results with abnormal chest hrct scan result, which was mild pulmonary fibrosis. two subjects had mild restrictive spirometry examination results with normal chest scan hrct results. suliman et al.18 in their study at the zürich university hospital, state that spirometry is only able to detect 59 of 102 ssc-ild patients. errors in the detection of lung abnormalities in these ssc patients are partly due to the low level of sensitivity and the limitations of the spirometry device, which cannot distinguish the cause of the restriction whether it is due to lung abnormalities, or from the stiffness of the chest and abdominal skin that is common in ssc patients.18 in this study, some subjects had mild restrictive spirometry results, but their chest scan hrct results were normal. these subjects had skin disorders in the form of diffuse cuticle sclerosis that affects the chest wall and abdomen. this suggests that spirometry has limitations and can show false positive or false negative results, and can lead to false diagnosis if used as the primary modality in ssc-ild detection. on chest x-ray, 45 subjects (60%) had abnormal results, and 30 subjects (40%) had normal results. in the group of subjects with normal chest x-ray, 16 subjects (21%) had abnormal hrct scan results. in the group of subjects with normal chest x-ray but abnormal hrct scan results, 9 subjects (12%) had table 2 spirometry results of systemic sclerosis patients spirometry results total (n=75) n (%) normal 3 (4) restrictive lung diseases mild moderate severe very severe 43 (57) 19 (25) 24 (32) 0 0 n/a 29 (39) note: n/a= not available; not all subjects undergo spirometry examination althea medical journal. 2022;9(1) 52 restrictive spirometry results; restrictive mild in 4 subjects (5%) and moderate restrictive in 5 subjects (7%). a study conducted by morales-cárdenas et al.19 mentions that the hrct scan can detect ssc-ild at the disease onset. this suggests that chest x-ray examination is not accurate in detecting sscild at the onset of the disease. however, the spirometry examination as an additional modality can increase accuracy in ssc-ild diagnosis, especially in health facilities that do not have access to hrct chest scans or at ssc patients who cannot perform hrct thoracic scans.20 four subjects (5%) had a chest x-ray image of active tb in this study. according to a study conducted by agrawal et al.13 in 2019, the radiological features of ild are similar to pulmonary tuberculosis, so misdiagnosis often occurs. when a chest hrct scan is performed on a subject who has a chest x-ray in the form of active tb, there is no visible table 3 chest x-ray results of systemic sclerosis patients variables total (n=75) n (%) proportion chest x-ray resultsb normal pattern 30 (40) 0.400 abnormal cardiomegaly bronchopneumonia suggestive ild bronchitis pleural effusion aortic atherosclerosis tuberculosis pneumonia 45 (60) 22 (29) 9 (12) 8 (10) 7 (9) 6 (8) 6 (8) 4 (5) 3 (4) 0.600 0.293 0.120 0.106 0.093 0.080 0.080 0.053 0.040 note: some subjects have more than one abnormality on chest x-ray, ild=interstitial lung disease table 4 hrct scan results of the systemic sclerosis patients hrct scan results total (n=56) n (%) proportion ground glass opacities bronchiectasis irregular pleural margins honeycombing subpleural cyst subpleural lines 46 (82) 35 (62) 13 (23) 8 (14) 6 (11) 2 (3) 46 (82) 35 (62) 13 (23) 8 (14) 6 (11) 2 (3) note: not all subjects undergo hrct scan examination and most of the subjects has more than one lung abnormality based on hrct scan examination, hrct=high-resolution computed tomography table 5 fibrosis severity score based on hrct scan examination of systemic sclerosis patients variables total (n=45) n (%) proportion normal mild moderate severe 2 (4) 7 (15) 9 (20) 27 (60) 0.044 0.155 0.200 0.600 note: not all hrct scan results are calculated for the degree of pulmonary fibrosis althea medical journal march 2022 althea medical journal. 2022;9(1) 53 infiltrate characteristic of tb infection. this suggests that chest x-rays cannot differentiate infiltrates due to ssc fibrosis or from tb infection and may cause errors in the diagnosis of pulmonary abnormalities in ssc patients. on the chest hrct scan, the most common type of lung lesion in ssc patients with pulmonary abnormalities was the type of ggo lesion, which were 46 subjects (82%). this is consistent with the study conducted by sambataro et al.21 in 2020, which states that the type of ggo lesions often appears on the chest hrct scan of ssc patients with pulmonary abnormalities. this study is a qualitative descriptive study that evaluates data from spirometry, chest x-ray, and hrct scan recorded in the systemic sclerosis patient registry; however, not all subjects undergo chest x-ray or chest hrct examination, so that not all results are recorded. the subject’s condition when performing spirometry examination was not recorded in the systemic sclerosis patient registry. this can lead to bias since several intrapulmonary and extrapulmonary conditions do not result from ssc, such as skin and muscle stiffness at the chest and abdominal wall, pregnancy, and spine abnormalities affecting chest expansion.12 all data taken are only based on the sclerosis systemic patient registry, which may cause errors in data input actions. data errors have been minimized by cross-checking with data from the respirology division for spirometry results and radiology department for chest x-ray and hrct scan results. some subjects did not undergo supporting examinations at hospital, so the incomplete data could not be searched in the patient’s medical record. in conclusion, most ssc patients have restrictive lung disease based on spirometry examination, and abnormality based on chest x-ray and hrct scan examination. the hrct scan examination remains the gold standard in a suspected interstitial lung disease case. furthermore, spirometry and chest x-ray cannot detect early interstitial lung disease. spirometry cannot distinguish the causes of restrictive lung disease resulting from ssc or skin abnormalities in ssc patients. further study is needed to explore the lung abnormalities in systemic sclerosis using various modalities. funding internal research grant from universitas padjadjaran. references 1. kasper d, fauci a, longo d, hauser s, jameson j, loscalzo j. harrison’s principles of internal medicine. 19th ed. new york: mcgraw-hill; 2015. p. 2154–5. 2. dewi s, isbagio h, purwaningsih eh, kertia n, setiabudy r, setiati s. a doubleblind, randomized controlled trial of ciplukan (physalis angulata linn) extract on skin fibrosis, inflammatory, immunology, and fibrosis biomarkers in scleroderma patients. acta med indones. 2019;51(4):303–10. 3. fett n. scleroderma: nomenclature, etiology, pathogenesis, prognosis, and treatments: facts and controversies. clin dermatol. 2013;31(4):432–7. 4. kumar v, abbas a, aster j. robbins and cotran pathologic basis of disease. 9th ed. philadelphia: elsevier; 2014. 5. padmandani wpa, dewi s, hamijoyo l. correlation between serum c-reactive protein (crp) and soluble cd40 ligand (scd40l) with disease activity by modified rodnan skin score (mrss) in systemic sclerosis patients in indonesia. ina j rheum. 2018;10(2). [cited 2021 january 28]. available from: https:// journalrheumatology.or.id/index.php/ijr/ article/view/100. 6. budiman am, dewi s, prananta ms. clinical manifestation and laboratory finding of sclerosis systemic patient in dr. hasan sadikin general hospital bandung: a descriptive quantitative study. ina j rheum. 2018;10(1):15–9. 7. hant fn, herpel lb, silver rm. pulmonary manifestations of scleroderma and mixed connective tissue disease. clin chest med. 2010;31(3):433–49. 8. hassoun pm. lung involvement in systemic sclerosis. presse med. 2011;40(1 pt 2):e3– 17. 9. khanna d. diagnosis and treatment of systemic and localized scleroderma. expert rev dermatol. 2011;6(3):287–302. 10. bussone g, mouthon l. interstitial lung disease in systemic sclerosis. autoimmun rev. 2011;10(5):248–55. 11. solomon jj, olson al, fischer a, bull t, brown kk, raghu g. scleroderma lung disease. eur respir rev. 2013;22(127): 6–19. 12. wong cj, hamlin np, editors. the perioperative medicine consult handbook. new york: springer; 2013. 13. agrawal n, dave l, shrivastava n, sharma sumartini dewi et al.: lung abnormalities in systemic sclerosis patients through spirometry, chest x-ray, and high-resolution computed tomography scan althea medical journal. 2022;9(1) 54 p. study of clinico-radiological profile of interstitial lung disease patients attending crgh ujjain. int j med sci diagnosis res. 2019;3(12):25–30. 14. vizioli l, ciccarese f, forti p, chiesa am, giovagnoli m, mughetti m, et al. integrated use of lung ultrasound and chest x-ray in the detection of interstitial lung disease. respiration. 2017;93(1):15–22. 15. varga j, denton cp, wigley fm, allanore y, kuwana m, editors. scleroderma: from pathogenesis to comprehensive management. 2nd ed. cham, switzerland: springer international publishing; 2017. 16. assayag d, kaduri s, hudson m, hirsch a, baron m. high resolution computed tomography scoring systems for evaluating interstitial lung disease in systemic sclerosis patients. rheumatology. 2012;(s1):003. 17. meier fmp, frommer kw, dinser r, walker ua, czirjak l, denton cp, et al. update on the profile of the eustar cohort: an analysis of the eular scleroderma trials and research group database. ann rheum dis. 2012;71(8):1355–60. 18. suliman ya, dobrota r, huscher d, nguyen-kim tdl, maurer b, jordan s, et al. pulmonary function tests: high rate of false-negative results in the early detection and screening of sclerodermarelated interstitial lung disease. arthritis rheumatol. 2015;67(12):3256–61. 19. morales-cárdenas a, pérez-madrid c, arias l, ojeda p, mahecha mp, rojasvillarraga a, et al. pulmonary involvement in systemic sclerosis. autoimmun rev. 2016;15(11):1094–108. 20. yani h, dewi s, rahmadi ar. correlation between serum krebs von den lungen-6 levels with forced vital capacity and modified rodnan skin score of patients with restrictive lung disease in diffusetype systemic sclerosis. ina j rheum. 2019;11(2):145–7. 21. sambataro d, sambataro g, pignataro f, maglione w, malatino l, vancheri c, et al. quantification of ground glass opacities can be useful to describe disease activity in systemic sclerosis. diagnostics (basel). 2020;10(4):225. althea medical journal march 2022 amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 206 distribution of rifampicin-resistant tuberculosis patients based on presumptive drug-resistant tuberculosis criteria at dr. hasan sadikin hospital 2016–2019 dinda nursyafira misyatin,1 arto yuwono soeroto,2 ferdy ferdian2 1faculty of medicine universitas padjadjaran, indonesia, 2departement of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: dinda nursyafira misyatin, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km 21, jatinangor, sumedang, indonesia, e-mail: dinda17009@mail.unpad.ac.id introduction tuberculosis (tb), an infectious disease caused by mycobacterium tuberculosis, is still a significant health problem in indonesia. this disease ranks third in the world after india and china. in 2018, approximately 845,000 cases were reported in indonesia, of which 240,000 cases were drug-resistant (dr)-tb. the high number of dr-tb makes the disease still a burden,1 with the highest tb incidence rate in west java province. dr. hasan sadikin general hospital bandung has been the primary referral for dr-tb in west java since 2012. there are 15,393 presumptive dr-tb patients and 1,779 dr-tb patients in 2012–2019.2 diagnosis of dr-tb begins with identifying presumptive dr-tb patients with one or more of 9 presumptive dr-tb criteria based on the regulation of the ministry of health of the republic of indonesia no. 67/2016.3 xpert mtb/rif has tested the presumptive dr-tb patients to detect the resistance. moreover, xpert mtb/rif gives ct values as a potential measure of bacterial burden.4 the bacterial load before treatment affects the time needed for the eradication.5 the information about ct values among nine presumptive dr-tb criteria can be a reference for clinicians to focus more on specific criteria, which can result in a higher treatment success rate. this study aimed to identify the distribution of rr-tb patients based on nine presumptive dr-tb criteria and xpert mtb/rif ct values at dr. hasan sadikin general hospital bandung. methods this descriptive study collected and analyzed data from the e-tb manager and medical althea medical journal. 2022;9(4):206–211 abstract background: diagnosis of drug-resistant tuberculosis (dr-tb) begins with identifying presumptive dr-tb patients using xpert mtb/rif, as a diagnostic test to detect resistance to rifampicin. the study aimed to identify the distribution of rifampicin-resistant tuberculosis (rr-tb) patients based on presumptive dr-tb criteria at dr. hasan sadikin general hospital bandung. moreover, this study also explored the xpert mtb/rif ct values. methods: this was a descriptive-retrospective study from 570 medical records of dr-tb patients collected at the multidrug-resistant tuberculosis (mdr-tb) clinic of dr. hasan sadikin general hospital from 2016 to 2019. the inclusion criteria were suspected patients with the xpert mtb/rif ct values in the very low-low and medium-high categories. data were analyzed using frequency distribution. results: the most common presumptive dr-tb criteria among dr-tb patients were relapse cases (52.3%). presumptive dr-tb criteria, with a high percentage result of medium-high ct values, were category ii treatment failure (80.9%). conclusion: relapse case and category ii treatment failure are presumptive dr-tb criteria, which need more attention from clinicians. keywords: presumptive dr-tb criteria, tuberculosis, xpert mtb/rif ct values https://doi.org/10.15850/amj.v9n4.2593 althea medical journal. 2022;9(4) 207 records of the dr-tb patients in the mdr-tb clinic at dr. hasan sadikin general hospital, bandung, west java, indonesia. the data collected was from 2016 to 2019, using the total sampling method. the inclusion criteria of this study were all medical records of dr-tb patients that had information about the patient’s presumptive dr-tb criteria and xpert mtb/rif ct values. incomplete medical records were excluded. this study was approved by the health research ethics committee universitas padjadjaran, with ethical clearance no. 835/un6.kep/ec/2020. the nine presumptive dr-tb criteria were based on the ministry of health regulation no. 67/2016. the nine criteria consisted of category ii treatment failure, tb patients whose sputum remained smear-positive after three months of treatment, those with a history of non-standard treatment, and those who used quinolones or 2nd line drug injection for at least one month. included was the category i treatment failure: tb patients whose sputum remained smear-positive after two months of treatment, relapsed, returned after default, and presumptive tb close contacts of a known dr-tb patient, and tb-human immunodeficiency virus (hiv) co-infection who was unresponsive to tb treatment. the frequency and percentage of each presumptive dr-tb criteria were calculated. ct values were semi-quantitative, which provided results that categorized values as high (ct≤16), medium (16<ct≤22), low (22<ct≤28), and very low (28<ct≤38). the categorization of xpert mtb/ rif ct values of each presumptive dr-tb in this study was high-medium (ct ≤ 22) and lowvery low (ct > 22). presumptive dr-tb criteria and xpert mtb/rif ct values were analyzed using descriptive statistical analysis. results in total, 570 medical records on presumptive dr-tb throughout 2016–2019 were analyzed. the most common presumptive dr-tb criteria which gave a positive result for dr-tb were relapse cases (52.3%). next, was the category i treatment failure (16.7%), and the return after default (14.0%) (table 1). interestingly, relapse cases had a high number in both medium-high and very low-low ct values (figure 1). xpert mtb/rif was used to test patients, which gave ct values that were representative of the bacterial burden. the criteria for presumptive tb-dr had a high percentage of having a high bacterial burden based on xpert mtb/rif ct values (table 2). the criteria for presumptive dr-tb with a high percentage of medium-high ct values were category ii treatment failure (80.9%). then, the following were tb patients whose sputum remained smear-positive after two months of category i treatment (75.0%), category i treatment failure (73.6%) and relapse case (72.2%) (table 2). table 1 frequency of patients at dr. hasan sadikin general hospital period 2016–2019 based on presumptive dr-tb criteria (minister of health decree no. 67/2016)3 presumptive dr-tb criteria dr-tb patient (n=570) n % 1. category ii treatment failure 21 3.7 2. tb patients whose sputum remains smear-positive after 3 months of category ii treatment 16 2.8 3. tb patients who have a history of non-standard treatment and use quinolones or 2nd line drug injections for at least one month 18 3.2 4. category i treatment failure 95 16.7 5. tb patients whose sputum remains smear-positive after two months of category i treatment 32 5.6 6. relapse 298 52.3* 7. return after default 80 14.0 8. presumptive tb close contacts of a known dr-tb patient 8 1.4 9. tb-hiv co-infection who did not respond to tb treatment 2 0.3 note. * the most common presumptive dr-tb criteria dinda nursyafira misyatin et al.:distribution of rifampicin-resistant tuberculosis patients based on presumptive drug-resistant tuberculosis criteria at dr. hasan sadikin hospital 2016–2019 althea medical journal. 2022;9(4) 208 table 2 xpert mtb/rif ct values on presumptive dr-tb criteria3 presumptive dr-tb criteria xpert mtb/rif ct values vl-l m-h n % n % 1. category ii treatment failure 4 19.1 17 80.9 2. tb patients whose sputum remains smear-positive after 3 months of category ii treatment 6 37.4 10 62.6 3. tb patients who have a history of non-standard treatment and use quinolones or 2nd line drug injections for at least one month 8 44.4 10 55.6 4. category i treatment failure 25 26.4 70 73.6 5. tb patients whose sputum remains smear-positive after two months of category i treatment 8 25.0 24 75.0 6. relapse 83 27.8 215 72.2 7. return after default 27 33.7 53 66.3 8. presumptive tb close contacts of a known dr-tb patient 5 62.5 3 37.5 9. tb-hiv co-infection who did not respond to tb treatment 1 50.0 1 50.0 note: h=high (ct≤16), m=medium (16<ct≤22), l=low (22<ct≤28), and vl=very low (28<ct≤38) althea medical journal december 2022 figure 1 distribution of presumptive dr-tb criteria based on xpert mtb/rif ct values note: 1=category ii treatment failure, 2=tb patients whose sputum remains smear-positive after three months of category ii treatment, 3=tb patients who have a history of non-standard treatment and use quinolones or 2nd line drug injection for at least one month, 4=category i treatment failure, 5= tb patients whose sputum remains smear-positive after two months of category i treatment, 6= relapse, 7=return after default, 8=presumptive tb close contacts of a known dr-tb patient, 9= tb-hiv who is not responding to tb treatment, h=high (ct≤16), m=medium (16<ct≤22), l=low (22<ct≤28), and vl=very low (28<ct≤38). althea medical journal. 2022;9(4) 209dinda nursyafira misyatin et al.:distribution of rifampicin-resistant tuberculosis patients based on presumptive drug-resistant tuberculosis criteria at dr. hasan sadikin hospital 2016–2019 discussion this study found that relapse cases were the most common criteria for presumptive drtb among 570 dr-tb patients at dr. hasan sadikin general hospital during 2016–2019. interestingly, of 5,541 tb patients with presumptive dr-tb criteria, 3,303 patients (59.6%) were categorized as relapse cases.2 relapse cases (52.3%) being the most common presumptive dr-tb criteria in tb-rr patients are understandable. another study conducted at three clinics offering programmatic management of drug-resistant tuberculosis (pmdt) services in west java, central java, and east java in 2011–2013 had the same results.6 additionally, a study in cambodia showed similar results even though it did not use the same nine criteria as in indonesia.7 relapse case was the most common presumptive drtb criteria among cambodia’s dr-tb patients. on the other hand, a study in india with five presumptive dr-tb criteria showed that the most common presumptive dr-tb criteria among dr-tb patients were treatment failure cases.8 a relapse case is a patient whose recent treatment outcome is cured or completed but returned with tb symptoms.3 relapse cases can be due to the recurrent original infection or reinfection with new m. tuberculosis.3 moreover, indonesia still has a high burden of dr-tb and a high transmission rate of drugresistant m. tuberculosis, which can contribute to the high number of relapse cases caused by reinfection.1,9 in addition, the leading cause of a high proportion of mdr/rr-tb among relapse cases was a failure to diagnose mdr/rr-tb at the first presentation.10 recurrent cases also contribute to the high number of relapse cases in indonesia. recurrent cases can be due to inadequate treatment, poor compliance during drug-susceptible tuberculosis (dstb) treatment, and individual vulnerability such as low nutrition, diabetes mellitus, hiv infection, old age, and residual lung damage from previous tb disease.11 in addition to relapse cases, the results of this study also showed that most of the contributors to the high number of dr-tb patients were the presumptive dr-tb criteria related to ds-tb treatment. a study in china found that recurrent infections are more common than reinfection.12 there has been no study that distinguishes recurrent tuberculosis and reinfection in indonesia. xpert mtb/rif has been used to detect dr-tb rapidly in indonesia since 2012. xpert mtb/rif detects m. tuberculosis resistance to rifampicin and ct values to estimate the bacterial load. the xpert mtb/rif ct values are comparable to smear microscopy as a measure of m. tuberculosis burden.13 however, the xpert mtb/rif ct values cannot replace culture as a measurement of m. tuberculosis burden because of the low correlation between xpert mtb/rif ct value and culture positivity.13 ct values in the medium and high categories, especially ct<21 are more likely to give positive smear results than the low and very low categories. xpert mtb/rif was used to examine patients with one or more presumptive dr-tb criteria. this study found that relapse cases were high for both the medium-high and very low-low categories. this was understandable because more than 50% of rr-tb patients came from relapse cases as the presumptive dr-tb criteria. on the other hand, another result study showed that the percentage of each presumptive criteria tended to give highmedium ct values. this study also showed that among the nine presumptive dr-tb criteria, the highest percentage of ct values in the medium-high category was category ii treatment failure (80.9%). category ii is designed to overcome isoniazid resistance and reduce the risk of rifampicin resistance. the category ii regimen comprised of eight months of rifampicin, ethambutol, and isoniazid supplemented with streptomycin for the initial two months and pyrazinamide for three months.14 the wide use of rifampicin throughout the whole treatment course from category i and ii regimens increases the prevalence of rifampicin resistance among previously treated tb patients.15 the world health organization (who) recommends that category ii regimens should no longer be prescribed to patients requiring tb retreatment and that drug-susceptibility testing (dst) should be performed for treatment options.14 the most available dst is xpert mtb/rif, but it can only detect rifampicin resistance.16 category ii regimen is still prescribed for patients requiring retreatment and who are sensitive to rifampicin.14 according to the study result, the most common presumptive dr-tb criteria in drtb patients were relapse cases. however, the criteria that had the highest percentage of medium-high ct values were category ii treatment failure. the ct values estimate the bacterial load in patients.4 in category ii treatment failure, the dst can be delayed because the test follows the treatment’s althea medical journal. 2022;9(4) 210 timeline. meanwhile, a relapse case will be tested as soon as the patient has suspected tb symptoms.3 however, relapse case patients are more likely to have diagnostic delays because of the lack of distribution of xpert mtb/rif testing in indonesia.17 patients from outside rural areas have longer diagnostic delays than patients from the city.18 interestingly, most patients administered at mdr-tb clinic dr. hasan sadikin general hospital have poor knowledge of dr-tb.19 they are mostly unaware of the etiology and risk factors of dr-tb, transmission and the name of the drug they received during treatment. the level of knowledge will affect their effort in looking for treatment and compliance towards dr-tb treatment. delay in diagnosis and initiation of dr-tb treatment can contribute to the high bacterial burden, estimated with high ct values.20 the amount of bacterial burden can affect treatment success, one of the factors that independently increase treatment success in dr-tb is afb smear ≤+1, which means it has a low bacterial burden.21 relapse case still has a high percentage of ct values in the mediumhigh category (72.2%). the limitation of this study is that from the many rr-tb patients at dr. hasan sadikin bandung general hospital, not all have information on the ct values on xpert mtb/ rif results. to conclude, relapse cases are the most common presumptive dr-tb criteria among dr-tb patients, and category ii treatment failure has a high percentage of having a high bacterial burden based on xpert mtb/rif ct values. these presumptive dr-tb criteria should receive more attention from clinicians in managing the tb therapy. references 1. world health organization. global tuberculosis report. geneva, switzerland: who; 2019. 2. management sciences for health. e-tb manager: report tb06 [internet]. [cited 2020 october 13]. available from: etbmanager.sitb.id 3. ministry of health republic of indonesia. minister of health decree no. 67/2016 about tuberculosis control. jakarta: ministry of health republic of indonesia; 2016. 4. fradejas i, ontañónb, muñoz-gallegoi, ramirez-vela mj, lópez-roa p. the value of xpert mtb/rif-generated ct values for predicting the smear status of patients with pulmonary tuberculosis. j clin tuberc other mycobact dis. 2018;13:9–12. 5. sabiiti w, azam k, farmer ecm, kuchaka d, mtafya b, bowness r, et al. tuberculosis bacillary load, an early marker of disease severity: the utility of tuberculosis molecular bacterial load assay. thorax. 2020;75:606–8. 6. van kampen sc, susanto nh, simon s, astiti sd, chandra r, burhan e, et al. effects of introducing xpert mtb/rif on diagnosis and treatment of drug-resistant tuberculosis patients in indonesia: a pre-post intervention study. plos one. 2015;10(6):e0123536. 7. khann s, mao et, rajendra yp, satyanarayana s, nagaraja sb, kumar amv. linkage of presumptive multidrug resistant tuberculosis ( mdr-tb ) patients to diagnostic and treatment services in cambodia. plos one. 2013;8(4):e59903. 8. gautam pb, mishra a, kumar s. prevalence of rifampicin resistant mycobacterium tuberculosis and associated factors among presumptive tuberculosis patients in eastern uttar pradesh: a cross sectional study. int j community med public health. 2018:5(6):2271–6. 9. cudahy pgt, wilson d, cohen t. risk factors for recurrent tuberculosis after successful treatment in a high burden setting: a cohort study. bmc infect dis. 2020;20(1):789. 10. ragonnet r, trauer jm, denholm jt, marais bj, mcbryde es. high rates of multidrugresistant and rifampicin-resistant tuberculosis among re-treatment cases: where do they come from? bmc infect dis. 2017;17(1):36. 11. trinh qm, nguten hk, nguyen vn, nguyen tva, sintchenko v, brais bj. tuberculosis and hiv co-infection-focus on the asiapacific region. int j infect dis. 2015;32: 170–8. 12. liu y, zhang xx, yu jj, liang c, xing q, yao c, et al. tuberculosis relapse is more common than reinfection in beijing, china. infect dis (lond). 2020;52(12):858–65. 13. najjingo i, muttamba w, kirenga bj, nalunjogi j, bakesiima r, olweny f, et al. comparison of genexpert cycle threshold values with smear microscopy and culture as a measure of mycobacterial burden in five regional referral hospitals of ugandaa cross-sectional study. plos one. 2019;14(5):e0216901. 14. world health organization. guidelines for treatment of drug-susceptible tuberculosis althea medical journal december 2022 althea medical journal. 2022;9(4) 211 and patient care, 2017 update. geneva, switzerland: who; 2017. 15. zignol m, van gemert w, falzon d, sismanidis c, glazio p, flyod k, et al. surveillance of anti-tuberculosis drug resistance in the world: an updated analysis, 2007–2010. bull world health organ. 2012; 90(2):111–9d. 16. world health organization. automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: xpert mtb/rif assay for the diagnosis of pulmonary and extrapulmonary tb in adults and childrenpolicy update. geneva, switzerland: who press; 2013. 17. soeroto ay, lestari bw, santoso p, chaidir l, andriyoko b, alisjahbana b, et al. evaluation of xpert mtb-rif guided diagnosis and treatment of rifampicinresistant tuberculosis in indonesia: a retrospective cohort study. plos one. 2019;14(2):e0213017. 18. nuraeni n, suryadinata h, lestari bw. geographical factors in diagnostic delay among multidrug resistant tuberculosis patients. althea med j. 2017;4(3):444–8 19. ramadhani ar, lestari bw, suryadinata h. knowledge toward drugs resistant tuberculosis in one of the highest burden drug resistant country. althea med j. 2018;5(3):127–32 20. htun ym, khaing tmm, aung nm, yin y, myint z, aung st, et al. delay in treatment initiation and treatment outcomes among adult patients with multidrug-resistant tuberculosis at yangon regional tuberculosis centre, myanmar: a retrospective study. plos one. 2018;13(12): e0209932. 21. soeroto ay, pratiwi c, santoso p, lestari bw. factors affecting outcome of longer regimen multidrug-resistant tuberculosis treatment in west java indonesia: a retrospective cohort study. plos one. 2021;16(2): e0246284. dinda nursyafira misyatin et al.:distribution of rifampicin-resistant tuberculosis patients based on presumptive drug-resistant tuberculosis criteria at dr. hasan sadikin hospital 2016–2019 vol 6 no 4 full text final.indd althea medical journal. 2019;6(4) 164 amj december 2019 amj. 2019;6(4):164–71 factors influencing the cervical cancer screening uptake among medical lecturers at faculty of medicine universitas padjadjaran sri yusnita irda sari,1 phavithra rathakirushnan,2 edwin armawan3 1department of public health faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: cancer is the leading cause of death worldwide. in indonesia, cervical cancer is one of the most occurring types of cancer. it is acknowledged that early screening can prevent cervical cancer. this study aimed to explore what factors influenced the screening uptake and to correlate characteristics, perceived susceptibility, and self-efficacy of pap smear uptake among medical faculty lecturers. methods: this was a cross-sectional analytical study conducted among female lecturers in the faculty of medicine, universitas padjadjaran from october to november 2013. the questionnaire was used to collect data using a purposive sampling method. data collected were tabulated into frequency and percentage and the correlation was performed using pearson chi-square. results: from a total of 79 respondents who participated, only 55.7% of medical lecturers had ever taken pap smear. reasons for not taking pap smear were time (77.1%) and the perception of not being at risk (22.9%). however, most of the respondents (84.8%) were willing to have a screening test for cervical cancer routinely. there was a significant correlation between age (p=0.001), level of education (p=0.003) and duration of marriage (p=0.001) with the uptake of pap smear. conclusions: the factors that are influencing the uptake of screening are not having the time to take the test and the perception of not being at risk of the disease. there is a correlation between age, level of education and duration of marriage with screening uptake. awareness of the importance of screening should also be promoted among female doctors. keywords: awareness, cervical cancer, pap smear, screening correspondence: sri yusnita irda sari, department of public health faculty of medicine, universitas padjadjaran, jalan eyckman no. 38 bandung, indonesia. e-mail: italatif@yahoo.com introduction cervical cancer is the leading cause of death among women, occurring more commonly in under-developed and developing countries.1 gynecological cancer is a type of cancer that arises in women’s reproductive organs.2 gynecological cancer arises with an increment in age, therefore early detection through screening and tests can decrease its incidence.2 cervical cancer is placed as the second most common type of cancer in women.3 the highest rate of death caused by cervical cancer occurred among women in developing countries.3 in indonesia4, cervical cancer seems to be the most occurring type of cancer and is positioned as the first followed by breast, ovary, skin, thyroid, rectum, lymph node, uterus, colon, and nasopharynx. cervical cancer is caused primarily by human papillomavirus (hpv).5 continuous infection of the cervix with specific highrisk types of hpv is a prerequisite for the development of cervical cancer.6 there are two methods in preventing cervical cancer from occurring, one way is to find and treat the precancerous cells before they become cancerous (screening) and the other way is to prevent the pre-cancers in the beginning (vaccination).7 detection of cervical cancer is performed in a althea medical journal. 2019;6(4) 165 was given to the respondents before handing out the questionnaires, which were given personally to each lecturer whenever they had free time and each respondent was given adequate time to answer the questionnaire. the respondents were encouraged to clear their doubts regarding the questionnaire and once the respondent had finished answering, each questionnaire was checked to see if they had filled in the questionnaire completely. data were tabulated into frequency and percentage to find correlation studies between the characteristics, perceived susceptibility, and self-efficacy on pap smear uptake. pearson chi-squared test was used to find a correlation in this study. this study was carried out with ethical clearance from the health research ethics committee faculty of medicine, universitas padjadjaran. results this study was to identify the presence out of 337 female lecturers working in faculty of medicine universitas padjadjaran, only 79 were participated in this study, consisting of lecturers in medicine and midwifery. the majority of the medical lecturers were middleaged with a master degree as the highest level of education. most of them were married with duration of more than 5 years and the number of children was less than 3 (table 1). the data revealed that only half of the respondents had taken pap smear and only half of them had it done 3 times or more. the majority of the respondents in this study had taken their previous pap smear more than 2 years ago and a large number of them stated that they did not routinely get screened for cervical cancer. government hospital and private practice clinic was the most frequent place responded by the participants for pap smear uptake (table 2). among all the respondents, only a minority of medical lecturers (12.70%) had hpv vaccinated; whereas the remaining respondents who did not take hpv vaccination stated a factor of ‘time’ as the barrier to vaccination. the risk perception of respondents on cervical cancer was mostly answered as ‘no’. the majority of the study subjects were willing to do pap smear for screening routinely. in this study, a large number of lecturers took pap smear as early screening and did it by their means; while the lecturers who did not get screened stated that time was the barrier to take routine screening (table 3). there was a significant correlation between few ways, one of it is cytological screening and the management of the abnormal papanicolau testing.7 according to the american cancer society,7 all women should start to get screened at the age of 21. it is recommended for women aged 30–65 to get pap smear testing every 3 years.7 a study conducted in uganda8 on medical workers in muago hospital showed that 81% of their staff have never been screened for cervical cancer. this shows that medical workers with a higher level of education do not necessarily practice screening methods for cervical cancer even though the awareness of cervical cancer is sufficient.8 a study conducted in jamaica9 showed that the highest percentage of reason for not undergoing pap smear test is that they have no symptoms and therefore perceive that they have no risk toward the disease. most studies conducted on screening uptake have correlated knowledge level with screening uptake of pap smear. similar studies in the united states conclude that there is a high correlation between education and screening uptake.9 therefore, this study was carried out to find out what were the factors that influenced the uptake of cervical cancer screening and to correlate the characteristics, perceived susceptibility and self-efficacy with the uptake of pap smear among medical faculty lecturers. methods this analytical study was carried out in october–november 2013 in the faculty of medicine universitas padjadjaran, bandung, indonesia. to evaluate the factors that influenced the uptake of pap smear and the correlation between characteristics, perceived susceptibility and self-efficacy with the uptake of pap smear among medical lecturers, a set of questionnaires consisted of 17 questions were distributed. samples were collected using purposive sampling method. in total, 79 female medical faculty lecturers were selected after matching the study subjects using the inclusion and exclusion criteria. the inclusion criteria of the research were married lecturers who signed the informed consent; whereas the exclusion criteria were lecturers who previously underwent a total hysterectomy. based on the health belief model theory10, two variables were assessed in this study; the independent variables which were the characteristics, perceived susceptibility and self-efficacy, and the dependent variable was the uptake of pap smear. informed consent sri yusnita irda sari et al.: factors influencing the cervical cancer screening uptake among medical lecturers at faculty of medicine universitas padjadjaran althea medical journal. 2019;6(4) 166 amj december 2019 age, level of education and duration of marriage with the uptake of pap smear. however, perceived susceptibility and self-efficacy showed no correlation with the uptake of pap smear among medical lecturers (table 4). discussion an efficient way to prevent cervical cancer is by screening as early detection, and this is done by performing a pap smear onto a patient.7 the sole function of this test is to examine and to identify pre-cancerous changes in the cervix.11 in previous research, the pap test has reduced death rates among women in developing countries, while hpv vaccination has been proven to be effective against cervical cancer although it may not prevent all cases of cervical cancer.7,12 therefore, it is still crucial for women to get routine pap smear although they have been vaccinated or are not at risk.7,10 this study finding has shown that only 12.7% of medical faculty lecturers have taken hpv vaccination and only 55.7% have taken table 1 the characteristic of female medical lecturers from faculty of medicine, unviersitas padjadjaran characteristic n % age mean ± sd 44.21 ± 11.95 age category (years) 20–30 5 6.3 31–40 40 50.6 41–50 6 7.6 51–60 17 21.5 >60 11 13.9 level of education medical doctor 21 26.6 master degree 52 65.8 ph.d degree 6 7.6 marital status married 76 96.2 divorced 1 1.27 deceased 2 2.53 duration of marriage <5 years 11 13.9 5–10 years 22 27.8 >10 years 46 58.2 number of children no children 2 2.5 1 13 16.5 2 39 49.4 3 20 25.3 4 4 5.1 5 1 1.3 note: phd=doctorate of philosophy althea medical journal. 2019;6(4) 167 cervical cancer.13 in this study, the majority of the lecturers perceive themselves as having low risk for cervical cancer, and this could be one of the reasons why the screening uptake is low. this finding could influence the screening uptake for cervical cancer by using the health belief model that states perceived risk could pap smear. the reason for a low number of getting hpv vaccination is due to lack of time, while 31.6% state that they are not at risk. the result is similar to other studies conducted concerning the uptake of the hpv vaccine; the barriers to vaccination are regarding the adverse reaction of the vaccine and the perception of having a low risk towards table 2 the practice of pap smear screening among medical lecturers from faculty of medicine, unviersitas padjadjaran n % ever taken pap smear yes 44 55.7 no 35 44.3 risk perception of cervical cancer yes 25 31.6 no 54 68.4 frequency of pap smear uptake (n=44)* once 9 20.5 twice 12 27.3 3 times 9 20.5 >3 times 14 31.8 previous pap smear exam (n=44) * <1 year ago 6 13.6 1–2 years ago 21 47.7 2–3 years ago 5 11.4 >3 years ago 9 20.4 don’t remember 3 6.8 the regularity of pap smear uptake (n=44) * once in a year 12 27.3 twice in a year 3 6.8 three times in a year 1 2.3 did not do routinely 28 63.6 a place to get pap smear (n=44) * government hospital 12 27.3 government hospital and private practice clinic 4 9.1 government hospital and laboratory 5 11.4 private practice clinic 17 38.6 private practice clinic and laboratory 1 2.3 laboratory 4 9.1 others 1 2.3 note: * data only taken from 44 respondents, others did not answer. sri yusnita irda sari et al.: factors influencing the cervical cancer screening uptake among medical lecturers at faculty of medicine universitas padjadjaran althea medical journal. 2019;6(4) 168 amj december 2019 influence the behavior of an individual.10 a total of 58 of 79 (73.4%) respondents in this study hold a master’s or ph.d degree as their highest level of education, showing that the majority of the population have high level of education which should lead to good knowledge regarding the disease, as well as high awareness of its risk factors and preventive measures. however, in this study, the uptake for cervical cancer screening and hpv vaccination is low among respondents (table 1). in contrast, a study conducted in india12 among rural women showed that women who are more aware of the disease are more likely to get screened for cervical cancer compared to women with poor knowledge about the disease. most of the respondents have less than 3 children from their marriage while only 1 respondent has 5 children from their marriage. a study conducted on the cofactors leading to carcinogenesis of cervical cancer screening has shown that high parity is associated with increased risk of having cervical cancer.14 this condition could probably result in that most lecturers in this study perceive that they are not at risk because most of them have a low parity. regarding the frequency of obtaining a pap smear among medical lecturers, less than half had screening more than 3 times in their lifetime and only a total of 21 medical lecturers claimed the last time they have been screened was 1 to 2 years ago. based on the screening guidelines, women aged 30–69 years old are encouraged to get screened once in 3 years.15 furthermore, this study found that most of the medical faculty lecturers did not get screened routinely due to their busy schedule in finding time to go for screening. in the health belief model, the perceived barrier is one of the factors that can influence individual behavior. in a similar study conducted among postgraduate women, it is reported that lack of time is the main reason for the barrier of screening.10 this study assessed the place where pap smear was taken and found that most of the table 3 the willingness to have cervical cancer screening among medical lecturers from faculty of medicine unviersitas padjadaran n % willingness to have cervical cancer screening routinely yes 67 84.8 no 12 15.2 reason for taking pap smear recommended by doctor 1 2.3 check up 8 18.2 early screening 34 77.3 recommended by friend 1 2.3 reason for not taking pap smear no time 27 77.1 not at risk 8 22.9 influence or recommendation to get pap smear husband/partner 4 9.1 doctor 9 20.5 doctor and colleague 2 4.5 colleague 5 11.4 no one 21 47.7 others 3 6.8 althea medical journal. 2019;6(4) 169 respondents took pap smear in a private practice clinic and government hospital. these two places were popular among medical faculty lecturers due to the convenience of the location and the facility. moreover, among respondents who had not taken pap smear, 27 of them stated they had no time. this could be due to the time constraint that they faced or because of their heavy workload. a previous study done in england16 has shown similar findings in which the women respond that time constraint is one of their limitations for pap smear screening. the willingness to be screened routinely in this study was high, accounting for 84.8%. the large percentage of willingness to be screened could be influenced by knowledge of the importance of cervical cancer test which can influence screening behavior in women.10 the remaining 15.2 % of respondents who did not want to be screened could result in believing that they were not at risks, such as having their partner or husband deceased. according to a study relating the health belief model to cervical cancer screening, it is stated that one of the reasons for not participating in pap smear was the belief that the individuals were not at risk of cervical cancer.10 therefore, this could be one of the factors influencing the uptake of cervical cancer screening among table 4 correlation between the characteristics and the pap smear uptake characteristics pap smear uptake pearson correlation p-valueyes no age (years old) <35 3 16 16.146 0.001* ≥35 41 19 level of education medical doctor 6 15 8.529 0.003* master’s/phd 38 20 marital status married 43 33 0.624 0.581 divorced/deceased 1 2 duration of marriage(years) ≤10 8 25 22.723 0.001* >10 36 10 number of children ≤2 29 25 0.275 0.600 >2 15 10 perceived susceptibility risk of having cervical cancer yes 10 15 3.652 0.056 no 34 20 self-efficacy hpv vaccine yes 4 6 1.129 0.325 no 40 29 willingness to take pap smear routinely yes 40 27 2.868 0.090 no 4 8 note : * statistically significant at p < 0.05. sri yusnita irda sari et al.: factors influencing the cervical cancer screening uptake among medical lecturers at faculty of medicine universitas padjadjaran althea medical journal. 2019;6(4) 170 amj december 2019 medical faculty lecturers. most of the respondents claimed that ‘no one’ provided recommendations for taking pap smear, which interprets that it is their initiatives for the screening uptake. this strong self-motivation to undergo screening could be caused by their high level of education. correlation between characteristics of respondents, perceived susceptibility, and selfefficacy with the uptake of pap smear has been assessed. the findings in this study showed a high correlation (p=0.001) between the ages of respondents with the uptake of pap smear. a previous study conducted on correlating practice and knowledge on cervical cancer revealed that women aged more than 35 were likely to take pap smear compared to younger women.12 this study also showed a correlation between levels of education with pap smear screening among medical faculty lecturers (p=0.003), similar to a study among indian community women, affirming that knowledge has a high significance with screening uptake among women.12 furthermore, marital status in respondents did not correlate with the screening uptake. in comparison to a previous study, it shows that marital status has significance in the uptake of pap smear.17 duration of marriage among respondents in the study was correlated to the pap smear uptake (p=0.001), comparable to a study conducted in qatar18 which revealed that women who were married longer were more likely to get screened for cervical cancer. parity among respondents showed no correlation with taking pap smear (p=0.600), it contrasted to a study that showed a high significance between parity and screening uptake.18 the reason for low uptake in women with parity was because most respondents had only 2–3 children and therefore perceived that they had lower risk towards cervical cancer and perceived that they did not require the test. perceived susceptibility was evaluated among the respondents by correlating the risk of contracting cervical cancer with the screening uptake. the result showed that there was no correlation between perceived susceptibility and uptake of pap smear among the medical lecturers (p=0.056). the health belief model states that the beliefs of an individual contracting a disease will influence their screening uptake.10 thus, in our study, medical faculty lecturers who are well informed about the disease perceived low risk of having cervical cancer which influenced their uptake of pap smear. self-efficacy in respondents was assessed by correlating hpv vaccination and willingness to be routinely screened with the uptake of cervical cancer among medical faculty lecturers. self-efficacy is based on personal behavior, their perception of being at risk, the barriers to screening, which will eventually determine the screening.10 in this study, it showed no correlation between self-efficacy and the uptake of pap smear. vaccination for hpv vaccine was not correlated with the uptake of pap smear (p=0.325). although the findings of this study showed a willingness to routinely screened for pap smear was satisfactory, however, it was not significantly correlated with the uptake of pap smear (p=0.090), this result related to the reason that the main barrier for regular screening among the respondents was mostly due to time constraint. the limitation of this study was the low response rate from the respondents to participate in the study and also the limited time for the researcher to complete the study. in conclusion, the findings found in this study show that most of the female medical lecturers perceive themselves as having no risk of cervical cancer and in most of them, time was the barrier for screening uptake. furthermore, age, level of education and duration of marriage are highly correlated with pap smear uptake. therefore, government hospitals or private hospitals should promote pap smear screening regularly to increase the uptake of screening among doctors. gynecologists play an important role in encouraging their colleagues to undergo screening and the benefits of it. the awareness for screening should be promoted among female doctors so that they will be more aware of screening practices and furthermore they will be able to schedule a time for screening. references 1. joy t, sathian b, bhattarai c, chacko j. awareness of cervix cancer risk factors in educated youth: a crosssectional,questionnaire based survey in india, nepal, and sri lanka. asian pac j cancer prev. 2011;12(7):1707–12. 2. centers for disease control and prevention. gynecological cancers: basic information. [cited 2019 october 9] available from: <http://www.cdc.gov/ cancer/gynecologic/basic_info/index. htm>. 3. singh s, badaya s. factors influencing althea medical journal. 2019;6(4) 171 uptake of cervical cancer screening among women in india: a hospital based pilot study. j community med health educ. 2012;2(6):1–6. 4. aziz mf. gynecological cancer in indonesia. j gynecol oncol. 2009; 20(1):8–10. 5. saha a,chaudhary an, bhowmik p, chatterjee r. awareness of cervical cancer among female students of premier colleges in kolkata, india. asian pac j cancer prev. 2010;11(4):1085–90. 6. makwe cc, anorlu ri. knowledge of and attitude toward human papillomavirus infection and vaccines among female nurses at a tertiary hospital in nigeria. int j womens health. 2011;3:313–7. 7. american cancer society. cervical cancer. [cited 2019 october 9] available from: http://www.cancer.org/content/cancer/ en/cancer/cervical-cancer.html. 8. mahajan sm, jadhav vs, magane ar, adchitre sa, salve sb. awareness and screening practices of cervical cancer among nursing staff working in tertiary care hospital. int j community med public health. 2017;4(10):3590-5. 9. ndejjo r, mukama t, musabyimana a, musoke d. uptake of cervical cancer ccreening and associated factors among women in rural uganda: a cross sectional study. plosone. 2016;11(2):e0149696. 10. tavafian ss. predictors of cervical cancer screening: an application of health belief model. in: rajamanickam r, editor. topics on servical cancer with an advocacy for prevention. 1st ed. london: intech publisher; 2012. p. 1–24. 11. tacken ma, braspenning jc, hermens rp, spreeuwenberg pm, van der hoogen hj, de bakker dh, et al. uptake of cervical cancer screening in the netherlands is mainly influenced by women’s beliefs about the screening and by the inviting organization. eur j public health. 2007;17(2):178–85. 12. albrow r, blomberg k, kitchener h, brabin l, patnick j, tishelman c et al. interventions to improve cervical cancer screening uptake amongst young women: a systematic review. acta oncol. 2014;53(4):445–51. 13. ashwathy s, quereshi ma, kurian b, leelamoni k. cervical cancer screening: current knowledge & practice among women in a rural population of kerala, india. indian j med res. 2012;136(2):205–10. 14. cassidy b,schlenk ea. uptake of human pappilomavirus vaccine: a review of literature and report of a quality assurance project. j pediatr health care. 2012;26(2):92–101. 15. tasic d, lazarevic i, knezevic a, tasic l, pikula a, perisic z et al. the impact of environmental and behavioural cofactors on the development of cervical disorders in hr-hpv-infected women in serbia. epidemiol infect. 2018;146(13):1714-23. 16. canadian task force on preventive health care. recommendations on screening for cervical cancer. cmaj. 2013;185(1):35–45. 17. waller j, bartoszek m, marlow l, wardle j. barriers to cervical cancer screening attendence in england: a population-based survey. j med screen. 2009;16(4):199–204. 18. jelastopulu e, karnaki p, bartsokas c, plotas p, sissouras a. screening for cervical cancer-uptake and associated factors in a representative sample in the city of patras,west-greece. universal journal of public health. 2013;1:7–13. 19. al-meer fm, aseel mt, al-khalaf j, alkuwari mg, ismail mf. knowledge, attitude and practices regarding cervical cancer screening among women visiting primary health care in qatar. east mediterr health j. 2011;17(11):855–61. sri yusnita irda sari et al.: factors influencing the cervical cancer screening uptake among medical lecturers at faculty of medicine universitas padjadjaran amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 185althea medical journal. 2022;9(4):185–190 larvicidal effects of citrus peels extracts against culex pipiens mosquitoes abiodun obembe,1 opeyemi g. oso2 1department of zoology, kwara state university, malete, nigeria 2department of zoology, university of ibadan, ibadan, nigeria abstract background: mosquitoes transmit severe diseases such as malaria, lymphatic filariasis, dengue fever, and yellow fever. these diseases result in significant morbidity and mortality in humans around the world. this study aimed to provide information on the larvicidal potential of different citrus species peels against culex mosquito larvae. methods: ethanol extracts of the peels of four citrus species, such as citrus sinensis (sweet orange), citrus reticulata (tangerine), citrus latifolia (lime), and citrus paradisi (grape) fruits were tested for larvicidal properties against culex pipiens at different concentration (3 mg, 5 mg, 7 mg and 8 mg in 100 ml) on 25 larva per concentration. percentage mortality was recorded for each of the concentrations used. results: only culex latifolia induced the death of all the mosquito larvae (100%) at 5 mg/ml concentration of the extract, meanwhile culex reticulata resulted in the lowest mortality rate (80%). however, a hundred percent (100%) mortality of the larvae, was observed at 8 mg/ml of all the types of extracts evaluated. conclusion: the result indicates that the peels of these citrus species, especially culex latifolia, hold potential for control of culex pipiens mosquito larvae. keywords: culex pipiens, citrus peels, ethanol extracts correspondence: dr. opeyemi g. oso, ph.d, department of zoology, university of ibadan, ibadan, nigeria, e-mail: opeyemi.immaculate@gmail.com introduction mosquitoes constitute a nuisance and are of great public health concern globally. culex pipiens mosquitoes are considered vectors of several diseases such as lymphatic filariasis (lf), west nile virus, japanese encephalitis, saint louis encephalitis, dengue and rift valley fever with some being fatal in the absence of treatment and others causing lifelong disabilities and impairment.1 culex mosquito species are also responsible for a serious nuisance problem with high biting rates exceeding 100 bites/person/night.2 the culex pipiens quinquefasciatus is a prominent vector species that feeds on both humans and animals,3 thereby increasing its implication in pathogen transmission to both host groups. factors such as low or inefficient drug distribution in nigeria,4 mass drug administration (mda) failure in ghana and burkina faso5 and the ability of the culicine mosquitoes to transmit low levels of microfilariae6 have further led to a review of the world health organization (who) filariasis elimination strategy to include vector control.7 in nigeria, culex and aedes species are responsible for transmitting lf, dengue and yellow fever.8 larval source management through larviciding and or environmental modification represents a key supplementary means recommended for mosquito vector control in nigeria.4 efforts towards a search for effective natural mosquito larvicide will contribute to the drive for the incorporation of mosquito larval control into the overall integrated mosquito vector management plan. citrus fruit is grown and consumed worldwide and in many cases, processed into juice to preserve them from spoilage. waste materials from citrus could be processed into flavonoids, dietary fibre, methane, essential oils, carotenoids, and other essentials https://doi.org/10.15850/amj.v9n4.2786 althea medical journal. 2022;9(4) 186 materials.9,10 these processed materials could serve as antimicrobials and antioxidants against different organisms.11 due to the chemical composition of citrus peels, leaves, flowers, and other parts of citrus, their effectiveness as biological control agents differ from one organism to another. this study was designed to provide information on the larvicidal potential of the peels of different citrus species against culex mosquito larvae. this information will serve as a basis for determining the possible use of citrus peels to control culex pipiens mosquito larvae, the vectors of such deadly diseases such as lymphatic filariasis. methods four citrus species, such as citrus sinensis (sweet oranges), citrus reticulata (tangerine), citrus paradisii (grape), and citrus latifolia (lime) were purchased from a local market in ilorin and identified by a plant taxonomist at kwara state university, malete, nigeria (figure 1). althea medical journal december 2022 the citrus species peels were removed and air dried at room temperature for some days. the dried peels were pulverized with a blender in the laboratory into powder and were weighed using the weighing balance, yields were 140.9 g, 86.5 g, 46.5 g, and 50.0 g for sweet orange, tangerine, grape, and lime respectively. the powdered sieved peels were dissolved in a volume of ethanol (ml) which is five times (5x) their weight (mg). fifty grams of lime peel were dissolved in 250 ml of ethanol and kept for 24 hours with periodic shaking using a rocker at 125 rpm, the same process was repeated for each citrus species. the filtered and the filtrate were collected. the procedure was repeated three times with a new volume of ethanol. the filtrates were pooled and placed in a water bath for the ethanol to evaporate. culex pipiens larvae were collected from natural breeding sites around the kwara state university campus, malete, kwara state, nigeria using a dipper (figure 2). mosquito larvicidal assay was conducted at different test concentrations (3 mg, 5 mg, 7 mg, and 8 mg) figure 1 map of nigeria and kwara state as the study area althea medical journal. 2022;9(4) 187abiodun obembe and opeyemi g. oso: larvicidal effects of citrus peels extracts against culex pipiens mosquitoes table mortality rates of mosquito larvae exposed to different citrus peel extracts citrus species observed percentage mortality (%+sd) 3 mg/ml 5 mg/ml 7 mg/ml 8 mg/ml citrus sinensis 80±1.15 88±2.08 92±1.00 100 citrus reticulata 80±.0.00 80±0.57 92±1.15 100 citrus latifolia 80±0.57 100 100 100 citrus paradisi 76±0.57 96±0.57 100 100 of citrus peels extract. one hundred milliliters of distilled water were taken in a series of 250 ml glass beakers. the measured extracts were dissolved in 2 ml of the solvent (ethanol) used to prepare the extract. the dissolved citrus peel extract was added to a beaker’s 100 ml of water. a control was also maintained by adding 2 ml of solvent ethanol to 100 ml water, 25 larvae per concentration were introduced into different beakers. the temperature (28±2ºc) and humidity (78±5%) were recorded during the experiment in the laboratory using a thermohygrometer. the mosquito larva mortality rates were recorded at the end of 24 hours and the experiment replicated thrice.12 controls were exposed to the solvent (ethanol alone). during the treatment period, the larvae were not fed. the percentage mortality of culex larvae induced by each citrus peel extract was calculated for each concentration. ethical approval for this study was obtained from the university of ilorin ethical review committee no. uerc/asn/195. results the result of mortality rates induced by the different citrus peel extracts against culex pipiens mosquito larvae was presented in table. citrus latifolia showed the highest larvicidal activity against the larvae compared figure 2 larval collection from the study area althea medical journal. 2022;9(4) 188 to lowest activity induced by citrus paradisi. at the lowest concentration of 3 mg/ml, citrus sinensis, citrus reticulata, and citrus latifolia had the same percentage of mortality (80%), whereas citrus paradisi induced 76% culex pipiens mosquito larva mortality. at 5 mg/ml, only citrus latifolia brought about the death of all the mosquito larvae (100%), meanwhile citrus reticulata showed the lowest mortality rate (80%). at 7 mg/ml, larvicidal activities of citrus sinensis and citrus reticulata were the same (92%), meanwhile citrus latifolia and citrus paradisi elicited 100% mortality of the larvae. at the highest concentration (8 mg/ ml), all the citrus peel extracts induced 100% mortality against the larvae. citrus latifolia peel extract showed a consistently higher mortality rate at the different concentrations. discussion this study identified the larvicidal activities of different citrus peel extracts against culex pipiens mosquitoes. the result has shown that the effectiveness of the citrus peel extract is high. the high effective concentration was found to be 8 mg/ml, although the lowest concentration of 3 mg/ml also demonstrated some effectiveness in controlling culex larvae. for all the different species of citrus used in the study, the higher the concentration of the extract, the higher the mortality rate of the culex larvae. this is in tandem with a similar study conducted in india.13 however, it is in deviance with another study elsewhere, where the absolute mortality was observed at a lower concentration.14 this could be due to some factors, such as the handling of the culex species used or other effects of experimental errors. minor or significant stress could have occurred on the culex species used during transportation or transferring the species in the laboratory during the experimental process. another factor could be attributed to the lack of a photoperiod of 12 hours light and 12 hours dark as the world health organization required during the experimental process.12 for citrus lemon peel extract, the absolute mortality occurred at 8 mg/ml, this is in disagreement with other studies where absolute mortality occurred at 100 mg/ml.15,16 this could be due to the differences in the method of extracting the active ingredient for the experimental studies. however, limonene remains the active ingredient found in lemon peels which are found to be active against insects and could be used in obstructing the activities of larvae.17 citrus sinensis peel extract showed a progressive mortality rate in culex species as the concentration of the extract increased, this was also found in a similar study conducted elsewhere in southsouth nigeria.18 moreover, the known active ingredient (saponins) is effective against the life cycle of many insects that are of public health importance to humans and animals.18–20 for this study, the 7 mg/ml concentration culex reticulata peel extract showed almost complete mortality in culex species, which agrees with previous studies using different vectors. for citrus reticulata, the effective ingredient includes terpenes limonene, sabinene gammaterpinene, octanal, and capraldehyde; these have been proven to be responsible for mortality in vectors.21,22 although grapefruit is used as an anti-obesity and body cleansing promoter,23–25 it also has antibacterial, antifungal, and larvicidal properties.26–29 in the same vein, in this study, citrus paradisi (grapefruit) had a full lethal effect on culex species larval at 7 mg/ml concentration. this aligns with other reports where citrus paradisi was used alongside allium sativum to control of culex quinquefasciatus larvae and adults. the effectiveness of culex paradisi peel extract has been linked to diallyl-disulphide, linalool, citronellal, and caryophyllene oxide as the major active ingredient.30 overall, the results of this study demonstrate that the different citrus peel extracts, particularly culex latifolia, hold potential for the control of culex pipiens mosquito larvae. the limitation of the study is that we did not consider fractionation and testing of the bioactive components of the extracts. therefore, further studies should include these aspects. in conclusion, the citrus peel extracts of culex latifolia have a potential effect to be used for the biocontrol of culex pipiens mosquito larvae. references 1. kauffman eb, kramer ld. zika virus mosquito vectors: competence, biology, and vector control. j infect dis. 2017;216(suppl_10):s976–90. 2. mbida am, etang j, akono n, talipouo a, awono-ambene 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duerr hp, dietz k, eichner m. determinants of the eradicability of filarial infections: a conceptual approach. trends parasitol. 2005;21(2):88–96. 7. world health organization. accelerating work to overcome the global impact of neglected tropical diseases: a roadmap for implementation: executive summary. geneva: world health organization; 2012. 8. okogun gr, anosike jc, okere a, nwoke b, esekhegbe a. epidemiological implications of preferences of breeding sites of mosquito species in midwestern nigeria. ann agric environ med. 2003;10(2):217–22. 9. soni n, prakash s. efficacy of fungus mediated silver and gold nanoparticles against aedes aegypti larvae. parasitol res. 2012;110(1):175–84. 10. benelli g, caselli a, canale a. nanoparticles for mosquito control: challenges and constraints. j king saud univ sci. 2017;29(4):424–35. 11. selim a, radwan a, arnaout f. seroprevalence and molecular characterization of west nile virus in egypt. comp immunol microbiol infect dis. 2020;71:101473. 12. world health organization. guidelines for laboratory and field testing of mosquito larvicides. geneva, switzerland:who publication; 2005. 13. murugan k, kumar pm, kovendan k, amerasan d, subrmaniam j, hwang j. larvicidal, pupicidal, repellent and adulticidal activity of citrus sinensis orange peel extract against anopheles stephensi, aedes aegypti and culex quinquefasciatus (diptera: culicidae). parasitol res. 2012;111(4):1757−69. 14. muniandy pd, riswari sf, ruchiatan k. larvicidal activity of citrus aurantifolia decoction against aedes aegypti larvae. althea med j. 2020;7(1):35–9. 15. saadawi ss, eltalbi r, erkhaies w, abid s, alennabi ka. effect of thymus vulgaris, mentha piperita and pelargonium citrosum leaf, syzygium aromaticum buds and citrus limonoids peels extracts as mosquito larvicidal and pupicidal agent. ijpsat. 2021;28(2):76–83. 16. chattopadhyay a, bakshi sd, betal s, banerjee pk. molecular identification and control of culex mosquito by citrus limon in west bengal, india. int j mosq res. 2021;8(1):06–10. 17. wahyuni d. larvicidal activity of essential oils of piper betle from the indonesian plants against aedes aegypti l. j applied environ biol sci. 2012;2(6):249–54. 18. ukpong ig. environmental control of malaria: can citrus sinensis peel be a potent larvicide for household vector control?. gsc biological pharmaceutical sci. 2019;9(3):085–90. 19. bagavan a, rahuman a, kamaraj c, geetha k. larvicidal activity of saponins from achyranthes aspera against aedes aegypti and culex quinquefasciatus (diptera: culicidae). parasitol res. 2008;103(1):223–9. 20. milind p, dev c. orange: range of benefits. int res j pharm. 2012;3(7):59–63. 21. dias c, moraes d. essential oils and their compounds as aedes aegypti l. (diptera: culicidae) larvicides; review. parasitol res. 2014;113(2):565–92. 22. oliviera acsd, fernandes cc, santos ls, candido acbb, magalhães lg, miranda mld. chemical composition, in vitro larvicidal and antileishmanicidal activities of the essential oil from citrus reticulata blanco fruit peel. braz j biol. 2021;83:e247539. 23. niijima a, nagai k. effect of olfactory stimulation with flavor of grapefruit oil and lemon oil on the activity of sympathetic branch in the white adipose tissue of the epididymis. exp biol med. 2003;228(10):1190–2. 24. nagai k, niijima a, horii y, shen j, tanida m. olfactory stimulatory with grapefruit and lavender oils change autonomic nerve activity and physiological function. auton neurosci. 2014;185:29–35. 25. stiles k. the essential oils complete reference guide: over 250 recipes for natural wholesome aromatherapy. salem, ma, usa: page street publishing; 2017. abiodun obembe and opeyemi g. oso: larvicidal effects of citrus peels extracts against culex pipiens mosquitoes althea medical journal. 2022;9(4) 190 26. okunowo w, oyedeji o, afolabi l, matanmi e. essential oil of grape fruit (citrus paradisi) peels and its antimicrobial activities. am j plant sci. 2013;4(7b):1–9. 27. churata-oroya d, ramos-perfecto d, moromi-nakata h, martínez-cadillo e, castro-luna a, garcia-de-la-guarda r. antifungal effect of citrus paradisi “grapefruit”on strains of candida albicans isolated from patients with denture stomatitis. rev estomatol hered. 2016;26(2):78–84. 28. ivoke n, ogbonna pc, ekeh fn, ezenwaji ne, atama ci, ejere vc, et al. effects of grapefruit (citrus paradisi macf) (rutaceae) peel oil against developmental stages of aedes aegypti (diptera: culicidae). southeast asian j trop med public health. 2013;44(6):970–8. 29. pérez-fonseca a, alcala-canto y, salem azm, alberti-navarro ab. anticoccidial efficacy of naringenin and a grapefruit peel extract in growing lambs naturallyinfected with eimeria spp. vet parasitol. 2016;232:58–65. 30. mahanta s, khanikor b. mosquitocidal activity of twenty-eight plant essential oils and their binary mixtures against culex quinquefasciatus, (diptera: culicidae). heliyon. 2021;7(2):e06128. althea medical journal december 2022 amj vol 10 no 1 march 2023 rev.indd althea medical journal. 2023;10(1) 1althea medical journal. 2023;10(1):1–7 determinants of hypertension treatment adherence during the covid-19 pandemic: lesson learned from various studies sites in indonesia raehan satya deanasa,1 alifa alya zalfa,1 lathifah dzakiyyah zulfa,2 nurul mufliha patahuddin,3 sofia hana,3 anak agung bagus putra indrakusuma,4 aizar vesa prasetyo,4 gita julianti malik,5 hesti azzahra tosadapotto,6 raza syahlevi suwandri,6 muhammad nur mahmudi,7 rizma adlia syakurah8 1faculty of medicine, universitas sriwijaya, south sumatera, indonesia, 2faculty of medicine, universitas kristen indonesia, east jakarta, indonesia, 3faculty of medicine, universitas padjadjaran, west java, indonesia, 4faculty of medicine, universitas udayana, bali, indonesia, 5faculty of medicine, universitas halu oleo, southeast sulawesi, indonesia, 6faculty of medicine, universitas pembangunan nasional veteran jakarta, dki jakarta, indonesia, 7faculty of medicine, universitas lambung mangkurat, south kalimantan, indonesia, 8faculty of public health, universitas sriwijaya, south sumatera, indonesia abstract background: hypertension is the most common comorbid disease which can cause further complications in covid-19 patients. on the contrary, the pandemic has also caused lower health services and adherence to hypertension therapy. this study aimed to examine the impact of the covid-19 pandemic on medication adherence in people with hypertension in indonesia. methods: the research was conducted using an analytical quantitative method. patients with hypertension from seven islands across indonesia were recruited based on eligibility criteria during bulan bakti 2021, a social outreach by ikatan senat mahasiswa kedokteran indonesia about basic health across indonesia. the demographic and medication history of the respondents were recorded. the indonesian version of the morisky medication adherence scale (mmas-8) questionnaire was distributed, and the medication adherence level was assessed. results: a total of 1155 patients, mainly females (62.2%) participated in this study. more than half of the patients had low adherence (55.25%). males (adjusted odd ratio (aor) 0.777 [ci 95% 0.529–1.019]), employed (aor 0.857 [ci 95% 0.495–1.483]), higher income (aor 0.522 [ci 95% 0.393–0.713]), and those who had information from healthcare worker (aor 0.583 [ci 95% 0.361–0.878]) were found to have better medication adherence in multivariate logistic regression test. conclusion: medication adherence level in patients with hypertension during the pandemic is markedly low. integrated preventive and promotive measures, especially from healthcare workers, are needed to prevent further morbidity and mortality. keywords: adherence, covid-19, hypertension, indonesia, social determinant of health correspondence: raehan satya deanasa, faculty of medicine, universitas sriwijaya, jalan dr. muhammad ali, sekip jaya, kemuning, palembang, south sumatera, indonesia, e-mail: raehansatyad@gmail.com introduction the presence of comorbid diseases is one of the factors that can increase the risk of infection and worsen the condition of patients with covid-19.1 laboratory confirmed cases of patients with covid-19 and with any comorbidity have worsened clinical outcomes. a higher number of comorbidities is also linked to worse clinical outcomes.2 hypertension is one of the most common comorbid diseases experienced by patients who died from covid-19. about 12% of patients with hypertension diagnosed with covid-19 have a worse outcome.3 hypertension is a noncommunicable disease characterized by a systolic blood pressure greater than or equal to 140 mmhg and diastolic blood pressure of 90 mmhg. hypertension is becoming more common, especially in low-middle-income https://doi.org/10.15850/amj.v10n1.2675 althea medical journal. 2023;10(1) 2 nations, and estimated 31.1% of individuals in the globe had hypertension in 2010. hypertension is more common in low-middle income nations (31.5% or 1.04 billion persons) than in high-income nations (28.5% or 349 million people).4 based on the 2018 riset kesehatan dasar indonesia (riskesdas), the prevalence of hypertension in the population aged over 18 years is around 34.1%, that is increased from 25.8% in 2013.5 interestingly, hypertension is also known as a silent killer because it rarely causes symptoms. this asymptomatic condition is the leading cause of non-adherence to hypertension treatment.6 treatment adherence is one of the efforts to control non-communicable diseases. better controlled hypertension may increase life expectancy, lower the economic burden, and improve quality of life.7 in nepal, indonesia, and several countries in sub-saharan africa and oceania, treatment rates for women are fewer than 25%, and for males, are less than 20%. moreover, women and men in other countries in north africa, central and south asia, and eastern europe have control rates below 10%.8 the recommendation of the joint national committee 7 has revealed that efforts to prevent the worsening of hypertension are lifestyle modifications, starting from diet regulation, increased activity, reduced salt intake, and weight loss. anti-hypertensive drugs as prophylaxis are needed to achieve the target of 135/85 mmhg if the lifestyle modification recommendations are unsuccessful.8 hypertension is considered to be uncontrolled if the systolic blood pressure is 140 mmhg and diastolic blood pressure is 90 mmhg based on an average of three measurements with or without antihypertensive treatment.9 non-adherence to treatment is one of the reasons for uncontrolled hypertension. several studies have shown that the medication adherence rate in developed countries is only 50% and even lower in developing countries. nonadherence to treatment is a big problem because it can lead to treatment failure and increase the possibility of complications.10 several factors associated with treatment non-adherence are the administration of lots of medication, the fear of the side effects, the belief that the condition is getting better, the lack of knowledge about the treatment, and the lack of follow-up to the nearest health facility.11, 12 the covid-19 pandemic may impact on hypertension health services, leading to treatment non-adherence. a study conducted althea medical journal march 2023 by world health organization (who) has shown increased barriers to health care for non-communicable diseases with greater severity of covid-19 transmission. the impact of covid-19 on health services is in the form of restrictions on the procurement of routine follow-ups, the deployment of some staff to serve covid-19 patients, and the unavailability of drugs or other health products.13 a study in the low-resource healthcare setting country found that 40% of patients with hypertension and type 2 diabetes mellitus reported the adverse impact of the covid-19 pandemic on drug availability and routine follow-up schedules, which then led to an increase in patient non-adherence to medication.10 therefore, this study explored the impact of the pandemic on medication adherence in those with hypertension in indonesia by using the modified morisky adherence scale 8 (mmas 8) questionnaire. methods this study was an empirical analytic study, using quantitative approaches with measurement parameters of treatment adherence among those with hypertension during the covid-19 pandemic using questionnaires. this was a multicenter study in indonesia conducted on those diagnosed with hypertension. data collection was conducted by the indonesian medical students executive boards association (imseba) which participated during month of service program (bulan bakti 2021). the scope of the study was limited to variables related to the adherence to treatment of those with hypertension during pandemics. this research was conducted after receiving permission from the ethics commission of the faculty of medicine, sriwijaya university no.093-2021. all of the respondents consented, which was mandatory as a person had the right to choose and needed to know the goals and steps they followed during the study. the well-being, fairness, and life protection of the respondents were maintained by weighing the risks and steps of research implementation. confidentiality of data and the privacy of the respondents were guaranteed. the variable in this study was the level of adherence to the treatment of hypertension during the covid-19 pandemic, which was defined as the observance of those with hypertension to take the treatment as directed by doctors. this variable was measured using eight questionnaire questions from the morisky medication adherence scale in althea medical journal. 2023;10(1) 3raehan satya deanasa et al.: determinants of hypertension treatment adherence during the covid-19 pandemic: lesson learned from various studies sites in indonesia the indonesian version of indonesian that had been validated with cronbach’s alpha coefficient result of 0.824 and test-retest reliability test results using spearman’s rank correlation of 0.881.14 questions in the form of closed questions yes and no and the results of the questionnaire were assessed using the guttman scale which was given as score of 1 if yes and score of 0 if not. the accumulated score was then categorized; if less than 6, then it was categorized as non-adherent, and if it was more than 6 then it was categorized as obedient.15 in this study, the adherence level of respondents was ranged based on mmas-8 score into three groups, low adherence (mmas <6), medium adherence (6 to <8), and high table 1 demographic status of respondents with hypertension (n=1,115) demographic variables n % gender female male 718 437 62.2 37.8 age (year) <40 40–49 50–59 60–69 >70 455 248 274 103 75 39.4 21.5 23.7 8.9 6.5 domicile java sumatra kalimantan sulawesi west nusa tenggara bali papua 614 146 42 127 81 134 11 53.2 12.6 3.6 11 7 11.6 1 level of education elementary junior high senior high bachelor degree or higher 108 78 475 494 9.4 6.8 41.1 42.8 employment status employed unemployed retired 534 74 547 46.2 6.4 47.4 income (idr) >2,843,000 <2,843,000 683 472 59.1 40.9 duration of hypertension <1 year 1–5 year >5 year 587 320 248 50.8 27.7 21.5 complication yes no 973 182 84.2 15.8 source of information family media healthcare worker individual 239 237 545 134 20.7 20.5 47.2 11.6 note: idr= indonesian rupiah althea medical journal. 2023;10(1) 4 adherence (=8). for the analysis purposes, the patients were classified into two, adherence and non-adherence, based on the mmas-8 score; non-adherent (mmas-8 score <6) and adherent (mmas-8 score ≥6).12 univariate analysis was employed using a crosstab between sociodemographic and treatment adherence, followed by a chisquare test.16 multivariate analysis of all independent variables together (overall) was conducted with logistic regression tests when the variable met the criteria to find out how much the variables studied contributed to the adherence to taking hypertension drugs during the covid-19 pandemic and how many factors outside the study were able to influence it. the regression test was used to identify the most important independent variables. results a total of 1,155 respondents with hypertension participated in this study, of whom 50.85% had hypertension for <1 year and 84.2% had complications. the majority of respondents were females (62.2%) and categorized into four groups of age namely <40 years old (39.4%), 40–49 years old (21.5%), 50–59 years old (23.7%), 60–69 years old (8.9%), and >70 years old (6.5%). most of the patients’ domiciles were in java (53.2%), followed by sumatra (12.6%), bali (11.6%), sulawesi (11%), and others, as shown in table 1. those with higher education, including high school and bachelor’s or higher, were the largest in level education. the participants were more likely retired (47.4%) or employed (46.2%). most respondents received information from a health care worker (47.18%), contributing to 56.91% of respondents with high adherence to medication (table 2). of 1,115 respondents, most were in low adherence (55.25%) classification. there was 616 subjects who adhered to and 539 subjects who were non adhere to hypertension treatment. after a stepwise test that eliminated insignificant variables, the final model was obtained. the logistic regression analysis identified the predicting factor for medication adherence. male (aor 0.777 [ci 95% 0.529–1.019]) had better treatment adherence than female. retirees were 0.857 times to be non-adhere or were known to have a lower chance to nonadhere to the treatment than the unemployed patients (aor 0.857 [95% ci: 0.495–1.483). a patient who had income over the minimum wage (>rp2,843,000) would non-adhere half times compared to the patients who have income below (aor 0.522 [95% ci: 0.393– 0.713). in this study, source information on hypertension is also known to be the one factor of treatment adherence. patient who got information from family (aor 0.816 [95% ci: 0.498–1.337) and healthcare (aor 0.583 [95% ci: 0.361–0.878) workers had the lower chance to non-adhere compared to the patient who got the information independently. discussion women with hypertension (n=718, 62.2%) participated more in this study than men (37.8%). this is consistent with the indonesia family life survey (ifls-5), where the prevalence of women is higher than that of men in indonesia.15 differences in gender and age would affect the probability of hypertension events. at the age of >60 years, women are more likely to have hypertension than men since women experience the menopause period, which involves hormonal changes that increase blood pressure.16 the female respondents with hypertension treatment in our study had lower adherence than males (p<0.001). however, another study has shown that women are more likely to adhere to hypertension medication because female are more aware of individual health due to the availability of time and opportunities to visit treatment centers than males.17 our study shows that a person at work has a lower risk of non-adherence to treatment than other employment statuses. this result is different from several previous studies, showing that people who work are even more althea medical journal march 2023 table 2 adherence level of respondents with hypertension from seven islands across indonesia (n=1,115) adherence level (score) n % low adherence (<6) 616 55.2 medium adherence (6 to <8) 416 37.3 high adherence (=8) 123 11 althea medical journal. 2023;10(1) 5 difficult to come to the health service unit for treatment.18–20 interestingly, our study also shows that someone with an income lower than idr 2,800,000 is at risk for more disobedience. the salary factor for those with an income above the minimum wage in jakarta is 6.08 times more adherence to treatment.21 all respondents had access to information about hypertension, diet, and lifestyle. most of them get information related to hypertension and lifestyle from health care workers (47.18%), others get from family members or table 3 bivariable and multivariable analysis results demographic variables total study population crude odds ratio adjusted odds ratio n % cor 95% ci (minmax) p aor 95% ci (min-max) p gender female male 718 437 62.2 37.8 1 0.821 0.636-1.058 0.128 1 0.777 0.529-1.019 0.069 age (year) <40 40–49 50–59 60–69 >70 455 248 274 103 75 39.4 21.5 23.7 8.9 6.5 1 0.874 0.783 0.907 0.77 0,625-1.222 0.568-1.079 0.570-1.442 0.459-1.291 0.432 0.135 0.679 0.322 domicile java sumatra kalimantan sulawesi west nusa tenggara bali papua 614 146 42 127 81 134 11 53.2 12.6 3.6 11 7 11.6 1 1 0.768 1.095 1.065 1.429 0.691 1.168 0.526-1.122 0.549-2.185 0.700-1.621 0.831-2.457 0.469-1.018 0.306-4.451 0.173 0.797 0.768 0.197 0.061 0.820 level of education elementary junior high senior high bachelor degree or higher 108 78 475 494 9.4 6.8 41.1 42.8 1 2.045 1.502 1.285 1.245-3.359 0.881-2.560 0.982-1.681 0.005 0.135 0.068 employment status employed unemployed retired 74 534 547 6.4 46.2 47.4 1 0.624 1.1259 0.380-1.022 0.895-1.502 0.061 0.263 1 0.857 1.776 0.495-1.483 1.276-2.474 0.582 0.001 income (idr) >2.843.000 <2.843.000 472 683 40.9 59.1 1 0.666 0.518-0.856 0.002 1 0.522 0.393-0.713 <0.001 duration of hypertension <1 year 1–5 year >5 year 248 320 587 21.5 27.7 50.8 1 1.013 1.202 0.738-1.391 0.839-1.722 0.934 0.315 complication yes no 973 182 84.2 15.8 1 0.724 0.506-1.035 0.077 source of information family media healthcare worker individual 134 239 237 545 11.6 20.7 20.5 47.2 1 0.893 0.641 0.631 (0.893-0.549) (0.641-0.398) (0.631-0.410) 0.650 0.067 0.036 1 0.816 0.616 0.583 0.498-1.337 0.380-1.001 0.361-0.878 0.419 0.050 0.011 raehan satya deanasa et al.: determinants of hypertension treatment adherence during the covid-19 pandemic: lesson learned from various studies sites in indonesia althea medical journal. 2023;10(1) 6 neighbors (20.69%), and media information either online or print media (11.6%). respondents who sought information from a healthcare worker have high adherence.22 an effective way to deliver information is by direct contact with active interaction between patients and healthcare workers, which can increase patients’ adherence to medication.23 the limitation of this study is that the lots of laboratory needs to be improved. however, this research included large samples, minimizing fault in result and conclusion. in conclusion, adherence level to medication in patients with hypertension during the pandemic is lower in females, non-employed, and lower-income. the source of information from non-healthcare workers might give barriers to the patients. low adherence may result in higher complications. thus educational intervention is essential to highrisk low-adherent groups, primarily in the covid-19 pandemic era. integrated preventive and promotive measures, especially from healthcare workers, are needed to prevent further morbidity and mortality. acknowledgment the researchers are thankful to the community empowerment division of ikatan senat mahasiswa kedokteran indonesia (ismki) year 2021/2022 and the contributing institution for the 2021 ismki month of service (bulan bakti) for their coordination in taking the data. references 1. susilo a, rumende cm, pitoyo cw, santoso wd, yulianti m, herikurniawan h, et al. coronavirus disease 2019: tinjauan literatur terkini. jurnal penyakit dalam indonesia. 2020;7(1):45–67. 2. guan wj, liang wh, zhao y, liang hr, chen zs, li ym, et al. comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis. eur respir j. 2020;55(5):2000547. 3. gunawan a, prahasanti k, utama mr. pengaruh komorbid hipertensi terhadap severitas pasien yang terinfeksi covid 19. jurnal implementa husada. 2020;1(2):136–51. 4. mills kt, stefanescu a, he j. the global epidemiology of hypertension. nat rev nephrol. 2020;16(4):223–37. 5. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. laporan nasional riskesdas 2018. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan; 2020. 6. nurhidayati i, aniswari, ay, sulistyowati ad, dan sutaryono s. penderita hipertensi dewasa lebih patuh daripada lansia dalam minum obat penurun tekanan darah. jurnal kesehatan masyarakat indonesia. 2018;13(2):1–5. 7. chaker l, falla a, vander ls, muka t, imo d, jaspers l, et al. the global impact of noncommunicable disease on macro-economic productivity: a systematic review. eur j epidemiol. 2015;30(5):357–95. 8. ncd risk factor collaboration (ncdrisc). worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. lancet. 2021;398(10304):957–80. 9. page mr. the jnc-8 hypertension guidelines: an in-depth guide. am j manag care. 2014;20(1 spec no):e8. 10. shimels t, kassu ra, bogale g, bekele m, getnet m, getachew a, et al. magnitude and associated factors of poor medication adherence among diabetic and hypertensive patients visiting public health facilities in ethiopia during the covid-19 pandemic. plos one. 2021;16(4): e0249222. 11. srikartika vm, cahya ad, hardiati rsw. analisis faktor yang memengaruhi kepatuhan penggunaan obat pasien diabetes mellitus tipe 2. jurnal manajemen dan pelayanan farmasi. 2016;6(3):205– 12. 12. singh m, lal p. non-communicable diseases: challenges and impact of covid-19 pandemic. indian pract. 2020;73(11):30–6. 13. world health organization ncd department. rapid assessment of service delivery for ncds during the covid-19 pandemic. geneva: who; 2020. 14. riani da. validasi 8-item morisky medication adherence scale versi indonesia pada pasien hipertensi dewasa di puskesmas kabupaten sleman dan kota yogyakarta [thesis]. yogyakarta: universitas gadjah mada; 2017. 15. khayyat sm, hyat ars, alhazmi rsh, mohamed mm, abdul hm. predictors of medication adherence and blood pressure control among saudi hypertensive patients attending primary care clinics: a cross-sectional study. plos one. 2017;12(1):e0171255. 16. bantas k, gayatri d. gender and althea medical journal march 2023 althea medical journal. 2023;10(1) 7 hypertension (data analysis of the indonesia basic health research 2007). jurnal epidemiologi kesehatan indonesia. 2019 ;3(1):7–18. 17. bidmon s, terlutter r. gender differences in searching for health information on the internet and the virtual patient-physician relationship in germany: exploratory results on how men and women differ and why. j med internet res. 2015;17(6):e156. 18. cho sj, kim j. factors associated with nonadherence to antihypertensive medication. nurs health sci. 2014;16(4):461–7. 19. listiana d, effendi s, saputra ye. faktorfaktor yang berhubungan dengan kepatuhan penderita hipertensi dalam menjalani pengobatan di puskesmas karang dapo kabupaten muratara. journal of nursing and public health. 2020;8(1):11–22. 20. tambuwun aa, kandou gd, nelwan je. hubungan karakteristik individu dengan kepatuhan berobat pada penderita hipertensi di puskesmas wori kabupaten minahasa utara. jurnal kesmas. 2021;10(4):112–21. 21. pratiwi w, harfiani e. faktor-faktor yang berhubungan dengan kepatuhan dalam menjalani pengobatan pada penderita hipertensi di klinik pratama gki jabar jakarta pusat. prosiding seminar nasional riset kedokteran (sensorik). 2020;1(1):27–40 22. sinuraya rk, destiani dp, puspitasari im, diantini a. tingkat kepatuhan pengobatan pasien hipertensi di fasilitas kesehatan tingkat pertama di kota bandung. jurnal farmasi klinik indonesia. 2018;7(2):124– 33. 23. lu ch, tang st, lei yx, zhang mq, lin wq, ding sh, et al. community-based interventions in hypertensive patients: a comparison of three health education strategies. bmc public health. 2015;15:33. raehan satya deanasa et al.: determinants of hypertension treatment adherence during the covid-19 pandemic: lesson learned from various studies sites in indonesia amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 181 transfusion reactions in pediatric cancer patients cakra jati pranata,1 nur suryawan,2 delita prihatni3 1faculty of medicine universitas padjadjaran, indonesia, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: cakra jati pranata, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, email: cakrajatipranata@gmail.com introduction suppression of bone marrow is frequently occurred in patients with cancer due to its disease as well as an effect of chemotherapy, resulting in a decrease of red cells, leucocytes, and platelets. the primary management of low red cells and platelet counts or anemia and thrombocytopenia, respectively, is blood transfusion which is an essential component of supportive management.1 generally, transfusion tends to be safe and has many benefits, however, there is still a risk and complication known as transfusion reactions.1 these reactions vary from mild to life-threatening. reactions can occur during transfusion (acute reactions) or in days, even weeks, after the transfusion (delayed reactions).2 several factors that affect transfusion reactions, among others the patient comorbidity.3 due to a decrease of immunity, patient with cancer tends to suffer from transfusion reactions.4 moreover, discrepancy on blood cell antigen5 is also related to a higher risk of reaction from a blood transfusion.3 the recommendation of blood transfusion to patients with cancer is a modification component of packed red cells or thrombocyte concentrate of which the leukocyte component has been reduced and irradiated.6 however, some places still use conventional packed red cells and thrombocyte concentrate that might increase the risk of transfusion reactions.6 amj. 2020;7(4):181–6 abstract background: transfusion is an essential component of supportive management for cancer patients with anemia and thrombocytopenia. it is generally safe; however, it has several risks and complications including those caused by transfusion reactions. this study aimed to describe transfusion reactions in pediatric cancer patients in a tertiary hospital in indonesia. methods: this was a descriptive cross-sectional study with a total sampling method. a prospective analysis was performed on episodes of blood transfusion in pediatric patients aged younger than 18 years old with cancer and were hospitalized at the department of child health of the hospital from july to august 2019. after the consent of the parents, the patients were interviewed for various transfusion reactions. data collected were presented using tables and charts. results: leukemia was the most frequent cancer in children cancer patients who need transfusion. out of 42 children included, 155 episodes of transfusion were observed with 22 episodes showed transfusion reactions (14.2%). the most frequent manifestations were pruritus (31.8%), followed by combination of pruritus and erythema (27.4%) and fever (13.6%). these reactions appeared mostly in 1 to 2 hours (27.2%), with most were mild reactions (59.1%). conclusions: transfusion reactions mostly occur among pediatric patients with cancer in the acute phase with clinical manifestation of allergic reactions, predominantly mild. early identification of these reactions will result in better treatment and prevention for recurrence of transfusion reactions. keywords: allergy, cancer, children, leukemia https://doi.org/10.15850/amj.v7n4.1820 althea medical journal. 2020;7(4) 182 amj december 2020 data on transfusion reactions among pediatric cancer patients at dr. hasan sadikin general hospital bandung as a referral hospital in west java is still limited. therefore, the study on transfusion reactions among pediatric patients with cancer was explored. methods this study design was a cross-sectional study with a descriptive approach. the technique of data collection was the total sampling method. a prospective analysis was performed on all pediatric patients aged younger than 18 years old that were diagnosed with cancer and hospitalized at dr. hasan sadikin bandung general hospital from july to august 2019. data about reaction transfusion was collected by using a standardized closed question interview method based on the form of transfusion reaction report from the department of clinical pathology dr. hasan sadikin bandung general hospital. data were analyzed according to their transfusion episode established, based on the transfusion time and blood component. the exclusion criteria were the patient who did not fill in the questionnaire. the data was taken daily, for table 1 clinical characteristic of pediatrics patients with cancer undergone blood transfusion in dr. hasan sadikin general hospital bandung period july–august 2019 total (n=43) n % age group 0–<5 years old 10 23.8 5–<10 years old 13 31.0 10–18 years old 19 45.2 gender male 19 54.8 female 23 45.2 blood type a 15 35.7 b 8 19.0 ab 6 14.3 o 13 31.0 rhesus + 41 97.6 rhesus 1 2.4 clinical diagnosis acute leukemia 1 2.4 acute myeloblastic leukemia 7 16.7 acute lymphoblastic leukemia 22 52.4 chronic myeloblastic leukemia 1 2.4 neuroblastoma 2 4.8 retinoblastoma 2 4.8 osteosarcoma 5 11.9 non hodgkin’s cancer lymphoma 1 2.4 hodgkin’ cancer lymphoma 1 2.4 althea medical journal. 2020;7(4) 183cakra jati pranata et al.: transfusion reactions in pediatric cancer patients 30 consecutive days at a time. after informed consent to the parents, the interview was conducted with both parents and patients. the patient aged older than 12 years old was interviewed using the auto anamnesis method, and for patients aged younger than 12 years old using alloanamnesis method. the data that was gathered then reviewed in the form of blood transfusion monitoring data that was recorded in the medical record of the patient. this study was approved by the research ethics committee of universitas padjajaran no. 120/ul6.kp/et/2019 and permission was given by the medical research ethics committee of dr. hasan sadikin general hospital bandung no. lb/x.3/102/2018. variables of this study were patient identity (age, sex, blood type, and clinical diagnosis), transfusion episode (blood components), and transfusion reactions (clinical manifestation and onset). the data were analyzed using descriptive statistics and processed by using microsoft® excel 2016 and ibm® spss® version 22. the data was then presented in the form of a table, percentage, and chart to draw patient identity, transfusion episodes, and transfusion reactions. results in total, data on 42 patients with one hundred fifty-five episodes of transfusion were collected. blood transfusion was mostly given to males (54.8%). about half of the patients (45.2%) were in the age group 10 to 18 years old. the most blood type in this study was blood type a (35.7%) and rhesus (+) (97.6%). the clinical diagnosis was acute table 2 clinical manifestation of transfusion reactions based on blood components clinical manifestation blood components total packed red cells thrombocyte concentrate n % n % n % fever, pruritus, and erythema 1 4.5 1 4.5 2 9.1 pruritus and erythema 4 18.3 2 9.1 6 27.4 fever and shortness of breath 1 4.5 1 4.5 pruritus 3 13.5 4 18.3 7 31.8 shortness of breath 1 4.5 1 4.5 fever 2 9.1 1 4.5 3 13.6 shivering 1 4.5 1 4.5 back pain 1 4.5 1 4.5 table 3 clinical manifestation of transfusion reactions by the diagnosis clinical manifestation diagnosis total leukemia non-leukemia n % n % n % fever, pruritus, and erythema 2 9.1 0 0 2 9.1 pruritus and erythema 4 18.3 2 9.1 6 27.4 fever and shortness of breath 1 4.5 1 4.5 pruritus 5 22.7 2 9.1 7 31.8 shortness of breath 1 4.5 1 4.5 fever 3 13.6 3 13.6 shivering 1 4.5 1 4.5 back pain 1 4.5 1 4.5 althea medical journal. 2020;7(4) 184 amj december 2020 leukemia lymphoblastic (52.4%), followed by acute myeloblastic leukemia (16.7%). of 155 transfusion episodes, 22 episodes had transfusion reactions (14.2%) experienced by thirteen patients of whom two patients had repeated reactions. thrombocyte concentrate was frequently used in transfusion (54.2%), followed by packed red cells (45.8%). the clinical manifestations due to transfusion reactions were pruritus (31.8%), followed by both pruritus and erythema (27.4%) and fever (13.6%). while investigating the reactions based on blood components, packed red cell was the component that was more related to transfusion reactions (54.4%) as shown in table 2. furthermore, leukemia was the most manifestation related to transfusion reactions (table 3). based on the onset, most of the transfusion reactions occurred within 1 to 2 hours after starting transfusion (27.2%) as depicted in table 4. in this acute transfusion reaction, 59.1% experienced a mild reaction. discussions this study has reported that the age group of 10 to 18 years and male are predominantly given a blood transfusion, similar to the study from brazil.7 based on epidemiological studies, cancer occurring between the ages of 15 and 30 years is 2.7 times more common than cancer occurring during the first 15 years of life.8 susceptibility to cancer is generally higher in males, although some cancers are more common in women.9 lymphoblastic leukemia acute is a type of cancer that frequently needs a transfusion.7 leukemia is one of the most prevalent cancers in indonesia. of 155 transfusion episodes, transfusion reactions have been reported in 22 episodes (14.2%). leukemia requires transfusion intensively and this cancer is the most cancer related to repeated transfusion reactions. repeated blood transfusions might be associated with the production of alloantibodies against one or more antigens, which complicate subsequent transfusions, including the increased risk of delayed transfusion reactions.10 furthermore, repeated transfusion reactions are also associated with patient comorbidity.3 interestingly, the number of transfusion reactions in our study is relatively higher compared with the study conducted in brazil that reported transfusion reactions of 1.13%.11 generally, a patient with cancer is immune suppressed, leading to an increase in transfusion reaction risks.4 one of the reasons is the inability of the immune system to reject antigen received during transfusion, due to immunodeficiency states of b and t lymphocytes. patients with cancer may have an undetected immunoglobulins level that causes the presence of discrepancy in blood cell antigen.5 moreover, aside from cancer itself, the use of blood components affects transfusion reactions as well.12 the study in blood bank hospital has established a protocol that patients with cancer should be given leuco-depleted blood table 4 distribution of transfusion reactions based on onset transfusion reactions n % onset 0–15 minutes 1 4.5 >15–30 minutes 4 18.3 >30 minutes–1 hour 3 13.7 >1–2 hours 6 27.2 >2–3 hours 3 13.7 >3 hr 5 22.6 type of acute transfusion reaction mild 13 59.1 moderate-severe 7 31.8 life-threatening 2 9.1 althea medical journal. 2020;7(4) 185 components.7 in contrast, most of the blood components for blood transfusion given to patients in this study are thrombocyte concentrate and followed by packed red cells; no leuco-depleted blood component. packed red cells and thrombocytes can contain leukocytes, higher than the leuco-depleted blood component.13 this affects the component containing human leukocyte antigen (hla) and proinflammatory cytokines such as il1β, il-6, il-8, and tnf that are relatively high and can increase the incidents of transfusion reactions, especially non-hemolytic reactions.6 the use of leuco-depleted blood component is more effective to reduce the risk of transfusion reactions.12 furthermore, our study has shown that most of the transfusion reactions have been recorded in the acute phase (>24 hours) with most patients experienced mild reactions. interestingly, transfusion reactions can occur in a shorter onset, which is within the first hour,14 or even in 15 minutes after starting transfusion.1 taken together, the transfusion reactions are acute and not delayed. one possibility is an increased th2 and decreased th1 profile that is related to an increase risk of hypersensitivity.15 ige recipients may react to the donor of plasma protein that tends to release mast cell mediators.16 this phenomenon also explains that the clinical manifestation of pruritus appeared the most. similar to the study in brazil, exposed allergic reactions is transfusion reactions that are generally occurring within pediatric patients with cancer.3 however, a fever could be the most frequent transfusion reaction as opposed in a study from uganda.11 interestingly, the number of pruritus incidents is high, suggesting as one of the allergic manifestations (31.8%) shows in a relationship of patients’ age on transfusion reactions. the children aged 1 to 2 years old tend to be more susceptible to nonhemolytic transfusion reactions, whereas those older than 2 years are prone to experience allergic reactions, nevertheless, it may be required further study.3 this study has limitations among others that the transfusion reactions result is not from observation but interview. the data might give a recall bias. a good clinical observation is the need for further study. to conclude, transfusion reactions in children with cancer mostly occur in leukemia with frequent allergic reactions as clinical manifestation. the onset is acute with most experienced as a mild reaction. since the occurrence of transfusion reactions in children with cancer is relatively higher than total transfusion reactions at dr. hasan sadikin general hospital, it requires an effort to decrease and prevent repeated transfusion reactions by utilizing the leukocyte-reduction technology and gamma irradiation. the form for transfusion reactions needs to be improved as monitoring and evaluation of the occurrence of transfusion reaction. references 1. chakravarty-vartak u, shewale r, vartak s, faizal f, majethia n. adverse reactions of blood transfusion: a study in a tertiary care hospital. int j sci stud 2016;4(2):90–4. 2. payung w, rachmawati am, arif m. factors in acute transfusion reaction. indonesian journal of clinical pathology and medical laboratory. 2016;22(3):274–8. 3. pedrosa ak, pinto fj, lins ld, deus gm. blood transfusion reactions in children: associated factors. j pediatr (rio j). 2013;89(4):400–6. 4. dasararaju r, marques mb. adverse effects of transfusion. cancer control. 2015;22(1):16–25. 5. subramaniyan r, gaspar bl. a closer look into blood group discrepancy arising due to an underlying malignancy. rev bras hematol hemoter. 2016;38(4):361–3. 6. simancas-racines d, osorio d, marticarvajal aj. arevalo-rodriguez i. leukoreduction for the prevention of adverse reactions from allogeneic blood transfusion. cochrane database syst rev. 2015;(12):cd009745. 7. de freitas jv, de almeida pc, guedes mvc. transfusion reactions profile in oncology pediatrics patients. j nurs ufpe on line. 2014;8(7):3030–8. 8. bleyer a, viny a, barr r. cancer in 15to 29-years-olds by primary site. oncologist. 2006;11(6):590–601 9. dorak mt, karpuzoglu e. gender differences in cancer susceptibility: an inadequately addressed issue. front genet. 2012;3:268 10. bhuva dk, vachhani j. red cell alloimmunization in repeatedly transfused patients. asian j transfus sci. 2017;11(2):115–20. 11. waiswa mk, moses a, seremba e, ddungu h, hume ha. acute transfusion reactions at a national referral hospital in uganda: a prospective study. transfusion. 2014;54(11):2804–10. 12. kato h, uruma m, okuyama y, fujita h, cakra jati pranata et al.: transfusion reactions in pediatric cancer patients althea medical journal. 2020;7(4) 186 amj december 2020 handa m, tomiyama y, et al. incidence of transfusion-related adverse reactions per patient reflects the potential risk of transfusion therapy in japan. am j clin pathol. 2013;140(2):219–24. 13. nency ym, sumanti d. penggunaan transfusi komponen darah pada anak. sari pediatr. 2011;13(3):159–64. 14. apriastini nkt, ariawati k. risk factors of acute blood transfusion reactions in pediatric patients in sanglah general hospital. bali med j. 2017;6(3):534–8. 15. yanagisawa r, shimodaira s, sakashita k, hidaka y, kojima s, nishijima f, et al. factors related to allergic transfusion reactions and febrile non-haemolytic transfusion reactions in children. vox sang. 2016;110(4):376–84 16. sharma s, sharma p, tyler ln. transfusion of blood and blood products: indications and complications. am fam physician. 2011;83(6):719–24. althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 17 correspondence: reemarachna poravi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone : 08170209211, email : reema_pillay@hotmail.com salmonella sp. and shigella sp.in house flies in jatinangor reemarachna poravi,1 ramlan sadeli,2 berlian isnia fitrasanti,3 sunaryati sudigdoadi 2 1faculty of medicine, universitas padjadjaran, 2department of microbiology, faculty of medicine, universitas padjadjaran, 3department of forensics and medicolegal, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: diarrhea is a common problem in indonesia and mostly caused by pathogenic bacteria such as salmonella sp. and shigella sp., transmitted by house flies. the incidence of acute diarrhea has been rising over the years. the aim of this study is to determine if salmonella sp. and shigella sp. can be found in house flies in jatinangor. methods: a descriptive study was done, involving 20 samples of house flies caught from houses and street vendors in jatinangor during the period of march 2012 to january 2013. bacteria were isolated from house flies and identified using various biochemical tests. results: shigella sp. was isolated from 5% of the house flies caught in jatinangor. the house flies caught from the street vendors revealed a higher percentage of bacteria than those caught from houses. conclusion: only shigella sp. can be isolated from house flies in jatinangor. however, a small percentage of shigella sp. was also found from the house flies captured around jatinangor. [amj.2014;1(1):17–20] keywords: house flies, salmonella sp., shigella sp. salmonella sp. dan shigella sp. pada lalat rumah di jatinangor abstrak latar belakang: di indonesia, diare merupakan masalah kesehatan yang sering terjadi dan sebagian besar disebabkan oleh bakteri pathogen seperti salmonella sp. and shigella sp yang terdapat pada lalat rumah. angka kejadian diare akut terus meningkat dari tahun ke tahun. tujuan dari penelitian ini adalah untuk menemukan bakteri salmonella sp. dan shigella sp. pada lalat rumah di jatinangor. metode: penelitian ini merupakan penelitian deskriptif yang melibatkan 20 sampel lalat rumah yang ditangkap dari rumah dan pedagang kaki lima (pkl) di jatinangor selama periode maret 2012–januari 2013. bakteri diisolasi dari lalat rumah dan diidentifikasi dengan menggunakan berbagai tes biokimia. hasil: shigella sp. diisolasi dari 5 % lalat rumah yang tertangkap di jatinangor . lalat rumah yang ditangkap dari pkl mempunyai persentase yang lebih tinggi daripada bakteri yang ditangkap dari rumah. simpulan: hanya shigella sp. yang dapat diisolasi dari lalat rumah di jatinangor. sebagian kecil dari shigella sp. juga ditemukan dari lalat rumah yang ditangkap di sekitar jatinangor. kata kunci: lalat rumah , salmonella sp , shigella sp introduction incidence of acute diarrhea and typhoid has been rising over the years. in indonesia, diarrhea is indeed a major public health concern.1-4 this is supported with the fact that indonesia is among one of the few countries with low sanitation and food hygiene levels.4 apart from that, diarrhea cases among medical students studying in indonesia are identified every year. salmonella sp. and shigella sp. accounts for most of the diarrhea cases that occur worldwide.3,5 muscadomestica or house fly is known to be a potent vector in transmitting althea medical journal. 2014;1(1) 18 amj june, 2014 table 1 percentage of sample with positive results for different tests by place house flies caught in houses (n=10) house flies caught in street vendors (n=10) lactose 0 10% gas 80% 60% h2s 10% 10% mobility 90% 70% indole 50% 40% urease 70% 40% citrate 70% 80% table 2 identification of the bacteria by biochemical test results samples caught from houses bacteria samples caught from street vendors bacteria 1 shigella sp. a providenciarettgeri 2 providenciarettgeri b proteus mirabilis 3 proteus mirabilis c proteus vulgaris 4 serratia sp. d no gram negative bacteria 5 proteus mirabilis e serratia sp. 6 providenciarettgeri f enterobacter cloacae 7 serratia sp. g klebsiellaoxytoca 8 proteus vulgaris h hafniaalvei 9 providenciarettgeri i proteus vulgaris 10 providenciarettgeri j serratia sp. these pathogenic bacteria.6 however, whether the house fly is a potent vector in transmitting these bacteria in jatinangor is still questionable. this research is conducted to determine if salmonella sp. and shigella sp. can be isolated from house flies in jatinangor. the results of this research will serve as an additional knowledge and can be used as a guide for defining preventive measures to be taken. methods this is a descriptive study involving 20 samples of house flies caught from houses and street vendors in jatinangor during the period of march 2012 to january 2013. twenty house flies were caught around jatinangor using an electric net and used as sample. the common places where house flies can be easily found namely houses and street vendors were included as the source of sample collection. injured house flies were excluded from the study. the house flies caught were then soaked in tryptic soy broth (tsb) and were incubated at 37ºc for a day.7-9as for the bacterial isolation, the solution used for soaking the house flies was cultured on mac conkey agar. the agar was incubated at 37ºc for 24 hours.9,10 after one day, the colonies that were streaked on the mac conkey agar were analyzed and the non-lactose fermented colonies were distinguished from the lactose fermented ones. the non-lactose fermented colonies were stained using gram staining to identify gram negative rods. various biochemistry tests such as kligler iron agar (kia), motility, indole and urease (miu) agar and citrate agar were performed on the samples that revealed gram negative rods. the results were interpreted and a comparison on the bacteria species found were made between the samples of house flies caught from houses and street vendors.9,10 results the majority of the bacteria isolated from the house flies show lactose negative results (table 1). eighty percents of the samples althea medical journal. 2014;1(1) 19 caught from houses and 60% of the samples caught from street vendors revealed positive gas test. most of the bacteria present in the samples caught from houses showed a higher percentage for mobility and indole and urease productions compared to those caught from street vendors. furthermore, the samples of house flies caught from street vendors revealed a higher percentage of bacteria that generate energy from citrate, thus exhibit a positive result. the interpretation of the results from the biochemical tests was matched accordingly to identify the bacteria. the various types of bacteria found in each sample of house flies caught (table 2). discussion based on the results of this study, there were many types of enteric bacteria found in jatinangor. the percentages of salmonella sp. and shigella sp. found were 5% and 0% respectively. the other samples from the same set of house flies caught revealed 25% of providenciarettgeri, 20% of serratia sp., 15% of proteus mirabilis, 15% of proteus vulgaris, 5% of enterobacter cloacae, 5% of klebsiellaoxytoca and 5% of hafniaalvei. only one of the 20 samples revealed no gram negative bacteria. these results may be less satisfactory because of the short study time. salmonella sp. has the potential of infecting house flies during the later stages of adult house flies’ life. this could probably be a reason why no salmonella sp. was found. this finding is similar to the findings of a research that involved isolating salmonella sp. from house flies for 5 years.11,12 furthermore, a small sample size were used in this study due to the limited time when larger sample sizemay yield highly positive results for the bacteria isolated from the house flies due to a higher number of bacteria isolated.11 there is also a possibilitythat the bacteria present in the house flies were killed by the electricity produced by the electric net during sample collection activity. however, this fact is still unknown and it is considered to be a study limitation. in comparison with a study done in malaysia, the identification of bacteria found in both studies is roughly the same.9this could be due to the similarity ingeographical location between malaysia and indonesia. moreover, another study done in iran revealed that the highest proportion of bacteria found was escherichia coli (36.5%) and proteus sp.(14.8%). the study also revealed that there were not many enterobacteriaceae found.13in comparisons with this study, proteus covers about 30% of the entire samples. the varied results may probably due to the differences in geographical location, climate and temperature. providenciarettgeri, serratia sp. and proteus sp. are known to cause urinary tract infections in humans. proteus sp., enterobacter cloacae and klebsiellaoxytocainhabit the human intestinal tract, but they may travel to other organs or structures causing other diseases. hafniaalvei is rarely considered to be pathogenic.14 among the 20 house flies caught as sample, one sample revealed that there were only lactose fermented colonies present. this result does not prove or conclude that there are no pathogenic bacteria found, as the lactose fermented colonies may consist of pathogenic bacteria. from table 2, it can be proven that there are more bacteria isolated from the house flies caught from street vendors than the ones caught from houses around jatinangor. therefore, an assumption can be made based on this finding that street vendors are generally not a safe place to eat and measures are required to educate people on actions such as proper hand washing technique before and after meal, make sure that the food should be fresh and not prepared long beforehand. references 1. yusmidiarti. environmental health facilities and women behavior and diarrhea incidence in under five in work area of pasar ikan community health center, teluk segara subdistrict, bengkulu municipality, in 2010 [thesis].yogyakarta: gadjah mada university; 2011. 2. farthing m, lindberg g, dite p, khalif i, salazar-lindo e, ramakrishna bs, et al. world gastroenterology organisation practice guideline: acute diarrhea. milwaukee: world gastroenterology organisation; 2008. 3. simpson e, wittet s, bonilla j, gamazina k, cooley l, winkler jl. use of formative research in developing a knowledge translation approach to rotavirus vaccine introduction in developing countries. bmc public health. 2007;7:281. reemarachna poravi, ramlan sadeli, berlian isnia fitrasanti, sunaryati sudigdoadi: salmonella sp. and shigella sp.in house flies in jatinangor althea medical journal. 2014;1(1) 20 amj june, 2014 4. fening ko, edoh da. the impact of socioeconomic status and sanitation levels on the prevalence of diarrheal diseases in the akim oda area of ghana. the internal journal of epidemiology [online journal] 2009 [cited 2012 july 26].available from: http://www.ispub.com/ 5. ogg b, cochran s. flies in the home. lincoln: university of nebraska–lincoln extension lancaster county; 2012 [cited 2012 june 26]; available from: http://lancaster.unl. edu/pest/resources/flies015.shtml. 6. townsend l. entfact-506: how far can house flies fly? department of entomology, college of agriculture, food and environment, university of kentucky; 2010 [cited 2012 july 29]; available from: http://www2.ca.uky.edu/entomology/ entfacts/ef506.asp 7. ngan v. maggot debridement therapy. new zealand: dermnet nz; 2005; [cited 2012 july 26]; available from: http://dermnetnz. org/procedures/maggots.html. 8. collier r. new interest in maggot therapy. cmaj. 2010;182(2):e121–2 9. nazni wa, seleena b, lee.hl, jeffery j, trogayah ta, sofian ma. bacteria fauna from the house fly, muscadomestica (l.). trop biomed. 2005;22(2):225–31. 10. butler jf, garcia-maruniak a, meek f, maruniak je. wild florida house flies (muscadomestica) as carriers of pathogenic bacteria. florida entomologist. 2010;93(2):218–23 11. durham s. shoo fly! roke of house flies in spreading salmonella in poultry. agricultural research magazine. 2008; 56(3):22 12. uesugi ar, danyluk md, mandrell re, harris lj. isolation of salmonella enteritidis phage type 30 from a single almond orchard over a 5-year period. j food prot. 2007;70(8):1784–9. 13. lowe c, willey b, o’shaughnessy a, lee w, lum m, pike k, et al. outbreak of extended-spectrum β-lactamase– producing klebsiellaoxytoca infections associated with contaminated hand washings inks. emerg infect dis. 2012; 18(8):1242–7. 14. podschun r, fischer a, ullmann u. characterisation of hafniaalvei isolates from human clinical extra-intestinal specimens: haemagglutinins, serum resistance and siderophore synthesis. j med microbiol. 2001;50(3):208–14. althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 25 effects of bengkoang (pachyrhizus erosus (l) urb juice in hampering blood glucose in rat models adrian dwiputra widyarman1, emma nurdiamah2, nanny natalia muliani soetedjo3 1faculty of medicine, universitas padjadjaran, bandung, indonesia 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of internal medicine, faculty of medicine, universitas padjadjaran/dr hasan sadikin general hospital, bandung, indonesia abstract background : the prevalence of diabetes mellitus in indonesia tends to increase and is predicted to reach 21.3 millions in 2030. bengkoang (pachyrhizus erosus (l) urb. is one of the traditional medicine frequently used in diabetes treatment.the objective of this study is to assess the effectiveness of bengkoang juice in hampering blood glucose increase. methods : fourty alloxan-induced diabetic wistar rats were used in this study. after 16 hours of fasting, the blood glucose was measured using glucometer easytouch blood glucose/cholesterol/uric acid multifunction monitoring system. the positive control group was given 7 ml of distilled water and 50% glucose solution with 2.5 g/kg dosage while the study group were given 7 ml of bengkoang juice and 50% glucose solution with 2.5 g/kg dosage. blood glucose was re-checked after 2 hours. this procedure was performed in october 2012.the results were analyzed using student’s t-test with α = 0.05. results : the result shows a significant difference in blood glucose increase between the control and study groups with a score of 121.11 mg/dl and 324.45 mg/dl respectively. this result shows that bengkoang juice increases blood glucose level in wistar rats. conclusions: in conclusion, bengkoang (pachyrhizus erosus (l) urb. juice has no effect in hampering the blood glucose level increase in wistar rats. [amj.2014;1(1):25–9] keywords: alloxan, blood glucose, diabetes mellitus, pachyrhizus erosus (l) urb. pengaruh bengkoang (pachyrhizus erosus (l) urb juice dalam menghambat glukosa darah pada tikus abstrak latar belakang: prevalensi diabetes mellitus di indonesia cenderung meningkat dan diperkirakan mencapai 21,3 juta pada tahun 2030. bengkoang (pachyrhizus erosus ( l ) urb adalah salah satu obat tradisional yang sering digunakan untuk pengobatan diabetes. tujuan penelitian ini adalah untuk menilai efektivitas jus bengkoang dalam menghambat peningkatan glukosa darah. metode: empat puluh tikus wistar yang telah diinduksi diabetes aloksan digunakan dalam penelitian ini. setelah 16 jam puasa, glukosa darah diukur dengan menggunakan glucometer glukosa darah easytouch / kolesterol/asam urat monitoring system multifunction. kelompok kontrol positif diberi 7 ml air suling dan larutan glukosa 50 % dengan 2,5 g / kg dosis sedangkan kelompok studi diberi 7 ml jus bengkoang dan larutan glukosa 50 % dengan 2,5 g / kg dosis . glukosa darah diperiksa kembali setelah 2 jam. prosedur ini dilakukan pada hasil oktober 2012 dianalisis menggunakan t -test student dengan α = 0,05. hasil: hasil penelitian menunjukkan perbedaan yang signifikan dalam peningkatan glukosa darah antara kelompok kontrol dan kelompok studi dengan skor 121.11 mg / dl dan 324,45 mg / dl masing-masing . hasil ini menunjukkan bahwa jus bengkoang meningkatkan kadar glukosa darah pada tikus wistar . simpulan: bengkoang ( pachyrhizus erosus ( l ) urb jus tidak berpengaruh dalam menghambat kenaikan kadar glukosa darah pada tikus wistar . kata kunci: aloksan , glukosa darah , diabetes mellitus , pachyrhizus erosus ( l ) urb. correspondence: adrian dwiputra widyarman, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281298004423, email: adrian.dwiputra92@gmail.com althea medical journal. 2014;1(1) 26 amj june, 2014 introduction diabetes mellitus is a metabolic disease which is characterized by hyperglycemia caused by insufficient insulin production, decreased insulin effectiveness, or both.1 diabetes mellitus is divided into several types, one of them is diabetes mellitus type 2 where the hyperglycemia is caused by insulin resistance.1 the classic symptoms of diabetes mellitus are polyuria, thirst, recurrent blurred vision, paresthesia, and fatigue. however, most of the diabetic patients have an insidious onset of hyperglycemia and appeared asymptomatic. the disease is usually detected during routine laboratory studies.1 the morbidity and mortality rate of diabetes mellitus is staggering. diabetes mellitus is a disease with many dangerous complications such as renal disease, eye disease, nerve disease, heart disease, and stroke that lead to high financial expenditure.2 around 346 million people worldwide have diabetes mellitus. in 2004, it was estimated that there were 3.4 million deaths caused by diabetes mellitus and this number will increase two-fold by 2030.3 in indonesia, the number of diabetes mellitus patients will reach 21.3 millions by 2030.4 this estimation makes diabetes mellitus one of the world’s important health problems because diabetes and its complication have a big impact to the economic and health sectors.3 in order to prevent the complication and to increase the quality of life of the patient, a good treatment method for diabetes mellitus is needed. currently, the treatment for diabetes mellitus type 2 depends on diet programs to prevent hyperglycemia and drugs to decrease the hyperglycemia, such as sulphonylurea, metformin, and biguanide. however, these drugs have several side effects such as hypoglycemia, body weight increase, gastrointestinal disturbance, and anemia5. diet programs are also not effective because more than half of the diabetes mellitus patients fail to adhere to the program1. this situation leads to frequent use of herbal medicine by diabetes mellitus patients.6 herbal medicine or phytomedicine is a treatment method using one or several parts of a plant. this method has already been used since ages ago along with conventional treatment. the herbal medicine use has increased during the last 30 years. nevertheless, a consultation with a physician before using it is recommended because herbal medicine may cause allergic reactions or interact with other drugs.7 one of the herbal medicines used in for diabetes mellitus treatment is bengkoang. bengkoang (pachyrhizus erosus (l) urb is a plant in fabaceae family.8 this plant originates from mexico and have spread to several countries, including indonesia.9 the plant consists of stem, leaf, flower, fruit, root, and tuber. the leaf ’s shape is varied and almost all parts of this plant are covered by fine hair except the flower.10 the tuber can weigh up to 2 kg. the tuber has many nutritional contents that are good for the body such as carbohydrate, protein, low fat, calcium, magnesium, phosphor, and several vitamins.10 the sweet taste comes from carbohydrates such as glucose, fructose, sucrose, and inulin.15 inulin is also frequently used as glucose substitute in diabetic patient and dieting people.11 the tuber also contains a poisonous substance called rotenone which is frequently used as an insecticide, but this substance is only found in a very small amount.10 bengkoang tuber is usually eaten12 or used as cosmetic ingredient for skin whitening or sunblock.13 it also has been used empirically to treat diabetes mellitus in the form of bengkoang tuber’s juice which is consumed in the morning and before sleep.14 this effect is most likely caused by the inulin in the tuber juice that have low caloric value and has the effect of hampering glucose absorption in the intestines.11 the purpose of this study is to confirm the effect of bengkoang juice in hampering blood glucose increase in wistar strain rats. methods this study used a laboratory experiment design and the subjects were male and female wistar strain rats, weighed 150–200 gram, and were around 3 months of age. bengkoang tubers (pachyrhizus erosus (l) urb were acquired from subang, west java. the plant species identification is done by the department of biology, faculty of mathematics and natural sciences, universitas padjadjaran. the bengkoang juice was made by following the traditional method. the tuber was washed first using clean water, peeled, and grated. the grated tuber was squeezed and filtered to get the juice. the amount given was 7 ml based on the converted calculation using the conversion table based on the human dose. the juice was althea medical journal. 2014;1(1) 27 given orally. the glucose was given to induce blood glucose increase so the bengkoang juice effect in hampering blood glucose increase could be assessed. glucose was given in the solution form at 50% concentration and 2.5 g/kg dose. the glucose was given orally. alloxan was given in the solution form at 5% concentration and 125 mg/kg dose. alloxan was given subcutaneously. the wistar rats were kept in a standard cage for 1 week prior to study with free access to standard food and water. the rats were randomly divided into three groups. diabetes was induced in 2 groups using 5% alloxan solution at 125 mg/kg dose after 16 hours of fasting with free access to water. after 48 hours the fasting blood glucose level was checked through blood sampling from the tail vein. the sample was obtained by cutting the tip of the tail. the blood samples were tested using glucose test strip and glucometer, easytouch blood glucose/cholesterol/ uric acid multi-function monitoring system (easytouch gcu), and rats with fasting a blood glucose level greater than 100 mg/dl were included in the study. group 1 with non-diabetic rats were given 7 ml of distilled water and glucose solution as the negative control group. group 2 with diabetic rats were given 7 ml of distilled water and glucose solution as the positive control group. group 3 with diabetic rats were given 7 ml of bengkoang juice and glucose solution as the study group. after 2 hours, the blood glucose level was re-checked using the glucose test strip and glucometer as 2 hour post-prandial blood table 1 blood glucose level group 1 (non diabetic) blood glucose level (mg/dl) fasting 2 hours postprandial increase 95 106 11 107 147 40 95 125 30 106 101 -5 90 130 40 110 183 73 95 145 50 106 116 10 84 95 11 87 135 48 mean 97.5 128.3 30.8 glucose level. this procedure was performed in october 2012. the results were expressed as mean. the data were analyzed using student’s t-test with α = 0.05 to see the differences of blood glucose increase between the positive control group and the study group. results the mean increase of blood glucose level is 121.11 mg/dl which is higher compared to group 1 (non-diabetic group / normal rats) (table 2). table 2 blood glucose level group 2 (diabetic not given bengkoang juice) blood glucose level (mg/dl) fasting 2 hours post-prandial increase 560 700 140 167 250 83 325 524 199 515 700 185 295 125 -170 321 414 93 506 700 194 190 566 466 135 125 -10 mean 334.89 456 121.11 adrian dwiputra widyarman, emma nurdiamah, nanny natalia muliani soetedjo: effects of bengkoang (pachyrhizus erosus (l) urb juice in hampering blood glucose in rat models althea medical journal. 2014;1(1) 28 amj june, 2014 the mean increase of blood glucose level is 324.45 mg/dl which is even higher compared to group 2 (table 3). in the normality test (shapiro-wilk), the p-value was greater than 0.05 which means the data were normal. in homogeneity test (levene statistic), the p-value was greater than 0.05 which means the data were homogenous. in student’s t-test, the p-value was 0.004, which means that there is a significant difference in blood glucose level increase between the positive control group and the study group. discussion inulin has a fiber-like effect11 that could hamper blood glucose increase. from the data shown in table 2 and table 3, the blood glucose level increase in the study group was greater than the positive control group. the t-test also shows a significant difference between both groups. these statements show that bengkoang juice increases the 2 hours pp blood glucose level in wistar rats. this finding is probably caused by the carbohydrate contents, such as glucose, fructose, and sucrose, in bengkoang juice that causes higher carbohydrate intake. this higher carbohydrate intake causes an increase in blood glucose level. this finding also contradicts people’s belief that bengkoang juice can be used to treat diabetes mellitus14 and the blood glucose hampering effect of inulin.11 based on the analysis and discussions above, it can be concluded that bengkoang juice have no effect in hampering blood glucose increase in wistar rats. reference 1. gardner dg, shoback dm, greenspan fs. greenspan's basic & clinical endocrinology. san francisco: mcgraw-hill medical; 2007 2. williams rh, larsen pr. williams textbook of endocrinology. philadelphia: saunders; 2003. 3. who. diabetes fact sheet. 2012.[cited 2012 april 12]; available from: http:// www.who.int/mediacentre/factsheets/ fs312/en/index.html. 4. departemen kesehatan republik indonesia. tahun 2030 prevalensi diabetes melitus di indonesia mencapai 21,3 juta orang. [cited 2012 december 4]; available from: http://www.depkes.go.id/ index.php/berita/press-release/414tahun-2030-prevalensi-diabetes-melitusdi-indonesia-mencapai-213-juta-orang. html. 5. moller de. new drug targets for type 2 diabetes and the metabolic syndrome. nature. 2001;414(6865):821–7. 6. al-rowais na. herbal medicine in the treatment of diabetes mellitus. saudi med j. 2002;23(11):1327–31. 7. ehrlich sd. herbal medicine. 2011. [cited 2012 april 22]; available from: http:// table 3 blood glucose level group 3 (diabetic given bengkoang juice) blood glucose level (mg/dl) fasting 2 hours post-prandial increase 196 700 504 295 541 246 401 700 299 506 700 194 116 700 584 286 484 198 246 600 354 243 566 323 90 406 316 325 700 375 524 700 176 mean 293.45 617.9 324.45 althea medical journal. 2014;1(1) 29 www.umm.edu/altmed/articles/herbalmedicine-000351.htm. 8. integrated taxonomic information system. pachyrhizus erosus (l.) urb. taxonomy and nomenclature.2011. [cited 2012 march 7]; available from: http://www.itis. gov/servlet/singlerpt/singlerpt?search_ topic=tsn&search_value=26824. 9. karuniawan a. cultivation status and genetic diversity of yam bean (pachyrhizus erosus (l.) urban) in indonesia. göttingen: cuvillier verlag; 2004. 10. sørensen m. yam bean: pachyrhizus dc. rome: ipgri; 1996. 11. niness kr. inulin and oligofructose: what are they? j nutr. 1999;129(7 suppl):1402s–6s. 12. muaris hindah. kudapan. jakarta: gramedia pustaka utama; 2004. 13. surtiningsih. cantik dengan bahan alami: cara mudah, murah dan aman untuk mempercantik kulit. jakarta: elex media komputindo; 2005. 14. rahayu t. aneka resep ampuh ramuan tradisional penumpas kanker, hepatitis, & diabetes mellitus. yogyakarta: araska publisher; 2011. p. 116. 15. moongngarm a, trachoo n, sirigungwan n. low molecular weight carbohydrates, prebiotic content, and prebiotic activity of selected food plants in thailand. advance journal of food science and technology. 2011;3(4):269–74 adrian dwiputra widyarman, emma nurdiamah, nanny natalia muliani soetedjo: effects of bengkoang (pachyrhizus erosus (l) urb juice in hampering blood glucose in rat models amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 61althea medical journal. 2023;10(2):61–68 knowledge level of covid-19 prevention in banjar gambang communities, seraya village, karangasem, indonesia i gede aswin parisya sasmana,1 wilson halim,1 ni komang ayu amanda setiari jaya,1 made ayu kurniati atmaja,1 christine edgar,1 jane carissa sutedja,1 christo timothy mamangdean,1 grace veronika wijaya,1 made dea avrilia kusumadewi,1 desak made wihandani2 1faculty of medicine, universitas udayana, bali, indonesia, 2department of biochemistry, faculty of medicine, udayana university, bali, indonesia abstract background: problems to covid-19 are closely related to the level of knowledge and community prevention. therefore, to overcome covid-19, increased knowledge and prevention are needed. this study aimed to evaluate the correlation between prevention and knowledge level about covid-19. methods: a cross-sectional study using a convenience sampling approach was conducted in banjar gambang, karangasem, indonesia, in april 2022. the knowledge level and preventive behavior towards covid-19 were measured using the covid-19 preventive behaviors index (cpbi) and the knowledge, attitudes, and practice toward covid-19 (kapcov-19) questionnaire. the data were analyzed using spss software version 26.0. results: a total of 52 respondents were included, who had excellent level of knowledge (44.2%) and moderate prevention behaviour (48.1%). a strong and significant correlation was found between the preventive index and the knowledge levels of covid-19 (r=0.548; p<0.001). the level of knowledge was significantly related to the level of preventive behavior (p=0.003), as well as the education level (r=0.323; p=0.02) and age (r=-0.346; p=0.012). conclusion: the level of knowledge and the individual prevention behavior toward covid-19 are directly proportional to each other. those who have a low level of knowledge, might affect their prevention behavior toward covid-19, therefore, personalized socialization of covid-19 prevention is still required. keywords: covid-19, kapcov-19, knowledge, preventive behaviors index correspondence: dr. dr. desak made wihandani, m.kes, department of biochemistry faculty of medicine, udayana university, jalan pb. sudirman denpasar, bali, indonesia, e-mail: dmwihandani@unud.ac.id introduction coronavirus disease 2019 (covid-19) continues to increase in transmission. a serious threat to public health has been caused by the pandemic brought on by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2).1 around 440 million people worldwide have been confirmed positive for covid-19. each person experiences different symptoms, but common symptoms are cough, fever, loss of taste or smell, headache, difficulty breathing, fatigue, muscle aches, runny nose, sore throat, diarrhea, nausea, and vomiting.2 the sars-cov-2 virus has the ability to adapt to its host due to its high mutation rate, so the virus can evolve rapidly.3,4 this event is evident from the change in the covid-19 disease from a pandemic to an endemic. one of the mutations experienced is point mutations that can randomly create different strains in each region and develop a unique characteristic, which will then produce the effects of the virus and how the virus interacts with humans.5 in order to prevent covid-19 transmission, the health protocol guidelines have been made by the world health organization (who).6 in indonesia, there are new regulations related to quarantine, self-isolation, integrated isolation, lockdown, and large-scale social restrictions (pembatasan sosial berskala besar, psbb).7 however, the success of this strategy depends on several factors, in particular the support and compliance of the community in https://doi.org/10.15850/amj.v10n2.2857 althea medical journal. 2023;10(2) 62 following government prevention guidelines.8 in several studies that have been carried out, it has been found that women and people with higher levels of education tend to have a higher level of compliance with health protocol guidelines made by the government.9 likewise with people who perceive the virus as a serious threat and people who trust health institutions.10 according to the 2021 covid-19 task force report, public compliance with health protocols is assessed from the behavior of wearing masks, maintaining distance and avoiding crowds (3m), admonishing or reminding 3m, and institutional compliance. on the zoning map of community compliance in maintaining distance and avoiding crowds, it is known that eastern bali has community compliance of 79–90%, while other areas of bali have 91–100% compliance.11 karangasem is one of the regencies located in the eastern part of the island of bali. although karangasem is in the second lowest rank of the total positive confirmed cases in bali, the case fatality rate (cfr) in karangasem occupies the highest position at 7.43%, even exceeding denpasar city which is the capital of bali province.12 in addition, karangasem regency also occupies the bottom two positions in terms of first, second, and third doses of vaccination.13 to prevent wider transmission of the virus, good knowledge and understanding from the community are needed.14 this knowledge is not only limited to how to prevent it, but also an understanding of the disease, modes of transmission, treatment methods, and the complications that may occur.15 this study aimed to find out about the correlation of knowledge level and the prevention of covid-19, especially in the community of banjar gambang, seraya village, karangasem, bali, indonesia. methods a descriptive-analytical method and a crosssectional method were used. this study was conducted in banjar gambang, seraya village, karangasem, bali, indonesia on april 24, 2022, and has been ethically approved by faculty of medicine, udayana university with ethical number [2022.01.1.0460]. the inclusion criteria were the people of banjar gambang, seraya village, karangasem aged 17–80 years, were willing to participate in the study, and answered the questionnaire completely. filling out the questionnaire was assisted by the surveyor who would explain each item in communicatively but still in althea medical journal june 2023 line with the subject matter. meanwhile, the exclusion criteria were, participants suffering from covid-19 at the time of data collection. a total of 52 people were involved in this study. the sample size was determined based on the arikunto method.16 data collection was carried out by interviewing at community halls and from house to house in order to obtain primary data. the questionnaires used included questionnaires on respondent characteristics such as gender, age, education level, education, covid-19 information source, covid-19 infection history, and the covid-19 vaccination history), knowledge, attitude, and practice toward covid-19 (kapcov-19), and the covid-19 preventive behaviors index (cpbi).17,18 the kapcov-19 questionnaire, in particular, the knowledge section was used. this questionnaire included 12 items of knowledge level questions with 9 favorable items (statements that support or side with the research object) and 3 non-favorable items that could be answered with (true, false, and do not know). the correct answer will get a 1 score while the wrong or don’t know the answer will get a 0 score. the final score was calculated and categorized into excellence (score 9–12), moderate (score 4–8), and poor (score 0–3) knowledge. this questionnaire had a cronbach’s alpha of 0.71 for reliability. determination of the level of preventive action was carried out using the cpbmi questionnaire which has been adjusted to the regulation of the indonesian health minister (hk.01.07/menkes/413/2020) to assess covid-19 preventive measures which consisted of 10 questionnaire items (8 favorable questions and 2 non-favorable questions) with a score range between 1 to 5 for each item. the final score was calculated and categorized into excellence (score 41–50), moderate (score 21–40), and poor (score 10–20) behavior index. this questionnaire had a cronbach’s alpha of 0.75 for reliability. the characteristics of each variable were conducted using univariate analysis to describe and also to explain the data. besides, to determine the relationship and correlation between variables, a bivariate analysis using the pearson correlation test (with spearmen’s test as an alternative) was conducted. results of the 52 respondents, the majority of respondents were male (n=29; 56%), were in the age range of 29–49 years (n=24; 46%) and althea medical journal. 2023;10(2) 63i gede aswin parisya sasmana et al.: knowledge level of covid-19 prevention in banjar gambang communities, seraya village, karangasem, indonesia had an education equivalent to elementary school (n=19; 36%) (table 1). most of the respondents were farmers (n=13; 25%). information about covid-19 was mostly obtained from the mass media (n= 23; 44%). from all respondents, there was 1 person (2%) who was confirmed positive for covid-19. the history of covid-19 vaccination in respondents shows that there were 2 respondents (3%) who had not received the covid-19 vaccine, 3 respondents (6%) who had just received the first dose of vaccine, as many as 13 people (25%) had just received the second dose of vaccine, 34 respondents (65%) had received the third dose of vaccine. measuring the knowledge level and the covid-19 prevention index showed that the average scores of participants were 38.79±6.18 table 1 characteristics of respondents characteristic n (%) knowledge score prevention score mean score ± sd p mean score ± sd p gender male female 29 (56) 23(44) 8.55±2.37 9.00±1.98 0.569 36.90±6.37 41.17±5.10 0.012* age (year) <29 29–49 50–80 6 (12) 24 (46) 22 (42) 9.83±1.33 9.50±1.47 7.63±2.57 0.015* 40.00±9.32 39.50±5.39 37.68±6.15 0.534 education unschooled primary school middle school high school graduation and above 9 (17) 19 (36) 6 (12) 15 (29) 3 (6) 7.11±2.26 8.53±2.50 9.67±1.50 9.87±1.13 7.67±2.31 0.028* 34.89±5.95 40.21±5.08 40.17±6.43 39.53±7.14 35.00±4.39 0.180 occupation farmer unemployed seller labor others 13 (25) 11 (21) 7 (13) 5 (10) 16 (31) 7.46±2.44 8.55±2.81 9.43±1.81 10.00±0.71 9.25±1.57 0.105 35.92±5.76 37.73±7.09 41.29±7.16 41.60±2.41 39.87±5.75 0.215 sources of information family public health service mass media social media other never 11 (21) 5 (10) 23 (44) 2 (3) 5 (10) 6 (12) 8.27±2.33 10.20±1.10 9.26±1.51 10.50±.71 9.80±1.30 5.00±1.67 0.003* 37.82±6.16 41.40±6.43 39.52±5.87 44.00±2.83 39.80±5.54 33.00±6.23 0.133 diagnostic history of covid-19 infection yes no 1 (2) 51 (98) 11 8.71±2.19 47 38.63±6.13 covid-19 vaccination history not vaccinated first dose second dose third dose 2 (3) 3 (6) 13 (25) 34 (66) 8.50±2.12 7.00±1.00 9.31±1.70 8.71±2.41 0.302 40.00±8.49 33.33±4.04 38.61±6.16 39.26±6.24 0.463 total 8.75±2.20 38.79±6.18 althea medical journal. 2023;10(2) 64 and 8.75±2.20 which were categorized as moderate prevention index against covid-19 and knowledge level, respectively. gender (p=0.012) had a significant result (p<0.05) on the prevention scores, while education level (p=0.028), age (p=0.015), and the source of information (p=0.003) were significant (p<0.05) to the knowledge score. this study results showed a score of 8.75±2.20 from a maximum score of 12. for prevention, the average scores was 38.79±6.18 from a maximum score of 50 (table 1). the composition of the frequency of respondents’ knowledge levels and covid-19 precautions was shown in figure 1. the data showed that most respondents had a good knowledge level of covid-19 (n=23; 44%), besides, there were 16 respondents (31%) who have a moderate level of knowledge, and 25% had a low level of knowledge. meanwhile, from the covid-19 preventive behavior index, it was found that as 46% had high preventive scores of behaviors, meanwhile 48% had moderate scores, and only 6% had low preventive measures. the results of 12 statements regarding the level of knowledge about covid-19 and 10 statements regarding the level of precautions about covid-19 found that there was a correlation between level of knowledge and age, level of education, and history of covid-19 vaccination. a strong negative relationship was found between the level of knowledge and the age of respondent which was significant (r=-0.346; p=0.012) along with a strong positive correlation between the level althea medical journal march 2023 table 2 knowledge about covid-19 in banjar gambang communities, seraya village, karangasem, indonesia items of questionnaire responses true n (%) false n (%) i don’t know n (%) the main clinical symptoms of covid-19 are fever, fatigue, dry cough, and myalgia 40 (77) 11 (21) 1 (2) unlike the common cold, stuffy nose, runny nose, and sneezing are less common in persons infected with the covid-19 virus. 17 (32) 34 (66) 1 (2) there currently is no effective cure for covid-2019, but early symptomatic and supportive treatment can help most patients recover from the infection. 28 (54) 23 (44) 1 (2) not all persons with covid-2019 will develop into severe cases. only those who are elderly, have chronic illnesses, and are obese are more likely to be severe cases. 45 (87) 7 (13) 0 (0.0) eating or contacting wild animals would result in the infection by the covid-19 virus. 14 (27) 37 (71) 1 (2) persons with covid-2019 cannot infect the virus others when a fever is not present. 28 (54) 23 (44) 1 (2) the covid-19 virus spreads via the respiratory droplets of infected individuals. 43 (83) 8 (15) 1 (2) ordinary residents can wear general medical masks to prevent the infection by the covid-19 virus 51 (98) 1 (2) 0 (0.0) children and young adults don't need to take measures to prevent the infection by the covid-19 virus 12 (23) 40 (77) 0 (0.0) to prevent the infection by covid-19, individuals should avoid going to crowded places such as train stations and avoid taking public transportations 47 (90) 5 (10) 0 (0.0) isolation and treatment of people who are infected with the covid-19 virus are effective ways to reduce the spread of the virus 46 (88) 5 (10) 1 (2) people who have contact with someone infected with the covid-19 virus should be immediately isolated in a proper place. in general, the observation period is 14 days 43 (83) 9 (17) 0 (0.0) althea medical journal. 2023;10(2) 65 of knowledge and the level of education with significant results obtained (r=0.323; p=0.02) (table 2). another analysis of the correlation between preventive measures and age (r=0.268; p=0.055), education level (r=0.082; p=0.565), and history of covid-19 vaccination (r=0.113; p=0.426) showed a weak correlation between preventive measures and age, education level, and history of covid-19 vaccination which was not significant. there was a strong correlation between the level of knowledge about covid-19 and precautions (r=0.548; p<0.001). discussion this study found gender did not affect knowledge scores, however, women’s prevention scores were found to be statistically i gede aswin parisya sasmana et al.: knowledge level of covid-19 prevention in banjar gambang communities, seraya village, karangasem, indonesia figure 1 frequency composition of covid-19 knowledge levels in participants (a). chart of the frequency composition of the covid-19 prevention behavior index (b). table 3 prevention of covid-19 in banjar gambang communities, seraya village, karangasem, indonesia items of questionnaire responses always n (%) often n (%) sometimes n (%) seldom n (%) never n (%) keep a distance of 1 meter in your everyday interactions with people outside of your household 16 (31) 23 (44) 7 (13) 5 (10) 1 (2) use a facemask when you leave your home 20 (38) 22 (42) 6 (12) 3 (6) 1 (2) work from home, if possible 14 (27) 23 (44) 9 (17) 5 (10) 1 (2) avoid any non-essential local travel 17 (33) 13 (25) 12 (23) 9(17) 1 (2) avoid any non-essential international travel 21 (40) 23 (44) 4 (8) 2 (4) 2 (4) wash your hands regularly 23 (44) 23 (44) 4 (8) 2 (4) 0 (0) keep informed about covid-19 6 (12) 19 (36) 16 (31) 8 (15) 3 (6) not make any changes to your lifestyle 2 (4) 8 (15) 5 (10) 19 (36) 18 (35) continue to see people outside of your household 3 (6) 14 (27) 8 (15) 8 (15) 19 (36) comply with track and trace service, if contacted 25 (48) 19 (36) 2 (4) 5 (10) 1 (2) a level of knowledge b prevention behavior index poor moderate excellent moderate poor excellent 44% 46% 25% 6% 48% 31% althea medical journal. 2023;10(2) 66 significant. a study in northern nigeria has a similar conclusion, gender is not associated with the knowledge scores.19 interestingly, that study found significancy on the prevention score. meanwhile, a study conducted in saudi arabia reported that there was a gender significance in the knowledge score as well as on prevention score.20 in northern nigeria the results might be due to the beliefs and customs that exist in that country. good knowledge scores did not always show good prevention. for example, when asked whether they would attend a wedding during this pandemic, it was found that 58% of the participants who chose to remain present were participants who had a high knowledge scores. it was also found that 38% of participants would continue to attend funerals, 42% to eid prayers, and 49% to friday prayers, showing that culture and religion have an influence on choices and levels of prevention.21 furthermore, our study has shown that age has a significance relationship with the knowledge score, aged less than 29 years have a higher average knowledge score, similar to study in northern nigeria19 and saudi arabia.20 in addition, study in saudi arabia has shown a relation between age and prevention score.20 however, another research found that the level of knowledge was found to be better in the younger age range (36–65 years). age might increase, the capability in storing new information and knowledge will be weaker. in contrary, in a study with a high predominance of the elderly population, it has shown that younger people have higher levels of knowledge.15 from the three studies, almost the same results were obtained where age contributed to the knowledge score, this could occur due to an increase in understanding and information received with age.20 this research also found the significance of education on the knowledge scores, with the highest average knowledge scores being found in participants with high school education and sources of information were also significant on knowledge scores with the mass media as a main source of information. research from northern nigeria and saudi arabia also found that there was a significant correlation between education and knowledge scores as well as prevention scores in saudi arabia.19,20 in these studies sites, the sources of information on knowledge or prevention score were not included, however, 43% of participants in northern nigeria19 received information from radio and 25% from health workers. the significance of education on knowledge scores can be explained by differences in processing information and also how much information can differ in each educational background.19,20 this study shows that there is a strong correlation and relationship between the level of knowledge and preventive measures for covid-19. this finding is slightly different from the previous research which showed a weak correlation between the level of knowledge, action, and behavior toward the covid-19 outbreak in the population of central iran.22 this might happen because of the difference in the time of research, namely between 2020 and 2022. this comparison also shows that respondents who have a high level of knowledge are currently taking good precautions against covid-19. there were significant results between covid-19 prevention measures in each category of knowledge level, indicating that people with a good level of knowledge have good covid-19 prevention measures. students with a good level of knowledge tend to take preventive measures against covid-19, especially among public health students who may have often received education about covid-19 on campus environment.23 a study in the saudi arabian population has shown that high level of prevention behavior of covid-19 transmission is associated with high level of knowledge.20 vice versa, a lack of awareness of covid-19 preventive measures is associated with a poor level of knowledge. this may be because self-report studies can lead to different interpretations in society.24 in indonesia, similar result has been shown from semarang, indicating relationship between the level of knowledge and the practice of preventing covid-19.25 the reliability and validity test were not used in our questionnaire due to limited population. however, the tests were carried out using the population that had similar characteristic around several village in bali, indonesia that could represent the research sample. in conclusion, most of the respondents has a good level of knowledge about covid-19 and have taken moderate precautions by having the third dose of vaccination. in addition, age and education level play a significant role. moreover, the preventive measures for covid-19 are more predominantly carried out among female. awareness programs need to be employed to increase knowledge, leading to more precautionary measures against covid-19. althea medical journal june 2023 althea medical journal. 2023;10(2) 67 acknowledgment we would like to express our appreciation to the hippocrates scientific group (kih), faculty of medicine, udayana university and all participants who have supported this research. references 1. saeed s, o’brien sf, abe k, yi ql, rathod b, wang j, et al. severe acute respiratory 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validation in two samples from the united kingdom. eval health prof. 2021;44(1):77–86. 18. zhong bl, luo w, li hm, zhang qq, liu xg, li wt, et al. knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. int j biol sci. 2020;16(10):1745–52. 19. habib ma, dayyab fm, iliyasu g, habib ag. knowledge, attitude and practice survey of covid-19 pandemic in northern nigeria. plos one. 2021;16(1):e0245176. 20. al-hanawi mk, angawi k, alshareef n, qattan amn, helmy hz, abudawood y, et al. knowledge, attitude and practice toward covid-19 among the public in the kingdom of saudi arabia: a cross-sectional study. front public health. 2020;8:217. 21. ogoina d, mahmood d, oyeyemi as, okoye oc, kwaghe v, habib z, et al. a national survey of hospital readiness during the covid-19 pandemic in nigeria. plos one. 2021;16(9):e0257567. 22. moradzadeh r, nazari j, shamsi m, amini i gede aswin parisya sasmana et al.: knowledge level of covid-19 prevention in banjar gambang communities, seraya village, karangasem, indonesia althea medical journal. 2023;10(2) 68 s. knowledge, attitudes, and practices toward coronavirus disease 2019 in the central area of iran: a population-based study. front public health. 2020;8:599007. 23. akbar a, hardy fr, maharani ft. hubungan tingkat pengetahuan dan sikap terhadap tindakan pencegahan coronavirus disease 2019 (covid-19) pada mahasiswa kesehatan masyarakat upn veteran jakarta. in: ainaya na, editor. prosiding seminar nasional kesehatan masyarakat 2020; 2020 september 19; jakarta. jakarta: universitas pembangunan nasional veteran jakarta; 2020. p. 98–110. 24. bazaid as, aldarhami a, binsaleh nk, sherwani s, althomali ow. knowledge and practice of personal protective measures during the covid-19 pandemic: a crosssectional study in saudi arabia. plos one. 2020;15(12):e0243695. 25. sutiningsih d. hubungan tingkat pengetahuan dan sikap dengan praktik pencegahan covid-19 pada masyarakat pengguna internet di kota semarang. j epidemiol kesehat komunitas. 2021;6(2):300–6. althea medical journal june 2023 amj vol 7 no 2 2020_200720.indd althea medical journal. 2020;7(2) 51amj. 2020;7(2):51–4 bleeding volume, blood pressure, and consciousness level in association with the mortality rate among patients with intracerebral hemorrhage at dr. soetomo general hospital, surabaya mohammad pratama jauhar putra,1 achmad firdaus sani,2 puji lestari,3 mohammad saiful ardhi2 1faculty of medicine, airlangga university, surabaya, indonesia, 2department of neurology, dr. soetomo general academic hospital, surabaya, indonesia, 3department of public health, faculty of medicine, airlangga university, surabaya, indonesia abstract background: intracerebral hemorrhage is one of the deadliest acute conditions. the volume of bleeding and its location are factors that alter consciousness level, leading to death. this study aimed to explore the association between bleeding volume, blood pressure, and consciousness level with the mortality rate among patients with intracerebral hemorrhage, so proper treatment and diagnosis can be conducted efficiently. methods: this was an observational retrospective study conducted from october 2018–july 2019. bleeding volume, blood pressure, consciousness level, and mortality as the outcomes of the patients with intracerebral hemorrhage were evaluated. consciousness level was determined by using the glasgow coma scale score. data were collected from the medical record of intracerebral hemorrhage patients of the neurologic department in dr. soetomo general academic hospital surabaya in the period of 2016. the chi-square analysis method was used to determine the correlation between variables. results: in total, 51 medical records were retrieved, and the majority of the patients were in the 45–60 years old group (54.9%). the mortality during hospitalization was 17.6% with most of them (82.4%) had bleeding volume less than 30 cc. interestingly, the bleeding volume correlated with the consciousness level (p=0.001) and the outcome of the patients (p=0.02). the blood pressure shows a correlation with the volume of bleeding (p=0.009). conclusions: bleeding volume and consciousness level as determined by the glasgow coma scale score show significant correlations with the mortality rate in patients with intracerebral hemorrhage. keywords: intracerebral hemorrhage, mortality rate, volume of bleeding correspondence: mohammad pratama jauhar putra, faculty of medicine, airlangga university, jalan mayjen prof. dr. moestopo no.47, surabaya, east java, indonesia. e-mail: tommy_gkb@yahoo.co.id introduction intracerebral hemorrhage has been increased by 47 % during the year 1990 to 2010 worldwide. in indonesia, approximately over a million people are reported to have a stroke, and east java is one of the big three provinces with the highest rate of stroke.1 intracerebral hemorrhage is one of the deadly acute conditions, mostly occurred in the first 48 to 72 hours, caused by the neurological condition of the patients.2 the mortality rate in the first 30 days is 40 % and this rate is increased by 10 % in 1 year. intracerebral hemorrhage is bleeding in the parenchymal brain tissue,3 leading to the deterioration of the patient. not only the bleeding, but the location of the bleeding is one of the factors resulting in death. computed tomography (ct) scan is one of the radiological imaging that is commonly used to determine the degree of bleeding in intracerebral hemorrhage cases. during the ct scan, part of the brain where the hemorrhage has occurred presents as a white mass with a hypodense area in the surrounding area. there are a lot of factors that can affect the clinical outcome of intracerebral hemorrhage https://doi.org/10.15850/amj.v7n2.1751 althea medical journal. 2020;7(2) 52 amj june 2020 (120–129 over 80–89), hypertension stage 1 (130–139 over 90–9) and hypertension stage 2 (>160 over >100). bleeding volume was divided into two categories; volume <30 ml and >30 ml. the consciousness level was measured by the glasgow coma scale (gcs) score, taken when they first admitted to the hospital. the glasgow coma scale score was divided into three categories; severe (<8 points), moderate (8–12 points) and mild (>12 points). the bleeding volume was divided into two categories of <30 cc, and >30 cc. the outcomes of the patients was categorized into two, alive when they were discharged from the hospital or death during the hospitalization. only complete data were included. exclusion criteria were patients diagnosed with subarachnoid hemorrhage or intraventricular hemorrhage, and when the location of the bleeding was infratentorial. the chi-square analysis method was used to assess the significant association between variables. the method of this study had been approved by the ethical committee of dr. soetomo general hospital no. 0701/ kepk/x/2018. patients. this study aimed to explore the association between bleeding volume, blood pressure, and consciousness level with the mortality rate among patients with intracerebral hemorrhage. this study was needed to improve the clinical treatment and the diagnosis of intracerebral hemorrhage. methods this was an analytic observational retrospective study, using medical record retrieved from the medical records centre in dr. soetomo general hospital, surabaya. data were taken from the department of neurology in the period of january to december 2016. the characteristic data of patients were collected such as gender and age. the age category was divided into three groups; young adult (18–45 years old), adult (45–60 years old), and old or geriatric patients (>60 years old). furthermore, data on blood pressure, bleeding volume, consciousness level, and outcomes of the patient were retrieved. blood pressure was divided into four categories following the joint national committee 7; which were normal (<120 over <80), elevated table 1 consciousness level, bleeding volume, and blood pressure in relation with the outcomes among patients with intracerebral hemorrhage at dr. soetomo general hospital surabaya outcome p-value death alive consciousness level <8 4 1 0.0001* 8–12 4 20 >12 1 21 bleeding volume <30 cc 5 37 0.02* >30 cc 4 5 blood pressure normal 1 1 0.597 prehypertension 1 hypertension stage 1 1 hypertension stage 2 8 39 note: consciousness level was determined by glasgow coma scale score; severe (<8 points), moderate (8-12 points) and mild (>12 points).* statistically significant. althea medical journal. 2020;7(2) 53 results of 117 medical records retrieved, only 51 data were considered eligible to be analyzed according to the exclusion and inclusion criteria. male (n=29) was slightly more prevalent compared to females (n=22) and the age of intracerebral hemorrhage patients was mostly in the adult group (54.9%) with an average of 53.36 years old (data not shown). the blood pressure among intracerebral hemorrhage patients was predominantly in the category of hypertension stage 2 (n=47; 92.2%). the percentage of the gcs was mild (n=22; 43.1 %), moderate (n=24; 47.1%) and severe (n-5; 9.8%) as shown in table 1. the bleeding volume category <30cc was detected in 82.4 % (n=42) with a mean bleeding volume of 11.34 cc. for the category >30cc there was 17.6 % (n=9)) with a mean bleeding volume of 51.18 cc. the total patients who died during hospitalization were 17.6 % (n9) and mostly were alive which was 82.4 % (n=42). there was a significant relationship between the outcome of the intracerebral hemorrhage and consciousness level (p0.0001) and bleeding volume (p 0.02) as shown in table 1. interestingly, even though there was a high number of hypertension stage 2 among patients, the bleeding volume was mostly <30cc with p-value 0.009 as depicted in table 2. however, no significant difference between consciousness level and bleeding volume (p=0.339) nor blood pressure (p=0.329). discussion this study has shown that the most prevalent age group with intracerebral hemorrhage is the adult group (45–60 years old) similar to another study however, some other studies also show that age older than 60 years old is more prevalent.4 the contradictory result of this study may correlate with the condition in indonesia. in indonesia1, the highest number of smokers belongs to the adult group. since smoking is one of the risk factors of intracerebral hemorrhage, it may be the reason why most of the intracerebral hemorrhage patients are into an adult group in this study.1 high blood pressure is one of the most common risk factors in intracerebral hemorrhage. the high blood pressure would make blood vessels in the brain ruptured and bleeding occurs. among the four categories, most of the patients (38 of 51) are in the hypertension stage 2 group. this result is similar to another study, showing that the mean initial systolic of the intracerebral hemorrhage patient is 187±37.64 mmhg and the mean initial diastolic of the intracerebral hemorrhage is 107±23.2 mmhg.4 increased blood pressure is not only increasing the incidence of hemorrhagic stroke but also infarction stroke.5 furthermore, blood pressure is one of the strong predictors of the mortality rate. high blood pressure causes neurological deterioration, and especially in intracerebral hemorrhage cases, the deterioration is deadly.6 high blood pressure also increases the chance of increasing the size of hematoma. this might happen because high blood pressure will promote the process of the ‘wear and tear’ of the blood vessels and it will cause bleeding that happens repeatedly.2 glasgow coma scale score has a significant correlation with the 30-day mortality of the patients. the larger the volume of hematoma and the lower the glasgow coma scale score is, the higher the risk of the patient to dying during mohammad pratama jauhar putra et al.: bleeding volume, blood pressure, and consciousness level in association with the mortality rate among patients with intracerebral hemorrhage at dr. soetomo general hospital, surabaya table 2 blood pressure and level of consciousness in relation with bleeding volume among patients with intracerebral hemorrhage at dr. soetomo general hospital surabaya volume of bleeding p-value <30 cc >30 cc blood pressure normal 1 1 0.009* prehypertension 1 hypertension stage 1 1 hypertension stage 2 41 6 note: * statistically significant althea medical journal. 2020;7(2) 54 amj june 2020 coast of peninsular malaysia. neurology asia. 2012;17(2):93–9. 5. zia e, hedblad b, pessah-rasmussen h, berglund g, janzon l, engström g. blood pressure in relation to the incidence of cerebral infarction and intracerebral hemorrhage. hypertensive hemorrhage: debated nomenclature is still relevant. stroke. 2007;38(10):2681–5. 6. willmot m, leonardi-bee j, bath pmw. high blood pressure in acute stroke and subsequent outcome a systematic review. hypertension. 2004;43(1):18–24. 7. wang cw, liu yj, lee yh, hueng dy, fan hc, yang fc, et al. hematoma shape, hematoma size, glasgow coma scale score and ich score: which predicts the 30-day mortality better for intracerebral hematoma? plos one. 2014;9(7):e102326. 8. broderick jp, diringer mn, hill md, brun nc, mayer sa, steiner t, et al. determinants of intracerebral hemorrhage growth: an exploratory analysis. stroke. 2007; 38(3):1072–5. 9. poungvarin n, suwanwela nc, niphon poungvarin, venketasubramanian n, wong lks, navarro jc, et al. grave prognosis on spontaneous intracerebral hemorrhage: gp on stage score. j med assoc thail. 2006;89(suppl 5):s84–93. 10. chen hs, hsieh cf, chau tt, yang cd, chen yw. risk factors of in-hospital mortality of intracerebral hemorrhage and comparison of ich scores in a taiwanese population. eur neurol. 2011;66(1):59–63. 11. suthar nn, patel kl, saparia c, parikh ap. study of clinical and radiological profile and outcome in patients of intracranial hemorrhage. ann afr med. 2016;15(2):69– 77. 12. qureshi ai, tuhrim s, broderick jp, batjer hh, hondo h, hanley df. spontaneous intracerebral hemorrhage. n engl j med. 2001;344(19):1450–60. 13. salihović d, smajlović d, ibrahimagić oć. does the volume and localization of intracerebral hematoma affect short-term prognosis of patients with intracerebral hemorrhage?. isrn neurosci. 2013;2013: 327968. hospitalization.7,8 in asian, a low initial glasgow coma scale and a high volume of bleeding are independent factors of bad prognosis.9,10 the higher the volume of bleeding in the patient, the risk of the patient to have abad outcome, or in this case, death, is higher.11 this statement confirms our study where the volume of bleeding shows a significant correlation with the outcome of the patient. side, the volume of bleeding, the glasgow coma scale score, intracerebralhemorrhage score, and hematoma shape are all significantly affecting the 30-day mortality rate of the patients.7 low glasgow coma scale score can occur when there is a massive volume of bleeding because of the intracranial pressure or direct compression to the pons or thalamus.12,13 the limitation of the study is that complete medical records retrieved are not in sufficient numbers. the bigger data set is needed to represent the reliability of the result, therefore, further study collecting more data is preferable. to conclude, bleeding volume and consciousness level as determined by the glasgow coma scale score show a significant correlations with the mortality rate in patients with intracerebral hemorrhage. further follow up study is of great interest in exploring the quality of life of the patients with intracerebral hemorrhage. references 1. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. riset kesehatan dasar 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2013. 2. aguilar mi, brott tg. update in intracerebral hemorrhage.neurohospitalist. 2011;1(3): 148–59. 3. macellari f, paciaroni m, agnelli g, caso v. neuroimaging in intracerebral hemorrhage. stroke. 2014;45(3):903–8. 4. yousuf rm, fauzi arm, jamalludin ar, how sh, amran m, shahrin tca, et al. predictors of in-hospital mortality in primary intracerebral hemorrhage in east amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 200 amj december 2020 clinical profile of adverse cutaenous drug reactions in patients with human immunodeficiency virus puteri nabilah maharani,1 oki suwarsa,2 susantina3 1faculty of medicine universitas padjadjaran, indonesia, 2department of dermatology & venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: puteri nabilah maharani, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang , indonesia, e-mail: nabilahpm@gmail.com introduction human immunodeficiency virus (hiv) has been known as a pandemic disease since its first discovery. at the end of 2017, there were 36.9 million individuals infected by hiv globally. among them, 1.8 million cases were a new infections. it also found that there were 940.000 cases of acquired immune deficiency syndrome (aids)-related death.1 in indonesia1, there is an increase in a number of people living with hiv (plhiv) and the number of aids-related death cases. the number of plhiv increased from 610.000 in 2015 to 630.000 in 2017. the number of aids-related death is also increased from 37.000 in 2015 and 39.000 in 2017.1 hiv targets on a cluster of differentiation 4 (cd4) cells (t helper cells) of its host. this leads to progressive deterioration of hosts’ immune systems and causes immunodeficiency in hivinfected patients. the hiv-infected patients could progress into aids. this phase is identified when the cd4 count has reached <200/μl or when the individual develops one or more opportunistic infections.2 hiv is treated with highly active antiretroviral therapy (haart) which is a combination of antiretroviral (arv).3 opportunistic infections (ois) are an infection that emerges due to a weakened immune systems and are often found in hiv patients. in hiv-infected patients, ois could be life-threatening and are the major cause of aids-related death.2 patients amj. 2020;7(4):200–5 abstract background: adverse cutaneous drug reactions (acdrs) are common problems in patients during the treatment of various diseases. the clinical feature varies from mild manifestation such as morbilliform, urticaria, and contact dermatitis, to severe manifestation such as stevens-johnson syndrome (sjs) and toxic epidermal necrolysis (ten). patients infected with the human immunodeficiency virus (hiv) have an increased risk of developing acdrs due to immune system disruption. this study aimed to describe the clinical features of acdrs in hiv patients and the drugs that cause acdrs. methods: this study was a retrospective study using secondary data from medical records of hiv patients with acdrs who visited teratai clinic of dr. hasan sadikin general hospital bandung from 2014 to 2018. total sampling was applied and results were presented in percentage. results: there were 94 hiv patients with acdrs out of 557 hiv patients. adverse cutaneous drug reactions are commonly found in males aged 20–39 years old. the clinical features found were morbilliform (85.6%), sjs (8.9%), urticaria (4.4%), and erythroderma (1.1%). the most common drugs causing acdrs were cotrimoxazole (30%), efavirenz (28.9%), and nevirapine (16.7%). conclusions: the prevalence of acdrs in hiv patients in this study is 16.9%. the most common clinical features are morbilli form and sjs with cotrimoxazole, efavirenz, and nevirapine causing most of the acdrs. keywords: adverse cutaneous drug reactions, antiretroviral, drug hypersensitivity https://doi.org/10.15850/amj.v7n4.1955 althea medical journal. 2020;7(4) 201 with aids are required to take ois drugs and arv. the use of several medications and dysregulation of the immune system could induce adverse drug reactions and drug interactions.4,5 adverse cutaneous drug reactions (acdrs) are rash found in a layer of skin and mucosa that emerges due to hypersensitivity reaction towards drugs. drug eruption rates varied from 0–8% and were found to be a common problem for inpatients globally.6 the clinical features vary such as morbilliform, urticaria, contact dermatitis, stevens-johnson syndrome (sjs), toxic epidermal necrolysis (ten), etc. acdrs were found to be the most common form of adverse drug reaction in hiv patients. it was reported that drug hypersensitivity occurs a hundred times more frequent in hiv patients compared to hiv-negative individuals.7 stevens-johnson syndrome is a severe and rare skin disorder characterized by painful blister lesions that widespread on the skin and mucous membranes. incidence of sjs has been linked to the deterioration of the immune system found in hiv infection.7 these manifestation could affect patients’ adherence and outcomes to therapy, which eventually affect morbidity and mortality rate in hiv patients. this study aimed to describe the local prevalence, patients’ characteristics such as sex, age, and cd4 count also clinical features and drug causing acdrs. methods this study was conducted from september– november 2019 in teratai clinic dr. hasan sadikin general hospital bandung using a retrospective cross-sectional approach as the study design. this study used secondary data, which were patients’ medical records as its instrument. the population of this study was hiv/aids patients undergoing arv therapy in teratai clinic. inclusion criteria were medical records of hiv patients diagnosed with acdrs while undergoing arv therapy from 2014–2018 in teratai clinic. the exclusion criteria were incomplete medical records. the sampling was total sampling. the total number of the case was 94 but only 90 cases were evaluable. the research has been approved by the research ethics committee of the universitas padjadjaran (835/un6.kep/ ec/2019). this study was started by collecting data on hiv patients that were diagnosed with acdrs in teratai clinic. the result was presented in percentage. results this study found 94 cases from 2014–2018 with the prevalence of 16.9%. acdrs in hiv patients were found to be more prevalent in men (70%) compared to women (30%). the puteri nabilah maharani et al.: clinical profile of adverse cutaenous drug reactions in patients with human immunodeficiency virus table 1 characteristics of hiv patients with acdrs characteristics hiv patients with acdrs (n=90) n % age (years old) <20 2 2.2 20–29 36 40 30–39 35 38.9 40–49 14 15.6 50–59 3 3.3 gender male 63 70 female 27 30 history of allergy yes 6 6.7 no 11 12.2 unknown 73 81.1 note: acdrs=adverse cutaneous drug reactions althea medical journal. 2020;7(4) 202 amj december 2020 cases were commonly found in age between 20–39 years old (78.9%). the majority of the patients do not know their allergy status prior to the incident (81.1%). only 6.7% of the patients have been diagnosed with the allergy before. this study found that the most common clinical features of acdrs were morbilliform and sjs (85.6% and 8.9% respectively). half number of the patients (50%) found to be in the aids phase. only 2 patients (2.2%) have a high number of cd4. morbilliform was found in a wide range of populations with variable cd4 count. other clinical features such as sjs, urticaria, and erythroderm primarily were found in individuals with low cd4 count. forty-eight patients (53.3%) have opportunistic infection. opportunistic infections found in hiv patients were candidiasis (41.7%), tuberculosis (27%), toxoplasmosis (16.7%), syphilis (4.2%), and others (8.5%). cotrimoxazole has the highest number of case-related to acdrs (27.8%). efavirenz and nevirapine were the most common cause of acdrs found among the arv group (26.7% and 14.5% respectively). several drugs, consisting of a combination of antituberculosis, antiretroviral, and antibiotic groups, caused thirteen cases (14.5%). discussions this study found predominance in males aged between 20–39 years old. the number of male patients is 63 (70%) with an m/f sex ratio of 2.33. this observation is similar to several studies in asia in china4 and korea8 as well as a study in another part of indonesia.9 however, other studies show different results, for example, study in cameroon, central africa10 found that 82.9% of hiv patients with drug eruptions were female. similar to a study in south africa that shows a high number of female patients.11 this difference is assumed to be caused by the demographic. in indonesia, there was a higher number of male patients in the hiv-infected population.1 the relation between acdrs and sex was assumed to be influenced by several factors such as body fat percentage, hormonal factor, and enzyme activities.12 this study found the majority of the patients were between 20–39 years old. this result is similar to previous studies that also showed a majority of the patients were in age between 30–40 years old, which is reproductive age.4,8,9 history of allergy was assumed to influence the incidence of acdrs. a previous study has found there was the higher rate of allergic history in the drug eruption group compared table 2 cd4 count in hiv patients with adverse cutaneous drug reactions and with opportunistic infection cd4 count (cell/mm3) <200 200–499 ≥500 total clinical features morbiliform 37 38 2 77(85.6) stevens-johnson syndrome 6 2 0 8(8.9) urticaria 1 3 0 4(4.4) erythroderm 1 0 0 1(1.1) total 45(50) 43(47.8) 2(2.2) 90 opportunistic infections tuberculosis 9 4 13(27) candidiasis 17 3 20(41.7) toxoplasmosis 7 1 8(16.7) syphilis 1 1 2(4.2) others 3 2 5(10.4) total 37(77) 11(23) 48 note: cd4= cluster of differentiation 4 althea medical journal. 2020;7(4) 203 to the control group, indicating a correlation between the two.4 another study has shown there was no substantial correlation between sex and history of allergy to acdrs in hiv patients.13 in this study, only 6.7% of people have an allergic history. this low number thought to be caused by the high number of patient that does not know their allergy status. this study found half number of the patients (50%) was in the aids phase, characterized by low cd4 count. a study in south africa revealed that there was a decreased number of cd4 in hiv patients with ten.14 the exact mechanism of sjs and ten was still not clearly understood. it has been linked to the depletion of skin-protective cd4 regulatory t cells that have an important role in maintaining the homeostasis of the skin. the loss of regulatory t cell leads to expansion of cd8 effect or t cell that could injure keratinocyte. the depletion of cd4 cell found in the hiv population thus increase the risk of developing severe acdrs, such as sjs and ten.14,15 the low number of cd4 also associated with susceptibility to acquiring ois.8,16 in this study, there were 77% of patients with a low count of cd4 accompanied with ois. this is caused by the incapability of the host’s immune system to counter pathogens. this condition requires patients to take both arv and ois medications simultaneously. this could induce drug interactions that lead to acdrs. 17 in this study, there were 48 cases (53.3%) that accompanied ois. the most common ois is candidiasis and tuberculosis (41.7% and 27% respectively), similar to find in korea,8and in india.16 the high number of tuberculosis in this study could also be supported by the high incidence rate of tuberculosis in indonesia.18 in this study, morbilliform and sjs were found to be the most common clinical features of acdrs (85.6% and 8.9% respectively). a previous study in the same clinic in teratai clinic from 2005 until 2014 has shown similar results that morbilliform and sjs as the most common clinical features in acdrs among hiv patients (89.7% and 8.7% respectively).12 the previous study also found that 55% of the cases found within the group with low cd4 count (<200 cell/mm3).12 in this study, the suspected drugs were predominant in non-nucleoside reverse puteri nabilah maharani et al.: clinical profile of adverse cutaenous drug reactions in patients with human immunodeficiency virus table 3 clinical features in hiv patient with acdrs suspected drugs clinical features of acdrs morbilliform urticaria sjs erythroderm total nrti zidovudin 1 (1.3) 1 (12.5) 2 (2.2) nnrti nevirapin 11 (14.3) 2 (25) 13 (14.5) efavirenz 20 (26) 4 (100) 24 (26.7) rilpivirine 1 (1.3) 1 (1.1) antituberculosis 3 (3.9) 1 (100) 4 (4.4) antibiotic cotrimoxazole 23 (29.8) 2 (25) 25 (27.8) amoxicillin 1 (1.3) 1 (1.1) clindamycin 1 (1.3) 1 (1.1) antifungal fluconazole 3 (3.9) 1 (12.5) 4 (4.4) analgesic acetaminophen 2 (2.6) 2 (2.2) combination 11 (14.3) 2 (25) 13 (14.5) total 77 4 8 1 90 note: acdrs=adverse cutaneous drug reactions, nrti=nucleoside reverse transcriptase inhibitor, nnrti= nonnucleoside reverse transcriptase inhibitor, sjs= stevensjohnson syndrome althea medical journal. 2020;7(4) 204 amj december 2020 transcriptase inhibitors (nnrti) drugs and antibiotic drugs. efavirenz and nevirapin have the highest number of cases among nnrti drugs, 26.7% and 14.5% respectively. cotrimoxazole has the highest number as a suspected drug with 27.8%. similar to the study in jakarta17 nevirapine is the most common drug to cause acdrs, as common as 15% to 32%. nevirapine has been used as the most common nnrti drugs due to its cost-effectiveness, but often associated with adverse drug reactions that could affect cutaneous, hepatic, or systemic.19 this study found a lower number of cases associated with nevirapine compared to efavirenz. this result is assumed to be caused by the lessened use of nevirapine due to its known inclination with adverse drug reactions. the exact mechanism of nevirapine causing acdrs is still not well understood. it is thought to be related to genetic factors, particularly hla. a study found nevirapine shares a common binding groove f pocket with hla-c*04:01 which increased the risk of hypersensitivity reactions when exposed to nevirapine.19 in this study, sjs as a severe form of acdrs was found to be commonly caused by cotrimoxazole (25%) and nevirapine (25%). again, similar to findings in jakarta that the occurrence of stevens-johnson syndrome is higher in nevirapine compared to efavirenz.17 another study in canada20 revealed that the incidence of sjs and/or ten was 1–2 per 1000 individuals in hiv patients. the incidence of sjs and/or ten in hiv patients often linked to the increased risk of hypersensitivity reaction in hiv patients. it was reported that hiv patients are a hundred times more frequent to acquire drug hypersensitivity compared to hiv negative-individuals.7 the exact mechanism of increased risk of hypersensitivity reaction in hiv patients is still unclear. it primarily has been linked to dysregulation of the immune system. the continuous injury of hiv-infected cells and depletion of immunoregulatory cells induce immune response and release of cytokine. this leads to immune activation which is associated with increased production of ip10 and mig, tnf-α, il-6, ifn-α, and il-10. immune activation also increased levels of ifn-ɣ that induce an increase in drug presentation and leads to an increased risk of developing hypersensitivity reaction.15 other factors such as changes in drug metabolism, oxidative stress, and genetic factors also have been associated.7,17 the limitation of this study is that the diagnosis presented on the data was not confirmed with a specific test which could identify the exact drug causing acdrs. in conclusion, cdrs are found to be common in hiv patients, with the prevalence of 16.9%. a high number of cases is found in a young adult males with low cd4. the most common clinical features of acdrs are morbilliform and sjs. the most common drug acdrs are cotrimoxazole, efavirenz, and nevirapine. references 1. unaids. unaids data 2018. geneva: unaids; 2018. p.376 2. abbas ak, lichtman ah, pillai s. basic immunology: functions and disorders of the immune system. 5th ed. st. louis: elsevier; 2016 3. kementerian kesehatan republik indonesia. pedoman nasional tatalaksana klinis infeksi hiv dan terapi antiretroviral pada orang dewasa. jakarta: kementerian kesehatan ri; 2012. 4. li yy, jin ym, he lp, bai js, liu j, yu m, et al. clinical analysis of hiv/aids patients with drug eruption in yunnan, china. sci rep. 2016;6:35938. 5. hughes ca, tseng a, cooper r. managing drug interactions in hiv-infected adults with comorbid illness. cmaj. 2015;187(1):36–43. 6. pandapotan ra, rengganis i. approach to diagnosis and treatment of drug allergy. jurnal penyakit dalam indonesia. 2017;4(1):45–52. 7. minhajat r, djaharuddin i, halim r, benyamin af, bakri s. drugs hypersensitivity reaction in patient with human immunodeficiency virus infection. j allergy ther. 2017;8(1):1000252. 8. kim yj, woo jh, kim mj, park dw, song jy, kim sw, et al. opportunistic diseases among hiv-infected patients: a multicenter-nationwide korean hiv/aids cohort study, 2006 to 2013. korean j intern med. 2016;31(5):953–60. 9. dewi isl, hidayati af. manifestation of skin disorders in hiv & aids patients. berkala ilmu kesehatan kulit dan kelamin. 2015;27(2):97–105 10. kouotou ea, nansseu jr, ngono vn, tatah sa, bissek acz, ndam ecn, et al. prevalence and clinical profile of drug eruptions among antiretroviral therapyexposed hiv infected people in yaoundé, cameroon. dermatology research and practice. 2017;2017(1):6216193. althea medical journal. 2020;7(4) 205 11. masenyetse lj, manda som, mwambi hg. an assessment of adverse drug reactions among hiv positive patients receiving antiretroviral treatment in south africa. aids res ther. 2015;12:6. 12. armeinesya s, rowawi r, hamda me. manifestations of allergic drug eruption to antiretroviral in hiv/aids patients at teratai clinic dr. hasan sadikin general hospital. jsk. 2018;4(1):24–8. 13. tesiman j, sundaru h, karjadi th, setiati s. prevalence and predictors of atopy in hiv/aids patients. jurnal penyakit dalam indonesia. 2016;3(2):93–9. 14. yang c, mosam a, mankahla a, dlova n, saavedra a. hiv infection predisposes skin to toxic epidermal necrolysis via depletion of skin-directed cd4+ t cells. j am acad dermatology. 2014;70(6):1096–102. 15. peter j, choshi p, lehloenya rj. drug hypersensitivity in hiv infection. curr opin allergy clin immunol. 2019;19(4):272–82. 16. usmani mh, qureishi r, patel r, kumar pm. clinical spectrum of opportunistic infections in hiv positive patients. j evol med dent sci. 2015;4(24):4076–85. 17. yunihastuti e, widhani a, karjadi th. drug hypersensitivity in human immunodeficiency virus-infected patient: challenging diagnosis and management. asia pac allergy. 2014;4(1):54–67. 18. kementerian kesehatan ri. current status of integrated community based tb service delivery and the global fund work plan to find missing tb cases. jakarta: kementerian kesehatan ri; 2017. 19. pavlos r, mckinnon ej, ostrov da, peters b, buus s, koelle d, et al. shared peptide binding of hla class i and ii alleles associate with cutaneous nevirapine hypersensitivity and identify novel risk alleles. sci rep. 2017;7(1):8653. 20. mittmann n, knowles sr, koo m, shear nh, rachlis a, rourke sb. incidence of toxic epidermal necrolysis and stevensjohnson syndrome in an hiv cohort: an obseravtional, retrospective case series study. am j clin dermatol. 2012;13(1):49– 54. puteri nabilah maharani et al.: clinical profile of adverse cutaenous drug reactions in patients with human immunodeficiency virus a lt h e a m e d ic a l jo u r n a l v o lu m e 9 n u m b e r 4 y e a r 2 0 2 2 volume 9, number 4 december, 2022 e-issn 2337-4330 original articles larvicidal effects of citrus peels extracts against culex pipiens mosquitoes abiodun obembe, opeyemi g. oso application of replicate organism detection and counting method (rodac) in measuring mycobacterium tuberculosis contamination in high burden laboratories lidya chaidir, neng rina susilawati, mandala ajie, jessi annisa, muti’ah nurul jihadah outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia nubella citresna zakiyyah, suryani gunadharma, ahmad rizal ganiem distribution of rifampicin-resistant tuberculosis patients based on presumptive drug-resistant tuberculosis criteria at dr. hasan sadikin general hospital bandung 2016–2019 dinda nursyafira misyatin, arto yuwono soeroto, ferdy ferdian relationship between the risk of eating disorders and the concentration capacity of high school students samantha shania setijawan, felicia kurniawan characteristics and risk factors of patients with acute ischemic stroke in dr. hasan sadikin general hospital bandung, indonesia nesyia tara restikasari, uni gamayani, lisda amalia, sofiati dian, aih cahyani physical fitness is correlated with quality of life among elderly gymnastics club from haji general hospital surabaya, indonesia hasan hasan, rita vivera pane risk factor of stillbirth among pregnant women at dr. hasan sadikin general hospital bandung from 2017–2020 david immanuel, hadi susiarno, windi nurdiawan level of knowledge, attitude, and practices of general physicians in west java, indonesia on middle ear inflammation aziza salsabila, lina lasminingrum, sally mahdiani, shinta fitri boesoirie, bambang purwanto knowledge towards thalassemia and willingness to screen among students in public senior high school 3 bandung, indonesia rima destya triatin, lulu eva rakhmilia, yunia sribudiani, susi susanah editor in chief edhyana k. sahiratmadja managing editor mas rizky a.a syamsunarno external editors gerald pals kamisah yusof alexander kwarteng kittiphong paiboonsukwong r. tedjo sasmono jarir at thobari soegianto ali trevino aristarkus pakasi andani eka putra pudji lestari herry garna internal editors yunia sribudiani ronny lesmana afiat berbudi nur atik muhammad hasan bashari sri endah rahayuningsih irma ruslina defi reni ghrahani mohammad ghozali astrid feinisa khairani nur melani sari eko fuji ariyanto copyeditors hanna goenawan julia ramadhanti poppy siti chaerani djen amar electronic production engineer devi fabiola syahfitri site administrator & layout editor ati sulastri  offline secretariat elsa purwita editorial address jl. prof. dr. eijkman 38 bandung, indonesia 40161 mobile: 082216237668/081320178724 phone (+62) 022-2032170 ext. 1401 fax: (+62) 022-2037823 e-mail: chiefeditor.amj@gmail.com website: http://journal.fk.unpad.ac.id/index.php/amj volume 9, number 4 december, 2022 e-issn 2337-4330 original articles larvicidal effects of citrus peels extracts against culex pipiens mosquitoes abiodun obembe, opeyemi g. oso application of replicate organism detection and counting method (rodac) in measuring mycobacterium tuberculosis contamination in high burden laboratories lidya chaidir, neng rina susilawati, mandala ajie, jessi annisa, muti’ah nurul jihadah outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia nubella citresna zakiyyah, suryani gunadharma, ahmad rizal ganiem distribution of rifampicin-resistant tuberculosis patients based on presumptive drug-resistant tuberculosis criteria at dr. hasan sadikin general hospital 2016–2019 dinda nursyafira misyatin, arto yuwono soeroto, ferdy ferdian relationship between the risk of eating disorders and the concentration capacity of high school students samantha shania setijawan, felicia kurniawan characteristics and risk factors of patients with acute ischemic stroke in dr. hasan  sadikin general hospital bandung, indonesia nesyia tara restikasari, uni gamayani, lisda amalia, sofiati dian, aih cahyani physical fitness is correlated with quality of life among elderly gymnastics club from  haji general hospital surabaya, indonesia hasan hasan, rita vivera pane risk factor of stillbirth among pregnant women at dr. hasan sadikin general  hospital bandung from 2017–2020 david immanuel, hadi susiarno, windi nurdiawan level of knowledge, attitude, and practices of general physicians in west java,  indonesia on middle ear inflammation aziza salsabila, lina lasminingrum, sally mahdiani, shinta fitri boesoirie,  bambang purwanto knowledge towards thalassemia and willingness to screen among students in public  senior high school 3 bandung, indonesia rima destya triatin, lulu eva rakhmilia, yunia sribudiani, susi susanah page 185–190 191–197 198–205 206–211 212–217 218–222 223–227 228–233 234–240 241–247 author’s guidelines althea medical journal (amj) is a peer reviewed electronic scientific publication journal in 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emiol rec. 2012;87(28/29):261–76. no author given mental care and relief support for victims of the earthquake occurred in eastern part of japan. seishin shinkeigaku zasshi. 2011;113(9):825–44. volume with supplement rushton l, hutchings sj, fortunato l, young c, evans gs, brown t, et al. occupational cancer burden in great britain. br j cancer. 2012;107(suppl1):s3–7. edition with supplement north cs, pollio de, smith rp, king rv, pandya a, suris am, et al. trauma exposure and posttraumatic stress disorder among employees of new york city companies affected by the september 11, 2001 attacks on the world trade center. disaster med public health prep. 2011;(5 suppl 2):s205– 13. books and other monographs personal author(s) sax pe, cohen cj, kuritzkes dr. hiv essentials 2012. 2nd ed. burlington: world headquarters; 2012. editor(s) as the author baxter r, editor. a cellular dermal matrices in breast surgery, an issue of clinics in plastic surgery. mountlake terrace: saunders; 2012. organization as the author unaids. meeting the investment challenge tipping the dependency. geneva: who library cataloguing data; 2012. chapter in a book pignone m, salazar r. disease prevention and health promotion. in: diedrich c, lebowitz h, holton b, editors. 2012 current medical diagnosis and treatment. 51st ed. new york: the mcgraw-hill companies; 2012. p. 1–21. conference proceedings wilson b, hamilton n, editors. airborne particulate exposures: the environmental and occupational perspectives. proceedings of the wsn mining health and safety conference; 2012 april 17–19; sudbury. ontario: golder associates; 2012. conference paper tirilly p, lu k, mu x. predicting modality from text quiries for medical image retrieval. in: cao y, kalpathy-cramer j, unay d, editors. mm 11. proceeding of the 2011 international acm workshop on medical multimedia analysis and retrieval; 2011 nov 28–dec 01; arizona, usa. new york: acm; 2011. p. 7–12. dissertation rohim s. kontruksi diri dan perilaku komunikasi gelandangan di kota jakarta (studi fenomenologi terhadap julukan gelandangan “manusia gerobak”) [dissertation]. bandung: universitas padjadjaran; 2012. electronic material journal article in electronic format mahmood om, goldenberg d, thayer r, migliorini r, simmons an, tapert sf. adolescents’ fmri activation to a response inhibition task predicts future substance use. addictive behaviors [internet] 2012 [cited 2012 may 12]. available from: http:// www.sciencedirect.com. homepage world health organization. cardiovascular disease (cvds) [internet] [cited 2021 may 6]. available from: https://www. who.int/health-topics/cardiovasculardiseases#tab=tab_1. editorial board contact: althea medical journal mobile: 082216237668/081320178724 e-mail: chiefeditor.amj@gmail.com amj.fkunpad@gmail.com amj vol 8 no 1 march 2021.indd althea medical journal. 2021;8(1) 7 effect of health education video on knowledge about stunting among women in childbearing age annisa nuraini,1 puspa sari,2 sri astuti,2 lani gumilang,2 didah2 1midwifery study program faculty of medicine universitas padajadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: annisa nuraini, midwifery study program, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: annisaaaanuraini@gmail.com introduction good nutrition is essential for optimal brain development and physical growth. therefore, the nutritional intake needs to be arranged as early as possible; particularly in the first 1000 days of life, known as the golden growth period in human life. if the nutritional demand is not fulfilled, the growth and development of the children will be hindered.1 toddler aged 24–59 months are experiencing a very rapid growth process, hence, they are easy to get malnutrition.2 one of the nutritional deficiencies experienced by toddlers is stunting. there are many factors that cause stunting, such as maternal malnutrition. in addition, inadequate infant and young child feeding (iycf) can also cause stunting.3 toddler with a nutritional status value of length/height below -2sd is designated as stunted, whereas severely stunted if the nutritional status value is below -3sd.4 linear growth disorders or stunting is occurred mainly within 2–5 years, as the side effects of lack of nutritional intake.2 the global nutrition report 2014 has shown that indonesia is among 17 countries out of 117 countries with three nutritional problems, which are stunting, wasting, and overweight in toddlers.5 the national health research data has reported in 2018 that the prevalence of stunting (30.8%) is higher than other nutritional problems such as malnutrition (17.7%), underweight (10.2%), and obesity (8%).6,7 west java has a similar prevalence of stunting (29.2%).8,9 based on data from the national team for the acceleration of poverty amj. 2021;8(1):7–12 abstract background: toddlers aged 24–59 months are experiencing a very rapid growth process; however, they are also prone to have nutritional problems, including stunting. stunting occurs mainly within the first 2 to 5 years of life. the main cause is a lack of knowledge on toddler’s nutritional intake among women of childbearing age. this study aimed to explore the effect of health education using video media on the knowledge about stunting among women of childbearing age. methods: this was a quantitative, experimental study with one group pretest-posttest design conducted in july–november 2019 on women of childbearing age in the working area of public health center (pusat kesehatan masyarakat, puskesmas) jatinangor, west java, indonesia. respondents were recruited using the multistage random sampling according to the inclusion criteria. a pre-test was administered before the health education session on stunting and a post-test was administered afterwards. data collected were then analyzed using the wilcoxon test. results: in total, 211 women were included. education video on stunting was proved to significantly increase the respondent’s knowledge on stunting (p=0.000, r value= 0.690). conclusions: health education video clearly increases knowledge on stunting among women of childbearing age. thus, video medium can be used as a preferred method for disseminating knowledge on various health topics. keywords: childbearing age, knowledge, stunting, video, women https://doi.org/10.15850/amj.v8n1.2150 althea medical journal. 2021;8(1) 8 althea medical journal march 2021 reduction (tnp2k) in 2017, the prevalence of stunting in sumedang regency has reached 41.08%, while in jatinangor district the number of stunted toddlers is 19.23%.9 stunting is influenced by several factors, such as maternal factors, hygiene and sanitation, a clean and healthy lifestyle, nonoptimal nutritional intake, no breastfeeding, and infection.3 in addition, lack of knowledge can be one of the causes of stunting. furthermore, a lack of knowledge can occur among women of childbearing age. most of them think that stunting is not a big problem and they do not know the future implication of stunting. moreover, they do not understand the nutritional needs which should be fulfilled during the first 1000 days of life.3 therefore, it is important to know the impacts and efforts to prevent stunting in order to reduce the high prevalence of stunting in indonesia. one of the efforts to prevent stunting is health education. health education can give motivation to individuals in applying the knowledge and behavioral changes.10,11 in addition, health education can be carried out with various media, such as video media as the most effective tools to deliver information.12,13 fulfillment of nutrition in the first 1000 days of life is very important; especially to prevent stunting. therefore, it is necessary to have a good understanding regarding the fulfillment of nutrition at the 1000 days of life. however, the knowledge of women of childbearing age regarding the importance of nutrition in the first 1000 days of life in jatinangor is still low. they do not know about stunting, as the complication of less nutritional intake.14 therefore, we were interested in providing health education; especially about stunting by using video. the aim of this study was to explore the effect of health education through video on the knowledge about stunting among women of childbearing age. methods this research was an experimental study with one group pre and post-test design. the population in this study was women of childbearing age who lived in the working area of the public health center jatinagor. the area included 7 villages which were cibeusi, cipacing, cikeruh, sayang, hegarmanah, cileles, and cilayung. the public health center jatinangor had reported that there were a total of 14,225 women of childbearing age in 2018. the multistage random sampling technique was used in this study. the sampling process began with cluster sampling, then proportionated random sampling was applied to determine the proportionate number of samples per village and sample of each rw. after that, the simple random sampling technique was carried out. sampling with simple random sampling was conducted by ordinal mode, by taking the names of women of childbearing age with odd numbers. the oddnumbered names of women of childbearing age were used as research samples. this study was conducted from july to november 2019. this study has been registered in the research ethics committee universitas padjadjaran (no.1018/un6.kep/ec/2019). there were 221 women of childbearing age who had met the inclusion criteria. the questionnaire used was taken from previous study (courtesy of sri astuti15) with the modification. the questionnaire had been tested for validity and reliability in cisempur and the result of the test was valid and reliable. the questions in the pre-test and posttest questionnaires used closed questions in the form of true, false, and unknown statements. before the research was carried out, respondents were given an informed consent sheet and signed in as an agreement to participate in the research. a questionnaire was given before and after a health education video about stunting. the video concept was created by the researcher and the video creation process was assisted by the video maker in the form of a moving animation video to make it more interesting to watch as well as to understand the material easier. the video content explained stunting, starting from the definition of stunting, the prevalence of stunting in indonesia and west java, the factors which cause stunting, the impact of stunting, efforts to prevent stunting, and the role of nutrition in preventing stunting. the duration of the video was 6 minutes 52 seconds. respondents were required to watch the video from beginning to end so that the material would have been delivered properly. the references for stunting education in the video were obtained from who, the indonesian ministry of health, and various journals. the video was further sent to the respondent through whatsapp, and thus the respondents could re-watch the video. a posttest was carried out to measure respondent’s knowledge about stunting 7 days after the education using the same questionnaire. the data were analyzed using the wilcoxon test to determine the effect of health education through video media on knowledge. althea medical journal. 2021;8(1) 9annisa nuraini et al.: effect of health education video on knowledge about stunting among women in childbearing age table 1 knowledge about stunting among women of childbearing age knowledge pre-test post-test n % n % good 48 21.7 154 69.7 enough 72 32.6 47 21.3 less 101 45.7 20 9 table 2 knowledge about stunting among women of childbearing age in each village in the area of public health center jatinangor village knowledge pre-test post-test n % n % cilayung good 1 6.3 7 43.8 enough 3 18.8 7 43.8 less 12 75* 2 12.5 total 16 100 16 100 cibeusi good 5 20.8 15 62.5 enough 6 25 3 12.5 less 13 54.2 6 25 total 24 100 24 100 cileles good 7 25.9 17 63 enough 5 18.5 7 25.9 less 15 55.6 3 11.1 total 27 100 27 100 cikeruh good 2 6.9 21 72.4 enough 12 41.4 5 17.2 less 15 51.7 3 10.3 total 29 100 29 100 sayang good 9 27.3 26 78.8 enough 15 45.5 5 15.2 less 9 27.3 2 6.1 total 33 100 33 100 hegarmanah good 13 32.5** 29 72.5 enough 11 27.5 9 22.5 less 16 40 2 5 total 40 100 40 100 cipacing good 11 21.2 39 75 enough 20 38.5 11 21.2 less 21 40.4 2 3.8 total 52 100 52 100 note: * the most ‘less’ knowledge and ** the most ‘good’ knowledge during the pre-test althea medical journal. 2021;8(1) 10 althea medical journal march 2021 results knowledge about stunting among women of childbearing age in the working area of public health center jatinangor was as followed; 45.7% had less knowledge in the pre-test, which was increased to good knowledge in 69.7% (table 1). women who had less knowledge were mostly (75%) lived in cilayung, those who had good knowledge were mostly (32.5%) lived in hegarmanah (table 2). the knowledge before and after health education interventions through video media showed a significant increased (p=0.00; wilcoxon test) and a strong level of effect with a correlation value (r=0.690). discussion our study has shown an increase in the knowledge about stunting among women of childbearing age after health education through video media. women living in cilayung have less knowledge compared to those living in hegarmanah who have more ‘good’ knowledge (table 2). the distance of cilayung is the farthest from the center of jatinangor district compared to other villages, which is 4 kilometers away.16 information acquisition about health is also influenced by the distance between places of residence to health services.17 therefore, it is important to pay attention to the distance between the places of residence to the health service provider of information. health services provide various health information, one of which is nutrition in toddlers. therefore, the distance of residence to health services can affect knowledge.17 the knowledge about stunting, particularly among women of childbearing age, is very important. in addition, the level of knowledge of women of childbearing age about nutrition plays a role in nutritional problems in indonesia, one of which is stunting.10 therefore, it is very important for women of childbearing age to have good knowledge about stunting, including its effects and prevention efforts. the efforts to increase knowledge about stunting can be done through health education. health education can motivate someone to apply the given knowledge, in this case, knowledge about stunting.11 health education can be carried out by using various media, including visual, audio, and audiovisual media. in the study, audiovisual media videos were used. the content of the video is including the definition of stunting, the prevalence of stunting in west java and indonesia, the risk factor of stunting, the impact of stunting, and the role of nutrition in preventing stunting. the video used is in the form of a moving animation video to make the education more interesting and the conveyed message can be easily accepted by the audience. education through video media is one of the media for learning methods aiming to improve cognitive and psychomotor abilities. furthermore, it can influence attitudes and emotions since it uses various techniques and effects.18 furthermore, there is a significant increase in knowledge after video education, showing that the effect of health education through video media is effective (p=0.000). in addition, the level of influence of health education through video media has a strong level of influence with a correlation value of r=0.690. moreover, health education through video media can increase knowledge and it can change the attitude.12 they can learn more information than the existing lecture method.19 video media is one of the effective learning media in increasing knowledge. the “cone experience” theory by edgar dale classifies media based on learning experiences which are obtained starting from direct learning experiences, learning experiences that can be achieved through images and learning experiences that are abstract. if we prefer to experience learning process which more concrete and richer, we can use media that is around the base of the experience cone. for example, learning process experience, which is concrete, is the use of audio-visual media such as, video, since by using audio-visual media learners can more easily receive information provided. dale predicts that the acquisition of learning outcomes is around 30% through table 3 effect of health education through video media on the knowledge about stunting among women of childbearing age mean s.d median pvalue r pre-test 57.3 18.9 56.6 0.000 0.690 post-test 78.2 14.5 83.3 note: s.d= standard deviation althea medical journal. 2021;8(1) 11annisa nuraini et al.: effect of health education video on knowledge about stunting among women in childbearing age the sense of sight, while through the sense of hearing is 20%.19 audiovisual media can increase knowledge.13 the benefits of using teaching or counseling materials which are presented in the form of a video of film make it easier for someone to learn on their own, can present a competitive situation, can be repeated, can display something in more detail, and can be accelerated or slowed down, so that it will be easier to absorb information. therefore, the use of audiovisual media; such as video can make it easier for someone to absorb the information; besides, it can increase knowledge. video media which is used as a learning method is considered more interesting and it is easier to understand its meaning.12, 20 limitations in this study are followed; we cannot confirm whether the respondent actually has watched the video at home after the pre-test until the next 7 days before the post-test has been carried out. we could only send reminders to the respondents every day to remind the respondents. the respondent may get bored with the same contents, therefore, different contents would be interesting to be applied. to conclude, there is an increase in the knowledge about stunting as an effect of health education through video media among women of childbearing age in the working area of public health center jatinangor. references 1. hidayat ms, pinatih gni. prevalensi stunting pada balita di wilayah kerja puskesmas sidemen karangasem. e-jurnal medika udayana. 2017;6(7):33416. 2. ayuningtyas a, simbolon d, rizal a. asupan zat gizi makro dan mikro terhadap kejadian stunting pada balita. jurnal kesehatan. 2018;9(3):444–9. 3. who. childhood stunting: challenges and opportunities. report of a promoting healthy growth and preventing childhood stunting colloquium. geneva: world health organization; 2014. 4. who. guideline: assessing and managing children at primary health-care facilities to prevent overweight and obesity in the context of the double burden of malnutrition: updates for the integrated management of childhood illness (imci). geneva: world health organization; 2017. 5. haddad l, achadi e, bendech ma, ahuja a, bhatia k, bhutta z, et al. the global nutrition report 2014: actions and accountability to accelerate the world’s progress on nutrition. j nutr. 2015;145(4):663–71. 6. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. hasil utama riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2018. 7. waroh yk. pemberian makanan tambahan sebagai upaya penanganan stunting pada balita di indonesia. embrio. 2019;11(1):47–54. 8. arsyati am. pengaruh penyuluhan media audiovisual dalam pengetahuan pencegahan stunting pada ibu hamil di desa cibatok 2 cibungbulang. promotor. 2019;2(3):182–90. 9. rahmandiani rd, astuti s, susanti ai, handayani ds, didah d. hubungan pengetahuan ibu balita tentang stunting dengan karakteristik ibu dan sumber informasi di desa hegarmanah kecamatan jatinangor kabupaten sumedang. jurnal sistem kesehatan. 2019;5(2):74–80. 10. hadisuyitno j, riyadi bd, supariasa idn. efektivitas penyuluhan terhadap perubahan pengetahuan kadarzi dan phbs ibu balita di desa pulungdowo, kecamatan tumpang, kabupaten malang. vidya. 2017;25(1):110–5. 11. dewi m, aminah m. pengaruh edukasi gizi terhadap feeding practice ibu balita stunting usia 6–24 bulan (the effect of nutritional knowledge on feeding practice of mothers having stunting toddler aged 6–24 months). indonesian journal of human nutrition. 2016;3(1):1–8. 12. dahodwala m, geransar r, babion j, de grood j, sargious p. the impact of the use of video-based educational interventions on patient outcomes in hospital settings: a scoping review. patient educ couns.. 2018;101(12):2116–24. 13. wirawan s, abdi lk, sulendri nks. penyuluhan dengan media audio visual dan konvensional terhadap pengetahuan ibu anak balita. kemas: jurnal kesehatan masyarakat. 2014;10(1):80–7. 14. nurlaela d, sari p, martini n, wijaya m, judistiani rtd. efektivitas pendidikan kesehatan melalui media kartu cinta anak tentang 1000 hari pertama kehidupan dalam meningkatkan pengetahuan pasangan calon pengantin di kua kecamatan jatinangor. jkesv. 2018;3(2):62–8. 15. astuti s. upaya promotif untuk meningkatkan pengetahuan ibu balita althea medical journal. 2021;8(1) 12 althea medical journal march 2021 tentang pencegahan stuntingdengan media integrating card di kecamatan jatinangor kabupaten sumedang. jurnal pengabdian kepada masyarakat. 2018;2(6):466–9. 16. ropika an. pemahaman dan praktik pencegahan tekanan darah tinggi di desa cilayung (tinjauan antropologis). umbara. 2018;3(1):14–24. 17. agritubella sm, delvira w. efektifitas poster pola diit 1000 hari pertama kehidupan (hpk) terhadap pengetahuan ibu hamil tentang nutrisi dalam pencegahan stunting di puskesmas rambah kabupaten rokan hulu. jurnal endurance. 2020;5(1):168– 79. 18. soekidjo n. promosi kesehatan dan perilaku kesehatan. jakarta rineka cipta. 2012. 19. huda m. pembelajaran berbasis multimedia dan pembelajaran konvensional (studi komparasi di mts al-muttaqin plemahan kediri). jurnal penelitian. 2016;10(1):125– 46. 20. ornelas ij, ho k, jackson jc, moo-young j, le a, do hh, et al. results from a pilot video intervention to increase cervical cancer screening in refugee women. health educ behav. 2018;45(4):559–68. amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 89 forced expiratory volume in 1 second and forced vital capacity in bronchial asthma patients in relation with asthma exercise atika andianti,1 vita murniati tarawan,2 hendarsyah suryadinata3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: atika andianti, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: atika0311@gmail.com introduction asthma is a heterogeneous disease characterized by chronic inflammation of the respiratory tract. the disease is characterized by a history of respiratory tract symptoms such as wheezing, shortness of breath, chest tightness, coughing, and various limitations of the airways during expiration that varies in time and intensity.1 these symptoms occur because of the inflammatory response in the respiratory tract obstructing the respiratory tract and causing bronchial hyperresponsiveness, which are the characteristics of functional abnormalities in patients with asthma.2 asthma is a common respiratory disease, of which approximately 18% of the population with lung diseases accompanied by asthma. asthma is estimated to cause an average of 250,000 deaths annually.3 aerobic physical activity is one of the non-pharmacological treatments of asthma.1 it causes progressive desensitization to the feeling of breathlessness and greater control of asthma symptoms.4,5 some studies showed that aerobic exercise causes an increase in forced expiratory volume in 1 second (fev1) and forced vital capacity (fvc) in patients with asthma.6 aerobic physical activity designed specifically for people with asthma is called asthma exercise. movements in asthma exercise area dapted to serve the capabilities and needs of the patient based on asthma severity. previous amj. 2020;7(2):89–94 abstract background: aerobic physical activity is one of the non-pharmacology management approaches of asthma. the asthma foundation of indonesia (yayasan asma indonesia, yai) has designed an aerobic physical activity for people with asthma, known as asthma exercise. asthma exercise is expected to increase the overall functional capacity of the lungs. one way to measure lung function is by measuring the score of forced expiratory volume in 1 second (fev1) and forced vital capacity (fvc). the objective of the study was to explore the difference in fev1 and fvc between bronchial asthma patients with and without asthma exercise. methods: this study involved asthma patients from the bandung asthma association (perhimpunan asma bandung, pab) who did asthma exercise (n=28), and as control patients from the pulmonology clinic in dr. hasan sadikin general hospital were selected who did not do asthma exercise. the research data used were primary data from the spirogram examination. asthma patients were selected based on inclusion and exclusion criteria. this research used unpaired numerical comparative analytical hypothetical tests with a cross-sectional design. results: the study showed the mean of fev1 and fvc in the group with asthma exercise (1.6107±0.3780l and 2.0396±0.3465l) was higher than the group without asthma exercise (1.3750±0.4702l and 1.7164±0.4632l). statistical difference test using independent t-test indicated a score of p=0.044 for fev1 and p=0.005 for fvc between the two groups. conclusions: there are significant differences in fev1 and fvc between bronchial asthma patients with and without asthma exercise. furthermore, asthma exercise is recommended for asthma patients to improve their lung function. keywords: asthma exercise, fev1, fvc https://doi.org/10.15850/amj.v7n2.1781 althea medical journal. 2020;7(2) 90 amj june 2020 research stated that there is an increase of lung function based on peak expiratory flow (pef) measured by peak flow meter for about 11.9% in patients with asthma after doing asthma exercise for eight weeks in a row.7 lung function can also be measured by fev1 and fvc using spirometry examination.8 aims of this study was to determine the differences in fev1 and fvc values among bronchial asthma patients with and without asthma exercise. methods this study used an unpaired comparative analytical method of two groups with a crosssectional approach. the sample size was based on the calculation of the minimum sample size by using the unpaired comparative analytic formula with significances of α=5%, β=90%, s=0.3402, and x1–x2=0.3, sample for each group which is 28.9 the population in this study was bronchial asthma patients divided into two groups: patients with asthma exercise and without asthma exercise. the asthma exercise group consisted of bronchial asthma patients who were the members of the bandung asthma association (perhimpunan asma bandung, pab). inclusion criteria for the group with asthma exercise were the bronchial asthma patients in pab who had performed asthma exercise for a minimum of eight weeks regularly. patients with comorbid conditions, such as heart diseases, renal diseases, musculoskeletal diseases, and other lung diseases, pregnancy, and had performed any regular aerobic activity other than asthma exercise were excluded. the control group consisted of bronchial asthma patients from the pulmonology clinic of dr. hasan sadikin general hospital. inclusion criteria for the control group were the bronchial asthma patient in the pulmonology clinic of dr. hasan sadikin general hospital who had not performed asthma exercise. patients with comorbid conditions, such as heart diseases, renal diseases, and other lung diseases, and who had performed any regular aerobic activity were excluded. data were obtained at dr. hasan sadikin general hospital from september until november 2015. data on subjects’ characteristics, history of the disease, history of asthma therapy, and control-based asthma classification were obtained from history taking. the height and weight of subjects were obtained from a physical examination. criteria for asthma classification was determined by asthma attack frequency in the past four weeks, which were daytime asthma symptoms more than twice per week, night waking due to asthma, need for a reliever for symptoms more than twice per week, and activity limitation due to asthma. subjects were included in controlled asthma if subjects had none of these events, partially controlled asthma if subjects had 1–2 of these events, table 1 characteristic of bronchial asthma patients with or without asthma exercise characteristics asthma exercise (n=28) without asthma exercise(n=28) p-value n range mean ±sd n range mean ±sd age (years) 32–72 56.39±8.68 27–73 49.03±11.16 0.094 sex 0.001 male 3 9 female 25 19 weight (kg) 46–88 62.17±9.84 40–136 67.27±17.82 0.080 height (cm) 141–170 152.15±6.62 141.2–169 154.3±6.79 0.769 body mass index (kg/m2) 19.56–33.9 26.92±4.25 18.26–58.09 28.34±7.73 0.150 asthma classification 0.443 controlled 13 5 partly controlled 11 14 uncontrolled 4 9 history of asthma therapy 0.259 reliever 11 14 controller 17 14 althea medical journal. 2020;7(2) 91 and uncontrolled asthma if subjects had 3–4 of these events.1 the fev1 and fvc data were collected through spirometry measurements. it started by ensuring that all components of the spirometer were ready for use in the measurement. a mouthpiece was then inserted into the subjects’ mouth. subjects breathed normally three times. subjects then subsequently performed maximal inspiration and maximal expiration as perfect as possible and as soon as possible from the mouth to the mouthpiece in an upright body position. the start button was then pressed at the same time as the subjects began to perform expiration. measurement results of fev1and fvc could be seen on the spirometer screen, showing a curve of the relationship between time (second) and lung volume change (liter), and on the print out of spirogram. data were analyzed with the homogeneity test of the subjects by using levene’s test for equality of variace (p≥0.05). homogeneity of the subjects was based on age, sex, weight, height, body mass index, control-based asthma classification, and history of asthma therapy. the normality of data distribution was tested by using shapiro-whilk (p>0.05) because the sample size was less than 50 per group. independent t-test would be used if data were normally distributed, otherwise the mannwhitney test would be used. statistical analysis is considered significant with a value of p<0.05. the data were processed and analyzed using microsoft excel 2007 and version 15.0 of statistical passage for social sciences (spss). data were displayed in tabular forms. this study was conducted after obtaining approval from the health research ethicsl committee of dr. hasan sadikin general hospital with a number of lb.04.p1/a05/ ec/268/vii/2015. examination of the subjects performed after the subjects were given explanations about the research procedures and had signed informed consent forms voluntarily. the subjects had the freedom to withdraw from participation in the research with no further consequences. confidentiality was maintained during the research project. results homogeneity of the subjects was tested by using levene’s test for equality of variance. table 1 showed the general characteristics of the subjects; age, weight, height, body mass index, asthma classification, and medical history resulted in p≥0.05, indicating these characteristics were homogenous. the characteristics of the subjects in sex resulted in p<0.05, indicating these characteristics were non-homogenous. saphiro wilk test was performed to analyze whether the fev1 and fvc data were distributed normally. table 2 showed the value of p≥0.05, indicating the data were normally distributed. hypothesis testing for differences in fev1 and fvc between the two groups conducted with an independent t-test. table 3 showed the results of hypothesis testing showed the value of p<0.05 for both fev1 and fvc, indicating there were significant differences in fev1 and fvc between bronchial asthma patients with and without asthma exercise. discussion characteristics of the subjects based on the results of levene’s test for equality of variance showed homogeneous characteristics based on age, weight, height, body mass index, asthma classification, and history of asthma treatment for p≥0.05, while characteristics based on sex were non-homogenous because the p-value was <0.05. the fev1 and fvc values tend to increase with age until 20 years old in females and 25 years old in males, then gradually decreased in general. the greater decline in fev1 than fvc causes the age-related fall in fev1/fvc in adults.10 the trend of asthma was reversed after adolescent which higher in females than males. the airway caliber and lung function of male adults are greater than table 2 data distributions normality test group with asthma exercise (n=28) without asthma exercise (n=28) p-value data distribution p-value data distribution fev1* 0.050 normal 0.695 normal fvc** 0.056 normal 0.210 normal note: *fev1= forced expiratory volume in 1 second,**fvc= forced vital capacity atika andianti et al.: forced expiratory volume in 1 second and forced vital capacity in bronchial asthma patients in relation with asthma exercise althea medical journal. 2020;7(2) 92 amj june 2020 female adults. the smaller airway caliber in females causes increases in airway resistance and co2 retention in blood. in general, female sex hormones aggravate asthma and other allergic diseases, whereas male sex hormones suppress such diseases. females also seem to be born with th2 bias, which is important in asthma pathophysiology. female sex hormones, such as progesterone and estrogen increase the secretions of interleukin-4 and total ige levels. stress and concern about eating habits that cause obesity to develop more frequently in females. the relation between obesity and asthma is explained by several mechanisms, which are mechanical factors such as lower lung volume and compliance and smaller diameter of the peripheral airways; systemic inflammation caused by fat-cell-secreting adipokines including il-6, tumor necrosis factor (tnf)-α and eotaxin; a decrease in adiponectin, an obesity hormone with an anti-inflammatory effect; and an increase of oxidative stress.11 data distributions based on the results of saphiro whilk test showed the fev1 and fvc data were distributed normally because the p-value was ≥0.05. an independent t-test was used for hypothesis testing because the data were normally distributed. results from the independent t-test showed there were differences in fev1 and fvc values between bronchial asthma patients with and without asthma exercise. these can be seen from the mean difference of 0.2357 l for fev1 and 0.3232 l for fvc between the two groups. the differences in fev1 and fvc between the two groups in this study were statistically significant (p<0.05). these results are supported by several previous studies. a study conducted by farid r et al.6 in iran aimed to see the results of aerobic activity intervention on the subjects with asthma and it showed that the intervention impact changes in fev1 and fvc between the exercise and control groups were statistically significant (p<0.05). another study conducted by sahat cs et al.7 in west java by giving asthma exercise intervention for subjects with asthma showed that there were significant differences with p<0.05 in both fev1 and fvc between the exercise and control groups. vital lung capacity is affected by the habit of doing physical activity or aerobic exercise. the volume and pattern of respiratory ventilation are regulated by the respiratory center in the brain stem by sending nerve impulses through the intercostal muscles and the diaphragm. the respiratory center in the brain stem is stimulated by the proprioceptive receptors in moving muscles, tendons, and joints when a person performing the aerobic activity. stimulation of the respiratory center by aerobic activity will increase the rate and depth of breathing to improve the fvc, oxygen consumption, and the rate of diffusion of oxygen.8 aerobic activity, or in this study is in the form of asthma exercise, affects lung function table 3 fev1 and fvc between bronchial asthma patients with or without asthma exercise fev1* with asthma exercise (n=28) without asthma exercise (n=28) fev mean (l) 1.6107 1.3750 standard deviation 0.3780 0.4702 p-value 0.044 mean difference 0.2357 95% confidence interval 0.0071-0.4643 fvc mean (l) 2.0396 1.7164 standard deviation 0.3465 0.4632 p-value 0.005 mean difference 0.3232 95% confidence interval 0.1040-0.5424 note: *fev1= forced expiratory volume in 1 second, **fvc= forced vital capacity althea medical journal. 2020;7(2) 93 by increasing blood flows through the lungs including respiratory muscles so that the volume of oxygen that diffuses into the pulmonary capillaries is larger or maximum and oxygen consumption in the blood is increased.9,12 blood flows carry oxygen and nutrients such as calcium and potassium to the respiratory muscles. calcium ions in the muscles are increased due to an increase in calcium ions released by the sarcoplasmic reticulum. calcium ions serve to a muscle action potential and increase the work of respiratory muscles so that muscles mass can be maintained, furthermore improve the strength of the respiratory muscles resulting in improvement of pulmonary ventilation, lung compliance, and reduction of the amount of air trapped in the lungs and respiratory tract resistance.7,8 also people with asthma will be forced to perform a deep inspiration that fills the entire airway with air after the completion of asthma exercise.8 this results in sufficient inspiratory pressure for maximum ventilation so the air movement is better even though the amount of breathing is less.12 increased lung volume after a maximum inspiration will increase the amount of air that can be forcibly expelled in the first second after a maximal inspiration so that the fev1value increases.3 research by handayani et al.13 showed that asthma exercise can cause an increase of cortisol secretion by the adrenal cortex, resulting in an increased response of beta-adrenergic receptors on smooth muscles of the respiratory tract, furthermore reducing hyperresponsiveness of respiratory tract due to decreased amount of circulating eosinophils and also inhibiting the production of cytokines in the respiratory tract. previous studies in animal models of asthma stated that aerobic exercise causes a decrease of eosinophils and airway inflammation and remodeling. this happens due to decreased expression of th2 cytokines (il-4, il-5, and il-13) and nf-jb and increased expression of anti-inflammation cytokines, which are il-10 and il-1ra.14,15 reduced airway inflammation and remodeling cause the expansion of the respiratory tract to increase, there by improving the score of fev1.13 improved lung function by asthma exercise influences a decrease in asthma symptoms and an increase in the ability of asthmatics to undertake daily physical activity.16 increased capacity of oxygen uptake while breathing causes desensitization to breathlessness which increases the threshold when the asthma symptom is felt.17 asthma exercise can improve residual airflow and decrease breathing ventilation, these are accompanied by the strengthening of the expansion of the bronchus so that the air will be in the lung at longer intervals in between breaths during exercise.6,14 this results in more powerful and effective inspiration and expirationin patients with asthma. furthermore, tolerance to physical activity will also be increased from time to time.17 significant differences in fev1 and fvc between bronchial asthma patients with and without asthma exercise were marked in the subjects in the asthma exercise group, who had performed a regular exercise for eight weeks period. long-term exercises cause the change of plasticity of airway smooth muscle cytoskeleton or the interaction of myosin and actin, furthermore enable the smooth muscle fibers to become more resistant to spasmogens. habitual exercises cause the reorganization of the contractile apparatus of the airway smooth muscle which enables the smooth muscle fibers to adapt to changes in cell shape. a previous study of the animal models showed that habitual exercise increases the thickness of epithelial cells and the number of proliferating bronchiolar epithelial cells.18 the long term aerobic training also leads to increased capillarization of the muscle; therefore, the more oxygen-rich blood supply can be delivered to the working muscles. the result of this research is also consistent with a study conducted by farid r et al.6 stated there are improvements of fev1 and fvc after the research subjects undertook two monthsprogrammed aerobic activities regularly. sahat et al.7 also conducted a similar study providing asthma exercise intervention for 8 weeks and showed significant differences in fev1 and fvc between the intervention and control groups. the limitation of the study is that this study was carried out at one time and in two different population groups that may affect the homogeneity of the characteristics of the subject. recall bias may occur when patients filled out the datasheet associated with asthma manifestations to determine controlbased asthma classification of the patients. the future longitudinal study is needed to determine the effect of asthma exercise on lung function measured by fev1 and fvc. as a conclusion, there are significant differences in lung function between bronchial asthma patients with and without asthma exercise. therefore, health service should not only focus on providing interventions for atika andianti et al.: forced expiratory volume in 1 second and forced vital capacity in bronchial asthma patients in relation with asthma exercise althea medical journal. 2020;7(2) 94 amj june 2020 asthma patients pharmacologically but also non-pharmacologically, including exercise regularly. it is suggested that pab follows up the member’s regularity to asthma exercise every week is recommended to improve lung function in an asthma patients. references 1. global initiative for asthma. gina reports 2015, global strategy for asthma management and prevention. fontana usa: global initiative for asthma; 2015. 2. global initiative for asthma. gina reports 2012, global strategy for asthma management and prevention. fontana usa: global initiative for asthma; 2012. 3. nikmah sn, purba a, defi ir. efektivitas latihan incentive spirometry dengan latihan pernapasan diafragma terhadap fungsi paru, kapasitas fungsional, dan kualitas hidup penderita asma bronkial alergi. mkb. 2014;46(1):39–47. 4. mcardle wd, katch fi, katch vl. exercise physiology: nutrition, energy, and human performance. 7th ed. philadelphia: lippincott williams & wilkins; 2010. 5. dogra s, kuk j, baker j, jamnik v. exercise is associated with improved asthma control in adults. eur respir j. 2011;37(2):318–23. 6. farid r, azad fj, atri ae, rahimi mb, khaledan a, talaei-khoei m, et al. effect of aerobic exercise training on pulmonary function and tolerance of activity in asthmatic patients. iran j allergy asthma immunol. 2005;4(3):133–8. 7. sahat cs, irawaty d, hastono sp. peningkatan kekuatan otot pernapasan dan fungsi paru melalui senam asma pada pasien asma. jki. 2011;14(2):101–6. 8. fatima ss, rehman r, saifullah, khan y. physical activity and its effect on forced expiratory volume. j pak med assoc. 2013; 63(3):310–2. 9. hutapea md, angliadi a. perbandingan fev1 (forced expiratory volume in one second) pada mahasiswa yang aktif dan tidak aktif berolahraga. jurnal eclinic. 2013;1(1). 10. sharma g, goodwin j. effect of aging on respiratory system physiology and immunology. clin interv aging. 2006;1(3): 253–60. 11. choi is. gender-specific asthma treatment. allergy asthma immunol res. 2011;3(2): 74–80. 12. raton r, polii r, marunduh sr. pengaruh latihan aerobik terhadap forced expiratory volume in one second (fev1) pada mahasiswa pria dengan kelebihan berat badan (overweight). jurnal e-biomedik. 2013;1(2):884–9. 13. handayani rn, agustiningsih d, djunaedi a. effect of swimming and asthmatic exercise on forced expiratory volume in 1 second (fev1) and levels of cortisol hormone in asthmatic patients. j med sci. 2012;44(1):78–83. 14. mendes fa, almeida fm, cukier a, stelmach r, jacob-filho w, martins ma, et al. effects of aerobic training on airway inflammation in asthmatic patients. med sci sports exerc. 2011;43(2):197–203. 15. vieira rp, claudino rc, duarte ac, santos âb, perini a, faria neto hc, et al. aerobic exercise decreases chronic allergic lung inflammation and airway remodeling in mice. am j respir crit care med. 2007; 176(9):871–7. 16. turner s, eastwood p, cook a, jenkins s. improvements in symptoms and quality of life following exercise training in older adults with moderate/severe persistent asthma. respiration. 2011;81(4):302–10. 17. heikkinen sa, quansah r, jaakkola jj, jaakkola ms. effects of regular exercise on adult asthma. eur j epidemiol. 2012; 27(6):397–407. 18. scichilone n, morici g, zangla d. effects of exercise training on airway responsiveness and airway cells in healthy subjects. j appl physiol (1985). 2010;109(2):288–94. amj vol 8 no 1 march 2021 final.indd althea medical journal. 2021;8(1) 50 althea medical journal march 2021 relationship between narcissism, self-esteem, and social media addiction in preclinical medical students helen susanto,1 eva suryani,2 yunisa astiarani,3 felicia kurniawan3 1school of medicine and health sciences, atmajaya catholic university of indonesia, jakarta, indonesia, 2department of psychiatry and behavioral sciences school of medicine and health sciences, atmajaya catholic university of indonesia, jakarta, indonesia, 3department of public health and nutrition school of medicine and health sciences, atmajaya catholic university of indonesia, jakarta, indonesia correspondence: helen susanto, school of medicine and health sciences, atmajaya catholic university of indonesia, jalan pluit raya no.2, jakarta, indonesia, e-mail: helen.susanto@hotmail.com introduction the use of social media has increased abundantly as internet usage grows. one hundred and fifty million people in indonesia are classified as active users of social media. on average, indonesian spends three hours and twenty-six minutes per day using social media.1 social media addiction is a disorder where individuals displayed an unhealthy compulsion to access social media while not paying attention to their time and health.2 a study in china shows that 34% of 19 to 28 years old university students have suffered from social media addiction; whereas a study in myanmar shows 27.5% of university students have social media addiction.3 individuals with social media addiction are often more indolent to interact with their friends and family, decreased academic performance, more sensitive, and nervous.4 addiction also becomes a deep concern for medical students. in iran, the level of social media addiction among medical students has reached 12.4%.5 internet addiction has a negative impact on medical students, especially on their academic achievements, and physical health.5 high social anxiety, low self-esteem and depression are also associated with social media addiction in medical students.6 considering the amount of social network addiction and the negative impacts it amj. 2021;8(1):50–5 abstract background: narcissism is a condition in which people have a constant demand to be complimented and prioritized. self-esteem is a subjective evaluation of one’s worth. several studies have linked narcissism and low self-esteem as a risk factor of social media addiction, a disorder where individuals displayed an unhealthy compulsion to access social media until it disrupts other activities. this study aimed to discover the relationship between narcissism, self-esteem, and social media addiction in preclinical medical students. methods: this study was a cross-sectional observational analytical study on 211 preclinical medical students at the atma jaya catholic university of indonesia. instruments used in this study were narcissistic personality inventory-16 (npi-16), rosenberg self-esteem scale (rses), and bergen social media addiction scale (bsmas). data were analyzed statistically using chi-square in stata analytic program. results: of all respondents, 6.6% were narcissistic, 19.9% had low self-esteem, and 34.6% had social media addiction. there was a significant relationship between narcissism and social media addiction (p 0.021) and between self-esteem and social media addiction (p 0.002). conclusions: there is a relationship between narcissism, self-esteem, and social media addiction in university students. this indicates the importance of preliminary psychological screening in students, especially regarding self-esteem, narcissism, and social media addiction, to develop approaches that will ensure good academic achievements and physical health among students.. keywords: narcissism, self-esteem, social media, social media addiction https://doi.org/10.15850/amj.v8n1.2097 althea medical journal. 2021;8(1) 51 potentially creates, researchers have started examining the risk factors of social media addiction. a positive link between social networking addiction and narcissism has been established as well as a negative relationship between social media addiction and high selfesteem.7 however, research on the relationship of narcissism, self-esteem, and social media addiction in medical students in indonesia is limited. therefore, we wanted to investigate the connection between narcissism, selfesteem, and social media. methods this research was an observational analytic study with a cross-sectional approach. this design was chosen to find out the relationship between narcissism, self-esteem, and social media addiction among preclinical medical students from the school of medicine and health sciences atma jaya catholic university of indonesia, from the class of 2017 to 2019. the students were chosen with the cluster sampling method and the study was conducted from may 2019 to may 2020. this study’s design had been approved by the committee of ethics atma jaya catholic university of indonesia. after signing informed consent, several questionnaires were distributed among others a demographic questionnaire, bergen social media addiction scale (bsmas), narcissistic personality inventory (npi-16), and rosenberg self-esteem scale (rses). bsmas and npi-16 had not been validated in bahasa indonesia, therefore, it had been used the english version, considering the minimum toefl score for preclinical medical students was 450. the bergen social media addiction scale (bsmas) questionnaire had a cronbach’s alpha of 0.88. this questionnaire measured the six items of social media obsession: salience, mood modification, tolerance, withdrawal, conflict, and relapse. in total there were six questions, each measured with a 5-point likert scale. the respondent had social media addiction if he/ she obtained a score above 19.8,9 the narcissistic personality inventory (npi-16) questionnaire had a 0.72 cronbach’s alpha. npi-16 focused on five narcissism criteria: leadership, self-efficacy, assertiveness, vanity, and envy. in total there were 16 items in this questionnaire, each was answered with a yes or no question. when the respondent answered ‘yes’ in more than 8 questions, then the respondent had a narcissistic personality.10 the indonesian translation of the rosenberg self-esteem scale (rses) questionnaire used in this study had a 0.706 cronbach’s alpha and 15 rses was used to measure the self-esteem level of the respondent. this questionnaire contained 10 questions, each using a 4-point likert scale. the maximum score from this questionnaire was 30 and a score above or equal to 15 indicated high self-esteem whereas below 15 had low self-esteem.7 the data collected were further analyzed using chi-square. results there were 211 respondents with ages varying from 16 to 21 years old (mean 19.02 years old). most respondents (66.4%;n140) were below the average age, and 67.8% (n143) were female. the age when the respondents first access social media varied from 6 to 17 years old (mean 11.37 years old). the majority started when they were below the mean age helen susanto et al.: relationship between narcissism, self-esteem, and social media addiction in preclinical medical students table 1 summary of the npi-16, rses, and bsmes score score n % npi-16 narcissistic not narcissistic 14 197 6.6 93.4 rses low self-esteem high self-esteem 42 169 19.9 80.1 bsmes addicted not addicted 73 138 34.6 65.4 note: npi-16; narcissistic personality inventory-16 questionnaire, rses rosenberg self esteem scale questionnaire; indonesian version; bsmes bergen social media addiction scale questionnaire althea medical journal. 2021;8(1) 52 althea medical journal march 2021 table 2 social media addiction based on characteristics of respondents characteristics of respondents social media addiction n % age under 19 years >19 years 53 20 37.9 28.2 gender male female 20 53 29.4 37.1 class 2017 2018 2019 20 33 20 29.4 46.5 27.8 of 11.37 years old (53.6%; n113 respondents). about 73.0% (n154) used social media for > four hours per day, 10.9% (n23) for 3-<4 hours each day, and 10.9% (n23) for 2-<3 hours each day. mainly, the respondents used smart phone to access social media (96.7%; n=204), whereas the second most used gadget was computer/laptop (57.8%; n=122), followed by a tablet (47.4%; n=100). social network sites were the most used social media (54.5%), then media sharing sites (50.7%), status update services (45.5%), wikis (41.2%), weblog/blogs (34.1%), and social bookmarking (58.8%), respectively. narcissism, measured by the narcissistic personality inventory-16 questionnaire, was determined in 6.6% (n14) and 19.9% (n=42) table 3 social media addiction based on usage of social media characteristics usage of social media characteristics social media addiction n % age when they first accessed social media under 11.37 years old above or equal to 11.37 years old 42 31 42.9 27.4 duration of social media usage/day less than 2 hours less than 3 hours less than 4 hours more or equal to 4 hours 2 7 5 59 18.2 30.4 21.7 38.3 gadget used to access social media (from the most common) smartphone computer/laptop tablet others 71 36 31 72 34.8 29.5 31.0 35.0 type of social media used (from the most common) social network sites media-sharing sites status-update service wikis weblog/blogs social bookmarking 40 36 37 31 26 43 34.8 33.6 38.5 35.6 36.1 34.7 althea medical journal. 2021;8(1) 53helen susanto et al.: relationship between narcissism, self-esteem, and social media addiction in preclinical medical students table 4 relationship between narcissism and social media addiction narcissism social media addiction total p-value or ci 95%yes no n % n % n % yes 9 64.3 5 35.7 14 100 0.021 3.741 1.205-11.616 no 64 32.5 133 67.5 197 100 have a low self-esteem score, measured by the indonesian rosenberg self esteem scale questionnaire. there were 37.6% (n=73) respondents with media social addiction, assessed with the bergen social media addiction scale questionnaire (table 1). the results showed that there were more respondents under the age of 19.02 years who experienced social media addiction (57.9%; n=53). females experienced more social media addiction (37.1%; n=53). respondents from class of 2018 had the highest level of social media addiction (46.5%; n=53) (table 2). respondents who accessed social media for the first time under the age of 11.37 years experienced more social media addiction (42.9%; n=42). respondents who accessed social media for more than or equal to four hours tended to experience social media addiction (38.3%; n=59). the study also found that 34.8% (n=71) who commonly accessed their account from the smart phone also experienced social media addiction, and 34.8% (n=40) who used social network sites most commonly also suffered from social networking dependency as depicted in table 3. table 4 revealed a meaningful connection between narcissism and social media addiction as 64.3% (n=9) had a narcissistic personality who also experienced social media addiction (p-value <0.021; fischer’s exact bivariate). the odds ratio was 3.741, suggesting that individuals with narcissism had a risk of 3.741 times chance to experience from social media addiction. the results showed that 54.8% (n=23) with low self-esteem suffer from social media addiction (p-value=0.002; chi-square bivariate analysis), showing an evident relationship between the level of self-esteem and social media addiction. the odds ratio of 2.881, suggesting that individuals with low self-confidence had a risk of 2.881 times more probable to experience a social media addiction. discussion a meaningful connection has been found between narcissism and social media addiction (64.3%), as well as between self-esteem and social media addiction (54.8%), resulting in 34.6% of preclinical medical students who suffered from social media addiction. as many as 37.9% aged under 19 years old in this study have experienced social media addiction. this age falls under the category of adolescents based on psychosocial development theory by erik erikson (age 13–20 years). indeed, the risk of experiencing social networking addiction is greater in adolescents.12 more respondents with addiction have already begun accessing social media during their school-age (42.9%). the school environment has become a psychosocial element that can affect the growing incidence of social media addiction.13 the majority of the respondents (73%) have sustained social networking dependency table 5 relationship between self-esteem and social media addiction selfesteem social media addiction total p-value or ci 95%yes no n % n % n % low 23 54.8 19 45.2 42 100 0.002 2.881 1.443-5.753 high 50 29.6 119 70.4 169 100 althea medical journal. 2021;8(1) 54 althea medical journal march 2021 accessed social media for more than or equal to four hours each day. there is a review that there is a correlation between the period of media platform usage and depression in university undergraduates.3 social media addicts also need a long time to use their social media, and the duration they need to achieve satisfaction will increase.14,15 overall, 34.6% of the respondents have experienced social media addiction, a little higher compared to study in myanmar, where 27.5% of students experienced social media addiction.3 there is a substantial connection between the level of narcissism and social networking dependency (p=0.021). there are 6.6% who have a narcissistic personality. interestingly, 64.2% of respondents experienced narcissism and social media addiction (or 3.741), suggesting that individuals who experience narcissism have a risk of 3.741 times greater to suffer from social media addiction. there is thus a definite connection between narcissism and social media addiction. individuals with high egotism use social media as a tool to exhibit their life’s free to as many people as possible.16 in order to receive positive feedback, narcissists may also manipulate their posts to create the image they want to build.17 our study shows a significant connection between the level of self-confidence and social networking addiction (p=0.002). a total of 19.9% has low self-esteem, and 54.8% have experienced social media addiction. the or 2.881 indicates that individuals with a minimum self-confidence have a risk of 2.881 times higher to experience a social media addiction low self-confidence is associated with behavior and communication problems, feeling deviant, and wanting to avoid others.18 they often regard media platforms as a protected place to hide from direct interaction with others.16 social media addiction has a meaningful relationship with a low level of confidence or a high level of narcissism. social media addiction is inversely proportional to confidence.7 limitations of this study include the risk of recall bias. several respondents have admitted difficulty in remembering the age they first used social media. also, this study only describes the relationship between variables as this is a cross-sectional study. further study is needed to be conducted in another area in indonesia to provide overall data related to narcissism, self-esteem, and social media addiction in indonesia. in conclusion, there is a significant relationship between narcissism, self-esteem, and social media addiction among preclinical medical students. the relationship between narcissism, self-esteem, and social media addiction among university students indicates the importance of preliminary psychological screening to their academic achievements and physical health. references 1. hootsuite, we are social . digital 2019 global digital overview [internet] 2019 [ cited 2020 august 4] available from: https://datareportal.com/reports/digital2019-indonesia 2. şahin c. social media addiction scale -student form: the reliability and validity study. turkish online journal of educational technology. 2018;17(1):169182. 3. win ks, maung t, win t, soe k, sein tt. social network addiction (sna) related depression among students at kyaukse university, mandalay region, myanmar. south east asia journal of public health. 2017;7(1):23-28. 4. andreassen cs, pallesen s. social network site addiction an overview. curr pharm des. 2014;20(25):4053–61. 5. taha mh, shehzad k, alamro as, wadi m. internet use and addiction among medical students in qassim university, saudi arabia. sultan qaboos univ med j. 2019;19(2):e142-147. 6. yücens b, üzer a. the relationship between internet addiction, social anxiety, impulsivity, self-esteem, and depression in a sample of turkish undergraduate medical students. psychiatry res. 2018;267:313– 318. 7. hawi n, samaha m. the relations among social media addiction, self-esteem, and life satisfaction in university students. social science computer review. 2016;35(5):576-586. 8. chen i-h, strong c, lin y-c, tsai m-c, leung h, lin c-y, et al. time invariance of three ultra-brief internet-related instruments: smartphone application-based addiction scale (sabas), bergen social media addiction scale (bsmas), and the nineitem internet gaming disorder scale short form (igds-sf9) (study part b). addict behav . 2020;101:105960. 9. lin c-y, broström a, nilsen p, griffiths md, pakpour ah. psychometric validation of the persian bergen social media addiction althea medical journal. 2021;8(1) 55helen susanto et al.: relationship between narcissism, self-esteem, and social media addiction in preclinical medical students scale using classic test theory and rasch models. j behav addict. 2017;6(4):620–9. 10. gentile b, miller j, hoffman b, reidy d, zeichner a, campbell w. a test of two brief measures of grandiose narcissism: the narcissistic personality inventory–13 and the narcissistic personality inventory-16. psychol assess. 2013;25(4):1120-1136. 11. della. behaviour therapy untuk meningkatkan self-esteem pada mahasiswa universitas indonesia yang mengalami distress psikologis [thesis]. depok: universitas indonesia; 2012. 12. dalvi-esfahani m, niknafs a, kuss dj, nilashi m, afrough s. social media addiction: applying the dematel approach. telematics and informatics. 2019;43:101250. 13. jia j, li d, li x, zhou y, wang y, sun w. psychological security and deviant peer affiliation as mediators between teacherstudent relationship and adolescent internet addiction. computers in human behavior. 2017;73:345–52. 14. idubor i. investigating social media usage and addiction levels among undergraduates in university of ibadan, nigeria. journal of education, society and behavioural science. 2015;7(4), 291-301. 15. andreassen cs. online social network site addiction: a comprehensive review. curr addict rep. 2015;2(2):175–84. 16. andreassen cs, pallesen s, griffiths md. the relationship between addictive use of social media, narcissism, and self-esteem: findings from a large national survey. addict behav. 2017;64:287–93. 17. hawk s, van den eijnden r, van lissa c, ter bogt t. narcissistic adolescents’ attentionseeking following social rejection: links with social media disclosure, problematic social media use, and smartphone stress. computers in human behavior. 2019;92:65-75. 18. salehi m, azarbayejani a, shafiei k, ziaei t, shayegh b. self-esteem, general and sexual self-concepts in blind people. j res med sci. 2015;20(10):930-936. amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 163 relationship between parenting style and maternal personal hygiene with children’s personal hygiene in north jakarta, indonesia rebeka milenia magany,1 prissilia nanny djaya,2 felicia kurniawan2 1school of medicine and health sciences, atma jaya catholic university of indonesia, 2department of public health and nutrition, atma jaya catholic university of indonesia correspondence: dr. dr. prissilia nanny djaya, m.s., sp.gk, department of public health and nutrition, atma jaya catholic university of indonesia, jalan pluit raya 2, jakarta, indonesia, e-mail: nanny.djaya@atmajaya.ac.id introduction since early childhood, personal hygiene needs practicing because it is an essential mechanism in breaking the chain of infection of various diseases, such as diarrhea, worm infection, and dental caries.1,2 in primary school age, children start to understand and learn the behavior to maintain their health status. perceptions and habits acquired at this stage are the basis of personal hygiene practices that may be performed for the rest of an individual’s life.3 factors affecting a person’s personal hygiene are social practices, personal preferences, body image, socioeconomic status, knowledge, health motivation, cultural variables, and physical condition. essential factors affecting children’s personal hygiene are parenting style and maternal personal hygiene.3–7 parenting styles are divided into exposure (authoritative) and non-exposure (authoritarian, permissive, mixed, or inconsistent).8 the best parenting style parents should apply is non-exposure or democratic because it will encourage children to have more independent characteristics.9–12 children with authoritative parents have exhibited more independent behavior in maintaining personal hygiene.13 studies on the relationship between parents’ hygiene and children’s hygiene have not been conducted until now, although a study has shown that parents’ handwashing habits might affect their children’s handwashing habits,3 whereas parents’ dental health habits influence their children’s oral health.14,15 this study aimed to explore the relationship between parenting style and maternal personal hygiene with their children’s personal althea medical journal. 2022;9(3):163–167 abstract background: personal hygiene habits need to be practiced since early childhood because they are essential mechanisms in breaking the chain of transmission of various diseases. important factors that affect children’s personal hygiene are parenting style and maternal personal hygiene. this study aimed to determine the relationship between parenting style and maternal personal hygiene with their children’s personal hygiene. methods: this study was an analytic observational study with a cross-sectional method conducted in july–december 2019. parenting style and personal hygiene questionnaires were completed by students’ mothers from four primary schools in north jakarta (n=327). the study used the total sampling method. data collection was analyzed using chi-square and fisher exact test. results: the study showed that 98.5% of students were raised with a non-exposure or authoritative parenting style, of which 57.5% of mothers had poor personal hygiene. moreover, 61.8% of students had poor personal hygiene. interestingly, there was a significant relationship between maternal personal hygiene and children’s personal hygiene (p=0.023). however, there was no significant relation between parenting style and children’s personal hygiene (p=0.065). conclusions: the maternal and children’s personal hygiene are related, but not the parenting style therefore, parents need to apply proper parenting style supported by other factors, such as good maternal personal hygiene, to encourage and educate children in achieving good personal hygiene. keywords: maternal, parenting style, personal hygiene, primary school students https://doi.org/10.15850/amj.v9n3.2294 althea medical journal. 2022;9(3) 164 hygiene. those variables were chosen due to the importance of learning personal hygiene from an early age. methods this study was an analytic observational study with a cross-sectional method. the samples included 327 students in fourth, fifth, and sixthgrade and their mothers from four primary schools in penjaringan, north jakarta. the selection criteria for inclusion were students who were present when data collection was carried out and were willing to participate in the study, as well as parents who were willing to participate and filled out every question in the questionnaire. the exclusion criteria were students with physical or mental disabilities. this sampling technique was a total sampling. a total of 327 respondents met the inclusion criteria. all the selected students from the four schools completed the questionnaire. the ethical clearance was obtained from the ethical committee of the school of medicine and health sciences at the atma jaya catholic university of indonesia, with the number 04/07/kep-fkikuaj/2020. data collection was carried out at four primary schools in july–december 2019. these schools were selected from 418 schools in north jakarta with a convenience sampling method based on their locations and accessibility. data were collected from students by interviews based on the questionnaires. parallelly, data from mothers were collected by distributing questionnaires via the students to be filled out by their mothers at home and the students submitted the completed questionnaires at school the following day. research instruments used in this study were parenting style questionnaire and personal hygiene questionnaire. the parenting style questionnaire consisted of 26 questions about the parent-child relationship. each question had a choice of a, b, c answers which were scored as a=1; b=2; c=3. the scores were summed up with the cut-off value of 52. a total score of less than 52 was categorized as a nonexposure or authoritative parenting style. a total score of more than or equal to 52 was categorized as an exposure parenting style consisting of authoritarian, permissive, and mixed or inconsistent parenting styles.9 the personal hygiene questionnaire consisted of 10 questions about personal hygiene aspects. a score of one was given to each answer if the answer was a good personal hygiene habit and a score of 0 if the answer was a poor personal hygiene habit. respondents were categorized as having good personal hygiene if the total score was more than eight and washed their hands before eating and after defecating. respondents were categorized as having poor personal hygiene if the total value was less than or equal to eight or do not wash their hands before eating and table 1 distribution of primary school students by grade, gender, maternal age, and maternal education level variable n percentage (%) grade 4 5 6 105 114 108 32.1 34.9 33 gender male female 167 160 51 49 maternal age (years old) 17–25 26–35 36–45 46–55 56–65 1 78 186 60 2 0.3 23.9 56.9* 18.3 0.6 maternal education level no formal education/did not graduate from primary school primary (primary–middle school) secondary (high school) tertiary (college or university) 10 139 151 27 3 42.5 46.2 8.3 althea medical journal september 2022 althea medical journal. 2022;9(3) 165rebeka milenia magany et al.: relationship between parenting style and maternal personal hygiene with children’s personal hygiene in north jakarta, indonesia after defecating.16 the data analysis was carried out with the spss statistical program. the relationship between the independent and dependent variables was analyzed using chi-square and fisher exact test. results out of 660 students from four primary schools in penjaringan, 327 students and their mothers were included, with the most prevalent gender was males (51%). most mothers in this study were in their late adulthood (56.9%) and had a secondary education level or high school (46.2%) (table 1). most students had authoritative parents (98.5%) and had poor personal hygiene (61.8%). most of their mothers also had poor personal hygiene (57.5%) (table 2). there was no relation between parenting style and children’s personal hygiene (p=0.65) as shown in table 3. interestingly, there was a relationship between maternal personal hygiene and children’s personal hygiene (p= 0.023) as depicted in table 4. discussions parenting style can affect the independence and level of children’s personal hygiene.13 however, our study shows that there is no relationship between parenting style and children’s personal hygiene. other factors table 2 distribution of primary school students by parenting style, personal hygiene, and maternal personal hygiene variable n percentage (%) parenting style exposure authoritarian permissive mixed or inconsistent non-exposure (authoritative) 5 1 4 0 322 1.5 0.3 1.2 0 98.5 student’s personal hygiene poor good 202 125 61.8 38.2 maternal personal hygiene poor good 188 139 57.5 42.5 table 3 relationship between parenting style and children’s personal hygiene parenting style children’s personal hygiene total n (%) p-valuegood n (%) poor n (%) non-exposure 124 (38.5) 198 (60.5) 322 (98.5) 0.65exposure 1 (20) 4 (80) 5 (1.5) total 125 (38.2) 202 (61.8) 327 (100) table 4 relationship between maternal personal hygiene and children’s personal hygiene maternal personal hygiene children’s personal hygiene total n (%) p-valuegood n (%) poor n (%) good 63 (40) 76 (60) 139 (42.5) 0.023poor 62 (18.3) 126 (76.6) 188 (57.5) total 125 (38.2) 202 (61.8) 327 (100) althea medical journal. 2022;9(3) 166 might also influence the children’s personal hygiene, including social practices, personal preferences, body image, socioeconomic status, culture, knowledge, health motivation, and physical condition.3–7 in our study, only the social practice has been explored, consisting of parenting style and maternal personal hygiene. if the parenting style is appropriate, children could independently maintain their personal hygiene; yet the example given by the mother is not proper, the child would not necessarily have good personal hygiene. therefore, parents need to apply the proper parenting style supported by other factors, such as good maternal personal hygiene, to encourage and educate children in achieving good personal hygiene.3,4,17 most parents in this study have a nonexposure or authoritative parenting style. children with authoritative parents are more independent, responsible, and cooperative.8,9 authoritative parenting is the best parenting style to build children’s independence in caring for their personal hygiene.13 our study shows a relationship between maternal personal hygiene and children’s personal hygiene, in line with other study showing a relationship between the parents’ role and clean and healthy behavior of their children.18 similarly, parents’ handwashing behavior may also affect their children’s handwashing behavior.3,19 family is children’s first environment to learn appropriate habits and behavior. children learn a lot from parents and adults around them, especially from mothers who have an essential role in caring for and being role models for their children.3,17,20 this study has limitation that only maternal personal hygiene and parenting styles have been explored as variables affecting their children’s personal hygiene. however, other factors might also influence personal hygiene, and all these factors need to complement each other to achieve good personal hygiene. further study exploring other factors are encouraged. to conclude, although no significant relationship between parenting style and children’s personal hygiene, maternal personal hygiene has a significant relation to their children’s personal hygiene. therefore, parents need to apply the proper parenting style supported by other factors, such as good maternal personal hygiene, to encourage and educate children in achieving good personal hygiene. acknowledgement we would like to thank the students and parents, as well as the principals of the stella maris primary school, westin primary school, penjaringan 08 pagi public primary school, and penjaringan 10 pagi public primary school, who have granted permission to participate in the study. references 1. sarkar m. personal hygiene among primary school children living in a slum of kolkata, india. j prev med hyg. 2013;54(3):153–8. 2. gbd 2016 diarrhoeal disease collaborators. estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the global burden of disease study 2016. lancet infect dis. 2018;18(11):1211–28. 3. song ih, kim sa, park ws. family factors associated with children’s handwashing hygiene behavior. j child health care. 2013;17(2):164–73. 4. potter pa, perry ag, stockert pa, hall am. fundamentals of nursing. 8th ed. st. louis: elsevier mosby; 2013. 5. hermawati h. hubungan pola asuh keluarga dengan kemandirian perawatan diri anak usia sekolah. jurnal kesehatan qamarul huda. 2020;8(1):29–33. 6. berns rm. child, family, school, community: socialization and support. 10th ed. wadsworth: cengage learning; 2015. 7. berliana n, pradana e. hubungan peran orang tua, pengaruh teman sebaya 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sehat anak usia sekolah di sd inpres talikuran kecamatan kawangkoan utara. e-journal keperawatan 2018;6(1):1–6. 19. rihiantoro t. peran orang tua dalam kebiasaan mencuci tangan pada anak usia 6–8 tahun. jurnal keperawatan. 2016;12(1):161–7. 20. silalahi v, putri rm. personal hygiene pada anak sd negeri merjosari 3. jurnal akses pengabdian indonesia. 2017;2(2):15–23. rebeka milenia magany et al.: relationship between parenting style and maternal personal hygiene with children’s personal hygiene in north jakarta, indonesia althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 40 amj june, 2014 nutritional status of schizophrenic patients at department of psychiatry in dr. hasan sadikin general hospital tiara aulia maisyarah1, gaga irawan nugraha2, lynna lidyana3 1faculty of medicine, universitas padjadjaran, 2department of nutritional sciences, faculty of medicine, universitas padjadjaran, 3department of psychiatry, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital abstract background: currently, schizophrenia is associated with many health problems due to weight changes caused by lifestyle changes and consumption of antipsychotic drugs (apds). nutritional status assessment is needed in order to lower the comorbidity through early detection of risk factors. methods: this descriptive cross-sectional study involved 94 schizophrenic patients selected using consecutive sampling in october 2012 in psychiatry outpatient department, dr. hasan sadikin general hospital, bandung. an anthropometric measurement was verified (body mass index and waist circumference), physical activity level, type of antipsychotic drugs (apds) used and duration of treatment acquired from medical records. results: among the subjects, 29.8% were 28–37 years old, with 69.1% males and 30.9% females. most of them suffered from paranoid schizophrenia (71.3%). the body mass index (bmi) of 46.8% subjects were normal, 45.74% were overweight, whereas 7.45% were underweight. male subjects mostly had smaller waist circumference (78%) compared to females who were dominantly above normal (52%). physical activity levels were mostly sedentary (76%). single typical apd were dominantly prescribed (46%). subjects with normal bmi were mostly found among single typical apds prescribers (53.5%), whereas the majority of atypical apds users were overweight (61.9%). a total of 63% subjects had been prescribed apds for 1–5 years, dominated by subjects with normal body mass index (78%). conclusions: the majority of study subjects (46.8%) were found normal in terms of the body mass index. male subjects mostly had normal waist circumference (78%) while females have a higher risk with measurement above normal as a more dominant finding (52%). [amj.2014;1(1):40–7] keywords: nutritional status, pscychiatry, schizophrenia status gizi pasien skizofrenia di departemen psikiatri rumah sakit dr. hasan sadikin bandung abstrak latar belakang: saat ini skizofrenia merupakan suatu penyakit mental dengan komorbiditas yang tinggi akibat perubahan gaya hidup, faktor predisposisi, dan dampak mengonsumsi obat antipsikotik yang membuat penderita kerap mengalami perubahan berat badan. oleh karena itu, diperlukan deteksi dini perubahan berat badan pada pasien skizofrenia sebagai pertimbangan penyusunan tatalaksana yang komprehensif. metode: studi deskriptif potong lintang ini dilakukan untuk mengetahui status gizi pasien skizofrenia di klinik rawat jalan departemen psikiatri sub bagian dewasa rumah sakit dr. hasan sadikin bandung. pengukuran indeks massa tubuh (imt) dan lingkar pinggang dilakukan pada 94 pasien skizofrenia dewasa. wawancara mengenai pekerjaan juga dilakukan untuk mengetahui tingkat aktifitas fisik, riwayat pengobatan responden didapatkan melalui rekam medis. hasil: dari 94 responden (65 pria dan 29 wanita) mayoritas berusia 28–37 tahun (29.8%). sebanyak 46.8% responden memiliki imt normal, 45.74% responden adalah overweight, dan 7.45% termasuk dalam kategori underweight. responden pria memiliki ukuran lingkar pinggang yang mayoritas normal (78%), sedangkan wanita sebagian besar memiliki ukuran lingkar pinggang di atas normal (52%). tingkat aktifitas fisik responden rata-rata tergolong ringan (67%). kebanyakan responden diberikan obat antipsikotik correspondence: tiara aulia maisyarah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285721652156, email: tiara.aulia.m@gmail.com althea medical journal. 2014;1(1) 41 introduction schizophrenia is a mental illness with similar prevalence throughout the world, which is 1% of the total population. the disease is commonly found between the ages of 15 and 55, with a higher incidence in males.1,2 schizophrenia is known as a major mental illness due to its major impact on almost all aspects of the patient’s life, that often leads to difficulty in interaction with others.2 nowadays, schizophrenia is associated with many health problems due to weight changes that increases morbidity and mortality.3 it can also be caused by genetics, predisposing factors, lifestyle changes, and antipsychotic drugs (apds) consumption.4 an alteration in body weight is a common problem found in schizophrenic patients as they may experience weight gain or vice versa. weight loss, that can be caused by hypophagia, restrictive diet, and other health problems, is usually found at the beginning of the treatment.5 on the other hand, the lifestyle of schizophrenic patients who more likely prefer fatty foods and consume fewer vegetables, is exacerbated by the side effects of antipsychotic drug use which may cause great impact by increasing the risk of obesity to 2–3 times greater than the general population.4 these events will further increase the incidence of premature death due to cardiovascular disorders.6 during treatment, patients are given apds which works by blocking dopamine receptors that, in addition to treating the positive symptoms of schizophrenia such as hallucinations and delusions, can also stimulate appetite and cause metabolic disorders.7 the increasing use of atypical antipsychotics also increases the incidence of dramatic weight gain in patients with schizophrenia. hyperglycemia and diabetes are complications that can further increase the level of comorbidity and mortality, with obesity and antipsychotic drugs consumption as the greatest risk factor for diabetes development in schizophrenia.8 health problems in people with schizophrenia are generally difficult to diagnose, causing delay in treatment.8 this is due to the difficulty of the patient to express grievances. in addition, as many as 60% of health problems are not detected due to low monitoring by health services. comorbidity can be prevented with early detection for early treatment, including through lifestyle modification.8 the physical health of patients with schizophrenia is an important issue to consider when preparing a comprehensive treatment.9 assessment of the nutritional status, such as measurement of body mass index and waist circumference, is expected to detect risk factors that may increase comorbidity and mortality.10 methods this descriptive cross-sectional study was conducted during october 2012. patients from psychiatry outpatient clinic of dr. hasan sadikin general hospital, bandung, indonesia who were diagnosed as schizophrenic according to the diagnostic and statistical manual of mental disorders 4th edition (dsm-iv) with the age of ≥ 18 years received explanations on the goal and benefit of the study while accompanied by their family. an informed consent was signed to indicate the family’s understanding and permission to include the patients in the study as subjects. the family members that were allowed to give consent for the patient’s participation parents/guardian/kin/landlady, aged ≥ 21 years/married, with a healthy mental state. patients who were not accompanied by a family member when the study took place were excluded. a total of 94 subjects were recruited using the consecutive sampling technique. the variables used in this research were subject characteristics that included age, gender, and subtype diagnosis of schizophrenia (established by a psychiatrist and obtained from the medical record). the nutritional status was determined by calculating the body mass index (weight (kg)/height (m)2) and were then classified based on the body mass index for the asia pacific region by who: tipikal tunggal (46%) dan sebanyak 63% telah mengonsumsi obat antipsikotik selama 0–5 tahun. simpulan: mayoritas responden memiliki imt yang normal dengan ukuran lingkar pinggang wanita lebih tinggi dibandingkan dengan pria. kata kunci: status gizi, psikiatri, skizofrenia tiara aulia maisyarah, gaga irawan nugraha, lynna lidyana: nutritional status of schizophrenic patients at department of psychiatry in dr.hasan sadikin general hospital althea medical journal. 2014;1(1) 42 amj june, 2014 underweight (<18.5), normal (18.5–22.9), and overweight (≥ 23). the results of the waist circumference measurement based on the who, were compared to the asian standards: high if > 90 cm for males and > 80 cm for females. the information on physical activity level was obtained through interviews about daily activities of the subject. the classification was as follows: (1) sedentary; those with activities that do not require a lot of energy, sedentary lifestyle is one of the examples. (2) active; table 1 overall characteristics of the subjects (n=94) variables frequency percentage gender male 65 69.1 female 29 30.9 age (years old) 18–27 17 18.1 28–37 28 29.8 38–47 27 28.7 48–57 18 19.1 58–67 4 4.3 subtypes diagnosis hebephrenia schizophrenia 15 16 paranoid schizophrenia 67 71.3 postschizophrenic depression 2 2.1 residual schizophrenia 3 3.2 unspecified schizophrenia 7 7.4 antipsychotic drugs (apds) used by patients typical apds 43 45.7 atypical apds 21 22.3 combination of typical and atypical apds 7 7.4 combination of two typical apds 23 24.5 duration of apds treatment 0–5 years 68 72.3 6–10 years 16 17 11–15 years 10 10.6 physical activity level sedentary 63 67 active 25 26.6 vigorous 6 6.4 althea medical journal. 2014;1(1) 43 those with mild activity level, meaning that they regularly do active to vigorous activities at certain times. (3) vigorous; those who work hard for a few hours on a regular basis, for example, a swimmer, a farmer (without engine) and workers who lift heavy weights.11 the history of treatment was also assesseds based on two things: (1) type of antipsychotic drugs consumed (the last antipsychotic drugs consumed when the study took place), (2) duration of treatment (which covers the period since the subject started to take antipsychotic drugs for the first time until the time the study took place.) the data were further processed and analyzed according to the descriptive method using spss (for windows) to seek for the frequency and to create cross tabulation. results sixty five males and 29 females with the age ranging from 18 to 67 years participated in this study with most subjects (n=28 or 29.8%).) were in the age group of 28–37 years (table 1). the majority of subjects (33) did not have a job (35.1%). there were 71% of subjects who suffered from paranoid schizophrenia. more subjects were on typical apds (46%) compared to atypical apds (22%). around 24% of subjects were given combination of two typical apds. this percentage was higher than the number of subjects given the combination of atypical and typical apds (22%). haloperidol ranked first as the typical apdmost commonly prescribed to the subjects (64.9%), followed by risperidone (21.3%). most of the subjects (72%) had been taking antipsychotic medication over a period of 0–5 years and fewer subjects had taken the medication after that time span. subjects with a normal body mass index (46.81%) were the highest in frequency compared to other categories (table 2) although the difference was very small from the percentage of subjects with overweight status based on the body mass index ( 45.74%). the majority of male subjects had a waist circumference of ≤ 90 cm (78%), while the distribution for female subjects was almost equal in both categories. most of the subjects (67%) had sedentary physical activities. normal bmi and overweight were found in all age groups (table 3). of the total subjects (n=94), normal bmi was the highest proportion in the 38–47 age group (16%). the highest percentage of overweight was found in the age group 28–37 and 38–47, both with 12 subjects table 2 nutritional status of the patients variables frequency percentage bmi underweight 7 7.4 normal 44 46.8 overweight 43 45.7 waist circumference male ≤ 90 cm 51 54.3 > 90 cm 14 14.9 female ≤ 80 cm 14 14.9 > 80 cm 15 16 (12.8%). most of the subjects who were given typical apds had normal bmi (53.5%). in contrast, subjects who consumed atypical apds were mostly overweight (61.9%). however, overweight subjects were also found in typical apds users with a percentage of 18.1%. haloperidol users had normal bmi (52.5%). however, the consumption of haloperidol combined with cpz caused the majority of the subjects to be overweight (52.4%). all quetiapine, olanzapine (single and +cpz), clozapine and aripiprazole users were also overweight. from all the subjects who took apds for 0–5 years, 32 (47.1%) were overweight. subjects with normal and overweight bmis were found in all groups, while underweight subjects were absent in the group that had taken apds for 11–15 years. discussion the majority of subjects had a normal bmi (46.81%), a finding that is similar to the result of a study conducted by sadhya et al.5 regarding the nutritional status of patients with schizophrenia in an outpatient clinic of a hospital in dhaka. overweight in schizophrenic patients may be influenced by many things, such as genetics, lifestyle, and antipsychotic drug use.4 however, there is a significant relationship between overweight and apd side effects (particularly for the atypical tiara aulia maisyarah, gaga irawan nugraha, lynna lidyana: nutritional status of schizophrenic patients attending outpatient department of psychiatry in dr.hasan sadikin hospital althea medical journal. 2014;1(1) 44 amj june, 2014 group); the consumption of apds was the major risk factor for obesity in schizophrenic patients.8 these drugs stimulate the appetite and tendency to eat sweet or fatty foods, which gives a direct effect on the nervous system and metabolism that control satiety and weight loss. other factors, such as low levels of physical activity due to mental disorder, can also be taken into account as risk factors. we should be wary of this condition because it will increase the incidence of premature death due to cardiovascular disorders that commonly occurs in patients with schizophrenia.7 in addition, underweight subjects were also found, which might be caused by hypophagia, restrictive diet, and other health problems.5 another factor that may play a role is that the low socioeconomic subjects were less able to meet the needs for balanced nutrition for the body. the results of this study suggested that women with a waist circumference of > 80 cm (52%) had a higher risk than the majority of men with a waist circumference of ≤ 90 cm (78%). these findings contradict the results of the study conducted in malaysia on the nutritional status of patients with schizophrenia in the outpatient clinic of universiti kebangsaan hospital malaysia that statedhigh waist circumference is more common in male subjects.12 most of the subjects were categorized as having a sedentary physical activity level. this condition is a risk factor for weight gain. in patients with schizophrenia, weight gain due to minimal activity could be coupled with an increase in appetite due to the apds side effects.7 based on the information obtained from the relevant clinic, all patients used a health insurance scheme, i.e. jamkesmas or askes,so apds can be obtained free of charge. however, there were differences in drug dosage for each insurer; only three types of apds were available for the users of jamkesmas, which were from the typical apd class (haloperidol, chlorpromazine, and trifluoperazine), while the drug and dosage of apds for askes users are more varied, which include typical apds as in jamkesmas, with the addition of table 3 overall characteristics of the patients included in the study according to the bmi general concept bmi (%) underweight normal overweight age (years old) 18–27 5.9 52.9 41.2 28–37 21.4 35.7 42.9 38–47 0 55.6 44.4 48–57 0 44.4 55.6 58–67 0 50 50 antipsychotic drugs (apds) used by patients typical apds 7 53.5 39.5 atypical apds 4.8 33.3 61.9 combination of typical and atypical apds 0 71.4 28.6 combination of two typical apds 13 39.1 47.8 duration of treatment 0–5 years 7.4 45.6 47.1 6–10 years 12.5 43.8 43.8 11–15 years 0 60 40 note: bmi= body mass index althea medical journal. 2014;1(1) 45 atypical apds, namely clozapine, olanzapine, risperidone, and quetiapine.13,14 haloperidol is the most commonly consumed typical apds. the reason is because haloperidol effectively relieves the positive symptoms and is readily available from both health insurances. unlike typical drugs, atypical apds are pointed out as effective antipsychotic drugs to relieve both positive and negative symptoms and they tend to be ‘safe’ because of the lack of extrapyramidal effects compared to the typical group.15 apds from this class are not available for jamkesmas users, so they can only be prescribed to the askes users. a small number of subjects who were prescribed atypical apds showed a number of typical drug-sensitive subjects so atypical apd was not necessary. a total of 72.3% subjects had been taking antipsychotic medication in a span of 0–5 years. the reason that may impact this high percentage was the patient’s high compliance. the less number of subjects who took the drug for more than 5 years indicating the possibility of a decline in adherence regarding follow-up given that the control of the disease is performed every month for life and the high mortality rate among patients with schizophrenia. there is a relationship between body mass index and age. body weight increases until the age of 49 years and decreases slightly after 50 years. increased weight in middle age is caused by the accumulation of more fat due to the higher appetite leadingto increased energy intake and fat-rich diet. weight loss in elderly is due to decreased muscle mass caused by reduced protein intake and decrease in the size and number of muscular fibers and bone mineral mass caused by degenerative diseases.16 a total of 53.5% of the subjects who were given typical apds were categorized as having normal bmi. this was supported by a study conducted by czobor et al.17 regarding the effects of typical apds, such as haloperidol, on weight gain which stated that this type is the type of antipsychotic that had the least significant effect on overweight than other antipsychotics. however, a meta-analysis by alisson et al.18 mentioned that haloperidol could still increase as much as 0,48 kg body weight after ten weeks, while trifluoperazine does not cause any significant weight gain. in contrast, there were more overweight subjects in the atypical apduser category. however, normal bmis are still found in many risperidone users. risperidone, as well figure 1 antipsychotic drugs (apds) used by patients according to bmi (n=94) tiara aulia maisyarah, gaga irawan nugraha, lynna lidyana: nutritional status of schizophrenic patients attending outpatient department of psychiatry in dr.hasan sadikin hospital althea medical journal. 2014;1(1) 46 amj june, 2014 as haloperidol, does not significantly cause overweight.18 clozapine and olanzapine are the two atypical apds that are related to a high mortality rate due to cardiovascular diseases caused by obesity.18 based on the literature, weight gain may happen as a 3.5–4 kg increase in weight in the first ten weeks of clozapine/ olanzapine consumption and will continue to rise, especially for patients undergoing longterm treatment.5 weight changes will continue to occur in a given period. in patients taking clozapine, weight gain will occur until week 46 (± one year).18 based on the description above, the effects of apds in the early years, which is an increase of that exceeds the normal limit, give impact on the higher frequency of overweight subjects in 0–5 years group.18 as people age, the ability of the body metabolism will decrease. with a long-term apds consumption and low physical activity, obesity may be a risk factor after the first year of treatment.18 one of the limitations of this study is the unknown nutritional intake of the study samples as a direct effect on nutritional status. moreover, there is no information available on the bmi and waist circumference of the subjects before starting the treatment so it is unknown whether the subjects experienced any alteration of body weight or not. to conclude, most of the subjects’ nutritional status are normal in relation to bmi. the majority of male subjects have normal waist circumferences, whereas most women have waist circumferences that are higher than the standard. a control of nutritional status should be performed periodically each time the patient comes for the monthly follow-up. patients with abnormal alteration in the bmi and waist circumference need to be subjected to nutrition and lifestyle modification. however, further research can be perfomed by adding nutritional assessment through laboratory testing, such as lipid profile, cholesterol, and blood glucose assessments as a risk factor for early detection. in addition, the function of the general health of patients regarding the ability to respond to the study is also noteworthy since schizophrenia has a substantial impact in the overall function of the patient. references 1. mcgrath j, saha s, chant d, welham j. schizophrenia: a concise overview of incidence, prevalence, and mortality. epidemiol rev. 2008;30(1):67–76. 2. sadock bj, sadock va. kaplan & sadock's synopsis of psychiatry: behavioral sciences / clinical psychiatry. 10th ed. new york: lippincott williams & wilkins; 2007. p. 468–97. 3. saha s, chant dc, mcgrath jj. meta– analyses of the incidence and prevalence of schizophrenia: conceptual and methodological issues. int j methods in psychiatr res. 2008;17(1):55–61. 4. aquila r. management of weight gain in patients with schizophrenia. j clin psychiatry. 2002;63 suppl 4:33-6 5. sadhya g, selimuzzaman, islam r. nutritional status psychiatric patients attending opd at a selected tertiary hospital. taj. 2009;22(1):82–7. 6. tandon r, nasrallah h. subjecting meta– analyses to closer scrutiny: little support for differential efficacy among second– generation antipsychotics at equivalent doses. arch gen psychiatry. 2006;63 (8):935–7. 7. teixeira pjr, rocha fl. metabolic side effects of antipsychotics and mood stabilizers. rev psiquiatr rio gd sul. 2006; 28(2):186–96. 8. nasrallah h. an overview of common medical comorbidities in patients with schizophrenia. j clin psychiatry. 2005;66 suppl 3:3–4. 9. mas–expósito l, mazo a, emeterio ms, teixidó m, lalucat–jo l. physical health and schizophrenia in clinical practice guidelines and consensus statements. j addict res ther. 2012;s8(001):1–5. 10. world health organization. fact sheet no 311: obesity and overweight.. geneva: who media centre; 2011 [cited 2012 april 26]; available from: http://www.who.int/ mediacentre/factsheets/fs311/en/. 11. united nations university, world health organization, food and agriculture organization of the united nations. human energy requirements: report of a joint fao/who/unu expert consultation . rome: fao; 2004. 12. ainsah o, salmi r, osman cb, shamsul as. relationship between antipsychotic medication and anthropometric measurements in patients with schizophrenia attending a psychiatric clinic in malaysia. hong kong journal of psychiatry. 2008;18(1):23–7. 13. kementrian kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor 1455/menkes/ sk/x/2010 tentang formularium althea medical journal. 2014;1(1) 47 program jaminan kesehatan masyarakat. jakarta: kementrian kesehatan republik indonesia; 2010. 14. pt asuransi kesehatan. keputusan direksi pt askes (persero) nomor 0437/ kep/1111 tentang daftar dan plafon harga obat (dpho) pt askes (persero) edisi xxxi periode januari–desember 2012. jakarta: pt. askes; 2011. 15. amir n. skizofrenia. in: elvira sd, hadisukanto g, editors. buku ajar psikiatri. jakarta; badan penerbit fkui. 2010. p. 170–6. 16. mungreiphy nk, kapoor s, sinha r. association between bmi, blood pressure, and age: study among tangkhul naga tribal males of northeast india. journal of anthropology. 2011;2011:748147 17. czobor p, volavka j, sheitman b, lindenmayer jp, citrome l, mcevoy j, et al. antipsychotic–induced weight gain and therapeutic response: a differential association. j clin psychopharmacol. 2002; 22(3):244–51. 18. allison db, mentore jl, heo m, chandler lp, cappelleri jc, infante mc, et al. antipsychotic–induced weight gain: a comprehensive research synthesis. am j psychiatry. 1999;156(11):1686–96. tiara aulia maisyarah, gaga irawan nugraha, lynna lidyana: nutritional status of schizophrenic patients attending outpatient department of psychiatry in dr.hasan sadikin hospital amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 216 proportion of traumatic avascular necrosis on hip joint at dr. hasan sadikin general hospital bandung in 2016–2020 annisa nurrizki baroqah,1 undang ruhimat,2 yoyos dias ismiarto3 1faculty of medicine universitas padjadjaran, indonesia, 2department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of orthopedic and traumatology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: annisa nurrizki baroqah, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: annisa17001@mail.unpad.ac.id introduction avascular necrosis (avn) is a disease that involves damage to the arterial blood supply or venous stasis in the bone, resulting in the death of osteocytes and bone marrow.1 based on the etiology, avn is classified into traumatic and non-traumatic.1,2 traumatic avn is occurred, causing fracture and/or dislocation of the bone in which the most commonly site is involving the head of femur.3 one of the most frequent clinical manifestations of avn is pain in the groin that can spread to the thighs and buttocks.3,4 furthermore, some avn patients can experience pain on walking, and decreased range of motion (rom) of the hip joint, with trendelenburg signs and crepitus.3 avn could become progressively more severe if left untreated because of death of bone marrow and osteocytes, resulting in bone structural changes and thus the head of femur collapse.5 eventually, these conditions could cause the use of total hip arthroplasty (tha) in younger individuals, leading to disability and decreased quality of life.6 a tha might be a financial burden because it is quite expensive.7 therefore, avn should be of particular concern and should be considered in the clinical settings.6 the avn could affect all ages with a peak in the age of 30 to 65 years, of whom more than 20,000 patients require hospital treatment.3 in addition, the incidence of avn in sweden8 reached 4.7 cases/10.000 people per year. the althea medical journal. 2021;8(4):216–219 abstract background: traumatic factors affecting the femur such as fractures and dislocations can cause complications in the form of avascular necrosis (avn), if not treated immediately, avn is one of the contributors to total hip arthroplasty (tha) usage and disability which will have an impact on productivity and quality of life. hence, it is necessary to understand the epidemiology of avn caused by traumatic factors. this study aimed to determine the proportion of traumatic avn on the hip joint at dr. hasan sadikin general hospital. methods: a descriptive-observational study with a cross-sectional study design was conducted on all patients registered in the medical record database, with a diagnosis of avn on the hip joint at dr. hasan sadikin general hospital bandung in 2016–2020. traumatic avn was included and patients with incomplete medical record data were excluded. results: in total, 210 patients were registered in the medical records and only 56 had complete medical records, and 10.5% (22 of 210) were diagnosed with traumatic avn of the hip joint, consisting of 14 male with most of the trauma (n=11) caused by avn were femoral neck fractures and 20 patients were of productive age (18–64 years old). most of the patients underwent surgical therapy with a tha (n=20). conclusion: the proportion of avn on the hip joint caused by trauma is 10.5%. however, this disease should not be underestimated because avn has the potential to cause disability and impact the quality of life. keywords: avascular necrosis, hip joint, proportion, trauma https://doi.org/10.15850/amj.v8n4.2195 althea medical journal. 2021;8(4) 217 etiology of most cases was idiopathic (56.6%) and traumatic (25.2%).8 a different situation is occured in japan,9 with about 2.5–3 new cases/1000 persons per year and 51% of avn cases mainly due to steroid use.2,9 differences in outcomes in sweden8 and japan9 reflect the differences in avn characteristics in culture and environmental exposure. hence, understanding the avn epidemiology in indonesia is important, considering the lack of studies regarding the avn. moreover, dr. hasan sadikin general hospital bandung is the highest referral hospital in west java. the objective of this study was to explore the proportion of avn on the hip joint due to trauma treated at hasan sadikin general hospital bandung in 2016–2020. methods this was a descriptive-observational research with cross-sectional study design, using a total sampling method. data from 2016 to 2020 were collected, and a total of 210 patients were diagnosed with avn on the hip joint at dr. hasan sadikin general hospital bandung. patients with inaccessible medical record and missing data were excluded (n=154). of the remaining 56 medical records with a diagnosis of avn, some were defined as traumatic avn (n=33) and non-traumatic avn (n=23). afterward, we also excluded double medical record from traumatic avn (n=11). eventually, only 22 medical records met the criteria for avn in the hip joint due to trauma. the data were then described and presented in text, tables, and figures. the ethical clearance for this study was obtained from the research ethics committee of universitas padjadjaran no. 583/un6.kep/ec/2020. results a total of 210 patients were registered and diagnosed with avn from 2016 to 2020 of whom only 22 met the inclusion criteria. therefore, the proportion of avn was only 10.5%. the proportion of male patients among all traumatic avn patients was 14 of 22. hence, the male-to-female ratio in this study was 7:4. based on the patient’s age, the age was 43 years old (range 19–71 years), indicating no pediatric patients (≤18 years) in this study (table). traumatic avn affected the hip join more in unilateral side than bilateral, in which the proportion of the right hip joint was similar as the left hip joint. patients commonly had a table proportions of traumatic avascular necrosis from dr. hasan sadikin general hospital in 2016–2020 characteristics n=22 sex male female 14 8 age children (≤18 years) adult (>18–64 years) elderly (>64 years) 0 20 2 type of trauma neck of femur fracture unspecified fracture periprosthetic fracture stabilized fracture inferior pubic rami fracture neglected posterior hip dislocation 11 6 1 1 1 2 location of avn hip joint unilateral (left hip joint) unilateral (right hip joint) bilateral 9 9 4 note: avn= avascular necrosis annisa nurrizki baroqah et al.: proportion of traumatic avascular necrosis on hip joint at dr. hasan sadikin general hospital bandung in 2016–2020 figure treatment of traumatic avascular necrosis patients note: tha= total hip arthroplasty , thr= total hip replacement, orif= open reduction internal fixation treatment fr eq ue nc y tha/thr partial hip replacement orif plate screw 0 5 10 15 20 fracture of the neck of femur. this study found that all treated patients had avn grade iv according to the ficat & arlet classification and about 20 of 22 patients underwent surgical therapy with tha (figure). althea medical journal. 2021;8(4) 218 fracture of the neck of femur. this study found that all treated patients had avn grade iv according to the ficat & arlet classification and about 20 of 22 patients underwent surgical therapy with tha (figure). discussion the four years proportion of avn due to trauma among all avn patients in this study was 10.5% (22 of 210). this is in accordance with a previous study that avn due to trauma is less than nontrauma.2 most of the patients are in their productive age (>18–64 years), and this is consistent with previous studies suggesting that the 30–65 year age group is susceptible to avn.3,4,10 our study also shows that male is in a higher proportion than female. many risk factors may associate with traumatic avn such as fracture due to high energy trauma that is related to the culture where occupations with high risk of trauma are often performed by male.11 the location of the occurrence of avn correlates with the blood supply. the bone area that is often the location of this avn is the sub-articular areas. they are mostly covered by cartilage and are located farthest from the blood vessels. consequently, this area is vulnerable because of the limited supply of local blood vessels.12 the head of the femur is the most common location for avn because the neck of the femur has limited collateral blood vessels.3,13 the head of femur is supplied by two important anastomoses that provide collateral blood flow. the first is between the inferior gluteal artery and the medial circumflex femoral artery, and the other is the anastomosis between the superior gluteal artery and medial/lateral circumflex femoral artery.14 disruption such as high energy trauma to the hip area can cause avn on hip joint. the result of this study proved that half of the patients (11 of 22) experience a femoral neck fracture that disrupts the blood vessels, resulting in avn in the hip joint. other types of trauma in this study are unspecified fracture, periprosthetic fracture, stabilized fracture, inferior pubic rami fracture, and neglected posterior hip dislocation. falls, traffic accidents, slips, and accidents while playing football are possible causes of trauma such as femoral neck fracture in this study. the clinical manifestation that most often makes patients come to the hospital is pain.3,4,6 most of the patients in this study had chronic pain from several months to several years ago. pain is felt when the patient is active and will improve with rest. afterward, the patient althea medical journal december 2021 may also experience limitations in hip joint movement, limps or trendelenburg sign, and numbness. signs and symptoms may worsen if the avn affects both sides of the hip joint, as most avn are affected on the bilateral side of the hip joint.15 however, this contrast with the findings in this study which showed that most patients with traumatic avn affect the unilateral hip joint. with more samples, the data should be more representative to show whether traumatic avn would affect more unilateral or bilateral hip joint. management of avn in hip joint can be both nonsurgical and surgical. the use of weight bearing protection such as crutches, drug treatment, and physical therapy can be given as initial management. however, if the avn on hip joint progresses rapidly and nonsurgical management is ineffective, surgical management can be performed. patients with more than 15% necrotic volume and patients with arco stage 1–3 can receive core decompression, osteotomy, and nonvascularized bone transplantation. joint replacement or tha can be chosen if the femoral head has collapsed, there is already a features of late-stage arterial occlusion (arco stage 3c–4), and severe joint function loss or moderate/severe painis present.1 in this study, almost all patients had late stage avn in hip joint. therefore, 20 of the 22 patients underwent surgical therapy with tha. our study has several limitations. this study is cross-sectional and the cross sectional study design does not help to determine the association between trauma and avn. however, despite the shortcomings that have been mentioned before, all forms of high energy trauma such as falls, slips, and even traffic accidents affecting the pelvic area especially hip joint should be considered as a traumatic avn. to conclude, the proportion of avn in the hip joint caused by trauma is 10.5%. however, this disease should not be underestimated because avn has the potential to cause disability and is a common cause of tha usage, leading to a financial burden. references 1. zhao d, zhang f, wang b, liu b, li l, kim sy, et al. guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version). j orthop translat. 2020;21:100–10. 2. liu f, wang w, yang l, wang b, wang j, chai w, et al. an epidemiological study althea medical journal. 2021;8(4) 219annisa nurrizki baroqah et al.: proportion of traumatic avascular necrosis on hip joint at dr. hasan sadikin general hospital bandung in 2016–2020 of etiology and clinical characteristics in patients with nontraumatic osteonecrosis of the femoral head. j res med sci. 2017;22:15. 3. lespasio mj, sodhi n, mont ma. osteonecrosis of the hip: a primer. perm j. 2019;23:18–100. 4. li d, liu p, zhang y, li m. alterations of sympathetic nerve fibers in avascular necrosis of femoral head. int j clin exp pathol. 2015;8(9):10947–52. 5. scaglione m, fabbri l, celli f, casella f, guido g. hip replacement in femoral head osteonecrosis: current concepts. clin cases miner bone metab. 2015;12(suppl 1):51–4. 6. goyal t, singh a, sharma r, choudhury ak, arora ss. osteo-necrosis of femoral head in north indian population: risk factors and clinico-radiological correlation. clin epidemiol glob health. 2019;7(3):446–9. 7. pedneault c, george ss, masri ba. challenges to implementing total joint replacement programs in developing countries. orthop clin north am. 2020;51(2):131–9. 8. bergman j, nordström a, nordström p. epidemiology of osteonecrosis among older adults in sweden. osteoporos int. 2019;30(5):965–73. 9. fukushima w, fujioka m, kubo t, tamakoshi a, nagai m, hirota y. nationwide epidemiologic survey of idiopathic osteonecrosis of the femoral head. clin orthop relat res. 2010;468(10):2715–24. 10. lamb jn, holton c, o’connor p, giannoudis pv. avascular necrosis of the hip. bmj. 2019;365:i2178. 11. popere s, shinde ss, patel r, kulkarni a. a cross sectional study of outcomes of muscle pedicle grafting in neck of femur fractures and avascular necrosis of femoral head. injury. 2020;51(7):1622–5. 12. blom a, warwick d, whitehouse mr, editors. apley & solomon’s system of orthopaedics and trauma. 10th ed. boca raton, florida: crc press; 2018. 13. adesina o, brunson a, keegan thm, wun t. osteonecrosis of the femoral head in sickle cell disease: prevalence, comorbidities, and surgical outcomes in california. blood adv. 2017;1(16):1287–95. 14. seeley ma, georgiadis ag, sankar wn. hip vascularity: a review of the anatomy and clinical implications. j am acad orthop surg. 2016;24(8):515–26. 15. winn ak, win tns. bilateral avascular necrosis of hip in young malaysian female with sle. ajorr. 2019;2(1):1–8. amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 218 characteristics and risk factors of patients with acute ischemic stroke in dr. hasan sadikin general hospital bandung, indonesia nesyia tara restikasari,1 uni gamayani,2 lisda amalia,2 sofiati dian,2 aih cahyani2 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: nesyia tara restikasari, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west java-indonesia, e-mail: nesyia17001@mail.unpad.ac.id introduction world health organization (who) describes stroke as clinical manifestation of focal or global cerebral dysfunction, which develops rapidly, lasts over 24 hours, that may lead to death, with no apparent cause apart from that of vascular origin.1 stroke is the second most common cause of death and the third most common cause of disability globally.2 in indonesia, the prevalence of stroke is rising from the previously reported seven per thousand population in indonesia basic health research (riset kesehatan dasar, riskesdas) 2013 to 10.9 per thousand population reported in riskesdas 2018.3,4 ischemic stroke is the most prevalent type of stroke, encompassing about 75% of all stroke incidents in asia and 67.1% of those in indonesia.5,6 various risk factors can affect infarction that disrupts blood flow to the brain. such factors can be generally classified into nonmodifiable risk factors such as age, gender, family history of stroke, race, and modifiable risk factors including, hypertension, diabetes mellitus, cardiovascular disease, dyslipidemia, smoking, obesity, diet, physical inactivity, and alcohol consumption. about 90% of stroke cases are attributable to modifiable risk factors.7,8 the development of today’s medical sciences and practices indeed brings improvement in managing various risk factors for ischemic stroke. this condition should be followed by a decrease in the incidence of ischemic stroke. however, the incidence of althea medical journal. 2022;9(4):218–222 abstract background: stroke is the second most common cause of death globally and the third most common cause of disability. the prevalence of stroke is increasing despite managing various stroke risk factors that have improved considerably. ischemic stroke is the most prevalent type, and about 90% of stroke events are attributable to modifiable risk factors. this study aimed to explore the characteristics and risk factors of patients with acute ischemic stroke in dr. hasan sadikin general hospital. methods: a descriptive cross-sectional study was conducted retrospectively in october 2020, using a total sampling method on medical records of acute ischemic stroke patients in dr. hasan sadikin general hospital year 2019. medical records with incomplete and missing data were excluded. demographic and known risk factors data were collected and presented in the table. results: of the 355 subjects, male patients (n=69, 76.7%) were predominant, with the age range of 55–64 years old (36.1%). the majority of the subjects had an ischemic stroke of large-artery atherosclerosis (68.2%) with carotid system involvement (93.2%). as much as 305 subjects (85.9%) had hypertension as the risk factor, followed by dyslipidemia (47.3%), heart disease (39.4%), previous stroke history (33.8%), smoking (25.6%), diabetes mellitus (24.5%), hyperuricemia (12.1%), and blood disorders (2.3%). conclusions: males in the older age group have a higher risk of getting acute ischemic stroke with ischemic stroke of large-artery atherosclerosis and carotid system involvement, and hypertension has the highest prevalence. keywords: acute ischemic stroke, characteristics, hypertension, risk factors https://doi.org/10.15850/amj.v9n4.2362 althea medical journal. 2022;9(4) 219 ischemic stroke did not decrease over time. the best strategy to control the incidence rate of ischemic stroke is primary prevention through early detection and intervention of the risk factors.7 knowing risk factor of ischemic stroke could help the preventive programs. there are no recent studies about risk factor characteristic of ischemic stroke in west java. the aim of this study was to have an overview of patient characteristics and risk factors for acute ischemic stroke in west java by using data from dr. hasan sadikin general hospital bandung in 2019 as a top-referral hospital in west java, indonesia. methods a descriptive study was conducted retrospectively using a cross-sectional study method in october 2020. secondary data were obtained from the resume of medical records in the neurology ward of dr. hasan sadikin general hospital using total a sampling method. the subjects in this study were all medical records that met the inclusion criteria, including a diagnosis of ischemic stroke for 2019. medical records with incomplete and missing data were excluded. the variables in this study were age, sex, ischemic stroke subtype based on etiology, vascular system involvement, and risk factors. ages were grouped into 15–24, 25–34, 35–44, 45–54, 55–64, 65–74, and ≥75 years old, aimed to provide a better description regarding the increasing ischemic stroke cases for each additional 10 years of age from the early adult period. ischemic stroke subtypes based on etiology were categorized into large-artery atherosclerosis (embolus/thrombosis), cardioembolism, small-vessel occlusion (lacune), and strokes of undetermined etiology. the vascular system involvement was classified into the carotid and vertebrobasilar systems. the data collected included known risk factors such as hypertension, diabetes mellitus, smoking, dyslipidemia, heart diseases, previous stroke history, hyperuricemia, and blood disorders. heart diseases encompass coronary heart disease, rheumatic heart disease, and heart rhythm abnormalities or cardiac arrhythmias. blood disorders comprise thrombocytopenia, hypercoagulability, and polycythemia vera. the data were processed descriptively using microsoft® excel 2016. the data were then presented in tables for the frequency and percentage distribution. this study was approved by the research ethics committee nesyia tara restikasari et al.: characteristics and risk factors of patients with acute ischemic stroke in dr. hasan sadikin general hospital bandung, indonesia table 1 characteristics of patients with acute ischemic stroke in west java from dr. hasan sadikin general hospital bandung year 2019 (n=355) characteristics n (%) age (years) 15–24 25–34 35–44 45–54 55–64 * 65–74 ≥75 2 1 28 67 128 88 41 0.6 0.3 7.9 18.9 36.1 24.8 11.5 gender male* female 183 172 51.5 48.5 ischemic stroke subtypes large-artery atherosclerosis * cardioembolism small-vessel occlusion (lacune) undetermined etiology 242 98 12 3 68.2 27.6 3.4 0.8 vascular involvement carotid system * vertebrobasilar system 331 24 93.2 6.8 note. * the most prevalent frequency althea medical journal. 2022;9(4) 220 of universitas padjadjaran with an ethical exemption letter number 834/ un6.kep/ ec/2020. results there were 361 cases of acute ischemic stroke in the neurology ward of dr. hasan sadikin general hospital from january to december 2019. six data were excluded due to incompleteness, resulting in 355 subjects that were eligible for the study. it was found that the prevalence of ischemic stroke tends to increase with age, with the peak prevalence in the 55–64 year age group (36.1%). based on gender, ischemic stroke was more common in males (51.5%). ischemic stroke of largeartery atherosclerosis was the most prevalent subtype (68.2%), followed by cardioembolism (27.6%), small-vessel occlusion (lacune) (3.4%), and strokes of undetermined etiology (0.8%). in terms of vascular involvement in ischemic stroke, it was found that carotid system involvement was more common (93.2%) than vertebrobasilar system involvement (table 1). risk factors analysis showed that 85.9% had hypertension, 47.3% had dyslipidemia, 39.4% had heart disease, 33.8% had a previous stroke history, 25.6% were active smokers or had a history of smoking, 24.5% had diabetes mellitus; while hyperuricemia was detected in 12.1%, and blood disorders only in 2.3%, as shown in table 2. discussions ischemic stroke has been associated with both non-modifiable and modifiable risk factors. age is one of the non-modifiable risk factors. the incidence and risk of stroke increase with age, an estimated two-fold increase for each decade after 55 years of age.7 a report from the american heart association (aha) suggests that ischemic stroke incidence is decreased significantly in people ≥60 years old. this may be related to the population’s life expectancy, where the total population tends to decrease with age.9 in agreement with these statements, this study found that the prevalence of ischemic stroke tends to increase with age which it starts to increase significantly in the age group of 35–44 years. the prevalence peaks in the age group of 55–64 years and then tends to decrease in the subsequent groups. this finding is in accordance with a study conducted in bali which reported similar results.10 the increase in the incidence of ischemic stroke in the elderly correlated with the cumulative effect of aging or degeneration of body organs, including the cardiovascular system, accompanied by increased risk factors such as hypertension and diabetes mellitus, causing susceptibility to ischemic stroke.7,10 in general, men tended to have a higher incidence of ischemic stroke than women. however, in our study, the difference was narrow.9,11 a study conducted in saudi arabia shows that ischemic stroke is more common in men than women.12 this is consistent with the finding of this study, where the ischemic stroke is more commonly found in male than female patients, with only a subtle difference. this finding is also in line with the previous studies conducted in manado and bali.10,13 normal estrogen level in premenopause women has a protective effect against stroke, leading to a lower risk of stroke compared to men in younger and middle-aged groups. however, the risk tends to be higher at an elderly age.14 althea medical journal december 2022 table 2 distribution of risk factors for acute ischemic stroke in west java from dr. hasan sadikin general hospital bandung in 2019 risk factors n (%) hypertension dyslipidemia heart diseases previous history of stroke smoking diabetes mellitus hyperuricemia blood disorders 305 168 140 120 91 87 43 8 85.9 47.3 39.4 33.8 25.6 24.5 12.1 2.3 althea medical journal. 2022;9(4) 221 the previous study demonstrated that the ischemic stroke’s cardioembolic subtype is the most prevalent, followed by largeartery atherosclerosis and lacunar stroke.15 interestingly, our study showed that ischemic stroke from large-artery atherosclerosis was the most prevalent, followed by cardioembolic and lacunar stroke. this finding is in line with a study conducted in jakarta.16 a study conducted in south korea reported that carotid vascular system is more frequently involved in ischemic stroke than the vertebrobasilar system.17 similarly, our study shows that the carotid vascular system involvement is more frequently found. the leading risk factors for stroke in indonesia, based on the study in 2015, were age, coronary heart disease, diabetes mellitus, hypertension, and heart failure.8 hospital-based study in jakarta showed that hypertension, dyslipidemia, and diabetes mellitus are the most prevalent risk factor for ischemic stroke.16 another hospital-based study conducted in egypt demonstrated that the most common risk factor for ischemic stroke was hypertension, followed by dyslipidemia and smoking.18 not much different result in this study, where hypertension, dyslipidemia, and heart diseases were found to be the most prevalent risk factors. from those findings, hypertension consistently with being the most prevalent risk factor for ischemic stroke, while the distribution of the other risk factors tends to be slightly different in each study. as much as 85.9% of subjects in this study had a prior history of hypertension. this finding is also similar to studies conducted in sleman and manado, where a high prevalence of stroke was associated with hypertension.7,13 hypertension is characterized by increased blood pressure leading to high intraluminal pressure. these mechanical changes altered the endothelium and vascular smooth muscle. when blood cells interact with the altered endothelium, a local thrombus is formed, and atherosclerosis formation is accelerated. this condition increases the risk of cerebral ischemic lesions due to local thrombosis as well as embolism originating from the distal vessels.19 according to riskesdas 2018, the prevalence of hypertension in indonesia is 34.1%, of whom 13.3% did not take any medication, while 32.3% did not regularly take medication.4 along with the fact that hypertension is often asymptomatic, the patient neither recognized that they had hypertension nor sought any treatment. thus, the hypertension was found together with complicated symptoms. this situation indicates that the risk of ischemic stroke associated with hypertension in indonesia might be high. a population-based study in the united states suggested that as many as 9% to 16% of all ischemic stroke cases might be avoided only by eliminating hypertension.20 for that matter, early detection and management of risk factors may prevent the occurrence of ischemic stroke. preventive interventions should be designed according to the current pattern of risk factors for ischemic stroke, especially those with high prevalence. a retrospective study using data obtained from medical records, including this study, has various limitations, such as incomplete and missing data. many other risk factors should be accounted for, such as behavioral factors (e.g., physical inactivity and unhealthy diet history), obesity, and a family history of stroke. however, the medical record needs to record complete information about these factors, limiting the possible risk factors in this study. future studies should consider these other factors to better describe the current pattern of ischemic stroke risk factors. in conclusion, ischemic stroke is found mainly in the 55–64 age group and is more common in males. ischemic stroke of largeartery atherosclerosis is the most prevalent and commonly involves the carotid vascular system. a predominant risk factor is hypertension, thus suggesting that preventive actions against the modifiable risk factor should be prioritized. references 1. sacco rl, kasner se, broderick jp, caplan lr, connors jj, culebras a, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(7):2064–89. 2. who. leading causes of death and disability 2000-2019: a visual summary [internet]. [cited 2021 jan 29]. available from: https://www.who.int/data/stories/ leading-causes-of-death-and-disability2000-2019-a-visual-summary 3. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2013. 4. badan penelitian dan pengembangan nesyia tara restikasari et al.: characteristics and risk factors of patients with acute ischemic stroke in dr. hasan sadikin general hospital bandung, indonesia althea medical journal. 2022;9(4) 222 kesehatan kementerian kesehatan republik indonesia. laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2018. . 5. suwanwela n, poungvarin n, asian stroke advisory panel. stroke burden and stroke care system in asia. neurol india. 2016;64 suppl:s46–51. 6. yudiarto f, machfoed m, darwin a, ong a, karyana m, siswanto s. indonesia stroke registry (s12.003). neurology. 2014;82(10 supplement):s12.003. 7. setyopranoto i, bayuangga hf, panggabean as, alifaningdyah s, lazuardi l, dewi fst, et al. prevalence of stroke and associated risk factors in sleman district of yogyakarta special region, indonesia. stroke res treat. 2019;2019:2642458. 8. ghani l, mihardja lk, delima d. faktor risiko dominan penderita stroke di indonesia. buletin penelitian kesehatan. 2016;44(1):49–58. 9. virani ss, alonso a, benjamin ej, bittencourt ms, callaway cw, carson ap, et al. heart disease and stroke statistics—2020 update: a report from the american heart association. circulation. 2020;141(9):e139–596. 10. kesuma nmts, dharmawan dk, fatmawati h. gambaran faktor risiko dan tingkat risiko stroke iskemik berdasarkan stroke risk scorecard di rsud klungkung. intisari sains medis. 2019;10(3):720–9. 11. barker-collo s, bennett da, krishnamurthi rv., parmar p, feigin vl, naghavi m, et al. sex differences in stroke incidence, prevalence, mortality and disability-adjusted life years: results from the global burden of disease study 2013. neuroepidemiology. 2015;45(3):203–14. 12. zafar a, al-khamis f, al-bakr a, alsulaiman a, msmar a. risk factors and subtypes of acute ischemic stroke. a study at king fahd hospital of the university. neurosciences (riyadh). 2016;21(3):246–51. 13. kabi gycr, tumewah r, kembuan mahn. gambaran faktor risiko pada penderita stroke iskemik yang dirawat inap neurologi rsup prof. dr. r. d. kandou manado periode juli 2012–juni 2013. e-clinic. 2015;3(1):457–62. 14. samai aa, martin-schild s. sex differences in predictors of ischemic stroke: current perspectives. vasc health risk manag. 2015;11:427–36. 15. montaner j, perea-gainza m, delgado p, ribó m, chacón p, rosell a, et al. etiologic diagnosis of ischemic stroke subtypes with plasma biomarkers. stroke. 2008;39(8):2280–7. 16. harris s, sungkar s, rasyid a, kurniawan m, mesiano t, hidayat r. toast subtypes of ischemic stroke and its risk factors: a hospital-based study at cipto mangunkusumo hospital, indonesia. stroke res treat. 2018;2018:9589831. 17. chung j, park sh, kim n, kim w, park jh, ko y, et al. trial of org 10172 in acute stroke treatment (toast) classification and vascular territory of ischemic stroke lesions diagnosed by diffusionweighted imaging. j am heart assoc. 2014;3(4):e001119. 18. soliman rh, oraby mi, fathy m, essam am. risk factors of acute ischemic stroke in patients presented to beni-suef university hospital: prevalence and relation to stroke severity at presentation. egypt j neurol psychiatry neurosurg. 2018;54(1):8. 19. johansson bb. hypertension mechanisms causing stroke. clin exp pharmacol physiol. 1999;26(7):563–5. 20. hisham nf, bayraktutan u. epidemiology, pathophysiology, and treatment of hypertension in ischaemic stroke patients. j stroke cerebrovasc dis. 2013;22(7):e4– 14. althea medical journal december 2022 amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 198 radiological findings of pulmonary tuberculosis in children at dr. hasan sadikin general hospital bandung 2018–2019 nanda mia ghaesani,1 ristaniah rose effendy,2 diah asri wulandari3 1faculty of medicine universitas padjadjaran, indonesia, 2department of radiology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: nanda mia ghaesani, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: nandamia66@gmail.com introduction tuberculosis (tb) remains a major cause of death worldwide according to the world health organization (who).1 indonesia is ranked as the second largest tb contributor with 845,000 cases in 2019, who reports that there are approximately 119,520 (12%) cases of tb in children all over the world, and about 14,520 (16%) children died of tb in 2019.1 high mortality rates for children compared to their estimated of cases suggests poorer access to diagnosis and treatment.1 approximately 73,285 cases of pulmonary tb in west java with 31,814 cases in children aged 1 month to less than 18 years. bandung, is one of the cities in west java that has the highest incidence of pulmonary tb with an estimated 5,592 cases in 2018 according to basic health research (riset kesehatan dasar, riskesdas),2 the mortality rate of tb is almost 50% in children aged less than 5 years.3 pulmonary tuberculosis is an infectious disease caused by mycobacterium tuberculosis (mtb),4 mostly transmitted by inhalation of droplets nuclei when a person with active pulmonary tb coughs, sneezes, or talks. those who have a poor immune system, and live in tb endemic areas, poor socioeconomic conditions, and smoking may have an increased incidence number of tb. children are prone to have a high risk of getting tb. clinical manifestations are mostly general and non-specific symptoms similar to other conditions. children with pulmonary tb generally show no symptoms for some time due to a typical paucibacillary disease.4 diagnosis of pulmonary tb is complicated althea medical journal. 2021;8(4):198–203 abstract background: tuberculosis (tb) remains a major cause of death worldwide, especially in children. indonesia is ranked second as the largest contributor to tb. chest x-rays have been used to diagnose pulmonary tb in children, however, the results are varied. therefore, this study was performed to explore the radiological findings among children with pulmonary tb. methods: retrospective descriptive study was conducted by analyzing the chest x-ray findings retrieved from the medical records of all pulmonary tb children treated at dr. hasan sadikin general hospital during 2018 to 2019. inclusion criteria were medical records of patients aged 1 month to 18 years diagnosed with pulmonary tb who underwent chest x-ray (n=223). results: the highest incidence of pulmonary tb was found in the group of 10–18 years (43.9%) and female (50.2%). the results of chest x-ray were infiltrates (65.0%), lymphadenopathy (11.7%), cavity (7.6%), calcifications (7.6%), miliary (4.9%), pleural effusion (3.1%) and atelectasis (1.8%). conclusion: infiltrates are the major finding on chest x-ray in children with tb. keywords: chest x-ray, children, pulmonary tuberculosis https://doi.org/10.15850/amj.v8n4.2338 althea medical journal. 2021;8(4) 199 in children, because it is difficult to isolate mtb from sputum. therefore chest x-ray remains a supporting tool for the diagnosis of tb in children.5 there are several radiological findings of pediatric pulmonary tb such as lymphadenopathy, infiltrates, calcifications, pleural effusions, and others. hilar lymphadenopathy is a characteristic feature of tb in children and is often the only radiological finding in 50% of pediatric cases.6 chest x-ray in most cases of lung caused by chronic infection or inhalation of foreign bodies can sometimes resemble pulmonary tb.7 a normal chest x-ray of children can often resemble an abnormal chest x-ray because of less than optimal chest x-ray taking and misinterpretation.6 therefore, understanding chest x-ray of pediatric pulmonary tb for diagnostic purposes in both clinical practice and research is important. previous study has shown that chest x-ray findings is mostly infiltrate (55.2%), and other findings in small proportion such as pleural effusion with infiltrate, milliary, pleural effusion, and atelectasis.8 another study has found different findings mostly as hilar lymphadenopathy (52%) and a small proportion as calcification, miliary.9 this abnormal chest x-ray findings have been found in patients with negative tuberculin skin test (tst) results. since there has been no similar study conducted in bandung, this study aimed to explore radiological findings among children with pulmonary tb treated at dr. hasan sadikin general hospital, bandung. methods a retrospective descriptive study was conducted by looking at the chest x-ray findings from the medical records of pediatric patients diagnosed with pulmonary tb. this study was conducted at the pediatric ward of dr. hasan sadikin general hospital bandung in 2018– 2019. a total sampling method was employed (n=713). the inclusion criteria for this study were medical records of patients aged 1 month to 18 years diagnosed with pulmonary tb who underwent chest x-ray. children with extrapulmonary tb (n=357) were excluded. furthermore, incomplete medical records were also excluded (n=133). this research has been approved by the research ethics committee, universitas padjadjaran with number 813/ un6.kep/ec/2020 and also by the research development and ethics committee of dr. hasan sadikin general hospital with number lb.02.01/x.2.2.1/23478/2020. in children, tb was diagnosed based on the typical clinical symptoms of tuberculosis, with one or more of the following: (a) weight loss or no gain in the previous 2 months; (b) fever (≥2 weeks) and /or recurrent without apparent cause; (c) cough (≥2 weeks); (d) lethargic (≥2 weeks). these symptoms persisted despite adequate therapy, positive bacteriological confirmation by positive microbiological examination (acid-fast bacilli or rapid molecular test), evidence of tb infection (positive tuberculin test results or close contact with tb patients), and suggestive tb chest x-ray images.10 the following information was extracted from available medical records such as age, gender, tb treatment history, contact with adults with pulmonary tb, bacillus calmette guerin (bcg) immunization, nutritional status, other clinical findings or complaints felt by the patient observed by the examiner at the time of the examination, such as weight loss or no increasing weight in the previous 2 months, fever (≥2 weeks), cough (≥2 weeks), lethargy (≥2 weeks), enlarged lymph nodes ≥1 cm in size,10 positive tst,11 bacteriological confirmation, and comorbidity. chest x-ray was reviewed for the presence of the following variables such as hilar/ paratracheal lymphadenopathy, described as nodular masses or lobulated opaque according to site.12 furthermore, infiltrate was described as a cloudy or infiltrating spot which is generally over the upper plane of the lung although it can occur anywhere in the lung.6 milliary was described as small nodular opacities (≤3 mm in diameter), diffuse, and uniform across the plane of the lung to the edge of the lung plane,6 whereas cavity was described as air-filled cavity occuring in areas with parenchymal damage.6 calcification was described as hard or calcified node, atelectasis was described as collapse of the air space, and pleural effusion was described as homogeneously opacified fluid level or pleural opacification.12,13 the data were processed using microsoft excel 2016, and presented descriptively by calculating the amount and proportion in the tables. results a total of 223 medical records at dr. hasan sadikin general hospital were included in this study taken from january 2018 to december 2019. the mean age of the patients was 7.81 years and the median age was 8 years (range <1–18 years old). most of the patients were aged between 10–18 years (43.9%) with the nanda mia ghaesani et al.: radiological findings of pulmonary tuberculosis in children at dr. hasan sadikin general hospital bandung 2018–2019 althea medical journal. 2021;8(4) 200 table 1 characteristics of children with pulmonary tuberculosis at dr. hasan sadikin general hospital bandung year 2018–2019 (n=223) characteristic n (%) age, years old mean median (range) 7.81 8 (<1–18 ) age group in years <1 1–<5 5–<10 10–18 24 (10.8) 73 (32.7) 28 (12.6) 98 (43.9) gender male female 111 (49.8) 112 (50.2) tb treatment history* history of tb contact bcg immunization** 110 (49.3) 62 (27.8) 151 (67.7) nutritional status severe malnutrition moderate malnutrition normal overweight 84 (37.7) 52 (23.3) 84 (37.7) 3 (1.3) clinical findings fever ≥2 weeks cough ≥2 weeks weight loss or no gain in the previous 2 months malaise lymph node enlargement positive tst*** 109 (48.9) 104 (46.6) 72 (32.3) 19 (8.5) 29 (13.0) 35 (15.7) bacteriological confirmation positive afb**** positive genexpert positive culture 22 (9.9) 27 (12.1) 1 (0.4) comorbids autoimmune disease cancer chronic lung disease diabetes mellitus malnutrition nephrotic syndrome pneumonia hiv 9 (4.0) 4 (1.8) 11 (4.9) 1 (0.5) 136 (61.0) 8 (3.6) 56 (25.1) 6 (2.7) note: all data are presented as n (%) unless stated otherwise, *tb: tuberculosis,**bcg: bacillus calmette guerin,***tst: tuberculin skin test,****afb : acid-fast bacilli althea medical journal december 2021 althea medical journal. 2021;8(4) 201 table 2 distribution of chest x-ray findings of pulmonary tuberculosis in children at dr. hasan sadikin general hospital bandung year 2018–2019 pulmonary tb (n= 223) n % infiltrate lymphadenopathy (hilar/paratracheal) cavity calcification milliary pleural effusion atelectasis 145 26 17 17 11 7 4 65.0 11.7 7.6 7.6 4.9 3.1 1.8 note: one pediatric pulmonary tb patient can show more than 1 radiological findings proportion of male patients (49.8%) less than female and most of them came with a history of tb treatment (49.3%). history of contact with the source of tb cases was found in 27.8% of patients. most of the subjects had a history of bcg immunization (67.7%) and the nutritional status was mostly undernutrition which was severe (37.7%) and moderate malnutrition (23.3%). fever ≥2 weeks was the most common clinical findings (48.9%) and 15.7% had a positive tst. bacteriological confirmation showed positive afb in only 9.9% of patients, positive genexpert (12.1%), and positive culture (0.4%). most of the patients had more than one disease that occured simultaneously with malnutrition (61.0%). the most frequent lesions found on chest x-ray of pediatric pulmonary tb cases were infiltrates (65.0%), followed by lymphadenopathy (11.7%), cavities (7.6%), calcifications (7.6%), milliary (4.9%), pleural effusion (3.1%) and atelectasis (1.8%) as shown in table 2. discussion pediatric tuberculosis patients at dr. hasan sadikin general hospital bandung in 2018– 2019 were mostly aged between 10–18 years (69.4%) and the least was younger than 1-year-old (10.8%). this is similar to a study in shandong, china14 in 2019, reporting that the incidence of pulmonary tb often occurred in the 15–17 year age group (83.3%). this finding is also in line with studies showing that adolescents have a higher risk of developing tb disease because most of adolescents have high levels of tb exposure and they are more likely to spend time in an enclosed space, such as social gathering places or schools.6,11 furthermore, most of pulmonary tb in children is female (50.2%), similar to the previous study which accounted for 56.6%.15 contact with the source of tb cases was found in 27.8% of patients, slightly higher than the previous study.14 this difference might be caused by the nature of the disease. bcg protection against pulmonary tb is well known with efficacy rates (0–80%) and is greater when bcg is given in infancy or at school age.16 however in this study pulmonary tb is mostly observed in 67.7% of children who have a history of bcg immunization. moreover, a research conducted in mumbai, india15 has shown that almost all children have been vaccinated with bcg, suggesting that tb can occur in children vaccinated with bcg . most of the nutritional status in this study is undernutrition, which is severe (37.7%) and moderate malnutrition (23.3%). this finding is in line with a study in north sumatera, indonesia.17 undernutritional status has a 3.31 times greater risk of experiencing pulmonary tb in children compared to children who have good nutritional status. the most common clinical finding in this study is fever at ≥2 weeks (48.9%) similar to the previous study.10,18 tuberculin skin test (tst) shows positive result in 15.7% of patients. however, a negative result may be pointing out falsenegative tst results due to incorrect test administration or interpretation, immune disorders, malnutrition, immunosuppressive medications, neonatal patient, severe tb cases, malignancy, and expired tst kit. a negative tst does not rule out mtb infection or the possibility of tb. therefore, it is important to carry out other tb diagnostic tests.11 acid-fast bacilli and genexpert examination in this study have more negative results. this finding is similar to another study which showed more negative results of afb and genexpert examination.18 the negative afb examination and genexpert results might be due to tb in young children who generally have paucibacillary disease, accompanied by inadequate cough physiology to expectorate infectious sputum.4 culture examinations nanda mia ghaesani et al.: radiological findings of pulmonary tuberculosis in children at dr. hasan sadikin general hospital bandung 2018–2019 althea medical journal. 2021;8(4) 202 were mostly done with blood specimen that were not included in this study. most of the results from sputum or gastric aspirates were negative (8.5%). the percentage of patients with culture negative in england is 13%.19 this negative result due to negative cultures could include multiple disease states.19 several medical conditions are comorbid for tb. the most comorbidity in this study is malnutrition (59.6%). malnutrition can lead to secondary immunodeficiency that increases the host’s susceptibility to infection. the most common chest x-ray finding is infiltrate (65.0%), similar to another study.8 the infiltrates in this study can be caused by mtb that reaches the pulmonary alveoli which then causes parenchymal inflammation. another finding is lymphadenopathy (11.7%).5 hilar lymphadenopathy is the hallmark of tb in children and is often the only chest x-ray finding.6 lymphadenopathy is more common in younger children than adolescents. it may also be due to parenchymal lesions such as infiltrates that may obstruct the visualization of enlarged lymph nodes, although both findings may appear at the same time.5 therefore, it is important not to rule out pulmonary tb despite the absence of the most characteristic radiological findings which is lymphadenopathy and it is still necessary to combine radiological examination with other diagnostic tests. cavity in this study has mostly been observed in the 10–18 year age group (7.6%), which is more common than the study in mumbai, india.15 cavitation in older children and adolescents is higher than in younger children.6 cavitation can occur in older children due to higher mycobacterial load which is similar to the adult-type disease.15 some lesions in lung tissue can mostly heal to form fibrosis or calcification. calcification can occur from 6 months to 4 years after infection, however, it may occur earlier in young children. miliary lesion results from mtb infiltration into the blood vessels, leading to hematogenous dissemination.13 this type of lesion can occur in young children because of their immature immune system.20 pleural effusion with bacteriological confirmation has been found in only a small percentage which is similar to the study in mozambique.5 this is mostly due to a delayed-type hypersensitivity reaction to mtb antigens that leak into the pleural space from the subpleural primary focus.13 furthermore, atelectasis may occur because the thymus gland can resemble to atelectasis, especially on chest x-ray with rotational asymmetry or caused by bronchial obstruction.6 the limitation of this study is the use of a retrospective study. there is a lot of data missing or not available. descriptive data might not determine a clear association between variable data and radiological findings. most of the population was drawn from patients being treated with severe tb or pulmonary tb with other diseases that could provide a bias. most patients had only an anteroposterior (ap) projection and lacked of the lateral projection, which is important for lymphadenopathy evaluation, thus, some findings might have been missed. further research is needed to determine the radiological findings of pulmonary tb in children with better research methods including patients who were treated at outpatient clinic as the population. this study concludes that most of the chest x-ray findings of pediatric pulmonary tb patients treated at dr. hasan sadikin general hospital bandung has an infiltrate, followed by lymphadenopathy, cavity, calcification, milliary, pleural effusion and atelectasis. these findings need further research to explore the use of chest x-ray as diagnostic criteria for tb in children. references 1. world health organization. global tuberculosis report 2020. geneva: who; 2020. 2. tim riskesdas 2018 kementerian kesehatan ri. laporan provinsi jawa barat: riskesdas 2018. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan; 2019. 3. roy rb, whittaker e, seddon ja, kampmann b. children and mycobacterium tuberculosis: a review of susceptibility and protection. lancet infect dis. 2019; 19(3):e-96–108. 4. holmberg pj, temesgen z, banerjee r. tuberculosis in children. pediatr rev. 2019;40(4):168–78. 5. garcía-basteiro al, lópez-varela e, augusto oj, gondo k, muñoz j, sacarlal j, et al. radiological findings in young children investigated for tuberculosis in mozambique. plos one. 2015;10(5):e0127323. 6. smith kc, john sd. pediatric tb radiology for clinicians. san antonio, tx: heartland national tb center; 2012. 7. majdawati a. uji diagnostic gambaran lesi foto thorax pada penderita dengan klinis tuberkulosis paru. mutiara medika. althea medical journal december 2021 althea medical journal. 2021;8(4) 203 2010;10(2):180–8. 8. salwani d, nasir uz, yunihastuti e, harimurti k, andriansjah a. kemampuan gabungan gejala klinis dan pemeriksaan radiologis serta biakan mgit 960 dalam diagnosis tuberkulosis paru pada pasien hiv. j penyakit dalam indones. 2018;5(2):88–93. 9. poluan aga, loho e, ali rh. hubungan gambaran fototoraks dan uji tuberkulin pada anak dengan diagnosis tuberkulosis paru di rsup prof. dr. r. d. kandou manado periode januari 2012–desember 2012. e-clinic. 2014;2(1):3664. 10. asik a, hastuti eb, evarini, editors. petunjuk teknis manajemen dan tatalaksana tb anak. jakarta: direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan republik indonesia; 2016. 11. world health organization. guidance for national tuberculosis programmes on the management of tuberculosis in children. 2nd ed. geneva: world health organization; 2014. 12. manikkam s, archary m, bobat r. chest x-ray patterns of pulmonary multidrug resistant tuberculosis in children in a high hiv-prevalence setting. s afr j radiol. 2016;20(1):1–6. 13. roya-pabon cl, perez-velez cm. tuberculosis exposure, infection and disease in children: a systematic diagnostic approach. pneumonia (nathan).2016;8:23. 14. tao nn, li yf, liu yx, liu jy, song wm, liu y, et al. epidemiological characteristics of pulmonary tuberculosis among children in shandong, china, 2005–2017. bmc infect dis. 2019;19(1):408. 15. pereira nmd. clinical profile and outcome of children with tuberculosis in a tertiary care hospital in mumbai, india. sri lanka j child health. 2019;48(4):338–44. 16. mangtani p, abubakar i, ariti c, beynon r, pimpin l, fine pem, et al. protection by bcg vaccine against tuberculosis: a systematic review of randomized controlled trials. clin infect dis. 2014;58(4):470–80. 17. gurning fp, eliska e, pratama my. analysis of factors related to the incidence of pediatric pulmonary tuberculosis in sibuhuan general hospital. jurnal berkala epidemiologi. 2018;6(3):268–75. 18. soekotjo fn, sudarwati s, alam a. clinical profile of tb in children at pediatric outpatient clinic hasan sadikin hospital bandung 2016. j med health. 2019;2(3):818–27. 19. nguyen mvh, levy ns, ahuja sd, trieu l, proops dc, achkar jm. factors associated with sputum culturenegative vs culture-positive diagnosis of pulmonary tuberculosis. jama netw open. 2019;2(2):e187617. 20. concepcion ndp, laya bf, andronikou s, daltro pan, sanchez mo, uy jau, et al. standardized radiographic interpretation of thoracic tuberculosis in children. pediatr radiol. 2017;47(10):1237–48. nanda mia ghaesani et al.: radiological findings of pulmonary tuberculosis in children at dr. hasan sadikin general hospital bandung 2018–2019 amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 70 althea medical journal june 2021 knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students joy david marcellino triditra limbong,1 kuswinarti,2 truly sitorus2 1faculty of medicine universitas padajadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: joy david marcellinotriditra limbong, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: joy17001@mail.unpad.ac.id introduction coronavirus disease-2019 (covid-19), a disease caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2) has caused serious implications and received a lot of international attention, especially in public health sector.1 the pandemic has affected 191 countries in the world, and indonesia is one of the countries affected. the first case of covid-19 was detected in wuhan, china in late december 2019.1 as of december 2020, 543,975 confirmed cases and 17,081 deaths caused by covid-19 have been reported in indonesia.2 this constant rise in the confirmed case and death numbers due to covid-19 are affected by several factors such as central and regional government health protocols, population density, individual adherence towards government health protocols, and quality of the national health care system.3 several medications have been used as pharmacological therapy for covid-19, such as glucocorticoids, janus kinase (jak) inhibitors which have been proven to improve clinical outcomes and azithromycin which has been proven to have antiviral activity towards sarscov-2, along with several other medications.4 although potential therapies for covid-19 exist, there is still no specific pharmacological therapy for covid-19.5 the current best strategy in containing the covid-19 pandemic amj. 2021;8(2):70–6 abstract background: coronavirus disease-2019 (covid-19) has caused serious implications and has received a lot of international attention, especially in public health sector. the main strategy for containing the covid-19 pandemic includes preventive methods such as wearing masks, which requires individual awareness and initiative to adhere to the protocol. this study described the level of knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students who were selected due to their high mobility and rate of activity. methods: this study used a descriptive design and a cross-sectional approach, conducted from october to november 2020. undergraduate students from all faculties of universitas padjadjaran year 2017– 2019 were invited to participate, using an online questionnaire to assess the knowledge, attitude, and practices towards the covid 19 pandemic. the result was given numeric values and scored. the mean value of the scores was used as a reference value to describe the level of knowledge, attitude, and practices. results: from a total of 483 students, 99.5% had good knowledge, 87.9% had good attitude, and 67% had a good practices towards covid-19. conclusions: the overall levels of knowledge, attitudes, and practices towards covid-19 among undergraduate students are good, as well as the adherence to government health protocols and initiatives in seeking information regarding covid-19. several specific areas such as transmission through dead bodies, exercise and vitamin supplementation, and anxiety when reading information about covid-19 are areas of interest for the improvement of education. keywords: attitude, coronavirus disease-2019, knowledge, practices, students https://doi.org/10.15850/amj.v8n2.2282 althea medical journal. 2021;8(2) 71 are preventive methods such as wearing masks, frequent hand washing, and physical distancing.6,7 these preventive methods require individual awareness and initiative to adhere to these protocols.8 knowledge, attitude, and practices towards disease is an essential factor in determining health decisions and health outcomes.9 young adult is an important group to study since this age group has been reported to have lower adherence to government health protocols. this age group also commonly presents with mild symptoms or asymptomatic. since they have high social activity and mobility, this age group greatly contributes to the rise of the covid-19 confirmed cases and mortalities.10 this study aimed to describe the level of knowledge, attitude, and practices of universitas padjadjaran undergraduate students towards the covid-19 pandemic. furthermore, the level of adherence of the students towards the government protocols, as a part of the young adult age group was described. methods this study used a descriptive design and a cross-sectional approach. it was carried out from october to november 2020. the inclusion criteria were undergraduate students from 16 faculties of universitas padjadjaran from the year of 2017–2019 who had voluntarily agreed to participate by filling out an informed consent form. the exclusion criteria were students who incorrectly filled out the questionnaire. the sampling method used was total sampling, and a total of 483 students had participated in this study. this study had been approved by the research ethics committee, universitas padjadjaran no. 1012/un6.kep/ec/2020. the data was collected using an online questionnaire created with google forms. the questionnaire was acquired from a previous study with several edits, with approval from the author.11 the questionnaire consisted of 32 questions, comprised of 14 knowledge questions, 6 attitude questions, and 12 practice questions. the questionnaire also acquired characteristics of the subjects such as faculty and year. the knowledge question answer choices were “ true” or “false”, with a maximum score of 14. the answers of the respondents for the knowledge questions were decided to be correct or incorrect by cross-checking the answers with information from the latest literature on covid-19. the attitude question answer choices were “strongly agree”, ”agree”, ”neutral”, ”disagree”, or “strongly disagree”, with a maximum score of 30. the practices questions answer choices were “always”, ”often”, ”sometimes”, ”rarely”, or “never”, with table 1 characteristics of undergraduate students of universitas padjadjaran variables frequency( n=483 ) percentage (%) year 2017 2018 2019 239 139 105 49.5 28.8 21.7 faculty agriculture industrial technology agriculture animal husbandry communication science cultural sciences dentistry economics and business fishery and marine science geological engineering law mathematics and natural science medicine nursing pharmacy psychology social and political science 3 25 9 20 16 19 13 2 0 10 20 285 24 8 8 21 0.6 5.2 1.9 4.1 3.3 3.9 2.7 0.4 0 2.1 4.1 59 5 1.7 1.7 4.3 joy limbong et al.: knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students althea medical journal. 2021;8(2) 72 althea medical journal june 2021 table 2 knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students of universitas padjadjaran variables frequency (n=483 ) percentage (%) knowledge good satisfactory 481 2 99.5 0.5 attitude positive negative 425 58 87.9 42 practices positive negative 324 159 67 33 a maximum score of 60. each answer was assigned a score, and each subject’s total score was calculated. the average score for knowledge, attitude, and practices was used as a reference value. for knowledge, subjects with a score more than 75% of the maximum score were categorized as “good”, and subjects with a score between 55% and 75% of the maximum score were categorized as “satisfactory”, and subjects with a score less than 55% of the maximum score were categorized as “poor”. for attitude and practices, subjects with a score of more than 75% of the maximum score were classified as “positive”, and subjects with a score less than 75% of the maximum score were classified as “negative”. the questionnaire had been tested for validity with the pearson product formula and was considered valid with a correlation value of ≥0.5. all knowledge and attitude questions achieved good validity. the reliability was tested with cronbach’s alpha formula and considered reliable with a coefficient ≥0.7. all knowledge and attitude questionnaires achieved good reliability. the validity and reliability testing was performed in september 2020 on 30 respondents. the respondents were randomly selected from several instant messaging groups consisting of universitas padjadjaran undergraduate students. results in total, 483 undergraduate students had participated in this study, and all 483 students fulfilled the criteria previously set. the total amount of universitas padjadjaran students from the year 2017–2019 was 21,976 students, thus, only 2.2% of all students participated in this study. most of the students who participated were from the year 2017 (49.5%). the response rate from each faculty ranged from 0 to 285 responses, with the lowest response rate (0%) from the faculty of geological engineering, and the highest response rate (59%) from the faculty of medicine (table 1). the majority of students had a “good” score on knowledge questions (99.5%) as well as a good attitude (87.9%) towards the covid-19 pandemic. more than half of the respondents (67%) had good practices for government covid-19 protocols as shown in table 2. the data for the knowledge questions were not normally distributed. the median of the scores acquired was 13 (range 10–14). more than 95% of respondents answered correctly on questions regarding etiology, symptoms, and treatment of covid-19. fewer respondents answered correctly on questions regarding transmission and spread, with only 89% answering correctly regarding transmission through dead bodies, and 81.4% answering correctly regarding spread through fomites. the data for the attitude questions were not normally distributed. the median of the scores acquired was 25 (range 18–30). most of the students recognized the importance of obeying government covid-19 protocols, obtaining information about covid-19, and had a positive view towards covid-19 patients (table 4). the data for the practice questions were not normally distributed. the median of the scores acquired was 48 (30–60). practices regarding protection from the transmission, received good scores, which were always wearing a mask when going outside (92.5%), always washing their hands frequently (59.8 %), and often washing their hands frequently (31.1%). practices regarding a healthy lifestyle received poorer scores, with only 9.9% of students always routinely exercising and 15.7% often althea medical journal. 2021;8(2) 73joy limbong et al.: knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students routinely exercising, while only 17.6% always received enough rest, and 30 % often received enough sleep. discussion this study aimed to describe the knowledge, attitude, and practices of universitas padjadjaran undergraduate students towards the covid-19 pandemic, resulting in most of the students have good knowledge (99.5%), positive attitude (87.9%), positive practices (67%). a similar study has been previously conducted in another part of indonesia, although with lower percentage.11 however, our study has a higher percentage result compared to other studies in bangladesh and india.12,13 regarding knowledge, correct answer was given on etiology (95%), clinical symptoms (91.1%), and management of covid-19 (99%), with a lower percentage on questions regarding transmission and spread of covid-19, specifically spread through dead bodies of covid-19 patients, correlates with previously cited studies from indonesia and india.11,13 the large proportion of respondents answering correctly on questions regarding etiology, clinical symptoms, and management of covid-19 indicates that information provided by the government through the official website covid19.go.id as well as television and radio has provided good education, however, some topics need further education. answer that dead bodies of covid-19 patients are still able of spreading covid-19 was given from 11% of the students. this answer is incorrect since the indonesian ministry of table 3 knowledge of undergraduate students of universitas padjadjaran towards covid-19 questions correct(%) incorrect (%) 1. covid-19 is a disease caused by sars-cov-2 95 5 2. the main clinical symptoms of covid-19 are fever, fatigue, dry cough, and myalgia 91.1 8.9 3. people with covid-19 also show no symptoms, called otg (people without symptoms) 99.8 0.2 4. people with covid-19 who have chronic diseases such as diabetes, heart disease, and obesity have an increasingly severe condition 95 5 5. children and teenagers do not need to make efforts to prevent covid-19 infection because they have a strong immune system 98.8 1.2 6. people with covid-19 who show no symptoms or otg (people without symptoms) cannot infect the virus to others 98.3 1.7 7. covid-19 is spread through the respiratory droplets of people infected with covid-19 92.5 7.5 8. the dead bodies of people with covid-19 who have not been buried can be a source of the spread of the covid-19 virus 89 11 9. covid-19 only spreads through fomites, it does not spread through the air 81.4 18.6 10. currently, there is no effective drug for covid-19, but the treatment of early symptoms and intensive care can help people with covid-19 to recover 99 1 11. to prevent covid-19 infection, we must avoid going to crowded places like markets and train stations as well as avoid using public transportation 98.3 1.7 12. avoiding travel across cities can prevent the spread of covid-19 98.8 1.2 13. the transmission of sars-cov-2 can be prevented by not touching the face 96.5 3.5 14. isolation and treatment of people infected with the covid-19 virus are effective ways to reduce the spread of the virus 99.2 0.8 althea medical journal. 2021;8(2) 74 althea medical journal june 2021 health has issued specific protocols for the burial of covid-19 patients which ensures the safety of everyone involved. knowledge about the spread through dead bodies is important in indonesia due to recent occurrences of rejection of covid-19 patients’ dead bodies in some parts of indonesia. this phenomenon of dead bodies and burial rejection may cause substantial negative mental and social effects on the patient’s families.14 covid-19 is only able to spread through fomites, and not able of spreading through air according to 18.6% of students. this answer does not correlate with a study that demonstrated covid-19 that spread through respiratory droplets of persons with covid-19, as well as through contact with fomites.1 knowledge regarding covid-19 transmission is important because the transmission is the basis of preventive methods such as wearing masks, washing hands frequently with soap, and physical distancing. therefore, a correct understanding of the transmission of covid-19 may improve adherence to government health protocols. good knowledge of covid-19 has also been proven to correlate with better health protocol practices.11 on attitude, most students have good adherence to government protocols and recognized the threat and importance of dealing with covid-19. interestingly, reading the information regarding covid-19 has caused them to experience anxiety and fear. this result is supported by a previous study in bangladesh15 in which students admitted to experiencing mild to severe depression, and mild to severe anxiety. this may be an area of further focus for education by the government, on methods to control and reduce anxiety and stress in the middle of the covid-19 pandemic. it is important to acquire information regarding covid-19 from the government and to adhere to government health protocols. this study also shows that a large majority of the students have good individual awareness and adherence towards information and protocols regarding covid-19 from the government. not all covid-19 patients are violators of government health protocols. one example is the existence of family or house clusters of covid-19 transmission. in family or house clusters, an individual who has adhered to government health protocols may contract covid-19 from other family or house members who have been exposed to covid-19 when going outside.16 however, a negative stigma should not be given to covid-19 patients. negative stigma towards patients of a particular disease has been shown to cause substantial mental and social impacts that may outgrow the primary disease, especially in pandemic situations such as the covid-19 pandemic.17 on questions about practices, the students table 4 attitude of undergraduate students of universitas padjadjaran towards the covid-19 pandemic questions strongly agree (%) agree (%) neutral (%) disagree (%) strongly disagree (%) 1. keeping up with the information regarding the number of covid-19 cases is important for the community 52.6 37.3 9.3 0.8 0 2. after knowing the information on the number of cases of covid-19, i felt worried/ scared 14.7 48.7 27.5 7.2 1.9 3. keeping up with the information regarding the government's call for covid-19 preventive efforts is important for the community 79.9 17.8 1.9 0 0.4 4. all people with covid-19 are those who violate the government's call in the efforts to prevent transmission of covid-19 2.5 4.8 21.1 49.1 22.6 5. people with covid-19 should not be given a negative stigma in society 67.5 25.1 6.4 1 0 6. people with covid-19 who isolate themselves show that they have a responsibility in preventing the transmission of covid-19 81.8 16.6 1.7 0 0 althea medical journal. 2021;8(2) 75 have shown good practices on the use of masks, physical distancing, and frequent hand washing. interestingly, some students still have routinely performed practices regarding a healthy lifestyles, such as regular exercise, vitamin consumption, and regular rest. this is of great significance due to the proven effect of exercise and vitamins towards improving immune status to prevent covid-19.18,19 furthermore, the majority wear masks as well as performing physical distancing when present in a crowded place. moreover, most of the students wash their hands with soap. taken together, the data reveals that adherence towards the main preventive methods of covid-19 is good which is wearing masks, washing hands with soap, and physical distancing. interestingly, a few students do not change their clothes before entering their house and contacting family members, and this requires further improvement as sarscov-2 can stay viable on clothes for up to 96 hours, and thus becoming a possible source of transmission towards family members.20 the limitations of the current study are among others that the distribution of the respondents throughout the faculty are uneven with the largest proportion is from the faculty of medicine. this might be a bias toward the study result. in conclusion, the undergraduate student in universitas padjadjaran has a good level of overall knowledge, attitude, and practices towards covid-19. further improvement joy limbong et al.: knowledge, attitude, and practices towards the covid-19 pandemic among undergraduate students table 5 practices regarding covid-19 among undergraduate students of universitas padjadjaran questions strongly agree (%) agree (%) neutral (%) disagree (%) strongly disagree (%) 1. in the last few days, have you worn a mask when you were in a crowded place? 92.5 6.4 0.4 0 0.6 2. in the last few days, have you implemented physical distancing when you were in the crowd? 51.3 36.2 11.2 1 0 3. in the last few days, have you used hand sanitizer when you were in crowded places? 65 23.4 10.4 1 0 4. in the last few days, have you washed your hands with soap after going to a crowded place? 72.5 17.6 8.7 1.2 0 5. in the last few days, have you immediately changed your clothes before entering the house and having contact with family members? 38.9 31.7 19.9 6.8 2.7 6. as a college student, have you educated people around you with the knowledge of the preventive efforts of covid-19? 19.5 44.9 29.4 5.4 0.8 7. in the last few days, i have eaten vegetables and fruit. 9.9 15.7 32.9 30.2 11.2 8. in the last few days, i have had enough rest. 12 20.1 30.2 23.2 14.5 9. in the last few days, i have been exercising routinely. 19 33.5 32.7 13 1.7 10. in the last few days, i have taken vitamins or supplements to increase my immune system. 59.8 31.1 7.7 1.4 0 11. in the last few days, i have been cleaning up my house more frequently. 19 33.5 32.7 13 1.7 12. in the last few days, i have been washing my hand with soap more. 59.8 31.1 7.7 1.4 0 althea medical journal. 2021;8(2) 76 althea medical journal june 2021 needs to be implemented in promoting the government website as the main hub of information and simplifying information regarding covid-19 transmission and spread. education about lifestyle practices such as exercise, rest, and a healthy diet must be reinforced, just as important as wearing masks and frequent handwashing. references 1. rothan ha, byrareddy sn. the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak. j autoimmun. 2020;109:102433. 2. john hopkins university & medicine. covid-19 dashboard by the center for systems science and engineering (csse) at johns hopkins: global map. 2020. [cited 20/12/20] available from: https:// coronavirus.jhu.edu/map.html. 3. priyadarsini sl, suresh m. factors influencing the epidemiological characteristics of pandemic covid 19: a tism approach. international journal of healthcare management. 2020;13(2):89–98. 4. rabby mii. current drugs with potential for treatment of covid-19: a literature review. j pharm pharm sci. 2020;23(1):58–64. 5. cortegiani a, ingoglia g, ippolito m, giarratano a, einav s. a systematic review on the efficacy and safety of chloroquine for the treatment of covid-19. j crit care. 2020;57:279–83. 6. adhikari sp, meng s, wu y-j, mao y-p, ye r-x, wang q-z et al. epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review. infect dis poverty. 2020;9:29. 7. lewnard ja, lo nc. scientific and ethical basis for social-distancing interventions against covid-19. lancet infect dis. 2020; 20(6):631–3. 8. gadarian sk, goodman sw, pepinsky tb. partisanship, health behavior, and policy attitudes in the early stages of the covid-19 pandemic. ssrn e-journal. 2020. [cited 20/12/12] availabe from: https://dx.doi. org/10.2139/ssrn.3562796. 9. szymona-pałkowska k, janowski k, pedrycz a, mucha d, ambroży t, siermontowski p,et al. knowledge of the disease, perceived social support, and cognitive appraisals in women with urinary incontinence. biomed res int. 2016;2016:3694792. 10. nivette a, ribeaud d, murray a, steinhoff a, bechtiger l, hepp u, et al. noncompliance with covid-19-related public health measures among young adults in switzerland: insights from a longitudinal cohort study. soc sci med. 2021;268:113370. 11. saefi m, fauzi a, kristiana e, adi wc, muchson m, setiawan me,et al. validating of knowledge, attitudes, and practices questionnaire for prevention of covid-19 infections among undergraduate students: a rasch and factor analysis. eurasia j math sci tech ed. 2020;16(2):em1926. 12. ferdous mz, islam mds, sikder mdt, mosaddek asmd, zegarra-valdivia ja, gozal d. knowledge, attitude, and practice regarding covid-19 outbreak in bangladesh: an online-based cross-sectional study. plos one 2020;15(10):e0239254. 13. singh jp, sewda a, shiv dg. assessing the knowledge, attitude and practices of students regarding the covid-19 pandemic. journal of health management. 2020;22(2): 281–90. 14. casman c, kurniawan k, wijoyo eb, pradana aa. studi literatur: penolakan jenazah covid-19 di indonesia. jurnal kesehatan manarang. 2020;6(khusus):18–26. 15. islam mda, barna sd, raihan h, khan mdna, hossain mdt. depression and anxiety among university students during the covid-19 pandemic in bangladesh: a web-based cross-sectional survey. plos one. 2020;15(8):e0238162. 16. wang z, ma w, zheng x, wu g, zhang r. household transmission of sars-cov-2. journal of infection.2020; 81(1): 179–182. 17. sulistiadi w, slamet sr, harmani n. handling of public stigma on covid-19 in indonesian society. kesmas: national public health journal. 2020; special issue(1):70–6. 18. xu z, chen y, yu d, mao d, wang t, feng d,et al. the effects of exercise on covid-19 therapeutics: a protocol for systematic review and meta-analysis. medicine (baltimore).2020; 99(38): e22345. 19. bilezikian jp, bikle d, hewison m, lazaretti-castro m, formenti am, gupta a et al. mechanisms in endocrinology: vitamin d and covid-19. eur j endocrinol. 2020;183(5): r133–47. 20. harbourt de, haddow ad, piper ae, bloomfield h, kearney bj, fetterer d et al. modeling the stability of severe acute respiratory syndrome coronavirus 2 (sarscov-2) on skin, currency, and clothing. plos negl trop dis.2020;14(11): e0008831. amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 121amj. 2021;8(3):121–7 human papillomavirus infection and awareness of human papillomavirus vaccines among various ethnicities in libya salma korbag, issa korbag department of chemistry, college of arts and science, university of benghazi, al kufra, libya abstract background: human papillomavirus (hpv) plays a role in increasing the risk of cervical cancer and other cancers. this study aimed to explore the incidence of hpv infection among various ethnicities in libya. furthermore, awareness and knowledge of hpv vaccines in the community were explored. methods: a descriptive study was conducted to present hpv infection among cancer cases using the national cancer registry of libya year 2011–2020, including gender, skin color, and ethnicity. furthermore, awareness and knowledge of the hpv vaccines were assessed using questionnaires distributed through social media. data were presented in percentage. results: in total, there were 33,526 (58.1%) infected hpv-related cancers out of 57,620 cancer cases, of whom 25,296 (75.4%) were women and 8,230 (24.6%) were men. based on cancer sites, the incidence of hpv-related cancers among whites was higher (>63% and more) than blacks except for anal cancer, of which blacks had a slightly higher incidence (54% in females and 57% in males). based on ethnicity, native libyans such as tabu, touareg, and berbers had different cancer sites. moreover, the knowledge and awareness about hpv and related cancers were very poor among the population in libya. conclusions: although hpv cancers represent a high percentage of cancer burdens among libyans, awareness and knowledge on hpv and related cancer are lacking. better education and provision of the hpv vaccines for future generations may eliminate and reduce hpv-related cancers. keywords: anal cancer, cervical cancer, hpv, libya, sexually transmitted disease correspondence: salma korbag, department of chemistry, college of arts and science, university of benghazi, al kufra, libya, e-mail: salma.omar46@yahoo.com introduction human papillomavirus (hpv) is a common sexually transmitted virus, infecting most women and men during their lives. based on the cancer potential, viruses are classified into high risk and low risk.1,2 in many cases, infection with the hpv occurs without the appearance of any symptoms. however, hpv infection may develop in various types of cancer in some women and men, in accordance with the target organ. about 70% of hpv16 and hpv-18 are at high risk of causing cervical cancer (cc), in addition to a subset of genital anal cancer especially in the vagina, vulva, anus, penis, and pharyngeal cancers.3,4 currently, there are three hpv vaccines available in the global market, that are highly effective against various hpv genotypes.5-9 the bivalent vaccine covers hpv-16 and hpv-18; whereas the quadrivalent vaccine covers also low-risk hpv-6 and hpv-11, next to the highrisk hpv-16 and hpv-18. moreover, five other extra high-risk genotypes of the nonavalent vaccines have been added, including hpv-31, hpv-33, hpv-45, hpv-52, and hpv-58. the protection against hpv infection is about nine years and a minimum of twenty years for high antibody concentration levels.10 many countries have started hpv vaccination programs, right after the introduction of hpv vaccines. for example, mexico had adopted the first quadrivalent hpv vaccine in 2006. the world health https://doi.org/10.15850/amj.v8n3.2250 althea medical journal. 2021;8(3) 122 althea medical journal september 2021 organization (who) had finally recommended routine vaccination against hpv in 2009. the actual effectiveness of hpv vaccines has become increasingly evident in countries with high vaccine absorption, especially in young women before exposure to hpv.11 at the population level, the effects of vaccination against hpv decrease the hpv prevalence, cellular abnormalities in the cervix, and genital warts (gws).12,13 the committee on immunization practices (cip) recommends that the vaccine should be administered routinely to females and males aged between 11 and 12; however, a study in this age group is limited.14,15 this study aimed to determine the prevalence of hpv infected cases in developing various cancers in libya in the past decade. furthermore, knowledge of hpv vaccines in the community was explored, hoping to educate various ethnicities in libya about different types of hpv infection in women and men, and awareness of vaccinations against hpv. methods this descriptive study had used nationally representative data from the national cancer registry of libya year 2011–2020, predominantly from the national hospital’s medical records. the incidence of hpv infection-associated cancer was stratified by gender, skin color, and ethnicity. as for ethnicity, the african native people in libya were tabu, touareg, and berbers; the asian was mostly arabs; the european were turks, caucasians, albanians, and armenians as shown in figure. since this investigation used secondary data freely available in the public domain where there was no mentioning of the sample identity, ethical approval was unnecessary. to assess hpv knowledge and vaccine in the community, twitter and facebook were used to recruit participants. a short validated questionnaire was distributed between 2019 and 2020 to explore the extent of citizens’ education and knowledge of vaccines against papillomavirus. the data was anonymously gathered, therefore, ethical approval was not required. data was further presented in percentage. results the total subjects registered hpv infections in the national registry from 2011 to 2020 were 57,620, including 72.8% cancer in females and 27.2% in males. furthermore, infected hpvrelated cancers was found in 33,526 (58.1%) of whom 75.4% (n=25,296) were females and 24.6% (n=8,230) were males (table 1). although there was variation in the exact number of hpv-related cancers in libya, data confirmed that hpv was associated with most cancers in the genital area, accounting for 60% and 52%, respectively, among females and males. of those hpv infection cases in women, figure libyan country and dominant ethnic groups althea medical journal. 2021;8(3) 123salma korbag, issa korbag: human papillomavirus infection and awareness of human papillomavirus vaccines among various ethnicities in libya table 1 incidence of human papillomavirus-related cancers based on infected organ site, stratified by gender in libya from 2011 to 2020 gender total all cancer site cases (n) (%) (%)*** female -all hpv-related cancers -other cancer total female ovaries cervix anus vulva oropharynx vagina 25,296 9,264 8,786 3,968 1,697 952 629 16,638 41,934 60* 40* 72.8** 36 35 16 7 4 2 male -all hpv-related cancers -other cancer total male oropharynx anus penis total 8,230 4,115 2,971 1,144 7,456 15,686 57,620 52* 48* 27.2** 100** 50 36 14 note. *percentage in total females (n=41,934) or males (n=15,686); **percentage of all hpv related cancers and other cancer (n=57,620); ***percentage in cancer site for all hpv related cancers in female (n=25,296) or males (n=8,230). the acceptability of hpv vaccination was explored, resulting in 63% who were willing to be vaccinated, whereas the other 37% were a negative their attitude regarding the vaccine. those unwilling to be vaccinated believed that they had no risk of developing hpv infection, genital warts, or even cervical cancer or other cancers. other 17% were worried that there was no use of the hpv vaccine in libya. respondents concerned with the safety and the efficacy of hpv vaccination accounted for 20%, participants who questioned the source of the vaccine and showed concern regarding the high price of the vaccine were 63%. more than 83% of participants agreed on educating the community about hpv infection and vaccines. discussion our study provided an important source of baseline data for hpv-related cancers in libya in the last decade 2011–2020. there were 58.1% infected hpv-related cancers of total 57,620 cancer cases in the national cancer registry, which predominantly (75.4%) affect women. through this report, it is advised to improve awareness of the hpv vaccine and to reduce the burden of hpv-related cancers and diseases. currently, approval by the libyan ministry of health and the libyan government to adopt the hpv vaccine is awaiting. vaccination against hpv may reduce the incidence of hpv-related cancers and precancerous lesions in libya, therefore, ovarian (36%) and cervical cancer (cc; 35%) alone represented predominantly of all hpvrelated cancers; whereas pharyngeal cancer accounted for 4%. on the contrary, oropharynx cancer in men accounted for 50% of total hpvrelated cancer (table 1). hpv-related cancers affected ethnic groups to varying degrees. generally, rates of hpv-associated cancers in whites (85%) were higher than in blacks (15%). based on the cancer site, the incidence of hpv-related cancers among whites was higher (>63% and more) than among blacks, except for anal cancer, where blacks had a slightly higher incidence (54% in females and 57% in males) (table 2). furthermore, stratifying by tribes, the incidence among natives, especially among tabu (1%) and touareg (2%), were considered consistently low, whereas the native berbers were high (33%) similarly to arabs (37%) and of european origin (27%). in gender stratification within ethnicity; ethnic differences were for some types of hpv-related cancers in which whites (85%) had a high incidence of pharyngeal cancer (77% females, 96% males). among women, whites had the highest incidence of ovary cancer (83%) and vulvar cancer (85%). tribes of tabu, touareg, and berbers had consistently lower rates (table 2). in a parallel study, a total of 300 respondents had completed the questionnaire, of whom only 0.125% were aware of and knew about the hpv vaccination (table 3). furthermore, althea medical journal. 2021;8(3) 124 althea medical journal september 2021 table 2 incidence of hpv-related cancers sites by ethnicities and gender in libya from 2011 to 2020 cancer site skin color ethnicity black white native asian origin (arabs) european origin n % n % tabu berber touareg n % n % n % n % n % hpv-related cancers in female: ovary cervix anus vagina vulva oropharynx 1,773 1,110 1,463 1,801 117 198 123 15 17 37 54 25 15 23 9,869 5,356 2,532 1,561 351 1,089 421 85 83 63 46 75 85 77 49 745 965 85 65 113 35 1 27 20 13 40 28 8 1,452 347 844 45 17 34 15 33 12 18 7 10 8 4 105 201 796 13 9 27 12 2 7 16 2 6 7 3 1,648 725 1,140 244 59 165 123 37 26 24 39 37 40 30 1,200 780 1,046 243 11 71 223 27 28 22 39 7 17 55 hpv-related cancers in male: penis anus oropharynx 814 109 951 129 16 11 57 4 4,390 880 730 2,987 84 89 43 96 126 89 170 32 6 15 15 3 215 2 161 211 10 0 14 21 0 2 10 154 0 0 1 16 928 287 330 229 42 46 28 23 907 245 480 372 42 39 42 37 note: color skin is divided into black and white. ethnicity is divided by native (tabu, berbers, touareg,); asian origin (arabs: yemenite gulf, levant, and iraq); european origin (turks, caucasians, albanians, and armenians). initial responses to the hpv vaccination within the libya public are favorable. not surprisingly, it sparked debate about data on hpv and related cancers in men and women, suggesting that hpv infection contributed to anal, penile, pharyngeal, and other cancers; given the specific link between hpv and penile, anal and pharyngeal cancer found in men who had sex with men. the incidence of cancer-related hpv infection is high among libyan women. the rate of anal cancer is higher in men, about 36%; while the pharyngeal or oropharynx cancer rate is about 50% higher. for all combinations of hpv and penile-related sites, the rate is in the 14% range (table 1). the incidence of hypopharyngeal cancer among men is two times higher than that of women. interestingly, the increased incidence of men might be due to several factors, including smoking and alcohol use which are both responsible for hypopharyngeal cancer.16,17 furthermore, the cancer rate might be high due to sexual behavior and unhealthy diets. however, the pattern of hpv-associated cancers seemed to affect men only. as for cervical and ovarian cancer in women, which have higher rates, sexual behavior and genetic factors might be the predominant risk factors. the results have shown that men are more susceptible to pharyngeal cancer for several reasons and factors, including hpv and smoking, alcoholic beverages, and drugs. moreover, blacks have a high incidence of anal cancer (47% females, 57% males) and europeans (42%), while arabs (46%), and europeans (39%) have a high incidence of penile cancer. all hpv-related cancers have covered nearly all types of cervical cancer and some types of cancers of the vulva, vagina, penis, anus, and pharynx. as for the pharynx, hpv might infect the back of the throat, base of the tongue, and tonsils. interestingly, the medical records noted that there were patients with two or more types of genital cancers such as ovarian and uterine cancer, or otherwise with another site such as colorectal and ovarian cancer at the same time. moreover, there were those afflicted with two types such as uterine, renal cell carcinoma (rcc) and cancer of unknown primary (cup); also, ovarian and cup, nonhodgkin lymphoma (nhl) and cervix cancer; otherwise, vagina and cervix; bladder, ovary, cervix cancers; (ovarian, gastrointestinal cancer and cup; ca-125 ovarian and uterine; rectal cancer, colon cancer, ovary), and others. we did not find the explanation for these cases, althea medical journal. 2021;8(3) 125salma korbag, issa korbag: human papillomavirus infection and awareness of human papillomavirus vaccines among various ethnicities in libya as it was unknown why cancer appeared in two or more genitals and other organs in the same patient. perhaps, there was a link between several factors such as early marriage, sexual disorder, reproduction, frequent miscarriages, early sexual life, diet, race, and homosexuals with two or more sex partners. to hypothesize, this may occur due to an interaction between environmental and genetic factors, leading to abnormal gene expression and hpv infection. table 3 knowledge and awareness around hpv and hpv vaccine knowledge statement answer gender know do not know female male n % n % n % n % history of papillomavirus (hpv) related lesions 300 100 hpv infection is widespread 300 100 hpv can cause serious diseases 300 100 hpv can infect both genders 4 1 296 96 1 3 most hpv infected people develop cancer 3 1 297 97 1 2 hpv can lead to genital warts (gws) 300 100 gws affect both genders 300 100 hpv-related with penile cancer 300 100 hpv-related with cc 300 100 hpv infection transmission through sexual intercourse 300 100 early sexual debut increases the risk of contracting hpv 300 100 using condoms reduces the risk of hpv transmission 300 100 a high number of sexual partners increases the risk of contracting hpv 300 100 hpv infection transmitted from mother to child during pregnancy and delivery 1 1 299 100 1 hpv infection transmission from a carrier to his/ her partner only if the carrier shows symptoms 300 100 a person may be hpv-infected and is unaware 5 2 295 97 3 1 there are no specific therapies for hpv infection 300 100 heard about hpv vaccine 2 1 296 98 2 1 anti-hpv vaccine is safe 1 1 299 100 1 both genders can be vaccinated against hpv 2 1 298 99 1 1 hpv vaccine is effective after starting sexual activity 300 100 anti-hpv vaccination must be mandatory for boys and girls before the sexual debut and for at risk subjects 300 100 ages recommended the vaccines between 9 to 12 300 100 anti-hpv vaccines are capable of preventing the occurrence of cc and gws 3 1 297 97 1 2 total % 0.125 99.875 althea medical journal. 2021;8(3) 126 althea medical journal september 2021 thus, functional changes to oncogenes play a significant role in the occurrence and evolution of hpv-16 and hpv-18 rates associated with rates of estrogen receptor (er), progesterone receptor (pr), tumor protein p53, and ki67 infection. moreover, hpv also destroys the normal sex hormone function, which weakens the antiestrogenic effect of progesterone in the organs and increases the malignant transformation of cells. hpv may induce cell cycle activity of ki67 positive cells; as the expression level of ki67 increases, the numbers of copies of hpv also increase. there is no logical explanation for having multiple carcinomas in different organs of the same person. based on the cancer site, the incidence of hpv-related cancers among whites was higher (>63% and more) compared to blacks, except in anal cancer, of which blacks had a slightly higher incidence (54% in females and 57% in males). oropharynx cancer was higher in white men (96%) than in white women (77%). based on ethnicity, native libyans such as tabu, touareg, and berbers had different cancer sites. the challenge of this study was the community’s awareness of hpv-related cancers and vaccines against hpv. the knowledge and awareness of hpv and related cancer were inadequate among the population in libya. libyan-born tabu and berbers had the lowest hpv positivity in fewer hpv risk behaviors, including early age at first sexual intercourse, multiple sexual partnerships, and current smoking. the congruent genotypes and the biological factor might be responsible for hpv infection, and prevention of hpv depended on the awareness and promotion of vaccines against hpv and the number of doses allowed according to types of hpv vaccination. in high-risk hpvs, viruses that have a high possibility to develop cancer, include genotype hpv 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59; of which two genotypes are the most prevalent, which are genotype hpv 16 and 18, causing the majority of hpv-linked cancers.14,15 there are vaccines for hpv available, which cover high-risk hpv genotype 16 and 18 (2-valent), and another one also covers lowrisk hpv genotype 6 and 11 (4-valent). genital warts, predominantly caused by low-risk hpv genotype 6 and 11, are not carcinogenic. recently, the 9-valent (gardasil 9) vaccine is available consisting of 9 genotypes hpvs (6, 11, 16, 18, 31, 33, 45, 52, and 58).18 a two-dose series of hpv vaccines for both genders should be given as early as nine years.19 in addition, a three-dose series may be given to those who start the vaccine series at age 15 or older, and to people with certain weakened immunity. vaccination against hpv is also recommended up to 26 years for women and 21 years for men who have not received adequate vaccinations. thus, adolescents should be vaccinated before exposure to hpv infection or be sexually active. interestingly, most women under the age of 30 can self-clear hpv infection on their own within a few months or years. the vaccine will not eliminate hpv infection. besides, the vaccine does not protect against all types of hpv, therefore, even women who are already vaccinated, still need to have regular pap and pelvic exams, as the vaccine’s effectiveness is not known yet. there is a lack of knowledge and awareness of hpv infection and vaccines, therefore, educational initiatives are essential. the importance of organized enlightenment for health care workers and the media, who are the most preferred sources of information, is imperative. due to the low knowledge level, the media and health professional promotion need to raise awareness. this study used secondary data, so it faced several limitations, among others; the data was not supported by the age of the respondents. a better database in age groups could further support cancer management as cancer-related hpv infection was significant among different age groups. to conclude, hpv-related cancer has infected 60% of women and 52% of men. ovarian and cervical cancers in women are the predominant cases, and the oropharynx and anal are more prevalent in men. although hpv cancers represent a high percentage of the cancer burden among libyans, knowledge and awareness on hpv and related cancers are lacking. better education and provision of hpv vaccines for future generations may eliminate and reduce hpv-related cancers. furthermore, due to low knowledge levels, media and the promotion of health professionals must raise community awareness. references 1. giuliano ar, lu b, nielson cm, flores r, papenfuss mr, lee jh, et al. age-specific prevalence, incidence, and duration of human papillomavirus infections in a cohort of 290 us men. j infect dis. 2008;198(6):827–35. 2. korbag s, korbag i. a new study biological role of hpv infection, oral contraceptive althea medical journal. 2021;8(3) 127 use, sex hormones and bisphenol a and increase rate cancer of cervical in libya. j. med chem sci. 2020;3(4):354–62. 3. petrosky e, bocchini jr. ja., hariri s, chesson h, curtis cr, saraiya m, et al., use of 9-valent human papillomavirus (hpv) vaccine: updated hpv vaccination recommendations of the advisory committee on immunization practices. mmwr morb mortal wkly rep. 2015; 64(11): 300–4. 4. brianti p, de flammineis e, mercuri sr. review of hpv-related diseases and cancers. new microbiol. 2017;40(2):80–5. 5. brewer nt, fazekas ki. predictors of hpv vaccine acceptability: a theory-informed, systematic review. prev med. 2007;45(2– 3):107–14. 6. stanley m. hpv vaccination in boys and men. hum vaccin immunother. 2014;10(7):2109–11. 7. bharadwaj m, hussain s, nasare v, das bc. hpv & hpv vaccination: issues in developing countries. indian j med res. 2009;130(3):327–33. 8. st laurent j, luckett r, feldman s. hpv vaccination and the effects on rates of hpv-related cancers. curr probl cancer. 2018; 42(5):493–506. 9. centers for disease control and prevention (cdc). recommendations on the use of quadrivalent human papillomavirus vaccine in males—advisory committee on immunization practices (acip), 2011. mmwr morb mortal wkly rep. 2011; 60(50):1705–8. 10. parkin dm, bray f. chapter 2: the burden of hpv-related cancers. vaccine. 2006; 24 suppl 3:s3/11–25. 11. mcbride kr, singh s. predictors of adults’ knowledge and awareness of hpv, hpvassociated cancers, and the hpv vaccine: implications for health education. health educ behav. 2018;45(1):68–76. 12. winer rl, lee sk, hughes jp, adam de, kiviat nb, koutsky la. genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. am j epidemiol. 2003;157(3):218–26. 13. moscicki ab, schiffman m, kjaer s, villa ll. chapter 5: updating the natural history of hpv and anogenital cancer. vaccine. 2006;24 suppl 3:s3/42–51. 14. wilkin t, lee jy, lensing sy,stier ea, goldstone se, berry jm, et al. safety and immunogenicity of the quadrivalent human papillomavirus vaccine in hiv-1-infected men. j infect dis. 2010; 202(8):1246–53. 15. chin-hong pv, palefsky jm. natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus. clin infect dis. 2002;35(9):1127–34. 16. palefsky jm. human papillomavirusrelated disease in men: not just a women’s issue j adolesc health. 2010;46(4 suppl):s12–9. 17. wendland em, kops nl, comerlato j, horvath jdc, bessel m, sperb d, et al. stop hpv study protocol: a nationwide casecontrol study of the association between oropharyngeal cancer and human papillomavirus (hpv) infection in brazil. bmj open. 2020;10(1):e031602. 18. signorelli c, odone a, ciorba v, cella p, audisio ra, lombardi a, et al. human papillomavirus 9-valent vaccine for cancer prevention: a systematic review of the available evidence. epidemiol infect. 2017;145(10):1962–82. 19. stanley ma, sudenga sl, giuliano ar. alternative dosage schedules with hpv virus-like particle vaccines. expert rev vaccines. 2014;13(8):1027–38. salma korbag, issa korbag: human papillomavirus infection and awareness of human papillomavirus vaccines among various ethnicities in libya althea medical journal. 2021;8(1) 56 althea medical journal march 2021 patient satisfaction on surgical service decision time in emergency department of a tertiary hospital in indonesia shabrina adzania,1 nucki nursjamsi hidajat,2 elsa pudji setiawati2 1faculty of medicine universitas padjadjaran, indonesia, 2department of orthopedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: shabrina adzania, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, email: shabrina.adzania@gmail.com introduction patient satisfaction is often used as an imperative source of information to evaluate and develop a plan to improve health services’ quality.1 patient satisfaction is associated with patient compliance undergoing therapy and patients’ tendency to choose their healthcare provider.2,3 the emergency department (ed) has to maintain the quality of its services to deliver effective and efficient patient care. among all of the emergency cases, surgical patients with emergency conditions have a high risk of getting complications after procedures, medical errors, and death.4 at least 60% of surgical cases in lower-middle income countries are emergency.5 decision time is one of the service quality indicators that is being evaluated in the surgical services of the ed. the study from iran shows that emergency patients’ satisfaction score has a negative correlation with the dimension of time.6 the objectives of this study were to evaluate the patient satisfaction receiving surgical services in the emergency department of dr. hasan sadikin general hospital, the top referral hospital in west java indonesia, and to assess its correlation with surgical services decision time. methods a descriptive-analytic study with a crosssectional design was conducted from september to november 2019. the ethical amj. 2021;8(1):56–62 abstract background: patient satisfaction survey is essential for evaluating and developing plans to improve health services’ quality. one of the emergency department service quality indicators is decision time. overcrowding of the emergency room as a result of long decision time may cause dissatisfaction among patients. this study aimed to evaluate the satisfaction level of patients receiving surgical services and the correlation between the satisfaction level and surgical service decision time. methods: a cross-sectional descriptive analytical study was conducted from september to november 2019 at the emergency department of dr. hasan sadikin general hospital. the consecutive sampling method was applied and a total of 110 patients met the inclusion and exclusion criteria. patient satisfaction was assessed using a validated questionnaire and data on decision time was obtained from the patient’s medical record. spearman correlation test was used to analyze the data. result: this study discovered that most of the respondents were satisfied with the service (92.7%) and that decision was mostly made in less than 2 hours (79.1%). a weak negative correlation (ρ=0.144), was identified between decision time and patient satisfaction, albeit insignificant (p=0.067), with a confidence interval of 95% (α=5%). conclusions: this study suggested that there is no correlation between patient satisfaction and decision time. thus, decision time is not the main factor that determines patient satisfaction. keywords: decision time, emergency department, patient satisfaction, service quality, surgery https://doi.org/10.15850/amj.v8n1.2025 althea medical journal. 2021;8(1) 57 approval number from the research ethics committee of universitas padjadjaran was 1015/un6.kep/ec/2019. the population of the study was 6,903 patients receiving surgical services at ed in 2018. after the calculation of the sample for the analytic correlative study, a minimum sample of 92 respondents was set.7 primary data of satisfaction was obtained from the patient or relative with a consecutive sampling method. the inclusion criteria of the study were patients that received surgical services with determined decision time and willing to give their consent. the exclusion criteria of the study were unconscious patient without a relative, patients aged under 18 years old, and patients without decision time data. the respondents signed the informed consent form after the researcher explained the procedure and objectives of the study. a selfadministered ed specialized questionnaire that was translated into the indonesian language was used.6 this questionnaire had undergone reliability and validation testing previously. the cronbach’s alpha reliability coefficient of the translated instrument was 0.957 and every item of the questionnaire was valid with pearson product-moment correlations ranged from 0.438 to 0.935. after the respondents filled in the ed specialized questionnaire, demographic data were obtained. secondary data of decision time was obtained from the medical record of ed patients. this study used this specialized instrument to obtain data as specific and valid as possible. the patient’s relatives’ judgment regarding the ed services was considered to be able to describe the patients’ judgment because of the emotional attachment of patients and their relatives in ed settings. patient satisfaction was categorized into satisfied and not satisfied. the category was based on the average total score of the questionnaire. the hospital service quality standards categorized decision time into <2 hours and ≥2 hours. decision time in less than 2 hours was considered as good service. when the patient came to the ed, they were approached by the triage staff and categorized based on the triage indicator. after that, they were sent to the surgical ward or medical ward where they got further examinations and treatments. decision time was the time duration since the patient had come to the surgical ward or medic ward of ed until the decision of hospitalized, surgery in the operation room, or discharge from the hospital. this study focused on ed surgical ward patients. the hospital put standard indication to be achieved at a minimum of 85% patients for decision time and patient satisfaction level. hospitalized patients were those who were admitted to the inpatient ward or intermediate high care unit. discharged patients were those who voluntarily go home or refused to be treated. as weekday admissions, monday to friday were considered. all saturdays and sundays were considered weekend admissions. admission shift was categorized into the morning, afternoon, and night with the ranged time between 7 am to 2 pm, 2 pm to 9 pm, and 9 pm to 7 am, respectively. statistical analysis was implemented to determine the frequency distribution and association of the variables. spearman’s rank correlation test was used to determine the correlation between variables with a confidence interval of 95% was defined as statistically significant. results a total of 110 subjects that met inclusion and exclusion criteria were analyzed. the data excluded were those who had filled the questionnaire before the decision time was determined (n=5) and subjects without decision time data (n=2). most of the respondents were the patient’s relative with a proportion of 96.4%. table 1 summarized the demographic characteristics of the respondents. there were more female respondents (62.7%) than male respondents. the majority of the group was in the age range of 30–64 years old. the respondents in the age range of 18–29 years old were the most satisfied (93.5%). when classified by educational level, the majority of the respondents went to high school or lower education (79.8%) with a satisfied category proportion at 98.9%. most of the dissatisfied respondents came from those who went to university (33.3%). the results of the study showed that the majority of patients visiting the ed paid with insurance (70%). the satisfaction rate was higher for those who belong to the fee for services group (97%). based on the decision time, patients with insurance had a higher number in receiving decision time of fewer than 2 hours (79.2%). the average of respondents on weekday was 16 subjects; whilst in the weekend was 13 subjects. most of the respondents on weekends and weekdays were satisfied with the services with a higher proportion on weekend admissions (96.3%) than weekday admissions shabrina adzania et al.: patient satisfaction on surgical service decision time in emergency department of a tertiary hospital in indonesia althea medical journal. 2021;8(1) 58 althea medical journal march 2021 table 1 demographic characteristics of respondents demographic characteristic n % decision time patient satisfaction <2 hours ≥2 hours satisfied not satisfied n % n % n % n % respondent patient relative 4 106 3.6 96.4 3 84 75.0 79.2 1 22 25.0 20.8 4 98 100 92.5 0 8 0 7.5 gender male female 41 69 37.3 62.7 33 54 80.5 78.3 8 15 19.5 21.7 37 65 90.2 94.2 4 4 9.8 5.8 age (years) 18-29 30-64 31 79 28.2 71.8 26 61 83.9 77.2 5 18 16.1 22.8 29 73 93.5 92.4 2 6 6.5 7.6 educational level did not go to school high school or lower university missing 1 87 21 1 0.9 79.8 19.3 0.9 1 69 16 100 79.3 76.2 0 18 5 0 20.7 23.8 1 86 14 100 98.9 66.7 0 1 7 0 1.1 33.3 payment insurance fee for services 77 33 70.0 30.0 61 26 79.2 78.8 16 7 20.8 21.2 70 32 90.9 97.0 7 1 9.1 3.0 admission day weekday weekend 83 27 75.5 24.5 67 20 80.7 74.1 16 7 19.3 25.9 76 26 91.6 96.3 7 1 8.4 3.7 admission shift morning afternoon night missing 31 63 15 1 28.4 57.8 13.8 0.9 26 50 10 83.9 79.4 66.7 5 13 5 16.1 20.6 33.3 29 58 14 93.5 92.1 93.3 2 5 1 6.5 7.9 6.7 first time in er* yes no missing 70 39 1 64.2 35.8 0.9 54 32 77.1 82.1 16 7 22.9 17.9 66 35 94.3 89.7 4 4 5.7 10.3 decision released hospitalized surgery missing 21 55 31 3 19.6 51.4 29.0 2.7 17 43 24 81.0 78.2 77.4 4 12 7 19.0 21.8 22.6 20 49 30 95.2 89.1 96.8 1 6 1 4.8 10.9 3.2 *emergency room of dr. hasan sadikin general hospital (91.6%). the majority of the respondents came in the afternoon shift (57.8%), and was satisfied with the services irrespective of their admission shift. most of the patients’ decision time was less than 2 hours regardless of their payment method, admission day, and admission shift. the respondents had their first time in ed (64.2%), and most of the patients were hospitalized after receiving surgical services in ed (51.4%). based on patient satisfaction, the highest rate of dissatisfied patients belonged in those who were hospitalized (10.9%). the data showed that 92.7% of the study subjects were satisfied with the services (table 2). based on the decision time categories, 79.1% of the patients met the service quality indicator of fewer than 2 hours. althea medical journal. 2021;8(1) 59shabrina adzania et al.: patient satisfaction on surgical service decision time in emergency department of a tertiary hospital in indonesia table 3 patient satisfaction level regarding 20 items of questionnaire statements s* nurses care about my treatment 94% nurses inform me about the remaining the treatment 95% nurses attended to me patiently 92% nurses relieved me of the pain well 90% admission staff guided me appropriately 93% the behavior of the admission staff was suitable 96% the environment of the emergency room was calm and quiet 68% the emergency room was well equipped 88% the environment of the emergency room was hygienic 72% the physician told me about my treatment course 92% the behavior of the physician was respectful 94% the physician’s explanation about the remaining treatment was enough 93% the physician spent a sufficient time examining me 89% the waiting time before seeing the doctor was appropriate 82% the waiting time before the admission process was appropriate 86% i would recommend this hospital to my acquaintances 89% i am satisfied with the quality of services in the emergency room 84% the emergency room of this hospital is well functioning 93% the family of the patient is respected in this hospital 89% the family can spend an appropriate amount of time beside the patient 94% note: *s = percentage of satisfied respondents with an average total score range between 2.51-4.00 analysis of the items of the patient satisfaction questionnaire showed that most of the respondents felt satisfied with every item (table 3). the highest satisfaction percentage referred to an item that states “the behavior of the admission staff was suitable’’ (96% of the respondents are satisfied). the lowest satisfaction percentage referred to an item that states “the environment of the emergency room was calm and quiet” (68% of the respondents are satisfied) followed by “the environment of the emergency room was hygienic” (72% of the respondents are satisfied). bivariate analysis indicated that decision time and patient satisfaction had a negative correlation (ρ=-0.144). spearman’s rho showed a weak correlation between the variables. the table 2 frequency distribution of decision time and patient satisfaction n % decision time <2 hours ≥2 hours total 87 23 110 79.1 20.9 100 patient satisfaction satisfied not satisfied total 102 8 110 92.7 7.3 100 althea medical journal. 2021;8(1) 60 althea medical journal march 2021 correlation between patient satisfaction and decision time was not statistically significant with p-value= 0.067 (ci=95%) (table 4). discussion this study has shown that most of the subjects are satisfied with the health services provided in the emergency department of dr. hasan sadikin general hospital. the finding is similar to a study in the usa among trauma patients,8 as well as a study in palestine that shows a high overall satisfaction of ed patients.9 the measurement of healthcare service quality felt by the patient is defined as patient satisfaction.6 other than the achieved standard of satisfaction indicator, most of the subjects have a decision time of fewer than 2 hours. however, our result has shown an insignificant correlation between decision time and patient satisfaction. this intriguing finding is contrary to previous studies, suggesting a significant relationship between patient satisfaction and time-related service quality indicators.6,9–13 most of the respondents in our study are the relatives of the patients, as conducted in other studies.11,6 the majority of our respondents are female similar to another study in medan, indonesia.12 however, in some other places such as in iran the majority of relatives in the study are male, aged older than 30 years old.11,14 similar to study in lampung, indonesia, the majority of subjects is ranged within 18–29 years old and they are more satisfied with the services rather than respondents from the age group of 30–64 years old,13 however, a study in the usa8 shows otherwise, that younger respondents gave low patient satisfaction scores. similar to another study on ed in indonesia and iran, the majority of the respondents have an education level of high school or lower education.11,13 the frequency of dissatisfied respondents is highest on those who have to university background, similar to the result in another study in iran.11 most of the respondents paid for the services with insurance. the satisfaction rate is higher in the fee for the services group. the respondents with insurance were satisfied with the service and there is a significant relationship between hospital service quality and insurance patient satisfaction.15 most of the respondents in our study have come on a weekday and in the afternoon shift. interestingly, in other studies most of the respondents have come on vacation days and night shift.14 in the present study, most of the patients are further hospitalized, whereas in studies in iran most of the ed patients are discharged.11,14 the emergency department is one of the hospital services that provide first treatment for the patient who comes on his own to the hospital or the continuation of services for referred patient or patients came with the public safety center. it has a role to give accurate, fast, and careful emergency services. the services must be available for wide-range of socioeconomic levels and corresponding to people’s needs.16 due to its unique dynamic of works, ed has an important role in affecting patient satisfaction. this also indicated that a specialized instrument to measure ed patient satisfaction level is needed.6 the percentage of distribution of the answers to questionnaire items shows that the highest satisfaction percentage refers to items that describe the ed staff, which is considered high.9,11 interestingly, this study shows that the lowest satisfaction percentage refers to items described in the environment of ed, in opposite to the study in palestine that ed environment has been considered to have a high rank of satisfaction.9 the study in iran hospital ed shows that items referring to ed environment cleanness and neatness have a low satisfaction level, similar to our study.11 the physical aspects of ed are on the average level of satisfaction with the highest level on the cleanliness of ed.14 patient satisfaction can be reviewed based on various aspects. based on hospital management, decision time is a quality indicator that has implications for the patient. however, satisfaction is multidimensional.17 thus, patient satisfaction is not only defined table 4 bivariate analysis on decision time and patient satisfaction variable category satisfied not satisfied ρ p-value* n % n % decision time <2 hours 79 77.5 8 100 0.144 0.067 ≥2 hours 23 22.5 0 0 notes: *not statistically significant with ci of 95%. althea medical journal. 2021;8(1) 61shabrina adzania et al.: patient satisfaction on surgical service decision time in emergency department of a tertiary hospital in indonesia by decision time. this study discovers decision time is not the main factor affecting patient satisfaction and had a weak correlation which was not statistically significant. this also indicated that further research is needed to determine factors affecting surgical patient satisfaction. there is a strong correlation between physician interpersonal skills and patient satisfaction.18 various studies have found a significant relationship between patient satisfaction and response time, service procedure, also ed environmental coziness.12,13 repeated information from staff regarding the delayed medical examination received by the patients has a positive effect on satisfaction level in comparison with not receiving any information. this study has measured patient satisfaction based on their perception of every aspect of emergency department satisfaction on the questionnaire. another study in ed with the servqual approach has shown that there is a significant relationship between patient satisfaction with dimensions of reliability, responsiveness, tangibility, assurance, and empathy. the tangibility is the dominant variable in determining patient satisfaction.19 the limitation of the study is among others the number of human resources and data collection time. due to the unique dynamic of the ed and patient or relative emotional situation, there is a quite long time gap between visit time and the ethically appropriate condition for the researcher to approach the patients. in conclusion, there is no correlation between patient satisfaction and decision time. additionally, decision time is not the main factor in determining patient satisfaction. most of the respondents are satisfied with the services. further studies to discover factors affecting patient satisfaction in the emergency department are needed. moreover, the health care provider should maintain and improve health services quality, focusing on satisfaction items. references 1. al-abri r, al-balushi a. patient satisfaction survey as a tool towards quality improvement. oman med j. 2014;29(1):3–7. 2. finch t, shim tn, roberts l, johnson o. treatment satisfaction among patients with moderate-to-severe psoriasis. j clin aesthet dermatol. 2015;8(4):26–30. 3. fatima t, malik sa, shabbir a. hospital healthcare service quality, patient satisfaction and loyalty: an investigation in context of private healthcare systems. international journal of quality & reliability management. 2018;35(6):1195–214. 4. havens j, peetz a, do w, cooper z, kelly e, askari r, et al. the excess morbidity and mortality of emergency general surgery. j trauma acute care surg. 2015;78(2):306– 11. 5. mccord c, ozgediz d, beard jh, debas ht. general surgical emergencies. in: debas ht, donkor p, gawande a, jamison dt, kruk me, mock cn, editors. essential surgery: diseases control priorities. 3rd ed (volume 1). washington, dc: world bank publication; 2015. chapter 4. p. 61–76. 6. atari m, atari m. brief emergency department patient satisfaction scale (bepss); development of a new practical instrument. emerg (tehran). 2015;3(3):103–8. 7. dahlan ms. besar sampel dalam penelitian kedokteran dan kesehatan. jakarta: epidemiologi indonesia;2016. 8. rogers f, horst m, to t, rogers a, edavettal m, wu d, et al. factors associated with patient satisfaction scores for physician care in trauma patients. j trauma acute care surg. 2013;75(1):110–4. 9. amro n, kamel ama, qtait m, yagi h, amro b, amro r, et al. factors affect patients satisfaction in emergency departments in palestine. journal of health, medicine and nursing. 2018;54:50–6. 10. messina g, vencia f, mecheroni s, dionisi s, baragatti l, nante n. factors affecting patient satisfaction with emergency department care: an italian rural hospital. glob j health sci. 2014;7(4):30–9. 11. soleimanpour h, gholipouri c, salarilak s, raoufi p, vahidi rg, rouhi aj, et al. emergency department patient satisfaction survey in imam reza hospital, tabriz, iran. int j emerg med. 2011;4:2. 12. sinurat s, perangin-angin ih, sepuh jcl. hubungan response time perawat dengan tingkat kepuasan pasien bpjs di instalasi gawat darurat. jurnal penelitian keperawatan. 2019;5(1):1–9. 13. nurlina d, rifai a, jamaluddin j. faktorfaktor yang memengaruhi kepuasan pasien instalasi gawat darurat rumah sakit tni ad tk iv 02.07. 04 bandar lampung tahun 2017. jurnal ilmu kesehatan masyarakat. 2019;8(03):78–88. 14. eshghi m, rahmani f, derakhti b, abdollahi f, tajoddini s. patient satisfaction in the althea medical journal. 2021;8(1) 62 althea medical journal march 2021 emergency department: a case of sina hospital in tabriz. journal of emergency practice and trauma. 2016;2(1):15–20. 15. yuniarti s. hubungan antara kualitas pelayanan rumah sakit dengan tingkat kepuasan pasien bpjs di ruang perawatan rsud sultan syarif mohamad alkadrie kota pontianak tahun 2015. jurnal proners. 2015;3(1):11039. 16. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 47 tentang pelayanan kegawatdaruratan. jakarta: kementerian kesehatan republik indonesia; 2018. 17. goddard gj, raab g, ajami ra, gargeya vb. customer relationship management: a global perspective. hampshire, england: gower publishing limited;2012. 18. soremekun oa, takayesu jk, bohan sj. framework for analyzing wait times and other factors that impact patient satisfaction in the emergency department. j emerg med. 2011;41(6):686–92. 19. septiani a. pengaruh faktor-faktor kualitas pelayanan terhadap kepuasan pasien di instalasi gawat darurat rsud kabupaten sumedang. coopetition. 2016;7(1):1–22. amj vol 7 no 3 september edited.indd althea medical journal. 2020;7(3) 136 amj september 2020 clinical characteristics of rhabdomyosarcoma in children: a 4-year study in a tertiary hospital in indonesia lelani reniarti,1 nur fatharani,2 nur suryawan1 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia correspondence: lelani reniarti, department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur 38, bandung, west javaindonesia, e-mail: lelanir@yahoo.com introduction rhabdomyosarcoma (rms) is the most common soft-tissue sarcomas (sts) and the third most common solid extracranial tumor in children.1,2 incidence of rms in india accounts for around 1 to 4.5% of all malignancies in children.3 each year, approximately 350 children are diagnosed with rms in the united states,4 while in jakarta, indonesia, the study has shown that there are only 44 rms cases in 8-years time and 11 rms cases in 4 years at dr. cipto mangunkusumo general hospital and dharmais cancer hospital, respectively.5,6 rms is originated from embryonic mesenchyme that differentiates into striated or skeletal muscle.7 therefore, rms could rise anywhere throughout the human body where there is skeletal muscle or not such as the urinary bladder, bile ducts, etc.8 the symptoms are not always in the form of a lump. the clinical presentations depend on the primary location of the tumor where the majority of symptoms are related to the compression of local structures by the masses and may cause organ-specific symptoms.8 this non-specific pattern could complicate rms detection and cause a diagnostic delay.1,9 survival rate of children with rms has increased from 25% in 1970 to 70% in 2001. however, mortality rates remain significantly higher in developing countries than in developed countries. this may also be attributable to the high frequency of detection and diagnostic delays among them.10 currently, research and literature studies on the clinical characteristics of rhabdomyosarcoma in indonesia are very limited. this study aimed to describe the clinical characteristics of rhabdomyosarcoma in children admitted at dr. hasan sadikin general hospital, bandung. amj. 2020;7(3):136–41 abstract background: rhabdomyosarcoma (rms) is the most common soft-tissue sarcomas (sts) in children. even though the survival rate has increased, the mortality rates remain significantly higher in developing countries due to delay in diagnosis contributed by its diverse and clinical manifestations. this study aimed to describe the clinical characteristics of rms patients at the department of child health, dr. hasan sadikin general hospital, bandung, indonesia. methods: a descriptive cross-sectional retrospective study was conducted using a total sampling method on medical records of rms patients aged ≤ 18-year-old during a 4-year period (2015-2018). data on patient demographics, clinical manifestations, biopsy procedure, histopathological subtype, tumor size, primary site, pre-treatment staging, and treatment were reviewed and presented. results: of 30 data retrieved, male (57%), aged 1 to 5-year-old (47%), and diagnosed through open biopsy (63%) comprised the majority of the patients. more than half of the patients came with advanced stage of the disease (80%) and were treated with chemotherapy (83%). most rms patients had a tumor located in the head and neck region (40%) with a size of >5 cm (70%) and embryonal subtypes (43%). the remaining patients experienced alveolar subtype (17%), spindle cell subtype (13%), and unknown subtype (27%) of rms. conclusions: children with a tumor in the head and neck region should be suspected as rhabdomyosarcoma, as there are various clinical characteristics of rms in children found in this study. keywords: clinical characteristics, primary site, rhabdomyosarcoma https://doi.org/10.15850/amj.v7n3.1871 althea medical journal. 2020;7(3) 137 methods this study was performed at dr. hasan sadikin general hospital, a tertiary hospital in bandung, west java, indonesia using a descriptive cross-sectional design and total sampling method. a retrospective analysis was performed on medical records of children (n=40) who were diagnosed with rms through biopsy during the period of 2015–2018. incomplete medical records were excluded (n=10). the medical records were reviewed for patient identities, clinical manifestations, biopsy procedure, histopathological subtype, tumor size, primary site, tnm staging, and treatment. tumor size had been used in evaluation for pre-treatment tnm staging according to children’s oncology group soft-tissue sarcoma committee’s (cog-sts).11 the histological subtype classification used in this study was based on the newest classification table 1 clinical manifestations of children with rhabdomyosarcoma clinical manifestations n % painless mass/lump/swelling 24 80 local pain 3 10 proptosis 3 10 ophthalmoplegia 1 3 spontaneous bleeding 3 10 epistaxis 1 3 nasal congestion 1 3 vomiting 1 3 urinary obstruction 1 3 convulsions 1 3 pale 2 7 limb weakness 2 7 figure age of children with rhabdomyosarcoma lelani reniarti et al.: clinical characteristics of rhabdomyosarcoma in children: a 4-year study in a tertiary hospital in indonesia althea medical journal. 2020;7(3) 138 amj september 2020 table 2 clinical characteristics of childhood rhabdomyosarcoma clinical characteristics n % gender male 17 57 female 13 43 age (years old) ≤1 2 7 >1–5 14 47 >5–10 3 10 >10–15 6 20 >15–18 5 17 biopsy procedure open biopsy 19 63 fnab 11 37 tumor size ≤5 cm 6 20 >5 cm 21 70 not specified 3 10 histopathological subtype embryonal 13 43 alveolar 5 17 spindle cell 4 13 not specified 8 27 primary site head and neck 12 40 trunk 5 17 urogenital tract 5 17 extremities 8 27 tnm staging ii 1 3 iii 6 20 iv 18 60 not specified 5 17 treatment operation 1 3 chemotherapy 14 47 operation-chemotherapy 10 33 operation-radiation 1 3 chemotherapy-radiation 1 3 not given 3 10 note: fnab= fine-needle aspiration biopsy althea medical journal. 2020;7(3) 139lelani reniarti et al.: clinical characteristics of rhabdomyosarcoma in children: a 4-year study in a tertiary hospital in indonesia from who (2013).12 pre-treatment staging used a modified tnm system based on the primary site, either favorable or unfavorable site.7 this study was approved by the research ethics committee of universitas padjadjaran and dr. hasan sadikin general hospital. further acknowledgment had been received by the department of child health and the department of anatomical pathology dr. hasan sadikin general hospital. the data collected were analyzed using descriptive statistics and then presented by using tables and charts (microsoft® excel 2016 and ibm® spss® version 20). results a total of 30 children with confirmed rms by biopsy were included during the 4-year study period. the median aged was 5 years old (range; 9 months to 18 years old). the highest incidence occurred in the age group of 1-5 years (figure). male patients outnumbered female patients with m:f ratio 1.3:1. patient demographics and tumor characteristics were summarized in table 2. while the majority of the patients complained about a painless mass in their body, some patients came with other signs related to the primary site (table 1). tumor size was assessed in 27 patients only, of whom 21 patients with tumor >5 cm. biopsy was performed in open biopsy (n=19; 63%) or fine-needle aspiration biopsy (11; 37%). tumor size had been used in evaluation for pre-treatment tnm staging according to the cog-sts committee’s, of embryonal types (n=12), 3 patients had botryoid subtype of embryonal. interestingly, the pleomorphic subtype was not found in this study. the histological subtype classification used in this study was based on the newest classification from who (2013). more than half of the patients (57%) had a tumor in an unfavorable site. tumor located in the facial, orbital, nose, lip, and neck were included in the head and neck group. tumor in upper extremity was more dominant than lower extremity that counted in 75% of the patients. tumor in extremities was most common in the age group 10–15 years. tumor located in the intraabdominal and vertebrae were included in the trunk group while tumor in the bladder, testis, vulva, and vagina was included in the urogenital group. only 25 out of 30 children’s staging were identified. of the 27 patients in whom treatment was initiated, the vast majority of the patients were treated with chemotherapy (83%) where 47% of them with chemotherapy only and the rest with combination therapy. around 67% of children who had surgical resection had tumors >5 cm. three patients died before giving any kind of therapy in the care center. pre-treatment staging used a modified tnm system based on the primary site, either favorable or unfavorable site. discussions the results of this study showed more male (54.05%) rhabdomyosarcoma (rms) is the most common soft-tissue sarcomas (sts) in children, included in the top 10 most common malignancies. nevertheless, rms incidence is relatively rare.7 in our center, there were only 30 rms children during the 4 years period. the median age is 5 years old or about 59.5 months. this finding is similar to a study conducted in china13 showing a median age of 61.5 months. in our study, most of the children (63%) aged below 10 years and the highest age-adjusted incidence in the category of aged 1–5 years, similar to a various studies published earlier.6,7 male patients outnumbered female patients with m:f ratio 1.3:1. this finding also similar to the previous studies, that consistently showed a gender differential incidence of child health cancer worldwide with m:f ratio around 1.2:1.13,14 swelling or lump is the main presenting symptom in this study. this result is in accordance with a study in sub-saharan africa10 showing that all the children have presented with swellings, while more than half of the patients in romania1 presented with swelling in varying sites. some of the additional symptoms may result from the compression of local structures by the masses.8 this often vague and non-specific symptom may cause a delay in the admission of these children to the care center, leading to the advanced stage of the disease.10 the diagnosis of rms usually has been preferably performed by direct open biopsy.8 an adequate biopsy sample is critical for an accurate biopsy, hence, fine needle aspiration biopsy (fnab) is not recommended however, in this research study, an open biopsy was conducted to about 63% of the patients and the rest used fnab similar to another study in jakarta.6 the fnab is a fast, highly safe, and effective method, therefore, fnab is still used for the detection of carcinoma. fnab is less expensive than open biopsy, does not require anesthesia, and also less traumatic, hence, it althea medical journal. 2020;7(3) 140 amj september 2020 could save more time and money, and also more convenient for the patient. nonetheless, open surgical biopsy provided a more definitive diagnostic histology than fnab.15 a histologic subtype can be observed from biopsy samples microscopically. the most common subtype in this study is embryonal rms, followed by alveolar and spindle cells. this result is quite similar to the findings from east egypt and china that showed embryonal is the most frequent histopathologic subtype followed by alveolar and spindle cell though with quite different numbers.16,17 plemorphic subtype has not been found in this research because it is really rare to occur in children and more common in adult patients.18 interestingly, there are patients with an unknown subtype of rms. this is evidence that some tumors can not be characterized by the pathologist.18 the size of the tumor can only be party assessed since the tumor is in the unreachable location. the majority of the patients had tumors >5 cm.1,17 around 70% of the patients with tumor >5 cm passed away. this high mortality may be caused by patient delays in seeking medical care that is influenced by socioeconomic status and education degree of the parents. this delay could slow down the establishment of the diagnosis which is proven to be related to the increasing size of the tumor.9 education for the community and medical personnel is important to increase alertness for rms to further improve the prognosis. rhabdomyosarcoma may occur in any anatomic location of the body. in this study, we have identified the most frequent primary sites are head and neck followed by extremities, then the trunk and urogenital tract as known.19 however, another study in china has shown different primary sites with the genitourinary system is the most frequent site, followed by head and neck, then extremities.17 these differences may be caused by age range prevalent in each study. in this study, only 27 out of 30 patients were given treatment. almost half of the patients (47%) only had chemotherapy while 33% had chemotherapy combined with surgical resection. similar to the study in jakarta, only 41% had chemotherapy, while 39% had a combination of chemotherapy and surgical resection.6 the majority of the patients who came to the care center were in the advanced stages.1,6,20 this may be related to the low socioeconomic status, educational background of the parents, and other causes. unfortunately, in this study, neither socioeconomic status nor education degree has been noted. this limitation may lead to further exploration. to conclude, children with a tumor in the head and neck region should be suspected as rhabdomyosarcoma. there are various clinical characteristics similar to the results of previous studies around the globe. interestingly, late presentation is commonly seen; therefore, public health awareness and promotion are urgently needed. references 1. diaconescu s, burlea m, miron i, aprodu s, mihăilă d, olaru c, et al. childhood rhabdomyosarcoma. anatomo-clinical and therapeutic study on 25 cases. surgical implications. rom j morphol embryol. 2013;54(3):531–37. 2. hessissen l, kanouni l, kili a, nachef mn, el khorassani m, benjaafar n, et al. pediatric rhabdomyosarcoma in morocco. pediatr blood cancer. 2010;54(1):25–28. 3. alex ra, nayak dr, devaraja k, reddy na, singh r, shetty s. head-and-neck rhabdomyosarcoma: our experience. ann indian acad otorhinolaryngol head neck surg. 2018;2(1):1–4. 4. hawkins ds, spunt sl, skapek sx, committee cog soft tissue sarcoma committee. children’s oncology group’s 2013 blueprint for research: soft tissue sarcomas. pediatr blood cancer. 2013;60(6):1001–08. 5. rini at, edhy k, gatot d, windiastuti e, ciputra y. rabdomiosarkoma pada anak: gambaran klinis di 2 institusi. indonesian journal of cancer. 2008;2(2):55–59. 6. gatot d, windiastuti e. rabdomiosarkoma pada anak: luaran klinis pada pasien yang mendapat terapi. indonesian journal of cancer. 2011;5(2):83–87. 7. perez ea, kassira n, cheung mc, koniaris lg, neville hl, sola je. rhabdomyosarcoma in children: a seer population based study. j surg res. 2011;170(2):e243–e51. 8. hayes-jordan a, andrassy r. rhabdomyosarcoma in children. curr opin pediatr. 2009;21(3):373–78. 9. ferrari a, miceli r, casanova m, meazza c, favini f, luksch r, et al. the symptom interval in children and adolescents with soft tissue sarcomas. cancer. 2010;116(1):177–83. 10. ibikunle aa, taiwo ao, braimah ro, abdullahi k, malami ua. orofacial rhabdomyosarcoma: a 5-year althea medical journal. 2020;7(3) 141 clinicopathologic study from sub-saharan africa. clin cancer invest j. 2018;7(2):56. 11. crist wm, anderson jr, meza jl, fryer c, raney rb, ruymann fb, et al. intergroup rhabdomyosarcoma study-iv: results for patients with nonmetastatic disease. j clin oncol. 2001;19(12):3091–102. 12. rudzinski er, anderson jr, hawkins ds, skapek sx, parham dm, teot la. the world health organization classification of skeletal muscle tumors in pediatric rhabdomyosarcoma: a report from the children’s oncology group. arch pathol lab med. 2015;139(10):1281–87. 13. li m, bian x, jing r, zhang a, sun n, ju x, et al. retrospective analysis of rhabdomyosarcoma (rms) in children in a single center. thorac cancer. 2018;9(9):1180–84. 14. dorak mt, karpuzoglu e. gender differences in cancer susceptibility: an inadequately addressed issue. front genet. 2012;3:268. 15. 15. nassar a. core needle biopsy versus fine needle aspiration biopsy in breast—a historical perspective and opportunities in the modern era. diagn cytopathol. 2011;39(5):380–88. 16. badr m, al-tonbary y, mansour a, hassan t, beshir m, darwish a, et al. epidemiological characteristics and survival studies of rhabdomyosarcoma in east egypt: a five-year multicenter study. isrn oncol. 2012;2012. 17. ma x, huang d, zhao w, sun l, xiong h, zhang y, et al. clinical characteristics and prognosis of childhood rhabdomyosarcoma: a tenyear retrospective multicenter study. int j clin exp med. 2015;8(10):17196. 18. sultan i, qaddoumi i, yaser s, rodriguezgalindo c, ferrari a. comparing adult and pediatric rhabdomyosarcoma in the surveillance, epidemiology and end results program, 1973 to 2005: an analysis of 2,600 patients. j clin oncol. 2009;27(20):3391– 97. 19. bansal d, das a, trehan a, kapoor r, panda nk, srinivasan r, et al. pediatric rhabdomyosarcoma in india: a singlecenter experience. indian pediatr. 2017;54(9):735–38. 20. akyüz c, sarı n, yalçın b, varan a, kutluk t, büyükpamukçu m. long-term survival results of pediatric rhabdomyosarcoma patients: a single-center experience from turkey. pediatr hematol oncol. 2012;29(1):38–49. lelani reniarti et al.: clinical characteristics of rhabdomyosarcoma in children: a 4-year study in a tertiary hospital in indonesia amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 151 thoracic radiography findings of multi-drug resistant tuberculosis at dr. hasan sadikin general hospital bandung mareta tada kurnia,1 iyus maolana yusup,2 prayudi santoso3 1faculty of medicine universitas padjadjaran, indonesia 2department of radiology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: mareta tada kurnia, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: mareta17001@mail.unpad.ac.id introduction tuberculosis (tb) is an infectious disease which is caused by mycobacterium tuberculosis. this disease is one of the most common respiratory infections in the world, especially in developing countries such as indonesia, with second highest incidence of tb cases.1,2 multi-drug resistant tuberculosis (mdr-tb) is when mycobacterium tuberculosis is resistant to at least isoniazid and rifampicin, which are the most effective first-line anti-tb drugs.1 according to the world health organization (who), there were 24,000 mdr-tb cases in indonesia in 2019 with 2.4% incidence and only 13% of cases have been treated. data from the west java provincial health office has shown that there were over 1,500 mdr-tb cases in west java in 2018 of which 100 cases in bandung, however, there was a slightly decrease. in 2019 with over 1,000 cases in west java and less than 100 cases in bandung.1 radiological examination plays an essential role in tb diagnosis. radiological examination images show the location, area, and morphology of the lesions, such as cavity, consolidation, plural, effusion, and fibrosis. however, the radiological features are varied and not always distinctive. in addition, a chest radiograph is also useful in monitoring treatment response and detection of complications.3 a study found that mdr-tb contains multiple lung cavities, multiple nodules, bronchiectasis, and infiltration.3 drug-sensitive tuberculosis (dstb) lesions are less common and the majority are infiltration, consolidation, cavity, and althea medical journal. 2022;9(3):151–155 abstract background: the prevalence of multidrug-resistant pulmonary tuberculosis (mdr-tb) continues to increase, especially in indonesia. thoracic radiography examination plays a role in the tb diagnosis by providing findings of typical lesions in patients. the aim of the study was to determine the thoracic radiography findings in mdr-tb patients. methods: this was a cross-sectional retrospective descriptive study. this study had explored secondary data from medical records of patients who previously had a clinical diagnosis of mdr-tb and underwent thoracic radiography examinations at the department of radiology, dr. hasan sadikin general hospital, bandung on july–august 2020. results: of the 110 data collected, the average age was 37±12.6 years with male patients were predominantly prevalent and 65.5% had large lesions. the most frequent findings of lesions were calcification (94.5%) and fibrosis (90.9%). other major findings were infiltration (88.2%), consolidation (55.5%), cavity (65.5%), ground-glass opacity (60.9%) while other were found in less than half of the cases such as, bronchiectasis (23%), nodule (34.5%), atelectasis (36.4%), lymphadenopathy (34.5%) and others. interestingly, the miliary pattern was not found. conclusion: large lesions, calcification, fibrosis, infiltration, consolidation, cavities, and ground-glass opacities are the main features of the radiographic findings in the majority of mdr-tb patients. keywords: multi-drug resistant, thoracic radiograph, tuberculosis https://doi.org/10.15850/amj.v9n3.2618 althea medical journal. 2022;9(3) 152 ground-glass opacity.4 in indonesia, especially in west java, there has been no study yet regarding the radiographic features of mdr-tb. the high incidence of mdr-tb in indonesia encourages clinicians to be able early to detect this disease early to provide accurate and early therapy management. the objective of the study was to determine the thoracic radiography findings of mdr-tb patients at dr. hasan sadikin general hospital bandung, the referral hospital for mdr-tb in west java, particularly in bandung. methods this was a descriptive cross-sectional retrospective study. the study had used 110 samples of thoracic radiographs of patients who underwent chest radiography at the department of radiology, dr. hasan sadikin general hospital, bandung for the period 15 july–31 august 2020 who were clinically diagnosed with mdr-tb based on rapid molecular test, bacterial culture, and drug sensitivity examinations according to standard diagnosis algorithm in indonesia.5 chest radiograph samples were obtained from the medical record and re-evaluated by an expert radiologist. this study has been approved by the research ethics committee of universitas padjajaran no. 626/un6.kep/ec/2020 and from the ethics committee of dr. hasan sadikin general hospital bandung no lb.02.01/x.2.2.1/19550/2020. data were analyzed using statistical software (microsoft excel 2019 and ibm spss version 22,0). categorical data consisted of gender and lesion characteristics. numerical data consisted of age which was stated as mean and standard deviation. lesion characteristics were listed as percentages. statistical calculations were carried out using the univariate method, statistical calculations using the frequency table of lesion characteristics. results of the 110 data collected, the most of patients with mdr-tb were male (66%) with a mean age of 37±12.6 years. based on lesion area, most patients had large lesions (65.5%) and only small proportion of patients (5.5%) had minimal lesions (table 1). the most common findings on chest table 1 radiologic findings in patients with multi-drug resistant tuberculosis (mdr-tb) lesion characteristics proportion (n=110) area of the lesion, n (%) minimal moderate large 6 (5.5) 32 (29) 72 (65.5) radiographic findings, n (%) miliary pattern tree-in-bud nodules pleural effusion bullae bronchiectasis nodules lymphadenopathy atelectasis consolidation ground-glass opacity cavity infiltration fibrosis calcification 0 (0) 7 (6.4) 11 (10) 16 (14.5) 26 (23.6) 38 (34.5) 38 (34.5) 40 (36.4) 61 (55.5) 67 (60.9) 72 (65.5) 97 (88.2) 100 (90.9) 104 (94.5) althea medical journal september 2022 althea medical journal. 2022;9(3) 153mareta tada kurnia et al.: thoracic radiography findings of multi drug resistant tuberculosis at dr. hasan sadikin general hospital bandung radiographs of patients were calcification (94.5%) as presented in figure 1; whereas fibrosis (90.9%) and infiltration (88.2%) were also prevalent as shown in figure 2. other radiographic findings were in a lesser frequent such as cavity (65.5%), groundglass opacity (60.9%), consolidation (55.5%). interestingly, the miliary pattern was not found in radiographic findings of mdr-tb patients (table 1). discussion our study has shown that mdr-tb patients tend to be more common in men. several other studies have similar result showing that males are more prevalent in mdr-tb cases. to date, there have been no conclusive studies explaining the relationship between the incidence of mdr-tb and gender. the higher proportion of male with mdr-tb might be based on individual behaviors affecting adherence to treatment as well as the risk of tb exposure.6 another factor causing resistance to anti-tb drugs and mdr-tb is smoking. smoking is an independent risk factor for mdr-tb. smoking interferes with the alveolar macrophage figure 1 large lesion in the mdr-tb patient figure 2 cavity, atelectasis, infiltrate, and fibrosis in mdr tb patients althea medical journal. 2022;9(3) 154 activity, decreases the immune response of pulmonary lymphocytes, and decreases the cytotoxic activity of natural killer cells, thereby increasing the likelihood of infection. smoking also changes the metabolic clearance rate of anti-tb drugs by triggering the activity of cytochrome p450 cyp 1a1, cyp1a2, cyp2e1, and uridine 5’diphosphate (udp) glucuronosyltransferase, thereby minimizing the effectiveness of treatment.7 in this study, the age range of the patients was 19–66 years (mean 37 years). most mdr tb cases have occurred in the productive age, which might be related to high mobility and social interactions and thus might increase the risk of tb exposure and also decrease the effectiveness of tb treatment.8 large lesions were found in 65.5% of cases and this is consistent with previous studies.5,9,10 the long duration of the disease is suspected to be the reason of the many large lesions found in mdr-tb patients.9 furthermore calcification was the most common lesion in our study (94.5%), meanwhile in another retrospective study, the calcified lesion was found in only 46% of patients.11 calcification often occurred in long-term infections, such as tb. calcification is one of the signs of tb which contains many components of mycobacterium tuberculosis.12 another common lesion found in our study was fibrosis (90.9%). fibrosis is formed during the healing or remodelling process which includes the activation and recruitment of fibroblasts, extracellular matrix materials, and distortion of normal tissue structures. inflammatory cytokines il1β, tgf-β, ifn-γ, il-6, il-8, and il -12 regulate fibrosis formation leading to restrictive ventilatory defect in tb.13 fibrosis appears to increase the risk of developing atelectasis which was found in 36.4% of cases.14 another lesion found in high percentage in this study, is infiltration (88.2%). infiltration at the onset of tb infection seems to cause significant damage in the future. firthermore, the cavity was found in 65.5% of patients, similar percentage to another study.16 a cavity is formed when the area of caseous necrosis liquefies and communicates with the bronchi. cavitary lesion is the primary mode of disease transmission due to the high bacterial content which allows the increase in drug-resistant mycobacteria. the cavitary lesion increases the likelihood of mycobacterium tuberculosis resistance due to high oxidation and thick cavity walls which prevent the drug from penetrating the source of infection and reaching adequate concentrations.15 additionally, most patients had groundglass opacity (67%) and consolidation (61%) conform other study among mdr-tb patients.9 however, the presence of consolidation is not always specific to infection. consolidation with ipsilateral hilar or paratracheal lymph node enlargement is predominant in tb patients.17 other lesions are present in lower percentage such as the presence of nodules and lymphadenopathy (34.5%). in addition, in patients who were resistant to the anti-tb drugs, there was also an increase in cavitation of nodules.18 bronchiectasis was found in 23.6% of patients and. bronchiectasis was more frequent in mdr-tb than in ds-tb. in tuberculosis, bronchiectasis is caused by active inflammation and damage to the bronchial walls.19 lesions that were rarely seen in this study were bullae (14.5%), pleural effusions (10%), and tree-in-bud nodules (6.4%). in contrary, studies showed that tree-in-bud nodules were one of the most common lesions found in mdrtb patients. the tree-in-bud image results from the bronchogenic spread of necrosis and granulomatous inflammation.20 moreover, military lesion in our study was not found, consistent with another study that only found miliary lesions in 1% of patients.10 this study has several limitations, among others that this study did not include variables that could be comorbid with mdr-tb. furthermore, as this study was conducted at one hospital in bandung, the results obtained may not reflect the overall situation in the region. to conclude, the main features of the radiographic findings in the majority of mdr-tb patients from bandung are large lesions with calcification, fibrosis, infiltration, consolidation, cavities, and ground-glass opacities. future studies examining the variables related to mdr-tb comorbidities and performing the study in several mdr-tb referral hospitals in indonesia are of great interest. references 1. who. tuberculosis fact sheets. 2020 [cited 2020 february 16]. available from: https:// www.who.int/news-room/fact-sheets/ detail/tuberculosis. 2. who. global tuberculosis report 2020. geneva: world health organization; 2020. 3. laya bf, sto. domingo mcl, javier xm, sanchez m. drug resistant tuberculosis: radiologic imaging manifestations. wfpi althea medical journal september 2022 althea medical journal. 2022;9(3) 155mareta tada kurnia et al.: thoracic radiography findings of multi drug resistant tuberculosis at dr. hasan sadikin general hospital bandung tb corner. 2015;1(1):1–5. 4. majdawati a, icksan ag, lolong d. comparison of chest x-ray lesion characteristics of multidrug-resistant tuberculosis and non-tuberculous mycobacterial infection. pol j radiol. 2019;84:e162–70. 5. kementrian kesehatan ri. petunjuk teknis manajemen terpadu pengendalian tuberkulosis resistan obat. jakarta: direktorat jenderal pengendalian penyakit dan penyehatan lingkungan kementrian kesehatan republik indonesia; 2018. 6. yang y, zhou c, shi l, meng h, yan h. prevalence and characterization of drugresistant tuberculosis in a local hospital of northeast china. int j infect dis. 2014;22:83–6. 7. chiang yc, lin ym, lee ja, lee cn, chen hy. tobacco consumption is a reversible risk factor associated with reduced successful treatment outcomes of anti-tuberculosis therapy. int j infect dis. 2012;16(2):e130–5. 8. mehari k, asmelash t, hailekiros h, wubayehu t, godefay h, araya t, et al. prevalence and factors associated with multidrug-resistant tuberculosis (mdr-tb) among presumptive mdrtb patients in tigray region, northern ethiopia. can j infect dis med microbiol. 2019;2019:2923549. 9. icksan ag, napitupulu mrs, nawas ma, nurwidya f. chest x-ray findings comparison between multi-drug-resistant tuberculosis and drug-sensitive tuberculosis. j nat sci biol med. 2018;9(1):42–6. 10. sulaiman sc, handayani l, suwandi msy, soedarsono s. gambaran radiografi tuberkulosis paru multidrug-resistant. j respirasi. 2018;4(3):71–5. 11. zahirifard s, amiri mv, karam mb, mirsaeidi m, ehsanpour a, masjedi mr. the radiological spectrum of pulmonary multidrug-resistant tuberculosis in hivnegative patients. iran j radiol. 2003;1(3– 4):161–6. 12. iida t, uchida k, lokman n, furukawa a, suzuki y, kumasaka t, et al. calcified granulomatous lung lesions contain abundant mycobacterium tuberculosis components. j mycobac dis. 2014;4(1):142. 13. ravimohan s, kornfeld h, weissman d, bisson gp. tuberculosis and lung damage: from epidemiology to pathophysiology. eur respir rev. 2018;27(147):170077. 14. cherian ra, lowrey b. atelectasis. in: kissane j, neutze ja, singh h, editors. radiology fundamentals: introduction to imaging & technology. 6th ed. new york: springer international publising; 2020. p. 89–97. 15. barroso ec, mota rms, santos ro, sousa alo, barosso jb, rodrigues jln. risk factors for acquired multidrug-resistant tuberculosis. j pneumologia. 2003;29(2):89–97. 16. wáng yxj, chung mj, skrahin a, rosenthal a, gabrielian a, tartakovsky m. radiological signs associated with pulmonary multidrug resistant tuberculosis: an analysis of published evidences. quant imaging med surg. 2018;8:161–73. 17. yeh jj, chen sc, teng wb, chou ch, hsieh sp, lee tl, et al. identifying the most infectious lesions in pulmonary tuberculosis by high-resolution multi-detector computed tomography. eur radiol. 2010;20(9):2135– 45. 18. ballester an. computed tomography features of multi-drug-resistant pulmonary tuberculosis in non-hiv-infected patients. tamil nadu: sm group; 2016. 19. li d, he w, chen b, lv p. primary multidrugresistant tuberculosis versus drug-sensitive tuberculosis in non-hiv-infected patients: comparisons of ct findings. plos one. 2017;12(6):e0176354. 20. kim w, lee ks, kim hs, koh wj, jeong bh, chung mj, et al. ct and microbiologic follow-up in primary multidrug-resistant pulmonary tuberculosis. acta radiol. 2016;57(2):197–204. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 220 correlation of serum potassium status and heart score in acute coronary syndrome patients verina logito, nida suraya, dewi kartika turbawaty departement of clinical pathology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: verina logito, department of clinical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur no. 38, bandung, indonesia, e-mail: verinalogito@gmail.com introduction acute coronary syndrome (acs) is a cardiac emergency with discomfort in the chest or other symptoms, as a result of myocardial ischemia. acute coronary syndrome comprises of unstable angina pectoris, non-q wave myocardial infarction or myocardial infarction without st-segment elevation (non-st elevation myocardial infarction/nstemi), and q wave myocardial infarction or myocardial infarction with st-segment elevation (stelevation myocardial infarction/stemi.1 from year to year, cases of heart disease show an increase as the first cause of death in the world. based on the results of basic health research (riset kesehatan dasar, riskesdas) of the ministry of health of the republic of indonesia in 2018, the prevalence of coronary heart disease in indonesia has reached 1.5% or around 2 million inhabitants. the prevalence is increased at the age over 45 years in men and after menopause in women. acs was ranked second among 50 inpatient death ratings at the dr. hasan sadikin general hospital in bandung, based on a diagnosis in 2017.1,2 patients with acs develop hypokalemia, which can increase the risk of lethal ventricular arrhythmias.3,4 hypokalemia can be considered as an acute-phase response to adrenergic activation, which stimulates sodium-potassium-atpase bonds and encourages potassium into cells.5 another potential mechanism of hypokalemia in acs is reactive hyperinsulinemia in response to elevated serum glucose due to adrenergic activity. insulin will stimulate potassium to enter the muscles and liver, so insulin reduces the serum potassium concentration. if hypokalemia in acs is driven primarily by adrenergic mechanisms, then in patients with diabetes, there is sympathetic nerve althea medical journal. 2021;8(4):220–223 abstract background: patients with acute coronary syndrome (acs) often experience hypokalemia which increase the risk of ventricular arrhythmia. the heart score can identify the prognosis of acs. this study aimed to examine the correlation between serum potassium and heart score on acs. methods: this was a cross-sectional observational, correlative analytic study. the data were taken retrospectively using secondary data. inclusion criteria were all acs patients who had been examined for serum potassium parameters at the emergency room of dr. hasan sadikin general hospital bandung in 2019. the heart score was calculated based on history (h), electrocardiogram (e), age (a), risk factors (r), and troponin (t). subjects were divided into low risk, intermediate risk, and high risk groups based on the heart score value. results: fifty-two acs subjects were mostly male with a mean±sd age of 59±9 years. all subjects had moderate and high heart scores, with 79% subjects having normokalemia. there was no correlation between heart score and serum potassium levels (r = -0.083, p=0.279). conclusion: there is no relationship between serum potassium and the heart score that may need to determine the prognosis in acs patients. further study is imperative to explore serum potassium levels which might begin to decline 24 hours after the acute attack. keywords: acs, heart score, prognosis, serum potassium https://doi.org/10.15850/amj.v8n4.2397 althea medical journal. 2021;8(4) 221 dysfunction associated with autonomic neuropathy. thus, the potassium levels in acs patients with diabetes will increase.6,7 low-risk acs patients can be well-managed in an outpatient clinic. meanwhile, acs patients with intermediate to high risk should be managed more quickly and aggressively, with hospitalization and consultation with a cardiology consultant. heart score aims to identify the risk of patient with undifferentiated chest pain that is useful for supporting medical decision-making by doctors.8 the heart score is assessed based on five different variables, the scores being summed up for the patient being evaluated. these variables are history (h), 12-lead electrocardiogram (e), age (a), risk factor (r), and troponin (t). the scores range from 0 to 2 in each of these five categories, with the lowest score of 0 and the highest score of 10. the heart score is divided into low risks (scores 0–3), intermediate risks (scores 4–6), and high risks (scores 7–10). therefore, the heart score can be used to determine prognosis in acs patients.1,9 this study aimed to examine the relationship between serum potassium status and the heart score approach in acute coronary syndrome patients who were admitted to the emergency room of dr. hasan sadikin general hospital bandung in 2019. methods this research method was a cross-sectional study, using observational correlative analytic design. the total sampling method was employed. retrospective data collection using secondary data taken from the laboratory information system (lis) and patient medical records. the subjects of this study were patients with acs who were admitted to the emergency room of dr. hasan sadikin general hospital bandung in 2019. the inclusion criteria were unstable angina pectoris (uap), st-elevation myocardial infarction (stemi) and non-st-elevation myocardial infarction (nstemi) with and without risk factors. data on serum potassium was collected. the exclusion criteria were patients with incomplete laboratory medical record data. the ethical clearance for this study was given by the ethics committee of faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung no lb.02.01/x.6.5/69/2020. the data obtained were conducted with spearman rank correlation test to determine the relationship between serum potassium verina logito et al.: correlation of serum potassium status and heart score in acute coronary syndrome patients levels and the heart score approach in acute coronary syndrome patients, then the data were processed statistically with microsoft excel and spss 17.0. results during 2019, 52 data of acs patients who met the inclusion criteria were collected, consisting of 40 male and 12 female with a mean±sd age of 59±9 years (range 37–83 years). there were patients with uap (n=12), nstemi (n=19), stemi (n=21). the results of potassium levels were mostly (77%) normal (3.5–5 mg/dl), and only 5 subjects were hypokalemia (2.9–3.4 mg/dl) and 6 other subjects with hyperkalemia (5.1– 6.6 mg/dl) as shown in table 1. the correlation of serum potassium with heart score using spearman rank analysis revealed a coefficient r=-0.083 (p=0.279), thus, there was a very weak and insignificant table 1 characteristics of patients with acute coronary syndrome admitted to emergency room, dr. hasan sadikin general hospital in 2019 characteristics n=52 age (year) mean ± sd age criteria, n (%) <45 45–64 ≥ 65 59 ± 9 4 (8) 36 (69) 12 (23) gender, n (%) male female 40 (77) 12 (23) type of acs, n (%) unstable angina stemi nstemi 12 (23) 21 (40) 19 (37) potassium level, n (%) hypokalemia normokalemia hyperkalemia 5 (10) 41 (79) 6 (11) heart score, n (%) low (0–3) moderate (4–6) high (7–10) 16 (31) 36 (69) note: sd= standard deviation, acs= acure coronsry syndrome, stemi= st-elevation myocardial infarction, nstemi= non-st-elevation myocardial infarction althea medical journal. 2021;8(4) 222 negative correlation between serum potassium and heart score. the proportion of subjects in the normokalemia group who had moderate heart score were 14 subjects (27%) and high heart score were 27 subjects (52%). there was no significant relationship between serum potassium and heart score (p>0.591) (table 2). discussion acute coronary syndrome (acs) is the highest cause of death in the world.2 the incidence rate of acs increases higher in women and men aged 55 to 64 years.10 this is in accordance with the characteristics of our respondents aged 59 years (range 37–83 years). our study included 40 male and 12 female, supporting that male have a greater risk of suffering from acs compared to female. the risk factor for acs in male aged 45 years, while in female at age 55 years.11 furthermore, most of the study subjects showed normal potassium levels, ranged from 3.5 to 4.9 mg/dl. score was 4.3 mg/dl (range 3.4–6.5 mg/dl), and on a high heart score was 4.1 mg/dl (range 2.9–6.6 mg/dl), and there was statistically no significant difference (p>0.05). potassium levels <3.5 mg/dl which has a moderate heart score of 2% and a high heart score of 8%, at a potassium level of 3.5–5 mg/dl which has a moderate heart score of 27% and a high heart score of 52%, at potassium levels >5 mg/dl which had a moderate heart score of 2% and a high heart score of 10%, statistically test showed no significant relationship (p>0.05). therefore, we can hypothesize that potassium levels are directly proportional to the heart score. in such manner, the higher the potassium level, the higher the heart score produced. our study showed that the correlation coefficient between serum potassium and heart score was -0.083 with p=0.279 (>0.05), meaning that there is no correlation between serum potassium and heart score. patients with acs in acute attacks generally have transient hypokalemia, which can increase the risk of ventricular arrhythmias.12 transient hypokalemia can be considered as an acutephase response to adrenergic activation, which stimulates sodium-potassium-atpase bonds and pushes potassium into cells, resulting in most acs patients with hypokalemia.12,13 interestingly, other study shows there is a significant different in age for stemi and nstemi group; as well as significant differences in sodium levels between stemi and nstemi patients.14 however, the levels of potassium (p=0.625) and chloride (p=0.423) did not have a significant difference between both groups.14 the results of this study, however, are not in line with the results of previous studies, resulting in the low percentage of hypokalemia caused by several factors, including low research subjects numbers, that dominated by normokalemia.12 the other factors are disruptive factor electrolyte levels, especially against potassium levels, which have not been considered before. factors such as a history of diuretics and the presence of preexisting illnesses that affect potassium levels. imbalance in potassium levels does not take place quickly. in this study, the acs patients were predominantly normokalemia (n=41), and came to an acute attack, indicating that the imbalance in potassium levels does not take place immediately. hypokalemia will occur 24 hours after the onset of acs, when the patient is transferred to the cardiac intensive care unit (cicu) or when the doctor visit the cicu the next day.15,16 therefore, further research is needed which measures potassium levels periodically. the limitation of this study is that the periodic potassium checks are not conducted. table 2 proportions of subjects with moderate and high heart scores based on the potassium level variable totaln=52 heart score p-valuemoderate (4–6) n (%) high (7–10) n (%) potassium level hypokalemia normokalemia hyperkalemia 5 41 6 1 (2) 14 (27) 1 (2) 4 (8) 27 (52) 5 (10) 0.591* note: *chi square test althea medical journal december 2021 althea medical journal. 2021;8(4) 223 furthermore, there is no data on history of previous drug consumption and diseases that may affect potassium levels as a risk factor for the incidence of acs. in conclusion, there is a very weak and insignificant negative correlation between serum potassium and heart score to determine prognosis in acs patients. there are many factors that influence the prognosis of acs patients, among others potassium parameters. therefore, it is recommended that further studies need to measure potassium regularly as well as to gather data on history of previous drugs and disease that may affect potassium level. references 1. nadeem m, ahmed ss, farooq s. risk factors for coronary heart disease in patients below 45 years of age. pak j med sci. 2013;29(1):91–6. 2. world health organization. cardiovascular disease (cvds) [internet] [cited 2021 may 6]. available from: https://www. who.int/health-topics/cardiovasculardiseases#tab=tab_1. 3. xi h, yu rh, wang n, chen xz, zhang wc, hong t. serum potassium levels and mortality of patients with acute myocardial infarction: a systematic review and metaanalysis of cohort studies. eur j prev cardiol. 2019;26(2):145–56. 4. ali m, umer m, butt um, tawwab s, qureshi ma, akram z. frequency of ventricular arrhythmias in acute myocardial infarction and its relationship with hypokalemia. j cardiovasc med cardiol. 2018;5(4):036–8. 5. iqbal r, sami a, ilyas m, iftekhar mf, ullah r, arafat y. hypokalemia in patients with acute myocardial infarction. pak heart j. 2019;52(01):27–30. 6. plakth y, gilutz h, shiyovich a. the association of concomitant serum potassium and glucose levels and in-hospital mortality in patients with acute myocardial infarction (ami). soroka acute myocardial infarction ii (sami-ii) project. int j cardiol. 2019;287:39–45. 7. faraj hr. clinical study of some electrolytes (sodium, chloride and potassium) with patients in acute coronary syndrome (acs) in thiqar governorate, iraq. int j curr microbiol app sci. 2015;4(3):700–5. 8. six aj, backus be, kelder jc. chest pain in the emergency room: value of the heart score. neth heart j. 2008;16(6):191–6. 9. colombo mg, kirchberger i, amann u, heier m, thilo c, kuch b, et al. admission serum potassium concentration and long-term mortality in patients with acute myocardial infarction: results from the monica/ kora myocardial infarction registry. bmc cardiovasc disord. 2017;17(1):198. 10. mahmoud an, taduru ss, mentias a, mahtta d, barakat af, saad m, et al. trends of incidence, clinical presentation, and inhospital mortality among women with acute myocardial infarction with or without spontaneous coronary artery dissection: a population-based analysis. jacc cardiovasc interv. 2018;11(1):80–90. 11. dong m, mu n, ren f, sun x, li f, zhang c, et al. prospective study of effect endogenous estrogens on myocardial no-reflow risk in postmenopausal women in acute myocardial infarction. j interv cardiol. 2014;27(5):437–43. 12. sekiyama h, nagoshi t, komukai k, matsushima m, katoh d, ogawa k, et al. transient decrease in serum potassium level during ischemic attack of acute coronary syndrome: paradoxical contribution of plasma glucose level and glycohemoglobin. cardiovasc diabetol. 2013;12:4. 13. barkas f, elisaf m. serum potassium levels and mortality in acute myocardial infarction: myth or fact? angiology. 2018;69(8):657–9. 14. ciptono f, rahayu m. the differences of sodium, potassium and chloride levels in stemi and nstemi patients. indones j clinical pathol med laboratory. 2017;24(1):91–4. 15. madias je, shah b, chintalapally g, chalavarya g, madias ne. admission serum potassium in patients with acute myocardial infarction: its correlates and value as a determinant of in-hospital outcome. chest. 2000;118(4):904–13. 16. uluganyan m, ekmekçi a, murat a, avşar ş, ulutaş tk, uyarel h, et al. admission serum potassium level is associated with in-hospital and long-term mortality in stelevation myocardial infarction. anatol j cardiol. 2016;16(1):10–5. verina logito et al.: correlation of serum potassium status and heart score in acute coronary syndrome patients amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 75 perceptions of medical students in bandung towards online and offline learning in the anatomy laboratory during the covid-19 pandemic wulan mayasari,1 cindy saskia alsadila,2 fifi veronica1 1department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia correspondence: wulan mayasari, dr.,mh. kes., aifo-k, department of biomedical sciences, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: wulan.mayasari@unpad.ac.id althea medical journal. 2023;10(2):75–80 abstract background: coronavirus disease 2019 (covid-19) that surged throughout the world in 2019 and engulfed indonesia in 2020 had changed many aspects of people’s activities significantly, when altering the offline anatomy laboratories to online. this study aimed to determine the perspective of medical students in bandung regarding the learning process in online and offline anatomy laboratories during the covid-19 pandemic. methods: this descriptive study had used modified questionnaires with a likert scale. the respondents were 184 students from the 2018 or 2019 class of the faculty of medicine in bandung, who participated in both online and offline anatomy laboratory learning methods. sampling was carried out using the purposive sampling method. the data were presented in a frequency table and calculated by spss. results: regarding ‘material understanding’, most students (57.0%) disagreed that online anatomy laboratory activities were better than offline. in terms of ‘facilities and infrastructure’, 38.0% students disagreed that online anatomy laboratory learning facilities were more adequate than offline. on the aspect of ‘teacher’s perception’, most students agreed (39.0%) that teacher’s performance was better in online anatomy laboratory activities. conclusion: this study shows that medical students prefer to combine online and offline anatomy laboratory activities. keywords: anatomy laboratories, online and offline learning, student’s perception introduction covid-19 is an infectious disease caused by the sars-cov-2 which spreads through droplets of infected people. covid-19 can attack the respiratory tract, ranging from mild to severe symptoms and can even cause death. therefore, the rapid spread of covid-19 must be prevented immediately by adhering the health protocols set by the government, such as staying away from crowds, washing hands, wearing masks, reducing mobility, and maintaining distance.1,2 furthermore, many aspects of life have changed. activities that are usually conducted face-to-face are now difficult to do, such as working indoors, shopping, eating at restaurants, music events, and even visiting public places such as hospitals, are considered as triggers to increase spread of covid-19. many activities are carried out as much as possible using the online methods. one of the activities that was strongly affected by covid-19 was in the education sector. covid-19 has caused education to no longer be implemented with conventional face-to-face pattern. the ministry of education and culture republic of indonesia has issued circular letter no.4 of 2020 on the implementation of education policies in the emergency period of the spread of coronavirus disease, one of which is by conducting learning from home through online learning.3 although it looks new, online education methods have actually started to be used in https://doi.org/10.15850/amj.v10n2.2705 althea medical journal. 2023;10(2) 76 previous learning methods, such as e-learning, youtube, the ministry of educational and culture website, edmodo, and even whatsapp. there are various educational methods in higher education that are applied in indonesia, but due to the current conditions, all learning methods are carried out online. similarly, the anatomy laboratory learning process in several medical faculties was delayed at the beginning of the emergence of the pandemic, and online learning was thus conducted entirely in their respective homes.4–8 however, the implementation of online learning is still not as maximized as face-to-face conventional learning, even though there are some obstacles that occur in the conventional face-to-face learning process.9 the online and offline learning processes must be beneficial for lecturers and students to achieve learning objectives the use of online learning technology must be utilized optimally to develop the clinical abilities of medical students or doctors.10 in addition, the use of conventional face-toface learning processes technology can be more effective when combined with online learning.11,12 technological advances are expected to facilitate online learning and telemedicine utilization after the end of the covid-19 pandemic.5 the existence of a curriculum in higher education is very important. the implementation of online and offline education methods as a whole in higher education involve a curriculum that need to be planned to get better results and to adjust the educational progress while suppressing the spread of covid-19.11 the curriculum has an important role to carry out quality education, and create people who master certain knowledge and skills.12,13 the establishment of a good higher education with a good curriculum will produce qualified college graduates to build the indonesian nation. perception retrieval is useful for knowing people’s experience, thus, the perception can be used as evaluation material to improve and find solutions to existing problems.11 conventional anatomy learning requires offline sessions to enhance the experience of studying cadaveric models in the anatomy laboratory. in the online anatomy laboratory, the method is transformed into an indirect experience of learning cadaveric models through anatomy videos, schematic pictures, 3d anatomical atlases, and more. this online activity is experienced at all levels of education. this study aimed to explore the perspective of medical students in bandung on the learning process online and offline in anatomy laboratories during the covid-19 pandemic. methods this study was a descriptive study. the population in this study was medical students in the bandung area class of 2018 or 2019 who took part in the online and offline anatomy laboratory learning methods. sampling was calculated using purposive sampling method, one of the non-random sampling methods that was carried out by taking respondents as samples by determining certain conditions with a minimum sample size of 86 people. the data were obtained using a questionnaire with the likert scale, consisting of questionnaire on aspects of material understanding (7 questions), aspects of facilities and infrastructure (1 question) and perception of teachers (6 questions). questionnaire was disseminated through social media line and whatsapp. the aspects asked in the questionnaire included students’ perspective in the learning process, supporting facilities for learning anatomy, and the lecturers’ position in the learning process. before distribution, the questionnaire was tested for validity and reliability to 30 respondents who were a sample of the population from three medical faculty in bandung, including universitas padjadjaran, pasundan university, and bandung islamic university to obtain a distribution of values close to the normal curve.14 this research was conducted online from august to december 2021. course study guide (cs) was distributed to the medical students to understand and had the knowledge on anatomy. csg was used by lecturers to teach students using various strategies. students used csg to guide the learning process, especially anatomy.16 the respondent’s data were processed using microsoft excel software and presented in tabular form. the result of the study was analysed from the percentage students’ answer.15 this research has been approved by the research ethics committee of universitas padjadjaran, ethical approval no. 786/un6. kep/ec/2021. results in a total of 830 medical school students in the bandung area class of 2018 or 2019, 184 students were included with age range of althea medical journal june 2023 althea medical journal. 2023;10(2) 77wulan mayasari et al.: perceptions of medical students in bandung towards online and offline learning in the anatomy laboratory during the covid-19 pandemic 19–23 years, predominantly female students (69%). the distribution of the students among medical schools in the bandung area was depicted in table 1. the overall response rate in the population was 28.7%. in the knowledge aspect of the csg, there were many students who did not memorize or know the csg (36.4%). students who were lacked of knowledge about csg tended to be less able to capture material more effectively. the students needed to be informed that understanding csg was important for the continuity of the anatomy learning process both online and offline to make it more effective. in the aspect of understanding the material, students (56.0%) disagreed that online anatomy laboratory learning activities were more motivating than offline; students (58.0%) did not agree that online anatomy laboratory activities made it easier for students to understand the purpose of learning compared to offline. furthermore, students (61.0%) did not agree that online anatomy laboratory activities added more knowledge and conclusion than offline. there were students (55.0%) did not agree that online anatomy laboratory activities were more effective for learning objectives than offline. in addition, students (50.0%) disagreed that anatomy laboratory materials taught online were more effective for learning objectives than offline, students (53.0%) did not agree that anatomy laboratory materials taught online were more supportive of learning activities. furthermore, students (47.0%) disagreed that anatomy laboratory materials taught online are more supportive of problem-solving on exams than offline. in terms of material understanding, the majority of students (54.5%) disagreed that online anatomy laboratory activities were better than offline (table 2). for facilities and infrastructure, 38.0% students did not agree that online anatomy laboratory learning facilities were more adequate than offline. however, the results of this aspect of understanding the material had a slight difference in the answer agree, with a percentage of 37.0% students agreeing that online anatomy laboratory learning was more adequate than offline (table 3). as for questions about perception of teachers, the majority of students agreed that material explanations (45.0%) and preparation of teaching materials (47.0%) were better in online anatomy laboratory activities, as well as the opportunity to discuss and to ask questions about anatomy laboratory activities. teachers provided more opportunities (42.0%) and provided more clearer answer (42.0%) to online anatomy laboratory activities. however, students did not agree that in terms of giving examples of anatomical materials (42%) and interaction between teachers and students (46%), it was better and more effective in online anatomy laboratory activities. the majority of students (39.0%) agreed that the teacher performance was better in online anatomy laboratory activities. this result had a slight difference with regard to teaching performance, students did not agree if teaching performance was table 1 characteristics of respondents characteristic number (n) percentage (%) gender male female 57 127 31.0 69.0 origin of the university universitas padjadjaran bandung islamic university maranatha christian university jenderal achmad yani university pasundan university 84 49 0 23 28 45.7 26.6 0.0 12.5 15.2 knowledge of csg yes no 117 67 63.6 36.4 total 184 100 note: csg: course study guide althea medical journal. 2023;10(2) 78 better in online anatomy laboratory activities. based on the survey there were several obstacles experienced in the online anatomy laboratories learning process, one of the obstacles most felt by most students was internet problem (n=139, 76%). in addition, 131 students (71.0%) experienced a lack of motivation. other problems were the less althea medical journal june 2023 table 2 questionnaire on aspects of material understanding, facilities and infrastructure, and perception of teachers questionnaire strongly disagree n (%) disagree n (%) agree n (%) strongly agree n (%) aspects of material understanding online anatomy laboratory activities motivate me to learn anatomy by objective learning in each laboratory topic rather than offline 25 (14.0) 104 (56.0)* 39 (21.0) 16 (9.0) online anatomy laboratory activities make it easier for me to understand each item that is by the purpose of learning objective learning rather than offline. 31 (17.0) 106 (58.0)* 32 (17.0) 15 (8.0) online anatomy laboratory activities further add to my knowledge and skills, by the purpose of learning objective learning rather than offline 31 (17.0) 112 (61.0)* 32 (17.0) 9 (5.0) online anatomy lab activities make me more effective at learning objectives than offline 28 (15.0) 102 (55.0)* 40 (22.0) 14 (8.0) anatomical laboratory materials that have been taught online are more by objective learning in modules than offline 18 (10.0) 93 (50.0)* 59 (32.0) 14 (8.0) anatomy laboratory materials that have been taught online are more supportive of other learning activities (lectures and tutorials) than offline 20 (11.0) 98 (53.0)* 50 (27.0) 16 (9.0) anatomy laboratory materials that have been taught online are more supportive of problem solving on exams than offline 20 (11.0) 87(47.0)* 59(32.0) 18(10.0) aspects of facilities and infrastructure online anatomy laboratory learning facilities (video, power point, atlas, lms) are more adequate than offline (anatomical models, atlases, textbooks, modules) 22 (12.0) 70 (38.0)* 68 (37.0) 24 (13.0) perception of teachers in online anatomy laboratory activities, teachers explain the material better than offline 10 (5.0) 66 (36.0) 83 (45.0)* 25 (14.0) in online anatomy laboratory activities, teachers prepare teaching materials better than offline 7 (4.0) 54 (29.0) 86(47.0)* 37 (20.0) in online anatomy laboratory activities, teachers give students more opportunities to discuss and ask questions than offline 7 (4.0) 68 (37.0) 77 (42.0)* 32 (17.0) in online anatomy laboratory activities, teachers respond to questions better and more clearly than offline 11 (6.0) 70 (38.0) 78 (42.0)* 25 (14.0) in online anatomy laboratory activities, teachers provide examples of anatomical materials better and clearer than offline 17 (9.0) 78 (42.0)* 67 (36.0) 22 (12.0) in online anatomy laboratory activities, teaching interaction with students is more effective than offline 31 (17.0) 86 (46.0)* 47 (26.0) 20 (11.0) note: * the most prevalent result althea medical journal. 2023;10(2) 79 conducive (62.0%) and the limitations of gadgets (29.0%). other technical problems also occurred, such as students not having proper applications used by teachers because the applications were paid, so students did not have access to anatomical laboratory props. this caused obstacles for students such as being unable to visualize anatomical structures in three dimensions and could not directly edit anatomical models that resulted in a lack of understanding of the online anatomy learning process. as a result of covid-19, the anatomy laboratory learning process became an obstacle for students. although students preferred the offline learning process of anatomy in aspects of understanding materials and infrastructure facilities, the offline learning process had more obstacles than the online learning process. the most common obstacles experienced by students were the distance to campus (39.7%) and the cost of living which was more expensive (32.6%) compared to the online learning process in the anatomy laboratories. in addition, offline anatomy laboratory activities were also considered to be less flexible and requires more time and effort to implement. offline anatomy laboratory activities with a lot of material in a limited time was also one of the obstacles that must be overcome, this caused the material explained by lecturers to be to too fast and cannot be repeated as can be done in the online of anatomy laboratories learning process. this caused the anatomy laboratory activities to become less directed and some materials needed to be corrected. as a result, students felt that the material provided was incomplete and very much imposed things because they had to study independently on anatomical pre-lab tasks. sitting position was also considered to affect the teaching and learning process in offline anatomy learning because the voice of lecturers tended not to be heard by students sitting behind so that students were less able to capture the material clearly. the capture of material by students was also influenced by the classroom atmosphere which was often less conducive and made other students less focused on paying attention, so the implementation of anatomical laboratories was not maximal, and students needed to repeat the lesson after the lab session. for facilities and infrastructure, materials and cadavers were considered inadequate by students. the facilities provided by the faculty were considered insufficient for a large number of students, such as there was only 1 anatomical model that could be used simultaneously by 12 people. lack of technological updates was also one of the obstacles that students felt. in addition, several universities did not have anatomy laboratory facilities on their campuses, thus students had to go to other campuses to use anatomy laboratory facilities. discussion this study shows that most of the respondents disagree that the online method in learning anatomy increases learning motivation, knowledge, and effectiveness. a similar study that compared online and offline earning processes at the medical faculty in india had a similar result to this study, which stated that students tended to prefer online rather than offline anatomy laboratory activities in the aspect of facilities and infrastructure.16 in other research, students were more satisfied with the online anatomy learning process because students could contact the lecturer at any time and recordings of learning activity material were available which made it easier for students to repeat learning at any time.17–19 statistically, there is no significant difference between the online and offline learning process. students can ask questions to lecturer at any time, students are equally involved in the online and offline learning processes due to the teacher’s equally good performance in the online and offline anatomy learning process.17,20 the limitations of this research are the relatively low total response rate, the difficulty of equalizing the number of respondents at each university and also the need for interpersonal communication with each student to meet the number of respondents. in conclusion, students tend to prefer a combination of online and offline anatomy laboratory activities. there are several aspects that are superior to online activities, such as visualization and simple schematic picture to increase the anatomy learning process. in offline activities, students can discuss and interact with the lecturer using the cadaver models. in this study, in terms of material understanding and infrastructure facilities, online anatomy laboratory activities are superior and in the aspect of the perception of teaching, online anatomy laboratory activities are excel. wulan mayasari et al.: perceptions of medical students in bandung towards online and offline learning in the anatomy laboratory during the covid-19 pandemic althea medical journal. 2023;10(2) 80 references 1. world health organization, international labour organization. preventing and mitigating covid-19 at work: policy brief, 19 may 2021. geneva: world health organization; 2021 [cited 2022 april 14]. available from: https://apps.who.int/iris/ handle/10665/341328. 2. direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan republik indonesia. pedoman pencegahan dan pengendalian coronavirus disease (covid-19). 4th ed. jakarta: direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan republik indonesia; 2020. 3. alami y. media pembelajaran daring pada masa covid-19. tarbiyatu wa ta’lim. 2020;2(1):49–56. 4. alsoufi a, alsuyihili a, msherghi a, elhadi 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tenggara timur. cmj. 2021;9(1):169–77. althea medical journal june 2023 amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 27 risk factors for patients with gonococcal urethritis at dr. hasan sadikin general hospital bandung, indonesia in 2013–2019 pati aji achdiat,1 jefferson basta erguna ginting,2 chrysanti3 1department of dermatology and venereology, faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, bandung, indonesia, 2faculty of medicine, universitas padjadjaran, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: jefferson basta erguna ginting, faculty of medicine universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, e-mail: jeffersonbeg20@gmail.com introduction urethritis is an inflammation of the urethra, and a common genitourinary syndrome encountered in men in clinical practice. neisseria gonorrhea, a diplococcal gramnegative bacteria, is one of the etiologic agents causing urethritis.1 transmission of this bacteria generally occurs through sexual contact with people infected with gonorrhea, either genito-genital, ano-genital, or orogenital. the common clinical manifestations that prompt people to seek a healthcare facility are purulent urethral discharge and painful urination (dysuria). it can also be accompanied by edema and erythema of the urethral meatus.2 globally, gonorrhea ranks as the third most common sexually transmitted infection (sti), with an estimated 87 million new cases in 2016.3 in indonesia, the incidence of gonorrhea reaches 5.6 per 100,000 adult men. this is the second-highest incidence rate in southeast asia after thailand.3 there is no specific data regarding the incidence of gonococcal urethritis in indonesia, however in bandung, it was recorded that in 2020 there were 1,723 sti cases.4 previous reports have shown that many factors were found to be associated with gonorrhea cases in men, such as sociodemographic factors and high-risk sexual althea medical journal. 2023;10(1):27–31 abstract background: gonorrhea is the second most common sexually transmitted infection in southeast asia. many factors cause gonococcal urethritis, and each region has its characteristics. this study aimed to determine the risk factors among patients with gonococcal urethritis at dr. hasan sadikin general hospital bandung. methods: this was a descriptive study with a retrospective and total sampling method, reviewing the gonococcal urethritis patient medical records obtained from dr. hasan sadikin general hospital bandung from 2013 to 2019. sociodemographic, clinical manifestations, and sexual or risky behaviors data were collected. results: among 97 males with gonococcal urethritis, unmarried males (54.6%) and the age category of 20–24 years (35.1%) were predominant, with high school education/equivalent (58.8%). based on their sexual behavior, the majority had more than one sexual partner in the past month (63.9%) and had never used a condom when having sex (55.7%). additionally, there was also a group of man who had sex with man (msm) (14.4%) and illicit drug users (19.5%). conclusions: males in the young adult age group, single, have a high education level, have multiple sexual partners, and never used a condom during having sex, have a higher risk of having gonococcal urethritis. identifying these most reported risk factors may help health care providers design effective prevention strategies. unmarried young adults should be a primary focus in receiving educational programs. they should be informed regarding the impact of multiple sexual partners, condom usage, and illicit drug on gonococcal urethritis infection among men. keywords: gonorrhea, risk factor, urethritis https://doi.org/10.15850/amj.v10n1.2537 althea medical journal. 2023;10(1) 28 behavior factors. in 2014–2018 in the united states, the majority of gonorrhea cases in men were those aged 20–24 years and 25–29 years.5 meanwhile, a research in melbourne in 2019 found that the risk was high in men who used injecting drugs in the last 12 months.6 furthermore, in 2019 a study in ghana reported that most the patients had more than one sexual partner in the past month and had a high school educational levels.7 interestingly, these studies have shown that each location has its own risk factor characteristics. the differences in risk factors between geographic locations might be caused by economic, sociocultural, norms, and traditions that are unique to the regions. therefore, the aim of the study was to explore the characteristics of risk factors for gonococcal urethritis in bandung, west java, indonesia, especially from the tertiary care facilities, dr. hasan sadikin general hospital, which is expected to be important in formulating strategies for the prevention and management of gonococcal urethritis in the future. methods this research was conducted with a retrospectively descriptive method using medical record data obtained from the department of dermatology and venereology, dr. hasan sadikin general hospital bandung, in 2013–2019. the inclusion criteria were male patients diagnosed with gonococcal urethritis at dr. hasan sadikin general hospital bandung in the period 2013–2019. the exclusion criteria were incomplete, inaccessible, and or duplicate data during the study period. the data were processed with microsoft® excel 2019 and ibm® spss® v.25. this research had received an ethical exemption from the research ethics committee of universitas padjadjaran no. 700/un6.kep/ec/2020. the results were presented in tables and figures to show the characteristic of gonococcal urethritis patients, sociodemographic, clinical manifestations, and sexual or risky behavior profile in number and percentage. results during the observation, there were 97 data. males with gonococcal urethritis were the highest in the year 2013 (n=32 patients). there were variations in clinical manifestation observed among male patients with gonococcal urethritis, of which mucopurulent urethral discharge and painful urination commonly occurred. three patients experienced complications in the form of epididymitis, tysonitis, and abscesses on the tyson gland. as many as 18 patients were co-infected with other pathogens that caused stis, precisely 5 patients (5.2%) with syphilis, 3 patients (3.1%) with hiv, and 10 patients (10.3%) with other stis (genital warts, trichomoniasis, and genital herpes) (table 1). the age of patients varied from the youngest age of 18 years and the oldest age of 60 years (median age 25 years; interquartile range 23–33 years). all patients received formal education with 90.7% (n=88) having graduated from high level education. there were 53 (54.6%) unmarried or single patients althea medical journal march 2023 table 1 characteristics of gonococcal urethritis characteristic total (n=97) n % clinical manifestation urethral discharge urethral discharge + dysuria urethral discharge + dysuria + erythema urethral discharge + dysuria + erythema + edema 29 43 18 7 29.9 44.3 18.6 7.2 complications epididymitis, tysonitis, or abscesses on the tyson gland 3 3.1 coinfection syphilis hiv other stis (genital warts, trichomoniasis, and genital herpes) 5 3 10 5.2 3.1 10.3 note: hiv= human immunodeficiency virus. stis= sexually transmitted infections althea medical journal. 2023;10(1) 29pati aji achdiat et al.: risk factors for patients with gonococcal urethritis at dr. hasan sadikin general hospital bandung , indonesia in 2013–2019 (table 2). the majority of patients had multiple sexual partners with the median number of sexual partners of the patients in the past month being 2 (iqr, 1–5) and 62 patients (63.9%) had more than one sexual partner in the past month. the most recent sexual partner of patients was a girlfriend or friend (n=48; 49.5%), then a female sex worker (n=13; 13.4%). most of the patients in this study never used a condom when having sex (n=54, 55.7%). there were 14 men patients (14.4%) who had sex with men (msm) group. those who had or frequently used drugs mostly used marijuana (table 3). discussion our study shows that male with gonococcal urethritis is predominantly found in the young table 2 sociodemographic risk factors among patients with gonococcal urethritis variable total (n=97) n % age group (year)* 15–19 20–24 25–29 30–34 35–39 >39 9 34 19 14 8 13 9.3 35.1 19.6 14.4 8.2 13.4 educational level elementary school/equivalent junior high school/equivalent senior high school/equivalent college/academy 2 7 57 31 2.1 7.2 58.8 31.9 marital status single/unmarried married divorced 53 42 2 54.6 43.3 2.1 note: *cdc age group classification5 table 3 sexual and risky behaviour among patients with gonococcal urethritis variable total (n=97) n % number of sexual partners in the past month <2 ≥2 35 62 36.1 63.9 using a condom when having sex never 25% 50% 75% always 54 6 25 9 3 55.7 6.2 25.8 9.3 3.0 sexual orientation heterosexual homosexual bisexual 83 6 8 85.6 6.2 8.2 illicit drug use (marijuana, heroin, or ecstasy) yes sometimes never 11 8 78 11.3 8.2 80.5 althea medical journal. 2023;10(1) 30 adult age group (20–29 years) with median age of 25 years old. this finding is similar to the previous study in brazil.8 the existence of behavioral, biological, and cultural factors triggers young people to engage in risky sexual behavior. biologically, sexual hormones are active during adolescence and young adults, coupled with of technological developments and the rapid flow of information media as a means of cultural exchange in society without filtering good or bad may predispose to risky sexual behavior.9–11 the majority of the patients in this study have high school or college education, similar to study from ghana.7 this implies that higher educational attainment does not guarantee safer sexual behavior, and they are not well informed about gonococcal urethritis or stis in general, including preventive measures. sexual health education is a very important strategy in preventing stis. in indonesia, sexual health education is still not included in the learning curriculum.12 therefore, further research is needed regarding the level of knowledge and strategies for implementing sexual health education at the high school level. in this study, most of the patients were unmarried, consistent with research conducted in ukraine and ghana.7,13 the incidence of gonorrhea in unmarried men is higher than in married men. this reflects riskier sexual behavior in unmarried men, such as changing sexual partners. on the other hand, married status can be a barrier for someone to have free sex because sexual needs are met and marriage is considered sacred and must be maintained properly.14,15 sexual contact is the most important way of gonococcal bacteria transmission. our study shows that most the patients had more than one sexual partner in the last month and a median of two sexual partners, similar to previous studies in ghana and ukraine.7,10 having multiple sexual partners is one of the risky sexual behaviors. it becomes a risk factor for a person contracting an sti, including gonorrhea, because the possibility of gonorrhea transmission is getting bigger.10 in this study, most of the patients had never used a condom while having sex, and few rarely used it. this result is consistent with research in australia which concluded that a group of men who rarely or never used a condom during sexual intercourse were 1.5 times more likely to develop gonococcal urethritis than the group who always used a condom.16 this shows that using condoms can protect a person from stis if they are used regularly and correctly. the inconsistent use of condoms can be caused by reason of reduced enjoyment when using condoms or a lack of knowledge about the benefits of condoms in the prevention of gonococcal urethritis or other stis.17 men who have sex with men (msm) are one of the key populations at increased risk of developing hiv and other stis due to a higher prevalence of community disease, behavioral, or biologic factor. in this study, there are fewer msm compared to heterosexual men, similar to the study from ukraine.13 this small number of cases of gonococcal urethritis in the msm group could be caused by the location of gonorrhea infection which tends to be extragenital organs, as in a study in lisbon which showed that of all gonorrhea diagnoses in the reported msm group, the majority of cases occurred in extragenital organs, with the highest proportion at anorectal sites.18 nearly one-fifth of the patients in this study had used illicit drugs. the type of drug that most commonly consumed is marijuana, which is in accordance with previous studies in sweden and the united kingdom.19,20 marijuana causes damage to the central nervous system which will interfere with thinking and decisionmaking processes or disinhibition which ultimately leads to an increase in risky sexual behavior.19,20 there is a limitation in this study, namely data collection was conducted retrospectively where there were incomplete or limited data on medical records. to conclude, males in the young adult age group, single, have a high education level, have more than one sexual partner in the past month, and never used a condom during having sex, have a higher risk of having gonococcal urethritis. there are also msm and illicit drug users in this study. identifying these most reported risk factors may help health care providers design effective prevention strategies. unmarried young adults should be a primary focus in receiving educational programs. they should be informed regarding the impact of multiple sexual partners, condom usage, and illicit drug on gonococcal urethritis infection among men. references 1. bachmann lh, manhart le, martin dh, seña ac, dimitrakoff j, jensen js, et al. advances in the understanding and treatment of male urethritis. clin infect dis. 2015;61(suppl 8):s763–9. althea medical journal march 2023 althea medical journal. 2023;10(1) 31pati aji achdiat et al.: risk factors for patients with gonococcal urethritis at dr. hasan sadikin general hospital bandung, indonesia in 2013–2019 2. kirkcaldy rd, weston e, segurado ac, hughes g. epidemiology of gonorrhoea: a global perspective. sex health. 2019;16(5):401–11. 3. who. report on global sexually transmitted infection surveillance, 2018. geneva: world health organization; 2018. 4. dinas kesehatan kota bandung. profil kesehatan kota bandung tahun 2020. bandung: dinas kesehatan kota bandung; 2021. [cited 2021 december 28]. available from: https://dinkes.bandung. go.id/download/profil-kesehatan-kotabandung-2020/ 5. center for disease control and prevention. sexually transmitted disease surveillance 2018. atlanta, georgia: u.s. department of health and human services; 2019. [cited 2020 november 21]. available from: https://www.cdc.gov/std/stats18/ stdsurveillance2018-full-report.pdf 6. phillips tr, fairley ck, chen my, bradshaw cs, chow epf. risk factors for urethral gonorrhoea infection among heterosexual males in melbourne, australia: 2007-17. sex health. 2019;16(5):508–13. 7. dela h, attram n, behene e, kumordjie s, addo kk, nyarko eo, et al. risk factors associated with gonorrhea and chlamydia transmission in selected health facilities in ghana. bmc infect dis. 2019;19(1):425. 8. barbosa mj, moherdaui f, pinto vm, ribeiro d, cleuton m, miranda ae. prevalence of neisseria gonorrhoeae and chlamydia trachomatis infection in men attending std clinics in brazil. rev soc bras med trop. 2010;43(5):500–3. 9. pitasari da, sunarko m. studi retrospektif : profil infeksi gonore. berk ilmu kesehat kulit kelamin. 2019;31(1):41–5. 10. gale m, hayen a, truman g, varma r, forssman bl, macintyre cr. demographic and geographical risk factors for gonorrhoea and chlamydia in greater western sydney, 2003–2013. commun dis intell q rep. 2017;41(2):e134–41. 11. de peder ld, da silva cm, nascimento bl, malizan ja, madeira hs, horvath jd, et al. prevalence of sexually transmitted infections and risk factors among young people in a public health center in brazil: a cross-sectional study. j pediatr adolesc gynecol. 2020;33(4):354–62. 12. menteri pendidikan dan kebudayaan republik indonesia. permendikbud no 59 tahun 2014 tentang kurikulum 2013 sekolah menengah atas/madrasah aliyah. jakarta: kementerian pendidikan dan kebudayaan republik indonesia; 2014. available from: http://simpuh.kemenag. go.id/regulasi/permendikbud_59_14.pdf 13. boiko i, akimova v, mazur l, savchenko i, kohut i, krynytska i. the clinicoepidemiological profile of patients with gonorrhoea and challenges in the management of neisseria gonorrhoeae infection in an sti clinic, ternopil, ukraine (2013-2018). j med life. 2020;13(1):75–81. 14. nur r, marhun fa, larasti rd, mantao e, ashari mr, mallongi a. marital status and sexually transmitted infections in internal medicine polyclinic and dermatology & venereology polyclinic of undata general hospital of palu in 2018. indian j public health res dev. 2020 ;11(4):818–22. 15. puspitorini d, hans l. a retrospective study: the profile of new gonorrhoeae patients. berk ilmu kesehat kulit kelamin. 2017;29(1):59–64. 16. scott n, mcbryde e, kirwan a, stoové m. modelling the impact of condom distribution on the incidence and prevalence of sexually transmitted infections in an adult male prison system. plos one. 2015;10(12):e0144869. 17. kanda l, mash r. reasons for inconsistent condom use by young adults in mahalapye, botswana. afr j of prim health care fam med. 2018;10(1):e1–7. 18. ribeiro s, de sousa d, medina d, castro r, lopes â, rocha m. prevalence of gonorrhea and chlamydia in a community clinic for men who have sex with men in lisbon, portugal. int j std aids. 2019;30(10):951– 9. 19. paquette r, tanton c, burns f, prah p, shahmanesh m, field n, et al. illicit drug use and its association with key sexual risk behaviours and outcomes: findings from britain’s third national survey of sexual attitudes and lifestyles (natsal-3). plos one. 2017;12(5):e0177922. 20. strandberg a, skoglund c, gripenberg j, kvillemo p. alcohol and illicit drug consumption and the association with risky sexual behaviour among swedish youths visiting youth health clinics. nordisk alkohol nark. 2019;36(5):442–59. amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 25 attitude and behavior towards self-medication using non-steroidal anti-inflammatory drugs and paracetamol among housewives in hegarmanah village, jatinangor kuswinarti,1 aisyah binti mohamad rohim,2 siti aminah3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: kuswinarti, department of biomedical sciences faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, e-mail: wiwinsumarlan@yahoo.com introduction the range of medicines available directly to the public is commonly practiced today with a wider choice and has been used as self-medication.1 self-medication is determined as non-prescription drugs used by patients without consultation from medical practitioners.2,3 based on the national socio economic survey-statistics indonesia (survey sosial ekonomi nasional-badan pusat statistik, susenas-bps) indonesia, in 2014, the percentage of population who have self-medication using modern medicine by 90.54%, medicine traditional 20.99%, and others 4.06%.4 however, they do not practice self-medication correctly, whether the dosage is too high or wrong drug classes have been chosen which is not appropriate with the clinical symptoms. self-medication can be beneficial for patients, healthcare providers, the pharmaceutical industry and governments, with a condition that the patients must have the responsibility of self-care.5 in indonesia, drug classification is categorized into over-the-counter (otc), limited otc, controlled drugs and narcotics.7 over-the-counter drugs are drugs that can be consumed without physician’s prescription,7 for example for pain. pain can be described as an unpleasant sensory and emotional experience associated with actual or potential amj. 2020;7(1):25–30 abstract background: the use of drugs by self-medication is widely practiced worldwide. one of the most common drugs used without prescription is analgesic and this is predominantly used among housewives since they are sometimes suffering from minor ailments due to house chores burden. the study aimed to explore the attitude and behavior of non-steroidal anti-inflammatory drugs (nsaids) and paracetamol usage among housewives in jatinangor, west java-indonesia. methods: a cross-sectional study was performed from august–november 2013. after informed consent, housewives living in hegarmanah village, jatinangor were included by filling in a validated questionnaire to assess the level of attitude and behavior of nsaids and paracetamol usage. the data were presented in percentages. the score was given and categorized as good, moderate and poor for both attitude and behavior. results: of a total 110 housewives participated in this study, the attitude of housewife towards the drug use was good (59.1%), moderate (33.6%) and poor (7.3%), whereas the behavior was good (46.4%), moderate (52.7%) and poor (0.9%). conclusions: the majority of the respondents have moderate to good attitude as well as behavior toward the usage of nsaids and paracetamol as self-medication. public health education and awareness are important to ensure safe and useful self-medication. keywords: attitude, behavior, nsaids, paracetamol, self-medication https://doi.org/10.15850/amj.v7n1.1721 althea medical journal. 2020;7(1) 26 amj march 2020 tissue damage. the effects of pain can lead to a tremendous cost in health care costs, rehabilitation and lost worker productivity based on days of work missed, hours of work lost, and lower wages, as well as the emotional and financial burden it places on patients and their family.8 to relieve pain, the world health organization (who) provides a three steps management starting by giving non-opioids, mild-opioids and strong opioids.6 paracetamol and some non-steroidal anti-inflammatory drugs (nsaids) are categorized in nonopioids and available over-the-counter, and thus they are the most commonly used drugs for self-medication.9 improper use of these drugs can lead to several side effects such as hepatic failure, gastrointestinal disturbance, cardiovascular problem and worsening of asthma.10,11 the who suggests that public health education and increased awareness are important.5 by determining the attitude and behaviour of the society, the current conditions on their drug usage can be assessed and the outcome might be used to plan an intervention to ensure good and safe self-medication among the community. as housewives are usually the ones who takes care of the household, this study was aimed to explore the attitude and behavior of non-steroidal anti-inflammatory drugs (nsaids) and paracetamol among housewives in jatinangor methods this study was conducted in hegarmanah village, jatinangor, west java, indonesia from august to november 2013. the study design was descriptive with a cross-sectional approach. the inclusion criteria were all married housewives who resided in the village and agreed to participate in this study by filling in an informed consent form. no exclusion criteria in this study. permission from the local authorities was cleared and the study was approved by the health research ethics committee of faculty of medicine universitas padjadjaran (no: 241/un6.c2.1.2/ kepk/2013). the questionnaire contained 9 questions related to attitude and 13 questions related to behavior. the attitude was explored by determining the responses on the application of the drugs on all levels of pain, correct dosage, the role of prescriptions in consuming the drugs, side effects, and usage of prescribed drugs. the responses on each statement were designated as ‘agree’ or ‘not agree’. the behaviour was determined by assessing the habitual reasons for self-medications, types of pain-killer frequently used for pain, an indication of use, frequency and dosage intake of the drugs. the responses were stated as ‘frequently’, ‘seldom’ or ‘never’. furthermore, two questions had ‘yes’ or ‘no’ choices for answers. score was given and totaled up to classify the respondents into good (≥68%), moderate (34–68%) and poor (≤33%) for attitude; also good (≥70%), moderate (39–69%) and poor (≤38%) for behavior. four questions were not given scoring as these questions allowed the respondents to answer more than one answer, including questions about the type of analgesic used, the reason for self-doing medication use, the symptoms treated with self-medication, and the group of people for self -medication. the questionnaire was first tested for validity and reliability before distributed to the respondents. for validity, each question was tested and correlated. a correlation value of ≥0.3 was set to ensure that the question was valid. for reliability test, cronbach’s alpha was tested by statistical product and services solutions (spss) statistics program. the questionnaire’s coefficient reliability was considered reliable if ≥0.7. the data was then collected and the results were presented in frequency and table forms. table 1 education level of housewives in hegarmanah village, jatinangor, sumedang, west java, indonesia education frequency (n=100) percentage (%) elementary school 60 54.6 junior high school 31 28.2 senior high school 18 16.4 university graduates 1 0.9 althea medical journal. 2020;7(1) 27kuswinarti et al.: attitude and behavior towards self-medication using non-steroidal anti-inflammatory drugs and paracetamol among housewives in hegarmanah village, jatinangor results in total, there were 110 housewives recruited, with a mean age of 41 years old (s.d+12.5). the largest population of the study (54.6%) was from the lowest education background which was elementary school, as depicted in table 1. most of the respondents (59.1%) had a good attitude towards the drug’s usage, followed by moderate (33.6%) and poor (7.3%) attitude, whereas half of the respondents had moderate behavior (52.7%), followed by good (46.4%) and very little had a poor behavior (0.9%) as shown in figure 1. the type of analgesics used was paracetamol (76.4%), which was the top on the list as the most chosen analgesic by the respondents (figure 2). the most chosen reason for doing selfmedication was ‘no need to seek medical practitioner for minor ailments’ (table 2). the headache came as the most frequent reason (86.4%) (table 3), and most of the respondents use self-medication on themselves (99.1%) (table 4) discussions this study has explored the attitude and behaviour of housewives about self-medication use. overall, the attitudes on drugs use among housewives are good (59.1%), however, their behaviour is moderate (52.7%). interestingly, most of respondents have elementary figure 1 the level of attitude and behaviour of housewives in hegarmanah village jatinangor, sumedang, west java, indonesia during august–november 2013 figure 2 types of analgesic used housewives in hegarmanah village, jatinangor, sumedang, west java, indonesia althea medical journal. 2020;7(1) 28 amj march 2020 table 2 reasons for doing self-medication reasons frequency (n=out of 110) percentage (%) time-saving 29 26.4 no need to seek medical practitioner for minor ailments 42 38.2* cheaper 35 31.8 quick-relief 36 32.7 analgesics drugs are easily available 25 22.7 convenient 34 30.9 note: * the most chosen reason education (54.6%). the percentages of respondents from each education background does not represent the proportion in the community itself, as only interested eligible participants have been taken as study subjects. most of the housewives have a good level of attitude on self-medication drugs. generally, people are well aware of the side effects that may occur during self-medication. most of them acknowledge that a doctor’s role is necessary when the pain worsens or when they in need of controlled drugs. however, some still thought that it has no harm to buy controlled drugs themselves or even do self-dosing. a question has been asked to the respondents whether drug dosage could be reduced by them, and more than half of the respondents agreed on this, which is not a proper way to do. table 3 symptoms treated with self-medication symptoms frequency (n=out of 110) percentage (%) headache 95 86.4 toothache 46 41.8 fever 42 38.2 flu 43 39.1 joint pain 26 23.6 dysmenorrhea 15 13.6 diarrhea 8 7.3 breathing difficulty 1 0.9 nausea 4 3.6 others 4 3.6 table 4 the group of individual for self-medication consumers frequency (n=out of 110) percentage (%) self 109 99.1 husband 36 32.7 children 29 26.4 parents 6 5.5 others 3 2.7 althea medical journal. 2020;7(1) 29kuswinarti et al.: attitude and behavior towards self-medication using non-steroidal anti-inflammatory drugs and paracetamol among housewives in hegarmanah village, jatinangor interestingly, a study on medical students has shown that they increased the dose without medical advice.3 incorrect drug dosage can lead to an improper practice of self-medication.12 as for the behaviour of the housewives in this study, most of them (52.7%) had a moderate behaviour towards self-medication drugs and they do self-medication to counter pain. this is good as who acknowledges that self-medication is necessary to first encounter the pain.13 however, as stated in the attitude statement, even in the practice, most of the respondents will reduce drug dosage themselves. some of the respondents did not, or only sometimes, follow the dosage requirement written on the drug’s packaging, which is quite alarming. apart from being harmful, wasting time and money, side effects can arise when the proper practice of selfmedication is ignored.12 this is one of the reasons that contribute to the moderate behaviour level of the respondents. the most common drug used for selfmedication in this study is paracetamol as expected since paracetamol is one of the most drugs available easily on the market.9 interestingly, some of the respondents have chosen mefenamic acid as their first choice of drug to counter pain. mefenamic acid is not supposed to be sold otc, as a prescription is needed to buy the drug. however, some pharmacies still sell controlled drugs even without prescription from the physician. some respondents do not know the type of drugs that they took to alleviate pain, leading to problems in the future. by not knowing what kind of drugs they have taken, they may cause overdosage or usage of different classes of drugs that are inappropriate with the symptoms.12 self-medication is time saving, no need to seek medical practitioners for minor ailments, cheaper, easily available, convenient and it gives quick relief. comparing with a study among housewives in northern india14, self-medication has been chosen because repeated consultations to the doctor may cause a burden to them financially and it is time-consuming. physician is only consulted when the symptoms are serious enough or could not be relieved by medication.14 in our study, almost all respondents seek medical practitioners when symptoms worsen, which shows correct conduct of action as unrelieved pain may indicate a chronic medical condition, where medical intervention is needed. correct conduct of self-medication can save patients’ time from seeing doctors, it is economical and may even save a life in acute conditions.5 the most common symptoms treated by self-medication among the respondents are a headache. a study on self-medication among iranian university students has shown that the most common condition encountered with self-medication is headache,15 whereas in india common cold is the main reason for doing selfmedication.16 dysmenorrhoea is also common for self-medication action since most of the respondents are in their reproductive age. interestingly, some respondents have used analgesics for the wrong symptoms such as diarrhea, breathing difficulty and nausea. this improper act may lead to a complication, especially to those who have breathing difficulty and nausea since the consumption of nsaids can worsen asthma and may cause gastrointestinal disturbance.11 almost all of the respondents have taken drugs for themselves, and most of them are reluctant to do selfmedication on their children because they are afraid of improper drug dosage given to their children. this shows that most of them have good awareness of the importance of proper drug usage. there are several limitations to this study. some respondents have been interviewed in small groups, therefore, some answers may not be truly answered leading to a possibility of measurement bias for some other respondents. however, it provides useful information on the attitude and behaviour of self-medication among housewives in hegarmanah village, jatinangor. further study is needed to elaborate and confirm these findings. to conclude, the majority of the housewives in hegarmanah village jatinangor have moderate to good attitude as well as behavior toward the usage of nsaids and paracetamol as self-medication. an educational program on self-medication should be conducted to increase awareness to the society for them to practice safe and effective self-medication. the government must also be stricter on pharmacies as they should not sell controlled drugs to consumers without a prescription. references 1. aoyama i, koyama s, hibino h. selfmedication behaviors among japanese consumers: sex, age, and ses differences and caregivers’ attitudes toward their children’s health management. asia pac fam med. 2012;11(1):7. 2. du y, knopf h. self-medication among children and adolescents in germany: results of the national health survey for althea medical journal. 2020;7(1) 30 amj march 2020 children and adolescents (kiggs). br j clin pharmacol. 2009;68(4):599–608. 3. el ezz nf, ez-elarab hs. knowledge, attitude and practice of medical students towards self medication at ain shams university, egypt. j prev med hyg. 2011;52(4):196–200. 4. badan pusat statistik indonesia. persentase penduduk yang mengobati sendiri selama sebulan terakhir menurut provinsi dan jenis obat yang digunakan, 2002-2018. jakarta: bps-statistic indonesia; 2019. [cited 2019 october 30] available from: https://www.bps. go.id/dynamictable/2015/09/19/926/ persentase-penduduk-yang-mengobatis e n d i r i s e l a m a s e b u l a n t e r a k h i r menurut-provinsi-dan-jenis-obat-yangdigunakan-2002-2018.html 5. james h, handu ss, al khaja kaj, otoom s, sequeira rp. evaluation of the knowledge, attitude and practice of self-medication among first-year medical students. med princ pract. 2006;15(4):270–5. 6. world health organization. who’s cancer pain ladder for adults; 2009. [cited 2019 october 30]. available from: https://www. who.int/cancer/palliative/painladder/en/. 7. chaerunissa ay, surahman e, imron ssh. farmasetika dasar: konsep teoritis dan aplikasi pembuatan obat. bandung, indonesia: widya padjadjaran; 2009. 8. institute of medicine (us) committee an advancing pain research, care, and education. relieving pain in america: a blueprint for transforming prevention, care, education, and research. washington dc: national academies press; 2011. 9. abay sm, amelo w. assessment of selfmedication practices among medical, pharmacy, and health science students in gondar university, ethiopia. j young pharm. 2010;2(3):306–10. 10. bresalier rs, sandler rs, quan h, bolognese ja, oxenius b, horgan k, et al. cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. n eng j med. 2005;352(11):1092–102. 11. süleyman h, demircan b, karagöz y. anti-inflammatory and side effects of cyclooxygenase inhibitors. pharmacol rep. 2007;59(3):247–58. 12. supardi s, notosiswoyo m. pengobatan sendiri sakit kepala, demam, batuk dan pilek pada masyarakat di desa ciwalen, kecamatan warungkondang, kabupaten cianjur, jawa barat. majalah ilmu kefarmasian. 2005;ii(3):134-44 13. suleman s, ketsela a, mekonnen z. assessment of self-medication practices in assendabo town, jimma zone, southwestern ethiopia. res social adm pharm. 2009;5(1):76–81. 14. kaushal j, gupta m, jindal p, verma s. selfmedication patterns and drug use behavior in housewives belonging to the middle income group in a city in northern india. indian j community med. 2012;37(1):16–9. 15. sarahroodi s, maleki-jamshid a, sawalha af, mikaili p, safaeian l. pattern of selfmedication with analgesics among iranian university students in central iran. j family community med. 2012;19(2):125–9. 16. badiger s, kundapur r, jain a, kumar a, pattanshetty s, thakolkaran n, et al. self-medication patterns among medical students in south india. australas med j. 2012;5(4):217–20. amj vol 7 no 3 september edited.indd althea medical journal. 2020;7(3) 142 amj september 2020 type of coronary artery plaque in relation to epicardial fat volume in coronary heart disease patients: a cardiac computed tomography scan study iman imaduddin robandi, ristaniah d. soetikno, dian k. dewi department of radioloy faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung, indonesia correspondence: iman imaduddin robandii, department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur 38, bandung, indonesia, e-mail: imaduddinr142@gmail.com introduction coronary heart disease (chd) is a disease caused by plaque that has accumulated in the lumen of the coronary arteries, leading to a limited supply of oxygen to the heart muscle.1-3 the chd is one of the most common cardiovascular diseases, a disorder of the heart and blood vessels including stroke, rheumatic heart disease, and other conditions.4 according to world statistics, there are 9.4 million deaths each year caused by cardiovascular disease, and 45% of these deaths are caused by chd. it is estimated that the number will increase to 23.6 million in 2030.4,5 in 2013, the highest prevalence for cardiovascular disease in indonesia is chd. the incidence of chd is mainly found in the age between 65– 74 years (3.6%) followed by the age group of 75 years and above (3.2%), the age group of 55–64 years (2.1%), and the age group 35–44 years old (1.3%).6 dr. hasan sadikin general hospital bandung has handled the cases of chd in 2017 as many as 764 outpatients and 3836 inpatients, with the incidence of male patients more than women, a ratio of 4:1.7 the development of atherosclerosis is started with the formation of foam cells that are induced by chronic hyperlipidemia, namely excessive fat intake in a long time.8 epicardial fat can affect the formation of coronary atherosclerosis due to the absence of a fibro fascia layer that is able to inhibit the diffusion of free fatty acids and adipokines from epicardial fat to the walls of the blood vessels and surrounding heart muscle.9 the accumulation amj. 2020;7(3):142–8 abstract background: coronary heart disease (chd) is a disease that raises public health concerns due to its high morbidity and mortality rates. anatomically, epicardial fat is located around the heart and coronary system, making it important in the development of coronary atherosclerosis. this study aimed to explore the relationship between epicardial fat volume (efv) and the type of coronary artery plaque by using cardiac computed tomoghraphy (ct)-scan. methods: this was a cross-sectional observational analytic study on patients diagnosed with chd aged > 20 years who had undergone cardiac ct-scan at the department of radiology, dr. hasan sadikin general hospital, bandung, indonesia between february and june 2019. data collected from the ctscan were analyzed using the chi-square test. results: from 54 chd patients, consisting of an equal number of male and female patients, with a majority of above 60 years old (31.5%), a correlation was identified between increased amount of efv and mix and hard plaques in the right cirumflex artery (rca) (p<0.026) and left circumflex (lcx) (p<0.038)on the left main(lm) and left anterior descending (lad) arteries, no significant correlation was observed between efv and the type of plaque (p>0.05). conclusions: there is a significant relationship between the efv value, efv category, and the type of coronary artery plaque in chd patients in rca and lcx arteries. however, this correlation is not observed in lm and lad arteries. keywords: artery plaque, cardiac ct-scan, coronary heart disease, epicardial fat volume https://doi.org/10.15850/amj.v7n3.1904 althea medical journal. 2020;7(3) 143 of epicardial fat increases the secretion of local inflammatory mediator that triggers atherosclerotic processes and other systemic effects.9,10 previous studies have shown that increased epicardial fat volume (efv) might progress into coronary atherosclerosis in the near to medium term with an average of 2.7/year).10 the thickening of epicardial adipose tissue should be considered as a more accurate risk factor in cardiovascular disease.11 hence, it is a potential therapeutic target, as well as an examination target that shows an association between epicardial fat and coronary heart disease by using a cardiac computed tomography (ct)scan. ct-scan is more accurate in measuring the accumulation of adipose tissue or epicardial fat due to higher spatial resolution.11 measurement of efv can be performed using several imaging modalities such as echocardiography, cardiac ct-scan with multi sliced computed tomography (msct), and magnetic resonance imaging (mri). the efv measurement using a cardiac ct-scan with or without contrast is conducted manually by tracing the epicardial layer in each piece from the appendix atrium to the heart apex. the thickness of epicardial fat is identified by hounsfield units (hu) which is set at -250 to -30, then the computer measures efv automatically.12,13 another study has shown the normal efv value <125 ml. value >125 ml is considered not normal, however, efv>100 ml is able to estimate chd.12 epicardial fat has a role in atherosclerosis, an increase in epicardial fat volume has a relationship with the type of plaque without calcification and plaque with a mixture of calcifications that cause stenosis in the coronary artery lumen.13 the influence of epicardial fat volume on the degree of severe coronary artery stenosis is mainly due to soft plaque and mix plaque-type atherosclerosis.14 epicardial fat tissue contributes to the pathogenesis of coronary atherosclerosis. atherosclerotic plaques are classified into calcified, non-calcified, and mixed lesions. the attenuation assessment of hu ≥130 is considered the type of calcification. a cardiac ct-scan analysis has shown that calcified plaque if at least 0.5 mm2 in the identified area diameter has a density ≥130 hu.15 furthermore, uncalcified plaques are divided into 2 based on hounsfield unit (hu) values, which are low plaque (hu 0-49) that is considered to be lipid-rich plaques, and medium (hu 50-129) is considered fibrous-rich plaques.15 in plaques that show calcification ≤50% of the plaque area is classified as a mixture.12 since research on the relationship of coronary artery plaque iman imaduddin robandi et al.: type of coronary artery plaque in relation to epicardial fat volume in coronary heart disease patients: a cardiac computed tomography scan study figure 1 assessment of the type of coronary artery plaque althea medical journal. 2020;7(3) 144 amj september 2020 types with epicardial fat volume in patients with coronary heart disease using a ct scan of the heart has never been done in the dr. hasan sadikingeneral hospital bandung, this study aimed to find the relationship of coronary artery plaque types with epicardial fat volume in patients with coronary heart disease using a ct scan of the heart. methods this study was an observational analytic study with a cross-sectional design, conducted in patients with chd. the chd patients aged >20 years old, who underwent cardiac ct scan at dr. hasan sadikin general hospital bandung from february to june 2019 were recruited. this study measured epicardial fat volume (efv) and the type of coronary artery plaque based on calcification formed. this study was approved by the ethical committee of dr. hasan sadikin general hospital bandung with the number lb.02.01/x.6.5/111/2019. in brief, cardiac 128-slice ct scans (the scenaria se, hitachi healthcare) was used, consisting of digital imaging and communication in medicine (dicom) data. aquarius intuition client ver.4.4.12.196.3577 post-processing workstation, terarecon software, terarecon ct-cardiac workflow software terarecon-aquarius intuition client ver. 4.4.12.196.3577, terarecon 3d fat analysis. trace data on the results of the ctscan of the heart i.e. the type of plaque on the coronary arteries (figure 1) and the fev (figure 2). the assessment of coronary artery stenosis by reconstructing dicom data using terarecon software, ct-cardiac analysis workflow that made a reconstruction of volume rendering technique (vrt), multi planar reformation (mpr), curved planar reformation (cpr), then the amount of stenosis in each branch of the coronary arteries i.e. right circumflex artery (rca), left circumflex (lcx) artery, left ain (lm) artery left anterior descending (lad) artery was assessed. coronary artery stenosis was caused by atherosclerotic plaque lesions in the form of calcified, non-calcified, or mixed plaque. quantitative measurement of plaque types was measured using plaque analysis methods by assessing the hounsfield units (hu). the coronary ct-scan images were analyzed using an image archiving and communication system. if an abnormal segment was identified, the coronary artery was evaluated using the aquarius workstation (terarecon, san mateo, ca) and the non-calcified plaque volume was measured. categories based on ct (hu) value: low (hu 0–49; considered plaque rich in fat) and moderate attenuation composition (hu 50–129; considered as fibrous plaque). the plaque was color-coded and the volume of figure 2 assessment of epicardial fat volume althea medical journal. 2020;7(3) 145 each component was measured. the colorcoded area was manually adjusted, including the thickness of the blood vessel wall, and the surrounding tissue is eliminated. a 2 curved multiplanar reconstructing baselines and follow-up ct were displayed in parallel and then identical segments were compared side by side using the aquarius workstation.15 as for the efv measurement procedure, terarecon-aquarius intuition client software ver. 4.4.12.196.3577, terarecon 3d fat analysis was used. with the semi-automatic method on axial pieces with a thickness of 1–3 mm, it was done manually by tracing the epicardial layer in each cut from the appendix to the atrium of the heart. epicardial adipose tissue was identified by hounsfield units (hu) which were set at -250 to -30, then efv was then automatically measured by the computer. the epicardial fat volume (efv) data was then categorized as normal and abnormal. epicardial fat was identified as a hypodense lesion that surrounded the myocardium and was bounded by the pericardium the efv data normality test was conducted with the saphiro wilk test (n=54) and data was normal distributed if the value of p> 0.05. the bivariate analysis aimed to examine the relationship of efv with the degree of coronary artery stenosis, using the anova test if the efv data were normally distributed, or the kruskallwallist test if the efv data were not normally distributed. data analysis was performed using the statistical product and service solution (spss) program for windows version 18.0. results of 54 chd patients, that were equally distributed in gender, the majority was aged above 60 years (31.5%). the majority had a volume of epicardial fat detected >125 ml which was categorized as abnormal. the average value of fraction ejection was 49.33 range 13.92–88.49). the average of calcium score was 398.72 (range 0–4778). there was a significant relationship in the value and category of efv with the type of coronary artery plaque in chd patients. it was not all plaque collection sites had the same results. in rca and lcx, plaque type iman imaduddin robandi et al.: type of coronary artery plaque in relation to epicardial fat volume in coronary heart disease patients: a cardiac computed tomography scan study table 1 characteristics of patients with coronary heart disease from dr. hasan sadikin general hospital characteristics total (n) percentage (%) gender male 27 50.0 female 27 50.0 age (years) ≤30 4 7.4 31-40 6 11.1 41-50 12 22.2 51-60 15 27.8 >60 17 31.5 epicardial fat volume normal <125 ml 17 31.5 abnormal >125 ml 37 68.5 ejection fraction averange±sd 49.33±18.81 median (min-max) 52.58 (13.92–88.49) calcium score averange±sd 398.72±776.30 median (min-max) 65.10 (0.0–4778) althea medical journal. 2020;7(3) 146 amj september 2020 and epicardial fat volume had a significant correlation with p=0.026 and p=0.038, respectively. in contrast, in the lm and lad, no significant different between the type of plaque and epicardial fat volume (table 2). discussions this study shows the characteristics of patients with coronary heart disease (chd) of whom the relationship has been analyzed between the epicardial fat volume (efv), and the type of plaque in the coronary arteries. interestingly, measurement of epicardial fat volume carried out at the workstation as described by gorteret al. in bertaso et al. did not reveal the assessment of the visceral layer of the pericardium.13 it was carried out manually from the center of the left atrium to the top of the left ventricle, and all extrapericardial tissue was eliminated. the images then segmented using attenuation thresholds that vary between −250 hu and −30 hu so that they depict the epicardial fat portion in each slice. this did not include myocardium, coronary arteries, coronary calcium, aorta, and blood clusters. the epicardial fat area at each level was added across the slices and multiplied by the thickness of the slices and the number of slices to determine the total epicardial fat volume (figure 2). this method is also used to measure epicardial fat volume reported by alexopoulos et al.13 age distribution ranges from 30 years to 80 years. this is adjusted to the inclusion criteria taken. the age characteristics of the subjects of this study are in accordance with 2015 heart disease and stroke heart disease statistical data which states the prevalence of chd in the united states starting from age >20 years and the coronary artery atherosclerosis process begins to emerge in the second decade of life. the age distribution and the amount of epicardial fat volume have a bearing on the potential for coronary atherosclerosis, so in this case, it is directly proportional to the increase in the increase in the calcium score. there is conformity with the types of soft plaque, mix plaque, and hard plaque. this study found the results of coronary compliance in rca and lcx patients who have epicardial volume values of more than 125 ml have a correlation with the type of mix plaque and hard plaque. the majority of chd patients in our study was aged above 60 years with a percentage of 31.5%, however, there was also an age over 30 years have significant value (table1). the volume of epicardial fat detected is predominantly above 125 ml which is included in the abnormal category (n=37) that directly proportional to the average age above 60 years affected by chd. the average of fraction table 2 correlation of plaque types with epicardial fat volume plaque/burdens epicardial fat volume total p-value normal abnormal rca soft 3 (37.5%) 5 (62.5%) 8 (100%) 0.026* hard 5 (17.2%) 24 (82.8% 29 (100%) mix 9 (56.3%) 7 (43.8%) 16 (100%) lm soft 2 (25.0%) 6 (75,0%) 8 (100%) 0.802 hard 2 (14.3%) 12 (85.7%) 14 (100%) mix 2 (22.2%) 7 (77.7%) 9 (100%) lad soft 1 (100.0%) 0 (0.0%) 1 (100%) 0.183 hard 6 (22.2%) 21 (77.8%) 27 (100%) mix 8 (34.8%) 15 (65.2%) 23 (100%) lcx soft 6 (60.0%) 4 (40.0%) 10 (100%) 0.038* hard 3 (15.0%) 17 (85.0%) 20 (100%) mix 6 (28.6%) 15 (71.4%) 21 (100%) note: rca= right circumflex artery, lm= left main, lad= left anterior descending, lcx= left circumflex. * was statistically significant p<0.05 althea medical journal. 2020;7(3) 147 ejection is 49.33 (range 13.92–88.49) and the average of calcium score is 398.72 with a wide range (0–4778). the average volume of epicardial fat found in population-based studies ranged from 68±34 ml to 124±50 ml. in a study including patients from the framingham group, the average volume of epicardial fat was 110±41 ml in women and 137±53 ml in men.16 epicardial fat is a deposit of visceral fat which partly shares its metabolic and systemic inflammatory effects so that it has an effect on the wall coronary arteries. epicardial fat is consistently associated with metabolic syndrome and coronary heart disease. according to current knowledge, ef thickness >5 mm, or volume >125 ml or 68 ml/m² are considered abnormal.16 in accordance with data from the ministry of health republic of indonesia in 2013, bertaso et al.16 has suggested that the normal efv value is <125 ml and the not normal>125 ml. however, other study argued that epicardial fat has a role in atherosclerosis, an increase in epicardial fat volume has a relationship with the type of plaque without calcification and plaque with a mixture of calcifications that cause stenosis in the coronary artery lumen.13 the effect of epicardial fat volume on the degree of severe coronary artery stenosis mainly due to soft plaque and mix-hard plaque type or atherosclerosis.14 the limitation of this study is that this study did not include risk factors for chd among patients. furthermore, the evaluation of efv and the degree of coronary artery stenosis is highly dependent on the operator’s ability to reconstruct dicom data from cardiac ct scans to conclude, there is a significant relationship between the efv value, efv category, and the type of coronary artery plaque in chd patients in rca and lcx arteries. however, this correlation is not observed in lm and lad arteries. further research needs to be done with a greater number of subjects and vary both female and male patients, including the coverage of all adults, including other risk factors for chd in patients undergoing cardiac ct-scan examination. references 1. american heart association. coronary artery disease-coronary heart disease. article. 2015. [cited 2019 january 26] available from: https://www.heart.org/ en/health-topics/consumer-healthcare/ what-is-cardiovascular-disease/coronaryartery-disease 2. national heart, lung, and blood institute (nhlbi). coronary heart disease. 2017. [cited 2019 january 26]. available from: https://www. nhlbi.nih.gov/health-topics/coronaryh e a r t d i s e a s e # : ~ : tex t = c o ro n a r y % 2 0 microvascular%20disease%20affects%20 the,heart%20works%20to%20learn%20 more. 3. kotseva k, wood d, de bacquer d, de backer g, rydén l, jennings c, et al.. euroaspire iv: a european society of cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 european countries. eur j prev cardiol. 2016;23(6):636–48. 4. european society of gynecology (esg), association for european paediatric cardiology (aepc), german society for gender medicine (dgesgm), regitzzagrosek v, lundqvist cl, borghi c, et al. esc guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the european society of cardiology (esc). eur heart j. 2011;32(24):3147–97. 5. wong nd. epidemiological studies of chd and the evolution of preventive cardiology. nat rev cardiol. 2014;11(5):276–89. 6. biro komunikasi dan pelayanan masyarakat kementerian kesehatan ri. penyakit jantung penyebab kematian tertinggi, kemenkes ingatkan cerdik. 2017. [cited 2019 january 30] available f r o m : . h t t p : / / s e h a t n e g e r i k u . ke m ke s . go.id/baca/umum/20170801/2521890/ penyakit-jantung-penyebab-kematiante r t i n g g i ke m e n ke s i n ga t ka n c e rd i k2/#:~:text=penyakit%20jantung%20 p e n y e b a b % 2 0 k e m a t i a n % 2 0 t e r t i n g g i % 2 c % 2 0 k e m e n k e s % 2 0 ingatkan%20cerdik,-0&text=survei%20 sample%20regristration%20system%20 (srs,yakni%20sebesar%2012%2c9%25. 7. rumah sakit dr. hasan sadikin. rangking penyakit di instalasi rawat inap dan rawat jalan periode januari-desember 2017. bandung: rumah sakit dr. hasan sadikin;2017. 8. chatzikonstantinou a, ebert ad, schoenberg so, hennerici mg, henzler t. atherosclerosis in intracranial, extracranial, and coronary arteries with aortic plaques in patients with ischemic stroke of undetermined etiology. int j iman imaduddin robandi et al.: type of coronary artery plaque in relation to epicardial fat volume in coronary heart disease patients: a cardiac computed tomography scan study althea medical journal. 2020;7(3) 148 amj september 2020 neurosci. 2015;125(9):663–70. 9. sacks hs, fain jn, holman b, cheema p, chary a, parks f, et al. uncoupling protein-1 and related messenger ribonucleic acids in human epicardial and other adipose tissues: epicardial fat functioning as brown fat. j clin endocrinol metab. 2009;94(9):3611–5. 10. yerramasu a, dey d, venuraju s, anand dv, atwal s, corder r, et al. increased volume of epicardial fat is an independent risk factor for accelerated progression of sub-clinical coronary atherosclerosis. atherosclerosis. 2012;220(1):223–30. 11. demircelik mb, yilmaz oc, gurel om, selcoki y, atar ia, bozkurt a, et al. epicardial adipose tissue and pericoronary fat thickness measured with 64-multidetector computed tomography: potential predictors of the severity of coronary artery disease. clinics (sao paulo). 2014;69(6):388–92. 12. aslanabadi n, salehi r, javadrashid a, tarzamni m, khodadad b, enamzadeh e, et al. epicardial and pericardial fat volume correlate with the severity of coronary artery stenosis. j cardiovasc thorac res. 2014;6(4):235–9. 13. alexopoulos n, mclean ds, janik m, arepalli cd, stillman ae, raggi p. epicardial adipose tissue and coronary artery plaque characteristics. atherosclerosis. 2010;210(1):150–4. 14. rajani r, shmilovich h, nakazato r, nakanishi r, otaki y, cheng vy, et al. relationship of epicardial fat volume to coronary plaque, severe coronary stenosis, and high-risk coronary plaque features assessed by coronary ct angiography. j cardiovasc comput tomogr. 2013;7(2):125–32. 15. you s, sun js, park sy, baek y, kang dk. relationship between indexed epicardial fat volume and coronary plaque volume assessed by cardiac multidetector ct. medicine (baltimore). 2016;95(27):e4164. 16. bertaso ag, bertol d, duncan bb, foppa m. epicardial fat: definition, measurements and systematic review of main outcomes. arq bras cardiol. 2013;101(1):e18–28. althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 21 correspondence: gowre govindasamy, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: 08170206588, email: gowre_7@yahoo.com isolation and identification of pathogenic fungi from air conditioners in tutorial rooms of the faculty of medicine, universitas padjadjaran gowre govindasamy1, usep abdullah husin2, yoni fuadah syukriani3, sunarjati sudigdoadi2, yanti mulyana2 1faculty of medicine, universitas padjadjaran, 2department of microbiology, faculty of medicine, universitas padjadjaran, 3department of forensic and legal medicine, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: awareness about health problems caused by air conditioner is very important. thus, it is crucial to have knowledge about proper maintenance of air conditioner. at the faculty of medicine, universitas padjadjaran, air conditioners are used in every tutorial rooms. this study was performed to provide adequate information on the fungi, such as aspergillus, penicillium and mucor, found in air conditioners. methods: a descriptive laboratory study was used to identify the presence and the type of pathogenic fungi from air conditioners in tutorial rooms. thirty-four samples were collected from the air outlet grille of the air conditioners and cultured on sabouraud agar at 27°c for 2 weeks. fungi presence were then identified microscopically results: the results showed that the majority of air conditioners in tutorial rooms of the faculty of medicine, university padjadjaran contained many types of fungus that grew in sabouraud agar. from 34 samples, thirty two samples were positive and 2 samples were negative. various fungus have been identified, those were penicillium (37.5%), aspergillus (25%), mucor (2.5%) and unidentified (35%) conclusions: the majority of air conditioners in tutorial rooms of the faculty of medicine, universitas padjadjaran contained many types of opportunistic fungus. [amj.2014;1(1):21–4] keywords : air conditioner, aspergillus, fungi, mucor, penicillium isolasi dan identifikasi jamur patogen dari pendingin udara di kamar tutorial dari fakultas kedokteran, universitas padjadjaran abstrak latar belakang : kesadaran tentang masalah kesehatan yang disebabkan oleh pendingin udara sangat penting. dengan demikian , sangat penting untuk memiliki pengetahuan tentang perawatan yang tepat dari pendingin udara. di fakultas kedokteran, universitas padjadjaran, pendingin udara digunakan di setiap kamar tutorial . penelitian ini dilakukan untuk memberikan informasi yang memadai tentang jamur, seperti aspergillus, penicillium dan mucor, yang ditemukan di pendingin udara. metode: sebuah studi laboratorium deskriptif digunakan untuk mengevaluasi keberadaan dan jenis jamur patogen dari pendingin udara di kamar tutorial. tiga puluh empat sampel dikumpulkan dari kisikisi pendingin udara dan dikultur pada sabouraud agar pada 27 °c selama 2 minggu. pertumbuhan jamur kemudian diidentifikasi secara mikroskopis. hasil : hasil penelitian menunjukkan bahwa pada sebagian besar pendingin udara di ruang tutorial fakultas kedokteran universitas padjajdjaran terdapat banyak jamur yang dapat tumbuh di sabaroaud agar, 32 hasil positif dan 2 hasil negatif untuk pertumbuhan jamur . jamur yang tumbuh adalah penicillium (37,5%, aspergillus (25%), mucor (2,5%) dan tidak teridentifikasi (35%). simpulan : sebagian besar pendingin udara di ruang tutorial fakultas kedokteran universitas padjadjaran jatinangor menunjukkan adanya pertumbuhan jamur oportunistik kata kunci : aspergillus, jamur , mucor , penicillium, pendingin udara althea medical journal. 2014;1(1) 22 amj june, 2014 introduction in this era, the most frequently used cooling machine for buildings is the air conditioner. air conditioner has brought benefits to human’s life in the form of comfort during hot weather. even though air conditioner has its own disadvantages such as being costly compared to other appliances and uses a lot of electricity. people are very keen in using air conditioner and they are unaware about the health problems that might be caused by the air conditioner. appropriate knowledge on proper maintenance of air conditioner is very important because some pathogenic microorganisms, such as aspergillus sp., penicillium sp, legionella , and others, may grow in the air conditioner and pose risks for human being.1,2 according to a research conducted in poland, it has been proven that there are increased concentrations of mycotoxin moulds penicillium sp and aspergillus sp. in the air of buildings with poor ventilation or damaged and ineffective air conditioning systems.3 mycotoxin is a poisonous substance produced by fungi which is capable of causing diseases and death in humans and animals.4 another research was conducted in the united states to reveal the statistics of infection caused by aspergillus sp., known as aspergillosis. it has also been confirmed that there is an increase in the number of aspergillosis-related hospitalization. the average hospitalization days of patients with aspergillosis is longer and the cost is also higher compared to patients without aspergillosis.5 however, less data are provided for asian countries such as indonesia and malaysia. more studies should be conducted in asian countries to know the prevalence and emerging of the pathogenic infections caused by fungus. by understanding more about pathogenic fungus, we can prevent the infection through creating public awareness through various public health programs. this is to guarantee a healthier life and a better future for the community. the setting of tutorial rooms is selected because students of the faculty of medicine, universitas padjadjaran spend almost nine hours every week in the tutorial rooms compared to other rooms such as the clinical skill room and lecture hall where they spend less time. methods this study was a descriptive study to identify the presence of pathogenic fungi in air conditioners of tutorial rooms at the faculty of medicine, universitas padjadjaran. samples used for this research were swabs from air outlet grille of the air conditioners in tutorial rooms. the sampling method was simple random sampling based on the number of the tutorial rooms. the inclusion criteria were samples from air conditioners that were routinely used and had not been cleaned for more than a month. air conditioners that were out of service and tutorial rooms which are not frequently used were excluded from the study to avoid bias. the experiment was started by taking swabs from the inner surface of the air conditioner where the air outlet grille was located. the cotton swab was then placed in a sterile container with physiologic saline as a transport medium. later, the cotton swabs used to take the samples from air conditioner were inoculated directly on the sabouraud’s agar with chloramphenicol. the samples that were inoculated onto the sabouraud’s agar were then incubated for 2 weeks at 27 ºc and observed everyday for the growth of fungi. the growing colonies were later observed macroscopically and microscopically. microscopic examination was performed on by first wiping the object glass using cotton balls soaked with 95% alcohol or burnt directly over the spirit lamp to free the slide from fat.6 then, samples from every growing colony were retrieved using the cellophane tape. a drop of lactophenol cotton blue was added to the slide and the specimen from the cellophane tape was gently applied on the cleansed object glass.7 the slide was the examined under a microscope. the identification of fungus was made by observing the reproductive structures, such as the spores, and the macroscopic appearance of the culture. results microbiological examinations were conducted on 34 samples from swabs that were collected from the air conditioner’s air outlet grille. these samples were collected over a period of 2 weeks from the tutorial rooms of the medical faculty. the samples were inoculated directly onto the sabouraud agar on the same day when the samples were collected. althea medical journal. 2014;1(1) 23 discussion this study shows that the majority of air conditioners in tutorial rooms of the faculty of medicine, universitas padjadjaran contain many types of fungus that can grow a colony in sabouraud agar. this may be due to a number of reasons such as the air conditioners are not serviced, cleaned, and maintained as they should, so there is an ample time for the fungus to grow. fungi can grow on soft porous insulation materials known as the filter, which is used in air conditioners to absorb moisture and volatile organics.8 these organics are used by fungus as nutrients for growth.8 the temperature of the air conditioner when it is on and off can affect the growth of fungus because fungus can survive in cold and warm temperature.9 in addition, the condition of the tutorial room itself can affect the growth of fungus. the windows in tutorial rooms are seldom opened because the air conditioner is switched on. a closed area will have a poor air ventilation and this will trap the indoor air which contains dust in the room, making it the nutrition source for the microorganisms.10 table 1 fungal growth on sabouraud agar fungal growth total growth percentage (%) positive 32 94.1 negative 2 5.9 table 2 fungus colony identification fungus colony number of colony percentage (%) penicillium 30 37.5 aspergillus 20 25 mucor 2 2.5 unidentified 28 35 the positive samples were then evaluated macroscopically and microscopically for identifying the fungus according to the features of the fungus, such as like hyphae, spore, color, and others. the total number of colonies was 80. furthermore, the presence of trash under the table and in the garbage bin also provides the necessary nutrition for fungus and other microorganisms.10 thus, there are many factors that help the fungus to grow in the tutorial room. to prevent this condition, routine cleaning is the simplest way to control fungal contamination in air conditioners.10 the types of fungus that can grow in the air conditioners, as shown by this study are, among others, aspergillus, penicillium and mucor, which are categorized in opportunistic fungus.12 this is in line with the types of fungus commonly found in air conditioners in the other studies. 8,12 these opportunistic fungus, normally take advantage from those with weakened immunity but does not normally cause illness in people with healthy immune system.7 when there is a decrease in human immune system, the spore from aspergillus, penicillium or mucor that is inhaled will produce an allergic reaction, with lungs as the most common organ to be attacked. infection by aspergillus is known as aspergillosis, while infections caused by penicillium and mucor are referred to as penicilliosis and zygomycosis, respectively.12 a research in pune, india, on air conditioners in operating theaters of several different hospitals showed fungal isolation in split air conditioner and window-mounted units with a prevalence of 3.1% and 30.3%, respectively. however, fungus in air conditioners in tutorial rooms of faculty of medicine shows a higher prevalence of aspergillus and mucor.11 nonetheless, there are no standards or threshold limit values (tlvs) established yet to judge what the acceptable, tolerable, or normal quantity of mold.13,14 in conclusion, it is revealed that the pathogenic fungi are presence in the air conditioners from tutorial rooms with the frequency of 94.1%. the types of fungus found are penicillium (37.5%), aspergillus (25%), mucor (2.5%) and unidentified (35%). measures should be taken in order to prevent further dispersal of these pathogenic fungi to the surrounding air to maintain high quality air. actions that should be implemented first are regular cleaning, servicing, and maintenance of air conditioner to prevent microorganisms’ growth. adequate knowledge on pathogenic fungi is essential to create public awareness to avoid diseases that can be caused by fungus. as a result, it is important to emphasize that fungal colonization of air-conditioning systems should not be ignored, especially in hospital settings.8 gowre govindasamy, usep abdullah husin, yoni fuadah syukriani, sunarjati sudigdoadi, yanti mulyana: isolation and identification of pathogenic fungi from air conditioners in tutorial rooms althea medical journal. 2014;1(1) 24 amj june, 2014 references 1. department of architectural engineering. fungi and bacteria in ventilation systems. pennsylvania: the pennsylvania state university; 2008. [cited 2013 january 26]. available from: http://www.engr.psu.edu/ iec/abe/topics/ventilation.asp 2. occupational safety and health administration. safety and health topics: biological agents. washington: united states department of labor; 2006. [cited 2013 january 26]. available from: http:// www.osha.gov/sltc/biologicalagents/ index.html 3. łukaszuk c, krajewska-kułak e, baran e, szepietowski j, białynicki-birula r, kułak w, et al. analysis of the incidence of fungal pathogens in air of the department of dermatology, venereology and allergology of medical university in wrocław. adv med sci. 2007;52 suppl 1:15–7. 4. bennett jw, klich m. mycotoxins. clin microbiol rev. 2003;16(3):497–516. 5. warnock dw. trends in the epidemiology of invasive fungal infections. nihon ishinkin gakkai zasshi. 2007;48(1):1–12. 6. mcpherson ra, pincus mr. henry’s clinical diagnosis and management by laboratory methods. 21st ed. philadelphia, united states: elsevier health sciences; 2006. 7. world health organization. laboratory manual for diagnosis of fungal opportunistic infections in hiv/aids patients. new delhi: who publications; 2009; [cited 2012 may 15]. available from: http://apps.searo.who.int/pds_ docs/b4416.pdf 8. ljaljevic-grbic m, vukojevic j, stupar m. fungal colonization of air-conditioning systems. arch biol sci (belgrade). 2008;60(2):201–6. 9. tang jw. the effect of environmental parameters on the survival of airborne infectious agents. j r soc interface. 2009;6 suppl 6:s737–46 10. hamada n, fujita t. effect of air-conditioner on fungal contamination. atmospheric environment. 2002;36(35):5443–8. 11. kelkar u, kulkarni s. contaminated air conditioners as potential source for contaminating operation theatre environment. int j infect control. 2012; 8(1):45–8 12. brooks gf, carroll kc, butel js, morse sa. jawets, melnick, adelberg’s medical microbiology. 24th ed. michigan, united states: mcgraw-hill medical; 2007. 13. centers for disease control and prevention. basic facts: molds in the environment. atlanta: cdc; 2012. [cited 2013 january 24]. available from: http://www.cdc.gov/ mold/faqs.htm#test 14. united states environmental protection agency (epa). mold and moisture. 2012. [cited 2013 january 24]. available from: http://www.epa.gov/mold/ amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 104 althea medical journal june 2021 histopathological findings in sudden cardiac death: 5-years autopsy experience in a tertiary hospital in bandung, indonesia gian nugraha,1 nita novita,2 hermin aminah usman3 1faculty of medicine universitas padjadjaran, indonesia, 2department of forensic and medicolegal faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: gian nugraha, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: giannugraha9@gmail.com introduction death is the cessation of biological functions that maintain one’s life, occurred naturally by aging or pathological event, or unnatural by third parties such as criminal conduct, selfmurder, homicide, or traffic accident. if the cause of death is undetermined and suspicion of violence has been found, unnatural death should be considered before a natural death is concluded and affirmed by a medico legal examination that is autopsy. likewise, in sudden death, further examination is requisite to establish the cause of death.1,2 sudden death (sd) is a death that occurs within 24 hours of the onset of symptoms or unexplained death. more than 50% of sd is caused by cardiovascular diseases, referred to sudden cardiac death (scd).3 scd is an unexpected death caused by cardiovascular diseases, with or without a history of heart diseases, witnessed within 1 hour after an acute attack in clinical status, or witnessed to be alive within 24 hours before.4 even though scd incidences have declined due to the advancement of ischemic heart disease management, scd remains a significant public health issue, placed among the top contributors for premature mortality burden, and responsible for up to 50% of potential life lost from heart diseases.5 approximately 7 million death/year is booked for scd or equals 1–2 death/1000 people.6 incidence of scd cases varies, from 41.8/100.000 individuals in china to 99.4/100.000 individuals annually in australia and new zealand and 50–100/100.00 in north america and europe.7 there is no study in general about the incidence/prevalence of scd in indonesia, neither in dr. hasan sadikin general hospital, bandung. scd can be amj. 2021;8(2):104–10 abstract background: sudden death (sd) is a sudden and unexpected death with an unknown cause. however, it has been assummed that the most common causes of sudden deaths are cardiovascular or noncardiovascular causes such as gastrointestinal disease, respiratory disease, genitourinary disease, epilepsy, and trauma. this study aimed to portray histopathological findings and causes of sudden cardiac death (scd) cases based on 5 year autopsy experience in a tertiary hospital in bandung, indonesia. methods: this study was a descriptive cross-sectional study exploring causes of scd from 2015 to 2019 at dr. hasan sadikin general hospital, bandung, indonesia. all medical records with scd and histopathology findings were retrieved from september to december 2020. only cases with histopathological examination results were included. results: scd was found in 7 of 16 patients with sudden death. coronary atherosclerosis was the most common (n=4), followed by myocardial infarction (n=2) and ruptured aortic aneurysm (n=1). myocarditis and calcific aortic valve diseases were not found. conclusions: in this study, the most common cause of scd is coronary atherosclerosis, which is identified mainly in older and male patients. keywords: autopsy, forensic, coronary atherosclerosis, sudden cardiac death https://doi.org/10.15850/amj.v8n2.2324 althea medical journal. 2021;8(2) 105 identified by understanding the pathogenesis process of the disease through autopsy. it is classified into coronary atherosclerosis, myocardial infarction (mi), myocarditis, aortic valve disease, and ruptured aortic aneurysm.2 in autopsy, macroscopic and microscopic findings are requisite in establishing the cause of death.8 due to the high number of cardiovascular diseases, cardiovascular deaths, and scd cases worldwide our study aimed to give a portrait of the causes in scd cases and the histopathological findings based on 5 year autopsy experience in a tertiary hospital in bandung, indonesia. methods this study was conducted from september to december 2020 with descriptive crosssectional research. medical records of a diagnosed patient with scd from 2015 to 2019 were collected as the data source. the research ethics committee of universitas padjadjaran had approved data collection using the medical record with ethical exemption number: 746/un6.kep/ec/2020 and the research committee of dr. hasan sadikin general hospital. the total sampling method was used in this study. medical records were evaluated, included the causes of scd with the histopathology findings of the heart, gender, and age. data were considered eligible if the patient was diagnosed with scd by autopsy and were histopathologically examined in the forensic installation, dr. hasan sadikin general hospital. data were excluded when an autopsy procedure was not performed, no histopathology examination, and if the cardiovascular system did not cause the sd. data were then grouped according to the cause of scd with its histopathology findings of the heart as followed; coronary atherosclerosis, myocardial infarction, myocarditis, calcific aortic valve disease, and ruptured aortic aneurysm. in this study, the age variable was obtained from the estimated age during the autopsy procedure and then grouped into elderly (≥60), late adults (46– 59), early adults (26–45), and younger (≤25). the data were then analyzed and presented descriptively in frequency tables (microsoft office excel 2016) and narrated to portrait scd gian nugraha et al.: histopathological findings in sudden cardiac death: 5-years autopsy experience in a tertiary hospital in bandung, indonesia figure 1 flow chart of data collection of sudden cardiac death 2015–2019 note: sd= sudden death. inclusion criteria are scd, sudden cardiac death althea medical journal. 2021;8(2) 106 althea medical journal june 2021 cases based on the caused and histopathology findings, age, and gender. results during the 2015–2019 periods, only 16 out of 77 autopsied sd cases proceeded to histopathology examination, of which 7 were diagnosed with scd. the most common scd cases were in the elderly group. the youngest patient was 50 years old and the oldest was 70 years old. there was thus a trend that the incidence and the risk of scd were increased in the older population, although due to a low number of cases, statistical analyses could not be calculated. based on gender, the male patient was predominantly among the cases (6 of 7 cases). the most common histopathology finding of scd was coronary atherosclerosis (4 of 7 cases) as the primary contributing factor as the cause of death whereas myocardial infarction and accompanied by atherosclerosis as the etiology was found in 2 of 7 cases. the remaining 1 case was attributed to a ruptured aortic aneurysm with an atheromatous appearance. interestingly, there was no case found on neither myocarditis nor calcific aortic valve disease. as for cases of coronary atherosclerosis (case 1–4), it showed a variety of appearances, such as intimal thickening, fibrous cap, ruptured plaque, and others. nevertheless, all of them already developed the final stage of the atherosclerotic lesion, calcification, of which lumen occlusion (3 of 4 cases) had developed over 80%. the case of myocardial infarction (case 5) implied the infarction had been going on in the first 24 hours due to the edema. the other myocardial infarction (case 6) implied infarction had been going on for 3 to 7 days and was accompanied by rupture of the heart in macroscopic findings. in the ruptured aneurysm (case 7), the aneurysm developed in the thoracic aorta, leading to massive blood loss. discussion in scd cases, especially in out-hospital settings and unwitnessed death, suspicion elements of unnatural death or involvement of third parties should be considered in the first place. further examination is requisite to show beyond doubt that the case is linked with a medicolegal case or not, which may lead to trials and is the law of this country. visum et repertum (ver), a powerful letter concluded by the doctor through comprehensive examination or autopsy holds a critical value and as legitimate evidence in the trials, which incorporate the mechanism of death, cause of death, and manner of death, also concludes whether the case is related to medicolegal cases or not. therefore, autopsy serves as a procedure to ascertain the cause of death, issuing death certificates, and conclude medicolegal cases.1 in the advancement of technology, medicolegal autopsies procedure, specifically in scd cases, do not only serve as tools to ascertain the cause of death but also serve as knowledge for preventing scd by knowing underlying cardiac disorder, which can be hereditary, through integrating genetic testing in the management of scd. information about the risk of evolving disease in the family might of beneficial thus prevention can immediately table 2 cause of death based on histopathology findings among patient with sudden cardiac disease histopathology findings frequency coronary atherosclerosis 4 myocardial infarction atheromatous plaque platelet aggregation thrombus growth 2 myocarditis lymphocytic neutrophilic eosinophilic giant cell calcific aortic valve disease ruptured aortic aneurysm atheromatous dissecting 1 table 1 characteristics of scd data characteristics frequency (n=7) age group younger (≤25 years old) early adult (26–45 years old) late adult (46–59 years old) elderly (≥60 years old) 2 5 gender male female 6 1 althea medical journal. 2021;8(2) 107gian nugraha et al.: histopathological findings in sudden cardiac death: 5-years autopsy experience in a tertiary hospital in bandung, indonesia be carried out.9 in this study, the most common cause of death of sd cases is cardiac compared to all sd cases. although the number of the cases is limited, another study has shown that up to 85% of sd cases are of cardiac origin.10 this limited number might be due to financial elements, ethical consideration, community knowledge of autopsy, and religion, that may contribute to the low number of autopsies in figure 2 histopathological with hematoxylin and eosin (h&e) stain findings of 7 scd cases note: case 1-4, coronary atherosclerosis. 1. lumen occlusion <80%, intimal thickening, plaque ulceration, and calcification. 2a. lumen occlusion >80%, intimal thickening, and calcification. 2b. 100x magnifications, arrow indicated cholesterol crystal plaque. 3a. lumen occlusion >80%, intimal thickening, and fibrous cap. 3b. ruptured plaque and calcification. 4. lumen occlusion >80%, intimal thickening, and calcification. case 5-6, myocardial infarction. 5. fragmentation of fiber, inflammatory cell infiltration, and edema. 6a. the waviness of fiber. 6b. fragmentation of fiber. 6c. inflammatory cell infiltration. 6d. contraction band and necrosis. 7. ruptured aortic aneurysm with wall thinning, hyalinization of tunica media, adventitia with inflammation cell, and ruptured lumen with clotting althea medical journal. 2021;8(2) 108 althea medical journal june 2021 indonesia and worldwide.11 only 16 out of 77 (20.7%) of autopsied cases in our study have been proceeded to histopathology examination since the procedure is not conducted as compulsory. the association of european cardiovascular pathology guidelines for autopsy investigation of scd suggests that histopathological examination is one of the minimum standards procedure.12 in fact, histopathological examination holds an essential function to confirm, establish, or reject macroscopical examination.13 this study has shown that the mechanism of death of 40% out of 428 autopsy cases has been found by microscopic examination, even though no abnormality has been shown in the macroscopic examination. in practice, extensive autopsy (including histopathology and lab examination) can suppress the unexplained cause of death from 5–10% to 1–5%.10 in other countries, such as denmark, forensic autopsies are compulsory when external examination cannot establish the cause of death or related to the criminal investigation, and the histopathology examination is conducted as a routine examination.14 those statements should serve as a role model for indonesia to fulfill the primary standard in performing the autopsy, to reveal and to establish the cause of death, as well as to publish the death certificate. a similar study in manado, indonesia,15 has also shown a low incidence of scd due to low cases proceeded to autopsy to establish the cause of death. furthermore, our study has shown that the most common cause of scd cases is coronary atherosclerosis. about 70 to 80% causes of death in scd cases general population is coronary heart disease (chd).7,10 those findings are related and may cause many risk factors for scd parallel with a risk factor for chd itself.16 coronary atherosclerosis is correlated with myocardial infarction due to depletion of oxygen from anatomical alteration. pathologists conclude that at least 80% lumen occlusion is needed for infarction to develop. however, this number is still debatable; it turns out a relatively small degree of coronary atheroma still can cause infarction.2 infarction in our 4 coronary atherosclerosis findings is absent in this study. these findings could occur when sampling errors are not carried out at the center of the lesion. mi can be focal, diffuse, and patchy, and it needs hours to develop due to microscopical changes in ischemic circumstances.14 other studies conclude that scd in coronary atherosclerotic settings could result from myocardial electrical instability from coronary disease structural impairment or acute ischemia.16 in this study, all coronary atherosclerotic findings are accompanied by calcification lesions. calcification is responsible for plaque progression and increased lumen occlusion that worsening and provokes cardiovascular disease (cvds) episodes, leading to death. however, based on previous research, consuming statins would control and prevent the diseases’ severity by decreasing plaque formation and stabilization of plaque. this indicates that all of the luminal narrowing and calcification cases in this study may be caused by an uncontrolled and untreated disease that provoke cardiovascular disease (cvds) episodes and causing death.17 interestingly, all of the mi cases in our study are caused by the atherosclerotic lesion, causing hypoperfusion and myocyte death, conform to the theory that the most common cause of myocardial infarction death is an atherosclerotic plaque and only 10% of transmural mi coronary atherosclerosis finding. platelet aggregation and thrombus might thus the cause of this infarction. furthermore, the duration and severity of blood flow reduction are the essential factors in disease outcome.18 mi could cause scd from disturbing cardiac contractility, electrical stimulation of heart or arrhythmia, myocardial fibrosis, cardiac aneurysms, and rupture of the heart.2 rupture of an aneurysm is the most frequent extracardiac etiology of the scd, categorized as atheromatous type and dissecting type; of which atheromatous type is the most common type; similar to our finding, which is mainly in the abdominal aorta. although our case is in the thoracic part; this may be due to a low number of samples included. the blood would penetrate the degenerated vessels’ weakest point, leaked to the surrounding tissue, and causing death.2 the incidence of scd occurs mainly in the elderly population.7 there is a correlation between increased risk of scd around age 35 years with increased chd prevalence.19 in the young population (<35 years), scd incidences are much lower, approximately 0.01/100 populations annually, and primarily due to inherited genetic diseases.12 based on gender, the incidence of scd cases is more significant in males, with almost 4–7 fold in the population before 65 years old.19 in manado15, 9 out of 10 scd cases are male, it is althea medical journal. 2021;8(2) 109 similar to our finding in this study. coronary atherosclerosis, myocardial infarction, and ruptured aortic aneurysm, cvds in general, need time to establish their pathogenesis and cause mortality. therefore, those diseases relatively more often take place in the adult population. tobacco, alcohol, excessive salt intake, obesity, hypertension, diabetes, physical inactivity, air pollutant, and toxic metals were responsible for developing cvds. hence, better policy, surveillance, research, treatment, and both primary or secondary prevention are needed to reduce the burden of these preventable diseases, especially for susceptible populations.4,20 there are some limitations to this study. firstly, the low number of autopsy and histopathological examinations as a method to diagnose scd affects the study’s result, however, the distribution may reflect the general findings in another study. secondly, most of the medical records show many unknown identity patients (n=125, 41.9%); implying that the case is not being thoroughly examined, neither autopsy nor histopathology examination. in conclusion, the most common cause of scd in our study is coronary atherosclerosis, mainly in the older population and males. since scd is one of the highest burdens of mortality, it becomes a public health issue. understanding histopathology findings is thus necessary to establish the cause of death, to fulfill the minimum standard of autopsy in scd cases, and to improve the management and prevention in reducing the mortality of scd. references 1. suryadi t. penentuan sebab kematian dalam visum et repertum pada kasus kardiovaskuler. jurnal averrous. 2019;5(1):63–75. 2. saukko p, knight b. knight’s forensic pathology. 4th edition. boca raton: taylor & francis; 2016. 3. nofal hk, abdulmohsen mf, khamis ah. incidence and causes of sudden death in a university hospital in eastern saudi arabia. east mediterr health j. 2011;17(9):665–70. 4. deo r, albert cm. epidemiology and genetics of sudden cardiac death. circulation. 2012;125(4):620–37. 5. isbister j, semsarian c. sudden cardiac death: an update. intern med j. 2019;49(7):826–33. 6. parakh n. sudden cardiac death. j pract cardiovasc sci. 2015;1(2):113–9. 7. wong cx, brown a, lau dh, chugh ss, albert cm, kalman jm, et al. epidemiology of sudden cardiac death: global and regional perspectives. heart lung circ. 2019;28(1):6–14. 8. suryadi t. kematian 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autopsy. j forensic sci. 2010;55(1):85–8. 14. yazdanfard pd, christensen ah, tfelthansen j, bundgaard h, winkel bg. non-diagnostic autopsy findings in sudden unexplained death victims. bmc cardiovasc disord. 2020;20:58. 15. rorora jd, tomuka d, siwu j. temuan otopsi pada kematian mendadak akibat penyakit jantung di blu rsu prof. dr. r. d. kandou manado periode 2007-2011. jurnal e-clinic. 2014;2(3):6037. 16. sara jd, eleid mf, gulati r, holmes dr. sudden cardiac death from the perspective of coronary artery disease. mayo clin proc. 2014;89(12):1685–98. 17. jinnouchi h, sato y, sakamoto a, cornelissen a, mori m, kawakami r, et al. calcium deposition within coronary atherosclerotic lesion: implications for plaque stability. atherosclerosis. 2020;306:85–95. 18. ghafoor m, kamal m, nadeem u, husain an. educational case: myocardial infarction: histopathology and timing of changes. acad pathol. 2020;7:2374289520976639. 19. jazayeri ma, emert mp. sudden cardiac gian nugraha et al.: histopathological findings in sudden cardiac death: 5-years autopsy experience in a tertiary hospital in bandung, indonesia althea medical journal. 2021;8(2) 110 althea medical journal june 2021 death: who is at risk? med clin north am. 2019;103(5):913–30. 20. tzoulaki i, elliott p, kontis v, ezzati m. worldwide exposures to cardiovascular risk factors and associated health effects: current knowledge and data gaps. circulation. 2016;133(23):2314–33. amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 1 the ventilation-to-area ratio and house lighting relate to the incidence of pulmonary tuberculosis adil jihad muhammad,1 pudji lestari,2 agung dwi wahyu widodo3 1faculty of medicine universitas airlangga surabaya, indonesia, 2department of public health faculty of medicine universitas airlangga surabaya, indonesia, 3department of medical microbiology faculty of medicine universitas airlangga surabaya/dr. soetomo general hospital surabaya, indonesia correspondence: adil jihad muhammad, faculty of medicine universitas airlangga surabaya, jalan mayjen prof. dr. moestopo no.47, surabaya, indonesia, e-mail: adiljihad13@gmail.com amj. 2020;7(1):1–5 abstract background: indonesia is one of the heavy burden countries with high pulmonary tuberculosis incidence in the world. the physical condition of houses is one of the environmental factors on how the infection spreads. the objective of this study was to provide supporting facts between the physical environment of the houses and the incidence of pulmonary tuberculosis. methods: this was an observational analytic study with a case-control design, using checklists among pulmonary tuberculosis patients (n 32) and their healthy controls (n 32). study subjects were chosen by simple random sampling. the study was performed from march to august 2019 at the public health center (pusat kesehatan masyarakat, puskesmas) in sawahan district, surabaya. the incidence of pulmonary tuberculosis was related to various factors, including window existence, window opening habit, ventilation-to-area ratio, humidity, temperature, lighting, and occupancy density. the collected data were analyzed using the chi-square test to assess statistical significance with a p-value <0.05 was considered significantly related. results: the ventilation-to-area ratio (p<0.05) and house lighting (p<0.00) were related to pulmonary tuberculosis incidence, whereas other factors such as window existence, window opening habit, temperature, and occupancy density were not. conclusions: the ventilation-to-area ratio and house lighting have been proven to be related to pulmonary tuberculosis incidence. government regulation on building permit needs to be encouraged to reduce the spreading and the incidence of pulmonary tuberculosis. keywords: house lighting, pulmonary tuberculosis, ventilation-to-area ratio introduction tuberculosis is an airborne disease caused by mycobacterium tuberculosis and still a problematical disease for public health.1 in indonesia, east java province has a high prevalence of pulmonary tuberculosis, second after west java province.2 the sawahan public health center (pusat kesehatan masyarakat, puskesmas) covers areas of sawahan and petemon sub-district in sawahan district, one of 31 districts in surabaya, and being 3rd among the districts with a high number of incidence.3 there are many ways of prevention of tuberculosis, that have been conducted by the government and nonprofit organizations, also directed by the local community groups. the prevention of tuberculosis that has been carried out includes a free obligatory bcg vaccination, free antituberculosis drugs and mask for the patients, and many other workshops to enhance the knowledge of tuberculosis infection. however, tuberculosis prevention of environmental and behavioral aspects seem to be lacking, especially when it comes to how to live healthy and have a healthy house. the criteria of healthy houses have been written in the decree of the ministry of health of indonesia, mentioning that a house has to be reviewed from the building material, components and layout, lighting, air quality, ventilation, water, food storage, waste, and also https://doi.org/10.15850/amj.v7n1.1821 althea medical journal. 2020;7(1) 2 amj march 2020 the occupancy density.4 therefore, this study was conducted to identify the relationship between the incidence of tuberculosis and the physical condition of houses, such as window existence, window opening habit, ventilationto-area ratio, humidity, temperature, lighting, and occupancy density. the result of this study is expected to be able to assess the importance of the physical condition of healthy houses in reducing tuberculosis incidence. methods this was an analytic observational case-control study, conducted after obtaining approval from three authorities including the national unity and politics agency (badan kesatuan bangsa dan politik, bakesbangpol) surabaya, the surabaya health department, and the health research ethics committee of the faculty of table 1 standard of the healthy house according to the decree of ministry of health of republic of indonesia5 variables standard window existence yes window opening habit yes occupancy density >8m2/people ventilation-to-area ratio 10% humidity 40-60% rh temperature 18-30°c lighting >60 lux note: rh: relative humidity table 2 house condition among pulmonary tuberculosis patients compared to controls variable case control or (95% ci) p-value* n(%) mean±sd n(%) mean±sd window existence yes 25(78.1) 28(87.5) 2.778 (0.933-8.270) 0.320 no 7(22.9) 4(12.5) window opening habit yes 18(56.3) 25(78.1) 1.000 (0,060-16.713) 0.062 no 14(43.8) 7(22.9) occupancy density (people/m2) 13.2±11 15.4±13.3 ≥8 people/m2 21(65.6) 23(71.9) 1.152 (0.405-3.275) 0.790 <8 people/m2 11(14.4) 9(28.1) ventilation-to-area ratio (%) 4.3±4.4 7.4±6.7 ≥10% 2(6.3) 9(28.1) 5.870 (1.155-29.826) 0.020** <10% 30(93.8) 23(71.9) humidity (% rh) 55.2±5.8 53.6±6.3 40-60% rh 25(78.1) 28(87.5) 0.802 (0.218-2.954) 0.740 <40% rh or >60% rh 7(22.9) 4(12.5) temperature (°c) 33±0.8 33.1±1.1 18-30°c <18°c or >30°c 32(100) 32(100) lighting (lux) 30.8±27.9 75±41.1 >60 lux 3(9.4) 22(68.3) 21.267 (5.222-86.601) 0.000** <60 lux 29(90.6) 10(11.8) note: *pearson’s chi-square, **statistically significant, sd: standard deviation; or: odds ratio; ci: confidence interval; rh: relative humidity medicine, universitas airlangga, surabaya. a total of 32 pulmonary tuberculosis patients of puskesmas sawahan from january 2018 to july 2019 were collected by simple random althea medical journal. 2020;7(1) 3 sampling. healthy controls were selected, recruited from one of the 3 houses next to the cases. only those who agreed on being a study subject were included. observational checklists were distributed to assess the various physical condition including window existence, window opening habit, and occupancy density. as for the ratio of ventilation-to-area, humidity, temperature, and lighting were measured by the researchers during house visits with meter roll, hygrometer, thermometer, and lux meter, respectively. the standard of a healthy house was defined according to the decree of the ministry of health of the republic of indonesia (table 1). the collected data were analyzed using the chi-square test to assess statistical significance with a p-value <0.05 considered as significantly related. results in total, houses of 32 pulmonary tuberculosis patients and their healthy controls were assessed, and compared to the standard of healthy house, defined according to the decree of ministry of health of republic of indonesia (table 1). most of the subjects were aware of window existence (53 of 64) in their homes and opened it frequently (43 of 64). however, most of the cases were not aware of the importance of ventilation (30 of 32) and lighting (29 of 32) in their house. window existence, window opening habit, temperature, and occupancy density were not related to pulmonary tuberculosis incidence (p>0.05). interestingly, the ratio of ventilation-to-area (p<0.05) and house lighting (p<0.00) were related to pulmonary tuberculosis incidence (table 2). moreover, data on the temperature and humidity in surabaya during the period of march and august 2019 were collected from two measuring stations in perak i and juanda, showing that most humid percentages was in march (65%) and the lowest was in august (36.5%); whereas the temperature was stable over time (table 3). discussion this study has assessed the relationship between the incidence of tuberculosis and the physical condition of the houses such as window existence, window opening habit, occupancy density, ventilation-to-area ratio, humidity, temperature, and lighting. the majority of the pulmonary tuberculosis patients and the healthy controls from their neighborhood have been found to be aware of the need for every house to have a window and open it regularly. although there is no relation between pulmonary tuberculosis incidence and window existence or window opening habit, this result is in line with another study in surakarta city,6 but not with a study in puskesmas pamulang.7 furthermore, our result has shown that the occupancy density is not related significantly to pulmonary tuberculosis incidence, conforming other studies.8,9 it is well known that tuberculosis is more active in an environment with warmer temperatures.11 humidity is also proven to be a factor that plays a role in tuberculosis infection.12 however, humidity and temperature in this study have been found to be not related significantly to the incidence of pulmonary tuberculosis, in contrast with other studies.13 in surabaya city, humidity as well as the temperature. varies depending on the season. adil jihad muhammad et al.: the ventilation-to-area ratio and house lighting relate to the incidence of pulmonary tuberculosis table 3 humidity and temperature in surabaya city from march to august 201710 month perak i measuring station juanda measuring station average humidity (% rh) temperature (°c) humidity (% rh) temperature (°c) humidity (% rh) temperature (°c) march 75 33.3 55 34 65 33.7 april 71 33.5 56 34.4 63.5 34 may 62 33.8 46 34 54 33.9 june 64 32.7 46 34 55 33.4 july 65 33.1 46 33 55.5 33.1 august 31 33.5 42 32 36.5 32.8 average 54.9 33.5 note: rh: relative humidity althea medical journal. 2020;7(1) 4 amj march 2020 compared to data from the meteorological, climatological, and geophysical agency (badan meteorologi, klimatologi, dan geofisika, bmkg) surabaya in 2017, the average humidity and temperature are similar to our results in this study which is in the same month as the study conducted (table 3). the average humidity and temperature in surabaya city might thus affect the humidity and temperature in the houses. the ratio of ventilation-to-area and house lighting has been found to be related to the incidence of tuberculosis.14 this might be due to the low quality of building permit (izin membangun bangunan, imb) services in surabaya city that does not mention a detailed important health factor of a building.15 although it is mentioned in the law of imb that every building built must consider health factors, but there is no statement referred to the house criteria according to the decree of the ministry of health.16 also, there is no obligation to have ventilation and lighting planning on simple buildings such as residential houses. the ventilation and lighting planning are only required for not-simple buildings such as office towers.17 the limitation of this study is that the houses of the pulmonary tuberculosis patients are similar, and the difference between cases and controls is not significant. studies on the susceptibility and incidence of pulmonary tuberculosis based on environmental factors need further exploration, next to other factors related to the mtb spreading. in conclusion, there is no relationship between pulmonary tuberculosis incidence and various house and environment conditions such as the window existence, window opening habit, occupancy density. the humidity and temperature are also not related which may be due to the dry season. the relation with pulmonary tuberculosis incidence is more on the ratio of ventilation-toarea and house lighting. it is suggested that the quality of imb service needs to be improved, including the integration service for health inspection. therefore, government regulation on building permit needs to be encouraged to reduce the spreading and thus the incidence of pulmonary tuberculosis. acknowledgments we would like to thank puskesmas sawahan, surabaya city for providing the data needed in this research. references 1. cruz-knight w, blake gumbs l. tuberculosis: an overview. prim care. 2013; 40(3):743–56. 2. kementerian kesehatan republik indonesia. profil kesehatan indonesia tahun 2018. jakarta: kementerian kesehatan republik indonesia; 2019 [cited 2019 november 4]. available from: http:// www.depkes.go.id/resources/download/ pusdatin/profil-kesehatan-indonesia/ profil-kesehatan-indonesia-2018.pdf 3. dinas kesehatan kota surabaya. profil kesehatan kota surabaya tahun 2016. surabaya: dinas kesehatan kota surabaya; 2017 [cited 2019 november 4]. available from: http://www.depkes.go.id/ re s o u rc e s / d ow n l o a d / p ro f i l / p ro f i l _ k a b _ ko ta _ 2 0 1 6 / 3 5 7 8 _ j a t i m _ k o t a _ surabaya_2016.pdf 4. kementerian kesehatan republik indonesia. keputusan kementerian kesehatan republik indonesia no. 829/ menkes/sk/1999 tentang persyaratan kesehatan perumahan. jakarta: kementerian kesehatan republik indonesia; 1999. 5. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia no. 1077/menkes/ per/v/2011 tentang pedoman penyehatan udara dalam rumah. jakarta: kementerian kesehatan republik indonesia; 2011. 6. susanti li, astuti d, darnoto s. hubungan antara kondisi fisik rumah dan perilaku dengan kejadian tuberkulosis paru di wilayah kerja puskesmas sangkrah kota surakarta tahun 2016 [undergraduated thesis]. universitas muhammadiyah surakarta; 2016. 7. zuriya y. hubungan antara faktor host dan lingkungan dengan kejadian tb paru di wilayah kerja puskesmas pamulang tahun 2016 [undergraduated thesis]. jakarta: universitas islam negeri syarif hidayatullah; 2016. 8. mukarromah u, lagiono, triyantoro b. hubungan praktik pencegahan dan kondisi fisik rumah penderita tb paru dengan kejadian tb paru di wilayah kerja puskesmas ii sumpiuh kabupaten banyumas tahun 2016. keslingmas 2018;37(1):47–55. 9. selviana, hernawan ad, khitama i. analisis spasial sebaran kasus dan lingkungan berpotensi penularan tuberkulosis paru. althea medical journal. 2020;7(1) 5adil jihad muhammad et al.: the ventilation-to-area ratio and house lighting relate to the incidence of pulmonary tuberculosis jurnal vokasi kesehatan. 2016;2(2):152–9. 10. pemerintah kota surabaya. statistik sektoral kota surabaya tahun 2017. surabaya: pemerintah kota surabaya; 2018 [cited 2019 november 4]. available from: https://www.surabaya.go.id/uploads/ a t t a c h m e n t s / 2 0 1 8 / 1 2 / 4 0 7 1 0 / 1 . _ keadaan_geografis.pdf ?1544408374 11. fares a. seasonality of tuberculosis. j glob infect dis. 2011;3(1):46–55. 12. lestari p, sustini f, endaryanto a, asih r. home humidity increased risk of tuberculosis in children living with adult active tuberculosis cases. univ med. 2011;30(3):138–45. 13. muslimah ddl. keadaan lingkungan fisik dan dampaknya pada keberadaan mycobacterium tuberculosis: studi di wilayah kerja puskesmas perak timur surabaya. jurnal kesehatan lingkungan. 2019;11(1):26–34. 14. pradita er, suhartono, dewanti nay. kondisi faktor fisik rumah yang terkait dengan tuberkulosis paru di puskesmas bandarharjo kota semarang. jurnal kesehatan masyarakat. 2018;6(6):94–102. 15. azizah i, navastara a. identifikasi permasalahan pelayanan izin mendirikan bangunan (imb) di kota surabaya melalui surabaya single window. jurnal teknik its. 2019;8(1):c7–12. 16. presiden republik indonesia. undangundang republik indonesia no. 28 tahun 2002 tentang bangunan gedung. jakarta: pemerintah republik indonesia; 2002. 17. menteri pekerjaan umum dan perumahan rakyat republik indonesia. peraturan menteri pekerjaan umum dan perumahan rakyat republik indonesia no. 05/ prt/m/2016 tentang izin mendirikan bangunan gedung. jakarta: kementerian pekerjaan umum dan perumahan rakyat republik indonesia; 2016. amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 65 implementation of comprehensive geriatric assessment in elderly-friendly public health centers and general public health centers in bandung astri keli,1 sharon gondodiputro,2 nita arisanti2 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: astri keli, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan raya bandungsumedang km. 21, jatinangor, sumedang, indonesia, email: astri16002@mail.unpad.ac.id introduction the number of the elderly in west java in 2017 was 4.16 million people and it is predicted that the number will reach to 5.07 million or 10.04% in 2021.1 bandung city as the capital of west java will have elderly about 9.17% of the total population.2 the aging process represents the accumulation of changes in organ and mental function, which causes the elderly susceptible to various diseases or symptoms, called the geriatric syndrome.3 the health providers should be able to recognize this syndrome to provide prompt treatment and prevent further complications.3 the public health center (pusat kesehatan masyarakat, puskesmas) is a primary health facility that has the authority to provide early detection assessment to identify health disorders and to refer the patients to the hospital if needed, according to the regulation of the minister of health republic of indonesia no. 67/2015.4 there are two types of puskesmas, namely eldery-friendly public health centers (puskesmas santun lansia), a puskesmas that has a program specifically designed to deliver comprehensive geriatric health care, prioritizing the promotive and preventive actions4 and the other type is puskesmas in general that provide health care for all ages and do not have a specific program for the elderly. based on the regulation of the minister of health republic of indonesia no. 67/2105, a comprehensive geriatric assessment (cga) should be carried out regardless of the type amj. 2020;7(2):65–71 abstract background: comprehensive geriatric assessment (cga) is a comprehensive, multi-dimensional biopsychosocial examination. the cga is conducted at the primary health facility such as the public health centers (pusat kesehatan masyarakat, puskesmas); categorized as eldery-friendly public health centers (puskesmas santun lansia), a puskesmas where one of its programs provides health care for the elderly, and puskesmas in general, where there is no specific program for the elderly. the purpose of the study was to analyze the difference between puskesmas santun lansia and puskesmas in providing cga. methods: a comparative analytical study was carried out from august to november 2019, involving puskesmas santun lansia (n=6) and puskesmas (n=12) in bandung city. from each puskesmas, two elderly were selected and observed for the cga. the assessment consisted of the identity of the elderly, anamnesis, vital sign examination, physical examination, assessment of nutritional status, functional, psychosocial, social, cognitive, and mental assessment. the collected data were analyzed using the chisquare or fisher’s exact test. results: this study showed that there was no difference between puskesmas santun lansia and puskesmas in the cga, except in the simple nutritional anamnesis (p=0.003), anamnesis of the symptoms or signs of the dysfunction of the organ system (p=0.034), and body mass index measurement (p=0.009). conclusions: the cga is not well implemented in both puskesmas. in the future, both of the puskesmas should enhance their knowledge and skills to provide the cga as mentioned in the regulation of the minister of health no. 67/2015. keywords: comprehensive geriatric assessment, elderly, puskesmas, puskesmas santun lansia https://doi.org/10.15850/amj.v7n2.1923 althea medical journal. 2020;7(2) 66 amj june 2020 of the puskesmas.3 the cga is conducted by a team of doctors, nurses, nutritionists, and trained public health workers.3 the cga is a multidimensional and biopsychosocial approach that assesses not only diseases as a standard medical assessment, but also to detect various conditions, such as physical, mental, functional, social, and environment that can worsen the health status of the elderly.3,5 a study to evaluate the implementation of the cga at the puskesmas has not been carried out. the purpose of this study was to analyze the difference between puskesmas santun lansia and puskesmas in providing the cga. methods a quantitative comparative analytical study was performed involving 6 puskesmas santun lansia and 12 puskesmas in bandung city, west java, indonesia from august to november 2019. the 12 puskesmas was chosen from 74 puskesmas by random number using a computer. from each puskesmas, 2 (two) elderly patients who were being examined by the health providers were selected and observed. consecutive sampling was conducted to select the elderly. the total samples were 12 elderly from puskesmas santun lansia and 24 elderly from puskesmas. permission to do the study was obtained from three institutions, namely bandung city mayor office, bandung city health office, and the selected puskesmas. this study had received the ethical clearance from the ethics committee of universitas padjadjaran bandung, indonesia, under the ethical clearance number 891/un6.kep/ ec/2019. the inclusion criteria were health providers who examined the patients in the selected puskesmas and had worked at the same puskesmas for more than 1 year. the exclusion criteria were the health providers who stopped the examination for any reason. the variables were 10 components of cga. the components were: 1) patient’s identity: age, gender, address; economic status (income and had a health insurance); social relationship with the member of the family or their neighbours that affect their health status; the environment assessment; and the persons who lived with the elderly or had the closest relationship with the elderly (living arrangement); 2) anamnesis consisted of the chief complaint, the history of the disease, the history of surgery, the history of treatment (medicine from the doctor and others), the history of family diseases, the simple nutritional anamnesis, and the anamnesis of the symptoms or signs of the dysfunctions of table 1 patient’s identity, economic status, social relationship, environmental conditions, and living arrangement no questions asked by the health provider puskesmas santun lansia n=12 puskesmas n=24 p-value 1 identity yes 12 24 n/a no 0 0 2 economic status yes 0 0 n/a no 12 24 3 social relationship yes 0 0 n/a no 12 24 4 environmental conditions yes 0 0 n/a no 12 24 5 living arrangement yes 4 2 0.149* no 8 22 notes: *fisher’s exact test; n/a= not applicable althea medical journal. 2020;7(2) 67 theorgan system; 3) the vital sign consisted of the level of consciousness, blood pressure, and heart rate; 4) physical examinations consisted of the examination of the neurology system (nerve reflex), respiratory system (sounds of the lungs), cardiovascular system (heart sounds), gastrointestinal system (epigastric palpation, bowel sounds), urogenital system (costovertebral angle tenderness test), musculoskeletal system (range of motion examination), hematology system (examination of the conjunctiva), andmetabolicendocrine system (examination of the enlargement of the thyroid gland); 5) table 2 anamnesis and vital sign examination no anamnesis and vital sign puskesmas santun lansian=12 puskesmas n=24 p-value 1 anamnesis a. chief complain yes 12 24 n/a no 0 0 b. history of disease yes 7 15 1.000* no 5 9 c. history of surgery yes 1 1 1.000* no 11 23 d. history of treatment yes 7 11 0.480** no 5 13 e. history of the family disease yes 0 1 1.000* no 12 23 f. simple nutritional anamnesis yes 6 1 0.003* no 6 23 g. symptoms or signs of the dysfunction of the organ system yes 4 1 0.034* no 8 23 2 vital sign examination a. level of consciousness yes 2 1 0.253* no 10 23 b. blood pressure yes 12 24 n/a no 0 0 c. heart rate yes 6 13 0.813** no 6 11 notes: * fisher’sexacttest; ** chi-square test; n/a=not applicable astri keli et al.: implementation of comprehensive geriatric assessment in elderly-friendly public health centers and general public health centers in bandung althea medical journal. 2020;7(2) 68 amj june 2020 assessment of nutritional status consisted of the measurements of the body mass index, nutritional intake, and mini nutritional assessment; 6) examination of the functional status measured by activity daily of living barthel; 7) assessment of psychosocial status as measured by geriatric depression scales; 8) assessment of social problems (neglected or abuse); 9) cognitive status by abbreviated mental test; and 10) mental status by the 2-minute method. each component was put in a checklist and during the observation, the researchers would fill “yes” if the components were carried out by the health provider and would fill “no” if the components were not carried out by the health provider. this checklist was provided for every elderly that was examined by the health provider. before the observation, the researcher explained the purpose, benefits, and risks of the study both to the health provider who conducted the examination and the patient. if they both agreed to participate in the study, they signed the informed consent form. the data were collected not only by observation, but the researcher also checked the patient’s medical records for taking additional information related to the components observed. the collected data were presented by tables and were analyzed using the chi-square test and fisher’s exact test. results a study on the difference between puskesmas santun lansia and puskesmas in providing the cga had been carried out involving 18 puskesmas. the elderly patients consisted of 11 males and 25 females. this study discovered that every elderly who came to the puskesmas was given an initial assessment/screening by a nurse. the assessment was a measurement of blood pressure and a short anamnesis on the patient’s complaint. then, the patient moved to the examination room where health provider table 3 physical examination of the organ systems no physical examination of the organ systems puskesmas santun lansia n=12 puskesmas n=24 p-value 1 neurology yes 0 0 n/a no 12 24 2 respiratory and cardiovascular yes 12 24 n/a no 0 0 3 gastrointestinal yes 6 6 0.157* no 6 18 4 urogenital yes 2 0 0.105* no 10 24 5 musculoskeletal yes 2 4 1.000* no 10 20 6 hematology yes 2 2 0.588* no 10 22 7 metabolicendocrine yes 2 3 1.000* no 10 21 notes: *fisher’sexact test; ** chi-squaretest; n/a= not applicable althea medical journal. 2020;7(2) 69 waited to conduct a further examination. the initial assessment and examination could be carried out in the same room or a separate room. ten of the 18 puskesmas, had a separate room to conduct the initial assessment and examination. not all the examination was conducted by a physician. the examination was conducted by a physician in seventeen of 18 puskesmas, while in one puskesmas it was conducted by a midwife. the patients’ identity was one of the components of the cga that was always asked by the health providers at both types of puskesmas. the economic status, social relationship, and environmental conditions were never asked by the health providers. the question about the persons who lived or had the closest relationship with the elderly was asked at some of the puskesmas (table 1). the statistical test using the fisher’s exact test revealed that there was no difference between the puskesmas santun lansia and puskesmas in asking about the persons who lived or had the closest relationship with the elderly (p=0.149). regarding the anamnesis, only the chief complaint was always asked at both puskesmas. the history of surgery, history of the family disease, and the symptoms or signs of the dysfunctions of the organ system were rarely asked at both puskesmas. the history of disease and treatment was not always asked at both puskesmas. this study discovered that there was a difference between puskesmas santun lansia and puskesmas in asking about nutritional status and symptoms or signs of the dysfunction of the organ system (p-value=0.003 and 0.034, respectively). the health providers at the puskesmas santun lansia frequently asked those topics to the elderly compared to the health providers at the puskesmas. regarding the vital sign examination, the blood pressure was always examined by the health providers, but the level of consciousness was rarely examined by them. moreover, the heart rate was not always examined at both puskesmas (table 2). this study discovered that the physical examinations of the system that always examined were the respiratory system and cardiovascular system. other examinations were based on patient complaints. the physical examination that never checked was the examination of the neurology system. (table 3). the examination of nutritional status that never conducted at both puskesmas, was mna and nutrient intake records. body mass index (bmi) was the only nutritional status assessment examined at the puskesmas, but most of it was conducted at the puskesmas santun lansia (table 4). this study showed that screening of the functional status, psychosocial status, social status, cognitive status, and mental status as part of the cga was not carried out at both puskesmas. the health providers mentioned that they did not have the time to do them, because there were many patients to be examined. discussions the comprehensive geriatric assessment can identify multidimensional problems suffered by the elderly. the identified problems contribute to the planning of treatment effectively to reduce mortality.5 the first component of the cga is the patient’s identity. the name, age, gender, and address can avoid table 4 nutritional status assessment nutritional status assessment puskesmas santun lansian=12 puskesmas n=24 p-value mna yes 0 0 n/a no 12 24 nutritional intake yes 0 0 n/a no 12 24 bmi measurements yes 10 9 0.009** no 2 15 notes: mna= mini nutritional assessment; bmi= body mass index;** chi-square test; n/a= not applicable astri keli et al.: implementation of comprehensive geriatric assessment in elderly-friendly public health centers and general public health centers in bandung althea medical journal. 2020;7(2) 70 amj june 2020 confusion in the provision of services to patients.6 in this study, the economic, social, and environmental issues were not assessed. a study discovered that at the community level, the socioeconomic and environmental factors severely influenced the elderly health status such as cognitive impairment, physical impairment, health decline, and mortality.7 the economic activity is essential for the elderly to improve the quality of life and their daily life activities. a previous study revealed that the health of an elderly can be influenced by their daily activities, demographic characteristics, and habits. elderly women are influenced by the economic and social demographic activities gained from their partners.8 the environmental factors are associated with the risk of falling. environments with outdoor parks can reduce falls, depression, and stress. the exposure to the sun can stabilize the heart rhythm in some people and has benefits in improving sleep quality and alleviating anxiety.9 the persons who live with the elderly are very important. they play a role as their caregiver. they help to carry out daily activities and support patients emotionally and financially. the elderly who have mobility problems will need a caregiver in doing basic activities such as moving, bathing, eating, drinking, and so on. the caregiver has the responsibility to take the patient to a health facility and to listen to the doctor’s explanation directly to prevent any misunderstood in taking care of the elderly.10 this study discovered that vital signs examination was not always examined. the vital signs are important because they are considered as the basic data to identify some organ problems especially in the elderly. the vital signs are also used to see the disease progression and therapeutic efficacy.11 this study discovered that the physical examination of all the organ systems was not carried out completely. the examinations were only performed according to the patient’s complaint. the dysfunction of the organ systems in the elderly frequently do not appear in any symptoms or signs, so it is an obligation to the health providers to perform a physical examination completely with or without any complaints from the elderly. this can help healthcare professionals to detect disease, to treat promptly and to prevent further complications.12 nutrient intake records and mna are very important tools to detect nutritional status.13 this study discovered that those tools were never conducted to the elderly. the elderly are one of the vulnerable groups susceptible to nutritional difficulties.13 the mna is highly recommended as the first-step examination to detect nutritional difficulties in the elderly.13 this study discovered that not all of the patient’s bmi was measured by the health providers. the bmi can be used to detect malnutrition.14 obesity is a major problem in the elderly and a factor in enhancing chronic diseases, morbidity, mortality, and may decrease quality of life.14 other examinations for the elderly are functional, psychosocial, social, cognitive, and mental assessment. this study discovered that those examinations were not conducted at the puskesmas. the functional assessment is used to evaluate the ability of the elderly to help themselves in daily activity. functional assessment should be performed as part of a holistic treatment for the elderly.15 all the life changes experienced by the elderly make them more sensitive, feeling of loneliness, depression, and isolation. psychosocial aspects greatly affect one’s physical health. some psychosocial problems have a role in increasing the risk of hypertension, stroke, and cardiovascular disease. the complexity of psychosocial problems makes it very difficult to detect.16 good social support will improve psychological and physical health.17 psychosocial problems, social assessment, cognitive and mental assessment are unfortunately not examined in the puskesmas. each of these components has a role in the health status of the elderly. changes in the structure and function of the brain in the elderly cause cognitive decline. cognitive disorders occur gradually to the experience of dementia. loneliness also plays a role in the impairment of cognitive function.18,19 detection of mental status is highly recommended in primary health facilities. early detection will help identify psychological or mental health problems in the elderly.20 this study has some limitations. the cga should be carried out for a new elderly patient. during the study, there were no new patients who came to the puskesmas. eventhough the standard of health care for the elderly at the puskesmas commences since 2015, the patient’s medical record was not yet revised according to the cga. this condition made the researcher had to explore the existing medical record to prove if the cga was performed or not. if there were no statements written related to the components of the cga in the medical record, the researchers decided that althea medical journal. 2020;7(2) 71 those components were not assessed or asked. it can be concluded that cga is not yet fully implemented in both puskesmas. the health providers at the puskesmas should be aware that standard medical assessment is not enough to identify the elderly’s health problems. the elderly condition is not a single one, but multi-dimension and multi-morbidity. a comprehensive assessment should be carried out to explore other issues than physical impairment, such as functional impairments and the economic, environmental, and social issues which affect elderly health. it is an input to a comprehensive intervention plan that can improve the elderly wellbeing and quality of life. references 1. west java bps-statistics indonesia. profil lansia provinsi jawa barat 2017. bandung: badan pusat statistik provinsi jawa barat; 2018. 2. bps-statistics indonesia. proyeksi penduduk kabupaten/kota provinsi jawa barat 2010-2020. jakarta: badan pusat statistik; 2015. 3. ministry of health republic of indonesia. peraturan menteri kesehatan nomor 67 tahun 2015 penyelenggaraan pelayanan kesehatan lanjut usia di pusat kesehatan masyarakat. jakarta: kemenkes ri; 2015. 4. ministry of health republic of indonesia. pedoman puskesmas santun lansia bagi petugas kesehatan. jakarta: kemenkes ri; 2010. 5. welsh tj, gordon al, gladman jr. comprehensive geriatric assessment a guide for the non-specialist. int j clin pract. 2014;68(3):290–3. 6. yudhawati dd, listiowati e. evaluasi penerapan identifikasi pasien di bangsal rawat inap rsi siti aisyah madiun. jurnal medicoeticolegal dan manajemen rumah sakit. 2015;4(2):1–10. 7. zeng y, gu d, purser j, hoenig h, christakis n. associations of environmental factors with elderly health and mortality in china. am j public health. 2010;100(2):298–305. 8. kim cb, yoon sj, ko j. economic activity and health conditions in adults aged 65 years and older: findings of the korean national longitudinal study on aging. healthcare (basel). 2017;5(4):63–71. 9. joseph a, choi ys, quan x. impact of the physical environment of residential health, care, and support facilities (rhcsf) on staff and residents: a systematic review of the literature. environ behav. 2016;48(10):1203–41. 10. faronbi jo, faronbi go, ayamolowo sj, olaogun aa. caring for the seniors with chronic illness: the lived experience of caregivers of older adults. arch gerontol geriatr. 2019;82:8–14. 11. chester jg, rudolph jl. vital signs in older patients: age-related changes. j am med dir assoc. 2011;12(5):337–43. 12. kaye ja, maxwell sa, mattek n, hayes tl, dodge h, pavel m, et al. intelligent systems for assessing aging changes: home-based, unobtrusive, and continuous assessment of aging. j gerontol b psychol sci soc sci. 2011;66 suppl 1(suppl 1):i180–90. 13. lozoya rm, martínez-alzamora n, marín gc, guirao-goris sja, ferrer-diego rm. predictive ability of the mini nutritional assessment short form (mna-sf) in a free-living elderly population: a crosssectional study. peerj. 2017;5:e3345–61. 14. önal ae, seker s, kaya i, temizkan n, gur so, tezoglu c, et al. the body mass index and related factors of aged living in a district of istanbul, turkey. int j gerontol. 2012;6(3):177–81. 15. ajayi sa, adebusoye la, ogunbode am, akinyemi jo, adebayo am. profile and correlates of functional status in elderly patients presenting at a primary care clinic in nigeria. afr j prim health care fam med. 2015;7(1):810–6. 16. ross l, jennings p, williams b. psychosocial support issues affecting older patients: a cross-sectional paramedic perspective. inquiry. 2017;54: 46958017731963 . 17. oluwagbemiga o. effect of social support systems on the psychosocial well-being of the elderly in old people s homes in ibadan. j gerontol geriatr res. 2016;5(5):1000343. 18. canadian task force on preventive health care, pottie k, rahal r, jaramillo a, birtwhistle r, thombs bd, et al. recommendations on screening for cognitive impairment in older adults. cmaj. 2016;188(1):37–46. 19. vance de, marson dc, triebel kl, ball kk, wadley vg, humphrey sc. physical activity and cognitive function in older adults: the mediating effect of depressive symptoms. j neurosci nurs. 2016;48(4):e2–12. 20. samuels s, abrams r, shengelia r, reid mc, goralewicz r, breckman r, et al. integration of geriatric mental health screening into a primary care practice: a patient satisfaction survey. int j geriatr psychiatry. 2015;30(5):539–46. astri keli et al.: implementation of comprehensive geriatric assessment in elderly-friendly public health centers and general public health centers in bandung amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 8 monitoring obstacles of toddlers growth in public health center margahayu raya bandung city during the covid-19 pandemic: from cadre perspective natasya alifah sekarani,1 dewi marhaeni diah herawati,2 fedri ruluwedrata rinawan2 1faculty of medicine, universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: natasya alifah sekarani, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: natasya18005@mail.unpad.ac.id introduction growth monitoring in children under five (toddlers) is one of the specific nutrition interventions to accelerate the reduction of stunting in indonesia.1 monitoring the growth of toddlers by cadres, through weighing and measuring body length or body height, needs to be carried out according to the guidelines.1 the goal is to detect stunting toddlers at a younger age so that early intervention can be employed.2 based on the 2014 global nutrition report, indonesia is one of 117 countries with three nutritional problems, one of which is stunting.1 in the report of basic health research (riset kesehatan dasar, riskesdas) 2018, the stunting prevalence in indonesia has a slight decrease to 30.8%, compared to riskesdas 2013.3 the findings of the indonesian toddler nutritional status study (studi status gizi balita indonesia, ssgbi) in october 2019, the prevalence of stunting in toddlers has decreased into 27.67%, however, the target has not been reached yet.4 on march 11, 2020, the world health organization (who) officially announced coronavirus disease (covid-19) as a pandemic since the virus has spread globally.5 monitoring the growth of toddlers at posyandu has become irregular due to the covid-19 pandemic.2 the decrease in the percentage of toddlers weighed during the first three months of the covid-19 pandemic also proves that.2 the purpose of this study was to investigate the obstacles in monitoring the growth of toddlers at posyandu during the covid-19 pandemic. methods the research design was qualitative with althea medical journal. 2023;10(1):8–13 abstract background:toddler growth monitoring is one of the specific nutritional interventions used to accelerate stunting reduction. the covid-19 pandemic has reduced various ‘minimum service standards‘coverages, including toddler growth monitoring. this study aimed to explore the obstacles of toddler growth monitoring at the integrated service center (pusat pelayanan terpadu, posyandu) during the covid-19 pandemic. methods: this was a qualitative study with an interpretivism paradigm. the unit of analysis was posyandu of margahayu raya public health center, bandung city, west java. primary data were obtained through in-depth interviews with 10 cadres from different posyandu from september-december 2021. the data were collected using a semi-structured interview guide and a recorder, and analyzed using nvivo software. results: during the covid-19 pandemic, toddler weighing had been suspended for several months. starting in august 2020, cadres and public health center officers worked to ensure that toddlers’ weight, body length, and height could be monitored despite the numerous obstacles. conclusion: the obstacles to toddler growth monitoring are inadequate instruments of toddler body height measuring during home visits, minimum cadre skills, a lack of toddlers’ mother awareness to bring their toddlers to posyandu, and a lack of public awareness to follow health protocols. keywords: cadre, covid-19 pandemic, growth monitoring, public health center, stunting https://doi.org/10.15850/amj.v10n1.2677 althea medical journal. 2023;10(1) 9 the interpretivism paradigm, as the aim of the study was to obtain detailed and specific information.6 this study was approved by the research ethics committee of universitas padjadjaran (no. 631/un6.kep/ec/2021). the unit of analysis was integrated service center (pusat pelayanan terpadu, posyandu) in the working area of margahayu raya public health center in buah batu district of bandung, west java. cadres who have been actively monitoring the growth and development of toddlers since before the covid-19 pandemic until the covid-19 pandemic were included. exclusion criteria were cadres who did not fill out the research consent form. data were collected from september to december 2021. trusted informants were selected by first asking how many years they had been a cadre on that posyandu. the selected informants were cadres who played an important role in posyandu, such as the chairman, the vice, or other posyandu administrators. the primary data was gathered through an online in-depth interview method, using google meetings or whatsapp video calls. interviews were conducted until the data was saturated. the total number of informants in this study was 10 cadres who monitored the growth of toddlers at the various posyandu, shown in table 1. this research used the theoretical sampling technique since the researchers departed from theoretical propositions. the research instrument was the researcher with a semistructured interview guide. the questions were self-made and were reviewed by an expert in the field of in-depth interviews. one by one, questions were asked in a structured and deepened manner according to the critical probing that had been prepared based on previous studies. the questions focused on the description of growth monitoring activities, anthropometric tools used, and the process of recording measurement results before and during the covid-19 pandemic. furthermore, the researchers also asked questions based on informant answers outside the interview guide. researchers used video recording devices via google meetings and voice recording devices via voice memos to collect data. the recording data were then transcribed into text and analyzed with nvivo software. results in march 2020, the covid-19 pandemic was formally announced in indonesia. there was a restriction regulation to go outside. therefore, table 1 characteristics of informants informant's initials name integrated service center k1 k2 k3 k4 k5 k6 k7 k8 k9 k10 ms 17 ms 2 cj 12a cj 8 ms 8 ms 9 ms 18 ms 20 ms 15a cj 6 the body weight of the toddlers could not be monitored regularly every month at posyandu. this was supported by one of the informants’ statements: “posyandu in early 2020 still be held from january to march. after that, there was no weighing for a while due to the (covid-19) pandemic...” (k2) however, the cadres still tried to measure the body length or body height of toddlers to be carried out in the next august and february, as expressed by the following cadre: “we received an appeal for no weighing group at the beginning of march 2020, but especially in february (and) august, (posyandu was) opened” (k4) despite several obstacles, weighing and body length or body height measuring could begin in august 2020. cadres found it difficult to use a stature meter to measure the body height of toddlers, especially during home visits. consequently, they used a cloth meter to measure both the toddler’s body height also the baby’s body lengths. the following informant explained that: “…(a tool) that were affixed to the wall, (stature meter), but if we went door to door, we couldn’t carry such tools. so, i bought cloth meter...” (k1) cadres also had obstacles when posyandu reopened during the covid-19 pandemic. because cadres had visited toddler mothers at home, their awareness of bringing their toddlers to posyandu was reduced. one of the following informants explained it this way: “…(mothers of toddlers became) comfortable to being visited … (toddlers mothers) awareness to come to posyandu became difficult again… (toddlers) mothers must be socialized again…” (k9) other cadres also stated similar thing: natasya alifah sekarani et al.: monitoring obstacles of toddlers growth in public health center margahayu raya bandung city during the covid-19 pandemic: from cadre perspective althea medical journal. 2023;10(1) 10 “…it was better that way (door-to-door method) because there would be more targets, rather than waiting the toddlers to go to posyandu, uhh, it was very difficult for them to come…” (k10) furthermore, cadres found it difficult to educate toddler mothers to follow health protocols when they visited posyandu, as stated by one of the following informants: “...sometimes (we asked) why did not you wear a mask. (they answered) forgot ma’am. but we must (wrote) a report that we wore a mask when we were doing the activities. (we) told them to go home again, but their home was so far away. even though it had been announced on the speaker too, for do not forget to wear a mask, but sometimes mothers forgot just like that” (k7) the staff of the public health center also had obstacles in monitoring the growth of children under five. they could not go to posyandu or accompany cadres monthly during the covid-19 pandemic. according to the cadre, the staff of public health center had an additional burden in covid-19 vaccination activities. that was stated in the statement of one of the informants: “before the (covid-19) pandemic, every month public health center staff came to posyandu, but after the (covid-19) pandemic, not like that, maybe they were still busy because of the (covid-19) vaccine (program) for more than a year…” (k7) to validate the cadre measurements results, the officers of the public health center were still monitoring and evaluating the posyandu where there were many stunted toddlers. some cadres had not been able to accurately measure the body length or body height of toddlers, as explained by the following informant: “…the public health center (officers) althea medical journal march 2023 table 2 monitoring the growth of toddlers during the covid-19 pandemic in the work area of the margahayu raya public health center no. theme key insight 1. toddler weight weighing time not routine every month 2. body length or body height measurement time every february and august 3. obstacles that faced by cadres a. difficulty in using a stature meter, espe-cially when visiting toddler homes; there-fore, cadres used a cloth meter to measure toddler body height and baby body length b. toddler’s mothers had decreased aware-ness of bringing their toddlers to posyan-du, since they were used to being visited by cadres at their homes c. it was difficult to educate toddler’s moth-ers who visited posyandu to obey health protocols d. the cadre skills training provided by public health center officers was only for ca-dre representatives before the day of tod-dlers’ body length or body height meas-urement 4. obstacles that faced by public health center officers a. the covid-19 vaccination program is an additional task for officers at the public health center, making them unable to di-rectly accompany cadres when the process of weighing and measuring body length or body height was held b. during the monitoring-evaluation of po-syandu with a large number of malnour-ished toddlers, the officers of public health center discovered that some cadres were unable to measure the body length or height of the toddlers properly althea medical journal. 2023;10(1) 11natasya alifah sekarani et al.: monitoring obstacles of toddlers growth in public health center margahayu raya bandung city during the covid-19 pandemic: from cadre perspective intervened directly, (they asked the cadres) how could many (toddlers) from this area were stunted… indeed there was an error from the cadre too. (the cadre) did not measure it correctly. because from us, it was not just one (cadre) appointed … we were rotated…” (k6) in addition, the officers of the public health center also still found cadres who had not been able to properly weigh toddlers, as observed when the officers conducted monitoring and evaluation on posyandu where many cases of undernourished toddlers, as stated by one of the informants: “...sometimes the method of weighing was not correct. (public health center staff ) would ask, why were there so many undernourished toddlers ... and then, (public health center) staff did monitoring-evaluation again and taught (the cadre) how to weigh it correctly ...” (k2) training about procedures of weighing and measuring toddlers from the officers of the public health center was only given to cadre representatives and just before the schedule of measuring toddler body length or body height, as stated by one of the informants: “…(related to the procedure) for measuring toddlers, the public health center often holds a meeting before taking measurements… usually, only one cadre attended, and that was me. when i was taught (by public health center staff ) how to measure like this… i told the other cadres that the way to measure it was like this…” (k1) discussion covid-19 has had an impact on various aspects, one of which is health, which has created many struggles in carrying out any existing programs.7 our study has found that weighing toddlers could not be monitored for several months due to the covid-19 pandemic. children under five should be monitored regularly.1 overweight toddlers can also be at risk for stunting.8 stunting is one of the malnutrition conditions that harm the toddler’s life.2 stunting toddlers can be at risk for suboptimal cognitive development,10 obesity,11 or respiratory infections.12 interestingly, a study in bogor showed that babies under the age of two years who regularly come to the posyandu are also at the risk of experiencing stunting.9 therefore, regular visits to posyandu are important to monitor the growth and development of toddlers. as time went by, toddler growth monitoring can be carried out again during the covid-19 pandemic, even without direct assistance from the staff of the public health center. the staffs of public health center have been too busy to run a covid-19 vaccination program as the program is the primary global focus to prevent an increase in covid-19 cases.8 however, in this study, monitoring and evaluation of under-five growth monitoring activities were still carried out by puskesmas officers with the aim of validating the results of children under five measurement by cadres. monitoring and evaluating a community empowerment program is one of the success factors of a program.13 the covid-19 pandemic has also created several challenges for cadres in carrying out monitoring activities for toddler growth . cadres have difficulty convincing mothers of toddlers to follow health protocols during posyandu activities. sufficient understanding of the importance of public health protocols can also help prevent the spread of covid-19 cases.14 awareness of toddler mothers to bring their toddlers to posyandu has decreased. apart from being afraid of contracting covid-19, they also forget to bring their toddlers to the posyandu like before the covid-19 pandemic era, therefore, the cadres have to visit each other’s homes. several factors could influence mothers of toddlers to bring their toddlers to posyandu routinely.15,16 these factors include a low household income background and toddler mother’s satisfaction with the quality of cadre services, reflecting good cadre skills.16 furthermore, good knowledge of the mothers about the dangers of malnutrition that can occur to their toddlers, and strong support from cadres,15 could also be the factors influencing the routine visit to posyandu. the lack of public awareness about the dangers of stunting also became a challenge for posyandu cadres in dealing with stunting cases in the area.17 during the covid-19 pandemic, cadres did not use the proper tools to measure toddler body height, which may affect the measurement results.18 body length and height should be measured using an infantometer and a stature meter, respectively.18 however, there is now a digital body height instrument that is more practical.19 that tool has been proven to have a high level of precision and accuracy, and can be used as an alternative tool, particularly when measuring toddler body height using the door-to-door method.19 in addition to the right measuring tools, cadres must also have sufficient knowledge and skills in weighing and measuring the body length or body height of toddlers.4 there are althea medical journal. 2023;10(1) 12 still some cadres who need more skills, because the training from public health center officers is given to only some cadres. the issues related to a lack of cadre quality in early stunting detection, such as weighing toddlers, are still unresolved.20 training on the procedure for weighing21 and measuring body length or body height4 for toddlers needs to be given to all cadres. that training could improve the knowledge and skills of cadres in carrying out anthropometric measurements.4,21 sufficient skills could avoid the possibility of biased measurement results.2 this study has several limitations. due to covid-19 restriction regulations, the cadre interviews have to be conducted online, and the observations related to toddler growth monitoring activities at posyandu are unable to take place. in conclusion, the cadres and the officers at public health center have faced several obstacles in monitoring the growth of toddlers during the covid-19 pandemic. the most significant obstacles to the continuation of growth monitoring activities are the inadequate availability of instruments to measure toddler body height for a home visit, the lacking of the skills of the cadres in weighing and measuring body length or height, the awareness of toddler mothers to bring their child to posyandu, and the lack of public awareness to obey health protocols during posyandu activities. therefore, recommendations have been made to the bandung city health office to provide digital body height measuring tools to all posyandu to make it easier for cadres to measure body height toddlers during home visits and to conduct regular training for all cadres to improve cadre skills equally. in addition, suggestions for public health center officers include reminding cadres to provide socialization to toddler mothers to bring their toddlers to posyandu and educating the mothers about the importance of following health protocols. references 1. wardani z, sukandar d, baliwati yf, riyadi h. intervention strategies for stunting based on analytic network process in bangka belitung province of indonesia. afr j food agric nutr dev. 2021;21(3):17656– 68. 2. wandira ba, suarayasa k. the impact of the covid-19 pandemic on the posyandu program in palu city. ijires. 2021;8(2):140–5. 3. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. laporan nasional riskesdas 2018. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan; 2019. 4. rohmah fn, arifah s. optimalisasi peran kader kesehatan dalam deteksi dini stunting. bemas. 2021;1(2):95–102. 5. alharahsheh hh, pius a. a review of key paradigms: positivism vs 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yamazaki c, kameo s, herawati dmd, sekarwana n, raksanagara a, et al. factors influencing mother’s participation in posyandu for improving the nutritional status of children under-five in aceh utara district, aceh province, indonesia. bmc public health. 2016;16:69. 17. hamdie na, sompa at, nur ma. community empowerment strategy in handling efforts of stunting in malutu village, hulu sungai selatan. saudi j econ fin. 2020;4(9):446– 52. 18. casadei k, kiel j. anthropometric measurement. treasure islands (fl): statpearls publishing; 2023. 19. resmiati, putra me. akurasi dan presisi alat ukur tinggi badan digital untuk penilaian status gizi. j endurance. 2021;6(3):616– 21. 20. wulandari n, margawati a, rahfiludin z. the iiplementation of nutrition improvement programs for underweight children, wasting and stunting in the department of health, central buton district, southeast sulawesi. j gizi indones. 2021;9(2):86–96. 21. lubis z, syahri im. pengetahuan dan tindakan kader posyandu dalam pemantauan pertumbuhan anak balita. kemas. 2015;11(1):65–73. natasya alifah sekarani et al.: monitoring obstacles of toddlers growth in public health center margahayu raya bandung city during the covid-19 pandemic: from cadre perspective amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 191 application of replicate organism detection and counting method (rodac) in measuring mycobacterium tuberculosis contamination in high burden laboratories lidya chaidir,1,2 neng rina susilawati,2 mandala ajie,2 jessi annisa,3 muti’ah nurul jihadah4 1department of biomedical sciences, faculty of medicine, universitas padjadjaran, indonesia, 2research center for care and control of infectious diseases, universitas padjadjaran, indonesia, 3advanced biomedical laboratory, faculty of medicine universitas padjadjaran, indonesia, 4center for translational biomarker research, universitas padjadjaran, indonesia correspondence: lidya chaidir, m.si, ph.d, department of biomedical sciences, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: lidya.chaidir@unpad.ac.id introduction laboratory technicians are known to pose a higher risk of mycobacterium tuberculosis infection from processing clinical samples. a retrospective study shows that the incidence rate of developing tuberculosis (tb) in either skilled or unskilled laboratory technicians is the highest compared to non-laboratory workers, achieving 422 cases per 100,000 people each year1 despite the rigid quality control (qc) in tb laboratories. therefore, national government bodies and the world health organization (who) have published biosafety guidance to minimize the risk of tb laboratory-acquired infections.2,3 detailed minimum biosafety precautions for various types of tb diagnostics, such as ziehl–neelsen (zn) staining, culture, molecular testing, and qc, have been published. the existing qc protocol for the laboratory mainly revolves around contamination prevention,4–6 test result reliability, and external quality assessment,7–9 facilities airflow assessment and calibration,2,4,6 as well as crosscontamination assessment.9,10 however, concrete measurements of the biosafety risk of exposure to m. tuberculosis in tb laboratories althea medical journal. 2022;9(4):191–197 abstract background: technicians working in high burden tuberculosis (tb) laboratories pose a higher risk of being infected by mycobacterium tuberculosis from clinical samples. contamination control is mandatory to detect the release of bacteria into the working environment and to minimize the risk of exposure to the workers. the contamination measurement is rarely performed due to the lack of standard methodology. this study optimized and applied a unique culture-based method named replicate organism detection and counting (rodac) plates to assess the presence of m. tuberculosis contaminant in the laboratory with high burden of clinical samples. methods: rodac was applied on twenty working surfaces in the mycobacteriology laboratory of universitas padjadjaran. the results of rodac were compared with dna-based detection from the same working surfaces using in-house is6110 real-time pcr (is6110-qpcr). the detection limit of the rodac plate was 19.6 cfu ml-1. results: from all working surfaces tested, two distinct colonies were found on rodac plate stamped on the ziehl-neelsen staining basin. those colonies were identified as m. tuberculosis and nontuberculous mycobacteria (ntm), as confirmed by the mpt64 antigen test and the presence of acidfast bacilli. is6110-qpcr detected the presence of m. tuberculosis dna in ten sampling points, including the zn staining basin, incubators, and microscopy areas. is6110-qpcr detected more working surface contamination versus rodac. however, it was noted that rodac, which was a culture-based method, detected live bacteria, while pcr could not distinguish between live and dead bacteria. conclusion: the application of the rodac plate is more suitable for monitoring the contamination of live bacteria in the working environment and to inform a proper corrective action. keywords: contamination control, is6110, mycobacterium tuberculosis, qpcr, rodac https://doi.org/10.15850/amj.v9n4.2789 althea medical journal. 2022;9(4) 192 are rarely done due to the lack of standard methodology,11 so individual laboratories should improvise to ensure biosafety. this study was performed to optimize and apply a unique culture-based method named replicate organism detection and counting (rodac) plates to assess the presence of m. tuberculosis contaminant in the laboratory with a high burden of clinical samples. culture-based method using rodac plate is designed to monitor common bacterial contamination, but also works on m. tuberculosis contamination detection. this method is useful in identifying surface contaminants with a capture rate between 38– 60%, depending on the recovery time.11 rodac can also detect the release of viable bacteria to the environment, and unlike the gold standard polymerase chain reaction (pcr) based tests which can detect both dead and viable bacteria. this experiment was conducted to prove rodac effectivity compared to a pcrbased test to detect contamination in twenty surface areas in the tb research laboratory in universitas padjadjaran. the experiment results are used as the basis for improving a standard protocol for biosafety and biosecurity in a high burden tb laboratory. methods the experiment was conducted in the mycobacteriology laboratory of the faculty of medicine, universitas padjadjaran. the study did not use human samples for bioanalysis. therefore, no ethics statement was needed in conducting the experiments. the workflow was described in figure 1. the laboratory consisted of four units: 1) sputum processing and primary culture area; 2) media preparation area; 3) incubator area; 4) observation (microscopy) area (table 1 and figure 2). m. tuberculosis h37rv (atcc 27294™) was used in all optimization steps and as a positive control for the experiment. the bacterium was inoculated in a solid ogawa medium for 21 days prior to the experiment. middlebrook 7h11 (difco) for rodac was prepared with slight modification from the original protocol by daneau et al.11 briefly, mycobacteria middlebrook 7h11 agar was sterilized and supplemented with 10% oleic acid-albumin-dextrose-catalase (oadc) enrichment, 0.06% oleic acid, 5% albumin, and 0.5% glycerol. premixed polimixin b, amphotericin b, nalidixic acid, trimethropim, azlocilin (panta) were used to inhibit other bacteria’s growth. the media were then poured into rodac plates, 16 ml each, and stored at 4°c for a maximum 4 weeks. the inhibition effect of panta on m. tuberculosis growth was observed by inoculating reference strain h37rv on rodac plates supplemented with panta 2%. an inoculum of one mcfarland of m. tuberculosis h37rv was prepared and serially diluted up to 10-6. each 10-1 to 10-6 dilutions were then inoculated onto rodac plates and incubated at 37°c for 28 days. total plate althea medical journal december 2022 figure 1 sampling and detection platforms for contamination check althea medical journal. 2022;9(4) 193lidya chaidir et al.: application of replicate organism detection and counting method (rodac) in measuring mycobacterium tuberculosis contamination in high burden laboratories counts were performed at the end of the incubation period to determine the assay’s detection limit. sampling was done on various surfaces in 4 areas in the mycobacteriology laboratory (table 1 and figure 2). rodac plates were stamped on surfaces in the sampling area, with a one-minute contact time,11 including the class ii biosafety cabinet (bsc) type a2 before, during, and after performing sputum processing and primary culture; lab gowns; zn staining basin; and the microscopes. the plates were then incubated at 37°c and observed for 28 days. the presence of mycobacteria growth on the media was confirmed through zn staining and mpt64 antigen test (sd bioline, yongin, korea).12 a swab technique using sterilized cotton swabs was performed table 1 sampling areas and points a. sputum processing and primary culture area 1. class ii bsc type 2a before culture 2. interior surface of class ii bsc type 2a during culture 3. exterior surface of class ii bsc type 2a during during 4. class ii bsc type 2a 5 minutes after disinfection 5. technician’s gloves during culture assay 6. lab gowns (forearm and thigh) 7. floor 8. workbench 9. zn staining basin b. media preparation area 1. media preparation bench 2. floor 3. workbench 4. 37°c incubator c. incubator area 1. floor 2. sample processing bench 3. 37°c incubator d. observation area 1. inverted microscope 2. light microscope 3. floor 4. microscope bench figure 2 sampling points layout. a) sputum processing and primary culture room, b) media preparation room, c) incubator room. d) observation room althea medical journal. 2022;9(4) 194 on the same surface areas for is6110-qpcr analysis, which covered around 12 cm2, similar to the diameter of the rodac plate. the swabs were then dipped in phosphate buffer saline (pbs) solution and stored at 4°c prior to deoxyribonucleic acid (dna) extraction. dna from swab samples was extracted using a qiamp dna mini kit (qiagen, usa) as instructed by the manual. seven microliters of extracted dna was used as a template for is6110-qpcr for m. tuberculosis in a twenty microliter reaction.13 is6110-qpcr reaction was performed using platinum qpcr supermixudg (invitrogen, usa) in iq5 thermal cycler (biorad laboratories, inc.). the quality of the reactions was carefully controlled by including positive, negative, and internal controls for every reaction. results at the end of the incubation period, the growth of m. tuberculosis on rodac plates was observed at dilution 10-1 to 10-5 and no growth was observed at dilutions 10-6. based on the number of colonies on the most diluted series, it was found that the detection limit of the rodac plate was 19.6 cfu ml-1. the growth of bacteria was observed on the rodac plate stamped at the zn staining basin. two distinct colonies were seen on the plate. both colonies were subjected to zn staining to see the presence of acid-fast bacilli and mpt64 antigen detection to identify the m. tuberculosis complex. one colony was identified as m. tuberculosis complex and the other colony as non-tuberculous mycobacteria (ntm) (table 2). no growth was detected on rodac plates stamped on other sampling surfaces. m. tuberculosis dna was detected at 10 sampling points, mostly in the areas where zn staining activities were carried out (3 areas), incubators (2 areas), and observation rooms (2 areas). the results of the rodac plates and is6110-qpcr were shown in table 3. discussion a robust protocol for microbial risk assessment in high burden tb laboratories is nonexistent due to the wide variety of diagnostic levels and scopes per laboratory.14 therefore, the individual laboratories must improvise the way to control the release of pathogenic m. tuberculosis into the environment despite good microbiological practice (gmp) has been applied. rodac plates are commonly used for other microbial risk assessments, which inspired us to evaluate the reliability of this method as an alternative for assessing high burden tb laboratory. after optimization of the medium (by using middlebrook 7h10, which is selective for mycobacteria), we determined its least limit of detection. it was 19.6 cfu ml-1 equivalent to conventional mycobacterial cultures ranging from 10–100 cfu ml-1.15 twenty sampling points in the tb laboratory were then stamped by rodac plates and were swabbed for further qpcr tests. rodac plates are moderately sensitive to detect m. tuberculosis contaminants on the working surfaces. the bacteria captured at the staining basin were confirmed as m. tuberculosis and ntm,16,17 which is commonly althea medical journal december 2022 table 2 colonies grown on rodac plate stamped on afb staining basin’s surface morphology zn mpt64 species positive positive mtb positive negative ntm note: zn= ziehl–neelsen, mpt64= mycobacterium protein tuberculosis, mtb= mycobacterium tuberculosis, ntm= nontuberculous mycobacteria althea medical journal. 2022;9(4) 195 found as environmental bacteria. it explains the possibilities of improper disposal or disinfection of staining waste material into the zn staining basin and bacterial decay from the microscope slide to the basin during the staining process, which is still alive. the result of this experiment is very important, given alive bacilli can infect laboratory workers. by knowing the results, we have improved our decontamination process, restricted access during the staining process, and personal protective equipment to ensure biosafety. known for its higher sensitivity in m. tuberculosis detection,13,18,19 qpcr of insertion sequence is6110 was also performed in this experiment. lower cycle threshold (ct) values, indicating a higher load of m. tuberculosis dna, were detected in areas that include processing of clinical samples and positive culture, such as zn staining basin, light microscope, incubators, biosafety cabinets, and technician’s gloves during the sputum culture process. the only exception is the zn staining basin which still contained alive bacteria. most probably, the dna detected by is6110 came from dead cells, as evidenced by undetected growth on rodac plates. positive qpcr with no growth on rodac plates indicates dna remains from dead or non-viable bacteria located on the surfaces which have been killed by routine surface disinfection or room sterilization using a uv lamp. referring to these results, room sterilization and proper waste/working surface disinfection are important to assure laboratory biosafety. our study was limited by the performance of the rodac plate in a research-based high burden tb laboratory. the detection limit of the rodac plate still needs to be improved so that it can capture a lower number of live mycobacteria in other clinical environments, such as hospital wards, outpatient clinics, and others. possible routes of contamination are contaminated droplets, gloves, plate or inoculation tube surface, and aerosols from the open front of class ii bsc11 despite being calibrated routinely. proper disinfection and uv irradiation of work surfaces, bsc maintenance and calibration, and refresh lidya chaidir et al.: application of replicate organism detection and counting method (rodac) in measuring mycobacterium tuberculosis contamination in high burden laboratories table 3 comparison between rodac plates and is6110-qpcr sampling points rodac is6110qpcr bacterial inoculation room class ii bsc type iia before culture (a1) work surface during culture (a2) arm rest during culture (a3) after disinfection(a4) technician's gloves (during culture, a5) lab gown (after culture, a6) floor (a7) workbench (a8) zn staining basin (a9) growth detected dna detected dna detected dna detected dna detected media preparation room media preparation laminar (b1) floor (b2) workbench (b3) liquid culture incubator (b4) dna detected dna detected dna detected incubation room floor (c1) workbench (c2) solid culture incubator (c3) dna detected microscopic observation room inverted microscope (d1) light microscope (d2) floor (d3) workbench (d4) dna detected dna detected note: rodac= replicate organism detection and counting, bsc= biosafety cabinet, zn= ziehl–neelsen, qpcr= quantitative polymerase chain reaction, dna= deoxyribonucleic acid althea medical journal. 2022;9(4) 196 training for the laboratory technician must be given a special attention in maintaining laboratory biosafety, especially in high burden laboratories.20 rodac plates are suitable for biosafety assessment in tb laboratories on a routine basis, even though there is still a lack of data regarding the previous applications. as a simple routine assessment for high burden setting laboratory, rodac usage is advised due to its reproducible and fast ability to detect the release of viable bacteria. several studies reported the application of the method in different clinical settings, such as on the surfaces in the patient-care compartment of ambulances.21 another study applied rodac for recovery of multidrug-resistant organisms, 780 environmental surfaces in 63 rooms of patients on contact precautions in four intensive care units at one hospital.22 although those studies applied rodac plates to detect the presence of other live bacteria, not tb. further studies in the application of tb clinics can also be considered to detect the release of aerosol containing bacteria from patients’ coughs. it is recommended to complement it with a pcr test as a support to monitor the spread of environmental dna contamination. to conclude, the application of rodac plate is more suitable for monitoring the contamination of live bacteria in the working environment, and to inform a proper corrective action. further studies are needed, not only in a larger number of sampling points and laboratory settings but also in a wider variety of comparing the method to gain more data on rodac reliability. acknowledgement we thank the west java referral laboratory for supporting the technical work and providing a work space for rodac measurement in the laboratory. this study was funded by the internal grant of the laboratory division of the research center for care and control of infectious diseases, universitas padjadjaran. references 1. garnett j, jones d, chin g, spiegel jm, yassi a, naicker n. occupational tuberculosis among laboratory workers in south africa: applying a surveillance system to strengthen prevention and control. int j environ res public health. 2020;17(5):1462. 2. world health organization. tuberculosis laboratory biosafety manual. geneva: world health organization; 2012. 3. shinnick tm, glipin c. a risk assessmentbased approach to defining minimum biosafety precautions for tuberculosis laboratories in resource-limited settings. applied biosafety. 2012;17(1):6–10. 4. van soolingen d, wisselink hj, lumb r, anthony r, van der zanden a, gilpin c. practical biosafety in the tuberculosis laboratory: containment at the source is what truly counts. int j tuberc lung dis. 2014;18(8):885–9. 5. find. tb laboratory quality management systems towards accreditation harmonized checklist (incorporating slipta and gli stepwise process towards tb laboratory accreditation) [internet]. 2016. [cited 2022 april 17]. available from: https://www.finddx.org/wp-content/ uploads/2016/07/new-tb-harmonizedchecklist-v2.1-2-2016.pdf. 6. european centre for disease prevention and control. handbook on tuberculosis laboratory diagnostic methods in the european union: technical report. stockholm: ecdc; 2018. 7. ancona n, bernardo j, desmond e, etter m, gaynor a, jamieson f, et al. mycobacterium tuberculosis: assessing your laboratory [internet]. silver spring, md: association of public health laboratories; 2019. [cited 2022 april 17]. available from: https:// www.aphl.org/aboutaphl/publications/ documents/id-2019apr-tb-toolkit.pdf. 8. kim ck, chang cl. quality assurance of laboratory tests for tuberculosis. korean j clin microbiol. 2009;12(4):147–53. 9. shiferaw mb, hailu ha, fola aa, derebe mm, kebede at, kebede aa, et al. tuberculosis laboratory diagnosis quality assurance among public health facilities in west amhara region, ethiopia. plos one. 2015;10(9):e0138488. 10. johnson mg, lindsey ph, harvey cf, bradley kk. recognizing laboratory cross-contamination: two false-positive cultures of mycobacterium tuberculosis— oklahoma, 2011. chest. 2013;144(1):319– 22. 11. daneau g, nduwamahoro e, fissette k, rudelsheim p, van soolingen d, de jong bc, et al. use of rodac plates to measure containment of mycobacterium tuberculosis in a class iib biosafety cabinet during routine operations. int j mycobacteriol. 2016;5(2):148–54. 12. arora j, kumar g, verma ak, bhalla m, sarin r, and myneedu vp. utility of mpt64 antigen detection for rapid confirmation althea medical journal december 2022 althea medical journal. 2022;9(4) 197 of mycobacterium tuberculosis complex. j glob infect dis. 2015;7(2):66–9. 13. chaidir l, ganiem ar, vander zanden a, muhsinin s, kusumaningrum t, kusumadewi i, et al. comparison of real time is6110-pcr, microscopy, and culture for diagnosis of tuberculous meningitis in a cohort of adult patients in indonesia. plos one. 2012;7(12):e52001. 14. forbes ba, hall gs, miller mb, novak sm, rowlinson mc, salfinger m, et al. practical guidance for clinical microbiology laboratories: mycobacteria. clin microbiol rev. 2018;31(2):e00038–17. 15. van zyl-smit rn, binder a, meldau r, mishra h, semple pl, theron g, et al. comparison of quantitative techniques including xpert mtb/rif to evaluate mycobacterial burden. plos one. 2011;6(12):e28815. 16. nambiar r, chatellier s, bereksi n, van belkum a, singh n, barua b, et.al. evaluation of mycotube, a modified version of lowenstein–jensen (lj) medium, for efficient recovery of mycobacterium tuberculosis (mtb). eur j clin microbiol infect dis. 2017;36(10):1981–8. 17. mickymaray s, alfaiz fa, paramasivam a. efficacy and mechanisms of flavonoids against the emerging opportunistic nontuberculous mycobacteria. antibiotics (basel). 2020;9(8):450. 18. kyaw sp, hanthamrongwit j, jangpatarapongsa k, khaenam p, leepiyasakulchai c. sensitive detection of the is 6110 sequence of mycobacterium tuberculosis complex based on pcr-magnetic bead elisa. rsc adv. 2018;8(59):33674–80. 19. raj a, singh n, gupta kb, chaudhary d, yadav a, chaudhary a, et al. comparative evaluation of several gene targets for designing a multiplex-pcr for an early diagnosis of extrapulmonary tuberculosis. yonsei med j. 2016;57(1):88–96. 20. hanscheid t, grobusch mp. biosafety and tuberculosis laboratories in africa. lancet infect dis. 2010;10(9):582–3. 21. obenza a, cruz p, buttner m, woodard d. microbial contamination on ambulance surfaces: a systematic literature review. j hosp infect. 2022;122:44–59. 22. okamoto k, rhee y, schoeny m, lolans k, cheng j, reddy s, et al. centers for disease control and prevention epicenters program. flocked nylon swabs versus rodac plates for detection of multidrugresistant organisms on environmental surfaces in intensive care units. j hosp infect. 2018;98(1):105–8. lidya chaidir et al.: application of replicate organism detection and counting method (rodac) in measuring mycobacterium tuberculosis contamination in high burden laboratories amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 198 outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia nubella citresna zakiyyah,1 suryani gunadharma,2 ahmad rizal ganiem2 1faculty of medicine universitas padjadjaran, indonesia 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: nubella citresna zakiyyah, faculty of medicine universitas padjadjaran, jalan raya bandungsumedang km. 21 jatinangor, sumedang, indonesia, e-mail: nubella17001@mail.unpad.ac.id althea medical journal. 2022;9(4):198–205 abstract background: tuberculous meningitis (tbm) is a severe form of extrapulmonary tuberculosis. one of the most common complications of tbm is hydrocephalus, with a higher risk of mortality. this study aimed to evaluate the outcome among tbm patients with or without hydrocephalus. methods: this study was a retrospective cross-sectional comparative analytical study. a total sampling was employed based on the number of traceable resumes of tbm patients treated at the department of neurology dr. hasan sadikin general hospital, bandung, indonesia in 2018. results: of the 127 data of tbm patients, 55 (43.3%) had hydrocephalus, and 72 (56.7%) did not. the median age of tbm patients with and without hydrocephalus was 34 years (iqr 26–45) and 35 years (iqr 24–44), respectively. decreased consciousness dominated the clinical symptoms for 94.5% in the hydrocephalus group and 84.7% in the non-hydrocephalus group. hospital-acquired pneumonia occurred mainly in the hydrocephalus group (29.1%), whereas urinary tract infections mainly occurred in without hydrocephalus group (18%). there was a significant difference between the outcome of hydrocephalus and non-hydrocephalus (p=0.005). mortality was higher in patients with hydrocephalus compared to those without hydrocephalus. conclusions: the outcome of tbm patients with hydrocephalus is worse than those without hydrocephalus, as reflected by a higher grade of tbm, higher mortality rate, and lower good recovery upon treatment administration. therefore, prompt diagnosis and treatment are needed to improve the outcome and survival among tbm patients with hydrocephalus. keywords: hydrocephalus, outcome, tb meningitis introduction tuberculosis (tb) is one of the oldest known diseases to affect humans, caused by infection with mycobacterium tuberculosis. indonesia is the third most infected country with tb globally after india and china. the world health organization (who) estimated that the incidence of tb in indonesia in 2018 was around 316 per 100,000.1 tb usually infects the lungs. however, it can also infect other organ systems, known as extrapulmonary tb. one severe form of extrapulmonary tb is tuberculous meningitis (tbm), which has high mortality.2 the mortality rate for tbm is high, around 20–41%. therefore, the most essential factors in lowering the complications and mortality rate are early diagnosis and treatment of the disease.3 the most common and significant factor that is closely correlated with the incidence of tbm is human immunodeficiency virus (hiv) co-infection.4 other factors contributing to the incidence of tbm include diabetes mellitus,5 alcoholism, and chronic use of corticosteroids.6 progressivity of tb infection, whether pulmonal or extrapulmonal is several folds higher and more aggressive among immunocompromised individuals; hence, these patients are at higher risk of developing tuberculous meningitis and accounts higher rate of mortality.7 in tbm, mycobacterium tuberculosis initially seeds the meninges and forms a highly https://doi.org/10.15850/amj.v9n4.2304 althea medical journal. 2022;9(4) 199 infectious foci termed rich foci, specifically located beneath the pia mater, or attach to the adjacent ventricle and/or cortical tissue. rupture of these bacteria-filled foci will induce excessively and life-threatening inflammatory reactions. exudative lesion and debris produced from this process could potentially disrupt nearby tissues; if the exudate encloses the nervous system particularly cranial nerves, it will cause cranial nerve palsies. vasculitis of the cerebrovascular system arises due to endothelial and basal membrane involvement. another aspect that must be taken into account is that the exudate and inflamed meninges can also obstruct the cerebrospinal fluid (csf) flow within the cerebral ventricle system, causing hydrocephalus.8,9 the prognosis of tbm is influenced by many factors. previous findings suggest that clinical, laboratory, and radiological findings could predict the outcome of tbm.10,11 clinical parameters consisted of headache, seizure episode(s), positive neck stiffness, febrile, hydrocephalus, and neurological deficits upon examination (including comatose episode); laboratory parameters consisted of hiv serology test and/or other comorbidities, high csf protein concentration, and meningeal enhancement on radiographical imaging are all associated with poorer prognosis of tbm.10,11 the incidence of hydrocephalus among adult patients with tbm is approximately 65%. hydrocephalus is the cause of death and severe neurogenic deficits among tbm cases.3 several current studies have reported that tbm patients with hydrocephalus, particularly those who left untreated had poorer prognosis and significantly lower survival rate if compared with the tbm patients without hydrocephalus or tbm hydrocephalus patients that received treatment.10–14 this study aimed to identify the difference between the outcome of tbm patients with or without hydrocephalus treated in a tertiary hospital. methods this research was a retrospective crosssectional comparative analytical study using the medical records of patients obtained from the department of neurology dr. hasan sadikin general hospital bandung. data collection and processing were carried out in august 2020. the inclusion criteria were patients with a final diagnosis of tbm, admitted to the hospital in 2018, and aged >18 years. the exclusion criteria of this study were patients with a history of incomplete treatment and incomplete head imaging data. this research received ethical approval from the research ethics committee of universitas padjajaran, with the number 650/un6.kep/ec/2020 and the ethics committee of dr. hasan sadikin general hospital bandung, with lb.02.01/x.2.2.1/19544/2020. the data collected from the medical record included demographic data, length of stay, symptoms, physical examination, and supporting examinations among others sodium and blood sugar levels, cerebrospinal fluid analysis, head imaging, hiv status, nosocomial infections, medications, surgery performed, and the outcomes, that was assessed using the glasglow outcome scale (gos). determination of gos interpretation was carried out when the patient was discharged from the hospital by determining the presence of language disorders, motoric strength, and consciousness. the data were then interpreted to be gos 1 in patient who died; gos 2 patient was coma; gos 3 patient was in a sopor or somnolent state or had a degree of motor strength of 0 to 3 or had language disorders; gos 4 patients was in compos mentis with a degree of motor strength 4; gos 5 patient was in a state of compos mentis with a degree of motor strength of 5 or had mild neurological sequelae. data processing was carried out by calculating the mean, number, percentage, and interquartile range of characteristics of patients with or without hydrocephalus, including age, sex, symptoms, laboratory findings, radiology, tbm degree, hiv status, surgery performed, and nosocomial infection during treatment. the gos interpretation was then analyzed using mann-whitney test. results this study found 146 data of patients who were treated with a diagnosis of tbm, of whom 127 were included. in general, this study was dominated by males (51.9%). interestingly, more females were in the group without hydrocephalus (54%). the mean age of tbm patients with and without hydrocephalus was not significantly different, which was 34 (iqr 26–45) and 35 (iqr 24–44), respectively. the most common length of stay was >7 days in most patients with hydrocephalus (54.4%) or without hydrocephalus (79%), as shown in table 1. furthermore, decreased consciousness was the most common clinical symptom in this study. other symptoms, such as fever, nausea, headache, neck stiffness, and nubella citresna zakiyyah et al.: outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia althea medical journal. 2022;9(4) 200 other signs of increased intracranial pressure (icp), were higher in tbm with hydrocephalus. there was various supporting examinations, as shown in table 2. the mean blood sodium levels were lower in patients without hydrocephalus (130 meq/l; iqr 126–137). blood sugar levels were lower in tbm without hydrocephalus (107 mg/dl; iqr 94–126.7). the mean csf protein content was higher in tbm with hydrocephalus (932 mg/dl; iqr 194.5–2228.5). the mean csf cell count was higher in tbm with hydrocephalus (95 cells/ ml; iqr 27.5–264.5). the percentage of csf lymphocytes was higher in tbm without hydrocephalus (71%; iqr 40.5–91.2). the percentage ratio of csf sugar to blood sugar was lower in tbm with hydrocephalus (21; iqr 10.75–31.25). the most common finding of head imaging in tbm with hydrocephalus was communicant hydrocephalus (78.2%). interestingly, hiv positive in tbm without hydrocephalus (29.2%) was found to be higher than those with hydrocephalus (9.1%). the diagnosis of tbm in this study was most commonly probable in both groups, with hydrocephalus (70.4%) and without hydrocephalus (78.6%). grade 2 tbm was frequently found in both groups with hydrocephalus (78.2%) and without hydrocephalus (82.1%). the most common nosocomial infections in patients with hydrocephalus was hospital-acquired pneumonia (29.1%) and in patients without hydrocephalus was urinary tract infections (18%). the mortality number during treatment was almost twice higher in patients with hydrocephalus (51.6%) compared to those without hydrocephalus (26.6%). the mean length of stay to death in subjects with and without hydrocephalus was 4 days (iqr 2–13). anti-tuberculosis drugs (atd) were given to all tbm patients. surgery management for hydrocephalus was performed only in 25.4% of patients, and the others did not undergo surgery (74.6%), of whom 25.3% refused surgery, and the rest had no indication of surgery, as depicted in table 3. the outcome of tbm patients had shown that a higher mortality rate was found in hydrocephalus patients (56.4%), as shown in table 4. in contrast, patients without hydrocephalus had moderate disability outcomes such as mild motor impairment (41.6%). there was a significant difference between the outcome of hydrocephalus and non-hydrocephalus (p=0.005) (data not shown). based on the gos, the mean of the tbm with hydrocephalus was 1.49 (iqr 2–4) and without hydrocephalus was 2.53 (iqr 0–4) (data not shown). table 1 characteristics of adult tuberculosis meningitis patients with or without hydrocephalus admitted to dr. hasan sadikin general hospital year 2018 characteristic tuberculous meningitis (n=127) with hydrocephalus (n=55) n (%) without hydrocephalus (=76) n (%) sex male female 33 (60) 22 (40) 33 (46) 39 (54) age, in years–median (iqr)* 34 (26–45) 35 (24–44) length of stay >7 days <7 days 31 (56.4) 24 (43.6) 57 (79) 15 (21) clinical symptoms decreased consciousness fever nausea neck stiffness headache nerve disorder increased intracranial pressure seizure 52 (94.5) 44 (80) 16 (29.1) 47 (85.4) 48 (87.3) 5 (9.1) 3 (5.4) 3 (5.4) 61 (84.7) 49 (68) 13 (18) 56 (77.7) 52 (72.2) 7 (9.7) 1 (1.3) 7 (9.7) note: all data are presented in n (%) unless specifically stated, *there were some data not available althea medical journal december 2022 althea medical journal. 2022;9(4) 201nubella citresna zakiyyah et al.: outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia table 2 supporting examination of adult tuberculosis meningitis patients with or without hydrocephalus admitted to dr. hasan sadikin general hospital year 2018 supporting examination tuberculous meningitis (n=127) with hydrocephalus (n=55) n (%) without hydrocephalus (=76) n (%) laboratory examination blood blood natrium (meq/l) – median (iqr)* blood glucose (mg/dl) – median (iqr)* csf protein (mg/dl) – median (iqr)* cell (sel/ml) – median (iqr)* % lymphocyte – median (iqr)* % csf glucose:blood glucose ratio–median (iqr)* 130 (126–137) 112 (95–123) 932 (194.5–2228.5) 95 (27.5–264.5) 67 (38–91) 21 (10.75–31.25) 133 (126–133) 107 (94–126.7) 233 (114–918) 75.50 (7.5–206.5) 71 (40.5–91.2) 32 (19–46.7) radiology head ct scan communicating hydrocephalus non-communicating hydrocephalus 43 (78.2) 12 (21.8) 0 0 hiv positive status* 5 (9.1) 14 (29.2) diagnosis of tbm* definite probable possible 3 (11.1) 19 (70.4) 5 (18.5) 1 (3.6) 22 (78.6) 5 (17.8) tbm grade 1 2 3 0 43 (78.2) 12 (21.8) 3 (4.5) 55 (82.1) 9 (13.4) infection during treatment: hap non-hap bloodstreaminfection urinary tract infection surgicalsiteinfection no infection 16 (29.1) 3 (5.4) 6 (10.9) 3 (5.4) 33 (60) 7 (9.7) 3 (4.2) 5 (6.9) 13 (18) 49 (68) number of patients died during the treatment 31 (56.4) 16 (26.6) length of stay until death median (iqr) 4 (2 13) 4 (2–13) note: all data are presented in n (%) unless specifically stated, *there were some data not available table 3 management of adult tuberculous meningitis patients management tuberculous meningitis (n=127) with hydrocephalus (n=55) n (%) without hydrocephalus (=76) n (%) drugs atd mannitol acetazolamide anticonvulsant 55 (100) 1 (1.8) 17 (30.9) 2 (3.6) 72 (100) 1 (1.4) 1 (1.4) 7 (9.7) operation operated not operated 14 (25.4) 41 (74.6) 72 (100) note: all data are presented in n (%) unless specifically stated, atd= anti-tuberculosis drugs althea medical journal. 2022;9(4) 202 table 4 outcome in adult tuberculous meningitis patients outcome tuberculous meningitis (n=127) with hydrocephalus (n=55) n (%) without hydrocephalus (=76) n (%) death 31 (56.4)* 17 (23.6) neurovegetative state 1 (1.8) 0 (0) severe disability (patient dependent on daily support) 2 (3.6) 4 (5.6) moderate disability (patients independent in daily life) 7 (12.7) 30 (41.6)* good recovery 14 (25.5) 21 (29.2) note: all data are presented in n (%) unless specifically stated, * the most prevalent outcome. althea medical journal december 2022 discussion in this study, the most frequent clinical manifestation among tbm patients without hydrocephalus are decreased consciousness (94.5%), headache (87.3%), neck stiffness (85.4%), and fever (80%); while nausea, nerve disorder, seizure and increased intracranial pressure are in lesser percentage. patients with hydrocephalus also had neck stiffness and headache. as for the tbm patients without hydrocephalus, different results were reported from case series gathered in china, where the headache was the most common reported symptom (89.2%), followed by fever, neck stiffness, nausea and or vomiting, weakness and anorexia, and other constitutional symptoms.15 a systematic review has resulted the neck stiffness as the most commonly reported manifestation, followed by decreased alertness.16 interestingly other study in malaysia shows different order of manifestation among 143 adult tbm-hydrocephalus patients, the most common clinical presentations were fever (86.7%), followed by lesser percentage of neck stiffness, impaired consciousness, symptoms of raised intracranial pressure, hemiplegia, cranial nerve palsy, and seizure episode.12 decreased consciousness is defined as a reduced or the absence of response towards external stimuli. in general, it can be caused either by a structural or localized abnormality within the central nervous system, systemic anomalies, or both. structural abnormalities that could lead to decreased consciousness include acute stroke, traumatic cerebral injury, meningitis, intracranial hemorrhage, and cerebral distention as seen in hydrocephalus patients.17 mechanical assault from hydrocephalus, acute intracranial hemorrhage or direct trauma and tissue injury as the direct consequence of meningitis could damage the reticular activating system within the brainstem that projects into various neurological sites such as the thalamus, cortical layer and dorsal compartment of pons and midbrain, resulting in altered consciousness/sensorium.18 pathophysiology of the origin of headaches in infectious diseases is not well understood. intracranial hypertension syndrome, meningeal irritation, and activation of pain structures via the trigeminovascular system are some pathogenic mechanisms of headaches.19 in this case, tbm patients with and without hydrocephalus also experienced symptoms that refer to increased intracranial pressures other than decreased sensorium and headache, such as nausea, nerve deficits, and seizure. commonly, the intracranial pressure is measured no higher than 20 mmhg. since the cerebral compartment sits within the enclosed, complex cranial cavity, the other intracranial compartment will either deviates or compress as compensation for increased intracranial pressure; this phenomenon is also called as monro-kellie doctrine.20 hence, significant ventricular dilatation as occurs in hydrocephalus will produce mass effect towards the post-rema area and vertibulocochlear nerve, where nausea and vomiting is controlled.21 neck stiffness has long been known as a typical characteristic of meningeal irritation (i.e., meningitis). the mechanism underlying this process is not clearly explained. however, meningeal irritation is suggested to cause nociceptor activation within the spinal cord that passes on to the cervical region and triggers althea medical journal. 2022;9(4) 203 muscle rigidity.22 seizure is considered a familiar entity in tuberculous meningitis, with the incidence ranging from 17–93%. meningeal and ventricular inflammation are correlated with the prominent production of inflammatory cytokines (il-1, il-6, cox-2, and pge-2); hence, activating microglia, astrocytes, and cerebral endothelial cells, resulting in epileptogenic activity within the brain. meningitis also increases the permeability of blood-brain barrier, causing extravasation of interstitial fluid and edema, leading to seizure episodes.23 the tbm accompanied by hydrocephalus is highly associated with the seizure.12 recurrent, uncontrolled seizures can progress to status epilepticus leading to a poor prognosis. patients with central nervous system infection and recurrent seizures can be given anti-seizure prophylaxis to prevent recurrent seizures, at least during the acute period of illness.23 cerebrospinal fluid analysis has a crucial role in the definitive diagnosis of meningitis. tbm is a chronic disease characterized by clear cerebrospinal fluid (csf), increased protein concentration, lymphocytedominated pleocytosis, and a low glucose concentration.13 in this study, an increase in protein concentration was four times higher in csf groups with and without hydrocephalus. disruption in the blood-brain barrier refers to an increase in csf protein, which can inhibit csf circulation, interfere with absorption, and even cause obstruction leading to hydrocephalus after the presence of csf protein leukocyte aggregation.12 this causes the increase in csf protein to be higher in patients with hydrocephalus. this study showed an increase in white blood cells in the presence of lymphocyte dominance. a decreased ratio of csf to blood glucose occurred in both groups. decreased glucose is due to impaired glucose transport to the choroid plexus as decreased blood flow, bloodbrain barrier transport, increased metabolism in the brain, and transport to the venous system.24 ventriculomegaly in hydrocephalus causes compression to the brain, leading to decreased blood flow and perfusion.25 the severity of tbm at the baseline of treatment was assessed according to the british medical research council staging system and is divided into three grades.26 hydrocephalus might be significantly associated with advanced tbm grade.3 increased severity was significantly associated with delayed treatment, leading to increased mortality and morbidity.27 in this study, grade 2 tbm is the most frequent in groups with hydrocephalus and without. tbm can cause metabolic complications, among others, hyponatremia, which is occurred in more than 50% of patients. the most common cause of hyponatremia is cerebral wasting syndrome. in addition, it can also be caused by using diuretics to treat hydrocephalus.15 this study found hyponatremia in hydrocephalus. the use of diuretics in hydrocephalus might contribute to the occurrence of hyponatremia. length of stay increases the risk of nosocomial infections and is associated with a poor prognosis.16 the most frequent hospital infections were pneumonia and surgical site infection, followed by urinary tract infections and bloodstream infections.17 this study shows that hospital-acquired pneumonia (hap) occurs mostly in the group with hydrocephalus, whereas urinary tract infections (uti) occur in the group without hydrocephalus. utis are primarily associated with catheter placement during treatment.17 the high incidence of hap in brain injury is associated with decreased consciousness resulting in microaspiration.18 this explains the higher incidence of hap in subjects with hydrocephalus. patients without hydrocephalus were treated >7 days more than those with hydrocephalus. this is because the number of patients who died during the treatment was more prominent in patients with hydrocephalus. thus, hydrocephalus is associated with higher mortality than those without hydrocephalus. anti-tuberculosis drugs (atd) were administered to all subjects. inflammation in the choroid plexus can increase excess csf production, thereby increasing intracranial pressure and hydrocephalus in tbm.28 high intracranial pressure occurred in 5.4% of patients with hydrocephalus and only 1.3% in subjects without hydrocephalus. acetazolamide was administered to 30.9% of patients with hydrocephalus. acetazolamide administration in hydrocephalus is symptomatic in purpose and works by suppressing csf production through carbonic anhydrase inhibition. carbonic anhydrase is an enzyme necessary for csf production and it dissociates carbonic acid into a positive hydrogen ion and a negative bicarbonate ion, the production of these products drives the activity of sodium/hydrogen exchanger (nhe) and anion exchanger (ae2) at the choroidal plexus epithelium, which promotes the csf nubella citresna zakiyyah et al.: outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia althea medical journal. 2022;9(4) 204 release into the ventricle. thus, carbonic anhydrase inhibition is a considerable non–surgical modality to symptomatically manage hydrocephalus.29 although the guideline and consensus regarding the use of acetazolamide for hydrocephalus in tbm cases are not clearly postulated, nearly half of the patients in a prospective cohort study from india had significant improvement and reduction of disability index after receiving both acetazolamide and mannitol.3 mannitol, frequently available in 20%, is an osmotic agent that increases extracellular osmolality, shifting water molecules from the intracellular into the extracellular compartment; this decreases the high intracranial tension resulting from the accumulation of cerebrospinal fluid.29 the outcome was assessed using gos; which was died. died under treatment occurred mostly in tbm with hydrocephalus. our result shows a significant difference between the gos of the tbm with and without hydrocephalus. furthermore, the result showed that the gos mean of tbm without hydrocephalus was higher than tbm with hydrocephalus, indicating that the outcome of tbm without hydrocephalus was better than those with the hydrocephalus. the outcome in patients with hydrocephalus had a worse outcome compared to those without hydrocephalus. hydrocephalus was one of the predictors of mortality and morbidity in tb. moderate disability occurs in many subjects without hydrocephalus. in accordance with previous research, prolonged treatment does not provide higher mortality but has a higher chance of developing neurological disability.24 tbm patients with hydrocephalus tend to have poorer prognosis and survival than patients without hydrocephalus. mortality rate is reported to be higher among tbm patients with hydrocephalus, along with disability index and survival.10–14 hydrocephalus is also considered a prognostic factor that could predict the poor outcome among tbm patients in a retrospective study from china.30 the limitation of this study is the use of retrospective data. further research can be carried out using analytical methods to calculate the significance of the characteristics of tbm with and without hydrocephalus to the outcome. in conclusion, tbm patients with hydrocephalus have a worse outcome than those without hydrocephalus, as reflected by the higher tbm grade, 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the management of tuberculous meningitis with hydrocephalus: a systematic review and sarawak institution’s experience. asian j neurosurg. 2022;17(2):189–98. 14. chalasani r, goonathilake mr, waqar s, george s, jean-baptiste w, yusuf althea medical journal december 2022 althea medical journal. 2022;9(4) 205 ali a, et al. the outcome of surgical intervention (ventriculoperitoneal shunt and endoscopic third ventriculostomy) in patients with hydrocephalus secondary to tuberculous meningitis: a systematic review. cureus. 2022;14(5):e25317. 15. luo m, wang w, zeng q, luo y, yang h, yang x. tuberculous meningitis diagnosis and treatment in adults: a series of 189 suspected cases. exp ther med. 2018;16(3):2770–6. 16. wen l, li m, xu t, yu x, wang l, li k. clinical features, outcomes and prognostic factors of tuberculous meningitis in adults worldwide: systematic review and meta-analysis. j neurol. 2019;266(12):3009–21. 17. cooksley t, rose s, holland m. a systematic approach to the unconscious 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budiman atm, suraya n, faried a, parwati i. characteristics of cerebrospinal fluid in tuberculous meningitis patients with hydrocephalus. ijihs. 2018;6(2):57–62. 25. oliveira lm, nitrini r, román gc. normalpressure hydrocephalus: a critical review. dement neuropsychol. 2019;13(2):133– 43. 26. török me. tuberculous meningitis: advances in diagnosis and treatment. br med bull. 2015;113(1):117–31. 27. hsu pc, yang cc, ye jj, huang py, chiang pc, lee mh. prognostic factors of tuberculous meningitis in adults: a 6-year retrospective study at a tertiary hospital in northern taiwan. j microbiol immunol infect. 2010;43(2):111–8. 28. tandon v, mahapatra ak. management of post-tubercular hydrocephalus. child nerv syst. 2011;27(10):1699–707. 29. eftekhari s, westgate csj, uldall ms, jensen rh. preclinical update on regulation of intracranial pressure in relation to idiopathic intracranial hypertension. fluids barriers cns. 2019 nov 26;16(1):35. 30. huang hj, ren zz, dai yn, tong yx, yang dh, chen mj, et al. old age and hydrocephalus are associated with poor prognosis in patients with tuberculous meningitis: a retrospective study in a chinese adult population. medicine (baltimore). 2017;96(26):e7370. nubella citresna zakiyyah et al.: outcomes of tuberculous meningitis patients with or without hydrocephalus from a tertiary hospital in west java, indonesia amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 93 level of knowledge and attitude towards covid-19 among high school students in depok arnold,1 fifi veronica,2 vycke yunivita2 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia correspondence: dr. vycke yunivita kd, dr., m.kes, department of biomedical sciences, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west java-indonesia, e-mail: v.yunivita@unpad.ac.id introduction coronavirus disease 2019 (covid-19) is an infectious disease caused by the sarscov-2 virus.1 it can spread through humanto-human transmission and indirect contact with contaminated objects.2 indonesia has implemented a large-scale social distancing, increasing the capacity of covid-19 diagnostic tests, and launching a national research consortium to accelerate innovations to combat the disease.3 washing hands regularly, wearing a mask, physical distancing, and other health protocols are the best strategy to prevent transmission of the virus.4,5 the covid-19 has infected 118,058,503 people in the world (march 12, 2021), 1% infected indonesian that happened in 2% of people in west java, and 15% were living in depok.6 the world health organization (who) on march 11, 2020, declared the novel coronavirus (covid-19) a global pandemic, all countries imposed restrictions on community activities and some countries were locked down.7 this condition causes some people to feel anxiety in their daily life. when anxiety affects large numbers of people, panic buying can occur and make some consequences such as restrictions in daily activities, avoidance behaviours leading to limited sociability, and self-medication.8 with limited activities, electronic media has become the public’s main in getting the latest information about covid-19. the obtained information can affect the knowledge, understanding, behavior, and even habits of the community’s perception of covid-19.9–11 knowledge and attitude are important factors in determining health decisions and health outcomes.8 knowledge and attitude althea medical journal. 2022;9(2):93–99 abstract background: depok is the city with the largest covid-19 cases in west java, indonesia. the application of health protocol for high school student as the second-largest age group depends on the level of knowledge and attitudes that can be affected by gender. this study aimed to determine the level of knowledge and attitudes based on the gender of high school students towards covid-19 in depok. methods: this study was a cross-sectional analytic study, conducted from june 2020 to june 2021. the data was collected using a google form application with a validated questionnaire and the research subjects were high school students in depok. knowledge of covid-19 was assessed with 18 questions, true or false questions. correct answer was assigned 1 point. points were summed for a total knowledge score of poor, moderate, or good. attitude was assessed with 6 questions. for each answer given, subjects with a total score of >18 were assessed as a positive attitude. results: of a total of 273 respondents, 238 had met the inclusion criteria. most of the respondents had a moderate level of knowledge (60.5%) and most of the respondents (89%) had a positive attitude towards covid-19. no significant differences in level of knowledge or attitude between males and females (p>0.05). conclusions: high school students in depok have a moderate level of knowledge and have a positive attitude in dealing with covid-19 which is not influenced by gender. the lack of information regarding the timing of vaccine administration and examination of covid-19 needs to be a concern for high school students in depok. keywords: attitude, covid-19, depok, high school students, knowledge https://doi.org/10.15850/amj.v9n2.2513 althea medical journal. 2022;9(2) 94 information are necessary because unclear information and negative attitudes toward covid-19 can generate stress and panic among the population.12 therefore, efforts are needed to evaluate people’s knowledge and behavior related to covid-19 to assess the public’s awareness of covid-19 and behavior related to preventing transmission and taking action when infected by the disease. depok as one of the big cities in the province of west java, indonesia, is located between jakarta and bogor, and has 11 subdistricts. covid-19 was first detected in depok and became the city with the highest covid-19 cases in west java.13 the high risk of spreading covid-19 and positive cases in depok city can be caused by many factors, such as geographical location, human mobility, knowledge, and attitudes of depok city residents.14 about 9.43% of indonesia’s population is in the age range of 15–19 years.15 the population at this age is categorized as teenagers, at the level of high school students. high school students are the most active in traveling during the pandemic, therefore, they are at risk of getting covid-19. due to the lack of information regarding the level of knowledge and attitudes of high school students related to covid-19 in depok, this study was conducted to determine the level of knowledge and attitudes of high school students about covid-19 in depok. recent studies have shown that gender and age can affect a person’s behavior and knowledge. gender is associated with a person’s roles and obligations given by society, as well as his status in the family and society. these aspects influenced the risks that they take and face, as well as their efforts to improve their health.16 this study aimed to determine the level of knowledge and attitude based on the gender of high school students towards covid-19 in depok. methods this study was an analytic research with a cross-sectional study design and was carried out from april to june 2021 in high schools in depok. the tool or material used was a valid questionnaire (18 questions for knowledge and 6 questionnaires for attitude) in the form of a google form. the knowledge questionnaire was tested using the pearson correlation test, and the reliability test used the cronbach’s alpha (α) test with a 95% confidence level showing the results of α=0.671 (reliable), and α=0.786 (reliable) for the attitude questionnaire. the inclusion criteria in this study were high school students in depok who could access the questionnaire link. subjects’ answers were included if the subjects agreed to fill out the form and excluded if the response have exceeded the deadline; multiple responses from the same person; did not complete the questionnaire or fill out the questionnaire. sampling was carried out using a total sampling technique from probability sampling based on a sub-district in depok. determination of the number of samples based on the slovin formula with the results of 110 research respondents.17 this study had been approved by the research ethics committee, universitas padjadjaran no. 323/un6.kep/ec/2021. the questionnaire evaluated the level of knowledge in the form of questions with true/false answers. the correct answer was given a score of 1 and the wrong answer was given a score of 0. the level of knowledge was considered “good” if the correct answer was >75%, “moderate” if the correct answer =56– 75%, and “poor” if the correct answer was <56%. the questionnaire assessing attitudes towards covid-19 used a likert scale, which althea medical journal june 2022 table 1characteristics of respondents characteristic frequency (total = 238) percentage age (years)* 18 (14-21) gender male female 90 148 37.8 62.2 grade level 10 11 12 110 101 27 46.2 42.4 11.3 note: *=data presented in median (min, max) althea medical journal. 2022;9(2) 95arnold et al.: level of knowledge and attitude towards covid-19 among high school students in depok specified the responders’ level of agreement on four points, namely 4 for strongly agree, 3 for agree, 2 for disagree, and 1 for strongly disagree. subjects with a score greater than or equal to 75% of the maximum score were classified as “positive”, and subjects with a score less than 75% of the maximum score were classified as “negative”.10 the data were analysed using the spss software computer program and were analyzed by descriptive statistics and chisquare correlation analysis. data were presented in tables and diagrams. table 2 distribution of the answers of knowledge level on covid-19 in the high school students in depok no knowledge male (n=90) female (n=148) total (n=238) correct correct correct n (%) n (%) n (%) 1 corona virus can survive in the air for three hours in aerosol form 72 (80) 131 (88.5) 203 (85.3) 2 corona virus has similarities with the sars virus 72 (80) 131 (88.5) 203 (85.3) 3 patients without comorbid diseases such as obesity and hypertension are more susceptible to corona virus infection 53 (58.8) 76 (51.3) 129 (54.2) 4 children are more susceptible to corona virus infection than the elderly 72 (80) 122 (82.4) 194 (81.5) 5 corona virus cannot enter through the eyes 51 (56.6) 95 (64.1) 146 (61.3) 6 if a person's hands touch items that have been contaminated and then touch the nose area, the virus can enter and cause symptoms 87 (96.6) 147 (99.3) 234 (98.3) 7 loss of smell is one of the specific complaints of being infected with the corona virus 84 (93.3) 147 (99.3) 232 (97.5) 8 sore throat, cough, runny nose, and fever can be one of the early symptoms of corona virus infection 84 (93.3) 148 (100) 232 (97.5) 9 being in a crowd increases the risk of being infected by the corona virus 89 (98.8) 148 (100) 237 (99.6) 10 masks made of cotton cloth have higher effectiveness in filtering virus particles than surgical masks 48(53.3) 100 (67.5) 148 (62.2) 11 antibiotics are effective in preventing and treating corona virus infections 32 (35.5) 57 (38.5) 89 (37.4) 12 it is not safe to receive letters or packages from abroad 46 (51.1) 60 (40.5) 106 (44.5) 13 spraying alcohol all over the body can treat the corona virus 69 (76.6) 97 (65.5) 166 (69.7) 14 pcr test results can be known no later than 1 day 30 (33.3) 45 (30.4) 75 (31.5) 15 the accuracy rate of rapid antigen test is almost 100% 27 (30) 46 (31) 73 (30.7) 16 the antibody rapid test procedure begins with taking a blood sample from the fingertip which is then dropped onto the rapid test kit 76 (84.4) 141 (95.2) 171 (71.8) 17 the corona virus vaccine works by stimulating the formation of specific immunity against the corona virus. so that when exposed, a person will be able to avoid 100% transmission or serious illness due to the disease 30 (33.3) 47 (31.7) 77 (32.4) 18 the corona virus vaccine is carried out 2 times and according to the schedule, which is at least 1 week from the first vaccine 15 (16.6) 35 (23.6) 50 (21) althea medical journal. 2022;9(2) 96 results of the hundreds of schools in 11 sub-districts in depok, only 10 schools from 8 sub-districts were collected. it was because most schools were busy preparing for the admission of new students (penerimaan peserta didik baru, ppdb), so the responses received tended to be slow and needed to be followed up. furthermore, some schools did not allow research to be carried out because the school was a boarding school, and students were prohibited from using gadgets. there were also some schools that refused because they had not been accredited. from a total of 238 respondents, the majority of respondents in this study were 18 years old, female, and in the 10th grade (table 1). althea medical journal june 2022 table 3 level of knowledge and attitude toward covid-19 among the high school students no attitude male female total sa n(%) a n(%) d n(%) sd n(%) sa n(%) a n(%) d n(%) sd n(%) sa n(%) a n(%) d n(%) sd n(%) 1 i always wash my hands regularly to avoid and prevent the transmission of the corona virus 65 (72.2) 25 (27.8) 0 0 112 (75.7) 36 (24.3) 0 0 177 (74.4) 61 (25.6) 0 0 2 i limit my activities by staying at home to avoid transmission of the corona virus 47 (52.2) 38 (42.2) 3 (3.3) 2 (2.2) 72 (48.6) 64 (43.2) 11 (7.4) 1 (0.7) 119 (50) 102 (42.9) 14 (5.9) 3 (1.3) 3 t a k i n g m e d i c i n e s such as herbs, supplements, and vitamins to prevent corona virus infection is not a problem for me 39 (43.3) 42 (46.7) 0 9 (10) 49 (33.1) 92 (62.2) 7 (4.7) 0 88 (37) 134 (56.3) 16 (6.7) 0 4 i feel calm during the lockdown 20 (22.2) 33 (36.7) 22 (24.4) 15 (16.7) 25 (16.9) 89 (60.1) 28 (18.9) 6 (4.1) 45 (18.9) 122 (51.3) 50 (21) 21 (8.8) 5 i always wear a mask every time i leave the house 55 (61.1) 32 (35.6) 2 (2.2) 1 (1.1) 119 (80.4) 29 (19.6) 0 0 174 (73.1) 61 (25.6) 2 (0.8) 1 (0.4) 6 i don’t mind doing selfisolation for a few days after traveling out of town/ country 0 45 (50) 36 (40) 2 (2.2) 0 80 (54.1) 61 (41.2) 0 97 (40.8) 125 (52.5) 13 (5.5) 2 (0.8) note: sa= strongly agree, a= agree, d= disagree, sd= strongly disagree althea medical journal. 2022;9(2) 97 table 4 proportion categorized of knowledge and attitude towards covid-19 items frequency (total=238) percentage (%) knowledge good moderate poor 51 144 43 21.4 60.5 18.1 attitude* positive negative 212 25 89.1 10.5 note: *one subject is not included because missed one answer most respondents (85.2%) knew that the corona virus was able to survive longer in the air in aerosol form, knew the symptoms when infected with the corona virus, and knew that the virus was transmitted through contaminated items (table 2). however, there were still many respondents who did not know that co-morbidities were factors that aggravate the course of the disease (45.8%), the ability of the coronavirus to enter the body through the eyes (38.7%), the ineffectiveness of cloth masks (37.9%), the procedure of rapid test (68.5%) and the antibiotics that could not kill viruses (62.7%) (table 2). in the corona virus examination, most of the respondents (69.4%) did not know the accuracy of the rapid antigen test and when the pcr test results could be received (68.5%) (table 2). there was a misconception among the most respondents (67.7%) that vaccination could prevent 100% of corona virus infections (table 2). based on the results of knowledge research, it was found that 17.8% of male respondents had good knowledge and 23.6% of female respondents had good knowledge. there was no difference in the proportion of moderate and poor level of knowledge between males and females. there was also no significant difference between the knowledge categories in males vs females (p>0.05) nor by age (data not presented). based on the results of attitude research, it was found that 74.6% of respondents strongly agreed in terms of washing hands, 50% in term of limiting activities outside the home, 73.1% in terms of using masks, 18.9% in terms of feeling calm during the pandemic, and 40.7% in term of self-isolation for a while after traveling out of town/country. of the 91.9% of female respondents had positive attitudes and 84.4% of male respondents had positive attitudes but there was no significant correlation difference between attitudes and gender (p>0.05) or by age (data not presented). discussions the respondents of this study were aged 4–21 years, the majority were female, and most had moderate knowledge towards covid-19. similar studies were conducted in saudi10 (18– 28 years old), india11 (more than 18 years) and ethiopia18 (18–29 years old) which also used the same type of study and questionnaire instrument. the results are good level of table 5 comparison between males and females in terms of knowledge and attitude towards covid-19 items malen (%) female n (%) p-value knowledge good moderate poor 16 (17.8) 55 (61.1) 19 (21.1) 35 (23.6) 89 (60.1) 24 (16.2) 0.438 attitude* positive negative 76 (84.4) 13 (14.4) 136 (91.9) 12 (8.1) 0.131 note: *one subject is not included because missed one answer arnold et al.: level of knowledge and attitude towards covid-19 among high school students in depok althea medical journal. 2022;9(2) 98 knowledge in saudi,10 moderate in india11 and poor level of knowledge in ethiopia.18 whereas in the ploso district, jombang regency19, it was found that 67% of high school students had a good level of knowledge towards covid-19. in contrast to the others, with different knowledge categories, the results of study in the philippines showed that the level of knowledge of respondents aged 16–29 years was low (scores 75% and below).20 the difference in these results could be influenced by the age of the subject participating in each study. the present study did not show a correlation between age and knowledge toward covid-19 but studies in saudi and the philippines did.10,20 based on the results of attitudes, it was discovered that most of the respondents have a positive attitude towards covid-19 as well as the results of study in saudi,10 india,11 ethiopia,18 and philippine.20 in this study, female are superior to males in terms of knowledge and attitudes although there is no correlation between gender and level of knowledge nor attitude towards covid-19. the results of this study conform to researches in bangladesh,21 which states that the proportion of good knowledge, positive attitudes, and good practices is higher in female respondents. without exception, female are more likely than male to do recommended preventions,21 and they have more time to read or discuss with their environment. this causes female to have a tendency to behave better than male.22 this finding is further validated by a meta-analysis demonstrating that women were 49.5% more likely to practice and adopt health-protective behaviors in the context of a pandemic outbreak.16 thereby, increasing covid-19 education and health protocol socialization to the community, both gender and young age, is needed to increase knowledge and reduce negative attitudes toward covid-19. there are some limitations of our study, we used a different questioning tool from others studies, which could influence the analysis of the results. to conclude, high school students in depok have a moderate level of knowledge and positive attitude towards covid-19. further improvements need to be implemented in school to increase knowledge, positive attitudes, and simplify information regarding the transmission and spread of covid-19 to students. acknowledgements the authors would like to thank kurnia wahyudi and sri yusnita from the department of public health, faculty of medicine, universitas padjadjaran, indonesia, for their advice on methodology of research. we also thank all respondents for their cooperation in this study. references 1. yang l, liu s, liu j, zhang z, wan x, huang b, et al. covid-19: immunopathogenesis and immunotherapeutics. sig transduct target ther. 2020;5(1):128. 2. lotfi m, hamblin mr, rezaei n. covid-19: transmission, prevention, and potential therapeutic opportunities. clin chim acta. 2020;508:254–66 3. setiati s, azwar mk. covid-19 and indonesia. acta med indones. 2020;52(1):84–9. 4. adhikari sp, meng s, wu y, mao y, ye r, wang q, et al. a scoping review of 2019 novel coronavirus during the early outbreak period: epidemiology, causes, clinical manifestation and diagnosis, prevention and control. infect dis poverty. 2020;9(1):29. 5. lewnard ja, lo nc. scientific and ethical basis for social-distancing interventions against covid-19. lancet infect dis. 2020;20(6):631–3. 6. kahar f, dirawan gd, samad s, qomariyah n, purlinda de. the epidemiology of covid-19, attitudes and behaviors of the community during the covid pandemic in indonesia. int j innov sci res technol. 2020;5(8):1681–7. 7. cucinotta d, vanelli m. who declares covid-19 a pandemic. acta biomedica. 2020;91(1):157–60. 8. bhat ss, vashisth a, kumari s, singh ok, farooque n, baccha s. development of social stigmatization during a pandemic caused by covid-19. j adv med dent sci res. 2020;8(5):71–4. 9. bao h, cao b, xiong y, tang w. digital media’s role in the covid-19 pandemic. jmir mhealth uhealth. 2020;8(9):e20156. 10. baig m, jameel t, alzahrani sh, mirza aa, gazzaz zj, ahmad t, et al. predictors of misconceptions, knowledge, attitudes, and practices of covid-19 pandemic among a sample of saudi population. plos one. 2020;15(12):e0243526. 11. roy d, tripathy s, kar sk, sharma n, verma sk, kaushal v. study of knowledge, attitude, anxiety &amp; perceived mental althea medical journal june 2022 althea medical journal. 2022;9(2) 99 healthcare need in indian population during covid-19 pandemic. asian j psychiatr. 2020;51:102083. 12. lin y, huang l, nie s, liu z, yu h, yan w, et al. knowledge, attitudes and practices (kap) related to the pandemic (h1n1) 2009 among chinese general population: a telephone survey. bmc infect dis. 2011;11:128. 13. rochmyaningsih d. indonesia finally reports two coronavirus cases. scientists worry it has many more. washington, dc: american association for the advancement of science; 2020. [cited 2020 september 09]. available from: https://www.science. org/content/article/indonesia-finallyreports-two-coronavirus-cases-scientistsworry-it-has-many-more. 14. firmansyah t. ini alasan mengapa depok rawan penyebaran covid-19. republika [internet]. 2020 [cited 2020 september 9]. available from: https://www.republika. c o . i d / b e r i t a / q e x t 7 w 3 7 7 / i n i a l a s a n m e n g a p a d e p o kra wa n p e nye b a ra n covid19 15. badan pusat statistik. penduduk berumur 15 tahun ke atas menurut golongan umur dan jenis kegiatan selama seminggu yang lalu, 2008–2022. [cited 2022 june 23]. available from: https://www.bps. go.id/statictable/2016/04/04/1904/ p e n d u d u k b e r u m u r 1 5 t a h u n k e a t a s m e n u r u t g o l o n g a n u m u r d a n jenis-kegiatan-selama-seminggu-yanglalu-2008---2022.html. 16. moran kr, del valle sy. a meta-analysis of the association between gender and protective behaviors in response to respiratory epidemics and pandemics. plos one. 2016;11(10):e0164541. 17. tejada j, punzalan j. on the misuse of slovin’s formula. philipp stat. 2012;61(1):129–36. 18. haftom m, petrucka p, gemechu k, mamo h, tsegay t, amare e, et al. knowledge, attitudes, and practices towards covid-19 pandemic among quarantined adults in tigrai region, ethiopia. infect drug resist. 2020;13:3727–37. 19. saputro aa. tingkat pengetahuan virus covid-19 pada peserta didik kelas x sma, smk, dan ma wilayah kecamatan ploso kabupaten jombang. prosiding seminar nasional olahraga. 2020;2(1):12–18. [cited 2022 june 23 ]. availbale from: https://www.academia.edu/59211970/ t i n g k a t _ p e n g e ta h u a n _ v i r u s _ c o v i d _ 1 9 _ pa d a _ p e s e r ta _ d i d i k _ kelas_x_sma_smk_dan_ma_wilayah_ k e c a m ata n _ p l o s o _ k a b u pat e n _ jombang_oleh_arnaz_anggoro_saputro_ stkip_pgri_jombang. 20. tuppal cp, ninobla mmg, ruiz mgd, loresco rd, tuppal smp, panes ii, et al. knowledge, attitude, and practice toward covid-19 among healthy population in the philippines. nurse media j nurs. 2021;11(1):61–70. 21. hossain mb, alam mz, islam ms, sultan s, faysal mm, rima s, et al. do knowledge and attitudes matter for preventive behavioral practices toward the covid-19? a crosssectional online survey among the adult population in bangladesh. heliyon. 2020;6(12):e05799. 22. wulandari a, rahman f, pujianti n, sari ar, laily n, anggraini l, et al. hubungan karakteristik individu dengan pengetahuan tentang pencegahan coronavirus disease 2019 pada masyarakat di kalimantan selatan. j kesehat masy indones. 2020;15(1):42–6. arnold et al.: level of knowledge and attitude towards covid-19 among high school students in depok vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 181 six-minutes walk test characteristics in geriatric outpatient clinic at dr. hasan sadikin general hospital bandung hanifah,1 yuni s. pratiwi,2 tri damiati pandji3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung indonesia correspondence: hanifah, faculty of medicine faculty of medicine universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, e-mail: hanifahonly@gmail.com introduction one indicator of a successful health program is an increased life expectancy index (lci). according to the indonesian statistic central bureau (badan pusat statistik, bps),1 the lci in indonesia during the last 4 decades is increasing up to 73.6 years in 2020. the number of elderly globally is predicted to reach 11.34% of the total population, following the higher number of the elderly population in indonesia. based on law no.13/1998 about ‘the elderly welfare’, the elderly is a person aged equal or more than 60 years. west java is one of the provinces in indonesia that has an old-structured district; the percentage of the elderly population in the area is more than 7%. this phenomenon is considered as both a good achievement and a challenge for government in facing the elderly problems.1 there are many physiological changes detected in the elderly. during the aging process, homeostasis function is not optimal, causing a dysfunction in many organs of the body.2 in musculoskeletal organs, aging causes a reduction in strength, endurance, size, and weight of the muscles in general. furthermore, the flexibility of the joints is lower and gets easily inflamed, causing declining of a range of motion (rom).3 the physiologic changes also occur in cardiovascular system. the heart becomes more hypertrophic and hyperresponsive to sympathetic stimulus, explaining why an exercise even with low intensity can induce heart fatigue in the elderly. moreover, the artery is more rigid that causes the inefficient circulation in supplying the oxygen to the tissues.4 the reduced muscle mass, the strength and endurance, the lower rom, and the lower amj. 2019;6(4):181–5 abstract background: the six-minute walk test (6mwt) is a safe, easy to perform, and inexpensive test to evaluate the functional and exercise capacity in the elderly. the purpose of this study was to describe the 6mwt distance achieved among elderly patients. methods: this descriptive study was conducted from january to november 2014 using medical records in the geriatric outpatient clinic of the department of internal medicine at dr. hasan sadikin general hospital from 2012 to 2014. the main variable was the distance achieved by the 6mwt, compared based on age, sex, and body mass index. results: the average distance of the 6mwt in 122 elderly was 237.56 m. the highest results were in the youngest age group of 60–69 year old with an average distance of 243.87 m. a male elderly patients had an average distance of 245.26 m, and the elderly with high body mass index had 248.57 m. conclusions: the distance achieved among the elderly during the 6mwt is relatively short. increased physical activity such as walking is recommended for the elderly. keywords: elderly, mobility, six-minute walking test althea medical journal. 2019;6(4) 182 amj december 2019 flexibility may all cause unstable movement of the elderly with the consequences that walking pattern becomes irregular, the step is shortened, and the walking speed is slower. furthermore, the wrong walking pattern makes the energy used becomes inefficient and the covered distance will be much lower.5 walking is a complex activity that requires integration between strength, balance, and endurance. walking is a very important element of mobility, whereas mobility is a significant factor in determining the success of a person in completing activities of daily living and also to assesses the functional capacity.6 mobility capability assessment can be performed by several tests; one of them is the ‘six-minutes walk test‘ (6mwt). this test is easy to do, inexpensive, and better tolerated by the elderly. this test can be used as an indicator of the therapy’s progression. the capacities that can be assessed by the 6mwt are the functional capacity, and this is closely related to daily activities and physical exercise capacity in some diseases, such as heart and lung disease.7,8 functional and physical capacity are tools to predict the outcome, impact, and prognosis of a disease. moreover, this can determine the patient’s treatment plan and to assess the effectiveness of a treatment in patients. the aim of this study was to explore the characteristics among the elderly in the outpatient clinic in doing the ‘six-minutes walk test’ (6mwt). methods this quantitative descriptive study was conducted in a geriatric outpatient clinic of the department of internal medicine at dr. hasan sadikin general hospital. data of all patients aged at least 60 years who visited the outpatient clinic from 2012 to 2014 were collected and the result of the ‘six-minutes walk test’ (6mwt) was retrieved. in brief, patients were asked to walk back and forth between two points within 3 meters for 6 minutes according to the patient’s usual daily walking speed. patients were allowed to rest and to resume the test as soon as possible after resting. during the test, the patient might not be given a motivation because it would affect the test results. after 6 minutes, the patients were asked to stop and allowed to rest. the covered distance by patient was then recorded as the result of 6mwt. in some cases in the medical records, only speed of walking was written, therefore, this had to be changed back into the distance by multiplying the speed by 360 seconds (6 minutes).11 besides, the results obtained were compared with normal values based on the ‘european working group on sarcopenia in older people’ which was 0.8 m/s equal to 288 m. according to previous research, the results below 0.8 m/s indicated a worse prognosis and a higher number of dependences to others in geriatric patients.12 the result of 6mwt was further presented alongside with age group, gender, and body mass index. age was grouped per decade, that was 60–69 years, 70–79 years, and ≥ 80 years; since the loss of muscle strength occurred at an average rate of 12–14% every ten years after a person aged 50 years.9 furthermore, gender classification was made since there might difference occurred in the functional capacity of women and men.10 data on length and height were collected and body mass index was calculated, resulting in an index of underweight <18, normal 18–24, and overweight >24. this study used a patient’s medical records were highly confidential owned by the hospital. therefore, the authorization was involved. the ethical principle that should not be violated in this study was confidentiality, so all information obtained from patients’ medical records must be kept confidential. statistical analysis was performed using anova or t-test wherever available. results in total, 275 elderly patients had visited the outpatient clinic of the department of internal medicine at dr. hasan sadikin general hospital in 2012–2014, however, only 122 medical records were successfully retrieved due to incomplete data. the mean age of the elderly patients was 70 years old (s.d. 7 years), and the mean body mass index was 25.59 (s.d. 4.5) as shown in table 1. in this study, the average 6mwt in the elderly patients was 237.56 m and the highest average 6mwt result achieved was at the age of 60–69 years (table 2), however, anova test revealed no significant differences in 6mwt between age groups (p=0.526). furthermore, the average 6mwt results of the elderly males was higher than females (table 2), and no significant differences in 6mwt between males and females (p=0.347; unpaired t-test). interestingly, the average of 6mwt results in overweight elderly was higher than other groups, however, no significant differences between the group of body mass index (p=0.198; anova). althea medical journal. 2019;6(4) 183 table 2 the result of distance achieved by ‘6-minutes walk test’ (6mwt) based on age group, gender, and body mass index mean sd minimum maximum age group; years old 60–69 243.87 99.16 32.4 540 70–79 238.01 100.31 36 576 ≥80 206.61 101.95 90 360 gender male 245.26 94.7 32.4 540 female 227.87 105.72 36 576 body mass index underweight 154.44 72.89 90 273.6 normal 237.21 100.25 32.4 576 overweight 248.57 98.33 36 540 note: sd= standar deviation, the distance of the ‘6-minutes walk test’ was in meter discussions this study has shown that the ‘six-minutes walk test’ among the elderly in the outpatients clinic in our study is 237.56 m. this result is lower than the normal values based on the european working group12 on sarcopenia in older people, which is 288 m, indicating a worse prognosis and a higher number of dependencies to others in geriatric patients. the results also differ from other studies, for example, a study conducted in 7 countries in america that shows an average distance of 6mwt is 571 m.12 furthermore, study in thailand has shown that the average 6mwt among elderly in the dwelling community is 334.68 m,2 while a study conducted in indonesia has shown the 6mwt among elderly who live in institutions is 298.92 m.5 the results in this study show a much lower result compared to study in america, but close to other asian countries. this might be since the fact that people in western countries have a higher body structure than the asian.13 moreover, the population in the developing countries have a lower health status than the western because of differences in lifestyle, diet, and geographical location that may cause the differences in anthropometric data which then indirectly affect the outcome test.14 in general, the average 6mwt yield in this study is lower than the average test in the elderly in the community. the 6mwt result is influenced by several factors. the lower result in this study is because the study has been done in the hospital; possibly means the data has been obtained from unhealthy elderly. some diseases can cause a decline in 6mwt results, such as chronic obstructive pulmonary disease, heart disease, cognitive disorders, arthritis, and musculoskeletal diseases.15 furthermore, the variability of the 6mwt result is predominantly related to age, gender, and body mass index. 2 in general, elderly people are associated with the gradual reduction of muscle mass and table 1 characteristics of the elderly patients visited the outpatients clinic at dr. hasan sadikin general hospital 2012–2014 total percentage (%) age (years old) 60–69 62 51 70–79 50 41 ≥80 10 8 gender male 68 56 female 54 44 body mass index underweight 8 7 normal 52 43 overweight 62 50 hanifah et al.: six-minutes walk test characteristics in geriatric outpatient clinic at dr. hasan sadikin general hospital bandung althea medical journal. 2019;6(4) 184 amj december 2019 strength, and the increasing prevalence of the disease. all those things make the 6mwt in patients with older age declines.3 our study is confirming that the farthest distance achieved by 6mwt is in the group 60–69 years and is tended to decline, with the shortest 6mwt is in the group ≥ 80 years, however, no significant differences between age groups. as for gender, the average 6mwt in women is lower than in men, and again no statistical difference has been shown between the genders. this result is contradicted the study in brazil7 that reported a significant difference between gender. there is a tendency of a high rate of mortality among men and high disability in women, therefore, men who are able to reach old age are the men who are healthier compared to women, suggesting that men have higher functional ability than women.17 obesity increases the weight-bearing mass during walking thus it makes the step becomes shorter.18 therefore, the average of 6mwt is lower in people who have a higher body mass index. however, this study shows different results. the highest average 6mwt is tended to be in the elderly who has an overweight, although there are no significant differences in 6mwt between the bmi group as shown in other studies.7 it may be due to the physical capacity of the elderly that has a negative correlation with the amount of total body fat compared to body mass index.18 therefore, a high body mass index does not always mean high total fat. the limitation of this study is that there are no data for the patient’s illness. this is important because the type of disease may also affect the differences in 6mwt results, especially when the study is conducted at the hospital. therefore, a comparative study with elderly who are not attending the hospital is needed. to conclude, our study has shown the average distance achieved by 6mwt among elderly patients who visited the geriatric outpatient clinic is short. furthermore, there is no significant association between the average of 6mwt results and gender, or age group, or bmi. the health care in maintaining the functional capacity in the elderly must be performed correctly, therefore, whenever it is possible, walking is encouraged for the mobility of the elderly. references 1. kantor menteri negara perencanaan pembangunan nasional/ badan perencanaan pembangunan nasional (bappenas) dan badan pusat statistik. press release: tahun 2025, angka harapan hidup penduduk indonesia 73,7 tahun. 2010 [cited 2014 march 02]. available from: https://www. bappenas.go.id/id/berita-dan-siaranpers/berita/tahun-2025-angka-harapanhidup-penduduk-indonesia-737-tahun/ 2. thaweewannakij t, wilaichit s, chuchot r, yuenyong y, saengsuwan j, siritaratiwat w, et al. reference values of physical performance in thai elderly people who are functioning well and dwelling in the community. phys ther. 2013;93(10):1312– 1320. 3. lauretani f, russo cr, bandinelli s, bartali b, cavazzini c, di iorio a, et al. ageassociated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. am j physiol. 2003;95(5):1851–60. 4. sinclair aj, morley je, vellas b, editors. pathy’s principles and practice of geriatric medicine. 5th ed. hoboken, new jersey (united states): wiley-blackwell; 2012. 5. novy tct, vitriana v, sastradimaja sb, defi ir. effect of overground walking and treadmill exercise on walking speed and walking ability in elderly. ijihs. 2013;1(1):29–36. 6. simões la, dias j, marinho kc, pinto cl, britto rr. relationship between functional capacity assessed by walking test and respiratory and lower limb muscle function in community-dwelling elders. rev bras fisioter. 2010;14(1):24–30. 7. bautmans i, lambert m, mets t. the sixminute walk test in community dwelling elderly: influence of health status. bmc geriatr. 2004;4(1):4–6. 8. cruz-jentoft aj, baeyens jp, bauer jm, boirie y, cederholm t, landi f, et al. sarcopenia: european consensus on definition and diagnosis report of the european working group on sarcopenia in older people. br geriatrics soc. 2010;39(4):412–423 9. milanović z, pantelić s, trajković n, sporiš g, kostić r, james n. age-related decrease in physical activity and functional fitness among elderly men and women. clin interv aging. 2013;8(1):549–556. 10. nicklett ej. sex, health behaviors and social support: functional decline among older diabetics. am med j. 2012;3(2):82–92. 11. ilgin d, ozalevli s, kilinc o, sevinc c, cimrin ah, ucan es. gait speed as a functional capacity indicator in patients with chronic obstructive pulmonary disease. ann althea medical journal. 2019;6(4) 185 thorac med. 2011;6(3):141–146. 12. casanova c, celli b, barria p, casas a, cote c, de torres j, et al. the 6-min walk distance in healthy subjects: reference standards from seven countries. eur respir j. 2011;37(1):150–6. 13. peterson mj, crowley gm, sullivan rj, morey mc. physical function in sedentary and exercising older veterans as compared to national norms. j rehabil res dev. 2004;41(5):653–8. 14. klamklay j, sungkhapong a, yodpijit n, e patterson p. anthropometry of the southern thai population. intl j industrial ergon. 2008;38(1):111–8. 15. gill tm, allore hg, gahbauer ea, murphy te. change in disability after hospitalization or restricted activity in older persons. j am med assoc. 2010;304(17):1919–28. 16. gorman bk, read jng. gender disparities in adult health: an examination of three measures of morbidity. j health soc behav. 2006;47(2):95–110. 17. oeser a, chung cp, asanuma y, avalos i, stein cm. obesity is an independent contributor to functional capacity and inflammation in systemic lupus erythematosus. arthritis rheum. 2005;52(11):3651–9. 18. marcus r, addison o, lastayo p. intramuscular adipose tissue attenuates gains in muscle quality in older adults at high risk for falling: a brief report. j nutr disord ther. 2013;17(3):215–218. hanifah et al.: six-minutes walk test characteristics in geriatric outpatient clinic at dr. hasan sadikin general hospital bandung amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 81 reliability of rt-qpcr pooling method for covid-19 detection in various cycle threshold values muhammad fauzan alif radjawali,1 muti’ah nurul jihadah,2 lidya chaidir2,3 1faculty of medicine, universitas padjadjaran, indonesia, 2center for translational biomarker research, universitas padjadjaran, indonesia, 3department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia correspondence: lidya chaidir, m.si, ph.d, department of biomedical sciences, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: lidya.chaidir@unpad.ac.id introduction coronavirus disease 2019 (covid-19) is caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which first appeared in wuhan city, china, in late december 2019. sars-cov-2 is believed to be part of an animal coronavirus that mutates, spreads and rapidly evolves among the human population.1 sars-cov-2 can be transmitted through feces, blood, contaminated object, but the direct transmission is via respiratory droplets,2 therefore, a quick investigation and sufficient tools to contain the pandemic and break the chains of transmission is needed. the clinical spectrum of covid-19 disease is heterogeneous, ranging from asymptomatic to organ damage with delayed diagnosis. patients with covid-19 can increase risk of infection for caregivers, as well as the mortality rate of patients.3,4 according to the world health organization (who), there are more than 444 million cases, with a death toll of more than five million cases until march 2022. indonesia has more than five million positive cases, with more than 150,000 confirmed deaths.5 although covid-19 transmission has weighed indonesia’s burden, the country has brought down the covid-19 cases from its peak and has maintained this trend from september 2021 to the end of the year. however, it escalated again at the end of january 2022, when the omicron variant emerged. this variant is revealed to be ten times more contagious compared to the original variant.6 globally, ba.5 variant of omicron is spreading across several areas and proved to reduce neutralization titres in in althea medical journal. 2023;10(2):81–87 abstract background: reverse transcriptase quantitative real-time polymerase chain reaction (rt-qpcr) is a standard method to detect sars-cov-2, the cause of covid-19 disease, albeit expensive for some laboratory settings. the pooling test is widely used for large-scale screening to speed up the turnaround time and reduce the cost of the rt-qpcr. however, the pooling test involves mixing a certain number of specimens which theoretically increases the possibility of false-negative results. this study aimed to evaluate the accuracy of the pooling test compared with the non-pooling test in different ct values as a surrogate for viral load. methods: rt-qpcr was performed in three groups of samples: non-pooling (individual samples), pooling of 5 samples and 11 samples, with various ranges of ct value in the respective group: x<25 (n=4); 25<x<30 (n=5), x<30 (n=16), and negative sample (n=5). agreement and kappa values were calculated. four of twenty-five individual samples resulted in false-negative after pooling. results: by taking all samples without applying the cut-off value to the calculation, the agreement in pooling of 5 samples was 0.86 (kappa 0.31) and of 11 samples was 0.64 (kappa 0.96). when the cutoff value of ct<37 was applied, percent agreement and kappa were 1.00, respectively, for both pooling methods. conclusions: pooling up to 11 samples shows high concordance with rt-qpcr with individual samples with ct<37. interpreting pooling results in a very low viral load (ct≥37) must be considered due to the increased possibility of inconclusive results. keywords: cycle threshold (ct) value, covid-19, pooling test, rt-qpcr https://doi.org/10.15850/amj.v10n2.2940 althea medical journal. 2023;10(2) 82 vitro studies, in vaccinated and convalescent cohorts.7 to date, the most common method to detect infection of the sars-cov-2 virus is reverse transcriptase quantitative real-time polymerase chain reaction (rt-qpcr), which is relatively expensive for resource-limited countries.8,9 while efficiency in handling covid-19 is urgently needed, community transmissions are still difficult to control, and extensive contact tracing should be supported by accurate and sensitive population scale testing.10,11 therefore, many countries have applied a pooling test for extensive scale screening to reduce costs and speed up the diagnostic process.12 a pooling method involves mixing several samples in a tube before performing the test. when the test result of the group is negative, all individuals in the respective pool can be declared as negative. in contrast, a positive result indicates that one or more individuals in the group have positive results. in this case, retesting of individual specimens will be carried out.13 several factors can affect the pooling test’s accuracy, including the pool size and disease prevalence.14 unfortunately, published data from indonesia regarding pooling test accuracy in various pool sizes and ct values is still limited. this study aimed to evaluate the reliability of the rt-qpcr pooling method in various cycle threshold (ct) values compared to regular rtqpcr covid testing protocol. then, to ensure that the pooling test might help to detect low to high ct values, positive samples with various ct values were included in this study. the pooling of five and 11 samples were evaluated. each pooling test was compared with rtqpcr from the individual sample (non-pooling method). the agreement between pooling and individual samples was calculated. methods samples were selected from the collection (bio-archive) of specimens in the biosafety level 3 (bsl-3) facility, central laboratory, universitas padjadjaran, as one of the national laboratory networks for covid-19 (code c.67) as recommended by the ministry of health at hk.01.07/menkes/4642/2021. the selected ct value of individual sars-cov-2 positive samples spanned a large range of ct of lower than 40 and was selected randomly by considering viral transport medium (vtm) condition. vtm lower than 300 ml, change in color, and inactive vtm type would be excluded. the samples included different ct values: x<25 (n=4); 25<x<30 (n=5), x>30 (n=16), althea medical journal june 2023 sample size to be statistically approved to determining kappa value n=30 x<25 n=4 25<x<30 n=5 x>30 n=16 negative samples n=5 control vs pool 5 vs pool 11 (the most efficient pool size based on a positive rate of an areas) percent agreement & kappa value figure 1 research flowchart althea medical journal. 2023;10(2) 83 table 1 cycle threshold values non-pooling vs. pool 5 vs. pool 11 subject non-pooling pool 5 pool 11 n gene orf1ab gene internal n gene orf1ab gene internal n gene orf1ab gene internal control gene control gene control gene a 37.86 38* 23.74 40.86* 40.7* 26.41 41,36* 41.5* 28.19 b 21.13 21.66 24.36 23.52 24.63 26.86 24.72 25.92 27.49 c 16.16 17.29 23.96 19.48 20.51 27.91 19.87 20.92 27.95 d 30.02 30.01 28.51 31.94 32.68 31.29 33.59 34.65 32.32 e 28.87 29.85 28.45 30.33 30.85 29.8 31.4 32.08 31.56 f 20.67 21.57 25.76 23.02 24.13 28.25 24.31 25.39 29.3 g 33.49 33.5 23.21 36.08 36.77 27.07 37.22 37.58 28.57 h 26.55 26.61 26.94 29.87 30 29.41 31.14 31.47 30.81 i 35.01 35.5 30.02 38.52 38.53 33.78 38.29 38,99* 32.12 j 28.82 29.74 28.37 30.36 31.19 30.25 30.83 32.1 30.88 k 20.77 21.62 25.93 23.66 24.78 28.75 24.71 25.89 29.92 l 34.56 34.84 24.22 36.61 36.87 26.53 38,06* 38.33 27.83 m 33.46 34.06 24.72 36.58 36.33 28.04 36.32 36.02 27.6 n 34.27 34.08 23.27 34.73 36.12 25.98 38.02 37.39 27.26 o 35.19 35.36 25.04 38.39 37.69 26.95 38,69* 38.11 28.61 p 33.46 34.06 24.72 36.58 36.33 28.04 36.32 36.02 27.02 q 34.27 34.08 23.27 34.73 36.12 25.98 38.02 37.39 27.26 r 35.19 35.36 25.04 38.39 37.69 26.95 38,69* 38.11 28.61 s 36.71 36.07 19.02 36.83 38.42 23.57 40.33* 36.79 22.39 t 36.59 36.17 20.48 38.58 38.18 23.57 40.09* 38.48 23.91 u 37.47 38* 22.4 40.47* 41 28.79 40.97* 41.5* 29.46 v 37.17 38.23 23.28 40.17* 41.23* 26.92 40.87* 41.93* 27.66 w 38* 37.05 23.95 41* 30.05* 28.1 42* 40.75* 28.96 x 23.69 23.86 19.95 26.51 26.88 24.25 35.41 34.59 20.04 y 28.99 29.01 25.5 36.77 38.23 24.02 40 38.08 26.46 note: *retested or adjusted above 40 as gene detected (-) muhammad fauzan alif radjawali et al.: reliability of rt-qpcr pooling method for covid-19 detection in various cycle threshold values and negative samples (n=5). specimens with ct values below 25 were considered to have a high rna viral load, while those with ct values between 25 and 30 were considered to have an intermediate viral load. specimens with ct values higher than 30 were considered low viral load, thus representing culturable virus amounts, and have been assumed to be infectious.15 pools of five & 11 (n = 30 each) were made to be compared to non-pooling rtqpcr (n=30) (figure 1). the minimum sample size to calculate the kappa value and the most efficient pool size based on the positivity rate of an area were considered before conducting the study. considering that the pool testing was useful for populations with infection rates below 5% and our goal was to cut the usual cost of rtqpcr pooling five & 11, a total of 30 specimens from the central laboratory universitas padjadjaran were taken for our study.16,17 this study simulated a pooling test conducted in low prevalence conditions and low resource settings. to obtain five and 11 pooling samples, fifty microliters of the positive specimen, acting as one positive sample, were mixed with 200 and 500 μl of vtm (brand citoswab and iblue) simulating four and ten negative samples. after that, 200 μl of nonpooling samples and 200 μl of pooled samples althea medical journal. 2023;10(2) 84 from the mixture were extracted using the guangzhou date sarscov-2 extraction kit. 75 μl rna acquired from the extraction were amplified using daan gene sarscov-2 rtqpcr kit on lightcycler® 96 system. daan gene kit employs two one-step rt-qpcr assays using fluorescent probes for alternative sarscov-2 genes, called orf1b and the n gene and endogenous internal control. the ct value and the mean cycle thresholds difference (δ ct) of n and orf1ab gene were also analyzed to see the effect of dilution on the sample in the pooling test. this study obtained ethical approval issued by the research ethics committee of universitas padjadjaran with no. 168/un6. kep/ec/2021. the rt-qpcr results were interpreted by applying lightcycler 96 sw 1.1, and the determination of the positive and negative samples was based on the instructions in the daan kit manual. if the test sample had no amplification curve or ct>40 in the channel but has amplification in the internal control channel, the sample could be judged as negative. the sample could be considered positive if all the genes appeared and ct was not more than forty. if only one of the genes had amplification, it was recommended to repeat the test. if the retest was consistent with the previous result, it was reported as positive; however, if the retest was negative, it was reported as negative. several samples with the same or different results between pooling and non-pooling entered into percent agreement and cohen’s kappa calculation to obtain information about the similarity and reliability of the pooling method compared to the rt-qpcr non-pooling method.18 results the various cycle threshold values of the experiments by pool size and target gene was shown in table 1. four samples out of 25 non-pooling positive samples had a negative value when entering pooling five and pooling 11. several inconclusive results in pooling 11 turned positive after retesting according to daan gene manual instructions (table 1). the average of cycle threshold value samples with various treatments was shown in figure 2. additionally, pooling samples generally had higher ct values than those obtained from a single sample where the mean (x sign) in each treatment was 31.13, 33.72, and 35.25 for the n gene while for orf1ab gene were 31.42, 34.24, and 35,2. the mean ct difference (∆ct) between a sample of the non-pooling with pool althea medical journal june 2023 target gene n gene n gene ct v al ue ( x= m ea n, li ne =m ed ia n control pool 5 pool 11 5 0 10 15 20 25 30 35 40 45 figure 2 average of cycle threshold value samples with various treatments althea medical journal. 2023;10(2) 85 five and the non-pooling with pool 11 were 2.59 and 4.11 for the n gene, while the orf1ab gene was 2.81 and 3.78 (figure 2). these values helped us to see the effect of dilution on the sample in the pooling test and predicted the range detection of the sars-cov-2 ct value that could be detected by the pooling five method up to the pooling 11 method rt-qpcr. the percentage of agreement and cohen’s kappa calculations were conducted as shown in table 2 and table 3. discussion contact tracing is a mandatory to prevent the massive transmission of sars-cov-2, however, proper tracing is hampered by the high-cost of rt-qpcr as the gold standard test, and the need for rapid turn-around time diagnosis. the pooling method is one of the alternative solutions for large-scale screening and contact tracing. however, different pooling methods are applied in different settings, and reports of the reliability of pooling method are still limited. this study evaluated pooling of five and 11 samples and calculated the agreement (and cohen’s kappa) compared with the non-pooling (individual) sample results. the results showed that the agreement of both pooling was excellent for samples with ct<37 compared with the non-pooling method. other studies have shown that pooling five to 11 samples is recommended and acceptable; although there are shifting ct values in the pooling method, this technique is considerably reliable.19–21 theoretically, the ct value shifts -3.3 in 100% qpcr efficiency in 10-1 dilution.22 as the increase of pool size, the shifting in ct values follows a linear regression model: difference ct=0.187×pool size (n)+0.498 (r2=0.53). dorfman equation shows that the optimal pool size is 11 when the disease prevalence is ±0.66%, as shown by a study in korea.23 therefore, to model pooling test performance in low prevalence and low resource setting, pool size five and 11 was evaluated in this study. pooling of five and 11 samples still shows perfect agreement with rt-qpcr from the individual sample if the ct<37 as in individual studies shows that pooling does not affect the sensitivity of detecting sars-cov-2 when the ct of the original specimen is lower than 35 and performed in ten samples pool setting.24,25 however, samples with ct>37 could be negative or inconclusive when, included in pool 11, making a false negative result. on the other hand, some literature reported that the sars-cov-2 culture positivity rate decreases progressively on ct value 33.26 no viral cultures were obtained from samples with ct>34.27 the culture specimens were last detected at ct values=35.28 it was assumed that pooling samples to up to 11 in our experiment was still table 3 two-by-two table of pool method vs. non-pooling results (ct< 37) non-pooling results total test n=26 agreement (%) kappa value (95% ci)positive n=21 negative n=5 pool 5 positive 21 0 21 100 1 negative 0 5 5 pool 11 positive 21 0 21 100 1 negative 0 5 5 table 2 two-by-two table of pool method vs. non-pooling results non-pooling results total test n=30 agreement (%) kappa value (95% ci)positive n=25 negative n=5 pool 5 positive 21 0 21 86 0.64 (0.31; 0.96) negative 4 5 9 pool 11 positive 21 0 21 86 0.64 (0.31; 0.96) negative 4 5 9 muhammad fauzan alif radjawali et al.: reliability of rt-qpcr pooling method for covid-19 detection in various cycle threshold values althea medical journal. 2023;10(2) 86 reliable for implementation because ct values >37 had a low viral load for a chain infection. this study has only used one type of vtm and rt-pcr kit in the pooling experiment, this is a limitation of this study. indonesian laboratories use various types of vtm, including inactive vtm as some compositions may disturb the rna extraction process and molecular detection result.29 moreover, various rt-pcr kits, ranging from simplex to multiplex kits were also used in indonesian clinical laboratories—possibly having various limits of detection (lod). lastly, a communitybased study is also needed to evaluate the implementation of pooling five and 11 samples with various disease prevalence ranges. in conclusion, pooling up to 11 samples has demonstrated high concordance with rtqpcr with individual samples with ct<37. interpreting pooled results at very low viral loads (ct≥37) should be considered due to the increased possibility of inconclusive results. references 1. liu yc, kuo rl, shih sr. covid-19: the first documented coronavirus pandemic in history. biomed j. 2020;43(4):328–33. 2. lotfi m, hamblin mr, rezaei n. covid-19: transmission, prevention, and potential therapeutic opportunities. clin chim acta. 2020;508:254–66. 3. guan wj, ni zy, hu y, liang wh, ou cq, he jx, et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020;382(18):1708–20. 4. rong xm, yang l, chu hd, fan m. effect of delay in diagnosis 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side observations. viruses. 2021;13(8):1459. 16. bujang ma, baharum n. guidelines of the minimum sample size requirements for cohen’s kappa. epidemiol biostatistic public health. 2017;14(2):e12267. 17. ben-amotz d. optimally pooled viral testing. epidemics. 2020;33:100413. 18. mchugh ml. interrater reliability: the kappa statistic. biochem med (zagreb). 2012;22(3):276. 19. alcoba-florez j, gil-campesino h, garcíamartínez de artola d, díez-gil o, valenzuelafernández a, gonzález-montelongo r, et al. increasing sars-cov-2 rt-qpcr testing capacity by sample pooling. int j infect dis. 2021;103:19–22. 20. sawicki r, korona-glowniak i, boguszewska a, stec a, polz-dacewicz m. sample pooling as a strategy for community monitoring for sars-cov-2. sci rep. 2021;11(1):3122. althea medical journal june 2023 althea medical journal. 2023;10(2) 87 21. lim kl, johari na, wong st, khaw lt, tan bk, chan kk, et al. a novel strategy for community screening of sars-cov-2 (covid-19): sample pooling method. 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lancet infect dis. 2020;20(11):1231–2. 27. la scola b, le bideau m, andreani j, hoang vt, grimaldier c, colson p, et al. viral rna load as determined by cell culture as a management tool for discharge of sarscov-2 patients from infectious disease wards. eur j clin microbiol infect dis. 2020;39(6):1059–61. 28. huang cg, lee km, hsiao mj, yang sl, huang pn, gong yn, et al. culture-based virus isolation to evaluate potential infectivity of clinical specimens tested for covid-19. j clin microbiol. 2020;58(8):e01068–20. 29. van bockel d, munier cm, turville s, badman sg, walker g, stella ao, aggarwal a, yeang m, condylios a, kelleher ad, applegate tl. evaluation of commercially available viral transport medium (vtm) for sars-cov-2 inactivation and use in point-of-care (poc) testing. viruses. 2020;12(11):1208. muhammad fauzan alif radjawali et al.: reliability of rt-qpcr pooling method for covid-19 detection in various cycle threshold values amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 93 prevalence of gastroesophageal reflux disease among diabetic patients at sharif medical city hospital, lahore, pakistan syed muslim mehdi,1 usman baig,1 muhammad shahid iqbal2 1department of medicine, sharif medical city hospital, lahore, pakistan, 2department of community medicine, sharif medical and dental college, lahore, pakistan correspondence: dr. usman baig, mbbs, department of medicine, sharif medical city hospital, sharif medical city road, off raiwind road, jati umra, lahore, pakistan, e-mail: usman.baig1147@gmail.com introduction diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia, resulting from defects in insulin secretion, insulin action, or both. insulin is an anabolic hormone that is released by the islets of langerhans in the pancreas. in pancreatic b cells, insulin secretion is stimulated by the alteration of cellular array of messenger molecules. type 1 diabetes mellitus, also known as insulin-sensitive diabetes mellitus, results when the pancreas produces little or no insulin. children between the age of 10 and 14 years old are most likely to develop it; whereas in type 2 diabetes mellitus, also called insulin resistant, the tissues resist the effects of insulin, followed by insufficient insulin production by the pancreas later in life. it occurs most often in middle-aged and older people, however, there has been an increase in the prevalence of type 2 diabetes mellitus among children.1–3 as in diabetes mellitus, long-term hyperglycemia is linked with a number of co-morbidities including cardiovascular diseases, nerve damage (neuropathy), renal disease, retinopathy, and skin conditions.4 it is one of the causes of several gastrointestinal motility disorders, including gastroesophageal reflux disease (gerd) and gastroparesis. the mechanism of development of gerd in diabetics is multifactorial and is linked with obesity, neuropathy and hormonal imbalance of ghrelin and motilin. obesity causes higher intra-abdominal pressure leading to hiatal herniation, which reduces lower esophageal tone and causes acid reflux. diabetes induces neuropathy causes gastropathy and esophageal dysmotility.5 chronic gastroesophageal reflux disease can lead to barrett’s esophagus and esophageal adenocarcinoma as well as negatively affecting the patient’s living conditions, productivity and sleep.6 althea medical journal. 2023;10(2):93–98 abstract background: diabetes mellitus has been linked to various gastrointestinal motility disorders, including gastroesophageal reflux disease (gerd). this study aimed to determine the proportion of gerd in patients with diabetes mellitus. methods: this descriptive cross-sectional study was conducted at the medical outpatient department of sharif medical city hospital, lahore, from october to december, 2020. patients previously diagnosed with type ii diabetes were included using non-probability consecutive sampling, and the gerdq questionnaire was used to determine the frequency. ibm spss statistics version 23 was used for the analysis of data. results: of the 273 participants, 183 (67.0%) were male and the mean age was 51.13±12.8 years. the mean duration of diabetes was 6.97±4.76 years and oral hypoglycemic agents were used by 133 (48.7%) participants. overall, 133 (48.7%) of the participants had gerd with a mean gerdq score of 10.8(±1.4). conclusions: almost half of the participants have gerd; the most common symptom is regurgitation of stomach contents. awareness should be raised, and early screening should be done to prevent longterm complications. keywords: diabetes mellitus, gastroesophageal reflux disease, gerdq questionnaire, obesity, pakistan https://doi.org/10.15850/amj.v10n2.2881 althea medical journal. 2023;10(2) 94 the worldwide prevalence of diabetes is 9.3%, and in pakistan it is 14.6%.7,8 the prevalence of gerd among the population of pakistan ranges from 22–24%.9,10 the aim of this study was to determine the frequency of gerd in the diabetic population as a recent meta-analysis showed that there is a significant association between diabetes and gerd.11 this study is essential due to variations in frequencies of gerd in the diabetic population of different countries. our study will fill the literature gap and help physicians in early detection and treatment of gerd and this will also reduce the risk of the development of barrett’s esophagus and esophageal adenocarcinoma. methods it was a descriptive cross-sectional study conducted in medical outpatient department of sharif medical city hospital, lahore from october to december, 2020 after approval from the ethics committee of sharif medical and dental college, lahore (ref no. smdc/ smrc/138-20). the location of lahore city on the map of pakistan is shown in figure 1. sample size of 273 was calculated with the help of winpepi statistical program, with confidence of 95% with acceptable difference of 0.05 and assumed proportion of 0.23.12,13 patients previously diagnosed with type ii diabetes were included using non-probability consecutive sampling. patients with gestational diabetes mellitus, crohn’s disease, ulcerative colitis and diabetes insipidus were excluded. informed consent was taken from the patients and gerdq questionnaire was filled out on spot. it was a six-item, likert scale-based questionnaire consisting symptoms in the last week which included frequency of heartburn, epigastric pain, nausea, sleep disturbance, regurgitation and use of additional medicine besides the prescribed ones. the presence of gerd was determined based on summing up the individual score of all questions and comparing the total with a cut-off value of 9, having a sensitivity of 66% and specificity of 64%.14 for analysis of data, spss version 23 was used. for quantitative variables, like age, bmi, duration of diabetes and gerdq score, mean±sd were calculated. frequency was calculated for qualitative variables like gender, education, and occupational status. body mass index (bmi) cut-off values used to classify the nutritional status of participants were of the asian population. the normal bmi range was 18.5–22.9 kg/m2. patients with bmi between 23–24.9 kg/m2 were considered overweight and those with bmi greater than 25 kg/m2 were obese.15 post-stratification chi-square was applied and value ≤0.05 was considered significant. althea medical journal june 2023 figure 1 location of lahore on the map of pakistan* *source: wikipedia/nordnordwest althea medical journal. 2023;10(2) 95syed muslim mehdi et al.: prevalence of gastroesophageal reflux disease among diabetic patients at sharif medical city hospital, lahore, pakistan table 1 sociodemographic characteristics of participants characteristics frequency (n) percentage (%) age group of participants (in years) ≤40 41–50 51–60 61–70 ≥71 50 46 127 44 6 18.3 16.9 46.5 16.1 2.2 gender male female 183 90 67.0 33.0 educational status primary secondary post-secondary graduation/higher 25 41 112 95 9.2 15.0 41.0 34.8 occupational status employed unemployed 100 173 36.6 63.4 total family income (in pkr) 1 usd= 160pkr <30,000 30,000–50,000 >50,000 37 37 199 13.6 13.6 72.8 note: pkr= pakistan rupee results there were 273 participants, of which 183 (67.0%) were male. the most common age group was between 51 to 60 years. complete sociodemographic characteristics are shown in table 1. the duration of diabetes in most subjects was between 5–10 years and they were obese i. almost half (48.7%) were using oral medications for glycemic control. history of smoking was absent in 258 (94.5%) and 94 (34.4%) exercised regularly and were following nutritional recommendations offered by their physicians. among the other medications used by participants, the most common were antihypertensives which were being used by 43 (15.8%). clinical characteristics of participants and their comparison between those with and without gerd are shown in table 2. the participants had an average gerdq score of 8.96 (±2.1). gerd was present in 133 (48.7%) participants with a mean score of 10.8 (±1.4). the most common symptom in the study was regurgitation of stomach contents and night sleep disturbance; the frequency of symptoms is shown in table 3. discussions the frequency of gerd in diabetics is greater when compared with that of the normal population of america (18.1% to 27.8%), europe (25.9%), australia (11.6%) and nigeria (7.6%).16–19 diabetics also have a higher frequency of gerd than the general population of asian countries, including pakistan, supporting that diabetes-associated induced neuropathy could be the cause of gerd in diabetic population.9,10,20,21 the result of the study is close to those conducted in america and saudi involving diabetic population.22,23 however, the frequency of gerd in diabetics in the study is greater than those of indonesia, china and mexico.24–26 gerd frequency in indonesian diabetics is 30.2% and is less than the frequency among participants of this study. this could be due to the fact that the mean bmi (24.07±4.32 kg/m2 ) of the participants and the duration of diabetes (median=2 years) is less than that of our study (bmi=28.4±5.18 kg/m2, median duration=6 years).24 mexican study also showed less frequency, this could be possibly due to racial and geographical factors.25 in chinese study, a different questionnaire (reflux disease questionnaire) was used which could be accountable for the differences in results.26 studies conducted in turkey and bangladesh showed increased frequency of gerd in diabetics compared to this study.27,28 this could be because the study conducted in bangladesh only involved participants admitted in hospital and among those, most of them had co-morbidities.27 whereas, a selfdevised questionnaire was used in turkish study which could have led to the differences in results of both studies.28 althea medical journal. 2023;10(2) 96 there is a higher proportion of individuals between the ages of 51 and 60 years old, suggesting that the majority of diabetesrelated comorbidities begin to manifest in this age range, resulting in frequent hospital visits. the higher number of male participants in the study could be due to the limited access of women in rural areas to tertiary care hospitals and their reliance on male family members for transportation. this could be a contributor to the gender disparity in the study. there was a higher number of participants with diabetes for more than five years who had symptoms of gerd compared to those with diabetes for less than five years, indicating that an increased duration of diabetes may be a contributing factor, as observed in other studies.11 however, the results were not consistent for those with a duration of diabetes greater than 10 years due to the small number of participants in this group. the limitations of this study included a small sample and being limited to a single site. more hospitals could have been involved to have a large number of patients and to have patients from different localities. the latest studies in this regard should be done using 24-hour esophageal ph monitoring and manometry. in conclusion, awareness regarding gerd symptoms should be raised in diabetics as almost half of the participants had gerd in the study. the most common symptom being regurgitation of stomach contents and sleep disturbance. screening should be done to devise early strategy and management. this could lower the risk of development of complications of gerd. source of funding: no funding to declare. disclaimer: none conflict of interests: none to declare. althea medical journal june 2023 table 2 clinical characteristics of participants with and without gerd (n= 273) clinical characteristics gerd (n) nongerd (n) x2 p-value nutritional status (bmi) normal range (18.5–22.9) overweight at risk (23–24.9) obese i (25–29.9) obese ii (≥30) 6 43 39 45 18 8 79 35 44.67 <0.001 duration of diabetes (years) <5 5–10 >10 33 88 12 52 65 23 10.98 0.004 diet control yes no 109 24 116 24 0.38 0.84 exercise yes no 67 66 52 88 4.85 0.028 medication for diabetes none oral medication oral medications and insulin 9 77 47 20 56 64 9.19 0.007 table 3 frequency of gerd symptoms among the participants symptoms 0 day (never) 1 day (mild) 2–3 days (moderate) 4–7 days (severe) n (%) n (%) n (%) n (%) heartburn acid regurgitation stomach pain or discomfort nausea night sleep disturbance 94 (34.4) 78 (28.6) 121 (44.3) 145 (53.1) 83 (30.4) 69 (25.3) 92 (33.7) 46 (16.8) 63 (23.1) 65 (23.8) 74 (27.1) 82 (30.0) 83 (30.4) 57 (20.9) 87 (31.9) 36 (13.2) 21 (7.7) 23 (8.4) 8 (2.9) 38 (13.9) althea medical journal. 2023;10(2) 97 references 1. kharroubi at, darwish hm. diabetes mellitus: the epidemic of the century. world j diabetes. 2015;6(6):850–67. 2. rorsman p, braun m. regulation of insulin secretion in human pancreatic islets. annu rev physiol. 2013;75:155–79. 3. maahs dm, west na, lawrence jm, mayer-davis ej. epidemiology of type 1 diabetes. endocrinol metab clin north am. 2010;39(3):481–97. 4. papatheodorou k, banach m, bekiari e, rizzo m, edmonds m. complications of diabetes 2017. j diabetes res. 2018;2018:3086167. 5. punjabi p, hira a, prasad s, wang x, chokhavatia s. review of gastroesophageal reflux disease (gerd) in the diabetic patient. j diabetes. 2015;7(5):599–609. 6. martinucci i, de bortoli n, russo s, bertani l, furnari m, mokrowiecka a, et al. barrett’s esophagus in 2016: from pathophysiology to treatment. world j gastrointest pharmacol ther. 2016;7(2):190–206. 7. saeedi p, petersohn i, salpea p, malanda b, karuranga s, unwin n, et al. global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the international diabetes federation diabetes atlas, 9th edition. diabetes res clin pract. 2019;157:107843. 8. akhtar s, nasir ja, abbas t, sarwar a. diabetes in pakistan: a systematic review and meta-analysis. pak j med sci. 2019;35(4):1173–8. 9. jafri n, jafri w, yakoob j, islam m, manzoor s, jalil a, et al. perception of gastroesophageal reflux disease in urban population in pakistan. j coll physicians surg pak. 2005;15(9):532–4. 10. riaz h, kamal sw, aziz s. gastroesophageal reflux disease (gerd) in students of a government medical college at karachi. j pak med assoc. 2010;60(2):147–50. 11. sun xm, tan jc, zhu y, lin l. association between diabetes mellitus and gastroesophageal reflux disease: a meta-analysis. world j gastroenterol. 2015;21(10):3085–92. 12. abramson jh. winpepi updated: computer programs for epidemiologists, and their teaching potential. epidemiol perspect innov. 2011;8(1):1. 13. lee sd, keum b, chun hj, bak yt. gastroesophageal reflux disease in type ii diabetes mellitus with or without peripheral neuropathy. j neurogastroenterol motil. 2011;17(3):274–8. 14. jonasson c, wernersson b, hoff dal, hatlebakk jg. validation of the gerdq questionnaire for the diagnosis of gastrooesophageal reflux disease. aliment 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[prevalence of gastroesophageal reflux disease in patients with type 2 diabetes mellitus]. med clin (barc). 2014;143(5):232–3. 26. sun h, yi l, wu p, li y, luo b, xu s. prevalence of gastroesophageal reflux disease in type ii diabetes mellitus. gastroenterol res pract. 2014;2014:601571. 27. saglan y, bilge u, unluoglu i. frequency of gastroesophageal reflux disease in patients with type 2 diabetes mellitus. biomed res. 2017;spesial issue:s507–12. 28. rouf ma, khan m, sharif ju, karim mr, rahman mm, ahmed h, et al. prevalence of gerd in type ii diabetes mellitus patients admitted in a tertiary care hospital of bangladesh. mymensingh med j. 2017;26(4):710–5. althea medical journal june 2023 amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 187 platelet-rich fibrin enhances fracture healing in tibial long bone: an experiment in rabbit nucki nursjamsi hidajat, dicky mulyadi, m. rizal chaidir, taufan herwindo dewangga department of orthopaedic and traumatology faculty of medicine universitas padjadjaran dr. hasan sadikin general hospital bandung, indonesia correspondence: taufan herwindo dewangga, department of orthopaedic and traumatology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur no. 38, bandung, indonesia, e-mail: taufanhdewangga@gmail.com introduction defect fracture is a fracture characterized by loss of part of the diaphyseal bone fragment. the defect cannot be healed without operative intervention with a bone graft or with the osteogenesis distraction method. high energy trauma, tumor resection, surgery revision, bone development impairment, and infection can cause a large bone defects with few healing potentials. bone defect cases in hasan sadikin general hospital were reported about 447 cases in 2007.1,2 the combination of mechanical and biological techniques to shorten the healing process of bone defect has been studied recently. bone graft, involving the use of growth factors, platelet-rich plasma, and platelet-derived growth factors, has shown promising results.3,4 platelet rich fibrin (prf) has been the focus of recent studies for its potential in accelerating the healing process. prf excels more than prp in terms of growth factors secretion that is more relatively consistent with longer duration and also its ease to obtain.5 this study aimed to determine the quality of defect fracture healing on long bone histologically, on subjects treated with bone graft with and without the combination of prf. methods this study was an experimental study with a completely randomized design. the subjects of the study were 18 adult male rabbits, aged 24 months, weighted 3–4 kilograms, and healthy. rabbits that were ill had anatomical defects, and had weight loss more than 10% off initial weight were excluded. the infected amj. 2020;7(4):187–93 abstract background: fracture on long bone is a complicated case to manage. bone graft procedure involving growth factors has been widely studied with promising results. recently, platelet-rich fibrin (prf) has been introduced as having potential in healing process. this study aimed to explore the quality of fracture healing on long bones treated with bone graft with and without prf combination. methods: this study was conducted between october to november 2018 on 18 rabbits that were divided into 2 groups. a 5 mm fracture was created on tibial bones and the fracture was stabilized using a 2.0 mm mini plate. the defect was then treated by an autogenic bone graft with and without prf. histological analysis was conducted 3 weeks after the treatment and a scoring was performed using the salkeld system. the quality of union; cortex development and remodeling; and bone graft incorporation and new bone formation were then analyzed. results: there were significant differences between fractures in rabbits given prf than those without prf in terms of union quality (p 0.040), cortex growth and remodeling (p 0.0001), bone graft and new bone union (p 0.0001), as well as in the total salkeld score (p 0.0001). conclusions: prf given with bone graft therapy can enhance the quality of fracture healing of a long bone. further studies on how the prf content influences fracture healing process needs to be performed to further explore this effect. keywords: bone graft, defect fracture, platelet rich fibrin https://doi.org/10.15850/amj.v7n4.1960 althea medical journal. 2020;7(4) 188 amj december 2020 or dead rabbit was dropped out of the study. the study was conducted in pharmacology and therapy laboratory of universitas padjadjaran in collaboration with the department of anatomical pathology, dr. hasan sadikin general hospital, from october–november 2018 after approval was released from department of orthopaedic and traumatology and the research ethics committee dr. hasan sadikin general hospital (no. lb.02.01/x.2.2.1/19761/2018). eighteen male rabbits were divided into 2 groups, a group with segmental fracturization on the tibia and treated with an autogenic bone graft (group k-1) and a group with segmental fracturization on the tibia and treated with autogenic bone graft and prf (k-2). there was 1 week of adaptation process for the rabbits to be familiar with the study environment. this study consisted of 3 steps, first was bone fracturization and then stabilization with plate and screw; the second was autogenic bone graft, third was an addition of prf to the k-2 group. in brief, the subject was anesthetized by ketamine hydroxychloride 50 mg/kg body weight intramuscular with diazepam 5 mg/kg body weight. the hair on the front lower leg was cut and given antiseptic. the incision was made until the bone was exposed. the bone segment was cut 5 mm at the middle part of the tibia using an oscillator knife. washing using physiological saline was done to prevent osteonecrosis. the fracture fragment was fixated using miniplate (2.0 mm) and 4 screws on the subject’s tibia. the average thickness of human’s cortical bone is 10 times bigger than average cortical bones of rabbit. the bone segment was cut 5mm on this study with the analogy of 5 cm segmental defect on human’s tibial bone.6 figure 1 rabbit bone tibial bone segmental defect fixation using a miniplate figure 2 fibrin clot between acellular plasma and red blood cell after centrifugation8 althea medical journal. 2020;7(4) 189nucki nursjamsi hidajat et al.: platelet-rich fibrin enhances fracture healing in tibial long bone: an experiment in rabbit the second step was the use of an autogenic bone graft from 5 mm bone that was obtained from the making of the defect itself. this whole bone segment was crushed into smaller pieces to make it easier for grafting. the last step was the addition of prf for the second group. autologous prf was prepared from 8 ml of arterial blood from the central artery of the rabbit’s ear before sedation. a blood sample without anticoagulant was collected onto a 10 ml glass tube and centrifugated at 3000 rpm for 10 minutes. the fibrin clot in the middle part of the tube was the one used for graft material.7 the surgical wound was then closed by suture with catgut on 3/0 and the subject was given cefazoline 30 mg/kg bw/day intramuscular on thigh’s muscle 2 times a day, alternating right and left, for 3 days. a tibial bone sample was obtained 3 weeks after surgery for histologic evaluation. the tibial bone was brought in formalin liquid to the department of anatomical pathology, dr. hasan sadikin general hospital. histologic evaluation was performed using salkeld scoring system by a pathologist consultant to minimize possible bias. table 1 salkeld scoring system9 description grade quality of union • no sign of fibrous or other unions 0 • fibrous union 1 • fibrocartilaginous union or cartilage union 2 • mineralizing cartilage and bone union 3 • bone union 4 cortex development and remodeling • no cortex formed 0 • densification of new bone along exterior borders 1 • recognizable formation of both the outer cortex border and the medullary space 2 • cortices formed but incomplete bridging 3 • complete formation of cortices with the bridging of the defect 4 bone-graft incorporation and new-bone formation • no new bone, all or most of graft visible • graft material present, no incorporation, and no newbone formation 0 • graft present, some incorporation with new-bone formation, and a small amount of new bone 1 • graft present, some incorporation with new-bone formation, and a moderate amount of new bone 2 • decreasing graft, increasing new bone • graft present, some incorporation with new-bone formation continues with host bone, and early remodeling changes in new bone 3 • decreased amount of graft (compared with grade 3), good graft incorporation, and ample new bone 4 • less amount of graft still visible (compared with garde 4), good incorporation of graft and new bone with host and ample new bone 5 • no graft visible, extensive new bone • difficult to differentiate graft from new bone, excellent incorporation, and advanced remodeling of new bone with graft and host 6 althea medical journal. 2020;7(4) 190 amj december 2020 results group 1 had 4 samples as a control group with a score 1. histological appearance demonstrated signs of fibrous union (figure 3a). furthermore, group 1 had 5 samples with score 2 that had signs of fibrocartilaginous union or cartilage. group 2 had 5 samples with a score 5. histological appearance with score 5, demonstrated signs of fibrocartilaginous or cartilage union, figure 3 a. histological appearance of group 1 with score 1, b. histological appearance of group 2 with score 5 a b table 2 score of group 1 and 2 based on the salkeld scoring system sample number union quality cortex development and remodeling bone-graft incorporation and new-bone formation total salkeld score point* group 1 1 1 1 2 2 2 3 1 1 4 2 2 5 2 2 6 2 2 7 1 1 8 1 1 9 2 2 group 2 1 2 1 1 4 2 3 1 1 5 3 2 1 1 4 4 2 1 1 4 5 2 2 1 5 6 2 2 1 5 7 3 1 1 5 8 2 1 1 4 9 2 2 1 5 note: total salkeld score point 3 weeks post-operation althea medical journal. 2020;7(4) 191 table 3 comparison of union quality, cortex development and remodeling, bone-graft incorporation and new-bone formation, and total salkeld score point 3 weeks post-operation between group 1 and 2 variable group p-valuei ii n=9 n=9 union quality 0.040** median 2.00 2.00 range (min-max) 1.00-2.00 2.00-3.00 cortex development and remodeling 0.0001** median 0.00 1.00 range (min-max) 0.00 1.00-2.00 bone-graft incorporation and new-bone formation 0.0001** median 0.00 1.00 range (min-max) 0.00 1.00 total salkeld score point 3 weeks post-operation 0.0001** mean ± sd 1.55±0.527 4.55±0.527 median 2.00 5.00 range (min-max) 1.00-2.00 4.00-5.00 densification of new bone along outer margin, and graft material slightly united with new bone development, and few new bone formation (figure 3 b). the comparison between group 1 and group 2 in terms of union quality, cortex development and remodeling, bone-graft incorporation and new-bone formation, and numerical data of total salkeld score point 3 weeks post-operation, all resulted in p-value <0.05, which was significant, suggesting that prf addition to autologous bone graft therapy could enhance the quality of long bone defect fracture healing histologically. discussion this study has analyzed callus formation using the histological examination. however, the method might have some drawbacks regarding subjectivity from the pathologist, which can be minimized by using a scoring system that is salkeld scoring system. the result of this study has shown a significant difference between the group that has been treated with only autologous bone graft and the group treated with autologous bone graft and with the addition of prf. the prf has a positive effect on new bone formation on calvarial bone or flat bone when used either alone or combined with bone graft. the effect of prf on periodontal defect has a better effect on the periodontal defect. our study has a better study period, which is for 3 weeks. callus formation is predicted to happen in the second up to the third week. differentiation of stem cells into chondrogenic and osteogenic cells might occur in the third week, creating a biological environment that is optimum for new bone formation.10-12 this study used cortical bone graft as material to fill the bone defect because long bone defect fracture needs firm structural support that could not be fulfilled by a cancellous bone graft. the synthetic bone graft is not chosen because of the extra cost needed and the possibility of immunological rejection. the slower rate of union between cortical bone grafts with host bone could show the acceleration effect of bone healing after prf addition in this study. the prf is a natural reservoir for growth nucki nursjamsi hidajat et al.: platelet-rich fibrin enhances fracture healing in tibial long bone: an experiment in rabbit althea medical journal. 2020;7(4) 192 amj december 2020 factors, forming a solid fibrin matrix, prf is obtained by centrifugation blood that has been taken without anticoagulant. it works by slowreleasing several growth factors necessary in regulating proliferation, migration, mesenchymal cell growth.15 ling et al.16 compared the effect of prp and prf on the proliferation and differentiation process of osteoblast in mouse samples, showing that prf is better than prp because prf is a slow-released autologous growth factor. prf demonstrates a better and more durable effect on cell proliferation and differentiation, and it is formed from a natural and progressive polymerization during centrifugation. this relatively slow and progressive polymerization could increase cytokine binding onto fibrin mesh. many pdgf and tgf contained prf especially on day 14 may then slowly decrease. the autologous growth factor could influence cells for 5–7 days. this dissolved molecule is believed to be bound on prf fibrin mesh and could go off controllably and has a relatively long effect. it is caused by an abundant amount of fibrin on prf that could prevent proteolytic degradation of the growth factors. stages of bone healing with a bone graft that consist of inflammation, osteoblast differentiation, osteoinduction, osteoconduction, and remodeling occur at the first 14 days after bone graft insertion, hence, prf stimulates bone regeneration well.16 however, faot et al.17 have a different result from the previous study, showing that prf does not increase bone healing on rabbit tibial bone defect fracture. there are several flaws from his study, such as no stable fixation to protect the blood clot and further bone damage potential because of increased activity of the animal samples after the first week of study. another flaw is that the rabbit’s tibial bone anatomy itself could not maintain the prf membrane to be attached to the bone defect, therefore, with the cut blood vessels, prf only has a paracrine effect.17 although this study has shown significant results of prf addition, however, there are some other inevitable drawbacks. the main problem is a small sample number that may not be an absolute indicator to prove the effectiveness of prf. this study could be a preliminary study for a bigger sample study. rabbit as an animal model may also not be the best choice, because a rabbit walks using its 4 legs, not like a human with only 2 legs. another thing is that this study only analyzes bone healing histologically. several methods like radiology, biochemical, biomechanical, and gene expression analysis have not been carried out. in conclusion, this study shows that prf given along with bone graft therapy can enhance the quality of defect fracture healing on a long bone. future study about the prf content that influences the fracture healing process needs further exploration. references 1. kanthan sr, kavitha g, addi s, choon dsk, kamarul t. platelet-rich plasma (prp) enhances bone healing in non-united critical-sized defects: a preliminary study involving rabbit models. injury. 2011;42(8):782–9. 2. mills la, simpson ahrw. the relative incidence of fracture non-union in the scottish population (5.17 million): a 5-year epidemiological study. bmj open. 2013;3(2):e002276. 3. lascombes p, popkov d, huber h, haumont t, journeau p. classification of complication after progressive long bone lengthening: proposal of a new classification. orthop traumatol surg res.2012;98(6):629–37 4. hasler cc, krieg ah. current concept of leg lenghtening. j child orthop. 2012;6(2):89– 104 5. kazemi d, fakhrjou a, dizaji vm, alishahi mk. effect of autologous platelet rich fibrin on the healing of experimental articular cartilage defect of the knee in an animal model. biomed res int. 2014;2014:486436 6. bagi cm, berryman e, moalli mr. comparative bone anatomy of commonly used laboratory animals: implications for drug discovery. comp med. 2011;61(1):76– 85 7. department of laboratory animal resources the university of toledo. guidelines for blood collection: rodents and rabbits. 2011 [cited 2017 september 13] available from: https://www.utoledo. e d u / g u i d e l i n e f o r b l o o d c o l l e c t i o n rodents-and-rabbits.pdf 8. ehrenfest dmd, bielecki t, jimbo r, barbé g, corso md, inchingolo f, et al. do the fibrin architecture and leukocyte content influence the growth factor release of platelet concentrates? an evidence-based answer comparing a pure platelet-rich plasma (p-prp) gel and a leukocyteand platelet-rich fibrin (l-prf). curr pharm biotechnol. 2012;13(7):1145–52 9. salkeld sl, patron lp, barrack rl, cook sd. the effect of osteogenic protein-1 on althea medical journal. 2020;7(4) 193 the healing of segmental bone defects treated with autograft or allograft bone. j bone joint surg am. 2001;83(6):803–16. 10. leteve m, passuti n. current concepts in bone graft substitutes. new journal of glass and ceramics. 2018;8(3):39–54 11. pripatnanont p, nuntanaranont t, vongvatcharanon s, phurisat k. the primacy of platelet rich fibrin on bone regeneration of various grafts in rabbit’s calvarial defect. j craniomaxillofac surg. 2013;41(8):191–200. 12. pastor mf, floerkemeier t, witte f, nellesen j, thorey f, windhagen h, et al. repetitive recombinant human bone morphogenetic protein 2 injection improve the callus microarchitecture and mechanical stiffness in a sheep model of distraction osteogenesis. orthop rev (pavia). 2012;4(1):e13. 13. miller md, thompson sr, hart j. miller’s review of orthopaedics. 6th ed. philadelphia: elsevier health sciences; 2012. p.1–5 14. venkataraman n, bansal s, bansal p, narayan s. dynamic of bone graft healing around implants. j int clin dent res organ. 2015;7:40–7 15. pluemsakunthai w, kuroda s, shimokawa h, kasugai s. a basic analysis of platelet-rich fibrin: distribution and release of plateletderived growth factor-bb. inflammation and regeneration. 2013;33(3):164–7. 16. he l, lin y, hu x, zhang y, wu h. a comparative study of platelet-rich fibrin (prf) and platelet-rich plasma (prp) on the effect of proliferation and differentiation of rat osteoblasts in vitro. oral surg oral med oral pathol oral radiol endod. 2009;108(5):707–13 17. faot f, deprez s, vandamme k, camargos gv, pinto n, wouters j, et al. the effect of l-prf membranes on bone healing in rabbit tibiae bone defect: micro-ct and biomarker results. sci rep. 2017;7:46452. nucki nursjamsi hidajat et al.: platelet-rich fibrin enhances fracture healing in tibial long bone: an experiment in rabbit amj vol 10 no 1 march 2023 rev.indd a lt h e a m e d ic a l jo u r n a l v o lu m e 1 0 n u m b e r 1 y e a r 2 0 2 3 volume 10, number 1 march, 2023 e-issn 2337-4330 original articles determinants of hypertension treatment adherence during the covid-19 pandemic: lesson learned from various studies sites in indonesia raehan satya deanasa, alifa alya zalfa, lathifah dzakiyyah zulfa, nurul mufliha patahuddin, sofia hana, anak agung bagus putra indrakusuma, aizar vesa prasetyo, gita julianti malik, hesti azzahra tosadapotto, raza syahlevi suwandri, muhammad nur mahmudi, rizma adlia syakurah monitoring obstacles of toddlers growth in public health center margahayu raya bandung city during the covid-19 pandemic: from cadre perspective natasya alifah sekarani, dewi marhaeni diah herawati, fedri ruluwedrata rinawan clinical characteristics of patients with different sars-cov-2 variants in south kalimantan, indonesia haryati, mohammad isa, ali assagaf, ira nurrasyidah, erna kusumawardhani, desi rahmawaty intervention of kusuma milk-shake drink on cervical dilatation and duration of labor: experience from bengkulu, indonesia dwie yunita baska, elly wahyuni, nispi yulyana risk factors for patients with gonococcal urethritis at dr. hasan sadikin general hospital bandung, indonesia in 2013–2019 pati aji achdiat, jefferson basta erguna ginting, chrysanti lipid profile in early and late stage among patients with nephrotic syndrome-related chronic kidney disease in dr. hasan sadikin general hospital bandung, indonesia in 2016– 2019 haya hanif mahardika, ahmedz widiasta, viramitha kusnandi rusmil low bone mineral density, sedentary lifestyle, and depression as risk factors for frailty syndrome at a home care facility in west jakarta, indonesia yvonne suzy handajani, jonathan christianto subagya, nelly tina widjaja level of knowledge, attitude, and behavior among specialists of otorhinolaryngology-head and neck surgery in west java, indonesia towards cochlear implants annisa ramadhanti, lina lasminingrum, sally mahdiani, arif dermawan, bambang purwanto characteristics of nasal foreign body cases in dr. hasan sadikin general hospital bandung henzen ghesan hampry, sinta sari ratunanda, melati sudiro, wijana, raden ayu hardianti saputri correlation between vertebral slippage in spondylolisthesis with ligamentum flavum thickening in dr. soebandi hospital, jember, east java, indonesia heni fatmawati, alvin candra, nindya s rumastika, al munawir, muh. hasan, i nyoman semita editor in chief edhyana k. sahiratmadja managing editor mas rizky a.a syamsunarno external editors gerald pals kamisah yusof alexander kwarteng kittiphong paiboonsukwong r. tedjo sasmono jarir at thobari soegianto ali trevino aristarkus pakasi andani eka putra pudji lestari herry garna internal editors yunia sribudiani ronny lesmana afiat berbudi nur atik muhammad hasan bashari sri endah rahayuningsih irma ruslina defi reni ghrahani mohammad ghozali astrid feinisa khairani nur melani sari eko fuji ariyanto copyeditors hanna goenawan julia ramadhanti poppy siti chaerani djen amar electronic production engineer devi fabiola syahfitri site administrator & layout editor ati sulastri  offline secretariat elsa purwita editorial address jl. prof. dr. eijkman 38 bandung, indonesia 40161 mobile: 082216237668/081320178724 phone (+62) 022-2032170 ext. 1401 fax: (+62) 022-2037823 e-mail: chiefeditor.amj@gmail.com website: http://journal.fk.unpad.ac.id/index.php/amj volume 10, number 1 march, 2023 e-issn 2337-4330 original articles determinants of hypertension treatment adherence during the covid-19 pandemic: lesson learned from various studies sites in indonesia raehan satya deanasa, alifa alya zalfa, lathifah dzakiyyah zulfa, nurul mufliha patahuddin,  sofia hana, anak agung bagus putra indrakusuma, aizar vesa prasetyo, gita julianti malik,  hesti azzahra tosadapotto, raza syahlevi suwandri, muhammad nur mahmudi, rizma adlia syakurah monitoring obstacles of toddlers growth in public health center margahayu raya  bandung city during the covid-19 pandemic: from cadre perspective natasya alifah sekarani, dewi marhaeni diah herawati, fedri ruluwedrata rinawan clinical characteristics of patients with different sars-cov-2 variants in south kalimantan, indonesia haryati, mohammad isa, ali assagaf, ira nurrasyidah, erna kusumawardhani, desi rahmawaty intervention of kusuma milk-shake drink on cervical dilatation and duration of labor: experience from bengkulu, indonesia dwie yunita baska, elly wahyuni, nispi yulyana risk factors for patients with gonococcal urethritis at dr. hasan sadikin general  hospital bandung, indonesia in 2013–2019 pati aji achdiat, jefferson basta erguna ginting, chrysanti lipid profile in early and late stage among patients with nephrotic syndrome-related chronic  kidney disease in dr. hasan sadikin general hospital bandung, indonesia in 2016−2019 haya hanif mahardika, ahmedz widiasta, viramitha kusnandi rusmili low bone mineral density, sedentary lifestyle, and depression as risk factors for  frailty syndrome at a home care facility in west jakarta, indonesia yvonne suzy handajani, jonathan christianto subagya, nelly tina widjaja level of knowledge, attitude, and behavior among specialists of otorhinolaryngologyhead and neck surgery in west java, indonesia towards cochlear implants annisa ramadhanti, lina lasminingrum, sally mahdiani, arif dermawan, bambang purwanto characteristics of nasal foreign body cases in dr. hasan sadikin general hospital bandung  henzen ghesan hampry, sinta sari ratunanda, melati sudiro, wijana,  raden ayu hardianti saputri correlation between vertebral slippage in spondylolisthesis with ligamentum flavum  thickening in dr. soebandi hospital, jember, east java, indonesia   heni fatmawati, alvin candra, nindya s rumastika, al munawir, muh. hasan,  i nyoman semita page 1–7 8–13 14–20 21–26 27–31 32–36 37–42 43–50 51–55 56–60 author’s guidelines althea medical journal (amj) is a peer reviewed electronic scientific publication journal in english which is published every 3 months (march, june, september, and december). althea medical journal publishes articles related to research in biomedical sciences, clinical medicine, family-community medicine, and public health. general instructions to avoid duplication, amj does not receive articles that are already published or submitted to other journals which are 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2012;107(suppl1):s3–7. edition with supplement north cs, pollio de, smith rp, king rv, pandya a, suris am, et al. trauma exposure and posttraumatic stress disorder among employees of new york city companies affected by the september 11, 2001 attacks on the world trade center. disaster med public health prep. 2011;(5 suppl 2):s205– 13. books and other monographs personal author(s) sax pe, cohen cj, kuritzkes dr. hiv essentials 2012. 2nd ed. burlington: world headquarters; 2012. editor(s) as the author baxter r, editor. a cellular dermal matrices in breast surgery, an issue of clinics in plastic surgery. mountlake terrace: saunders; 2012. organization as the author unaids. meeting the investment challenge tipping the dependency. geneva: who library cataloguing data; 2012. chapter in a book pignone m, salazar r. disease prevention and health promotion. in: diedrich c, lebowitz h, holton b, editors. 2012 current medical diagnosis and treatment. 51st ed. new york: the mcgraw-hill companies; 2012. p. 1–21. conference proceedings wilson b, hamilton n, editors. airborne particulate exposures: the environmental and occupational perspectives. proceedings of the wsn mining health and safety conference; 2012 april 17–19; sudbury. ontario: golder associates; 2012. conference paper tirilly p, lu k, mu x. predicting modality from text quiries for medical image retrieval. in: cao y, kalpathy-cramer j, unay d, editors. mm 11. proceeding of the 2011 international acm workshop on medical multimedia analysis and retrieval; 2011 nov 28–dec 01; arizona, usa. new york: acm; 2011. p. 7–12. dissertation rohim s. kontruksi diri dan perilaku komunikasi gelandangan di kota jakarta (studi fenomenologi terhadap julukan gelandangan “manusia gerobak”) [dissertation]. bandung: universitas padjadjaran; 2012. electronic material journal article in electronic format mahmood om, goldenberg d, thayer r, migliorini r, simmons an, tapert sf. adolescents’ fmri activation to a response inhibition task predicts future substance use. addictive behaviors [internet] 2012 [cited 2012 may 12]. available from: http:// www.sciencedirect.com. homepage world health organization. cardiovascular disease (cvds) [internet] [cited 2021 may 6]. available from: https://www. who.int/health-topics/cardiovasculardiseases#tab=tab_1. editorial board contact: althea medical journal mobile: 082216237668/081320178724 e-mail: chiefeditor.amj@gmail.com amj.fkunpad@gmail.com althea medical journal. 2014;1(1) 48 amj june, 2014 teratogenic effects of ethanol extract of soursop leaves (annona muricata folium) on mouse (mus musculus) fetus yunita suryani1, truly deti rose sitorus2, setyorini irianti3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of obstetric and gynecology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: soursop leaf ethanol extract (annona muricata (l) folium) contains acetogenins which are cytotoxic and have the ability to halt cell growth. this study aimed to understand whether acetogenins have teratogenic effects on mice fetus (mus musculus). methods: this study was performed at the pharmacology and therapy laboratory of the faculty of medicine, universitas padjadjaran, bandung, between october and november 2012. the study was an experimental laboratory study utilizing 27 pregnant mice which were divided into 3 groups. the first group was the negative control, the second was given soursop leaf ethanol extract at pre-implantation phase (day 1 to 5) and the third had the extract provided in the organogenesis phase (day 6 to 15). laparotomy was performed on the 19th day of pregnancy. the parameters used were the number of implantation, the number of live and dead or resorbed fetus, the weight and length of the fetus, as well as the macroscopic external morphology abnormalities. the data gained from test subjects were compared to those of the control group. the statistical test used was the normality tes with the kolmogorov-smirnov method which was then followed by t-test or mann-whitney statistical tests. results: the experiment exhibited significant differences in the weight and length of the fetus (p-value 0.000), proving that soursop leaf ethanol extract could inhibit intrauterine growth. aside from that, external morphological abnormalities such as hemorrhage on the head, face, neck, back, forelimbs, hindlimbs, and microcephaly were also found. conclusion: the soursop leaf ethanol extract (annona muricata (l) folium) has a teratogenic effect on mouse (mus musculus) fetus. [amj.2014;1(1):48–53] key words: acetogenins, soursop leaf ethanol extract, teratogenic efek teratogenik ekstrak etanol daun sirsak (annona muricata folium) terhadap fetus mencit (mus musculus) abstrak latar belakang: ekstrak etanol daun sirsak (annona muricata folium) mengandung senyawa aktif acetogenins yang bersifat sitotoksik atau dapat menghambat pertumbuhan sel. penelitian ini dilakukan untuk mengetahui efek teratogenik acetogenins terhadap fetus mencit (mus musculus). metode: penelitian ini dilakukan di laboratorium farmakologi dan terapi fakultas kedokteran universitas padjadaran periode oktober–november 2012. penelitian bersifat eksperimental laboratorik dengan metode sampel acak menggunakan 27 ekor mencit hamil yang dibagi dalam 3 kelompok. kelompok 1 sebagai kontrol negatif, kelompok 2 diberikan ekstrak etanol daun sirsak pada masa praimplantasi (hari ke-1 sampai ke5), dan kelompok 3 menerima ekstrak pada masa organogenesis (hari ke-6 sampai ke-15). laparotomi dilakukan pada hari ke-19 kehamilan. parameter yang digunakan berupa jumlah hasil implantasi, jumlah fetus hidup, jumlah fetus mati atau resorbsi, berat dan panjang badan fetus, serta abnormalitas morfologi eksternal fetus yang dinilai secara makroskopis. data yang didapat pada kelompok perlakuan dibandingkan dengan kelompok kontrol. uji statistik yang digunakan adalah uji normalitas data dengan uji kolmogorovcorrespondence: yunita suryani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285721900454, email: yunita.suryani206@gmail.com althea medical journal. 2014;1(1) 49 introduction the phenomenon of “back to nature” trend in the society, in which herbal or traditional drug consumption is increasing, currently draws a lot of attention.1 the medical professionals cannot turn a blind eye to this trend. the increasing use of herbal traditional medicines is not unrelated to the increasing trend of diseases in the last decade. the world health organization (who) recorded that at least 6 million people die each year because of cancer. one of the anti-cancer herbal medicine which is widely used in the society during the last years was soursop leaf (annona muricata (l) folium). the soursop leaf extract contains acetogenins, which is regarded as an anti-cancer compound as this compound is cytotoxic to cancer cells by inhibiting their proliferation.2 acetogenins is highly penetrating. aside its role as an anticancer agent, the soursop leaf has alsobeen empirically used to treat tingling, reduce cholesterol level, ease blood flow on light stroke, treat hypertension, hemorrhoid, urinary tract infection, and dysuria, as well as as a relaxant and treatment for seizure.3 however, the soursop leaf ethanol extract has never gone through any pre-clinical examination phase to test its toxicity, including the teratogenic test.4,5 the purpose of this study was to analyze whether the soursop leaf ethanol extract (annona muricata (l) folium) has a teratogenic effect on mouse (mus musculus) fetus, which was assessed through the number of implantation, live fetus, and intrauterine death (or resorption), as well as the weight and length of fetus and external morphological assessment. methods this study was conducted between october– november 2012 at the pharmacology and therapy laboratory of the faculty of medicine, universitas padjadjaran. the objects in this study were 27 female mice (mus musculus) and 12 fertile mice from the swiss webster strain, with the average weight of 20–30 grams. all mice were adapted for a week before being paired and given treatment. female mice used were adult, healthy, actively moving, and pregnant mice which were 8–10 weeks old and already had had a vaginal plug after being paired with male mice. this vaginal plug was the sign of the first day of pregnancy. this study was a laboratory experimental research with complete random sampling method. all pregnant female mice were divided into three groups, with 9 mice in each group. during pregnancy, the mice smirnov dan dilanjutkan dengan uji tatau mann-whitney. hasil: hasil penelitian menunjukkan perbedaan signifikan pada berat dan panjang fetus mencit (nilai p 0,000), sehingga ekstrak etanol daun sirsak terbukti menghambat pertumbuhan intrauteri. selain itu ditemukan juga kelainan morfologi eksternal seperti perdarahan pada kepala, wajah, leher, punggung, tangan, kaki, dan mikrosefali. simpulan: ekstrak etanol daun sirsak (annona muricata folium) memiliki efek teratogenik terhadap fetus mencit (mus musculus). kata kunci: acetogenins, ekstrak etanol daun sirsak, teratogenik table 1 total number and average number of implantation, live fetus, dead fetus or resorbed as well as the weight and length of fetus group number of mother total number average number + sd average +sd implantation result dead fetus/ resorbed live fetus implantation result dead fetus/ resorbed weight (gram) length (cm) 1 9 97 40 57 10.78+1.86 4.44+5.79 1.04+0.323a 2.18 + 0.466a 2 9 86 40 46 9.56+4.42 4.44+4.67 0.86+0.225b 1.79 + 0.451b 3 9 82 14 68 9.11+3.62 1.56+2.07 0.73 + 0.359b 1.87 + 0.403b note: differing letter on a column indicates significance (p <0.05) yunita suryani, truly deti rose sitorus, setyorini irianti: soursop leaves (annona muricata folium) on mice (mus musculus) fetus althea medical journal. 2014;1(1) 50 amj june, 2014 in the first group (negative control) were nurtured and given food, water, and 1 ml of carboxymethylcellulose (cmc) 1% from the 1st to 18th day of pregnancy. the second and third group had the same treatment regarding food and water, with the addition of 2.34 mg of soursop leaf ethanol extract in 1 ml 1% cmc given per oral. the difference was that the second group had the soursop leaf ethanol extract treatment at the pre-implantation phase, which was between the 1st to 5th day of pregnancy, the third group had the same treatment during the organogenesis phase, which was between the 6th and 15th day of pregnancy. the parameters assessed were the total number of fetus, the number of live fetus, dead fetus or resorbed fetus as well as the weight and length of the fetus and also the morphological abnormalities when fetus was extracted via laparotomy on the 19th day of pregnancy. all data were then documented and statistically analyzed. the data from the treatment groups (2 and 3) were compared to the negative control group (first group). the data normality test was done using the kolmogorov-smirnov test which was followed with the statistical difference test using t-test method if it was normal and mann-whitney if it is not normal.6 results the result showed that the group treated with the soursop leaf ethanol extract had less number of implantation. yet, there was no significant difference between the total number of fetus and dead or resorbed fetus in these three groups (p >0.05). the average weight and length of fetus had significantly declined (p <0.05) in the treatment groups (2 and 3). external morphological abnormalities were not found in the control group. however, in the treatment groups (2 and 3) there was a tendency towards external morphological abnormalities. the abnormalities were hemorrhage on the head, face, neck, back, forelimb, hindlimb, and the presence of microcephaly. table 2 frequency of fetus with morphological abnormalities group number of mother total fetus frequency of hemorrhage frequency of microcephaly total head neck face back forelimb hindlimb 1 9 97 0 0 0 0 0 0 0 0 2 9 86 16 5 1 0 9 0 1 0 3 9 82 54 16 5 2 16 6 9 1 figure 1 normal live fetus (without abnormalities) from group 1 (control) althea medical journal. 2014;1(1) 51yunita suryani, truly deti rose sitorus, setyorini irianti: soursop leaves (annona muricata folium) on mice (mus musculus) fetus figure 2 fetuses of the second group. they have smaller size compared to control. and there are fetuses that experienced intrauterine death, either dead fetus (a) or resorbed fetus (b). morphological abnormalities were found as hemorrhage on the head (c), neck (d), back (e), and hindlimb (f) figure 3 mice fetus of the third group. dead fetus was found (a), fetus with hemorrhage on the head and eyes (b), back (c), forelimbs and hindlimbs, and also microcephaly (d), and also fetus which underwent intrauterine death (e) althea medical journal. 2014;1(1) 52 amj june, 2014 discussion soursop leaf ethanol extract (annona muricata (l) folium) with 2.34 mg/day dosage has a teratogenic effect to mouse fetus which was shown by the length and weight reduction of fetus and presence of hemorrhage of the head, neck, back, forelimbs, and hindlimbs, as well as microcephaly. the soursop leaf ethanol extract can penetrate the placenta and both alkaloid and acetogenin content in the extract can affect fetus intrauterine growth. the weight and length of fetuses in the second and third group showed significant reductions when compared to those of the first group as the negative control. the cytotoxic nature of acetogenins in the soursop leaf ethanol extract (annona muricata (l) folium) acts by inhibiting the energy transport in the form of adenosine triphosphate (atp) which is used in the cellular proliferation. the effect is that the energy production inside the cells is halted, disturbing the growth and proliferation of cells.3,7 this disturbed cell growth is one of the teratogenic mechanisms which inhibits the metabolic phase for normal growth.8 as such, the acetogenins in the soursop leaf ethanol extract (annona muricata (l) folium) is proven to be capable of causing intra uterine growth retardation (iugr). the mice that received treatment, both in the second and third groups, showed hemorrhage on the head, face, neck, back, forelimbs, and hindlimbs. the hemorrhage or bleeding is an event of the leaking of blood from the cardiovascular system that is indicated by the accumulation of blood inside a cavity or tissue due to viscosity disturbance at different parts of the fetus which differs from the viscosity of plasma blood and the presence of extracapillary spaces. in normal conditions, the embryo develops inside amnion fluid which is isotonic to the bodily fluid.9 however, the presence of the alkaloid in the soursop leaf (annona muricata (l) folium) which can either be reticuline, coclaurine, coreximine, atherosperminine, stepharine, anomurine, and anomuricine can penetrate the placenta and affect the osmotic pressure disturbance, which then causes viscocity disturbance and hemorrhage in different parts of the body.9,10 microcephaly happened in one of the fetuses in the third group which was treated by soursop leaf extract (annona muricata (l) folium) at the organogenesis phase. microcephaly is a disturbance caused by the failure of the brain to grow, leading to the failure of the skull to expand. neural crest cells are prone to teratogen because they leave the neuroectoderm from which they originate.11 in addition, the cytotoxic nature of acetogenins, which is present in the soursop leaf ethanol extract (annona muricata (l) folium),acts to inhibit the metabolic phase which is crucial for a normal brain growth, hence causing microcephaly. as such, it is proven that the soursop leaf ethanol extract (annona muricata (l) folium) can have a teratogenic effect on mouse (mus musculus) fetus. references 1. hidayat i. bergabung dan berjalan bersama sidomuncul: kembali ke alam, untuk sehat dan bahagia. jakarta: pt. sidomuncul; 2012 [cited 24 april 2012]; available from: http://www.sidomuncul.com/index.php. 2. wicaksono a. kalahkan kanker dengan sirsak. jakarta: citra media mandiri; 2011. 3. tim trubus cipta usaha. my healthy life: daun sirsak vs kanker. jakarta: pt. trubus swadaya; 2012. 4. haumahu da. uji farmakologi dan uji toksisitas. yogyakarta: laboratorium penelitian dan pengujian terpadu universitas gajah mada; 2011 [cited 24 april 2012]; available from: http://lppt. ugm.ac.id/berita-200-uji-farmakologi-dan -uji-toksisitas.html. 5. berkowitz ba. development & regulation of drugs. in: katzung bg, editor. basic and clinical pharmacology. new york: mcgrawhill companies; 2007. p. 64–74. 6. dahlan ms. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. 7. zuhud ea. kanker lenyap berkat sirsak. jakarta: agromedia pustaka; 2011. 8. lisanti e, suryono ia. teratologi. bandung: lubuk agung; 2011. 9. widyastuti n, widiyani t, listyawati s. efek teratogenik ekstrak buah mahkota dewa (phaleria macrocarpa (scheff.) boerl.) pada tikus putih (rattus norvegicus l.) galur winstar. bioteknologi. 2006;3(2):56−62. 10. leboeuf m, legueut c, cavé a, desconclois j, forgacs p, jacquemin h. [alkaloids of annonaceae. xxix. alkaloids of annona muricata]. planta med. 1981;42(1):37–44. 11. sadler t. langman's medical embryology. north carolina: williams and wilkins; 1995. amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 61althea medical journal. 2022;9(2):61–69 trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 nedra wati zaly,1 mugia bayu rahardja,2 murtiningsih1 1institute of health and technology pkp dki jakarta, jakarta, indonesia, 2national research and innovation agency, jakarta, indonesia abstract background: fertility is the main component of population dynamics that determines the population structure of a country. one method to measure fertility is to analyze the birth interval. this study aimed to identify determinants of birth interval based on the indonesian demographic and health survey (idhs) data in 2007, 2012, and 2017. methods: this study design was descriptive using idhs data from 2007, 2012, and 2017 with a crosssectional study design. samples were mothers who gave birth to their last living child in the last five years. results: in the idhs 2007, the birth interval at risk (<24 months) was 11.8%, increased in the 2012 idhs to 12.1%, and decreased in the 2017 idhs to 9.8%. in the three-period idhs, the same determinants of the birth interval were discovered, such as the age of the woman, duration of breastfeeding, use of contraception, the status of the child before the last child, mother’s education level, and wealth quintile. however, in 2007, the sex of the child before the last child and the number of surviving children also influenced the birth interval. in 2017 the number of children who were still alive also affected the birth interval. the most dominant factor influencing the occurrence of short birth intervals after controlling for other variables was the survival status of the previous child. conclusion: the short birth interval is the most prevalent in the 2012 idhs. optimal birth interval has the potential to improve maternal, neonatal, and infant health. keywords: birth interval, female reproduction, the health of mother and child correspondence: ns. nedra wati zaly, s.kep., m.kep, institute of health and technology pkp dki jakarta, jalan raya pkp, kelapa dua wetan, ciracas, jakarta, indonesia, e-mail: nedrawati12@gmail.com introduction indonesia as one of the developing countries in southeast asia faces a big challenge, namely an excessive population, which is around 270 million people. indonesia’s total fertility rate (tfr) has decreased from 2.6 in 2007 to 2.4 in 2017 based on the 2007 and 2017 idhs data.1,2 even though it has decreased in 10 years, this is still not in line with the indonesian government plan. fertility is one of the factors that play an important role in population growth.3 fertility is the major component of population dynamics that determines the population structure of a country. birth interval (time between two consecutive live births) is a more acceptable method of measuring fertility than other methods.4 delayed marriage, higher education, smaller family, absence of child death experience, and living in food secured households were associated with the small number of children. fertility was significantly higher among women with no child sex preference.5 fertility behavior is usually influenced by the interaction of several biological, socioeconomic, and demographic factors. birth interval is a good index of current fertility changes.3 the use of contraception is one of the factors that affect birth interval which has been supported through government programs. this is made clear by a study in ethiopia that mentions the importance of contraceptive use factors in influencing birth interval. the short birth interval is still a concern for women due to religious factors, https://doi.org/10.15850/amj.v9n2.2643 althea medical journal. 2022;9(2) 62 length of breastfeeding, unwanted pregnancy, and not using contraception. increasing access and coverage of contraceptive use as well as involving religious leaders in family planning programs are important strategies that need attention.6 factors that influence the family in determining the decision to adjust the birth interval include socioeconomic factors, partner psychology, partner age, and cultural factors. however, not all couples of childbearing age know the benefits of long-term pregnancy spacing, so there are still many couples of childbearing age who have children who are too close or too far apart.7 in addition, several studies conclude that the factors that affect birth interval include; gender of the last child, maternal age, length of time breastfeeding before conception and pregnancy, use of contraception, and place of delivery of the last child.8 birth intervals less than 24 months are considered short and intervals more than 5 years are considered long. both short and long intervals are considered inadequate.9 birth interval that is very short or too long directly affects the occurrence of risky pregnancies. pregnancy with a distance that is too close can cause bleeding, anemia, and premature rupture of membranes, so couples of childbearing age need to be able to plan and determine the spacing of pregnancies.7 besides being risky for the mother giving birth, the short birth interval is also a risk for the baby. the results of another study in jambi10 stated that respondents who had a short birth interval had a 1.94 times risk of experiencing low birth weight (lbw) compared to respondents who had an optimal birth interval. on the other hand, the long birth intervals can also affect the occurrence of preeclampsia. the incidence of preeclampsia is more at risk at birth intervals <2 years and birth ≥5 years.11 this study aimed to identify determinants of birth interval based on indonesian demographic and health survey (idhs) data in 2007, 2012, and 2017. methods this study used the data collected in the indonesian demographic and health survey (idhs). in 2007, 2012, and 2017 idhs was conducted by the national population and family planning board (badan kependudukan dan keluarga berencana nasional, bkkbn), statistics indonesia (badan pusat statistik, bps), and the ministry of health (kementerian althea medical journal june 2022 kesehatan, kemenkes) with a nationally representative sample. the sample frame of the idhs was the master sample of census blocks (cbs) from the 2000 and 2010 population census. the frame for the household sample selection was the updated list of ordinary households in the selected census blocks. the idhs sample was selected using a stratified, two-stage cluster design and cbs was the sampling unit for the first stage. for the 2017 idhs, a representative sample of approximately 47,963 households from 1,970 cbs was selected. in the first stage, 1,970 cbs were selected from the list of enumeration areas based on the sampling frame. in the second stage, a complete listing of 25 households was carried out in each selected cbs. the analyzes presented in this study on birth interval in 2007, 2012, and 2017 idhs was based on the 9,980, 10,703, and 10,446 women respectively who had at least one birth during a five-year period selected from the idhs data. variable observed for this study was the age of the woman at the time of delivery of the child before the last child, the sex of the child before the last child, duration of breastfeeding for the previous child, number of surviving children, contraceptive use, the status of the child before the last child, mother’s education level, place of residence, and wealth quintile. the data were analyzed in two phases. first, descriptive analysis was used to provide an overview of birth interval by an independent study. bivariate analysis using the chi-square test to determine the significance of the relationship between birth interval and the independent variables studied. second, the likelihood ratio test and wald test were used in multivariate logistic regression analysis. multivariate logistic regression analysis of the determinants of the birth interval was performed. the idhs data collection was downloaded from the dhs website in compliance with the access policy (https://microdata.worldbank. org/index.php/catalog/3477). the procedures and questionnaires for idhs were following the standard dhs survey protocol approved by the icf institutional review board (irb) and conforming with the u.s. department of health and human services regulations for the protection of human subjects (45 cfr 46) (https://dhsprogram.com/methodology/ p r o t e c t i n g t h e p r i v a c y o f d h s -s u r v e y respondents.cfm). the ethical clearance of the 2017 idhs has referred to the dhs-7 project which was an ethical review carried out by icf irb on march 11, 2015. althea medical journal. 2022;9(2) 63nedra wati zaly et al.: trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 results the results showed that in the 2007 idhs, the risk birth interval (<24 months) was 11.8%, increased in the 2012 idhs by 12.1%, and decreased in the 2017 idhs by 9.8%. the independent variables that affect birth interval in the 2007 idhs, 2012, and 2017 are shown in table 1. the age of women at risk (age <20 years and >35 years) decreased starting from the 2007 idhs by 23.9%, in 2012 by 22%, and in 2017 by 18.2%. the gender of the previous child was more male in the 2007 idhs, 2012, and 2017. infants who were not breastfed in the 2007 idhs were 11.6%, in 2012 it was 7.5%, and in 2017 it was 4.7%. the number of living children (>2 children) in the 2007, 2012, and 2017 idhs were almost the same, namely 50.8%, 49.5%, and 48.9%. similarly, the survival status of children was almost the same at 94.1%, 94.6%, and 95.7%. the use of contraception fluctuated from the 2007 idhs, 2012 to the 2017 idhs from 91.7%, 91%, and 93.6%. women who did not go to school decreased from the 2007 idhs, 2012 to 2017 by 4.5%, 3.5%, and 1.7%, respectively. most of the respondents lived in rural areas in the 2007 idhs, 2012, and 2017, namely 40.8%, 54.8%, and 51.3%. furthermore, the wealth quintile fluctuated from 2007 by 23.3%, increased in 2012 to 30.6%, and in 2017 decreased to 27.9%. in the idhs 2017, the factors influencing the occurrence of birth intervals were the age of women, duration of breastfeeding, number of children born alive, use of contraception, table 1 distribution of research variables from the idhs data for the year 2007, 2012 and 2017* variable idhs 2007 idhs 2012 idhs 2017 n % n % n % birth interval ≥24 months <24 months 8,807 1,173 88.2 11.8 9,403 1,300 87.9 12.1 9,424 1,022 90.2 9.8 age of woman at birth the child before the last child 20–35 years <20 and >35 years 7,592 2,388 76.1 23.9 8,350 2,353 78.0 22.0 8,548 1,898 81.8 18.2 child’s gender before the youngest child male female 5,181 4,799 51.9 48.1 5,584 5,119 52.2 47.8 5,434 5,012 52.0 48.0 breastfeeding duration not breastfed ≤18 months >18 months 1,153 6,560 2,267 11.6 65.7 22.7 805 8,150 1,748 7.5 76.1 16.3 495 6,113 3,838 4.7 58.5 36.7 number of children still alive ≤2 children >2 children 4,908 5,072 49.2 50.8 5,408 5,295 50.5 49.5 5,342 5,104 51.1 48.9 ever used contraceptive yes no 9,152 828 91.7 8.3 9,737 966 91.0 9.0 9,782 664 93.6 6.4 child status before the last child still living death 9,389 591 94.1 5.9 10,125 578 94.6 5.4 9,999 447 95.7 4.3 education level no education primary secondary higher 452 4,602 4,299 628 4.5 46.1 43.1 6.3 375 3,849 5,334 1,145 3.5 36.0 49.8 10.7 182 3,097 5,620 1,547 1.7 29.6 53.8 14.8 place of residence urban rural 4,047 5,933 40.6 59.4 4,835 5,868 45.2 54.8 5,092 5,354 48.7 51.3 household wealth index the poorest poor middle rich the richest 2,324 1,967 1,966 1,866 1,857 23.3 19.7 19.7 18.7 18.6 3,270 2,094 1,917 1,776 1,646 30.6 19.6 17.9 16.6 15.4 2,917 2.040 1,908 1,831 1,750 27.9 19.5 18.3 17.5 16.8 9,980 100.0 10,703 100.0 10,446 100.0 note: idhs= indonesian demographic and health survey, *idhs secondary data, 2007, 2012, and 2017, processed althea medical journal. 2022;9(2) 64 previous child’s life status, women’s education, and wealth quintile (table 2). there were 7 factors affected birth interval in the idhs 2017. meanwhile, in the 2012 idhs, the factors affecting the occurrence of birth interval were the age of women, duration of breastfeeding, contraceptive use, previous child’s life status, women’s education, and wealth quintile. there were 6 factors affected birth interval in the 2012 idhs. in contrast to what happened in the althea medical journal june 2022 table 2 relationship between birth interval and observed independent variables* variable idhs 2007 (n=9,980) pvalue idhs 2012 (n=10,703) pvalue idhs 2017 (n=10,446) pvalue≥24 months <24 months ≥24 months <24 months ≥24 months <24 months age of woman at birth the child before the last child 20–35 years <20 and >35 years 6,767 2,039 89.1 85.4 824 349 10.9 14.6 0.000 7,445 1,958 89.2 83.2 905 395 10.8 16.8 0.000 7,740 1,684 90.5 88.7 808 214 9.5 11.3 0.016 child’s gender before youngest child male female 4,534 4,273 87.5 89.0 647 526 12.5 11.0 0.018 4,902 4,501 87.8 87.9 682 618 12.2 12.1 0.824 4,924 4,500 90.6 89.8 510 512 9.4 10.2 0.154 breastfeeding duration not breastfed ≤18 months >18 months 978 5,875 1,953 84.8 89.6 86.2 175 685 314 15.2 10.4 13.8 0.000 684 7,166 1,553 85.0 87.9 88.8 121 984 195 15.0 12.1 11.2 0.019 435 5,475 3,514 87.9 89.6 91.6 60 638 324 12.1 10.4 8.4 0.001 number of children still alive ≤2 children >2 children 4,289 4,517 87.4 89.1 619 555 12.6 10.9 0.010 4,733 4,670 87.5 88.2 675 625 12.5 11.8 0.283 4,856 4,568 90.9 89.5 486 536 9.1 10.5 0.016 ever used contraceptive yes no 8,139 668 88.9 80.6 1013 160 11.1 19.4 0.000 8,667 736 89.0 76.2 1,070 230 11.0 23.8 0.000 8,881 543 90.8 81.8 901 121 9.2 18.2 0.000 child status before the lastchild still living death 8,408 398 89.6 67.4 980 193 10.4 32.6 0.000 9,011 392 89.0 67.8 1,114 186 11.0 32.2 0.000 9,100 324 91.0 72.5 899 123 9.0 27.5 0.000 education level no education primary secondary higher 394 4,148 3,757 508 87.3 90.1 87.4 80.9 58 454 542 120 12.7 9.9 12.6 19.1 0.000 298 3,452 4,710 943 79.5 89.7 88.3 82.4 77 397 624 202 20.5 10.3 11.7 17.6 0.000 150 2,861 5,089 1,324 82.4 92.4 90.6 85.6 32 236 531 223 17.6 7.6 9.4 14.4 0.000 place of residence urban rural 3,578 5,229 88.4 88.1 469 704 11.6 11.9 0.673 4,262 5,141 88.1 87.6 573 727 11.9 12.4 0.396 4,600 4,824 90.3 90.1 492 530 9.7 9.9 0.684 household wealth index the poorest poor middle rich the richest 1,969 1,734 1,764 1,695 1,644 84.7 88.2 89.7 90.9 88.5 355 233 202 171 213 15.3 11.8 10.3 9.1 11.5 0.000 2,750 1,863 1,719 1,602 1,469 84.1 89.0 89.7 90.2 89.2 520 231 198 174 177 15.9 11.0 10.3 9.8 10.8 0.000 2,528 1,866 1,775 1,670 1,585 86.7 91.5 93.0 91.2 90.6 389 174 133 161 165 13.3 8.5 7.0 8.8 9.4 0.000 total 8,807 88.2 1,173 11.8 9,403 87.9 1,300 12.1 9,424 90.2 1,022 9.8 note: idhs= indonesian demographic and health survey, *idhs secondary data, 2007, 2012, and 2017, processed althea medical journal. 2022;9(2) 65 2007 idhs, those that affected the occurrence of birth intervals were the age of the woman, the gender of the child, the number of children born alive, the duration of breastfeeding, the use of contraception, the previous life status of the child, women’s education, and wealth quintile. there were 8 factors affected birth interval in the 2007 idhs. in the 2007–2017 range in the idhs data for 2007, 2012, and 2017, the factors that influenced birth interval were the woman’s age, duration of breastfeeding, contraceptive use, previous child’s life status, education level, and household wealth index. the number of children born alive (parity) was significantly affected by the birth interval in the 2007 and 2017 idhs, while the child’s gender factor significantly affected on birth interval only in the 2007 idhs. the results of the multivariate analysis of the factors that influenced short birth interval can be seen in table 3. the factor that did not affect the birth interval in the 3 idhs periods was the gender of the previous child. in the 2007 idhs, the factors that significantly influenced birth interval were the woman’s age, duration of breastfeeding, contraceptive use, previous child’s life status, education table 3 odds ratio based on binary logistic regression for the effect of observed independent variables on a birth interval, idhs 2007, 2012 and 2017* variable idhs 2007 idhs 2012 idhs 2017 or p-value ci 95% or p-value ci 95% or p-value ci 95% age of woman at birth the child before the last child 20–35 years <20 and >35 years 1.27 1.00 0.013 1.05–1.53 0.89 1.00 0.194 0.76–1.06 0.77 1.00 0.002 0.65–0.91 child’s gender before the youngest child male female 1.13 1.00 0.054 0.99–1.28 0.97 1.00 0.596 0.86–1.09 0.89 1.00 0.897 0.79–1.02 breastfeeding duration not breastfed ≤18 months >18 months 1.16 1.24 1.00 0.041 0.000 1.04–1.37 1.10–1.38 1.55 1.11 1.00 0.001 0.207 1.21–1.99 0.94–1.32 1.37 1.21 1.00 0.043 0.010 1.01–1.85 1.05–1.39 number of children still alive ≤2 children >2 children 1.08 1.00 0.283 0.94–1.23 0.95 1.00 0.407 0.84–1.07 0.73 1.00 0.000 0.64–0.84 ever used contraceptive yes no 0.55 1.00 0.000 0.45–0.67 0.48 1.00 0.000 0.40–0.57 0.57 1.00 0.000 0.45–0.70 child status before the last child still living death 0.21 1.00 0.000 0.16–0.27 0.28 1.00 0.000 0.23–0.36 0.25 1.00 0.000 0.20–0.32 education level no education primary secondary higher 0.31 0.30 0.51 1.00 0.000 0.000 0.000 0.21–0.46 0.24–0.39 0.41–0.65 0.45 0.32 0.49 1.00 0.000 0.000 0.000 0.32–0.64 0.26–0.39 0.40–0.59 0.54 0.30 0.50 1.00 0.007 0.000 0.000 0.35–0.85 0.24–0.38 0.42–0.60 place of residence urban rural 1.15 1.00 0.075 0.98–1.34 1.21 1.00 0.009 1.05–1.39 1.24 1.00 0.006 1.06–1.45 household wealth index the poorest poor middle rich the richest 2.28 1.69 1.31 0.99 1.00 0.000 0.000 0.019 0.957 1.78–2.90 1.33–2.14 1.05–1.65 0.79–1.25 2.36 1.52 1.30 1.09 1.00 0.000 0.000 0.026 0.468 1.87–2.97 1.21–1.93 1.03–1.64 0.87–1.37 2.42 1.35 1.01 1.15 1.00 0.000 0.019 0.943 0.246 1.89–3.09 1.05–1.73 0.78–1.30 0.91–1.46 note: idhs= indonesian demographic and health survey, *idhs secondary data, 2007, 2012, and 2017, processed nedra wati zaly et al.: trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 althea medical journal. 2022;9(2) 66 level, and household wealth index. in contrast to the 2012 idhs, the factors that significantly influenced birth interval were duration of breastfeeding, contraceptive use, previous child’s life status, education level, place of residence, and household wealth index. meanwhile, in the 2017 idhs, the factors that significantly influenced birth interval were the woman’s age, duration of breastfeeding, contraceptive use, previous child’s life status, education level, place of residence, and household wealth index. discussion birth interval is the period between the previous child’s birth date and the last child’s birth date.12 optimal birth interval is beneficial for the health of the mother and baby for the better. short birth interval (space between births less than 24 months) can be detrimental to the health of mother and child.13 the ideal birth spacing is more than 24 months. reproductive organs can prepare to get pregnant again at that time.14 therefore, it is very important to pay attention to the distance because it is closely related to the reproductive health of women and the health of children born. the risk of low birth weight (lbw) babies will also be reduced by keeping the distance between births.8 a healthy reproductive age range is a safe age for women to experience pregnancy and childbirth, which is 20 to 35 years.15 meanwhile, age <20 years and >35 years are the ages that are at risk for women to experience pregnancy and childbirth. this is because, after <20 years, a woman’s uterus and pelvis have not yet grown to their adult size. likewise, at the age of >35 years, maternal diseases such as hypertension, diabetes mellitus, obesity, and aging of the uterine organs (cell degeneration) are easy to occur. all of these are things that increase the risk for women who experience pregnancy and childbirth at that age.16 the age of the mother referred to in this study is the age of the mother at the time of giving birth to the child before the last child. this is because this study used secondary data from the idhs, so the birth spacing data were obtained by comparing the data of the last child with the previous child. the results of the bivariate analysis in this study found that maternal age significantly affected birth intervals in the 2007 idhs, 2012, and 2017. meanwhile, the results of multivariate analysis showed that women aged 20–35 years had a higher chance of experiencing short birth spacing than women aged <20 years and >35 years old. the effect of women’s age with short birth interval is probably due to the current trends of marriage. the delay in marriage causes the reproductive age to be shorter. therefore, women who marry late will speed up the birth gap. this is confirmed by research which explains that women who experience social pressure due to late marriage will try to accelerate the birth rate (by shortening the birth distance).16 this is also in line with research in ethiopia which states that women who marry late are closely related to the birth interval. women who marry late are getting older, so they should have children immediately after marriage and plan to have the desired number of children before the end of their reproductive period.17 our study has shown that the duration of breastfeeding affects birth intervals. women who do not breastfeed have a higher risk of experiencing shorter birth intervals compared to women who breastfeed >18 months (or:1.16; or:1.55; or 1.37). this proves that the duration of breastfeeding in the previous child shows a relationship with a short birth interval. three studies found an association between shorter birth intervals and shorter breastfeeding duration. one study found shorter birth intervals without breastfeeding compared to exclusive or mixed breastfeeding.18 in line with research in iran19 that the duration of breastfeeding is an independent factor of birth interval. this shows that breastfeeding duration of more than 2 years is more likely to have a longer birth interval than a breastfeeding duration of less than 6 months.19 it can be concluded that breastfeeding duration can prolong the birth spacing period by slowing down female fertility. couples need to set the ideal pregnancy distance, which is >2 years (qur’an surah al baqoroh verse 233), and thus, a mother should breastfeed her children for 2 full years because breastfeeding is a natural way to space out pregnancy up to 2 years. the t-interval that is too close results in the inability of families to take good care of their children, it is hoped that mothers will breastfeed their babies for up to 18 to 24 months so that the baby’s nutrition is fulfilled.20 birth interval is also affected by contraceptive use. couples who do not use contraception have a higher chance of experiencing shorter birth intervals than couples who use contraception (or 1.82 in the idhs year 2007; or 2.08 in the idhs althea medical journal june 2022 althea medical journal. 2022;9(2) 67 year 2012; or 1.75 in the idhs year 2017). this is in line with a study in ethiopia6 that stated the importance of contraceptive use factors in influencing birth interval. short birth interval is still a concern for ethiopian women due to factors such as religion, length of breastfeeding, unwanted pregnancies and not using contraception.6 important strategies that need to be considered are the coverage of contraceptive use, increasing access, and involvement of religious leaders in family planning programs.6 in addition, the factor that most influences birth interval is the use of contraceptive methods.12 the results of another study also stated that women who did not use any contraceptive method were more likely to have shorter birth intervals than women who used all forms of contraception.21 the survival status of children born previously also affects the occurrence of birth intervals. the short birth interval was 4 times more likely to occur in women who had a previous child death than in women whose children had previously lived (or 4.76 in the idhs year 2007, or 3.57 in the idhs year 2012, and or 4 in the idhs year 2017). this shows that the previous child’s survival factor is the most dominant influencing birth interval. when a baby/child dies, the mother will stop breastfeeding (unless the children are twins), and the mother will be at risk of getting pregnant more quickly than if she still has babies.22 this is also to the research that says that short birth interval tends to occur. in subsequent births in couples who experience child death. spouses tend to want to make efforts to have children immediately to replace lost children.19 the results of the study prove that birth interval can be influenced by a woman’s education level. short birth interval is more at risk for women who graduate from college than women who do not go to school. in 2007, the possibility of short births in women who graduated from college was 3 times (aor= 3.22) than women who did not attend school. furthermore, it decreased in 2012 the risk of 2 times (aor = 2.22) and decreased again in 2017 the risk of 1 time (aor= 1.85) experienced short birth interval in women who graduated from college compared to women who did not attend school. the short birth interval that occurs in college graduates is probably due to a delay in marriage. higher education women tend to marry late, limiting their reproductive years and the number of children.21 this is not in line with research related to women’s education in bangladesh19 which states that women without formal education tend to have a short birth in subsequent births. likewise, research in ethiopia12 shows that education level affects short birth intervals. the short birth interval is 3 times more likely to occur in women without formal education compared to women with formal education.12 women with low formal education are at risk for experiencing short birth intervals. mothers’ low education is related to their lack of information and knowledge about various things including how to maintain reproductive health. this is also explained in another study which stated that low formal education affects women’s understanding and/or knowledge about contraception and birth interval as well as behavior seeking information on reproductive health.16 unlike what happened in indonesia, it was found that women who did not attend school were at risk of this to happen. the short birth interval was lower than female university graduates (aor=0.31; aor=0.45; aor=0.54). the possibility of this happening could be due to the successful family planning program carried out by the indonesian government. this can be seen from the increasing percentage of women aged 15–49 years who use family planning tools/methods from the 1991–2017 idhs.2 in addition, half of the women have been exposed to information about family planning by the media.23 this study found that women from the lowest wealth quintile are twice as likely to experience short birth intervals as women from the top wealth quintile. this statement is in line with other studies which state that women with low-income levels have shorter pregnancy intervals than women with higher education. this is related to women with low incomes choosing not to use contraception so that unwanted pregnancies occur.24 the results of this study indicate that the most dominant factor influencing the occurrence of short birth intervals after controlling for other variables is the survival status of the previous child. the risk of shortdistance births is 4 times for women who experience child death compared to women whose previous children are still alive. this is in line with research in manipur, india25 which showed that the child’s previous survival status was the most important in determining the pattern of child spacing for social and biological reasons. socially, couples who have experienced the loss of a child as an infant avoid contraception with the motivation to nedra wati zaly et al.: trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 althea medical journal. 2022;9(2) 68 have another child as a substitute. biologically, infant mortality interferes with breastfeeding which contributes to the return of fertility, and the absence of contraception can increase the likelihood of subsequent early conception.25 this study also provides evidence that child mortality will have an impact on shorter delivery intervals for subsequent children. child mortality also affects other factors, namely breastfeeding and contraceptive use. women who will stop breastfeeding will be fertile again soon and are at risk of pregnancy if they do not use contraception. this is because lactational amenorrhea arising from breastfeeding can prolong the birth interval.25 the relationship between child mortality and the birth interval is more related to maternal behavior, such as discontinuation of contraceptive use and cessation of breastfeeding. mothers who stop breastfeeding result the mother fertility returning quickly.22 in general, the increase in infant mortality rate can be caused by babies born with short birth intervals, maternal age who are too young or too old, or babies born to mothers with high parity.2 maternal age and high parity are at risk of death in children. due to the death of a previous child, couples tend to try to get pregnant again to replace immediately the child who has died. this results in a short birth interval with the occurrence of child deaths.19 a mother’s education affects the occurrence of short birth spacing. mothers without formal education tend to have a short birth interval with subsequent births.19 when a child dies in a mother without formal education, the mother will likely try as soon as possible to be able to obtain a substitute child. this incident can be caused by the lack of understanding of mothers about reproductive health. in contrast, mothers with college graduates are likely to experience short birth intervals due to delays in marriage so that couples will shorten their reproductive period. this statement is in line with research that states that study-oriented factors are one of the causes of women getting married late.26 when a baby or child dies, it is very likely that mothers with college graduates will immediately plan to have another child due to their limited reproductive age. this study has several limitatations, since the study used secondary data, researchers had limited direct access to respondents, and researchers can only process existing data. the sample in this study were married women who had at least 2 children, and did not exclude women who had abortions or miscarriages, so there might be an underrepresentation of birth interval. in conclusion, the largest percentage of short birth interval is in the 2012 idhs data (12.1%). in the 2007 idhs, the factors that significantly influence birth interval are the woman’s age, duration of breastfeeding, contraceptive use, previous child’s life status, education level, and household wealth index. in contrast to the 2012 idhs, factors that have a significant effect on birth spacing are duration of breastfeeding, contraceptive use, previous child’s life status, education level, place of residence, and household wealth index. meanwhile, in the 2017 idhs, the factors that significantly affect birth interval are the woman’s age, duration of breastfeeding, contraceptive use, previous child’s life status, education level, place of residence, and household wealth index. optimal birth interval has the potential to improve maternal, neonatal, and infant health. birth interval is expected to be a basic priority for policymakers to improve maternal and child health. child mortality is the most dominant factor influencing the occurrence of short birth intervals after being controlled by other variables. efforts that can be made to improve maternal and child health are to develope strategies to reduce neonatal, infant, child, and perinatal mortality. this study recommends increasing awareness about optimal birth interval and increasing the use of modern contraception, improving maternal and child health services, and providing health education to mothers regarding the care of babies to toddlers who are still very susceptible to illness. references 1. national population and family planning board (bkkbn), statistics indonesia (bps), ministry of health (kemenkes), icf. indonesia demographic and health survey 2012. jakarta, indonesia: bkkbn, bps, kemenkes, and icf; 2013. 2. national population and family planning board (bkkbn), statistics indonesia (bps), ministry of health (kemenkes), icf. indonesia demographic and health survey 2017. jakarta, indonesia: bkkbn, bps, kemenkes, and icf; 2018. 3. singh, sa. human fertility behavior through birth interval models: overview. am j theor appl stat. 2016;5(3):132–7. 4. nath dc, leonetti dl, steele ms. analysis of birth intervals in a non-contracepting indian population: an evolutionary ecological approach. j biosoc sci. althea medical journal june 2022 althea medical journal. 2022;9(2) 69 2000;32(3):343–54. 5. mekonnen w, worku a. determinants of fertility in rural ethiopia: the case of butajira demographic surveillance system (dss). bmc public health. 2011;11:782. 6. gebrehiwot sw, abera g, tesfay k, tilahun w. short birth interval and associated factors among women of childbearing age in northern ethiopia, 2016. bmc women’s health. 2019;19(1):1–9. 7. laili u, masruroh n. penentuan jarak kehamilan pada pasangan usia subur. j kesehat al-irsyad. 2018;xi(2):52–7. 8. ejigu ag, yismaw ae, limenih ma. the effect of sex of the last child on short birth interval practice: the case of northern ethiopian pregnant women. bmc res notes. 2019;12(1):4–9. 9. barbosa r, alves mtssb, nathasje i, chagas d, simões vf, silva l. factors associated with inadequate birth intervals in the brisa birth cohort, brazil. rev bras ginecol obstet. 2020;42(2):67–73. 10. kurniasari l. the correlation of parity, birth spacing and preeclampsia history toward lbw incidence at rsia annisa jambi in 2017. sci j. 2018;7(1):53–7. 11. fatkhiyah n, khodiyah m. determinan maternal kejadian preeklampsia (studi kasus di kabupaten tegal, jawa tengah). j keperawatan soedirman. 2016;11(1):53– 61. 12. hailu d, gulte t. determinants of short interbirth interval among reproductive age mothers in arba minch district, ethiopia. int j reprod med. 2016;2016:1–17 13. ajayi ai, somefun od. patterns and determinants of short and long birth intervals among women in selected subsaharan african countries. medicine (baltimore). 2020;99(19):e20118. 14. monita f, suhaimi d, ernalia y. hubungan usia, jarak kelahiran, dan kadar hemoglobin ibu hamil dengan kejadian berat bayi lahir rendah di rsud arifin achmad provinsi riau. jom fk. 2016;3:1–5. 15. dorland, newman. kamus kedokteran dorland. 31st ed. jakarta: egc; 2010. 16. muluneh aa, kassa zy, siyoum m, gebretsadik a, woldeyes y, tenaw z. determinants of sub-optimal birth spacing in gedeo zone, south ethiopia: a case-control study. int j women’s health. 2020;12:549–56 17. chernet ag, shebeshi ds, banbeta a. determinant of time-to-first birth interval after marriage among ethiopian women. bmc women’s health. 2019;19(1):1–6. 18. pimentel j, ansari u, omer k, gidado y, baba mc, andersson n, et al. factors associated with short birth interval in lowand middle-income countries: a systematic review. bmc pregnancy childbirth. 2020;20(1):1–17. 19. khan jr, bari w, latif ahmm. trend of determinants of birth interval dynamics in bangladesh. bmc public health. 2016;16(1):1–11. 20. adriani m. pengantar gizi masyarakat. 6th ed. jakarta: kencana indonesia; 2016. 21. nausheen s, bhura m, hackett k, hussain i, shaikh z, rizvi a, et al. determinants of short birth intervals among married women: a cross-sectional study in karachi, pakistan. bmj open. 2021;11(4):1–10. 22. montgomery, mr. cohen b. from death to birth: mortality decline and reproductive change. washington, d.c.: national academy press; 1998. 23. arsyad ss. determinan fertilitas di indonesia. j kependud indones. 2016;11(1):1–14. 24. wulandari df, history a, wulandari df, malang k, java e. literature review: factors influence birth interval from couples in childbearing age. matern neonat health j. 2021;0825(2016):20–36. 25. singh sn, singh n, narendra r. demographic and sosio-economic determinants of birth interval dynamics in manipur: a survival analysis. online j health allied sci. 2010;9(4):3. 26. maqhfirah d. makna hidup pada wanita yang terlambat menikah. j divers. 2018;4(2):109–18. nedra wati zaly et al.: trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 45 management of juvenile nasopharyngeal angiofibroma in a referral hospital in west java, indonesia yussy afriani dewi, ifiq budiyan nazar 1department of otorhinolaryngology, head, and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: ifiq budiyan nazar, department of otorhinolaryngology, head, and neck surgery , faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur no. 38 bandung, indonesia, email: ifiq82nazar@gmail.com introduction juvenile nasopharyngeal angiofibroma (jna) is a hypervascular, slow growing, and locally destructive tumor. the tumor is histologically benign, however, jna is aggressive and destructive, spreading from sphenopalatine foramen with extension occurring into the osseous and soft tissue structures.1,2 the incidence of jna is 0.05–0.5% of all headneck tumors, and is relatively higher in india and egypt compared to america and europe. in asia and the middle east, the incidence is around 1:5,000 and 1:60,000. the lesion mostly affects adolescent males with the highest incidence between 14–18 years old.3 the jna presents clinically with nasal obstruction, recurrent epistaxis, facial numbness, ear fullness, rhinorrhea, cheek swelling, sinusitis, nasopharyngeal mass, headaches, visual changes, proptosis, and orbital involvement.1,2,4 the diagnosis of jna is based on history taking and physical examination, confirmed by multiplanar imaging studies such as computed tomography (ct) or magnetic resonance imaging (mri).5,6 the ct scan helps in better delineation of osseous involvement of tumor, while mri is useful for assessing intracranial extension. moreover, the ct angiography is used to define the tumor blood supply and the vascular composition of the tumor since the jna is highly vascular and amj. 2020;7(1):45–50 abstract background: juvenile nasopharyngeal angiofibroma (jna) is a fibrovascular tumor originating from the supero-posterior area of the sphenopalatine foramen. this tumor is histologically benign, but is clinically malignant because jna has potentially destructive spread extending to the skull base and the cranium. the aim of the study was to evaluate the management of jna in dr. hasan sadikin general hospital bandung, a referral hospital in west java. methods: this was a descriptive retrospective study using medical record data of jna patients during the period of 2011-2018. the stage of jna was designated, based on the fisch classification. results: there were112 jna cases, consisting of 99% male and 1% female. most of them (97%) were aged 10-20 years old (median16 years old). the chief complaints were nasal obstruction (46%) and recurrent epistaxis (36%). most of the jna stage was stage ii (43%). major feeding vessel of jna was from an internal maxillary artery (imax) and ascending pharyngeal artery (28%). preoperative management was equal for ligation and embolization. the complication of embolization was local pain (75%). the most surgical technique performed was the transpalatal approach (41.36%). blood loss in a different stage in jna surgery with embolization was less than surgery with ligation. there were patients (10%)with residual disease after 6 months follow-up. conclusions: jna is essentially a disease of the adolescent males. the management of jna patients is surgery, mostly using transpalatal technique. preoperative embolization of jna is a safe procedure, minimizes intraoperative blood loss, decrease the incidence of residual or recurrence, and shortening the duration of the surgery. keywords: embolization, fisch classification, internal maxillary artery, juvenile nasopharyngeal angiofibroma, ligation https://doi.org/10.15850/amj.v7n1.1787 althea medical journal. 2020;7(1) 46 amj march 2020 predominantly blood supplied via the branches of external carotid artery (eca), mainly from the internal maxillary artery (imax), multiple branches of ipsilateral eca, contralateral eca, and internalcarotidartery (ica).2 surgery is the mainstay of treatment for jna.1,4,6 the surgical approaches are including transpalatal, lateral rhinotomy, facial degloving, or endoscopy technique.1,7 since jna is an aggressive tumor with a strong tendency to bleed, the surgical resection can be complicated by massive hemorrhage. an important advancement in treatment is preoperative intra-arterial embolization, which is now widely accepted and performed to reduce blood flow to the tumor. an alternative way is carotid artery ligation, as some hospitals may lack the facilities and infrastructure required for embolization.2 in addition to the management of jna, the recurrence rate is also an important factor. patients younger than 18 years have a recurrence rate of 48.2%. the study exploring the characteristics of preoperative management of jna, intraoperative blood loss, postoperative complications, and recurrence of jna in indonesia is still very limited. therefore, our study aimed to evaluate the management of jna in dr. hasan sadikin general hospital bandung, as a referral hospital in west java indonesia. methods a descriptive retrospective hospital-based study was conducted in dr. hasan sadikin general hospital, a referral hospital in west java, reviewing the management of jna by collecting a medical records of patients with jna from 2011 to 2018. the inclusion criteria were complete medical record data on patients underwent preoperative ligation before surgical resection (group a) and patients underwent preoperative intraarterial embolization before surgical resection (group b). all patients were operated by the same team of surgeon and evaluation of the blood loss was also conducted by the same team of nursing staff. the classification of fisch was used for staging. stage i was designated as tumor limited to the nasopharynx and nasal cavity with no bone destruction, stage ii was designated as a tumor invading the pterygomaxillary fossa, the maxillary antrum, the ethmoid and sphenoid sinuses with bone destruction. furthermore, stage iii was designated as tumor invading table 1 the distribution chief complains among juvenile nasopharyngeal angiofibroma patients (n=112) from dr. hasan sadikin general hospital year 2011–2018 chief complain n % nasal obstruction 52 46 recurrent epistaxis 40 36 headache 11 10 protruding nasal mass 8 7 proptosis 1 1 facial swelling table 2 the distribution of major feeding vessel among juvenile nasopharyngeal angiofibroma patients based on ct angiography major feeding vessel number of patients % imax 23 21 ascending pharyngeal artery 8 7 imax & ascending pharyngeal artery 31 28 bilateral supply 13 12 unilateral supply 29 26 internal carotid artery 8 7 note: imax= internal maxillary artery althea medical journal. 2020;7(1) 47yussy afriani dewi et al.: management of juvenile nasopharyngeal angiofibroma in a referral hospital in west java, indonesia the infratemporal fossa, the orbit, and the parasellar area, but remaining lateral to the cavernous sinus, and stage iv was designated as tumor with invasion of the cavernous sinus, the optic chiasm or the pituitary fossa. preoperative embolization and angiography were performed by experienced interventional radiologist. surgery was performed within 24–72 hours after embolization. surgical approach depended upon the stage of the tumor and approaches used were endoscopic approach, lateral rhinotomy, transpalatal and facial degloving. blood loss was estimated by measuring the total fluid collected by suction and blood absorbed by gauze pieces. all data were described in percentage and presented in tables or figures. results in total, there were 112 medical record data from 2011 to 2018, consisting of a male (n=111; 99%) and only one female. the age was predominantly (n=109;97%) between 10–20 years old (median 16 years old). the primary presenting symptoms were nasal obstruction (n=52;46%) and recurrent epistaxis (n=40; 36%) (table 1). the tumors were staged according to the fisch staging, consisting of stage i (n=29;26%), stage ii (n=48;43%), stage iii (n=27;24%) and stage iv (n=8;7%), respectively. the ct angiography examination showed that 28% had blood supply from the internal maxillary artery (imax) and ascending pharyngeal artery, 26% from the unilateral supply, and 12% from the bilateral supply. the imax was also shared in the arterial supply (21%), and ascending pharyngeal artery (7%) (table 2). preoperative methods performed in 112 jna patients were by ligation of the external carotid artery (n=54;48%) and by embolization (n=58;52%) (figure 1), whereas surgical approaches for jna were based on the stage of the tumor, which are transpalatal technique (n=41), facial degloving (n=40), lateral rhinotomy (n=9), and closed approach or endoscopic resection) (n=22). figure1 preoperative methods in juvenile nasopharyngeal angiofibroma patients table 3 blood loss in a different stage of juvenile nasopharyngeal angiofibroma patients based on ligation and embolizationa stage group a group b no. subjects % blood loss (ml)* no. subjects % blood loss (ml)* stage i 14 26 330 15 26 240 stage ii 23 43 660 25 43 450 stage iii 13 24 820 14 24 600 stage iv 4 7 1200 4 7 900 note: blood loss in the group underwent ligation (group a) and embolization (group b). * mean blood loss n n althea medical journal. 2020;7(1) 48 amj march 2020 intraoperative blood loss was measured by calculating the volume of blood that was collected in tubes. description of intraoperative blood loss, vascular supply, and stage for a tumor that underwent ligation (group a) was presented side by side with those with embolization (group b). preoperative embolization has been effective in decreasing intraoperative blood loss than artery ligation. intraoperative blood loss from surgery with ligation ranges from 330–1200 ml and preoperative embolization ranges from 240–900 ml (table 3). of the total 58 patients who performed preoperative embolization, several complications were found, predominantly as local pain (n=43;26%) (table 4). postoperative complications and tumor recurrence remain the most tangible clinical outcomes. postoperative imaging was conducted after 6 months of follow-up, however, some patients were lost in follow up. of 47 patients from group a (ligation group), 4 had a residual disease and 45 patients from group b (embolization group), 7 had residual disease. no patients were dead in this case. discussions this study reported that jna patients registered in dr. hasan sadikin general hospital are predominantly (99%) males, and a majority in the age group of 10–20 years with a median age of 16 years old. our study is similar to a study that reported that the jna has a predilection in the adolescent males with an age range of 7–21 years, and the highest incidence is between the age of 14–18 years.4 the etiology of this tumor is not known yet, however, there are several theories, one of those is due to hormonal imbalance such as excessive estrogen production or androgen deficiency. based on this theory, there is a relationship between the tumor with gender and age of the patients.4,8 patients with jna present with a variety table 4 complications of preoperative embolization of among juvenile nasopharyngeal angiofibroma patients complication number of patients % local pain 43 74 nausea 8 14 local subcutaneous edema 5 9 temporary visual loss 1 2 stroke 1 2 figure 2 postoperative imaging as follow-up after 6 months of surgery althea medical journal. 2020;7(1) 49 of major complaints. in this study, the most common complaints are nasal congestion and epistaxis similar to the symptoms of jna reported such as nasal congestion (80–90%), recurrent epistaxis (45–60%), headache (25%) that occurs when the tumor has spread to the paranasal sinuses, and facial swelling (10–18%). other symptoms such as anosmia, deafness, rhinolalia, cheek deformity, and palate swelling can also be found in patients with jna. nasopharyngeal angiofibroma is difficult to palpate, and a touch of a finger on the surface of the tumor can cause massive bleeding.8,9 juvenile nasopharyngeal angiofibroma is hypervascular and predominantly supplied by the external carotid artery (eca) circulation via the imax. they are associated with morbidity from local mass effect, bony erosion and remodeling of the bone, nasal obstruction, haemorrhage, and cranial nerve palsies. these tumors are surgically resected with the open procedure in ligation of eca to decrease intraoperative blood loss. preoperative embolization is performed to these tumors by interventional radiology and then resected by open surgery or by using endoscopy. the purpose of embolization is to decrease intraoperative blood loss. the blood supply for jnas can be variable, with blood supply from multiple branches of the eca, contralateral eca branches, and small branches arising from the internal carotid artery (ica). the ct angiography performed during the preoperative embolization procedure delineates the specific blood supply to jna, allowing the surgeon to plan a surgical approach, anticipate areas of increased bleeding.2,10,11 the extirpation surgery technique that is often used is the transpalatal approach. the choice of surgical approach in jna is generally based on the location, size, and extension of the tumor to the surrounding tissue, age and general condition of the patient, successful embolization before surgery and the experience of the surgeon.10 in this study, all cases managed with surgery as the main therapy for jna such as transpalatal surgery, facial degloving, endoscopic surgery, and surgery using a lateral rhinotomy. before the surgical removal of the tumor, external carotid artery ligation has been performed to some respondents, and others with embolization. preoperative embolization of the jna makes it easier to identify anatomical landmarks during surgery without massive bleeding and facilitating the procedure. consequently, preoperative embolization helps to reduce surgical morbidity.11–13 endoscopic surgery has many advantages compared to traditional approaches, as this has a wider view of the tumor and anatomical landmarks from several angles become possible, better visualization of the interface between the tumor and adjacent bone and soft tissues. the result is more accurate and complete resection for control of bleeding can be performed. another advantage of endoscopic surgery is that incisions for skin, mucosa, and osteotomies are unnecessary, affecting less the growth of the midface of adolescents. incisions and closure were not needed, reduces the duration of the operation and postoperative complications, such as pain, dysesthesia, and trismus.2,14 all patients have been followed up with endoscopic examination and ct scan after six months postoperatively. although most of them have no residual disease, some have residual disease. predicting the recurrence of jna is influenced by the age and the tumor stage of the patients. the higher chances of recurrence are younger and the later stage of jna. early diagnosis not only helps in better management but also prevents recurrences.15 the limitation of this study is that the data collected is from the medical records and follow up cannot be controlled, therefore, the follow-up data is not properly evaluated. as a conclusions, jna is a common disease of adolescent males, with the major feeding vessels are from the internal maxillary artery and ascending pharyngeal artery. the common chief complaints arenasal obstruction and epistaxis. the stage ii has predominantly occurred. the management of jna in west java is surgery, mostly using a transpalatal technique. preoperative embolization of jna is a safe procedure without any substantial risk of neurological complications, that can minimize intraoperative blood loss, leading to a decreased incidence of residual or recurrence, and shortened operation duration. references 1. hodges jm, mcdevitt as, el-sayed ali ai, sebelik me. juvenile nasopharyngeal angiofibroma: current treatment modalities and future considerations. indian j otolaryngol head neck surg. 2010;62(3):236–47. 2. oliveira ja, tavares mg, aguiar cv, azevedo jf, sousa jr, almeida pc, et al. comparison between endoscopic and open surgery yussy afriani dewi et al.: management of juvenile nasopharyngeal angiofibroma in a referral hospital in west java, indonesia althea medical journal. 2020;7(1) 50 amj march 2020 in 37 patients with nasopharyngeal angiofibroma. braz j otorhinolaryngol. 2012;78(1):75–80. 3. garça mf, yuca sa, yuca k. juvenile nasopharyngeal angiofibroma. eur j gen med. 2010;7(4):419–25. 4. persky m, manolidis s. vascular tumors of the head and neck. in: johnson jt, rosen ca, editors. bailey’s head and neck surgery: otolaryngology, volume 1. 5th ed. philadelphia: lippincot williams & wilkins ; 2014. p. 2021–8. 5. zahara np. angiofibroma nasofaring belia dengan diagnosis awal hemangioma kapilare [internet] 2016 [cited 2019 september 28]. available from: https:// docplayer.info/35679798-angiofibromanasofaring-belia-dengan-diagnosis-awalh e m a n g i o m a k a p i l a r e n i m i m p u t r i zahara.html 6. alimli ag, ucar m, oztunali c, akkan k, boyunaga o, damar c, et al. juvenile nasopharyngeal angiofibroma: magnetic resonance imaging findings. j belg soc radiol. 2016;100(1):63. 7. moideen sp. staging systems for juvenille nasopharyngeal angiofibroma. [internet]. 2019 [cited 2019 september 28] available from: https://www.e4ent. com/articles/staging-systems-juvenilenasopharyngeal-angiofibroma/ 8. anggreani l, adham m, musa z, lisnawati l, bardosono s. gambaran ekspresi reseptor estrogen β pada angiofibroma nasofaring belia dengan menggunakan pemeriksaan imunohistokimia. oto rhino laryngologica indonesiana. 2011;41(1):8–16. 9. bawa ipa, dewi ya, permana ad. karateristik angiofibroma nasofaring belia di smf/ksm ilmu kesehatan t.h.t.k.l/ rshs bandung tahun 2011-2016. in: dewi ya, ratunanda s, editors. proceeding of the 2nd world head and neck cancer day; 2016 july 27-28. bandung, indonesia. bandung: fk unpad; 2016. p. 313–21 10. hutabarat i, dewi ya, permana ad. efektifitas embolisasi preoperatif pada pasien angiofibroma nasofaring belia di fk unpad/rshs bandung periode 2015-2016. in: dewi ya, ratunanda s, editor. proceeding of the 2nd world head and neck cancer day; 2016 july 27–28. bandung, indonesia. bandung: fk unpad; 2016. p 323–32 11. tiwari pk, teron p, saikia n, saikia hp, bhuyan ut, das d. juvenile nasopharyngeal angiofibroma: a rise in incidence. indian j otolaryngol head neck surg. 2016;68(2):141–8. 12. ballah d, rabinowitz d, vossough a, rickert s, dunham b, kazahaya k, et al. preoperative angiography and external carotid artery embolization of juvenile nasopharyngeal angiofibromas in a tertiary referral paediatric centre. clin radiol. 2013;68(11):1097–106. 13. sharma ak, jain k, manth s, rawat ds, mishra pc. a comparative study of preoperative transarterial embolized v/s unembolized cases of juvenile nasopharyngeal angiofibroma. int j med sci educ. 2018;5(3):375–84. 14. kasem maho, awad as, al bosraty ham, kamel ai. preoperative embolization of nasopharyngeal angiofibromas: the role of direct percutaneous injection of cyanoacrylate glue in conjunction with particulate endovascular approach. egypt j radiol nucl med. 2016;47(4):1431–41. 15. moorthy pns, ranganatha reddy b, qaiyum ha, madhira s, kolloju s. management of juvenile nasopharyngeal angiofibroma: a five year retrospective study. indian j otolaryngol head neck surg. 2010;62(4):390–4. amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 77 clinical manifestation and hematologic interpretation of pediatric systematic lupus erythematosus at initial presentation: 2-years observation hasti savira yudiana,1 reni ghrahani,2 adhi kristianto sugianli3 1faculty of medicine universitas padjadjaran, indonesia, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesiaa correspondence: hasti savira yudiana, faculty of medicine, universitas padjajaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: hasti_savira@yahoo.co.id amj. 2021;8(2):77–82 abstract background: systemic lupus erythematosus (sle) is an autoimmune disease characterized by a spectrum of clinical manifestations, immunological abnormalities, and varied laboratories results. in children, sle manifestation is particularly more severe, involving more organs. hematological manifestation has been known as the most common manifestation. the purpose of this study was to describe the clinical manifestations and hematologic interpretation of pediatric sle at initial presentation. methods: this retrospective data collection study was conducted at the department of child health dr. hasan sadikin general hospital bandung on medical records from a two-year period of 2017– 2018. the clinical manifestations were categorized into malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, renal disorders, and neurological disorders. the hematologic interpretations were categorized into anemia, leukopenia, neutropenia, lymphopenia, and thrombocytopenia. clinical manifestations and hematological interpretations were presented as occurrence percentages and stratified into three age-group of pre-pubertal, peri-pubertal, and post-pubertal. results: among 79 pediatric sle patients (median age 14 years old; iqr 11–16), female gender was predominant. abnormalities hematologic interpretation occurs in more than half of the patients (83.5%). malar rash and anemia were the commonest findings among all age groups. increased occurrence of neuropsychiatric and renal disorders were observed in all age-groups. conclusions: malar rash and anemia are important findings among pediatric sle patients. furthermore, the occurrences of the neuropsychiatric and renal disorders are also important. keywords: hematologic interpretation, neuropsychiatric, renal disorder, pediatric, systemic lupus erythematosus introduction systemic lupus erythematosus (sle) is a complex multi-system autoimmune illness characterized by a broad spectrum of clinical manifestations, with immunological and laboratory abnormalities. it can affect all people of both genders and various races/ ethnicities, age groups, socioeconomic status, and others. the incidence of sle in the world has reached 0.3–23.7 per 100,000 population per year.1 the prevalence of sle in the asia pacific is 0.9–3.1 per 100,000 populations per year. in addition, lupus is also considered an illness that has a fairly high mortality rate. in 2016, the indonesian ministry of health reported a high mortality number of hospitalized lupus patients which was 550 out of 2,166 patients.2 pediatric sle is defined as a systemic autoimmune disease whose symptoms occur before the age of 18.3 the occurrence of pediatric sle is about 10–20% of total sle cases, with an incidence of 0.3–0.9 per https://doi.org/10.15850/amj.v8n2.2153 althea medical journal. 2021;8(2) 78 althea medical journal june 2021 100,000 children per year. the previous study has reported that children-onset has more diverse and heavier manifestation.1,4 hematologic abnormality is one of the most common manifestations of sle in children with approximately 50% of cases. abnormalities hematologic interpretation in sle consists of leukopenia, with lymphopenia, neutropenia, or both; anemia and thrombocytopenia.4-8 therefore, the hematology examination is one of the most frequent examinations and criteria for identifying sle patients based on the american college of rheumatology (acr) 1997 and the systemic lupus international collaborating clinics (slicc) 2012.7,9,10 children growth period contribute to the severity of pediatric sle.1 therefore, the identification of pediatric sle becomes more challenging. dr. hasan sadikin general hospital, as our study site, is a tertiary hospital, located in the west java province, admitting pediatric sle patients with approximately 249 cases annually. a limited study has been done to identify the clinical manifestation and hematologic result among pediatric sle at this population level, particularly for age-group in the children growth period. this study was conducted to have a better understanding of the clinical manifestation and hematologic interpretation of pediatric sle at initial presentation. methods this was a descriptive study with retrospective data, collected from patient medical records from 1 january 2017 to 31 december 2018. these two years period study was conducted at the department of child health dr. hasan sadikin general hospital bandung. this study retrieved and screened medical records for outpatient and inpatient according to the icd10 diagnosis of systemic lupus erythematosus (icd-10-cm codes m32*). screened data were selected based on inclusion and exclusion criteria. the inclusion criteria of this study were pediatric patients (<18 years) with sle based on acr and slicc3,10 who had complete hematologic examination such as hemoglobin, leukocytes, neutrophils, lymphocytes, platelets, and hematocrit at the time of initial diagnosis. the exclusion criteria were incomplete and unclear information data written in the medical record and an irregular routine visits to the hospital. the variables used in this study were age, gender, and clinical manifestations that were categorized as malar rash, discoid rash, photosensitivity, oral ulcers, arthritis, renal disorders, and neurological disorders. furthermore, data on hematology results, including hemoglobin levels, erythrocyte index i.e. mcv, mch, mchc, number of leukocytes, neutrophils, lymphocytes, and platelets were retrieved. the hematologic interpretation was defined and categorized into: anemia, leukopenia, neutropenia, lymphopenia, and thrombocytopenia. anemia was designated as hemoglobin level <11g/dl for children aged 6–59 months, <11.5d/dl for aged 5–11 years, and <12 d/dl for aged >11 years; leukopenia was designated as leukocytes level <4,000/ mm3, neutropenia as neutrophils level <1,000/mm3, lymphopenia as lymphocytes level <1500/mm3, and thrombocytopenia as thrombocytes level <150,000/mm3.4,5,8 to analyze the clinical manifestation and hematologic interpretation, we had defined age group into three categories based on prepubertal growth period (male of age ≤9 years old and female ≤8 years old); peripubertal (male of age >9–<14 years old and female > 8–<13 years old); and post-pubertal (male ≥14 years old and female ≥ 13 years old).11 general demographic, clinical manifestation, and hematologic interpretation were presented as frequency, to present table 1 hematological values at initial presentation of newly diagnosed systemic lupus erythematosus pediatric patients at the department of child health, dr. hasan sadikin general hospital bandung during 2017 and 2018 hematological value median iqr hemoglobin levels (g/dl) leukocyte (mm3) neutrophils (mm3) lymphocyte (mm3) platelet (mm3) hematocrit levels (%) 9.5 6,300 3,842 1,460 229,000 29.5 8.0–11.5 4,030–9,170 2,276–6,425 857–2,232 152,000–329,000 24.3–36.2 note: iqr= interquartile range althea medical journal. 2021;8(2) 79hasti savira yudiana et al.: clinical manifestation and hematologic interpretation of pediatric systematic lupus erythematosus at initial presentation: 2-years observation the overall insight of the data population. the stratification with the age group was performed to observe the occurrence of clinical manifestation and hematologic interpretation among the age group category. all the data were analyzed using statistical software (ibm spss ver. 19, chicago, il, usa). this study was approved by the ethics committee of universitas padjadjaran (no.651/un6.kep/ ec/2019) and the health research ethics committee of dr. hasan sadikin general hospital (no.lb.02.01/x.2.2.1/10522/2019). results a total of 185 data were screened according to the icd-10-cm:m32, however, only 79 data fulfilled the inclusion criteria. characteristics of newly diagnosed pediatric sle patients at the department of child health, dr. hasan sadikin general hospital bandung between 1 january 2017 and 31 december 2018 were dominated by a female (92.4%) with a ratio of male:female was 1:12. the median age of the cases was 14 years old (range 11–16 years). in general, anemia was observed at initial presentation among the pediatric sle population (n=61;77.2%). the hematological values at the initial presentation were depicted in table 1. based on the age group of pediatric sle, the most common clinical manifestation at the onset of disease was malar rashes, which was found in the range 20–30% of all age-group. photosensitivity was the second common clinical manifestation among the prepubertal and post-pubertal groups, 25%, and 23.3%, respectively. the renal disorders and discoid rashes were more likely to be found as a second clinical manifestation in the peripubertal group. the interesting findings were the increased trend of neurologic disorders occurrence and renal disorders among agegroup (figure 1). the occurrence of anemia was the most common hematological manifestation among all the age-group, ranging between 37.5–46%. lymphopenia, with or without figure 1 clinical manifestations of pediatric systemic lupus erythematosus patients based on age group note: n=number of clinical manifestations frequency observed in 79 patients, which can have more than one clinical manifestation althea medical journal. 2021;8(2) 80 althea medical journal june 2021 leukopenia was observed as the second frequent hematological manifestation in peripubertal and post-pubertal, 27% and 32.6%, respectively. meanwhile, the occurrence of thrombocytopenia was found more frequent in pre-pubertal (25%). among all the hematological manifestations, such as anemia with thrombocytopenia, anemia with lymphopenia, or anemia, leukopenia and lymphopenia, were a frequent combination of hematological manifestations among the pediatric sle populations (figure 2). discussion this study shows the initial presentation of clinical manifestation and hematologic interpretation of pediatric sle, which is important to the identification of sle. in this study, the clinical manifestations from pediatric sle are very diverse, both in terms of numbers and types of abnormalities. malar rashes are the most common clinical manifestation in all age groups category within this study. this finding is similar to the previous report, which observes mucocutaneous disorder, especially malar rashes, occurs in almost every case of sle.12 the main cause of the malar rash is uv light that stimulates keratinocytes to produce innate cytokine and trigger cell death, and promote inflammatory infiltrates which damage skin tissues.13 skin disorders likely to be the easiest finding to recognize and to examine, either by patients or by physicians.14 therefore, the malar rashes are the important finding of this study. neuropsychiatric disorders or npsle and renal disorders are among the causes of mortality and morbidity in children with sle.3,15 in this study, the occurrence of npsle and renal disorder increased among the age groups. npsle is caused by autoantibody production, micro-angiopathy, intrathecal production of pro-inflammatory cytokines, and premature atherosclerosis that disturb the integrity of the blood-brain barrier and allow, thus, more proteins or cells access to the cns.15,16 the mechanism of renal disorder is the deposition of the antigen-antibody complex on glomeruli and promotes inflammation and adjacent cell proliferation such as endothelial cells, epithelial cells, and mesangial cells.3,4,15 figure 2 hematological manifestation of pediatric systemic lupus erythematosus patients based on age group note: n=number of clinical manifestations frequency observed in 79 patients, which can have more than one hematological manifestationn althea medical journal. 2021;8(2) 81 although the previous study has shown that renal and neuropsychiatric disorders were the most commonly found clinical manifestations in the pre-pubertal group, however, we observe in our current study that the occurrence of the renal disorder increases with the agegroup due to complexity of the disease to the body metabolism. on the other hand, npsle is more likely to occur in older age due to difficulties observing psychiatric symptoms in small children. moreover, a neuropsychiatric disorder is usually found at a follow-up or in the first year after the first diagnosis of sle is done. 3,4,15,16 hematologic abnormalities present as high as 83.5% among all pediatric sle, and anemia is the most common abnormality. specific autoantibodies might directly attack, opsonize, phagocyte, and lyse erythrocytes, leukocytes, and thrombocytes, leading to the decreased amount in the blood.17 anemia is generally caused by several factors i.e. low erythropoiesis due to low erythropoietin in chronic disease; low levels of ferritin, and hemolytic anemia. the occurrence of anemia reported by other studies is ranging between 50–70%.6,18 leukopenia, with or without lymphopenia or neutropenia, and thrombocytopenia are also common in pediatric sle.5,19 leukopenia can be accompanied by lymphopenia, neutropenia, or both. lymphopenia in sle is generally caused by a decreased number of t and b lymphocytes due to an increased number of natural killer cells, a decreased number of proteins that regulate complement, resulting in complement-mediated lysis. furthermore, it can be caused by the presence of cytotoxic anti-lymphocyte antibodies.5,18 the number of pediatric sle with lymphopenia increases, in line with the increase of age when the first diagnosis of sle. leukopenia can also be caused or worsened by the use of immunosuppressant drugs that may suppress the bone marrow.5,19 thrombocytopenia in sle is generally caused by the increase of platelet destruction and the presence of anti-platelet antibodies that might attack antigens on the surface of the platelet. in addition, similar to leukopenia, thrombocytopenia can also be caused by the use of immunosuppressant drugs, which can interfere with platelet production.5 limitations of this study are among others the small numbers of pediatric sle cases over two years of study, which may lead to an overestimated percentage of occurrences among the age groups. there is limited information in examinations available to determine other causes of various hematologic abnormalities. further study recruiting more cases is of great interest, therefore, the age-group population could be distributed evenly, which can present the actual estimated number of occurrence of both clinical manifestation and hematologic interpretation in pediatric sle patients. in conclusion, clinical manifestation and hematologic interpretation of pediatric sle patients are important factors. malar rash and anemia are the common findings among all age-group of pediatric sle patients. the occurrences of neuropsychiatric and renal disorder among age-group are observed as important finding in this study. references 1. pons-estel gj, ugarte-gil mf, alarcón gs. epidemiology of systemic lupus erythematosus. expert rev clin immunol. 2017;13(8):799–814. 2. pusat data dan informasi kementrian kesehatan republik indonesia. situasi lupus di indonesia. jakarta: kementrian. kesehatan.republik indonesia; 2017. p. 1–7. [cited 2019 feb 22]. available form: https://pusdatin.kemkes.go.id 3. aggarwal a, srivastava p. childhood onset systemic lupus erythematosus: how is it different from adult sle? int j rheum dis. 2015;18(2):182–91. 4. levy dm, kamphuis s. systemic lupus erythematosus in children and adolescents. pediatric clin north am. 2012;59(2):345– 64. 5. bashal f. hematological disorders in patients with systemic lupus erythematosus. open rheumatol j. 2013;7:87–95. 6. thakur n, chandra j, dhingra b, singh v. pediatric lupus: varied haematological picture and presentation. indian j hematol blood transfus. 2015;31(1):68–70. 7. tarr t, dérfalvi b, győri n, szántó a, siminszky z, malik a, et al. similarities and differences between pediatric and adult patients with systemic lupus erythematosus. lupus. 2015;24(8):796–803. 8. oehadian a, suryadinata h, dewi s, pramudyo r, alisjahbana b. the role of neutrophyl lymphocyte count ratio as an inflammatory marker in systemic lupus erythematosus. acta med indones. 2013;45(3):170–4. 9. kasjmir yi, handono k, wijaya lk, hamijoyo l, albar z, kalim h, et al. rekomendasi perhimpunan reumatologi hasti savira yudiana et al.: clinical manifestation and hematologic interpretation of pediatric systematic lupus erythematosus at initial presentation: 2-years observation althea medical journal. 2021;8(2) 82 althea medical journal june 2021 indonesia: diagnosis dan pengelolaan lupus eritematosus sistemik. jakarta: perhimpunan ahli penyakit dalam indonesia; 2011. p. 1–46 [cited 2019 may 8] available form: http://reumatologi. or.id/ 10. karuniawaty tp, sumadiono s, satria cd. perbandingan diagnosis systemic lupus erythematosus menggunakan kriteria american college of rheumatologi dan systemic lupus international collaborating clinics. sari pediatri. 2017;18(4):299–303. 11. abdwani r, abdalla e, al-zakwani i. unique characteristics of prepubertal onset systemic lupus erythematosus. international journal of pediatrics. 2019;2019:9537065. 12. ghrahani r, setiabudiawan b, sapartini g. pola antibodi antinuklear sebagai faktor risiko keterlibatan sistem hematologi lupus eritematosus sistemik pada anak. majalah kedokteran bandung. 2015;47(2):124–8. 13. stannard jn, kahlenberg jm. cutaneous lupus erythematosus: updates on pathogenesis and associations with systemic lupus. curr opin rheumatol. 2016;28(5):453–9. 14. evalina r. gambaran klinis dan kelainan imunologis pada anak dengan lupus eritematosus sistemik di rumah sakit umum pusat adam malik medan. sari pediatri. 2016;13(6):406–11. 15. soybilgic a. neuropsychiatric systemic lupus erythematosus in children. pediatric ann. 2015;44(6):e153–8. 16. muscal e, brey rl. neurological manifestations of systemic lupus erythematosus in children and adults. neurol clin. 2010;28(1):61–73. 17. sasidharan p, bindya m, sajeeth kumar k. hematological manifestations of sle at initial presentation: is it underestimated? isrn hematol. 2012;2012:961872. 18. janoudi n, bardisi es. haematological manifestations in systemic lupus erythematosus. in: almoallim dh, editor. systemic lupus erythematosus. london: intechopen; 2012. p. 363–82. [cited 2019 feb 22] available from: https:// www.intechopen.com/books/systemiclupus-erythematosus/haematologicalm a n i f e s t a t i o n s i n s y s t e m i c l u p u s erythematosus 19. carli l, tani c, vagnani s, signorini v, mosca m. leukopenia, lymphopenia, and neutropenia in systemic lupus erythematosus: prevalence and clinical impact—a systematic literature review. semin arthritis rheum. 2015;45(2):190–4. amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 111 effect of annona muricata l. leaf ethanol extract in ccl4 hepatitis rat model kuswinarti,1 ilham asrori azka,2 dwi prasetyo3 1departement of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3departement of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: kuswinarti, departement of biomedical sciences faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: wiwinsumarlan@gmail.com introduction hepatitis is an infection or inflammation disease of the liver which is caused by toxic chemical substances, such as carbon tetrachloride (ccl4). 1,2 this compound has been frequently used for experimental studies to observe liver damage. the hepatotoxic effect of ccl4 is a result of an oxidative stress process, that to some extent caused by the partial pressure of reactive oxygen in tissues. in ccl4 induced liver injury model, oxidative stress can provoke and promote lipid peroxidation that damage the hepatocellular membrane, followed by the release of pro-inflammatory chemokines and cytokines.3,4 this process introduces an imbalance to the effect of radicals outnumbering anti-oxidants.5 because of it is very reactive nature, free radicals tend to accrue electrons from other substances to reach stability. this chain reaction will eventually produce damages in the cellular structures such as the membranes, structural proteins, enzymes, as well as nucleic acid.6 annona muricata l. leaf contains the phytochemical compound acetogenins. the presence of this compound in annona muricata l. leaf has an anti-oxidant activity which may prevent the damages caused by free radicals on cells.7 free radicals or reactive oxygen species (ros) play an important role in oxidative stress and pathophysiology of various diseases, including liver disease and other functional disorders.8,9 the most damaging to biological amj. 2021;8(2):111–5 abstract background: liver can be damaged by various factors, including the oxidative stress mechanism. this damage can be inhibited by the application of anti-oxidant. the annona muricata l. leaf is known to have antioxidant properties. this study aimed to explore the effect of annona muricata l. leaf extract against hepatitis in rats. methods: an experimental study was performed on 25 male wistar rats that were given annona muricata l. leaf ethanol extract at 200 mg/kgbw, 400 mg/kgbw, and 600 mg/kgbw for eight days. the ccl4 was administrated on the eighth day and the rats were laparotomized on the next day. the average number of normal hepatocytes was counted in one field of view. this study was conducted at the laboratory of pharmacology and therapy of the faculty of medicine, universitas padjadjaran in september–october 2012. results: the negative control group showed an intact cell membrane, homogenous cytoplasm, and round nucleus, whereas the positive control group showed necrosis marked by a ruptured cell membrane, vacuolated cytoplasm, and degenerated nucleus. the average number of normal hepatocytes counted in the negative control and the positive group was 404.91±34.09 cells and 23.16±7.84 cells, respectively. in the treatment group, the normal hepatocytes were 95.91±20.96 cells (200 mg/kgbw), 74.53±13.59 cells (400 mg/kgbw) and 46.84±8.46 cells (600 mg/kgbw). statistically significant inhibition was observed (p<0.05). conclusions: the annona muricata l. leaf ethanol extract can inhibit liver tissue damages in hepatitis model rats, possibly due to the presence of acetogenins as an anti-oxidant agent. keywords: annona muricata l. leaf ethanol extract, ccl4, hepatocyte https://doi.org/10.15850/amj.v8n2.2225 althea medical journal. 2021;8(2) 112 althea medical journal june 2021 systems are the reactive oxygen species (ros), in which of importance are superoxide (•o2-), hydroxyl (•oh), and per hydroxyl (•o2h). tissue damage caused by ros is dubbed as oxidative damage and the factors which can prevent this are referred to as anti-oxidant.6,10 carbon tetrachloride is well absorbed in the digestive tract and respiratory tract of humans and animals. in liquid form, carbon tetrachloride can be absorbed via the skin, but in vapor form, its dermatological absorption is slow. carbon tetrachloride is well distributed throughout the body with higher concentrations in the liver, brain, kidneys, muscles, fat, and blood. its main excretion is through respiration as well as through feces and urine.11 after absorption, carbon tetrachloride is metabolized by cytochrome enzyme p450 inside the smooth endoplasmic reticulum of the hepatocytes. carbon tetrachloride is then cleaved to become trichloromethyl (ccl3) which is a very reactive free radical (ccl4+e →ccl3+cl -). trichloromethyl can cause the formation of lipid radicals by oxidizing fatty acids contained within the phospholipid membrane. a peroxidation of lipid can occur if this lipid radical reacts with oxygen. this is an autocatalytic reaction and can, thus, cause a chain reaction. the effect of such a reaction is the damage to the structural integrity of and disturbance upon the functioning of the hepatocytes. if the damage progresses and irreversible, that will induce hepatocyte cell death.12 annona muricata l. leaf is extensively used as an anti-oxidant. furthermore, it has also been used to reduce blood sugar in diabetic patients, as anti-nociceptive, and antiinflammation.13–15 acetogenins are found in the family annonaceae. acetogenins consist of c35−c39 carbon and have 2 hydrocarbon chains that connects the 2,4-disubstituted-y-lactone group to variants of the tetrahydrofuran (thf) ring. the hydrocarbon chain of this compound contains oxygenating groups such as hydroxyls, acetoxyls, and/or ketones.16 the study aimed to explore the effect of annona muricata l. leaf ethanol extract on the inhibition of liver tissue damage on hepatitis model rats. methods the design of this study was an experimental study, involving 25 male rats of wistar strain induced by the hepatotoxic material ccl4 were used as hepatitis model rats. the administration of ccl4 had damaged the liver, marked by degenerative changes such as necrosis and hepatocyte swelling, and vacuole formation inside the cells. the damage was observed on the liver of the experimental rats after the induction of ccl4 intraperitoneally. 17 the wistar rats aged 2–3 months, weight 200–250 gram each were included, and those with weight loss of more than 10% during adaption were excluded. the rats were divided into 5 groups, which were: negative control (no treatment nor induction), positive control (no treatment but with induction of ccl4), group treated with annona muricata l. leaf ethanol extract (amee) at 200 mg/kgbw, 400 mg/ kgbw, 600 mg/kgbw. in brief, a simplicia of annona muricata l. leaf was made, which was then reduced into grains. the grains were then macerated for 3x24 hours with 95% ethanol. the annona muricata l. leaf ethanol extract was then intensified with a rotary evaporator at 70°c until a viscous liquid extract was formed. the annona muricata l. leaf ethanol extract was then administered for eight days. the ccl4 was applied on the eight-day, and on the next day, the rats were laparotomised. the histological preparation was performed using the hematoxylin-eosin staining method and observed on 400×magnification for qualitative observation. quantitatively, the average number of normal hepatocytes was counted in one field of view. each group consisted of 5 rats. preparations were made for each rat and viewed the normal hepatocyte cells in one field of view 15 times. then averages of the result were counted. the average number of normal hepatocyte data in one field of view of preparation was statistically analyzed by oneway analysis of variance (anova) test and followed by tukey post hoc test. the result of p<0.05 indicated statistical significance. results the effect of annona muricata l. leaf ethanol extract was qualitatively observed by histopathological images as shown in figure 1. microscopical examination in the negative control group showed normal liver tissue. hepatocytes have a round complete nucleus, homogenous unvacuolated cytoplasm, and intact cell membrane. hepatocytes were orderly arranged around vena centralis. the administration of ccl4 in the group of positive control showed clear tissue necrosis althea medical journal. 2021;8(2) 113kuswinarti et al.: effect of annona muricata l. leaf ethanol extract in ccl4 hepatitis rat model especially in the area surrounding vena centralis (centrilobular necrosis). on the intact hepatocytes, vacuolated cytoplasm was present (ballooning degeneration). on other hepatocytes, ruptured cell membranes were found. these conditions showed a disorganized structure of hepatic lobules. microscopic examination in groups treated with 200 mg/kgbw, 400 mg/kgbw, and 600 mg/kgbw of amee showed that some hepatocytes had necrosis with the ruptured cell membrane. the morphology of the normal hepatocytes in treated with 200 mg/kgbw amee group was not as clearly defined as in the negative control group and the structure of hepatic lobules was seen as in a more orderly nature compared to the positive control group. the morphology of normal hepatocytes in the 400 mg/kgbw amee group was not as clearly distinct as in the negative control group and the structure of hepatic lobules was in a more disorderly manner compared to the 200 mg/ kgbw amee group. the morphology of normal hepatocytes in the 600 mg/kgbw amee group was not clear as in the negative control group and the structure of hepatic lobules had virtually lost any presence of orderliness. the group with the most amounts of figure 1 effect of annona muricata l. leaf ethanol extract observed by histopathological images (hematoxylin-eosin staining; 400× magnification) althea medical journal. 2021;8(2) 114 althea medical journal june 2021 normal hepatocytes was the negative control group which was 404.91±34.09 cells. the amee 200 mg/kgbw group had average normal hepatocytes of 95.91±20.96 cells; amee 400 mg/kgbw group with 74.53±13.59 cells; and amee 600 mg/kgbw group with 46.84±8.46 cells. the positive control group had 23.16±7.84 cells normal hepatocytes. the number of hepatocyte normal cells in the negative control group compared to the positive control group was statistically significant (p<0.05), showing the success of ccl4 induction in damaging liver cells. on the treated groups, there was an inhibition of the damage on the rats’ liver by retaining more normal cells which was deemed as statistically significant (p<0.05). discussion acetogenins is a phytochemical compound in annona muricata l. leaf that has an antioxidant activity which might prevent the damage of the liver caused by free radicals or reactive oxygen species (ros) on cells. ros plays an important role in oxidative stress caused by ccl4. in the negative control group, normal liver tissue has been observed. in the positive control group, there is extensive damage to the rats’ liver tissue. histopathological conditions of rats’ liver show that 24 hours after ccl4 induction, apoptosis has been found in the hepatocytes of the centrilobular region with characteristics of chromatin condensation of the nucleus and ballooning of the cytoplasm.17 on the treatment groups which are the 200 mg/kgbw, 400 mg/kgbw, and 600 mg/kgbw of amee groups, the rats’ liver preparations show better results compared to the positive control group. annona muricata l. leaf has been found to have an anti-oxidant effect of the acetogenins,7 that may prevent the occurrence of subsequent bonds between the free radical and the membrane which then halted the peroxidation of the membrane, resulting in a lower rate of necrosis. as such liver damage by induction ccl4 can be inhibited by prior administration of annona muricata l. leaf ethanol extract. on the 400 mg/kgbw and 600 mg/kgbw amee groups, normal cell numbers are less compared to the 200 mg/kgbw amee group. this shows that the dosage of 200 mg/kgbw of amee while being the lowest, is the most potent to prevent liver tissue damage. these results are in agreement with another research that a low dosage of aqueous extract of 50 mg/ kgbw gives greater protection compared to a higher dosage against ccl4, 18 possibly because of maximum biological tolerance of the rats’ body.19 the effect of chemical compound overload at high dosage can cause adverse effects and as such the smaller dosage can be deemed as more effective.20 to conclude, the annona muricata l. leaf ethanol extract can inhibit liver damage in hepatitis model rats, possibly due to the presence of acetogenins role as an antioxidant. figure 2 average number of normal hepatocytes in one field of view negative control : 404.81±34.08 positive control : 23.16±7.84 amee 200 mg/kgbw : 95.91±20.96 amee 400 mg/kgbw : 74.53±13.59 amee 600 mg/kgbw : 46.84±8.46 group n um be r of n or m al h ep at oc yt es 450.00 400.00 350.00 300.00 250.00 200.00 150.00 100.00 50.00 0.00 negative control positive control amee 200 mg/kgbw amee 600 mg/kgbwamee 400 mg/kgbw althea medical journal. 2021;8(2) 115 references 1. ghany m, hoofnagle jh. approach to the patient with liver disease. in: kasper d, braunwald e, fauci as, hauser sl, longo dl, jamesoon jl, editors. harrison’s principles of internal medicine. 16th ed. new york: mcgraw-hill; 2004. p. 1808−13. 2. tanaya g, kuswinarti k, dewi ns. annona muricata linn leaf effect in inhibiting sgpt elevation. althea medical journal. 2015;2(1):86–9 3. dutta s, chakraborty ak, dey p, kar p, guha p., sen s, et al. amelioration of ccl4 induced liver injury in swiss albino mice by antioxidant rich leaf extract of croton bonplandianus baill. plos one. 2018;13(4):e0196411 4. feng y, wang n, ye x, li h, feng y, cheung f, et al. hepatoprotective effect and its possible mechanism of coptidis rhizome aqueous extract on carbon tetrachloride induced chronic liver hepatotoxicity in rats. j ethnopharmacol. 2011;138(3):683–90 5. kamel hh, azza h, walaa msa, mohamed ah. protective effect of some antioxidants against ccl4-induced toxicity in liver cells from brl3a cell line. journal of american science. 2010;6(10):992−1003. 6. murray rk, bender da, botham km, kenelly pj, rodwell vw, weil pa. harper’s illustrated biochemistry. 28th ed. new york: mcgraw-hill medical; 2009. 7. baskar r, rajeswari v, kumar ts. in vitro antioxidant studies in leaves of annona species. indian j exp biol. 2007;45(5):480−5. 8. lestari cr, sumarawati t, nasihun t. the effect of cmce propolis extract administration on interleukin–1(il-1) levels and the hepatocyte histopathological findings of rats induced with ccl4. sains medika. 2020;11(1):7–13 9. maulina m. pengaruh pemberian xanthone terhadap gambaran nekrosis sel hepar tikus putih (rattus norvegicus) jantan yang diinduksi karbon tetraklorida (ccl4). sel. 2015;2(1):10–21 10. krismayogi ga, ratnayanti igad, linawati nm, wiryawan igns, sugiritama iw, wahyuniari iai, et al. purple cabbage extract cream effect on erythema score of male wistar rats back skin exposed to uv-b radiation. biomedical and pharmacological journal 2018:11(1):343–51 11. world health organization, international programme on chemical safety. carbon tetrachloride: health and safety guide. geneva: world health organization; 1998. 12. crawford jm. cellular adaptation, cell injury, and cell death. in: kumar v, abbas ak, fausto n, editors. robbins and cotran pathologic basis ofdisease. 7th ed. philadelphia: saunders; 2004. p. 3−46. 13. adewole s, caxton-martins e. morphological changes and hypoglycemic effects of annona muricata linn. (annonaceae) leaf aqueous extract on pancreatic β-cells of streptozotocintreated diabetic rats. afr j biomed res. 2006;9:173−87. 14. desousa ov, vieira gd, de pinho jdrg, yamamoto ch, alves ms. antinociceptive and anti-inflammatory activities of the ethanol extract of annona muricata l. leaves in animal models. int j mol sci. 2010;11(5):2067−78. 15. kuswinarti k, savira k, rudiman r. the analgesic effect of ethanol extract soursop (annona muricata l.) leaves in wistar rats. althea medical journal. 2018;5(4):196–200 16. fang xp, rieser mj, gu zm, zhao gx, mclaughlin jl. annonaceous acetogenins: an updated review. phytochemical analysis. 1993;4(1):27−48. 17. shi j, aisaki k, ikawa y, wake k. evidence of hepatocyte apoptosis in rat liver after the administration of carbon tetrachloride. am j pathol. 1998;153(2):515−25. 18. arthur fkn, woode e, terlabi eo, larbie c. evaluation of hepatoprotective effect of aqueous extract of annona muricata (linn.) leaf against carbon tetrachloride and acetaminophen-induced liver damage. j nat pharm. 2012;3(1):25−30. 19. cone m. low doses of hormonelike chemicals may have big effects: scientists seek ‘fundamental changes’ in testing and regulation of chemicals that mimic human hormone. environmental health news; 2012 [cited 2020 december 10]; available from: https://www.scientificamerican. com/article/low-doses-hormone-likechemicals-may-have-big-effects/. 20. the society of toxicology. animals in research: the importance of animals in the science of toxicology. reston: the society of toxicology; 2006 [cited 2020 december 10]; available at: https://www.toxicology. org/pubs/docs/air/air_final.pdf. kuswinarti et al.: effect of annona muricata l. leaf ethanol extract in ccl4 hepatitis rat model amj vol 8 no 1 march 2021 final.indd althea medical journal. 2021;8(1) 35 diastolic blood pressure as a predictor of mortality in intracerebral hemorrhage stroke patients with hypertension cep juli,1 uni gamayani,1 nur atik2 1department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: cep juli, department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur 38, bandung, indonesia, e-mail: cepjuli42@gmail.com introduction stroke is a common cerebrovascular disease in which intracerebral hemorrhage (ich) constitutes 10% to 15% of all strokes. the global incidence of ich range is from 10 to 20 cases per 100,000 population.1–4 riset kesehatan dasar (riskesdas) 2018 in indonesia has shown the stroke prevalence is 10.9/mil.5 stroke is the leading cause of death in the neurology, and most of the strokerelated death is due to ich. the mortality rate of ich stroke is found to be higher in lowand middle-income countries, and the majority of stroke-related deaths that occurred in this area are younger than 60 years old. in hospitalbased studies, the 30-day mortality ranges between 30% and 40%.6 chronic hypertension is reported to be a major risk factor for ich stroke. this chronic hypertension is found in 78–88% of patients with ich stroke.1–4 according to the joint national committee (jnc) vii, the risk of a stroke starts when blood pressure is reaching 115/75 mmhg and will double for every 20mmhg systolic and 10 mmhg diastolic pressure increase. systolic and diastolic blood pressures play a role in the occurrence of stroke. however, several studies suggested that starting from the age of 50 years old, diastolic blood pressure tends to decrease; thus, systolic blood pressure has a profound influence on the occurrence of stroke.7 an important mechanism involving hypertension as the risk for ich stroke is the rupture of penetrating arteries triggered by chronic hypertension and an acute increase in normal arterial and capillary blood pressure. chronic hypertension can result in changes in arterioles, which include fibrinoid necrosis, amj. 2021;8(1):35–42 abstract background: intracerebral hemorrhage (ich) stroke contributes to a considerable number of deaths, ranging between 30% and 40% of the overall stroke mortality. the incidence of stroke increases with higher blood pressure. high blood pressure at the onset of ich stroke is a strong predictor for mortality and morbidity. this study aimed to explore the role of diastolic blood pressure as a predictor of death in ich stroke patients. methods: data on 113 ich stroke patients with chronic hypertension were collected from the medical records of patients treated in the neurology ward of dr. hasan sadikin general hospital bandung, indonesia, in 2019. data collected were patient characteristics, hypertension status, systolic and diastolic blood pressures, and patient outcome. analysis was then performed using the mann-whitney test. results: this study revealed a positive correlation (p=0.031) between diastolic blood pressure and death in ich stroke patients with chronic hypertension. conclusions: high diastolic blood pressure is associated with mortality in ich stroke patients with chronic hypertension. keywords: diastolic, intracerebral hemorrhage, predictor, stroke, systolic https://doi.org/10.15850/amj.v8n1.2099 althea medical journal. 2021;8(1) 36 althea medical journal march 2021 lipohyalinosis, medial degeneration, and microaneurysm formation.8 decreased level of consciousness is the most important prognostic sign among patients suffering from ich strokes. patients with a decrease in consciousness show a poor prognosis. all ich stroke patients with a very severe decrease of consciousness died in the acute phase. other factors that lead to poor prognosis in the acute phase of the ich stroke are age, a poor score of ‘national institute of stroke scale’ (nihss), location of the ruptured blood vessel, high hematoma volume (>30 cc), high leukocyte count and random blood sugar (rbs) score, midline shift, hematoma expansion, secondary subarachnoid hemorrhage (sah), hydrocephalus, and high blood pressure at the onset.3,6–9 high blood pressure at the onset of the ich stroke is one of the predictors of high mortality and morbidity. uncontrolled blood pressure in patients with ich stroke leads to a poor prognosis in the form of a recurrent stroke or death. a sustained increase in blood pressure can cause the patient to have an enlarged hematoma.3 previous studies have explored the role of systolic blood pressure and mean arterial pressure (map) score and their relationship with mortality in stroke patients with hypertension as the risk factor. our study specifically sought to understand the role of diastolic blood pressure as a predictor of mortality in ich stroke patients with hypertension as the risk factor. methods this was a cross-sectional analytic observational study using retrospective secondary data from medical records of patients treated at the neurology ward dr. hasan sadikin general hospital, bandung, indonesia. those patients were diagnosed as having ich stroke with hypertension as the risk factor, and data were collected throughout the year 2019. the inclusion criteria of those patients were ich stroke patients with head ct scan images but without contrast, presenting a hemorrhage that matched the type of hemorrhage caused by hypertension. patients with signs of infection at presentation, diabetes mellitus (dm), and primary subarachnoid hemorrhage were excluded. each patient record was coded anonymously to ensure confidentiality during statistical analysis. the protocol study was approved by the research ethics committee of universitas padjadjaran. data were analyzed statistically by first testing the numerical data normality using the shapiro-wilk test. to compare the means of the numerical data that were normally distributed, the unpaired t-test was used. meanwhile, the mann-whitney test was used for data that were not normally distributed. the categorical data were tested using the chi-square test with the kolmogorov-smirnov and exact-fisher tests used as the alternative tests when the requirements of the chi-square test could not be met. the p-value ≤0.05 was considered significant. results total data from 113 ich stroke patients were collected. the majority of the patients were male (51.3%) and <60 years of age (64.6%). the mean systolic blood pressure was 179.6±21.5 mmhg and diastolic pressure was 101.1±10.9 mmhg. the mean arterial pressure (map) of the subjects was 127.0±12.7 mmhg. the predominant symptom of intracranial high pressure observed was a decrease in consciousness or somnolence in 70 (61.9%) patients. the average leukocyte count was 11,676.5±3,623.8 and the average random blood sugar level was 127.8±35.8. most of the ich strokes were located in basal ganglia and internal capsule (40.7%) with secondary sah presentation (39.8%), the midline shift(9.7%) and hydrocephalus (11.5%) (table 1). the outcome of patients with intracerebral hemorrhage stroke based on age and gender were compared, resulting in no statistical difference between patients’ outcome and age or gender as shown in table 2. the outcome of patients with intracerebral hemorrhage stroke was compared based on various blood examinations, showing that the mean of leucocyte was higher in patients who died compared to those who were alive. interestingly, the blood glucose was tended to higher in patients who had died, although the difference was not statistically significant. the patient outcome was further compared based on increased intracranial pressure symptoms, including the level of consciousness which were decreased consciousness (somnolence), decreased consciousness (soporous), headache, vomiting, and seizure. the results showed that decreased consciousness (soporous) was a statistically significant difference between patient outcomes. patients who had died were more soporous. blood pressure parameters observed, including systolic, diastolic, and mean arterial althea medical journal. 2021;8(1) 37cep juli et al.: diastolic blood pressure as a predictor of mortality in intracerebral hemorrhage stroke patients with hypertension table 1 characteristic of patients with intracerebral hemorrhage stroke at dr. hasan sadikin general hospital year 2019 characteristic n (%) gender male 58 (51.3) female 55 (48.7) age category <60 years old 73 (64.6) > 60 years 40 (35.4) systolic blood pressure mean±std 179.6±21.5 median 180.0 range (min-max) 120.0–240.0 diastolic blood pressure mean±std 101.1±10.9 median 100 range (min-max) 80–150 mean arterial pressure mean±std 127.0±12.7 median 126.7 range (min-max) 93.3–170 leukocyte count mean±std 11,676.5±3,623.8 median 11,440 range (min-max) 4,650–26,530 random blood sugar level mean±std 127.8±35.8 median 120.0 range (min-max) 81.0–338.0 symptoms of high intracranial pressure somnolence 70 (61.9) soporous 18 (15.9) headache 48 (42.5) vomiting 43 (38.1) seizure 4 (3.5) nihss score mean±std 11.5±4.9 median 11 range (min-max) 3–25 radiology results location of hemorrhage basal ganglia/internal capsule 46 (40.7) thalamus 30 (26.5) pons 9 (8.0) cerebellum 6 (5.3) lobar 14 (21.2) important radiological features secondary sah 45 (39.8) midline shift 11 (9.7) hydrocephalus 13 (11.5) note: nihss=national institute of stroke scale; sah= subarachnoid hemorrhage; std= standard deviation. categorical data were presented in number/frequency and percentage; numerical data was presented in mean, median, standard deviation, and range. althea medical journal. 2021;8(1) 38 althea medical journal march 2021 pressure were all statistically higher in patients who had died as shown in table 5. the ct head scan features based on the location, including basal ganglia/internal capsule, thalamus, pons, cerebellum, lobar, presence of secondary sah, midline shift, and hydrocephalus were compared between patients who survived and patients who died. results showed that the location in secondary sah, midline shift, and hydrocephalus more occurred in the patients who died. table 2 outcome of patients with intracerebral hemorrhage stroke based on age and gender variable patient outcome p-valuealive (n=90) dead (n=23) n (%) n (%) age category <60 year >60 year 62 (68.9) 28 (31.1) 11 (47.8) 12 (52.2) 0.059 gender male female 43 (47.8) 47 (52.2) 15 (65.2) 8 (34.8) 0.135 table 3 outcome of patients with intracerebral hemorrhage stroke based on blood examination and nihss score variable patient outcome p-valuealive (n=90) n (%) dead (n=23) n (%) leukocyte count(/mm3) mean±std median range (min-max) 11,060.1±3,167.5 10,795 4,650–26,530 14,088.7±4,315.9 14,320 7,330–26,000 0.0001 * leukocyte category <10000/mm3 > 0000/mm3 34 (37.8) 56 (62.2) 4 (17.4) 19 (82.6) 0.065 random blood sugar level (mg/dl) mean±std median range (min-max) 123.0±27.2 120 81–240 146.6±55.4 132 92–338 0.091 random blood sugar category <140 mg/dl >140 mg/dl 76 (84.4) 14 (15.6) 12 (52.2) 11 (47.8) 0.001 * nihss score mean ± std median range (min-max) 10.4±4.5 10 3–20 15.5±4.1 15 10–25 0.0001 * nihss category mild moderate severe 11 (12.2) 58 (64.4) 21 (23.3) 0 (0.0) 11 (47.8) 12 (52.2) 0.012 * note: nihss= national institute of stroke scale; std standard deviation; *p <0.05. althea medical journal. 2021;8(1) 39cep juli et al.: diastolic blood pressure as a predictor of mortality in intracerebral hemorrhage stroke patients with hypertension discussions this study has found several predictors of death in patients with ich stroke; i.e. decreased consciousness, poor nihss score, leukocytosis, high random blood sugar level, secondary sah, midline shift, hydrocephalus, systolic blood pressure, map, and diastolic blood pressure. decreased level of consciousness is the most important sign of poor prognosis in patients with ich stroke. decreased consciousness in patients with ich stroke is caused by the effect of mass and increased intracranial pressure or table 4 comparison of various increased intracranial pressure symptoms and outcome of patients with intracerebral hemorrhage stroke variable patient outcome p-valuealive (n=90) n (%) dead (n=23) n (%) somnolence** yes no 59 (65.6) 31 (34.4) 11 (47.8) 12 (52.2) 0.118 soporous** yes no 7 (7.8) 83 (92.2) 11 (47.8) 12 (52.2) 0.0001* headache yes no 41 (45.6) 49 (54.4) 7 (30.4) 16 (69.6) 0.190 vomiting yes no 32 (35.6) 58 (64.4) 11 (47.8) 12 (52.2) 0.279 seizure yes no 3 (3.3) 87 (96.7) 1 (4.3) 22 (95.7) 1.000 note: *= p <0.05; **decreased consciousness table 5 comparison of blood pressure and outcome of patients with intracerebral hemorrhage stroke variable patient outcome p-valuealive (n=90) dead (n=23) systolic blood pressure mean±std median range (min-max) 176.7±19.3 180 120–220 190.9±26.3 190 140–240 0.018 * diastolic blood pressure mean±std median range (min-max) 100.2±10 7 100 80–150 104.4±11.2 100 80–120 0.031 * map mean±std median range (min-max) 125.4±11.9 126.7 93–170 133.2±14.3 133.3 100–160 0.004 * note: map mean arterial pressure; * p<0.05; std standard deviation althea medical journal. 2021;8(1) 40 althea medical journal march 2021 table 6 comparison of ct-head scan feature based on location and the outcome of patients with intracerebral hemorrhage stroke variable patient outcome p-valuealive (n=90) n (%) dead (n=23) n (%) basal ganglia/internal capsule yes no 38 (42.2) 52 (57.8) 8 (34.8) 15 (65.2) 0.517 thalamus yes no 22 (24.4) 68 (75.6) 8 (34.8) 15 (65.2) 0.316 pons yes no 6 (6.7) 84 (93.3) 3 (13.0) 20 (87.0) 0.313 cerebellum yes no 5 (5.6) 85 (94.4) 1 (4.3) 22 (95.7) 1.000 lobar yes no 10 (22.2) 70 (77.8) 4 (17.4) 19 (82.6) 0.613 secondary sah yes no 28 (31.1) 62 (68.9) 17 (73.9) 6 (26.1) 0.0001 * midline shift <0.5 cm > 0.5 cm no 9 (10.0) 5 (5.6) 76 (84.4) 2 (8.7) 12 (52.2) 9 (39.1) 0.0001 * hydrocephalus yes no 2 (2.2) 88 (97.8) 11 (47.8) 12 (52.2) 0.0001 * note: sah= subarachnoid hemorrhage, *= p<0.05 direct involvement of the reticular activation system of the brainstem.8 nihss is a stroke-specific quantitative scale that examines levels of consciousness, language function, neglect, visual field, eye movement, facial symmetry, motor strength, sensory, and coordination. nihss has been originally designed as a research tool to measure basic data in clinical trials on acute stroke patients. this scale is widely used as a clinical assessment tool to evaluate stroke patients, determine appropriate treatment, and can be considered to have a better predictive factor for neurological outputs in ich stroke compared to the glasgow coma scale (gcs) only. nihss correlates with the objective measure of stroke severity. increasing nihss score reflects an unfavorable ich stroke output. poor nihss score is associated with hematoma volume at the onset of the ich stroke.10 a high leukocyte count at onset is one of the predictors of death in patients with ich stroke. several reports have shown that in patients with ich stroke, a correlation is found between increased leukocyte count at onset and initial neurological deterioration that will then lead to poor outcomes. early leukocytosis is significantly associated with early neurological deterioration and mortality. leukocytosis in ich stroke patients is caused by increased catecholamine release and corticosteroid production that positively correlates with the hemorrhage volume.11 the random blood sugar level is associated with a high risk of mortality among ich stroke patients. studies have shown that patients with elevated random blood sugar levels have althea medical journal. 2021;8(1) 41cep juli et al.: diastolic blood pressure as a predictor of mortality in intracerebral hemorrhage stroke patients with hypertension a higher incidence of brain complications and more extensive hemorrhage, recurrent hemorrhage, blood barrier destruction leading to brain edema exacerbation, neuronal apoptosis, and poor functional outcomes. a study showed that elevated random blood sugar level in patients with ich stroke was an independent predictor of mortality in non-diabetic patients. hyperglycemia in acute neurological injuries is associated with catecholamine surge and immune stress response. the elevated random blood sugar level reflects the severity of the stroke as a stress reaction to a serious brain injury.12 secondary sah, midline shift, and hydrocephalus are the next predictors of death in this study. patients with ich stroke are often deteriorating during the first 24–48 hours after onset. this deterioration can be explained by the ongoing hemorrhage but it is most frequently associated with the development of edema around the lesion, the effect of lesion on the blood flow, metabolism in the brain, brain tissue shift, and herniation. mass-induced effects in patients with hematomas are more common than in patients with ischemia due to the volume of additional substances that add to the edema. mostly, the effect of the hematoma pressure on the hemisphere results in the midline shift without herniation of the brain. when the effect of mass is severe, the brain tissue swells or protrudes into a different compartment, which is referred to as the process of herniation. a shift in the brain tissue can also cause compression or expansion of blood vessels and infarction of the area that receives blood supply from the artery and secondary hemorrhage. blood can also enter the ventricular space, which will substantially increase the mortality risk. the ventricular system can also be compressed in various places. hematomas in the putamen or cerebral lobes can damage the monro foramen, causing dilatation of the contralateral lateral ventricles. the thalamus hematoma often blocks and compresses the third ventricle, causing hydrocephalus of both lateral ventricles. cerebral hemorrhage can compress the iv ventricles or cerebral aqueduct, causing obstructive hydrocephalus from the third and lateral ventricles. brain tissue shift, herniation, secondary infarction, blood entering the ventricles, and hydrocephalus lead to the worsening of the ich stroke clinical signs and symptoms.8 hypertension is the most important risk factor for ich stroke. a meta-analysis on 68 blood pressure reduction trials showed that a reduction of 10 mmhg of the systolic blood pressure and 5 mmhg of diastolic blood pressure is associated with a reduction in the incidence of stroke by 36% and a reduction in the mortality caused by cardiovascular disease by 16%.13 in many cases, patients with ich stroke are assigned in the hypertensive crisis criteria. in a hypertensive crisis, the systolic blood pressure reaches 180 mmhg and the diastolic pressure becomes very high, up to 120 mmhg.14,15 the role of systolic and diastolic blood pressures in ich stroke cannot be ignored because each of them independently affects the blood vessels.16 a previous study has reported that high diastolic blood pressure damages the endothelium of the intracerebral arteries, causing rupture of the blood vessels.17 ich stroke occurs spontaneously when a weak blood vessel in the brain ruptures and increases the intracranial pressure, causing damage to brain cells around the hematoma. high blood pressure is associated with hematoma growth expansion that results in poorer functional outcomes and increased mortality risk. onethird of patients with ich stroke rapidly develop hematoma during the first few hours of the stroke. the leaking blood also displaces and compresses the surrounding tissue.18 the limitation of this study is that this study has been conducted in a single center hospital, therefore, a larger multicenter study is recommended to further validate the result. another limitation is that no data available on the blood volume of the hemorrhage image from the head ct scanasthis might be important predictors of death in ich stroke. in conclusion, diastolic blood pressure can be used as a predictor of death in ich stroke patients with hypertension as the risk factor. references 1. zaidi g, 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elserafy s, mahmoud w. the nihss score can predict the outcome of patients with primary intracerebral hemorrhage. egypt j neurol psychiatr neurosurg. 2019;55(1):21 11. behrouz r, hafeez s, miller cm. admission leukocytosis in intracerebral hemorrhage: associated factors and prognostic implications. neurocrit care. 2015;23(3): 370–3 12. kongwad li, hegde a, menon g, nair r. influence of admission blood glucose in predicting outcome in patients with spontaneous intracerebral hematoma. front neurol. 2018; 9: 725 13. flint ac, conell c, ren x, banki nm, chan sl, rao va, et al. effect of systolic and diastolic blood pressure on cardiovascular outcomes. n engl j med. 2019;381(3): 243–51 14. marik pe, varon j. hypertensive crises: challenges and management. chest. 2007;131(6):1949–62 15. rodriguez ma, kumar sk, de caro m. hypertensive crisis. cardiol rev. 2010;18(2):102–7 16. seitz rj, donnan ga. recovery potential after acute stroke. front neurol. 2015; 6: 238 17. vishram jkk, borglykke a, andreasen ah, jeppesen j, ibsen h, jørgensen t, et al. impact of age on the importance of systolic and diastolic blood pressures for stroke risk: the monica, risk, genetics, archiving, and monograph (morgam) project. hypertension. 2012;60(5):1117–23. 18. parmar p. stroke: classification and diagnosis. clinical pharmacist. 2018; 10(1):doi:10.1211/pj.2018.20204150 amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 100 prevalence of opportunistic infection in central nervous system among patients with hiv/aids at dr. hasan sadikin general hospital bandung, indonesia dinda sayyidah laela fatimatuzzahra,1 ahmad rizal ganiem,2 aih cahyani,2 suryani gunadharma,2 sofiati dian2 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: dinda sayyidah laela fatimatuzzahra, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, e-mail: dinda17010@mail.unpad.ac.id introduction human immunodeficiency virus (hiv) and acquired immunodeficiency syndrome (aids) is a major global public health issues, including in indonesia.1 in 2018, it was estimated around 640,000 people were infected with hiv, but only 51% (327,000) people knew their infection status, and only 17% (108,000) people received antiretroviral therapy (arv) in indonesia.2 delayed diagnosis due to uninformed and limited medical services and also low coverage of arv have caused many patients to visit the hospital at the late stage of the disease with very low cd4+ cells, and are frequently hospitalized for opportunistic infections.3 opportunistic infections are infections of microorganisms that in normal conditions are not virulent enough to cause clinical disease. however, in the immunocompromised host, these microorganisms can cause clinical disease.4 opportunistic infections can occur in various organs of the system, including althea medical journal. 2022;9(2):100–105 abstract background: the low coverage of diagnosis and treatment in patients with human immunodeficiency virus (hiv) infection in indonesia increases the risk of opportunistic infections that affects various organs, including the central nervous system (cns). this study aimed to determine the prevalence of opportunistic infections in the cns among hospitalized patients with hiv/acquired immune deficiency syndrome (aids) at dr. hasan sadikin general hospital bandung, indonesia. methods: in this cross-sectional study with a total sampling method, data were collected from hiv/ aids patients who were diagnosed with cns opportunistic infection and hospitalized in the neurology ward during the period 2015–2019. data were presented as median (interquartile range) and percentage frequency. results: among the 2,606 hiv/aids patients registered, 219 (8.4%) were accompanied by cns opportunistic infections. the highest number was cerebral toxoplasmosis (58.9%;n=129) followed by tuberculous meningitis (33.3%; n=73) and cryptococcal meningitis (7.8%; n=17). most of the patients admitted for unconsciousness (64.4%;n=141), with unknown hiv-infection status (61.2%;n=134). among patients with positive hiv-infection status, only 50.6% (43/85) patients were taking antiretroviral therapy (art) and 24.7% (21/85) patients dropped out art before being diagnosed with cns opportunistic infections. the cd4+’s median value was 21 cells/mm3 (iqr 9-61.25), with mortality during hospitalization was 36.5% (80/219). conclusions: the prevalence of cns opportunistic infections among hiv-infected patients is 8.4%, dominated by cerebral toxoplasmosis, and laboratory result showed very low cd4+ levels. the diagnosis of hiv infection is shortly made before hospitalization, and those who has been diagnosed have low compliance with art. the mortality rate during hospitalization is high. keywords: aids, cns opportunistic infections, prevalence https://doi.org/10.15850/amj.v9n2.2298 althea medical journal. 2022;9(2) 101 the central nervous system (cns). cns opportunistic infections include tuberculous meningitis, cryptococcal meningitis, cerebral toxoplasmosis, cytomegalovirus (cmv) encephalitis, and progressive multifocal leukoencephalopathy (pml).5 these diseases can cause tissue damage and leads to death, so it is important to make a correct and fast diagnosis in the order to get appropriate management that will improve patient outcome.6 there are limited data regarding the prevalence of cns opportunistic infections in hiv/aids patients in west java. therefore, a study at dr. hasan sadikin general hospital bandung, the main referral hospital in west java, is important to conduct. the aim of this study was to determine the prevalence of cns opportunistic infections in hiv/aids patients at dr. hasan sadikin general hospital, bandung. this study is expected to represent data from west java entirely, moreover will be useful in indonesia, as west java is the largest populated province in indonesia.7 furthermore, the results of this study can become an insight for health workers related to the burden of diseases and increasing early detection so that complications can be prevented and improve patient outcomes. methods this study was a descriptive retrospective with a cross-sectional study design using secondary data. the subjects of this study were hiv/aids positive patients who were hospitalized at the department of neurology dr. hasan sadikin bandung from 2015 to 2019. inclusion criteria were patients diagnosed with cns opportunistic infections related to hiv/aids. missing data were excluded. data collected from august to november 2020. this study was approved by the research ethics committee universitas padjadjaran number: 735/un6.kep/ec/2020. data were collected and categorized based on research variables, including diagnosis of cns opportunistic infections such as tuberculous meningitis, cryptococcal meningitis, cerebral toxoplasmosis, cytomegalovirus (cmv) encephalitis, and progressive multifocal leukoencephalopathy (pml). other variables were gender, age, chief complaint, the hiv status before current hospitalization. those who knew their hiv status were checked for the duration of hiv/aids, and the status of using arv. the blood count data, hemoglobin, leukocytes, differential count, platelets, as well as the cd4+ count were taken from the medical record. the hospitalization outcome was also noted. data were analyzed with descriptive statistics using the ibm spss version 25. data were analyzed with a normality test and continued with a number (n), proportion (%), median and interquartile range (iqr). results during 2015–2019, there were 2,606 hiv/ aids patients hospitalized at dr. hasan sadikin bandung, 242 of whom had cns opportunistic infections, including 23 relapse cases that were excluded. the prevalence of cns opportunistic infections was 8.4% (219/2,606). there were 199/209 patients (95.2%) who had one opportunistic infection and 10/209 patients (4.8%) who had two opportunistic infections. patients who had two opportunistic infections consisting of cerebral toxoplasmosis and tuberculous meningitis (9/10; 90%) and then tuberculous meningitis and cryptococcal meningitis (1/10; 10%) as shown in table 1. the cns opportunistic infections recorded in 219 cases, consisted of cerebral toxoplasmosis in 129 cases (58.9%), tuberculous meningitis in 73 cases (33.3%), and cryptococcal meningitis in 17 cases (7.8%). there were no records of patients hospitalized with other opportunistic infections (table 2). the median age of the patients was 33 years (iqr 26–39) and mostly male, 160/219 (73%). patients presented with decreased consciousness (64.4%), headache (17.4%), seizures (8.2%), weakness of the limb (7.3%), speech disturbances (1.4%), and behavioral change (0.4%) as a chief complaints. only 85 patients (38.8%) had known their hiv infection status before arrival, with a median duration of hiv infection being 5 months (iqr 2–36). among the 85 patients, there were 43 patients (50.6%) currently using arv, 21 patients (24.7%) had never used arv and 21 patients (24.7%) had dropped out from arv. of the 21 patients who dropped out from arv, 19 patients (90.5%) stopped due to their compliance, and 2 patients (0.5%) due to side effects such as nausea, vomit, and skin hyperpigmentation. the cd4+ examination was performed in 134 patients (61%) and median was 21 cells/mm3 (iqr 9–61.25). routine blood tests were performed in all patients, but differential count data was only available in 56 patients (26%). from these tests, hemoglobin median was 11.6 g/dl (iqr 9.88–13.3), leukocytes 7060 cells/mm3 (iqr dinda sayyidah laela fatimatuzzahra et al.: prevalence of opportunistic infection in central nervous system among patients with hiv/aids at dr. hasan sadikin general hospital bandung, indonesia althea medical journal. 2022;9(2) 102 4700–9785), platelets 242 thousand cells/mm3 (iqr 173–309). differential count examination showed median for basophils and band neutrophils were 0% (iqr 0–0), eosinophils were 0% (iqr 0–1), segment neutrophils were 79% (iqr 70–89), lymphocytes were 10% (iqr 5.25–16), and monocytes were 6% (iqr 4–8.75). during hospitalization, 139 patients survived (63.5%) including 21 discharged patients based on their request and 80 patients (36.5%) died. patients with the highest mortality rate were tuberculosis meningitis (48%), followed by cryptococcal meningitis (41.2%) and cerebral toxoplasmosis (27.1%). patient characteristics for each diagnosis including gender, age, chief complaint, hiv status, routine blood count, and mortality during hospitalization can be seen in table 3. discussions in this study, it was found that the prevalence of cns opportunistic infections in hiv/aids patients hospitalized at dr. hasan sadikin general hospital was 8.4%. this number was similar to the study conducted at cipto mangunkusumo hospital, which was 9%.8 the most common cns opportunistic infections were cerebral toxoplasmosis (58.9%) followed by tuberculous meningitis (33.3%) and cryptococcal meningitis (7.8%). there was no patient with other cns opportunistic infections. the distribution of these diagnoses among cns opportunistic infections is consistent with the same as similar studies in the same place (dr. hasan sadikin general hospital) at different periods (2007–2012) or in several other places.9–11 patients with cns opportunistic infections in this study were predominantly male (73%). this may be related to the prevalence of hiv/ aids patients in indonesia. in general, male patients of hiv/aids are higher than female (>60%).12 cns opportunistic infections mostly occurred in the early adult, with a median of 33 years (iqr 26-39). opportunistic infections usually occur when the patient had entered the aids phase, which is 7–10 years from the first exposure to hiv, so it could be estimated that many risk factor behaviors of hiv are done by the young generation in indonesia.13 this age range was a productive age group, so it can become a serious problem of psychological, social, and economic besides their physical problems.14 many patients did not know their hiv infection status before being hospitalized due to cns opportunistic infections. one of the reasons was that hiv infection was table 1 distribution of opportunistic infection in the central nervous system among patients hospitalized (n=2,606) in dr. hasan sadikin bandung during 2015–2019 number of cns opportunistic infection diagnoses number of patients (n) proportion n/n=x (%) one opportunistic infection 199 95.2 two opportunistic infections 10 4.8 total 209 100 table 2 prevalence of opportunistic infection in the central nervous system among hiv/aids patients hospitalized (n=2,606) in dr. hasan sadikin bandung during 2015–2019 diagnosis number of confirmed diagnoses (n) prevalence n/n=x(%) cerebral toxoplasmosis 129 58.9 tuberculous meningitis 73 33.3 cryptococcal meningitis 17 7.8 pml cmv encephalitis total 219 100 note: pml = progressive multifocal leukoencephalopathy, cmv= cytomegalovirus althea medical journal june 2022 althea medical journal. 2022;9(2) 103dinda sayyidah laela fatimatuzzahra et al.: prevalence of opportunistic infection in central nervous system among patients with hiv/aids at dr. hasan sadikin general hospital bandung, indonesia asymptomatic or only mild non-specific at the initial phase, patients did not realize it until the infection became aids, which was characterized by the presence of certain opportunistic diseases.13 this caused high patients to come with a chief complaint related to their opportunistic infection. among the patients who already knew their infection status, the incidence of arv drop-out was still high and could be related to the high incidence of cns opportunistic infections. a study showed factors associated with arv drop-out, including lower cd4+ cell counts and lack of support from family or friends.15 in indonesia, there is still discrimination against hiv patients and very low coverage of the hiv treatment cascade.2,14 these conditions may be related to the death number caused by aids in indonesia is still the highest compared to other countries in southeast asia.2 the most common chief complaint in this study was decreased consciousness, followed by headache, seizures, and weakness of the limbs. these complaints are very specific complaints about cns disorders. other studies showed the clinical manifestations of cns infection were the same, including headache, decreased consciousness, seizures, limb weakness, fever, nausea, and chronic cough.10 however, in this study, symptoms such as fever and nausea, were not become chief complaints because of mild and nonspecific symptoms. hiv-infected patients become aids when the cd4+ cell count is ≤200 cells/mm3.16 this table 3 characteristics of hiv / aids patients with opportunistic infections in central nervous system, hospitalized in dr. hasan sadikin general hospital bandung during 2015–2019 characteristic ct (n=129) n (%) tm (n=73) n (%) cm (17) n (%) male; n (%) 97 (75.2) 50 (68.5) 13 (76.5) age in year – median (iqr) 33 (26-39) 33 (26-39) 31 (28-38) knowing the status of hiv before current hospitalization 49 (38) 25 (34.2) 11 (64.7) duration of hiv/aids diagnosed in months – median (iqr) 4 (2-48) 4 (2-12) 6 (1-36) usage of arv; n(%) ongoing drop-out never 27 (55.1) 9 (18.4) 13 (26.5) 13 (52) 7 (28) 5 (20) 3 (27.3) 5 (45.4) 3 (27.3) chief complain; n(%) decreased consciousness headache seizure limb weakness speech disturbances behavioral change others 75 (58.1) 20 (15.5) 17 (13.2) 13 (10.1) 2 (1.6) 2 (1.6) 60 (82.3) 7 (9.6) 1 (1.4) 3 (4.1) 1 (1.4) 1(1.4) 6 (35.3) 11 (64.7) laboratory examination hemoglobin in g/dl – median (iqr) leucocytes in cells/mm3– median (iqr) differential counts in % –median (iqr)* basophil eosinophil neutrophil band neutrophil segment lymphocyte monocyte platelets in 103 cells/mm3 –median (iqr) cd4+ in cells/mm3 – median (iqr)** mortality during hospitalization; n(%) 12.2 (10.25-13.55) 7000 (4715-9395) 0 (0-0) 0 (0-1) 0 (0-0,5) 78 (70-87) 12 (7-15.5) 6 (4-9.5) 248 (178-308.5) 20.5 (9.75-51.5) 35 (27.1) 10.8 (9.1-12.9) 7110 (4625-10622.5) 0 (0-0) 0 (0-0) 0 (0-0) 86 (71,5-90.5) 10 (4.25-18.25) 5,5 (3-6.75) 237 (170-320.5) 29 (6.5-83.5) 38 (52) 12.4 (10.62-13.28) 7100 (3850-9395) 0 (0-0) 0 (0-6) 0 (0-1) 88 (62-91) 6 (5-16) 6 (4-12) 234 (119-296.5) 16.5 (4-146) 7 (41.2) note: ct= cerebral toxoplasmosis, tm= tuberculous meningitis, cm= cryptococcal meningitis, *differential counts examination was only available in 33 ct patients, 16 tm patients and 7 cm patients, **cd4+ counts was only available in 90 ct patients, 36 tm patients and 8 cm patients althea medical journal. 2022;9(2) 104 study showed cd4+ median value was 21 cells/ mm3 and 95.5% of cases had cd4+ ≤200 cells/ mm3. the highest median cd4+ was found in tuberculous meningitis, followed by cerebral toxoplasmosis and cryptococcal meningitis. these findings were the same as the theory that cd4+ is usually lower in cryptococcal meningitis patients compared to tuberculous meningitis and cerebral toxoplasmosis.17 hiv patients often had abnormalities on blood tests, which also occurred in this study including anemia (78%), lymphopenia (44.6%), leukopenia (18.3%), and thrombocytopenia (15.1%). these results were similar to studies conducted by subhash et al. blood abnormalities in hiv patients were caused by immune cell damage, viral cytopathic effects, side effects therapy, and suppression of hematopoiesis.18 the outcome of death during hospitalization was 36.5%, mostly occurred to tuberculous meningitis (52%), followed by cryptococcal meningitis (41.2%) and cerebral toxoplasmosis (27.1%). this outcome was similar to several other studies.19,20 the limitation of this study is the incomplete data of the study. data were not available for 5 months of the study period, namely january 2015, february 2015, march 2015, september 2017, and august 2019. also, there were several incomplete variables, including cd4+ and differential count variables. future studies are needed to collect the complete data to increase the accuracy of the prevalence study. in conclusion, the prevalence of cns opportunistic infections in hiv/aids patients hospitalized at dr. hasan sadikin general hospital in 2015–2019 is 8.4% with the highest case being cerebral toxoplasmosis, which mostly occur in productive age and very low cd4+ cell levels (<100 cells/mm3). many of these patients do not know their hiv infection status when they come with complaints of cns opportunistic infections. the drop-out art rates before diagnosis of cns opportunistic infections and deaths during treatment are still high. therefore, earlier diagnosis and antiretroviral treatment are compulsory to control the disease progressivity characterized by opportunistic infections including cns opportunistic infections. references 1. pendse r, gupta s, yu d, sarkar s. hiv/aids in the south-east asia region: progress and challenges. j virus erad. 2016;2(suppl 4):1–6. 2. unaids. unaids data 2019. [cited 2020 april 19] available from: https://www. unaids.org/sites/default/files/media_ asset/2019-unaids-data_en.pdf. 3. jeong sj, italiano c, chaiwarith r, ng ot, vanar s, jiamsakul a, et al. late presentation into care of hiv disease and its associated factors in asia: results of tahod. aids res hum retroviruses. 2016;32(3):255–61. 4. riccardi n, rotulo ga, castagnola e. definition of opportunistic infections in immunocompromised children on the basis of etiologies and clinical features: a summary for practical purposes. curr pediatr rev. 2019;15(4):197–206. 5. who. indonesia communicable disease profile. geneva: who; 2006. p. 33–4. 6. bowers km, mudrakola vv. neuroinfections: presentation, diagnosis, and treatment of meningitis and encephalitis. emj neurol. 2020;8(1):93–102. 7. wulandari f, ayu sm. hubungan tingkat pengetahuan dan sikap dengan perilaku pemeriksaan sadari mahasiswi. prosiding seminar nasional ikakesmada peran tenaga kesehatan dalam pelaksanaan sdgs. yogyakarta: universitas ahmad dahlan; 2017. p.137–44. 8. afrita y. prevalensi infeksi otak komorbid pada pasien hiv/aids rawat inap di rscm tahun 2010 dan faktor-faktor yang berhubungan [minor thesis]. jakarta: universitas indonesia; 2011. 9. lestari a, dian s, chrysanti c. predictor of mortality in acquired immunodeficiency syndrome patients with central nervous system opportunistic infections. althea med j. 2016;3(4):577–82. 10. imran d, estiasari r, maharani k, sucipto, lestari dc, yunus re, et al. presentation, etiology, and outcome of brain infections in an indonesian hospital: a cohort study. neurol clin pract. 2018;8(5):379–88. 11. mawuntu ahp, imran d, jannis j, prihartono j. angka kematian pasien aids dengan infeksi oportunistik otak di rscm. neurona. 2011;28(3):767. 12. saktina pu, satriyasa bk. karakteristik penderita aids dan infeksi oportunistik di rumah sakit umum pusat sanglah denpasar periode juli 2013 sampai juni 2014. e-jurnal medika udayana. 2017;6(3):1–6. 13. kumay v, abbas ak, aster jc, editors. robbins basic pathology. 10th ed. philadelphia: elsevier; 2018. p. 174–82. 14. limalvin np, wulan sucipta putri wc, kartika sari ka. gambaran dampak althea medical journal june 2022 althea medical journal. 2022;9(2) 105 psikologis, sosial dan ekonomi pada odha di yayasan spirit paramacitta denpasar. intisari sains medis. 2020;11(1):81–91. 15. siregar ay, pitriyan p, wisaksana r. hiv patients drop out in indonesia: associated factors and potential productivity loss. acta med indones. 2016;48(3):207–16. 16. hernandez-vargas ea, middleton rh. modeling the three stages in hiv infection. j theor biol. 2013;320:33–40. 17. tan il, smith br, von geldern g, mateen fj, mcarthur jc. hiv-associated opportunistic infections of the cns. lancet neurol. 2012;11(7):605–17. 18. bhardwaj s, almaeen a, ahmed wani f, thirunavukkarasu a. hematologic derangements in hiv/aids patients and their relationship with the cd4 counts: a cross-sectional study. int j clin exp pathol. 2020;13(4):756–63. 19. efsen amw, panteleev am, grint d, podlekareva dn, vassilenko a, rakhmanova a, et al. tb meningitis in hiv-positive patients in europe and argentina: clinical dutcome and factors associated with mortality. biomed res int. 2013;2013:373601. 20. luma hn, tchaleu bcn, mapoure yn, temfack e, doualla ms, halle mp, et al. toxoplasma encephalitis in hiv/aids patients admitted to the douala general hospital between 2004 and 2009: a cross sectional study. bmc res notes. 2013;6:146. dinda sayyidah laela fatimatuzzahra et al.: prevalence of opportunistic infection in central nervous system among patients with hiv/aids at dr. hasan sadikin general hospital bandung, indonesia vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 192 amj december 2019 comparison of gastrocnemius muscle strength between basketballs and non-basketball player titing nurhayati,1 sharmili mohanan,2 marietta shanti prananta3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: titing nurhayati, department of biomedical sciences faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: dr.titing@gmail.com introduction physical activity is consisting of various forms of movements that require energy, for example, swimming, walking, jogging, football, basketball and many more. basketball is one of the best aerobic exercises,1 is one of the most preferred activities by the community nowadays.2 the most important muscle used in this game is the gastrocnemius muscle which is located in the calf region. this muscle is used for plantar flexing ankle when knee is extended. this muscle helps to maintain balance and stabilize the body during vigorous movement. this muscle has an important role for a jump shot, sprinting speed as well as getting low in a defensive stance. the gastrocnemius muscle provides momentum to an individual by bending the feet while shooting.2 to reach a better gastrocnemius muscle strength, a basketball player has to train six days in a week, 1−3 times a day and 1−2 hours per practice.3 there is no previous study about gastrocnemius muscle in a basketball player, despite this muscle is being one of the most important muscles in a basketball game. however, previous study has been conducted about the isokinetic analysis of hamstring and quadriceps femoris in turkish second division basketball players.4 according to kisner and colby (1990), strength is defined as the capability of either a single or a group of muscle, either by dynamically or statically, producing tension and resulting force in one maximal effort, based on the demands placed upon them.5 hoggan health microfet 2 manual muscle testing (mmt) handheld dynamometer has been widely used in many studies, mainly because it is portable and cost-effective. this dynamometer also precisely measures forces from different planes. it is a light-weighted amj. 2019;6(4):192–5 abstract background: basketball is one of the best aerobic-predominant exercises and the most important muscle used in this sport is the gastrocnemius muscle. this muscle plantar flexes the ankle when the knee is extended to maintain the balance and to stabilize the body during vigorous movements. furthermore, the gluteus, quadriceps, hamstrings, and calves may get activated when running up and down the court and jump in the air when doing basketball training. this study was conducted to compare the gastrocnemius muscle strength in basketball and non-basketball players. methods: this analytical study was to measure the gastrocnemius muscle strength in basketball (n=16) and non-basketball (n=16) players, using hand-held dynamometer (hhd). gender, weight, height, body mass index (bmi) and maximal gastrocnemius muscle strength were recorded and compared between groups. the study was conducted from august to october 2013 in the faculty of medicine, universitas padjadjaran. results: the maximal gastrocnemius muscle strength showed no significant differences both in basketball and non-basketball players for females and males with p-value 0.092 and 0.711, respectively. conclusions: there is no significant difference in gastrocnemius muscle strength between basketball and non-basketball players in males as well as in females. presumably, there are other muscles that take parts to develop leg power by doing the right weight-training exercises. keywords: basketball, gastrocnemius muscle, handheld dynamometer althea medical journal. 2019;6(4) 193 tool that comes in an ergonomic shape. furthermore, this tool is accredited by the medico-legal community for its precision and validity. in microfet2, it has a maximum capacity of 667 newtons (n).6 the objective of this study was to compare the gastrocnemius muscle strength between a basketball player and non-basketball player. methods the study was an analytical study using crosssectional method. the subject of this study was students in the faculty of medicine, universitas padjadjaran. thirty-two subjects were included in the study, including sixteen basketball players and sixteen non-basketball players. each group consisted of eight males and eight females. this study was conducted in october 2013. the inclusion criteria were students who were members of the basketball team of the faculty of medicine of whom trained basketball regularly for 12 months, twice per week. the non-basketball players were those who did not play basketball. the students had no medication used with known cardiac or musculoskeletal effects. the exclusion criteria were those who were having a history of lower extremity injury and history of hip, ankle and knee surgery that needed medication by the medical professions.7,8 the main goal and procedures were explained to the subjects. upon agreeing to participate, the subjects filled the informed consent form. the students were asked to lie on a flatsurfaced bed with their shoes of the dominant leg taken off. the examiner had to fix the strap of the dynamometer on his/her hand. before placing the dynamometer on the feet of the students, the dynamometer was made sure to be in the “on” mode and the reading shows 0.0 newton (n). furthermore, the footpad of the hand-held dynamometer was placed on the sole at the prominent area right below the toes horizontally. the students had to plantarflex the ankle for 6.0 seconds (s) while the examiner resisted the movement. while the students were performing the plantar flexion, the examiner gave words of encouragement such as “keep flexing and give your best force”. the procedure was performed three times on each subject. the first measurement was omitted because it was a practice trial for the subjects to get the feeling of pushing against the dynamometer. the test was then conducted twice on the same side with a rest period of 2 minutes. force values in newton (n) were recorded. obtained data were presented into tables and statistically analyses were conducted using the t-test (spss v. 15.0). the results were considered statistically significant if the p-value was less than 0.05 (p<0.05). analyses were performed by comparing the basketball and non-basketball players. results the physical characteristic of male and female basketball players in this study was shown in table 1. the p-value for both the male and female physical characteristics was more than 0.05 therefore both groups were homogenous and could be compared. the maximal gastrocnemius muscle strength table 1 physical characteristics of basketball players and non-basketball players based on gender basketball player non-basketball player p (mean±sd) (mean±sd) male weight (kg) 69.50±11.40 68.18±13.54 0.837 height(cm) 169.25±6.36 174.62±5.15 0.085 bmi 24.14±2.59 22.35±3.76 0.288 female weight (kg) 58.65±16.95 57.25±6.81 0.835 height(cm) 159.56±9.35 160.87±6.37 0.748 bmi 22.83±5.17 22.14±2.58 0.739 note: sd=standard deviation; bmi=body mass index titing nurhayati et al.: comparison of gastrocnemius muscle strength between basketballs and non-basketball player althea medical journal. 2019;6(4) 194 amj december 2019 in male and female basketball players and nonbasketball players was shown in table 2. the p-value was more than 0.05 for both males and female, thus there was no statistical difference between both groups. however, there was a trend that basketball players had higher gastrocnemicus muscle strength although it was not significantly different. discussion the result of our study shows that there is no difference between basketball players and non-basketball players for both males and females. presumably because two muscles strengthening the exercise and both of them were made up the calf i.e. the gastronemius and soleus muscles.6 furthermore, there are some factors that may contribute to this result, the tool itself which is the hand-held dynamometer, the patient’s comfort towards the tool and the training of the players. the reliability and validity of the handheld dynamometer are unquestionable with the evidence of previous studies.7 in order for the test to be reliable, the examiner must have a great mechanical advantage over the subject’s maximal muscle strength. it is noted that when the level of movement gets tougher, the handheld dynamometer becomes less reliable.7 in this study, for the plantar flexor movement, the lever arm is short. during the pilot work to measure the plantar flexion, the hand-held dynamometer appears to be difficult though there are attempts of changing the subject’s and the examiner’s position.7 apart from the limitations above, the comfort position while using the dynamometer could be considered. though the dynamometer has a pad to lay on the body part of the subject of the study, there is disparity such as the examiner’s ability. the subject may feel pain after repeated trials at the placement site because the resistance has been applied. another issue is that strong subjects may have “give in” a little when they sense they might have weighed down the examiner.7 therefore, to handle the dynamometer and to obtain a reliable and valid data, the examiner has to be trained beforehand.10 as for the basketball players, the limitations would be due to the lack of training to strengthen their gastrocnemius muscle.3 in this study, the basketball players practice twice per week and each practice lasts for 3 hours. australian institute of sports guidelines shows that a basketball player has to train, six times per week, 1−3 times per day and each practice should be held 1−2 hours.3 to increase the muscle strength, three phases should be taken into account. the first phase is the warm-up phase, which, in this phase, an individual can perform a few minutes of light walking. the second phase is the weight training phase and the third phase is the cool down phase which is similar to the first phase (warm-up phase). in an isotonic progressive-resistance program, an exercise frequency of an individual should be at least five days per week rather than two days per week to reach an increment of muscular strength.12 for an isometric program, a training session for 5 days per week shows a maximal isometric strength and as for an isokinetic program, which is the latest form of weight-training program, it shows a great enhancement of muscular performance. the isokinetic strength has been obtained after training for 4 days per week for 7 weeks; all these factors should be taken into account in further studies.12 the limitation of this study is possibly due to the lack of specific training among basketball player students to increase the strength of the gastrocnemius muscle. furthermore, no information about the type of previous training that has been done by basketball and non-basketball players. as a conclusions, there is no significant differences between the gastrocnemius muscle strength among basketball players and nonbasketball players students, as well as for the male and female in both groups. the current training program for the basketball players is insufficient to increase the maximal table 2 maximal gastrocnemius muscle strength in male and female basketball player and non-basketball player maximal gastrocnemius muscle strength basketball player non-basketball player p (mean±sd) (mean±sd) male 116.47±20.74 112.73±18.80 0.711 female 96.93±16.18 86.16±13.41 0.092 note: sd=standard deviation althea medical journal. 2019;6(4) 195 gastrocnemius muscle strength, therefore, the exercise program has to be optimized. references 1. bright p. what muscles are needed in basketball?. [cited 2013 march 13]. available from: http://www.ehow.com/ how-does_4570028_muscles-neededbasketball.html. 2. leavitt mo. 2008 physical activity guidelines for americans. washington: u.s. department of health and human services; 2008. p. 8. 3. australian sports commission. basketball. australian government. [cited 2013 november 15]. available from: https:// www.sportaus.gov.au/schools/schools/ sports/basketball. 4. findikoglu g, alemdaroglu u, koklu y, kocak fu, erol e. isokinetic analysis of hamstring and quadriceps muscles in turkish second division basketball players. ovidius university annals, series physical education and sport/science, movement and health,. 2011;11(1):5−7. 5. jones k, barker k. human movement explained: physiotherapy practice explained. 1st ed. edinburgh: butterworthheinemann; 1995. p. 197. 6. ambegaonkar, shultz sj, perrin dh, schmitz rj, ackerman ta, schulz mr. lower body stiffness and muscle activity differences between female dancers and basketball players during drop jumps. sports health. 2011; 3(1): 89–96. 7. kelln bm, mckeon po, gontkof lm, hertel j. hand-held dynamometry: reliability of lower extremity muscle testing in health, physically active, young adults. j sport rehabil. 2008;17(2):160−70. 8. holmes jr, alderink gj. isokinetic strength characteristics of the quadriceps femoris and hamstring muscles in high school students. phys ther.1984;64(6):914−8. 9. potach dh, katsavelis d, karst gm, latin rw, stergiou n. the effects of a pylometric training program on the latency time of the quadriceps femoris and gastrocnemius short-latency responses. j sports med phys fitness. 2009;49(1):35−43. 10. andrews aw, thomas mw, bohannon rw. normative values forisometric muscle force measurement obtained with hand-held dynamometers. phys ther. 1996;76(3):248−59. 11. siller g. how to improve your 1-on-1 battles with muscular strength and endurance training. pro learning systems. [cited 2013 november 17]. available from: http:// prolearning.com/hockey/strength.htm. 12. foss ml, keteyian sj. fox’s physiological basis for exercise and sports. 6th ed. michigan: william c brown pub/mcgrawhill; 1998. p. 353−5. titing nurhayati et al.: comparison of gastrocnemius muscle strength between basketballs and non-basketball player amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 155 characteristics of neonates with hyperbilirubinemia in cileunyi, west java muhammad rizki fonna,1 nia kania,2 gita tiara dewi nasution2 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: muhammad rizki fonna, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, e-mail: muhammad17349@mail.unpad.ac.id introduction hyperbilirubinemia, also known as jaundice, is a clinical condition in babies characterized by yellowish skin and sclera due to increased serum bilirubin levels.1 the majority of jaundice is generally classified as physiological, however, the rest still have a potential to become pathological with a higher risk of various complications. therefore, the incidence of jaundice needs attention.2 the prevalence of babies with hyperbilirubinemia in the united states3 is 65%, in nigeria4 33%, and in malaysia5 75%. in indonesia, the incidence of jaundice in term babies, especially in west java province, is ranging from 10.4% to 85%.3,6 causes of hyperbillirubinemia are considered to be predisposing factor, and common causes include maternal, perinatal and neonatal factors.7 these causes are also influenced by several risk factors, such as preterm babies (<37 weeks), babies with low birth weight (lbw), and the mode of delivery.8 jaundice is a problem in neonates that is often faced by health professionals, which occurs in about 60% of term neonates and is even higher in preterm neonates.6 therefore, the amj. 2021;8(3):155–8 abstract background: neonates are prone to hyperbilirubinemia or jaundice due to the immaturity of various organ systems and complications at birth. immature organ systems occur primarily in preterm babies and babies with low birth weight (lbw). the incidence of hyperbilirubinemia is about 60% among term neonates and is higher in preterm neonates. this study aimed to determine the characteristics of neonates with hyperbilirubinemia. methods: this study used a cross sectional research design. samples were obtained from medical records of neonates with hyperbilirubinemia throughout 2019 at annisa medical center hospital, bandung regency. data on neonates that met the inclusion criteria were selected, including gender, gestational age, birth weight, mode of delivery, bilirubin levels (before and after phototherapy), and duration of treatment. data analysis was performed using univariate statistical calculations. results: from 786 data obtained, the prevalence rate of hyperbilirubinemia was 21.2%. male neonates with hyperbilirubinemia were predominantly prevalent (n=103; 61.7%); whereas preterm neonates accounted for 51.5% (n=86), normal weight (85.6%), and born through vaginal delivery (n=116; 69.5%). after treatment, total bilirubin levels decreased, with the percentage of the >10 mg/dl group decreasing from 97.0% to 10.2%. the average duration of treatment for neonates with hyperbilirubinemia was 4.4 days, however, the neonates who were treated less than the average were 71.3%. conclusions: preterm male is predominantly prevalent among neonates with hyperbilirubinemia, although they have conformed birth weight and vaginal delivery mode. the duration of treatment for neonates with hyperbilirubinemia mostly does not exceed 4 days, as long as the treatment reduces the total bilirubin level. good therapeutic management in the first week of hyperbilirubinemia neonates is required. keywords: characteristics, hyperbilirubinemia, neonates https://doi.org/10.15850/amj.v8n3.2328 althea medical journal. 2021;8(3) 156 althea medical journal september 2021 examination of jaundice in neonates should be carried out at the time of the neonatal visit or when examining the babies at the clinic.6 this problem is related to the neonatal mortality rate (nmr) in indonesia of 15 deaths per 1000 births in 2017, which is relatively high,9 compared to the world health organization (who) sustainable developments target of 12 deaths per 1000 births.10 considering that there are still many neonates who experience hyperbilirubinemia, including in west java and bandung regency, this study aimed to explore the characteristics of neonates suffering from hyperbilirubinemia at annisa medical center (amc) hospital bandung regency. methods the research was a descriptive study, involving data on neonates with hyperbilirubinemia recorded at the annisa medical center (amc) hospital bandung regency in 2019. data on gender, gestational age, birth weight, mode of delivery, total bilirubin levels, and duration of treatment were noted. this research obtained permission from the ethics committee of universitas padjadjaran with the number 1066/un6.kep/ec/2020. the data was further explored using the microsoft office excel program, and the univariate method was conducted to determine the characteristics of neonates with hyperbilirubinemia according to the variables reviewed. the data were then presented in frequency. results in total, 786 neonates were recorded, of which 167 had hyperbilirubinemia, thus the prevalence rate of neonates with hyperbilirubinemia at amc hospital bandung regency was 21.2%. male neonates were the most prevalent neonates (61.7%) with hyperbilirubinemia. furthermore, 51.5% of the neonates were preterm although most had normal birth weight based on gestastional age (85.6%). most of the neonates were born by normal vaginal delivery. based on total bilirubin levels, most of the neonates had lower total bilirubin level after treatment and most of them were hospitalized for less or equal to 4 days as shown in table. table characteristics of neonates with hyperbilirubinemia (n=167) registered at amc hospital bandung regency in 2019 characteristics n % gender male female 103 64 61.7 38.3 gestational age full term preterm 81 86 48.5 51.5 birth weight normal low very low 143 21 3 85.6 12.6 1.8 mode of delivery cesarean section vaginal delivery 51 116 30.5 69.5 total bilirubin level (mg/dl) before treatment <10 >10 after treatment <10 >10 treatment duration (days) <4 >4 5 162 150 17 119 48 3.0 97.0 89.8 10.2 71.3 28.7 althea medical journal. 2021;8(3) 157muhammad rizki fonna et al.: characteristics of neonates with hyperbilirubinemia in cileunyi, west java when all neonates were included, the percentage of neonates with normal birth weight who experienced hyperbilirubinemia was 20.6%. low birth weight neonates who had hyperbilirubinemia were 24.7%, whereas very low birth weight neonates who had hyperbilirubinemia were 50.0%. similarly for the mode of delivery, the percentage of neonates born by cesarean section who experienced hyperbilirubinemia was 22.9% and through vaginal delivery was 20.6% (data not shown). discussions the prevalence rate of neonates with hyperbilirubinaemia in this study was 21.2%, and compared to the cileunyi area and its surrounding in east bandung, this number is still relatively high.11 male neonates were predominantly prevalent (61.7%), similar to another study conducted previously at a tertiary hosiptal in bandung.11 however, the effect of gender on the increase in bilirubin levels is still unclear. factors that are thought to influence the metabolism of bilirubin in male babies are the y chromosome which causes increased metabolism and deficiency of enzyme system maturation in the formation, metabolism, and elimination of serum bilirubin.6 the percentage of preterm neonates with hyperbilirubinemia was 51.5%. preterm neonates are more prone to hyperbilirubinemia than term neonates.12 this might be related to organ immaturity in premature babies, which causes physiological functions to not work properly. the low activity of the enzyme uridine diphosphate glucuronyl transferase (udpgt) causes a low ability to conjugate bilirubin in neonates. moreover, the short lifespan of red blood cells in neonates leads to an increase in the hemolysis process, which results in an increase in unconjugated bilirubin.12 furthermore, there is a higher risk for immaturity of the hepatic organs in neonates with low birth weight leading to low excretion of bilirubin, leading to increased bilirubin levels in the blood.12 interestingly, our study showed that the majority of neonates (85.6%) with normal birth weight had hyperbilirubinemia, similar to other studies which showed that the percentage of neonates with normal birth weight tended to be high.13–15 these results contradict the previously mentioned hypothesis.12 the number of patients might limit the statistical analysis, therefore, further studies with a larger number of neonates should be performed. moreover, most of neonates with hyperbilirubinemia were born through normal vaginal delivery, similar to the study in yogyakarta.16 however, in another place in bogor, west java, half of the neonates with hyperbilirubinemia were born by assisted abnormal birth mode delivery and cesarean section.17 the study explains that it may be due to the possibility of various complications during delivery through the procedure.7 in this study, before treatment, 97% of neonates with hyperbilirubinemia had a total bilirubin level of >10 mg/dl, which decreased after treatment. however, 10.2% still has a high level. after 24 hours of treatment, preterm neonates decreased by 2.25 mg/dl, whereas term neonates by 2.6 mg/dl.3 interestingly, another study showed that the average total bilirubin level after phototherapy treatment decreased by 4.64 mg/dl, whereas if additional massage therapy or field massage was applied, the average total bilirubin level decreased further by 7.17 mg/dl.18 these results indicate that treatment given to neonates with hyperbilirubinemia is effective in reducing bilirubin levels; the closer phototherapy is to the body, the more effective it is.19 in addition, another study reported that there was no significant difference in phototherapy position in either the supine position or position change because the number of areas treated with phototherapy was the same despite the change in position.20 in this study, neonates with hyperbilirubinemia have been treated an average of 4.4 days (range 2–21 days). however, most of the neonates (71.3%) had been treated for less than 4 days, similar to another study in sanglah hospital.5 in conclusion, neonates with hyperbilirubinemia are predominantly male and preterm. however, normal birth weight, and vaginal delivery have the potential to develop hyperbilirubinaemia. appropriate treatment may reduce total bilirubin levels to normal levels. references 1. mitra s, rennie j. neonatal jaundice: aetiology, diagnosis, and treatment. br j hosp med (london). 2017;78(12):699704 2. martin cr, cloherty jp. neonatal hyperbilirubinemia. in cloherty jp, eichenwald ec, stark ar. manual of neonatal care. 5th ed. philadelphia: lippincolt williams & wilkins; 2008. p. althea medical journal. 2021;8(3) 158 althea medical journal september 2021 185–221. 3. dewi aks, kardana im, suarta k. efektivitas fototerapi terhadap penurunan kadar bilirubin total pada hiperbilirubinemia neonatal di rsup sanglah. sari pediatri. 2016;18(2):81–6. 4. chime g, egenede j, arute j. prevalence of neonatal jaundice on central hospital, warri, delta state, nigeria. int j health res. 2011;4(3):123–6. 5. parwata wss, putra pj, kardana m, artana wd, sukmawati m. the characteristic of neonatal hyperbilirubinemia before and after phototherapy at sanglah hospital, denpasar, bali in 2017. intisari sains medis. 2019;10(2):309–12. 6. 6. rafie r, nopiyanti a. pengaruh berat badan lahir rendah terhadap ikterus neonatorum pada neonatus di ruang perinatologi rsud karawang provinsi jawa barat tahun 2016. jurnal ilmu kedokteran dan kesehatan. 2017;4(1):12-17. 7. faiqah s. hubungan usia gestasi dan jenis persalinan dengan kadar bilirubinemia pada bayi ikterus di rsup ntb. jurnal kesehatan prima. 2014;8(2):1355–62. 8. fatmawati l, sumiati s. analisis faktorfaktor yang berhubungan dengan kejadian hiperbilirubin. journals of ners community. 2017;8(1):11–9. 9. windiarto t, yusuf ah, santoso ad, nugroho s, latifah s, solih r, et al. profil anak indonesia 2018. jakarta: kementerian pemberdayaan perempuan dan perlindungan anak (kpppa); 2018 10. world health organization. health in the sustainable development goals. india: world health organization; 2016 11. nurani nb, kadi fa, rostini t. incidence of neonatal hyperbilirubinemia based on their characteristics at dr. hasan sadikin general hospital bandung indonesia. althea medical journal. 2017;4(3):431–4. 12. auliasari na, etika r, krisnana i, lestari p. faktor risiko kejadian ikterus neonatorum. pediomaternal nursing journal. 2019;5(2): 183–8. 13. wijaya fa, suryawan iwb. faktor risiko kejadian hiperbilirubinemia pada neonatus di ruang perinatologi rsud wangaya kota denpasar. medicina. 2019;50(2):357–64. 14. cholifah, djauharoh, machfudloh h. faktor-faktor yang berpengaruh terhadap hiperbilirubinemia di rs muhammadiyah gersik. midwiferia. 2017;3(1):14–25. 15. hosea mk, etika r, lestari p. hyperbilirubinemia treatment of neonatus in dr. soetomo hospital surabaya. folia medica indonesiana. 2015;51(3):183–6. 16. puteri irp. hubungan antara berat bayi lahir (bbl) dengan kejadian ikterik pada neonatus di ruang perinatologi rsud wonosari. jurnal kesehatan ibu dan anak akademi kebidanan an-nur. 2017;2(2):9– 18. 17. madiastuti m, chalada s. faktor-faktor yang berhubungan dengan kejadian neonatus hiperbilirubin di rsb pasutri bogor provinsi jawa barat tahun 2016. jurnal ilmu dan budaya. 2017;40(55):6385–403. 18. novianti n, mediani hs, nurhidayah i. pengaruh field massage sebagai terapi adjuvan terhadap kadar bilirubin serum bayi hiperbilirubinemia. jurnal keperawatan padjadjaran. 2017;5(3):315– 27. 19. buthani vk, committee on fetus and newborn. phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. pediatrics. 2011;128(4):e1046– 52. 20. bhethanabhotla s, thukral a, sankar mj, paul vk, deorari ak. effect of position of infant during phototherapy in management of hyperbilirubinemia in late preterm and term neonates: a randomized controlled trial. j perinatol. 2013;33(10):795–9. amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 24 comparison of cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis mohammad arianto satrio wicaksono,1 cep juli,2 chandra calista,2 uni gamayani,2 aih cahyani,2 paulus anam ong2 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: mohammad arianto satrio wicaksono, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: mohammad17009@mail.unpad.ac.id introduction stroke is a rapidly developing clinical sign of focal or global disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.1 stroke can be classified into ischaemic and haemorrhage stroke.2 intracerebral haemorrhage (ich) stroke is a subtype of haemorrhage stroke, characterized by neurological dysfunction caused by a focal collection of blood within the brain parenchyma or ventricular system, which is not caused by trauma.1 although ich accounts for only 10–20% of all strokes, worldwide it causes 50% of stroke-related mortality and disability.3,4 hypertension is one of the main risk factors for intracerebral haemorrhage stroke.5 uncontrolled hypertension can lead to hypertensive crisis.6 a hypertensive crisis can be defined as severe increase in systolic blood pressure greater than or equal to 180 mmhg and/or a diastolic blood pressure greater than or equal to 120 mmhg.7 intracerebral haemorrhage can cause several negative outcomes, including cognitive impairment.4 the mini-mental sate examination (mmse) is a widely used assessment tool to assess global cognitive function. the mmse has several althea medical journal. 2022;9(1):24–29 abstract background: intracerebral haemorrhage (ich) stroke is characterized by neurological dysfunction, caused by focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma. hypertension is one of the main risk factors for intracerebral haemorrhage. hypertensive crisis, which is a more severe type of uncontrolled hypertension may aggravate the cognitive outcomes. the aim of this study was to compare cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis. methods: this study was a retrospective comparative analytic study, combined with a case-control study from august to november 2020. all medical records of patients with intracerebral haemorrhage, who were admitted to dr. hasan sadikin general hospital bandung in 2019, were collected. the total score of mini-mental state examination (mmse) which was recorded in the medical record was taken and compared between groups using the mann-whitney test. the mmse was conducted on the day of discharge, and the minimum education level of the patients was elementary school. results: we found a total of 109 medical records with ich, 67 of which were with hypertensive crisis. the median mmse score in the hypertensive crisis group was slightly higher than in the nonhypertensive crisis group. furthermore, there was no statistical difference in mmse scores between intracerebral haemorrhage patients with and without hypertensive crisis (p-value=0.439). conclusion: there is no difference in cognitive function between intracerebral haemorrhage patients with and without hypertensive crisis. further study is of great value to explore the relation between intracerebral haemorrhage patients with and without hypertensive crisis. keywords: cognitive function, hypertensive crisis, intracerebral haemorrhage https://doi.org/10.15850/amj.v9n1.2368 althea medical journal. 2022;9(1) 25 advantages, including brevity and good validity, and has been translated and validated into various languages.8 intracerebral haemorrhage in the presence of severe hypertension, such as a hypertensive crisis tends to have a high risk of hematoma expansion.9 increased bleeding volume may worsen cognitive function. this study aimed to compare the cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis on discharge day. methods this study was a retrospective study with a comparative analytic method of two independent groups, using a case-control mohammad arianto satrio wicaksono et al.: comparison of cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis table 1 characteristics of intracerebral haemorrhage patients with and without hypertensive crisis characteristics with hypertensive crisis (n=67) without hypertensive crisis (n=42) p-value n % n % gender male female 31 36 46 54 19 23 45 55 0.916 occupation unemployed student office worker entrepreneur farmer/fisherman/labourer others 41 0 15 4 4 3 61 0 22 6 6 5 22 1 15 2 1 1 52 2 36 5 2 2 0.452 ich location right hemisphere left hemisphere frontal lobe parietal lobe temporal lobe occipital lobe brainstem cerebellum basal ganglia thalamus 30 36 1 9 13 0 4 3 19 23 45 54 1 13 19 0 6 5 28 34 24 17 2 6 7 3 1 2 13 12 57 41 5 14 17 7 2 5 31 29 0.209 0.178 x0.558 0.900 0.719 x0.055 x0.647 x1.000 0.772 0.531 risk factor hypertension dyslipidemia diabetes mellitus ischemic heart disease atrial fibrillation 66 21 5 5 1 98 31 7 7 2 35 14 1 2 1 83 33 2 5 2 x0.005 0.829 x0.403 x0.705 x1.000 history of stroke first time recurrent 52 15 77.6 22.4 31 11 73.8 26.2 0.650 note: ich= intracerebral haemorrhage, all use chi-square test except x= fisher’s exact test althea medical journal. 2022;9(1) 26 althea medical journal march 2022 table 2 distribution of age, intracerebral haemorrhage volume, and years of education in patients with intracerebral haemorrhage patients with and without hypertensive crisis characteristic n with hypertensive crisis (n=67) without hypertensive crisis (n=42) p-value age, median (iqr), years 109 55 (48–59) 54 (45–60.75) x0.462 ich volume, median (iqr), ml 56 16.14 (5.95–23.75) 10.07 (4.30–22.6) x0.351 years of education, median (iqr) 92 12 (6–12) 12 (9–12) x0.385 note: ich= intracerebral haemorrhage, iqr= interquartile range, x= mann-whitney test table 3 comparison of mmse score in intracerebral haemorrhage patients with and without hypertensive crisis mmse score with hypertensive crisis (n=67) without hypertensive crisis (n=42) p-value mmse score mean± sd median min-max 22.36±5.68 24 5–30 22.88±6.29 23.5 7–30 x0.439 note: mmse= mini-mental state examination, ich= intracerebral haemorrhage, iqr= interquartile range, x= mannwhitney test approach. data were taken from medical records of ich patients. data collection was carried out from august 2020 to november 2020, after obtaining approval from the research ethics committee universitas padjadjaran, with ethics number 027/un6. kep/ec/2021. we collected all medical records of ich patients with and without hypertensive crisis, who were admitted to dr. hasan sadikin general hospital bandung from january 2019 to december 2019. only subjects who had a total score of mini-mental state examination (mmse) conducted on discharge day, with a minimum education level of elementary school were recruited. the mmse score was already stated in the medical record. medical records with incomplete mmse scores, decreased level of consciousness on discharge day, deceased patient, and aphasia were excluded from this study. the included subjects were then divided into two groups with and without hypertensive crisis. hypertensive crisis status was determined by measuring blood pressure recorded in the medical record and/or final diagnosis by the doctor in charge. the data were analyzed by ibm spss ver.25. data normality test using the kolmogorovsmirnov method (n>50) was performed on the group with hypertensive crisis, while shapiro-wilk (n<50) was performed on the group without hypertensive crisis. the mannwhitney test was used to compare the total mmse scores between the two groups. results from a total of 276 subjects with ich during study period, 109 (39.5%) were included in this study. the data excluded were due to 52 subjects deceased (31.1%) which was 36.5% subjects with hypertensive crisis and 63.5% without hypertensive crisis. other subjects that were excluded were due to incomplete data, consciousness, aphasia, and illiterate. there were 67 subjects with hypertensive crisis and 42 subjects without hypertensive crisis with the female prevalence was higher than male in both groups, 54% and 55%, respectively (table 1). the majority of patients in both groups were unemployed (61% and 52%). the main stroke location in the group with hypertensive crisis was in the left hemisphere (54%) and thalamus (34.%), whereas the right hemisphere (57%) and basal ganglia (31%) were the main locations in non-hypertensive crisis group. in both groups, hypertension had the highest prevalence althea medical journal. 2022;9(1) 27 of risk factors (98.5% and 83.3%) followed by dyslipidemia (31% and 33%). most of the subjects in both groups had no previous history of stroke (78% and 74%). there was a statistically significant difference in the incidence of hypertension (p<0.05) in both groups. the median age in the group with a hypertensive crisis was higher than in the group without hypertensive crisis (table 2). the hypertensive crisis group had the similar median education level as the nonhypertensive crisis group. the median of ich volume in the hypertensive crisis group was larger compared to the groups without hypertensive crisis. there were no statistically differences in age, ich volume, and education level between the two groups (p>0.05). furthermore, the median mmse score in the group with a hypertensive crisis was slightly higher than the group without hypertensive crisis (table 3). for the normality test, we performed the kolmogorov-smirnov method on the group with hypertensive crisis, while the shapiro-wilk on the group without the hypertensive crisis. the distribution of data showed abnormalities. hypothesis testing was conducted using the mann-whitney method in both groups and there was no significant difference between the two groups (p> 0.05). discussion in this study, females were predominated in both groups. this finding is consistent with a previous descriptive cross sectional study, which found that females are predominantly prevalent.10 this condition could be due to longer life span of women, as the incidence of stroke increases with age.11 however, this result might also due to the high prevalence of male previously excluded in this study. interestingly, a meta-analysis study has found that the incidence of intracerebral haemorrhage in an asian population is 15% lower in female than in male, although the difference was not statistically significance.3 according to a systematic review and metaanalysis of 59 studies in 19 countries, the incidence of intracerebral haemorrhage tends to be higher in men.12 in this study, both groups showed that the majority of patients had 12 years of education. a longitudinal study also showed consistent findings in education levels, which found that 63% of primary intracerebral haemorrhage patients had 10 years or more of education.4 however, these findings were inconsistent with another study showing that elementary school is the highest prevalence.10 deep brain haemorrhage location tended to occur in both groups, specifically in the basal ganglia and thalamus. this could be due to the high prevalence of hypertension in this study.13 intracerebral haemorrhage located in deeper structures tend to occur in patient with hypertension, with the most common site being the basal ganglia (55%), followed by thalamus (26%).9 in this study, left hemisphere lesions tended to occur in the hypertensive crisis group, while right hemisphere lesions tended to occur in the non-hypertensive crisis group. the importance of cognitive deficits is in the left hemisphere and supratentorial lesions, followed by the territory of anterior and posterior cerebral arteries.14 left hemisphere lesions have a main role for most cognitive domains, mainly in the language aspect, while right hemisphere lesions are mainly associated with visuospatial and executive functions.15 hypertension is the most frequent risk factor in patients with primary intracerebral haemorrhage.4 our study has also demonstrated that hypertension is the risk factor with the highest prevalence with a significant difference between both groups. this study has found that the majority of stroke events in both groups are the first-time stroke events. previous study has also shown that of spontaneous ich patients, a previous medical history of stroke or transient ischemic stroke was found in only 15% of patients.13 in this study, the median age of hypertensive crisis group was higher than non-hypertensive crisis group. possibly, it is caused by increased arterial stiffness, which reduces the arterial buffering capacity, leading to age-associated changes in blood pressure.16 this study also has found that the median of ich volume in hypertensive crisis group is higher than nonhypertensive crisis group. it could be due to the existing evidence supports that there is an association between systolic blood pressure and hematoma expansion.17 however, data on education and ich volumes were incomplete and might interfere with the results. the median mmse score of hypertensive crisis groups was slightly higher than the non-hypertensive crisis group. this might be caused by predominant female gender in the non-hypertensive crisis group compared to the hypertensive crisis group (55% and 54%). female is associated with vascular cognitive impairment by related degenerative pathology that would interact with vascular pathology.18 recurrent stroke in the non-hypertensive crisis group has a higher incidence compared to the mohammad arianto satrio wicaksono et al.: comparison of cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis althea medical journal. 2022;9(1) 28 hypertensive crisis group (26% and 22%). patients with a history of stroke have a steeper rate of cognitive decline. however, our study has shown no significant difference in cognitive function between the groups with and without hypertensive crisis, contrary to other studies showing that there is a relationship between cognitive impairment and hypertension severity.13,19 however, the study has some limitations such as lack of evidence of a temporal relationship between exposure and outcome.19 in addition, there is no significant difference in stroke location between the two groups in this study. as the location of stroke, especially the left hemisphere and cortical lobe, it is an important factor for cognitive function. the limitation of this study could interfere with the result of the study. the small sample size is due to the large number of data excluded due to the high mortality of patient and incomplete data in this study. in addition, the day of the mmse test performed in each subject is different, so that it might affect the results. furthermore, pre-stroke cognitive status is not assessed in this study. pre-existing cognitive impairment is one of the strongest prognostic factors for subsequent cognitive decline.13 the duration of hypertension is also an important determinant of cognitive impairment. there is an adverse effect of increasing the duration of hypertension on cognition.20 in this study, the duration of hypertension is not assessed which may interfere with the results. in conclusion, there is no significant difference in cognitive impairment between the hypertensive group and the nonhypertensive group. further studies are recommended to pay attention to factors such as pre-stroke cognitive impairment, duration of hypertension, and variability in blood pressure. the mmse score in this study has shown a cognitive impairment in both groups. education about the risk of hypertensive crisis is of great value to prevent stroke and further cognitive impairment. appropriate treatment of ich patients with and without hypertensive crisis to prevent further cognitive impairment is needed. in addition, further studies need to be conducted on the relationship between hypertensive crisis and cognitive function, to assess whether there is a significant worsening of cognitive function in the hypertensive crisis condition. references 1. sacco rl, kasner se, broderick jp, caplan lr, connors jj, culebras a, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(7):2064–89. 2. parmar p. stroke: classification and diagnosis. pharmaceutical j [online journal] 2018. [cited 2021 july 15]. available from: https://pharmaceuticalj o u r n a l . c o m / a r t i c l e / l d / s t r o k e classification-and-diagnosis 3. ikram ma, wieberdink rg, koudstaal pj. international epidemiology of intracerebral hemorrhage. curr atheroscler rep. 2012;14(4):300–6. 4. biffi a, bailey d, anderson cd, ayres am, gurol em, greenberg sm, et al. risk factors associated with early vs delayed dementia after intracerebral hemorrhage. jama neurol. 2016;73(8):969–76. 5. an sj, kim tj, yoon bw. epidemiology, risk factors, and clinical features of intracerebral hemorrhage: an update. j stroke. 2017;19(1):3–10. 6. alshami a, romero c, avila a, varon j. management of hypertensive crises in the elderly. j geriatr cardiol. 2018;15(7):504– 12. 7. suneja m, sanders ml. hypertensive emergency. med clin north am. 2017;101(3):465–78. 8. myrberg k, hydén lc, samuelsson c. the mini-mental state examination (mmse) from a language perspective: an analysis of test interaction. clin linguist phon. 2020;34(7):652–70. 9. kumar s. hypertension and hemorrhagic stroke. hypertens j. 2017;3(2):89–93. 10. lofissa sp, ong pa, atik n. demographic and risk factors of intracerebral hemorrhage stroke patients in dr. hasan sadikin general hospital bandung in 2007–2016. althea med j. 2018;5(1):32–7. 11. boehme ak, esenwa c, elkind msv. stroke risk factors, genetics, and prevention. circ res. 2017;120(3):472–95. 12. poon mtc, bell sm, salman ra. epidemiology of intracerebral haemorrhage. front neurol neurosci. 2015;37:1–12. 13. benedictus mr, hochart a, rossi c, boulouis g, hénon h, van der flier wm, et al. prognostic factors for cognitive decline after intracerebral hemorrhage. stroke. 2015;46(10):2773–8. 14. danovska m, peychinska d. post-stroke cognitive impairment–phenomenology althea medical journal march 2022 althea medical journal. 2022;9(1) 29 and prognostic factors. j imab annual proceeding scientific paper. 2012;18:290–7. 15. sagnier s, munsch f, bigourdan a, debruxelles s, poli m, renou p, et al. the influence of stroke location on cognitive and mood impairment. a voxel-based lesion-symptom mapping study. j stroke cerebrovasc dis. 2019;28(5):1236–42. 16. rockwood mrh, howlett se. blood pressure in relation to age and frailty. can geriatr j. 2011;14(1):2–7. 17. qureshi ai. the importance of acute hypertensive response in ich. stroke. 2013;44(6 suppl 1):s67–9 18. chen x, duan l, han y, tian l, dai q, wang s, et al. predictors for vascular cognitive impairment in stroke patients. bmc neurol. 2016;16:1–15. 19. muela hcs, costa-hong va, yassuda ms, moraes nc, memória cm, machado mf, et al. hypertension severity is associated with impaired cognitive performance. j am heart assoc. 2017;6(1):e1004579. 20. power mc, tchetgen tchetgen ej, sparrow d, schwartz j, weisskopf mg. blood pressure and cognition: factors that may account for their inconsistent association. epidemiology. 2013;24(6):886–93. mohammad arianto satrio wicaksono et al.: comparison of cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 211 relationship between nomophobia and attention among medical students in jakarta, indonesia kevin tanoto,1 eva suryani,2 satya joewana2 1faculty of medicine & biomedical sciences, catholic university of atma jaya indonesia, jakarta, indonesia, 2departement of psychiatry faculty of medicine & biomedical sciences, catholic university of atma jaya indonesia, jakarta, indonesia correspondence: eva suryani, department of psychiatry, faculty of medicine & biomedical sciences catholic university of atma jaya indonesia, jalan pluit raya no.2, jakarta, indonesia, e-mail: eva.suryani@atmajaya.ac.id introduction inventions and improvements in technology change lifestyle. one of the inventions that have caused a big lifestyle change is the invention of handphones. handphones that used to have simple features like sending short message services (sms) and phone calls have now evolved into smartphones with various features. the features that smartphones provide include global positioning system (gps), high-resolution touch screens, access to the internet, social media, even both offline and online games.1,2 the comfort and ease provided by smartphones have been a part of the lifestyle of modern society. data provided by the ministry of communication and information republic of indonesia (kominfo) has shown that there are more than 100 million active smartphone users in the year 2018.3 the ease and comfort brought by smartphones are also accompanied by several disadvantages in young adults. students that score highly on the smartphone addiction scale (sas) are linked with depression, anxiety, and lower sleep quality.4 detrimental effects on physical and psychological health are also found on excessive cellular phone usage.5 smartphone usage has been used at inappropriate times and places, for example during driving, praying, studying in the library, during a lecture, and watching movies in theatres.6,7 another disadvantage of excessive smartphone usage is nomophobia, a phobia of no mobile phone. nomophobia is a short form of ‘no mobile phone phobia’ that is defined as a fear of being out of mobile phone contact. this is considered as a modern age phobia introduced to our lives as a byproduct of the interaction between people and mobile information and communication technologies, especially amj. 2020;7(4):211–5 abstract background: the advancements in technology in the form of smartphones have made life easier; however, some negative effects have been recorded with regards to the use of smartphone. among these negative effects are nomophobia, or a phobia of no mobile phone, and lack of attention. this study explored the relationship between nomophobia and attention in medical students. methods: this was a cross-sectional analytic study on medical students in jakarta in 2019. the nomophobia questionnaire (nmp-q) was used to measure the level of nomophobia and the six letter cancellation test (slct) was used to measure attention. data collected were analyzed using a simple linear regression test. results: there was a weak negative relationship between the severity of nomophobia and attention (r=0.161). however, nomophobia score was a very weak predictor for attention with an adjusted r-squared score of 0.021. conclusions: nomophobia does not necessarily affect the attention of medical students. excessive mobile phone use does cause nomophobia and lack of attention. therefore, smartphones need to be used wisely. keywords: attention, nomophobia, smartphone https://doi.org/10.15850/amj.v7n4.2033 althea medical journal. 2020;7(4) 212 amj december 2020 smartphones.8 a research in india has shown that college students have nomophobia with predominantly moderate nomophobes as well as severe nomophobes.9 another study in india and turkey have shown that college students have a high risk of having nomophobia.10,11 moreover, a study in saudi arabia has shown that only 90 of 622 colleges student is found to be not nomophobic.12 the result shows that many smartphone users are nomophobic. this is a global problem as there has been a link between nomophobia and distraction caused by smartphones. excessive smartphone usage is linked to a lower grade point average (gpa) and a lack of attention, resulting in a decrease in gpa.13 nomophobia is also related to anxiety, compulsive smartphone usage, and panic.14 there are reports of excessive a mobile phone usage among medical students. the time spent on mobile phone is for recreational activities or academic improvements. some medical students admit to being distracted by mobile phones which may affect patient safety and academic performance. therefore, this study aimed to explore the relationship between nomophobia and attention among medical students. methods this study was an analytic study using a crosssectional approach, performed among medical students of the university of atma jaya from november to december 2019. based on the sample size formula for linear regression analysis, the minimum sample needed was 92 respondents. the method used to acquire respondents in this research was simple random sampling among students after class. the study was conducted after approval of the ethical clearance that was provided by the ethical committee of school of medicine and biomedical science, university of atma jaya. since the questionnaire was in english, the inclusion criteria were a minimum toefl score of 450 and had a smartphone with internet access. students were first verbally informed about the study and those who were interested in taking part in the study filled in the informed consent form before filling in the nomophobia questionnaire (nmp-q) to measure the level of nomophobia. furthermore, the six letter cancellation test (slct) was given to measure the attention of the respondents. finally, they were asked if they had attention disorders. the nmp-q was a four-dimensioned questionnaire. the dimensions were not being able to communicate, losing connectedness, not being able to access information, and giving up convenience. nmp-q consisted of 20 items and each item was measured with a 7-score likert scale. the scores were then summed up to get a total score from the respondents. the scores were divided into 3 categories which were mild (20–60), moderate (61–100), and severe (101–140). the slct was a test where participants were given a sheet containing 33 rows and 12 columns of letters and 6 target letters (figure). participants were asked to identify the target letters among the 33 rows and 12 columns of letters then cancel the target letters. the time given for the participants to cancel all the letters was 1 minute and 30 seconds. the result of slct was the total number of letters canceled subtracted by the number of letters wrongly canceled. data gathered from nmp-q and slct were put into statistical package for the social science (spss) v.22.0. a simple linear regression test was used to measure the strength of the relationship between the nomophobia score and slct score. a result of adjusted r-squared made into percentage was used to see if the independent variable was a good predictor of the dependent variable. the higher the percentage, the better a predictor variable explained a variable. results initially, 198 medical students were interested table 1 degree of nomophobia severity among medical students in jakarta degree of severity n percentage mild 39 20.52% moderate 134 70.52% severe 17 8.94% note: the nmp-q results were categorized by score ranges of 20–60 (mild nomophobia), 61–100(moderate nomophobia), and 101–140 (severe nomophobia) althea medical journal. 2020;7(4) 213kevin tanoto et al.: relationship between nomophobia and attention among medical students in jakarta, indonesia table 2 average of nmp-q and slct score among medical students in jakarta undergraduate students nmp-q score in different categories nmp-q score (p>0.05) slct (p>0.05)mild moderate severe 3rd year 47.41 77.69 111 73.98 51.40 2nd year 46.87 79.65 107.5 76.44 52.10 1st year 50.42 79.13 108.28 75.72 50.37 note: the difference in mean scores of nmp-q and slct was statistically significant (p>0.05) and participated in this study, however, there were 8 participants with a low toefl score and were thus further excluded, resulting in 190 participants consisting of 70 male (36.8%) and 120 female (63.2%) medical students. the degree of severity in nomophobia was shown in table 1, which was mild (20.52%), moderate (70.52%), and severe (8.94%). the nomophobia questionnaire (nmp-q) score and single letter cancellation test (slct) scores among students were further compared between the year of studies as shown in table 2. there was in the average nmp-q scores (f 2.187=0.301) and slct scores (f 2.187=0.384) between the 1st to 3rd year, however, the difference was not statistically significant (p=0.741 and p=0.681, anova test). furthermore, there was no statistically significant difference in nmp-q score (p= 0.666) between male (median=73.5) and female (median=75) students (mann whitney test), indicating that most of the respondents had moderate nomophobia. the average score of mild, moderate, and severe nomophobia were 48.38±9.62, 78.60±9.99, 109.05±5.61, respectively. slct scores from each category of nomophobia were measured. the mean and standard deviation of slct scores from participants with mild nomophobia, moderate nomophobia, and severe nomophobia was presented in table 4. a simple linear regression test was conducted, resulting in an r-value of 0.161 which indicated a weak relationship and an adjusted r-squared score of .021. this showed that the nomophobia score had a very weak relationship with the alteration in the slct score (figure). discussion this study explores the relationship between nomophobia and attention among young table 3 nmp-q scores among respondents based on degree of severity degree of severity mean standard of deviation minimum maximum mild 48.38 9.62 20 59 moderate 78.60 9.99 60 99 severe 109.05 5.61 100 122 note: the nmp-q results were categorized as mild (20-60), moderate (61-100), and severe (101-140). table 4 slct scores of respondents based on severity of nomophobia severity of nomophobia slct score mean standard of deviation minimum maximum mild 53.61 12.09 27 80 moderate 50.94 9.38 27 79 severe 48.70 11.22 28 66 note: the nmp-q results were categorized as mild (20-60), moderate (61-100), and severe (101-140) althea medical journal. 2020;7(4) 214 amj december 2020 adults, especially in medical students. the study results show that nomophobia score does not explain the alteration in slct score and there is a negative weak correlation between them (r-value 0.161). a weak negative relationship result is also shown in a study conducted in india, that excessive mobile phone usage is linked with nomophobia and the excessive usage causes distractions which eventually lowers attention.10 although the correlation is statistically significant (p=<0.05), but the research lacks in the direct relationship between nomophobia and attention. distraction is also caused by the constant need to look at a mobile phones whenever ‘pop up’ notifications appear or when there is a need to use the feature a smartphone provides. nomophobia can also be positively correlated with extraversion,15 and extraversion itself is related to lower levels of attention compared to introverts.16 interestingly, various studies explore the relationship between mindfulness and nomophobia. mindfulness, measured by the mindful attention awareness scale (maas), is used to measure the attention on present moment and experiences, and it seems that mindfulness has a significant and negative relationship with nomophobia.17 another similar research performed on respondents after a 20-minute lecture. after the lecture, a quiz about the lecture was given to assess the attention of students. participants were then asked to fill in the nmp-q. the result shows a strong correlation between high nmp-q scores and lowers scores in a few parts of the quiz which indicates that there is a weak relationship between nomophobia and attention.18 the limitations of the study are that this study lacks in the screening of attention disorders such as attention deficit hyperactivity disorder (adhd), a mental health disorder that can cause above normal levels of hyperactive and impulsive behaviors, resulting in trouble focusing their attention on a single task. furthermore, the questionnaire is in english that needs language validation to increase the same perception among respondents. to conclude, nomophobia does not affect attention among medical students. excessive mobile phone usage does cause nomophobia and a lack of attention, but the lack of attention is not related to nomophobia. the lack of attention found might be caused by other function of mobile phones such as pop up notifications, smartphone-related function perceived as ‘productive breaks’ such as games or contacting relatives, and studyrelated activities such as searching for medical guidelines. further research needs to focus on other factors affecting attention related to excessive mobile phone usage and other adverse effects. references 1. min k, lee jy, won wy, park jw, min ja, hahn c, et al. development and validation figure relationship between nomophobia score and slct score althea medical journal. 2020;7(4) 215 of a smartphone addiction scale (sas). plos one. 2013;8(2):e56936. 2. aguilera-manrique g, márquez-hernández vv, alcaraz-córdoba t, granados-gámez g, gutiérrez-puertas v, gutiérrez-puertas l. the relationship between nomophobia and the distraction associated with smartphone use among nursing students in their clinical practicum. plos one. 2018;13(8):e0202953. 3. rahmayani i. indonesia raksasa teknologi digital asia. jakarta: kementerian komunikasi dan informatika republik indonesia; 2015 [cited 2018 nov 1] available from: https://kominfo.go.id:443/ content/detail/6095/indonesia-raksasateknologi-digital-asia/0/sorotan_media. 4. demiṙci ̇ k, akgönül m, akpinar a. relationship of smartphone use severity with sleep quality, depression, and anxiety in university students. j behav addict. 2015;4(2):85–92. 5. taneja c. the psychology of excessive cellular phone use. delhi psychiatry journal. 2014;17(2):448–51. 6. billieux j, maurage p, lopez-fernandez o, kuss dj, griffiths md. can disordered mobile phone use be considered a behavioral addiction? an update on current evidence and a comprehensive model for future research. curr addict rep. 2015;2:156–62. 7. opoku ra. attitudes towards mobile phone usage in public places among young saudi adults. int j mob commun. 2017;15(3):235–51. 8. yildirim c, correia ap. exploring the dimensions of nomophobia: development and validation of a self-reported questionnare. comput human behav. 2015;49:130–7. 9. farooqui ia, pore p, gothankar j. nomophobia: an emerging issue in medical institutions? j ment health 2018;27(5):438–41. 10. prasad m, patthi b, singla a, gupta r, saha s, kumar jk, et al. nomophobia: a crosssectional study to assess mobile phone usage among dental students. j clin diagn res. 2017;11(2):zc34–9. 11. yildirim c, sumuer e, adnan m, yildirim s. a growing fear: prevalence of nomophobia among turkish college students. inform dev. 2016; 32(5):1322–31. 12. alahmari ms, alfaifi aa, alyami ah, alshehri sm, alqahtani ms, alkhashrami ss, et al. prevalence and risk factors of nomophobia among undergraduate students of health sciences colleges at king khalid university, abha, saudi arabia. int j med res prof. 2018;4(1):429–32. 13. bragazzi nl, del puente g. a proposal for including nomophobia in the new dsm-v. psychol res behav manag.2014;7:155–60. 14. argumosa-villar l, boada-grau j, vigil-colet a. exploratory investigation of theoretical predictors of nomophobia using the mobile phone involvement questionnaire (mpiq). j adolesc. 2017;56:127–35 15. blumenthal td. extraversion, attention, and startle response reactivity. pers indiv differ. 2001;31(4):495–503 16. arpaci i, baloğlu m, kesici s. a multigroup analysis of the effects of individual differences in mindfulness on nomophobia. inform dev. 2017;35(160):1–9. 17. mendoza j, pody b, lee s, kim m, mcdonough i. the effect of cellphones on attention and learning: the influences of time, distraction and nomophobia. comput human behav. 2018;86:52–60. kevin tanoto et al.: relationship between nomophobia and attention among medical students in jakarta, indonesia amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 159 visualization of carotid doppler in patients with ischemic stroke at dr. hasan sadikin general hospital bandung year 2016–2019 olivia,1 ahmad rizal ganiem,2 syarief hidayat3 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: olivia, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: livolivia3@gmail.com introduction stroke is a non-communicable disease that has been known as the primary cause of disability and vascular death worldwide.1 the world health organization (who) defines stroke as rapidly developing clinical signs of focal or global disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin, and classified into ischemic and hemorrhagic types.2 nationally, the 2018 basic health research (riset kesehatan dasar, riskesdas) reported that the prevalence of stroke in indonesia was 10.9 per 1,000 population.3 blood flow to brain region in ischemic stroke patients is disrupted due to pathological changes that occur in blood vessels, mainly caused by advanced atherosclerotic plaques. these plaques may rupture and form a thrombus, which can then become the source of embolus, both of which lead to arterial occlusion resulting in territorial infarcts of variable size.4 these arterial pathological changes, both plaque morphological characteristics and blood flow, can be observed using a widely available, economical, noninvasive imaging modality, namely doppler amj. 2021;8(3):159–63 abstract background: various pathological changes in both the intra and extracranial arteries that supply the brain can cause disturbance of cerebral blood flow and perfusion leading to cerebral dysfunction. doppler ultrasound is able to assess these changes. this study was performed to evaluate the anatomical and physiological changes found in the carotid arteries of patients with ischemic stroke using doppler ultrasound. methods: the cross-sectional descriptive study design with total sampling method was conducted on the medical records of ischemic stroke patients who had carotid doppler ultrasound at the department of cardiology and vascular medicine dr. hasan sadikin general hospital bandung from 2016 to 2019. demographic data, such as stroke diagnoses and plaque characteristics recorded in the doppler reports were collected. results: there were 38 data sets collected. the distribution and characteristics of atherosclerotic plaques were similar between the two carotid systems, with the same percentage of plaque being found in the right (31.6%) and left (36.8%) carotid system. the most common type of plaque found was type iii and was located in the common carotid artery. thrombus was absent in all patients. intimal media thickening was found in 13.2% right system and 15.8% left system. stenosis was present in 34.2% of patients, and most had <50% stenosis. peak systolic velocity increased (>125 cm/s) in 5.3% of the right system and 7.9% of the left system of the internal carotid artery. conclusions: most of the atherothrombotic and thromboembolic type of ischemic stroke patients in this study have normal carotid doppler ultrasound features. further study on the presence of plaque in ischemic stroke patients in indonesia is needed. keywords: atherosclerotic plaque, carotid doppler ultrasound, ischemic stroke https://doi.org/10.15850/amj.v8n3.2285 althea medical journal. 2021;8(3) 160 althea medical journal september 2021 ultrasound.5,6 pathological changes that occur in the carotid artery as the site of symptomatic lesions most often occur in ischemic stroke patients using doppler ultrasound.7 therefore, this study aimed to evaluate anatomical and physiological changes found in the carotid arteries of patients with ischemic stroke using doppler ultrasound. methods this was a descriptive cross-sectional study. secondary data were collected from medical records of the patients at the department of cardiology and vascular medicine, dr. hasan sadikin general hospital bandung, from january 2016 to december 2019. inclusion criteria were adult patient >18 years, diagnosed with atherothrombotic or thromboembolic stroke in the carotid system, and underwent carotid doppler ultrasound examination. patients with incomplete data were excluded from the study. the data collected in this study were age, gender, stroke location (left or right carotid system), anatomical assessment, and functional assessment of carotid doppler examination. anatomical assessment included plaque characteristics (presence, location, and type), presence of thrombus, intimal media thickening, and degree of carotid artery stenosis which were then classified into six categories (<50%, 50–70%, 70–95%, 90–95%, >95%, no stenosis). plaque echogenicity was classified as pure hypoechoic (type i), hypoechoic with a small hyperechoic area (type ii), hyperechoic with a small hypoechoic area (type iii), and hyperechoic (type iv).5 the functional assessment included the peak systolic velocity (psv) of the carotid artery. data was collected after obtaining ethical approval from the research ethics committee universitas padjadjaran (790/un6.kep/ec/2020) and dr. hasan sadikin general hospital bandung (lb.02.01/x.2.2.1/19917/2020). data were presented in tables. results during the study period, 116 ischemic stroke patients underwent carotid doppler examination. of these, 73 data were excluded because the type of stroke did not meet the inclusion criteria. of the 43 eligible data, 5 data were excluded due to incomplete data, so that the remaining 38 records were eligible for analysis. the median age for ischemic stroke was 59 years (range 49–64), with female patients out numbering male patients (60.5% vs 39.5%). the carotid system involved in ischemic stroke was found to be almost the same between the right and left carotid systems (table 1). among 38 patients, plaque was found in 18 patients (12 in right carotid system only, 14 in the left, and 8 patients had plaque in both systems). the presence of plaque was slightly more common in the left carotid system. the most common plaque type found in both systems was type iii (66.7% on the right, 50.0% on the left), followed by type ii (25.0% on the right, 42.9% on the left). type i plaques were found in 1 right carotid system (8.3%) and type iv plaques in 1 left carotid system (7.1%). nearly all plaques were found in the common carotid artery (88.3% on the right, 92.9% on the left), and only a small proportion in the internal carotid artery. intimal media thickening was found in 5 right carotid systems (13.2%) and 6 left carotid systems (15.8%). stenosis was present in 34.2% of patients. among patients with stenosis, most of them had <50% stenosis (table 2). functional assessment showed that there was an increase in psv in a minority of the patient’s internal carotid arteries (5.3% on the table 1 ischemic stroke patients characteristics (n=38) characteristics n(%) age (years)–median (iqr) 59 (49–64) gender, n (%) male female 15 (39.5) 23 (60.5) stroke system, n (%) right carotid system left carotid system 18 (47.4) 20 (52.6) althea medical journal. 2021;8(3) 161olivia et al.: visualization of carotid doppler in patients with ischemic stroke at dr. hasan sadikin general hospital bandung year 2016–2019 right and 7.9% on the left). common carotid artery blood flow was within normal limits in all subjects (table 3). discussion stroke incidence and atherosclerotic plaque formation increases with age, with the highest incidence at age 60 years or older. the median age in this study was 59 years, in accordance with previous studies where most of the patients belonged to the age group of 60–69 years.8,9 the incidence was more common in women, in contrast to what was found in the riskesdas 2018 which revealed that the incidence was almost the same between men and women.3 most of the patients had left carotid system stroke. this finding is different from 2 studies conducted in south india, where in the first study, most of the patients had right system stroke, and another study showed the equal numbers of right and left system stroke patients.6,9 another study in the united states of america showed similar results to this study, in which left-hemispheric anterior circulation ischemic strokes were table 2 anatomical assessment of carotid doppler examination (n=38) carotid doppler examination report right carotid system n(%) left carotid system n(%) atherosclerotic plaque present* absent 12(31.6) 26(68.4) 14(36.8) 24(63.2) plaque type** type i type ii type iii type iv 1(8.3) 3(25) 8(66.7) 0(0) 0(0) 6(42.9) 7(50) 1(7.1) plaque location** common carotid artery internal carotid artery 10(83.3) 2(16.7) 13(92.9) 1(7.1) thrombus present absent 0(0) 38(100) 0(0) 38(100) intimal media thickening present absent 5(13.2) 33(86.8) 6(15.8) 32(84.2) stenosis <50% 50–70% 70–95% 95–99% >99% no stenosis 11(29) 1(2.6) 1(2.6) 0(0) 0 (0) 25(65.8) 12(31.6) 0(0) 0(0) 1(2.6) 0(0) 25(65.8) note: * = 8 patients had bilateral plaques, ** = n subjects were 12 in the right carotid system and 14 in the left carotid system table 3 functional assessment of carotid doppler examination (n=38) peak systolic velocity (psv) right carotid system n(%) left carotid system n(%) location common carotid artery <125 cm/s >125 cm/s 38(100) 0(0) 38(100) 0(0) internal carotid artery <125 cm/s >125 cm/s 36(94.7) 2(5.3) 35(92.1) 3(7.9) althea medical journal. 2021;8(3) 162 althea medical journal september 2021 slightly more common than right-hemispheric stroke.10 these data revealed that there was no significant difference between the incidence of right and left carotid system strokes. left system stroke has a slightly higher incidence due to hemodynamic differences in the left carotid artery, the direct branch of the aorta, where there is higher stress and intimal damage.10 this study specifically involved ischemic stroke patients with atherothrombotic or thromboembolic origin. however, majority of patients had no signs of atherosclerotic plaque in the carotid arteries. this finding differs from previous evidence in which the extracranial carotid artery was the most common plaque location.4,11 this is probably due to ethnic differences, where atherosclerotic lesions in asian people are more frequently found in the intracranial vessels.12 the causes are still unknown but presumably related to genetics and nutritional factors.12 a study in the south korea showed that patients with the genetic variant rnf213, one of the most susceptible genes for moyamoya disease among east asians, was associated with an increased risk and early onset of intracranial atherosclerotic disease.13 however, study in china shows that the incidence is also different within the country. a higher incidence was found in areas of a more westernized lifestyle, indicating that nutritional factors also play a role in the intracranial lesions formation.14 in patients with atherosclerotic plaques, plaque characteristics were then assessed. this study has similar findings to a study in india which showed that more plaque is located in the common carotid artery.11 vulnerable plaque, indicated as plaque with a high degree of echolucency, is prone to rupture and may result in thrombus formation. in this study, the most common plaque found was type iii, followed by type ii, indicating that the plaque found was more stable.5 this could explain the total absence of thrombus in this study. the presence of plaque that was more stable in this study was probably due to the fact that the subjects of this study were stroke patients, while other studies mostly reported plaque formation in non-stroke subjects to predict the stroke incidence. vulnerable plaque could have already ruptured, causing an embolism leading to the diagnosis of an ischemic stroke. previous studies have also shown a strong correlation between echolucent plaques and an increased risk of ipsilateral stroke in asymptomatic carotid artery stenosis patients.15 intimal media thickening of carotid artery might be present as the earliest sign of progressive atherosclerosis.16 in this study, patients were classified as having intimal media thickening when the intimal media thickness found was >1.00 mm. most patients had normal intimal media thickness. stenosis was found in a minority of patients. previous studies have shown that carotid stenosis is clinically important if the stenotic degree is >60%.7 in this study, most of the patients with stenosis were included in the criteria for insignificant stenosis (<50%) . this finding is similar to a study conducted in india, where most of the subjects had <50% stenosis.6,17 one of the most accurate predictors of internal carotid artery stenosis is the psv assessment.9 previous studies have shown that psv >125 cm/s is correlates with >60% stenosis of the carotid artery, which is clinically important.7 most of the patients in this study had normal results in their psv assessment in the common and internal carotid arteries. this study has several limitations. first, carotid doppler ultrasound has not yet become part of the standard examination performed in patients with atherothrombotic ischemic stroke, so data are still scarce. besides, it was done in a single medical center with a limited period of time, hence, the sample size was small and might not represent the actual condition. second, this study did not record risk factors that could have interfered with the findings. third, data on the involvement of patients with stroke system in this study were obtained from the referral doctor’s statement, not directly from the results of brain imaging. further studies are suggested to have a larger sample size and risk factors assessment so that more precise results can be obtained. to conclude, most of the atherothrombotic and thromboembolic type ischemic stroke patients in this study have normal carotid doppler ultrasound features. among patients with pathological changes, most prevalent changes found are atherosclerotic plaques, with type iii plaques and located in the common carotid artery. further studies comparing the presence of extracranial and intracranial plaques among indonesian are needed. references 1. turana y, tengkawan j, chia yc, nathaniel m, wang jg, sukonthasarn a, et al. hypertension and stroke in asia: a comprehensive review from hope asia. j clin hypertens. 2020;00:1–9. althea medical journal. 2021;8(3) 163olivia et al.: visualization of carotid doppler in patients with ischemic stroke at dr. hasan sadikin general hospital bandung year 2016–2019 2. sacco rl, kasner se, broderick jp, caplan lr, connors jj, culebras a, et al. an updated definition of stroke for the 21st century: a statement for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(7):2064–89. 3. kementerian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2018. jakarta; kementerian kesehatan republik indonesia 2018.. 4. hossmann k-a, heiss w-d. neuropathology and pathophysiology of stroke. in: brainin m, heiss w-d, editors. textbook of stroke medicine. 3rd ed. cambridge, uk: cambridge university press; 2019. p. 1–37. 5. marques md, lima jac. current imaging approaches and challenges in the assessment of coronary artery disease. in: yuan c, hatsukami t, mossa-basha m, editors. vessel based imaging techniques. cham, switzerland: springer. 2020. p.229– 244. 6. chamarthi m, kumar l, nirusha r, pravallika i, kejriwal gs. color doppler evaluation of carotid arteries in stroke patients: a study conducted in a rural tertiary care medical college hospital in south india. iosr j dent med sci. 2017;16(01):04–9. 7. lászló c. ultrasound in acute ischemic stroke. in: brainin m, heiss wd, editors. textbook of stroke medicine. 3rd ed. cambridge, uk: cambridge university press; 2019. p. 90–107. 8. 8boehme ak, esenwa c, elkind msv. stroke risk factors, genetics, and prevention. circ res. 2017;120(3):472–95. 9. fernandes m, keerthiraj b, mahale ar, kumar a, dudekula a. evaluation of carotid arteries in stroke patients using color doppler sonography: a prospective study conducted in a tertiary care hospital in south india. int j appl basic med res. 2016;6(1):38–44. 10. hedna vs, bodhit an, ansari s, falchook ad, stead l, heilman km, et al. hemispheric differences in ischemic stroke: is lefthemisphere stroke more common? j clin neurol. 2013;9(2):97–102. 11. pathak mr, gautam m, pathak yr. evaluation of extracranial carotid arteries in ischemic stroke patients using color doppler sonography and correlation with various risk factors. j nobel med coll. 2019;8(2):10–4. 12. arboix a. cardiovascular risk factors for acute stroke: risk profiles in the different subtypes of ischemic stroke. world j clin cases. 2015;3(5):418–29. 13. bang oy, chung jw, cha j, lee mj, yeon jy, ki cs, et al. a polymorphism in rnf213 is a susceptibility gene for intracranial atherosclerosis. plos one. 2016;11(6):e0156607. 14. ritz k, denswil np, stam ocg, van lieshout jj, daemen mjap. cause and mechanisms of intracranial atherosclerosis. circulation. 2014;130(16):1407–14. 15. paraskevas ki, veith fj, spence jd. how to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting. stroke vasc neurol. 2018;3(2):92–100. 16. haq s, mathur m, singh j, kaur n, sibia rs, badhan r. colour doppler evaluation of extracranial carotid artery in patients presenting with acute ischemic stroke and correlation with various risk factors. j clin diagn res. 2017;11(3):tc01–5. 17. ramasamy m, rao ad, radhakrishnan s. color doppler evaluation of carotid arteries in cerebral ischemia. int j contemp med surg radiol. 2020;5(3):c57–61. amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 138 althea medical journal september 2021 implementation of youth information and counseling centers related to hiv/aids prevention in a junior high school in bandung shifa nadya rahma,1 insi farisa desy arya,2 rudi wisaksana3 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: shifa nadya rahma, faculty of medicine, universitas padjajaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: shifanadyaa@gmail.com introduction according to data from the united nations programme on hiv and aids (unaids) in 2016, there were 48,000 new human immunodeficiency virus (hiv) infections and 38,000 deaths from acquired immune deficiency syndrome (aids) in indonesia.1 the duration from hiv infection to aids varies, but is usually around 8–11 years.2 the incidence of aids cases in indonesia shows that the most cases are at the age of 20–29 years.3 therefore, adolescents aged 10–19 years are the population group with the highest risk of contracting hiv infection.3 this is due to their low knowledge of hiv/aids. the 2012 indonesian demographic health survey (idhs) shows that only 11.37% of young adults aged 15–24 in indonesia had good knowledge of hiv prevention.1 the national population and family planning board (badan kependudukan dan keluarga berencana nasional, bkkbn) has developed a program, called ‘planning generation’ (generasi berencana, genre), including the youth information and counseling center (program informasi kesehatan remaja, pik-r). pik-r is a forum for family life planning for adolescents which is managed from, by and for adolescents to provide information and counseling services, one of which is about adolescent amj. 2021;8(3):138–43 abstract background: adolescents are the population group most at risk of human immunodeficiency virus (hiv) infection due to low knowledge about hiv/acquired immune deficiency syndrome (aids). the national population and family planning board (badan kependudukan dan keluarga berencana nasional, bkkbn) has developed the youth information and counseling center (pusat informasi dan konseling remaja, pik-r) program as a forum for information and counseling services, one of which is about adolescent reproductive health (arh) including hiv/aids. this study aimed to explore whether the implementation of the programs related to hiv/aids prevention in adolescents, specifically in junior high school in bandung city. methods: a qualitative descriptive study was carried out at a junior high school in bandung in august 2018. this study used a purposive sampling technique and data were collected by conducting indepth interviews with nine program administrators who were then transcribed and coded based on the pik-r management guidelines using the nvivo12 software, observing the program activities and documentations study which were then triangulated. results: several indicators in the growing stage had been implemented according to the guidelines, consisting of mastering arh education materials including hiv/aids, conducting activities in the form of providing materials and peer counseling although without a secretariat room, and establishing networks and partnerships. conclusions: the pik-r program can be a media for preventing hiv/aids among junior high school students in bandung regardless of resource limitations. therefore, supports from bkkbn and the school itself is needed to improve the implementation of this program. keywords: adolescent, hiv/aids,implementation, prevention, pik-r https://doi.org/10.15850/amj.v8n3.2252 althea medical journal. 2021;8(3) 139 reproductive health (arh), including hiv/ aids. the existence and role of pik-r in the youth environment are very important in helping adolescents obtain comprehensive information and youth-friendly counseling services.4 the pik-r program has been implemented in several junior high schools in bandung since 2013. guidelines for the management of pik-r were published by bkkbn in 2012.4 however, according to the population control and family planning services (dinas pengendalian penduduk dan keluarga berencana, dppkb) of bandung, the implementation is still varied and has not based on existing guidelines. based on the pik-r management guidelines, there are three stages in the implementation of pik-r. the first stage is the formation stage which is called the growing stage (tahap tumbuh). then in its development, the program moves to the firm stage (tahap tegar) and the last is the upright stage (tahap tegak), each of which has its own indicators, including (1)educational materials controlled by the peer educators, (2)activities undertaken, (3)facilities, infrastructure, and human resources, and (4)networks and partnerships.4 researchers used indicators of growing stages in accordance with pik-r management guidelines as a reference in this study. the aim of this study was to determine how the implementation of the pik-r program was carried out in junior high school as a manifestation of the hiv/aids prevention program in adolescents in bandung. methods this research was a case study with a qualitative descriptive approach, conducted in august 2018 at a public junior high school (sekolah menengah pertama negeri, smpn) in bandung which had the pik-r program. schools that had been implementing the pik-r program were asked to participate. according to the dppkb of bandung, there were four junior high schools in bandung that had been implementing the pik-r program, including smpn 51, smpn 39, smpn 35, and smp plus al-ghifari. however, only smpn 51 was still actively participating in this program based on site visits, thus, this school was further enrolled in the study. this study used the purposive sampling technique until there was saturation of the data. data collection was carried out by structured interviews with program administrators based on the pik-r management guidelines. the answers from the informants were recorded using a mobile phone voice recorder. program activities were then observed when they introduced pik-r activities and presented educational materials to new members. consecutively, the study of documentation was carried out by examining documents such as the decree for the establishment and implementation of pik-r at smpn 51 bandung, the pik-r database and organizational profile, application for program implementation permits, and training participation certificates. data analysis was performed using qualitative data processing software, (nvivo12, qsr international usa). the recorded interviews were transcribed and then coded and categorized. the conclusion of the interview was triangulated with observation and documentation study. this research was approved by the health research ethics committee of universitas padjadjaran no. 494/un6.kep/ec/2018, as well as approval from the smpn 51 bandung. results the informants of this research were 9 active pik-r administrators consisting of 3 coaches, 1 chairman, 2 peer educators, 2 peer counselors, and 1 secretary. the steps for establishing pik-r include 1) a meeting of youth members for the formation of pik-r and pik-r management to discuss the importance of forming pik-r and agree on its formation, 2)consultation and coordination to obtain support/approval with local leaders regarding the plan to establish pik-r (school principals), 3)arrange the names and composition of the pik-r management, 4) develop a program of activities in accordance with the indicator growing stage pik-r, and 5)inaugurated the establishment of pik-r which was strengthened by a decree from the concerned pik-r supervisor.4 the results of the interview showed that the pik-r smpn 51 bandung was formed four years ago because it was appointed directly by the dppkb of bandung city to participate in the city-level pik-r competition. this coincided with the need for schools to anticipate students from committing juvenile delinquency such as free sex, drug abuse, smoking, and others. “firs, it was formed because of the students’ anticipation needs to avoid free sex, use of cigarettes, and drug abuse, whereas incidentally it was also appointed from the dppkb. “ (co3) the formation of the pik-r was strengthened by the existence of a decree from shifa nadya rahma et al.: implementation of youth information and counseling centers related to hiv/aids prevention in a junior high school in bandung althea medical journal. 2021;8(3) 140 althea medical journal september 2021 table 1 informant characteristics code gender age (years old) position active period (year) c1 female 14 chairman 1 co1 female 41 coach 4 co2 male 42 coach 4 co3 female 56 coach 4 pe1 female 14 peer educators 1 pe2 male 14 peer educators 1 pc1 female 15 peer counselor 1 pc2 female 14 peer counselor 1 s1 female 14 secretary 1 the current principal. the decree also attached the management structure of pik-r smpn 51 the year 2018 which consists of patrons, namely the dppkb of bandung, the person in charge, namely the principal of the smpn 51 bandung, the supervisor of the pik-r in bandung, the rancasari district health center, the rancasari police, the family planning coordinator in the district of rancasari, and the deputy head of student affairs, four mentors from the counseling teacher, one chairperson, one deputy chairperson, two secretaries, one treasurer, three peer educators, two peer counselors, one life skills section, one documentation section, and one public relation section which was also in accordance with the wall magazine management structure made by pik-r members. the results of this study indicated that the steps for establishing pik-r at smpn 51 bandung were in accordance with the pik-r management guidelines. the pik-r growing stage program activities consist of genre materials controlled by peer educators, which are 8 family functions, maturity of marriage age, arhtriad (hiv/ aids, sexuality, and drugs), and life skills.4 based on the results of this study, pik-r members mastered various pik-r materials, especially the arhtriad, prevention of early marriage, and other adolescent problems. materials were obtained from various sources such as the internet, books, counseling classes, and the gathering for pik-r members. “the main material is about the arhtriad: hiv/aids, sex, drugs. “ (c1) “the materials were about adolescent issues, hiv, the dangers of smoking, premarital sex and pregnancy, and drugs.” (pc2) the main activities of pik-r in its the growing stage are to increase awareness in the school environment by using print media such as wall magazines, leaflets, posters, and recording and reporting on a regular basis.4 while the implementation of activities in the pik-r program at smpn 51 bandung included peer counseling, extracurricular demonstrations, gathering of administrators and members, member recreation, and outreach counseling to elementary school students confirmed with a permit. peer counseling at pik-r smpn 51 bandung was mainly done in class and after the flag ceremony on monday as a place for students to confide. some informants mentioned that this counseling was carried out regularly every one or two months. the results of this study indicated that the activities carried out by pik-r smpn 51 bandung have not met the activity indicators at the growing stage because the activities have not used printed media such as posters, etc., but the outreach activity outside of school has met the upright stage.4 “we routinely provide information in the field after the ceremony every one or two months. there are counseling activities to the classroom but not routine.” (c1) facilities, infrastructure, and human resources that need to be fulfilled in the growing stage are a secretariat room, a signboard with a minimum size of 60x90 cm, a minimum management organizational structure consisting of a supervisor, chairperson, secretary, treasurer, program and activity sections, and a minimum of 2 peer educators who have been trained in the substance of the genre program.4 this study showed that the pik-r smpn 51 bandung did not have a secretariat room or a signboard. previously, they had their althea medical journal. 2021;8(3) 141shifa nadya rahma et al.: implementation of youth information and counseling centers related to hiv/aids prevention in a junior high school in bandung own room, but due to the limited number of classrooms, the secretariat room was converted into a classroom. thus, pik-r members at this school had activities in the counseling room or unused classrooms after school. in addition, bkkbn had provided genre board games that can be used during gathering sessions. “there used to be a basecamp on the top floor about 3 years ago, but due to the changed of the school principal and the lack of required classroom, the pik-r secretariat room was used as a classroom. so, we gathered in an unused classroom.” (co1) according to information from the chief, there were 14 active administrators from grade 9, three of whom were peer educators according to the management structure attachment in the 2018 decree issued by the principal. at the beginning of the programs’ formation, two peer educators and counselors from this school had participated in training from the bkkbn in 2016 which was strengthened by a certificate of participation. the result of this study indicated that the facilities and infrastructure at pik-r smpn 51 bandung were not in accordance with the pik-r management guidelines because of the limitations of the school in terms of human resources, pik-r smpn 51 bandung was in accordance with the guideline at the growing stage. in the pik-r growing stage, there must be collaboration with stakeholders inside the community, for example, the school principal, as well as the nearest public health center (pusat kesehatan masyarakat, puskesmas) with pik-r as a medical reference point.4 there were several institutions that had a collaboration with pik-r at smpn 51 bandung, including the bkkbn through dppkb of bandung, puskesmas, and national narcotics board (badan narkotika nasional, bnn). based on this information, pik-r in this school had established partnerships in accordance with the growing stage of the existing guidelines. discussion hiv prevention among adolescents is integrated into biomedical, behavioral, and structural systems that can be achieved with adequate knowledge.5,6 peer education and counseling are effective tools to promote healthy behavior among adolescents.7 however, pik-r, the peer education and counseling mediation program was only implemented in one junior high school in bandung. similar finding were found in banda aceh that only 7 out of 47 senior high schools implemented this program and this was due to the lack of youth participation and limited human resources.8 the implementation of pik-r at smpn 51 bandung has met the criteria for the growing stage including mastering hiv/aids material and delivering it in peer education and counseling activities. these results showed similarities with pik-r in sukowono district which carried out activities in the form of counseling for adolescents in the community and school environment.9 this indicates that the pik-r management guidelines are the basis for the implementation of this program. peer counseling techniques have also been practiced by high school students in cimahi and bandung10 and junior high school in pik-r wijaya kusuma to raise awareness regarding arh.11 not only in indonesia, a peer mentorship program to provide support and knowledge about hiv/aids were also carried out among young orphans in southern uganda.12 this study did not assess how the implementation of this program in improving adolescents’ knowledge about hiv/aids. however, peer education activities on hiv/ aids conducted in secondary schools in nigeria demonstrated its effectiveness in increasing knowledge, attitudes and behavior towards hiv prevention.13 the spanish adolescents hiv prevention intervention, compas, also demonstrated improved outcomes in hiv knowledge and attitudes and condom use intentions.14 in north surabaya, most students acquire knowledge on adolescent reproductive health showed a strong attitude (50%) towards adolescent reproductive health.15 these studies imply that school-based education and counseling such as the pik-r program has the potential to increase students’ knowledge about hiv and reproductive health. there are several challenges faced by smpn 51 bandung in fulfillment of facilities and infrastructure. pik-r in karawang schools showed the same problem where they did not have secretariat room.16 the use of a game similar to the genre board game to deliver educational material called zig-zaids had been developed to prevent aids and then evaluated for use in adolescents in the study by schall et al.17 in brazil. the results of this study indicate the ability of games to stimulate the participants’ learning abilities in an entertaining way that supports the use of genre games in the implementation of pik-r. collaborating with other institutions such as bkkbn or ngo at smpn 51 bandung is needed althea medical journal. 2021;8(3) 142 althea medical journal september 2021 to improve the quality programs such as in pik-r sman 5 makassar.18 in addition to the minimal number of schools implementing this program, the utilization of this program is also still low. a study conducted at senior high school in makassar city found that only 24.3% of the students used adolescent reproductive health services such as pik-r. meanwhile, reproductive health knowledge is related to the utilization of these services.19 another study in bekasi city found that only 54.88% of students were aware of the pik-r program and only 8.11% participated in the program. similarly, students who participated in the pik-r program showed significantly lower negative behaviors.20 therefore, the implementation of pik-r should be more encouraged and supported as an effective way to improve the knowledge and behavior of adolescents. the limitation of this study is that the data collection which is performed in the only school that is still actively running the pik-r program while other schools are no longer running the program. further studies can be done to assess how this program affects the knowledge and behavior of adolescent about hiv/aids prevention in bandung in particular and in others regions in indonesia in general. in conclusion, the only pik-r currently running at junior high school in bandung, smpn 51 bandung, has been implementing the program in growing stage following the pik-r management guidelines published by bkkbn with all its limitations. this program can be a media prevention of hiv/aids among adolescent students and should be implemented in more schools in bandung. therefore, the full support of the bkkbn and the school itself is needed to improve the implementation of this program. references 1. unaids. country factsheet indonesia 2019 [internet]. 2019 [cited 2020 dec 4]. available from: http://www.unaids.org/ en/regionscountries/countries/indonesia 2. yoshimura k. current status of hiv/ aids in the art era. j infect chemother. 2017;23(1):12–6. 3. kementerian kesehatan ri. situasi dan analisis hiv aids. jakarta: kementerian kesehatan ri; 2014. p.1–6. 4. badan kependudukan dan keluarga berencana nasional direktorat bina ketahanan remaja. pedoman pengelolaan pusat informasi dan konseling remaja dan mahasiswa. jakarta: badan kependudukan dan keluarga berencana nasional direktorat bina ketahanan remaja; 2014. 5. hosek s, pettifor a. hiv prevention interventions for adolescents. curr hiv/ aids rep. 2019;16(1):120–8. 6. diclemente rj, jackson jm. towards an integrated framework for accelerating the end for the global hiv epidemic among young people. sex educ. 2014;14(5):609– 21. 7. abdi f, simbar m. the peer education approach in adolescentsnarrative review article. iran j public health. 2013;42(11):1200–6. 8. safrizan s, mawarpury m, sofia s, usman s, sahputra i. students’ knowledge level towards generation planning program in the city of banda aceh. strada jurnal ilmiah kesehatan. 2021;10(1):10–6. 9. wahyuningrum dm, gani ha, ririanty m. upaya promosi kesehatan pendewasaan usia perkawinan oleh pusat informasi konseling remaja (pik-r) ditinjau dari teori precede-proceed. pustaka kesehatan. 2015;3(1):186–92. 10. nurfazriah i, sunjaya dk, susanah s. the peer counseling model in adolescents reproductive health for senior high school students. glob med health commun. 2018;6(3):209–19. 11. isni k, matahari r. the role of wijaya kusuma’s youth information and counseling center (pik-r) on adolescent health problems. international journal of public health science (ijphs). 2018;7(1):27–32. 12. nabunya p, ssewamala fm, mukasa mn, byansi w, nattabi j. peer mentorship program on hiv/aids knowledge, beliefs, and prevention attitudes among orphaned adolescents: an evidence-based practice. vulnerable child youth stud. 2015;10(4):345–56. 13. adeomi aa, adeoye oa, asekunolarinmoye eo, abodunrin ol, olugbengabello ai, sabageh ao. evaluation of the effectiveness of peer education in improving hiv knowledge, attitude, and sexual behaviours among in-school adolescents in osun state, nigeria. aids res treat. 2014;2014:131756. 14. espada jp, orgilés m, morales a, ballester r, huedo-medina tb. effectiveness of a school hiv/aids prevention program for spanish adolescents. aids educ prev. 2012;24(6):500–13. 15. muthmainnah m, nurmala i, siswantara althea medical journal. 2021;8(3) 143shifa nadya rahma et al.: implementation of youth information and counseling centers related to hiv/aids prevention in a junior high school in bandung p, rachmayanti rd. implementation of adolescent health programs at public schools and religion-based schools in indonesia. j public health res. 2021. doi: https://doi.org/10.4081/jphr.2021.1954 16. oon s. kebijakan pelaksanaan pusat informasi konseling remaja (pik r) berbasis sekolah di karawang. health science growth journal. 2017;2(1):47–62. 17. schall vt, monteiro s, rebello sm, torres m. evaluation of the zig-zaids game: an entertaining educational tool for hiv/ aids prevention. cad saúde pública (rio de janeiro). 1999;15(suppl 2):s107–19. 18. alyas a. implementasi kebijakan kesehatan reproduksi. al-fikr. 2011;15(1):195–214. 19. violita f, hadi en. determinants of adolescent reproductive health service utilization by senior high school students in makassar, indonesia. bmc public health. 2019;19(1):286. 20. hastuti d, alifiasari a, hernawati n, oktriyanto o, puspitasari md. effectiveness of “pik-r” program as an extracurricular for high/vocational school students in preventing negative behaviors of adolescents. cakrawala pendidikan. 2019;38(1):1–15. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 224 patients’ satisfaction in public and private primary health care: a study in karawang regency, west java, indonesia meliannisa afader,1 putri halleyana rahman,2 deni kurniadi sunjaya3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia, 3department of public health, faculty of medicine universitas padjadjaran, indonesia correspondence: meliannisa afader, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, email: meliannisaafader@gmail.com introduction the alma ata declaration in 1978 and the astana declaration in 2018 have made primary health care (phc) the foundation of the sustainable development goals (sdgs) in 2030 to achieve universal health coverage (uhc).1–3 health care can be provided through public and private providers. the government usually provides public health care through national healthcare systems.4 in indonesia, as mandated by law, the government has launched the national health insurance (jaminan kesehatan nasional, jkn) program, which is expected to become a reliable program to achieve uhc gradually.5 health service providers include all health facilities that cooperate with the healthcare and social security agency (badan penyelenggara jaminan sosial kesehatan, bpjs kesehatan) in the form of first-level health facilities (fasilitas kesehatan tingkat pertama, fktp) and advanced-level referral health facilities.6 a phc is carried out at the fktp, consisting of public health centers (pusat kesehatan masyarakat, puskesmas), private practices althea medical journal. 2021;8(4):224–230 abstract background: primary health care is the foundation of the sustainable development goals (sdgs) to achieve universal health coverage (uhc). patient satisfaction with the health services acquired is one of the factors to achieve the uhc target. this study aimed to determine patients’ satisfaction in public and private primary health care centers. methods: this quantitative analytic study with a cross-sectional method was conducted in five subdistricts of karawang regency based on community satisfaction surveys. the instrument used was a standard questionnaire with nine dimensions and filled with a survey approach by the respondents. data was transformed from ordinal to numeric using rach modelling. then, numerical data were analysed with chi square test in ibm spss statistic 23 version to determine differential between public and private groups. results: in total, 193 respondents were included of whom 123 patients were from public health centers (pusat kesehatan masyarakat, puskesmas) and 70 from private primary care (clinic). three dimensions had differences in satisfaction, including the requirements (p=0.001); systems, mechanisms, and procedures (p=0.001); and service time (p=0.001). the other six dimensions such as cost (p=0.534); product specification type of service (p=0.213); implementer competence (p=0.163); implementer behavior (p=0.000); handling of complaints, suggestions, and advances (p=0.448); and facilities infrastructure (p=0.063) were not proven to have differences in satisfaction. overall, patients’ satisfaction level at puskesmas (67.5%) was lower than at clinics (88.6%) (p=0.001). conclusion: patients’ satisfaction with the puskesmas is lower than the clinic. further study with a larger sample size and more complete dimension is needed. keywords: clinic, patient satisfaction, private primary health care, public health center https://doi.org/10.15850/amj.v8n4.2340 althea medical journal. 2021;8(4) 225 (general practitioners and dentist), pratama clinics (government and private sector), and class d pratama hospitals.6 puskesmas is a health service facility that organizes public health efforts and first-level individual health efforts, by prioritizing promotive and preventive efforts, to achieve the highest level of public health in its working area.7 meanwhile, private clinics are primary health services that belong to the private sector.8 private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.4 health services often get many complaints from their patients. as an effort to improve services, it is necessary to conduct the quality of the health services through the community satisfaction index as a measure of optimizing public performance by a government official to the community.9 based on the regulations of the ministry of administrative and bureaucratic reform of the republic of indonesia10 each public institution should measure the level of customer satisfaction. thus, puskesmas as public health care and clinics as private health services must measure the quality of their services. patient satisfaction with the health services acquired is one of the factors to achieve the uhc target.11 therefore, the number of visits to puskesmas develops the perception that the patient has recieved a good service. however, this number of visits is not equivalent to patient satisfaction.12 other studies evaluated in the systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector. the public sector appears frequently to lack timeliness and hospitality towards patients.4 a study conducted in denpasar11 showed differences in health service satisfaction at the puskesmas and clinics. puskesmas have a better level of satisfaction than the private clinic. previous research on patient satisfaction in east karawang13 showed that patients are on a satisfying scale. based on these studies, it is interesting to find out more about the level of patient satisfaction in health facilities in karawang, especially public health centers and private clinics as well as on what dimensions the differences in patient satisfaction levels occur. this study aimed to determine patients’ satisfaction in public and private primary health care centers in karawang regency, west java, indonesia. methods this research was a quantitative analytic study with a cross-sectional method using a survey method. the total sampling technique was used by filling out a questionnaire survey conducted in november 2019. the inclusion criteria were patients who had come at least two times to the puskesmas and clinics in five subdistricts at karawang regency and aged between 18–60 years. the questionnaire was used to assess patient satisfaction, issued by the ministry of administrative and bureaucratic reform of republic of indonesia, modified by the department of public health, faculty of medicine, universitas padjajaran. the questionnaire was based on nine satisfaction dimensions, with 29 questions using a likert scale of five answers categories. the questionnaire was drafted with a 5-point likert response scale ranging from 1 (not satisfied) to 5 (very satisfied). this questionnaire can determine the level of satisfaction of the puskesmas and clinic, and on what dimensions differences in satisfaction between the two health facilities. the validity of the questionnaire concerning the raw variance obtained was 38.1%. this questionnaire met the minimum requirements of 20% unidimensionality. the overall interaction reliability index between person and items was 0.94, including the excellent category. furthermore, the reliability index of the person was in the suitable category (0.85) with a separation of 2.36, meaning that the data grouping was diverse; the more varied the group, the more representative the data. the item reliability index (0.93) was in the excellent category with a separation of 3.76, meaning that the data grouping was diversed.14 the data obtained were inputted into microsoft® excel 2019. data analysis in ordinal form was transformed using the rasch model, assisted by winstep® software version 5.1.0. then, the numerical data were analyzed by chi square test on ibm spss statistic 23 version to determine the difference between public and private groups. the research ethics committee of universitas padjajaran approved this study with ethical clearance no 1359/ un6.kep/ec/2019. results of the 193 respondents who were included, 123 respondents were patients from puskesmas and 70 from clinics. the characteristics of respondents were based on age, gender, formal meliannisa afader et al.: patients’ satisfaction in public and private primary health care: a study in karawang regency, west java, indonesia althea medical journal. 2021;8(4) 226 education, occupation, health insurance membership, house ownership, vehicle ownership, and income (table 1). respondents at puskesmas were generally (80.5%) aged 21–55 years, female (78.0%), had elementary school education (47.2%), and did not have a job (67.5%). respondents, in general, had become members of jkn (71.5%), owned a house (75.6%). respondents owned a vehicle, of whom 81.3% had a two-wheeled vehicle, and only 4.9% owned a 4-wheeled vehicle. in terms of income, respondents (68.3%) stated that they had an income below the regional minimum wage (rmw) (table 1). table 1 characteristics of respondents from the public health care (puskesmas) and private primary health care (clinic) at karawang regency dimension health facility p-valuepuskesmas (n=123) clinic (n=70) n(%) n(%) age (year) 18–20 21–55 >55 8 (6.5) 99 (80.5) 16 (13.0) 2 (2.8) 58 (82.9) 10 (14.3) 0.541 gender female male 96 (78.0) 27 (22.0) 57 (81.4) 13 (18.6) 0.712 formal education elementary school junior high school senior high school diploma / undergraduate 58 (47.2) 42 (34.1) 22 (17.9) 1 (0.8) 25 (35.7) 18 (25.7) 18 (25.7) 9 (12.9) *0.001 occupation have a job have no job 40 (32.5) 83 (67.5) 37 (52.9) 33 (47.1) *0.006 membership status of health insurance membership of national health insurance (bpjs jkn-kis) non membership of any insurance 88 (71.5) 35 (28.5) 61 (87.1) 9 (12.9) *0.013 house ownership own house dwell rent 93 (75.6) 25 20.3) 5 (4.1) 57 (81.4) 11 (15.7) 2 (2.9) 0.643 vehicle ownership own vehicle do not have vehicle 100 (81.3) 23 (18.7) 60 (85.7) 10 (14.3) 0.552 two-wheeled vehicle have do not have 100 (81.3) 23 (18.7) 59 (84.3) 11 (15.7) 0.696 four-wheeled vehicle have do not have 6 (4.9) 117 (95.1) 6 (8.6) 64 (91.4) 0.358 income < rmw (rp2,275,751.00) rmw (rp2,275,751.00) to double rmw (rp.4,551,430.00) >double rmw (rp4,551,430.00) 84 (68.3) 30 (24.4) 9 (7.3) 37 (52.9) 25 (35.7) 8 (11.4) 0.102 note: bpjs= badan penyelenggara jaminan sosial, jkn: jaminan kesehatan nasional, kis= kartu indonesia sehat, rmw= regional minimum wage althea medical journal december 2021 althea medical journal. 2021;8(4) 227meliannisa afader et al.: patients’ satisfaction in public and private primary health care: a study in karawang regency, west java, indonesia similar to puskesmas, respondents in the clinic were generally (82.9%) aged 21– 55 years, female (81.4%), graduated from elementary school (35.7%) and had a job (52.9%). a total of 87.1% of respondents had been members of the bpjs, owned a house (81.4%), and 84.3% owned a two-wheeled vehicle. respondents at the clinic stated that they had an income below the rmw (52.9%) (table 1). there were significant differences between patients at the puskesmas and at the clinic in terms of education (p=0.001), occupation (p=0.006), as well as the membership of health insurance (p=0.013) (table 1). besides, in term of patient satisfaction index for health services at the puskesmas and the clinic, this study also found differences (p=0.001). patients who went to the clinic (88.6%) were more satisfied than the most patients who went to the puskesmas (67.5%), overall, patients’ satisfaction level at puskesmas was lower than at clinics (table 2). there were 3 dimensions that had differences in satisfaction, including the requirements (p=0.001); systems, table 2 comparison of satisfaction levels between puskesmas and clinics dimension health facility p-valuepuskesmas (n=123) clinic (n=70) n(%) n(%) requirements satisfaction dissatisfaction 83 (67.5) 40 (32.5) 62 (88.6) 8 (11.4) *0.001 systems, mechanisms, and procedures satisfaction dissatisfaction 83 (67.5) 40 (32.5) 62 (88.6) 8 (11.4) *0.001 service time satisfaction dissatisfaction 75 (61.0) 48 (39.0) 59 (84.3) 11 (15.7) *0.001 cost satisfaction dissatisfaction 92 (74.8) 31 (25.2) 52 (74.3) 18 (25.7) 0.534 product specification type of service satisfaction dissatisfaction 74 (60.2) 49 (39.8) 49 (70.0) 21 (30.0) 0.213 implementer competence satisfaction dissatisfaction 74 (60.2) 49 (39.8) 50 (71.4) 20 (28.6) 0.163 implementer behavior satisfaction dissatisfaction 76 (61.8) 47 (38.2) 47 (67.1) 23 (32.9) 0.534 handling of complaints. suggestions, and advances satisfaction dissatisfaction 69 (56.1) 54 (43.9) 54 (77.1) 26 (37.1) 0.448 facilities and infrastructure satisfaction dissatisfaction 84 (68.3) 39 (31.7) 57 (81.4) 13 (18.6) 0.063 all dimensions satisfaction dissatisfaction 83 (67.5) 40 (32.5) 62 (88.6) 8 (11.4) *0.001 note: *significant different if p<0.05 althea medical journal. 2021;8(4) 228 mechanisms, and procedures (0.001); service time (p=0.001). the other 6 dimensions such as cost (p=0.534); product specification type of service (0.213); implementer competence (p=0.163); implementer behavior (p=0.534); handling of complaints, suggestions, and advances (p=0.448); facilities and infrastructure (p=0.063) were not proven to have differences in satisfaction (table 2). discussion the findings showed that the majority of respondents were patients at the puskesmas. both patients in puskesmas and clinics mainly were aged 21–55 years, female, members of the national health insurance, owned a house, a vehicle, and had an income below the regional minimum wage. however, in terms of education and occupation dimensions, the patients at the clinic have significantly differences than patients at the puskesmas as well as the membership of health insurance (p<0.05). the dimensions of formal education, occupation, and membership status in health insurance influenced the choice of health facilities. in contrast, other factors had no bearing on the decision to use a health facility. these results are consistent with a study in jambi,15 showing that formal education affects patients’ choices in health care facilities. the higher a person’s education level would affect how they access their information and knowledge to handle the problem that will affect their behavior, especially health behavior.15 occupational dimensions affected the patients’ choice of health facilities. most patients who had jobs preferred clinics while patients who did not have jobs preferred puskesmas to obtain health services. having a job means that the patients have a regular income so they could afford for better healthcare. membership on health insurance also affected the patients’ choice of health facilities. according to research in india,16 people with health insurance are more likely to choose to maintain their health in a hospital or clinic because they can afford it. income and having insurance are essential determinants and imply that the poor have access problems. overall dimension shows that patients satisfaction were significantly different between puskesmas and clinic (p=0.001). patients who went to the private clinic were more satisfied than most patients who went to the puskesmas, especially in terms of requirements, systems, mechanisms, procedures and service time. the dimensions of requirements; system, mechanisms, and procedures; also service time were linearly related to patient satisfaction in both healthcare facilities. a similar study in bali11 contradicted this finding, showing that patients’ satisfaction at the puskesmas was higher than at the private clinic. respondents at puskesmas tend to be more satisfied than at government clinics and private clinics. it may be related to the level of education and jkn membership status. the education level of respondents who visited the puskesmas tended to be lower than other types of fktp. respondents who received contribution assistance from the government (pbi) of 100% said they were satisfied with health services at the puskesmas, possibly because they received contribution assistance from the government. moreover, it may also relate to the increasing quality of puskesmas due to iso accreditation. the lowest patient satifaction in private clinics is caused by dissatisfaction with the dimensions of physical appearance (tangible) quality due to the limited parking space and the inconvenience of the waiting room. the problem is probably related to the high number of visits to private clinics.11 patient’s satisfaction on the dimension of requirements was different between puskesmas and the clinic. another study conducted in surabaya17 reported that technical and administrative requirements should be relevant to the type of service provided. apparently, to satisfy the necessity of puskesmas and clinic is not complicated.17 these prerequisites must be satisfied both actually and authoritatively in overseeing wellbeing administrations in wellbeing offices.10 the system, mechanism, and procedures at the puskesmas and clinic affected patient’s satisfaction between the puskesmas and the clinic. variables in the system, mechanism and procedures must be easy to understand, and information about service procedures should be displayed. also, staff can assist by explaining procedures and the flow of services to patients. similarly, the results of a study in medan showed that a reasonable service procedure should be easy to understand, simple, and straightforward.18 previous research on community satisfaction conducted at east karawang13 showed that the dimensions of communication and courtesy of medical personnel had met patient satisfaction. however, several other althea medical journal december 2021 althea medical journal. 2021;8(4) 229meliannisa afader et al.: patients’ satisfaction in public and private primary health care: a study in karawang regency, west java, indonesia dimensions have not met patient satisfaction, such as infrastructure, types of equipment, means of communication, and speed of service.13 besides, dimensions of speed of service affected patient satisfaction. the measurement could be seen from the service speed, waiting time, and consultation time with medical personnel.10 these results are in accordance with the study in sampit19 which showed that health services are considered good if they could be served quickly without waiting too long, and services are considered terrible if they wait too long. the limitation of this study is that the minimum number of samples required to assess the five sub-districts was not met. the sample of this study did not represent all patients in the puskesmas and clinics in karawang regency. moreover, other dimensions that influence the difference in satisfaction levels between puskesmas and clinics in this study are unknown. this study also has limitations on several dimensions of patient satisfaction, which are not different from patient satisfaction at puskesmas and the clinic. in-depth research on data collection and analysis needs to be conducted to examine which dimensions affect patient satisfaction. this is crucial as the results of this study can be the baseline for the government of karawang or even west java to make policies related to health services. in conclusion, the perception of patient satisfaction with the puskesmas is generally lower than the clinic. knowing the difference in satisfaction levels between puskesmas and clinics is very important to know the strengths and weaknesses of each. this data can be used as the primary material to improve the quality of health services. the quality of excellent health services will have an impact on increasing health rates in karawang regency. the management of the puskesmas must evaluate this shortcoming because the puskesmas as a governmental health facility must be comparable to those managed by the private sector. further study with a larger sample size and complete-dimension is needed. references 1. rifkin sb. alma ata after 40 years: primary health care and health for all-from consensus to complexity. bmj glob health. 2018;3(suppl 3):e001188. 2. rasanathan k, evans tg. primary health care, the declaration of astana and covid-19. bull world health organ. 2020;98(11):801–8. 3. gupta j, vegelin c. sustainable development goals and inclusive development. int environ agreements. 2016;16:433–48. 4. basu s, andrews j, kishore s, panjabi r, stuckler d. comparative performance of private and public healthcare systems in lowand middle-income countries: a systematic review. plos med. 2012;9(6): e1001244. 5. irwandy. kajian literature: evaluasi pelaksanaan program jaminan kesehatan nasional di indonesia. jurnal kebijakan kesehatan indonesia. 2016;5(3):110–4. 6. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 5 tahun 2018 tentang perubahan ketiga atas peraturan menteri kesehatan nomor 71 tahun 2013 tentang pelayanan kesehatan pada jaminan kesehatan nasional. jakarta: kementerian kesehatan republik indonesia; 2018 7. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 7 tahun 2014 tentang pusat kesehatan masyarakat. jakarta: kementerian kesehatan republik indonesia; 2014 8. rachmad ra, wahyati e, dan kurnia e. implementasi peraturan menteri kesehatan nomor 9 tahun 2014 tentang klinik pada penyelenggaraan poliklinik kesehatan desa di kabupaten batang. soepra jurnal hukum kesehatan. 2015;1(1):14–26. 9. sukanti s, utomo h. analisis indeks kepuasan masyarakat (ikm) pada pelayanan publik di puskesmas kalicacing kota salatiga. among makarti. 2015;8(1):108. 10. menteri pendayagunaan aparatur negara dan reformasi birokrasi republik indonesia. peraturan menteri pendayagunaan aparatur negara dan reformasi birokrasi republik indonesia nomor 14 tahun 2017 tentang pedoman penyusunan survei kepuasan masyarakat unit penyelenggara pelayanan publik. jakarta: kementrian pendayagunaan aparatur negara republik indonesia; 2017. 11. widiastuti nm, nopiyani nms, karmaya inm. perbedaan kepuasan pasien jaminan kesehatan nasional pada empat jenis fasilitas kesehatan tingkat pertama. public health prevent med arch. 2015;3(2):119– 25. althea medical journal. 2021;8(4) 230 12. putrajaya mr, wijaya in, nugraheni g. indonesia towards universal health coverage: indonesia health card holders satisfaction on pharmaceutical service at primary health cares. indian j public health res develop. 2019;10(6):523–8 13. suswardji e, martini n, meliana r. pengaruh pelayanan puskesmas terhadap kepuasan pasien di puskesmas adiarsa karawang timur. jurnal manajemen. 2012;09(2):609–21. 14. sumintono b, widhiarso w. aplikasi model rasch untuk penelitian ilmu-ilmu sosial. rev ed. cimahi: trim komunikata publishing house; 2014. 15. putri md. faktor-faktor yang berhubungan dengan pemilihan tempat persalinan tahun 2015 (studi di kecamatan sarolangun kabupaten sarolangun jambi). jurnal kesehatan masyarakat universitas diponegoro. 2016;4(2):18392. 16. srivastava d, mcguire a. patient access to health care and medicines across low-income countries. soc sci med. 2015;133:21–7. 17. sari im, sulistyarini w, hertanti d. efektivitas kinerja pelayanan berbasis sistem e-health di rumah sakit umum daerah (rsud) dr. soewandhi surabaya. jurnal penelitian administrasi publik. 2020;6(1):106–19. 18. astuti s, nyorong m, januariana ne. pengaruh pelayanan kesehatan gigi dan mulut terhadap kepuasan pasien di puskesmas sentosa baru kota medan. jurnal kesmas prima indonesia. 2020;2(2):26–37. 19. indrawan ibmd. pengaruh kualitas pelayanan jkn-kis terhadap kepuasan peserta jkn-kis pada pemanfaatan pelayanan kesehatan di rsud dr. murjani sampit. kindai. 2020;16(2):201–19 althea medical journal december 2021 amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 69 relationship between clean, healthy living behaviour, and covid-19 infection at the parigi public health center, west java, indonesia putri asyri wa indhillah,1 ardini saptaningsih raksanagara,2 sharon gondodiputro2 1faculty of medicine, universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: putri asyri wa indhillah, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: putri18001@mail.unpad.ac.id introduction coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sarscov-2).1 the total number of confirmed covid-19 cases in indonesia ranked 17th in the world as of february 11, 2022, with a total of 4,677,554 cases.2 one of the increases in the total number of covid-19 occurred in pangandaran regency, west java, indonesia, with a total case of 1,464 on april 1, 2021, and increased to 6,535 cases on august 26, 2021.3 pangandaran regency is a national tourism strategic area (kawasan strategis pariwisata nasional, kspn) that becomes the main tourists destination that allows increased transmission. an increase in covid-19 cases can cause a public health emergency (kedaruratan kesehatan masyarakat, kkm), which causes losses in various sectors. therefore, it is necessary to control it through guidelines for the prevention and control of covid-19 according to the regulation minister of health (keputusan menteri kesehatan, kepmenkes) number hk.01.07/menkes/413/2020. one form of prevention is clean and healthy living behavior (perilaku hidup bersih dan sehat, phbs). there are six phbs indicators related to covid-19 based on kepmenkes number hk.01.07/menkes/413/2020, namely behavior of using clean water, washing hands with clean water and soap, healthy latrines, consuming fruits and vegetables every day, daily physical activity, and do not smoking at home.1 several studies using descriptive analysis methods explain theories regarding phbs indicators at the household level with the risk of being infected with sars-cov-2.4–11 research in the united kingdom (uk) explains that there is no association between subjectively reported physical activity and covid-19 infection.12 besides, there is study explaining that there is an association between althea medical journal. 2023;10(2):69–74 abstract background: coronavirus disease 2019 (covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). one form of prevention is implementing clean and healthy living behaviour (perilaku hidup bersih dan sehat, phbs) at the household level. this study aimed to analyze the association between phbs at the household level and covid-19 cases at the parigi public health center, west java, indonesia. methods: this was an unmatched case control study carried out in september–october 2021 with respondents from parigi public health center, pangandaran regency, west java, indonesia, involving 63 people for each case and control group. sampling was conducted by the non-probability method. data were collected using a checklist to measure the implementation of phbs at the household level. data were analyzed by statistical analysis, using the chi-square or fisher exact test and odds ratio. results: there was no statistically significant difference between the implementation of phbs at the household level and the incidence of covid-19 (p=0.668). conclusion: the implementation of phbs at the household level is not related to the incidence of covid-19. further studies are needed with larger population, looking for causal relationship, and controlling for confounding variables. keywords: clean and healthy living behaviour, coronavirus disease 2019, parigi public health center https://doi.org/10.15850/amj.v10n2.2715 althea medical journal. 2023;10(2) 70 hand washing and a reduced risk of seasonal coronavirus infection, which is believed to have the same transmission mechanism as sarscov-2.13 a study conducted in israel explained that there is an association between smoking and the incidence of covid-19 infection.14 another study employing the scoping review method concluded that smoking has a protective effect against covid-19 but can cause severe clinical symptoms in individuals with covid-19 disease.15 in the pangandaran regency, there has been no research on the association between the implementation of phbs and covid-19 infection. therefore, the purpose of this study was to analyze the association between the implementation of phbs at the household level and the incidence of covid-19 infection in the working area of puskesmas parigi in pangandaran regency, west java, indonesia. methods this study employed a quantitative method with an unmatched case-control design conducted in september–november 2021 in public health center (pusat kesehatan masyarakat, puskesmas) parigi, pangandaran regency’s work area, which includes cibenda, ciliang, karangbenda, karangjaladri, and parigi villages. the research sample for this study was residents recorded in the daily report of covid-19 or seeking treatment at the puskesmas parigi from june–september 2021. the inclusion criteria for the case group were residents who had confirmed covid-19 through pcr examination and were recorded by the covid-19 surveillance team at the puskesmas parigi from june 2021 to september 2021, willing to be interviewed, aged ≥18 years, and willing to fill out the checklist. the exclusion criteria for the case group were residents who died during primary data collection. the inclusion criteria for the control group were residents who sought treatment at the puskesmas parigi and had never been diagnosed with covid-19 from june–september 2021, could be contacted by the researcher by phone, aged ≥18 years, and were willing to fill out a checklist. the exclusion criteria consisted of residents who died during primary data collection, lived in the same house as a person confirmed positive for covid-19 through polymerase chain reaction (pcr) examination. the minimum size of subjects in this study was 124 people for each case and control group. the total number of research subjects who filled out the checklist was 154 people. however, there were 13 people from the case and control groups who did not meet the inclusion criteria. at last, this study involved 126 respondents consisting of 63 respondents for each case and control group. data were collected in two periods, the initial period and the extra period. in the initial period, the data were collected from research subjects from june to july 2021 by sending a link of the checklist form through text messages and interviews. respondents who participated were 62 people. due to this number did not meet the minimum number of the research subjects, the researcher decided to increase the number of research subjects from the case and control groups by collecting data from august to september 2021 and changing the method of collecting primary data on the implementation of phbs from may 2021 in an extra period. changes to data collection were carried out by creating whatsapp groups and distributing the links of checklist form to research subjects from june to september 2021. interviews were carried out in the control group with a ratio of 1:1 to the case group in collecting the data. the number of respondents increased to 126 respondents consisting of 63 respondents for each case and control group. the variables in this study were respondents’ characteristics including age which was categorized into 18–29 years, 30–49 years, and ≥50 years, gender; addresses came from the villages of cibenda, ciliang, karangbenda, karangjaladri, and parigi; educational background categorized into low (elementary school, junior high school, and senior high school), and high (college/university); occupation; income categorized into ≤ pangandaran regency minimum wage (upah minimum kabupaten, umk) and ˃ pangandaran regency minimum wage; phbs indicators in household level were the behavior of using clean water, washing hands with clean water and soap, using healthy latrines, consuming fruits and vegetables every day, daily physical activity, and not smoking inside the house. the implementation of phbs was categorized into implementing and not implementing. the implementing category of phbs was designated as respondent who applied the six phbs indicators, and not implementing of phbs means that the respondents did not fully apply the phbs indicators in their daily life; covid-19 infections were categorized into covid-19 and non-covid-19. the instrument althea medical journal june 2023 althea medical journal. 2023;10(2) 71 table 1 frequency distribution of respondents characteristics of case and control group characteristics covid-19 (n=63) non-covid-19 (n=63) p-value n % n % age (years) 18–29 30–49 ≥ 50 26 26 11 41 41 17 27 20 16 43 32 25 0.422 gender male female 21 42 33 67 21 42 33 67 1.000 address (village) cibenda ciliang karangjaladri karangbenda parigi 5 8 14 13 23 8 13 22 21 37 15 7 12 11 18 24 11 19 17 29 0.199 education low (elementary, junior and senior high school) high (college/university) 4 22 6 35 16 25 25 40 0.004 occupation not working working 14 49 22 78 27 36 43 57 0.005 income ≤ umk* pangandaran (≤1.860.591) ˃ umk* pangandaran (˃1.860.591) 35 28 56 44 40 23 63 37 0.719 notes: *regency minimum wage (upah minimun kabupaten, umk) putri asyri wa indhillah et al.: relationship between clean, healthy living behaviour, and covid-19 infection at the parigi public health center, west java, indonesia used was a modified health promotion-based phbs implementation checklist with an additional implementation period from may 2021. this study has obtained permission from two institutions, namely national unity and politics (badan kesatuan bangsa dan politik, kesbangpol) and the puskesmas parigi. meanwhile, an ethics permit has been obtained from the research ethics committee of universitas padjajaran number 675/un6. kep/ec/2021. statistical analyses used in this study were chi-square and odds ratio (or). results in this study, there were 126 respondents consisting of 63 respondents for each case and control group. there were several characteristics of the respondents between the case and control groups which were statistically significant, namely the educational background (p=0.007) and occupation (p=0.005) (table 1). characteristics of the respondents that were not statistically significant were age (p=1.000), address (p=0.199), and income (p=0.719). differences in the characteristics of the respondents were tested using the chi-square test. the results showed that there was no association between phbs indicators and the incidence of covid-19 infection at the puskesmas parigi, pangandaran regency (table 2). the majority of respondents in this study did not practice phbs. according to the chi-square test results, there was no association between the implementation of phbs in the household level and the incidence of covid-19 infection at the puskesmas parigi in pangandaran regency (p-value=0.668) (table 3). discussion the number of checklist forms filled in this study was 154 out of 387 checklist forms distributed. the majority of case group respondents who filled out the checklist were from july 2021 period. this was due to the high number of covid-19 cases in the althea medical journal. 2023;10(2) 72 working area of the puskesmas parigi, which reached 200 cases. most of the respondents in the control group who filled out the checklist questionnaire came from the june 2021 period due to the large distribution and the largest number of checklist questionnaire distributed in that period. most of the respondents were 18–29 years old. there was no statistical difference in gender characteristics between the case and control groups because the distribution between women and men was the same. the characteristics of respondents by address did not describe the incidence of covid-19 in each village in the puskesmas parigi working area. the majority of the case groups had a high level of education, and most of the respondents had jobs with a percentage of 78%. most of the case groups worked as civil servants, nurses, and midwives. this allows risk factors for covid-19 to occur, namely a history of travel to areas with high transmission of covid-19 or direct contact with individuals positively infected with sars-cov-2.16 the phbs indicators concerning the behavior of using clean water and washing hands with soap cannot be analyzed, however, several studies have indicated that there is an association between washing hands 6–10 times a day with a reduced risk of seasonal coronavirus infection, whose transmission mechanism is believed to be the same as sarscov-2.13 another study shows that washing hands with clean water and soap or alcoholbased liquids can reduce the risk of covid-19 because alcohol has the ability to dissolve the fatty components contained in the viral envelope, making it effective for eradicating sars-cov-2.4,17 the use of healthy latrines with the incidence of covid-19 infection was not statistically significant, but the use of healthy latrines was a risk factor for the incidence of covid-19 infection. this supports the theory that transmission through fecal-oral route is still possible and further research is needed.7,8,18 consuming vegetables and fruit is a factor althea medical journal june 2023 table 2 association of the application of phbs indicators at the household level with the incidence of covid-19 infection in the working area of the puskesmas parigi, pangandaran regency clean and healthy lifestyle behavior covid-19 (n=63) non-covid-19 (n=63) p-value or(95% ci)yes no yes no n % n % n % n % the behavior of used clean water 63 100 0 0 63 100 0 0 n/a n/a washed hands with soap 63 100 0 0 63 100 0 0 n/a n/a used the proper toilet 61 97 2 3 60 95 3 5 **1.000 1.52(0.24–9.45) consumed fruits and vegetables every day 30 48 33 52 35 56 28 44 *0.373 0.72(0.36–1.46) do physical activity every day 53 84 10 16 51 81 12 19 *0.639 1.24(0.49–3.13) non-smoking behavior at home 32 51 31 49 32 51 31 49 *1.000 1.00(0.49–2.01) notes: *chi-square test; **fisher exact test; n/a= not applicable table 3 association of clean and healthy lifestyle at the household level and the covid-19 infection in the working area of the puskesmas parigi, pangandaran regency implementation of clean and healthy lifestyle behaviour incidence of covid-19 infection p-value or (95% ci)covid-19 non-covid-19 n % n % apply 15 24 13 21 0.668 1.20(0.51–2.78) not apply 48 76 50 79 althea medical journal. 2023;10(2) 73 in preventing covid-19 infection. this supports the theory that intake of vegetables and fruit functions as antioxidants to fight free radicals, vitamins to maintain body functions, and minerals to maintain body and organ performance.6 if an individual is malnourished or has an unhealthy diet, he or she will be susceptible to infection by covid-19.5,6 in this study, there was no association between physical activity and the incidence of covid-19 infection. this finding supports a study which explains that there is no association between subjectively reported physical activity and the incidence of covid-19 infection.12 this happened because the measurement of physical activity was not carried out objectively and was only based on self-reports. the covid-19 pandemic has led to a decrease in physical activity.19 however, the results in this study do not support the theory that decreased physical activity or excessive physical activity can make individuals more susceptible to sars-cov-2 infection.9,10,20 the results of this study cannot support the theory that smoking has a protective effect on the incidence of covid-19.15 this theory is not supported by other studies which argue that smoking has a protective effect on covid-19 infection.21 there are other theories explaining that smokers are more susceptible to covid-19 infection because of the increased expression of the ace-2 receptor.11,15 another study explains that there is an association between smoking behavior and the incidence of covid-19 infection which cannot be supported by the results of this study.14 people who smoke and are infected with sars-cov-2 have worse negative progression than people who do not smoke.15,22,23 some of the shortcomings in this study include the number of respondents who did not meet the minimum number of research subjects, unable to conclude causality, did not directly observe the implementation of phbs due to limited face-to-face meeting during the covid-19 pandemic, and bias in remembering the implementation of phbs since mei 2021 for the case and control groups which might affect the results of the study. further studies with larger population, using statistical analysis that can conclude a causal correlation, and considering controlling for confounding variables, namely educational background and occupation are needed. in conclusion, there is no association between the implementation of phbs at the household level and the incidence of covid-19. references 1. ministry of health republic of indonesia. pedoman pencegahan dan pengendalian coronavirus disease (covid-19). jakarta: ministry of health republic of indonesia; 2020. 2. who. who coronavirus disease (covid-19) dashboard [internet]. 2022 [cited 2022 february 23]. available from: https://covid19.who.int/table 3. dinas komunikasi dan informatika. angka kejadian kabupaten pangandaran [internet]. 2021 [cited 2021 may 1]. available from: https://covid19. pangandarankab.go.id/ 4. gupta mk, lipner sr. hand hygiene in preventing covid-19 transmission. cutis. 2020;105(5):233–4. 5. butler mj, barrientos rm. the impact of nutrition on covid-19 susceptibility and long-term consequences. brain behav immunol. 2020;87:53–4. 6. rodriguez-leyva d, pierce gn. the impact of nutrition on the covid-19 pandemic and the impact of the covid-19 pandemic on nutrition. nutrients. 2021;13(6):1–9. 7. heller l, mota cr, greco db. covid-19 faecal-oral transmission: are we asking the right questions? sci total environ. 2020;729:138919. 8. odih ee, afolayan ao, akintayo io, okeke in. could water and sanitation shortfalls exacerbate sars-cov-2 transmission risks? am j trop med hyg. 2020;103(2):554–7. 9. woods ja, hutchinson nt, powers sk, roberts wo, gomez-cabrera mc, radak z, et al. the covid-19 pandemic and physical activity. sport med health sci. 2020;2(2):55–64. 10. crisafulli a, pagliaro p. physical activity/ inactivity and covid-19. eur j prev cardiol. 2020;28(16):e24–6. 11. van zyl-smit rn, richards g, leone ft. tobacco smoking and covid-19 infection. lancet respir med. 2020;8(7):664–5. 12. zhang x, li x, sun z, he y, xu w, campbell h, et al. physical activity and covid-19: an observational and mendelian randomisation study. j glob health. 2020;10(2):1–9. 13. beale s, johnson am, zambon m; flu watch group; hayward ac, fragaszy eb. hand hygiene practices and the risk of human coronavirus infections in a uk community cohort. wellcome open res. 2021;5:98. 14. israel a, feldhamer e, lahad a, levinzamir d, lavie g. smoking and the risk of putri asyri wa indhillah et al.: relationship between clean, healthy living behaviour, and covid-19 infection at the parigi public health center, west java, indonesia althea medical journal. 2023;10(2) 74 covid-19 in a large observational [online journal]. medrxiv. 2020. [cited 2022 february 23]. available from: https:// www.medrxiv.org/content/10.1101/2020 .06.01.20118877v2.full-text. 15. haddad c, bou malhab s, sacre h, salameh p. smoking and covid-19: a scoping review. tob use insights. 2021;14:1179173x21994612. 16. lampton lm. covid-19. in: kallerman rd, rakel dp. conn’s current therapy 2021. philadelphia: elsevier health sciences; 2021. p. 554–8 17. haque m. handwashing in averting infectious diseases: relevance to covid-19. j popul ther clin pharmacol. 2020;27(s pt 1):e37–52. 18. purnama sg, susanna d. hygiene and sanitation challenge for covid-19 prevention in indonesia. kesmas. 2020;1(special issue):6–13. 19. pitanga fjg, beck cc, pitanga cps. should physical activity be considered essential during the covid-19 pandemic? int j cardiovasc sci. 2020;33(4):401–3. 20. rowlands av, dempsey pc, gillies c, kloecker de, razieh c, chudasama y, et al. association between accelerometerassessed physical activity and severity of covid-19 in uk biobank. mayo clin proc innov qual outcomes. 2021;5(6):997– 1007. 21. tattan-birch h, perski o, jackson s, shahab l, west r, brown j. covid-19, smoking, vaping and quitting: a representative population survey in england. addiction. 2021;116(5):1186–95. 22. vardavas ci, nikitara k. covid-19 and smoking: a systematic review of the evidence. tob induc dis. 2020;18:20. 23. patanavanich r, glantz sa. smoking is associated with covid-19 progression: a meta-analysis. nicotine tob res. 2020;22(9):1653–6. althea medical journal june 2023 amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 156 effectiveness of online height measurement training for parents fitri yuniarti,1 yenni zuhairini,2 fedri ruluwedrata rinawan2 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health, faculty of medicine universitas padjadjaran, indonesia correspondence: fitri yuniarti, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west java-indonesia, e-mail: fitri18002@mail.unpad.ac.id introduction stunting is the impaired growth and development experienced by children due to poor nutrition, repeated infections, and inadequate psychosocial stimulation. stunting is a global nutritional problem, affecting 165 million children under the age of five worldwide.1 as many as 80% of stunted children under the age of five live in 14 countries around the world, and indonesia ranks fifth in the country with the highest stunting.1 early age is the golden age of child development because growth occurs very rapidly at this stage. growth in height is very important because one of the indicators of children’s health is indicated by growth in height.2 elementary school age (6–12 years) is known as the second highest peak of growth after three years, this is the most important stage in the development of physical qualities of adults. this can be done by measuring the height for a school-age child (tinggi badan anak baru masuk sekolah, tbabs).3 based on the previous survey, the prevalence of stunting for elementary school children was found to be very high in rural areas (41.7%) than in urban areas (29.3%), with a prevalence of 35% for school-age children (6–12 years) classified as stunting.4 this is caused by various internal and external factors. parental education, occupation, and socioeconomic status have a weak relationship with the nutritional status of preschool children.4 indonesia is experiencing a state of great public concern for covid-19, so there is a need for a blockade by government policies to break the chain of spreading the covid-19 outbreak.5 however, the covid-19 pandemic has affected maternal and child health services and resulted in schools being closed, even though schools are potential places to monitor children’s growth and development. in march 2020, the world health organization (who) officially declared covid-19 a pandemic. furthermore, the government has stipulated althea medical journal. 2022;9(3):156–162 abstract background: the incidence of stunting in indonesia is high (30.8%), therefore, regular monitoring of children’s height growth is needed. however, during the covid-19 pandemic, the health service’s checks are limited, as well as schools as a potential place to monitor children’s growth are closed. this study aimed to assess the effectiveness of online height measurement training for parents. methods: this was a quantitative research with one group pre-and post-intervention design. it was conducted in a rural area in west java, from august to november 2021. the parents of school students were included with a purposive sampling method. the training media was in the form of height measurement videos. the assessment of parents’ skills was an online check sheet with a likert scale of 1–5 using the whatsapp application. analyzes were performed with the paired t-test. results: in total, 86 parents were included, all of whom were mothers with the majority (51.2%) age range of 36–45 years. parental education varied with most elementary school graduates (27.9%). most mothers did not work (59.3%). as for the students, the majority were female students (60.5%) between 6–9 years old. the skill score before and after training was effective (d=2.04; p=<0.001). conclusions: online height measurement training using video has high effectiveness in improving parents’ skills to self-practice measurement at home. keywords: height, online, skills, training https://doi.org/10.15850/amj.v9n3.2622 althea medical journal. 2022;9(3) 157 government regulation number 21 of 2020 concerning large-scale social restrictions (pembatasan sosial berskala besar, psbb) to facilitate the handling of covid-19. therefore, psbb can indirectly lead to a reduction in stunting prevention monitoring programs.6 monitoring children’s growth and development during the pandemic cannot be done independently by parents at home due to limited motivation and knowledge about measuring height. therefore, a training is needed to improve skills so that parents can carry out correct and accurate anthropometric measurements. previous research suggested motivating mothers to use anthropometry at home and educating the people around them.7 the purpose of this study was to assess the effectiveness of online height measurement training for parents so that parents can immediately check their children if they are stunted. methods this study has used pre and post-experimental methods in the form of one group design, namely research that only includes one group without a comparison group (control). this research was conducted in a rural area, namely karangsembung village, jamanis district, tasikmalaya regency, west java province from august to november 2021. the subjects involved in this study were 86 parents of school children who met the inclusion criteria with purposive sampling method. the inclusion criteria in this study were parents of students aged 6–9 years who had androidbased smartphones and had an internet quota. the exclusion criteria were parents who were not willing to participate in the study. prior to the online height measurement training, respondents were given an explanation of the technical details of online research through the whatsapp application. then the respondent signed the informed consent form as a sign of agreeing to participate in the study. the initial step of the research was to assess the skills of parents before being given training, parents were asked to practice how to measure height according to what they know, then this assessment will be observed online via whatsapp video calls. this assessment used a checklist containing 8 assessment items derived from standardized videos and had been tested for validity and reliability so that it can be used for research. skill scores using a likert scale of 1–5. the use of the likert scale made it easy to measure the opinions and attitudes of respondents, with 1=very poor, 2=poor, 3=fair/neutral, 4=good, 5=very good with a maximum of 40 points. after the pre-intervention assessment, respondents were given a video on how to measure height sourced from the who training course which had been translated into indonesian, then it was suggested to watch and practice independently according to the video. the time limit for self-study was a maximum of 1 week, then respondents were asked to contact the researcher to schedule a final assessment of measurement skills online. the final assessment used the same checklist as the initial assessment. the variables used in this study were skill scores before and after the intervention. characteristics of respondents consisted of age, education, occupation, sex of the child, and age of the child. all data collected was kept confidential. skill scores were analyzed with the stata version 14 application and then presented in percentages, numbers, and diagrams. statistical analysis used was paired t-test because the results of the normality test of the respondents’ skill figure 1 confirmatory factor analysis fitri yuniarti et al.: effectiveness of online height measurement training for parents althea medical journal. 2022;9(3) 158 scores were normal. this research has been approved by the research ethics committee of universitas padjadjaran with the ethical exemption number 750/un6.kep/ec/2021. data were collected by observing 86 respondents consisting of parents of school students aged 6–9 years. the method used to assess the validity of the questionnaire in this study was confirmatory factor analysis (cfa). a good construct was if it had a load factor of at least 0.30. thus, if the value was 0.30, then the indicator was valid. based on figure 1, there were 8 assessment items which were research material, each of which had a value of more than 0.30 so the results of the analysis were valid. the reliability test was used to measure a questionnaire or observation sheet which was an indicator of a variable or construct and to state whether a person’s answer to a statement was consistent or stable from time to time. a variable was said to be reliable if it gave a cronbach alpha value >0.60. based on table 1, it can be seen that if each item had a cronbach’s alpha value greater than 0.6 then the assessment sheet could be said to be reliable. the normality test method used to test the residual normality was the shapirowilk test. results all respondents were mothers of 86 students from 2 elementary schools in karangsembung village. the age of the most respondents was in the range of 36–45 (51%). education varied with most graduating from elementary school (28%). most respondents did not work (59%). the male and female students measured in this study were 39% and 61%, respectively, with ages between 6–9 years, and the majority were 7 years (50%). before receiving the training, most of the respondents already knew the basics of measuring height. the average skill score before training was 31 whereas the average skill score after training was 37.9. there was a very significant difference in the distribution of pre and post-height measurement training interventions (p<0.000). the effect of this training was categorized as large because d >0.8 according to cohen’s d effect size category (figure 2). discussions this study involved 86 respondents consisting of mothers aged 36–45 years who were late adulthood but the skill score before and after training was effective. a similar study was conducted in sukoharjo district, pringsewu regency8 in 2016 involving 42 posyandu cadres aged ≥26 years with the results that there were 29 (69.0%) posyandu cadres who had good performance. in addition, the results of the chi-square test showed that there was a table 2 normality test skills w v z prob>z description pre-intervention 0.99343 0.476 -1.620 0.94734 normal post-intervention 0.95559 3.235 2.583 0.00490 not normal differential 0.99347 0.476 -1.635 0.94894 normal althea medical journal september 2022 table 1 reliability test skill variable cronbach’s alpha description take off your shoes and headdress 0.926 reliable install measuring tools 0.936 reliable position the child correctly 0.919 reliable look straight ahead 0.924 reliable child body fixation 0.925 reliable move the tool until it touches the child’s head 0.927 reliable reading measurements results 0.927 reliable record measurement results 0.920 reliable althea medical journal. 2022;9(3) 159fitri yuniarti et al.: effectiveness of online height measurement training for parents table 3 respondent characteristics category frequency (n) percentage (%) age (years old) 26–35 36–45 46–55 56–65 31 44 10 1 36 51 12 1 level of education no school elementary school primary high school high school undergraduate postgraduate diplome 2 24 14 18 22 3 3 2 28 16 21 26 4 4 occupation does not work trader government employees honorary teacher non-formal teacher midwife laborer entrepreneur 51 5 12 11 3 2 1 1 59 6 14 13 4 2 1 1 child’s gender male female 34 52 39 61 child’s age 6 years old 7 years old 8 years old 9 years old 10 43 18 15 12 50 21 17 table 4 respondent skill score skill variable mean preintervention skill scores using a likert scale mean postintervention skill scores using a likert scale p-value take off your shoes and headdress 4.8 5.0 <0.001 install measuring tools 4.9 5.0 <0.001 position the child correctly 3.4 4.7 <0.001 look straight ahead 3.7 4.7 <0.001 child body fixation 2.6 4.3 <0.001 move the measuring tool until it touches the child’s head 3.6 4.7 <0.001 reading measurements results 3.6 4.6 <0.001 record measurement results 4.2 4.6 <0.001 mean 31 37.9 <0.001 althea medical journal. 2022;9(3) 160 relationship between age and the performance of the elderly posyandu cadres (p=0.027).8 although the education level of most respondents is elementary school with 24 respondents and 51 respondents are not workers, this is not a limitation in understanding and practicing the material in the video. this is in line with another research. which states that there is no relationship between age, marital status, level of education, and length of time being a cadre on the level of activity of posyandu cadres.9 however, this is inversely proportional to the research conducted in sukoharjo district, pringsewu regency, the results showed that there was a significant relationship between age, knowledge, attitude, motivation, rewards, leadership with the performance of elderly posyandu cadres.8 the age of the children who were the target of the study was 6–9 years. more than half of them are female students (60.5%), with the majority age being 7 years (50%). to achieve optimal growth and development since preadolescent, namely the age of 10–12 years, it is necessary to prepare the child’s body in advance from the aspect of health status, and the factors that affect growth and development by looking at the previous age, namely 6–9 years, which is a sloping time in the child’s growth phase so that at this age, children’s growth monitoring can be done independently by parents at home.10 skills assessment was carried out using a check sheet containing 8 items adapted from the height measurement video from the who training course which had been modified into indonesian. in the video, the measuring instrument used is a stadiometer11 while in this study a tape meter that has been validated can be used to measure height. the lowest score before training with an average of 2.6 was found in the respondents who were less skilled in fixing the child’s body and most of the respondents did not push the child’s stomach slowly, while the highest score with an average point of 4.9 was the respondent’s score on the ability to attach a tape measure on the wall in an upright position. there was a change in the score after the training, namely the highest point with an average of 5 on the assessment of the respondent’s ability to install measuring instruments and remove footwear and headdress for children, the lowest point was the respondent’s ability to fix the body and slowly push the child’s stomach at 4.3. however, there was a significant change between the skill results before and after training in the height measurement. changes in the respondent’s skill score increased convinced to be due to receiving information by providing audiovisual training. practices and simulations make it easy to remember what they have to do and can see it live.12 it takes a faster time to capture information through the involvement of many senses. after receiving the height measurement video, the improvement in skill scores increased due to the time lag for the respondents to learn and practice independently. this self-practice helps parents better remember what they are learning and practicing. the results of a study showed that video-based training was very effective in figure 2 effect size based on mean comparison althea medical journal september 2022 althea medical journal. 2022;9(3) 161fitri yuniarti et al.: effectiveness of online height measurement training for parents improving the cognitive skills of trainees.13 significant differences in skill scores on pretest and posttest anthropometric measurements before and after training also occurred in other studies.14,15 in addition, this significant difference is also influenced by audiovisual media, where the use of video was more effective in changing behavior.16,17 in general, it can be concluded that training with audiovisual media can significantly increase knowledge compared to respondents who do not participate in training activities.18,19 in contrast, another study has shown that training has no significant effect on performance.20 this study has several limitations. data collection was carried out in a pandemic situation, so the research socialization process became very difficult, besides, kindergarten and elementary schools had implemented limited face-to-face learning so that good time arrangements were needed to disseminate information and scheduling between researchers and respondents. however, this research was helped by the good coordination and relationship between teachers and researchers so that information could be disseminated through the whatsapp group of parents. although the height measurement training activity is carried out online, it is expected to have many benefits for increasing parents’ awareness in monitoring their child’s growth and development which can be done independently at home, thus, they can immediately check their children if there are growth problems. to conclude, online height measurement training is proven to be effective in monitoring height measurements that can be done at home. online training method can also be developed as an educational tool in socializing how to monitor children’s growth and development using electronic media in the form of videos. references 1. unicef. improving child nutrition: the achievable imperative for global progress. new york: united nations children’s fund; 2013. 2. haddad l, achadi e, ag bendech m, ahuja a, bhatia k, bhutta z, et al. the global nutrition report 2014: actions and accountability to accelerate the world’s progress on nutrition. j nutr. 2015;145(4):663–71. 3. elfindri e, ancok d, syahruddin s, yulius y. korelasi pendapatan dengan tinggi badan anak baru masuk sekolah (tbabs). populasi. 1993;4(1):85–99. 4. utami rdp, nggadjo fx, murhayati a. hubungan antara pendidikan, pekerjaan dan ekonomi orang tua dengan status gizi pada anak usia pra sekolah. jurnal kesehatan madani medika. 2018;9(1):64– 70. 5. nursofwa rf, sukur mh, kurniadi bk. penanganan pelayanan kesehatan di masa pandemi covid-19 dalam perspektif hukum kesehatan. inicio legis. 2020;1(1). 6. saputra h, salma n. dampak psbb dan psbb transisi di dki jakarta dalam pengendalian covid-19. media kesehatan masyarakat indonesia. 2020;16(3):282– 92. 7. sari ll. pelatihan pengukuran status gizi balita dengan menggunakan antropometri sebagai upaya pencegahan stunting sejak dini pada ibu di darat sawah seginim bengkulu selatan. jurnal kreativitas pengabdian kepada masyarakat (pkm). 2022;1(1):169–76. 8. supriyatno h. faktor-faktor yang mempengaruhi kinerja kader posyandu lansia. jurnal ilmiah kesehatan. 2017;6(2):91–8. 9. sukandar h, faiqoh r, effendi js. hubungan karakteristik terhadap tingkat aktivitas kader posyandu kecamatan soreang kabupaten bandung. jurnal sistem kesehatan. 2019;4(3):102–9. 10. wijanarko b, rahmawati nt, sudargo t. perbedaan pola pertumbuhan tinggi badan, tinggi duduk, indeks skelik antara anakanak daerah rural dan urban usia 7–15 tahun di daerah istimewa yogyakarta. gizi indon. 2011;34(1):74–81. 11. sulistyawati s. pengembangan stadiometer sebagai alat ukur tinggi badan dan tinggi lutut. jurnal pengelolaan laboratorium pendidikan. 2019;1(1):7–14. 12. rusdiarti r. analisis pengukuran ketepatan antropometri tinggi badan balita pada pelatihan kader posyandu di panduman kecamatan jelbuk. hijp. 2019;11(2):173– 81. 13. purnomo e, wijayanto p. efektivitas model pelatihan parenting autisme berbasis media video. jurnal kwangsan. 2018;6(1). 14. evita d, mursyid a, siswati t. pelatihan meningkatkan pengetahuan dan keterampilan kader puskesmas dalam penerapan standar pemantauan pertumbuhan balita di kota bitung. j gizi dietetik indones. 2013;1(1):15–21. 15. rokhaidah r, herlina h. pengaruh pelatihan penggunaan aplikasi pemantau pertumbuhan anak terhadap praktik althea medical journal. 2022;9(3) 162 mandiri ibu dalam pemantauan stunting. dunia keperawatan: jurnal keperawatan dan kesehatan. 2021;9(1):55. 16. purniawan ae. efektifitas media poster dan audio visual (video) terhadap pengetahuan ibu tentang tb paru (studi di desa winong kecamatan pati kabupaten pati) [minor thesis]. semarang: universitas muhammadiyah semarang; 2016 [cited 2021 december 30]. available from: http://repository.unimus.ac.id/23/ 17. antari i, riandani sd, siwi in. efektivitas penggunaan media video dan leaflet terhadap perilaku mencuci tangan dalam pencegahan diare. jurnal kesehatan madani medika. 2020;11(1):27–34. 18. septikasari m, budiarti t. upaya peningkatan keterampilan kader dalam pemantauan perkembangan anak. e-dimas. 2020;11(1):81–6 19. wahyuni s, mose jc, sabarudin u. pengaruh pelatihan kader posyandu dengan modul terintegrasi terhadap peningkatan pengetahuan, sikap dan keikutsertaan kader posyandu. jurnal riset kebidanan indonesia. 2019;3(2):95–101. 20. ningsi ca, alhabsji t, utami hn. pengaruh pelatihan dan promosi terhadap motivasi dan kinerja karyawan (studi pada karyawan pt. pln (persero) area kendari). jurnal administrasi publik. 2015;5(2):131–43. althea medical journal september 2022 amj vol 8 no 1 march 2021 final.indd althea medical journal. 2021;8(1) 28 althea medical journal march 2021 clinical characteristics of pediatric with germ cell tumor: experience in a developing country lelani reniarti,1 anisah febri,2 nur melani sari1 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 2faculty of medicine, universitas padjadjaran, indonesia correspondence: anisah febri, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: anisah.febri29@gmail.com introduction germ cell tumor (gct) is an abnormal tissue development from primordial germ cell that has various clinical manifestations and histopathology. normally, this primordial germ cell can arise in the ovarium and testicle,1,2 as well as in the extragonadal sites including the mediastinum, intracranial, and sacrococcygeal. most of the patients have intragonadal gct.3 this tumor has numerous histological subtypes. the clinical manifestations vary with tumor site, histologic subtypes, and stages. the main manifestations of gct are abdominal pain, abdominal distention, and palpable mass at the site of the tumor.4 other manifestations are weight loss and precocious puberty.1 this tumor can be benign or malignant. three-percent of malignancy in pediatric aged 0–8 is occupied by gct and the incidence increase by 15% during adolescence.3 gct is more common in girls with an incidence of 5.3 per million in girls and 4.3 per million in boys.5 epidemiological study has shown that asian countries have the highest incidence of gct, including indonesia.6 five-years survival rate of this tumor is 98% in the earlier stage and 80% for the malignant tumor.3 currently, the study reporting clinical manifestations of pediatric gct patients in indonesia is still limited. this study aimed to gather information about clinical manifestations among pediatric gct patients in dr. hasan sadikin general hospital, a top referral hospital in west java. furthermore, the outcome of the gct treatment was explored. it is expected that knowing these approaches will help clinicians to get a proper amj. 2021;8(1):28–34 abstract background: germ cell tumor (gct) occurs in 3% of pregnancy malignancies and increases by 15% during adolescence. in developing countries, the five-year survival rate is 98% and 80% for gct earlier stage and malignant tumor, respectively. this study aimed to gather information about clinical manifestations of gct and to evaluate the treatment outcome in pediatric gct patients at dr. hasan sadikin general hospital, bandung, indonesia. methods: a descriptive cross-sectional study design with a total sampling method was conducted using secondary data from the medical record of pediatric patients diagnosed with gct from 2015 to 2018. data on nutritional status, clinical characteristics, histopathology stage, hematological profiles, chemical markers, treatment methods, completeness of treatment, and outcome at the end of treatment were collected and presented using tables and charts. results: of the 44 subjects, girls (77.3%) were predominant, with a mean age of 2 years old and normal nutritional status (59.1%). patients generally had abdominal mass (97.7%) and most had intragonadal gct (95.5%), with ovarium (76.2%) as the most common location. the most frequent gct histopathology was yolk sac tumor (34.1%), with an alpha-fetoprotein (afp) level of >100.000 (6.8%). almost all patients (97.7%) had undergone surgery; however, 47% of patients did not complete their treatment. at the end of treatment, the majority of patients survived (86.4%). conclusions: germ cell tumor has various clinical characteristics. understanding these characteristics will enable clinicians to make a proper diagnosis and provide immediate management that will lead to a better prognosis. keywords: alpha-fetoprotein, teratoma, yolk sac tumor https://doi.org/10.15850/amj.v8n1.1876 althea medical journal. 2021;8(1) 29 diagnosis, immediate management, and a better prognosis. methods this research design was a cross-sectional study using secondary data from the hospital information system (sirs), cancer registry, the in-and outpatient medical records. the data of pediatric patients with germ cell tumor (gct) was collected in augustseptember 2019, including pediatric patients who were hospitalized in dr. hasan sadikin general hospital from 2015 to 2018. the data collection technique in this study was the total sampling method. international classification of disease (icd) with code 10 was used with the site codes for tumor were ovary (c56), testis (c62.9), mediastinum (c37), retroperitoneum (c48), and intracranial (c49). the exclusion criteria were incomplete medical records in histopathology result and stage, and patients who did not do the biopsy. this study had been approved by the research ethics committee of universitas padjajaran, bandung no. 809/un6.kep/ec/2019 and by the medical research ethical committee of dr. hasan sadikin general hospital, bandung no.lb.02.01/x.2.2.1/12579/2019. variables in this study were patient identities (age of diagnosis and gender), nutritional status, clinical manifestations (at the first visit), pathologic features (site, staging, and histopathology feature of tumor), hematological profiles (hemoglobin level, hematocrit level, leukocyte count, and thrombocyte count), tumor marker such as alpha-fetoprotein (afp), lactic acid dehydrogenase (ldh) and beta-human chorionic gonadotropin (β-hcg), methods of treatment, completeness of treatment and outcome at the end of treatment. to determine the hematological profiles and tumor marker level, the normal values were used, based on gender and age of patients. the stage of gct was based on the children’s oncology group (cog).7 cancer chemotherapy protocol was used to determine the completion of the treatment. the data were described and presented in the form and table or chart using microsoft® excel 2016 and ibm® spss® version 20. results there were 206 data fulfilled the icd codes 10 from the inand outpatient medical records, however, 24 data were missing table 1 profile and clinical manifestation of pediatric patients with germ cell tumor in dr. hasan sadikin general hospital 2015–2018 characteristic n % gender boys girl 10 34 22.7 77.3 age categories ≤5 years >5–10 years 10–15 years >15–18 years 15 8 9 12 34.1 18.2 20.5 27.3 clinical manifestation abdominal mass abdominal pain weight loss pale abdominal tightening intermittent fever menstrual disorder precocious puberty vaginal discharge vaginal bleeding bronchospasm 43 15 7 7 6 5 4 3 3 2 2 97.7 34.1 15.9 15.9 13.6 11.4 9.1 6.8 6.8 4.5 4.5 lelani reniarti et al.: clinical characteristics of pediatric with germ cell tumor: experience in a developing country althea medical journal. 2021;8(1) 30 althea medical journal march 2021 and 123 data were not gct cases such as fibroma, cystadenoma mucinosum, and rhabdomyosarcoma. of the 59 gct data, only 44 data fulfilled the inclusion criteria, of which 15 data had incomplete histopathology data or staging. the study showed that the incidence of pediatric gct was mostly aged2 years old (13.6%) and aged 17 years old (11.4%). the first peak was observed during the first 2 years of life both in girls and boys. the second peak was observed at the age of 15–17 years both in girls and boys. the lowest incidence was found at the age of 3 and 10 years old. most of gct patients were females (77.3%). among the patient under 5 years old, gct was more common in boys than girls (b:g = 2:3). in the older patient, gct was more common in girls than boys (b:g = 1:28). overall, gct was more common in girls than in boys (b:g=1:3.4). majority of patients presented with a combination of signs and symptoms. almost all of the patients had abdominal mass (97.7%), then followed by abdominal pain (34.1%), and weight loss as well as pale (both 15.9%). other symptoms included abdominal tightening, intermittent fever, menstrual disorder, precocious puberty, vaginal discharge, and vaginal bleeding were shown in table 1. more than half of gct patients had normal nutritional status (59.1%). severe malnutrition was found in 11.4%, mostly aged below 10 years old, whereas the moderate malnutrition patients were aged between 15– 18 years old as shown in table 2. overall, gct was predominantly occurred intragonadal (95.5%), with the location of the gct tumor varied with gender as boys had testicular gct and girls had ovarium gct (94.1%), followed by abdominal gct and vaginal gct. the testicular gct was most frequent in the age group below 5 years, whereas ovarian tumors table 2 nutritional status and tumor features of pediatric patients with germ cell tumor in dr. hasan sadikin general hospital 2015–2018 characteristic gender age (years) n(%) boy girl ≤5 >5–10 >10–15 >15–18 nutritional status severe malnutrition moderate malnutrition normal overweight 0 10 0 0 32 0 1 1 5 9 0 1 7 0 1 0 9 0 0 0 11 1 0 0 32(72.7) 10(22.7) 1(2.3) 1(2.3) tumor location ovarium testis abdomen vagina 0 10 0 0 32 0 1 1 5 9 0 1 7 0 1 0 9 0 0 0 11 1 0 0 32(72.7) 10(22.7) 1(2.3) 1(2.3) histopathology seminoma dysgerminoma germinoma mature teratoma immature teratoma yolk sac tumor choriocarcinoma embryonal carcinoma mixed gct 1 0 0 0 0 9 0 0 0 0 11 0 10 2 6 0 1 4 0 0 0 3 0 11 0 1 0 0 4 0 3 0 0 0 0 1 0 5 0 0 1 1 0 0 2 1 2 0 4 1 3 0 0 1 1(2.3) 11(25) 0(0) 10(22.7) 2(4.5) 15(34.1) 0(0) 1(2.3) 4(9.1) stage benign i ii iii iv 0 2 2 5 1 9 12 2 9 2 2 5 2 5 1 2 3 0 3 0 0 2 2 3 2 5 4 0 3 0 9(20.5) 14(31.8) 4(9.1) 14(31.8) 3(6.8) althea medical journal. 2021;8(1) 31lelani reniarti et al.: clinical characteristics of pediatric with germ cell tumor: experience in a developing country most frequent in the age group 15 to 18 years. histologically, the most frequent gct were yolk sac tumor (34.1%), followed by dysgerminoma (25%), mature teratoma (22.7%), mixed germ cell tumor (9.1%), immature teratoma (4.5%), and seminoma (2.3%) as well as embryonal carcinoma (2.3%). germinoma and choriocarcinoma were not found in this study. in boys, yolk sac tumor was predominant, with an age group below 5 years old in most of the cases. in girls, dysgerminoma was predominant with the majority was in the age group between 10 to 15 years old. only 20.9% (9 of 44) patients had benign gct. the stage of the gct in this study had stage i (31.8%), stage ii (9.1%), stage iii (31.8%), and stage iv (6.8%) as depicted in table 2. almost all patients (97.7%) underwent surgery, either surgery only or combined with chemotherapy, based on the stage and type of histopathology. the majority of benign gct received only surgery (75%), while the majority of malignant gct underwent both surgery and chemotherapy (75%). the chemotherapy given was the combination of bleomycin, cisplatin, and etoposide, known as the bep regiment. only about half of patients completed their treatment (52.3%). there were many factors that patients did not complete their treatment, including died during treatment because of the progressivity of the tumor. the other reasons for incompletion of treatment are a side effect of chemotherapy, sepsis, and loss to followup. however, 1 patient (5%) had died after completing the last chemotherapy cycle due to his worsening condition. benign gct had a better outcome than malignant gct. benign gct at the age group 15–18 years old had a better outcome, whereas in malignant gct the age group below 5 years old had a better outcome (table 3). anemia was occurred in 79.5% (35 out of 44), which was common in malignancy. furthermore, 68.2% had a low hematocrit level. more than half of the patients had normal leukocytes (61.4%). no patient had low thrombocytes, most of them (56.8%) had normal thrombocytes and interestingly, 43.2% had high thrombocytes. tumor markers such as alpha-fetoprotein (afp), lactic acid dehydrogenase (ldh), and beta-human chorionic gonadotropin (β-hcg) were detected in most cases. overall, the afp level elevated in most patient of which 6.8 % table 3 treatments of pediatric patients with germ cell tumor in dr. hasan sadikin general hospital 2015–2018 treatment gender age (years) n(%) boy girl ≤5 >5–10 >10–15 >15–18 benign surgery chemotherapy surgery+chemotherapy 0 0 0 6 1 1 1 1 0 0 0 1 0 0 0 5 0 0 6(75) 1(12.5) 1(12.5) malignant surgery chemotherapy surgery+chemotherapy 1 0 9 8 0 18 1 0 12 3 0 4 3 0 6 2 0 5 9(25) 0(0) 27(75) completeness of treatment completed treatment dead during treatment interrupted treatment 3 2 5 20 4 10 8 3 4 6 0 2 3 3 3 6 0 6 23(52.3) 6(13.6) 15(34.1) outcome at the end of treatment benign alive dead malignant alive dead 0 0 8 2 7 1 23 3 1 1 11 2 1 0 7 0 0 0 6 3 5 0 7 0 7(87.5) 1(12.5) 31(86.1) 5(13.9) althea medical journal. 2021;8(1) 32 althea medical journal march 2021 of patients had afp level up to >100.000. ldh was elevated in 11 patients including patients with yolk sac tumor, dysgerminoma, mature teratoma, and seminoma. β-hcg was elevated in patients with dysgerminoma, yolk sac tumor and mature teratoma, as shown in table 4. at the end of treatment, the majority of gct patients were alive (86.4%). patients with stage i gct had a better outcome and stage iv gct had a worse outcomes, of whom (33.3%) were dead. seminoma, embryonal carcinoma, and mixed gct had a better outcome in which all patients were alive. immature teratoma has the worst outcome in which half of the patients were dead (table 5). discussions the study has described the pediatric patients with germ cell tumor (gct) in dr. hasan sadikin general hospital 2015–2018 of which girls are predominant (77.3%). this finding is similar table 4 hematological profiles and tumor marker of pediatric patients with germ cell tumor in dr. hasan sadikin general hospital 2015–2018 characteristic low normal high n % n % n % hematological profiles hemoglobin hematocrit leukocyte thrombocyte 35 30 6 0 79.5 68.2 13.6 0 9 14 27 25 20.5 31.8 61.4 56.8 0 0 11 19 0 0 25 43.2 tumor marker afp ldh β-hcg 10 15 17 34.5 57.7 73.9 19 11 6 65.5 42.3 26.1 table 5 end of treatment condition of pediatric patients with germ cell tumorin dr. hasan sadikin general hospital 2015–2018 characteristics condition alive dead n % n % stage benign i ii iii iv 8 13 3 12 2 88.9 86.7 75 85.7 66.7 1 1 1 2 1 11.1 13.3 25 14.3 33.3 histopathology seminoma dysgerminoma germinoma mature teratoma immature teratoma yolk sac tumor choriocarcinoma embryonal carcinoma mixed gct 1 10 0 9 1 12 0 1 4 100 10 90.9 90 50 80 0 100 100 0 1 0 1 1 3 0 0 0 0 10 9.9 10 50 20 0 0 0 total 38 86.4 6 13.6 althea medical journal. 2021;8(1) 33lelani reniarti et al.: clinical characteristics of pediatric with germ cell tumor: experience in a developing country to a study in turkey8 that girls are common (61.4%) among gct pediatric patients, as well as a study in pakistan9 (52.7%). the incidence of pediatric gct is biphasic; the first peak incidence is observed during the first 2 years of life and the second peak incidence is observed at the age of 15–17 years. our study has reported a similar peak mostly which is patients aged 2 years old (13.6%) and aged 17 years old (11.4%) and the previous study in turkey8 shows a similar results, as well as another study in the us.10 interestingly, a study in the us has shown the first peak before 1 year old. the older the age, the incidence of ovarian gct is increased while the testicular gct is decreased. the striking female predominance relates to the high prevalence of ovarian tumors in adolescent patients. the majority of patients present with a combination of signs and symptoms. almost all patients have abdominal mass (97.7%), abdominal pain (34.1%), and weight loss as well as paleness. the same percentage has been found between abdominal pain and abdominal mass, which are the primary sign and symptoms in children in turkey (43.6%).8 interestingly, only one-third of patients have malnutrition which is moderate malnutrition (27.3%) and severe malnutrition (11.4%), similar to a study in india.11 furthermore, intragonadal gct have predominantly occurred as also shown in a study from turkey,8 pakistan,9 and finland.12 mature teratoma is the most common gct.4,8,12 for example, yolk sac tumors are common (34.1%), followed by dysgerminoma (25%), mature teratoma (22.7%). in opposite, mature teratoma study is more predominant in the us (74.8%).4 moreover, gct is mostly malignant, with various stages, however, many gct patients have been diagnosed at an early stage of the disease. depends on the stages and type of histopathology result, most of the patients (97.7%) would undergo surgery, or in combination with chemotherapy. tumor markers are important in the diagnosis and follow-up. high afp, ldh, and β-hcg have been detected in 34.5%, 57.7%, and 73.9% of the subject, respectively. most of the patients had anemia which is common in malignancy. this can be caused by a chronic disease process, or due to iron deficiency. furthermore, red cell hypoplasia and megaloblastic anemia in malignancies might occur.13 some limitations found in this study are among others the retrospective study design from a single hospital that has failed to demonstrate the correlation between stage and condition at the end of treatment. a longer period and using multi-centered hospital data, the number of respondents can be increased and further explored. to conclude, germ cell tumor has many clinical characteristics, therefore, is important to diagnose gct. knowing the clinical manifestation, histopathology, hematological profiles, and chemical marker will help clinicians to get a proper diagnosis, immediate management, and a better prognosis. references 1. olson ta. germ cell tumor. in: lanzkowsky p, lipton jm, fish jd, editors. lanzkowsky’s manual of pediatric hematology and oncology. 6th ed. cambridge, massachusetts: academic press; 2016. p. 555–67. 2. hall c, ritz b, cockburn m, davidson tb, heck je. risk of malignant childhood germ cell tumors in relation to demographic, gestational, and perinatal characteristics. cancer epidemiol. 2017;46:42–9. 3. pierce jl, frazier al, amatruda jf. pediatric germ cell tumors: a developmental perspective. adv urol. 2018;2018:9059382. 4. lin x, wu d, zheng n, xia q, han y. gonadal germ cell tumors in children: a restrospective review of a 10-year singlecenter experience. medicine (baltimore). 2017;96(26):e7386. 5. kaatsch p, häfner c, calaminus g, blettner m, tulla m. pediatric germ cell tumors from 1987 to 2011: incidence rates, time trends, and survival. pediatrics. 2015;135(1):e136–43. 6. poynter jn, fonstad r, tolar j, spector lg, ross ja. incidence of intracranial germ cell tumors by race in the united states, 19922010. j neurooncol. 2014;120(2):381–8. 7. cecchetto g. gonadal germ cell tumors in children and adolescents. j indian assoc pediatr surg. 2014;19(4):189–94. 8. i̇ncesoy-özdemir s, ertem u, şahin g, bozkurt c, yüksek n, ören ac, et al. clinical and epidemiological characteristics of children with germ cell tumors: a single center experience in a developing country. turk j pediatr. 2017;59(4):410–7. 9. nasir iui, ashraf mi, ahmed n, shah mf, pirzada mt, syed aa et al. clinical profile , treatment and survival outcomes of peadiatric germ cell tumours : a pakistani perspective. j pak med assoc. 2016;66(suppl 3)(10):s119–21. althea medical journal. 2021;8(1) 34 althea medical journal march 2021 10. poynter jn, amatruda jf, ross ja. trends in incidence and survival of pediatric and adolescent patients with germ cell tumors in the united states , 1975 to 2006. cancer. 2010;116(20):4882–91. 11. srivastava r, pushpam d, dhawan d, bakhshi s. indicators of malnutrition in children with cancer : a study of 690 patients from a tertiary care cancer center. indian j cancer. 2015;52(2):199–201. 12. pauniaho sl, saonen j, helminem m, heikinheimo o, vettenranta k, heikinheimo m. germ cell tumors in children and adolescents in finland : trends over 1969–2008. cancer causes control. 2014;25(10):1337–41. 13. gaspar bl, sharma p, das r. anemia in malignancies: pathogenetic and diagnostic considerations. hematology. 2015;20(1):18–25. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 193 relationship between nutritional status and school achievement of elementary school students aged 10–13 years christy venada,1 felicia kurniawan,2 isadora gracia,3 yunisa astiarani2 1school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia, 2department of public health and nutrition, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia, 3department of dental medicine, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia correspondence: christy venada, school of medicine and health sciences, atma jaya catholic university of indonesia, jalan pluit raya no. 2, north jakarta, indonesia, e-mail: christyvenada@gmail.com introduction when one talks about education, school achievement is something that one cannot forget as it stands as a benchmark in determining how successful the students are. in 2018, the programme for international student assessment (pisa) has conducted a study on gauging indonesian students’ reading competence, mathematics, and science. compared to global statistics, indonesia currently ranks at the bottom with stagnant growth in the recent 15 years.1 school achievement is affected by many factors such as nutritional status, intelligence, self-esteem, family support, and others.2 nutritional status is one of the important factors that affect the school achievement of a student in elementary school. the better nutritional status, the better school achievement of student.3 based on the 2018 of basic health research (riset kesehatan dasar, riskesdas) data, daerah khusus ibukota (dki) jakarta ranks second in the prevalence of malnourished children aged 5–12 years from all provinces.4 on top of that, several studies have shown that under nutrition and over nutrition significantly affect school althea medical journal. 2021;8(4):193–197 abstract background: school achievement is a crucial element in determining the students’ success. nutritional status is one of the factors that influence school achievements. this study aimed to analyze the relationship between nutritional status and school achievements among elementary school students. methods: the cross-sectional analytic observation was conducted during april–november 2019 using a total sampling approach. four elementary schools in penjaringan, north jakarta were chosen and students aged >10 years were selected. the data collected were gender, age, weight, height, and midterm test scores recorded in the school report, including mathematics, science, and indonesian language. the nutritional status was assessed by body mass index (bmi) and classified upon permenkes 2 tahun 2020, which were deficient, sufficient, and overnutrition. assessment of school achievement based on midterm test scores, categorized according to the 2016 assessment guidelines for elementary schools (panduan penilaian untuk sekolah dasar), into three classifications of good, fair, and poor. data were analyzed using chi-square. results: of the 436 students, 21.8% (n=95) of students were considered good, 28.2% (n=123) were fair, and 50% (n=218) were poor. the nutrition level was deficient in 9.6% (n=42) students, whereas 54.8% (n=239) students had sufficient nutrition, and 35.6% (n=155) students had overnutrition. bivariate analysis test showed a statistically insignificant relationship between nutritional status and school achievement (p>0.05). conclusion: this study indicates that nutritional status does not affect school achievement. further study is needed to determine other factors such as health, intelligence, anxiety, motivation, family, and living environment that may influence school achievement. keywords: elementary school students, nutritional status, school achievement https://doi.org/10.15850/amj.v8n4.2306 althea medical journal. 2021;8(4) 194 achievement. well-nourished children may also have great school achievements.5,6 the high prevalence of under nutrition and over nutrition in dki jakarta is underpinned by the absence of research that states the relationship between nutritional status and school achievement of elementary school students, especially in north jakarta. nutritional status can have a long-term impact on daily activities and achievement. therefore, this study aimed to determine the relationship between nutritional status and school achievement in children aged ten years and over in north jakarta. methods this research was a cross-sectional, analytic observational study, which was conducted in four schools at penjaringan, north jakarta, from april to november 2019, including two public and two private schools. a total sampling approach was applied to 652 students aged over ten years from two government owned primary schools and two private schools. exclusion criteria were students who suffered from attention-deficit/hyperactivity disorder (adhd), mental retardation, or quadriplegic, and students who did not attend school. this data were assessed with data on students’ health conditions from the principal. before gathering data, informed consent was obtained from the principal. ethical clearance was obtained from the chairman of the ethics committee of the faculty of medicine at the atma jaya catholic university of indonesia with the number 17/06/kepfkujaj/2020. the weight and height of the students were measured three times with tanita sclaes and a microtome to calculate body mass index (bmi). the bmi was then classified according to the regulation of the minister of health, the republic of indonesia (peraturan menteri kesehatan ri, permenkes ri) no 2 year 2020,7 which stipulated undernutrition, sufficient, and overnutrition. bmi that was below -2 standard deviations (sd) was categorized as undernourished. bmi between -2 sd and +1 sd was categorized as sufficient nutrition. bmi above +1 sd was categorized into overnutrition.7 the mid-term test scores for the subjects tested on the elementary school national exams, including mathematics, science, and indonesian, were taken from their mid-semester school report cards. scores were classified based on the 2016 assessment guide for elementary schools (panduan penilaian untuk sekolah dasar) which referred to the class intervals of each minimum score required (kriteria ketuntasan minimal-kkm) by the school, to determine good, fair, and poor.8 the research data were analyzed with statistical software for data science (stata) version 16 for windows, where the data were table 1 characteristic of students from four elementary schools in north jakarta variable n % gender male female 240 196 55.1 44.9 age 10 years 11 years 12 years 13 years 226 137 68 5 51.8 31.4 15.6 1.2 education level 4th grade 5th grade 6th grade 94 156 186 21.5 35.8 42.7 elementary school sdn 08 sdn 10 stella maris westin 159 148 47 82 36.5 33.9 10.8 18.8 note: sdn= sekolah dasar negeri (public elementary school) althea medical journal december 2021 althea medical journal. 2021;8(4) 195christy venada et al.: relationship between nutritional status and school achievement of elementary school students aged 10–13 years divided into univariate and bivariate data. univariate data showed the respondents distribution based on characteristics (gender, age, class), school achievement, and nutritional status. in contrast, bivariate data showed the respondents distribution based on the relationship between nutritional status and school achievement. chi-square was used to analyze bivariate data. the data were presented in tables. results out of 652 students from four schools, only 436 students qualified as respondents in this study. the number of boys was slightly higher (55.1%) compared to girls (table 1). in terms of school achievement, most of the respondents had a “poor” predicate compared to “good” and “fair” students. meanwhile, the prevalence of respondents with sufficient nutritional status was 54.8% and overnutrition and deficient nutritional status were 35.5% and 9.6% (table 2). bivariate analysis of the relationship between nutritional status and school achievement resulted in p=0.416 (p>0.05), indicating that there was no relationship between nutritional status and school achievement (table 2). discussion in riskesdas 2018, the prevalence of nutritional status of children aged 5–12 years who have sufficient nutrition is projected at 62.9% in dki jakarta,4 and our study shows a slightly lower number (54.8%). having sufficient nutrition means the food is in accordance with the daily needs of the body. foods that contains adequate nutritional intake can meet the children’s nutritional needs and affect their nutritional status.9 children with good or normal nutritional status will be able to learn more, create healthier and more productive adults,10 resulting in a better future generation of the nation. overnutrition status in this study is classified as obese. based on the 2018 riskesdas data, the prevalence of nutritional status (bmi by age) in children aged 5–12 years and adolescents aged 13–15 years in dki jakarta province showed approximately 29.2% and 25.1%, respectively, slightly lower than the prevalence of overnutrition status in this study, which is 35.5%. as for the undernutrition status in this study or otherwise classified as malnourished, our study shows that the deficiency status is 9.6%, slightly higher than the prevalence of deficiency nutritional status in children aged 5–12 years and adolescents aged 13–15 years, which are 7.9% and 8.1%, respectively.4 a study has shown that there are more respondents with low school achievement in 3 school subjects, namely: indonesian, mathematics, and science.9,11 the low school achievement proves that the learning efforts of elementary students are still considered poor. several factors might make someone excel in school: learning motivation, family support, intelligence, talents, interests, and others. the relationship between nutritional status and school achievement, which is not significant in this study, is completely different from the study conducted in yogyakarta,12 that has shown a significant result. this study explains that if the child’s nutritional status improves, the school achievement will also be better. thus, the nutritional status is one of the critical factors that directly contribute to the quality of child growth and development. consuming good and balanced nutrition may lead to better grades in school. a better score is an indicator that a child’s education at school is also good. carbohydrates, protein, table 2 relationship between nutritional status and school achievement of elementary school students aged 10–13 year old nutritional status school achievement total good fair poor n % n % n % n % deficient 10 23.8 13 31 19 45.2 42 9.6 sufficient 59 24.7 65 27.2 115 48.1 239 54.8 over 26 16.8 45 29 84 54.2 155 35.6 total 95 21.8 123 28.2 218 50 436 100 note: p=0.416 althea medical journal. 2021;8(4) 196 iron, and other nutrients play an important role in the thought processes, common sense, and concentration. having these 3 abilities naturally results in better learning efficiency as well. on the other hand, malnourished children would easily get sleepy and lack energy to participate in school activities, leading to declining school achievement.12 the results of this study contradict another study in kediri,13 which shows a relationship between overnutrition and children’s school achievement. the study implies that obese children tend to have poor health. overnutrition can cause a decrease in children’s activity and creativity, causing a sense of laziness, therefore, it might decrease children’s level of intelligence. one of the causes of obesity is increased fat deposits that can block blood flow to the brain. the blocked blood flow causes a lack of oxygen levels in the brain, causing concentration problems. concentration problems greatly affect the child’s learning process so that it declines at school. study in pekanbaru9 has found the same results as this study, showing no relationship between nutritional status and school achievement in students (p=0.771). school achievement is not only influenced by nutritional status but is multifactorial. in general, students’ school achievement can be influenced by factors that come from internal factors and external factors. opinions about school achievement are a multifactorial variable, supported by other studies, suggesting that there are many other factors that affect school achievement, such as physical health or physiology, genetics, child psychology, intelligence, talents, interests, motivation in the family environment, school environment, and community environment around children.14 nutritional status is not only determined by anthropometric measurements or bmi.15 nutritional status can be determined biochemically, specifically by blood examinations in the laboratory, for example iron deficiency anemia which can cause a decrease in concentration, intelligence, and school achievement. in terms of study weakness, this study only examines one variable which is nutritional status. in fact, other variables may affect school achievement, but are not excluded, such as learning motivation, learning anxiety, and family support. further research is needed on the relationship between nutritional status and school achievement of elementary school students with improvements in assessing various factors. in conclusion, there is no significant relationship between nutritional status and school achievement. since school achievement is multifactorial, further study is very interesting to assess other factors that can affect school achievement. acknowledgment we would like to thank the principals and students of sdn penjaringan 08 pagi, sdn penjaringan 10 pagi, sds stella maris, and sds westin for their participation. references 1. schleicher a. pisa 2018: insights and interpretations. oecd publishing [internet] 2019 [cited 2021 january 18]. available from: https://www.oecd.org/. 2. dalyono m. psikologi pendidikan. jakarta: rineka cipta; 2009. 3. wahyuningsih e. hubungan status gizi dengan prestasi belajar pada anak kelas v sdn 01 kadilanggon wedi klaten. jurnal involusi kebidanan. 2014;4(8):47–59. 4. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. laporan nasional riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2019. p. 154–66. 5. asmare b, taddele m, berihun s, wagnew f. nutritional status and correlation with academic performance among primary school children, northwest ethiopia. bmc res notes. 2018;11(1):805. 6. wingfield rj, graziano pa, mcnamara jp, janicke dm. is there a relationship between body mass index, fitness, and academic performance? mixed results from students in a southeastern united states elementary school. curr issues educ. 2011;14(2):1–10. 7. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 2 tahun 2020 tentang standar antropometri anak. jakarta: kementerian kesehatan republik indonesia; 2020. 8. direktorat pembinaan sekolah dasar. panduan penilaian untuk sekolah dasar (sd). jakarta: direktorat pembinaan sekolah dasar direktorat jenderal pendidikan dasar dan menengah kementrian pendidikan dan kebudayaan; althea medical journal december 2021 althea medical journal. 2021;8(4) 197 2016. 9. muchlis m, ernalia y, firdaus f. hubungan status gizi dengan prestasi belajar siswa sekolah dasar negeri 063 di pesisir sungai siak kecamatan rumbai pesisir kota pekanbaru. jurnal online mahasiswa bidang kedokteran. 2015;3(1):8224. 10. mustika pwsd. hubungan status gizi dengan prestasi siswa di sdn 010 pangkalan kerinci kabupaten pelalawan 2017. menara ilmu. 2017;11(78):92–100. 11. amany t, sekartini r. hubungan antara status gizi dengan prestasi belajar siswa sdn 03 pondok cina depok tahun 2015. sari pediatri. 2017;18(6):487–91. 12. maku a, mendri nk, devianto a. hubungan antara status gizi dengan prestasi belajar anak sekolah dasar di sdn ngringin depok sleman yogyakarta. caring: jurnal keperawatan. 2018;7(1):1–8. 13. antono sd. perbedaan prestasi belajar antara siswa obesitas dan tidak obesitas pada siswa sekolah dasar di kota kediri. jurnal ilmu kesehatan. 2017;5(2):84–90. 14. rawung mm, wungouw his, pangemanan dhc. hubungan status gizi dengan prestasi belajar siswa sd katolik st fransiskus xaverius kakaskasen kota tomohon. ebiomedik. 2020;8(1):11–8. 15. maleke v, umboh a, pateda v. hubungan status gizi dengan prestasi belajar siswa sekolah dasar di kecamatan modoinding. e-clinic. 2015;3(3):750–3. christy venada et al.: relationship between nutritional status and school achievement of elementary school students aged 10–13 years althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 30 amj june, 2014 effect of cucumis sativus l on glucose absorption through intestinal mucosal membrane of wistar rat models fitri amalia,1 samsudin surialaga,2 sylvia rachmayati3 1faculty of medicine, universitas padjadjaran, 2 departement of biochemistry, faculty of medicine, universitas padjadjaran, 3departement of clinical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: the cucumis sativus l has been used in traditional medicine for several conditions, with one of them being diabetes mellitus. the purpose of this experiment is to observe the anti-hyperglycemic effect of cucumis sativus l on glucose absorption through the intestinal mucosal membrane of wistar rats. methods: the research was conducted on september–november 2012 at biochemistry laboratory, faculty of medicine, universitas padjadjaran. using in situ perfusion method, the rat’s epithelial mucosa in the intestine was bathed in a simple glucose solution in control, and bathed in glucose and cucumis sativus l infusion in treatment. after admission, a sample was taken from the digestive tract and the glucose level was measured through a spectrophotometer. result: there is no significant difference in the absorption of control and treatment solution. conclusion: the cucumis sativus l does not have any significant effect on the glucose absorption through the intestinal mucosal membrane. further studies are still needed to reveal the antihyperglycemic mechanism of cucumis sativus l.[amj.2014;1(1):30–4] keywords: antihyperglycemic effect, cucumis sativus l (cucumber), diabetes mellitus, glucose absorption. pengaruh cucumis sativus l pada penyerapan glukosa melalui usus mukosa membran tikus wistar abstrak latar belakang: buah timun (cucumis sativus linn.) telah dipercaya sebagai obat tradisional beberapa penyakit, salah satunya adalah diabetes melitus. penelitian ini ditujukan untuk mengetahui efek antihiperglikemi buah timun terhadap transpor glukosa melalui sel epitel mukosa usus halus tikus wistar. metode: dengan menggunakan metode perfusi in situ, usus halus tikus dialiri larutan glukosa selama 60 menit untuk kontrol dan larutan glukosa yang telah diberi infusa timun selama 60 menit untuk perlakuan. sampel yang diambil berupa cairan yang dialirkan ke usus pengambilan dilakukan pada menit ke 0, 15, 30, 45, 60, kemudian dilakukan pengukuran kadar glukosa dengan menggunakan spektofotometri. penelitian ini dilakukan pada september–november 2012 di laboratorium biokimia, fakultas kedokteran, universitas padjadjaran hasil: tidak terdapat perbedaan bermakna antara penyerapan glukosa pada larutan kontrol dengan larutan perlakuan. simpulan: cucumis sativus l tidak memiliki pengaruh yang signifikan terhadap penyerapan glukosa melalui membran mukosa usus. penelitian lebih lanjut masih diperlukan untuk mengetahui mekanisme anti hyperglycemic cucumis sativus l. kata kunci: cucumis sativus l (cucumber), diabetes mellitus, efek antihyperglycemic, penyerapan glukosa . correspondence: fitri amalia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: 081280929465, email: fitri.ahermanto@gmail.com althea medical journal. 2014;1(1) 31 introduction diabetes mellitus is a metabolic disorder with an increase in blood glucose above the normal level (random blood glucose ≥200 mg/dl).1 according to world health organization (who) in 2011, 346 million people suffer from this disease globally. in indonesia, it is predicted by 2030 the prevalence of this disease would be around 21,3 million people.2 uncontrolled diabetes mellitus may cause a serious complications that lead to death. in 2004, approximately 3.4 million people died because of hyperglycemia. during the period of 2005–2030 it is predicted that mortality caused by diabetes mellitus would have doubled.3 to reduce the mortality and morbidity in diabetes mellitus, the treatment focuses on reducing the hyperglycemia. this can be achieved by maintaining a healthy diet, regular exercise, and consuming oral antidiabetic drugs.1 in addition to conventional therapy herbal medicine has shown the effect to control diabetes mellitus.4 cucumber (cucumis sativus l) is believed to be originating from a wild plant in india. cucumis sativus l contains a lot of phytochemicals that show many pharmacological activities, among them are hypoglycemia and antimicrobial agents.5 a study on diabetic and normal rats shows a significant reduction in blood glucose after 9 days of oral cucumis sativus l extract daily therapy.6 another study in rats shows that cucumis sativus l is effective to prevent alloxaninduced hyperglycemia.7 although previous studies have demonstrated that cucumis sativus l has an antihyperglycemic effect on blood glucose, the exact mechanism of how it works is still unknown. therefore, this study was conducted to observe the antihyperglycemic effect of cucumis sativus l on the glucose absorption in the small intestine. methods the cucumis sativus l was purchased from local market at jatinangor and was identified by department of biology, faculty of mathematics and natural science, universitas padjadjaran. the fruit was cut into small pieces, then it was added into an infusion pot with the same proportion of aquadest to create an infusion.8 five healthy male wistar rats, 3–4 months old (150–250 gr) were fasted overnight and allowed access to water ad libitium. one week table 1 glucose means rat solution i (mg/ dl) solution ii (mg/dl) 1 6.83 2.06 2 14.09 15.9 3 7.27 13.27 4 18.38 28.47 5 18.88 22.35 mean 13.09 16.41 note: solution i=glucose solution (mg/dl), solution ii=glucose solution and cucumis sativus l infusion (mg/dl) before the experiment, the rats were adapted. the rats that died from the adaptation process were excluded from the experiment.8,9 the health research ethics committee, faculty of medicine, universitas padjadjaran has reviewed this research and guaranteed that the research would follow guidelines of the international conference on harmonisationgood clinical practice (ich-gcp). this research used in situ perfusion method which enables the intestine to function normally for 6–8 hours.10 overnight fasted rats received intramuscular anesthetic injection using ketamin 0.1 ml/100 gr body weight. there were two treatments that were given, first a 25 ml glucose solution for 60 minutes, then a 25 ml glucose solution added with 1 ml cucumis sativus l infusion for another 60 minutes. every 15 minutes, a 2 ml sample was taken from the remaining solution.10 trichloroacetic acid (tca) 8,0% was used to deproteinized the samples, which were then centrifuged at 3000 rpm for 10 minutes. the supernatants were mixed with glucose reagent and incubated in the waterbath at 37°c for 10 minutes. the absorbancy of the samples was read using a spectophotometer at 500 nm wave length.10 the data distributions were checked using saphiro-wilk normality test and were analyzed by paired t-test using statistical product and service solution (spss) 15 software. the results were considered statistically significant if the p-values were <0.05.11 result the glucose absorptions of solution i (glucose fitri amalia, samsudin surialaga, sylvia rachmayati: effect of cucumis sativus l on glucose absorption through intestinal mucosal membrane of wistar rat models althea medical journal. 2014;1(1) 32 amj june, 2014 solution) and solution ii (glucose solution and cucumis sativus l infusion) were summarized in table 1. the result of the comparison meant that in solution i and ii glucose absorption shows that there is no statistically significant between the two (p > 0.05). from 5 rats, 4 of them showed the highest glucose absorption on the first 15 minutes (table 2). the rat number 3 and 4 have the highest glucose absorption on the first 15 minutes, while the rat number 2 has the highest on the last 15 minutes, and rat number 4 on the second 15 minutes (table 3) table 2 remaining and absorbed glucose concentration from solution i rat time (minutes) absorbancy means glucose that remains (mg/dl) glucose that were absorpted (mg/dl) 1 (222.4 g) 0 0.181 65.10 15 0.120 43.16 21.94 30 0.120 43.16 0.00 45 0.117 42.08 1.08 60 0.105 37.77 4.31 mean 46.25 6.83 2 (241.3 g) 0 0.314 114.18 15 0.188 68.36 45.82 30 0.175 63.63 4.73 45 0.159 57.81 5.82 60 0.159 57.81 0.00 mean 72.35 14.09 3 (232.8 g) 0 0.230 83.63 15 0.200 72.72 10.91 30 0.164 59.63 13.09 45 0.152 55.27 4.36 60 0.150 54.54 0.73 mean 65.15 7.27 4 (235.4 g) 0 0.302 111.02 15 0.190 69.85 41.17 30 0.167 61.39 8.46 45 0.123 44.72 16.67 60 0.102 37.50 7.22 mean 64.89 18.38 5 (235.7 g) 0 0.312 113.86 15 0.187 68.24 45.62 30 0.160 58.39 9.85 45 0.116 42.33 16.06 60 0.105 38.32 4.01 mean 64.22 18.88 althea medical journal. 2014;1(1) 33 disscussion the results from the analysis in table 1 show that there is no statistically significant difference between the glucose absorption in solution i and ii. it suggested that this may be due to some possibilities including the possibility that the antihyperglycemic effect of cucumis sativus l involves a different process of glucose metabolism, such as by decreasing plasma glucagon, and that the antihyperglycemic effect of cucumis sativus l is only effective after a prolonged treatment.6 from this experiment, it can be concluded that cucumis sativus l does not have any significant effect on glucose absorption table 3 remaining and absorbed glucose concentration from solution ii rat time (minutes) absorbancy means glucose that remains (mg/dl) glucose that were absorpted (mg/dl) 1 (222.4 g) 0 0.126 45.32 15 0.121 43.52 1.80 30 0.119 42.80 0.72 45 0.111 39.92 2.88 60 0.103 37.05 2.87 mean 42.08 2.06 2 (241.3 g) 0 0.268 97.45 15 0.254 92.36 5.09 30 0.232 84.36 8.00 45 0.204 74.18 10.18 60 0.177 64.36 40.33 mean 82.54 15.90 3 (232.8 g) 0 0.293 106.54 15 0.197 71.63 34.91 30 0.154 56.00 15.63 45 0.151 54.90 1.10 60 0.147 53.45 1.45 mean 68.50 13.27 4 (235.4 g) 0 0.400 147.70 15 0.269 98.89 48.81 30 0.184 67.64 31.25 45 0.109 40.00 27.64 60 0.092 33.82 6.18 mean 77.61 28.47 5 (235.7 g) 0 0.329 120.07 15 0.268 97.81 22.26 30 0.165 60.21 37.60 45 0.096 35.03 25.18 60 0.084 30.65 4.38 mean 68.75 22.35 fitri amalia, samsudin surialaga, sylvia rachmayati: effect of cucumis sativus l on glucose absorption through intestinal mucosal membrane of wistar rat models althea medical journal. 2014;1(1) 34 amj june, 2014 through the intestinal mucosal membrane. further studies are still needed to understand the antihyperglycemic mechanism of cucumis sativus l . references 1. fauci as, weiner c, braunwald e, kasper dl, hauser sl, longo dl, et al. harrison’s value pack 17th ed. new york: mcgrawhill; 2008. p. 2277, 2282. 2. departemen kesehatan republik indonesia. tahun 2030 prevalensi diabetes melitus di indonesia mencapai 21,3 juta orang. jakarta: 2009 [cited 2012 april 30]; available from: http://www.depkes.go.id/ index.php/berita/press-release/414tahun-2030-prevalensi-diabetes-melitusdi-indonesia-mencapai-213-juta-orang. html. 3. world health organization. diabetes. 2011 [cited 2012 april 30]; available from: http://www.who.int/mediacentre/ factsheets/fs312/en/index.html. 4. khan a, safdar m. role of diet, nutrients, spices, and natural products in diabetes mellitus. pak j nutr. 2003;2(1):1–12. 5. lim tk. edible medicinal and nonmedicinal plants: volume 2, fruits. new york: springer; 2012. p. 239–47. 6. minaiyan m, zolfaghari b, kamal a. effect of hydroalcoholic and buthanolic extract of cucumis sativus seeds on blood glucose level of normal and streptozotocininduced diabetic rats. iran j basic med sci. 2011;14(5):436–42. 7. dixit y, kar a. protective role of three vegetable peels in alloxan induced diabetes mellitus in male mice. plant foods hum nutr. 2010;65(3):284–9. 8. ehrhardt c, kim kj. drug absorption studies: in situ, in vitro and in silico models. new york: springer; 2008. p. 48–50. 9. who. research guidelines for evaluating the safety and efficacy of herbal medicines. manila: world health organization regional office for the western pacific; 1993. p. 38. 10. achmad s. mechanism of membrane transport. jatinangor: universitas padjadjaran; 2006. p. 1–4. 11. dahlan ms. statistik untuk kedokteran dan kesehatan. 4th ed. jakarta: salemba medika; 2009. p. 60. amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 131 anticandidal activity of lactoferrin, apolactoferrin, and oligosaccharides on mueller-hinton and sabouraud dextrose agar against fluconazole resistant-candida albicans maureen miracle stella,1 sem samuel surja,2 zita arieselia3 1school of medicine and health sciences, atma jaya catholic university of indonesia, jakarta, indonesia, 2department of parasitology, school of medicine and health sciences, atma jaya catholic university of indonesia, jakarta, indonesia, 3department of pharmacology and pharmacy, school of medicine and health sciences, atma jaya catholic university of indonesia, jakarta, indonesia correspondence: zita arieselia, md, m. biomed, department of pharmacology and pharmacy school of medicine and health sciences, atma jaya catholic university of indonesia, jalan pluit raya no. 2, north jakarta, indonesia, e-mail: zita.arieselia@atmajaya.ac.id introduction candidiasis is an infectious disease that is widely recognized as a major cause of mortality and morbidity in the community.1 the spectrum of infections caused by candida spp. is very vast, ranging from an infection that is not fatal and only affects the mucocutaneous layer to invasive infections which potentially reach the bloodstream known as candidaemia.2 at present, resistance to antifungals is a challenge for health workers in the world. azole antifungals are the drugs most frequently used as therapy for candida infections. however, their extensive use in various countries provokes resistance to the drug. c. albicans isolates from candidemic patients have the lowest incidence of azole resistance (0–5%). the incidence of fluconazole resistance in c. albicans isolates from oropharyngeal candidiasis (opc) is higher and depends upon previous fluconazole treatment and prior opc infections. c. glabrata has the highest incidence of azole resistance among candida clinical isolates and exhibits intrinsic decreased susceptibility to the azole antifungals. in the althea medical journal. 2022;9(3):131–138 abstract background: the demand for novel, useful, potential, and safe antifungal drugs and rapid fungal susceptibility test methods due to antifungal resistance and high prevalence of candida albicans infection are continuing. therefore, this study aimed to assess and compare the antifungal activity of lactoferrin, apolactoferrin, and oligosaccharides isolated from human, bovine, goat, and formula milk against c. albicans on mueller-hinton agar supplemented with 2% glucose and 5 µg/ml methylene blue and sabouraud dextrose agar. methods: lactoferrin, apolactoferrin, and oligosaccharides were extracted from human, bovine, goat, and formula milk. lactoferrin was identified using the bradford test and sodium dodecyl sulfate-polyacrylamide gel electrophoresis. oligosaccharides were identified using thin-layer chromatography. the antifungal activity of lactoferrin, apolactoferrin, and oligosaccharides against fluconazole-resistant candida albicans atcc 10231 was determined and compared using the disk diffusion method on mueller-hinton agar and sabouraud dextrose agar. the inhibition zone formed around the disk was observed after 24 hours of incubation. results: lactoferrin showed an inhibition zone on sabouraud dextrose agar against c. albicans, but not on mueller-hinton agar. meanwhile, apolactoferrin and oligosaccharides showed no antifungal activity on both agar media. conclusion: different agar media in the diffusion disk test can give different results even though using the same test method and substance. these results could shed light and become the useful references on why some potential antifungals could yield a different results in in-vitro studies, in-vivo studies, or clinical trials. keywords: agar media, apolactoferrin, candida albicans, lactoferrin, oligosaccharides https://doi.org/10.15850/amj.v9n3.2408 althea medical journal. 2022;9(3) 132 asia-pacific region, fluconazole resistance in c. tropicalis ranges from 0 to 83%. the worldwide incidence of fluconazole resistance in c. parapsilosis disseminated infections ranges between 2 and 5%. as c. krusei exhibits intrinsic resistance to fluconazole, there is some controversy about whether its increased infection rate is related to fluconazole prophylaxis or previous treatment. due to this issue, health workers need proper methods for susceptibility testing that are cheap and rapid to get results regarding the latest antifungal as a potential candidiasis therapy.3 milk contains various bioactive agents that act as antifungals, including lactoferrin (lf ), apolactoferrin (apolf ), and oligosaccharides.4 oligosaccharides are reported to inhibit the adhesion of c. albicans on intestinal epithelial cells. several other studies have also shown that lf, apolf, and oligosaccharides isolated from milk have an antifungal effect, especially against c. albicans and c. krusei.5,6 the problem of resistance has prompted researchers to seek a quick and accurate antifungal susceptibility test. disk diffusion is a method of susceptibility testing that can provide qualitative results in zones of inhibition. this method is simple, flexible, and cost-effective. additionally, it also can be used as an alternative to the broth dilution method. several previous studies have shown that testing the same antifungal agent on different agar media can give different results.5,7,8 in this study, the antifungal effects of lf, apolf, and oligosaccharides contained in human milk, bovine milk, goat milk, and formula milk were examined on two different agar media (sabouraud dextrose agar (sda) and mueller-hinton agar supplemented with 2% glucose and 5 µg/ml methylene blue (mhgmb)) against c. albicans by disk diffusion method. this study aimed to assess and compare the antifungal activity of lactoferrin, apolactoferrin, and oligosaccharides isolated from human, bovine, goat, and formula milk against c. albicans on mueller-hinton agar supplemented with 2% glucose and 5 µg/ml methylene blue and sabouraud dextrose agar and it is hoped that it could be used as a reference for further research to find suitable media to test the antifungal activity of lactoferrin, apolactoferrin, and oligosaccharides against c. albicans. methods this in vitro experimental study was conducted in january–february 2020 in parasitology laboratory, school of medicine and health sciences, atma jaya catholic university of indonesia, jakarta. this study has been approved by ethical committee with ethical clearance number: 17/02/kep-fkuaj/2019. four types of milk were used in this study, human, bovine, goat, and formula milk. human milk was obtained from a breastfeeding donor with the criteria that the donor had just given birth 1 year earlier, was still breastfeeding her baby, did not smoke, or consumed alcohol. for donors, informed consent was requested first. human milk was put in specialized human milk containers. bovine and goat milk is obtained from cattle farms in east jakarta. the milk was stored in a freezer with a temperature of -20°c for a maximum of 3 months before use and thawed by immersing the milk container in lukewarm water before usage.9 formula milk used for babies aged 0 to 6 months contains 50 mg lactoferrin/100 grams of milk. ten grams of formula milk was dissolved in 50 ml of water. milk that was used in this study was purified and isolated into human milk lactoferrin (hlf ), bovine milk lactoferrin (blf ), goat milk lactoferrin (glf ), and formula milk lactoferrin (flf ). lactoferrin was isolated and purified using the modified hassan abdalla method.10 the procedures involved include alkalizing the milk, making the solution in contact with open air, and adding organic solvents. milk alkalization was carried out by mixing 50 ml of milk with 3 ml of 40% naoh so that the naoh concentration becomes 2.4 g/l. let the alkalized milk come into contact with the open air for one night. after being left for one night, the solution will form 2 layers where the lower layer is red, and the upper layer is white milk fat, which is formed due to the saponification reaction. the red layer was taken for the next procedure, and the fat layer was removed. the red solution was then filtered using whatman paper number 1. the filtration results were mixed using acetone as much as two times the filtration volume to precipitate lactoferrin. the residue was washed with acetone several times until the lactoferrin is entirely precipitated. the evaporation of acetone from lf is modified by inserting the residue into a vacuum jar desiccator for one night, while the hassan abdalla method uses low-temperature centrifugation. when the residues appeared dry, lactoferrin was stored in a cuvette tube in the -20ºc freezer until they are used for the test.10 lactoferrin was identified using the bradford test to determine the presence or absence of protein content and sodium dodecyl althea medical journal september 2022 althea medical journal. 2022;9(3) 133maureen miracle stella et al.: anticandidal activity of lactoferrin, apolactoferrin, and oligosaccharides on mueller-hinton and sabouraud dextrose agar against fluconazole resistant-candida albicans sulfate-polyacrylamide gel electrophoresis (sds-page) to determine the molecular weight. a positive result is indicated by a blue color in the solution, while a negative result is indicated by the absence of a blue color change. the sds-page procedure was carried out in several steps, including sds-page gel preparation, running buffer preparation, reducing sample buffer preparation, sample preparation, and sds-page running. the molecular weight of lactoferrin can be read by observing the bands formed, compared with available markers. lactoferrin was inserted into the dialysis membrane in 100 ml of 0.1 m citric acid solution and left for one night at room temperature. a dialysis membrane containing lf was then transferred to a beaker containing 100 ml of aquadest and leave it for one night at -4°c. after that, the apolactoferrin formed in the dialysis membrane was taken and stored in the eppendorf tube for further testing.11 milk samples were isolated into human milk oligosaccharides (oh), bovine milk oligosaccharides (ob), goat milk oligosaccharides (og), and formula milk oligosaccharides (of). oligosaccharides were made by mixing 10 ml of milk sample and 40 ml of chloroform and methanol in a ratio of 2: 1. then, the samples were inserted into the vortex for 5 to 10 minutes. the resulting emulsion was centrifuged for 30 minutes at 6000 rpm. the layer formed at the top of the solution was taken. meanwhile, the layer formed at the bottom of the solution (chloroform and denatured protein) was removed. this entire procedure was repeated using the layer formed on top of the solution to ensure fat and protein separation from the sample. the oligosaccharides were then moved into the eppendorf tube and stored in the freezer for further testing.12 the presence or absence of oligosaccharides content in a sample was ascertained by performing thin-layer chromatography (tlc). samples (4 ul) were spotted on tlc silica gel 60f254, 20–20 cm (emd/merck, darmstadt, germany) and run on eluent consisting of a mixture of solutions: n-butanol/acetic acid/ water (2:1.1:1, v/v/v). the tlc tape/spot was colored using dap dye consisting of a solution of diphenylamine, aniline, acetone, and phosphoric acid (merck kgaa, darmstadt, germany), and incubated in an oven at 120°c for approximately 10–15 min until the yield band was visible. the standards used in this tlc consist of xylooligosaccharide standards from xylose (x1), xylobiose (x2), xylotriose (x3), xylotetraose (x4), xylopentaose (x5), and xylohexaose (x6), glucose (g), and mannose (m). the oligossachrides tested were oh (1), ob (2), og (3), and of (4). the potential antifungal activity of lf, apolf, and oligosaccharides against c. albicans atcc 10231 (resistant to fluconazole) was tested using the kirby-bauer disk diffusion method. this species was subcultured in chrom agar (oxoid brilliance™ candida agar, england) for species confirmation. c. albicans appears as a green colony on the agar. the disk diffusion method was carried out according to the clinical laboratory standard institute (clsi) m44. this study used sabouraud dextrose agar (sda, oxoid, united kingdom) and muellerhinton agar supplemented with 2% glucose and 5 µg/ml methylene blue (mh-gmb, oxoid, united kingdom). blank disk (oxoid, united kingdom) was dipped into lf, apolf, and oligosaccharides. fluconazole (hangzhou hyper chemicals limited, china) was used as a positive control, and the negative control was aquadest. the disk diffusion results in inhibition zones were compared after incubation for 24 hours at 35°c. results lactoferrin was formed as a red paste (figure 1). the bradford test gave positive results indicated by a blue color change in all samples (figure 2). these results indicate protein in all milk. based on sds-page analysis, there was a faint band between the 72 and 95 kda marker bands (figure 3), which indicated the molecular weight of proteins in all samples. the above results strongly suggest the presence of lf in the isolates. apolf appeared as a yellowish-white paste with difficulty dissolving in water (figure 1). the results of the tlc analysis are shown in figure 4. the formed band revealed that the sample contained oligosaccharides with a high concentration by a thick band’s appearance. the samples extended between the third and fifth sugars indicating that the oligosaccharides isolated from human milk were most likely xylotriose, xylotetraose, and xylopentaose. lactoferrin from various types of milk against c. albicans atcc 10231 showed inhibition zones in sda. the largest zone of inhibition was shown by blf and glf of 23 mm. meanwhile, the smallest zone of inhibition was produced by flf of 16.67 mm. however, in mhgmb, there was no inhibition zone against c. albicans atcc 10231 (table). the inhibition althea medical journal. 2022;9(3) 134 test of apolactoferrin and oligosaccharides against c. albicans did not show any inhibition zone on either sda or mh-gmb. discussion this in vitro experimental study shows that using different test media can give different results even though using the same test method and substance. these results indicate that the susceptibility test results of the substances that have the potential to be antifungal are influenced by the type of assay, the composition of the assay media, and the tested isolates’ figure 1 lactoferrin (above); apolactoferrin (below) figure 2 the bradford assay for lactoferrin althea medical journal september 2022 althea medical journal. 2022;9(3) 135 resistance profile. this could also shed light on why some potential antifungals could yield different in in-vitro studies, in-vivo studies, or clinical trials.7,8 in this study, both hlf, blf, glf, and flf inhibited the growth of c. albicans in sda, but not in mh-gmb. a study by andrés et al.13 shows that lf ’s antifungal activity depends on the cells’ energy metabolism. in the absence of oxygen, starved c. albicans was almost resistant to different lactoferrin concentrations, unlike non-starved cells exposed to this protein under oxygenic conditions, which were susceptible in lf concentration-dependent way. candida spp. needs a sugar-rich medium to grow properly.13 this is supported by miramón et al.14, the figure 3 sodium dodecyl sulfate-polyacrylamide gel electrophoresis (sds-page) for lactoferrin figure 4 thin layer chromatography (tlc) for oligosaccharides maureen miracle stella et al.: anticandidal activity of lactoferrin, apolactoferrin, and oligosaccharides on mueller-hinton and sabouraud dextrose agar against fluconazole resistant-candida albicans althea medical journal. 2022;9(3) 136 contributions of carbohydrate starvation, oxidative, and nitrosative stress play a crucial role in fungal resistance.10 sda has much more glucose than mueller-hinton agar (mha), making sda widely used for candida spp. culture preservation.7 different compositions and properties where sda is more acidic (ph 5.6±0.2) while mh-gmb has a more neutral ph (ph 7.2–7.4) could also produce a different result.9,11 a study showed that, the susceptibility of fluconazolesusceptible c. albicans and fluconazoleresistant c. albicans to fluconazole could give different results at ph 7 and when the ph decreased.8 this suggests that differences in the test media’s ph can affect the antifungal activity against c. albicans.8,11,12 mueller-hinton agar was used as the medium in this study because it is the agar medium most often used for susceptibility testing. however, previous studies showed that c. albicans experienced poor growth with mha. this makes mha, not a suitable medium for testing antifungal susceptibility with inhibitory mechanisms such as fluconazole against c. albicans strains. one of the lf antifungal mechanism targets is the cell membrane, similar to fluconazole antifungal mechanism. this study also showed no inhibition of lf against c. albicans, so mha should not be used in carrying out the lf test against c. albicans.13,14 the antifungal susceptibility test of apolactoferrin against c. albicans on both sda and mh-gmb media did not show any inhibition zone, indicating that the isolated apolactoferrin could not inhibit the growth of c. albicans in this assay. the absence of a zone of inhibition of apolactoferrin against c. albicans is thought to be due to technical constraints. the apolactoferrin cannot be adequately absorbed into the disk because of its insoluble substance nature. however, these results contrast with a study which showed that apolactoferrin could directly inhibit the growth of c. albicans, while lf does not show any antifungal activity.5 media with iron concentrations above 0.5 mmol/l can eliminate fungal growth’s inhibitory effect, even at 10% concentrations. iron concentration in the growth medium of c. albicans is essential for the regulation of iron-uptake mechanisms that can affect the virulence of apolactoferrin. this study has used. 24-well dishes (nunclon) in the assay method and rpmi 1640 with l-glutamine and without antibiotics or serum as the assay medium for fungal growth.5 furthermore, the lactoferrin used in this study also came from sigma chemical co. (st. louis, mo, usa). from this, it can be concluded that the test media and the isolation technique of the related agent can affect the results of the inhibition test against c. albicans. the antifungal activity against c. albicans cells is not solely due to the chelation of iron by lactoferrin but also involves another complex mechanism involving genetic resistance when lactoferrin comes into contact with candida cells.5,15 the oligosaccharides against c. albicans showed no inhibition zone around the disk in both sda and mh-gmb. this indicates that the oligosaccharides isolated from various types of milk could not inhibit the growth of c. albicans atcc 10231 in the disk diffusion method. this is thought to be related to the mechanism of inhibition of oligosaccharides against c. albicans. oligosaccharides suppress the growth of c. albicans by blocking the surface of the c. albicans cell structures that are needed to bind to epithelial cells. oligosaccharides also inhibit the pathogenicity of c. albicans by inhibiting the growth of its hyphae. also, the morphogenesis of c. albicans is inhibited by the presence of oligosaccharides, especially during table inhibition zone on mueller-hinton and sabouraud dextrose agar comparison antifungal agents inhibition zone (mm) mueller-hinton agar sabouraud dextrose agar i ii iii mean i ii iii mean fluconazole 25 23 27 25 24 23 22 23 aquadest 0 0 0 0 0 0 0 0 hlf * 0 0 0 0 22 20 21 21 blf ** 0 0 0 0 25 23 21 23 glf *** 0 0 0 0 25 21 23 23 flf **** 0 0 0 0 17 17 16 16.67 note: *hlf: human lactoferrin, **blf: bovine lactoferrin, ***glf: goat lactoferrin, ****flf: formula lactoferrin althea medical journal september 2022 althea medical journal. 2022;9(3) 137 the initiation of hyphae.6,16-19 saccharides can also function as prebiotics in the body that suppress the growth of c. albicans, especially when combined with lactobacillus spp., bacteroides spp., and bifidobacterium infantis, which are normal microbiota and probiotics in the intestine.20 in addition, from the results of this study that is limited to disk diffusion test, this method should only be used as a screening test to determine the antifungal agent’s potency. various agar media should also be used to compare differences in the inhibition test results, as in this study. susceptibility assays such as macrodilution, microdilution, or e-test should also be done after the disk diffusion test to confirm the result. one of the limitations of this study was only the disk diffusion method was conducted. therefore, more research is required to determine these agents’ antifungal mechanisms in various growth media and susceptibility tests. moreover, it is recommended to examine lactoferrin, apolactoferrin, and oligosaccharides activity by performing in vivo tests on animal models. to conclude, different agar media in the disk diffusion test for the same agent and isolate can give different results. lactoferrin has shown potential inhibition against c. albicans in sda, but not in mh-gmb. meanwhile, apolactoferrin and oligosaccharides did not show any antifungal activity in both types of agar. these results could shed light and become the useful references on why some potential antifungals could yield a different results in in-vitro studies, in-vivo studies, or clinical trials. references 1. pappas pg, kauffman ca, andes dr, clancy cj, marr ka, ostrosky-zeichner l, et al. clinical practice guideline for the management of candidiasis: 2016 update by the infectious diseases society of america. clin infect dis. 2015;62(4):e1– 50. 2. brooks gf, carroll kc, butel js, morse sa, mietzner ta. jawetz, melnick & adelberg’s medical microbiology. 26th ed. new york: mcgraw-hill eucation; 2013. 3. whaley sg, berkow el, rybak jm, nishimoto at, barker ks, rogers pd. azole antifungal resistance in candida albicans and emerging non-albicans candida species. front microbiol. 2017;7:2173. 4. triantis v, bode l, van neerven rjj. immunological effects of human milk oligosaccharides. front pediatr. 2018;6:190. 5. andersson y, lindquist s, lagerqvist c, hernell o. lactoferrin is responsible for the fungistatic effect of human milk. early hum dev. 2000;59(2):95–105. 6. nilakanta h, drews kl, firrell s, foulkes ma, jablonski ka. a review of software for analyzing molecular sequences. bmc res notes. 2014;7:830. 7. rubio mc, gil j, de ocáriz ir, benito r, rezusta a. comparison of results obtained by testing with three different agar media and by the nccls m27-a method for in vitro testing of fluconazole against candida spp. j clin microbiol. 2003;41(6):2665–8. 8. danby cs, boikov d, rautemaa-richardson r, sobel jd. effect of ph on in vitro susceptibility of candida glabrata and candida albicans to 11 antifungal agents and implications for clinical use. antimicrob agents chemother. 2012;56(3):1403–6. 9. rollo de, radmacher pg, turcu rm, myers sr, adamkin dh. stability of lactoferrin in stored human milk. j perinatol. 2014;34(4):284–6. 10. abdalla h, mohamed h (al-ain, ae). method for purifying lactoferrin [internet]. al ain, united arab emirates: united arab emirates university; 2016 [cited 2020 december 28]. available from: https:// www.freepatentsonline.com/9458225. html. 11. majka g, śpiewak k, kurpiewska k, heczko p, stochel g, strus m, et al. a high-throughput method for the quantification of iron saturation in lactoferrin preparations. anal bioanal chem. 2013;405(15):5191–200. 12. balogh r, jankovics p, béni s. qualitative and quantitative analysis of n-acetyllactosamine and lacto-n-biose, the two major building blocks of human milk oligosaccharides in human milk samples by high-performance liquid chromatographytandem mass spectrometry using a porous graphitic carbon column. j chromatogr a. 2015;1422:140–6. 13. andrés mt, acosta-zaldívar m, fierro jf. antifungal mechanism of action of lactoferrin: identification of h+-atpase (p3a-type) as a new apoptotic-cell membrane receptor. antimicrob agents chemother. 2016;60(7):4206–16. 14. miramón p, dunker c, windecker h, bohovych im, brown ajp, kurzai o, et al. cellular responses of candida albicans to phagocytosis and the extracellular maureen miracle stella et al.: anticandidal activity of lactoferrin, apolactoferrin, and oligosaccharides on mueller-hinton and sabouraud dextrose agar against fluconazole resistant-candida albicans althea medical journal. 2022;9(3) 138 activities of neutrophils are critical to counteract carbohydrate starvation, oxidative and nitrosative stress. plos one. 2012;7(12):e52850. 15. stanciu g, aonofriesei f, lupsor s, popescu a, sirbu r. study of phenolic compounds and antimicrobial activity of lavandula angustifolia l. flowers macerates. rev chim. 2019;70(5):1800–4. 16. mehta a, kumar m, bhumbla u, vyas a, dalal as. comparison of different media for germ tube production by candida albicans: a retrospective study. int j curr microbiol app sci. 2018;7(6):819–23. 17. fernandes ke, carter da. the antifungal activity of lactoferrin and its derived peptides: mechanisms of action and synergy with drugs against fungal pathogens. front microbiol. 2017;8:2. 18. prasad t, chandra a, mukhopadhyay ck, prasad r. unexpected link between iron and drug resistance of candida spp.: iron depletion enhances membrane fluidity and drug diffusion, leading to drug-susceptible cells. antimicrob agents chemother. 2006;50(11):3597–606. 19. hundshammer c, minge o. in love with shaping you—influential factors on the breast milk content of human milk oligosaccharides and their decisive roles for neonatal development. nutrients. 2020;12(11):3568. 20. kojima y, ohshima t, seneviratne cj, maeda n. combining prebiotics and probiotics to develop novel synbiotics that suppress oral pathogens. j oral biosci. 2016;58(1):27–32. althea medical journal september 2022 amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 168 clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung 2017–2021 exel wibowo,1 arif dermawan,2 melati sudiro2 ¹faculty of medicine universitas padjadjaran, indonesia, ²department of otorhinolaryngology head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: arif dermawan, dr., sp.t.h.t.k.l.(k)., m.kes., department of otorhinolaryngology head & neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur no. 38 bandung, indonesia, email: ad_tht@yahoo.co.id introduction allergic rhinitis is a disorder of nasal mucosa due to exposure to allergen particles that cause inflammation mediated by immunoglobulin e (ige).1 the symptoms include nasal congestion, runny nose, sneezing, an itchy nose, and loss of smell when the nasal mucosa is exposed to allergens. allergic rhinitis affects about 10% to 30% of the world’s population. based on a previous study, the prevalence of allergic rhinitis in indonesia is 38.2%.2 the diagnosis of allergic rhinitis is made based on history taking, physical examination, and supporting examination.1 a complete history is required to look for potential triggers, nasal symptoms, and a family history of atopy. clinical signs observed from physical examination act as objective evidence to rule out the differential diagnosis and may indicate the presence of comorbidities. physical examination is performed by anterior rhinoscopy, which shows hypertrophy and pale inferior turbinate mucosa with clear secretions. nasal endoscopy can be performed to assess the nasal cavity in more detail and support the diagnosis of allergic rhinitis.3,4 the comorbidities include asthma, conjunctivitis, chronic rhinosinusitis with or without nasal polyps, otitis media with effusion, and adenoid hypertrophy. those comorbidities cause sleep disturbance which acts as factors that worsen the quality of life if not given the appropriate treatment.5 definitive diagnosis is made by detecting allergen-specific ige or the skin prick test.6 the clinical diagnosis of allergic rhinitis, which is established as a prerequisite for appropriate treatment, requires comprehensive data from the history and physical examination. althea medical journal. 2022;9(3):168–173 abstract background: the clinical diagnosis of allergic rhinitis requires comprehensive data from the history and physical examination. despite being a substantial component of the diagnosis of allergic rhinitis, there is a paucity of studies about clinical signs of allergic rhinitis in indonesia. this study aimed to describe the clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung. methods: this cross-sectional study was conducted at dr. hasan sadikin general hospital bandung in 2021, including secondary data of patients with allergic rhinitis from medical records registered from 2017 to 2021. data on the characteristics, clinical signs, and allergic rhinitis comorbidities were collected and presented in tables. results: the most common clinical sign was turbinate hypertrophy (74%), followed by pale nasal mucosa (59%) and clear nasal discharge (59%). the most prevalent comorbidities were chronic rhinosinusitis, adenoid hypertrophy, and asthma. conclusion: the clinical signs observed from allergic rhinitis patients may vary, with the most common findings, including nasal turbinate hypertrophy, pale nasal mucosa, and clear nasal discharge. the findings may help clinicians to diagnose allergic rhinitis needed for therapy management. keywords: allergic rhinitis, clinical signs, diagnosis https://doi.org/10.15850/amj.v9n3.2682 althea medical journal. 2022;9(3) 169 despite being a substantial component of the diagnosis of allergic rhinitis, there is a paucity of studies about clinical signs of allergic rhinitis in indonesia. this study aimed to describe the clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung. methods this study was a descriptive observational study with a cross-sectional design conducted from january to december 2021 at the department of otorhinolaryngology head and neck surgery dr. hasan sadikin general hospital bandung. the study subjects were patients diagnosed with allergic rhinitis from january 2017 to october 2021. the sample was selected using the total sampling method. secondary data were taken from medical records and after obtaining ethical clearance from the health research ethics committee of dr. hasan sadikin general hospital bandung no. 816/un6.kep/ec/2021. the inclusion criteria in this study were patients diagnosed with allergic rhinitis confirmed by a skin prick test, while the exclusion criteria were incomplete or missing medical records. the study variables were age, gender, family history of atopic disease, classification, cardinal symptoms, physical findings, and comorbidities. the collected data were analyzed using microsoft excel 2020 software to calculate the frequency of findings and presented in tables. results out of 463 patients with allergic rhinitis, 260 were included. the distribution of gender, age groups, and family history of the atopic disease was provided in table 1. the classification of allergic rhinitis was described in table 2 based on the aria-who guidelines. the most prevalent classification was moderate-severe persistent allergic rhinitis (45%), and the least prevalent was moderate-severe intermittent (4%). the most common cardinal symptom was nasal congestion (87%), followed by a runny nose (81%), sneezing (72%), and an itchy nose (49%). the physical findings included the nasal cavity, left and right ears, and oropharynx examinations. on anterior rhinoscopy examination, the most common clinical manifestations were inferior turbinate hypertrophy (74%) with pale mucosa (59%) and clear discharge (59%). on nasal endoscopic examination, inferior turbinate hypertrophy (82%) and clear nasal secretions (72%) were found in almost all patients. the most common comorbidities were chronic rhinosinusitis without polyps (53%), adenoid hypertrophy or sleep disturbances (23%), and asthma (11%). only 19% of patients had no comorbidities. table 1 characteristics of allergic rhinitis patients at dr. hasan sadikin general hospital (n=260) characteristics n % gender male female 127 133 49 51 age group (year) < 10 10–19 20–29 30–39 40–49 ≥ 50 22 62 63 30 38 45 8 24 24 12 15 17 family history of atopic disease yes no unknown 107 145 8 41 56 3 exel wibowo et al.: clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung 2017–2021 table 2 classification of allergic rhinitis in patients at dr. hasan sadikin general hospital according to aria-who guidelines classification frequency (n) percentage (%) mild intermittent 84 32 mild persistent 47 18 moderate-severe intermittent 11 4 moderate-severe persistent 118 45 total 260 100 althea medical journal. 2022;9(3) 170 althea medical journal september 2022 table 3 cardinal symptoms, physical findings, and distribution of comorbidities in patients with allergic rhinitis at dr. hasan sadikin general hospital findings frequency (n) percentage (%) cardinal symptoms nasal obstruction runny nose sneezing itchy nose 220 205 182 125 87 81 72 49 anterior rhinoscopy nasal mucosa calm pale/livid hyperemic nasal discharge clear purulent inferior turbinate hypertrophy 100 153 7 154 9 192 38 59 3 59 3 74 ear examination hyperemic mucosa secret clear purulent tympanic membrane perforation 4 6 2 21 2 2 1 8 oropharynx examination hyperemic mucosa tonsil hypertrophy grade 2 grade 3 grade 4 3 23 6 3 1 9 2 1 nasal endoscopy inferior turbinate hypertrophy nasal discharge clear purulent septum deviation adenoid hypertrophy postnasal drip middle turbinate hypertrophy middle meatus opening sufficient narrow congested uncinate process edema polyps grade 1 grade 2 grade 3 214 203 16 82 59 56 52 155 93 12 110 3 4 18 82 78 6 32 23 22 20 60 36 5 42 1 2 7 comorbidities asthma chronic rhinosinusitis without polyps chronic rhinosinusitis with polyps chronic suppurative otitis media adenoid hypertrophy 28 138 25 9 59 11 53 10 3 23 althea medical journal. 2022;9(3) 171 discussion in the present study, the number of the female with allergic rhinitis patients was higher than that of males. the higher prevalence of female allergic rhinitis patients might occur due to estrogen and progesterone, which increase mast cell and ige activity, making females more susceptible to atopic diseases such as allergic rhinitis and asthma.7 the most prominent age groups were 10–19 and 20–29 year, who are still in school-age and productive age. allergic rhinitis in both age groups impacts decreased productivity due to impaired concentration at school or work caused by the symptoms experienced, prompting patients to seek help from health facilities.1,6 many studies have shown that a family history of atopy is a risk factor for allergic rhinitis. a study in sweden concluded that children born to parents with allergy have an increased 2–9 folds risk of allergic rhinitis.8 another study on turkish adolescents with allergic rhinitis showed that 53% of the study population had at least 1 parent with atopy.9 similarly, a study in indonesia has shown that 54% of cases present with an atopic family history.2 these data were consistent with the results of our study, where nearly half (41%) of the patients had a family history of atopic disease. the classification of persistent moderatesevere allergy was the most common form in our study, similar to the previous studies conducted in clinical settings.5,10 the reduced quality of life in patients with moderate-severe persistent allergic rhinitis might have caused the patients to be more likely to seek medical therapy than patients with milder allergic rhinitis classifications.5 cardinal symptoms of allergic rhinitis include nasal congestion, runny nose, sneezing, and itchy nose.1 in a study involving 979 allergic rhinitis patients in france showed that nasal congestion was found in 82% of patients, followed by the runny nose (89%), sneezing (82%), and itchy nose (68%).10 these were consistent with our study. the discrepancy between some studies with others could be explained by the varied symptoms of allergic rhinitis and comorbidities the study subjects might have. the anterior rhinoscopy examination showed inferior turbinate hypertrophy, clear secretions, and pale mucosa in most study samples. inflammatory mediators released by mast cells cause interstitial edema of the nasal mucosa, resulting in turbinate hypertrophy.11 a study in tanzania on 193 allergic rhinitis patients noted concha hypertrophy (69%), and another study in north vietnam found turbinate hypertrophy (70%).12,13 the mechanisms of increased watery nasal secretions include histamine-induced mucosal gland hyperactivity and plasma leakage.11 clear and watery nasal discharge was observed in 59%; however, the number of patients who complained of a runny nose was quite high (81%). the difference might occur due to patients with intermittent allergic rhinitis or patients who had received previous treatment, which allowed the secretions to be not visible at the time of the examination. a pale mucosal color caused by chronic inflammation of the nasal mucosa is associated with the level of eosinophil infiltration, which is a hallmark of allergic rhinitis. a study in japan showed that the proportion of pink or normal mucosal color was 57%, and pale was 43%.14 however, the study did not include the diagnosis of allergic rhinitis as an inclusion criterion that the subjects might not had before the examination.14 in contrast to the study, our study was conducted on patients diagnosed with allergic rhinitis, and the most common color of the mucosa was pale blue (59%). the subjectivity in determining the mucosa color might have affected the results of both studies. this study included the results of ear and oropharynx examinations. a small proportion of patients in this study showed ear membrane perforation (8%) and ear discharge (3%) which could be associated with chronic suppurative otitis media. previous studies have shown that allergic rhinitis is a risk factor for chronic suppurative otitis media. the mechanism involved is nasal mucosa inflammation of allergic rhinitis patients can cause eustachian tube dysfunction, making it easier for acute infections to recur and inflammatory response of the middle ear mucosa to the allergens occur as in nasal mucosa.15,16 tonsil hypertrophy was found in 31 cases (12%), with grade 2 (9%) being the most common compared with grade 3 (2%) or 4 (1%). a study in italy17 has shown that children with persistent upper airway obstruction might be due to inflammation as allergen stimulation increases the risk of mild tonsillar hypertrophy but decreases the risk of severe tonsillar hypertrophy (grades 3 and 4). the turbinate hypertrophy possibly in allergic rhinitis can prevent allergens from reaching the tonsils and stimulate further hypertrophy.17 the nasal endoscopic examination provides a more detailed evaluation of the nasal cavity than the anterior rhinoscopy.1,18 nasal exel wibowo et al.: clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung 2017–2021 althea medical journal. 2022;9(3) 172 endoscopic examination in this study showed inferior turbinate hypertrophy (82%) and clear secretions (78%), and these numbers are lesser found in physical examination. the limited scope of anterior rhinoscopy might explain these differences compared to nasal endoscopy. the examination of anterior rhinoscopy and nasal endoscopy were done on different days, which allowed the symptoms to improve or worsen, and symptoms of allergic rhinitis may appear intermittently. nasal endoscopic examination in this study included an assessment of the osteomeatal complex. there was hypertrophy of the middle turbinate (20%), edema of the uncinate process (42%), and narrowing of the middle meatus (36%) that could play a role in the mechanism of chronic rhinosinusitis by impairing the drainage of the frontal, maxillary, and anterior ethmoid sinuses.19 nasal endoscopy can also be performed to detect comorbidities such as adenoid hypertrophy and nasal polyps in patients.18 allergic rhinitis must include the detection of comorbidities that can worsen the patient’s quality of life if not treated appropriately.4,5 the most frequent comorbidity found in this study was chronic rhinosinusitis without nasal polyps (53%), followed by adenoid hypertrophy (23%), asthma (11%), chronic rhinosinusitis with polyps (10%), and chronic suppurative otitis media (3%). a previous study conducted in bandung, indonesia, found that rhinosinusitis (50%), nasal polyps (25%), and asthma (10%) were the most prevalent comorbidities.20 another study conducted in dar es salam, tanzania, showed the most common comorbid was adenoid hypertrophy (31%), followed by nasal polyps (14%), sinusitis (9%), and otitis media with effusion (9%).12 the high proportion of comorbidities in the present study could be caused by the research location, dr. hasan sadikin general hospital bandung, which is a top referral hospital in west java province, so patients tend to have more severe diseases. the difference in the proportion of comorbidities in the mentioned studies could be related to geographic factors and the multifactorial nature of the comorbidities. this research, however, is subject to several limitations. the data presented in this study were taken from medical records dependent on the extent of the physician’s assessment of the patients. nevertheless, some clinical signs of allergic rhinitis were not assessed and therefore not recorded, for examples clinical signs such as adenoid facies, dennie-morgan lines, and transverse nasal folds that may be present in allergic rhinitis patients. another limitation came from the large number of medical records that could not be included in this study. further studies are suggested to include clinical signs that were not available in this study and to be carried out in a larger population to obtain a more precise result. to conclude, the clinical signs observed from allergic rhinitis patients may vary with the most common findings including nasal turbinate hypertrophy, pale nasal mucosa, and clear nasal discharge. the findings may help clinicians to diagnose allergic rhinitis needed for therapy management. references 1. bousquet j, khaltaev n, cruz aa, denburg j, fokkens wj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008 update: in collaboration with the world health organization, ga(2)len and allergen. allergologie. 2009;32(8):306– 19. 2. fauzi, sudiro m, lestari bw. prevalence of allergic rhinitis based on world health organization (aria-who) questionnaire among batch 2010 students of the faculty of medicine universitas padjadjaran. althea med j. 2015;2(4):620–5. 3. scadding gk, kariyawasam hh, scadding g, mirakian r, buckley rj, dixon t, et al. bsaci guideline for the diagnosis and management of allergic and nonallergic rhinitis (revised edition 2017; first edition 2007). clin exp allergy. 2017;47(7):856–89. 4. kakli ha, riley td. allergic rhinitis. prim care. 2016;43(3):465–75. 5. moeis rm, sudiro m, herdiningrat rs. allergic rhinitis patient characteristics in dr. hasan sadikin general hospital bandung indonesia. althea med j. 2014;1(2):70–4. 6. seidman md, gurgel rk, lin sy, schwartz sr, baroody fm, bonner jr, et al. clinical practice guideline: allergic rhinitis. otolaryngol neck surg. 2015;152(1_ suppl):s1–43. 7. fröhlich m, pinart m, keller t, reich a, cabieses b, hohmann c, et al. is there a sex-shift in prevalence of allergic rhinitis and comorbid asthma from childhood to adulthood? a meta-analysis. clin transl allergy. 2017;7:44. 8. westman m, kull i, lind t, melén e, stjärne p, toskala e, et al. the link althea medical journal september 2022 althea medical journal. 2022;9(3) 173 between parental allergy and offspring allergic and nonallergic rhinitis. allergy. 2013;68(12):1571–8. 9. tamay z, akcay a, ergin a, guler n. effects of dietary habits and risk factors on allergic rhinitis prevalence among turkish adolescents. int j pediatr otorhinolaryngol. 2013;77(9):1416–23. 10. bousquet pj, demoly p, devillier p, mesbah k, bousquet j. impact of allergic rhinitis symptoms on quality of life in primary care. int arch allergy immunol. 2013;160(4):393–400. 11. okubo k, kurono y, ichimura k, enomoto t. allergology international japanese guidelines for allergic rhinitis 2017. allergol int. 2017;66(2):205–19. 12. ivanovich k, ivanovich ka, bondareva gp, thao ntp. allergic rhinitis complicated by hypertrophy of the mucous membrane of nasal turbinates in patients of northern vietnam. biomed res ther. 2020;7(6):3813–8. 13. mapondella kb, massawe wa. prevalence of allergic rhinitis and associated complications among patients receiving otorhinolaryngology services at muhimbili national hospital. med j zambia. 2018;45(2):72–81. 14. motomura c, odajima h, yamada a, taba n, murakami y, nishima s. pale nasal mucosa affects airflow limitations in upper and lower airways in asthmatic children. asia pac allergy. 2016;6(4):220. 15. nemati s, shakib rj, shakiba m, araghi n, azimi sz. allergic rhinitis in adults with chronic suppurative otitis media. iran j otorhinolaryngol. 2015;27(81):261. 16. zernotti me, pawankar r, ansotegui i, et al. otitis media with effusion and atopy: is there a causal relationship? world allergy organ j. 2017;10(1):1–9. 17. ameli f, brocchetti f, tosca ma, schiavetti i, ciprandi g. tonsil volume and allergic rhinitis in children. allergy rhinol (providence). 2014;5(3):137–42. 18. small p, keith pk, kim h. allergic rhinitis. allergy asthma clin immunol. 2018;14(suppl 2):51. 19. bandyopadhyay r, biswas r, bhattacherjee s, pandit n, ghosh s. osteomeatal complex: a study of its anatomical variation among patients attending north bengal medical college and hospital. indian j otolaryngol head neck surg. 2015;67(3):281. 20. aziza a, dermawan a, dewi vyk. effectiveness of allergic rhinitis management related to who guideline on allergic rhinitis and its impact on asthma (aria). althea med j. 2016;3(4):538–44. exel wibowo et al.: clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung 2017–2021 amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 99 poor glycemic control correlates with iron deficiency anemia in type 2 diabetes mellitus talitha imani kaltsum,1 pusparini2 1faculty of medicine, universitas trisakti, jakarta, indonesia , 2department of clinical pathology, faculty of medicine, universitas trisakti, jakarta, indonesia correspondence: prof. dr. dr. pusparini, sp.pk, department of clinical pathology, faculty of medicine, universitas trisakti, jalan kyai tapa no. 1 grogol , jakarta barat, indonesia, e-mail: pusparini@trisakti.ac.id introduction diabetes mellitus (dm) is still an important global health problem.1 the international diabetes federation (idf) data 2021 shows that at least 537 million people aged 20–79 years worldwide suffer from dm, equivalent to a prevalence rate of 10.5% of the population in the same age range.2 in 2019, indonesia ranks seventh among the ten countries with the most dm cases, comprising 10.7 million.3 laboratory tests are used for diagnosing and monitoring dm, such as glycated hemoglobin (hba1c), the predominant hemoglobin found in the hba1 fraction, accounting for 5% of the total normal adult hemoglobin and attaining 15% in dm.4 the hba1c assay, used for determining blood glucose during the last 2–3 months, is also the best single test for the risk of tissue damage caused by high blood glucose.5 hba1c is currently the gold standard for the diagnosis of dm. the use of hba1c for diagnosis and therapeutic monitoring in patients with type 2 dm who have anemia requires caution because anemia may give rise to falsely high or low hba1c results that do not correspond to the patient’s condition.3 patients with type 2 dm are at risk of various comorbidities and complications, including iron deficiency anemia (ida). the incidence rate of ida in type 2 dm without nephropathy has reached around 40 to 55%.6,7 the primary mechanism underlying the relationship of type 2 dm with ida is still unclear, but it is thought due to low-grade inflammation. various studies have shown that patients with type 2 dm have significantly increased serum concentrations of hepcidin, tumor necrosis factor, and interleukin-6.8–12 anemia as a worldwide health issue negatively impacts the quality of life and utilization of medical facilities. therefore, anemia in patients with dm must be managed immediately after diagnosis, as this may althea medical journal. 2023;10(2):99–103 abstract background: glycated hemoglobin (hba1c) has been used extensively to diagnose and monitor diabetes mellitus (dm). patients with type 2 dm are at risk of experiencing comorbidities and complications such as iron deficiency anemia (ida). this study aimed to determine the correlation of hba1c with iron deficiency anemia (ida) in type 2 dm. methods: this cross-sectional study was conducted on 115 types 2 dm patients at a hospital in south jakarta, indonesia from november to december 2021. data on hba1c levels and ida were obtained from medical records. data were analysed with the chi-square test and significancy at p<0.05. results: in total, 43 men and 72 women with type 2 dm were included, with predominantly age over 45 years (89.6%), had dm for more than ten years (55.7%), had obesity i (53.9%), and with hypertension as the most common comorbidity (65.2%). furthermore, the patients did not smoke (64.3%), had poor glycemic control ((76.5%) and had anemia (58.3%). there was a significant relationship between hba1c levels and ida (p=0.003). conclusion: this study shows a relationship between hba1c and ida in type 2 dm, therefore, dm patients with poor glycemic control need to be well monitored for iron deficiency anemia. keywords: hba1c, iron deficiency anemia, type 2 diabetes mellitus https://doi.org/10.15850/amj.v10n2.2937 althea medical journal. 2023;10(2) 100 lead to the pathogenesis and development of severe cardiovascular disease and diabetic nephropathy.13 moreover, type 2 dm patients aged over 60 years are also more susceptible to anemia.13 in addition, the prevalence of anemia is higher in uncontrolled dm.14 studies conducted in india have reported that there is definitely an inverse relationship between ida with hba1c levels in type 2 dm.14,15 in ida, hba1c increases concomitanly with reduced hemoglobin concentrations due to iron deficiency.14 conversely, other studies report that hba1c concentrations are lower in dm with ida.16,17 studies on the correlation of hba1c with ida in type 2 dm have shown controversies, while additionally, the prevalence of dm in indonesia and throughout the world is steadily increasing. this study aimed to determine the correlation of hba1c with ida in type 2 dm. methods this cross-sectional study based on medical records was conducted at metropolitan medical center hospital in south jakarta from november to december 2021, involving 115 respondents (43 males and 72 females). data collection was carried out using the simple random sampling method. patients of this study were mainly from the middle to high socioeconomic class. the inclusion criteria in this study were age over 18 years, diagnosis as type 2 dm with or without ida, and availability of complete data on the laboratory results for hba1c, complete blood count, and iron status, i.e. serum iron (si), total iron binding capacity (tibc), transferrin saturation, ferritin. the exclusion criteria were incomplete medical records, pregnancy, chronic kidney disease (ckd), neuropathy, and diabetic nephropathy. the hba1c concentration was categorized into good glycemic control (<6.5%), and signifying poor glycemic control (≥6.5%).18 the diagnosis of ida was established from the criterion of microcytic hypochromic anemia based on the morphology of peripheral blood smears and using one of the following indicators; a) presence of 2 out of 3 of the following parameters: si <50 mg/dl, tibc >350 mg/dl, or transferrin saturation <15%; b) serum ferritin concentration <20 mg/l.19 the data were presented descriptively using percentage, mean, standard deviation if the data had normal distributions; median and minimum–maximum range if the data had abnormal distributions. the analysis of the hba1c concentrations as compared to ida table 1 clinical characteristics of type 2 dm patients in metropolitan medical center hospital, jakarta, year 2021 (n=115) clinical characteristic n (%) gender male female 43(37.4) 72 (62.6) age (years); mean±sd ≥45 ˂45 61.25±13.58 103 (89.6) 12 (10.4) bmi (kg/m2); mean±sd ≥25 ˂25 25.77±4.31 62 (53.9) 53 (46.1) duration of dm (years); mean±sd ˃10 ≤10 12.64±5.11 64 (55.7) 51 (44.3) comorbidities none hypertension allergy dyslipidemia pulmonary tuberculosis 17 (14.8) 75 (65.2) 9 (7.8) 9 (7.8) 5 (4.3) smoking history smoker non-smoker 41 (35.7) 74 (64.3) note: bmi= body mass index; sd= standard deviation althea medical journal june 2023 used the chi-square test at p<0.05. this study was approved by the ethical clearance committee, faculty of medicine, universitas trisakti, no. 72/ker-fk/ix/2021. results the majority of subjects were females (62.6%), aged ≥45 years (89.6%) with bmi 25 kg/m2 (53.9%), and duration of dm ˃10 years (55.7%). the most frequent comorbidity was hypertension (65.2%). most of patients did not have smoking history (64.3%) (table 1). laboratory data showed that the majority of the patients had hba1c ≥6.5% with a mean of 8.06±2.1 (table 2), indicating that 23.5% had controlled dm. there was a strong relationship (p=0.003) between hba1c and iron deficiency anemia (table 3). on the other hand, there was no significant relationship between bmi (p=0.236), duration of dm (p=0.624), hypertension (p=0.190), and iron deficiency anemia. althea medical journal. 2023;10(2) 101talitha imani kaltsum and pusparini: poor glycemic control correlates with iron deficiency anemia in type 2 diabetes mellitus discussions the results of the study showed that the majority subjects (76.5%) have poor glycemic control, similar to other study showing that patients with higher hba1c concentrations (7.3±0.9%) have more ida.15 reduced bone marrow reticulocytes production in ida, which is counteracted by delayed clearance of older erythrocytes by reticuloendothelial cells, results in increased hba1c concentrations as a consequence of a longer lifespan of the earlier forms of erythrocytes and an increased in the mean age of circulating erythrocytes.5 the study has shown a significant relationship between hba1c concentrations and ida in patients with type 2 dm (p=0.003), consistent with previous studies, where the hba1c concentration is increased or uncontrolled in type 2 dm patients with ida.14,15 on the other hand, patients with ida may have lower hba1c concentrations due to the severity of ida.16 in indian society, where ida is a nutritional problem, and local community members are of low socioeconomic status, the effect of hba1c concentrations may have different results from our study on ida, although not significantly different. we conducted the study in a hospital with patients mainly from the middle to upper socioeconomic class.16 ida is inversely correlated with hba1c concentration.14 this indicates that when the hb concentrations decrease in response to the severity of iron deficiency in patients with anemia, hba1c rises accordingly.14,20 table 2 laboratory data of type 2 dm patients in metropolitan medical center hospital, jakarta, year 2021 variable n(%) median (min.–max.) hba1c (%); mean ±sd <6.5 ≥6.5 8.06±2.1 27 (23.5) 88 (76.5) hemoglobin (g/dl); mean ±sd no anemia anemia 11.39±3.21 48 (41.7) 67 (58.3) iron status * si (mg/dl) tibc (mg/dl) transferrin (%) ferritin (mg/dl) 26 (9–138) 334 (99–494) 9.4 (2.4–49.5) 12.54 (1.34–557.8) note: si: serum iron; tibc: total iron binding capacity, *= examined only in patients with anemia (67 subjects). anemia: hb <13 g/dl in adult men; hb <12 g/dl in adult non-pregnant women.19 table 3 relationship between hba1c, bmi, duration of dm, hypertension and iron deficiency anemia in patients with type 2 diabetes mellitus variable iron deficiency anemia (ida) p-value present absent hba1c (%) <6.5 ≥6.5 9 58 18 30 0.003* bmi 25 kg/m2 < 25 kg/m2 33 34 29 19 0.236 duration of dm (years) >10 years 10 years 36 31 28 20 0.624 hypertension present absent 47 20 28 20 0.190 note: : *= p<0.05 significant difference (chi-square); bmi= body mass index; dm= diabetes mellitus althea medical journal. 2023;10(2) 102 the increased lifespan of the red blood cells, in conjunction with the increase in hba1c concentrations and the reduction in ferritin concentrations is found in the majority of ida cases. the hba1c concentrations in patients with diabetes are generally increased when these patients have an iron deficiency compared to the controls with adequate iron. body iron is mainly stored as ferritin, indicating the body’s iron load status.15 this study showed the importance of periodic examinations for iron status and hb in patients with type 2 dm because iron and hb might affect hba1c to evaluate glycemic control, before planning the management of these patients.14,15,17 there is a need for ida screening to correct disorders before determining the treatment goal as the optimal control of hba1c, especially when these concentrations are at the diagnostic threshold.14,17 the mechanism of the relationship between type 2 dm and ida is not known with certainty. several hypotheses related to this topic include a) the occurrence of chronic inflammation in type 2 dm is caused by the activation of proinflammatory cytokines such as interleukin 6, interleukin 8, tumor necrosis factor α, and interferon γ; b) abnormalities in the production and release of erythropoietin by the kidneys and increased hepcidin concentrations in the liver; c) anemia is caused by the direct effect of a reduction in red cell lifespan mediated by proinflammatory cytokines; d) iron deficiency in type 2 dm increases the concentration of angiogenic factors, resulting in anemia; e) iron and proinflammatory cytokines increase oxidative stress, causing endothelial dysfunction and abnormalities in angiogenic balance, resulting in anemia.8–12 in this study, most of the anemia cases had bmi<25 kg/m2, but no relationship between bmi and ida in type 2 dm (p=0.236), similar to other study.21,22 however, obesity is associated with cytokines and hepcidin release that may interfere with the utilization of iron, thereby increasing the risk of anemia. studies conducted in china and colombia have reported that anemia is less common in overweight or obese patients.23,24 serum ferritin levels in the obese group, rather than being lower, are approximately similar to those in the healthy control group, makes this parameter unreliable to be used.21 another explanation is that obesity may also be due to higher intakes of iron, protein, and other micronutrients consumed to prevent ida.25 in this study, most anemia cases have a dm duration of more than ten years, however, no correlation between the dm duration with ida incidence in patients with type 2 dm (p=0.624) as also reported in other study.22 dm cases of more than five years duration tend to have anemia because the more prolonged exposure to hyperglycemia causes an increase in inflammatory cytokines with antierythropoietin effects, resulting in a reduction in the circulating red cell count. however, this may not be related because the duration of dm depends on the speed of the patient’s treatment.13 the majority of anemia cases suffered from hypertension, however, no correlation of hypertension with ida in patients with type 2 dm (p=0.190), as shown in another study.26 interestingly, hypertension in dm patients increases the risk of renal impairment and the subsequent development of anemia.26,27 however, another study has reported that hypertension is not essential in determining dm cases at risk of anemia, which may be due to modifications in food consumption affecting the parameters mentioned above.25 the limitation of this study is the incomplete data on the parameters si, tibc, transferrin saturation, and ferritin in patients without anemia. therefore, these parameters cannot be analyzed further in connection with the hba1c concentrations. to conclude, there is a relationship between hba1c and ida in type 2 dm. it is recommended that patients with type 2 dm and ida should be treated for ida before using hba1c as a guide for diagnosis and therapeutic monitoring. further studies are needed on the mechanism 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significance of hba1c test in diagnosis and prognosis of diabetic patients. biomark insights. 2016;11:95– 104. 19. aldallal s. iron deficiency anaemia: a short review. j cancer res immunooncol. 2016;2(1):106. 20. aboughazala lm, el f, ae z, khotb fm, shimaa g. influence of iron deficiency anemia on hemoglobin a1c. al-azhar univ j virus res stud. 2021;3(1):1–19. 21. sal e, yenicesu i, celik n, pasaoglu h, celik b, pasaoglu ot, et al. relationship between obesity and iron deficiency anemia: is there a role of hepcidin? hematology. 2018;23(8):542–8. 22. barbieri j, fontela pc, winkelmann er, zimmermann cep, sandri yp, mallet ekv, et al. anemia in patients with type 2 diabetes mellitus. anemia. 2015;2015:354737. 23. kordas k, centeno zyf, pachón h, soto azj. being overweight or obese is associated with lower prevalence of anemia among colombian women of reproductive age. j nutr. 2013;143(2):175–81. 24. song p, li l, man q, wang c, meng l, zhang j. case-control study of anaemia among middle-aged and elderly women in three rural areas of china. bmj open. 2014;4(8):e004751. 25. awofisoye oi, adeleye jo, olaniyi ja ea. prevalence and correlates of anemia in type 2 diabetes mellitus: a study of a nigerian outpatient diabetic population. sahel med j. 2019;22(2):55–63. 26. taderegew mm, gebremariam t, tareke aa, garedew g. anemia and its associated factors among type 2 diabetes mellitus patients attending debre berhan referral hospital, north-east ethiopia: a crosssectional study. j blood med. 2020;11:47– 58. 27. adane t, getawa s. anaemia and its associated factors among diabetes mellitus patients in ethiopia: a systematic review and meta-analysis. endocrinol diabetes metab. 2021;4(3):e00260. talitha imani kaltsum and pusparini: poor glycemic control correlates with iron deficiency anemia in type 2 diabetes mellitus amj vol 9 no 2 june 2022 rev.indd althea medical journal. 2022;9(2) 117 knowledge, attitude, and perception about autopsy among community in bandung aisyah putri pratiwi,1 berlian isnia fitrasanti,2 sani tanzilah2 1faculty of medicine universitas padjadjaran, indonesia, 2department of forensic and medicolegal, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: aisyah putri pratiwi, faculty of medicine, universitas padjadjaran, jalan raya bandung–sumedang km. 21 jatinangor, sumedang, indonesia, email: aisyah17003@mail.unpad.ac.id introduction an autopsy is a comprehensive evaluation of the body and circumstances surrounding an individual’s death to find the cause of death.1 in general, there are two types of autopsy, namely clinical autopsy, also known as a hospital or academic autopsy, and medicolegal or forensic autopsy. a clinical or academic autopsy is conducted by the medical officer who has been permitted by the family. a forensic autopsy is performed according to legal systems; some can be conducted without the decease’s next of kin’s permission. this autopsy is performed on the legal authorities’ instructions responsible for investigations of sudden, suspicious, obscure, morbid, litigation, or criminal death.2,3 several studies found that there has been a drastic decrease in the rate of the autopsy performed by hospitals around the world in the last few decades.4,5 the autopsy rate is calculated by the total number of autopsies performed by hospitals expressed as a percentage of the country’s total number of deaths.4 the hospital autopsy (clinical autopsy) rate in the united states was 41% in 1946, 34.9% in 1972, and 21.7% in 1975. in 1981, the united states’ autopsy rate was 15.7%, and in 2003 it had fallen to 11%.6 subsequently, the decline continued until 2007, the rate of the autopsy performed by hospitals in the united states reached 4.3%.7 the decline in clinical autopsy also occurred in england and wales. the hospital autopsy rate decreased from 8.9% in 1966 to 1.7% in althea medical journal. 2022;9(2):117–124 abstract background: autopsy is a comprehensive evaluation of the body and the circumstances surrounding an individual’s death. currently, autopsy rates in various countries have been decreased in recent years. this decrease was due to the rejection by people who had inadequate knowledge, attitudes, and perceptions about autopsies. this study aimed to determine the knowledge, attitudes, and perceptions of bandung residents about autopsies. methods: this cross-sectional descriptive observational study involved people in the bandung city who were over the age of 20 years during the period august to september 2020. the sample was obtained using a snowball system. research subjects filled out a questionnaire through a google form containing questions about knowledge, attitudes, and perceptions. the results were categorized based on the median for each variable. results: subjects with questionnaire data obtained were 378 people with an average age of 30.30±13.48 years, and most (66.9%) were female. a total of 259 people had adequate knowledge (68.5%), 254 people (67.2%) had a positive attitude, and 249 people (65.9%) had a positive perception, with a median value of 7, 6, and 12, respectively. however, 95 people did not agree to do an autopsy on their relatives or family to determine the cause of death. conclusion: the subject as a whole shows adequate knowledge, positive attitude, and perception. however, there are still some people who show inadequate knowledge and poor attitudes and perceptions about autopsies. keywords: attitudes, autopsy, community, knowledge, perception https://doi.org/10.15850/amj.v9n2.2539 althea medical journal. 2022;9(2) 118 1991.6 in 2013, the average hospital autopsy rate in the united kingdom was 0.69%, with details of the autopsy rate in england at 0.51%, in poland at 2.13%, 0.65% in wales and 0.46% in northern ireland.4 similar circumstances were found in china, zambia, and the netherlands.6,8 the data above shows that the reduction is particularly pronounced only in the autopsy performed by the hospital (clinical autopsy). the decrease in the clinical autopsy rate is due to the refusal to perform an autopsy.6 unlike clinical autopsy, the medicolegal autopsy does not require family consent. in indonesia, a forensic autopsy is performed for some suspicious death or needs more investigation purposes. however, once an investigator decides on the need for an autopsy, even the deceased’s next of kin cannot hinder its implementation (article 134 indonesia’s code of criminal procedure and article 222 indonesia’s penal code). an autopsy report performed by a forensic pathologist is considered valid evidence.9 a forensic pathologist who will perform a clinical autopsy needs permission from the deceased’s next of kin.10,11 however, getting permission can be difficult because the deceased’s next of kin considers the autopsy differently from the forensic pathologist.10 this rejection can be caused by several factors such as lack of knowledge and inadequate perception of the autopsy.6,12 wrong perceptions circulating in the community, such as organs or tissues are taken and sold, or medical students use their organs and remain for practice. apart from that, other factors also affect humanitarian reasons, religious differences, and administrative costs, which cause the next of kin to refuse to perform an autopsy.6,13 the negative perception is caused by several factors such as lack of knowledge about autopsy among people, religious and cultural reasons, and the use of other techniques or procedures to make a conclusive diagnosis, which causes autopsy to be considered an unnecessary procedure.6,12 therefore, this study was conducted to investigate people’s knowledge, attitude, and perceptions about autopsy in bandung. methods this research was descriptive survey research with a cross-sectional research design on bandung citizens. this study’s inclusion criteria were the bandung citizens who were over 20 years of age. the exclusion criteria in this study were people not willing to fill out the questionnaire. the sampling technique used was the snowball system on subjects that met the inclusion and exclusion criteria. researchers obtained subjects based on family or friend relations. furthermore, those subjects were asked to select friends or family to be the subject. the questionnaire used was a modified questionnaire from a research questionnaire conducted by kaoje au (2016).14 researchers made modifications based on different environmental conditions. the questionnaire includes three parts such as knowledge, attitudes, perceptions (kap) about the autopsy. the questionnaires were distributed online using the google form. the knowledge in this study referred to either facts or information about the autopsy known to the respondent. respondents’ attitudes and perceptions were categorized as negative and positive. the variables of this study were knowledge, attitudes, and perceptions of respondents. the normality test was carried out using the kolmogorovsmirnov test. the median value obtained from the respondent’s score data was used as the reference value for the knowledge, attitude, and perception variables based on the test results. this median value was used as a cutoff point to interpret the results of the respondents’ scores. for knowledge and attitude variables, scores above the median were considered good and positive. values below the median were considered inadequate and negative. however, for the perception variable, the value category is reversed. values above the median are considered to have negative perceptions. values below the median mean that in the category of positive perception, the questionnaire’s statements are wrong statements about the autopsy. this research has received a research permit from the research ethics committee of universitas padjadjaran with number 703/ un6.kep/ec / 2020. results four hundred and twenty-three people accessed the internet link containing the google form questionnaire. however, only 387 people were bandung citizens and proceeded to the informed consent section. of the 387 people, 386 of them were willing to take part in the research. then only 378 met the inclusion and exclusion criteria. althea medical journal june 2022 althea medical journal. 2022;9(2) 119 table 1 characteristics of research subjects characteristics n=378 frequency (n) percentage (%) age (years) 20–29 30–39 40–49 50–59 >60 242 34 38 59 5 64.0 9.0 10.1 15.6 1.3 gender male female 125 253 33.1 66.9 occupation college student government employees private employees entrepreneur housewife retired unemployment police officer 194 71 66 27 13 3 2 2 51.3 18.8 17.5 7.1 3.4 0.8 0.5 0.5 education level high school diploma undergraduate postgraduate 196 14 126 42 51.9 3.7 33.3 11.1 religion muslim christian catholic 358 10 10 94.7 2.7 2.7 aisyah putri pratiwi et al.: knowledge, attitude, and perception about autopsy among community in bandung most of the research subjects were in the age range of 20 to more than 30 years, most of them were female, and more than half had high school education. most of the occupations were students, and the majority of respondents were muslim (table 1). the average value obtained from the results of the questionnaire containing the variables of knowledge, attitudes, and perceptions based on the socio-demographic characteristics of respondents was depicted in table 2. there were differences in the mean scores of knowledges, attitudes, and perceptions based on gender, age group, occupation, education level, and religion of the respondents. as a reference, the median value for knowledge was 7, 6 for attitude, and 12 for the perception variable. based on this reference, 243 respondents under the age of 30 years had the lowest average knowledge about autopsy but tended to have a good perception of autopsy (table 2). only 36 (9.5%) respondents were aware that a medicolegal autopsy had been performed and did not require their next of kin’s consent. a total of 217 (57.4%) respondents incorrectly answered the clinical autopsy (p5). then 245 respondents incorrectly answered the question about the purpose of the autopsy (p8). meanwhile almost all of the respondents knew that autopsies were performed by forensic doctors (p11) and answered one of the objectives of the autopsy which was to help research and teaching (p9) correctly, more than 50% of the respondents answered correctly for other knowledge questions (table 3). the distribution of community responses to the proposed attitude statements was shown in table 4. the assessment of a positive althea medical journal. 2022;9(2) 120 althea medical journal june 2022 table 2 value of knowledge, attitudes, and perceptions of research subjects (n=378) knowledge attitude perception general characteristic mean ± sd median (cut off ) 7.1 ± 1.87 7 5.88 ± 1.36 6 11.57 ± 2.76 12 based on gender male (n=125) female (n=253) 7.04 ± 1.86 7.13 ± 1.87 6.09 ± 1.30 5.77 ± 1.38 11.71 ± 3.04 11.50 ± 2.62 based on age 20–29 years old (n=243) 30–39 years old (n=34) 40–49 years old (n=38) 50–59 years old (n=59) >60 years old (n=5) 6.89 ± 1.94 7.29 ± 1.64 7.39 ± 1.63 7.66 ± 1.69 7.40 ± 2.30 6.00 ± 1.34 5.85 ± 1.10 5.63 ± 1.30 5.56 ± 1.50 5.60 ± 2.19 10.98 ± 2.57 13.21 ± 2.36 12.21 ± 2.97 12.53 ± 2.73 12.80 ± 5.02 based on occupation college student (n=194) government employees (n=71) private employees (n=64) not working (n=46) police officer (n=2) 7.02 ± 1.86 7.68 ± 1.46 6.74 ± 1.94 6.92 ± 2.15 8.00 ± 2.82 5.94 ± 1.35 5.51 ± 1.49 6.03 ± 1.22 5.61 ± 1.21 7.00 ± 0.00 10.77 ± 2.55 12.56 ± 3.03 12.15 ± 2.33 12.13 ± 2.49 17.50 ± 3.53 based on education level high school (n=196) diploma (n=14) undergraduate (n=126) postgraduate (n=42) 6.87 ± 201 7.57 ± 1.99 7.14 ± 1.71 7.93 ± 1.31 6.01 ± 1.32 5.43 ± 1.50 5.73 ± 1.34 5.86 ± 1.49 11.08 ± 2.64 11.64 ± 2.49 12.06 ± 3.14 12.36 ± 3.14 based on religion muslims (n=358) christians (n=10) catholics (n=9) 7.12 ± 1.87 6.40 ± 2.01 7.30 ± 1.41 5.85 ± 1.37 6.80 ± 0.79 6.00 ± 0.81 11.68 ± 2.74 9.70 ± 2.75 9.70 ± 2.36 note: numbers in bold mean that the value is above the median or cut-off that consider as good scores table 3 knowledge about autopsy questions correct answern(%) a medicolegal autopsy is an examination performed on bodies with unnatural deaths 232 (61.4) an autopsy is done not only for legal purposes 313 (82.8) a medicolegal autopsy is a form of autopsy 290 (76.7) a medicolegal autopsy is an autopsy that requires permission from family/ relatives 36 (9.5) a clinical autopsy is an autopsy that does not require family/next of kin’s permission 161 (42.6) knowing the cause of a person's death is not the goal of an autopsy 293 (77.5) an autopsy can help determine whether pre-death medical care (medication) is appropriate 306 (80.9) an autopsy is performed to provide for a tissue or organ transplant 133 (35.2) autopsies can aid medical teaching or research 342 (90.5) the autopsy was done to reveal the mistakes that hospitals and doctors made 232 (61.4) an autopsy is usually performed by a forensic specialist 347 (91.8) althea medical journal. 2022;9(2) 121 attitude was if the respondent agreed by answering “yes” to the question. a total of 105 (27.8%) respondents felt the need for a clinical autopsy, especially in the medicolegal autopsy, 131 (34.7%) respondents felt it was very important to do it. in general, research subjects had a positive attitude towards autopsy (table 4). table 5 assessed the respondents’ perceptions by looking at the answers to the respondent’s agreement on a statement. perception was inadequate if the respondent agreed with the statement and vice versa. there was a relatively close difference in perception, but it could be seen that the frequency of respondents choosing to disagree showed a better perceptions. in addition, most of the respondents had chosen to be neutral about the statement. table 6 has shown the knowledge, attitudes, and perceptions of bandung city residents after being divided into good and poor by using the reference value of each variable. a total of 259 people had adequate knowledge (68.5%), 254 people (67.2%) had a positive attitude, and 249 people (65.9%) had a positive perception, with median values of 7, 6, and 12, respectively. table 4 attitudes towards autopsy questions very important n (%) urgent n (%) not important n (%) yes n (%) no n (%) what does the respondent think about clinical autopsy? 105 (27.8) 263(69.6) 10(2.7) what does the respondent think about medicolegal autopsy? 131 (34.7) 237 (62.7) 10 (2.65) does the respondent think the information regarding the purpose of the autopsy is insufficient? 299 (79.1) 79 (20.9) does the respondent support autopsy practice? 349 (92.3) 29 (7.6) does the respondent feel the need to know the cause of death of a family member/relative who died? 318 (84.1) 60 (15.9) would the respondent agree to carry out autopsy examinations on the family members or relatives' bodies to determine the cause of death? 283 (74.9) 95 (25.1) aisyah putri pratiwi et al.: knowledge, attitude, and perception about autopsy among community in bandung table 5 perceptions of autopsy questions strongly agree n(%) agree n(%) neutral n(%) disagree n(%) strongly disagree n(%) an autopsy is against the respondent’s religion 11 (2.9) 22 (5.8) 246 (65.1) 84 (22.2) 15 (3.9) the body of the corpse must not be tampered with for any reason 31 (8.2) 66 (17.4) 178 (47.0) 87 (23.0) 16 (4.2) autopsy examinations have no benefit to those who are still alive 44 (11.6) 54 (14.2) 129 (34.1) 108 (28.5) 43 (11.3) the autopsy examination caused further difficulty and suffering for the bereaved family 17 (4.5) 54 (14.3 185 (48.9) 107 (28.3) 15 (3.9) althea medical journal. 2022;9(2) 122 discussion the research subjects had an average age of 30.30±13.48, with the youngest being 20 years old and the oldest 68 years old. in this study, the results showed that the average value of knowledge increases with age. these results are in accordance with the theory which states that the older one gets, the level of maturity and strength of a person will be more mature in thinking and working. in the elderly group or above 60 years old, it can be seen that their average knowledge score is lower than the 50–59 year age group. the elderly will choose information that is only relevant to them because they begin to experience difficulty understanding new information, especially in large amounts. this also confirms that the elderly will also experience a decline in learning new things.15 when viewed from the type of work the research subjects have, there are differences in the value of knowledge of each working group. this is in accordance with a research, which stated that one’s work can affect knowledge and experience.16 it was found that the police obtained the highest level of knowledge. this could be based on the duties of the police related to the autopsy implementation, especially medicolegal autopsy. in addition, the lowest value of knowledge was achieved by respondents who did not work. the reason might be that they do not have the benefits they received in the work environment. one of the advantages is that it can increase selfdevelopment, usually obtained from light activities such as sharing knowledge between colleagues.17 knowledge of the subject seems to be sufficient by looking at the subjects who already know the definition and purpose of an autopsy. however, there are still many mistakes in answering the permission of family or relatives for medicolegal and clinical autopsies. it can be seen that the public does not fully understand the autopsy classification and prerequisite documents for autopsy. judging from the characteristics of the respondent’s age, it turns out that the attitude has a pattern as the age increases, the attitude value will decrease. ithis can be seen in the age group of 20–29 years who achieved an average attitude score of 6.00, and this value continued to decline until the age group of 50– 59 years which had an average attitude score of 5.56. this is consistent with a meta-analysis review conducted, showing that the attitudes of older respondents are more negative than that of younger people.18 on the other hand, there is no significant relationship between age and perception because it does not have a meaningful pattern from the table section, which is also stated by one of the descriptive studies.19 table 6 of this study shows that bandung residents tend to already have good knowledge, attitudes, and perceptions. however, there are still 1 in 3 people who have poor knowledge of attitudes and perceptions about the autopsy, which is consistent with previous studies.12,14 this study showed that most people answered at least the importance of an autopsy in both clinical autopsy and medicolegal autopsy, and only ten people said that autopsy was not important. as many as 92% supported the practice of autopsy, and 78.8% agreed to perform an autopsy on their family or relatives. this is also in accordance with a similar study, conducted at the university college hospital, ibadan, nigeria.6 most of the public has known that a medicolegal autopsy is generally carried out in suspicious deaths seen in the first statement of knowledge. people are aware that a medicolegal autopsy is more important than a clinical autopsy. these are why medicolegal autopsy rates have remained stable. a study in northern ireland20 found that the medicolegal autopsy rate has remained fairly stable despite the decline in clinical autopsy rates. attitudes can be influenced by the experiences they have. this study has limitations, one of which is the sampling system used is a snowball. as a result, variations in the characteristics table 6 perceptions of autopsy variable good n(%) poor n(%) knowledge (median=7) 259 (68.5) 119 (31.4) attitude (median=6) 254 (67.2) 124 (32.8) perception (median=12) 249 (65.8) 129 (34.1) althea medical journal june 2022 althea medical journal. 2022;9(2) 123 of respondents are not well distributed, so they do not represent the population. results and interpretations can be different if more samples are taken and it is better to get a comparison of samples that are in accordance with the characteristics of the population. in addition, this study did not ask about the experiences of the respondents regarding the implementation of the autopsy. therefore, the results could be different if the research was conducted again by asking about the experience and conclusions can be made about the experiences and attitudes obtained. in conclusion, community’s knowledge, attitudes, and perceptions tend to be good. however, some people have poor knowledge, attitudes, and perceptions about autopsies, which leads to a lower rate of clinical autopsies than medicolegal autopsies. the factors that influence the knowledge, attitudes, and perceptions of the bandung residents’ are age, education level, occupation, and religion. it is recommended that further research on autopsy knowledge in the community in order to increase their perception or understanding of autopsies as well as research on conventional autopsies, such as virtual autopsies or imaging of corpses. references 1. wagner sa. color atlas of the autopsy. 2nd ed. boca raton: crc press;. 2017. 2. saukko p, knight b. knight’s forensic pathology. 4th ed. boca raton: crc press; 2016. p.665. 3. widowati w, ohoiwutun yat, nugroho fm, samsudi s, suyudi ga. peranan autopsi forensik dan korelasinya dengan kasus kematian tidak wajar. refleksi hukum. 2021;6(1):1–18. 4. turnbull a, osborn m, nicholas n. hospital autopsy: endangered or extinct? j clin pathol. 2015;68(8):601–44. 5. park j-p, kim sh, lee s, yoo sh. changes in clinical and legal autopsy rates in korea from 2001 to 2015. j korean med sci. 2019;34(47):e301. 6. oluwasola oa, fawole oi, otegbayo aj, ogun go, adebamowo ca, bamigboye ae. the autopsy knowledge, attitude, and perceptions of doctors and relatives of the deceased. arch pathol lab med. 2009;133(1):78–82. 7. hoyert dl. the changing profile of autopsied deaths in the united states, 1972–2007. nchs data brief. 2011;(67):1– 8. 8. blokker bm, weustink ac, hunink mgm, oosterhuis jw. autopsy rates in the netherlands: 35 years of decline. plos one. 2017;12(6):e0178200. 9. dumais j. kewajiban polisi (penyidik) untuk meminta otopsi (visum et repertum) terhadap korban kejahatan (kajian pasal 133 kuhap). lex crimen. 2015;4(5):5–12. 10. stempsey we. the penetrating gaze and the decline of the autopsy. ama j ethics. 2016;18(8):833–8. 11. blokker b, weustink a, wagensveld i, von der thüsen j, pezzato a, dammers r, et al. conventional autopsy versus minimally invasive autopsy with postmortem mri, ct, and ct-guided biopsy: comparison of diagnostic performance. radiology. 2018;289(3):658–67. 12. carwen s, fitrasanti bi, darmawan b. community knowledge and perception on autopsy in jatinangor, west java from august to october 2013. althea med j. 2015;2(3):303–7. 13. laksmi pp, alit ibp, henky h. deskripsi faktor-faktor yang memengaruhi penolakan otopsi pada kasus kematian yang diduga tidak wajar. e-jurnal medika udayana. 2020;9(7): 86–91. 14. kaoje a, mohammed u, abdulkarim a, raji m, ango u, magaji b. knowledge, attitude, and perception of postmortem examination among doctors and nurses in a tertiary hospital of sokoto, nigeria. j forensic sci med. 2016;2(2):78–84. 15. johansson m, marcusson j, wressle e. cognitive impairment and its consequences in everyday life: experience of people with mild cognitive impairment or mild dementia and their relative. int psychorgeriatr. 2015;27(6):949–58. 16. pangesti adh. gambaran tingkat pengetahuan dan aplikasi kesiapsiagaan bencana pada mahasiswa fakultas ilmu keperawatan universitas indonesia tahun 2012 [minor thesis]. depok: universitas indonesia; 2012 17. weijs-perrée m, appel-meulenbroek r, arentze t, romme g. the influence of the physical work environment of business centres on social networking and knowledge sharing in the netherlands. intell build int. 2019;11(2):105–25. 18. kite me, stockdale gd, whitley jr, be, johnson bt. attitudes toward younger and older adults: an updated meta-analytic review. j soc issues. 2005;61(2): 241–66. 19. tuty dwn, widiyanti e, utam bw. korelasi faktor pembentuk persepsi aisyah putri pratiwi et al.: knowledge, attitude, and perception about autopsy among community in bandung althea medical journal. 2022;9(2) 124 dengan persepsi konsumen terhadap media pemasaran online. caraka tani. 2017;32(2):108–15. 20. loughrey m, mccluggage t, toner p. the declining autopsy rate and clinicians’ attitudes. ulster med j. 2000;69(2):83–9. althea medical journal june 2022 amj vol 7 no 3 september2.indd althea medical journal. 2020;7(3) 111 knowledge and attitude on human immunodeficiency virus among migrant worker candidates in east java, indonesia faiz murfid gunawan,1 pudji lestari,2 erwin astha triyono3 1faculty of medicine universitas airlangga, surabaya, indonesia, 2department of public health faculty of medicine universitas airlangga, surabaya, indonesia, 2department of internal medicine, universitas airlangga, dr. soetomo general hospital, surabaya, indonesia correspondence: faiz murfid gunawan, faculty of medicine, universitas airlangga, jalan mayjen prof. dr. moestopo no.47, surabaya, east java, indonesia, e-mail: faizmg30@gmail.com introduction data published by the directorate general of disease control and environmental health (ditjen pp & pl), the ministry of health of the republic of indonesia on the human immunodeficiency virus-acquired immune deficiency syndrome (hiv-aids) problem quarter iv, recorded from october to december 2018, has shown that the number of reported hiv cases is over 13,000 individuals, with comparison among gender between men and women is 2:1. the highest percentage of hiv infections reported is in the age group of 25– 49 years old (69.6%), followed by 20–24 years old (15.6%), and the age group of ≥50 years old (8.3%). furthermore, the highest percentage of hiv risk factors reported are men (20%), heterosexuals (19%), and the use of unsterile needles among intravenous drug users (idu) (1%).1 in addition, transmission between mother to child contributes to increase the number of hiv cases, especially by mothers of whom are infected by their heterosexual partners or also by being idu.2 in 2018, hiv patients in indonesia have reached almost 50 thousand and the province of east java ranks first in the number of hiv patients with an incidence of over 8,000 in the same year.3 there is a report showing that the indonesia migrant workers (tenaga keja indonesia,tki) groups have a tendency to participate in spreading hiv and aids in the community.3 according to the international labor organization (ilo), this spreading is caused by amj. 2020;7(3):111–6 abstract background: in 2018, east java province becomes the province with the highest number of human immunodeficiency virus (hiv) cases in indonesia with an incidence of more than 8,000 cases. this province has various groups of indonesian migrant workers (tenaga kerja indonesia, tki) working in various sectors in different countries, making them prone to hiv infection. this study aimed to determine the level of knowledge and attitude towards hiv and acquired immune deficiency syndrome (aids) among migrant worker candidates in east java. methods: this was a cross-sectional descriptive study conducted in august 2018 in the provincial manpower and transmigration office of east java, indonesia. the knowledge and attitude towards hiv disease were assessed using a self-validated questionnaire distributed to 104 migrant worker candidates as the subjects of this study. results: eighty-nine percent of the subjects had good knowledge, while 98% of them had good attitudes towards hiv disease. furthermore, 86% had good attitudes toward hiv transmission. however, no correlation was observed between the subjects’ level of knowledge and their attitude (p=0.334). conclusions: in general, the level of knowledge and attitudes of migrant worker candidates in east java towards hiv disease is good. nevertheless, more knowledge and education on healthy behavior need to be envisaged for this group. keywords: attitude, hiv, indonesia, knowledge, migrant workers https://doi.org/10.15850/amj.v7n3.1824 althea medical journal. 2020;7(3) 112 amj september 2020 several factors such as lack of information and socialization about hiv and aids, situations and shelters that allow unhealthy sex, sexual violence by employers, illegal recruitment processes that allowing migrant workers to fall into human trafficking.4 also, while abroad, some migrant workers who are long separated from a partner, often tempted to have sex with a new partner with or without a stable relationship. the new partner could be either fellow migrant workers or workers from other countries.4 therefore, the researchers were interested in exploring the level of knowledge and attitudes of prospective migrant workers from the province east java towards hiv infection and aids. methods this research was a descriptive study using a cross-sectional approach. data were obtained using a questionnaire exploring the level of knowledge and attitudes among 104 candidates migrant workers who were residing at the department of manpower and transmigration in the province of east java during august 2018 were recruited using a random sampling method. subject consent was obtained before data collection. a self-validate questionnaire was distributed to the study subjects, consisting of demographic information, followed by 23 questions about knowledge and 8 questions about attitude. information on the demographic of the respondents included gender, age, and marital status. knowledge of respondents was assessed based on 23 questions, divided into 3 groups of questions including general knowledge, ways of transmission, and ways of prevention. data obtained were analyzed and presented in tabular form. the relationship between the level of knowledge and attitudes of respondents about hiv and aids was calculated using the chi-square method (spss v.22.0). apart from that, the relationship between the level of knowledge and the characteristics of respondents, the spearman analysis method, except for age was analyzed using the chi-square method. results of the 104 respondents included in this study, females (75%) and aged between 21–39 years (67%) were predominantly presented and unmarried (49%). in general, respondents had a good level of knowledge about hiv disease (86%) (table 2). the majority of respondents also had a good attitude about hiv and aids (95%). analysis exploring the relationship between the level of knowledge and attitudes of respondents about hiv and aids has shown no significant relationship between the level of knowledge about hiv/aids and their attitude with p= 0.806 the relationship between the level of knowledge about hiv-aids and the characteristic of the respondents had been illustrated in table 3. statistical analysis showed that the 3 characteristics of respondents, including gender, age, and marital status, did not have a correlation with the level of knowledge (p>0.05). table 4 presented the attitude of prospective migrant workers from the province east java towards hiv infection and aids disease in relation to the characteristic of the respondents. the result showed that gender, age, and marital status did not have a correlation with the attitude of the respondents, evidenced by the p-value that exceeded 0.05. discussion this study explored the knowledge and perception of prospective indonesian migrant workers (tenaga kerja indonesia; tki) in the manpower and transmigration office, the province of east java. this study results in good knowledge of hiv/aids in most of the respondents. the result is similar to most of the families of hiv patients who have a good level of knowledge about hiv/aids,5 as well as study in turkey6 involving undergraduate health science students. most respondents think that hiv disease can be prevented by using condoms when having intercourse and by avoiding alternating drug injections.6 the question about hiv that can be transmitted through saliva contact or kissing the lips turns out to be one of the questions that most of the respondents incorrectly answered (75%). there are a lot of misconceptions related to the transmission of hiv transmission, especially those related to hiv which can be transmitted by mouth kissing.7 the high level of public knowledge about hiv/aids can be increased with health education carried out by hospitals clinics, education at school, and through community advertising in mass media or social media.8 knowledge about hiv/aids can be a way althea medical journal. 2020;7(3) 113 table 1 demographic data of migrant workers candidates from the east java province characteristics frequencies (n) percentage (%) gender female 78 75 male 26 25 age (years old) ≤20 26 25 21–39 70 67 ≥40 8 8 marital status married 48 46 unmarried 51 49 divorce 5 5 to prevent transmission of hiv, although good knowledge does not always guarantee that people will not carry out activities that are at risk of hiv transmission.9 wrong knowledge by inaccurate information or incomplete or too excessive, or the existence of wrong beliefs in the community that influences specifically information on hiv/aids will emerge and develop in society in the form of a myth, meaning that people’s perceptions and beliefs are actually wrong. as a result of the emergence and development of myths about hiv/aids will lead to discriminatory attitudes and community stigmatization of people living with hiv/aids (plwha) and their families.10 a good level of knowledge can prevent someone from stigmatizing plwha. stigma arises because people do not know about true and complete hiv information, especially in the mechanism of hiv transmission, groups of people at risk of contracting hiv, and how to prevent hiv infection, including the use of condoms. stigma is the biggest obstacle to preventing hiv transmission and treatment. beside, the stigma of plwha also causes people who have symptoms or are suspected of suffering from hiv to be reluctant to do a test to find out their hiv status because if the results are positive, they fear that they will be rejected by their families and especially by their partners.11 most of the respondents in our study (94.2%) have a good attitude towards hiv/ aids, in contrast to a study in iran12 that only 1 of 5 participants have good attitudes related to hiv. the attitude related to hiv/ aids apparently also affects tolerance to hiv patients, as evidenced in research in iran12 that they are better off avoiding hiv sufferers. there is strong negative feedback if they find out that they are hiv-infected. this strong negative emotion is caused by the perception of hiv as a death sentence. the stigma associated with being hiv-positive includes disruption of social relationships, sexual relationships, and employment; and the perception that life faiz mufid gunawan et al.: knowledge and attitude on human immunodeficiency virus among migrant worker candidates in east java, indonesia table 2 level of knowledge and attitudes about hiv and aids among prospective migrant worker candidates from the east java province variable frequencies (n) percentage (%) level of knowledge good 89 86 lack 15 14 attitude good 99 95 lack 5 5 althea medical journal. 2020;7(3) 114 amj september 2020 is better by not knowing their hiv status.13 knowledge turns out not to have a significant impact on respondents’ attitudes. there is thus a need for additional information about sexually transmitted infections (stis) including hiv/aids to provide changes in knowledge and attitudes related to hiv. as shown in our study, the level of knowledge about hiv/ aids is not associated with the attitude of the respondents (p=0.334). a similar study in turkey6 also showed that only 28% had a good attitude from total respondents who have a good attitude toward hiv. however, a different results may occur, for example, there is a significant relationship between the level of knowledge and student attitudes related to hiv/aids,14 showing that there is a positive correlation between the level of knowledge and attitudes of respondents. this is evidenced by the many misperceptions of respondents about hiv/aids in the study, which proves that misconceptions about table 3 level of knowledge and characteristics of prospective migrant workers from the east java province towards hiv disease characteristics level of knowledge p-value poor good gender female 26 0.729 male 6 72 age ≤20 3 23 0.523 21–39 10 60 ≥40 2 6 marital status married 6 45 0.309 unmarried 7 41 divorce 2 3 table 4 relationship of attitudes and characteristics of prospective migrant workers from the east java province towards hiv disease respondents about hiv/aids characteristics attitudes p-value poor good gender female 2 24 0.482 male 13 65 age ≤20 2 24 0.535 21–39 4 66 ≥40 0 8 marital status married 2 49 0.745 unmarried 3 45 divorce 3 2 althea medical journal. 2020;7(3) 115 hiv/aids in the community greatly influence attitudes towards hiv/aids.15 education and information play a key role in reducing stigma and thus must focus on dismantling myths and clarifying misunderstandings.16 in general, the average respondents have a good level of knowledge and attitude. this is evidenced by good health screening and training before each departure that usually provides a debriefing for prospective migrant workers to avoid various diseases that can cancel their departure, including hiv/aids.17 this procedure may be different from migrant workers whose status is illegal or not official through pjtki. the candidates of migrant workers are vulnerable for several reasons. first, usually, their passports are handed over by the employer where they do not have full power and ultimately must fulfill all the wishes of the employer.18 second, they do not have a legal work permit, that’s what makes migrant workers vulnerable to be forced labor or forced prostitution. this may make illegal migrant workers particularly vulnerable to getting hiv because of the risk of having sexual relations with multiple people.19 in addition, the absence of medical examinations upon arrival can cause the spread of hiv/aids from migrant workers who have just returned from the countries where they have worked. the health examination of migrant workers upon the arrival phase becomes an urgent need to prevent transmission of various diseases in the destinated country.17 this should be a concern of the local government, especially to prevent the possibility of contracting hiv disease to migrant workers. the government could reduce hiv transmission among migrant workers with regulations. first, the procedure for migrant worker recruitment can only be allowed via official pjtki, and illegal broker agents are prohibited to recruit migrant workers. also, the government can also determine the destination of airports for repatriation in order to facilitate screening at the time of arrival.17 this research is inseparable from the limitations and shortcomings. in this study, the education level is not included as one of the factors that might be influential in the analysis. in addition, this study has lacked in-depth interviews with the respondents, important to know whether respondents have a stigma for hiv infection. the researchers also have difficulty in finding data on migrant workers affected by hiv/aids. in conclusion, most of the prospective candidates of migrant workers in the province of east java have good knowledge and perception. although in this study no significant relationship found between the knowledge and attitudes among migrant workers about hiv/aids, however, it is suggested that knowledge would indirectly affect perception. thus, more education to increase the knowledge level might make an individual more concerned about hiv disease and can behave well towards people with hiv/ aids. education on healthy behaviour among candidates migrant workers is of great need. references 1. direktorat jenderal pencegahan dan pengendalian penyakit kementerian kesehatan republik indonesia. laporan perkembangan hiv aids & infeksi menular seksual (ims) triwulan iv tahun 2018 [internet]. siha.depkes.go.id. 2019 [cited 2019 november 13]. available from: http://siha.depkes.go.id/portal/ files_upload/laporan_hiv_tw_ii_20192. pdf. 2. forbes j, alimenti a, singer j, brophy j, bitnun a, samson l, et al. a national review of vertical hiv transmission. aids. 2012;26(6):757–763. 3. andarmoyo s. perilaku pencegahan diri terhadap penularan hiv/aids pada calon tenaga buruh migran/tki/tkw di ponorogo. jurnal aristo. 2013;1(2):77-87. 4. international labour organization (ilo). flipchart pencegahan dan penaggulangan hiv dan aids [internet]. 2011 [cited 2019 november 13]. available from: https:// www.ilo.org/wcmsp5/groups/public/a s i a / r o b a n g ko k / i l o j a k a r t a / documents/publication/wcms_249791. pdf 5. bhagavathula a, bandari d, elnour a, ahmad a, khan m, baraka m et al. a cross sectional study: the knowledge, attitude, perception, misconception and views (kapmv) of adult family members of people living with human immune virus-hiv acquired immune deficiency syndrome-aids (plwha). springerplus. 2015;4(1):769. 6. maimati m , tekin hh, sener mm. level of knowledge and attitude towards hiv/ aids among undergraduate students in konya, turkey. j community med health educ. 2018;8(4):1000624. 7. fonner v, dalglish s, kennedy c, baggaley r, o’reilly k, koechlin f et al. effectiveness faiz mufid gunawan et al.: knowledge and attitude on human immunodeficiency virus among migrant worker candidates in east java, indonesia althea medical journal. 2020;7(3) 116 amj september 2020 and safety of oral hiv preexposure prophylaxis for all populations. aids. 2016;30(12):1973–1983. 8. orisakwe ee, ross aj, ocholla po. correlation between knowledge of hiv, attitudes and perceptions of hiv and a willingness to test for hiv at a regional hospital in kwazulu-natal, south africa. afr j prim health care fam med. 2012;4(1):376. 9. sudikno s, simanungkalit b, siswanto s. pengetahuan hiv dan aids pada remaja di indonesia (analisis data riskesdas 2010). jurnal kesehatan reproduksi. 2011;1(3):145–154. 10. oktarina, hanafi f, budisuari m. hubungan antara karakteristik responden, keadaan wilayah dengan pengetahuan, sikap terhadap hiv/aids pada masyarakat indonesia. bulletin penelitian sistem kesehatan. 2009;12(4):362–368. 11. shaluhiyah z, mustofa sb, widjanarko b. stigma masyarakat terhadap orang dengan hiv/aids. jurnal kesehatan masyarakat nasional. 2015;9(4):333–338. 12. shokoohi m, karamouzian m, mirzazadeh a, haghdoost a, rafierad a, sedaghat a, et al. hiv knowledge, attitudes, and practices of young people in iran: findings of a national population-based survey in 2013. plos one. 2016;11(9):e0161849. 13. st. lawrence j, kelly j, dickson-gomez j, owczarzak j, amirkhanian y, sitzler c. attitudes toward hiv voluntary counseling and testing (vct) among african american men who have sex with men: concerns underlying reluctance to test. aids educ prev. 2015;27(3):195–211. 14. fauziah an. hubungan tingkat pengetahuan dan sikap tentang hiv/aids pada mahasiswi akbid mamba’ul ulum surakarta. jurnal kesehatan samodra ilmu. 2017;8(1):39–45. 15. handayani a, trihandini i. hubungan tingkat pengetahuan hiv/aids dengan sikap dan perilaku berisiko hiv/aids pada pria kawin dan pria belum kawin: analisis lanjut survei demografi dan kesehatan indonesia 2012 [minor thesis]. jakarta: universitas indonesia; 2014 [cited 2019 november 13]. available from: http://lib. ui.ac.id/naskahringkas/2016-04/s55330ade%20handayani. 16. abdi ia, ereg d, ali m, rahlenbeck s. knowledge and attitudes about aids/ hiv in a semi-nomadic population in somaliland. j community health. 2013;38(2):246–249. 17. kinasih se, dugis vma. perlindungan buruh migran indonesia melalui deteksi dini hiv/aids pada saat reintegrasi ke daerah asal. masyarakat, kebudayaan, dan politik. 2015;28(4):198–210. 18. sulaksono e. the patterns of human trafficking on indonesian migrant workers: case study of riau islands and johor border crossing. masyarakat: jurnal sosiologi. 2018;23(2):167–186. 19. nuraeny h. trafficking of migrant workers in indonesia: a legal enforcement and economic perspective of prevention and protection efforts. european research studies journal. 2017;xx(4b):16–26. amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 223 physical fitness is correlated with quality of life among elderly gymnastics club from haji general hospital surabaya, indonesia hasan hasan,1 rita vivera pane2,3 1faculty of medicine, airlangga university, surabaya, indonesia, 2faculty of medicine, nahdlatul ulama university of surabaya, indonesia, 3department of physical and rehabilitation medicine, haji general hospital surabaya, indonesia correspondence: dr. dr. rita vivera pane, sp.kfr-k., fipp., cips, department of physical medicine and rehabilitation medicine, haji general hospital surabaya, jalan manyar kertoadi surabaya, indonesia, e-mail: dr.rita@unusa.ac.id introduction the aging process occurs progressive and irreversible, often impacting the quality of life (qol).1 the indonesian elderly population in 2021 was 29.3 million people, or equal to 10.8% of its population.2 the number of elderly people worldwide in 2019 was 703 million, more than children under five years old.3,4 the aging process affects the body functions, including a decrease in muscle strength and exercise capacity. the elderly often use the limited capacity of their body function to fulfill the activities of daily life (adl).5 the elderly are generally physically less active than younger adults. however, the elderly can increase their physical activity, which prevents mortality and increases functional independence.6 regular physical activity (pa) improves physiological parameters such as vo2max and muscle strength. moreover, it also affects mental health, emotional and psychological function, social well-being, and cognitive function improvement.7 physical fitness is the ability of a body to carry out physical activities or to perform daily tasks productively without any limitations or causes excessive fatigue.8 physical fitness is strongly related to physical conditions. a good level of physical fitness is that the person can carry out activities for a long time.9 physical fitness is one of the important althea medical journal. 2022;9(4):223–227 abstract background: indonesia is the fourth most populated country, of whom 10.8% are elderly people. the quality of life (qol), which includes physical health, psychological health, social relationships, and the environment, is crucial as physical fitness may reflect the ability to perform daily activities without significant fatigue. the objective of this study was to explore the correlation of physical fitness with the qol among the elderly. methods: this was an analytic observational study with a cross-sectional approach, including members of the elderly gymnastics club of the haji general hospital surabaya. the physical fitness value was measured based on vo2max using a 6-minute walk test (6mwt). the vo2max (0.03 x mileage(m) + 3.98 cc/kilogram body weight/minute) was categorized into poor, moderate, and good. the qol was assessed with whoqol-100 and grouped into poor, moderate, and good qol. data were analyzed by the spearman correlation test. results: in total, 33 elderly were recruited, with an average age was 67.85±6.11 years (range 60–78), mean height was 1.49±0.09 m, mean weight was 57.65±10.53 kg, and mean bmi was 24.92±3.69. the mean vo2max was 16.96±2.37, and the qol was 64.61±6.82 ml/kg/minute. the 6mwt resulted in the physical fitness of poor (15%; n=5), moderate (36%; n12), and good (48%; n16). the whoqol assessment showed moderate (30%; n=10) and good (61%; n=23) qol. spearman correlation test results showed a correlation between physical fitness and the qol (coefficient 0.356 and p= 0.042). conclusions: there is a correlation between physical fitness and qol among the elderly, suggesting that increasing physical fitness among the elderly, adjusted to their physical health condition, is important to get a good quality of life. keywords: elderly, physical fitness, qol, gymnastics club, whoqol https://doi.org/10.15850/amj.v9n4.2791 althea medical journal. 2022;9(4) 224 factors for carrying out physical activities and sports, which positively impacts cognitive, psychomotor, and affective development.10 physical activity and physical fitness are positively related to physical function,11 and related to the prevention and management of several health-related conditions faced by the elderly.12 the most commonly used method to evaluate functional capacity is the 6-minute walking test (6mwt).13 the maximum oxygen (o2) consumption or vo2 max has been defined as the maximum capacity to transport and use oxygen. vo2max is often used to measure an individual’s aerobic capacity. normally, vo2max level decreases gradually with aging, about a 10% decrease rate per decade after 25 years, and 15% over 50 years.14 the most important indicators of the health and well-being of the elderly are the quality of life (qol).3 according to the world health organization (who), the qol could be assessed by person’s perception of their position in life, in the context of culture and values in their surrounding environment, as well as with the goals, expectations, standards, and attention of each individu.15 there are several instruments of qol assessment, such as world health organization quality of life (whoqol)-100, whoqolbref, and whoqol-old.15 the whoqol is a simple instrument and can be evaluated in all ages. the study of the qol of the elderly using the whoqol-bref conducted in indonesia showed that most of the elderly had low quality of life scores on several aspects of each domain, consisting of energy adequacy, ability to carry out adl, satisfaction with physical capacity, ability to work, ability to concentrate, acceptance of physical appearance, satisfaction with sex life, financially sufficient, information availability, recreational activities, and transportation.16 the objective of this study was to determine the correlation of physical fitness with quality of life using whoqol-bref among members of the elderly gymnastics club at haji general hospital of surabaya. methods this study was an analytical observational study design with a cross-sectional approach. the sampling technique used simple random sampling with a minimum of 33 samples. the elderly aged 60 until 80 years who were members of the elderly gymnastics club of haji hospital surabaya for at least six months and routinely exercised two times a week were included in this study. elderly people with heart disease and lung disease were excluded from the study. demographic data such as age, gender, height, and weight were recorded. vo2max was an indicator of physical fitness. in this study, we used the 6-minute walk submaximal test to measure vo2max with the formula= (0.03 x mileage(m))+3.98 cc/kilogram body weight/minute. in brief, participants walked on a 30 meters track for 6 minutes. after 6 minutes, the distance traveled by the participants was calculated. the result was categorized into poor, moderate, and good, with scores <13.98, 13.98–16.98, and >16.98, respectively. whereas the quality-of-life value was obtained using the whoqol-bref assessment instrument questionnaire with 24 items, including four domains physical, psychological, social, and environmental health. whoqol-bref questionnaire was asked to all participants separately before or after the 6-minute walking test was performed. the whoqol-bref questionnaire in this study was performed by interviewing each respondent with the same interviewer to minimize confounding factors. all respondents in this study were members of routine gymnastics. they voluntarily came to hajj general hospital of surabaya with the assumption that their cognitive function was good, so there was no need to evaluate the mmse before the whoqol-bref evaluation was carried out. the quality of life was divided into five categories include very poor (0–20), poor (21–40), moderate (41–60), good (60–80), and very good (80–100). ethical approval of this study was obtained from the research ethics committee of the faculty of medicine, airlangga university, surabaya number 142/ ec/kepk/fkua/2017. all data was collected using microsoft excel, while the statistical analysis was performed using ibm spss 24 version. when the data were not distributed normally, the normality test had been employed, so the nonparametric test was performed. we performed the spearman correlation test to analyze the correlation between physical fitness and qol. results in total, 33 elderly people, and members of the elderly gymnastics club at haji general hospital surabaya, were included. the average age was 67.85±6.11 years, ranging from 60 to 78 years. the average height was 1.49±0.09 althea medical journal december 2022 althea medical journal. 2022;9(4) 225hasan hasan and rita vivera pane: physical fitness is correlated with quality of life among elderly gymnastics club from haji general hospital surabaya, indonesia m, weight was 57.65±10.53 kg, and bmi was 24.92±3.69. the average vo2max was 16.96 ± 2.37, and qol was 64.61±6.82 ml/kg/minute (table 1). there was no poor qol in this study. of five elderly people with poor physical fitness were 80%; with moderate qol and 20% with good qol. twelve elderly people with moderate physical fitness were 25% with moderate qol and 75% with good qol. while sixteen elderly people had good physical fitness, they were 19% with moderate qol and 81% had good qol (table 2). the result showed there was a correlation between physical fitness with qol among the elderly in the elderly gymnastics club of haji general hospital surabaya (p=0.042). however, the correlation coefficient result was 0.356, representing a weak correlation. table 2 physical fitness life of the elderly members of the gymnastics club of haji hospital surabaya based on age and gender physical fitness poor moderate good age (mean) 71 70.8 64.6 male (n) 2 5 4 female (n) 3 7 12 note: vo2max was an indicator of physical fitness. vo2max formula=(0.03 x mileage(m))+3.98 cc/kilogram body weight/minute with poor, moderate, and good with score <13.98, 13.98-16.98, and >16.98, respectively table 4 correlation between physical fitness with quality of life physical fitness quality of life total p-value* poor moderate good poor moderate good total 4 3 3 10 1 9 13 23 5 12 16 33 0.042 note: *statistical analysis using the spearman correlation test with a significant value of p (<0.05) table 1 characteristics of the elderly members of the gymnastics club of haji hospital surabaya based on physical fitness and quality of life min max median mean ± sd age (year) body height (m) weight (kg) bmi vo2max (ml/kg/minute) quality of life 60.00 1.35 36.00 16.65 11.63 54.50 78.00 1.71 89.00 32.87 20.18 78.00 67 1.52 59 23.82 17.48 62.75 67.85 ± 6.11 1.55 ± 0.09 59.53 ± 10.53 24.92 ± 3.69 16.96 ± 2.37 64.61 ± 6.82 note: vo2max was an indicator of physical fitness table 3 quality of life of the elderly members of gymnastics club of haji hospital surabaya, based on age and gender quality of life poor moderate good age (mean) 68.9 67.3 male (n) 3 8 female (n) 7 15 althea medical journal. 2022;9(4) 226 discussions vo2max components used in this study are age, gender, weight, height, and distance in the 6mwt. the 6mwt is commonly used to evaluate functional capacity because of its simplicity, ease of interpretation, and adl representativeness.5 the average vo2max obtained in this study was 64.6 ml/kg/minute. a population-based study in china showed the average vo2max among people above 50 years was 36.8±9.2 ml/kg/minute.17 similarly, the vo2max among people in another study above 60 years was 39.2 ml/kg/minute in man and 31.1 ml/kg/minute in women.18 the results of vo2max in this study were higher than other studies. since they are members of the elderly gymnastics club of haji general hospital of surabaya, who routinely do gymnastics three times a week, leading to a higher vo2max compared to other populations of the same age. the qol results show that about onethird had moderate qol, and two third were good. interestingly, the elderly in communitydwelling aged from 80 until 93 years in poland presents a good level of qol.1 it is worth noting that the elderly’s physical and mental health are the result of their life experiences and the current situation, which is determined by many psychosocial and spiritual factors. therefore, emotional, spiritual, and cognitive domains need to be included in addition to physical and social health in quality-of-life criteria, indicating that there is a relationship between physical activity and various aspects of qol.19 this study has a significant correlation between physical fitness and whoqolbref. another study has shown that the superior 6mwt performance participant may be affected by their good qol in several domains.13 interestingly, there is a significant correlation between 6mwt distance and qol in the elderly.5 there is a positive assessment of the elderly in qol domains associated with their physical fitness level, mobility endurance, upper and lower body strength, balance, coordination, and speed.1 furthermore, there is a relationship between physical fitness and physical health. those with poor physical health may not be able to perform tasks productively without fatigue, which also affects the quality of life. a study has identified differences between functional fitness and quality of life among elderly women based on their physical activity levels, which were measured using the global recommendations on physical activity for health, showed that older adults who met these physical activity recommendations achieved slightly good in all qol domains.20 quality of life impacts a person’s satisfaction in living his/her daily life. the religious or spiritual experience, as well as the cognitive ability, could accept the physical condition and age, or chronic illness suffered, thus allowing them to understand their condition. our respondents in this study have routinely received knowledge about health and how to maintain physical conditions and improve them whenever it is still possible to improve. this study shows a weak correlation between qol and physical fitness; respondents with poor physical fitness have more moderate than good qol. on the other hand, respondents who have good physical fitness have more good qol. interestingly, there is a respondent who has a poor fitness category but with good qol. by deeper investigation, we found that this respondent is always satisfied with his current condition. he told us that his culture or religion teaches him to always be grateful to god in all circumstances and to always compare with people with worse qol than himself. therefore, it is necessary to include spiritual and cognitive elements in the qol domain.19 the limitation of the study is that other domains, such as spirituality, have not been evaluated, which may be affected the quality of life, especially among the elderly. further study may need to consider this domain. in conclusion, physical fitness among the elderly is correlated with quality of life, suggesting that physical fitness among the elderly needs to be enhanced, albeit it must be monitored by a 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8. rohmah l, muhammad hn. tingkat kebugaran jasmani dan aktivitas fisik siswa sekolah. jpok. 2021;09(01):511–9. 9. sinuraya jf, barus jbnb. tingkat kebugaran jasmani mahasiswa pendidikan olahraga tahun akademik 2019/2020 universitas quality berastagi. kinestetik. 2020;4(1):23–32. 10. rozi f, safitri sr, syukriadi a. evaluasi tingkat kebugaran jasmani mahasiswa pada perkuliahan pendidikan jasmani iain salatiga. j edutrained. 2021;5(1):13–8. 11. gu x, chang m, solmon ma. physical activity, physical fitness, and health-related quality of life in school-aged children. j teach phys educ. 2016;35(2):117–26. 12. ayenigbara io. the contributions of physical activity and fitness for the optimal health and wellness of the elderly people. j gerontol geriatr. 2020;68(1):40–6. 13. serra aj, de carvalho pdtc, lanza f, de amorim flandes c, silva sc, suzuki fs, et al. correlation of six-minute walking performance with quality of life is domain and gender-specific in healthy older adults. plos one. 2015;10(2):e0117359. 14. kim ch, wheatley cm, behnia m, johnson bd. the effect of aging on relationships between lean body mass and vo2max in rowers. plos one. 2016;11(8):e0160275. 15. bangun bck, gondodiputro s, andayani s. insomnia and quality of life in the elderly: whoqol-bref and whoqolold indonesian version. kemas. 2020;16(2):249–55. 16. hidayati ar, gondodiputro s, rahmiati l. elderly profile of quality of life using whoqol-bref indonesian version: a community-dwelling. althea med j. 2018;5(2):105–10. 17. xiang l, deng k, mei q, gao z, yang t, wang a, et al. population and agebased cardiorespiratory fitness level investigation and automatic prediction. front cardiovasc med. 2022;8:758589. 18. loe h, rognmo ø, saltin b, wisløff u. aerobic capacity reference data in 3816 healthy men and women 20-90 years. plos one. 2013;8(5):e64319. 19. gill dl, hammond cc, reifsteck ej, jehu cm, williams ra, adams mm, et al. physical activity and quality of life. j prev med public health. 2013;46 suppl 1(suppl 1):s28–34. 20. nawrocka a, polechoński j, garbaciak w, mynarski w. functional fitness and quality of life among women over 60 years of age depending on their level of objectively measured physical activity. int j environ res public health. 2019 mar 18;16(6):972. hasan hasan and rita vivera pane: physical fitness is correlated with quality of life among elderly gymnastics club from haji general hospital surabaya, indonesia amj vol 9 no 1 march 2022.indd althea medical journal. 2022;9(1) 1althea medical journal. 2022;9(1):1–5 knowledge and attitude among doctors towards use of prophylactic vitamin k in neonatal bleeding disorders in department of obstetrics and gynecology: experience from haj el-safi hospital, sudan rawan mohamed sabri hassan,1 abrar bakry malik,2 mohamed eltayieb elawad,3 ebtihal modather mohammed,2 ahmed sami abdalla osman3 1school of medicine, ahfad university for women, khartoum, sudan, 2faculty of medicine, omdurman islamic university, khartoum, sudan, 3faculty of medicine, national ribat university, khartoum, sudan abstract background: vitamin k is crucial for neonates to prevent bleeding disorders. raising awareness of vitamin k use would show positive outcomes. this study aimed to assess the knowledge and attitude of prophylactic use of vitamin k for bleeding disorders in neonates among doctors working in the department of obstetrics and gynecology at haj el-safi hospital, sudan. methods: a descriptive cross-sectional study was conducted in february 2019, involving 36 doctors selected by convenience sampling. data were collected by an interview-based questionnaire designed to measure the knowledge level of doctors toward vitamin k deficiency classification and interactions, guidelines availability and adherence, and parents counseling. data were analyzed and presented in tables. results: the doctors involved in this study were 36, including 7 registrars, 6 medical officers, 23 house officers, mostly aged 20–25 years (n=29), and female (n=27). the level of knowledge about the classification of vitamin k deficiency and the interaction of vitamin k with other drugs among doctors was mostly good (n=14 and n=15, respectively). registrars were the most in the good category (n=6, and n=7, respectively). most doctors (n=23) were aware of vitamin k guidelines, while only 15 have continuous adherence, 16 of doctors counseled parents about the importance of prophylactic vitamin k. conclusion: the level of knowledge towards prophylactic vitamin k use in neonatal bleeding disorders among doctors in the department of obstetrics and gynecology at haj el-safi hospital is good. keywords: bleeding disorder, neonate, obstetrics, vitamin k correspondence: abrar bakry malik, sudan, omdurman, p.o. box 382. postal code 14415, e-mail: bakry.abrar287@ gmail.com introduction neonatal prophylaxis or prevention of neonatal diseases is an essential condition of the general population and consequently reduces the costs of the health services. vitamin k is the generic name for a family of compounds with a standard chemical structure of 2-methyl 1-,4 naphthoquinone. it is a fat-soluble vitamin that is naturally present in some food and is available as a dietary supplement.1 also, it is a required enzyme for the synthesis of a protein involved in hemostasis and bone metabolism, and other diverse physiological functions. also, it is crucial in reducing the risk of osteoporosis, bleeding disorders, and coronary heart disease.2–4 vitamin k dissolves in fat and is an essential element for synthesizing clotting factors ii, vii, ix, and x. despite its importance, the human body does not store it in large quantities, and a short-life characterizes its clotting factors derivatives. so, we have to intake it sufficiently from external sources to prevent hemorrhagic disorders.5 there are two types of vitamin k, and the first is extrinsic k-1, which can be obtained from vegetable oils and green vegetables. the second is intrinsic k-2, which is produced by normal intestinal flora.6 a systematic review has shown that the best prevention of neonates from bleeding disorders is taking vitamin k intramuscularly. however, the triple doses oral regimen could https://doi.org/10.15850/amj.v9n1.2518 althea medical journal. 2022;9(1) 2 be good alternative.7 vitamin k deficiency bleeding in neonates is a relatively common problem affecting in its late form around 4.4 to 10.5 out of 100,000 in europe and around 1 out of 6,000 in asian countries. the neonatal mortality rate for africa is estimated at 28 deaths per 1,000 live births.8,9 although this disease is common and sometimes causes death, its management is simple and cost effective. increasing the awareness of this disease, therefore, will produce positive outcomes. unfortunately, no studies in sudan have been found. so, this study aimed to assess knowledge and attitude of using prophylactic vitamin k for bleeding disorders in neonates among doctors working in the obstetrics and gynecology department, haj el-safi hospital in khartoum state, sudan. the study is expected to come with data that may improve the strategies and plans to improve the knowledge of health personnel. methods this study was a cross-sectional descriptive observational study conducted in february 2019 at haj el-safi hospital, one of the biggest hospitals in north khartoum, sudan. the hospital had 3 departments: internal medicine, surgery, and obstetrics and gynecology. it contains two wards for internal medicine, four wards for surgery and one ward for obstetrics and gynecology. bed capacity was 10 in obstetrics and gynecology, 24 in internal medicine, and 15 in surgery. the staff in the hospital consisted of 136 doctors as a minimum. the doctors in each department were 36 in obstetrics and gynecology, 50 in medicine, and 50 in surgery. the study population was all doctors in the department of obstetrics and gynecology at haj el-safi hospital, whose inclusion criteria were the entire population, so there was no need for exclusion criteria since the target population had been wholly met. the sampling technique used was total sampling. this study was approached through an observational complete coverage hospital-based study, in which a total of 36 doctors participated. the researcher met all subjects (n=36) using a structured self-administered questionnaire to collect the required data. data collection includes demographic variables, the position (registrar, medical officer and house officer), basic knowledge, knowledge of vitamin k prophylactic questions, attitude towards vitamin k prophylactic althea medical journal march 2022 table 1 respondents’ characteristics characteristics n age (years old) 20–25 26–30 31–35 above 36 29 5 1 1 gender male female 9 27 position registrar medical officer house officer 7 6 23 total 36 questions measured using a questionnaire developed by interview-based researchers. we assessed the level of knowledge by asking participants 6 questions. knowledge of vitamin k deficiency classification and drug interaction questions were classified into good, moderate, and poor. the availability of guidelines for vitamin k use, adherence to these guidelines, and parents counseling about vitamin k were yes/no questions. meanwhile, the source of information about vitamin k was multiple choices questions. all results were obtained according to the frequency in each answer class. the study was approved by the ethics committee for research unit, school of medicine, ahfad university for women, the ethics committee for research unit and the ministry of health in khartoum state, sudan. verbal consents were taken from the doctors. each doctor was informed that the data collected from this study would be used for strictly scientific purposes, and no names would appear in the questionnaire. the data were analyzed using simple statistics through the social sciences (spss) package for windows version 22 software, and the results were depicted in tables. results the study showed that the doctors were mainly in the age group 20–25 years (29 out of 36) and female (27 out of 36), while according to the position, most of the doctors were house officers 23 out of 36 (table 1). the level of knowledge about the classification of vitamin k deficiency among althea medical journal. 2022;9(1) 3rawan mohamed sabri hassan et al.: knowledge and attitude among doctors towards use of prophylactic vitamin k in neonatal bleeding disorders in department of obstetrics and gynecology: experience from haj el-safi hospital, sudan table 2 knowledge level of vitamin k deficiency classification among doctors doctors level of knowledge total good (n) moderate (n) poor (n) registrar medical officer house officer total 6 2 6 14 3 9 12 1 1 8 10 7 6 23 36 table 3 knowledge level towards interactions of vitamin k with other drugs among doctors doctors level of knowledge total good (n) moderate (n) poor (n) registrar medical officer house officer total 7 3 5 15 0 2 9 11 0 1 9 10 7 6 23 36 table 4 source of information about prophylactic use of vitamin k in neonates source of information n university self-reading conferences others total 20 7 6 3 36 doctors was mostly good (14 out of 36), registrars were the most in the good category (6 out of 36) (table 2). the knowledge level of the vitamin k interaction with other drugs was also mostly good (15 out of 36); all registrars were also in the good category (7 out of 7) (table 3). regarding information sources about prophylactic use of vitamin k in neonates, this study showed that most doctors (20 out of 36) got information from the university (table 4). most doctors answered yes when asked about the knowledge of guidelines availability (23 out of 36), adherence to guidelines (15 out of 36), and parents counseling (16 out of 36) about the importance of prophylactic vitamin k (table 5). discussion in this study, the level of knowledge about the classification of vitamin k deficiency and the interaction of vitamin k with other drugs among doctors was mostly good. registrars were the position with the most in the good category. in general, registrars outperform lower positions in terms of knowledge level, and this can be attributed to their long experience and interest focused on maternal and child health. a study that included 200 dentists reported that only 23 are aware of vitamin k deficiency bleeding disorders. the vast difference in knowledge can be attributed to the difference in the target population since dentists may not face vitamin k deficiency bleeding, except as a complication.10 also, most of the participants are aware about vitamin k guidelines in neonates compared to 38.9% of obstetric doctors in the study conducted in new zealand.11 this indicates that doctors practicing in sudan are well updated with the new guidelines. more than half of the respondents stated that their source of information regarding vitamin k prophylaxis was university lectures and studying for exams. at the same time, 7 out of 36 said it was self-reading, 6 out of 36 said they heard it at conferences while 3 out of 36 stated it was other sources. as many as 15 out of 36 of the doctors indicated using vitamin k according to the guidelines. meanwhile, 34.8% indicated occasional use of vitamin k. this might be due to differences in the patients’ needs or doctor’s personal opinion. according to a study conducted in new zealand,11 all the doctors and 71% of midwives emphasized the importance of vitamin k prophylaxis for newborns. also, the study revealed that all newborns should take althea medical journal. 2022;9(1) 4 vitamin k by unanimous doctors and 54.7% of midwives. furthermore, all doctors and 74.2% of midwives confirmed that giving children vitamin k is the cornerstone of their clinical practice.11 according to a study conducted in slovenia, doctors applied prophylactic vitamin k to 9 out of 10 slovene newborns and 22 out of 32 croatian newborns. in sudan, differences in the application of vitamin k are also found.12 this study found that 16 of participants answered yes to whether health care professionals counseled their patients about prophylactic vitamin k. this is an abysmal percentage because it is essential to educate the families about prophylactic vitamin k to achieve a much healthier society. this is probably influenced by the poor counseling skills of most health care professionals; due to lack of time or workload, generally, there is a bad attitude towards counseling patients in sudanese hospitals. in a review that discusses the main obstacles that contribute to the decrease in the use of vitamin k to prevent hemorrhagic diseases, it is found that the awareness of medical personnel is one of them. in contrast, repeated refusal of parents to give the vitamin to their babies has led to an increased rate of bleeding disorders due to vitamin k deficiency.13–15 according to a study, vitamin k is commonly given as prophylaxis after birth to prevent the newborn’s hemorrhagic disease (hdn). among infants who have not received vitamin k prophylaxis at birth, the incidence of hdn is estimated at 35 (10.5 to 80) per 100,000 live births, being lower in high-income countries at 8.8 (5.8 to 17.8) per 100,000 live births.16 in the first edition of its pocketbook of hospital care for children, the world health organization (who) did not make a universal recommendation on routine vitamin k prophylaxis. instead, it advised health providers to follow their respective national guidelines to decide the need for prophylaxis.17 in 2010, the who reviewed the available evidence on key questions, including routine vitamin k prophylaxis, to update the recommendations in the second edition of its pocketbook of hospital care for children.18 in comparison to this study, there are no local guidelines for vitamin k route in sudan. the late vitamin k deficiency burden is significant in lacking vitamin k prophylaxis at birth. given the high risk of mortality and adverse neurodevelopmental outcomes in the survivors, 22 and 25% to 67%, respectively. in one study from thailand,19 the burden assumes importance from a public health point of view.19 in sudan, no study has been conducted. according to this study, the majority of all neonates was given vitamin k prophylaxis, with over half always given intravenous route vitamin k prophylaxis.20 compared to this study, not half of the neonates were given vitamin k prophylaxis. this study has limitations. we conducted the study in non-specialized hospital for a short time, although we need a more extensive study in sudan. we recommend similar studies to be carried out involving more hospitals, especially specialized ones, reflecting the accurate picture of how well doctors know and are aware of the need for preventive vitamin k. in conclusion, the level of knowledge towards prophylactic vitamin k use in neonatal bleeding disorders among doctors in the department of obstetrics and gynecology at haj el-safi hospital is good. among study participants, registrars illustrated good knowledge in terms of classification and interaction of vitamin k, in contrast to medical officers and house officers who described their knowledge as poor knowledge. to better understand these attitude differences, it is necessary to improve better education and communication with professionals regarding newborn vitamin k prophylaxis. importantly, in the future, vitamin k should be given to neonates immediately after birth. acknowledgment the authors did not receive financial support or personal assistance for the work. althea medical journal march 2022 table 5 knowledge of guidelines availability, adherence to guidelines, and parents counseling on the importance of prophylactic vitamin k question answer (n=36) yes (n) no (n) sometimes (n) knowledge of guidelines availability adherence to guidelines parents counseling 23 15 16 13 13 10 0 8 10 althea medical journal. 2022;9(1) 5 conflict of interest the authors have no conflicts of interest to declare. author contributions dr. rawan mohamed sabri hassan: formulated the research idea, conceived and designed the study. dr. abrar bakry malik: interpreted, analyzed the data, and wrote the initial draft. also, revised the manuscript. dr. mohamed eltayieb elawad, dr. ebtihal modather mohammed, and dr. ahmed sami abdalla osman: provided research materials, collected, and organized the data. references 1. booth sl. vitamin k: food composition and dietary intakes. food nutr res. 2012;56(1):5505. 2. ferland g. the discovery of vitamin k and its clinical applications. ann nutr metab. 2012;61(3):213–8. 3. hamidi ms, gajic-veljanoski o, cheung am. vitamin k and bone health. j clin densitom. 2013;16(4):409–13. 4. berenjian a, mahanama r, kavanagh j, dehghani f. vitamin k series: current status and future prospects. crit rev biotechnol. 2015;35(2):199–208. 5. van winckel m, de bruyne r, van de velde s, van biervliet s. vitamin k, an update for the paediatrician. eur j pediatr. 2009;168(2):127. 6. akbari s, rasouli-ghahroudi aa. vitamin k and bone metabolism: a review of the latest evidence in preclinical studies. biomed res int. 2018;2018:4629383. 7. sankar mj, chandrasekaran a, kumar p, thukral a, agarwal r, paul vk. vitamin k prophylaxis for prevention of vitamin k deficiency bleeding: a systematic review. j perinatol. 2016;36(suppl 1):s29–35. 8. centers for disease control and prevention (cdc). notes from the field: late vitamin k deficiency bleeding in infants whose parents declined vitamin k prophylaxis-tennessee, 2013. mmwr morb mortal wkly rep. 2013;62(45):901–2. 9. grady sc, frake an, zhang q, bene m, jordan dr, vertalka j, et al. neonatal mortality in east africa and west africa: a geographic analysis of district-level demographic and health survey data. geospat health. 2017;12(1):501. 10. gopalasamy k. awareness among final year and postgraduate dental students on bleeding disorders’: a questionnaire based study. ijsr. 2017;6(3):2157–61. 11. gosai s, broadbent rs, barker dp, jackson pm, wheeler bj. medical and midwifery attitudes towards vitamin k prophylaxis in new zealand neonates. j paediatr child health. 2014;50(7):536–9. 12. jug došler a, petročnik p, mivšek ap, zakšek t, skubic m. neonatal prophylaxis: prevention of vitamin k deficiency haemorrhage and neonatal ophthalmia. zdr varst. 2015;54(3):184–93. 13. majid a, blackwell m, broadbent rs, barker dp, al-sallami hs, edmonds l, et al. newborn vitamin k prophylaxis: a historical perspective to understand modern barriers to uptake. hosp pediatr. 2019;9(1):55–60. 14. kerruish nj, mcmillan j, wheeler bj. the ethics of parental refusal of newborn vitamin k prophylaxis. j paediatr child health. 2017;53(1):8–11. 15. hamrick hj, gable ek, freeman eh, dunn ll, zimmerman sp, rusin mm, et al. reasons for refusal of newborn vitamin k prophylaxis: implications for management and education. hosp pediatr. 2016;6(1):15–21. 16. sankar m, chandrasekaran a, kumar p, thukral a, agarwal r, paul v. vitamin k prophylaxis for prevention of vitamin k deficiency bleeding: a systematic review. j perinatol. 2016;36(s1):s29–35. 17. who. pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. who: geneva; 2005. 18. who. pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. 2nd ed. who: geneva; 2013. 19. isarangkura pb, chuamsumrit a, hathirat p. idiopathic vitamin k deficiency in infants: its roles in infant morbidity and childhood handicaps. thromb haemost. 1989;62:363. 20. khambalia az, roberts cl, bowen jr, nassar n. maternal and infant characteristics by mode of vitamin k prophylaxis administration. j paediatr child health 2012;48(8):665–8. rawan mohamed sabri hassan et al.: knowledge and attitude among doctors towards use of prophylactic vitamin k in neonatal bleeding disorders in department of obstetrics and gynecology: experience from haj el-safi hospital, sudan althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 1 correlation between hemoglobin level, attention and working memory scores jannatin aliya indrina1, anam ong2, ihrul prianza prajitno3 1faculty of medicine, universitas padjadjaran,2department of neurology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of anatomy, faculty of medicine, universitas padjadjaran abstract background: attention and working memory functions have important roles in daily activities. normal level of hemoglobin is required for optimum attention and working memory functions. this study aims to analyze the correlation between hemoglobin level, attention, and working memory scores in medical students who attended atlas medical pioneer (amp) basic program xxi. methods: the total population sample for this cross-sectional study included 27 males and 19 females. the hemoglobin level was meassured by using cyanmethemoglobin method. digit symbol test, digit span forward and backward test, trail making test a and b, and stroop test were used to assess attention and working memory scores. the study was conducted from september to november 2012 in jatinangor campus of the faculty of medicine, universitas padjadjaran and clinical pathology laboratory of dr. hasan sadikin general hospital. the correlation analysis was performed using computer. results: the correlation between hemoglobin level in males and attention on trail making test a score was (r=0.144) (p=0.474). while the correlations with thetrail-making test b and stroop test scores were (r=0.332) (0.091), and (r=-0.320) (p=-0.103), respectively. for females, the correlations with the trail making test a, trail making test b, and stroop test scores were (r=0.121) (p=0.622), (r=-0.232) (p=0.338), and (r=0.137) (p=0.576), respectively. meanwhile, the correlation between hemoglobin level and the working memory on digit symbol test, digit span forward test, and digit span backward test scores for-males were (r=0.256) (p=0.197), (r=0.419) (p=0.029), and (r=0.113) (p=0.576), respectively. for-females, the same correlations were (r=0.412) (p=0.080), (r=-0.299) (p=0.213), and (r=-0.028) (p=0.909), respectively. the only test that showed statistically significant result was digit span forward test in males. conclusions: there is evident of weak correlation between hemoglobin level, attention, and working memory scores in medical students who attended amp basic program xxi. this may be due to the confounding factors affecting attention and working memory as well as a small sample size. [amj.2014;1(1):1–5] keywords: attention score, hemoglobin level, working memory score korelasi antara kadar hemoglobin, pencapaian skor atensi, dan skor memori kerja abstrak latar belakang: fungsi atensi dan memori kerja memiliki peranan penting dalam aktivitas sehari-hari. kadar hemoglobin yang normal dibutuhkan untuk mencapai fungsi atensi dan memori kerja yang optimal. penelitian bertujuan untuk menganalisis korelasi antara kadar hemoglobin, skor atensi, dan memori kerja pada mahasiswa kedokteran yang mengikuti pendidikan dasar xxi atlas medical pioneer (amp). metode: studi potong lintang dengan jumlah sampel 46 orang, terdiri atas 27 orang laki-laki dan 19 orang perempuan. perhitungan kadar hemoglobin menggunakan metode cyanmethemoglobin. digit symbol test, digit span forward dan backward test, trail making test a dan b, dan stroop test digunakan untuk menilai skor atensi dan memori kerja. penelitian dilaksanakan dari bulan september–november 2012 di kampus fakultas kedokteran universitas padjadjaran jatinangor dan laboratorium patologi klinik rumah sakit dr. hasan sadikin. analisis korelasi menggunakan komputer. correspondence: jannatin aliya indrina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: 085624298487, email: j.aliyaindrina@yahoo.com althea medical journal. 2014;1(1) 2 amj june, 2014 introduction in daily life, human gets a wide range of information from the environment. this information will be processed by the human brain system to determine decisions. this process is called cognitive function.1 cognitive function is included into the mental activity that is conducted consciously.2 there are some examples of cognitive function e.g. attention, memory, executive control, emotion, and language.3 some of the most important cognitive functions are attention and memory. attention is the human ability to concentrate or focus on a stimulus. the attention can be used to determine planning and decision making. meanwhile, memory is often described as a storage of information and recall of informations. memory is divided into declarative memory and non-declarative memory. working memory as a part of declarative memory takes the form of human executive functions to create plans and make decisions. non-declarative memory is formed unconsciously because human has a storage of memory on previous actions.3,4 attention and working memory actually work together despite the fact that the position of working memory is higher than attention because working memory is capable to divide or split the focus of attention to some stimulus.5 working memory can divide attention from one action to another action without loss of interrelated information.6 the factors that affect a person’s attention and working memory in normal environmental conditions are crowded environment and individual conditions e.g. condition of the cardiovascular system, hemoglobin characteristics, nutrition, history of disease, motivational factors, and physical activity.4,7-8 the attention and working memory are processed by the system of the human brain, specifically in the frontal and prefrontal parts. there are some factors which may affect the information processing e.g. neurons, blood circulation, and nutrients in brain circulation.1,3,9 the blood circulation contains glucose and oxygen which are bound to hemoglobin.10 the hemoglobin then releases oxygen which is used by the neurons for metabolism. besides oxygen, neurons use glucose as a source of metabolism.9 the results of metabolism are the action potential of neurotransmitter in neuronal cells and synaptic plasticity forming.1,11 synaptic plasticity is the process of neuronal pathways formation and synapse transmission for neurons resulting in neuronal activity that leads to attention and memory.12-14 low hemoglobin level could interfere the neuronal cell metabolism and impulse delivery.15-16 if this happens, the process of thinking and cognitive brain function in particular executive function may be disturbed.17-18 this research on the correlation between hemoglobin level, attention, and working memory scores in medical students who attended atlas medical pioneer (amp) basic program xxi was conducted to find correlations between hemoglobin level, attention, and working memory scores that are beneficial for medical students during their activities related to adventure and very dangerous activities that need attention and working memory in terms of coordination, determination of accurate and fast decisions, receiving various new information from amp program and other activities in their daily life. methods a cross-sectional study was done involving 46 medical students (27 males and 19 females) hasil: korelasi antara kadar hemoglobin laki-laki dengan skor atensi pada trail making test a (r=0,144) (p=0,474), trail making test b (r=0,332) (0,091), dan stroop test (r=-0,320) (p=-0,103). pada perempuan hasil trail making test a (r=0,121) (p=0,622), trail making test b (r=-0,232) (p=0,338), dan stroop test (r=0,137) (p=0,576). hasil korelasi antara kadar hemoglobin laki-laki dengan skor memori kerja pada digit symbol test (r=0,256) (p=0,197), digit span forward test (r=0,419) (p=0,029), dan-digit span backward test (r=0,113) (p=0,576). pada perempuan hasil digit symbol test (r=0,412) (p=0,080), digit span forward test (r=-0,299) (p=0,213), dan digit span backward test (r=-0,028) (p=0,909). tes yang memiliki nilai signifikan hanya digit span forward test pada laki-laki. simpulan: terdapat korelasi lemah antara kadar hemoglobin, atensi, dan memori kerja pada mahasiswa yang mengikuti pendidikan dasar xxi amp. hal ini dapat terjadi karena confounding factor yang dapat memengaruhi atensi dan memori kerja seseorang serta jumlah sampel penelitian yang sedikit. kata kunci: kadar hemoglobin, skor atensi, skor memori kerja althea medical journal. 2014;1(1) 3jannatin aliya indrina, anam ong, ihrul prianza prajitno: the correlation between hemoglobin level, attention, and working memory scores who attended amp basic program xxi, who met these inclusion criterias: have completed the basic program, signed informed consent and passed laboratory examinations. the subject that had not enough sleep before the test, took some medication, or consumed foods and drinks that contained caffein were excluded. the hemoglobin level was measured using the cyanmethemoglobin method. the measurement of attention used 3 types of tests, namely trail making test a and b and stroop test, while the measurement of working memory used 3 types of tests, namely digit span forward test, digit span backward test, and digit symbol test. the study was conducted from september to november 2012 in jatinangor campus of the faculty of medicine, universitas padjadjaran and laboratory of clinical pathology in dr.hasan sadikin general hospital. our study used shapiro-wilk normality test to determine the distribution of variables. digit symbol test, digit span backward test, trail making test b, and stroop test had p value>0.05 which showed normal distribution of data while digit span forward test and trail making test a had p value <0.05 showing that the distribution of data was nonnormally distributed. because the number of data was less than 50, the correlation between the variables in our study were measured by using pearson test.13 results in male students, from 27 people, there were 25 people with normal hemoglobin level and 2 people with low hemoglobin level. whereas in female students, from 19 people, there were 15 people with normal hemoglobin level and 6 people with low hemoglobin level. the female students were more likely to have low hemoglobin level compared to male students. the mean age of all subjects was 19 years old the correlation between the hemoglobin level and the attention score in male students for trail making test a and trail making test b table 1 student demographics hemoglobin levels mean age (min-max) normal low total gender male 25 2 27 19 (18–22) female 15 4 19 19 (18–22) total 40 6 46 was very weak and insignificant value (r=0.144, p=0.474; r=0.332, p=0.091). the correlation between the hemoglobin level and the attention score for stroop test was weak and insignificant (r= -0.320, p=0.103). the negative correlation showed the opposite correlation. the correlation between the hemoglobin level and the attention score in female students for trail making test a and stroop test was very weak and insignificant (r=0.121, p=0.622; r=0.137, p=0.576). the correlation between the hemoglobin level and the attention scores for trail making test b was weak and insignificant (r=-0.232, p=0.338). the negative correlation showed the opposite correlation. the correlation between the hemoglobin level and the working memory score in male students for digit symbol test was weak and insignificant (r=0.256, p=0.197). the correlation between the hemoglobin level and the working memory score for digit span forward test was moderate and significant (r=0.419, p=0.029). the correlation between the hemoglobin level for digit span backward test was very weak and insignificant (r=0.113, p=0.576). the correlation between the hemoglobin level and working memory score in female students for digit symbol test was moderate and insignificant (r=0.412, p=0.080). the correlation between the hemoglobin level and working memory score for digit span forward test and digit span backward test was very weak and insignificant (r=-0.299, p=0.213; r=0.028, p=0.909). the negative correlation showed the opposite correlation. discussion based on our study, there is evident of weak correlation between hemoglobin level and attention and working memory scores in medical students who attended amp basic program xxi. however, statistically, the correlation between the hemoglobin level and the attention and working memory scores are mostly insignificant. there are some negative althea medical journal. 2014;1(1) 4 amj june, 2014 table 4 correlation between hemoglobin level and working memory score in male students digit symbol digit span forward digit span backward hemoglobin level male (n=27) r 0.256 0.419 0.113 p 0.197 0.029 0.576 * r= coefficient of correlation , p= significance value, n= the number of data table 5 correlation between hemoglobin level and working memory score in female students digit symbol digit span forward digit span backward hemoglobin level female (n=19) r 0.412 -0.299 -0.028 p 0.080 0.213 0.909 * r= correlation coefficient, p= significance value, n= number of data such as partial pressure of oxygen (po2), potential hydrogen (ph), partial pressure of carbon dioxide (pco2), temperature, and 2,3-bipshosphoglycerate concentration were not checked. therefore, to have more significant results, further study with bigger sample, adequate environment test, and assessment of all characteristics of hemoglobin is needed. references 1. guyton ac, hall je. cerebral cortex, intellectual function of the brain, learning and memory. in: guyton ac, hall je. text book of medical physiology 11th ed. philadelphia: elsevier saunders;2006.p.714–27. 2. turana y, mayza a, jannis j. artikel konsep: tes penapisan fungsi kognitif pada pelayanan kesehatan primer di indonesia. medika. 2009;xxxv(7). [cited 2012 mei 15]. available from: http://www.jurnalmedika.com/tarifiklan/257-tes-penapisan-fungsi-kognitifpada-pelayanan-kesehatan-primer-diindonesia. 3. kay j, tasman a. essential of psychiatry. england: john wiley & son, ltd; 2006. 4. sadock, james b, alcott v. kaplan & sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 10th ed. philadelphia: lippincott williams & wilkins;2007. 5. dehn mj. working memory and academic learning: assessment and intervention. 1st ed. hoboken, new jersey: john wiley & son inc.; 2008. 6. stone m, ladd sl, gabrieli jde. the role of selective attention in perceptual and affective priming. am j psychol. 2000 fall; table 3 correlation between hemoglobin level and attention score in female students trail making a trail making b stroop test hemoglobin level female (n=19) r 0.121 -0.232 0.137 p 0.662 0.338 0.576 * r= coefficient of correlation, p=significance value, n= the number of data results in this study showing the opposite direction because some medical students with higher hemoglobin level in fact have a low test result and vice versa. this may be due to the confounding factors that affect a person’s attention and working memory such as crowded environment and individual conditions e.g. condition of the cardiovascular system, hemoglobin characteristics, nutrition, history of disease, motivational factors, and physical activity, which may affect the results of this study. 4,7-8 our study has limitations. first, the sample is small. second, inadequate environment test and general condition that can interfere the study participants when answering the test. third, the characteristics of hemoglobin table 2 correlation between hemoglobin level and attention score in male students trail making a trail making b stroop test hemoglobin level male (n=27) r 0.144 0.332 -0.320 p 0.474 0.091 0.103 * r=coefficient of correlation, p= significance value, n= the number of data althea medical journal. 2014;1(1) 5jannatin aliya indrina, anam ong, ihrul prianza prajitno: the correlation between hemoglobin level, attention, and working memory scores 113(3):341–58. 7. sestieri c, shulman gl, corbetta m. attention to memory and the environment: functional specialization and dynamic competition in human posterior parietal cortex. j neurosci. 2010;30(25):8445–56. 8. peterson jc. the adaptive neuroplasticity hypothesis of behavioral maintenance. neural plast. 2012;2012: 516364. 9. zhang k, zhu l, fan m. oxygen, a key factor regulating cell behavior during neurogenesis and cerebral disease. front mol neurosci. 2011;4:5. 10. schechter an. hemoglobin research and the origins of molecular medicine. blood. 2008;112(10):3927–38. 11. mattson mp, gleichman m, cheng a. mitochondria in neuroplasticity and neurological disorder. neuron. 2008;60(5):748–66 12. cognifit. reasons why active neurons and brain cells are better cells. 2012. [cited 2012 september 15]. available from: http://www.cognifit.com/active-neurons. 13. gage fh. neurogenesis in the adult brain. j neurosci. 2002;22(3):612–3. 14. kolb b, muhammad a, gibb r. searching for factors underlying cerebral plasticity in the normal and injured brain. j commun disord. 2011;44(5):503–14. 15. john hopkins medicine. anemia affects body and maybe the mind. 2006 [cited 2012 september 19]. available from: http://www.hopkinsmedicine.org/press_ releases/ 2006/09_13_06.html. 16. hulthén l. iron deficiency and cognition. scand j nutr. 2003;47(3):152–6. 17. the internet stroke center. neuronal function: importance of oxygen and glucose. the internet stroke center. 2009 [cited 2012 agustus 23]. available from: http:// www.strokecenter.org/professionals/ brain-anatomy/cellular-injury-duringischemia/neuronal-function-importanceof-oxygen-and-glucose/. 18. weiskoff rb, feiner j, hopf hw, viele mk, watson jj, kramer jh, et al. oxygen reverses deficit of cognitive function and memory and increase heart rate induced by acute severe isovolemic anemia. anesthesiology. 2002;96(4):871–7. 19. hajarisman n. seri buku ajar statistika multivariat. bandung: universitas islam bandung; 2008. amj vol 7 no 3 september edited.indd althea medical journal. 2020;7(3) 149 hemoglobin level decrease after open heart surgery in a tertiary hospital in indonesia anabella nifulea,1 reza widianto sudjud,2 rama nusjirwan3 1faculty of medicine universitas padjadjaran, indonesia, 2department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of thoracic and vascular surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: anabella nifulea, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: beanifulea@yahoo.com introduction cardiovascular disease is the number one cause of death in the world. estimated that 17.9 million people died of cardiovascular disease in 2016, representing 31% of all deaths in the world.1 with heart disease as the number one killer in the world, there are a lot of treatments carried out to prevent death. one of them is open-heart surgery.2 open heart surgery is usually conducted by connecting the heart to the cardiopulmonary bypass (cpb) machine.3 the most common open-heart surgeries are coronary artery bypass graft (cabg) surgery and heart valve surgery.4,5 the use of cpb machines will cause hemodilution. hemodilution occurs due to the process of mixing the blood of patients with priming fluid in the extracorporeal circuit.6 hemodilution will cause a decrease in hemoglobin (hb) levels.7 besides hemodilution, hemolysis can also cause a decrease in hemoglobin levels. hemolysis is the damage of the red blood cell membrane integrity, causing the hemoglobin released and its levels fall.8 hemolysis during openheart surgery might also be caused by the use of cpb machines.9 several things can cause hemolysis; the first cause is trauma due to cpb engine pumps caused by high shear stress. the second cause is an augmented or assisted venous return (avd). the third cause is the arterial cannula.10–12 excessive decreased in hemoglobin levels can cause serious complications such as dyspnea, hypotension, tachycardia, and loss of consciousness.13 the aim of the study was to explore the decrease of hemoglobin levels after openheart surgery. it is expected that the result might give information for clinicians to amj. 2020;7(3):149–52 abstract background: open heart surgery is usually performed by connecting the heart to a cardiopulmonary bypass (cpb) machine. the use of the cpb machine may decrease the hemoglobin level and a very low hemoglobin levelcould cause serious complications.this study aimed to explore the decrease in hemoglobin level after open heart surgery. methods: a cross-sectional retrospective descriptive study was conducted on medical records of patients underwent coronary artery bypass graft (cabg) surgery and heart valve surgery in a tertiary hospital in indonesia in 2018. the total sampling method was deployed to all medical records of patients underwent cabg surgery (n=25) and patients underwent heart valve surgery (n=3). results: the decrease in hemoglobin level among young-adult female patients after heart valve surgery was 6.8 g/dl. the average decrease in mid-adult male and female patients after cabg surgery were 6 g/dl and 5.8 g/dl, respectively, and, after the heart valve surgery, the levels were 8.5 g/dl and 5.4 g/dl, respectively. the average decrease in hb level among late-adult male and female patients after cabg surgery was 6.1 g/dl and 5.4 g/dl, respectively. conclusions: hemoglobin level decreases after an open heart surgery. therefore, observation on the hemoglobin level to prevent complications and to facilitate early treatment is necessary. keywords: coronary artery bypass graft surgery, heart valve surgery, hemoglobin https://doi.org/10.15850/amj.v7n3.1924 althea medical journal. 2020;7(3) 150 amj september 2020 prevent the decrease of hb levels during openheart surgery. methods this study was a retrospective descriptive study with a cross-sectional design, conducted from june to november 2019 using secondary data from the medical record database in dr. hasan sadikin general hospital, bandung. all data of the patients aged ≥18 years old who underwent cabg and heart valve surgery in 2018 were collected. only data with complete medical records were included. the exclusion criteria were incomplete data on hb values before and after cabg or heart valve surgery. those who had low hb levels before cabg and heart valve surgery were also excluded. the normal hb value of adult men was 13.5– 18 g/dl and of adult women was 12–15 g/ dl.14 data collection was carried out after obtaining ethical approval number 955/ un6.kep/ec/2019 issued by the research ethics committee of universitas padjajaran, and research licensing letter issued by the research ethics committee of dr. hasan sadikin general hospital bandung (no. lb.02.01/x.2.2.1/1781/2019). the selected data was analyzed and presented in a table to illustrate the decrease of hemoglobin levels. results in total, data were collected from cabg surgery patients (n=25) and heart valve surgery patients (n=3). the characteristic of the patients was shown in table 1. there were no young adult patients who underwent cabg surgery, and there were no late adult patients who underwent heart valve surgery. the majority of cabg surgery patients were in the late adult group (64%) and male (88%) patients, whereas, the majority of heart valve surgery patients were in the middle adult group (66.7%) and female patients (66.7%). the decrease of hemoglobin levels after table 1 characteristics of patients underwent open heart surgery age groups cabg surgery (n=25) heart valve surgery (n=3) male female n % male female n % young adult (18–35 years old) 0 0 0 0 0 1 1 33.3 middle adult (36–55 years old) 8 1 9 36 1 1 2 66.7 late adult (>55 years old) 14 2 16 64 0 0 0 0 total 22 3 25 100 1 2 3 100 note: cabg= coronary artery bypass graft table 2 decrease of hemoglobin levels after open heart surgery based on age groups and gender age groups gender cabg heart valve x̅ hb preoperative (g/dl) x̅ hb postoperative (g/dl) decrease hb levels (g/dl) x̅ hb preoperative (g/dl) x̅ hb postoperative (g/dl) decrease hb levels (g/dl) young adult male (18–35 years old) female 13.6 6.8 6.8 middle adult male 15.2 9.2 6 15.6 7.1 8.5 (35–55 years old) female 13.3 7.5 5.8 13.9 8.5 5.4 late adult male 14.9 8.8 6.1 (>55 years old) female 12.9 7.5 5.4 note: cabg, coronary artery bypass graft althea medical journal. 2020;7(3) 151 open-heart surgery based on age groups and gender were shown in table 2. data from the female patient showed preoperative hb was 13.6 g/dl, and postoperative hb was 6.8 g/dl. there was a significant decrease of hb levels up to 50%. in the middle adult group (36 – 55 years old), the decrease of hb levels in male patients and female patients after cabg surgery was 6 g/dl and 5.8 g/dl, respectively. the decrease of hb levels in male patients and female patients after heart valve surgery was 8.5 g/dl and 5.4 g/dl, respectively. the average decrease of hb levels in male patients after cabg surgery was 6.1 g/dl, and in female patients was 5.4 g/dl. table 3 showed the number of packed red blood cell (prbc) transfusion after open-heart surgery, based on age groups and gender. in the middle adult group, the average prbc transfusion in male and female patients after cabg surgery was 490.5 ml and 894 ml, respectively, whereas the administration of prbc transfusion in male and female patients after heart valve surgery was 525 ml and 183 ml, respectively. in the late adult group, the average number of prbc transfusions received by male and female patients after cabg surgery was 531.1 ml and 457.5 ml, respectively. discussion the result of this study showed that patients of cabg surgery were predominantly male (88%), conform the other study showing that men have a higher risk of coronary heart disease than women.15 men have a higher risk of coronary heart disease because men smoke more and have higher alcohol consumption than women.16 men also have a higher risk of heart valve disease than women.17 however, our study shows that there is a trend that female was more prevalent than men, although the numbers of patients are very limited. furthermore, the age of patients who underwent of cabg surgery in this study are predominantly (64%) the late adult group (>55 years old). this data is similar to data from the ministry of health republic of indonesia.18 as for patients with heart valve surgery in this study, the middle adult group (36–55 years old) was predominant (66.7%). in this study, the average decrease of hemoglobin levels in male and female patients of the middle adult group after cabg surgery is 6 g/dl and 5.8 g/dl, and after heart valve surgery is 8.5 g/dl and 5.4 g/dl respectively. furthermore, the average decrease of hemoglobin levels in male and female patients of late adult group after cabg surgery is 6.1g/ dl and 5.4 g/dl. the decrease of hemoglobin is almost 50% of the baseline of hemoglobin before surgery. the decrease of hemoglobin levels in male patients is greater than female patients after cabg surgery and after heart valve surgery. the result of this study is similar to a study that examined the decrease of hemoglobin levels after cardiac surgery in dhaka, bangladesh.19 the monitoring of the hemoglobin in that study was taken on the 1st, 3rd, and 7th post-operative days. interestingly, the decrease of hemoglobin levels can be caused by hemolysis and hemodilution due to the use of cpb machines.6–9 further study is needed to find out the factors that cause the difference in the decrease of hemoglobin levels. in this study, all patients have received prbc transfusion after cabg surgery and heart valve surgery. the purpose of prbc transfusion is to prevent tissue hypoxia related to anemia.20 as a standard procedure, prbc transfusion will be given after heart surgery when hemoglobin levels reach the transfusion threshold ≤7 g/dl.13 in this study, all patients received prbc transfusion even though some of the decreases in hemoglobin levels have not yet reached the threshold of prbc transfusion. further research is needed to find out the factors that influence this result. there are some limitations to this study. the hemoglobin monitoring has been only anabella nifulea et al.: hemoglobin level decrease after open heart surgery in a tertiary hospital in indonesia table 3 packed red blood cell transfusion given after open heart surgery based on age groups and gender young adult (18–35 years old) middle adult (35–55 years old) late adult (>55 years old) male female male female male female x̅ prbc (ml) cabg 490.5 894 531.1 457.5 heart valve 385 525 183 note: cabg= coronary artery bypass graft; prbc= packed red blood cell althea medical journal. 2020;7(3) 152 amj september 2020 conducted in the same day after the surgery. hemoglobin level needs to be monitored regularly. furthermore, the complete medical records before and after open-heart surgery needs to be well recorded. more patients’ data analysis needs to be performed to have a good view on the hemoglobin decrease after open heart surgery. in conclusion, the hemoglobin level is decreased after open heart surgery. therefore, it is necessary to observe the decrease in hemoglobin levels for prevention and treatment if the decrease exceeds normal. references 1. world health organization. cardiovascular diseases. 2017 [cited 2019 mar 3]. available from: https://www.who.int/healthtopics/cardiovascular-diseases#tab=tab_1 2. weisse ab. cardiac surgery: a century of progress. tex heart inst j. 2011;38(5):486– 90. 3. hessel ea. history of cardiopulmonary bypass (cpb). best pract res clin anaesthesiol. 2015;29(2):99–111. 4. melly l, torregrossa g, lee t, jansens jl, puskas jd. fifty years of coronary artery bypass grafting. j thorac dis. 2018;10(3):1960–7. 5. samiei n, hakimi mr, mirmesdagh y, peighambari mm, alizadeh-ghavidel a, hosseini s. surgical outcomes of heart valves replacement: a study of tertiary specialied cardiac center. arya atheroscler. 2014;10(5):233–7. 6. hwang nc. preventive strategies for minimizing hemodilution in the cardiac surgery patient during cardiopulmonary bypass. j cardiothorac vasc anesth. 2015;29(6):1663–71. 7. mak ma, smołka a, kowalski j, kuc a, klausa f, kremens k, et al. can cardiopulmonary bypass system with blood priming become a new standard in coronary surgery? kardiol pol. 2016;74(8):726–32. 8. barcellini w, fattizzo b. clinical applications of hemolytic markers in the differential diagnosis and management of hemolytic anemia. dis markers. 2015;2015:635670. 9. passaroni ac, de moraes silva ma, yoshida wb. cardiopulmonary bypass: development of john gibbon’s heartlung machine. rev bras cir cardiovasc . 2015;30(2):235–45. 10. vermeulen windsant ic, hanssen sj, buurman wa, jacobs mj. cardiovascular surgery and organ damage: time to reconsider the role of hemolysis. j thorac cardiovasc surg. 2011;142(1):1–11. 11. passaroni ac, felicio ml, de campos nlkl, silva ma de m, yoshida wb. hemolysis and inflammatory response to extracorporeal circulation during on-pump cabg: comparison between roller and centrifugal pump systems. braz j cardiovasc surg. 2018;33(1):64–71. 12. goksedef d, omeroglu sn, balkanay oo, yalvac esd, talas z, albayrak a, et al. hemolysis at different vacuum levels during vacuum-assisted venous drainage: a prospective randomized clinical trial. thorac cardiovasc surg. 2012;60(4):262– 8. 13. widyapuspita o, boom ce. manajemen transfusi perioperatif pada pasien bedah jantung dewasa dengan mesin pintas jantung paru. jai (jurnal anestesiologi indones. 2016;8(3):188-205. 14. keohane em, smith lj, walenga jm. rodak’s hematology: clinical principles and applications. 5th ed. st. louis: elsevier; 2016. 15. bots sh, peters sae, woodward m. sex differences in coronary heart disease and stroke mortality: a global assessment of the effect of ageing between 1980 and 2010. bmj glob health. 2017;2(2):e000298. 16. spence jd, pilote l. importance of sex and gender in atherosclerosis and cardiovascular disease. atherosclerosis. 2015;241(1):208–10. 17. vakamudi s, wu y, jellis c, mick s, gillinov a, mihalijevic t, et al. gender differences in the etiology of mitral valve disease. j am coll cardiol. 2017;69(11 suppl):1972. 18. biro komunikasi dan pelayanan masyarakat kementrian kesehatan republik indonesia. penyakit jantung penyebab kematian tertinggi, kemenkes ingatkan cerdik. 2017 [cited 2019 dec 27]. available from: http://sehatnegeriku.kemkes.go.id/baca/ umum/20170801/2521890/penyakitjantung-penyebab-kematian-tertinggikemenkes-ingatkan-cerdik-2/ 19. aftabuddin m, rajbhandhari n, rahman mz, islam n, khan os. cardiopulmonary bypass induced hematological changes in patients undergoing cardiac surgery. bangladesh heart j. 2015;30(2):53–7. 20. müller mm, geisen c, zacharowski k, tonn t, seifried e. transfusion von erythrozytenkonzentraten: indikationen, trigger und nebenwirkungen. dtsch arztebl int. 2015;112(29–30):507–18. amj vol 7 no 2 2020_200805 final.indd althea medical journal. 2020;7(2) 99 relationship between calcification on mammography and human epidermal growth factor receptor 2 (her-2) expression in breast carcinoma zulfadli,1 hari soekersi,1 raden yohana,2 birgitta m. dewayani3 1department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: zulfadli, department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadilkin general hospital, jalan pasteur 38, bandung, jawa barat, indonesia, email: fadlipasir@yahoo.com. introduction the first rank of malignancy in women is breast carcinoma. new breast carcinoma cases have been recorded about were 2.1 million in 2018. according to the globocan, the mortality rate of breast carcinoma in the world has been predicted as many as 626,000 cases in 2018, and it is a major cause of death in malignant disease.1 mammography is the radiological modality of choice for screening and diagnosis of breast carcinoma, with a sensitivity of 75–85% and a specificity of 90%.2 one mammographic anomaly that is easily detected, and often the earliest signs of malignant breast disease is a very small calcium deposit in breast soft tissue known as micro calcification (mc). although mc is also associated with benign conditions such as secretory disease and fat necrosis, about 40% of breast cancer are often accompanied by mc. the mc size is less than 1 mm and the mc is the only mammographic feature that shows the presence of a tumor and its ppresence is a major risk factor for breast cancer. a previous study has found that mc in malignant lesions tends to be smaller, more numerous, and occur in the milk ducts and other related structures in the breast and follow the anatomy of the duct.3 there are several possible causes of calcification, including the development of scar tissue after biopsy or surgery, fluid accumulation, epithelial proliferation, tissue necrosis, and inflammation. inflammation has been previously linked to amj. 2020;7(2):99–104 abstract background: breast carcinoma shows over-expression of human epidermal growth factor receptor 2 (her-2) in 18 to 20% of the cases. this type of cancer is very progressive and has a poor prognosis. this study aimed to determine the association between the calcification on mammography with her-2 expression in breast carcinoma as a marker of breast carcinoma aggressiveness. methods: this was an analytic observational study with a case-control design. patients with breast carcinoma at the department of radiology and department of anatomical pathology of dr. hasan sadikin general hospital bandung from july–september 2019 were enrolled in this study. samples were consecutively collected. the association of calcification on mammography and her2 expression was analyzed using the chi-square test. result: in total, 40 patients were included, consisting of 20 individuals with her-2 positive and 20 individuals with her-2 negative. the youngest was 40 years old and the oldest was 73 years old. statistical test results showed that there was a significant association between calcifications in mammography and her-2 expression (p-value = 0.0001, or 13.22; 95% ci 2.7–62.6). conclusions: there is a significant association between calcification on mammography and her-2 expression in breast carcinoma, suggesting that positive calcification mammography was 13.22 times higher in patients with her-2 positive compared to patients with negative calcifications. keywords: breast neoplasms, calcification, her-2, mammography https://doi.org/10.15850/amj.v7n2.1963 althea medical journal. 2020;7(2) 100 amj june 2020 poor breast cancer prognosis and disease progression, possibly due to the recruitment of macrophages that promote tumor growth and proteinases which decrease the extracellular matrix. suspicious morphology is calcification of mammography that can be suspected in the direction of malignancy can be classified into breast imaging reporting and data system (birads) 4b or 4c and bi-rads 5 for fine linear branching calcification.4–6 the immunohistochemical (ihc) profile examinations have been used extensively as a basis for selecting hormonal therapy and targeting therapy. examination of ihc can detect cancer cell hormone receptor types, namely estrogen receptor (er) and progesterone receptor (pr), as well as expression of human epidermal growth factor receptor-2 (her-2). her-2 is a protooncogene that belongs to the epidermal growth factor receptor (egfr) group. amplification of her-2 is considered a poor independent prognostic factor in invasive breast carcinoma and has been associated with changes in clinical response to systemic treatment of breast cancer such as with chemotherapy and antiestrogens. her-2 is positive in about 18–20% of breast cancers. positive her-2 can be classified as her-2 type (enriched) if her2 is positive and estrogenic and progesterone receptors are negative. her2-positive luminal b if her-2 is positive and one or both hormones are positive, while negative her-2 can be classified as luminal a if her-2 is negative and one or both of the hormone receptors is positive and low ki-67 and her2-negative luminal b if her-2 is negative and one or both of the hormone receptors is positive and high ki67 and basal-like (triple-negative) if her2 and both hormone receptors are negative. overexpression of her-2 increases the ‘survival’ of breast cancer cells by increasing cell proliferation, inhibiting cell apoptosis (death), and increasing angiogenesis by increasing the production of vascular endothelial growth factor. studies show that there is a correlation between calcifications found on mammography with her-2 overexpression in primary breast carcinoma patients compared with patients who did not overexpression of her-2. amplification of her-2 is considered as an independent poor prognostic factor in invasive breast carcinomas and has been associated with altered clinical responsiveness to systemic breast cancer treatment such as chemotherapy and antiestrogens.7–10 the aim of the study was to determine the relationship between calcification on mammography and her-2 expression in breast carcinoma. methods this study was an observational analytic approach with a case-control study design. subjects over 40 years old with preoperative breast carcinoma through histopathological examination had undergone immunohistochemical her-2 examination. the minimum samples number for each group is 20 samples. then the total sample for the 2 groups is 40 samples divided into 20 subjects with positive her-2 results and 20 subjects with negative her-2 results. all subjects were undergo mammography examination from july to september 2019. this study was approved by the ethical committee of universitas table 1 characteristics of research subjects based on age and ihc results variable n % age (years) 40–60 33 82.5 >60 years 7 17.5 ihc result her-2 type 12 30 her2-positive luminal b 8 20 her2-negative luminal b 15 37.5 basal-like /triplenegative 5 12.5 luminal a total 40 100 note: ihc= immunohistochemistry althea medical journal. 2020;7(2) 101 padjadjaran. the mammograms were obtained with digital mammography (metaltronica helianthus type, italy). standard craniocaudal and lateral views were carried out in all subjects. the mammograms of all subjects were blindly reviewed by an experienced breast radiologist. mammographic findings were categorized as with or without calcifications. the her-2 status was determined by ihc staining of tissue sections with primary antibody anti-pd-l1 rabbit monoclonal (clone 28-8, cat no. ab205921, abcam, inc cambridge, usa)with 1:200 dilution and cd133 polyclonal mouse antibody from elabscience (e-ab-16223) usa with 1:100 dilution. detection was carried through with streptavidin-biotin immunoperoxide complex. positive her-2 if ihc staining +3 (uniform membrane coloring and more than 10% invasive tumor cells). negative her-2 if ihc staining 0 (none membrane coloring and less than 10% invasive tumor cells) or positive 1 (weak membrane coloring and more than 10% invasive tumor cells). the samples analysis was done by a pathologist that was an expert in ihc examination at the department of anatomical pathology dr. hasan sadikin general hospital. the chi-square test was used to evaluate the association between mammographic findings and her-2 expression in breast carcinomas. all statistical tests were twosided while the statistical significance of the observed difference was set at p<0.05. the odds ratio (or) value resulted from the chisquare test was to measure the strength of causal and effect relationships. all data were analyzed using statistical package for the social sciences statistical software (spss) version 24.0 for windows. results most breast cancer patients were aged 40–60 years (82.5%), and most with her-2 negative luminal b ihc results (37.5%). characteristics of research subjects based on age and ihc results in study subjects were presented in table 1). the mammoghrapy result with mc from a patient was shown in figure 1. characteristics of the study subjects based on the findings of calcifications in each molecular subtype were depicted in figure 2. the relationship of calcification on mammography with her-2 overexpression compared with patients who did not overexpress her-2 in breast carcinoma sufferers was shown in table 2. the relationship of calcification on mammography with her-2 overexpression compared with patients who did not in breast carcinoma sufferers. in the positive her-2 figure 1 mammogram (rmlo) showing microcalcifications (arrow) zulfadli et al.: relationship between calcification on mammography and human epidermal growth factor receptor 2 (her-2) expression in breast carcinoma althea medical journal. 2020;7(2) 102 amj june 2020 group, patients with positive calcification mammography were 17 (85.0%) and negative calcifications were 3 (15.0%). in the negative her-2 group, patients with positive calcification mammography were 6 (30.0%) and negative calcifications were 14 (70.0%). chi-square test analysis results obtained a p-value of 0.0001, meaning that there was a statistically significant relationship between calcification in mammography with her2 expression in breast carcinoma. the or was 13.22 (95% ci 2.7-62.6), suggesting that positive calcification mammography was 13.22 times higher in positive of her-2 compared to patients with negative calcifications. discussion our study shows that the most age distribution with carcinoma in the breast was the age group 40–60 years (82%). this is following the literature that the incidence of breast cancer increases with age and 95% of cases of breast cancer occur in women aged 40 years or more. breast cancer rarely occurs at a young age of less than 40 years.11 the most ihc results from this study subjects are her-2 negative luminal b (37%). it was similar to another study that reported the highest incidence is her-2 negative luminal b (31%).12 in a prospective study has found that triple negative as the most subtypes (23%) followed by her-2 negative luminal b (21%).10 interestingly, positive calcifications have been shown in 15% of subjects with negative her-2 similar to other research (10%).10 calcification in subjects with negative her-2 is thought to be related to factors other than her-2 such as hormonal factors. another study has found a relationship between hormonal figure 2 characteristics of study subjects based on the findings of calcification in each molecular subtype table 2 relationship of calcification on mammography with her-2 overexpression compared with did not overexpress her-2 in patients with breast carcinoma. mammography group or ci (95%) p-valueher-2 positive her-2 negative n=20 n=20 positive calcification 17 (85.0%) 6 (30.0%) 13.22 0.0001 negative calcification 3 (15.0%) 14 (70.0%) (2.790–62.670) note: chi -square test*. significance value base on p-value <0.05 althea medical journal. 2020;7(2) 103 receptors which are positive estrogen receptor and calcification on mammography.6 calcification may have another cause such as a history of inflammation and previous tissue necrosis.6 positive calcifications in the her-2 negative luminal b and triple negative molecular subtypes which are her-2 negative groups may give negative calcification imaging on mammography, with her-2 negative luminal b as the most calcifications in the negative her-2 group. another study has shown that luminal a, her-2 negative luminal b and triple negative in the negative her-2 group which provided calcification on mammography with luminal a as the most subtypes.10 negative calcifications in the positive her2 group (15%) may occur in positive her-2 luminal b as also found in another study that showed samples in the positive her-2 group with negative mc on mammography (20%).10 figure 2 shows that the most mc have been found in the her-2 type, similar to another study that the most calcifications in the her2 type subtype have positive calcifications.6,10 table 2 has shown a significant relationship between calcification on mammography and her-2 expression in breast carcinoma. in this study, positive calcifications found (85%) are associated with positive her-2. another study has shown positive calcifications and positive of her-2 expression in more than 60%.4,10 the correlation of calcifications on mammography with her-2 expression with an or of 13.22, suggesting that the risk of positive her-2 on positive calcification on mammography is 13.22 times compared to negative calcification. another study shows a relationship with a higher or of 8.1.10 the weakness of the study is that there are subjects who still have dense fibrogranular tissue, although they are over 40 years old. therefore, the position on mammography needs to be improved. also, some subjects have large and hard masses, making it difficult to cover by mammography tools. in conclusion, there is a significant relationship between calcification on mammography with her-2 overexpression in breast carcinoma with an or of 13.22. calcifications detected during mammography not only have diagnostic value but it can also predict the choice of therapy. references 1. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2018;68(6):394–424. 2. tadwalkar rv, rapelyea ja, torrente j, rechtman lr, teal cb, mcswain ap, et al. breast-specific gamma imaging as an modality for the diagnosis of invasive breast cancer with correlation to tumor size and grade. br j radiol. 2012;85(1014):e212–6. 3. cai h, huang q, rong w, song y, li j, wang j, et al. breast microcalcification diagnosis using deep convolutional neural network from digital mammograms. comput math methods med. 2019;2019:2717454. 4. naseem m, murray j, hilton jf, karamchandani j, muradali d, faragalla h, et al. mammographic microcalcifications and breast cancer tumorigenesis: a radiologic-pathologic analysis. bmc cancer. 2015;15:307. 5. zonderland h, smithuis r. bi-rads for mammography and ultrasound 2013. netherlands: radiology assistant; 2014 [cited 2020 january 20] available from https://radiologyassistant.nl/ breast/bi-rads-for-mammography-andultrasound-2013 6. nyante sj, lee ss, benefield ts, hoots tn, henderson lm. the association between mammographic calcifications and breast cancer prognostic factors in a population-based registry cohort. cancer. 2017:123(2):219–27. 7. wiguna nip, manuaba ibtw. karakteristik pemeriksaan imunohistokimia pada pasien kanker payudara di rsup sanglah periode 2003-2012. e-jurnal medika udayana. 2012;3(7). [cited 2020 january 20] available from: https://ojs.unud.ac.id/ index.php/eum/article/view/9809 8. elias sg, adams a, wisner dj, esserman lj, van’t veer lj, mali wpthm, et al. imaging features of her2 overexpression in breast cancer: a systematic review and metaanalysis. cancer epidemiol biomarkers prev. 2014;23(8):1464–83. 9. wang x, chao l, chen l, tian b, ma g, zang y, et al. correlation of mammographic calcifications with her2/neu overexpression in primary breast carcinomas. j digit imaging. 2008;21(2): 170–6. 10. rashmi s, kamala s, murhty ss, kotha s, rao ys, chaudhary kv. predicting the molecular subtype of breast cancer based on mammography and ultrasound findings. indian j radiol imaging. 2018;28(3):354–61. zulfadli et al.: relationship between calcification on mammography and human epidermal growth factor receptor 2 (her-2) expression in breast carcinoma althea medical journal. 2020;7(2) 104 amj june 2020 11. jardines l, goyal s, fisher p, royce m, weitzel j, royce m, goldfarb sb. breast cancer overview: risk factors, screening, genetic testing, and prevention. cancer network. 2015 [cited 2020 january 20] available from: https://www. cancernetwork.com/view/breast-canceroverview-risk-factors-screening-genetictesting-and-prevention 12. kondov b, milenkovikj z, kondov g, petrushevska g, basheska n, bogdanovskatodorovska m, et al. presentation of the molecular subtypes of breast cancer detected by immunohistochemistry in surgically treated patients. open access maced j med sci. 2018;6(6):961–7. vol 6 no 4 full text final2.indd althea medical journal. 2019;6(4) 186 amj december 2019 the bacterial vaginosis among pregnant women in jatinangor aw wan yi,1 sunarjati sudigdoadi,2 hadi susiarno2 1faculty of medicine universitas padjadjaran, indonesia, 2departement of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of obstetrics and gynaecology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: aw wan yi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, e-mail: aw_wan-yi@hotmail.com introduction vaginitis is often assumed as a part of ordinary reproductive life in women since most of the childbearing age women experience some kind of vaginitis at least once in their life. the three most common etiologies of vaginitis are bacteria (bacterial vaginosis) accounts for 40– 45%, followed by fungi (candida vaginitis) for 20–25%, and parasites (trichomonal vaginitis) for 15–20%.1 hence, bacterial vaginosis (bv) is an extremely prevalent vaginal condition and the number one cause of vaginitis in women of childbearing age.2 phenomenon in bv is best to be described as polymicrobial, superficial vaginitis which involving a reduced amount of hydrogen-peroxide producing lactobacillus, a normal aerobic vaginal microflora that later changes to a mixed anaerobic, gram-negative or gram-variable bacterial flora such as mycoplasma hominis, bacterioides species, mobiluncus species, and gardnerella vaginalis.3,4 most of the women are usually reluctant to seek medical treatment when they come across with an abnormal vaginal discharge as they often misinterpret and assume it as a normal discharge. this ‘culture of silence’ is the one that shrouds the gynecologic morbidity.1 women infected with bv are mostly asymptomatic.2 globally, bv is common among reproductiveage women.5 the prevalence of bv in asian pregnant women is quite high, for example in japanese (13.6%), in thais (15.9%), and indonesian (18%) women.6 furthermore, bv prevalence is also higher than that of other a symptomatic infectious diseases during pregnancy.6 pregnant women with positive bv are at significant risk of some serious implications such as premature rupture of membrane, preterm labor and amj. 2019;6(4):186–91 abstract background: bacterial vaginosis (bv) is polymicrobial that causes superficial vaginitis due to a shift in vaginal flora. in pregnant women, bv can result in a significant risk of some serious consequences. the objective of this study was to identify the bv prevalence and to explore the characteristics and personal hygiene practices among pregnant women. methods: this study was conducted in desa cipacing, jatinangor, using the cross-sectional descriptive method, including pregnant women. the bv was detected by gram-stained vaginal smears using nugent score. furthermore, other microorganisms such as trichomoniasis and candidiasis were detected by direct microscopic observation. the questionnaire was distributed, consisting of details of personal hygiene practices. results: in total, 17.9% of 52 pregnant women included were diagnosed with bv and 14.3% with mixed infection. pregnant women with bv were predominantly aged younger than 25 years (61.1%), nullipara (50%) and in a second-trimester pregnancy (50%). conclusions: bacterial vaginosis (bv) is common among young pregnant women, predominantly in their first pregnancy. it is related to personal hygiene practices, indicating the need for targeted interventions of healthcare education among these young pregnant women to reduce the bv prevalence. keywords: bacterial vaginosis, personal hygiene, pregnancy, vaginal discharge althea medical journal. 2019;6(4) 187 delivery, low birth weight infant, intraamniotic infection, chorioamnionitis, and post-cesarean endometritis.7 previous study in jatinangor has reported that out of a total of 2000 pregnant women attended to public health center (pusat kesehatan masyarakat, puskesmas) jatinangor in the year 2013, about 25% were categorized under the high-risk pregnancy group,8 which is an alarming sign. therefore, more attention should be given to pregnant women who are infected with bv. an increase of attention is drawn because so far no data is available about the study of risk factors for bv in indonesia.9 a recent study has proved that the asymptomatic bv prevalence is highest during the secondtrimester pregnancy,10 and that a higher frequency of genital infections is associated with inappropriate genital hygiene habits.11 the primary objective of this study was to assess the bv prevalence among pregnant women in jatinangor. also, the study aimed to explore the characteristics and personal hygiene practices as potentially modifiable risks for bv. methods this study was part of a cohort study, including pregnant women, infants and children under five-year-old in kecamatan jatinangor, kabupaten sumedang, jawa barat, conducted in the collaboration of multiple sectors. this cross-sectional descriptive study was carried out in march 2014. the samples of vaginal secretion collected from healthy pregnant women living in desa cipacing, kecamatan jatinangor, kabupaten sumedang, jawa barat. this study was conducted with approval by the health research ethics committee, faculty of medicine, universitas padjadjaran. the estimated minimal sample size was 53, however, a total of 56 pregnant women aged older than 15 years old were included. after obtaining verbal and written informed consent, the interview session was initiated using questionnaire forms consisted of details of personal hygiene practices. following speculum examination, the vaginal discharge was collected using a cotton-tipped swab, suspended in 1.5 milliliters of nacl in a plastic transport tube. specimen collection was performed by a qualified midwife in charge. each of the samples collected was stored temporarily in a transport container with ice figure 1 (a)gram-stained vaginal smear of normal vaginal flora (b)gram-stained vaginal smear from the woman with positive bacterial vaginosis table 1 prevalence of microorganism among pregnant women in jatinangor infection cases n (%) bacterial vaginosis only 10 (17.85%) mixed infection 8 (14.29%) negative bv 38 (67.86%) total 56 (100%) note: bv: bacterial vaginosis, mixed infection: infection of both bacterial vaginosis and vulvovaginal candidiasis (a) (b) aw wan yi et al.: the bacterial vaginosis among pregnant women in jatinangor althea medical journal. 2019;6(4) 188 amj december 2019 packs before being sent to the microbiology laboratory for the detection of pathogens at the faculty of medicine, universitas padjadjaran. gram-stained smears were observed microscopically and accessed using the nugent score for bv. the result was reported as positive bv when the smear had a nugent score of 7 to 10, after quantifying 3 bacterial morphotypes (lactobacilli, gardnerella vaginalis and mobiluncus species); while negative bv was reported when the smear showed a nugent score of 0 to 3. under direct microscopic observation, other microorganisms such as trichomoniasis and candidiasis could be detected. results in total, 56 pregnant women aged between 17 and 44 (mean age 28 years old) were included, and 17.9% (n=10) was infected with bv only; whereas 14.29% (n=8) had mixed infection with both bv and vulvovaginal candidiasis (vvc) as shown in table 1. the microorganism under the microscope had been shown in figure 1. table 2 characteristics of pregnant women infected with bacterial vaginosis (n=18) characteristics frequency n age (years) <25 11 25–34 5 >34 2 educational level 2 elementary school 4 junior high school 11 senior high school 1 university graduate parity nulliparity 9 primiparity 6 multiparity 3 gestational age (weeks) 0–14 3 15–28 9 29–42 6 the characteristic among pregnant women with positive bv was presented (table 2). the age range of women with positive bv was 15 to 37 years old; 61.1% completed upper secondary school. half of the pregnant women with positive bv were nullipara and commonly occurred in second-trimester pregnancy or gestational age of 15-28 weeks. furthermore, personal hygiene practices of pregnant women with bv infection were presented in table 3. discussion the prevalence of bacterial vaginosis in this study is comparable to the who report.6 another study in india has a similar result among young women in reproductive age.12 however, a higher bv prevalence (30.7%) has been reported among indonesian pregnant women elsewhere.9 even more, in nepalese pregnant women, bv infection was detected table 3 personal hygiene practices of pregnant women infected with bacterial vaginosis personal hygiene practice frequency n usual underwear material 11 cotton 6 hosiery 1 others agent used for genital area cleaning 10 water 1 body wash 7 feminine hygiene products ways of genital area cleaning 14 front to back 2 back to front 2 random hand washing before and after genital area cleaning always 11 never 1 sometimes 6 althea medical journal. 2019;6(4) 189 in 52.6%.13 hence, the much lower rate of bv prevalence in our study may be due to the difference in methodology; which is nugent’s criteria vs. amsel’ s criteria in nepal.10,13 nugent scoring system is considered as the gold standard for bv diagnosis, but unfortunately, due to its time-consuming methodology and the costly needs of lab equipment and experts for its interpretation, most of the clinicians are unable to utilize the method effectively.10 based on the result of our study, the highest frequency of bv infection is among women aged <25 years. this corresponds to a recent study in nigeria10 and india.13 however, an older age group with bv infection was also reported to be around 26 to 40 years old,9 suggesting that the bv infection is a common finding within the childbearing age. thus, the sexually active age group has a risk factor of bv infection and promiscuity even more.2,5 interestingly, the estimated prevalence of symptomatic and asymptomatic bv infection is around 30% in the general population of women aged 14 to 49 years,14 indicating that sexual activity and the number of lifetime sexual partners could be factors contributing to bv prevalence. pregnant women with nulliparity are more prone to bv infection compared to primipara and multipara, however, a previous study has shown that bv prevalence was high in women with a history of parity ≤2.15 in contrast, another study has reported women with parity >5 with the highest bv prevalence.9 the parity might not have a significant correlation to bv.9 the present study has shown that bv among pregnant women mostly occurs in second-trimester pregnancy or gestational age of 15–28 weeks, following with the study in nigeria.10 since bv was prevalent among these pregnant women, the exploration for a better look upon the link between personal hygiene practices and bv is warranted. hence, this illustrates the necessity of targeted interventions at associated hygienic behavior to reduce bv prevalence. previous studies hold some questions about the potential risks of wearing nylon and synthetic types underwear to the development of reproductive tract infections since the poor perspiration absorption and maintenance of perineal humidity disadvantages may enable the disturbance of normal vaginal flora.11,16 however, the present study has found no difference to this aspect though cotton underwear is strongly encouraged by gynecologists due to its excellent ventilation with a contribution to the maintenance of the vulvar microbiota.17 pregnant women with bv infection were highly used to wear cotton panties daily. following the cotton material as the most preferred type of underwear among subjects in this study, hosiery type underwear also showed high popularity among pregnant women with bv infection, as shown in another study that there is an increased frequency of genital infection with the use of cotton and hosiery type of underwear.11 in pregnant women with bv infection, water has been used to clean the genital area followed by the use of feminine hygiene products. this result is on contrary to the previous report showing a lower frequency of genital infections among those who have used water for cleaning the genital area.11 interestingly, some feminine hygiene products currently available in the market do not provide protection against vaginitis and even have harmful effects on the vaginal immune barrier and thus may increase the susceptibility to infections.18 most of the pregnant women have practiced front to back cleaning in the perineal area, only a few have a wrong genital area hygiene cleaning practices, i.e. back to front or random which may cause the transfer of microorganisms from the anus to the vagina,11 indicating that most of the women in the community have performed perineal cleaning correctly. the normal intestinal flora escherichia coli (e coli) is the predominant uropathogenic organism in women suffering from urinary tract infections (utis), thus cleaning genitals from front to back is associated with a reduced frequency of uti instead of bv infection.19,20 as for hand washing, most of the pregnant women stated to have their hands washed each time before and after cleaning their genital area. this is in contrast with the previous study showing that genital infections are the least found among those with the habit of often washing hands before and after using the toilet.11 this study still held some limitations. information bias may occur during the interview session because requesting personal hygiene practices is a sensitive issue. further research concerning the factors which influence the host susceptibility to bv should be performed to provide beneficial information and recommendations in the reproductive health care of pregnant women. these factors including multiple sexual partners, coital frequency, toilet behavior, use of douche, uncircumcised partner, previous medical history of genital tract infection and so on. healthcare providers who are in charge of reproductive-aged patients aw wan yi et al.: the bacterial vaginosis among pregnant women in jatinangor althea medical journal. 2019;6(4) 190 amj december 2019 should be concerned about this issue and give appropriate advice regarding feminine hygiene care. more comprehensive and precise studies are needed to reveal any relationships between personal hygiene practices and associated genital infections. to conclude, the bacterial vaginosis prevalence among pregnant women in desa cipacing, kecamatan jatinangor is 17.9%. proper education and training programs by a healthcare professional on genital hygiene practices which area a crucial aspect of women’s health are useful. acknowledgments we express our sincere gratitude especially to dr. rtd judistiani, the principal investigator for the cohort study of pregnant women, infants and children under five years old in kecamatan jatinangor who has allowed us to participate in conducting the present study as part of the cohort study. we are thankful to all the staff and students of the midwifery diploma program, a staff of department epidemiology and biostatistics, a staff of department microbiology who contributed to this study and all the pregnant women for their participation and cooperation during the study. references 1. singh a, walia i, dhaliwal l, editors. demedicalizing women’s health. new delhi: gyan publishing house; 2010 2. centers for disease control and prevention. bacterial vaginosis:cdc fact sheet. 2010[cited 2014 february 8]; available from: http://www.cdc.gov/std/ bv/stdfact-bacterial-vaginosis.htm. 3. cunningham fg, leveno kj, bloom sl, hauth jc, rouse d, spong cy. williams obstetrics. 23rd ed. new york city: mcgrawhill; 2010. p. 813–4. 4. donati l, di vico a, nucci m, quagliozzi l, spagnuolo t, labianca a, et al. vaginal microbial flora and outcome of pregnancy. arch gynecol obstet. 2010;281(4):589– 600. 5. kenyon c, colebunders r, crucitti t. the global epidemiology of bacterial vaginosis: a systematic review. am j obstet gynecol. 2013;209(6):505–23. 6. thinkhamrop j. antibiotics for treating bacteria vaginosis in pregnancy: rhl commentary (last revised: 4 july 2007). the who reproductive health library. geneva: world health organization [cited 2014 february 8]; available from: https:// extranet.who.int/rhl/es/node/75891. 7. soper de. genitourinary infections and sexually transmitted diseases. in: berek js, editor. berek & novak’s gynecology. 14th ed. philadephia: lippincott williams & wilkins; 2007. p. 542–7. 8. pusat kesehatan masyarakat (puskesmas) jatinangor. hasil cakupan kesehatan kecamatan jatinangor 2013. sumedang: pusat kesehatan masyarakat (puskesmas) jatinangor; 2013 9. ocviyanti d, rosana y, olivia s, darmawan f. risk factors for bacterial vaginosis among indonesian women. med j indones. 2010;19(2):130–5. 10. ibrahim sm, bukar m, galadima g, audu bm, ibrahim ha. prevalence of bacterial vaginosis in pregnant women in maiduguri, northeastern nigeria. niger j clin pract. 2014;17(2):154–8. 11. sevil s, kevser o, aleattin u, dilek a, tijen n. an evaluation of the relationship between genital hygiene practices and genital infection. gynecol obstet. 2013;3(6):1–5. 12. madhivanan p, krupp k, chandrasekaran v, karat c, arun a, cohen c, et al. prevalence and correlates of bacterial vaginosis among young women of reproductive age in mysore, india. indian j med microbiol. 2008;26(2):132–7. 13. shrestha s, tuladhar n, basnyat s, acharya g, shrestha p, kumar p. prevalence of vaginitis among pregnant women attending paropakar maternity and women’s hospital, thapathali, kathmandu, nepal. nepal med coll j. 2011;13(4):293–6. 14. koumans eh, sternberg m, bruce c, mcquillan g, kendrick j, sutton m, et al. the prevalence of bacterial vaginosis in the united states 2001-2004 associations with symptoms, sexual behaviors, and reproductive health. sex transm dis. 2007;34(11):864–9. 15. ajani g, oduyebo o, haruna m, elikwu c. nugent scores of pregnant women in a tertiary institution in nigeria. adv microb. 2012;2(4):531–6. 16. klebanoff ma, nansel tr, brotman rm, zhang j, yu kf, schwebke jr, et al. personal hygienic behaviors and bacterial vaginosis. sex transm dis. 2010;37(2):94–9. 17. runeman b, rybo g, forsgren-brusk u, larko o, larsson p, faergemann j. the vulvar skin microenvironment: impact of tight-fitting underwear on microclimate, althea medical journal. 2019;6(4) 191 ph and microflora. acta derm venereol. 2005;85(2):118–22. 18. fashemi b, delaney ml, onderdonk ab, fichorova rn. effects of feminine hygiene products on the vaginal mucosal biome. microb ecol health dis. 2013;24:1–6. 19. brooks g, carroll kc, butel j, morse s. enteric gram-negative rods (enterobacteriaceae). in: brooks g, butel j, carroll kc, morse s, mietzner t, editors. jawetz melnick & adelbergs medical microbiology 25th ed. new york city: mcgraw-hill medical; 2010. p. 217–8. 20. moustafa mf, makhlouf em. association between the hygiene practices for genital organs and sexual activity on urinary tract infection in pregnant women at women’s health center, at assiut university hospital. j am sci. 2012;8(9):512–22. aw wan yi et al.: the bacterial vaginosis among pregnant women in jatinangor amj vol 7 no 3 september edited.indd althea medical journal. 2020;7(3) 159 perspective of cikahuripan villagers on traditional health service provisions in government regulation no. 103 year 2014 hashfi khairuddin,1 rizal chaidir,2 deni kurniadi sunjaya3 1faculty of medicine universitas padjadjaran, indonesia, 2department of orthopedics and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: hashfi khairuddin, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, email: hasshfi@gmail.com. introduction traditional health services have long been rooted in individuals in the household, especially starting in the 2nd century to the 19th century. in the batupuaro sub-district, baubau city, traditional health services have been started since 1986. in the dayak tribe, traditional medicine itself stands in line with the dayak tribe’s existence. whereas the muna tribe, wakontu village, wadaga subdistrict, west muna regency, said that traditional medicine had existed before medical practices.1–4 the indonesian government has issued a government regulation number 103 in 2014 concerning the traditional health services, which regulates the implementation of traditional health services, including responsibilities, central and local government authorities, types of traditional health services, traditional health service procedures, resources, research and development, publication and advertising, community empowerment, funding, guidance, and supervision as well as an administrative penalty.5 the obligation to obtain permission and intervention regulation can potentially disrupt the course of traditional health services that have been trusted by the community long before the application of the regulation. this is supported by a previous study showing that the indonesian traditional herbal medicine association (aspetri) is not ready in the implementation of government regulation number 103/2014.6 interestingly, there are no amj. 2020;7(3):159–4 abstract background: traditional health service is one of the health services that is still currently used in indonesia, especially in rural communities. the government has been regulating these services since 2014. despite its long existence, there is a recent increase of potential regulation violation among traditional health service providers. this study aimed to explore the perspective of the cikahuripan villagers on government regulation on traditional health services. methods: this was a qualitative study using in-depth interviews and direct observations on traditional health services in cikahuripan village. sixteen informants consisting of 8 villagers who met the inclusion criteria and another 8 informants in the triangulation negative case analysis, member checking, peer debriefing, and observation was involved. result: there were two different perspectives in the community on traditional health service provisions in the government regulation. supporters of the regulation believed that the regulation would make traditional health services more responsive and safer, which would improve service quality and health benefits as well as imposing effective sanctions. in contrast, the opposition believed that regulations were too late, would make the costs for licensing expensive, and too complicated. conclusions: there are two different public perspectives on the regulation of traditional health services, which are supporting and opposing the regulation. it is expected that the local government create a derivative of the regulation by making adjustment to the community’s situation. keywords: laws, perceptions, regulations, traditional health services https://doi.org/10.15850/amj.v7n3.1912 althea medical journal. 2020;7(3) 160 amj september 2020 data on the total number of traditional health services in west bandung or west java, who have permission and opinion on this matter. the community’s demands for traditional medicine is about 20% of indonesia’s total population. thus, the implementation of regulation could bring up different opinions in society. on one side, the government has created rules for safety and comfort in utilizing traditional health services. on the other hand, this regulation is enough to restrict the community’s traditional health services, therefore, the differences in perception can occur in the community.7 previous studies have not yet analyzed the perception of the community as a user when government regulation number 103/2014 is started. the purpose of this study was to explore the community’s perspectives in cikahuripan village, lembang, west bandung, regarding government regulation number 103/2014, regulations that govern traditional health services. methods this research was conducted in cikahuripan village from august to october 2019 using a qualitative research design with grounded theory to explore the processes, activities, and events experienced by respondents. the sampling method used in this study was a theoretical sampling, that was not referring to the number of samples, but the amount of data obtained from the respondents until the data saturation had been reached and therefore aimed to create a theory.8 the inclusion criteria in this study were residents of west bandung regency who lived in cikahuripan village, had used traditional health services, and agreed to become research subjects. the exclusion criteria in this study were people who had limited senses such as blind, impaired hearing, impaired speech, and the mentally disabled. in determining the respondents, a purposive sampling technique was conducted by visiting and conducting in-depth interviews with one of the traditional health services in cikahuripan village and asking respondents who had used traditional health services in the village. next, the snowball sampling technique was performed to get other respondents until the saturation of the data was reached. saturation was achieved when eight respondents who entered as inclusion criteria were interviewed thoroughly. furthermore, a negative case analysis was conducted to increase trustworthiness in this study, by interviewing the cikahuripan villagers who had never used traditional health services as triangulation respondents. eight triangulation respondents were interviewed thoroughly in this study until achieving saturation. the method in this study was in-depth interviews using open-ended questions, therefore, the informant could tell the widest possible extent about his/her experiences and perspectives. first, they were interviewed by asking their health-seeking behavior to determine whether they had used traditional health services. respondents were given a short explanation about the regulations governing traditional health services pp no. 103/2014, and their perspectives regarding these regulations were explored. the researcher also checked the informants who were interviewed. source triangulation with negative case analysis, observation, and member checking was done to increase trust worthiness. the researcher also had made observations to strengthen the theory that would be formed. the observation was carried out by going directly to one of the traditional health services available in cikahuripan village, then asking and seeing firsthand how the traditional health care methods were carried out. in brief, the results of each interview were transcribed into text form. then, data reduction and analysis were conducted to select and focus on the gross data that appeared in the field. furthermore, we conducted data encoding, i.e., breaking the data and rearranging the data in the form of words or phrases as representatives of the data fractions. categorization, the results of data coding, were grouped into homogeneous categories for the process of interpretation, then the preparation of themes, namely by grouping categories in a collection of categories that were considered homogeneous. furthermore, content analysis, the process of data interpretation, in the form of material categorization based on related topics were conducted. thick description, interpretation of the data in the form of strong and deep descriptions and narratives expressed were performed and then analyzing the content analysis, analyzing the results from the perspective of the community.9 several perspectives from the first responder (r1) to the sixteenth (r16) were quoted and referred with codes assigned to them from r1 to r16. r1–r8 was respondents who had used traditional health services, while althea medical journal. 2020;7(3) 161hashfi khairuddin et al.: perspective of cikahuripan villagers on traditional health service provisions in government regulation no. 103 year 2014 r9–r16 was respondents who had never used traditional health services, and designated as a triangulation. this research had been approved by the research ethics committee universitas padjadjaran, with the registration number of 902/un6.kep/ec/2019 results the respondents included consisted of men and women, aged 17–65 years, education level were varied between elementary school graduates to diploma. the jobs of the respondents were farmers, ranchers and milking workers, students, hotel employees, traders, market workers, construction workers, parking attendants, housewives, teachers, and traditional health workers. public opinions of violations in traditional health services according to government regulation number 103/2014 was polarized into two sides. there was a support for the regulation, but there was also an opposition to the regulation as shown in table 1. cikahuripan villagers assumed that regulations governing traditional health services were a form of accountability for traditional health services in providing health services. like r7 said, “the regulations intend to make the traditional health services more accountable so that they are more careful, and there is a potential threat of being punished by the law.” all forms of actions taken by traditional health services could be justified legally. regulation in traditional health services was considered to increase security in traditional health services in conducting services. this showed the community’s sense of insecurity in utilizing traditional health services at this time, so that this regulation was expected to increase the security of traditional health services. r5 also said, “people like us now look for traditional health services. we do not look for the best, but we are looking for the official ones, so they should not be careless at least. our leg is important to support life and daily activities.” from some opinions, it was seen that the community was very concerned about the safety of traditional health services and that security for consumers was also guaranteed. the community also had the opinion that if the government prohibited traditional health services, the community would be more careful. regulations were considered to increase the security of traditional health services, thereby increasing public confidence in using traditional health services. the public believed that with regulations, traditional health services would improve the quality of their services. as said by r5, “compared to the traditional health services that are not licensed, the provided treatment is better in the licensed ones.” r5 was one of the respondents who had used traditional health services that had followed government regulations and felt that the health services provided were indeed better. with the regulation, traditional health services were considered to provide more health benefits than before. r5 believed that, “traditional health services is becoming official. cooperation is also maintained with the local health department and public health center (pusat kesehatan mayarakat, puskesmas). even if we use traditional medicine, we also need drugs, antibiotics, anti-pruritic, as well as the prohibition of some foods. compared to those who are not licensed, the healing process is faster in those who are licensed.” with the regulation, it was also considered by the public that there were sanctions for every violator of the regulation. as said by r1, “now, there are sanctions for traditional birth attendants (traditional health services), so they are no longer allowed.” this was considered reasonable by the community as protection for users of traditional health services. however, the community also considered that there was a table content analysis of public perceptions of traditional health services regulation pro cons accountability late enactment security increased cost quality increase increased complexity health benefit increase ignorance sanctions on violator demand mismatch althea medical journal. 2020;7(3) 162 amj september 2020 delay in the enactment of this regulation. r2 said, “it can be said that the rules are late. why was it not enacted earlier? these services have been around for a long time, and there are already many patients using it.” the community considered that the traditional health services that already existed could not be blamed because they had been around for a long time and were rooted culturally in the community. the regulation was also perceived to cause traditional health services more expensive, contradicting the principles of traditional health services, which was low cost. r9 said, “if there were an obligation to use a permit, i am afraid it would be expensive. it is just not fair for the poor.” this regulation was considered by the community to only make the traditional health service system complicated. as said by r4, “if we comply with the regulations, we must use permits. it is rather complicated. i do not agree.” whereas the formation of traditional health services was based on the needs of the community and the capabilities of traditional health service providers, which would be discussed next. community needs and the ability of traditional health service providers formed the basis for the formation of traditional health services, as said by r16, “when it comes to regulations, here we (traditional health services) only help, we do not even advertise. if anyone needs help, how can we reject it?” the regulation was considered not friendly to traditional health services, which were formed due to community needs. due to regulations that were considered unfriendly by the people of cikahuripan village, many people were ignoring these regulations. as said by r3, “even though traditional health services violate regulations, people still want to go there because they already believe they have experienced it themselves.” in addition, researchers also made observations of the only traditional health service in cikahuripan village, resulting in that this traditional health service had no permission from the government. the service did not put up advertisements or signposts and only served if there was a need from the community. the type of treatment was rehabilitative, including massage and giving water accompanied by prayer for patients with broken bones. the services provided were in accordance with the regulations, although they had no permit according to the regulations discussion there are two perceptions of cikahuripan villagers on regulations governing traditional health services. there is support for the regulation and there is opposition against the regulation, each with different reasons. the existence and application of traditional health services are a necessity of the community. as in the dayak community, traditional medicine is currently still used in irrational diseases that never heal. in the community, traditional health services are considered effective in curing various diseases and eventually become a necessity for the community. the dayaks believe that before or after seeing a doctor or health worker, they must seek alternative medicine or traditional health services.3 in gayolues regency, aceh province, traditional health services are believed to be able to increase the health and strength of the body. the benefits match up the expectations of the gayo people. it also illustrates that traditional health services have become the needs of the community.10 the people of lede village, tilabu regency, and north maluku province also feel better after the treatment of traditional health services. the service and recovery rate of traditional health services is felt far better. this makes lede villagers trust and visits traditional health services more often compared to conventional health services. this illustrates that traditional health services are a necessity for the people of lede village.11 furthermore, the people of tellusiattinge, bone regency, south sulawesi, strongly believes in traditional health services to treat various diseases for generations. it is this belief that makes the community seeks traditional health services so that traditional health services become the community’s needs.13 as in west java, research conducted in rural communities shows that public confidence in traditional medicine is still high. traditional medicine does not do a lot of information literacy in carrying out its practice. however, long-standing community trust makes traditional health services an inseparable community needs.12 in our research, it has been proven that traditional health services have become the community’s needs. that is the reason why people do not agree with the existing traditional health service regulations, due to the practice limitation of althea medical journal. 2020;7(3) 163hashfi khairuddin et al.: perspective of cikahuripan villagers on traditional health service provisions in government regulation no. 103 year 2014 traditional health services. this is supported by several studies that prove that traditional health services have become an integral part of the community and are a necessity for the community in seeking treatment. if this regulation has been implemented in all regions of indonesia, it can be predicted that there will be many rejections from various groups of people regarding this regulation. the interview results of researchers on traditional health services in the village of cikahuripan have shown the unpreparedness of traditional health workers to implement this regulation. the traditional practitioner considers that its existence is only to meet the needs of the people who often ask them for help. this is also supported by the indonesian traditional herbal medicine association (aspetri), as it is not ready to implement this regulation.6 from the economical perspective of the community, traditional health services are preferred because they are cheaper than conventional health services. these are found in studies conducted in various places such as in lede village, pulautalibu regency, north maluku, also in tellusiattinge, bone regency, south sulawesi. the people tend to choose traditional health services because it is more affordable, or they never ask for wages or fees in providing their services.11,13 in our study people show rejection of the existence of regulation due to economic reasons. traditional health services that are known to be cheap and never charge fees are afraid to lose their economic value or become more expensive and even set costs if they follow this regulation. in terms of the responsibility of traditional health services, research conducted in west java shows that most traditional health services usually claim their healing success from god’s gift. this makes the customer and the government cannot do anything if there are cases that are detrimental.12 this is in line with the expectations of cikahuripan villagers with the enactment of this regulation. this regulation is expected by the community to be one of the solutions so that traditional health services can be more responsible for what they have done and get appropriate sanctions if violations occur in practice. however, research conducted on rural communities in the west java states that the dissemination of information from west java provincial government for traditional medicine has been quite successful. this is different from the perspective of the community and health services in the village of cikahuripan. they do not know anything about the rules or appeals in the use of traditional health services. the researchers must briefly explain the related laws in advance so that the community can give their perceptions regarding the regulation. insufficient dissemination of comprehensive information was found in this study.12 a study in west java concerning regulations governing traditional health services showed that the community welcomed this regulation in contrast with the previous study; our study has found that the people of cikahuripan village have two different perceptions; support and reject the regulation.12 in the national health system, the government is responsible as a supervisor or steward of the public services. to carry out the stewardship function of government in traditional health services, they enact laws to regulate traditional health services. as an instrument, the permit takes the role as a guide, or to drive citizens’ behavior. licensing is also intended to provide guidance, regulation, control, and supervision of traditional health services. permission is issued by the authorities as an instrument to influence relations with citizens in order to be willing to follow the ways they advocate in order to achieve concrete goals.14,15 to provide that function, the government enacts the government regulation number 103/2014 on traditional health services, which is expected to increase the quality of traditional health services along with decreasing side effects that are medically irresponsible.16 this is in accordance with part of the community that supports the regulation of traditional health services, in which the regulation is believed to improve the quality of services, health benefits, and security of traditional health services. this regulation is also believed to help the accountability of traditional health services. with the regulation, if a violation is committed by a traditional health person or a traditional health worker, then the patient can report it to the health service, then public health office will conduct a sudden inspection to the alternative medicine and directly ask the therapist. however, it does not directly guarantee if alternative medicine will fulfill its responsibilities as a business actor that harms consumers. patients can report the violation directly to the police if they feel they are victims of malpractice or neglect of alternative healers.17 this is in accordance with the perception of the community that considers that regulations governing traditional health althea medical journal. 2020;7(3) 164 amj september 2020 services will impose sanctions on traditional health services that violate them. this study was limited to the village of cikahuripan, lembang subdistrict, west bandung regency. however, the data was derived from facts in the field. to conclude, there are two different perspectives in the community of villagers of cikahuripan village regarding the regulation 13/2014; some who support and others are opposed the traditional health services. supporters of the regulation believe that the regulation would make traditional health services more responsive, safer, improving service quality, increase health benefits, and impose effective sanctions, whereas opposition of the regulation believes that regulations would make the costs for licensing expensive, and too complicated. some even do not care about the regulations because they believed that traditional health services have always become a part of the community and therefore, cannot be regulated. references 1. triratnawati a. pengobatan tradisional, upaya meminimalkan biaya kesehatan masyarakat desa di jawa. jurnal manajemen pelayanan kesehatan. 2010;13(2):69–73. 2. wahid wol, basri loa. sejarah pengobatan tradisional orang buton di kecamatan batupoaro kota baubau: 1986 2016. journal idea of history. 2018;1(1):49–62. 3. asmawati, hartati z, emawati. makna pengobatan tradisional badewah suku dayak bagi masyarakat muslim di kalimantan tengah. jurnal studi agamaagama. 2018;8(1):82–115. 4. harwati j, niampe l, wardani ak. tradisi pengobatan pamole pada suku muna desa wakontu kec. wadaga kabupaten muna barat. jurnal kelisanan sastra dan budaya. 2018;1(2):93–9. 5. presiden republik indonesia. peraturan pemerintah republik indonesia nomor 103 tahun 2014 tentang pelayanan kesehatan tradisional. jakarta: pemerintah republik indonesia; 2014. 6. murpratiwi r, jati sp, suparwati a. analisis kesiapan asosiasi pengobat tradisional terhadap rencana implementasi peraturan pemerintah nomor 103 tahun 2014 tentang pelayanan kesehatan tradisional di kota semarang. jurnal kesehatan masyarakat. 2016;4(1):65–75. 7. badan pusat statistik indonesia. persentase penduduk yang mempunyai keluhan kesehatan dan penggunaan obat menurut provinsi dan jenis kelamin [internet]. jakarta: badan pusat statistik indonesia; 2016. [cited 2020 january 4] available from: https://www.bps. go.id/statictable/2012/05/02/1619/ persentase-penduduk-yang-mempunyaikeluhan-kesehatan-dan-penggunaano b a t m e n u r u t p r o v i n s i d a n j e n i s kelamin-2009-2014.html 8. qureshi ha. theoretical sampling in qualitative research: a multi-layered nested sampling scheme. international journal of contemporary research and review. 2018;9(8):20218–22. 9. cresswell jw, cresswell jd. research design: qualitative, quantitative, and mixed methods approaches. 5th ed. california: sage publication; 2017. p. 232-62. 10. fitrianti y, angkasawati tj. pengobatan tradisional gayo untuk ibu nifas. buletin penelitian sistem kesehatan. 2015;18(2):111–9. 11. rismawati, sifatu wo. pengobatan tradisional pada masyarakat di desa lede kabupaten pulau taliabu provinsi malluku utara. etnoreflika. 2017;6(3):249–56. 12. rahman mt, sulthonie aa, solihin. “sosiologi informasi pengobatan tradisional religius” kajian di masyarakat perdesaan jawa barat. jurnal studi agama dan masyarakat. 2018;14(2):100–11. 13. adiwijaya ae. eksistensi pengobatan tradisional di tellusiattinge. jurnal kajian sosial dan budaya. 2019;3(2):10–8. 14. jefri r. teori stewardship dan good governance. economics bosowa journal. 2018;4(3):14–28. 15. fathoni n, tisnanta s. konstruksi makna izin sebagai instrumen pengendalian versus kebijakan kemudahan investasi di provinsi lampung. jurnal hukum peratun. 2018;1(1):79–100. 16. kartika d. pelayanan kesehatan tradisional dan perlindungan hukum bagi pasien. soepra jurnal hukum kesehatan. 2016;2(1):1–16. 17. kamal u. konstruksi perlindungan konsumen jasa pengobatan alternatif (studi kasus di kota semarang). journal of private and commercial law. 2017;1(1):69–84. althea medical journal. 2014;1(2) 54 amj december, 2014 effects of analgesic advertisements on community in hegarmanah village, jatinangor nurhayati binti shaharuddin1, eva m. hidayat2, jupiter sibarani3 1faculty of medicine, universitas padjadjaran,2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of urology, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital, bandung abstract background: currently, there are numerous analgesic advertisements which have been published in various media and have also attracted attention of the society. the aim of this study is to find out effects of analgesic advertisements on awareness and attention towards these advertisements on the community in hegarmanah village, jatinangor. methods: the study used the descriptive method with participants consisting of community members in hegarmanah village who have seen, watched or heard about the analgesic advertisements and who were aged 18 years and above. the sample for this study consisted of 100 respondents. this study was conducted in september 2012–december 2012. results: the results showed that 82% of the respondents have seen the ads in at least the last 3 months and mostly watched them on television. about 52% of respondents agreed that many of the ads did not provide sufficient information. in addition, 50% only read a little bit of the ads rather than the whole advertisement. fifty three percents of the respondents had the intention to try the medication after seeing the ads. more than 80% were aware about how to use the medication, medication’s side effects, warnings and contraindications and 65% agreed that, they could make a better decision on their health condition after seeing the ads. conclusions: the analgesic advertisements indeed affected the community by making them aware about the ads and attracted them to buy as well as try the product itself. further studies on factors which influence intake of over-the-counter analgesic drugs and also about the self-medication are required. [amj.2014;1(2):54–9] keywords: analgesic advertisements, effects, society pengaruh iklan analgesik terhadap masyarakat di desa hegarmanah, jatinangor abstrak latar belakang: saat ini, banyak iklan analgesik yang ditayangkan di beberapa media dan telah menarik perhatian masyarakat. penelitian ini bertujuan untuk mengetahui pengaruh iklan analgesik terhadap kesadaran dan pemahaman mengenai obat analgesik pada masyarakat di desa hegarmanah, jatinangor. metode: penelitian ini menggunakan metode deskriptif dengan melibatkan partisipan yang terdiri dari anggota masyarakat di desa hegarmanah yang telah melihat, menyaksikan atau mendengar tentang iklan analgesik dan berusia 18 tahun ke atas. sampel penelitian ini terdiri dari 100 responden. penelitian ini dilakukan pada bulan september 2012-desember 2012. hasil: hasil penelitian menunjukkan bahwa 82% dari responden telah melihat iklan di setidaknya 3 bulan terakhir dan sebagian besar menonton di televisi. sekitar 52% dari responden setuju bahwa banyak dari iklan tidak memberikan informasi yang cukup. selain itu, 50% hanya membaca sedikit iklan daripada seluruh iklan. lima puluh tiga persen dari responden memiliki niat untuk mencoba obat setelah melihat iklan. lebih dari 80% yang sadar tentang penggunakan, efek samping, peringatan dan kontraindikasi obat dan 65% setuju bahwa, mereka bisa membuat keputusan yang lebih baik tentang kondisi kesehatan mereka setelah melihat iklan. simpulan: iklan analgesik memang memengaruhi masyarakat dengan membuat mereka paham tentang correspondence: nurhayati binti shaharuddin, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 817 020 5754, email: sweety_atie@yahoo.com althea medical journal. 2014;1(2) 55 introduction analgesic is a medication to eliminate pain.1 currently, a lot of people consume over-thecounter 2 (otc) drugs because it will reduce the number of visits to primary care offices and save money as it is cheaper than consulting the doctor.2 thus, a lot of consumers simply take this medication without reading or being aware of how the medication should be consumed.3 many of them have inappropriate knowledge on how to take this medication and just consume the medication according to their knowledge which later can lead to serious problems.3 every medication has its own side effects and contraindications and can cause harmful effects if taken without any attention to side effects, contraindications and dose.3 the medication might not be effective and may even cause further suffering for the person who takes it.3 the best way to treat this problem is by visiting the doctor to consult about the illness itself.3 meanwhile, people are more likely to buy their own medication at the pharmacy rather than visiting the doctor because of the easy access and the lower price of the medication compared to consulting the doctor.3the most common drugs that can be bought by the community is the otc drugs which are usually advertised in various media, such as television, radio, magazine and internet.3 the analgesic drugs that are usually advertised on television are medicine for headache, stomachache and others.4 in indonesia there is a regulation on drug advertisements which should be obeyed by advertising companies.5 the function of this regulation is to make sure that the information delivered to the society is true and beneficial.5 however, many pharmaceutical companies produce advertisements only to increase their profit rather than to give adequate information about their products, as not all information is written in the advertisement.6 thus, these misleading advertisements consist of inadequate information regarding their products.7 the food and drug administration (fda) of the united stated has made a regulation to assure the safety, security and effectiveness of drugs advertisements to protect the society.8 indonesia also has its own authority who is responsible for the drugs advertisement regulation which is known as the indonesia’s national agency for drug and food control (nadfc).9 this authority protects the indonesian public from counterfeit drugs and illegal products.9 for this reason, the nadfc has made a regulation in 2009 to protect society from unappropriate drugs promotion.10 based on this regulation, it decided that every pharmaceutical company should get permission from the nadfc before releasing any promotion of its products.10 therefore, this study on the effects of analgesic advertisements on the community in hegarmanah village, jatinangor was conducted to asses the impacts of these ads to the society. the society’s knowledge on the ads was also assessed to evaluate the correct understanding of what people saw, heard, or read in the ads. it is expected that this study would give a better understanding especially for the pharmaceutical companies in terms of better analgesic advertisements and to create awareness among the society members regarding the information given and to follow the instruction. methods this community survey used a self-conducted questionnaire as the instrument. this questionnaire is divided into two categories, respondent’s characteristics and questions regarding analgesic advertisements. the characteristic part includes questions on name, age, gender, address, occupation, last education, monthly salary, and ethnicity. concerning the analgesic advertisements, 15 questions were required to be answered by the respondents. this study used the descriptive method and was conducted from september 2012 to december 2012. the populations for the study were the people of hegarmanah village, obat yang diiklankan dan menarik mereka untuk membeli serta mencoba produk tersebut. penelitian lebih lanjut tentang faktor-faktor yang memengaruhi penggunaan obat analgesik yang dijual bebas dan juga tentang pengobatan sendiri masih diperlukan. [amj.2014;1(2):54–9] kata kunci: iklan analgesik, efek, masyarakat nurhayati binti shaharuddin, eva m. hidayat, jupiter sibarani: effects of analgesic advertisements on community in hegarmanah village, jatinangor althea medical journal. 2014;1(2) 56 amj december, 2014 jatinangor. the total population was calculated by using the slovin formula: based on the calculation above, the total population covered 100 respondents. the inclusion criteria for this study were people who have already seen or heard the advertisements about the analgesic table 1 respondent characteristic distribution variables total percentage (%) gender female male 60 40 60 40 age 18–27 28–37 38–47 48–57 58–67 50 23 19 5 3 50 23 19 5 3 occupations housewife government employee private employee farmer student entrepreneur others 29 0 9 5 12 27 18 29 0 9 5 12 27 18 education primary school junior high school senior high school university 11 25 42 22 11 25 42 22 income < 250,00 255,000 – 500,000 505,000 – 750,000 755,000 – 1,000,000 > 1,000,000 9 8 16 13 18 14.1 12.5 25.0 20.3 28.1 ethnicity sunda jawa batak others 66 8 1 25 66 8 1 25 and who were 18 years and older. the respondents were selected randomly in hegarmanah village. the exclusion criterion was incomplete questionnaires. validation and reliability tests were performed to 30 respondents and the results show that it was a valid and reliable questionnaire (> 0.700). data were analyzed using descriptive analysis to find the percentage for each question in the questionnaire. results the majority of the people who responded to this questionnaires were female (60%) around 18 to 27 years old (32%), housewife (29%) with low education status (42%), had a monthly income of more than rp 1,000,000 (28.1%) and were sundanese (66%) (table 1). discussion in the last three months, 82% of the respondents were aware of the existence of the analgesic advertisements and which they mostly watched on television. this showed that, there were a lot of analgesic advertisements which have been published or broadcasted that have captured the attention of the society.this might be caused by the fact that the advertisements were attractive and some of them even used popular celebrities n ≈ n 1 + ne² n ≈ 7 758 1 + (7 758) (0.1)² n ≈ 7 758 1 + (77.58) n ≈ 7 758 78.58 n ≈ 98.73 n ≈100 respondents note: n = number of respondents n = population sample e = error tolerance (10%) to promote the drug. every advertisement should include all information required by the authority. however, there were still numerous companies which did not provide sufficient information as 52% agreed that information in the advertisements was not enough. society stated that, some of the information were written in small fonts and located at the bottom part of advertisement which made it difficult to read. half of the respondents only read a small part of the advertisement because they considered the duration of the advertisement on television too short and did not provide enough time to read the complete information. besides, some of them stated that they did not feel like reading the ads and only saw it once. althea medical journal. 2014;1(2) 57 although otc analgesic medications can easily be purchased from various types of places such as pharmacies, supermarket and drug stores, many of them preferred the pharmacy because they were more confident in the pharmacy rather than a mere shop as it was more reliable and clean. however, 36% more preferred to buy the medication from the grocery shop as the shop was nearby their house and also the prices were cheaper than buying the medication at the pharmacy or consulting the doctor. about 61% of respondents had intention to find more information on analgesic advertisements which they have seen or heard. most of them would find it on the internet as the internet was the easiest way to find information. the respondents also used the alternative way like asking the family or neighbor who knew about the drugs or find it out from magazines or books. the analgesic advertisement gave effect towards the society because as they watch the advertisement, it made them want to buy and try the medication especially when they had the similar symptom as shown in the advertisement. they stated that the advertisements were attractive and triggered them to try it, however 47% stated that they did not feel like trying it even though the ads were attractive. they only bought the medicine if there was any complaint or just consulted the doctor rather than simply buy the medicine. most of the respondents were satisfied with the medicine as the effect was similar to what was promoted in the advertisements. only 23% did not get the effect that they really wanted when they used the medication. more than 80% were aware about the warning, side effects, contraindication, dosage intake and how to use the medication. they stated that they read first the instructions which were usually written at the back of the box before the intake of the medication. however, there were still respondents who did not understand the instructions because some of them could not read and did not bother to ask other people about the instructions. to make it worse, since there was no improvement, they would simply take the medication beyond the instruction. meaning, they would take the dosage more than was instructed. more than half of the respondents took a good initiative to discontinue taking the drugs if there was a sign of side effect that occur to them. according to the respondents, they would stop immediately when they noticed a side effect. there were 37% who would consult the doctor about the problem because they believed that the doctor could help them to cure the side effect. however, there were still some respondents (4%) who were not concerned and just let it be as according to them it was only a small matter and did not cause any harm to them. besides 63% felt that by seeing or hearing the analgesic advertisements could help them to make a better decision about their health status because some of them stated that their problem might be similar to those shown in the advertisements however, another 35% did not have any confidence that just by seeing the advertisements could help them made the right decision regarding their health. they also mentioned that their health could only be confirmed by the doctor as the doctor has more understanding about the illness. in conclusion, the analgesic advertisements give effects toward the community by making table 2 effects of analgesic advertisements on community distribution variables yes (%) no (%) awareness on analgesic advertisements 82 18 complete information stated in analgesic advertisement 48 52 intention to find more information about analgesic advertisements 61 39 intention to try the drugs after seeing the advertisements 53 47 improvement of symptom as shown in the advertisements 77 23 intention towards warning, side effect and contraindication 87 13 understand how to use the drugs 83 17 dosage intake according to instructions 89 11 effects of analgesic advertisements on society health 65 35 nurhayati binti shaharuddin, eva m. hidayat, jupiter sibarani: effects of analgesic advertisements on community in hegarmanah village, jatinangor althea medical journal. 2014;1(2) 58 amj december, 2014 table 3 effects of analgesic advertisements on community distribution questionnaires total (%) media for analgesic advertisements television radio magazine newspaper internet others 75 5 2 5 11 2 total number of analgesic advertisements seen by population in the last three months none one two three four five six seven eight nine ten > ten intention to read based on one analgesic advertisement by respondent read everything almost everything only half only a little not read everything 9 6 9 15 7 12 0 0 1 0 0 41 8 10 13 50 19 place to get otc analgesic drugs pharmacy drug store shop others media to find more information about analgesic drugs book magazine newspaper internet others action taken in the case of side effect stop usage let it be consult doctor change drugs others 51 11 37 1 15 8 23 31 23 55 4 37 3 1 them aware about the ads and also attract them to buy as well as try the medication itself. others can make further studies on the factors which influence intake of over-the-counter analgesic drugs and the self-medication. references 1. dorland. dorland’s illustrated medical dictionary: analgesic. 32th ed. philadephia: elsevier saunders; 2011. p. 71. 2. london pa, shostak d. potential reduction in unnecessary visits to doctors from safe and appropriate use of otc medicines could save consumers and taxpayer billions annually. washingon dc: the your health at hand; 2011 [cited 2012 july 13]. available from. http://www. yourhealthathand.org/images/uploads/ london_cost_saving_study_061711.pdf 3. ary. jangan sembarangan beli obat althea medical journal. 2014;1(2) 59nurhayati binti shaharuddin, eva m. hidayat, jupiter sibarani: effects of analgesic advertisements on community in hegarmanah village, jatinangor warung. jakarta: 108jakarta.com; 2012 [cited 2012 july 13]. available from: http://www.108jakarta.com/ j a k a r t a / 2 0 1 2 / 0 7 / 1 3 / 1 8 6 2 / j a n g a n sembarangan-%20beli-obat-warungan. 4. kimin a. paracetamol: komponen obat flu paling popular. tangerang: apotekputer. com; 2012 [cited 2012 june 10]. available from: http://apotekputer.com/ma/index. php?option=com_content&task=view&id= 50&itemid=1. 5. supardi s, handayani rs, herman mj, raharni, susyanty al. kebijakan periklanan obat dan obat tradisional di indonesia. bul. penel. sistem kes. 2011;14(1):59–67 6. greene ja, choudhry nk, kesselheim as, brennan ta, shrank w. changes in directto-consumer pharmaceutical advertising following shifts from prescriptiononly to over-the counter status. jama. 2012;308(10):973–5. 7. turisno be. perlindungan konsumen dalam iklan obat. masalah-masalah hukum. 2012;41(1):9. 8. huh j, delorme de, reid ln, an s. direct-toconsumer prescription drug advertising. minneapolis: minnesota medicine; 2010 [cited 2012 june 10]. available from: http://www.minnesotamedicine. c o m / pa s t i s s u e s / pa s t i s s u e s 2 0 1 0 / march-2010/clinical-jisu-march-2010. 9. gross a. indonesia pharmaceutical update 2012. bethesda: pasific bridge medical publication; 2012 [cited 2012 june 10]. available from: http://www. pacificbridgemedical.com/publications/ indonesia-pharmaceutical-update-2012/. 10. supardi s. kajian peraturan perundangundangan tentang iklan obat dan peran serta masyarakat dalam pengawasannya. jur kefarmasian indo. 2009;1(3):112–20. amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 116 althea medical journal june 2021 lethal dose of calcium bentonite in wistar rats dwika audiyananda,1 hendro sudjono yuwono,2 adria adnan2 1faculty of medicine universitas padjadjaran, indonesia, 2department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: dwika audiyananda, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, email: dr.dwikaaudiyananda@gmail.com introduction traditional medicine has been often used for self-medication, however, health professionals are reluctant to use them since the efficacy of traditional medicine has not been scientifically proven and the safety of its usage in humans is still low.1 clay is a type of drug derived from natural resources and has been used for generations.2 the type of clay often used as a treatment is calcium bentonite, smectite group mineral soil composed of 80% montmorillonite and calcium content.2,3 calcium bentonite is made from mineral weathering and the hardening of the volcanic ash that occurs in the atmosphere of alkaline water.4 calcium bentonite has a selective adsorption ability for a wide range of organic materials by maintaining their natural characteristics to match the ph of living things and have a surface containing negative electromagnetic.5,6 the adsorption properties of calcium bentonite depend on the form and surface width. the greater amount of surface area, the more chemical substances that can be bound and the pores can be completely filled in. the dry form of calcium bentonite has been widely used as an antiseptic and antidote for bacteria and chemical poisoning.2,7 research on calcium bentonite safety is needed to develop bentonite into a phytopharmaca. one of the methods to determine the toxicity classification is based on the value of ld50 or median lethal dose of a substance.1,7 ld50 is a statistically calculated dose of a substance that causes death in 50% amj. 2021;8(2):116–20 abstract background: calcium bentonite is a type of clay produced by a devitrification of volcanic ash which is often used as a traditional medicine to absorb toxins and waste products of metabolism. the aim of this study was to determine the lethal dose of calcium bentonite in wistar rats to explore its toxicity level and safe use. methods: fifty male and female wistar rats were randomly divided into five groups for each sex. the control group was given 5 cc aquadest whereas the other four groups received calcium bentonite solution of 50 mg/kgbw, 300 mg/kgbw, 2,000 mg/kgbw, and 5,000 mg/kgbw, respectively, at a single dose. the weight was observed for up to 7 days and analyzed using the unpaired t-test and mannwhitney test. the death rate was calculated using the probit analysis. median lethal dose results were then classified according to loomis criteria. results: no deaths occurred at the highest dose, suggesting that the median lethal dose value of calcium bentonite was >5,000 mg/kgbw. no weight loss occurred due to the administration of calcium bentonite and a significant increase in the body weight was even observed in the male rat group. interestingly, a significant decrease was found in the female rats group when compared to the control group. conclusions: calcium bentonite is classified as a practically non-toxic material with a median lethal dose of over 5,000 mg/kgbw. keywords: calcium bentonite, ld50, toxicity https://doi.org/10.15850/amj.v8n2.2227 althea medical journal. 2021;8(2) 117 of the research subject.7 the aim of this study was to determine the median lethal dose of calcium bentonite in wistar rats (rattus novergicus), therefore, the toxicity level can be classified, as well as the safety usage. methods this study was carried out from october− november 2012 in the animal laboratory of the department of pharmacology and therapy faculty of medicine universitas padjadjaran. the protocol study was approved by the research ethics committee faculty of medicine universitas padjadjaran no 204/ un6.c2.1.2/kepk/2012. calcium bentonite was obtained from the chemical laboratory, faculty of mathematics and science education, universitas pendidikan indonesia that was taken from karangnunggal, tasikmalaya, jawa barat, indonesia. laboratory tests were performed to confirm the accuracy of the calcium bentonite substance at the chemistry laboratory, bandung institute of technology. fifty healthy male and female wistar rats (rattus novergicus) aged 8−12 weeks old and 200±50 g weight were used. all rats were housed in a homogenous temperature and dark-light cycle for 7 days with ad libitum access to food and drink. calcium bentonite powder was weighed using digital scales in accordance with the dose of each treatment group and further dissolved in aquadest of 5 ccs. the wistar rats have fasted for 24 hours before the administration of calcium bentonite.8 the rats were randomly divided into five groups for each sex. the control group was given 5 cc aquades and four other groups received a single dose of calcium bentonite solution given per sonde with a dosage of 50 mg/kgbw, 300 mg/kgbw, 2,000 mg/kgbw, and 5,000 mg/kgbw, respectively.7 the routine weighing was conducted in all wistar rats for up to 7 days after treatment and the standard food after the treatment was given. all dead rats were counted after the administration of a single dose of calcium bentonite. data from the dead animals were calculated using probit analysis and then the results were classified into the toxicity criteria based on loomis.8 normality and homogeneity of the body weight data were tested using the saphirowilk. data between treatment groups and a control group were statistically analyzed using unpaired t-test and mann whitney. results there were no deaths in both male and female rats up to 7 days after the administration up to the highest dose of 5,000 mg/kgbw at a single dose of oral calcium bentonite. therefore, the graphic from probit analysis for this study was not available. similiarly, the ld50 value of a single dose of calcium bentonite could not be calculated because as there were no dead rats. the body weight in male and female rats from routine weighing in 7 days was depicted dwika audiyananda et al.: lethal dose of calcium bentonite in wistar rats figure 1 changes of mean body weight (g) in male rats observed in 7 days after a single dose of oral calcium bentonite g ra m day dose 50 mg/kgbw dose 300 mg/kgbw dose 2,000 mg/kgbw dose 5,000 mg/kgbw control althea medical journal. 2021;8(2) 118 althea medical journal june 2021 in figure 1 and 2. all of the groups gained weight and there was no decrease in body weight by 10% from the initial weight. shapiro-wilk test or normality test results showed abnormal distribution in male group data (p<0.05) and normal distribution for female group data (p>0.05). compared to control group, male rats had significant different in body weight using dose of 300, 2,000 and 5,000 mg/kgbw with significance of p=0.047, 0.009, and 0.009 respectively as shown in table 1. on the contrary, a significant decrease was observed in the average body weight of female rats between group 3 compared with the control group (193.6±14.74 vs 216.60±15.14; p=0.041), whereas no significant difference, with other groups. table 1 body weight among male rats in treatment groups compared with the control group median (minimum−maximum) p value group 1 dose 50 mg/kgbw 212 (187-248) 0.465 group 2 dose 300 mg/kgbw 237 (187-248) 0.047* group 3 dose 2,000 mg/kgbw 272 (265-306) 0.009* group 4 dose 5,000 mg/kgbw 324 (308-351) 0.009* group 5 control 221 (198-236) note: p-value comparing the group with control group unpaired t-test. * statistically different compared with the control group figure 2 changes of mean body weight (g) in female rats observed in 7 days after a single dose of oral calcium bentonite dose 50 mg/kgbw dose 300 mg/kgbw dose 2,000 mg/kgbwday g ra m table 2 body weight among female rats in treatment groups compared with the control group body weight mean±s.d p-value group 1 dose 50 mg/kgbw 211.80±9.41 0.564 group 2 dose 300 mg/kgbw 211±20.63 0.638 group 3 dose 2,000 mg/kgbw 193.6±14.74 0.041* group 4 dose 5,000 mg/kgbw 229.20±12.56 0.190 group 5 control 216.60±15.14 note: p-value comparing the group with control group unpaired t-test. * statistically different compared with the control group althea medical journal. 2021;8(2) 119 discussion our study has explored the lethal dose of calcium bentonite in wistar rats (rattus novergicus), resulting in no difference of ld50 value between male and female rats, thus all subjects have the same sensitivity to the material and no gender variation.10 furthermore, it is apparent that ld50 of calcium bentonite >5,000 mg/kgbw has been shown as practically non-toxic materials according to loomis criteria.8 after 7 days of administration of singledose oral calcium bentonite, there is an increase in body weight daily (figure 1 and 2). furthermore, calcium bentonite has no toxic effect on the growth and development of the wistar rats’ body weight. the substances would have significant side effects if there is a weight loss of more than 10% from their baseline and significant differences or changes of body weight between treatment groups compared with the control group.8,10 interestingly, we found a significant increase in the average body weight between group 2 (dose 300 mg/kgbw), group 3 (dose 2,000 mg/kgbw), and group 4 (dose 5,000 mg/kgbw) compared with the control group (p<0.05), suggesting that a single dose of oral calcium bentonite does not suppress appetite and do not interfere with the metabolism of nutrients coming from food or drink.12 however, there is a significant decrease in the average body weight in female rat groups between group 3 (dose 2,000 mg/kgbw) compared with the control group, but routine measurement showed there was no body weight loss of more than 10% from the initial weight in that group. therefore, body weight loss is not affected by the administration of calcium bentonite and probably due to the hormonal and metabolic effects of female rats.10 our findings are consistent with the safety data sheet from the thermofisher scientific and the carl roth company, in which the ld50 value of oral bentonite is more than 5,000 mg/ kgbw.11,12 substances with ld50 values higher than 5,000 mg/kgbw by the oral route are regarded as being safe or practically non-toxic based on loomis criteria.8,12 the available studies on the toxicity of calcium bentonite indicate that the principal exposure pathway of concern is the inhalation of respirable dust by occupationally exposed cohorts. bentonite itself is probably not more toxic than any other particulate not otherwise regulated. it is not classified as a carcinogen by any regulatory or advisory committee, but some bentonite may contain variable amounts of respirable crystalline silica, a recognized human carcinogen. however, the data have too many limitations to estimates the side effect of calcium bentonite for humans at current exposure levels.13 several studies have been conducted to study the effects of oral exposure of bentonite to humans. for example, the safety of bentonite has been evaluated when administered to protect the human gastrointestinal system from the adverse effects of aflatoxins. the used calcium bentonite was tested on a group of volunteers to determine the safety and tolerance of the clay itself during a shortterm experiment. the results demonstrate the relative safety of such material in human beings for example only mild gastrointestinal effects such as abdominal pain, bloating, constipation, diarrhea, and flatulence have been reported in some participants after receiving 1.5 and 3 g/ day for a period of 2 weeks. no significant dosedependent effects were observed for blood chemistry.14 literature review by moosavi4 on 2,500 scientific articles published in pubmed has shown that the effect of the clay on various organs of the body, resulting in no side effects of clay when used with the right dose. there are several limitations to this study. first, histopathological examination of animal organs such as liver or kidneys were not performed, therefore, the effects of toxicity on a microscopically are not known. second, there were no observations of toxicity symptoms were carried out, including motor activity, condition of the tail, feathers, eyes, heart, lungs, nasal secretions, body temperature, salivation, defecation, and urination due to limited tools for assessing these symptoms. in conclusion, present data suggest that a single-dose of oral calcium bentonite has ld50 more than 5,000 mg/kgbw and classified as practically nontoxic materials based on loomis criteria. future studies should clarify the safe usage of multiple-dose of calcium bentonite to explore the prolonged toxic effect of the substance. references 1. bhusnure og, shinde mc, vijayendra ssm, gholve sb, giram ps, birajdar mj. phytopharmaceuticals: an emerging platform for innovation and development of new drugs from botanicals. jddt. 2019;9(3-s):1046–57. 2. gomes cf, gomes jh, da silva ef. dwika audiyananda et al.: lethal dose of calcium bentonite in wistar rats althea medical journal. 2021;8(2) 120 althea medical journal june 2021 bacteriostatic and bactericidal clays: an overview. environ geochem health. 2020;42(11):3507–27. 3. behroozian s, svensson sl, li ly, davies je. broad-spectrum antimicrobial and antibiofilm activity of a natural clay mineral from british columbia, canada. mbio. 2020;11(5):e02350–20. 4. moosavi m. bentonite clay as a natural remedy: a brief review. iran j public health. 2017;46(9):1176–83. 5. maisanaba s, pichardo s, puerto m, gutiérrez-praena d, cameán am, jos a. toxicological evaluation of clay minerals and derived nanocomposites: a review. environ res. 2015;138:233–54. 6. massaro m, noto r, riela s. past, present and future perspectives on halloysite clay minerals. molecules. 2020;25(20):4863. 7. barile fa. clinical toxicology: principle and mechanisms. 3rd ed. boca raton: crc press; 2019. 8. loomis ta, hayes aw. loomis’s essential of toxicology. 5th ed. san diego: academic press; 2019. 9. world health organization regional office for the western pacific. research guidelines for evaluating the safety and efficacy of herbal medicines. manila: who regional office for the western pacific; 1993 [cited 2021 june 6] available from: https://apps. who.int/iris/handle/10665/207008. 10. jothy sl, zakaria z, chen y, lau yl, latha ly, sasidharan s. acute oral toxicity of methanolic seed extract of cassia fistula in mice. molecules. 2011; 16(6):5268–82. 11. thermofisher scientific. safety data sheet bentonite powder. loughborough, uk; 2020 [cited 2021 june 27] available from: https://www.fishersci. c o . u k / c h e m i c a l p r o d u c t d a t a _ u k / wercs?itemcode=b/1300/60 12. carl roth gmbh+co kg. safe work australiacode of practice: safety data sheet of bentonite pure. schoemperlenstr, karlsruhe, germany; 2020 [cited 2021 june 27] available from: https://carlroth. com › medias › sdb-0113-au-en.pdf 13. maxim ld, niebo r, mcconnell ee. bentonite toxicology and epidemiology – a review. inha toxicol. 2016;28(13):591– 617. 14. mitchell nj , kumi j, aleser m, elmore se, rychlik ka, zychowski ke, et al. shortterm safety and efficacy of calcium montmorillonite clay (upsn) in children. am j trop med hyg. 2014 ;91(4):777–85. amj vol 10 no 2 june 2023 (2).indd althea medical journal. 2023;10(2) 104 prevalence and factors associated with anxiety among uncontrolled hypertensive patients in public health centers in lhokseumawe, aceh, indonesia mulyati sri rahayu, sri wahyuni faculty of medicine, universitas malikussaleh, aceh, indonesia correspondence: dr. mulyati sri rahayu m.si, faculty of medicine, universitas malikussaleh, jalan meunasah, uteunkot cunda, lhokseumawe, aceh, indonesia, email: mulyati.srirahayu@unimal.ac.id introduction hypertension accounts for the highest mortality rate worldwide as a significant modifiable risk factor for cardiovascular disease.1 in 2010, hypertension affected one-third of the global adult population. the prevalence of hypertension globally is expected to rise to 29% by 2025.2 high blood pressure is estimated to cause 7.5 million deaths, about 12.8% of the total of all deaths worldwide. this accounts for 57 million disability adjusted life years (dalys) or 3.7% of total dalys.3 according to the 2018 basic health research survey, the national prevalence of hypertension was 34.1% for indonesians and 9.32% for acehnese, population from aceh.4 furthermore, in lhokseumawe city, 27.43% of people over 18 years old and 26.45% of the acehnese have been diagnosed with hypertension.5 consequently, hypertension is becoming a significant public health issue. patients with hypertension, like other chronic medical diseases, often have strong emotions beyond the physiological effects of the disease, increasing their probability of developing mental health problems such as anxiety.6,7 furthermore, a two-way relationship exists between anxiety and high blood pressure; hypertensive patients are more likely to experience anxiety, while adults with anxiety are at risk of high blood pressure.8 there is a high degree of multimorbidity between mental disorders such as anxiety and other non-communicable conditions, including hypertension. it makes their comanagement in primary care a logical choice. therefore, this study aimed to determine the althea medical journal. 2023;10(2):104–109 abstract background: patients with hypertension frequently experience intense emotions in addition to the physiological effects of the disease, which tend to increase the risk of developing mental health issues such as anxiety. however, the connection between hypertension and anxiety remains uncertain. this study aimed to evaluate the prevalence and factors associated with anxiety in uncontrolled hypertensive patients in public health facilities. methods: this cross-sectional study was conducted in four public health centers in lhokseumawe city, aceh province, indonesia. subjects were selected using consecutive sampling. data on sociodemographic factors and comorbid conditions were obtained. blood pressure was recorded, and severity was classified according to the jnc-7 guidelines. the hamilton rating scale for anxiety (hrs-a) was used to detect anxiety in each participant. data were analyzed using used the chi-square test. results: of the 60 respondents consisting of men (31.7%) and women (68.3%), 34 (56.7%) had mild anxiety, 22 (36.7%) had moderate anxiety, and 3 (5%) had severe anxiety. there was a significant association (p=0.007) between anxiety and duration of hypertension. on the contrary, no association in age, gender, level of education, and type 2 diabetes comorbidities (p>0.05). conclusions: anxiety is common among hypertensive patients in primary healthcare settings and is associated with the duration of hypertension. primary care physicians should be on the front lines in finding anxiety disorders, and making the necessary referrals or therapy. keywords: anxiety, type 2 diabetes, uncontrolled hypertension https://doi.org/10.15850/amj.v10n2.2981 althea medical journal. 2023;10(2) 105 prevalence and factors associated with anxiety among hypertensive patients visiting public health centers in lhokseumawe city, aceh, indonesia. methods a cross-sectional study was conducted in four public health centers (pusat kesehatan masyarakat, puskesmas) in lhokseumawe city, aceh province, namely puskesmas blang mangat, puskesmas muara dua, puskesmas mon geudong, puskesmas muara satu, and puskesmas banda sakti. the approval and ethical clearance were obtained from the faculty of medicine of the university of muhammadiyah sumatera utara (no:832/ kepk/fkumsu/2022, 30 june 2022). a consecutive sampling method to select uncontrolled hypertensive patients in these primary care settings was used. the inclusion criteria were uncontrolled hypertensive patients over 18 years old. patients who had controlled blood pressure, who denied participation and those who could not communicate were excluded. de-identification of patients were used to ensured that the information remained completely confidential. the questionnaire was distributed among the patients to collect the following data: sociodemographic characteristics (age, sex, educational status) and disease information (family history of hypertension, duration of hypertension diagnosis, and comorbidities. information related to comorbid conditions were obtained from the patient medical report, included type 2 diabetes and stroke). the hamilton rating scale for anxiety (hrs-a), a 14-item module, was used to assess the anxiety levels of each participant. scores 0–17, 18–24, and 25–30 represent mild, moderate, and severe anxiety, respectively. the reliability of the hrs-a questionnaires was 0.756.9 the reliability’s test conducted toward the table 1 sociodemographic characteristics of the study participants (n=60) characteristics n percentage (%) age; mean (sd) 49.85 (8.2) gender male female 19 41 32 68 education level low high 31 29 52 48 duration of hypertension 5 year > 5 years 7 53 12 88 family history of hypertension yes no 60 0 100 0 type 2 diabetes yes no 14 46 23 77 stroke yes no 0 60 0 100 grade of hypertension stage 1 stage 2 35 25 58 42 anxiety normal mild moderate severe 1 34 22 3 2 56 37 5 mulyati sri rahayu and sri wahyuni: prevalence and factors associated with anxiety among uncontrolled hypertensive patients in public health centers in lhokseumawe, aceh, indonesia althea medical journal. 2023;10(2) 106 translated version with cronbach’s alpha value of 0.793.10 blood pressure was measured using a mercury column sphygmomanometer for cathegorizing blood pressure control. our study determined the severity using the jnc7 guidelines11 as follows: pre-hypertension (systolic blood pressure (sbp) 120–139 mmhg and diastolic blood pressure (dbp) 80–89 mmhg), stage 1 hypertension (sbp 140–159 mmhg, and dbp 90–99 mmhg), and stage 2 hypertension (sbp 160–179 mmhg and dbp 100–109 mmhg). the data obtained were analyzed using computer statistical software (spss). each variable was calculated and represented as a number (percentages) in the table and figure. chi square test analysis was performed to determine if there were significant associations between study variables and anxiety classification. the significance (p-value) was set at 0.05. results of the total 60 patients, 41 (68%) were women, with the mean age of the entire population of 49.8±8.3 years. among educational status, most of the population had low levels of education, which was elementary to junior high school (n=31, 52%). the data showed that 58% (n=35) of the patients had stage 1 hypertension, and only (25) 42% had stage 2 hypertension. information related to comorbid conditions were obtained from the patient reported. approximately 46 (77%) of the participants did not have comorbidities other than hypertension, while 14 (23%) had type 2 diabetes. all subjects had a family history of hypertension (table 1). about 56% (n=34) of the respondents had mild anxiety, while only 5% (n=3) had severe anxiety. approximately 69% (n=24) of the patients with stage 1 hypertension exhibited mild anxiety, and 29% had severe anxiety. on the contrary, 52% (n=13) and 8% (n=2) of stage 2 hypertensive patients reported moderate and severe anxiety, respectively. however, there was no significant association between grade of hypertension and anxiety (p=0.096) (figure 1). table 2 summarized the association of several sociodemographic and clinical factors with anxiety. only the duration of the hypertension diagnosis was associated with anxiety (p=0.007). no other significant relationships were found with other variables among study subjects. discussion in this study, anxiety was common among patients with hypertension receiving primary care. most of the patients had mild to moderate anxiety. more than 50% of our patients with stage 1 and 2 hypertension experience mild to severe anxiety; as shown in study from nepal, that reported over 80% of hypertensive adult patients had mild anxiety.12 the presence of a significant prevalence of mental health disorders in phc patients with chronic conditions, as documented by the world health organization and the world organization of family doctors13, supports the findings of our study. the high percentage of the anxiety prevalence was supported by althea medical journal june 2023 figure 1 distribution of anxiety among the hypertensive patients (n=60) 69% 26%29% 29% 0% 40% 52% 8% althea medical journal. 2023;10(2) 107mulyati sri rahayu and sri wahyuni: prevalence and factors associated with anxiety among uncontrolled hypertensive patients in public health centers in lhokseumawe, aceh, indonesia table 2 factors associated with anxiety among patients with hypertension (n=60) variables category anxiety p-value normal mild moderate severe age (year) ≤ 49.85 > 49.85 1 (4.5) 0 16 (72.7) 18 (47.4) 4 (18.2) 18 (47.4) 1 (4.5) 2 (5.3) 0.087 gender male female 0 1 (2.4) 10 (52.6) 24 (58.5) 9 (47.7) 13 (31.7) 0 3 (7.3) 0.423 education low high 0 1 (3.4) 16 (51.6) 18 (62.1) 12 (38.7) 10 (34.5) 3 (9.7) 0 0.237 type 2 diabetes yes no 0 1 (2.2) 7 (50.0) 27 (58.7) 6 (42.9) 16 (34.8) 1 (7.1) 2 (4.3) 0.848 course of hypertension (years) ≤ 5 > 5 1 (14.3) 0 6 (85.7) 28 (52.8) 0 22 (41.5) 0 3 (5.7) 0.007* grade of hypertension stage 1 stage 2 1 (2.9) 0 24 (68.6) 10 (40) 9 (25.7) 13 (52) 1 (2.9) 2 (8) 0.096 note: *p <0.05 a study conducted in pakistan which found more than 50% of the patients identified with uncontrolled hypertension presented with an anxiety.14 in our study, hypertensive patients are prone to anxiety. according to the distribution of anxiety among the hypertension, only 1.7% participant is without anxiety or normal. however, the relationship was not statistically significant between grade of hypertension and anxiety (p=0.096). a study conducted in primary care clinics in saudi arabia reported no significant relationship between anxiety and hypertension, which aligns with our findings. however, it was indicated that the presence of hypertension increases the probability of developing a psychological disorder. it also highlighted that approximately 29% of hypertensive patients had achieved adequate blood pressure control, which could explain why the association between hypertension and developing anxiety did not reach statistical significance in their study.15 high levels of anxiety and depression are frequently associated with chronic diseases such as high blood pressure in adults.16 anxiety symptoms are an independent risk factor for incident hypertension.8 the course/duration of uncontrolled hypertensive patients is the only factor significantly associated with anxiety in our study (p=0.007). this result is consistent with research on depression and diabetic patients as chronic diseases. long-term diabetes has increased the probability of experiencing depression by 5.4 times.17 in a study conducted in gondar, ethiopia, the duration of a patient’s disease was a significant predictor of depression. furthermore, previous research has shown that an increased risk of complications and healthcare costs with the duration of dm may increase the probability that diabetic patients may acquire psychological disorders. the symptoms of anxiety have been associated with a diagnosis of hypertension assessed 5 years later, although the mechanisms underlying these associations remain to be determined.18 our findings contradict previous study reported that the course of hypertension did not affect the incidence of anxiety.19 the variation might be due to the difference in sample size, study design and a data collection tool to measure anxiety. women have a higher prevalence of anxiety than men in the general population and patients with hypertension. however, we found that gender was not significantly associated with anxiety. this result is similar to a study conducted among nepalese hypertensive adult patients who reported a non-significant association between gender and anxiety.12 however, a study from ethiopia and afghanistan showed a relationship between female patients and anxiety.19,20 female patients were 4.25 times more likely to have anxiety than males among hypertensive patients.19 this link may be partially explained by the fact that anxiety has been attributed to hormonal changes associated with pregnancy, postpartum, and menopause.21 this study findings have not shown a significant correlation between anxiety and educational level. our present result confirmed the study conducted in the south of the netherlands.22 our finding also differs althea medical journal. 2023;10(2) 108 from the study conducted in ethiopia; illiterate (incapable of reading and writing) were 2.72 times more likely to develop anxiety than patients with secondary and tertiary education.19 moreover, other study has shown that adult hypertensive patients who cannot read or write are 7.89 times more likely to have anxiety.23 this could be because patients with low educational levels have poor perception and treatment of health. the observed difference could be because of previous studies were not specifically among uncontrolled hypertensive patients and included patients with controlled hypertension as well and different scales used to assess anxiety. type 2 diabetes contributes to the development of anxiety disorders in hypertensive patients. all our patients with comorbid diabetes had moderate to severe anxiety. however, we found no association between comorbid diabetes mellitus and anxiety. previous studies suggest an association between hypertensive diabetic patients and anxiety.19,20,24 patients with comorbid diabetes mellitus were 2.98 times more likely to experience anxiety compared to patients without other comorbid conditions.19 hypertension and anxiety are interrelated. on the one hand, anxiety can increase the incidence and progression of hypertension and the risk of cardiocerebrovascular disorders. on the other hand, hypertension tends to exacerbate anxiety.8 therefore, examining the factors that influence anxiety in hypertensive patients were crucial to preventing and treating hypertension and improving patients’ quality of life. the limitations of this study is among others the study design, that is crosssectional study. therefore, the findings cannot establish a connection between anxiety and characteristics associated with uncontrolled hypertensive patients. further studies are needed on the other factors between high blood pressure and the development of anxiety. the cause of anxiety is widely varied, and can not all be identified in this study. therefore, the association between anxiety and hypertension should be carefully considered. furthermore, the sample is small since some respondents refused to participate. anxiety is probably diagnosed among patients who refuse to participate. in conclusion, a high prevalence of anxiety in hypertensive patients in public health centers in lhokseumawe, aceh, with a significant association of anxiety with the duration of hypertension. the screening for anxiety disorders among uncontrolled hypertensive patients in primary care should be considered to start the referral or therapy. references 1. world health organization. fact sheets of hypertension. 2021 [cited 2022 october 30]. available from: https://www.who. i n t / n e w s r o o m / f a c t s h e e t s / d e t a i l / hypertension. 2. mills kt, stefanescu a, he j. the global epidemiology of hypertension. nat rev nephrol. 2020;16(4):223–37. 3. world health organization. global health observatory (gho) data raised blood pressure. 2022. [cited 2022 october 30] available from: https://www.who.int/ data/gho/indicator-metadata-registry/ imr-details/3155. 4. badan penelitian dan pengembangan kesehatan kemenkes ri. laporan nasional riset kesehatan dasar (riskesdas) tahun 2018. jakarta: badan penelitian dan pengembangan kesehatan kemenkes ri; 2019. [cited 2022 october 30]. available from: https://www.litbang.kemkes.go.id/ laporan-riset-kesehatan-dasar-riskesdas/. 5. badan penelitian dan pengembangan kesehatan kemenkes ri. laporan provinsi aceh riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan kemenkes ri; 2019. [cited 2022 october 30]. available from: https://dinkes.acehprov.go.id/uploads/ riskesdaskabkotaceh.pdf. 6. dejean d, giacomini m, vanstone m, brundisini f. patient experiences of depression and anxiety with chronic disease: a systematic review and qualitative meta-synthesis. ont health technol assess ser. 2013;13(16):1–33. 7. liu y, ju y, cui l, liu t, hou y, wu q, et al. association between dietary fiber intake and incidence of depression and anxiety in patients with essential hypertension. nutrients. 2021;13(11):4159. 8. pan y, cai w, cheng q, dong w, an t, yan j. association between anxiety and hypertension: a systemic review and meta-analysis of epidemiological studies. neuropsychiatr dis treat. 2015;11:1121– 30. 9. ramdan im. reliability and validity test of the indonesian version of the hamilton anxiety rating scale (ham-a) to measurework-related stress in nursing. j ners. 2018;14(1):33–40. althea medical journal june 2023 althea medical journal. 2023;10(2) 109 10. kautsar f, gustopo d, achmadi f. uji validitas dan reliabilitas hamilton anxiety rating scale terhadap kecemasan dan produktivitas pekerja visual inspection pt. widatra bhakti. prosiding senatek. 2015;1(1):588–92. 11. lukito aa, harmeiwaty e, hustrini nm, editors. konsensus penatalaksanaan hipertensi 2019. jakarta: indonesian society of hypertension; 2019. [cited 2022 october 30]. available from: http://faber. inash.or.id/upload/pdf/article_update_ konsensus_201939.pdf. 12. shah s, adhikari s, aryal s, adhikari tb, sah sk, paudel bs, et al. anxiety and depression among hypertension adults in tertiary care hospitals of nepal. psychiatry j. 2022;2022:1098625. 13. world health organization, world organization of family doctors. integrating mental health into primary care: a global perspective. geneva: world health organization; 2008 [cited 2022 october 30]. available from: https://apps.who.int/ iris/handle/10665/43935 14. yousuf fs, arif a, bibi r, almas a. association of depression and anxiety with hypertensive crisis: a cross-sectional study from a hospital setting in karachi, pakistan. cureus. 2022;14(9):e29792. 15. baghdadi lr, alhassan mk, alotaibi fh, alselaim kb, alzahrani aa, almusaeed ff. anxiety, depression, and common chronic disease, and their association with social determinants in saudi primary care. j prim care community health. 2021;12: 21501327211054987. 16. cuevas ag, williams dr, albert ma. psychosocial factors and hypertension: a review of the literature. cardiol clin. 2017;35(2):223–30. 17. ebrahim m, tamiru d, hawulte b, misgana t. prevalence and associated factors of depression among diabetic outpatients attending diabetic clinic at public hospitals in eastern ethiopia: a cross-sectional study. sage open med. 2021;9:20503121211066244. 18. ginty at, carroll d, roseboom tj, phillips ac, de rooij sr. depression and anxiety are associated with a diagnosis of hypertension 5 years later in a cohort of late middle-aged men and women. j hum hypertens. 2013;27(3):187–90. 19. aberha m, gebeyehu a, ayano g. prevalence and factors associated with anxiety among patients with hypertension on follow up at menelik-ii referral hospital, addis ababa ethiopia. j psychiatry. 2016;19(4):378. 20. hamrah ms, hamrah mh, ishii h, suzuki s, hamrah ae, et al.. anxiety and depression among hypertensive outpatients in afghanistan: a cross-sectional study in andkhoy city. int j hypertens. 2018;2018:8560835. 21. russell ej, fawcett jm, mazmanian d. risk of obsessive-compulsive disorder in pregnant and postpartum women: a metaanalysis. j clin psychiatry. 2013;74(4):377– 85. 22. ringoir l, pedersen ss, widdershoven jwmg, pop vjm. prevalence of psychological distress in elderly hypertension patients in primary care. neth heart j. 2014;22(2):71– 6. 23. edmealem a, olis cs. factors associated with anxiety and depression among diabetes, hypertension, and heart failure patients at dessie referral hospital, northeast ethiopia. behav neurol. 2020;2020:3609873. 24. ismail z, mohamad m, isa mr, fadzil ma, yassin sm, ma kt, et al. factors associated with anxiety among elderly hypertensive in primary care setting. j ment health. 2015;24(1):29–32. mulyati sri rahayu and sri wahyuni: prevalence and factors associated with anxiety among uncontrolled hypertensive patients in public health centers in lhokseumawe, aceh, indonesia amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 79 cancer antigen 125 serum level in head and neck diffuse large b-cell lymphoma igor hutabarat, agung dinasti permana, yussy afriani dewi department of otorhinolaryngology head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: igor hutabarat, department of otorhinolaryngology head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur 38, bandung, west javaindonesia, e-mail: igorhutabarat@gmail.com introduction diffuse large b-cell lymphoma (dlbcl) is the most often found lymphoma subtype (31%) of all non-hodgkin lymphoma (lnh). this lymphoma is a unique lymphoid malignant disease because it has different characteristics ranging from clinical symptoms, morphology, immunology, and molecular phenotypes that can affect the treatment and prognosis of the disease.1 the lnh is predominantly occurred at a productive age around 45–64 years old and histologically, dlbcl is the most prevalent. interestingly, there is a correlation between gender, age and clinical diagnosis with histological type lymphoma.2 the national basic health research (riset kesehatan dasar, riskesdas) conducted by the ministry of health republic of indonesia in 2013 has shown that the yogyakarta province has the highest prevalence of lymphoma, and the west java province has the highest estimated number of lymphoma patients with almost 3,000 patients.3 the diagnosis of dlbcl is obtained from history, physical examination, routine blood tests, plain chest x-ray, and computed tomography (ct) of the head and neck. establishing a definite diagnosis of dlbcl is obtained from histopathological examination of biopsy tissue in nodules or tumors in the head region of the neck, and the prognosis of dlbcl can be observed with the international prognostic index score (ipi score).4 nearly two decades ago, ldh is the only biological parameter included in the ipi score for dlbcl. some studies report the percentage of dlbcl patients with an increase in serum lactate dehydrogenase (ldh) levels which is relatively low, ranging from 10.2% to 37%. therefore, new tumor markers are needed as an indicator of disease activity in evaluating treatment success.5 interestingly, high expression of cancer antigen 125 (ca-125) serum levels has been found in lnh patients. dlbcl patients with high ca-125 serum levels amj. 2020;7(2):79–83 abstract background: diffuse large b-cell lymphoma (dlbcl) is the most common subtype of the nonhodgkin lymphoma (lnh). until now, lactate dehydrogenase (ldh) is the only tumor marker to assess dlbcl progression; however, increased ldh is a relatively non-specific biomarker. cancer antigen 125 (ca-125) serum level have been used as a tumor marker in ovarian cancer. the aim of this study was to explore the possible role of ca-125 serum level as a tumor marker in head and neck dlbcl. methods: this was an observational descriptive study among consecutively sampled dlbcl patients. ca-125 serum level examination was carried out (advia centaur ca-125ii) and described along with the clinical characteristics of dlbcl patients. results: dlbcl was mostly observed in males (54.05%), most often in the 55-65 year age group (51.3%), with stage 1 dlbcl was the most prevalent (71.9%). the mean ca-125 serum level was 22.9 u/ml and increased in patients with advanced dlbcl. conclusions: increased ca-125 serum level in dlbcl, especially at advanced stages, suggests that ca125 serum level may be of benefit as a tumor marker in the head and neck dlbcl. further study is in need to explore the role of ca-125. keywords: cancer antigen 125, diffuse large b-cell lymphoma, lactate dehydrogenase, non-hodgkin https://doi.org/10.15850/amj.v7n2.1788 althea medical journal. 2020;7(2) 80 amj june 2020 have worse prognostic factors at diagnosis, higher relapse rates, and worse life expectancy.6 ca-125 serum level is also significantly higher in advanced lnh patients (stage 3 or 4) than in the early stages (stage 1 or 2).7 the biological information given by ca-125 serum is different from other serum markers such as levels of ldh released by lymphoma cells. the fact that ldh levels provide information about the number of tumor cells in the body and table 1 characteristics of diffuse large b-cell lymphoma patients at dr. hasan sadikin general hospital, bandung parameters n % sex male 20 54.05 female 17 45.95 age (years) 17–25 1 2.7 26–35 36–45 1 2.7 46–55 9 24.3 56–65 19 51.3 ≥65 7 18.9 stages i 27 72.9 ii 5 13.5 iii 3 8.1 iv 2 5.5 ecog-ps* 0 25 67.5 1 7 18.9 2 3 8.1 3 2 5.5 4 ldh** normal (85–27 u/l) 26 70.2 >1-3 times normal 9 24.3 > 3 times normal 2 5.5 ipi score*** 0–1 30 81 2 3 8.1 3 3 8.1 4 1 2.8 note: * ecog-ps:the eastern cooperative oncology group performance status; ** ldh: lactate dehydrogenase; ***ipi score,: international prognostic index score althea medical journal. 2020;7(2) 81 lymphoma proliferation activities, whereas an increase in ca-125 serum level reflects the patient’s response to the potential for tumor invasion and provides a measure of infiltration activity.8 in light of the fact above, this study aimed to explore whether ca-125 serum levelscan serve as a tumor markers in the head and neck dlbcl. methods this study was a descriptive observational study to determine the ca-125 serum level in dlbcl patients. the selection of study subjects was conducted by consecutive sampling. patients who fulfilled the inclusion and exclusion criteria based on the order of patient arrival were recruited. determination of sample size in this study was in accordance with the study objectives by using the formula for determining the sample size for study observational descriptive, a large sample formula was used. the minimum sample number was 37 subjects. the study was conducted at dr. hasan sadikin general hospital bandung, at the outpatients clinic of otolarhyngology head and neck surgery in march–august 2018. the protocol of the study was approved by the ethical committee of dr. hasan sadikin general hosptal bandung with no. lb.04.01/a05/ec/093/iii/2018. the eastern cooperative oncology group (ecog) performance status (ps), were designated as followed: status 0 fully active, able to carry on all pre-disease performance without restriction; status 1 restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work; status 2 ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours; status 3 capable of only limited self-care; confined to a bed or chair more than 50% of waking hours; status 4 completely disabled; cannot carry on any self-care; totally confined to bed or chair and status 5 death. the ipi score was used to determine the prognosis. the stage of lnh patients was defined as early stages (stage 1 or 2) and late stages (stage 3 or 4). ca-125 serum level (u/ ml) was further measured and < 35u/ml was the cutoff point value. results were presented in tables in percentages. results of dlbcl patients included (n=37), male (54.05%) was predominantly occurred compared to female. the age group of 5665 years was the most prevalent (51.3%) and stage 1 dlbcl was the most (72.9%) as shown in table 1. most of the patients had ecog-ps score 0 (67.5%) and predominantly had normal ldh level (70.2%), with the ipi score 0–1 was the highest (81%). extranodal location was found in 13.5%. mean value of ca-125 serum levels in 37 subjects was 22.9u/ ml (s.d 4.85), and most of them (86.49%) had below 35 u/ml serum ca-125 level as shown in table 2. discussions our results showed more male (54.05%) patients were found compared to female patients. this result is similar to the previous study from 13 hematology centers in indonesia showing that the incidence of lnh is slightly more common in male than female, with a ratio of 1.6: 1.2.3 males are thought to be at greater risk of lnh because of smoking habits, occupational factors, and environmental exposure such as pesticides, however, studies to identify exposure patterns for the incidence of lnh has never been done in indonesia. in indonesia, farmers, forest workers, and agricultural workers are mostly men. potentially dangerous exposures among these groups include pesticides that contain phenoxy acids, organophosphates, organochlorines, benzene, and other organic solvents.3 interestingly, there is also an increase in the incidence of lnh based on age. non-hodgkin’s lymphoma is more common in the productive group as shown in this study which is 45–64 age group. diffuse large b-cell lymphoma is table 2 cancer antigen-125 serum level in diffuse large b-cell lymphoma patients at dr. hasan sadikin general hospital ca-125 serum levels number of subject proportion 0-34 u/ml 32 86.5% ≥35 u/ml 5 13.5% note: cut off point for ca-125 serum level of <35 u/ml igor hutabarat et al.: cancer antigen 125 serum level in head and neck diffuse large b-cell lymphoma althea medical journal. 2020;7(2) 82 amj june 2020 like most cancers, the disease will increase with age, reflecting the damage to dna of cells that accumulates over time. damage can occur due to biological processes or from exposure to risk factors. a study clearly shows that there is a significant correlation between age and histopathology type of lymphoma.2 the mean ca-125 serum level is 22.9 u/ml (s.d.4.85); which is below 35 u/ml. individuals with ca-125 serum levels that exceeded cut-off ≥ 35 u/ml are diagnosed with advanced stage dlbcl. this result is following another study showing that ca-125 serum level will increase beyond the cut-off ≥ 35 u/ml at an advanced stage. this study also shows an association between high ca-125 serum level and the involvement of the lung, pleuro-pericardial or mediastinal peritoneum and/or abdomen in advanced lnh. an increased serum ca-125 level with involvement of pleural effusions could represent pleuro-peraticardial or peritoneal mesothelial cell responses to tumor activity. lymphokine released by advanced lnh shows direct involvement by tumor activity as the main stimulus for ca-125 production.9 in this study, in outpatient clinic shows that most dlbcl stadium was in stage 1 as many as 72.9%. there has been no previous study describing the epidemiology of the dlbcl stage. this can be estimated that the study has been conducted in the outpatient clinic. patients with more advanced stages (stage 3 and 4) usually complain about diregional lumps other than the head and neck, and thus advanced dlbcl patients are not expected to visit the outpatient clinic of otorhinolaryngology head and neck surgery. moreover, these patients have a good ecog score performance status with a score of 0 is the most common since the respondents were in earlier stages. stage is directly proportional to ecog performance status, thus it supports the findings of this study that the stage 1 is the most prevalent, the ecog performance status score is mostly equal as 0 which is optimal.10 furthermore, the ldh serum levels were found normal for the early stage respondent. the ldh associated with several characteristics of diseases such as symptoms, tumor size, and organomegaly. lactate dehydrogenase serum activity is increased in many cancer patients and thus may serve as a prognostic marker.11 the ldh serum is also found to be involved in tumor metabolism. the hallmark of most cancer cells is a metabolic change in which cancer cells depend on anaerobic respiration as the main energy source. this involves the production of lactate from glucose under a sufficiently oxygenated environment, known as the warburg effect. therefore, tumor cells take excess glucose and use it to accelerate growth and replication. lactate dehydrogenase serum generally increases in disorders of lymphoid proliferation. in patients with lnh, ldh serum levels have prognostic importance and thus can be used to monitor treatment response and recurrence.11 the results of our study show that the ipi score 0–1 is the highest with 81% in the study subjects with normal ca-125 serum level, having a low risk with a 5-year life expectancy of 73%. these results show that based on the calculation of the ipi component score of 81% of the dlbcl study subjects are found more at the age of ≤60 years, stage 1 and 2, normal ldh levels, no extranodal locations, and ecogps 0. the limitation of this study is that the study method is an observational descriptive study, therefore, a further correlation between the increase in ca-125 serum level and stage, ldh level, ipi score, ecog-ps on dlbcl on the head and neck have not been performed due to lack of the study respondents numbers. further study is needed to explore these associations. in a conclusion, the ca-125 serum levels in dlbcl patients in the early stage are normal. an increased ca-125 serum level in dlbcl, especially at advanced stages suggests that ca125 serum levels may be of benefit as a tumor marker in the head and neck dlbcl. further study is in need to explore the role of ca-125. references 1. kementerian kesehatan republik indonesia. data dan kondisi penyakit limfoma di indonesia. infodatin pusat data dan informasi kementerian kesehatan ri. 2015 [cited 2020 march 18] available from: https://www.kemkes.go.id/resources/ download/pusdatin/infodatin/infodatinlimfoma.pdf 2. dwianingsih ek, indrawati, hardianti ms, malueka rg , iswar rr, sutapa s, et al. histopathological features of lymphoma in yogyakarta, indonesia. asian pac j cancer prev. 2016;17(9):4213–16. 3. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar (riskesdas) 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri; 2013 4. cheson bd, fisher ri, barrington sf, althea medical journal. 2020;7(2) 83 cavalli f, schwartz lh, zucca e, et al. recommendations for initial evaluation, staging, and response assessment of hodgkin and non-hodgkin lymphoma: the lugano classification. j clin oncol. 2014; 32(27):3059–67. 5. ziepert m, hasenclever d, kuhnt e, glass b, schmitz n, pfreundschuh, et al. standard international prognostic index remains a valid predictor of outcome for patients with aggressive cd20+b-cell lymphoma in the rituximab era. j clin oncol. 2010;28(14):2373-2380. 6. gutiérrez a, martínez-serra j, barceló b, sampol a, vinas l, gonzales g, et al. prognostic value of serum ca125 levels in diffuse large b-cell lymphoma: potential role of a new sex and age adjusted reference value. int j lab hematol. 2010; 32(6 pt 2): 582–9. 7. dilek i, ayakta h, demir c, meral c, ozturk m. ca 125 levels in patients with nonhodgkin lymphoma and other hematologic malignancies. clin lab haematol. 2005;27(1):51–5. 8. memar b, aledavood a, shahidsales s, ahadi m, farzadnia, raziee hr, et al. the prognostic role of tumor marker ca-125 in b-cell non-hodgkin’s lymphoma. iran j cancer prev. 2015;8(1):42–6. 9. garg s, goyal b. evaluation of ca-125 as a prognostic marker in patients with non-hodgkin’s lymphoma. international journal of medical and health research. 2017;3(4):13–5. 10. paoli cj, bach ba, quach d, tsai kt, wong b, kallich j. performance status of realworld oncology patients before and after first course of chemotherapy. the journal of community and supportive oncology. 2014; 12(5):163–70. 11. yadav c, ahmad a, d’souza b, agarwal a, nandini m, prabhu ka, et al. serum lactate dehydrogenase in non-hodgkin’s lymphoma: a prognostic indicator. indian j clin biochem. 2016;31(2):240–2. igor hutabarat et al.: cancer antigen 125 serum level in head and neck diffuse large b-cell lymphoma amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 228 risk factor of stillbirth among pregnant women at dr. hasan sadikin general hospital bandung from 2017–2020 david immanuel,1 hadi susiarno,2 windi nurdiawan2 ¹faculty of medicine universitas padjadjaran, indonesia, ²department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: david immanuel, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: david18006@mail.unpad.ac.id introduction stillbirth is a pregnancy condition when the fetus dies at 20 weeks’ gestation or after.1 the world health organization (who) has different criteria in defining stillbirth, primarily from the gestational age and fetal weight aspects. for international comparison and reporting, who set 28 weeks of gestation as the cut-off and 1,000 grams as the weight. classification of stillbirth is based on the gestational age (in weeks) when the diagnosis is established, for stillbirth that occurrs from 20 to 28 weeks of gestation is called early stillbirth, and after 28 weeks as late stillbirth. another classification relies on its occurrence between any time during labor/delivery period, with antepartum stillbirth that occurred before labor onset and intrapartum stillbirth that occurred during the labor process.2 on average, 2.6 million stillbirth cases were reported worldwide in 2015 (varies from 2.4– 3.0 million), with 98% of cases reported being from low and middle-income countries and 66% from developing countries. one of them is indonesia which took the eighth position as a country with the highest number of stillbirth cases, along with other nations such as india, china, and pakistan.3 in indonesia, there were 3,097 cases reported in west java province from a total of 935,003 births and 129 cases in bandung city from a total of 39,571 births, with the number of cases mentioned were accumulated from both male and female fetuses.4 several factors associated with stillbirth are classified based on the pathological origin, such as maternal, fetal, placental, althea medical journal. 2022;9(4):228–233 abstract background: stillbirth is one of the most devastating pregnancy outcomes that affects approximately 2.6 million pregnancies worldwide. several factors have been identified to be associated with stillbirth, and grouped based on the pathophysiological aspects, such as maternal, placental, fetal, and unknown or unexplained factors. this study aimed to describe the prevalence, along with the baseline and risk factor characteristics of stillbirth among singleton pregnancies at dr. hasan sadikin general hospital bandung. methods: a descriptive, cross-sectional study design was conducted, including all stillbirth medical records from 2017 to 2020 obtained from the department of obstetrics and gynecology, dr. hasan sadikin general hospital bandung. medical records with complete baseline data, 2nd–3rd trimester pregnancies, and singleton pregnancies were collected. results: the prevalence of stillbirth cases in this study was 2.2%. most of the cases occurred in the age range of 20–35 years old (64.4%) with the gestational age of >28 weeks (65.8%). of all risk factors observed, hypertensive disorders were the most common medical conditions found (45.6%), followed by unknown factors (17.8%), and congenital abnormalities (14.2%). conclusions: the majority of stillbirth patients are at their optimal reproductive age, nulliparity, and have hypertensive disorders during pregnancy, specifically the superimposed preeclampsia subtype. although the prevalence is considerably low, early management of the risk factors, particularly hypertensive disorder, is important to prevent its occurrence. keywords: characteristics, prevalence, risk factor, stillbirth https://doi.org/10.15850/amj.v9n4.2646 althea medical journal. 2022;9(4) 229 external/obstetric, and unknown origin. other classification systems are also available: relevant condition at death (recode), causes of death and associated conditions (codac), tulip, perinatal society of australia and new zealand-perinatal death classification (psanz-pdc), and international classification of diseases 10th revision-perinatal mortality (icd-pm).2,6,7 stillbirth affects the mother and the family psychologically, and researches have shown that higher depression and anxiety level were found in women with prior history of stillbirth compared to women with no prior history.5 this study aimed to describe the prevalence, baseline, and risk factor characteristics of stillbirth among singleton pregnancies at a tertiary hospital from 2017–2020. methods this study was a descriptive cross-sectional study; samples were collected from the department of obstetrics and gynecology, dr. hasan sadikin general hospital bandung by total sampling. inclusion criteria were stillbirth medical records with complete baseline characteristics data, 2nd–3rd trimester pregnancies, and singleton pregnancies. medical records with incomplete baseline data and multiple gestations (twin pregnancies) were excluded from this study. baseline characteristics consisted of maternal age (years), gestational age (weeks), obstetrical status (parity and abortion), on-site body mass index, and a number of risk factors. the risk factors assessed were hypertensive disorders in pregnancy that comprised of preeclampsia, superimposed preeclampsia, eclampsia, and chronic hypertension,8,9 intrauterine infection, diabetes mellitus, that further subdivided into type 1 and type 2, amniotic fluid abnormalities, anemia in pregnancy, premature rupture of membrane (prom), intrauterine growth restriction (iugr), antepartum hemorrhage (aph), placental abruption, umbilical cord prolapse. congenital abnormalities, specifically major type, were based on the national birth defects prevention network (nbdpn) and defined as abnormalities that required surgery or medical treatment, had a serious impact on health, or had a significant impact on appearance.10 unknown/unexplained factor is defined as the absence of any clinical risk factors or causes of death based on the antenatal examination, placental, and fetal autopsy.2,11 data from medical records were collected after obtaining ethical clearance from the research ethics committee universitas padjadjaran (739/un6.kep/ec/2021) and dr. hasan sadikin general hospital bandung (lb.02.01/x/2.2.1/19986/2021). eligible data were processed by using microsoft excel 2019 and ibm® spss® 25. results there were 385 stillbirth cases recorded from a total of 10,166 births counted from 2017 to 2020. of 385 stillbirth cases, 92 data were not available, and 74 data did not meet the inclusion criteria, with the distribution as follows: three twin pregnancies, one data with unknown maternal age, five patients with a gestational age of <20 weeks (miscarriage), 11 patients with unknown gestational age, and 54 incorrect/inaccurate data. hence, the rest 219 subjects were used, making the prevalence of stillbirth in this study 2.2%, with a case rate of 22 per 1,000 births. baseline characteristics (table 1) showed the highest cases count among patients aged 20–35 years old (n=141, 64.4%) and >28 weeks’ gestational age group (n=144, 65.8%). the mean and median for the maternal age were 30 and 31 years old, respectively. meanwhile for the gestational age, both the mean and median were 30 years old. obstetrical status showed high cases among zero parities and one parity. most of the patients had never had an abortion. data regarding the body mass index (bmi) of patients were obtained from the measurement done in the first 12 hours since the patients admitted to the hospital, not from the pre-pregnancy nor first trimester bmi due to the absence of data. based on the risk factor characteristics, most patients had hypertensive disorders during pregnancy (n=100, 45.6%), which further classified into preeclampsia (n=27, 12.3%), superimposed preeclampsia (n=55, 25.1%), eclampsia (n=16, 7.3%), and chronic hypertension (n=2, 0.9%); followed by unknown origin (n=39, 17.8%) the diagnosis was made from the absence of any pathological evidence from the antenatal history, physical and laboratory examinations (as indicated) and fetal autopsy; and major congenital abnormalities (n=31, 14.2%). some abnormalities in this study were classified based on the organs involved, such as (1) neural tube defects (ntds) comprised of anencephaly, hydranencephaly, corpus callosum agenesis, and alobar holoprosencephaly, (2) congenital heart david immanuel et al.: risk factor of stillbirth among pregnant women at dr. hasan sadikin general hospital bandung from 2017–2020 althea medical journal. 2022;9(4) 230 althea medical journal december 2022 table 1 baseline characteristics of mothers who had a stillbirth at the department of obstetrics & gynecology, dr. hasan sadikin general hospital bandung 2017–2020 characteristics results (n= 219) n % x ̅(min-max) age (years) <20 20–35 >35 14 141 64 6.4 64.4 29.2 30 (14 – 44) gestational age (weeks) 20–28 >28 75 144 34.2 65.8 30 (20 – 42) obstetrical status parity 0 1 2 ≥3 abortion 0 1 2 ≥3 67 66 56 30 181 29 9 0 30.6 30.1 25.6 13.7 82.7 13.2 4.1 0 body mass index* (kg/m2) <18.5 18.5–22.9 23–24.9 ≥25 20–28 weeks n=75 1 33 15 26 >28 weeks n=144 0 27 22 95 26.9 (17.6 – 50.4) defects (chd): tetralogy of fallot (tof), ectopia cordis, and fetal pericardial effusion, and (3) congenital gastrointestinal disorders consisting gastroschisis, duodenal atresia and congenital diaphragmatic hernia. the results showed hydrops fetalis outnumbered the other abnormalities subtypes (n=12, 5.5%) (table 2). assessment of the distribution of risk factors showed the highest cases among patients with single risk factors (table 3). discussion the prevalence of stillbirth in this study is 2.2%, resulting in the sbr of 22 cases per 1,000 births. this result is almost two times higher than the goal set by sustainable development goals (sdgs); with an sbr target of fewer than 12 cases per 1,000 births. the mean age of the patients included in this study is 30 years old. approximately 64.4% of cases occurred in the age range of 20–35 years, corresponding with the previous study done on the nearby region, tasikmalaya district, west java province in 2017, where the highest occurrence of stillbirth belong to the population between 20– 35 years old with the percentage of 68.4%.12 other studies done in nepal from 2017–2019 and ethiopia in 2018 showed similar results, where most of the cases have occurred at the age range of 21–30 years old (67.1%) and 20– 34 years old (77.7%), respectively.13,14 stillbirth at 28 weeks gestation or after was more frequently seen in this study with a median of 30 weeks. similar results were also reported in the united states of america from march 2020–september 2021, 55.8% with a median of 29 weeks.15 obstetrical status based on the previous study from tasikmalaya district in 2017 and global network sites from 2010–2019 both showed the highest cases count among primiparity and multiparity rather than nulliparity, meanwhile, nulliparity accounted for the highest cases count (30.6%) in this study.12,16 bmi was measured in the first 12 hours since the patient was admitted to the hospital. pre-pregnancy and first-trimester anthropometry data were unavailable since most of the patients got antenatal care outside the study location, and the rest of them got no antenatal care. almost half of the patients in this study had althea medical journal. 2022;9(4) 231 table 2 risk factor of stillbirth at the department of obstetrics and gynecology dr. hasan sadikin general hospital bandung 2017–2020 risk factors subtypes results n % unknown/unexplained 39 17.8 maternal hypertensive disorders in pregnancy preeclampsia superimposed preeclampsia eclampsia chronic hypertension 27 55 16 2 12.3 25.1 7.3 0.9 intrauterine infection unspecified 2 0.9 diabetes mellitus type i type ii 0 1 0 0.5 amniotic fluid abnormalities oligohydramnios polyhydramnios 2 1 0.9 0.5 anemia unspecified iron deficiency 6 3 2.7 1.4 prom 28 12.8 iugr 16 7.3 unspecified aph 1 0.5 placental placental abruption with aph placenta previa with aph placental abruption without aph 10 6 8 4.6 2.7 3.7 cord cord prolapse 2 0.9 fetal congenital abnormalities hydrops fetalis dandy walker syndrome 12 1 5.5 0.5 neural tube defects anencephaly hydranencephaly corpus callosum agenesis alobar holoprosencephaly 3 1 1 2 1.4 0.5 0.5 0.9 congenital heart disorders tetralogy of fallot ectopia cordis fetal pericardial effusion 1 2 1 0.5 0.9 0.5 congenital gastrointestinal disorders gastroschisis duodenal atresia congenital diaphragmatic hernia 2 1 1 0.9 0.5 0.5 macrosomia 2 0.9 megavesica 1 0.5 others previous cesarean section obstetric complication (asphyxia) maternal sepsis 6 2 1 2.7 0.9 0.5 note: prom= premature rupture of membrane, iugr= intrauterine fetal growth restriction, aph= antepartum hemorrhage, unspecified= no information regarding the etiology or underlying cause. david immanuel et al.: risk factor of stillbirth among pregnant women at dr. hasan sadikin general hospital bandung from 2017–2020 althea medical journal. 2022;9(4) 232 althea medical journal december 2022 hypertensive disorders during pregnancy that werer further subdivided into preeclampsia, superimposed preeclampsia (preeclampsia preceded by chronic hypertension), eclampsia, and chronic hypertension. this finding is in accordance with another study conducted in the united states of america which showed that most of the stillbirth patients had hypertensive disorders (20.9%) and were subdivided into chronic hypertension and pregnancy–related hypertension, which consisted of gestational hypertension, superimposed preeclampsia, preeclampsia, hellp syndrome, and eclampsia.15 similar result was reported from a cross sectional research conducted among middle-east population in 2015 with a percentage of 22.5%.17 however, different results were reported by studies from tasikmalaya district, west java province, and a systematic review involving 85 reports across 50 countries worldwide in 2017, that most of the stillbirth patients had unknown/ unexplained stillbirths, with a percentage of 56.7% and ranging from 32.1% to 43.7%, respectively.6,12 in this study, 17.8% of patients had no known etiology or possible cause for the occurrence of stillbirth. this finding is different from the studies previously mentioned which unknown origin was the leading factor.6,12 different results were also reported by a study in nepal from 2017–2019, where one-third of stillbirth patients had unknown causes or possible causes of stillbirth.13 congenital abnormalities affect 31 (14.2%) stillbirth patients in this study. this finding is higher from the previous systematic review involving several countries worldwide, with an overall percentage of 11%, but lower than what was reported from a study in qatar with the percentage of 21.6%.6,17 superimposed preeclampsia is a condition where preeclampsia is preceded by chronic hypertension (hypertension beginning before 20 weeks gestation and or persisting after 12 weeks postpartum).8 the ‘conversion’ from chronic hypertension (uncomplicated state) to preeclampsia remains unclear. however, several factors were suspected to be involved in its pathological process, such as the imbalance between the pro-angiogenic factors: vascular endothelial growth factor (vegf) & placental growth factor (plgf); and anti-angiogenic factors: soluble fms like tyrosine kinase-1 (sflt-1) & soluble endoglin (seng), it is also mentioned that the preexisting endothelial dysfunction due to the vascular shear stress and endothelial injury in women with longstanding (chronic) hypertension may contribute to the imbalance of the previously mentioned angiogenic factors and thus exacerbate the occurrence of preeclampsia.18,19 preeclampsia could lead to stillbirth by several mechanisms: abnormality or pathology of placentation in preeclampsia characterized by the defect in spiral artery remodeling, abnormal trophoblastic invasion, along with the increased vascular resistance could lead to placental ischemia and fetal hypoperfusion; hence, several adverse effects could ensue such as iugr, fetal distress, and stillbirth.20 this study has several limitations. previous data regarding the maternal and risk factor characteristics of stillbirth in indonesia were not available. hence, the similarity and comparison between the result in this study and data before 2017 could not be concluded. this study was also single–centered, which the results might not represent the actual condition in west java province and indonesia. pre-pregnancy bmi could not be obtained since the subjects had prenatal/antenatal care (pnc/anc) outside the study location. in conclusion, the prevalence of stillbirth in this study is considerably low. of all recorded factors available, most patients have hypertensive disorders, specifically superimposed preeclampsia subtype, followed by an unknown factor and congenital abnormalities. among the abnormalities, hydrops fetalis accounts for the highest proportion. multi-centered study with a prolonged period is recommended to increase the study population. thus more table 3 risk factor(s) distribution of stillbirth number of risk factor(s) results (n = 219 n % 0 1 2 3 39 141 32 7 17.8 64.4 14.6 3.2 althea medical journal. 2022;9(4) 233 precise results can be obtained. analysis of the correlation between the risk factor and stillbirth occurrence is also recommended to establish further and differentiate significant and possible risk factor(s) of stillbirth. references 1. stillbirth collaborative research network writing group. causes of death among stillbirths. jama. 2011;306(22):2459–68. 2. tavares da silva f, gonik b, mcmillan m, keech c, dellicour s, bhange s, et al. stillbirth: case definition and guidelines for data collection, analysis, and presentation of maternal immunization safety data. vaccine. 2016;34(49):6057–68. 3. blencowe h, cousens s, jassir fb, say l, chou d, mathers c, et al. national, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. lancet glob health. 2016;4(2):e98–108. 4. dinas kesehatan provinsi jawa barat. profil kesehatan provinsi jawa barat tahun 2012. bandung: dinas kesehatan provinsi jawa barat; 2012. 5. gravensteen ik, jacobsen em, sandset pm, helgadottir lb, rådestad i, sandvik l, et al. anxiety, depression and relationship satisfaction in the pregnancy following stillbirth and after the birth of a live-born baby: a prospective study. bmc pregnancy childbirth. 2018;18(1):41. 6. reinebrant he, leisher sh, coory m, henry s, wojcieszek am, gardener g, et al. making stillbirths visible: a systematic review of globally reported causes of stillbirth. bjog. 2018;125(2):212–24. 7. wojcieszek am, shepherd e, middleton p, gardener g, ellwood da, mcclure em, et al. interventions for investigating and identifying the causes of stillbirth. cochrane database syst rev. 2018;4(4):cd012504. 8. khedagi am, bello na. hypertensive disorders of pregnancy. cardiol clin. 2021;39(1):77–90. 9. wang w, xie x, yuan t, wang y, zhao f, zhou z, et al. epidemiological trends of maternal hypertensive disorders of pregnancy at the global, regional, and national levels: a population-based study. bmc pregnancy childbirth. 2021;21(1):364. 10. desilva m, munoz fm, mcmillan m, kawai at, marshall h, macartney kk, et al. congenital anomalies: case definition and guidelines for data collection, analysis, and presentation of immunization safety data. vaccine. 2016;34(49):6015–26. 11. man j, hutchinson jc, heazell ae, ashworth m, levine s, sebire nj. stillbirth and intrauterine fetal death: factors affecting determination of cause of death at autopsy. ultrasound obstet gynecol. 2016;48(5):566–73. 12. mahardika a, ningrum wm. gambaran faktor risiko pada ibu dengan bayi lahir mati (stillbirth) di kabupaten tasikmalaya tahun 2017. j midwifery public health. 2019;1(2):3027. 13. sharma b, bhattarai s, shrestha s, joshi r, tamrakar r, singh p, et al. maternal and fetal characteristics and causes of stillbirth in a tertiary care hospital of nepal: secondary analysis of registry-based surveillance data. bmj open. 2021;11(8):e045012. 14. berhe t, gebreyesus h, teklay h. prevalence and determinants of stillbirth among women attended deliveries in aksum general hospital: a facility based cross-sectional study. bmc res notes. 2019;12(1):368. 15. desisto cl, wallace b, simeone rm, polen k, ko jy, meaney-delman d, et al. risk for stillbirth among women with and without covid-19 at delivery hospitalization-united states, march 2020–september 2021. morb mortal wkly rep. 2021;70(47):1640–5. 16. mcclure em, saleem s, goudar ss, garces a, whitworth r, esamai f, et al. stillbirth 2010–2018: a prospective, populationbased, multi-country study from the global network. reprod health. 2020;17(suppl 2):146. 17. maducolil mk, abid h, lobo rm, chughtai aq, afzal am, saleh hah, et al. risk factors and classification of stillbirth in a middle eastern population: a retrospective study. j perinat med. 2018;46(9):1022–7. 18. kametas na, nzelu d, nicolaides kh. chronic hypertension and superimposed preeclampsia: screening and diagnosis. am j obstet gynecol. 2022 feb;226(2s):s1182–95. 19. phipps e, prasanna d, brima w, jim b. preeclampsia: updates in pathogenesis, definitions, and guidelines. clin j am soc nephrol. 2016;11(6):1102–13. 20. fox r, kitt j, leeson p, aye cyl, lewandowski aj. preeclampsia: risk factors, diagnosis, management, and the cardiovascular impact on the offspring. j clin med. 2019;8(10):1625. david immanuel et al.: risk factor of stillbirth among pregnant women at dr. hasan sadikin general hospital bandung from 2017–2020 amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 87 vascular endothelial growth factor expression in correlation with stage juvenile nasopharyngeal angiofibroma ifiq budiyan nazar, yussy afriani dewi, agung dinasti permana department of otorhinolaryngology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: ifiq budiyan nazar, department of otorhinolaryngology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur no 38, bandung, indonesia, e-mail: ifiq82nazar@gmail.com introduction juvenile nasopharyngeal angiofibroma (jna) is a mesenchymal tumor with its constituent tissue originating from the stromal and blood vessels with dense collagen. the tumor predominantly arises from the superior part of the sphenopalatine foramen and the posterolateral wall of the nasopharynx.1 juvenile nasopharyngeal angiofibroma is a histologically benign, but clinically malignant tumor because it can damage the bone and extend to the surrounding tissue.2,3 the incidence of jna is 0.05–0.5% of all head and neck tumors and is relatively occurred more in india and egypt compared to america and europe. moreover, in asia, the incidence is around 1: 5,000 while in the middle east 1: 60,000. these lesions are almost always found in adolescent male patients, in the age range of 9–19 years with the highest incidence between the ages of 14–18 years.4–6 in indonesia, jna is reported 2 to 4 cases in 1 year.7 at dr. hasan sadikin general hospital bandung, there were 112 jna patients for the period of 2011–2018 with 111 male and 1 female, and most of them were in the age range of 10–20 years.8 the staging of the tumor can be seen from the ct scan results with the classification system based on the expansion of the tumor; the higher the clinical stage, and the more extensive lesions caused. the most commonly used and developed system in recent literature is the radkowski classification. amj. 2021;8(2):87–92 abstract background: juvenile nasopharyngeal angiofibroma (jna) is a benign tumor of mesenchymal tissue, originating from the stromal and blood vessels with dense collagen. however, jna has a malignant tumor-like property because it can cause erosion of surrounding bone. vascular endothelial growth factor (vegf) plays a role in the angiogenesis process. the expression of vegf is the best marker to determine the occurrence of angiogenesis in jna. this study aimed to determine the correlation between vegf expression and jna clinical stage. methods: this was a cross-sectional correlational analytic observational study on medical records and paraffin blocks of all patients with jna at dr. hasan sadikin general hospital bandung during the period of 2016 to 2019. immunohistochemistry examination of vegf expressions was performed and vegf expression was rated based on staining intensity, percentage distribution, and histoscore. data were then analyzed using the spearman correlation test. results: of 24 patients, 23 males and 1 female, 58% demonstrated a strong intensity of staining. the positivity of vegf cell percentage was identified as 26–50% (n=6 patients), 51–75% (n=11), and >75% (n=7). the median vegf histoscores were 2.5, 6.5, and 12 in jna stage i, stage ii, and stage 3, respectively, with the greater vegf histoscore had a higher clinical stage with a correlation coefficient of (rs) 0.723 (p=0.002). conclusions: there is a strong correlation between increased vegf expression and jna clinical stage. vegf expression can be used as a prognostic factor of jna. keywords: angiogenesis, juvenile nasopharyngeal angiofibroma, staging, vascular endothelial growth factor https://doi.org/10.15850/amj.v8n2.2170 althea medical journal. 2021;8(2) 88 althea medical journal june 2021 this assessment includes the extension to the posterior pterygoid and the rate of skull base erosion. this system considers the choice of surgical approach and the risk of recurrence.4,5 the cause of jna is not yet clearly known, being genetic factors, molecular alterations, hpv infections, and related to hormones that may play an important role in jna development.9 the growth of tumor tissue is related to increased estrogen production and reduced production of androgen hormones.10 furthermore, jna has biological characteristics of angiogenic histogenetic tumors.11 various attempts to determine tumor pathogenesis have been carried out by studying the expression of growth factors and oncogenes such as c-kit and c-myc. those studies support that vascular endothelial cells can become postembryonic undifferentiated mesenchyme cells and can be induced into other mesenchymal non-hemopoietic cell phenotypes. the gstm1 gene has been involved in the formation of jna. loss of gstm1 expression or null genotype has been observed in these tumors. angiogenesis in tumors is influenced by angiogenic factors such as basic fibroblast growth factor (bfgf), vascular endothelial growth factor (vegf), angiogenin, transforming growth factor (tgf), thrombopoietin, angiopoietin i, cytokines, angiogenic enzymes, and indirect activated activation factor. the vegf encourages enzymes and proteins that are important for the process of degradation of the basic membrane, useful for endothelial cells for migration and invasion which are important stages in angiogenesis. overexpression of vegf is associated with tumor progression and prognosis in various tumors, including jna. furthermore, the vegf contributes to proliferation and suggests the promotion of vascularity. the increased neovascularization, decreased apoptosis, and increased endothelial cell proliferation may lead to progressive and increased clinical stages.12,13 study on immunohistochemical examination for the vegf, tgfβ, estrogen and progesterone receptors (er-pr), and proliferating cell nuclear antigen (pcna), taken from anatomic pathological preparations of jna patients has shown that vegf, tgfβ, and pcna are widely expressed in jna tissue, and are positively related to the clinical stage and the prognosis of jna.14 the expression and subcellular distribution of several angiogenesis factors have been studied such as tgfβ, bfgf, vegf-r 1-2, and hypoxia inducible factor (hif-1α).15 the results show that the growth of vascularization and the progression of the clinical stage of jna are influenced by factors released by fibroblasts in the stroma. however, the effect of vegf is still debatable. interestingly, vegf expression is not significantly related to the puberty status, stage of the tumor, intraoperative blood loss, and the recurrence of the jna.16 the vegf has a central role in the pathways and stages of tumor angiogenesis, and especially the degradation of extracellular matrix and proliferation of vascular endothelial cells. increased endothelial cell proliferation will further increase microvascular density as well as increase vegf expression. the vegf expression is the best marker for determining the precence of angiogenesis in jna.15 therefore, the aim of this study was to determine the correlation between vegf expression and the clinical stage of jna. methods this study was a correlational analytic with a cross-sectional design. the secondary data of medical records of all jna patients at dr. hasan sadikin general hospital bandung period 2016–2019 was used, including the data of immunohistochemistry examination taken from paraffin blocks the study was conducted from may to october 2019. this study protocol was approved by the ethics committee of hasan sadikin hospital no: lb.02.01/ x.6.5 / 185/2019. inclusion criteria were data of patients diagnosed with jna, whereas the exclusion criteria were patients with residual or recurrent jna and incomplete medical records. the patients were then divided into three stages, using radkowski. tumor size was determined based on tumor diameter ≤4 cm and >4 cm. the immunohistochemistry (ihc) examination of the paraffin block conducted in the anatomical pathology section of the dr. hasan sadikin general hospital was further classified according to the clinical stage. the vegf expression was examined as followed: immunohistochemical smear with antibodies against vegf was performed with the incubation with vegf primary antibodies (mouse monoclonal antibody anti-human vegf, 100 μg, pa1080, bosterbio-usa) with a 1:200 dilution for one night; the incubation with secondary antibodies for 30 minutes; the enzymatic detection system abc (avidinalthea medical journal. 2021;8(2) 89ifiq budiyan nazar et al.: vascular endothelial growth factor expression in correlation with stage juvenile nasopharyngeal angiofibroma biotin complex) using peroxidase, and dab (diamino benzidin) enzymes as counterstain enzymes using hematoxylin eosin. the positive values were indicated by golden brown to the old color. the expression of vegf was assessed on the stromal and endothelial cells of the tumor and was counted visually with a multiheaded binocular light microscope at 400x magnification performed by 2 examiners at the same time and preparation. the vegf expression was further rated based on staining intensity, percentage distribution, and vegf histoscore. the score for the intensity of cell absorption on ihc staining was divided into a score of 0 or negative/ when there was no vegf expression, a score of 1+ or weak, a score of 2+ or moderate, 3+ or strong. of all tumor cells expressing positive, the distribution percentage score was determined for <25% (1+), 26–50% (2+), 51–75% (3+), and >75% (4+) the vegf expression was calculated semiquantitatively using the h-score formula with the formula [intensity x distribution]. the h score were 0 or negative, 1–4 as weakly positive, 5–8 as moderate positive, and 9–12 as strongly positive. results in total, 24 data was retrieved diagnosed with jna according to the inclusion and exclusion table 1 clinical characteristic of patients with juvenile nasopharyngeal angiofibroma at dr. hasan sadikin general hospital bandung period 2016–2019 variable total gender male female 23 1 age (year) 10–14 15–19 20–24 14 8 2 mean (sd) 15.6 (3.4) range 11-24 note: sd= standard deviation table 2 relationship between stage of juvenile nasopharyngeal angiofibroma with vegf expression, histoscore, and tumor size vegf expression jna stage total correlation coefficient (rs) p-value*i ii iii n n n n intensity of staining weak strong 5 3 4 4 1 7 10 14 0.414 0.044 distribution percentage < 25% 26–50% 51–75% >75% 6 2 7 1 2 6 6 11 7 0.832 <0.001 vegf histoscore ** median range 2.5 2–9 6.5 3–9 12 4–12 0.723 0.002 tumor size ≤ 4 cm > 4 cm 4 4 8 8 4 20 0.548 0.006 note: vegf= vascular endothelial growth factor; jna, juvenile nasopharyngeal angiofibroma; rs= correlation coefficient, *spearman test p< 0.05; ** histoscore in median criteria, being the youngest age found was 11 years and the oldest age was 24 years. the mean age was 15.6 years old (standard deviation, sd 3.4 years), as shown in table 1. the relationship between vegf expression and tumor size according to the clinical stage as depicted in table 2. the intensity ratio based on clinical stage showed a correlation coefficient (rs) of 0.414 (p=0.044, spearman correlation test), indicating a significant relationship between the intensity of staining of vegf expression to clinical stage. furthermore, the percentage of vegf distribution showed a significant correlation althea medical journal. 2021;8(2) 90 althea medical journal june 2021 with spearman correlation of 0.832 (p<0.001) with the clinical stage. the vegf histoscore variable median for stage i, stage ii, and stage iii were 2.5, 6.5, and 12, respectively. the rs the vegf histoscore to the clinical stage was 0.723 (p=0.002), suggesting that there was a significant relationship between vegf histoscore and vegf expression variable at anb clinical stage. the greater the vegf histoscore value, the higher the clinical stage (table 2). this study observed the intensity of the immunoreactivity and the percentage of positive cells that were initially estimated semi-quantitatively by light microscopy at 200x magnification in stromal cells and endothelial cells of jna (figure 1). weak expression of vegf was shown by pale brown color and positive cell distribution <25% (figure 1a), while strong expression showed figure 1 intensity of staining of vegf expression a b table 3 relationship between tumor size with age and vegf expression tumor size total correlation coefficient (rs) p-value*≤4 cm >4 cm age (year) 10–14 15–19 20–24 4 10 8 2 14 8 2 0.479 0.018 vegf expression intensity of staining weak strong distribution percentage <25% 26–50% 51–75% >75% 4 4 6 14 2 11 7 10 14 6 11 7 0.529 0.625 0.008 0.001 vegf histoscore *) median 2 9.5 0.660 <0.001 note: vegf=vascular endothelial growth factor; rs= correlation coefficient, *spearman test p< 0.05; ** histoscore in median note: a= weak expression (ihc 200x) b= strong expression (ihc 200x) althea medical journal. 2021;8(2) 91 dark brown staining and cell distribution >75% (figure 1b). based on radiological examination using ct scan, it showed that there was a relationship between tumor size and jna stage with the correlation coefficient value of 0.6 (p=0.002, spearman test). the relationship between tumor size and age in jna patients showed a significant correlation coefficient of 0.479 (p=0.018), as well the correlation between tumor size and vegf staining intensity that showed a statistical of rs 0.529 (p=0.008). the correlation to percentage distribution was 0.625 (p=0.001), and to the vegf histoscore was 0.660 (p <0.001) (table 3). discussion our study has explored the correlation between vegf expression and the clinical stage of juvenile nasopharyngeal angiofibroma (jna) at dr. hasan sadikin general hospital bandung period 2016–2019. the jna patients are predominantly male in this study, with the most prevalent age group is between 10–15 years old (54%), conforming to various studies in malaysia17 as well in jakarta, indonesia.2 jna has a predilection in the adolescent boys age range of 7–21 years with the highest incidence between the ages of 14–18 years and rarely at the age of 25 years.6 although the etiology of nasopharyngeal angiofibroma is unknown, this might be related to hormonal imbalance,4,9 such as an excess estrogen production or androgen deficiency.4,18 it seems that there is a relationship between tumors with the sex and age of the patient.7 in this study, strong staining (58.3%) and distribution percentage of >50% (75%) are the most predominant result of the vegf examination. the vegf expression has a significant correlation with the clinical stage (table 2). many studies had reported the escalation of vegf expression in jna, suggesting that the escalation of vegf expression in jna is correlated with the advanced clinical stage.10,15 however, another study has reported a different finding, vegf expression had no significant correlation with clinical stage of jna.16 as a pro-angiogenic growth factor that has a prominent role in tumor biology, vegf could induce vasculogenesis and angiogenesis. vegf has a correlation with the increase of proliferation and the density of blood vessels.10 however, some others show that proangiogenic factor in benign tumors has more effects towards blood vessel growth compared to tumor growth.19 the determination of the jna stage is based on the results of a ct scan with contrast. the characteristic assessment of ct scans is tumor size. there is a relationship between tumor size and jna clinical stage. high expression of vegf also has influenced the increase in tumor size. the higher the level of vegf expression, the larger the tumor size. previous studies have shown similar results, angiogenesis affects tumor growth.1,18 in tumor growth, neovascularization has two effects; namely supplying nutrients and oxygen, and the newly formed endothelial cells that stimulate the growth of tumor cells around them, through the secretion of polypeptides such as pdgf, gm-csf, and il-1. in cancers with high cell proliferation, tumor growth is faster, showing that the larger tumor size the higher degree of histopathology.20 the limitation of the study is difficulty in getting jna patients with stage i. furthermore, the process of staining the ihc with antibodies to vegf requires a long incubation time and dilution several times to get good results on sample readings. in conclusion, there is a strong correlation between increased vegf expression and the jna stage. higher of vegf expression may worsen the prognosis of jna. examination of vegf expression can be used as a marker to assess the prognostic factors of jna. references 1. shancez-romero c, carlos r, molina jpd, thompson ldr, de almeida op, pina ar. nasopharyngeal angiofibroma: a clinical, histopathological and immunohistochemical study of 42 cases with emphasis on stromal features. head neck pathol. 2018;12(1):52–61 2. anggreani l, adham m, musa z, lisnawati, bardosono s. gambaran ekspresi reseptor estrogen β pada angiofibroma nasofaring belia dengan menggunakan pemeriksaan imunohistokimia. orli. 2011;41(1):8–16 3. sun x, guo l, wang h, yu h, wang j, meng x, et al. the presence of tumor-infiltrating il-17 producing cells in juvenile nasopharyngeal angiofibroma tumor microenvironment is a poor prognostic factor. am j otolaryngol. 2014;35(5):582–8 4. nicolai p, schreiber a, villaret ab. juvenile angiofibroma: evolution of management. int j pediatr. 2012;2012:412545. 5. garcea mf, yuca sa, yuca k. juvenile nasopharyngeal angiofibroma. eur j gen ifiq budiyan nazar et al.: vascular endothelial growth factor expression in correlation with stage juvenile nasopharyngeal angiofibroma althea medical journal. 2021;8(2) 92 althea medical journal june 2021 med. 2010;7(4):419–25. 6. persky m., manolidis. s. vascular tumors of the head and neck. in: johnson jt, rosen ca. editors. bailey’s head and neck surgery-otolaryngology 5th (ed). baltimore: lippincott williams & wilkins: 2014. p.1999–2031. 7. adham m, zahara np, suroyo i, lisnawati, bardosono s. relationship of radiological and surgical variables and vascular endothelial growth factor expression with recurrence in juvenile nasopharyngeal angiofibroma. journal of physic: conference series. 2018;1073(4):042038. 8. dewi ya, nazar ib. management of juvenile nasopharyngeal angiofibroma in a refferal hospital in west java, indonesia. althea medical journal. 2020;7(1):45–50. 9. li w, ni y, lu h, hu l, wang d. current perspectives on the origin theory of juvenile nasopharyngeal angiofibroma. discov med. 2019;27(150):245–54. 10. liu z, wang j, wang h, wang d, hu l, liu q, et al. hormonal receptors and vascular endothelial growth factor in juvenile nasopharyngeal angiofibroma: immunohistochemical and tissue microarray analysis. acta otolaryngol. 2015; 135(1):51–7. 11. zhang m, sun x, yu h, hu l, wang d. biological distinctions between juvenile naopharyngeal angiofibroma and vascular malformation: immunohistochemical study. acta histochem. 2011;113(6):626–30. 12. melincovici cs, boşca ab, şuşman s, márginean m, mihu c, istrate m, et al. vascular endothelial growth factor (vegf)key factor in normal and pathological angiogenesis. rom j morphol embryol. 2018;59(2):455–67. 13. le t, new j, jones jw, usman s, yalamanchali s, tawfik o, et al. inhibition of fibroblast growth factor receptor with azd4547 mitigates juvenile nasopharyngeal angiofibroma. int forum allergy rhinol. 2017;7(10):973–79. 14. saylam g, yücel ot, sungur a, onerci m. proliferation, angiogenesis and hormonal markers in juvenile nasopharyngeal angiofibroma. int j pediatr otorhinolaryngol. 2006;70(2):227–34. 15. schuon r, brieger j, heinrich yr, szyfter w, mann wj. immunohistochemical analysis of growth mechanisms in juvenile nasopharyngeal angiofibroma. eur arch otorhinolaryngol. 2007;264(4):389–94. 16. hota a, sarkar c, gupta sd, kumar r, bhalla as, thakar a. expression of vascular endothelial growth factor in juvenile angiofibroma. int j pediatr otorhinolaryngol. 2015;79(6):900–2. 17. saniasiaya j, abdullah b, ramli rr. surgical management and outcome of juvenile nasopharyngeal angiofibroma in a single centre: a fifteen year experience. egypt j ear nose throat allied sci. 2016:18(1): 39–41. 18. ralli m, fusconi m, visconti ic, martelucci s, de vincentis m, greco a. nasopharyngeal angiofibroma in an elderly female patient: a rare case report. mol clin oncol. 2018; 9(6):702–4. 19. pandey p, mishra a, tripathi am, verma v, trivedi r, singh hp, et al. current molecular profile of juvenile nasopharyngeal angiofibroma: first comprehensive study from india. laryngoscope. 2016;127(3): e100–106. 20. hong is. stimulatory versus suppressive effects of gm-csf on tumor progression in multiple cancer types. exp mol med. 2016;48(7):e242. vol 6 no 3 full text fix.indd althea medical journal. 2019;6(3) 140 amj september 2019 the risk factors and collateral system in coronary artery disease among patients in bandung gabriella graziani,1 toni m. aprami,2 r. b. soeherman3 1faculty of medicine universitas padjadjaran, indonesia, 2department of cardiology & vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: gabriella graziani, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: gabzgraziani24@gmail.com introduction ischemic heart disease (ihd) is the major cause of death in the world.1 according to the ministry of health republic of indonesia, cardiovascular disease, especially coronary artery disease (cad), is the major cause of death in indonesia and diabetes mellitus has been known as the highest co-morbidity for cardiovascular disease with 308 cases per 100.000 population.2 in more than 90% of cases, there is a lack of blood flow that causes an atherosclerotic plaque obstruction, leading to myocardial ischemia, known as an acute coronary syndrome or an acute myocardial infarct.1 an adequate collateral system of coronary arteries may prevent myocardial ischemia.3,4 however, the collateral system is sometimes affected by various risk factors such as dyslipidemia, obesity, hypertension, diabetes mellitus, and smoking habit.5 the risk factors, consisting of behavioral factors and metabolic factors,6 may affect the collateral systems in different ways. for example, a high level of lowdensity lipoprotein (ldl) is toxic for endothelial cells and smooth muscle cells; and inhibits the proliferation and migration of these cells. the oxidized ldl inhibits migration of vascular endothelial growth factor (vegf) as an angiogenic agent.8 furthermore, smoking inhibits growth factor secretion that plays an important role in angiogenesis.8,9 other risk factor is hypertension which is characterized by a decrease in nitric oxide (no) biosynthesis, and no can disrupt the angiogenesis.10 the collateral system in diabetic patients is more pronounced compared to non-diabetic patients due to an impaired microvascular function.11 interestingly, obesity is associated with impaired coronary collateral vessel amj. 2019;6(3):140–3 abstract background: the slow blood flow may cause atherosclerotic plaque, leading to an obstruction in the arterial circulation, and thus resulting in among others myocardial ischemia. there are many risk factors associated with the collateral system such as dyslipidemia, obesity, hypertension, diabetes mellitus, and smoking habit. this study aimed to determine the association between risk factors and collateral system in patients in bandung. methods: this was an analytical cross-sectional study, using data of 186 medical records taken from dr. hasan sadikin general hospital in october 2013. the risk factors were assessed and the prevalence ratio reflected the association between the risk factors and the collateral system was analyzed. results: the study revealed no significant association between each risk factor and the collateral system, including obesity (p=0.690), smoking (p=0.175), dyslipidemia (p=0.747), and diabetes mellitus (p=0.616); however, only hypertension was associated (p=0.020). furthermore, no significant association was found between the number of risk factor and the collateral system (p=0.233). conclusions: of the risk factors published, only hypertension is a significant risk factor among patients in bandung, while others including obesity, smoking, dyslipidemia and diabetes mellitus are not associated. further study needs to be performed to explore other risk factors in coronary artery disease, and to prevent the disease among the population. keywords: collateral, coronary artery disease, risk factor althea medical journal. 2019;6(3) 141 development, thus patients with diabetes mellitus have a more affected collateral system.12 it is suggested that the more the risk factors, the more the collateral system is affected. this study aimed to determine the association between risk factors and collateral system in patients in bandung. methods this was an analytical cross-sectional study involving data from medical records from january to december 2012, taken consecutively from the medical records archive at dr. hasan sadikin general hospital in october 2013. all patients diagnosed with cad and had an angiographic examination were included. clinical information, such as gender, age, and various risk factors known to influence the development of collaterals, including a history of hypertension, smoking habit, obesity, dyslipidemia, and diabetes mellitus were documented. incomplete data on risk factors and angiographic examination were excluded. this study had been approved by the health research ethics committee. to determine the quality of the collateral systems in the angiograms, rentrop score was calculated by an experienced cardiologist interventionist. patients were considered to have dyslipidemia when the total cholesterol level was ≥200 mg/dl, triglyceride ≥200 mg/dl, ldl ≥130 mg/dl, and high-density liporpotein (hdl) <40 mg/dl.7 hypertension was defined as blood pressure ≥140/90 mmhg. patients were considered to have diabetes mellitus when fasting blood glucose level was higher than 126 mg/dl. obesity was designated as body mass index (bmi) ≥30.00 kg/m2.13 the statistical analysis was performed by statistical product and service solution (spss); bivariate analysis was used because this study involved one dependent variable and one independent variable. hypothesis testing was determined by the chi-square method. the prevalence ratio (pr) was further calculated. results in total, there were 223 patients admitted in the department of cardiology, dr. hasan sadikin general hospital, consisting of 183 men and 40 women, and only 186 had complete data as table 1 baseline characteristics characteristics rentrop total n=186good poor n=117 n=69 age (yr) mean (sd) 59.09 (9.33) 54.9 (8.51) 57.53 (9.24) median 59 54 57 range 44 42 53 sex; n (%) male 96 (82.1) 58 (84.1) 154 (82.8) female 21 (17.9) 11 (15.9) 32 (17.2) height (m) mean (sd) 1.63 (0.07) 1.62 (0.07) 1.63 (0.07) median 1.65 1.63 1.64 range 0.38 0.31 0.38 weight (kg) mean (sd) 64.18 (11.24) 65.55 (10.15) 64.69 (10.84) median 65 65 65 range 75 44 75 risk factors; n (%) obesity 2 (1.7) 1 (1.4) 3 (1.6) smoking 68 (58.1) 47 (68.1) 115 (61.8) dyslipidemia 77 (65.8) 47 (68.1) 124 (66.7) dm 31 (26.5) 16 (23.2) 47 (25.3) hypertension 81 (69.2) 36 (52.2) 117 (62.9) note: dm=diabetes mellitus gabriella graziani et al.: the risk factors and collateral system in coronary artery disease among patients in bandung althea medical journal. 2019;6(3) 142 amj september 2019 shown in table 1. the rentrop score was good (n117; 62.9%) and poor (n69; 37.1%). the result of this study revealed that there was no association between each risk factors and the collateral system, such as obesity (p=0.70), smoking (p=0.18), dyslipidemia (p=0.75) and diabetes mellitus (p=0.62), however, hypertension was associated with the collateral system (p=0.02), although the ci 95% was low 0.45–0.93 (table 2). furthermore, no association was found between the number of risk factors involved and the collateral system (p=0.23) as shown in table 3. discussion this study has shown that diabetes mellitus has no association with the collateral development, conforming study performed by zorkun et al.13 the collateral flow index (cfi) has been also reported to be no difference between diabetic and non-diabetic patients.14 the differentiation in cofactors that influence collaterals and the differentiation between angiogenesis and arteriogenesis may play an important role. interestingly, our study also shows that there is no association with other coronary risk factors, including obesity, dyslipidemia, and smoking habit. the data taken in this study did not consider any treatment used by the patients. the use of antihypertensive, anti-diabetic, and lipid-lowering drugs has been considered as a positive risk factor.13 the only result with a significant finding in our study is hypertension which has an association with the collateral development. hypertension is considered to have a protective factor from poor collateral circulation, as analyzed using the prevalence ratio. the development of collateral circulation is initiated by a steep pressure gradient between high pre-occlusive and very low post-occlusive pressure regions. subsequently, deformation of the endothelial cells might occur through the increased pulsatile fluid shear stress (fss). the process of arteriogenesis can be drastically stimulated by increases in fss.15 myocardial hypoxia is the main factor in stimulating collateral circulation and to dilate stenotic coronary vessels.15 when the stenosis has occluded of 70% in the vessel table 2 result of the association between modifiable risk factors and collaterals risk factors rentrop p-value prevalence ratio confidence interval 95%poor (n=69) good (n=117) obesity yes 1 2 0.70 0.90 n.d.no 68 115 smoking yes 47 68 0.18 1.32 n.d.no 22 49 dyslipidemia yes 47 77 0.75 1.07 n.d.no 22 40 dm yes 16 31 0.62 0.90 n.d. no 53 86 hypertension yes 36 81 0.02 0.64 0.45–0.93no 33 36 note: dm diabetes mellitus; n.d.=not determined table 3 result of the association between the number of risk factors and collaterals rentrop category total p-value a b c poor (score 0–1) 17 48 4 69 0.23 good (score 2–3) 18 93 6 117 total 35 141 10 186 note: a=<2 risk factors; b=2-3 risk factors; c=4-5 risk factors althea medical journal. 2019;6(3) 143gabriella graziani et al.: the risk factors and collateral system in coronary artery disease among patients in bandung diameter, distal coronary pressure would fall and thus increase the endothelial shear stress at the other collaterals, causing a dilation of the collateral progressively through the remodeling process.6 subsequently, the stenosis may develop into a complete occlusion and in this condition, collateral circulation may reach a maximum adaptation.15 occlusion may cause ischemia and the development of collateral systems if the occlusions develop gradually.15 the previous study showed that the development of collateral circulation is affected by ischemic symptoms and the severity of occlusion in a long-term condition. the history of angina pectoris, pre-infarction angina, and time to cardiac catheterization are associated with a higher prevalence of collateral circulation.16 in this study, information about symptoms, length of the symptoms occurred, and the severity of the occlusions are lacking, therefore, as limitation of this study, the severity of the occlusion is not considered. also, only one cardiologist interventionist has reviewed the angiograms, thus, no inter-observer data available. to conclude, our study shows no association between various coronary risk factors and coronary collateral circulation, except for hypertension. further study needs to be performed to explore other risk factors in coronary artery disease, and to prevent the disease among the population. references 1. kumar v, abbas ak, fausto n, editors. robbins and cotran pathologic basis of disease. 7th ed. philadelphia: elsevier saunders; 2005. 2. world health organization. cause of death 2008: data sources and methods. geneva: who; 2011 3. ege mr, açıkgöz s, zorlu a, sincer i, güray y, güray u, et al. mean platelet volume: an important predictor of coronary collateral development. platelets 2013;24(3):200–4 4. meier p, hemingway h, lansky aj, knapp g, pitt b, seiler c. the impact of the coronary collateral circulation on mortality: a meta analysis. eur heart j. 2012; 33(5):614–21. 5. koerselman j, van der graaf y, de jaegere p, grobbee de. coronary collaterals : an important and underexposed aspect of coronary artery disease. circulation. 2003;107(19):2507–11. 6. bonow ro, mann dl, zipes dp, libby p, editors. braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. philadelphia: elsevier saunders; 2011. 7. jellinger ps, smith da, mehta ae, ganda o, handelsman y, rodbard hw, et al. guidelines for management of dyslipidemia and prevention of atherosclerosis: executive summary. endocr pract. 2012;18(2):269– 93. 8. kinnaird t, stabile e, zbinden s, burnett ms, epstein se. cardiovascular risk factors impair native collateral development and may impair efficacy of therapeutic interventions. cardiovasc res. 2008;78(2):257–64. 9. mouquet f, cuilleret f, susen s, sautière k, marboeuf p, ennezat pv, et al. metabolic syndrome and collateral vessel formation in patients with documented occluded coronary arteries: association with hyperglycaemia, insulin-resistance, adiponectin and plasminogen activator inhibitor-1. eur heart j. 2009;30(7):840– 9. 10. kiefer fn, neysari s, humar r, li w, munk vc, battegay ej. hypertension and angiogenesis. curr pharm des. 2003:9(21):1733–44. 11. werner gs, richartz bm, heinke s, ferrari m, figulla hr. impaired acute collateral recruitment as a possible mechanism for increased cardiac adverse events in patients with diabetes mellitus. eur heart j. 2003;24(12):1134–42. 12. yilmaz mb, biyikoglu sf, akin y, guray u, kisacik hl, korkmaz s. obesity is associated with impaired coronary collateral vessel development. int j obes relat metab disord. 2003;27(12):1541–5. 13. zorkun c, akkaya e, zorlu a, tandogan i. determinants of coronary collateral circulation in patients with coronary artery disease. anadolu kardiyol derg. 2013;13(2):146–51. 14. zbinden r, zbinden s, billinger m, windecker s, meier b, seiler c. influence of diabetes mellitus on coronary collateral flow: an answer to an old controversy. heart. 2005; 91(10):1289–93. 15. schaper w. collateral circulation past and present. basic res cardiol. 2009;104(1):5– 21. 16. kurotobi t, sato h, kinjo k, nakatani d, mizuno h, shimizu m, et al. reduced collateral circulation to the infarctrelated artery in elderly patients with acute myocardial infarction. j am coll cardiol.2004; 44(1):28–34. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 188 correlation between birth length, growth, and development among children in rempoah village banyumas, central java, indonesia sahda vania salsabiila,1 qodri santosa,2 vitasari indriani,3 kurniawati arifah,2 joko setyono,4 1faculty of medicine universitas jenderal soedirman, indonesia, 2department of child health, faculty of medicine universitas jenderal soedirman/margono soekarjo hospital purwokerto, indonesia, 3department of clinical pathology, faculty of medicine universitas jenderal soedirman/margono soekarjo hospital purwokerto, indonesia, 4department of biochemistry faculty of medicine universitas jenderal soedirman, indonesia correspondence: dr. dr. qodri santosa, m.si.med., sp.a, department of child health, faculty of medicine jenderal soedirman university/margono soekarjo hospital purwokerto, central java, indonesia, e-mail: qodrisantosa@gmail.com althea medical journal. 2021;8(4):188–192 abstract background: the first 1,000 days of life are the foundation for growth and development of children in the next period. birth length may represent growth and development during the intrauterine life. this study aimed to explore the correlation of birth length, growth, and development in children. methods: this was analytic observational study with a cross-sectional design. total sampling was taken, obtaining 368 children aged 6−60 months in several integrated service post (pos pelayanan terpadu, posyandu), conducted from october to november 2018. data were gathered from the book of maternal and child health (kesehatan ibu dan anak, kia), including birth length, body length/height, and nutritional status using weight-for-length/height index. data were analyzed by spearman and eta test. results: birth length was not correlated with nutritional status (p=0.108, r=0.084), but had a good correlation with body length/height (p=0.027, r=0.115) and development based on the kia book (f calculated > f table, ƞ=0.245). conclusions: there is a correlation between birth length and body length/height as well as a correlation between birth length and development based on the kia book. it is important for the community and health workers to monitor growth and development of children, by maximizing the use of kia book. keywords: birth length, children, development, growth introduction the degree of children’s health can reflect the nation’s health, since children are the next generation of a country. optimization of children development is necessary to obtain a good quality of children’s future, especially in the first 1,000 days of a child’s life as the foundation for the next period.1 based on the basic health research (riset kesehatan dasar) in 2018, about 13.8% of toddlers are malnourished and 30.8% of children are stunted in indonesia.2 approximately 20.2% of malnourished children in indonesia have a history of short birth length, which is less than 48 cm.3 in 2018, banyumas was ranked fifth for short birth length children in central java.4 regular monitoring is essential to detect any disturbances in early childhood development. length at birth can describe a child’s growth since intrauterine through the size of the birth length.5 previous studies have shown that birth length is associated with child’s growth and development.6,7 low birth length can describe growth barriers due to malnutrition during intrauterine periods.8 previous study suggests that birth length is one of the determinants or factors that may delay in child development.9 children with low birth length are at risk of delay or developmental disorders, such as cognitive ability barriers and muscle maturity disorders.5,10 https://doi.org/10.15850/amj.v8n4.2369 althea medical journal. 2021;8(4) 189 the study of children’s growth and development in rempoah village has never been done, therefore, this study aimed to correlate the birth length with children’s growth and development in rempoah village, baturaden district, banyumas, central java, indonesia. methods the study used an analytic observational design with a cross-sectional approach. secondary data from the book of maternal and child health (kesehatan ibu dan anak, kia) were collected and the protocol of the study was approved by the medical research ethics commission universitas jenderal soedirman purwokerto (no: 009/kepk/i/2021). the sampling technique used in this study was total sampling that recruited children aged 6−60 months at the integrated service post (pos pelayanan terpadu, posyandu) bina kasih i–xi rempoah village, during the period from october to november 2018. children under 2 years old with chronic/congenital diseases or history of prematurity for children or incomplete data were excluded. measurements in this study were conducted by cadres using standardized and calibrated equipments. the independent variable was length at birth, whereas the dependent variable was children’s growth and development, including nutritional status based on weight for length/ height index, body length/height at the time of measurement, and development. data were analyzed by spearman and eta test. the results were significant if the p-value was less than 0.05 (spearman test) and the f-calculated value was more than the f-table (eta test). results a total of 368 out of 568 children were included in this study. the most prevalent age group in this study was the age group of 25– 36 months (27.4%) with more boys (54.3%) than girls (45.7%). most of the children had normal/good nutritional status (74.7%) and age-appropriate development based on the kia book (93.8%) (table 1). the median birth length of the children was 49 cm (range 40– 58) and the mean±sd was 48.4 cm±2.245. correlation analysis using spearman test showed no statistically significant correlation between birth length and nutritional status sahda vania salsabiila et al.: correlation between birth length, growth, and development among children in rempoah village banyumas, central java, indonesia table 1 basic characteristics of children aged 6−60 months from rempoah village, banyumas, central java for the period from october to november 2018 characteristics frequency (n) % age (months) 6–12 13–24 25–36 37–48 49–60 46 66 101 90 65 12.5 17.9 27.4 24.5 17.7 gender male female 200 168 54.3 45.7 nutritional status severely wasted/wasted normal risk of over nutrition/over nutrition/obese 25 275 68 6.8 74.7 18.5 development based on the kia book age-appropriate not appropriate 345 23 93.8 6.3 birth length (centimeters) 40–44 45–49 50–54 55–59 18 244 104 2 4.9 66.3 28.3 0.5 althea medical journal. 2021;8(4) 190 (p=0.108). however, there was a significant correlation between birth length and body length/height at the time of measurement (p=0.027) with a positive correlation direction, but very weak correlation (r=0.115) (table 2). the eta test indicated that there was a significant correlation (f calculated > f table) between birth length and development based on the kia book with a positive correlation direction, but the correlation was weak (ƞ =0.245). discussion in this study, there is a correlation between birth length and body length/height as well as correlation between birth length and development based on the kia book, but no significant correlation between birth length and nutritional status. similar to previous studies, most of the children aged 25−36 months, more boys with excellent or normal nutritional status.8,9,11 furthermore, most of the children (91.7%) have normal or age-appropriate development based on the kia book.12 however, this study shows no significant correlation between birth length and nutritional status. interestingly, previous studies using length/height for age as the nutritional status indicator have shown an association between birth length and nutritional status.7 the birth length that is not correlated with nutritional status might be due to the higher level of parents’ awareness and knowledge to fulfill children’s dietary needs, including providing exclusive breastfeeding and complementary breasfeeding foods (makanan pendamping air susu ibu, mpasi) adequately. the level of parental knowledge about toddlers’ adequacy and nutritional needs will affect the type of food their children eat. optimal and adequate intake of nutrients can reduce the effects of poor intrauterine growth.13,14 malnutrition is a very complex problem since nutritional status is related to many factors such as knowledge of nutrition, family socioeconomic status including poverty, cultural issues in society, community beliefs, food processing techniques, and diet.15 there is an association between birth length and body length/height at the time of measurement in a positive direction, but the correlation is very weak. a cohort study of 4,000 children in brazil16 has predicted a significant and positive correlation between birth length and child’s length/height in the future with a weak correlation (r=0.25). length at birth may represent the intrauterine growth of the child.5 birth length is a critical or essential factor in the linear growth of children aged 0−24 months. children born with short birth length experienced a slight increase in body length/height compared to other children in their age.17 furthermore, length/height is determined by the interaction between genetic factors, maternal environmental conditions, pregnancy, and nutritional intake.18,19 the correlation between birth length and body length/height illustrates that length at birth is related to children’s length/height in the future. early growth of children since intrauterine period needs to be considered properly. length at birth correlates with development of children as registered on the kia book. short birth length indicates a disruption of child’s growth intrauterine, and this might be due to inadequate nutritional intake of the mothers. therefore, children with short birth lengths are at risk for developmental delays or disruptions.6,7 children with short birth lengths are more susceptible to infections which might further disrupt the growth process of the brain, leading to barriers of cognitive abilities that have an impact on children’s achievements, exploratory interest, and future thinking abilities.5,10 children with short birth lengths are also at risk of experiencing muscle maturity obstacles, that may cause a decrease in motor skills. proper rough or smooth motor table 2 correlation between birth length, nutritional status, body length/height at measurement, and development based on the kia book birth length (cm) n p-value r eta (ƞ ) f calculated f table nutritional status 368 0.108 0.084 body length/height at measurement 368 0.027 0.115 development based on the kia book 0.245 23.36 3.86 althea medical journal december 2021 althea medical journal. 2021;8(4) 191sahda vania salsabiila et al.: correlation between birth length, growth, and development among children in rempoah village banyumas, central java, indonesia abilities will support children in exploring and interacting with the environments as well as their cognitive, language, socio-emotional development, and vice versa.20 there are limitations in this study, such as the measurements that have been performed at one-time by cadres and no direct training to cadres in conducting anthropometric measurements. future study using cohort study might be useful to observe the children’s growth and development patterns. furthermore, this study did not control for various factors that might influence children’s growth and development, such as a history of complications or conditions during pregnancy and childbirth, developmental stimulation, parenting styles, and others. these factors might be of great benefit to be explored in future studies. to conclude, birth length is correlated with length/height and development based on kia book, but has no correlation with nutritional status. regular monitoring of children development at the posyandu every 3−6 months is imperative. health workers and policy makers are expected to optimize the use of kia book and conduct counseling or socialization about the importance of the children’s growth and development to the community. moreover, mother should pay attention to the adequacy of nutritional intake before and during pregnancy. acknowledgment we would like to thank the universitas jenderal soedirman purwokerto for providing funding for this research through the blu research program competency research scheme 2018. references 1. beal t, tumilowicz a, sutrisna a, izwardy d, neufeld. a review of child stunting determinants in indonesia. matern child nutr. 2018;14(4):e12617. 2. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. hasil utama riset kesehatan dasar (riskesdas) tahun 2018. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2018. 3. trihono, atmarita, tjandrarini dh, irawati a, utami nh, tejayanti f, et al. pendek (stunting) di indonesia, masalah, dan solusinya. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan; 2015. 4. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. laporan provinsi jawa tengah riskesdas 2018. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2019. 5. supariasa i, bakri b, fajar i. penilaian status gizi. 2nd ed. jakarta: egc; 2016. 6. nurmalasari rg, widyastuti y, margono m. hubungan panjang badan lahir dengan perkembangan anak usia 3–24 bulan di kabupaten gunungkidul tahun 2017. jurnal kesehatan ibu dan anak. 2017;11(1):57–61. 7. utami nh, rachmalina r, irawati a, sari k, rosha bc, amaliah n, et al. short birth length, low birth weight and maternal short stature are dominant risks of stunting among children aged 0–23 months: evidence from bogor longitudinal study on child growth and development, indonesia. malays j nutr. 2018;24(1):11–23. 8. hairunis mn, salimo h, dewi ylr. hubungan status gizi dan stimulasi tumbuh kembang dengan perkembangan balita. sari pediatri. 2018;20(3):146–51. 9. kirkegaard h, möller s, wu c, häggström j, olsen sf, olsen j, et al. associations of birth size, infancy, and childhood growth with intelligence quotient at 5 years of age: a danish cohort study. am j clin nutr. 2020;112(1):96–105. 10. grantham-mcgregor sm, fernald lch, kagawa rmc, walker s. effects of integrated child development and nutrition interventions on child development and nutritional status. ann n y acad sci. 2014;1308:11–32. 11. prastiwi mh. pertumbuhan dan perkembangan anak usia 3–6 tahun. jiksh. 2019;8(2):242–9. 12. dardjito e, sistiarani c, nurhayati s. deteksi pertumbuhan dan perkembangan balita melalui penggunaan buku kia. kesmas indonesia. 2014;6(3):166–75. 13. rahman ms, howlader t, masud ms, rahman ml. association of low-birth weight with malnutrition in children under five years in bangladesh: do mother’s education, sosio-economic status, and birth interval matter? plos one. 2016;11(6):e0157814. 14. akombi bj, aghoke, hall jj, wali n, renzaho amn, merom d. stunting, wasting, and underweight in sub-saharan africa: a systematic review. int j environ res public althea medical journal. 2021;8(4) 192 health. 2017;14(8):863−81. 15. ariati nn, fetria a, padmiari iae, purnamawati aap, sugiani pps, suarni nn. description of nutritional status and the incidence of stunting children in early childhood education programs in baliindonesia. bali med j. 2018;7(3):723−6. 16. araújo clp, hallal pc, nader ga, menezes amb, victora cg. size at birth and height in early adolescence: a prospective birth cohort study. cad saúde publica. 2008;24(4):871–8. 17. svefors p, rahman a, ekström ec, khan ai, lindström e, persson lå, et al. stunted at 10 years: linear growth trajectories and stunting from birth to pre-adolescence in a rural bangladeshi cohort. plos one. 2016;11(3):e0149700. 18. jelenkovic a, yokoyama y, sund r, hur ym, harris jr, brandt i, et al. associations between birth size and later height from infancy through adulthood: an individual based pooled analysis of 28 twin cohorts participating in the codatwins project. early hum dev. 2018;120:53–60. 19. latif rvn, istiqomah n. determinan stunting pada siswa sd di kabupaten pekalongan. unnes j public health. 2017;6(1):68−74. 20. larson lm, yousafzai ak. a meta-analysis of nutrition interventions on mental development of children under-two in lowand middle-income countries. matern child nutr. 2017;13(1):e12229. althea medical journal december 2021 amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 145 clinical features and outcomes of patients with tetanus at dr. hasan sadikin general hospital bandung 2015–2019 ananda pratama kesumaningtyas gunawan,1 ahmad rizal ganiem,2 siti aminah,2 lisda amalia,2 sofiati dian2 1faculty of medicine universitas padjadjaran, indonesia, 2departement of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: ananda pratama kesumaningtyas gunawan, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km 21, jatinangor, sumedang, indonesia, e-mail: ananda17002@mail.unpad.ac.id introduction tetanus, a disease caused by a neurotoxin released by the causative bacterium clostridium tetani, is characterized by painful muscle spasms all over the body.1,2 clinically, tetanus may be classified into 4 forms, including generalized, localized, cephalic, and neonatal tetanus.3 even though tetanus is a vaccine-preventable disease, tetanus still becomes an important health issue worldwide, particularly in developing countries due to high mortality rates and low immunization coverage.4 about one million new cases of tetanus are reported in the world each year, with mortality in up to a quarter of the cases.5 however, the mortality rate has shown a decline after the immunization programs were performed in many countries.6 indonesia has performed the extended program on immunization (epi) since 1979 to eradicate tetanus, through tetanus toxoid (tt) immunization among couples, pregnant women, and infants.7 elementary school students also become the population target of the tetanus vaccination program in indonesia, with the vaccination scope has reach >90% since 1990.8 this strategy gives protection to both women and men until young adult age.8 moreover, women of reproductive age receive additional vaccination as prevention of neonatal tetanus since 1996.8 the mortality rate of adult tetanus patients in indonesia after performing epi remains high, compared with other southeast asian countries.6 besides vaccination history, clinical althea medical journal. 2022;9(3):145–150 abstract background: tetanus is a disease characterized by painful muscle spasms all over the body, which still becomes an important health issue worldwide, particularly in developing countries due to the high mortality rate. the clinical features also affect the mortality rate of adult tetanus patients. tetanus severity score (tss) is a prognostic scoring system developed in vietnam that uses clinical features to predict the mortality rate in adult tetanus patients. the aim of this study was to describe the clinical features and outcomes of adult tetanus patients using tss. methods: a descriptive, cross-sectional study with a total sampling method was conducted between 2015 and 2019. a total of 71 medical records of adult generalized tetanus patients in the department of neurology dr. hasan sadikin general hospital bandung were collected to analyze the clinical features and outcomes using tss. statistical analysis was performed using spss software ver. 25.0. results: among seventy-one tetanus patients, 62 (87%) were male, and the average age was 55.2±11.2 years. more than half of the patients (71%) were having grade iii or worse and experienced dysautonomia complications (58%). the mortality rate was 38% and those who survived at discharge, 89% had tss score <8, where as 37% who died had tss score ≥8. conclusion: tetanus in bandung has a high mortality rate. those who have died have high tss scores, while the survivors have low tss scores, suggesting that the tss is a prospective scoring to predict the mortality rate in patients with tetanus in indonesia. keywords: clinical features, outcomes, tetanus, tetanus severity score https://doi.org/10.15850/amj.v9n3.2299 althea medical journal. 2022;9(3) 146 features like age, the onset of symptoms, and port of entry also affect the mortality in adult tetanus patients.9 tetanus severity score (tss) is a prognostic scoring system developed in vietnam and introduced in the year 2006 by thwaites et al.10 which uses certain clinical features to predict the mortality rate of adult tetanus patients. studies about clinical features and outcomes among adult tetanus patients using tss in the world, including in indonesia are still lacking. the aim of this study was to describe the clinical features and outcomes of adult tetanus patients using tss. methods this was descriptive research with a crosssectional study design. secondary data from medical records of all adult generalized tetanus patients aged 18 years old and older admitted to the neurology ward of dr. hasan sadikin bandung hospital between 2015 to 2019 were collected. medical records with incomplete and missing data were excluded. the characteristic variables used in this study were age, sex, presence of autonomic dysfunction, grade of tetanus, blood pressure on admission, heart rate on admission, the temperature on admission, and patient status at discharge. grade of tetanus was classified into five grades according to patel and joag grading.11 the clinical feature variables were classified based on the tss scoring system (table 1). due to a lack of operational definition in the original article, difficulty breathing on admission was then defined as respiratory rate >30 times/minute on admission. all patients with punctured wounds, incised wounds, torn wounds, excoriation wounds, and other types of injuries, except post-operative wound, postpartum wounds, and open fractures were classified as other entry sites.10 the variable co-existing medical conditions are defined according to the american society of anesthesiologists (asa) physical status scale.10 those clinical features are then calculated individually. in the original article, the cutpoint of tss was 8, with a score ≥8 indicated a high mortality or predicted death (53%) and score <8 indicated a low mortality (6.3%).10 the present study was approved by research ethics committee universitas padjadjaran with ethical number 731/un6. kep/ec/2020. data analysis was performed using spss software ver. 25.0. results during the study period, a total of 141 adult patients were admitted with generalized tetanus. out of 141 patients, 71 patients with complete medical records were included. the average age was 55.2±11.2 years, with predominantly male (87%). more than half of the patients (58%) experienced autonomic table 1 tetanus severity score10 clinical features score age (years) ≤70 71–80 >80 0 5 10 time from the first symptom to admission (days) ≤2 3–5 >5 0 -5 -6 difficulty breathing on admission no yes 0 4 co-existing medical conditions fit and well minor illness or injury moderately severe illness severe illness not immediately life threatening immediately life-threatening illness 0 3 5 5 9 entry site internal or injection other or unknown 7 0 highest blood pressure recorded during the first day in the hospital (mmhg) ≤130 131–140 >140 0 2 4 highest heart rate recorded during the first day in the hospital (bpm) ≤100 101–110 111–120 >120 0 1 2 4 lowest heart rate recorded during first day in hospital (bpm) ≤110 >110 0 -2 highest temperature recorded during the first day in the hospital (0c) ≤38.5 38.6–39 39.1–40 >40 0 4 6 8 althea medical journal september 2022 althea medical journal. 2022;9(3) 147ananda pratama kesumaningtyas gunawan et al.: clinical features and outcomes of patients with tetanus at dr. hasan sadikin general hospital bandung 2015–2019 dysfunction. based on the grading of patel-joag, most patients (41%) had a grade 3. in-hospital mortality was 38%. the highest proportion of mortality was found in the patient with grade v (80%) with the second highest was grade iv (68%), followed by grade ii (17%). half of the patients (51%) were admitted to the hospital quickly which was ≤2 days after the first symptom. almost all patients (97%) had no difficulty breathing on admission, and mostly (88%) had no underlying systemic disease. the most common entry site (99%) was unknown. the frequency of the highest systolic blood pressure recorded during the first day in the hospital varied. almost half of the patients (45%) had the highest systolic blood pressure ≤130 mmhg. many patients (68%) had the highest heart rate recorded during the first day in the hospital ≤100 times/minute. almost all patients (99%) had the lowest heart rate of ≤110 times/minute. the majority of patients had the highest temperature recorded during the first day in hospital ≤38.50c (94%). all characteristics of the study subjects were shown in table 2. fifty-six subjects had scores <8, while the remaining 15 subjects had scores ≥8. the distribution of clinical features according to tetanus severity score was shown in table 3. further, 39 of 44 survived patients (89%), had scores <8. ten of 27 subjects (37%) who died at discharge had score ≥8 (table 4). discussion in this study, the average age of the subjects was 55.2±11.2 years. this is nearly similar to the previous study which showed the average age of 57.9±18.4 years,12 and another study from china with the average age of 55.53±15.39 years.13 male patients (87%) were higher than female patients (13%). this is also parallel with other previous studies.14,15 male patients are more likely to have tetanus because of their outdoor work which can increase the risk of injuries.4 in addition, women are more likely to receive more vaccination for tetanus than male, for example before getting married and during pregnancy, which may contribute to more protection against tetanus for the sex group.4,16 more than half of patients experienced table 2 characteristics of adult tetanus patients (n=71) characteristics n % gender male female 62 9 87 13 presence of autonomic dysfunction present absent 41 30 58 42 grade of tetanus grade i grade ii grade iii grade iv grade v 4 6 29 22 10 6 8 41 31 14 systolic blood pressure on admission (mmhg) median (iqr) 130 (120–140) diastolic blood pressure on admission (mmhg) median (iqr) 80 (80–90) heart rate on admission (bpm) median (iqr) 88 (80–100) temperature on admission (℃) median (iqr) 36.8 (36.6–37.3) patient status at discharge survived died 44 27 62 38 althea medical journal. 2022;9(3) 148 table 3 distribution of clinical features according to tetanus severity score (n=71) clinical features score n (%) age (years) ≤70 71–80 >80 0 5 10 63 (89) 6 (8) 2 (3) time from first symptom to admission (days) ≤2 3–5 >5 0 -5 -6 36 (51) 19 (27) 16 (22) difficulty breathing on admission no yes 0 4 69 (97) 2 (3) co-existing medical conditions fit and well minor illness or injury moderately severe illness severe illness not immediately life-threatening immediately life-threatening illness 0 3 5 5 9 62 (87) 5 (7) 4 (6) 0 0 entry site internal or injection other or unknown 7 0 1 (1) 70 (99) highest blood pressure recorded during the first day in the hospital (mmhg) ≤130 131–140 >140 0 2 4 32 (45) 12 (17) 27 (38) highest heart rate recorded during the first day in the hospital (bpm) ≤100 101–110 111–120 >120 0 1 2 4 48 (68) 7 (10) 8 (11) 8 (11) lowest heart rate recorded during the first day in the hospital (bpm) ≤110 >110 0 -2 70 (99) 1 (1) highest temperature recorded during the first day in the hospital (0c) ≤38.5 38.6–39 39.1–40 >40 0 4 6 8 67 (95) 3 (4) 0 1 (1) table 4 discharge outcome of adult tetanus patients (n=71) tss score status at discharge survived (n=44) n (%) death (n=27) n (%) <8 39 (89) 17 (63) ≥8 5 (11) 10 (37) note: tss= tetanus severity score althea medical journal september 2022 althea medical journal. 2022;9(3) 149ananda pratama kesumaningtyas gunawan et al.: clinical features and outcomes of patients with tetanus at dr. hasan sadikin general hospital bandung 2015–2019 autonomic dysfunction (58%), similar to previous study showing that autonomic dysfunction was common in generalized tetanus.5 the presence of autonomic dysfunction, shown by episodes of tachycardia, sweating and hypertension, is due to the involvement of preganglionic nerve terminals of the sympathetic nervous system by the neurotoxin.5 most patients were presented with generalized tetanus grade 3 (41%), consistent with the previous study, showing that most patients presented with tetanus grade 3 according to patel and joag’s grading.16 after reclassifying the clinical parameters into what is asked in the tss and calculating the individual score of the subjects in the study, it is found that most patients are admitted to the hospital quickly, ≤2 days after the first symptom, mostly had no systemic disease nor difficulty breathing on admission. a case report from east nusa tenggara, indonesia showed a similar result, i.e patient was admitted quickly, 2 days after the first symptom, had no systemic disease, and had no difficulty breathing on admission.18 the most common entry site includes superficial wounds on the head and neck, trunk, and extremities (99%). vital signs of this study, such as highest blood pressure, highest heart rate, lowest heart rate, and highest temperature which recorded during the first day in the hospital as differentiating factors for the prediction of mortality, hence it is difficult to compare these parameters with other studies. in-hospital mortality was 38%, similar to other study.19 the highest proportion of mortality was found in the patient with grade v (80%), followed by grade iv (68.1%). higher grades can predict a higher mortality rate.11 among subjects who survived, around 80% had tss score <8. this is in line with what has been found in the study in vietnam10, that score of tss <8 can predict a better outcomes. on the other hand, most patients who died also had a score <8. these low scores may be caused by several factors, i.e difference in population between vietnam and indonesia, and the entry site as one parameter in the tss scoring system is quite different from the usual prone wound for tetanus, which in this scoring system was categorized as another category with score 0.20 this study has some limitations: (1) due to its design, this study can not analyze the correlation between the tss score and the discharge outcome directly; (2) some parameters in the scoring system were difficult to be calculated using available data in the medical records; (3) due to limited time, the sample size in this study was small; and (4) other parameters outside the tss, like infection during hospitalization, which may affect mortality in tetanus patients were not analyzed in this study. in conclusion, tetanus in bandung, indonesia has a high mortality rate. one-third of patients who died had high tss scores, while the survivors had low tss scores, suggesting that the tss is a prospective scoring to predict the mortality rates in patients with tetanus in indonesia. further prospective study with regular and accurate vital signs measurements and better entry site categorizing is needed to evaluate the performance of tss. references 1. mahieu r, reydel t, maamar a, tadié jm, jamet a, thille aw, et al. admission of tetanus patients to the icu: a retrospective multicentre study. ann intensive care. 2017;7:12. 2. yen lm, thwaites cl. tetanus. lancet. 2019;393:1698. 3. narang m, khurana a, gomber s, choudhary n. epidemiological trends of tetanus from east delhi, india: a hospital-based study. j infect public health. 2014;7(2):121–4. 4. fan z, zhao y, wang s, zhang f, zhuang c. clinical features and outcomes of tetanus: a retrospective study. infect drug resist. 2019;12:1289–93. 5. hassel b. tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. toxins (basel). 2013;5(1):73–83. 6. kyu hh, mumford je, stanaway jd, barber rm, hancock jr, vos t, et al. mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015. bmc public health. 2017;17(1):179. 7. sugiharto m, ristrini r. profil tetanus neonatorum dalam rangka kebijakan eliminasi tetanus maternal dan neonatal di kabupaten bangkalan provinsi jawa timur, tahun 2012–2014. bul penelit sistem kesehat. 2016;19(2):149–56. 8. pusat data dan informasi kementerian kesehatan ri. eliminasi tetanus maternal dan neonatal. bul jendela data informasi kesehat. 2012;1:1–22. [cited 2021 jan 08]. available from: https://pusdatin.kemkes. go.id/resources/download/pusdatin/ buletin/buletin-mnte.pdf 9. saltoglu n, tasova y, midikli d,burgut r, althea medical journal. 2022;9(3) 150 dündar ih.prognostic factors affecting deaths from adult tetanus. clin microbiol infect. 2004;10(3):229–33. 10. thwaites cl, yen lm, glover c, tuan pq, nga ntn, parry j, et al. predicting the clinical outcome of tetanus: the tetanus severity score. trop med int health. 2006;11(3):279–87. 11. patel jc, joag gg. grading of tetanus to evaluate prognosis. indian j med sci. 1959;13:834–40. 12. sun c, zhao h, lu y, wang z, xue w, lu s, et al. prognostic factors for generalized tetanus in adults: a retrospective study in a chinese hospital. am j emerg med. 2019;37(2):254–9. 13. wang x, yu r, shang x, li j, gu l, rao r, et al. multicenter study of tetanus patients in fujian province of china: a retrospective review of 95 cases. biomed res int. 2020;2020:8508547. 14. an vt, khue pm, yen lm, phong nd, strobel m. tetanus in ho chi minh city, vietnam: epidemiological, clinical and outcome features of 389 cases at the hospital for tropical diseases. bull soc pathol exot. 2015;108(5):342–8. 15. derbie a, amdu a, alamneh a, tadege a, solomon a, elfu b, et al. clinical profile of tetanus patients attended at felege hiwot referral hospital, northwest ethiopia: a retrospective cross sectional study. springerplus. 2016;5(1):892. 16. demicheli v, barale a, rivetti a. vaccines for women for preventing neonatal tetanus. cochrane database syst rev. 2015:2015(7):cd002959. 17. khrisnan l, anam, panigoro r. factors affecting mortality in adult tetanus patients. althea med j. 2015;2(2):157–61. 18. surya r. skoring prognosis tetanus generalisata pada pasien dewasa. cdk. 2016;43(3):199–203. 19. tosun s, batirel a, oluk ai, aksoy f, puca e, bénézit f, et al. tetanus in adults: results of the multicenter id-iri study. eur j clin microbiol infect dis. 2017;36(8):1455–62. 20. diaye dsn, schwarzinger m, obach d, poissy j, matheron s, casalino e, et al. effectiveness and cost of quick diagnostic tests to determine tetanus immunity in patients with a wound in french emergency departments. bmc infect dis. 2014;14:603. althea medical journal september 2022 amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 216 amj december 2020 risk factors of dementia in elderly of bandung city, indonesia: a community-dwelling study sarah fitri janaris,1 sharon gondodiputro,2 nita arisanti2 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: sarah fitri janaris, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, email: sarahfitri915@gmail.com. introduction indonesia faces a progressive increase in the elderly population. cognitive disorders as one of the geriatric syndromes have the risk to develop into mild cognitive impairment and dementia.1–3 according to the world health organization (who), there are 50 million people in the world experiencing dementia and 10 million new cases annually.3 it is estimated that the number of people in the asia-pacific region experiencing dementia will increase by the amount of 23 million in 2015 to 71 million people in 2050, including in indonesia that are expected to experience dementia with around 4 million people in 2050.4 there are various risk factors for dementia, including age, gender, marital status, education level, occupation, genetic carrier apoe allele 4, drug consumption, comorbidity, living arrangements, and outdoor activities.2,5–7 the purpose of this study was to analyze risk factors related to the occurrence of dementia in the elderly in the community. this study is expected to be useful information for primary health care in finding the risk factors associated with dementia for early detection and preventing the development of dementia. methods an analytical cross-sectional study was carried out using the secondary datacollected from june to august 2016, consisted of the characteristics of the respondents, the mini-mental state examination (mmse) instrument, and the mini-cog assessment instrument (mini-cog). the respondents were elderly who visited the integrated health post (pos pembinaan terpadu, posbindu). the amj. 2020;7(4):216–22 abstract background: multiple organ degenerative processes are parts ofa normal biological process in aging. one of the geriatric syndromes is cognitive disorders that range from a mild cognitive impairment to dementia. the aim of this study was to analyze factors contributing to the occurrence of dementia in the elderly. methods: a cross-sectional analytical study was conducted using secondary data on 306 elderly people who visited the integrated health post (pos pembinaan terpadu, posbindu) from june to august 2016 in bandung city, indonesia. nine variables were included in this study:age, gender, education level, marital status, occupation, living arrangements, social participation, comorbidity, and dementia. the dementia status was measured by the mini-mental state examinationand mini cog assessment instruments. data were then analyzed statistically using chi-square, fisher exact, and kolmogorov-smirnov tests, as well as using the multivariate logistic regression. result: around 35.3% (95%ci=30%–40.6%) of respondents had dementia. there were relationships between dementia and age (p=0.035), level of education (p=0.000), and social participation (p=0.001). social participation was the most dominant risk factor of dementia (or=2.703;95%ci=1.491-4.902). conclusions: age, education level, and social participation are risk factors that contribute to dementia. the elderly who has less than two times per week of social participation has a 2.7 times higher risk for having dementia compared to the elderly who has more than two times per week of social participation. keywords: dementia, elderly, mini-mental state examination, risk factors https://doi.org/10.15850/amj.v7n4.2105 althea medical journal. 2020;7(4) 217 total number of posbindu was 29 posbindu. the selection of respondents was conducted based on consecutive sampling, while posbindu selection was performed based on a simple random sampling. this study had been approved by the ethics committee of universitas padjadjaran bandung, indonesia, no. 759/un6.kep/ec/2019. the inclusion criteria were male and female, aged ≥60 years. the dementia was measured based on the measurement of mmse. the exclusion criteria were answers to questionnaires that could not be read by the researchers. based on these criteria, 306 of the 313 questionnaires were included in this study. the variables included in this study were 9 variables consisted of 1) age, were grouped into 60–70 years old and >70 years old; 2) gender was classified into “male” and “female”; 3) the level of education was grouped into “has no formal education” or the last education was“elementary school “junior high school”, “senior high school”, or “higher than senior high school”; 4) the marital status was classified into “no spouse” and “has a spouse”; 5) occupation was grouped into “not working” and “working”; 6) household arrangements were grouped into “live alone”, “with spouses only”, “with spouses and or other family members”; 7) social participation within one week weregrouped into “0–1 times/week” and “≥2 times/week”; 8) diseases/symptoms wereclassified into “no diseases or symptoms”, “one disease or symptoms”, “two diseases or symptoms”, and “more than two diseases or symptoms”; and 9) dementiawasgrouped into “dementia” and “not dementia”. dementiawas designated when the respondent had a score of mmse ≤23 for respondents with the highest level of education was high school or ≤25 for respondents with an education level higher than high school. for the respondent who could not read and write, a mini-cog instrument was used with a cut-off point <3 designated as dementia. the collected data were analyzed using ibm spss statistics software, version 22.0. the bivariate analysis using chi-square statistical test was conducted on age, gender, education level, marital status, occupation, social participation, and disease status. the statistical test of kolmogorov-smirnov was performed on the living arrangements variable. moreover, a multivariate logistical sarah fitri janaris et al.: risk factors of dementia in elderly of bandung city, indonesia: a community-dwelling study table 1 characteristics of elderly visited the integrated health post (posbindu) characteristics frequency (n) percentage (%) age (years old) 60–70 204 66.7 >70 102 36.3 gender: female 245 80.1 male 61 19.9 education level: ≤ elementary school 169 55.2 junior high school 54 17.7 senior high school 60 19.6 >senior high school 23 7.5 marital status: no spouse 149 48.7 with spouse 157 51.3 occupation: not working 243 79.4 still working 63 20.6 althea medical journal. 2020;7(4) 218 amj december 2020 regression test was performed on variables that had a p-value <0.25 of the bivariate statistical test results. in the selected variables, a multicollinearity test was also performed to identify a strong correlation between two or more independent variables. the results of the test were strongly correlated when the value of variance inflation factor (vif) >5, correlates moderately when the vif value was <1 or ≤5, and there was no correlation if the value of vif =1.8 furthermore, the pseudo-r2 test with cox & snell and nagelkerke also performed to determine the predictable variable variance of the dependent variables from the independent variables. results from 306 questionnaires, there were 286 questionnaires obtained using the mmse and 20 questionnaires obtained using the mini-cog instrument. table 1 showed that most of the respondents were 60–70 years old (66.7%), predominantly female (80.1%), and most of them had an education level of junior high school (72.88%), still living with their spouse (51.3%), and had no work (79.4%). the study found that the proportion of dementia measured by mmse was quite high at 35.3% (95%ci=30%–40.6%). the mmse questionnaire measured 5 domains of cognitive impairment, i.e. orientation; memory and calculations; language and, constructional praxis (the ability to draw objects). the results showed that the most cognitive disorder discovered in this study was impaired in the constructional praxis (66.1%), as shown in table 2. this study showed that of the 8 risk factors, only 3 factors related to the occurrence of dementia, i.e. age, level of education, and social participation (table 3). a logistic regression analysis was carried out on 5 variables that had a p-value <0.25. those variables were age, education level, marital status, social participation, and the status of disease/symptom. the results of the statistical test, the most dominant risk factor for the occurrence of dementia was social participation (table 4). the odds ratio of the elderly who had social participation with a frequency less than 2 times a week was 2.703 times of the odds ratio of the elderly who had social participation with a frequency of ≥2 times a week. in the multicollinearity test, the value of the variance inflation factor (vif) was between 1.013 and 1.215. this result indicated there was a moderate correlation between independent variables. moreover, this study found that the value of the pseudo-r2 was 0.136 based on the tests of cox & snell and 0.187 on the nagelkerke tests. these results indicated that the proportion of variable variance can be predicted from independent variables was only 13.6% and 18.7%. social participation that was carried out by the respondents in the past week were religious activities, sports, working or trading, and arisan. the arisan was an informal social gathering that took place at a fixed interval at each member’s home in turn. this social gathering was a form of rotating saving (microfinance) in indonesian culture where a kind of lottery was conducted and members took turns to win an amount of money previously deposited by all members. (table 5). discussion dementia in the elderly is one of the symptoms of geriatric syndrome. in this study, the proportion of dementia in the elderly is high, amounted to 35.3% (95%ci=30%–40.6%). age, education level, and social participation are the risk factors for dementia. the elderly who have a low-frequency of social participation have a 2.7 times higher risk for dementia compared to the elderly who have a high-frequency of social participation. the proportion of dementia in this study table 2 domains of the cognitive impairment using mmse instruments* domains normal (%) impaired (%) orientation 223(78.0) 63(22.0) memory 176(61.5) 110(38.5) attention and calculation 188(65.7) 98(34.4) language 222(77.6) 64(22.4) constructional praxis 97(31.7) 189(66.1) notes: *from 306 questionnaires, only 286 questionnaires included, consisted of the mmse test result althea medical journal. 2020;7(4) 219sarah fitri janaris et al.: risk factors of dementia in elderly of bandung city, indonesia: a community-dwelling study is quite high compared to other studies (1.314.3%) that has used the fourth edition of the diagnostic and statistical manual of mental disorder2 and the tenth edition of the international classification diseases to the undetectable respondents of dementia.9 our study has used the mmse instrument as a screening tool for dementia. the mmse instrument has a sensitivity of 90% and a specificity of 69%.5 most of the respondents suffered a disruption in the constructional praxis domain, a visual capability that works on threedimensional spaces such as remembering a place.10 this domain can be used as early detection and diagnostic clarification tool for alzheimer’s disease and lewy body dementia (lbd). lbd patients with low mmse scores table 3 risk factors related to dementia risk factors dementia (%) no dementia (%) total p-value age 0.011 60–70 years old 62(30.4) 142(69.6) 204 >70 years old 46(45.1) 56(54.9) 102 gender: 0.660 female 85(34.7) 160(65.3) 245 male 23(37.7) 38(62.3) 61 education level: 0.000 ≤ elementary school 81(47.9) 88(52.1) 169 junior high school 13(24.1) 41(75.9) 54 senior high school 11(18.3) 49(81.7) 60 >senior high school 3(13.0) 20(87.0) 23 marital status: 0.115 no spouse 46(30.9) 103(69.1) 149 with spouse 62(39.5) 95(60.5) 157 occupation: 0.715 not working 87(35.8) 156(64.2) 243 still working 21(33.3) 42(66.7) 63 living arrangements 0.472** live alone 6(50.0) 6(50.0) 12 with spouse only 18(38.3) 29(61.7) 47 with spouse and other family members 84(34.0) 163(66.0) 247 social participation: 0.000 0-1 time/week 88(45.8) 104(54.2) 192 ≥2 times/week 20(17.5) 94(73.8) 114 disease/symptom: 0.141 no disease/symptom 8(20.5) 31(79.5) 39 one disease/symptom 74(39.2) 115(60.8) 189 two diseases/symptoms 22(34.9) 41(65.1) 63 > two diseases/symptom 4(26.7) 11(73.7) 15 total 108(35.3) 198(64.7) 306 notes: * fisher’s exact statistical test; ** kolmogorov-smirnov statistical test althea medical journal. 2020;7(4) 220 amj december 2020 would have poorer manifestations in image copying tests compared to alzheimer’s patients with low mmse scores but are succeeded in the image copying tests.10 this study has found 5 variables that are not related to dementia i.e. gender, marital status, occupation, living arrangements, and disease status. interestingly, women have a higher risk of dementia compared to men due to genetic factors and higher female life expectancy.11,12 however, this study has shown that gender is not related to the risk of dementia. this result is likely caused by the number of female respondents, which is eight times more than male respondents. marital status becomes one of the risk factors for dementia. an individual who has a partner tends to be able to maintain cognitive function through social support given by the partner, in opposed to a widowed man or woman, who are more prone to stress, resulting in decreased cognitive function.9 however, our study shows that marital status is not related to the risk of dementia. the difference in results obtained between this study and previous study is assumed that most of the respondents in our study have no spouse but still live with their children and other family members, therefore, social and emotional support are still provided by their family members. the working elderly have better cognitive performance than the elderly who are retired or have never worked at all.7 work can sustain and improve cognitive function, although the aging process is taking place, the cognitive part of the brain has a better compensation for cognitive decline.13 interestingly, our study found that the work status of the respondent was unrelated to the risk of dementia. the results are likely to occur because respondents who do not work still do other activities that could reduce the risk of dementia. the living arrangements are not related to the risk of dementia. there is no difference in the risk of mild cognitive impairment among individuals living alone with individuals living together with their partners.14 moreover, the severity of comorbidities cannot assess the cognitive changes in dementia patients so that comorbidities are not included in the risk factors of dementia.15 there are 3 factors related to the occurrence of dementia, which are age, education level, table 4 multivariate regression logistic variables β s.e. wald df sig. exp(β) 95.0% ci for exp(β) lower upper step age -0.590 0.278 4.492 1 0.034 0.554 0.321 0.957 1a education level 0.561 0.161 12.150 1 0.000 1.753 1.278 2.403 marital status 0.098 0.275 0.127 1 0.722 1.103 0.644 1.888 social participation 1.003 0.304 10.862 1 0.001 2.727 1.502 4.952 disease/ symptom -0.063 0.185 0.114 1 0.735 0.939 0.653 1.351 constant -0.866 0.774 1.253 1 0.263 0.421 step age -0.591 0.278 4.504 1 0.034 0.554 0.321 0.956 2a education level 0.563 0.161 12.264 1 0.000 1.757 1.282 2.408 marital status 0.090 0.274 .109 1 0.741 1.095 .640 1.871 social participation 0.999 0.304 10.798 1 0.001 2.715 1.496 4.925 constant -0.989 0.684 2.091 1 0.148 0.372 step age -0.567 0.268 4.460 1 0.035 0.567 0.335 0.960 3a education level 0.554 0.158 12.281 1 0.000 1.740 1.276 2.371 social participation 0.995 0.304 10.727 1 0.001 2.703 1.491 4.902 constant -0.862 0.564 2.336 1 0.126 0.423 althea medical journal. 2020;7(4) 221 and social participation. age becomes one of the risk factors associated with the occurrence of dementia. as we age, the occurrence of mild cognitive disorders increases and this makes the chance of dementia higher.2 as for the education factor, there is an increased risk of dementia in respondents with low education. individuals with low education levels have a lower cognitive function that makes a higher risk of dementia.13 social and economic status had an impact on the quality of the education gained by individuals, suggesting that these factors increase the incidence of dementia.13 furthermore, the study has found that the elderly who has a low frequency of social participation has a risk of 2.7 times higher for dementia compared to the elderly who has a high frequency of social participation. social participation can encourage the elderly to remain active so that cognitive function can be maintained and the risk of dementia can be reduced.16 various social participation has been conducted by the elderly. religious activities such as religious studies (pengajian) become the main activity carried out by the elderly. religious activities can reduce the risk of mild cognitive disorder.17 respondents who performed religious activities on weekly basis tend to experience a slower rate of cognitive decline than those who rarely do religious activities. on the contrary, another study shows no link between religious activities and cognitive decline. it may be due to the different religious levels that may have different impacts on the cognitive function, so further study is required.7 other social participation undertaken by respondents are sports, working, social gathering, and organizational meetings. the exercise that is carried out with a group of the elderly proved some benefits, not only physical fitness but also emotional support that can lower the risk of cognitive impairment in the elderly.7 the elderly who are actively involved with social activities can also maintain cognitive abilities and improve cognitive reserve.16 the model developed in this study has shown that the status of education and social participation are the predictors of dementia. the most dominant factor associated with dementia is the social participation factors, nevertheless, this model generated only 13.6–18.7%, indicating that there are 81.3–86.4% other factors related to the occurrence of dementia in the elderly. this is strengthened by the result of a multicollinearity test that showed the vif values between 1.013-1.215. this study has some limitations. detection of dementia in this study is only carried out by using mmse instruments. further examination to make a definite diagnosis of dementia is required. the method used in this study is a cross-sectional analysis, so it cannot be identified whether the respondent lives with his/her family, does not work, or does not do any activities due to dementia, or those factors that causing dementia. another limitation of this study is that there are more female compared to male respondents. this unequal distribution has made the gender factor is not related to the occurrence of dementia. furthermore, the pseudo-r2 produced only 13.6% and 18.7%, thus, there are still other factors related to the occurrence of dementia in the elderly. these limitations, it does not reduce the importance of this study. to conclude, this study has shown that the prevalence of dementia is quite high in the community. this situation needs to be followed up by further examination and intervention, otherwise, the occurrence of dementia will cause major problems both cognitive, physical, and social. references 1. senn n, monod s. development of a comprehensive approach for the early diagnosis of geriatric syndromes in general practice. front med (lausanne). 2015;2:78. 2. lipnicki dm, crawford j, kochan na, trollor jn, draper b, reppermund s, et al. risk factors for mild cognitive impairment, dementia, and mortality: the sydney memory and ageing study. j am med dir assoc. 2017;18(5):388–95. 3. world health organization. dementia. 2017 [cited 2019 january 24] available from: https://www.who.int/news-room/ fact-sheets/detail/dementia 4. alzheimer’s disease international, alzheimer’s australia. dementia in the asia pacific region. london: alzheimer’s disease international; 2014. 5. katsaouni p, papamichail e, maillis a. exploring dementia in primary health care: comorbidities and diagnostic tools. int j caring sci. 2017;10(1):110–6. 6. sommerlad a, ruegger j, singh-manoux a, lewis g, livingston g. marriage and risk of dementia: systematic review and metaanalysis of observational studies. j neurol neurosurg psychiatry. 2018;89(3):231–8. 7. adam s, bonsang e, grotz c, perelman s. occupational activity and cognitive reserve: sarah fitri janaris et al.: risk factors of dementia in elderly of bandung city, indonesia: a community-dwelling study althea medical journal. 2020;7(4) 222 amj december 2020 implications in terms of prevention of cognitive aging and alzheimer’s disease. clin interv aging. 2013;8:377–90 8. daoud ji. multicollinearity and regression analysis. j phys conf ser. 2017;949:012009. 9. sundström a, westerlund o, kotyrlo e. marital status and risk of dementia: a nationwide population-based prospective study from sweden. bmj open. 2016;6:e008565. 10. li x, rastogi p, gibbons ja, chaudhury s. visuo-cognitive skill deficits in alzheimer’s disease and lewy body disease : a comparative analysis. ann indian acad neurol. 2014;17(1):12–8. 11. podcasy jl, epperson cn. considering sex and gender in alzheimer disease and other dementias. dialogues clin neurosci. 2016;18(4):437–46. 12. beam cr, kaneshiro c, jang jy, reynolds ca, pedersen nl, gatz m. differences between women and men in incidence rates of dementia and alzheimer’s disease. j alzheimer’s dis. 2018;64(4):1077–83. 13. langa km. cognitive aging, dementia, and the future of an aging population. in: future directions for the demography of aging. washington, dc: the national academic press; 2018. 14. brenowitz wd, kukull wa, beresford saa, monsell se, williams ec. social relationships and risk of incident mild cognitive impairment in u.s alzheimer’s disease centers. alzheimer dis assoc disord. 2014;28(3):253–60. 15. hamel r, ramakers i, oosterveld s, melis rj, rikkert mo, sistermans n, et al. o1-06-02: the influence of comorbidities on cognitive decline and conversion to dementia in patients with mild cognitive impairment. alzheimer dement. 2014;10(4):139. 16. tomioka k, kurumatani n, hosoi h. social participation and cognitive decline among community-dwelling older adults: a community-based longitudinal study. j gerontol b psychol sci soc sci. 2018;73(5):799–806. 17. sun y, ma w, wu y, koenig hg, wang z. the mediating effect of depression in religiosity and cognitive function among chinese muslim elderly. neuropsychiatry (london). 2018;08(03):1046–53. amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 37 reversal reaction in leprosy patients: study on prevalence, sociodemographic characteristics, and precipitating factors at a tertiary referral hospital in west java, indonesia hendra gunawan,1 risa miliawati,1 renasha firda hanannisa2 1department of dermatology and venereology, faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia correspondence: renasha firda hanannisa, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, e-mail: renasha17001@mail.unpad.ac.id introduction leprosy is a chronic granulomatous disease caused by mycobacterium leprae (m. leprae), which mainly affects the skin and peripheral nerve, and the other organs, such as nose and testis.1 this disease occurs mainly in developing countries in tropical and subtropical regions.2 globally, 208,619 new cases of leprosy were reported in 2018. the majority of cases occurred in the south-east asia region with 71% of all new cases.3 indonesia is the country with the third largest leprosy case in the world after india and brazil, with 15,107 new cases in 2017. based on the provinces in indonesia, west java ranks second with the largest new leprosy cases after east java, with a total of 1,813 new cases.3,4 leprosy is often characterized by an immune reaction, which is caused by the body’s immune response to the infectious organism, m. leprae.5 based on clinical, histopathologic, and immunological criteria, leprosy is classified into two polar forms, tuberculoid leprosy (tt) and lepromatous leprosy (ll). there are borderline groups between the two polar forms, for example borderline tuberculoid (bt), mid-borderline (bb), and borderline lepromatous (bl).6 sudden changes in the immune-mediated response to m. leprae antigen are called leprosy reactions.7 although multidrug althea medical journal. 2022;9(1):37–42 abstract background: heretofore, leprosy remains one of the most stigmatizing diseases with serious social consequences. patients with leprosy might develop inflammatory reactions that interrupt with stable and chronic disease which are called leprosy reactions. type 1 leprosy reactions, also known as reversal reactions (rr), are caused by immune responses that initially decreases, then “reverses” to become more intense, leading to considerable disability. the aim of this study was to identify the prevalence, sociodemographic characteristics, and precipitating factors of reversal reaction in leprosy patients. methods: this was a retrospective study with a cross-sectional design, with an approach to collecting data from the medical records of the leprosy clinic, department of dermatology and venereology dr. hasan sadikin general hospital bandung west java, during january 2015–december 2019. results: the results showed that 53 patients (24.7%) of the total 214 leprosy patients experienced a reversal reaction. the most frequent type of leprosy with reversal reaction was borderline lepromatous (bl) (56.5%). most of the patients were male (68%), aged between 25–44 years (47.2%), unemployed patients (35.8%), and the last education was senior high school (71.7%). physical stress was suspected as the most precipitating factor in reversal reaction patients (50.9%). conclusions: the prevalence of leprosy patients with reversal reaction in a tertiary referral hospital west java, indonesia is 24.7%, with various characteristics based on sociodemographic. physical stress is suspected as the most precipitating factor of rr in leprosy patients. early diagnosis of reversal reaction is important to prevent nerve damage and disability. keywords: leprosy, patient’s sociodemographic, prevalence, reversal reaction https://doi.org/10.15850/amj.v9n1.2329 althea medical journal. 2022;9(1) 38 therapy (mdt) is effective, the morbidity from the reaction remains high. there remains an unmet need for effective therapy to prevent or mitigate nerve damage due to the reactions.8 there are two types of leprosy reaction, type 1 leprosy reaction, also known as reversal reaction (rr), and type 2 leprosy reaction or erythema nodosum leprosum (enl).9 rr is a type iv hypersensitivity immune response caused by a specific increase in cell-mediated immunity against m. leprae. this reaction usually occurs during the first months of treatment to several years after the first symptoms of peripheral neuropathy.2 rr manifests as pre-existing hypopigmented or slightly erythematous macules that become red and swollen, induration of existing plaque, ulceration formation, and the progressive neuritis that often leading to sensory and motor neuropathy.9,10 there are several factors that trigger rr, such as focal infections, psychological and physical stresses, vaccination, chemotherapy, puerperium, and use of oral contraceptives.11 systemic symptoms are uncommon, but acute inflammation of the peripheral nerves occurs, leading to neurological impairment, which if not treated promptly and appropriately will lead to permanent loss of neurological function, usually due to the development of deformities of varying degrees.12 studies on leprosy reactions in west java, indonesia are still limited and incomplete. the purpose of this study was to identify the prevalence, sociodemographic characteristics, and precipitating factors for reversal reaction in leprosy patients at a tertiary referral hospital in west java, indonesia. methods this research was a retrospective study with a cross-sectional design, approved by the research ethics committee of the universitas padjadjaran no. 893/un6.kep/ec/2020 and by the medical research ethics committee dr. hasan sadikin general hospital bandung no. lb.02.01/x.2.2.1/22551/2020. data were collected using medical records from the leprosy clinic at the department of dermatology and venereology dr. hasan sadikin general hospital bandung west java. the target population in this study used a total sampling of outpatient and inpatient diagnosed with leprosy patients with rr during january 2015–december 2019. data collected were anamnesis, physical and laboratory examinations. the number of reversal reaction patients was conducted and reviewed based on sociodemographic, including age, gender, occupation, last education, and precipitating factors. incomplete data were excluded. the data were further processed with microsoft® excel 2013, and presented in tables. results from january 2015–december 2019, 230 leprosy patients were enrolled in this study. sixteen patients were excluded due althea medical journal march 2022 figure distribution of reversal reaction patients based on leprosy type n um be r of p at ie nt s distribution of reversal reaction patients based on leprosy type leprosy types based on clinical forms tt bt bb bl ll 17 occured not occured 4 0 10 20 30 40 50 60 70 80 50 67 30 23 17 3 3 althea medical journal. 2022;9(1) 39hendra gunawan et al.: reversal reaction in leprosy patients: study on prevalence, sociodemographic characteristics, and precipitating factors at a tertiary referral hospital in west java, indonesia to inaccessible and incomplete data. the remaining two hundred and fourteen patients were eligible and had been identified in this study. the distribution of leprosy cases based on the classification of the world health organization (who) and ridley jopling was summarized in table 1. mb was the most prevalent type with 190 cases (88.8%), whereas pb with 24 cases (11.2%). based on the clinical form of leprosy, bl leprosy was the most frequent type (45.3%) (table 1). from a total of 214 leprosy patients, reversal reaction was documented in 53 patients (24.7%). bl leprosy was the clinical form that most commonly developed leprosy reactions with the number of 30 patients (56.6%). figure showed the distribution of reversal reaction patients based on leprosy type. of the 53 patients with a reversal reaction, the results showed that male had the highest frequency with 36 patients (68%). reversal reaction most occurred in the age range of 25–44 years (47%). in this study, it was found that unemployed patients had the highest frequency of 19 patients (36%). the data table 1 distribution of new leprosy cases based on leprosy types leprosy type new leprosy cases (n=214) n % pb tt bt 24 4 20 11.2 1.9 9.3 mb bb bl ll 190 40 97 53 88.8 18.6 45.3 24.7 note: bb= mid-borderline leprosy; bl= borderline lepromatous leprosy; bt= borderline tuberculoid leprosy; ll= lepromatous leprosy; mb=multibacillary leprosy; pb= aucibacillary; tt= tuberculoid leprosy table 2 distribution of reversal reaction patients based on sociodemographic characteristics patient characteristics total rr patients (n=53) n % gender male female 36 17 68 32 aged (years) 0–4 5–14 15–24 25–44 45–64 ≥ 65 0 0 11 25 15 2 0 0 21 47 28 4 occupation unemployment housewife entrepreneur labor government employees farmer 19 12 10 8 3 1 36 23 19 15 6 2 last education not finished primary school primary school junior high school senior high school bachelor 0 4 8 38 3 0 8 15 72 6 note: rr= reversal reaction althea medical journal. 2022;9(1) 40 showed that the most common education of patients was senior high school (72%). physical stress was suspected as the most frequent precipitating factor in leprosy patients with reversal reaction (51%). there were six cases with undetected precipitating factors. sociodemographic characteristics and precipitating factor of reversal reaction in leprosy patients were summarized in table 2 and table 3. discussions leprosy reactions can cause poor quality of life in leprosy patients.8 early diagnosis of the reaction is important to detect the risk of developing leprosy disease and prevent complications, such as nerve damage and disability. the total leprosy patients in this study were 214 patients, of which 24.7% of these leprosy patients experienced a reversal reaction. the most prevalent type of leprosy in these patients is mb, conform the who classification. this number is similar to the previous study in denpasar.13 leprosy patients with mb type have more visible symptoms compared to paucibacillary (pb) type, therefore, many patients with mb type come to medical health care and seek the treatment.14 interestingly, according to ridley and jopling’s classification, bl is the most frequent type of clinical form in leprosy patients (45.3%). this is in contrast to study from thailand16 that found borderline tuberculoid leprosy (bt) was the most common clinical form of all leprosy patients (32.4%). leprosy has five different types based on clinical, histopathologic, and immunological criteria.1 each country and region has a different result in the highest number of leprosy type, depending on the patient education about leprosy disease, health care facilities in the region, and the patients condition who come to the hospital and do an examination. fifty-three patients have developed a reversal reaction from overall leprosy patients (24.7%). this data can be interpreted as the prevalence of leprosy with reversal reaction of patients treated at the leprosy clinic in dr. hasan sadikin general hospital. this study found that the most reactions occurred in leprosy patients with bl type (56.6%). this is in contrast with the study in surabaya14 which found bb as the most frequent type among all reversal reaction patients. reversal reaction mainly occurs in borderline forms of leprosy, such as bt, bb, and bl forms.11 multivariate analysis showed that borderline forms of leprosy and the mb treatment regimen were known to be major risk factor for the development of leprosy reactions.15,18 the reversal reaction was observed in the presence of inflammatory infiltration by predominance cd4+ t lymphocytes, differentiated macrophages, human leukocyte antigen expression, giant cell formation, and epidermal thickening.6 this inequality in this study might be due to the highest prevalence of leprosy patients with bl type. leprosy reactions are more commonly found in males than females with a ratio of 2:1.14 male has increased mobility and frequent interactions with the community, leading to increased access to contact with the disease more than female.15 self-report rates are also higher among men. the age group most affected (47.2%) by leprosy reaction was 25–44 years, comparable to study in other site in indonesia.13 based on sociodemographic characteristics, unemployed people were found to be the highest in reversal reaction patients (35.8%). unemployment has been studied as a high-risk factor from leprosy studies in a high-risk community setting in sri lanka.17 most of the patients had senior high school as their last education (71.7%). this is similar to a previous study conducted in eight out of the 20 countries with a high burden of leprosy, such as brazil, india, myanmar, sri lanka, bangladesh, indonesia, egypt, and philippines which reported that undergraduate althea medical journal march 2022 table 3 distribution of reversal reaction precipitating factors precipitating factors rr patients (n=53) frequency (n) percentage (%) physical stress infection psychological stress menstruation unknown 27 19 10 1 6 51 36 19 2 11 note: rr= reversal reaction althea medical journal. 2022;9(1) 41 of education had an association with a higher leprosy incidence among neighbors.18 moreover, physical stress is suspected as the highest precipitating factor causing rr in leprosy patients (50.9%). stress is a state of the physical, psychological, and emotional tension in a person which can reduce half of his immunity in certain situations.19 stress is also an immunostimulator. these both pathways play an important role that may lead to lymphoid tissue, spleen, and other organ through the nervous system and humoral connections. a considerable number of common chemical transmitters (for example endorphins, substance p) can act both directions, indicating the immune system as a “mobile brain”. this impairment of the immune balance can precipitate a leprosy reaction.20 this study has limitations that the study was a retrospective study using secondary data from medical records. collecting medical records in the last 5 years might be challenging as there are missing or incomplete data. in conclusion, the prevalence of rr is 24.7% among all leprosy patients in our study. the most frequent type of leprosy with rr is bl leprosy type and have various sociodemographic characteristics. the most of the patients are male, aged between 25–44 years, unemployed, and the last education is senior high school. physical stress is suspected as the most precipitating factor for rr in leprosy patients. references 1. kumar b, kar hk, editors. ial textbook of leprosy. 2nd ed. new delhi, india: jaypee brothers medical publishers; 2016. 2. de freitas mrg, said g. leprous neuropathy. handb clin neurol. 2013;115:499–514. 3. world health organization. global leprosy update, 2018: moving towards a leprosyfree world. weekly epidemiological record. 2019;94(35/36):389–412. 4. pusat data dan informasi kementerian kesehatan ri. infodatin kusta 2018: hapuskan stigma dan diskriminasi terhadap kusta. jakarta: pusat data dan informasi kementerian kesehatan ri; 2018. 5. world health organization. leprosy hansen disease: management of reactions and prevention of disabilities: technical guidance. geneva: world health organization; 2020. 6. bhat rm, prakash c. leprosy: an overview of pathophysiology. interdiscip perspect infect dis. 2012;2012:181089. 7. bilik l, demir b, cicek d. leprosy reactions. in: ribón w, editor. hansen’s diseases: the forgotten and neglected diseases. london, uk: intechopen ltd; 2019. 8. chhabra n, bhattacharya sn, singal a, ahmed rs, verma p. profile of oxidative stress in response to treatment for type 1 leprosy reaction. lepr rev. 2015;86(1):80– 8. 9. naafs b, van hees clm. leprosy type 1 reaction (formerly reversal reaction). clin dermatol. 2016;34(1):37–50. 10. sung sm, kobayashi tt. diagnosis and treatment of leprosy type 1 (reversal) reaction. cutis. 2015;95(4):222–6. 11. nery jadac, filho fb, quintanilha j, machado am, oliveira sdesc, sales am. understanding the type 1 reactional state for early diagnosis and treatment: a way to avoid disability in leprosy. an bras dermatol. 2013;88(5):787–92. 12. chaitanya vs, lavania m, nigam a, turankar rp, singh i, horo i, et al. cortisol and proinflammatory cytokine profiles in type 1 (reversal) reactions of leprosy. immunol lett. 2013;156(1–2):159–67. 13. sari lpvc, darmada igk. prevalensi dan karakteristik penderita reaksi kusta tipe 1 di poliklinik kulit dan kelamin rsup sanglah periode januari–desember 2014. e-jurnal medika udayana. 2018;7(11):44088. 14. pratamasari ma, listiawan my. retrospective study: type 1 leprosy reaction. berkala ilmu kesehatan kulit dan kelamin. 2015;27(2):137–43. 15. rao sm, moodalgiri vm.. leprosy in a tertiary care hospital, bagalkot, india: clinical study and a reappraisal in the post-elimination era. medica innovatica. 2015;4(2):23–8. 16. suchonwanit p, triam chaisri s, wittayakornrerk s, rattanakaemakorn p. leprosy reaction in thai population: a 20-year retrospective study. dermatol res pract. 2015;2015:253154. 17. dabrera tme, tillekeratne lg, fernando msn, kasturiaratchi stk, østbye t. prevalence and correlates of leprosy in a high-risk community setting in sri lanka. asia pac j public health. 2016;28(7):586– 91. 18. pescarini jm, strina a, nery js, skalinski lm, de andrade kvf, penna mlf, et al. socioeconomic risk markers of leprosy in high-burden countries: a systematic review and meta-analysis. plos negl trop hendra gunawan et al.: reversal reaction in leprosy patients: study on prevalence, sociodemographic characteristics, and precipitating factors at a tertiary referral hospital in west java, indonesia althea medical journal. 2022;9(1) 42 dis. 2018;12(7):0006622. 19. ramadhona a, supriyanto s, martini s. prevention effort of leprosy reactions based on risk factor analysis at sumberglagah leprosy hospital mojokerto. kne life sci. 2018;4(9):161–71. 20. sharma n, patel nm, mahakal n. lepra reactions clinical & histopathological study. ijsr. 2013;2(1):185–6. althea medical journal march 2022 amj vol 8 no 1 march 2021.indd althea medical journal. 2021;8(1) 1amj. 2021;8(1):1–6 neutrophil-to-lymphocyte ratio and covid-19 symptom-based severity at admission m. fuad,1,2 amaylia oehadian,2 delita prihatni,3 marthoenis4 1department of internal medicine, faculty of medicine, universitas syiah kuala, dr zainoel abidin hospital, banda aceh, indonesia 2department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of clinical pathology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 4department of psychiatry and mental health nursing, syiah kuala university, banda aceh, indonesia abstract background: increased neutrophil-to-lymphocyte ratio (nlr) is an independent risk factor for mortality in covid-19 patients and is considered as an early warning sign of covid-19 severity. this study aimed to observe the differences in nlr at admission between patients with mild, moderate, and severe symptoms of covid-19 treated in a referral hospital in banda aceh, indonesia. methods: a total of 114 patients with covid-19 admitted to a referral hospital in banda aceh, indonesia, during march–september 2020 were included in this study. demographic information and baseline laboratory data, including the nlr, were collected. descriptive and inferential statistics were used to analyze the data. results: the median nlr at admission was higher among patients with moderate to severe symptoms than those with mild symptoms [6.54 (2.80–97.00, iqr 4.81–9.44) vs 2.27 (0.79–5.07, iqr 1.43-2.98), p <0.001]. covid-19 patients who died had a higher nlr than those who survived [10.88 (4.17– 47.50, iqr 7.00–15.17) vs 6.15 (2.80–97.00, iqr 4.63–8.50), p 0.02]. patients with moderate-severe symptoms had an initial nlr of 4.63–8.50 and decreased to 2.75–5.43 at the end of the treatment had a greater chance of survival. there was an increased probability of death in patients with moderatesevere symptoms whose initial nlr was 7.00–15.17, which was then elevated to 14.33–23.25. conclusions: different nlr at admission is seen among covid-19 patients with mild and moderatesevere symptoms, leading to significantly different outcomes. the nlr can be used as a simple parameter to determine the severity of the disease and predict the outcome of covid-19 patients. keywords: covid-19, neutrophil-to-lymphocyte ratio, symptoms severity correspondence: marthoenis, department of psychiatry and mental health nursing, universitas syiah kuala, desa ceurih, ulee kareng, banda aceh, indonesia. e-mail: marthoenis@unsyiah.ac.id introduction the novel coronavirus, the sars-cov-2, was first recognized in the city of wuhan, china in december 2019. the disease caused by the virus, the covid-19, since then become a global emerging concern due to its rapid outbreak, fast worldwide spread, and high fatality rate. by the end of december 2020, the world health organization (who) confirmed more than 80 million positive cases and more than 1.7 million death globally.1 in indonesia, more than 700.000 cases and more than 21,000 death have been confirmed.2 meanwhile, in the province of aceh, more than 8,700 cases, 344 death, and more than 7,400 have recovered from the disease by the end of december 2020.3 studies related to covid-19 have been focused on various aspects of the disease, ranging from clinical factors, patients’ condition and outcome as well as the community perception, attitude, and behavior toward the disease. description of clinical factors of the disease is important to help clinicians in treating and predicting the outcome of treatment. neutrophil to lymphocyte ratio (nlr) is https://doi.org/10.15850/amj.v8n1.2255 althea medical journal. 2021;8(1) 2 althea medical journal march 2021 moderate symptoms, severe symptoms with pneumonia, and critical.15 mild covid-19 was defined as patients with viral respiratory tract infection with non-specific symptoms (fever, malaise, cough with/without sputum, anorexia, muscle pain, sore throat, shortness of breath, mild pneumonia, nasal congestion, headache, diarrhea, nausea, and vomiting). moderate covid-19 was defined as a patient with pneumonia without severe pneumonia, no need for oxygen supplementation. severe covid-19 was defined as pneumonia with either respiratory rate more than 30/minutes, respiratory distress, oxygen saturation <93% in room air, pao2/fio2 ratio < 300.15 all patients with covid-19, aged 18 above, admitted to the hospital between march to september 2020, were included in the study. patients with an incomplete blood test, suffering from cancer, or already had blood problems prior to covid-19 were excluded from the study. secondary data on the patient’s clinical features were generated from the hospital medical record, including the patient’s diagnosis and its severity during admission, blood test examination results such as neutrophil and lymphocyte, duration of hospitalization, and outcome of the treatment. the characteristics of the patients were described using the frequency and percentage parameters. for numerical data, the normality test was performed first using the shapiro wilk test, then descriptively presented in the form of mean and standard deviation if the data were normally distributed or median and ranges (minimum-maximum) if the data were not normally distributed. to observe the difference in the neutrophil lymphocyte ratio in covid-19 patients with mild and moderate-severe symptoms, the unpaired t-test was used, if the data were normally distributed and the mann whitney test if the data were not normally distributed. the result of the statistical test was significant if p<0.05. the analysis was performed using the spss statistical program. results the characteristics of patients with moderate to severe symptoms of covid-19 were older, spent the longer duration of hospitalization, a higher proportion of comorbid including hypertension, diabetes, health problem and secondary infection, a higher mean of neutrophil percentage but a lower mean of lymphocyte percentage compared to the an independent risk factor of mortality among hospitalized covid-19 patients.4 the nlr is a reflection of the balance between the innate immune response (neutrophils) and adaptive immunity (lymphocytes). nlr is calculated by dividing the absolute number of neutrophils by the absolute number of lymphocytes or the percentage of neutrophils divided by the percentage of lymphocytes from the peripheral blood sample.5 thus, the nlr value can be obtained immediately by carrying out routine blood tests upon admission to the hospital. the physician can identify the risks in the early stages of covid-19 patients; thus, the treatment can be adjusted to reduce hospital deaths. during admission, a high level of nlr defines the severity of the diseases and predicts a poor prognosis.6-8 increased nlr in covid-19 patients, along with age and white blood cells count are also associated with a higher rate of mortality,9 and it remains as the independent predictor of critical illness of covid-19.10 however, there is a study that has found a non-significant contribution of nlr toward the death in covid-19 cases.11 nevertheless, it is generally approved that nlr can be used as an early warning signal for the deterioration of covid-19 patient condition12 and high nlr can be considered as a prognostic marker of diseases severity in patients with covid-19.13,14 examination the nlr is, therefore, an important step in the treatment of covid-19 patients. furthermore, the vast majority of earlier reports come from developed countries, where the treatment of patients is at the most sophisticated level. the report from developing countries such as indonesia is limited. therefore, this study aimed to observe the differences of ncl between mild, and moderate to severe symptoms of covid-19 admitted to a covid-19 provincial referral hospital in the province of aceh, indonesia. methods this retrospective cross-sectional study was conducted at the respiratory intensive care unit (ricu) and special covid-19 nursing ward of a general teaching hospital in banda aceh, indonesia. the hospital is the main provincial referral hospital that serves approximately 5 million population in the province. the ministry of health republic of indonesia had divided the severity of covid-19 symptoms into five categories; which were no symptoms, mild symptoms with no complication, althea medical journal. 2021;8(1) 3m. fuad et al.: neutrophil-to-lymphocyte ratio and covid-19 symptom-based severity at admission table 1 demographic and clinical characteristics of the patients during hospital admission variable covid–19 symptoms p-valuemild (n=60) moderate–severe (n=54) age (year), mean±sd 41±15 53±11 <0.001a* gender, n (%) male female 37 (61.7) 23 (38,3) 35 (64.8) 19 (35,2) 0.728c day of hospitalization–, median (min–max) 4 (2–8) 5 (2–10) 0.001b* comorbid, n (%) hypertension diabetes mellitus hearth problem chronic obstructive pulmonary disease secondary infection 6 (10) 5 (8.3) 0 (0.0) 1 (1.7) 0 (0.0) 14 (25.9) 24 (44.4) 9 (16.7) 1 (1.9) 5 (9.3) 0.026c* <0.001c* 0.001d* 1.000d 0.022d* clinical, median (min–max) breathing (x/min) body temperature (ºc) periphery oxygen saturation (%) 20 (12–60) 36.7 (35.8–38.9) 98 (94–99) 26 (20–32) 37 (35.8–39.2) 90 (70–98) <0.001b* 0.002b* <0.001b* blood test hemoglobin (g/dl), mean ± sd hematocrit (%), mean ± sd leukocyte total (x1000/mm3) , median (min–max) thrombocyte (x1000/mm3), median (min–max) neutrophil (%), mean ± sd lymphocyte (%), mean ± sd monocyte (%), median (min–max) 14±1.7 41.4±4.9 7.1 (3.1–15.9) 285 (115–636) 60±10 29±9 8 (3–14) 13.6±1.8 40.3±4.9 9.2 (4.6–25) 231 (85–577) 82±7 13±5 5 (1–16) 0.265a 0.238a 0.001b* 0.260b <0.001a* <0.001a* <0.001b* duration of hospitalization (day), median (min–max) 8 (4–19) 9 (2–25) 0.015b* treatment outcome, n (%) death recover 0 (0) 60 (100) 9 (16.7) 45 (83.3) 0.001d* note: at–test, bmann whitney u test, cchi square, dfisher exact, *significant at <0.05 patients with mild symptoms of covid-19, as shown in table 1. a higher mortality rate was also found among patients with moderate to severe symptoms in this study (16.6%). the patients who died had significantly, (p=0.02) higher nlr than surviving patients [10.88 (4.17– 47.50, iqr 7.00–15.17)] vs [6.15 (2.80–97.00, iqr 4.63–8.50)]. the median of nlr during admission was 2.27 (iqr 1.43–2.98) among patients with mild symptoms, while among moderate to severe symptoms patients was 6.54 (iqr 4.81–9.44). before the hospital discharge, the median nlr was 1.92 (iqr 1.39–2.52) among those with mild symptoms and 4.14 (iqr 2.91–8.50) among patients with moderate to severe symptoms, as shown in table 2. discussion a higher level of nlr among patients with moderate to severe symptoms compared to those with mild symptoms has been found althea medical journal. 2021;8(1) 4 althea medical journal march 2021 predictive and prognostic nomogram which could guide the clinicians to shorten the course of the disease, fasten the recovery, alleviate the shortage of medical supplies and lower mortality rate in covid-19 patients.20 meanwhile, none of those mild symptoms died but have recovered following the treatment. the 16.6% mortality rate in this study is significantly higher than reported in an epidemiological study, where only 6.3% of death is found among covid-19 patients with moderate and severe cases, administered in brazilian hospitals.18 the reason for a higher mortality rate in this study population is not well understood, since other possible determinants, such as age and other physical problems, have not been examined in this study. our study has several limitations. this study did not evaluate the correlation of comorbidity in nlr such as diabetes and secondary infection, which could also increase neutrophil. second, this study did not evaluate the changes of nlr and severity of the illness on a day-to-day basis. moreover, we have retrieved secondary data from the medical records where some laboratory data were missing. further study on the correlation among other demographic factors toward mortality of covid-19, which are not specifically investigated in this study, could be conducted. in conclusion, this study has highlighted several important clinical findings. the nlr could be used as one of the standpoints for the treatment of patients with suspected covid-19 during admission. a higher level of nlr tends to get severe and poor prognosis, thus special attention and treatment are required. furthermore, the nlr can be used as a simple parameter to help determine the severity of the disease and predict the outcome of covid-19. in the present study, supporting the earlier findings.6-8 high level of nlr during admission should become an alarming sign of the patients’ prognosis, thus the physicians require to treat them differently than lower nlr patients. the patients with a higher level of nlr that usually come with moderate to severe symptoms, such as fever, cough, respiratory tract infection– pneumonia, oxygen saturation lower than 93%, usually require immediate treatment at the respiratory intensive care unit. immediate treatment in this unit could improve the outcome of the treatment.16,17 the changes of nlr value during admission in moderate to severe symptom covid-19 compared to the nlr value on hospital discharge could predict the outcome. the chance of survival is greater in moderate to severe symptom covid-19, whose nlr value is decreasing. in contrast, death risk is greater in those who have nlr elevation. the changing of nlr during the course of the disease could be reflected as inflammation process alteration in line with clinical improvement or deterioration. in deteriorated patients, there is an increase in inflammation, reflected by neutrophil elevation and declined of lymphocyte which resulted in nlr elevation. until now, there is no study addressing the changing of nlr along the course of covid-19 in indonesia. the higher mortality rate among patients with moderate to severe symptoms in this study (16.7%) is consistent with previous reports, which also suggest the importance of prompt treatment of those with moderate to severe symptoms.18,19 higher nlr among patients who died in this study confirms that nlr is a single independent risk factor of mortality in covid-19 patients.4 scoring the nlr is therefore considered as a powerful table 2 difference of nlr during admission and before the hospital discharge among covid–19 patients variable covid–19 symptoms p–valuemild n=60 moderate-severe n=54 nlr during admission median (min–max) iqr 2.27 (0.79–5.07) 1.43–2.98 6.54 (2.80–97.00) 4.81–9.44 <0.001* nlr before discharge median (min–max) iqr 1.92 (0.51–4.00) 1.39–2.52 4.14 (0.93–95.00) 2.91–8.50 <0.001* note: p–value using mann whitney u test, *significant at < 0.05, iqr= interquartile range, nlr= neutrophil to lymphocyte ratio althea medical journal. 2021;8(1) 5 references 1. world health organization. coronavirus disease (covid-19) pandemic [internet]. geneva: wold health organization; 2020 [cited 2020 dec 28]. available from: h t t p s : / / w w w. w h o . i n t / e m e r g e n c i e s / diseases/novel-coronavirus-2019 2. ministry of health republic of indonesia. situasi terkini perkembangan (covid-19) [internet]. jakarta: kemenkes ri; 2020 [cited 2020 dec 28]. available from: https://www.kemkes.go.id/index.php 3. dinas kesehatan pemerintah aceh. data covid-19 aceh [internet]. dinkes aceh; 2020 [cited 2020 dec 28]. available from: https://dinkes.acehprov.go.id/ 4. liu y, du x, chen j, jin y, peng l, wang hhx, et al. neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with covid-19. j infect. 2020;81(1):e6–12. 5. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet. 2020;395(10223):497–506. 6. wang s, fu l, huang k, han j, zhang r, fu z. neutrophil-to-lymphocyte ratio on admission is an independent risk factor for the severity and mortality in patients with coronavirus disease 2019. j infect. 2020; s0163-4453(20)30630-7.doi:10.1016/j. jinf.2020.09.022 7. biswas ps, sen d, homchoudhary a, makkar d, kapoor m, goyal a. association of demographic, clinical, laboratory, and radiological characteristics with outcomes of covid-19 patients: a systematic review and meta-analysis. j microbiol infect dis. 2019;9(3):121–35. 8. rizo-téllez sa, méndez-garcía la, floresrebollo c, alba-flores f, alcántarasuárez r, manjarrez-reyna an, et al. the neutrophil-to-monocyte ratio and lymphocyte-to-neutrophil ratio at admission predict in-hospital mortality in mexican patients with severe sars-cov-2 infection (covid-19). microorganisms. 2020;8(10):1560. 9. moradi ev, teimouri a, rezaee r, morovatdar n, foroughian m, layegh p, et al. increased age, neutrophil-tolymphocyte ratio (nlr) and white blood cells count are associated with higher covid-19 mortality. am j emerg med. 2021;40:11-14. 10. lian j, jin c, hao s, zhang x, yang m, jin x, et al. high neutrophil-to-lymphocyte ratio associated with progression to critical illness in older patients with covid-19: a multicenter retrospective study. aging (albany ny). 2020;12(14):13849–59. 11. xu j, xu c, zhang r, wu m, pan c, li x, et al. associations of procalcitonin, c-reaction protein and neutrophil-to-lymphocyte ratio with mortality in hospitalized covid-19 patients in china. sci rep. 2020;10(1):15058 12. imran mm, ahmed u, usman u, ali m, shaukat a, gul n. neutrophil/lymphocyte ratio – a marker of covid-19 pneumonia severity. int j clin pract. 2021;2021:e13698. https://doi.org/10.1111/ijcp.13698 13. pimentel gd, dela vega mcm, laviano a. high neutrophil to lymphocyte ratio as a prognostic marker in covid-19 patients. clin nutr espen. 2020;40:101–2. available from: https://doi.org/10.1016/j. clnesp.2020.08.004 14. haghjooy javanmard s, vaseghi g, manteghinejad a, nasirian m. neutrophilto-lymphocyte ratio as a potential biomarker for disease severity in covid-19 patients. j glob antimicrob resist. 2020;22:862–3. available from: https:// doi.org/10.1016/j.jgar.2020.07.029 15. ministry of health republic of indonesia. keputusan menteri kesehatan republik indonesia nomor hk.01.07menkes-413-2020 tentang pedoman pencegahan dan pengendalian coronavirus disease 2019 (covid–19). jakarta; 2020. [cited 2020 dec 27] available from: https:// www.kemkes.go.id/resources/download/ info-terkini/covid-19 dokumen resmi/ kmk no. hk.01.07-menkes-413-2020 ttg pedoman pencegahan dan pengendalian covid-19.pdf 16. mayer kp, sturgill jl, kalema ag, soper mk, seif sm, cassity ep, et al. recovery from covid-19 and acute respiratory distress syndrome: the potential role of an intensive care unit recovery clinic: a case report. j med case reports. 2020;14(1):161. 17. möhlenkamp s, thiele h. ventilation of covid-19 patients in intensive care units. herz. 2020;45(4):329–31. 18. sousa gjb, garces ts, cestari vrf, florêncio rs, moreira tmm, pereira mld. mortality and survival of covid-19. epidemiol infect. 2020;148:e123 19. li x, xu s, yu m, wang k, tao y, zhou y, et al. risk factors for severity and mortality in adult covid-19 inpatients in wuhan. j allergy clin immunol. 2020;146(1):110–8. m. fuad et al.: neutrophil-to-lymphocyte ratio and covid-19 symptom-based severity at admission althea medical journal. 2021;8(1) 6 althea medical journal march 2021 available from: https://doi.org/10.1016/j. jaci.2020.04.006 20. kerboua ke. nlr: a cost-effective nomogram to guide therapeutic interventions in covid-19. immunol invest. 2020;00(00):1–9. available from: https://doi.org/10.1080/08820139.2020 .1773850 amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 144 althea medical journal september 2021 risk factors for febrile seizures in children aged 6–59 months in surabaya, east java febrianto adi husodo,1 sitti radhiah,2 pramita anindya nugraheni,2 1faculty of medicine universitas hang tuah, indonesia, 2department of child health faculty of medicine universitas hang tuah/dr. ramelan naval hospital, surabaya, indonesia correspondence: febrianto adi husodo, faculty of medicine universitas hang tuah, jalan gadung no. 1 komplek barat rsal dr. ramelan, surabaya, east java, indonesia, e-mail: husodo9@gmail.com introduction febrile seizures are a common problem in children, frequently encountered in pediatric emergency practice and are the most common cause of seizures in children under five years of age.1,2 parents are often afraid of the occurence of febrile seizures because they think their child would die.3 about 66% of mothers are concerned about febrile seizures and consider febrile seizures to be life-threatening for their children. the mothers believed that the seizures will cause brain damage and paralysis may occur,4 indicating the need for promotive and preventive efforts to parents, especially about the risk factors for febrile seizures. febrile seizures often occur at the age of 6–60 months with a temperature of ≥38oc. this condition is not due to a central nervous system infection, electrolyte or metabolic disorders, and without a previous history of epilepsy.1,5,6 febrile seizures are divided into two groups, namely simple febrile seizures and complex febrile seizures.3 simple febrile seizures are brief (less than 15 minutes), tonic-clonic, and occur once every 24 hours.3 whereas complex febrile seizures usually show a picture of focal or partial seizures on one-sided or generalized seizures preceded by partial seizures, seizure duration of more than 15 minutes and seizure more than once for 24 hours.3 the percentage of febrile seizures in indonesia was 2–4% in 2008 and at the age interval of 6 months–7 years,7 compared with the percentage of febrile seizures in the united states and western europe which is 2–5% at the age of 6 months–5 years with a peak incidence at 12–18 months of age.8 based amj. 2021;8(3):144–8 abstract background: febrile seizures are common in children under 5 years of age. parents are concerned when their children have seizures; therefore, it is necessary to provide promotive and preventive education regarding the risk factors for febrile seizures so that parents are more prepared. this study aimed to explore the risk factors for febrile seizures in children. methods: this case-control study was conducted on 170 children. sampling was carried out by purposive sampling on inpatients and/or outpatients at the department of child health dr. ramelan naval hospital surabaya during may 2019–july 2020. secondary data for children with fever were retrieved from medical records, with seizures (n=85) and without seizures (n=85) as a control group. furthermore, data on temperature, age, birth weight, and history of asphyxia were analyzed and compared, using the chi-square test or fisher’s exact test. results: there was a significant difference between the case and control groups regarding the history of asphyxia and the occurrence of febrile seizures (p=0.002; or=26.39; and 95% ci 1.52-455.62). there was no significant difference between the risk factors for high temperature (p=0.12), age (p=0.52), or birth weight (p=0.37) with the occurrence of febrile seizures. conclusions: a history of asphyxia in children under five years is a risk factor for febrile seizures. appropriate education from health professionals can help parents improve their knowledge, attitudes, and practices in dealing with febrile seizures and their risk factors. keywords: children aged 6–59 months, febrile seizure, risk factors https://doi.org/10.15850/amj.v8n3.2351 althea medical journal. 2021;8(3) 145 on gender, febrile seizures are more common in males than females, with a ratio of 1.3:1.9 risk factors for febrile seizures include fever, age, family history, prenatal history (age at pregnancy), or perinatal history (asphyxia, gestational age, and low birth weight babies).10 several genes are associated with febrile seizures, such as scn1a, scn1b, scn9a, tmem16, cpa6, and gabgr2.11–13 tonsillitis, upper respiratory tract infection, otitis media, roseola infantum, or shigella gastroenteritis frequently cause fever and are contributing factor in the incidence of febrile seizures.14 rhinovirus, adenovirus and enterovirus are the most common viruses in children with febrile seizures where these viruses are found along with other viruses.15 meanwhile, influenza and parainfluenza viruses are most commonly found as a single infection.15 vaccines, blood iron levels, or blood zinc levels are also associated with the occurrence of febrile seizures.8,11,14,15 this study aimed to explore the risk of febrile seizures in children under 5 years old. moreover, the result might be useful for health professionals in promoting and preventing the risk factor related to febrile seizure to the parents. methods this case-control study was conducted at dr. ramelan naval hospital surabaya, by obtaining secondary data from medical records from may 2019–july 2020. the group of children with febrile seizures was compared with the control group without seizures. inclusion criteria for children with febrile seizures aged 6–59 months with a temperature of ≥37.5oc (axillary). exclusion criteria were incomplete medical records, presence of central nervous system infection, metabolic or electrolyte disorders, long-term use of anticonvulsant drugs, presence of tumors in the central nervous system and a history of seizures without previous fever. the inclusion and exclusion criteria for the control group were similar to the case group, except for the seizure. the sample size based on the calculation was 170 subjects, thus 85 cases and 85 controls. sample selection used the purposive sampling method. this study was approved by the health research ethics committee, dr. ramelan naval hospital surabaya. data analysis included descriptive analysis, chi-square hypothesis test, and fisher’s exact hypothesis test. descriptive analysis showed the frequencies and percentages of the samples. chi-square showed a significant difference when the author compared the case and control groups with the independent categorical variable. this study used chi-square when the number of samples met with chi-square requirements (no blank cells, no cells with an expected value of less than one, and the number of cells with an expected value of less than five not more than 20% of all cells). chi-square with yate’s correction was used for the independent categorical variable in the 2x2 table and met the chi-square requirements. the independent categorical variables that did not meet the requirements of the chi-square test used fisher’s exact test in the 2x2 table. the pearson chi-square used the 4x2 table for the independent categorical variable and met the requirements of the chi-square test. parameter of the strength of the relationship between risk factor variables and febrile seizures was expressed as the odds ratio. significant value if p≤0.05 with a confidence interval of 95%. results in total, 2341 samples of medical record data were obtained and 182 samples were selected, of which 170 samples were taken according to the sample size calculation. data on general characteristics of research subjects in the case and control groups showed that the gender in the case and control groups were mostly male both in cases (65.9%) and controls (55.3%) (table 1). analysis of risk factors for febrile seizure and characteristic variables showed that most of the cases group had a temperature of ≥38oc (95.3%), whereas all children in the control group had a fever. however, there was no significant difference between case and control groups regarding temperature with febrile seizures (p=0.12). similarly, there was no significant difference between case and control groups regarding birth weight with febrile seizures (p=0.37). also on age, the results showed no significant difference between case and control groups regarding age with febrile seizures (p=0.52). interestingly, there were more children without a history of asphyxia in the control group (100%) than in the case group (87.1%), indicating that there was a significant difference between the case and control groups regarding the history of asphyxia with febrile seizures (p=0.002; odds ratio=26.39; and 95% confidence interval 1.52-455.62) (table 2). febrianto adi husodo et al.: risk factors for febrile seizures in children aged 6–59 months in surabaya, east java althea medical journal. 2021;8(3) 146 althea medical journal september 2021 discussion our study has explored the correlation in this study, we have explored the risk factors related to children with febrile seizures under 5 years of age. male is more prevalent than the female with a ratio of 1.9:1, similar to the study in palembang, with 1.3:1.9 some of the possible risk factors associated with children with febrile seizures in this study does not seem significant. for example, temperature during fever with febrile seizure (p=0.12), indicating that temperature during fever is not a risk factor for febrile seizures, conforming a study in libya,16 although a study in jaipur, india has shown a significant difference.17 febrile seizures can occur due to the susceptibility of the developing (immature) central nervous system to the effects of fever, so that the neuronal excitability increases which prompt children to develop febrile seizures. furthermore, febrile seizures may also be table 1 clinical characteristics of febrile children with or without seizure characteristic febrile children with seizure n(%) without seizure n(%) gender male female 56(65.9) 29(34.1) 47(55.3) 38(44.7) table 2 risk factors related to febrile seizure variable febrile children (n=85) p or (95% ci) testwith seizure n(%) without seizure n(%) temperature (axillary) ≥38oc <38oc 81(95.3) 4(4.7) 85 (100) 0.12 fisher birth weight <2500 gram ≥2500 gram 4 (4.7) 81 (95.3) 1 (1.2) 84 (98.8) 0.37 fisher age 6–12 months 13–24 months 25–36 months 37–59 months 34 (40) 24 (28.2) 17 (20) 10 (11.8) 32 (37.6) 20 (23.5) 16 (18.8) 17 (20) 0.52 chi-square history of asphyxia yes no 11 (12.9) 74 (87.1) 85 (100) 0.002 26.39 (1.52-455.62) yate’s correction note: *or= odds ratio; **ci= confidence interval influenced by genetic and environmental factors.8,10 this study showed that there was no significant difference between the case and control groups regarding birth weight with febrile seizures (p=0.37) and statistically, birth weight was not a risk factor for febrile seizures. a hospital-based research conducted in semarang10 showed a similar results (p=0.75), as well as study in iran.18 inversely, a case-control study from tunisia showed a significant difference in mean birth weight (p=0.023) with the case group had a lower mean than the control group (2960±780 grams versus 3300±820 gram).19 infants with low birth weight could experience hypoxiaischemia and/or hemorrhage in the brain’s ventricles. moreover, hypoxic ischemia or occurrence of infection early in the child’s life could alter neuronal excitability and is associated with susceptibility to future febrile seizure, especially when there is adequate stimulation such as fever.10 the insignificant results of this study is probably due to limited data. further study classifying birth weight into low birth weight (<2500 grams), very low birth weight (<1500 grams), or extremely low birth weight (<1000 grams) is of great interest. in this study, there was no significant difference between the case group and the control group regarding age with febrile seizures (p=0.52), similar to a case-control study conducted on tunisian children (p=0.15), however there was a trend that the cases had a younger age (21.42±12.72 versus althea medical journal. 2021;8(3) 147febrianto adi husodo et al.: risk factors for febrile seizures in children aged 6–59 months in surabaya, east java 24.90±13.90).19 interestingly, another study in semarang found a significant difference (p=0.006) between age-related groups.10 children under two years of age have a 3.4 times greater risk of febrile seizures than children over two years of age (or=3.40; ci95% 1.39-8.30).10 in this study, the most cases of febrile seizure were in the age group of 6–12 months, and the percentage of febrile seizure decreased in the case group with increasing age. in another study site in palembang, 33.5% of children aged 1–2 years had febrile seizures.9 the vulnerability of the central nervous system (cns) may cause febrile seizures since the developmental window period of cns is less than 2 years of age. when the neuronal excitability increases, children may promptly develop febrile seizures which are also influenced by genetic, environmental factors, and the inability of the inhibitory function of neurons.8,10 once again, the insignificance of the results of this study is probably due to data limitations, and the measuring unit of age used in medical records is “years”, thus affecting the data distribution in the variable category of this study which used units of “month”. interestingly, the history of asphyxia is significantly associated with febrile seizures (p=0.002; or 26.39, 95% ci 1.52-455.62), which means that children with a history of asphyxia are 26.39 times more likely to develop febrile seizure than children without history of asphyxia. however, the 95% confidence interval shows a wide confidence interval, which indicates that the sample size is too small with various possible hypotheses and inaccurate estimates. a study of three-yearold children in fuchu-tokyo examined 17,044 children, which aimed to detect the cause of exogenous seizures in children. this study found that the frequency of asphyxia neonates was more significant in children with febrile seizures (p<0.001),20 suggesting that a history of asphyxia could be a risk factor for a febrile seizure. however, the case-control study in semarang has found no significant difference between the two groups (p=0.09).10 the high risk in this study is probably because asphyxia causes hypoxic conditions and epileptogenous lesions, which increase neuronal excitability and/or impair the inhibitory function of neurons. therefore, these children are more susceptible to febrile seizures when receiving adequate stimulation such as fever.10 there are some limitations in this study. the results of our study had only one significant variable, thus, we could not proceed to a multivariate analysis to assess the effect of several risk factors on febrile seizures. further studies involving more data might have a further overview of the risk factors associated with febrile seizures among children. the study concludes that temperature, age, or birth weight do not affect the incidence of febrile seizure in children under five years old. however, a history of asphyxia is a risk factor for febrile seizures. regardless of the results, health professionals should educate the parents well on dealing with the various risk factors that may be related to febrile seizures, as well as inform the parents what medicine they should prepare at home, and when to go or call the doctor or emergency team. appropriate education will enhance the knowledge, attitudes, and practices of parents in dealing with a febrile seizure and its risk factors. references 1. eskandarifar a, fatolahpor a, asadi g, gaderi i. the risk factors in children with simple and complex febrile seizures: an epidemiological study. int j pediatr. 2017;5(6):5137–44. 2. jarrett oo, fatunde oj, osinusi k, lagunju ia. pre-hospital management of febrile seizures in children seen at the university college hospital, ibadan, nigeria. ann ib postgrad med. 2012;10(2):6–10. 3. arief rf. penatalaksanaan kejang demam. cermin dunia kedokteran-232. 2015;42(9):658–61. 4. syahida ja, risan na, tarawan vm. knowledge and attitude on febrile seizure among mothers with under-five children. althea medical journal. 2016;3(4):649–54. 5. subcommittee ob febril seizures. clinical practice guideline-febrile seizure: guidelines for the neurodiagnostic evaluation of the child with a simple febrile seizure. pediatrics. 2011;127(2):389–94. 6. patterson jl, carapetian sa, hageman jr, kelley kr. febrile seizures. pediatr ann. 2013;42(12):249–54. 7. kakalang jp, masloman n, manoppo jich. profil kejang demam di bagian ilmu kesehatan anak rsup prof. dr. r. d. kandou manado periode januari 2014– juni 2016. e-clinic. 2016;4(2):14396. 8. leung akc, hon kl, leung tnh. febrile seizures: an overview. drugs context. 2018;7:212536. 9. nindela r, dewi mr, ansori iz. karakteristik penderita kejang demam di instalasi rawat althea medical journal. 2021;8(3) 148 althea medical journal september 2021 inap bagian anak rumah sakit muhammad hoesin palembang. jurnal kedokteran dan kesehatan. 2014;1(1):41–5. 10. fuadi, bahtera t, wijayahadi n. faktor risiko bangkitan kejang demam pada anak. sari pediatri. 2010;12(3):142–9. 11. einfeld dos, pellock jm. recent research on febrile seizures: a review. j neurol neurophysiol. 2013;4(165):19519. 12. mikati ma, tchapyjnikov d. febrile seizures. in: kliegman rm, st geme iii jw, blum nj, shah ss, tasker rc, wilson km, editors. nelson textbook of pediatrics. 21st ed. philadelphia: elsevier; 2020. p. 12071– 9. 13. feenstra b, pasternak b, geller f, carstensen l, wang t, huang f, et al. common variants associated with general and mmr vaccine-related febrile seizures. nat genet. 2014;46(12):1274–82. 14. camfield c, camfield p, neville b. febrile seizures. in: engel j, pedley ta, editors. epilepsy: a comprehensive textbook. 2nd ed. philadelphia: lippincott williams & wilkins; 2008. p. 659–65. 15. francis jr, richmond p, robins c, lindsay k, levy a, effler pv, et al. an observational study of febrile seizures: the importance of viral infection and immunization. bmc pediatr. 2016;16(1):202. 16. yousif ab, hafez lm, benkhaial fs. risk factors for febrile seizures in benghazi, libya: a case–control study. alexandria j pediatr. 2017;30(2):68–73. 17. sharawat ik, singh j, dawman l, singh a. evaluation of risk factors associated with first episode febrile seizure. j clin diagn res. 2016;10(5):sc10–3. 18. mahyar a, ayazi p, fallahi m, javadi a. risk factors of the first febrile seizures in iranian children. int j pediatr. 2010;2010:862897. 19. yahyaoui s, lammouchi m, yahyaoui o, olfa b, sonia m, samir b. risk factors for febrile seizures in tunisian children : a case-control study. j med surg pathol. 2018;4(3):1–5. 20. tsuboi t, okada s. exogenous causes of seizures in children: a population study. acta neurol scand. 1985;71(2):107–13. amj vol 8 no 1 march 2021 final.indd althea medical journal. 2021;8(1) 43 profile of osteomyelitis patients visiting the orthopedic clinic of dr. hasan sadikin general hospital, indonesia, in 2017–2018 aditya nugraha,1 hermawan nagar rasyid,2 hadyana sukandar3 1faculty of medicine universitas padjadjaran, indonesia, 2department of orthopedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of pulic health faculty of medicine universitas padjadjaran, indonesia correspondence: aditya nugraha, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: adtngrh@gmail.com introduction osteomyelitis is an inflammation process followed by bone damage and caused by infecting microorganisms.1 osteomyelitis can infect all bones especially long bones and attacks all ages.1 osteomyelitis is an infectious disease that is hard to diagnose and has a complex treatment because of its diversity, pathophysiology, clinical manifestation, and treatment.2,3 infection can be spread from adjacent tissues, through blood, or direct inoculation of bacteria inside the bones as a result of trauma or operation.4,5 clinical manifestation in the osteomyelitis patients shows unspecific symptoms,6 therefore, supporting examination is needed such as tissues sampling, radiological imaging, and lab examination.7,8 this research used classifications by lew and waldvogel.9 based on the disease onset, osteomyelitis is classified as acute and chronic; whereas the source of infection is classified as hematogenic, infection from adjacent tissues and direct inoculation of bacteria inside the bones as a result of trauma or operation.9,10 staphylococcus aureus is the most common bacteria found in osteomyelitis cases.2 depends on the patient’s condition and the course of the disease, the type of bacteria can be one or several types of bacteria in the lesion.3 an effective management for osteomyelitis is amj. 2021;8(1):43–9 abstract background: osteomyelitis is an inflammatory process caused by microorganism infection that leads to bone destruction. osteomyelitis may affect all bones, particularly long bones, and infects all ages. this disease is hard to diagnose and the treatment is complex due to the disease’s heterogenicity, pathophysiology, clinical presentation, and management. this study aimed to determine the profile of osteomyelitis inpatients and outpatients presented to the orthopedic clinic of dr. hasan sadikin general hospital bandung, indonesia. methods: this was a descriptive cross-sectional study conducted from july to october 2019 using the total sampling method. data were collected from the medical records of osteomyelitis inpatients and outpatients presented to the orthopedic clinic of dr. hasan sadikin general hospital bandung, indonesia from 2017–2018. data were then analyzed descriptively and the results were presented in frequencies. results: in total, 90 data were retrieved. most of data presented male patients (n= 69, 76.7%) with the age range of 20–29 years old (24.4%). the majority of these patients experienced chronic onset of disease (94.4%) located on the tibia (51.1%), which was caused by a post-operative procedure (61.1%). the most common treatment was operative procedure without antibiotic beads (51.1%). staphylococcus aureus was the common pathogens identified in these patients (22.2%). conclusions: the majority of osteomyelitis patients are males in productive age with chronic onset of disease located on the tibia caused by a post-operative procedure. staphylococcus aureus is the common pathogen involved and the most common treatment is an operative procedure without antibiotic beads.. keywords: infection, osteomyelitis, staphylococcus aureus https://doi.org/10.15850/amj.v8n1.2075 althea medical journal. 2021;8(1) 44 althea medical journal march 2021 to diagnose as early as possible and to treat aggressively through debridement and the proper use of antibiotics.11 the incidence of osteomyelitis in the united states4 is 21.8 cases per 100,000 people per year. osteomyelitis cases are more common in males than in the females.4 there is no clear data for the incidence rate in indonesia until today. a study in semarang12 has found that of the patients with chronic osteomyelitis, the male is more common. previous study in bandung13 found that the most prevalent age among chronic osteomyelitis patients is in the range of 17–25 years. osteomyelitis is still a problem in the health sector, especially in developing countries including indonesia. osteomyelitis requires quite difficult treatment, large fee, long time, complications that often occur especially in chronic cases. furthermore, a high number of open fractures is not well treated. therefore, the researchers were interested to explore the general characteristic of osteomyelitis patients at dr. hasan sadikin general hospital bandung, in light to improve the awareness of health professionals on osteomyelitis and to further prevent complications. methods this was a descriptive cross-sectional study conducted from july to october 2019, with a total sampling method. the data were collected from medical records of osteomyelitis inpatients and outpatients in the department of orthopedic in dr. hasan sadikin general hospital bandung from 2017–2018. the exclusion criteria were osteomyelitis with infection locations other than the femur, humerus, and tibia. incomplete or missing medical record data were also excluded. the research was conducted after obtaining approval from the research ethics committee of universitas padjadjaran, no. 87/un6.kep/ ec/2019, and research permit by the ethics training and committee of dr. hasan sadikin general hospital, bandung. data on age, gender, disease onset, infection location, given therapy, infection mechanism, the microorganism that caused the infection, and the length of time from the operation history or trauma to the emergence of infection were gathered. age was measured from the birth year of the individual to the time of the first treatment. disease onset was categorized as acute and chronic. acute was defined as infection under 6 weeks and chronic was defined as infection later than 6 weeks. infection location was categorized in the femur, humerus, or tibia bones. the therapy given was categorized into conservative and operative treatment. conservative treatment was defined when the oral antibiotic was given; whereas operative treatment was defined as a treatment that required a surgical procedure. the operative treatment was distinguished by the use of antibiotic beads. then the length of time was the duration from the last operative treatment until the patients diagnosed with osteomyelitis, and categorized based on less than eight weeks, 8–16 weeks, and more than 16 weeks from the history of the last medical procedure. results in total, 90 data of osteomyelitis patients were included. the characteristics of the patients were presented in table 1, showing that the patients were mostly male (76.7%). the average age of the osteomyelitis patients was 32.51 years old (s.d 17.8 years), ranging from 1 to 71 years old, however, the most often age is in the age group of 20–29 years (24.4%) and had chronic onset (94.4%). the location of infection was in the tibia bone 51.1%. based on the onset of disease, acute cases most often occurred in males (80%), in the age range of 1–9 years old (80%), with the infection location in the femur bone (60%). hematogenous was the most frequent cause (80%), and the chosen therapy was conservative (60%) with the microorganism that caused the infection was gram-positive cocci (67%). on the other side, based on the chronic cases most often occurred in male (74%), slightly in the older age range of 20–29 years (26%), with the infection location in the tibia bone (52%), infection mechanism caused by the post-operative (64%). the chosen therapy was operative without using antibiotic beads (52%), and the microorganism found in this study was mostly staphylococcus aureus (43%), followed by pseudomonas aeruginosa, klebsiella pneumoniae, staphylococcus epidermidis, and proteus mirabilis. based on gender, osteomyelitis cases in male most often had a chronic onset (94%), the age range of 20–29 years old (28%), with infection location in the tibia bone (51%), and post-operative was the most frequent cause (59%). the chosen therapy was operative without antibiotic beads (49%), and the microorganism that caused the infection was staphylococcus aureus (47%). in the female, most often had a chronic onset (95%), the althea medical journal. 2021;8(1) 45aditya nugraha et al.: profile of osteomyelitis patients visiting the orthopedic clinic of dr. hasan sadikin general hospital, indonesia, in 2017–2018 age range of 40–49 years old (28%), infection location in the tibia bone (52%), infection mechanism caused by post-operative (67%), the chosen therapy was operative without antibiotic beads (57%), and microorganism that caused the infection was gram-negative bacilli (54%). based on the infection mechanism, hematogenous was the most often occurred in femur bone (53%), and for post-operative was in the tibia bone 31 (56%), whereas for the post-trauma in the femur and tibia bones (44%). the length of time for the onset of osteomyelitis most often occurred after 16 weeks in patients with a post-operative and post-trauma history. discussion osteomyelitis patients in this study are mostly male (76.7%), in the age range of 20–29 years (24.4%), and with the chronic onset of disease (94.4%). the majority have osteomyelitis located on the tibia (51.1%), caused by the postoperative procedure (61.1%), the most common treatment operative procedure without antibiotic beads (51.1%) and staphylococcus aureus is the common pathogen (22.2%). table 1 demographic characteristics of osteomyelitis patients from dr. hasan sadikin general hospital year 2017–2018 variable total % gender male female 69 21 76.7 23.3 age (years old) 1–9 10–19 20–29 30–39 40–49 50–59 >60 8 15 22 12 16 10 7 8.9 16.7 24.4 13.3 17.8 11.1 7.8 onset acute chronic 5 85 5.6 94.4 location femur bone humerus bone tibia bone 39 5 46 43.3 5.6 51.1 infection mechanism hematogenous post-operative post-trauma 19 55 16 21.1 61.1 17.8 therapy choice conservative operative antibiotic beads without antibiotic beads 19 25 46 21.1 27.8 51.1 microorganism* staphylococcus aureus gram-positive cocci gram-negative bacilli n/a. 20 8 19 43 22.2 8.9 21.1 note: *taken from 47 patients with pus culture results althea medical journal. 2021;8(1) 46 althea medical journal march 2021 based on the results above, the ratio of cases between males and females is 3:1. this result is in accordance with the research conducted in spain,1 as well as a previous study in bandung.13 however, there is no significant difference in the general description of osteomyelitis between males and females. the only difference is that the most frequent age range of osteomyelitis in a female is in the age range of 40–49 years old (28%). the higher incidence of osteomyelitis in males than in females can be caused by the high cases of trauma, causing the bone fracture that is not treated properly as proved by the rates of traffic accident occurred most often in males.14 total patients with chronic onset of osteomyelitis (94.4%) are higher than the acute cases. osteomyelitis with chronic onset most often occurred in the age range of 20–29 (26%), with an infection mechanism caused by post-operative (64%), and occurred in the tibia bone (52%). interestingly, research conducted in the united states of america (usa) has shown that osteomyelitis most often occurred due to diabetes mellitus disease in the usa, in the age range of 50–59 years old.4 osteomyelitis with acute onset most often occurred in the age range of one to nine years old (80%), caused by the spread of infection hematogenously (80%), and most often occurred in the femur bone (60%). this result is in accordance with the research conducted table 2 characteristic of osteomyelitis patients based on onset variable onset acute (n=5) n (%) chronic (n=85) n (%) gender male female 4 (80) 1 (20) 65 (74) 20 (24) age (years old) 1–9 10–19 20–29 30–39 40–49 50–59 >60 4 (80) 1 (20) 0 0 0 0 0 4 (5) 14 (16) 22 (26) 12 (14) 16 (19) 10 (12) 7 (8) location femur bone humerus bone tibia bone 3 (60) 0 2 (40) 36 (42) 5 (6) 44 (52) infection mechanism hematogenous post-operative post-trauma 4 (80) 1 (20) 0 15 (18) 54 (64) 16 (19) therapy choice conservative operative antibiotic beads without antibiotic beads 3 (60) 0 2 (40) 16 (19) 25 (29) 44 (52) microorganism* staphylococcus aureus gram-positive cocci gram-negative bacilli n/a. 1 (33) 2 (67) 0 2 19 (43) 6 (14) 19 (43) 41 note: *taken from 47 patients with pus culture results althea medical journal. 2021;8(1) 47aditya nugraha et al.: profile of osteomyelitis patients visiting the orthopedic clinic of dr. hasan sadikin general hospital, indonesia, in 2017–2018 table 3 characteristic of osteomyelitis patients based on gender variable gender male (n=69) n (%) female (n=21) n (%) onset acute 4 (6) 1 (5) chronic 65 (94) 20 (95) age (years old) 1–9 6 (9) 2 (10) 10–19 10 (14) 5 (24) 20–29 19 (28) 3 (14) 30–39 8 (12) 4 (19) 40–49 10 (14) 6 (28) 50–59 9 (13) 1 (5) >60 7 (10) 0 location femur bone 31 (45) 8 (38) humerus bone 3 (4) 2 (10) tibia bone 35 (51) 11 (52) infection mechanism hematogenous 13 (19) 6 (28) post-operative 41 (59) 14 (67) post-trauma 15 (22) 1 (5) therapy choice conservative 12 (17) 7 (33) operative antibiotic beads 23 (34) 2 (10) without antibiotic beads 34 (49) 12 (57) microorganism* staphylococcus aureus 17 (47) 3 (27) gram-positive cocci 6 (17) 2 (18) gram-negative bacilli 13(36) 6 (54) n/a. 33 10 note: *taken from 47 patients with pus culture results table 4 description of location and length of time based on infection mechanism variable infection mechanism hematogenous (n=19) n(%) post-operative (n=55) n(%) post-trauma (n=16) n(%) location femur bone humerus bone tibia bone 10 (53) 1 (5) 8 (44) 22 (40) 2 (4) 31 (56) 7 (44) 2 (12) 7 (44) length of time < 8 weeks 8–16 weeks >16 weeks 2 (4) 11 (20) 42 (76) 2 (12) 2 (12) 12 (76) althea medical journal. 2021;8(1) 48 althea medical journal march 2021 in italy15, showing that the acute cases usually happened in children under five years old with hematogenous infection mechanism and most often occurred in the lower extremity. the infection location in the osteomyelitis patients most often occurrs in the tibia bone (51.1%) through a post-operative mechanism (56%). in contrary to a study conducted in the usa4, the most common location for osteomyelitis is the tarsal and metatarsal bones, followed by long bones such as the tibia. the most common cause of osteomyelitis in that research is diabetes mellitus, which causes the degradation of vascular function on the legs.4 similar to research conducted in spain that shows tarsal and metatarsal as the most common infection location.1 unfortunately, this study does not include patients with the infection location in the tarsal and metatarsal bones and look for data of blood glucose level. the infection mechanism is most often postoperative (61.1%). the osteomyelitis incident most often occurred after 16 weeks from the last medical procedure (76%) and occurred in the lower extremity (96%). most patients have experienced both open and closed fractures. interestingly, some patients insisted on going home, and the rest of them are not compliant to exercise control after medical treatment. the infection happened after the medical treatment is highly related to the patient compliance level, leading to high post-operative osteomyelitis incidents in this research.16 one of the risk factors that can cause infection after the medical treatment is the biofilm layer attached to the fixation implants.16 the most common location for osteomyelitis caused by post-operative is the lower extremities.16,17 interestingly, osteomyelitis most often occurrs in patients with an operation history of under two weeks.16,17 one of the factors of the reason why this happens is that probably the way of indonesian society in seeking treatment, therefore, a patient needs more time to get medical treatment. the chosen treatment most often performed is the debridement operative procedure without using antibiotic beads (46%). this procedure is performed in the chronic cases (52%) compared to the acute cases (40%). this data is in line with others studies resulting in that surgical management most often done in patients diagnosed with chronic osteomyelitis as a debridement procedure.11,18 debridement is very widely used for cases of chronic osteomyelitis, however, the operative procedure does not always solve the problem of this disease. therefore, comprehensive approach is needed to give the best therapy for patients.2,11 of the 90 patients recruited, there are only 52.2% patients with pus culture results, of whom staphylococcus aureus is the most common microorganism that caused osteomyelitis (42.6%), followed by gramnegative bacilli (40%). staphylococcus aureus is the most common bacteria that caused the infection, as confirmed by some other studies.19,20 staphylococcus aureus can interact with osteoblast to cause the bone infection.10 the limitation of this study is that diabetes mellitus has not been taken into account. further study is needed to explore the correlation of diabetes mellitus in relation to osteomyelitis. in conclusion, this study shows that the osteomyelitis patients are mostly male at productive age, with the majority of patients come with chronic onset. osteomyelitis most often occurrs in the tibia bone with a post-operative infection mechanism and has a medical history of operative treatment more than 16 weeks before the occurrence of osteomyelitis. the chosen therapy most often used is an operative procedure without antibiotic beads. staphylococcus aureus is the microorganism that most often caused osteomyelitis. references 1. prieto-pérez l, pérez-tanoira r, petkovasaiz e, pérez-jorge c, lopez-rodriguez c, alvarez-alvarez b, et al. osteomyelitis: a descriptive study. clin orthop surg. 2014;6(1)20–5. 2. taki h, krkovic m, moore e, abood a, norrish a. chronic long bone osteomyelitis: diagnosis, management and current trends. br j hosp med (lond). 2016;77(10):c161–4. 3. calhoun jh, manring mm, shirtliff m. osteomyelitis of the long bones. semin plast surg. 2009;23(2):59–72. 4. kremers hm, nwojo me, ransom je, wood-wentz cm, melton 3rdlj, huddleston 3rdpm. trends in the epidemiology of osteomyelitis a population-based study, 1969 to 2009. j bone joint surg am 2015;97(10):837–45. 5. rightmire e, zurakowski d, vrahas m. acute infection after fracture repair; management with hardware in place. clin orthop relat res. 2008;466(2):466–72. 6. panteli m, giannoudis pv. chronic osteomyelitis: what the surgeon needs to althea medical journal. 2021;8(1) 49 know. efort open rev. 2017;1(5):128– 35. 7. solomon l, warwick dj, nayagam s. apley’s and solomon’s concise system of orthopaedics and trauma. 4th ed. boca raton: crc press; 2014 8. michno a, nowak a, królicki l. review of contemporary knowledge of osteomyelitis diagnosis. world scientific news. 2018;92(2):272–82. 9. lew, dp, waldvogel f. osteomyelitis. lancet. 2004;364(9431):369–79. 10. roy m, somerson js, kerr kg, conroy jl. pathophysiology and pathogenesis of osteomyelitis. in: baptista ms, editor. osteomyelitis. london: intechopen; 2012 [cited 2019 may 11] available from: https://www.intechopen.com/books/ o s t e o mye l i t i s / p a t h o p hys i o l o g ya n d pathogenesis 11. lima all, oliveira pr, carvalho vc, cimerman s, savio e; diretrizes panamericanas para el tratamiento de las osteomielitis e infecciones de tejidos blandos group. recommendations for the treatment of osteomyelitis. braz j infect dis. 2014;18(5):526–34. 12. albertus aw, sutejo b. pengelolaan pasien osteomielitis kronis di rsup dr . kariadi semarang periode 2001-2005 [minor thesis]. semarang; dipenogoro university; 2007 [cited 2019 may 11]. available from: ht t p ://eprint s.u ndip.ac.id/2 2318/ 1/ albertus.pdf 13. indira sa, lokarjana l, pohan dk. gambaran pasien osteomielitis kronis di bagian bedah orthopaedi rsup dr. hasan sadikin bandung periode januari 2011-desember 2016 [minor thesis] cimahi: universitas jenderal ahmad yani; 2017 [cited 2019 may 11]. available from: h t t p : / / re p o s i to r y. u n j a n i . a c . i d / i n d ex . php?p=show_detail&id=375 14. angela za, tomuka dch, siwu j. pola luka pada kasus kecelakaan lalu lintas di blu rsu prof. dr. r. d. kandou manado periode 2010-2011, e-biomedik (ebm). 2013;1(1):676-85. 15. chiappini e, camposampiero c, lazzeri s, indolfi g, de martino m, galli l. epidemiology and management of acute haematogenous osteomyelitis in a tertiary paediatric center. int j environ res public health. 2017;14(5):477. 16. aytaç s, schnetzke m, swartman b, herrmann p, woelfl c, heppert v, et al. posttraumatic and postoperative osteomyelitis: surgical revision strategy with persisting fistula. arch orthop trauma surg. 2014;134(2):159–65. 17. hagen r. osteomyelitis after operative fracture treatment : a report of 62 cases treated with radical surgery and lincomycin ( lincocin® ). acta orthop scand. 1978;49(6):542-548. 18. rasyid hn. konsep baru dalam pembuatan beads mengandung campuran antibiotik dan polymethylmethacrylate untuk terapi osteomielitis kronis [dissertation]. bandung: universitas padjadjaran; 2006. 19. carek pj, dickerson lm, sack jl. diagnosis and management of osteomyelitis. am fam physician. 2001;63(12):2413–20. 20. groll me, woods t, salcido r. osteomyelitis: a context for wound management. adv ski wound care. 2018;31(6):253–62. aditya nugraha et al.: profile of osteomyelitis patients visiting the orthopedic clinic of dr. hasan sadikin general hospital, indonesia, in 2017–2018 amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 6 amj march 2020 amj. 2020;7(1):6–10 antibacterial effect of curcuma zedoaria extract on bacillus cereus and staphylococcus epidermidis vidya indryani, linda chiuman, linda leonando wijaya, gilbert lister, lexandria grandis faculty of medicine universitas prima, medan, indonesia abstract background: white turmeric (curcuma zedoaria), a plant used traditionally for medicine, is easily obtained at a relatively cheap price in indonesia. white tumeric contains alkaloids, phenols, saponins, glycosides, steroids, terpenoids, and other compounds; and these compounds have shown antimicrobials, antifungal, anticancer, antiallergic, antioxidant, and analgesic effects. the aim of this study was to determine the antibacterial effect of white turmeric (curcuma zedoaria) rhizome extract on the growth of bacillus cereus and staphylococcus epidermidis bacteria. methods: this was an experimental study with a post-test only control group design. it was carried out using the disc diffusion method with six treatments, consisting of negative control (aquadest), positive control (ciprofloxacin), and the extract of white turmeric rhizome with various concentrations. kruskal wallis test and one way anova were used to analyze the data. the results showed a statistically significant value smaller than α (0.021 <0.05), and the one way anova test had a statistically significant value (p) less than α (0.000 <0.05). results: the results of this research showed that the extract of white turmeric (curcuma zedoaria) inhibited the growth of bacillus cereus and staphylococcus epidermidis bacteria at concentrations of 25%, 50%, 75%, and 100% as shown by the diameter inhibitory zone between 10-20 mm, compared to the positive control which had >20mm. conclusions: curcuma zedoaria has an antibacterial effect against bacillus cereus and staphylococcus epidermidis. further study is needed, exploring the effectivity of white turmeric in the animal models. keywords: antibacterial, bacillus cereus, rhizome extract, staphylococcus epidermidis, white turmeric correspondence: linda leonando wijaya, faculty of medicine universitas prima indonesia, jalan ayahanda no. 55, sei putih tengah, medan petisah, medan, north sumatera, indonesia. e-mail: lindaleonando@yahoo.com introduction indonesia is a developing country, located in a tropical area where various infections occur. therefore, its population is susceptible to various infectious diseases, caused by virus, parasite or bacteria.1 one of the most prevalent disease in indonesia is diarrhea, that is associated with a high case fatality rate (cfr).2 the main cause of diarrhea are foodborne and waterborne pathogens, among others bacillus, salmonella spp., and campylobacter jejuni.3 bacillus is a genus of gram-positive, rod-shaped aerobes. bacillus cereus, for example, can be found in food and can release enterotoxins that can cause food poisoning. the main clinical symptoms are vomiting and diarrhea with abdominal pain.4 another interesting infection prevalent in indonesia is a skin infection that causes acne. acne often occurs on the surface of the skin in the face, neck, chest, and back. acne appears when sebaceous glands are too active, and the pores are blocked.5 in indonesia about 95– 100% of men and around 83–85% of women at the age of 16–17 years have acne.6 acne can also be caused by bacteria staphylococcus epidermidis. this bacterium is part of normal flora in the skin, but it can be harmful elsewhere. if staphylococcus epidermidis develops in the sebaceous glands, and the gland is blocked, it will produce substances that can irritate in the surrounding area, then swelling. rupture of the glands may cause inflammation to the surrounding skin tissue.7 antibiotics are usually used to treat https://doi.org/10.15850/amj.v7n1.1886 althea medical journal. 2020;7(1) 7 the faculty of medicine, university of prima indonesia in july–august 2019. the protocol research was granted ethical clearance by the ethical research commission of the universitas prima indonesia no. 017/kepk/ unpri/ix/2019. the sample used in this study came from the white turmeric rhizome plant in the form of dried simplicia powder obtained from upt materia medica batu, east java. curcuma zedoaria was washed and dried in a drying cabinet. after drying, curcuma zedoaria was blended in a blender. the extract was created by the maceration method using 96% ethanol which has been distilled at ten times the weight of curcuma zedoria, 1,000 grams of curcuma zedoaria powder was put into the container then 96% ethanol was added as many as 75 parts (7.5 ml). the powder was soaked for 5 days while being stirred frequently and being protected from light, and then it was filtered and cleaned. the filtered curcuma zedoaria was soaked again with 96% (2.5 ml) ethanol for 2 days and then filtered again. the filtrate was combined then concentrated with a rotary evaporator until it reached the preferred fluidity. the concentration of curcuma zedoaria extract used in this study was 25%, 50%, 75%, and 100% solved in aquabidest. the weight of the solute (extract) used was calculated using the following formula: presentation: solvent used x 100% volume of solution infections. incorrect use of antibiotics may result in drug resistance for pathogenic microbes, and the emergence of resistant microbes is a major cause of treatment failure. therefore, an alternative treatment such as medicinal plants that can be utilized its active antimicrobial content.8 indonesia has high biodiversity in plants, which means that the country has various potential plants that can be developed for medicinal uses. one example of a medicinal plant that is also known as spices is curcuma zedoaria. this plant can be found in many countries in asia. in indonesia, curcuma zedoaria can be found in mount dempo in sumatra, in east java teak forests, and many other areas.9 curcuma zedoaria contains compounds such as alkaloids, phenols, saponins, glycosides, steroids, terpenoids, which has antimicrobials, antifungal, anticancer, antiallergic, antioxidant, and analgesic properties.10 this study aimed to determine the antibacterial effect of curcuma zedoaria extract on the growth of gram-positive bacteria bacillus cereus and staphylococcus epidermidis, two types of bacteria often occur in indonesia methods this experiment was a posttest only control group experimental design. this research was conducted in the pharmacy and toxicology lab of the faculty of pharmacy, university of north sumatra and the microbiology laboratory in vidya indryani et al.: antibacterial effects of curcuma zedoaria extract on bacillus cereus and staphylococcus epidermidis table 1 the concentration of white turmeric rhizome extract white turmeric extract (gr) final volume (ml) concentration (%) 2.5 10 25 5.0 10 50 7.5 10 75 10.0 10 100 table 2 classification of antibacterial activity average inhibition zone diameter category >20 mm very severe 10–20 mm severe 5–10 mm moderate <5 mm weak figure 1 the inhibitory zones diameter measured using calipers after putting 25%, 50%, 75%, and 100% concentrations of curcuma zedoaria althea medical journal. 2020;7(1) 8 amj march 2020 about 6.8 gr mueller hinton agar (mha) was dissolved with 250 ml of distilled water into an erlenmeyer tube, then placed on an autoclave hotplate with a temperature of 121°c for 15 minutes, then 25 ml of mha was poured into the petri dish.13 nutrient broth (nb) powder 1 gr was put into a 500 ml beaker glass; then 150 ml of distilled water was added. then, it was heated on a hotplate until all the compounds were dissolved and homogeneous. after that, the solution was put into an erlenmeyer tube and then was put in the autoclave at 121°c for 45 minutes. furthermore, it was put in a test tube and then in the refrigerator before use.14 to prepare the bacterial suspension, 1 ose bacteria were inoculated into a 25 ml nb. bacterial culture in nb media was rocked using a shaker with a rotation speed of 120 rpm for 24 hours.the claudy bacterial culture indicated the growth of bacteria.15 to measure the antibacterial effect the kirby-bauer method (disc diffusion) was used. inhibitory effect of curcuma zedoaria extract on the growth of bacillus cereus and staphylococcus epidermidisas followed; the mueller hinton agar (mha) used 8 petri dishes and 28 whatman paper discs. whatman paper was made with a perforator so it was shaped into a 6 mm disk. before the bacteria were planted on the mha, the front of the petri dish was divided into four and labeled with stickers.16 on the surface of the mha, bacillus cereus and staphylococcus epidermidis were cultured using sterile cotton swabs on different petri dishes. the whatman paper discs that were soaked for ±15 minutes with different curcuma zedoaria extract were joined to the two bacterial cultures. as a positive control, 2 ciprofloxacin discs were used and as a negative control whatman paper discs were used, immersed in sterile distilled water for ±15 minutes. the paper discs were placed on the surface of the mha with the help of sterile tweezers with a little pressure so that whatman paper discs adhered well. paper discs were incubated at 37˚c for 48 hours. inhibitory zones or clear zones that formed on the paper discs were measured with the classification of an antibacterial activity as shown in table 2. the average of inhibition zone diameter was categorized as very severe when the diameter >20 mm; severe for diameter 10–20 mm, moderate for table 3 the inhibitory zone diameter of bacilluscereus experiment no. concentrations 25% 50% 75% 100% i 9.2 11.6 12.0 18.8 ii 10.5 12.7 14.2 19.2 iii 10.6 12.7 14.2 19.1 average 10.10 12.33 13.47 19.03 control + 29.6 control 0 note: inhibitory zone diameter was measured in mm table 4 the inhibitory zone diameter of staphylococcus epidermidis experiment no. concentrations 25% 50% 75% 100% i 11.5 12.3 16.3 20.3 ii 11.3 14 15.2 19.6 iii 12.1 13.4 16.5 20.2 average 11.63 13.23 16. 20.03 control + 27.7 control 0 note: inhibitory zone diameter was measured in mm althea medical journal. 2020;7(1) 9 diameter 5–10 mm, and weak for diameter <5 mm. the antibacterial effectiveness of curcuma zedoaria extract against bacillus cereus bacteria was observed using a sensitivity test indicated by the presence of inhibition zones or clear zones around disc paper. the inhibition zone diameter was measured using calipers after putting 25%, 50%, 75%, and 100% concentrations of curcuma zedoaria as shown in figure 1. results the diameter of inhibition zone of baccillus cereus was examined in triplo, measured using calipers after putting 25%, 50%, 75%, and 100% concentrations of curcuma zedoaria, and the average of diameter was 10.10 mm, 12.33 mm, 13.47 mm, and 19.3 mm, respectively. the positive control showed a strong inhibitory zone (29.6 mm) that was more than 20 mm, and the negative control was confirmed to have no inhibitory zone (table 3). the antibacterial effectiveness of curcuma zedoaria extract against staphylococcus epidermidis was depicted in table 4. curcuma zedoaria had an antibacterial property against the bacteria staphylococcus epidermidis at concentrations of 25%, 50%, 75%, and 100%, with the average inhibitory zone was 11.63 mm, 13.23 mm, 16.00 mm, and 20.03 mm, respectively. the positive control showed a strong inhibitory zone (27.7 mm) that was more than 20 mm, and the negative control was confirmed to have no inhibitory zone (table 4). discussion curcuma zedoaria in our study has confirmed to have antibacterial properties against bacillus cereus and staphylococcus epidermidis. the effectiveness of curcuma zedoaria extract is indicated by the inhibitory zone. the average of the inhibitory zone of bacillus cereus and staphylococcus epidermidis at various concentrations is between 10–20 mm. especially at 100% concentration, the diameter of inhibition zone is about 20 mm, indicating that curcuma zedoaria is a strong inhibitor.21 bacillus cereus and staphylococcus epidermidis are gram-positive bacteria that have cell wall structures with more peptidogly can and the hydrophilic nature that makes it more polar. curcuma zedoaria can penetrate the cell wall more easily because it contains polar flavonoid compounds.17 flavonoids contain phenol which can also disrupt and damage the microbial membrane.18 this can damage the cytoplasmic membrane of which can inhibit bacterial growth and follow by bacterial death.19 curcuma zedoaria also contains triterpenoid compounds. this can reduce the permeability of the cell membranes of the bacteria by damaging the purines, and again this can inhibit bacterial growth or cause death.18 the limitation of this study is that the components of curcuma zedoaria are not measured. therefore, future study is needed to reveal the specific benefit of white tumeric extract. to conclude, curcuma zedoaria has an antibacterial effect against bacillus cereus as well as staphylococcus epidermidis. further study is needed to explore the effectivity of curcuma zedoaria or white turmeric in the animal models. references 1. radji m. buku ajar mikrobiologi: panduan mahasiswa farmasi dan kedokteran. jakarta : egc. 2009. p. 107 2. agtini md. morbiditas dan mortalitas diare pada balita di indonesia tahun 20002007. buletin jendela data dan informasi kesehatan. 2011;2(2):26–32. 3. rahmawati f, bintari sh. studi aktivitas antibakteri sari daun binahong (anredera cordifolia) terhadap pertumbuhan bacillus cereus dan salmonella enteritidis. unnes j life sci. 2014;3(2):103–11. 4. brooks gf, carroll kc, butel js, morse sa, mietzner ta. jawetz, melnick, & adelberg mikrobiologi kedokteran (indonesian version). 25th ed. jakarta (id): egc; 2010. p.173 & 176. 5. handayani v. pengujian aktivitas antibakteri ekstrak etanol daun kersen (muntingia calabura l.) terhadap bakteri penyebab jerawat. jurnal fitofarmaka indonesia. 2015;2(1):94–6. 6. yustica fk, widiastuti ni, sapitri n, fitriastuti d. essential oils from alpinia purpurata (zingiberaceae): chemical composition and formulation of antiacne cream. indonesan journal of chemical research. 2019;4(1):14–21. 7. kursia s, lebang js, taebe b, burhan a, rahim wor, nursamsiar. uji aktivitas antibakteri ekstrak etilasetat daun sirih hijau (piper betle l.) terhadap bakteri staphylococcus epidermidis. ijpst. vidya indryani et al.: antibacterial effects of curcuma zedoaria extract on bacillus cereus and staphylococcus epidermidis althea medical journal. 2020;7(1) 10 amj march 2020 2016;3(2):72–7. 8. adila r, agustien a, nurmiati. uji antimikroba curcuma spp. terhadap pertumbuhan candida albicans, staphylococcus aureus dan escherichia coli. j bio ua. 2013;2(1):1–7. 9. saparinto c, susiana r. grow your own medical plant: panduan praktis menanam 51 tanaman obat populer di pekarangan. 1st ed. yogyakarta: lily publisher; 2016. p.452–453 . 10. putri ms. white turmeric (curcuma zedoaria): its chemical subtance and the pharmacological benefits. majority. 2014;3(7):88–93. 11. nuryant, s. aktivitas antifungi temu putih (curcuma zedoaria) terhadap trichophyton. as-syifaa. 2016;8(2):50–7. 12. busman, edrizal, wirahmi sd. daya hambat ekstrak rimpang temu putih (curcuma zedoaria) terhadap streptococcus mutans dan staphylococcus aureus. menara ilmu. 2019;xiii(6):19–28. 13. daely pj, sarwendah, laia hcg, damardi s. uji daya hambat anti bakteri air perasan daging buah nanas (ananas comosus (l) merr varqueen) terhadap bakteri eschericia coli. jurnal ilmiah universitas batanghari jambi. 2019;19(2):239–41 14. miksusanti, fitrya, marfinda n. aktivitas campuran ekstrak kulit manggis (garcinia mangostana l.) dan kayu secang (caesalpina sappan l.) terhadap bacillus cereus. jurnal penelitian sains.2011;14(3):41–7. 15. ayen ry, rahmawati, mukarlina. aktivitas antibakteri ekstrak metanol daun sembung rambat (mikania micrantha h.b.k) terhadap pertumbuhan bakteri bacilluscereus ihb b 379 dan shigella flexneri. protobiont. 2017;6(2):123–9 16. dicky a, apriliana e. efek pemberian ekstrak temulawak (curcuma xanthorrhiza roxb) terhadap daya hambat pertumbuhan staphylococcus aureus dan escherichia coli secara in vitro. jk unila. 2016;1(2):308–12 17. rundengan ch, fatimawali, simbalah. uji daya hambat ekstrak etanol biji pinang yaki (areca vestiaria) terhadap bakteri staphylococcus aureus, escherichia coli, pseudomonas aeruginosa. pharmacon. 2017;6(1):37–46. 18. supari ih, leman ma, zuliari k. efektivitas antibakteri ekstrak biji bengkuang (pachyrrhizus erosus) terhadap pertumbuhan streptococcus mutans cecara in vitro. pharmacon. 2016;5(3):33–9. 19. saputra o, anggraini n. khasiat belimbing wuluh (averrhoa bilimbi l.) terhadap penyembuhan acne vulgaris. majority. 2016;5(1):76–80. 20. arlofa n. uji kandungan senyawa fitokimia kulit durian sebagai bahan aktif pembuatan sabun. jurnal chemtech. 2015;1(1):18–22. 21. ngajow m, abidjulu j, kamu vs . pengaruh anti bakteri ekstrak kulit batang matoa (pometia pinnata) terhadap bakteri staphylococcus aureus secara in vitro. jurnal mipa unsrat online. 2013;2(2):128–32. amj vol 9 no 3 september 2022 (3).indd althea medical journal. 2022;9(3) 180 comparison of single centrifugation, double centrifugation and turn down-turn up techniques for platelet-rich plasma quality eva ayu maharani, dewi astuti department of medical technology laboratory polytechnic of health, ministry of health, jakarta, indonesia correspondence: eva ayu maharani, s.si, m.biomed, department of medical technology laboratory polytechnic of health, ministry of health, jakarta 3, jalan sumber pelita no.22 kemayoran, jakarta pusat, indonesia, email: evaayumaharani@gmail.com introduction platelet-rich plasma (prp) is a new concept used in the medical world, especially for wound healing or skin rejuvenating effects.1,2 the prp has been used for the treatment of acne, burns, and baldness, especially in women. platelets contain several growth factors that play a role in the formation or regeneration of blood vessels from the existing network of blood vessels. furthermore, platelets can improve oxygen supply to tissues when blood flow is reduced.3 although prp is a promising therapy, however, the standardization of the prp procedure has not been determined, and the quality examination of prp is still limited.3,4 in general, prp is obtained through a centrifugation process. there are various techniques in obtaining prp, ranging from the double centrifugation (dc) techniques at various temperatures, the buffy coat separation techniques, to the technique of adding a platelet activator.5 currently, there are also commercial prp kits, which are more expensive than conventional and manual methods.6 the main process that determines the quality of prp is the centrifugation process, which includes the number of spins of centrifugation, centrifugation time, centrifugal acceleration, and the volume of the blood.7,8 the prp procedure commonly used is the double centrifugation (dc) technique, however, there are also modifications, among others the turn down-turn up technique (dc-tdtu) which is claimed to produce a maximum number of platelets.9 to measure the optimization of the centrifugation process and the separation of blood cells from plasma, althea medical journal. 2022;9(3):180–184 abstract background: platelet-rich plasma (prp) is a new concept used in the medical world, especially for wound healing. the main process that affects the prp quality is the centrifugation process. this study aimed to assess the prp separation process and determine the best technique for various centrifugation processes. methods: this experimental study used acid citrate dextrose (acd) blood taken from 11 healthy respondents and compared three techniques including the single centrifugation (sc), the double centrifugation (dc), and the double centrifugation turn down turn up (dc-tdtu) techniques. the quality of prp was measured based on blood cell count (platelet, leukocyte, erythrocyte count, and ht value) at each stage of centrifugation. the examination was carried out in 2021 at the hematology laboratory, poltekkes jakarta 3. results: the mean values of platelets, leukocytes, and ht were increased in prp compared to plasma supernatant both using the dc and dc-tdtu techniques, whereas the sc technique decreased in plasma compared with whole blood. when the procedures using dc and dc-tdtu are carried out properly, platelets would be concentrated in the second centrifugation. however, some erythrocyte and leukocyte contamination occurred with the dc-tdtu technique compared to the dc technique. conclusion: the double centrifugation technique is the best platelet-rich plasma separation technique compared to the dc-tdtu and sc techniques. keywords: blood cells count, centrifugation, prp althea medical journal. 2022;9(3) 181 it is necessary to count platelets, leukocytes, erythrocytes, and hematocrit (ht) at each step of the centrifugation procedure.5 in this study, we compared the quality of prp obtained by various techniques which were single centrifugation (sc), double centrifugation (dc) and double centrifugation turn downturn up technique (dc-tdtu). the blood cell counts (platelet, leukocyte, erythrocyte count, and ht) were compared in order to assess the prp separation process and to determine the best quality among the three techniques. methods this research was an experimental study using acid citrate dextrose (acd) blood taken from 11 healthy respondents by routine blood tests within the normal range. the procedure has been approved by the ethics committee of poltekkes kemenkes jakarta 3 no kepkpkj3/043/vi/2021. the examination was carried out at the hematology laboratory, poltekkes kemenkes jakarta 3. blood samples for the three techniques were drawn in a vacuum tube (bd vacutainer acd solution a ref 364606) under strict aseptic precautions. the centrifuge type used was a swing centrifuge, conducted by the same person. in the single centrifugation (sc) technique, the blood was centrifuged at 3,200 rpm for 15 minutes, and the plasma supernatant was separated. furthermore, the cell counts, including platelet, leukocyte, erythrocyte count, and hematocrit (ht) were measured (sysmex xs500i hematology analyzer). in the double centrifugation (dc) technique, the first spin was performed at 400 g for 10 minutes. the plasma supernatant formed was separated into another tube without anticoagulant and then centrifuged at 1200 g for 10 minutes. the supernatant formed (the upper 2/3rd tube) was further separated from the precipitate (prp) before resuspending by a gently shaking tube. in the double centrifugation turn downturn up (dc-tdtu) technique, the first spin to collect plasma was performed at 200 g for 15 minutes with the vacuum tube facing down (inverted position) in the centrifuge. blood sediment was separated with a syringe through the rubber tube cap at the bottom of the tube for 3.5 ml (figure). the second centrifugation was carried out on the tube at 1600 g for 10 minutes with the position of the tube facing up (normal position). the supernatant formed was separated for 3.5 ml volume, and the precipitate (prp) was also separated for 1–2 ml in a different tube without anticoagulant. the data on the blood cell count were analyzed in each centrifugation process. statistical differences between whole blood, plasma from first centrifugation, and prp after double centrifugation techniques were tested using t-test and wilcoxon, based on the shapiro wilk distribution data test. p-value <0.05 was considered statistically significant. results the mean platelet, leukocyte, erythrocyte count, and ht in whole blood and prp in each technique and centrifugation step were shown in table 1. the platelet count on prp using dc figure preparations of prp using dc-tdtu technique after the first centrifugation eva ayu maharani et al.: comparison of single centrifugation, double centrifugation and turn down turn up techniques for platelet-rich plasma quality althea medical journal. 2022;9(3) 182 and dc-tdtu techniques showed an increase between the first and second centrifugation, whereas using the sc technique there was a decrease. interestingly, there was a significant difference (p<0.05) in the number of platelets between forms of whole blood, plasma, and prp. the leukocyte count showed an increase in the prp compared to plasma. the decrease in the leukocyte count from whole blood to plasma in the three techniques showed a significant difference (p<0.05). the mean erythrocytes count in the dc technique was lower than in the dc-tdtu and sc techniques. this result was also related to the ht value. our results showed that the ht value in the dc technique was smaller compared to the two techniques. discussion examination of blood cell count in the prp procedure is used to check the process of separating plasma from blood cells, where a large concentration of platelets is produced.5 every prp procedure and technique must be checked for quality because the composition of prp is different for every person, device, and method.10 centrifugation in the same rpm will exert different centrifugal forces if centrifuge rotors have different radius sizes, bucket types, or bucket sizes.11 in the dc and dc-tdtu techniques, the mean platelet count is 3 times higher than in the whole blood. according to the principle of prp centrifugation, the first centrifuge is to separate erythrocytes (bottom), buffy coats (middle), and plasma (top). the second centrifugation is to concentrate the platelet, which is suspended in the smallest volume of plasma. to ensure that the platelets are suspended and do not form a clot, prp should be prepared from anticoagulated blood, acd is the best anticoagulant for maintaining platelet viability compared with heparin and sodium citrate.12 the platelets have begun to be concentrated in the 1/3 volume of the tube bottom to form a white and slightly cloudy layer.5 in this procedure, each prp is incubated for 30 to 60 minutes at room temperature, to inhibit platelet aggregation, which can appear as clots that interfere with the blood cell count. the incubation aim also facilitates the settling of platelets onto the buffy coat.13 the number of platelets in plasma is less than platelets in whole blood. in the sc technique, the number of platelets in plasma is lower table 1 platelet, leukocyte, erythrocyte count, and ht value in whole blood, plasma, and prp parameter* sc dc dc td-tu platelet count whole blood plasma prp p-test 240.5±29.4 148.3±94 p < 0.05 240.5±29.4 507.5±89.8 1,123.3±441.5** p < 0.05 240.5±29.4 427.8±48.5 1,088.9±277.6** p < 0.05 leukocyte count whole blood plasma prp p-test 6.9±1.7 2.8±3.4 p < 0.05 6.9±1.7 1.2±0.7 3.8±2.5 p < 0.05 6.9±1.7 5.2±2.8 13.3±5.5** p < 0.05 erythrocyte count whole blood plasma prp p-test 4.1±0.5 0.2±0.3 p < 0.05 4.1±0.5 0.0 0.06±0.1** p < 0.05 4.1±0.5 1.6 ±0.6 3.0±0.8 p < 0.05 ht whole blood plasma prp p-test 3.8±5.2 2.2±2.8 p < 0.05 3.8±5.2 0.1±0.1 0.4±0.2 p < 0.05 3.8±5.2 15 ±6.2 27.9 ±8.1** p < 0.05 note: * number is mean + standard deviation; p-value < 0.05 statistically significant, ht, hematocrit; prp, platelet-rich plasma; sd, standard deviation; sc, the single centrifugation; dc, the double centrifugation; and dc-tdtu, the double centrifugation turn down turn up techniques althea medical journal september 2022 althea medical journal. 2022;9(3) 183 than the number of platelets in the whole blood, although some authors recommend the single-spin technique. another study proved that centrifugation of 541 g for 61 ml of whole blood at 5 minutes was optimal for obtaining high platelet in the sample.14 in this study, we also included a single centrifugation technique that is commonly used. the platelet counts in prp can affect and positively correlate with the concentration of growth factors and better clinical results.15,16 several studies have shown that prp therapy for hip disorders, shows maximum improvement with platelet concentrations 2–7 times higher than the number of platelets in the whole blood.17 the leukocyte count in prp should be counted because it is an important factor in tissue healing, although several studies have produced different hypotheses.18 the number of leukocytes in prp can have positive or negative effects. leukocytes can cause an inflammatory reaction, but some experts also find that leukocyte cells can act as antibacterial in prp and protect against infection. in addition, leukocyte cells correlated with an increased release of growth factors.4 a study showed that pdgf and tgf-β1 released from leukocytes play a role in the therapeutic process of fracture healing. however, another study has shown that prp rich in leukocytes can inhibit wound healing due to the release of reactive oxygen species (ros) by neutrophils in the wound area. the negative effect produced by leukocytes may not occur in all tissues, considering that there is a positive effect produced by leukocytes on prp.19 the results of this study have shown that the dc and dc-tdtu techniques have a higher average number of leukocytes in prp than plasma. prp has been filled with a buffy coat due to the first centrifugation. however, the leukocyte count in the dc-tdtu technique is higher than in the dc technique, indicating the large number of blood cell volumes remaining in plasma. the erythrocyte count and the ht value in prp indicate the presence or absence of erythrocyte contamination at each stage of the prp procedure.5 this study has shown that the erythrocyte count is minimal or even absent in the dc technique, although a small number of erythrocytes has been obtained in prp due to the process of concentration and resuspension with a buffy coat. in the dc-tdtu technique, there are still more blood cells than in the dc and sc techniques. in the dc-tdtu technique, red blood cells are separated from the plasma by taking a volume of 3.5 ml of erythrocytes from the bottom of the tube, but still leaving more erythrocyte volumes in the second centrifuge. this affects the higher ht value compared to the dc and sc techniques that separate plasma from the red blood cells. compared to the sc technique, the dc is being the preferred technique for prp preparation, as shown in a study for dermatologic use, due to its low cost, maximal platelet count, and adequate platelet volume.20 the recovery efficiencies data measures the effect of the volume of plasma after the centrifugation process.18 this measurement is part of the limitation of this study. the recovery efficiencies in plasma, platelet, and leukocyte have not been calculated due to the unavailability of plasma or buffy coat volume data after centrifugation. furthermore, specific analysis like growth factor measurement is needed to enhance the technique quality. to conclude, the dc technique is the best prp separation technique compared to the dctdtu and sc techniques. references 1. mangal u. influence of platelet rich plasma on orthodontic tooth movement: a review. biomed pharmacol j. 2017;10(3):1463–8. 2. alves r, grimalt r. a review of platelet-rich plasma: history, biology, mechanism of action, and classification. skin appendage disord. 2018;4(1):18–24. 3. puri n. platelet rich plasma in dermatology and aesthetic medicine. our dermatology online. 2015;6(2):207–11. 4. mazzocca ad, mccarthy mbr, chowaniec dm, cote mp, romeo aa, bradley jp, et al. platelet-rich plasma differs according to preparation method and human variability. j bone joint surg am. 2012;94(4):308–16. 5. dhurat r, sukesh m. principles and methods of preparation of platelet-rich plasma: a review and author′s perspective. j cutan aesthet surg. 2014;7(4):189. 6. gupta v, parihar as, pathak m, sharma vk. comparison of platelet-rich plasma prepared using two methods: manual double spin method versus a commercially available automated device. indian dermatol online j. 2020;11(4):575–9. 7. bhatia a, ramya b, biligi ds, prasanna bp. comparison of different methods of centrifugation for preparation of plateletrich plasma (prp). indian j pathol oncol. 2016;3(4):535. 8. astuti la, hatta m, oktawati s, chanda mh, djais ai. effect of centrifugation speed eva ayu maharani et al.: comparison of single centrifugation, double centrifugation and turn down turn up techniques for platelet-rich plasma quality althea medical journal. 2022;9(3) 184 and duration of the quantity of platelet rich plasma (prp). j int dent med res. 2018;11(3):850–6. 9. machado es, leite r, dos santos cc, artuso gl, gluszczak f, de jesus lg, et al. turn down-turn up: a simple and lowcost protocol for preparing platelet-rich plasma. clinics. 2019;74(13):1–6. 10. cozma cn, raducu l, jecan cr. platelet rich plasmamechanism of action and clinical applications. j clin investig surg. 2016;1(2):41–6. 11. castro ab, andrade c, li x, pinto n, teughels w, quirynen m. impact of g force and timing on the characteristics of platelet-rich fibrin matrices. sci rep. 2021;11(1):1–13. 12. anbar ts, el-ammawy te, el-metwally ym, abdel-rahman a, mohammed s. the effect of different speeds of centrifugation on platelet-rich plasma preparation. j egypt women’s dermatol soc. 2015;12(3):150– 5. 13. hamid msa. cost effectiveness of a plateletrich plasma preparation technique for clinical use. wounds. 2018;30(7):186–90. 14. marques fp, ingham sj, forgas a, franciozi ce, sasaki ph, abdalla rj. a manual method to obtain platelet rich plasma. acta ortop bras. 2014;22(2):75–7. 15. international cellular medicine society. guidelines for the use of platelet rich plasma. las vegas, nv: international cellular medicine society; 2011. 16. taniguchi y, yoshioka t, sugaya h, gosho m, aoto k, kanamori a, et al. growth factor levels in leukocyte-poor plateletrich plasma and correlations with donor age, gender, and platelets in the japanese population. j exp orthop. 2019;6(1):4–11. 17. garcia fl, williams bt, polce em, heller db, aman zs, nwachukwu bu, et al. preparation methods and clinical outcomes of platelet-rich plasma for intra-articular hip disorders: a systematic review and meta-analysis of randomized clinical trials. orthop j sport med. 2020;8(10):1–9. 18. perez agm, lana jfsd, rodrigues aa, luzo acm, belangero wd, santana mha. relevant aspects of centrifugation step in the preparation of platelet-rich plasma. isrn hematol. 2014;2014:1–8. 19. pavlovic v, ciric m, jovanovic v, stojanovic p. platelet rich plasma: a short overview of certain bioactive components. open med. 2016;11(1):242–7. 20. dashore s, chouhan k, nanda s, sharma a. preparation of platelet-rich plasma: national iadvl prp taskforce recommendations. indian dermatol online j. 2021;12:s12–23. althea medical journal september 2022 amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 88 profile of liver function among pediatric patients with dengue infection admitted to a tertiary referral hospital during the covid-19 pandemic ina rosalina, riyadi adrizain, chindy arya, anggraini alam, djatnika setiabudi department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: riyadi adrizain, dr., sp.a(k), m.kes, department of child health, faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, jalan pasteur 38, bandung, indonesia, e-mail: riyadispa@gmail.com introduction dengue is an infection caused by the dengue virus (denv-1, denv-2, denv-3, and denv-4), leading to damage to the liver and increased liver function.1–5 liver dysfunction varies from mild injury with an elevation of transaminases to severe hepatocyte injury that causes jaundice in patients.1,2 dengue is endemic in more than 100 countries, 70% in asia, with an increase in mortality rate annualy.6 according to the indonesia ministry of health, the incidence rate of dengue in indonesia is 27 per 100,000, and the case fatality rate is 0.96%.7 covid-19 is a newly emerging viral infection that caused a pandemic.8 after the first report in china in december 2019, the disease spread worldwide affecting more than 576 million people in 200 countries.8,9 in indonesia it affects more than 6 million people and causes 157,000 mortalities.10 due to its infectivity, the local government has decided to implement large-scale social restrictions (lssr) to respond to covid-19.11 this new regulation has disrupted and impeded access to health facilities, including medical care for acute infections such as dengue. meanwhile, people with acute fever also delayed treatment due to fear of the misperception of being infected by covid-19.12,13 a study in india has concluded that hepatic dysfunction depends on the severity of disease.15 there were elevated liver enzymes in the severe dengue group compared to the others.15 to date, there is a lack of studies about dengue infection during a pandemic, whereas the covid-19 pandemic may influence the healthcare system, including impeding health althea medical journal. 2023;10(2):88–92 abstract background: dengue infection is endemic in more than 100 countries; 70% of cases occur in asia. one of dengue infection complication is hepatic dysfunction. the covid-19 pandemic may cause a delay in seeking treatment and affect severe case of dengue infection when admitted to the hospital. this study aimed to analyze the liver function profile in dengue pediatric patients during the covid-19 pandemic. methods: all patients under 18 years old with confirmed dengue serology (ns-1 immunochromatography or igm anti-dengue (elisa) test and igg anti-dengue (elisa) test) in dr. hasan sadikin general hospital from 2021–2022 were included in this retrospective study. the patients were categorized based on the modified who classification of 2009. data were processed with spss® ver. 25 and analyzed using chisquare and one way-anova. results: in total, 85 patients were tested for the liver function; most severe dengue patients had abnormal sgot and sgpt levels (100% vs. 64%). the sgot and sgpt levels during the initial admission were higher in the severe dengue group (634 u/l and 271 u/l) and significantly different among groups (p=0.001 and p=0.032). the elevated sgot (1,339 u/l vs. 203 u/l vs. 87.3 u/l; p=0.014) and sgpt (438 u/l vs. 100 u/l vs. 42.8 u/l; p=0.005) levels were higher in the severe dengue group. conclusions: the severity of dengue is in line with the increase in sgot and sgpt levels. during the covid-19 pandemic, the liver dysfunction persists and may be interfered with by delays in dengue treatment. early recognition and prompt treatment are needed to decrease morbidity and mortality. keywords: covid-19, dengue, liver function test, pandemic https://doi.org/10.15850/amj.v10n2.2954 althea medical journal. 2023;10(2) 89 access for acute infection. consequently, this study aimed to analyze the liver function profile in dengue pediatric patients, including dengue patients without warning signs, with warning signs, and severe dengue during the pandemic of covid-19. methods this retrospective study included all pediatric patients under 18 years old in the registry with confirmed dengue serology admitted to dr. hasan sadikin general hospital from march 2021 to 2022. the institutional ethics committee had approved this study with number lb.02.01/x.6.5/195/2022. dengue serology tests were conducted using ns-1 immunochromatography or igm anti-dengue test and igg anti-dengue test (elisa test by biosynex). the patients were categorized based on the modified who classification of 2009 into dengue with or without the warning signs and severe dengue.16 the following data was obtained from the hospital medical records. patient gender, age and liver function test were retrieved, including serum glutamic pyruvic transaminase (sgpt), an enzyme found in renal, liver and skeletal (5–40 iu/l) and serum glutamic oxaloacetic transaminase (sgot), specific liver enzyme (7–56 iu/l) (abbott alinity). patients were grouped into groups with abnormal liver enzyme levels (sgot and sgpt tests) during hospitalization. initial sgot and sgpt tests were the liver enzyme result at hospital admission; elevated sgot and sgpt tests were the highest liver enzyme level during hospitalization. considering the anticipated prevalence of hepatic dysfunction in dengue to be around 50%, α error 5% (zα=1.96), β error 20% (zβ= 0.842) and a power of 80%, with a precision of 5%, according to the following formula (p= prevalence; q=(1-p); and d=precision).17 data were analyzed using the statistical package for the social science (spss) version 25. the statistical method employed for data analysis was the chi-square test for categorical outcomes. comparison of multiple means across disease severity was made using one way-anova with post hoc analysis with a level of significant <0.05. results during the observation, there were 97 data. from a total of 157 patients, 18% had dengue without warning signs, 53% had dengue with warning signs, and 29% had severe dengue (table 1). the age of the patient varied from one month to 17 years old, with average of 5.5 years old. the majority of the patient was male (61%). only 85 of 157 patients were enrolled on sgot and sgpt tests of whom the liver enzyme test was only performed in clinically severe cases, resulting in 12 patients were dengue without warning signs, 31 were dengue with warning signs, and 42 were severe dengue (table 2). most of the patients had abnormal sgot test during the first laboratory examination, 92% in dengue without warning sign group, 93.5% in dengue with warning sign group, and all patients with severe dengue group; whereas an abnormal sgpt results were only found in around 25% in dengue with or without warning sign group, and higher (64%) in patients with severe dengue group (table 2). the initial liver function test was significantly highest in the severe dengue group with the highest level of sgot was 634 u/l (p=0.001) compared to others during the critical phase. the initial sgpt level was higher in the severe dengue group was also significant higher compared to other groups (p=0.032). similarly, the elevated level of sgot and sgpt during the critical phase of dengue infection was the highest in the severe dengue group compared to other groups as shown in table 2. table 1 characteristic of pediatric patients with dengue, period 2021–2022 variable total (n=157) diagnose dengue without warning sign dengue with warning sign severe dengue 28 (18%) 84 (53%) 45 (29%) age (mean) 5.5 years old gender male female 96 (61%) 61 (39%) ina rosalina et al.: profile of liver function among pediatric patients with dengue infection admitted to a tertiary referral hospital during the covid-19 pandemic althea medical journal. 2023;10(2) 90 discussion this study is the first to evaluate elevated liver enzymes among dengue pediatric patients during pandemic. our study found that the dengue with warning signs is the most prevalent with the majority of patients was males, in line with study in india.18 however, this finding contrasts with previous systematic reviews that found females as a risk factor for severe dengue due to the higher cytokine production, increased permeability of capillary bed, and immune response among female patients.18–20 this difference result of male-to-female ratio could be due to the lower self-reporting among female patient in asian communities.18 hepatic involvement in infections of dengue varies from an asymptomatic elevation of the liver enzyme to fatal fulminant hepatic failure.1,21 denv targeted hepatocytes and caused liver disfunction.3 in our study, we found abnormal sgot levels in 90 to 100% patients of all groups, indicating that most pediatric dengue patients had liver dysfunction.14 the covid-19 pandemic has influenced society and the healthcare system, including the motivation to seek treatment for acute infetcions.12 the local government has decided to implement large-scale social restrictions (lssr) to respond to covid-19.11 this new regulation has disrupted and impeded access to health facilities, including medical care for acute infections such as dengue.12 the study from the philippines describes some factors that contributed to this problem, including financial constraints, mode of transportation and traffic density, location, and full hospital capacity due to covid-19 cases during the pandemic.12 according to a crosssectional study in turkey, fear of covid-19 misperception causes avoidance of going to the hospital and delayed medical treatment.13 the fear of covid-19 in patients with fever, cough and weakness which are considered covid-19 symptoms.13 the covid-19 pandemic adversely impacts the provision of essential health services in the south-east asian region, particularly in managing tuberculosis, hiv and dengue fever.22 nevertheless, our study found that pediatric patients with abnormal sgpt had less than abnormal sgot. the abnormal sgpt level was mainly found in the severe dengue group. in most studies, elevation in sgot is more often than sgpt during the first week of infection, with a tendency to decrease to normal levels within three weeks.1,2 this phenomenon is explained due to the release of sgot from damaged myocytes at the earlier stage.1,2 it was found that the level of sgpt was lower than sgot in each classification group. in line with other studies, these findings are due to the specification of sgpt as a liver enzyme and only found in low concentrations in skeletal muscle, brain, and intestinal.2,15,18 in contrast, sgot is released following damage to the liver, cardiac and skeletal muscle.2 the higher sgot and sgpt levels are aligned with the dengue’s severity. our study found that sgot and sgpt levels are higher in severe dengue group compared with the other during initial test and elevated test during hospitalization. in denv infection, high-level viremia is associated with the involvement of the liver in the severe form of the disease.1,21 mechanism of liver injury due to a direct effect of the virus or host immune response, circulatory compromise, and metabolic acidosis or hypoxia due to circulatory failure.18 table 2 liver function profile in dengue patients dengue without warning sign (n=12) dengue with warning sign (n=31) severe dengue (n=42) p-value abnormal sgot 11 (92%) 29 (93,5%) 42 (100%) 0.209 abnormal sgpt 3 (25%) 7 (22%) 27 (64%) 0.001 initial sgot test (u/l) 86.25 197 634 0.001 initial sgpt test (u/l) 42.8 96.9 271 0.032 elevated sgot (u/i) 87.3 203 1,339 0.014 elevated sgpt (u/l) 42.8 100 438 0.005 note: sgot= serum glutamic pyruvic transaminase, sgpt=serum glutamic oxaloacetic transaminase, abnormal sgot and sgpt test: the number of patients who had abnormal levels of the liver enzyme during hospitalization; initial sgot and sgpt test: the liver enzyme result at hospital admission; elevated sgot and sgpt test: the highest liver enzyme level during hospitalization althea medical journal june 2023 althea medical journal. 2023;10(2) 91ina rosalina et al.: profile of liver function among pediatric patients with dengue infection admitted to a tertiary referral hospital during the covid-19 pandemic the strengths of our study are that we have performed the first study in the pediatric population to estimate liver function tests in dengue patients, especially during the covid-19 pandemic. in addition, our study analyzes the subject’s disease severity and liver function profile. the limitations of our study are the subject selected from tertiary centers, which tend to find clustering of more severe cases. further study should analyze clinical signs and symptoms, including other laboratory findings including platelet, alkaline phosphatase, total bilirubin, direct bilirubin, and albumin in dengue patients. in conclusion, the severity of dengue is in line with the increase in sgot and sgpt levels. during the covid-19 pandemic, the incidence of liver dysfunction persists and may be interfered with by delays in dengue treatment. early recognition and prompt treatment are needed to decrease the morbidity and mortality of dengue patients. references 1. samanta j, sharma v. dengue and its effects on liver. world j clin cases. 2015;3(2):125– 31. 2. fernando s, wijewickrama a, gomes l, punchihewa ct, madusanka sdp, dissanayake h, et al. patterns and causes of liver involvement in acute dengue infection. bmc infect dis. 2016;16:319. 3. ahmed a, alvi ah, butt a, nawaz aa, hanif a. assessment of dengue fever severity through liver function tests. j coll physicians surg pak. 2014;24(9):640–4. 4. kularatne sa. dengue fever. bmj. 2015;351:h4661. 5. diamond ms, pierson tc. molecular insight into dengue virus pathogenesis and its implications for disease control. cell. 2015;162(3):488–92. 6. world health organization. dengue and severe dengue. geneva:who; 2022. [cited 2022 august 03]. available from: https:// www.who.int/news-room/fact-sheets/ detail/dengue-and-severe-dengue. 7. ministry of health republic of indonesia. profil kesehatan indonesia tahun 2021. jakarta: ministry of health republic of indonesia; 2021. 8. sookaromdee p, wiwanitkit v. covid-19 and tropical infection: complexity and concurrence. adv exp med biol. 2021;1318:333–41. 9. world health organization. global situation covid 19 [internet]. geneva: who; 2022. [cited 2022 august 03]. available from: https://covid19.who.int/. 10. world health organization. covid-19 indonesia [internet]. geneva: who; 2022. [cited 2022 august 03]. available from: https://www.who.int/countries/idn/ 11. adrizain r, jubaedah s, fitriany en, wicaksana r, hartantri y, prihatini d, et al. impact of social activity restriction and routine patient screening as a preventive measurement for tertiary referral hospital staff in a country with high covid-19 incidence. ijid reg. 2022;2:45–50. 12. ligsay ad, santos mlb, simbul es, tambio kjm, aytona mjm, alejandro gjd, et al. assessing the three-delay model factors affecting the healthcare service delivery among dengue patients during covid-19 surge in a public tertiary hospital: a convergent parallel mixed methods study. int j environ res public health. 2021;18(22):11851. 13. sürme y, özmen n, arik be. fear of covid-19 and related factors in emergency department patients. int j ment health addict. 2021:1–9. doi: 10.1007/s11469021-00575-2. 14. kementerian kesehatan republik indonesia. profil kesehatan indonesia tahun 2020. jakarta: kementerian kesehatan republik indonesia; 2020. 15. jagadishkumar k, jain p, manjunath vg, umesh l. hepatic involvement in dengue fever in children. iran j pediatr. 2012;22(2):231–6. 16. world health organization. dengue guidelines for diagnosis, treatment, prevention and control: new edition. geneva: who; 2009. 17. saha ak, maitra s, hazra sc. spectrum of hepatic dysfunction in 2012 dengue epidemic in kolkata, west bengal. indian j gastroenterol. 2013;32(6):400–3. 18. swamy am, mahesh py, rajashekar st. liver function in dengue and its correlation with disease severity: a retrospective crosssectional observational study in a tertiary care center in coastal india. pan afr med j. 2021;40:261. 19. sangkaew s, ming d, boonyasiri a, honeyford k, kalayanarooj s, yacoub s, et al. risk predictors of progression to severe disease during the febrile phase of dengue: a systematic review and meta-analysis. lancet infect dis. 2021;21(7):1014–26. 20. chakravarti a, roy p, malik s, siddiqui o, thakur p. a study on gender-related differences in laboratory characteristics althea medical journal. 2023;10(2) 92 of dengue fever. indian j med microbiol. 2016;34(1):82–4. 21. htun tp, xiong z, pang j. clinical signs and symptoms associated with who severe dengue classification: a systematic review and meta-analysis. emerg microbes infect. 2021;10(1):1116–28. 22. downey le, gadsden t, del v, vilas r, peiris d, jan s. the impact of covid-19 on essential health service provision for endemic infectious diseases in the southeast asia region: a systematic review. lancet reg health southeast asia. 2022;1:100011. althea medical journal june 2023 amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 12 knowledge and perception of diabetes mellitus among patients with type 2 diabetes mellitus in five public health centers in karawang, west java, indonesia khansa ainun nabila,1 maya kusumawati,2 ginna megawati3 1faculty of medicine universitas padjadjaran, indonesia, 2department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health, faculty of medicine universitas padjadjaran, indonesia correspondence: khansa ainun nabila, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: khansa17002@mail.unpad.ac.id althea medical journal. 2022;9(1):12–18 abstract background: diabetes mellitus (dm) is a chronic metabolic disease that causes various complications, leading to a high mortality rate and high medical costs. good knowledge and perception are essential for patients in understanding the disease and how to prevent the complications. this study aimed to assess the knowledge and perceptions of dm among patients with type 2 dm from the public health centers (pusat kesehatan masyarakat, puskesmas), the primary health care facility in west java. methods: the research design was quantitative observational with a cross-sectional method and descriptive approach. data were collected in 2019 from all dm patients living in five working areas of the puskesmas in karawang regency, west java, indonesia. data collection was performed by trained interviewers, using a validated translation of the diabetes knowledge questionnaire (dkq) (cronbach’s alpha 0.723) and the brief illness perception questionnaire (bipq) (cronbach’s alpha 0.74) to measure knowledge (24 questions) and to explore perception (8 questions), respectively. results: of the 211 respondents, 165 were predominantly female (76.4%) and aged 52–61 years old (35.2%). knowledge was moderate (55.8%), however, they had a negative perception of the disease (50.9%). conclusions: although most of the respondents have a moderate level of knowledge, their perception of dm is still negative. therefore, education for patients and the community needs to be evaluated to enhance knowledge and perceptions about diabetes mellitus. keywords: diabetes mellitus, knowledge, perception, public health center introduction diabetes mellitus (dm) is a group of metabolic diseases characterized by hyperglycemia due to impaired insulin secretion, ineffective use of insulin, or both. according to the international diabetes federation (idf) diabetes atlas, indonesia ranks seventh with the highest number of diabetic patients in the world in 2019.1 riset kesehatan dasar (riskesdas) 2018 has reported an increase in dm prevalence in west java compared to the year 2013.2 moreover, based on data of the karawang regional public hospital profile in 2013, dm ranks sixteenth among public hospitals in west java.3 type 2 dm can cause various complications, resulting in a high medical cost.1 providing education to dm patients about the knowledge and perception of the disease is therefore essential. better knowledge increases the better perception of the patients and, thus, misunderstanding about the disease can be corrected.4,5 furthermore, with good knowledge and perception, they would have better behavior and lifestyle. moreover, dm patients may improve self-management skills to prevent complications, and the cost of managing complications can be reduced.6,7 therefore, knowledge and perception of patients with type 2 dm is a particular concern. prevention can start from public health https://doi.org/10.15850/amj.v9n1.2287 althea medical journal. 2022;9(1) 13 centers as the first level of health care facility, known as primary health care. prevention and early detection of diabetes complications can provide various benefits for individuals with dm and economic conditions, so that the health costs incurred for dm can be reduced.1 the study on the knowledge and perception about type 2 dm in karawang has not been widely published earlier, therefore, the researcher was interested in exploring the knowledge and perception among patients with dm about their disease in karawang. this study is expected to be the initial basis for increasing educational efforts as one of the pillars in preventing dm in the community, especially in primary health care services such as in a public health center (pusat kesehatan masyarakat, puskesmas), as well as to strengthen the local health systems through local empowerment, since most of the health services focus on curative management. methods the research design was quantitative observational with a cross-sectional method with a descriptive approach. this study was part of research entitled “penilaian cepat akses layanan kesehatan primer di lima kecamatan di kabupaten karawang tahun 2019,” exploring primary health care access and facility in karawang, west java in 2019. in brief, a total sampling was carried outby retrieving all dm patients living in five working areas of the public health centers (puskesmas) in the karawang district, west java indonesia, namely puskesmas batu jaya, puskesmas cikampek, puskesmas lemah abang, puskesmas rengasdengklok, and puskesmas tempuran, karawang. this study involved more than 100 trained interviewers at the time of data collection. data collection was carried out in november 2019 by approaching all patients. these dm patients were invited to the puskesmas to participate in the study by answering the questionnaire. the exclusion criteria of this study were incomplete data. the protocol of this study was approved by the ethics committee of universitas padjadjaran under the ethical clearance number 1359/ un6.kep/ec/2019. this study used validated translation questionnaires; the diabetes knowledge questionnaire (dkq) to explore the knowledge (cronbach’s alpha 0.723) and the brief illness perception questionnaire (bipq) to explore the perception (cronbach’s alpha 0.74).8,9 khansa ainun nabila et al.: knowledge and perception of diabetes mellitus among patients with type 2 diabetes mellitus in five public health centers in karawang, west java, indonesia table 1 characteristics of type 2 diabetes mellitus patients from 5 public health centers in karawang based on their knowledge and perception characteristics frequency (n) percentage (%) knowledge mean±sd perception mean±sd gender male female 39 126 23.6 76.4 10.7±3.1 9.6±2.8 39.1±15.0 40.3±12.9 age (years) 22–31 32–41 42–51 52–61 62–71 72–81 4 7 53 58 36 7 2.4 4.2 32.1 35.2 21.8 4.2 8.8±1.7 10.7±4.0 10.6±2.7 9.6±2.8 9.6±3.0 9.1±3.6 42 ±12.3 35.3±19.5 38.9±14.4 42.0±11.4 38.8±13.1 42.6±18.6 level of education completed did not graduate from elementary school elementary school junior high school high school university 52 73 18 19 3 31.5 44.2 10.9 11.5 1.8 8.9±2.3 9.5±2.7 11.6±3.2 13.1±1.9 8.3±0.6 40.5±14.7 40.2±13.5 43.8±9.3 35.5±13.1 35.3±8.1 occupational status unemployed worker 107 58 64.9 35.2 9.7±2.8 10.3±3.1 40.5±13.6 39.8±13.4 althea medical journal. 2022;9(1) 14 the dkq consisted of 24 question items with the answer option to each question was in the form of “yes”, “no”, and “do not know”. one point was given for each correct answer, whereas the wrong and “do not know” answer was 0. the scores obtained by the respondents were summed up and then categorized into high (17–24), moderate (10–16), or low (0–9). the higher the score obtained indicated that the patient’s knowledge about dm was getting better.10 the bipq consisted of 8 questions on a scale with a likert-type scoring between 1 and 10, and an additional one open question. the score was calculated according to the numbers listed on the scale, then the results were added up for questions number 1, 2, 5, 6, 8. on contrary, questions number 3 about personal control, number 4 about treatment control, and number 7 about coherence, the table 2 knowledge of patients about diabetes mellitus based on diabetes knowledge questionnaire-24 no. questions yes n (%) no n (%) do not know n (%) 1. eating too much sugar and other sweet foods is a cause of diabetes 131 (79.4) 18 (10.9) 16 (9.7) 2. kidneys produce insulin 31 (18.8) 14 (8.5) 120 (72.7) 3. in untreated diabetes, the amount of sugar in the blood usually increases 143 (86.7) 10 (6.1) 12 (7.3) 4. if i am diabetic, my children have a higher chance of being diabetic 85 (51.5) 52 (31.5) 28 (17) 5. diabetes can be cured 116 (70.3) 30 (18.2) 19 (11.5) 6. a fasting blood sugar level of 210 is too high 106 (64.2) 28 (17) 31 (18.8) 7. the best way to check my diabetes is by testing my urine 65 (39.4) 52 (31.5) 48 (29.1) 8. regular exercise will increase the need for insulin or other diabetic medication 87 (52.7) 14 (8.5) 64 (38.8) 9. an insulin reaction is caused by too much food 76 (46.1) 13 (7.9) 76 (46.1) 10. medication is more important than diet and exercise to control my diabetes 78 (47.3) 78 (47.3) 9 (5.5) 11. diabetes often causes poor circulation 113 (68.5) 20 (12.1) 32 (19.4) 12. cuts and abrasions on diabetes heal more slowly 111 (67.3) 44 (26.7) 10 (6.1) 13. diabetics should take extra care when cutting their toenails 128 (77.6) 25 (15.2) 12 (7.3) 14. a person with diabetes should cleanse a cut with iodine and alcohol 119 (72.1) 27 (16.4) 19 (11.5) 15. the way i prepare my food is as important as the foods i eat 129 (78.2) 23 (13.9) 13 (7.9) 16. diabetes can damage my kidneys 90 (54.5) 14 (8.5) 61 (37) 17. diabetes can cause loss of feeling in my hands, fingers, and feet 147 (89.1) 15 (9.1) 3 (1.8) 18. shaking and sweating are signs of high blood sugar 108 (65.5) 36 (21.8) 21 (12.7) 19. frequent urination and thirst are signs of low blood sugar 83 (50.3) 64 (38.8) 18 (10.9) 20. tight elastic hose or socks are not bad for diabetics 26 (15.8) 74 (44.8) 65 (39.4) 21. a diabetic diet consists mainly of special foods 121 (73.3) 25 (15.2) 19 (11.5) 22. the usual cause of diabetes is a lack of effective insulin in the body 60 (36.4) 4 (2.4) 101 (61.2) 23. diabetes is caused by the failure of the kidneys to keep sugar out of the urine 50 (30.3) 17 (10.3) 98 (59.4) 24. there are two main types of diabetes: type 1 (insulin dependent) and type 2 (non insulin dependent) 58 (35.2) 5 (3) 102 (61.8) althea medical journal march 2022 althea medical journal. 2022;9(1) 15 score calculation was reversed. then, the score of each question was added up to get the final result of the perception score. the respondent’s perception was positive if the score was less than equal to the average score obtained by all respondents. a negative perception was designated when the score was more than the average score obtained by all respondents. the higher the number of scores obtained on the entire questionnaire, the more negative the perception of the disease, indicating that those persons feel more threatened because of their disease.11 results out of 211 respondents, only 165 were eligible for analysis, mostly female respondents. based on the respondent’s characteristics, most respondents were between 52–61 years old, graduated from elementary school and unemployed. the mean score for knowledge was 9.9±2.9 and for perception was 40.0±13.4. the average knowledge score of respondents was 9.8±2.8. the result showed that 55.8% of respondents had a moderate level of knowledge (table 4). the most correctly answered by respondents was question number 17 about the complications of dm (n=147; 89.1%), and the question that was the least correctly answered was question number 9 about the etiology of dm (n=13; 7.9%). the distribution of the perception among type 2 dm showed that the average perception of respondents was 40.04. more than half of the respondents had a negative perception of the disease (table 5). in detail, the perception was the most positive when answering question number 4 regarding belief about therapy or management obtained to control the disease. this showed that the respondents felt able to control the disease. on the contrary, the most negative perception was in question number 6 regarding the concern about the disease. table 3 the perception of patients about diabetes mellitus based on brief illness perception questionnaire no. questions 0n (%) 1 n (%) 2 n (%) 3 n (%) 4 n (%) 5 n (%) 6 n (%) 7 n (%) 8 n (%) 9 n (%) 10 n (%) 1. how much does your illness affect your life? 28 (17) 3 (1.8) 4 (2.4) 8 (4.8) 1 (0.6) 31 (18.8) 11 (6.7) 18(10.9) 12 (7.3) 7 (4.2) 42 (25.5) 2. how long do you think your illness will continue? 17 (10.3) 3 (1.8) 4 (2.4) 13 (7.9) 10 (6.1) 38 (23) 11 (6.7) 12(7.3) 13 (7.9) 6 (3.6) 38 (23) 3. how much control do you feel you have over your illness? 12 (7.3) 3(1.8) 3 (3.8) 9 (5.5) 7 (4.2) 24 (14.5) 6 (3.6) 11(6.7) 11 (6.7) 8 (4.8) 71 (43) 4. how much do you think your treatment can help your illness? 8 (4.8) 1 (0.6) 3 (1.8) 2 (1.2) 2 (1.2) 15 (9.1) 7 (4.2) 10(6.1) 13 (7.9) 11 (6.7) 93 (56.4) 5. how much do you experience symptoms from your illness? 10 (6.1) 9 (5.5) 10 (6.1) 7 (4.2) 3 (1.8) 30 (18.2) 9 (5.5) 19(11.5) 13 (7.9) 7 (4.2) 48 (29.1) 6. how concerned are you about your illness? 17 (10.3) 4 (2.4) 4 (2.4) 7 (4.2) 2 (1.2) 20 (12.1) 6 (3.6) 12(7.3) 14 (8.5) 6 (3.6) 73 (44.2) 7. how well do you feel you understand your illness? 26 (15.8) 13 (7.9) 7 (4.2) 12 (7.3) 3 (1.8) 28 (17) 10 (6.1) 15(9.1) 14 (8.5) 3 (1.8) 34 (20.6) 8. how much does your illness affect you emotionally? (e.g., does it make you angry, scared, upset, or depressed?) 44 (26.7) 5 (3) 5 (3) 6 (3.6) 5 (3) 17 (10.3) 7 (4.2) 10(6.1) 10 (6.1) 3 (1.8) 53 (32.1) khansa ainun nabila et al.: knowledge and perception of diabetes mellitus among patients with type 2 diabetes mellitus in five public health centers in karawang, west java, indonesia althea medical journal. 2022;9(1) 16 discussion this study explored the knowledge and perception about dm among type 2 dm patients living in karawang as the highest dm prevalence in west java. in this study, most of the respondents were female, similar to the study conducted in pakistan.4 this result is probably due to the low literacy rate for women in indonesia. the 2018 national socio-economic survey (survei sosial ekonomi nasional-susenas) shows that the literacy rate for women over 15 years is only 93.99%. in addition, the overall average length of school for girls is also low. data in 2018 shows that the average length of time to attend school for girls over 15 years of age is only about 8.26 years.12 the data obtained showed that the average score of elderly respondents was low. this is probably due to decreased cognitive function, adaptation, and motivation in the elderly, so this is one of the obstacles to obtaining information and education about dm.4,13 the results showed that the level of knowledge of respondents who completed high school was high. similar results are found in studies in nepal and nigeria.13,14 people who have a high level of education are more likely to have higher curiosity. in addition, people with high levels of education may have easier access to get information and knowledge through various media.13,15 this study showed that respondents who worked had a high level of knowledge. the possible reason for this was that people who worked tended to have a higher income so that people who worked could easily get access to information about dm, such as from the internet, radio, television, private clinics, and others. a person’s work environment can also be a source of information about dm.14 the data obtained from this study showed that the perception score of female respondents was high. the same result is found in a study in thailand.16 this may occur because, generally, women have a low level of education, so the knowledge and control of their disease are not good and result in a worse perception of the disease they suffer.16 the data contained in the 2019 indonesian women’s profile issued by the ministry of women’s empowerment and child protection states that the percentage of women over 15 years of age who do not complete primary school level and do not or have never attended school is also quite high.12 this study showed a difference in the patient’s perception score of the disease when viewed from the respondent’s age. respondents with an age range between 22– 31 years had an average score of 42±12.3. a previous study shows that age is one of the characteristics that can influence a patient’s perception of his/her disease.15 younger patients may have poorer perceptions. the reason may be that younger patients perceive the disease as detrimental to their lives and has a significant emotional impact.17 this study showed the best respondents’ perception was of those who completed their education at the university level. education is one of the factors that can encourage a person’s control of the disease. a good level of education allows a person to get adequate health althea medical journal march 2022 table 4 knowledge of type 2 diabetes mellitus patients from 5 public health centers in karawang knowledge frequency (n) percentage (%) high moderate low 2 92 71 1.2 55.8 43 total 165 100 table 5 perception of type 2 diabetes mellitus patients from 5 public health centers in karawang perception frequency (n) percentage (%) positive negative 81 84 49.1 50.9 total 165 100 althea medical journal. 2022;9(1) 17 information to help increase self-confidence in controlling their disease and understanding their condition.18 previous studies have suggested that low levels of education will lead to low patient knowledge, which can affect the patient’s choice of treatment and worsen their condition. if the patient’s condition worsens, the patient’s perception of the disease will be even more negative.19 the results of this study indicated that respondents who worked had a high perception score. this may occur because people who work feel that their illness affects their work, such as causing absenteeism, reduced productivity, and inability to do their jobs due to complications from the disease, so that the patient’s perception of the disease becomes negative.20 the limitations of the study are that since this research is a descriptive study, the researcher cannot determine and analyze what causes a positive and negative perceptions in patients and why the level of knowledge of certain groups of patients is higher than the other groups. further research is needed to explore more about the causative factors to get better results. to conclude, the type 2 dm patients living in karawang have a moderate level of knowledge, however, with a negative perception of dm. therefore, education among diabetic patients and the public need to be evaluated to enhance the knowledge and the perception of diabetes mellitus. references 1. international diabetes federation. idf diabetes atlas. 9th ed. brussel, belgium: international diabetes federation; 2019. 2. badan penelitian dan pengembangan kesehatan kementrian kesehatan ri. hasil utama riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan ri; 2018. 3. rumah sakit umum daerah karawang. profil rumah sakit umum daerah (rsud) kabupaten karawang tahun 2013. karawang: rumah sakit umum daerah karawang; 2013. 4. shams n, amjad s, seetlani nk, ahmed w. diabetes knowledge in elderly type 2 diabetes mellitus patients and association with glycemic control. j liaquat uni med heath sci. 2016;15(2):71–7. 5. vos rc, kasteleyn mj, heijmans mj, de leeuw e, schellevis fg, rijken m, et al. disentangling the effect of illness perceptions on health status in people with type 2 diabetes after an acute coronary event. bmc fam pract. 2018;19(1):35. 6. kugbey n, asante ko, adulai k. illness perception, diabetes knowledge and selfcare practices among type-2 diabetes patients: across-sectional study. bmc res notes. 2017;10(1):381. 7. srisanthanakrishnan v, shah pb. knowledge and perception of diabetes among patients with type 2 diabetes mellitus attending rural health care centre, tamil nadu, india. int j community med public health. 2016;3(9):2538–42. 8. agrimon oh. exploring the feasibility of implementing self-management and patient empowerment through a structured diabetes education programme in yogyakarta city indonesia: a pilot cluster randomized controlled trial [dissertation]. adelaide: the university of adelaide; 2014. [cited 2021 july 10]. available from: https:// digital.library.adelaide.edu.au/dspace/ bitstream/2440/87696/8/02whole.pdf. 9. indrayana s, fang sy. validitas dan reliabilitas the brief illness perception questionnaire versi bahasa indonesia pada pasien diabetes mellitus. dinamika kesehatan. 2019;10(1):361–7. 10. larasati la, andayani tm, kristina sa. hubungan tingkat pengetahuan terhadap outcome klinik pasien diabetes melitus tipe 2. jmpf. 2019;9(2):101–8. 11. karataş t, özen ş, kutlutürkan s. factor structure and psychometric properties of the brief illness perception questionnaire in turkish cancer patients. asia pac j oncol nurs. 2017;4(1):77–83. 12. kementerian pemberdayaan perempuan dan perlindungan anak republik indonesia. profil perempuan indonesia 2019. jakarta: kementerian pemberdayaan perempuan dan perlindungan anak republik indonesia; 2019. 13. shrestha n, yadav sb, joshi am, patel bdp, shreta j, bharher dl. diabetes knowledge and associated factors among diabetes patients in central nepal. int j collab res intern med public health. 2015;7(5):82– 91. 14. jasper us, ogundunmade bg, opara mc, akinrolie o, pyiki eb, umar a. determinants of diabetes knowledge in a cohort of nigerian diabetics. j diabetes metab disord. 2014;13:39. 15. perwitasari da, faridah in, kulle y, yulistika m. relationship between perception with the quality of life of t2dm patients in dok khansa ainun nabila et al.: knowledge and perception of diabetes mellitus among patients with type 2 diabetes mellitus in five public health centers in karawang, west java, indonesia althea medical journal. 2022;9(1) 18 ii jayapura hospital. iop conf ser mater sci eng. 2017;259:012004. 16. boonsatean w, carlsson a, dychawy rosner i, östman m. sex-related illness perception and self-management of a thai type 2 diabetes population: acrosssectional descriptive design. bmc endocr disord. 2018;18:5. 17. kim s, kim e, ryu e. illness perceptions, self-care management, and clinical outcomes according to age-group in korean hemodialysis patients. int j environ res public health. 2019;16(22):4459. 18. boonsatean w. the influences of income and education on the illness perception and self-management of thai adults with type 2 diabetes. j diabetes metab disord. 2016;3:017. 19. al-kayyis hk, perwitasari da. illness perception and quality of life in type 2 diabetes mellitus patients in lampung, indonesia. glob j health sci. 2018;10(7):136–47. 20. ruston a, smith a, fernando b. diabetes in the workplace-diabetic’s perceptions and experiences of managing their disease at work: a qualitative study. bmc public health. 2013;13:386. althea medical journal march 2022 amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 241 knowledge towards thalassemia and willingness to screen among students in public senior high school 3 bandung rima destya triatin,1 lulu eva rakhmilia,2 yunia sribudiani,1 susi susanah3 1department of biomedical sciences, faculty of medicine universitas padjadjaran, indonesia, 2department of public health, faculty of medicine universitas padjadjaran, indonesia, 3department of child health, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: rima destya triatin, dr., msc, department of department of biomedical sciences, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km 21, jatinangor, sumedang, indonesia, email: rima.destya@unpad.ac.id introduction thalassemia is an inherited abnormality of the globin chain influencing the structure and function of hemoglobin. since it is an autosomal recessive disease, individual carrying only one thalassemia mutation, named thalassemia carrier does not show any symptoms. this condition lead to difficult clinical detection. nevertheless, when a thalassemia carrier is married to a thalassemia carrier partner, there is a 25% possibility of having an affected child. ineffective bone marrow erythropoiesis and excessive hemolysis in thalassemia patients cause an increased need for blood transfusions.1 a previous systematic review identified 64–89% of major beta-thalassemia patients requiring regular blood transfusions every 2 and 4 weeks.2 also, infants and children affected by thalassemia will have physical development disturbance, thus increasing the burden of disease. therefore, in countries with a high prevalence of thalassemia carriers, preventive strategy is essential to reduce the risk of thalassemia in the next generation. among population worldwide, 1.5% are indicated as thalassemia carriers. mostly, they live in the “thalassemia belt”, extending along the shores of the mediterranean and throughout the arabian peninsula, turkey, althea medical journal. 2022;9(4):241–247 abstract background: thalassemia carrier screening is a major preventive measure potentially influenced by the level of knowledge, particularly in adolescents. therefore, this study aimed to analyze the effect of health education on knowledge of thalassemia in adolescents and its association with their willingness to do thalassemia screening. methods: a cross-sectional study was conducted using data regarding knowledge of thalassemia before and after health education sessions from 229 students at public senior high-school 3 bandung. all participants attended a one-day health education in july 2019. a questionnaire was filled in to measure their knowledge regarding thalassemia before and after the session, including knowledge on etiology and definition, risk of disease, clinical manifestations, treatment, complication, prognosis, and disease prevention. only data with complete questionnaire responses were included. these responses were scored quantitatively and analyzed for their association with participants’ willingness to screen. results: participants were knowledgeable concerning thalassemia before the health education session (median, range: 60.0, 25.0-90.0), and knowledge was increased significantly after the education session (median, range: 80.0, 35.0-100.0) with an increased median difference=19.99 (p-value <0.001). although there was no significant association between the overall post-test score on participants’ willingness to screen (p-value >0.05), the willingness was slightly associated with improved knowledge regarding the risk of disease (or: 1.02; 95%ci: 1.00-1.03; p-value <0.005). conclusion: health education regarding thalassemia significantly increases general knowledge of thalassemia. however, improving knowledge is not significant in influencing adolescents’ motivation to take the screening tests. keywords: health education, knowledge, screening, thalassemia https://doi.org/10.15850/amj.v9n4.2730 althea medical journal. 2022;9(4) 242 iran, india, and southeast asia, including indonesia.3,4 several preventive measures have been proposed in indonesia, such as genetic counseling and carrier screening, as the best options for facing thalassemia.5,6 however, these approaches have been relatively unsuccessful, particularly in adolescents, due to a lack of willingness to screen in the target population.7 a previous study in west java showed that only about 50% of adolescents were willing to screen for thalassemia voluntarily, while 9.3% were suspected of having minor beta-thalassemia.7 possible reasons for this barrier are a lack of knowledge, that adolescents have lower knowledge on thalassemia than adults and a lack of understanding of the concept of thalassemia carriers.8,9 another study in west java showed that many high-school students were unaware of the disease inheritance and the importance of genetic screening tests before providing educational modules.10 furthermore, it is well known that health education can improve the knowledge and perspectives of individuals regarding a situation or disease, particularly asymptomatic condition such as thalassemia carrier.11 a previous study in malaysia has indicated an increase in the rate of genetic screening tests immediately after implementation of health education.12 however, another study in turkey showed that the implementation of hemoglobinopathies screening test significantly decreased the prevalence of newborns with thalassemia.13 this finding indicates the urgency to undertake screening tests early in life before they decide to get married and plan a pregnancy. currently, there is still limited study that can explain indepth how improving knowledge through health education can increase willingness to participate in genetic screening tests for adolescents in indonesia. therefore, this study aimed to analyze the effects of health education on knowledge on thalassemia in adolescents and its association with their willingness to screen. it is expected that with the improvement of knowledge through health education, adolescents would be more open to thalassemia screening tests. methods this study was cross-sectional using secondary data from the academic leadership grant (alg) project at the medical genetic working group, faculty of medicine, universitas padjadjaran. this project involved students from public senior high school (sekolah menengah atas negeri, sman) 3 bandung, indonesia. this high school was selected because the high school was recognized as a high rank public school with good information exposure. final grade students, who were mostly adolescents, were invited to participate in a one-day health education session on thalassemia which was held in july 2019. health education session was held in parallel in each class. it was started with a presentation related to thalassemia by a qualified counselor, using the same presentation slides for each class, and followed by an interactive discussion. this health education was part of the community service provided by the faculty of medicine, universitas padjadjaran. before and after the session, participants were asked to fill in a questionnaire, developed by the medical genetic working group universitas padjadjaran, including experts in thalassemia, genetics, and public health. questionnaire development has been described in the previous article.14 data from all participants attending the health education session were included in this study, but data of participants who failed to complete both questionnaires were excluded from the analysis. with 80% power of the study, we calculated a minimum of 178 participants required to find statistical significance for 20% knowledge difference. ethical clearance has been provided by the ethical committee of the universitas padjadjaran bandung, with number 887/un6. kep/ec/2021. the questionnaire was developed to measure participants’ knowledge of thalassemia, particularly regarding the etiology and definition, risk of disease, clinical manifestation, treatment, complication, prognosis, and disease prevention. each aspect of knowledge was measured by 2 to 5 questions and thus contained 20 true-or-false questions (table 1). this questionnaire has been developed by experts in this field and was considered relevant to the presentation of the counselor. each answer to this questionnaire was assessed. the correct answer was scored 1 and zero otherwise, and subsequently summarized based on the related aspects of knowledge. finally, the scores were transformed to a scale of 0–100, according to the percentage of correct answers. the levels of knowledge were then quantified as an overall general knowledge and separately according to the above-mentioned aspects of knowledge. in addition, participants were also asked about their willingness to get althea medical journal december 2022 althea medical journal. 2022;9(4) 243rima destya triatin et al.: knowledge towards thalassemia and willingness to screen among students in public senior high school 3 bandung thalassemia screening after participating in a health education session, with “yes” or “no” answers. the quantitative level of knowledge pre and post education session, which was then called the pre-test and post-test scores, was checked for the normality of the data distribution. to measure the effect of health education on participants’ knowledge, a comparative analysis using the wilcoxon signed rank test between pre-test and post-test was performed. the difference in scores between pre-test and post-test was considered as knowledge improvement. furthermore, the association of knowledge improvement and post-test score on participants’ willingness to screen was measured by performing the independent t-test and the mann-whitney u test, respectively. five percent type i of error was adjusted in this study, and thus the p-value <0.05 was considered statistically significant. statistical analysis and data visualization were performed in r version 4.0. results of 298 individuals who participated in the thalassemia education session, 229 had completed the pre-test and post-test. most respondents were late adolescents with a median age of 17 years and had never gotten in thalassemia education or had family/ relative with thalassemia. only one respondent had a first-degree relative with a history of thalassemia. details of these characteristics are summarized in table 1. overall, participants were already knowing about thalassemia before the education session (median, range: 60.0, 25.0–90.0). after the education session, participants showed better knowledge about thalassemia (median difference of pre-test and post-test=19.99, table 1 characteristics of students from public senior high school 3 bandung characteristics (median, range) n (%) age 17(14-18) gender male female 87 (38.0) 142 (62.0) experience in thalassemia education never ever unclear 212 (92.6) 2 (0.9) 15 (6.6) family history of thalassemia yes no 1 (0.4) 228 (99.6) relationship with thalassemia family members no relatives with thalassemia first-degree relatives 228 (99.6) 1 (0.4) table 2 the score of knowledge related to thalassemia before and after health education sessions among students from public senior high-school bandung aspects of knowledge pre-test score post-test score p-value median min-max median min-max etiology and definition risk of disease disease manifestation treatment complication prevention overall knowledge 66.7 50.0 66.7 50.0 100.0 80.0 60.0 0–100 0–100 0–100 0–100 0–100 20–100 25–90 100.0 50.0 100.0 50.0 100.0 100.0 80.0 0–100 0–100 0–100 0–100 0–100 0–100 35–100 <0.001 <0.001 <0.001 0.18 <0.001 <0.001 <0.001 althea medical journal. 2022;9(4) 244 p-value <0.001) (figure 1 and table 2). the slightest median differences were seen in treatment and disease risk (table 2), but the knowledge distribution of disease risk has shown the most prominent shift after attending the education session. although most respondents were willing to get a genetic screening test for thalassemia after attending thalassemia education (87.3%), the willingness to take the screening test did not depend on the participants’ knowledge of thalassemia. the overall post-test score and the overall score improvement did not significantly influence respondents’ willingness to screen (figure 2). however, this study showed that respondents willing to get the screening test had a higher level of knowledge (median: 80 vs. 75, p-value= 0.107). also, there was a slight association between the willingness to screen and improved knowledge about the risk of thalassemia (or: 1.02; 95%ci: 1.00, 1.03; p-value < 0.005). discussion in this study, the effects of health education on knowledge on thalassemia in adolescents and its association with their willingness to screen was measured this study found that health education at school. has significantly improved adolescents’ knowledge of thalassemia, and thus, this activity could have a good general understanding of thalassemia. a remarkable improvement in knowledge was found in the aspect of the risk of disease. although it was found that the respondents had a high willingness to screen, good knowledge about thalassemia and a significant improvement in knowledge were not associated with the willingness to test screening. several studies have shown significant effect of health education in improving knowledge and attitude towards inherited disease prevention, such as thalassemia.10,12 similarly, the findings of the current study althea medical journal december 2022 figure 1 different test scores regarding knowledge of thalassemia before and after thalassemia education sessions note: in the box plots, the boundary of the box closest to zero indicates the 25th percentile, a black line within the box marks the median, and the boundary farthest from zero indicates the 75th percentile. whiskers above and below the box indicate the 10th and 90th percentiles. points above and below the whiskers indicate outliers outside the 10th and 90th percentiles. (*)/(**)/(***): statistically significant, ns= not significant. althea medical journal. 2022;9(4) 245 show an improvement in knowledge of thalassemia after providing health education to the respondents, especially about the risk of the disease. these findings agree with the previous studies showing the effectiveness of educational modules in improving the level of knowledge about thalassemia prevention.10,12 however, these previous studies showed that the level of knowledge was not retained in a long-term, indicating the need for a long term or sustainable availability of accessible resources to make the knowledge lasts longer. this study identified that improved knowledge of thalassemia was accompanied by a high rate of willingness to perform screening tests. however, this study failed to identify a statistical association between knowledge improvement and motivation on screening tests. although this study found a significant association between willingness to screen and risk of disease, the effect size was considered too small to influence willingness to screen. these results are inconsistent with previous studies, which indicate a lack of knowledge and understanding of the personal concept of disease as a barrier to screening tests.9,11,15 this discrepancy is possibly becauese knowledge is not the only factor driving the motivation to perform genetic tests, but rather personal perspectives on the test itself.16,17 a previous study has identified that anxiety of invasive procedures, which also apply to the thalassemia screening tests, can influence the willingness to take screening tests.18 despite their knowledge about the benefits of genetic testing in thalassemia prevention, there are still some contradictory effects of the test. these potential side effects might influence the motivation to get the test, particularly related to reproductive attitude. for example, positive findings in a genetic test for thalassemia, especially in reproductive age, are considered to negatively influence marriage opportunities.15 also, evidence of a negative perspective on living with thalassemia and worries of being stigmatized potentially increase the fear of finding the disease, which is also one of the barriers to a screening test.19 rima destya triatin et al.: knowledge towards thalassemia and willingness to screen among students in public senior high school 3 bandung figure 2 association of overall post-test scores on respondents’ willingness to screen (a) and association of preand post-test difference scores on respondents’ willingness to screen (b) note: in the box plots, the boundary closest to zero indicates the 25th percentile, a black line within the box marks the mean, and the boundary farthest from zero indicates the 75th percentile. whiskers above and below the box indicate the 10th and 90th percentiles. points above and below the whiskers indicate outliers outside the 10th and 90th percentiles. (*)/(**)/(***)= statistically significant, ns= not significant. althea medical journal. 2022;9(4) 246 families provide a strong motivation for the screening test in which a better understanding of parents could encourage their children to get the test.20 therefore, family support and motivation are considered essential to complete a good understanding of thalassemia and thus to improve the willingness of adolescents to participate in thalassemia screening tests. some limitations needed to be addressed. this current study used only a few question items to identify robust associations from each aspect of knowledge about the motivation for a genetic screening test. it can be seen in the low density of data distribution in each aspect of knowledge. in addition, this study could not deeply elucidate why respondents were unwilling to take the screening test due to the limited information available. however, this study also had some strengths. it has identified a comprehensive understanding that health promotion and education can improve the awareness of thalassemia among adolescents and the response rate to genetic screening tests compared to previous studies. in addition, this study used a reproducible method to evaluate the effectiveness of health education practically, especially related to the risk and prevention of thalassemia. although health education was performed separately in several groups, the use of standardized materials has maintained the validity and reliability of the measurements. also, current study included more than the required sample size to conduct a powerful analysis further analysis is needed to understand indepth how health education about thalassemia in adolescents can improve their perspective towards thalassemia prevention, particularly genetic screening test. factors influencing the willingness to screen need to be studied in-depth to improve strategies to increase public’s willingness to take genetic testing. also, further validation of the improved knowledge of thalassemia risk on willingness to test is required. in conclusion, health education regarding thalassemia can significantly improve adolescents’ knowledge of thalassemia, but it fails to associate with a high willingness to screen. further study on factors associated with knowledge and willingness to screen is required to validate our findings and identify more considerable factors influencing such preventive measures. acknowledgment we would like to acknowledge ms. putri halleyana adrikni rahman for her assistance in data collection and data entry, and late prof. dadang sjarif hidajat effendi for funding this research. references 1. wahidiyat i, wahidiyat pa. genetic problems at present and their challenges in the future: thalassemia as a model. paediatr indones. 2016;46(5):189–94. 2. betts m, flight pa, paramore lc, tian l, milenković d, sheth s. systematic literature review of the burden of disease and treatment for transfusion-dependent betathalassemia. clin ther. 2020;42(2):322– 37.e2. 3. chapin j, giardina pj. chapter 40: thalassemia syndromes. in: hoffman r, benz ej, silberstein le, heslop he, weitz ji, anastasi j, et al., editors. hematology: basic principles and practice. 7th ed. philadelphia: elsevier; 2017. p. 546–70. e10. 4. husna n, sanka i, al arif a, putri c, leonard e, handayani nsn. prevalence and distribution of thalassemia trait screening. j med sci. 2017;49(3):106–13. 5. rujito l, mulyanto j. adopting mass thalassemia prevention program in indonesia: a proposal. jkki. 2019;10(1):1– 4. 6. rujito l. genetic counseling in indonesia as a mandatory service. jkki. 2018;9(1):1–2. 7. alyumnah p, ghozali m, dalimoenthe nz. skrining thalassemia beta minor pada siswa sma di jatinangor. j sistem kesehatan. 2016;1(3):133–8. 8. wong lp, george e, tan ja. public perceptions and attitudes toward thalassaemia: influencing factors in a multi-racial population. bmc public health. 2011;11:193. 9. chien sy, chuang mc, chen ip. why people do not attend health screenings: factors that influence willingness to participate in health screenings for chronic diseases. int j environ res public health. 2020;17(10):3495. 10. rakhmilla le, larasati r, sahiratmadja e, rohmawaty e, susanah s, effendi sh. assessing knowledge about thalassemia among reproductive age population after video media education. j biomed clin sci. 2017;2(2):30–2. 11. karimzaei t, masoudi q, shahrakipour m, navidiyan a, j jamalzae aa, zoraqi bamri a. knowledge, attitude and practice of althea medical journal december 2022 althea medical journal. 2022;9(4) 247 carrier thalassemia marriage volunteer in prevention of major thalassemia. glob j health sci. 2015;7(5):364–70. 12. ngim cf, ibrahim h, abdullah n, lai nm, tan rkm, ng cs, et al. a webbased educational intervention module to improve knowledge and attitudes towards thalassaemia prevention in malaysian young adults. med j malaysia. 2019;74(3):219–25. 13. topal y, topal h, ceyhan mn, azik f, çapanoğlu m, kocabaş cn. the prevalence of hemoglobinopathies in young adolescents in the province of muğla in turkey: results of a screening program. hemoglobin. 2015;39(4):247–50. 14. rakhmilla le, susanah s, rohmawaty e, effendi sh. effectiveness of an educational intervention in providing knowledge about the prevention of thalassemia: an effort to reduce new thalassemia cases. asian j epidemiol. 2018;11(2):59–64. 15. alkhaldi sm, khatatbeh mm, berggren vem, taha ha. knowledge and attitudes toward mandatory premarital screening among university students in north jordan. hemoglobin. 2016;40(2):118–24. 16. haga sb, barry wt, mills r, ginsburg gs, svetkey l, sullivan j, et al. public knowledge of and attitudes toward genetics and genetic testing. genet test mol biomarkers. 2013;17(4):327–35. 17. chin jj, tham hw. knowledge, awareness, and perception of genetic testing for hereditary disorders among malaysians in klang valley. front genet. 2020;11:512582. 18. hussain i, majeed a, rasool mf, hussain m, imran i, ullah m, et al. knowledge, attitude, preventive practices and perceived barriers to screening about colorectal cancer among university students of newly merged district, kpk, pakistan a cross-sectional study. j oncol pharm pract. 2021;27(2):359–67. 19. boardman fk, clark c, jungkurth e, young pj. social and cultural influences on genetic screening programme acceptability: a mixed-methods study of the views of adults, carriers, and family members living with thalassemia in the uk. j genetic couns. 2020;29(6):1026–40. 20. mat mac, yaacob lh, zakaria r. parental knowledge on thalassaemia and factors associated with refusal to screen their children. malays j med sci. 2020;27(1):124–33. rima destya triatin et al.: knowledge towards thalassemia and willingness to screen among students in public senior high school 3 bandung amj vol 10 no 1 march 2023 rev.indd althea medical journal. 2023;10(1) 56 correlation between vertebral slippage in spondylolisthesis with ligamentum flavum thickening in dr. soebandi hospital, jember, east java, indonesia heni fatmawati,1 alvin candra,2 nindya s. rumastika,3 al munawir,3 muh. hasan,4 i nyoman semita5 1department of radiology, faculty of medicine, university of jember, indonesia, 2faculty of medicine, university of jember, indonesia, 3department of pathological anatomy, faculty of medicine, university of jember, indonesia, 4department of anatomy, faculty of medicine, university of jember, indonesia, 5department of surgery, faculty of medicine, university of jember, indonesia correspondence: dr. heni fatmawati, m.kes. sp.rad, department of radiology, faculty of medicine, university of jember, jalan kalimantan no. 37, tegalboto campus, jember, east java, indonesia, email: fatmawatiheni@unej.ac.id introduction ligamentum flavum (lf) plays a crucial role in intervertebral motion and intrinsic spinal stability in sitting and standing postures, as well as the protector of the posterior wall of the spinal canal and neural foramina.1–3 in abnormal conditions such as increased mechanical stress and chronic inflammation, the lf undergoes several changes, such as hypertrophy.4–5 spondylolisthesis is a slipping of the vertebra, however, the neural arch is still intact. spondylolisthesis may compromise the stability of spine and increase axial load that may stress surrounding structures. previous studies have investigated the causes of spondylolisthesis, especially degenerative spondylolisthesis (ds). the most common potential risk factors identified are gender, activity level, body mass index (bmi), facet joint’s sagittal orientation, mechanical stress in lf, and ligament hyperlaxity.6,7 tissue damage due to mechanical stress can be the initial trigger of the inflammatory reaction, which then develops into scar tissue, and althea medical journal. 2023;10(1):56–60 abstract background: spondylolisthesis is a vertebral slip condition that compromises the body’s axial alignment and structures such as ligamentum flavum. the ligamentum flavum thickening may play a role in spondylolisthesis. the purpose of this study was to investigate the correlation between the slippage of vertebral body (spondylolisthesis) with ligamentum flavum thickening as a tissue response regarding increased mechanical stress. methods: an analytical retrospective radiological observational was used a cross-sectional study from the results of mri examination in dr. soebandi hospital, jember, indonesia, collected from 2018-2021 using the simple random sampling method. ligamentum flavum thickness and the degree of vertebral slip were measured using t2-weighted mr imaging and the correlation was analyzed using fisher’s exact test. results: of 102 spondylolisthesis data records, 34 were taken, being female was the most prevalent cases in the age group above 60 years, with the most vertebral segment shift occurring at the l4–l5 level. there was a significant correlation. (p= 0.02; rr= 4.8) between ligamentum flavum thickening and vertebral slip in spondylolisthesis. conclusion: the significant correlation between ligamentum flavum thickening and vertebral slip in spondylolisthesis suggest that mechanical stress has caused spondylolisthesis, by inducing chronic inflammation that results in hypertrophy of ligamentum flavum. lumbar segmental instability due to spondylolisthesis is a factor contributing to the development of ligamentum flavum hypertrophy. keywords: ligamentum flavum thickening, magnetic resonance imaging, spondylolisthesis https://doi.org/10.15850/amj.v10n1.2794 althea medical journal. 2023;10(1) 57 accumulation of the scar tissue will result in lf hypertrophy.8,9 the stability of the spine is influenced by many things, one of which is the integrity of the ligamentous structures in the vertebrae. the ligamentum flavum (lf) is one of several ligaments that help support the stability of the vertebrae. in the event of spinal instability, the supporting elements of the vertebrae try to maintain spinal stability in various ways, one of which is tissue hypertrophy.10,11 this study was conducted to investigate whether there was a correlation between increasing slip degree of spondylolisthesis and lf thickening to prove that spondylolisthesis has caused lf hypertrophy. methods an analytical retrospective observational study was conducted in dr. soebandi hospital, jember, indonesia, in january 2022. data from mri of patients diagnosed with spondylolisthesis by a radiologist from 2018 to 2021 were collected. the exclusion criteria were data from patients with incomplete medical records, spinal disorders other than spondylolisthesis (such as tumors, infection, and inflammatory spondylitis previous lumbar surgery), and traumatic spondylolisthesis. data were chosen using a simple random sampling method, with total sample size of 34 data patients for one-tailed correlation analysis with type 1 error (α) and type 2 error (β) allowed up to 5% and 20%, respectively. the data were collected using the data collecting form by the variable investigator. two independent investigators participated in this study and were educated to use the same measurement standards before the start of the study. the vertebral slippage was measured using the mid-sagittal view of t2-weighted mri images. vertebral slippage was the relative horizontal displacement of the superior vertebral body over the inferior vertebral body. meyerding classification was used to categorize the degree of slip. if more than 2 different levels were involved, the segment with the largest degree of slip was chosen. conflicting results from two investigators were resolved by the third investigator. ligamentum flavum thickening was measured using axial view of t2-weighted mri images, as shown in figure 1. the level measuring by the investigator was the same as where the vertebral slippage was measured, in line with the facet joint of table 1 characteristics of patients with spondylolisthesis in dr. soebandi hospital, jember, indonesia year 2018 to 2021(n=34) characteristics n (%) gender male female 8 (24) 26 (76) age (year) 41–60 > 60 12 (35) 22 (65) level of slip l3–l4 l4–l5 l5–l6 l5–s1 5 (15) 23 (67) 1 (3) 5 (15) the two vertebral bodies involved. lf was considered as thickened if its length was >4 mm. if there were more than 2 different levels involved, the segment with the largest degree of slip was chosen. conflicting results from two investigators were resolved by the third investigators. research data were then tabulated into a microsoft excel worksheet (microsoft corp., washington, usa) and statistically analyzed using statistical package for social science (spss) for windows (version 24.0; ibm corp., armonk, ny). the continuous variables were categorized into pre-determined groups. vertebral slip was categorized into 4 groups based on meyerding classification (grade i–iv). ligamentum flavum thickening was categorized into 2 groups that is thickened (> 4 mm) and non-thickened group (≤4 mm). the fisher’s exact test was used to analyze the correlation between lf thickening and vertebral slip in spondylolisthesis. this study was approved by the ethical review board of the medical faculty university of jember, registration number 1573/ h25.1.11/ke/2021. this study adhered to strobe guidelines for reporting observational studies. results the spondylolisthesis cases between year 2018 and 2021 included 24% males and 76% females. the age group with the most spondylolisthesis cases was individuals over 60 years old (65%), followed by 41–60 years old patients (35%), and none were under 40 heni fatmawati et al.: correlation between vertebral slippage in spondylolisthesis with ligamentum flavum thickening in dr. soebandi hospital, jember, east java, indonesia althea medical journal. 2023;10(1) 58 years old. the level of vertebral slip mostly inflicted by spondylolisthesis was l4–l5 (67%), as shown in table 1. measurement of vertebral slip and lf thickening showed that grade i spondylolisthesis was mostly nonthickened (79.3%). interestingly, in grade ii spondylolisthesis, all samples were thickened. the results showed a significant difference (p<0.02; fisher’s exact test), indicating a significant correlation between the increase in the degree of vertebral slip and the thickening of the lf. the risk ratio result showed that the degree of vertebral slip had a risk factor of 4.8 times for lf thickening (table 2). discussion our study has shown that most spondylolisthesis patients are female (76%), consistent with the demographics of degenerative spondylolisthesis. this result might be due to ligament laxity and hormonal effects. post-menopausal women experience an increased expression of estrogen receptors in their vertebral facet joints, therefore, in post-menopausal women with degenerative spondylolisthesis, facet arthritis is more common than spinal stenosis. in addition, pregnancy is also thought to play a role in the occurrence of degenerative spondylolisthesis. during pregnancy, the spine stability is compensated due to an increased in body weight, and the center of mass of the body moves forward. increased body mass will also increase stress on the facet joints, ligaments around the vertebrae, and the vertebrae themselves.13 furthermore, the age of the patient plays a significant role, as shown in the result that the age group above 60 years is the highest incidence (65%), followed by the age group 41–60 years (35%). the gegenerative type of spondylolisthesis often occurs at over 40 and most commonly occurs in the sixth decade of life. the cause of spondylolisthesis might be due to a degenerative process that occurs later in life. the degenerative processes include degeneration of the intervertebral discs, arthritis of the facet joints, osteoporosis of the senile vertebrae, and degeneration of the ligaments that table 2 vertebral slip and lf thickening measurement result vertebral slip degree ligamentum flavum thickening total p value risk ratio yes no ii 5 (100%) 0 (0%) 5 0.02 4.8 i 6 (20.7%) 23 (79.3%) 29 althea medical journal march 2023 figure 1 lumbar mri demonstrated anterior vertebral slippage (a) with grade ii slippage, and ligamentum flavum thickening (b) with 4.66 mm (left ligamentum flavum) and 4.69 mm (right ligamentum flavum) thickness a b althea medical journal. 2023;10(1) 59heni fatmawati et al.: correlation between vertebral slippage in spondylolisthesis with ligamentum flavum thickening in dr. soebandi hospital, jember, east java, indonesia support the spine. the degeneration process will cause instability in the spine, thus the alignment, especially the sagittal alignment, is disturbed. impaired sagittal alignment is a state of spondylolisthesis.14 the location of the vertebral shift has shown that the most vertebral segment shift occurred at the l4–l5 level (67%). spondylolisthesis, especially the degenerative type, mostly occurs at the l4–l5 level.15 the anatomical reason that the l4–l5 is the most common location for degenerative spondylolisthesis is due to the orientation of the facet joints at that level. the facet joints at the l4–l5 level, which are sagittal oriented at an angle of more than 45 degrees, increase the risk of developing degenerative spondylolisthesis by 25 times. the occurrence of sacralization at l5 also increases the chance of dysplastic type spondylolisthesis at the l4–l5 level.7,15,16 our study shows that there is a correlation between vertebral segment shift and ligamentum flavum thickening (p-value <0.05; fisher’s exact test), indicating that the greater the displacement of the vertebral segments, the greater the likelihood of thickening of the ligamentum flavum (rr= 4.8). the cadaveric study has shown that the integrity of the intervertebral disc and the strength of the ligaments supporting the spine must be compromised for significant spine instability to occur.17 the integrity of the intervertebral disc is considered to have a more significant influence than the strength of the ligaments that support the spine. the ligamentum flavum, especially in the lumbar spine, is prone to inflammation. the axial load of the lumbar spine is greater than the other segments. if there is instability in the spine, the ligamentous structure would be exposed to mechanical stress, and inflammation. inflammation that occurs continuously or chronically will trigger the process of hypertrophy of the ligamentum flavum. hypertrophy of the ligamentum flavum is the main cause of ligamentum flavum thickening.2,5,18–21 the distribution of vertebral displacement degrees found in this study consist of grade i and ii and none in grade iii and iv groups. this finding is in line with the findings found in degenerative spondylolisthesis. the slipping of the vertebral segments will be obstructed due to the intact posterior vertebral elements, in this case the neural arch.15 this study has several limitations that must be considered in the interpreting of the outcomes. numerous factors contribute to spondylolisthesis, including gender, age, body mass index, and history of pregnancy. to better understand the pathogenesis of spondylolisthesis, these additional factors should be included in future analyses. in conclusion, there is a significant correlation between ligamentum flavum thickening and vertebral slip in spondylolisthesis, suggesting that mechanical stress has caused spondylolisthesis, by inducing chronic inflammation that results in hypertrophy of ligamentum flavum. lumbar segmental instability due to spondylolisthesis is a factor contributing to the development of ligamentum flavum hypertrophy. references 1. kolte vs, khambatta s, ambiye mv. thickness of the ligamentum flavum: correlation with age and its asymmetry-an magnetic resonance imaging study. asian spine j. 2015;9(2):245–53. 2. moon hj, park yk, ryu y, kim jh, kwon th, chung hs, et al. the angiogenic capacity 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level. dis markers. 2014;2014:786543. 20. de decker s, da costa rc, volk ha, van ham lml. current insights and controversies in the pathogenesis and diagnosis of discassociated cervical spondylomyelopathy in dogs. vet rec. 2012;171(21):531–7. 21. hirabayashi s. ossification of the ligamentum flavum. spine surg relat res. 2017;1(4):158–63. althea medical journal march 2023 amj vol 9 no 1 march 2022 rev.indd a lt h e a m e d ic a l jo u r n a l v o lu m e 9 n u m b e r 1 y e a r 2 0 2 2 volume 9, number 1 march, 2022 e-issn 2337-4330 original articles knowledge and attitude among doctors towards use of prophylactic vitamin k in neonatal bleeding disorders in department of obstetrics and gynecology: experience from haj el-safi hospital, sudan rawan mohamed sabri, abrar bakry malik, mohamed eltayeb elawad, ebtihal modather mohammed, ahmed sami abdalla snakebites and the effect of serum anti bisa ular (sabu) antivenom at dr. hasan sadikin general hospital bandung, indonesia: an overview period 2015–2019 sharon noor alya, enny rochmawaty, achadiyani, muhammad hasan bashari, hardisiswo soedjana knowledge and perception of diabetes mellitus among patients with type 2 diabetes mellitus in five public health centers in karawang, west java, indonesia khansa ainun nabila, maya kusumawati, ginna megawati body mass index, a body shape index, and waist to height ratio in predicting elevated blood pressure bryan junius winata, veronika maria sidharta, linawati hananta, vetinly, nawanto agung prastowo comparison of cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis mohammad arianto satrio wicaksono, cep juli, chandra calista, uni gamayani, aih cahyani, paulus anam ong glasgow outcome scale assessment in patients with cerebral toxoplasmosis brigitta berlianty, sofiati dian, ahmad rizal ganiem reversal reaction in leprosy patients: study on prevalence, sociodemographic characteristics, and precipitating factors at a tertiary referral hospital in west java, indonesia hendra gunawan, risa miliawati, renasha firda hanannisa therapeutic outcomes of pediatric acute myeloblastic leukemia patients at a tertiary hospital in bandung, indonesia filbert lois marcus, nur suryawan, delita prihatni lung abnormalities in systemic sclerosis patients through spirometry, chest x-ray, and highresolution computed tomography scan sumartini dewi, waliyyuddin robbani, iceu dimas kulsum maternal characteristics and histopathological features of placenta accreta spectrum in dr. hasan sadikin general hospital bandung, period 2015–2020 yuktiana kharisma, hasrayati agustina, sri suryanti, birgitta maria dewayani, bethy suryawati hernowo editor in chief edhyana k. sahiratmadja managing editor mas rizky a.a syamsunarno external editors gerald pals kamisah yusof alexander kwarteng kittiphong paiboonsukwong tedjo sasmono jarir at thobari soegianto ali trevino aristarkus pakasi andani eka putra pudji lestari herry garna internal editors yunia sribudiani ronny lesmana afiat berbudi nur atik muhammad hasan bashari sri endah rahayuningsih irma ruslina defi reni ghrahani mohammad ghozali astrid feinisa khairani nur melani sari eko fuji ariyanto copyeditors hanna goenawan julia ramadhanti poppy siti chaerani djen amar electronic production engineer devi fabiola syahfitri site administrator & layout editor ati sulastri  offline secretariat elza purwita editorial address jl. prof. dr. eijkman 38 bandung, indonesia 40161 mobile: 082216237668/081320178724 phone (+62) 022-2032170 ext. 1401 fax: (+62) 022-2037823 e-mail: chiefeditor.amj@gmail.com website: http://journal.fk.unpad.ac.id/index.php/amj volume 9, number 1 march, 2022 e-issn 2337-4330 original articles knowledge and attitude among doctors towards use of prophylactic vitamin k in neonatal bleeding disorders in department of obstetrics and gynecology: experience from haj el-safi hospital, sudan  rawan mohamed sabri, abrar bakry malik, mohamed eltayeb elawad, ebtihal modather mohammed, ahmed sami abdalla snakebites and the effect of serum anti bisa ular (sabu) antivenom at dr. hasan sadikin general hospital bandung, indonesia: an overview period 2015–2019 sharon noor alya, enny rochmawaty, achadiyani, muhammad hasan bashari, hardisiswo soedjana knowledge and perception of diabetes mellitus among patients with type 2 diabetes mellitus in five public health centers in karawang, west java, indonesia khansa ainun nabila, maya kusumawati, ginna megawati body mass index, a body shape index, and waist to height ratio in predicting elevated blood pressure bryan junius winata, veronika maria sidharta, linawati hananta, vetinly, nawanto agung prastowo comparison of cognitive function between intracerebral haemorrhage stroke patients with and without hypertensive crisis mohammad arianto satrio wicaksono, cep juli, chandra calista, uni gamayani, aih cahyani, paulus anam ong glasgow outcome scale assessment in patients with cerebral toxoplasmosis brigitta berlianty, sofiati dian, ahmad rizal ganiem  reversal reaction in leprosy patients: study on prevalence, sociodemographic characteristics, and precipitating factors at a tertiary referral hospital in west java, indonesia hendra gunawan, risa miliawati, renasha firda hanannisa therapeutic outcomes of pediatric acute myeloblastic leukemia patients at a tertiary hospital in bandung, indonesia filbert lois marcus, nur suryawan, delita prihatni lung abnormalities in systemic sclerosis patients through spirometry, chest x-ray, and high-resolution computed tomography scan sumartini dewi, waliyyuddin robbani, iceu dimas kulsum maternal characteristics and histopathological features of placenta accreta spectrum in dr. hasan sadikin general hospital bandung, period 2015–2020 yuktiana kharisma, hasrayati agustina, sri suryanti, birgitta maria dewayani, bethy suryawati hernowo page 1–5 6–11 12–18 19–23 24–29 30–36 37–42 43–48 49–54 55–60 author’s guidelines althea medical journal (amj) is 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organization as a source who. who position paper on hepatitis a vaccines. wkly epid emiol rec. 2012;87(28/29):261–76. no author given mental care and relief support for victims of the earthquake occurred in eastern part of japan. seishin shinkeigaku zasshi. 2011;113(9):825–44. volume with supplement rushton l, hutchings sj, fortunato l, young c, evans gs, brown t, et al. occupational cancer burden in great britain. br j cancer. 2012;107(suppl1):s3–7. edition with supplement north cs, pollio de, smith rp, king rv, pandya a, suris am, et al. trauma exposure and posttraumatic stress disorder among employees of new york city companies affected by the september 11, 2001 attacks on the world trade center. disaster med public health prep. 2011;(5 suppl 2):s205– 13. books and other monographs personal author(s) sax pe, cohen cj, kuritzkes dr. hiv essentials 2012. 2nd ed. burlington: world headquarters; 2012. editor(s) as the author baxter r, editor. a cellular dermal matrices in breast surgery, an issue of clinics in plastic surgery. mountlake terrace: saunders; 2012. organization as the author unaids. meeting the investment challenge tipping the dependency. geneva: who library cataloguing data; 2012. chapter in a book pignone m, salazar r. disease prevention and health promotion. in: diedrich c, lebowitz h, holton b, editors. 2012 current medical diagnosis and treatment. 51st ed. new york: the mcgraw-hill companies; 2012. p. 1–21. conference proceedings wilson b, hamilton n, editors. airborne particulate exposures: the environmental and occupational perspectives. proceedings of the wsn mining health and safety conference; 2012 april 17–19; sudbury. ontario: golder associates; 2012. conference paper tirilly p, lu k, mu x. predicting modality from text quiries for medical image retrieval. in: cao y, kalpathy-cramer j, unay d, editors. mm 11. proceeding of the 2011 international acm workshop on medical multimedia analysis and retrieval; 2011 nov 28–dec 01; arizona, usa. new york: acm; 2011. p. 7–12. dissertation rohim s. kontruksi diri dan perilaku komunikasi gelandangan di kota jakarta (studi fenomenologi terhadap julukan gelandangan “manusia gerobak”) [dissertation]. bandung: universitas padjadjaran; 2012. electronic material journal article in electronic format mahmood om, goldenberg d, thayer r, migliorini r, simmons an, tapert sf. adolescents’ fmri activation to a response inhibition task predicts future substance use. addictive behaviors [internet] 2012 [cited 2012 may 12]. available from: http:// www.sciencedirect.com. homepage world health organization. cardiovascular disease (cvds) [internet] [cited 2021 may 6]. available from: https://www. who.int/health-topics/cardiovasculardiseases#tab=tab_1. editorial board contact: althea medical journal mobile: 082216237668/081320178724 e-mail: chiefeditor.amj@gmail.com amj.fkunpad@gmail.com amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 37 low bone mineral density, sedentary lifestyle, and depression as risk factors for frailty syndrome at a home care facility in west jakarta, indonesia yvonne suzy handajani,1 jonathan christianto,2 nelly tina widjaja1 1centre for health research, atma jaya catholic university of indonesia, jakarta, indonesia, 2school of medicine and health sciences atma jaya catholic university of indonesia, jakarta, indonesia correspondence: prof. dr. drg. yvonne suzy handajani, mkm, centre for health research, atma jaya catholic university of indonesia, jalan pluit raya no. 2, north jakarta, indonesia, e-mail: yvonne.hand@atmajaya.ac.id introduction life expectancy is increasing globally. the rising life expectancy has led to the growth of the elderly population. in indonesia, the centre bureau of statistics of indonesia in 2018 reported that the life expectancy for women was 73.19 years, and for men it was 69.3 years.1 the percentage of indonesian elderly is expected to reach 21.4% by 2050.2,3 indonesia has entered the aging population era because its elderly population has already surpassed 7% of the nation’s total population.2 the increase in the elderly population may reflect the success of the nation’s social and economic development. on the other hand, it may also affect the nation’s healthcare sector. the elderly tend to have a decline in functional capability and adaptation as a result of the body system’s function deterioration, which is often referred to as a frailty syndrome. frailty is a condition related to aging. frailty phenotypes include decreased strength of handgrips, exhaustion, body weight loss, low physical activity, and slow speed gait.4 a systematic review reported the prevalence of frailty and pre-frail in the community of 10.7% and 41.6%, respectively 5 whereas a study in indonesia reported the prevalence of frailty was 52.2%.6 frailty increases the risk of premature death, falls, fractures, dementia which impair quality of life therefore, increasing health care cost.7 a study in germany has shown a relationship between an increase in the frailty index and an increase in health care costs.8 the cost for frailty in-patient was €2,104, higher than that of a non-frailty patient (€268). for its althea medical journal. 2023;10(1):37–42 abstract background: the life expectancy in indonesia is increasing. the rising number of the elderly people plays a vital role for a country to achieve development success. however, it has many consequences in the health sector, including a frailty syndrome. this study aimed to explore the association between frailty and related factors. methods: : this cross-sectional study was conducted at a home care facility in west jakarta between september and october 2019, using a simple random sampling method. data were analyzed using the chi-square test and multivariate logistic regression. the inclusion criteria were members of the home care aged ≥60 years and had signed a written informed consent. results: in total, 97 respondents were included. female gender and bone mineral density (bmd) were associated with frailty syndrome (p=0.018 and p=0.05, respectively). multivariate logistic regression analysis showed the odds ratio of frailty for the female gender (or= 3.319; 95% ci 1.045–10.543), low bone mineral density (or= 4.939; 95% ci 1.516–16.090), depression (or= 7.622; 95% ci 1.246 – 46.621), and low physical activity (or = 3.639; 95% ci 1.096 – 12.079). conclusions: there is a relationship between female gender and bone mineral density with frailty syndrome with the risk factors for frailty syndrome in this study are female gender, low bone mineral density, depression, and low physical activity. keywords: bone density, depression, elderly, frailty, physical activity https://doi.org/10.15850/amj.v10n1.2683 althea medical journal. 2023;10(1) 38 risks and impacts, frailty can be a concerning issue for the elderly population. the elderly may develop various health problems such as nutrition, bone density, disability, physical activity, and depression as they get older. research on the relationship between bone mineral density and frailty syndrome in indonesia is still limited. the purpose of this study was to determine the association between frailty and its risk factors, especially bone mineral density, at a home care facility in west jakarta. methods the design of this study was analytic and crosssectional, conducted between september and october 2019 at a home care facility in west jakarta, indonesia. the sampling method used in this study was simple random sampling. the minimum sample size was 96. the sample size was calculated using planned proportion at a 95% confidence level to achieve a 5% margin of error, with previous frailty prevalence in indonesia of 52.2%.6 after obtaining permission from the head of home care and written informed consent signed by the respondents, the respondents were recruited. respondents with physical and mental limitations were excluded. characteristic of respondents included age, gender, and educational level. furthermore, data on body mass index (bmi), bone mineral density (bmd), functional status, depression, and physical activity were collected. body mass index (bmi) was categorized by measuring the body weight and height using a stature meter and weight scale. bone mineral density was measured using bone sonometry and categorized into three groups namely normal, osteopenia, and osteoporosis. the assessment of activity of daily living (adl) and instrumental activity of daily living (iadl) was done using the barthel index and categorized into three groups namely independent, adl or iadl disability, adl and iadl disability. physical activity was measured using a 24-hour physical activity recall report and converted to physical activity ratio (par) to calculate the physical activity level (pal) formula with the final score category such as sedentary, active, and very active. depression was assessed by the geriatric depression scale (gds) with categories: not depressed, probably depressed, and depressed. frailty was assessed by the survey of health, aging, and retirement in europe frailty instrument (share-fi), as depicted in table 1. the share-fi contains the fried phenotypes of frailty, including decreased strength of handgrips, exhaustion, body weight loss, low physical activity, and slow speed gait, with closed questions in every aspect except for the strength of handgrips. the result of share was converted through share-fi calculator. frailty was categorized into non-frail, pre-frail, and frailty. however, in multivariate analysis, the categorization was divided into non-frail and pre-frail to frailty. the bivariate chi-square and multivariate logistic regression were used to analyze the relationship between frailty and determinant factors. a p-value lower or equal to 0.05 (p≤0.05) was considered as statistically table 1 definition of frailty operational definition measurement categorization frailty a geriatric syndrome, where the elderly experience a state of increased vulnerability related to aging caused by decreased function and reserves in various physiological systems and affects resistance to deal with stressors also increased death vulnerability.9 instruments: share-fi, dynamometer measuring way: -conducting interviews and checking grip strength with dynamometer -the results of interviews and hand grip strength checks were entered into the share-fi calculator according to gender to determine the frail status of respondents bivariate: [0] = non-frail [1] = pre-frail [2] = frailty multivariate: [0] = non-frail [1] = pre-frail and frailty frail the predicted d factor score of frailty calculator < 6 in female or < 7 in male9 pre-frail the predicted dfactor score of frailty calculator 0.32 – 2.13 in female or 1.21 – 3.01 in male9 althea medical journal march 2023 althea medical journal. 2023;10(1) 39yvonne suzy handajani et al.: low bone mineral density, sedentary lifestyle, and depression as risk factors for frailty syndrome at a home care facility in west jakarta, indonesia significant. this study was approved by the ethics committee of the school of medicine and health sciences, atma jaya catholic university of indonesia with ethical clearance number 21/01/kep-fkuaj/2020. results this study involved 97 home care members aged 60 years and over. most of the respondents were aged ≥ 65 years, female, and had higher level of education. the respondents were predominantly obese, had osteopenia, were not depressed, and were independent based on functional status, however, had lower physical activity as shown in table 2. a relationship was found between gender and bone mineral density with frailty (p= 0.018 and p= 0.005, respectively). however, there was no significant association between age, educational level, bmi, disability, depression, and physical activity as shown in table 3. further multivariate analysis showed that gender, bone mineral density, depression, and physical activity were related to pre-frailty and frailty and were considered risk factors for frailty, with the strongest association being depression followed by low bone mineral density, as depicted in table 4. discussions this study showed that gender and bone mineral density were statistically significant with frailty on bivariate analysis. further multivariate analysis showed female gender (or= 3.319; 95% ci 1.045–10.543), low bone mineral density (or= 4.939; 95% ci 1.516– 16.090), depression (or= 7.622; 95% ci 1.246–46.621), and low physical activity (or= 3.639; 95% ci 1.096–12.079) are risk factors for frailty syndrome. female gender has a significant relationship with frailty.10,11 in addition to gender, low bone mineral density is also related to frailty.12,13 interestingly, a study in brazil showed an increase in frailty cases in the low category of pal.14 in indonesia, the relationship between depression and frailty has been proven, suggesting depression as a risk factor for frailty.15 in a 2-year cohort study also showed that low physical activity and depression as table 2 characteristics of the elderly at the home care facility variable n % age 60–64 years ≥ 65 years 38 59 39.2 60.8 gender male female 27 70 27.8 72.2 educational level < 9 years ≥ 9 years 26 71 26.8 73.2 bmi underweight normal-overweight obese 3 47 47 3.1 48.5 48.5 bone mineral density normal osteopenia osteoporosis 11 72 14 11.3 72.4 14.4 functional status independent adl/iadl disable 61 36 62.9 37.1 depression not depressed depressed 86 11 88.7 11.3 physical activity active sedentary 24 73 24.7 75.3 frailty status non-frail pre-frail frailty 57 34 6 58.8 35.1 6.2 total 97 100 note: bmi= body mass index, adl= activity of daily living, iadl= instrumental activity of daily living althea medical journal. 2023;10(1) 40 risk factors for frailty.16 other variables such as age, educational level, bmi, and disability do not show significant relationship with frailty. this study recruited a sample from an urban area with middle socioeconomic status, which differentiates this study from another study in malaysia that recruited a sample in a rural area with a low socioeconomic status.17 the socioeconomic background may cause the discrepancies in results. previous studies have found a relationship between educational level and frailty.18,19 the difference in the statistical analysis may be caused by the length of the education category. in this study, we used a 9-year cut-off, while other studies used different categories.17 the respondents of this study were able to adapt well to the routines and activities of life so that there was no difference between education less or more than 9 years. a study conducted in china found a relationship between underweight and frailty, but not obesity.20 the association between bmi categories and frailty remains unclear because several studies have obtained different results. althea medical journal march 2023 table 3 relationship between gender and bone mineral density with frailty syndrome characteristics non-frail pre-frail frailty p n % n % n % age 60–64 years ≥ 65 years 22 35 57.9 59.3 14 20 36.8 33.9 2 4 5.3 6.8 0.927 gender male female 22 35 81.5 50 4 30 14.8 42.9 1 5 3.7 7.1 0.018* educational level < 9 years ≥ 9 years 12 45 46.2 41.7 11 23 42.3 24.9 3 3 11.5 4.4 0.208 bmi underweight normal-overweight obese 2 27 28 66.7 57.4 59.6 0 19 15 0 40.4 31.9 1 1 4 33.3 2.1 8.5 0.144 bone mineral density normal osteopenia osteoporosis 8 47 2 72.7 65.3 14.3 2 21 11 18.2 29.2 78.6 1 4 1 9.1 5.6 7.1 0.005* functional status independent adl/iadl disable 39 18 63.9 50 19 15 31.1 41.7 3 3 4.9 8.3 0.389 depression not depressed depressed 54 3 62.8 27.3 27 7 31.4 63.6 5 1 5.8 9.1 0.076 physical activity active sedentary 18 39 75 54.3 5 29 20.8 39.7 1 5 4.2 6.8 0.176 note: *p < 0.05 = statistically significant , bmi= body mass index, adl= activity of daily living, iadl= instrumental activity of daily living table 4 multivariate logistic regression analysis of frailty and determinants factors frailty p or 95% ci lower upper age gender educational level body mass index bone mineral density functional status depression physical activity 0.354 0.042 0.542 0.416 0.008 0.897 0.028 0.035 0.622 3.319 0.703 0.693 4.939 1.071 7.622 3.639 0.228 1.045 0.227 0.286 1.516 0.377 1.246 1.096 1.697 10.543 2.179 1.677 16.090 3.044 46.621 12.079 althea medical journal. 2023;10(1) 41 this may be due to the different methods used to measure body mass index. central obesity is more related to the incidence of frailty than general obesity measurement.21 this study found no significant relationship between disability and frailty. however, a study in korea22 and another part of indonesia23 showed different results from this study. this might be due to differences in research background or setting, as well as the number of participants. our study recruited respondents in a community-based place, while other studies recruited respondents in a hospital23 or health centers.22 these background dissimilarity might cause differences in the analysis results. in addition, the results of the analysis of the frailty variables may differ because of different research instruments. there are several instruments besides share to assess frail status in individuals, for example the frailty index (fi), fried criteria, and frail score (fs). the limitation of this study is that it is a cross-sectional study that assesses conditions at a point in time. another limitation is that the target population in this study is limited, so further research should be conducted on a wider population. in conclusion, frailty syndrome tends to occur in individuals with low bone mineral density, female gender, depression, and sedentary. further cohort studies on the relationship between frailty and risk factors are suggested. references 1. badan pusat statistik. angka harapan hidup (ahh) menurut provinsi dan jenis kelamin, 2010-2018. [cited 12 april 2019] available from: https://www.bps.go.id/ linktabledinamis/view/id/1114 2. kementerian kesehatan republik indonesia. analisis lansia di indonesia. jakarta: pusat data dan informasi kementerian kesehatan republik indonesia; 2017. 3. badan pusat statistik republik indonesia. statistik penduduk lanjut usia 2017. jakarta: badan pusat statistik; 2018. 4. xue q-l. the frailty syndrome: definition and natural history. clin geriatr med. 2011;27(1):1–15. 5. collard rm, boter h, schoevers ra, oude voshaar rc. prevalence of frailty in community-dwelling older persons: a systematic review. j am geriatr soc. 2012;60(8):1487–92. 6. handajani ys, widjaja nt, turana y. frailty decreases physical health domain of quality of life in nursing home elderly. univ med. 2015;34(3):213–9. 7. kojima g, liljas aem, iliffe s. frailty syndrome: implications and challenges for health care policy. risk manag healthc policy. 2019;12:23 8. bock j-o, könig h-h, brenner h, haefeli we, quinzler r, matschinger h, et al. associations of frailty with health care costs–results of the esther cohort study. bmc health serv res. 2016;16(1):128. 9. romero-ortuno r, walsh cd, lawlor ba, kenny ra. a frailty instrument for primary care: findings from the survey of health, ageing and retirement in europe (share). bmc geriat. 2010;10:57. 10. corbi g, cacciatore f, komici k, rengo g, vitale df, furgi g, et al. interrelationships between gender, frailty, and 10-year survival in older italian adults: an observational longitudinal study. sci rep. 2019;9(1):1–7. 11. ahrenfeldt lj, möller s, thinggaard m, christensen k, lindahl-jacobsen r. sex differences in comorbidity and frailty in europe. int j public health. 2019;64(7):1025–36. 12. bartosch p, mcguigan fe, akesson ke. progression of frailty and prevalence of osteoporosis in a community cohort of older women–a 10-year longitudinal study. osteoporos int. 2018;29(10):2191–9. 13. araujo ecss, pagotto v, silveira ae. association of bone mineral density with frailty, pre-frailty, and osteoporosis in community-dwelling elderly: a prospective study. j geriatr med gerontol. 2017;3(3):033. 14. da silva vd, tribess s, meneguci j, sasaki je, garcia-meneguci ca, carneiro jao, et al. association between frailty and the combination of physical activity level and sedentary behaviour in older adults. bmc public health. 2019;19(1):1–6. 15. rensa r, setiati s, laksmi pw, rinaldi i. factors associated with physical frailty in elderly women with low socioeconomic status in urban communities: a crosssectional study. acta med indones. 2019;51(3)220–9. 16. serra-prat m, papiol m, palomera e, arús m, cabré m. incidence and risk factors for frailty in the community-dwelling elderly population: a two-year follow-up cohort study. j gerontol geriatr res. 2017;6:6. 17. mohd hamidin fa, adznam sn, ibrahim yvonne suzy handajani et al.: low bone mineral density, sedentary lifestyle, and depression as risk factors for frailty syndrome at a home care facility in west jakarta, indonesia althea medical journal. 2023;10(1) 42 z, chan ym, abdul aziz nh. prevalence of frailty syndrome and it associated factors among community-dwelling elderly in east coast of peninsular malaysia. sage open med. 2018 may 29;6:2050312118775581. 18. brigola ag, alexandre t da s, inouye k, yassuda ms, pavarini sci, mioshi e. limited formal education is strongly associated with lower cognitive status, functional disability and frailty status in older adults. dement neuropsychol. 2019;13(2):216– 24. 19. lenardt mh, carneiro nhk, binotto ma, setoguchi ls, cechinel c. the relationship between physical frailty and sociodemographic and clinical characteristics of elderly. esc anna nery. 2015;19(4):585–92. 20. xu l, zhang j, shen s, hong x, zeng x, yang y, et al. association between body composition and frailty in elder inpatients. clin interv aging. 2020;15:313. 21. liao qj, zheng z, xiu sl, chan p. waist circumference is a better predictor of risk for frailty than bmi in the communitydwelling elderly in beijing. aging clin exp res. 2018;30:1319–1325. 22. shim h, kim s, kim m, kim bs, jeong e, lee yj, et al. older men living with spouse and older women living with spouse and children have lower frailty prevalence: the korean frailty and aging cohort study (kfacs). ann geriatr med res. 2020;24(3):204–10. 23. setiati s, laksmi pw, aryana igps, sunarti s, widajanti n, dwipa l, et al. frailty state among indonesian elderly: prevalence, associated factors, and frailty state transition. bmc geriatr. 2019;19(1):182. althea medical journal march 2023 amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 111 impact of instagram usage intensity on self-esteem among preclinical medical students maria christina sekarlangit,1 denio a. ridjab,2 eva suryani,3 v. dwi jani juliawati21 1school of medicine and health sciences, atma jaya catholic university of indonesia, 2departement of medical education unit, school of medicine and health sciences, atma jaya catholic university of indonesia, 3departement of psychiatry and behavioral sciences, school of medicine and health sciences, atma jaya catholic university of indonesia, indonesia correspondence: dr. med. dr. denio adrianus ridjab, sp. jp-k, department of medical education unit, school of medicine and health sciences, atma jaya catholic university of indonesia, jalan pluit raya no. 2, north jakarta, indonesia, e-mail: denio.ridjab@atmajaya.ac.id introduction instagram is a social media that focuses on sharing audio-visual content such as photos or videos and offers different communication options with photos, videos, or texts.1 instagram users in indonesia are reported to be the largest in asia pacific with forty-five million users,2 making it one of the fastest growing social media in indonesia. most of the instagram users use this platform to upload their own photos or videos. this can be a trigger for other instagram users to compare themselves to the content they see. according to the social comparison theory by leon festinger,3 humans tend to maintain their selfimage. knowing one’s self-image is to compare oneself to others. if the group is compared to a group with a higher socio-economic level or other things that are considered valuable, an upward social comparison might occur which has a negative impact. thus, these unfavorable social comparisons affect how people view themselves, and have undesirable effects such as negative body image and declined selfesteem.4 students have the risk of using social media excessively because it is easily accessible and can be used to treat mental stress due to academic burden.5 a study in lebanon6 stated that students who frequently use social media have lower self-esteem due to feelings of inferiority. self-esteem is a person’s perspective on himself, which is influenced by many factors such as family, friends, and the mass media. it has an essential role in daily behavior and decisions. individuals with low levels of self-esteem are more likely to isolate themselves and increase the risk of developing depression.7 another study showed that the althea medical journal. 2022;9(2):111–116 abstract background: instagram is one of the social media that is growing rapidly in indonesia. however, the impact of instagram usage intensity, especially on the users’ emotional well-being, is still unclear. this study aimed to explore the impact of the intensity of using instagram on the self-esteem among preclinical medical students in jakarta. methods: this study was an observational analytic study with a cross-sectional approach in preclinical medical students in jakarta, indonesia, conducted from january 2020 to january 2021. sampling was performed by stratified random sampling followed by simple random sampling. instagram usage intensity and self-esteem were measured using the instagram intensity scale questionnaire (iisq) and the rosenberg self-esteem scale (rses). data were analyzed using the chi-square test. results: of the108 students, 45.4% had used instagram above the usage intensity average (average 3.01), of whom 30.6% had low self-esteem (15 out of 49). there was a significant relationship between instagram usage intensity and self-esteem (p=0.031). conclusion: instagram usage intensity has an impact on the self-esteem of preclinical medical students. further studies are needed to explore this issue, as to see other contributing factors and a larger population with different characteristics. keywords: instagram, intensity, self-esteem, social media https://doi.org/10.15850/amj.v9n2.2307 althea medical journal. 2022;9(2) 112 frequency of instagram use was correlated with depressive symptoms, self-esteem, general and physical appearance anxiety, and body dissatisfaction, mediation by social comparison.8 seeing the harmful effects of low self-esteem and the moderately high use of instagram among students, this study aimed to explore how the intensity of instagram use would affect self-esteem among medical students. methods this research was an analytic observational study with a cross-sectional approach to 108 preclinical medical students at the school of medicine and health sciences atma jaya catholic university of indonesia who regularly used instagram. they were chosen by the stratified random sampling method followed by simple random sampling. the study protocol was approved by the ethics committee of atma jaya catholic university of indonesia (no. approval: 18/11/kep-fkikuaj/2020), and all participants provided informed consent. data were collected from november to december 2020 using a questionnaire distributed via a google forms link. the questionnaire used to measure the intensity of instagram use was the instagram intensity scale questionnaire (iisq). there were eight questions in this questionnaire which were measured using a five-point likert scale with cronbach’s alpha value of 0.83. the intensity of instagram use was obtained by calculating the mean of all the items in the althea medical journal june 2022 questionnaire.10 the average score obtained by participants grouped into those who used instagram on average, above, and below the average intensity of instagram usage. this was done to compare the instagram use intensity of each respondent with their peer group, which is representated by the average score. the rosenberg self-esteem scale (rses) was created to assess a person’s global self-esteem measured using a four-point likert scale with cronbach’s alpha of 0.89. this questionnaire contains ten questions, including five positive items and five negative items that needed to be reverse coded. scores were totalled, and a higher score implies a higher level of self-esteem.1,9,10 the data obtained from the two questionnaires were then analyzed using the chi-square test to evaluate the impact of the instagram usage intensity on self-esteem among students. results this study involved 108 respondents with an average age of 20 years (range 17 to 22 years; sd=0.94). most of the respondents were female (71.3%). the respondents’ body mass index (bmi) was not normally distributed with eight respondents having bmi >28, while the rest had bmi <26 (mean of 22.4; range 16.2 to 32.7; sd=3.54). almost all respondents (98.2%) had chosen mobile phones as the most frequently used devices to access instagram. the three main reasons for using instagram were table 1 demographic characteristics of preclinical medical students associated with self esteem characteristics self-esteem level high low n % n % age (years) <20 ≥20 63 22 80.8 73.3 15 8 19.2 26.7 gender male female 29 56 93.5 72.7 2 21 6.5 27.3 bmi underweight (<18.5) normal (18.5 – <25) overweight (25 – <30) obese (≥30) 12 56 10 7 85.7 75.7 76.9 100 2 18 3 14.3 24.3 23.1 note: bmi= body mass index althea medical journal. 2022;9(2) 113maria christina sekarlangit et al.: impact of instagram usage intensity on self-esteem among preclinical medical students for entertainment (97.2%), to maintain relationships and communication with old friends (83.3%), and to follow public figures or celebrities (45.4%). respondents had used instagram for quite a long period of time with an average of 5.8 years (range 2–10 years). the results also shown that 50.9% had two instagram accounts. most respondents have never received negative comments (90.7%). demographic characteristics associated with self-esteem showed that more respondents aged above or equal to 20.05 years had low self-esteem (26.7%). respondents with low self-esteem were mostly female (27.3%). based on bmi, low self-esteem was mostly experienced in the group of respondents with a normal bmi (24.3%) (table 1). the results showed that respondents who used cell phones to access instagram had lower levels of self-esteem (21.7%). table 2 instagram usage associated with self-esteem instagram usage characteristics self-esteem level high low n % n % gadgets frequently used to access instagram cell phone tablet laptop/computer 83 1 1 78.3 100 100 23 21.7 three main reasons for using instagram maintain relationships and communication with old friends gain new friends entertainment online shopping channel hobbies follow public figures or celebrities others 75 12 82 26 18 35 7 83.3 92.3 78.1 72.2 75.0 71.4 100 15 1 23 10 6 14 16.7 7.7 21.9 27.8 25.0 28.6 years since the first time using instagram <5.8 years ≥5.8 years 38 47 79.2 78.3 10 13 20.8 21.7 account(s) 1 account 2 accounts more than 2 accounts 35 44 6 81.4 80.0 60.0 8 11 4 18.6 20.0 40.0 received negative comments yes no 8 78 80.0 81.6 2 21 20.0 18.4 table 3 scores of the instagram intensity scale questionnaire and rosenberg self-esteem scale among preclinical medical students summary of the iisq and rses scores n % iisq lower than average (<3.01) higher than or on average (>3.01) 59 49 54.6 45.4 rses low self-esteem (<15) high self-esteem (>15) 23 85 21.3 78.7 note: iisq= instagram intensity scale questionnaire, rses= rosenberg self-esteem scale, mean iisq (3.01 points) was used althea medical journal. 2022;9(2) 114 respondents who used instagram to follow public figures or celebrities had the lowest self-esteem level (28.6%). the results also showed that respondents who had more than two instagram accounts had the lowest level of self-esteem, namely 40.0%, and respondents who had received negative comments when using instagram were also stated to had lower levels of self-esteem (20.0%) (table 2). the iisq showed that the average intensity of the respondents’ instagram use was 3.01 points, with 54.6% below the average. the rses questionnaire showed that 78.7% had high self-esteem (table 3). there was a significant relationship (p-value 0.031) between the instagram usage intensity and the level of self-esteem (table 4). discussion this study has shown that there is a strong relationship between instagram usage intensity and self-esteem among medical students. the age range of respondents was 17–22 years old, with a mean of 20.05. it was found that students with low self-esteem were identified in every age group. this might be due to the internet and social media being used by university students to overcome mental stress related to academic burden, but it has a negative impact on students who open their social media more often to believe that their lives are less happy than other people.5,6 more female respondents have lower self-esteem than men. a previous study has stated that women tend to have a low levels of self-esteem associated with social media use because social media can increase negative social comparisons leading to bad moods and decreased levels of self-esteem.11 interestingly, this study also found that more respondents with normal bmi (18.5–<25) have low self-esteem. this may occur due to self-dissatisfaction and a desire to achieve beauty standards, which, although unrealistic, were set, normalized, and supported by the number of modified and beautified-edited photos uploaded on instagram.8,12,13 almost all respondents use cell phones to access instagram, of which 21.7% have low self-esteem levels. smartphones use is said to be correlated with a person’s low psychological well-being.14 the use of cell phones tends to become a compulsive behavior, thus leads to decreased self-control. students who use instagram to follow public figures or celebrities have the lowest level of self-esteem. social media users, especially celebrities, tend to post a picture of the ideal life. this then causes other users to assume that what they see are standards and norms without knowing these public figures and celebrities’ real daily life. such uploads trigger instagram users to make negative social comparisons, which lead to negative feelings and decreased selfesteem.15,16 respondents in this study have used instagram for quite a long time, with an average length of use of 5.8 years. more than half of respondents have used instagram longer than average, of whom 21.7% have low self-esteem. also, more respondents with more than two instagram accounts (40.0% or 4 respondents) have a low level of self-esteem. the length of time a person has used instagram and the number of accounts certainly increases one’s exposure to instagram, leading to a higher risk of having negative effects from the platform. most respondents have never received negative comments while using instagram. however, of respondents who had received negative comments, 20.0% had low self-esteem. negative responses received via social media are associated with low selfesteem.11 moreover, high-intensity online interactions make responses obtained faster and in greater numbers. this study shows an evident relationship between instagram intensity usage and the user’s self-esteem. as many as 30.6% (15 out of 49) respondents with the instagram intensity of use above or equal to 3.01 points have low self-esteem levels. the intensity of instagram use is defined as the frequency and duration of table 4 relationship between instagram usage intensity and self-esteem instagram usage intensity self-esteem level p-valuehigh low n % n % lower than average (<3.01) 51 86.4 8 13.6 0.031 higher than or on average (>3.01) 34 69.4 15 30.6 althea medical journal june 2022 althea medical journal. 2022;9(2) 115 use, as well as active engagement, the extent to which individuals were emotionally connected to instagram, and instagram’s integration into its users’ daily lives.9 social media’s function was to make communication easier, but this purpose has shifted to become a ‘competition’ for each individual to maintain their social status in cyberspace. users become more focused on building relationships and images on social networks, leading to high-intensity use of social media.17 instagram, focused on sharing visual and audiovisual media, triggers social comparisons among its users. this social comparison and desire to obtain peer approval caused varying self-esteem scores.18 other studies have also stated that instagram causes its users to experience negative feelings and make negative social comparisons, leading to bad moods and decreased self-esteem levels.11,16 if the harmful effects of instagram were supported by high intensity of use, it would undoubtedly affect the way someone views themselves negatively, leading to a decrease in one’s self-esteem level.16 this study has several limitations. the cross-sectional study design could not see the relationship between the two variables in a causal manner. also, respondents of this study may not represent the population, for they are students from the same university. the data collection of this research was self-reported, so there was always a possibility of human error. furthermore, instagram is the only social media being focused in this research. as time goes by, social media platforms are growing rapidly, with the messaging platform such as whatsapp and telegram as the most dominant activity, followed by networking (linkedin, facebook), media sharing (i.e., youtube, instagram, snapchat), microblogging (i.e., twitter). more unique platforms are expected to affect one’s self-esteem level.19 this study also did not assess other factors that can affect self-esteem, or oppositely factors that are affected by social media usage. more studies are being conducted to evaluate the connection between social media use and mental health, as current studies showed a high prevalence of depression in high-intensity social media usage.20,21 further studies are needed to know more about these issues. to conclude, the use of instagram has a negative impact on the self-esteem of medical students. this needs to be observed in other populations with different age groups and occupancies to back-up instagram usage regulations to minimalize the negative effects of the social media, especially on young adults. references 1. romero-rodríguez j, aznar-díaz i, marínmarín j, soler-costa r, rodríguez-jiménez c. impact of problematic smartphone use and instagram use intensity on self-esteem with university students from physical education. int j environ res public health. 2020;17(12):4336. 2. ganesha a. instagram has 45 million users in indonesia, the largest in asia pacific. jakarta globe [internet] 2017 [cited 2020 january 11]. available from: https://jakartaglobe.id/news/instagram45-million-users-indonesia-largest-asiapacific/. 3. corcoran k, crusius j, mussweiler t. social comparison: motives, standards, and mechanisms. in: chadee d, editor. theories in social psychology. oxford, uk: wileyblackwell; 2011. p. 119–39. 4. chou hg, edge n. “they are happier and having better lives than i am”: the impact of using facebook on perceptions of others’ lives. cyberpsychol behav soc netw. 2012;15(2):117–20. 5. chathoth v, kodavanji b, arunkumar n, pai sr. internet behaviour pattern in undergraduate medical students in mangalore. int j innov res sci eng technol. 2013;2(6):2133–2136. 6. hawi ns, samaha m. the relations among social media addiction, self-esteem, and life satisfaction in university students. soc sci comput rev. 2016;35(5):576–86. 7. orth u, robins r w, meier l l, conger r d. refining the vulnerability model of low self-esteem and depression: disentangling the effects of genuine self-esteem and narcissism. j pers social psychol. 2016;110(1):133–49. 8. sherlock m, wagstaff d. exploring the relationship between frequency of instagram use, exposure to idealized images, and psychological well-being in women. psychology of popular media culture. 2019;8(4):482–90. 9. pettijohn ii tf, lapiene ke, pettijohn te, horting al. relationships between facebook intensity, friendship contingent self-esteem, and personality in u.s. college students. cyberpsychology. 2012;6(1):2. 10. trifiro b. instagram use and it’s effect on well-being and self-esteem [thesis]. smithfield, rhode island, usa: bryant university; 2018 [cited 2020 april 12]. available from: https://digitalcommons. bryant.edu/cgi/viewcontent.cgi?articl maria christina sekarlangit et al.: impact of instagram usage intensity on self-esteem among preclinical medical students althea medical journal. 2022;9(2) 116 e=1003&context=macomm#:~:text=t he%20study’s%20results%20show%20 t h a t % 2 0 i t % 2 0 i s % 2 0 i n t e n s i t y % 2 0 o f % 2 0 u s e , n o t % 2 0 u s e % 2 0 t h e % 2 0 application%20intensely. 11. neira cjb, barber bl. social networking site use: linked to adolescents’ social self-concept, self-esteem, and depressed mood. australian journal of psychology. 2014;66(1):56–64. 12. wagner c, aguirre e, sumner em. the relationship between instagram selfies and body image in young adult women. first monday. 2016;21(9):6390. 13. kleemans m, daalmans s, carbaat i, anschütz d. picture perfect: the direct effect of manipulated instagram photos on body image in adolescent girls. media psychology. 2016;21(1):93–110. 14. horwood s, anglim j. problematic smartphone usage and subjective and psychological well-being. comp hum behav. 2019;97:44–50. 15. haferkamp n, krämer n. social comparison 2.0: examining the effects of online profiles on social-networking sites. cyberpsychol behav soc netw. 2011;14(5):309–14. 16. lup k, trub l, rosenthal l. instagram #instasad?: exploring associations among instagram use, depressive symptoms, negative social comparison, and strangers followed. cyberpsychol behav soc netw. 2015;18(5):247–52. 17. rosenberg k, feder l, editors. behavioral addictions criteria, evidence, and treatment. 1st ed. oxford, uk: academic press, elsevier inc; 2014. p.119–208. 18. stapleton p, luiz g, chatwin h. generation validation: the role of social comparison in use of instagram among emerging adults. cyberpsychol behav soc netw. 2017;20(3):142–9. 19. yoon s, wee s, lee vsy, lin j, thumboo j. patterns of use and perceived value of social media for population health among population health stakeholders: a crosssectional web-based survey. bmc public health. 2021;21(1):1312. 20. pantic i. online social networking and mental health. cyberpsychol behav soc netw. 2014;17(10):652–7. 21. karim f, oyewande aa, abdalla lf, chaudhry ehsanullah r, khan s. social media use and its connection to mental health: a systematic review. cureus. 2020;12(6):e8627. althea medical journal june 2022 amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 176 amj december 2020 differences in bleeding episodes in severe hemophilia a based on nutritional status wenny simamora,1 susi susanah,2 amaylia oehadian3 1faculty of medicine universitas padjadjaran, indonesia, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: wenny simamora, faculty of medicine, universitas padjajaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: wennyahs@gmail.com amj. 2020;7(4):176–80 abstract background: hemophilia a is a congenital bleeding disorder caused by the deficiency of coagulation factor viii and is characterized by joint bleeding, especially in weight-bearing joints. an excess weight may cause bleeding in hemophilia due to increased joint tension. this study aimed to determine the differences in bleeding episodes between severe hemophilia a patients with and without excess weight. methods: a comparative observational analytic study was conducted in march–november 2019 using a cross-sectional design. subjects were patients with severe hemophilia a registered in the indonesian hemophilia society association in west java and had had severe hemophilia a for at least two years old with complete data on date of birth, height, weight, and bleeding intensity. subjects were divided into groups with excess weight (excess weight) and without excess weight (non-excess weight). nutritional status in adults was determined based on age-specific percentile bmi. bleeding episodes were determined as frequency of bleeding in one year. the mann-whitney statistical test was used to observe the difference between groups. results: of 226 severe hemophilia a patients registered, only 155 patients were included. of these, 121 patients did not have excess weight and 34 had excess weight. the median bleeding episodes of in the non-excess weight and excess weight groups were 24(1–48) and 24(8–48), respectively (p=0.761). conclusions: there is no difference in bleeding episodes between severe hemophilia a patients with excess weight and without excess weight. however, good nutrition education needs to be provided to these patients since excess weight may increase bleeding in joints. keywords: bleeding episodes, excess weight, severe hemophilia a introduction hemophilia is a congenital bleeding disorder caused by a deficiency of coagulation factors. the deficiency of certain coagulation factors determines the hemophilia type. deficiency of coagulation factor viii is known as hemophilia a and deficiency of coagulation factor ix as hemophilia b.1 survey conducted by the world federation of hemophilia in 2017 has reported that there are 315,423 individuals with bleeding disorders throughout the world, including 196,706 people with hemophilia a.2 hemophilia in indonesia accounts for 2,054 patients.2 hemophilia is characterized by spontaneous joint bleeding and excessive bleeding triggered by among others an injury.3 hemophilia is classified based on severity into mild, moderate, and severe hemophilia.1 people with hemophilia (pwh) especially those with severe hemophilia can experience spontaneous muscle and joint bleeding,1 usually in the lower limbs, which are weightbearing joints.4 the risk of being overweight in people with hemophilia (pwh) increases as a result of physical inactivity due to over protection from the parents.5 excessive body weight increases the risk of joint bleeding https://doi.org/10.15850/amj.v7n4.1938 althea medical journal. 2020;7(4) 177 in pwh who often experience arthropathy and can cause bleeding in hemophilia due to increased joint tension.5 the higher the body weight, the greater the mechanical stress that is imposed on the joints, especially weightbearing joints, causing damage to the tissues and connective structures of the joints.6 research conducted in the netherlands showed that there was a decrease in the hemophilia activities list (hal) score, increased bleeding, and the use of factor viii with a higher concentration in hemophilia patients who were overweight.7 using the hal score, hemophilia patients with overweight have an impaired functional ability compared with hemophilia patients with normal weight.7 a higher frequency of bleeds and a trend towards higher use of fviii concentrate is also observed.7 there has been no research in indonesia about differences in bleeding episodes based on nutritional status in people with hemophilia. therefore, our study aimed to determine differences in bleeding episodes between severe hemophilia a patients with and without excess weight. methods a comparative observational analytic study was conducted in march–november 2019 using a cross-sectional design. subjects were those with severe hemophilia a registered in the indonesian hemophilia society association in west java. inclusion criteria were severe hemophilia a with complete data, i.e. date of birth, height and weight, and bleeding intensity, and at least two years old since the use of bmi charts was not recommended for children under two years old according to the cdc. exclusion criteria were incomplete data, had died during the study, or otherwise could not be contacted. the minimum sample size needed per group was 25 subjects, with the choice of alpha significance level (α)= 5%, beta (β)= 5%, the combined standard deviation (s)= 2.948 and the mean difference (x1-x2)= 3 kg/ m2. this study was approved by the research ethics committee universitas padjajaran, with ethical number 1270/un6.kep/ec/2019. the variables assessed were nutritional status as independent variables and bleeding episodes as dependent variables. bleeding episodes were designated as the frequency of manifestations of bleeding experienced by the subject in one year. several characteristics of the subjects, consisting of age, age of diagnosis, manifestations of bleeding, and nutritional status were described. the age was the group was classified into a group of children (2–18 years) and adults (≥18 years) based on different ways of determining nutritional status. nutritional status in adults was determined based on body mass index (bmi), which was the ratio of body weight in kilograms to the square of height in meters. in children, nutritional status was based on the bmi percentile, which was specific to age and sex.9 the subjects were classified into two groups, those with excess weight and the other with no excess weight. the excess weight group was subjects with overweight and obesity whereas the non-excess weight group was subjects with underweight and normal weight. the height and weight were measured at the last hospital visit. the data were then plotted to determine the nutritional status. the episodes of bleeding were measured from the time the subject was contacted up to the one-year back. measurement of bleeding intensity was counted on how many manifestations of bleeding had appeared in the past year. the collected data were processed using microsoft excel and ibm spss v.25.0. the data normality was tested using the shapiro-wilk test to determine the distribution of various variables. the mannwhitney statistical test was used to determine the difference in bleeding episodes in the nutritional status group. the significance of the hypothesis test was based on p<0.05. data analysis results were presented in tables and figures. results of 338 people with hemophilia in west java, 226 were severe a hemophilia and only 155 subjects met the inclusion criteria. most people with hemophilia a were under 18 years old (67.1%) of whom 63.9% was diagnosed after one-year-old. the most frequent manifestation of bleeding experienced by pwh was hemarthrosis (99.4%), while the least was intracranial hemorrhage (14.2%) (table 1). the median of episodes of subject bleeding was 24 (range 1–8). the bleeding episodes were shown based on the nutritional status of people with severe hemophilia a who had excess weight and non-excess weight (table 2). the result showed a p-value of 0.761, suggesting there was no significant difference in the bleeding episodes of people with severe hemophilia a who had excess weight and non-excess weight. however, those with excess weight had tended to have more bleeding episode with a minimum wenny simamora et al.: differences in bleeding episodes in severe hemophilia a based on nutritional status althea medical journal. 2020;7(4) 178 amj december 2020 table 1 characteristics of people with hemophilia registered in the indonesian hemophilia society association in west java characteristics n (%) age group 2–18 years old 104 (67.1) >18 years old 51 (32.9) diagnosis age group <1 year old 51 (32.9) ≥1 year old 99 (63.9) unknown 5 (3.2) bleeding manifestation ecchymosis 109 (70.3) hematoma 99 (63.9) hemarthrosis 154 (99.4) epistaxis 75 (48.4) gum bleeding 139 (89.7) intracranial bleeding 22 (14.2) multiple hematomas 56 (36.1) hemarthrosis-hematoma 97 (62.6) hemarthrosis-ecchymosis 110 (71.0) nutritional status non-excess weight 121 (78.1) excess weight 34 (21.9) bleeding episode of 8 and a max of 48. discussion our study has explored people with hemophilia (pwh) registered in the indonesian hemophilia society association in west java in relation to the period of bleeding. the median age of the pwh was 14 years old (range 2–43), and the majority was pediatric patients (2–18 years old). in another study, adult patients are more prevalent (70%).10 this difference might be due to the availability of clotting factors and the costs required that are still obstacles in the prophylaxis protocol in indonesia and other developing countries.11 in more developed countries, there is a higher percentage of adult patients since the prophylaxis is available, which is one of the factors that increase the life expectancy of people with hemophilia.2,9 our study shows that the age of diagnosis of people with severe hemophilia a is above one year old (63.9%). this result is opposite to other studies showing that the manifestations in people with severe hemophilia would appear before one year old, especially when the period of learning to crawl and walk.12 this difference can be due to the lack of public knowledge about hemophilia. some consider the cause of bleeding symptoms is due to table 2 episodes of bleeding among people with severe hemophilia a based on nutritional status nutritional status median bleeding episode (min-max) p-value non-excess weight 24 (1-48) 0.761* excess weight 24 (8-48) total note: * mann-whitney test althea medical journal. 2020;7(4) 179wenny simamora et al.: differences in bleeding episodes in severe hemophilia a based on nutritional status another disorder/disease or because of a lack of health facilities to diagnose hemophilia.13 the most bleeding manifestation experienced by the subject is hemarthrosis (99.4%), which is consistent with another study.14 hemarthrosis is most often experienced because this type of bleeding can also occur spontaneously when pwh performs routine activities as usual.14 bleeding occurs because small capillaries in the synovial membrane rupture, causing joints to become stressed, and the synovial membrane is squeezed and pulled,14 as well as when a person performs routine activities, such as walking, climbing stairs, or bumping into something.14 someone with a normal coagulation system can prevent bleeding, but not in pwh.14 the least bleeding manifestation experienced in pwh is intranial hemorrhages (14.2%). intracranial hemorrhage usually occurs due to spontaneous trauma, although in a small proportion.12 the intracranial hemorrhage is also a significant cause of death in pwh.1,12 there is thus no significant difference (p=0.791) in bleeding episodes based on nutritional status of people with severe hemophilia a, however, there is a trend that pwh with excess weight had more bleeding episodes. this is similar to the study showing that no difference in bleeding episodes in people with hemophilia who had excess weight and those who had not.8 however, association has been shown in the netherlands (p=0.045).7 the difference could be due to the small number of subjects, or any other factors related to bleeding episodes. the limitations of this study are incomplete data of age at hemophilia diagnosis and confounding variables such as the treatment, lifestyle, and recall bias for bleeding. people with severe hemophilia a may not remember precisely the bleeding episodes at the time of the interview. a better diary to write down the bleeding episode might be necessary. to conclude, there is no difference in bleeding episodes in the group that has excess weight and no excess weight. however, there is a trend that the minimum bleeding episodes in the group that has excess weight are higher. further studies are interesting to evaluate the confounding variables that may relate to the finding. references 1. peyvandi f, garagiola i, young g. the past and future of haemophilia: diagnosis, treatments, and its complications. lancet. 2016;388(10040):187–97. 2. world federation of hemophilia. report on the annual global survey 2017. montreal, quebec, canada: world federation of hemophilia; 2018 [cited 2019 october 1]. available from: http://www1.wfh.org/ publications/files/pdf-1714.pdf 3. tanto c, priantono d, sjakti ha. hemofilia. in: tanto c, liwang f, hanifati s, pradipta ea, editors. kapita selekta kedokteran. 4th ed. jakarta: media aesculapius; 2014. p. 53–5. 4. tiktinsky r, kenet g, dvir z, falk b, heim m, martinowitz u, et al. physical activity participation and bleeding characteristics in young patients with severe haemophilia. haemophilia. 2009;15(3):695–700. 5. soucie jm, wang c, siddiqi a, kulkarni r, recht m, konkle ba. the longitudinal effect of body adiposity on joint mobility in young males with haemophilia a. haemophilia. 2011;17(2):196–203. 6. radzevič v, raistenskis j, ragelienė lr, kowaiski im. relationship between physical activity and functional ability in school-aged children with hemophilia. pol ann med. 2013;20(1):13–8. 7. biere-rafi s, haak bw, peters m, gerdes vea, büller hr, kamphuisen pw. the impairment in daily life of obese haemophiliacs. haemophilia. 2011;17(2):204–8. 8. tuinenburg a, biere-rafi s, peters m, verhamme p, peerlinck k, kruip mjha, et al. obesity in haemophilia patients: effect on bleeding frequency, clotting factor concentrate usage, and haemostatic and fibrinolytic parameters. haemophilia. 2013;19(5):744–52. 9. wong te, majumdar s, adams e, bergman s, damiano m lou, deutsche j, et al. overweight and obesity in hemophilia: a systematic review of the literature. am j prev med. 2011;41(6 suppl 4):s369–75. 10. pocoski j, ma a, kessler cm, boklage s, humphries tj. cardiovascular comorbidities are increased in u.s. patients with haemophilia a: a retrospective database analysis. haemophilia. 2014;20(4):472–8. 11. septarini ad, windiastuti e. terapi profilaksis versus on-demand pada pasien hemofilia berat dengan hemartrosis. sari pediatri. 2016;11(5):311–6. 12. zimmerman b, valentino la. hemophilia: in review. pediatr rev. 2013;34(7):289–95. 13. saxena k. barriers and perceived limitations to early treatment of althea medical journal. 2020;7(4) 180 amj december 2020 hemophilia. j blood med. 2013;4:49–56. 14. white w, christie b, orto c. common bleeding episodes. new york: national hemophilia foundation; 2013 [cited 2019 october 1] available from: https:// www.hemophilia.org/sites/default/files/ document/files/nurses-guide-chapter-4common-bleeding-episodes.pdf amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 106 aspartate aminotransferase to platelet ratio index score in correlation with neutrophil-to-lymphocyte ratio and platelet-tolymphocyte ratio to predict hepatic cirrhosis in hepatitis c patients jane haryanto, agnes rengga indrati, tiene rostini department of clinical pathology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: jane haryanto, dr., department of clinical pathology faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, jalan pasteur no. 38 bandung, indonesia, email: jane.haryanto@yahoo.com introduction hepatitis c is one of the causes of hepatic cirrhosis. patients with hepatitis c have a 50– 85% chance of developing hepatic cirrhosis. hepatic cirrhosis causes 1.4 millions death each year; the causes of cirrhosis of the hepatic are due to alcohol, 348,000 cirrhosis patients; hepatitis c, 326,000 patients; and hepatitis b, 371,000 patients.1,2 liver tissue biopsy still uses as the gold standard for diagnosis of hepatic cirrhosis despite its very invasive nature and various risks that accompany procedures such as bleeding. furthermore, the results of biopsy are highly dependent on the accuracy of the tissue drawing and the expertise of the anatomical pathologist in carrying out the biopsy procedure.3 as the biopsy procedure has many limitations, alternative non-invasive procedures are explored to determine the accurate and acceptable diagnosis of liver fibrosis. some simple serum markers have been widely reported as the substitutes for assessing liver fibrosis, such as aspartate aminotransferase to platelet ratio index (apri), and many other markers. among all markers, apri has been extensively used since it is simple and inexpensive.4–8 other research have stated that the aspartate aminotransferase (ast) score to platelet ratio index (apri) can distinguish mild and severe fibrosis in people with chronic hepatitis c, so that, it can predict the possibility of hepatic cirrhosis in patients with hepatitis althea medical journal. 2022;9(2):106–110 abstract background: tissue biopsy examination which is an invasive procedure has become the mainstay for hepatic cirrhosis identification in patients with hepatitis. alternatively, noninvasive method using the aspartate aminotransferase (ast) to platelet ratio index (apri) score has been developed to predict hepatic cirrhosis. furthermore, the neutrophil lymphocyte ratio (nlr) and platelet lymphocyte ratio (plr) have been used to predict the severity of hepatitis c. this study aimed to analyze the relationship between apri scores and nlr and plr in chronic hepatitis c patients. methods: this correlative cross-sectional observational study used secondary data of complete blood counts such as neutrophil, lymphocyte, and platelet values, as well as ast values of patients with hepatitis c in the outpatient and inpatient installation of dr. hasan sadikin general hospital during 2019. the inclusion criteria were patients aged ≥18 years, male and female, who were diagnosed as hepatitis c patients, patients who had ast examination data, leukocytes, count type, and platelets. data were analyzed using the spearman rank correlation test. results: the 123 subjects were dominantly male with an age range of 46–55 years. there was no correlation between the apri and nlr scores (p=0.229). however, there was a moderate and significant negative correlation between apri and plr scores with a correlation coefficient of -0.468 (p=0.000). conclusion: there is a significant negative correlation between apri and plr scores to predict the occurrence of hepatic cirrhosis in patients with hepatitis c. keywords: apri score, hepatitis c, hepatic cirrhosis, nlr, plr https://doi.org/10.15850/amj.v9n2.2553 althea medical journal. 2022;9(2) 107 c.4–7,9 indicators of systemic inflammation such as neutrophil-to-lymphocyte ratio (nlr) and platelet-to-lymphocyte ratio (plr) are expected to be activated in chronic inflammatory processes that occur in people with hepatitis c.10 the progressivity of hepatitis c disease will cause fibrosis of the liver. thus, the nlr and plr can assess the severity of liver fibrosis.11–12 based on the literature study, the authors wanted to identify the relationship between the apri score and the nlr and the plr as predictors for determining the severity of mild fibrosis and severe hepatic cirrhosis in patients with hepatitis c.10–18 this study aimed to determine the correlation between apri scores with nlr and plr in patients with hepatitis c. the study’s results are expected to predict the state of hepatitis c patients who experienced hepatic cirrhosis without having invasive examination. methods this study was conducted at the laboratory of clinical pathology, dr. hasan sadikin general hospital, bandung (rshs). the research method was a cross-sectional study using a correlative analytic observational design. the subjects were hepatitis c patients treated in the inpatient and outpatient installation of internal medicine department rshs. clinical data were collected from the patient’s medical records from january to december 2019. the inclusion criteria were patients aged ≥18 years, male and female, diagnosed as hepatitis c patients, with ast examination data measured by an enzymatic method (pyridoxal5-phosphate uv method), leukocytes, count type, and platelets measured by flow cytometry method. exclusion criteria were hepatitis c patients younger than 18 years old with a history of thrombocytopenia due to other diseases. the sample size in this study was all patients diagnosed with hepatitis c and treated in the internal medicine ward, as well as outpatients at the gastroenterohepatology clinic of the dr. hasan sadikin general hospital from january-december 2019. the research data were statistically processed with microsoft excel and spss 17.0. the collected data were checked for distribution using the kolmogorovsmirnov test and then analyzed by pearson or spearman rank correlation test to determine the correlation between apri score with nlr and plr in chronic hepatitis c patients. the ethical clearance was obtained from the ethical committee in dr. hasan sadikin general hospital with no. lb.02.01/x.6.5/271/2020. results during the january to december 2019 period, the number of subjects who met the inclusion criteria was 65 inpatients and 58 outpatients. twenty-six subjects were excluded from this study due to a lack of laboratory results. the normality test showed that all patient subjects’ age data and apri scores were abnormally distributed (p>0.05). the data characteristics of the study subject are shown in table 1. subjects with severe malignancy were found in males by 67.5 % compared to females (32.5%), and most occurred in the 36–45 year age group, namely 40.7% (table 1). the results of apri scores, neutrophils lymphocytes ratio (nlr), platelet lymphocyte ratio (plr) in hepatitis c patients can be seen in table 2. findings of the analysis using spearman rank found that the correlation coefficient between the nlr apri scores was 0.109, p=0.229 (p>0.05), meaning that there was a weak and insignificant relationship between the apri scores and nlr. from the results of the analysis using spearman rank, the correlation coefficient between apri and plr scores was -0.468, p=0.000 (p<0.05), meaning that there was a significant negative correlation between apri and plr scores. discussion table 1 characteristics of patient data characteristics total (n=123) n % age (year) 18–35 36–45 46–55 56–65 > 65 9 50 34 15 15 7.3 40.7 27.6 12.2 12.2 gender male female 83 40 67.5 32.5 patient status inpatient outpatient 65 58 52.8 47.2 jane haryanto et al.: aspartate aminotransferase to platelet ratio index score in correlation with neutrophil -to-lymphocyte ratio and platelet-to-lymphocyte ratio to predict hepatic cirrhosis in hepatitis c patients althea medical journal. 2022;9(2) 108 this study was dominated by patients aged 36–55 years, or 60–70% of the subjects. it is similar to findings of klevens et al.14 reporting that hepatitis c patients mostly were 40–59 years old. the study subject’s average age is 49 years, compared to other studies that reported the age of hepatitis c patients, was 49.51±10.45 in patients with cirrhosis and 45.31±14.28 in patients with chronic hepatitis c.17 two different studies also reported similar results that the subject’s average age is 52 years.17,19 however, there are studies in which the mean or median age of the subjects is more than or equal to 60 years.19,20 the predominance of male subjects found in this study is also reported in most literatures. in this study, male hepatitis c patients reached 67.5%. likewise, in other studies, male subjects are reported more than female subjects (59–81%).21–23 the apri score correlated significantly to the fibrosis stage in patients with chc. it was known that platelet counts decreased, and ast levels increased with the progression of liver fibrosis. platelet generation diminished secondary to a decreased production of thrombopoietin by hepatocytes. also, platelets were sequestered and destructed in the spleen as liver fibrosis advanced and portal hypertension developed. as to ast, ongoing liver injury increased its release from mitochondria, and fibrosis decreased its clearance.24,25 several studies have shown that the nlr and plr values can predict the severity of patients with hepatitis c.10,26 in cirrhotic patients, immune and inflammatory systems are activated and inflammatory markers, such as interleukin-6 (il-6), tumor necrosis factor-α (tnf-α), and neutrophil counts are elevated.27 thus, nlr can be used as a marker of systemic inflammatory response. it has found that increased nlr reflects the progression of systemic inflammation which is associated with poor clinical outcomes in liver disease.27 the primary mechanisms for thrombocytopenia in cirrhosis are decreased production of thrombopoietin (tpo) in the liver and splenic platelet sequestration. thrombopoietin acts at all stages of thrombopoiesis and synergizes with other cytokines to stimulate both megakaryocytopoiesis and thrombopoiesis as well as platelet release into the circulation. liver fibrosis (grade 3⁄4) and liver function correlate with low tpo serum levels. as tpo is synthesized in the liver, impaired hepatic function may reduce tpo production.28 thus, a low plr can predict an undesirable progression of hcv infection-related liver disease.10,28 statistical tests showed no correlation between apri scores and nlrs in hepatitis c patients. this was following another study which stated that the value of leukocytes such as neutrophils fluctuated in response to infection.29 these variations are not correlated with the possible nlr apri scores in patients with hepatitis c. serial nlr screening will increase the validity in predicting the severity of patients with hepatitis c.24,29 this is in line with study conducted by wróblewska a et al.16 who have got the nlr correlation to assess the degree of damage in hepatitis c patients with serial nlr examinations at week 24th. statistical tests on the correlation between apri and plr scores in hepatitis c patients showed a significant negative correlation. if the apri score was minor, the plr value would be even more significant, and vice versa. these results are following research which have stated that plr is negatively correlated with hepatic fibrosis, which in this study is assessed by the apri score.15 the regulation of platelet formation is influenced by thrombopoietin (tpo) which is formed in the liver.24 so liver infection will disrupt tpo production, affecting platelet production.17,24 this is in line with the research which stated that the greater the liver damage, the more it will affect platelet productivity.19 another study showed that plr and nlr are known biomarkers of systemic inflammation, indicating the immune response.10 table 2 results of apri scores, neutrophils lymphocytes ratio (nlr), platelet lymphocyte ratio (plr) in hepatitis c patients parameter median min-max apri 0.94 0.12-123.92 neutrophil lymphocyte ratio (nlr) 2.96 0.68-98.00 platelet lymphocyte ratio (plr) 110.51 4,97-2,038.83 althea medical journal june 2022 althea medical journal. 2022;9(2) 109jane haryanto et al.: aspartate aminotransferase to platelet ratio index score in correlation with neutrophil -to-lymphocyte ratio and platelet-to-lymphocyte ratio to predict hepatic cirrhosis in hepatitis c patients platelets are thought to act as carriers of effect or immune cells in chronic systemic inflammation, although the mechanism is still widely studied.20 nlr is a parameter that reflects systemic inflammation and the general nutrition status of patients.27 besides, plr is a parameter that reflects systemic inflammation as well as the liver function. the primary mechanism for thrombocytopenia in cirrhosis is decreased production of tpo in the liver.28 thus, a decrease in the plr value can predict the progression of hepatitis c disease, characterized by liver fibrosis.10 the limitations of this study were that the study subjects were not normally distributed, periodic hematologic examinations were not included, as well as data regarding the history of previous drug consumption and duration of illness that could affect the nlr and plr values in predicting fibrosis severity in patients with hepatitis c. to conclude, there is a moderate and significant negative correlation between apri and plr scores to determine the severity of fibrosis in hepatitis c patients. plr can be considered as biomarker to predict the occurrence of hepatic cirrhosis in patients with hepatitis c acknowledgement we would like to thank all the patients for participating in the study. we thank the clinicians and the staffs of dr. hasan sadikin general hospital for help extended towards the collection of samples and maintenance of the records. references 1. national center for complementary and integrative health. national health interview survey 2017. maryland, usa: nccih; 2018 [cited 2020 june 16] available from: https://www.nccih.nih. gov/research/statistics/nhis/2017 2. loaeza-del-castillo a, paz-pineda f, oviedo-cárdenas e, sánchez-avila f, vargas-vorácková f. ast to platelet ratio indec (apri) for the noninvasive evaluation of liver fibrosis. ann hepatol. 2008;7(4):350–7. 3. papadopoulos n, vasileiadi s, papavdi m, sveroni e, antonakaki p, dellaporta e, et al. liver fibrosis staging with a combination of apri and fib-4 scoring system in chronic hepatitis c as an alternative to transient elastography. ann gastroenterol. 2019;32(5):498–503. 4. elias t, rustam e, leonardo bd, juwita s, mabel hms, et al. aspartate aminotransferase to platelet ratio index and fibroscan for predicting liver fibrosis with chronic hepatitis b. the indonesian journal gastroenterology, hepatology, and digestive endoscopy. 2013;14(3):139–44. 5. yoav l, muriel w, ruth ck, shimon s, gerardo zl. non-invasive diagnosis of liver fibrosis and cirrhosis. world j gastroenterol. 2015;21(41):11567–83. 6. shin wg, park sh, jang mk, hahn th, kim jb, lee ms, kim dj, jun sy, park ck. aspartate aminotransferase to platelet ratio index (apri) can predict liver fibrosis in chronic hepatitis b. dig liver dis. 2008;40:267–74. 7. ola gb, ola ses, naglaa hs. comparative study between liver biopsy and noninvasive biomarkers in assessment of hepatic fibrosis in children with chronic liver diseases. egypt pediatric assoc gaz. 2021;69:26. 8. seipalla se, nurahmi n, abd samad i. analysis of liver fibrosis degree with apri score and fib-4 index on patients with non-alcoholic fatty liver disease. indones j clin pathol med lab. 2020;26(2):158–61. 9. shaheen aa, myers rp. diagnostic accuracy of the aspartate aminotransferase-toplatelet ratio index for the prediction of hepatitis c-related fibrosis: a systematic review. hepatology. 2007;46(3):912–21. 10. meng x, wei g, chang q, peng r, shi g, zheng p, et al. the platelet-to-lymphocyte ratio, superior to the neutrophil-tolymphocyte ratio, correlates with hepatitis c virus infection. int j infect dis. 2016;45:72–7. 11. abd el hafez ma, kasemy zaa. effect of direct-acting antivirals on plateletto-lymphocyte ratio and neutrophil-tolymphocyte ratio in patients with hepatitis c virus-related thrombocytopenia. egypt j intern med. 2019;31:296–301. 12. zheng j, cai j, li h, zeng k, he l, fu h, et al. neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as prognostic predictors for hepatocellular carcinoma patients with various treatments: a metaanalysis and systematic review. cell physiol biochem. 2017;44(3):967–81. 13. yen y-h, kuo f-y, kee k-m, chang k-c, tsai m-c, hu t-h, et al. apri and fib 4 in the evaluation of liver fibrosis in chronic hepatitis c patients stratified by ast levels. plos one. 2018;13(6):e0199760. althea medical journal. 2022;9(2) 110 14. klevens rm, canary l, huang x, denniston mm, yeo ae, pesano rl, et al. the burden of hepatitis c infection-related liver fibrosis in the united states. clin infect dis. 2016;63(8):1049–55. 15. he q, he q, qin x, li s, li t, xie l, et al. the relationship between inflammatory marker levels and hepatitis c virus severity. gastroenterol res prac. 2016;2016:2978479. 16. wróblewska a, lorenc b, cheba m, bielawski kp, sikorska k neutrocyte to lymphocyte ratio predicts the presence of replicative hepatitis c virus strand after therapy with direct-acting antivirals. clin exp med. 2019;19(3):401–6. 17. lee k, sinn dh, gwak g, cho hc, jung s, paik y, et al. prediction of the risk of hepatocellular carcinoma in chronic hepatitis c patients after sustained virological response by aspartate aminotransferase to platelet ratio index. gut liver. 2016;10(5):796–802. 18. ji f, zhou r, wang w, bai d, he c, cai z. high post-treatment α-fetoprotein levels and aspartate aminotransferase-toplatelet ratio index predict hepatocellular carcinoma in hepatitis c virus decompensated cirrhotic patients with the sustained virological response after antiviral therapy. j interf cytokine res. 2017;37(8):1–7. 19. sripongpun p, tangkijvanich p, chotiyaputta w, charatcharoenwitthaya p, chaiteerakij r, treeprasertsuk s, et al. evaluation of aspartate aminotransferase to platelet ratio index and fibrosis-4 scores for hepatic fibrosis assessment compared with transient elastography in chronic hepatitis c patients. jgh open. 2020;4(1):69–74. 20. gozdas ht, ince n. elevated mean platelet volume to platelet ratio predicts advanced fibrosis in chronic hepatitis c. eur j gastroenterol hepatol. 2020;32(4):524–7. 21. abd el-atty ea, el-shayb esi, belal mo. noninvasive methods for fibrosis assessment in chronic hepatitis c virus infection. menoufia med j. 2018;32(3):943– 8. 22. fujita k, kuroda n, morishita a, oura k, tadokoro t, nomura t, et al. fibrosis staging using direct serum biomarkers are influenced by hepatitis activity grading in hepatitis c virus infection. j clin med. 2018;7(9):267. 23. karagöz e, tanoğlu a, ülçay a, erdem h, turhan v, kara m, et al. mean platelet volume and red cell distribution width to platelet ratio for predicting the severity of hepatic fibrosis in patients with chronic hepatitis c. eur j gastroenterol hepatol. 2016;28(7):744–8. 24. galbraith jw, donnelly jp, franco ra, overton et, rodgers jb, wang he. national estimates of healthcare utilization by individuals with hepatitis c virus infection in the united states. clin infect dis. 2014;59(6):755–64. 25. loaeza-del-castillo a, paz-pineda f, oviedo-cárdenas e, sánchez-avila f, vargas-vorácková f. ast to platelet ratio index (apri) for the noninvasive evaluation of liver fibrosis. ann hepatol. 2008;7(4):350–7. 26. kuo y-h, kee k-m, hsu n-t, wang j-h, hsiao c-c, chen y, et al. using ast-platelet ratio index and fibrosis 4 index for detecting chronic hepatitis c in a largescale community screening. plos one. 2019;14(10):e0222196. 27. biyik m, ucar r, solak y, gungor g, polat i, gaipov a, et al. blood neutrophil-tolymphocyte ratio independently predicts survival in patients with liver cirrhosis. eur j gastroenterol hepatol. 2013;25(4):435– 41. 28. peck-radosavljevic m. thrombocytopenia in chronic liver disease. liver int. 2017;37(6):778–93. 29. li x, wang l, gao p. chronic hepatitis c virus infection. medicine (baltimore). 2019;98(39):e17300. althea medical journal june 2022 amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 61 correlation between hemoglobin concentration and cardiorespiratory fitness in adolescent sportsmen billy leoprayogo,1 venna,2 ignatio rika haryono,3 francisca tjhay4 1school of medicine and health sciences atma jaya catholic university of indonesia, indonesia, 2department of clinical pathology school of medicine and health sciences atma jaya catholic university of indonesia, indonesia, 3department of physiology school of medicine and health sciences atma jaya catholic university of indonesia, indonesia, 4department of medicine biology school of medicine and health sciences atma jaya catholic university of indonesia, indonesia correspondence: francisca tjhay, department of medicine biology, school of medicine and health sciences atma jaya catholic university of indonesia, jl. pluit raya no. 2, penjaringan, jakarta utara, indonesia, e-mail: francisca.tjhay@atmajaya.ac.id amj. 2020;7(2):61–4 abstract background: sport is a physical activity that increases human body oxygen demand. hemoglobin has a major role to fulfill the oxygen demand. the ability to fulfill this demand was also seen as cardiorespiratory fitness. sportsmen have a high cardiorespiratory fitness due to the intensity and frequency of training. this study aimed to explore the effect of hemoglobin concentration on cardiorespiratory fitness of adolescent sportsmen. methods: this was a cross-sectional study conducted from october–november 2019. male badminton and basketball sportsmen aged 15–19 years old in jakarta and bogor were recruited (n=72). hemoglobin concentration was measured with a digital hemoglobinometer. the vo2max was estimated with a beep test. fitnessgram® performance standard was used for the classification of cardiorespiratory fitness. the hemoglobin concentration and cardiorespiratory fitness were then analyzed (spearman and kruskal-wallis). results: there was a correlation between hemoglobin concentration and cardiorespiratory fitness (p=0.001), although the correlation was weak (r=0.38). kruskal-wallis analysis showed there was a significant mean difference in hemoglobin concentration on cardiorespiratory fitness groups (p=0.005). conclusions: the mean of the hemoglobin concentration in the healthy fitness zone (hfz) cardiorespiratory group is higher than in the need improvement (ni) group and the need improvement within health risk (ni-hr) group. keywords: adolescent sportsmen, cardiorespiratory fitness, hemoglobin concentration introduction sport is a form of physical activity that is planned and structured, involving various movements of many muscle groups which are done repeatedly. sports have a good impact on adolescent’s bodies such as increased bone density, cognitive development, and also an increase in cardiorespiratory fitness which is expressed by an increase in vo2max.1 basketball and badminton are physical activities.2,3 both of these exercises increase the body’s oxygen demand because it performs repeated muscle contraction in large quantities for a period of time and both sports require movement from the upper and lower extremities. hemoglobin is needed to fulfill this need because of its role as the transporter of the oxygen from the lungs to tissues and muscles throughout the body.4 hemoglobin also acts as a buffer that maintains the ph of the blood to remain in optimal condition for aerobic metabolism.5 looking at the role of hemoglobin during exercise, hemoglobin concentration also affects the quality of individual cardiorespiratory fitness. the vo2max had an increase of about 1% for each increase in https://doi.org/10.15850/amj.v7n2.1847 althea medical journal. 2020;7(2) 62 amj june 2020 hb concentration by 0.3 g/dl.6 this shows the effect of hb in cardiorespiratory fitness. this study aimed to explore the correlation between hemoglobin concentration and cardiorespiratory fitness, especially in adolescent sportsmen. adolescents were targeted to improve their cardiorespiratory fitness by exercising regularly to increase and maintain their physical fitness. methods this was a cross-sectional study conducted from october–november 2019 among male badminton and basketball players aged 15–19 years old in jakarta and bogor. the sampling technique was a snowball sampling until the number of respondents met the sample target. the inclusion criteria were those who were willing to take part in the study after consent and underwent the hemoglobin concentration examination. in brief, the hemoglobin concentration was measured with a digital hemoglobinometer with an azide-methemoglobin method that has been tested for the validity and reliability using within the run and between day methods. the hemoglobin concentration was then grouped into the following; low concentration with hb <14 g/dl, normal concentration with hb 14–17.5 g/dl, and high concentration with hb >17.5 g/dl. each respondent went through hemoglobin examination before conducting the beep test which was calculated using a quadratic formula model to estimate the vo2max. cardiorespiratory fitness was then classified with the fitnessgram® performance standard classification based on the estimated vo2max. the respondents were then group into cardiorespiratory fitness groups; healthy fitness zone (hfz), need improvement (ni) group, and need improvement within health risk (ni–hr) group. table 1 distribution of hemoglobin concentration and cardiorespiratory fitness hemoglobin concentrationa total low normal high cardiorespiratory fitness ni-hr 7 15 2 24 ni 4 17 3 24 hfz 19 5 24 total 11 51 10 72 note: a = hemoglobin concentration for male adolescent; low=hb concentration <14 g/dl; normal=hb concentration =14–17.5 g/dl; high=hb concentration >17.5 g/dl. the cardiorespiratory fitness was grouped into; ni-hr=need improvement within health risk, ni = need improvement, hfz=healthy fitness zone the data obtained were then processed using the spss program. data distribution was tested by the kolmogorov-smirnov. when data were not normally distributed, the spearman correlation test was performed and continued with the kruskal-wallis hypothesis test. results in total, there were 77 male sportsmen recruited, consisting of basketball players and badminton players. due to rejection in the hb concentration examination, 5 subjects were excluded, thus, only 72 sportsmen were included for further analysis. the average hemoglobin concentration of these sportsmen was 15.9±1.6 g/dl (range 12.5– 18.7 g/dl). there were 11 sportsmen who had low hb concentrations, which fall in the cardiorespiratory group of ni–hr (n=7), ni (n=4), but none in the hfz group. the distribution of hemoglobin concentration among the cardiorespiratory fitness group was shown in table 1. a correlation test between hemoglobin concentration and cardiorespiratory fitness had shown a value of r=0.38 (p=0.001), suggesting a positive mild correlation between hemoglobin concentration and cardiorespiratory fitness. table 2 mean of hemoglobin concentration and cardiorespiratory in fitness group cardiorespiratory fitness mean hb concentration (g/dl) ni-hr 15.3 ni 15.7 hfz 16.7 note: ni-hr= need improvement within health risk; ni= need improvement; hfz= healthy fitness zone althea medical journal. 2020;7(2) 63 there was a different mean of hemoglobin concentration on cardiorespiratory fitness groups (kruskal-wallis test, p=0.005). a post hoc analysis was used after the kruskal-wallis test to know which group have different mean hemoglobin concentration. it showed a value of p=0.02 for hfz and ni group, p=0.001 for hfz and ni-hr group, and p=0.40 for ni and ni-hr group (p<0.05). these results indicated that the hfz had a significant difference of mean hemoglobin concentration with both ni and ni-hr groups, but between the ni and nihr group, no statistical difference was found. the mean hemoglobin concentration of each cardiorespiratory fitness group was shown in table 2. discussion sport is a physical activity which increases the oxygen demand of the human body. there are physiological changes that occur during exercise such as a 1.5 to 2 times increased heart rate than at rest and an increase in respiratory rate from about 16 times/minute up to 60–80 times/minute.7 this physiological change is an attempt that our body does to meet the increase in oxygen consumption that occurs from about 250 ml/minute at rest to 3000–5000 ml/minute when exercising.8 the oxygen needed by the body to meet the increased demand when doing exercise is delivered by hemoglobin. this study has shown that the average hemoglobin concentration is higher in sportsmen with higher cardiorespiratory fitness. blood composition changes during and after exercise, and there is an effect of exercise on red blood cells oxygen supply ability. plasma volume is decreased and hematocrit is increased during exercise. the increase of hematocrit occurs relatively due to the blood plasma volume loss. blood plasma exits the blood vessels into the extracellular space due to a difference in osmotic pressure caused by muscle metabolites and increased capillary hydrostatic pressure.9 interestingly, another study on the effect of blood donation on cardiorespiratory fitness observed the changes in cardiorespiratory fitness of respondents before and after 450 ml blood donation. respondents conducted blood tests and beep tests on the first day continued with blood donation on the second day. second blood test and second beep test on the third day. the study showed that the decline in cardiorespiratory fitness 24 hours after blood donation were generally not visible. however, the group with good cardiorespiratory fitness experienced a significant decline after blood donation.10 the parameter of blood that affects cardiorespiratory fitness is the oxygencarrying capacity of the blood which is the role of hemoglobin. the recovery of blood volume after 24 hours of blood donation reaches a volume that was almost similar to the beginning, but the hemoglobin concentration was not returned to the initial concentration due to hemodilution. this study showed the same results as there were differences in hemoglobin concentration on the hfz group with other groups as the hfz group have better cardiorespiratory fitness than the other groups. the relationship of hemoglobin concentration with cardiorespiratory fitness has shown that vo2max has the strongest relationship with oxygen-carrying capacity from the blood. the parameters that play a major role in the carrying capacity of oxygen are hemoglobin concentration, blood volume, and also the total mass of hemoglobin. the parameter which has the strongest relationship to the oxygen-carrying capacity is the total mass of hemoglobin,11 suggestings that the correlation in this study is weak. future research is needed to elucidate the cardiorespiratory fitness and their factors that might improve the quality of physical fitness in adolescent sportsmen. there are factors affecting hemoglobin concentration in the blood.12 this study has managed to control these factors which include sportsmen smoking behavior, previous hematological disorders, history of iron supplementation therapy, and history of living in high-altitude places, however, this study has no data of sportsmen’s regular diet to evaluate daily iron intake.13,14 the recommended intake for iron is 10.8–18.4 mg/day.15 iron intake highly affects hemoglobin concentration, which may cause false positive on the low hemoglobin concentration in the ni–hr group. in conclusion, there is a positive correlation between hemoglobin concentration and cardiorespiratory fitness in sportsmen aged 15–19 years old in this study, especially those in the healthy fitness zone. the hemoglobin concentration varies among sportsmen, which the majority of them within the normal range. therefore, sports clubs and the sportsmen should aware of how hemoglobin concentration could affect cardiorespiratory fitness and how to improves or maintain the performance of sportsmen in competition, as cardiorespiratory fitness improve endurance and recovery time of physical fitness. billy leoprayogo et al.: correlation between hemoglobin concentration and cardiorespiratory fitness in adolescent sportsmen althea medical journal. 2020;7(2) 64 amj june 2020 references 1. mckinney j, lithwick dj, morrison bn, nazzari h, isserow sh, heilbron b, et al.. the health benefits of physical activity and cardiorespiratory fitness. bc med j. 2016;58(3):131–7. 2. silva am, santos da, matias cn, minderico cs, schoeller da, sardinha lb. total energy expenditure assessment in elite junior basketball players: a validation study using doubly labeled water. j strength cond res. 2013;27(7):1920–7. 3. briggs ma, cockburn e, rumbold pls, rae g, stevenson ej, russell m. assessment of energy intake and energy expenditure of male adolescent academy-level soccer players during a competitive week. nutrients.2015;7(10):8392–401. 4. longeville s, stingaciu lr. hemoglobin diffusion and the dynamics of oxygen capture by red blood cells. sci rep. 2017;7(1):10448. 5. chowdhury a, dasgupta r, majumder sk. changes in hemoglobin–oxygen affinity with shape variations of red blood cells. j biomed opt. 2017;22(10):1–9. 6. otto jm, montgomery he, richards t. haemoglobin concentration and mass as determinants of exercise performance and of surgical outcome. extrem physiol med. 2013;2(1):33. 7. savonen kp, lakka ta, laukkanen ja, halonen pm, rauramaa th, salonen jt, et al. heart rate response during exercise test and cardiovascular mortality in middleaged men. eur heart j. 2006;27(5):582–8. 8. nicolò a, girardi m, bazzucchi i, felici f, sacchetti m. respiratory frequency and tidal volume during exercise: differential control and unbalanced inter dependence. physiol rep. 2018;6(21): e13908. 9. mairbäurl h. red bloodcells in sports: effects of exercise and training on oxygen supply by red blood cells. front physiol. 2013;4:332. 10. mail j, mohamed r, farah n, aziz ar,muhamed amc. the influence of different levels of cardiorespiratory fitness on excercise performance 24 hour post blood donation in maledonors. mal j med health sci. 2018;14(supp 1):126–33. 11. otto jm, o’doherty af, hennis p, cooper pj, grocott m, snowdon c, et al. association between preoperative haemoglobin concentration and cardiopulmonary exercise variables: a multicentre study. perioper med (lond). 2013;2:18 12. jamali nh, jamali ah, khand aa, mahesar h, arain mi. factors affecting the body mass index, haemoglobin and serum ferritin level in students. am j blood res. 2017;7(3):18–28. 13. cairo darc, silva lr, bustani nc, marques cd. irondeficiency anemia in adolescents; a literature review. nutr hosp. 2014;29(6):1240–9. 14. ocas-cordova s, tapia v, gonzales gf. hemoglobin concentration in children at different altitudes in peru: proposal for [hb] correction for altitude to diagnose anemia and polycythemia. high alt med biol. 2018;19(4):398–403. 15. ghosh s, sinha s, shivakumar n, thomas t, sachdev hs, kurpad av. daily iron requirements in healthy indian children and adolescents. indian pediatr. 2019;56(7):551–5. amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 181 positive postoperative blood cultures in major abdominal surgery patients attending a tertiary hospital in durban, south africa irfaan adam,1 yoshan moodley2 1nelson r. mandela school of medicine, university of kwazulu-natal, durban, south africa, 2directorate for research and postgraduate support, durban university of technology, durban, south africa correspondence: yoshan moodley, phd, directorate for research and postgraduate support, durban university of technology, steve biko road, durban, south africa, e-mail: moodleyyo@ukzn.ac.za introduction it is estimated that each year more than 300 million patients undergo surgical procedures worldwide.1 the international surgical outcomes study group (isos) has reported that infectious complications are amongst the most frequently encountered complications during the postoperative period and occur in 9.0% of surgical patients.2 moreover, surgical site infection, pneumonia, and urinary tract infections are the most common infectious complications observed during the postoperative period.3 the causative microbiological agents of these infectious complications occasionally enter the bloodstream, where they may cause a secondary infection.4 meanwhile, the isos estimated that postoperative bloodstream infections occured in only 0.9% of surgical patients worldwide, the associated mortality was the highest amongst all categories of postoperative infectious complication.2 although microorganisms might enter the bloodstream through everyday activities, such as during brushing of teeth, these are efficiently disposed of by the immune system in healthy individuals and do not cause infection.4 however, anaesthesia and surgery can impair the immune response.5,6 this might althea medical journal. 2021;8(4):181–187 abstract background: evidence from high-income countries suggests that bloodstream infection is an essential complication following major surgery. however, studies of bloodstream infections following major surgery in lower-income settings, particularly in africa, are rare. this study aimed to determine the incidence of postoperative bloodstream infection and to explore any association with mortality in highrisk laparotomy patients in south africa. methods: this study was a retrospective study, reviewing 435 consecutive adults who underwent laparotomy at a south african tertiary hospital over a five-year period. incident postoperative bloodstream infection, defined as a positive blood culture following surgery, was determined from laboratory reports in the patient’s medical chart. source infections and the causative microorganisms were established from laboratory reports. inpatient mortality was determined from the patient’s hospital discharge summary. data were summarized using descriptive statistics. potential associations between bloodstream infection and mortality were tested using the chi-square test. results: the incidence of postoperative bloodstream infection was 7.4%. klebsiella pneumoniae, escherichia coli, and staphylococcus aureus were isolated from 21.9%, 18.7%, and 15.6% of blood cultures. mortality in patients with bloodstream infection was 46.9% vs. 16.1% in patients without bloodstream infection (p<0.001). conclusions: postoperative bloodstream infection is an essential complication following major abdominal surgery with k. pneumoniae, e. coli, and s. aureus being the most common causative agents. bloodstream infection is associated with a higher risk of postoperative mortality. further studies are recommended to confirm the findings and improve patient management. keywords: blood culture, microbiology, mortality, postoperative period, surgery https://doi.org/10.15850/amj.v8n4.2472 althea medical journal. 2021;8(4) 182 explain the incidence of bloodstream infection in surgical patients, as well as the disastrous consequences of this specific postoperative complication. the microbiological culture of blood specimens remains the gold standard for diagnosing bloodstream infections.7 blood specimens can be inoculated into a microbiological culture medium and incubated for a few days to grow medically important microorganisms that may be the causative agents of bloodstream infection. alternatively, liquid microbiological culture media in blood culture bottles can also ‘grow’ microorganisms.7 as most bloodstream infections occur secondary to a surgical site infection, pneumonia, or urinary tract infection, the causative microbiological agent of the bloodstream infection is often the same as the primary infection.3 false positive results for a blood culture can occur when commensal organisms on the skin, which might be introduced during specimen collection, are ‘grown’ rather than true pathogenic microorganisms.7 bacteria are the most common group of microorganisms isolated from positive blood cultures. the most frequently reported bacterial species isolated from positive blood cultures include: staphylococcus spp., streptococcus spp., acinetobacter, corynebacterium, enterobacteriaceae, pseudomonas aeruginosa, clostridium spp., and bacteroides spp.8 although the african surgical outcomes study (asos) reported that only 1.3% of surgical patients experienced postoperative bloodstream infection, postoperative mortality in afflicted patients can be as high as 40%.9 therefore, in keeping with the findings of isos,2 bloodstream infections appear to be of importance in african surgical settings. it should be noted that there were several surgical specialties included in asos and isos, and there was also no sub-analysis that investigated the occurrence of bloodstream infection according to surgical specialty.2,9 in addition, asos and isos were conducted across several countries, and the analysis for infectious complications was not presented by country.2,9 due to these limitations, it might be inappropriate to extrapolate the results for bloodstream infections from asos and isos to a specific south african patient population undergoing major abdominal surgery, such as laparotomy patients. there might be differences in case-mix, resource availability, and other relevant variables between different countries. these differences might have implications regarding the management of bloodstream infections in different settings. there is a paucity in the literature regarding studies that have specifically sought to describe positive postoperative blood cultures in south african major abdominal surgery populations. a south african study of positive postoperative blood cultures in this traditionally high-risk surgical population could improve our countryspecific understanding of this complication and improve abdominal surgery patients’ clinical management in south african settings. this study aimed to determine the incidence of postoperative bloodstream infection and to explore any association with mortality in a high-risk surgical population of south african laparotomy patients. methods this study was a retrospective chart review at the tertiary-level inkosi albert luthuli central hospital (ialch) in durban, south africa. the inclusion criteria for the study were laparotomy surgery patients, aged >18 years old, had the laparotomy at ialch between january 2006 and december 2010. the exclusion criteria were repeat laparotomies for the same patient or if the patient had missing data for the postoperative period. we found the patients for our study by looking through the operating room register throughout the study period. after applying the inclusion and exclusion criteria, the study sample consisted of 435 consecutive adult patients. all patient data were collected through a retrospective chart review process, maintained as an electronic patient registry. source documents reviewed during this process included patient admission notes, physicians’ or surgeons’ progress notes, laboratory reports, and the patient discharge summary. the variables investigated in this study included patient demographic characteristics, indications for surgery, the urgency of surgery, comorbidities, laboratory results, and postoperative mortality. the study outcome was bloodstream infection, as defined by a positive blood culture result following surgery. for this study, a positive blood culture result was defined as any postoperative blood culture which yielded a pathogenic microbial isolate. culture results reported as contaminants were not considered to be positive blood cultures. blood cultures were serially performed; therefore, blood specimens from a patient that consistently yielded no microbial growth were considered negative for bloodstream althea medical journal december 2021 althea medical journal. 2021;8(4) 183 table 1 characteristics of patients undergoing laparotomy at the tertiary-level inkosi albert luthuli central hospital in durban, south africa period 2006 to 2010 (n=435) characteristic n (%) demographics male median age; years (interquartile range) 292 (67.1) 42 (30–56) indication for surgery bleeding cancer infection trauma/injury other 12 (2.8) 183 (42.1) 35 (8.0) 149 (34.3) 56 (12.9) urgency of surgery elective emergency 288 (66.2) 147 (33.8) comorbidity hypertension diabetes mellitus cardiovascular disease metastatic carcinoma obstructive lung disease current smoker 140 (32.2) 57 (13.1) 50 (11.5) 88 (20.2) 25 (5.7) 44 (10.1) irfaan adam, yoshan moodley: positive postoperative blood cultures in major abdominal surgery patients attending a tertiary hospital in durban, south africa infection. all blood cultures were performed at a sanas-accredited laboratory within the ialch complex. mortality was collected as a separate variable in the patient registry and was determined from the patient discharge summary. data were analyzed using quantitative techniques. descriptive statistics were used to determine the distribution of various characteristics in the study sample. results for the descriptive statistical analysis were presented as medians with interquartile range (iqr) or as frequencies and percentages. the cumulative incidence of positive blood cultures following laparotomy was calculated using standard epidemiologic methods and presented as a percentage along with a corresponding 95% confidence interval (ci). the microbiology of positive blood cultures following laparotomy was descriptively presented as frequencies and percentages. we compared the proportion of patients who had long operations (>2 hours), contaminated procedures, and blood transfusions between the positive blood culture group and the negative blood culture group with the chisquare test. bivariate statistics, namely the chi-square test, was used to compare mortality between patients with and without positive blood culture results. the results of the bivariate statistical analysis for mortality were presented as a crude odds ratio with a 95% ci. statistical significance was set at p<0.050. the statistical analysis was performed using the statistical package for the social sciences, version 27.0 (ibm, usa). this study was approved by the biomedical research ethics committee of the university of kwazulu-natal, south africa (protocol number brec/00000870/2019). results of the 435 selected patients, 292 (67.1%) were male with a median age of 42 years old (iqr: 30.0–56.0) (table 1). the laparotomy was electively performed in 288 patients (66.2%). cancer (n=183; 42.1%), and trauma or injury (n=149; 34.3%) were the most common indications for surgery. hypertension (n=140; 32.2%), metastatic carcinoma (n=88; 20.2%), and diabetes (n=57; 13.1%) were the most prevalent comorbidities. of the study sample comprising 435 patients, 32 had positive blood culture during the postoperative period (cumulative incidence: 7.4%, 95% ci: 5.3–10.2%). a comparison of the incidence between positive blood culture and other types of healthcareassociated infections (pneumonia, surgical althea medical journal. 2021;8(4) 184 site infection, urinary infection) showed that positive blood culture was the third most important (7.4%) after surgical site infection (14.9%) and pneumonia (8.5%) (figure). the comparison of long surgery (>2 hours), contaminated procedure, and blood transfusion in the positive and negative blood culture groups showed that all three characteristics were significantly higher in patients who had positive blood cultures when compared with patients who had negative blood cultures (table 2). the microbiology of positive blood cultures in this study showed that more than one species of microorganism was isolated from three of these blood cultures. the source of the bloodstream infection was established in 17 of 32 positive blood cultures, with the most common source being infection of intra-abdominal origin (n=9). the three most commonly isolated microorganisms from blood cultures in this study were klebsiella pneumoniae (7 of 32), escherichia coli (6 of 32), and staphylococcus aureus (5 of 32) (table 3). postoperative mortality in the entire study sample was 18.4% (80/435 patients). of the patients without positive blood cultures (n=403), there were 65 postoperative deaths. this group equated to a mortality rate of 16.1% (95% ci: 12.9-20.0%). of the patients with positive blood cultures (32 patients), there were 15 postoperative deaths. this equated to a mortality rate of 46.9% (95% ci: 30.9-63.6%) in this group. when postoperative mortality was statistically compared between the two figure 1 comparison of positive blood culture incidence with other types of healthcare associated infections table 2 comparison of important characteristics between positive and negative blood culture groups characteristic positive blood culture (n=32) negative blood culture (n=403) p-value surgery >2 hours, n (%) contaminated procedure, n (%) blood transfusion, n (%) 18 (56.3) 14 (43.8) 25 (78.1) 155 (38.5) 72 (17.9) 130 (32.3) 0.048 <0.001 <0.001 althea medical journal december 2021 althea medical journal. 2021;8(4) 185 groups, patients with positive blood cultures were found to have a 4.6-fold higher risk of postoperative mortality when compared with patients who did not have positive blood cultures (odds ratio=4.6, 95% ci: 2.2–9.6; p<0.001). discussion this study reports three key findings. firstly, approximately 7 in every 100 major abdominal surgery patients suffered a postoperative bloodstream infection in our setting. secondly, the common causative agents of bloodstream infection in our setting were k. pneumoniae, e. coli, and s. aureus. lastly, bloodstream infection was associated with a 4.6-fold higher risk of postoperative mortality. the incidence of bloodstream infection in this study was 8.2 times higher than that reported for isos and 5.7 times higher than that reported for asos.2,9 this variation can be attributed to the difference in case-mix between our study compared to both the isos and asos studies. isos and asos included a combination of minor and major surgical procedures, whereas our dataset comprised major surgery patients exclusively. the incidence of bloodstream infection in isos table 3 description of the microbiology of positive blood cultures (n=32) characteristic n polymicrobial infection 3 possible source of infection intra-abdominal infection pneumonia urinary tract infection catheter could not be established 9 3 3 2 15 microorganisms acinetobacter baumanii candida albicans enterobacter aerogenes enterobacter cloacae enterococcus faecalis escherichia coli klebsiella pneumoniae morganella morganii staphylococcus aureus stenotrophomonas maltophilia 3 4 1 3 4 6* 7* 1 5* 1 note: *the most prevalence microorganism in blood culture of patients undergoing laparotomy irfaan adam, yoshan moodley: positive postoperative blood cultures in major abdominal surgery patients attending a tertiary hospital in durban, south africa and asos may be diluted by including low-risk surgeries in these studies. patients undergoing major surgical procedures are at higher risk for infection due to comorbidity and risk factors for source infections when compared with patients undergoing less invasive surgical procedures. severe or advanced comorbidity may usually be present in patients undergoing major surgery, which might impair healing and/or the immune response to infection in the perioperative period.10 this would then predispose these patients to source infections and subsequent bloodstream infection. major surgery also involves long skin incisions for surgical access and the duration of procedures can exceed two hours.11,12 these factors can increase the exposure time for the development of source infections.11,12 the three most commonly isolated microorganisms from blood cultures in this study (k. pneumoniae, e. coli, and s. aureus) are well known causative agents of infectious complications during the postoperative period. klebsiella pneumoniae and e. coli are often reported as some of the most common microorganisms associated with bloodstream infections.13 the incidence of k. pneumoniae bloodstream infections has been increasing worldwide over many years.13 escherichia coli can cause deep surgical site infection if the bowel is inadvertently perforated during abdominal surgery or might cause infection due to poor toilet hygiene and poor care of the surgical wound during the postoperative period.14 staphylococcus aureus is a commensal organism found on the skin surface but has the potential to cause infection of surgical incisions.14 our findings for the presumed source of the bloodstream infection further emphasize the importance of pneumonia, surgical site infection, and urinary tract infection on secondary bloodstream infections in a high-risk surgical population. our study association between bloodstream infection and mortality agrees with that reported for isos and asos. patients with a bloodstream infection are at higher risk for postoperative mortality when compared with patients who do not have a bloodstream infection. however, there was a difference in the magnitude of the incidence of mortality observed in our study compared with that reported for isos and asos. in our study, the incidence of mortality in patients with bloodstream infection was approximately four times higher than that reported by isos and 11 times higher than that reported by asos. it highlighted an essential difference in the althea medical journal. 2021;8(4) 186 epidemiology of this complication between populations undergoing procedures of varying surgical complexity (low-risk versus high-risk procedures) and the specific major surgery (high-risk procedure) population. based on our study findings, we propose three recommendations. firstly, we propose that the risk of postoperative bloodstream infection and its consequences are communicated to major surgery patients during the consent process for their procedures. secondly, we recommend that physicians and surgeons adhere to infection control policies and implement additional strategies to reduce the risk of postoperative source infections in patients undergoing major surgical procedures in our setting. some of these strategies might include antibiotic prophylaxis within 30 minutes of skin incision, disinfection of hands, adhering to aseptic techniques during invasive anaesthetic procedures (eg., central venous catheter insertion, arterial line insertion, epidural catheter insertion, and others). also, maintaining normothermia intraoperatively, limiting the number of people present in theatre to only essential personnel, donning face masks, and newer strategies such as glycaemic control, transfusing blood and blood products only if necessary, and conforming to enhanced recovery after surgery (eras) principles.15 lastly, we recommend implementing more stringent monitoring for the source of infections following major surgery in our setting. this study has several strengths. an adequate sample size of 435 patients was tested for a statistical association between positive blood cultures and postoperative mortality. furthermore, the study population was appropriate, consisting of patients undergoing a high-risk surgical procedure associated with infectious complications during the postoperative period. we were also able to provide a thorough description of the microbiology of positive blood cultures. however, there were also several limitations to this study. the data were obtained from a single, tertiary level center and our study findings might not be completely generalizable to other settings. only inpatient outcomes were considered as there was no post-discharge follow-up of patients. there is a possibility that out-of-hospital bloodstream infection could have been missed. similarly, mortality was measured at the inpatient level only. furthermore, this was a retrospective study, so the possibility of errors in record keeping cannot be ruled out. we acknowledge that this research has limitations, and these limitations can only be addressed through extensive, prospective, multicenter research studies, including postdischarge follow-up. in conclusion, postoperative bloodstream infection is a critical complication in south african patients undergoing major abdominal surgery. interpretation of the microbiological culture results suggests that k. pneumoniae, s. aureus, and e. coli are essential pathogenic microorganisms in those patients with postoperative bloodstream infections. in keeping with reported outcomes from isos and asos, bloodstream infection is associated with significant postoperative mortality. this study is essential as it provides information on postoperative bloodstream infections, which will help improve the management of patients with this condition in the future. we recommend further studies to confirm our findings, as additional research on this topic is needed to improve patient management. references 1. weiser tg, haynes ab, molina g, lipsitz sr, esquivel mm, uribe-leitz t, et al. size and distribution of the global volume of surgery in 2012. bull world health organ. 2016;94(3):201–9f. 2. international surgical outcomes study group. global patient outcomes after elective surgery: prospective cohort study in 27 low-, middleand high-income countries. br j anaesth. 2016;117(5):601– 9. 3. horan tc, culver dh, gaynes rp, jarvis wr, edwards jr, reid cr. nosocomial infections in surgical patients in the united states, january 1986–june 1992. national nosocomial infections surveillance (nnis) system. infect control hosp epidemiol. 1993;14(2):73–80. 4. christaki e, giamarellos-bourboulis ej. the complex pathogenesis of bacteremia: from antimicrobial clearance mechanisms to the genetic background of the host. virulence. 2014;5(1):57–65. 5. cruz ff, rocco pr, pelosi p. antiinflammatory properties of anesthetic agents. crit care. 2017;21:67. 6. dąbrowska am, słotwiński r. the immune response to surgery and infection. cent eur j immunol. 2014;39(4):532–7. 7. ombelet s, barbé b, affolabi d, ronat jb, lompo p, lunguya o, et al. best practices of blood cultures in lowand middlealthea medical journal december 2021 althea medical journal. 2021;8(4) 187 income countries. front med (lausanne). 2019;6:131. 8. chmielarczyk a, pomorska-wesołowska m, romaniszyn d, wójkowska-mach j. healthcare-associated laboratoryconfirmed bloodstream infections-species diversity and resistance mechanisms, a four-year retrospective laboratory-based study in the south of poland. int j environ res public health. 2021;18(5):2785. 9. biccard bm, madiba te, kluyts h-l, munlemvo dm, madzimbamuto fd, basenero a, et al. perioperative patient outcomes in the african surgical outcomes study: a 7-day prospective observational cohort study. lancet. 2018;391(10130):1589–98. 10. avishai e, yeghiazaryan k, golubnitschaja o. impaired wound healing: facts and hypotheses for multi-professional considerations in predictive, preventive and personalised medicine. epma j. 2017;8(1):23–33. 11. li py, yang d, liu d, sun sj, zhang ly. reducing surgical site infection with negative-pressure wound therapy after open abdominal surgery: a prospective randomized controlled study. scand j surg. 2017;106(3):189–95. 12. chacon e, eman p, dugan a, davenport d, marti f, ancheta a, et al. effect of operative duration on infectious complications and mortality following hepatectomy. hpb (oxford). 2019;21(12):1727–33. 13. li l, huang h. risk factors of mortality in bloodstream infections caused by klebsiella pneumonia: a single-center retrospective study in china. medicine (baltimore). 2017;96(35):e7924. 14. owens cd, stoessel k. surgical site infections: epidemiology, microbiology and prevention. j hosp infect. 2008;70 suppl 2:3–10. 15. gifford c, christelis n, cheng a. preventing postoperative infection: the anaesthetist’s role. continuing education in anaesthesia critical care and pain. 2011;11(5):151–6. irfaan adam, yoshan moodley: positive postoperative blood cultures in major abdominal surgery patients attending a tertiary hospital in durban, south africa amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 32 lipid profile in early and late stage among patients with nephrotic syndrome-related chronic kidney disease in dr. hasan sadikin general hospital bandung, indonesia in 2016−2019 haya hanif mahardika,1 ahmedz widiasta,2 viramitha kusnandi rusmil2 1faculty of medicine universitas padjadjaran, indonesia, 2department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: ahmedz widiasta, dr., sp.a(k), m.kes, department of child health, faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, jalan pasteur no. 38, bandung, indonesia, e-mail: ahmedzwidiasta@gmail.com introduction according to the national kidney foundation disease outcome quality initiative (nkf k/doqi), chronic kidney disease (ckd) is defined as kidney abnormalities whether it is structurally or functionally, present for ≥3 months with significant impact on the health with or without decreased glomerular filtration rate (gfr) <60 ml/min/1.73 m2 body surface area (bsa).1–3 ckd is a major health problem in children with an increased prevalence globally. the annual incidence rate is 8%.4 based on data from riset kesehatan dasar (riskesdas) 2018, the prevalence of ckd among adolescents (≥15 years old) in west java is 0.48%, of which dyslipidemia is the major risk factor.5 a research conducted in dr. hasan sadikin general hospital bandung in 2016, the number of children’s ckd cases was 52.6 nephrotic syndrome (ns) is commonly found in children. according to the international study of kidney disease in children (iskdc), ns is defined as having proteinuria >40 mg/ m2/hour with hypoalbuminemia, swelling, and hyperlipidemia.7 globally, its incidence is 2–7 cases/100.000 children. patients with progressive ns in resistant-steroid type might lead ckd and or end-stage kidney disease (eskd).7 hyperlipidemia is one of the several manifestations of ns and is caused by increased lipoprotein synthesis by the liver and decreased lipoprotein lipase activity.8 hypercholesterolemia has been reported in children with ns.9,10 dyslipidemia, a known risk factor for atherosclerosis, has become the main focus in clinical research, althea medical journal. 2023;10(1):32–36 abstract background: chronic kidney disease (ckd) is a major health problem in children with an increased prevalence globally. ckd is strongly associated with nephrotic syndrome (ns) and dyslipidemia, which become a progressive factor of ckd. this study aimed to describe the lipid profile of children with ckd and ns in dr. hasan sadikin general hospital bandung, indonesia. methods: an observational-retrospective study was conducted with a cross-sectional design involving 150 medical records of children aged 1−18 years who were diagnosed with ckd with ns. lipid profile data, including total cholesterol, triglycerides, ldl, and hdl, were collected from 2016−2019 using the total sampling method. subjects with incomplete lipid profile data were excluded from the study. results: among the fifty-two children that were eligible and fulfilled the inclusion criteria, 88.5% were diagnosed with stage 1 ckd, and 32.7% were aged between 6−11 years and boys were predominant (67.3%). lipid profile changes were found in the ldl, hdl, and total cholesterol serum levels between ckd stage i and ii–v. conclusions: lipid profile of ckd pediatric patients with ns in dr. hasan sadikin general hospital bandung in 2016−2019 showed hypertriglyceridemia and hypercholesterolemia. most subjects were in stage i of ckd and steroid-resistant nephrotic syndrome, and comparison between stages of ckd and types of nephrotic syndrome is lacking. a prospective analytical study would be more reliable in proofing its significance. keywords: chronic kidney disease, cholesterol, lipid profile, nephrotic syndrome, triglyceride https://doi.org/10.15850/amj.v10n1.2524 althea medical journal. 2023;10(1) 33 as it is a potentially modifiable risk factor.10,11 however, the study regarding the lipid profile of pediatric ckd and ns in dr. hasan sadikin general hospital bandung is limited. in addition, dyslipidemia, as one of the factors contributing to the progression of pediatric ckd, is often under-treated despite notable advances in its treatment.12 this study aimed to describe the lipid profiles in children with ckd and ns in dr. hasan sadikin general hospital bandung from 2016 to 2019. this study may suggest a new strategy for treatment plans early as possible. furthermore, this study may increase clinicians’ knowledge and awareness regarding lipid profiles in children with ckd and ns, and might serve as a new basis for future research. methods this study was an observational study with a cross-sectional design. data on children diagnosed with ckd with ns in dr. hasan sadikin general hospital bandung in 2016−2019 were retrieved from hospital information system of hasan sadikin general hospital. furthermore, complete lipid profile laboratory examinations were collected. inaccessible medical records were excluded from this study. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran no. 74/un6.kep/ec/2019 and lb.02.01/x.2.2.1/1722/2019. data on subjects’ characteristics such as age, gender, and laboratory results of lipids were collected. age was defined as the patient’s age at the time of ckd diagnosis. the children’s age was based on the national institute of child health and human development (nichd) standard and categorized into infant (<2 years old), toddler (2−5 years old), early childhood (6−11 years old), and adolescent (12−18 years old).13 lipid laboratory results were categorized based on the american academy of pediatrics (aap) 2020.14,15 triglyceride (tg) values were categorized differently for 1−9 years and >9−18 years-age group. for 1−9 years-age group, triglycerides value was categorized into acceptable (<75 mg/dl), borderlinehigh (75−99 mg/dl), and high (≥100 mg/dl), whereas for the >9-18 years-age group, acceptable (<90 mg/dl), borderlinehigh(90−129 mg/dl); high (≥130 mg/dl). total cholesterol (c) values were categorized into acceptable (<170 mg/dl), borderlinehigh (170−199 mg/dl), and high (≥200 mg/ dl). the ldl values were categorized into acceptable (<110 mg/dl), borderline-high (110−129 mg/dl), and high (≥130 mg/dl). the hdl values were categorized into low (<40 mg/dl), borderline-high (40−45 mg/dl), and acceptable(>45 mg/dl).14 diagnosis and stages of ckd were based on diagnosis in the medical records. all analyses were performed with microsoft® excel2016 dan ibm® spss® ver 22. the data were presented as mean and standard deviation. results of the 150 patients’ data collected, only 52 met the inclusion criteria namely children aged 1−18 years , diagnosed with ckd and ns and had their lipid profile examined, including total cholesterol, triglycerides, ldl, and hdl. the lipid profiles in the other subjects were excluded due to their inadequacy lipid profile data. some subjects only had their cholesterol haya hanif mahardika et al.: lipid profile in early and late stage among patients with nephrotic syndromerelated chronic kidney disease in dr. hasan sadikin general hospital bandung , indonesia in 2016−2019 table 1 characteristics of children with chronic kidney disease on stages of nephrotic syndrome (n=52) characteristics stage of ns based ckd stage i n(%) stage ii–v n(%) age group <2 years 2−5 years 6−11 years 12−18 years 5(9.6) 16(30.8) 17(32.7) 8(15.4) 0(0) 1(1.9) 3(5.7) 2(3.8) gender male female 31(59.7) 15(28.8) 4(7.6) 2(3.8) note: ckd= chronic kidney disease; ns= nephrotic syndrome althea medical journal. 2023;10(1) 34 or triglyceride tests because of the standards applied by the health system by the hospital before the study was conducted. the characteristics of children in the age group 6−11 years had the highest number (38.5%), followed by the age group 2−5 years (32.7%). more than half of the subjects were comprised of boys (67.3%) with a mean age of 7.23 ± 4.5 years. stage i ckd has a higher frequency than stage ii–v. in general, the subjects had high category lipid laboratory measurement results. the majority of subjects were ckd stage i with steroid-resistant nephrotic syndrome (92.3%) as illustrated in table 2. based on laboratory results of lipid measurements, triglyceride values in the two age groups 1−9 and >9−18 years were included in the high category. interestingly, in the 1−9 years of age group, 61.5% were ckd stage 1, whereas in the >9−18 years it was 26.9%. the high category was also found in other lipid measurement values. of all subjects at all stages of ckd, 61.5% had high total cholesterol serum and 21.1% were in the acceptable category. the ldl result also showed 61.5% were in the high category. similar to other lipid measurements, hdl was shown at 55.8%, which was in the acceptable category as shown in table 2. discussions hypertriglyceridemia, hypercholesterolemia, or combined dyslipidemia have been found in more than half of the children, whereas most of them were diagnosed with stage 1 ckd and steroid-resistant nephrotic syndrome. hypertriglyceridemia was found in both groups of 1–9 years old and >9–18 years old, and the majority had stage 1 ckd due to reduced activity of lipoprotein lipase in plasma.16,17 in contrast, higher triglyceride level in the higher ckd stage were found in adult cases.6 the discrepancies between child and adult cases were caused by the underlying mechanism. most ckd in adulst was related to diabetes mellitus, obesity, and hypertension.6 hence the change in lipid profile is usually found in the early stage of ckd. in children, most ckd is related to glomerular disease and congenital anomalies. in contrast, the althea medical journal march 2023 table 2 laboratory results of lipid measurement of children with chronic kidney disease and nephrotic syndrome based on stages (n=52) mean ± sd total stage i n(%) stage ii–v n(%) triglycerides, 1−9 years of age; n=35 acceptable borderline-high high 269.88 ± 204.3** 2 (3.8) 4 (7.7) 29 (55.8) 2 (3.8) 3 (5.7) 27 (51.9) 0 (0) 1 (1.9) 2 (3.8) triglycerides, >9−18 years of age; n=17 acceptable borderline-high high 2 (3.8) 5 (9.6) 10 (19.2) 2 (3.8) 5 (9.6) 7 (13.5) 0 (0) 0 (0) 3 (5.7) total cholesterol acceptable borderline-high high 309.1 ± 175.5 11 (21.2) 9 (17.3) 32 (61.5) 10 (19.2) 7 (13.5) 29 (55.8) 1 (1.9) 2 (3.8) 3 (5.7) ldl acceptable borderline-high high 223.3 ± 158 14 (26.9) 6 (11.5) 32(61.5) 13 (25) 4 (7.7) 29(55.8) 1 (1.9) 2 (3.8) 3(5.7) hdl acceptable borderline-high low 48.8 ± 17.3 29(55.8) 9(1.3) 14(26.9) 26(50) 8(1.,4) 12(23) 3(5.7) 1(1.9) 2(3.8) note: ** both aged groups; results were reported using mean and standard deviation for quantitative variables althea medical journal. 2023;10(1) 35 histologic morphology of vessels and the heart were still normal.3,6 the dyslipidemic condition reflects an altered metabolism of lipoprotein. the suggested mechanisms are dyslipidemic condition, which might be due to decreased activity of lecithin cholesterol acyltransferase (lcat), hepatic lipase due to proteinuria, and lipoprotein lipase. these reduced enzyme activities affects lipoprotein metabolism and have its mechanisms. reduced activity of lcat, possibly due to its deprivation in plasma, results in a depletion of cholesterol ester esterification from cholesterol to be carried by hdl and impair the hdl maturation, leading subsequently to sustained triglycerides enrichment of hdl and explaining hypertriglyceridemia condition. this mechanism is compound with the depletion of lcat.18,19 it is also reported that decreased lipoprotein lipase is responsible for ldl elevation due to impaired cholesterol transfer into peripheral tissue.16 in the patient with ckd only, reduced hdl level in serum is commonly found.20 while in this study, a significant high hdl, low ldl, and total cholesterol serum levels were found in the early ckd stage, consistent with a study on a nephrotic patient in which normal to reduced hdl.8,16 nephrotic range proteinuria affects the clearance of hdl in circulation by decreasing hepatic lipase activity in liver. increased cholesteryl ester transfer protein (cetp), reduced hepatic expression of scavenger receptor-b 1 (sr-b1), and lcat loss are the mechanism suggested that causing hdl metabolism dysfunction results in cholesterol ester-poor and triglyceride-rich lipoprotein; thus normal-to-low hdl found in serum. the majority of the children are not at stage 1 ckd and proteinuria. these account for acceptable hdl serum. in the early stages of ckd, commonly found an acceptable or decreased hdl serum level condition while reduced hdl is generally present in patients with advanced ckd and esrd.21 the limitation of this study is that not all pediatric ckd patients with ns have lipid profile analysis, thereby reducing the number of potential subjects to be included in the sample. furthermore, the lipid profile of patients with ckd and ns should be tested as early as possible after the diagnosis is established. the data do not represent all stages in ckd or ns, because most of the subjects were ckd stage i and steroid-resistant ns resulting in a lack of comparison between stages of ckd and types of ns. more advanced statistical analysis would be more reliable in proving the significance of this study. as a consideration, the condition of worsening dyslipidemia might be complicated by cardiovascular disease, as it is known as a risk factor for atherosclerosis. thus, children with ckd should be screened for dyslipidemia.22,23 in conclusion, dyslipidemic children mostly found in the early stage of ckd. this study only provides a temporary picture of lipid profile in a short period which prevents the collection of more comprehensive data on patients size and numbers. a future prospective study with a longer period is needed to monitor the lipid profile in relation to the progression of ns and ckd. references 1. inker la, astor bc, fox ch, isakova t, lash jp, peralta ca, et al. kdoqi us commentary on the 2012 kdigo clinical practice guideline for the evaluation and management of ckd. am j kidney dis. 2014;63(5):713–35. 2. levin a, stevens pe., bilous rw, coresh j, de fransisco alm, de jong pe, et al. kidney disease: improving global outcomes (kdigo) ckd work group. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney int suppl. 2013;3(1):1–150. 3. becherucci f, roperto rm, materassi m, romagnani p. chronic kidney disease in children. clin kidney j. 2016;9(4):583-91. 4. halle mp, lapsap ct, barla e, fouda h, djantio h, moudze bk, akazong ca, priso eb. epidemiology and outcomes of children with renal failure in the pediatric ward of a tertiary hospital in cameroon. bmc pediatr. 2017;17(1):202. 5. badan penelitian dan pengembangan kesehatan. riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan;2018. 6. widiasta a, pardede so, rachmadi d. correlation between ldl, hdl, total cholesterol , and triglyceride with the degree of chronic kidney disease in children. am j clin med res. 2017;5(1): 1–5. 7. hussain n, zello ja, vasilevska-ristovska j, banh tm, patel vp, patel p, et al. the rationale and design of insight into nephrotic syndrome: investigating genes, health and therapeutics (insight): a prospective cohort study of childhood haya hanif mahardika et al.: lipid profile in early and late stage among patients with nephrotic syndromerelated chronic kidney disease in dr. hasan sadikin general hospital bandung , indonesia in 2016−2019 althea medical journal. 2023;10(1) 36 nephrotic syndrome. bmc nephrol. 2013;14:25. 8. pandey jc, prasad ck. lipid profile abnormalities in nephrotic syndrome. asian j biomed pharm sci. 2016;6(54): 17–19. 9. dnyanesh d, dnyanesh s, shenoy v. a study of serum lipids in nephrotic syndrome in children. iosr j dent med sci 2014;13(3): 1–6. 10. krishnaswamy d, indumati v, satishkumar d, vijay v, shekanawar maharudra, maligi amareshwara, et al. serum proteins, initial and follow-up lipid profile in children with nephrotic syndrome. int j appl biol pharm technol. 2011;2(3): 59–64. 11. said s, hernandez gt. the link between chronic kidney disease and cardiovascular disease. j nephropathol. 2014;3(3):99– 104. 12. wilson ac, schneider mf, cox c, greenbaum la, saland j, white ct, et al. prevalence and correlates of multiple cardiovascular risk factors in children with chronic kidney disease. clin j am soc nephrol. 2011;6(12):2759–65. 13. national institute of child health and human development us department of health and human services. the nichd study of early child care and youth development: findings for children up to age 4 1/2 years [internet]. washington, dc: us government printing office; 2006. [cited 2021 august 28]. available from: https://www.nichd.nih.gov/publications/ product/20 14. stewart j, mccallin t, martinez j, chacko s, yusuf s. hyperlipidemia. pediatr rev. 2020;41(8):393–402. 15. expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents; national heart, lung, and blood institute. expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. pediatrics. 2011;128 suppl 5(suppl 5):s213–56. 16. vaziri nd. disorders of lipid metabolism in nephrotic syndrome: mechanisms and consequences. kidney int. 2016;90(1):41– 52. 17. chan dt, dogra gk, irish ab, ooi em, barrett ph, chan dc, et al. chronic kidney disease delays vldl-apob-100 particle catabolism: potential role of apolipoprotein c-iii. j lipid res. 2009;50(12):2524–31. 18. blaton v. dyslipidemia at chronic renal failure. ejifcc. 2009;20(1):59–66. 19. ooi em, chan dt, watts gf, chan dc, ng tw, dogra gk, et al. plasma apolipoprotein c-iii metabolism in patients with chronic kidney disease. j lipid res. 2011;52(4):794–800. 20. saland jm, pierce cb, mitsnefes mm, flynn jt, goebel j, kupferman jc, et al. dyslipidemia in children with chronic kidney disease. kidney int. 2010;78(11):1154–63. 21. vaziri nd. hdl abnormalities in nephrotic syndrome and chronic kidney disease. nat rev nephrol. 2016;12(1):37–47. 22. mitsnefes mm. cardiovascular disease in children with chronic kidney disease. j am soc nephrol. 2012;23(4):578–85. 23. tian j, niu l, an x. cardiovascular risks in chronic kidney disease pediatric patients. exp ther med. 2017;14(5):4615–9. althea medical journal march 2023 althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 6 amj june, 2014 effect of topical application of binahong [anredera cordifolia (ten.) steenis] leaf paste in wound healing process in mice gurwinder kaur a/p gurcharan singh1, novi vicahyani utami2, hermin aminah usman3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of pathology anatomic, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: wound caused by trauma poses challenging daily clinical problems for physicians in hospitals and other health services. it has high risk for mortality and morbidity. binahong [anredera cordifolia (ten.) steenis] plant originates from china and can be found abundantly in indonesia. the objective of this research is to investigate the effect of topical application of binahong leaf paste on wound healing process. methods: a laboratory experimental study was conducted at the pharmacology laboratory, universitas padjadjaran, from october to december 2012 by using 27 mus muscularis mice which were divided into 3 groups: group 1 (sodium chloride 0.9%), group 2 (binahong) and group 3 (povidone iodine 5%). binahong leaves were crushed and were mixed with water to make a paste. the application was given for 12 days. on day zero, 1.0 cm2 of wound was incised at the back of the mice, and further on day 1, 4, 8 and 12, the percentage of wound contraction was measured. the data was analyzed using mann-whitney test. results: the study indicated that the percentage of wound contraction in group 2 on day 4 (1.17%), day 8 (23.7%) and day 12 (76.14%) is the highest among all groups. the result showed that the comparison between binahong and nacl was highly significant on day 12, p= 0.001 (p < 0.05) and the data for comparison between binahong and povidone iodine on day 12 was significant with p= 0.003 (p < 0.05). conclusions: topical application of binahong leaf paste shows better result in wound healing process of mus muscularis mice. from this study it can be concluded that binahong promotes wound healing and can be used for home remedies for wound care and as an alternative traditional way to treat wound. [amj.2014;1(1):6–11] keywords: binahong [anredera cordifolia (ten.) steenis], povidone iodine, wound healing efek aplikasi pasta daun binahong [anrederacordifolia (ten.) steenis] secara topikal dalam proses penyembuhan luka pada tikus jenis musmuscularis abstrak latar belakang: luka yang disebabkan oleh trauma menjadi masalah klinis yang menantang bagi para dokter di rumah sakit maupun bagi petugas kesehatan lainnya dalam melakukan pekerjaan sehari-hari. luka yang timbul tersebut memiliki risiko yang tinggi terhadap mortalitas dan morbiditas. tanaman binahong [anrederacordifolia (ten.) steenis] berasal dari cina dan banyak ditemukan di indonesia. tujuan dari penelitian untuk mengetahui efek dari aplikasi pasta daun binahong secara topikal terhadap proses penyembuhan luka. metode: penelitian eksperimental ini dilakukan di laboratorium farmakologi, universitas padjadjaran, mulai oktober–desember 2012, menggunakan tikus jenis musmuscularis sebanyak 27 ekor, dibagi menjadi 3 kelompok: kelompok 1 (natrium klorida 0,9%), kelompok 2 (pasta daun binahong) dan kelompok 3 (povidone iodine 5%). daun binahong dihancurkan dan ditambahkan sedikit air sehingga menjadi bentuk pasta. perlakuan diberikan selama 12 hari. pada hari 0 dilakukan insisi pada punggung tikus untuk membuat luka sebesar 1,0 cm2. persentase kontraksi luka akan dinilai pada hari ke-1, 4, 8, dan 12. kontraksi luka correspondence: gurwinder kaur a/p gurcharan singh, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170206321, email: gurwin2789@yahoo.com althea medical journal. 2014;1(1) 7 adalah pengurangan luas pada area luka. hasil penilaian tersebut akan dibandingkan pada tiap kelompok untuk melihat efektivitas aplikasi topikal pasta daun binahong. data akan dianalisis dengan uji mannwhitney. hasil: hasil penelitian menunjukkan bahwa persentase kontraksi luka kelompok 2 pada hari ke-4 (1,17%), hari ke-8 (23,7%), dan hari ke-12 (76,14%) adalah lebih tinggi dibandingkan dengan kelompok lainnya. hasil juga menunjukkan bahwa terdapat perbedaan sangat signifikan antara perbandingan binahong dan natrium klorida pada hari ke-12, dengan p=0,001 (p<0,05). perbandingan antara binahong dan povidone iodine pada hari ke-12 juga menunjukkan hasil signifikan dengan p=0,003 (p<0,05). simpulan: aplikasi pasta daun binahong secara topikal menunjukkan hasil yang lebih baik dalam proses penyembuhan luka pada tikus jenis musmuscularis. dari penelitian ini dapat disimpulkan bahwa binahong mempercepat penyembuhan luka serta dapat digunakan untuk perawatan luka di rumah dan sebagai cara alternatif yang bersifat tradisional untuk mengobati luka. kata kunci: binahong [anrederacordifolia (ten.) steenis], penyembuhan luka, povidone iodine introduction wound caused by trauma poses challenging clinical problems for physicians in hospitals and other health services in their daily work.1 it is a pathological process which results in the disruption of the continuity of the skin and its underlying tissues due to physical injury.2,3 it is estimated that 10.5 of 1000 population currently suffers from acute wound.4 acute wound takes 5−10 days to heal.1 acute wound that is not managed well can progress into chronic wounds which are more difficult to manage.4 chronic wounds take longer time to heal, which may range from weeks up to 2 years.1 worldwide, 6 million people suffers from chronic wounds.4 wound is a major problem that relates to the high risk of mortality and morbidity.1 wound management is important for the healing process to decrease mortality and morbidity. healing process is essential to restore the continuity and function of the skin and its underlying tissues to their normal condition.5,10 therefore, to be able to treat wound as soon as possible at home, some communities tend to prefer herbal medicine compared to conventional medicine because it is more accessible. in addition, herbal medicine is less expensive, less toxic, less side effects and easier to use.4,6 one of the herbal remedies used by the indonesian community to treat wound is binahong [anredera cordifolia (ten.) steenis].7 this basellaceae family plant is originated from china.8 it is found abundantly in indonesia and contains active components that are beneficial. it has many pharmacological properties such as antimicrobial, anti-inflammatory, anticancer, antioxidant, antifungal, and antitumor properties.8-10 the active components in this plant include saponin, tannins, terpenoids, alkaloids and flavonoid. saponin seems to have an effect on the activation and synthesis of transforming growth factor-β (tgf-β1) and also on modification of tgf-β1 and tgf-β2 receptors in fibroblasts.7 this is essential for the formation of the collagen matrix in the remodeling phase.5 therefore, binahong is expected to increase the rate of the healing process. binahong leaf extract increases wound healing process.10 however there is no research that has been conducted to observe the effect of topical application of binahong leaf paste on wound healing process. this study can provide information to the community about the benefits of binahong leaf paste for wound healing. in this research, topical application of binahong and povidone iodine in mus muscularis mice was compared. povidone iodine is an antiseptic agent that serves as standard requirement for every wound care and for pre-operative procedures in hospitals and general practices worldwide.11 the percentage of wound contraction as the effect of topical application of binahong leaf paste on wound healing process in mus muscularis mice was compared to that of the povidone iodine. the higher percentage of wound contraction indicates better wound healing process. methods this research is an experimental study on mus muscularis mice which were randomly divided into 3 groups. each group contained 27 mus muscularis model mice that were male, aged gurwinder kaur, novi vicahyani utami, hermin aminah usman: topical application of binahong [anredera cordifolia (ten.) steenis] leaf paste for wound healing process in mice althea medical journal. 2014;1(1) 8 amj june, 2014 2−3 months, weighing 17−25 g, and healthy. fresh binahong leaves used in this study was obtained from jalan sukawening, bandung. the leaves were identified in the plant taxonomy laboratory of universitas padjadjaran. next, the fresh leaves were washed thoroughly few times under running tap water. sterilization was done by steaming the leaves in boiling water with a temperature of 100 celsius in a cooker for 15−20 minutes. the leaves were then dried in room temperature for few minutes and then crushed thoroughly using a stir bar. some water was added to create the paste form. an incision was performed to induce wounds in mice. injection of 1.0 ml phenobarbitol was performed at the dorsal midline to keep the mice unconscious and to eliminate pain sensation during wound incision. after 15−20 minutes, all the mice were checked for their consciousness and the experiment was started after the mice were unconscious. next, all mice were shaved at the back around the area of dorsal midline region using a shaver. then, 1.0 cm2 diameter was measured using the vernier caliper and a permanent marker was used to create a square on the mice to indicate the site of incision. after few seconds, a scalpel was used to make the incision over the marked area. skin on the back of the mice was pinched between the thumb and index finger to make sure the skin that will be wounded is incised and cut using scissors. the groups were treated by nacl 0.9%, binahong leaf paste and 5% povidone iodine respectively. before the binahong leaf paste was applied, the wounded area was cleaned. this procedure was performed twice daily for 12 days. the percentage of wound healing from the group treated with binahong was then compared to the mice treated with nacl and povidone iodine. to measure wound healing process in this study, the percentage of wound contraction (%) technique has been implemented. the size of the wounded area was measured using ruler in centimeter (cm) and was calculated. progressive changes in the wounded area were examined on day 1, 4, 8, and 12. the percentage of wound contraction is calculated as a percentage of the reduction in wounded area using the following formula: [(initial wound area-specific day wound area) / initial wound area] × 100%. the data was analyzed statistically using non parametric (mann-whitney) test. the p-value for statistic significancy was set on (<0.05). the research was conducted during the period of october−november 2012 at the pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran, bandung, indonesia. the study was carried out with prior approval from the animal ethical committee, faculty of medicine, universitas padjadjaran. results a total of 27 mice were recruited in this study. during observation, it was found that mice number 5 (group 2) and mice number 1 (group 3) had large increase in wound area, therefore excluded from the study. from figure 1, it can be seen that there was no changes in mean for all the 3 groups figure 1 mean percentage of wound contraction in three groups on day 0, 1, 4, 8 and 12 althea medical journal. 2014;1(1) 9gurwinder kaur, novi vicahyani utami, hermin aminah usman: topical application of binahong [anredera cordifolia (ten.) steenis] leaf paste for wound healing process in mice during the 1st day. the control group which only received topical application of nacl twice daily, showed decrease in percentage (-1.15%) on day 4. on day 8, the percentage increased to 15.03%. it was shown that the mean of the highest percentage of the control group from day 1 to day 12 was 32%. meanwhile, for the treatment group which received topical application of binahong twice daily, it can be seen that there was an increase in percentage of wound area from day 1 to day 12 with the highest percentage of 76.14%. on day 4, the mean percentage was 1.17% and on day 8 the mean was 23.7%. it can be also seen from table 1 that for group 3, which received topical application of povidone iodine twice daily, the highest mean percentage from day 1 to day 12 was 48.67%. on day 4, the mean percentage was -0.56%, and on day 8 it was 15.77%. there was no significant difference between the percentage of wound contraction (%) in group 1 & 2 on day 1, 4 and 8 as the p-value was more than 0.05. the p-value on day 12 was less than 0.05 which showed that it was significant, thus it can be concluded that binahong is better than sodium chloride in wound healing process. there was no significant difference between the wound contraction (%) percentage in group 2 and 3 on day 1, 4 and 8 as the p-value was more than 0.05. the p-value on day 12 was less than 0.05 which showed that it was significant. thus, it can be concluded that binahong is better than povidone iodine in wound healing process. discussion wound healing of the skin can be divided into 3 phases: inflammatory, proliferative and remodeling phase. the inflammatory phase is the initial phase which ranges from 2−6 days.6 binahong leaf paste has antiseptic and anti-inflammatory effects. one of the active ingredients of binahong plant is saponin. it has properties that make the wound site microbefree. this compound binds to the bacteria and alters its membrane permeability, thus resulting in destruction of the bacteria.12 therefore, saponin prevents delayed wound healing caused by microorganisms. in addition, saponin increases tgf-β1 activity which recruits the inflammatory cells to the wounded site, thus accelerating the inflammatory phase.5 interestingly, in group treated with povidone iodine, there was a decrease in wound percentage. povidone iodine only contains antiseptic property. it has free iodine elements which interact with the enzymes and proteins of the cell wall leading to disruption of the structure. this results in death of the microbes.11 the decrease in wound percentage could be caused by certain fungus or bacterial spore infection to the mice. povidone iodine may require a longer time to kill certain microorganisms. the next phase of wound healing process is the proliferative phase (day 6−10).5 the proliferative phase (reepithelization and neovascularisation) which is optimum on day 5.6 the wound healing as expected was better in phase 2 (day 4−8) in all groups, and the healing process was the best in group 2 as it is shown to have a higher wound contraction percentage. this might be due to saponin property in binahong leaves that acts as an angiogenic agent. it regulates the vascular endothelial growth factor (vegf) expression which causes an increase in the mitogenic activity of the endothelial cells for the formation of new blood vessels. saponin, thus, increases the angiogenesis process in the proliferative phase.5 in contrast, in this phase it can be seen that there is no difference in increment in wound contraction percentage in both nacl and povidone iodine. therefore, both treatments have no effect on wound healing process. the last phase in the wound healing process is the remodeling phase (day 10−12).5 table 1 mann-whitney test results on the comparison of percentage of wound contraction between group 1 (sodium chloride/ control) and group 2 (binahong) day wound contraction percentage p-value interpretation group 1 group 2 1 0 0 0.743 not significant 4 -1.15 1.17 0.888 not significant 8 15.03 23.17 0.200 not significant 12 32 76.14 0.001 significant althea medical journal. 2014;1(1) 10 amj june, 2014 the data shows that in term of the percentage of wound contraction on day 12, the highest percentage was observed in the group treated with binahong compared to the groups treated with povidone iodine and nacl (76%, 48% and 32% respectively). from this data, binahong is better than povidone iodine and nacl. this can be supported based on the theory that saponin has an effect on the activation and synthesis of tgf-β1 and also in modification of tgf-β1 and tgf-β2 receptors on fibroblasts. therefore, a direct effect in the process of wound healing is due to the increase of tgf-β1 and tgf-β2 receptor expressions on fibroblasts. this will stimulate the fibronectin synthesis. fibronectin is a protein that mediates cellular adhesive interactions, by cross-linking with collagen.5 this process is to form provisional extracellular matrix which is an important step in the remodeling phase.5 the data was not significant from day 0 to day 8 and significant on day 12 in all groups. the comparison between group 1 and 2 in table 2, shows a marked difference p=0.001 .this shows that binahong is clearly better than sodium chloride. lastly, for the comparison between group 2 (binahong) and group 3 (povidone iodine) in table 3, the statistical results seem to be highly significant on day 12 (0.003). the less p-value indicates the better effect of the treatment used in the experiment. therefore, the most prominent effect of binahong can be observed on day 12 (remodeling phase), the day when the active compounds gave the most effect. in addition to its effect on tgf-β1, saponin also increases the hydroxyproline content of the granulation tissue which strengthens and supports the collagen matrix in the remodeling phase.5 compared to other researches, which is a study on ethanolic extract of anredera cordifolia (ten.) or steenis leaves which shows that the extract of binahong improves wound healing in guinea pigs. based on the results of the research, saponin, flavanoids and alkaloids found in the leaves help in the healing process.10 another wound healing based research shows that saponin has antibacterial effect which helps in accelerating healing process.12 in conclusion, topical application of binahong [anredera cordifolia (ten.) steenis] leaf paste shows a beneficial effect on higher wound contraction percentage in wound healing process in mus muscularis mice suggesting that topical application of binahong leaf paste has more benefits compared to povidone iodine. further research has to be conducted focusing on the histopathological results on the effect of binahong leaf paste in wound healing process. this will provide more evidents as the cells involved in wound healing can be observed and evaluated. therefore, binahong leaf paste can be use widely as an alternative for wound care after further research is conducted. references 1. velnar t, bailey t, smrkolj v. the wound healing process: an overview of the cellular and molecular mechanisms. j int med res. 2009;37(5):1528−42. 2. solanki r. treatment of skin diseases through medicinal plants in different region of the world. ijbr. 2011;2(1):73−80. 3. arunachalam kd, subashini s. preliminary phytochemical investigation and wound healing activity of myristica andamanica leaves in swiss albino mice. j med plant res. 2011;5(7):1095−106. 4. sasidharan s, nilawatyi r, xavier r, latha ly, amala r. wound healing potential of elaeis guineensis jacq leaves in an infected albino rat model. molecules. 2010;15(5):3186−99. 5. william s, rebecca g. robbins and cotran pathologic basis of disease. 8th ed.; table 2 mann-whitney test results on the comparison of wound contraction percentage between group 2 (binahong) and group 3 (povidone iodine) day wound contraction percentage p-value interpretation group 2 group 3 1 0 0 0.442 not significant 4 1.17 -0.56 0.878 not significant 8 23.17 15.77 0.328 not significant 12 76.14 48.67 0.003 significant althea medical journal. 2014;1(1) 11 philadelphia: saunders elsevier; 2010. 6. singer aj, clark ra. cutaneous wound healing. n engl j med. 1999;341(10):738−46. 7. yuliani sh, fudholi a, pramono s, marchaban. the effect of formula to physical properties of wound healing gel of ethanolic extract of binahong [anredera cordifolia (ten.) steenis]. ijpsr. 2012;3 (11):4254−9. 8. sumartiningsih s. the effect of binahong to hematoma. world academy of science, engineering and technology. 2011;5(6): 679−81. 9. astuti sm, sakinah m, andayani r, risch a. determination of saponin compound from anredera cordifolia (ten.) steenis plant (binahong) to potential treatment for several diseases. journal of agricultural science. 2011;3(4):224−32. 10. miladiyah i, prabowo br. ethanolic extract of anredera cordifolia (ten.) steenis leaves improved wound healing in guinea pigs. univ med. 2012;31(1):4−11. 11. kumar s, babu r, reddy i, uttam a. povidone iodine-revisited. ijda. 2011;3(3):617−20. 12. keerthi aap, mendis wsj, jansz er, ekanayake s, perera msa. a preliminary study on the effects of an antibacterial steroidal saponin from borassus flabellifer l. fruit, on wound healing. j natn sci foundation sri lanka. 2007;35(4):263−5. gurwinder kaur, novi vicahyani utami, hermin aminah usman: topical application of binahong [anredera cordifolia (ten.) steenis] leaf paste for wound healing process in mice amj vol 8 no 1 march 2021 final.indd althea medical journal. 2021;8(1) 24 althea medical journal march 2021 anti-migration effect of aaptos suberitoides fraction in hct-116 colorectal cancer cell line dany muhammad daffa,1 muhammad hasan bashari,2 eko fuji ariyanto,2 tenny putri,3 nurul qomarilla3 1faculty of medicine, universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3laboratory of advanced biomedicine, faculty of medicine, universitas padjadjaran, indonesia correspondence: dany muhammad daffa, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km.21, sumedang, indonesia, e-mail: dany17001@mail.unpad.ac.id introduction cancer is one of the non-communicable diseases that ranks second in mortality rate worldwide of which colorectal cancer is the second most common prevalent according to the world health organization (who) data in 2018.1 nowadays, colorectal cancer treatments have a good prognosis when it is treated in early-phase. unfortunately, most patients come in a late-phase conditions leading to ineffective treatment.2 latephase treatment may also lead to unwanted side effects and complications. moreover, chemotherapy causes weakness, shortness of breath, diarrhea, constipation, and even heart attack.3,4 therefore, patients need more effective treatment in suppressing cancer activity to increase life expectancy and inhibit metastasis. indonesia is an archipelagic country with a sea covering a two-third area of the country. the ocean has high marine biodiversity and marine biota is known to have a good impact on health, amongst many of them is sea sponge. sea sponge apparently can be utilized for cancer treatment.5 an example of this is eribulin, a halichondria okadai derivate that has been used for the treatment of breast cancer and liposarcoma metastatis.6 another sea sponge that has potency as an anti-cancer agent is aaptos suberitoides. one active compound, aaptamine, has been known with invitro to have anti-cancer activity.7 the aaptos suberitoides extract can inhibit 20–40% migration activity in hct-116.8 in the hcc1954 cell line, this extract (5 mg/l) reveals 45.23% gap closure in 72 hours.9 moreover, this extract (5 mg/l) has a potent effect in mda-mb 231 tnbc cell line.10 amj. 2021;8(1):24–8 abstract background: colorectal cancer is the second leading cause of mortality and the most prevalent cancer worldwide. most patients, who come with late-stage, have ineffective treatments and some side effects in chemotherapy. aaptos suberitoides has potential anti-cancer effects due to its bioactive compounds such as aptamine. this study aimed to evaluate the migration inhibition effect of aaptos suberitoides fraction in hct-116 cell line. methods: this study was an experimental study. aaptos suberitoides specimen was taken in tinjil island and fractionated with ethyl acetate. hct-116 cell line was added with aaptos suberitoides fraction and cellular migration activity was observed in 48 hours of which the scratch assay was performed. the gap closure area was determined with imagej software. results: the data showed that a low concentration of aaptos suberitoides fraction inhibited migration activity in hct-116 cell line as follow; 1 and 5 mg/l aaptos suberitoides fraction inhibit 3-4 % cancer cell migration in 24 hours, and 10-11% inhibition in 48 hours, respectively. however, 10 mg/l fraction concentration only inhibited 7-14% of the migration effect. conclusions: aaptos suberitoides fraction suggests insignificant migration inhibition in colorectal cancer cells and only inhibits less than 15 % hct-116 cell line. keywords: aaptos suberitoides, hct-116, scratch assay https://doi.org/10.15850/amj.v8n1.2231 althea medical journal. 2021;8(1) 25 to prove that aaptos suberitoides has an anti-cancer effect especially in colorectal cell line migration, we had conducted aaptos suberitoides anti-migration potency in hct116 cell line. methods this was an experimental study conducted in cell culture and cytogenic laboratory universitas padjadjaran, in august 2020. aaptos suberitoides specimen was collected from tinjil island and fractionated by liquidliquid extraction method in aquades, n-hexane, and ethyl acetate solvent. the ethyl acetate fraction, which was the most potent in those fractions was diluted with dimethylsulfoxide (dmso) 100%. fraction concentration in this research was set as 1 mg/l, 5 mg/l, and 10 mg/l based on ic50 of aaptos suberitoides maceration extract for hct-116 as published previously.8 this research used hct-116 as a cell line. the cell line was cultured in roswell park memorial institute (rpmi) medium with additional supplementation of 10% fetal bovine serum (fbs) and 1% penstrep in culture cell incubator, setin a controlled temperature at 37°c and co2 concentration in 5%. the cell was seeded in 12 well plates using different concentrations that were 0,1,5, and 10 mg/l with three replication for every treatment set in one timetrial. when measuring in vitro cells, a migration scratch assay was performed. first, this cell line was seeded in 24 hours. then the medium was changed with another medium in which fbs concentration was 1% to induce cellular starvation. this condition was needed to decrease bias when observing cell proliferation. after 18 hours, the medium was then replaced again by a medium with 10% fbs concentration. the sample was then scratched and washed with phosphate buffered saline (pbs). the gap area was captured by a microscope at 0,24, and 48 hours. gap closure area was performed by 100% (cleft treatment area in 24 or 48 hours/cleft treatment area in 0 hour x 100%). migration inhibition rate wass performed by (treated gap closure area (1 or 5 or 10 mg/l)/controlled gap closure area (0 mg/l)) -100%. the gap closure area was analyzed using imagej software. the gap closure against control were calculated with excel (microsoft, usa) software and was presented in percentage. shapiro-wilk test was performed as normality testing. one-way anova with posthoc analysis was performed as hypothesis testing and was considered statistically significant if p <0.05. results after cellular starvation, hct-116 cell line dany muhammad daffa et al.: anti-migration effect of aaptos suberitoides fraction in hct-116 colorectal cancer cell line figure 1 mean gap closure area of hct-116 treated with aaptos suberitoides fraction (0, 1, 5, and 10 mg/l) for 0,24 and 48 hours note: *p = 0.84 **p = 0.84 ***p = 1.1 althea medical journal. 2021;8(1) 26 althea medical journal march 2021 was given with aaptos suberitoides fraction as treatment in low concentration until 48 hours. our data showed that treated cells had lower migration activity than control cells. the normality test showed that the data had a normal distribution. one-way anova analysis showed that the p-value in 24 hours was 0.84 and thep-value in 48 hours was 1.13 (p >0.05) (figure 1). based on the gap closure area, in cells treated with 1 and 5 mg/l aaptos suberitoides fraction concentration, migration inhibition occurred 3–5% in 24 hours and 10– 11% in 48 hours, respectively. then in cells treated with 10 mg/l aaptos suberitoides fraction concentration, the migration inhibition is observed in 7% after 24 hours and 14% in 48 hours, respectively. the microscopic pictures were shown in figure 2. discussion the cellular gap closure in our study indicates a statistically insignificant result, although the data seems in normal variances. these results can not prove that low concentration fraction (1, 5, and 10 mg/l) have a significant migration-inhibition impact. theoretically, aaptos suberitoides contains alkaloid compound such as aaptamine, isoaaptamine, and dimethyleaaptamine which have an important role in migration inhibition.11 based on biochemical activity, aaptamine can increase cofilin-1 concentration.12 cofilin-1 detach f-actin filament by using the actindepolymerizing factor (adf), then it inhibits actin-myosin movement.13 increase of cofilin-1 expression also inhibit matrix metalloprotein (mmp) activity, especially mmp-1, mmp-3, mmp-9.14 moreover, mmp inhibition is affected with activator protein-1(ap-1) and nuclear factor-κb (nf-κb) activity too. aaptamine can deactivate mitogen-activated protein kinase (mapk) and ap-1. additionally, aaptamine also decreases proinflammatory cytokine expressions such as cyclooxygenase-2, tumor necrosis factor-alfa, interleukin-1 beta, and nfκb. consequently, ap-1 and nf-κb inhibition also can inhibit mmp expression.15 our data has an insignificant result. after 24 hours, gap closure activity in the treatment cell almost reaches 50% near the control. this condition can occur because of the increase of mmp activity after cellular starvation. this increase of mmp activity can also directly increase the migration activity higher than the migration-inhibition effect.16 the purpose of cellular starvation is to alleviate proliferation bias in this research. cellular starvation inhibits cellular proliferation and induces cell cycle arrest.17 however, the mmp activity as a side effect may be higher than the migrationinhibition effect of aaptos suberitoides fraction in 1, 5, and 10 mg/l. this research has some limitations. this figure 2 microscopic pictures from scratch assay in control (0 mg/l) and treated cell (1, 5, and 10 mg/l) for 0, 24, 48 hours incubation althea medical journal. 2021;8(1) 27dany muhammad daffa et al.: anti-migration effect of aaptos suberitoides fraction in hct-116 colorectal cancer cell line research trial set only one-time trials without positive control. this condition can impact data significance. further study needs to be conducted using positive control. furthermore, we can not eliminate aaptos suberitoides that has the anti-migration effect, since other studies have proved otherwise with supporting result.8,9,10 to evaluate this research, method evaluation is needed. using other migration assays like boyden chamber assay and oris may affect the result. other bias elimination methods like starvation setting and mitomycin c treatment can be considered. in conclusion, aaptos suberitoides fraction in this study has insignificant anti-migration effect on hct-116 cell line. the further explorative study is imperative to show the anti-migration effect of aaptos suberitoides references 1. who. cancer [internet]. who. [cited 2020/06/27] available from: http://www. who.int/topics/cancer/en/ 2. crosbie ab, roche lm, johnson lm, pawlish ks, paddock le, stroup am. trends in colorectal cancer incidence among younger adults—disparities by age, sex, race, ethnicity, and subsite. cancer med. 2018;7(8):4077–86. 3. pearce a, haas m, viney r, pearson s-a, haywood p, brown c, et al. incidence and severity of self-reported chemotherapy side effects in routine care: a prospective cohort study. plos one. 2017;12(10):e0184360. 4. keramida k, charalampopoulos g, filippiadis d, tsougos e, farmakis d. cardiovascular complications of metastatic colorectal cancer treatment. j gastrointest oncol. 2019;10(4):797–806. 5. calcabrini c, catanzaro e, bishayee a, turrini e, fimognari c. marine sponge natural products with anticancer potential: an updated review. mar drugs. 2017;15(10):310. 6. shetty n, gupta s. eribulin drug review. south asian j cancer. 2014;3(1):57–9. 7. dyshlovoy sa, venz s, shubina lk, fedorov sn, walther r, jacobsen c, et al. activity of aaptamine and two derivatives, demethyloxyaaptamine and isoaaptamine, in cisplatin-resistant germ cell cancer. j proteomics. 2014;96:223–39. 8. bashari mh, samodro mr, ramadhan ws, daffa dm, nugrahani ad, subhan b, et al. the anti-cancer activity of indonesian marine sponge aaptos suberitoides extract on colon cancer cells. int j pharm res. 2019;11: 609–15 9. bashari mh, arsydinilhuda fz, ilhamsyah rs, nugrahani ad, nurdin ra, kartikasari a, et al. the ethanol extract of marine sponge aaptos suberitoides suppress cell viability, cell proliferation and cell migration in her2-positive breast cancer cell line. asian pacific j cancer prev. 2021;22(s1):25–32. 10. andriani h, usman ha, dewayani bm, hernowo bs, bashari mh. aaptos suberitoides extract inhibits cell migration in triple negative breast cancer and decreases nf-κb and mmp-9. trop j nat prod res. 2020; 4(11):918–21. https:// doi.org/10.26538/tjnpr/v4i11.13 11. xuan cuong d, boi vn, nhan tkt, dong dh, quang tm, kim tram pt, et al. polyphenol content, phytochemistry compositions and antioxidant activities of different extract from marine sponge aaptos suberitoides grown in nhatrang bay, vietnam. int j pharm pharm sci. 2019;11(9):80–6. 12. dyshlovoy sa, naeth i, venz s, fedorov sn, shubina lk, stonik va, et al. p2.19 aaptamine, demethyloxyaaptamine, and isoaaptamine: a proteomic-based screening of protein targets in cisplatinresistant tumor cells. ann oncol. 2012;23 suppl 5:v28. 13. popow-woźniak a, mazur aj, mannherz hg, malicka-błaszkiewicz m, nowak d. cofilin overexpression affects actin cytoskeleton organization and migration of human colon adenocarcinoma cells. histochem cell biol. 2012;138(5):725–36. 14. tsai c-h, lin l-t, wang c-y, chiu y-w, chou y-t, chiu s-j, et al. over-expression of cofilin-1 suppressed growth and invasion of cancer cells is associated with upregulation of let-7 microrna. biochim biophys acta. 2015;1852(5):851–61. 15. kim m-j, woo sw, kim m-s, park j-e, hwang j-k. anti-photoaging effect of aaptamine in uvb-irradiated human dermal fibroblasts and epidermal keratinocytes. j asian nat prod res. 2014;16(12):1139–47. 16. endo h, owada s, inagaki y, shida y, tatemichi m. glucose starvation induces lkb1-ampk-mediated mmp-9 expression in cancer cells. sci rep. 2018;8(1):10122. 17. huang y, fu z, dong w, zhang z, mu j, zhang j. serum starvation-induces downregulation of bcl-2/bax confers apoptosis in tongue coating-related cells in vitro. mol med rep. 2018;17(4):5057–64. amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 194 amj december 2020 urine color analysis of hydration status in employees working in bandung, indonesia liza karina hauteas r. sutono,1 rudi supriyadi,2 yenni zuhairini1 1faculty of medicine universitas padjadjaran, indonesia, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: liza karina hauteas r. sutono, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: lisakarinahauteas@gmail.com introduction well-hydrated or normohydration is a condition where water intake and excretion are in balance.1 when the fluid balance in the body fails to be preserved, dehydration can occur, which is the process of fluid loss in the human body. one of the causes of dehydration is excessive sweating with insufficient water intake.1 previous study conducted on workshop workers demonstrates a strong connection between fluid intake and hydration status.2 a group respondents considered to be at risk of dehydration is field workers because they work in a hot working environment among others under the sun exposure, and they spend a lot of energy while doing their work. field workers also often do not pay attention to the balance of water intake and excretion. loss of fluid, approximately 1% of body weight, can usually be compensated within 24 hours by the body. it is characterized by increased thirst and urine concentration. if the process of fluid loss continues, the water volume in the blood will decrease and overall blood volume is decreased as well. as a result, the heart will have difficulty maintaining blood perfusion to other organs, leading to impaired cardiovascular function, which can be marked by a decrease in blood pressure and an increase in heart rate. dehydration that occurs persistently can cause blood perfusion to the skin, kidney, or brain to decrease. furthermore, it can cause disturbances in concentration, headaches, fatigue, reduced physical performance, impaired thermoregulatory function, kidney damage, and can be life-threatening.1,3 there are various ways to assess a hydration status, one of which is to observe the color of urine, which is simple, practical, fast, and inexpensive. this assessment has amj. 2020;7(4):194–9 abstract background: dehydration can be compensated for by the body. however, if it occurs persistently, it can cause concentration problems, thermoregulation disorders, kidney damage, and other lifethreatening disorders such as cardiovascular disorders. urine color is a simple indicator to assess a person’s hydration status. the purpose of this study was to explore the hydration status of employees working in bandung, indonesia. methods: this was a descriptive cross-sectional study conducted from march to november 2019. this study was a part of another study exploring urine color levels. urine was collected on sunday morning when the employees were free. water intake and workload before urine examination were not taken into account. hydration status was divided into three categories: well-hydrated, mild/moderate dehydration, and severe dehydration. a total sampling method was used to collect data. results: in total, 178 subjects who met the study criteria participated in the study. the majority of respondents were 40-79 years old, male, did not have hypertension or diabetes, and active smokers. most respondents experienced severe dehydration (44.7%) although 58.1% had consumed ≥8 glasses of water/day. conclusions: more than half employees have consumed adequate amount of water; however, the majority are severely dehydrated when assessed based on their urine color. further study on the balance of water intake and excretion is needed to explore the phenomenon of dehydration in the morning. keywords: dehydration, hydration status, urine color https://doi.org/10.15850/amj.v7n4.1916 althea medical journal. 2020;7(4) 195 been validated, both in adults and children.4,5 one of the factors that can affect the urine color density is the amount of water that dissolves urine color compounds, which are urochrome, uroerythrin, and urobilin. the water amount in the urine in the dehydrated individuals will be lower than the urine color compounds, causing darker urine color.5,6 this study aimed to determine the hydration status variations by observing the color of urine among field workers in bandung, for early detection of dehydration status, in order to further exploring the preventive action. methods this research was a descriptive, crosssectional study, conducted from march to november 2019. the hydration status based on urine color analysis was determined among adult employees in bandung. this study used the secondary data from a previous study. in brief, a questionnaire was distributed during the world kidney day 2019 event, held by dr. hasan sadikin general hospital in collaboration with the indonesian nephrology association (perhimpunan nefrologi indonesia, pernefri). urine was taken on a sunday morning when the employees were free or not working. their water intake and workload before the urine examination were not taken into account. the exclusion criteria were incomplete data on age, gender, amount of water intake per day, smoking status, or comorbid disease statuses such as hypertension and diabetes. after consent, the respondents filled out a questionnaire and collected their urine on a transparent tube for free urine examination. the result was consulted to the doctor present at the event. the urine obtained was then compared with the standard urine color chart, released by the ministry of health republic of indonesia (2018) by placing a white paper behind the tube, and therefore the urine color was more visible (figure 1). there were eight colors of urine that was designated into level 1 to 8, indicating the palest urine color to the darkest concentrated urine color, respectively. this level of urine color was pointing out to the hydration level that was categorized into well-hydrated (level 1–3), mild/moderate dehydration (level 4–5), and severe dehydration (level 6–8). all respondents were given information about this study, and those who were willing to take part in this study were asked to sign an agreement form. this study had been approved by the research ethics committee of universitas padjadjaran bandung (no. 996/ un6.kep/ec/2019). results in total, 178 data were obtained for this study, however, 73 data were incomplete and thus only 105 data were taken into further analysis. the characteristics of the employees showed that the majority was male (80.95%) and aged figure 1 standard urine color chart7 liza karina hauteas r. sutono et al.: urine color analysis of hydration status in employees working in bandung, indonesia althea medical journal. 2020;7(4) 196 amj december 2020 table 2 hydration level and water intake among employees in bandung frequency (n) percentage (%) level of hydration well-hydrated 26 24.76 mild/moderate dehydration 32 30.48 severe dehydration 47 44.76 water intake (glass/day): <8 44 41.90 ≥8 61 58.10 note: well-hydrated (level 1–3), mild/moderate dehydration (level 4–5) and severe dehydration (level 6–8). >40 years old (52.38%). hypertension was detected in 10.48%, diabetes in 2.86% and half of them were active smokers (50.4%), as shown in table 1. the majority of employees were in severe dehydration (44.76%), although the majority of subjects had consumed ≥8 glasses of water per day (58.10%) as shown in table 2. the hydration level based on water intake per day was shown in figure 2, which illustrated the high number of respondents who were in mild/moderate and severe dehydration conditions despite consuming water ≥8 cups per day (figure 2). however, a t-test performed to reveal the significance of the relationship between hydration level with consumed water had shown no significant relationship between hydration level with the consumed water (p=0.059, data not shown). discussions the level of hydration has been divided into three categories; well/good hydration, mild/ moderate dehydration, and severe dehydration. the hydration has been based on age, gender, or whether there is a comorbid disease such as hypertension and diabetes, type of smokers, and how much water per day is consumed. the daily water intake is recommended as much as 8 cups or about 2–2.5 liters per day.1,8 however, table 1 characteristics of employees characteristic (n=105) frequency(n) percentage (%) age (year): 19–39 50 47.62% >40 55 52.38% gender male 85 80.95% female 20 19.05% hypertension yes 11 10.48% no 94 89.52% diabetes yes 3 2.86% no 102 97.14% smokers active 53 50.48% passive/non-smoker 52 49.52% althea medical journal. 2020;7(4) 197 this study shows that there is no significant relationship between daily consumed water with hydration level (p=0.059), although others reported a strong relationship.2 this different result might be caused by the study number. further study is needed to explore this relationship. interestingly, the condition of mild/ moderate or severe dehydration is still high in individuals who have consumed 8 glasses of water per day (figure 2). dehydration usually occurs due to lack of water intake or when water excretion exceeds water intake, therefore, the urine will be concentrated and produce a darker color.6,9 morning urine may have a darker color since there is a is lack of water intake at the previous night. the lack of water in the blood can reduce the blood plasma rate towards the kidneys, it can reduce the rate of renal filtration that will be detected by the kidneys. the kidneys will increase water reabsorption and only a small amount of water is excreted through urine. the body can detect the rise of water in the blood within 10 minutes after rehydration.9,10 our study has shown that the highest percentage of severe dehydration are those among the aged range of 40–79, however, the majority have consumed more than 8 cups of water per day, as recommended by the ministry of health republic of indonesia. kidney function will decrease through aging, and there will be changes in the structure and function of the kidneys, leading to a reduced number and size of the nephron. the change begins at the age of 20 years, which occurs progressively but slowly. the significant change might be detected at the age of 50 years. this study also reported that reduced renal ability to concentrate urine comes along with aging thus it can increase the risk of dehydration, 11 making this one of the factors that causes a large number of concentrated urine findings in the elderly individuals in the study. the majority of our respondents were male and the largest percentage of severely dehydrated man has consumed more than 8 glasses of water per day. in opposite to this study, other study showed that dehydration is more common in women because women have more fat proportion in the body, thus, the water amount is lower.12 however, when associated with kidney aging, males produce consistently more concentrated urine than females.13 after the age of 40 years, the glomerular filtration rate (gfr) in males will decline by 1% per year, while in women gfr will remain stable until 50 years of age.14 this can be caused by the estrogen hormone that may provide a protective effect on the kidneys. androgen hormones instead may have a negative effect on kidney aging. estrogen can stimulate the synthesis of nitrite oxide (no) which has a vasodilator effect on various blood vessels including the renal arteries. the vasodilator effect may improve the perfusion to kidney cells and it maintains kidney cell survival. estrogen cans also the amount of angiotensin ii and angiotensin-converting enzyme (ace) and therefore reducing its activity, which is figure 2 hydration level based on daily water intake liza karina hauteas r. sutono et al.: urine color analysis of hydration status in employees working in bandung, indonesia althea medical journal. 2020;7(4) 198 amj december 2020 vasoconstrictors in blood vessels, including blood vessels in the kidneys. poor blood flow may accelerate kidney damage as the age progresses. conversely, the androgen hormone that presents in large amounts in males can stimulate the renin-angiotensin system (ras), causing dehydration to occur easier in males than in females.11, 13–15 dehydration is one of the causes of acute kidney dysfunction, which is usually reversible and has no long-term effects on the kidneys. however, when dehydration occurs persistently, it can cause permanent kidney damage. kidney damage can lead to the disruption of the overall kidney function, including kidney function to concentrate urine, which then can indirectly affect the color of the urine.3 in addition to dehydration, some conditions such as hypertension, diabetes, and smoking status, can also affect kidney health. according to the national institute of diabetes and digestive and kidney disease, hypertension is the condition of consistently rising or high blood pressure.16 hypertension can thus damage blood vessels in the kidneys. high blood pressure in the blood vessels will cause the blood vessels to constrict so that nutrients to the kidney will be reduced and can cause kidney cells damaged and disrupt kidney function.17 however, the number of respondents with hypertension status in our study is only about 10.5%. in addition to hypertension, hyperglycemia in uncontrolled diabetic patients can cause glycosylation of the basement membrane protein resulting in thickening of the glomerular basement membrane. there is an accumulation of glycoprotein-like substances in the mesangial basement membrane that may disrupt glomerular capillaries, and all of that complex processes can cause kidney damage.18,19 kidney damage can also be caused by the nephrotoxic effect of smoking whose mechanism is not completely clear. however, some hypotheses state that smoking can cause endothelial cell dysfunction, produce oxidative stress, proinflammation, leading to glomerulosclerosis and atrophy of the kidney tubule. the adverse effects of smoking can affect the incidence of chronic renal failure in adults.20 dehydration can adversely affect the health conditions in general, leading to reduced concentration and work performance and thus affecting the effectiveness and work results. in addition to being detrimental at the individual level, it can also have an impact at the community level. this study’s limitations are the data obtained through questionnaires regarding water intake per day, hypertension status, smoking status, and diabetes status. question on data on water intake per day has used glass/day as a unit, and there is no specific volume on how many ml of glass referred to the questionnaire. hypertension and diabetes status are also not accompanied by the length of time they have the disease. hypertension or diabetes may exist without the individual knows. smoking status is not accompanied by information on smoking intensity. the category of passive smokers/non-smokers is also not further detailed. the medication used is not documented. the standard urine color chart for reference has been taken from the leaflet, making a speculative assessment due to the color change over time. future study is needed to obtain more specific information in the questionnaire. it is also recommended to add some other variables that influence the hydration level such as body weight, fat mass in the body, physical activity performed by each subject, kidney disease status, and others. to conclude, the majority of male respondents in our study are in severe dehydration based on urine color taken in the morning, although most of them have a habit of consuming ≥8 glasses per day. they are aged 40–79 years, do not have hypertension or diabetes, and are active smokers. therefore, it is important to educate the male workers on kidney health, the importance of adequate water intake, and the impact of dehydration on health. moreover, forging a standard chart of urine color in the bathroom can trigger the employees to easily identify their hydration status and drink more water in case of severe dehydration. acknowledgment we were grateful to the employees of pd kebersihan, bandung, who participated in the study. references 1. international chair for advanced studies on hydration. human hydration [internet]. 2016 [cited 2019 apr 3]. available from: http://cieah.ulpgc.es/en/main 2. sari na, nindya ts. hubungan asupan cairan, status gizi dengan status hidrasi pada pekerja di bengkel divisi general engineering pt pal indonesia. media gizi indones. 2018;12(1):47–53. 3. roncal-jimenez c, lanaspa ma, jensen t, sanchez-lozada lg, johnson rj. althea medical journal. 2020;7(4) 199 mechanisms by which dehydration may lead to chronic kidney disease. ann nutr metab. 2015;66:10–3. 4. baron s, courbebaisse m, lepicard em, friedlander g. assessment of hydration status in a large population. br j nutr. 2015;113(1):147–58. 5. kavouras sa, johnson ec, bougatsas d, arnaoutis g, panagiotakos db, perrier e, et al. validation of a urine color scale for assessment of urine osmolality in healthy children. eur j nutr. 2016;55(3):907–15. 6. hagn rg, waldréus n. an aggregate urine analysis tool to detect acute dehydration. int j sport nutr excercise metab. 2013;23(4):303–11. 7. biro umum kemkes ri. infografis bagan warna urin [internet]. 2018 [cited 2019 apr 4]. available from: http://roum. kemkes.go.id/berita/index.php 8. kementrian kesehatan ri. pedoman gizi seimbang. jakarta: kemenkes ri; 2014. p.1–99 9. benelam b, wyness l. hydration and health: a review. nutr bull. 2010;35(1):3– 25. 10. péronnet f, mignault d, du souich p, vergne s, bellego l le, jimenez l, et al. pharmacokinetic analysis of absorption, distribution and disappearance of ingested water labeled with d2o in humans. eur j appl physiol. 2012;112(6):2213–22. 11. chmielewski p, strzelec b, borysławski k, chmielowiec k, chmielowiec j, dąbrowski p. effects of aging on the function of the urinary system: longitudinal changes with age in selected urine parameters in a hospitalized population of older adults. anthropol rev. 2016;79(3):331–45. 12. penggalih mhst, sofro zm, rizqi er, fajri y. prevalensi kasus dehidrasi pada mahasiswa universitas gadjah mada. j gizi klin indones. 2014;11(2):72. 13. perinpam m, ware eb, smith ja, turner st, kardia slr, lieske jc. key influence of sex on urine volume and osmolality. biol sex differ. 2016;7(1):1–8. 14. sobamowo h, prabhakar ss. the kidney in aging: physiological changes and pathological implications. mol biol aging. 2017;146:303–40. 15. weinstein jr, anderson s. the aging kidney : physiological changes. adv chronic kidney dis. 2010;17(4):302–7. 16. national institute of diabetes and digestive and kidney disease (niddk). high blood pressure & kidney disease [internet]. 2014 [cited 2019 nov 11]. available from: https://www.niddk.nih.gov/healthinformation/kidney-disease/high-bloodpressure 17. bahar b, kadrianti e, nani. hubungan hipertensi dengan kejadian gagal ginjal di rs ibnu sina makassar periode januari 2011–desember 2012. maj kedokt indones. 2014;4(2):163–8. 18. sari n, hisyam b. hubungan antara diabetes melitus tipe ii dengan kejadian gagal ginjal kronik di rumah sakit pku muhammadiyah yogyakarta periode januari 2011–oktober 2012. j kedokt dan kesehat indones. 2014;6(1):11–8. 19. rivandi j, yonata a. hubungan diabetes melitus dengan kejadian gagal ginjal kronik. majority. 2015;4(9):27–34. 20. xia j, wang l, ma z, zhong l, wang y, gao y, et al. cigarette smoking and chronic kidney disease in the general population: a systematic review and meta-analysis of prospective cohort studies. nephrol dial transplant. 2017;32(3):475–87. liza karina hauteas r. sutono et al.: urine color analysis of hydration status in employees working in bandung, indonesia amj vol 7 no 1 2020edit2.indd althea medical journal. 2020;7(1) 40 amj march 2020 profile of upper extremities function among stroke outpatients in dr. hasan sadikin general hospital, bandung putri pamulani,1 novitri,2 sofiati dian3 1faculty of medicine universitas padjadjaran, indonesia, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of neurology faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: putri pamulani, faculty of medicine, universitas padjadjaran jalan raya bandung-sumedang km 21, jatinangor, sumedang, jawa barat, indonesia, email: pamulaniputri@gmail.com. introduction stroke is one of the leading causes of disability in the older population, involving many aspects of life such as physical, emotional, and social life. as stroke mortality rates decline, these older people are more likely to have residual impairments that affect their activity of daily living (adl).1 the prevalence of stroke in indonesia is about 7 per 1000 population and mostly aged 45 years old and older are affected. dr. hasan sadikin general hospital in bandung as a referral hospital has more than 500 stroke patients admitted every year.2,3 stroke affects not only patients, but their family members are also involved and have to deal with the sequeles of its residual impairments. consequently, post-stroke related-disability continues to be another point of concern.4 this is shown by several stroke impact measures that have been developed, such as health-related quality of life (hrqol) and stroke impact scale (sis). the world health organization (who) has published the international classification of impairments, disabilities, and handicaps in 1980, which is frequently used in classifying stroke after its effect.5 it has been reported previously that there is 2,490 billion disability-adjusted life years (dalys) or 361 dalys per 1000 population. among all the diseases mentioned, cardiovascular and circulatory diseases are accounted for 11.8% of global dalys; the major diseases within this group are ischemic heart disease (5.2%), hemorrhagic stroke (2.5%), ischemic stroke (1.6%), and hypertensive heart disease (0.6%).6 approximately, 75% of stroke survivors have upper extremities (ue) amj. 2020;7(1):40–4 abstract background: stroke is one of the leading causes of death and disabilities worldwide. among all types of disabilities, disturbance in upper extremities functions is at the highest percentage. this study aimed to determine the profile of upper extremities function among stroke outpatients in dr. hasan sadikin general hospital bandung as an initial step to provide a better follow up and management. methods: the design of this study was a descriptive study, conducted from april to october 2014 among stroke outpatients in the department of physical medicine and rehabilitation dr hasan sadikin general hospital, bandung based on a consecutive sampling method. the function of upper extremities was tested by chedoke arm and hand integrated version 9 (cahai-9). result: in total, 42 patients were included, consisting of a male (n=25) and a female (n=17). nine tasks were performed with dependently by the patients such as open the coffee jar (n22; 52%), call 118 (n24;57%), draw a line with a ruler (n22;52%), pour a glass of water (n33;79%), wring out washed cloth (n26;62%) do up five-button (n31;74%), dry back with the towel (n25;60%), put toothpaste on a toothbrush (n25;60%), and cut medium resistance putty(n32;76%). conclusions: the majority of stroke outpatients in the sub-acute phase still have a dependent function of upper extremities. better patient management and interventions focusing on this function need to be enhanced for a better outcome. keywords: cahai-9, disability, impairment, stroke, upper extremities https://doi.org/10.15850/amj.v7n1.1762 althea medical journal. 2020;7(1) 41 impairment and half of them have to learn to compensate by using less-involved hand.7 the ue makes a significant contribution to most adl and ue impairment can compromise participation in many essential and meaningful tasks.1 regarding the evidence of high post-stroke ue disturbance, data of the post-stroke ue function’s profile is necessary for further management.1 various ue measurements are available to examine the ue function. one of them is the chedoke arm and hand activity inventory (cahai), a new validated upperlimb measurement using a 7-point quantitative scale to assess functional recovery of the arm and hand after a stroke attack. there are 4 versions of cahai, including cahai-7, cahai-8, cahai-9, and cahai-13. the number shows the total tasks that must be performed by patients. the examiners have options to choose any version without risking a significant finding that may influence the validity of the test. the internal consistency among cahai tests is 0.98, suggesting that there is an item’s redundancy that by doing only 6 items the result can achieve 0.95 consistency. the objective of this study was to explore the profile of ue function among stroke outpatients in dr. hasan sadikin general hospital, bandung. methods the design of this study was a descriptive study, conducted from april to october 2014 among stroke outpatients in the department of physical medicine and rehabilitation, dr. hasan sadikin general hospital based on the consecutive sampling method. patients were first signed informed consent to participate in this research. data on age, the onset of stroke, and paretic side of the ue were collected before the test. the onset of stroke was grouped as the sub-acute onset of 2 weeks to 6 months and chronic onset > 6 months. the tasks of cahai-9 consisted of nine activities, described followed; 1) open the coffee jar, 2) call the local emergency number 118, adapted from 911 the usa emergency number, with personal communication with susan barecca, founder of cahai, 3) draw line with a ruler, 4) pour a glass of water, 5) wring out the washcloth, 6) do up five buttons, 7) dry back with a towel, 8) put toothpaste on the toothbrush, and 9) cut medium resistance putty. the examiner observed how the patients carried out the tasks and interpreted the score. subsequently, the ue function was measured with chedoke arm and hand inventory version 9 (cahai-9) followed by the 7-points scale of interpretation.8 the score of 1–5 was interpreted as ‘need for assistance and supervision’, and a score of 6–7 was interpreted as ‘modified and total independence’. each task was further categorized into an ‘independent’ and ‘dependent’ group, meaning that in performing daily activities, whether patients still at least needed some assistance in the period of their post-stroke recovery. the number of respondents performing the tasks was summed up and described in table 1 basic characteristic of stroke patients in dr. hasan sadikin general hospital, bandung variables frequency percentage (%) age (years old) ≤44 5 12 45–54 11 26 55–64 21 50 65–74 5 12 onset of stroke sub-acute 27 64 chronic 15 36 paretic side right 24 57 left 18 43 note: sub-acute onset 2 weeks to 6 months. chronic onset > 6 month. putri pamulani et al.: profile of upper extremities function among stroke outpatients in dr. hasan sadikin general hospital, bandung althea medical journal. 2020;7(1) 42 amj march 2020 percentage. the study was approved by the health research ethics committee faculty of medicine, universitas padjadjaran. results in total, 42 post-stroke patients were included, with the age ranging from 44 to 74 years old of whom most patients (n=21;50%) were in the group of 55 to 64 years old followed by younger age group of 45–54 years old (n=11; 26%) as shown in table 1. based on the onset of stroke, the sub-acute onset was higher than the chronic onset (n=27;64%). all subjects had their right side as their dominant upper extremity (ue)of whom most of the patients had right ue paresis (n=24;57%). of the tasks performed according to cahai-9 tasks, most patients were dependently in doing the 9 tasks as the following result; open the coffee jar (n=22;52%), dial 118 (n=24;57%), draw a line with a ruler (n=22;52%), pour a glass of water, (n=33;79%), wring out the washed cloth (n=26;62%), do up five button (n=31;74%), dry back with a towel (n=25;50%), put toothpaste on a toothbrush (n=25;60%), cut a medium putty (n=32;76%). discussion after the interpretation of the cahai-9 score, the result of this study shows that most of the post-stroke patients are still dependent on performing the daily activities and still at least need some assistance in the period of their post-stroke recovery. the recovery of ue becomes very important regarding its significant role in adl. a profile of ue function in performing basic daily tasks is required before therapy, treatment, and further management. cahai-9 as the measurement tool has been used considering its good clinical utility and representative outcome of daily ue function that correlates with impairment.9 our study has shown that age group 55– 64 years old reached the highest percentage among all groups (51%), which is different from a preceding study conducted by construction of national surveillance system for cardiovascular and cerebrovascular disease of korean neurological association with their highest percentage (88.8%) of daly lost due to stroke in the age group 65–74 years old.10 interestingly, there is an increasing incidence of ischemic stroke in the young (age 20–54) for both black and white patients over time. national data of canada shows that the risk factors of stroke are increasing in young ages, especially in people with obesity and diabetes. lifestyle changes are assumed to be the leading cause of this phenomenon of the dropping age of stroke onset in society.11 all subjects in this study have their right ue as the dominant side. right, and left paretic sides occurred in 57% and 43%, respectively. the involvement of ue in stroke can be explained by the evidence of the middle cerebral artery (mca) infarct as the most common type of stroke.12,13 the relation table 2 the 7-point scale for cahai-9 and the interpretation among post-stroke patients (n=42) in dr. hasan sadikin general hospital. cahai-9 tasks scale* interpretation 1 2 3 4 5 6 7 dependent independent n % n % 1. open the coffee jar 12 2 2 3 3 10 10 22 52% 20 48% 2. call 118 13 4 2 1 4 11 7 24 57% 18 43% 3. draw a line 5 11 1 5 12 8 22 52% 20 48% 4. pour a glass 10 5 1 5 12 5 4 33 79% 9 21% 5. wring out the washed cloth 11 4 2 5 4 6 10 26 62% 16 38% 6. do up five buttons 12 2 5 4 8 8 3 31 74% 11 26% 7. dry back with a towel 11 3 5 1 5 8 9 25 60% 17 40% 8. put toothpaste on a toothbrush 11 3 2 3 6 8 9 25 60% 17 40% 9. cut a medium putty 12 3 3 3 11 6 4 32 76% 10 24% note: *cahai; chedoke arm and hand activity inventory. the 7-points scale to cahai-9 tasks was given to the patients; score 1 to 5 as a need for assistance and supervision and interpreted as a dependent; score 6-7 as modified and total independence and interpreted as an independent. althea medical journal. 2020;7(1) 43putri pamulani et al.: profile of upper extremities function among stroke outpatients in dr. hasan sadikin general hospital, bandung between ue impairment and its functional “use” and “non-use” phenomenon shows the compensation of the non-paretic side to learn to do more tasks. consequently, the paretic side will not be used to its full capacity. considerable non-use of the paretic side, both in duration and in intensity, and both during unimanual and bimanual activities in patients with chronic stroke have been reported as such the patients compensate for this with the increased use of the non-paretic side.14 this may lead to the poor outcome of the paretic side. however, several training programs can improve the outcome of the paretic side by using non-paretic ue as a “teaching hand” to the paretic side. bilateral transfer (bt) occurs in the stroke patients with the same phenomenon features as noted in the healthy individuals, with a higher incidence among men and a bigger effect when the trained healthy hand is the dominant one, to the paretic non-dominant hand.15 most subjects in this study are sub-acute patients (64%). early after the stroke onset or in an acute setting, the patients need to be properly managed considering the emergency condition of admission to limit morbidity and mortality.16 the onset of stroke is a very important aspect to note regarding the outcome of stroke-related impairment. there is a critical-time window during the first 3 months after stroke when most plasticity can be expected. however, the improvement of activities after stroke, such as dexterity is mainly driven by learning compensation strategies rather than by neural repair. the strategies can be performed by learning to reuse the same body segments in the same way as subjects did before the stroke.17 the objectivity of the examiner is of important to measure ue daily function based on the cahai test. the profile of ue function after stroke shows the relation of impairment degree and functional use. although there is no interpretation of total scoring, cahai proves that there is a strong relation between ue impairment and its function. as the severity of ue impairments increases, the cahai score will decrease. the cahai-9 has been used in this study according to its affordability and performance effectiveness. the outcome in this study is categorized into the dependent and independent groups. most tasks have been measured as a dependent. the dependent group contributes to more than half of the total subjects in each task of the measurement. the interpretation is explained based on each task since there is no total score interpretation. the absence of total score interpretation would not be a problem since the total score itself already show the correlation between impairment severity with ue function (personal communication with barecca, et al.). the more severe the impairment is, the lower the cahai total score will be. in order not to put aside other aspects, the recovery of motor impairment should be considered since this motor impairment is determined by several factors such as the salvation of penumbral tissue in the first days to weeks after stroke, the alleviation of diaschisis, the homeostatic and learningdependent (hebbian) neuroplasticity, and the behavioral compensation strategies. these mechanisms underlying recovery are very interactive and operate in different and limited time-windows after stroke onset.14 there are some limitations in this study; first, the absence of total score interpretation of cahai makes the categorization of the outcome less clear. however, the 7-point scales represent the direct and clear correlation between impairment and functional loss of the impaired ue. second, the variables in this study are limited. further research should consider including demography data and other basic characteristics of the respondents, depending on the study intention. the profile of ue function after stroke can be beneficial to the proper management including therapy, medication, and education. a point to concern is the education part; patients should independently practice the cahai tasks and keep doing other safe daily tasks to train their impaired ue at home to maximally regain its function. to conclude, our study shows that the upper extremities function of more than half stroke outpatients is dependent. this result may serve as information for better patient management and intervention to obtain better outcomes of post-stroke patients. acknowledgment researchers would like to acknowledge susan barecca and the cahai team as the founder of the cahai measurement tool that has provided a very useful tool, especially for this study. references 1. harris je, eng jj. paretic upper-limb strength best explains arm activity in people with stroke. phys ther. althea medical journal. 2020;7(1) 44 amj march 2020 2007;87(1):88–97. 2. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesua. riset kesehatan dasar 2013. jakarta: kementerian kesehatan ri; 2013. p. 91. 3. 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[cited 2019 november 27]. available from: http://repository.maranatha.edu. 4. patel md, tilling k, lawrence e, rudd ag, wolfe cd, mckevitt c. relationships between long-term stroke disability, handicap and health-related quality of life. age ageing. 2006;35(3):273–9. 5. abubakar sa, isezuo sa. health related quality of life of stroke survivors: experience of a stroke unit. int j biomed sci. 2012;8(3):183–7. 6. murray cj, vos t, lozano r, naghavi m, flaxman ad, michaud c, et al. disabilityadjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990– 2010: a systematic analysis for the global burden of disease study 2010. lancet. 2012;380(9859):2197–223. 7. sullivan je, hedman ld. a home program of sensory and neuromuscular electrical stimulation with upper-limb task practice in a patient 5 years after a stroke. phys ther. 2004;84(11):1045–54. 8. barreca s, stratford p, masters l, gowland c, lambert c, griffiths j, et al. the chedoke arm and hand activity inventory administration guidelines version 2: general instruction for administering cahai. hamilton: chedoke arm and hand inventory (cahai); 2004 [cited 2014 december 7]. available from: https:// www.cahai.ca/layout/content/cahaimanual-english-v2.pdf 9. rowland t, gustafsson l, turpin m, henderson r, read s. chedoke arm and hand activity inventory-9 (cahai-9): a multi-centre investigation of clinical utility. int j ther rehabil. 2011;18(5):290–8. 10. hong ks. disability-adjusted life years analysis: implications for stroke research. j clin neurol. 2011;7(3):109–14. 11. kissela bm, khoury jc, alwell k, moomaw cj, woo d, adeoye o, et al. age at stroke: temporal trends in stroke incidence in a large, biracial population. neurology. 2012;79(17):1781–7. 12. ng ys, stein j, ning m, black-schaffer rm. comparison of clinical characteristics and functional outcomes of ischemic stroke in different vascular territories. stroke. 2007;38(8):2309–14. 13. fauci as, braunwald e, kasper dl, hauser sl, longo dl, jameson jl, et al. harrison’s principles of internal medicines. 17th ed. new york: mcgraw-hill companies; 2008. 14. michielsen me, selles rw, stam hj, ribbers gm, bussmann jb. quantifying nonuse in chronic stroke patients: a study into paretic, nonparetic, and bimanual upperlimb use in daily life. arch phys med rehabil. 2012;93(11):1975–81. 15. ausenda c, togni g, biffi m, morlacchi s, corrias m, cristoforetti g. a new idea for stroke rehabilitation: bilateral transfer analysis from healthy hand to the paretic one with a randomized and controlled trial. int j phys med rehabil. 2014;3(8):1–8. 16. jauch ec, saver jl, adams p, bruno a, connors jj, demaerschalk bm, et al. guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(3):870–947. 17. bumaa f, kwakkela g, ramseyc n. understanding upper limb recovery after stroke. restor neurol neuros. 2013;31(6):707–22. althea vol 1 no 2 edit.indd althea medical journal. 2014;1(2) 60 amj december, 2014 bixa orellana l leaf infusion as an anti-inflammatory agent in carrageenan-induced wistar rats sabrina munggarani yusuf, 1 enny rohmawaty, 2 rama nusjirwan3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: one of the characteristics of inflammation is swelling or edema. inflammation can be treated with traditional medicine, such as bixa orellana l. bixa orellana l leaf contains flavonoid and tannin responsible for its anti-inflammatory effect. this study was conducted to analyse the ability of bixa orellana l leaf infusion (boli) to suppress paw edema in carrageenan-induced wistar rats. methods: this study was conducted in the animal laboratory of department of pharmacology and therapy faculty of medicine universitas padjadjaran in october 2012. bixa orellana l leaves were procured from lembang, bandung, and were botanically identified at the herbarium of universitas padjadjaran, jatinangor. thirty female wistar rats were randomly divided into five groups. group 1 was given 5 ml aquades as a control, three groups received boli with 0,09 g; 0,18 g; and 0,36 g dosage respectively; and group 5 was given 0,9 mg diclofenac. at 1 hour after treatment, all rats were induced by carrageenan injection subcutaneously. paw edema changes were quantified at 0, 1, 2, 3, 4, 5, 6, and 24 hour afterwards. data were analysed using kruskal-wallis and mann-whitney test results: based on paw edema inhibition percentage, 0.18 g of boli was shown most effective (16.97%) compared to 0.09 g (10.96%) and 0.36 g (7.50%). interestingly, no significant differences of anti-inflammatory effect were observed between groups that were treated with 0,18 g of boli and diclofenac (p > 0,005). conclusions: the boli with effective dosage 0.18 g (equivalent with 200 g bodyweight/day) suppress inflammation comparable to diclofenac. [amj.2014;1(2):60–4] keywords: anti-inflammatory, bixa orellana l leaf, edema infusa daun kesumba (bixa orellana l) sebagai anti inflamasi pada tikus wistar yang diinduksi carrageenan abstrak latar belakang: salah satu ciri khas dari peradangan atau inflamasi adalah adanya pembengkakan atau edema. peradangan dapat diobati dengan obat tradisional, seperti kesumba (bixa orellana). daun kesumba diketahui mengandung flavonoid dan tanin yang berfungsi sebagai anti-inflamasi. penelitian ini dilakukan untuk menganalisis kemampuan infusa daun kesumba (bixa orellana) (boli) dalam mengurangi edema tungkai pada kaki tikus wistar yang diinduksi carrageenan. metode: penelitian ini dilakukan di laboratorium hewan departemen farmakologi dan terapi di rumah sakit umum dr. hasan sadikin bandung pada bulan oktober 2012. daun kesumba (bixa orellana l) diperoleh dari lembang, bandung, dan diidentifikasi botani di herbarium universitas padjadjaran, jatinangor. tiga puluh tikus wistar betina secara acak dibagi menjadi lima kelompok. kelompok 1 diberi 5 ml aquades sebagai kontrol, tiga kelompok menerima boli dengan 0,09 g; 0,18 g; dan masing-masing 0,36 g dosis; dan kelompok 5 diberi 0,9 mg diklofenak. pada 1 jam setelah pengobatan, semua tikus diinduksi oleh subkutan injeksi karagenan. perubahan edema tungkai diukur pada 0, 1, 2, 3, 4, 5, 6, dan 24 jam sesudah pengobatan. data dianalisis dengan menggunakan kruskal-wallis dan uji mann-whitney. hasil: berdasarkan persentase pengurangan edema tungkai, kelompok 0,18g boli terlihat paling efektif (16,9%) dibandingkan dengan 0,09 g (10,9%) dan 0,36 g (7,5%). tidak ada perbedaan yang signifikan dari correspondence: sabrina munggarani yusuf, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281513130450, email: sabrinamyusuf@yahoo.com althea medical journal. 2014;1(2) 61 efek anti-inflamasi yang diamati antara kelompok-kelompok yang diobati dengan 0,18 g boli dan diklofenak (p> 0.005). simpulan: infusa daun kesumba (boli) dengan dosis efektif 0,18 g (setara dengan 200 g berat badan / hari) menekan peradangan sama baik dibandingkan dengan diklofenak. [amj.2014;1(2):60–4] kata kunci: anti-inflamasi, daun kesumba (bixa orellana l), edema introduction inflammation is a protective response invoked in organisms towards alteration in normal tissues. it has five main characteristics, which are rubor (redness), tumor (swelling), calor (heat), dolor (pain), and functiolaesa (loss of function). chronic inflammation can cause rheumatoid arthritis, atherosclerosis, and tuberculosis. therefore, anti-inflammatory drugs, both steroidal and non-steroidal, play a pivotal role in taking the response under control.1 bixa orellana l, the so-called “lipstick tree” from bixaceae family, has been approved safe for human consumption by the food and drug administration (fda) of the usa. it is beneficial intreating fever, stomachache, sore throat, burn injury, and epilepsy pertaining to its anti-inflammatory effect.3 a previous study) using bixa orellana l leaf extract proved flavonoid and tannin in favor of that advantage. moreover, there are some other chemical compounds found within bixa orellana l leaf, for instance sterol, saponin, and ishwarane.4 this study was conducted to analyse the anti-inflammatory effect of bixa orellana l. leaf infusion (boli) for an easier homebased production. wistar rats was induced by carrageenan to generate paw edema. efficacy of boli compared to diclofenac and the most effective dosage were determined. methods this experiment was conducted in the animal laboratory of department of pharmacology and therapy in dr. hasan sadikin general hospital bandung in october 2012. bixa orellana l. leaves were procured from lembang, bandung, and were botanically identified at the herbarium of universitas padjadjaran in jatinangor. thirty healthy female wistar rats (2–3 months old) weighing ± 200-50 g were used as subjects. all rats were housed in homogenous temperature and darklighted cycle for 7 days with ad libitum access to food and drink. the rats were subsequently fasting for the next 24 hours to promote optimal inflammatory response. the procedure was done in accordance with the russel and burch’s principle of humane experimental techniques: reduction, refinement and replacement (3r).5 the boli was prepared from dried bixa orellana l. leaves weighed according to dosage and 100 ml of water for every treatment group. mixed raw material was heated in an infusion pan for 15 minutes after the temperature reached 90˚cwhile being stirred every 5 minutes. next, boli was filtered usingflannel fabric.thirty millilitersof boliwere used for each rat in the treatment group receiving as much as 5 ml. extra water was added to gain boli volume as required.6 at one hour before treatment, basal right paw volume was quantified with a pletysmometer until lateral maleoluswhich was marked with a label sticker. wistar rats were randomly divided into five groups. group 1 served as the negative group and was given 5 ml aquades, three groups received boli with 0.09 g; 0.18 g; and 0.36 g dosage respectively; and last group positive group was given 0.9 mg diclofenac. all treatments were given orally. an hour afterwards, edema was induced by carrageenan injection subcutaneously in sub plantar area of the posterior right paw. in order to alleviate the pain, all rats were locally anesthesized using 20 mg/kg bw of ketamine hydrochloride intraperitoneally prior to subcutaneous injection. paw edema volume changes were determined at 1, 2, 3, 4, 5, 6, and 24 hour (v1, v2, v3, v4, v5, v6, and v24) after treatment. moreover, the efficacy of each treatment group to suppress paw edema was calculated compared to negative group. results were classified into stadium 1 (% edema inhibition < 10% or poor), stadium 2 (% edema inhibition 10-15%or moderate), and stadium 3 (% edema inhibition >15%or excellent). data were statistically analysed using kruskalwallis and mann-whitney non-parametric tests when data distribution was not in normal distribution. the p value ≤ 0.05 was set to show significant difference. sabrina munggarani yusuf, enny rohmawaty, rama nusjirwan: bixa orellana leaf infusion as an antiinflammatory agent in carrageenan-induced wistar rats althea medical journal. 2014;1(2) 62 amj december, 2014 results as expected, negative group had the largest paw edema changes at 3 hour after treatment (1.36 ml) and the smallest paw edema changes were seen in group of rats given 0.18 g of boli at 24 hour after treatment (0,83 ml) (table 1). the group given 0.18 g of boli had the smallest mean paw edema changes. data were then conversed into percentage. paw volume in all groups gradually increased at 1 to 3 hour time point, and then started to fall afterwards. this proved the efficacy of carrageenan to optimally induce edema-forming effect at the first two hours after injection, after which was inhibited by both treatment groups and positive group. kruskal-wallis test was exerted to identify the effect of various dosage of boli towards mean paw volume. paw edema was significantlysuppressed at 2 and 6 hour after treatment (p < 0.05). when compared to negative group, significant differences were not shown solely in group given 0.09 g of boli. in addition, significant difference among three dosages of boli (p < 0.05) was merely seen between groups given 0.18 g and 0.36 g of boli at 4 and 6 hour time points. the group treated with 0.18 g of boli had the biggest inhibition (16.97%) followed closely by diclofenac (13.79%). both groups did not show significant differences when compared using mann-whitney test. discussion anti-inflammatory effect in rats was examined by calculating suppression of paw edema as the simplest chemical method in the animal laboratory of the department of pharmacology and therapy. carrageenan was admintered as the inducer of inflammation due to its acute, non-immune, well-studied, and easily produced response. the efficacy of carrageenan was related to its biphasic course of reaction (figure 1). the first phase was mediated by histamine, serotonin, 5-hydroxytryptamine, and bradykininrelease lasting for 2 hours.7 the inability of nonsteroidal anti-inflammatory drugs (nsaids), such as diclofenac, to intervene was because this phase did not comprise the activation of cyclooxygenase (cox) pathway. on the contrary, the second phase being manipulated was carried out by prostaglandin, protease, and lysosome production for as long as 3-5 hours, or even 24 hours after injection.8 enhancement of paw edema at 1–3 hour time interval was also observed in the group treated with diclofenac. due to its half life (1–2 hours), diclofenac attained optimal antiinflammatory effect at 2-3 hours after oral administration. it suppressed nitric oxide (no) by altering the uptake and release of fatty acid responsible for the syntesis of arachidonic acid, the precursor of cox.2,9 identical response also occured in the treatment groups. this can be explained by the ability of chemical constituents in boli, flavonoid and tannin, to block the second phase of carrageenan-induced inflammatory reaction.while flavonoid inhibited the production of cox-2 and inducible nitric oxide synthase (inos), tannin helped decrease reactive oxygen species (ros) and free radicals concentration in the blood through its oxidation.10,11,12 tannin is also capable of forming complex with protein, polysaccharide, alkaloid, nucleic acid, and mineral.13 therefore, further study should be conducted to examine the effect of tannin administration topically to accelerate wound healing. different dosages of boli showed significantly different anti-inflammatory effect at 2 and 6 hour. after administration, flavonoid metabolites obtained maximal serum concentration at 1 hour and last for 4 hours. during that period, flavonoid concentration in table 1 paw edema volume changes at various time point group v0 v1 v2 v3 v4 v5 v6 v24 mean + sd* 1 0.66 1.15 1.28 1.36 1.31 1.33 1.25 0.96 1.16 2 0.61 1.05 1.16 1.25 1.13 1.11 1.08 0.90 1.03 3 0.56 1.00 1.01 1.16 1.06 1.11 0.98 0.83 0.96 4 0.61 1.01 1.10 1.30 1.26 1.23 1.18 0.91 1.07 5 0.68 1.00 1.00 1.20 1.18 1.11 1.05 0.90 1.01 althea medical journal. 2014;1(2) 63 blood plasma is minimally altered.14 factors that affect the time required for flavonoid to achieve its peak serum concentration include variation of food matrix and metabolism enzymes, causing disparities among efficacy in polyphenol absorption.15 on the other hand, it was assumed that the elimination of half life of boli was 6 hours after treatment with carrageenan. there was no significant differences between the group with 0.09 g of boli and the negative group. this might be explained due to dosage that was insufficient to attain optimal serum concentration.14 when comparing effects among treatment groups, only the group with 0.18 g and 0.36 g of boli displayed significant differenceat 4 and 6 hour after treatment. the group with 0.18 g of boli was most effective. inefficiency of 0.36 g of boli might have occured due to the waning of its anti-inflammatory effect. however, this assumption should be verified in further studies. mean paw edema inhibition percentage clearly showed efficacy when groups were compared. no significant differences were found between 0.18 g of boli and the positive group. thus, 0.18 g of boli was able to prevent paw volume from increasing which was comparable to diclofenac, rating stadium 3. on the contrary, the group with 0.09 g of boli was classified as stadium 2 and the group with 0,36 g of boli was inclusive to stadium 1 as an anti-inflammatory agent. these results provided scientific evidence for the benefit of bixa orellana l. leaf used to counter disruptive effect of inflammation, in harmony with the prior study conducted by keong et al.4 using extract of bixa orellana l. leaf. bixa orellana l. leaf in the form of both extract and infusion showed comparable antiinflammatory effect because the ratio between the plant and the diluent did not have significant impact to the chemical compounds contained within. in fact, chemical compositions in the leaf are mainly dependent on the temperature and duration of the extraction process. as conclusion, our present data suggested that bixa orellana l. leaf infusion has an antiinflammatory effect that are comparable to diclofenac with the most effective dosage 0.18 g equivalent 200 g body weight/day. further studies may clarifty its potential as a topical anti-inflammatory agent as well as its probable toxic effect. references 1. kumar v, abbas a, fausto n, editors. pathologic basis of disease. 8th ed. philadelphia: saunders elsevier; 2010. 2. katzung bg, masters sb, trevor aj, editors. basic and clinical pharmacology. 11th ed. new york: mc.graw-hill companies, inc.; 2009. 3. chengaiah b, mallikarjuna kr, kumar km, alagusundaram m, chetty cm. medicinal importance of natural dyes a review. int j pharmtech res. 2010;2(1);144–54. 4. yoke keong y, arifah ak, sukardi s, roslida ah, somchit mn, zuraini a. bixa orellana leaves extract inhibits bradykinin-induced inflammation through suppression of nitric oxide production. med princ pract. 2011;20(2):142–6. 5. balls m. the principles of humane figure1 paw changes percentage at every time point sabrina munggarani yusuf, enny rohmawaty, rama nusjirwan: bixa orellana leaf infusion as an antiinflammatory agent in carrageenan-induced wistar rats althea medical journal. 2014;1(2) 64 amj december, 2014 experimental techniques: timeless insights and unheeded warnings. altex;2010;27 (special issue):19–23 6. syamsuni ha. ilmu resep. jakarta: penerbit buku kedokteran egc; 2005. 7. morris cj. methods in molecular biology. in: paul g. winyard, derek a. willoughby, editors. 2003 inflammation protocols. new jersey: humana press; 2003. p. 115–21. 8. suralkar aa, sarda ps, ghaisas mm, thakare vn, deshpande ad. in-vivo animal models for evaluation of anti-inflammatory activity. pharmainfo.net [online journal] 2008 [cited 2012 april 28]. available at: http://www.pharmainfo.net/reviews/ v ivo a n i m a l m o d e l s eva l u a t i o n a n t i inflammatory-activity 9. hardman jg, limbard le, editors. goodman & gilmans: the pharmacological basis of theurapeutics. 10th ed. new york: mcgraw-hill companies, inc.; 2001. 10. hämäläinen m, nieminen r, vuorela p, heinonen m, moilanen e. antiinflammatory effects of flavonoids: genistein, kaempferol, quercetin, and daidzein inhibit stat-1 and nf-kappab activations, whereas flavone, isorhamnetin, naringenin, and pelargonidin inhibit only nf-kappab activation along with their inhibitory effect on inos expression and no production in activated macrophages. mediators inflamm. 2007;2007:45673. 11. jeffers md. tannin as anti-inflammatory agents [dissertation]. oxford, ohio: miami university; 2006. 12. liang yc, huang yt, tsai sh, lin-shiau sy, chen cy, lin jk. suppression of inducible cyclooxygenase and inducible nitric oxide synthase by apigenin and related flavonoids in mouse macrophages. carcinogenesis. 1999;20(10);1945–52. 13. frutos p, hervás g, giràldez fj, mantecón ar. tannins and ruminant nutrition. span j agric res. 2004;2(2);191–202. 14. miyake y, sakurai c, usuda m, fukumoto s, hiramitsu m, sakaida k, et al. difference in plasma metabolite concentration after ingestion of lemon flavonoids and their aglycones in humans. j nutr sci vitaminol (tokyo).2006;52(1);54–60. 15. manach c, williamson g, morand c, scalbert a, rémésy c. bioavailability and bioefficacy of polyphenols in humans. am j clin nutr. 2005:81(1 suppl); 230s–42s. 16. ye q, liang y, lu j. effect of different extracting methods on quality of chrysanthemum morifolium ramat infusion. asia pac j clinnutr. 2007;16 suppl 1:183–7. amj vol 7 no 3 september2.indd althea medical journal. 2020;7(3) 117 preservation in paraffin oil: alternative for fungi preservation in simple laboratory concept sem samuel surja,1 gabi vania sally,2 favian sergius ruby hartoyo,2 sandy vitria kurniawan,3 yanto budiman4 1department of parasitology school of medicine and health sciences universitas katolik indonesia atma jaya jakarta, indonesia, 2school of medicine and health sciences universitas katolik indonesia atma jaya jakarta, indonesia, 3department of pharmacology school of medicine and health sciences universitas katolik indonesia atma jaya jakarta, indonesia, 4department of radiology school of medicine and health sciences universitas katolik indonesia atma jaya jakarta, indonesia correspondence: sem samuel surja, department of parasitology, school of medicine and health sciences universitas katolik indonesia atma jaya jakarta, jl. pluit raya no. 2, penjaringan, jakarta utara, indonesia, e-mail: sem.samuel@atmajaya.ac.id amj. 2020;7(3):117–21 abstract background: a good collection of fungi culture can be maintained with good preservation methods. with appropriate methods, preservation can be performed in low-budget laboratories, such as with periodic subculture and preservation in either sterile water or in paraffin oil. the aim of this study was to assess the viability, morphology, contamination, and antifungal susceptibility profile of fungi preserved in sterile water or paraffin oil compared to a periodic subculture. methods: this study was an experimental study using aspergillus sp., trichophyton mentagrophytes and candida albicans conducted in the parasitology laboratory, school of medicine and health sciences, universitas katolik indonesia atma jaya, jakarta from march to october 2019. the fungi were preserved by a periodic subculture or in sterile water or in paraffin oil for six months. a comparison of viability, morphology, contamination, and antifungal susceptibility profile between methods were made before and after six months of study. results: the viability of all the fungi was maintained in both periodic subculture and preservation with paraffin oil. however, the t. mentagrophytes was not viable in preservation using sterile water. all methods could maintain the morphology without contamination. there were reductions in the inhibition zone against antifungal drug in preservation with sterile water and paraffin oil. conclusions: preservation in paraffin oil is superior to preservation in sterile water in terms of maintaining fungal viability. this method is suitable for the use in a simple laboratory, albeit considerations should be given to the reduction of inhibition zone. keywords: fungi, paraffin oil, preservation, sterile water introduction there are over 1.5 million various fungi strains in the world and only 100.000 strains are already identified. the identifying process of a fungus takes a long time, therefore, culture collection is important to maintain strains of the fungus viable before it can later be identified.1 medically or biotechnologically important fungi are considered paramount to preserve because of their unique properties and practical value in various aspects of human life.2,3 these strains are important for producing enzymes, proteins, vitamins, bioactive compounds, antimicrobial substances, and biopolymers. its application in the medical aspect could be in the field of diagnostic or development of new therapeutics.3 a good culture collection needs a good preservation method that can preserve a fungus for a long time. there are many methods of fungi preservation techniques, such as periodic subculture, freeze-drying preservation technique, preservation in sterile water or paraffin oil, and many more. periodic subculture is the easiest way to preserve fungi for a short period, however, it has some disadvantages such as the inability to ensure https://doi.org/10.15850/amj.v7n3.1975 althea medical journal. 2020;7(3) 118 amj september 2020 fungus viability for a long preservation period and potential of human errors in labeling. currently, the freeze-drying preservation technique is the method of choice for long-term fungal preservation. its major drawback is it requires advance high-technology equipment, thus, it cannot be performed in a simple laboratory.4 alternatively, most educational or research institutes prefer using periodic subcultures in preserving their fungi due to the higher cost of previous technique studies have shown that preservation in sterile water or paraffin oil could be used to preserve a wider range of fungi. these traditional methods could maintain the long-term viability of the fungi and only require basic microbiology laboratory skills and equipment. therefore, these twopreservation methods could be done in a simple laboratory.5–8 with an increasing number of antifungal resistances of many unusual and rare fungi, studies examining the susceptibility profile of fungi are now widely conducted. most of the source of the fungi is culture collection since strains should be collected over years to reach an amount sufficient to be studied.9 as for culture collection, many studies included viability and contamination as parameters in preservation technique research, but the alteration of antifungal susceptibility has been never examined. assessment of this parameter is important since alteration caused by preservation technique could cause misinterpretation of antifungal susceptibility results and potentially mislead treatment strategy. this study aimed to assess the viability, morphology, contamination, and antifungal susceptibility profile of fungi preserved with sterile water or paraffin oil. aspergillus sp. and trichophyton mentagrophytes were used to represent fast-growing and slow-growing molds and candida albicans to represent yeast. the result of this study was to be applied in a simple laboratory. methods this experimental study was conducted in the parasitology laboratory, school of medicine and health sciences, universitas katolik indonesia atma jaya, jakarta from march to october 2019. aspergillus sp., t. mentagrophytes, and c.albicans were obtained from the culture collection of the laboratory. all cultures were initially grown in sabouraud dextrose agar (sda, oxoid, united kingdom). the preservation techniques used were periodic subculture and preservation in sterile water or paraffin oil (figure 1). the periodic subculture method was performed by simply transferring fungi into a new sda once every two months.10 preservation with sterile water was conducted initially by flooding cultured fungi with 6–7 ml sterile water. the culture was scrapped lightly using pipette tips. the suspension was withdrawn and transferred to the mccartney tube.11 as for preservation in paraffin oil, fungi were first inoculated onto slant of sda inside the mccartney tubes. cultured fungi were then flooded with autoclaved paraffin oil until 1 cm above the culture.4,8 all fungi were preserved using these three methods for six months at room temperature. figure 1 preservation in paraffin oil (left) and sterile water (right) althea medical journal. 2020;7(3) 119 table 1 viability, morphology, and contamination of aspergillus sp., trichophyton mentagrophytes, and candida albicans before and after preservation parameters fungi before preservation after six months periodic subculture sterile water paraffin oil viability aspergillus sp. + + + + t r i c h o p h y t o n mentagrophytes + + + candida albicans + + + + morphology aspergillus sp. + + + + t r i c h o p h y t o n mentagrophytes + + + candida albicans + + + + contamination aspergillus sp. t r i c h o p h y t o n mentagrophytes + candida albicans note: viable fungus was markedas (+). morphology was marked as (+) if fungi showed typical morphology of the species. contamination was marked as (+)if it occured before preservation, fungi were tested for its viability, microscopic morphology, and antifungal susceptibility. the rice cream test was used for yeast (c. albicans) and the slide culture technique was used for molds (aspergillus sp. and t. mentagrophytes).12,13 morphology were checked based on its characteristic.14 antifungal susceptibility was examined using the disk diffusion technique according to clsi m51-a for aspergillus sp. and t. mentagrophytes and clsi m60 for c. albicans.13–15 it was measured using an average the zone of inhibition against voriconazole disk for aspergillus sp., itraconazole disk for t. mentagrophytes, and fluconazole disk for c. albicans. all assessments were conducted in two times of repetition. after being preserved for six months, the preserved cultures were reassessed for its viability, microscopic morphology, antifungal susceptibility, and level of contamination. the revival of fungi preserved in sterile water was conducted by inoculating 0.2–0.3 ml of the suspension with a sterile pipette to sda.11 for the revival of fungi preserved in paraffin oil, preserved fungi were swabbed and transferred into sda. additionally, every two months preserved cultures were checked for its viability by transferring preserved cultures in a new medium. this study was approved by the ethical committee, school of medicine and health sciences atma jaya catholic university of indonesia no:06/05/kep-fkuaj/2019 and no: 13/06/kep-fkuaj/2019. results periodic subculture and preservation in paraffin oil could maintain the viability of aspergillus sp., t. mentagrophytes, and c. albicans, while preservation in sterile water could maintain the viability of aspergillus sp. and c. albicans but not t.mentagrophytes (table 1). candida albicans preserved in paraffin oil showed slower growing time (5–7 days) than periodic subculture and in sterile water (24–48 hours). aspergillus sp. grew after 3–4 days for periodic subculture and paraffin oil, and 4 days for sterile water. t. mentagrophytes’ growing time was 5–7 days for periodic subculture and paraffin oil. in all viable fungi, microscopic morphology was not changed. c. albicans showed the marked formation of blastospore, pseudohyphae, and chlamydospore in the rice cream test, aspergillus sp. showed uniseriatephialides on the conidial head, and t. mentagrophytes showed some hyphae that were spiralshaped with spores arranged in the group. contaminations were not shown in any fungi except t. mentagrophytes preservation with sterile water. results of microscopic morphology and contamination were summarized in table 1. when tested by using the disk diffusion test, there was a reduction in the zone of inhibition for preservation in paraffin oil. the zone of inhibition for c. albicans showed the highest reduction from 34 mm to 25 mm after preservation in paraffin oil. both aspergillus sp. sem samuel surja et al.: preservation in paraffin oil: alternative for fungi preservation in simple laboratory concept althea medical journal. 2020;7(3) 120 amj september 2020 and t. mentagrophytes preserved in paraffin oil, reduction in the zone of inhibition were around 7 mm. for the periodic subculture method and preservation in sterile water, there was the only a low reduction in the zone of inhibition. results of the antifungal susceptibility profile were summarized in table 2. discussion preservation in paraffin oil could maintain the viability of aspergillus sp., trichophyton mentagrophytes, and c. albicans. moreover, paraffin oil could maintain microscopic morphology before and after preservation with no contamination. this is in accordance with a study by smith d et al.7 which preserved 58 strains of fungi and 47 strains that were still viable after being stored for 20 years in paraffin oil. similarly, ajello et al.6 also preserved 34 strains of fungi in paraffin oil and all strains that were still viable after being stored for 19–21 months. preservation in sterile water could maintain the viability of aspergillus sp. and c. albicans. similar studies by mcginnis mr et al.11 showed aspergillus sp. could still viable until 12 months and c. albicans until 60 months with no contamination after preservation in sterile water. moreover, suciatmih s et al.5 conducted a preservation study with sterile water and resulted in a 100% survival rate, and de caprilles ch et al.16 conducted a preservation study for 20 years and the survival rate around 50% with 22.8% contamination. in our study, t. mentagrophytes (dermatophyte) did not survive after being preserved in sterile water. some studies had reported that dermatophytes were more difficult to preserve in the long term using sterile water for example karabıçak n et al.17 reported that 3% of 1186 samples did not survive in sterile water after 12 years and all were dermatophytes. these studies along with our study have shown that preservation in sterile water could be used for shorter preservation time (around five years) than paraffin oil. this method is not preferred for dermatophyte and maybe also for another slow-growing fungus. in the antifungal susceptibility test, there was a reduction in the zone of inhibition against the antifungal drugs, which could be interpreted as an increase of resistance in the fungi. the reason for the reduction in the zone of inhibition at the disk diffusion test is unclear. a study assessing this issue after the preservation method is lacking. we assume increased resistance against antifungal has something to do with materials used in preservation. the adaptation process can change how fungi react to certain conditions. fungi in nutrient-limited conditions somehow become adapted in that harsh condition and maximizing its capability to survive. autophagy is an important response when cells are starving, to maintain viability in a state of malnutrition. it refers to a group of processes that involves the degradation of cytoplasmic components.18 autophagy in mold and yeast could function as a nutrient recycling pathway that supports survival in growth that occurs under nutrient-limited conditions.18,19 we believe this mechanism increases the resistance of the fungi against the antifungal drugs. when fungi in both preservation methods were revived and further subcultured in a nutrient-rich medium, the susceptibility profile might be gradually increased to its original pattern. there was an elongation of c. albicans growth. in general, c. albicans growth was visible after 24–48 hours. inoculum of c. albicans from preservation in paraffin oil grew in a slower time (5–7 days). this phenomenon table 2 antifungal susceptibility (zone of inhibition) of aspergillus sp., trichophyton mentagrophytes, and candida albicans before and after preservation parameters fungi before preservation (mm) after six months periodic subculture sterile water paraffin oil antifungal susceptibility aspergillus sp. 35 34 32 30 30 31 25 25 trichophyton mentagrophytes 45 40 45 45 36 38 candida albicans 32 34 33 32 34 35 25 24 note: zone of inhibition was expressed in millimeter (mm) althea medical journal. 2020;7(3) 121 could be explained by the ability of paraffin oil to inhibit oxygen ingress into the culture, so the metabolism of the fungi was suppressed. inhibited metabolism will further inhibit the sporulation of the fungi.6,20 there could be a slight elongation in the growing time of the fungus for the first revival. when the culture was transferred into a new medium for the second time, fungi would regain its growth rate to normal.7 this study has potential limitations. preservation was only performed for six months. longer preservation time should be performed to further observe the potential of these preservation techniques. given the limited fungi used in this study, more species and strain are needed for further study. also, these preservation techniques need some additional examination to prove its capability on maintaining genotypic and phenotypic stability of the culture. the molecular method should be performed for such purpose. in conclusion, preservation in paraffin oil maintain viability, microscopic morphology, as well as preventing contamination of preserved fungi. assessment of antifungal susceptibility profile using preserved fungi in paraffin oil should consider the increased resistance at a first revival after preservation. further subculture might be needed for this purpose. preservation in paraffin oil is superior to sterile water and this technique is encouraged to be used in a simple laboratory. references 1. smith d. culture collections over the world. int microbiol. 2003;6(2):95–100. 2. prakash o, nimonkar y, shouche ys. practice and prospects of microbial preservation. fems microbiol lett. 2013;339(1):1–9. 3. sievers m. culture collections in the study of microbial diversity, importance. in: nelson ke, editor. encyclopedia of metagenomics. boston: ma springer; 2015. p. 111–114. 4. machmud m. teknik penyimpanan dan pemeliharaan mikroba. bul agrobio. 2001;4(1):24–32. 5. suciatmih s, rachmat r. pengujian survival jamur yang dipreservasi dalam air dan parafin cair [survival testing of preserved fungi in water and liquid-paraffin ]. berita biologi. 2005;7(5):241–8. 6. ajello l, grant vq, gutzke ma. use of mineral oil in the maintenance of cultures of fungi pathogenic for humans. ama arch derm syphilol. 1951;63(6):747–9. 7. smith d, onions ahs. a comparison of some preservation techniques for fungi. trans br mycol soc. 1983;81(3):535–40. 8. buell cb, weston wh. application of the mineral oil conservation method to maintaining collections of fungous cultures. am j bot. 1947;34(10):555–61. 9. surja ss, adawiyah r, houbraken j, rozaliyani a, sjam r, yunihastuti e, et al. talaromyces atroroseus in hiv and nonhiv patient: a first report from indonesia. med mycol. 2020;58(4):560-63 10. james c, welsh c. microbiology: a laboratory manual. 11th ed. england: pearson education; 2017 11. mcginnis mr, padhye aa, ajello l. storage of stock cultures of filamentous fungi,yeasts, and some aerobic actinomycetes in sterile distilled water. appl microbiol. 1974;28(2):218–22. 12. rosana y, matsuzawa t, gonoi t, karuniawati a. modified slide culture method for faster and easier identification of dermatophytes. microbiol indones. 2014;8(3):135–9. 13. haley ld, callaway cs. laboratory methods in medical mycology. 4th ed. atlanta, ga: u.s. department of health, education and welfare, center for disease control; 1978. 14. surja ss, wijaya m, padmasutra l, yolanda h, joprang fs, makimian r, et al. atlas parasitologi kedokteran. 1st ed. jakarta: penerbit universitas katolik indonesia atma jaya; 2019. 15. agarwal rk, gupta s, mittal g, khan f, roy s, agarwal a. antifungal susceptibility testing of dermatophytes by agar based disk diffusion method. int j curr microbiol appl sci. 2015;4(3):430–6. 16. de capriles ch, mata s, middelveen m. preservation of fungi in water (castellani): 20 years. mycopathologia. 1989;106(2):73–9. 17. karabıçak n, karatuna o, akyar i. evaluation of the viabilities and stabilities of pathogenic mold and yeast species using three different preservation methods over a 12-year period along with a review of published reports. mycopathologia. 2016;181(5–6):415–24. 18. reggiori f, klionsky dj. autophagic processes in yeast: mechanism, machinery and regulation. genetics. 2013;194(2):341–61. 19. pollack jk, harris sd, marten mr. autophagy in filamentous fungi. fungal genet biol. 2009;46(1):1–8. 20. hartsell se. microbiological process report. maintenance of cultures under paraffin oil. appl microbiol. 1956;4(6):350–5. sem samuel surja et al.: preservation in paraffin oil: alternative for fungi preservation in simple laboratory concept amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 128 althea medical journal september 2021 igg levels in human papillomavirus infection associated with clinical stage of head and neck squamous cell carcinoma yussy afriani dewi, agung dinasti permana, fanny yudhiono department of otorhinolaryngology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: yussy afriani dewi, department of otorhinolaryngology-head and neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital , jalan pasteur 38, bandung indonesia, e-mail: yussy.afriani@unpad.ac.id introduction head and neck squamous cell carcinoma (hnscc) is a cancer that arises from the mucosal epithelium of the upper aerodigestive tract.1 head and neck squamous cell carcinoma is an aggressive, life-threatening cancer associated with a high mortality rates. the incidence of hnscc is about 90% of all head and neck cancers and is the sixth in the world. head and neck squamous cell carcinoma is the seventh leading cause of death and is increasing in developing countries by about 500,000 cases per year.2,3 the prevalence of head and neck cancer at dr. hasan sadikin general hospital bandung for the 2010–2014 period was 31.2%.4 human papillomavirus (hpv) is one of the factors that cause the growth of abnormal cells. the hpv infection causes interactions between oncoprotein e6 and p53 in cell cycle control settings, apoptosis, and dna repair. disruption of tp53 leads to cancer proliferation and progression. the p53 and p73 proteins have similar domain structures, indicating analogous biological activity and contribute to the increased risk of hpv-16 in hnscc. p53 instability leads to p21 transcription, deregulation of dna repair, and inhibition of p53 proapoptotic function. decreased p21, degradation of dna deregulation, and inhibition of proapoptotic function may result in proliferation; whereas the decreased function of p53 proapoptosis can directly increase progressivity. furthermore, the increased proliferation of epithelial cells with amj. 2021;8(3):128–31 abstract background: head and neck squamous cell carcinoma (hnscc) is an invasive neoplasm of epithelial tissue in the head and neck and one of the etiologies of hnscc is human papillomavirus (hpv) which may be associated with the clinical stage of hnscc. hpv infection in squamous cell epithelium produces specific igg antibodies against hpv. igg titer of hpv can help identify patients who are at risk for hpvrelated cancers. this study aimed to explore the association between igg titer of hpv with the clinical stages of hnscc. methods: the design of this study was analytic cross sectional, conducted at the outpatient clinic of otorhinolaryngology-head and neck surgery, division of oncology, dr. hasan sadikin general hospital bandung period september–december 2017. patients with hnscc were recruited, and history was taken. furthermore, histopathologic examination and hpv igg serology examination were performed using the elisa method. the hpv igg levels were compared by stage and data were analyzed using the shapiro wilks test and unpaired t test. results: the hpv igg was high in 75% (n=21) of hnscc patients in the advanced stage and low in 25% (n=7) of patients in the early stage. there was a significant relationship between hpv igg titer and early and advanced stage of hnscc (p=0.001). conclusions: the hpv igg titer is related to the clinical stage of hnscc indicating that the higher the hpv igg level, the more advanced the clinical stage. further study is needed to explore hpv igg levels as a prognostic marker in hnscc. keywords: hnscc stage, hpv igg, squamous cell carcinoma https://doi.org/10.15850/amj.v8n3.2171 althea medical journal. 2021;8(3) 129 high levels of hpv igg causes progressivity of tumor.5 the increased risk of hnscc is related to hpv-16 seropositivity examined using igg elisa. hpv-16 is also a risk factor associated with oropharyngeal squamous cell carcinoma (opscc). moreover, hpv has also been linked to the pathogenesis of oral cancer. the death rate of head and neck squamous cell carcinoma is very high, associated with the stage of the tumor when patients first come to the hospital.6,7 this research was aimed to explore the correlation between igg hpv titer and the clinical stage of hnscc methods this study was a cross-sectional analytic study at the outpatient clinic of otorhinolaryngologyhead and neck surgery, division of oncology, dr. hasan sadikin general hospital bandung period september–december 2017. hnscc patients were collected before recruitment. informed consent was obtained from all individual participants included in the study. inclusion criteria were patients with head and neck tumors in the early and advanced stages with histopathological results of squamous cell carcinoma (scc). furthermore, hnscc patients were included when they had not received radiation therapy, chemotherapy, or chemoirradiation. exclusion criteria were patients with residual or recurrence of scc, multiple carcinomas, patients who had received radiotherapy. the study was approved by the research ethics committee of dr. hasan sadikin hospital bandung, indonesia no. lb.04.01/a05/ec/304/x/2017. clinical stages were designated by earlystage (i-ii) hnscc, and advanced stage (iii-iv) based on the 2017 american joint committee on cancer (ajcc). the locations of hnscc were the oropharynx, paranasal sinuses, nasopharynx, oral cavity, and larynx. histopathology of scc was classified based on the results of the biopsy showing squamous differentiation microscopically. the hpv igg levels were obtained from blood serum and examined by elisa method using monoclonal antibodies of with quantitative serum levels of 156–10.000 u/ml. statistical analysis was performed using the mann whitney test and the fisher’s exact correlation test. results in total, 28 patients with hnscc were included, the most of patients were male (19 of 28) with a mean age of 53.78±8.385 years (range 33– 70 years). there was no relationship between gender (p=0.646) or age (p=0.972) with the clinical stage of hnscc (table 1). based on the location of the tumor, the most prevalent site was in the larynx (n=17) whereas advanced stage was the most prevalent site as shown in table 2. interestingly, there was a significant relationship between the hpv igg levels and the clinical stage of hnscc (p=0.001). the hpv igg levels in the advanced stage (4,708±1,386) were significantly higher than in the early-stage (2,344±1,255) as shown in table 3. discussion head and neck cancers are all cancers that originate in the upper aerodigestive tract, including the sinonasal tract, oral cavity, table 1 characteristics of patients with head and neck squamous cell carcinoma from dr. hasan sadikin general hospital in 2019 characteristics early stage advanced stage total p-value n=7 n=21 sex male female 4 3 15 6 19 9 *0.646 age (year) 31–40 41–50 ˃50 0 3 4 2 2 17 2 5 21 **0.927 mean±sd (age) median (age) range 52.42±6.267 51.000 45.00-61.00 54.23±9.071 55.000 33.00-70.00 53.78±8.385 55.000 33.00-70.00 **0.630 note: * fisher’s exact test p<0,05. ** kolmogorov smirnov test yussy afriani dewi et al.: igg levels in human papillomavirus infection associated with clinical stage of head and neck squamous cell carcinoma althea medical journal. 2021;8(3) 130 althea medical journal september 2021 table 2 tumor locations in patients with head and neck squamous cell carcinoma at dr. hasan sadikin hospital in 2019 tumor locations clinical stage early stage advanced stage oropharynx paranasal sinus nasopharynx larynx 2 1 0 4 3 3 2 13 pharynx, or larynx. about 90% of head and neck cancers are squamous cell carcinomas. cancers originates in the cells that line the mouth, nose, throat, ears, and also the surface of the tongue.1,8 gender is a risk factor for head and neck cancer. hnscc is more frequent in males than females, conform to the result in this study which showed that the male:female ratio of hnscc patients was 2:1. this result is similar to a study in the asia pacific, which involved patients with hnscc in various educational centers with a male:female ratio of 4:1.2 this might be related to exposure to cigarette smoke, alcohol, and carcinogenic. moreover, patients with advanced stage are also mostly found in the male gender.2,9 head and neck cancer is common in old age. our initial search of medical records showed that of a total of 638 hnscc patients, 51.9% were from the 51–60 year age category and 23.8% were 60–70 years old. in our current study, patients >50 years were 75%, confirming that the patients of hnscc mostly were at an average age of 57 years.10 this is caused by a long process of carcinogenesis. due to the carcinogenesis process from normal tissue needs a long time. the highest prevalence of hnscc is among tobacco users, of whom 74% smoke >10 packs/year.5,10 according to the 2017 ajcc, hnscc patients come at the advanced stage (iii–iv) 75%. the staging was designated based on the tnm scoring system namely tumor size, lymph nodes involvement, and metastasis. only 25% of patients seek medical attention in the early stages (i–ii). the main factors are difficulty in diagnosis, lack of symptoms, and lack of knowledge, besides the inadequate health facilities. the initial symptoms of head and neck tumors are typical, only resembling upper respiratory tract infections, stomatitis, voice changes, and nasal congestion.11 human papillomavirus has been found in premalignant tumors and malignant tumors of the head and neck. malignancy occurs due to hpv infection mediated by e6 and e7 proteins expression, inhibiting tumor suppressor gene pathways by inactivating tp53.12 the combined effect of the oncogeneous hvp, e6, e7, and e5 induces cell cycle progression in epithelial cells squamous oral cavity that is differentiated and growth suppressed, leading to carcinogenesis by proliferation deregulation, decreased apoptosis, genomic instability, and transformation processes. measurement of several specific hpv16 antibodies in serum up to 15 years before the diagnosis of oropharyngeal cancer has shown a correlation between baseline hpv16 antibodies and antigens of e1, e2, e6, and e7 in oropharyngeal cancer.12,13 in this study, the value of the hpv igg level in the clinical stage of hnscc stage i–ii and stage iii–iv were 2.1 and 4.9, respectively, suggesting a significant relationship (p=0.000) between the variable hpv igg levels and both. hpv infection in squamous cell epithelium causes the formation of specific antibody antigens. the antibodies formed are specific igg against hpv.14 examination of hpv igg antibodies in opscc patients in this study found that 95.6% had detectable igg antibodies, which can be used as predictor of table 3 comparison of hpv igg levels based on clinical stage in patients with head and neck squamous cell carcinoma variable early stage advanced stage p-value i–ii (n=7) iii–iv (n=21) hpv igg level mean±sd median range 2,344±1,255 2.100 998-4,350 4,708±1,386 4.900 1,100-6,800 0.001** note: **unpaired t-test, p <0.05 althea medical journal. 2021;8(3) 131yussy afriani dewi et al.: igg levels in human papillomavirus infection associated with clinical stage of head and neck squamous cell carcinoma opscc risk. specific hpv igg antibodies serve as markers of squamous cell carcinogenesis and are important for strategies for the prevention or early detection of squamous cell carcinoma.7,15 the hpv serology was positively correlated with 86% of hnscc patients who had been examined for hpv-dna pcr and p16 ihc. the e7 antibody titer in serum was also positively correlated with p16 in hnscc tissue, thus supporting the association between serological antibody and clinical stage with the incidence of hnscc.10 limitations in this study include the limited number of sample in the early-stages compared to the advanced stages. the hpv igg examination has been detected by serum serology, measuring cumulative exposure of an individual to hpv infection. thus, further research could be done to identify hnscc caused by hpv using more sensitive and specific examination such as the combination of p16 immunohistochemistry and pcrhpvdna. in conclusion, there is a correlation between increased levels of hpv igg and the clinical stage of hnscc. higher hpv igg levels worsens the prognosis of hnscc. examination of hpv igg levels can be used as a marker to assess the progression of hnscc. references 1. agrawal gp, joshi ps, agrawal a. role of hpv-16 in pathogenesis of oral epithelial dysplasia and oral squamous cell carcinoma and correlation of p16ink4a expression in hpv-16 positive cases: an immunohistochemical study. isrn pathology.2013;2013:807095. 2. yan w, wistuba, ii, emmert-buck mr, erickson hs. squamous cell carcinomasimilarities and differences among anatomical sites. am j cancer res. 2011;1(3):275–300. 3. syrjänen s. human papillomaviruses in head and neck carcinomas. n engl j med. 2007;356(19):1993–5. 4. sabirin msm, permana ad, soeseno b. epidemiologi penderita tumor ganas kepala leher di departemen telinga hidung tenggorokan-kepala leher rumah sakit dr. hasan sadikin bandung, indonesia, periode 2010–2014. tunas medika jurnal kedokteran & kesehatan. 2016;3(1):269. 5. kreimer ar, johansson m, waterboer t, kaaks r, chang-claude j, drogen d, et al. evaluation of human papillomavirus antibodies and risk of subsequent head and neck cancer. j clin oncol. 2013;31(21):2708–15. 6. cleary rk, cmelak aj. human papillomavirus–positive oropharyngeal squamous cell carcinoma demographics, prognosis, and staging. clin oncol. 2016;1:1018. 7. kerishnan jp, gopinath sc, kai sb, tang t-h, ng hl-c, rahman zaa, et al. detection of human papillomavirus 16-specific igg and igm antibodies in patient sera: a potential indicator of oral squamous cell carcinoma risk factor. int j med sci. 2016;13(6):424– 31. 8. jiang r, ekshyyan o, moore-medlin t, rong x, nathan s, gu x, et al. association between human papilloma virus/epstein-barr virus coinfection and oral carcinogenesis. j oral pathol med. 2015;44(1):28–36. 9. sathish n, wang x, yuan y. human papillomavirus (hpv)-associated oral cancers and treatment strategies. j dent res. 2014;93(7 suppl):29s–36s 10. khanal s, joh j, kwon am, zahin m, perez ca, dunlap ne, et al. human papillomavirus e7 serology and association with p16 immunohistochemistry in squamous cell carcinoma of the head and neck. exp mol pathol. 2015;99(2):335–40. 11. rakhmawulan ia, dewi ya, nasution n. profile of head and neck cancer patients at department of otorhinolaringologyhead and neck surgery dr. hasan sadikin general hospital bandung. amj. 2015;2(4):474–9. 12. liang c, marsit cj, mcclean md, nelson hh, christensen bc, haddad ri, et al. biomarkers of hpv in head and neck squamous cell carcinoma. cancer res. 2012;72(19):5004–13. 13. anderson ks, wallstrom g, langseth h, posner m, cheng jn, alam r, et al. pre-diagnostic dynamic hpv16 igg seropositivity and risk of oropharyngeal cancer. oral oncol. 2017;73:132–7. 14. dalianis t. human papillomavirus and oropharyngeal cancer, the epidemics, and significance of additional clinical biomarkers for prediction of response to therapy (review). int j oncol. 2014;44(6):1799–805. 15. fakhry c, qualliotine jr, zhang z, agrawal n, gaykalova da, bishop ja, et al. serum antibodies to hpv-16 early proteins warrant investigation as potential biomarkers for risk stratification and recurrence of hpvassociated oropharyngeal cancer. cancer prev res (phila). 2016;9(2):135–41. althea vol 1 no 2 edit.indd althea medical journal. 2014;1(2) 70 amj december, 2014 correspondence: afini tiara resi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone : +62 87805726372, email : afini.tiararesi12@gmail.com larvacidal effect of imperata cylindrical root decoction against culex sp. larvae afini tiara resi1, diah dhianawaty d.2 , neneng syarifah s.3 1faculty of medicine, universitas padjadjaran, 2department of biochemistry, faculty of medicine, universitas padjadjaran, 3department of parasitology, faculty of medicine, universitas padjadjaran, bandung, indonesia abstract background: filariasis is one of the neglected tropical diseases. about 337 of 401 districts in indonesia are endemic areas for filariasis, especially in sumatera, kalimantan, and papua. culex sp. is one of the lymphatic filariasis vectors which can be controlled by insecticide, including larvacide. this study was conducted to determine the larvacidal effect of imperata cylindrical root decoction against culex sp. larvae. methods: this study was conducted at the laboratory of parasitology, faculty of medicine, universitas padjadjaran during the period of september to november 2012. the study object was culex sp. larvae iii/iv instars. the design of this study was experimental laboratory using true experimental approach. the larvae were divided into three groups: negative control (distilled water), reference (abate®), and decoction. the number of larvae in each group was 25 larvae, and the effects were evaluated by the total number of dead larvae in 48 hours under observation. the data were then analyzed by mann-whitney test and probit test. results: the result of the mann-whitney test to compare imperata cylindrica root decoction treatment to distilled water as control was significant (p<0.05). however, abate® gave a better result. the probit test result was lc50: 63% and lc90: 489%. conclusions: imperata cylindrical root decoction has a larvacidal effect against culex sp. larvae [amj.2014;1(2):70–4] keywords: culex sp., filariasis, imperata cylindrica (l.) beauv., larvacidal, lc50 pengaruh larvasida rebusan akar alang-alang (imperata cylindrical) terhadap larva nyamuk (culex sp.) abstrak latar belakang: filariasis merupakan salah satu penyakit tropis yang terabaikan. sekitar 337 dari 401 kabupaten di indonesia adalah daerah endemik untuk filariasis terutama di sumatera, kalimantan, dan papua. nyamuk (culex sp.) adalah salah satu vektor filariasis limfatik yang dapat dikendalikan oleh insektisida, termasuk larvasida. penelitian ini dilakukan untuk mengetahui pengaruh larvasida dari rebusan akar alang-alang terhadap larva nyamuk (culex sp.) metode: penelitian ini dilakukan di laboratorium parasitologi, fakultas kedokteran, universitas padjadjaran selama periode september-november 2012. objek penelitian adalah larva nyamuk (culex sp.) instar iii / iv. desain penelitian ini adalah eksperimental laboratoris dengan menggunakan pendekatan eksperimental yang benar. larva dibagi menjadi tiga kelompok: kontrol negatif (air suling), referensi (abate®), dan rebusan. jumlah larva dalam setiap kelompok adalah 25 larva, dan efek dievaluasi dengan jumlah total larva mati dalam 48 jam di bawah pengawasan. data kemudian dianalisis dengan uji mann-whitney dan uji probit. hasil: hasil uji mann-whitney untuk membandingkan pemberian rebusan akar alang-alang (imperata cylindrica) terhadap air suling sebagai kontrol adalah signifikan (p <0,05). namun, abate® memberikan hasil yang lebih baik. hasil tes probit adalah lc50: 63% dan lc90: 489%. simpulan: rebusan akar alang-alang (imperata cylindrical) memiliki efek larvsidal terhadap larva nyamuk (culex sp.) [amj.2014;1(2):70–4] kata kunci: nyamuk (culex sp.), filariasis, alang-alang (imperata cylindrica (l.) beauv), larvasida, lc50 althea medical journal. 2014;1(2) 71 introduction filariasis is one of the neglected tropical diseases in the world.1,2 data from the ministry of health of the republic of indonesia show that out of 401 districts/cities in indonesia, 337 are still endemic for filariasis.3 culex sp. is one of the filariasis disease vectors that carries wuchereria bancrofti, brugia malayi and brugia timori parasites.4,5 abate® is one of the larvacides used to reduce the spread of filariasis vector due to its ability to kill mosquito larvae.4 however, the long -term use of abate® will lead to resistance in some mosquitoes, including culex sp. mosquitoes.6 this resistance can occur in various ways and through different mechanisms.4 therefore, there is a need for a new larvacide with less effects on human health but effective to kill larvae. imperata cylindrica is one of the most troublesome weeds in the world7 but the root extraction from this weed has several benefits for health thatthis weed is classified into one of the medicinal plants.8 the root extraction from i. cylindrica contains flavonoid and tannin. the levels of flavonoids in i. cylindrica is 0.32% while for tannin it is 9.20%.9 sudjari et al. (2006) cited that flavonoids and tannins have mosquito larvacide effect and each has different mechanisms to kill the larvae.10 the method for processing the i. cylindrical root’in this experiment was decoction. this method is more suitable for roots with hard texture because decoction procedure needs more time during boiling than infusion.11 methods the study was conducted at the laboratory of parasitology, faculty of medicine, universitas padjadjaran during the period of september to november 2012. the study was conducted in 3 weeks. the objects of the study were culex sp. larvae iii/iv instars. the design of this study was experimental laboratory research, with true experimental approach. the objects of this study were assigned into one of the three groups: treatment group, positive control group, and negative control group. the characteristics for both groups were homogenous.12 randomization was performed in both treatment group and control group. the inclusion criterion for this experimental study was culex sp. larvae iii/ iv instars, while the exclusion criterion was culex sp. larvae in moribund state. according to who criteria, the number of larva in each container should be 25 culex sp. larvae iii/ iv instars.14 the number of larvae needed in this experiment was 675 larvae. details of larva count: 8 containers at preliminary test 1, 4 containers at preliminary test 2, and 15 containers at final test. there were 2 types of variable used in this study, which were independent and dependent variables. the independent variable for this study was the concentration of i. cylindrica root decoction while the dependent variable was the larvacidal effect occurred in the experiment. the larvacidal effect was assessed from the number of larvae died or the number of larvae in a moribund state.12 the experiment was started by preparing the instruments and materials, including containers, disposable cups, a decoction set, pipettes, data recording forms, distilled water, i. cylindrica (l.) beauv roots, abate®, larvae, and larvae food. roots of the i. cylindrica were taken from the arboretum unpad during the period of 26 september to 10 october 2012. the roots were collected when the plant was not flowering. the decoction process was started by weighing the fresh roots of 500 grams. the roots were sliced into small pieces (2 cm) and then boiled in 500 ml of distilled water using a stainless steel pot (decoction set). the boiling process was performed for 30 minutes with a temperature of 900c. the thirty minutes started when the temperature had reached 900c.11 the root decoction solution was divided into a number of concentrations (100 ml volume) and was used immediately. larvae were fed with mice food until they reached third or fourth instars. larvae were divided into 3 groups of samples: the treatment group, negative control group and positive control group. three steps were used in this experiment. the first step was the preliminary test for screening the larvacidal effect of i. cylindrica root decoction when the larvae were exposed to negative control (distilled water) and several root decoction solution concentrations (15%, 30%, 45%, 60%, 75%, 90%, and 100% concentrations). the most effective concentration was then re-tested in a follow up experiment. the next step was the subsequent test when the larvae were exposed to the negative control (distilled water), and 3 concentrations of root decoction solution which included were the most effective concentration from the previous test with an afini tiara resi, diah dhianawaty d, neneng syarifah s: larvacidal effect of imperata cylindrical root decoction against culex sp. larvaehouse flies in jatinangor althea medical journal. 2014;1(2) 72 amj december, 2014 table 1 data from preliminary test and subsequent test preliminary test subsequent test control 15% 30% 45% 60% 75% 90% 100% control 95% 100% 0 5 11 7 9 14 12 20 0 12 18 addition and subtraction of 5% concentration (most effective concentration, most effective concentration plus 5%, and most effective concentration minus 5%) the most effective concentration from this second step was then re-tested in the final test. only 1 concentration of i. cylindrical root decoction was tested in the final test with 5 repeated tests. the results were then compared to the positive control group (abate®) and negative control group (distilled water). the control group was also tested 5 times.12 the larvae tested were kept in containers. each container consisted of 25 culex sp. larvae and was observed for 48 hours. every hour, the number of dead larvae was recorded. the observation was carried out until all larvae died or in a state of near-death (moribund state). larvae were considered dead or in moribund state if they did not respond to stimulation (making reflex motion), which were touch and water splash simulations. the concentration that killedmost larvae or that kill all larvae most rapidly was considered to be the most effective concentration.12 the larvae in this study were provided with food because the experiment would be conducted in a quite long time period. the food was especially provided when there was an increase in mortality in the negative control group.14 the containers were kept at a room temperature (25–280c), with 12 hours of light, followed by 12 hours without light (12l:12d).12 the data analysis was conducted using spss 15.0 software. hypothesis testing for numerical comparative data to determine the larvacidal effect of the root decoction was done from final experimental data. the data was initially tested using kolmogorovsmirnov test to determine the normality of data distribution. if the p-value <0.05, the data distribution is considered not normal which led to the use of the mann-whitney test. meanwhile, if the p-value >0.05, meaning that the data distribution is normal, unpaired t-test should be used. to determine the value of the lc50 and lc90, data were obtained from the preliminary test 1. the analyzes table 2 final experiment results group total larvae number of dead larvae (48 hours) imperata cylindrical root decoction (100%) 1 25 19 2 25 17 3 25 16 4 25 14 5 25 16 distilled water 1 25 1 2 25 0 3 25 0 4 25 1 5 25 0 abate® 1 25 25 2 25 25 3 25 25 4 25 25 25 25 were performed using the probit test.12 results the preliminary test was conducted in week 1 and the subsequent test was performed in week 2. from both tests, i. cylindrical root decoction in 100% concentration showed the highest mortality, so it was re-tested in a final experiment. the kolmogorov-smirnov test was conducted on final experiment data. all data had a significance value of below 0.05, showing abnormal variations in all data. the effect of larvacide was then compared using a non-parametric test, i.e. mann-whitney test (table 3). althea medical journal. 2014;1(2) 73 it was clear that i. cylindrical root decoction has a larvacidal effect against culex sp. larvae. however, it can be affirmed that abate® still has a better effect than the root decoction (table 4). the probit model results, y= -2.402 + 1.442 x, where y is the probit, and x is the concentration log from i. cylindrical root decoction concentration (table 4). from the probit model it was discovered that lc50 for i. cylindrica root decoction was 63% and lc90 was 489%. discussion based on the results of this study, there the testing of larvacide effects of roots decoction needed 3 steps. each step is conducted in 48 hours. an hourly observation is performed to count the dead larvae. the time needed for killing a half of the 25 larvae and to kill all larvae in 48 hours is the parameter to measure the larvacidal activity. the data from the experiment was analyzed using spss software in this study. the first test was to test the normality of the data distribution using the kolmogorov-smirnov test. the results show that the data distribution for all groups was not normal (p<0.05); hence, non-parametric tests was selected for further analysis. a non-parametric test for numericcomparative data (mann-whitney) was used in this study. the result shows that there were differences in larvacidal effects (p-value <0,05) between 100 % i. cylindrica root decoction and negative control (distilled water) and positive control (abate®). however, the larvacidal effects of root decoction on culex sp. larvae are much smaller when compared to abate® larvacidal effect. the effective concentration for larvacide is determined by lc50 and lc90. lc50 and lc90 of i. cylindrica root decoction were counted using the probit test, and the results were 63% for lc50 and 489% for lc90. this means that root decoction with 63% concentration is needed to kill 50% larvae within 48 hours, while abate® can kill all the larvae in 1 hour. in conclusion, i. cylindrica root decoction has a larvacidal effect against culex sp. larvae third and fourth instars but the effect is less. the weak larvacidal effect of i. cylindrica root decoction is probably due to the small amount of flavonoids in the i. cylindrica root. there is also a possibility that the decoction method produces less than maximum amount of flavonoid that can be extracted. therefore, a follow up study using a new method is needed to discover the active compounds table 3 mann-whitney test results parameter p-value (alpha=5%) interpretation 100% imperata cylindrica root decoction-aquades number of dead larvae 0.00 significant 100% imperata cylindrica root decoction-abate number of dead larvae 0.00 significant table 4 concentration logarithm & probit test results mortality total larvae concentration mortality (%) concentration log probit 5 25 15 20% 1.18 4.16 11 25 30 44% 1.48 4.85 7 25 45 28% 1.65 4.42 9 25 60 36% 1.78 4.64 14 25 75 56% 1.88 5.15 12 25 90 48% 1.95 4.95 20 25 100 80% 2.00 5.84 afini tiara resi, diah dhianawaty d, neneng syarifah s: larvacidal effect of imperata cylindrical root decoction against culex sp. larvaehouse flies in jatinangor althea medical journal. 2014;1(2) 74 amj december, 2014 in the i. cylindrica root that possibly has a larvacidal effect in addition to flavonoid and tannin. another study may be conducted by using dried i. cylindrica roots. dried roots can be used any time. furthermore, a study using aedes sp larvae is also important to assess the possibility to use i. cylindrica root decoction in preventing the disease transmitted by aedes sp. references 1. perera m, whitehead m, molyneux d, weerasooriya m, gunatilleke g. neglected patients with a neglected disease? a qualitative study of lymphatic filariasis. plos negl trop dis. 2007;1(2):e128. 2. kline k, mccarthy js, pearson m, loukas a, hotez pj. neglected tropical diseases of oceania: review of their prevalence, distribution, and opportunities for control. plos negl trop dis. 2013;7(1):e1755. 3. departemen kesehatan republik indonesia. rencana nasional program akselerasi eliminasi filariasis di indonesia 2010-2014.jakarta. kkri;2010. [cited 2012 april 21]. available from: http://www.pppl.depkes. g o . i d / _ a s s e t / _ d o w n l o a d / nat i o na l _ plan_filariasis_2010-ind__2010-14. pdf 4. natadisastra d, agoes r. parasitologi kedokteran: ditinjau dari organ tubuh yang diserang. jakarta. penerbit buku kedokteran egc; 2009.p.150-60, 317, 359 5. simonsen pe, mwakitalu me. urban lymphatic filariasis. parasitol res. 2013;112(1):35-44. 6. hamdan h, sofian-azirun m, ahmad nw, lim lh. insecticide resistance development in culex quinquefasciatus (say), aedes aegypti (l.) and aedes albopictus (skuse) larvae against malathion, permethrin and temephos. trop biomed. 2005;22(1):4552. 7. miller jh. nonnative invasive plants of southern forests : a field guide for identification and control. asheville: usda; 2003.p.50-1. [cited 2012 april 25]. available from: http://www.srs.fs.usda. gov/pubs/viewpub.php?index=5424 8. ahmad fb, ismail g. medicinal plants used by kadazan dusun communities around crocker range. asean review of biodiversity and environmental conservation (arbec);2003 [cited 2012 april 25]. available from: http://kdca.org. my/wp-content/files/medicinal_crange. pdf. 9. ayeni ke, yahaya sa. phytochemical screening of three medicinal plants neef leaf (azadirachta indica), hibiscus leaf (hibiscus rosasinensis), and spear grass leaf (imperata cylindrical). continental j pharmaceutical sciences. 2010;4:47-50. 10. sudjari, iskandar a, telussa as. pengaruh dekok daun mint (mentha arvensis var javanica) sebagai larvasida nabati nyamuk anopheles sp di pantai balekambang, kecamatan bantur, kabupaten malang. fakultas pendidikan kedokteran universitas brawijaya:malang. 2005 [cited 2012 may 10]. available from: http://elibrary.ub.ac.id/ handle/123456789/18325 11. suranto a. khasiat & manfaat madu herbal. jakarta: agromedia; 2004.p.87 12. who. guidelines for laboratory and field testing of mosquito larvicides. geneva.who;2005. [cited 2012 april 22] available from:http://whqlibdoc. who.int/hq/2005/who_cds_whopes_ gcdpp_2005.13.pdf afini tiara resi, diah dhianawaty d, neneng syarifah s: larvacidal effect of imperata cylindrical root decoction against culex sp. larvaehouse flies in jatinangor amj vol 7 no 2 2020_200804 final.indd althea medical journal. 2020;7(2) 84 amj june 2020 knowledge, attitude, and behavior among parents with cerebral palsy children visiting dr. hasan sadikin general hospital bandung maria christina shycha moenardi,1 ellyana sungkar,2 dewi hawani3 1faculty of medicine universitas padjadjaran, indonesia, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of child health faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung, indonesia correspondence: maria christina shycha moenardi, faculty of medicine universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, e-mail: shychamoenardi@gmail.com introduction children with cerebral palsy (cp) have many disabilities and abnormalities that restrict their daily activities and development. brain damage during its development is irreversible.1 management for cp mainly focuses on medical rehabilitation to manage their disabilities and to increase the quality of life.2,3 social and environmental factors are also crucial for maintaining optimal development.2,3 children with cp demand more intense care from their parents compared to normal children at their age.4–6 therefore, family especially parents as their caregiver plays a crucial role in cp development milestone.2,3 moreover, socioeconomic condition, marital conflicts, and other parental responsibilities give additional burden to parents.6–8 knowledge of the parents about cp may worsen these conditions.3,7 poor knowledge will impact the attitude of the parents and their daily behavior, leading to failure in their children’s development. good knowledge develops a supportive and cooperative attitude, resulting in proper daily behavior and indirectly supporting the development of their children.3,7,9 the aim of this study was to explore the knowledge, attitude, and behavior among parents with cp children. methods this study was a descriptive quantitative study, conducted from september to october 2014 at the physical medicine and rehabilitation amj. 2020;7(2):84–8 abstract background: cerebral palsy (cp) as a non-progressive syndrome of motor function and posture disturbance is caused by the abnormality or damage on the brain during its development. children with cp usually have motor, sensory, communication, and intellectual disturbances. medical rehabilitation is important; however, the environmental aspect is also crucial for their development. parents as their caregivers may have good knowledge to assist their children during rehabilitation. this study aimed to explore the knowledge, attitude, and behavior among parents with cp children. methods: this study was descriptive quantitative study and conducted at the physical medicine and rehabilitation clinic of dr. hasan sadikin general hospital bandung during september to october 2014. parents of cp children were asked to complete a questionnaire that was specifically designed for this study after their consent was obtained. results: from a total of 31 parents, 51.6% had good knowledge about cp; 58.1% had good attitude toward cp children, and 51.6% had good behavior while taking care of their children. conclusions: the majority of parents with cp children have good knowledge, attitude, and behavior towards cp children. the knowledge of risk factors of cerebral palsy are poor, therefore, it is necessary for doctors and therapists to provide more education sessions on the risk factors and other related topics about cerebral palsy. keywords: attitude, behavior, cerebral palsy, knowledge, parents https://doi.org/10.15850/amj.v7n2.1790 althea medical journal. 2020;7(2) 85 table 1 characteristics of parents with cerebral palsy children visiting dr. hasan sadikin general hospital bandung variables frequency (n=31) percentage (%) role in family father 10 32.26 mother 21 67.74 age group (years) 20–29 13 41.94 30–39 14 45.16 >40 4 12.90 occupation civil employee 1 3.23 private employee 4 12.90 entrepreneur 3 9.68 farmer 5 16.13 housewife 18 58.06 education elementary school 7 22.58 junior high school 9 29.03 senior high school 15 48.39 parental status parent with spouse 30 96.77 single parent 1 3.23 number of children in family 1 14 45.16 2 13 41.94 3 2 6.45 >4 2 6.45 child’s age <1 year old 4 12.90 1–5 years old 18 58.07 5–12 years old 6 19.35 >12 years old 3 9.68 patient type control/routine therapy 30 96.77 loss to follow up 1 3.23 income (each month) < rp1,000,000.00 11 35.48 rp1,000,000.00−rp5,000,000.00 15 48.39 rp5,000,000.00−rp10,000,000.00 5 16.13 maria christina shycha moenardi et al.: knowledge, attitude, and behavior among parents with cerebral palsy children visiting dr. hasan sadikin general hospital bandung althea medical journal. 2020;7(2) 86 amj june 2020 clinic in dr. hasan sadikin general hospital bandung. this study was conducted after being approved by the ethical committee of dr. hasan sadikin general hospital. the study subjects were parents with cp children. on descriptive sample calculation, the minimum subjects for this study were 30 and eligible parents were asked to participate using a consecutive sampling method. self-designed questionnaires were distributed, consisted of 12 questions for knowledge, 8 for attitude, and 9 for behavior. other variables including a role in the family, age of parents, occupation, education, parental status, number of children in the family, age of cp children, and monthly income were collected. each answer to the question had its score. the total individual score was then counted for the average value. parents with individual same or more than the average value for knowledge, attitude, and behavior were categorized as “good”, whereas parents with an individual score less than average value were categorized as“poor” group. results in total, thirty-one parents were included in this study, and the characteristics of those parents were shown in table 1. the age of subjects was in the range of 21−50 years old, with an average of 32.52 years old with most of them was in the age group 30−39 years old. the majority (48.39%) had finished their senior high school education. most of these parents (45.16%) only had one child, the one with cp, aged predominantly between 1–5 years old, and they came to the hospital with their cp children for routine therapy. most of the subjects (48.39%) had income rp1,000,000.00 to rp5,000,000.00 each month, however, all of these parents had used national health insurance (badan penyelenggara jaminan sosial kesehatan, bpjs) for the therapy of their cp children. the questionnaire result revealed an average score for knowledge was 8.42, for attitude was 25.7, and for behavior was 28.03. more than half (51.61%) of the parents had good knowledge, good attitude (58.06%), and good behavior (51.61%). most subjects gave the right answer about knowledge; such as they knew the cause of cerebral palsy, however, only a few knew the term of their children’s condition. most of the subjects did not know the risk factors of cp. most of them realized the importance of frequent and long term rehabilitation, but only a few understood the goal of the rehabilitation programs for their children. they believed that medical rehabilitation might cure their children of cp. they did not understand the goal of rehabilitation is to maximize their children’s daily function, but they realized that their children need special care, more than other children. as for attitude, 58.06% of parents showed good attitude toward cp children. from the interview, they stated that their children’s condition had added financial burden and reduced their time. the parents came to the rehabilitation doctor at least once for consultation monthly. the majority of fathers tended to have lower knowledge, attitude, and behavior score compared to mothers, although no statistical analysis had been table 2 knowledge, attitude, and behavior of parents with cerebral palsy children visiting dr. hasan sadikin general hospital bandung variables frequency (n=31) percentage (%) knowledge good 16 51.61 poor 15 48.39 attitude good 18 58.06 poor 13 41.94 behavior good 16 51.61 poor 15 48.39 althea medical journal. 2020;7(2) 87 performed. subjects from the age group 2029 years old had the highest knowledge level as well as for attitude and behavior. as for the education level, higher education showed better knowledge, attitude, and behavior. discussions parents with cp children play a significant role in taking care of their cp children as these children demand more intense care. good knowledge, attitude, and behavior may give these parents an aid to handle their situation. our study has shown that the majority of the parents, especially the mothers are housewives, similar to other studies in india10 and africa.11 majority of mothers have had worked previously, but they quit their job because of their children’s condition.10,11 knowledge levels of all parents were good, however, few subjects know the terminology for their children’s condition. the parents often misuse the disease terminology or name of the disease as cp, instead, the parents use part of the symptoms to explain the disease, including the children ‘can’t walk’, are ‘failure to thrive’, or have ‘seizure’. this result is similar to a study in india; that only 45.3% of parents know that ‘cerebral palsy’ as the name of the disease.12 the parents in our study also have low knowledge about the risk factors of cp. this may be due to a lack of information about the related topics from medical officers such as doctors, nurses, or therapists, as also reported in various studies.12,13 same as the importance of medical rehabilitation for cp children, only a few understand the goal of rehabilitation. therefore, the information about rehabilitation therapy to parents is important. an educational film could be given to the parents to increase the level of knowledge. this increases knowledge of the parents at all educational level.12 most of the parents mention that the cp child gives a financial burden and a decrease in personal time. the cp children are included in the bpjs program, yet, for each visit to dr. hasan sadikin general hospital bandung, extra cost for such as transport expense, meal, and others is needed. there is also no pattern of increasing knowledge based on the level of income. this result was supported by another study,that stated socioeconomic status does not have an impact to increase knowledge about cp in parents.12 interestingly, the duration time at home or with their children also give a big impact on knowledge, attitude, and behavior level of the parents.8 for example; fathers tend to have lower knowledge, attitude, and behavior level than mothers. mothers were the main caregivers and spend more time with their children than the father.5,6,8 similar to the type of job; outside the house jobs, such as civil employees and farmers spend more time outside the house and thus may have additional burden leading to decrease attention to their children.6–8 importantly, being a single parent, it seems that the knowledge, attitude, and behavior scores were below the average. chronically ill children have its pressure, leading an increase of stress level and eventually, decrease of attitude and behavior.14 parents with cp children aged 12 years or older has a low attitude and behavior score. this may due to longer exposure to cp children, including all of their disabilities, financial problems, and all other consequences. this situation leads to increased stress and indirectly impacts parents’ attitude and behavior.6–8 when the cp children growing older, parents will face more difficult.15 this includes worsening of physical problems, more difficult to maintain social relationship with the community, negative impacts on parents’ job, and more financial problems.15 the limitation of this study is that questionnaire used is self-designed and not validated yet. there is also no standard yet for the good and poor level of knowledge, attitude, and behavior as we use this average score. furthermore, we did not compare the level of knowledge, attitude, and behavior with various variables. further study to explore these parameters is needed to assess the knowledge, attitude, and behavior among parents with cp children to increase the quality of life of both parents and children. to conclude, even though the majority of parents with cp children in this study have good knowledge, attitude, and behavior, it is important to educate the parents as the main caregiver of cerebral palsy children as well as the community about the risk factors and other related topics about cp. references 1. swaiman kf, ashwal s, ferriero dm, schor nf. cerebral palsy. in: swaiman kf, wu yw, editors. swaiman’s pediatric neurology. 5th ed. edinburgh: elsevier saunders; 2012. p. 999–1008. 2. verschuren o, wiart l, hermans d, maria christina shycha moenardi et al.: knowledge, attitude, and behavior among parents with cerebral palsy children visiting dr. hasan sadikin general hospital bandung althea medical journal. 2020;7(2) 88 amj june 2020 ketelaar m. identification of facilitators and barriers to physical activity in children and adolescents with cerebral palsy. j pediatr. 2012;161(3):488–94. 3. aran a, shalev rs, biran g, gross-tsur v. parenting style impacts on quality of life in children with cerebral palsy. j pediatr. 2007;151(1):56–60. 4. bagnara c, bajraszewski e, carne r, fosang a, kennedy r, ong k, et al. cerebral palsy an information guide for parents. 5thed. melbourne: the royal children’s hospital; 2008.p. 7–9. 5. raina p, o’donnell m, rosenbaum p, brehaut j, walter sd, russell d, et al. the health and well-being of caregivers of children with cerebral palsy. j am acad pediatr. 2005;115(6):626–36. 6. wang hy, jong yj. parental stress and related factors in parents of children with cerebral palsy. kaohsiung j med sci. 2004;20(7):334–40. 7. gupta a, singhal n. positive perceptions in parents of children with disability. dcid journal. 2004;15(1):22–35. 8. park ms, chung cy, lee km, sung kh, choi ih, kim tw. parenting stress in parents of children with cerebral palsy and its association with physical function. j pediatr orthop b. 2012;21(5):452–6. 9. soekidjo notoadmodjo. promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta; 2012. p. 47–8. 10. nimbalkar s, raithatha s, shah r, panchal da. a qualitative study of psychosocial problems among parents of children with cerebral palsy attending two tertiary care hospitals in western india. isrn family med. 2014;2014:769619. 11. olawale oa, deih an, yaadar rk. psychological impact of cerebral palsy on families: the african perspective. j neurosci rural pract. 2013;4(2):159–63. 12. arora sk, aggarwal a, mittal h. impact of an educational film on parental knowledge of children with cerebral palsy. int j pediatr. 2014;2014:573698. 13. huang yp, kellett m, st john w. cerebral palsy: experiences of mother after learning their child’s diagnosis. j adv nurs. 2010;66(6):1213–21. 14. brown rt, wiener l, kupst mj, brennan t, behrman r, compas be, et al. single parenting and children with chronic illness: an understudied phenomenon. j pediatr psychol. 2008;33(4):408–21. 15. davis e, shelly a, waters e, boyd r, cook k, davern m, et al. the impact of caring for a child with cerebral palsy: quality of life for mothers and fathers. child care health dev. 2010;36(1):63–73. amj vol 8 no 1 march 2021.indd althea medical journal. 2021;8(1) 13 relationship between nutrition intake and hemoglobin levels in toddlers aged 12–24 months triastika ayu nurjannah,1 fardila elba,2 sefita aryuti nirmala,2 ariyati mandiri,2 merry wijaya2 1midwifery study program faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: triastika ayu nurjannaha, midwifery study program faculty of medicine, universitas padjajaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: triastikaayu@gmail.com amj. 2021;8(1):13–7 abstract background: the toddler period is a crucial life period and needs special attention. toddlers need to have a proper amount and good quality of nutrition from daily food to prevent anemia. this study aimed to explore the relationship between nutritional intake and hb level in toddlers aged 12–24 months in sumedang district, west java, indonesia. methods: this was a cross-sectional quantitative conducted in august–november 2019 on 96 toddlers aged 12–24 months. toddlers were recruited using proportioned simple random sampling method. the mothers of these toddlers were asked to complete a food record for three consecutive days for their toddlers. data were then processed using the nutrisurvey application while the hemoglobin (hb) level was measured using a digital hb tool. all data were analyzed using a pearson correlation test. results: most mothers of these toddlers graduated from senior high school (45.8%) and were housewives (78.1%). the iron requirement was met 61 toddlers (63.5%). most toddlers were not anemic (56.3%) with a mean hb of 10.99 gr/dl. a relationship was established between iron intake and hb level (p=0.000). conclusions: low iron intake is associated with hb level in toddlers aged 12-24 months in sumedang district, west java province, indonesia. a nutrition program needs to be well set-up for toddlers in this area. keywords: hemoglobin levels, nutritional intake, toddlers introduction toddlers need to have a proper amount and right quality nutrients from daily diets; therefore, the toddler period is a crucial life period and needs special attention. toddlers under five are among those who are vulnerable to malnutrition. according to the nutrition adequacy ratio (nar), proper nutritional intake is needed for toddlers under five to prevent anemia,1 in which hemoglobin (hb) levels are lower than normal values.2 hemoglobin (hb) is an oxygen-carrying compound in red blood cells,3 and the level hb is a parameter used to determine the prevalence of anemia. according to the 2018 basic health research (riset kesehatan dasar, riskesdas), the prevalence of anemia in toddlers under five is 38.5%.4 anemia is more common in toddlers aged 12–17 months than in toddlers aged 36–49 months the influencing factor is among others the increased physiological needs, whereas the need for iron will also increase at the age of one year. in this period, anemia iron deficiency increases, besides there is insufficient absorption of iron and bleeding.5 the occurrence of anemia in toddlers is generally caused by low levels of hemoglobin in the blood due to a lack of nutritional intake. if the nutritional intake does not meet the amount and composition of balanced nutrients, it may cause anemia.6 anemia due to a lack of nutrients plays a role https://doi.org/10.15850/amj.v8n1.2115 althea medical journal. 2021;8(1) 14 althea medical journal march 2021 in hemoglobin formation, for example, due to lack of consumption or absorption disorders. the nutritional substances referred to includes iron, which functions as a catalyst to form hemoglobin.7 iron is an essential microelement for the body, needed for blood formation to synthesize hemoglobin. excess iron is stored as protein ferritin and hemosiderin in the liver, spinal cord, and the rest in the lymph and muscles. the main difficulty in meeting iron needs is the low absorption rate of iron in the body, especially iron from plant sources, which only being absorbed for 1–2%. low iron intake is common in individuals who eat a less diverse diet. also, lack of food supply, poor food distribution, poverty, and ignorance, coupled with the habit of consuming foods that can interfere with the absorption of iron such as coffee and tea at mealtimes, resulting in lower iron uptake. lack of iron intake, low iron reserves in the body, or a lot of blood loss, will cause anemia to appear rapidly.8 the efforts that can be done to overcome the problem of anemia in toddlers are by consuming foods rich in iron (fe). this study aimed to determine the relationship between nutritional intake and hb levels in toddlers aged 12–24 months. methods this was a quantitative study with a crosssectional design conducted at the south sumedang public health center, sumedang regency, west java, in august–november 2019, after obtaining approval from three authorized agencies, including the sumedang health department, sumedang community public health center, and the health research ethics committee universitas padjadjaran no. 1009/un6.kep/ec/2019. the sampling technique was probability sampling with the proportioned simple random sampling method. the study instruments were a food record questionnaire and a digital hb tool (easy touch gchb). the mothers of the toddler were asked to record the food intake within three days. the data were further processed using the nutrisurvey application and analyzed using a pearson correlation test. results in total, this study included 98 toddlers aged 12–24 months. the education of the mothers was mostly senior high school (45.8%), and the most mothers were housewives (78.1%) (table 1). of 96 toddlers, 43.8% had anemia. the mean hemoglobin level of a toddler underfive aged 12–24 months was 10.99 gr/dl +/1.6 (range 7–15). based on nutritional intake, it was found that iron intake was not fulfilled in 35 (36.5%) respondents (table 2). the average of iron was 14.93 mg +/11.9 (range 1–63), indicating that the adequate level of iron intake for toddlers the standard of nutritional adequacy. the normal value of iron intake for toddlers aged 12–24 months was table 1 characteristic of the mothers who have toddlers aged 12–24 months characteristics n % education elementary school 13 13.5 junior high school 25 26.0 senior highschool 44 45.8 college 14 14.6 occupation housewife 75 78.1 labor 2 2.1 entrepreneur 13 13.5 civil servant 1 1.0 teacher 2 2.1 lecturer 1 1.0 midwife 1 1.0 doctor 1 1.0 althea medical journal. 2021;8(1) 15triastika ayu nurjannah et al.: relationship between nutrition intake and hemoglobin levels in toddlers aged 12-24 months 8 mg/day. there was a correlation between iron intake and hb level (p=0.000) as shown in table 3. there was a relationship between iron protein intake and hb levels (p=0.000) (data not shown). discussion this study has shown that there is a relationship between nutritional intake and hemoglobin levels (p=0.000), as 42 toddlers (43.7%) have anemia, suggesting nutritional deficiencies since there is an unfulfilled iron intake in (36.5%). this is in line with research by nurhidayati9, which states that there is a significant relationship between nutritional intake and hemoglobin level. lack of nutritional intake or food intake will result in malnutrition, affecting the speed of hemoglobin formation, and the blood concentration decreases, causing hemoglobin levels to fall. this occurs because there is insufficient iron available for the formation of hemoglobin, so that the production of hemoglobin is lower than normal, thus, it is possible to develop anemia.10 anemia is a condition in which the number of red blood cells is reduced or does not contain enough hemoglobin. hemoglobin is found in red blood cells, which carry oxygen to body tissues and develop body tissues. anemia in toddlers under five causes growth disorders and various disease susceptibilities. the toddlers may look pale, lethargic, and have reduced appetite. the process of forming hemoglobin in the body requires nutritional table 2 distribution of hemoglobin levels and nutrient intake among toddlers aged 12–24 months from south sumedang public health center, sumedang regency, west java variable n % hemoglobin levels anemia 42 43.8 no anemia 54 56.3 iron intake fulfilled 61 63.5 not fulfilled 35 36.5 table 3 value of hemoglobin levels and nutritional intake variable mean median standard deviation min max hemoglobin levels 10.99 11.00 1.688 7 15 iron 14.93 12.10 11.965 1 63 table 4 relationship between nutritional intake and hemoglobin levels of toddlers aged 12–24 months iron intake hemoglobin levels score p*anemia no anemia total n % n % n % fulfilled 16 26.2 45 73.8 61 100 0.000 not fulfilled 26 74.3 9 25.7 35 100 note: *pearson correlation test althea medical journal. 2021;8(1) 16 althea medical journal march 2021 intake. therefore, to prevent anemia, toddlers under five should consume, among others, liver, meat, fish, eggs, avocado, nuts, spinach, and seeds. hemoglobin is the main protein in the human body that functions to transport oxygen from the lungs to the peripheral tissues and vice versa to transport co2 from the peripheral tissues to the lungs.11 furthermore, the average iron intake in toddlers aged 12–24 months in this study was 14.93 mgm which has met the nutritional adequacy standard. the nutritional adequacy rate (nar) for toddlers aged 12–24 months is 8 mg/day. maternal education, mother’s occupation, family income, number of toddler, and mother’s parenting style may play important role in nutritional adequacy.12 this is confirmed that the mothers have a high school education (45.8%) and work as housewives (78.1%). there is a significant relationship between maternal education and maternal knowledge about anemia.13 this impacts the nutritional intake of toddlers under-five which will affect hemoglobin levels with a significant value. it is known that the higher the maternal education, the better knowledge in preventing anemia because the higher a person’s education level, the easier it is to receive information so that the more knowledge one has. the level of maternal knowledge about nutrition as a housewife will affect the type of food consumed daily. there is a significant relationship between maternal occupational status and maternal knowledge about anemia (p=0.003). mother’s status and type of work may affect the availability of time to manage food because they tend to determine the diversity of household food consumption. working as a housewife provided time for others to pay attention to nutritional intake for themselves and their families. this study found that there is a relationship between iron protein intake and hb levels (p=0.000). other studies also have shown a significant relationship between iron intake and hemoglobin levels.15,16 iron has a vital role in the formation of hemoglobin. the higher iron intake, the better hemoglobin levels.14 this study has some limitations. many things cause anemia in toddlers under-five. this study only limits the problem to the relationship between nutrition intake and hemoglobin levels in toddlers aged 12–24 months. it could have been followed up longer by food or diet intervention to explore the effect of nutritional intake on hb levels. in conclusion, the intake of nutrients consisting of iron has a significant relationship to hb levels in toddlers aged 12–24 months at the public health center in south sumedang. an iron-rich nutrition program needs to be well set up for toddlers in this area. references 1. adriani m, wirjatmadi b. gizi dan kesehatan balita: peranan mikro zinc pada pertumbuhan balita. jakarta: kencana prenadamedia group; 2014. 2. masthalina h. pola konsumsi (faktor inhibitor dan enhancer fe) terhadap status anemia remaja putri. kemas. 2015;11(1):80–6. 3. wardhani jp, rahfiludin mz, pradigdo sf. perbedaan aktivitas fisik, kadar hb, dan kesegaran jasmani (studi pada siswi kek dan tidak kek di sman 1 grogol kabupaten kediri). jkm. 2017;3(3):205–12. 4. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar (riskesdas). jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri; 2018. 5. singh, patra. extent of anaemia among preschool children in eag states, india: a challenge to policy makers. anemia. 2014;2014:868752. 6. fitriany j, saputri ai. anemia defisiensi besi. averrous. 2018;4(2):1–14. 7. vanbuskirk km, ofosu a, kennedy a, denno dm. pediatric anemia in rural ghana: a cross-sectional study of prevalence and risk factors. j trop pediatr. 2014;60(4):308–17. 8. ekorinawati w. hubungan asupan zat besi dengan kadar hemoglobin dan kadar ferritin pada anak usia 6 sampai 24 bulan di puskesmas kratonan [minor thesis]. surakarta: universitas muhammadiyah surakarta; 2010. 9. kementrian kesehatan ri.. profil kesehatan indonesia tahun 2016. jakarta: kemenkes ri; 2017 10. nurhidayati a, hapsari e. hubungan asupan nutrisi dengan kadar hb pada ibu hamil di bps suratini suwarno surakarta. jurnal kesehatan kusuma husada. 2014; 5(1):47 11. mustofa fl, rusmini h. hubungan kebiasaan sarapan pagi dan kadar hemoglobin terhadap konsentrasi belajar pada mahasiswi program studi kedokteran angkatan 2014 universitas malahayati bandar lampung. jurnal medika malahayati. 2014;1(3):113–8. althea medical journal. 2021;8(1) 17 12. putri rf, sulastri d, lestari y. faktor-faktor yang berhubungan dengan status gizi anak balita di wilayah kerja puskesmas nanggalo padang. jurnal kesehatan andalas. 2015;4(1):254–61 13. rahmawati s. hubungan tingkat pendidikan dan status pekerjaan ibu dengan pengetahuan ibu tentang anemia pada anak balita di kelurahan nambangan kidul kecamatan manguharjo kota madiun [minor thesis]. surakarta: universitas muhammadiyah surakarta; 2015. 14. silvia a, kartini a, nugraheni sa. hubungan asupan zat gizi (protein, zat besi, vitamin c) dan pola (siklus, lama) menstruasi dengan kadar hemoglobin (studi pada remaja putri di smk negeri 10 semarang). jkm: jurnal kesehatan masyarakat (e-journal). 2019;7(4):504–16. 15. pradanti cm, wulandari m, k sulistya h. hubungan asupan zat besi (fe) dan vitamin c dengan kadar hemoglobin pada siswi kelas viii smp negeri 3 brebes. jurnal gizi unimus. 2015;4(1):24–9 16. al rahmad ah. pengaruh asupan protein dan zat besi (fe) terhadap kadar hemoglobin pada wanita bekerja. jurnal kesehatan. 2017;8(3):321–5. triastika ayu nurjannah et al.: relationship between nutrition intake and hemoglobin levels in toddlers aged 12-24 months amj vol 9 no 4 desember 2022 final.indd althea medical journal. 2022;9(4) 234 level of knowledge, attitude, and practices of general physicians in west java, indonesia on middle ear inflammation aziza salsabila,1 lina lasminingrum,2 sally mahdiani,2 shinta fitri boesoirie,2 bambang purwanto2 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology-head and neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: aziza salsabila, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, e-mail: aziza18002@mail.unpad.ac.id. introduction otitis media (om) is an inflammatory process in the middle ear. epidemiologists from the centers for disease control and prevention (cdc) conducted a survey in 2007, which showed that there were 24.5 million cases worldwide with the primary diagnosis of otitis media. in indonesia, there are no standard epidemiological data nationally, as well as data on the prevalence of otitis media. a study in west java reported that the total visits to the referral hospital in bandung for the period 2010 to 2019 were over 186 thousand visits, of which over 33 thousand cases or around 18% were otitis media (om), indicating that the prevalence of om in west java is high.1–3 otitis media (om) is classified into acute otitis media (aom), otitis media with effusion (ome), and chronic suppurative otitis media (csom), each of which are closely related and overlapping conditions. the diagnosis of om is established based on the history taking or anamnesis, for example, by looking at the signs and symptoms that have been assisted by supporting examinations. after being diagnosed, treatment will be carried out, depending on the classification.1,4 proper diagnosis and appropriate therapy aim to prevent complications that may lead to adverse health effects. the most common complication of om is hearing loss. when it occurs in children of growing age, hearing loss may result in speech delays, learning disorders, and socialization disorders that may indirectly reduce the quality of human life. another complication is the expansion of the disease to other organs, which results in higher treatment costs and increased morbidity and mortality. early and adequate management is needed to althea medical journal. 2022;9(4):234–240 abstract background: the prevalence of middle ear inflammation in west java is still relatively high. general practitioners are at the forefront who see and treat the patients directly; thus, the number of cases can be reduced by increasing the competence of general practitioners. this study aimed to determine the level of knowledge, attitude, and practices of general practitioners in west java towards middle ear inflammation, as an evaluation for improving health services in the community. methods: this research was a descriptive study with a questionnaire conducted in august–december 2021 conducted online with a probability sampling technique of at least 368 general practitioners in west java. the level of knowledge, attitude, and practices were calculated using the guttman scale. the data were presented as a frequency distribution. results: the results showed that the majority of the general practitioners still had poor knowledge of middle ear inflammation (n=325; 84.6%) as well as the attitude (n=333; 86.7%) and the level of practice (n=340; 88.5%). conclusions: the level of knowledge, attitude, and practices of general practitioners in west java towards middle ear inflammation is poor. special interventions and approaches are needed to improve the competence of general practitioners in west java based on the standard competency of indonesian doctors. keywords: attitude, practices, knowledge, middle ear inflammation https://doi.org/10.15850/amj.v9n4.2655 althea medical journal. 2022;9(4) 235 treat and prevent the complications.5–7 general practitioners, as the front liners in the health system, have to treat general medical conditions and to refer patients to hospitals and advanced medical services whenever further management is needed. in the indonesian doctor competency standard, recognizing and treating om is a competency that a doctor upon graduation must achieve. a doctor, in his/her daily clinical practice, will come across various cases of otitis media. classifying the om types becomes a challenging process for a general practitioner which may lead to overdiagnosis, overtreatment, or inappropriate use of antibiotics, which can significantly impact the patient’s health. it is important to classify each condition properly and perform a proper examination and treatment management to prevent recurrent middle ear inflammation and complications. therefore, the purpose of this study was to assess the level of knowledge, attitude, and practices of general practitioners in west java towards middle ear inflammation. the results of this study were expected to be useful for analyzing the understanding and knowledge of general practitioners about middle ear inflammation and providing benefits to society and the world of medicine.8 methods this study was a cross-sectional descriptive study using a primary data questionnaire obtained online as a research instrument to assess the level of knowledge, attitude, and practices on middle ear inflammation among general practitioners in west java. the research population was general practitioners who worked in west java. research subjects were selected through simple random sampling with a total population of 9,047 general practitioners. the probability sampling technique was used to obtain a minimum sample of 368 respondents. questionnaires were distributed randomly across social media through collaboration with the indonesian doctor association (ikatan dokter indonesia, idi) in west java, alumnus of medical universities in west java, and others. respondents who met the inclusion criteria filled in the questionnaire. the inclusion criteria were general practitioners actively working in the west java area. the exclusion criteria were general practitioners who went on leave and came to west java to take specialist education. this research was conducted from august to december 2021. the research protocol, subject information sheet, and consent form were approved by the research ethics committee of universitas padjadjaran (ethical approval no. 826/un6. kep/ec/2021). the instrument consisted of an informed consent form, the characteristics of the respondents, including gender, age, medical table 1 demographic characteristics of general practitioners in west java in 2021 (n=384) variable total (n) percentage (% ) gender female male 243 141 63.3* 36.7 university universitas padjadjaran islam bandung university jenderal ahmad yani university kristen maranatha university others 192 74 38 21 74 50* 19.2 9.9 5.5 19.2 age young adult (20–40 years old) middle adult (41–60 years old) elderly (>60 years old) 349 30 5 90.9* 7.8 1.3 work place hospital private clinic public health center others 215 139 78 18 47.8* 30.9 17.3 4 note: *the highest frequency . aziza salsabila et al.: level of knowledge, attitude, and practices of general physicians in west java, indonesia on middle ear inflammation althea medical journal. 2022;9(4) 236 practice experience, place of work, university origin, year of graduation as a doctor, and questions to assess the level of knowledge, attitude, and respondents’ practices towards middle ear inflammation. the questionnaire developed by the authors is in accordance with the competencies required by general practitioners, based on the standard competency of indonesian doctors (standar kompetensi dokter indonesia, skdi). the assessment of the level of knowledge, attitude, and practices was calculated using the guttman scale, which gave the respondents a chance to choose between the two answers that were true or false for all the questions based on their knowledge. the answer was given a value of 1 (one) if it was correct and a value of 0 (zero) was given if it was incorrect. before the study, the validity and reliability tests were carried out on 60 respondents using cronbach’s alpha. the results showed that level of the questionnaire was 0.566 (medium reliability). there were 8 questions regarding knowledge of middle ear inflammation. the level of knowledge was considered good if the value was >76–100%, sufficient if the value was 56–75%, and poor if the value was <56%.12 attitude and practices were considered good if the value was 100% and poor if the value was <100%. treatment of middle ear inflammation (otitis media) included skdi level 4a (four) for acute otitis media while 3a (three) for otitis media with effusion and chronic suppurative otitis media, indicating that a general practitioner was required to be able to diagnose, to complete treatment, and to refer if there were any complications. furthermore, a general practitioner must have perfect points for his attitude and practices.10 the data were in a frequency distribution, presented in tables. results the total samples obtained were 384 respondents, including 141 male (36.7%) and 243 female (63.3%) general practitioners who graduated from various universities in west java, predominantly from universitas padjadjaran (n=192; 50%) as shown in table 1. the included general practitioners were table 2 assessment of knowledge based on the correct answers distribution (n=384) no knowledge questions correct answer n (%) 1. pneumatic otoscopy is a necessary examination to diagnose csom. 136 (35.4) 2. adenoids are organs that play a role in the pathophysiology of otitis media. 206 (53.6) 3. most aom sufferers are at the age of <2 years. 255 (66.4)* 4. the following is an overview obtained on ome. 152 (39.6) 5. systemic antibiotics are always required in aom patients aged less than 2 years. 208 (54.8) 6. oral decongestants are drugs that should be given to aom. 101 (26.3) 7. antibiotic ear drops are the main treatment for csom. 205 (53.4) 8. tympanoplasty is a procedure to remove fluid from the middle ear. 289 (75.3)* note: *csom=chronic suppurative otitis media, aom=acute otitis media, ome=otitis media with effusion.,*have correct answer for >56%. althea medical journal december 2022 table 3 level of knowledge on middle ear inflammation among general practitioners from west java (n=384)) level of knowledge total (n) percentage (% ) good 19 4.9 sufficient 40 10.4 poor 325 84.6 note: *the highest frequency althea medical journal. 2022;9(4) 237 dominated by young doctors (n=349; 90.9%) who worked for < 5 years (n=289; 75.3%). most of the respondents worked in hospitals (47.8%), private clinics (30.9%) or a smaller percentage in public health centers or other places such as independent practice. only two questions had correct answers for >56%; question no. 3 most aom sufferers are at the age of <2 years (66.4%), and question no 8. tympanoplasty is a procedure to remove fluid from the middle ear. (75.3%) as depicted in table 2. the questionnaire results showed that most of the respondents had poor knowledge (84.6%) (table 3). the questionnaire to assess the attitude of the respondents consisted of 7 questions. attitude was regarded as good if the value was 100% and poor if the value was less than 100%. in other words, if the respondents could answer all of the questions, the attitude was good; if they could not, then the attitude was still poor (table 4). six items made up the questionnaire used to gauge the respondents’ practices. when the value was 100%, practices were considered good; when it was less than 100%, they were considered poor. if responders responded effectively to all the questions, the practices were good; otherwise, they were poor (table 4). the results showed that the attitude of the respondents was predominantly poor (86.7%) as well as for practice (88.5%) (table 5). when viewed from the references table 4 assessment of attitude and practices level based on the correct answers distribution (n=384) no attitude and practices questions correct answer n (%) attitude questions 1. i believe that all tympanic membrane perforations can close spontaneously once the otitis media has healed. 274 (71.4) 2. as a general practitioner, i must be able to carry out the management of acute otitis media to completion. 357 (93) 3. if i do not carry out the management of aom in children completely, it can cause communication and learning disorders. 371 (96.6) 4. i believe that all otitis media can be cured. 295 (76.8) 5. is ear examination necessary in all patients with upper respiratory tract infections? 281 (73.2) 6. ome requires careful examination and the assistance of pneumatic otoscopy. 300 (78.1) 7. i agree that patients with recurrent aom are indicated for tonsillectomy. 213 (55.5) practices questions 1. i will always give antibiotics in the first 48 hours to children with mild aom symptoms. 242 (63) 2. i will refer to an ent specialist for patients with csom with complications. 383 (99.7) 3. i always perform a tuning fork examination on patients with suspected otitis media. 141 (36.7) 4. i always recommend a photo examination of schuller and stenver in patients with csom. 203 (52.9) 5. i always do ear toilets with h2o2 in the clinic for patients with otorrhoea. 202 (52.6) 6. i will prescribe analgesics without antibiotics in the first 48 hours for patients with mild aom. 286 (74.5) note: aom=acute otitis media; ome=otitis media with effusion; ent=ear, nose, throat; csom= chronic suppurative otitis media; h2o2=hydrogen peroxide. aziza salsabila et al.: level of knowledge, attitude, and practices of general physicians in west java, indonesia on middle ear inflammation althea medical journal. 2022;9(4) 238 used by respondents in studying middle ear inflammation, the majority of respondents read textbooks as the main reference, followed by the discussion or consultation with colleagues. some respondents read journals, and some others gained knowledge about inflammation of the middle ear through symposiums, training, and a small proportion of respondents used other sources such as the clinical practice guide in primary care, the internet, guideline from the ministry of health, several medical applications, and guidelines from the indonesian otorhinolaryngologyhead and neck surgery society (table 6). discussion this study found that most general practitioners in west java still have poor knowledge, attitude, and practices towards middle ear inflammation. research on knowledge, attitude, and practices toward middle ear inflammation has previously been carried out in several countries, such as india and rwanda, with respondents in the communities, such as parents with children in a specific age group. assessing the level of parental awareness is of great interest, so that interventions in the form of education can be carried out to increase awareness that can reduce the number of cases, mortality rates, and morbidity rates from otitis media.11,12 in contrast, our study approaches general practitioners as the front line in the community health system, who will see and treat the patient’s condition directly. here, the same goal has been directed to reduce the number of cases but in a different way. middle ear inflammation is a disease that needs attention because this disease can be prevented, either through preventive or promotive measures. furthermore, its complications can be prevented through appropriate curative measures. general practitioners are health workers who have the main control to prevent, diagnose, treat, and refer to follow-up services if there are complications to control disease and achieve patient welfare. a general practitioner is required to have the appropriate competence to achieve overall health. the knowledge, attitude, and practices of the general practitioners in this study are still poor and must be improved. health is an investment for developing productive human resources both socially and economically, so indirectly general practitioners have an important influence on the development of various other sectors and have an important role in developing the country.13,14 knowledge results from sensing a particular object through sight, hearing, smell, taste, and touch. knowledge is an important domain to determine a person’s attitude and actions. practices that are based on knowledge will last longer than practices that are not based on knowledge. these three things are interrelated and cannot be separated.12,15 althea medical journal december 2022 table 5 attitude and practices on middle ear inflammation among general practitioners from west java (n=384) attitude and practices total (n) percentage (% ) attitude good poor 51 333 13.3 86.7 practices good poor 44 340 11.5 88.5 table 6 respondent’s reference to learn middle ear inflammation references total (n) percentage (% ) textbook peer discussion journal symposium training others 317 274 231 151 73 20 29.7 25.7 21.7 14.2 6.8 1.9 althea medical journal. 2022;9(4) 239 if the knowledge is good, it will determine attitudes and practices that tend to be good. on the other hand, if the knowledge is poor, it will be more difficult to form good attitude and practices. this statement was strengthened in the study, as we can see the knowledge, attitude, and practices of the general practitioners are still poor and mostly the questions that were not answered correctly by the respondents were questions about the diagnosis and management of otitis media. when general practitioners in west java still have poor knowledge, especially about this topic, then the application of attitude and practices would also not be good because these things are two things that go hand in hand. better competence of general practitioners is still needed to diagnose and carry out effective and efficient management.12 one of the efforts and solutions that can be offered to this problem is to build fundamental skills, especially in terms of analytical thinking and critical thinking, from the pre-clinical period to the time of becoming a doctor. critical thinking is the ability to recognize problems, seek, and evaluate related information to get the right conclusions. if future doctors instill and practice this mindset, especially in the pre-clinical period, doctors will be more aware of the importance of a disease to be studied with various approaches. a doctor must also realize that every case encountered, such as middle ear inflammation, must be seen and studied comprehensively because in essence, one problem caused by one disease can spread to other problems.16 otitis media is more common in childhood, related to the anatomical structure, physiology, and immunity. the most common complications encountered in otitis media cases are disturbances in children’s growth and development, which will indirectly reduce the quality of life of children who are the nation’s successors. this proves that a disease cannot be underestimated and must be operated on comprehensively to prevent a bigger bad impact. if curiosity is built from the start, learning will also be more effective because it has a basic wall in the form of a strong reason to learn something. the doctors formed are those who have the self-awareness to continue seeking knowledge and maintain lifelong learning principles. it is hoped that the doctors formed will be of higher quality.17–19 the briefing in question can be in the form of seminars, workshops, symposia, upgrading and updating of knowledge, socialization of management, as well as direct discussion sessions with experts, namely doctors who are specialists in their field. skills training can also be carried out directly by experts. it is recommended that training can be carried out regularly. medical science will continue to develop and be updated. dissemination of training information through social media can also be effective in this global era.20 the limitation of this research is the difficulty in getting respondents. the researchers came from universitas padjadjaran, so the respondents were dominated by respondents who graduated from the same university, making the data taken less evenly distributed. in conclusion, the knowledge, attitude, and practices of the general practitioners in west java are still poor. to increase the awareness and competence of general practitioners, providing material on middle ear inflammation in several ways, both face-to-face and online, is needed to help general practitioners develop knowledge of middle ear inflammation. therefore, accuracy in managing middle ear inflammation can be carried out more effectively and efficiently. references 1. bluestone cd, simons jp, healy gb. bluestone and stool’s pediatric otolaryngology. 5th ed. shelton, connecticut: people’s medical publishing house-usa; 2014. 2. prawiranata ma. pola penyakit otitis media sebelum dan era bpjs di rsup hasan sadikin [thesis]. bandung: universitas padjadjaran; 2020. 3. rosenfeld rm, schwartz sr, pynnonen ma, tunkel de, hussey hm, fichera js, et al. clinical practice guideline: tympanostomy tubes in children. otolaryngol head neck surg. 2013;149(1 suppl): s1–35. 4. lieberthal as, carroll ae, chonmaitree t, ganiats tg, hoberman a, jackson ma, et al. the diagnosis and management of acute otitis media. pediatrics. 2013;131(3):e964–99. 5. chang je, shapiro nl, bhattacharyya n. do demographic disparities exist in the diagnosis and surgical management of otitis media? laryngoscope. 2018;128(12):2898–901. 6. kucur c, özbay i̇, topuz mf, erdoğan o, oğhan f, güvey a, et al. acute otitis media complications: a single center experience. j clin exp investig. 2017;8(4):120–3. 7. kingery j, taylor w, braun d. acute otitis media. osteopathic fam physician. 2016;8(6):22–5. aziza salsabila et al.: level of knowledge, attitude, and practices of general physicians in west java, indonesia on middle ear inflammation althea medical journal. 2022;9(4) 240 8. konsil kedokteran indonesia. standar kompetensi dokter indonesia. jakarta: konsil kedokteran indonesia; 2012 [cited 2021 january 31]. available from: http:// www.kki.go.id/assets/data/arsip/skdi_ perkonsil,_11_maret_13.pdf 9. kementrian kesehatan republik indonesia. informasi sdm kesehatan nasional [internet] 2021 [cited 2021 jun 30]. available from: http:// bppsdmk.kemkes.go.id/info_sdmk/info/ index?prov=32&&rumpun=101 10. wawan a, dewi m. teori dan pengukuran pengetahuan, sikap, dan perilaku manusia. yogyakarta: nuha medika; 2011. 11. mukara kb, waiswa p, lilford r, tucci dl. knowledge and care-seeking practices for ear infections among parents of underfive children in kigali, rwanda: a crosssectional study. bmc ear nose throat disord. 2017;17:7. 12. dabholkar yg, wadhwa a, deshmukh a. a study of knowledge, attitude, and practices about otitis media in parents in navimumbai. j otol. 2021;16(2):89–94. 13. qureishi a, lee y, belfield k, birchall jp, daniel m. update on otitis media– prevention and treatment. infect drug resist. 2014;7:15–24. 14. homøe p, heidemann ch, damoiseaux ra, lailach s, lieu jec, et al. panel 5: impact of otitis media on quality of life and development. int j pediatr otorhinolaryngol. 2020;130(suppl 1):109837. 15. pui m, nicol am, brauer m, palad f, carlsten c. a qualitative study of the knowledge, attitudes, and behaviors of people exposed to diesel exhaust at the workplace in british columbia, canada. plos one. 2017;12(8):e0182890. 16. zayapragassarazan z, menon v, kar s, batmanabane g. understanding critical thinking to create better doctors. j adv med educ res. 2016;1(3):9–13. 17. fu j, li l, liang z, xu s, lin n, qin p, et al. etiology of acute otitis media and phenotypic-molecular characterization of streptococcus pneumoniae isolated from children in liuzhou, china. bmc infect dis. 2019;19(1):168. 18. dyche l, epstein rm. curiosity and medical education. med educ. 2011;45(7):663–8. 19. van dyke mk, pirçon jy, cohen r, madhi sa, rosenblüt a, parra mm, et al. etiology of acute otitis media in children less than 5 years of age: a pooled analysis of 10 similarly designed observational studies. pediatr infect dis j. 2017;36(3):274–81. 20. hua w, song d, xue j, cao y, zhu d. improving knowledge/skills, selfefficacy and practices regarding weight management among general practitioners: a pilot trial of an integrated intervention program. prim health care open access. 2018;8(4):1000313. althea medical journal december 2022 amj vol 8 no 4 december 2021new.indd althea medical journal. 2021;8(4) 210 outcomes of tuberculous meningitis patients with hydrocephalus with or without cerebrospinal fluid diversion nabila chantikarizky hasanah,1 akhmad imron,2 ahmad rizal ganiem3 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurosurgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: nabila chantikarizky hasanah, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, e-mail: nabila.chantika@gmail.com introduction tuberculosis (tb) is a major cause of health problems and is one of the ten causes of death worldwide.1 of all tb cases, extrapulmonary tb accounts for 20–25%. tuberculous meningitis infects the meninges lining of the brain and is the most severe form of extrapulmonary tb, which can cause disability and death.2 hydrocephalus is a complication often found in patients with tuberculous meningitis and is one of the poor predictors.3 hydrocephalus can be classified into communicating and non-communicating hydrocephalus.4 in tuberculous meningitis, hydrocephalus occurs due to impaired cerebrospinal fluid (csf) flow in the subarachnoid space caused by inflammatory infiltrates. furthermore, csf flow obstruction causes enlargement of the ventricular system of the brain and may be accompanied by increased intracranial pressure.5 the management of hydrocephalus in tuberculous meningitis patients varies, and until now, there are no specific universal guidelines regarding surgical management indications.6 treatment of hydrocephalus can be done with drugs or with operative measures as indicated. non-communicating hydrocephalus is a life-threatening condition, so the use of drugs is considered ineffective and usually requires an operative procedure althea medical journal. 2021;8(4):210–215 abstract background: hydrocephalus is a common complication in tuberculous meningitis patients and is a poor predictor with high mortality and morbidity rates. therefore, early diagnosis, detection, and treatment of hydrocephalus are important. cerebrospinal fluid diversion is the process used to drain accumulated fluid in the brain and spinal cord. this study aimed to explore the outcome of tuberculous meningitis patients with hydrocephalus who underwent cerebrospinal fluid diversion and who did not. methods: this was a retrospective cross-sectional descriptive study, including tuberculosis meningitis patients with hydrocephalus, admitted at the department of neurology dr. hasan sadikin bandung general hospital during the period 2018. functional outcomes were grouped based on the glasgow outcome scale. results: of the 55 patients, only 14 (25.5%) underwent cerebrospinal fluid diversion. the outcome of patients with cerebrospinal fluid diversion was 8 of 14 good, 1 of 14 poor, and 5 of 14 died. the outcome of patients without cerebrospinal fluid diversion was 13 of 41 good, 2 of 41 poor, and 26 of 41 died. most tuberculous meningitis patients with hydrocephalus, with or without the cerebrospinal fluid diversion procedure were at an advanced stage with a high mortality rate. conclusion: the proportion of good functional outcomes in patients with cerebrospinal fluid diversion is higher than in patients without the cerebrospinal fluid diversion. keywords: cerebrospinal fluid diversion, hydrocephalus, outcome, tuberculous meningitis https://doi.org/10.15850/amj.v8n4.2300 althea medical journal. 2021;8(4) 211 in the form of csf diversion, namely, shunt surgery such as ventriculoperitoneal shunt and ventriculoatrial shunt, external ventricular drain, and endoscopic third ventriculostomy.4,7 the most common types of csf diversion are ventriculoperitoneal (vp) shunt and external ventricular drain (evd). the high mortality and morbidity rates in tuberculous meningitis patients with hydrocephalus require proper diagnosis, early treatment, and hydrocephalus treatment.3,4,8 nevertheless, there is still diversity and uncertainty in the outcome of patients undergoing csf diversion procedures until now.4,6 therefore, a descriptive study is needed to determine the outcome of tuberculous meningitis patients with hydrocephalus who underwent csf diversion. this study aimed to explore the outcome of tuberculous meningitis patients with hydrocephalus who underwent csf diversion and who did not. methods the study was conducted with a crosssectional retrospective descriptive method in tuberculous meningitis patients with hydrocephalus at the department of neurology dr. hasan sadikin general hospital bandung admitted during 2018. a total sampling was conducted, with inclusion criteria being adults aged >18 years, diagnosed with tuberculous meningitis and with hydrocephalus as evidenced by brain imaging results. data on patients who discontinued the treatment were excluded from the study. the research received approval from the research ethics committee of universitas padjadjaran number 630/un6.kep/ec/2020 and a research permit according to the research and research and ethics committee of dr hasan sadikin general hospital. data on body temperature at admission in the hospital were noted. the severity of tuberculous meningitis was grouped into three levels according to the british medical research council (bmrc) based on glasgow coma scale (gcs) and the presence of neurologic deficits was defined as follows; grade 1 was defined as a gcs score of 15 without focal neurologic deficit, grade 2 as gcs 11–14 or gcs 15 with neurologic deficit, and grade 3 as gcs 10. head imaging results confirming the diagnosis of hydrocephalus were retrieved by measuring ventricular enlargement using the evans’ ratio by comparing the length of maximum ventricular width and the maximum width of the calvaria bone with more than 0.3 considered as hydrocephalus. indications of csf diversion were based on the initial level of consciousness, and neurological status.9 outcome data were grouped based on the glasgow outcome scale (gos) with the following interpretation: gos value of 1 was designated as death; gos value of 2 was for comatose patient; gos value of 3 was for sopor or somnolent patient, or otherwise patient with the motoric strength 0 to 3, or there was a language disorder; gos value of 4 was for patient in a composted state with a degree of motoric strength of 4; and gos value of 5 in a patient in a composted state with a final degree of motor strength of 5 or having mild neurological sequelae. the gos was assessed based on measurement just before discharge from the hospital. furthermore, the outcome was grouped into good functional outcome, poor functional outcome, and death; gos 1 would be death, gos 2 and 3 would be classified as poor functional outcomes, and gos 4 and 5 would be classified as good functional outcomes. results in 2018, 146 patients were treated for tuberculous meningitis at dr. hasan sadikin general hospital, 65 (44.5%) of patients had hydrocephalus. of the 65 tuberculous meningitis with hydrocephalus, only 55 patients (85%) met the inclusion criteria, and 10 (15%) were excluded for several reasons such as 4 (6%) were discharged at their request, 5 (8%) had an outcome that could not be assessed due to the patient switched treatments, and 1 (2%) was under the influence of medication. this study divided patients (n=55) into two criteria based on their management which were with csf diversion (n=14; 25%) and without csf diversion (n=41; 75%). characteristics of tuberculous meningitis patients with hydrocephalus are shown in table 1. there was no difference in the proportions related to demographic characteristics of tuberculous meningitis patients and clinical symptoms that were only given drug therapy or with csf diversion procedures (table 1). table 2 shows an overview of the proportion of characteristics related to the management. the most common type of nosocomial infection in patients was hospital acquired pneumonia. all patients were given anti-tuberculosis drug therapy and dexamethasone. the most common cause of death was non-neurological causes in the form of nosocomial infections. in nabila chantikarizky hasanah et al.: outcomes of tuberculous meningitis patients with hydrocephalus with or without cerebrospinal fluid diversion althea medical journal. 2021;8(4) 212 patients with csf diversion, vp shunt was the most common type of performed procedure (13 of 14). in terms of the proportion of patients’ outcome based on the severity of tuberculous meningitis and the gos underwent csf diversion action, it was found that 8 patients treated with csf diversion had good outcomes: gos 4 was 3, and gos 5 was 5. a total of 5 patients died, and 1 patient had a poor outcome gos 3 (table 3). table 4 shows the proportion of patients’ outcome based on the severity of tuberculous meningitis and the gos underwent csf diversion action, who were only given therapy in the form of drugs. most of the patients died (n=26; 63%), and 2 (5%) had poor functional outcome. only 13 (32%) had good functional outcome (table 4). discussions the proportion of hydrocephalus in tuberculous meningitis patients in this study is 44.5%, similar to a 6-year retrospective study conducted in northern taiwan with a percentage of 44.4%.3 this study reveals no difference in the proportion related to demographic characteristics or clinical symptoms between patients who were given only drug therapy and those who underwent csf diversion. the mean age of patients was 32 years (iqr 26–42). the majority of patients in this study were male, similar to a previous study in the department of neurology dr. hasan sadikin general hospital for the period january 2014–september 2016.10 tuberculous meningitis is an infection that triggers the immune system and althea medical journal december 2021 table 1 characteristics of tuberculous meningitis patients with hydrocephalus with or without csf diversion admitted in dr. hasan sadikin general hospital in 2018 characteristics with csf diversion (n=14) without csf diversion (n=41) n n (%) male 8 25 (61) age in years–median (iqr) 33 (24.25–44.25) 32 (27.5–49) chief complaint altered sensorium headache seizures 13 1 0 36 (88) 3 (7) 2 (5) body temperature (°c)–median (iqr) 36.95 (36.5–37.1) 37.5 (37–37.8) level of consciousness compos mentis (gcs 15) somnolent (gcs 12–14) sopor (gcs 8–11) coma (gcs 3–7) 1 13 0 0 3 (7) 30 (73) 8 (20) 0 (0) motoric level normal hemiparesis/hemiplegia tetraparesis/tetraplegia paraparesis/paraplegia 3 8 3 0 11 (27) 19 (46) 9 (22) 2 (5) degree of tuberculous meningitis (mrc staging) stage i stage ii stage iii 0 12 2 0 (0) 31 (76) 10 (24) anti-hiv positive * 0 of 12 5 of 34 imaging (ct scan) communicating hydrocephalus non-communicating hydrocephalus 11 3 32 (78) 9 (22) note: information on hiv (human immunodeficiency virus) status was only available for 46 people, namely n=12 with csf diversion and n=34 without csf diversion althea medical journal. 2021;8(4) 213nabila chantikarizky hasanah et al.: outcomes of tuberculous meningitis patients with hydrocephalus with or without cerebrospinal fluid diversion releases cytokines that can increase body temperature.11 in this study, there were variations in the patients’ body temperature with a mean value of 37.3 °c (iqr 36.8 °c–37.8 °c). decreased consciousness at the somnolent level is the most frequent clinical symptom that underlies the patient being admitted to the hospital and. is related to the severity of tuberculous meningitis and can be a marker of hydrocephalus.4,12 hydrocephalus is a common complication of tuberculous meningitis. it is associated with poor outcome.4,13 hydrocephalus can cause an increase intracranial pressure, causing various clinical symptoms and requiring immediate action.14 according to a previous research, communicating hydrocephalus types are more often found in cases of tuberculous meningitis than non-communicating types,4 in line with the findings of our study. the management of hydrocephalus in tuberculous meningitis patients varies. in our study, patient management was carried out with medical therapy in drugs or csf diversion measures such as vp shunt/evd if indicated. the outcome in tuberculous meningitis patients with hydrocephalus is related to several things. the presence of hemiparesis, paraparesis, and grade iii of tuberculous meningitis may lead to a poor prognosis.4 our study found that a large number of patients had hemiparesis and paraparesis, 22% of patients had grade iii mrc tuberculous meningitis. this percentage is similar to the findings of the proportion in a study in malaysia, which stated that patients with grade iii were 22.8%.15 furthermore, there is a relationship between the severity of tuberculous meningitis and poor outcome3, as was also found in our study which showed that of the total patients with meningitis grade iii, 92% of patients died. the length of inpatient stay can also determine the outcome. interestingly, there is an interplay between the length of stay of patients and the presence of nosocomial infections.16 prolonged length of stay can table 2 management of tuberculous meningitis patients with hydrocephalus with or without csf diversion, admitted in dr. hasan sadikin general hospital in 2018 characteristics with csf diversion (n=14) without csf diversion (n=41) n n (%) length of inpatient staying days – median (iqr) 21.5 (11.5– 27.5) 5 (3 – 19.5) nosocomial infections hospital acquired pneumonia catheter-associated urinary tract infections/urosepsis others without infections 4 1 0 9 10 (24) 3 (7) 1 (2) 28 (68) drug administration anti-tuberculosis drugs corticosteroids acetazolamide 14 14 2 41 (100) 41 (100) 15 (37) duration between the decision and the csf diversion procedure < 1 day > 1 day 10 4 n/a n/a csf diversion types ventriculoperitoneal (vp) shunt external ventricular drain (evd) 13 1 n/a n/a length of stay for patients who died§ (days) – median (iqr) 12 (9 – 64) 3.5 (1.75 – 5) cause of death§ non-neurological causes neurological causes 4 1 14 (54) 12 (46) note: information on the length of treatment for patients who died and the cause of death was n=5 in patients with csf diversion and n=26 in patients without csf diversion althea medical journal. 2021;8(4) 214 increase the risk of nosocomial infections and lead to poor outcomes.17 however, our study found that there was no difference in the proportion regarding the incidence of nosocomial infections in patients with csf diversion and those without. hence, the proportion of deaths in patients without csf diversion due to neurological reasons was higher than in those with csf diversion. this is related to the existence of patients who refuse the csf diversion procedure. from a total of 10 patients who refused csf diversion, 80% died with the most common cause of death due to neurological causes. there was a difference in outcome between patients who underwent csf diversion and those who did not. a total of 8 of 14 patients who underwent csf diversion had a good functional outcome. meanwhile, only 31% of patients without csf diversion had a good functional outcome, as opposed to the previous study conducted in malaysia,15 stating that patients who underwent csf diversion procedure had a worse outcome than patients who only received drug therapy due to the delay in the patients referral to the neurosurgery department and thus the disease is at an advanced stage.15 in this study, the good outcome in patients undergoing csf diversion may be related to several things. it is known that the vellore score iv (the condition of the patient in a coma state with abnormal posture) is associated with a poor outcome.6 in our study, no initial consciousness level of coma was found. in addition, the duration of time between the patients admitted to the hospital and the implementation of csf diversion procedure in most patients was <1 day. in pediatric patients, suffering from tuberculous meningitis and hydrocephalus with ‘early shunt’ (<2 days), had a better outcome than ‘late shunt’ (>2 days).18 these may be related to the high number of good functional outcome in patients undergoing csf diversion. the number of patients who died was 56%. this mortality proportion is similar to a previous study conducted in northern taiwan.3 this study found that the mortality rate in patients who did not undergo csf diversion was higher than in those who underwent csf diversion. apart from refusal of csf diversion procedure, as previously stated, another possible cause of mortality in patients without csf diversion is non-neurological causes such as nosocomial infection. whereas of the total people who underwent csf diversion, 5 of 14 patients died with a median length of stay of table 3 outcomes of patients with csf diversion based on the severity of tuberculous meningitis and the glasgow outcome scale degree of tuberculous meningitis (mrc staging) glasgow outcome scale (n=14) death poor functional outcome good functional outcome gos 1 gos 2 gos 3 gos 4 gos 5 i ii iii 0 3 2 0 0 0 0 1 0 0 3 0 0 5 0 note: gos= glasgow outcome scale; poor functional outcome was designated as a gos 2 and 3; good functional outcome was for scales of 4 and 5 table 4 outcome of patients without csf diversion based on the severity of tuberculous meningitis and the glasgow outcome scale degree of tuberculous meningitis (mrc staging) glasgow outcome scale (n=41) death poor functional outcome good functional outcome gos 1 gos 2 gos 3 gos 4 gos 5 n (%) n (%) n (%) n (%) n (%) i ii iii 0 (0) 17 (41) 9 (22) 0 (0) 1 (2) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 3 (7) 1 (2) 0 (0) 9 (22) 0 (0) note: gos= glasgow outcome scale; poor functional outcome was designated as a gos 2 and 3; good functional outcome was for scales of 4 and 5 althea medical journal december 2021 althea medical journal. 2021;8(4) 215 12 days (iqr 9–64), and it was known that the cause of death was mostly due to nonneurological causes. limitation in this study is due to incomplete data since this is a retrospective study. prospective analytical methods with more complete and accurate data at specific times might provide more insight for the treatment outcomes after a certain period of time. this study concludes that most tuberculous meningitis patients with hydrocephalus, admitted in dr. hasan sadikin general hospital 2018, with or without the cerebrospinal fluid diversion procedure, are at an advanced stage with a high mortality rate. the proportion of good functional outcomes in patients undergoing the cerebrospinal fluid diversion is higher than patients without the cerebrospinal fluid diversion. references 1. world health organization. global tuberculosis report 2020. geneva: world health organization; 2020. 2. ramirez-lapausa m, menendez-saldana a, noguerado-asensio a. extrapulmonary tubercolosis:an overview. rev esp sanid penit. 2015;17:3–11. 3. hsu pc, yang cc, ye jj, huang py, chiang pc, lee mh. prognostic factors of tuberculous meningitis in adults: a 6-year retrospective study at a tertiary hospital in northern taiwan. j microbiol immunol infect. 2010;43(2):111–8. 4. raut t, garg rk, jain a, verma r, singh mk, malhotra hs, et al. hydrocephalus in tuberculous meningitis: incidence, its predictive factors and impact on the prognosis. j infect. 2013;66(4):330–7. 5. davis a, meintjes g, wilkinson rj. treatment of tuberculous meningitis and its complications in adults. curr treat options neurol. 2018;20(3):5. 6. rizvi i, garg rk, malhotra hs, kumar n, sharma e, srivastava c, et al. ventriculoperitoneal shunt surgery for tuberculous meningitis: a systematic review. j neurol sci. 2017;375:255–63. 7. rajshekhar v. management of hydrocephalus in patients with tuberculous meningitis. neurol india. 2009;57(4):368– 74. 8. wilkinson rj, rohlwink u, misra uk, van crevel r, mai nth, dooley ke, et al. tuberculous meningitis. nat rev neurol. 2017;13(10):581–98. 9. palur r, rajshekhar v, chandy mj, joseph t, abraham j. shunt surgery for hydrocephalus in tuberculous meningitis: a long-term follow-up study. j neurosurg. 1991;74(1):64–9. 10. budiman atm, suraya n, faried a, parwati i. characteristics of cerebrospinal fluid in tuberculous meningitis patients with hydrocephalus. ijihs. 2018;6(2):57–62. 11. davis ag, rohlwink uk, proust a, figaji aa, wilkinson rj. the pathogenesis of tuberculous meningitis. j leukoc biol. 2019;105(2):267–80. 12. sharma p, garg rk, verma r, singh mk, shukla r. incidence, predictors and prognostic value of cranial nerve involvement in patients with tuberculous meningitis: a retrospective evaluation. eur j intern med. 2011;22(3):289–95. 13. huang hj, ren zz, dai yn, tong yx, yang dh, chen mj, et al. old age and hydrocephalus are associated with poor prognosis in patients with tuberculous meningitis: a retrospective study in a chinese adult population. medicine (baltimore). 2017;96(26):e7370. 14. peng j, deng x, he f, omran a, zhang c, yin f, et al. role of ventriculoperitoneal shunt surgery in grade iv tubercular meningitis with hydrocephalus. childs nerv syst. 2012;28(2):209–15. 15. kanesen d, kandasamy r, hieng aws, tharakan j, lim cj, abdullah jm. outcome of hydrocephalus in tuberculous meningitis. a retrospective study. research square [preprints] 2020 [cited 2020 november 22]. available from: https://www. researchsquare.com/article/rs-77026/v1. 16. hassan m, tuckman hp, patrick rh, kountz ds, kohn jl. hospital length of stay and probability of acquiring infection. ijphm. 2010;4(4):324–38. 17. george aj, boehme ak, siegler je, monlezun d, fowler bd, shaban a, et al. hospital-acquired infection underlies poor functional outcome in patients with prolonged length of stay. isrn stroke. 2013;2013:312348. 18. kemaloglu s, özkan ü, bukte y, ceviz a, özates m. timing of shunt surgery in childhood tuberculous meningitis with hydrocephalus. pediatr neurosurg. 2002;37(4):194–8. nabila chantikarizky hasanah et al.: outcomes of tuberculous meningitis patients with hydrocephalus with or without cerebrospinal fluid diversion amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 63amj. 2021;8(2):63–69 sars-cov-2 transmission and epidemic characteristics in jining city, china jianwei zhou,1 yu li,2 cui kong,3 jiang yu,1 yizhao li,4 qinghua zhang,5 yao liang6 1medical laboratory, affiliated hospital of jining medical university, jining city, shandong province, china, 2medical college, jining medical university, jining city, shandong province, china, 3nursing department, affiliated hospital of jining medical university, jining city, shandong province, china, 4rehabilitation department, fangan rehabilitation hospital of jinan city, jinan, china, 5neurology department, shandong provincial hospital affiliated to shandong first medical university, jinan, china, 6health school of jining city, jining city, shandong province, china abstract background: severe acute respiratory syndrome coronavirus-2 (sars-cov-2) that causes severe acute respiratory syndrome has spread to hundreds of countries and infected millions of people, causing more than a hundred thousand deaths. this study aimed to describe the epidemic characteristics of sars-cov-2 and its transmission in a city in china. methods: this was a descriptive study on retrospective data collected from january to february 2020 from reports issued by the authority of jining city, china, including data on travel history, transmission, gender, and age of infected persons. results: during the period january and february 2020, 52 cases were confirmed to be sars-cov-2 infections with more than half were males (n=32, 61.5%) and and in the age grup of 31–50 yars old (53.8%). the modes of transmission were mostly primary infections (n=23) and a history of travel to and from outside of shandong province (n=14). interestingly, the infection was the 4th transmission and most primary infectious persons did not transmit the virus to others. conclusions: the key characters of infected people in jining city in early epidemic time with the exception of exogenous inputs are male gender, city dweller, and middle-aged people of 31–50 years old. there is a restricted transmission in jining city of china at the early phrase of the sars-cov-2 epidemic, indicating that the strategy for the fight against sars-cov-2 is effective to some extent and worth to be learned by the members of the global village. this strategy includes actions such as home isolation, collective centralized quarantine, social distancing, and face mask use. keywords: jining city, epidemic characteristics, sars-cov-2, transmission correspondence: jianwei zhou, medical laboratory, affilitated hospital of jining medical university, jining city, shandong province, china. e-mail: immunolife@126.com introduction severe acute respiratory syndrome coronavirus-2 (sars-cov-2) has spread in hundreds of countries and made millions of people infected with more than two hundred thousand death.1 in this pandemic, lots of cities in the world have been invaded by the virus; and among them, there are some cities of china at the primary stage of the epidemic. wuhan is the epidemic epicentral in china and many other cities of and out of hubei province are involved,2 such as huanggang, shanghai, hangzhou, and so on. the epidemic and clinical characteristics of sars-cov-2 infection in first-tier cities have been described in some reports.3,4 however, relatively few reports about virus transmission in small cities. as one of sixteen prefecture-level cities of shandong province, jining city belongs to a third-tier city in china. however, it is famous in the world for the confucius’ hometown– qufu which is a county that belong to jining. in this pandemic of sars-cov-2, jining cannot escape by sheer luck. in this article, we retrospectively collected and analyzed the https://doi.org/10.15850/amj.v8n2.2373 althea medical journal. 2021;8(2) 64 althea medical journal june 2021 figure 1 geographical position of jining city in china note: (a) jining city is located in the east of china, southwest of shandong province, or northeast of wuhan city, the area where sars-cov-2 first found. (b) the geographical distribution of cases with sars-cov-2 infection in jining city (n22), qufu city (n14), and yanzhou district (n8) althea medical journal. 2021;8(2) 65 epidemic data related to sars-cov-2, further presented the transmission panorama and demographic characteristics of the city and elucidated information or ideas for future research in the aspects of prevention, control, and epidemic analysis. methods the design of the study was a descriptive study, and the data source was the reports issued by the authority of jining city, including the traveling history, the transmission, the gender, and age of the infected persons. furthermore, reports of jining municipal health committee, rencheng district health committee of jining city, and other local authority’s media, as well as the detailed information related to the cases infected with sars-cov-2 was collected, organized, and analyzed. data were collected from january 24 to february 16, 2020. all data of individuals with sars-cov-2 infection issued by the authority of jining city were taken as the study subjects. with the data, the traveling history, the transmission, the gender, and age of the infected persons were analyzed. age was further categorized from infant to the elderly with 10 years of interval and presented in a histogram. the residence of the cases was also categorized and presented whether cases from countryside, town, or county. the study was approved by the ethics committee of the hospital affiliated to jining medical university. results there were 52 cases with sars-cov-2 infection reported in jining city. out of total of 11 counties or districts, no cases were found in three counties i.e. weishan, liangshan, and yutai county as shown in figure 1. there were figure 2 traveling experience out of shandong province among cases with sars-cov-2 infection note: wh, wuhan; zz, zhengzhou; bj, beijing; cq, chongqing: cs, changsha; jx, jiangxi and a city in hubei province except for wuhan jianwei zhou et al.: sars-cov-2 transmission and epidemic characteristics in jining city of china althea medical journal. 2021;8(2) 66 althea medical journal june 2021 different numbers of infectious cases in the remaining 8 administrative regions. the most prevalent cases were from the urban district i.e. jining city (22), qufu city (14), and yanzhou district (8). furthermore, cases in sishui, wenshang, and jiaxiang county were only 2 in each region, and only 1 case was founded in jinxiang and zoucheng county; and no case in liangshan, weishan, and yutai county. furthermore, the travel history of the cases was explored. the confirmed dates for 52 cases with sars-cov-2 infection were ranged from january 24 to february 16, 2020. there were 14 cases that had been travelled outside shandong province, of whom 7 cases had entered wuhan; 2 cases had traveled to zhengzhou; and 5 cases had a travel experience in one of the following cities: beijing, chongqing, changsha, jiangxi, and a city of hubei province except for wuhan (figure 2). in total there were 52 cases of whom 32 were male (61.5%), and 37 (71.2%) individuals infected with sars-cov-2 came from the city, including jining city and its affiliated counties and districts. interestingly, 5 (9.6%) came from town and 10 (19.2%) came from the countryside. most of the infected cases (n=38, 73.1%) had no traveling history to other provinces as shown in figure 3. among the infected cases, the eldest age was 91 years old, and the youngest age was only 4 years old. the most common cases were from age category 31–40 years (n14) and 41– 50 years (n14) and the total proportion was 53.8%. furthermore, the age category >50 years old was the second most prevalent age group with 30.7% of the total case (figure 3). in the present study, we analyzed the infection source, confirmed date, and the relationship between the infected persons. a graphical figure of the transmission of sarscov-2 in jining city was presented in figure 4. there were 23 cases in the first transmission of sars-cov-2 infection. the number for the second, third, and fourth transmission was 21, 2, and 4 cases, respectively. discussion the pandemic of sars-cov-2 has been a severe threatening to human health worldwide.5 in china, the novel coronavirus spread in many cities at the beginning of 2020. except for dongying city, the cases of sars-cov-2 emerged in the other fifteen cities of shandong province. this study puts the eyes on one of the prefecture-level cities—jining city which is famous for qufu city where is the hometown of confucius, a well-known thinker, and educator.6 as the results showed, there were 52 cases of sars-cov-2 infection in nine counties or districts of jining city. the urban district of jining city, qufu city, and yanzhou district figure 3 distribution of cases with sars-cov-2 from jinning, china, based on gender, residence, and age althea medical journal. 2021;8(2) 67 were the top three regions with a higher number of infected cases. the reason for this status is that jining, qufu, and yanzhou is the prefecture-level, the traveling, and the railway transport city, respectively, and the number of infection cases is associated with the degree of population mobility.7 in the gender analysis of 52 cases, the percentage of the female and male was 38.5% and 61.5%, respectively. this was similar to chans’8 report in which the female and male ratios were 32% and 68%. in ryu’s9 investigation, more than two-third (10 in 15) of individuals infected with sars-cov-2 figure 4 panorama of sars-cov-2 transmission of 52 cases in jining city, china note: most of the transmission caused by the primary infected persons were terminated after the first transmission. there was one case that came back from beijing and transmitted the pathogen for three generations. the relationship between the infected person and the contact one was described from the angle of the latter, e.g. case 32 was the wife of case 7. as to the common infectious source or the two persons cannot be identified whom actually transmitted the pathogen, the relationship is described with the little sequence of the case and infected persons. for example, case 18 is aunt of case 24, while case 28 is the grandmother of the case 24. red, green, blue, yellow, and grey ball presents the first, second, third, fourth generation of infection and the common transmission source, respectively. the number in the ball means the case which is sequenced according to the confirmed date. an: uncle; au: aunt; cp: contact person; cw: co-worker; da: daughter; ebw: elder brother’s wife; fa: father; fil: father-inlaw; fr: friend; g:grandfather; gg: great-grandmother; gm: grandmother; ys: younger sister; hu: husband; mo: mother; ni: niece; sil: sister-in-law; re: relative; so: son; sp: spouse; ybw: younger brother’s wife. jianwei zhou et al.: sars-cov-2 transmission and epidemic characteristics in jining city of china althea medical journal. 2021;8(2) 68 althea medical journal june 2021 were male. in huang’s10 study, the percent of the male was high to 73.2%, while the rate in wang’s11 paper was only 54.3%. although there are differences in the ratios of the male in different reports, it is obvious that the case number of the male was more than that of the female. in the infected population, the age almost covered every phase: from elder men to little children, and the average age was 45.3 years. this was very near to fang’s12 report, in which the average age of the patients with sars-cov-2 infection was 45.1 years. it is also consistent with the mean age of 47.0 years in guan’s13 study. certainly, there are inconsistent references about the average age of the infected person, for example, 37 years for yang’s4 report about chongqing and 32.5 years for a study on nanjing.14 as the epicenter of this epidemic, the mean age was reported as 55.5 and 56.0 years in two reports focused on wuhan8, and it was obvious that the data were higher than in others cities. whether the average age of the people infected with sarscov-2 in non-epicenter usually is younger than that of the epicenter area needs further observation. to analyze the cases with different age groups, we found that the percentage of age group 31–50 years was 53.8%, which was significantly higher than other reports.4,15 however, the percentage of this age group is more than one-third and higher than those of other age groups in those studies. the ratio for the age more than 71 years was 11.5%, similar to another report.15 in the range of age younger than 10 years, only 5.8% cases with sarscov-2 infection in this study, a little bit higher than reported in other references.15,16 these findings probably indicate that the youngster is not easy to be infected with sars-cov-2, and the reason possibly is that this population consists of the students of primary and middle school. they usually live in a relatively small space and have very little social activities, and hence, they have a very low chance to be infected with sars-cov-2. of 52 cases, 71.2% came from the city which including jining city and the affiliated counties and districts of the city; while less than 30% of the persons with sars-cov-2 infection came from towns and countryside. this finding is consistent with chen’s and lin’s16 reports. this point is determined by the relatively greater popular mobility of city dwellers. according to such a character, it is suggested that the city is of the primary importance for controlling the transmission of sars-cov-2. according to the epidemic investigation reported by the local health authority17, graphics has been drawn out to describe the transmission of sars-cov-2 in this study. there were 23 index persons who were taken as the initial transmission source. these index cases were responsible for the local epidemic of sars-cov-2 to some extent. among them, 14 cases had clear travel histories out of shandong provinces, indicating that the inputting cases were the main infectious source for a city of non-epicenter such as jining city.4 in all of the spread brought by 23 index infectors, there was only one time for the four generations of transmission, two generations of transmission happened five times, and most of the primary infectious person did not transmit the virus to others. the reality strongly proved that the preventing strategies against sarscov-2 infection were very effective, such as home isolation, collective centralization quarantine, keeping social distance, wearing a face masks.18,19 besides, from figure 4 we could found that the transmission usually happened between the relatives of a family, so the family cluster was the main element for virus spreading in jining city. therefore, the prevention and control of sars-cov-2 transmission between the family members or relatives are rather important during the sars-cov-2 epidemic.20 there are two limitations in the study at least, which is the lack of clinical information of all the cases and the other is that the infectious resource for the index persons remains unknown. however, these limitations do not affect the analysis of the epidemic characteristic of sars-cov-2 in jining city. to conclude, there is a restricted transmission in jining city of china at the early phase of the sars-cov-2 epidemic. the key characters of the infected people in this epidemic are, besides exogenous input, mainly male, city dweller, and middle-aged people of 31–50 years old. according to the panorama and epidemic characteristic of sars-cov-2 in jining city, china, it is suggested that the strategy for the fight against sars-cov-2 is effective to some extent and worthy to learn by the members of the global village, such as home isolation, collective centralization quarantine, keeping social distance, and wearing a face mask. acknowledgment the authors thank jining municipal health committee, rencheng district health althea medical journal. 2021;8(2) 69 committee, and qilu evening paper for the reports related to the epidemic status of sarscov-2 of jining city. the information contained in these open reports is an important reference for this study. references 1. who. who coronavirus disease (covid-19) dashboard data last updated: 2021/1/23, 4:57pm cet. 2021[cited 2021 january 23] available from: https:// covid19.who.int/. 2. du w, han s, li q, zhang z. epidemic update of covid-19 in hubei province compared with other regions in china. int j infect dis. 2020;95:321–5. 3. wan s, xiang y, fang w, zheng y, li b, hu y, et al. clinical features and treatment of covid-19 patients in northeast chongqing. j med virol. 2020;92(7):797–806. 4. yang k, xiao ly, liu yf, shi dy, lu h , li t, et al. epidemiological and clinical characteristics of coronavirus disease 2019 in non-epidemic areas: report of 57 cases. j third mil med univ. 2020;42(6):555–9. 5. yin x, riva l, pu y, martin-sancho l, kanamune j, yamamoto y, et al. mda5 governs the innate immune response to sars-cov-2 in lung epithelial cells. cell rep. 2021;34(2):108628. 6. dong x. confucious vs einstein: who would be a better gerontologist? innov aging. 2018;2(suppl 1):347. 7. phan lt, nguyen tv, luong qc, nguyen tv, ngyyen ht, le hq, et al. importation and human-to-human transmission of a novel coronavirus in vietnam. n engl j med. 2020;382(9):872–4. 8. zhou f, yu t, du r, guan f, liu y, liu z, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395(10229):1054–62. 9. ryu s, chun bc, korean society of epidemiology 2019-ncov task force team. an interim review of the epidemiological characteristics of 2019 novel coronavirus. epidemiol health. 2020;42:e2020006. 10. huang c, wang y, li x, ren l, zhao j, hu y, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet 2020;395(10223):497–506. 11. wang d, hu b, hu c, zhu f, liu x, zhang j, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirusinfected pneumonia in wuhan, china. jama. 2020;323(11):1061–9. 12. fang xw, mei q, yang tj, zhang l, yang y, wang yz, et al. clinical characteristics and treatment strategies of 79 patients with covid-19. chinese pharmacological bulletin. 2020;36(4):12–8. 13. guan wj, ni zy, hu y, liang wh, ou cq, he jx. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020; 382(18):1708–20. 14. hu z, song c, xu c, jin g, chen y, xu x, et al. clinical characteristics of 24 asymptomatic infections with covid-19 screened among close contacts in nanjing, china. sci china life sci. 2020;63(5):706–11. 15. epidemiology working group for ncip epidemic response, chinese center for disease control and prevention. the epidemiology characteristics of an outbreak of 2019 novel coronavirus disease (covid-19) in china. chin j epidemiol. 2020;41(2):145–51. 16. lin jf, wu mn, wu hc, zhang t, wu c, li fd. epidemiological characteristics of coronavirus diseases 2019 in zhejiang province. preventive medicine. 2020;32(3):217–221,225. 17. jining municiple health commission. the epidemic status of sars-cov-2 in jining city. 2020 [cited 2020 january 18], available from: http://wjw.jining.gov.cn/ art/2020/2/18/art_59856_2452811.html 18. chu dk, akl ea, duda s, solo k, yaacoub s, schünemann hj, et al. physical distancing, face masks, and eye protection to prevent person-to-person transmission of sarscov-2 and covid-19: a systematic review and meta-analysis. lancet. 2020; 395(10242):1973–87. 19. liu w, yue xg, tchounwou pb. response to the covid-19 epidemic: the chinese experience and implications for other countries. int j environ res public health. 2020;17(7):2304. 20. chan jf, yuan s, kok kh, to kk, chu h, yang j, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet. 2020; 395(10223):514–23. jianwei zhou et al.: sars-cov-2 transmission and epidemic characteristics in jining city of china amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 132 althea medical journal september 2021 clinical manifestations and laboratory examination findings of hepatocellular carcinoma at a tertiary care facility in bandung: an annual observation study grace amanda maharani,1 eka surya nugraha,2 adhi kristianto sugianli3 1faculty of medicine universitas padjadjaran, indonesia, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, bandung, indonesia correspondence: grace amanda maharani, faculty of medicine, universitas padjajaran, jalan raya bandung sumedang km 21, jatinangor, sumedang indonesia, e-mail: graceamanda2910@gmail.com amj. 2021;8(3):132–7 abstract background: hepatocellular carcinoma (hcc) is the most prevalent liver cancer with high mortality. early detection is important for better patient outcomes. the aim of this study was to explore clinical manifestations and laboratory examinations among hcc patients in a tertiary care facility. methods: this was a cross-sectional descriptive study with a total sampling method, reviewing the medical records of patients with hcc in the outpatient clinic of dr. hasan sadikin general hospital between january and december 2019. clinical manifestations, laboratory findings, and imaging results data were collected. results: of the 112 hcc patients included in this study, the hcc findings among new patients at the outpatient clinic were 8.4%, with hepatitis b (80.8%) as the major etiology. complaints of abdominal pain (65.2%) were frequent. aspartate aminotransferase (ast) and alanine aminotransferase (alt) levels were elevated in 90.6% and 67% of patients, and total bilirubin levels were increased in 58.8% of patients. in contrast, hemoglobin and albumin levels decreased in 56.2% and 78.1% of patients, respectively. the characteristics of tumor were mainly multinodular, with a size of 3–10 cm. conclusions: the annual proportion of hcc at dr. hasan sadikin general hospital in 2019 is 8.4% among all outpatient gastrointestinal and hepatology cases, with hepatitis b as the most common etiology. abdominal pain is the predominantly prevalent clinical manifestation with elevated alt and ast levels. keywords: clinical manifestation, hepatocellular carcinoma, supporting examination introduction hepatocellular carcinoma (hcc) is one of the primary liver malignancies originating from liver parenchymal cells,1 hcc is caused by chronic liver fibrosis due to viral infection (hepatitis b or c virus) or metabolic disorders (fatty liver and excessive alcohol consumption). the presence of hcc is often unidentified unless signs and symptoms appear due to the tumor size or the advanced stage of the disease.2 the barcelona clinic liver cancer (bclc) guideline has been currently used to diagnose and manage hcc.3 upon entering the symptomatic stage, clinical manifestations are similar to those of cirrhosis with pain originating in the right upper abdomen that may spread to the shoulder, followed by weight loss and hepatomegaly.4 liver cancer is the sixth most common cancer globally and the fourth rank of cancer mortality. hcc contributes to approximately 75 to 85% of liver cancer cases.5 in indonesia, liver cancer ranks fourth as the most common cancer and mortality due to cancer.6 according to the indonesian association for the study of the liver (perhimpunan peneliti hati indonesia, pphi), the incidence of hcc in indonesia is 13.4 per 100,000 population age-standardized rate (asr).7 https://doi.org/10.15850/amj.v8n3.2333 althea medical journal. 2021;8(3) 133 the previous report has shown that the prevalence of hepatitis b virus (hbv) in indonesia is 7.1%, classified as intermediate to high endemicity.8 the prevalence of hbv among hcc patients is estimated to be 37– 68%, leading to the most common etiology of hcc.9 moreover, clinical manifestations and laboratory results among this disease are still unclear, leading to high mortality. therefore, the aim of this study was to explore the clinical manifestations and laboratory examinations among hcc patients in tertiary care facilities, dr. hasan sadikin general hospital, bandung. this finding will help the clinicians to make an early diagnosis for a better prognosis. methods this was a cross-sectional descriptive study conducted between october and november 2020. data were taken from the medical records of outpatients with a diagnosis of hcc, according to the icd-10 code at dr. hasan sadikin general hospital from january to december 2019. inclusion criteria were newly diagnosed hcc patients with afp levels of ≥400 ng/ml, or radiological findings concluded as hcc.10 exclusion criteria were patients with a history of other malignancies, liver metastatic malignancies, and medical records that were not accessible during the study period. data on patients diagnosed with hcc were accessed using icd-10 codes c.22 for “malignant neoplasm of liver and intrahepatic bile ducts” and c.22.0 for “liver cell carcinoma”. this study has received permission from the research ethics committee of the universitas padjadjaran no. 633/un6.kep/ec/2020 dated july 20, 2020, and research permit issued by research ethics committee of dr. hasan sadikin general hospital bandung no. lb.02.0/x.2.2.1/19549/2020. data were summarized using an electronic worksheet, microsoft® excel 2016, and processed using ibm® spss® version 25. the results were presented in tables and figures to show the characteristics of hcc patients, clinical manifestations, and laboratory examinations profiles in numbers and percentages. results during observation, the proportion of hcc in this study was 8.4% (192 of 2284 patients). nevertheless, only 112 subjects were included in this study for further analysis as shown in figure 1. the median age at diagnosis was 53 years with an interquartile range of 61–46 years, predominantly in males (73.2%). a total of 59 of 112 subjects had a history of hepatitis b as the underlying cause of hcc. the presence of multinodular mass was 85.7% (24 of 28 data collected). from the 35 data retrieved, the size of nodule ranged from 3–10 cm (54.3%), followed by nodules >10 cm (40%) (table 1). figure 1 study flowchart annual number of new patient visits at the gastroenterohepatology clinic n=2284 screened hcc diagnosis according to icd-10 n=192 included n=112 excluded inaccessible medical records (n=45) normal sfp and/or radiological finding (n=32) previous history of malignancy (n=3) grace amanda maharani et al.: clinical manifestations and laboratory examination findings of hepatocellular carcinoma at a tertiary care facility in bandung: an annual observation study althea medical journal. 2021;8(3) 134 althea medical journal september 2021 table 1 characteristics of patient with hepatocellular carcinoma variable hepatocellular carcinoma (n=112 ) n % age (years) median (iqr)a 53.5(61-46) gender male female 82 30 73.2 26.8 etiologyb hepatitis b hepatitis c non-hepatitis 59 9 5 80.8 12.3 6.9 tumor nodulec singular multinodular 4 24 14.3 85.7 the largest nodule size (cm)c <3 3–10 >10 2 19 14 5.7 54.3 40 note: a=iqr: interquartile range, b=of those reporting etiology and clinical classification, c=of those reporting diagnostic imaging there were variation in clinical manifestation observed among patients with hcc, the most common being abdominal pain (65.2%), ascites (40.2%), and weight loss (27.7%) (figure 2). laboratory examination findings in hcc subjects were characterized by decreased serum albumin and hemoglobin levels, increased alt and ast levels, and total serum bilirubin. figure 2 clinical manifestations of hepatocellular carcinoma althea medical journal. 2021;8(3) 135grace amanda maharani et al.: clinical manifestations and laboratory examination findings of hepatocellular carcinoma at a tertiary care facility in bandung: an annual observation study discussion hepatocellular carcinoma (hcc) is a liver malignancy originating from hepatocytes and is the most common primary liver malignancy, followed by intrahepatic cholangiocarcinoma.5 patients with hcc tend to be diagnosed at an advanced stage, and treatment is challenging at this stage. in contrast, patients with hcc in the early stage usually do not show abnormalities, both clinical manifestations and liver function. therefore, the diagnosis of hcc is generally delayed until it reaches an advanced stage.2 the clinical presentation may vary among others; dull abdominal pain in the right upper quadrant spreading to the shoulder, weight loss, and hepatomegaly. clinical manifestations of hcc patients with cirrhosis generally shows hepatic encephalopathy, ascites, and jaundice.4 however, in hcc patients without a history of cirrhosis, the clinical manifestations are usually similar to the classic tumor signs and symptoms, i.e., anorexia, malaise, weakness, weight loss,11 which is consistent with the findings of our study. our study shows that hcc is predominantly found in males, with a male-to-female ratio of 2.7:1 and median age of 53 years. this finding is similar to previous studies reported in different countries or continents, which indicates hcc as a global problem worldwide.12,13 in general, the prevalence of hepatitis b in indonesia is higher than other hepatitis infections and hepatitis b is the most common etiology of hcc, as previously reported.9,14 furthermore, the most common symptom in hcc patients in our study was abdominal pain, consistent with the study from saudi arabia.12 structural damage to the liver interferes with various physiological processes in the body. one of them is the leakage of aminotransferase enzymes produced in the liver into the bloodstream, characterized by elevated liver enzymes in most patients such as ast and alt levels, similar to studies from the united states.15 in this study, hematological examination showed that most of the patients had decreased hemoglobin levels. the liver is also an organ that plays a role in storing iron. liver damage causes iron depletion, which leads to anemia. moreover, gastrointestinal bleeding due to portal hypertension also contributes to decreased hemoglobin levels, which can be exacerbated by impaired coagulation factors produced by the liver.16 there was an increase in bilirubin levels in most of patients, similar to the study from saudi arabia.12 damage to hepatocytes also results in impaired bilirubin metabolism which increases intrahepatic hyperbilirubinemia.17 patients with liver damage have impaired albumin synthesis. decreased albumin levels can also be caused by the diluting effects of water and salt retention, accumulation of protein in ascites fluid and extracellular space.18 albumin levels in this study were found to be decreased in most patients, which is consistent with finding from the united states.13 in this study, most of the patients had multinodular tumors. however, a study in jakarta resulted that singular nodules were more common than multiple.14 the size of the most common nodules ranged from 3 to 10 table 2 laboratory examination results of hepatocellular carcinoma patients variable n result interpretation decrease normal elevated n % n % n % hematology test hemoglobin leukocyte thrombocyte 112 112 112 63 6 22 56.2 5.4 19.6 46 58 70 41.1 51.8 62.5 3 48 20 2.7 42.8 17.9 liver function test alt ast bilirubin albumin 103 106 102 105 82 78.1 34 10 42 23 33.0 9.4 41.2 21.9 69 96 60 67.0 90.6 58.8 coagulation test prothrombin time 103 56 54.4 47 45.6 note: alt=alanine aminotransferase; ast=aspartate aminotransferase; n=number of hcc patients being tested; (-)=no data or interpretation available althea medical journal. 2021;8(3) 136 althea medical journal september 2021 cm, followed by large nodules with size >10 cm. this is similar to a previous report, which showed that nodules >3 cm in size tend to be more common than nodules measuring <3 cm.14 treatment options for multinodular hcc patients are quite challenging because based on bclc staging, it could be categorized as intermediate stage. the patient’s liver function is a crucial factor in determining whether the patient is still eligible for resection, which was not as successful as the earlier stages. palliative procedures such as trans-arterial chemoembolization (tace) or transplantation may be employed.3,19 moreover, patients with larger tumor sizes at the time of diagnosis also have lower overall survival rates.20 this study has several limitations. first, we conducted retrospective data collection because the data in the medical records were limited or incomplete. as previously described, the diagnosis of hcc is a challenge, particularly in the early stage, where clinical manifestations or laboratory examinations still do not show remarkable findings. second, we were unable to retrieve the occurrence time of clinical manifestation, which may contribute to the different stages of hcc. third, although we screened and observed the diagnosis of hcc through the icd-10 code, there may be a potential bias from the population, in which patients with hcc as a secondary diagnosis and are not included in the icd-10 code. to conclude, the proportion of hcc in our study is 8.4% among the total annual gastrointestinal and hepatology cases visiting the outpatient clinic at dr. hasan sadikin general hospital, with hepatitis b as the most common etiology. the most frequent clinical manifestation is abdominal pain, followed by ascites. radiological finding are characteristic of a multinodular liver mass. increased levels of alt and ast can help identify the occurrence of hcc. these findings may contribute to better diagnosis and management of patient, especially in the early stage of hcc. references 1. sia d, villanueva a, friedman sl, llovet jm. liver cancer cell of origin, molecular class, and effects on patient prognosis. gastroenterology. 2017;152(4):745–61. 2. dimitroulis d, damaskos c, valsami s, davakis s, garmpis n, spartalis e, et al. from diagnosis to treatment of hepatocellular carcinoma: an epidemic problem for both developed and developing world. world j gastroenterol. 2017;23(29):5282–94. 3. bruix j, reig m, sherman m. evidencebased diagnosis, staging, and treatment of patients with hepatocellular carcinoma. gastroenterology. 2016;150(4):835–53. 4. carr bi, editor. hepatocellular carcinoma: diagnosis and treatment. 3rd ed. switzerland: springer international publishing; 2016. 5. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2018;68(6):394–424. 6. 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[cited 2021 february 5]. available from: https://gco.iarc.fr/today/data/ factsheets/populations/360-indonesiafact-sheets.pdf 7. hasan i, loho im, editors. konsensus nasional penatalaksanaan karsinoma sel hati. jakarta: perhimpunan peneliti hati indonesia; 2017. 8. yano y, utsumi t, lusida mi, hayashi y. hepatitis b virus infection in indonesia. world j gastroenterol. 2015;21(38):10714–20. 9. muljono dh. epidemiology of hepatitis b and c in republic of indonesia. euroasian j hepato-gastroenterol. 2017;7(1):55–9. 10. zhang j, chen g, zhang p, zhang j, li x, gan d, et al. the threshold of alpha-fetoprotein (afp) for the diagnosis of hepatocellular carcinoma: a systematic review and metaanalysis. plos one. 2020;15(2):e0228857. 11. singal ag, marrero ja. hepatocellular carcinoma. in: podolsky dk, camilleri m, fitz jg, kalloo an, shanahan f, wang tc, editors.yamada’s textbook of gastroenterology part 4. 6th ed. hoboken: john wiley & sons ltd; 2016. p. 2146–65. 12. aljumah aa, kuriry h, al-zunaitan m, al ghobain m, al muaikeel m, al olayan a, et al. clinical presentation, risk factors, and treatment modalities of hepatocellular carcinoma: a single tertiary care center experience. gastroenterol res pract. 2016;2016:1989045. 13. kuftinec gn, levy r, kieffer da, medici v. hepatocellular carcinoma and associated clinical features in latino and caucasian patients from a single center. ann hepatol. 2019;18(1):177–86. 14. loho im, hasan i, rinaldi c, dewiasty e, gani ra. hepatocellular carcinoma in a tertiary referral hospital in indonesia: lack of improvement of one-year survival rates althea medical journal. 2021;8(3) 137grace amanda maharani et al.: clinical manifestations and laboratory examination findings of hepatocellular carcinoma at a tertiary care facility in bandung: an annual observation study between 1998–1999 and 2013–2014. asian pac j cancer prev. 2016;17(4):2165– 70. 15. wong py, xia v, imagawa dk, hoefs j, hu kq. clinical presentation of hepatocellular carcinoma (hcc) in asian-americans versus non-asian-americans. j immigr minor health. 2011;13(5):842–8. 16. gkamprela e, deutsch m, pectasides d. iron deficiency anemia in chronic liver disease: etiopathogenesis, diagnosis and treatment. ann gastroenterol. 2017;30(4):405–13. 17. subbiah v, west hj. jaundice (hyperbilirubinemia) in cancer. jama oncol. 2016;2(8):1103. 18. carvalho jr, machado mv. new insights about albumin and liver disease. ann hepatol. 2018;17(4):547–60. 19. abbasoglu o. role of liver resection in the management of multinodular hepatocellular carcinoma. world j hepatol. 2015;7(20):2237–40. 20. wu g, wu j, wang b, zhu x, shi x, ding y. importance of tumor size at diagnosis as a prognostic factor for hepatocellular carcinoma survival: a population-based study. cancer manag res. 2018;10:4401– 10. amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 115 profile of apoptotic marker genes and histopathology of the placenta in pregnancies with pre-eclampsia herlambang herlambang,1 rina nofri enis,2 susan tarawifa,2 huntari harahap,3 anggelia puspasari,4 citra maharani,4 erny kusdiyah5 1department of obstetrics and gynecology, faculty of medicine and health sciences universitas jambi/raden mattaher hospital jambi, 2department of anatomy, faculty of medicine and health sciences, universitas jambi, 3department of physiology, faculty of medicine and health sciences, universitas jambi, 4department of biochemistry, faculty of medicine and health sciences,universitas jambi, 5department of public health, faculty of medicine and health sciences,universitas jambi correspondence: dr. dr. herlambang, sp. og.kfm, department of obstetrics and gynecology, faculty of medicine and health sciences universitas jambi/raden mattaher hospital, jl. letjen suprapto no.33, telanaipura, jambi, indonesia, email: herlambang_fkik@unja.ac.id introduction maternal mortality rate (mmr) in developing countries is still a problem. the mmr ratio for the southeast asian region in 2015 was 164 deaths for every 100,000 live births. in indonesia, the mmr in 2017 was 177 for every 100,000 live births;1 whereas in jambi province in 2020 was 94 per 100,000 live births.2 the causes of maternal death in indonesia are bleeding (30%), pre-eclampsia (27.1%), infection (7.3%), and other causes (40.8%). it is obvious that pre-eclampsia is the second leading cause of maternal death after bleeding.3 pre-eclampsia is a hypertension and a renal organ dysfunction that causes proteinuria after 20 weeks of gestation, and usually appears during the gestational period. hypertension during pregnancy is characterized by systolic althea medical journal. 2023;10(2):115–122 abstract background: pre-eclampsia (pe) is a hypertensive disorder in pregnancy and a significant cause of maternal and perinatal mortality and morbidity. failure of spiral artery remodeling due to abnormal apoptosis, triggers disturbances in the mother and the baby’s growth. this study aimed to identify the profile of apoptotic marker genes and histopathological features of the placenta in pregnancies with pre-eclampsia. methods: this study had used case-control method. samples were taken from normal pregnancies (n=25) and pregnant women with pre-eclampsia (n=25) using a purposive sampling method from several hospitals in jambi. qrt-pcr was used to examine apoptotic gene expression from placental tissue and hematoxyline eosin staining to view the placenta’s microscopic appearance. the targeted genes were bcl2-associated x (bax) and b-cell lymphoma 2 (bcl-2). histopathological changes of the placenta observed were syncytial node, cytotrophoblast, villous edema, hypervascularization, fibrosis stroma, atherosis, infarction, and thrombosis. results: relative bax genes expression were increased once in placenta pre-eclampsia compared to controls, but not statistically significant (p-value>0.05). there was no difference between the decline of bcl-2 gene expression in pre-eclampsia placenta compared to the control (p-value >0.05). histopathological changes in the placenta were syncytial node and cytotrophoblast (25 of 25), villous edema (19 of 25), hypervascularization (24 of 25), fibrosis stroma (22 of 25), atherosis (12 of 25), infarction (17 of 25), and thrombosis (24 of 25). conclusion: the expression of bax genes in pre-eclampsia tends to increase compared to normal pregnancy, and the expression of bcl-2 decreases. the histopathological features of pre-eclampsia pregnancy placenta are mostly syncytial nodes, cytotrophoblasts, stromal fibrosis, and thrombosis. keywords: bax, bcl-2, histopathology placenta, pre-eclampsia https://doi.org/10.15850/amj.v10n2.3088 althea medical journal. 2023;10(2) 116 blood pressure in excess of 140 mmhg and diastolic blood pressure in excess of 90 mmhg or both.4 among all pregnant women worldwide, 5–8% suffer from pre-eclampsia, which is associated with an increased risk of maternal and infant morbidity and mortality.5,6 the exact pathogenesis of pre-eclampsia is still unknown. in a normal pregnancy, apoptosis plays an essential role in regulating placental development. trophoblast apoptosis increases with placental growth and advancing gestation. pre-eclampsia is commonly associated with multiple theories, such as vascular disease and placental endothelial dysfunction.7 epidemiological studies in previously different populations has shown that placental apoptosis is primarily associated with preeclampsia related pregnancy complications of various etiologies, including oxidative stress and hypoxia.8 damage to the structure and reduced number of endothelial cells of the trophoblast will result in hypoperfusion of blood to the placenta. this process inhibits the implantation, regulation and proliferation of trophoblast development.9,10 placental hypoxia induces apoptosis through two mechanisms; the initiation phase (activation of caspase) and the execution phase. the initiation phase occurs through the intrinsic pathway (mitochondria pathway) and the extrinsic pathway (death receptor pathway). placental hypoxia mainly leads to apoptosis through the intrinsic pathway. in the intrinsic pathway, the apoptosis signal is mediated directly from the mitochondria in response to cellular stress, such as dna damage that will initiate the activation of the apoptosis signal. there is thus an imbalance between the pro-apoptotic protein (bax) and the antiapoptosis (bcl-2). trophoblasts exposed to hypoxia causes an increase in bax expression and a decrease in bcl-2 expressions.8,9 this apoptotic expression might serve as a marker for pre-eclampsia. histopathological examination of the placenta with pre-eclampsia has shown infarcts, and sclerotic lesions, also narrowed arteries and arterioles.11 the lesions are characterized by atherosis, infarction, and thrombosis of the placenta. therefore, this study aimed to identify apoptotic marker gene profiles and histopathological features of the placenta in pregnancies with pre-eclampsia. methods the research was a descriptive-analytic study with a case-control approach, including pregnant women diagnosed with pre-eclampsia according to the american college of obstetricians and gynecologists 2013, such as hypertension (systolic blood pressure ≥ 140 mmhg and or diastolic blood pressure ≥ 100 mmhg) after 20 weeks of pregnancy. the respondents were recruited by purposive sampling method at raden mattaher hospital jambi and mitra hospital jambi city. as for control group, normotensive healthy women with gestational age matched with the preeclamptic group were recruited. the exclusion criteria were twin pregnancy, the mother with signs of active clinical infection, pregnancy with assisted technology for fertilization, and kidney as well as hepatic failure history. all respondents were followed until childbirth. placental specimens were taken after birth, from the full thickness section from maternal and fetal side, in 2 cm x 2 cm size, then put into a pot containing 10% buffer formalin. the placental tissues were then made into a paraffin block to proceed to the microscopic examination stage. the hematoxyline-eosin staining was performed to view the placenta’s macroscopic appearances. after staining, the image j application was used for counting cells and another microscopic finding in magnification 40 times. the histopathological variables evaluated in the placenta were syncytial node, cytotrophoblast, villous edema, hypervascularization, fibrosis stroma, atherosis, infarction, and thrombosis. all examinations were carried out in the biomolecular laboratorium faculty of medicine and health sciences. this research had received ethical approval from the medical and health research ethics committee from the faculty of medicine, public health and nursing universitas gadjah mada with ref. no. ke/fk/1189/ec/2020. the identification of apoptotic gene profiles was examined using qrt-pcr. rna isolation from placenta samples was carried out according to the manufacturer’s protocol using an rna extraction kit (promega, usa). before rna isolation, the placental tissue was put into rna lysis buffer, and then the tissue was homogenized using a sterile pestle, followed by centrifugation at 14,000 rpm for 10 minutes at 40 to separate the insoluble material. reverse transcription was performed on approximately 7 µg of each rna sample to synthesize complementary dna (cdna). the cdna was prepared using arctic thermal cycler pcr (thermo fisher, usa) and a cdna synthesis kit (promega, usa). the althea medical journal june 2023 althea medical journal. 2023;10(2) 117 table 1 primers and sequences in realtime pcr studies genes name forward primer reverse primer bax 5ʹ-ccttttctactttgccagcaaac-3ʹ 5ʹ-gaggccgtcccaaccac-3ʹ bcl-2 5ʹ-atg tgt gtg gag agc gtc aac c-3ʹ 5ʹ-tga gca gag tct tca gag aca gcc-3ʹ gapdh 5’-agc cac atc gct cag aca c-3’ 5’-gcc caa tac gac caa atc c-3’ herlambang herlambang et al.: profile of apoptotic marker genes and histopathology of the placenta in pregnancies with pre-eclampsia thermal cycle used for cdna synthesis was performed at 25°c for 5 minutes, 42°c for 60 minutes, and 70°c for 15 minutes. synthesized cdna was stored at -20 °c until later use. gene expression was then analyzed using the cdna template for qrt-pcr reactions the human glyceraldehyde-3-phosphate dehydrogenase (gapdh) gene was used as a standard to normalize the relative expression of the bax and bcl-2 genes. amplification of the bax and bcl-2 genes was performed in a 20 µl reaction mix containing the following reagents: 2 µl of bax and bcl-2 forward primer, 2 µl of bax and bcl-2 reverse primer, 10.0 µl of sybr green master mix (promega, usa), 2.8 µl of nuclease-free water, 0.2 µl of dna dye, and 3 µl of cdna. all the qrt-pcr was performed according to the manufacturer’s instructions using the picoreal96 real-time pcr system (thermo fisher, usa). thermal cycling conditions for the bax and bcl-2 genes were 1 cycle for 2 min at 95oc, followed by 40 cycles for the denaturation process at 95oc for 15 sec and 1 min for annealing at 60oc, and for dissociation at 60oc for 2 min. thermal cycling conditions for gapdh were 1 cycle at 95oc for 5 min, followed by 55 cycles of denaturation process at 95oc for 10 sec, annealing at 60oc for 20 sec, and elongation at 72°c for 10 seconds. fold changes in relative expression levels of bax and bcl-2 were quantified using the 2-δδcq method (livak), using an average of a housekeeping gene as a reference. statistical analysis used was independent student t-test for parametric data and a mann-whitney test for non-parametric to find the differences between the pe and normal pregnancy groups. the data were considered statistically significant if p<0.05. results in total, pre-eclampsia (pe) pregnant women (n=25) and the normal (normotension) pregnant women (n=25) were included. maternal characteristics showed that the age of pregnant women in the pe group was higher than the control, however, the difference was not significant (table 2). the proportion of pe was higher in women with primigravida table 2 characteristic research subject characteristic control (n=25) pe (n=25) p-value maternal ages (year) mean high risk, n low risk, n 29 ± 6.16 8 17 29.28 ± 6.65 10 15 0.924* 0.556*** blood pressure (bp) sbp (mmhg) dbp (mmhg) 110 (100–130) 70 (60–80) 170 (150–210) 100.00 (80–150) < 0.001** <0.001** gravidity, n primigravida multigravida 10 20 13 17 0.426*** parity, n nulliparous multiparous 11 19 14 16 0.432*** gestasional age, n pre term a term 5 25 14 16 0.012*** birth weight iugr normal 1 24 12 13 0.000*** note: pe=pre-eclampsia, sbp=systolic blood pressure, dbp= diastolic blood pressure, iugr=intrauterine growth retardation, * independent t-test, ** non-parametric test-mannwhitney test, ***chi-square test althea medical journal. 2023;10(2) 118 or nulliparous, but again was not significantly different. gestational characteristics such as gestational age at birth was a term, and low birth weight or known as intra uterine growth retardation (iugr) showed a higher percentage in infants born to pregnant women with pe compared to infants born to normotensive pregnant women. the mean value of bax gene expression was higher in the case group; whereas the mean value of bcl-2 gene expression was lower in the case group, however, the statistical test (independent t-test) showed no significant difference (p-value >0.005). furthermore, the cq value from running qpcr was lower in preeclamptic pregnancies than in normotensive pregnancies, with fold changes indicating the bax gene increased one time in the preeclamptic pregnancy group compared to the normotensive pregnancy group. cq values of bcl-2 were lower in pre-eclamptic pregnancies than in normotensive pregnancies, with fold changes indicating the bcl-2 gene increased one time in the normal pregnancy group compared to the pre-eclamptic pregnancy group. the expression of the bcl-2 gene in pregnancies with pe was even lower than in normal pregnancies (figure 1). the histopathology of the placenta of pe patients after staining with hematoxylin-eosin showed syncytial nodes, cytotrophoblast cells, villous edema, hypervascularization, stromal fibrosis, atherosis, infarction, and thrombosis. most pe subjects in the pregnancy althea medical journal june 2023 figure 1 relative expression of bax and bcl-2 genes between pregnancies with pre eclampsia and normal pregnancies. p-value bax and bcl-2 genes >0.005 pre-eclampsiacontrol pre-eclampsiacontrol table 3 overview of pre-eclampsia placental histopathological changes characteristics pre-eclampsia normal pregnancy n n syncytial knot 25 25 cytotrophoblast cells 25 25 villous edema 19 9 hypervascularization 24 12 stromal fibrosis 22 8 atherosis 12 5 infarction 17 2 thrombosis 24 12 althea medical journal. 2023;10(2) 119 group had syncytial nodes, cytotrophoblast cells, hypervascularization, stromal fibrosis, infarction, and thrombosis. some subjects also showed atherosis and villous edema in their histopathological placental samples. discussion data from maternal characteristics in this study showed that 10/25 of pregnancies with pe were in the high-risk age range, conform a high risk of pregnant women suffering from pe at the age of <20 years or >35 years.12 the reproductive organs in women aged <20 years are still immature, and not ready for a pregnancy process, that is at risk for an abnormal placenta. in the other side, the female reproductive organs older age at >35 years begin to develop a degenerative process that interferes the implantation process and the development of trophoblasts in the placenta. poor trophoblast invasion will further interfere with the remodeling of spiral arteries, followed by ischemic placenta and inflammation, which is one of the pathogenesis of pe. moreover, a woman at this age has a 5% chance of giving birth to a baby with a chromosomal abnormality.13 our results has shown that pe pregnant women are mostly nulliparas, conforms to another study that also found a relationship between nullipara and pe.14 pre-eclampsia is at risk for nulliparas or primigravidas, as endothelial dysfunction in the placenta causes vasoconstriction, resulting in increased of blood pressure and pe.15 in addition, the increased of blood pressure associated with pe occurs during pregnancy and resolves after birth. in pregnancy, apoptosis plays a role in placental growth. apoptosis is a cell regulation in maintaining homeostatic conditions of tissue remodeling. apoptosis plays a role during the attachment process, followed by trophoblast invasion, spiral artery transformation, trophoblast differentiation, and the process of immune tolerance to paternal antigens expressed by trophoblast cells. apoptotic trophoblast cells are also found in normal pregnancy placentas on both the maternal and perinatal sides.11,16 in response to genotoxic or cellular stress, abnormal placental apoptosis affects the placenta’s endothelial cells and induces extensive placental apoptosis.17 hypoxiainduced cellular stress is the most frequent factor triggering increased p53 gene expression in pe.18 increased expression of the pro-apoptotic gene p53 leads to excess apoptosis leading to trophoblast damage. another study found a change in the expression of the p53 gene from the placenta of pregnant women with pe compared to the normotensive pregnancy group.19 in preeclampsia, increased p53 expression occurs in the trophoblast layer due to the previous transcription of other pro-apoptotic proteins, including p21 and bax. 19,20,21 the expression imbalance between pro-apoptotic and anti-apoptotic genes is associated with excessive apoptosis and syncytial degeneration. the expression of bcl-2, an anti-apoptotic gene, is higher than the expression of the bax gene, which is an essential pro-apoptotic gene for normal placental development and pregnancy continuity. on the other hand, overexpression of bax in placental tissue may lead to failure of placental development through excessive pre-eclampsia placentanormal placenta figure 2. histopatological of placenta. (a) placental vascular in normal pregnancy. (b) cytotrophoblast cells. (c) syncytial knot in normal pregnacy. (d) placental villous. (e) infarction in pe placenta (f) hypervascularisation in pe. (g) syncytial knot in pe. original magnification x40 herlambang herlambang et al.: profile of apoptotic marker genes and histopathology of the placenta in pregnancies with pre-eclampsia a b c d e g f h althea medical journal. 2023;10(2) 120 apoptotic mechanisms.22,23 the results obtained in this study showed an increase in bax gene expression levels one time higher in pregnancies with pe compared to normal pregnancies. the increased apoptosis in pe occurs via an intrinsic pathway in response to cellular stress. this condition initiates the pro-apoptotic bax protein, which is produced further to suppress the regulation of the antiapoptotic gene bcl-2, so that the expression of the bcl-2 gene is lower than the pro-apoptotic gene expression. this study found that the level of bcl-2 gene expression was one time lower in pregnancies with pe compared to normal pregnancies. so that in pregnancies with pe, the ratio of bax gene expression compared to bcl-2 is 1:1, even though not statistically significant. in previous studies, the intrinsic and extrinsic pathways are related because p53 can also increase the expression of several death receptors through the extrinsic pathway.24,25 histopathological examination of pe placenta showed placental infarction and sclerosis, causing narrowing of the arteries and arterioles. another factor that triggers pe is apoptosis, which results from placental hypoxia leading to placental ischemia. furthermore, there are changes in syncytial nodes, cytotrophoblasts, villous edema, hypervascularization, atherosis, stromal fibrosis, infarction, and thrombosis, similar to other study.26 the pe may thus harm placental morphology and consequently affects the fetus.26 several other studies have proofed the significance relationship between the microscopic changes of the placenta with the incidence of pe.27,28,29 the changes are due to a lack of oxygen perfusion in the preeclamptic placenta. in the mature placenta, cytotrophoblast cells will be reduced, but in pe, many new villi are formed to support the lack of placental perfusion. the more trophoblast cells and new villi are formed. inflation of trophoblasts that will become cytotrophoblasts occurs due to inadequate oxygen perfusion. the function of the cytotrophoblast itself is for gas exchange, where the cytotrophoblast will replace the endothelial function of the arterioles. the typical mature placenta in each villus only has 20% of cytotrophoblasts; while in pe cytotrophoblasts that functions as gas exchange is increased to compensate the hypoxic state.29 the ischemic process in pregnant women with pe triggers the inflammatory process in the endothelial wall. this proliferation is characterized by the thickening of the tunica intima, resulting in constriction of blood vessels. stromal fibrosis is also found in the placentas due to the presence of tissues that have not experienced a lack of oxygen perfusion. the formation of stromal fibrosis is associated with impaired vascularization. however, fibrosis can be referred as a repair process in damaged tissue with fibroblastic proliferation due to chronic inflammation due to hypoxia and a lot of tissue necrosis in blood vessels in the long term.28 in pre-eclampsia placenta, there is a change in vascularization in the form of hypervascularization, which is due to angiogenesis or the formation of new vessels. angiogenesis occurs due to reduced oxygen perfusion and is a normal response of oxygendeprived tissues. vascular endothelial growth factor (vegf) is essential in forming new blood vessels. the placenta is in inadequate perfusion in pe until the spiral arteries change. the placenta in this state undergoes hypoxia and ischemia resulting in necrosis and infarction.25 atherosis is also found in preeclamptic placentas caused by abnormalities of blood vessels, blood flow, and blood composition. vascular abnormalities in the pe placenta are caused by the absence or only part of the spiral arteries being invaded by trophoblast cells. abnormal blood flow in pe affects the spiral arteries, where the spiral arteries are arteries that supply the villi. the reduced oxygen supply of the villi causes smooth muscle cells to move toward the tunica intima. the proliferation of smooth muscle cells and deposition of extracellular matrix by smooth muscle in the intima transforms fatty patches into mature fibrofatty atheroma and plays a role in the progressive growth of atherosclerotic lesions. oxygen deprivation due to damage to spiral arteries causes necrosis, and hypoxic trophoblasts secrete thromboxane as a vasoactive factor, leading to thrombosis. thromboxane is produced as a vasoactive agent that compensates for endothelial damage.27 the limitation of the study is that the pregnancy is a late pregnancy. ideally, the respondents are from several trimesters, to determine the histopathological results and apoptosis pattern at each pregnancy stage. in conclusion, pre-eclampsia pregnant women are mostly delivered a term with intra uterine growth. expression of bax gene in pe is higher and of the bcl2 gene is lower than in normotensive pregnancies. the histopathological findings althea medical journal june 2023 althea medical journal. 2023;10(2) 121 of most pe pregnancies have syncytial nodes, cytotrophoblasts, stromal fibrosis, and thrombosis. references 1. who. maternal mortality the sustainable development goals and the global strategy for women’s, children’s and adolescent’s health [internet]. who.int. 2020 [cited 2022 october 12]. available from: https:// www.who.int/news-room/fact-sheets/ detail/maternal-mortality. 2. dinas kesehatan provinsi jambi. profil kesehatan provinsi jambi tahun 2020. jambi: dinas kesehatan provinsi jambi; 2021 [cited 2022 october 10]. available from: https://dinkes. jambiprov.go.id/file/informasi_publik/ micaymdiwlnbkzgmty0mti2nzkyoa_ wkt1641267928_xtlnbkzg.pdf 3. kasriatun k, kartasurya mi, nugraheni sa. faktor risiko internal dan eksternal 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c. histopathological study of placenta in pregnancy with hypertension in western odisha. iosr-jdms. 2017;16(6):100–4. 29. klatt ec, kumar v. robbins and cotran: review of pathology. 4th ed. philadelphia: elsevier saunders; 2014. althea medical journal june 2023 amj vol 8 no 2 june 2021 edit.indd althea medical journal. 2021;8(2) 93 urinary tract stones risk factors in patients with benign prostatic hyperplasia in west java, indonesia iman surendroputro tjahjodjati,1 bambang sasongko noegroho,2 aaron tigor sihombing2 1faculty of medicine, universitas padjadjaran, indonesia, 2department of urology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, correspondence: iman surendroputro tjahjodjati, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: surendroputro@gmail.com introduction benign prostate hyperplasia (bph) is one of the diseases often discovered in men aged 70–79 years by 80%.1,2 in the course of the disease, bph will become benign prostatic enlargement (bpe) that obstructs the lower urinary tract.3,4 this obstruction causes lower urinary tract symptoms (luts) and about 25–50% of individuals with bph experience luts.3,5 one of the complications of bph is urinary tract stones, especially bladder stones.5 benign prostatic hyperplasia is not the only risk factor related to the occurrence of urinary tract stones, but there are also intrinsic and extrinsic factors.6 the intrinsic factors consist of age, sex, race, heredity, metabolic disorders, systemic diseases, urinary tract infections, and anatomic abnormalities of the urinary tract, whereas the extrinsic factors consist of patterns of nutrition, climate, occupation, and education level.6,7 the symptoms of lower urinary tract stones in patients with bph can be masked by symptoms of the bph. the most frequent symptoms are hematuria (37.1%) and urinary disorders (32.5%). about 2.6% of patients with bladder stones have experienced symptoms of acute urinary retention that are probably caused by bph or the stones themselves. lower urinary tract stones in patients with bph often go undetected because 15.5% are asymptomatic and are only found on routine examinations.5 imaging tests are not carried out regularly on patients with bph in indonesia.8 imaging tests are only provided if the patients have hematuria, recurrent urinary tract infections, renal insufficiency, excessive urine residues, history of stones, and history amj. 2021;8(2):93–8 abstract background: urinary tract stones are common in patients with benign prostatic hyperplasia (bph); therefore, an imaging test is needed for patients who have risk factors for the formation of urinary tract stones. the purpose of this study was to explore the factors associated with the presence of urinary tract stones in patients with bph as information to conduct imaging tests. methods: a cross-sectional quantitative analytic study was conducted on medical records of patients with bph, both with and without urinary tract stones, or patients with urinary tract stones registered at the department of urology, dr. hasan sadikin general hospital, indonesia, from 2015 to 2018. data on age, body mass index, hypertension, use of antihypertensive drugs, diabetes mellitus, and hyperuricemia were collected and analyzed using the mann-whitney, chi-square, fisher exact test, and multivariate logistic regression statistical test to compare variables between bph with and without urinary tract stones. results: in total, 235 bph patients were registered, of whom 74 (31.5%) had urinary tract stones. the median age was 64 years old. there was a relationship between age (p=0.030), diabetes mellitus (p=0.043), and the occurrence of urinary tract stones in patients with bph. the most dominant risk factor was diabetes mellitus (or=3.000, 95%ci 1.03-8.69). conclusions: age and diabetes mellitus are the risk factors for urinary tract stones in patients with bph. bph patients with diabetes mellitus are at a 3-fold risk for urinary tract stones. diabetes mellitus in bph patients is an indication to conduct imaging tests. keywords: benign prostatic hyperplasia, diabetes mellitus, urinary tract stones https://doi.org/10.15850/amj.v8n2.2257 althea medical journal. 2021;8(2) 94 althea medical journal june 2021 of surgery on the urinary tract,8 leading to undiagnosed urinary tract stones. therefore, the purpose of this study was to analyze other risk factors related to the presence of urinary tract stones in bph patients as extra information to conduct the imaging tests. methods a cross-sectional analytical study was carried out using secondary data from registries and medical records of patients with bph with or without urinary tract stones in the department of urology dr. hasan sadikin general hospital bandung, west java, indonesia. these patients were registered at the hospital from 2015 to 2018. this study was approved by the research ethics committee of universitas padjadjaran bandung number 749/un6.kep/ ec/2019. the bph patients were grouped into group 1 that had bph without urinary tract stones, and group 2 that had bph with urinary tract stones. the inclusion criteria in this study were registries and medical records of bph and urinary tract stones with bph patients which contained data of age, blood pressure, body mass index (bmi), diabetes status, hyperuricemia status, and the use of antihypertensive drugs. double registries/ medical records of the same patients were excluded. age was divided into ≤59 years, 60– 69 years, and ≥70 years. blood pressure was divided into no hypertension when systolic blood pressure was ≤139 mmhg or diastolic blood pressure ≤89 mmhg or the history of hypertension was not recorded, and having hypertension when systolic blood pressure ≥140 mmhg or diastolic blood pressure ≥90 mmhg or there was a history of hypertension.9 no obesity was designated when bmi <23 kg/m2, and obesity if bmi ≥23 kg/m2.10 no diabetes mellitus (dm) was designated when fasting blood sugar level was <126 mg/dl and dm when fasting blood sugar level was ≥126 mg/dl. not hyperuricemia when blood uric acid level was ≤6.8 mg/dl and hyperuricemia when blood uric acid level was >6.8 mg/dl. the use of antihypertensive drugs was recorded as using and not using antihypertensive drugs. to test the distribution of the numerical data, the kolmogorov-smirnov test was carried out and when the result was not normally distributed, the bivariate statistical test used in this study was the non-parametric mannwhitney test. the chi-square statistical test was used for analyzing hypertension, obesity, and the use of antihypertensive drugs while fisher’s exact test was used for analyzing the dm and hyperuricemia data. the logistic regression statistical test was used to analyze the most dominant factor for the occurrence of urinary tract stones in patients with bph. the statistical analyses was performed using ibm spss statistics software, version 25.0. results in total, data on 235 patients with bph were retrieved, of which 31.5% had urinary tract stones (table 1). moreover, most locations of urinary tract stones were in the lower urinary tract (47.3%). interestingly, the location of the stones would be both upper and lower urinary tract stones (32.4%). the median age of bph patients was 68 years old, whereas the median age of bph patients with urinary tract stones was 64 years old. the results showed that there was a relationship between age and the occurrence of urinary tract stones in bph patients (p=0.030). the bph with urinary tract was mostly affected in patients aged 60–69 years (58.1%). the increasing age was a risk for urinary tract stones in bph patients (p=0.004). table 1 distribution of bph patients registered in the dr. hasan sadikin general hospital 2015–2018 frequency (n) percentage (%) bph 161 68.5 bph with urinary tract stones : upper urinary tract stones lower urinary tract stones upper and lower urinary tract stones 74 15 35 24 31.5 20.3 47.3 32.4 total 235 100 note: bph= benign prostatic hyperplasia althea medical journal. 2021;8(2) 95iman surendroputro tjahjodjati et al.: urinary tract stones risk factors in patients with benign prostatic hyperplasia in west java, indonesia there were 5 risk factors for urinary tract stones in bph patients that were tested statistically, which were hypertension, obesity, diabetes mellitus, hyperuricemia, and the use of antihypertension drugs as shown in table 5. this study showed that there was a similar percentage between hypertensive and normotensive bph patients experiencing urinary tract stones (32.3% and 31.6%, respectively). the result showed that there was no relationship between hypertension and urinary tract stones in bph patients. obesity is one of the factors that contributed to the occurrence of urinary tract stones. this study had shown that 30.3% of obesity a patient with bph had urinary tract stones. this percentage was lower compared to patients who were not obese. however, there was no relationship between obesity and the occurrence of urinary tract stones in bph patients. interestingly, the percentage of diabetes mellitus in bph patients with urinary table 3 other risk factors for urinary tract stones in bph patients risk factor bph urinary tract stones in bph total p-value (n=161) (n=74) (n=235) hypertension no hypertension hypertension missing 52(68.4) 65(67.7) 24(31.6) 31(32.3) 76 96 63 0.921** obesity no obesity obesity missing 71(68.3) 46(69.7) 33(31.7) 20(30.3) 104 66 65 0.845** diabetes mellitus no diabetes mellitus diabetes mellitus missing 147(72.4) 7(46.7) 56(27.6) 8(53.3) 203 15 17 0.043*** hyperuricemia no hyperuricemia hyperuricemia missing 9(28.1) 4(25) 23(71.9) 12(75) 32 16 187 1.000*** the use of antihypertensive drugs negative positive missing 52(68.4) 65(67.7) 24(31.6) 31(32.3) 76 96 63 0.826** notes: ** chi-square statistical test, *** fisher’s exact test table 2 age as a risk factor for urinary tract stones in bph patients risk factor bph bph with urinary tract stones total p-value (n=161) (n=74) (n=235) age (n) median, years minimum, years maximum, years 68 48 97 64 48 86 0.030* ≤59 years old (n, %) 60–69 years old (n, %) ≥70 years old (n, %) 30(18.6) 59(36.6) 72(44.7) 13(17.6) 43(58.1) 18(24.3) 43(18.3) 102(43.4) 90(38.3) 0.004** notes: * mann-whitney statistical test, ** chi-square statistical test althea medical journal. 2021;8(2) 96 althea medical journal june 2021 tract stones was 53.3%. this percentage was higher compared to patients without diabetes mellitus. there was a relationship between diabetes mellitus and urinary tract stones in bph patients (p=0.043). hyperuricemia was found only in 16 of 48 bph patients. of these, 12 bph patients were found with urinary tract stones and there was no relationship between hyperuricemia with the occurrence of urinary tract stones in bph patients. furthermore, there was no relationship between the use of antihypertensive drugs with the occurrence of urinary tract stones in bph patients. antihypertensive drugs were used by bph patients who had hypertension or with a history of hypertension. the two most commonly antihypertensive drugs used were calcium-channel blockers and angiotensinconverting enzyme inhibitors (table 4). the most dominant risk factor for the occurrence of urinary tract stones in bph patients was diabetes mellitus. the bph patients with diabetes mellitus had a 3-fold risk of developing urinary tract stones compared to bph patients without diabetes mellitus (odds ratio=3.000; the wald value was >3.84 and p-value <0.05; ci 95% 1.039–8.695). discussions factors associated with the occurrence of urinary tract stones include age, race, heredity, metabolic syndrome, systemic disease, urinary tract infections, anatomical abnormalities of the urinary tract, nutritional patterns, climate, and occupation.4,6,7 our study has shown that hypertension, obesity, hyperuricemia, and the use of antihypertension drugs are not related to the presence of urinary tract stones in bph patients. interestingly, age and diabetes mellitus are associated with the presence of urinary tract stones in bph patients. hypertension as a risk factor for urinary tract stones is still controversial. a systematic review and meta-analysis study have shown that hypertension significantly increases the excretion of calcium, oxalate, and uric acid in the urine, leading to stone formation.11 furthermore, the occurrence of hypertension can also be caused by the occurrence of kidney stones, so that there is a two-way relationship between the incidence of hypertension and urinary tract stones.12 however, a report from germany13 revealed that there was no difference in the risk of kidney stones between patients with hypertension and patients who were not, similar to our study that shows no relationship between hypertension and urinary tract stones in bph patients. this is probably because most hypertensive patients are currently under treatment. the study has shown that obesity is associated with an increased risk of kidney stones,12 by excreting more calcium, oxalate, and uric acid in urine. furthermore, increased body mass index is associated with a significantly decreased urine ph.14,15 about 63% of the stones in obese people contain uric acid stones.15 however, our result shows no relationship between obesity and the presence of urinary tract stones in bph patients. this controversial result is probably caused by the small number of obese patients in this study, which is only 38.8% of bph patients. the level of blood uric acid contributes to the formation of urinary tract stones. the higher levels of blood uric acid, the higher the risk of urinary tract stones.16 hyperuricemia will reduce the ph in urine, which can cause uric acid stones.16 however, our result shows that there is no relationship between hyperuricemia with the presence of urinary tract stones in bph patients. this study contradicts the previous studies, again it might be due to the small number of samples and many data were missing. in indonesia, not all bph patients are tested for blood table 4 antihypertension drugs antihypertension drugs bph urinary tract stones in bph total n (%) n (%) n=102* calcium-channel blocker angiotensin-converting enzyme inhibitor angiotensin receptor blocker diuretics b-blocker 34 (69.4) 20 (62.5) 5 (62.5) 5 (71.4) 4 (66.7) 15 (30.6) 12 (37.5) 3 (37.5) 2 (28.6) 2 (33.3) 49 32 8 7 6 notes: * one patient could consume more than one type of antihypertension drug althea medical journal. 2021;8(2) 97 uric acid levels routinely. a retrospective cohort study has shown that thiazide-type antihypertensive drugs can reduce the risk of urinary tract stone formation, by reducing calcium levels in the urine.17 on the contrary, another antihypertensive drug of angiotensinconverting enzyme-inhibitor (acei) or angiotensin receptor blocker (arb) and calcium channel blocker (ccb) can increase the level of calcium in the urine, thus it serves as a risk to the formation of urinary tract stones.17 in our study, there was no relationship between the use of hypertension drugs with the presence of urinary tract stones. this is likely due to the length of time hypertension patients have suffered from hypertension and the duration of taking antihypertensive drugs are not recorded. two of the risk factors associated with the presence of urinary tract stones in bph patients are age and diabetes mellitus. with the increasing age, the risk for urinary tract stones in bph patients is getting higher. the peak age of urinary tract stones in this study was 60–69 years old. after the peak of its age, the risk of urinary tract stones will diminish.6 diabetes mellitus is one of the metabolic syndromes in addition to hypertension and obesity which is the risk factor of urinary tract stones.18 insulin resistance caused by diabetes mellitus will lead to the formation of uric acid stones of 30–40%.18 other studies mentioned that diabetics with urinary stones have 6 times the risk of uric acid stone formation compared to people with urinary tract stones that do not have diabetes mellitus.19 the results of our study reveals that bph patients accompanied by diabetes mellitus have a 3-fold risk of urinary tract stones compared to bph patients without diabetes mellitus. this study has some limitations. the source of this study was secondary data from the registries and medical records with many missing data in the medical records, resulting in incomplete analysis of each variable used a different number of samples. the method used in this study is a retrospective design. the development of the disease could thus not be followed up and monitored. moreover, urinary tract stones are formed due to many factors, both intrinsic and extrinsic. in this study, not all factors have been examined. to conclude, diabetes mellitus is associated with the occurrence of urinary tract stones in bph patients. the diabetes mellitus status can be used as information for conducting imaging tests routinely to identify urinary tract stones in bph patients. references 1. lim kb. epidemiology of clinical benign prostatic hyperplasia. asian j urol. 2017;4(3):148–51. 2. nagarathnam m, latheef saa. prevalence of lower urinary tract symptoms in patients of benign prostatic hyperplasia attending tertiary care hospital in the state of andhra pradesh. j dr ntr univ health sci. 2017;6(3):154–7. 3. thiruchelvam n. benign prostatic hyperplasia. surgery (oxford). 2014;32(6):314–22. 4. roehrborn cg. benign prostatic hyperplasia: etiology, pathophysiology, epidemiology, and natural history. in: wein aj, kavoussi lr, partin aw, peters c. campbell-walsh urology. 11th ed. philadephia: elsevier; 2016. p. 3242–88. 5. jung jh, park j, kim wt, kim hw, kim hj, hong s, et al. the association of benign prostatic hyperplasia with lower urinary tract stones in adult men: a retrospective multicenter study. asian j urol. 2018;5(2):118–21. 6. liu y, chen y, liao b, luo d, wang k, li h, et al. epidemiology of urolithiasis in asia. asian j urol. 2018;5(4):205–14. 7. aggarwal r, srivastava a, jain sk, sud r, singh r. renal stones: a clinical review. emj urol. 2017;5(1):98–103. 8. tjahjodjati, soebadi dm, umbas r, poernomo bb, wijanarko s, mochtar ca, et al. panduan penatalaksanaan klinis pembesaran prostat jinak (benign prostatic hyperplasia/bph). 3rd ed. jakarta: iaui; 2017. p. 1–12. 9. lukito aa, harmeiwaty e, hustrini nm, editors. konsensus penatalaksanaan hipertensi 2019. jakarta: perhimpunan dokter hipertensi indonesia; 2019. p. 7–8. 10. world health organization regional office for the western pacific. the asiapasific perspective: redefining obesity and its treatment. sydney: health communications australia; 2000. p. 17. 11. besiroglu h, otunctemur a, ozbek e. the metabolic syndrome and urolithiasis: a systematic review and meta-analysis. ren fail. 2015;37(1):1–6. 12. boyd c, wood k, whitaker d, assimos dg. the influence of metabolic syndrome and its components on the development of nephrolithiasis. asian j urol. 2018;5(4):215–22. 13. pfau a, knauf f. update on nephrolithiasis: core curriculum 2016. am j kidney dis. iman surendroputro tjahjodjati et al.: urinary tract stones risk factors in patients with benign prostatic hyperplasia in west java, indonesia althea medical journal. 2021;8(2) 98 althea medical journal june 2021 2016;68(6):973–85. 14. trinchieri a, croppi e, montanari e. obesity and urolithiasis: evidence of regional influences. urolithiasis. 2017;45(3):271–8. 15. aydogdu o. urinary stone disease and obesity: different pathologies sharing common biochemical mechanisms. world j nephrol. 2012;1(1):12–5. 16. lim d-h, kim m, hong s, kim y-g, lee c-k, choi sw, et al. is the serum uric acid level independently associated with incidental urolithiasis? j rheum dis. 2018;25(2):116–21. 17. alexander rt, mcarthur e, jandoc r, welk b, hayward js, jain ak, et al. antihypertensive medications and the risk of kidney stones in older adults: a retrospective cohort study. hypertens res. 2017;40(9):837–42. 18. wong y v, cook p, somani bk. the association of metabolic syndrome and urolithiasis. int j endocrinol. 2015;2015:1–9. 19. abou-elela a. epidemiology, pathophysiology, and management of uric acid urolithiasis: a narrative review. j adv res. 2017;8(5):513–27. althea medical journal. 2014;1(1) 35 gastroprotective effect of carrot (daucus carota l.) juice in rat models wong hui jiin1, eva m. hidayat2, kiki lukman3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of surgery, division of digestive surgery, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital, bandung, indonesia abstract background: gastritis has become one of the very common gastrointestinal tract disorders in clinical practice. one of the factors causing gastritis is the prolonged intake of nonsteroidal anti-inflammatory drugs (nsaids) which is commonly adopted by people suffering pain. the nsaids such as aspirin cause loss of mucosal integrity resulting in gastric mucosa inflamation. carrot (daucus carota l.) has long been used as a traditional medicine for various ailments. the presence of flavonoids and carotenoids in carrot is associated with gastroprotective effect. methods: the present study was undertaken to determine the gastroprotective effect of 4.08 g carrot juice administered by feeding tube on the hydrochloric acid (hcl) concentration in the stomach in aspirin-induced wistar-strain rats. this was a laboratory experimental study performed at the pharmacology laboratory faculty of medicine universitas padjadjaran, bandung indonesia in october 2012. the parameter used hcl concentration determined by titration method. results: the result of carrot juice consumption together with aspirin shows a statistically significant reduction in hcl concentration in the stomach (p<0.05). the result was also significant when compared with another medication, misoprostol. conclusion: carrot juice extract possesses gastroprotective effect when consumed with aspirin and thus support the use of carrot as an alternative treatment. [amj.2014;1(1):35–9] keywords: aspirin, carrot juice extract, gastroprotective, hcl concentration efek perlindungan lambung dengan jus wortel (daucus carota l.) pada tikus abstrak latar belakang: gastritis merupakan salah satu kelainan pada saluran pencernaan yang sering ditemui. salah satu penyebab dari gastritis adalah pemakaian nonsteroidal anti-inflammatory drugs (nsaids) dalam waktu lama dan biasanya digunakan oleh orang yang menderita sakit. obat-obatan nsaid seperti aspirin dapat menyebabkan integritas mukosa menghilang dan terjadinya inflamasi pada mukosa lambung. wortel (daucus carota l.) merupakan tanaman tradisional yang sudah banyak digunakan untuk berbagai macam penyakit. flavonoid dan carotenoid yang ada pada wortel memiliki efek perlindungan terhadap lambung. metode: penelitian dilakukan untuk menentukan efek perlindungan lambung dengan jus wortel pada konsentrasi hcl dalam lambung tikus yang diinduksi dengan aspirin. penelitian ini merupakan suatu studi eksperimental yang dilakukan di laboratorium farmakologi fakultas kedokteran universitas padjadjaran, bandung, indonesia pada bulan oktober 2012. parameter yang digunakan adalah konsentrasi hcl yang ditentukan dengan metode titrasi. hasil: hasil dari penggunaan jus wortel bersama dengan aspirin menunjukkan penurunan konsentrasi hcl yang signifikan pada lambung (p<0.05). hasil ini juga signifikan bila dibandingkan dengan medikasi lain yaitu, misoprostol. simpulan: ekstrak jus wortel memiliki efek perlindungan lambung ketika digunakan dengan aspirin dan hal ini mendukung wortel sebagai pengobatan alternatif. kata kunci: aspirin, jus wortel, efek perlindungan lambung, konsentrasi hcl correspondence: wong hui jiin, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170209121, email: hui_jiin88@yahoo.com althea medical journal. 2014;1(1) 36 amj june, 2014 introduction gastritis is defined as an inflammatory disorder in the gastric mucosa layer. the etiological factors include helicobacter pylori infection, prolonged intake of non-steroidal antiinflammatory drugs (nsaids) and excessive use of irritant to stomach such as alcohol.1 nsaids-associated gastrointestinal side effects are still high in community.2 treatment with modern drugs such as prostaglandin analog, for example misoprostol, is often prescribed for nsaids-related gastric injury. however, the medication gives relieves to the gastritis but produces several adverse effects.3 according to the world health organization (who) in 1980, in spite of the numerous adverse effects, research on medicinal plants is highly recommended in a condition where there is a lack of safe synthetic drugs.4 carrot, which is also known as daucus carota l., contains active ingredients necessary to maintain health.5 carrot has high nutritional values such as for vitamin a, b, c, d, e, potassium, copper, folic acid, magnesium, flavonoids, and carotene.6 the present study was undertaken to determine the gastroprotective effect of carrot juice on the hydrochloric acid (hcl) concentration in the stomach and to compare the effect to that of misoprostol in aspirininduced rats. methods carrots were purchased from the local market in jatinangor, indonesia. the carrots used were cultivated in lembang, indonesia. carrots were identified before the study by drs. joko kusmoro, m.p, a taxonomist, from biology department of universitas padjadjaran (unpad). the part of the carrot used for this study was the taproot. first, the fresh taproots were washed, cut into small pieces, and then blended without adding water.7 then the homogenized taproots were filtered, and the pulps were removed. only the juice obtained was used for the experiment. subjects in this study consisted of 24 male rats (rattus norvegicus), wistar-strain, age 7-8 weeks, with a body weight between 200-250 grams. the rats had 7 days adaptation prior to the study at the pharmacology laboratory faculty of medicine universitas padjadjaran, bandung indonesia. rats were fed on standard rodent pellets diet with water given ad libitum. after the adaptation period, the rats were randomly put into 4 groups. each group consisted of 6 rats. all groups were given different interventions except for the food and water which were standardized. the experiment was performed for 7 days. the ethical clearance was obtained from the health research ethics committee of the faculty of medicine, universitas padjadjaran (197/un6. c2.1.2/kepk/2012). the design of the study was laboratory table 1 experimental groups group food and drink composition group 1 (control negative) standard food and water (ad libitum) + aspirin (90 mg) group 2 (control positive) standard food and water (ad libitum) + aspirin (90 mg) + carrot juice (4.08 g) group 3 (test group) standard food and water (ad libitum) + aspirin (90 mg) + misoprostol (0.0144 mg) group 4 (compare group) standard food and water (ad libitum) note: all treatments were given per oral using feeding tube althea medical journal. 2014;1(1) 37 experimental with complete random sampling. the study was undertaken to determine the gastroprotective effect of carrot juice on hydrochloric acid (hcl) concentration in the stomach and to compare the effect with that of misoprostol in aspirininduced rats. after 7 days of experiment, all the rats underwent fasting for 18 hours. on day 8, all rats were given anesthesia using diethyl ether and later they were sacrificed. the abdomen of the rat was opened to seek for the stomach and the edges. the edge of the stomach, pylorus and esophagus were all tied and the stomach was removed. the stomach was washed with normal table 2 mean hcl concentration (molar) by group group parameter concentration of hcl (molar) 1 ( negative control ) 0.0012 ± 0.00028 2 ( positive control ) 0.0011 ± 0.00022 3 ( test group) 0.0005 ± 0.00014 * 4 ( compare group) 0.0006 ± 0.00010 * # note: values are shown as the mean ± sd * p < 0.05 compared with positive control group # p < 0.05 compared with test group saline, dried, and later opened through the greater curvature.8 the stomach content was collected and centrifuged for 20 minutes at the speed of 3000 rpm. later, 1 ml of the supernatant fluid was taken carefully and diluted with 10 ml of aqueous solution (ratio of 1:10). the concentration of hcl was confirmed using the titration method. one ml of supernatant fluid was diluted with 10 ml aqueous solution and then mixed well and 3 drops of phenolphthalein were added as an indicator. finally, it was titrated with naoh 0.01 m until the color started to change into pink. the amount of naoh used for the titration was counted to determine the concentration of hcl in the stomach of the rats.8 the statistical test used in this study was independent sample t-test. the test was performed with 95% (α= 5%) confidence. the hypothesis is accepted if p<0.05. this study takes place at the pharmacology laboratory faculty of medicine, universitas padjadjaran, bandung indonesia in the month of october 2012. results based on the results, group 1 has the highest mean hcl concentration while the lowest mean hcl concentration was seen in group 3 (table 2). the independent sample t-test was used to investigate the mean concentration of figure 1 mean hcl concentration in the stomach of rats by group. group 3 and 4 shows a decrease in hcl concentration compared to group 2. hcl, hydrochloric acid wong hui jiin, eva m. hidayat, kiki lukman: gastroprotective effect of the carrot (daucus carota l.) juice in rat models althea medical journal. 2014;1(1) 38 amj june, 2014 hcl between groups. the result shows no significant difference in hcl concentration between group 1 and group 2 (p > 0.05). in group 3, the administration of aspirin and carrot juice together shows a significant decrease in hcl concentration in the stomach compared to that observed in the aspirin alone group 2, p< 0.05. when compared, the administration of carrot juice (group 3) and misoprostol (group 4) with aspirin presents a different result with carrot juice also shows a significant decrease. co-administration of aspirin and misoprostol (group 4) shows a significant decrease when compared to aspirin alone (group 2). discussion non-steroidal anti-inflammatory drugs (nsaids) such as aspirin, is known to induce inflammation in the gastric mucosa. aspirin is a common medication taken by community to reduce pain. aspirin works by inhibiting cox-1 and cox-2, which in turn will suppress the prostaglandin formation. in the stomach, prostaglandin plays an important role in defense and repair. prostaglandin involves with increasing mucous and bicarbonate secretion, inhibiting stomach acid production, and increasing the blood flow to stomach wall.9 therefore, the imbalance between the aggravating factors, nsaids, and maintenance of mucosal integrity, the prostaglandin, resulting in gastritis. (has no verb) in this study, group 2 (positive control) which was induced with aspirin did not show any increase in the hcl concentration compared to group 1. this is because the parameter used here was the concentration of hcl. administration of aspirin inhibits the prostaglandin. when prostaglandin decreases, bicarbonate secretion also decreases. however, the amount (n) of hydrogen ion secreted is not affected even though the bicarbonate decreases. so, when amount of hydrogen ion is same, provided the volume is same, the concentration will not change. therefore, in the aspirin-induced group, it explains the reason why the concentration of hcl was not affected. carrot (daucus carota l.) is one of the very popular vegetable and well known for its health benefits in the community. in the present study, it was observed that carrot triggers significant reduction in hcl concentration in aspirin-induced rat model. the presence of flavonoids in carrot that reduces the gastric acidity may be due to two factors, h+ secretion inhibition and increase of prostaglandin formation.10 therefore when prostaglandin increases, it stimulates secretion of mucous and bicarbonate, maintains the mucosal blood flow and also mucosal cell turnover and repair.7 the increase (or excess?) of bicarbonate binds to the free acid which neutralizes the acid generated by parietal cell and thus resulting in decrease of acid concentration in aspirininduced. the inhibition of h+ also promotes further decrease in acid concentration. an alkaline ph in the surrounding environment of the stomach is important to restore a damaged region (restitution).9 therefore, when acid concentration decreases, it is assumed that the gastric epithelial cells will heal. the presence of carotenoids in carrot (mostly β-carotene) which have anti-oxidant properties that are able to neutralize the free radical reactive oxygen molecules produced by the damaged mucosal cells.11 in this study, the effect of carrot juice extract is also compared to the use of misoprostol. this is because carrot containing the flavonoids and carotenoids that have similar mechanisms of action as misoprostol. misoprostol is a synthetic analog of prostaglandin-1 (pge1) which is used as the primary prevention for ulcer in those who are taking aspirin medication.9 based on the statistical study, it is observed that misoprostol has a significant difference (p<0.05) compared to the control positive group and test group. from the results, 4.08 g of carrot juice per day is suggested to have a gastroprotective effect in aspirin-induced rat model. this is statistically proven with a p-value (p<0.05) between group 2 and group 3 that is significant. the gastroprotective effect in this study is only based on the measurement of hcl concentration in the stomach. in conclusion, the results of this study shows that carrot (daucus carota l.) juice extract able to lower down the hcl concentration in aspirininduced environment. therefore, as reported, the presence of carotenoids, flavonoids, and other bioactive compounds in carrot may be associated with gastroprotective effect. thus, this study supports the consumption of carrot juice extract as an alternative treatment for gastritis and prevention for ulceration induced by aspirin. references 1. johns hopkins medicine. health library on digestive disorder-gastritis. (cited 2012 althea medical journal. 2014;1(1) 39 november 26); available from: http:// www.hopkinsmedicine.org/healthlibrary/ c o n d i t i o n s / d i g e s t i v e _ d i s o r d e r s / gastritis_85,p00371/. 2. lanas a, garcía-rodríguez la, arroyo mt, bujanda l, gomollón f, forne m, et al. effect of antisecretory drugs and nitrates on the risk of ulcer bleeding associated with nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. am j gastroenterol. 2007;102(3):507–15. 3. harvey ra, champe pc, editors. pharmacology. 2nd ed. philadelphia: lippincott williams & wilkins; 2000.p. 235–41 4. eisenberg dm, kessler rc, foster c, norlock fe, calkins dr, delbanco tl. unconventional medicine in the united states: prevalence,costs and patterns of use. n engl j med. 1993;328(4):246–52. 5. world health organization. who's fact sheet no. 134: traditional medicine. geneva:who; 2003. 6. united states department of agriculture. usda national nutrient database for standard reference, release 25. washington dc: usda's agricultural service;2012. 7. khatib n, angel g, nayna h, kumar jr. gastroprotective activity of the aqueous extract from the roots of daucus carota in rats. ijrap. 2010;1(1):112–9. 8. john ta, onabanjo ao. effect of an aqueous extract of entandrophragma utile bark on gastric acid secretion in rat and isolated ileum contractility in guinea pig. afr j biomed res. 2010;13(3):197–206. 9. valle jd. principles of internal medicine. in: fauci as, kasper dl, longo dl, braunwald e, hauser sl, jameson jl, et al., editors. 17th ed. new york: mcgraw-hill; 2008. p. 1855–70. 10. gálvez j, de medina fs, jiménez j, zarzuelo a. effects of flavonoids on gastrointestinal disorders. studies in natural products chemistry. 2001;25(f):607–49. 11. amarowicz r, pegg rb, moghaddam pr, barl b, weil ja. free-radical scavenging capacity and antioxidant activity of selected plant species from the canadian prairies. food chemistry. 2004;84(4):551– 62. wong hui jiin, eva m. hidayat, kiki lukman: gastroprotective effect of the carrot (daucus carota l.) juice in rat models amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 55 maternal characteristics and histopathological features of placenta accreta spectrum in dr. hasan sadikin general hospital bandung, period 2015–2020 yuktiana kharisma,1,2 hasrayati agustina,1 sri suryanti,1 birgitta m. dewayani,1 bethy s. hernowo1 1department of anatomical pathology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2department of anatomical pathology, faculty of medicine universitas islam bandung, indonesia correspondence: yuktiana kharisma, dr., m.kes, department of anatomical pathology, faculty of medicine universitas islam bandung, jalan taman sari no. 22, bandung, indonesia, email: yuktiana@gmail.com introduction placenta accreta spectrum (pas), also known as morbidly adherent placenta, is a condition of abnormal trophoblast invasion of either parts or all of the placenta into the myometrial layer of the uterine wall. this abnormal attachment has important clinical implications, leading to severe maternal and neonatal mortality and morbidity.1 the incidence of pas has increased in various parts of the world. the pas affects approximately 3 in 1,000 pregnancies and a 5-fold increase in incidence over the last 3 decades.2 a cohort study in ireland found an increase in cesarean section (cs) birth rates by 4.1% in 1975 to 20.7% in 2010. the cs birth rate increased from 17% to 64% during the same period. the increase in cs birth rate also occurs in asia, including indonesia. studies conducted in asia found that the incidence of pas is 1 per 1,000 pregnancies. since 2016, the incidence of pas in indonesia has touched 2% and is still increasing today.3–5 several risk factors for pas include intrauterine procedures such as cesarean section, manual placenta, placenta previa, in vitro fertilization, curettage myomectomy, age, parity, smoking, asherman’s syndrome, althea medical journal. 2022;9(1):55–60 abstract background: the placenta accreta spectrum (pas) incidence has inclined today. the pas is divided into three histopathological classifications, including accreta, increta, and percreta, associated with maternal, fetal morbidity, and mortality. this study aimed to explore the maternal characteristics and histopathological features in pas at dr. hasan sadikin general hospital bandung. methods: this descriptive observational study involved 135 cases from january 2015–december 2020 at dr. hasan sadikin general hospital that met the inclusion criteria. the pas histopathological classification was evaluated based on maternal characteristics such as age, parity, cesarean section (cs), and miscarriage. results: the incidence of placenta accreta from 2015 to 2020 was 37.0%, whereas increta was 43.4%, followed by percreta at 19.3%. the maternal age of placenta accreta and increta mainly occurred at the age of 30–34 years with the prevalence of 40% and 46%, respectively, whereas percreta was aged 35–39 yo (27%). most parities in placenta accreta, increta, percreta were three. interestingly, 93% of cases had a cs history. furthermore, the miscarriage history for accreta was 18%, increta 29% and percreta 38%. conclusion: the highest incidence of pas in dr. hasan sadikin general hospital is placenta increta, which mainly occurs at the age of 30–34 years. almost all pas patients have a history of cs; however, most of the patients do not have a miscarriage history. keywords: characteristics, histopathological features, increta, percreta, placenta accreta spectrum https://doi.org/10.15850/amj.v9n1.2631 althea medical journal. 2022;9(1) 56 hypertension, infection in the uterus, as well as multiparity. history of cesarean section and placenta previa are risk factors that are often encountered in pas; whereas other risk factors are still unknown in contributing to the pathogenesis of placenta accreta.6 maternal morbidity in pas has reached 60%, including hysterectomy, need for blood transfusion, and prolonged length of stay with mortality exceeding 7%. the incidence of perinatal complications is also increasing due to premature birth, low birth weight, and small fetus for gestational age7,8 resulting in the increasing need for neonatal intensive care unit (nicu) and resuscitation requirements.9 considering the magnitude of complications in both mother and baby in mothers with pas and the lack of research on the characteristics of pas during the last five years, we are interested in exploring the characteristics of pas patients at dr. hasan sadikin general hospital bandung, a referral hospital in west java. by identifying risk factors for pas, its incidence in the future may be reduced. therefore, this study aimed to determine the incidence characteristics of maternal-fetal in pas patients at dr. hasan sadikin general hospital bandung. methods this study was a descriptive-analytic study of 135 pas patients, collecting secondary data obtained through medical records in dr. hasan sadikin general hospital bandung during 2015–2020. the study included only complete data, such as maternal age, parity, history of cesarean section (cs), history of miscarriage, and a histopathological pas group. the histopathological classification of pas was conducted through microscopic examination to assess the depth of trophoblast invasion into the myometrium, with the classification as follows: placenta accreta, increta, and percreta. the maternal characteristics were evaluated in each histopathological pas group. the research ethics committee of universitas padjadjaran has approved this study by ethics approval letter number: 777/un6.kep/ec/ 2021. results there was an increase in the incidence rate of pas in dr. hasan sadikin general hospital period 2015–2020. in 2015, there were 3 cases out of 2,452 total deliveries. a total of table 1 incidence and characteristics of placenta acreta spectrum patients in dr. hasan sadikin general hospital bandung period 1 january 2015–31 december 2020 characteristics incidence placenta accreta placenta increta placenta percreta n=50 (%) n=59 (%) n=26 (%) age (years old) <25 25–29 30–34 35–39 ≥ 40 2 (4) 15 (30) 20 (40) 13 (26) 2 (3) 18 (30) 27 (46) 8 (14) 4 (7) 0 (0) 6 (23) 6 (23) 7(27) 7(27) parity 2 3 4 >4 10 (20) 19 (38) 12 (24) 9 (18) 25 (43) 22 (37) 6 (10) 6 (10) 2(8) 8(31) 10(38) 6(23) history of cesarean delivery yes no 48 (96) 2 (4) 55 (93) 4 (7) 22 (85) 4(15) history of miscarriage yes no 9 (18) 41 (82) 17 (29) 42 (71) 10 (38) 16 (62) althea medical journal march 2022 althea medical journal. 2022;9(1) 57yuktiana kharisma et al.: maternal characteristics and histopathological features of placenta accreta spectrum in dr. hasan sadikin general hospital bandung, period 2015–2020 9 cases of pas were found in 2016 with 2,190 total deliveries, while in 2017, there were 23 cases of pas with 2,707 total deliveries. the incidence of pas in 2018 was 27 cases with 3,051 total deliveries. in 2019 and 2020, there were 33 and 40 cases of pas with a total of 3,140 and 2,252 deliveries, respectively, as described in figure 1. in 2015, 2016, and 2018 there were more cases of placenta increta than other subtypes of the depth of invasion of pas, while in 2017 and 2020, it was found that the number of cases of placenta accreta was very dominant. the highest incidence of placenta percreta was found in 2019 (figure 2). the incidence of placenta increta was 43.4%, placenta creta was 37.0%, and placenta percreta was 19%. the range of maternal age characteristics in placenta accreta and increta occurred at the age of 30–34 years (40% and 46%). however, placenta percreta had the highest percentage at the age of 35–39 years (27%). the highest parity in placenta accreta, increta, and percreta was three. interestingly, 93% of patients with pas had a history figure 1 incidence rate of placenta accreta spectrum at dr. hasan sadikin general hospital bandung between 2015 and 2020 figure 2 incidence of placenta accreta spectrum based on the depth of placental invasion into the myometrium in dr. hasan sadikin general hospital bandung in ci de nc e ra te 2.00% 1.80% 1.60% 1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% 2015 2016 2017 2018 2019 2020 althea medical journal. 2022;9(1) 58 of cesarean sections. moreover, most pas patients did not have a history of abortion in a previous pregnancy. all neonates to mothers with placenta accreta were born alive, while two babies were stillborn in cases of placenta increta and percreta (data not shown). the pas was diagnosed through histopathological examination through a microscope examination to confirm pas diagnosis and evaluate the depth of trophoblast invasion into the myometrium. the placenta accreta was diagnosed based on microscopic findings of direct attachment of the chorionic villi to the myometrium, either without the decidua or the nitabuch layer (figure 3a). the presence of the chorionic villi invasion showed penetration in the myometrium (increta) (figure 3b). in placenta percreta, it was diagnosed by assessing the presence of invasion of the chorionic villi to penetrate the uterine serosa (figure 3c). discussion the pas is characterized by abnormal attachment of the placenta to the uterine wall, caused by the absence or deficiency of the decidual nitabuch layer. abnormal placentation causes high morbidity and mortality for both the mother and neonates. the incidence of pas increases to 1/533 pregnancies. placenta accreta spectrum is considered to be a major cause of postpartum hemorrhage and is a significant cause of maternal and neonates’ morbidity and mortality.10 in this study, the incidence of pas in dr. hasan sadikin general hospital bandung reached as many as 135 cases out of 15,792 total deliveries in 2015–2020. the pas incidence rate increased from 0.12% in 2015 to 1.78% in 2020. similarly, the incidence of pas in greece has increased in the last 30 years,11 with an increase in risk factors for pas.6 the main risk factor for the development of pas is a history of cesarean section delivery.10 all patients in this study had a history of cesarean section in a previous pregnancy. a history of the cesarean section is one of the critical risk factors in the incidence of pas. cesarean section is the most common cause of scar tissue formation in the myometrium, at higher risk of developing pas when accompanied by placenta previa.3 clearly, the countries with high levels of the cesarean section have an increased incidence of pas.12 althea medical journal march 2022 figure 3 histopathological appearance of the pas, a) chorionic villi attached to the myometrium (placenta accreta), b) chorionic villi penetrated the myometrium (placenta increta), c) chorionic villi penetrated the tunica serosa (placenta percreta) althea medical journal. 2022;9(1) 59 furthermore, higher maternal age is a risk factor for pas,6 for example, mothers aged 35 years or older have a higher risk of experiencing pas. this relationship is influenced by the possibility of the number of parity and comorbid placenta previa, which can be one of the causes of decidual defects as a risk factor for pas.3 in this study, most mothers with pas were between the ages of 30–34 years; however, there were some outliers found in women less than 25 years old and women more than 40 years old who experienced pas. although all mothers with pas in this study had a parity of 2 or more, several studies suggested cases of pas that occurred in primiparas.13,15 with the incidence of 22.7/10,000 cases. this condition is associated with other risk factors for pas, such as a history of uterine instrumentation such as curettage, history of uterine surgery, and infection of the uterine wall. the previous history of surgery on the uterus is still not a strong risk factor because several studies have shown different results. uterine curettage has the strongest significance concerning the incidence of pas but cannot be the sole factor in its pathogenesis. moreover, a study in the united states has shown a significant relationship between invasive procedures of the uterus (laparoscopy, hysteroscopy, and uterine curettage) and pas, depending on the frequency of procedures performed by the patient.3 in this study, only a small proportion of pas patients had a history of miscarriages in a previous pregnancy. similar to study in japan showing no significant relationship between a history of miscarriage.14 the placenta accreta spectrum is significantly associated with maternal and infant morbidity. in this study, a baby was stillborn on a placenta increta and percreta. similarly, a study in australia has reported an increased risk of stillbirth (rr 5.4, and ci 99% 4.0–7.3) and neonatal death (rr 8.0, and ci 99% 1.5–41.6) in infants born prematurely in mothers with pas.15 one of the pathogenesis of pas is an endometrial-myometrial defect that causes failure of normal decidualization at the site of the uterine scar. this allows abnormal trophoblast invasion into the myometrium.16 the decidua potentially regulates trophoblast invasion. besides, the disruption of decidual integrity results in loss of inherent regulation and uncontrolled invasion of extravillous trophoblasts through the entire depth of the myometrium. the extent of penetration of villous tissue in the myometrium is most likely related to the degree of decidual-myometrial damage.17 conditions such as manual removal of the placenta, uterine curettage, and endometritis are more likely to cause abnormally adherent placentation (accreta). on the other hand, surgical scars over the entire thickness of the myometrium were associated with an absence of endometrial reepithelization and vascular remodeling around the scar area. this contributes to abnormally invasive placentation (increta/percreta).10,17,18 the obstetric and gynecological history of the patients in this study has not been explored further to identify other risk factors that may be associated with trophoblast invasion in pas. this study found that the number of cases of placenta increta dominated in the last 6 years, followed by placenta accreta and placenta percreta. the diagnosis of pas has been conducted through antenatal imaging and histopathological assessment. placenta accreta is the most common subtype of pas, whereas placenta increta is a minority subtype in australia and new zealand.8 the development of pas is a complex multifactorial process. the underlying molecular mechanism is not widely known. several hypotheses regarding the formation of pas reveal that the etiopathogenesis of the disorder is caused by a decidual defect and excessive invasion of trophoblast cells.19,20 this study has several weaknesses, excluding the characteristics such as demographic factors, socioeconomic factors, comorbidities in pregnancy, history of intrauterine instrumentation, and smoking history. furthermore, risk factors of mothers with incomplete data on curettage, body mass index, and comprehensive clinical outcome mother and babies have been excluded. the study on the relationship between pas and clinical outcomes needs to be further explored to get a more holistic picture of pas, especially in west java, indonesia. in conclusion, placenta increta has the highest incidence at dr. hasan sadikin general hospital bandung from 2015 to 2020. the characteristics of the maternal age for placenta accreta and increta ranges from 30–34 years, while, the highest percentage of placenta percreta is 35–39 years. all mothers with pas in this study are multiparous with varying amounts of parity. moreover, almost all pas patients in this study have a history of cesarean section, and a small proportion of pas patients had a miscarriage history. it is necessary to conduct yuktiana kharisma et al.: maternal characteristics and histopathological features of placenta accreta spectrum in dr. hasan sadikin general hospital bandung, period 2015–2020 althea medical journal. 2022;9(1) 60 further research on the characteristics of mothers with pas accompanied by an assessment of maternal and neonate clinical outcomes with a more significant number of research samples. references 1. silver rm, lyell dj. placenta accreta spectrum. in: queenan jt, spong cy, lockwood cj, editors. protocols for highrisk pregnancies: an evidence-based approach. 7th ed. hoboken, nj: wileyblacwell; 2021. p. 571–80. 2. belfort ma, shamshirsaz aa, fox ka. the diagnosis and management of morbidly adherent placenta. semin perinatol. 2018;42(1):49. 3. garmi g, salim r. epidemiology, etiology, diagnosis, and management of placenta accreta. obstet gynecol int. 2012;2012:873929. 4. jauniaux e, chantraine f, silver rm, langhoff-roos j, figo placenta accreta diagnosis and management expert consensus panel. figo consensus guidelines on placenta accreta spectrum disorders: epidemiology. int j gynaecol obstet. 2018;140(3):265–73. 5. jauniaux e, collins s, burton gj. placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. am j obstet gynecol. 2018;218(1):75–87. 6. carusi da. the placenta accreta spectrum: epidemiology and risk factors. clin obstet gynecol. 2018;61(4):733–42. 7. hartiningrum i, fitriyah n. bayi berat lahir rendah (bblr) di provinsi jawa timur tahun 2012–2016. j biometrika kependudukan. 2018;7(2):97–104. 8. farquhar cm, li z, lensen s, mclintock c, pollock w, peek mj, et al. incidence, risk factors and perinatal outcomes for placenta accreta in australia and new zealand: a case–control study. bmj open. 2017;7(10):e017713. 9. balayla j, bondarenko hd. placenta accreta and the risk of adverse maternal and neonatal outcomes. j perinat med. 2013;41(2):141–9. 10. society of gynecologic oncology; american college of obstetricians and gynecologists and the society for maternal–fetal medicine, cahill ag, beigi r, heine rp, silver rm, et al. placenta accreta spectrum. am j obstet gynecol. 2018;219(6):b2–16. 11. el gelany s, mosbeh mh, ibrahim em, mohammed m, khalifa em, abdelhakium ak, et al. placenta accreta spectrum (pas) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in minia, egypt: a prospective study. bmc pregnancy childbirth. 2019;19(1):313. 12. morlando m, sarno l, napolitano r, capone a, tessitore g, maruotti gm, et al. placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. acta obstet gynecol scand. 2013;92(4):457–60. 13. bheeshma b, nithyananda b, fatima s, anjum f. a retrospective study of placenta cretas: a 4 year experience at modern government maternity hospital, hyderabad. iaim. 2017; 4(5):31–6. 14. kyozuka h, yamaguchi a, suzuki d, fujimori k, hosoya m, yasumura s, et al. risk factors for placenta accreta spectrum: findings from the japan environment and children’s study. bmc pregnancy childbirth. 2019;19(1):447. 15. baldwin hj, patterson ja, nippita ta, torvaldsen s, ibiebele i, simpson jm, et al. maternal and neonatal outcomes following abnormally invasive placenta: a populationbased record linkage study. acta obstet gynecol scand. 2017;96(11):1373–81. 16. jauniaux e, jurkovic d. placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease. placenta. 2012;33(4):244– 51. 17. badr da, al hassan j, wehbe gs, ramadan mk. uterine body placenta accreta spectrum: a detailed literature review. placenta. 2020;95:44–52. 18. jauniaux e, bhide a. prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: a systematic review and meta-analysis. am j obstet gynecol. 2017;217(1):27–36. 19. maybin ja, hirani n, brown p, jabbour hn, critchley ho. the regulation of vascular endothelial growth factor by hypoxia and prostaglandin f2α during human endometrial repair. j clin endocrinol metab. 2011;96(8):2475–83. 20. tsuzuki t, okada h, cho h, tsuji s, nishigaki a, yasuda k, et al. hypoxic stress simultaneously stimulates vascular endothelial growth factor via hypoxia-inducible factor-1α and inhibits stromal cell-derived factor-1 in human endometrial stromal cells. hum reprod. 2012;27(2):523–30. althea medical journal march 2022 amj vol 9 no 2 june 2022 rev.indd a lt h e a m e d ic a l jo u r n a l v o lu m e 9 n u m b e r 2 y e a r 2 0 2 2 volume 9, number 2 june, 2022 e-issn 2337-4330 original articles trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 nedra wati zaly, mugia bayu rahardja, murtiningsih association of maternal obesity and pregnancy outcomes timoty krisna sukoco, dini hidayat, raden tina dewi judistiani hearing profile of children below three years old at jatinangor integrative health care center, west java, indonesia fidkya allisha, wijana, sally mahdiani knowledge and attitudes towards premarital screening among adolescents: a study in a university setting annisa triska almanda dewi, ari indra susanti, fedri ruluwedrata rinawan, sharon gondodiputro, neneng martini dietary intake, nutritional status, and quality of life in patients with thalassemia major steven yulius usman, salvabilla azheema rahmat, vetinly, felicia kurniawan level of knowledge and attitude towards covid-19 among high school students in depok arnold, fifi veronica, vycke yunivita prevalence of opportunistic infection in central nervous system among patients with hiv/ aids at dr. hasan sadikin general hospital dinda sayyidah laela fatimatuzzahra, ahmad rizal ganiem, aih cahyani, suryani gunadharma, sofiati dian aspartate aminotransferase to platelet ratio index score in correlation with neutrophil-tolymphocyte ratio and platelet-to-lymphocyte ratio to predict hepatic cirrhosis in hepatitis c patients jane haryanto, agnes rengga indrati, tiene rostini impact of instagram usage intensity on self-esteem among preclinical medical students maria christina sekarlangit, denio a. ridjab, eva suryani, v. dwi jani juliawati knowledge, attitude, and perception about autopsy among community in bandung aisyah putri pratiwi, berlian isnia fitrasanti, sani tanzilah editor in chief edhyana k. sahiratmadja managing editor mas rizky a.a syamsunarno external editors gerald pals kamisah yusof alexander kwarteng kittiphong paiboonsukwong tedjo sasmono jarir at thobari soegianto ali trevino aristarkus pakasi andani eka putra pudji lestari herry garna internal editors yunia sribudiani ronny lesmana afiat berbudi nur atik muhammad hasan bashari sri endah rahayuningsih irma ruslina defi reni ghrahani mohammad ghozali astrid feinisa khairani nur melani sari eko fuji ariyanto copyeditors hanna goenawan julia ramadhanti poppy siti chaerani djen amar electronic production engineer devi fabiola syahfitri site administrator & layout editor ati sulastri  offline secretariat elza purwita editorial address jl. prof. dr. eijkman 38 bandung, indonesia 40161 mobile: 082216237668/081320178724 phone (+62) 022-2032170 ext. 1401 fax: (+62) 022-2037823 e-mail: chiefeditor.amj@gmail.com website: http://journal.fk.unpad.ac.id/index.php/amj volume 9, number 2 june, 2022 e-issn 2337-4330 original articles trends in determinants of birth interval based on data from the indonesian demographic health survey in 2007, 2012, and 2017 nedra wati zaly, mugia bayu rahardja, murtiningsih association of maternal obesity and pregnancy outcomes timoty krisna sukoco, dini hidayat, raden tina dewi judistiani hearing profile of children below three years old at jatinangor integrative health  care center, west java, indonesia fidkya allisha, wijana, sally mahdiani knowledge and attitudes towards premarital screening among adolescents: a study in a university setting annisa triska almanda dewi, ari indra susanti, fedri ruluwedrata rinawan, sharon gondodiputro, neneng martini dietary intake, nutritional status, and quality of life in patients with thalassemia major steven yulius usman, salvabilla azheema rahmat, vetinly, felicia kurniawan level of knowledge and attitude towards covid-19 among high school students in depok arnold, fifi veronica, vycke yunivita prevalence of opportunistic infection in central nervous system among patients with hiv/aids at dr. hasan sadikin general hospital dinda sayyidah laela fatimatuzzahra, ahmad rizal ganiem, aih cahyani, suryani gunadharma, sofiati dian aspartate aminotransferase to platelet ratio index score in correlation with neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio to predict hepatic cirrhosis in hepatitis c patients jane haryanto, agnes rengga indrati, tiene rostini impact of instagram usage intensity on self-esteem among preclinical medical students maria christina sekarlangit, denio a. ridjab, eva suryani, v. dwi jani juliawati knowledge, attitude, and perception about autopsy among community in bandung aisyah putri pratiwi, berlian isnia fitrasanti, sani 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chen y, liao b, luo d, wang k, li h, et al. epidemiology of urolithiasis in asia. asian j urol. 2018;5(4):205–14. organization as a source who. who position paper on hepatitis a vaccines. wkly epid emiol rec. 2012;87(28/29):261–76. no author given mental care and relief support for victims of the earthquake occurred in eastern part of japan. seishin shinkeigaku zasshi. 2011;113(9):825–44. volume with supplement rushton l, hutchings sj, fortunato l, young c, evans gs, brown t, et al. occupational cancer burden in great britain. br j cancer. 2012;107(suppl1):s3–7. edition with supplement north cs, pollio de, smith rp, king rv, pandya a, suris am, et al. trauma exposure and posttraumatic stress disorder among employees of new york city companies affected by the september 11, 2001 attacks on the world trade center. disaster med public health prep. 2011;(5 suppl 2):s205– 13. books and other monographs personal author(s) sax pe, cohen cj, kuritzkes dr. hiv essentials 2012. 2nd ed. burlington: world headquarters; 2012. editor(s) as the author baxter r, editor. a cellular dermal matrices in breast surgery, an issue of clinics in plastic surgery. mountlake terrace: saunders; 2012. organization as the author unaids. meeting the investment challenge tipping the dependency. geneva: who library cataloguing data; 2012. chapter in a book pignone m, salazar r. disease prevention and health promotion. in: diedrich c, lebowitz h, holton b, editors. 2012 current medical diagnosis and treatment. 51st ed. new york: the mcgraw-hill companies; 2012. p. 1–21. conference proceedings wilson b, hamilton n, editors. airborne particulate exposures: the environmental and occupational perspectives. proceedings of the wsn mining health and safety conference; 2012 april 17–19; sudbury. ontario: golder associates; 2012. conference paper tirilly p, lu k, mu x. predicting modality from text quiries for medical image retrieval. in: cao y, kalpathy-cramer j, unay d, editors. mm 11. proceeding of the 2011 international acm workshop on medical multimedia analysis and retrieval; 2011 nov 28–dec 01; arizona, usa. new york: acm; 2011. p. 7–12. dissertation rohim s. kontruksi diri dan perilaku komunikasi gelandangan di kota jakarta (studi fenomenologi terhadap julukan gelandangan “manusia gerobak”) [dissertation]. bandung: universitas padjadjaran; 2012. electronic material journal article in electronic format mahmood om, goldenberg d, thayer r, migliorini r, simmons an, tapert sf. adolescents’ fmri activation to a response inhibition task predicts future substance use. addictive behaviors [internet] 2012 [cited 2012 may 12]. available from: http:// www.sciencedirect.com. homepage world health organization. cardiovascular disease (cvds) [internet] [cited 2021 may 6]. available from: https://www. who.int/health-topics/cardiovasculardiseases#tab=tab_1. editorial board contact: althea medical journal mobile: 082216237668/081320178724 e-mail: chiefeditor.amj@gmail.com amj.fkunpad@gmail.com amj vol 8 no 3 september 2021 final.indd althea medical journal. 2021;8(3) 164 althea medical journal september 2021 comparison of cognitive function of ischemic stroke patients with and without pneumonia amanda diannisa azzahra,1 lisda amalia,2 chandra calista,2 sofiati dian,2 siti aminah,2 paulus anam ong2 1faculty of medicine universitas padjadjaran, indonesia, 2departement of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: amanda diannisa azzahra, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: amanda17001@mail.unpad.ac.id introduction stroke is the most common cause of disability in adults. neurologic deficit after stroke, such as neurologic deterioration, neuromuscular, psychiatry, and cognitive impairment are the causes of disability.1 about 25–30% of stroke survivors develop vascular cognitive impairment (vci) or vascular dementia (vad).2 neuroanatomical lesion, cerebral vessels lesion, and alzheimer’s disease contribute to poststroke cognitive impairment.3 pneumonia is a common complication following acute ischemic stroke with a reported incidence of 5–26%.4 the incidence of pneumonia correlates with prolonged immobilization, decreased level of consciousness, and dysphagia.5 pneumonia, once it occurs, activates an adaptive immune response directed against central nervous system (cns) antigens thus worsening brain injury after stroke.6 patients hospitalized with pneumonia only were associated with worse functional and cognitive impairment.7 the possibility of pneumonia complication may worsen the cognitive function of ischemic stroke patients. the mini mental state examination (mmse) is widely used as a screening tool for cognitive deficits. this includes tests of orientation, attention, memory, language, and visuospatial skills.8 this instrument consists of 11 questions that only take 5–10 minutes to complete.7 the objective of this study was to compare cognitive function in ischemic stroke patients with and without pneumonia. amj. 2021;8(3):164–9 abstract background: pneumonia is a common complication of ischemic stroke that may worsens brain injury, leading to cognitive impairment as well as patient outcome. the aim of this study was to compare cognitive function in ischemic stroke patients with and without pneumonia. methods: this study was a comparative numerical analytic retrospective cross-sectional study that was conducted from september 2020 to february 2021. this study used data from ischemic stroke patients treated at dr. hasan sadikin general hospital in 2019 with the total sampling method. data were stratified into patients with pneumonia and without pneumonia. the mini mental state examination (mmse) was used to measure cognitive function in both groups and scores were compared using the mann-whitney test. results: of the 164 data, 25 were patients with pneumonia and 139 without pneumonia. male patients were predominantly prevalent in the pneumonia and non-pneumonia groups. hemiparesis was the most common neurological deficit. the mmse score was significantly lower in the pneumonia group (22.6±5.4 vs. 24.7±4.8, respectively; p-value=0.032). conclusions: cognitive function is more prevalent in ischemic stroke patient with pneumonia compared to non-pneumonia. however, other factors such as recurrent stroke and possible vascular risk factors should be considered for future studies to better identify the relationship between ischemic stroke and pneumonia. keywords: cognitive function, ischemic stroke, pneumonia https://doi.org/10.15850/amj.v8n3.2356 althea medical journal. 2021;8(3) 165 methods this observational analytic comparative numerical study used secondary data from medical records of ischemic stroke patients who were admitted to dr. hasan sadikin general hospital bandung. the study was conducted from september 2020 to february 2021. measurement of cognitive function was assessed using the mmse. medical records of ischemic stroke patients were collected from january to december 2019 which met the mmse inclusion criteria with a total sampling technique. medical records were excluded from this study when they had incomplete mmse scores. the mmse was not performed might be due to low level of education, decreased level of consciousness, and global or motoric aphasia and deceased. furthermore, the level of consciousness was assessed by using the glasgow coma scale (gcs) and stroke deficit was assessed using national institutes of health stroke scale (nihss). this study has been approved by the research ethics committee of universitas padjadjaran no. 025/un6.kep/ec/2021. the data were tested for normality using the shapiro-wilk test for dataset of <50 samples. the mann-whitney test was used for the analysis of abnormally distributed continuous data. the analysis was performed by comparing the mmse scores in the pneumonia and non-pneumonia groups. statistically significant was considered when p≤0.05. data were analyzed using ibm® spss ver. 25. results during the study period, 547 ischemic stroke patients were hospitalized at dr. hasan sadikin general hospital bandung, however, only 164 were eligible for further analysis. the excluded subjects were 120 who were deceased and 263 without mmse scores (153 with incomplete medical records data, 56 with severe aphasia, and 54 with decreased level of consciousness) as shown in figure 1. there were 164 eligible subjects consisting of 25 patients with pneumonia and 139 without pneumonia. male patients were more predominantly prevalent in both pneumonia and non-pneumonia group (64% and 56.1% respectively). the average of age in both subjects was not significantly different (60±11.3 in the pneumonia vs. 60.6±11 in the non-pneumonia group). education was slightly lower in the pneumonia group (9.4±0.6 vs. 9.7±0.2 years of education). in the pneumonia group, most of the subjects were office worker (44%) while subjects who were unemployed had the highest prevalence in the non-pneumonia group (49.6%), as shown in table 1. the level of consciousness assessed using the glasgow coma scale (gcs) tended to be lower in the pneumonia group than in the non-penumonia group (14.2±1.8 vs. 14.7±0.9, respectively), although the scores were not statistically different. stroke deficits assessed using the national institutes of health stroke scale (nihss) were higher in the pneumonia group (8.5±3.7 vs. 6.7±3.6, respectively; figure 1 subject selection medical records of ischemic stroke patients at dr. hasan sadikin general hospital bandung in 2019 n=547 met exclusion criteria: deceased (n=120) had no mmse score (n=263) incomplete medical record data (n=153) severe aphasia (n=56) decreased level of consciousness (n=54) eligible for study n=164 amanda diannisa azzahra et al.: comparison of cognitive function of ischemic stroke patients with and without pneumonia althea medical journal. 2021;8(3) 166 althea medical journal september 2021 p-value 0.046). hemiparesis was the most common neurologic deficit seen in both groups. subjects with lesion in parietal lobe had the highest prevalence in pneumonia group (24%) while lesion in the basal ganglia had the highest prevalence in the non-pneumonia group (30.6%). in the pneumonia group, most of the lesions were located on parietal lobe table 1 comparison of demographic characteristics of ischemic stroke patients with or without pneumonia at dr. hasan sadikin general hospital in 2019 patients characteristics pneumonia (n=25)n(%) no pneumonia (n=139) n(%) p-value gender, n (%) men women 16(64) 9(36) 78(56.1) 61(43.9) 0.463 age mean ± sd median iqr 60±11.3 59 8 60.6±11 60 14 0.889 years of education mean ± sd median iqr 9.4 ± 0.6 12 6 9.7 ± 0.2 12 6 0.711 occupation, n (%) unemployed office worker entrepreneur farmer/fisherman/laborer others 8(32) 11(44) 4(16) 0(0) 2(8) 69(49.6) 51(36.7) 5(3.6) 10(7.2) 4(2.9) 0.059 table 2 clinical characteristic of ischemic stroke patients with and without pneumonia from dr. hasan sadikin general hospital in 2019 variable pneumonia (n=25)n(%) no pneumonia (n=139) n(%) p-value level of consciousness (gcs) mean ± sd median iqr 14.2±1.8 15 0 14.7±0.9 15 0 0.266 stroke severity level (nihss) mean ± sd median iqr 8.5±3.7 7 6.75 6.7±3.6 6 5 0.046* neurologic deficit, n (%) dysphagia dysarthria hemiparesis 7 (28) 10 (40) 21 (84) 16 (11.5) 77 (55.4) 122 (87.8) 0.175 lesion location, n (%) frontal lobe parietal lobe temporal lobe occipital lobe cerebellum pons basal ganglia thalamus lateral periventricle 3 (12) 6 (24) 3 (12) 1 (4) 1 (4) 1 (4) 2 (8) 0 (0) 5 (20) 9 (6.5) 19 (13.7) 16 (11.5) 11 (7.9) 4 (2.9) 5 (3.6) 43 (30.9) 8 (5.8) 31 (22.3) 0.348 note: *p<0.05; gcs = glasgow coma scale; nihss = national institute of health stroke scale; iqr = interquartile range althea medical journal. 2021;8(3) 167amanda diannisa azzahra et al.: comparison of cognitive function of ischemic stroke patients with and without pneumonia (24%) while the basal ganglia lesion had the highest prevalence in the non-pneumonia group (30.9%) (table 2). cognitive function was evaluated using the mmse. the mmse scores were lower in the pneumonia group (22.6±5.4 vs. 24.7±4.8; p-value=0.032), which was statistically significant (table 3). discussion this study has compared the cognitive function of ischemic stroke patients with and without pneumonia, resulting that the pneumonia complication is more common in men, office worker, patients with hemiparesis, lower gcs, lower nihss, and lesion in parietal lobe. this finding is consistent with a retrospective study showing that ischemic stroke patients are predominantly prevalent in men.9 women have a lower incidence of stroke due to the protective effects of estrogen on cerebral and peripheral vascular disease. estrogen may increase blood flow, by decreasing vascular reactivity; whereas testosterone has the opposite effect. in addition, genes on the y-chromosome are partially involved in higher blood pressure and hypertension in men.10 interestingly, a study in guangzhou, china11 has shown that ischemic stroke incidence is higher in patients with a higher education level who are already retired. higher socioeconomic status is associated with an increased risk of ischemic stroke due to cardiovascular disease and an unhealthy lifestyle.11 furthermore, our study also found that in the group with pneumonia and without pneumonia there were office workers at 44% and 36.7%, respectively. office workers experience increased stress from their life and work which might affect blood pressure and cerebral endothelium. however, another study has found that stroke risk is inversely related to education level.12 in a previous study in bandung13, hemiparesis is the most common neurologic deficit occurred in stroke-associated pneumonia (sap) patients, which is consistent with our findings (87.8%). it is associated with prolonged immobilization and increased sputum accumulation which predisposes the patient to infection. hemiparesis, dysarthria, and dysphagia are among the many risk factors that contributed to the sap incidence.13,14 our study shows that dysphagia is more prevalent in pneumonia group, similar to other studies, showing that dysphagia has increased the risk of pneumonia more than 3-folds among stroke patients.15 dysphagia has impaired the protective reflexes of the laryngeal and swallowing, leading to an increased risk of aspiration.5,15 it is therefore important to identify and modify these risk factors in stroke patients. nil per os status at admission, institutionalized formal dysphagia screening protocol, enteric feeding method, and early mobilization are some of the prophylactic measures against sap. these should be done to limit the sap complication that may have a detrimental effect on stroke outcome.14 this study has also showed that ischemic lesion mostly occurred in the parietal lobe in the pneumonia group whereas the basal ganglia in the non-pneumonia group. the middle cerebral artery (mca) is the most common artery involved in stroke and is a major determinant of stroke-associated infection.15,16 the lateral surface of the brain and the basal ganglia are supplied by mca through four segments (m1, m2, m3, m4). basal ganglia are supplied by m1 and the parietal lobe by m2.16 interestingly, mca infarction is a strong predictor of cognitive impairment due to its association with working memory tasks (or=2.96).17 basal ganglia connection with prefrontal cortex is associated with cognition and memory function. it also supports habit-like learning and language processing. the parietal cortex contributes to spatial perception and attention. damage to the basal ganglia or parietal cortex might impair cognitive function.18 this study found that the mean age for pneumonia group is lower than nonpneumonia group. our result is in contrary to a retrospective case-control study, showing that older age is one of many risk factors table 3 comparison of mmse scores in ischemic stroke patients with and without pneumonia complication patients characteristics pneumonia (n=25) no pneumonia (n=139) p-value mean±sd 22.6±5.4 24.7±4.8 0.032* median 23 26 note: * p< 0.05 althea medical journal. 2021;8(3) 168 althea medical journal september 2021 for stroke-associated pneumonia.5 several factors are associated with an increased risk of pneumonia in older age groups, such as immune senescence and an increased risk of aspiration in the elderly.5 the findings in our study are in line with a study, showing that decreased level of consciousness and stroke severity predispose stroke patients to develop pneumonia.13 decreased level of consciousness is associated with decreased cough reflex, impaired esophageal sphincter, and swallowing function, thus, increasing the aspiration risk.13 furthermore, our study shows that the pneumonia group has higher nihss score. a higher nihss score indicates a more severe stroke and is related to a larger infarct size,4,5 leading to immunosuppression state making the patients more susceptible to infections.13 higher nihss scores are also associated with worse cognitive impairment (or=1.35).17 our study shows that mmse scores are lower in the pneumonia group, consistent with a cohort study on cognitive status using the teng modified mini-mental state (3ms) examination in cardiovascular patients, so cognitive function and pneumonia have a bidirectional relationship.19 during an episode of pneumonia, the systemic inflammatory level is increased and the higher levels may accelerate time to dementia caused by neuroinflammation.19 pneumonia is aggravated the ischemic cascade by increasing t helper 1 directed against central nervous system (cns) antigens.6 moreover, pneumonia is associated with hypoxia that begins the ischemic stroke cascade, leading to excite toxicity and oxidative damage, resulting in aggravated injury to neuron, glia, and endothelial cells.20 this study has several limitations. of the 427 potential subjects, only 164 fulfilled the inclusion criteria. this might be due to the natural history of the disease since most ischemic stroke patients are admitted in the hospital with decreased consciousness or have aphasia, thus, the mmse assessment cannot be performed on these patients. the overall findings of this study have shown that higher nihss scores are associated with pneumonia, which is known to be a predictor of worse cognitive impairment in stroke patients and is considered a confounding factor.17 additionally, this study do not consider other confounding factors, such as recurrent stroke and vascular risk factors that might interfere with the study outcomes. in conclusion, cognitive function is more prevalent in ischemic stroke patient having pneumonia compared to non-pneumonia, suggesting this indicates a relationship between cognitive function of ischemic stroke patients and pneumonia. other factors such as recurrent stroke and vascular risk factors should be considered for future studies to better identify the association of ischemic stroke and pneumonia. references 1. osemene ni. the neurologic complications of ischemic stroke. us pharm. 2013;38(1):hs1–5 2. kalaria rn, akinyemi r, ihara m. stroke injury, cognitive impairment and vascular dementia. biochim biophys acta. 2016;1862(5):915–25. 3. 3sun jh, tan l, yu jt. post-stroke cognitive impairment: epidemiology, mechanisms and management. ann transl med. 2014;2(8):80. 4. nam kw, kwon hm, lim js, lee ys. leukoaraiosis is associated with pneumonia after acute ischemic stroke. bmc neurol. 2017;17(1):51. 5. de castillo llc, sumalapao dep, pascual jlr. risk factors for pneumonia in acute stroke patients admitted to the emergency department of a tertiary government hospital. natl j physiol pharm pharmacol. 2017;7(8):855–9. 6. winklewski pj, radkowski m, demkow u. cross-talk between 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[updated 2020 aug 10]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2020 [cited 2020 dec 5] available from: https://www.ncbi.nlm.nih. gov/books/nbk499997/ 17. jaillard a, grand s, le bas jf, hommel m. predicting cognitive dysfunctioning in nondemented patients early after stroke. cerebrovasc dis. 2010;29(5):415–23. 18. squire l, berg d,bloom fe, du lac s, ghosh a, spitzer nc. fundamental neuroscience. 3 rd ed, cambridge, massachusetts: academic press elsevier; 2008. p.1277 19. shah fa, pike f, alvarez k, angus d, newman ab, lopez o, et al. bidirectional relationship between cognitive function and pneumonia. am j respir crit care med. 2013;188(5):586–92. 20. lakhan se, kirchgessner a, hofer m. inflammatory mechanisms in ischemic stroke: therapeutic approaches. j transl med. 2009;7:97. amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 170 amj december 2020 correlation between anemia and malaria infection severity in patients with type 2 diabetes mellitus in nigeria adedeji david atere,1,2 henry chijindu okpoli,2 kelvin aimuemwosa uwumarogie,2 adebimpe iyanuoluwa moronkeji2 1department of medical laboratory science, faculty of basic medical sciences, adeleke university, ede, osun state, nigeria, 2department of medical laboratory science, achievers university, owo, ondo state, nigeria correspondence: adedeji david atere, department of medical laboratory science, faculty of basic medical sciences, adeleke university, ede, nigeria, e-mail: ateread@gmail.com introduction malaria is the most common vector-borne parasitic disease of the globe and still a main public health challenge in more than a hundred countries across the globe with more than 2.5 billion people at the chance, causing a few million deaths yearly.1 a recent study has shown a correlation between plasmodium infection and blood glucose levels. plasmodium depends exclusively on an exogenous supply of glucose for survival due to the inability to store energy in form of glycogen.2 on the other end, diabetes mellitus (dm) is one of the most wellknown non-transmittable diseases, that has an absolute or relative insulin lack.3 diabetes is a degenerative disease characterized via disordered metabolism and hyperglycemia due to insufficient levels of the hormone insulin with or without additional resistance of insulin’s impact on many body cells.4 there is insulin-dependent diabetes mellitus (iddm) which is generally alluded to as type 1 diabetes, and insulin-independent diabetes additionally referred to as type 2 diabetes. type 2 dm is found in around 70–90% of diabetic cases and normally impacts humans aged 30 years and above.5,6 evidence has clearly stated that dm will be pandemic in many developing and industrialized nations, attributable to the western-style diet.3 in tropical africa, malaria poses a dangerous amj. 2020;7(4):170–5 abstract background: malaria and diabetes mellitus are still a significant global public health problem despite the phenomenal progresses in clinical sciences related to the diseases. both anemia and malaria parasitemia are common in developing countries. it is therefore important to diagnose and determine the correlation between anemia level and malaria infection severity in diabetic patients for better management. methods: patients with diabetes mellitus (dm) infected with malaria were recruited (n=50) as subjects and non-diabetic patients were used as control in this study, who were further divided into two subgroup: non-dm infected with malaria (n=25) and non-dm without malaria parasitemia (n=25). blood sample were collected to examine the fasting blood sugar (fbs) level, packed cell volume (pcv), hemoglobin (hb) level, and malaria parasitemia. statistical analysis was then performed using anova with a p value of less than or equal to 0.05 considered statistically significant. results: the parasite density in dm with malaria was significantly lower (p<0.05) than in the non-dm with malaria. interestingly, there was a higher pcv and hemoglobin level (p<0.05) in dm with malaria when compared with non-dm with malaria. conclusions: dm patients infected with plasmodium have low parasite density but higher hemoglobin level and pcv compared to the control group. there is no correlation between the severity of anemia and malaria parasitemia in dm patients infected with malaria when compared to non-diabetic subjects infected with malaria. further studies are needed to explore the correlation between hemoglobin level in dm and plasmodium infection. keywords: anemia, hemoglobin, hyperglycemia, malaria, parasitemia https://doi.org/10.15850/amj.v7n4.2085 althea medical journal. 2020;7(4) 171 wellbeing danger for quite a long time more than some other ailment, with 80% of malaria cases and mortality going on in africa, affecting both young and old. regardless of extra special development in medical sciences, malaria and dm continue to be a chief killer.7,8 anemia is two times as common in dm in comparison with non-diabetic.9 anemia is described as a condition where the hemoglobin (hgb) level is reduced, which diminishes the oxygencarrying limit of red blood cells to tissues. it is likewise a worldwide general health problem affecting both advanced and developing nations.9 despite all these scientific shreds of evidence, anemia is not associated with about 25% of diabetic patients. moreover, the danger of anemia is better in people with diabetic nephropathy in comparison with individuals with nephropathy from other sources as this is associated with a greater speedy decline in the glomerular filtration rate (gfr). there is a significant correlation of anemia with exceptionally low serum erythropoietin in men and women with either type 1 or type 2 diabetes, even without advanced kidney ailment or overt uremia.10 the etiology of anemia in diabetes is multi-factorial and these encompass nutritional deficiencies, concomitant autoimmune diseases, drugs, inflammation, and hormonal changes further to kidney disease.11 anemia and malaria parasitemia is endemic in developing nations among others in nigeria. it is therefore important to diagnose malaria in dm patients and further determine the correlation between the degree of anemia and severity of malaria infection in dm to oversee it fittingly. subsequently, this study is aimed to overcome any barrier in information and providing useful data to the medical and scientific community in the management of dm infected with plasmodium falciparum. methods this was a case-control study, performed between january to august 2019, including 100 subjects from owo metropolis-nigeria, comprised of dm patients infected with malaria (n50) and non-dm patients as a control group. fasting plasma glucose levels greater than 7.0 mmo/l on two or more occasions were designated as dm.3 the control was further regrouped as non-dm patients infected with malaria (n25) and non-dm without malaria parasitemia (n25). all the participants were aged between 30–70 years old. the medical and personal information had been obtained via a comprehensive questionnaire. exclusion criteria were diabetic patients with medical complications, including hypertension, human immunodeficiency virus (hiv), hepatitis, and cancer. pregnant and breastfeeding mothers were also excluded from the study. participants in this study had been fully briefed on the study protocols inside the health facility and then they were required to sign a written consent. ethical approval with registration number fmc/ow/380/vol.lxx/66 was obtained from the ethical review committee, federal medical centre, owo-nigeria. six milliliters (6 ml) of venous blood was aseptically collected from the mediancubital vein after 12 hours of fasting. three milliliters (3 ml) of collected venous blood was dispensed into a fluoride oxalate bottle, gently mixed, and thereafter used for the determination of fasting blood sugar to confirm diabetic condition. blood levels of fasting blood sugar were estimated using the standard spectrophotometric technique.12 the remaining 3 ml of venous blood was dispensed into an ethylene diamine tetra-acetic acid (edta) bottle for determination of packed cell volume (pcv), hemoglobin concentration, and malaria parasitemia. the packed cell volume (pcv) and hemoglobin concentration were determined by the manual method as described by cheesbrough.12 the malaria parasite density test was determined from giemsa stained peripheral blood smear.12 the level of parasitemia was in a microliter (ul) of blood thick film preparation, graded as low or + (1 to 999/ul), moderate or ++ (1000 to 9999/ ul) and severe or +++ (> 10,000/ul), based on who criteria13 and al-salahy et al.14 malaria parasite density was estimated by counting parasites against white blood cells. the number of parasites per microliter was calculated as follows. one way analysis of variance (anova) was used for comparison within the groups. a correlation was used to test the association between variables among dm with malaria. data were presented using mean±standard deviation (mean±sd) for all quantitative values. the level of significance was taken as a 95% confidence interval and p values less than or equal to 0.05 were considered significant. a statistical package for social sciences (spss) v.23.0 was used for the analysis of the data. adedeji david atere et al.: correlation between anemia and malaria infection severity in patients with type 2 diabetes mellitus in nigeria althea medical journal. 2020;7(4) 172 amj december 2020 table 1 presentation of age and haematological parameters on control and study subjects in means±standard deviation dm non-dm with malaria (n=50) with malaria (n=25) without malaria (n=25) age (years) 50.9±17.48 a,b 39.12±11.35 c 39.40±10.33 c hgb (g/dl) 12.43±1.59 a 10.74±1.68 b,c 13.64±1.16 a,c pcv (%) 35.67±6.84 a,b 32.12±5.04 b,c 40.78±3.39 a,c note: * significant at p≤0.05, a = significantly different from non-dm with malaria; b = significantly different from nondm without malaria; c = significantly different from dm with malaria, hgb= hemoglobin, pcv= packed cell volume results the mean age among respondents was as followed: dm with malaria was 50.9 years old ±17.48, non-dm with malaria 39.12 years old ±11.35, and non-dm without malaria 39.40 years old ±10.33, respectively. the hb and pcv values were compared between groups as shown in table 1. there was a lower significant value of pcv and hemoglobin in dm with malaria when compared with non-dm without malaria. furthermore, there was statistically significant higher hemoglobin and pcv in diabetic subjects with malaria than non-dm patients with malaria (p<0.05). in figure 1, there was a statistically significant higher blood glucose concentration in diabetic subjects when compared with nondiabetics with and without malaria. figure 2 shows that the mean parasite density in diabetic subjects with malaria was significantly lower than in the non-diabetic group with malaria. figures 3 and 4 show the correlation between malaria parasite densities and packed cell volume (p=0.844, r=0.029) and hemoglobin (p=0.952, r=-0.009) respectively, and no statistically significant correlation was observed. discussion the association of malaria with either hyperglycemia or hypoglycemia has been documented in several studies since there is a dependency of malaria parasites on an exogenous supply of glucose for survival due figure 1 fasting blood glucose (fbg) among dm with malaria, non-dm with malaria, and non-dm without malaria althea medical journal. 2020;7(4) 173adedeji david atere et al.: correlation between anemia and malaria infection severity in patients with type 2 diabetes mellitus in nigeria to the inability to store calories in form of glycogen.2,15 diabetes and malaria are common in developing countries with high fatalities and are thus major public health problems.15 approximately 216 million cases of plasmodium falciparum malaria has been documented in 2016 and induced an estimated 445,000 deaths, frequently among children residing in sub-saharan africa.1,11 malaria is one of the major causes of anemia in endemic areas, which is one of the inceptive factors for blood transfusion in those regions. the figure 2 malaria parasite density among dm and non-dm patients with malaria figure 3 correlation between malaria parasite density and packed cell volume in diabetic patients with malaria althea medical journal. 2020;7(4) 174 amj december 2020 majority of fatalities attributed to malaria have occurred directly or indirectly from anemia.11 additionally, anemia, an index of malnutrition, is common in plasmodium falciparum infection and has been reported aggravating its complications.16-17 the result of this study revealed a significantly lower malaria parasite density count in diabetic subjects when compared with control subjects with malaria parasitemia. this is in accordance with a study which revealed a higher parasite density in non-diabetic subjects when compared with diabetic patients,18 but other study contradicted the result that reported the possibility of high malaria infection in diabetic patients.19 interestingly, there was a significantly higher (p<0.05) pcv and hemoglobin in dm with malaria when compared with nondiabetics without malaria. this corroborates earlier reports that malaria is one of the leading causes of anemia.11 even though dm has been documented as a diverse group of metabolic disorders that are often related to an excessive disease burden in developing countries such as nigeria3, anemia has not been reported as one of its symptoms. in this study, there is no statistically significant correlation between malaria parasite densities, packed cell volume, and hemoglobin in dm patients with malaria parasitemia. in p. falciparum malaria, there may be sequestration of red blood cells containing mature parasites in the microcirculation.11 this simply means the density of the malaria parasite is corresponding to the severity of anemia. possibly, this is correlated with higher hemoglobin and pcv in dm with malaria in comparison with non-dm with malaria that we found in this study. another factor that contributes to reduce the anemia rate among dm patients infected with plasmodium infection is the anti-malarial property of the glucose-lowering drug metformin taken by dm patients. metformin is the most broadly used oral glucose-lowering drugs and it has been recognized for its antimalarial properties.20 in a massive study done in ghana, metformin used for dm has been discovered to have an appreciably decrease incidence of malaria compared to those without.20 with the anti-malarial property of this drug, there is a reduced level of red cells that are parasitized. for this reason, few red cells are hemolysed and a reduction in the severity of anemia in diabetes is therefore observed.15,20 one of the limitations of this work is that we could not ascertain the anti-malarial properties of metformin. therefore, similarly, studies need to be executed to assess the antimalaria properties of anti-diabetic drugs with a larger sample size. in conclusion, low parasite density, high hemoglobin, and pcv are present in dm figure 4 correlation between malaria parasite density and hemoglobin in diabetic patients with malaria althea medical journal. 2020;7(4) 175adedeji david atere et al.: correlation between anemia and malaria infection severity in patients with type 2 diabetes mellitus in nigeria patients infected with plasmodium. hence, there is no correlation between the severity of anemia and malaria parasitemia in dm patients with parasitemia. further study is needed to explore the anti-malarial properties of metformin. acknowledgments the authors appreciate the support of all the participants, the resident doctors, and all staff of the department of chemical pathology laboratory, federal medical centre, owo. conflicts of interest the authors declare that this manuscript was approved by all authors and competing interests did not exist. funding self-sponsored references 1. who. word malaria report 2017. geneva: world health organization; 2017. 2. atere ad, akinbo db, abiodun op, okpoli hc. blood pressure and plasma levels of blood glucose among subjects screening by malaria rapid diagnostic test in indigenous area, ondo state. jamps. 2017;13(4):1–7. 3. ogbera ao, ekpebegh c. diabetes mellitus in nigeria: the past, present and future. world j diabetes. 2014;5(6):905–11. 4. fadairo jk, atere ad, ogidiolu to, abiodun op. assessment of some coagulation indices among type ii diabetic subjects in a tertiary facility in south west region, nigeria. iosr-jdms. 2016;15(6):159–63. 5. atere ad, ale bg, adejumo bi, abiodun op, solomon uc. correlation between oxidative stress markers and atherogenic indices in type 2 diabetes mellitus. jsrr. 2016;12(4):1–9. 6. siddappa mn, ramprasad kr. assessment of serum ferritin level and its correlation with hba1c in diabetic nephropathy. ajms. 2020;11(2):46–51. 7. eze em, ezeiruaku f, ukaji d. experiential relationship between malaria parasite density and some haematological parameters in malaria infected male subjects in port harcourt, nigeria. glob j health sci. 2012;4(4):139–48. 8. who. world malaria report 2018. geneva: world health organization; 2018 [cited 2019 march 16] vailable from: https:// a p p s . w h o . i n t / i r i s / b i t s t r e a m / h a n d le/10665/275867/9789241565653-eng. pdf 9. gitonga cw, edwards t, karanja pn, noor am, snow rw, brooker sj. plasmodium infection, anaemia and mosquito net use among school children across different settings in kenya. trop med int health. 2012;17(7):858–70. 10. maiese k. erythropoietin and diabetes mellitus. world j diabetes. 2015;6(14):1259–73. 11. white nj. anaemia and malaria. malar j. 2018;17:371. 12. chessbrough m. district laboratory practice in tropical countries: part 2. 2nd ed. cambridge: cambridge university press; 2009. 13. who. basic malaria microscopy: part i learner’s guide. geneva: world health organization; 1991. 14. al-salahy m, shnawa b, abed g, mandour a, al-ezzi a. parasitaemia and its relation to hematological parameters and liver function among patients malaria in abs, hajjah, northwest yemen. interdiscip perspect infect dis. 2016;2016:5954394. 15. kalra s, khandelwal d, singla r, aggarwal s, dutta d. malaria and diabetes. j pak med assoc. 2017;67(5):810–3. 16. sakwe n, bigoga j, ngondi j, njeambosay b, esemu l, kouambeng c, et al. relationship between malaria, anaemia, nutritional and socio-economic status amongst under-ten children, in the north region of cameroon: a cross-sectional assessment. plos one. 2019;14(6):e0218442. 17. sakzabre d, asiamah ea, akorsu ee, abaka-yawson a, dei dika n, kwasie da, et al. haematological profile of adults with malaria parasitaemia visiting the volta regional hospital, ghana. advances in hematology. 2020;2020:9369758. 18. ndiok eo, ohimain ei, izah sc. incidence of malaria in type 2 diabetic patients and the effect on the liver: a case study of bayelsa state. j mosq res. 2016;6(15):1–8. 19. o’hara jk, kerwin lj, cobbold sa, tai j, bedell ta, reider pj, et al. targeting nad+ metabolism in the human malaria parasite plasmodium falciparum. plos one. 2014; 9(4):e94061. 20. casqueiro j, casqueiro j, alves c. infections in patients with diabetes mellitus: a review of pathogenesis. indian j endocrinol metab. 2012;16 suppl 1(suppl1):s27–36. amj vol 7 no 4 december 2020.indd althea medical journal. 2020;7(4) 165amj. 2020;7(4):165–9 sweet taste threshold among medical students with family history of diabetes mellitus nasya aisah latif,1 yulia sofiatin,2 maya kusumawati,3 rully m.a. roesli,3 1faculty of medicine universitas padjadjaran, indonesia 2department of public health faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: diabetic patients have low sensitivity towards sweet taste, thus consuming more sugar. a young adult with family history of diabetes mellitus (fhd) who lives with diabetic parents may have an increased risk of overconsumption of sugar due to a similar dietary pattern, leading to diabetes. this study aimed to explore the difference in the sweet taste threshold (stt) between students with and without a family history of diabetes mellitus. methods: this cross-sectional study was conducted in october–november 2018 on class 2018 medical students living in a student dormitory who were divided into those with family history of diabetes (fhd) and those without it (non-fhd). family history of diabetes and other known diseases were selfreported. the three-ascending forced choice method was used to determine the sweet recognition threshold. mann-whitney analysis was used to compare the sweet taste thresholds between the two groups. results: a total of 183 subjects participated in this study. the non-fhd group had a higher rank of sweet taste threshold than subjects in the fhd group (94.21 vs 81.16), albeit insignificant (p=0.192). interestingly, the modes of best estimation threshold (bet) for non-fhd group was than the fhd group (0.067 m vs 0.043 m). conclusions: the bet for students without family history of diabetes is higher than those with family history of diabetes. it is imperative that low sugar consumption campaign should also aim young people without fhd. keywords: diabetes, medical student, sweet taste threshold, sugar campaign correspondence: nasya aisah latif , faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia. e-mail: nasya16001@mail.unpad.ac.id introduction diabetes is an irreversible disease characterized by hyperglycaemia. in 2013, 6.9% of the population in indonesia were diabetes, and this number is increased by 1.6% in 2018.1 about 10.7% of global mortality is caused by diabetes.2 economical burden caused by this disease worldwide is estimated to reach 727 million usd.2 one of the unmodifiable risk factors for diabetes is family history. children who have parents with diabetes, known as a family history of diabetes (fhd)have an increased risk of diabetes 2–4 times higher than non-diabetic parents.2,3 individual with diabetes show higher insulin resistance.4 the modifiable risk factor includes lifestyles such as dietary habits.2 the whole family would share the similar dietary and physical patterns, for example, children would adopt the pattern of their parents and thus put the children at a higher risk of developing diabetes by 29%.5 overconsumption of sugar shows a positive association with the development of diabetes mellitus. studies have shown that indonesian adults with fhd have consumed more sugar than the world health organization (who) recommendation, even though they know they are facing a high risk of developing diabetes.6,7 in young adults, taste plays an important role in dietary choice.8 in order to taste a certain taste and interpret it correctly, a minimum concentration is required, known https://doi.org/10.15850/amj.v7n4.1940 althea medical journal. 2020;7(4) 166 amj december 2020 the amount of dextrose was weighed using an analytical balance. solution concentrations were determined based on a previous pilot study of 25 individuals from the population. 0.00004 m, 0.0002 m, 0.001 m, 0.005 m, 0.025 m, 0.125 m, 0.625 m, and 3.125 m was the concentration used for the pilot test. the lowest and highest result from the pilot test were used to make the concentration range for the actual test (0.002 m, 0.006 m, 0.018 m, 0.054 m, 0.162 m, 0.486 m, 1.458 m, and 4.374 m). each subject was given an adequate explanation of the procedure. they were asked to rinse their mouth with distilled water before starting each set to neutralize their mouth. next, subjects were asked to taste the sample from left to right with the sip-andspit technique. after one set of concentration, they were asked to choose and record which solution has a different taste and identify the taste they felt. the tasting procedure was done once. the sweet taste threshold (stt) of the students was determined by using the individual best estimation threshold (bet), which was a geometric mean of 2 concentrations; the first concentration was the first of the subsequent correct answer; the second concentration was the least wrong answer. the analysis was conducted based on fhd. group bet was used to compare the stt using the mann-whitney test. statistical analysis was conducted using ibm® spss statistics version 23 for windows. all statistical tests was performed using a level significance of <0.05 results one hundred and ninety-three out of two hundred and seventy-four medical students of universitas padjadjaran were agreed to participate in the test, but only 183 subjects carried out the test after excluded due to illness on the day of the test or dropped out. they were then grouped based on their fhd. the characteristic of the students showed that gender and body mass index (bmi) were not significantly different between the two groups (table 1). the best estimation threshold (bet) of the majority of students without fhd was 0.090 m while in those with fhdwas 0.030 m, however, there was no significant difference between the two groups (p=0.192; mann whitney test). furthermore, the mean rank of stt for each group was compared, resulting in higher ranks among students without fhd than those with fhd which was 94.21 vs 81.16, respectively. as recognition threshold.9 diabetic patients show a low taste sensitivity, leading to a higher taste threshold.10 higher sweet taste threshold (stt) means that a higher sugar concentration is needed. medical students are assumed to be more aware of health problems, including the knowledge of their family’s health problem and their lifestyle. as a specific group of young adults, the first-year medical students have been chosen to minimize the role of the new environment toward their taste threshold. this study aimed to analyze the difference in sweet taste threshold between medical students with or without fhd. the result is expected to be adopted into a diabetes prevention program. methods a cross-sectional study was conducted in october–november 2018 at the student’s dormitory hall of bale wilasa universitas padjadjaran to minimize distraction and to keep the room test odour free, since the taste was known to be affected by odour. the protocol of this study was approved by the research ethics committee universitas padjadjaran (no: 1311/un6.kep/ec/2018) all medical students in universitas padjadjaran batch 2018 filled an online form that contained informed consent, demographic data, and questions about inclusion and exclusion criteria. the eligibility requirement for this study was individuals in a healthy state. students with a known medical conditions, such as diabetes mellitus, hypertension, stroke, cancer, chemotherapy, radiotherapy, and having a cold or flu on the day of a test or any behaviours that might influence taste sensitivity, such as smoking and alcohol addiction were excluded. fhdwas self-reported. a day prior to the sweet taste threshold examination, all eligible subjects were informed not to drink, eat, or brush their teeth 1 hour before the test. three-ascending forced choice (3-afc) methods was used to determine the recognition threshold.9 this procedure forced the subject to choose between a set of 3 solutions, 2 blank samples, and 1 target sample. there were 8 sets of test samples, each set was separated by a tray in an ascending concentration order from left to right. each solution sample was labelled by 3 random digit numbers. the order of blanks and sample was randomized for each set. the sugar solution was made from dextrose monohydrate and commercially distilled water. althea medical journal. 2020;7(4) 167nasya aisah latif et al.: sweet taste threshold among medical students with family history of diabetes mellitus table 1 baseline characteristics of medical students based on family history of diabetes parental diabetes p-valueno (n=152) yes (n=31) n % n % gender male 47 30.9 12 38.7 0.406 female 105 69.1 19 61.3 bmi (kg/m2) underweight (<18.5 kg/m2) 22 14.5 4 12.9 0.323 normal weight (18.5–22.9 kg/m2) 82 53.9 14 45.2 overweight (23–24.9 kg/m2) 20 13.2 5 16.1 obese (≥25 kg/m2) 28 18.4 8 25.8 the bet in students without a family history of diabetes was higher than students with a family history of diabetes, which was 0.067 m vs 0.043 m, respectively. discussion the taste sensitivity can be affected by gender,11 bmi,12 age,11 smoking,13 and alcohol consumption.14 in our study, there are no significant differences in age and bmi between students with a family history of diabetes (fhd) and those without. in this study, we do not analyze smoking habits and alcohol consumption, since these factors have been excluded in the beginning. there are students (n17) in the group without fhd that falsely identify the sweet taste for bitter or sour. other students (n3) have marked the wrong check box on the paper at the 7th and 8th set of the test. these false responses can be caused by sensory adaptation; after tasting several similar stimuli, the subject may be partially adapted to the samples therefore when presented with higher stimuli and it may be perceived as weaker concentration than before, thus they responded with an incorrect answers.9 some students (n7) already identify the sweet taste at the lower concentration, but the response has changed to “sour” or “bitter” at the higher concentration (6th or 7th concentration). other students (n6) can only identify sweet taste on the seventh or eighth concentration, and one student could not identify the sweet taste at all. these students might have taste receptor abnormalities. the sweet taste threshold (stt) of the students without fhd in this study is higher than the stt of those with fhd, but not significantly differs. this result is in contrary to previous studies in chicago.15 similar to our study, the study in jakarta7 also showed no statistical significance (p=0.137). the different results from this study can be caused by several factors. first, increasing awareness for the past thirty years could change people’s behaviour. in the 1970s there was no adequate prevention campaigns for diabetes.16 the second national health & nutrition exam survey (nhanes ii) showed that only half of the people with diabetes knew they had the disease.16 in 1977, the centres for disease control (cdc) started to fund projects in the united states to reduce diabetes mortality and morbidity through secondary and tertiary prevention.16 it explained the higher sweet taste threshold among respondents with fhd in the 1970s. the role of up bringing in diet pattern was very strong. a study in 2018 showed that people with fhd were more aware of the disease compared to those without fhd.17 there was also a positive association between family history of diabetes with a healthier diet and regular exercise.18 a consistent reduced sugar intake can increase taste sensitivity. a study with 13 subjects that tried a three-month low-sugar diet can perceived sucrose to be significantly sweeter.19 it explained the lesser difference in stt between respondents with and without fhd. althea medical journal. 2020;7(4) 168 amj december 2020 of indonesians have their blood glucose checked, and around 73.7% of diabetic patients are undiagnosed.2 it is estimated that type 2 diabetes may arise 4 to 6 years before the clinical diagnosis.20 the proportion of respondents with a family history of diabetes among the study population is 19.6%, higher than the reported prevalence (8.5%). in conclusion, our study has shown that the group bet for sweet taste in medical students without a family history of diabetes is higher than those with family history, although the difference is not statistically significant. it suggests that a low sugar diet campaign should also aim at those without a family history of diabetes. further study on young adults other than medical students will strengthen the importance of this study. acknowledgment this study has been funded by the internal grant of universitas padjadjaran through academic leadership grant (alg), with prof. rully m.a roesli as the principal investigator. references 1. the national institute of health research and development ministry if health republic of indonesia. national basic the medical student is a special population. by choosing medicine as the future profession they have higher attention toward health and disease prevention. many students choose to study medicine because of personal or family experience. their exposure to the illness of family member might play an important role in deciding to follow a healthier lifestyle, including eating less sugar which leads to a lower sweet taste threshold. stt among medical students without fhd are varied. it could be caused by unawareness of parental diabetic status, leading to misclassification. a study in india5 showed that families who lived together tend to have a similar dietary habits. those who are raised by undiagnosed parents are assumed to be living with a high sugar intake for a long period can lower the stt. this may reduce the sensitivity, caused by the ability of sense of taste to adapt.9 there are limitations to this study. despite clear instruction not to communicate with other respondents, the room setting used for multiple subjects at the same time due to limited time, resources, and space may not ideally be followed. family history of diabetes in this study is self-reported which could lead to misreporting. there is a possibility that the respondent might not know their parents’ status of diabetes. a limited number table 2 distribution of sweet taste threshold parental diabetes total no (n=152) yes (n=31) n % n % n % bet (m) 0.00037 1 0.7 1 0.5 0.003 3 2.0 3 1.6 0.010 24 15.8 5 16.1 29 15.8 0.030 39 25.7 13 41.9 52 28.4 0.090 59 38.8 11 35.5 70 38.3 0.280 9 5.9 2 6.5 11 6.0 0.841 6 3.9 6 3.9 2.525 6 3.9 6 3.9 7.576 5 3.3 5 3.3 p-value 0.192 note: bet= best estimation threshold, m= molar (mol/l), p-value was obtained using mann whitney statistical test althea medical journal. 2020;7(4) 169 health research (riskesdas) 2013. jakarta: the national institute of health research and development ministry if health republic of indonesia; 2013. 2. international diabetes federation. idf diabetes atlas. 7th ed. brussels, belgium: international diabetes federation; 2015. 3. papazafiropoulou a, papanas n, melidonis a, maltezos e. family history of type 2 diabetes: does having a diabetic parent increase the risk? curr diabetes rev. 2017;13(1):19–25. 4. dash dk, choudhury ak, singh m, mangaraj s, mohanty bk, baliarsinha ak. effect of parental history of diabetes on markers of inflammation, insulin resistance and atherosclerosis in first degree relatives of patients with type 2 diabetes mellitus. diabetes metab syndr. 2018;12(3):285–9. 5. patel sa, dhillon pk, kondal d, jeemon p, kahol k, manimunda sp, et al. chronic disease concordance within indian households: a cross-sectional study. plos med. 2017;14(9):e1002395. 6. sami w, ansari t, butt ns, ab hamid mr. effect of diet on type 2 diabetes mellitus : a review. int j health sci (qassim). 2017;11(2):65–71. 7. yolanda v, antono l, kurniati a. sensory evaluation of sweet taste and daily sugar intake in normoglycemic individuals with and without family history of type 2 diabetes : a comparative cross-sectional study. int j diabetes res. 2017;6(3):54–62. 8. kourouniotis s, keast rsj, riddell lj, lacy k, thorpe mg, cicerale s. the importance of taste on dietary choice, behaviour and intake in a group of young adults. appetite. 2016;103:1–7. 9. lawless ht, heymann h. sensory evaluation of food: principles and practice, 2nd ed. new york, springer; 2010. 10. khera s, saigal a. assessment and evaluation of gustatory in patients with diabetes mellitus type ii : a study. indian j endocrinol metab. 2018;22(2):204–7. 11. puputti s, aisala h, hoppu u, sandell m. factors explaining individual differences in taste sensitivity and taste modality recognition among finnish adults. j sens stud. 2019;34:e12506. 12. vignini a, borroni f, sabbatinelli j, pugnaloni s, alia s, taus m, et al. general decrease of taste sensitivity is related to increase of bmi: a simple method to monitor eating behavior. dis markers. 2019;2019:2978026. 13. chéruel f, jarlier m, sancho-garnier h. effect of cigarette smoke on gustatory sensitivity, evaluation of the deficit and of the recovery time-course after smoking cessation. tob induc dis. 2017;15:15. 14. silva cs, dias vr, regis almeida ja, brazil jm, santos ra, milagres mp. effect of heavy consumption of alcoholic beverages on the perception of sweet and salty taste. alcohol alcohol. 2016;51(3):302–6. 15. lawson wb, zeidler a, rubenstein a. taste detection and preferences in diabetics and their relatives. psychosom med. 1979;41(3):219–27. 16. narayan kmv, williams d, gregg ew, cowie cc, editors. diabetes public health: from data to policy. new york: oxford university press; 2011. p. 493–6 . 17. joshi s, ashok p, kharche j, godbole g. study of relation between family history of diabetes mellitus and awareness of diabetes mellitus in pune urban population. natl j physiol pharm pharmacol. 2018;8(10):1418–21. 18. choi j, choi jy, lee sa, lee km, shin a, oh j, et al. association between family history of diabetes and clusters of adherence to healthy behaviors: cross-sectional results from the health examinees-gem (hexa-g) study. bmj open. 2019;9(6):e025477. 19. wise pm, nattress l, flammer lj, beauchamp gk. reduced dietary intake of simple sugars alters perceived sweet taste intensity but not perceived pleasantness. am j clin nutr. 2016;103(1):50–60. 20. porta m, curletto g, cipullo d, de la longrais rr, trento m, passera p, et al. estimating the delay between onset and diagnosis of type 2 diabetes from the time course of retinopathy prevalence. diabetes care. 2014;37(6):1668–74. nasya aisah latif et al.: sweet taste threshold among medical students with family history of diabetes mellitus amj vol 10 no 2 june 2023(1).indd althea medical journal. 2023;10(2) 110 clinicopathological characteristics of cervical carcinoma with pelvic lymph node metastases in dr. hasan sadikin general hospital, bandung year 2013–2021 henny sri rejeki,1 sri suryanti,1 anglita yantisetiasti,1 kemala isnainiasih mantilidewi,2 gatot nyarumenteng adhipurnawan winarno2 1department of pathological anatomy, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia2department of obstetrics and gynecology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: henny sri rejeki, dr, department of pathological anatomy, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, jalan pasteur 38, bandung, indonesia, e-mail: hennysrirejeki@gmail.com introduction based on data from the global cancer statistics (globocan) 2020, the incidence of cervical cancer has reached 604,127 new cases with a mortality rate of 341,831 cases each year.1 the mortality rate occurs about 90% of deaths in low to middle-income countries. in indonesia, the number of new cases of cervical cancer in 2020 was 3,425 cases and was ranked first in the incidence of female reproductive tumors based on the indonesia society of gynecologic oncology (inasgo).2 the distribution of cervical cancer from inasgo for 2020 metastase 2021 based on the figo stage of cervical cancer was 12.1%, 31.4%, 50.5%, and 4.9% for stages i, ii, iii, and iv, respectively.2 the prognosis for stage ia and iia cervical cancer is 80% and 63%, respectively.3 the survival rate of patients who are free of metastases is about 81.5%.4 a study among french population showed that about 15% of cervical cancer patients with metastases could survive up to 5 years.5 high risks prognostic factors associated with poor postoperative survival rates include lymph node metastases, parametrial extension, lympho vascular invasion, depth of stromal invasion, histologic type, differentiation, tumor size, and age. among the prognostic factors, the worst is lymph node metastases.6,7 this study aimed to determine the characteristics of cervical carcinoma patients with lymph node metastasis at dr. hasan sadikin general hospital, bandung. althea medical journal. 2023;10(2):110–114 abstract background: carcinoma of the cervix is the most common gynecological malignancy, which ranks first among carcinomas in indonesia. lymph node metastasis is a risk of recurrence, affecting survival and therapy. the purpose of this study was to determine the clinicopathological characteristics of cervical carcinoma with pelvic lymph node metastasis that had undergone radical hysterectomy and lymphadenectomy at dr. hasan sadikin general hospital, bandung. methods: this study used a cross-sectional retrospective descriptive study. data on the clinical stage i–ii cervical cancer patients with pelvic lymph node metastasis were collected from the archives of the pathological anatomy laboratory during period from 2013 to 2021. data were presented in percentage. results: there were 64 data patients, and the most common age of cervical carcinoma ranged from 40 to 50 years old (52%), the most common stage was stage ii (66%), and the most frequent histopathological type was squamous cell carcinoma (70%). the highest degree of differentiation was moderate differentiation (50%). there was no difference in tumor size between sizes <4 cm and ≥4 cm. conclusions: the cases of cervical carcinoma at dr. hasan sadikin general hospital bandung are treated with radical hysterectomy and lymphadenectomy. the patients generally aged between 41–50 years old, stage ii, and squamous cell carcinoma with a moderate degree of differentiation. keywords: cervical carcinoma, metastase, pelvic lymph node https://doi.org/10.15850/amj.v10n2.2776 althea medical journal. 2023;10(2) 111 methods this study used a cross-sectional observational descriptive method. the population were patients with cervical cancer who had undergone radical hysterectomy and lymphadenectomy and had been diagnosed histopathologically from 2013 to 2021 at dr. hasan sadikin general hospital bandung, indonesia. data including on age, stage, type of histology, degree of differentiation, and tumor size were collected from the histopathological anatomical pathology laboratory archive and medical records. the level of differentiation applied only to squamous cell carcinoma (scc) and adenocarcinoma. cervical carcinoma was diagnosed through histopathological examination to confirm the definitive diagnosis. the examination was characterized by morphology, pattern, nuclear pleomorphism, and mitotic activity.8 the data were presented in numbers and percentages for categorical variables. this research received ethical approval from the research ethics committee of universitas padjajaran number: 728/un6.kep/ec/2021. results in total, 64 data were retrieved. from cases of cervical carcinoma with pelvic lymph node metastases at dr. hasan sadikin general hospital bandung from 2013 to 2021, the highest incidence of cervical carcinoma with pelvic lymph node metastases was found in 2018 (figure 1). the average age of patients was 40–50 years (52%, n=33) (table 1). the youngest patient in this study was 29 years old, suggesting an association with the main etiology of the disease, namely hpv infection, which was related to sexual activity. in this study there table 1 characteristics of subjects characteristics n (%) age (years) <40 40–50 51–60 >60 20 (31) 33 (52) 8 (12) 3 (5) stage i ii 22 (34) 42 (66) histopathology type squamous cell carcinoma adenocarcinoma adenosquamous carcinoma clear cell carcinoma neuroendocrine carcinoma 45 (70) 10 (16) 5 (8) 3 (5) 1 (1) grading well-differentiated moderate poorly differentiated non-grading 7 (11) 32 (50) 16 (25) 9 (14) size of tumour <4 cm ≥4 cm 32 (50) 32 (50) figure 1 incidence of cervical carcinoma with pelvic lymph node metastases in dr. hasan sadikin, bandung in 2013–2021 n um be r of c as es scc 2013 2014 2015 2016 2017 2018 2019 2020 2021 adenocarinoma adenosquamous clear cell ca neuroendocrine ca 0 2 4 10 8 6 12 14 16 years henny sri rejeki et al.: clinicopathological characteristics of cervical carcinoma with pelvic lymph node metastases in dr. hasan sadikin general hospital, bandung, year 2013-2021 althea medical journal. 2023;10(2) 112 was only one elderly patient (>65 years). the most common stage was stage ii (66%). the most frequently found histopathological type was squamous cell carcinoma (70%; n=45). the highest grading of differentiation was moderate differentiation (50%; n=32). there was no difference in tumor size between sizes <4 cm and ≥4 cm. the most common histopathology type was squamous cell carcinoma (70%) (figure 2a&b), followed by adenocarcinoma (16%) (figure 2c), adenosquamous (8%) (figure 2d&e), clear cell carcinoma (5%) (figure 1f&g) and neuroendocrine carcinoma (2%) (figure 2h&i). discussion in this study, most cases of cervical carcinoma with pelvic lymph node metastases are found at the age of 40–50 years. this result is in line with data from the international agency for research on cancer (iarc) that cervical cancer is most often found in women aged >45 years old.8 data from inasgo in 2021 revealed that cervical cancer was most found at the age of 36–55 years.2,21 therefore, the incidence of cervical scc in young adult women <30 years is very rare.19,20 age is one of the factors that affect the prognosis of patients and the maturity of the immune system in the body. this is related to the ability of immunity which increases and will slowly decrease, especially at a rather advanced age.9 the most common type of histopathology is squamous cell carcinoma (scc). these results are almost the same as those found by another study which shows that the prognostic survival rate in patients with early-stage cervical cancer is 74%, 22%, althea medical journal june 2023 b a c d e g f h i figure 2 histopatological appearance of carcinoma cervix uteri note: a) keratinizing squamous cell carcinoma (scc), b) non-keratinizing scc, c) adenocarcinoma, d) adenosquamous carcinoma, squamous differentiation e) adenosquamous carcinoma, glandular differentiation, f) clear cell carcinoma, hobnail appearance, g) clear cell carcinoma, tumour is composed of cells with clear to pale eosinophilic cytoplasm, h) neuroendocrine carcinoma, nested pattern, i) neuroendocrine carcinoma, cells with scant cytoplasm and hyperchromatic nuclei althea medical journal. 2023;10(2) 113henny sri rejeki et al.: clinicopathological characteristics of cervical carcinoma with pelvic lymph node metastases in dr. hasan sadikin general hospital, bandung, year 2013-2021 and 4% for squamous, adenocarcinoma and adenosquamous carcinoma types.10 another study in jakarta found that in 2006– 2010, in 2.297 cases of cervical cancer, the histopathological distribution was 57.6%, 12.4%, 8.4% and 0.5% rates for squamous cell carcinoma, adenocarcinoma, adenosquamous cell carcinoma, and clear cell carcinoma, respectively.11 in addition, another result showed that the frequency of positive pelvic nodes by histology was three-fold higher in squamous carcinoma than in adenocarcinoma.12 some studies reported that adenocarcinoma has a worse prognosis than squamous cell carcinoma.13–16 however another research reported that there was no difference regarding the survival rate of the patients based on the histopathological type of adenocarcinoma versus squamous cell carcinoma.17 based on the characteristic of the stage, almost all patients were classified into stage ii (early stage). this is in accordance with the therapeutic guidelines issued by the ministry of health of the republic indonesia concerning the national guidelines for cervical cancer management medical service, that definitive therapy in the form of surgery is carried out in the early stage of cervical cancer.3 tumor size is closely related to the risk of lymph node metastases. another finding showed a worse prognosis in cervical cancer patients with tumor size ≥4 cm compared to cervical cancer patients with tumor size <4 cm.18 other research shows similar data in this regard.22,23 with recurrence rates of 86.6% and 45.1%, respectively. cancer patients with the lower clinical stage (stage ib) have a slower recurrence rate than patients with advanced cancer stage (> stage ib).18 the staging of cervical cancer is based on the international federation of gynaecology and obstetrics (figo) stage. there have been revisions of figo 2009 and figo 2018. in figo 2009 the determination of pelvic lymph node metastases was determined after definitive therapy (radical hysterectomy and pelvic lymphadenectomy) and did not affect the stage. figo 2018 set one of theparameters to determine staging, namely pelvic lymph node metastases (determinedbased on imaging or histopathology examination). based on figo 2018, cervical cancer with pelvic lymph node metastases was diagnosed as stage iiic1. the 2018 figo stage allows pelvic lymph node metastases to be determined beforedefinitive therapy is carried out so that it can affect the therapy given to the patient. definitive therapy according to the 2021 national comprehensive cancer network (nccn) guidelines for stage iiic1 cervical cancer (pelvic lymph node metastases) ispelvic external beam radiation therapy and brachytherapy. based on the changes in the 2018 figo stage and the 2021 nccn guidelines, it is hypothesized that this is the cause of the decreased incidence of cervical cancer with pelvic lymph node metastases undergoing radical hysterectomy and pelvic lymphadenectomy from 2019 to 2021. there are several limitations in this study such as the study was conducted at a single center. the risk factors that could be regarded as confounding factors such as smoking, long-term oral contraceptive use, and human papillomavirus (hpv) infection are not studied. in conclusion, patients with cervical cancer at dr. hasan sadikin general hospital, bandung in period 2013 to 2021 mostly occur in the age range of 40–50 years, stage ii, subtypes squamous cell carcinoma, and a moderate degree of differentiation. references 1. sung h, ferlay j, siegel rl, laversanne m, soerjomataram i, jemal a, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worlwide for 36 cancers in 185 countries. ca cancer j clin. 2021;71(3):209–49. 2. indonesian society of gynecologic oncology. national data of cervical cancer. jakarta: the institute; 2020 3. himpunan onkologi ginekologi indonesia. panduan penatalaksanaan kanker serviks kementerian kesehatan republik indonesia. jakarta: the institute; 2018. 4. carneiro sr, fagundes mda, rosario pdjo, neves lmt, souza gs, pinheiro mcn. fiveyear survival and associated factors in women treated for cervical cancer at a reference hospital in the brazilian amazon. plos one. 2017;12(11):e0187579. 5. lorin l, bertaut a, hudry d, beltjens f, roignot p, lepinoy mcb, et al. about invasive cervical cancer: a french population based study between 1998 and 2010. eur j obstet gynecol reprod biol. 2015;191:1–6. 6. li d, xu x, yan d, yuan s, ni j, lou h. prognostic factors affecting survival and recurrence in patient with early cervical squamous cell cancer following radical hysterectomy. j int med res. 2019;48(4): althea medical journal. 2023;10(2) 114 1–13. 7. ferdous j, khatun s, akhter s, chowdhury s, pervin s, amir m, et al. evaluation of the risk factors for pelvic lymph node metastasis in early stage cervical cancer.j cancer ther. 2018;9(12):1011–26. 8. herrington cs, bray f, ordi j. tumours of the uterine cervix. in: kurman rj, carcangiu ml, herrington cs, young rh, editors. who classification of tumours of the female reproductive organs. lyon; iarc; 2020. p. 335. 9. lu x, zhou y, meng j, jiang l, gao j, fan x, et al. epigenetic age acceleration of cervical squamous cell carcinoma converged to human papillomavirus 16/18 expression, immunoactivattion, and favourable prognosis. clin epigenetics. 2020;12:23. 10. biewenga p, velden jvd, mol bw, stalpers lja, schilthuis ms, steeg jw, et al. prognostic model for survival in patients with early stage cervical cancer. cancer. 2011;117(4):768–76. 11. tricia d. distribution of age, stage, and histopathology of cervical cancer: a retrospective study on patients at dr. cipto mangunkusumo hospital, jakarta, indonesia 2006–2010. j obstet gynecol. 2011;35(1):21–4. 12. lin aj, wright jw, dehdasti f, siegel b, markovina s, schwarz j, et al. impact of tumor histology on detection of pelvic and para-aortic nodal metastasis with fdg-pet in stage ib cervical cancer. int j gynecol cancer. 2019;29(9):1351–4. 13. mabuchi s, okazawa m, matsuo k, kawano m, suzuki o, miyatake t, et al. impact of histological subtype on survival of patients with surgically-treated stage ia2-iib cervical cancer: adenocarcinoma versus squamous cell carcinoma. gynecol oncol. 2012;127(1):114–20. 14. kato t, watari h, takeda m, hosaka m, mitamura t, kobayashi n, et al. multivariate prognostic analysis of adenocarcinoma of the uterine cervix with radical hysterectomy and systemic lymphadenectomy. j gynecol oncol. 2013;24(3):222–8. 15. huang yt, wang cc, tsai cs, lai ch, chang tc, chou hh, et al. clinical behaviors and outcomes for adenocarcinoma or adenosquamous carcinoma of cervix treated by radical hysterectomy and adjuvant radiotherapy or chemoradiotherapy. int j radiat oncol biol phys. 2012;84(2):420–7. 16. xie l, chu r, wang k, zhang x, li j, zhao z, et al. prognostic assessment of cervical cancer patients by clinical staging and surgical-pathological factor: a support vector machine-based approach. front oncol. 2020;10:1353. 17. andrijono. kanker serviks. 4th ed. jakarta: divisi onkologi departemen obstetri-ginekologi fakultas kedokteran universitas indonesia, 2012. p. 77–112. 18. widhiarta pk, mahendra in, aryana mbd, megaputra ig. faktor-faktor klinikopatologi kekambuhan kanker serviks stadium 0– iia2 pasca histerektomi radikal di rsup sanglah periode 2019–2020. intisari sains medis. 2021;12(1):196–200. 19. stoller m bc ct, ferenczy as. tumours of the uterine cervix. in: kurman rj hc, young r, editor. who classification of tumours of the female reproductive organs. lyons; who; 2014. p. 172–80. 20. hacker nf, vermoken jb. cervical cancer. in: berek js, hacker nf, editors. berek & hacker’s gynecologic oncology. 7th ed. philadelphia: wolter kluwers; 2021. p. 247–49. 21. witkiewicz ak, wright tc, ferenczy as, ronnet bm, kurman rj. carcinoma anad other tumors of the cervix. in: kurman rj, elleson lh, ronnet bm, editors. blaustein’s pathology of the female genital tract. 6th ed. new york: springer science & business media; 2013. p. 253–72. 22. feng m, xu l, he y, sun l, zhang z, et al. elevated pd-l1 expression (cd274) enhanced expression in cervical squamous cell carcinoma. int j clin exp pathol. 2018;11(11):5370–8. 23. chen z, pang n, du r, zhu y, fan l, cai d, et al. elevated expression of progammed death-1 and programmed death ligand-1 negatively regulates immune response againt cervical cancer servik. mediators inflamm. 2016;2016:6891482. althea medical journal june 2023 althea medical journal. 2014;1(2) 94 amj december, 2014 improvement of near vision for low vision patients in national eye healthcare center cicendo eye hospital 2010–2011 muhammadnur rachim enoch1, ine renata musa2, titing nurhayati3 1faculty of medicine, 2department of ophthalmology, faculty of medicine, universitas padjadjaran/ national eye center cicendo hospital bandung, 3department of physiology, faculty of medicine, universitas padjadjaran abstract background: “low vision” is a term used refer to a person having a visual acuity of less than 6/18 (20/60) to light perception (lp). people with low vision can still be treated to perceive or see objects, although several limitations occur. treatments for people with low vision include either optical or non-optical devices. this research aims to reveal visual acuity for near vision that can serve as corrective benchmark after devices for near vision are given. methods: this is a retrospective descriptive research, using medical records from the national eye healthcare center, cicendo eye hospital, for the period of august 2010–september 2011 as the subject of the research. approximately 475 patients were listed, 263 female and 212 male. the number of patients with low vision given with corrective device for near vision were 81 patients. results: the result showed that visual acuity was corrected after corrective devices for near vision with the size of 1–10 m were given. conclusions: the highest of overall corrections or improvements for near vision are the one under the category of “severe visual impairment”. [amj.2014;1(2):94–9] keywords: low vision, optical devices, visual acuity peningkatan penglihatan jarak dekat pada penderita“ low vision” di rs mata nasional cicendo 2010–2011 abstrak latar belakang: “low vision” adalah istilah yang mengacu pada seseorang yang memiliki ketajaman visual kurang dari 6/18 (20/60) dengan persepsi cahaya. orang dengan low vision masih dapat diobati untuk melihat benda meskipun dengan berbagai keterbatasan. pengobatan terhadap penderita low vision meliputi perangkat optik atau non-optik.. penelitian ini bertujuan untuk menggambarkan ketajaman visual penglihatan dekat yang dapat berfungsi sebagai pedoman perbaikan setelah perangkat diberikan. metode: penelitian ini merupakan penelitian deskriptif retrospektif dengan menggunakan rekam medis dari pusat mata nasional kesehatan, rs mata cicendo, periode agustus 2010–september 2011 sebagai subjek penelitian. sekitar 475 pasien yang terdaftar terdiri atas 263 perempuan dan 212 laki-laki, 81 diantaranya diberikan perangkat korektif untuk penglihatan dekat. hasil: ketajaman visual dapat diperbaiki setelah dilakukan pemberian perangkat korektif untuk penglihatan jarak dekat dengan ukuran 1–10 m. simpulan: peningkatan penglihatan jarak dekat terbaik adalah pada kelompok low vision yang termasuk kategori “gangguan penglihatan berat”. [amj.2014;1(2):94–9] kata kunci: low vision, perangkat optik, ketajaman visual correspondence: muhammadnur rachim enoch, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628212098 5470, email: muhammadnurrachim@gmail. com althea medical journal. 2014;1(2) 95 introduction low vision is one of the severe visual or optical issues aside from blindness. according to the who, low vision is a term used refer to a person having a visual acuity of less than 6/18 (20/60) to light perception (lp), or having a visual field of less than 10 degrees from the fixation point that cannot be treated or corrected only with standard refractive devices.1 low vision is different than blindness; people with low vision can still be treated, although several limitations occur.2 people with low vision can come from any age. according to a study conducted by the who, approximately 285 million people across the world were suffering from visual impairment, whereas 39 million suffered from blindness and others from low vision.1 in the united states of america, the number of people with low vision has reached 2.4 million. according to studies in indonesia, people with low vision have a relatively high prevalence, which is around 9/10.000 children, or approximately 210,000 children in indonesia.3 in 1987, a study was conducted in bandung, resulting in the conclusion that 1.56% of children in elementary school s, or approximately 70,200 children, were suffering from low vision.4 according to the international classification of disease, 9th revision, clinical modification, low vision, people with low vision are classified into several categories: moderate visual impairment, severe visual impairment, profound visual impairment, near total visual loss, and total blindness. such classification is based on visual acuity; hence treatments are also affected.5-8 treatments for people with low vision come in various kinds, including either optical or non-optical devices. optical devices are deemed the most efficient for people with low vision since such devices can improve the visual quality and thus decrease dependences on other people. most of the notable nonoptical devices are books with large fonts, reading stands, and reading light. on the other hand, there are many kinds of optical devices , such as magnifierfor near vision, and telescopes for distance vision.9 in the study conducted by hinds et al.10 in england, it was concluded that there were improvements on life quality among patients after they had been given corrective devices for near vision, allowing them to read books, newspapers, price tags, and tickets easily. therefore, it was interested in revealing the visual acuity for near vision which could provide improvements and corrections when several optical devices such as magnifiers were given to the patients with low vision at cicendo eye hospital. methods this descriptive cross-sectional study was this research used medical records of patients with low vision at the national eye center, cicendo eye hospital, for the period of august 2010– september 2011 as the subject of research, which fulfilled both inclusion and exclusion criteria. the inclusion criteria were medical records of patients with low vision with visual acuity of 6/18 to light perception at refraction, low vision, contact lens clinic, national eye center, cicendo eye hospital, whereas the exclusion criteria were incomplete medical records. this research used the retrospectivedescriptive method, using medical records from cicendo eye hospital. the collected data included patients’ identifications (name, age, and sex), visual acuity, and corrective devices given. the descriptive method was used, displayed and presented in frequency distribution tables and graphics. results it can be inferred that the overall number of patients treated for a year at refraction, low vision, and contact lenses clinic was 475 patients, with 212 male patients (44.63%) and 263 female patients (55.37%) (table 1). most of the patients with low vision for a year were under the age of 11–20 years old (24.21%). the lowest number was under the aged of above 80 years old (0.63%). the patients with low vision who were given a device for near vision were 81 patients or 17.05 %, whereas those who were not given such devices were 394 patients or 82.95% (figure 1). patients with low vision having table 1 demographic data distribution of patients with low vision, based on sex sex frequency percentage male 212 44.63% female 263 55.37% muhammadnur rachim enoch, ine renata musa, titing nurhayati: improvement of near vision for low vision patients in national eye healthcare center cicendo eye hospital 2010–2011 althea medical journal. 2014;1(2) 96 amj december, 2014 improvements after given low vision device were 66 patients (81.48%), whereas patients with no improvements whatsoever were 15 patients (18.52%) (figure 2). the highest percentage of patients who have improvement after given low vision device was under the category of severe visual impairment (100%) and followed by the category of moderate visual impairment which have improvement about 92.30% (figure 3). from 41 patients with low vision who were given spectacles, only 31 patients (70.60%) gained improvements, whereas other 10 patients (24.40%) did not. out of 40 patients with low vision who were given table 2 frequency distribution of patients with low vision, based on age age (years old) frequency percentage 0–10 70 14.74% 11–20 115 24.21% 21–30 94 19.79% 31–40 77 16.21% 41–50 44 9.26% 51–60 35 7.37% 61–70 20 4.21% 71–80 17 3.58% > 80 3 0.63% stand magnifiers, only 35 (87.50%) gained improvements whereas the other five patients (12.50%) did not (figure 4). discussion in this research, it was revealed that the total number of patients with low vision treated during the period of august 2010–september 2011 was 475 patients, 212 patients were male whereas 263 were female. this is in accordance with previous studies conducted by the who , stating that women had more risks than men. it was also revealed that the majority of patients with low vision were under the category of 11–20 years old, with 115 patients. however, this is not in line with a study conducted by the who , which stated that the number of patients with low vision were the same at all categories of age. this is probably caused by several possibilities: patients with low vision who came to the polyclinic at cicendo eye hospital were referred patients, thus this result could not entirely describe the distribution of the number of patients to all categories of age. out of 475 patients with low vision, 81 patients were given low vision device for near vision, whereas the other 364 patients were not given since they had lower visual acuity measured by hand movement to no light perceptions. from out of the 81 patients given low vision device, only 66 patients or 81.48% gained improvements, which is in accordance with the study conducted by tom h. margrain figure 1 frequency low vision patients given corrective device althea medical journal. 2014;1(2) 97 that only 23% of patients with low vision could read 1 m-sized writings. after they were given a low vision device, 88% of these patients could read those writings.11 the visual acuity level that gained the most improvement percentage was under the category of severe visual impairment: 100%. this was due to the fact that the number of patients under that category was the least if compared to those in other categories. furthermore, the visual acuity of patients under the category of severe visual impairment was better than that of those under the category of profound visual impairment and near-total vision loss, thus the improvement percentage was better. in this research,the low vision device s used were magnifiers in the form of spectacles, and stand magnifiers . these devices were considered the best among others since they had been proven to improve visual acuity for near vision. this was in accordance with a study conducted in england, which stated that 9 out of 10 patients gained improvements in reading after they had been given such low vision device.11 figure 2 frequency based on corrective treatment results after corrective device for near vision were given figure 3 frequency of corrective improvements on patients with low vision, based on improvement results muhammadnur rachim enoch, ine renata musa, titing nurhayati: improvement of near vision for low vision patients in national eye healthcare center cicendo eye hospital 2010–2011 althea medical journal. 2014;1(2) 98 amj december, 2014 in this research, it was mentioned that one of such devices that had the biggest percentage was the stand magnifier, since stand magnifiers have higher dioptric values than spectacles do. stand magnifiers have dioptric values from +16d to +36d, whereas spectacles only have dioptric values from +3d to +20d. furthermore, using spectacles can pose difficulties in maintaining focal length. unlike spectacles, stand magnifiers have length-holders which allow us to maintain focal length, and users can read in a much better way. another kind of low vision device is the hand magnifier , which was not used in this research due to its dioptric values rather similar to those in spectacles. hand magnifiers also pose similar difficulties in maintaining focal length as spectacles do. using such devices would be less practical since users should also use their hands to hold the device . it can be concluded from this research that visual acuity for 1−10m will gain improvement after patients are given visual−aiding devices for near vision. the highest improvement percentage is the one under the category of severe visual impairment. it is suggested that further research should give attention to other factors causing low vision for improvements of near or far vision, improvement factors, as well as the patient’s reading quality. references 1. who. visual impairment and blindness. 2011[cited 8 april 2012]; available at: http://www.who.int/mediacentre/ factsheets/fs282/en/. 2. american academy of ophthalmology. optics of human eye. clinical optics, 4th ed. san fransisco: aao; 2009, p.105-115 3. congdon n ocb, klaver cc, klein r, muñoz b, friedman ds, kempen j, taylor hr, mitchell p causes and prevalence of visual impairment among adults in the united states. uk pubmed central. 2004. 4. hosni i. konsepdasar low vision; pelatihan guru low vision se jawa barat; 24 juli 2007; bandung. jawa barat: unit pelaksanateknisbalaipelatihan guru sekolahluarbiasadinaspendidikanjawa barat; 2007. 5. miller km. clinical optics. 3th ed. san fransisco: america academy of ophthalmology; 2007, p.243–67 6. fletcher dc. low vision rehabilitation. ophthalmology monographs. san fransisco; america academy of ophthalmology; 1999, p.1–133 7. kageyama jy, chun mw. video-based low vision devices. duane’s , clinical ophthalmology. chicago; j. b. lippincott ; 2004, p.1–8 8. khurana ak. community ophthalology. comprehensive ophthalmology, 4th edition. rohtak; ahnsan pub; 2008, p.443–4 9. faye ee. duane’s clinical ophtamology. michigan: little, brown; 2004. p. 1–46 10. hinds a, sinclair a, park j, suttie a, paterson h, macdonald m. impact of an interdisciplinary low vision service on the figure 4 frequency of low vision device for patients with low vision, based on improvement results althea medical journal. 2014;1(2) 99 quality of life of low vision patients. br j ophthalmol. 2003 nov;87(11):1391–6 11. margrain th. helping blind and partially sighted people to read: the effectiveness of low vision aids. br jophthalmol. 2000 aug;84(8):91–121 muhammadnur rachim enoch, ine renata musa, titing nurhayati: improvement of near vision for low vision patients in national eye healthcare center cicendo eye hospital 2010–2011 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 1 femur fracture patient characteristics in dr. hasan sadikin general hospital bandung indonesia january–december 2011 mohamad firdaus1, nucki nursjamsi hidajat2, nani murniati3 1faculty of medicine, universitas padjadjaran, 2department of orthopaedics and traumatology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, 3department of anatomy, faculty of medicine, universitas padjadjaran abstract background: femur fracture is one of the most common orthopedic cases which may occur in all age groups. its incidence can be characterized by several aspects, such as patient’s age, sex, causes, location and many more. the aim of this study was to understand the characteristics of femur fracture patients in dr. hasan sadikin general hospital bandung indonesia during the period of january to december 2011 methods: a descriptive study was conducted using 89 medical records of femur fracture patients in the department of orthopedic and traumatology dr. hasan sadikin general hospital bandung from january to december 2011. the inclusion criteria of the study were medical records containing patient aged 2059 years data who were diagnosed with femur fracture, sex, cause of fracture, type of fracture, location of fracture, type of treatments given, and the length of hospitalization. data were analyzed using frequency distribution. results: of 60 cases of motor vehicle accidents, there were more male (77.53%) than female who suffered from fracture. closed fracture was more common with 52 cases of closed fracture compared to 29 cases of proximal fracture. of 35 patients accepted treatment, 30 patients were treated by surgery and hospitalized for 21–30 days. conclusion: young male adults are the most common group suffering from femur fracture. a continuous epidemiology study must be carried out on annual basis so that a better view of the incidence and the location of femur fracture as well as the type of treatment given to patients can be observed. keywords: adults, characteristics, femur fracture correspondence: mohamad firdaus bin barakath, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 817 020 9335 email: firdose_89@yahoo.com.my introduction femur fracture is one of the most common orthopedic cases. according to a report in sweden, the prevalence was 10 cases of 100,000 people every year.1 in dr. hasan sadikin general hospital bandung, there was about 20.84% femur fractures from total fracture cases (173 from 830 cases).2 there are many factors contributed to the incidence of femur fracture, such as: age, sex, body weight and height, previous history of any fracture, drug usage, trauma, weakness and bone malformation related to malnourished, chronic deseases, osteoporosis and others.3 the older the females, the more decrease their bone strength especially after menopause because of the reduction of hormones such as growth hormone, estrogen,and progesterone. as a result, the absorption of calcium and vitamin d will be disturbed.4 formation of weaker bone also increases the incidence of fracture. the most common causes of fracture due to trauma are \motor vehicle accidents, fall and repetitive stress on certain part of the leg.3 the location of femur fracture can vary from head fracture, neck fracture, shaft fracture to the fracture of distal part of the bone. there two types of fracture: open and closed fracture. treatment of femur fracture can be operative or non–operative depends on the type and the severity of the fracture.3 the objective of the study is to describe the characteristics of femur fracture patients in dr. hasan sadikin general hospital bandung from january to december 2011. althea medical journal. 2015;2(1) 2 amj march, 2015 table 1 total cases of femur fracture age (years) sex total cases male female number % number % 20–29 29 32.59 6 6.74 35 30–39 15 16.85 7 7.87 22 40–49 11 12.36 5 5.62 16 50–59 14 15.73 2 2.24 16 total 69 77.53 20 22.47 89 methods a descriptive study was conducted using 103 medical records of femur fracture patients in the department of orthopedics and traumatology dr. hasan sadikin general hospital bandung from january to december 2011. of 103 medical records, 89 medical records were eligible and 14 medical records reported to be lost. the inclusion criteria of the study were medical records that contained data of patient aged 20–59 years who were diagnosed with femur fracture, sex, cause of fracture, type of fracture, location of fracture, type of treatments given, and the length of hospitalization. data were analyzed using frequency distribution. ethical clearence was given by the health research ethic committee dr. hasan sadikin general hospital. results the total number of femur fracture recorded in dr. hasan sadikin general hospital bandung was 103 cases. fourteen medical records of 103 cases could not be found, thus were excluded from this study. only 35 cases were agreed to be treated for their fracture. the patients were treated by either operative or non–operative methods. forty seven patients out of a total of 89 patients refused to be treated because the patients could not pay the treatment and seek for other alternative treatments. they were scared to be operated. one patient was shifted to other hospital or 6 patients were died before the treatments were carried out. according to table 1, the majority of the patients were male aged between 20–29 years. most of the cause of fracture was accidents involving motorcycles. closed and proximal fracture were the common type and the location of femur fracture (table 2). three of four patients in non-operative group had lenght of hospitalized between 1–10 days, while most of patients in nonoperative group (38.24%) had 21–30 days. thirty patients received either internal fixation or external fixation for operative treatments. most of patients were treated by adjoining the fractured bone by fixing plate and screws to hold the plate, on the bone. non–operative treatments include closed reduction and casting of the affected limbs. discussion based on the characteristics of age for patients diagnosed with femur fracture, most of the patients are male young adult. this finding is in line with a research done in saudi arabia5 that stated male aged between 20–29 years old is the most frequent cases found. from the most common cause leading to fracture, this study found that motor vehicle accidents were more than half of the total incidence of femur fracture. examples of motorvehicle accidents involve motorcycles, cars, buses or trucks. since more males are involved in handling and driving vehicles, more males affected fractures than females. the most common type of fracture reported was closed fracture, over 50% of 52 cases. closed fracture is the most common fracture because the femur bone itself is a strong bone and also covered by strong thick layers of muscle around the thigh region. therefore, it will need a very strong trauma for the bone to break its continuity and pierce out of the thigh muscles. moreover, most of the reported open fracture happens at the distal region, where the muscle layers are thinner and will be easier for the bone fragments to pierce out of the skin.7 althea medical journal. 2015;2(1) 3 from these result, the most frequent fracture location on femur is the proximal part. the neck of femur, which connects the head and the body of femur, is the weakest connection on femur, thus making it is prone to fracture injuries with even the slightest trauma.7 of 35 patients received treatment, 30 patients had operative procedure. this will shorten the healing period and reduces the possibility of having any complications.8 as for the length of stay in hospital, the mode length of those who undergoes surgery is around 21–30 days. a study done in england9 also shows that the median length of stay is around 23 days for proximal femur fracture repair. another study in peterborough district hospital10 shows that the length of stay is around 21.6 days. this is necessary to check for the presence of any complication after the surgery. the length of hospitalization also depends on the severity of the injury. those who were suffering with multiple fractures in other location of body usually will be admitted for a longer period, as we can see that there were 5 patients who were treated for more than 31 days, mainly caused by the seriousness of the injury they suffered from. as for non-operative treatment, patients can be discharged once they are treated, as long as there is no complication following the treatment. as for non-operative patients, the lenght of hospitalization is shorter as 3 out of 4 patients were discharged within the first 10 days of admission. the 4 non–operative table 2 causes, type and location of femur fracture femur fracture number of cases percentage (%) causes of fracture motorvehicle accident 60 67.42 fall 1 1.12 explosion 1 1.12 unspecified 27 30.34 type of fracture open 19 21.35 closed 52 58.43 unspecified 18 20.22 location of femur fracture proximal 29 32.58 shaft 25 28.09 distal 22 24.72 unspecified 13 14.61 table 3 type of treatments and the length of stay for those with complete medical records length of stay (days) operative non–operative total n % n % 1–10 4 11.76 3 8.82 7 11–20 8 23.53 0 0 8 21–30 13 38.24 1 2.94 14 > 31 5 14.71 0 0 5 total 30 88.24 4 11.76 34* note: * this data is excluding one medical record where the treatment and length of hospitalization was not mentioned in the medical records. mohamad firdaus, nucki nursjamsi hidajat, nani murniati: femur fracture patient characteristics in dr. hasan sadikin general hospital bandung indonesia january–december 2011 althea medical journal. 2015;2(1) 4 amj march, 2015 treatments, 3 were done on patients with closed fracture. from the 3 patients, 2 patients were discharged within the first 10 days of admission. this is usually because of the noncomplicated closed fracture and its chances for contamination are lower if compared to open wound that is usually present with open fractures. however, the choice of treatment according to the guidelines is through surgery, open reduction internal fixation, also known as orif. this method usually reduces chances of complication such as mal–union and non– union as the bone will be placed in a proper anatomical alignment and be held by plate and screws placed on the bone.3 there were few factors that lead to the limitation of this research. several medical records that fullfil the inclusion criteria could not be found during this study. moreover, incompleteness of medical records also cause a unspecified classification of the characteristic this study recommends that a continuous epidemiology study must be carried out on yearly basis so that a better view of the incidence and location of femur fracture and the type of treatment given to patients can be seen. through this way, a prevention method can be developed, such as educating the public about the main cause leading to incidence of femur fracture and socialization of save driving among young adults references 1. weiss rj, montgomery sm, al dabbagh z, jansson ka. national data of 6409 swedish inpatients with femoral shaft fractures: stable incidence between 1998 and 2004. injury. 2009;40(3):304–8. 2. febriya r. pola kasus fraktur di ugd perjan rs dr. hasan sadikin periode januari– desember 2007 [minor thesis]. bandung; universitas padjadjaran; 2007 3. solomon l, warwick d, nayagam s. apley’s system of orthopaedics and fractures. 8th ed. london: hodder arnold; 2010. p. 539– 80,684–704. 4. harris st, jaffe rb, shoback d. menopause and bone loss. j clin endocrinol metab. 2006;91(3):0–0 5. khan zu, al–asiri ka, iqbal j. injury patterns from road traffic accidents. pak j med sci; 2010;26(2):394–7. 6. gardner m, steinberg l. peer influence on risk taking, risk preference, and risky decision making in adolescence and adulthood: an experimental study. dev psychol. 2005;41(4):625–35. 7. moore kl, dalley af, agur amr. clinically oriented anatomy. 6th ed. philadelphia, the usa: lippincott williams & wilkins; 2009. p. 516–20, 545–58, 569–81 8. handoll hh, parker mj. conservative versus operative treatment for hip fractures in adults. cochrane database syst rev. 2008 ;(3):cd000337. 9. griffiths r, alper j, beckingsale a, goldhill d, heyburn g, et al. management of proximal femoral fractures 2011. anaesthesia. 2012;67(1):85–98. 10. siegmeth aw, gurusamy k, parker mj. delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. j bone joint surg br. 2005;87(8): 1123–6. amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 30 glasgow outcome scale assessment in patients with cerebral toxoplasmosis brigitta berlianty,1 sofiati dian,2 ahmad rizal ganiem2 1faculty of medicine universitas padjadjaran, indonesia, 2department of neurology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: brigitta berlianty, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, west javaindonesia, e-mail: brigittaberlian@gmail.com introduction toxoplasmosis is an infection caused by toxoplasma gondii (t. gondii).1 this parasite has infected 30–50% of the human population in the world.2,3 cerebral toxoplasmosis is an infection of t. gondii that affects the brain with high mortality and morbidity rates, especially in low-to middle-income countries and tropical regions, including indonesia.4,5 cerebral toxoplasmosis is an opportunistic infection that is often found in people living with human immunodeficiency virus/acquired immune deficiency syndrome (hiv/aids) known as plwha.6–8 as many as 30–70% of plwha infected with t. gondii have central nervous system disorders.9,10 assessment of functional outcomes in cerebral toxoplasmosis patients is needed as an evaluation tool regarding management. to assess the success of a patient’s treatment, it should not only be assessed whether the patient is still alive or dead, but there is a need for a measuring instrument that can better explain the condition of nerve function when the patient survives. one of the measuring instruments proposed is the glasgow outcome scale (gos). the gos is a scale originally used to assess the outcome of brain injury.11 recently, it is widely used to describe another neurological dysfunction. the gos has a scale of five category ranging from gos 1 whether patients has died to gos 5 whether patients recover with good neurological function.12–14 there have been no studies related to functional outcomes assessment in cerebral toxoplasmosis patients using gos in indonesia. this study aimed to explore the althea medical journal. 2022;9(1):30–36 abstract background: cerebral toxoplasmosis is a toxoplasma gondii infection affecting the brain. assessment of the functional outcome after treatment is needed as an evaluation for therapeutic management. one of the instruments used is the glasgow outcome scale (gos). this study aimed to assess the functional outcome of cerebral toxoplasmosis patients using gos. methods: a cross-sectional descriptive study with total sampling method was conducted. medical records were retrieved from patients with cerebral toxoplasmosis registered at the department of neurology, dr. hasan sadikin general hospital, bandung during year 2017–2019. inclusion criteria were patients with cerebral toxoplasmosis aged >18 years and had a positive hiv serological test. the gos was assessed and presented in frequency, using microsoft excel and spss software ver. 25.0. results: of 87 patients, 68% had somnolent on admission to the hospital, 51% had hemiparesis/ hemiplegia, and 76% had gos 3, indicating severe disability. almost one third (28%) of patients died during hospitalization with non-neurological complications as the most common cause of death (63%). on discharge from the hospital, 82% of the survivors were fully alert, 40% had hemiparesis/ hemiplegia, and 33% had gos 4 (mild disability). conclusions: most of the cerebral toxoplasmosis patients come to the hospital with severe disability. during the treatment, one third of patients died, and those who survived had mild disability. gos has improved after hospitalization, suggesting that gos is useful for assessment of therapeutic management. keywords: cerebral toxoplasmosis, glasgow outcome scale, opportunistic infection, toxoplasma gondii https://doi.org/10.15850/amj.v9n1.2290 althea medical journal. 2022;9(1) 31 functional outcome of patients with cerebral toxoplasmosis as assessed by gos. methods the study was conducted using a crosssectional descriptive method and a retrospective approach to cerebral toxoplasmosis patients at dr. hasan sadikin general hospital, bandung from 2017 to 2019. secondary data were obtained by total sampling through medical records at the department of neurology, dr. hasan sadikin general hospital bandung, collected from august to november 2020. the inclusion criteria in this study were patients with a diagnosis of cerebral toxoplasmosis aged >18 years and had a positive hiv serological test results. exclusion criteria were patients who went home at their brigitta berlianty et al.: glasgow outcome scale assessment in patients with cerebral toxoplasmosis table 1 characteristics of patients with cerebral toxoplasmosis from dr. hasan sadikin general hospital, year 2017–2019 characteristics n (%) demography age in years–median (iqr) 34 (26–41)a gender male female 66 (76) 21 (24) chief complaint decreased consciousness headache seizures motoric disorders visual disorders speech disorders 57 (65) 12 (14) 11 (13) 5 (6) 1 (1) 1 (1) supporting examination ct scan* mass or lesion no mass or lesion 84 (98) 2 (2) igg anti toxoplasma an examination was carried out no examination statement cd4** –median (iqr) 69 (79) 18 (21) 20.5 (9–56)a comorbidities yes no 45 (52) 42 (48) treatment drug administration pyrimethamine pyrimethamine + clindamycin high dose cotrimoxazole 3 (3) 58 (67) 26 (30) length of alive patient care –median (iqr) the patient died in treatment length of patient stay until death –median (iqr) 15 (12–19)a 24 (27.6) 4 (3–7.75)a cause of death neurological non-neurological unknown 7 (29.2) 15 (62.5) 2 (8.3) notes: all data were presented as n (%) unless stated otherwise was median (iqr)a, * ct scan results were only available for 86 data, **cd4 examination results were only available for 64 data althea medical journal. 2022;9(1) 32 request thus they did not undergo complete treatment. this research received approval from the research ethics committee of universitas padjadjaran no. 636/un6.kep/ ec/2020 as well as a research permit by the research and development committee and ethics committee of dr. hasan sadikin general hospital, bandung. data collected from the patient’s medical records were analyzed and processed using microsoft excel and spss. the data included in this study were age, gender, chief complaints, level of consciousness, motoric skills, comorbidities, drug administration, length of treatment, and results of supporting examinations such as ct scan, igg anti-toxoplasma, cd4 count. when the patients died, the cause of death was recorded. the diagnostic criteria for cerebral toxoplasmosis used were based on igg anti toxoplasma examination and/or ct scan. patient consciousness was determined based on clinical conditions, categorized into compos mentis, somnolence, sopor, and coma. assessment of the gos in determining the functional outcome of the patients was difficult to assess using retrospective data, however, the gos assessment in this study was performed by considering the condition of consciousness, language disorders, and the motoric skills of the patients, and was defined as followed: gos 1 was death, gos 2 was coma, gos 3 was sopor/somnolence or motoric strength 0-3 or language disorder, gos 4 was compos mentis with motoric strength 4, and gos 5 was compos mentis with motoric strength 5 or got mild neurological sequelae. furthermore, gos 2 and 3 were categorized as bad outcomes while 4 and 5 as good outcomes.12–14 the causes of the death were categorized into neurological, non-neurological, and unknown causes. neurological causes were designated as the abnormalities in the central nervous system, for example due to herniation and hydrocephalus; whereas non-neurological causes included respiratory failure, septic shock, and sudden cardiac arrest. other causes were designated as unknown causes. results in total, 96 data from patients diagnosed with cerebral toxoplasmosis were retrieved. however, those with negative hiv serology results (n=1) and those who returned home at their request (n=8) were excluded from the study. thus, 87 patient data were included. the mean age of the patients was 34 years (interquartile range 26–41 years) with male was predominantly prevalent (76%) and most of them came with a chief complaint of decreased consciousness (65%) as shown in table 1. the ct scan results showed that the mass or lesions was mostly in the brain (98%). interestingly, patients who had no brain mass or lesions (n=69; 79%) had reactive antitoxoplasma igg results. the mean cd4 count was 20.5 cells/mm3 (interquartile range 9–54.7). most of the patients had more than one disease that was occurred simultaneously, with the majority were pulmonary infections and severe metabolic disorders (52%). most althea medical journal march 2022 table 2 level of consciousness and motoric conditions characteristics admission (n=87) discharge (n=63) n (%) n (%) level of consciousness compos mentis somnolence sopor coma 21 (24) 59 (68) 7 (8) 52 (82) 10 (16) 1 (2) language disorders yes no difficult to assess 25 (29) 62 (71) 38 (60) 25 (40) motoric disorders none hemiparesis/hemiplegia tetraparesis/tetraplegia can-not be assessed 9 (10) 44 (51) 32 (37) 29 (2) 23 (36) 25 (40) 14 (22) 1 (2) althea medical journal. 2022;9(1) 33brigitta berlianty et al.: glasgow outcome scale assessment in patients with cerebral toxoplasmosis of the treatments had used pyrimethamine and clindamycin (67%). during the treatment, 24 patients (28%) died. the mean length of stay for patients who survived was 15 days (interquartile range 12–19), whereas the length of stay for patients who died was 4 days (interquartile range 3–7.7). the most common causes of death were non-neurological causes (63%), namely respiratory failure, septic shock, and sudden cardiac arrest. of neurological causes (n=7; 29%) 6 had herniations and 1 had hydrocephalus. the level of consciousness and motoric skills of patients during admission and discharge showed that most of the patients had a high level of somnolence (68%) and had hemiparesis/hemiplegia (51%) as depicted in table 2. at the time of discharge, most of them had a level of consciousness of compos mentis (82%), however, motoric conditions hemiparesis/hemiplegia were still about 40%. at the time of admission to the hospital, the patients were mostly in gos 3 (76%), while at the time of discharge 28% were on gos 1 or had died or had better conditions in gos 4 (33%) and gos 5 (25%). of the 66 patients who were initially on gos 3 on the admission, 24 patients died, however, 10 patients improved to gos 5, 21 patients to gos 4, while the rest remained on gos 3. discussions opportunistic infections involving central nervous system in hiv-positive patients at dr. hasan sadikin general hospital bandung in 2017–2019 has shown that 58% are caused by t. gondii infection. based on the results of the study, 72% of patients survived while 28% died. patients who survived had a good outcome. the majority of patients with cerebral toxoplasmosis (68%) experienced somnolent during hospital admission, had hemiparesis/ hemiplegia (51%), and had gos 3 or severe disability (76%). almost one third (28%) died during hospitalization with non-neurological complications as the most common cause of death (63%). on discharge from the hospital, 82% of the survivors were fully alert, 40% still had hemiparesis/hemiplegia, and 33% had gos 4 or mild disability. previous study has shown that the prevalence of toxoplasmosis in indonesia was 44%, and 19% of patients with cerebral toxoplasmosis died.15–16 assessment of functional outcomes using gos is carried out when the patients have been admitted to the hospital and then discharged by considering the level of consciousness, language disorders, and motoric disorders. in our study, the level of consciousness shows an improvement, for example the somnolence state (68%) became compos mentis (82%). this is similar to other study, showing that the level of consciousness of cerebral toxoplasmosis patients at admission has a mean glasgow coma scale of 13 or somnolence.17 language disorders are difficult to assess (71.3%) when the patients are admitted to the hospital, because the patients come in a somnolence and sopor state; whereas table 3 glasgow outcome scale scale admission (n=87) discharge (n=87) n (%) n (%) 1 : death 2 : persistent vegetative 3 : severe disability 4 : moderate disability 5 : good recovery 66 (76) 15 (17) 6 (7) 24 (28) 12 (14) 29 (33) 22 (25) table 4 distribution of the glasgow outcome scale admission (n) discharge (n) gos 5 (n=22) gos 4 (n=29) gos 3 (n=12) gos 2 (n=0) gos 1 (n=24) gos 5 (6) gos 4 (15) gos 3 (66) 6 6 10 8 21 1 11 24 althea medical journal. 2022;9(1) 34 on discharged from the hospital the patients reported no language disorder. moreover, the percentage of motoric condition of the patients who are in hemiparesis/hemiplegia condition on admission decreased on discharge. the most prevalent gos at admission is gos 3 (76%), which is categorized as a bad outcome, indicating that many patients have severe disability.13 after treatment, most patients have gos 4 which is a mild disability or gos 5 which is in good recovery,13 similar to study showing that cerebral toxoplasmosis patients who survive would have a good functional outcome.16 the level of consciousness has a relationship with the patient’s functional outcome because it can describe the condition of the disease and damage of the brain.18,19 in this study, the majority of patients presented with somnolence condition and have a good outcome after treatment, conform the study showing that patients with coma and sopor would have poor outcomes of gos, whereas somnolence and compos mentis have good outcomes.20 the demographic characteristics of cerebral toxoplasmosis patients have a mean age of 34 years and the majority are male (76%), and this is in accordance with several other studies.21,22 cerebral toxoplasmosis is a disease that causes clinical manifestations related to central nervous system disorders.4,23 a decrease in consciousness is the most common complaint.16 the ct scan results showed that the majority of patients have mass or lesions in the brain. moreover, anti-toxoplasma igg has reactive results, and cd4 cells are low. the ct scan results may show several lesions, hypodensity, ring-shaped, accompanied by edema around the lesion in the basal ganglia and corticomedullary junction.24,25 in general, anti-toxoplasma igg patients have positive/ reactive results and low cd4 count.26 cd4 has an important role in suppressing the activation of t. gondii. more than 95% of cerebral toxoplasmosis is an activation of latent infection, especially in patients with cd4 levels <100 cells/mm3.17,27 treatment also determines the patient’s functional outcome. in our study, patients have been given a combination treatment of pyrimethamine and clindamycin. however, other combination of treatment may exist such as a combination of pyrimethamine and sulfadiazine, or a combination of pyrimethamine, clindamycin, and 1% cotrimoxazole.16,28 patients receiving pyrimethamine and sulfadiazine as first-line treatment have a better treatment success rates.26,29 patients who are intolerant or allergic to sulfadiazine can be given clindamycin. although it is known that the combination treatment of pyrimethamine and clindamycin has a lower effectiveness than the combination of pyrimethamine and sulfadiazine.16 this combination is given because of the lack of sulfadiazine preparations in indonesia. the length of stay for surviving patients has a mean value of 15 days (interquartile range 12–19), and clinical improvement has been observed after 10 days of successful treatment.17 in more severe levels, the duration of treatment may be longer.16 previous study has shown that the average of length of stay for living patients was 16.9 days in hospital and the median for patients who died was 15 days (interquartile range 3–61).30 interestingly, the cause of death is not caused by neurological disorders and about 10% is not known for certain. however, the cause of death may be due to neurological disorders in other areas.16 the difference is because most patients have other comorbidities such as pulmonary infections and severe metabolic disorders. the limitation of this study is that the relationship between the level of patient improvement and the treatment carried out has not been explored further, therefore further study is needed. to conclude, most of the patients with cerebral toxoplasmosis come to the hospital with severe disabilities. during the treatment, 27.6% patients died, and patients who are survived have mild disability. the glasgow outcome score improved after hospitalization, suggesting that gos can be used for reliable assessment. references 1. barman b, tiewsoh i, lynrah k, wankhar b, issar n. cerebral toxoplasmosis with fever and erythematous macular rash: an initial presentation in an advanced hiv infection. trop parasitol. 2018;8(1):41–4. 2. lee j, ryu js. current status of parasite infections in indonesia: a literature review. korean j parasitol. 2019;57(4):329–39. 3. tuda j, adiani s, ichikawa-seki m, umeda k, nishikawa y. seroprevalence of toxoplasma gondii in humans and pigs in north sulawesi, indonesia. parasitol int. 2017;66(5):615–8. 4. vidal je. hiv-related cerebral althea medical journal march 2022 althea medical journal. 2022;9(1) 35brigitta berlianty et al.: glasgow outcome scale assessment in patients with cerebral toxoplasmosis toxoplasmosis revisited: current concepts and controversies of an old disease. j int assoc provid aids care. 2019;18:2325958219867315. 5. de oliveira gb, da silva mal, wanderley lb, da cunha correia c, ferreira ecb, de medeiros zm, et al. cerebral toxoplasmosis in patients with acquired immune deficiency syndrome in the neurological emergency department of a tertiary hospital. clin neurol neurosurg. 2016;150:23–6. 6. pustorino g, ferlazzo e, carpentieri ms, cianci v, gasparini s, campello m, et al. cerebral toxoplasmosis diagnosed by brain tissue pcr analysis in an immunocompetent patient. neurol clin pract. 2017;7(5):436–8. 7. flegr j, prandota j, sovičková m, israili zh. toxoplasmosis-a global threat. correlation of latent toxoplasmosis with specific disease burden in a set of 88 countries. plos one. 2014;9(3):e90203. 8. elsheikha hm, marra cm, zhu xq. epidemiology, pathophysiology, diagnosis, and management of cerebral toxoplasmosis. clin microbiol rev. 2020;34(1):e00115–9. 9. yostila d, armen a. toxoplasmosis cerebri pada hiv aids. jurnal kesehatan andalas. 2018;7(supplement 4):96–9. 10. schlüter d, barragan a. advances and challenges in understanding cerebral toxoplasmosis. front immunol. 2019;10:242. 11. wilson l, boase k, nelson ld, temkin nr, giacino jt, markowitz aj, et al. a manual for the glasgow outcome scaleextended interview. j neurotrauma. 2021;38(17):2435–46. 12. weir j, steyerberg ew, butcher i, lu j, lingsma hf, mchugh gs, et al. does the extended glasgow outcome scale add value to the conventional glasgow outcome scale? j neurotrauma. 2012;29(1):53–8. 13. mcmillan t, wilson l, ponsford j, levin h, teasdale g, bond m. the glasgow outcome scale-40 years of application and refinement. nat rev neurol. 2016;12(8):477–85. 14. fuller gw, hernandez m, pallot d, lecky f, stevenson m, gabbe b. health state preference weights for the glasgow outcome scale following traumatic brain injury : a systematic review and mapping study. value health. 2016;20(1):141–51. 15. wang zd, wang sc, liu hh, ma hy, li zy, wei f, et al. prevalence and burden of toxoplasma gondii infection in hiv-infected people: a systematic review and metaanalysis. lancet hiv. 2017;4(4):e177–88. 16. sonneville r, schmidt m, messika j, hssain aa, da silva d, klein if, et al. neurologic outcomes and adjunctive steroids in hiv patients with severe cerebral toxoplasmosis. neurology. 2012;79(17):1762–6. 17. indrayani i. uji validitas kadar cd4 untuk diagnosis toksoplasmosis serebri pada penderita acquired immuno deficiency syndrome [thesis]. denpasar: universitas udayana; 2011. 18. kodliwadmath hb, koppad sn, desai m, badiger sp. correlation of glasgow outcome score to glasgow coma score assessed at admission. int surg j. 2016:3(4):1959–63. 19. indradmojo c, zaiyanah m, setijowati n, eddy mi. faktor-faktor yang mempengaruhi nilai glasgow outcome scale pada pasien trauma kepala (studi di igd rsud dr. iskak tulungagung). maj kesehat. 2020;7(3):183–90. 20. suwaryo paw, yuwono p. penggunaan glasgow outcome scale dalam penilaian kondisi pasien pasca cedera kepala. jurnal ilmiah kesehatan keperawatan. 2018;13(3):107–13. 21. hassana ds, hadisaputro s, sofro mau. toxoplasmosis and cerebral toxoplasmosis in hiv/aids patients in kariadi hospital, semarang. j epid kes kom. 2021:6(1):213– 7. 22. azovtseva ov, viktorova ea, bakulina eg, shelomov as, trofimova tn. cerebral toxoplasmosis in hiv-infected patients over 2015–2018 (a case study of russia). epidemiol infect. 2020;148:e142. 23. mendez oa, koshy aa. toxoplasma gondii: entry, association, and physiological influence on the central nervous system. plos pathog. 2017;13(7):e1006351. 24. wibawani r, soeprijanto b, ferriastuti w, triono ea. head computed tomography images of hiv/aids patients with suspected cerebral toxoplasmosis in dr. soetomo general hospital surabaya. biomolecular health sci j. 2019;02(01):21–6. 25. bondarenko av, katsapov dv, gavrylov av, didova tv, nahornyi ia. immunodiagnostics of cerebral toxoplasmosis depending on permeability of blood-brain barrier. wiad lek. 2020;73(2):285–8. 26. abbasi fard s, khajeh a, khosravi a, et al. fulminant and diffuse cerebral toxoplasmosis as the first manifestation of hiv infection: a case presentation and althea medical journal. 2022;9(1) 36 review of the literature. am j case rep. 2020;21:e919624. 27. ozaras r, karaismailoglu b, vatan a, hasiloglu z, sahin s, oz b. cerebral toxoplasmosis. qjm. 2016;109(7):491–2. 28. greenway mrf, sacco ka, burton mc. in deep: cerebral toxoplasmosis. am j med. 2017;130(7):802–4. 29. patel j, kuppachi s. aki in a patient with cerebral toxoplasmosis. kidney360. 2020;1(4):316–7. 30. opintan ja, awadzi bk, biney ijk,ganu v, doe r, kenu e, et al. high rates of cerebral toxoplasmosis in hiv patients presenting with meningitis in accra, ghana. trans r soc trop med hyg. 2017;111(10):464–71. althea medical journal march 2022 amj vol 7 no 3 september2.indd althea medical journal. 2020;7(3) 128 amj september 2020 response to chemotherapy in patients with gestational trophoblastic neoplasia in dr. hasan sadikin general hospital farisa raudina,1 yudi mulyana hidayat,2 sylvia rachmayati3 1faculty of medicine universitas padjadjaran, indonesia, 2department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr hasan sadikin general hospital bandung, indonesia, 2department of clinical pathology faculty of medicine universitas padjadjaran/dr hasan sadikin general hospital bandung, indonesia correspondence: farisa raudina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, e-mail: farisaraudina@rocketmail.com introduction gestational trophoblastic disease (gtd) is a group of diseases that originate from an abnormal proliferation of placental trophoblast cells, which occur after fertilization.1,2 gestational trophoblastic disease consists of partial and complete hydatidiform mole known as a benign tumor and malignant gestational trophoblastic neoplasia (gtn). based on the histopathological characteristics, gtn is categorized into invasive mole, choriocarcinoma, placental site trophoblastic tumor (pstt), and epithelioid trophoblastic tumor (ett).1 clinical diagnosis of gtn refers to the prognostic score and staging system of gtn.3 both of these are necessary to assess the prognosis, risk factors and stage of gtn to optimize therapy. a prognostic scores can be used to define the severity stages of gtn by using the risk factor of the gtn patient as an indicator. the prognostic score created by the international federation of gynecology and obstetrics (figo) is an improved scoring system that combines figo anatomical staging (stage i through iv) with the world health organization (who) prognostic scores (score 1 to 4 for each category).4,5 based on the figo prognostic score, gtn is classified amj. 2020;7(3):128–35 abstract background: the incidence of gestational trophoblastic neoplasia (gtn) is high in indonesia. based on the figo prognostic score, gtn is classified into low-risk and high-risk categories. the high-risk group requires multidrug chemotherapy whereas the low-risk group requires single-drug chemotherapy. response to chemotherapy would reflect the remission rate. the aim of this study was to describe the response to chemotherapy in gtn patients. methods: this was a cross-sectional descriptive retrospective study on medical records of patients with gtn treated in dr. hasan sadikin general hospital during the period of 2016 to 2018. the inclusion criteria were gtn patients who received >3 cycles of chemotherapy while the exclusion criteria were incomplete, inaccessible, or missing data. data were collected on patient’s age, parity, history of previous pregnancy, pregnancy-therapy interval, tumor size, number and location of metastases, and history of failed chemotherapy. results: of the189 medical records of the gtn patient collected, only 88 met the inclusion criteria, (63.6% low risk and 36.4% high risk). most patients were responsive to chemotherapy (61.4%), aged <40 years old, multiparity, tumor size >5 cm, had 4 month interval from previous pregnancy <4 months, had a history of molar pregnancy, had no metastases, and no previous failed chemotherapy. conclusions: the chemotherapy response in gestational trophoblastic neoplasm patients is fairly good with most patients are in the low-risk groups. specific tumor markers used in early diagnosis of gtn may play a major role. keywords: figo, prognostic score, gestational trophoblastic neoplasia, remission rate https://doi.org/10.15850/amj.v7n3.1894 althea medical journal. 2020;7(3) 129 into low-risk and high-risk categories. the low-risk category is defined by stages 1, 2 and 3 gtn and a figo score of <7, whereas the high-risk category is defined by stages 2, 3 and 4 gtn and a figo score of >7. low-risk gtn patients should receive methotrexate (mtx) or actinomycin-d as a single-agent chemotherapy regimen, while high-risk gtn patients should receive a multi-agent/ combination regimen consisting of etoposide, methotrexate, folinic acid, cyclophosphamide, and vincristine (ema-co) with a multi-agent/ combination regimen consisting of etoposide, methotrexate, folinic acid, cyclophosphamide, and vincristine (ema-co) with or without adjuvant therapy such as surgeryor radiation.6 epidemiological studies have showed that the incidence of gtn in asia is higher than in europe and north america.7 dr. hasan sadikin general hospital has reported yearly that there is 730 existing old cases. additionally, there are 5 new cases in 2018 and 23 new cases of gtn between 2017 and 2018.8 the gtn has a high mortality rate in the past, but currently, it is one of the malignancies with the lowest mortality rate due to high recovery rate.7 the increased recovery rate of gtn is caused by the discovery of specific tumor markers which aids the early diagnosis of hydatidiform mole and gtn. the tumor marker is human chorionic gonadotropin (hcg), a glycoprotein hormone produced by the placenta, and its varying levels provide useful clinical information on gtn diagnosis.1 the gestational trophoblastic disease produces β-hcg in a longer cycle than normal pregnancy.2 the success of the chemotherapy regimen given can be monitored by changes in β-hcg levels. aside from being a tumor marker, β-hcg is also used to determine the patient’s response to the chemotherapy regimen given during a specified cycle (usually 2-3 cycles).9 this response is determined by measuring serum β-hcg levels that are monitored after chemotherapy.10 the chemotherapy response to low-risk and high-risk gtndoes not always produce the same results. research providing data about the response of gtn chemotherapy and the characteristics of gtn patients in indonesia is scars. therefore, this study was conducted to describe the chemotherapy response and the characteristics of gtn patients in dr. hasan sadikin general hospital, that served as a referral hospital in west java. the result of this study was expected to assist clinicians in predicting the prognosis of gtn patients and to adjust the chemotherapy regiment. methods this research was a descriptive study with a retrospective cross-sectional study design. secondary data were obtained from patients’ medical records at dr. hasan sadikin general hospital during 2016–2018. data of patients diagnosed with gestational trophoblastic neoplasia were collected. inclusion criteria were patients who received three cycles of chemotherapy. the exclusion criteria in this study were medical recordsof patients with incomplete or less than 3 cycles of chemotherapy and medical records that were inaccessible or data missing. this study used total sampling as the sample collection method. the variables inquired in this study were the type of gtn based on the figo score (low-risk and high-risk). the data on demography and clinical characteristics i.e. age, parity, tumor period, previous pregnancy, metastatic location, number of metastases, history of failed chemotherapy were noted, including the chemotherapy response which was categorized as responsive, partial, and unresponsive. responsive chemotherapy response was defined by serum β-hcg levels of <5 miu/ml, the partial response when serum β-hcg levels decreased by 50% from baseline, and unresponsive when serum β-hcg levels remained at baseline or even increased. this study protocol was approved by the research ethics committee universitas padjadjaran with the number 764/un6. kep/ec/2019 as well as the research ethics committee of dr. hasan sadikin general hospital bandung no. 283/un6.kep/ec/201 8lb.02.01/x.2.2.1/11572/2019. after ethical approval was obtained, medical records were selected according to inclusion and exclusion criteria. data were then presented in tables and figures to infer a conclusion. results a total of 189 patients with diagnosis of gestational trophoblastic neoplasia (gtn) was collected of whom only 88 patients met the inclusion criteria. diagnosis and management of gtn were determined based on the figoprognostic score, whereas distinguishing specific types of gtn was designated through histopathological examination. the included patients were diagnosed based on the figo prognostic scores of whom 19 were diagnosed based on the results of histopathological examination. there were 56 (63.6%) patients were included in the low-risk category and farisa raudina et al.: response to chemotherapy in patients with gestational trophoblastic neoplasia in dr. hasan sadikin general hospital althea medical journal. 2020;7(3) 130 amj september 2020 32 (36.4%) patients were in the high-risk category. the characteristic of the patients was, however, not all listed on the medical record. fifty-six patients had complete characteristics, whereas the data of previous pregnancy history, pregnancy-therapy interval, and tumor size were incompletein 32 patients. the age of patients with gtn was mostly <40 years old, with the age group of 21 to 35 years old was table 1 clinical characteristics of patients with gestational trophoblastic neoplasia characteristics n % age < 40 years 57 64.8 > 40 years 31 35.2 parity primi 21 23.9 multi 57 64.8 grande 10 11.4 previous pregnancy history* mole 60 80.0 term birth 13 17.3 abortion 2 2.7 pregnancy-therapy interval * < 4 months 37 58.7 4–6 months 10 15.9 7–12 months 7 11.1 >12 months 9 14.3 tumor size* <3 cm 8 12.5 3–4 cm 14 21.9 >5 cm 42 65.6 metastasis location lung 17 19.3 kidney 1 1.1 gastrointestinal tract 1 1.1 liver/brain no metastasis 65 73.8 number of metastatic tumors 1–4 21 91.3 5–8 2 8.7 previous history of failed chemotherapy singledrug 4 4.5 multidrugs 2 2.3 none 82 93.2 note: *incomplete data althea medical journal. 2020;7(3) 131 the most prevalent (64.8%). the patients were mostly multiparous (64.8%) and had a history of molar pregnancy (80%) as shown in table 1. the majority had a pregnancy-therapy interval of <4 months (58.7%) with a tumor size of >5 cm (65.6%). most of them had no metastases (65 of 88). those with metastases had lung metastases (19.3%). most patients had no history of failed chemotherapy (93.2%). furthermore, of those gtn patients who received chemotherapy, 54 patients (61.4%) were responsive to chemotherapy, 32 patients (36.4%) had a partial response and 2 patients (2.3%) were unresponsive as depicted in table 2. most of the responsive patients (70.4%) were categorized as low-risk gtn. of those gtn patients who were responsive to chemotherapy were mostly aged <40 years (70.4%), were multiparous (64.9%), had a history of previous molar pregnancy (84.1%), had a pregnancy-therapy interval of<4 months (56.4%), had a tumor size of >5 cm (62.5%), had no metastases (75.6%) and had no history of failed chemotherapy (91.1%). the characteristic of gtn patients who were responsive to chemotherapy was shown in table 3. the percentage of chemotherapy responses was 50% in both the single drug regimen and multidrug regimen. the chemotherapy response among gtn patients based on the type of chemotherapy regimen was presented in table 4. discussion this study has recruited patients with gtn, diagnosed with figo prognostic score, of whom 63.6% has been categorized as a lowrisk gtn and 36.4% as a high-risk gtn. most low-risk gtn patients in this study have a figo score of 4. this result is consistent with previous study that has reported the majority of gtn patients are low-risk.11 gestational trophoblastic neoplasm is a malignant tumor that can be treated completely with chemotherapy, and surgery is only considered when indicated. moreover, surgery is not recommended in high-risk gtn patients who have high figo scores because of the risk of bleeding.12 the figo prognostic scores have been determined by the characteristics of gtn patients. by knowing the characteristics of patients, the risk level of gtn can be predicted earlier.3 in this study, most of the gtn patients are under the age of 40 years. this is consistent with the results of other studies that showed that gtn often appears at reproductive age.6,13 furthermore, our study shows that that most patients are multiparous, have a history of molar pregnancy, and havea pregnancytherapy interval of <4 months (table 1). patients with a history of molar pregnancy, multiparous, and have a pregnancy-therapy interval of <4 months have a higher risk to develop invasive moles.9 other types of gtn can arise from various types of pregnancy. choriocarcinoma occurs in 50% of molar pregnancies, 25% of abortions, and 25% of term births. the average choriocarcinoma has a pregnancy-therapy interval of >12 months.14,15 in placental site trophoblastic tumour (pstt) and epitheloid trophoblastic tumour (ett), the pregnancy-therapy interval of patients varies greatly from 6 months to 20 years.12 this study has also shown that most patients have a tumor size of >5 cm, metastasize in the lungs, have several metastatic tumors between 1 to 4, and have no history of failed chemotherapy. this is similar to research on the pathology of the gtn type which reports that patients with choriocarcinoma often experience metastasis, that occurs in the lungs (80%), in the vagina (30%)as well as in the brain and liver (10%).14 patients with gtn who have undergone history taking, physical examination, laboratory and supporting examinations table 2 chemotherapy response among patients with gestational trophoblastic neoplasia based on low-risk and high-risk category category chemotherapy response responsive partial unresponsive n % n % n % low-risk 38 70.4 16 50 2 100 high-risk 16 29.6 16 50 total 54 100 32 100 2 100 farisa raudina et al.: response to chemotherapy in patients with gestational trophoblastic neoplasia in dr. hasan sadikin general hospital althea medical journal. 2020;7(3) 132 amj september 2020 table 3 chemotherapy response among patients with gestational trophoblastic neoplasia based on clinical characteristics (1) characteristic chemotherapy response responsive partial unresponsive n % n % n % age < 40 years 38 70.4 18 56.2 1 50 > 40 years 16 29.6 14 43.7 1 50 total 54 100 32 100 2 100 chemotherapy response primi 12 22.2 8 25.0 1 50 multi 35 64.8 21 65.6 1 50 grande 7 13.0 3 9.4 total 54 100 32 100 2 100 previous pregnancy history* mola 37 84.1 21 72.4 2 100 abortus 7 15.9 6 20.7 aterm 2 6.9 total 44 100 29 100 2 100 pregnancy-therapy interval* <4 months 22 56.4 15 68.18 4–6 months 9 23.1 1 50 7–12 months 3 7.7 3 13.6 1 50 > 12 months 5 12.8 4 18.2 total 39 100 22 100 2 100 tumor size* <3 cm 5 12.5 3 13.6 3–4 cm 10 25.0 3 13.6 1 50 >5 cm 25 62.5 16 72.7 1 50 total 40 100 22 100 2 100 metastasis location lung 9 16.7 8 25.0 kidney 1 1.8 gastrointestinal tract 1 3.1 liver/brain nometastasis 41 75.9 22 68.7 2 100 total 54 100 32 100 2 100 althea medical journal. 2020;7(3) 133 such as increased β-hcg levels, and a history of resistant chemotherapy will then be assessed by figo prognostic scores to decide the treatment.3 β-hcg levels in patients are monitored every week until consecutively reaching a normal level for three times.2,7 if β-hcg levels are within normal limits, patients will be monitored every month for 12 months for low-risk patients and 18 months for highrisk patients. six months afterward, β-hcg levels are monitored once a year. monitoring is recommended for 5 years.12 this need to be performed to categorize the chemotherapy response of the given regimen. the responsiveness of chemotherapy has been shown that 61.4% of patients is responsive, 36.4% have partial chemotherapy responses, and 2.3% is unresponsive (table 2). furthermore, 38.6% have received chemotherapy for at least three cycles but have not recovered and did not continue treatment. in our study, the patients who are responsive for chemotherapy is from low-risk gtn (70.4%), whereas from high-risk gtn is accounted for 29.6%. interestingly, other studies have shown that low-risk gtn has a remission rate of 93–100%, of which the highrisk gtn has a remission rate of 86–94%.12 in contrast, other study shows that gtn remission rate is quite low, which is 75–100% for low-risk gtn and 67–88% for high-risk gtn.16 the result of this study has shown that the remission rate of gtn patients in dr. hasan sadikin general hospital is relatively lower compared to various studies from other countries, especially in high-risk gtn category patients. asian people are susceptible to an aggressive disease progression that may be caused by several biological factors and table 3 chemotherapy response among patients with gestational trophoblastic neoplasia based on clinical characteristics (2) characteristic chemotherapy response responsive partial unresponsive n % n % n % number of metastatic tumors 1–4 13 100 8 80 5–8 2 20 >8 total 13 100 10 100 previous history of failed chemotherapy singledrug 3 5.4 1 3.1 multidrug 2 3.6 none 51 91.1 31 96.9 2 100 total 56 100 32 100 2 100 table 4 chemotherapy response among patients with gestational trophoblastic neoplasia based on the type of chemotherapy regimen chemotherapy regimen chemotherapy response totalresponsive partial unresponsive n % n % n % singledrug 27 50 14 43.5 2 100 43 multidrug 27 50 18 56.2 45 total 54 100 32 100 2 100 88 farisa raudina et al.: response to chemotherapy in patients with gestational trophoblastic neoplasia in dr. hasan sadikin general hospital althea medical journal. 2020;7(3) 134 amj september 2020 irregular chemotherapy. this is shown by patients who initially have a low-risk gtn then have been progressing into high risk gtn and it thus requires a second-line regimen to achieve the remission.6,13 patients with β-hcg levels of >100,000 miu/ml, history of metastasis, high figo scores, and age of >40 years often experience resistance to chemotherapy and require more time to achieve remission.13 patients with gtn who are responsive to chemotherapy are mostly from the age group of <40 years (70.4%), multiparous (64.8%), have a previous history of molar pregnancy (84.1%), have a pregnancy-therapy intervals of <4 months (56.4%), have atumor size of >5 cm (62.5%), have no history of metastasis (75.9%) and have no history of chemotherapy failure (91.1%). the gtn patients with pulmonary metastases (16.7%) are responsive to chemotherapy. these results are similar to a study in iran17 on the characteristics of gtn patients who have received chemotherapy with methotrexate for the first time. patients with an age of >40 years tend to have a lower survival and remission rate. patients who have a resistant response to chemotherapy have often been found in patients with pregnancytherapy intervals of >4 months.12 the risk of developing a chemotherapy resistance is increased up to four times in these patients.17 furthermore, patients with partial and unresponsive chemotherapy responses are mostly in the age of <40 years old (table 3). it should be noted that these patients have not yet recovered and are at risk of developing metastasis. it is therefore necessary to monitor patients who have partial or unresponsive responses to maintain their treatment. the percentage of responsive chemotherapy patients in the single-drug regimen group and multi-drug regimen group are similar, showing that the treatment decisioning gtn patients in dr. hasan sadikin general hospital is in accordance with the risk category (tabe 4). most low-risk gtn patients at dr. hasan sadikin general hospital have been given mtx for a period of 5 days every 14 days as the first line therapy. a study has shown that patients who are given actinomycin-d as their second line therapy are easier to develop resistance compared to patients with a combined regimen (ema-co) as their second line therapy. patients who have a low-risk figo score of 5 and 6 need special attention because their remission rate are lower and tend to be resistant to single regimen chemotherapy.11 high-risk gtn patients should receive ema-co combination chemotherapy with or without adjuvant therapy such as surgery or radiation.2,18 this regimen is given on 1st day, 2nd day, and 8th day.3 high-risk gtn patients who have resistance should be given ema/ ep combination chemotherapy regimen (etoposide, methotrexate, folinic acid, etoposide, and cisplatin). the remission rate of the ema/ep regimen reaches up to 75– 80%. the regimen which is often used to treat high risk gtn patients with chemotherapy resistance in dr. hasan sadikin general hospital is te/tp combination chemotherapy regimen (paclitaxel and etoposide alternating with paclitaxel and cisplatin every two weeks).11 research on the level of remission of the te/ tp regimen has not been done, however, this regimen is as effective as the ema/ep regimen with lower toxicity.11,17 chemotherapy response at dr. hasan sadikin general hospital is not as high as in developed countries (86–94%) especially in high-risk gtn patients (29.6%), therefore, it is necessary to examine various risk factors that might affect it, including the type of therapeutic regimen.17 the limitation of this research is the design of this study, which was retrospective and descriptive. further study should be conducted with a prospective study design to assess the chemotherapy response of gtn patients and the risk factors that influence it. follow-up and education for patients also need to be conducted correctly, considering the number of gtn patients with incomplete chemotherapy and patients with partial and non-responsive responses who are lost to follow up. this study was considered a weak evidence to prove any causal relationship between the variables. the number of incomplete medical record data had made this study difficult to maintain its accuracy. to conclude, most gtn patients in dr. hasan sadikin general hospital are responsive (61.4%) and most of them are categorized as low-risk groups (70.4%). gestational trophoblastic neoplasm patients with responsive chemotherapy response were mostly from the age group of <40 years, multiparous, had a history of previous molar pregnancy, the pregnancy-therapy interval of <4 months, tumor size of >5 cm, have no history of metastases and no history of previously failed chemotherapy. patients with a responsive chemotherapy response to a single drug regimen and multidrug regimen have similar results, indicating that selection of the therapy regimen based on the respective risk groups is effective. althea medical journal. 2020;7(3) 135 references 1. jagtap sv, aher v, gadhiya s, jagtap ss. gestational trophoblastic diseaseclinicopathological study at tertiary care hospital. j clin diagn res. 2017;11(8):ec27–30. 2. cunningham fg,leveno kj, bloom sl, spong cy, dashe js, hoffman bl, et al, editors. williams obstetrics. 24th ed. new york: mcgraw-hill education; 2014. p. 1358. 3. brown j, naumann rw, seckl mj, schink j. 15 years of progress in gestational trophoblastic disease: scoring, standardization, and salvage. gynecol oncol. 2017;144(1):200–7. 4. ngan hys, kohorn ei, cole la, kurman rj, kim sj, lurain jr, et al. trophoblastic disease. int j gynaecol obstet. 2012;119 suppl 2:s130–6. 5. hoffman bl, schorge jo, bradshaw kd, halvorson lm, schaffer ji, corton mm. williams gynecology. 3rd ed. new york: mcgraw hill professional ; 2016. p. 270 . 6. froeling fem, seckl mj. gestational trophoblastic tumours: an update for 2014. curr oncol rep. 2014;16(11):408. 7. union for international cancer control, who. gestational trophoblastic neoplasia: 2014 review of cancer medicines on the who list of essential medicines. [cited 2019 feb 20]. available from: https:// w w w. w h o . i n t / s e l e c t i o n _ m e d i c i n e s / committees/expert/20/applications/ g e s t a t i o n a l tr o p h o b l a s t i c n e o p l a s i a . pdf ?ua=1 8. departemen/ksm obstetri dan ginekologi fk unpad rsup dr. hasan sadikin. laporan tahunan 2018. bandung: fk unpad rsup dr. hasan sadikin; 2018. 9. ngan hys, seckl mj, berkowitz rs, xiang y, golfier f, sekharan pk, et al. update on the diagnosis and management of gestational trophoblastic disease. int j gynecol obstet. 2018;143 suppl 2:79–85. 10. kong y, yang j, jiang f, zhao j, ren t, li j, et al. clinical characteristics and prognosis of ultra high-risk gestational trophoblastic neoplasia patients: a retrospective cohort study. gynecol oncol. 2017;146(1):81–6. 11. santaballa a, garcía y, herrero a, laínez n, fuentes j, de juan a, et al. seom clinical guidelines in gestational trophoblastic disease. clin transl oncol. 2018;20(1):38– 46. 12. chapman-davis e, hoekstra a v., rademaker aw, schink jc, lurain jr. treatment of nonmetastatic and metastatic low-risk gestational trophoblastic neoplasia: factors associated with resistance to single-agent methotrexate chemotherapy. gynecol oncol. 2012;125(3):572–5. 13. li j, yang j, liu p, ren t, zhao j, feng f, et al. clinical characteristics and prognosis of 272 postterm choriocarcinoma patients at peking union medical college hospital: a retrospective cohort study. bmc cancer. 2016;16(1):347. 14. foster br, elsayes km, menias co, shaaban am, salama me, olpin jd, et al. gestational trophoblastic disease: clinical and imaging features. radiographics. 2017;37(2):681–700. 15. litkouhi b, al-khan a. gestational trophoblastic disease. in: apuzzio jj, vintzileos am, berghella v, alvarez-perez jr, editors. operative obstetrics 4th ed. boca raton: crc press; 2017. p. 523–33. 16. alazzam m, tidy j, osborne r, coleman r, hancock bw, lawrie ta. chemotherapy for resistant or recurrent gestational trophoblastic neoplasia. cochrane database syst rev. 2016;2016(1):cd008891. 17. mousavi as, zamani a, khorasanizadeh f, gilani mm, zendehdel k. resistance to single-agent chemotherapy and its risk factors in low-risk gestational trophoblastic neoplasms. j obstet gynaecol res. 2015;41(5):776–83. 18. may t, goldstein dp, berkowitz rs. current chemotherapeutic management of patients with gestational trophoblastic neoplasia. chemother res pract. 2011;2011:806256. farisa raudina et al.: response to chemotherapy in patients with gestational trophoblastic neoplasia in dr. hasan sadikin general hospital amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 125althea medical journal. 2022;9(3):125–130 hygiene and sanitation factors affecting contamination of soil-transmitted helminths in household water sources in jember, indonesia epafroditus sanjaya adiguna,1 wiwien sugih utami,2 ika rahmawati sutejo,3 bagus hermansyah,2 yunita armiyanti2 1faculty of medicine university of jember, indonesia, 2department of parasitology, faculty of medicine university of jember, indonesia, 3department of biochemistry, faculty of medicine university of jember, indonesia abstract background: water sources used by households are at risk of contamination by soil-transmitted helminths (sth). hygiene and sanitation have an essential role in the transmission and contamination of sth. the objective of this study was to analyze whether there was an association between hygiene and sanitation factors with sth contamination in household water sources in jember regency, east java province, indonesia. methods: this cross-sectional analytic study was carried out from december 2020 to march 2021, including 46 samples from 23 respondents in sukowono district and 23 respondents in sukorambi district, jember regency, selected using a purposive sampling technique. primary data on hygiene and sanitation risk factors were obtained from questionnaire interviews. the sth contamination in household water sources was examined by sedimentation and flotation methods. data were analyzed using fisher exact test. results: the identification of sth contamination in household water sources using microscope examination found hookworm species contaminated 9% (n=4) of water sources. there was a significant association between the type of human sewage disposal with sth contamination in household water sources (p=0.037). there was no association between hygiene and other sanitation factors with sth contamination in household water sources (p>0.05). conclusion: human sewage disposal that goes directly to sewers and rivers can cause contamination of water sources by sth. therefore, it is important to dispose of human waste in septic tanks that comply with health requirements to prevent the transmission of sth to humans through water sources. keywords: dug well, hookworm, household water, human sewage disposal correspondence: dr. wiwien sugih utami, dr., m.sc, department of parasitology, faculty of medicine, university of jember, jalan kalimantan 37 kampus bumi tegal boto jember indonesia, e-mail: wiwien.dr@unej.ac.id introduction water is one of the basic needs of humans. water sources used by households have a risk of being contaminated by soil-transmitted helminth (sth).1 soil-transmitted helminth infestation is still one of the health problems in indonesia. the prevalence of sth infestation in indonesia is still relatively high, varying between 2.5% to 62%.2 several studies have proven that water sources can be contaminated by sth. a study in iraq3 found that from 104 samples examined, 4.8% of water sources were contaminated by hookworms and 1.9% by ascaris lumbricoides. another study conducted in bandung, indonesia4 detected ascaris lumbricoides egg in dug wells used by the community. hygiene and sanitation have an essential role in the transmission and contamination of sth in the environment. transmission of sth occurs through the fecal-oral route and skin penetration which is associated with hygiene and sanitation factors.2,5 these hygiene and sanitation factors are hand washing habits, nail cutting habits, defecation sites, pit latrine facilities, and water source facilities.6,7 jember regency is one of the regencies in https://doi.org/10.15850/amj.v9n3.2587 althea medical journal. 2022;9(3) 126 east java province, where most of the population lives in rural areas. some households in jember regency have not practiced hygiene well, with 31.85% of households have not practiced good hygiene habits. the population of sukowono district and sukorambi district who do not have access to improved pit latrines is 70.45% and 53.49%, respectively.8 the objective of this study was to analyze whether there was an association between hygiene and sanitation factors with sth contamination in household water sources in sukowono and sukorambi, jember regency, east java province, indonesia. methods this research design was a cross-sectional analytic study. the study was conducted from december 2020 to march 2021 in sukokerto village, sukowono district, and dukuh mencek village, sukorambi district, jember regency, east java province. the sample of this study was the people in sukokerto village, sukowono district, and dukuh mencek village, sukorambi district, jember regency. the sample size of this study was 46 people, with 23 samples from sukokerto village, sukowono district, and 23 samples from dukuh mencek village, sukorambi district. the sampling table 1 respondents’ characteristics characteristics n % gender male female 17 29 37 63 age (years) 18–45 45–59 ≥60 26 13 7 57 28 15 education level no education elementary school junior high school senior high school college 2 21 18 1 4 4 46 39 2 9 occupation farmer housewife private sector worker teacher laborer student unemployed 12 17 5 1 7 2 2 26 37 11 2 15 4 4 althea medical journal september 2022 technique used in this study was purposive sampling. the inclusion criteria for this study were respondents aged ≥18 years old, who could communicate well and had household water sources such as a dug well, artesian well, or tap water. respondents who used rivers as water sources were excluded from this study. the hygiene and sanitation factors were identified through questionnaire interviews. the questionnaire consisted of demographic information and questions about handwashing habits, defecation sites, nail cutting habits, pit latrine ownership, human sewage disposal type, household water source type, and distance between the water source and human sewage disposal. water samples were taken from household water sources such as artesian wells, dug wells, and tap waters. each source was taken as much as 2 liters of water and deposited for 5–7 days. water deposit was examined using sedimentation and flotation methods at the parasitology laboratory, faculty of medicine, university of jember. sedimentation was conducted by centrifuge with 2000 rpm for 15–20 minutes. the flotation was done using saturated sucrose solution to float sth eggs. soil-transmitted helminths in water samples were identified through a microscope examination with 100x althea medical journal. 2022;9(3) 127epafroditus sanjaya adiguna et al.: hygiene and sanitation factors affecting contamination of soil-transmitted helminths in household water sources in jember, indonesia and 400x magnification and according to the world health organization’s (who) bench aids for the diagnosis of intestinal parasites guidance.9 this study was approved by the ethics committee of the faculty of medicine, university of jember no: 1541/h25.1.11/ ke/2021. data were analyzed using fisher exact test and odds ratio. results characteristics of respondents based on gender, age, education level, and occupation were presented in table 1. more than half of the respondents in this study were female (63%) compared to male respondents. most of the respondents were aged 18–45 years or adults (57%), had elementary school education level (46%) and had jobs as housewives (37%) and farmers (26%). water sources contaminated by sth in this study were 4 dug wells (9%). the sth species that contaminated the water sources were hookworms and the distribution of sth contamination was shown in table 2. there was no association between hygiene factors and sth contamination in household water sources based on the fisher exact test (table 3). there was also no association between some of the sanitation factors, such as pit latrine ownership, household water source type, and the distance of the water source from the human sewage disposal, with sth contamination in household water sources. there was a significant association between the human sewage disposal type and sth contamination in water sources (p-value=0.037) (table 4). discussion in this study, the majority of the respondents was female who generally had a role in managing hygiene and sanitation conditions in their homes. however, sth infection is not affected by gender. sth infection is more affected by socioeconomic status, population density, hygiene habits, and sanitation in the individual’s environment.10 the respondents of this study were primarily adults with a range of 18–45 years. those results were similar to the study conducted in kediri district, jawa timur province, the majority of the respondents were female and adults. table 2 findings for soil-transmitted helminth contamination in water sources species household water source n % dug well artesian well tap water positive ascaris lumbricoides hookworm trichuris trichiura 4 4 9 negative 31 2 9 42 91 total 35 2 9 46 100 table 3 hygiene factors with sth contamination in water sources hygiene negative positive p-value n % n % handwashing habit yes no 40 2 87 4 4 9 1.000 defecation site pit latrine river/ground 36 6 78 13 4 9 1.000 nail cutting habit regularly (once/week) irregularly (not once/week) 27 15 59 33 3 1 6 2 1.000 althea medical journal. 2022;9(3) 128 studies on sth were generally more focused on children, although sth can infect people of all ages.11 housewife and farmer jobs are common in rural communities. farmers have a higher risk of sth infection due to frequent contact with the soil, while housewives are at risk of sth infection when doing housework related to the soil, such as cleaning the yard. those findings were similar to the study conducted in palembang, that showed the majority of the parents were elementary education levels and worked as housewives and farmers.10 the low level of education and certain professions, such as farmers, are some of the risk factors for sth infection.10,12 water sources contaminated by sth were dug into wells with a total of 4 samples (8.7%). the low percentage of sth contamination was supported by a study conducted in iraq3 which found a low percentage of sth contamination (6.7%). contamination of water sources by sth is caused by several factors, such as poor hygiene and sanitation, contamination from the environment or agriculture activities, climate, and socio-economics.1,13,14 the majority of the respondents in this study had good hygiene habits and adequate sanitation facilities. good hygiene habits and adequate sanitation could be some factors that caused the low percentage of contamination. the soil-transmitted helminth species which contaminated water sources in this study was hookworm. this study was similar to a study in nigeria, which detected contamination of water sources by hookworm species. in the study conducted in nigeria, an inadequate human sewage disposal system caused hookworm contamination.1 similar to some of the respondents in this study, some of the households in the nigeria study had a human sewage disposal system directly discharged into the environment, which caused hookworm contamination in water sources.1 this study discovered no significant association between hygiene factors with sth contamination in household water sources. most of the respondents have applied these hygiene habits, showing that other factors caused the contamination. some possible factors causing the contamination were agricultural and environmental activities, such as using human feces as fertilizer and the accumulation of residential fecal waste.12,14,15 besides being supported by these factors, the water sources in this study were also only contaminated by hookworm species. hookworms are transmitted through larvae penetrating the skin, and they do not always need dirty hands and nails to transmit like a. lumbricoides and t. trichiura eggs. these results were supported by studies in southern ethiopia16 and bangladesh17, which stated that regular hand washing and nail cutting habits did not reduce the infection of hookworm. this study showed a significant association between human sewage disposal type with sth contamination (p=0.037), but there was no association between pit latrine ownership and sth contamination. a study in ethiopia18 also found that there was no association between pit latrine ownership with sth table 4 sanitation factors with sth contamination in water sources sanitation negative positive p-value odds ration % n % pit latrine ownership yes no 38 4 83 9 4 9 1.000 human sewage disposal* septic tank river/sewer 34 8 74 17 1 3 2.2 6.5 0.037 12.750 household water source tap water & artesian well dug well 10 32 22 70 4 9 0.562 distance between the water source and human sewage disposal >10 m yes no 23 19 50 41 2 2 4 4 1.000 althea medical journal september 2022 althea medical journal. 2022;9(3) 129 prevalence. other factors that support the prevalence and contamination of sth are pit latrine construction and conditions. apart from having pit latrine facilities, a household needs to have a pit latrine with well-maintained construction such as adequate human sewage disposal. study in another part of ethiopia6 stated that sth infestation and contamination were associated with indiscriminate disposal of human feces. damaged or inadequate human sewage disposal facility results in human feces being wasted in the environment and causes parasitic contamination.6,18 in this study respondents who had human sewage disposal to a river or sewer were 12.75 times more likely to have sth-contaminated water sources in their homes than respondents who had human sewage disposal to a septic tank (or=12.750). liquid waste and human feces must be disposed of in a closed and protected place such as a septic tank. disposing of human feces in sewers or rivers causes parasites, infective eggs, and sth larvae to contaminate the surrounding environment, such as water sources.6 there is no association between the household water source type and sth contamination. this result indicated that several other factors caused the contamination. a study in bangladesh15 stated that water sources could be contaminated by pathogens when there was damage or malfunction in the construction of water sources. water sources that already had a protected construction are still at risk of contamination when they experience damage or malfunction in protective barriers such as walls, pipes, or wellheads. malfunctions of water source construction cause microorganisms to easily enter water sources from the outside environment.15 we also did not find any association between the distance of water source from human sewage disposal with sth contamination. a study about parasitic contamination in wells in iran19 also stated that there was no association between the distance of the water source from sources of contamination with parasite contamination. one of the factors that determine pathogen contamination is the position of the water source with human sewage disposal. the position of the water source higher on the ground reduces the flow of waste from the septic tank or other pollutant source to the water source.19,20 the limitation of the study are the measurement of hygiene and sanitation factors only using questionnaire interviews. there was potential for bias because there was a possibility that some respondents tended to choose answers that were not necessarily following reality. ideally, the data collection on hygiene and sanitation should be performed by observation. in conclusion, there is an association between the type of human sewage disposal and sth contamination in water sources. human sewage disposal that goes directly to sewers and rivers can cause contamination of water sources by sth. therefore, it is important to dispose of human waste in septic tanks that comply with health requirements to prevent the transmission of sth to humans through water sources. references 1. chollom sc, iduh mu, gyang bj, idoko ma, ujah a, agada go, et al. parasitological evaluation of domestic water sources in a rural community in nigeria. br microbiol res j. 2013;3(3):393–9. 2. kementerian kesehatan republik indonesia. peraturan menteri kesehatan ri nomor 15 tahun 2017 tentang penanggulangan cacingan. jakarta: kementerian kesehatan republik indonesia; 2017. 3. al-morshidy kah, al-amari mjy. detection of parasitic contamination in hilla city drinking water/babylon province/iraq. adv in nat appl sci. 2015;9(3):80–4. 4. sari syi, hamda me, cahyadi aic, utami jm, ravichandran m, raksanagara a. detection of entamoeba sp. and helmith eggs from water sources in urban slum area in bandung municipality. jurnal kesehatan masyarakat andalas. 2016;11(1):26–32. 5. al-tameemi k, dayoub a, mazloom m. contamination of water with helminth eggs: a case study of sourani dam laketartus governorate. asian j pharm clin res. 2019;12(10):3–5. 6. gizaw z, adane t, azanaw j, addisu a, haile d. childhood intestinal parasitic infection and sanitation predictors in rural dembiya, northwest ethiopia. environ health prev med. 2018;23(1):26. 7. mahmud ma, spigt m, bezabih am, pavon il, dinant gj, velasco rb. efficacy of handwashing with soap and nail clipping on intestinal parasitic infections in school-aged children: a factorial cluster randomized controlled trial. plos med. 2015;12(6):e1001837. 8. dinas kesehatan kabupaten jember. profil kesehatan kabupaten jember 2018. epafroditus sanjaya adiguna et al.: hygiene and sanitation factors affecting contamination of soil-transmitted helminths in household water sources in jember, indonesia althea medical journal. 2022;9(3) 130 jember: dinas kesehatan kabupaten jember; 2019. 9. world health organization. bench aids for the diagnosis of intestinal parasites. 2nd ed. geneva: world health organization; 2019. 10. annisa s, dalilah d, anwar c. hubungan infeksi cacing soil transmitted helminths (sth) dengan status gizi pada siswa sekolah dasar negeri 200 kelurahan kemasrindo kecamatan kertapati kota palembang. majalah kedokteran sriwijaya. 2018;50(2):92–104. 11. munawaroh s, arwati h, wardhani p. contamination of water and soil of rice fields with soil transmitted helminths as source of transmission to farmers in grogol sub-district, kediri district. qanun medika. 2020;4(1):51–8. 12. noviastuti ar. infeksi soil transmitted helminths. majority. 2015;4(8):107–16. 13. omarova a, tussupova k, berndtsson r, kalishev m, sharapatova k. protozoan parasites in drinking water: a system approach for improved water, sanitation and hygiene in developing countries. int j environ res public health. 2018;15(3):495. 14. widiyanto af, yuniarno s, kuswanto k. polusi air tanah akibat limbah industri dan limbah rumah tangga. kemas. 2015;10(2):246–54. 15. ercumen a, pickering aj, kwong lh, mertens a, arnold bf, benjamin-chung j, et al. do sanitation improvements reduce fecal contamination of water, hands, food, soil, and flies? evidence from a cluster-randomized controlled trial in rural bangladesh. environ sci technol. 2018;52(21):12089–97. 16. amare hh, lindtjørn b. helminth infections among rural schoolchildren in southern ethiopia: a cross-sectional multilevel and zero-inflated regression model. plos negl trop dis. 2020;14(12):e0008002. 17. ercumen a, benjamin-chung j, arnold bf, lin a, hubbard ae, stewart c, et al. effects of water, sanitation, handwashing and nutritional interventions on soiltransmitted helminth infections in young children: a cluster-randomized controlled trial in rural bangladesh. plos negl trop dis. 2019;13(5):e0007323. 18. oswald we, stewart aep, kramer mr, endeshaw t, zerihun m, melak b, et al. association of community sanitation usage with soil-transmitted helminth infections among school-aged children in amhara region, ethiopia. parasit vectors. 2017;10(1):91. 19. yousefi z, ziaei hezarjaribi h, enayati aa, mohammadpoor ra. parasitic contamination of wells drinking water in mazandaran province. iran j environ health sci eng. 2009;6(4):241–6. 20. rahayu p, joko t, dangiran hl. hubungan faktor risiko pencemaran sumur gali dengan kualitas bakteriologis di lingkungan pemukiman rw iv kelurahan jabungan kota semarang. jurnal kesehatan masyarakat. 2019;7(3):156–63. althea medical journal september 2022 althea no 1 vol 1 edit 02092014.indd althea medical journal. 2014;1(1) 12 amj june, 2014 success rate of phacoemulsification for cataract in patients with high-degree myopia in national eye center cicendo eye hospital bandung, indonesia nadia khairina budiman1, andrew maximilian knoch2, yuni susanti p3 1faculty of medicine, universitas padjadjaran, 2department of ophtalmology, faculty of medicine, universitas padjadjaran/national eye center cicendo eye hospital bandung, 3department of physiology, faculty of medicine, universitas padjadjaran abstract background: phacoemulsification is one of the procedures performed in cataract with high-degree myopia patients. patients with high-degree myopia have a higher risk for postoperative complications due to phacoemulsification which affects their visual acuity. these patients also have higher manifest refraction compared to cataract without high-degree myopia. this study aims to evaluate the success rate of phacoemulsification for cataract in patients with high-degree myopia in national eye center, cicendo eye hospital bandung, indonesia. methods: a descriptive study was performed by collecting data from medical records on phacoemulsification in cataract patients with high-degree myopia at the national eye center, cicendo eye hospital, during january–december 2011. there were 79 cases out of 136 cases that met the inclusion criterias, those were cataract patients with high-degree myopia who underwent phacoemulsification and patients who did regular follow up visits. data were analyzed using computer. results: the results showed that from 79 cases, 44(55.7%) cases involved female patients. visual acuity after phacoemulsfication increased gradually at 1–2 months follow-up. eighty one percent cases have been corrected at best with a visual acuity of higher than 6/18. no intraoperative complication occurred in 96.2% of the cases but 3.8% cases had zonular dialysis and vitreous prolaps as intraoperative complication. meanwhile, corneal edema as postoperative complications occurred in 58.3% of the patients. a total of 17 (21.5%) cases had manifested refraction more than ±2.00 diopter. conclusions: phacoemulsification in cataract with high-degree myopia resulted in good visual acuity and minimal complications. however, extreme manifest refraction still occurs in several patients [amj.2014;1(1):12–6] keywords: cataract, high-degree myopia, phacoemulsification tingkat keberhasilan fakoemulsifikasi pada penderita katarak yang disertai miopia tinggi di pusat mata nasional rumah sakit mata cicendo, bandung, indonesia abstrak latar belakang: miopia tinggi diketahui berhubungan dengan terjadinya katarak. kasus-kasus tersebut memiliki risiko komplikasi fakoemulsifikasi yang lebih tinggi dibandingkan katarak biasa dan dapat memengaruhi tajam penglihatan serta kualitas hidup pasien sehingga dibutuhkan evaluasi mengenai tingkat keberhasilan fakoemulsifikasi. penelitian ini bertujuan untuk mengetahui gambaran tajam penglihatan pascabedah, komplikasi,dan refraksi manifes pada penderita katarak disertai miopia tinggi yang menjalani prosedur fakoemulsifikasi. metode: penelitian dilakukan dengan metode deskriptif dengan pengambilan data sekunder dari rekam medis di pusat mata nasional rumah sakit mata cicendo pada januari–desember tahun 2011. ada 79 kasus dari 136 kasus yang memenuhi kriteria inklusi yaitu penderita katarak dengan derajat miopia tinggi yang menjalani fakoemulsifikasi dan rutin datang berobat. data diolah menggunakan program komputer. correspondence: nadia khairina budiman, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281312349359, email: nadiakhairina09@yahoo.com althea medical journal. 2014;1(1) 13nadia khairina budiman, andrew maximilian knoch, yuni susanti p: success rate of phacoemulsification for cataract in patients with high-degree myopia in bandung indonesia introduction cataract is the leading cause of blindness in the world. the world health organization (who) stated that cataract causes 39% of blindness, 18% of refractive error, and 10% of glaucoma. the who also estimated that 18 million people suffer from bilateral blindness caused by cataract.1 high-degree myopia is known as a risk factor for cataract.2 phacoemulsification is a common method used for cataract extraction today.3 with the development of cataract surgery, patients’ expectation for the successful visual acuity outcome is very high. in addition, phacoemulsification is also one of the best procedures with good and fast recovery.4,5 phacoemulsification is one of the procedures performed in cataract with highdegree myopia patients. cataract patients with high-degree myopia have higher postoperative risk and intraoperative complications compared to cataract without high-degree myopia with retinal ablations as the most common complication.6,7 intraocular pressure increase may also occur in early period of postoperative phacoemulsification.6 this intraocular pressure increase and its complication may affect visual acuity. moreover, the postoperative manifest refraction in cataract patients with high-degree myopia tends to be higher than in cataract patients without highdegree myopia.8 because of the lack of study on evaluation of phacoemulsification in cataract patients with high-degree myopia, this study aims to evaluate the success rate of phacoemulsification using the parameters of visual acuity, complication, and manifest refraction after phacoemulsification in cataract patients with high-degree myopia in national eye center cicendo, eye hospital,bandung 2011. methods a descriptive study was conducted in high-degree myopia cataract patients who underwent phacoemulsification procedure at the national eye center, cicendo eye hospital, in january–december 2011. this study was conducted by collecting data from medical records on phacoemulsification in cataract patients with high-degree myopia. there were 79 cases out of 136 cases that met the inclusion criteria, which was cataract patients with high-degree myopia who underwent phacoemulsification and patients who did regular follow up visits. meanwhile 57 cases had to be excluded. the exclusion criteria include incomplete data and patients with other diseases in addition to cataract and highdegree myopia which can affect their visual acuity. the postoperative data on uncorrected visual acuity (ucva) and best corrected visual acuity (bcva) during the first and 1–2 months follow up; intraoperative and postoperative complication data; and postoperative manifest refraction data were collected. these data were then processed using computer. results a total of 79 data sets were available. of these, 44 (55.7%) cases involved female patients, and 35 (44.3%) cases involved male patients. twenty six patients (32.9%) were 50–59 years old, while 23 (29.1%) patients were 60–69 years old. the median of this study was 59 years old and the mean was 58 years old. range of age in this study was 28 until 85 years old. from all cataract patients with high-degree myopia who underwent phacoemulsification in this study, 59.5% came from bandung. patients who came from outside bandung were from west java area; jakarta bogor, tangerang, hasil: hasil penelitian menunjukkan bahwa tajam penglihatan tanpa koreksi 1 hari pascabedah fakoemulsifikasi pada 49,4% kasus dibawah 6/60 yang berangsur membaik pada kunjungan 1–2 bulan. sebanyak 81,0% kasus memiliki tajam penglihatan dengan koreksi terbaik diatas 6/18. terdapat 96,2% kasus yang tidak mengalami komplikasi intrabedah. edema kornea sebagai komplikasi 1 hari pascabedah fakoemulsifikasi cukup banyak terjadi yaitu sebanyak 45,6%. pada penelitian ini didapatkan refraksi manifes dengan rentang -12.00 sampai +10.00 dioptri, 78,5% berada dalam rentang ±2.00. simpulan: prosedur pada katarak miopia tinggi menunjukkan hasil penglihatan yang baik dan komplikasi minimal , tetapi pada katarak yang disertai miopia tinggi masih terdapat pasien yang memiliki refraksi manifes yang cukup berat. kata kunci: fakoemulsifikasi, katarak, miopia tinggi althea medical journal. 2014;1(1) 14 amj june, 2014 bekasi (jabotabek), and central java area. about 96.2% were poor patients while general patients only made up 3.8%. most patients came with asuransi kesehatan wajib (53.2%) and jaminan kesehatan masyarakat (21.5%). asuransi kesehatan wajib is a compulsory health insurance in a company or in a certain country. jaminan kesehatan masyarakat is a comprehensive health care program by the government including preventive, promotive, curative, and rehabilitative for poor people. the range of preoperative visual acuity in this study was 20/25 to hand movement, with the biggest percentage (91.1%) for poor (<6/60) visual acuity, based on the who category for guidelines to monitor the outcome of cataract surgery. only 4 patients (5.1%) have good (6/6–6/18) preoperative visual acuity. after the patients had gone through the phacoemulsification procedure, they underwent visual acuity examination on the first day of follow up. there was an increase in visual acuity although 49.9% still had poor visual acuity. sixteen (20.3%) cases were in borderline (<6/18–6/60) and 24 (30.4%) cases showed good visual acuity. on the 1st–2nd month follow up, there was an increase in visual acuity with 53.2% cases had good uncorrected visual acuity (ucva) (table 1). twenty two (27.8%) cases had visual acuity of more than 0.5. best corrected visual acuity examinations table 1 uncorrected and best corrected visual acuity on the 1st–2ndmonthsfollow-up visual acuity classification ucva bcva case percentage (%) case percentage (%) good (6/6–6/18) 42 53.2 64 81 borderline (<6/18–6/60) 17 21.5 7 8.9 poor (<6/60) 20 25.3 8 10.1 total 79 100 79 100 ucva = uncorrected visual acuity; bcva = best corrected visual acuity table 2 postoperative manifest refraction manifest refraction case percentage (%) <-2.00 15 19.0 -2.00–0.00 29 36.7 0.01–2.00 33 41.8 >2.00 2 2.5 total 79 100 table 3 intraoperative complications complication case percentage (%) no complication 76 96.2 viteous prolapse 2 2.5 zonular dialysis 1 1.3 total 79 100 were also performed in the 1st–2nd months follow up. nevertheless, there were still 8 (10.1%) cases that had poor best corrected visual acuity (bcva). the range of bcva in this study from hand movement was 6/6. there were 52 cases (65.8%) that had visual acuity above 0.5. there was no further investigation about the causes of poor visual acuity in these patients. the range of manifest refraction in this study was from -12.00 to +10.00. there were still 17 (21.5%) cases that had extreme manifest refraction or more than ±2.00 diopter. of these, 70.5% cases underwent axial length examination by ultrasound biometry. intraoperative complications in this study were vitreous prolapse and zonular dialysis. these complications are shown in table 3. only 3 cases (3.8%) suffered from intraoperative complications. patients who suffered from zonular dialysis had poor ucva, i.e. 0.05, and high manifest refraction of +10.00 but good bcva, i.e. was 0.50. one of the patients who suffered from prolapsed vitreous had poor ucva which, i.e. 0.05 and bcva 0.3. corneal edema as a postoperative complication occurred in 46 (53.3%) cases. however, in 1st–2nd months follow up visits, the complications gradually disappeared. discussion gender is known as a risk factor of cataract and female patients are more at risk for cataract althea medical journal. 2014;1(1) 15nadia khairina budiman, andrew maximilian knoch, yuni susanti p: success rate of phacoemulsification for cataract in patients with high-degree myopia in bandung indonesia than men.9 jeon and kim10 found that cataract patients with high-degree myopia are younger than cataract patients without myopia with a mean age of 59.60±12.28, while cataract patients without myopia patients has a mean age of 67.47±11.36. a study by joshi and shakya11 showed that 61.3% cataract patients without high-degree myopia who underwent phacoemulsification have preoperative visual acuity of less than 6/60, meanwhile only 9.09% have visual acuity above 6/18. one day postoperative visual acuity in cataract patients without high-degree myopia patients tends to be poor, only 28% patients have near normal visual acuity or better than 6/18 in both eyes.12 tinley et al.13 found that 83% cataract patients without high-degree myopia have 2 week postoperative ucva of more than 6/12. a study by kim jh et al.14 showed 92.3% patients have a bcva of 20/20 six months after phacoemulsification. patients with poor bcva might have corneal opacity and glaucoma or other ocular diseases.15 axial length examination using iolmaster biometry was found to be more accurate and had better manifest refraction than ultrasound biometry.16 the iolmaster biometry was a complete system that could perform keratometry, anterior chamber depth, corneal white to white and calculated intraocular lens (iol) power.17 high-degree myopia might cause error in determining iol power, so the surgeon have to re-check the keratometer and a-scan.18 axial length of more than 26 mm is a risk factor of phacoemulsification complications, including posterior capsule rupture and vitreous loss (8.5%) mentioned in zare et al study.7 corneal edema is a common postoperative phacoemulsification, about 20.7% cases experience corneal edema in 1 day postoperative phacoemulsification with mature cataract.19 although corneal edema is a common complication, viscoelastic can be used to improve the protection of corneal endothel during phacoemulsification and decrease the occurrence of corneal edema as a complication.20 in conclusion, phacoemulsification is a safe procedure for cataract patients with high-degree myopia. this procedure has low complication and good visual outcome. however, the manifest refraction seen in some patients is still extreme. this might happen due to the inaccurate iol power measurement. by using iolmaster biometry or ultrasound biometry with experts, this error can be minimalized. corneal edema as a postoperative complication can also be minimalized by using the appropriate viscoelastics to protect the corneal endothelial cells. further investigation to evaluate the poor visual outcome also is needed so proper treatment can be planned. data about cataract diagnosis based on nucleus hardness are also needed because cataracts with hard nucleus need longer operation time and have higher risks for complication. with these data, we can evaluate whether the hard nucleus is a risk factor for complications in phacoemulsification or not. for further study, the correlation between axial length and manifest refraction after phacoemulsification should be evaluated. references 1. who. vision 2020 the right to sightglobal initiative for the elimination of avoidable blindness: action plan 2006–2011. geneva: who library cataloguing data; 2007 2. tsai ck, teng mc, wu pc, kuo hk. clinical features of patients featuring cataracts in a myopia-endemic area of taiwan. chang gung med j. 2006;29(4):406–11. 3. oetting ta. cataract surgery for greenhorns. iowa: medrounds publications; 2005 4. hashemian sj, pakdel f, foroutan a, joshaghani m, ghaempanah j, mohebbi table 4 one day postoperative complication complication case percentage (%) no complication 32 40.5 severe corneal edema 36 45.6 minimal corneal edema 10 12.7 kerato conjunctivitis 1 1.3 total 79 100 althea medical journal. 2014;1(1) 16 amj june, 2014 m, et al. microcoaxial phacoemulsification versus conventional phacoemulsification: a prospective study. iranian journal of ophthalmology. 2011;23(4):43–8. 5. hennig a. sutureless non-phaco cataract surgery: a solution to reduce worldwide cataract blindness? community eye health. 2003;16(48):49–51. 6. steinert rf, editor. cataract surgery technique, complications, management. 2nd ed. philadephia: saunders; 2004. 7. zare m, javadi ma, einollahi b, baradaranrafii ar, feizi s, kiavash v. risk factors for posterior capsule rupture and vitreous loss during phacoemulsification. j ophthalmic vis res. 2009;4(4):208–12. 8. raut ds, ramchandani s, desai c, kumthekar p. refractive surprises in post radial keratotomy cataract surgery and review of literature to calculate lens power in post refractive surgery cases. journal of the bombay ophthalmologists’ association. 2005;14(2):32–7. 9. wimalasundera s. is gender a risk factor for cataract? galle medical journal. 2008; 13(1):44–7. 10. jeon s, kim hs. clinical characteristics and outcomes of cataract surgery in highly myopic koreans. korean j ophthalmol. 2011;25(2):84–9. 11. joshi mr, shakya s. change in refractive status of the patients undergoing phacoemulsification surgery. nepal med coll j. 2009;11(1):19–22. 12. huang w, zheng y, wang l, huang s, liu b, jin l, et al. five-year incidence and postoperative visual outcome of cataract surgery in urban southern china: the liwan eye study. invest ophthalmol vis sci. 2012;53(13):7936–42. 13. tinley cg, frost a, hakin kn, mcdermott w, ewings p. is visual outcome compromised when next day review is omitted after phacoemulsification surgery? a randomised control trial. br j ophthalmol. 2003;87(11):1350–5. 14. kim jh, park cs, chung ty, chung es. clinical evaluation of accommodative intraocular lens implantation in high myopic eyes. korean j ophthalmol. 2008; 22(2):81–6. 15. malik ar, qazi za, gilbert c. visual outcome after high volume cataract surgery in pakistan. br j ophthalmol. 2003;87(8):937–40. 16. eleftheriadis h. iolmaster biometry: refractive results of 100 consecutive cases. br j ophthalmol. 2003;87(8):960–3. 17. kanski jj, bowling b. clinical ophthalmology a systemic approach. 7th ed. china: elsevier; 2011. 18. gogate p, wood m. recognising ‘high-risk’ eyes before cataract surgery. community eye health. 2008;21(65):12–4. 19. ermiss ss, ozturk f, inan uu. comparing the efficacy and safety of phacoemulsification in white mature and other types of senile cataracts. br j ophthalmol. 2003;87(11): 1356–9. 20. kiss b, findl o, menapace r, petternel v, wirtitsch m, lorang t, et al. corneal endothelial cell protection with a dispersive viscoelastic material and an irrigating solution during phacoemulsification. j cataract refract surg. 2003;29(4):733–40. amj vol 9 no 1 march 2022-2.indd althea medical journal. 2022;9(1) 43 therapeutic outcomes of pediatric acute myeloblastic leukemia patients at a tertiary hospital in bandung, indonesia filbert lois marcus,1 nur suryawan,2 delita prihatni3 1faculty of medicine universitas padjadjaran, indonesia, 2department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of clinical pathology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: filbert lois marcus, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: filbert.mcs@gmail.com introduction acute myeloblastic leukemia (aml) is a subtype of leukemia characterized by infiltration into the bone marrow, blood, and other tissues. the infiltration itself is composed of abnormally differentiated, clonal, and proliferative myeloid cells. acute myeloblastic leukemia accounts for 20% of acute leukemia in children although its prevalence is less common than acute lymphoblastic leukemia.1 according to surveillance, epidemiology, and end result (seer), there were 1,291 pediatric aml patients between 2001–2007 in the united states.2 other data recorded in the pediatric department of cipto mangunkusumo general hospital, jakarta3 showed that between 2007–2010, there were 93 patients with a mortality number of 50 patients. even though aml is usually found in adults, aml has become the 5th most common malignancy in children and the prognosis is often terrible.4 the high mortality rate for this leukemia subtype is influenced by many predisposing factors, such as delays in detection and problems with access to healthcare facilities.5 the clinical features that appear in aml are various. for the most part, the initial signs and clinical manifestations are regularly vague such as pallor, fever, bruises, and loss of blood. other patients may also experience headaches, althea medical journal. 2022;9(1):43–48 abstract background: acute myeloblastic leukemia (aml) is a subtype of leukemia characterized by myeloid infiltration into the bone marrow, blood, and other tissues. aml ranks 5th malignancy in children and the prognosis is poor. after chemotherapy, the outcomes vary. therefore, this study aimed to provide further insight into the therapeutic outcomes of pediatric aml patients. methods: this study was conducted with a cross-sectional descriptive method. the data were obtained from the medical records of children diagnosed with aml at the department of child health of dr. hasan sadikin general hospital in 2017–2019 with the total sampling method. data including age at determination, gender, laboratory values including hemoglobin, leukocyte, thrombocyte as well as blast cell count on peripheral blood smear were collected. also, the bone marrow punctures gathered were clustered based on the french-american-british (fab) classification. data were presented in tables. results: in total, 46 data of aml patients were retrieved, with the age category at first diagnosis was >5–12 years (48%) and predominantly males (63%), children with moderate anemia (41%), leukocytosis (35%), severe thrombocytopenia (46%), and blast cell count ≥20% (83%). aml-m2 was the most common subtype (30.4%). the majority of patients (91%) underwent chemotherapy and most (45%) patients died during chemotherapy conclusion: the outcome of aml therapy among children is mostly poor, and particularly die during chemotherapy. early detection and follow-up of patients to continue therapy are important aspects to reduce the mortality rate of aml. keywords: acute myeloblastic leukemia, child cancer, outcome of therapy https://doi.org/10.15850/amj.v9n1.2315 althea medical journal. 2022;9(1) 44 bloating, gum hypertrophy, weak extremities, and loss of weight.4 laboratory values may reveal low hemoglobin, low thrombocyte, and hyperleukocytosis.1 however for a proper diagnostic method, a peripheral blood smear and bone marrow puncture should be conducted, which will be further classified under the french-american-british (fab) classification based on its cytochemical staining of the blasts and morphologies.6 the therapy given to aml patients is mostly divided into curative and supportive therapy. curative therapy aims to diminish the leukemic cells and achieve remission, while supportive therapy aims to prevent and overcome symptoms and side effects of curative therapy. curative therapy itself is also grouped as induction and consolidation chemotherapy phases.7 one of the guidelines used in the management of pediatric aml patients in indonesia is the national pilot protocol for aml in indonesian children. according to the guidelines, aml therapy in children could last more than 3 months and then be evaluated with laboratory markers to check whether it is remised or not.8 over time, therapies and technology have developed in treating aml patients. according to the seer from 1975 to 2008 it was revealed that the survival rate increased from less than 20% to more than 60%.1 nevertheless, about 20–40% of patients experience a relapse and this becomes another challenge in maintaining patients’ survival.9 besides, the success of therapy depends on the patient’s obedience in following each curing method. some patients choose to do alternative therapy or discontinue therapy for several reasons.10 after going through a series of medications, aml patients showed various outcomes, there were patients who were cured and some have died. the parameters of therapeutic success were assessed by evaluating the patient’s bone marrow specimens, both the percentage of blasts that were decreased and those that persisted. some cured patients may also show re-emerging of leukemic cells or we call it a relapse. the prognosis of aml patients can vary and may be influenced by several risk factors or underlying diseases. moreover, the prognosis of aml patients is not as great as all patients.11 previous research at dr. hasan sadikin general hospital showed that 38.4% of patients passed away while having aml therapy in 2014–2016.5 there is still a lack of study covering therapeutic outcomes in childhood aml at dr. hasan sadikin general hospital. therefore, this study aimed to provide more information about the therapeutic outcomes of aml patients in children at dr. hasan sadikin general hospital. this information could help to evaluate and select further therapy to improve the survival rate. methods this study was conducted with a descriptive method. the data were obtained from the medical records of children diagnosed with aml at the department of child health dr. hasan sadikin general hospital. inclusion criteria were children who had been diagnosed with aml from 2017 to 2019 using the total sampling method. exclusion criteria were incomplete, missing, and inaccessible medical records. data including age at determination and gender were collected. laboratory values were also checked including hemoglobin, leukocyte, thrombocyte as well as blast cell counts on the peripheral blood smears. this study defined hb <6 g/dl as severe anemia, 6–8.9 g/dl as moderate anemia, 9–11.9 g/dl as mild anemia, and ≥12 g/dl as normal. for leukocytes, <10,000 cells/mm3 was defined as normal, 10,000–49,999 cells/mm3 as high normal, 50,000–99,000 cells/mm3 as hyperleukocytosis, ≥100,000 cells/mm3 as severe hyperleukocytosis. for thrombocyte, <20,000 cells/mm3 was defined as severe thrombocytopenia, 20,000–99,999 cells/ mm3 as thrombocytopenia, ≥100,000 cells/ mm3 as normal. for blast counting, <20% was defined as normal and ≥20% as high blast cell count. also, the bone marrow punctures gathered were clustered based on the fab classification which depends on the cytoplasm, chromatin, nucleolus, cell size morphologies. m0 was an acute myeloblastic leukemia, minimally differentiated. m1 was an acute myeloblastic leukemia without maturation. m2 was an acute myeloblastic leukemia with maturation. m3 was acute promyelocytic leukemia, hypergranular. m4 was acute myelomonocytic leukemia. m5 was acute monoblastic leukemia, poorly differentiated. m6 was erythroleukemia. m7 was acute megakaryoblastic leukemia. this study also included the “no classification” criteria because the results of bone marrow puncture were ambiguous. in addition, chemotherapy status was also obtained whether the patients did therapy or not. finally, the outcome of therapy was also evaluated, whether complete remission, relapsed and death, died during althea medical journal march 2022 althea medical journal. 2022;9(1) 45 table 1 characteristics of acute myeloblastic leukemia in children registered at dr. hasan sadikin general hospital in 2017–2019 (n=46) characteristics total n % age (years old) 1–5 >5–12 >12–18 16 22 8 35 48 17 gender male female 29 17 63 37 filbert lois marcus et al.: therapeutic outcomes of pediatric acute myeloblastic leukemia patients at a tertiary hospital in bandung, indonesia chemotherapy, loss to follow up, or even refused chemotherapy. this study has been approved by the research ethics committee of universitas padjadjaran with the number of ethical clearance 634/un6.kep/ec/2020 and research permit issued by the research ethics committee of dr. hasan sadikin general hospital bandung no. lb.02.01/x.2.2.1/19546/2020. the data were processed and presented in frequency in the form of tables. results from 81 medical records, 46 subjects met the inclusion criteria during 2017–2019. most of the exclusion was based on the incompleteness of the data. this may also be due to the uncertain diagnosis of aml as determined by the description of the bone marrow puncture. most of the aml patients were diagnosed for the first time in the age category >5–12 years (47.8%) and were predominantly male (63%) table 2 laboratory examination laboratory examination total (n=46) n % hemoglobin <6 g/dl (severe anemia) 6–8.9 g/dl (moderate anemia) 9–11.9 g/dl (mild anemia) ≥12 g/dl (normal) 7 19 17 3 15 41 37 7 leukocyte <10,000 cells/mm3 (normal) 10,000–49,999 cells/mm3 (high normal) 50,000–99,000 cells/mm3 (hyperleukocytosis) ≥100,000 cells/mm3 (severe hyperleukocytosis) 11 16 11 8 24 35 24 17 thrombocyte <20,000 cells/mm3 (severe thrombocytopenia) 20,000–99,999 cells/mm3 (thrombocytopenia) ≥100,000 cells/mm3 (normal) 21 17 8 46 37 17 blast cell count <20% (normal) ≥20% (high) 8 38 17 83 bone marrow puncture* m0 (acute myeloblastic leukemia, minimally differentiated) m1 (acute myeloblastic leukemia without maturation) m2 (acute myeloblastic leukemia with maturation) m3 (acute promyelocytic leukemia, hypergranular) m4 (acute myelomonocytic leukemia) m5 (acute monoblastic leukemia, poorly differentiated) m6 (erythroleukemia) m7 (acute megakaryoblastic leukemia) no classification 1 7 14 5 3 3 1 0 12 2 15 30 11 7 7 2 0 26 note: *=classified under the french-american-british (fab) classification althea medical journal. 2022;9(1) 46 (table 1). laboratory examination data were recorded when the patient was first diagnosed with aml. from the measurement of hemoglobin levels, most of the patients showed moderate anemia (n=19; 41%), leukocytosis was high normal (n=16; 35%) and severe thrombocytopenia (n=21; 46%). a peripheral blood smear was also done and the blast cell count was evaluated. majority of patients (n=38; 83%) showed high blast cells (table 2). in addition, the core diagnosis of aml, bone marrow puncture should be conducted. there were 12 of 46 subjects whose fab classification results were not listed in the medical records. besides, the m2 classification was more common in aml patients (n=14; 30%), whereas m1 and m3 classifications were presented in 7(15%) and 5(11%) patients consecutively (table 2). the chemotherapy given to the patients was depicted in table 3. this variable was evaluated after the patients were diagnosed with aml, either the patient decided to accept some kind of chemotherapy regimen or the patient decided to refuse chemotherapy. the results showed that 42 patients underwent chemotherapy (91%) while the rest did not undergo chemotherapy (table 3). this study also evaluated the response to chemotherapy among patients who received treatment. the majority of patients (n=19; 45%) passed away while bearing chemotherapy. a total of 15 patients (36%) dropped out or lost to follow-up while undergoing chemotherapy cycles. there were 5 patients (12%) who finished their treatment cycle but relapsed and died. in addition, there were 3 patients (7%) who completed their treatment cycle and achieved complete remission (table 3). discussion the results of this study indicate that most of the aml in children is diagnosed at the age of >5–12 years while different studies conducted in the united states demonstrate that the age of diagnosis mostly occurs at the age of less than 1 year and diagnosed at the age of 1–4 years in another study.2,12 boys were predominantly found in this study and consistent with the previous studies.12 acute myeloblastic leukemia shows some abnormal laboratory values like other types of leukemia. on the patient’s blood test, hemoglobin level and thrombocyte were low but usually, the leukocyte count was increased. low levels of hemoglobin and thrombocyte could be reflected by several clinical features that existed in the patients, such as pallor, easy bleeding, and bruising.1 in this study it was found that more than 90% of patients were anemic (<12g/dl) and more than 80% of patients had thrombocytopenia (<100,000 cells/mm3). these findings are supported by similar studies showing that aml patients have anemia and thrombocytopenia on laboratory findings.13 there were 35 patients (76%) with leukocytosis ≥10,000 cells/mm3, even 8 of them had severe hyperleukocytosis (≥100,000 cells/mm3). likewise, an increase in white blood cells was found in a previous study. all these values may be due to the accumulation of leukemic cells in the bone marrow and interfering with normal blood cell production resulting in anemia, thrombocytopenia, and hyperleukocytosis in aml patients.14 peripheral blood smears are also conducted in blood tests. according to ciesla’s15 theory, aml patients as well as other acute leukemia patients often show high levels in immature blood cells or blasts. this theory correlates with the result of this study that most aml patients showed high levels of blast cell (≥20%). the main diagnostic method for aml patients is bone marrow puncture where it can evaluate myeloblasts infiltration in the bone marrow,15 then classified using fab classification. this study showed that 14 patients (30.4%) had table 3 chemotherapy status and therapeutic outcomes total (n=46) n % chemotherapy status undergo chemotherapy no chemotherapy 42 4 91 9 therapeutic outcome (n=42) complete remission relapse and died died during chemotherapy loss to follow up 3 5 19 15 7 12 45 36 althea medical journal march 2022 althea medical journal. 2022;9(1) 47 m2 classification along with m1 and m3 in second and third places. none of the patients showed the m7 subtype in this study. mukda et al.16 collected data on pediatric aml in one hospital in thailand showing that m2 was the most common subtype followed by m1. for comparison, we found a study in european countries containing aml patients with fabclassification. it was stated that the most common subtype was m2.17 this fab-based classification demonstrates quite various results in each study. from the information listed above, it can be assumed that the most common fab subtypes in children are m1, m2, and m3. after the patients are confirmed by bone marrow puncture, the patients should undergo chemotherapy to reduce the leukemic cells. on the other hand, some patients refuse to do therapy for some reason. of the 46 subjects in this study, there were 4 subjects (9%) who refused to undergo chemotherapy. the main reason patients refuse chemotherapy is because they doubt the effectiveness of chemotherapy or prefer alternative medicine. a study in china18 was also conducted on the childhood aml therapy. the study revealed that sixty patients (32%) refused chemotherapy. the reason for therapy refusal may be related to poor economic status and low knowledge about leukemia.18 however, most of the subjects (91%) in this study decided to undergo chemotherapy. chemotherapy is divided into twophases, namely the induction phase and the consolidation phase. the induction phase is directed to achieve remission (blast cells <20%) and controlled leukemic process which will be evaluated by re-performing a bone marrow puncture, whereas the consolidation phase is a more intensive therapy to remove the remaining leukemic cells.19 although chemotherapy is still ongoing, some patients could not survive. a local study at cipto mangunkusumo general hospital jakarta3 showed that death in the induction and consolidation phases was the highest contributor, 38% and 34%, respectively. this study results are also similar to a previous study conducted at the cipto mangunkusumo general hospital jakarta. there were 19 patients (45.2%) died during the process of chemotherapy. moreover, 5 patients (12%) were found to have relapsed and passed away in this study. a similar previous study on the outcome of aml therapy also demonstrated 20.3% of patients were found to have relapsed and died.18 high mortality rates are still a major problem in lower-middle income countries. the high mortality rate can be caused by many factors such as the clinical condition of patients, punctual schedule of chemotherapy, and the availability of bone marrow transplantation methods.3 therapy abandonment also plays a big challenge in curing aml patients. many patients drop out during chemotherapy. this study showed that 15 patients (36%) abandoned therapy. this occurs when they are already on a chemotherapy regimen or starting their first cycle of chemotherapy. patients need to come to the hospital every 1–3 weeks to continue the chemotherapy cycle. this variable was determined by assessing the data written in the medical record of the last chemotherapy conducted and there was no further information whether the patient passed away or survived. previous study on cancer management in children at dr. hasan sadikin general hospital bandung revealed that 51% of aml patients abandoned therapy.5 therapy abandonment in lowermiddle income countries such as indonesia, could be related to financial problems, doubts about possible cures and alternative medicine.5,18 despite the poor outcome in aml patients, this study found that 3 patients (7%) achieved complete remission. when compared with western countries where the survival rate for pediatric aml is more than 50%, improvement and evaluations in therapeutic methods are still needed.1 in comparison, a previous study in the us showed that 74% of pediatric aml patients had a good response to the chemotherapy.20 the limitations of this study are incomplete medical records and samples taken from one center only. in addition, chemotherapy in the medical record was not classified into the induction or consolidation phase. hence, adequate information and a larger sample size are needed to generalize the study. it is recommended for further studies to identify risk factors for pediatric aml mortality. in conclusion, aml predominantly occurs in the age group of >5–12 years and males. the most common laboratory findings in children with aml are moderate anemia, leukocytosis, severe thrombocytopenia, and high blast cell count. the most common fab subtype is aml-m2. majority of patients undergo therapy and most patients die during chemotherapy. references 1. lanzkowsky p, lipton j, fish jd, editors. filbert lois marcus et al.: therapeutic outcomes of pediatric acute myeloblastic leukemia patients at a tertiary hospital in bandung, indonesia althea medical journal. 2022;9(1) 48 manual of pediatric hematology and oncology. 6th ed. london: academic press; 2016. p. 390–406. 2. dores gm, devesa ss, curtis re, linet ms, morton lm. acute leukemia incidence and patient survival among children and adults in the united states, 2001–2007. blood. 2012;119(1):34–43. 3. sjakti ha, gatot d, windiastuti e. hasil pengobatan leukemia mieloblastik akut pada anak. sari pediatri. 2016;14(1):40-5. 4. ward e, desantis c, robbins a, kohler b, jemal a. childhood and adolescent cancer statistics, 2014. ca cancer j clin. 2014;64(2):83–103. 5. sari nm, reniarti l, suryawan n, susanah s, wahyudi k. burden of pediatric cancer treatment: results of online pediatric cancer registry prototype 1 at a third referral hospital in indonesia. althea medical journal. 2017;4(3):461–7. 6. chen g, wu j. molecular classification of acute leukemia. in: chaubey yp, editor. proceedings of statistics 2011 canada/ imst 2011-fim xx; 2011 july 1–4; montreal, canada. singapore: world scientific; 2013. p. 60–74.. 7. direktorat pengendalian penyakit tidak menular, direktorat jenderal pp & pl kementrian kesehatan ri. pedoman penemuan dini kanker pada anak. jakarta: kementerian kesehatan ri; 2011. 8. rubnitz je. current management of childhood acute myeloid leukemia. pediatr drugs. 2017;19(1):1–10. 9. sander a, zimmermann m, dworzak m, fleischhack g, von neuhoff c, reinhardt d, et al. consequent and intensified relapse therapy improved survival in pediatric aml: results of relapse treatment in 379 patients of three consecutive aml-bfm trials. leukemia. 2010;24(8):1422–8. 10. handayani k, sitaresmi mn, supriyadi e, widjajanto ph, susilawati d, njuguna f, et al. delays in diagnosis and treatment of childhood cancer in indonesia. pediatr blood cancer. 2016;63(12):2189–96. 11. harrison cj, hills rk, moorman av., grimwade dj, hann i, webb dkh, et al. cytogenetics of childhood acute myeloid leukemia: united kingdom medical research council treatment trials aml 10 and 12. j clin oncol. 2010;28(16):2674– 81. 12. barrington-trimis jl, cockburn m, metayer c, gauderman wj, wiemels j, mckeancowdin r. trends in childhood leukemia incidence over two decades from 1992 to 2013. int j cancer. 2017;140(5):1000–8. 13. davis as, viera aj, mead md. leukemia: an overview for primary care. am fam physician. 2014;89(9):731–8. 14. rahadiyanto ky, liana p, indriani b. pola gambaran darah tepi pada penderita leukimia di laboratorium klinik rsup dr. moh. hoesin palembang. maj kedokteran sriwijaya. 2014;46(4):259–65. 15. ciesla b. hematology in practice. 3rd ed revised. philadelphia: fa davis co; 2019. 16. mukda e, pintaraks k, sawangpanich r, wiangnon s, pakakasama s. flt3 and npm1 gene mutations in childhood acute myeloblastic leukemia. asian pacific j cancer prev. 2011;12(7):1827–31. 17. støve hk, sandahl jd, abrahamsson j, asdahl ph, forestier e, ha sy, et al. extramedullary leukemia in children with acute myeloid leukemia: a populationbased cohort study from the nordic society of pediatric hematology and oncology (nopho). pediatr blood cancer. 2017;64(12):1–9. 18. xu xj, tang ym, song h, yang sl, shi sw, wei j. long-term outcome of childhood acute myeloid leukemia in a developing country: experience from a children’s hospital in china. leuk lymphoma. 2010;51(12):2262–9. 19. nannya y, kurokawa m. [acute myeloid leukemia]. nihon rinsho. 2012;70 suppl 8:496–500. 20. abrahamsson j, forestier e, heldrup j, jahnukainen k, jónsson óg, lausen b, et al. response-guided induction therapy in pediatric acute myeloid leukemia with excellent remission rate. j clin oncol. 2011;29(3):310–5. althea medical journal march 2022 amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 80 knowledge and attitudes towards premarital screening among adolescents: a study in a university setting annisa triska almanda dewi,1 ari indra susanti,1,2 fedri ruluwedrata rinawan,2 sharon gondodiputro,2 neneng martini1,2 1midwifery diplome program, faculty of medicine universitas padjadjaran, indonesia, 2departement of public health, faculty of medicine universitas padjadjaran, indonesia correspondence: annisa triska almanda dewi, midwifery diplome program, faculty of medicine universitas padjadjaran, jalan raya bandung sumedang km 21, jatinangor, sumedang, indonesia, e-mail: annisa17043@mail.unpad.ac.id introduction premarital screening (pms) is a screening that needs to be done by couples before marriage. pms can detect sexually transmitted infections (stis) and genetic predisposition to disease.1 implementation of pms can reduce the incidence of genetic diseases and also prevent the transmission of infections that have an impact on reproductive health. pms consists of blood group, hepatitis b, toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex (torch), hiv/aids, blood sugar, and urine tests.2 these tests are essential since there are still many incidences of genetic diseases and stis in indonesia. the health profile of indonesia in 2019 has shown 46,064 hbsag-reactive mothers and 6,439 hivpositive pregnant women.3 more than 90% of hiv-infected babies are affected by hiv-positive mothers.4 concerning infection diseases, 95% of hepatitis transmission occurred vertically, specifically from hepatitis b-positive mothers to their babies.5 as for genetic diseases, indonesia is one of the countries at high risk of thalassemia since indonesia has many thalassemia trait carriers.6 it is estimated that around 3,000 babies with thalassemia are born each year.7 in many countries, pms is a mandatory requirement for couples who want to marry. only the tetanus toxoid (tt) immunization card has become mandatory before marriage in indonesia.8 the test of pms is still in the form of a recommendation.9 a previous study conducted in yemen10 shows that most medical students agree and have sufficient knowledge on each component of the premarital health test. however, a few students reject it, so they need education about pms to increase althea medical journal. 2022;9(2):80–85 abstract background: premarital screening (pms) is an action to prevent the occurrence of genetic and the transmission of infectious diseases. the screening has been recommended and promoted in indonesia. this study aimed to assess the level of knowledge and attitudes towards premarital screening among teenagers in a university setting. methods: this study used a cross-sectional design, including 310 adolescents aged 18–21 years at obtained through a non-random consecutive sampling at universitas padjadjaran. the data was collected from october 2020 until january 2021 using a close-ended questionnaire, assessing knowledge and attitude towards the pms. the frequency knowledge level was grouped as good, moderate, and poor. the attitude level was categorized as positive and negative. results: most of the respondents (90.3%) had good knowledge of pms. respondents who had positive attitudes (79%) strong agreed that carrying out pms was important, and 51% perceived that pms needed to be a mandatory procedure before marriage. however, 59.6% had no idea how to deal if the result of the pms was positive. conclusion: in general, adolescents at universitas padjadjaran have good knowledge and a positive attitude towards pms. however, comprehensive information about pms is still needed, especially on decision points that must be taken after getting the test results. keywords: adolescent, attitude, knowledge, premarital screening https://doi.org/10.15850/amj.v9n2.2502 althea medical journal. 2022;9(2) 81 knowledge and attitudes, especially those who reject it.10 adolescence is the right period to increase knowledge because this period is full of biological, cognitive, emotional, and social changes, as well as ongoing brain development.11 the long period in adolescence also allows for many changes that directly or indirectly affect attitudes. the views of the education obtained and where they live also affect differences in knowledge and attitudes towards pms.12 a group of university students is well-positioned to receive the appropriate information.13 therefore, this study aimed to describe the level of knowledge and attitudes towards adolescents’ premarital screening in a university setting. methods this descriptive study used a cross-sectional approach and was carried out from october 2020 to january 2021 at universitas padjadjaran. the inclusion criteria in this study were university students aged 18–21 years who had filled informed consent form voluntarily. the study excluded students who were married. the sample size was estimated using the descriptive sample size formula with estimated precision (95% confidence level).14 the number of samples (n=310) was divided proportionally into 16 faculties. this study obtained approval from the research ethics committee, universitas padjadjaran with no. 1015/un6.kep/ec/2020. this study collected data using a closeended questionnaire that assessed knowledge and attitudes towards the premarital test. the questionnare was obtained from the relevant literature with permission from the author. a certified professional english level (c2) translator translated the english components into indonesian. then, these components were developed into questionnaire statements. the questionnaire consists of 3 parts. the first part was about the socio-demographic data, including gender, domicile, faculty, academic level, and personal and family medical history. the second part measured knowledge comprising 15 statements about premarital screening, its purpose, availability in indonesia, included tests, disease targets of premarital screening, and who need the test. measurements used the guttman scale with two options: “true” or “false”. in the third part, 25 statements were constructed to assess attitudes towards pms. the measurement used a likert scale with four scale options, “strongly agree”, “agree”, “disagree”, or “strongly disagree”, without providing a “neutral” option that can improve validity.15 the questionnaire was tested for validity and reliability on 30 adolescents in bandung. all of the attitude statements could be processed on the validity test. however, three statements on the knowledge questionnaire could not be table 1 distribution of respondent’s characteristics characteristic frequency (n) percentage (%) gender male female 77 233 24.8 75.2 domicile city district 216 94 69.7 30.3 faculty health non-health 75 235 24.2 75.8 academic level 1–4 5–8 74 236 23.9 76.1 personal history of diseases yes no 26 284 8.4 91.6 family history of diseases yes no 35 275 11.3 88.7 annisa triska almanda dewi et al.: knowledge and attitudes towards premarital screening among adolescents: a study in a university setting althea medical journal. 2022;9(2) 82 processed on the validity test. therefore, the translation of the statement was improved so the meaning was better understood and it was not ambiguous.16 the knowledge and attitude had cronbach’s alpha values of 0.618 and 0.863, respectively. the research questionnaire was uploaded to the google form and shared via email and chat application (line). the research data was entered into the spss version 15.0 data processing system. the correct answer in the knowledge questionnaire was scored as one and the wrong answer as 0. the maximum score of the knowledge questionnaire was 15, which then was presented into three categories. knowledge was good if the score was ≥75%, sufficient if the score was 56–74%, and poor if the score was less than 55%.12 while the maximum score for the attitude questionnaire was 100, which was categorized as positive if the value was 75%, and negative if the value was <75%.17 results in total, 382 responses were collected during three months of data collection. then, 310 data were taken using consecutive non-random sampling, according to the sample size, and sufficed the proportions of each faculty. most of the respondents (75.2%) were female, 69.7% of respondents lived in the city, and 75.8% of respondents were from non-health faculties. in addition, 8.4% of adolescents had a history of disease, and 11.3% had a family history of disease (table 1). the primary source of pms information was obtained from online media (39.4%), from friends (14.2%), and only 8.1% of respondents received it from health workers, as shown in figure. almost all adolescents at universitas padjadjaran (90.3%) had good knowledge of pms and most of the respondents (75.5%) had a positive attitude towards the premarital figure information sources of premarital screening althea medical journal june 2022 39.4% 12.9% 6.5% 9.7% 13.5%14.2% 8.1% online media friends family campus school health service print media table 2 knowledge level and attitude towards premarital screening among adolescents at universitas padjadjaran variable frequency (n) percentage (%) knowledge good moderate poor 280 29 1 90.3 9.4 0.3 attitude positive negative 234 76 75.5 24.5 althea medical journal. 2022;9(2) 83annisa triska almanda dewi et al.: knowledge and attitudes towards premarital screening among adolescents: a study in a university setting medical test (table 2). most of the respondents (79%) strongly agreed that it was essential to do the pms, 73.2% of respondents strongly agreed to consider pms to be mandatory in indonesia, and 53.2% of respondents strongly agreed that they were convinced to carry out a premarital screening. most of the respondents (73.5%) strongly agreed that preventing disease transmission to their offspring was the reason for conducting pms. the majority of respondents did not agree with the reasons for refusing to do a pms. the reason for refusing to do a pms because a positive result might prevent marriage was agreed by 9.7% of respondents. as many as 44.8% of adolescents agreed they would carry out pms even though their partners do not ask for it; 52.3% of adolescents also strongly agreed that the right time to carry out pms was before marriage. if the results of pms showed that they would transmit the disease to their offspring, 45.8% of adolescents agreed that table 3 attitude towards premarital screening among adolescents (n=310) at universitas padjadjaran attitude description strongly agree agree disagree strongly disagree % % % % carrying out pms is important considering that pms should be carried out in indonesia convinced to carrying out pms 79 73.2 53.2 20.3 23.2 40.6 3 1.6 5.5 3 1.9 0.6 reasons for approval to carry out pms prevent transmission diseases to my children ensure my partner’s health prevent transmission diseases to me ensuring my fitness for marriage 73.5 71 71 63.9 23.2 25.8 26.5 31 2.9 2.9 2.6 5.2 0.3 0.3 0 0 reasons for refusal to carry out pms do not want to interfere with god’s will the results may not be in favor of my choice it can prevent my marriage if the results are positive it may cause a family’s declination of marriage continuance the result will be an insult to me 0.6 1.6 1.6 1.6 1 3.5 5.8 9.7 7.7 2.3 31.0 45.5 46.8 42.9 41.6 64.8 47.1 41.9 47.7 55.2 i am willing to carry out pms despite the fact that my partner will not ask me to do so if my partner asks me to do so 43.5 41.9 44.8 37.7 8.1 13.5 3.5 20.3 perceive the appropriate time to take a premarital health test is: in engagement before marriage after married 24.2 52.3 2.6 44.5 39.7 7.1 24.8 7.1 37.1 6.5 1 53.2 response if the test results indicate that you will transfer the disease onto your offspring: continue my engagement and marriage, because i believe in god cancel the engagement my decision to continue marriage is based on the possibility of disease occurrence itself have no idea how to deal continue my engagement and marriage if there is a family compulsion continue to carry out engagement and marriage based on emotional considerations 18.7 5.8 24.2 21.9 10.3 7.7 40.6 33.9 45.8 37.7 38.7 33.9 31.9 43.5 21.3 28.4 41.9 42.9 8.7 16.8 8.7 11.9 9.0 15.5 perceiving that pms test is necessary to be generated as a required procedure before marriage 51.0 36.5 10.3 2.3 perceiving there should be laws and regulations to stop marriage with positive results in pms 18.7 28.1 36.5 16.8 note: pms= premarital screening althea medical journal. 2022;9(2) 84 the decision to continue the marriage depends on how likely the disease was. attitude regarding the pms policy, 51.0% of adolescents strongly agreed that pms needs to be a mandatory procedure before marriage. furthermore, 36.5% of adolescents did not agree to regulations and laws to stop marriage in pms-positive cases (table 3). discussion this study showed that adolescents in universitas padjadjaran had good knowledge of pms. knowledge of pms is all the learning outcome about pms from information sources.18 one’s knowledge is continuously formed whenever a reorganization of new understanding occurs.12 adolescents who had good knowledge in this study meant a correct understanding of pms. the majority of adolescents in this study had good knowledge because they were university students. this is consistent with a study in jordan19 that shows university students have good knowledge about mandatory premarital screening. the character of the respondents as university students affects the learning process. a person with higher education receives information from media or other people more quickly, which can increase knowledge. likewise pms information, the more people discuss or read the media about pms, the more knowledge they will have.12 generally, adolescents in universitas padjadjaran had a positive attitude towards premarital medical tests. this finding is consistent with the study in yemen10 that many of the respondents agreed to undergo a premarital screening program. the adolescent’s reason for carrying out premarital health tests was to prevent the spread of disease to their offspring. do not want to interfere with god’s will, as a reason for refusing pms was approved only by several adolescents in this study. this is in contrast to the study conducted in yemen10, those who do not conduct pms regard taking the test as interfering with god’s will. however, the adolescent’s belief was not a reason for refusing to perform a premarital screening, which means that adolescents in the university understood the purpose of carrying out pms. the majority of adolescents agreed that the appropriate time to conduct pms was before marriage. it reveals that adolescents are already aware that performing pms can avoid disappointment after marriage if there are positive cases.10 besides that, the appropriate time to do pms was when about to get engaged/ propose, which was only approved by some adolescents and was not approved by others. determining the appropriate time to carry out premarital screening is very important because it will affect the implementation of the test. teenagers in this study agreed that if they received a positive result on pms (which could transmit a disease to their offspring), the continuation of the marriage plans would depend on how likely the disease was. in contrast to the results presented in a study on medical students, the response is to cancel the marriage.10 this study also showed that some adolescents did not know what to do if they got positive results when doing a premarital health test. it recorded that information about decision and continuation after getting the test results was needed to support adolescents’ attitudes. most adolescents felt that pms needed to be a mandatory procedure before marriage, meaning, that most adolescents agreed that all couples should do pms. this is consistent with the findings of a study in north jordan19 that most respondents thought all future couples should perform pms. only a tiny proportion of adolescents feel the regulations and laws to stop marriage in positive cases during pms are needed. this is very different from a study conducted in yemen10, which found that 62% of the respondents accepted these regulations and laws. related to the appropriate time for pms, the family has prepared for the marriage, so it is not easy for couples to leave each other. canceling the engagement is also not easy; there will be a possibility of stigma on the couple and their families.19 therefore, providing appropriate information to couples who perform pms is needed. henceforth, adolescents who already know pms well can have a more positive attitude. the limitation of this study is that the current result only presented educated adolescents from a university; therefore, it is not representative of adolescents in indonesia generally. it considers education as one of the factors that influence knowledge and attitudes.12 therefore, a similar study is needed to reach out to more respondents from various education levels . to conclude, adolescents in universitas padjadjaran have good knowledge and positive attitudes towards pms. however, some adolescents do not know what to do if they get a positive result on a premarital health test and continue their risky marriage. therefore, it is althea medical journal june 2022 althea medical journal. 2022;9(2) 85 necessary to provide complete information about pms for adolescents to increase their knowledge which will enhance positive attitudes,20 especially on what decision they should make after receiving the results of the premarital health test. references 1. moussa s, al-zaylai f, al-shammari b, al-malaq ka, rashed al-shammari s, alshammari tf. knowledge and attitude towards premarital screening and genetic counseling program among female university students, hail region, saudi arabia. int j med health res. 2018;4(1):1– 6. 2. kemenkes ri. 7 jenis tes dalam cek pranikah yang akan dijalani calon pengantin jakarta: direktorat promosi kesehatan dan pemberdayaan masyarakat kemenkes ri; 2019 [cited 2021 june 21]. available from: https://promkes.kemkes.go.id/7jenis-tes-dalam-cek-pra-nikah-yang-akandijalani-calon-pengantin. 3. budijanto d. data dan informasi profil kesehatan indonesia tahun 2019. jakarta: kementerian kesehatan republik indonesia; 2020. 4. fitria a, aisyah s. analisis tes hiv dengan sikap ibu hamil dalam pencegahan penyakit hiv/aids di wilayah kerja upt puskesmas stabat lama tahun 2018. jurnal ilmiah universitas batanghari jambi. 2019;19(1):183–90. 5. bustami a, anita a. pencegahan transmisi virus hepatitis b pada masa perinatal. jurnal ilmiah keperawatan sai betik. 2020;15(2):145–56. 6. jaka psd, lestari dwwd, rujito l. persepsi calon pasangan menikah di banyumas terhadap skrining thalassemia: studi kualitatif. buletin penelitian kesehatan. 2019;47(2):115–24. 7. hastuti rp. analisis faktor yang berhubungan dengan tingkat kecemasan orang tua anak thalasemia di rsud ahmad yani metro. jurnal kesehatan metro sai wawai. 2015;8(2):49–54. 8. shodikin f, garfes hp. implementasi premarital check up sebagai syarat pra nikah di kantor urusan agama (kua) kecamatan tanah abang. dirasat. 2020;15(1):23–34. 9. yulivantina ev, gunarmi g, mufdlilah m. interprofessional collaboration in premarital services at tegalrejo community health public, yogyakarta. journal of health. 2021;8(1):42–54. 10. al-nood ha, al-akmar mm, al-erynai ef. knowledge and attitudes of sana’a university medical students towards premarital screening. yemeni j med sci. 2016;10:39–46. 11. alderman em, breuner cc; committee on adolescence. unique needs of the adolescent. pediatrics. 2019;144(6):e20193150. 12. budiman ra. kapita selekta kuesioner pengetahuan dan sikap dalam penelitian kesehatan. jakarta: salemba medika; 2013. 13. astuti s, judistiani td, rahmiati l, susanti ai. comparison of knowledge, attitude, motivation-to-breastfeed exclusively between allied health students and students of other fields at universitas padjadjaran. majalah kedokteran bandung. 2016;48(3):176–80. 14. hulley sb, cummings sr, bowner ws, grady dg, newman tb. designing clinical research. 4th ed. philadelphia: wolters kluwer health/lippincot william & wilkins; 2013. 15. decastellarnau a. a classification of response scale characteristics that affect data quality: a literature review. qual quant. 2018;52(4):1523–59. 16. sarwiningsih r. the comparison accuracy estimation of test reliability coefficients for national chemistry examination in jambi province on academic year 2014/2015. jkpk.2017;2(1):34–42. 17. nugraheni sa, martini m, kartasurya m, johan i, ambari rp, sulistiawati e, et al. the change of knowledge and attitude of bride and groom candidate after reproductive health pre-marital course by kua officer. kemas. 2018;14(1):126–32. 18. wati w, richard sd, wahyuningsih a. pengetahuan dan sikap mahasiswa terhadap skrining pra nikah: literature review. jurnal penelitian keperawatan. 2021;7(1):65–72. 19. alkhaldi sm, khatatbeh mm, berggren ve, taha ha. knowledge and attitudes toward mandatory premarital screening among university students in north jordan. hemoglobin. 2016;40(2):118–24. 20. ali m, elshabory n, hassan h, zahra n, alrefai h. perception about premarital screening and genetic counseling among males and females nursing students. iosr jnhs. 2018;7(1):51–7. annisa triska almanda dewi et al.: knowledge and attitudes towards premarital screening among adolescents: a study in a university setting amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 43 level of knowledge, attitude, and behavior among specialists of otorhinolaryngology-head and neck surgery in west java towards cochlear implants annisa ramadhanti,1 lina lasminingrum,2 sally mahdiani,2 arif dermawan,2 bambang purwanto2 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology-head and neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: annisa ramadhanti, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: annisa18053@mail.unpad.ac.id introduction hearing loss and deafness are experienced by 5.5% of the world’s population, or approximately 430 million people.1,2 the prevalence of hearing loss in indonesia reaches 2.6%, with a 0.09% prevalence of deafness. the prevalence of hearing loss and deafness in west java is also close to the national prevalence, which is approximately 2.5% and 0.06%.3,4 normally, humans can hear up to 25 decibels (db), while hearing loss patients’ hearing ability varies depending on the disease’s severity.5 mild degree of hearing loss was diagnosed when the patient hears sounds in the range of 26–40 db, moderate degrees within a range of 41–60 db, severe degrees within a range of 61–80 db, and very severe hearing loss is when the patient can only hear sounds of 81 db or more.6 hearing loss can also be grouped into conductive, sensorineural and mixed hearing loss.7 hearing loss can affect the “golden period” of hearing and speech development in the first 6 months until 2 years of life. therefore, it is important to do screening, detection, and treat hearing loss as early as possible.7–9 choice of treatment for patients with severe and very severe sensorineural hearing loss is hearing aids or cochlear implants, as an effort to restore hearing.10,11 althea medical journal. 2023;10(1):43–50 abstract background: hearing loss and deafness are still an issue in indonesia, especially in west java, with a prevalence of 2.5% and 0.06%, respectively. cochlear implants are intended for patients with severe sensorineural hearing loss to stimulate the remaining auditory nerves. based on their competency standards, otorhinolaryngology-head and neck surgery (orl-hns) specialists are expected to be able to inform patients and families about the cochlear implantation procedures. this study aimed to explore the level of knowledge, attitudes, and behavior of orl-hns specialists in west java towards cochlear implants. methods: this study was a descriptive study with a cross-sectional approach. primary data were collected through a questionnaire filled out by orl-hns specialists who were actively working in west java in 2021–2022. results: data from 157 specialists showed that 41.4% (n=65) had good knowledge about cochlear implants, and 43.9% (n=69) had adequate knowledge, however, 62.4% (n=98) showed a negative attitude. in addition, 99.3% (n=156) showed good behavior. conclusions: orl-hns specialists in west java have a sufficient level of knowledge, negative attitude, and good behavior towards cochlear implants. the negative attitude of the specialists need to be bettered, updating their knowledge about how cochlear implants work and their effectiveness for patients with hearing impairments might give them a new perspective and hopefully change their attitude towards cochlear implants. keywords: cochlear implants, hearing loss, orl-hns https://doi.org/10.15850/amj.v10n1.2684 althea medical journal. 2023;10(1) 44 the cochlear implant is an electronic device containing a current source and an array of electrodes to stimulate functional auditory nerve fibers. a cochlear implant is surgically placed and has two components. the outer component is placed behind the ear, the inner components are implanted under the skin, and the electrode is implanted in the cochlea at the scala tympani.10,12 the cochlear implant captures sound from the microphone behind the ear. then the sound processing section selects and regulates the sound and forwards it to the implant body under the skin, where the sound waves will be converted into electrical impulses by the transmitter and the receiver. next, the electrical impulses are delivered to the auditory nerves by the electrode array section in the cochlea. hearing loss patients with cochlear implants cannot hear as clearly as normal people, but this device provides a representation of sound that is expected to help patient understand speech.12,13 the installation of cochlear implants in indonesia is considered to be very low, which only 1,500 users, according to data from the indonesian cochlear implant family organization (keluarga implan koklea indonesia).14 based on the indonesian national population and family planning agency (badan kependudukan dan keluarga berencana nasional) statement, 4.8 million indonesian children are born each year.15 meanwhile, data from the ministry of health shows that the proportion of congenital hearing loss reaches 0.11%.3 therefore, it can be estimated that approximately 5,000 babies will be born with congenital hearing loss every year in indonesia.16 the lack of cochlear implantation in indonesia, especially in west java, can be influenced by the lack of parents’ awareness to immediately check their child with an indication of hearing loss, the inability to pay for the cochlear implants, which is relatively expensive (30 to 50 million rupiahs), or lack of clarity of information given by the doctor regarding the management of congenital deafness and sensorineural hearing loss.17,18 competency of indonesian otorhinolaryngology-head and neck surgery (orl-hns) specialists for congenital deafness is at level 3a, meaning that orl-hns specialists are expected to be able to diagnose, provide initial therapy, and make non-emergency referrals. in addition, their competency for perceptive deafness and conductive deafness is at level 4, means that orl-hns specialists are expected to be able to do screening, diagnose, educate, and carry out treatment. therefore, orl-hns specialists should be able to provide information to patients and their families regarding the cochlear implantation procedure.19 therefore, this research was conducted to identify the level of knowledge, attitude, and behavior of orl-hns specialists in west java towards cochlear implants. methods this study was a descriptive study with a cross-sectional approach that aimed to obtain information and provide an accurate situation profile.20 each subject was observed once and the measurement of subject variables was carried out during the examination to obtain the level of knowledge, attitudes, and behavior of orl-hns specialists in west java towards cochlear implants. primary data was obtained through a questionnaire. this research was conducted online from july 2021 to january 2022. the subject population of this research was orl-hns specialists who were actively working in west java 2021–2022. the research sample was taken using the total sampling technique, which means that the entire population was taken as a sample unit.21 data measurement in this study was done using the guttman scale, which is a cumulative scale used to answer questions clearly and consistently. for example, yes or no, agree or disagree, and so on. each respondent’s answer was given the same points.22 an online questionnaire regarding the level of knowledge, attitudes, and behavior of orlhns specialists in west java towards cochlear implants was distributed using a google form. the questionnaire contained research explanation sheets, informed consent forms, characteristics of the respondents (age, education, work experience as a doctor, work institution, and telephone number), 10 knowledge questions, 4 attitude questions, and 4 behavioral questions. knowledge questions with correct answers were worth 1 point, and an incorrect answer was worth 0 point with “do not know” answers were entered as incorrect answers. the total score of the knowledge questions ranged from 0 to 10 points. then categorization was done base on the number of points, 8 to 10 points (76–100%) were categorized as good knowledge, 6 to 7 points (56–75%) were categorized as adequate knowledge, and 0 to 5 points (<56%) categorized as poor knowledge.22 althea medical journal march 2023 althea medical journal. 2023;10(1) 45annisa ramadhanti et al.: level of knowledge, attitude, and behavior among specialists of otorhinolaryngology-head and neck surgery in west java towards cochlear implants table 1 demographic characteristics of orl-hns specialists in west java (n=157) variable frequency (n) percentage (% ) age (years old) 25–35 36–45 >45 22 73 62 14.0 46.5 39.5 educational degree master’s doctorate 145 12 92.4 7.6 work experience (years) 0–5 5–10 10–15 >15 19 22 38 78 12.1 14.0 24.2 49.7 work institution class a general hospital class b general hospital class c general hospital class d general hospital class a specialist hospital class b specialist hospital class c specialist hospital private clinic / public health center 20 89 60 7 1 1 1 4 12.7 56.7 38.2 4.5 0.6 0.6 0.6 2.5 on attitude and behavior questions, a positive question with a “yes” answer was worth 1 point and a “no” answer was worth 0 points. on the other hand, for negative questions, the answer “no” was worth 1 point and the answer “yes” was worth 0 point. attitude and behavior questions ranged from 0 to 4 points. then categorization was done based on the number of points, 3 to 4 points (50–100%) were categorized as positive attitude/good behavior, and 0 to 2 points (<50%) were categorized as negative attitude/ poor behavior.22 the collected data were then analyzed using descriptive statistics using statistical software (microsoft® excel 2016 and ibm® spss® version 25).23 before the study was conducted, the questionnaire had been tested for validity with pearson correlation and showed a significance level of 0.01.24 the reliability test was also carried out using cronbach’s alpha and showed reliability level of 0.6 which means that the reliability was accepted.25 validity and reliability tests were carried out on 50 orlhns specialists outside west java. this study has also received ethical approval from the research ethics committee of universitas padjadjaran with reference number 911/un6.kep/ec/2021 and registration number 0121090969. results there were 157 respondents (96.3% of total number of orl-hns specialists in west java) which were dominated by the age group of 36–45 years with a total of 73 respondents (46.5%), education level of master’s degree with a total of 145 respondents (92.4%), and work experience of more than 15 years with a total of 78 respondents (49.7%) (table 1). considering that the respondents were orl-hns specialists in west java, the respondents may work in 2–3 working institutions.26 therefore, when the data on work institutions were added up, the result was more than 100%. the data showed that most of the respondents worked in class b general hospital with a total of 89 respondents (56.7%), followed by class c general hospital with 60 respondents (38.2%), class a general hospital with 20 respondents (12.7%), and class d general hospital with 7 respondents (4.5%). four respondents (2.5%) also worked in private clinics/public health center, and there was 1 respondent (0.6%) in each class a, b, and c specialist hospital (table 1). data on knowledge, attitudes, and behavior based on the distribution of questionnaire questions were listed in table 2, table 3, althea medical journal. 2023;10(1) 46 althea medical journal march 2023 table 2 assessment of knowledge level based on questions distribution no knowledge questions n= 157 level of knowledge n (%) true n (%) false n (%) do not know n (%) 1. the prevalence of congenital hearing loss in indonesia reaches 1 permille. 108 (68.8) 20 (12.7) 29 (18.5) 108 (68.8) 2. in very severe sensorineural hearing loss, the auditory nerve does not function at all. 81 (51.6) 75 (47.8) 1 (0.6) 75 (47.8) 3. all people with congenital hearing loss are candidates for cochlear implants. 55 (35) 101 (64.3) 1 (0.6) 101 (64.3) 4. cochlear implants are only suitable for hearing loss in children. 15 (9.6) 142 (90.4) 0 (0) 142 (90.4) 5. cochlear implants may be indicated for single-sided deafness. 101 (64.3) 52 (33.1) 4 (2.5) 101 (64.3) 6. cochlear implants work by amplifying sound. 49 (31.2) 105 (66.9) 3 (1.9) 105 (66.9) 7. cochlear implants work by stimulating the median nerve. 57 (36.3) 92 (58.6) 8 (5.1) 92 (58.6) 8. a cochlear implant consists of two main components, external and internal component. 145 (92.4) 6 (3.8%) 6 (3.8) 145 (92.4) 9. cochlear implantation is done in several stages (candidacy, surgery, and habilitation). 152 (96.8) 5 (3.2) 0 (0) 152 (96.8) 10. cochlear implants must be replaced within a certain period of time. 42 (26.8) 103 (65.6) 12 (7.6) 103 (65.6) and table 4, whereas table 5 showed the cumulative results of the level of knowledge, attitudes, and behavior of respondents towards cochlear implants. respondent’s level of knowledge about cochlear implants was assessed from 10 questions. the results showed that 9 out of 10 questions were answered well by the majority of respondents (table 2). meanwhile, the level of attitude assessed from 4 questions. only 2 out of 4 questions given were successfully answered by the majority of respondents (table 3). as for the level of behavior, which was also assessed from the 4 questions, all questions were answered well by most of the respondents (table 4). the results showed that 65 respondents (41.4%) had good knowledge, 69 respondents (43.9%) had adequate knowledge (10.4%), and 23 respondents (14.6%) had poor knowledge regarding cochlear implants. it also showed that 59 respondents (37.5%) had a positive attitude and the another 98 respondents (62.4%) had a negative attitude towards cochlear implants. however, 156 respondents (99.3%) had good behavior towards cochlear implants, and the another 1 respondent (0.6%) still had poor behavior (table 5). discussion a cochlear implant is a procedure that aims to help people with hearing loss understand speech, thereby facilitating communication in daily activities.10,12,15,27 cochlear implantation is expected to help increase user productivity, considering that the highest prevalence of hearing loss patients is found in groups of people who are not in school, do not work, and have low economic level.4,27 as orl-hns specialists, respondents have a 3a competency level in the congenital deafness management and level 4 competency in the perceptive and conductive deafness management. thus, respondents are expected to have good knowledge, attitudes, and behaviors regarding cochlear implants in order to be able to screen, diagnose, and althea medical journal. 2023;10(1) 47annisa ramadhanti et al.: level of knowledge, attitude, and behavior among specialists of otorhinolaryngology-head and neck surgery in west java towards cochlear implants educate patients and their families about cochlear implants.21 knowledge is information obtained by a person after sensing an object, through sight, hearing, smell, taste and touch. knowledge is influenced by internal factors such as education and age. the higher a person’s education, the higher his knowledge is expected to be, while increasing age is often associated with increasing the maturity of a person’s soul, as well as the experience he has. knowledge is also influenced by external factors such as the work environment. therefore, the background characteristics of the respondents will affect their level of knowledge.24 a person’s knowledge will affect his attitude and behavior, so that these three things are interrelated. attitude is a view of an object or stimulus based on convictions and beliefs that can be positive or negative. meanwhile, behavior is a response or action taken against an object or stimulus.24 the relationship between knowledge, attitudes, and behavior can be found in this research result. as an orl-hns specialist, the respondent should have good knowledge about cochlear implants. nevertheless, data from a total of 157 respondents showed that the highest level of knowledge, namely 69 respondents (43.9%) had adequate knowledge, while only 65 respondents (41.4%) had good knowledge. in addition, the other 23 respondents (14.6%) had poor knowledge. from this level of knowledge, the majority of respondents have good behavior towards cochlear implants, namely 156 respondents table 3 assessment of attitude level based on questions distribution no attitude questions n= 157 level of attitude n (%)yes n (%) no n (%) 1. i believe that screening for hearing loss in infants should be carried out in a fully-equipped health facilities 115 (73.2) 42 (26.8) 42 (26.8) 2. i believe that after a cochlear implant, the patient’s hearing will be as good as a normal person’s. 104 (66.2) 53 (33.8) 53 (33.8) 3. i agree that the patient's age at surgery does not contribute to a successful perception of hearing and speech. 45 (28.7) 112 (71.3) 112 (71.3) 4. i agree if the cost of cochlear implant equipment and surgery are fully covered by the government. 142 (90.4) 15 (9.6) 142 (90.4) table 4 assessment of behavior level based on questions distribution no behavior questions n= 157 level of behavior n (%) yes n (%) no n (%) 1. i would suggest hearing aids for patients with very severe sensorineural hearing loss while checking the patient's eligibility for cochlear implants. 152 (96.8) 5 (3.2) 152 (96.8) 2. i will examine the hearing of a 2 year old child who cannot yet form simple words. 155 (98.7%) 2 (1.3%) 155 (98.7) 3. i will do a hearing screening on babies before they reach 3 months of age. 150 (95.5) 7 (4.5) 150 (95.5) 4. i will perform cochlear implantation for all hearing-impaired patients. 16 (10.2) 141 (89.8) 141 (89.8) althea medical journal. 2023;10(1) 48 (99.3%). unfortunately, the results of the respondents’ attitude assessment showed that more respondents had a negative attitude, namely 98 respondents (62.4%), compared to the other 59 respondents (37.5%) who had a positive attitude. the relationship between respondents’ characteristics and the results of the study can also be seen from the age range and the average score obtained. respondents with an age range of 25–35 years had an average score of 14 out of 18 total questions, with an average knowledge score 7.4 out of 10 questions, attitude 2.2 out of 4 questions, and behavior 3.8 out of 4 questions. meanwhile, respondents with an age range of 35-45 years old had an average score of 13 out of 18 total questions, with an average knowledge score of 7.2 out of 10 questions, attitude 2.3 out of 4 questions, and behavior 3.8 out of 4 questions. then, respondents aged over 45 years had an average score of 13 out of 18 total questions, with an average value of knowledge 6.9 out of 10 questions, attitude 2 out of 4 questions, and behavior 3.7 out of 4 questions. this relationship indicates that younger respondents tend to have better knowledge. this kind of phenomenon may occur due to the development of medical science, especially in the field of orl-hns. the world’s first cochlear implantation in children was performed in 1983.28 meanwhile in indonesia, cochlear implantation was first performed in 2002, so information and practice of cochlear implants were still relatively new at that time.29 cochlear implantation at that time also prompted a reform of the teaching system during the medical residency program (program pendidikan dokter spesialis, ppds), which would affect the current level of knowledge of the respondents.. based on the level of education, respondents with a doctoral degree (s3) also have a slightly better average score than respondents with a master’s degree (s2), namely 14 points out of a total of 18 questions, with a knowledge score of 8 points out of 10 questions, attitude 2.3 points out of 10 questions., and behavior 3.9 points out of 4 questions. meanwhile, respondents with a master’s degree (s2) have an average score of 13 points out of a total of 18 questions, with details of the average knowledge value being 7 points out of 10 questions, attitude 2.2 points out of 4 questions, and behavior 3.8 points out of 4 questions. it is unfortunate that not all respondents have good knowledge of cochlear implants, even some respondents show a concerning level of knowledge and attitude , namely 2 points out of 10 questions, and 0 points out of 4 questions. even during the study, the orl-hns specialist in west java showed a lack of concern for cochlear implants, as evidenced by the many subjects who needed to be contacted repeatedly and subjects who refused to participate in the study by ignoring suggestions from the researcher and the head of the association of otolaryngology head and neck surgery specialists in west java (perhimpunan dokter spesialis telinga, hidung tenggorok, bedah kepala leher, perhati-kl jabar). efforts that can be made to improve this situation are to increase the knowledge of orl-hns specialists regarding cochlear implants, especially those who are actively working in west java. these efforts may be in the form of evaluating and improving the quality of the ppds in the orl-hns diseases table 5 level of knowledge, attitude, and behavior of orl-hns specialists in west java towards cochlear implants (n=157) variable frequency (n) percentage (% ) knowledge good adequate poor 65 69 23 41.4 43.9 14.6 attitude positive negative 59 98 37.5 62.4 behavior good poor 156 1 99.3 0.6 althea medical journal march 2023 althea medical journal. 2023;10(1) 49 study program, especially regarding cochlear implant procedures. as a doctor, the principle of lifelong learning must also be maintained by the orlhns specialists to keep up with developments in medical science from time to time.30 thus, to increase the knowledge of orl-hns specialists who are actively working, especially in west java, about cochlear implants, this can be done through briefings such as socialization, seminars, workshops, symposia, as well as discussions among colleagues or with experts in cochlear implants field. this study also aims to remind orl-hns specialists to always seek the latest information regarding disease management, especially cochlear implants. practical and theoretical constraints took part in this study’s limitations. the practical constraint of this study was the number of participants. authors collaborated with perhati-kl jabar to obtain respondents’ data and distribute the research questionnaires. however, not all members of perhati-kl jabar were willing to take part in this study, so the findings might not accurately describe the population of interest. as for the theoretical constraints, this study cannot be used to establish cause and effect relationships considering its design as a descriptive study. therefore, this study has limitations in concluding why respondents have such knowledge, attitudes, and behaviors. not to mention that respondents might also be dishonest or otherwise provide socially desirable responses. however, this study can be used as a foundation for other studies and to deal with the possible biased responses, respondents were told that their answers would be kept confidential and anonymous. therefore, they fill ou the questionnaire independently. although this study has certain limitations, it is hoped that the results of this study can be used as input and basic data in the field of medical science regarding the level of knowledge, attitudes, and behavior of orlhns specialists in west java towards cochlear implants, as well as being considered for efforts to improve knowledge or competence level of the orl-hns specialists towards cochlear implants. in conclusion, orl-hns specialists in west java have an adequate level of knowledge and good behavior regarding cochlear implants. however, their attitude was not as expected. most of the orl-hns specialists in west java have negative attitude towards cochlear implants. hopefully, the result of this study can be taken into consideration so that orl-hns specialists are interested in broadening their horizons and learning more about cochlear implants. references 1. astolfi l. editorial need of translational research on hearing loss recovery. ijap. 2021.;6(2)2–6. 2. tordrup d, smith r, kamenov k, bertram my, green n, chadha s. global return on investment and cost-effectiveness of who’s hear interven17tions for hearing loss: a modelling study. lancet glob health. 2022 ;10(1):e52–62. 3. kementerian kesehatan republik indonesia. hasil riset kesehatan dasar riskesdas 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2013. 4. harpini a. infodatin disabilitas rungu. 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in: muyassaroh m, iriani d, editors. bunga rampai kesehatan telinga, hidung, dan tenggorok. semarang: spesialis tht-kl rsup dr. kariadi; 2020. p. 60–3. 30. arnold rm. lifelong learning and being more aware of yourself. j pain symptom manage. 2020:s0885-3924(20)30762.-4 althea medical journal march 2023 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 26 amj march, 2015 profile of handgrip strength, anthropometry, nutritional status and activities of daily living among geriatrics at karitas nursing home, bandung thawaneswaaran1, novitri2, yuni susanti pratiwi3 1faculty of medicine, 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology universitas padjadjaran, bandung. abstract background: reduced handgrip strength is an aging process that influences the activities of daily living among elderly people. handgrip strength varies greatly with age, gender, anthropometric measurement and nutritional status. this study aimed to determine the profile of handgrip muscle strength, physical characteristic, nutritional assessment and activities of daily living among elderly methods: this study was conducted at karitas nursing home, bandung on september 2012. this is a descriptive study by collecting primary data from 28 elderly people. data were collected in 2 days within 2 weeks. the first data collection included details of anthropometric measurement and handgrip measurement. the second data collection included face to face interview using standardized questionnaire for mini nutritional assessment and barthel index. result: the mean age of the respondents was 74.14 ± 8.5189 years. the average reading on handgrip muscle strength was 30.84 ± 12.0175 lbs for right hand and 27.77 ± 11.3778 lbs for left hand. for anthropometric measurement, most of the respondents had normal weight body mass index status (39.3%). nutritional status of respondents evaluated by mini nutritional assessment showed that most of the respondents were at risk of malnutrition (64.3%). the activities of daily living assessment based barthel index showed that half of the respondents were dependent in activities of daily living (50%). conclusions: from this study, it can be concluded that the grip strength of all the respondents are weaker. majority have normal body weight, malnutrition risk, and half of the subjects are depend on others in doing their daily activities. key words: activities of daily living, anthropometry, elderly, handgrip strength, nutritional status correspondence: thawaneswaaran rajendran, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628170204977 email: waranthawanesh89@yahoo.com introduction in 2012, 810 million people who were 60 years old or over accounted for 11.5% of the global population.1 in indonesia, population ageing has started to emerge as a distinct demographic feature and the proportion of elderly people, which remained around 6 percent during the period of 1950 to 1990, has now exceeded 8% and is projected to rise to 13 percent by 2025, and to 25 percent by 2050. this means that by 2050, one in four indonesians would be classified as an elderly, compared to the current one in twelve.2 the increase of elderly people in indonesia is due to the rise of life expectancy for indonesian, leading to the increase of the elderly population size. elderly people are also referred to as geriatrics in medical dictionaries.2 there are five classic geriatrics problems, with fall as the main problem. in normal physiology, there is a strong relationship between falls and muscle strength. in the aging process, the decline in muscle strength with age is a well-known phenomenon. it causes an overall muscle mass decrease. with this decline, an increased risk of untoward outcomes such as disability in activities of daily living (adl), functional limitations, falls, and mortality is seen.3 however, the awareness towards the importance of muscle strength among elderly people or geriatrics is still low. physiologically, muscle strength is influenced by certain factors such as age, gender, and anthropometric traits such as fat percentage, body mass index, althea medical journal. 2015;2(1) 27 nutritional status, depression level and adl.4 there are various ways to measure muscle strength in human body. handgrip strength is one of the most reliable clinical measures of human muscle strength and it is widely used as a clinical observation to test the hand function in people with disease. to measure the handgrip muscle strength, handgrip dynamometer is normally used.5 earlier studies have established that age, gender and anthropometric traits are the influencing factors of handgrip strength.6 poor nutrition is not a natural concomitant of aging, older adults are at risk for malnutrition due to physiological, psychological, social, dietary, and environmental risk factors. weight loss in elderly people is often associated with a loss of muscle mass and can ultimately impact the functional status. the progression to malnutrition is often insidious and undetected. it is influenced by adequate food intake both in terms of quantity and quality and also by the physical health of the individual. the nutritional status of elderly people has been related to functional ability to perform basic daily activities without assistance.7 activity of daily living is commonly used as predictors for health condition and muscle strength. ten studies provides information about the predictive value of muscle strength or hand grip strength on adl. out of ten, seven studies concludes that grip strength is a significant predictor of adl disability.8 handgrip muscle strength is a surrogate measurement of overall muscular strength. the handgrip strength is an important indicator to predict adl disability, which can be clinically useful in identifying elderly people who might benefit from an intervention that prevents disability or increases physical functioning in daily life. apart from that, handgrip strength is also a predictor of all mortality causes in elderly population and may serve as a convenient tool for prognostication of mortality risk among elderly people. according to the description above, this study aimed to determine the profile of handgrip muscle strength, physical characteristic, body mass index, nutritional status and activities of daily living among elderly people at karitas nursing home, bandung. methods this was descriptive study conducted in karitas nursing home, bandung . the inclusion criteria for the subjects are elderly people who live in karitas nursing home, bandung. subjects aged more than 60 years old can understand verbal instructions, subjects who did not suffer from neuromusculoskeletal disease and the subjects who did not suffer physical injury. the exclusion criteria are subject chosen in the selected sample refuses or reject the study. ethics approval was obtained from the health research ethics committee of faculty of medicine universitas padjadjaran and informed consent was obtained from all respondents. data were collected in 2 days within 2 weeks. in the first time, data collection included details of physical characteristics/anthropometric measurement and handgrip measurement. the second time, data collection included face to face interview using standardized questionnaire for mini nutritional assessment (mna) and barthel index. inform consent was given to each subject. all subjects signed a personal consent form, after identified their name, id number and age. explanation and instruction were given to all subjects. examination is conducted in a quiet room where the subject and examiner are free from distraction of noise. the room was setting in normal temperature. the subjects were placed in a position that provided overall support to the body, so that the subjects can concentrate on their test. ensure that the part proximal to the tested part is stabilized.9 handgrip muscle strength generated by maximum muscle contraction is the ability to generate tension against a resistance. it measures using handgrip dynamometer. grip strength measurements were taken in standing position with the elbow joint held in full extension, the shoulder joint adducted and neutrally rotated and the forearm and wrist joint held in neutral position. hold the grip dynamometer with one hand; grip the dynamometer between fingers and palm at the base of the thumb. arm positioning was demonstrated by the operator. each subject was instructed to breathe in through the nose and blow out through pursed lips as a maximum grip effort was made. next step, the subjects were instructed to squeeze the handle of the dynamometer as hard as possible and to hold for about 5 seconds. the dynamometer output that reflects the highest force exerted during gripping verbal encouragement was offered during the test by commanding the subjects to “pull! pull!” and “pull!” the measurements were obtained for both extremities, and about 2 to 5 minutes of resting interval were allowed between testing. two trials were allowed but thawaneswaaran, novitri, yuni susanti pratiwi: profile of handgrip strength, anthropometry, nutritional status and activities of daily living among geriatrics at karitas nursing home, bandung althea medical journal. 2015;2(1) 28 amj march, 2015 the higher reading was used for data analysis. the unit of the reading is in kilogram (kg).9 weight was taken by a portable human weighing machine with an accuracy of 0.5 kg. the machine was placed on the plane surface and then the subjects were asked to stand straight on the machine wearing minimum clothing. height was measured with the help of a measuring tape. the subjects were asked to stand straight and then vertical distance from the ground to the vertex of the subject. the body mass index (bmi) was calculated from the collected height (meter) and weight (kg). the following formula was used to measure bmi.bmi= weight (kg)/ (meter).4 the nutritional status of the subjects was evaluated by questionnaire method. the mna was used to evaluate the subjects. the mna is an assessment tool used to identify elderly people aged more than 60 years old who were malnourished or at risk of malnutrition. mini nutritional assessment consists of 18 questions on food intake, weight loss, mobility, psychological stress or acute disease, presence of dementia or depression, bmi and etc. after taking data from the individual, the total score was calculated. scores of 24-30 were considered normal nutritional status, 17-23.5 indicate at risk of malnutrition, and less than 17 indicate malnutrition.10 barthel index is used to measure the adl. the barthel index belongs to the activities of daily living assessment field and measures the functional independence at personal care, mobility, locomotion and excretion. each item is scored according to the patient’s ability to perform activities either independently, with some help, or completely depending on help. the version used assesses the functional independence in ten activities such as feeding, bathing, grooming, dressing, bowl and bladder care, toilet use, transfers, ambulation, and stair climbing. patient's performance established using the best available evidence by asking the patient, friends or relatives, and nurses would be the usual source. direct observation and common sense are also important total of the patient's scores for each item. total possible scores range from 0–20, with lower scores indicating increased mild disability, 10-14 moderate disability, 5-9 severe disability, and 0-4 indicate very severe disability.11 results overall there were 28 respondents who lived in karitas nursing home, which consists of 21 female and 7 male. table 1 showed table 1 profile handgrip strength by age and sex age (years) gender n hand mean ± sd status 60–64 male 2 right 37.35 ± 6.7175 weak left 38.80 ± 9.3338 weak female 2 right 21.90 ± 1.4142 weak left 23.70 ± 1.4142 weak 65–69 male 0 right left female 3 right 31.37 ± 4.14015 weak left 25.80 ± 3.0643 weak 70–74 male 2 right 46.40 ± 18.5262 weak left 43.55 ± 19.4454 weak female 9 right 27.82 ± 10.0713 weak left 23.79 ± 8.8578 weak 75+ male 3 right 49.67 ± 7.7106 weak left 43.57 ± 8.3291 weak 7 right 22.66 ± 5.7183 weak left 20.46 ± 5.6435 weak althea medical journal. 2015;2(1) 29 table 2 frequency distribution of respondents by body mass index (bmi), malnutrition indicator score (mis), and barthel index score (bis) bmi n=28 mis n=28 bis n=28 underweight 4 normal 8 very disability 1 normal weight 11 at risk 18 severe disability 1 overweight 4 malnourished 2 moderate disability 3 obese 9 mild disability 9 indipendent in adl 14 that all the subjects had weak handgrip strength with female subjects as majority. table 2 showed that mostly subjects had normal weight status (11/28) but majority were (18/28) at risk for being malnourished based on malnutrition indicator score meanwhile based bis most of them had independent adl (14/28) discussions the majority of respondents who lived in karitas nursing home, bandung, were female respondents and the highest number of respondents were aged in range of 70-74 years old. the frequency of female respondents was higher than male respondents after age of 64 years old. from the total number of respondents, female elderlies were older than males. life expectancy for female is higher than male due to three main factors; genetic, hormones and cardiovascular risk.12 women constitute a majority of the elderly population and even in most countries, the oldest people population have a greater majority . at present, nearly 60 percent of indonesian oldest people are women and this proportion is expected to increase to 64 percent by 2030.2, 12 grip strength of right and left hand were not similar. the results show that the right hand had greater grip strength than left hand in both sexes. the right hand was the dominant hand of the subjects. a general rule is often used to suggest that dominant hand is about 10% stronger than non dominant hand.6 one explanation for difference might due to use of more muscle and muscular hypertrophy in dominant hand which leads to increased strength. the difference in grip strength between two hands in the present study shows right grip strength more or less 10% higher than left grip strength for both males and females.13 however these findings are much lower compared to data from mathiowetz v.9 in western population, the mean handgrip strength can be as much as 1.5 times greater than people in the karitas nursing home, bandung. this suggests that grip strength norms from the western population may not accurately represent the local population and reference values are needed. genetic variation, health status and different lifestyle could also be the reasons for the difference observed between our findings with the western elderly’s.9 in this present study, men have greater handgrip strength than women, (table 2). the gender difference in grip strength variation might due to the variation of the activity level in two sexes. from the everyday life, it was observed that male performed more physical activity with greater work load or may be due to lower strength per arm muscle area.14 handgrip strength was found to increase until the thirties and decrease with accelerated speed after forties.6 with aging, muscle mass was lost due to motor neuron death and muscle cell shrinking due to inactivity. apart from that nutritional deficit, lower body weight, diminished use of muscle, reduced physical activity or sedentary lifestyle and poor health in the elderly also may cause the handgrip strength to decline progressively. hormonal changes, particularly decreases in testosterone and growth hormone levels, may be associated with decreased muscle mass. disease may cause decrease in strength through inactivity or they may have a direct effect in muscle. the older people in the present study, (table 1) also showed a decline in grip strength which might be due to the same reason mentioned above.14 elderly who had higher weight and height were found to have higher handgrip thawaneswaaran, novitri, yuni susanti pratiwi: profile of handgrip strength, anthropometry, nutritional status and activities of daily living among geriatrics at karitas nursing home, bandung althea medical journal. 2015;2(1) 30 amj march, 2015 measurements. similar results were shown by kamarul et al.15 studies. elderly who had low weight may have low muscle mass, hence, weaker physical strength resulted in poor handgrip measurement.14 the results of this present study, (table 2) showed most number of subjects remained in normal weight range. the results of previous study conducted by patterson proved that bmi has poor correlation with strength.16 studies by chilima et al. have proven that the association of elderly poor nutritional status has poor functional ability and strength.17 lower muscle mass could be related to under nutrition. the studies showed that most of the subjects with weak grip strength are at risk for malnutrition indicator score. studies conducted in asian countries showed that average intakes among population of older people often fall below the official dietary recommendations.7 among 240 communities, living indonesian elderly the median energy intake was below the assessed requirement while iron, thiamin and folate intakes were below the recommended values. the relationship between nutrition status and handgrip strength was not really understood. further study is required in this direction.17 the adl is commonly used as predictors for health conditions and muscle strength among elderly.8 the study showed that most of the subjects were still independent in adl. elderly who had higher barthel index had higher measurement in handgrip strength as found in previous studies.16 as a conclusion, the profile of overall handgrip muscle strength among elderly people at karitas nursing home, bandung are weak. the profile of physical characteristic showed that the higher the age the weaker the grip strength. most of the respondents have normal weight for bmi status. most of the respondents are at risk of malnutrition and the profile of activities of daily living showed half of the respondents are dependent in activities of daily living. references 1. kadar ks, francis k, sellick k. ageing in indonesia-health status and challenges for the future. ageing int. 2013;38(4):261–70. 2. abikusno n. older population in indonesia: trends, issues and policy responses. bangkok: unfpa indonesia and country technical services team for east and south-east asia; 2007. 3. ensrud ke, ewing sk, cawthon pm, fink ha, taylor bc, cauley ja, et al. a comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men. j am geriatric soc. 2009;57(3):492–8. 4. sartorio a, lafortuna cl, pogliaghi s, trecate l. the impact of gender, body dimension and body composition on handgrip strength in healthy children. j endocrinol invest. 2002;25(5):431–5. 5. bohannon rw. dynamometer measurements of hand-grip strength predict multiple outcomes. percept mot skills. 2001;93(2):323–8. 6. massy-westropp nm, gill tk, taylor aw, bohannon rw, hill cl. hand grip strength: age and gender stratified normative data in a population-based study. bmc research notes. 2011;4(1):127. 7. boedhi-darmojo r. trends in dietary habits of the elderly: the indonesian case. asia pac j clin nutr. 2002;11(suppl s1):s351–4. 8. vermeulen j, neyens j, van rossum e, spreeuwenberg m, de witte l. predicting adl disability in communitydwelling elderly people using physical frailty indicators: a systematic review. bmc geriatrics. 2003;11(1):33. 9. bohannon rw. quantitative testing of muscle strength: issues and practical options for the geriatric population. top geriatric rehabil. 2002;18(2):1–17. 10. guigoz y. the mini nutritional assessment (mna®): review of the literature-what does it tell us? j nutr health aging. 2006;10(6):446–68. 11. minosso jsm, amendola f, alvarenga mrm, de campos oliviera ma. validation of the barthel index in elderly patients attended in outpatient clinics in brazil. acta paul enferm. 2010;23(2):218–23. 12. eskes t, clemens h. why do women live longer than men. eur j obstet gynecol reprod biol. 2007;133(2):126–33. 13. mathiowetz v. comparison of rolyan and jamar dynamometers for measuring grip strength. occup ther int. 2002;9(3):201–9. 14. kaur m. age-related changes in handgrip strength among rural and urban haryanvi jat females. homo. 2009;60(5):441–50. 15. kamarul t, ahmad ts, loh wy. handgrip strength in the adult malaysian population. j orthop surg (hongkong). 2006;14(2):172–7 16. paterson dh, govindasamy d, vidmar m, cunningham d, koval jj. longitudinal study of determinants of dependence in an elderly population. j am geriatr soc. 2004;52(10):1632–8. althea medical journal. 2015;2(1) 31 17. chilima dm, ismail sj. nutrition and handgrip strength of older adults in rural malawi. public health nutr. 2001;4(1):11–7. thawaneswaaran, novitri, yuni susanti pratiwi: profile of handgrip strength, anthropometry, nutritional status and activities of daily living among geriatrics at karitas nursing home, bandung amj vol 10 no 1 march 2023.indd althea medical journal. 2023;10(1) 14 clinical characteristics of patients with different sars-cov-2 variants in south kalimantan, indonesia haryati,1 mohammad isa,1 ali assagaf,1 ira nurrasyidah,1 erna kusumawardhani,1 desi rahmawaty2 1department of pulmonology and respiratory medicine, faculty of medicine, lambung mangkurat univesity, ulin general hospital, banjarmasin, indonesia, 2faculty of medicine, lambung mangkurat univesity, banjarmasin, indonesia correspondence: dr. desi rahmawaty, faculty of medicine, lambung mangkurat university/ulin general hospital, jalan a. yani no.43, banjarmasin, south kalimantan, indonesia, e-mail: rahmawatydesi@hotmail.com althea medical journal. 2023;10(1):14–20 abstract background: severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has undergone various mutations of corona virus disease 2019 (covid-19). the world health organization (who) has designated b.1.617.2 (delta) and b.1.1.529 (omicron) as variants of concern (voc). since clinical features and epidemiological characteristics of patients infected with sars-cov-2 variants remain largely unknown, especially in indonesia, this study aimed to identify the clinical characteristics of covid-19 patients from south kalimantan, indonesia. methods: data from medical records of covid-19 patients at ulin general hospital banjarmasin from june 2021 to february 2022 were randomly extracted, containing demographic data, comorbidities, and laboratory data, as well as the type of virus. results: in total, 32 patients were included, 9 were infected with delta, 14 with probable omicrons, and 9 with non-voc. patients in the probable omicron group were significantly older than other groups (median age 64 years old, range 54–73 years; p=0.049), had hypertension as the dominant comorbidity (85.7%; p=0.039), the onset appeared slightly earlier (median 3 days; range 2-3 days, p=0.062), with no anosmia symptom (p=0.006). critical illness predominated and mostly survived in all variants but was not statistically significant (p=0.590 and 0.726, respectively). the three variants showed similarities in laboratory findings; hence, statistical analysis suggested that the leucocytes differed significantly (p=0.020). conclusions: patients with the likely omicron variant are much older, have hypertension as their main comorbidity, do not have any symptoms of anosmia, and have higher leukocyte counts compared to other variants. keywords: clinical characteristics, covid-19, delta, non-voc, probable omicron . introduction corona virus disease 2019 (covid-19) pandemic has spread rapidly to over 200 nations since its appearance in december 2019, including indonesia. globally, more than 400 million people have been infected, resulting in over 5 million deaths.1 the first wave of covid-19 reported cases in indonesia was identified on march 2, 2020, and the number gradually dropped in april 2021. the second wave began in june 2021, and the number had steadily decreased by october 2021. the third wave started in late january 2021. as of february 2021, the total number of confirmed cases was 4,708,043, contributing to 144,958 deaths.2 severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the etiologic agent of covid-19, belongs to the betacoronavirus genus. it is a virus with positive-sense singlestranded rna with approximately 30,000 bases and replicates utilizing the viral rnadependent rna polymerase, lacking the proofreading function.3 as a consequence, the virus has a high capability for generating genetic variants by selecting a genetically varied population based on fitness and or environmental adaption. with such a massive pool of infected people worldwide, https://doi.org/10.15850/amj.v10n1.2810 althea medical journal. 2023;10(1) 15 a rapid generation of variants with increased infectivity and or resistance to the host’s immunological response is predicted.4 multiple viral strains have evolved and grown in numerous nations. the world health organization (who) has designated several variants as a variant of concern (voc), including b.1.617.2 (delta) and b.1.1.529 (omicron) variants.5 the delta variant is more transmissible, has a higher viral load, has a high reinfection rate, and evades natural immunity.6 although the delta has become the dominant variant in indonesia since its first appearance in april 2021,7 the omicron variant, which was recently discovered, is quickly surpassing the delta as the most prevalent sars-cov-2 variant. while there is still much to learn about omicron’s epidemiology, available evidence suggests that it might have a higher transmission rate than the previous delta variant. it has the ability to avoid the immune protection provided by antibodies from either the vaccine or previous sars-cov-2 infection.8 ulin regional hospital banjarmasin, as a main covid-19 referral hospital in south kalimantan, has treated many covid-19 patients, including delta and omicron variants, during the second and third waves. this study aimed to identify the clinical characteristics of covid-19 patients infected with different sars-cov-2 variants at ulin general hospital, south kalimantan. to our knowledge, this is the first study in indonesia. methods the design of the study was a descriptive study. this research has been approved by the research ethics committee of ulin hospital banjarmasin with registration number 17/iiireg riset/rsud/22. all cases were from ulin regional hospital banjarmasin and met the clinical diagnostic criteria of covid-19. cases had positive results on reverse-transcriptase–polymerasechain-reaction (rt-pcr) assays of specimens taken from nasopharyngeal swabs. during the second and third waves, from june 2021 to february 2022, 32 cases of covid-19 patients were randomly selected and tested to differentiate the variant. the delta variants and the non-vocs were identified based on whole-genome sequencing (wgs) performed by the indonesian center for biomedical research and development and basic health technology. probable omicron infection was suggested by spike-gene target failure (sgtf) on the covid-19 rt-pcr test. the data observed included demographic variables and laboratory investigation. the demographic variables were age, gender, comorbidities, history of smoking, history of vaccine, the onset of disease (the first day of any symptom until the day of admission), symptoms, disease severity (asymptomatic, mild, moderate, severe, or critically illness based on indonesia covid-19 management guidelines for the severity of clinical presentation) and outcome patient survived or died. laboratory data include complete blood count (cbc) and inflammatory markers such as absolute lymphocyte count (alc), neutrophil to lymphocyte ratio (nlr), c-reactive protein (crp), lactate dehydrogenase (ldh) at the beginning of hospital admission. statistical analysis was performed with ibm spss 25.0. categorical variables were summarized as counts and percentages, then proceeded with fisher’s exact test. numerical variables were reported in median and interquartile ranges. test for normality and homogeneity with kolmogorov-smirnov and levene’s tests. the anova test was performed on normally distributed, homogeneous variables, and the kruskal-wallis test was performed on variables that did not meet one of the criteria. statistical significance was indicated by a p-value less than 0.05. results infection with the probable omicron variant of covid-19 tended to affect older patients (median 64 years; range 54-73). based on gender, both delta and omicron variants were dominated by males (66.7% and 71.4%), while non-voc variants were dominated by females (77.8%). hypertension was the most common comorbidity in delta (55.6%), probable omicron (85.7%), and voc (33.3%) variants. meanwhile, diabetes was the second most common comorbidity in patients with delta (44.4%) and probable omicron (50.0%) variants (table 1). interestingly, smoking history was only found in one patient with probable omicron variant infection. in this study, 44.4% of delta patients and 35.7% of omicron patients had a history of the covid-19 vaccine, but in nonvoc patients, only 11.1% were found. the day of onset of clinical symptoms was uniform in all three variants, but the omicron variant appeared slightly earlier (median 3 days). cough, shortness of breath, and fever were the most common symptoms in all three variants. there were no patients with anosmia in the haryati et al.: clinical characteristics of patients with different sars-cov-2 variants in south kalimantan, indonesia althea medical journal. 2023;10(1) 16 probable omicron variant, while 33.3% were found in the delta variant and 55.6% in the non-voc. based on the severity of the disease, patients with moderate or critical degree dominated the delta variant, both 33.3%. probable omicron variant and non-voc were dominated by critical illness by 50.0% and 55.6%, respectively. the survival rate of the delta and probable omicron variant appears to be high at 77.8% and 71.4%, respectively. statistical analysis of the demographic and clinical characteristics of the patients in this study revealed that only age (p=0.049), comorbid hypertension (p=0.039), and the presence of anosmia (p=0.006) had significant differences in the three covid-19 variants. the patient’s laboratory findings showed that hemoglobin, leukocyte, and platelet count between groups were normal. neutrophilia had been seen in all three variants, and lymphopenia was more observed in the nontable 1 demographics and clinical characteristics at admission based on covid-19 variants characteristics delta n=9 probable omicron n =14 non-voc n =9 p-value age in yr, median (iqr) 51 (49–62) 64 (54–73) 43 (39–58) 0.049 gender male female 6 (66.7%) 3 (33.3%) 10 (71.4%) 4 (28.6%) 2 (22.2%) 7 (77.8%) 0.073 comorbidities hypertension diabetes mellitus obesity coronary heart disease heart failure malignancy chronic kidney disease 5 (55.6%) 4 (44.4%) 3 (33.3%) 1 (11.1%) 1 (11.1) 0 (0.0%) 1 (11.1%) 12 (85.7%) 7 (50.0%) 1 (7.1%) 0 (0.0%) 5 (35.7%) 2 (14.3%) 2 (14.3%) 3 (33.3%) 1 (11.1%) 2 (22.2%) 2 (22.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0.039* 0.210 0.372 0.165 0.128 0.492 0.771 history of smoking 0 (0.0%) 1 (7.1%) 0 (0.0%) 1.000 history of covid-19 vaccine 4 (44.4%) 5 (35.7%) 1 (11.1%) 0.382 onset in days, median (iqr) 4 (2–5) 3 (2–3) 5 (4–7) 0.062 symptom cough fever shortness of breath anosmia nausea and/ or vomitus diarrhea fatigue myalgia sore throat headache runny nose 7 (77.8%) 8 (88.9%) 4 (44.4%) 3 (33.3%) 4 (44.4%) 1 (11.1%) 3 (33.3%) 1 (11.1%) 1 (11.1%) 0 (0.0%) 1 (11.1%) 8 (57.1%) 10 (71.4%) 7 (50.0%) 0 (0.0%) 4 (28.6%) 1 (7.1%) 5 (35.7%) 0 (0.0%) 3 (21.4%) 0 (0.0%) 0 (0.0%) 9 (100%) 8 (88.9%) 7 (77.8%) 5 (55.6%) 2 (22.2%) 4 (44.4%) 1 (11.1%) 2 (22.2%) 1 (11.1%) 1 (11.1%) 0 (0.0%) 0.075 0.610 0.396 0.006* 0.703 0.088 0.482 0.165 1.000 0.563 0.563 disease severity asymptomatic mild moderate severe critical 0 (0.0%) 2 (22.2%) 3 (33.3%) 1 (11.1%) 3 (33.3%) 0 (0.0%) 5 (35.7 %) 2 (14.3%) 0 (0.0%) 7 (50.0%) 0 (0.0%) 1 (11.1%) 2 (22.2%) 1 (11.1%) 5 (55.6%) 0.590 outcome survived deceased 7 (77.8%) 2 (22.2%) 10 (71.4%) 4 (28.6%) 5 (55.6%) 4 (44.4%) 0.726 althea medical journal march 2023 althea medical journal. 2023;10(1) 17haryati et al.: clinical characteristics of patients with different sars-cov-2 variants in south kalimantan, indonesia voc. the nlr and alc had similar values between the three variants; hence ldh and crp were increased in all three variants. there was no statistically significant difference in the laboratory findings at admission for the three variants of covid-19, except for the leukocyte count (p=0.020). discussion more than two years have passed since the covid-19 pandemic, and cases in indonesia continue to rise, as well as hospitalization and death. however, sars-cov-2 has been undergoing several mutations, prompting concern that these mutations could result in a more severe and lethal covid-19. variant b.1.617.2 (delta) and b.1.1.529 (omicron) are both variants of concern, which are variants that contain one or more mutations that allow the virus to be more transmissibble and lessen the virus’ receptivity to treatment or affect effectiveness of vaccinations. the delta variant has spread rapidly across a mostly unvaccinated country since first identified in india in december 2020, resulting in many cases, hospitalizations, and deaths. two months after india’s first case, the delta variant spread rapidly in indonesia. it caused a massive surge in daily new confirmed covid-19 cases, leading to an increase in the hospital bed occupancy rate (bor).9 on december 15, 2021, the identification of the first omicron variant of sars-cov-2 in indonesia sparked interest. given the experience from other countries, the delta variant will most likely be displaced by omicron as the dominant variant in indonesia.10 the s gene target failure (or s gene dropout) is one of the omicron variant’s mutations, as the pcr testing fails to detect one of the multiple sections of the targeted gene, allowing a marker for focused genome sequencing.11 in this study, infection of probable omicron variant covid-19 tends to affect older patients (median age 64 years old), compared to the delta variant (median age 51 years old) and non-voc (median age 43 years old), indicating that three variants of covid-19 have significant age differences (p=0.049). similarly, another study has shown that older age has a higher risk of covid-19 than the younger population.12 older people are more susceptible to severe sars-cov-2 infection due to the aging table 2 laboratory findings at admission based on covid-19 variants laboratory findings at admission normal range delta n =9 probable omicron n =14 non-voc n =9 p-value hemoglobin in g/dl, median (iqr) 12.0–16.0 13.9 (13.0–14.6) 12.0 (9.5–13.8) 12.6 (11.7–14.6) 0.272 leukocytes × 109/l, median (iqr) 4.5–11.0 5.9 (5.6–6.7) 7.9 (6.0–10.8) 5.9 (5.4–7.3) 0.020* platelet count × 109/l, median (iqr) 150–400 186 (162–274) 179 (167–242) 228 (163–267) 0.572 neutrophil %, median iqr) 40–60 66.2 (62.2–72.0) 68.2 (56.9–76.2) 72.0 (67.0–75.7) 0.596 lymphocyte %, median (iqr) 20–40 21.5 (20.2–23.4) 20.8 (11.8–31.1) 18.6 (15.7–24.6) 0.810 eosinophils %, median (iqr) 1.0–3.0 1.0 (1.6–0.6) 0.3 (0.2–1.9) 0.0 (0.0–0.6) 0.260 nlr, median (iqr) 3.1 (2.8–3.2) 3.4 (1.9–6.4) 3.7 (2.7–4.8) 0.593 alc × 109/l, median (iqr) 1.3 (1.1–1.6) 1.5 (0.8–2.8) 1.2 (0.8–1.3) 0.423 ldh in u/l, median (iqr) < 400 618.0 (342.0–940.0) 418.0* (378.0–577.0) 668.5 (424.5–729.8) 0.468 crp in mg/dl, median (iqr) < 6.00 12.0 (5.2–29.8) 40.6** (18.8–142.9) 22.5 (6.0–33.1) 0.259 note: *n=9, due to limited data on admission, ** n=8, due to limited data on admission, iqr= interquartile range, nlr= neutrophil to lymphocyte ratio, alc= absolute lymphocyte count, ldh= lactate dehydrogenase, crp= c-reactive protein, voc= variant of concern althea medical journal. 2023;10(1) 18 process that produces a variety of physiologic modifications in the immune system. these modifications impair the immune system’s capacity to combat latent and new infections, and mount appropriate vaccination responses. increased proinflammatory phenotypes may affect an individual’s vulnerability to coronavirus infections, the illness course, and clinical consequences.13 previous research on sars-cov-2 showed that people with comorbidities were at higher risk of poor clinical outcomes,12 and the most critical components are cardiovascular disorders and diabetes.14 elderly patients with comorbidities are among the highest risk groups for sars-cov-2 and fatal outcomes.15 in this study, hypertension was the most common comorbidity in patients with delta, probable omicron, and non-voc infection. in addition, diabetes is the second most common comorbidity in patients with delta and probable omicron variants. in a meta-analysis study, hypertension was an independent risk factor for critical covid-19. covid-19 patients with hypertension were associated with a significantly increased risk of developing a critical illness and mortality,16 and diabetes was the best predictor of covid-19-related death.17 several diabetes-related aspects have been taken into account. individuals with diabetes ares prone to infection due to increased activation of the renin-angiotensin system (ras) in various organs associated with a worsened inflammatory response.18 furthermore, the diabetic population has pulmonary dysfunction due to reduced lung volume, pulmonary diffusing capacity, bronchomotor tone, ventilation control, and noradrenergic innervation impairment.19 furthermore, the increased cv risk associated with diabetes and hypertension can exacerbate a poor covid-19 prognosis.17 interestingly, in this study, infected delta (44.4%) and omicron patients (35.7%) had a history of the covid-19 vaccine, but lower in infected non-voc patients (11.1%). the history of the covid-19 vaccine was thought to have a dominant role in the progression of the disease. even though the prevalence of delta variant infection was not different between the vaccinated and unvaccinated population, the proportion of covid-19 hospitalization, disease progression, and deaths was significantly lower in the partially vaccinated and fully vaccinated than in the unvaccinated.20 there is currently no accurate data on how vaccination can protect against infection with omicron variants. uk health security agency (ukhsa) stated that two vaccinations are less effective against the omicron variant than they were against prior variants, and their effectiveness declines with time. however, the vaccine is effective at about 59% against omicron mortality in those over 50.21 the omicron variant had many mutations in the spike protein, resulting in more significant evasion of immunological protection produced by past sars-cov-2 infection and possibly even existing covid-19 vaccines.22 the day of onset or the interval between onset of symptoms and hospital admission on the omicron variant appeared to be slightly earlier (median 3 days), compared to the delta variant (median 4 days) and non-voc (median 5 days). in addition, the median time from the onset of symptoms to the first admission to the hospital was seven days.23 however, another study showed that the median duration from the first sign of symptoms to hospital admission was five days in the first wave of covid-19.24 the most common clinical symptoms reported in all three variants were cough in delta (77.8%), probable omicron (57.1%), and non-voc (100%). furthermore, fever and shortness of breath are also prevalent. interestingly, there were no patients with anosmia in the probable omicron variant, whereas anosmia was found in the delta variant (33.3%) and in the non-voc (55.6%). thus, there were significant differences in the presence of anosmia between the three variants of covid-19 (p=0.006). preliminary data suggest that anosmia appears less common in omicron infection than reported for other strains and variants.25 an experimental study on the golden hamster showed that omicron infection caused less damage to the olfactory mucosa and most likely lowered the risk of developing anosmia.26 at first evaluation, patients with a moderate or critical degree dominated the delta variant (33.3%), probable omicron variant (50%), and non-voc (55.6%). although half of the patients with possible omicron infections were critical, the survival rate was relatively high (71.4%), suggesting that infection by the omicron variant may fall into a bad state, but improvement can still be expected. the median value of hemoglobin, leukocyte, and platelet count between groups was normal. these results is in line with previous study which showed no difference in cbc values at diagnosis.27 however, other studies revealed low hemoglobin, high leukocytes, althea medical journal march 2023 althea medical journal. 2023;10(1) 19 and low platelet count that correlated with mortality.28 however, leukocyte value is higher in the probable omicron group compared to other groups (p=0.020). neutrophilia was detected in all three variants, and lymphopenia was observed in the non-voc. a meta-analysis shows that lymphopenia and neutrophilia in admission are linked to poor outcomes in covid-19 patients.29 our study also shows that the nlr and alc had similar values between the three variants, and ldh and crp are increased in all three variants. previous study suggests that anc, nlr, ldh, and crp values are significantly increased in patients with severe and critical diseases compared to mild and moderate diseases.30 this study has a limitation that this is only a single-center research study with minimal samples. more extensive studies are needed to better describe the clinical characteristics of the covid-19 population with different variants to construct data and provide insights into this ongoing pandemic, especially in indonesia. in conclusion, most patients in all variants have predominant comorbidities such as hypertension and dm. the probable omicron variant infected in older patients, with onset slightly earlier, has no anosmia symptom, and a relatively higher survival rate. laboratory findings for the three variants showed similar results, namely normal values for hemoglobin, leukocyte, platelet, neutrophilia, nlr, and alc, as well as elevated ldh and crp. the sars-cov-2 variants are constantly evolving and changing. which can lead to change in the characteristics of the virus. information about infection characteristics with new variants is crucial for decision-making about control approaches and strategies. conflicts of interest the author reports no conflicts of interest in this work. funding there was no source of funding for this research. references 1. world health organization. who coronavirus (covid-19) dashboard. 2022. [cited 2022 february 12]. available from; https://covid19.who.int/ 2. the ministry of health of the republic of indonesia. covid-19 situation in indonesia. 2022. [cited 2022 february 12]. available from: https://covid19.go.id/ 3. salleh mz, derrick jp, deris zz. structural evaluation of the spike glycoprotein variants on sars-cov-2 transmission and immune evasion. int j mol sci. 2021;22(14):7425. 4. das jk, roy s. a study on non-synonymous mutational patterns in structural proteins of sars-cov-2. genome. 2021;64(7):665– 78. 5. world health organization. classification of omicron (b.1.1.529): sars-cov-2 variant of concern. [cited 2022 february 12]. available from: https://www.who.int/ news/item/26-11-2021-classification-ofomicron-(b.1.1.529)-sars-cov-2-variantof-concern 6. luo ch, morris cp, sachithanandham j, amadi a, gaston d, li m, et al. infection with the sars-cov-2 delta variant is associated with higher infectious virus loads compared to the alpha variant in both unvaccinated and vaccinated individuals. medrxiv [preprint]. 2021;2021.08.15.21262077. 7. fibriani a, stephanie r, alfiantie aa, siregar alf, pradani gap, yamahoki n, et al. analysis of sars-cov-2 genomes from west java, indonesia. viruses. 2021;13(10):2097. 8. khan na, al-thani h, el-menyar a. the emergence of new sars-cov-2 variant (omicron) and increasing calls for covid-19 vaccine boosters-the debate continues. travel med infect dis. 2022;45:102246. 9. tenda ed, asaf mm, pradipta a, kumaheri ma, susanto ap. the covid-19 surge in indonesia : what we learned and what to expect. breathe (sheff ). 2021;17(4):210146. 10. kadir a, deby s, sunarno sdam. a systematic review of omicronooutbreak in indonesia: a case record and how the country is weathering the new variant of covid-19. eur j mol clin med. 2022;09(01):364–73. 11. torjesen i. covid-19 : omicron may be more transmissible than other variants and partly resistant to existing vaccines, scientists fear. bmj. 2021:375:n2943. 12. alam mr, kabir mr, reza s. comorbidities might be a risk factor for the incidence of covid-19: evidence from a web-based survey. prev med rep. 2021;21:101319. 13. bajaj v, gadi n, spihlman ap, wu sc. aging , immunity , and covid-19: how haryati et al.: clinical characteristics of patients with different sars-cov-2 variants in south kalimantan, indonesia althea medical journal. 2023;10(1) 20 age influences the host immune response to coronavirus infections?. front physiol. 2021;11:571416. 14. li b, yang j, zhao f, zhi l, wang x, liu l, et al. prevalence and impact of cardiovascular metabolic diseases on covid-19 in china. clin res cardiol. 2020;109(5):531–8. 15. karagiannidis c, mostert c, hentschker c, voshaar t, malzahn j, schillinger g, et al. case characteristics, resource use, and outcomes of 10 021 patients with covid-19 admitted to 920 german hospitals: an observational study. lancet respir med. 2020;8(9):853–62. 16. du y, zhou n, zha w, lv y. hypertension is a clinically important risk factor for critical illness and mortality in covid-19: a meta-analysis. nutr metab cardiovasc dis. 2021;31(3):745–55. 17. corona g, pizzocaro a, vena w, rastrelli g, semeraro f, isidori am, et al. diabetes is most important cause for mortality in covid-19 hospitalized patients: systematic review and meta-analysis. rev endocr metab disord. 2021;22(2):275–96. 18. almyroudi mp, dimopoulos g, halvatsiotis p. the role of diabetes mellitus and obesity in covid 19 patients. pneumon. 2020;33(3):114–7. 19. fuso l, pitocco d, antonelli-incalzi r. diabetic lung, an underrated complication from restrictive functional pattern to pulmonary hypertension. diabetes metab res rev. 2019;35(6):e3159. 20. thangaraj jwv, yadav p, kumar cg, shete a, nyayanit da, rani ds, et al. predominance of delta variant among the covid-19 vaccinated and unvaccinated individuals, india, may 2021. j infect. 2022;84(1):94– 118. 21. uk health security agency. how well do vaccines protect against omicron? what the data shows [internet]. 2022. [cited 2022 february 24]. available from: https://ukhsa.blog.gov.uk/2022/02/10/ how-well-do-vaccines-protect-againstomicron-what-the-data-shows. 22. wang y, zhang l, li q, liang z, li t, liu s, et al. the significant immune escape of pseudotyped sars-cov-2 variant omicron. emerg microbes infect. 2022;11(1):1–5. 23. wang d, hu b, hu c, zhu f, liu x, zhang j, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china. jama. 2020;323(11):1061– 9. 24. lei s, jiang f, su w, chen c, chen j, mei w, et al. clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. eclinicalmedicine. 2020;21:100331. 25. bukhari mh. recently discovered omicron: fifth wave of pandemic in pakistan. what strategies can be adopted to control its spread? j islamic int med coll. 2021:16(4):212-214. 26. armando f, beythien g, kaiser fk, allnoch l, heydemann l, rosiak m, et al. sars-cov-2 omicron variant causes mild pathology in the upper and lower respiratory tract of hamsters. nat commun. 2022;13(1):3519. 27. pozdnyakova o, connell nt, battinelli em, connors jm, fell g, kim as. clinical significance of cbc and wbc morphology in the diagnosis and clinical course of covid-19 infection. am j clin pathol. 2021;155(3):364–75. 28. mousavi sa, rad s, rostami t, rostami m, mousavi sa, mirhoseini sa, et al. hematologic predictors of mortality in hospitalized patients with covid-19: a comparative study. hematology . 2020;25(1):383–8. 29. henry bm, cheruiyot i, vikse j, mutua v, kipkorir v, benoit j, et al. lymphopenia and neutrophilia at admission predicts severity and mortality in patients with covid-19: a meta-analysis. acta biomed. 2020;91(3):e2020008. 30. taj s, fatima sa, imran s, lone a, ahmed q. role of hematological parameters in the stratification of covid-19 disease severity. ann med surg (lond). 2021;62:68–72. althea medical journal march 2023 althea vol 1 no 2 edit.indd althea medical journal. 2014;1(2) 65 differences of anxiety levels between students of natural sciences and social studies major based on school environmental factors in senior high schools with rintisan sekolah bertaraf internasional scheme arviana adamantina putri1, leonardo lubis2, tatang muchtar sutaryan3 1faculty of medicine, universitas padjadjaran, 2department of anatomy, faculty of medicine, universitas padjadjaran, 3department of psychiatry, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital, bandung abstract background: senior high schools with rintisan sekolah bertaraf internasional (rsbi) scheme are senior high schools that pilot international standards in learning methods and high curriculum targets. this factor may lead to a rise of anxiety amongst students, both for students in natural sciences major and social studies major. there are three factors which cause anxiety in the school environment, namely: dissatisfaction towards the curriculum, the teacher, and the school management. methods: this study used retrospective cohort design. subjects were selected using the convenience sampling method. natural sciences students (n=32) and social studies students (n=14) had their anxiety level measured using the taylor manifest anxiety scale. the dissatisfaction towards the school environment factors was assessed using a school evaluation questionnaire. results: the anxiety measurement showed that students in both natural sciences and social studies major experienced severe anxiety (natural sciences vs. social studies: 75% vs. 86%). the study results based on the school evaluation questionnaire showed dissatisfactions towards the three school environmental factors (curriculum factor, natural sciences vs. social studies: 59% vs. 64%; teacher factor, natural sciences vs. social studies: 3% vs. 43%; school management factor, natural sciences vs. social studies: 3% vs. 14%). the chi-square test results showed that the difference in the anxiety levels between the students of natural sciences and social studies majors was insignificant (p>0.05). conclusions: students of natural sciences and social studies majors of senior high schools with rsbi scheme experienced severe anxiety. however, there is no strong evidence that the school environment causes this severe anxiety. [amj.2014;1(2):65–9] keywords: anxiety level, natural sciences, senior high school with rsbi scheme, school environment factors, social studies perbedaan tingkat kecemasan antara siswa kelas ilmu pengetahuan alam dan siswa kelas sosial berdasarkan faktor lingkungan sekolah di sekolah menengah atas rintisan sekolah bertaraf internasional abstrak latar belakang: sekolah menengah atas rintisan sekolah bertaraf internasional (sma rsbi) adalah sekolah menengah atas yang menggunakan standar internasional dalam metode pembelajaran dan kurikulum. faktor ini dapat menyebabkan kenaikan kecemasan di kalangan siswa, baik bagi siswa kelas ilmu pengetahuan alam dan siswa kelas ilmu sosial. ada tiga faktor yang menyebabkan kecemasan di lingkungan sekolah, yaitu: ketidakpuasan terhadap kurikulum, guru, dan manajemen sekolah. metode: penelitian ini menggunakan desain kohort retrospektif. subjek dipilih dengan menggunakan metode convenience sampling. tingkat kecemasan siswa kelas ilmu pengetahuan alam (n = 32) dan siswa correspondence: arviana adamantina putri, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285223880048, email: p_arviana@yahoo.com althea medical journal. 2014;1(2) 66 amj december, 2014 introduction teenage period is the transition into adulthood, a time to seek identity, as well as the period when biological, cognitive, and moral developments occur. teenager characteristic of identity searching may cause anxiety, which is a common psychological disorder in teenagers.1 in a previous study, it was found that 47.7% of teenagers experienced anxiety.2 this anxiety may arise from, among others, problems arising from the school environment.3 anxiety caused by the school environment can be due to three factors: curriculum, teacher, and school management.4 an example of the curriculum factor that may trigger anxiety is a learning target which is too high, as well as non-conducive learning climate. the attitude and behavior of teachers, for example unfriendly teachers, can become a trigger of anxiety caused by the teacher factor. anxiety may also be induced by the school management factor such as the limited facilities and infrastructures in the school.4 if those factors are not well-managed, the rise of anxiety among students is unavoidable. anxiety is an uncomfortable feeling without any clear cause. anxiety is often accompanied by autonomic symptoms such as headache, palpitation, dyspnea, anxious, and sweating.5 aside from the autonomous nervous system, three main neurotransmitters also play some roles in anxiety, namely norepinephrine (ne), serotonin, and gamma-aminobutyric acid (gaba).5,6 these three neurotransmitters can affect the limbic system and the emotional behaviors.5,7 anxiety can also affect the way of thinking, perception, and learning of the afflicted, which may lead to confusion and reversion of perception and may affect learning through decreased concentration, memory, and abilities to connect one thing to another.5 these effects can deprive the students from participating in the learning process, especially for students of schools with rsbi scheme. schools with rsbi scheme include schools that pilot international standards in all learning activities and have high curriculum targets.8 as such, the pressure and competition are higher. this may easily trigger anxiety among the students. in senior high schools with rsbi scheme, when students started the eleventh grade, they arere assigned to two majors, the natural sciences (ilmu pengetahuan alam, ipa), and social studies (ilmu pengetahuan sosial) ips. in natural sciences class, the learning is emphasized on theleft brain, such as logic, reasoning, numbers, and lists. this is contrary to the class of social studies, which put emphasis on communication and social functions, using more of the right brain.9,10 likewise, the study burden in both natural science and social studies majors may trigger anxiety among students.11 however, there is no certain description yet on the difference in anxiety level between the students of natural sciences and social studies major based on a survey of brain functional area. therefore, this study aimed at assessing the difference in the level of anxiety between students of natural sciences and social studies majors in senior high schools with rsbi scheme. methods there were 4 senior high schools with rsbi scheme in the city of bandung at the time of the study. those were sma negeri 3 bandung, sma negeri 5 bandung, sma negeri 1 baleendah bandung, and sma krida nusantara bandung. this study used convenience sampling to select respondents with sman 3 bandung as the study site. this school was selected because it applied rsbi scheme and ranked the highest in kelas ilmu sosial (n = 14) diukur dengan menggunakan skala kecemasan taylor manifest. ketidakpuasan terhadap faktor lingkungan sekolah dinilai menggunakan kuesioner evaluasi sekolah. hasil: pengukuran kecemasan menunjukkan bahwa siswa di kelas ilmu pengetahuan alam dan ilmu sosial sama sama pernah mengalami kecemasan yang berat (ilmu pengetahuan alam vs studi sosial: 75% vs 86%). hasil penelitian berdasarkan kuesioner evaluasi sekolah menunjukkan ketidakpuasan terhadap tiga faktor lingkungan sekolah (faktor kurikulum, ilmu pengetahuan alam vs studi sosial: 59% vs 64%; faktor guru, ilmu pengetahuan alam vs studi sosial: 3% vs 43 faktor manajemen sekolah, ilmu pengetahuan alam vs ilmu sosial;%: 3% vs 14%). hasil uji chi-square menunjukkan bahwa perbedaan tingkat kecemasan antara siswa kelas ilmu pengetahuan alam dan siswa kelas ilmu sosial jurusan tidak signifikan (p> 0,05). simpulan: siswa kelas ilmu pengetahuan alam dan kelas ilmu sosial di sma rsbi mengalami kecemasan yang berat. namun, tidak ada bukti kuat yang menunjukkan bahwa lingkungan sekolah sebagai penyebab kecemasan yang berat ini. [amj.2014;1(2):65–9] kata kunci: tingkat kecemasan, ilmu pengetahuan alam, sma rsbi, faktor lingkungan sekolah, ilmu sosial althea medical journal. 2014;1(2) 67 the city of bandung.8 this study was conducted in sman 3 bandung during the period of october to december 2012, with students in grade xii as the study population. the subjects consisted of students of natural science major (n = 32; 56% male, and 44% female), and students of social studies major (n= 14; 29% male and 71% femalewho were enrolled in the school during the academic year of 2012–2013 and willing to fill out the questionnaire. students who were absent at the time of study and those who did not complete the questionnaire were excluded. this study was an analytic descriptive study with retrospective cohort design. independent variables of the study were natural science or social studies students and the environment of sman 3 bandung school. the dependent variable was the anxiety level measured by taylor manifest anxiety scale (tmas). the tmasscore of ≤ 9 represents the category of mild anxiety, score of 10–15 represents moderate anxiety, and score of ≥ 16 represents severe anxiety at the beginning of the study, convenience sampling was used to obtain respondents. the respondents then completed their biodata, informed consent form, tmas questionnaire, and school evaluation questionnaire, which was a questionnaire to measure the degree of satisfaction towards the school. data obtained were then tested using the chi-square method in spss 20.0. this study has gained approval from the ethic committee of health research, faculty of medicine, universitas padjadjaran. results the results of the tmas questionnaire completed by the respondents, i.e.32 natural sciences students and 14 social studies students, were categorized into not anxious, mild anxiety, moderate anxiety, and severe anxiety with most students, both in the natural sciences and social studies majors, were assigned to the severe anxiety group (table 1). a certain disatisfaction degree towards factors in the school among students with severe anxiety (table 2). of the three factors, the curriculum was the most disliked factor by the majority of students, both from the natural sciences major and the social studies major. for the other two factors, the level of dissatisfaction was not significant, except for the teacher factor in the social studies major, which was quite high. table 1 comparison of anxiety levels between students of natural sciences and social studies majors majors classification of anxiety level total (%) mild anxiety moderate anxiety s e v e r e anxiety n (%) n (%) n (%) natural sciences 3 (9) 5 (16) 24 (75) 32 (70) social studies 1 (7) 1 (7) 12 (86) 14 (30) total 4 (9) 6 (13) 36 (78) 46 (100) chi-square test was performed to reveal the significance of the difference between the level of anxiety of the natural science students and social studies students (table 3). this test was also used to assess the correlation between anxiety and dissatisfaction towards school factors (table 4, 5, 6). all test results with p>0.05 were considered insignificant, which was the case in the difference in anxiety level between the students natural science and social studies majors. the correlation table 2 comparison of satisfaction level on school factors between students of natural sciences and social studies majors with severe anxiety majors natural sciences s o c i a l studies n (%) n (%) satisfaction towards the curriculum moderate 8(33) 4(33) unsatisfied 15(63) 8(67) very dissatisfied 1(4) 0(0) total 24(100) 12(100) s a t i s f a c t i o n towards the teachers satisfied 6(25) 4(33) moderate 18(75) 8(67) dissatisfied 0(0) 0(0) total 24(100) 12(100) s a t i s f a c t i o n t o w a r d s the school management satisfied 3(13) 0(0) moderate 20(83) 7(58) dissatisfied 1(4) 5(42) total 24(100) 12(100) arviana adamantina putri, leonardo lubis, tatang muchtar sutaryan: differences of anxiety levels between students of natural sciences and social studies major in senior high schools with rintisan sekolah bertaraf internasional scheme althea medical journal. 2014;1(2) 68 amj december, 2014 between anxiety and dissatisfaction to the school factors was also unproven in this study. discussion severe anxiety was experienced by most of the social studies students, with 86% of them experienced severe anxiety. meanwhile, 75% of the natural science students experienced severe anxiety. this may be due to the fact that the social studies students use more of their right brain, which functions include communication and other social functions. the right prefrontal cortex is the reservoir of anger, anxiety, and fear.12,13 hyperactivity on the right prefrontal cortex can cause imbalance between the two hemispheres, making anxiety harder to manage.14 brain is not the only factor that influence anxiety since external factors can also have an important role in the rise of anxiety. one of those factors is the school environmental factors which consist of curriculum, teacher, and school management factors.4 students with severe anxiety from both natural sciences and social studies majors were dissatisfied with the implemented curriculum. this is due to the target of the curriculum which was too high compared to the average national exam (ujian nasional, un) target. the learning process that used two different languages, very tight assignments, and high standard of scoring may also create the dissatisfaction.4,8 the pressure for students was great and may lead to a feeling of dissatisfaction towards the implemented curriculum, which is also a factor for the rise of anxiety in students. however, table 3 chi-square analysis results on the difference in anxiety level between the students of natural science and social studies majors majors classification of anxiety level p mild anxiety + average anxiety s e v e r e anxiety n(%) n(%) natural sciences 8(18) 24(52) 0.69 social studies 2(4) 12(26) total 10(22) 36(78) table 4 chi-square analysis results on the correlation between anxiety level and satisfaction towards curriculum curriculum factor classification of anxiety level p mild anxiety + average anxiety s e v e r e anxiety n(%) n(%) unsatisfied 6(13) 24(52) 0.72moderate + satisfied 4(9) 12(26) total 10(22) 36(78) table 5 chi-square analysis results on the correlation between anxiety level and satisfaction towards teacher teacher factor classification of anxiety level p mild anxiety + average anxiety s e v e r e anxiety n(%) n(%) unsatisfied 2(5) 5(11) 0.63moderate + satisfied 8(17) 31(67) total 10(22) 36(78) table 6 chi-square analysis results on the correlation between anxiety level and satisfaction towards school facilities school management factors classification of anxiety level p mild anxiety + average anxiety s e v e r e anxiety n(%) n(%) unsatisfied 0(0) 3(6) 1.00moderate + unsatisfied 10(22) 33(72) total 10(22) 36(78) althea medical journal. 2014;1(2) 69 the correlation between the anxiety level and dissatisfaction towards the curriculum had no statistical significance (p > 0.05), this can be due to the fact that this was a pilot study and the first one in bandung city for this topic. the insignificant result of this study can also be due to the sample size that is too small. ideally, the sample size for this study to represent the situation in bandung city should be calculated based on the following formula: n= n 1+ne2 information: n = sample size n = total population e = error tolerance (0,05) according to the formula, the total population size has to be known. there are 4 senior high schools with rsbi scheme in bandung city. the total population of students in the 4 schools was not determined in this study due to the limited time for completing the study, which led to the use of convenience sampling for sample collection. references 1. costello ej, mustillo s, erkanli a, keeler g, angold a. prevalence and development of psychiatric disorders in childhood and adolescence. arch gen psychiatry.2003;60(8):837-44. 2. haryadi d. perilaku bermasalah remaja muncul lebih dini. 2007. [cited 2012 april 22]. available from: http://wartawarga. g u n a d a r m a . a c . i d / 2 0 1 0 / 0 4 / p e r i l a ku bermasalah-remaja-muncul-lebih-dini/ 3. mighwar a. psikologi remaja: petunjuk bagi guru dan orangtua. bandung: pustaka setia; 2006. 4. astuti es, resminingsih. pelayanan konseling pada satuan pendidikan menengah. jakarta: grasindo; 2010. 5. sadock bj, kaplan hi, sadock va. kaplan and sadock’s synopsis of psychiatry. virginia: wolter kluwer/lippincott williams & wilkins; 2008. 6. kay j, tasman a. essentials of psychiatry. chichester: john wiley & sons; 2006. 7. mccance kl, huether se, brashers vl. pathophysiology: the biological basis for disease in adults and children. oxford: elsevier health sciences; 2009. 8. direktorat jenderal manajemen pendidikan dasar dan menengah, direktorat pembinaan sekolah menengah atas. panduan penyelenggaraan program rintisan sma bertaraf internasional. jakarta: departemen pendidikan nasional; 2009. 9. brynie fh. brain sense: the science of the senses and how we process the world around us. new york: american management association; 2009. 10. kalat jw. biological psychology. wadsworth: cengage learning; 2012 11. sarwono sw. psikologi remaja. jakarta: raja grafindo perkasa; 2011. 12. fitzgerald mjt, gruener g, mtui e. clinical neuroanatomy and neuroscience. 5th ed. philadelphia: saunders elsevier; 2007. 13. fuster jm, bodner m, kroger jk. crossmodal and cross-temporal association in neurons of prefrontal cortex. nature. 2000; 405(6784): 347-51 14. balconi m, ferrari c. rtms stimulation on left dlpfc affects emotional cue retrieval as a function of anxiety level and gender. depress anxiety. 2012 ;29(11):976-82. arviana adamantina putri, leonardo lubis, tatang muchtar sutaryan: differences of anxiety levels between students of natural sciences and social studies major in senior high schools with rintisan sekolah bertaraf internasional scheme althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 114 amj march, 2015 effect of centella asiatica leaves on gastric ulcer in rats ester mariska1, trully d. sitorus2, januarsih a. rachman3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of biology cell, faculty of medicine, universitas padjadjaran, bandung, indonesia abstract background: gastric ulcer is disruption of gastric mucosal integrity due to lack of smaller defensive factors (e.g. mucus levels) than gastric aggressive factors. centella asiatica is a traditional medicine that contains triterpenoids and flavonoids. the objective of this study was to analyze the effect of ethanol extract of centella asiatica leaves for preventing gastric mucus level reduction of aspirin-induced gastric ulcer model in rats and compared it to misoprostol. methods: an experimental laboratory study using 24 rats that were divided into 4 groups. group i (negative control) received carboxymethy cellulose (cmc) solution, group ii (positive control) received cmc and aspirin 450mg/kg, group iii (tested group) received centella asiatica 400 mg/kg and aspirin 450 mg/kg, group iv (compared group) received misoprostol 72μg/kg and aspirin 450mg/kg for three days. then the rats were laparatomied and their gastric mucus levels were measured. the results were statistically analyzed by independent t-test. results: the mean levels of gastric mucus of group i, ii, iii, iv, respectively were 0.112; 0.035; 0.537; 0.455 optical densities per gram of tissue. the statistical test suggested a significant difference between the positive control group and tested group. moreover there is no significant difference between the tested group and compared group. conclusions: centella asiatica leaves can prevent gastric mucus level reduction of aspirin-induced gastric ulcer model in rats and has similar effect in gastric mucus level with misoprostol. keywords: centella asiatica, gastric mucus, gastric ulcer, misoprostol correspondence: ester mariska, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 813 8684 1321 email: ester_mariska@yahoo.com introduction gastric ulcer is disruption of gastric mucosal integrityand arises from the smaller level of defensive factors (e.g. mucus levels) than gastric aggressive factors.1this condition can be triggered by the use of aspirin as anti-inflammatory and antiplatelet over a long period of time. patients with gastric ulcers often complain of epigastric pain, burning sensation, nausea, and vomiting. the pain arises after eating. this situation led to decreased patient’s productivity. therefore, the patients require treatments which may include modern medicine, such as misoprostol, or traditional medicine. the mechanism of action of misoprostol as a prostaglandin analogue is stimulating the secretion of mucus and bicarbonate, reducing mucosal cell turnover, and increasing mucosal blood flow.1 traditional medicines have been used for treatment from generation to generation based on experiences.2 the percentage of indonesian population who use traditional medicine is about 22.26% in 2008.3 traditional medicine is medicine derived from plants, animals, minerals, or a mixture of these materials. one of these traditional medicines is centella asiatica. centella asiatica is a short-stemmed creeping plant that have been used as a cure for leprosy, syphilis, fever, and plays a role in wound healing, increasing work capacity of neurotransmitters in the brain, and revitalizing body tissues. it grows in tropical and subtropical regions, e.g. indonesia. centella asiatica has branched tap root, green leaves in a fan-shaped or kidney-shaped, round flowers, and small fruits. the height of centella asiatica is 10-50 cm.4 the objective of this study was to analyze the effect of centella asiatica against gastric althea medical journal. 2015;2(1) 115 ulcers and to compare the effect of centella asiatica with misoprostol. methods an experimental study was carried out, using 24 male wistar strain rats with inclusion criterias as follows: 8-12 weeks old, 150-200 grams weight, active movement, clean hair, no wound on the body, and normal stools. the exclusion criteria are weight lost more than 10% of the initial body weight during the figure 1 procedures of the experiment ester mariska, trully d. sitorus, januarsih a. rachman: effect of centella asiatica leaves on gastric ulcer in rats althea medical journal. 2015;2(1) 116 amj march, 2015 adaptation and sickness after the adaptation. the rats were obtained from the laboratory of sekolah ilmu teknologi hayati institut teknologi bandung and were adapted for seven days in the pharmacological laboratory of dr.hasan sadikin general hospital bandung to prevent or minimize the stress in a new environment.5 the leaves of centella asiatica were obtained from kebun percobaan manoko, kecamatan lembang, west bandung, west java and extracted in balai penelitian tanaman rempah dan obat, bogor, west java. the fresh leaves were harvested at the age of 3-6 months. the leaves were sorted and washed to clean from dirt or foreign material and reduce from microbial. then, the leaves were pulverized. next, the sample was mixed with ethanol (70%) with a ratio of 1:5 in shaking water bath for 3 hours and allowed to steady for 16 hours. the sample was filtered by filter paper, concentrated in a rotatory evaporator at 500c for 6 hours, and dried with a freezer dryer for 2 days. twenty kg of wet centella asiatica plant (all parts) became 836.5 grams of dried leaves and became 96 grams of dried extract. the dose of extract was 400 mg/kg body weight.6 misoprostol was used as a comparative drug and obtained from pt novell pharmaceutical laboratories. misoprostol as a prostaglandin analogue has mechanisms of action for stimulating the secretion of mucus and bicarbonate, reducing mucosal cell turnover, and increasing mucosal blood flow.1 the dose of misoprostol was 72 μg/kg body weight. in this study, aspirin was used to create a gastric ulcer condition in the rats and was obtained from pt bayer indonesia. aspirin belongs to a class of nonsteroidal anti-inflammatory drugs (nsaids). mechanism of action of nsaids is to inhibit synthesis of prostaglandin. this mechanism can harm mucosal defense and repair, as well as stimulating mucosal damage. the nsaids are weak acids. the nsaids will remain as non-ionized lipophilic form if nsaids are in acidic environment. in that condition, nsaids will cross through the lipid membranes of epithelial cells and be trapped in the cell. if the drugs are trapped inside the cell, then the cell will be damaged.1the dose of aspirin was 450 mg/kg body weight. the doses used in this study were the results from conversion using table experimental animals and humans.7 centella asiatica extracts, aspirin, and misoprostol were dissolved in 5 ml cmc solution and given orally to the rats.8 the rats were divided into 4 groups. group i (negative control) received carboxymethy cellulose (cmc) solution, group ii (positive control) received cmc and aspirin 450mg/ kg, group iii (tested group) received centella asiatica 400 mg/kg and aspirin 450 mg/ kg, group iv (compared group) received misoprostol 72μg/kg and aspirin 450mg/kg during three days. the function of group i was to determine the normal gastric mucus level in rats. after 3 days, all the rats were scarified by ketamine and were laparatomied. their gastric mucus levels were collected and measured by spectrophotometer (wavelength 605 nm) using the green ap, lander je, turner, dh (1981) method. the measurement of gastric mucus levels was done in the laboratory of unit penelitian kesehatan rumah sakit umum pusat dr. hasan sadikin bandung. the results were analyzed using independent t-test. the test in this study used confidence interval (ci) 95% (α= 5%). the procedures were based on the research of m. sancar et. al. (2009).9 the measurement of mucus levels were based on the green ap, lander je, turnerdh (1981) method.10 (figure 1) table 1 gastric mucus levels of the gastric ulcer induced rats group gastric mucus level (optical density units per gram of tissue) group i group ii group iii group iv 1 0.186 0.047 0.585 0.528 2 0.050 0.028 0.720 0.370 3 0.070 0.061 0.652 0.573 4 0.140 0.015 0.339 0.361 5 0.134 0.011 0.411 0.556 6 0.092 0.048 0.513 0.342 mean(sd) 0.112(0.051) 0.035(0.020) 0.537(0.145) 0.455(0.108) althea medical journal. 2015;2(1) 117ester mariska, trully d. sitorus, januarsih a. rachman: effect of centella asiatica leaves on gastric ulcer in rats results the results of measurement of rat gastric mucus levels can be seen in table 1. there was a significant difference in the mean of mucus level of gastric between group i and ii (table 2). this result states that induction of aspirin (450 mg/kg) can decrease mucus level and create a gastric ulcer model in rats. there was a significant difference in the mean of mucus level of gastric between group ii and iii (table 3). this result state that centella asiatica extract can prevent a declining of mucus levels of aspirin-induced gastric ulcer model in rats. there was no significant difference in the mean of mucus level of gastric between group iii and iv (table 4). this result state that centella asiatica extract has similar effect in preventing gastric mucus level reduction of aspirin-induced gastric ulcer model in rats with misoprostol. discussions the gastric mucus is produced by epithelial cells on the surface of gastroduodenal organ. the mucus consists of water (95%), mucin, and lipid. the functions of gastric mucus are lubricate to protect mucous from mechanical damage, protect gastric lining from self-digestion from pepsin (without disturbing the activity of pepsin) and from acid by neutralizing hcl (without disturbing the function of hcl in the lumen).1,11 this study showed that rats which received centella asiatica extract (400 mg/kg) prior to administration of aspirin (450 mg/kg) for three consecutive days had mean mucus level 0.537 optical density per gram of tissue. it demonstrated that centella asiatica extract can prevent declining of mucus levels of aspirininduced gastric ulcer model in rats (p<0.05). centella asiatica consists of triterpenoids and flavonoids. triterpenoid is the most common component in centella asiatica.4 centella asiatica has been proved to have roles as wound healing, anti-inflammatory, and antioxidant. a research of shukla et al. stated that asiaticoside derived from centella asiatica had a role in wound healing in vitro and in vivo. it was proved by increasing tensile strength, collagen, fibroblast proliferation, and wound epithelization in guinea pig and rat. its role in wound healing was also proved from the increasing angiogenesis in vitro.12 the research also stated that saponin, asiatic acid, madecassoside derived from centella asiatica had the effect of wound healing by inducing the production of collagen type i to stimulate the wound healing process.4 normal phases of wound healing consist of hemostasis, inflammation, proliferation, and remodeling. centella asiatica has a role in the proliferative phase. this phase is dominated by granulation tissue formation and epithelization. in this phase there will be releasing of macrophage and growth factor from platelets to stimulate migration and activating of fibroblast. then, fibroblast will produce an important substance for wound healing. one of the substances is collagen.13 research of frederico et al. stated that there is a positive correlation between the flavonoids received from centella asiatica and antioxidant. centella asiatica can absorb or neutralize free radicals. free radicals can damage proteins, dna, and lipids in cell membrane.14 research of huang et al. stated that asiatic acid derived from centella asiatica had the effect as antiinflammatory. anti-inflammatory response can be seen from declining malondyaldehyde and nitric oxide levels. both of them are produced by impact of free radicals that attack plasma table 2 effect of aspirin in reducing gastric mucus levels in rats n mean (sd) mean difference (ci 95%) p* group i 6 0.112 (0.051) 0.077 (0.024-0.130) 0.006 group ii 6 (0.035 0.020) table 3 effect of centella asiatica and aspirin-induced gastric ulcer in gastric mucus level n mean (sd) mean difference (ci 95%) p* group ii 6 0.035 (0.020) 0.502 (0.350-0.653) <0.001 group iii 6 0.537 (0.145) althea medical journal. 2015;2(1) 118 amj march, 2015 membrane. anti-inflammatory response can also be seen by increasing antioxidant enzyme, e.g. catalase, superoxide dismutase (sod), and glutathione peroxidase in liver tissue.15 a research of somchit et al. stated that asiatic acid and madecassic acid derived from centella asiatica had the effect as analgesic and anti-inflammatory.16 moreover, this study showed that centella asiatica (400 mg/kg) had similar effect with misoprostol in preventing gastric mucus levels reduction of aspirin-induced gastric ulcer model in rats (p ≥ 0.05). the conclusion of this study is centella asiatica leaves can prevent gastric mucus level reduction of aspirininduced gastric ulcer model in rats. references 1. valle jd. peptic ulcer disease and related disorders. in: fauci as, kasper dl, longo dl, braunwald e, hauser sl, jameson jl, et.al., editors. harrison’s principles of internal medicine. 17thed. the us: mcgraw-hill companies, inc.; 2008. p. 1855–72. 2. badan pengawas obat dan makanan republik indonesia. kriteria dan tata laksana pendaftaran obat tradisional, obat herbal terstandar dan fitofarmaka. jakarta: bpom; 2005. 3. kementrian kesehatan republik indonesia. profil kesehatan tahun 2008. jakarta: departemen kesehatan republik indonesia; 2009. 4. winarto wp, surbakti m. khasiat dan manfaat pegagan tanaman penambah daya ingat. jakarta: pt agromedia pustaka; 2003. 5. badan tenaga nuklir nasional. pedoman etik penggunaan dan pemeliharaan hewan percobaan. jakarta: batan; 2011. 6. abdulla ma, al-bayaty fh, younis lt, hassan mia. anti-ulcer activity of centella asiatica leaf extract against ethanolinduced gastric mucosal injury in rats. j med plant res. 2010;4(13):1253–59. 7. paget ge, barnes jm. toxicity tests. in: lawerence dr, bacharach al, editors. evaluation of drug activities: pharmacometrics. in:. new york: academic press. 1964. p. 135–65. 8. wijayani a, ummah k, tjahjani s. karakterisasi karbosimetil selulosa (cmc) dari eceng gondok eichornia crassipes (mart) solms. indo j chem. 2005;5(3):228– 31. 9. sancar m, hantash t, okuyan b, apikoglurabus s, cirakli z, gulluoglu mg, et al. comparative effectiveness of glycyrrhiza glabravs. omeprazole and misoprostol for treatment of aspirin-induced gastric ulcers. afr j pharm pharmacol. 2009;3(12):615– 20. 10. green ap, lander je, turner dh. the effect of stress and indomethacin, carbenoxolone, salbutamol, metiamide, zolimidine and cf19415 on rat gastric mucus. j pharm pharmacol. 1981;33(6):348–52. 11. sherwood l. human physiology: from cells to systems. 7th ed. canada: brooks/cole, cengage learning; 2010. 12. shukla a, rasik am, jain gk, shankar r, kulshrestha dk, dhawan bn. in vitro and in vivo wound healing activity of asiaticoside isolated from centella asiatica. j ethnopharmacol. 1999;65(1):1–11. 13. mackay d, miller al. nutritional support for wound healing. altern med rev. 2003;8(4):359–77. 14. pittella f, dutra rc, junior dd, lopes mtp, barbosa nr. antioxidant and cytotoxic activities of centella asiatica (l) urb. int j mol sci. 2009;10(9):3713–21. 15. huang s-s, chiu c-s, chen h-j, hou w-c, sheu m-j, lin y-c, et al. antinociceptive activities and the mechanisms of antiinflammation of asiatic acid in mice. evid based complement alternat med. 2011:2011;895857. 16. somchit mn, sulaiman mr, zuraini a, samsuddin l, somchit n, israf da, et al. antinociceptive and antiinflammatory effects of centella asiatica. indian j pharmacol. 2004;36(6):377–80. table 4 effect of centella asiatica and misoprostol in gastric mucus level induced rats n mean (sd) mean difference (ci 95%) p* group iii 6 0.537 ± 0.145 0.081 (0.083-0.246) 0.147 group iv 6 0.455 ± 0.108 amj vol 9 no 2 june 2022.indd althea medical journal. 2022;9(2) 74 hearing profile of children below three years old at jatinangor integrative health care center, west java, indonesia fidkya allisha,1 wijana,2 sally mahdiani2 1faculty of medicine universitas padjadjaran, indonesia, 2department of otorhinolaryngologyhead, and neck surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: fidkya allisha, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21 jatinangor, sumedang, indonesia, e-mail: fidkyaallisha@gmail.com althea medical journal. 2022;9(2):74–79 abstract background: hearing function is one of the most important factors affecting children’s development process. the first three years of life is a golden period of growth and development of children. this study was conducted to investigate the hearing profile of children below three years old at jatinangor integrative health care center (pos pelayanan terpadu, posyandu), west java, indonesia. methods: an observational cross-sectional study was conducted to 86 children below three years old who was selected by using multistage cluster sampling at 12 posyandu in jatinangor sub-district by using in-depth interview related to hearing loss risk factors, reaction test, and tympanometry test. results: the hearing loss prevalence of children below three years old in the jatinangor sub-district was 7.0%. of the 86 children, there were 2.3% (n=2) children with moderate conductive hearing loss, 1.2% (n=1) children with moderate sensorineural hearing loss, and 3.5% (n=3) children with very severe sensorineural hearing loss. fifty percent of children with sensorineural hearing loss were discovered without any risk factor. conclusions: the prevalence of hearing loss in children under three years old at the jatinangor integrative health care center is slightly higher than the national prevalence. fifty percent of children are found without risk factors, therefore universal newborn hearing examination (unhs) needs to be implemented at the national level in accordance with the guidelines of the joint committee for infant hearing (jcih) in which are integrated with primary health care units, tertiary health care centers otorhinolaryngology, and also the audiological center. keywords: children, early detection, hearing loss, hearing profile introduction the first three years of life is a golden period of growth and development in children in which there is a critical and rapid development of brain plasticity, which is very sensitive to the influence of external stimuli, as well as being flexible to take over the functions of the surrounding cells by forming synapses.1,2 the critical period of hearing and speech development begins in the first 6 months of life and continues until the age of 3 years.2 hearing function plays a significant role in optimizing the growth and development of children in the golden period. the implementation of periodic monitoring of hearing function in children from birth to three years is very important to ensure the presence of hearing loss from an early age. the joint committee on infant hearing (jcih) states that a diagnosis of hearing loss in children should be made at least at three months of age so that appropriate intervention can begin at six months of age.3,4 hearing loss is a problem that is quite commonly found in the national and even global settings. recent prevalence estimates indicate that in 2015 nearly half a billion people or about 6.8% of the world’s population had disabling hearing loss, and the prevalence rates will continue to rise. the world health organization (who) currently estimates that at least 34 million children under the age of 15 have disabling hearing loss. based on a 2012 https://doi.org/10.15850/amj.v9n2.2525 althea medical journal. 2022;9(2) 75 who report, approximately 7.5 million of these children were under the age of 5 years.5 the national survey of sight and hearing function in 7 provinces in indonesia6 from 1993 to 1996 showed that the prevalence of hearing loss and deafness was 16.8% and 0.4%, consecutively, with the main cause often found in children under three years were middle ear infections (3.1%), congenital hearing loss (0.1%), and hearing loss due to the noise exposure.6 according to who, around 50% of children with congenital hearing loss have no risk factors.7 lack of awareness of parents about hearing loss in their infants and children is a challenge that needs to be overcome nowadays.3 hearing loss is often ignored because the signs and symptoms that might appear in children are almost invisible, parents are not immediately aware of any hearing loss suffered by their children, sometimes children are considered to have autism or hyperactivity disorder because of their unruly behavior. parents are only aware of hearing loss in their children if there is no response to loud noises or speech delays.4 in indonesia, public health centers (pusat kesehatan masyarakat, puskesmas), as the frontline in promoting and implementing community health programs have an important role in monitoring and promoting childrens’ growth and development, including monitoring the development of hearing function and hearing loss in children, given the lack of parental awareness to detect hearing disorders. to carry out this role, the puskesmas organizes a program called the integrated healthcare center (pos pelayanan terpadu, posyandu). posyandu could carry out one of its basic functions as a monitor unit for child development.8 according to data obtained from the central bureau of statistic of sumedang district (badan pusat statistik kabupaten sumedang), jatinangor was the first most populous sub-district in sumedang district in 2016, with a population of 113,234.9,10 therefore, this study was aimed to determine the hearing profile of children under three years old at the jatinangor integrated healthcare center. methods this study was an observational study with a cross-sectional design conducted at 12 posyandu in jatinangor subdistrict from july to september 2018. after obtaining ethical approval from the ethics committee of universitas padjadjaran no. 787/un6.kep/ ec/2018, the research was conducted. the research subjects were children under three years old who were registered in 12 posyandu in 6 villages in jatinangor subdistrict. posyandu were selected through the multistage cluster sampling technique with a minimum sample size of 72 children under three years old who met the inclusion criteria including children aged 0–36 months, registered at posyandu in 6 villages in jatinangor subdistrict, and parents’ willingness to include their children in this study. exclusion criteria in this study were children with acute ear infections, acute upper respiratory infections, and cerumen impaction in one or two ears. physical examination of ears, nose, and throat by using an otoscope, nasal speculum, tongue spatula, and the head lamp was carried out before the hearing examination was carried out on the subject. the examinations conducted were in-depth interviews with parents related to hearing loss risk factors, reaction tests to determine the degree of hearing loss in children, and tympanometry tests to determine the condition of the childs’ middle ear to predict the type of hearing loss that might occur in children. indepth interviews of parents were performed by the main researcher as a medical student. the reaction test was conducted by using the horn to distinguish very severe hearing loss and using six grains of rice shaken in a ping pong ball to distinguish moderate hearing loss. positive reaction to sound stimuli included reflexive responses such as head or limb reflexes, whole-body startle, eye blinking or flutter, and suckling reflex in infants; also orientating or attention-type behavior such as the increased or decreased body gesture, eyes widening, searching, localization, quieting, and or vocalizations. children with a negative reaction to the horn sound stimuli were then classified as children with very severe hearing loss, while children with a positive reaction to the sound of the horn stimuli but have a negative reaction to the sound of six grains of rice being shaken in a pingpong ball were classified as children with moderate hearing loss. children with positive reactions to both sound stimuli were classified as children with normal hearing function. in this study, risk factors were grouped into 10 types based on the american academy committee on infant hearing statements,3 the degree of the hearing was grouped into three categories; normal, moderate hearing loss, and very severe hearing loss. the type of hearing loss was classified into conductive fidkya allisha et al.: hearing profile of children below three years old at jatinangor integrative health care center, west java, indonesia althea medical journal. 2022;9(2) 76 and sensorineural hearing loss based on the interpretation of the tympanometry test results. sensorineural hearing loss could be assumed if children with hearing loss showed normal tympanometry graph type a, whereas children with hearing loss with tympanometry other than type a graph were classified as having conductive hearing loss. the data obtained were then recorded on a research form which was then recapitulated and presented in tabular form. the descriptive statistic analysis was used to process and present the data. results of the 101 children who met the inclusion criteria, 15 were excluded. thus, 86 children who met the inclusion and exclusion criteria. the age of the children examined in this study ranged from 3 to 36 months with the most age group was 24–<36 months (39.5%), and the sex ratio was 1:1. the prevalence of hearing loss was 7.0%. of the 6 cases of hearing loss, 4 (4.7%) were moderate and 2 (2.3%) were very severe. both sensorineural and conductive hearing loss were presented equally in children below three years old (table). of the 4 children with sensorineural hearing loss, 2 children (50%) were found without risk factors, 1 child (25%) was found to have a risk factor for torchs infection, and 1 child (25%) was found to have a risk factor of low birth weight. the female group suffered more conductive hearing loss whereas the male group suffered more from sensorineural hearing loss (table). discussion our study shows that the prevalence of hearing loss in children in the jatinangor subdistrict is 7%, indicating that the prevalence of hearing loss in the jatinangor subdistrict is higher compared to indonesia’s prevalence. according to who, indonesia with a hearing loss prevalence of 4.2%, is one of the countries with high hearing loss prevalence in southeast and south asia, besides nepal (16.6%), althea medical journal june 2022 table hearing profile of children below three years old at jatinangor integrative health care center characteristic normal conductive hearing loss sensorineural hearing loss total moderate very severe moderate very severe n % n % n % n % n % n % gender male female 40 40 46.5 46.5 1 2 1.2 2.3 1 1.2 1 1 1.2 1.2 43 43 50 50 age (months) <6 6–<12 12–<24 24–<36 7 14 27 32 8.1 16.3 31.4 37.2 1 2 1.2 2.3 1 1.2 1 1 1.2 1.2 8 15 29 34 9.3 17.4 33.7 39.5 risk factors of hearing loss perinatal ototoxic low birth weight mechanical ventilation assistance for more than 5 days torchs infection severe asphyxia anatomical defect congenital hearing loss syndrome hereditary hyperbilirubinemia bacterial meningitis none 5 3 3 2 2 1 1 65 5.8 3.5 3.5 2.3 2.3 1.2 1.2 75.6 1 2 1.2 2.3 1 1.2 1 1 1 1 1.2 1.2 1.2 1.2 5 4 3 3 2 2 2 1 68 5.8 4.7 3.5 3.5 2.3 2.4 2.4 1.2 79.1 total 80 93.0 3 3.5 0 0 1 1.2 2 4.8 86 100% althea medical journal. 2022;9(2) 77 thailand (13.3%), bangladesh and sri lanka with each of the prevalence was 9%, myanmar (8%), india and maldives with each of the prevalence was 6%.10 this could be caused by the lack of awareness and knowledge about the health of hearing sense, the lack of facilities and infrastructure to prevent, detect, and intervene in hearing loss as early as possible, as well as the lack of cross-sectoral support in overcoming the problem of hearing loss.11 hearing loss in children could be caused by genetic (congenital) and non-genetic (acquired) factors. in this study, 50% of children with sensorineural hearing loss are found without risk factors, despite etiological evaluation, the etiology of snhl is reported to remain unknown in 25–45% of the cases,12 which supports our findings in this study. of all the inheritance patterns, autosomal recessive nonsyndromic hearing loss (arnshl) is the most common disease and accounts for approximately 80% of cases in nonsyndromic sensorineural hearing loss.13,14 autosomal recessive nonsyndromic hearing loss (arnshl) is usually characterized as congenital, nonsyndromic, severe-to profound, and nonprogressive sensorineural hearing loss. autosomal recessive transmission occurs in 77–93% of cases and is typically prelingual, while autosomal dominant hearing loss accounts for about 10–20% of cases and is most often postlingual. x-linked or mitochondrial inheritance is observed in the remaining.15 in this study obtained 3 (75%) of 4 children suffering from sensorineural hearing loss are male. nongenetic hearing loss (acquired) in children is mostly caused by prenatal infection, such as toxoplasmosis, rubella, cytomegalovirus, and herpes.16 in this study, 25% of children suffering from sensorineural hearing loss have risk factors for prenatal torchs infection. according to a study of infants in western sicily, italy,17 torch infections indicated independent significant risk factors (p=0.024). all torchs infections can cause similar signs before and after birth, such as stunted fetal growth, microcephalus, seizures, mental retardation, visual impairment, and cerebral palsy.13 in this study, children are found to have a severe degree of sensorineural hearing loss and impaired vision and growth and development. torchs infection can cause sensorineural hearing loss directly or indirectly. directly, infections due to the toxoplasma gondii parasite and infections due to viruses such as rubella, cytomegalovirus, herpes, and syphilis can cause damage to the cochlea and cell death in the cortical and stria vascular organs. meanwhile, indirect hearing loss is caused by a decrease in the ability of the body’s immunity, secondary infection, and immune response to antigens.14 this study found 1.2% had moderate sensorineural hearing loss and had a risk factor of low birth weight. low birth weight infants are identified as high-risk infants with associated pathophysiology and usually, the prognosis of low birth weight infants will be worse, especially in the early period of life compared to the normal infants. direct complications associated with low birth weight has various long-term effects, including developmental disorders, growth disorders, retinopathy, hearing loss, chronic lung disease, and congenital disorders.18 delayed myelination process in low-birth-weight infants will result in immaturity and physiological dysfunction of the body, including hearing function. a study of 3675 infants in north taiwan19 revealed independent risk factors for hearing loss in a tertiary medical center of vlbw infants who were born with a birth weight <1500 g. among these hearing-impaired infants, the craniofacial anomalies, the prolonged oxygen use, the pda ligation history, and the ototoxins usage yielded good predictions of hearing loss.19 there are 2.3% of children with moderate conductive hearing loss. a study of 234 australian infants referred for diagnostic testing from a newborn hearing screening program has shown similar findings, the prevalence of chl in the newborns according to the study was 2.97 per 1000.20 conductive hearing loss in the outer ear could be caused by; atresia of the ear canal, cerumen impaction, otitis externa circumscripta, osteoma of the ear canal, and others. meanwhile, conductive hearing loss in the middle ear is caused by; cathar tube/eustachian tube obstruction, otitis media, otosclerosis, tympanosclerosis, hemotympanum, and ossicular dislocation.20 two children with moderate conductive hearing loss in this study showed the type ‘b’ curve during the tympanometric test which indicated the presence of otitis media effusion (ome). ome can be caused by allergies and chronic upper respiratory tract infections. a study of hearing profiles of premature newborns in poland21 showed that the most serious problem-permanent-profound sensorineural bilateral hearing deficit (>90 db) was diagnosed in 1.42% of infants born <28 weeks gestational age (22/1548), in fidkya allisha et al.: hearing profile of children below three years old at jatinangor integrative health care center, west java, indonesia althea medical journal. 2022;9(2) 78 0.3% of those born between 29 and 32 weeks’ gestational age (16/5194) and in 0.02% of infants born <33 weeks’ gestational age (p<0.01).21 the existing public health practices do not provide for screening of high-risk infants either at birth or in subsequent childhood years. both community-based and schoolbased health programs were lack of facilities for basic hearing tests. consequently, diagnosis of hearing impairment is usually delayed and achieved mainly through the complications of the disease when detected by parents, carers, and health workers. this study provided reliable results given the limited resources of the instrument to evaluate the hearing function of children that might be faced by the primary health care service, especially in community-based health centers in the rural areas. the simple method and equipment of hearing function test enable the primary healthcare personnel to implement routine monitoring of children’s hearing function so that the hearing impairment could be detected earlier. the effects of early diagnosis were seen in newborns with and without unhs. in almost all cases, the care of both screened and unscreened and of both early and late confirmed populations in this have different outcomes and is likely to reflect the effect of unhs and early confirmation of hearing loss.22 the limitation of this study was the reaction test implemented in this study is only able to distinguish between moderate and very severe hearing loss, therefore, further study by using advanced audiological screening test needs to be conducted in the tertiary audiological center to provide the result of mild, moderate, severe, and very severe degree of hearing loss in children. also, in this study, risk factor was only investigated according to the american academy committee on infant hearing statements, further study is needed to evaluate other risk factors related to hearing loss. to conclude, the prevalence of hearing loss in children under three years old at jatinangor posyandu is slightly higher compared to the national prevalence. since fifty percent of the children are found without any risk factor, the universal newborn hearing examination (unhs) needs to be implemented at the national level in accordance with the joint committee for infant hearing (jcih) guideline. the periodic monitoring of children hearing function as early as possible between the ages of zero and three years is very important to ensure the presence of hearing loss because the signs and symptoms caused by hearing loss might be invisible. the unhs program should involve coordination between communitybased integrative health care centers and otorhinolaryngology health service centers as well as audiological centers. references 1. andriani r, sekartini r, suwento r, batubara jr. peran instrumen modifikasi tes daya dengar sebagai alat skrining gangguan pendengaran pada bayi risiko tinggi usia 0–6 bulan. sari pediatri. 2010;12(3):174–83. 2. hartanto f, selina h, zuhriah h, fitra s. pengaruh perkembangan bahasa terhadap perkembangan kognitif anak usia 1-3 tahun. sari pediatri 2011;12(6):386–90. 3. joint committee on infant hearing. year 2007 position statement: principles and guidelines for early hearing detection and intervention programs, pediatrics. 2007;120:898–921. 4. vos b, lagasse r, levêque a. main outcomes of a newborn hearing screening program in belgium over six years. int j pediatr otorhinolaryngol 2014;78(9):1496–502. 5. neumann k, chadha s, tavartkiladze g, bu x, white kr. newborn and infant hearing screening facing globally growing numbers of people suffering from disabling hearing loss. int j neonatal screen. 2019;5(1):7. 6. ministry of health republic of indonesia. telinga sehat pendengaran baik. 2010. [cited 2021 august 28]. available from: h t t p s : / / w w w. k e m k e s . g o . i d / a r t i c l e / view/840/telinga-sehat-pendengaranbaik.html. 7. world health organization. deafness and hearing loss. 2021. [cited 2021 august 28]. available from: https://www.who.int/ news-room/fact-sheets/detail/deafnessand-hearing-loss. 8. agustin a, rakhmawati w, nurlita l. gambaran pengetahuan kader di posyandu desa cipacing tentang perkembangan pada balita. students e-journal. 2012;1(1):759. 9. badan pusat statistik kabupaten sumedang. 2018. jumlah penduduk kabupaten sumedang menurut kecamatan tahun 2016. [cited 2021 september 19]. available from: https://sumedangkab. bps.go.id/statictable/2017/07/05/11/ jumlah-penduduk-menurut-kecamatandi-kabupaten-sumedang-tahun-2016. html. 10. world health organization. situation review and update on deafness, hearing althea medical journal june 2022 althea medical journal. 2022;9(2) 79 loss and intervention programmes. 2007. [cited 2021 september 21]. available from:https://apps.who.int/ iris/bitstream/handle/10665/205895/ b3177.pdf ?sequence=1&isallowed=y. 11. nugroho da, zulfikar, muyassaroh. kemampuan auditorik anak tuli kongenital derajat sangat berat dengan dan tanpa alat bantu dengar. med hosp. 2012;1(2):80–2. 12. van beeck calkoen ea, engel ms, van de kamp jm, yntema hg, goverts st, mulder mf, et al. the etiological evaluation of sensorineural hearing loss in children. eur j pediatr. 2019;178(8):1195–205. 13. zhang f, xu l, xiao y, li j, bai x, wang h. three myo15a mutations identified in one chinese family with autosomal recessive nonsyndromic hearing loss. neural plas. 2018;2018:5898025. 14. bai x, zhang c, zhang f, xiao y, jin y, wang h, et al. five novel mutations in loxhd1 gene were identified to cause autosomal recessive nonsyndromic hearing loss in four chinese families. biomed res int. 2020;2020:1685974. 15. duman d, tekin m. autosomal recessive nonsyndromic deafness genes: a review. front biosci (landmark ed). 2012;17(6):2213–36. 16. kimberlin dw, jester pm, sánchez pj, ahmed a, et al. valganciclovir for symptomatic congenital cytomegalovirus disease. n eng j med. 2015;372(10):933– 43. 17. salvago p, martines e, martines f. prevalence and risk factors for sensorineural hearing loss: western sicily overview. eur arch otorhinolaryngol. 2013;270(12):3049– 56. 18. cohen be, durstenfeld a, roehm pc. viral causes of hearing loss: a review for hearing health professionals. trends hear. 2014;18:2331216514541361. 19. wang ch, yang cy, lien r, chu sm, hsu jf, fu rh, et al. prevalence and independent risk factors for hearing impairment among very low birth weight infants. int j pediatr otorhinolaryngol. 2017;93:123–7. 20. dougherty w, kesser bw. management of conductive hearing loss in children. otolaryngol clin north am. 2015;48(6):955–74. 21. wroblewska-seniuk k, greczka g, dabrowski p, szyyfter-harris j, mazela j. hearing impairment in premature newborns—analysis based on the national hearing screening database in poland. plos one. 2017;12(9):e0184359. 22. pimperton h, blythe h, kreppner j, mahon m, peacock jl, stevension j, et al. the impact of universal newborn hearing screening on long-term literacy outcomes: a prospective cohort study. arch dis child. 2016;101(1):9–15. fidkya allisha et al.: hearing profile of children below three years old at jatinangor integrative health care center, west java, indonesia althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 63 solanum nigrum l. as a hepatoprotective agent muthiana rizky1, herri s. sastramihardja2, ismet muchtar nur 3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of pathology anatomy, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital, bandung, indonesia abstract background: liver damage may be caused by various factors. solanum nigrum l. fruit is known to contain flavonoid antioxidant which is responsible for its hepatoprotective effect. a study was conducted to determine the protective effect of solanum nigrum l. fruit infusion (snfi) on ccl4-induced hepatic cell damage in rats. methods: a complete randomized experimental study was conducted on 25 male wistar strain-white rats (rattusnorvegicus) which were divided into five groups during the period of september– october 2012. group i (negative control) was given standardized food and water; group ii (positive control) was induced by carbon tetrachloride (ccl4) 10% paraffin intraperitoneally by 8 ml/kg body weight on the 8th day of the study; group iii, iv, v (treated) were given solanum nigrum l. fruit infusion (snfi) by 22.5g/100ml, 45 g/100ml and 90g/100ml concentrations for 8 days, respectively, prior to ccl4 induction. the calculation of necrotic liver cells was performed in 48 hours after induction. data were statistically analyzed using kruskal-wallis test followed by mann-whitney post-hoc test. results: the percentage of necrosis liver cells in group iii, iv, and v was smaller compared to the positive control group. the protective effect of snfi against ccl4-induced hepatotoxicity may be related to its ability to elevate the antioxidant agent in the body. there were significant differences in necrotic between group ii and group iii, iv, v which were treated with snfi. conclusion: further investigation is required to characterize the active ingredients and the mechanism of snf action to confirm the hepatoprotective and antioxidant effects. keywords: ccl4, hepatoprotective, solanum nigrum l. correspondence: muthiana rizky, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8122038251 email: muthianarizky@yahoo.com introduction liver diseases constitute a major problem of both indonesia and worldwide proportions.1,2 liver plays many vital roles in metabolic processes, secretion of bilirubin, synthesis of plasma protein, and detoxification and excretion of xenobiotic (drugs, chemical agents, toxin) into the bile. thus, damage that occurs on the liver can cause a very poor impacts and in some cases results in death. hepatitis, for an example, has not only causes many deaths, but also brings on financial problems because of its high cost of treatment.3 moreover, treatments of hepatitis may cause many side effects.4 the use of traditional medicine including herbal medicines has been recommended by the world health organization (who) to maintain health, prevent and treat many diseases. in the case of hepatitis a, the herbal medicine can heal quickly and prevent post hepatitis syndrome, while in hepatitis b and c, herbal medicine can prevent disease progression to chronic stages.5 solanum nigrum l. is one alternative of hepatoprotective herb. the most important antioxidant compounds contained in solanum nigrum l. fruit is flavonoid which is known to have the ability to fight free radicals and prevent hepatotoxicity through various mechanisms.6,7 it is an evident from the previous study conducted by kuppuswamy raju, et al.8 that ethanol extract of dried fruits of solanum nigrum l. has given remarkable hepatoprotective effect in ccl4-induced liver damage in rats. carbon tetrachloride (ccl4) is known to causes the strongest hepatotoxicity. within the body, carbon tetrachloride is transformed into a highly toxic free radical which can lead to an oxidative stress condition that causes a great damage in cells, especially hepatocytes. ccl4 is widely used to induce the althea medical journal. 2015;2(1) 64 amj march, 2015 experimental animals to become hepatitis model because of its hepatotoxicity effect that are similar to classic presentations of viral hepatitis, such as necrosis, fatty liver, and toxic hepatitis.9 the study aims to determine the protective effect of solanum nigrum l. in ccl4-induced hepatic damage in rats using fruit infusion preparation. this infusion is simple to prepare, and easily applicable. methods a complete randomize expremintal study was conducted using 25 healthy male wistar strain-white rats (180–200 g) with 12 weeks of age procured from laboratorium ilmu hayati pusat antar universitas (pau), instituteof technology bandung (itb) on 24 september–10 october 2012. the experimental protocol was approved by health research ethics committee, faculty of medicine universitas padjadjaran as follows: 1) all the rats were fed by a standard animal food and water ad libitum in animal laboratory of department of pharmacology and therapy in faculty of medicine universitas padjadjaran, 2) after acclimatization of one week period, the animals were randomly divided into five groups which each group consists of five rats. 3) the plant materials were obtained from manoko farm, lembang, bandung and were botanically identified at the herbarium jatinangor, universitas padjadjaran. 4) the solanum nigrum l. used were green colored and washed thoroughly, the stalks and leaf petals were removed. each infusion preparation was respectively prepared using 22.5 g, 45 g, and 90 g of solanum nigrum l. fruit in 100ml of distillated water and was boiled in an infusion pan at 900 c for 15 minutes. after that, the herbal infusion was filtered and extra water was added to obtain the required volume. 5) group i served as negative control; group ii served as positive control; group iii, iv, v served as treated groups which were respectively given 3 ml of snfi by 22.5g/100ml, 45g/100ml and 90g/100ml concentrations daily for eight days. on the eighth day, ccl4 10% paraffin (8 ml/kg body weight) was intraperitoneally (ip) administered to all rats except rats in group i. after 48 hours, all the rats were sacrificed under ketamine hydrochloride anesthesia. the liver of each rat was promptly removed and washed with normal saline for further histopathological study. 6) liver samples were taken from medial one-third of the largest lobes and immediately fixed in 10% buffered formaldehyde solution until it is harden. samples were then embedded in paraffin wax, sectioned (5µm) with a microtome, stained with hematoxilin-eosin (h.e.), and mounted on glass slides with canada balsam. 7) one section from each rat was randomly chosen,then ten fields were observed. degrees of liver damages were estimated by counting the number of necrotic cells in each field under olympus light microscope at magnification of 10 x 40. images were captured by a digital camera. the grades of liver damage in different groups were assigned in percentage of necrosis (%). data were expressed as means ± standard deviation (sd). statistical analysis was performed using spss for windows version 17.0. the study data was analyzed using kruskal-wallis non-parametric test followed by mann-whitney post-hoc test for multiple comparison groups. statistical significance was set at the p < 0.05 level. results the hepatocytes of normal rats (group i) were intact and observed in fairly radial position in relation to central vein. ccl4induced rats (group ii) revealed the big areas of centrolobular hepatocytes necrosis, enlargement of sinusoids, reaction of inflammatory cells, vacuolization of cytoplasm, table 1 percentage of necrosis (%) rat 1 rat 2 rat 3 rat 4 rat 5 mean (sd)* group i 1.29 1.33 1.18 1.22 1.33 1.27 (0.07) group ii 39.08 37.79 42.55 33.56 33.35 38.95 (3.84) group iii 14.00 13.53 15.24 12.02 11.94 13.35 (1.39) group iv 16.48 16.30 22.49 17.34 14.22 17.35 (3.09) group v 21.45 22.82 19.38 24.68 23.57 22.38 (2.05) *sd: standard deviation althea medical journal. 2015;2(1) 65 figure 1 liver sections of rats. a. liver section of normal rats; b. liver section of control rat induced with ccl4 only; c. liver section of ccl 4 -induced rat pretreated with snfi (22.5g/100ml); d. liver section of ccl4-induced rat pre-treated with snfi (45g/100ml); e. liver section of ccl4-induced rat pre-treated with snfi (90g/100ml). (h&e stain, x100). h= hepatocytes; cv= central vein; ic= inflammatory cells; black arrow= sinusoid; white arrow= necrosis. muthiana rizky, herri s. sastramihardja, ismet muchtar nur : solanum nigrum l. as a hepatoprotective agent pycnotic and basophilic nuclear, and disarrangement of hepatocyte architecture. microscopic examination of rats treated with snfi (group iii, iv, v) showed slight alteration in hepatocytes with less necrotic areas in comparison to the positive control rats, the liver also showed some evidences of regeneration of hepatic cells which is manifested by increased number of binuclated cells. the percentage of necrosis (table 1) was determined by comparing the number of necrotic hepatocytes of each rat by the mean of total number of normal hepatocytes of negative control rats. all treated groups showed smaller percentage of necrosis in comparison to the positive control group. the smallest percentage of necrosis of treated groups could be seen in group iii (22.5g/100ml). the study showed that there was a significant difference between group i and group ii (p=0.008; p<0.05) indicating successful induction of ccl4. the snfi in concentrations of 22.5g/100ml (group iii), 45 g/100ml (group iv), and 90g/100ml(group v) was proven to inhibit liver cell damage significantly (p=0.008; p<0.05). discussion the present study investigates the protective effect of snfi on ccl4-induced liver damage of rats. carbon tetrachloride (ccl4) is widely used althea medical journal. 2015;2(1) 66 amj march, 2015 figure 2 box-plot graphic of percentage of necrosis based on groups to induce liver damage because it is metabolized by cytochrome p450 in the hepatocytes, forming a highly reactive trichlormethyl radical, leading to peroxidation of the lipid and further damage of cellular structures.2 in an agreement with giffen et al.10, ccl4 injection to rats in the present study resulted in significant increase of necrotic hepatocytes and also generated the appearance of sinusoidal enlargement, vacuolization of cytoplasm, and infiltration of inflammatory cells. antioxidant is a substance which can inhibit the oxidative processes and neutralize the free radicals.7 the protective effect of snfi against ccl4-induced hepatotoxicity may be related to its ability to elevate the antioxidant agent in the body. flavonoid is one of the most important antioxidant contained in solanum nigrum l. fruit. 6it was stated that many activities of flavonoid against free radicals that cause hepatocellular damage can be explained by its ability to act as the chelator and the anion superoxide scavenger that scavenges reactive oxygen species. moreover, flavonoid can lower the metabolic activation of ccl4 by cytochrome p450 by means of further inhibition of free radical generations.11 the study by histopathological examination of livers shows that the protective effect of solanumnigrum l.fruitproved that rats administered with snfi prior to ccl4 induction shows only slight alteration in the hepatocytes with less necrotic areas in comparison to the untreated group. this protection may be due to the effective blockage of oxidative stress and enhancement of the natural antioxidant in the liver.12 it is noted that the percentage of hepatocyt necrosis of rats in group iii, iv, and v were smaller when it is compared to the positive control group. the percentage of necrosis is then statistically analyzed using kruskalwalis non-parametrical test followed by mann-whitney post-hoc test. three different concentrations of snfi has given the same significant hepatoprotective effect (p=0.008; p<0.05) against ccl4-induced necrotic liver cells. this is in accordance with a previous study by raju et al.8 that dried fruit of solanum nigrum l. can counteract with hepatic injury induced by ccl4 injection due to its ability to maintain the structural integrity of hepatocytic cell membrane and regenerates the damaged liver cells. in conclusion, the present study shows that snfi at concentration of 22.5g/100ml, 45g/100ml, dan 90g/100ml demonstrates hepatoprotective effect against ccl4-induced the hepatic cell damage in rats. further investigation is required to characterize the active ingredients of this plant as well as its mechanism of action to confirm the hepatoprotective and antioxidant qualities. this study should also contribute to the evidence-based traditional medicines for the hepatoprotective effect of solanum nigrum l. fruit infusion. references althea medical journal. 2015;2(1) 67 1. world health organization. the global burden of disease: 2004 update. geneva: world health organization; 2008. 2. balitbangkes. laporan hasil riset kesehatan dasar (riskesdas) nasional 2007. jakarta: departemen kesehatan republik indonesia; 2008. 3. website liver sehat. lembar fakta hepatitis. 2010. [cited 2012 march 12]; available from: http://www.liversehat. com/index.php?p=17&id=11 4. dusheiko g. side effects of interferon alpha in viral hepatitis. [cited 2012 march 23]; available from: http://www. hepatitiscentral.com/hcv/ifn/sideeffects/ 5. mills s, bone k. principle and practice of phytotherapy : modern herbal medicine. philadelphia: churchill livingstone; 2000. 6. ravi v, saleem tsm, maiti pp, gauthaman k, ramamurthy j. phytochemical and pharmacological evaluation of solanum nigrum linn. afr j pharm pharmacol. 2009;3(9):454–57. 7. jain r, sharma a, gupta s, sarethy ip, gabrani r. solanum nigrum: current perspectives on therapeutic properties. alternat med rev. 2011;16(1):78–85. 8. raju k, anbuganapathi g, gukulanakrishnan v. effect of dried fruit of solanum nigrum linn againts ccl4induced hepatic damage in rats. biol pharm bull. 2003;26(11):1618–9. 9. hodgson e, levi pe. hepatotoxicity. in: hodgson e, editor. a text book of modern toxicology. 3rd ed. hokoben: john wiley & sons, inc; 2004. 10. giffen ps, turton j, andrews cm, barrett p, clarke cj, fung kw, et al. markers of experimental acute inflammation in the wistar han rat with particular reference to haptoglobin and c-reactive protein. arch toxicol. 2003;77(7):392–402. 11. babenko na, shakhonp e. effects of flavonoids on sphingolipid turnover in the toxin-damaged liver and liver cells. lipids health dis. 2008;7:1. 12. arulmozhi v, krishnaveni m, mirunalini s. protective effect of solanum nigrum fruit extract on the functional status of liver and kidney against ethanol induced toxicity. j biochem tech. 2012;3(4):339–43. muthiana rizky, herri s. sastramihardja, ismet muchtar nur : solanum nigrum l. as a hepatoprotective agent amj vol 7 no 3 september edited.indd althea medical journal. 2020;7(3) 153 talk shows and leaflets improve senior high school student knowledge of chronic kidney diseases laurencia imelda,1 rudi supriyadi,2 yenni zuhairini3 1faculty of medicine universitas padjadjaran, indonesia, 2departement of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran, indonesia correspondence: laurencia imelda, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, sumedang, indonesia, e-mail: mellaurensia@gmail.com introduction chronic kidney disease (ckd) is defined as an impaired kidney function or structure that has lasted for more than 90 days.1 a metaanalysis has shown a global prevalence of ckd of 11-13%.2 in indonesia, the prevalence of ckd reached 12.5% based on a study that was conducted by perhimpunan nefrologi indonesia (pernefri) in 2006.3 the increase of ckd events from year to year was shown in the result of riset kesehatan dasar (riskesdas), from 0.2% in 2013 to 0.38% in 2018.4 in 2014, west java was ranked as the 8th province with a highest ckd prevalence in indonesia.4 chronic kidney disease as an irreversible disease that lasts for a lifetime was ranked as the 18th leading cause of global deaths according to the global burden disease study in 2010.1 management of ckd patients, especially patients with terminal kidney disease, raises new problems. health service resources and existing health budgets in developing countries often cannot meet the needs of the community for the management of chronic kidney disease which is quite expensive.5 kidney disease financing is still the secondlargest badan penyelenggara jaminan sosial (bpjs) health financing after heart disease in indonesia until 2015.3 the existence of ckd as a burden of developing countries and its increasing prevalence require other approaches to deal with this disease.2,5,6 health promotion is important and relevant in amj. 2020;7(3):153–8 abstract background: the increase of chronic kidney disease (ckd) incidence and its related costs in developing countries have urged all levels of society prevent this disease. prevention can be effectively done when someone has good knowledge about the disease. this study aimed to observe the change in knowledge about ckd before and after education sessions in the form of talk shows as well as through the leaflet media among senior high school students. methods: this was a cross-sectional observational quantitative study on 71 first-grade students participated in world kidney day 2019 event. the questionnaire was distributed before and after the education program and data collected were analyzed using the wilcoxon-signed rank test and mannwhitney test to explore changes in the level of knowledge based on the characteristics of the subjects. results: in total, 158 severe ha patients and 21 severe hb patients were included with a median bleeding the median level of student knowledge before education was 76% (16-96%), which increased to 92% (28-100%) after education (p<0.001). no significant correlation was observed between knowledge about ckd and gender (p=0.486), family history of ckd (p=0.281), and health workers as parents (p=0.543). conclusions: there is a significant improvement in knowledge of ckd before and after an education session through talk shows and leaflets among senior high school students. health educations need to be regularly given to young adolescents using different approaches to increase their knowledge about various topics. keywords: chronic kidney disease, knowledge, leaflet, students, talk show https://doi.org/10.15850/amj.v7n3.1917 althea medical journal. 2020;7(3) 154 amj september 2020 today’s situation to empower individuals and communities to take action for their health.7 prevention and awareness-raising need to be preceded by good knowledge to run effectively. a study conducted in australia in 2018 showed that public knowledge about ckd was low.8 this condition has to be improved because behavior based on knowledge will last longer than behavior without a knowledge base.9 health education is an effort to deliver health messages to the public to gain knowledge and better health behavior.9 education can be done in various ways such as counseling, lecture, or seminar.9 world kidney day is a campaign that is carried out simultaneously throughout the world every thursday the second week in march as a moment to educate the public about the importance of kidney health. world kidney day in 2019, especially in west java, was filled with providing education to senior high school students, especially public senior high school (sekolah menengah atas negeri) 3 bandung, as early prevention in adolescents. through this opportunity, the study was carried out to analyze the difference of senior high school students’ knowledge about ckd before and after receiving education with both talk show and leaflet as an information media. methods an observational cross-sectional study was conducted at a high school in bandung. the questionnaire was distributed before and after education about chronic kidney disease. a total sampling was employed with minimum samples 53, and this study met the criteria by including 71 first-year students who participated in the world kidney day 2019 event. incomplete data of the respondents and missing answers of the questionnaire were excluded. the independent variable in the study was education with the talk show method and leaflet as the information media. the dependent variable was knowledge about ckd of the students. confounding variables in the study were family history of kidney disease and parents’ occupation. the questionnaire consisted of 25 questions, divided into six groups. some questions in the questionnaire were adapted from a validated questionnaire used in a previous study.8 the correct answer was given 1 point and the wrong answer or ‘don’t know’ were given 0 points. the final score was calculated as a percentage. data were collected after obtaining ethical approval from the research ethics committee universitas padjajaran bandung (no.1000/ un.6/kep/ec/2019). the knowledge scores were analyzed by paired t-test if the data were normally distributed or by the wilcoxon signed-rank test if the data were not normally distributed to explore whether there were significant differences in the level of knowledge before and after education. the mannwhitney test was used further to observe any difference in the level of knowledge based on the characteristics of the subjects. results in total, 71 students had met the inclusion criteria, consisting of females (64.8%) as shown in table 1. most students (95.8%) table 1 characteristic of senior high school students characteristics n(%) gender male 25 (35.2) female 46 (64.8) age (years), median (min-max) 15 (13–17) family history of ckd, n% yes 3 (4.2) no 68 (95.8) parents’ occupation, n(%) health workers 9 (12.7) non-health workers 62 (87.3) note: ckd= chronic kidney disease althea medical journal. 2020;7(3) 155laurencia imelda et al.: talk shows and leaflets improve senior high school student knowledge of chronic kidney diseases table 2 percentage of correct answers among senior high school students about chronic kidney disease questions correct answers, n(%) before education after education kidneys function (69.86%) (78.87%) 1. urine production 71(100%) 71(100%) 2. maintain blood pressure 47(66.1%) 62(87.3%) 3. spread fluid throughout the body 26(36.6%) 24(33.8%) 4. promote red blood cell formation 34(47.9%) 52(73.2%) 5. blood filtration 70(98.6%) 71(100%) clinical manifestations of ckd (65.91%) (69.86%) 6. high blood pressure 49(69%) 71(100%) 7. lower back pain 49(69%) 64(90.1%) 8. itching 20(28.2%) 48(67.6%) 9. change in urinary frequency and quantity 63(88.7%) 65(91.5%) 10. foamy urine 53(74.6%) 70(98.6%) risk factors of ckd (77.93%) (97.18%) 11. hypertension 54(76%) 71(100%) 12. diabetes mellitus 61(85.9%) 68(95.8%) 13. smoking 51(71.8%) 68(95.8%) kidneys health examination (68.07%) (73.23%) 14. blood test (creatinine, ureum level, gfr) 64(90.1%) 71(100%) 15. urine test (albumin/protein) 66(92.9%) 70(98.6%) 16. faecal test 15(21.1%) 15(21.1%) ckd prevention (88.38%) (97.53%) 17. stop smoking and avoid cigarette smoke 60(84.5%) 69(97.2%) 18. maintain water intake 69(97.2%) 70(98.6%) 19. maintain normal blood glucose 64(90.1%) 68(95.8%) 20. maintain normal blood pressure 58(81.7%) 70(98.6%) management of ckd (60%) (82.53%) 21. sodium intake restriction 44(62%) 69(97.1%) 22. fluid intake restriction 38(53.5%) 51(71.8%) 23. calorie intake restriction 34(47.9%) 53(74.6%) 24. protein intake restriction 41(57.7%) 53(74.6%) 25. restriction of herbs/drugs consumption 56(78.9%) 67(94.4%) note: ckd= chronic kidney disease stated no family history of ckd. some students had parents who worked as health workers, namely doctors, dentists, midwives, and pharmacists. the level of knowledge about ckd was measured using a questionnaire consisting of 25 questions and divided into six groups. the percentage of correct answers to each question was shown in table 2. the largest percentage of correct answers was found in althea medical journal. 2020;7(3) 156 amj september 2020 a group of questions about the prevention of ckd with the percentage of correct answers was 88.93% before education. before receiving education, all students already knew that the kidneys were organs that play a role in the production of urine. the percentage of correct answers in the group of questions about symptoms of ckd exceeded 60%, except for the question about itching as one of ckd symptoms with correct answers of 28.2%. a total of 56 students (78.9%) did not know that examination of kidney function cannot be done through a stool examination. that question became a question with the smallest correct answers percentage. the increase in the percentage of correct answers occurred on almost all questions after the students received an education, except for the question about kidney that did not play a role in spreading fluids throughout the body which decreased to 33.8% and questions about examining kidney function through feces that did not have percentage change in the number of correct. the highest increase in the percentage of correct answers was found in the group of questions about the management of ckd, which increased by 22.53%. the correlation between subject characteristics and the level of knowledge about ckd before education was shown in table 3. statistical tests showed no significant knowledge level difference between female and male students before education (p=0.486). the existence of a family history of kidney disease (p=0.281) and parents’ occupation as health workers (p=0.543) had no significant relationship with the level of knowledge about ckd. the final scores of the knowledge before and after education was tested with kolmogorov-smirnov and did not show normal distribution. the median level of students’ knowledge before education was 76% (16– 96%) and increased to 92% (28–100%) after education. a comparison test using a wilcoxon signed-rank test showed p-value of <0.001. there are 55 subjects with an increased level of knowledge, 7 subjects with the same level of knowledge, and 9 subjects with a decreased level of knowledge after education. the study showed significant differences in the level of students’ knowledge before and after education. discussion knowledge is everything that someone knows as the result of someone’s senses or intellect.9 the knowledge level examined in this research is the knowledge of students before and after receiving intervention in the form of education by talk show and leaflet as media, which has been assessed based on students’ ability to answer questions correctly. the study has shown that the knowledge of students regarding chronic kidney disease was 76%. the score is greater than some studies which were conducted in other countries that also examined the level of knowledge about ckd in the community and students.8,10,11 this score is similar to a study of students at a university in australia, which is 79%.8 the higher score table 3 correlation of characteristics of senior high school students and pre-educational scores characteristics total, n (%) pre-education scores, median (min-max) p value gender: male 25 (35.2%) 76 (28-92) 0.486* female 46 (64.8%) 72 (16-96) family history of ckd: yes 3 (4.2%) 60 (28-84) 0.281* no 68 (95.8%) 76 (16-96) parents’ occupation: health workers 9 (12.7%) 84 (28-92) 0.543* non-health workers 62 (87.3%) 74 (16-96) note: *mann-whitney test; ckd= chronic kidney disease althea medical journal. 2020;7(3) 157 in this study compare to other studies in the community is likely due to the educational background that the respondents all are high school students and have received lessons about biology at school. the knowledge can be influenced by several factors, including age, experience, level of education, and source of information.9 a research conducted in the families of hemodialysis patients, shows that families with diagnosed ckd members have good knowledge about ckd.12 this is also similar to a study conducted in australia which showed a correlation between ckd experience in the family and better knowledge about ckd.8 different from previous studies, this study has found no significant differences in the level of knowledge between students with and without a family history of ckd. this result shows that the students have not got enough information about ckd from the family even though there is family member who has experienced related to ckd. the correlation between education level and students’ knowledge of ckd is not measured in this study because of the uniform characteristics of the respondents. this study provides an overview of the level of knowledge about ckd at the level of high school education. sources of information on this research are health education given by talk shows and leaflets as the information media. beside them, the information could also be obtained through non-media sources such as parents, family, friends, and health workers.9 this study shows no significant difference between the level of knowledge of students whose parents worked as health workers and non-health workers. the result showed that parents who worked as health workers also apparently had not given enough information about ckd to their children. improvement in students’ knowledge about ckd after receiving an education was the result of education provided through interactive talk shows and leaflets as information media. media has an important role in process of teaching and learning, not only just as teacher complement but also as a determinant of teaching success.13 it is also determined by the teacher’s ability to choose the media.13 education with talk show method was considered more suitable and interesting given to high school students. education through seminars, which was modified to be an interactive talk show in this study, is an educational method that is considered effective in a large group.9 the existence of media such as leaflets could also help the education process and assisted students in re-learning the material that had been delivered. this result is consistent with which showed that education with the lecture method accompanied by leaflets or booklets has a greater influence than education with just the lecture method.14 education by using audiovisual media such as video and leaflets had an impact on improving knowledge of adolescents.15 there were students with posteducational scores that are equal to or even smaller compared to pre-educational scores. this might be due to the lack of student attention in listening and following the education provided. the limitation of this study is that the study only involved students in one high school as participants of world kidney day 2019, who were all first grade of science class students. therefore, the research might not adequately represent the level of knowledge of high school students as a whole. the data collected in the form of self-administered questionnaires which brings up some weaknesses such as questionnaires that were not properly filled out by the subjects. this study also has not yet measured other factors that can influence the subjects’ level of knowledge about ckd. to conclude, there is an improvement in knowledge among high school students about ckd after receiving education with talk show methods and leaflets as media. further studies with a broader range of respondents are needed to describe the knowledge about ckd among teenagers. other factors that can influence the knowledge about ckd should also be considered in future studies. the results of this study can be used as a reference for the government, health workers, and related parties to enhance the education and prevention of ckd in the community. acknowledgement we are grateful to high school students from sma negeri 3 bandung for their participation in this study. references 1. kidney disease: improving global outcomes (kdigo) ckd work group. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney inter suppl. 2013;3(1):1–150. 2. hill nr, fatoba st, oke jl, hirst ja, o’callaghan ca, lasserson ds, et al. global prevalence of chronic kidney disease–a systematic review and meta-analysis. laurencia imelda et al.: talk shows and leaflets improve senior high school student knowledge of chronic kidney diseases althea medical journal. 2020;7(3) 158 amj september 2020 plos one. 2016;11(7):e0158765 3. pusat data dan informasi kementrian kesehatan republik indonesia. situasi penyakit ginjal kronis. jakarta: pusat data dan informasi kementrian kesehatan republik indonesia; 2017. 4. badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia. hasil utama riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia; 2018. 5. nugent ra, fathima sf, feigl ab, chyung d. the burden of chronic kidney disease on developing nations: a 21st century challenge in global health. nephron clin pract. 2011;118(3):269–77. 6. khalil a, abdalrahim m. knowledge, attitudes, and practices towards prevention and early detection of chronic kidney disease. int nurs rev. 2014;61(2):237–45. 7. ali a, katz dl. disease prevention and health promotion: how integrative medicine fits. am j prev med. 2015;49(5 suppl 3):s230–40. 8. gheewala pa, peterson gm, zaidi str, jose md, castelino rl. public knowledge of chronic kidney disease evaluated using a validated questionnaire: a cross-sectional study. bmc public health. 2018;18(1):371. 9. notoatmodjo s. pendidikan dan perilaku kesehatan. jakarta: pt rineka cipta; 2003. 10. oluyombo r, ayodele oe, akinwusi po, okunola oo, gbadegesin ba, soje mo, et al. awareness, knowledge and perception of chronic kidney disease in a rural community of south-west nigeria. niger j clin pract. 2016;19(2):161–9. 11. avery nw, leggett ss, juncos la. strengthening chronic kidney disease knowledge among students attending a historically black university. the journal of nephrology social work. 2016;40(2):38– 43. 12. noviriyanti d, hasibuan p, handini m. tingkat pengetahuan, sikap, dan tindakan keluarga pasien hemodialisis mengenai gagal ginjal kronik di rsud dokter soedarso pontianak. jurnal mahasiswa pspd fk universitas tanjungpura. 2014;1(1). 13. mahnun n. media pembelajaran (kajian terhadap langkah-langkah pemilihan media dan implementasinya dalam pembelajaran). an-nida’: jurnal pemikiran islam. 2012;37(1):27–33. 14. safitri nrd, fitrianti dy. pengaruh edukasi gizi dengan ceramah dan booklet terhadap peningkatan pengetahuan dan sikap gizi remaja overweight. journal of nutrition college. 2016;5(4):374–80. 15. meidiana r, simbolon d, wahyudi a. pengaruh edukasi melalui media audio visual terhadap pengetahuan dan sikap remaja overweight. jurnal kesehatan. 2018;9(3):478–84. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 138 amj march, 2015 level of knowledge about hypertension in cilayung village district jatinangor, sumedang dian qisthi1, guswan wiwaha2, abdul hadi martakusumah3, elsa pudji setiawati2 1faculty of medicine, universitas padjadjaran, 2department of public health, faculty of medicine universitas padjadjaran, 3department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: hypertension known as a silent killer because it is often asymptomatic and causes target organ damage. prevention of hypertension and its complications are pharmacological and non-pharmacological therapy, making holistic knowledge of hypertension is paramount to establish good behavior. this is needed by hypertensive and non-hypertensive individuals. therefore, the study was conducted to identify any knowledge level differences between hypertensive and non-hypertensive groups. methods: respondents were 116 cilayung residents equally divided in hypertensive and non-hypertensive groups. respondent’s blood pressure was measured and they completed questionnaires during october 2012. this is an observational analytic cross-sectional study with chi-square test. results: the respondents’ characteristics in both groups dominated by females, aged 50-59 years, housewives, with elementary school background. most respondents in both groups had sufficient knowledge about hypertension in general, but the risk factors, treatment, and complications were still not enough. the result of the chi-square test was not significant with p=0.676. it was due to distribute health promotion and non-matched respondents’age. conclusion: there is no difference in level of knowledge about hypertension between both groups in cilayung. key words: differences, hypertension, level of knowledge correspondence: dian qisthi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285721376696 email: dianqisthi@gmail.com introduction hypertension is known as the silent killer because it is often asymptomatic. it makes people who suffer from hypertension do not realize they have hypertension until it causes fatal complications in target organs and can be life-threatening.1 besides, nowadays the prevalence of hypertension rises in many parts of the world.2 data from joint national committee (jnc) vii shows one billion people worldwide suffer from hypertension.2 in indonesia, based on national basic health research (riskesdas) 2007, 32.2% of the total indonesian population suffered from hypertension or approximately 60 million people.3 the prevalence of hypertension in west java is 29.4%.3 it is higher than prevalence of hypertension in jakarta.3 the prevention of hypertension and its complications are essential to prevent further increased morbidity and mortality due to hypertension. therefore it is necessary to socialize the prevention of hypertension and its complications through lifestyle modifications to the public. this socialization is expected could form a good knowledge about hypertension, so there will be good habits as well, and vice versa.4 this is suitable with the study in nigeria that showed relationship between level of knowledge with attitudes and behaviors in preventing hypertension.5 but in reality there are many erroneous opinions regarding hypertension in the community, such as the fact that some people consider hypertension as a curable disease, or that high blood pressure in the elderly is normal, and so on. the public knowledge about hypertension althea medical journal. 2015;2(1) 139 including diseases and hypertension depend on the health promotion program that is closely related to public education. health promotion program are divided into two major scopes, first is the health promotion in the scope of promotive and preventive program for non-hypertensive people, and the second is the health promotion in the scope of curative and rehabilitative program for hypertensive people.4 based on the previous study in the primary care in jatinangor and in electronic and mass media, the current health promotion activities were dominated in the scope of curative and rehabilitative through counseling method for hypertensive people diagnosed by health care provider. besides, health promotion activities may be ineffective and inefficient because of the health care providers have not arranged this activities in accordance with the characteristics of the target in health promotion activities. therefore, this study was conducted to identify any knowledge level differences between hypertensive and non-hypertensive groups, and to explain the characteristics and the level of knowledge that can help health care provider in determining most appropriate health promotion program for the public. methods the population of this study was 4.965 residents in 11 (eleven) rukun warga (rw) of cilayung village, district jatinangor, sumedang. the period of this study was from february to december 2012 with data collection conducted during october. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. respondents were also given a written description about this study and have to sign informed consent sheet before joining the study. the sample was divided into two groups: hypertensive and non-hypertensive groups. the inclusion criteria for both groups were cilayung village resident, willing to participate in this study, aged ≥ 18 years, and did not have any disease that could disrupt communication. the inclusion criteria for hypertensive group was having high blood pressure according to joint national committee (jnc) vii criteria when measured, or had been diagnosed with hypertension by health care providers, or had ever taken antihypertensive medications. the inclusion criteria for non-hypertensive group had normal blood pressure according to joint national committee (jnc) vii criteria when measured in this study, never had been diagnosed with hypertension by health care providers, and never had taken antihypertensive medications. sample size was determined by a formula appropriate for this study which was observational analytic study with two unpaired groups. from that formula, minimum sample needed in each group was 51 respondents, but in order to anticipate data missing that might occur in the study, the number of sample in each group obtained was 58 respondents. sampling method was probability sampling technique, with the type of simple stratified proportionate consecutive sampling. in this study, the blood pressure of the selected respondent was measured first and then the respondent filled in the questionnaire about the characteristics of respondent and the level of knowledge in hypertension. this study used observational analytic with cross-sectional design.6 the author categorized the knowledge to good, moderate, and poor knowledge by calculating the average and standard deviation score of all respondents. and then respondents with the score above the average added by standard deviation categorized with good knowledge, respondents with the score below the average minus standard deviation categorized with poor knowledge, and respondents with score between that points categorized with moderate. hypothesis test used was chisquare test.6 results table 1 showed the characteristic of the respondents in this study. based on the characteristics of sex and age of respondents, both groups were dominated by female respondents and 50–59 years old aged. there were more aging respondents in the hypertensive group than in the non-hypertensive group. both groups were also dominated by respondents with elementary school as educational background and had profession as a housewife. almost all respondents in both groups had ever heard about hypertension. the source of information in both groups mostly came from health care providers. the new fact that found in the study was that nonhypertensive group was also well-informed about hypertension through health promotion activities with counseling method. counseling about hypertension was obtained when the respondents in non-hypertensive group came dian qisthi, guswan wiwaha, abdul hadi martakusumah, elsa pudji setiawati: level of knowledge about hypertension in cilayung village district jatinangor, sumedang althea medical journal. 2015;2(1) 140 amj march, 2015 to health care provider while they were sick. the majority of respondents in both groups have moderate level of knowledge about hypertension. the result of the level of knowledge in both groups is shown in table 2. the result of the chi-square analysis to see whether there was any difference in the level of knowledge of hypertension in both groups is shown in table 3. p value obtained in this study was 0.676 (p> 0.05). it means there was no any difference in the level of knowledge in hypertension between both groups. both of groups had moderate level of knowledge about hypertension. but in the hypertensive group, there were fewer respondents with poor level of knowledge than in non-hypertensive group who also had poor level of knowledge about hypertension. from the result of all respondents’ answer in questionnaire about knowledge of table 1 respondent’s characteristics hypertensive group (%) n=58 non-hypertensive group (%) n=58 sex female 87,9 65,5 male 12,1 34,5 age 30−39 years old 8,6 25,9 40−49 years old 12,1 15,5 50−59 years old 32,8 36,2 60−69 years old 22,4 17,2 >69 years old 24,1 5,2 educational background elementary school 87,9 72,4 junior high school 5,2 13,8 senior high school 5,2 3,4 college 1,7 10,3 job no job 0 5,2 housewife 65,5 51,7 farmer 13,8 17,2 laborer 0 0 entrepreneur 17,2 17,2 teacher 1,7 5,2 private company employee 1,7 1,7 information about hypertension ever heard about it 98,3 77,6 never heard about it 1,7 22,4 source of information never heard about it 1,7 22,4 family, relatives, neighbors 29,3 36,2 health care services (doctors, midwives, cadre) 69 41,4 althea medical journal. 2015;2(1) 141 hypertension, there were over 60% of respondents answered correctly to questions concerning the definition and epidemiology of hypertension. while in the question about the risk factors of hypertension, there are more than 50% of respondents were not aware that frequent alcohol consumption, over weight, old age, and a family history of hypertension may increase the risk of developing hypertension. however, most respondents knew that stress or irritability and salty food (excessive salt intake) could increase the risk of hypertension. from respondents’ answers of both groups in the question about treatment and complications showed that there were still few people who knew the complications of hypertension and that the treatment of hypertension should be for lifetime. these findings suggest that knowledge about hypertension was still not enough, especially regarding risk factors, treatment, and complications. while in the other question about the risk factors, treatment, and complication of hypertension as described above, there were still few people could answer the questions correctly. these findings suggest that knowledge about hypertension was still not enough, especially regarding risk factors, treatment, and complications. discussions in this study hypertensive group was dominated by female respondents. this was not in accordance with article about further analysis of indonesian health survey 2007 that said hypertension is more common in male.3 this might occur because of the timing of data collection in this study was noon until late afternoon. at that time, there were more females at home as housewives, while males were not at home to do their job outside home. hypertensive group was dominated by respondents aged 50−59 years old, and there were also more respondents aged over 59 years in this group than in non-hypertensive group. this was consistent with previous surveys such as the joint national committee (jnc) vii, american heart association, and health profile of west java who said the risk of hypertension is also increasing if the age is increasing.2,7-8 in the hypertensive group, most of the respondents had elementary school as formal educational background and worked as housewives. the higher the educational background of respondents, the fewer the number of respondents with that background in the hypertensive group. this was consistent with the result of further analysis of indonesian health survey 2007, that indicates the incidence of hypertension is higher in people with low levels of educational background.3 respondents in hypertensive group were dominated by housewives. this is in line with a survey of hypertension, which suggests that high blood pressure affects more people with light work.3 in addition, it can also be caused by the timing of data collection of this study, which was from noon until late afternoon, when more females were at home than males. results of this study was not significant. it was different from a similar study conducted in pakistan.9 this difference might be due to the differences of sample characteristics between the research in pakistan and in jatinangor.9 research in pakistan was carried out in urban areas with a large sample size, which were 440 people, while the research in jatinangor wasn’t carried out in urban areas and the sample size was 116.9 in addition, it could also be caused by the new facts discovered during this study. the fact that health promotion activities for hypertension through counseling method not only received by the hypertensive group, but also by non-hypertensive group. as previously described, counseling was obtained by the non-hypertensive group when they came to health care providers (such as doctors and nurses) when they were sick. furthermore this study also found that the method of counseling through the mass media (such as the use of leaflets and posters) table 1 respondent’s characteristics level of knowledge hypertensive group (%) n=58 non-hypertensive group (%) n=58 p value poor 12,1 17,2 0,676 moderate 72,4 65,5 good 15,5 17,2 dian qisthi, guswan wiwaha, abdul hadi martakusumah, elsa pudji setiawati: level of knowledge about hypertension in cilayung village district jatinangor, sumedang althea medical journal. 2015;2(1) 142 amj march, 2015 was less effective and less efficient. this was demonstrated by the absence of the respondents who had received information about hypertension through the mass media. this could happen because of the quantity, quality, and distribution were still less. furthermore, the results was not significant due to absence of the matching process in age characteristic between the two groups of this study. this matching process can’t be carried out due to insufficient time to do so. in conclusion, the characteristics of hypertensive and non-hypertensive cilayung villagers were not so different, they were dominated with female, 50−59 years of age, elementary school as educational background, housewife, and most of them had ever received information about hypertension from health care providers. respondents in hypertensive and non-hypertensive groups had moderate level of knowledge about hypertension. and there was no any difference level of knowledge in hypertension between hypertensive and non-hypertensive groups in cilayung. from this study, author suggests that the awareness of health care providers for health promotion activities in the scope of promotion and prevention services with counseling methods should be increased for getting more targets in public, not just people who come to the health service. that’s because almost all respondents in this study knew about hypertension from the counseling that they got from general physician they met when they got sick. the general physician give them the information about their blood pressure when examining the vital signs. while the health promotion activities with mass media (public) should increase the quality by making more interesting design, increasing the quantity, and expanding the distribution. the whole health promotion activities can be focused on education about risk factors, treatment, and complications of hypertension because knowledge of these subjects was still not enough. in addition, further research is necessary to analyze the attitudes and behavior of people towards hypertension. this research was conducted to see whether the attitudes and behaviors formed are in accordance with the level of knowledge. and another further research needs to be done is to analyze the difference level of knowledge, attitudes, and behaviors in hypertension among people who have risks of hypertension and those who do not have risks. references 1. kaplan n. kaplan’s clinical hypertension. 9th ed. texas: lipincot william & wilkins; 2006. 2. lenfant c, chobanian av, jones dw, roccella ej. seventh report of the joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (jnc 7). circulation. 2003;107(24):2993−4. 3. rahajeng e, tuminah s. prevalensi hipertensi dan determinannya di indonesia. majalah kedokteran indonesia. 2009;59:580−7. 4. notoatmodjo s. promosi kesehatan teori dan aplikasi. jakarta: pt rineka cipta; 2010. 5. lyalomhe gbs, lyalomhe si. hypertensionrelated knowledge, attitudes and life-style practices among hypertensive patients in sub-urban nigerian community. j public health epidemiol. 2010;2(4):71−7. 6. dahlan ms. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. 7. roger vl, go as, llyod-jones dm, benjamin ej, berry jd, borden wb. heart disease and stroke statistic 2012 update : a report from the american heart association. circulation. 2011;125:e88−e96. 8. suseda. profil kesehatan jawa barat 2007. bandung: badan pusat statistik; 2008. 9. zafar sn, gowani sa, irani fa, ishaq m. awareness of the risk factors, presenting features, and complication of hypertension among hypertensives and normotensives. j pak med assoc. 2008;58(12):711−5. althea vol 1 no 2 edit.indd althea medical journal. 2014;1(2) 75 correspondence: raisa mentari moeis, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285720166375, email: raisamentari@gmail.com allergic rhinitis patient characteristics in dr. hasan sadikin general hospital bandung indonesia raisa mentari moeis1, melati sudiro2, rb. soeherman herdiningrat3 1faculty of medicine, universitas padjadjaran, 2department of otorhinolaryngology head and neck surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of celullar biology, faculty of medicine, universitas padjadjaran, bandung abstract background: allergic rhinitis affects 500 million people worldwide, especially children and adolescents. this disease interferes with daily activities and productivity, leading to decreased quality of life. allergic rhinitis is often accompanied by co-morbid conditions such as asthma, conjunctivitis, rhinosinusitis, urticaria and othersthat may worsen the disease. this study aimed to investigate the characteristics of patients with allergic rhinitis during the period of 2010-2011 in dr. hasan sadikin general hospital bandung. methods: this study was a descriptive study with a cross-sectional design using medical records of allergic rhinitis patients who visited the allergy clinic of the otorhinolaryngology ‒ head and neck surgery ( orl ‒ hns ) department of dr. hasan sadikin general hospital bandung. results: there were 167 patients diagnosed as suffering from allergic rhinitis during the study time with more women (53.3%) affected compared to men (46.7%). most of them were in the age group of 18-34 years old (52.7%) and their were student (53.3%). most were suffered from moderate-severe persistent allergic rhinitis based on the allergic rhinitis and its impact on asthma-world health organization (aria-who) classification (52.7%). co-morbid conditions were found in 73.7% of subjects and the allergic conjunctivitis (59.9%) was the most common. conclusions: allergic rhinitis is most commonly found in people at school age and productive age. most allergic rhinitis patients are classified into persistent moderate/severe, showing that the rhinitis symptom has already interfered with their daily activities and decreased their quality of life. [amj.2014;1(2):75–80] keywords : allergic rhinitis, co-morbid condition, school age karakteristik pasien rinitis alergi di rumah sakit dr hasan sadikin bandung indonesia abstrak latar belakang: rinitis alergi memengaruhi 500 juta orang di seluruh dunia, terutama anak-anak dan remaja. penyakit ini mengganggu kegiatan dan produktivitas sehari-hari serta menyebabkan kualitas hidup menurun. rinitis alergi sering disertai dengan penyakit penyerta seperti asma, konjungtivitis, rhinosinusitis, urtikaria dan lain-lain yang dapat memperburuk penyakit. penelitian ini bertujuan untuk mengetahui karakteristik pasien dengan riinitis alergi periode 2010-2011 di rumah sakit dr. hasan sadikin bandung. metode: penelitian ini merupakan penelitian deskriptif dengan desain potong lintang dengan menggunakan rekam medis pasien rinitis alergi yang mengunjungi klinik alergi departemen telinga, hidung, tenggorokan kepala dan leher (tht-kl)) rs dr. hasan sadikin bandung. hasil: ada 167 pasien yang didiagnosa menderita rinitis alergi selama usia sekolah. perempuan lebih banyak yang terkena dampak (53,3%) dibandingkan dengan laki-laki (46,7%). sebagian besar dari mereka berada di kelompok usia 18-34 tahun (52,7%) dan mereka adalah siswa (53,3%). berdasarkan klasifikasi organisasi allergic rhinitis and its impact on asthma-world health organization (aria-who) (aria-who) sebagian besar menderita rinitis alergi persisten sedang-berat (52,7%). kondisi co-morbid ditemukan di 73,7% dari subyek dan yang paling umum adalah konjungtivitis alergi (59,9%). simpulan : rinitis alergi paling sering ditemukan pada orang di usia sekolah dan usia produktif. sebagian besar althea medical journal. 2014;1(2) 76 amj december, 2014 introduction allergic rhinitis is an inflammatory process that occurs in the nasal mucosa after allergen exposure. it is mediated by immunoglobulin e. nasal symptoms usually include sneezing, nasal congestion, runny and itchy nose.1 this disease is a systemic inflammatory disease and its clinical manifestations are not only confined to the nose but can extend to other organs located near the nose such as eyes, sinuses, and ears. this condition interferes with daily activities and productivity, leading to decreased quality of sleep, hence decreased quality of life.2 the prevalence of allergic rhinitis has increased over the last 50 years. there are more than 500 million people around the world that are affected by this condition.1 the incidence of allergic rhinitis peaks in childhood and adolescents.3 in some countries, more than 50% of adolescents have symptoms of allergic rhinitis.1 allergic rhinitis is often accompanied by other diseases, which is also referred as comorbid conditions. the most frequent comorbid condition is asthma; however, the presence of other co-morbid conditions, such as conjunctivitis, nasal polyps, rhinosinusitis, and otitis media, are also quite often. the presence of co-morbid diseases has been linked to chronic inflammatory reactions and, also, complicated the disease.4 currently, there are still many who have not been diagnosed with allergic rhinitis because most people do not go to the doctor when they consider the symptoms are not too severe. allergic rhinitis can be a predisposition for certain co-morbid diseases.5 in addition, allergic rhinitis treatment is quite expensive. allergic rhinitis can also affect a person income due to the disruption of their work performance.1 therefore, this study aimed at understanding the characteristics of patients with allergic rhinitis based on sex, ages, occupation, classification, and presence of co-morbid conditions in patients seeking treatment at otorhinolaryngology-head and neck surgery (orl-hns) clinic of dr. hasan sadikin general hospital bandung in the period of 2010–2011. methods this study was a descriptive study using the cross-sectional method. patient characteristics were obtained from medical records. the study was conducted at the dr. hasan sadikin general hospital, bandung, indonesia with data from allergic rhinitis patients who visited the allergy clinic of the orl -hns department during the period of 1 january 2010–31 december 2011. the inclusion criterion was patients diagnosed with allergic rhinitis. data were excluded if the medical records were not complete. from 195 cases of allergic rhinitis during the period, 28 were excluded. the data were further analyzed and frequencies were calculated using spss version 17 and microsoft excel 2007. results the incidence of allergic rhinitis was higher in women (53.3%) compared to men (46.7%) with the highest incidence found in the age group 18–34 years old (52.7%), followed by the age group of ≤ 17 years old (27.5%). the number of events continued to decline starting from the age group of above 34 years old. by occupation, the highest incidence of allergic rhinitis was found in school/college students (53.3%). most of the allergic rhinitis cases were classified into the persistent moderate severe (52.7%) category, followed by mild persistent (22.2%), mild intermittent (15.6%) and intermittent moderate-severe (9.6%) categories. co-morbid conditions were found in 73.7% of patients with allergic rhinitis. most patients experienced conjunctivitis as a comorbid condition (59.9%). the second most frequently found co-morbid condition was asthma (24.6%), followed by urticaria (22.2%) and rhinosinusitis (9.6%). otitis media and chronic bronchitis were rare (0.6%). most patients with asthma (56.1%), conjunctivitis (55%), rhinosinusitis (56.3%), and urticaria (64.9%) were classified into the classification of allergic rhinitis moderatesevere persistent based on the aria – who classification. pasien rinitis alergi diklasifikasikan menjadi persisten sedang/berat. hal ini menunjukkan bahwa gejala rinitis telah mengganggu kegiatan sehari-hari dan menurunkan kualitas hidup mereka. [amj.2014;1(2):75–80] kata kunci : rinitis alergi, kondisi co-morbid, usia sekolah althea medical journal. 2014;1(2) 77 discussion in this study, the incidence of allergic rhinitis was higher in women (53.3%) than in men (46.7%). this is similar to a previous study performed in dr. hasan sadikin general hospital during the period of 2007–2009 which observed that 53% of patients with allergic table 1 characteristic of allergic rhinitis patients based on sex and occupation characteristic frequency percentage sex male 78 46.7% female 89 53.3% occupation student/college student 89 53.3% civil servant 31 18.6% private employee 29 17.4% housewife 14 8.4% others 1 0.6% not working 3 1.8% rhinitis treated at dr. hasan sadikin general hospital were female.6 by age, the largest number of patients belonged to the 18–34 years old age group with 88 patients (52.7%). the incidence rate continues to decline with age. similarly, an earlier study found that 58.2% of patients with allergic rhinitis were in the age group 10–29 years old.6 it appears that patients with allergic rhinitis are mostly classified into school age and productive age groups. allergic rhinitis can occur at any age, but its prevalence is higher among children and adolescents.1 this is because the immune response in children works more rapidly and also because there are a lot of new allergen stimulus for a child presented to the nasal passage.7 as for the young adults age, it is assumed that high incidence of rhinitis among young adults is caused by symptoms that are disturbing and causing a lower productivity, making many young adults patients in their productive age seek for treatment from the clinic. in terms of occupation, the incidence of allergic rhinitis is higher among students with 89 cases (53.3%), followed by the civil servants with 31 cases (18.6%), private sector employees with 29 cases (17.4 %), housewife with 14 cases (8.4%), other occupation with 1 case (0.6%), and 3 cases of unemployment (1.8%). this is similar to the results of an an earlier study in 2010 which found that 51.1% of patients with allergic rhinitis were students, figure 1 characteristic of allergic rhinitis patients based on age raisa mentari moeis, melati sudiro, rb. soeherman herdiningrat: allergic rhinitis patients characteristics in dr. hasan sadikin general hospital bandung althea medical journal. 2014;1(2) 78 amj december, 2014 followed by civil servants (26.5%).6 this correspondence with the age group with the highest incidence, which is the age group of 18 -34 years old, followed by the age group ≤ 17 years old, because most patients in those age groups are students. the severity of allergic rhinitis is reflected in reduced quality of life of the patients and, also, the duration of the symptom.1 the results of a study by bousquet8 that included 3,052 respondents in france showed that mild intermittent rhinitis was diagnosed in 11% of the patients, while mild intermittent rhinitis was found in 35%, mild persistent allergic rhinitis in 8% and persistent moderate in 35%. based on a previous research in dr. hasan sadikin general hospital bandung on 729 patients, it was found that 41.3% allergic rhinitis cases were classified as moderatesevere persistent rhinitis, 28% were mild persistent, 20.6% were mild intermittent, while 9.8% were classified as moderatesevere intermittent.6 similarly, this study showed that the highest number of cases,88 patients (52.7%), belonged to the moderatesevere persistent classification, while 37 cases (22.2%) were classified as persistent-mild, 26 cases (15.6%) were mild intermittent and 16 cases (9.6%) were moderate-severe intermittent. according to bousqet, the high percentage of patients with severe persistent allergic rhinitis in this study might be due to the fact that patients with moderate-severe persistent rhinitis tend to seek treatment to the doctor compared to those milder allergic rhinitis symptoms.8 a general populationbased study by v. bauchau found that most allergic rhinitis cases found were classified as mild-intermittent allergic rhinitis.2 the aria -who estimates that about 200 million people with allergic rhinitis also have asthma as a co-morbid condition.1 prevalence table 2 characteristic of allergic rhinitis patients based on aria – who classification classi�ication intermittent persistent frequency percentage frequency percentage mild 26 15,6% 37 22,2% moderate – severe 16 9,6% 88 52,7% figure 2 characteristic of allergic rhinitis patients based on co-morbid conditions and aria – who classi�ication althea medical journal. 2014;1(2) 79 of people with asthma without rhinitis is typically <2%. meanwhile in patients with rhinitis, the prevalence ranges between 10–40%.3 in this study, asthma was foudn in 41 patients (24.6%) and is the second most frequent co-morbid condition. josefine found that 42% of patients with allergic rhinitis also have symptoms of allergic conjunctivitis.9 in this study, conjunctivitis was the most common co-morbid condition, which was found in 100 patients (59.9%). the conjunctiva is 2–10 layers of cells containing mucin-producing goblet cells to hydrate the ocular surface with a layer of tears. there are also mast cells located around blood vessels and lymphatic glands of the conjunctiva. exposure of a person to allergens causes an allergic reaction and degranulation of mast cells as well as the emergence of eosinophils, basophils and cd4, leading to conjunctivitis symptoms.10 based on a study in the united states, 12.5% of rhinitis patients also experience rhinosinusitis as a co-morbid condition.11 this is thought to be caused by the inflammation of the nasal mucosa by an allergic reaction that leads to the congestion in the nasal mucosa; thereby disrupting the drainage of mucus in the osteomeatal complex. in addition, it was also suspected that allergens entering the nasal mucosa penetrates deeper into the sinus mucosa and causes an allergic reaction and congestion as well as mucus evacuation.12 in this study, 16 patients with allergic rhinitis also had rhinosinusitis. based on the results of a study by alexandrapaulosh, 28.1% of allergic rhinitis patients also had urticaria.13 in this study, 47 people (22.2%) with allergic rhinitis also had urticaria. this is assumed to be caused by the fact that a person with a history of atopy is at a greater risk for developing allergic reactions in other organs such as skin.1 allergic rhinitis is often found with otitis media, especially in children under 15 years old. in children with allergic rhinitis, 21% were found with otitis media. based on a study by tutie at dr. sardjito general hospital yogyakarta, the risk of otitis media effusion is 21 times higher in people with allergic rhinitis.14 however, in this study only 1 (0.6%) patient was found with otitis media. there was also one patient with chronic bronchitis (0.6%). no study, to our knowledge, examines the relationship between allergic rhinitis with chronic bronchitis. most allergic rhinitis patients with asthma (56.1%), conjunctivitis (55%), rhinosinusitis (56.3%) and urticaria (64.9%) are classified as moderate-severe persistent allergic rhinitis based on the aria-who classification. this reflects the situation that co-morbid conditions decrease the quality of life of these patients. allergic rhinitis is often accompanied by the presence of co-morbid conditions that can further decrease the patient’s quality of life. hence, a diagnosis of co-morbid conditions should not be left out during the examination of allergic rhinitis patients. although rhinitis is often considered as a mild disease, a proper treatment is needed to prevent the quality of life of the patients from decreasing further. references 1. bousquet j, khaltaev n, cruz aa, denburg j, fokkens wj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008*. allergy. 2008;63 suppl 68:8-160. 2. bauchau v, durham sr. prevalence and rate of diagnosis of allergic rhinitis in table 3 characteristic of allergic rhinitis patients based on co-morbid conditions frequency percentage presence of co-morbid condition with co-morbid condition 123 73,7% without co-morbid condition 44 26,3% co-morbid conditions asthma 41 24,6% conjunctivitis 100 59,9% rhinosinusitis 16 9,6% otitis media 1 0,6% urticaria 37 22,2% chronic bronchitis 1 0,6% raisa mentari moeis, melati sudiro, rb. soeherman herdiningrat: allergic rhinitis patients characteristics in dr. hasan sadikin general hospital bandung althea medical journal. 2014;1(2) 80 amj december, 2014 europe. eur respir j. 2004;24(5):758-64. 3. austen kf. allergies, aanaphylaxis and systemic mastocytosis. in: fauci as. harrison’s principles of internal medicine. 18th ed. boston: mcgraw-hill medical; 2012. p. 2715-6. 4. luskin at, scherger je, pollart sm. beyond the nose: the systemic inflammatory effects of allergic rhinitis. hosp phys. 2004;40(2):13-22. 5. ryan d, van weel c, bousquet j, toskala e, ahlstedt s, palkonen s, et al. primary care: the cornerstone of diagnosis of allergic rhinitis. allergy. 2008;63(8):981-9. 6. sudiro m. karakteristik penderita rinitis alergi di bagian ilmu kesehatan thtkl rs dr. hasan sadikin bandung tahun 2007-2009. prosiding kongres nasional perhimpunan dokter ahli (perhati-kl); 2010 july 7-10;makassar: perhimpunan dokter ahli tht-kl; 2010. 7. serra a, previtera am, triolo c, chiaramonte r, messina a. perspective research about the development of the allergic rhinitis. acta medica mediterania. 2010;26:7-10 8. bousquet j, neukirch f, bousquet pj, gehano p, klossek jm, le gal m, et al. severity and impairment of allergic rhinitis in patients consulting in primary care. j allergy clin immunol. 2006;117(1):158-62. 9. gradman j, wolthers od. allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic. pediatr allergy and immunol. 2006;17(7):524-6. 10. broide dh. the pathophysiology of allergic rhino conjunctivitis. allergy asthma proc. 2007;28(4):398-403. 11. schatz m. a survey of the burden of allergic rhinitis in the usa. allergy. 2007;62 suppl 85:9-16. 12. hellings pw, fokkens wj. allergic rhinitis and its impact on otorhinolaryngology. allergy. 2006;61(6):656-64. 13. alexandropoulos t, haidich a-b, pilalas d, dardavessis t, daniilidis m, arvanitidou m. characteristics of patients with allergic rhinitis in an outpatient clinic: a retrospective study. allergol immunopathol (madr). 2013;41(3):194200. 14. utami tf, sudarman k, rianto bud, christanto a. rinitis alergi sebagai faktor resiko otitis media supuratif kronis cdk. 2010;179:425-9. althea medical journal. 2015;2(3) 409 the relationship of age, parity and body mass index as risk factors to the incidence of uterine myoma in dr. hasan sadikin general hospital nurul ilma,1 dian tjahyadi,2 tina dewi judistiani3 1faculty of medicine, universitas padjadjaran, 2department of obstetric and gynaecology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung,, 3department of epidemiology and biostatistics, faculty of medicine, universitas padjadjaran abstract background: uterine myoma is a benign gynecological tumor which is commonly occurred in women. the incidence of uterine myoma in the world is 20–35% while in indonesia is about 2.4–11.7%. age, parity, and body mass index are correlated with the incidence of uterine myoma. this study aimed to determine the relationship among those factors towards uterine myoma, and to identify the prognostic value of body mass index in order to prevent uterine myoma. methods: a case-control study was conducted to examine 394 medical records of patients with uterine myoma at department of obstetrics and gynecology dr. hasan sadikin general hospital bandung from 2006 to 2011. the case group were 133 and the control group were 261. the data were the subject’s weight, height, age, and parity. the correlation among all variable and the occurrence of uterine myomas were conducted using multiple logistic regression analysis. results: there was no different range of age between the two groups. the incidence rate ratio of parity was 2.254 (95% confidence interval:1.310–3.876), followed by body mass index>33.0 incidence rate ratio was 1.691 (95% confidence interval: 0.477–5.994). from the receiver operating characteristic curve, it could be seen that the cut-off points for body mass index was 20.44 kg/m², and the risk of uterine myomas scaled up as the increase of body mass index. conclusions: parity and bmi can affect the risk of uterine myomas. to prevent the incident of uterine myomas, parity must be limited and bmi must be below the cut-off points (20.44 kg/m²). [amj.2015;2(3):409–13] keywords: body mass index, uterine myoma, parity correspondence: nurul ilma, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628567743088 email: nurul.ilma@yahoo.com introduction uterine myomas are benign tumors which most commonly struck women during their reproductive years.1,2 uterine myomas can cause several symptoms; the most common of which are dysmenorrhea and menorrhagia.3-5 the incidence of uterine myomas around the world is 20–35% while in indonesia the incidence of myoma is about 2.4–11.7%. in contrast to the data, in dr. hasan sadikin general hospital uterine myoma has become the most common gynecological tumor; the hospital annual report notes that the incidence of uterine myoma is about 6.43–12.46%. the incidence of uterine myomas increases in black women.1,7,8 it possibly occurred since black women are usually women with exposure of oral contraceptives.1,7 the incidence also increases in women who have the history of uterine myomas in their family.1,8 the risk of uterine myoma also increases in nuliparous and overweight women.1 the impact of uterine myomas including dysmenorrhea and menorrhagia can lead the victims to anemia, pelvic pain, infertility, and pregnancy complications like miscarriage, abnormal insertion of placenta (placenta previa and placenta acreta), premature labour, and postpartum hemorrhage.1,3,7 in addition, uterine myoma also can cause urinary symptoms.1,3 the changes of body mass index (bmi) influence the incidence of uterine myomas. in althea medical journal. 2015;2(3) 410 amj september, 2015 obese patients, the risk of myoma increases to 2.7 times greater than the patients with normal bmi.7 besides multiple factors in the growth of myoma have been mentioned, like reproductive hormone and race,1,3,7,8 there are other factors in the growth of myoma, namely: family history, lifestyle, and environmental condition.1,3 uterine myomas are closely associated with estrogen stimulation, especially where there is abundant peripheral conversion of androgen to estrogen in obese patients. 1,9,10 in a study by wise et al.11, it was stated that there is a relationship between the incidence of uterine myomas with body mass index obesity (with odds ratio [or] 1.36, 95% confidence interval [ci] 1.02–1.80) in the united states. in addition, vanessa et al.12, in their study stated that for black woman who had bmi exceeding the normal value had a risk of uterine myomas nearly 3 times (with or 2.7; 95% ci 2.3–3.2). moreover, in a study conducted by shikora et al.13, it was stated that most of the patients with uterine myoma had obese bmi, and there even is a subject with severe obese bmi. so far, the researcher has not found a study which focuses on finding the cut-off point of bmi and its prognostic value to prevent uterine myomas in indonesian population. this study can be considered as a pilot study. methods a case-control study was conducted among patients with uterine myomas at the department of obstetrics and gynecology dr. hasan sadikin general hospital bandung from 2006 to 2011. the weight, height, age and parity of the subjects were collected from medical records. the case was defined based on histopathological examination results of specimen, and as for controls were selected non-myoma subjects hospitalized during the same period. excluded were all gynecologic in-patients subjects with diabetes mellitus, cushing's syndrome, hypothyroidism, pregnancy and patients with incomplete records. as much as 133 cases and 261 controls were taken for analysis. the descriptive analysis about the characteristics of the subjects was performed by cross tabulation analysis (table 1). the analysis of the correlations between all variables and the occurrence of uterine myomas were performed by multiple logistic table 1 characteristic of the case and control groups variable case control p value n =133(%) n = 261 (%) age (years) 0.09 20–30 7 (5.26%) 28 (9.96%) 30–40 43 (32.3%) 95 (35.25%) > 40 83 (62.54%) 138 (54.79%) infertility 36 (27.1%) 45 (17.24%) 0.021* parity ≥ 1 primiparous 25 (18.79%) 38 (14.56%) 0.068 multiparous 0.004* <4 55 (41.35%) 96 (36.78%) ≥ 4 17 (12.78%) 82 (31.42%) body mass index 0.003* <19 7 (5.26%) 46 (17.63%) 19–23.6 53 (39.84%) 111 (42.53%) 23.7–28.3 50 (37.60%) 74 (28.35%) 28.4–33.0 19 (14.29%) 20 (7.66%) >33.0 4 (3.01%) 10 (3.83%) note: * based on chi – square test, if p value ≤ 0.05 significant; based on p value <0.25 can be done further analysis using multivariate logistic regression althea medical journal. 2015;2(3) 411 regression analysis (table 2). the analysis of the correlation between bmi and myoma uteri was performed by cross-tabulation analysis (table 3), and the analysis of cut-off points was performed by the receiver operating characteristic curve analysis (figure 1). result table 1 shows the distribution frequencies of study subjects’ characteristic between the case and the control groups. the percentage of subjects who obtained the highest incidence of uterine myomas are those women aged above 40 years at 56.10%, followed by woman in age group of 30–40 years at 35.03%, and the latter age group of 20–30 years at 8.88%. table 1 also shows that maternal age variable with a value of p=0.090; it indicated that there was no difference between the case and the control groups on the incidence of myomas uteri in this study. thus, it can be concluded that the subjects’ age variable of the study were comparable. based on the table 1, for infertile variable, subjects mostly came from the control group with p value 0.021. several other factors can influence infertility, not only uterine myomas. there was no difference between primiparous and multiparous subjects. however, there was a significant difference between parity <4 group and parity ≥ 4 (p=0.004). this can be explained by the repeated exposure to estrogen which can trigger the growth of the tumor, and also in multiparous subjects the tumor usually lies in non-vital areas in pregnancy. in addition, to age and parity, subjects table 2 multivariate analysis with the incidence of uterine myomas variable p value odd ratio 95% confidence interval age (years) 20–30 comparison 30–40 0.032* 0.364 0.144–0.919 > 40 0.133 0.690 0.425–1.119 parity nuliparous comparison parity ≥ 1 0.003* 2.254 1.310–3.876 body mass index <19 comparison 19–23.6 0.065 0.280 0.072–1.081 23.7–28.3 0.851 0.897 0.288–2.793 28.4–33.0 0.758 1.198 0.381–3.766 >33.0 0.416 1.691 0.477–5.994 note: * based on multivariate logistic regression, if p value ≤ 0.05 significant table 3 relationship between nutritional status with myomas uteri characteristic uterine myomas p value or 95% ci likelihood ratioyes no body mass index (kg/m²) 0,003 <19 7 46 comparison 19–23.6 53 111 3.138 1.328–7.414 8.130 23.7–28.3 50 74 4.440 1.856–10.623 13.852 28.4–33.0 19 20 5.914 2.135–16.380 13.051 >33.0 4 10 3.286 0.864–12.497 2.907 nurul ilma, dian tjahyadi, tina dewi judistiani: the relationship of age, parity and body mass index as risk factors to the incidence of uterine myoma in dr. hasan sadikin general hospital althea medical journal. 2015;2(3) 412 amj september, 2015 mostly came with bmi 19–23.6 (41.62%) as is shown in table 1. for bmi p=0.003, it showed significant difference between the nutritional status in the case and the control groups on the risk of uterine myomas. the multivariate logistic regression analysis from multivariate incidence rate ratio [irr]showed the highest risk of uterine myoma came from subjects with parity ≥1 , the risk was 2.254 times greater than subjects in nuliparous group (or 2.254, 95% ci 1.310– 3.876). this result is similar to a study by wise et al.14 who stated that the incidence of uterine myomas is higher in multiparous group (or 1.6; 95% ci 1.0–2.0). the highest risk for bmi variable came from subjects with bmi >33.0 (irr 1.691; 95% ci 0.477–5.994) and was followed by subjects with bmi 28.4–33.0 (irr 1.198; 95% ci 0.381– 3.766). based on table 3, the risk of uterine myoma scaled up as the increase of bmi, and there was significant relationship between body mass index and the risk of uterine myomas (p=0.003). subjects with bmi 28.4–33.0 and with bmi >33.0 had greater risk than subjects with bmi <19. based on this result, cut-off points were found using receiver operating characteristic analysis; the curve is shown in figure 1. cut-off points for bmi in relation to uterine myomas were 20.44 kg/m². from these cutoff points, it could be said that subjects who had bmi over 20.44 kg/m² had a greater risk of uterine myomas, and this cut-off point could be used as a baseline value to prevent the incidence of uterine myomas among women in reproductive years. discussion this study is the first study aimed to determine the relationship between age, parity and bmi as a risk factor for uterine myomas in indonesian population. the implication of result was significant as described by wise et al.14, who stated that the incidence of uterine myomas is higher in multiparous group with risk increase (or 1.6; 95% ci 1.0–2.0). the study also finds that there is a correlation between bmi and uterine myomas; this result is significant as described by wise et al.11, vanessa et al.12 and shikora et al.13 in this study, the cut-off points for bmi in relation to uterine myomas were 20.44 kg/m². based on these cut-off points, the subjects, who had bmi more than the baseline, had a greater risk of uterine myomas than the subjects with bmi under the baseline. one way to prevent the incident of uterine myomas was to maintain figure receiver operating characteristic (roc) curve althea medical journal. 2015;2(3) 413 bmi below the baseline (20.44 kg/m²). so far, the researcher has not found any study which focuses on finding the cut-off points of bmi to prevent uterine myomas. based on literature, the risk for uterine myomas increases for subjects with bmi overweight (25.0–29.9 kg/m²).1 it was needed a further study to determine other risk factors related to uterine myomas. as a conclusions, parity and bmi had influence risk of uterine myomas. to prevent the incident of uterine myomas, parity must be limited and bmi must be below the cut-off points (20.44 kg/m²). references 1. stewart ea. uterine fibroids. lancet. 2001;357(9252):293–8. 2. strawn ey, novy mj, burry ka, bethea cl. insulin-like growth factor i promotes leiomyoma cell growth in fitro. am j obstet gynecol. 1995;172(6):1837–44. 3. parker wh. etiology, symptomatology, and diagnosis of uterine myomas. fertil steril. 2007;87(4):725–36. 4. wallach ee, vlahos nf. uterine myomas: an overview of development, clinical features, and management. obstet gynecol. 2004;104(2):393–6. 5. glass rh, curtis mg, overholt s, hopkins mp. glass’ office gynecology. philadelphia: lippincott williams & wilkins; 2006. p. 178–80. 6. wiknjosastro h. ilmu kebidanan. 2nd ed. jakarta: bina pustaka; 2005. p. 337–45. 7. baird dd, dunson db, hill mc, cousins d, schectman jm. high cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. am j obstet gynecol. 2003;188(1):100–7. 8. stewart ea, morton cc. the genetics of uterine leiomyomata: what clinicians need to know. obstet gynecol. 2006;107(4):917– 21. 9. berman dm, rodrigues lm, nicklas bj, ryan as, dennis ke, goldberg ap. racial disparities in metabolism, central obesity, and sex hormone-binding globulin in postmenopausal women. j clin endocrinol metab. 2001;86(1):97–103. 10. gardner dg, shoback dm, greenspan fs. greenspan’s basic & clinical endocrinology. new york: mcgraw-hill medical; 2007. p. 719–23. 11. wise la, palmer jr, spiegelman d, harlow bl, stewart ea, adam-campbell ll, et al. influence of body size and body fat distribution on risk of uterine leiomyomata in u.s. black women. epidemiology. 2005;16(3):346–54. 12. jacoby vl, fujimoto vy, giudice lc, kuppermann m, washington ae. racial and ethnic disparities in benign gynecologic conditions and associated surgeries. am j obstet gynecol. 2010;202 (6):514–21. 13. shikora sa, niloff jm, bistrian br, forse ra, blackburn gl. relationship between obesity and uterine leiomyomata. nutrition. 1991;7(4):251–5. 14. wise la, palmer jr, harlow bl, spiegelman d, stewart ea, adams ll, et al. reproductive factors, hormonal contraception, and risk of uterine leiomyomata in africanamerican women: a prospective study. am j epidemiol. 2004;159(2):113–23. nurul ilma, dian tjahyadi, tina dewi judistiani: the relationship of age, parity and body mass index as risk factors to the incidence of uterine myoma in dr. hasan sadikin general hospital althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 90 amj march, 2015 spinach effects (amaranthus hybridus) on spatial memory intan leonita1, novi vicahyani utami2, yusuf wibisono3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of neurology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin hospital, bandung, indonesia abstract background: spatial memory reduction in elderly is predicted to increase up to twice every 20 years. spinach (amaranthus hybridus) is widely consumed by indonesian people and is believed to prevent declined spatial memory function. the aim of this study was to determine the effects of spinach on spatial memory in wistar rat induced by diazepam methods: an experimental study was conducted during the period of october to november 2012 in pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran. twenty five wistar rats were divided into 5 groups; two groups as controls, and 3 groups were given 100, 200, and 400mg/kg bw ethanolic extract of spinach (eesl), respectively. on day 7, group 3, 4, and 5 were given 1 mg/kg bw diazepam injection. morris water maze tests and calculations of escape latency time (elt) were performed on day 7 and 8. data were analyzed using analysis of variance (anova) and least significance difference (lsd) test. results: on day 7, group 2 experienced acceleration in elt compared to group 4 and group 5. on day 8, group 2 experienced acceleration in elt compared to group 3 and group 4. there was no significant increase in spatial memory in group 5 (eesl 400mg/kg bw) that due to the use of higher dosage does not always show better results. conclusions: eesl can prevent impairment of spatial memory with an effective dose of 200 mg/kg bw. keywords: amaranthus hybridus, diazepam, spatial memory, spinach correspondence: intan leonita, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 812 7059 491 email: intan_leonita@yahoo.com introduction prevalence of spatial memory dysfunction was predicted to increase at the age of 60.1 the memory dysfunction in elderly is mostly manifested as alzheimer's disease. alzheimer's disease is a progressive disorder of memory function so that the patient becomes difficult to perform daily routine and has a behavioral change.2 world health organization (who) predicted that alzheimer's cases will be double every 20 years, so in 2030 it can reach 65.7 million and reach 115.4 million people in 2050.3 nowadays, the treatment of spatial memory dysfunction is only symptomatic.4 based on that, prevention is essential. the prevention can be implemented by regular exercise, active mental stimulation, good sleep quality, stress management, active social life and consumption of healthy foods.5 the consumption of foods that is rich of antioxidants such as strawberry, blueberry, and spinach can inhibit the neurodegenerative process.6 spinach (amaranthus hybridus) is often consumed by indonesian people because it is believed to have many benefits. many studies have shown that spinach has a neuroprotective effect. however, there is no studies that have specifically observed at the effect of ethanolic extract of spinach (amaranthus hybridus) in maintaining spatial memory function. diazepam is a benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant, and amnesic properties and a long duration of action. its actions are mediated by enhancement of gamma-aminobutyric acid activity. it is used in the treatment of severe anxiety disorders, as a hypnotic in the shortterm management of insomnia, as a sedative and premedicant, as an anticonvulsant, and in the management of alcohol withdrawal syndrome (from martindale, the extra pharmacopoeia, 30th ed, p589).7 like other benzodiazepines, diazepam can impair shortterm memory and learn a new information as althea medical journal. 2015;2(1) 91 well as cause anterograde amnesia.8 the aim of this study is to determine the effect and effective dose of ethanolic extract of spinach (amaranthus hybridus) in preventing spatial memory reduction (by accelerating escape latency time) in white wistar rat induced by diazepam. methods this was an experimental study conducted during the period of october to november 2012 in pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran, bandung, indonesia. twenty five wistar rats (200–300 grams, 12–15 week sold, healthy and active) were used in this study with the following procedures: 1) the rats were adaptated for 7 days before treatment (placed in a closed container by wires hole, given appropriate light, standard pellet and water ad libitum) 2) spinach (amaranthus hybridus) used in this study was identified in the laboratory of plant taxonomy department of biological science universitas padjadjaran. three kg of spinach was heated in the oven into dried simplicia. after that, the maceration was processed by inserting dried simplicia into the macerator and then blended it by 95% ethanol for 3 x 24 hours. the obtained aqueous extract was filtered into a pulp reservoir until the aqueous extract become almost colorless. the whole aqueous extracts were concentrated by rotating evaporator to get extract concentrated. ethanolic extract of spinach (eesl) was diluted in 1ml of 1% cmc3. after adaptation, rats were divided into 5 groups. group 1 (negative control) and group 2 (positive control) were given food, water, and 1ml of cmc (carboxymethylcellulose) 1%. group 3, 4, and 5 were given food, water, and treated with ethanolic extract of spinach (each with the dosage 100, 200, and 400mg/ kg bw). all groups were treated for the next 7 consecutive days 4). on day 7, group 2, 3, 4 and 5 were injected by 1 mg/kg/bw diazepam after 90 minutes of the last treatment. subsequently, groups 2, 3, 4, 5 underwent morris water maze training session after 40 minutes of diazepam injection. group 1 which did not receive diazepam injection, underwent the morris water maze training session after 90 minutes of the last treatment. on day 8, all groups underwent morris water maze for the second time. the length of elt was obtained either day 7 or 8 from the morris water maze test. 5) the escape latency time (elt) was the time taken in seconds by the rats to swim from starting point to the hidden platform. maximal time to explore the platform was 2 minutes or 120 seconds. rats were allowed to explore the platform for additional 20 seconds. the elt recorded on the first day was considered as a training session. retention of this learned-task (memory) was examined in 24 hours after the first day trial (eighth day, 24 hours after the last dose). significant reduction in elt value of retention indicated improvement in memory. the results of the study were expressed as mean ± standard error of mean (sem) and were analyzed using analysis of variance (anova) followed by post hoc least significance difference (lsd). the p-values<0.05 were considered as statistically significant. results on day 7, the treatment group given with figure 1 graphic of elt on day7 intan leonita, novi vicahyani utami, yusuf wibisono: spinach effects (amaranthus hybridus) on spatial memory althea medical journal. 2015;2(1) 92 amj march, 2015 ethanolic extract of spinach 100, 200, and 400mg/kg bw showed a better elt on learning process compared to group 2 (positive control) after injection of diazepam (figure 1). the p-value in normality test was >0.05 which indicated the normal data distribution. homogenity test produced p−value 0.197 (p>0.05) which indicated the normal data variance, so then performed anova test. the anova test showed a p−value 0.001 (p<0.05) which indicated that there were elt significantly between the four groups. the group that had the difference of elt significantly with other groups can be identified by post hoc lsd test (table 1). the lsd test in group 2 with group 4 and in group 2 with group 5 produced each p−value <0.05. it showed that the ethanolic extract of spinach dose of 200mg/kg bw and 400mg/kg bw had effects in the process of learning by accelerating elt in rats induced by diazepam (table 2). on day 8, the treatment groups given ethanolic extract of spinach each 100, 200, and 400mg/kg bw showed a better elt compared to group 2 (positive control). it showed increases on spatial memory in groups 3, 4, and 5 (figure2). the anova test showed a p-value 0.044 (p<0.05) which indicated that there were differences of elt significantly among the four groups. the group that had the difference of elt significantly with other groups can be identified by post hoc lsd test (table 3). the lsd test in group 2 with group 3 and in group 2 with group 4 produced each p-value<0.05. it showed that the ethanolic extract of spinach dose of 100mg/kg bw and 200mg/kg bw had an effect on spatial memory by accelerating elt in rats induced by diazepam. discussion the results of the study on day 7 and 8 showed that the dosage of eesl 200 mg/kg bw (group 4) has a better result compared to other groups. these results indicate that the ethanolic extract of spinach (amaranthus hybridus) table 1 anova test of elt comparison (seconds) after induction of diazepam in group 2, 3, 4, and 5 (day 7) group mean (standard deviation) of elt (seconds) normality test p−value homogenity test p−value anova test p− value 2 88.31 (24.31) 0.835 3 65.13 (25.77) 0.524 0.197 0.001 4 37.91 (15.51) 0.557 5 56.90 (22.34) 0.623 description: group 1: rats were given standard food (pellet) and distilled water group 2: rats were given standard food (pellet) and distilled water and diazepam injection 1 mg/kg bw group 3: rats were given eesl 100 mg/kg bw and diazepam injection 1 mg/kg bw group 4:rats were given eesl 200 mg/kg bw and diazepam injection 1 mg/kg bw group 5:rats were given eesl 400 mg/kg bw and diazepam injection 1 mg/kg bw table 2 lsd test of elt comparison (seconds) in rats induced by diazepam between positive control group and group given ethanolic extract of spinach (day 7) lsd test p−value interpretation group 2 & 3 0.087 not significant group 2 & 4 0.001 significant group 2 & 5 0.024 significant group 3 & 4 0.047 significant group 3 & 5 0.529 not significant group 4 & 5 0.155 not significant althea medical journal. 2015;2(1) 93 dosage of 200mg/kg bw has the effect in preventing impairment of learning process and spatial memory by accelerating escape latency time in rats induced by diazepam. the results showed that the ethanolic extract of spinach (amaranthus hybridus) has the effect in preventing the decline in spatial memory by accelerating escape latency time in rats induced by diazepam, presumably because it owns compound of spinach namely folicacid, l-tyrosine, flavonoids, polyphenols, and beta-carotene.9,10 kruman11 stated that folate has a 5−methyltetrahydrofolate compound which provides methyl group to convert homocysteine into methionine, assisted by l− methionine synthase enzyme. homocysteine is a toxic and it can trigger apoptosis of brain cells due to dna damage.12 l-tyrosine compound plays a role in reducing lipid peroxidation and dna fragmentation thus providing neuroprotective effects.13 tyrosine provides neuroprotective effect to acute stress by preventing the depletion of neurotransmitters in neurons.14 flavonoids can stop oxidative reactions inducing neuronal damage by inhibiting the activation of caspase-3 as its role as an anti-apoptosis.15 flavonoids synthesize acetylcholine and factors such as brainderived neurotrophic factor (bdnf) and nerve growth factor (ngf) in the hippocampus and frontal cortex associated with spatial working memory improvement.15 flavonols epicathec combining physical activity can increase the retention of rats’ spatial memory with a mechanism involving angiogenesis in the hippocampus and increased regulation of genes associated with the learning process in the hippocampus.16 interaction of polyphenols with protein kinases and lipid kinases can activate the extracellular signal-regulated kinase (erk1/2) signaling pathway and protein kinase b/akt, leading to activation of camp response element-binding (creb) protein, a transcription factor that plays a role in increasing the number of neurotrophin expressions to improve memory and cognitive function.16 another study conducted by grodstein17 proved that beta-carotene functions as an antioxidant that can scavenge free radicals in lipidoxidation nerve cells and produce figure 2 graphic of elt on day 8 table 3 anova test of elt comparison (seconds) on spatial memory in group 2, 3, 4, and 5 (day 8) group mean (standard deviation) of elt (seconds) normality test p−value homogenity test p−value anova test p− value 2 17.96 (6.66) 0.354 3 10.92 (4.02) 0.610 0.530 0.044 4 8.66 (3.04) 0.954 5 14.93 (6.06) 0.442 intan leonita, novi vicahyani utami, yusuf wibisono: spinach effects (amaranthus hybridus) on spatial memory althea medical journal. 2015;2(1) 94 amj march, 2015 neuroprotective effects. the treatment group 5 (eesl 400mg/kg bw) showed a significant increase in spatial memory, but not significant compared to the other treatment groups, due to the use of higher dosage of vegetables does not always show better results than smaller dosage. smaller dosage can provide more effective results. possibility that occurs is the biological maximum tolerated dose in the rats.18 smaller dosages are more effective than larger dosages and how consistency of target plasma level forethanolic extract of spinach based on rat models.19 effective doses at lower dosage showed no oxicity effects that occur at these levels. chemical compounds given in small dosage can provide an effective and useful to a tissue or organ. in contrast, inexcessive dosages can give harmful effects on the body.20 the study was inhibited by lack of comparison between result on day 7 and day 8. this study concludes that there is an effect of ethanolic extracts of spinach (amaranthus hybridus) in preventing impairment on spatial memory by accelerating elt in white wistar rats induced by diazepam. the effective dosage of ethanolic extracts of spinach (amaranthus hybridus) in preventing impairment on spatial memory by accelerating elt in white wistar rats induced by diazepam is 200 mg/kg bw. advice given for further study should be done to determine the dominan compound of spinach in preventing spatial memory. references 1. european commission. alzheimer disease and other dementias. brussels; 2010 [cited 1 december 2012]; available from: http://ec.europa.eu/health/major_ chronic_diseases/diseases/alzheimer/ index_en.htm. 2. williams jm, barnhofer t, crane c, herman d, raes f, watkins e, et al. autobiographical memory specificity and emotional disorder. psychol bull. 2007;133(1):122– 48. 3. world health organization.fact sheet no 362: dementia.2012 [cited 10 may 2012]; available at:http://www.who.int/ mediacentre/factsheets/fs362/en/index. html. 4. wortmann m. role of the global movement. in: alzheimers disease international. proceeding of the fight against alzheimer’s disease and related disorders conference; 2008 october 30– 31; paris. paris:bibliotheque nationale de france; 2008 [cited 24 september 2012]; available at: http://www.plan-alzheimer. gouv.fr/img/pdf/alzheimer_conference_ en_081030.pdf. 5. smith m, robinson l, segal j. alzheimer’s and dementia prevention: how to reduce your risk and protect your brain as you age.santa monica: helpguard.org international;2012 [cited 3 december 2012]; available at: http://www. h e l p g u i d e . o r g / a r t i c l e s / a l z h e i m e r s d e m e n t i a / a l z h e i m e r s a n d d e m e n t i a prevention.htm. 6. joseph ja, shukitt-hale b, casadesus g. reversing the deleterious effects of aging on neuronal communication and behavior: beneficial properties of fruit polyphenolic compounds. am j clin nutr. 2005;81(1 suppl):313s–6s. 7. national center for biotechnology information. pubchem compound database; cid=3016 (diazepam). 2012. [cited 3 december 2012]; available athttp://pubchem.ncbi.nlm.nih.gov/co mpound/3016#section=informationsources. 8. yudofsky sc, hales re. the american psychiatric publishing textbook of neuropsychiatry and behavioral neurosciences.5ed. arlington: american table 4 lsd test of elt comparison of (seconds) between positive control group and the group given ethanolic extract of spinach (day 8) lsd test p−value interpretation group 2 & 3 0.035 significant group 2 & 4 0.007 significant group 2 & 5 0.344 not significant group 3 & 4 0.476 not significant group 3 & 5 0.213 not significant group 4 & 5 0.058 not significant althea medical journal. 2015;2(1) 95intan leonita, novi vicahyani utami, yusuf wibisono: spinach effects (amaranthus hybridus) on spatial memory psychiatric publishing, inc. 2008. p. 583– 584. 9. subhash gp, virbhadrappa sr, vasant ok. spinacia oleracea linn: apharmacognictic and pharmacological overview. ijrap. 2010;1(1):78–84. 10. gómez-pinilla f. brain foods: the effects of nutrients on brain function. nat rev neurosci. 2008;9(7):568–78 11. kruman ii, kumaravel ts, lohani a, pedersen wa, cutler rg, kruman y, et al. folic acid deficiency and homocysteine impair dna repair in hippocampal neurons and sensitize them to amyloid toxicity in experimental models of alzheimer’s disease. j neurosci. 2002;22(5):1752–62. 12. walker jg, batterham pj, mackinnon aj, jorm af, fenech m, kljakovic m, et al. oral folic acid and vitamin b-12 supplementation to preventcognitive decline in communitydwelling older adults with depressive symptoms—the beyond ageing project: a randomized controlled trial. am j clin nutr. 2012;95:194–203. 13. yao l-y, lin q, niu y-y, deng k-m, zhang j-h, lu y. synthesis of lipoamino acids and their activity against cerebral ischemic injury. molecules. 2009;14(10):4051–64 14. tumilty l, davison g, beckmann m, thatcher r. oral tyrosine supplementation improves exercise capacity in the heat. eur j appl physiol. 2011;111(12):2941–50. 15. vauzour d, vafeiadou k, rodriguezmateos a, rendeiro c, spencer jp. the neuroprotective potential of flavonoids: a multiplicity of effects. genes nutr. 2008;3(3-4):115–26. 16. kovacsova m, barta a, parohova j, vrankova s, pechanova o. neuroprotective mechanisms of natural polyphenolic compounds. act nerv super rediviva. 2010;52(3):181–6. 17. grodstein f, kang jh, glynn rj, cook nr, gaziano jm. a randomized trial of beta carotene supplementation and cognitive function in men: the physicians’ health study ii. arch intern med. 2007;167(20):2184–90. 18. cone m. low doses, big effects: scientists seek ‘fundamental changes’ in testing, regulation of hormone-like chemicals. environmental health services; 2012 [cited 1 december 2012]; available at: http://www.environmentalhealthnews. o r g / e h s / n e w s / 2 0 1 2 / l o wd o s e s b i g effects. 19. u.s department of health and human services food and drug administration, center for drug evaluation and research. guidance for industry, investigators, and reviewers: exploratory ind studies. rockville: center for drug evaluation and research food and drug administration.; 2006 [cited 1 december 2012]; available at: http://www.fda.gov/downloads/drugs/ ancecomplianceregulatoryinformation/ guidances/ucm078933.pdf. 20. the society of toxicology. animals in research: the importance of animals in the science of toxicology. reston:the society of toxicology; 2006 [cited 1 december 2012]; available at: http:// www.toxicology.org/ai/air/air_final.pdf. dancecomplianceregulatoryinformation/ guidances/ucm078933.pdf. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 601 malnutrition–inflammation score (mis) and physical activity among hemodialysis patients rizka putri hamuktiono,1 rudi supriyadi,2 nida suraya3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: protein energy malnutrition (pem) related to inflammation and physical activities reduction occur commonly among hemodialysis patients. this study aimed to describe malnutrition-inflammation score (mis) and physical activity of hemodialysis patients. methods: this study involved 117 patients in the hemodialysis unit of dr. hasan sadikin general hospital bandung from september to october 2014. secondary data were collected to examine mis and physical activity, which was measured by using baecke physical activity questionnaire. the collected data were presented using frequency distribution. results: eighty (68.4%) patients had mis <6, thirty seven (31.6%) patients had mis ≥6, and ninety four (80.3%) patients had light physical activity. conclusions: most of the patients have mis <6 and are physically inactive. [amj.2015;2(4):601–7] keywords: hemodialysis, malnutrition-inflammation score, physical activity correspondence: rizka putri hamuktiono, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285722536168 email: rizka.putri.h@gmail.com introduction the numbers of chronic kidney disease patients are rising rapidly in indonesia. the incidence of end-stage renal disease patients who experienced hemodialysis has increased, from 2.077 patients (in 2002) to 4.344 patients (in 2006).1 among hemodialysis (hd) patients, protein energy malnutrition (pem) is a common problem, which can be a strong predictor for morbidity and mortality.2 nutritional management is a required therapy and a periodic nutritional status assessment is crucial in identifying nutritional problems as early as possible.3 several studies have shown a strong correlation between pem and inflammation.4 malnutrition inflammation score is thus used as a simple, effective, and comprehensive method to measure malnutrition and inflammation in hd patients.2,3 additionally, hemodialysis patients usually experience a decrease in physical activity as a result of several factors, such as excessive utilization of muscle mass as energy source leading to sarcopenia and presence of comorbidity e.g. diabetes, anemia, bone or mineral disorder.5 the state of malnutrition and inflammation can assert influence on patients’ physical activity.6 physical activity assessment proves useful for identification of problem and intervention to improve the quality of life.7 there has not been any study about physical activity of hd patients in indonesia hence, this study aimed to examine mis and physical activity of hd patients. methods a descriptive study was carried out to hd patients in the hemodialysis unit of dr. hasan sadikin general hospital during september and october 2014. this study has been approved by the health research ethics committee. sampling was carried out by non-probability consecutive sampling. the minimum sample size was 96 and calculated using the formula for descriptive categorical variable with 10% althea medical journal. 2015;2(4) 602 amj december, 2015 precision (d). out of 137 hd patients, 117 fulfilled the inclusion criteria. the inclusion criteria were age ≥ 18 years, having experienced hemodialysis for at least 3 months, and having mis and physical activity records for the last 3 months. patients who did not fulfill the inclusion criteria were excluded. data on mis and physical activity were collected secondarily from a previous study entitled “hubungan polimorfisme pparg, kadar leptin, tnf alfa, dengan massa lemak pada penderita hemodialisis kronik”. furthermore, data of mis comprised four parts: food intake history, physical examination, body-mass index (bmi), and laboratory examination results. the enquiries to the patients included weight loss in the last 3-6 months and gi symptoms such as loss of appetites, nausea, vomiting, anorexia, diarrhea, dialysis history, subcutaneous fat depletion (in mid-upper arm and lateral trunk area), or muscle wasting (in shoulder and quadriceps muscles). the body mass index was divided into four categories respectively: ≥20, 18–19.9, 16–17.9, and <16 kg/m2, serum albumin was also divided into four categories: ≥4, 3.5–3.9, 3–3.4, and <3. meanwhile tibc was also divided into 4 categories: ≥250, 200– 249, 150–199, and <150 g/dl.3 final mis were categorized into 2 groups: <6 and ≥6.3 data on physical activity was collected table 1 general characteristics of respondents features n (%) sex male 55 (47) female 62 (53) age (years) ≤40 19 (16.2) 41–60 67 (57.3) >60 31 (26.5) causes of hd diabetes mellitus 29 (24.8) hypertension 56 (47.9) glomerulopathy 11 (9.4) obstructive nephropathy 5 (4.3) nephritis caused by hyperuricemia 1 (0.9) chronic pyelonephritis 12 (10.3) unknown 3 (2.6) table 2 malnutrition – inflammation score in hd patients features mis <6 mis ≥6 n n sex male 40 15 female 40 22 age (years) ≤40 17 2 40–60 47 20 >60 16 15 althea medical journal. 2015;2(4) 603rizka putri hamuktiono, rudi supriyadi, nida suraya: malnutrition–inflammation score (mis) and physical activity among hemodialysis patients table 3 distribution of mis components in hd patients features n % change in end dialysis dry weight (overall change in past 3-6 months) <0.5 kg 68 58.1 0,5–1 kg 29 24.8 ≥ 1 kg but < 5 % 15 12.8 ≥5% 5 4.3 dietary intake good appetite and no deterioration of dietary pattern 94 80.3 somewhat suboptimal solid dietary intake 19 16.2 moderate overall decrease to full liquid diet 4 3.4 hypo-caloric liquid to starvation 0 0 gastrointestinal symptoms no symptoms with good appetite 84 71.8 mild symptoms, poor appetite or nauseated occasionally 32 27.4 occasional vomiting or moderate gi symptoms 1 0.9 frequent diarrhea or vomiting or severe anorexia 0 0 functional capacity (nutritionally related functional impairment) normal to improved functional capacity, feeling fine 85 72.6 occasional difficulty with baseline ambulation, or feeling tired frequently 25 21.4 difficulty with otherwise independent activities (eg. going to bathroom) 5 4.3 bed/chair-ridden, or little to no physical activity 2 1.7 co-morbidity (including number of years on dialysis) on dialysis < 1 yr and healthy otherwise 76 65 dialyzed for 1-4 yr, or mild co-morbidity (excluding mcc*) 39 33.3 dialyzed > 4 yr, or moderate co-morbidity (including i mcc*) 2 1.7 any severe, multiple co-morbidity (> 2 mcc*) 0 0 decreased fat stores or loss of subcutaneous fat normal (no change) 53 45.3 mild 55 47 moderate 8 6.8 severe 1 0.9 signs of muscle wasting normal (no change) 53 45.3 mild 56 47.9 moderate 7 6 severe 1 0.9 body mass index : bmi = wt (kg)/ht 2 (m) ≥20 65 55.6 18–19.9 26 22.2 althea medical journal. 2015;2(4) 604 amj december, 2015 16–17.99 17 14.5 <16 9 7.7 serum albumin (g/dl) ≥ 4 73 62.4 3.5–3.9 31 26.5 3-3–4 9 7.7 <3 4 3.4 serum tibc (mg/dl) : ≥250 63 53.8 200–249 41 35 150–199 9 7.7 <150 4 3.4 *mcc (major comorbid condition) includes chf class iii or iv, full blown aids, severe cad, moderate to severe copd, major neurological sequlae, and metastatic malignancies or s/p recent chemotherapy one time using baecke physical activity questionnaire (bq).8 it was consequentially divided into 3 categories: light, moderate, and heavy. results most hd patients (83.8%) were above 40 years old, the rest were under 40. hypertension was the main cause (47.9%) of hemodialysis therapy, while diabetes mellitus was in the second place (24.8%). according to the study by kalantar-zadeh9, mis is categorized into <6 and ≥6. there were 80 patients whose mis was <6 and 37 patients whose mis was ≥6. more patients whose mis was ≥6 were from the age group between 40– 60 years (54%) and >60 years (40.5%). most patients still experienced dry weight loss <0.5 kg at the end of dialysis in the last 3-6 months. additionally, almost every patient (80.3%) still had good appetite and did not experience decrease in food intake. only a small number of patients experienced decrease in food intake (19.6%). furthermore, almost a third of the patients had gastrointestinal symptoms and patients generally experienced mild loss of appetite or nausea (27.4%). meanwhile, in the functional capacity aspects, 21.4% of patients sometimes had difficulty in performing basic activity or felt tired, 4.3% had difficulty with independent activities, and there was 1.7% who even were unable to do minimum activities (bed/chairridden). more than 50% of patients experienced a decrease in fat storage and displayed muscle wasting. most patients still had bmi ≥20 (55%), but there were 14.5% of patients whose bmi was <18 and 7.7% of patients whose bmi was <16. furthermore, based on laboratory parameters, the majority of patients (62.4%) table 4 physical activity in hd patients features physical activity low moderate sex male 41 14 female 53 9 age (years) ≤40 17 2 40–60 54 13 >60 23 8 althea medical journal. 2015;2(4) 605 had good albumin levels, but there were still patients (3.4%) with very low albumin levels i.e. less than 3g/dl. almost 50% of patients also had decreased serum tibc levels, 3.4% even had serum tibc levels that were lower than 150 mg/dl. the majority of hd patients had low levels of physical activity. out of the 117 sampled patients, 94% (80.3%) had low levels of physical activity and 23 (19.7%) had moderate levels of physical activity. no patients had high levels of physical activity. moderate physical activity was mostly found in patients older than 40 years old. the patients with mis ≥6 mostly had low levels of physical activity (83.8%). while from the mis categorization, it was discovered that higher levels of physical activity were mostly performed by patients with mis <13. the levels of physical activity in patients with higher mis were generally low. discussion in general, hd patients in dr. hasan sadikin general hospital bandung had good mis i.e. less than 6; this cut-off point was based on the study conducted by kalantar-zadeh et al.9 in other words, more patients had good nutritional status with low inflammation. based on this cut-off point, mis <6 can be categorized as “without malnutrition” and the higher mis as “with malnutrition”.3 this study, using the patient’s mis discovered that 68.4% of patients were without malnutrition and 31.4% were with malnutrition. a study by ebrahimzadehkor3 which involved 48 patients in iran, showed that 25% of patients had good nutritional status, while the rest suffered from malnutrition. moreover, high mis (≥6) was mostly found among patients who were in >40 years old age group. ebrahimzadehkor3 presented a relation between age and low score of mis in his study. in this study, some patients experienced a decrease in food intake and suffered from gastrointestinal symptoms such as poor appetite and nausea. causes of inadequate nutritional intake in patients with uremia are taste abnormalities (acuity, metal flavor, and dry mouth), gastropathy and enteropathy, accumulation of anorectic factors, inflammation and/or infection.2 in addition, a third of the patients also had mild comorbidities that could affect nutritional and inflammatory conditions. malnutrition in hd patients could be observed from the physical changes such as fat storage decrease and muscle wasting. this is appropriate with the study involving 809 hd patients by rambod et al.10 and based on bmi scores, bmi <18.5 is the indicator of malnutrition.2 in this study, 22.2% of patients had bmi <18. serum albumin levels can also be used to detect malnutrition in hd patients. serum albumin <3.5 g/dl indicates malnutrition. furthermore, with every 1 g/ dl decrease in albumin level, there is a 10% increase in mortality risk.2 in this study, 11.1% of patients had serum albumin levels that were lower than 3.5 g/dl, and some patients almost suffered a decrease in serum tibc levels. as an inflammatory marker, mis is similarly with il-6, and is slightly better than crp.10 every 2 points increase in mis is associated with a double mortality risk. early detection table 5 mis and physical activity features physical activity low moderate mis <6 63 17 ≥6 31 6 mis 0–6 68 19 7–12 21 4 13–18 3 0 19–24 2 0 25–30 0 0 *mis = malnutrition-inflammation score rizka putri hamuktiono, rudi supriyadi, nida suraya: malnutrition–inflammation score (mis) and physical activity among hemodialysis patients althea medical journal. 2015;2(4) 606 amj december, 2015 in patients with risks of malnutrition and inflammation can give a better identification so that patients can get nutritional and antiinflammatory interventions.10 in this study, 80.3% patients had low levels of physical activity. this finding agrees with a study by wong, et al.11 which discovered that more than 80% of patients has low levels of physical activity. patients with hd needed two 4-hour hemodialysis sessions in a week and therefore had a tendency to be more passive compared to the healthy population. procedures of hd itself can cause exhaustion and reduce physical activity level, and the presence of uremia can also decrease skeletal muscles’ functions.11 these could be observed in a third of the patients who suffered functional capacity disruption which resulted in fatigue and inability to do independent activities. additionally, patients older than 40 years mostly had low levels of physical activity, whereas other factors, such as mental and social changes, aging, unemployment, and decreased quality of life, can also contribute to the decrease of physical activity level among hd patients.5 in the group of patients with mis ≥6, there were more patients with low levels of physical activity. moderate levels of physical activity were mostly found in patients with mis <12, while patients with higher mis had low levels of physical activity. the group of patients with mis <6 was the group with the highest level of physical activity. besides, malnutrition and inflammation in hd patients cause increased proteolysis which leads to muscle wasting, included skeletal muscle, so hd patients have lower activity than passive non dialysis person.7 a decrease in physical activity in hd patients can happen because patients choose to reduce their activity due to the presence of muscular atrophy and physical changes triggered by malnutrition and inflammation.5 moreover, muscular atrophy could be observed in patients with mis >6, which means that these patients suffered from more severe malnutrition and inflammation. anand et al.6 noted that patients with malnutrition and inflammation have low levels of physical activity. the number of studies on the correlation between physical activity, malnutrition, and inflammation were still low.11 the low physical activity levels in hd patients lead to muscular atrophy and contribute to decrease physical functioning. low physical functioning has close correlation to low quality of life, increased hospitalization risk, and increased mortality rate.5 several studies showed intervention in physical activity to have benefits on metabolism and hemodynamic, quality of life, and functional capacity repair; hence an accurate strategy is needed to increase physical activity level in hd patients.7 the conclusion of this study is that most hd patients have mis that is lower than 6, hence more patients have poor nutritional and inflammatory status. besides, almost all patients have low level of physical activity. this study is not without flaws. the minimum sampling criterion with 10% precision was still not maximum in data collection, though it can still be tolerated in a medical research. the secondary data collection involving mis and physical activity measurement could also be a source of errors in this study. there has not been any previous study about physical activity and mis. hence, this study could encourage other researchers and medical workers to conduct further studies on the correlation between physical activity and mis. references 1. prodjosudjadi w, suhardjono a. end-stage renal disease in indonesia: treatment development. ethn dis. 2009;19(1 suppl 1):s1–33–6. 2. bossola m, muscaritoli m, tazza l, giungi s, tortorelli a, fanelli fr, et al. malnutrition in hemodialysis patients: what therapy? am j kidney dis. 2005;46(3):371–86. 3. ebrahimzadehkor b, dorri a-m, yapangharavi a-h. malnutrition-inflammation score in hemodialysis patients. zahedan j res med sci. 2014;16(8):25–8. 4. afşar b, sezer s, ozdemir fn, celik h, elsurer r, haberal m. malnutritioninflammation score is a useful tool in peritoneal dialysis patients. perit dial int. 2006;26(6):705–11. 5. avesani cm, trolonge s, deléaval p, baria f, mafra d, faxén-irving g, et al. physical activity and energy expenditure in haemodialysis patients: an international survey. nephrol dial transplant. 2012;27(6):2430–4. 6. anand s, chertow gm, johansen kl, grimes b, tamura mk, dalrymple ls, et al. association of self-reported physical activity with laboratory markers of nutrition and inflammation: the althea medical journal. 2015;2(4) 607 comprehensive dialysis study. j ren nutr. 2011;21(6):429–37. 7. li m, li l, fan x. patients having haemodialysis: physical activity and associated factors. j adv nurs. 2010;66(6): 1338–45. 8. afshar r, shegarfy l, shavandi n, sanavi s. effects of aerobic exercise and resistance training on lipid profiles and inflammation status in patients on maintenance hemodialysis. indian j nephrol. 2010; 20(4):185–9. 9. kalantar-zadeh k, kleiner m, dunne e, lee gh, luft fc. a modified quantitative subjective global assessment of nutrition for dialysis patients. nephrol dial transplant. 1999;14(7):1732–8. 10. rambod m, bross r, zitterkoph j, benner d, pithia j, colman s, et al. association of malnutrition-inflammation score with quality of life and mortality in hemodialysis patients: a 5-year prospective cohort study. am j kidney dis. 2009;53(2):298–309. 11. wong s, chan ym, lim ts. correlates of physical activity level among hemodialysis patients in selangor, malaysia. malays j nutr. 2011;17(3):277–86. rizka putri hamuktiono, rudi supriyadi, nida suraya: malnutrition–inflammation score (mis) and physical activity among hemodialysis patients althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 1 roles of microwave oven in preparation of microbiological growth media christian prijana,1 yanti mulyana,2 basuki hidayat3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of nuclear medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: sterilization of a growth medium before being utilized is a very important step in a microbiology laboratory. the common method for this purpose is by using the autoclave. however, autoclaving takes more time. to overcome this limitation, we tried to use the microwave oven. the aim of this study was to evaluate the ability of microwave oven in preparing the growth media. methods: this was a laboratory experimental study conducted at microbiology laboratory, faculty of medicine, universitas padjadjaran, from october to november 2014. the growth media used were: macconkey agar, in petri dishes, inoculated with escherichia coli; sabouraud agar, in petri dishes, inoculated with candida albicans; kligler iron agar (kia), in reaction tubes, inoculated with escherichia coli and salmonella typhi; simmons citrate agar, in reaction tubes, inoculated with klebsiella pneumoniae; muellerhinton (m-h) broth, in reaction tubes, inoculated with escherichia coli; and motility indole urea (miu) semisolid agar, in reaction tubes, inoculated with proteus sp.the media would be heated by microwave for 1, 2, and 3 minutes. results: from the total 54 dishes/tubes of various microwave-sterilized media, contaminations were only seen at 5 dishes/tubes. most of the media, except the one-minute-heated mueller-hinton broth, were sterilized more than half dishes/tubes. the identification function of all media in this study was performed well. conclusions: the utilization of microwave oven as an alternative sterilizing apparatus for microbiological growth media is very potential, particularly for two and three minutes duration of heating. [amj.2016;3(1):1– 5] keywords: growth media , microbiology, microwave, sterilization correspondence: christian prijana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628551100188, email: christianprijana@keromail.com introduction sterilize the growth medium before used is very important in the microbiology. the process of growth medium sterilization is commonly performed by using an apparatus named autoclave.1 there are two kinds of growth media sterilization process in between the microbiology laboratory; they are the sterilization of about-to-used-media, as well as the sterilization of the utilized media in order to decontaminate the media from the infectious contaminants. the disadvantage of autoclave sterilization process is taking a long period of time. during the autoclaving process, the temperature is 121oc and the pressure is 2 atm, for 15 minutes. sterilized objects are placed in an apparatus after heated around 1 hour. after the sterilization process, it still needs several hours to wait until the pressure inside the apparatus drops again up to 1 atm to permit opening the apparatus.2 the alternative sterilizing apparatus which will be tested in this study is the microwave oven. microwave oven operates by transmitting a very short invisible wave, named microwave. that will be immediately absorbed evenly by water, carbohydrates, and lipids. the microwave will excitate the atoms of the molecules which absorb wave and produce heat.3 a 600–750 w microwave oven which althea medical journal. 2016;3(1) 2 amj march 2016 is used at 100% power level will generate approximately 218–260oc of temperature. the heat produced by the microwave will at last denaturize the protein.4 the advantage of using microwave oven is the shorter time needed to produce heat. the objective of this study was to evaluate the ability of microwave oven in sterilizing growth media in different durations as well as the identification function of the microwave-sterilized growth media. methods this was a laboratory experimental study. the study was conducted at microbiology laboratory, faculty of medicine, universitas padjadjaran, from october to november 2014. this study was approved by health research ethics committee of faculty of medicine, universitas padjadjaran, bandung, indonesia . the media would be heated by microwave for 1, 2, and 3 minutes; each of which consisted of two dishes/tubes, except kligler iron agar with three tubes, and then incubated for 1x24 hours in the temperature of 37oc. afterwards, one of the dishes/tubes would be kept for 7x24 hours in the refrigerator in with temperature between 2–8oc to subsequently observe if there were contaminant growth on the media. rest of the media would be inoculated with certain microbes to subsequently observe the identification function of the microwavesterilized growth media, compared to the autoclaved media as control. the role of microwave oven was called potential in preparing a medium in certain duration if it could sterilize more than half of the dishes/tubes as well as preserving the identification function of media. the growth media used in this study were: macconkey agar, in petri dishes, inoculated with escherichia coli; sabouraud agar, in petri dishes, inoculated with candida albicans; kligler iron agar (kia), in reaction tubes, inoculated with escherichia coli and salmonella typhi; simmons citrate agar, in reaction tubes, inoculated with klebsiella pneumoniae; mueller-hinton (mh) broth, in reaction tubes, inoculated with escherichia coli; and motility indole urea (miu) semisolid agar, in reaction tubes, inoculated with proteus sp. results most media were still sterile after being kept in the incubator for 24 hours and then in the refrigerator for seven days (table 1). contaminations were just seen in 5 out of 54 dishes/tubes, four of which were seen on mueller-hinton broth and one of which was seen on kia. all contaminations were found after 24 hours incubation, no other contaminations seen during the 7 days period in the refrigerator. in the first experiment , one tube of one-minute-heated kligler iron agar was contaminated. in the second experiment , one tube of one-minute-heated mueller-hinton broth was contaminated. meanwhile, in the third experiment, four tubes of muellerhinton broth, one tube of one-minute-heated media, one tube of two-minute-heated media, and two tubes of three-minute-heated media were contaminated. the two minute duration of microwave heating succeed to sterilize all the media more than half of the dishes/tubes. the three table 1 result of recapitulation after sterilizing growth media using microwave oven and keeping in the refrigerator for 7 days type of medium one minute sterilization two minute sterilization three minute sterilization total sterile contami nated sterile contami nated sterile contami nated sterile contami nated macconkey 3 0 3 0 3 0 9 0 sabouraud 3 0 3 0 3 0 9 0 kia 2 1 3 0 3 0 8 1 citrate simmons 3 0 3 0 3 0 9 0 mh broth 1 2 2 1 2 1 5 4 miu 3 0 3 0 3 0 9 0 total 15 3 17 1 17 1 49 5 althea medical journal. 2016;3(1) 3 minute duration of microwave heating succeed to sterilize all the media more than half of the dishes/tubes as well. the one minute duration of microwave heating failed to sterilize more than half of the mueller-hinton broth tubes; however, it succeed to sterilize the other five media more than half of the dishes/tubes. since both tubes of the three-minute-heated mueller-hinton broth got contaminated after 24 hours of incubation, inoculation of e. coli for the three-minute-heated mueller-hinton broth could not be performed. one of the tubes was kept in the refrigerator for seven days. inoculation of microbes to the microwaveheated media generated similar changes with the autoclaved-media. apart from that, there was another phenomenon seen in this study. the microwave-sterilized media tended to have brighter or more transparent color than the autoclaved media. discussion table 1 showed that microwave oven succeed to sterilize most of the media. from the total 54 dishes/tubes of various microwavesterilized media, contaminations were only seen at 5 dishes/tubes. the results of this study is in accordance with the study conducted by bhattacharjee, et al. 5 which stated that the microwave is able to sterilize the microbiological growth media quickly. all contaminations in this study were found in tubes, no contamination was found on the petri dish. this result might be due to difficulties of burner’s heat in reaching the whole depth of a tube during the aseptic technique. the heat also probably failed to sterilize the tube because it was absorbed by hand while holding the tube. inoculation performed to microwavesterilized media generated similar changes to the autoclaved growth media. it indicated that the identification function of the media in this study was still performed well. e. coli fermented lactose that changed the color of macconkey agar into red. c. albicans produced cream-like colonies on sabouraud agar. kia turned into yellow at both the butt and slant as the result of glucose and lactose fermentation, meanwhile s. typhi fermented only glucose but not lactose, so that it changed the color of the butt only. s. typhi also generated black color near the site of inoculation due to the production of h2s. simmons citrate agar turned into blue due to the utilization of citrate by k. pneumoniae. e. coli colony generated turbidity christian prijana, yanti mulyana, basuki hidayat: roles of microwave oven in preparation of microbiological growth media figure 1 inoculation results of s. typhi to kligler iron agar (kia) from left to right: one minute microwave-heated medium; two minutes microwave heated medium; three minutes microwave-heated medium; and autoclaved medium as control. althea medical journal. 2016;3(1) 4 amj march 2016 at the mueller-hinton broth. the motility of proteus produced swarming around the site of inoculation, the utilization of urea decreased the ph and changed the color of media into pink.6,7 even though the temperature inside the microwave oven can destruct the identification component of a medium, the identification function of the media in this study was still performed well. this was probably due to the ability of microwave oven to excite the molecules contained in the media.8 the media immediately converts the microwave into heat energy that increases the temperature inside the microwave oven in such a short time, so that it is not long enough to destruct the identification component of growth media. based on study conducted by kothari, et al.9 microwave-sterilized liquid growth media is more fertile than the autoclaved media. in that study, various media were heated by microwave oven for 10 minutes. various bacteria and yeast inoculate to the microwavesterilized media generated higher cellular density and growth velocity than the bacteria, and yeast inoculates to the autoclaved.9 there were differences in color between the microwave-sterilized media and the autoclaved media. similar results were also stated by geczi et al.10 the study showed that liquid food treated with microwave have different color with untreated control and traditional-heated samples. they arecaused by the maillard reaction which occured during autoclaving.11 maillard reactions are group of various complicated non-enzymatic reactions between free amino groups of protein, usually the ε-amino groups of protein, and carbonyl groups of reducing sugars.12 this reaction results in the darkening of the autoclaved media’s color due to the production of melanoidines, the final products of the reaction.13 this study has some limitations. the temperature in the microwave oven, as well as in the refrigerator, could not be measured precisely but could only be estimated around 218–260oc for microwave oven and 2–8oc for the refrigerator. the longest duration of microwave heating in this study is only three minutes. even though there are still more sterile than contaminated mueller-hinton broth, the results of sterilizing the mueller-hinton broth generated some recommendations for further studies. there should be further studies in microwave-sterilizing the liquid media using more tubes and variations of heating duration. from this study, it can be concluded that the utilization of microwave oven, particularly with two and three minute duration of microwave heating, as an alternative sterilizing apparatus for microbiological growth media is very potential. the most potential heating durations are two and three minutes since they are able to sterilize more than half dishes/ tubes of all media in this study. references 1. neumann o, feronti c, neumann ad, dong a, schell k, lu b, et al. compact solar autoclave based on steam generation using broadband light-harvesting nanoparticles. proc natl acad sci u s a. 2013;110(29):11677–81. 2. bhowmik g. introduction to the laboratory. in: bhowmik g, editor. analytical techniques in biotechnology. new delhi: tata mcgraw-hill education; 2011. p. 27– 8. 3. brace cl. microwave tissue ablation: biophysics, technology, and applications. crit rev biomed eng. 2010;38(1):65–78. 4. chen l, wang n, li l. development of microwave-assisted acid hydrolysis of proteins using a commercial microwave reactor and its combination with lc-ms for protein full-sequence analysis. talanta. 2014;129:290–5. 5. bhattacharjee mk, delsol jk. does microwave sterilization of growth media involve any non-thermal effect? j microbiol meth. 2014;96:70–2. 6. carroll kc. bacteriology. in: brooks g, carroll kc, butel j, morse s, editors. jawetz melnick & adelbergs medical microbiology. 26 ed. new york: mcgraw-hill; 2012. p. 149–406. 7. mitchell tg. mycology. in: brooks g, carroll kc, butel j, morse s, editors. jawetz melnick & adelbergs medical microbiology. 26th ed. new york: mcgraw-hill; 2012. p. 671– 714. 8. mani d, arunan e. rotational spectra of propargyl alcohol dimer: a dimer bound with three different types of hydrogen bonds. j chem phys. 2014;141(16):164311. 9. kothari v, patadia m, trivedi n. microwave sterilized media supports better microbial growth than autoclaved media. res biotechnol. 2011;2(5):63–72. 10. geczi g, horvath m, kaszab t, alemany gg. no major differences found between the effects of microwave-based and conventional heat treatment methods on two different liquid fodds. plos one. althea medical journal. 2016;3(1) 5christian prijana, yanti mulyana, basuki hidayat: roles of microwave oven in preparation of microbiological growth media 2013;8(1):1–12. 11. bhattacharjee mk, sugawara k, ayandeji ot. microwave sterilization of growth medium alleviates inhibition of aggregatibacter actinomycetemcomitans by maillard reaction products. j microbiol meth. 2009;78(2):227–30. 12. teodorowicz m, fiedorowicz e, kostyra h, wichers h, kostyra e. effect of maillard reaction on biochemical properties of peanut 7s globulin (ara h 1) and its interaction with a human colon cancer cell line (caco-2). eur j nutr. 2013;52(8):1927– 38. 13. mohajjemzadeh f, hassanzadeh d, valizadeh h, siahi-shadbad mr, mojarrad js, robertson t, et al. assesment of feasibility of maillard reaction between baclofen and lactose by liquid chromatography and tandem mass spectrometry, application to pre formulation studies. aaps pharm sci tech. 2009;10(2):649–59. a lt h e a m e d ic a l jo u r n a l v o lu m e 9 n u m b e r 3 y e a r 2 0 2 2 volume 9, number 3 september, 2022 e-issn 2337-4330 original articles hygiene and sanitation factors affecting contamination of soil-transmitted helminths in household water sources in jember, indonesia epafroditus sanjaya adiguna, wiwien sugih utami, ika rahmawati sutejo, bagus hermansyah, yunita armiyanti anticandidal activity of lactoferrin, apolactoferrin, and oligosaccharides on mueller-hinton and sabouraud dextrose agar against fluconazole resistant-candida albicans maureen miracle stella, sem samuel surja, zita arieselia correlation between neutrophil-to-lymphocyte ratio (nlr) and immature-to-total neutrophil (i/t) ratio to bacterial infection among children with chronic kidney disease galuhafiar puratmaja, anggraini alam, dzulfikar djalil lukmanul hakim, sri endah rahayuningsih, dida akhmad gurnida, dany hilmanto clinical features and outcomes of patients with tetanus at dr. hasan sadikin general hospital bandung 2015–2019 ananda pratama kesumaningtyas gunawan, ahmad rizal ganiem, siti aminah, lisda amalia, sofiati dian thoracic radiography findings of multi drug resistant tuberculosis at dr. hasan sadikin general hospital bandung mareta tada kurnia, iyus maolana yusuf, prayudi santoso effectiveness of online height measurement training for parents fitri yuniarti, yenni zuhairini, fedri ruluwedrata rinawan relationship between parenting style and maternal personal hygiene with children’s personal hygiene in north jakarta rebeka milenia magany, prissilia nanny djaya, felicia kurniawan clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung 2017– 2021 exel billy wibowo, arif dermawan, melati sudiro cognitive outcome of intracerebral hemorrhage patients with and without pneumonia carissa vania pratama, cep juli, chandra calista, suryani gunadharma, yusuf wibisono, paulus anam ong comparison of single centrifugation, double centrifugation and turn down-turn up techniques for platelet-rich plasma quality eva ayu maharani, dewi astuti editor in chief edhyana k. sahiratmadja managing editor mas rizky a.a syamsunarno external editors gerald pals kamisah yusof alexander kwarteng kittiphong paiboonsukwong r. tedjo sasmono jarir at thobari soegianto ali trevino aristarkus pakasi andani eka putra pudji lestari herry garna internal editors yunia sribudiani ronny lesmana afiat berbudi nur atik muhammad hasan bashari sri endah rahayuningsih irma ruslina defi reni ghrahani mohammad ghozali astrid feinisa khairani nur melani sari eko fuji ariyanto copyeditors hanna goenawan julia ramadhanti poppy siti chaerani djen amar electronic production engineer devi fabiola syahfitri site administrator & layout editor ati sulastri  offline secretariat elsa purwita editorial address jl. prof. dr. eijkman 38 bandung, indonesia 40161 mobile: 082216237668/081320178724 phone (+62) 022-2032170 ext. 1401 fax: (+62) 022-2037823 e-mail: chiefeditor.amj@gmail.com website: http://journal.fk.unpad.ac.id/index.php/amj volume 9, number 3 september, 2022 e-issn 2337-4330 original articles hygiene and sanitation factors affecting contamination of soil-transmitted helminths in household water sources in jember, indonesia epafroditus sanjaya adiguna, wiwien sugih utami, ika rahmawati sutejo, bagus hermansyah, yunita armiyanti anticandidal activity of lactoferrin, apolactoferrin, and oligosaccharides on muellerhinton and sabouraud dextrose agar against fluconazole resistant-candida albicans maureen miracle stella, sem samuel surja, zita arieselia correlation between neutrophil-to-lymphocyte ratio (nlr) and immature-to-total neutrophil (i/t) ratio to bacterial infection among children with chronic kidney disease galuhafiar puratmaja, anggraini alam, dzulfikar djalil lukmanul hakim,  sri endah rahayuningsih, dida akhmad gurnida, dany hilmanto clinical features and outcomes of adult tetanus patients at dr. hasan sadikin general hospital bandung 2015–2019 ananda pratama kesumaningtyas gunawan, ahmad rizal ganiem, siti aminah, lisda amalia, sofiati dian thoracic radiography findings of multi drug resistant tuberculosis at dr. hasan sadikin general hospital bandung mareta tada kurnia, iyus maolana yusuf, prayudi santoso effectiveness of online height measurement training for parents fitri yuniarti, yenni zuhairini, fedri ruluwedrata rinawan relationship between parenting style and maternal personal hygiene with children’s personal hygiene in north jakarta, indonesia rebeka milenia magany, prissilia nanny djaya, felicia kurniawan clinical signs in allergic rhinitis patients at dr. hasan sadikin general hospital bandung 2017–2021 exel billy wibowo, arif dermawan, melati sudiro cognitive outcome of intracerebral hemorrhage patients with and without pneumonia carissa vania pratama, cep juli, chandra calista, suryani gunadharma, yusuf wibisono, paulus anam ong comparison of single centrifugation, double centrifugation and turn down-turn up techniques for platelet-rich plasma quality eva ayu maharani, dewi astuti page 125–130 131–138 139–144 145–150 151–155 156–162 163–167 168–173 174–178 179–183 author’s guidelines althea medical journal (amj) is a peer reviewed electronic scientific publication journal in english which is published every 3 months (march, june, september, and december). althea medical journal publishes articles related to research in biomedical sciences, clinical medicine, family-community medicine, and 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supplement rushton l, hutchings sj, fortunato l, young c, evans gs, brown t, et al. occupational cancer burden in great britain. br j cancer. 2012;107(suppl1):s3–7. edition with supplement north cs, pollio de, smith rp, king rv, pandya a, suris am, et al. trauma exposure and posttraumatic stress disorder among employees of new york city companies affected by the september 11, 2001 attacks on the world trade center. disaster med public health prep. 2011;(5 suppl 2):s205– 13. books and other monographs personal author(s) sax pe, cohen cj, kuritzkes dr. hiv essentials 2012. 2nd ed. burlington: world headquarters; 2012. editor(s) as the author baxter r, editor. a cellular dermal matrices in breast surgery, an issue of clinics in plastic surgery. mountlake terrace: saunders; 2012. organization as the author unaids. meeting the investment challenge tipping the dependency. geneva: who library cataloguing data; 2012. chapter in a book pignone m, salazar r. disease prevention and health promotion. in: diedrich c, lebowitz h, holton b, editors. 2012 current medical diagnosis and treatment. 51st ed. new york: the mcgraw-hill companies; 2012. p. 1–21. conference proceedings wilson b, hamilton n, editors. airborne particulate exposures: the environmental and occupational perspectives. proceedings of the wsn mining health and safety conference; 2012 april 17–19; sudbury. ontario: golder associates; 2012. conference paper tirilly p, lu k, mu x. predicting modality from text quiries for medical image retrieval. in: cao y, kalpathy-cramer j, unay d, editors. mm 11. proceeding of the 2011 international acm workshop on medical multimedia analysis and retrieval; 2011 nov 28–dec 01; arizona, usa. new york: acm; 2011. p. 7–12. dissertation rohim s. kontruksi diri dan perilaku komunikasi gelandangan di kota jakarta (studi fenomenologi terhadap julukan gelandangan “manusia gerobak”) [dissertation]. bandung: universitas padjadjaran; 2012. electronic material journal article in electronic format mahmood om, goldenberg d, thayer r, migliorini r, simmons an, tapert sf. adolescents’ fmri activation to a response inhibition task predicts future substance use. addictive behaviors [internet] 2012 [cited 2012 may 12]. available from: http:// www.sciencedirect.com. homepage world health organization. cardiovascular disease (cvds) [internet] [cited 2021 may 6]. available from: https://www. who.int/health-topics/cardiovasculardiseases#tab=tab_1. editorial board contact: althea medical journal mobile: 082216237668/081320178724 e-mail: chiefeditor.amj@gmail.com amj.fkunpad@gmail.com althea vol 2 no 3 final.indd althea medical journal. 2015;2(3) 303 community knowledge and perception on autopsy in jatinangor, west java from august to october 2013 siaw carwen,1 berlian isnia fitrasanti,2 budi darmawan3 1faculty of medicine universitas padjadjaran, 2department of forensic & legal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of nuclear medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: autopsy rate had declined dramatically throughout the world for the past decades. this phenomenon has raised concerns of the medical world. factors that contributed to this decline include lack of knowledge regarding autopsy among the people, religious reasons, unenthusiastic pathologists and others. this study was conducted to discover the community knowledge and perception of autopsy at jatinangor, west java. methods: a descriptive study was conducted in jatinangor during the period of august to october 2013. one hundred and ten respondents were included in this study by random sampling. after written informed consent, respondents were given a questionnaire. collected data were presented in the form of percentages in tables. results: most of the respondents were from the age group of 41–50, entrepreneur and senior high school. eighty seven (79.09%) respondents had heard about the term “autopsy”, but only 66 (75.86%) of them claimed that they knew about autopsy. however, only 53 from 87 respondents (60.92%) truly knew about autopsy. from 110 respondents, 58 (52.72%) of them knew the reasons to perform autopsy. fifty seven (51.81%) respondents would allow autopsy to be performed on themselves or family members. the main reason was given to discover the exact cause of death. the reasons of autopsy refusal were afraid of religion concerns and respect for the human body. conclusions: there are still members of the community who do not know about autopsy and its purposes. it is recommended that the government improves the community knowledge through various activities and programs. [amj.2015;2(3):303–307] keywords: autopsy, knowledge, perception correspondence: siaw carwen, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 83822837276, email: carwen1312@gmail.com introduction autopsy is a special surgical operation performed on a dead body, mainly to find out the exact cause of death. through autopsy, one is able to determine the accuracy of the diagnosis, the presence of comorbidities, and the involvement of a crime.1 autopsy rate had declined dramatically throughout the world for the past decades. according to centers for disease control and prevention, autopsy rate in the united states had fallen from 19% in 1972 to only 9% in 2007.2 another study showed that clinical autopsy rates in england and wales had fallen from 8.9 in 1996 to 1.7% in 1991. the decrease in autopsy rates was also proven in other countries like china, canada and france.3 this phenomenon was also observed in south east asia countries, such as malaysia, where the total number of clinical autopsy performed at the university hospital in kuala lumpur had reduced from 28% in 1970–1974, to 12% in 1980–1984.4 there were many factors contributed to this decline, such as lack of knowledge regarding autopsy among the people, religious and cultural reasons, unenthusiastic pathologists, and the use of other techniques or procedure to make conclusive diagnosis, causing autopsy to be regarded as an unnecessary procedure.3-5 althea medical journal. 2015;2(3) 304 amj september, 2015 there was a lack in research concerning autopsy in indonesia. jatinangor is an area in sumedang, west java, where the faculty of medicine of universitas padjadjaran is located and also where medical students live and interact with the community. it is expected that the presence of the medical students can contribute to the knowledge and perception of the community about the various issues on health including autopsy. the objective of this study was to discover the community knowledge and perception of autopsy in jatinangor. methods a descriptive study was conducted during the period of august to october 2013 in all the 12 villages of jatinangor. one hundred and ten respondents, age between 21 to 50 years old were included in this study by random sampling. the number of respondents interviewed in each village was approximately according to the total number of villagers staying in the particular village. people who refused to participate were excluded. this study was approved by health research ethics committee. the selected respondent was given information of the study and if the respondent agreed to participate, a written informed consent could be obtained. moreover, an interview was carried out based on a questionnaire, which consisted of a total of 15 questions. out of the 15 questions, 3 questions consisted of characteristics of the respondent (age, occupation and level of education), 7 questions were designed to assess the knowledge of the respondents, and score of 1 was given for each correct answer given by the subject. the 5 other questions were to discover the perception of the respondents. next, the collected data were presented in the form of percentages in tables. results most of the respondents were from the 4150 age group . entrepreneur was the top occupation among the respondents, whereas, senior high school was the level of education of most of the respondents (table 1). eighty seven (79.09%) respondents have heard of the term “autopsy”, but only 66 table 1 characteristic of the respondents characteristic n=110 % age group (years old) 21–30 37 33.64 31–40 33 30.00 41–50 40 36.36 occupation laborer/employee 23 20.91 housewife 18 16.36 entrepreneur 43 39.09 trader 21 19.09 government servant/police 5 4.55 level of education elementary school 20 18.18 junior high school 31 28.18 senior high school 45 40.09 diploma 7 6.36 undergraduate 7 6.36 postgraduate 0 0 total 110 100 althea medical journal. 2015;2(3) 305 (75.86%) of them claimed that they knew about autopsy. however, when asked to explain about autopsy, it was found that only 53 from 87 respondents (60.92%) truly knew about autopsy. ten (11.49%) respondents have heard about autopsy but had difficulty in explaining about it. four (4.60%) respondents misunderstood autopsy for adoption of child or amputation of some parts of the body. out of 110 respondents, 58 (52.72%) respondents knew the reasons for performing an autopsy, and 53 (48.18%) respondents knew that the type of autopsy performed when there was a suspicious death involving a crime, was the forensic or coroner’s autopsy. most (66.36%) of the respondents knew that there was a need to consent for autopsy. not all of the respondents gave their opinion of granting permission or not for autopsy. fifty seven (51.81%) respondents would allow autopsy to be performed on themselves or family members. the main reason given by the respondents to consent for autopsy was to discover the exact cause of death (table 2), while the main reason of autopsy refusal was afraid of mutilation (table 3). half of the respondents believed that autopsy is important. eighty (72.73%) respondents believed that the community should increase their knowledge on autopsy (table 4). two (1.82%) respondents felt that it was not necessary for the public to know more about autopsy, unless they work as polices, lawyers or forensic doctors who are needed for crime investigations. discussion most of the respondents responded that the reason to consent for autopsy was to discover the more exact cause of death, while a number table 2 reasons for granting permission for autopsy reason n % only permit if necessary 13 22.80 mandatory 4 7.02 wish to know the exact cause of death 40 70.16 total 57 100 table 3 reasons for autopsy refusal reason n % time and money consuming 1 4.00 religious concerns 6 24.00 respect t for the human body 7 28.00 afraid of mutilation 10 40.00 lack of understanding of autopsy 1 4.00 total 25 100 table 4 reasons that the community should increase their knowledge on autopsy reason n % only for the sake of knowing/extra information 35 43.75 people would be more willing to consent for autopsy 13 16.25 it is mandatory to know 2 2.50 the knowledge among the people is still insufficient 12 15.00 criminal rate is rising 10 12.50 people should know more about its benefits and purposes 8 10.00 total 80 100 siaw carwen, berlian isnia fitrasanti, budi darmawan: community knowledge and perception on autopsy in jatinangor, west java from august to october 2013 althea medical journal. 2015;2(3) 306 amj september, 2015 of the respondents only allow autopsy to be performed if it is truly necessary, for example, by the police to solve a crime issue. this is probably the reason why the decline in forensic autopsy rates is less drastic compared to clinical autopsy rates, proven in studies conducted in pekanbaru, indonesia, and kuala lumpur, malaysia.4,6 the similar scenario is also shown in a study conducted in northern ireland, where the rate of medicolegal autopsies remained fairly stable despite the decrease in the rate of clinical autopsies.7 medico-legal or forensic autopsy is generally guided by law, and it is usually performed when there is a murder or suspicious death. hence, people tend to allow this type of autopsy so that evidences can be gathered to solve the crime. on the other hand, clinical autopsy is performed in a natural death, usually caused by disease. therefore, the society usually regards this as an unnecessary procedure because the reasons to perform autopsy in a natural death do not outweigh the reasons to refuse it, such as the time and cost required for the autopsy, religious concerns, lack of understanding, respect towards the human body and fear of mutilation. despite the fact that discrepancy is proven between clinical and autopsy diagnoses, the rate of autopsy continues to decline.8,9,10 in indonesia, clinical autopsy was reported to be less favored.11 while the rate of clinical autopsy in united kingdom has decreased to 10% or less. this phenomenon is mainly due to development of modern diagnostic tools, causing autopsy to be considered unnecessary.12 moreover, fear of probable jurisdiction problems and lack of enthusiasm among pathologists also contributed to decline in autopsy rates.8 refusal of autopsy by the public is also caused by inappropriate portrayal of autopsy in movies and mass media. education to family members regarding the advantages of autopsy was observed as one of the factors that caused constant autopsy rates in some institutions.12 the main reason to reject autopsy by family members of the deceased in the study conducted in nigeria is the fear of mutilation of the body.3 majority of the people living in jatinangor are muslims (97.17%). in islam, the dead body must be buried within 24 hours of death as a sign of respect. some of the participants responded that “muslims are not allowed for an autopsy.” a response such as “my religion is against it” was given by one of the respondents. there were several limitations in this study. the questionnaire in this study was designed to discover the knowledge and perception on autopsy. the answers given by the respondents may, however, be dissimilar to their actual responses. moreover, indonesian or bahasa indonesia, which is the national language of indonesia, was used during the interview with the respondents. whereas communities living in jatinangor, mostly speak sundanese as their motherlanguage. a few of the respondents experienced difficulties in answering the open questions . in conclusion, there are still members of the community who do not know about autopsy and its purposes. the main reason of respondents who grant permission for autopsy if it is needed, is to know the exact cause of death, whereas the main reason of the respondents who refuse to give permission for autopsy is afraid of mutilation, followed by respect for the human body and religious concerns. it is recommended that the government improves the knowledge of jatinangor people regarding autopsy through various activities and programs. campaigns can be carried out to reduce religious objections to autopsy. moreover, by providing a clear picture on autopsy and its benefits, people would be more likely to opt for an autopsy when it is needed. references 1. tortora gj, derrickson b. principles of anatomy and physiology. 12th ed. danvers: john wiley & sons, (asia) pte ltd.; 2009. p. 8. 2. moyer cs. declining autopsy rates affect medicine and public health. american medical association. feb 20, 2012 [cited 2013 march 11]. available from: http://www.ama-assn.org/ amednews/2012/02/20/hlsa0220.htm. 3. oluwasola oa, fawole oi, otegbayo aj, ogun go, adebamowo ca, bamigboye ae. the autopsy: knowledge, attitude, and perceptions of doctors and relatives of the deceased. arch pathol lab med. 2009;133(1):78–82. 4. pathmananthan r, chandrasekharan n. declining post-mortems: a cause for concern. med j malaysia. 1985;40(4). 5. ming-hua z, dang-hui y. fluctuations in the rate of autopsy in china. chin med j. 2011;124(20):3403–7. 6. afandi d. profile of medicolegal autopsies in pekanbaru, indonesia 2007–2011. malaysian j pathol. 2012;34(2):123–6. althea medical journal. 2015;2(3) 307 7. loughrey m, mccluggage w, toner p. the declining autopsy rate and clinicians’ attitudes. ulster med j. 2000;69(2):83–9. 8. tavora f, crowder cd, sun cc, burke ap. discrepancies between clinical and autopsy diagnoses: a comparison of university, community, and private autopsy practices. am j clin pathol. 2008;129(1):102–9. 9. roberts dj. pathology: functionality in resource-poor settings. arch pathol lab med. 2013;137(6):748–51. 10. zhu kq, zhang sj. analysis of autopsy cases in 50 years. zhonghua nei ke za zhi. 2004;43(2):128–30. 11. afandi d, sampurna b, sutanto i, marwoto jw, chairani n, himawan s, et al. autopsy findings in severe malaria–a case report. med j indones. 2008;17(3):210–5. 12. ayoub t, chow j. the conventional autopsy in modern medicine. j r soc med. 2008;101(4):177–81. siaw carwen, berlian isnia fitrasanti, budi darmawan: community knowledge and perception on autopsy in jatinangor, west java from august to october 2013 althea medical journal. 2015;2(3) 363 the protective effect of field mint leaves in reducing stomach ulcer in rats induced by aspirin vanitha ratha krishnan,1 januarsih a. rachman,2 abdul hadi hassan3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine universitas padjadjaran, 3department of pathology anatomy faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: stomach mucosal wall erosion is caused by the imbalance of the aggressive factors and mucosal defensive factors due to the common causes such as the side effect of consuming non-steroidal antiinflammatory drugs. field mint (menthaarvensis) leaves have been used as an alternative option to cure and prevent the gastric problems. the aim of this study was to analyze the protective effect of field mint leaves infusion in reducing stomach ulcer in rats induced by aspirin. methods: the experimental study was conducted at histology laboratory of faculty of medicine, universitas padjadjaran, bandung. sixteen rats were divided into 4 groups randomly: group i (control negative group), group ii (control positive group, given 90mg/day aspirin, group iii (the treatment group, given 5cc of field mint leaves infusion and 90 mg aspirin) and group iv (the treatment group, given 5.6µg of misoprostol and 90 mg aspirin). mucosal wall erosions were determined by using microscope. data were analyzed using non-parametric kruskal-wallis test and mann-whitney u-test (ci 95% and p-value<0.05) results: group ii had high score of mucosal wall erosions after given only aspirin. in group iii and iv, the score of mucosal wall erosions were low. however there was no difference in score of mucosal wall erosions between group iii-iv (p<0.05) conclusions: field mint (menthaarvensis) leaves infusion is able to prevent stomach mucosal wall erosions induced by aspirin as misoprostol does. [amj.2015;2(3):363–68] keywords: aspirin, field mint (menthaarvensis), stomach mucosal wall erosions correspondence: vanitha ratha krishnan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170204955 email: vanitha102@hotmail.com introduction stomach ulcer is resulted from disparity of antagonistic gastric luminal factors such as acid and pepsin and defensive mucosal barrier function. many environmental and host factors can lead to an ulcer formation. this is caused by increasing the gastric acid secretion or weakening the mucosal barrier. one of the most significant causes of the ulcer is the use of non-steroidal anti-inflammatory drugs such as aspirin. aspirin causes an inhibition of cyclooxygenase enzyme (cox) which inhibits endogenous prostaglandin especially prostaglandin e1 (pge1), prostaglandin e2 (pge2) and prostaglandin analogue (pgi2). thus, mucosal defense is in breached. prostaglandin is accountable in regulating mucous cell secretion and since cox inhibits prostaglandin causing the barrier function is disrupted. the decreased prostaglandin inhibits basal bicarbonate secretion from mucosa and augmentation of acid production.1-4 traditional medicine remains widespread in many countries due to its affordability and availability. for example is the use of field mint plant which is a constant plant belonging to the mentha genus. this mint plant is found worldwide such as in europe, asia and north america. its mutual names include field mint, wild mint or corn mint. field mint is well-known by its scientific name mentha arvensis. the leaves of this herbal plant have a fresh mint aroma and used for cooking and medicinal purposes. furthermore, the essential oil extracted from the leaves also has althea medical journal. 2015;2(3) 364 amj september, 2015 many advantages. field mint tea is mainly used as an invigorating drink and condiment.5-9 moreover, field mint leaves have various medicinal properties in preventing gastrointestinal disorders. field mint oil can be used for both intrinsic and extrinsic indications. the food and drug administration (fda) approved the oil of mint a “generally regarded as safe” (gras) status. mint leaves have many benefits such as rich of antioxidants, for example phenols, vitamins including vitamin a, beta carotene and vitamin-c.6 thus, the present study was undertaken to determine the protective effects of 5 cc/day field mint leaves infusion in the experimental erosion of stomach mucosal layer in rats induced by aspirin. 5-9 methods in this study, the subjects used were 16 of 12 weeks white male wistar rats with 200 grams each adapted for one week. the rats were obtained from the pharmacological laboratory, faculty of medicine, universitas padjadjaran. the materials used in this study were fresh field mint (mentha arvensis) leaves. the leaves were purchased from the local vegetable supermarket (jatos) in jatinangor and were identified. the leaves were shade dried, finely powdered and made into an infusion. a total of 30 grams field mint (mentha arvensis) leaves powder was added with 500ml of water and an additional of extra water 2 times of the material weight (8ml) in a special pan to make the infusion. then, heated over a water bath for 15 minutes, calculated from the temperature in the pot at 900 c, and stirring was done occasionally. the infusion was filtered while still hot.39 the leaves were given in the form of 5cc/ rat infusion per oral. this particular dosage was given to attain an optimum effect of the study. drugs used in this study were aspirin and misoprostol. this study was an experimental laboratory study using a simple randomization design plan. a total of 16 rats were used as experimental animals and grouped randomly into 4 groups using random allocation method as follows: group i which was the negative control group was given aqueous solution. group ii which was the positive control group was given aspirin solution (90mg). group iii, the treatment group was given aspirin solution (90mg) and field mint (mentha arvensis) leaves infusion (5cc/rat) and group iv, also a treatment group was given aspirin solution (90mg) and misoprostol (3.6µg). before the study, the rats were adapted to the laboratory environment for one week. the rats were given food in the form of pellets and also water as needed. the rats were weighed every day and at the end of adaptation period and were observed closely to make sure they are healthy. next, all rats went on a fast. over the next five days, every morning each treatment group was given a respective drug: treatment group iii was given 5cc/rat field mint (mentha arvensis) leaves infusion and treatment group iv was given 3.6µg of misoprostol. one hour later, group iii and iv were given 90 mg aspirin. at the end, the rats went on a fast for 24 hours. finally, all rats were sacrificed with anesthesia using diethyl ether. the rats were dissected by laparotomy to obtain the gaster. the gastric mucosal layer (pyloric part) was then observed microscopically using the 100x and 400x magnifications after a fixation and staining. the depth of the mucosal wall erosion were observed and noted in each group. the extend of mucosal wall erosion were classified according to wattimena (1982) (table 1).10 the statistical analysis was conducted by using a computer. the statistical test showed ci 95% and p-value<0.05 (significant) and p-value <0.01 (highly significant). the microscopic data were analyzed by kruskalwallis test, to assess the median difference among those various groups. if the kruskaltable 1 scoring of the extend of mucosal wall erosion score no erosion 1 erosion only at the surface of mucosal layer 2 erosion at 1/3 upper region of gastric gland 3 erosion at 1/3 middle region of gastric gland 4 erosion at 1/3 lower region of gastric gland 5 erosion at muscularis mucosa 6 althea medical journal. 2015;2(3) 365 figure 1 microscopic observation of stomach mucosal erosion in group i (control group) and group ii (aspirin group) figure 2 microscopic observation of stomach mucosal erosion in group iii (field mint leaves infusion) and group iv (misoprostol) vanitha ratha krishnan, januarsih a. rachman, abdul hadi hassan: the protective effect of field mint leaves in reducing stomach ulcer in rats induced by aspirin althea medical journal. 2015;2(3) 366 amj september, 2015 wallis test is significant, the mann-whitney test was used to assess the median differences between two groups: group i-ii; group i-iii; group i-iv; group ii-iv; group iii-iv. results the microscopic results were obtained by microscopic evaluation to the stomach mucosal layer on the histological slide using the 100x and 400x light microscope. data were collected during the evaluation by observing the erosions of the mucosal layer of the rat`s stomach. the severity of gastric mucosal erosions was as illustrated below (figure 1 and figure 2). the microscopic wattimena score data collected from all four groups were analyzed by using non parametric kruskal-wallis test to asses statistical differences between various groups of animals with ci 95% and α = 5%. ho rejected when p-value < 0.05 and accepted when p-values > 0.05. from the statistical test, it is shown that there was a difference between those groups (table 2). the microscopic data collected were then analyzed by using mann-whitney u test to asses statistical difference between two groups of animals with ci 95% and α = 5%. ho rejected when p value < 0.05 and accepted when p value > 0.05. from the statistical test, there were differences between group i-ii, group i-iii, group i-iv, group ii-iii, group iiiv. however, there was no difference between group iii-iv (table 3). discussion it was proven from the results of the present investigation that the leaves infusion of field mint (mentha arvensis) possesses a protective effect in aspirininduced acute ulcer. it has shown a significant reduction in the gastric lesions of the aspirin treated groups of animals. although the etiology of the gastric ulcer is unknown in most of the cases, it is generally accepted that they are resulted from an imbalance between aggressive factors and the maintenance of mucosal wall integrity through the endogenous defense. from the microscopic results as stated above, it seems that aspirin can cause the erosions of the stomach mucosal layer. various factors are identified to be the risk factors and predisposing factors for the stomach mucosal wall erosion due to aspirin consumption. these factors have a close relation with the pathogenesis of aspirin-induced gastric ulcer. the disturbance in mucosal resistance allows the injury by endogenous factors such table 2 effects of field mint leaves infusion on aspirin induced in gastric mucosal erosions wattimena score) group wattimena score p 1 2 3 4 5 6 median range 0.000 group i 89% 10% 1% 0% 0% 0% 1 2 group ii 12% 21% 20% 16% 24% 7% 3 5 group iii 71% 18% 10% 1% 0% 0% 1 3 group iv 61% 28% 9% 2% 0% 0% 1 3 note : n = 100 areas of observation in each group; group i (control); group ii (aspirin); group iii (fli); group iv (misoprostol); p < 0,05 (significant); p<0.01 (highly significant) table 3 statistical comparison among groups comparison between groups mann-whitney u p-value i vs ii 802.000 0.000 i vs iii 4053.500 0.001 i vs iv 3558.000 0.000 ii vs iii 1322.000 0.000 ii vs iv 1505.000 0.000 iii vs iv 4549.500 0.188 note : n = 100 areas of observation in each group; p-value was calculated using mann whithney u test; group i (control); group ii (aspirin); group iii (fli); group iv (misoprostol); p < 0,05 (significant); p<0.01 (highy significant) althea medical journal. 2015;2(3) 367 as acid, pepsin, and bile salts. furthermore, aspirin administration for acute ulcer model of animals in this study was sufficiently induced mucosal erosions of the stomach even if it took four hours for ulcer induction before sacrificing. this was proven by the significant results of theaspirin group (group ii) mucosal wall erosions compared to the control group (group i) which only received aqueous solution and daily normal diet pellet. after ingestion of nsaids, the structural damage to the stomach surface epithelium occurs. the oxygen derived free radicals plays a big impact in the mechanism of aspirin induced gastric ulcers. aspirin induces the reactive oxygen metabolites in rats, which contributes to mucosal injury. the potential antioxidant protective effect of field mint leaves on gastric mucosal tissue is a topic of high current interest.11-13 the aspirin group (group ii) showed a significant increase in ulceration whereas in the field mint leaves infusion group (group iii), there was a significant reduction of the aspirin effect. field mint leaves are used as herbal remedies in folk medicine. menthol, caryophyllene and flavonoids which are the active agents in field mint leaves are known to possess a potent antiulcer activity. it also reduces gastric acid secretion induced by histamine in rats. field mint oil comprises vitamins a and c, omega-3 fatty acids, and minerals including potassium, manganese, iron, magnesium, calcium, and copper which increase the production of mucosal barrier in stomach mucosal wall. field mint leaves infusion inhibited the increase of the stomach mucosal wall lesions in aspirin induced lesions in rats. field mint leaves infusion pretreatment offered a protection against the action of aspirin showed that the presence of some antioxidant phytoconstituents might have the gastric mucosa from free radical-induced damage. the effective scavenging of free radicals by vitamin c and carotene may have reduced the progressive ulceration. field mint leaves contain flavonoids which can reduce gastric tissue histamine content. this fact in turn may have inhibited gastric secretions. carotene is a natural fat-soluble pigment which has antioxidant activity in vitro demonstrated that can take up singlet oxygen scavenge peroxyl radicals and inhibit lipid peroxidation.11-13 in the present study, it was found that animals in the control group (group i) also developed some erosions through microscopic observation. this could be due to the normal physiological changes in the gastric mucosal cells regulation as a response to the environmental factors in the laboratory such as temperature. the cells of the gastrointestinal tract have a rapid turnover rate, which makes its mucosa become one of the most rapidly proliferating tissues in the human body. under normal circumstances, cell populations within the gastrointestinal tract are maintained at a dynamic state because the cell loss due to the exposure of the gastric mucosa to ph, osmolarity and temperature is balanced by a continuous cell renewal. the other possible reason of the control group (group i) having mucosal wall erosions was due to its non-inflamed prior mucosal condition. inflamed gastric tissue is more resistant to aspirin-induced damage than noninflamed gastric tissue. physiologically, acid secretions in the stomach are under control of nervous and endocrine systems. the ph can reach a minimum level of 0.8. fasting for long periods of time can cause acidic conditions which leads to mucosal wall erosions. during the study, the rats went on a fast for 24 hours prior to sacrifice. furthermore, the gastric mucosal erosions of rats belonged to the field mint leaves infusion group (group iii) did not show a significant result when it was compared to the misoprostol group (group iv).the reason for this condition was due to the very similar mechanism of action of both field mint leaves and misoprostol which has an antioxidant effect to free radicals. for these results, it can be concluded that the 5 cc/day of field mint leaves infusion had an adverse protective effect toward aspirin-induced gastric erosions in rats. the study limitation was that the concentration of mint leaves infusion used was only one so the different effect from different concentration cannot be found. further study should be conducted using several concentration with larger sample size. references 1. katzung bg, masters sb, trevor aj. basic and clinical pharmacology. 11th ed. new york: mcgraw-hill companies inc; 2009. p. 584. 2. mitchell j. non-steroidal anti-inflammatory analgesic drugs. anaesthesiauk. 2006 [cited 2012 april 21]. available from: http://www.frca.co.uk/article. aspx?articleid=100633. 3. sinatra rs, jahr js, watkins-pitchford jm. the essence of analgesia and analgesics. vanitha ratha krishnan, januarsih a. rachman, abdul hadi hassan: the protective effect of field mint leaves in reducing stomach ulcer in rats induced by aspirin althea medical journal. 2015;2(3) 368 amj september, 2015 cambridge: cambridge university press; 2011. 4. gabriel se, jaakkimainen l, bombardier c. risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs: a meta-analysis. ann intern med. 1991; 115(10):787–96. 5. pandey ak, rai mk, acharya d. chemical composition and antimycotic activity of the essential oils of corn mint (mentha arvensis) and lemon grass (cymbopogon flexuosus) against human pathogenic fungi. pharmaceutical biology. 2003; 41(6):421–5. 6. moerman d. native american ethnobotany: a database of native american foods, drugs, dyes, and fibers of native american peoples derived from plants. dearborn michigan: university of michigan dearborn; 2003. 7. dwivedi d, khandelwal g, patidar rk, singh v. antimicrobial activity of mentha arvensis against clinical isolates of human cariogenic pathogensan in-vitro study. ijpsr. 2012;3(5):1355–60. 8. dorman hj, koşar m, kahlos k, holm y, hiltunen r. antioxidant properties and composition of aqueous extracts from mentha species, hybrids, varieties, and cultivars. j agric food chem. 2003; 51(16):4563–9. 9. akram m, uzair m, malik ns, mahmood a, sarwer n, madni a, et al. mentha arvensis linn.: a review article. j med plants res. 2011; 5(18):4499–503. 10. wattimena jr. l’hypoproteinemiae experimentale chez le rat, exploritation pharmacocinetique et pharmacologie du modele. these doctor d`etat es screces pharmaceutique. montpellier: universite de mountepellier; 1982. 11. mccord jm. the evolution of free radicals and oxidative stress. am j med. 2000;108(8):652–9. 12. becker jc, domschke c, pohle t. current approaches to prevent nsaid-induced gastropathy – cox selectivity and beyond. br j clin pharmacol. 2004; 58(6):587–600. 13. rahman k. studies on free radicals, antioxidants, and co-factors. clin interv aging. 2007; 2(2):219–36. althea medical journal. 2015;2(3) 458 amj september, 2015 pattern of intussusceptions on infants and children in dr. hasan sadikin general hospital bandung from 2009 to 2011 silmina kusmaheidi,1 rizki diposarosa,2 harry galuh nugraha3 1faculty of medicine universitas padjadjaran, 2department of pediatric surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: intussusception is the most frequent cause of acute intestinal obstruction in infants and toddlers. incidence was reported at 1.5 to 4 cases for every 1000 live birth. in dr. hasan sadikin general hospital, bandung, 55 cases were reported between 2005–2008. this study aimed to identify the characteristics of intussusception patients at department of pediatric surgery dr. hasan sadikin general hospital, bandung periode 2009–2011. methods: this was a retrospective descriptive study by using medical records of intussusceptions patient’s from january 2009 to december 2011. the information collected were age, gender, chief complaint, signs and symptoms, onset of symptoms, nutritional status, history of previous infection, type of intussusceptions, pathologic lead point, and complications; including bowel necrosis and sepsis. the collected data was analyzed and presented as percentages shown in tables results: there were 32 cases found, of which 84.4% affected well-nourished infants <1 year. male was predominant (2:1). bloody mucous stool was the major chief complaint (84.4%). accompanying symptoms were pain due to colic, vomiting, bloating, and abdominal mass. eleven patients were found with the onset of symptoms at ≤24 hours. thirty-one percent (31%) cases were reported with the history of respiratory tract infection and 44% cases with the history of diarrhea. most common type found was ileocolic. pathologic lead point was only found in a single case. conclusions: intussusception cases in dr. hasan sadikin general hospital are decreasing, with the characteristics mainly affect well-nourished children, under 1 year old, predominantly male. the prominent chief complaint is bloody mucous stool, whereas ileocolic is the most common type with history of infection. [amj.2015;2(3):458–62] keywords: bloody mucous stool, ileocolic-intussusceptions, infant correspondence: silmina kusmaheidi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281931248444 email: silminaheidi@yahoo.com introduction intussusception is invaginated condition of a part of intestines into a more distal part.13 this condition is the most common cause for acute intestinal obstruction in infants and children.1-4 if not treated immediately, intussusceptions can be potentially lethal; because it can obstruct arterial blood supply to the intestines, and cause necrosis and perforation of the intestines.2,3 the incidence of acute intussusceptions on infants and children is reported varying; between 1.5 to 4 cases for every 1000 live births.1,5 data on the acute intussusceptions incidence on infants and children in developing countries are still very few. according to bines and ivanoff2, van heek et al. reported a study in indonesia (1999) revealing that the number of intussusceptions patients each year was at 17.2 for every 1000 live births. in dr. hasan sadikin general hospital, bandung, indriasari (2008) reported that 55 intussusceptions cases were treated in the period of 2005–2008. in developing countries; including indonesia, it is common to find lack of continuous and updated data. therefore, it is not possible to know the most recent characteristics and description of intussusception patients. a previous study althea medical journal. 2015;2(3) 459 about intussusceptions patients profile was performed in the division of pediatric surgery, dr. hasan sadikin general hospital, bandung in the period of 2005–2008. nevertheless, for the period of 2009 to recent times, there had not been any further studies about the characteristics of intussusception patients. with that background, this study aimed to see the characteristics of intussusceptions patients in the division of pediatric surgery, dr. hasan sadikin general hospital, bandung, in the period of january 2009–december 2011. methods the methodology used in this study was retrospective descriptive on intussusceptions cases treated by the division of pediatric surgery, dr. hasan sadikin general hospital, bandung in the period of january 2009–december 2011. the population of this study was all patients diagnosed with intussusceptions treated in the division secondary data were obtained from the medical records; including age, gender, chief complaint, sign and symptoms, onset of symptoms, nutritional status, history of previous infection, type of intussusceptions, pathologic lead point (plp), and complications such as bowel necrosis and sepsis. incomplete medical record data of intussusceptions patients and those whose chief complaints were a continuation of the previous intussusceptions surgery were excluded from this study. data collection was carried out at dr. hasan sadikin general hospital, bandung in the months of august–november 2012. the data obtained from these medical records were processed. their frequency and percentage of each characteristic based on age, gender, chief complaint, other accompanying signs and symptoms, onset of symptoms, nutritional status, history of previous infections, type of intussusceptions, pathologic lead points and complications, were calculated. all calculations were executed using spss 17.0 and microsoft office excel 2007. the results were then presented in tables. results in the period between january 2009– december 2011, 47 intussusceptions cases were treated in dr. hasan sadikin general hospital, bandung. from all these cases, 15 cases (31.9%) had to be excluded because the patients coming had chief complaints of table 1 distribution of intussusception patients in rshs bandung in the period of january 2009 – december 2011 frequency gender male 22 female 10 age <1 year old 27 1-2 year old 1 >2 year old 4 chief complaints mucous bloody stool 27 vomiting 2 bloating 2 colicky abdominal pain 1 comorbidities colicky abdominal pain 31 vomiting 32 bloating 23 abdominal mass 8 onset of symptoms ≤24 hours 11 >24 hours 21 nutritional status good 27 bad 5 history of previous infections urti 10 diarrhea 14 type of intussusception ileocolic 23 ileocecal 2 ileoileal 1 ileocolocolic 5 jejunojejunal 1 pathologic lead point found (+) 1 not found (-) 31 necrosis 14 sepsis 5 silmina kusmaheidi, rizki diposarosa, harry galuh nugraha: pattern of intussusceptions on infants and children in dr. hasan sadikin general hospital bandung from 2009 to 2011 althea medical journal. 2015;2(3) 460 amj september, 2015 continuing previous intussusceptions surgery or incomplete data. therefore, the subjects appropriate to be analyzed were 32 cases (68.1%). twenty eight (28) patients (87.5%) under 2 years-old had no plp, whereas in 4 patients older than 2 years-old 1 plp was found in a 10 year old patient (table 2). table 1 show that in 32 cases fulfilling inclusion criteria, male was the predominant gender. the age range of intussusceptions patients were from 3 months old to 10 years old, whereas the most afflicted age group is 1 year, peaked at 8 months old. the most common chief complaint of the patients was mucous bloody stool. other comorbidities included colicky abdominal pain, vomiting, bloating, and abdominal mass. vomiting happened in all patients. patients who came to dr. hasan sadikin general hospital, bandung in this study had their chief complaints to be appearing within 1 hour to 14 days. most of them came more than 24 hours after the onset of symptom. most patients were well nourished; only 10/32 patients had history of acute respiratory tract infection, while gastrointestinal infection (diarrhea) occurred in 14/32. the type of intussusceptions most commonly found in the surgery was the ileocolic type, while the others were ileocecal, ileoileal, ileocolocolic and jejunojejunal. pathologic leading point in this study was revealed only in 1 case as multiple jejunal polyps; happening in >2 year-old patients, while the rest had no plp. (table 2) discussion in this study, most intussusception patients in dr. hasan sadikin general hospital, bandung were male, with 2:1 ratio between male and female. this was in accordance with those saying that previous study on intussusceptions was found more in males. aside from that, most studies revealed a ratio between male and female with2:1 or 3:2.1,2,5 most of the cases occurred in less than oneyear-old patients; with the peak at 8 months of age. this was in accordance with several studies stating that intussusceptions cases happened most commonly in children under 1 year old. according to a study in toronto5, 75% of intussusceptions cases occurred in children under 2 years old, whereas more than 40% occurred between the age of 3 to 9 months. while cusick and woodward1 stated that 50% of intussusceptions cases occurred between 3 and 10 months old and 65% occurred before 1 year old. indriasari (2008) reported that 77% of cases occurred to children aged 1 year old and less, with the peak at 1 year old (20%). as stated by ein and daneman5, 85% of classic symptoms of intussusceptions patients are sudden cholic abdominal pain which is severe and episodic. ravitch and young in ein and daneman5 also revealed vomiting as the most frequent early symptom on intussusception cases with 44%. both toronto serials discovered that vomiting is the second most common symptom after pain, with 80% within 1959–1968 and 48% within 1985– 1990. the mass or protrusion in stomach was reported at 65% of cases. however, according to the toronto serial of 1997, the percentage decreased to 22% without any clear reasons. it is different from the case with rectal bleeding which was reported with 60% in toronto serial cases in the year of 1968 and with 43% in 1997. according to ravitch in ein and daneman5, rectal bleeding is a more common sign than abdominal mass (95% in babies, 65% in older children). cusick and woodward1 stated that the triad of classic signs and symptoms (abdominal pain, vomiting, and rectal bleeding) are only complete on one-third of the patients. while a study conducted by ozguner et al. 6 stated that only a fifth or 20% of the patients experienced the classical triad symptoms. however, if waited for all classic signs and symptoms to appear before making a diagnosis, then it would be too late.5 in this study, the most common complaint was mucous bloody stool in 27 patients. most patients had other classic comorbidities such as colicky abdominal pain in 31 patients and vomiting in all children. abdominal mass only occurred in 8 patients. table 2 distribution of pathologic lead point (plp) according to age age ≤ 2 years old age > 2 years old frequency (%) frequency (%) plp(+) 0 0 1 3.1 plp(-) 28 87.5 3 9.4 althea medical journal. 2015;2(3) 461 therefore, most cases showed 3 classic signs and symptoms of intussusception (abdominal pain, vomiting, and rectal bleeding) in 21/32 of the child patients. this was higher than another study stating that the classical signs and symptoms of the triad appeared completely only in one-third or 30% of the cases. this might be due to the patients who came to dr. hasan sadikin general hospital, bandung were too late to be diagnosed with intussusceptions. in addition, in this study, the emergence of mucous bloody stool was the most common chief complaint when the patients came. this occurred because mucus and blood are the most visible change appearing for the parents, which became the main reason for the parents to bring their children for treatment. the onset of symptoms on intussusceptions patients is related with the degree of morbidity and mortality. the average length of time before any combination of the signs and symptoms leads to a diagnosis is about 24 hours.5 ravitch and mccune in janik7 clearly explained the incidence of abdominal gangrene and mortality rate of intussusceptions increased in 24 hours after onset of symptoms, with the peak at 72 hours. in developing countries, patients mostly come 24 hours after the onset of symptoms and this is related to the high mortality rate.2 ravitch in ein and daneman5 also estimated that ischemic process which is not only undiagnosed, but also unhandled within 2 to 5 days would be fatal. this lateness may bring serious complications such as necrosis and sepsis. in this study, most of the patients, 21/32, came later than 24 hours after the first onset of the symptoms. out of all patients, 14 experienced necrosis while 5 experienced sepsis. although nutritional status have not been much reported in asia, the all indian institute of medical science, new delhi, reported that all children who came with intussusceptions had normal nutritional status. in medan, indonesia, studies also reported that 87% of the intussusceptions patients had good nutritional status.2 in the year of 1905, hirschprung in ein and daneman5 reported that he never observed intussusceptions cases in malnourished children. the well-nourished assumption of hirschsprung means that most of those afflicted with intussusceptions have higher body weight percentile.5 in this study, most patients were well nourished while the rest of them, 5 patients were malnourished. some studies explained that the presence of history of acute respiratory tract infection or gastroenteritis infection often plays a role in intussusceptions.2,4,5,8 both acute respiratory tract infection and gastroenteritis infection can cause lymphatic tissue enlargement.4,5 ignacio and fallat4 described that most idiopathic intussusception cases occurred to children between the age of 6 to 36 months and are very susceptible to viral infection. this study discovered that out of 32 patients, only 10 had history of acute respiratory infection, whereas diarrhea history only occurred in 14 cases. in this study, the most frequently found type of intussusceptions during surgery was ileocolic intussusception. this was in accordance with the research stating that majority of intussusceptions cases in children was ileocolic.4,5,9 according to cserni et al.8, more than 90% of intussusceptions cases were ileocolic. aside of that, arnold et al.10 also stated that most of intussusception cases occurring in the age of less than 2 years old were ileocolic. only one case of plp was found in this case as multiple jejunum polyp. this is in accordance with other studies stating that the etiology of intussusceptions on most infants is unclear or idiopathic.8,11 in a study conducted by janik7, out of 20 children, only 3 who had their intussusceptions resected, and one of them was due to multiple jejunal polyp. this is similar to the case with plp in this study with multiple jejunal polyps. from this study, it can be concluded that intussusceptions patients treated in the division of pediatric surgery, department of surgery, dr. hasan sadikin general hospital, bandung in the period january 2009–december 2011 were decreasing. the characteristic mostly found was in the age of less than 1 year, with male predominance of 2:1 ratio. although most patients were well nourished, there was previous history of infections in either the respiratory tract or digestive tract. the most common type of intussusceptions was ileocolic. pathologic lead point was discovered in 1 case to more than 2 year-old patients. the most common complaint was mucous bloody stool; some patients experienced sepsis and in surgical findings, there were necrosis of the intestines. the limitations of this study were incomplete data from medical records and unspecified diagnostic method for the intussusceptions. references 1. cusick el, woodward mn. intussusception. in: burge dm, griffiths dm, steinbrecher ha, wheeler ra, editors. paediatric silmina kusmaheidi, rizki diposarosa, harry galuh nugraha: pattern of intussusceptions on infants and children in dr. hasan sadikin general hospital bandung from 2009 to 2011 althea medical journal. 2015;2(3) 462 amj september, 2015 surgery. 2nd ed. great britain: hodder education; 2005. p. 197–203 2. bines je, ivanoff b. vaccines and biologicals : acute intussusception in infants and children incidence, clinical presentation and management: a global perspective. world health organization; 2002. (cited 2012 september 25) available from: http://www.who.int/vaccinesdocuments/docspdf02/www640.pdf. 3. huppertz h-i, soriano-gabarró m, grimprel e, franco e, mezner z, desselberger u, et al. intussusception among young children in europe. pediatr infect dis j. 2006;25(1):s22–s9. 4. ignacio rc, fallat me. intussusception. in: holcomb gw, murphy jp, editors. ashcraft’s pediatric surgery. 5th ed. philadelphia: saunders elsevier; 2010. p. 508–16 5. ein sh, daneman a. intussusception. in: grosfeld jl, o’neill ja, coran ag, fonkalsrud ew, editors. pediatric surgery. 6th ed. philadelphia: mosby elsevier; 2006. p. 1313–41 6. ozguner if, savas car, baykal b. ileoileal invagination without obstruction in a four-year-old boy. j pediatr surg. 2004;39(10):1595–6. 7. janik js. nonischemic intussusception. j pediatr surg. 1977;12(4):567–70. 8. cserni t, paran s, puri p. new hypothesis on the pathogenesis of ileocecal intussusception. j pediatr surg. 2007;42:1515–9. 9. blevrakis e, tampakaki z, dimopoulou a, bakantaki a, blevrakis e, sakellaris g. small bowel intussusception with pelvic plastron secondary to acute appendicitis in child. j pediatr surg. 2010;45:e5–e7. 10. arnold m, sidler d, moore sw. compound colonic intussusception: a reason for failure of pneumatic reduction. j pediatr surg. 2010;45(10):e25–e8. 11. bucher bt, hall bl, warner bw, keller ms. intussusception in children: costeffectiveness of ultrasound vs diagnostic contrast enema. j pediatr surg. 2011;46:1099–105. amj vol 9 no 3 september 2022(2)update2.indd althea medical journal. 2022;9(3) 139 correlation between neutrophil-to-lymphocyte ratio (nlr) and immature-to-total neutrophil (i/t) ratio to bacterial infection among children with chronic kidney disease galuhafiar puratmaja, anggraini alam, dzulfikar djalil lukmanul hakim, sri endah rahayuningsih, dida akhmad gurnida, dany hilmanto department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia correspondence: galuhafiar puratmaja, dr., department of child health, faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, jalan pasteur no. 38, bandung, indonesia, e-mail: galuhafiar@gmail.com althea medical journal. 2022;9(3):139–144 abstract background: chronic kidney disease (ckd) in children has a long-lived impact, such as an increased risk of bacterial infection. infection may accelerate disease progression, making early detection crucial. inflammatory markers typically used for bacterial infection are c-reactive protein (crp) and procalcitonin (pct). this study aimed to determine the correlation between levels of neutrophil-tolymphocyte ratio (nlr) and immature-to-total-neutrophil ratio (i/t ratio) to bacterial infection in children with ckd as indicated by the serum levels of crp and pct. methods: observational analysis with a cross-sectional design was conducted from january 2019 to november 2021 in children from 3 months to 18 years old with ckd and bacterial infection. retrospective data were obtained from medical records at dr. hasan sadikin general hospital, bandung. correlation analysis was performed (spss program) at a 95% confidence level, and results were considered significant if the p-value <0.05. results: there were 42 children, and 57% were female; with a median age of 13 years (range 1–17 years). most patients had normal nutritional status (55%) although 40% were malnourished. correlation analysis between i/t ratio and nlr with pct was positive, with r=0.284 (p<0.05) and r=0.265 (p<0.05), respectively, whereas there was no significant correlation of i/t ratio (r=0,154; p>0.05) and nlr (r=0,188; p>0.05) to crp. conclusions: nlr and i/t ratios have a significant positive correlation with pct levels but not with crp levels. nrl and i/t ratios can be considered as alternative markers for diagnosing ckd in children with a bacterial infection. keywords: bacterial infection, c-reactive protein, children, chronic kidney disease, procalcitonin introduction chronic kidney disease (ckd) is a kidney dysfunction affecting children and adults that chronically progressed.1,2 this definition has been coined by kidney disease improving global outcomes (kdigo), which was updated in 2012.2 the incidence and prevalence of ckd have increased by 90% from 1990 to 2016,3 and varies in many countries. a multicentre study in turkey has reported that the ckd incidence is 10.9 cases per 1,000,000 children, in which 68% of cases progressed to end stage renal disease (esrd) with leading cause of death is cardiovascular diseases followed by infection. the bacterial infection is also strongly suspected as the major complication of ckd in indonesia.4 the primary etiology of ckd in children is congenital anomalies of the kidney and urinary tract (cakut), followed by steroidresistant nephrotic syndrome (srns), chronic glomerulonephritis, and renal ciliopathy.5 therefore, the clinical manifestation of ckd in children is varied. depending on the etiology, ckd could manifest into hematuria, edema, polydipsia, polyuria, nocturia, and enuresisresulting in poor linear growth and hypertension. the kdigo classifies ckd based on the etiology, glomerular filtration https://doi.org/10.15850/amj.v9n3.2673 althea medical journal. 2022;9(3) 140 rate (gfr) categories, and albuminuria. furthermore, the national kidney foundation kidney disease outcomes quality initiative (kdoqi) has grouped cdk based on the gfr, that is divided into five stages categorizes i.e. stages 1–3 as early stages and 4–5 as later stages, whereas stage 5 is the end stage of renal disease (esrd).6 decreased renal clearance in ckd leads to immune dysfunction and an increased inflammation activity.7,8 children with ckd are also prone to infection, and the most common infections are urinary tract infection (uti), pneumonia, and sepsis.1 these conditions may lead to systemic inflammatory response syndrome, resulting in poor prognosis, increased disease burden, and accelerated ckd progression; hence an early diagnosis of infection is crucial.1,9 culture has been recognized as the gold standard for definitive diagnosis of bacterial infection. however, it is rarely used due to its cost and resource limitations. some examinations that can give a clinical picture of bacterial infection are among other white blood cell (wbc), platelet count, erythrocyte sedimentation rate (esr), absolute neutrophil count (anc), c-reactive protein (crp) and procalcitonin (pct). the crp and pct have an acceptable specificity for diagnosing bacterial infection in a patient with kidney dysfunction.10,11 other parameters used to detect bacterial infection are the neutrophil lymphocyte ratio (nlr) which is increased acutely after bacterial infection (<6 hours), and the immature/total neutrophil ratio (i/t ratio).12,13 quick response of nlr is beneficial not only for the early assessment of bacterial infection but also helps diagnose sepsis, pneumonia, and covid-19.14–17 the progressive decrease in kidney function will result in an increase in polymorphonuclear cells, which in turn increases the i/t ratio.18 the nlr and i/t ratio examinations are inexpensive and easily found in primary health care with limited resources. in this study, we analyzed pct and crp as typical indicators of bacterial infection. this study aimed to prove a positive correlation between nlr and i/t ratio on the incidence of bacterial infection in children with ckd, as indicated by the crp and pct serum levels. methods a cross-sectional analytic observational study was conducted using retrospective data from patients’ medical records. data were collected from the central electronic database (sistem informasi rumah sakit, sirs) in dr. hasan sadikin general hospital, bandung, between january 2019 and november 2021. inclusion criteria were children aged three months to 18 years old who diagnosed with ckd stage 1–5 and had been diagnosed bacterial infection and had received antibiotic treatment. data on complete blood count, including differential count, nlr, i/t ratio, crp, and pct were collected from the laboratory. exclusion criteria were children with diabetes mellitus, a hematopoietic system disorder, a history of malignancy and chemotherapy, an acute ckd or otherwise with incomplete data. the sample size was calculated with a significance level of 5%, a 90% power test, and a correlation coefficient of 0.377, resulting in a minimum sample size of 42 subjects. characteristics of patients were shown in the frequency table. categorical variables were described by numbers and proportions, while numerical variables were described in terms of mean, standard deviation (sd) or median, and range depended on the data distribution. a correlation analysis was performed with the pearson correlation test if the variables were normally distributed or spearman’s rank if not normally distributed. variance analysis or the kruskal-wallis test was used to compare the differences between variables. multivariate analysis was conducted on possible confounding variables (age, gender, and nutritional status) using linear regression. variables were included in the analysis if the result was significant with a 95% confidence interval. the results were considered significant if the p-value ≤0.05. the data analysis had used spss 20.0. this study obtained permission and approval from the ethics committee of dr. hasan sadikin general hospital with number lb.02.01/x.6.5/371/2021. results out of 126 patients, 84 were excluded due to incomplete data and a history of chemotherapy, remaining a minimum data (n=42) of children with ckd. the characteristics of the children had shown that more than half were female (n=24; 57%) with a median age of 13 years (range 1–17 years) and most of the children were between 10 to 15 years old (67%) (table 1). the children had normal nutritional status (n=23; 55%), however, 40% children were malnourished, and 5% patients were obese. the laboratory parameter (ratio i/t, nlr, crp, dan pct) were not normally distributed (shapiro-wilk test) as shown in table 2. the althea medical journal september 2022 althea medical journal. 2022;9(3) 141galuhafiar puratmaja et al.: correlation between neutrophil-to-lymphocyte ratio (nlr) and immature-tototal neutrophil (i/t) ratio to bacterial infection among children with chronic kidney disease correlation between i/t ratio as well as nlr with pct showed that there was a positive correlation with r=0.284 (p=0.034) and r=0.265 (p=0.045), respectively (table 3). nlr increased as the value of the i/t ratio increased. in contrary, there was no correlation between i/t ratio or nlr with crp with r=0.154 (p=0.165) and r=0.188 (p=0.116), respectively (figure 1). discussion our study has explored nlr and i/t ratio in relation to infection marker crp and pct in children with chronic kidney disease (ckd). the majority of the children in this study were female (57%), in contrary to other study showing that male is more prevalence.18 interestingly, the frequency of congenital table 1 characteristics of children with chronic kidney disease (n=42) characteristic frequency (n) percentage (%) gender male female 18 24 43 57 age (year) 1–9 10–15 16–18 6 28 8 14 67 19 median: 13 range: 1–17 nutritional status severe malnutrition moderate malnutrition normal obesity 6 11 23 2 14 26 55 5 table 2 laboratory results in children with chronic kidney disease and normality test variable statistical value normality test (p-value) *mean (sd) median range ratio i/t 0.0 (0.014) 0.0 0.0–0.075 <0.001 nlr 7.30 (5.97) 5.52 0.75–28.29 <0.001 crp 5.81 (5.16) 4.57 0.22–23.27 <0.001 pct 52.60 (94.14) 17.56 0.08–509.72 <0.001 note: *based on shapiro-wilk test, i/t= immature/total neutrophil, nlr= neutrophil lymphocyte ratio, crp= c-reactive protein, pct= procalcitonin table 3 correlation of i/t ratio or nlr with crp and pct in children with chronic kidney disease correlation correlation coefficient (r) p-value*) i/t ratio with crp 0.154 0.165 i/t ratio with pct 0.284** 0.034** nlr with crp 0.188 0.116 nlr with pct 0.265** 0.045** note: *) one-tailed test, **) significant, i/t= immature/total neutrophil, nlr= neutrophil lymphocyte ratio, crp= c-reactive protein, pct= procalcitonin althea medical journal. 2022;9(3) 142 figure correlation between i/t ratio (a) or nlr (b) and pct in children with chronic kidney disease kidney disease known as congenital anomalies of kidney and urinary tract (cakut) is higher in males.1 however, this study did not highlight cakut as the primary etiology of ckd. additionally, this study had a smaller number of subjects. the age of children with ckd in this study ranged from 1 to 17 years old, dominated by the 10–15 age group with a median of 13 years old. several other studies have shown various median age of 10 years old,18 and others with younger age of 6 or 8 years old.19 low-grade chronic inflammations play a significant role in ckd progression and complication.8 kidney injury, hypoalbuminemia, decrease in cytokine and metabolite clearance may result in inflammation and proteinuria significantly and contribute to further kidney injury and pro-inflammation condition with increasing cytokine production.20 uremic environments in ckd produce oxidative and carbonyl stress that are highly pro-inflammatory.8 levels of inflammation biomarkers in ckd patients, such as crp, interleukin (il)-6, and tnf-α are elevted.21 increased inflammatory proteins are strong predictors of mortality, including cardiovascular deaths in patients with esrd.7,8 this study analyzed the correlation of the i/t ratio and nlr with frequently used inflammatory markers crp and pct in patients with ckd. the i/t ratio obtained in this study has a median 0% (range 0–0.075%). for sepsis diagnosis, the the i/t ratio cutoff value of >0.2% has a high sensitivity and specificity.22 however, previous studies never mentioned the value of i/t ratio in children with ckd. a study of ckd in adults has shown that i/t ratio of 68.7% is significantly higher than patients without infection.23 in this study, nlr has a median of 5.52 (range 0.75–28.29), in contrary to other study that shows a lower result (mean 2.48±2.96).24 interestingly, there is a significant difference between general population (1.75), patients with ckd not requiring dialysis (2.54), patients with ckd who required dialysis (2.42), and patients with ckd using peritoneal dialysis (3.15).25 relationships between inflammatory markers in children with ckd have not been studied. with r=0.265 (p-value=0.045), we inferred a low positive correlation between nlr and pct, according to guilford criteria. however, positive correlation is found between nlr and pct in adult patients with esrd, with r=0.285 (p-value <0.001).26 moreover, pct <0.5 and ≥0.5 have been associated with nlr.27 neutrophil extracellular traps (net) are responsible for the role of neutrophil in the pathology of ckd and the increase of nlr. net is a defense mechanism mediated by neutrophils, trapping bacterial pathogens by releasing dna out of the cell compartment.28 in a patient with uremia, net is associated with nlr and neutrophil count.28,29 this finding suggests that net is involved in the elevation of nlr, suggesting a possibility of having nlr as a new therapeutic target in ckd. a positive correlation is also found between the i/t ratio and the level of pct. a cut-off >0.2% for inflammatory disease has been set.22 interestingly, other studies revealed althea medical journal september 2022 althea medical journal. 2022;9(3) 143 neutrophil count that is relatively lower in neonates compared to adults. the maximum i/t ratio in neonates without infection is 0.16% in the first 24 hours and decreases into 1.2% within 60 hours after birth. age is also associated with the decrease of lymphocyte; a drastic decrease occurs between birth, young adulthood, and above 40 years old.30 in this study, age, gender, and nutritional status, which were considered confounding factors, were not proven. this study has some limitations. we cannot obtain serial exams on the study variables that would provide insight into the variable’s trend. moreover, in some patients, the timing of sample collection might not be at the time of disease onset. although no correlation was found between the i/t ratio and nlr with crp, however, the i/t ratio and nlr tended to have a positive correlation with crp. one reason might be a differences in sample size. a power test with a greater sample size might be needed to overcome this bias. however, this is the first study analyzing the correlation between nlr and the i/t ratio to the incidence of bacterial infection in children with ckd. in conclusion, the i/t ratio and nlr are considered suitable alternatives for bacterial infection marker such as pct in patients with ckd. this will help early diagnosis in health care facilities with limited resources to treat bacterial infection in children with ckd. a further longitudinal study with a larger sample size using serial examination is needed to confirm the correlation between the i/t ratio and nlr with crp and decide on the cut-off for each variable. conflict of interest the authors declare that there is no conflict of interest regarding the publication of this article. acknowledgments the authors are thankful to mr. hadyana for his guidance in the statistical analysis of the data. funding acknowledgments the authors received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. references 1. becherucci f, roperto rm, materassi m, romagnani p. chronic kidney disease in children. clin kidney j. 2016;9(4):583–91. 2. kidney disease: improving global outcomes (kdigo) ckd work group. kdigo 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. kidney int. 2013;3:1–150. 3. tuttle kr, alicic rz, duru ok, jones cr, daratha kb, nicholas sb, et al. clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the cure-ckd registry. jama netw open. 2019;2(12):e1918169. 4. pardede so, chunnaedy s. penyakit ginjal kronik pada anak. sari pediatri. 2016;11(3):199–206. 5. ashraf m, jan m, wani ka, ahmed p, ahmed j, ahmed sn. chronic kidney disease in children: a review. j ped nephrol. 2020;8(4):1–9. 6. uwaezuoke s, ayuk a, muoneke v, mbanefo n. chronic kidney disease in children: using novel biomarkers as predictors of disease. saudi j kidney dis transpl. 2018;29(4):775–84. 7. rachmadi d, rudiansyah m, bandiara r, lubis l. a narrative review: the inflammation in chronic kidney disease (ckd). int j pharm sci res. 2021;13(2):258– 65. 8. akchurin om, kaskel f. update on inflammation in chronic kidney disease. blood purif. 2015;39(1−3):84−92. 9. pardede s, rafli a, gunardi h. quality of life in chronic kidney disease children using assessment pediatric quality of life inventory. saudi j kidney dis transpl. 2019;30(4):812–8. 10. park jh, kim dh, jang hr, kim m-j, jung s-h, lee je, et al. clinical relevance of procalcitonin and c-reactive protein as infection markers in renal impairment: a cross-sectional study. crit care. 2014;18(6):640. 11. wu s-c, liang c-x, zhang y-l, hu w-p. elevated serum procalcitonin level in patients with chronic kidney disease without infection: a case-control study. j clin lab anal. 2019;34(2):e23065. 12. honda t, uehara t, matsumoto g, arai s, sugano m. neutrophil left shift and white blood cell count as markers of bacterial infection. clin chim acta. 2016;457:46–53. 13. setiawan h, prasetyorini t, djajaningrat h. gambaran it ratio pada neonatus dengan risiko sepsis di rsia hermina ciputat. jitek. 2015;3(1):1–9. 14. martins ec, silveira ldf, viegas k, beck ad, júnior gf, cremonese rv, et al. neutrophilgaluhafiar puratmaja et al.: correlation between neutrophil-to-lymphocyte ratio (nlr) and immature-tototal 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epidemiology of chronic kidney disease in children: a report from lithuania. medicina. 2021;57(2):112. 19. tuttle kr, alicic rz, duru ok, jones cr, daratha kb, nicholas sb, et al. clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the cure-ckd registry. jama netw open. 2019;2(12):e1918169. 20. greenberg jh, kakajiwala a, parikh cr, furth s. emerging biomarkers of chronic kidney disease in children. pediatr nephrol. 2018;33(6):925–33. 21. tu j, cheung ww, mak rh. inflammation and nutrition in children with chronic kidney disease. world j nephrol. 2016;5(3):274–82. 22. darnifayanti d, tjipta gd, rusdidjas r, lubis bm. immature-to-total neutrophil ratio as an early diagnostic tool of bacterial neonatal sepsis. paediatr indones. 2015;55(3):153–7. 23. mori k-i, noguchi m, sumino y, sato f, mimata h. use of procalcitonin in patients on chronic hemodialysis: procalcitonin is not related with increased serum calcitonin. isrn urol. 2012;2012. 24. skrzypczyk p, szyszka m, ofiara a, leszczyńska b, adamczuk d, daniel m, et al. ambulatory blood pressure monitoring and subclinical inflammation in children with chronic kidney disease. arterial hypertens. 2019;23(1):14−21. 25. okyay gu, i̇nal s, öneç k, er re, paşaoğlu ö, paşaoğlu h, et al. neutrophil to lymphocyte ratio in evaluation of inflammation in patients with chronic kidney disease. ren fail. 2013;35(1):29–36. 26. li p, xia c, liu p, peng z, huang h, wu j, et al. neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in evaluation of inflammation in non-dialysis patients with end-stage renal disease (esrd). bmc nephrol. 2020;21(1):511. 27. quan x, feng c, he j, li f, liao m, wen j, et al. serum procalcitonin correlates with renal function and immune components in early-stage renal transplant recipients. transplant proc. 2021;53(3):927–32. 28. ito s, ohno y, tanaka t, kobuchi s, ayajiki k, manabe e, et al. neutrophil/lymphocyte ratio elevation in renal dysfunction is caused by distortion of leukocyte hematopoiesis in bone marrow. ren fail. 2019;41(1):284–93. 29. kim j-k, hong c-w, park mj, song yr, kim hj, kim sg. increased neutrophil extracellular trap formation in uremia is associated with chronic inflammation and prevalent coronary artery disease. j immunol res. 2017;2017:8415179. 30. agarwal r, light rp. patterns and prognostic value of total and differential leukocyte count in chronic kidney disease. clin j am soc nephrol. 2011;6(6):1393.s. althea medical journal september 2022 althea medical journal. 2014;1(2) 100 amj december, 2014 the analgesic effect of pineapple fruit juice on mice ainul atiqah binti hilmi¹, vycke yunivita kd², henny anggraini sadeli³ 1faculty of medicine, universitas padjadjaran, 2 department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3 department of neurology, faculty of medicine, universitas padjadjaran/dr.hasan sadikin general hospital abstract background: pain is a feeling stimulated by the nervous system which can be suppressed by giving an analgesic agent. some studies revealed that pineapples have an analgesic effect. this study aim was to determine analgesic effect of pineapple on mice. methods: in this experimental study, the effect was examined by using a writhing method on the 28 male mice. subjects were divided into 4 groups with 7 mice each. the control group received aquades and other groups received pineapple fruit juice with 20%, 40% and 80% concentration with the dosage of 10 ml/ kg/body weight. after 30 minutes, 3% acetic acid was injected intraperitoneally to induce pain. writhing responseswere observed every 5 minutes for 30 minutes. results: the result for mean of total writhing reaction was 2.39±0.40, 1.92±0.40, 1.50±2.13, 1.66±0.11 respectively for group 1 to 4. these data indicated a significant decrease of total writhing response in mice with 20%, 40% and 80% concentration compared to control group (p=0.023;p=0.000 and p=0.000 respectively). most optimal concentration was40% with the protective percentage equal to 71.8%. conclusion: pineapple fruit juice concentrations (20%, 40%, and 80%has an analgesic effect with the most optimal concentration of 40%. [amj.2014;1(2):100–4] key words: analgesic, pain, pineapple fruit, writhing method efek analgesik jus buah nanas pada mencit abstrak latar belakang: nyeri adalah sensasi perangsangan sistem saraf yang dapat ditekan dengan pemberian zat analgetik. penelitian sebelumnya menemukan bahwa nanas memiliki efek analgesik. tujuan penelitian ini adalah untuk mengetahui efek analgesik nanas pada mencit. metode: efek analgesik diperiksa dengan menggunakan metode “writhing“ pada 28 mencit jantan. subyek penelitian dibagi menjadi 4 kelompok masing-masing 7 ekor. kelompok kontrol menerima aquades dan kelompok lainnya menerima jus buah nanas secara oral dengan konsentrasi 20%, 40% dan 80% dengan dosis 10 ml/kg/berat badan. setelah 30 menit, asam asetat 3% disuntikkan intra peritoneal untuk menginduksi nyeri. respons “writhing” diamati setiap 5 menit selama 30 menit. hasil: hasil rata-rata reaksi total ”writhing”adalah 2.39 ± 0.40, 1.92 ± 0.40, 1.50 ± 2.13, 1.66 ± 0.11 masingmasing untuk kelompok 1 sampai 4. data ini menunjukkan penurunan yang signifikan dari jumlah respon ”writhing” pada tikus dengan 20%, 40 % dan konsentrasi 80% dibandingkan dengan kelompok kontrol (p=0,023; p=0,000; dan p=0,000masing-masing). konsentrasi optimal adalah 40% dengan persentase pelindung sebesar 71,8%. simpulan: konsentrasi jus buah nanas (20%, 40% dan 80%) memiliki efek analgesik dengan konsentrasi paling optimal pada 40%. [amj.2014;1(2):100–4] kata kunci: analgesik, nyeri, nanas, writhing correspondence: ainul atiqahbinti hilmi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281912725563, +60199578082, email: ainul_1908@yahoo.com.my althea medical journal. 2014;1(2) 101 introduction pain is a feeling stimulated by the nervous system. it is a complex phenomenon that warns an individual about some tissue damage which currently is occurring or has occurred.1it happens when there is a damage or injury, the tissue will release some chemical mediators such as bradykinin, and prostaglandin (pge₂) which will stimulate pain sensation.2 this sensation can be supressed by using analgesic drugs such as paracetamol and ibuprofen. some plants also exhibit analgesic effects such as pineapple (ananascomosus). in previous study , pineapple had been proved as a plant that have an analgesic effect due to the presence of bromelain.3 this active compound which can be found in the root and stem of pineapple, bromelain, is a proteolytic enzyme which has many pharmacological activities such as analgesic agent, antiinflammatory, prevent edema, and increase tissue permeability of antibiotic drugs.4 in this study 3% acetic acid had been used to induce pain sensation on mice. acetic acid is an irritation agent that when injected intraperitoneally, it usually induces hypersensitivity.5 the objective of this study was to determine the 20%, 40% and 80% of the pineapple fruit juice concentration which has the protective result as an analgesic effect. methods the study subject used in this experiment were 28 healthy male mice (musmusculus) with body weight of 20–30 gram each which then were divided into 4 equal groups. the research materials in this study were pineapple fruit juice as the intervention with the concentration of 20%, 40% and 80% for group 2, group 3 and group 4 respectively. to make 20% concentration of pineapple fruit juice, 20 gram pineapple was used. the pineapple was blended finely, filtered to get the juice and added with 100 ml distilled water. for concentration of 40% and 80%, 40 gram and 80 gram of pineapple fruit were used respectively and then the same procedure was applied. other materials used were 3% acetic acid as the pain stimulation and aquades as placebo. all mice were left freely for one week as an adaptation period in the laboratory with optimal room temperature without any effort of intervention. prior to the experiment, all mice must undergo a fasting period for 18 hours with free access of drinking water.6 writhing method or abdominal contraction method was used in this study to evaluate the analgesic effect. for the experimental group, each will receive 20%, 40% and 80% pineapple fruit juice concentration respectively via oral and for thecontrol group, aquades was givenorally as a placebo. after 30 minutes, 30% acetic acid was injected intraperitoneally to induce pain. right after acetic acid was given , writhing response was observed. the reaction was observed for 5 minutes every 30 minutes right after giving acetic acid. the writhing reflexes observed on mice included abdominal contraction, stretching of the body, retraction of the abdomen followed by withdrawing of the lower limbs backward.7 protective percentage in this study was calculated by using the formula of 100% (total number of writhing in experimental group / total number of writhing in control group) x 100. for statistical analysis, analysis of variance (anova) was used to see whether significant differences between groups . the test then subjected to tukeyy hsd multiple comparison post test. this experiment was done in november 2012 at the animal laboratory of pharmacology and therapy, faculty of medicine, universitas padjadjaran , jatinangor, bandung, indonesia. results in this study, the data was analysed by using shapiro-wilk test to find its distribution and due to data skewness original data of mean of total writhing reaction in mice was transformed into a new data to meet the criteria of parametric test anova..the formula used was ((√ (x+1)). the new data has been recorded in table 1. table 2 showed a presence of significant difference t in each group with significant value of 0.000 (p<0.05). post hoc test by using tukeyy hsd method was conducted to find out in which group the significant difference can be found (table 3). all three experimental groups showed significant reduction in total number of writhing response comparing to control group (table 3). it means that the analgesic activity was significantly different from the control group (p<0.05), while in three experimental group, there was only a significant difference between group 2 and 3 (p<0.05). pineapple fruit juice with concentration of 40% show ed the most protective effect as an analgesic than other,which was 71.8 %. ainul atiqah binti hilmi, vycke yunivita kd, henny anggraini sadeli: the analgesic effect of pineapple fruit juice on mice althea medical journal. 2014;1(2) 102 amj december, 2014 table 2 difference total writhing reaction between groups group 1 group 2 group 3 group 4 p mean of total writhing reaction in mice 2.39 1.92 1.50 1.66 0.000 then, it was followed by 80% concentration which was 61.6% and the last one was 20% pineapple fruit juice concentration which was 35.4% (table 4). discussion based on its pathophysiology, pain can be classified into three types which are somatic, visceral and neuropathic pain.8 somatic pain is usually located at the peripheral, visceral pain involves intra-abdominal organ, and neuropathic pain involves afferent neural pathway.8 this study was conducted to examine the analgesic effect of the pineapple fruit (ananascomosus) juice on the mice models. the analgesic reactions were measured by the total number of writhing in the mice every 5 minutes for 30 minutes. the mean of total writhing reaction in mice was decreasing from the mean group until group 3 which received 40% concentration of pineapple fruit (ananascomosus) juice and increased again in the group 4 when the mice in this group had 80% concentration of pineapple fruit juice (table 1). this condition showed that the pineapple juice had a ceiling effect. ceiling effect is a condition where at certain dosage, the drugs does not give any therapeutic effect instead this condition can increase the side effect.9because of the ceiling effect, 80% concentration of pineapple fruit juice show ed decreasing analgesic effect. there was a significant difference between control group and experimental groups which received 20%, 40, and 80% pineapple fruit juice concentration (table 2 and 3). it revealed that at all concentrations, pineapple fruit juice showed its analgesic effect by reducing the bradykinin synthesis. but there was only a significant difference between group 2 and 3 in the experimental groups. almost all analgesic drugs prevent the pge₂ formation by inhibiting the activity of cyclooxygenase (cox) which is the enzyme responsible for pge₂ synthesis.10 in establishing the analgesic effect, bromelain will decrease the bradykinin level released when tissue is damaged . bradykinin will stimulate the production of prostaglandin while prostaglandin in turn will enhance the sensitivity of bradykinin toward its receptor.2 when bradykinin is low, it also will decrease the pge₂ synthesis and decrease the pain.11 moreover, comparison between group 2 (20% concentration of pineapple juice) and group 3 (40% concentration of pineapple juice) revealed a significant difference . from the protective percentage measurement, the result show ed that pineapple fruit juice with concentration of 40% ha d the most protective result. previously, there had been studies upon the effect of bromelain extract of pineapple stems towards the analgesic reaction in mice. the chemical constituent responsible for analgesic effect is known as bromelain which is a proteolytic enzyme. this active compound table 1 mean of total writhing reaction in mice groups mean of total writhing reaction in mice sd 1 2.39 0.40 2 1.92 0.26 3 1.50 2.13 4 1.66 0.11 note: group 1 : given aquades group 2 : given 20% pineapple fruit juice concentration group 3 : given 40% pineapple fruit juice concentration group 4 : given 80% pineapple fruit juice concentration althea medical journal. 2014;1(2) 103 table 3 post hoc test by tukeyy hsd method group comparison p sd 1 2 0.023 1 3 0.000 1 4 0.000 2 3 0.042 2 4 0.310 3 4 0.696 note: group 1 : given aquades group 2 : given 20% pineapple fruit juice concentration group 3 : given 40% pineapple fruit juice concentration group 4 : given 80% pineapple fruit juice concentration is present in the stem as well as in the fruit. from the data in this study, we can conclude that the pineapple fruit also has an analgesic activity like the stem. but to ensure the safety issue, several studies should be addressed to reveal the side effect, toxicity, minimum and maximum dosage of pineapple fruit as an analgesic. other studies can also be conducted to compare the pineapple fruit to other non– opioid analgesic that are commonly used in the community such as paracetamol and ibuprofen references 1. continuum health partners.definition and type of pain.[online web page] 2011 [cited 2012 april 15]. available from: http:// www.healingchronicpain.org/content/ introduction/definitions.asp. 2. bueno l, fioramonti j. visceral perception: inflammation and non-inflammatory mediators.bmj. 2002;51(suppl1): s19−23. 3. sudjarwo sa. anti-inflammatory and analgesic effect of bromelain in mice and rats.universa medicina. 2005;155–60. 4. bhattacharyya bk. bromelain: an overview. nat prodradiance.2008;7(4):359−63. 5. bueno l, fioramonti j, garcia-villar r. visceral afferent pathways: a source of new therapeutic targets for abdominal pain. aps. 2000;278(5):670−6. 6. smith a. fasting in rodents. norecopaveterinaer institute; 2009[cited 2012 may 8]. available from: http://www. norecopa.no/norecopa/vedlegg/fooddeprivation.pdf. 7. sureshkumar s, sivakumar t, chandrasekar m, suresh b. investigating the antiinflammatory and analgesic activity of leaves of wedeliachinensis (osbeck) merr. in standard experimental animal models. ijpr. 2006;5:123−9. 8. cole be. pain management: classifying, understanding, and treating pain. hosp phys. 2002;23−30. 9. aschenbrenner ds, venable sj. drug in nursing. 3rd ed. philadelphia: lippincott william & wilkins; 2009. 10. vane jr, botting rm. the mechanism of action of aspirin.thrombres. 2003;255−8. 11. brien s, lewith g, walker a, hicks sm, middleton d. bromelain as a treatment for table 4 protective percentage against 3% acetic acid group total writhing protective percentage (%) aquades 206 0 20% pineapple juice 133 35.4 40% pineapple juice 58 71.8 80% pineapple juice 74 61.6 ainul atiqah binti hilmi, vycke yunivita kd, henny anggraini sadeli: the analgesic effect of pineapple fruit juice on mice althea medical journal. 2014;1(2) 104 amj december, 2014 osteoarthritis: a review of clinical studies. evid based complement alternat med. 2004;1(3):251−7. althea vol 2 no 3 final.indd althea medical journal. 2015;2(3) 319 characteristics of patient with brachial plexus injury in neurophysiology laboratory of dr. hasan sadikin general hospital bandung, indonesia, from 2003 to 2012 ivan kurnianto,1 nani kurniani,2 arifin soenggono3 1faculty of medicine universitas padjadjaran 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: brachial plexus is a network of nerves that controls the upper limb. unfortunately, it can be injured easily which is called brachial plexus injury (bpi). it can cause disability. until now, the epidemiology of bpi in indonesia is still lacking. the aim of this study was to describe the characteristics of patients with bpi in bandung, in order to increase knowledge and attention of health care provider and community to prevent bpi. methods: this was a descriptive retrospective study. data from medical records of patients with bpi who underwent electromyography (emg) in neurophysiology laboratory dr. hasan sadikin general hospital, bandung from 2003 to 2012 were collected. the data included age, sex, mode of injury, affected side and distribution of paralysis. collected data were presented as percentages shown in tables. results: a total of 91 cases were collected during study period, which consisted of 69 males and 22 females (76% vs. 24%). most of them were in productive age group (11−20 years and 21−30 years). the main cause of brachial plexus injury was traffic accident (76%), followed by birth injury. distribution of paralysis was mostly in postganglionic area of cervical (c)5, c6, c7, c8 and thoracal (t)1 (67%). around two third of the cases involved the right side of upper limb. conclusions: the study showed that most of patients with bpi are male in their productive ages. traffic accident is the most common cause, and the most affected side is the right side of upper limb. [amj.2015;2(3):319–23] keywords: birth injury, brachial plexus injury, traffic accident correspondence: ivan kurnianto, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 857 1899 9864 email: ivan.kurnianto@gmail.com introduction brachial plexus injury (bpi) is one of the peripheral nerve disorders characterized by lesion in the brachial plexus. bpi can cause disability, and its manifestations are diverse, ranging from movement disorders to arm deformation. mode of injury and location of the nervous damage determine the clinical manifestations.1 the bpi can be caused by trauma (contusion and avulsion), compression, radiation, and surgery.1 according to mckinley et al2, the prevalence of bpi is 10% of the total peripheral nerve disorders and the incidence increases every year. the increasing number of cases is likely due to an increasing number of traffic accidents both in developed and developing countries. according to a study in india3, there are 94.4% cases of bpi caused by traffic (motor vehicle) accidents. the epidemiological study revealing the characteristics of patient with bpi is important, as it can be a tool to increase public awareness and service of care providers for this disease. there are some epidemiological studies in bpi, but the data are limited in indonesia. furthermore, studies of bpi put more emphasis on the incidence of bpi due to birth injury rather than describing the incidence of bpi in adult population. the aim of this study was to describe the characteristics of patients with bpi between 2003 to 2012 in the neurophysiology laboratory of dr. hasan sadikin general hospital bandung. althea medical journal. 2015;2(3) 320 amj september, 2015 methods the total population of medical records of patient with bpi who underwent electromyography (emg) for the first time in the neurophysiology laboratory of dr. hasan sadikin general hospital bandung from january 2003 to december 2012, were included in this study. it concluded 91 medical records. data were retrieved from medical records and archives of emg results, including age, sex, mode of injury, affected side and distribution of paralysis. the collected data were analyzed using descriptive statistical analysis. frequency distribution and percentage of the mentioned variables were calculated. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. results in this study, almost half of the cases of bpi were found in teenager and young adult (11−20 years and 21−30 years), i.e. 25% and 23%, respectively. in total, there were 63patients (69%) who were in productive age group (11−50 years). there were 52% of male patients in this study who were in productive table 1 the age group and sex distribution of the patients age in years sex n % male female <1 4 3 7 8 1−10 2 4 6 7 11−20 16 7 23 25 21−30 20 1 21 23 31−40 12 2 14 15 41−50 4 1 5 5 51−60 5 3 8 9 61−70 5 0 5 5 71−80 1 0 1 1 81−90 0 0 0 0 91−100 0 1 1 1 total 69 (76%) 22 (24%) 91 100 table 2 distribution of affected side and level paralysis level of paralysis affected side n % right left c5, c6, c7, c8, t1 (postganglionic) 40 21 61 67 c5, c6, c7, c8, t1 (preganglionic) 1 1 2 2 c5, c6 and c8, t1 2 0 2 2 c5, c6 (superior) 12 5 17 16 c8, t1 (inferior) 3 2 5 9 c5, c6, c7 2 0 2 2 c6, c7, c8, t1 1 0 1 1 c7, c8, t1 0 1 1 1 total 61 (67%) 30 (33%) 91 100 althea medical journal. 2015;2(3) 321 age (11−30 years old). male female ratio of bpi in this study was 3:1 (table 1). traffic accident was the most common cause of bpi, and accounted for 69 patients (76%). in addition, there were 22 patients who suffered bpi not caused by traffic accident. there were ten patients with history of birth injury, four patients fell from height, four neuropathy patients, two patients carried a heavy backpack, one patient had radical mastectomy, and one patient had working injury. most lesions in this study were global plexus palsy that involved postganglionic of cervical (c)5, c6, c7, c8 and thoracal (t)1 which was accounted for 61 patients (67%). the ratio between postganglionic and preganglionic of global palsy is 61:2. in this study, the patient with c5, c6 (superior) bpi was more than c8, t1 (inferior) bpi. the right side was involved more than the left side (table 2). the bpi related to traffic accident had lesion that were mostly postganglionic in c5, c6, c7, c8, t1 (n=52; 57%). two patients carrying heavy backpack had the lesion in c5, c6 (superior brachial plexus). all patients with radical mastectomy had lesion at postganglionic of global palsy sites namely, c5, c6, c7, c8, t1. the most common lesion in patients with neuropathy was c5, c6 (superior brachial plexus). there was a balanced distribution of lesions between postganglionic of global palsy sites namely, c5, c6, c7, c8, t1 and c5, c6 (superior brachial plexus) in patients with birth injury and fall from height (table 3). discussion brachial plexus is a part of peripheral nerve that combines and forms a network structure consisting of the root, trunk, division and cord. the final branches of brachial plexus are the five major nerves, i.e. the axillary nerve, musculocutaneous nerve, median nerve, radial nerve, and the ulnar nerve.1,4 epidemiology of bpi in different area in the world is various. in this study, 69% patients were in the productive age (11−50 years), and 76% of the total study population were male. this is consistent with three studies that have been conducted in western countries. according to steven et al.5, doi et al.6 and dubuisson7, most patients with bpi are men aged between 15−25 years old. the similar results have been submitted by darshan et al.3 and kaewpralad et al.8 who conducted the studies of bpi in asia. according to darshan et al.3 most of patients with bpi in india between 2002 to 2011 are male in the productive age group (21−30 years). according to kaewpralad et al.8, out of 178 patients with bpi, 156 of them were male with an average age of 29.6 years in thailand. the bpi could be caused by the events of traction, compression, radiation and surgery. traction is an attracted or detached (contusions) root of brachial plexus due to an increase in the distance between the head and the shoulder. as much as 95% of patients with bpi are caused by traction events.9 traction events are mostly caused by traffic accidents, but it could be also caused by birth injury, table 3 distribution of level paralysis and mode of injury mode of injury level of paralysis n %c5−t1 c5−t1 c5, c6 c5, c6 c8, t1 c5−c7 c6−t1 c7−t1 (post) (pre) c8, t1 (sup) (inf ) traffic accident 52 2 2 7 4 2 0 0 69 76 birth injury 4 0 0 4 1 0 0 1 10 12 fall from height 2 0 0 2 0 0 0 0 4 4 neuropathy 1 0 0 2 0 0 1 0 4 4 radical mastectomy 1 0 0 0 0 0 0 0 1 1 carrying heavy backpack 0 0 0 2 0 0 0 0 2 2 working injury 1 0 0 0 0 0 0 0 1 1 total 61 2 2 17 5 2 1 1 91 100 ivan kurnianto, nani kurniani, arifin soenggono: characteristics of patient with brachial plexus injury in neurophysiology laboratory of dr. hasan sadikin general hospital bandung, indonesia, from 2003 to 2012 althea medical journal. 2015;2(3) 322 amj september, 2015 fall or accident involving the shoulder. this is consistent with the results of this study. the most causes in patients with bpi who performed emg examination in this study were caused by traction from traffic accidents, accounted for 69 people (76%). traffic accident became the main cause of bpi because there were a huge of energy to make distance between arm and neck. the principal factors determining the extent of injury are the energy imparted by the blow and to a lesser degree, the direction and the relationship between arm and neck during the injury.10 the result is consistent with theories for the characteristics of patients with bpi proposed by narakas11 that 70% of cases of bpi were caused by traffic accidents and 70% were associated with motor accidents. the results of this study are also in accordance with the results of a national survey for bpi in india. there were 94.4% cases of bpi in india3 caused by road traffic accidents from 2002 to 2011. in this study, there were 10 patients (11%) who had lesion caused by birth injury, therefore birth injury became the second most frequent cause of bpi in this study. the incidence of birth injury of the plexus has been reported as between 3.6 cases per 1000 live birth.12 bilateral bpi due to birth injury are seen almost exclusively in the setting of breech presentation, in which traction on both shoulder may be applied to deliver the head. in another side of traction, brachial plexus injuries have been reported in cardiac surgery, orthopedic, schwannoma and general surgery as well as breast reconstruction.13,14 there is a wide variety of distribution of paralysis from bpi. it can occur due to differentiation of topography from each branch of nerve and the process of injury. the length of the root and the angle between root and spinal cord is influencing the lesion of bpi. according to measurement of sunderland in 1976, the length of each root is different. the length of c5, c6, c7 are 15mm, c8 17 mm, t125mm and each angle of the root of the brachial plexus is c5 1380; c61230; c7 1140; c81000; t1850.4 in this study, the distribution of lesion mostly occurred at postganglionic of c5, c6, c7, c8, t1 or global palsy on the right arm. the right arm as a dominant arm was found to be the most commonly injured (67%), which might be partially caused by the fact that the right arm as dominant arm has a reflex for protection. the lesion at postganglionic is more than preganglionic of c5, c6, c7, c8, t1 (ratio=61:2). lesion on preganglionic of brachial plexus occurs if there is an avulsion proximal to dorsal root ganglion that involves central nervous system that causes preganglionic lesion has worse prognosis than postganglionic lesion.15 in this study, 85% cases were caused by traffic accidents; and in 61 patients with lesion on c5, c6, c7, c8, t1 postganglionic, since in traffic accidents has occurred the traction, impaction and compression of the body that caused an extensive damaged of brachial plexus. seventeen patients had lesion at c5, c6 (superior of brachial plexus) or erb’s palsy. the distribution of erb’s palsy was more in patients with traffic accidents and birth injury.16 according to measurement of sunderland, c5 and c6 have the short length of ramus. it makes nerves become more susceptible to damage when the traction occurred.4 there was one patient (1%) with radical mastectomy in this study. actually, injuries to the brachial plexus during mastectomy and axillary dissection are rare.17 the cause of bpi during mastectomy are direct surgical injuries to the brachial plexus, over-traction during axillary exploration, or over manipulation of the upper extremity in order to improve exposure.18 this study has some limitations. it was conducted only in one hospital, which may not reflect the real epidemiology of bpi in general population. moreover, the collected data were from medical records. this situation caused the researcher could not explore deeper about the sort of vehicles used by patients, who were the birth attendants, fell from how many metres, what was the occupation of the patients, etc. it can be concluded, most of the patients with bpi are in productive age group (11−20 years and 21−30 years). the main cause of brachial plexus injury is traffic accident (76%), followed by birth injury. furthermore, distribution of paralysis is mostly in postganglionic area of cervical (c) 5, c6, c7, c8 and thoracal (t)1 (67%). around two third of the cases involves the right side. efforts need to be conducted to lower the incidence of traffic accident and birth injury. references 1. moore kl. clinically oriented anatomy. 6th ed. philadelphia: lippincott williams & walkins; 2010.p. 721−26. 2. mckinley wm. brachial plexopathies. [online serial] 2013 [cited 2013march5]. available from: http://www.pmr.vcu.edu. 3. jain dk, bhardwaj p, venkataramani h, sabapathy sr. an epidemiological study of althea medical journal. 2015;2(3) 323 traumatic brachial plexus injury patients treated at an indian centre. indian j plast surg. 2012;45(3):498−503. 4. snell rs. organisasi susunan saraf. in: sjamsir, editor. neuroanatomi klinik. jakarta: buku kedokteran egc; 2005.p. 1−26. 5. moran sl, steinmann sp, shin ay. adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis. hand clin. 2005;21(1):13−24. 6. doi k, muramatsu k, hattori y, otsuka k, tan sh, nanda v, et al. restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. indications and long-term results. j bone joint surg am. 2000;82(5):652−66. 7. dubuisson as, kline dg. brachial plexus injury: a survey of 100 consecutive cases from a single service. neurosurgery. 2002;51(3):673−82. 8. kaewpralad n, srisawasdi g. retrospective study of brachial plexus injured patients at siriraj hospital. j thai rehabili med. 2009;19(1):25−9. 9. songcharoen p, shin ay. brachial plexus injury: acute diagnosis and treatment. in: berger ra, weis apc, editors. hand surgery. philadelphia:lippincott williams & wilkins; 2004.p. 1005–25. 10. kandanwein ja, kretschmer t, engelhardt m, ritcher hp, antomiadis g. surgical intervention for traumatic lesions of the brachial plexus: retrospective study of 134 cases. j neurosurg. 2005;103:614−21. 11. narakas ao, hentz vr. neurotizationin brachial plexus injuries indication and results. clin orthop relat res. 1988;237:43−56. 12. evan jg, kay sp, weindling am, cranny g, ward a. congenital brachial palsy: incidence, causes, and outcome in united kingdom and republic of ireland. arch dis child fetal neonatal. 2003;88(3):185¬−89. 13. zhang j, moore ae. stringer: introgenicupper limb nerve injuries: a systematic review. anz j surg. 2011;81:227−36. 14. rashid m, salahuddin o, yousaf s, qazi ua, yousaf k. schwannoma of the brachial plexus; report of two cases involving the c7 root. j brachial plex peripher nerve inj. 2013;8:12−16. 15. taylor p. traumatic intradural avulsion of the nerve roots of the brachial plexus. brain. 2009;132(5):1121−23. 16. qattan am, sayed af, zahrani ay, mutairi sa, harbi ms, mutairi am, et al. narakas classification of obstetric brachial plexus palsy revisited. j hand surg. 2009;34(6):788−91. 17. wu jd, huang wh, huang zy, chen m, zhang gj. brachial plexus palsy after a left-side modified radical mastectomy with immediate latissimus dorsi flap reconstruction: report of a case. world j surg oncol. 2013;11(1):276. 18. godfrey pm, godfrey nv, fast a, kemeny m. bilateral brachial plexus palsy after immediate breast reconstruction with tram flaps. plast reconstr surg.1994;93(5):1078−9. ivan kurnianto, nani kurniani, arifin soenggono: characteristics of patient with brachial plexus injury in neurophysiology laboratory of dr. hasan sadikin general hospital bandung, indonesia, from 2003 to 2012 althea medical journal. 2015;2(3) 448 amj september, 2015 rural and urban differences in the eye health of high school students andi kusnawan,1 ine renata musa,2 jimmy setiadinata3 1faculty of medicine, universitas padjadjaran, 2department of ophthalmology, faculty of medicine, universitas padjadjaran/national eye center, cicendo eye hospital, bandung,, 3departement of physiology, faculty of medicine, universitas padjadjaran abstract background: visual impairment is a serious health problem. the world health organization (who) estimates that 80% of the incidence of visual impairment occurring globally could be prevented or treated. several factors responsible for high rates of uncorrected refractive errors are the lack of awareness about the early detection on the unequal distribution regarding health services and a culture of compliance. this study was aimed to identify the differences of the level of visual acuity and self-perception of the visual functions between high school students in the urban and rural areas. methods: a cross sectional study was conducted among 94 high school students in two different schools, urban and rural areas during november 2012, using the simple random sampling technique. the study was performed through interviews and examination of visual acuity using rapid assessments of avoidable blindness. the collected data were analyzed using mann-whitney test. results: a total of 93.6% of respondents had good visual acuity. self-perception of the visual functioning test showed that most respondents gave good answer. the statistical test using mann-whitney showed that there was no difference in level of visual acuity and self-perception of visual function between urban and rural students (p>0.05). conclusions: most of the high school students have good visual acuity and good self-perception of their visual function but there is no difference between rural and urban areas. [amj.2015;2(3):448–52] keywords: high school students, rural, self-perception regarding visual function, urban, visual acuity. correspondence: andi kusnawan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285723982556 email: andikusnawan@yahoo.com introduction visual impairment is a serious health problem occurring worldwide. the world health organization (who) estimates that approximately 314 million people are visually impaired and 45 million of them are blind. who estimates that 80% of the incidence of visual impairment can be prevented or treated.1,2 refractive error is one of the visual impairments that is common and easy to diagnose and can be corrected using glasses or contact lenses. in line with this, refractive errors can be detected by routine screening at a clinic or can also be screened in communities such as screening that was done at school.2-4 however, there are still obstacles in handling such cases. moreover, there is still lack of patient awareness regarding the vision problems several factors responsible for high rates of uncorrected refractive errors are the lack of awareness and early detection of the problem regarding visual impairment in the community. unequal distribution of health services in each region and the lack of a culture of compliance also remains an obstacle that contributes to this problem.2 however, in developing countries, socioeconomic and cultural factors prevent or hinder children from having access to ophthalmologic examination before school entry. unfortunately, the public health system in these countries does not provide children with easy access to such examination. thus, the implementation of screening programs of visual acuity in students is a great opportunity althea medical journal. 2015;2(3) 449 to evaluate their eye health and, sometimes, it is the first and rare chance of vision assessment for most students.3 indonesia is still facing the problem of health care distribution, which has not been equally disseminated. it also occurs on the aspects of eye health care. there is a deficiency in the number of ophthalmologists and an uneven distribution across regions in indonesia. furthermore, the indonesian health minister stated that 54 percent of ophthalmologists were gathered on java island and the rest were scattered on other islands of indonesia. this condition can lead to different level of eye health care services in certain areas and could result in different eye health level between areas in this country.5,6 this study aimed at determining whether there are differences in the level of visual acuity and self-perception of the visual function in high school students in the urban and rural areas, who do not use a refractive correction device. methods this is a cross sectional study, and was conducted to school children in two different high schools, an urban high school in bandung and a rural high school in sumedang. this study was conducted during november 2012. the participants of this study were students of a rural high school and an urban high school. urban and rural high schools were assumed to have differences in eye health care service provider coverage. this could be seen from the distance of each high school to a nearby eye health care service; from urban high school, it was only as far as 1.1 km whereas from rural high school it was as far as 14.6 km. the participants were only the students of urban high school and rural high school who did not use a refractive error correction device, eyeglasses, or contact lens. from urban high school, there were 325 students and 299 students from rural high school who did not use a refractive error correction device. those who did not follow the research until finished and had a history of surgery involving the media refractive were excluded. respondents from each high school meeting the inclusion and exclusion criteria for this study would be selected randomly. the minimum sample size for this study was 31 participants from each high school. the proportion of children visual impairment in previous studies was 9.32% and 30% of minimal proportion difference, with power test of 80% and 5% of significance level. visual acuity was measured using the rapid assessments of avoidable blindness (raab) technique. this technique used a chart with an “e” optotype size 18 of the snellen chart and an “e” optotype size 60. on examination, respondents were asked to read the chart at 6 or 3 meters distance on each eye, right eye and left eye. from this examination visual acuity 6/18, 6/60, and 3/60 will be obtained7. self-perception of the visual function was measured using the who prevention of blindness and deafness (pbd) visual functioning questionnaire which has been validated. the questionnaire consists of 20 questions covering information regarding the respondent’s characteristics and perception about visual function. the information included name of the student, age, gender and address. perception about visual function asked were about general vision, ocular pain or discomfort, distance vision difficulty, near vision difficulty, glare, light or dark adaptation, color vision difficulty, role limitations, and social functioning.8 table 1 demographic data characteristics rural high school urban high school n=48 % n=46 % gender male 21 43.8 24 52.2 female 27 56.3 22 47.8 age 14 year 2 4,2 6 13 15 year 31 64.6 34 73.9 16 year 15 31.3 6 13 andi kusnawan, ine renata musa, jimmy setiadinata: rural and urban differences in the eye health of high school students althea medical journal. 2015;2(3) 450 amj september, 2015 results ninety-six (96) high school students participated in this study. the respondents consisted of 48 students (51.1%) from rural high school and 46 students (48.9%) from urban high school. the age of the students ranged from 14 to 16 years-old, most of them were 15 years-old. thirty-one (31) students (64.6%) were from rural high school and 34 students (73.9%) were from urban high school. the numbers of male and female participants were almost equal. table 1 systematically provides information regarding the characteristics of the studied participants. the results of visual acuity measurements show that almost all students had normal visual acuity 6/18 in both eyes. normal visual acuity of 6/18 in both eyes was found in 88 (93.6%) students. visual acuity 6/60, in at least one eye, was found in 6 (6.4%) students. table 2 shows visual acuity from rural high school and urban high school. according to the location of the occurring visual impairment, there were four students with impaired vision in both eyes and two students with impaired vision in only one eye. the number of students who had impaired vision in urban high school were four students whereas at rural high school were two students. self-perception of high school students regarding visual function in general was at good level. only nine students stated that their conditions were very good. the rest stated that their conditions were good to bad. table 3 systematically provides information about the distribution of data on self-perception according to the median, maximum, and minimum. the mann-whitney test for comparison of the visual acuity in rural high school and urban high school was p = 0.372. the results demonstrate that visual acuity in both schools did not have significant difference. in general, self-perception of the visual function did not show any significant differences in both high schools. the mann whitney test showed p values were generally greater than 0.05. however, comparisons to questions regarding light or dark adaptation, the mann whitney test showed p = 0.026. discussion in this research, the level of visual acuity in both high school students almost (93.6%) showed normal conditions. this might occur because the subjects in this study were high school students who did not use refractive correction devices. children in the age range 14 to 16 years-old are the middle adolescence.9 at this level, a child can express feelings that occurred to him, including those t to his eyes. therefore,if there is abnormality in their body, including in the eye condition, they will immediately consult or complain to someone, either to teachers or parents. if this has been consulted, eye disorders may be corrected immediately. the number of students who had visual impairment in urban high school were four students and two students at rural high school. according to the mann whitney test there was no significant difference in visual acuity between urban high school and rural high school students. in the concept of public health, several factors can affect the level of health. these include genetics, social environment, social and economic status, health service, and behavior.10 self-perception of the visual function performed in both high schools in this study showed no significant difference. it is shown in the assessment of the condition of the eyesight. students in both high schools had given similar answer. most of them answered that their eyesight was in good condition which is in accordance with the results of visual acuity tests showing that 93.6% of the respondents have visual acuity in good condition. data collection was performed in table 2 visual acuity visual acuity rural high school n=48 urban high school n=46 two eyes one eye two eyes one eye 6/18 46(95.8%) 1(2.08%) 42(91.3%) 3(6.52%) 6/60 1(2.08%) 1(4.16%) 1(2.17%) 3(6.52%) 3/60 0 (0%) 0(0%) 0(0%) 0(0%) althea medical journal. 2015;2(3) 451 table 3 self perception about visual function variable median minimum maximum mann whitney test p general vision how would you rate your eyesight using both eyes? good very good bad 0.872 ocular pain/discomfort do you have pain or discomfort e in your eyes? moderate none severe 0.414 distance vision difficulty difficulty in going down steps or stairs none none moderate 0.140 difficulty in noticing obstacles while walking alone none none moderate 0.330 difficulty in doing activities outside of the house? none none moderate 0.656 difficulty in recognizing people from a distance of 20 mete none none severe 0.341 difficulty in seeing irregularities in the path when walking none none moderate 0.247 near vision difficulty difficulty in searching for something on a crowed shelf none none moderate 0.449 difficulty in seeing the level in a container when pouring none none moderate 0.420 difficulty in seeing close objects none none severe 0.747 difficulty in doing activities that require you to see well close up none none moderate 0.758 glare difficulty in seeing because of glare from bright lights? mild none severe 0.474 light/dark adaptation difficulty in seeing when coming inside after being in bright sunlight mild none extreme 0.026 color vision difficulty difficulty in seeing differences in colors none none moderate 0.131 role limitations difficulty in carrying out usual work none none severe 0.794 social functioning limitations hesitant to participate in social functions never never often 0.238 dependency felt that you are a burden on others never never often 0.578 mental well-being embarrassed because the condition of the eye never never often 0.447 worry about losing sight never never very often 0.524 andi kusnawan, ine renata musa, jimmy setiadinata: rural and urban differences in the eye health of high school students althea medical journal. 2015;2(3) 452 amj september, 2015 conjunction with student’s academic hours. that condition lead to the data collection process in this study, which was not a randomized in all classes. due to the limitations of the research competences of the instruments used to measure visual acuity, the instruments could only pass judgment on the cut of point of visual acuity condition, normal, and visual impairment. in conclusion, there is no difference in visual acuity between the students in rural high school and in urban high school. there was also no difference between self-perception of the visual function in both high schools. although there were no significant differences, some students still had poor visual acuity level. the level of visual acuity or visual impairment can be affected by other factors such as genetic. this factor causes abnormal refractive media condition or daily behavior; such as the habit of looking at the screen intensely, the intensity of reading books, and the position when reading a book. therefore, routine screening program organized by the school in collaboration with the school health unit (usaha kesehatan sekolah/uks) and public health center (pusat kesehatan masyarakat/puskesmas), should have some improvements. henceforth, the students who have visual acuity in bad condition should be provided with further examination and correction refractive device. although this study has been answered and the conclusion has been drawn, this study is still open for further analysis. it could be achieved by using different research methods or different measurements methods and with more respondents included in the study. references 1. who. action plan for the prevention of avoidable blindness and visual impairment 2009–2013. geneva: who library cataloguing data; 2010. 2. who. sight test and glasses could dramatically improve the lives of 150 million people with poor vision. [cited 2012 april]; available from: http:// w w w. w h o . i n t / m e d i a c e n t r e / n e w s / releases/2006/pr55/en/. 3. toledo cc, paiva apg, camilo gb, maior mrs, leite icg, guerra mr. early detection of visual impairment and its relation to academic performance. brazil; 2010 (cited agustus 2015). available from http:// www.scielo.br/pdf/ramb/v56n4/en_13. pdf 4. ilyas s, yulianti sr. ilmu penyakit mata. 4thed. jakarta: badan penerbit fkui; 2011. p. 72–82. 5. mikail b. masih dibutuhkan banyak dokter mata. padang: kompas.com; 2012 [cited 2012 december] available from: http://health.kompas.com/ re a d / 2 0 1 2 / 0 1 / 1 2 / 1 0 2 3 4 7 4 3 / m a s i h . dibutuhkan.banyak.dokter.mata 6. indonesia kekurangan banyak dokter mata. jakarta; 2012 [cited 2012 december] available from : http://m.pikiran-rakyat. com/node/214335 7. limburg h, meester w. rapid assessment of avoidable blindness (raab) instruction manual. london: international centre for eye health london school of hygiene & tropical medicine; 2007:20-22. 8. who. consultation on development of standards for characterization of vision loss and visual functioning. geneva: who; 2003; [cited 2012 april]; available from: http://www.who.int/ ncd/vision2020_actionplan/documents/ visualstandardssept03report.pdf. 9. sadock bj, sadock va. kaplan & sadock’s synopsis of psychiatry. 10thed. philadelphia: lippincott williams & wilkins; 2007. p.38. 10. who. the determinants of health. who; [cited 2012 december]; available from: http://www.who.int/hia/evidence/doh/ en/. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 147 creatine phosphokinase and visual analogue scale as indicators for muscle injury in untrained bodybuilders suresh shanmugam,¹ reni farenia,² nina tristina³ 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine universitas padjadjaran, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: skeletal muscle is a vital tissue in the human body to enable breathing, walking and performing several sports activities. however, this muscle is persistently injured throughout every sports session. some exercises demand a muscle injury occurrence in order to build a stronger muscle through an adaptation process namely bodybuilding exercise. importantly, every muscle injury should occur within a physiological range which can be identified by several biomarkers as well as pain scale. the aim of this study was to identify changes on the level of creatine phosphokinase (cpk) and visual analogue scale (vas) between pre and post training sessions and the correlation between these two indicators. methods: this was an observational analytical cross sectional comparison study which was conducted in october 2012 and the subjects were adult untrained bodybuilders at the jatinangor fitness center. the data was obtained by measuring serum cpk and marked vas. the data were analyzed by t-test, wilcoxon’s test and spearman’s correlation. results: both cpk and vas increased significantly by 296 u/l and 19.9 mm respectively. there was a strong positive significant correlation between vas and cpk (p=0.01, r = 0.711). conclusion: the healthy untrained bodybuilders chosen in this study experienced a mild (<2000 u/l) muscle injury throughout the training sessions with general increased cpk levels and vas measurement. [amj.2015;2(1):147–52] keywords: infra orbital foramen, palpation technique, superfacial marking technique correspondence: suresh shanmugam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170208187 email : suresh2889@yahoo.com.my introduction skeletal muscle is vital tissue in the human body as its function is to enable the body to perform various activities including sports. however, this muscle is persistently injured throughout every exercise session which requires high force eccentric and concentric contractions and this is even magnified in an unaccustomed exercise. thus, muscle injury is initiated with physical disruption of muscle components involving in generating and transmitting force1. there are many impacts on skeletal muscle during strenuous exercises including disruption of sarcomeres, cytoskeleton component, injury to muscle cell membrane and impairment of excitation contraction coupling process which eventually cause the loss of muscle ability to produce sufficient force. besides that, there will be increase in resting intracellular calcium level, presence of inflammatory reaction which causes breakdown of muscle content comprising of cell proteins and enzymes2. however, the injured skeletal muscle will return to normal condition through repairing process if the injury occurs within physiological range. bodybuilding exercise is a type of exercise that demands muscle injury occurrence through resistance training in order to build stronger muscle by adapting to increasing training intensity.2 the adaptation process is very important in untrained bodybuilders or the beginners, as this period is imperative in giving appropriate precursor for the occurrence of muscle adaptation. in the acute phase of adaptation which occurs during exercise and immediately after the end of exercise it causes muscle soreness as well as increased serum level of intracellular enzymes and release of muscle fiber content into circulation. currently, there is althea medical journal. 2015;2(2) 148 amj june, 2015 no clear consensus regarding the exact level of biomarkers level in determining overtraining status in untrained bodybuilders.3 creatine phosphokinase (cpk) enzyme is able to breakdown creatine by consuming adenosine triphosphate (atp) to form phosphocreatine which gives high energy to skeletal muscle aiding in producing greater force. besides that, this enzyme is often used as serum biomarker for detecting muscle injury with high sensitivity, and its ability to stay in circulation for 24 hours to 48 hours compare to other biomarkers.4 the normal level of cpk is <200 u/l but the elevation of cpk is considered normal in exercise, however it can be further classified into mild (<2000 u/l), moderate (2000-10,000 u/l) and severe (>10,000 u/l). no studies so far have established a normal range following an exercise period but the risk of kidney injury occurs when the level of cpk is above 6000 u/l.5 the evaluation of muscle soreness that becomes prominent after exercise can be performed using the visual analogue scale (vas) which is helpful in assessing pain intensity by marking on a vertical line of 10 cm line with both clearly marked edges.6 based on these, this research was conducted to evaluate the level of cpk and vas value before and after bodybuilding exercise in untrained bodybuilders as well as to find correlation between cpk and vas in untrained bodybuilders. methods the research was approved by the health research ethic committee of faculty of medicine, universitas padjadjaran. inform consent was obtained from 12 male untrained bodybuilders aged 17 ̶20 years old. the bodybuilders were chosen with the criteria of minimum 8 hours training per week during one month and the attendance was taken throughout their training sessions. all the subjects were refrained to participate in any strenuous activity 24 hours prior to measurement as well as history of simvastatin drug intake and alcohol consumption prior to measurement. besides that, the subjects who participated in this study were free of supplement usage during one month. an appropriate and experienced lab assistant was chosen for withdrawing blood samples. venous blood samples (3 cc) from brachial vein were obtained before and after bodybuilding exercise. the subjects underwent 1.5 hours training using maximum repetition (1rm) technique for 3 sets comprises 5 kg,10 kg, 12 kg until failure with minimum of 8 repetitions in each set. the subjects underwent training involving bench press, lateral raises, chest flyes, shoulder press, upright rows, leg curl, leg extension, leg press, pull-down, and crunches. the blood samples were analyzed on the same day of collection and the samples were stored at -20ºc until analysis using a spectrophotometer. the marked line by the subjects in vas was measured using a ruler in millimeter (mm). both blood samples for the cpk examination and vas measurement were taken 30 minutes before exercise and at 24 hours after exercise to measure pre and post measurements, respectively. besides that, heart rate (hr) and blood pressure (bp) were also taken before and after exercise period. the flow of research is depicted in figure 1. the data were analyzed by shapirowilk’s test, wilcoxon’s test, t-test, and spearman’s correlation statistical test between variables. results the data on cpk and bp were not normally distributed (p<0.05) whereas hr and vas were normally distributed with p>0.05. thus, data on cpk and bp were analyzed using wilcoxon’s test (non-parametric) and vas and hr using t-test (parametric). the median for pre cpk was 281 u/l, that was increased up to 577 u/l in post cpk (p=0.003). the result on the cpk data is shown in table 1. the mean for vas increased significantly (p<<0.001) from 31.7 mm in pre to 51.6 mm in post exercise. the difference of vas value between pre and post exercise was 19.9 mm and is shown in table 2. in addition, table 3 shows that the hr increased significantly about 39 beats/min table 1 result of wilcoxon’s test pre-post cpk for n=12 cpk (u/l) median min max range z p-value pre(30minutes) 281 143 6812 6669 2,981 0.003 post(24 hours) 577 275 34090 33815 althea medical journal. 2015;2(2) 149 figure 1 research flows suresh shanmugam, reni farenia, nina tristina: creatine phosphokinase and visual analogue scale as indicators for muscle injury in untrained bodybuilders althea medical journal. 2015;2(2) 150 amj june, 2015 or 36.4% (p<0.001) from pre to post exercise. table 4 shows data on bp revealed the systole increased from pre to post (p=0.034) whereas diastole increased about 5 mm/hg (p=0.009). the correlation between cpk and vas revealed that it was positively correlated in untrained body builders (r-value;-0.711; with strong correlation: p-value=0.01). discussions cpk is often used as marker to indicate muscle damage in athletes and most effective tools in evaluating sports performance.7 based on the cpk data, there were only 2 out of 12 untrained bodybuilders who had normal (<190 u/l) during pre-training period measurement with 143 u/l and 159 u/l respectively. though all the subjects had been chosen based on exclusion criteria, yet the cpk value before training sessions failed to return to normal level. however, this situation is considered normal for an individual who participates in resistance training comprises eccentric and concentric movements. besides that cpk elevation is still considered physiologic if the subjects never complain of renal failure symptoms such as decrease urine output or color changes as well as the cpk upper limit is less than 10,000 u/l.8 there was only 1 subject in this study who had the highest pre training cpk level with 6812 u/l. all the 12 subjects had significantly elevated cpk levels during post training measurements and mostly under mild (<2000 u/l) elevation except one subject who was under severe level of 34,090 u/l. though 1 subject had high pre training cpk and had severe elevated cpk post training, yet complains regarding renal failure symptoms was not encountered because kidney failure would not develop only based on cpk level because co-morbid situation such as sepsis, dehydration, and acidosis could contribute to this situation.9 majority of the subjects in this study had developed some point of adaptation to training with proven mildly elevated cpk level and adaptation period usually occurred within 4 to 10 days in the first week of training. the level of cpk in untrained bodybuilders is highly dependent on the period of rest between training sessions as this will reduce the lymphatic transport and release of enzyme from muscle fibers. besides period of rest, there are other factors such as intensity, training volume, hydration, and clearance level of cpk from blood systems. the elevation of cpk in this study was within physiological limit because all the subjects underwent training sessions without difficulties that debilitate them. physiologically, each training will damage skeletal muscle at the level of sarcolemma and z disks when the loading is higher than muscle ability.4,10 therefore, subjects with the highest level of cpk indirectly also indicate the lower muscle adaptation level, usually adaptation occurs with more recruitment of sarcomeres table 2 result of t-test for pre and post vas for n=12 hr (beats/min) standard deviation min max mean (x) range t p-value pre ± 23.7 2.0 80.0 31.7 78.0 4,834 <0.001 (30minutes) post ±18.7 19.0 93.0 51.6 74.0 (24 hours) table 3 result of paired t-test for pre and post heart rate (hr) for n=12 hr (beats/min) standard deviation min max mean (x) range t p-value pre ±6 62 80 68 18 11,710 <0.001 (10minutes) post ±13 90 132 107 42 (2 minutes) althea medical journal. 2015;2(2) 151 and signaling molecules.10 the adaptation to training can be obtained easily by increasing endurance training than strength training in early period as this will give good precursor for muscle development with appropriate amount of pro-inflammatory factors.10 almost all the untrained bodybuilders who underwent training exhibited some changes in vas though it was rather subjective compared to cpk. the soreness experienced by the subjects following training is due to presence of inflammatory mediators.11 the vas data showed average pain intensity increased from 31.71 mm to 51.75 mm post exercise. in pre training, some subjects showed to have lesser pain (<10mm) though some even had the highest level of pain with 80 mm. this is because the adaptation process and improper technique influence the soreness experienced by the subjects.11 the strong positive significant correlation existence between cpk and vas has been proven in this study. the subjects with the highest pre and post cpk level had shown to have the highest vas. the possible explanation is damage which occurs at sarcomere mainly at contractile filaments and z fibers causes excitation coupling dysfunctions and ends in loss of calcium homeostasis within skeletal muscle.12,13 eventually, this whole process initiates an autogenic process that results in elevated white blood cells and inflammatory mediators. these factors are able to damage the plasma lemma, endomysium, epimysium and perimysium which cause outpouring of muscle enzymes into circulation from proteolytic activity.1, 13 moreover, the substance released from an autogenic process are able to give stimulation to free nerve ending around muscle cells itself. therefore, the untrained bodybuilders who are still in an early period of bodybuilding exercise experience higher level of soreness and this highlights the importance for higher intensity of soreness in untrained bodybuilders to be evaluated for serum cpk level to measure severity of muscle damage.14 some subjects who exhibit small increase l of cpk and vas may have undergone great adaptation. the reason for adaptation lies in the level of reactive oxygen species (ros) produced of which higher level of ros may give negative effect to muscle adaptation process however this are areas still being studied.12, 13. the hr and bp both had increased significantly from pre to post training . the aim of taking these parameters was to evaluate the intensity level of training given in this study. the light intensity training which was suggested for untrained bodybuilders would increase the heart rate about 60–70%. however, in this study the increase was in a lower range suggesting heart rate arose mainly due to variety of subject’s adaptation level and period of rest between each set. the bp increased in this study was due to the need to supply the muscle with enough blood throughout training and bodybuilding training increases peripheral resistance by muscle force compression to peripheral arteriole.15 in conclusion, there was a significant increase in cpk level and vas from pre to post bodybuilding training in untrained bodybuilders. there was also a strong positive significant correlation between cpk and vas in untrained bodybuilders. based on this study, it is highly suggested to use these indicators to monitor and evaluate the progress of bodybuilders in fitness centers. besides that, the usage of vas as first line indicator followed by cpk as second line indicator in fitness centers will help to identify the effectiveness of fitness programs provided as well as help in identifying overtraining status among bodybuilders. if the cpk level is above 10,000 u/l it is better to stop physical activity for some period of time as this level suggests the subject is at the verge of developing overtraining status. references 1. crameri rm, aagaard p, qvortrup k, langberg h, olesen j, kjaer m. myofibre damage in human skeletal muscle: effects of electrical stimulation versus voluntary suresh shanmugam, reni farenia, nina tristina: creatine phosphokinase and visual analogue scale as indicators for muscle injury in untrained bodybuilders table 4 result of wilcoxon’s test on bp for pre and post (n=12) bp(mm/hg) median minimum maximum range z p-value pre systole 120 110 130 20 2.212 0.034 post systole 120 115 130 15 pre diastole 80 70 90 20 2.598 0.009 post diastole 85 75 90 15 althea medical journal. 2015;2(2) 152 amj june, 2015 contraction. j physiol. 2007;583(1):365– 80. 2. clarkson pm, hubal mj. exercise-induced muscle damage in humans. am j phys med rehabil. 2002;81(11):s52–69. 3. bloomer rj. the role of nutritional supplements in the prevention and treatment of resistance exercise-induced skeletal muscle injury. j sports med. 2007;37(6):519–32. 4. totsuka m, nakaji s, suzuki k, sugawara k, sato k. break point of serum creatine kinase release after endurance exercise. j appl physiol. 2002, 2002;93(4):1280-6. 5. kenny j-e. creatine kinase: how much is too much? clinical correlations, the new york university langone online journal of medicine. 2010. (cited 2012 december 12) available from: http:// www.clinicalcorrelations.org/?p=6560. 6. fusco a, foglia a, musarra f. the shoulder in sport: management, rehabilitation, and prevention. 1st ed. philadelphia:churchill livingstone elsevier. 2008. 7. brancaccio p, maffulli n, limongelli fm. creatine kinase monitoring in sport medicine. br med bull 2007;81– 82(1):209–30. 8. morandi l, angelini c, prelle a, pini a, grassi b, bernardi g, et al. high plasma creatine kinase: review of the literature and proposal for a diagnostic algorithm. j neurol sci. 2006;27(5):303–11. 9. paul gl, delany jp, snook jt, seifert jg, kirby te. serum and urinary markers of skeletal muscle tissue damage after weight lifting exercise. eur j appl physiol occup physiol. 1989;58(7):786–90. 10. tidball jg. inflammatory processes in muscle injury and repair. am j physiol, 2005;288(2):r345–53. 11. baird mf, graham sm, baker js, bickerstaff gf. creatine-kinaseand exercise-related muscle damage implications for muscle performance and recovery. j nutr metab. 2012;2012:960363. 12. aoi w, naito y, takanami y, kawai y, sakuma k, ichikawa h, et al. oxidative stress and delayed-onset muscle damage after exercise. free radic biol med. 2004;37(4):480–7. 13. allen dg, lamb gd, westerblad h. skeletal muscle fatigue: cellular mechanisms. physiol rev. 2008;88(1):287–332. 14. barbieri e, sestili p. reactive oxygen species in skeletal muscle signaling. j signal transduct. 2012;2012:982794 15. pickett tc, lewis rj, cash tf. men, muscles, and body image: comparisons of competitive bodybuilders, weight trainers, and athletically active controls. br j sports med. 2005;39(4):217–22. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 235 clinical profile and mortality in children with pneumonia ashvinii manivel,1 sri sudarwati,2 rb. soeherman herdiningrat3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of anatomy and cell biology, faculty of medicine universitas padjadjaran abstract background : pneumonia is the leading killer in under-five children. therefore, by identifying the danger signs, we are able to predict children who are at higher risk of mortality. the objective of the study is to identify the relationship between the clinical profile and mortality in children with pneumonia at dr. hasan sadikin general hospital, bandung. methods: this was an analytical study with a retrospective case control approach using medical records with patient’s age limitation of 1–60 month. the study period started on january 1st 2010 and ended on december 31st 2011. all types of pneumonia included whereas congenital anomalies, immunocompromised and down’s syndrome patients were excluded in this study. data were presented as frequency distribution. results : during the study period, there were 653 children under age of 5 with pneumonia. only 56 subjects met the inclusion and exclusion criteria. twenty-eight patients with pneumonia were cured and 28 died. based on the phi’s coefficient, tachycardia (α-value = 0.019) and hepatomegaly (α-value = 0.001) were significant predictors of death and based on the mantel-haenszel analysis, hepatomegaly (or=9.62, ci 95% 2.349–39.35) was significant as a risk for mortality. inability to drink, cyanosis, tachypnea, grunting, vomiting, convulsion, and unconsciousness were not related to mortality. conclusion: tachycardia and hepatomegaly have a significant relationship with mortality in under-five children with pneumonia. [amj.2015;2(1):235–40] keywords: children, clinical sign, death, pneumonia, predictor correspondence: ashvinii manivel, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287726091120 email: ashviniimanivel@hotmail.com introduction pneumonia has been the leading killer in under-five children where it kills more than 5 million children worldwide.1 it is the major cause of child mortality specially in developing countries.2 indonesia is one of the 15 countries that is responsible for three quarters of childhood pneumonia cases globally in underfive children.1 a national household health survey held in 2001 in indonesia showed that pneumonia causes death of in nearly 300 infants every day.3 in spite of the administration of antibiotics, the prevalence of pneumonia is high and still kills more children than aids, measles and malaria combined.1 who has implemented acute respiratory infection (ari) control program to screen children with higher risk of death. however, this program used lower chest wall findings as signs for predicting death, causing over referral of suspected pneumonia to the hospital.2,4 several studies showed tachypnea and anemia are predictors of death in pneumonic children, but it is understood that further research needed to determine their significance.2 it is also shown that inability to drink and cyanosis have been considered as danger signs for urgent referral and according to who, inability to drink and cyanosis has proven to be danger signs for very severe pneumonic patient.1 many studies have shown various clinical signs that predict death in pneumonia.2,3,5-8 however, less number of studies are carried out in indonesia. the objective of the study is to identify the relationship between the clinical profile and mortality among children with pneumonia in dr. hasan sadikin general hospital, bandung, indonesia. methods this was a retrospective case control study based on medical record. all children underalthea medical journal. 2015;2(2) 236 amj june, 2015 figure 1 flow chart on children of 1 month – 5 years old with pneumonia in 2010 and 2011 in department of child health of dr. hasan sadikin general hospital bandung. five children with any type of pneumonia admitted in department of child health of dr. hasan sadikin general hospital from january 1st 2010–december 31st 2011 were eligible for this study. patients with congenital anomalies, immunocompromised and down’s syndrome and incomplete data in the medical record were excluded. nine danger signs, i.e. tachycardia, tachypnea, cyanosis, grunting, convulsion, unconsciousness, inability to drink, vomiting, and hepatomegaly, were assessed to determine their relationship with death in children under-5 with pneumonia. the sample size of the study was calculated by using tachycardia as a significant mortality althea medical journal. 2015;2(2) 237 table 1 cross tabulation of clinical signs with mortality using phi’s coefficient variables died cured α tachycardia yes 5 0 0.019 no 23 28 tachypnea yes 27 25 0.299 no 1 3 cyanosis yes 4 2 0.388 no 24 26 grunting yes 5 3 0.445 no 23 25 convulsion yes 8 5 0.342 no 20 23 unconsciousness yes 9 3 0.051 no 19 25 inability to drink yes 2 0 0.150 no 26 28 vomiting yes 6 4 0.485 no 22 24 hepatomegaly yes 15 3 0.001 no 13 25 ashvinii manivel, sri sudarwati, rb. soeherman herdiningrat: clinical profile and mortality in children with pneumonia five children with any type of pneumonia admitted in department of child health of dr. hasan sadikin general hospital from january 1st 2010–december 31st 2011 were eligible for this study. patients with congenital anomalies, immunocompromised and down’s syndrome and incomplete data in the medical record were excluded. nine danger signs, i.e. tachycardia, tachypnea, cyanosis, grunting, convulsion, unconsciousness, inability to drink, vomiting, and hepatomegaly, were assessed to determine their relationship with death in children under-5 with pneumonia. the sample size of the study was calculated by using tachycardia as a significant mortality predictor with or 6.075.3 the level of significance was 0.05% and power of 80%. both case and control group showed the same ratio. total minimum sample size required for validity is 48; 24 children per group needed.9 univariate analysis was done to know the distribution and percentage of age and sex of patient. cross tabulation using phi’s coefficient was used to assess the relationship between the clinical profile and mortality. the level of significance was alpha <5%. maentel-haenszel was used to calculate althea medical journal. 2015;2(2) 238 amj june, 2015 the odd ratio to analyze the odds of death occurring in children with pneumonia results in 2010, 7.7% of pneumonia patients died, while in 2011, 5.5% patients died. in table 1, data showed that tachycardia and hepatomegaly had significant relationship with death in children under 5 with pneumonia. in table 2, odd ratio was analyzed. hepatomegaly (or 9.62; p= 0.02) correlated significantly with death in pneumonia patients. discussion the mortality rates in the department of child health of dr. hasan sadikin hospital, bandung in year 2010 was 7.7% and in 2011 was 5.1%. in the cross tabulation test, tachycardia and hepatomegaly were found as a significant predictor of death in pneumonia children. however, a study in papua new guinea showed no correlation between the 2 factors with mortality.5 occurrence of tachycardia can be explained table 2 bivariate analysis of clinical signs association with mortality using odd ratio variables died cured or 95% ci p tachycardia yes 5 0 no 23 28 tachypnea yes 27 25 3.24 0.031-33.22 0.322 no 1 3 cyanosis yes 4 2 2.17 0.363-12.92 0.396 no 24 26 grunting yes 5 3 1.81 0.389-8.447 0.449 no 23 25 convulsion yes 8 5 1.84 0.518-6.538 0.346 no 20 23 unconsciousness yes 9 3 3.95 0.937-16.60 0.061 no 19 25 inability to drink yes 2 0 no 26 28 vomiting yes 6 4 1.64 0.407-6.577 0.488 no 22 24 hepatomegaly yes 15 3 9.62 2.349-39.35 0.002 no 13 25 althea medical journal. 2015;2(2) 239 by the inflammatory reaction that interferes with the gaseous exchange in lung. the disturbances of gaseous exchange increases the alveolar and arterial po2 differences, thus leads to tachypnea and tachycardia as a compensation mechanism.10 a study conducted in thailand also showed that hepatomegaly has association to death.12 several mechanisms had been proposed to explain the presence of liver enlargement. it is suggested that congestion of liver with red blood cells in pneumonia patients with anemia or chronic liver disease could be a reason for enlarged liver.11,13 hyperinflation of lung could causes liver edge to be pushed further below and is palpable in the physical examination. although in this study other clinical signs showed no relationship, danger signs such as inability to drink and cyanosis were found to be important death predictors.5,14 when patients reach exhaustion, they experience a ventilation and perfusion mismatch, leading to a hypoxia state and probably respiratory failure.15 patients in dr. hasan sadikin general hospital received immediate interventions of ventilator and oxygen, so this could be a reason why cyanosis was not found in the subject. however inability to drink and grunting were mostly absent due to failure of physician in recording these signs during physical examination and history taking. convulsion and unconsciousness were not associated with death but associated with encephalopathy. in pneumonia, acute hypoxia can be the causative factor for hypoxic ischemic encephalopathy. this lack of oxygen to the brain will decrease the level of consciousness and causes convulsions to occur.16some patient experience vomiting which was probably due to bacterial causative pneumonia.17 the limitations of the study was the availability of data in the medical records. during the observation of the medical record, it was found that most of the physicians fail to note the important danger pneumonia signs in anamnesis and physical examination. a standardized medical record for pneumonia should be established by which physician must meet during the management of pneumonia patients. besides, most of the patients were sent home against advice. the mortality statuses of these patients were not known, thus limiting the number of data analyzed as patients underwent complete management of pneumonia. this study concludes that tachycardia and hepatomegaly is a significant mortality predictors in children under 5 with pneumonia at dr. hasan sadikin hospital, bandung. references 1. wardlaw t, johansson ew, hodge m. pneumonia: the forgotten killer of children. new york: the united nations children’s fund / world health organization; 2006 [cited 2012 march 16]; available from: http://www.unicef.org/. 2. lupisan s, ruutu p, erma abucejo-ladesma p, quiambao bp, gazom l, sombrero l, et al. predictors of death from severe pneumonia among children 2–59 months old hospitalized in bohol, philipines : implications for referral criteria for at firstlevel health facility. trop med int health. 2007;12(8):962–71. 3. kisworini p, setyati a, sutaryo. mortality predictors of pneumonia in children. paediatr indones. 2010;50(3):149–53. 4. mulholland k. childhood pneumonia mortality: a permanent global emergency. lancet. 2007;370(9583):285–9. 5. shann f, barker j, poore p. clinical signs that predict death in children with severe pneumonia. pediatr infect dis j. 1989;8(12):852–5. 6. deivanayagam n, nedunchelian k, ramasamy s, sudhandirakannan, ratnam s. risk factor for fatal pneumonia : a case control study. indian pediatr. 1992;29(12):1529–32. 7. narayanan m, falade a. clinical risk factors for death in children with pneumonia. australia: international child health review collaboration; 2006 [cited 2012 march 23]; available from: http://www. ichrc.org. 8. sehgal v, sethi gr, sachdev hp, satyanarayana l. predictors of mortality in subjects hospitalized with acute lower respiratory tract infections. indian pediatr. 1997;34(3):213–9. 9. sainani k. sample size for case control. stanford: 2007 [cited 2012 june 12]; available from: http://www.stanford.edu. 10. crowe je. kendig’s disorders of the respiratory tract in children. 7th ed. victor c, boat tf, editors. philadelphia: w.b. saunders company; 2006. 11. lakhanpaul m, atkinson m, stephenson t. community acquired pneumonia in children: a clinical update. arch dis child educ pract ed. 2004;89(2):29–34. ashvinii manivel, sri sudarwati, rb. soeherman herdiningrat: clinical profile and mortality in children with pneumonia althea medical journal. 2015;2(2) 240 amj june, 2015 12. suwanjutha s, ruangkanchanasetr s, chantarojanasiri t, hotrakitya s. risk factors associated with morbidity and mortality of pneumonia in thai children under 5 years. southeast asian j trop med public health. 1994;25(1):60–6. 13. wintrobe m, greer j. wintrobe’s clinical hematology. 12th ed. greer jp, editor. philadelphia: wolters kluwer health/ lippincott williams & wilkins; 2009. 14. nascimento-carvalho c, rocha h, jesus rs, benguigui y. childhood pneumonia: clinical aspects associated with hospitalization or death. braz j infect dis. 2002;6(1):22–8. 15. mbugua s. pneumonia in pre-school children. turku: turku university of applied sciences; 2011. 16. david r. clinical pediatric neurology. 3rd ed. david r, editor. new york: demos medical publishing; 2009. 17. prober c, sectish t. pneumonia. 18th ed. robert kliegman rb, hal jenson bs, editors. iowa: w.b.sanders; 2007. althea medical journal. 2015;2(3) 423 identification of risk factors for osteoporotic fracture using fracture risk assessment tool in dr. hasan sadikin general hospital, bandung, indonesia from june to december 2013 nik fatin farhana binti mohd rahhim,1 bambang tiksnadi,2 eppy buchori3 1faculty of medicine, universitas padjadjaran, 2department of orthopaedic & traumatology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of radiology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: osteoporosis has become a growing public health problem in indonesia. a definite estimation of osteoporosis prevalence in indonesia is not available due to the limited access of dual energy x ray absorptiometry (dxa) facilities. in 2008, the world health organization has developed a tool called fracture risk assessment tool to identify fracture risk based on the clinical risk factors. the study aimed to identify the risk factors of osteoporotic fracture using fracture risk assessment tool in dr. hasan sadikin general hospital, bandung, indonesia. methods: this descriptive study was conducted from june–december 2013 in orthopedic & traumatology, internal medicine, geriatric and surgery polyclinics dr. hasan sadikin general hospital, bandung to 77 respondents, aged 40–90 years, using the random sampling method. fracture risks were calculated online, and the data obtained were analyzed and presented using frequency distribution in tables. results: most of the respondents had low risk for osteoporotic fracture, and only 5.19% of them had moderate risk. the main risk factors were rheumatoid arthritis (57.14%), followed by current smoking (27.27%) and prolonged glucocorticoids consumption (25.98%). the moderate risk group was females, above 60 years old and with normal bmi or underweight with risks of previous fracture, parent’s previous hip fracture, rheumatoid arthritis and prolonged glucocorticoids exposure. conclusions: majority of the respondents have low risk for osteoporotic fracture. it must be taken into consideration that increasing age, rheumatoid arthritis, current smoking, prolonged glucocorticoids consumption, previous fracture and parent’s previous hip fracture can cause increased risk. [amj.2015;2(3):423–28] keywords: fracture, fracture probability, fracture risk assessment, osteoporosis correspondence: nik fatin farhana binti mohd rahhim, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85624820691 email: kin_frhan@yahoo.com introduction osteoporosis is a systemic skeletal disease characterized by low bone density and micro architectural deterioration of bone tissue with a consequent increase in bone fragility.1 osteoporosis has become a growing public health concern in asia. more than 50% of all osteoporosis-related fractures are estimated to occur in asia by 2050.2 in 2005, 2 out of 5 indonesians were reported to be at risk of osteoporosis. however, a definite estimation of osteoporosis prevalence in indonesia is not available due to the limited access of dual energy x ray absorptiometry (dxa) facilities; it makes this disease be considered as an under diagnosed disease.2 measurement of bone mineral density (bmd) using the dxa technology can identify individuals with low bone mass, which is a major characteristic of osteoporosis, yet, this technology is relatively expensive and widely unavailable in most developing asian countries. 2,3 osteoporosis is a silent disease. the occurrence of low trauma or fragility fracture has been identified as the outcome of osteoporosis. an estimation of one half of all clinical fractures occurs in persons without althea medical journal. 2015;2(3) 424 amj september, 2015 osteoporosis based on bmd. this indicates that the identification of other risk factors is required in order to identify individuals that are at highest risk for fracture.4 the who5 has developed a computer-based algorithm program called the fracture risk assessment (frax) tool which integrates the weight of clinical risk factors with or without the bmd results to predict the absolute percentage of risk for major osteoporotic fracture and hip fracture over the next 10 years.6-8 major osteoporotic fracture is defined as any osteoporosis related fractures such as clinical spine, wrist, proximal humerus and hip fracture.9 the frax tool is validated globally, applicable to both men and women from 40 to 90 years of age, cost-effective and countryspecific.3 this study was conducted to identify the distribution of risks for major osteoporotic fracture using frax tool among patients from 40 to 90 years of age in the polyclinics of dr. hasan sadikin general hospital, and could provide an overview of a rough estimation of the risk for osteoporotic fracture in bandung. methods a descriptive study was conducted from june–december 2013 in several polyclinics of dr. hasan sadikin general hospital. among selected polyclinics were the polyclinic of orthopedic & traumatology, polyclinic of internal medicine, polyclinic of geriatric and polyclinic of surgery. this study was conducted under a permission letter (no.: lb.02.01/c02/12526/xl/2013) approved by the health research ethics committee of dr. hasan sadikin general hospital. a total of 77 respondents from 40 to 90 years of age in the selected polyclinics were included using the random sampling method and all of them were informed of the objectives and benefits of the study before the interview. written informed consent was obtained prior to the interview. those refusing to be interviewed were excluded from this study. the interview was conducted based on the questions provided in the frax tool.5 questions included age, gender, weight, height, smoking status, three or more alcoholic units per day, parent with a hip fracture, previous fracture, rheumatoid arthritis, prolonged glucocorticoid consumption, secondary osteoporosis and bone mass density score (bmd). next, online calculation was conducted to calculate the respondent's percentage risk for major osteoporotic fracture over the next 10 years based on the integration of the clinical risk factors with or without the bone mass density (bmd) score. furthermore, fracture risks were classified into three groups: low risk (frax score of less than 10% of osteoporotic fracture), moderate risk (frax score between 1019% of osteoporotic fracture) and high risk (frax score of 20% or more for osteoporotic fracture).10 percentage of fracture risks obtained from the online calculation was then informed to the respondents. additionally, education on prevention of osteoporosis and fracture associated was also given after the interview to raise the awareness of the respondents on osteoporosis itself. the respondents were given education on lifestyle and dietary modifications as well as preventive measures such as fall preventions. apart from that, the respondents with moderate fracture risk were given recommendation to perform bone mass density (bmd) testing for further evaluation of their risk of osteopenia and osteoporosis. data obtained from all the respondents were recorded and analyzed descriptively using microsoft excel. results were then classified into risk groups, age specific, gender specific and body mass index related and presented using frequency distribution in the form of tables and chart. results most of the respondents had never performed any bmd testing before and only a few had done table 1 distribution of risk groups for major osteoporotic fracture* risk groups frequency (n) percentage (%) low 73 94.81 moderate 4 5.19 high 0 0.00 total 77 100 *examples are clinical spine, wrist, proximal humerus and hip fracture althea medical journal. 2015;2(3) 425 it, but failed to remember the score. therefore, the answers for the question on bmd were recorded as a 'no' for all respondents. the percentage of fracture risks calculated online using the frax tool was classified into 3 groups: low risk, moderate risk and high risk according to the standardized fracture risk categorization. the study showed that from all of the respondents, only 2 classifications were identified: low risk and moderate risk. low risk covered 94.81% of the two classifications. (table 1) in table 2, it is shown that all of the respondents had one or more risk factors of osteoporotic fracture although most of them were included in low risk group. the main risk factors occurred were rheumatoid arthritis (57.14%), followed by current smoking and prolonged glucocorticoids consumption (27.27% and 25.98%, respectively). four risk factors in the moderate risk group were identified: previous fracture, parent’s previous hip fracture, rheumatoid arthritis and prolonged glucocorticoids consumption. neither gender has high risk for major osteoporotic fracture based on frax tool. in addition, none of the male respondents have moderate risk for major osteoporotic fracture as all four of the respondents with moderate risk are females. (table 3). table 2 distribution of osteoporotic fracture risk factors risk factors alternative answers risk groups low moderate total frequency (n) percentage (%) frequency (n) percentage (%) frequency (n) percentage (%) previous fracture yes 8 10.39 1 1.30 9 11.69 no 65 84.42 3 3.90 68 88.32 previous yes 2 2.60 2 2.60 4 5.19 parent's hip fracture no 71 92.21 2 2.60 73 94.81 current smoking yes 21 27.27 0 0.00 21 27.27 no 52 67.53 4 5.19 56 72.73 glucocorticoids yes 19 24.68 1 1.30 20 25.98 no 54 70.13 3 3.90 57 74.02 rheumatoid arthritis yes 41 53.25 3 3.90 44 57.14 no 32 41.56 1 1.30 33 42.86 secondary yes 2 2.60 0 0.00 2 2.60 osteoporosis no 71 92.21 4 5.19 75 97.40 alcohol yes 0 0.00 0 0.00 0 0.00 no 73 94.81 4 5.19 77 100.0 table 3 distribution of risk groups based on gender gender risk groups total low moderate frequency (n) percentage (%) frequency (n) percentage (%) frequency (n) percentage (%) male 34 44.16 0 0.00 34 44.16 female 39 50.65 4 5.19 43 55.84 total 73 94.81 4 5.19 77 100 nik fatin farhana binti mohd rahhim, bambang tiksnadi, eppy buchori: identification of risk factors for osteoporotic fracture using fracture risk assessment tool in dr. hasan sadikin general hospital, bandung, indonesia from june to december 2013 althea medical journal. 2015;2(3) 426 amj september, 2015 the study focused on population with age range from 40 to 90 years old in which frax tool is only applicable. age was further subdivided into 5 groups. the age group of 60–69 years has the most number of respondents with moderate risk whereas for age group of 70–79 and 80–89 years, each has one respondent with moderate risk for major osteoporotic fracture. distribution of risk groups related to the body mass index (bmi) of respondents is shown in table 5. respondents with moderate risk for major osteoporotic fracture were found to have underweight and normal weight status. discussion in the present study, the frax tool provided the assessment of fracture probability in both genders, and has been calibrated to the epidemiology of indonesia which is available online.5 interaction of each of the clinical risk factors with or without the presence of bone mass density (bmd) score improved the accuracy for the fracture risk to be computed. some of the respondents with presence of two risk factors such as previous fracture, parent’s previous hip fracture, prolonged glucocorticoid exposure and rheumatoid arthritis had moderate risk for 10-year fracture probability. these four risk factors were considered as strong risk factors in which each of them had their significance for major osteoporotic fracture probability. a previous study also showed that individuals especially women with presence of one of these four risk factors without bmd score had moderate risk of 10-year major osteoporotic fracture probability.7 the distribution of risks for major osteoporotic fracture has been identified for all the respondents using the online calculation of frax tool. all the clinical risk factors on the frax tool such as age, bmi, previous fracture, parent’s previous hip fracture and prolonged glucocorticoid exposure have been integrated in order to calculate the fracture risk percentage. in the present study, it is identified that presence of more than one risk factor will subsequently cause an increment in the tenyear major osteoporotic fracture probability. for example, 3 out of 4 respondents with moderate risk for major osteoporotic fracture table 4 distribution of risk groups based on age age groups risk groups total low moderate frequency (n) percentage (%) frequency (n) percentage (%) frequency (n) percentage (%) 40–49 20 25.97 0 0.00 20 25.97 50–59 26 33.77 0 0.00 26 33.77 60–69 21 27.27 2 2.60 23 29.87 70–79 4 5.19 1 1.30 5 6.49 80–89 2 2.60 1 1.30 3 3.90 total 73 94.81 4 5.19 77 100 table 5 distribution of risk groups based on body mass index (bmi) body mass index (bmi) risk groups total low moderate frequency (n) percentage (%) frequency (n) percentage (%) frequency (n) percentage (%) underweight 7 9.09 1 1.30 8 10.39 normal 37 48.05 3 3.90 40 51.95 overweight 21 27.27 0 0.00 21 27.27 obese 8 10.39 0 0.00 8 10.39 total 73 94.81 4 5.19 77 100 althea medical journal. 2015;2(3) 427 had two risk factors present in which the tenyear fracture probability ranged from 11–12%. in a previous study, it showed the presence of more than one risk factor increased fracture probability in an incremental manner.7 all of the respondents with moderate risk for major osteoporotic fracture were female suggesting that women had higher risk of 10year fracture probability compared to men. a study reported that the probabilities for a major osteoporotic fracture ranged from 3.5% to 31% in women, and from 2.8% to 15% in men.7 another study showed, the 10-year probability of major osteoporotic fracture risk for all women was 12.0% and 10.7% for men.11 two of the respondents with moderate risk for major osteoporotic fracture within age range of 60 to 69 years old had fracture risk of 11%. the present study observed that as age increases, the 10-year fracture risk probability will also increase. age is indeed a strong risk factor that brings significance to the computed fracture risk. the result from a previous study conducted in united kingdom has reported that respondents with moderate risk for major osteoporotic fracture within age range of 6069 years old have fracture risk of 11%.7 the bmi of respondents were classified according to the center for disease control and prevention (cdc) into 4 categories: underweight (bmi below 18.5), normal weight (bmi 18.5–24.9), overweight (bmi 25.0–29.9) and obese (bmi of 30.0 and above). findings from the present study showed that respondents with lower bmi had higher fracture risk compared to those with higher bmi. fracture results from increased skeletal fragility that can be due to loss of bone mass. individuals with higher bmi tended to have higher bmd. hence, low bone mass and low body weight increased the risk for osteoporosis and fracture of an individual.2 despite the fact that majority of the respondents had low risk for major osteoporotic fracture based on the frax tool, education on lifestyle and preventive measures for osteoporosis was given to each one of them. these individuals did not require pharmacologic therapy but rather the knowledge on how to prevent fracture that is due to osteoporosis such as increasing the amount of daily calcium intake, doing physical activities and smoking cessation. as for respondents with moderate risk, it is recommended to have their bmd and additional clinical risk factors evaluated to prevent fracture and to decide whether or not pharmacologic therapy is required.10,12 several limitations were identified during the course of this study. although frax tool is well validated, there are several other risk factors that may be important in assessing individuals for 10-year fracture probability such as exercise and nutritional status. apart from that, time constraint had also been recognized as one of the study limitations as there was lack of time for data collection and analysis. the sample population of the study was imbalance in terms of the distribution between age groups and genders. since this study was conducted in the polyclinics of dr. hasan sadikin general hospital, the results of this study could not be generalized to the population of indonesia. in brief, this study identified that 95% of the respondents had low risk for major osteoporotic fracture and the remaining 5% had moderate risk of major osteoporotic fracture for the next ten years to come. the respondents identified with moderate risk were all females. apart from that, fracture risk probability increased as the age increased. this could be seen as all of the respondents with moderate risk for major osteoporotic fracture were above 60 years old. majority of the respondents with moderate risk were either underweight or with normal bmi. four strong risk factors in the moderate risk group were identified whereby each one of them brought significance in calculating the fracture risk probability. the risk factors were previous fracture, parent’s previous hip fracture, rheumatoid arthritis and prolonged glucocorticoids exposure. references 1. who. prevention and management of osteoporosis. geneva: who technical report series. 2003 2. mithal a, dhingra v, lau e. the asian audit epidemiology, costs and burden of osteoporosis in asia 2009. switzerland: arch osteoporos. 2009 3. watts nb, bilezikian jp, camacho rm, greenspan sl, harris st, hodgson sf, et al. american association of clinical endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of p o s t m e n o p a u s a l osteoporosis. endocr pract. 2010;16(3):1– 37. 4. donaldson mg, palermo l, schousboe jt, ensrud ke, hochberg mc, cummings sr. frax and risk of vertebral fractures: the nik fatin farhana binti mohd rahhim, bambang tiksnadi, eppy buchori: identification of risk factors for osteoporotic fracture using fracture risk assessment tool in dr. hasan sadikin general hospital, bandung, indonesia from june to december 2013 althea medical journal. 2015;2(3) 428 amj september, 2015 fracture intervention trial. j bone miner res. 2009;24(11):1793–9. 5. kanis ja. frax ® who fracture risk assessment tool. united kingdom: w o r l d health organization collaborating centre for metabolic bone diseases. 2008. 6. noor z, sumitro sb, hidayat m, rahim ah, taufiq a. assessment of microarchitecture and c r y s t a l structure of hydroxyapatite in osteoporosis. univ med. 2011;30(1):29–35. 7. kanis ja, johnell o, oden a, johansson h, mccloskey e. frax and the assessment of fracture probability in men and women from the uk. o s t e o p o r o s i s int. 2008;19(4):385–97. 8. horikawa a, miyakoshi n, shimada y, kodama h. frax and exercise : s h o u l d exercise be categorized as a risk factor in osteoporotic patients. open journal of orthopedics. 2013;3(2):133–36. 9. mccloskey e. frax ® identifying people at high risk of fracture. who fracture risk assessment tool, a new clinical tool for informed treatment d e c i s i o n s . switzerland: arch osteoporos. 2009 10. papaioannou a, morin s, cheung am, atkinson s, brown jp, feldman s, et al. 2010 clinical practice guidelines for the diagnosis and management o f osteoporosis in canada: summary. cmaj. 2010;182(17):1864–73. 11. leslie wd, lix lm, johansson h, oden a, mccloskey e, kanis ja. i n d e p e n d e n t clinical validation of a canadian frax tool: fracture prediction and model calibration. j bone miner res. 2010;25(11):2350–8. 12. kanis ja, oden a, johansson h, borgström f, ström o, mccloskey e. frax and its applications to clinical practice. bone. 2009;44(5):734–43. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 186 amj june, 2015 factors related with knowledge of basic life support among members of student body volunteer organizations at universitas padjadjaran nur fadilla,1 irvan afriandi,2 ruli herman sitanggang,3 elsa pudji setiawati2 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran bandung, indonesia, 3department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: mortality caused by accidents remains a public health challenge. prompt response during first aid accident may prevent disability or death. at universitas padjadjaran three student body volunteer organizations provide training in basic life support as the component of first aid. they are korps sukarela palang merah indonesia (ksr pmi), perhimpunan mahasiswa pecinta alam (pmpa) palawa, and unit search and rescue (sar). this study aims to assess the level of basic life support knowledge of the members in three organizations and the factors related with their knowledge. methods: the method used was a descriptive study carried out on subjects diagnosed with pss at the national ethis was a cross sectional study that included 59 members of three student body volunteer organizations of universitas padjadjaran that have received training in basic life support. a questionnaire about respondent’s characteristics, basic life support-related experiences, and basic life support’s knowledge was administered to the participants during october 2012 results: the total mean for the three student body volunteer organizations on questionnaire was 64.12±19.40 with minimum score was 25 and maximum score was 100. the interval of last period of training and basic life support-related experiences did not show statistically significant (p=0.647) and (p=0.357) however educational background related to basic life support knowledge showed statistically significant (p<0.01). conclusions: the level of basic life support knowledge in three student body volunteer organizations was moderate and that educational background has relation with the knowledge. the increase in number of effective training and application in the field may increase the knowledge on basic life support. [amj.2015;2(1):186–90] keywords: basic life support, knowledge, student body volunteer organizations correspondence: nur fadilla, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285691684546 email: nurfadilla23@gmail.com introduction mortality caused by accidents remains a public health challenge. according to world health organization (who), the number of death from traffic accidents in the world reaches 2.4 million/year,1 whereas international labour organization (ilo) estimates that every year 2 million people die from workplace accidents worldwide.2 united nations international strategy for disaster reduction (unisdr ) reported that during 1980–2010, there had been 321 natural disasters, accounted for 6.209 deaths per year.3 prompt response during first aid accident can prevent disability or death. first aid is a means in emergency state that aims to prevent disability or death.4 communities has an important role because they are the subject closest to the accidents, either being a victim or a helper for the victims in the accident. they need to be empowered as the first responder. in doing so they need to be trained in first aid.5 three student body volunteer organizations at universitas padjadjaran provide training in basic life support (bls) as the component of first aid. they are korps sukarela palang merah indonesia (ksr pmi) universitas padjadjaran, perhimpunan mahasiswa pecinta alam (pmpa) palawa universitas padjadjaran, and search and rescue (sar). ksr pmi universitas padjadjaran is a student organization under the supervision of palang merah indonesia that volunteer in social and humanity activities. palawa universitas padjadjaran is student body organization whose activities are based on adventure, social, environmental, and althea medical journal. 2015;2(2) 187 humanity. unit sar universitas padjadjaran is a humanitarian student organization that provides support in natural disaster. their activities include management before, at the moment, and after the disaster. as these student body organizations perform bls to provide first aid to save lives, the knowledge they carry about bls becomes an important issue. without proper knowledge, they would not be able to perform proper first aid. this study aims to assess the bls knowledge level of the members in the three student body organizations and the factors related with their knowledge. this study results in feedback for evaluation for further organizational improvement. methods this was a cross sectional study conducted during october 2012. the population of this study was all members of the three student body volunteer organizations at universitas padjadjaran, namely ksr pmi universitas padjadjaran, pmpa palawa universitas padjadjaran, and unit sar universitas padjadjaran. they were included in this study if actively registered as the members during 2012. those who did not present at the time of data collection and/or denied to participate in this study were excluded. all eligible members were asked to fill out questionnaire. the questionnaire consists of 17 questions covering information regarding respondent’s characteristics, bls-related experiences, and knowledge about bls. the characteristic information includes name of the organization, age, gender, address and educational background. bls related experiences were asked to indicate the extent of the last bls training period and to confirm whether a member had applied his/her bls skills. the bls knowledge was measured by 13 truefalse question formats. the questionnaire was piloted to a group of students as members of the student body other than the three student body volunteer organizations in the same university. results of the pilot study showed that the questionnaire on bls knowledge had a cronbach’s alpha 0.671. incomplete data filled during the study were returned to the respondents to be completed. all data collected were keyed in and analyzed using spss® for windows® version 15.0. univariate analysis was used to describe the respondent’s characteristics, data were presented as frequency distribution. numerical data were tested for normality using kolmogorov-smirnov test. since the data distribution was not normal, spearman correlation test was used to examine the relationship between bls knowledge and interval of last period of training, whereas table 1 distribution characteristics ofthe study participants variables frequency % mean±sd organization ksr pmi 19 32.2 pmpa palawa 13 22 unit sar 27 45.8 ages 20.34±1.66 gender male 30 50.8 female 29 49.2 last period training (months) 12.24±9.16 educational background medical faculty 18 30.5 nonmedical faculty 41 69.5 had applied bls skills yes 10 16.9 no 49 83.1 nur fadilla, irvan afriandi, ruli herman sitanggang, elsa pudji setiawati: factors related with knowledge of basic life support among members of student body volunteer organizations at universitas padjadjaran althea medical journal. 2015;2(2) 188 amj june, 2015 the relationship of bls knowledge with educational background and bls knowledge with bls related experience was examined using mann-whitney comparative test. statistical significance of the test was set at the level of 0.05. the ethical approval for this study was obtained from the health research ethic committee, faculty of medicine, universitas padjadjaran (no 238/un6.c2.1.2/ kepk/2012). results most patients were in the age group of 31–a total of 59 members of student body volunteer organizations participated in this study. among them 19 were from ksr pmi universitas padjadjaran, 13 were from pmpa palawa universitas padjadjaran, and 27 participants were from unit sar universitas padjadjaran. the mean ages of the participants was 20.34 (sd=1.66) and the number of male and female participants were almost equal. most of the participants were from non-medical faculty and admitted never applied bls skills. table 1 shows information about characteristics of the study participants. the range of ages in three student body volunteer organizations was quite varied. the age ranged from 18–22 years, 18–23 years, and 19–26 years in ksr pmi universitas padjadjaran, pmpa palawa universitas padjadjaran, and unit sar universitas padjadjaran, respectively. the mean ages were 19.37 (sd=1.12) in ksr pmi universitas padjadjaran, 19.8 (sd=1.21) in pmpa palawa universitas padjadjaran, and 21.26 (sd=1.70) in unit sar universitas padjadjaran. the female participants were predominately from ksr pmi universitas padjadjaran and male participants were predominately from unit sar universitas padjadjaran. all medical faculty participants were the members of ksr pmi universitas padjadjaran. the length of the last training ranged from 4–35 months, 4–7 months, 5–40 months in ksr pmi universitas padjadjaran, pmpa palawa universitas padjadjaran, and unit sar universitas padjadjaran, respectively. the mean of last period of training were 11.21 (sd=6.86) in ksr pmi universitas padjadjaran, 5.54 (sd=0.97) in pmpa palawa universitas padjadjaran, and 16.19 (sd=10.71) in unit sar universitas padjadjaran. table 2 shows frequency distribution of the study participants based on the student body organization. the total mean score on the bls knowledge questionnaire was 64.12 (sd=19.40) with the minimum score was 25 and maximum table 2 distribution of the study participants by the organization variable ksr pmi pmpa palawa unit sar total gender male 1 6 23 30 female 18 7 4 29 educational background medical faculty 18 0 0 18 nonmedical faculty 1 13 27 41 had applied bls skills yes 1 2 7 10 no 18 11 20 49 table 3 score of bls knowledge by the organization ksr pmi pmpa palawa unit sar min 33.33 33.33 25 max 100 66.67 83.33 mean±sd 81.14±18.18 46.79±10.51 60.49±13.59 median±iqr 91.67±25 50±16.67 58.33±16.67 althea medical journal. 2015;2(2) 189 score was 100. the total median score on the questionnaire was 58.33 (sd=33.33). table 3 shows the score of bls knowledge by the organization. ksr pmi universitas padjadjaran had the highest mean score followed by unit sar universitas padjadjaran and then pmpa palawa universitas padjadjaran. the score of bls knowledge was classified as good, moderate, or poor based on the mean and standard deviations. table 4 shows the bls knowledge level. more than 60% of study participants have moderate score. ksr pmi universitas padjadjaran, unit sar universitas padjadjaran, and pmpa palawa universitas padjadjaran dominated the good, moderate, and poor bls knowledge level. spearman correlation statistic test showed that the score of bls knowledge was not related to the interval of last period training (r=0.061, p=0.647). these data demonstrated that the bls knowledge score of members was not affected by the training done in recent or older time. the score of bls knowledge was positively related to educational background. the mannwhitney u score was 111.500 (p<0.01). these data showed that the participants from medical faculty had better score of bls knowledge than the participants from non-medical faculty. all medical faculty participants were the member ofksr pmi universitas padjadjaran who had mean score of 81.14 (sd=18.18), while 46.79 (sd=10.51) and 60.49 (sd=13.59) was the mean for pmpa palawa universitas padjadjaran and unit sar universitas padjadjaran. the score of bls knowledge was not related to bls related experience as shown by the result of mann-whitney comparative test (u=200.000, p=0.357). these results indicated there was no difference in the score of bls knowledge between the participants who had applied and never applied his/her bls skills. discussions the total mean score on the bls knowledge questionnaire among three student body volunteer organizations was 64.12 (sd=19.40). this score reveals a moderate bls knowledge level. the score of bls knowledge in this study does not relate to the interval of last period training (r=0.061, p=0.647). the possible explanation would be the bls knowledge is influenced by other factors that affect the effectiveness of training and can affect the knowledge obtained from the training.6 this factors mainly come from trainee characteristics such as intelligence, self-efficacy, motivation to learn, learning goal orientation, performance goal orientation, and instrumentality of the training.7,8 therefore, the results in this study is different from the current literature saying that someone’s knowledge and skills in first aid can be forgotten quickly as early as 30 days post training, due to limitation of knowledge retention.9 the bls knowledge in this study is not affected by limitation of knowledge but is most likely depending on each participant’s understanding about bls and the effectiveness of bls training they have had before. in this study, the participants from medical students had the highest mean score of bls knowledge. the participants from medical faculty will be more often exposed to the bls knowledge during academic activity. they will also receive knowledge based on their major, medical science.10 this may explain the reason they have better score of bls knowledge than the participants from non-medical faculty. in addition r, the score of bls knowledge was positively related to educational background (u=111.500, p<0.01). the score of bls knowledge does not relate to knowledge application experience (u=200.000, p=0.357). this result indicates there is no difference in the score of bls knowledge between the participants who has or has never had the bls before. a significant difference is discovered between the number of participants that have applied bls skills (10 participants) and those who have never applied bls skills (49 participants). unfortunately, the number of participants that have applied bls skills is too small and therefore the relation between bls knowledge and bls related experience could not be assessed. the conclusions are the bls knowledge level among student volunteer organization at universitas padjadjaran is moderate. of the nur fadilla, irvan afriandi, ruli herman sitanggang, elsa pudji setiawati: factors related with knowledge of basic life support among members of student body volunteer organizations at universitas padjadjaran table 4 bls knowledge level ksr pmi pmpa palawa unit sar total frequency good 10 0 0 10 17% moderate 8 7 24 39 66% poor 1 6 3 10 17% althea medical journal. 2015;2(2) 190 amj june, 2015 three factors studied on the influence in bls knowledge, one has relation to bls knowledge, the educational background. yet, other factors, the interval of last period training and bls related experience is not related to bls knowledge. the results of this study indicate there is a need to improve bls knowledge. some efforts can be made to improve bls knowledge such as by increasing the number of effective training, organizing a simulation of bls, and increasing the participation of student volunteer organization in the activities that provide them opportunity to apply bls. further research about other factors that may affect bls knowledge including trainee characteristics also needs to be performed. references 1. segre l. human eye anatomy: parts of the 1. pusat komunikasi publik kementerian kesehatan ri. kecelakaan lalu lintas penyebab kematian nomor 3. jakarta. 2011 [cited 2012 april 15]; available from: http://sehatnegeriku. com/kecelakaan-lalu-lintas-penyebabutama-kematian-nomor-3/. 2. ilo. keselamatan dan kesehatan kerja di indonesia. manila: international labour organization. 2004. 3. united nations international strategy for disaster reduction. indonesia disaster statistic. geneva. 2010. [cited 2012 april 15]; available from: http://www. preventionweb.net/english/countries/ statistics/ index.php?cid=80. 4. kartono m. pertolongan pertama. jakarta: gramedia pustaka utama. 2005 5. direktorat jenderal bina kesehatan masyarakat. kurikulum pelatihan penolong pertama kedaruratan. 2nd ed. jakarta: departemen kesehatan ri; 2006. 6. tannenbaum si, cannon-bowers ja, salas e, methieu je. factors that influence training effectiveness: a conceptual model and longitudinal analysis. orlando, florida: naval training systems center human, systems integration division; 1993. p. 16– 54 7. tziner a, fisher m, senior t, weisberg j. effects of trainee characteristics on training effectiveness. int j selection assessment. 2007;15(2):167–74. 8. quinones ma. contextual influences on training effectiveness. in: quinones ma, ehrenstein a, editors. training for a rapidly changing workplace: applications of psychological research. washington dc: american psychological association.1997. p. 177–99. 9. anderson gs, gaetz m, masse j. first aid skill retention of first responders within the workplace. scand j trauma resusc emerg med. 2011;19:11. 10. igwe mn, bakare mo, agomoh ao, onyeama gm, okonkwo ko. factors influencing knowledge about childhood autism among final year undergraduate medical, nursing and psychology students of university of nigeria, enugu state, nigeria. ital j pediatr. 2010;36:44. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 32 amj march, 2015 anxiety level in dyspeptic patients at the gastroenterohepatology outpatient clinic of dr. hasan sadikin general hospital bandung, indonesia radistrya sekaranti brahmanti,1 juke roslia saketi,2 harry saroinsong,3 primal sudjana2 1faculty of medicine, universitas padjadjaran, 2department of internal medicine, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of physiology, faculty of medicine, universitas padjadjaran abstract background: dyspepsia is a disease with a high worldwide prevalence, including in asia; however, the pathophysiology of the disease is still unclear. recent studies suggest adapting a biopsychosocial model to understand the pathophysiology of dyspepsia that proposes the important role of anxiety. the aim of this study was to assess the anxiety level in dyspeptic patients who visited the gastroenterohepatology outpatient clinic in dr. hasan sadikin general hospital bandung. methods: a cross-sectional descriptive study using total sampling method was conducted from september– november 2012 to 19 patients aged 36−85 years old who consisted of 11 women and 8 men patients dyspepsia syndrome in the gastroenterohepatology outpatient clinic dr hasan sadikin general hospital bandung. the anxiety levels were measured using the zung self-rating anxiety scale. all data were analyzed based on gender, age, and occupational status of the patients. results: eleven of the nineteen patients had high anxiety levels. women were more likely to experience high anxiety levels (8 of 11). the group with the highest number of patients with high anxiety was the 46−55 years old group, the high anxiety level was more common among patients who were government or private sector employees. conclusion: the anxiety level in dyspeptic patients who visited the gastroenterohepatology outpatient clinic in dr. hasan sadikin general hospital bandung was high. key words: anxiety levels, dyspeptic patients, zung self-rating anxiety scale correspondence: radistrya sekaranti brahmanti, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 812 1042 8927 email: sekar.brahmanti@gmail.com introduction abdominal discomfort is a symptom that has a myriad of cause with one of the most common causes is dyspepsia. dyspepsia refers to a disease that causes abdominal discomforts with postprandial fullness, early satiation, bloating, nausea, vomiting, and pain at the epigastric region.1 a minority of dyspeptic patients suffer from organic causes while the majority has been found to suffer from nonorganic dyspepsia or functional dyspepsia. although dyspepsia has a worldwide prevalence, the pathophysiology is still unclear. many research and studies have been performed and, recently, a biopsychosocial model is proposed alongside the brain-gut axis (bga) theory2 to explain the multifactorial etiology of the disease because there is a high prevalence of psychological comorbidity seen in dyspeptic patients with anxiety as the comorbidity with the highest prevalence.3 anxiety, which is defined as a condition of excessive worrying or anxiousness towards a few or more life events or problems for at least six months, has been known to have pathologic effects on the body, mediated by unclear mechanisms, where one of the effects is functional gastrointestinal disorders.4 the role of anxiety in functional dyspepsia has long been studied in western population, and recent attention has been given to performing a study in asian countries. in indonesia, few have focused on this study despite the high prevalence in both western althea medical journal. 2015;2(1) 33 and asian populations. in addition, the current management for dyspepsia still focuses on the dysfunction of the stomach. further research on this topic may reveal the significance of psychological aspect management in dyspeptic patients. to answer to this challenge, this study aimed to discover the anxiety level of dyspeptic patients visited the gastroenterohepatology outpatient clinic of dr. hasan sadikin general hospital during the period of september to november 2012. methods a cross-sectional descriptive study was conducted from september– november 2012 to 19 patients who consisted of 11 women and 8 men patients dyspepsia syndrome in the gastroenterohepatology outpatient clinic dr hasan sadikin general hospital bandung who aged using total sampling method. the age range of the patients was between 36−85 years old, which were divided into the following age group: 36−45 years (6/19 patients); 46−55 years (5/19 patients); 56−65 years (3/19 patients); 66−75 years (3/19 patients); 76−85 years (2/19 patients). five different occupational categories were identified as follows: housewive (6/19 patients); retired (6/19 patients); government employee (4/19 patients); private sector employee (2/19 patients); others (1/19 patients). the patients who had agreed to volunteerarily participate in the study filled the zung self-rating anxiety scale to determine the anxiety level. all data gathered were analyzed to determine the percentage of high and low anxiety levels from the total population and to compare the anxiety levels based on gender, age, and occupational status of the patients. results the result showed that eleven of the nineteen patients had high anxiety levels ( table 1). table 1 anxiety levels of dyspeptic patients anxiety levels n low 8 high 11 total 19 the comparison of gender among those patients with high anxiety levels revealed that women were more likely to experience high anxiety levels (8 of 11) (table 2). table 2 anxiety level based on gender gender anxiety level total low high n n n male 5 3 8 female 3 8 11 total 8 11 19 the group with the highest number of patients with high anxiety was the 46−55 years old group, followed by 36−45 years old age group with three patients, and 56−65 years old group and 66−75 years old group with two patients in each group. none of the patients in 76−85 years old. group experienced high level of anxiety (table 3). table 3 anxiety level based on age group age (years) anxiety level total low high n n n 36−45 3 3 6 46−55 1 4 5 56−65 1 2 3 66−75 1 2 3 76−85 2 0 2 total 8 11 19 in this study, most patients were housewives or retired, but based on the results shown in table 4, the high anxiety level was more common among patients who were government or private sector employees. the patients who were housewives had an even distribution of low and high anxiety levels while most retired patients had low anxiety levels. three out of four government employee patients and all private sector employee patients had high anxiety levels along with one patient whose occupation was categorized as ‘others’. radistrya sekaranti brahmanti, juke roslia saketi, harry saroinsong, primal sudjana: anxiety level in dyspeptic patients at the gastroenterohepatology outpatient clinic of dr. hasan sadikin general hospital bandung, indonesia althea medical journal. 2015;2(1) 34 amj march, 2015 discussion eleven out of nineteen dyspeptic patients in this study experienced a high level of anxiety (table 1) which is in line with the results of previous studies that stated the high prevalence of anxiety in dyspeptic patients.3,5 anxiety affects the gastrointestinal functions through the emotional motoric system (ems) that consists of hypothalamus, amygdala, and periaqueductal gray. the emotional motoric system (ems) is a part of the brain-gut axis theory, where it is thought to receive inputs from cortical structures involved in regulating or generating emotions and control motoric visceral functions.3,6 the ems structure has connections with the brain stem nuclei that control arousal (locus ceruleus) and with the autonomic nuclei (motoric vagal nuclei). locus ceruleus is crucial in anxiety due to its ascending noradrenergic projections and its role in regulating gastrointestinal responses through the connections with the autonomic nuclei where alterations in the autonomic output are seen in patients with anxiety, causing a low parasympathetic vagal tone. in addition to the activation of autonomic responses, the activation of the hypothalamuspituitary-adrenal (hpa) axis that leads to corticotrophin-releasing hormones and cortisol productions might also partake in the alteration of the sensorimotor gastric function.6 a previousexplanation has proposed a mediation of the mechanism between anxiety and functional dyspepsia.6,7 of the total eleven patients who had high anxiety levels, it was apparent that this condition was seen more in women than men (8 of 11). by referring to table 2, although it is believed that there is no great significance in the prevalence of dyspepsia based on gender1,5, other studies have shown that women have a high prevalence of functional gastrointestinal disorders which may have been attributed by the fact that women also have a high prevalence in visceral hypersensitivity and longer gastric emptying time8, both are implicated as the abnormalities of gastric motor function.6,7 some studies also suggest the role of sex hormones in mediating visceral hypersensitivity, where women tend to experience visceral hypersensitivity as estrogen and progesterone reach their nadir before menstruation. this was based on observations of premenopausal female patients who experience gastrointestinal symptoms such as bloating or abdominal cramping during menstruation.8 psychological and environmental aspects are also indicated to have more effect on women. a history of sexual abuse and domestic abuse was reported in many women who have functional dyspepsia.5,8 there was a peak prevalence of high anxiety levels in dyspeptic patients of the age group of 46−55 years old (table 3), which was also in line with previous studies observing age and dyspepsia. it was found that dyspepsia does not relate to any particular age group, but the prevalence of dyspepsia in the particular age group can show a trend. the trend or peak prevalence in this study showed a high prevalence of dyspeptic patients with high anxiety levels in the age group of 46−55 years old, which is also similar to a study in china9, where there is a peak prevalence of dyspepsia in age group of 41−50 years old. this trend may be attributed to more stress levels at this age group, low estrogen levels, and negative view on menopause. from the results shown in table 4, patients table 3 anxiety level based on age group occupation anxiety level total low high n n n housewife 3 3 6 retired 4 2 6 government employee 1 3 4 private sector employee 0 2 2 others 0 1 1 total 8 11 19 althea medical journal. 2015;2(1) 35 who were governmental or private employees had higher anxiety levels compared to those with other occupations. this is possibly due to more stress triggered by the work load. socioeconomic status has been shown to be a risk factor in functional dyspepsia patients.1,5,9 although more research needs to be done to observe socioeconomic status and its importance in functional dyspepsia, most studies have shown an association between the two factors. a study in china9 showed that “dissatisfaction of income” is a risk factor in dyspeptic patients. indeed, socioeconomic factors such as poor living condition, unemployment, low education, and low income have been shown in adults who were prevalent to dyspepsia.5 in conclusion, although the small population, this study revealed high anxiety levels in dyspeptic patients at the gastroenterohepatology outpatient clinic of dr. hasan sadikin general hospital. this result should be considered carefully due to inability to generalize the conclusion for wider population. this study and previous related studies supports the application of the biopsychosocial model and the bga axis theory that can be applied to further understand the mechanism behind dyspepsia, which is a disease with a heterogeneous etiology. to better understand the nature of this disease, further studies still need to be done to explore the relationship between biopsychosocial aspects and dyspepsia. references 1. miwa h, ghoshal uc, fock km, gonlachanvit s, gwee ka, ang tl, et al. asian consensus report on functional dyspepsia. j gastroenterol hepatol. 2012;27(4):626-41. 2. wu jc. psychological co-morbidity in functional gastrointestinal disorders: epidemiology, mechanisms and management. j neurogastroenterol motil. 2012;18(1):13-8. 3. barry s, dinan t. functional dyspepsia: are psychological factors of relevance?. world j gastroenterol. 2006;12(7):2701-7. 4. sadock bj, sadock va. kaplan & sadock’s comprehensive textbook of psychiatry. 10th ed. philadelphia: lippincott williams & wilkins; 2007. 5. mahadeva s, goh kl. epidemiology of functional dyspepsia: a global perspective. world j gastroenterol. 2006;12(17):2661-6. 6. van oudenhove l, vandenberghe j, geeraerts b, vos r, persoons p, demyttenaere k, et al. relationship between anxiety and gastric sensorimotor function in functional dyspepsia. psychosomatic medicine. 2007;69(5):455-63. 7. timmons s, liston r, moriarty k. functional dyspepsia: motor abnormalities, sensory dysfunction, and theurapeutic options. am j gastroenterol. 2004;96(7):739-49. 8. flier sn, rose s. is functional dyspepsia of particular concern in women? a review of gender differences in epidemiology, pathophysiologic mechanisms, clinical presentation, and management. am j gastroenterol. 2006;101(3):644-53. 9. yuyuan l, yuqiang n, weihong s, hua s. the link between psychosocial factors and functional dyspepsia: an epidemiological study. chin med j. 2002;115(7):1082-4. radistrya sekaranti brahmanti, juke roslia saketi, harry saroinsong, primal sudjana: anxiety level in dyspeptic patients at the gastroenterohepatology outpatient clinic of dr. hasan sadikin general hospital bandung, indonesia althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 469 correlation between six-minutes’ walk test and quality of life in heart failure patients syifa rahmani,1 erwinanto,2 rudolf andean3 1faculty of medicine universitas padjadjaran, 2department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: the problem of heart failure patient relates with reduced functional capacity and eventually leads to declined quality of life (qol). improved qol may not relate to better functional capacity since qol is influenced by patient’s expectation to the on-going treatment. this study was conducted to investigate the correlation between six-minutes’ walk test (6mwt) as a measure for functional capacity and qol of heart failure patient in dr. hasan sadikin general hospital. methods: this cross sectional study involved 32 patients who were on planned visit at the outpatient clinic of dr. hasan sadikin general hospital bandung from september to october 2013. subjects were chosen using consecutive sampling. the correlation of 6mwt and qol assessed using modified minnesota living and heart failure questionnaire (mlhfq) was analyzed through pearson’s correlation test. results: there was a significant correlation between distance covered in 6mwt and qol (r=-0.354, p<0.05). the mean of six-minute walk distance was 277.96 (±42.17) and mean of qol score was 33.41 (±7.88). in accordance with the findings in previous studies, this study revealed correlation between the distance obtained in 6mwt and the qol score in heart failure patient. conclusions: there is correlation between 6mwt and quality of life in outpatients with heart failure at dr. hasan sadikin general hospital. [amj.2015;2(4):469–73] keywords: heart failure, quality of life, six-minutes’ walk test correspondence: syifa rahmani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281321635192, email: rahmani.syifa@gmail.com introduction heart failure incidence is reported to be increasing not only due to aging, but also due to successful current therapies of cardiac disorder patients with prolong survival.1,2 assessment of quality of life (qol) in patients with heart failure is important to evaluate health influences in holistic aspects; including physical, emotional and social function. this can be made as consideration for doctor to give individual therapy.3 clinical symptoms in the patients, which limit their activities in daily living, impair their qol.4 qol impairment in the patient may be due to psychological problems, adverse effect of treatment, social limitation, and socio-economic problems.3,5 considering those factors, qol may be irrelevant with functional capacity. the clinical symptoms are also associated with their functional capacity which can be assessed sub maximally through six-minutes’ walk test (6mwt).5,6 several studies have been conducted to investigate the correlation between 6mwt and qol.7,8 previous studies demonstrate significant correlation between the two variables (6mwt and qol).7,8 in addition to that, this study is conducted to investigate the correlation between 6mwt and qol in patients with heart failure in dr. hasan sadikin general hospital bandung. this study might be the first study discussing this issue in dr. hasan sadikin general hospital. nevertheless, the result of this study may be different compared with the previous studies since the quality of life is influenced by patient’s expectation towards the treatment outcomes. in addition, differences in ethnicity is known to be associated with different qol in distinct althea medical journal. 2015;2(4) 470 amj december, 2015 populations.9 methods an analytical cross sectional study was conducted from september to october 2013 using primary data of the patients who were on planned visit at outpatient the clinic of dr. hasan sadikin general hospital. a total of 32 subjects were determined by calculating minimum sample size. consecutive sampling technique was used as the sampling method. inclusion criteria included patients with stable chronic hf with new york heart association (nyha) functional class ii and iii, aged at least 18 years old, and were able to understand indonesian language. subjects were excluded if the patients were found to have unstable angina or myocardial infarction during last one month, pulse during rest higher than 120 bpm, systolic pressure higher than 180 mmhg, and diastolic pressure higher than 100 mmhg. other than that, the excluded patients were also those with physical limitation due to other factors besides heart failure, e.g; musculoskeletal problems and pulmonary disease, mental illness that may hinder patients from answering questionnaire, stroke in last two months, anemia, infection, and incomplete data of questionnaire. prior to that, the subjects involved in this study were given information and signed consent approved by ethical committee of the institution. the qol was evaluated using specific instrument, namely modified minnesota living with heart failure questionnaire (mlhfq), which had been translated into indonesian language. the mlhfq has comprehensive questions that measures the most relevant domain of qol related to heart failure, including physical and emotional domains.5,10 however, question about sexual activity was investigated as not valid by kaawoan.11 the mlhfq used in this study was considered as modified mlhfq consisting of 20 questions with 1−4 scale. the total score would be in the range of 20−80, where 80 indicated the poorest qol. functional capacity was evaluated by performing 6mwt which has been proved as valid, simple, safe and useful tool.12 the 6mwt was conducted in 20 m indoor corridor by single table 1 characteristics of subjects characteristics number of subject(n = 32) statistical analysis (x*) age (years) 55.31 (±9.36) gender men 13 women 19 weight (kg) 57.48 (± 10.08) height (m) 1.55 (1.47-1.72) bmi** (kg/m2) 23.07 (±4.14) occupation housewife 17 entrepreneur 7 unemployed 5 civil servants and pensioner 3 functional classification of nyha# ii (%) 27 iii (%) 5 score of modified mlhfq## 33.41 (±7.88) 6-minutes’ walk distance (m) 277.96 (±42.17) note: *x= all in mean, except for height, **bmi=body mass index, #nyha= new york heart association, ##mlhfq= minnesota living with heart failure questionnaire althea medical journal. 2015;2(4) 471syifa rahmani, erwinanto, rudolf andean: correlation between six-minutes’ walk test and quality of life in heart failure patients examiner under supervision. the procedure of the test was performed according to the protocol of american thoracic society (ats). patients were allowed to self-pace and rest as needed as they traversed back and forth along a marked walkaway. standardized phrases were used while speaking to the subjects during the tests. at the end, the total distance achieved in six minutes was measured. statistical study was analyzed using statistical product and service solution version 13.0. saphiro wilk test was used for determining distribution of data in each variable. if the data were normally distributed, pearson correlation test was performed to analyze the correlation between the distance of 6mwt and the qol score. the score of p<0.05 meant that it was statistically significant. results the characteristics of subjects, six-minutes’ walk distance and modified mlhfq score, are summarized in table 1. all subjects successfully accomplished 6mwt. some subjects stopped for a while in the middle of the test due to mild dyspnea, then continued their walking. there were no severe complaints occurred during or after the tests. saphiro wilk normality test showed that the data of modified mlhfq score and 6mwt distance were normally distributed. pearson correlation test between distance obtained in 6mwt and score of modified mlhfq revealed weak and significant negative correlation (r=0,354, p=0,047), which meant that 6-minutes’ walk distance was inversely correlated to modified mlhfq score (figure 1). discussion measurement of qol is considered important to evaluate the influence of disease in patients’ life and how the patients confront it.3 the mean of modified mlhfq score in this study (33.34 ± 7.88) was lower than the study in brazil, which suggested better qol.7,8 ethnicity is known to have association with different qol in distinct populations.9 moreover, cross-cultural study between individualism and collectivism showed that country of residence has an overwhelming impact on qol (f4,666=59.31, p<0.001).13 other factors influencing qol in heart failure patients are nyha functional classification, personality motivation, gender, and age.4,14 the 6mwt is beneficial to observe functional status and predict mortality of the patients with heart failure.6,15 in this study, the mean of six-minutes’ walk distance (6mwd) was 277.96 meters (sd ±42.17) which was lower than that of the studies in brazil.7,8 the difference may be due to several factors such as body height, body weight, figure 1 correlation between 6-minutes’ walk distance and quality of life althea medical journal. 2015;2(4) 472 amj december, 2015 gender, motivation, and previous experience in performing the test.16 morbidity, nyha functional classification, medication, and age also influence the distance in 6mwt.16 this study elucidates that there was significant negative correlation between the distance covered in 6mwt and the qol in hf patient (r=-0.354, p<0,05). the longer the distance in 6mwt implicates lower modified mlhfq score, which means better qol. the correlation may occur since mlhfq consists of questions measuring the physical ability in hf patient, such as walking and climbing stairs.10 declined physical ability lowers the qol of heart failure patients.5 in the other hand, 6mwt reflects individual’s ability to perform daily activities.6 similar to the previous study, the result of this study showed the correlation between six-minutes walk distance and qol in heart failure patients.7,8 santos et al.7 showed significant and strong correlation (r=-0.62) between 6mwt and qol measured by mlhfq in brazilian samples. however, the study involved man only.7 other study conducted by nogueira et al.8 in brazil successfully showed the correlation between the two variables (r=-0.5). however, the 6mwt was performed twice in every subject which was different in once in every subjects in this study.8 different length of corridor for the 6mwt between ats recommendation (30 meters) and this study (20 meters) might be a limitation for this study.12 shorter corridor will require patients to take more time to reverse their directions.12 however, there are no significant effects for the length ranging from 15 to 49.2 meters.12 selection of 6mwt location according to ats is necessary to improve validity. in conclusion, the 6mwt correlates with quality of life measured by modified mlhfq. better exercise tolerance is associated with better qol of the outpatients with heart failure at dr. hasan sadikin general hospital. references 1. robert o. bonow m, douglas l. mann m, douglas p. zipes m, peter libby m. braunwald’s heart disease a textbook of cardiovascular medicine. 9th ed. philadelphia: elsevier; 2012. 2. mosterd a, hoes aw. clinical epidemiology of heart failure. heart. 2007;93:1137−46. 3. coelho r, ramos s, prata j, bettencourt p, ferreira a, cerqueira-gomes m. heart failure and health related quality of life. clin pract epidemiol ment health. 2005;1:19. 4. lewis ef, lamas ga, o’meara e, granger cb, dunlap me, mckelvie rs, et al. characterization of health-related quality of life in heart failure patients with preserved versus low ejection fraction in charm. eur j heart fail. 2007;9(1):83−91. 5. dunderdale k, thompson dr, miles jnv, beer sf, furze g. quality-of-life measurement in chronic heart failure: do we take account of the patient perspective? eur j heart fail. 2005;7(4):572−82. 6. enright pl. the six-minute walk test. respiratory care. 2003;48(8):783−5. 7. santos jja, brofman prs. six-minute walk test and quality-of-life in heart failure a correlative study with a brazilian sample. insuf cardiaca. 2008;3:72−5. 8. nogueira id, servantes dm, nogueira pa, pelcerman a, salvetti xm, salles f, et al. correlation between quality of life and functional capacity in cardiac failure. arq bras cardiol. 2010;95(2):238−43. 9. riegel b, moser dk, rayens mk, carlson b, pressler sj, shively m, et al. ethnic differences in quality of life in persons with heart failure. j card fail. 2008;14(1):41−7. 10. rector ts, carson pe, anand is, mcmurray jj, r.zile m, mckelvie rs, et al. assessment of long-term effects of irbesartan on heart failure with preserved ejection fraction as measured by minnesota living with heart failure questionnaire in the irbesartan in heart failure with preserved systolic function (i-preserve) trial. circ heart fail. 2012;5:217−25. 11. kaawoan aya. hubungan self care dan depresi dengan kualitas hidup pasien heart failure di rsup prof dr r.d. kandou manado [dissertation]. depok: universitas indonesia; 2012. 12. american thoracic society. ats statement: guidelines for the six-minute walk test. am j respir crit care med. 2002;166(1):111−7. 13. fu s-yk. the relationship between culture, attitude, social networks and quality of life in midlife australian and taiwanese men and women [dissertation]. brisbane: queensland university of technology; 2006. 14. mathisen l, andersen m, veenstra m, wahl a, hanestad b, fosse e. quality of life can both influence and be an outcome of general health perceptions after heart surgery. health qual life outcomes. 2007;5:27. 15. arslan s, erol mk, gundogdu f, sevimli s, aksakal e, senocak h, et al. prognostic althea medical journal. 2015;2(4) 473syifa rahmani, erwinanto, rudolf andean: correlation between six-minutes’ walk test and quality of life in heart failure patients value of 6-minute walk test in stable outpatients with heart failure. tex heart inst j. 2007;34(2):166. 16. enright pl, mcburnie ma, bittner v, tracy rp, mcnamara r, arnold a, et al. the 6-min walk test: a quick measure of functional status in elderly adults. chest. 2003;123(2):387−98. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 245 knowledge of personal hygiene among food handlers in canteen at faculty of medicine, universitas padjadjaran, october to november 2012 drasthya zarisha,1 budi darmawan,2 ardini s. raksanagara,3 elsa pudji setiawati3 1faculty of medicine universitas padjadjaran, 2department of nuclear medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of public health faculty of medicine, universitas padjadjaran abstract background: food borne diseases are caused by contamination of pathogenic microorganism and are still a major health problem throughout the world. there are 1,8 billion cases of diarrhea which mostly were caused by food contamination in 2005. food handlers are at risk of contaminating microorganism towards food they handle. the process of transmission can be prevented by practicing good hygiene while processing and handling food. the objective of this study was assessing knowledge among food handlers regarding their personal and food hygiene at canteen in faculty of medicine, universitas padjadjaran. methods: a descriptive study was conducted during the period of october to november 2012 to 14 food handlers in the canteen at faculty of medicine, universitas padjadjaran using 26 validated questions divided into 3 major parts, 14 questions for knowledge of hand washing, 9 questions for knowledge of utilization of clean water and 3 questions for knowledge of waste management. the scores were classified as good, moderate, and poor. data were analyzed using frquency distribution. results: majority of the respondents was male and common age group was 20–29 years old. eight of the respondents were senior high school graduates. based on working experience, majority of food handlers had been working for one and three years. none of the respondents had good knowledge. only 12 and 2 respondents had moderate and poor knowledge, respectively. conclusion: none of the respondents had good knowledge regarding hand washing, utilization of clean water and waste management. therefore, there is a need in providing more education about those aspects. [amj.2015;2(1):245–9] keywords: clean water, food handlers, hand washing, knowledge, waste management correspondence: drasthya zarishai, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85624944464 email: zarisha.drasthya@gmail.com introduction one of the vision by the ministry of health of the republic of indonesia in ‘indonesia sehat 2010’ is that indonesian people live in a clean environment and have healthy behavior.1 based on indonesian strategic plan on healthcare (renstra) year 2010–2014, there is a need in shifting the health paradigm of indonesian healthcare system from curative to preventive measure.2 one of the measures proposed by the ministry of health of indonesia was healthy and clean behavior (perilaku hidup bersih dan sehat/phbs). it is one of the efforts to elevate people’s health through preventive actions.3 furthermore, the ministry of health of indonesia produced some indicators for phbs measure based on social order of society, such as at home, at work, at school, at various health institution and at public place.3 this study focused on indicator of phbs at work, since there are only few studies conducted regarding this measure in indonesia and there are no reliable data that show proportion of workers who have been performing healthy and clean behavior at work until now. a person who has a direct contact with food and the utensils needs for preparing, processing until serving food were called food handlers.4 food handlers were the people who are at risk of contaminating or transmitting microorganism toward food they handle, through hands, nose or mouth.5 food borne illness are diseases caused by contamination of pathogenic microorganism in food consumed6 and still become a major public health problem throughout the world.7 there are althea medical journal. 2015;2(2) 246 amj june, 2015 1,8 billion cases of diarrhea with majority of cases caused by food contamination in 2005.8 indonesian health profile in 2010 recorded that diarrhea and gastroenteritis were ranked as the number one in-patient illness cause.9 the process of transmission can be prevented by practicing good hygiene while processing and handling food. canteen or cafeteria is an example of food retail business and service where most people consume food and drinks.10 it is also one of the working places of food handlers. students and staffs as healthcare providers frequently visit canteen and consumed food and drinks; therefore they need to be aware about the possibilities of having food borne illness through unsafe process of food handling. knowledge is one of the predisposing factors that facilitate a person’s behavior.11 a good knowledge of health (health literacy) can help a person to be aware on health and the community’s health.1 therefore, the main objective of this study was assessing knowledge among food handlers regarding their personal and food hygiene in canteen at faculty of medicine, universitas padjadjaran which demonstrate their understanding toward phbs indicators at working places. methods a descriptive study was conducted in the canteen at faculty of medicine, universitas padjadjaran and total of 14 food handlers were involved. sampling method used was total sampling. the data were collected using questionnaire, during the period of october to november 2012. inclusion criteria for the study were food handlers who were presently employed and the exclusion criteria were any food handlers who refuse to involve or being absent during the period of data collection. prior to filling the questionnaire, respondents were given informed consent that included explanation and complete information about the objective of the study. respondents gave voluntary consent regarding their involvement. questionnaire was pre-tested among food handlers with similar characteristics to the table 1 characteristics of food handlers characteristics n=14 gender male 8 female 6 age (years old) 20–29 6 30–39 2 40–49 3 50–59 3 educational background elementary school 2 junior high school 4 senior high school 8 working experience (years) 1 3 3 3 7 1 12 2 13 3 15 1 34 1 althea medical journal. 2015;2(2) 247 sample and was analyzed using computer. alpha cronbach test was carried out and the reliability coefficient was 0.91.12 few questions were modified and excluded to maximize reliability. twenty-six questions were divided into 3 major parts, 14 questions for knowledge of hand washing, 9 questions for knowledge of utilization of clean water and 3 questions for knowledge of waste management. the scores derived from the questionnaire were calculated using computer. mean and standard deviation were calculated from the scores and the results classified as good, moderate, and poor.13 data were analyzed using frequency distribution results majority of the respondents were male and common age group was 20–29 years old. eight of the respondents were senior high school graduates. based on working experience, majority of food handlers had been working for one and three years in canteen at faculty of medicine, universitas padjadjaran. (table 1) furthermore, according to the knowledge of handwashing procedures, all respondents understood the need to wash their hands before handling and serving food to the costumers. thirteen respondents were aware about the correct hand washing procedure, and understood the steps of good hand washing procedure. only eight of the respondents had good knowledge regarding the importance of hand washing after smoking. all respondents understood the need to use clean water for washing raw food before cooking it. only 9 respondents were aware about the importance of using clean and safe water during the process of making costumer’s drinks, and only 10 respondents were aware about using clean water in making ice cubes. (table 3). the knowledge of waste management was asked using 3 questions which were how to process the waste, to prevent dissemination of dirt and to clean the rubbish bin regularly. in this study, all subjects understood the importance of cleaning rubbish bin regularly and also the correct way to prevent dissemination of dirt into working area. (table 4) personal hygiene knowledge among the food handlers was graded into good, moderate, and poor. this study found that none of the respondents reached good knowledge, also only 12 respondents had moderate knowledge and 2 respondents had poor knowledge drasthya zarisha, budi darmawan, ardini s. raksanagara, elsa pudji setiawati: knowledge of personal hygiene among food handlers in canteen at faculty of medicine, universitas padjadjaran, october to november 2012 table 2 knowledge of respondents regarding hand washing knowledge on hand washing correct answer (n=14) incorrect answer (n=14) 1. hand washing prior to handling food 14 0 2. hand washing prior to serving food 14 0 3. correct method on hand washing 13 1 4. purpose of hand washing 13 1 5. correct time of hand washing after urinate 12 2 after defecation 14 0 after handling money 10 4 before serving food 13 1 after smoking 8 6 after coughing, sneezing or shaking people’s hand 10 4 after throwing or cleaning rubbish 11 3 6. knowledge regarding dirt that could be cleaned with washing hand 13 1 7 step(s) of hand washing (1) 13 1 8 step(s) of hand washing (2) 13 1 althea medical journal. 2015;2(2) 248 amj june, 2015 discussions one out of the five main risk factors of food borne illness is bad personal hygiene in food retail services as being stated in the center for disease control and prevention’s report ‘surveillance for food borne disease outbreaks-united states’.10 in this study, most respondents were males. a study conducted in hospital and medical college in solapur, india5 also stated that their majority of study populations were males. eight out of 14 food handlers have senior high school graduates as their education background. majority of the subjects aged are 20–29 years old. a study conducted by nee et al.14 showed that mostly food handlers have senior high school graduates as their educational background. twelve out of fourteen respondents have moderate knowledge, but none of the respondents scored well or in another word have good knowledge regarding healthy and clean behavior. this finding is similar to several studies regarding personal hygiene which were conducted among food handlers in other countries.5,14 all respondents understood the needs of having their hand washed after defecate and before they handle food. thirteen respondents were aware that they need to wash their hands before serving the food and this result is consistent with the finding from the study conducted by arunrao et al.5 all respondents realized the importance of washing raw food using clean and safe water. water obtained from unhygienic sources could be contaminated by microorganisms which are pathogenic to the human being.15 a study conducted by kitagwa16 observed that only 27% of their study population knows the importance of using safe and clean water to prevent contamination of microorganisms in food. overall, the knowledge regarding waste management among the respondents were good because all respondents were aware about the correct way to prevent dirt dissemination and regularly cleane the rubbish bin. based on who15, these 2 measures are important to prevent contamination of food. eight out of fourteen respondents who have moderate knowledge regarding the cleanliness also have senior high school graduates as their education background. having high level of education might influence the capability table 4 knowledge of respondents regarding waste management knowledge on waste management correct answer (n=14) incorrect answer (n=14) 1 correct way of processing waste 12 2 2 way to prevent dissemination of dirt 14 0 3 cleaning rubbish bin regularly 14 0 table 3 knowledge of respondents regarding clean water utilization knowledge on clean water utilization correct answer (n=14) incorrect answer (n=14) 1 clean water to wash raw food material 14 0 2 characteristics of clean and safe water 13 1 3 characteristics of clean and safe water (2) 13 1 4 correct time to use clean water washing raw vegetables and fruits 13 1 washing cooking utensils 12 2 washing raw food 13 1 added to processed food 12 2 making ice 10 4 making drinks 9 5 althea medical journal. 2015;2(2) 249 of the respondents in having better health knowledge.17 the ability to read, speak, write or listen are the fundamentals of a person’s ability to have a better understanding in their personal health.17 healthcare providers are the majority of the consumers in this canteen and they should understand and give concern about food borne illness and the way it transmits among food handlers.5 the result of this study showed that there are no respondents who have a good knowledge regarding phbs. therefore, there is a need in providing more education about personal hygiene which focuses on phbs to improve the health knowledge of the food handlers whom are involved in preparing food. this intervention can be done by all faculty members , particularly the students and other faculty members who are health physicians and healthcare workers. limitation of this study is during the study there was no evidence of diarrhea cases and food poisoning among students and lecturers who consumed food from those respondents. furthermore, further study should be conducted with more samples references 1. notoatmodjo s. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta; 2007. 2. kemenkes ri. rencana strategis kementerian kesehatan republik indonesia. jakarta: kementerian kesehatan republik indonesia; 2010. 3. kemenkes ri. peraturan menteri kesehatan republik indonesia: pedoman pembinaan perilaku hidup bersih dan sehat. jakarta: kementerian kesehatan republik indonesia; 2011. 4. kemenkes ri. keputusan menteri kesehatan ri tentang persyaratan hygiene sanitasi jasaboga. jakarta: kementerian kesehatan republik indonesia; 2003. 5. takalkar aa, kumavat ap. assesment of personal hygiene of canteen workers of government medical college and hospital, solapur. national journal of community medicine. 2011;2(3):448–51 6. slamet js. kesehatan lingkungan. jogjakarta: gadjah mada university press; 2004. 7. us food and drug administration. hazard analysis & critical control points (haccp). silver spring: us fda; 2004. [cited 2012 april 24] available from: http://www.fda. gov/food/guidanceregulation/haccp/ 8. who. fact sheet no 237: food safety and foodborne illness. 2007 [cited 2012 april 24]: available from: https:// f o o d h y g i e n e 2 0 1 0 . f i l e s . w o r d p r e s s . c o m / 2 0 1 0 / 0 6 / wh o fo o d _ s a fe t y _ fa c t sheet.pdf 9. kemenkes ri. profil kesehatan indonesia 2010. jakarta: kementerian kesehatan ri; 2010. 10. us department of health and human service, food and drug administration, center for food safety and applied nutrition. managing food safety: a manual for the voluntary use of haccp principles for operators of food service and retail establishment. 2006. [cited 2012 april 24] available from:http:// seafood.oregonstate.edu/.pdf %20links/ m a n a g i n g % 2 0 f o o d % 2 0 s a f e t y % 2 0 -%20a%20manual%20for%20the%20 voluntary%20use%20of %20haccp%20 p r i n c i p l e s % 2 0 fo r % 2 0 o p e ra to r s % 2 0 of%20food%20service.pdf 11. notoatmodjo s. promosi kesehatan: teori dan aplikasi. jakarta: rineka cipta; 2007. 12. dahlan ms. besar sampel dan cara pengambilan sampel. jakarta: salemba medika; 2010. 13. arikunto s. prosedur penelitian: suatu pendekatan praktik. jakarta: rineka cipta; 2006. 14. nee so, sani na. assessment of knowledge, attitudes and practices (kap) among food handlers at residential college and canteen regarding food safety. sains malaysiana. 2011;40(4):403–10. 15. who. five keys to safer food manual. france: who press; 2006. 16. kitagwa wg, bekker jl, onyangp ro. an assessment of knowledge, attitudes and practices of food handlers in food kiosks in relation to food hygiene in eldoret, kenya. ijcr. 2012;4(04):127–38. 17. baker dw. the meaning and the measure of health literacy. j gen intern med. 2006; 21(8):878–83. drasthya zarisha, budi darmawan, ardini s. raksanagara, elsa pudji setiawati: knowledge of personal hygiene among food handlers in canteen at faculty of medicine, universitas padjadjaran, october to november 2012 althea medical journal. 2015;2(2) 298 amj june, 2015 the role of socioeconomic factors contributed to the prevalence of children under five years old with small stature in jatinangor anggie indari1, elsa pudji setiawati2, rodman tarigan3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: indonesia is on the fifth in world population for children with small stature. it could affect to their future, so growth disorders should be detected as early as possible. the influence of growth disorders is inseparable from the socioeconomic condition of the family. this study aims to analyze the influence of socioeconomic based on education, occupation and family income towards small stature children under five years old in jatinangor. methods: this was a study of analytic cross sectional with multi-stage proportionate consecutive sampling. 110 samples of children under five years of age (12–59months) from 12 villages (6087 children) in jatinangor sub district were taken on october and november 2012. their height was measured using a microtoise based on who growth chart and the socioeconomic status was measured using questionnaire completed by their mother results: there were 32 children (29,1%) with small stature. the relationship between maternal education with short stature (p=0.310), father’s education with small stature (p=0.368), mother’s occupation with small stature (p=0.774), father’s occupation with small stature (p=0.524) and family income with small stature (p=0.890) after it was examined using chi-squre test were not significant (p>0.05). conclusion: in jatinangor, there are still many children with small stature under five years old and the socioeconomic factors do not have any relationship with this condition. [amj.2015;2(1):298–303] keywords: children under five years, small stature, socioeconomic correspondence: anggie indari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285694806011 email: anggie.indari@yahoo.com introduction indonesia is the fifth highest country in the world with a population of children with small stature.1 in 2010, there were approximately 35.7% of indonesian children under five years of age with small stature. in west java, it was 33.7%.2 children’s growth and development must be maintained and nurtured properly, because children are the future generation. therefore, growth disorders should be detected as early as possible. small stature is one of the children’s growth disorders characterized by children’s smaller height (<-2 sd on who growth charts) compared to children with similar age and gender. 3both children’s growth and development cannot be separated from the family role and the surrounding environment, including the family’s socioeconomic conditions. adler and newman4 stated that children who grow within the high socioeconomic families will be different from a child with relatively low socioeconomic families. the socioeconomic status can be measured by education, occupation, and family income. parent’s education will affect beliefs, confidence and parental behavior, which will have an impact on parenting every day. parents with a higher education level tend to know more knowledge that can be applied on children’s growth and development progress. based on data in terms of education level, 50% of workers in jatinangor are primary school graduates, and only 4.1% is a college graduate.5 another indicators for socioeconomic status are occupation and family income.4 occupation is closely related to income. occupation with a higher level will produce a bigger income that can help the economy of the families, and althea medical journal. 2015;2(2) 299 families with higher income level tend to select food material with better quality and quantity. in terms of occupation, 70% of people in jatinangor, working as farm workers, traders, laborers, employees and entrepreneurs. those occupations have an uncertain income that will affect their daily lifestyle. this study was undertaken to analyze the influence of socioeconomic based on education, occupation, and family income toward children with small stature under five years in jatinangor. methods this was an analytical study with crosssectional approach. this study was conducted in 12 villages in jatinangor sub-district, sumedang district, west java province on october and november 2012. the populations in this study were mother and children under five years (12–59 months) in 12 villages in jatinangor, which is in the cikeruh village, hegarmanah, cipacing, cibeusi, sayang, cileles, mekargalih, jatiroke, cisempur, cintamulya, cilayungand jatimukti village. from 6087 children, 110 children had been taken to be sampled. the method for the calculation was the method of slovin, while the sampling method was conducted by a multi-stage proportional consecutive sampling. in this method, the number of samples was taken, divided by the proportion of children under five years in the village as compared to the overall number of children under five years in jatinangor. the results of the calculations showed in table 1 data was collected by measuring child’s height using microtoise. then the results were plotted on the who growth chart. if the child’s height was less than-2 sd (standard deviation), the child was categorized as small stature.3 socioeconomic status was obtained by filling out the questionnaire directly by the mothers. parental education was divided into three levels, which is the primary education level, secondary and high education level. the parent’s job was also divided into 3 groups, namely formal occupation (civil servants, private employees, military, police), nonformal occupation (laborers, traders, selfemployed), and not working, including retired or housewives.6 family income was divided into two categories based on the minimum wage 2012 at sumedang district, which is to income less than idr1,240,000 classified into low categories, whereas if the above, classified as high category.7 the data obtained were then sorted regarding its completeness and then inserted into the computer to be processed and analyzed using the open sources program. the data analysis included calculating the prevalence of short stature, bivariate analysis with the chi-square test between each variable that is, education with small stature, occupation with small stature, and family income with small stature, and multivariate analysis with binary logistic analytic test to see the influence of the socioeconomic families toward children with small stature. anggie indari, elsa pudji setiawati, rodman tarigan: the role of socioeconomic factors contributed to the prevalence of short stature children under five years in jatinangor table 1 the number of samples per village no villages number of samples 1 cikeruh 12 2 hegarmanah 12 3 cipacing 18 4 cibeusi 7 5 sayang 10 6 cileles 7 7 mekargalih 8 8 jatiroke 8 9 cisempur 8 10 cintamulya 8 11 cilayung 6 12 jatimukti 6 total 110 child althea medical journal. 2015;2(2) 300 amj june, 2015 results the prevalence of small stature occurred in children under five years in jatinangor was 29.1%. the majority of parents of the children with small stature underwent the education level until primary and secondary level, where the parents have nearly the same percentage. only 9% of the parents have higher education level (figure 1). there was 63% (20 people) of the children with small stature have a housewife mother, 34% was informal worker and only 3% was a formal worker (figure 2). there was 81% (26 people) of the short stathere are 81% (26 people) of the children with small stature having a father who was an informal worker. among those, 19 people were an entrepreneur and 7 people were laborers. only 19% was formal worker (figure 3). based on the level of family income, 56% (18 people) of children with small stature had parents with incomes below the minimum wage 2012 at sumedang district which was below idr 1,240,000 (figure 4). the relationship between maternal education with short stature (p=0.310), father’s education with short stature (p=0.368), mother’s occupation with short stature (p=0.774), father’s occupation with short stature (p=0.524) and family income with short stature (p=0.890) that was examined using chi-square test were not significant (p>0.05). based on the sestet results, it can be concluded, at the 95% confidence level, there was no correlation between the mother’s education, father’s education, mother’s occupation, father’s occupation and family income with children with small stature under five years in jatinangor. the results of binary logistic test that measures the influence socioeconomic figure 1 education of mother and father of children with small stature figure 2 mother occupations in children with small stature althea medical journal. 2015;2(2) 301 families based on education, occupation and family income toward children with small stature under five years in jatinangor was not significant with the p value 0.474>0.05. based on these test results, it can be concluded, at 95% confidence, there was no influence of socioeconomic families based on education, occupation and family income toward children with small stature under five years in jatinangor. discussions prevalence of short stature children under five years in jatinangor was classified as moderate (29.1%). the result of this study does not have much difference with the incidence of short stature children in west java in the amount of 33.7%. the prevalence obtained in this study is also not much different from indonesian basic health survey (riset kesehatan dasar/ riskesdas). data from riskesdas2 showed that in 2010, there were 35.7% of children under five years of age have small stature. figure 1 shows that children with small stature mostly had parents with primary education, and secondary education level. only 9% of the children with small stature had parents with higher educational level backgrounds. the results were consistent with the theory that suggests that parental education affects the development of children, where the parents with higher education have more knowledge to be applied in daily parenting style. parental education will affect the confidence, belief, and parental behavior, which will have an impact on parenting style everyday.4,8 in figure2 and 3, shows parental occupation of children with small stature. based on the occupation mother, the mother who is either a worker or a housewife may have children with small stature. mother’s occupation, whether they work or not, can produce negative and positive effects on children. a study by glick9 mentioned that mothers who work will help the family economically that will produce beneficial effects for the nutritional status of the children, so that the children can grow and develop optimally. on the other hand, mother who work, especially who works with a dense time, did not have enough time to care for their children, including controlling the nutritional needs for the child. figure 3 showed father’s occupation in children with small stature. based on the results of this study, it seems that the majority anggie indari, elsa pudji setiawati, rodman tarigan: the role of socioeconomic factors contributed to the prevalence of short stature children under five years in jatinangor figure 3 father occupations in children with small stature figure 4 family incomes in children with small stature althea medical journal. 2015;2(2) 302 amj june, 2015 of children with small stature had a father who worked as informal workers such as laborers or self-employed. this father’s occupation will be related to the results of the studies about family income that showed in figure 4. in that figure, it can be seen that most of the children with small stature have parents with incomes below the minimum wage in sumedang. both of these results are related, where the work will affect family income. the higher a person’s rank or position in the job, the larger the income of the family owned. almost in all countries, children of parents with low incomes have worse health conditions compared to children with parents who live wealthy and prosperous. parental income may be related to the child’s health because it can affect the quality and quantity of health care services for children.10 further result of the study showed that there was no relationship between socioeconomic factors toward the prevalence of children with small stature under five years in jatinangor. these results different with the studies conducted in johannesburg11, where socioeconomic families influence short stature in children. it can happen due to the possibility of socioeconomic families that have no direct influence toward development of children. in other studies, there are factors that are directly related toward short stature in children, such as genetics, nutrition or chronic disease which may influence the development of children.12,13 in the conclusion, in jatinangor, there are still many children with small stature under five years and the socioeconomic factors have not relationship with that condition. further study should be carried out to find other factors that can cause children with small stature under five years old. references 1. unicef indonesia. indonesia sets targets to improve child nutrition. jakarta: unicef indonesia; 2010 [cited 2012 april 28] available at: http://www.unicef.org/ indonesia/media_12591.html. 2. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2010. jakarta : kementrian kesehatan republik indonesia; 2010. 3. who. who child growth standards: training course on child growth assessment. geneva: who press; 2008. p. 22. 4. adler ne, newman k. socioeconomic disparities in health: pathways and policies. health affairs. 2002;21(2):60–76. 5. badan perencanaan dan pembangunan daerah (bappeda) sumedang. laporan akhir studi kelayakan kawasan jatinangor sebagai kawasan perkotaan. sumedang: badan perencanaan dan pembangunan daerah; 2009. 6. pusat statistik pendidikan badan penelitian dan pengembangan. sistem pendidikan. jakarta: departemen pendidikan nasional republik indonesia; 2009. 7. pemerintah provinsi jawa barat. upah minimum kabupaten/kota di jawa barat tahun 2012. bandung: pemerintah provinsi jawa barat; 2012. 8. egerter s, bravemen p, sadegh-nobari t, grossman r, dekker m. issue brief 6 education and health: education matters for health. robert wood johnson foundation commission to build a healthier american. 2009. [cited 2012 april 28] available from: http://www. commissiononhealth.org/pdf/c270deb3b a 4 2 4 f b d b a e b 2 c d 6 5 9 5 6 f 0 0 e / issue%20brief%206%20sept%2009%20 -%20education%20and%20health.pdf 9. glick p. women’s employment and it’s relation to children’s health and schooling in developing countries: conceptual links, empirical evidence, and policies. cornell food and nutrition policy program working paper no 131. 2002. [cited 2012 april 28] available from: http://ssrn. com/abstract=424101 or http://dx.doi. org/10.2139/ssrn.424101 10. mayer se. the influence of parental income on children’s outcomes: raising children in new zealand. wellington: knowledge management group, ministry of social development new zealand. 2002. p. 37. 11. willey ba, cameron n, norris sa, pettifor jm, griffith pl. socio-economic predictors of stunting in preschool children a population-based study from johannesburg and soweto. s afr med j. 2009;99(6):450–6. 12. gardner dg, shoback d, editors. greenspan’s basic and clinical endocrinology. 8thed. san fransisco: the mcgraw-hill companies;2007. 13. senbanjo io, adeodu oo, adejuyigbe ea. influence of socio-economic factors on nutritional status of children in a rural community of osun state, nigeria. osun state, nigeria: department of pediatrics & child health, obafemi awolowo university teaching hospitals;2007. althea medical journal. 2015;2(2) 303 althea medical journal. 2015;2(3) 339 nutritional status and infectious disease of undernourished children under five in desa cipacing, jatinangor subdistrict, west java, from april to december 2012 palomina caesarea nurhasanah,1 dewi marhaeni diah herawati,2 resnaldi3 1faculty of medicine universitas padjadjaran, 2department of medical nutrition faculty of medicine universitas padjadjaran, 3department of nuclear medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: undernutrition frequently occurs in children under five. if not treated, it will cause acute health effects and affect on cognitive development, social, physical work capacity and productivity. undernutrition can be accompanied by the presence of infectious disease that can worsen the children’s nutritional status. this study aimed to describe the nutritional status and infectious disease of undernutrition children under five in jatinangor subdistrict. methods: a qualitative study was carried out to 7 parents and undernourished children under five, in desa cipacing, jatinangor. it was conducted from april to december 2012. the inclusion criterias were undernourished children under five with a history of infectious disease in the previous year, and the parents were willing to participate in this study. exclusion criteria were parents and/or the children who were not at home when the collection of the data was conducted.. data collection was conducted using measurement of nutritional status, in depth interview and environmental observation. the data were presented in tables, figures and narration. results: three subjects with undernutrition (-3sd to -2sd) and four subjects with severe undernutrition (<3sd). factors affecting poor nutritional status were weight loss, no significant weight gain, diet and eating habit, and onset of disease. commonly occurred infectious diseases were common cold, diarrhea, fever and cough. some factors affecting infectious diseases were family member transmission, immunization, and treatment behavior. conclusions: poor nutritional status and infectious diseases contribute to undernutrition in children under five. [amj.2015;2(3):339–45] keywords: children under five, infectious disease, nutritional status, undernutrition correspondence: palomina caesarea nurhasanah, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281321081108 email: palominacnh@gmail.com introduction the millennium development goals (mdgs) is an objective measure used globally to measure human development and poverty reduction. one of the indicators of mdgs is achieved through lowering the prevalence of children with undernutrition and severe undernutrition. undernutrition is one type of malnutrition that frequently occurs in infants.1 undernutrition and malnutrition itself can be determined by assessment of nutritional status using anthropometric parameters and weightfor-age, height-fo-age, or weightfor-height indices. undernutrition can cause several acute effects on health and long-term effects on cognitive and social development, physical work capacity and productivity if not treated. infectious diseases and malnutrition are major causes of mortality and morbidity in children in the developing country.2,3 based on a study, undernutrition may cause infectious disease because children have a low immune system so they are vulnerable to the disease.4 infectious diseases which frequently arise are diarrhea, helminthes althea medical journal. 2015;2(3) 340 amj september, 2015 infections, bronchopneumonia, and many more.4 undernutrition, infectious diseases and immune system form a simple cycle. if a person with normal nutritional status got an infectious disease but the infection is not treated, consequently, the disease will lower a person's nutritional status which will have an impact on the immune function.5,6 undernutrition is a predisposing factor to infection because it can lower the body's ability to invade the pathogen.3 furthermore, infectious diseases can also cause undernutrition and make a cycle.2 undernutrition–infectious disease cycle occurs when undernutrition increases the susceptibility to infectious diseases that can result in decreased food intake.3,6 infectious diseases mediate the undernutrition by reducing food intake, decreasing absorption of nutrient, increasing nutritional needs and also relieving endogen nutrients.3,6 infectious diseases also increase basal metabolic rate by increasing the body temperature therefore increasing the nutrient needs for metabolism.3 according to data from west java’s health profile, the incidence of undernutrition and severe undernutrition in kabupaten figure 1 undernutrition–infectious disease cycle figure 2 relation between infection and undernutrition althea medical journal. 2015;2(3) 341 sumedang (13.49%) exceeded the incidence of west java (12.28%).7 based on data in jatinangor 2011, desa cipacing, sumedang has the greatest incidence of undernutrition and severe undernutrition. this study aimed to describe the nutritional status and infectious disease of undernourished children under five in desa cipacing. methods a qualitative study8 was carried out to 7 parents who had undernourished children under five in desa cipacing, jatinangor. the study was conducted from april to december 2012. the study used the purposive sampling technique.8 the inclusion criteria were undernourished children under five. those children have a history of infectious disease in the previous year. their parents were willing to participate in this study. the exclusion criteria were parents and/or children who were not at home when the collecting of data was performed. this study used several methods to collect data. the nutritional status of children were determined by measuring the weight, height, and age. the nutritional status was obtained by using weight-for-age index and the ministry of health’s standard. an in-depthinterview was carried out to identify the presence or the experience of infectious disease. observation of the environment was also conducted to identify the eating habit of the children after collecting data, the initial stage for data analysis was the univariable analysis presented in tables and narrative text about the nutritional status and infectious disease of children under five. furthermore, after interview records were transcribed, the qualitative data analysis was performed by summarizing, coding and categorizing the obtained data. the last step was making conclusions.8 results the nutritional status and infectious disease of undernourished children under five in table 1 shows the result of anthropometric measurement and semi-structural interviews from seven respondents. seven subjects included in the study had body weight under the red line using the growth chart in kartu menuju sehat (kms). factors which affected the nutritional status of undernourished children under five were weight development, eating habit and diet, and also onset of disease. these factors were informed by the subject’s parents during the interview process. all subjects; parents acknowledged that there were weight loss from weight measurement in august by mhc up to weight measurement in october. in addition, to weight loss, no specific weight gain was also considered as the cause of children had under nutritional status. there was also subjects who experienced weight loss and no weight gain. problems of eating habits in these subjects was another condition that made them in undernourishedl status. thisproblem of eating habits could be in terms of quantity, quality, or type of foods. for example, one of the subjects had difficulty in eating rice because the subject is scared to it. decreased appetite was also the cause of these subjects who would not eat. based on the interviews, all subjects ate twice to three times a day. the types of meals given to the subjects were rice, vegetables, meatballs, tempeh, tofu, instant noodles and fruits. instant porridge purchased in a mini market was given to the subject who cannot table 1 characteristic of undernourished children under five sample age(month) weight (kg) nutritional status r1 13 6.7 -3sd sd -2sd undernutrition r2 27 8 < -3sd severe undernutrition r3 30 10 -3sd sd -2sd undernutrition r4 48 10 < -3sd severe undernutrition r5 29 8.5 < -3sd severe undernutrition r6 33 9 < -3sd severe undernutrition r7 28 10 -3sd sd -2sd undernutrition palomina caesarea nurhasanah, dewi marhaeni diah herawati, resnaldi: nutritional status and infectious disease of undernourished children under five in desa cipacing, jatinangor subdistrict, west java, from april to december 2012 althea medical journal. 2015;2(3) 342 amj september, 2015 eat rice. in addition, most of the subjects also ate snacks bought in shops or street vendors like biscuits, dodol, cireng, chocolate cake and chocolate. infectious diseases having arisen during children development was also one of the reasons the subject had under nutritional status. moreover, in the previous years, each child had several symptoms or diseases. based on interviews, 8 children had common cold, 6 children had diarrhea, 4 children had fever, 3 children had cough and 1 child had other symptom. almost all study subjects had common cold in the previous year and some of the subjects were interspersed with cough and figure 3 mapping concept figure 4 unicef conceptual frameworks, adapted from unicef12 althea medical journal. 2015;2(3) 343 fever. diarrhea was also a common disease in the subject and one of the subjects had a helminthes infection. some factors that affected infectious disease were family members exposed to infection, immunization, and treatment behavior. if there is one family member infected, she/ he has the potential to spread the infection to other family members. it could be seen by looking at the subjects’ parents condition when the interview and direct observations were conducted. basic immunizations were given after birth until the age of nine months to gain immunity so that the subjects were not susceptible to diseases. six of the seven subjects already got the full basic immunizations while only one who did not get the full basic immunizations. treatment behavior in this study was in the form of self medication by buying over the counter (otc) drugs in the market. there were six parents who seek treatment for their sick children, and only one who did not seek treatment. some of them also went to the primary health care (phc) to cure the disease. based on this study, the mapping concept about nutritional status and infectious disease was obtained. discussions undernutrition is one of malnutrition caused by macronutrient or micronutrient deficiencies.9 malnutrition can be assessed by nutritional status using weight and height measurement.10 in this study, nutritional status was according to the standard deviation of weight-for-age index and compared with theministry of health’s referral. unlike the height-for-age described past nutritional status, the weight-for-age index was used to describe present nutritional status.10 referring to that, children’s weight development influenced the determination of nutritional status. the other indices such as height-for-age or weight-for-height were not used because after compared with the referral, it led to different result (the undernourished children showed normal nutritional status while using these indices). weight-for-age index used to assess nutritional status was affected by current body weight measurement. in this study, both weight loss or no specific weight gained could be influenced by emerging infectious disease, history of low birth weight or the food intake. most of the children also ate snack bought at street vendors. the nutrient content of the snacks were not known so the children likely did not get the adequate nutrition. this eating habit could affect the nutritional status. according to masithah et al.11, a good and adequate quality diet influenced the nutritional status. the united nations children’s fund (unicef) established a conceptual framework about factors causing malnutrition affect in the individual household and community. the household food insecurity and inadequate care are one of the causes of malnutrition. the main causes that affect undernutrition in individuals were inadequate dietary intake and disease.12 similar to the unicef’s concept, in this study, factors affecting the undernutritional status were infectious disease, weight loss, no specific weight gain influenced by diet and eating habit. overall, these children under five had undernutrition and severe undernutrition status according to the ministry of health reference with the various factors that underlie the undernutrition. undernutrition and infectious disease influenced each other. undernutrition can decrease the immunity system so the person is susceptible to the infectious disease and vice versa. infectious diseases which occurred in these children within the previous year were diarrhea andrespiratory infections such as common cold with cough and fever, and also helminthes infections. these diseases did not show a difference when compared to the data of west java’s health profile of infectious disease.7 clinically, common cold or acute nasopharyngitis was one of acute upper respiratory tract infection (urti) caused by rhinovirus. cough was one of the body’s reflexes to remove foreign objects by removed air from the lungs.13 fever was a disease that cause an increase in body temperature because of increased in hypothalamic caused by pyrogen. an infectious disease could cause symptoms such as decreased appetite resulting in decreasing of food intake and disrupting nutrient absorption.3 chronic infectious disease without treatment could influence children’s condition thus cause undernutrition.3 helminthes infection in children could affect their nutritional status. intestinal helminthes such as ascaris lumbricoides, trichuris trichiura, and hookworm were the most common causes.14 helminthes infection can alter children’s nutritional status by absorbing their blood so it can cause lost of palomina caesarea nurhasanah, dewi marhaeni diah herawati, resnaldi: nutritional status and infectious disease of undernourished children under five in desa cipacing, jatinangor subdistrict, west java, from april to december 2012 althea medical journal. 2015;2(3) 344 amj september, 2015 iron and protein.14 helminthes infection also increased nutrient malabsorption, lost of appetite and decreased intake of nutrient.14 these related to the findings in this study that the children became undernourished when exposed to helminthes infection. furthermore, diarrhea had interrelationship with undernutrition.15 diarrhea as one of the most common disease reported in this study is a disease that could cause weight loss and undernutrition. the function of the body to absorb nutrient was decreasing and also there was fluid loss due to dehydration. these were the effect of diarrhea that could lead to undernutrition in children under five.15 diarrhea often occurred in children leads to decrease of body weight or no weight gain thus impacting the nutritional status. some parents thought that diarrhea in children under five was a common problem so that they did not give treatment to their children and eventually, could worsen the children’s condition. the spread of infectious disease was affected by the family condition and situation.16 if one of the family members was affected by the disease, other family members were at risk being infected.16 in this study, when mother got common cold, so did her child. it was caused by the mother who spent more time with her child than other family members. this condition made mother easily transmitted the disease to the children due to spread of infection in family.16 immunization is an administration of vaccine in order to increase the immunity system. basic immunization such as hepatitis b or measles were given after birth until the age of nine months. one of the children did not get full basic immunization because of low birth weight. in this study, children under five who got incomplete immunization turned out had more frequent infection (cold, fever, and diarrhea) when compared to children with full basic immunization. self medication was one of behavior treatment often done by the parents. parents tended to give otc drug to reduce the symptoms and waited until the child healed itself because they thought that the diseases were common in children. treatment through phc will be conducted by the parents if the disease has not been cured. infectious disease should be treated immediately because if not treated, it could affect their nutritional status.5 the limitations of this study were identification of health status during pregnancy, gestation age, birth weight and comparison with normal children were not carried out. it can be concluded that there were several factors contributed in undernourished children under five. those were eating habit, weight development, onset of infection, immunization, treatment and disease transmission by family members. the infectious disease occurred were diarrhea, helminth infection and upper respiratory infection (cold and cough). the study in the near future should conduct deeper interviews to obtain more information about the phenomenon in those areas. references 1. kusumawardhani n, martianto d. kaitan antara prevalensi gizi buruk dengan pdrb per kapita dan tingkatkemiskinan serta estimasi kerugian ekonomi akibat gizi buruk pada balita di berbagai kabupaten kota di pulau jawa dan bali. jurnal gizi dan pangan. 2011;6(1):100–8. 2. ambrus jl sr, ambrus jl jr. nutrition and infectious disease in developing countries and problems of acquired immunodeficiency syndrome. exp biol med (maywood). 2004;229(6):464–72. 3. calder pc, jackson aa. undernutrition, infection, and immune function. nutr res rev. 2000;13(1):32–7. 4. islamiyati, sadiman, katharina k. hubungan penyakit infeksi dengan gizi buruk pada balita di kecamatan metro barat tahun 2008. jurnal kesehatan metro sai wawai. 2009;2(1):32–6. 5. nelson ke. epidemiology of infectious diseases: general principles. in: nelson ke, williams cm. infectious disease epidemiology: theory and practice. 2nd ed. sudbury: jones and bartlett; 2007. p. 26-8. 6. schaible ue, kaufmann sh. malnutrition and infection: complex mechanisms and global impacts. plos med. 2007;4(5):e115. 7. dinas kesehatan. lampiran tabel profil kesehatan provinsi jawa barat tahun 2007. bandung: dinas kesehatan provinsi jawa barat.2008. 8. curry la, nembhard im, bradley eh. qualitative and mixed method provide unique contributions to outcomes research. circulation. 2009;119(10):1442–52. 9. fauci as, kasper dl, longo dl, braunwald e, hauser sl, jameson jl, et al., editors. malnutrition and nutritional assesment. 17th ed. new york: mcgraw-hill companies; 2008. 10. supariasa idn, bakri b, fajar i. penilaian althea medical journal. 2015;2(3) 345 status gizi. jakarta: egc; 2001. 11. masithah t, soekirman, martianto d. child care practices associated with child nutritional status in rural mulya harja, bogor. media gizi & keluarga. 2005;29(2):29–39. 12. unicef. unicef conceptual frameworks. new york: united nations children’sfund;2008 [cited 2013 february 01]; available from: http://www.unicef. org/nutrition/training/2.5/4.html. 13. madison jm, irwin rs. cough: a worldwide problem. otolaryngol clin north am. 2010;43(1):1–13. 14. who. soil-transmitted helminth infections. geneva: world health organization;2012. [cited 2013 february 01]. available from: http://www.who.int/mediacentre/ factsheets/fs366/en. 15. palupi a, hadi h, soenarto ss. status gizi dan hubungannya dengan kejadian diare pada anak diare akut di ruang rawat inap rsup dr. sardjito yogyakarta. jurnal gizi klinik indonesia. 2009;6(1):1–7. 16. mcwhinney ir, freeman t. the family in health and disease. in: mcwhinney ir, freeman t. textbook of family medicine. 3rded. new york: oxford university press; 2009. p. 217–28. palomina caesarea nurhasanah, dewi marhaeni diah herawati, resnaldi: nutritional status and infectious disease of undernourished children under five in desa cipacing, jatinangor subdistrict, west java, from april to december 2012 althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 497 profile of hand compartment syndrome in dr. hasan sadikin general hospital, west java, 2008−2012 kajendaran manogaran,1 nucki nursjamsi hidajat,2 arifin soenggono3 1faculty of medicine universitas padjadjaran, 2department of orthopaedics & traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology, faculty of medicine universitas padjadjaran abstract background: compartment syndrome is a serious disorder caused by elevated pressure in a muscle compartment that can progress to muscle and nerve damage. this disorder can happen to anyone but more frequently in young adults. the occurrence frequency of hand compartment syndrome is relatively low. the aim of this study is to identify the profile of compartment syndrome in patients hand methods: a descriptive study was perfomed to 15 cases that were collected from medical records from 2008-2012, in dr. hasan sadikin general hospital. the profile of the case consisted of age, sex, symptoms and signs, etiology, facsiotomy schedule after admission, length of stay and patient’s outcome. the collected data were presented using tables. results: the study showed that 12 out of 15 cases were males and 7 out of 15 cases were 20−39 years old patients. the common clinical findings were swelling, pain, limited range of motion and normal sensibility. the faciotomy procedure was conducted 1 day after the admission with length of stay more than 1 week. the patients condition were improved after operation. conclusions: hand compartment syndrome is a rare case, mostly affects younger adults and male. most of the symptoms and signs are swelling, limitation of movement, pain in the location area with normal sensibility. the faciotomy procedure is conducted 1 day after admission. the length of stay is more than 1 week with an improved outcome. [amj.2015;2(4):497–501] keywords: compartment syndrome, hand, swelling correspondence: kajendaran manogaran, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: kajendaran@yahoo.com introduction compartment syndrome is a serious medical disorder caused by elevated pressure in a muscle compartment that can progress to muscle and nerve damage. this condition is influenced by external and internal force or injury that increases the intracompartmental pressure.1,2 the most common findings for compartment syndrome are pain, tenderness and swelling. others include paraesthesia, pallor, paralysis and pulselessness.3,4 apart from clinical signs and symptoms, the important diagnostic method is by measuring intracompartmental pressure.5 the choice of treatment normally done for patient with compartment syndrome is through a surgical method. the essential step of patient treatment with compartment syndrome is by performing fasciotomy procedure to release the pressure within involved compartment.6,7 from the previous study in 2011 by duckworth and mcqueen5, it was noted that the occurrence of hand compartment syndrome is less frequent. the involvement of upper extremities is less common comparing to lower extremities. the yearly occurrence of acute compartment syndrome is 3.1 per 100.000 population with the ratio in male to female is 10:1.5 even though it is a rare syndrome, this condition can lead to a serious complication and affect the patient’s quality of life and daily living activities. the aim of the study is to identify the profile of patients with hand compartment syndrome which is a common orthopedic disorder. althea medical journal. 2015;2(4) 498 amj december, 2015 methods a descriptive study was performed to 15 medical records of patients with hand compartment syndrome during 2008-2012 in dr. hasan sadikin general hospital. the data collection was carried out from august 2013 to november 2013. the profile of the patients consisted of age and sex. futhermore, 7 out of 15 cases which were patients between 20−39 years old, were analyzed according to diagnosis criteria, etiology, facsiotomy schedule after admission, length of stay and patient’s outcome. the collected data was presented in tables for each variable to represent the hand profile of compartment syndrome. the study was approved by the health research ethics committee of dr. hasan sadikin general hospital. results from 2008 until 2012, there were only 15 cases of hand compartment syndrome. most of the cases were affected by male patients who were 20−39 years old . seven cases from 20−39 years old patients had been selected to identify other variables than age and sex. most of the patients had the same symptoms and signs. those were swelling, limited in range of motion, yet there was one patient who did not feel pain. from seven cases, most of the patients had an injury before and only one case was occur because of a tight bandage. fasciotomy was performed one day after the admission, but there were still cases performed more than 2 day after the admission. furthermore, the table 1 distribution of patients according to age and sex age (years) sex total (n)male (n) female (n) <20 2 3 5 20–39 7 0 7 40–59 2 0 2 >60 1 0 1 total 12 3 15 length of stay between patients varied from 6 to 74 days. most of the patients outcomes were improved. discussion the incidence of hand compartment syndrome is very low.5 in this study, only 15 cases found during 2008-2012. most of the cases were affected to 20−39 years old patients. the possible reason is adults normally more engaged in daily activities, sports activities, and more exposed to outer environment compare to other age group population. this finding is supported by epidemiology research done by duckworth and mcqueen.5 it is important to note that hand is important part of our body with many influential functions. gambrel explains that in a certain situation such as in sports or working environment, it requires overuse of hand in completing a task or activity. this can lead to higher chances of damage or injury to the hand.8 this study also shows that males are more affected by this syndrome than female. previous study by duckworth and mcqueen5 table 2 diagnostic criteria of compartment syndrome of the hand patient swelling pain rom* wound sensibility other disorders icp** 1 yes yes limited yes normal burn injury not done 2 yes yes limited yes normal leg injury not done 3 yes no limited yes no burn injury not done 4 yes yes limited no normal none not done 5 yes yes limited no normal none not done 6 yes yes limited yes normal leg injury not done 7 yes yes limited yes no none not done note: *rom, range of motion, **icp, intracompartmental pressure althea medical journal. 2015;2(4) 499 statistically presented that mostly males were usually the main sufferer in compartment syndrome cases with ratio of 10:1 to female. in this study, most of the patients have the history of injury before the occurrence of hand compartment syndrome. a previous study by mabvuure et al.6 supported this findings. the study also mentioned that trauma commonly resulted in compartment syndrome. traumatic accident and working hazard injury can prolong and progress to range of mild to severe hand injury as explained by chow et al.9 all the causal factors stated can explain the pathophysiology of the compartment syndrome as all the causes can either increase the compartment volume or decrease the compartment size.10 this condition increases intracompartmental pressure. diagnostic criteria of compartment syndrome of the hand are studied. it includes the clinical findings that are different from person to person and depend on the severity of disorder. results show common findings in all seven patients are swelling and limited range of motion. presence of swelling or pain sensation will limit the movement of hand and fingers. any deep or severe injury can cause damage to nerve and muscle, thus it progress into more chronic compartment syndrome. this condition as explained in previous articles will affect the normal functioning of the hand. other findings in the patients include pain, loss of sensibility, and wound. as already written in the literature before, the classic clinical findings are 5p (pain, paraesthesia, pallor, paralysis, pulselessness). in certain condition not all the findings will present, so it is important to study the characteristic of the syndrome before diagnosing the patient.3,5,10 measuring intracompartmental pressure is also an important diagnostic criteria for compartment syndrome as explained in study by duckworth and mcqueen.5 based on study, all seven cases did not use the measurement of intracompartment pressure, probably due to the emergency and serious disorder need a fast and prompt management. chandraprakasam and kumar4 also state that clinical findings are the most important part in diagnosing compartment syndrome and intracompartment pressure measurement can be done as the confirmation of disorder.4,10 fasciotomy is an invasive procedure to treat the compartment syndrome. the objective of this procedure is to open the involved tissue compartments to relieve the pressure before irreversible tissue damage occur.6 olson and glasgow suggested that if there was clinical indications of acute compartment syndrome more than 8 hours and with absence in muscular and neurologic function, then amputation procedure must be conducted.7,11 in this study, not all of the patients underwent fasciotomy promptly. as explained by ebraheim et al.12, the compartment syndrome should be diagnosed and treated as fast as possible. this is important to prevent progression of syndrome and prevent complications.3 patient can also develop a contracture of chronic stage in the compartment syndrome that is clinically characterized by fibrosis and a shortening of muscle because of inadequate vascularization. systemic complications include renal insufficiency is caused by rhabdomyolysis and myoglobulinaemia as the results of high intracompartmental pressure.13 it is important for patient to immediately consult to a doctor after an injury or trauma and to accept the kajendaran manogaran, nucki nursjamsi hidajat, arifin soenggono: profile of hand compartment syndrome in dr. hasan sadikin general hospital, west java, 2008−2012 table 3 profile of patients with compartment syndrome of the hand patient age (years) sex etiology fasciotomy (days after admission) length of hospital stay (days) outcome 1 30 male burn injury 7 42 improved 2 33 male accident 1 36 improved 3 24 male burn injury 15 74 complicated 4 20 male tight bandage 1 11 improved 5 20 male fall 3 39 improved 6 37 male accident 1 29 improved 7 28 male crush injury 1 6 complicated althea medical journal. 2015;2(4) 500 amj december, 2015 management plan provided for them. the other two cases require a longer time because it has other accompanying serious disorder (table 2). from seven cases, the length of stay in hospital varies, most patients have been treated for a longer time in hospital. the length of hospitalization is essential to check for presence of any complications after the operative procedure example such as local complications that are post-operative wound infection and deeper infection involving soft tissue or bones that could lead to amputation, nerve damage or other disorder.7,11 once the patient has recovered from the surgery without complications, then they can be sent home. the length of hospitalization also depends on the severity of the injury. multiple site injuries require more long term management. this applies to a patient that has been treated for a longer period. this study also represents the management outcome of hand compartment syndrome shown that most patients, five in number of cases discharged with an improved condition after management. most of these patients were managed well and fast to prevent any complication and the injury not to severe enough to cause irreversible disorder. from the study, two patient’s outcomes are complicated into nerve damage and contracture. it is because of the late admission after injury causing irreversible damage. according to study by szatmary et al.13 with a quick and proper treatment and management, the risks in developing complication can be avoided. this is important as it can preserve the normal hand functions and patient’s quality of life the limitation of the study is the low number of data obtained regarding this disease due to a rare disease factor. secondly, incompleteness of the information in medical records are also proved to be a barrier in the study. it is recommended that the necessary information should be completed in all medical records to ease further study of the disease. although compartment syndrome of the hand is considered as a rare disorder, it is important for the healthcare workers to develop skills and techniques for the diagnosis and management of the patients with this condition. public needs to be educated about the risk of having compartment syndrome. they should try avoiding the risk and causal factors of compartment syndrome to prevent the occurrence of this condition that could lead to many complications if it is untreated. they also should be educated about the overuse syndrome of hand especially for workers or athletes that often use repetitive and forceful movement of the hand. if they find any abnormality in hand, it will be better to immediately consult to a doctor to treat their conditions. it can be concluded that hand compartment syndrome is a rare case, mostly affected younger adults and male. most of the symptoms and signs are swelling, limitation of movement, pain in the location area with normal sensibility. the procedure to treat this condition is fasciotomy. futhermore, the length of stay is more than 1 week with an improved outcome. references 1. schubert ag. exertional compartment syndrome: review of the literature and proposed rehabilitation guidelines following surgical release. int j sports phys ther. 2011;6(2):126–41 2. sung cy, chung rk, ra ys, lee hs, lee gy. impending compartment syndrome of the forearm and hand after a pressurized infusion in a patient under general anesthesia. korean j anesthesiol. 2011;60(1):60−3. 3. cole a, pavlou v, warwick d. injuries of the shoulder, upper arm and elbow. in: solomon l, warwick d, nayagam s. apley’s system of orthopaedics and fractures. 9th ed. boca raton: crc press; 2010, p.711−4 4. chandraprakasam t, kumar ra. acute compartment syndrome of forearm and hand. indian j plast surg. 2011;44(2):212−8. 5. duckworth ad, mcqueen mm. focus on diagnosis of acute compartment syndrome. the journal of bone & joint surgery. 2011. [cited 2013 march 12]. available from: http://www.boneandjoint. org.uk/sites/default/files/focus%20 on%20diagnosis%20of %20acute%20 compartment%20syndrome.pdf 6. mabvuure nt, malahias m, hindocha s, khan w, juma a. acute compartment syndrome of the limbs: current concepts and management. open orthop j. 2012;6:535−43. 7. green dp. general principles. in: wolf sw, pederson wc, hotchkiss rn, kozin sh. green’s operative hand surgery. 6th ed. philadelphia: elsevier churchill livingstone; 2011 8. gambrell cr. overuse syndrome and the unilateral upper limb amputee: althea medical journal. 2015;2(4) 501 consequences and prevention. j prosthet orthot. 2008;20(3):126−32. 9. chow cy, lee h, lau j, yu it-s. transient risk factors for acute traumatic hand injuries: a case-crossover study in hong kong. occup environ med. 2007;64(1):47−52. 10. taylor rm, sullivan mp, mehta s. acute compartment syndrome: obtaining diagnosis, providing treatment, and minimizing medicolegal risk. curr rev musculoskelet med. 2012;5(3):206−13. 11. canale st, beaty jh, editors. campbell’s operative ortopaedics. 11th ed. philadelphia: mosby elsevier; 2008 12. ebraheim na, abdelgawad aa, ebraheim ma, alla sr. bedside fasciotomy u n d e r local anesthesia for acute compartment syndrome: a feasible and reliable procedure in selected cases. j orthop traumatol. 2012;13(3):153−7. 13. szatmary p, erdös j, constantin d, humenberger m, vécsei v, hajdu s. cute compartment syndrome in children: a case series in 24 patients and review of the literature. int orthop. 2010;35(4):569−75. kajendaran manogaran, nucki nursjamsi hidajat, arifin soenggono: profile of hand compartment syndrome in dr. hasan sadikin general hospital, west java, 2008−2012 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 73 malnourished under-five children feeding practices in cipacing village 2012 shinta tresna fujianti1, dewi marhaeni diah herawati2, fiva aprilia kadi3 1faculty of medicine, universitas padjadjaran, 2departement of medical nutrition, faculty of medicine, universitas padjadjaran, 3departement of child health, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: maternal parenting, especially feeding practices, is very important in childhood period and may affect the child’s nutritional state. proper nutrition affects the growth and development of children. the aim of this study is to describe parenting feeding practices in malnourished under-five children. methods: a descriptive study on 43 mothers with malnourished under-five children aged 12−59 months was performed in cipacing village, jatinangor, sumedang during the periode of october−november 2012. results: the composition of children based on their malnutrition status and description on good and poor parenting were presented in the result. twenty two children (51.2%) were severely under nourished, 18 children (41.9%) were under nourished, and 3 children (7%) experienced overweight. good maternal parenting was identified in child nurturing (86%), feeding frequency (93%), feeding style (62.8%), and situation of feeding (74.4%) while poor maternal parenting was observed in feeding time (55.8%) and types of food given (51.2%). conclusions: maternal parenting plays an important role in children nutrition status. keywords: children, feeding practice, malnutrition, maternal parenting. correspondence: shinta tresna fujianti, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628122401052 email: shintatresna@gmail.com introduction indonesia experiences the multiple nutritional problems which was the problem of undernutrition still not handled thoroughly and then a new problem arises. it is the problem of overnutrition.1 malnutrition is more common in infants and children. this is an important issue because children are vulnerable and their growth and development will affect the quality of adolescence and adulthood.2 at the children age, it occurs a brain cells development that can later affect the intelligence of the children. provided proper nutrition greatly affects on the growth of brain cells so in the malnourished children, the brain cell growth was inhibited itself then it could make the weight of the brain and brain cell size reduced resulting in the stunted growth and development.3,4 in adequate nutritional intake can inhibit growth and affect the quality of child which in turn can reduce the quality of human resources.5 malnutrition has a very complex dimension, and can be caused by many things, both internal and external. externally, one of which can be caused by maternal parenting.6,7 optimal development of children depends on how mothers take care their children. maternal parenting is an evident from how the mother give a sense of security and protection tothe child, feeding the child and providing an access to the health care.6,8 according to soekirman in the study of listyawati9, maternal parenting is the behavior of mother in proximity to the child in terms of feeding, hygiene, and giving love. parenting also associates tothe mother's condition in terms of physical and mental health proximity, nutrition, education and knowledge of good parenting. national basic health research (riskesdas) in west java province10 shows the events data severe under nutrition occurs approximately 3.1%, 9.9% under nutrition and 5.4% over nutrition. severe under nutrition and under althea medical journal. 2015;2(1) 74 amj march, 2015 nutrition occurs about 13.49% in the year 2007 in sumedang. there are about 10.20% of malnutrition cases in jatinangor and most numerous in the cipacing village about 85 children suffered under nutrition and 21 children suffered over nutrition. this study aims to describe maternal parenting in the feeding practices of underfive children who suffered the malnutrition, severe under nutrition, under nutrition and over nutrition in the cipacing village. methods a descriptive study was conducted by collecting the data in cipacing village, jatinangor, sumedang during the period of october−november 2012. forty three mothers with malnourished children aged 12−59 months were identified according to inclusion criteria as listed: 1) mothers who have children aged 12–59 months with severe undernutrition, under nutrition or overnutrition, 2) children who do not have any diseases that affect nutritional status, such as infectious disease, hiv /aids, etc. primary data were collected to measure the nutrition status and maternal parenting practices. the assessment of nutritional status was performed using anthropometric measurement in the children by weight for age index. the body weight was measured using the scales and compared to the age at the day of data collection in months.1,11 maternal parenting data were collected through the interviews using a questionnaire that include child nurturing, types of food given, feeding time, feeding frequency, feeding style and situation of feeding. data on the characteristics of the children malnutrition were dicovered by group of age, sex and nutritional status. maternal characteristics were seen by group of age (years), number of children, education level, occupation and income. twenty questions about parenting in feeding practices were asked in six categories. the scores of 4, 3, 2, and 1 were assigned to a, b, c, and d, respectively. from the total score of all respondents , a mean value was calculated. the individual data were then compared to the mean, if the table 1 characteristics of respondents category f (%) age (years) <20 1 (2) 20−35 32 (74) >35 10 (23) number of children < 2 29 (67) 2−4 9 (21) >4 5 (12) level of education elementary 11 (26) junior high 19 (44) senior high 13 (30) occupation labor 6 (14) housewife 34 (79) entrepreneur 3 (7) income (rupiah) < 1,007,500 25 (58) >1,007,500 18 (42) althea medical journal. 2015;2(1) 75 table 2 characteristics of children category f (%) age (months) 12−23 7 (16.3) 24−35 13 (30.2) 36−47 13 (30.2) 48−59 10 (23.3) sex male 22 (51.2) female 21 (48.8) nutritional status severe undernutrition 22 (51.2) undernutrition 18 (41.9) overnutrition 3 (7) score was less than the average the parenting was considered poor and if it is more than the average , the parenting was good. the nutritional status of children was assessed with a z-score of the weight for age chart. the data collected were then analyzed using a frequency distribution. results the majority of the respondents was between 20−35 years old (74.4%) and had less than two children (67.4%). respondents were generally graduated from junior high school (44.2%) and the amount of family income was still below the majority of the regional minimum wage sumedang which is less than rp1,007,500,00 (58.1%). the majority of children in this study was between 24−35 months and 36−47 months (30.2%) while the majority of the nutritional status was severe undernutrition (51.2%). maternal parenting feeding practices were assessed in 6 categories. the results were divided into the good and poor categories (table 3). from this study, the composition of food given to the children was identified. the majority of children were given rice and snacks (82%). furthermore, there was a small percentage (9%) of children who were given a fast food. only 9% of children received rice, vegetables, and fruit. in general, children were fed when they asked for food (54%). shinta tresna fujianti, dewi marhaeni diah herawati, fiva aprilia kadi: malnourished under-five children feeding practices in cipacing village 2012 discussion the percentage of children with malnutrition in this study is higher than the data from riskesdas.12 this condition can be caused by the differences in the time, population and sample studied. sosio-economic factors such as low education level and small family income may influence the children malnutrition.1 childhood period is a period when the children should receive proper nutrition.5 this can only be achieved through good maternal parenting. this is consistent with a study conducted by suranadi13 that good parenting can optimize the growth and development of children, both on physically and mentally. contrary, poor parenting of the mother could causes inadequate nutrition intake resulting in children malnutrition. the majority of mothers in this study practices is the good child nurturing. this means that parents in cipacing village know that better parenting can be achieved if the parents are the ones who do the parenting. parenting is the responsibility of both parents including father and mother.14 based on the type of food given, the majority of maternal parenting were classified in the poor category. in children with severe undernutrition and undernutrition, the mothers only give rice and snacks. meanwhile, children with over nutrition receive the full meals including rice, snacks, vegetables and fruits. this is not appropriate for feeding children over one year old, where the food given should be different from the food given to adults and with good variation.4,15 this mismatch can affect the nutritional state of children. based on the type of food given, the majority of maternal parenting were classified in the poor category. in children with severe undernutrition and undernutrition, the mothers only give rice and snacks. meanwhile, children with over nutrition receive the full meals including rice, snacks, vegetables and fruits. this is not appropriate for feeding children over one year old, where the food given should be different from the food given to adults and with good variation.4,15 this mismatch can affect the nutritional state of children. the majority of feeding time in this study was poor. the mother fed the child with no specific schedule. children were fed when they asked for food. this habit may have occurred because the mother did not have any knowledge about the concept of the food althea medical journal. 2015;2(1) 76 amj march, 2015 amount needed by children so the mothers feed the children when they seem like they want to eat.16 the mother should make a feeding schedule for the children. eating on a regular schedule may form the good habits for children. the majority of mothers fed the children three times a day with snacks between meals. feeding frequency is a category of parenting that can affect the nutritional status of children. the main foods are given 3 times a day: morning, noon and evening, with 2 snack times in between main meals.15 maternal parenting based on the feeding style was good. mother kept persuading her child to eat eventhough her child did not want to eat. the mother can persuade her child to eat by bringing the children to play while mother feeds the child or perhaps by giving food preferred by children.15 however, there are also mothers who do not persuade their children to eat when they do not want to eat. as a result, the children do not receive enough food.16 limitation of this study is the small sample size and the lack of comparison with children without malnutrition. as a conclusion, a good maternal parenting is observed for the child nurturing, feeding frequency, feeding style and the situation of child feeding. meanwhile, a poor maternal parenting is observed for the type of food given and the time of feeding. mother, as the primary caregiver and the closest person to the child, especially in childhood, should consider a better parenting in the feeding practices especially in the types of food given and the feeding time. village health workers, midwives and cadres should provide a counseling about a good parenting in a feeding practice in terms of child nurturing, types of food given, feeding time, feeding frequency, feeding style, and situation of feeding for the mother in order to reduce the incidence of malnutrition in the village. references 1. supariasa idn, bakri b, fajar i. penilaian status gizi. jakarta: egc; 2001. 2. alderman h, shekar m. nutrition, food security, and health. in: kliegman rm, stanton bf, st geme j, schor nf, behrman re, editor. nelson textbook of pediatrics. 19th ed. philadephia:elsevier saunders; 2011. p.170−6. 3. widjaja mc. gizi tepat untuk perkembangan otak & kesehatan balita. jakarta: kawan pustaka; 2007. 4. sutarno b, anggraini dy. menu sehat alami untuk batita &balita. jakarta: agromedia pustaka; 2010. 5. soetjiningsih, suandi i. gizi untuk tumbuh kembang anak. in: soetjiningsih, editor. tumbuh kembang anak dan remaja. jakarta: sagung seto; 2010. p.22−40. 6. riyadi h. faktor-faktor yang mempengaruhi status gizi anak balita di kabupaten timor tengah utara propinsi nusa tenggara barat. gizi dan pangan. 2011;6:66−73. 7. ventura ak, birch ll. does parenting affect children’s eating and weight status?. int j behav nutr phys act. 2008;5:15. 8. anwar hm. peranan gizi dan pola asuh dalam meningkatkan kualitas tumbuh kembang anak. seminar sehari departemen kesehatan republik indonesia. jakarta; 4 november 2000 [cited 7 may 2012]; available at: http://bocareyou.blogspot. com/2009/05/peranan-gizi-dan-polaasuh-dalam.html. 9. listyowati ld. peran pola asuh keluarga pada balita gizi buruk dan gizi kurang. 2011 [downloaded in 6 may 2012]; available at: http://alwaysnutritionist. blogspot.com/2012/03/peran-pola-asuhkeluarga-pada-balita.html. 10. dinas kesehatan provinsi jawa barat. tabel table 3 distribution children based on diversity in maternal parenting feeding practice maternal parenting feeding practice poor good f (%) f (%) child nurturing 6 (14) 37 (86) types of food given 22 (51.2) 21 (48.8) feeding time 24 (55.8) 19 (44.2) feeding frequency 3 (7) 40 (93) feeding style 16 (37.2) 27 (62.8) situation of feeding 11 (25.6) 32 (74.4) althea medical journal. 2015;2(1) 77 profil kesehatan provinsi jawa barat tahun 2007. bandung: dinas kesehatan provinsi jawa barat; 2008. 11. hendarto a, sjarif dr. antropometri anak dan remaja. in: soetjiningsih, editor. nutrisi pediatrik dan penyakit metabolik. jakarta: ikatan dokter anak indonesia; 2011. p.23−35. 12. kementerian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2010. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia; 2010. 13. suranadi l. studi tentang karakteristik keluarga dan pola asuh pada balita gizi kurang dan gizi buruk di kabupaten lombok barat. jurnal kesehatan prima. 2008;2(2):296−303. 14. soetjiningsih. tumbuh kembang anak. jakarta: egc; 1995. 15. pudjiadi s. ilmu gizi klinis pada anak. jakarta: gaya baru; 2001. 16. suhardjo. pemberian makanan pada bayi dan anak. jakarta: kanisius; 2010. shinta tresna fujianti, dewi marhaeni diah herawati, fiva aprilia kadi: malnourished under-five children feeding practices in cipacing village 2012 althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 550 amj december, 2015 correlation between postural stability and functional mobility in patients with knee osteoarthritis arlinda de hafsari,1 vitriana,2 alwin tahid3 1faculty of medicine, universitas padjadjaran, 2departmen of physiology faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: osteoarthritis (oa) is a degenerative joint disorder caused by progressive erosion of articular cartilage. the joint which is commonly affected is theknee joint. patient with knee oa has increasing pain with decreasing postural stability, and may cause decrease infunctional mobility of the body. the aim of this study was to analyze the correlation between stability and mobility in patients with knee oa. methods: a cross sectional study was performed to 43 patients from the rheumatology clinic ofdr. hasan sadikin general hospital, bandung, during september−october 2013. the ‘timed up and go’ (tug) test and stabillometric platform examination were performed to analyze the mobility and stability in subjects. the data were analyzed with spearman’s correlation. results: four subjects (9.30%) had normal functional mobility, 31 subjects (72.09%) had good mobility and need no help of others in their activities, and 8 subjects (18.60%) had problems and could not stand and walk without help. this study also found 39 subjects (90.69%) had high risk of fall. the p value were 0.005 for correlation between knee oa and lateral static postural stability, 0.138 with anteroposterior static stability, 0.067 with dynamic to position of top right stability, 0.344 with dynamic to position of top left stability, 0.384 with dynamic to position of bottom left stability and 0.357 with dynamic to position of bottom right stability. conclusions: there is a strong correlation between functional mobility with static postural stability, especially to the lateral position. [amj.2015;2(4):550–4] keywords: functional mobility, knee osteoarthritis, postural stability correspondence: arlinda de hafsari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85795915919 email: arlindadh@yahoo.com introduction osteoarthritis (oa) is also called degenerative joint disorder that iscaused by progressive erosion of articular cartilage.1,2 this disorder isthe most common joint disorder in the world. within western population, this disorder is one of the most common causes of pain, loss of normal function, and disability of adult. the symptoms that appear in this disorder may cause a mobility disruption which can cause limitation of daily activity. the joint commonly affected by oa is theknee joint.3 knee oa has a high rate of incident in the world.4 the oa is a most common rheumatic disease in indonesia. world health organization (who) data, shows oa cases in indonesia is 8.1% from the total population. the patient with knee oa has increasing pain and weakness that makes thepatient also has decreasing postural stability of the body, which may cause limitation of patient’s activity and motivation.5 postural stability is the body foundation to be able to stand and walk freely. the decrease of postural stability in elderly can make a contribution for increase fall risk when doing daily activity.6 knee oa is commonly associated with the postural stability and functional mobility impairment however based on literature concerning this subject , there was not a study which showed the correlation between postural stability and functional mobility in patients of knee oa. the aim of this study was to analyze the correlation between postural stability and functional mobilityin knee oa. methods a cross sectional study was carried out to 43 knee oa patients who came to the rheumatology clinic of dr. hasan sadikin althea medical journal. 2015;2(4) 551 general hospital, bandung, during september− october 2013. the oa outpatients were defined from patients ofthe rheumatology clinic who visited the rheumatology clinic for some follow-up or check-up on the day when the examiner came to the clinic. patients who agreed to be examined were included in this study, whereas the exclusion criterion is the patients who were not able to stand and walk alone without help. the selected patients were examined in the physical medicine and rehabilitation clinic with the ‘timed up and go’ (tug) test and stabillometric platform test. the purpose of the tug test was to identify how long the subject can stand, walk three meters, and back to the first position, and then sit down again. the criteria of tug test were: <10 seconds: normal, <20 seconds: good mobility, can walk alone without help, <30 seconds: problem, can not walk alone, need help, ≥14 seconds: high risk of falls. the stabillometric platform test was to identify the body balance of the patient and the time thepatient needed to move the body to lateral and anteroposterior. this test used the stabillometric platform tool which is based on the software program. the collected data were analyzed using spearman correlation. results the result of functional mobility using tug test can be classified into four classifications. most of the subjects had high risk of falls and only 9% had normal tug test (table 1). the result of static postural stability was acquired with the stabillometric platform test, and the results were the point of static condition that was describe by x and y point (table 2). this result shows the body stability of subject whether its position was to lateral or anteroposterior. after the static postural stability test, thesubjects were also examined for their dynamic postural stability. this test is also available in the same software of stabillometric platform, therefore the direction and the time were set by the software. it caused time limitation to examine these 43 subjects and the data were not obtained completely. the result of dynamic postural stability was obtained from stabillometric platform test. that result were the range of time that thesubjects needed for performing this test (table 3). after the result of postural stability and functional mobility of the subject was obtained, then the examiner identified the correlation between those variables using the spearman’s correlation (table 4). discussion the risk of fall can make a disruption of body balance that was associated with the functional mobility. if the balance was disrupted, the mobility also decrease and can cause a decreasing quality of life. the result arlinda de hafsari, vitriana, alwin tahid: correlation between postural stability and functional mobility in patients with knee osteoarthritis table 1 the result of mobility of the subjects using tug test tug (seconds) interpretation total <10 normal 4 subjects (9%) <20 good mobility, can walk alone without help 31 subjects (72%) <30 problem, can not walk alone, need help 8 subjects (19%) ≥14 high risk of falls 39 subjects (91%) table 2 static postural stability of subjects static stability total (%) x axis (balance to lateral) tendency to the right (positive value) 17 subjects (40%) tendency to the left (negative value) 23 subjects (53%) y axis (balance to anteroposterior) tendency to the front (positive value) 32 subjects (74%) tendency to the back (negative value) 8 subjects (19%) althea medical journal. 2015;2(4) 552 amj december, 2015 of this study also found a high risk of fall in the subjects which was around 91% or about 39 subjects. the knee oa associated with the presence of fall may cause worse functional mobility.7 in 2008, shaheen et al.8 published that patients with knee oa have a worse balance, both static and dynamic, and also worse functional mobility. the impairment of balance is also associated with pain suffered by the patients. most of thesubjects have a tendency to put the body in bending forward position (74%) (table 2), this explained why the subjects performed the dynamic stability test to anterior (top direction)more easily, since they needed more time to performed movement to posterior (bottom left or bottom right) (table 3) and it can be assumed that patients had less ability to compensate if they fell to the posterior direction. the point at which all the weight of the body can be concentrated is known as the center of gravity. the center of gravity depends on table 3 dynamic postural stability of subjects target in position range of time (seconds) total subject target in top right quarter <2 8 2–3 13 3–5 9 >5 4 target in top left quarter <2 7 2–3 11 3–5 7 >5 9 target in bottom left quarter <2 4 2–3 8 3–5 12 >5 10 target in bottom right quarter <2 4 2–3 9 3–5 10 >5 8 table 4 correlation coefficients (spearman’s) between static and dynamic postural stability and mobility function correlation p-value r x with tug 0.005 0.975 y with tug 0.138 0.376 postural stability in top right quarter with tug 0.067 0.706 postural stability in top left quarter with tug 0.344 0.046 postural stability in bottom left quarter with tug 0.384 0.025 postural stability in bottom right quarter with tug 0.357 0.049 note: p<0.005=there was significant correlation between two variables; p>0.005=there was not any significant variable between two variables althea medical journal. 2015;2(4) 553 the body’s shape and mass distribution. to obtain good acceleration of motion, the center of gravity must be within a person’s base of support to maintain stability.9 a study published by schmitt et al.4 in 2007 demonstrate that knee instability is an important predictor of knee movement strategies in persons with knee oa. in addition, a study by hsieh et al.5 in 2013, indicate that as thepostural stability decreased in patients with knee oa, the impairment increased. additionally, postural stability have weak association with the components of body functions and structures of patients with knee oa.5 this study also indicated that several patients with decreasing postural stability still can perform activities like walking, standing, and other without help. meaning their body functions was still good. in a study by zang w. et al.10 symptomatic knee oa is a common and growing condition that limits physical activity and mobility among many older persons. in this study, there were strong correlations between static postural stability with the impairment of mobility. on the other hand, dynamic postural stability has no correlation with impairment of functional mobility. this is shown on table 4 where the interpretation from the p value of static postural stability was <0.005, meaning that there were correlations between those two variables. in addition, based on the r value (r=0.975), the correlations between those variables were very strong. in contrast, the correlations between dynamic postural stability and impairment mobility were not found (p value=>0.005). this study also had limitations. this study was conducted on a small number of subjects since some oa patients had refused to be involved in this study due to limitation of theexaminer to give informed consent considering various educational background of the patient. subjects of this studywere also limited to the dr. hasan sadikin general hospital only therefore, it might not become a general reference about correlation of tug test as functional mobility and postural stability. this study used the non probability sampling method, which means the subjects were patientswho had a knee oa complaint and was examined directly without their complete medical record for considering other variables as confounding variables which are associated with knee oa, such as the severity of oa, age, sex, weight and trauma. the inclusion criteria for these samples were only for patients who visited the clinic and were diagnosed as oa in general and agreed to be examined for factors that may cause decreased static and dynamic postural stability in oa patients that had not been explored yet. this study also depended on the software with a fixed program , such as the time and direction of movement that wasalready set by this software. therefore, not all subjects could perform all the tests because of time limitation arranged by this software. in conclusion, there is correlation between static postural stability and functional mobility in patients with knee oa. in contrast, there is no correlation between dynamic postural stability and functional mobility in patients with knee oa. a further study is needed to explore more about factors that may contribute to postural stability in oa patients using other tools and a larger number of subjects. references 1. felson dt. osteoarthritis of the knee. n engl j med. 2006;354(8):841–8. 2. rosenberg ae. bones, joints, and softtissue tumors. in: vinay kumar m, md, frcpath, abul k. abbas m, nelson fausto m, jon c. aster m, phd, editors. pathologic basis of disease. 8 ed. china: saunders elsevier; 2010. p. 1205–56. 3. wallace d, barr c. the effect of hip bracing on gait in patients with medial knee osteoarthritis. arthritis. 2012; 2012: 240376. 4. schmitt lc, rudolph ks. influences on knee movement strategies during walking in persons with medial knee osteoarthritis. arthritis rheum. 2007;57(6):1018–26. 5. hsieh rl, lee wc, lo mt, liao wc. postural stability in patients with nee osteoarthritis: comparison with controls and evaluation of relationships between postural stability scores and international classification of functioning, disability and health components. arch phys med rehabil. 2013;94(2):340–6. 6. melzer i, benjuya n, kaplanski j. postural stability in the elderly: a comparison between fallers and non-fallers. age ageing. 2004;33(6):602–7. 7. alencar m, arantes p, dias j, kirkwood r, pereira l, dias r. muscular function and functional mobility of faller and non-faller elderly women with osteoarthritis of the knee. braz j med biol res. 2007;40(2):277– 83. 8. shaheen a, ayad k. impact of chronic arlinda de hafsari, vitriana, alwin tahid: correlation between postural stability and functional mobility in patients with knee osteoarthritis althea medical journal. 2015;2(4) 554 amj december, 2015 osteoarthritis of knee joint on postural stability and functional mobility in women. bull fac ph th cairo univ. 2008;13(1):317– 31. 9. karduna ar. introduction of biochemical analysis. in: oatis ca, editor. kinesiology the mechanis and pathomechanics of human movement. 2nd ed. india: lippincott williams and wilkins; 2009. p. 13–20. 10. zhang w, nuki g, moskowitz r, abramson s, altman r, arden n, et al. oarsi recommendations for the management of hip and knee osteoarthritis: part iii: changes in evidence following systematic cumulative update of research published through january 2009. osteoarthritis cartilage. 2010;18(4):476–99. vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 435 quadriceps and hamstring muscle strength in elderly based on lifestyle pang sze lyn,1 marina a moeliono,2 sumartini dewi3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia , 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: studies have shown that muscle strength will decline with aging and inactivity, with 1% to 3% loss of muscle strength each day. nevertheless, different lifestyles have different effect on muscle strength. this study was conducted to analyze the differences in quadriceps and hamstring muscle strength in elderly from 60–79 years olds according to lifestyle. methods: a cross-sectional study was conducted from september to november 2015. the subjects were 31 older persons from community who voluntarily participated the research procedure and were divided into 2 groups, active group and sedentary group according to international physical activity questionnaire (ipaq). quadriceps and hamstring muscle strengths were measured using the push and pull dynamometer. the collected data were analyzed using the wilcoxon rank sum test and the unpaired t-test. results: this study discovered that the mean difference in hamstring muscle strength was 6.09 ± 0.70, p< 0.001; median difference in quadriceps muscle strength was 5.00 (13.00, 6.50), p<0.001. conclusions: there is a higher quadriceps and hamstring muscle strength in elderly active lifestyle compared to elderly sedentary lifestyle. keywords: active lifestyle, elderly, hamstring muscle strength, quadriceps muscle strength, sedentary lifestyle correspondence: pang sze lyn, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: jocelynpang93@gmail.com introduction in the 21st century, the life expectancy of human being had been increasing. national development in indonesia has improved the health quality and the social conditions of the country, which then increases the life expectancy. based on law of the republic of indonesia number 13 year 1998, old age is defined as individual of 60 years old and above. according to elderly statistics 2013, older adults can be classified into three categories, which are young old group, adults aged 60–69 years old; middle old group, adults aged 70–79 years old; and old age group, adults aged 80 years old and above.1 there will be changes in older person which will decrease strength and lead to a decline in physical activities in older person. with aging, the lower extremity muscle loses muscle strength of 14% to 16% every 10 years and upper extremity muscle loses 2% to 12% every 10 years.2 the decrease in muscle mass can be seen more significantly in larger muscle. to improve mobility, the most crucial muscles involved are the quadriceps and hamstring muscle. in order to avoid the decrease in physical function of muscles in older person, we can reverse the factors that cause the condition by avoiding living a sedentary and inactive lifestyle. this study was conducted to observe the differences in quadriceps and hamstring strength in two groups of older persons, the young old group, aged 60–79 years old, according to gender and lifestyle. methods this study used crosssectional design and was conducted from september 2015 to november 2015. the data were collected from older person aged 60–79 years old. an ethical clearance letter was obtained from amj. 2017;4(3):435–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.644 althea medical journal. 2017;4(3) 436 amj september 2017 the health research ethics committee of faculty of medicine universitas padjadjaran. in bandung, older persons with sedentary lifestyle were mostly found at home, whereas older persons with active lifestyle were mostly found at taman lansia and dr. hasan sadikin general hospital where there are exercise sessions on certain days. the method for subject sampling was using random sampling. the criteria to determine which lifestyle the subjects belong to were based on international physical activity questionnaire (ipaq).3 in this questionnaire, there were three cut point values, which were low, medium, and high. the subjects of low category were grouped into sedentary lifestyle, while the subjects of medium and high category were grouped into active lifestyle. the inclusion criteria for research subjects were older persons aged ranging from 60 to 79 years old, and the ability to understand and perform instructions. meanwhile, the exclusion criteria were subjects with uncontrolled systemic diseases, malnutrition, body mass index (bmi) of less than 18.5 or having deformities in the leg. after selection based on inclusion and exclusion criteria, the subjects were asked to sign an informed consent form and the objectives and procedures of the test were explained and understood. to calculate the sample size, a two-tailed test with alpha value of 0.01 and the power of 0.8 were used. with three predictors, and coefficient of determination (r2) of 0.3, the total minimal sample calculated was 30 subjects. to measure the strength of quadriceps muscle, the subjects were asked to sit on a stool and a push-pull dynamometer was placed 5cm proximal to the distal aspect of lateral malleolus. the dynamometer was compressed against the leg, the subjects were asked to stretch the knee, so the force generated would be measured. for the hamstring muscle, the subjects were asked to lie down in a prone position while a push-pull dynamometer was placed 5cm proximal to the distal aspect of lateral malleolus. the dynamometer was compressed against the leg, subjects were asked to stretch the knee to 90 degrees, so the force generated was measured. the collected data were analyzed using the wilcoxon rank sum test for quadriceps muscle strength and the unpaired t-test was used for hamstring muscle strength. statistically significant result was considered when p<0.05. results there were 31 older persons included in the study. the wilcoxon rank sum test and unpaired t-test were performed to determine whether there was a difference in muscle strength. table 1 shows the mean value of age bmi and gender of subjects from active lifestyle and sedentary lifestyle. the age, bmi, as well as gender were not significantly different, therefore comparison could be made between different lifestyles. table 2 shows that the quadriceps muscle strength was normally distributed in sedentary lifestyle group, but not normally distributed in active lifestyle group. as for hamstring muscle strength, it was normally distributed in both types of lifestyle groups. to calculate the p-value, the wilcoxon rank sum test was used for quadriceps muscle strength and the unpaired t-test was used for hamstring muscle. the p value for the difference of the muscle strength for both groups was <5%, hence the null hypothesis was rejected. meanwhile, the p value for ratio of both muscle strengths was more than 5%, hence null hypothesis was accepted. from the data analysis above, the table 1 mean value of active and sedentary group based on age and bmi, and frequency of gender active (n=16) sedentary (n=15) p-value mean (sd) age 67.00 (6.11) 70.60(6.79) 0.184 * bmi 23.51 (3.29) 22.75 ( 2.76) 0.406 * gender, frequency(%) female 14 (87.5%) 11(73.3%) 0.394 ** male 2 (12.55) 4 (26.7%) note: * the p-value obtained using mann whitney test, **the p-value obtained using fisher’s exact test. althea medical journal. 2017;4(3) 437pang sze lyn, marina a moeliono, sumartini dewi: quadriceps and hamstring muscle strength in elderly based on lifestyle conclusion was that there was difference in quadriceps and hamstring muscle strength in older persons from sedentary and active lifestyle. discussion this study discovered that there were significant difference in quadriceps and hamstring muscle strengths in older persons from sedentary lifestyle group. according to ipaq, an active lifestyle requires moderate or vigorous physical activities like exercising, walking, bicycling, gardening, and heavy lifting.3 if ones do not exercise, they can perform other kinds of physical activities as stated above.4 there was a study in 2012 that proved this theory, where prolonged resistant type exercise training benefits both men and women equally.5 other study showed that older persons aged more than 80 years old do not show significant improvements after an exercise intervention, hence, older people from 60 to 79 years old can still improve muscle strength after exercise intervention.6,7 the ratio remains the same in both lifestyle groups. this suggests that both muscles that work correspondently will either improve or deteriorate together at the same rate.8 the lower muscle strength in older persons with sedentary lifestyle can be caused by the atrophy of muscle due to old age and limited activity, hence causing decrease in muscle mass and muscle strength. after 50 years of age, the human muscle mass will decrease in size to about -1 to -2% every year.9 although so, the significance of muscle mass in affecting muscle strength is not as prominent as alteration of muscle strength due to the old age.6,10 at home, older persons will spend most of their time sitting, watching television, reading, lying down, and resting. these decreases in physical activities may cause a low energy expenditure and, hence, decrease of basal metabolic rate.11 this will not only decrease lean muscle mass and strength, but there will be a more sped up rate of loss due to bed rest.12,13 in order to overcome loss of muscle strength, one of the ways is to remain active. many studies have been conducted to prove that exercise can improve muscle strength and mobility in older persons.14-16 even without exercise, maintaining an active lifestyle can also strengthen muscles for older persons.4 hence, this supports the result that older persons from active lifestyle have a higher muscle strength compared to older persons from sedentary lifestyle. there are a few limitations in this study; one of them is the usage of the push-pull dynamometer. by using this, force must be used to push against quadriceps or hamstring strength and if the examiner strength is not enough, this will decrease the sensitivity. some older persons followed this study after they were done with their exercise sessions; hence, this will influence the muscle strength reading by a little due to exhaustion after exercising. the height and weight of the subjects were table 2 normality test for quadriceps muscle strength and hamstring muscle strength normality test sig. value* quadriceps sedentary 0.200 active 0.002 hamstring sedentary 0.200 active 0.200 note: *sig. value stands for significant value, obtained using normality test. table 3 comparison of effects of different lifestyle on quadriceps muscle strenghth and, hamstring muscle strenghth muscle strength active (n=16) sedentary (n=15) standard error p value hamstring muscle strength mean (sd) 14.63 ( 2.09) 8.53 (1.767) 6.092 < 0.001 * quadriceps muscle strength median (interquartile range) 15.50 (3) 12.00 (5) 5.00 < 0.001 ** note: * p value obtained using unpaired t-test, ** p value obtained using wilcoxon rank sum test althea medical journal. 2017;4(3) 438 amj september 2017 asked but not measured; hence this will decrease the sensitivity of the bmi score as the subjects might recall their height and weight wrongly. these limitations can be taken into account in further studies. in conclusion, with these positive results, there is stronger muscle strength in older persons from active lifestyle compared to sedentary lifestyle. with these, we suggest that older persons should exercise and those who do not exercise can remain an active lifestyle in order to delay muscle strength deterioration and 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population-based, crosssectional study of older adults in the united states. bmc geriatrics. 2013;13(74):8. 11. kalyani rr, corriere m, ferrucci l. agerelated and disease-related muscle loss: the effect of diabetes, obesity, and other diseases. the lancet. 2014;2(10):819–29. 12. english kl, paddon-jones d. protecting muscle mass and function in older adults during bed rest. curr opin clin nutr metab care. 2010;13(1):34-9. 13. gill tm, allore h, guo z. the deleterious effects of bed rest among community-lving older persons. j gerontol a biol sci med sci. 2004;59(7):755–61. 14. straight c, lindheimer j, brady a, dishman r, evans e. effects of resistance training on lower-extremity muscle power in middle-aged and older adults: a systematic review and meta-analysis of randomized controlled trials. sports med. 2015;45(373):1–12. 15. porter mm. power training for older adults. appl physiol nutr metab. 2006;31(2):87– 94. 16. leblanc a, pescatello ls, taylor ba, capizzi ja, clarkson pm, michael white c, et al. relationships between physical activity and muscular strength among healthy adults across the lifespan. springerplus. 2015;4(557):11. 17. bhalla a, wang y, rudd a, wolfe cd. differences in outcome and predictors between ischemic and intracerebral hemorrhage the south london stroke register. stroke.2013;44(8):2174–81. 18. harris je, eng jj. paretic upper–limb strength best explains arm activity in people with stroke. phys ther. 2007;87(1):88–97. 19. kluding p, gajewski b. lower-extremity strength differences predict activity limitations in people with chronic stroke. phys ther.2009;89(1):73–81. 20. harris je, eng jj. individuals with the dominant hand affected following stroke demonstrate less impairment than those with the non-dominant hand affected. neurorehabil neural repair. 2006;20(3):380–9. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 119 basic training of student’s outdoor club increases muscle mass after five weeks of exercise in males novie salsabila1, m. rizal chaidir2, setiawan3 1faculty of medicine, universitas padjadjaran, 2department of orthopaedic and traumatology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of physiology, faculty of medicine, universitas padjadjaran abstract background: aerobic and anaerobic exercises, may lead to increase muscle mass. the aim of this study was to determine the change in muscle mass during basic training of students’ outdoor club. methods: this was an observational analytic study to college students who joined basic training of students’ outdoor club for 19 weeks. subjects consisted of 17 male and 15 female students, measured five times consecutively by using body fat/hydration monitor scale, with bioelectrical impedance analysis principle. data collection was performed five times, from february to july 2012 in bandung. statistical analysis was processed using analysis of variance (anova). results: the result in males showed the mean 43.35±3.15 on the initial measurement. the muscle mass further increased significantly after five, ten, fifteen, and nineteen weeks of exercise (43.73±3.18 (p<0.05); 44.07±2.97 (p<0.05); 44.08±2.84 (p<0.05); 44.72±2.78 (p<0.05); all data vs 43.35±3.15) respectively. in females, there was increased of muscle mass although not all were statistically significant. the baseline was 37.77±2.00 with increased muscle mass after five, ten, fifteen, and nineteen weeks of exercise (37.78±2.06 (p>0.05); 38.08±1.67 (p>0.05) ; 38.23±1.52 (p>0.05) ; 38.61±1.52 (p<0.05) vs 37.77±2.00) respectively. conclusion: basic training of student’s outdoor club increases muscle mass significantly after five weeks of exercise in males, but not in females key words: basic training, bioelectrical impedance analysis, hypertrophy, muscle mass, students outdoor club correspondence: novie salsabila, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: phone : +62 857 2145 0929 email: salsabila.novie@gmail.com introduction physical activity is a programmed, structured, and repetitive body movement.1 sport is defined as a physical activity which is done to increase health or improve deformity.2 sport is characterized by the differences in intensity, frequency, duration, and type.3 those characters influence the adaptation of human body to sport, such as muscle hypertrophy.4-6 hypertrophy is a condition of increasing muscle mass.7 based on the intensity, exercise is classified as mild (less than 50% maximum heart rate), moderate (50–85% maximum heart rate), and heavy (more than 85% maximum heart rate). while maximum heart rate is defined as 220 minus age.8 this article reports the result of the study that determined the increase of muscle mass after 19 weeks of exercise. methods the subjects of this study were college students who joined basic training of a students’ outdoor club. all of the subjects had been exercising for 19 weeks. they were included in this study after they agreed to participate as a subject in this study. on the other hand, they would be excluded if they had injury or the data needed were not completely collected. data collection was performed five times, starting from february to july 2012 in bandung. after receiving explanation about this study, and filling an informed consent letter, the subjects were included in 19 weeks of exercise. data collection was performed 5 times during the exercise, in the beginning, fifth week, tenth week, fifteenth week, and nineteenth week of exercise. data collection was performed althea medical journal. 2015;2(1) 120 amj march, 2015 five times because of differences in intensity exposure that was given in each period. the exposure given in this study started from low to moderate intensity in the first five weeks. in the second period, the intensity was from moderate to heavy. in the third period, tenth to fifteenth week, exercise was performed with moderate intensity. in the fifteenth to nineteenth week, exercise was perfomed with heavy intensity. total sampling method was used to determine the number of samples. a total of 32 subjects were included. subjects were divided into 2 groups, based on the sex. muscle mass was defined as muscle proportion of individual’s total body weight measured by body fat/hydration monitor scale, designed to measure the composition of fat, water, and muscle of the body by using the bioelectrical impedance analysis. the outcome of this study was the change of mean muscle mass from the baseline measurement. used as baseline for this study was the muscle mass determined in the first week, before any exposure was given. data was processed using thespss 17.0 version, and thestatistical analysis was carried out using analysis of variance (anova). results out of 47 subjects who fully participated in the basic training, there were 32 subjects who met the criteria for this study. twelve college students were excluded because of incomplete data collection. from those 32 subjects, 17 were male, with mean of age 19.18 (±1.131), and the remaining were female with mean of age 19.47 (±0.743). in male overall, there was a difference in the effect to increasemuscle mass with variations of intensity. the exposure given in this study started from low to moderate intensity in the first five weeks. in this period, muscle mass increase was not as big as in the second period, of which intensity was moderate to heavy. in the third period, tenth to fifteenth week, exercise was aimed to maintain the physical condition, by moderate intensity exercise. in the fifteenth to nineteenth week, exercise was with heavy intensity. in this last week, there was high increase in muscle mass compared with the periods before. the mean of muscle mass in the first measurement which was settled as baseline was 43.35±3.15 percent. there was a substantial increase in muscle mass in every period of measurement, especially in the last week (p=0.000 vs baseline) (figure 1). the baseline measurement of female subjects was 37.77±2.00 percent, and mean of muscle mass also increased in every measurement, but with statistical significance only in the last week of measurement (p=0.025 vs baseline). figure 1 average profile of muscle mass in male subject description : * statistically significant compared to baseline althea medical journal. 2015;2(1) 121 discussions the result of this study showed that there was statistically significant increase in muscle mass of male subjects receiving 19 weeks of training. this result proved that exercise influenced muscle mass. a study that was held by villareal et al.10, had similar result. the subjects in that study were adults with obesity, who were given aerobic exercises such as upstairs-downstairs, treadmill, and stationary cycling for 52 weeks with increasing intensity periodically. one mechanism of increasing muscle mass is hypertrophy, although still in controversy, hyperplasia might also occur. in a person who performs exercise, there is an increasing amino acid transport to muscle cell as a respond to pressure. amino acid is then rearranged to form contractile protein. contractile protein increases amount and size of myofibril.7 growth hormone/insulin-like growth factor-1 (gh/igf-1) and fibroblast growth factor-2 (fgf-2) influence growth. exercise increases the level of gh/igf-1 and fgf-2. fgf2 is responsible for myogenesis and capillary angiogenesis during muscle growth. the igf-1 maintains muscle mass by suppressing protein degradation, increasing uptake of amino acid, and also stimulating protein synthesis. protein igf-1 influences gh in protein synthesis by increasing amino acid uptake, also reducing the time needed for transcription and translation of mrna.7, 11 beside that, igf1 also has an effect on calcineurin pathway. calcineurin induces translocation of nuclear factor of activated t-cells (nfat), the substance that influences growth of skeletal muscle. in muscle with hypertrophy, there is an increasing level of enzymes in mitochondria. this enzyme synthesizes atp, that has a role in cross bridging of contractile protein when contraction occur.12, 13 the muscle increase in glycogen is stored as respond to exercise.14 glycogen is used when there is not enough glucose as energy source.15 the other local adaptation is the shifting source of energy, from carbohydrate to fat. using fat as energy source decreases the amount of fat deposit in the body. muscle and fat are body components, so decreased in fat stored in the body will increase proportion of muscle mass.7 in this study, there was no statistically significant result in female, except after the last week of measurement. basically, female subjects also experiences similar adaptation like in male. the difference between male and female is the hormonal system since male’s level of testosterone is more than female’s. testosterone induces transcription, translation, and synthesis of protein in target figure 2 muscle mass profile on female subjects description : * statistically significant compared to baseline novie salsabila, m. rizal chaidir, setiawan: basic training of student’s outdoor club increases muscle mass after five weeks of exercise in males althea medical journal. 2015;2(1) 122 amj march, 2015 cell. besides that testosterone has an anabolic function that stimulates structural protein synthesis in skeletal muscle and prevents its degradation. this function causes increasing protein deposit, especially in muscle cells.7, 16, 17 on the other side,, estrogen has an effect on fat deposit. estrogen stimulates the uptake of lipoprotein serum, and causes the decrease in total cholesterol and ldl serum level, increase level of hdl and triglyceride in serum, and decrease lipoprotein a serum. females have more estrogen level, leads to more fat deposit than males, rather than anabolic effect.7 references 1. whitney e, rolfes sr. understanding nutrition. 11th ed. belmont: thomson wadsworth; 2008 2. dorland, newman wa. dorland’s pocket medical dictionary. 28th ed. philadelphia: elsevier saunders; 2009 3. american college of sport medicine. cardiorespiratory training guidelines. acsm: indianapolis; 2011 4. volpe sl, rife fn, melanson el, merritt a, witek j, freedson ps. physiological changes in sixth graders who trained to walk the boston marathon. j sports med. 2002;1:128-35. 5. seynnes or, boer md, narici mv. early skeletal muscle hypertrophy and architectural changes in response to high-intensity resistance training. j appl physiol. 2007;102(1):368-73. 6. tesch p, trieschmann j, ekberg a. hypertrophy of chronically unloaded muscle subjected to resistance exercise. j appl physiol. 2004;96(4):1451-8. 7. guyton ac, hall je. textbook of medical physiology. 12th ed. philadelphia: elsevier saunders; 2010 8. slentz ca, duscha bd, johnson jl, ketchum k, aiken lb, samsa gp, et al. effects of the amount of exercise on body weight, body composition, and measures of central obesity. arch intern med. 2004;164(1):319 9. manual instruction of body fat/hydration monitor scale. perfect health; 2009 10. vilareal dt, chode mds, parimi n. weight loss, exercise, or both and physical function in obese older adults. n engl j med. 2011;364(13):1218-29. 11. gardner d, shoback d.greenspan’s basic and clinical endocrinology. 9th ed. san fransisco: mcgraw-hill companies: 2011. 12. wackerhage h, woods nm. exerciseinduced signal transduction and gene regulation in skeletal muscle. j sports med. 2002;1:103-4. 13. barrett ke, barman sm, boitano s, brooks h. ganong’s review of medical physiology. 23rd ed. san fransisco: mcgraw-hill companies; 2009. 14. murray rk. harper’s illustrated biochemistry. 28th ed. san fransisco: mcgraw-hill companies; 2009. 15. baar k, wende ar, jones te, marison m, nolte la, chen m, et al. adaptations of skeletal muscle to exercise: rapid increase in the transcriptional coactivator pgc-1. faseb j. 2002;16(14):1879-86. 16. molina p. endocrine physiology. 3rd ed. san fransisco: mcgraw-hill companies; 2009. 17. silbernagl s, despopoulos a. color atlas of physiology. 6th ed. new york: thieme; 2009. althea medical journal. 2016;3(2) 314 amj june 2016 dental caries severity based on the nutritional status of preschool children in jatinangor anggita dwi putri,1 etty sofia ma,2 julistio t.b. djais3 1faculty of medicine, universitas padjadjaran, 2department of oral health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the prevalence of dental caries in indonesia is still high. the pain caused by dental caries could interfere with children’s ability to eat and even their growth. this study aimed to discover the proportion of dental caries severity related to nutritional status in children aged 3–5 years. methods: this descriptive study was carried out in 3 pre-school education centers (pendidikan anak usia dini, paud) in the sub-district of jatinangor in september 2014. sixty four children were selected through cluster random sampling as samples. the degree of caries was measured by def-t index. nutritional status was determined by anthropometric measurements, i.e. body weight (bw)/body height (bh) or body mass index (bmi)/age index. results: there were 59 (92%) children suffered from dental caries out of which 48 (75%) children was severe, 6 (9%) children was moderate, and 10 (16%) children was mild. furthermore, 18 (28%) children were mildly undernourished and 46 (72%) were well-nourished. out of all the children with severe dental caries, 16 (34%) children had mild undernourishment while out of all the children with moderate-mild dental caries, 2 (12%) children had mild undernourishment. conclusions: children aged 3-5 years in the sub-district of jatinangor have a relatively severe dental caries even though their nutritional status are generally good. mildly undernourished children largely come from the group with severe dental caries. [amj.2016;3(2):314–8] keywords: dental caries, nutritional status, preschool children correspondence: anggita dwi putri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281296582285 email: anggitadwiputri@gmail.com introduction optimal growth is very important to children in order to achieve their maximum potential when they become adults. children growth acceleration during preschool age is lower than during infancy.1 it is because preschool children are already actively playing and tend to be picky with their food.1 as such, parents or caretakers need to pay special attention so that children’s food intake in preschool age does not decrease.1 dental caries is one of dental infectious diseases which can affect children’s food intake. pain caused by untreated dental caries can disturb the mastication process in children, leading to decreased food intake or even growth disruption.2 a study by alkarimi et al.3 in saudi arabia and another one by benzian et al.4 in the philippines stated that there is a significant correlation between the high degree of severity of dental caries with low body mass index (bmi) in children.3,4 in indonesia, the prevalence of dental caries is still fairly high. basic health research (riset kesehatan dasar, riskesdas) 2013 reported that decay missing filled-teeth (dmf-t) index among indonesians reached 4.6. this number means that an average indonesian has 5 teeth with dental caries.5 based on the description above, this study aimed to discover the proportion of dental caries severity related to nutritional status in children aged 3-5 years. methods this study was a descriptive study conducted in september 2014 in 3 pre-school education centers (pendidikan anak usia dini or paud) althea medical journal. 2016;3(2) 315 in the sub-distric of jatinangor, which were paud al-azhar, paud hayatushifa, and paud sayang bunda. all procedures in this study had been approved by the health research ethics committee faculty of medicine universitas padjadjaran. the sample was made up of 64 subjects who were selected by cluster random sampling. the inclusion criteria were 3-5 years old children with consenting parents or caretakers. table 1 basic characteristics variables n (64) % gender males 23 36 females 41 64 age (years) 3–4 7 11 4–5 35 55 5–< 6 22 34 father’s education elementary school 6 9 middle school 15 24 high school 34 53 higher education 5 8 unknown 4 6 mother’s education elementary school 2 4 middle school 15 23 high school 36 56 higher education 5 8 unknown 6 9 father’s occupation civil servants 7 11 employee (private) 18 29 self-employed 27 42 others 6 9 unknown 6 9 mother’s occupation civil servants 1 2 employee (private) 13 20 self-employed 3 5 housewives 39 61 unknown 8 12 anggita dwi putri, etty sofia ma, julistio t.b. djais: dental caries severity based on the nutritional status of preschool children in jatinangor althea medical journal. 2016;3(2) 316 amj june 2016 the children who were absent during data collection were excluded. the clinical examination to examine the severity of dental caries was done by a trained dental nurse in a location with sufficient lighting. def-t index comprises of: (1) decayed (d), which is the number of teeth with untreated dental caries, (2) extracted (e), which is the number of teeth that were extracted specifically due to dental caries, (3) filling (f ), which is the number of teeth with fillings. the three components (d,e, and f ) from each subject was summed up and presented as def-t index. body weight (bw) and body height (bh) measurement were done using digital weight scale (precision 0.1 kg) and microtoise (precision 0.1 cm) respectively. during the measurement, respondents were asked to wear only light or minimal clothing and not allowed to wear footwear, jackets, caps/hats, or bags. the severity of dental caries was measured using def-t index and then categorized into three groups according to the world health organization (who): low (0,0–1,1), moderate (2,7-4,4), and high (≥ 4,5). nutritional status was determined by using the z-score of bw/ bh or bmi/age index. index of bw/bh was used in under-five children, while bmi/age index was used for respondents who were 5 years old or older but not yet 6 years old. the values for z-score was calculated by using application who antro version 3.2.2 and then interpreted according to who 2006. the bw/bh or bmi/age index z-score was used for the interpretation. mild undernutrition is when -2 < z-score < -1 and good nutrition is when -1 ≤ z-scores < +2. all data was processed using computerized methods. results there were 64 subjects involved in this study. basic characteristics of the subjects that were recorded were gender, age, parents’ education, and parents’ occupation. most respondents were females and the largest proportion came from the 4-5 years old age group. the mean age of all the respondents was 57.59 (6.91) months old or roughly about 4 years and 10 months old (table 1). table 1 showed that the largest proportion of parents had middle school education. the largest proportion of fathers was selfemployed while the largest proportion of mothers was housewives. the respondents generally came from lower middle economy class. out of all respondents, 52 (92%) children were confirmed to have dental caries, 48 (75%) children was severe, 6 (9%) children was moderate, and 10 (16%) children was mild (table 2).. the overall mean def-t index (sd) was 7.61 (4.34), all of which was due to dental caries component (d). out of 18 (28%) children were mildly undernourished and 46 (72%) were wellnourished (table 3). out of all the children with severe dental caries, 16 (34%) children had mild undernourishment while out of all the children with moderate-mild dental caries, 2 (12%) children had mild undernourishment (table 4). table 2 severity of dental caries variables n (64) % severity of dental caries low(def-t 0,0-2,6) 10 16 moderate (def-t 2,7-4,4) 6 9 high (def-t ≥ 4,5) 48 75 table 3 nutritional status variables n (64) % nutritional status (bw/bh, bmi/age) -2 < sd < -1 (mild undernutrition) 18 28 -1 ≤ sd < +2 (good nutrition) 46 72 althea medical journal. 2016;3(2) 317 discussion in this study 92% of respondents suffered from dental caries with mean def-t index of 7.61. this result reflected that an average preschool child in jatinangor had 8 teeth with dental caries. this result was higher than other countries. a study in bangalore, india6 discovers that the prevalence of dental caries among preschool children there is 27.5% with mean def-t index of 0.854. the prevalence of dental caries among preschool children in riyadh, saudi arabia7 was 74.8% with def-t index of 6.1 while in kiambaa, kenya8, it is 59.5% with def-t index of 2.46.7,8 this could happen because in jatinangor, parent’s awareness and knowledge of the importance of dental health maintenance since early age was still lacking, as indicated by the high number of dental caries cases even though the majority of respondent’s mother was housewives (61%). table 4 showed that respondents with mild undernutrition mostly came from group of children with severe dental caries. this was a reflection of the correlation between severe dental caries with mild undernutrition. this conformed to an analytic study by alkarimi et al.3 in saudi arabi and another by benzian et al.4 in the philippines. those studies report a significant correlation between the high severity of dental caries and low bmi in children. those two studies had a different finding from a study by hong et al.9. hong et al.9 reported that there is a significant correlation between high severity of dental caries with high bmi (overweight) in children. the different findings were in agreement with a systematic review by hooley et al.10 on the correlation between bmi and dental caries among children aged 0-18 years. the study reports that dental caries has correlation with both high and low bmi. several factors that cause the difference in the above studies are the different scales used to measure the severity of dental caries, presence of other controlled variables, age of respondents, bmi range, and the socioeconomic status of the respondent. the conclusions of this study are that children aged 3-5 years old in the sub-district of jatinangor have a fairly high prevalence of dental caries, while the nutritional status among children are generally good and that children with mild undernutrition mostly come from the group with high severity of dental caries. the limitation of this study was on the use of study design (descriptive cross-section), which prevented the analysis of the correlation between the severity of dental caries and nutritional status. as such, the author recommends a further study to analyze the correlation between the two variables, while also taking into consideration the dental caries severity scale, bmi range, and other variables that can potentially affect dental caries and nutritional status such as socioeconomic status, nutritional intake, and respondent’s oral health. in general, the author also recommends the local health authority and public health center (pusat kesehatan masyarakat, puskesmas) to improve parent’s awareness and knowledge on the importance of early dental health maintenance. this is for reducing the high severity of dental caries in jatinangor subdistrict. references 1. ari istiany, rusilanti. gizi terapan. bandung: pt remaja rosdakarya; 2013. 2. sheiham a. dental caries affects body weight, growth and quality of life in pre-school children. br dent j. 2006;201(10):625¬−6. 3. alkarimi ha, watt rg, pikhart h, sheiham a, tsakos g. dental caries and growth in school-age children. pediatrics. 2014;133(3):616−23. 4. benzian h, monse b, heinrich-weltzien r, hobdell m, mulder j, van palenstein helderman w. untreated severe dental decay: a neglected determinant of low body table 4 respondent’s severity of dental caries and nutritional status severity of dental caries mild undernutrition good nutrition total high 16 (34%) 32 (66%) 48 moderate-low 2 (12%) 14 (88%) 16 total 18 46 64 anggita dwi putri, etty sofia ma, julistio t.b. djais: dental caries severity based on the nutritional status of preschool children in jatinangor althea medical journal. 2016;3(2) 318 amj june 2016 mass index in 12-year-old filipino children. bmc public health. 2011;11(1):558. 5. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2013. jakarta: kementrian kesehatan; 2013. 6. prakash p, subramaniam p, durgesh b, konde s. prevalence of early childhood caries and associated risk factors in preschool children of urban bangalore, india: a cross-sectional study. eur j dent. 2012;6(2):141–52. 7. wyne ah. caries prevalence, severity, and pattern in preschool children. j contemp dent pract. 2008;9(3):24−31. 8. njoroge n, kemoli a, gatheche l. prevalence and pattern of early childhood caries among 3-5 year olds in kiambaa, kenya. east afr med j. 2010;87(3):134−7. 9. hong l, ahmed a, mccunniff m, overman p, mathew m. obesity and dental caries in children aged 2-6 years in the united states: national health and nutrition examination survey 1999-2002. j public health dent. 2008;68(4):227−33. 10. hooley m, skouteris h, boganin c, satur j, kilpatrick n. body mass index and dental caries in children and adolescents: a systematic review of literature published 2004 to 2011. syst rev. 2012;1(1):57.. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 20 amj march, 2015 correlation of body mass index and health to quality of life among medical undergraduates sivanesan supramaniyam1, abdullah firmansah w.2, ellyana sungkar3 1faculty of medicine, universitas padjadjaran, 2department of medical nutrition, faculty of medicine, universitas padjadjaran, 3department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: overweight and obesity play a major role in an individual’s health with quality of life (hrqol). several studies reported that there are differences between the results in different communities since hrqol score in relation to bmi is sensitive to specific communities. the aim of this study was to investigate the relationship between the body mass index (bmi) and health with quality of life among the medical undergraduates of universitas padjadjaran, bandung methods: this study was an analytical cross-sectional study conducted from september to november 2012 in faculty of medicine universitas padjadjaran. a total of 280 respondents aged 16-30 were selected from the of 2009, 2010 2011 and 2012 classes of medical undergraduates after a thorough bmi screening. the overweight and obese subjects were selected using total sampling method, while subjects with normal bmi were sampled using simple random sampling. the subjects were asked to fill up short form 36 questionnaires. the correlation was assessed using spearman`s correlation test and the difference between the groups were analyzed using kruskal-wallis test. results: of the 260 respondents, there was a weak correlation between the bmi and total health with the quality of life of the undergraduates (rho = -0.173). among the eight scales used, there was no correlation shown in three scales, namely body pain, social function, and mental health, in any of the groups. conclusion: increased body mass index impairs the health-related quality of life of the respondents, except in scales such as body pain, social function, and mental health. keywords: body mass index, health related to quality of life, short form 36 correspondence: sivanesan supramaniyam, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628170208984 email: s.sivanesan89@hotmail.com introduction overweight and obesity is a medical condition where there is an excessive deposition of fat in body that has deleterious effects on health.1 according to world health organization (who) global estimate 2008, “1.5 billion adults, 20 and older were overweight. among them, over 200 million men and nearly 300 million women were obese. overall, more than 1 in 10 of the world`s adult population were obese ".1 based on the report of riset kesehatan dasar 2010 (riskesdas), the prevalence of overweight for adults more than 18 years in indonesia was 10 % and the prevalence of obesity for adults more than 18 years in indonesia was 11.7 % in accordance to the modified asian body mass index (bmi) cut-off points. meanwhile, it also reports that the prevalence of overweight for west java region was 10 % for year 2010, followed by prevalence for obesity which was 12.8 for year 2010 in accordance to the modified asian bmi cut-off points.2 according to who, “raised bmi is a major risk factor for non-communicable diseases such as cardiovascular diseases, diabetes, musculoskeletal disorders and cancer".1 population assessment of health related quality of life (hrqol) reported by centers for disease control and prevention (cdc) says that, hrqol is "an individual`s or group`s perceived physical and mental health over time".3 based on cdc`s report on hrqol of united states residents, for the years 20062010 , there was 16.2% reported that having only fair or poor self-rated health. while, 7.0% of united state residents, reported that having 14 or more days of activity limitation for the period of 2006-2010.4, 5 health related althea medical journal. 2015;2(1) 21 quality of life (hrqol) is an important tool in identifying burden of diseases that can be prevented, injuries, and disabilities. the hrqol data also may reveal the association between hrqol and the risk factors.6 overweight and obesity play a major role in an individual’s hrqol. several studies have been done previously about the association between the bmi and hrqol in sweden, korea, singapore and china. based on the swedish study, the results show that overweight and obesity in adults from the age range of 1634 for male and female have a negative effect on physical components (pcs) and mental components (mcs) of health related quality of life but the there is a difference between the results according to the community.7-9 this shows that the hrqol score in relation to bmi is sensitive to the community. the difference in the community may show significantly different results according the culture and beliefs of that particular population. therefore in this study the researcher intends to study the hrqol score of normal, overweight and obese groups of the local population. the target population is undergraduates of medical faculty of universitas padjadjaran aged from 16 to 30 years old. this population was chosen based on the researcher`s observation there are many undergraduates with overweight and obesity in the faculty. moreover, this population also chosen because it shows the functionality level of the future doctors since they have a big role in treating people for long hours. so, the findings of the study can be used by the faculty to control overweight and obesity among its undergraduates to produce a future doctor who is competent physically and mentally. methods the study design was analytical cross-sectional conducted from september to november 2012 in faculty of medicine universitas padjadjaran, jatinangor, sumedang. the population of this study was male and female medical undergraduates of universitas padjadjaran. the inclusion criteria were the medical undergraduates of universitas padjadjaran in jatinangor campus of the batch of 2009, 2010, 2011 and 2012 (class a & class b) who were willing to undergo screening process to measure their height and weight and to fill the questionnaire form. the exclusion criteria were students with chronic diseases. the body weight and height measured to calculate bmi of the students, which was computed from the rate of total weight in kilogram to square of height in meter, thus the measurement unit of bmi is kg/m¬2. the overweight and obese subjects were selected using total sampling method, meanwhile the normal bmi were sampled using simple random sampling with equal number of subjects from the normal bmi is selected as a comparison group. all the samples are given guidance about the questionnaire and asked to fill the questionnaire sheet. the questionnaire is a validated questionnaire used worldwide for assessing hrqol known as medical outcomes study short form 36 (sf-36). the hrqol is the perception of the respondents about their health`s influence on their quality of life; measured in terms of the score based on their response to the sf36 form. the total score for the hrqol is 100. the sf-36 contains 36 items that can be generally classified into eight main domains of health namely physical functioning (pf), role physical (rp), bodily pain (bp), general health (gh), vitality (vt), social functioning (sf), role-emotional (re) and mental health (mh). the scoring for each item is from 0 to 100. items with 6 options are scored as 100, 80,60,40,20 and 0. items with 5 options are scored from 100, 75, 50, 25 and 0. meanwhile, items with 3 options are scored as 0, 50 and 100. items with 2 options are scored as 0 or 100. the mean score for each of 8 scales are calculated and compared between the normal, overweight and obese groups. the correlation between the body mass index and hrqol which recorder into the 8 hrqol was analyzed using the spearman`s correlation. results the analysis was restricted to the age table 1 the weight status categories associated with body mass index in adults body mass index weight status below 18.5 underweight 18.5 – 24.9 normal 25.0 – 29.9 overweight 30.0 and above obese sivanesan supramaniyam, abdullah firmansah w, ellyana sungkar: correlation of body mass index and health to quality of life among medical undergraduates althea medical journal. 2015;2(1) 22 amj march, 2015 group of 16 to 30 years old. the total respondents that returned the questionnaire were 260 people out of 280 people who were selected after a thorough screening process. the non-response rate was 7.1%. table 2 showed that most of subject was female, especially in norm weight group meanwhile in overweight and obese groups mostly male the spearman correlation analysis method was used to study the relationship between the bmi status and hrqol of the undergraduates. this was done by correlating the values of bmi with the scores of hrqol of all the respondents. from this analysis, it was known that there was a negative correlation between the value of bmi and hrqol score. negative correlation in this case means that higher the values of bmi, the lower the hrqol total scores. the spearman correlation coefficient, rho = -0.173, significant at 0.05 level (table 3). discussion from the results obtained the total score of hrqol decreases as the bmi increases. so, it can be concluded thatthere is a negative correlation between the hrqol and the bmi. but, not all the components of hrqol are statistically significant for this negative correlation relationship between the hrqol and bmi. the hrqol can be divided into 2 main scales, namely pcs and mcs. the pcs includes components like physical functioning, role physical, bodily pain and general health. meanwhile, mcs includes vitality, social functioning, role of emotional, and mental health components. physical functioning is a scale that measures the ability to perform activities of daily living and also strenuous activities.7 from this study, it can be concluded that both the male and female respondents had limitations in performing activities of daily living and strenuous activities as their body mass index increases. obese group suffered the most from this limitation since the obese group is significantly different from the normal and overweight group based on the mannwhitney post hoc test. this is in accordance to a previous study on general population of sweden where the obese respondents had significantly lower physical functioning score compared to the respondents with normal bmi.7 there is no significant difference between the normal and overweight group suggesting that the normal and overweight group experienced relatively same level of limitations in performing daily activities and strenuous activities. this finding is in accordance to the study in china where the obese and pre-obese groups reported to have relatively same level of physical functioning score for male respondents.9 the female respondents of normal and overweight group showed no difference in physical functioning score maybe because the females of overweight group who are image sensitive have been frequently involved in regular exercise in order to get slim. so, this would have made strenuous activities much easier for them and had no difficulty in physical table 2 number of the respondents according to gender and bmi status bmi status male (n=122) female (n=138) normal 46 84 overweight 55 39 obese 21 15 note: bmi, body mass index table 3 correlation between bmi and hrqol (n=260) variables spearman`s rho p value health related quality of life (hrqol) -0.173 0.005* physical component (pcs) -0.188 0.002* physical functioning (pf) -0.285 0.000* role physical (rp) -0.074 0.236 bodily pain (bp) -0.188 0.777 general health (gh) -0.133 0.032* mental component (mcs) -0.144 0.020* vitality (vt) -0.194 0.002* social functioning (sf) -0.055 0.381 role-emotional (re) -0.121 0.051 mental health (mh) -0.086 0.166 note: p-value < 0.05, significant (*) bmi, body mass index althea medical journal. 2015;2(1) 23 functioning. rolephysical reflects the extent that physical health has a limiting effect on work or other activities.7 in this study, there is no correlation between the role-physical and bmi of the respondents.however,, the obese group is significantly different from the overweight and normal bmi group for male and total respondents. this is in accordance to the previous study where the score of role-physical in obese group is significantly different from the normal group.7 meanwhile, in female respondents, there is no any significant difference amongthe groups which is in accordance to the previous study.7 the possible reason for no correlation is possibly the age group of the respondents. body mass index (bmi) usually influences the physical health in long-term, for example, in adults of 40 plus of age. while, in this sample, the respondents are aged from 16-30 years old, causing the bmihas no effect on the physical health. bodily pain concerns the amount of pain felt and whether it interferes with normal activities.7 in this study, there is no correlation between the bodily pain and bmi of the respondents. moreover, there is no significant difference between the groups based on the kruskal-wallis test in males, females and total respondents as they experienced relatively same level of interference in normal activities due to body pain regardless of their body mass index status. this finding is in contrary to the findings from a previous study, where the bodily pain score is significantly different between the obese group and normal group.7 this finding is might be related to the role of the respondents as students. the bodily pain arises when an individual with excess body weight involved in stressful or hectic environment such as working environment. these undergraduates are less challenged in terms of physical, so showing no difference between the different bmi groups. general health measures perceived general health status.7 from this study, it can be concluded that as the body mass index of the respondents increases, the overall general health becomes worsen. however, there is no significant difference for male, female and total respondents; between the normal, overweight and obese groups of this study. this finding is in contrary to the findings from a previous study where the general health score is significantly different between the obese group and normal group.7 the contradicting result may be due to the respondents since the respondents are table 4 sf-36 scale and summary score (standard error) by bmi category for male and female bmi normal overweight obese k-w median median median p health related quality of life 81.2 78.9 69.7*** 0.005 physical component (pcs) 86.9 86.3 77.2*** 0.001 physical functioning (pf) 100.0 95.0 75.0*** 0.000 role physical (rp) 100.0 100.0 100*** 0.035 bodily pain (bp) 87.5 87.5 93.8 0.682 general health (gh) 70.0 70.0 65.0* 0.057 mental component (mcs) 77.3 71.9 65.1* 0.028 vitality (vt) 70.0 60.0* 62.5* 0.001 social functioning (sf) 77.5 77.5 76.3 0.591 role-emotional (re) 100.0 100.0 66.7*** 0.011 mental health (mh) 76.0 72.0 72.0 0.415 * p<0.05 compare with normal bmi group based on mann-whitney post-hoc test ** p<0.05 compare with overweight bmi group based on mann-whitney post-hoc test *** p<0.05 compare with normal & overweight bmi group based on mann-whitney post-hoc test sivanesan supramaniyam, abdullah firmansah w, ellyana sungkar: correlation of body mass index and health to quality of life among medical undergraduates althea medical journal. 2015;2(1) 24 amj march, 2015 medical students and the awareness towards general health maintenance is higher. “vitality measures the level of energy and tiredness among the respondents”.7 from this study, it can be concluded that the level of energy is decreased and respondents tend be more tired as the body mass index increases. for the male and total respondents, there is a significant difference between the normal and overweight group. meanwhile, there is also a significant difference between the normal and obese group. this is in accordance to a previous study on general population of sweden where the obese respondents had significantly lower vitality score compared to the respondents with normal bmi.7 but, there is no significant difference between the overweight and obese group suggesting that the level of energy between the overweight and obese respondents relatively same. meanwhile, for female respondents, there is no significant difference between the bmi groups. the same results were obtained among the women for vitality score in the research in sweden.7 social functioning concerns how social activities are affected by physical health or emotional problems.7 in this study, there is no correlation between the social functioning and bmi of the respondents. moreover, there is also no significant difference between the groups for male, female or total respondents. it shows that the social activity involvement due to physical or emotional problems is relatively same among the respondents of normal, overweight and obese groups. based on the swedish study, the male respondents had significant difference between the groups for social functioning in contrary to the results of this study; while the female respondents had no significant difference between the groups which is in accordance to this study.7 the respondents show no difference in social functioning because body mass index has no effect on their physical health and emotional problems, because medical students are capable of taking care of their physical health and also capable of overcoming emotional problems without any impact to their social life since they are specially trained to have good communication skills as a future doctor. role-emotional reflects the extent that work or other activities are limited by emotional problems.7 from this study, it can be concluded that there is no correlation between the body mass index and role-emotional scale. although there is no correlation, there is a significant difference between the obese to overweight and between normal to obese groups for male and total respondents. meanwhile, for female respondents there is no significant difference between the groups which is in accordance to the previous study.7 the respondents show no difference in role-emotional because the medical students are capable of overcoming emotional problems without any impact to their activities or routines. mental health measures the emotional well being of the respondents.7 there is no correlation between the bmi of the respondents and mental health. this shows that the emotional well being of all the respondents are relatively same regardless of their body mass index. this is also true based on the study of the general population of sweden and china, where there is no significant difference in the scores of mental health scale between the groups of normal, overweight and obesity for male and female respondents.7, 9 limitation of this study were we did not consider other factors except gender as influencing factors. from this study, it can be concluded that increased body mass index impairs the health related quality of life of the respondents, except in scales such as bodily pain, social functioning and mental health. references 1. who. fact sheet no 311: obesity and overweight. [downloaded in 5 may 2012] available at: http://www.who.int/ mediacentre/factsheets/fs311/en/index. html. 2. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. laporan riset kesehatan dasar 2010. kementerian kesehatan republik indonesia; 2010.[ downloaded in 5 may 2012] available at: http://www.litbang. d e p ke s . g o . i d / s i t e s / d o w n l o a d / b u ku _ laporan/lapnas_riskesdas2010/laporan_ riskesdas_2010.pdf.centers for disease control and prevention. measuring healthy days: population assessment of healthrelated quality of life. atlanta, georgia: cdc; 2000 [ downloaded in 2 may 2012] available at: http://www.cdc.gov/hrqol/ pdfs/mhd.pdf. 3. centers for disease control and prevention. health-related quality of life. 2012; [downloaded in 2 may 2012] available at: http://apps.nccd.cdc.gov/hrqol/trendv. asp?state=1&category=1&measure=8. cdc. health-related quality of life. 2012; [downloaded in 2 may 2012] available at: althea medical journal. 2015;2(1) 25 http://apps.nccd.cdc.gov/hrqol/trendv. asp?state=1&category=1&measure=1. 4. cdc. hrqol concepts. 2011; [downloaded in 2 may 2012] available at: http://www. cdc.gov/hrqol/concept.htm. 5. larsson u, karlsson j, sullivan m. impact of overweight and obesity on health-related quality of life--a swedish population study. int j obes relat metab disord 2002; 26(3):417-24. 6. wee hl, cheung yb, loke wc, tan cb, chow mh, li sc, et al. the association of body mass index with health-related quality of life: an exploratory study in a multiethnic asian population. value health. 2008; 11 suppl 1:s105-14. 7. wang r, wu mj, ma xq, zhao yf, yan xy, gao qb, et al. body mass index and healthrelated quality of life in adults: a population based study in five cities of china. eur j public health; 22(4):497-502. 8. cdc. bmi for adults. 2011 [updated 13 september 2011]; [downloaded in 2 may 2012] available at: http://www.cdc.gov/ healthyweight/assessing/bmi/adult_bmi/ index.html. sivanesan supramaniyam, abdullah firmansah w, ellyana sungkar: correlation of body mass index and health to quality of life among medical undergraduates althea medical journal. 2014;1(2) 81 antipyretic effect of cinnamomum burmannii (nees & t.nees) blume infusion in fever-induced rat models qatrunnada zainol1, eva m. hidayat2, stanza uga peryoga3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of child health, faculty of medicine, universitas padjadjaran/dr.hasan sadikin general hospital, bandung, indonesia abstract background : fever is a frequent clinical sign encountered in human especially in children. unfortunately, access to health care and medications (antipyretics) are hampered by shortage of services and affordability, which are accentuated by local resources mainly for those living in remote areas. therefore, using herbal medicineas an alternative in treating fever should be developed as substituent reliance on synthetic antipyretic. this study is conducted to observe antipyretic effect of cinnamomum burmannii (nees & t.nees) blume infusion using diphtheria tetanus pertussis (dtp) vaccine-induced fever in rats. methods: twenty-eight male wistar rats (150 200 g) were randomly allocated into control and treatment groups. fever was induced with dtp vaccine intramuscularly injected (0.7 ml/200 g body weight) and 4 hours later, distilled water (5 ml) was administered orally to the control group while the treatment group received 5 ml of 3%, 6%, and 12% of cinnamon infusion. rectal temperature was measured before the pretreatment, 4 hours after dtp vaccine-induced fever injection and at a 30-minute interval during 180 minutes after the infusion administration. all procedures and protocols were performed in october 2012 at the pharmacology laboratory, faculty of medicine, universitas padjadjaran, bandung. results: data analysis using the one way analysis of variance (anova) showed significant reduction (p<0.001) of rectal temperature after 30 minutes and duncan post-hoc test showed significant effect for 6% and 12% of cinnamon infusion groups. conclusion : the antipyretic effect of 6% and 12% of cinnamomum burmannii (nees & t.nees) blume infusion in fever-induced rat models is found in the first 30 minutes [amj.2014;1(1):81–5] keywords: antipyretic, cinnamomum burmannii (nees & t.nees) blume, fever, herbal medicine efek antipiretik infusa cinnamomum burmannii (nees & t.nees) blume pada tikus yang diinduksi demam abstrak latar belakang: demam merupakan suatu gejala yang sering muncul terutama pada anak-anak. antipiretik merupakan obat yang sering digunakan untuk meringankan demam, namun akses kepada pelayanan kesehatan dan pengobatan masih belum terjangkau bagi penduduk yang tinggal di daerah terpencil. menggunakan herbal sebagai alternatif pengobatan demam harus dikembangkan sebagai substituen terhadap ketergantungan pada obat sintetik. penelitian ini dilakukan dengan tujuan untuk mengetahui efek antipiretik infusa cinnamomum burmannii (nees & t.nees) blume pada tikus yang diinduksi demam menggunakan vaksin diphtheria tetanus pertussis (dtp). metode: penelitian yang dilakukan menggunakan 28 ekor tikus putih jantan galur wistar yang dikelompokkan secara acak dan diinjeksi dengan vaksin dtp (0.7 ml/200 g bb) secara intramuskular untuk menimbulkan demam. setelah 4 jam, kelompok kontrol diberikan 5ml air suling per oral dan kelompok uji diberikan infusa cinnamomum burmannii (nees & t.nees) blume per oral dengan dosis masing-masing 3%/5 ml, 6%/5 ml dan 12%/5 ml. pengukuran suhu tubuh dilakukan melalui rektal sebelum pemberian vaksin dtp, 4 jam setelah pemberian vaksin dtp dan 30 menit interval setelah perlakuan sampai menit 180. semua prosedur dan protokol dilaksanakan pada oktober 2012 di laboratorium farmakologi, fakultas kedokteran, universitas padjadjaran, bandung. hasil: hasil analisis data menggunakan uji anova menunjukkan penurunan yang signifikan (p<0.001) dari suhu rektal pada menit 30 dan dengan uji duncan post-hoc menunjukkan efek yang signifikan pada kelompok yang diberikan 6%/5 ml dan 12%/5 ml infusa cinnamomum burmannii (nees & t.nees) blume. pada menit 60–180 tidak ada penurunan yang signifikan (p>0.05) dari suhu rektal, dimungkinkan karena correspondence: qatrunnada zainol, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827699583, email: qatrunnada25@gmail.com althea medical journal. 2014;1(2) 82 amj december, 2014 introduction fever is an increase of body temperature due to changes which occur in the body thermoregulatory set-point caused by pyrogens. this is a frequent clinical sign encountered in human, which can be due to infectious or noninfectious diseases. developing countries such as indonesia, with high population density and large geographical area, may face disparities in the access to health care and medication due to limited resources, especially for those who live in remote areas where the access to the primary health care (phc) example such aspusat kesehatan masyarakat (puskesmas), are still difficult geographically difficult to reach. antipyretic side effects such as hypersensitivity, nausea, and vomiting occasionally occur in higher dosage consumption.1 hypersensitivity reactions can be from mild rashes to a more serious problem such as erythema multiforme disorder which is characterized by multiform skin lesions, stevens-johnson syndrome (sjs) and toxicepidermal necrolysis (ten) with promising poor prognosis.2 hence, herbal medicine is a kind of health treatment which we need to look into as an alternative in treating fever since it is relatively affordable and accessible so that we do not have to rely much on synthetic drugs. cinnamon is one of the examples of herbal medicine that is believed to have many beneficial health effects. with the genus name cinnamomum belonging to the family lauraceae, it comprises of many species and one of the species commonly used in indonesia is cinnamomum burmannii (nees & t.nees) blume.3 in a pharmacological study, a reduction of body temperature in mice was observed by the administration of decoctions of the dried twigs of cinnamon.4 while, an in vitro finding reveals that cinnamaldehyde, a chemical constituent of cinnamon can suppress production of endogenous pyrogens example such as tumor necrosis factor (tnf), interleukin-6 (il-6), and interleukin-1 (il-1)5 thus suggesting the role of cinnamaldehyde in providing hypothermic and antipyretic action. accordingly, we were interested in conducting a research on cinnamomum burmannii (nees & t. nees) blume, using the simplest method of extracting active compounds; infusion, to provide evidence for a potential role of cinnamomum burmannii (nees & t.nees) blume in the treatment of fever. methods a total of 28 male wistar rats (150–200 g) obtained from pusat penelitian antar universitas (ppau), institute of technology, bandung were used in this research. the rats were housed at the animal facility of the pharmacology laboratory, faculty of medicine, universitas padjadjaran, bandung with standard condition of temperature (25 ± 2°c). rats that have been used previously on other studies were excluded. seven days prior to starting of the experiment, the rats were kept under laboratory conditions and allowed unlimited food and water the rats were sacrificed with formalin injection at the end of experiment. seven rats were used in each intervention group. the research protocols and animal care procedure were approved by the health research ethics committee of the faculty of medicine, universitas padjadjaran, bandung. the cinnamomum burmannii (nees & t.nees) blume originates from padang, indonesia was bought from a herbal store in october 2012. the sample was identified as cinnamomum burmannii (nees & t.nees) blume by the laboratory of plant taxonomy, biology department, faculty of mathematics and natural sciences, universitas padjadjaran. the cinnamon barks were measured into suitable weight of 0.15 g, 0.30 g and 0.60 g. water is heated in the first level pot until it is boiled and cinnamon barks mixed with 5 ml of water were placed at the second level pot, heated until 90°c for 15 minutes with every 5 minutes the preparation is durasi kerja yang singkat dari cinnamomum burmannii (nees & t.nees) blume. simpulan: efek antipiretik pada pemberian dosis 6% dan 12% infusa cinnamomum burmannii (nees & t.nees) blume pada tikus yang diinduksi demam ditemukan pada 30 menit pertama. [amj.2014;1(1):81–5] kata kunci: antipiretik, cinnamomum burmannii (nees & t.nees) blume, demam, pengobatan herbal althea medical journal. 2014;1(2) 83 stirred. the preparation was then filtered using a flannel cloth and adding hot water through the pulp until the needed volume was obtained. the filtrate had a brown to dark brown colour varying according to the different concentrations. herbal infusion of cinnamomum burmannii (nees & t.nees) blume was kept in a container until the time of treatment. twenty-eight male wistar rats (150 200 g) were randomly allocated into 4 groups. the normal body temperature of each rat was measured rectally at predetermined intervals and recorded. the rectal temperature was measured by gently inserting a digital thermometer to a length of approximately 2.5cm intra rectal until stable reading was obtained or for up to 30 60s. for this, rats were restrained manually at the base of the tail. the accuracy of the thermometer was accurate to 0.1°c. after measuring basal rectal temperature, animals were injected intramuscularly with 0.7 ml/200 g body weight of dtp vaccine. rats were then returned to their housing cages. four hours after dtp vaccine injection, the rat’s rectal temperature was measured again, as described previously. only rats that showed an increase in temperature of at least 0.5°c were used for this study. the cinnamon infusion with doses of 3%, 6% and 12% were administered 5 ml orally to 3 groups of animals. the control group received 5 ml of distilled water orally. rectal temperature was measured at 30 minutes intervals during a period of 180 minutes after the infusion and distilled water administration. difference in mean values between groups were analyzed for each 30 minutes interval by a one way analysis of variance (anova) followed by duncan post-hoc test. statistical significance was assessed as p <0.05. results results of the antipyretic effect of the cinnamomum burmannii (nees & t.nees) blume infusion are presented in figure 1. thirty minutes after intervention (30’) an increase of rectal temperature by 0.5°c was observed in control animals which were given distilled water producing a mean rectal temperature of 38.24±0.24°c. treatment with 5 ml of 6% (group 3) and 12% (group 4) cinnamon infusion significantly (p<0.001) reduced fever induced by dtp vaccine at 30 minutes after oral figure 1 change in rectal temperature after intramuscular injection of vaccine dtp, oral administration of 5ml distilled water and 3 doses of cinnamomum burmannii infusion to rats with fever. all drugs were administered at 0 minutes (0’), n=7 for all groups qatrunnada zainol, eva m. hidayat, stanza uga peryoga: antipyretic effect of cinnamomum burmannii (nees & t. nees) infusion in fever-induced rat models althea medical journal. 2014;1(2) 84 amj december, 2014 administration by approximately 0.8°c. on the other hand, treatment with 5 ml of 3% cinnamon infusion (group 2) failed to reduce the temperature where it increased the rectal temperature by 0.4°c, slightly lower by 0.1°c as compared to the control group at 30 minutes after oral administration. the antipyretic effects of 2 doses of cinnamomum burmannii (nees & t.nees) blume were noted as early as 30 minutes after oral administration and the effect was not maintained for the next 30 minutes until 180 minutes after oral administration. there were fluctuant temperature values with no exact increasing or decreasing trend. rectal temperature of the entire group did not reduce to normal temperature at 180 minutes after oral administration. discussion theoretically, antipyretic acts works as an inhibitor on prostaglandin synthesis by inhibiting the enzyme cyclooxygenase (cox). cyclooxygenase enzyme is also influenced by the presence of cytokines such as tumor necrosis factor-α (tnf-α), interleukin-6 (il-6), interleukin-1 (il-1) and interferon-γ produced by monocytes and macrophage. meanwhile, monocytes and macrophage are stimulated by exogenous pyrogens when the body encounters with infection, toxins, or injury. in the absence of cox enzyme, arachidonic acid cannot be converted to prostaglandin (pgh2) hence no other prostaglandin as mediators of fever can be yield.6 diptheria tetanus pertussis (dtp) vaccine used in this research to induce fever in the rats was a combination of vaccine against infection of diphtheria, pertussis and tetanus. it is believed to have cause pyrogenic activity due to pertussis component in the vaccine in which the toxins presence in vaccine indirectly serves as exogenous pyrogens that cause fever.7 the antipyretic effect of cinnamon might be due to cinnamaldehyde content that may have inhibitory effect on secretion of il-1 and then prostaglandin synthesis. this correspond to a study conducted by a group of researchers from taiwan who reveal that cinnamaldehyde can suppress production of endogenous pyrogens (tnf, il-6, and il-1).5 the antipyretic effect of cinnamomum burmannii (nees & t.nees) blume may be due to these properties which influence in the chain breaking and prevention of prostaglandin release that cause fever. lower doses of cinnamomum burmannii (nees & t. nees) blume infusion had less efficacy in reducing rectal temperature. increase in temperature at minutes 60 and not reaching basal temperature could be due to shorter duration of action of cinnamon in decreasing the high temperature. whether returning to thermal regulatory set point to normal is due to persistent exist of endogenous pyrogens in the circulation for several hours.8 cinnamaldehyde, a chemical constituent of cinnamon which has inhibitory effect on secretion of endogenous pyrogen may not be sufficient enough to fully inhibit release of endogenous pyrogens, cox and the prostaglandins. therefore, a further research should be conducted on cinnamomum burmannii (nees & t. nees) blume using other methods of extracting the active compound which possibly result in higher concentration of cinnamaldehyde, thus will increases its effectiveness. for the control group, the decrease in temperature after 180 minutes can be explained since probably rats, as well as humans have their own mechanism in regulating body temperature. one of the ways is using their tail as thermoregulatory functions by dilating their tail blood vessel.9 it can be concluded that 5 ml of 6% and 12% cinnamomum burmannii (nees & t.nees) blume infusion per oral had antipyretic effect for the first 30 minutes. additional studies are needed to determine if the antipyretics effects of cinnamon were due to inhibitory effect of cinnamaldehyde on secretion of endogenous pyrogens, and compared with gold standard antipyretics example paracetamol to see whether there was a significant difference in antipyretic effect between cinnamon and paracetamol. the research also should be developed into clinical trial and lastly expanded into phytopharmaca. references 1. annette op. otc pain relievers and fever reducers [cited 2012 april 27]. available from: http://www.medicinenet.com/ analgesics_antipyretics/page4.htm. 2. lazar ajf, murphy gf. the skin. in: kumar v, abbas ak, aster jon k: editors. robbins and cotran pathologic basis of disease. 8ed.philadelphia: saunders elsevier; 2010. p. 1189–91 3. katzer g. indonesian cinnamon (cinnamomum burmannii (nees & t.nees) althea medical journal. 2014;1(2) 85 blume[nees & t. nees] blume). [cited 2012 april 29]. available from: http:// www.unigraz.at/~katzer/engl/cinn_bur. html#const. 4. thampuran ra, vijayan k. pharmacology and toxicology of cinnamon and cassia. boca raton: crc press; 2003. 5. chao lk, hua kf, hsu hy, cheng ss, lin if, chen cj, et al. cinnamaldehyde inhibits pro-inflammatory cytokines secretion from monocytes/macrophages through suppression of intracellular signaling. food chem toxicol. 2008;46(1):220–31 6. kumar, abbas, fausto, aster. mediators of inflammation. robbins and cotran pathologic basis of disease. philadelphia: saunders elsevier; 2010. 7. centers for disesae control and prevention (cdc). vaccine information statement. [cited n 2012 april 30]. available from: http://www.cdc.gov/vaccines/pubs/vis/ downloads/vis-dtap.pdf. 8. netea mg, kullberg bj , van der meer jwm. circulating cytokines as mediators of fever. clin infect dis. 2000;31 suppl 5:s178–84. 9. hanson a. the rat’s tail. [cited 2012 november 15]. available from: http:// www.ratbehavior.org/rattails.htm. qatrunnada zainol, eva m. hidayat, stanza uga peryoga: antipyretic effect of cinnamomum burmannii (nees & t. nees) infusion in fever-induced rat models althea medical journal. 2015;2(3) 398 amj september, 2015 influence of pre-match logical stimulus for applying and developing strategy to basketball team of faculty of medicine universitas padjadjaran razif fiil ikhlas,1 vita muniarti tarawan,2 vitriana3 1faculty of medicine, universitas padjadjaran, 2departmen of physiology faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: logical game is rarely used in sport program as a menu for athletes to prepare their condition in pre-match to improve their cognitive performance. the athletes who have good cognitive performance can think, analyze and solve the problem appeared. griffith builds a method to improve the athletes’ performance by stimulating their cognitive resources. this study aimed to know the influence of pre-match logical stimulus in applying and developing strategy in basketball players. methods: the subject of this study was the basketball team players of faculty of medicine universitas padjadjaran; they were chosen by total sampling based on inclusion and exclusion criteria. then, they were divided into two groups randomly: control and exposed groups. both groups will be compared based on the score of each item (in total of 17 items). the assessed items were technique and tactics in the game of basketball. this study was conducted in november 2012 for three weeks. the collected data were analyzed using paired-t test. results: score increased significantly (p<0.05) in all items for first to third from four times of data retrieval in the exposed group, whereas in the control group, score decreased significantly (p<0.05) in all items for first to third from four times of data retrieval. conclusions: pre-match logical stimulus can improve the performance, especially technique and tactic in the basketball game. [amj.2015;2(3):398–402] keywords: : basketball, logical stimulus, strategy correspondence: razif fiil ikhlas, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85294400305 email: raziffiilikhlas@gmail.com introduction logic is the study of methods and laws used to distinguish the forms of right reasoning from wrong reasoning. the principle of exercise by using logic in sport was first introduced by griffith who provides multiple methods of learning that can stimulate students' thought in improving their performance.1 related to the present focus; kavussanu et al.2 conducted a study on the effects of cognitive enhancement to the basketball players through biofeedback methods. the study asked subjects to perform free throw while being given distraction, which was aimed to divert their attention. as the result, they find factors that can affect the player in the successful and unsuccessful free throw as well as feedback to players in anticipation of the factors that make them fail. in addition, hong and o’neil3 conducted a study by giving questionnaires to subjects to see the effect on performance of cognitive stimulation in motivating based on self-regulation, selfefficacy and effort. as the result, they find that motivated players are able to improve their performance. this study aimed to know the influence of pre-match logical stimulus in tactical applying and developing for basketball players. methods this study was a double blinded and analytical research using t-paired test. the subject of this study was the basketball team players of the faculty of medicine universitas padjadjaran who were chosen by total sampling based on inclusion and exclusion criteria. the inclusion althea medical journal. 2015;2(3) 399 criteria were the male players of the basketball team, who have attended basketball practice or have been previously active in a basketball club. besides, the exclusion criteria were the players who were not students of the fourth grade, and who did not come on the first retrieval, and also who have experienced severe injury, illness, and visual impairment. the subjects were given questionnaires that consisted of questions about their identities, injuries, past experiences in basketball, position, and training. an additional questionnaire was given before retrieval, which consisted of questions about their conditions, problems, and other factors that could affect their performance. logical stimulus was given through a questionnaire constructed by the researcher based on literatures and discussions with experts, and comprised four optional questions and answers which allowed players to perform when confronted with certain situations. the data were collected four times where players were judged on 17 items, consisting of eight personal items and nine team items related to the cognitive aspects of basketball games. the assessment of each aspect was based on assessment parameters which consisted of indicators and value for each indicator (+ and -) was compiled by researchers from literatures and discussions table 1 average of personal item item average k1 x 1 k2 x 1 k1 x 2 k2 x 2 k1 x 3 k2 x 3 k1 x 4 k2 x 4 passing 65.89 67.22 63.56 69.78 61.89 72.00 60.22 74.33 positioning 67.44 66.56 65.56 69.44 63.67 71.78 62.44 73.11 stealing 67.11 66.56 65.67 67.89 64.44 69.89 63.56 71.11 blocking 65.00 67.56 63.22 69.78 61.78 71.89 60.00 74.11 decision 68.11 66.11 65.44 68.89 63.67 68.89 62.78 74.78 team work 69.11 68.56 67.56 70.56 65.44 74.00 64.11 75.44 vision 67.33 68.22 65.44 71.11 63.78 73.78 62.33 75.89 fleeing 66.33 67.11 64.89 69.89 63.11 71.56 61.00 73.67 x total 67.04 67.24 65.16 69.54 63.47 71.72 62.06 74.06 note: k1= control group, k2= exposed group, x 1= average score i, x 2= average score ii, x 3= average score iii x 4= average score iv, x total = average of total score of all items table 2 average of team item item average k1 x 1 k2 x 1 k1 x 2 k2 x 2 k1 x 3 k2 x 3 k1 x 4 k2 x 4 offense 72 69 70 72 68 80 67 84 defense 71 68 68 70 60 72 57 73 built up play 71 68 69 71 63 75 60 77 passing 66 64 63 68 62 72 61 73 positioning 68 64 66 68 64 72 63 71 pressing 69 65 66 70 57 71 55 74 marking 68 65 65 68 56 72 54 74 self-efficacy and regulated 83 84 83 84 76 85 75 86 creativity 82 79 81 81 77 82 75 83 x total 72.22 69.56 70 72.44 64.78 75.67 63 77.22 note: k1= control group, k2= exposed group, x 1= average score i, x 2= average score ii, x 3= average score iii x 4= average score iv, x total = average of total score of all items razif fiil ikhlas, vita muniarti tarawan, vitriana: influence of pre-match logical stimulus for applying and developing strategy to basketball team of faculty of medicine universitas padjadjaran althea medical journal. 2015;2(3) 400 amj september, 2015 with experts; the assessment was performed by the assessors every two minutes. this research was conducted in november 2012 for three weeks. results the subject consisted of 24 players: 11 for the exposed group and 13 for the control group. when conducting the retrieval process, two subjects in the exposed group and one subject in the control group were not present; therefore, the data were incomplete. in the processing of statistics, the numbers of both groups were equated with random selection of the control group. table 1 and 2 show a reduction of average in the control group score in all items, meanwhile, in the exposed group all of the scores were improving. table 3 shows the personal score of the control group reduced indicating significantly (p<0.05), except for decision and stealing in the third and fourth data did not reduced significantly (0.169 and 0.052). in addition, the personal score for exposed group has increased significantly (p<0.05), except for both positioning and teamwork in the third and fourth data did not have significant reduction (0.073 and 0.05). table 4 shows the exposed group significantly experienced improvement in all team items in comparison with the control group (t=–4.837 and p=0.00). discussion the statistics test showed that giving stimulus through logic game before a match could increase and develop the strategy of a basketball game significantly. this was found on an average of 17 out of 8 aspects of personal table 3 t-paired test for personal items item team x 1 / x 2 x 2 / x 3 x 3 / x 4 t p t p t p passing k1 4.950 0.001** 4.472 0.002** 5.000 0.001** k2 -4.914 0.001** -6.261 0.000** -2.066 0.073 positioning k1 9.430 0.000** 4.857 0.001** 3.773 0.005** k2 -4.914 0.001** -6.261 0.000** -2.066 0.073 decision k1 6.532 0.000** 3.600 0.007** 1.512 0.169 k2 -6.402 0.000** -4.996 0.001** -3.546 0.008** team work k1 3.092 0.015* 5.429 0.001** 2.309 0.050 k2 -6.000 0.000** -6.847 0.000** -2.726 0.026* vision k1 4.857 0.001** 4.472 0.002** 3.250 0.012* k2 -3.043 0.016* -6.532 0.000** -3.033 0.016* stealing k1 5.965 0.000** 3.773 0.005** 2.286 0.052 k2 -4.619 0.002** -4.243 0.003** -2.817 0.023* blocking k1 4.097 0.003** 4.274 0.003** 5.488 0.001** k2 -4.061 0.004** -4.642 0.002** -4.264 0.003** fleeing k1 2.490 0.038* 4.880 0.001** 2.873 0.021* k2 -6.934 0.000** -3.780 0.005** -6.008 0.000** note: k1= control group, k2= exposed group, x 1= average score i, x 2= average score ii, x 3= average score iii x 4= average score iv, * = p < 0.05, ** = p <0.01 table 4 t-paired test for team items x 1 t – x 2 t sd t sig (2 tailed) team 1/team 2 -5.889 7.305 -4.837 0.000** note: x 1t = average of total score of control group, x 2t = average of total score of exposed group, ** = p <0.01 althea medical journal. 2015;2(3) 401 assessment and 9 aspects of team assessment. the average of the exposed group was higher than the control group. the t-paired test showed that the score for the treatment group was significantly higher with p<0.05. this supports the previous theories stating that giving cognitive stimulus could increase the athletes’ performance. there was an insignificant increase in the positioning aspect, p=0.073, however, this aspect increased significantly at the previous scoring. this is assumed based on the research conducted by marois and ivanoff4, revealing that the players given logic stimulus could reach cognitive threshold towards the aspect stimulated, and then an insignificant increase would occur. this threshold is influenced by some factors affecting their cognitive processes such as cognitive resource, potential cognitive, attention, memory, cognitive inhibition, and executive function.5 the cognitive resource influences the speed and its capacity in processing and storing the information received, and makes it as an experience which will be a base for the following problem.6 while attention is a process to identify the received information at the time of being able to catch the meaning of that information, whether it is simple or complex information.5 this factor helps an individual to pay attention at simple and implicit things in order to catch the whole meaning of the information given.7 in addition, potential cognitive has the function to solve problems quickly and to be responsive. it is due to the fact that this factor identifies the quality of individual cognitive function to recall all background experiences from the previous knowledge and theories.8 furthermore, cognitive inhibition is a factor that organizes the affectivity and flexibility of the function of human brain by controlling all attention processes, reducing the disturbance thoughts, controlling motorist actions, and helping in changing and choosing important thoughts.9 moreover, the executive function plays a role in taking decision and thinking critically and creatively.10,11 there is another assumption of the result. five out of 9 players in the exposed group wrote in their questionnaire during the fourth data collection that they were tired, so they did not actively take position during the game. this was also supported by the note on the evaluation sheet stating that 4 out of 9 players were not active during the game. while the decreasing of the control group was assumed that they were under pressure because there was an increase of performance of the treatment group. glaze12 confirmed this by stating the causes such as the failure in formulating team’s play, loss of focus towards the purpose, unability to use the available resources, failure to maximize the ability and activities, loss of intrinsic motivation and failure to perform well. another assumption is that the players would have difficulty in performing maximally due to a difficult situation that they hardly solved even though they have tried by using their ability. the ability to solve the problem needs more responses which need to be trained.13,14 there were two limitations of this study. the first was the limitation for developing the questionnaire toward the other items related to the cognitive function for basketball game. the second was the limitation for developing the assessment parameters for each item in this study. more indicators for parameter and value categories were needed for item scoring. after four times data collection, it was found that the average of the treatment group has increased compared to the control group. also, a significant increase was found in all evaluation aspects from the first until the third retrieval of data collection. references 1. green cd. coleman roberts griffith. in: dewsburry da, wertheirmer m, editors. portraits of pioneers in psychology. new york: routledge; 2006. 2. kavussanu m, crews dj, gill dl. the effects of single versus multiple measures of biofeedback on basketball free throw shooting performance. ijsp. 1998;29(2):132–44. 3. hong e, o’neil hf. construct validation of a trait self-regulation model. int j psychol. 2001;36:186–94. 4. marois r, ivanoff j. capacity limits of information processing in the brain. trends coqn sci. 2005;9(6):296–305. 5. santrock wj. adolescence. 12th ed. new york: mcgraw-hill; 2008 6. kail r. speed of information processing: developmental change and links to intelligence. j sch psychol. 2000;38(1):51– 61. 7. klimkeit ei, mattingley jb, sheppard dm, farrow m, bradshaw jl. examining the development of attention and executive functions in children with a novel paradigm. child neuropsychol. 2004;10(3):201–11. 8. labouvie-gief g. emerging structures razif fiil ikhlas, vita muniarti tarawan, vitriana: influence of pre-match logical stimulus for applying and developing strategy to basketball team of faculty of medicine universitas padjadjaran althea medical journal. 2015;2(3) 402 amj september, 2015 of adult thought. in: arnet jj, tanner jl, editors. emerging adults in america. washington dc: apa books; 2006. 9. anderson va, anderson p, northan e, jacobs r, catroppa c. development of executive functions through late childhood and adolescence in an australian sample. dev neuropsychol. 2001;20(1):385–406. 10. klaczynski pa, byrnes jp, jacobs je. introduction to the special issue: the development of decision making. j appl dev psychol. 2001;22(3):225–36. 11. reyna vf, estrada sm, demarinis ja, myers rm, stanisz, mills ba. neurobiological and memory models of risky decision making in adolescents versus young adults. j exp psychol learn mem cogn. 2011;37(5):1125–42. 12. gaze s. team development and the five traits of great teams. 2011. [cited 2012 august 12]. available at: http:// greatresultsteambuilding.net/traits-greatteams/. 13. scott wd, beevers cg, mermelstein rj. depression vulnerable and non-vulnerable smokers after a failure experience: examining cognitive self-regulation and motivation. behav modif. 2008;32(4):519– 39. 14. kuhn d, katz j, dean d. developing reason. thinking & reasoning. 2004;10(2):197– 21. vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 196 amj december 2018 the analgesic effect of ethanol extract soursop (annona muricata l.) leaves in wistar rats kuswinarti,1 kendry savira,2 reno rudiman3 1department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia 2faculty of medicine universitas padjadjaran, indonesia, 3departement of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: kuswinarti, departmen of biomedical sciences faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, jawa barat, indonesia, email: wiwinsumarlan@yahoo.com introduction annona muricata l. (annonaceae ), known as soursop plants, are commonly found in central america to south america, including the north, northeast and southeast regions of brazil.1,2 in indonesia, especially west java province, many soursop plants are cultivated in the area of pelabuhan ratu sukabumi and rajamandala bandung. traditionally, the soursop leaves can be used for headaches, insomnia, cystitis, liver problems, diabetes mellitus, sedative, hypotensive activity, analgesic, anti-inflammatory, and antidysenteric.2,3 moreover, the leaves have parasiticidal, anti-rheumatic and anti-neuralgic effects.1,2 bioactive compounds of soursop leaves have been reported to be found such as acetogenins, alkaloids (isoquinoline, aporphine, protoberberine), tannin, coumarins, flavonoids, polyphenolic components, phytosterol (β-sitosterol, stigmasterol), vitamins b, c, and e.4–6 flavonoid is a strong inhibitor to lipid peroxidation, as a captor of reactive oxygen or nitrogen and also able to inhibit lipoxygenase and cyclooxygenase enzymes and as such, this compound can be used to reduce pain and thus serve as analgetic agent.7–9 studies regarding soursop leaves as antiinflammation, anti-rheumatic, and antineuralgia supported by pharmacological and clinical validation are still scarce1, especially soursop leaves cultivated in west java. this study aimed to explore the analgesic effect of the ethanol extract of soursop leaves from west java, using an animal model. methods this was an experimental study, conducted from may 2012 to january 2013, using wistar rats, to explore whether soursop leaves extract had an analgesic effect. the amj.2018;5(4):196–200 abstract background: pain is an emotional and sensory experience that is unpleasant and related to tissues damage. in the past, soursop (annona muricata l.) leaves have been believed to be able to relieve pain. this study aimed to explore the analgesic effect of soursop leaves and its effective dose in an animal model. methods: wistar rats (n=25) had been used in this experimental study, divided into 5 groups; consisting of a negative control group, experiment groups using extract soursop leaves with doses of 200mg/kgbw, 400 mg/kgbw and 600 mg/kgbw, and natrium diclofenac as a positive control. one hour after treatment, all groups of rats were induced by carrageenan-lambda in the feet. the basal retraction of rats’ legs was measured in 47oc water and repeated at two, four, and six hours. the data were analyzed using analysis of variance and tukey’s test. result: the dose of 200 mg/kgbw had no analgesic effect (p>0.05), while the dose of 600 mg/kgbw had the highest analgesic effect at 7.72 seconds on the 4th hour of induction. on the 6th hour, the dose of 400 mg/kgbw had the highest analgesic effect at 3.58 seconds. conclusions: extract soursop (annona muricata l.) leaves in this study have been proven to have an analgesic effect. keywords: analgesic. annona muricata l., soursop leaves althea medical journal. 2018;5(4) 197 hyperalgesia test applied was according to a modified randall-sellito.10–12 this study was performed in the pharmacology laboratory, faculty of medicine, universitas padjadjaran, and after ethical clearance, granted by the health research ethic committee faculty of medicine universitas padjadjaran. inclusion criteria in this study were white male wistar rats weighed at 180–220 grams, aged 2–3 months in healthy conditions and normal activity. experimental rats were randomly assigned to groups 1 to 5. group 1 was given 2 ml carboxymethyl cellulose (cmc) per oral and served as a negative control group. group 2 to 4 were given ethanol extract of soursop leaves per oral, with doses of 200, 400, and 600 mg/kgbw, respectively. group 5 as a positive control group was given natrium diclofenac per oral with a dose of 4.5 mg/kgbw. one hour after giving the experimental dose, carrageenan-lambda was given to the left foot to induce inflammation and pain. after two, four, and six hours of induction, respectively, measurement of left leg retraction time was examined in each group, by plunging their left leg to a water bath filled with 47oc water. the ankles of the rats were marked with waterproof tint as the marker of plunging. the length of the leg retraction time was limited to 15 seconds to avoid any thermal injuries. statistical analyses were conducted to compare the analgesic effect of different doses given and leg retraction time at two, four, and six hours after of induction, by using analysis of variance (f test), followed by tukey test. results the leg retraction time from various doses of soursop leaves ethanol extract treatment table 1 leg retraction time after administration of soursop leaves (annona muricata l.) ethanol extract group 2 hours 4 hours 6 hours x ± sd x ± sd x ± sd negative control 1.35 ± 0.27 1.61 ± 0.48 1.30 ± 0.27 dose 200mg/kgbw 1.91 ± 0.50 3.72 ± 1.65 1.49 ± 0.24 dose 400mg/kgbw 2.39 ± 0.61 4.86 ± 1.65 3.58 ± 1.49 dose 600mg/kgbw 3.36 ± 1.66 7.72 ± 2.04 3.36 ± 0.85 positive control 3.08 ± 1.06 3.73 ± 1.03 2.02 ± 0.57 note: x = average of leg retraction time in seconds; sd= standard deviation. natrium diclofenac was given for positive control. kuswinarti, kendry savira, reno rudiman: the analgesic effect of ethanol extract soursop (annona muricata l.) leaves in wistar rats table 2 tukey test on leg retraction time 2 hours after administration of soursop leaves (annona muricata l.) ethanol extract group (i) group (j) mean difference p (i-j) control negative dose 200mg/kgbw -0.564 0.073 dose 400mg/kgbw -1.046* 0.003* dose 600mg/kgbw -2.016* 0.000* natrium diclofenac -1.736* 0.000* dose 200mg/kgbw dose 400mg/kgbw -0.482 0.623 dose 600mg/kgbw -1.452 0.104 natrium diclofenac -1.172 0.134 dose 400mg/kgbw dose 600mg/kgbw -0.970 0.751 natrium diclofenac -0.690 0.822 dose 600mg/kgbw natrium diclofenac 0.280 1.000 note: *significancy was set on p<0.05 althea medical journal. 2018;5(4) 198 amj december 2018 per oral to wistar rats after 2 hours of carrageenan-lambda induction were as followed; there was a significant increase of leg retraction time with doses of 200, 400, and 600 mg/kgbw compared to negative control. this study indicated that the experiment doses shown an analgesic effect on the increase of leg retraction time. the soursop leaves ethanol extract dose of 600 mg/kgbw had an average analgesic effect of the highest at 7.72 seconds on the 4th hour of induction. the dose of 600 mg/kgbw had reached the maximum time equivalent to the treatment induced by natrium diclofenac, as a positive control. the result of leg retraction time after 2, 4, 6 hours of carrageenan-lambda induction with various doses of soursop leaves was shown in table 1. in summary, the leg retraction time from various doses of soursop leaves ethanol extract treatment per oral to wistar rats after 4 and 6 hours of carrageenan-lambda induction were as followed; there was a significant increase of leg retraction time with doses of 200, 400, and 600 mg/kgbw compared to negative control (table 2, 3, 4). as for the induction of carrageenan-lambda after 4 hours, there was a maximum leg retraction time comparable to positive control already with the dose of 200 table 3 tukey test on leg retraction time 4 hours after administration of soursop leaves (annona muricata l.) ethanol extract group (i) group (j) mean difference p (i-j) control negative dose 200mg/kgbw -2.110 0.199 dose 400mg/kgbw -3.252 0.018* dose 600mg/kgbw -6.112 0.000* natrium diclofenac -2.128 0.193 dose 200mg/kgbw dose 400mg/kgbw -1.142 0.739 dose 600mg/kgbw -4.002 0.003* natrium diclofenac -0.018 1.000 dose 400mg/kgbw dose 600mg/kgbw -2.860 0.043* natrium diclofenac 1.124 0.749 dose 600mg/kgbw natrium diclofenac 3.984* 0.003 note: *significancy was set on p<0.05 table 4 tukey test on leg retraction time 6 hours after administration of soursop leaves (annona muricata l.) ethanol extract group (i) group (j) mean difference p (i-j) control negative dose 200mg/kgbw -0.192 0.844 dose 400mg/kgbw -2.276 0.000* dose 600mg/kgbw -2.064 0.000* natrium diclofenac -0.716 0.101 dose 200mg/kgbw dose 400mg/kgbw -2.084 0.003* dose 600mg/kgbw -1.872 0.003* natrium diclofenac -0.524 0.502 dose 400mg/kgbw dose 600mg/kgbw 0.212 1.000 natrium diclofenac 1.560 0.091 dose 600mg/kgbw natrium diclofenac 1.348 0.091 note: *significancy was set on p<0.05 althea medical journal. 2018;5(4) 199kuswinarti, kendry savira, reno rudiman: the analgesic effect of ethanol extract soursop (annona muricata l.) leaves in wistar rats mg/kgbw that was further increased with the dose of 400, and 600 mg/kgbw; whereas for induction of carrageenan-lambda after 6 hours, the dose of 400 and 600 mg/kgbw showed comparable leg retraction time (3.58s and 3.36s, respectively) and showed no significant difference to positive controls (2.02s). discussion annona muricata produced antinociception action of activity in both neurogenic and inflammatory phases. metabolites of arachidonic acid (called eicosanoids) are involved in the inflammation process.1 in this study, carrageenan-lambda has been used. carrageenan-lambda is a red sea seaweed extract that is often used to induce pain in the laboratory setting for experimental study.2,13 this study shown that soursop leaf extract given an hour before administration of carrageenan-lambda induction has a comparable analgetic effect with natrium diclofenac. natrium diclofenac has been proven to have an analgesic effect and in this study, it is used as a positive control. the metabolites are produced via cyclooxygenase and lipoxygenase when the cell is activated by mechanical trauma, cytokines, growth factors or other stimuli. it has been proposed that the mechanism of antinociception may be caused by inhibition of cyclooxygenase (cox) and lipoxygenases (lox) and other inflammatory mediators such as flavonoids, present in the plant extract.1,2 flavonoids contained in soursop leaves are strong inhibitors to lipid peroxidation, and serve as a captor of reactive oxygen or nitrogen and also able to inhibit cyclooxygenase enzymes thereby reducing the biosynthesis of prostaglandins which are pain mediators and as such this compound can be used to reduce pain (analgesic).1,14 diclofenac is a phenyl acetic derivate that is relatively nonselective as a cox inhibitor. this drug has analgesic, antipyretic and anti-inflammatory effects by inhibiting prostaglandin synthesis. the inhibition of the synthesis of proinflammatory prostaglandins is one of such therapeutic targets to which some of the potent analgesic and anti-inflammatory agents.15 the analgesic effect can be seen by lengthened time of foot withdrawal. hyperalgesia by the inflammatory process because of an increased sensitivity to pain receptors and a decrease in the pain threshold. our study has shown that soursop leaf extract has an analgesic effect compared to the negative control group, and comparable to the positive control group diclofenac. interestingly, the length of induction with carrageenan-lambda has shown that there is an optimum effect of the inflammatory effect of carrageenan-lambda (i.e. 4 hours) and soursop leaves extract might be useful in lower doses. in this study, the strongest analgesic effect occurred at the 4th hour of induction probably the inhibitory effect on pain mediators was the most optimal, while at the 6th hour the inhibitory effect was reduced and caused no different dosage of 400 mg/kgbw and 600 mg/kgbw soursop leaf extract. this study has hampered some limitations. the result of leg retraction time varies greatly with a high standard deviation. since this experiment used an animal model, a minimal number of rats had been used. further study is needed to confirm the true effect of soursop leaves as an analgesic agent. soursop (annona muricata l.) leaves ethanol extract has been proven to have an analgesic effect on wistar rats induced by carrageenanlambda. soursop (annona muricata l.) extract may be useful in human, therefore, further in vivo study is needed. references 1. de sousa ov, vieira gdv, de pinho jdjr., yamamoto ch, alves ms. antinociceptive and anti-inflammatory activities of the ethanol extract of annonamuricata l. leaves in animal models. int j mol sci. 2010;11(5): 2067–78 2. moghadamtousi sz, fadaeinasab m, nikzad s, mohan g, ali hm, kadir ha. annona muricata (annonaceae): a review of its traditional uses, isolated acetogenins, and biological activities.int j mol sci. 2015;16(7):15625–58 3. coria-tellez av, montalvo-gonzalez e, yahia em, obledo-vazquez en. annonamuricata: a comprehensive review on its traditional medicinal uses, phytochemicals, pharmacological activities, mechanisms of action and toxicity. arab j chem 2018;11(5):662–91 4. salempa p. uji bio aktivitas senyawa metabolit sekunder ekstrak kloroform kulit batang sirsak (annonamuricata linn.) jurnal bionature. 2016;17(1):37–40 5. wurdianing i, nugraheni sa, rahfiludin z. efek ekstrak daun sirsak (annonamuricara linn.) terhadap profil lipid putih jantan (rattus norvegicus). jurnal gizi indonesia. 2014:3(1):7–12 6. suharyadi a, sukohara, muhartono. althea medical journal. 2018;5(4) 200 amj december 2018 pengaruh pemberian ekstrak etanol daun sirsak terhadap gambaran histopatologi ginjal tikus yang diinduksi dmba. medical jurnal of lampung university. 2014;3(4):27–34. 7. simanjuntak k. peran antioksidan flavonoid dalam meningkatkan kesehatan. bina widya. 2012;23(3):135–40 8. syamsul es, andani f, soemarie yb. analgesic activity study of ethanolic extract of callicarpalongifolia lamk in mice. trad med j. 2016;21(2):99–103 9. christiana i, evacuasiany e, hidayat m. the analgetic effect of kayu rapat bark infusion (parameria laervigata (juss.) moldenke) on male mice treated with thermal induction. jurnal medika planta. 2012;2(1):69–76 10. satos-nogueira e, redondo castro e, mancuso r, navarro x. randall-sellito test: a new approach for the detection of neuropathic pain after spinal cord injury. j neurotrauma. 2012;29(5):898–904 11. fajrin fa, nurrochmad a, nugroho ae, susilowati r. optimization of mice model of painful diabetic neuropathy (pdn). j med sci. 2017;49(3):97–105 12. parkar n, addepalli v. effect of nobiletin on diabetic neuropathy in experimental rats. austin j pharmacol ther 2014;2(5):1028. 13. mariappan g, saha bp, sutharson l, singh a, garg s, pandey l, et al. analgesic, antiinflammatory, antipyretic and toxicological evaluation of some newer 3-methyl pyrazolone derivates. saudi pharm j. 2011;19(2):115–22 14. arifin h, alwi ti, aisyahharma o, juwita da. kajian efek analgetik dan toksisitas subakut dari ekstrak etanol daun kitolod (isotomalongiflora l.) pada mencit putih jantan. jurnal sains farmasi & klinik. 2018:5(2):112–8 15. negm aa, furst de. nonsteroidal antiinflammatory drugs, disease-modifying antirheumatic drugs, nonopioid analgesics & drugs used in gout. in: katzung bg, editor. basic and clinical pharmacology. 14th ed. singapore: mcgraw-hill; 2017: p. 647. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 591 students’ perception on ideal age of marriage and childbearing mohanambehai subranmiam,1 kuswandewi mutyara,2 hanom husni syam3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran bandung/dr. hasan sadikin general hospital bandung abstract background: early-age marriage is still common in indonesia, especially in the rural areas. there are many negative effects of the marriage; the young brides may get lower education, lower social status, minimum reproduction control, higher maternal mortality, higher domestic violence rate and others. thus, this study is conducted to identify the students’ perception on the ideal age of marriage and childbearing. methods: a cross-sectional descriptive study was conducted from june to september 2013 in jatinangor using secondary data from jatinangor cohort survey team. the data comprised two hundred and twenty students from jatinangor senior high school and pgri vocational school. a hundred and ten males and a hundred and ten females were chosen by random sampling. questionnaires were given after the written informed consent was obtained from the students. results: the results showed 74.55% of the students chose 19¬–24 years old as the ideal age of marriage for a woman and 68.64% students chose 25–30 years old as the ideal age of marriage for a man. moreover, for childbearing, 25–30 years old was chosen to be the ideal age for both man and woman. the percentage of students agreed to this was 74.55% and 54.09% respectively. conclusions: majority of the students agreed on 19–24 years old and 25–30 years old as the ideal age of marriage for woman and man respectively. for childbearing, 25–30 years old was concluded as the ideal age for both genders. [amj.2015;2(4):591–6] keywords: childbearing, early marriage, ideal age of marriage correspondence: mohanambehai subranmiam, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6283821054454 email: monas1991@yahoo.com introduction in recent years, a transition of marital age and childbearing has been drastically changing in many countries. the latest international statistics by world health organization (who)1 indicated that more than 60 million women were married before the age of 18. as it is narrowed down to asian countries, half (46%) of child marriages occur in south asia.2 in india3 44.5% of women were married before the age of 18. meanwhile, in indonesia2 a survey conducted revealed 8.93% of married women were 15–19 years old.2 subsequently, some of these brides in indonesia had their first child by the age of 18 years old.4 it is one of the factors contributing to the high infant and maternal mortality.5 currently, west java has become one of the provinces that contribute to the high infant mortality rate in indonesia. according to data from child health program report of west java province year 2010–2012, the number of neonatal deaths that were reported in west java reached 3,624 and the infant mortality reached 4,650.6 early marriages have negative effects on the young woman and her child. as an example, early motherhood has an increased likelihood of neonatal death and stillbirth, low birth weight infants, and child and infant morbidity and mortality.7 furthermore, these young brides may also get lower education, lower social status at their in-law’s place, minimum reproductive control, higher maternal mortality, higher domestic violence rate and others.8 jatinangor where universitas padjadjaran is located is a highly populated area among west java province. it is dominated with young adult representing typical city in west java which has a rapid development progress. due to the current global situation of althea medical journal. 2015;2(4) 592 amj december, 2015 changing marital age trends and the negative effects of early marriage, this study was conducted to find out the perception of students on the ideal age of marriage and childbearing in jatinangor. methods this was a cross-sectional descriptive study which was conducted from june to november 2013 in jatinangor. the secondary data obtained from jatinangor cohort survey, faculty of medicine, universitas padjadjaran indonesia, west java, indonesia were taken from the students of senior high school and pgri vocational school in jatinangor, sumedang. the study was also approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the samples were taken using cluster random sampling method from ten senior high schools and vocational schools in jatinangor which reached a total of 3692 students. through the method, two schools were selected which were jatinangor senior high school and pgri vocational school which had a total of 854 students. the jatinangor cohort survey team randomly selected students in the first and second year of schooling from the both of schools which made up 277 students. these students were then given an informed consent form to be filled up by their parents or guardian. the selection criteria were based on the students’ willingness to participate in this study. the students who were absent on the day the data was taken and those who did not complete the questionnaire appropriately were excluded from the study. this presented a response rate of 81.5% which comprised one hundred and ten males and one hundred and ten females of pgri vocational school and jatinangor senior high school. they were used as the subjects of this study as they represented the school students. after a brief introduction, they were given questionnaires which were validated by the jatinangor cohort team to be filled up. the questionnaire consisted of two sections. the first section was on their personal details consisting of their name, gender, religion, date of birth, relationship status, race and their source of information about sex and child marriage. the second section was on the research topic which consisted of ten questions. these questions were related to their perception on ideal marital and childbearing age for male and female and also their reasons behind their answers. data from the students were then table 1 characteristic of respondent characteristics n (%) age (years old) 14 1 (0.5) 15 35 (15.9) 16 93 (42.3) 17 63 (28.6) 18 27 (12.3) 19 1 (0.5) religion muslim 218 (99.1) christian 2 (0.9) others 0 (0) inputted into the windows excel and classified into four age groups to identify the frequency for each question. results the majority of the students were aged 16 years old and 99.1% of the samples are muslims (table 1). for the relationship status, the majority of the students said they have dated before but were not dating anyone currently. apart from that, for the marital age of their parents, there was indication that 59.1% of the students’ mothers got married at the age ranged from 19–24 years old. meanwhile, 42.7% of the students’ fathers got married at 25–30 years old. as for childbearing, 52.7% of their mothers and 56.8% of their fathers had their first child at the age of 25–30 years old (table 2). there was indication that majority (74.6%) of the students chose 19–24 years old as the ideal age of marriage for a woman while 68.6% of students chose 25–30 years old as the ideal age of marriage for a man. majority of the students chose 25–30 years old as the ideal age of marriage for both man and woman. this was indicated by a percentage of 54.1% for woman and 74.6% for man (table 3). most students felt the main reason to get married and have a child was because adequate age had been reached (table 4). discussion this study depicts that both male and female students have perception 19–24 years old is althea medical journal. 2015;2(4) 593 the ideal age of marriage for woman. this was agreed by 164(74.6%) students. the reason given by majority of the students on the ideal marital age is because they perceive that adequate age has been reached to get married. this is due to the fact that the students are matured enough to know that a successful marriage requires a good balance between biological, psychological and sociological elements. biologically, their sexual needs are fulfilled. psychologically, mental maturity and emotional stability determines happiness in married life. meanwhile, sociologically, marriage makes a pair of couple legitimate as married couples legally.9 on the other hand, below 18 years of age was the category least chosen by the students as the ideal age of marriage for a woman. women of this age group are not prepared to start a family and they are still considered as a mohanambehai subranmiam, kuswandewi mutyara, hanom husni syam: students’ perception on ideal age of marriage and childbearing table 2 relationship status of respondent relationship status n (%) dated before yes 137 (62.3) no 83 (37.7) dating now yes 107 (48.6) no 113 (51.4) mother’s age of marriage (years old) <18 29 (13.2) 19–24 130 (59.1) 25–30 22 (10.0) >30 2 (0.9) not sure 37 (16.8) father’s age of marriage (years old) <18 2 (0.9) 19–24 87 (39.5) 25–30 94 (42.7) >30 0 (0) not sure 37 (16.8) mother’s age during first childbirth (years old) <18 2 (0.9) 19–24 116 (52.7) 25–30 64 (29.1) >30 0 (0) not sure 38 (17.3) father’s age during first childbirth (years old) <18 2 (0.9) 19–24 42 (19.1) 25–30 125 (56.8) >30 13 (5.9) not sure 38 (17.3) althea medical journal. 2015;2(4) 594 amj december, 2015 child. a similar study also shows that there is a higher rate of divorce among those who got married at this age due to lack of awareness to be responsible in married life.9 moreover, these young brides may also get lower education, lower social status at their in-law’s place, minimum reproductive control, higher maternal mortality, domestic violence rate and others. younger marital age also poses an increased risk of sexually transmitted diseases in comparison with older ages.10 on the other hand, 25–30 years old was chosen to be the ideal marital age for a man by both the genders. this was agreed by 67(30.5%) male and 84(38.2%) female students. the reason that was given by majority of the students is because they think that the adequate age has been reached for a man to settle down and become more responsible, financially stable and is ready to start a family. another study also shows there is a lack in emotional maturity among men who married early compared to the ones who married later.11 more females agreed to this age group compared to males as women these days are generally more matured compared to men (table 3). therefore, they prefer an elder man to be their life partner. this also explains why no female agreed that below 18 years of age is the ideal age of marriage for a man. regarding the perception on the ideal age for a woman to have her first child, 55 male and 64 female students chose 25–30 years old as their age group of choice. at this range of age, the reproductive organs of a woman are ready to conceive and give birth as they are more physically and mentally prepared. moreover, normal age pregnancy is considered a lowrisk situation compared to teenage pregnancy and elderly pregnancy in which increased table 3 perception on ideal age age of marriage and childbearing perception on ideal age of marriage perception of ideal age of childbearing male n (%) female n (%) total n (%) male n (%) female n (%) total n (%) for woman (years old) <18 2 (0.9) 1 (0.5) 3 (1.4) 0 (0) 1 (0.5) 1 (0.5) 19–24 84 (38.2) 80 (36.4) 164 (74.6) 52 (23.6) 43 (19.6) 95 (43.2) 25–30 20 (9.1) 29 (13.2) 49 (22.3) 55 (25.0) 64 (29.1) 119 (54.1) >30 4 (1.8) 0 (0) 4 (1.8) 3 (1.4) 2 (0.9) 5 (2.3) for man (years old) <18 3 (1.3) 0 (0) 3 (1.3) 0 (0) 0 (0) 0 (0) 19–24 (14.1) 18 (8.2) 49 (22.3) 13 (5.9) 9 (4.1) 22 (10.0) 25–30 67(30.5) 84 (38.2) 151 (68.6) 78 (35.5) 86 (39.1) 164 (74.6) >30 9 (4.1) 8 (3.6) 17 (7.7) 19 (8.6) 15 (6.8) 34 (15.5) table 4 reasons for ideal age of marriage and childbearing reasons marriage n (%) childbearing n (%) has reached the adequate age 179 (40.5) 153 (36.8) sufficient academic qualifications 70 (15.8) 42 (10.1) good for health 50 (11.3) 57 (13.7) already independent 98 (22.2) 95 (22.8) desire to start a family 32 (7.2) 55 (13.2) no reason 10 (2.3) 13 (3.1) others 3 (0.7) 1 (0.2) althea medical journal. 2015;2(4) 595 adverse obstetric and perinatal outcomes are faced.12 besides that, only 1 female student agreed below 18 years of age was the ideal age for this matter. this age is unsuitable for childbearing as there are many maternal complications such as anemia, pregnancy induced hypertension, sexually transmitted diseases and premature labor and delivery. the most common complications concerning the infant are related to low birth weight, due to either prematurity or intrauterine growth restriction, infection, chemical dependence, sudden infant death syndrome, and increased morbidity and mortality during the first year.7 furthermore, 5 students chose above 30 years old as the ideal age for a woman to have her first child. late age of first childbearing are more prone of causing diabetes mellitus, antepartum hemorrhage, hypertensive disorder in pregnancy, cesarean section, abnormal fetal presentation and many more.12,13 based on a research, delaying childbirth has significantly contributed to increasing rates of intrapartum primary cesarean delivery.14 the perception of students on the ideal age for man to have his first child was 25–30 years old. this was agreed by 164 students. according to many previous studies, this is said to be the ideal age as males will be in their reproductive peak and will be most fertile during this period. this is when a men’s sperm has the highest quality and quantity. therefore, they can produce healthy offspring with decreased risk of abnormalities.15 the age least agreed by the students were below 18 years of age. this is definitely not the ideal age to begin fatherhood as a man is not matured or prepared mentally, physically or emotionally to be a father. on the other hand, the evidence indicates that the offspring of older fathers have decreased fertility and an higher risk of birth defects, some cancers, and schizophrenia.16 on a side note, it was found certain limitations while conducting this study. for example, while answering the questionnaires, there were a few respondents who were dishonest by copying their classmates’ answers. then, it was needed tighter supervision with the aid of the classroom teacher. another hindrance was that the students were unable to understand the researcher’s explanation regarding the aim of the questionnaire at times due to improper grammar and language use. to counter this, it is suggested an external translator or a local person to aid when the explanation session is conducted. after knowing the perception of students on marriage and childbearing age, further study can be conducted on the factors affecting the students’ perception such as family background, education of parents and others. in conclusion, the majority of the male and female students have perception that 19–24 years old is the ideal age of marriage for woman and 25–30 years old is the ideal age of marriage for man. meanwhile, for age to have first child, 25–30 years old is perceived as the ideal age for both genders. references 1. national heart, lung, and blood institute.1. who. report no a65/13: early marriages, adolescent and young pregnancies. geneva: who; 2012. 2. jones gw. asia research institute working paper series no. 131: changing marriage patterns in asia. singapore: asia research insitute & department of sociology national university of singapore;2010. 3. raj a, saggurti n, balaiah d, silverman jg. prevalence of child marriage and its effect on fertility and fertility-control outcomes of young women in india: a cross-sectional, observational study. lancet. 2009;373 (9678):1883–9. 4. mukuria a, aboulafia c, themme a. the context of women’s health: results from the demographic and health surveys, 1994-2001. maryland: orc macro; 2005. 5. raj a, saggurti n, winter m, labonte a, decker mr, balaiah d et al. the effect of maternal child marriage on morbidity and mortality of children under 5 in india: cross sectional study of a nationally representative sample. bmj. 2010;340:b4258. 6. unpad. jawa barat penyumbang terbesar angka kematian bayi di indonesia 2012 [cited 2014 may 25]. available from: h t t p : / / w w w. u n p a d . a c . i d / 2 0 1 3 / 1 0 / jawa-barat-penyumbang-terbesar-angkakematian-bayi-di-indonesia/. 7. malamitsi-puchner a, boutsikou t. adolescent pregnancy and perinatal outcome. pediatric endocrinology reviews. pediatr endocrinol rev. 2006;(3 suppl 1): 170–1. 8. jensen r, thornton r. early female marriage in the developing world. gender and development. 2003;11(2):9–19. 9. jannah usf. pernikahan dini dan implikasinya terhadap kehidupan keluarga pada masyarakat madura mohanambehai subranmiam, kuswandewi mutyara, hanom husni syam: students’ perception on ideal age of marriage and childbearing althea medical journal. 2015;2(4) 596 amj december, 2015 (perspektif hukum dan gender). egalita. 2012;7(1):83–101. 10. kaestle ce, halpern ct, miller wc, ford ca. young age at first sexual intercourse and sexually transmitted infections in adolescents and young adults. am j epidemiol. 2005;161(8):774–80. 11. khairani r, putri de. perbedaan kematangan emosi pada pria dan wanita yang menikah muda. jurnal psikologi. 2008;1(2):136–9. 12. suwannachat b, ualalitchoowong p. maternal age and pregnancy outcomes. srinagarind med j. 2007;22(4):401–7. 13. joseph ks, allen ac, dodds l, turner la, scott h, liston r. the perinatal effects of delayed childbearing. obstet gynecol. 2005;105(6):1410–8. 14. smith gc, cordeaux y, white ir, pasupathy d, missfelder-lobos h, pell jp, et al. the effect of delaying childbirth on primary cesarean section rates. plos med. 2008; 5(7):e144. 15. sloter e, schmid t, marchetti f, eskenazi b, nath j, wyrobek a. quantitative effects of male age on sperm motion. hum reprod. 2006;21(11):2868–75. 16. bray i, gunnell d, smith gd. advanced paternal age: how old is too old?. j epidemiol community health. 2006;60(10):851–3. althea medical journal. 2015;2(3) 395 undernutrition affects the occurrence of acute respiratory infections in children under five years old in cipacing, jatinangor subdictrict, west java from october to november 2012 windi elsanita,1 deni kurniadi s,2 diah asri wulandari,3 elsa pudji setiawati4 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: millennium development goals’ (mdgs) aims to decrease mortality in children will be achieved if the cause ofmortality include acute respiratory infections (aris) is eliminated. acute respiratory infections are influenced by some factorssuch as nutritional status. the objective of this study was to analyze the correlation between nutritional status andthe occurrence of aris in children. methods: this study used retrospective cohort approach during october─november 2012. one hundred and ten mothers with children under five years old with different nutritional status were randomly selected and then asked about their history of respiratory symptoms. data were analyzed using chi square test. results: about 66 under five children (60%) with good nutrition status had aris occurrence of <7 times and 5 children (4.5%) had aris≥7 times. in children with undernutrition, about 30 children (27.3%) had aris<7 times and 9 children (8.2%) had aris≥7 times. bivariate analysis result showed that there was a correlation between nutritional status with the occurrence of aris in under five children (p<0.05). conclusions: acute respiratory tract infections are often experienced by undernutrition children. this study strengthens the essential to correct nutritional status to prevent the infections in children. [amj.2015;2(3):395–97] keywords: acute respiratory infections, children under five, nutritional status correspondence: windi elsanita, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285275577025 email: windielsanita@gmail.com introduction acute respiratory infections (aris) are common in under-five children and spread through direct contact with the etiologic organisms through the air.1 acute respiratory infections are caused by microorganisms into the length of the respiratory tract starting from the nose to the alveoli and takes place for a period up to 14 days.2 acute respiratory infections-causing microorganisms are rhinovirus, coronavirus, influenza virus, parainfluenza virus, adenovirus, and group a beta hemolytic streptococcus.3 according to the indonesian ministry of health, the average child gets aris 3─6 times per year.4 the symptoms of aris are listed based on the classification such as cough, runny nose, fever, sneezing, nasal congestion, and sore throat. severe respiratory infection may develop bluish fingernails and lips (cyanosis), and tension in the chest wall breath sounds rough and dry.3 factors which influence the occurrence of aris are nutritional status, socio-economic, socio-cultural, environmental, treatment-seeking behavior, readiness and preparedness of health workers as an effort to provide the best services for the treatment and prevention of the disease.4 nutritional status is a balance of a person's food intake in the form of specific variables. factors which affect the nutritional status are the biological environment, the physical environment, psychosocial factors and family factors.5 anthropometric assessment of nutritional status uses an index based on weight for age (w/a) according to the who 2005.6 in this case, nutrition in children determines the tendency to be affected by aris in children. good nutrition will form a good endurance in children against the environment. conversely, children with poor nutrition do not develop althea medical journal. 2015;2(3) 396 amj september, 2015 strong endurance so that these children are more likely to have the diseases, especially infections.7 arsyad8 stated that nutritional status, immunization, home environment, and socioeconomic factors influence the occurrence of aris in under-five children in bantimurung subdistrict. a similar study shows that there is a relationship between nutritional status with the occurrence of aris in soetomo hospital surabaya.9 a previous study shows that there is a correlation between nutritional status with the incidence aris in which undernourished children tend to experience the recurrent aris.10 this study calculated the frequency of aris in the past year experienced by children. the objective of this study was to analyze the correlation between nutritional status and the occurrence of aris in children. methods this qualitative study was conducted in cipacing during the period october─november 2012 to 110 mothers who have under-five children with different nutritional status were randomly selected and then asked about their history of respiratory symptoms. this study used retrospective cohort approach. informed consent was signed by the mothers for approval and respondents who did not agree were not included in the study. respondents were asked about symptoms of respiratory infections that occurred in children. respiratory symptoms asked were cough, fever, runny nose, wheezing, pain or discharge from the ears, bluish lips or pale skin, snoring, shortness of breath and husky. the frequency of aris in the previous year, was classified into <7 times and ≥7 times. it was based on the average number of children getting aris for 3─6 times in a year.4 the nutritional status of children was assessed by the who anthropometric standard 2005 after the categories of nutritional status were classified by the ministry of health. assessment of nutritional status by index weight for age (w/a) were performed according to who 2005. the z value for each level of nutritional status were severe undernourished <-3sd, undernourished -3 sd to <-2 sd, good nutrition -2 sd to 2 sd, and obese >2 sd. children with incomplete measurement w/a data were not included in the study.6 data were analyzed statistically using nonparametric chi-square test. the study variables were bivariate and the distribution of data was abnormal. results children with good nutrition were more than table 1 description nutritional status in children nutritional status frequency percentage (%) good nutrition 71 64.5 undernourished 39 35.5 table 2 description of aris in children aris frequency percentage (%) <7 times 96 87.3 ≥7 times 14 12.7 table 3 aris distribution based on the nutritional status nutritional status aris frequency percentage (%) good nutrition 66 (60) 5 (4.5) undernouris 30 (27.3) 9 (8.2) althea medical journal. 2015;2(3) 397 the undernourished ones (table 1). children who had aris <7 times were more than those with aris ≥7 times (table 2). children with good nutritional status tended to have less aris <7 times while undernourished children suffered more aris ≥7 times (table 3). the results of the analysis found that the chi square test for the variable nutritional status with the occurrence of aris shows a significant p value of p = 0.016 (p<0.05). p <0.05 mean that there was a relationship between nutritional status with the occurrence of aris in children under five years old. discussion nutritional status is a balance of one food intake expresses in the form of specific variables. nutritional status describes the adequacy or inadequacy of nutrients in a person as undernourished, good nutrition, and obese.5 nutrition plays a role in our bodies in form antibodies as a defense against infections or diseases that comes from environment. children with good nutrition will form adequate antibodies and are more rarely infected than undernourished ones.7 the result of this study showed that there was a correlation between nutritional status with the occurrence of aris. children with good nutrition were less likely to get a respiratory infection than undernourished children who had a tendency to get infected. therefore, it is important to improve nutritional status in children to prevent infection in the environment. acute respiratory infections are influenced by many factors such as nutritional status, socio-economic, socio-cultural, environmental, treatment-seeking behavior, readiness and preparedness of health workers as an effort to provide the best service for the treatment and prevention of the disease. this study only used two variables and could not compare more significant factors influencing the occurrence of aris in children. biased recall might occur because the symptoms of aris asked were from the previous year . it was mentioned that many factors can affect the nutritional status of children such as biological factors, physical environment, psychosocial factors and family factors. as a conclusion, improvement in these factors will improve the nutritional status in children.5 references 1. badan penelitian dan pengembangan kesehatan departemen kesehatan ri.. riset kesehatan dasar (riskesdas) 2007. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan ri; 2008. 2. behrman, kliegman, jenson. acute inflammatory upper airway obstruction. in: roosevelt ge, editor. nelson textbook of pediatrics. 17th ed. philadelphia: elsevier; 2004. p.1405─9. 3. goh dy, shek lp, wah lb. acute respiratory tract infections in children: outpatient management. bulletin national university hospital singapore.1999. [cited 2012 april 5]. available from: https:// w w w. n u h . c o m . s g / w b n / s l o t / u 3 6 0 9 / education/healthcare%20professionals/ e d u c a t i o n % 2 0 & % 2 0 t r a i n i n g % 2 0 opportunities/bulletin/bulletin_10.pdf 4. weber m, handy f. situasi pneumonia balita di indonesia. buletin jendela epidemiologi. 2010;3(september):1–10. 5. supriasa idn, bakri b, fajar i. penilaian status gizi. jakarta: penerbit buku kedokteran egc; 2002. 6. menteri kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor 1995/menkes/sk/ xii/2010 tentang standar antropometri penilaian status gizi anak. jakarta: kementerian kesehatan republik indonesia. 2010. 7. whitney e, rolfes sr. understanding nutrition. 11th ed. belmont, ca: thomson wadsworth; 2008. p. 181─94. 8. arsyad t. faktor determinan kejadian infeksi saluran pernapasan akut anak balita di kecamatan bantimurung kabupaten maros. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan ri; 2000. 9. rahmawati d. hubungan status gizi dengan kejadian ispa di urj anak rsu dr. soetomo surabaya. buletin penelitian rsu dr soetomo surabaya; 2008;10(3):141–6. 10. sukmawati, ayu sd. hubungan status gizi, berat badan lahir (bbl), imunisasi dengan kejadian infeksi saluran pernapasan akut (ispa) pada balita di wilayah kerja puskesmas tunikamaseang kabupaten maros 2010. media gizi pangan. 2010;x(2):16–20. windi elsanita, deni kurniadi s, diah asri wulandari, elsa pudji setiawati: undernutrition affects the occurrence of acute respiratory infections in children under five years old in cipacing, jatinangor subdictrict, west java from october to november 2012 althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 568 amj december, 2015 knowledge and attitude of senior high school students in jatinangor towards sexually transmitted infections in 2013 aisyah riseta aini hendrana,1 kuswandewi mutyara,2 rasmia rowawi3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of dermato-venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: sexually transmitted infections (stis) are major health problem. until today, the prevalence of stis is still high and the incidence is increasing. almost half of stis new cases occur in adolescents and young adults. it is assumed that there is a positive correlation of knowledge about stis with attitude and practices; therefore, giving proper information of stis to adolescents could influence their safe sexual practices, and further, it can prevent stis to occur. the objective of this study is to discover knowledge and attitude of senior high school students in jatinangor towards stis. methods: this descriptive study was conducted in sekolah menengah atas persatuan guru republik indonesia (sma pgri) jatinangor and sekolah menengah atas negeri (sman) jatinangor from may to september 2013. questionnaires were completed by 278 respondents selected by stratified cluster random sampling. results: more than half respondents had poor knowledge about stis (56.5%) while 53.2% of the respondents had positive attitude towards stis. most mentioned choices as the information source of stis were teacher (66.5%), followed by television/radio (45.3%), friends (37.8%), newspaper/magazine (21.2%), mother (16.2%), sibling (7.2%), and father (6.5%). conclusions: more detail information about stis is needed by adolescents as a way to encourage safe sexual practices. teacher and parents are expected to be the source information of stis while mass media can also be used to educate adolescents. education on stis for teachers is also needed since they are as the main source for educating the adolescents. [amj.2015;2(4):568–74] keywords: adolescent, attitude, knowledge, sexually transmitted infections correspondence: aisyah riseta aini hendrana, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8562345032 email: aisyahriseta@gmail.com introduction sexually transmitted infections (stis) are major health problem because of its effects on reproduction health and its role on increasing risk of acquired immunodeficiency syndrome (aids) for five to ten times.1,2 sexually transmitted infections other than human immunodeficiency virus (hiv)/aids are neglected and do not become priority in public health concern.1 additionally, the prevalence of stis is high; the estimated prevalence is 360.1 million across the globe, and the incidence of stis increases from time to time.3 almost half of the new cases of stis are found in adolescents and young adults.2 the high incidence of stis in adolescents is caused by the rapid development in sexual maturity and the increasing of sexual drive in adolescents.4 the last two factors lead the adolescents to begin sexually active behavior.5 the high prevalence of stis can be caused by lack of knowledge about stis.2 a study conducted by kurkowski6 discovered that adolescents had low knowledge about stis. the knowledge has a positive correlation with attitude and practice, so proper given information could influence adolescents’ safe sexual practice.7,8 the objective of this study was to discover knowledge and attitude of senior high school students in jatinangor towards stis. jatinangor, where universitas padjadjaran is located, is a rapid developing area with many adolescent ages. by conducting althea medical journal. 2015;2(4) 569 the study in this area, the incidence of stis in jatinangor adolescent may be prevented. methods this descriptive study was conducted from may to september 2013. the population of this study was the students from senior high schools in jatinangor. through stratified random cluster sampling technique, from randomly selected senior high school in jatinangor it was selected two schools: sekolah menengah atas persatuan guru republik indonesia (sma pgri) jatinangor and sekolah menengah atas negeri (sman) jatinangor. the respondents were 278 students selected from randomly selected class of both schools. inclusion criteria in this study were senior high school students in jatinangor, with total 3,674 students. this study took secondary data from jatinangor cohort team, faculty of medicine universitas padjadjaran. questionnaire with close-ended questions was used for data collection. questionnaire was developed from the previous study and the content validity which was done. after authorization was received from the selected senior high school, the study was informed and consent was obtained from the respondents. the knowledge about stis was measured by 15 positive questions and 5 negative questions. three answer choices (true, false, and do not know) were provided for each question. given point were one for correct answer and no point for ‘do not know’ and incorrect answers. the total score was obtained by summing the point from each question with maximum total score was 20. the total score of knowledge questions had a normal distribution, so this study used mean ( =9.12) as an indicator to categorize level knowledge, good knowledge (total score>9.12) and poor knowledge (total score<9.12). the knowledge questions were reliable (cronbach’s alpha=0.745). attitude towards stis was measured using likert scale questions, including 12 positive questions and 2 negative questions. four answer choices (strongly agree, agree, disagree, and strongly disagree) were provided for each question. for positive questions, given point was four for strongly agree, three for agree, two for disagree, and one for strongly disagree. for negative questions, given point was four for strongly disagree, three for disagree, two for agree, and one for strongly agree. total score was obtained by summing the point from each question, and maximum total score was 56. total score of attitude questions had a normal distribution, so this study used mean ( =42.94) as an indicator to categorize level of attitude knowledge, positive attitude (total score>42.94) and negative attitude (total score<42.94). the attitude questions were reliable (cronbach’s alpha=0.705). microsoft excel was used to analyze the data. descriptive analysis, including percentage, was carried out to get the respondents’ characteristic, knowledge, and attitude towards stis. ethical approval was obtained from health research ethics committee faculty of medicine universitas padjadjaran with ethical clearance number 329/un6.c2.1.2/kepk/2013. results the questionnaires were completed by 278 participants, out of these 58.6% were females and 41.4% were males. the age of respondents was ranged from 15 to 19 years old. most of the respondents had ever had a boy/girlfriend (89.6%) and currently had a boy/girlfriend (52.5%). majority of respondents (91.7%) lived with their parents. majority of respondents (66.5%) revealed that teacher was as their source information of stis, followed by television/radio (45.3%) and friends (37.8%). only a few students mentioned mother (16.2%) and father (6.5%) as their source information. there were more respondents who had poor knowledge (56.5%) than respondents who had good knowledge about stis (43.5%). mean of knowledge score was 9.12 (sd=3.651). most of the respondents knew that adolescent (60.1%) and multiple sexual partner (88.1%) are risk factor of stis. only about one third of respondents (39%) knew that bacteria are not the only cause of stis, while majority of respondents (78.1%) knew that aids is caused by hiv. regarding to transmission of stis questions, majority of respondents knew that stis can be transmitted from mother to fetus (61.9%) and through sharing needle injection (79.9%). almost three quarter of respondents (73.7%) answered correctly to question about aids as complication of stis; however, most of respondents did not know whether infertility (74.1%) and problem on pregnancy (56.5%) are the complication of stis. in response to the questions about the prevention of stis, more than three quarter of respondents (77%) answered correctly to question about faithful to sexual partner. there were more respondents who had positive attitude (53.2%) than respondents aisyah riseta aini hendrana, kuswandewi mutyara, rasmia rowawi: knowledge and attitude of senior high school students in jatinangor towards sexually transmitted infections in 2013 althea medical journal. 2015;2(4) 570 amj december, 2015 who had a negative attitude (46.8%) towards stis. mean of total score was 42.94 (sd=4.616). majority of the respondent had an appropriate response to each attitude questions, except for ‘people with stis must have had sexual intercourse’ question. more than three quarter of respondents (79.1%) had an inappropriate response to the question. discussion this study revealed that more than a half of respondents had poor knowledge. the result was consistent with previous study conducted by kurkowski.6 the result in the present study could arise probably because of education, environment, and social culture factors.9 although information about stis is given during junior high school through textbook and teacher, the information given is not detailed enough.10 furthermore, in indonesian culture, sexuality is considered taboo, so a discussion about sexuality is not supported.11 the present study found that large percentage of correct answer was shown in the question about hiv/aids, which is consistent with two previous studies conducted by anwar1 and fagan12 the result from this study showed that respondents have a better knowledge about hiv/aids compared to common stis. this may be explained by the fact that education is concentrated on aids.1 stis other than hiv/aids are neglected and do not become a priority in public health.1 table 1 characteristic of respondents characteristic percentage (%) gender: male 41.4 female 58.6 religion: muslim 99.6 christian 0.4 respondents has ever had a boy/girlfriend: yes 89.6 no 10.4 respondents currently has a boy/girlfriend: yes 52.5 no 47.5 whom respondents live with: parents 91.7 relative 7.2 alone 1.1 information sources of stis mother 16.2 father 6.5 sibling 7.2 teacher 66.5 friends 37.8 television/radio 45.3 newspaper/magazine 21.2 others 9.0 note: stis=sexually transmitted infections althea medical journal. 2015;2(4) 571 table 2 knowledge about stis question answer true (%) false (%) do not know (%) risk factor of stis prevalence in man is as high as in woman 56.3 10.8* 32.9 adolescents 60.1* 8.3 31.7 multiple sexual partners 88.1* 1.8 10.1 have suffered sti previously 14.1 28.2* 57.8 etiology of stis only bacteria 24.2 39.0* 36.8 aids is caused by hiv 78.1* 0.4 21.6 type of stis gonorrhea 38.8* 9.0 52.2 syphilis 34.2* 6.1 59.7 symptom of stis many patient does not have symptom 31.4* 21.7 47.0 yellowish discharge from urethral on male 45.0* 6.8 48.2 vaginal discharge on female 17.6* 33.8 48.6 transmission of stis only through sexual intercourse 69.1 18.7* 12.2 from mother to fetus 61.9* 3.2 34.9 sharing needle injection 79.9* 3.2 16.9 complication of stis aids 73.7* 0.4 25.9 infertility 21.6* 4.3 74.1 problem on pregnancy 41.0* 2.5 56.5 prevention of stis condom 42.4* 7.6 50.0 risk of stis in circumcised man is as high as in uncircumcised man 7.9 24.8* 67.3 faithful to sexual partner 77.0* 6.5 16.5 note: stis=sexually transmitted infections; aids=acquired immunodeficiency syndrome; hiv=human immunodeficiency virus, *correct answer based on the study in jakarta, 62% of senior high school students was given information about hiv/aids while only 17% was given information about stis.13 some areas in stis need special attention. majority of the respondents did not know or answered incorrectly to the question about etiology of common stis, risk factors, type, symptom, complications, and prevention of stis. these areas, except for type of stis, are not taught in junior high school,10 small percentage of respondents was knowledgeable about it. more than half of the respondents did not know whether gonorrhea and syphilis are type of stis, yet these topic actually have been introduced to the junior high school students.10 unfortunately, knowledge is not maintained by repetitive given information so respondents just forget about the information which was only given once.13 knowledge about stis is an essential prerequisite for safe sexual practice, which aisyah riseta aini hendrana, kuswandewi mutyara, rasmia rowawi: knowledge and attitude of senior high school students in jatinangor towards sexually transmitted infections in 2013 althea medical journal. 2015;2(4) 572 amj december, 2015 can lead to the decrease in the high prevalence of stis and suppress the increase of stis incidence.1,14 adolescents should be educated about the symptom of stis, so they know when they should seek medication.15 education about safe sexual practice as the prevention of stis is also important to delay the onset of sexual practice among adolescents.16 attitude is important to decide whether a person will perform risky sexual practice or not. the finding of this study reported that more than half of respondents had positive attitude towards stis, coinciding with previous study conducted in ethiopia.16 influence from teacher, educational institution, religion, and culture in indonesia may affect the present study result.9 junior high school teacher gives some information about stis, and indonesian culture is considered that sexual intercourse can only be done after marriage.10,11 these may make indonesian people had an appropriate response towards stis. majority of the respondents had an appropriate response to each attitude question, except for ‘people with stis must have had sexual intercourse’ question. majority of the respondents thought people with stis must have had sexual intercourse. almost all of the respondents thought that adolescents require more attention. adolescents are risk factor of stis because of their development in sexual maturity and increasing sexual drives. for that matter, adolescents require more attention, especially from their parents. 4,17,18 this present study revealed that teacher was the main information source of stis in adolescents. this is due to the fact that stis are the object of study in biology subject on junior high school in indonesia. junior high school students are introduced to the various type stis from textbook, but not the risk factor, the transmission, and the prevention of stis in table 3 attitude towards stis statements response strongly agree (%) agree (%) disagree (%) strongly disagree (%) i think, adolescents require more attention because they have high risk to get stis 64.4 32.4 2.5 0.7 i think, multiple sexual partners must be avoided 60.4 35.6 1.4 2.5 i think, aids is caused by hiv 37.8 54.7 6.1 1.4 i think, gonorrhoeae is stis 15.5 57.4 24.2 2.9 i think, syphilis is stis 15.2 53.6 25.4 5.8 i think, i will not get stis as long as i have sexual intercourse with person with no symptom * 10.4 31.7 41.7 16.2 i think, i need to worry to get stis if there is yellowish discharge from urethra (on man) or vaginal discharge (on woman) 28.8 47.1 21.2 2.9 i think, people with stis must have had sexual intercourse* 22.3 56.8 18.7 2.2 i think, sharing needle injection must be avoided 54.9 40.4 3.6 1.1 i think, stis must be avoided because people with stis have higher risk to get aids 46.2 48.4 4.7 1.7 i think, stis is harmful because it can cause infertility 26.7 50.6 20.2 2.5 i think, stis can be dangerous in pregnancy 27.2 60.1 9.4 3.3 i think, condom usage is important to prevent stis 20.9 52.5 23.4 2.5 i think, faithful to sexual partner is essential to prevent stis 49.5 41.5 7.6 1.4 note: stis=sexually transmitted infections; aids=acquired immunodeficiency syndrome; hiv=human immunodeficiency virus, *negative statement. for positive statements, appropriate responses are ‘strongly agree’ or ‘agree’. for negative statements, appropriate responses are ‘strongly disagree’ or ‘disagree althea medical journal. 2015;2(4) 573 detail.10 teacher and parents are expected to be the information sources of stis for adolescents, but only a few of respondents mentioned parents as their information source. this is due to stis is considered taboo in indonesia, which leads to a barrier between parents and children on discussing matters related to sexuality.11,18,19 certain condition causes many students seek information from mass media and friends, as seen in this study, which was corroborated with previous study conducted in india15. influence from media and friends are mostly negative.20 limitation in this study was presence of some non-valid questions in questionnaire. the solution for future research is to ensure validation score is sufficient before questionnaire is given to respondents. further study to investigate effective education method in promoting knowledge and attitude toward stis is recommended. more detailed information about stis is needed by adolescents as a way to encourage a safe sexual behavior, especially information about part of stis they are lacking in, which are the etiology of common stis, the risk factors, the type, the symptom, the complication, and the prevention of stis. this can be succeeded by educating the adolescents.7,8 teacher and parents are expected to be the information sources of stis.18 media also can be used to educate through its advertisement or health program. education should not only be given to adolescents, but also to their teachers as the main source information of stis. references 1. anwar m, sulaiman sa, ahmadi k, khan tm. awareness of school students on sexually transmitted infections (stis) and their sexual behavior: a cross-sectional study conducted in pulau pinang, malaysia. bmc public health. 2010;10(1):47–52. 2. da ros ct, schmitt cda s. global epidemiology of sexually transmitted diseases. asian j androl. 2008;10(1):110– 4. 3. rowley j, toskin i, ndowa f. global incidence and prevalence of selected curable sexually transmitted infections 2008. geneva: who library cataloguingin-publication data; 2012. p. 2–4. 4. christie d, viner r. abc of adolescence: adolescent development. bmj. 2005;330 (7486):301–4. 5. bankole a, malarcher s. removing barriers to adolescents’ access to contraceptive information and services. stud fam plan. 2010;41(2):117–24. 6. kurkowski jp, hsieh g, sokkary n, santos x, bercaw-pratt jl, dietrich je. knowledge of sexually transmitted infections among adolescents in the houston area presenting for reproductive healthcare at texas children’s hospital. j pediatr adolesc gynecol. 2012;25(3):213–7. 7. reis m, ramiro l, de matos mg, diniz ja. the effects of sex education in promoting sexual and reproductive health in portuguese university students. procedia soc behav sci. 2011;29(64):477–85. 8. reis m, ramiro l, de matos mg, diniz ja. nationwide survey of contraceptive and sexually transmitted infection knowledge, attitudes and skills of university students in portugal. int j clin hlth psyc. 2013;13(2):127–37. 9. wawan a. teori & pengukuran: pengetahuan, sikap, dan perilaku manusia. 1st ed. yogyakarta: nuha medika; 2010. p. 16–7. 10. furqonita d. sistem reproduksi pada manusia. in: nuryandani e, andayeni f, dewi lr, editors. seri ipa biologi 3 smp kelas ix. 1st ed. bandung: yudhistira ghalia indonesia; 2008. p. 13–5. 11. utomo a, reimondos a, utomo i, mcdonald p, hull th. digital inequalities and young adults in greater jakarta: a sociodemographic perspective. international journal of indonesian studies. 2013;1:79– 109. 12. fagan p, mcdonell p. knowledge, attitudes and behaviours in relation to safe sex, sexually transmitted infections (sti) and hiv/aids among remote living north queensland youth. aus nz j publ heal. 2010;34(suppl1):s52–s6. 13. mustikawati de, riono p, sutrisna a. analisis kecenderungan perilaku berisiko terhadap hiv di indonesia. jakarta: departemen kesehatan republik indonesia; 2009. p. 72–6. 14. gutierrez j-p, mcpherson s, fakoya a, matheou a, bertozzi sm. community-based prevention leads to an increase in condom use and a reduction in sexually transmitted infections (stis) among men who have sex with men (msm) and female sex workers (fsw): the frontiers prevention project (fpp) evaluation results. bmc public health. 2010;10(1):497–509. 15. mcmanus a, dhar l. study of knowledge, perception and attitude of adolescent aisyah riseta aini hendrana, kuswandewi mutyara, rasmia rowawi: knowledge and attitude of senior high school students in jatinangor towards sexually transmitted infections in 2013 althea medical journal. 2015;2(4) 574 amj december, 2015 girls towards stis/hiv, safer sex and sex education:(a cross sectional survey of urban adolescent school girls in south delhi, india). bmc womens health. 2008; 8(1):12–8. 16. shiferaw y, alemu a, girma a, getahun a, kassa a, gashaw a, et al. assessment of knowledge, attitude and risk behaviors towards hiv/aids and other sexual transmitted infection among preparatory students of gondar town, north west ethiopia. bmc res notes. 2011;4(1):505– 13. 17. sychareun v, thomsen s, chaleunvong k, faxelid e. risk perceptions of stis/hiv and sexual risk behaviours among sexually experienced adolescents in the northern part of lao pdr. bmc public health. 2013;13(1):1126–50. 18. biddlecom a, awusabo-asare k, bankole a. role of parents in adolescent sexual activity and contraceptive use in four african countries. int perspect sex reprod health. 2009:35(2)72–81. 19. mwambete kd, mtaturu z. knowledge of sexually transmitted diseases among secondary school students in dar es salaam, tanzania. afr health sci. 2006;6(3):165–9. 20. onyeonoro uu, oshi dc, ndimele ec, chuku nc, onyemuchara il, ezekwere sc, et al. sources of sex information and its effects on sexual practices among inschool female adolescents in osisioma ngwa lga, south east nigeria. j pediatr adolesc gynecol. 2011;24(5):294–9. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 137 profile of anemia on lung tuberculosis at dr. hasan sadikin general hospital and community lung health center bandung marizka adzani,1 nadjwa zamalek dalimoenthe,2 indra wijaya3 1faculty of medicine universitas padjadjaran, 2department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: tuberculosis (tb) is a chronic infectious disease caused by mycobacterium tuberculosis that can cause anemia. anemia is a lack of erythrocyte mass needed to carry adequate oxygen to the whole bodies. the aim of this study was to describe the anemia in adult lung tb patients at dr. hasan sadikin general hospital and community lung health center (balai kesehatan paru masyarakat, bkpm) bandung. methods: this descriptive study was conducted from august to october 2014. study subjects were adult tb patients who came for their first control to tb clinic dr. hasan sadikin general hospital and bkpm bandung after receiving oral antituberculosis drugs, and willing to comply in study. the exclusion criteria were patients with other chronic diseases, pregnant, menorrhagia, and hemoptoe. three ml of vein blood was taken and put into edta tube for routine hematologic measurement using automatic hematologic analyzer, sysmex kx-21®. results: there was 31 (63.26%) from 49 adult lung tb patients suffered anemia. in male subjects, mild and moderate anemia were found 57.14% and 42.86% respectively, and in female subjects were 58.82% and 41.18% respectively. in males, there were 42.86% normochromic normocytic, 42.86% hypochromic microcytic, 7.14% normochromic microcytic, and 7.14% hypochromic normocytic, while in females, there were 5.88% normochromic normocytic, 47.06% hypochromic microcytic, 17.65% normochromic microcytic, 29.41% hypochromic normocytic. conclusions: anemia is found in 63.26% adult lung tb patients, most of which are mild anemia and hypochromic microcytic, especially in female subjects. [amj.2016;3(1):137–40] keywords: anemia, hemoglobin, lung tuberculosis correspondence: marizka adzani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287821584924 email: marizkaadzani@yahoo.co.id introduction tuberculosis (tb) is one of the major health problems and causes second-most deaths due to infectious diseases worldwide. indonesia ranks fourth in countries with most tb patients after india, china, and south africa.1 tuberculosis is a chronic infectious disease caused by mycobacterium tuberculosis which commonly attacks the lungs.2 tb can cause various and complex hematologic abnormalities, one of which is anemia.3 isanaka et al.4 in 2011 reported that iron deficiency anemia as well as anemia without iron deficiency in tb patients are related to 2–3 fold increased risk of death. in tb patients, anemia could manifest as chronic-diseaserelated anemia, anemia due to coughing blood (hemoptysis), anemia due to malnutrition and sideroblastic anemia as side effect of isoniazid.2,5,6 anemia is functionally defined as insufficiency of eryhtrocyte mass to deliver oxygen in sufficient amount to peripheral tissues.6 al omar et al.7 in 2009 reported that anemia in adult tb patients happened as much as 60% in male and 45% in female, and 80% was normochromic normocytic anemia. the aim of this study was to describe the anemia in adult lung tb patients at dr. hasan sadikin general hospital and community lung health center (balai kesehatan paru masyarakat, bkpm) bandung. althea medical journal. 2016;3(1) 138 amj march 2016 methods this was a quantitative descriptive study, conducted from august to october 2014. the subjects were adult lung tb patients who came to tb clinic dr. hasan sadikin general hospital and bkpm bandung. subjects were chosen by consecutive sampling. study data was a primary data based on routine hematologic test results in adult lung tb patients. the inclusion criteria were patients diagnosed with tb, who received oral antituberculosis drugs and came for first time control to tb clinic at dr. hasan sadikin general hospital and bkpm bandung, who were willing to comply for study, adult aged >18 years old. the exclusion criteria were patients with other chronic diseases, hemoptysis, pregnancy, and menorrhagia. diagnosis of anemia in adult tb patients was confirmed when hemoglobin levels below 13 g/dl for male and below 12 g/dl for female; hematocrit levels below 42% for male and below 37% for female; eryhtrocyte count less than 4.95 million /mm3 for male and less than 4.25 million/mm3 for female. anemia is classified as hypochromic microcytic when mcv<80 fl and mchc <32%, as normochromic normocytic when mcv 80–100 fl and mchc 32–36%, as macrocytic when mcv>100 fl. severity of anemia in male patients is graded as mild:11–12.9 g/dl; moderate :8–10.9 g/ dl; and severe:≤8 g/dl. severity of anemia in female patients is graded as mild:11–11.9 g/ dl; moderate: 8–10.9 g/dl, and severe: ≤8 g/ dl.6 study procedures conducted were getting study permit from dr. hasan sadikin general hospital and bkpm; ethical clearance from study ethical commitee of dr. hasan sadikin general hospital; tb patients screening who fulfilled the inclusion and exclusion criteria in tb clinic dr. hasan sadikin general hospital and bkpm; performing informed consent by examiner; preparing study equipments and materials; taking 3ml blood samples from vein and putting into edta tubes; homogenizing samples and hematologic measurement using hematology analyzer device, sysmex kx-21®; processing and analyzing study results; and announcing the results to patients through clinic results the number of adult pulmonary tuberculosis patients who suffered from anemia was larger. the result showed that 31 of 49 subjects (63.26%) suffered anemia. seventeen was female (table 1). results of anemia distribution and frequency showed that there was no severe anemia found in male and female subjects table 1 characteristics of adult lung tb patients characteristics anemia (n= 31) no anemia (n= 18) gender male 14 12 female 17 6 age (year) mean 32.4 32.9 body mass index (m/kg2) mean 18.2 18.8 table 2 frequency distribution of anemia in adult lung tb patients gender anemia total mild n (%) moderate n(%) male 8 (57.14%) 6 (42.86) 14 (100%) female 10 (58.82%) 7 (41.18) 17 (100%) total 18 13 31 althea medical journal. 2016;3(1) 139marizka adzani, nadjwa zamalek dalimoenthe, indra wijaya: profile of anemia on lung tuberculosis at dr. hasan sadikin general hospital and community lung health center bandung (table 2). the most classification of anemia in women was hypochromic mikrositer, whereas, the most in men was normokrom normositer and hypochromic mikrositer (table 3). moderate anemia dominated with hypochromic microcytic anemia (table 4). discussion this study found that 31 out of 49 subjects (63.26%) had anemia. result of other studies was various outcomes. yaranal et al.3 in 2013 showed that anemia in tb patients occurred in as high as 74% of cases. lee et al.8 in 2006 reported that 31.9% tb patients suffer anemia. characteristic and frequency distribution of adult lung tb patients who had anemia in this study were 28.57% in males and 34.69% in females. al omar et al.7 in 2009 reported that anemia in adult lung tb patients occurs as much as 60% in male and 45% in female. this diversity in results maybe due to another coexisting disease.6 the median age for male and female lung tb patients in this study was 31 years old with range 15–57 years old. karoum et al.9 study reported that mostly, tb patients with anemia are over 16 years old. this study also showed that the average bmi of tb patients with anemia were 18.2 kg/cm2 (underweight) and in tb patients without anemia 18.8 kg/cm2 (normal) respectively. the data showed that tb patients who suffered from anemia had less nutrition, it is consistent with study by oliveira et al.10 in 2014 that mentioned 68.7% of pulmonary tb patients with anemia have a bmi of 18.21 kg/ m2, so that concludes anemia is associated with malnutrition. the distribution frequency results of this study showed that in male, 57.14% adult lung tb patients suffered mild anemia and 42.86% suffered moderate anemia. in female subjects, 58.82% had mild anemia and 41.18% had moderate anemia. there was no subject presented with severe anemia in this study. these results are comparable to the study conducted in 2012 by hungund et al.11, who reported that out of 100 tb patients, 50% have mild anemia, 37% have moderate anemia, but in hungund study, 9% have severe anemia. study kumar et al.12 in 2013 reported that 63 people have mild anemia. anemia in tb patients is related to chronic inflammation process, where erythropoiesis is inhibited by cytokines and iron metabolism is altered, which results mild to moderate degree of anemia.13,14 hematological changes that occur are often associated with the body’s immune response to tb infection. this study reported that in male adult, patients with lung tb, 42.86% had normochromic normocytic anemia, 42.86% had hypochromic microcytic anemia, 7.14% had normochromic microcytic anemia, 7.14% had hypochromic normocytic anemia, and table 3 anemia description in adult lung tb patients anemia type male n=14 female n=17 normochromic normocytic 6 1 hypochromic microcytic 6 8 normochromic microcytic 1 3 hipochromic normocytic 1 5 table 4 anemia classification in adult lung tb patients based on severity anemia type mild moderate total normochromic normocytic 6 1 7 hypochromic microcytic 4 10 14 macrocytic 0 0 0 normochromic microcytic 3 1 4 hypochromic normocytic 5 1 6 total 18 13 31 althea medical journal. 2016;3(1) 140 amj march 2016 none of them had macrocytic anemia. in female adult, patients with lung tb, 5.88% had normochromic normocytic anemia, 47.06% had hypochromic microcytic anemia, 17.65% had normochromic microcytic anemia, 29.41% had hypochromic normocytic anemia, and also none of them had macrocytic anemia. overall, this study reported that most of the cases were hypochromic microcytic anemia. this result is different compared to the study conducted by al omar et al.7 in 2009, which reported that 80% anemia in tb patients are normochromic normocytic type and only 20% anemia are hypochromic microcytic type; and study by lee et al.8 in 2006 which reported that 71.9% cases have normochromic normocytic anemia. study by atomsa et al.15 in 2014 reported that 37.5% cases have normokrom normositer and 30.4% hypochromic normositer. these differences in results might be caused by the existence of underlying anemia, most probably iron deficiency anemia. theoretically, iron deficiency anemia presents itself in 3 stages: iron depletion, iron deficient erythropoiesis, and finally iron deficiency anemia. in the first two stages, anemia does not occur yet. in the third stage, anemia is detected initially with normochromic normocytic type, which slowly progresses to be normochromic microcytic anemia and finally, hypochromic microcytic anemia occurs.6 conclusion of this study is 63.26% adult lung tb patients suffer anemia, most of which are mild anemia and the most category are hypochromic microcytic anemia. the limitation of this study is the absence of database for previous health examination results before laboratory checkup and previous medical history. recommendations for clinicians is to consider the importance of the examination of anemia in patients with tb and provide treatment of anemia. references 1. who. global tuberculosis report 2012. geneva: who; 2012 2. loscalzo j, editor. harrison’s pulmonary and critical care medicine. new york: mcgraw-hill education; 2010. 3. yaranal pj, umashankar t, harish sg. hematological profile in pulmonary tuberculosis. int j health rehabil sci. 2013;2(1):50–5. 4. isanaka s, mugusi f, urassa w, willett wc, bosch rj, villamor e, et al. iron deficiency and anemia predict mortality in patients with tuberculosis. j nutr. 2011;142(2):350–7. 5. piso rj, kriz k, desax m-c. severe isoniazid related sideroblastic anemia. hematol rep. 2011;3(1):e2. 6. harmening d,editor. clinical hematology and fundamentals of hemostasis. philadelpia: f.a davis co; 2009. 7. al-omar i, al-ashban r, shah a. hematological abnormalities in saudia suffering from pulmonary tuberculosis and their response to the treatment. res j pharma. 2009;3(4):78–85. 8. lee sw, kang ya, yoon ys, um sw, lee sm, yoo cg, et al. the prevalence and evolution of anemia associated with tuberculosis. j korean med sci. 2006;21:1028–32. 9. karoum a, mohamed b, siddig m, bari e. anemia in kassala area eastern sudan. sudan journal of medical sciences. 2009;4(1):31–5. 10. oliveira m, delogo k, oliveira hd, ruffino n, kritski a, oliveira m. anemia in hospitalized patients with pulmonary tuberculosis. j bras pneumol. 2014;40(4):403–10. 11. hungund b, sangolli s, bannur h, malur p, pilli g, chavan r, et al. blood and bone marrow findings in tuberculosis in adults. al ameen j med sci. 2012;5(4):362–366. 12. kumar s, singh u, saxena mk, saxena r. hematological and biochemical abnormalities in case of pulmonary tuberculosis patients in malwa region. ijbps. 2013;3(3):237–41. 13. muhammad a, sianipar o. determination of iron deficiency in chronic disease anemia by the role of stfr-f index. indonesian journal of clinical pathology and medical laboratory. 2005;12(1):9–15. 14. weiss g, goodnough lt. anemia of chronic disease. n engl j med. 2005; 352(10):1011– 23. 15. atomsa d, abebe g, sewunet t. immunological markers and hematological parameters among newly diagnosed tuberculosis patients at jimma university specialized hospital. ethiop j health sci. 2014;24(4):311–8. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 96 amj march, 2015 anti-inflammatory effect of trigona spp. propolis in restricting edema volume wulantika nurhayati1, vycke yunivita kusumah dewi2, teguh marfen djajakusumah3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: inflammation is a normal response that potentially harmful if it is uncontrolled. on the other hand, it is necessary to find an alternative anti-inflammatory as most anti-inflammatory drugs available nowadays still have adverse effects. trigona spp. propolis is one of the potential anti-inflammatory alternatives because of its flavonoid, especially caffeic acid phenethyl ester, which is known as an active compound in anti-inflammatory process. this study aimed to understand the anti-inflammatory effect of trigona spp. prolisin reducing edema volume in rat’s paw. methods: an experimental study was performed on 20 male wistar rats. the rats were divided into control and experimental groups with 10 rats in each group. control group was treated by propylene glycol 1 ml/day and experimental group was treated by trigona spp. propolis 200 mg/kg body weight/day. the inflammation was induced by subcutaneous injection of λ-carrageenan 1% at plantar one hour after the treatment. edema volumes were measured by plethysmometer every hour at 1 to 6 hours and once at 24 hours after induction. the difference in edema volumes was calculated in percentage. this study was conducted during october 2012 at the pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran bandung. results: the increase of edema volume (in percentage) in control group and trigona spp. propolis treated group are 100.64±32.22 and 56.46±20.38 respectively (p value=0.000). multiple comparisons using dunnet and duncan post hoc test showed significant differences that were observed at 3, 4, 5, and 6 hours after inflammatory induction. conclusion: trigona spp. propolis has an anti-inflammatory effect in reducing edema volume in rat’s paw. the most significant effect was observed at 3, 4, 5, and 6 hours after inflammatory induction. trigona spp. propolis might have a potential to be developed as a future anti-inflammatory drug. keywords: edema volume, inflammation, propylene glycol, trigona spp, propolis correspondence: wulantika nurhayati, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281394094866 email: wulantika.nurhayati@gmail.com introduction inflammation is a host response in vascularized tissues that is caused by cell injury by various exogenous and endogenous stimuli. the inflammatory response consists of vascular and cellular reaction. the unique feature of inflammation is reaction of blood vessels leading to accumulation of leucocytes and fluid in extravascular tissues that is called edema.1 physiologically, inflammation is protective response of the body to remove the noxious agent as well as the subsequent harmful events as consequence of the inflammation.2 it is the body’s effort to heal and reconstitute the injured tissues as process of repairing. however, on the other hand, this effort may be potentially harmful if uncontrolled and attack normal tissue.1 for this reason, anti-inflammatory drugs are being produced, which ideally will control the harmful sequelae of inflammation process without interfering its beneficial effects.1,3 eventhough anti-inflammatory drugs that are widely distributed have good enough efficacy, they still have many adverse effects. insomnia, euphoria, and depression in steroidal use and gastric irritation in nsaids (non-steroidal anti-inflammatory drugs) use are some examples of acute adverse effects from anti-inflammatory drugs.3,4 propolis (bee glue) is a natural product that is collected by the bees derived from resin or exudates of plants from apices of young leaves and mix with bees’ saliva.5-8 since early century, propolis has been believed as a product that has a lot of benefits for human.5,7,9 althea medical journal. 2015;2(1) 97 propolis, especially in brazil and china, is a herbal product that is used as anti-bacterial, anti-fungal, antioxidant, anti-inflammation, and anti-cancer.10 propolis is known having anti-inflammatory effect because its polyphenols (flavonoid, phenolic acidand its esther), terpenoid, steroid and amino acid.11 its flavonoid, especially cape (caffeic acid phenethyl ester) is known as an active compound in anti-inflammatory process which can inhibit production of cytokines il-1, il-6, tnf-α, and tgf-β12 through nf-κb pathway.13 its free radical scavenging activity can be mediated by the reduction of arachidonic acid metabolites by inhibiting lipoxygenase and cyclooxygenase.11 in spite of the fact that anti-inflammatory effect of propolis has been discovered in many researches11,14,15, propolis that has been intensely researched is that from bees species apis mellifera, not propolis from the species trigona spp. which are local bees from asia, especially indonesia6, that can produce more propolis than apis mellifera.6,7 the aim of this study is to evaluate antiinflammatory effect of an ethanol extract of trigona spp .propolis in limiting edema volumes of carrageenan-induced rat paw edema. methods twenty male wistar rats bred in interuniversity centre laboratory, bandung institute of technology were obtained from pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran bandung. the rats were 2-3 months old, 175±25 grams weight and in healthy condition (clean, has not been injured, and could actively move). rats were given pellets as standard food and tap water ad libitum in a room with good air circulation and illumination. before the experiment, animals were adapted in laboratory room for seven days. the ethanol extract of trigona spp. propolis was extracted by laboratory of food processing technique, faculty of agricultural industry, universitas padjadjaran bandung which then was filled by propylene glycol; the propolis to propylene glycol ratio was 1:12. propylene glycol that was used as a control was purchased from pt. brataco, bandung. lambda-carrageenan (λ-carrageenan) with 1% concentration was purchased from pt. sigma-aldrich, singapore, which was obtained from pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran bandung. equipments that were used are rat’s cage with food and drinking water bottle, scale, flannelette, pen, oral tube, syringe 1ml, and plethysmometer with 0.01 ml accuracy. rat paw volume was measured from lateral maleolus using plethysmometer. basal rat paw volume was measured before oral administration of propolis and propylene glycol. furthermore, propylene glycol 1 ml/ day per oral was administered to each rat in the control group and trigona spp. propolis 200 mg/kg body weight/day per oral was figure 1 percentage of edema volume difference althea medical journal. 2015;2(1) 98 amj march, 2015 administered to the control group through oral tube. dose of propolis that was given correspond to rat’s weight, then was diluted with propylene glycol until 1 ml. one hour later, rat’s left plantar was injected using 1% λ-carrageenan as inflammatory inductor. rat paw edema volume was measured at 1, 2, 3, 4, 5, 6, and 24 hours after carrageenan injection.16 this study was conducted during october 2012 in pharmacology and therapy laboratory, faculty of medicine, universitas padjadjaran bandung. data were analyzed using spss 15.0 for windows. significant differences between groups were determined by dunnet and duncan post hoc test for multiple comparisons after analysis of variance (anova). p<0.05 is considered statistically significant. results to evaluate anti-inflammatory effect, edema volume difference (in percentage) was calculated from the volume measured before carrageenan injection and each hour after induction. the mean percentage from each hour of measurements between control and conduction group was presented in figure 1. the increase of edema volume (in percentage) of those in control group and trigona spp. propolis treated group are 100.64±32.22 and 56.46±20.38 respectively (p value=0.000). multiple comparisons using dunnet and duncan post hoc test showed these significant differences that occurred at 3, 4, 5, and 6 hours after inflammatory induction. discussions this study showed that trigona spp. propolis 200 mg/kg body weight/day per oral has anti-inflammatory effect in limiting rat paw edema volumes. previous study has showed that aqueous extract apis mellifera’s propolis has antiinflammatory effect with dosage of 500mg/ kg body weight/day per oral15 and in ethanol extract with dosage of 3mg/kg body weight/ day in traparenteral14 as well as 200mg/kg body weight/day per oral.11 anti-inflammatory activity of propolis comes from its polyphenols (flavonoid, phenolic acidand its esther), terpenoid, steroid and amino acid.11 flavonoid typecaffeic acid phenethyl ester (cape) is the most common active compound from propolis tested11,13 and is believed to act as an active component in mediating anti-inflammatory process.9 the compound cape is believed be able to inhibit production of cytokinesil-1, il-6, tnf-α, and tgf-β12 through nf-κb pathway in nucleus13, free radical scavenging, and reduce the production of arachidonic acid metabolites by inhibiting lipooxygenase and cyclooxygenase.11 in conclusion, trigona spp. propolisis is a potential candidate to be developed as future anti-inflammatory drug. references 1. kumar v, abbas ak, fausto n. acute and chronic inflammation. robbins and cotran pathologic basis of disease. 7th ed. philadelphia, pennsylvania: saunders; 2005. p. 47–86. 2. tortora gj, derrickson b. the lymphatic system and immunity. principles of anatomy and physiology. hoboken, new jersey: john wiley & sons, inc; 2009. p. 844–5. 3. katzung bg. drugs used to treat disease of the blood, inflammation, &gout. basic & clinical pharmacology. 10th ed. new york: mcgraw-hill medical; 2007. p. 806–43. 4. burke a, smyth e, fitzgerald ga. analgesic-antipyretic agents. in: laurence l. brunton p, editor. goodman & gilman’s pharmacological basis of theurapeutics 11th ed. new york: mcgraw-hill; 2006. p. 671–715. 5. hasan aez. sehat & cantik dengan propolis. 1st ed. bogor: ipb press; 2010. p. 1–22. 6. mahani, karim ra, nurjanah n. keajaiban propolis trigona. 1st ed. jakarta: pustaka bunda; 2011. 7. alex. keajaiban propolis dalam mengobati penyakit. 1st ed. yogyakarta: pusaka baru press; 2011. 8. teixeira éw, negri g, meira rmsa, message d, salatino a. plant origin of green propolis: bee behavior, plant anatomy and chemistry. evid based complement alternat med. 2005;2(1):85–92 9. siregar hch, fuah am, octavianty y. propolis; madu multikhasiat. 1st ed. jakarta: penebar swadaya; 2011. 10. marcucci m. propolis: chemical composition, biological properties and therapeutic activity. apidologie [online jurnal]. 1995;26(2):83–99 [cited 17 april 2012]. available from:http://www.apidologie. o r g / a r t i c l e s / a p i d o / a b s / 1 9 9 5 / 0 2 / a p i d o l o g i e _ 0 0 4 4 8 4 3 5 _ 1 9 9 5 _ 2 6 _ 2 _ a r t 0 0 0 2 / a p i d o l o g i e _ 0 0 4 4 8 4 3 5 _ 1 9 9 5 _ 2 6 _ 2 _ althea medical journal. 2015;2(1) 99wulantika nurhayati, vycke yunivita kusumah dewi, teguh marfen djajakusumah: anti-inflammatory effect of trigona spp. propolis in restricting edema volume art0002.html 11. araujo mar, libério sa, m. rn, guerra, ribeiro mns, nascimento frf. mechanisms of action underlying the antiinflammatory and immunomodulatory effects of propolis: a brief review. rev bras farmacogn[internet]. 2012 feb [cited 2015 may 06] ; 22( 1 ): 208-219. available from: http://www.scielo.br/ scielo.php?script=sci_arttext&pid=s0102695x2012000100030&lng=en 12. chen m-f, keng pc, lin p-y, yang c-t, liao s-k, chen w-c. caffeic acid phenethyl ester decreases acute pneumonitis after irradiation in vitro and in vivo. bmc cancer [online jurnal]. 2005;5:158 [downloaded in 2 mei 2012]. available from: http:// w w w . b i o m e d c e n t r a l . c o m / 1 4 7 1 2407/5/158. 13. wang l-c, lin y-l, liang y-c, yang y-h, lee j-h, yu h-h, et al. the effect of caffeic acid phenethyl ester on the functions of human monocyte-derived dendritic cells. bmc immunology [online jurnal]. 2009;10:39 [downloaded in 2/05/2012]. available at: http://www.biomedcentral.com/14712172/10/39. 14. paulino n, dantas ap, bankova v, longhi dt, scremin a, de castro sl, et al. bulgarian propolis induces analgesic and anti inflammatory effects in mice and inhibits in vitro contraction of airway smooth muscle. jpharmacol sci. 2003;93(3):307– 13 15. demoura sal, negri g, salatino a, lima lddc, dourado lpa, mendes jb, et al. aqueous extract of brazilian green propolis: primary components, evaluation of inflammation and wound healing by using subcutaneous implanted sponges. evidence-based complementary and alternative medicine. 2011;2011:748283. 16. winyard pg, willoughby da. inflammation protocols. totowa, new jersey: humana press; 2003. p. 115–20. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 46 amj march, 2015 correlation between levels of serum amylase, lipase and triglyceride in acute pancreatitis patients gunalan govindarajan1, nina tristina2 1faculty of medicine, universitas padjadjaran, 2department of clinical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: acute pancreatitis is an inflammation of pancreas associated with reversible pancreatic parenchymal injury. studies in several countries indicate that the levels of amylase and lipase are usually elevated among patients with acute pancreatitis. furthermore, hyperlipidemia, mainly high levels of triglycerides, may present in acute pancreatitis. the aim of this study was to determine the levels of serum amylase and lipase as well as their correlation with serum triglyceride level in acute pancreatitis patients. methods: a retrospective study was conducted on medical records of 48 acute pancreatitis patients in dr. hasan sadikin general hospital bandung, indonesia from 2007to 2011. data collected from the medical records were age, sex, levels of serum amylase, lipase and triglyceride. the distribution of data was determined using shapiro-wilk test. the correlation between serum pancreatic enzyme and triglyceride was analyzed using spearman-rank test. results: most patients had increased levels of serum amylase and lipase in this study. however, no correlation between serum amylase and triglyceride (p-value = 0.312) was found. furthermore, there was no correlation between serum lipase and triglyceride (p-value = 0.241). conclusions: the levels of serum amylase and lipase increase in most patients with acute pancreatitis with no significant correlation between serum pancreatic enzymes (amylase and lipase) and triglyceride. key words: acute pancreatitis, amylase, lipase, triglyceride. correspondence: gunalan govindarajan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628179226451 email: gunz290590@gmail.com introduction pancreas is an accessory gland involved in digestion processes.1 pancreas secretes multiple enzymes to digest protein, carbohydrate and fat rich foods. enzyme that digests carbohydrate is pancreatic amylase. pancreatic lipase, cholesterol esterase and phospholipase aid in digestion of fat. meanwhile, the pancreatic enzymes involved in protein digestion are trypsin, chymotrypsin and carboxypolypeptidase. besides, multiple digestive enzymes, pancreas also release hormones such as insulin, glucagon, somatostatin and pancreatic polypeptides.2 pancreatitis is characterized by inflammation of the pancreas. this disease is classified into acute and chronic phase according to the course of injury to the pancreatic parenchyma. acute pancreatitis is inflammation of pancreas associated with reversible pancreatic parenchymal injury.3 acute pancreatitis is caused by several etiologic factors such as alcoholism, biliary tract diseases, metabolic disorders such as high triglyceride, genetic factors, mechanical factors or trauma, vascular disorders and infections.3 triglycerides particularly which exceeds 1000 mg/dl also serves as a cause of acute pancreatitis.4-9 acute pancreatitis is usually diagnosed by history taking, physical examination, laboratory findings and imaging studies.10-12 using laboratory measurement, measuring serum amylase and lipase levels can be useful for diagnosis. usually, the levels of serum amylase and lipase will be elevated.10 there were some studies that indicated the association between acute pancreatitis and hyperlipidemia, in which there is an elevation in the level of triglyceride in acute pancreatitis patients.5-9 in bandung, this correlation study has not been assessed. the aim of this study is to perform an analytical study in determining althea medical journal. 2015;2(1) 47 the correlation between the levels of serum amylaseand lipase and triglyceride among patients diagnosed with acute pancreatitis in dr. hasan sadikin general hospital bandung, indonesia . methods the research method used was analytical study using secondary data from medical records of patients diagnosed with acute pancreatitis in dr. hasan sadikin general hospital bandung, indonesia from 2007 to 2011. the study was carried out with prior approval of ethical committee of dr. hasan sadikin general hospital bandung. only patients with complete medical record data of serum amylase, lipase and triglyceride levels diagnosed with acute pancreatitis in dr. hasan sadikin general hospital bandung, indonesia from 2007 to 2011 were eligible for this study. data collected from the medical records were age, sex, levels of serum amylase, lipase and triglyceride. the distribution of data was determined using shapiro-wilk test. the correlation between serum pancreatic enzyme and triglyceride was analyzed using spearman-rank test. results there were total of 288 cases of acute pancreatitis reported from years 2007 to 2011. from those 288 cases, 88 medical records were lost. from the remaining 200 medical records of the patients, only 48 medical records (24%) were used in this study because the remaining medical records have incomplete data. the baseline characteristics of acute pancreatitis patients showed that most patients were in the age group of 51–60 years old (37.5%). female patients presented with the disease more than males (60.4%) (table 1). the data of the levels of serum amylase and lipase were not normally distributed, with the levels of amylase (median = 211.50 u/l, range 78-6978 u/l) and lipase (median=268.40 u/l, range=20.76082.2 u/l) (table 2). further analysis showed that majority of patients elevated amylase level (85.4% ), lipase level (97.9%), and tryglyceride level table 1 characteristic of acute pancreatitis patients age (years) gender male female total frequency (n) percentage (%) frequency (n) percentage (%) frequency (n) percentage (%) 1–10 1 5.3 1 3.4 2 4.2 11–20 0 0.0 3 10.3 3 6.2 21–30 4 21.1 3 10.3 7 14.6 31–40 2 10.5 4 13.8 6 12.5 41–50 3 15.8 2 6.9 5 10.4 51–60 6 31.6 12 41.4 18 37.5 61–70 0 0.0 4 13.8 4 8.3 71–80 3 15.8 0 0.0 3 6.2 total 19 100.0 29 100.0 48 100.0 table 2 levels of amylase, lipase and tg in acute pancreatitis patients median minimum maximum amylase 211.50 78.0 6978.0 lipase 268.40 20.7 6082.2 tg 167.00 47.0 370.0 gunalan govindarajan, nina tristina: correlation between levels of serum amylase, lipase and triglyceride in acute pancreatitis patients althea medical journal. 2015;2(1) 48 amj march, 2015 (60.4%)(table 3). however, serum amylase and lipase had no correlation with serum triglyceride (table 4). discussions acute pancreatitis is an inflammatory process of pancreas mainly caused by alcoholism in western countries, in which may be correlated with the results of some studies that showed that most of the patients are males.13 in our study, females are higher in number than males who are diagnosed with acute pancreatitis, however, with no statistically significant. this difference may be due to frequency of alcohol addiction among men in this country is not as severe as in western countries, which contributes to less male patients in this local setting. this disease also seems to be more common in patients above 40 years old. based on several studies conducted worldwide, this result is mainly due to the nature of etiology of acute pancreatitis. the common etiologic factor which is biliary tract diseases is more common in adults over 40 years old with high incidence in people in the age group of 51–60 years old.14 in this study, amylase and lipase level are increased in majority of patients. this result supports most of the studies conducted on acute pancreatitis. the high levels of serum amylase and lipase are caused by inflammation of pancreas and excessive exocytosis of pancreatic enzymes.10,15 acute pancreatitis is associated with high levels of serum triglycerides which is more than 1000mg/dl. this is mainly because high levels of triglycerides will tend to cause acute pancreatitis by two mechanisms. one of the mechanisms is by causing atherosclerosis in the blood vessels supplying the pancreas thus, leading to acute pancreatitis. the other mechanism is by increasing the activity of lipolytic lipase activity.5-8 based on the analysis of the data obtained in this study, there are no correlation among serum triglyceride with serum amylase and lipase because most of the patients have serum triglyceride level less than 400mg/dl. references 1. moore kl, dalley af, agur amr. clinically oriented anatomy. 6th ed. london: lippincott williams & wilkins; 2009. 2. hall je, guyton ac. guyton & hall physiology review. 11th ed. philadelphia: elsevier saunders; 2006. 3. kumar v, abbas ak, fausto n, aster j. robbins and cotran pathologic basis of disease, professional edition e-book. philadelphia: expert consult online: elsevier health sciences; 2009. 4. wang gj, gao cf, wei d, wang c, ding sq. acute pancreatitis: etiology and common pathogenesis. world j gastroenterol. 2009;15(12):1427–30. table 3 levels of amylase, lipase and tg in acute pancreatitis patients frequency (n) percentage (%) amylase normal 7 14.6 abnormal 41 85.4 lipase normal 1 2.1 abnormal 47 97.9 tg normal 19 39.6 abnormal 29 60.4 table 4 correlation between amylase and lipase toward tg amylase lipase tg r -0.149 0.173 p 0.312 0.241 n 48 48 althea medical journal. 2015;2(1) 49 5. tonsi af, bacchion m, crippa s, malleo g, bassi c. acute pancreatitis at the beginning of the 21st century: the state of the art. world j gastroenterol. 2009;15(24):2945–59. 6. pandol sj, saluja ak, imrie cw, banks pa. acute pancreatitis: bench to the bedside. gastroenterol. 2007;132(3):1127–51. 7. yadav d, pitchumoni cs. issues in hyperlipidemic pancreatitis. j clin gastroenterol. 2003;36(1):54–62. 8. ewald n, hardt pd, kloer h-u. severe hypertriglyceridemia and pancreatitis: presentation and management. curr opin lipidol. 2009;20(6):497–504. 9. gan si, edwards al, symonds cj, beck pl. hypertriglyceridemia-induced pancreatitis: a case-based review. world j gastroenterol. 2006;12(44):7197–202. 10. matull wr, pereira sp, o’donohue jw. biochemical markers of acute pancreatitis. j clin pathol. 2006;59(4):340–4. 11. kwon rs, brugge wr. new advances in pancreatic imaging. curr opin gastroenterol. 2005;21(5):561–7. 12. whitcomb dc. acute pancreatitis.n engl j med. 2006;354(20):2142–50. 13. satoh k, shimosegawa t, masamune a, hirota m, kikuta k, kihara y, et al. nationwide epidemiological survey of acute pancreatitis in japan. pancreas. 2011;40(4):503–7. 14. shen h-n, lu c-l, li c-y. epidemiology of first-attack acute pancreatitis in taiwan from 2000 through 2009: a nationwide population-based study. pancreas. 2012;41(5):696–702. 15. mcpherson ra, pincus mr, henry jb. henry’s clinical diagnosis and management by laboratory methods. 21st ed. philadelphia: saunders elsevier; 2007. gunalan govindarajan, nina tristina: correlation between levels of serum amylase, lipase and triglyceride in acute pancreatitis patients althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 253 intention for hepatitis b vaccination among male-to-female transgenders in bandung ain izzati khiruddin,1 irvan afriandi,2 laili aznur,3 elsa pudji setiawati2 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran, 3department of dental health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hepatitis b is still an alarming global disease nowadays. the majority of transmission is by sexual activity during adulthood and male-to-female transgender is a high risk group. despite protective vaccine is available, vaccination coverage among these high risk groups remained low. this study aimed to compare the differences in attitude, subjective norms, and perceived behavioral control between the intended group and unintended group for hepatitis b vaccination among male-to-female transgenders in bandung. methods: a cross-sectional study was conducted during september–november 2012 to 100 male-to-female transgenders residing in bandung. thirteen likert scales validated questionnaires were used to compare the attitude, subjective norms and perceived behavioral control by their intention of hepatitis b vaccination (theory of plan behavior/tpb). the respondents were recruited by the help of srikandi pasundan, that actively works in the issues of transgender. the inclusion criterias were they regard themselves as waria, consistent as a transgender for at least six months, residing in bandung, and sexually active within six months. independent variables consist of demographic characteristics and tpb construct variables. mann whitney test was used to analyze the data. results: among 75% of the unvaccinated respondents, majority (70.7%) have the intention to get hepatitis b vaccination. mann whitney analysis showed that there is a difference of attitude between the intended group and unintended group for hepatitis b vaccination, while there are no differences by their intention for subjective norms and perceived behavioral control. conclusion: the attitude influenced vaccination intention among male-to-female transgenders in bandung. [amj.2015;2(1):253–61] keywords: hepatitis b, male-to-female transgenders, theory of planned behavior, vaccination correspondence: ain izzati khiruddin, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6283821640179 email: ain_izzati184@yahoo.com introduction hepatitis b is still an alarming global disease nowadays. as the most serious viral hepatitis infection, hepatitis b becomes a crucial problem and hepatitis b virus (hbv) is now become a common threat in many areas around the world, especially in asian and african countries. hepatitis b virus causes more than 350 million people to have chronic liver infections.1 meanwhile, in indonesia, hepatitis b cases has been fluctuating nationally in the past few years and indonesia has been categorized as a high endemic country for chronic hepatitis b infection.2 hepatitis b virus or abbreviated as hbv can be transmitted by percutaneous or parenteral contact with blood or vaginal fluids and semen of infected people. even though they can be transmitted with the same manner as human immunodeficiency virus (hiv), but hbv is 50100 times more infectious compared to hiv.3 the center for disease control and prevention (cdc) stated that the primary risk factors associated with hepatitis b infection are birth to an infected mother, unprotected sex with an infected partner and having multiple sex partners, men who have sex with men (msm), history of other sexually transmitted disease as well as illegal injection drug use.4 nowadays, transmission by sexual activity is the majority during young adulthood. sex workers who have multiple sex partners, people with human immunodefieciency virus althea medical journal. 2015;2(2) 254 amj june, 2015 (hiv), and men who have sex with men are at the greater risk.5 there is a significant risk of transmission among the male-to-female transgenders and most of them do not have any specific form of sexual orientation and transgender people may identify as heterosexual, homosexual, or bisexual. there are several reasons why the male-to-female transgenders are high risk to be infected. stigma and discrimination, exploitation, and limited access to health facilities are some of the reasons why their population is at stake. due to discrimination, male-to-female transgender people are prone to work in informal sector like in hair salon, entertainment sector, and as sex workers. they also always move from one location to another, making them easier to transmit and get transmitted by sexually transmitted infections besides having multiple sex partners.6 according to the world health organization (who), hepatitis b is asexually transmitted infection that has a protective vaccine and the first vaccine against major human cancer available. so, vaccination becomes one of the most effective preventive measurements since 1982 in order to prevent the infection as well as its chronic consequences.3 although vaccine programs have been successfully lead to subsequent decline in the incidence of hepatitis b, vaccination coverage for high-risk adult groups like having multiple sex partner in the past six months and msm remains low. the cdc claimed that majority of new infections occur in the high-risk groups.4 relevant approaches for identifying the determinant factors that facilitate or inhibit hepatitis vaccination decision making in this population are important. the theory of planned behavior (tpb), as initially proposed by ajzen (1984), assumes that there is an important determinant of behavior which is behavioral intention. according to tpb, attitude, subjective norms, and perceive behavioral control are the factors that can influence someone’s intention.7 attitude is a personal evaluation toward an action, subjective norms is how people try to act or behave in a way that gets key people (sexual partner or friends) approval and perceived behavioral control is a belief that one has the power to perform an action.8 by understanding the factors related to intention of male-to-female transgenders to get hepatitis b vaccination, it can be known how to approach them in order to make them all covered by the vaccines. theory of planned behavior (tpb) is used widely to evaluate the factors that influence the intention especially the intention to take vaccination in order to improve the immunization coverage.9 so far in indonesia, especially in bandung, there is limited information that reveals the intention for hepatitis b vaccination with the implementation of tpb for male-to-female transgenders who are at the greater risk of transmitting the disease. despite of high fatality rate, there are other benefits by doing this study, i.e. avoid adverse economic burden, personal as well as social impact.5 therefore, this study aimed to estimate the percentage of male-to-female transgenders who intend to get hepatitis b vaccination and to compare the differences of attitude, subjective norms, and perceived behavioral control between the intended group and unintended group for hepatitis b vaccination among maleto-female transgenders in bandung. this study is expected to provide a basis for viral hepatitis b prevention and control programs among these populations methods this study was an observational crosssectional study conducted in bandung between september and november 2012. the population of the study was male-to-female transgenders residing in bandung. sample size for this study was calculated as minimum of 97 participants. sampling technique used was snowball sampling and the respondents were recruited by the help of a non-government organization (ngo) that actively works in the issues of transgenders, namely srikandi pasudan. the respondents were included if (i) they regard themselves as waria (indonesian term for male-to-female transgender), (ii) being a consistent transgender for at least six months based on self disclosure, (iii) residing in bandung, and (iv) sexually active within six months based on self disclosure. the male-tofemale transgenders who denied to participate due to various reasons were excluded from the study. the dependent variable for this study was the intention to get hepatitis b vaccination and was measured by asking ‘do you have the intention to get hepatitis b vaccine?’ the response was recorded as a yes or no. independent variables consist of demographic characteristics and tpb construct variables. demographic characteristics include age, highest education level, living area, sexual orientation (attracted to male, attracted to althea medical journal. 2015;2(2) 255 table 1 characteristics of study subjects characteristics male-to-female transgender (n=100) f % highest education level pre school 10 10.0 primary school 47 47.0 secondary school 42 42.0 living area municipal 95 95.0 district 5 5.0 ethnicity sunda 73 73.0 jawa 17 17.0 batak 9 9.0 others 1 1.0 occupation salon 43 43.0 sex worker 22 22.0 self employed 10 10.0 unemployed 17 17.0 busker 8 8.0 sexual attraction men only 99 99.0 men and women 1 1.0 female, both). the tpb constructs included attitude, subjective norms, and perceived behavioral control. all factors related to tpb constructs were measured by 13 agreement statements based on four-point likert scales ranging from 1 (strongly disagree) to 4 (strongly agree). attitude and subjective norms variables were assessed through five statements each, while perceived behavioral control variable was measured by three statements. the content validity of questionnaire was examined by the expert whereas its face validity was assessed by the transgender ngo activist. results of reliability test showed that the cronbach’s alphas of attitude, subjective norms and perceived behavioral controls subscales altogether were 0.72. all data were collected through a self-administered questionnaire. after getting the permission from the local authority, letters of consent were given to all selected participants and information regarding the study was explained in detail. the questionnaires were distributed after the participants were fully informed about the survey and have signed the letter of consent. after completing the questionnaire, the researcher checked its completeness. incomplete data were returned to the respondents to be completed. all data collected were entered and analyzed using computer. univariate analysis by descriptive statistics was used to describe the distributions of background and components of tpb outcome variables among study respondents in the forms of frequency distribution and percentage. bivariate analyses were used to assess the difference between components of tpb (attitude toward behavior, subjective norm, and perceived behavioral control) and the outcome variable, which is the intention of getting hepatitis b vaccination among the male-to-female transgenders in bandung. ain izzati khiruddin, irvan afriandi, laili aznur, elsa pudji setiawati: intention for hepatitis b vaccination among male-to-female transgenders in bandung althea medical journal. 2015;2(2) 256 amj june, 2015 since the data were not normally distributed, mann-whitney test was used to compare the median scores for likert items measuring tpb components across respondents by intention to take hepatitis b vaccination. confounding factors that are being considered were age and highest educational level. several interview sessions to a few selected informants were conducted after the quantitative dataset was analyzed for triangulation. the ethical clearance for this study was issued by the health research ethic committee, faculty of medicine, universitas padjadjaran. (no 319/un6.c2.1.2/kepk/2012) dated on 28 november 2012. results one hundred respondents participated in this study. age for male-to-female transgenders in bandung was quite varied, the age ranged from 20 to 58 years old. mean age for the respondent was 31 (standard deviation=9.56). based on the highest education level, the number of male-to-female transgenders whose education is primary school and secondary school are comparable. almost all respondents were living in bandung municipal area and were sundanese. more than forty percents of the respondents worked at beauty salon, while the rest worked as sex workers and self-employed. almost all male-to-female transgenders were attracted to men out of one hundred respondents, only 25% were already vaccinated against hepatitis b and the rest remained unvaccinated. from 75 respondents who had not get the vaccination, when asked ‘do you have the intention to get hepatitis b vaccination’, only 22 male-to-female transgenders (29.3%) did not demonstrate a clear intention to get vaccinated against hepatitis b by giving the answer ‘no’. those are shown in detail in the next figure. those who had already been vaccinated against hepatitis b were excluded for further analysis. mean age for group of respondents with hepatitis b vaccination status ‘no” was slightly younger 30 (standard deviation=9.16). their age ranged from 20 to 58 years old. besides age, other demographic characteristics for those who had not yet vaccinated are presented in the table 2. table 3 shows the complete results according to each statement regarding tpb determinant construct which are attitude, subjective norms, and perceived behavioral control. the evaluations towards hepatitis b vaccination among male-to-female transgenders are illustrated in percentage in the next table. figure 1 participation of study subjects althea medical journal. 2015;2(2) 257 bivariate analysis illustrated the result of nonparametric test, mann-whitney test towards the components of tpb with the intention of hepatitis b vaccination are shown in the table 4 in testing the predictive utility of theory of planned behavior as the framework for understanding vaccination motivating and inhibiting factors. the result implied that attitude exert a stronger influence over this decision making process than their subjective norms or perceived behavioral control. tables 4 describes the result in more details. two characteristics variables were concerned to be potential confounding factors; those were age (median 30 years) as well as highest education level. after conducting stratified analysis of attitude on those two potential confounding factors, the result showed that the level of education was proven as a confounding factor. discussions attitude among the male-to-female transgenders in bandung were assessed by using five questions. table 3 shows the complete result and illustration about attitude of male-to-female transgenders towards hepatitis b vaccination. majority of the respondents believe that they are at risk of getting hepatitis b infection in which (70.7%) agree and strongly agree (1.3%). nearly 90% agree that vaccination can protect them from getting the infection. according to a study informant (35 years old, ngo srikandi pasundan), most of the maleto-female transgenders felt they are at risk because they kow that injecting drug users are high risk to get hepatitis b and some of their sexual partners and friends are injecting drug table 2 demographic characteristics for those who have not yet vaccinated characteristics male-to-female transgender (n=75) f % highest education level pre school 5 6.7 primary school 39 52.0 secondary school 30 40.0 living area municipal 72 96.0 district 3 4.0 ethnicity sunda 53 70.7 jawa 15 20.7 batak 6 8.0 others 1 1.3 sexual attraction men only 74 98.7 men and women 1 1.3 occupation salon 31 41.3 sex worker 17 22.7 self employed 10 13.3 unemployed 13 17.3 busker 4 5.3 ain izzati khiruddin, irvan afriandi, laili aznur, elsa pudji setiawati: intention for hepatitis b vaccination among male-to-female transgenders in bandung althea medical journal. 2015;2(2) 258 amj june, 2015 users. unfortunately, the study informant (35 years old, ngo srikandi pasundan), claimed that most of the male-to-female transgenders still do not realize that men who have sex with men and having multiple sex partner increase the chance of getting hepatitis b infection and the mode of transmission of the disease was still poorly understood. nearly all of the respondents (92%) agreed that by vaccination they can protect their sexual partner/s against hepatitis b infection. however, more than half of the respondents (62.7%) believe that hepatitis b vaccination causes unpleasant side effects. this wrong perception was also discussed by jay a. jacob in his article that beliefs about safety of the vaccine, beliefs that coincidental symptoms they experienced after the vaccination were caused by it as well as perceive risks and consequences of contracting the disease after vaccination are powerful determinants for vaccination among adults.10 even when more than half of the male-to-female transgenders (64%) disagree that they do not need the vaccination, the rests of them still think that they do not need vaccination. the misperceptions and ignorance about vaccinepreventable disease and vaccine itself may reduce the desire for vaccination and denial to their use.10 the study informant (35 years old, ngo srikandi pasundan) said that because hepatitis b is not as famous as other sexually transmitted disease and takes a quite long time to show the effects, they tend to ignore the disease. meanwhile, subjective norms were table 3 percentages of respondents according to the statements based on tpb components statements (n=75) sd d a sa % % % % attitude 1 i believed i am at risk of getting hepatitis b 0.0 28.0 70.7 1.3 2 i believed by vaccination i can protect myself against hepatitis b infection 0.0 10.7 77.3 12.0 3 i believed by vaccination i can protect my sexual partner from hepatitis b infection 0.0 8.0 76.0 16.0 4 i am afraid hepatitis b vaccination will cause unpleasant side effects 0.0 37.3 57.3 5.3 5 i don’t need hepatitis b vaccination 1.3 62.7 34.7 1.3 subjective norms 6 my sexual partner thinks it is important for me to take hepatitis b vaccination 2.7 21.3 68.0 8.0 7 hepatitis b vaccination is not a common thing among male-to-female transgenders 0.0 34.7 53.3 12.0 8 the costs for hepatitis b vaccination is unaffordable for male-to-female transgenders 0.0 9.3 80.0 10.7 9 the schedule for hepatitis b vaccination is a hassle for a male-to-female transgender like me 1.3 16.0 70.7 12.0 10 i am motivated to take hepatitis b vaccination if other male-to-female transgender took the vaccination 0.0 20.0 70.7 9.3 perceived behavioral control 11 no one can arrange my decision to get hepatitis b vaccination 2.7 33.3 57.3 6.7 12 i have control over whether or not i get the hepatitis b vaccination 0.0 24.0 69.3 14.7 13 i need a visit from health care workers to vaccinate me against hepatitis b 0.0 14.7 70.7 14.7 note: sd= strongly disagree, d= disagree, a= agree, sa= strongly agree althea medical journal. 2015;2(2) 259 determined by wishes or perceived pressure by the important people or surrounding. five questions regarding subjective norms were answered and the results are listed in table 1.3 and 76% agree their sexual partners thought it is important for them to get hepatitis b vaccination.10 the study informant (35 years old, ngo srikandi pasundan) claimed that sexual clients or their partners usually encourage them to do positive actions especially when it is related with health. social support as well as relationship could have a significant effects on health and research supported the idea that cohesive communities often experience a better health outcome.11 a large number of respondents (65.3%) thought that hepatitis b vaccination is not a common thing among male-to-female transgenders. this situation might be due to lack of exposure or recommendations for vaccine and less peer dialogue about the hepatitis b vaccination, leading to a consideration that it is an to unusual phenomena if someone among the group has the vaccination.10 from the study informant’s (35 years old, ngo srikandi pasundan) point of view, most of male-to-female transgenders tend to ignore hepatitis b because the organ affected is liver and not as visible as the genital. however, if most of their male-to-female transgender friends have already been vaccinated and gained benefits from it they usually want to be vaccinated too. this is relevant to the statement that transgenders are motivated to take hepatitis b vaccination if other male-tofemale transgenders took the vaccination and nearly 80% of them agree with the statement. regarding the cost for vaccination, almost all respondents (90.7%) thought that the cost were unaffordable for them. according to lisa curran12 in her article, vaccine cost could be one of the contributing factors to the low coverage of vaccination among adults. the study informant (35 years old, ngo srikandi pasundan) said that it is true that money is the main concern for maleto-female transgenders but the reason why 9.3% disagree was if they were convinced that the vaccine was really important for them, they would took it no matter how much it cost. since male-to-female transgenders are highly mobile and living in an erratic work time schedule, majority of the respondents (82.7%) thought the schedule for hepatitis b vaccination is a hassle for a male-to-female transgender like them since they need to get three doses at certain period of time. for measuring perceived behavioral control, using three questions were used and each of the questions were built to see the self evident and reflected the belief that one has the power to perform the behavior and the result is illustrated in table 3. more than half of the respondents (64%) thought no one can tell them about their decision whether they want to get hepatitis b vaccination and more than two third of the respondents (76.4%) felt that they have control over whether or not they get the hepatitis b vaccination. however, 85.4% of the male-to-female transgenders need a visit from health care workers to vaccinate them against hepatitis b. according to the study informant (35 years old, ngo srikandi pasundan), it will be more effective if the vaccination was done to a group of male-to-female transgenders rather than they have to search for vaccination service individually. a study in ghent belgium13 shows that an outreach program performed to improve hepatitis b vaccination among sex workers results in 82.8% of t eligible sex workers started with a first vaccine dose and 71.5% received the second dose. this study has demonstrated that there are significant differences in attitude between the intended group and unintended group to vaccinate against hepatitis b. they really believed they are at risk of getting hepatitis b and they know that there is a vaccine that can protect them and their sexual partner against the disease. they are also aware that they need the vaccine but there is still a high number of respondents who are afraid that hepatitis b vaccination will cause unpleasant side effects. similar to a study conducted in illinois, when applying the tpb, between all of the variables only attitudes exhibiting the strongest relationship, it is concluded that positive attitude was a major predictor for a better outcome14. however, the differences in attitudes are influenced by educational level. furthermore, subjective norms and perceived behavioral control have no significant difference between the intended group and unintended group to get hepatitis b vaccination. even though approval of key people like their male-to-female transgender friends play a major role in motivating them to take the vaccination but it is not enough to show a significant difference in subjective norms by the intention to get the vaccination. reasons presented by the study informant (35 years old, ngo srikandi pasundan) regarding negative differences of subjective norms and perceived behavioral control are male-tofemale transgenders are inconsistent and ain izzati khiruddin, irvan afriandi, laili aznur, elsa pudji setiawati: intention for hepatitis b vaccination among male-to-female transgenders in bandung althea medical journal. 2015;2(2) 260 amj june, 2015 usually depends and follow their guardian or their “mummy”. approval from their guardian plays a major role in their decision making and is not included in the study. a study performed to predict intention for human papilloma virus (hpv) vaccination also reported that levels of perceived behavioral control have no effects on the intention while attitudes arethe strongest factor of the intention.15 the central questions of this study concerned with what factors inhibiting and facilitating intention of hepatitis b vaccination among male-to-female transgenders in bandung. although the result showed only attitudes show a significant different between theory driven measures of tpb and the intention to get hepatitis b vaccination among sample of male-to-female transgenders in bandung but from the questions, it could be dig out what influence the reluctance of maleto-female transgenders from getting hepatitis b vaccination. this indicates that tpb does provide a useful theory driven framework for understanding the determinants when maleto-female transgenders deciding to vaccinate against hepatitis b. judging from the fairly high rates of intention to get hepatitis b vaccination among male-to-female transgenders in bandung, social affairs and health offices should work together to create an integrated extension outreach program for vaccination along with routine check up for sexually transmitted disease for this high risk group. education highlighting how to change the attitude that acts as major predictor for better outcome should be given. routine counselling on hepatitis b and other sexually transmitted diseases to the male-to-female transgenders with the cooperation between public health authorities and ngos (such as srikandi pasundan) should be carried out during their routine meeting every monday morning in order to increase understanding about the disease. coordination can be done by the committee of srikandi pasundan. education in the form of videos and songs are more effective compared to brochure and pamphlet, according to the study informant (35 years old, ngo srikandi pasundan). further studies should investigate whether interventions targeting the attitudes towards hepatitis b vaccination impact maleto-female transgenders’ intention to receive a hepatitis b vaccination and hepatitis b vaccination uptake action. the study has some limitations such as questionnaire data is inevitably subjected to some error and response bias because it relies heavily on accurate self-reporting though care was taken to ensure anonymous data collection and thus encourage accurate questionnaire responses. references 1. cdc. world hepatitis day–july 28th. washington: center for disease control and prevention; 2011. [cited 2012 april 18]. available from: http://www.cdc.gov/ feature/dshepatitisawareness/ 2. depkes. profil kesehatan indonesia. jakarta: departemen kesehatan indonesia; 2007. 3. who. hepatitis b. geneva: world health organization; 2008. [cited 2012 april 17]. available from: http://www.who.int/ mediacentre/factsheets/fs204/en/ 4. cdc. hepatitis b information for health professionals. atlanta: center for disease control and prevention; 2012. [cited 2013 february 7]. available from: http:/www. cdc.gov/hepatitis/hbv 5. australian government department of health and ageing. national hepatitis b strategy 2010–2013. 2010 [cited 2012 april 21]. available from: http://www. health.gov.au/internet/main/publishing. nsf/content/ohp-national-strategies2010-hepb 6. wahyuddin. faktor-faktor yang memengaruhi keputusan waria melakukan tes hiv/aids pasca konseling hiv/aids di klinik ims dan vct veteran medan [dissertation]. medan: universitas sumatera utara; 2010. 7. ajzen i. behavioral interventions based on the theory of planned behavior. 2006 [cited 2012 april 17]. available from: http://people.umass.edu/aizen 8. rimer b, glanz k. theory at glance 2005. 2nd ed. u.s. department of health and human services national institutes of health; 2005. 9. gallagher s, povey r. determinants of older adults’ intentions to vaccinate against influenza: a theoretical application. j public health (oxf ). 2006;28(2):139–44 10. jacobson ja. residents’ role in immunizing adults: rationale, opportunity, obstacles, and strategies. virtual mentor. 2012;1(14):23–9. 11. story cr. influenza immunization status among african americans: factors influencing vaccine decisions [dissertation].knoxville: university of althea medical journal. 2015;2(2) 261 tennessee; 2012. 12. aafp. vaccination coverage in adults remains low, says cdc. american family physicians; 2012 [cited 17 april 2012]. available from: http://www.aafp.org. 13. mak r, traen a, claeyssens m, van renterghem l, leroux-roels g, vandamme p. hepatitis b vaccination for sex workers: do outreach programmes perform better?. sex transm infect. 2003 apr;79(2):157–9. 14. rah jh, hasler cm, painter je, chapmannovakofski km. applying the theory of planned behavior to women’s behavioral attitudes on and consumption of soy products. j nutr educ behav. 2004;36(5):238–44. 15. askelson nm, campo s, lowe jb, smith s, dennis lk, andsager j. using the theory of planned behavior to predict mother’s intention to vaccinate their daughters against hpv. j sch nurs. 2010;26(3):194– 202 ain izzati khiruddin, irvan afriandi, laili aznur, elsa pudji setiawati: intention for hepatitis b vaccination among male-to-female transgenders in bandung althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 22 amj march 2016 durian consumption effect on plasma malondialdehyde level as biomarker of stress oxidative in rats anugrah aulia ulil amri1, ani melani maskoen2, syarief hidayat3 1faculty of medicine universitas padjadjaran, 2department of biochemistry and molecular biology, faculty of medicine universitas padjadjaran, 3department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: excessive consumption of durian (durio zibethinus murray) in indonesia is often connected with its effect on health. this study aims to understand the effect of durian consumption to malondialdehyde (mda) in plasma as oxidative stress biomarker. methods: the study used an experimental research design on animal models, in the biochemistry and molecular biology department, faculty of medicine, universitas indonesia, july–august 2012. thirty two sprague-dawley rats were used, divided into four groups: control, treatment week 1, 2, and 3. each treatment group was given 20 gram durian fruit diluted with water until 20 ml volume per oral, divided into two doses (10 ml each) with 4 hours interlude between doses for 1 week, 2 weeks, and 3 weeks. all groups got normal diet and water ad libitum. plasma mda level was measured by tbars method, then analyzed using kurskalwallis and mann-whitney tests. results: seventeen samples were successfully decapitated (5 for control; 6 for week 1; 3 for week 2; 3 for week 3). average plasma mda level for control treatment week 1, 2 and 3 groups were 0.707 nmol/ml, 0.432 nmol/ml, 0.312 nmol/ml, and 0.746 nmol/ml respectively. data was significant (p<0.05) with p=0.02. compared with control group, a significant increase occurred in week 1 and 2 groups with p=0.028 and p=0.025 respectively. conclusions: results of durian consumption show mda level significantly decreases in week 1 and 2. however, mda level dramatically increases exceeding control group level in week 3. [amj.2016;3(1):22–8] keywords: durian, malondialdehyde, oxidative stress correspondence: anugrah aulia ulil amri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282111838844 email: anugrahaulia@aim.com introduction durian is a fruit unique in indonesia and other countries in southeast asia. with its unique taste and strong penetrating odor, durian is widely known and consumed in the society. however, there are rumours saying that the durian has an effect on health. people believe that the consumption of an inappropriate amount of durian may cause miscarriage in pregnant women, increase the cholesterol level and increase blood pressure or hypertension. in contrast, currently the durian fruit is popular in daily utilization because of its health promoting compounds. the importance of durian is mostly connected with its composition of antioxidant properties, flavanoid, flavanol, ascorbic acid and tannin.1-6 antioxidant is an important compound found in both human and nature which act as scavengers of free radicals and reduce the oxygen toxicity. the imbalance between antioxidant and the reactive oxygen species (ros) may result in oxidative stress. the ros are free radicals and peroxides that are derived from the oxygen metabolism and present in all aerobic organisms. these include superoxide radical (o2•-), peroxyl radical (hoo•), hydroxyl radical (oh•) and hydrogen peroxyde (h2o2). the ros play a significant role in many biological processes. the oxidative stress may affect molecules thus causing cell injuries which may lead to pathological processes in human.7 there are plenty methods of ros which can cause oxidative stress in cells. one of which is by attacking the membrane cells which have phospholipid bilayer properties. a lipid peroxidation reaction will then occur once the ros attack the polyunsaturated fatty acid (pufa) in the phospholipid bilayer of membrane cells causing a series of chain reaction. the althea medical journal. 2016;3(1) 23 reactions form plenty of radicals including alkyl radical, peroxyl and alkoxyil. as the more stable product, lipid peroxidation produces many aldehydes including saturated aldehydes (propanal, butanal, hexanal, octanal, decanal), 2,3-trans-unsaturated-aldehydes (hexenal, octenal, nonenal, decenal and undecenal), and a series of 4-hydroxylated,2,3-transunsaturated aldehydes (4-hydroxyundecenal, and 4-hydroxinonenal (hne)). among the metabolites produced, malonyldialdehyde (mda) was considered for a long time as the most important lipid peroxidation metabolite.8 the products of lipid peroxidation can be used as biomarkers of stress oxidative (figure 1).9 the purpose of this experiment was to measure the oxidative stress caused by the durian compounds antioxidant properties by studying rats which were fed with excessive amount of durian and observed the effect of anugrah aulia ulil amri, ani melani maskoen, syarief hidayat: durian consumption effect on plasma malondialdehyde level as biomarker of stress oxidative in rats figure 1 theoretical framework althea medical journal. 2016;3(1) 24 amj march 2016 the treatment on plasma mda level. methods an experimental research design was conducted on animal models. the experiment waserformed in rats to investigate the effect of durian consumption on blood ros level detected as plasma mda level. this study was conducted r five weeks starting from july 2012 to august 2012. the data were collected based on the results of the experiment. the study took place in the faculty of medicine universitas indonesia, jakarta, indonesia. the rats were divided into four different groups i.e. the control group for rats that did not consume durian; the group of week 1 for rats that consumed durian for 1 week, the group of week 2 for rats that consumed durian for 2 weeks, and the group of week 3 for rats that consumed durian for 3 weeks. in order to obtain maximum validity, the experiment should be repeated several times. while to estimate the number of observations for each variable the federer’s formula was used and resulted in 24 samples (figure 2). furthermore, the rats used in the experiment weighted between 100 and 200 gram. the rats were male young adult aged 7 week-old before adaptation with the type of sprague dawley rats. the rats were bought in bogor, jawa barat, indonesia, while the durian fruit used in the experiment was purchased from a local market in pramuka street, jakarta. all rats received a normal diet and ad libitum daily. group of week 1, week 2, and week 3 were also given 20 mg of durian that has been diluted to 20 ml of volume with distilled water. then, it given twice daily with each of 10 ml dilution and manually using a gastric tube. all methods were already approved by the health research ethics comittee. at the end of each observation period, every survived rat was sacrificed under deep ether anesthesia. next, the blood of each rat was collected directly by heart puncture and put in a heparinized tube. the plasma figure 2 federer’s formula note: n= minimum number of repetition needed for each treatment, minimum repetition for this study is 6 x 4(treatments)= 24 samples, in the samples, it was added 10% for drop out criteria 24 + (10% x 24) = 27 rats was obtained after separating the red blood cells by centrifugation at 3000 rpm for 15 minutes. all plasma were placed in -20oc until the mda measurement. the plasma mda was assayed using the thiobarbituric acid reactive substances (tbars) assay.10 the assay measures 2-tbars which were naturally present in tissues and reported in mda equivalents. the tbars assay were based on the reaction of a chromogenic reagent, 2-thiobarbituric acid, with mda at 25°c and ph 2-3.this reaction showed a pink-chromogen color which has a λ(max) of 532 nm that was able to be counted by the spectrophotometry. the plasma mda level was analyzed using a computerized analysis of the kurskall-wallis non-parametrical test and post-hoc analysis of mann-whitney test. results the study was initially conducted using 32 rats, and out of them, 15 rats were omitted and only 17 rats were successfully decapitated (table 1 and 2). in order to establish the mda concentration table 1 number of samples and the percentage sample group initial number final number percentage control 5 5 100% week 1 9 6 67% week 2 9 3 33% week 3 9 3 33% total 32 17 53.1% althea medical journal. 2016;3(1) 25 figure 3 mda standard curve table 2 body weight of rats group sample group initial body weight (gram) final body weight (gram) control 163.3 188 week 1 141 131.7 week 2 150 143.3 week 3 195 215 average 162.3 169.5 based on the absorption rate of sample plasma, the function of mda standard curve is needed (figure 3). the plasma mda level of rats established from the standard curve formula which was compared afterwards (table 3 and 4). generally, the average of mda concentration data is significant according to the kurskalwallis non-parametrical test. the p value was less than 0.05 (p=0.02). compared to the control group, the mda concentration is decrease in the 1 week treatment group. this data was significant according to the post-hoc test using the mann-whitney test with p=0.028. similarly, the 2 week treatment group was also showed significantly decrease compared to the control group with p=0.025. moreover, the week 3 treatment group was rather increase compared to the control group (p=0.655). discussion malondialdhyde (ch2(cho)2) is a routinely identified product of lipid peroxide chain reaction. lipid peroxidation occurs in both plants and animals. it involves a complex process, mainly described as initiation, propagation and termination, targeting methylene (rh) bridge in pufa. the double bond has a weak c-h bond which will make the hydrogen abstraction more susceptible in this condition.8 after the hydrogen abstraction, the carbon will have unpaired electron which will combine with oxygen to form a peroxyl radical (rooh). the peroxyl radical is capable of abstracting a hydrogen atom from adjacent anugrah aulia ulil amri, ani melani maskoen, syarief hidayat: durian consumption effect on plasma malondialdehyde level as biomarker of stress oxidative in rats althea medical journal. 2016;3(1) 26 amj march 2016 polyunsaturated fatty acid by itself therefore, starting a chain reaction which will damage the membrane thus, causing more extensive damage to the adjacent cells. along the process a plenty of ros were formed. in normal circumstances, the ros need to be quenched by antioxidant in order to prevent extensive damage. to date, the durian is majorly linked with its antioxidant properties including flavonoid, flavonol, ascorbic acid and tannin.1–6 the durian consumption on rats was significantly correlated with the plasma mda level. in the rat experiment the plasma mda levels of rats decreased in the week 1 and week 2 treatment groups compared to the control group. the decrease of the plasma mda level on the week 1 and week 2 treatment groups is probably related to the antioxidant compounds in durians as stated by many studies including the comparative study held by haruenkit r et al. the study asserted that durian nevertheless is a fruit that shows in vitro antioxidant activities and is the highest compared with the mangosteen and snake fruit.5 the antioxidant in durian might be able to decrease the level of damage from ros to the lipid, thus decreasing plasma mda level. on the contrary, after 3 weeks of durian consumption on the experimental rats, the plasma mda level was dramatically increased compared to the group of week 1 and week 2, and slightly exceeded the control group. although the data obtained was insignificant to control but clearly significant to week 2, the increase of plasma mda level on the week 3 treatment group was important. basically, the antioxidant is a compound that gives electron (electron donors). biologically, the antioxidant is widely known as the scavenger of oxidants and free radicals. the action of antioxidant does not only depend on the dose and the duration of administration but also on the type of the antioxidant itself as well as on the environment. for instance, vitamin e can only act as an antioxidant when the po2 is low. furthermore, the antioxidant also has a capacity of becoming pro-oxidant or radicals as occurred in vitamin e, vitamin c, and flavonoids.9 flavonoids which can be found in the durian including flavones, isoflavones, and flavanones acted as antioxidants against peroxyl and hydroxyl radicals and served as pro-oxidants in the presence of cu2+. both the antioxidant and the copper-initiated pro-oxidant activities of a flavonoid depend upon the number of hydroxyl substitutions in its backbone structure. the single hydroxyl substitution at position 5 provides no activity, whereas the table 3 plasma mda level of rats sample group n mda level (nmol/ml) p value* average mda level +sd control 5 0.707+0.203 0.02 week 1 6 0.432+0.179 week 2 3 0.312+0.101 week 3 3 0.746+0.225 note: * kruskal-wallis non-parametrical test table 4 comparison sample group mda level (nmol/ml) p value* concentration 1 +sb – concentration 2 +sb control – week 1 0.707+0.203 − 0,432+0.79 0.028 control – week 2 0.707+0.203 − 0.312+0.101 0.025 control – week 3 0.707+0.203 − 0.746+0.225 0.655 week 1 – week 2 0.432+0.179 − 0.312+0.101 0.197 week 1 – week 3 0.432+0.179 − 0.746+0.225 0.071 week 2 – week 3 0.312+0,101 − 0.746+0.225 0.050 note: * mann-whitney 2 independent samples althea medical journal. 2016;3(1) 27anugrah aulia ulil amri, ani melani maskoen, syarief hidayat: durian consumption effect on plasma malondialdehyde level as biomarker of stress oxidative in rats di-oh substitution at 3′ and 4′ is particularly important to the peroxyl radical absorbing activity of a flavonoid. the conjugation between rings a and b is an important pro-oxidant action of a flavonoid. the o-methylation of the hydroxyl substitutions inactivates the antioxidant and the pro-oxidant activities of the flavonoids.11,12 moreover, the antioxidant is also produced endogenously in rats’ body, such as the glutathione (gsh). in the same rats, the plasma gsh increased in the first and second week and fell dramatically in the third week compared to the control. the plasma gsh level increased in response to the durian consumption considering the amino acid compound of durian (including glycine, cysteine and glutamic acid) is essential to gsh synthesis. the decrease of the plasma gsh level was strongly related the use of gsh to reduce damage caused by the ros, meaning that pro-oxidant has been produced in the rats’ body. this experiment successfully decapitated 17 rats as samples. at the beginning of the study, the sprague-dawley rats bought were 7 weeks old (before adaptation). experimental rats usually have a lifespan as long as 2−3.5 years (average 3 years).13 in the experiment, rats died mostly during the period when the second dose has been administered to the first dose on the next day. other factors that should be considered in this error included the effects of durian supplementation to the rats such as the mechanical trauma, the age of the experimental rats and the operator’s skill. before the interventions began the rats were 8-week old, which was classified as young adult rats, and the average weight was 162.3 gram. according to the weight measurement, it could be predicted that the rats were young adults. considering this period, the spraguedawley rats have an average weight of 100−200 gram.13 therefore, doubts regarding the age of the rats could be at least cleared away. the operator’s skill is certainly affecting the experimental rats. the durian consumption was given with a conventional gastric tube in which the tube was directly inserted from the mouth of the rat through to the stomach. a mechanical trauma could arise following a repetitive injury of the stomach, including of the throat, liver and other related organs. besides, the durian aspiration could also cause a fatal damage. however, in this experiment the definite cause of the death was not observed. in conclusion, generally there are differences on the mda serum level of rats with durian consumption. the mda level on durian consumption for 1 week and 2 weeks have shown a significant decrease. however, after 3 weeks of durian consumption, the mda level has increased insignificantly. the data can be used as a prediction for the effect of durian consumption on health. the durian consumption is safe because it does not induce oxidative stress. however, continuous eating in excessive amount for a long period is still not recommended. this study has some limitations including the effect of durian consumption on different doses which remains unclear and the number of rats that died during the intervention period were too many and with unknown cause of death. in the future, to investigate the effect of durian consumption on experimental animals, some factors should be considered including observing the effect of durian consumption according to the dose, the initial training for the feeding operator before the intervention begin, and the use of a permanent feeding tube. references 1. avila ap, toledo f, park ys, jung st, kang sg, heo bg, et al. antioxidant properties of durian fruit as influenced by ripening. lwt-food sci tech. 2006;41(10):2118– 125. 2. leontowicz h, leontowicz m, haruenkit r, poovarodom s, jastrzebski z, drzewiecki j, et al. durian (durio zibethinus murr.) cultivars as nutritional supplementation to rat’s diets. food chem toxicol. 2008;46(2):581–89. 3. toledo f, avila ap, park ys, jung st, kang sg, heo bg, et al. screening of the antioxidant and nutritional properties, phenolic contents and proteins of five durian cultivars. int j food sci nut. 2008;59(5):415–27. 4. haruenkit r, poovardom s, vearasilp s, namiesnik j, sliwka-kaszynska m, park y, et al. comparison of bioactive compounds, antioxidant and antiproliferative activities of mon thong durian ripening. food chem. 2010;118(3):540–7. 5. haruenkit r, poovarodom s, leontowicz h, leontowicz m, sajewicz m, kowalska t, et al. comparative study of health properties and nutritional value of durian, mangosteen, and snake fruit: experiments in vitro and in vivo. j agric food chem. 2007;55(14):5842−9. 6. phutdhawong w, kaewkong s, althea medical journal. 2016;3(1) 28 amj march 2016 buddhasukh d. gc–ms analysis of fatty acids in thai durian aril. chiang mai j sci. 2005;32(2):169–72. 7. kumar v, abbas ak, fausto n, editors. robbins and cotran pathologic basis of disease, 8thed. philadelphia: elsevier inc; 2005. 8. repetto m, semprine j, boveris a. lipid peroxidation: chemical mechanism, biological implications and analytical determination. in: catala a, editor. lipid peroxidation. rijeka: intech; 2012. p. 1−21. 9. purnomo suryohudoyo. oksidan, antioksidan dan radikal bebas. in: ilmu kedokteran molekuler. kapita selekta. jakarta: sagung seto; 2000. p.31−46. 10. linsley md, ekinci fj, ortiz d, rogers e, shea tb. monitoring thiobarbituric acidreactive substances (tbars) as an assay for oxidative damage in neuronal cultures and central nervous system. j neurosci methods 2005;141(2):219−22 11. cao g, sofic s, prior rl. antioxidant and prooxidant behavior of flavonoids: structure-activity relationships. j free rad biol med 2014;22(5):749−60. 12. amid bt, mirhosseini h, kostadinović s. chemical composition and molecular structure of polysaccharide-protein biopolymer from durio zibethinus seed: extraction and purification process. chem cent j. 2012;6(1):117. 13. sengupta p. the laboratory rat: relating its age with human’s. int j prev med. 2013;4(6):624–6. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 546 amj december, 2015 anti-hyperglycemic effect of psidium guajava leaf infusion rizda nurul zartiana,1 samsudin surialaga,2 hikmat permana3 1faculty of medicine universitas padjadjaran, 2department of biochemistry and molecular biology faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: prevalence of diabetes mellitus is estimated to increase annually. numerous people use traditional medicine, such as the psidium guajava leaf to prevent this disease. this study aimed to analyse the effect of psidium guajava leaf to inhibit glucose absorption in intestine epithelial membrane of wistar rats. methods: this laboratory experimental study used 5 wistar rats as subjects in the laboratory of biochemistry at padjadjaran university from 10−26 october 2012. all rats were given three solutions by in situ perfusion method. the first was 25 ml 3.0 x 10-3 m glucose solution, the second was 25 ml 3.0 x 10-3 m glucose solution with 1 ml psidium guajava infusion added, and the third was 25 ml 3.0 x 10-3 m glucose solution. the sample from each solution was taken five times at 0, 15, 30, 45, and 60 minutes after the solutions were given. the spectrophotometer was to quantify the concentration of glucose from the samples. data were analyzed using friedman and wilcoxon test. results:the means of glucose concentration for each solution from the first solution to the third were 6.126 mg/dl, 2.447 mg/dl, and 5.345 mg/dl. the probability value showed significant difference between the first and second solutions (p ≤ 0.05). conclusions: psidium guajava leaf infusion can inhibit glucose absorption in wistar rat intestine and the effect is reversible. [amj.2015;2(4):546–9] keywords: glucose absorption, in situ perfusion, infusion, psidium guajava leaf correspondence: rizda nurul zartiana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 821 158 09 959 email: rizda.adiwinata@gmail.com introduction diabetes mellitus is a symptom resulting from impaired metabolism, accompanied by a condition with very high levels of glucose or commonly called hyperglycemia. this occurs due to the lack of hormone insulin; or the diminishing effectiveness of hormone insulin; or both. based on its etiology, diabetes mellitus was classified into four types: type 1 diabetes, type 2 diabetes, gestational diabetes, and other specific types.1 based on existing data, prevalence of diabetes mellitus worldwide was 2.8 % in 2000 and it was estimated to become 4.4 % in 2030. the number of people with diabetes mellitus is projected to rise from 171 billion in 2000 to 366 million in 2030. besides , there are 10 countries predicted to have the highest number of people with diabetes mellitus and the “top four” countries are india (79,4 million), followed by china (42,3 million), united states (30,3 million), and indonesia (21,3 million).2 one of the risk factors associated with diabetes is consuming food carbohydrates in excess. carbohydrates are easy to digest and absorbed, so it can increase thelevel of blood glucose faster.3 therefore, lots of people use herbs which have an effect to reduce blood glucose level. one of the herbs is guava or psidium guajava. a recent ethnopharmalogical study explained that the shaft, the fruit, and the leaves from psidium guajava had been used in many countries as treatment of diabetes mellitus.4 a previous study also showed that psidium guajava leaf extract can inhibit the activity of maltose, sucrose, and α-amylase enzyme, so it can lower level of blood glucose.5 this study aimed to analyse the effect of psidium guajava leaf to inhibit glucose absorption in intestine epithelial membrane of wistar rats. althea medical journal. 2015;2(4) 547 methods this study was conducted in the laboratory of biochemistry at padjadjaran university from 10−26 october 2012. psidium guajava leaves were obtained from the arboretum of sains faculty, universitas padjadjaran. the leaves were weighed 200 g. then chopped. two pots were required to make the infusion. next, water was added in the first pot and the second pot was put within. then, 200 ml distilled water was poured to the second pot, and the chopped leaves were put within and stewed for 15 minutes at a temperature of 900c. afterward, the infusion was filtered with a flannel fabric and poured into a measuring glass to make sure it was 100 ml infusion. this study used the complete randomized design for sampling method. the subjects of study are five healthy male wistar rats (2−3 months old) weighing 150−250 g. all rats were housed first in the laboratory environment for 7 days. then, the rats were made to fast for 18−24 hours however were still given access to water. the in situ perfusion tool was made by the sains faculty of institut teknologi bandung (itb) and designed by p. soedigdo and marsongkohadi. all the rats were totally anesthetized using 1.15 ml/100 mg body weight of ketamine hcl intramuscular then, fixation was performed on board. the ventral abdomen of rats was cleaned with 70% alcohol and abdominal surgery was performed with minor surgery set. the intestine of rats (small intestine) were measured 10 cm from pylorus, then add 25 cm long for used in experiment. an incision was made at both sides of the intestine, then a cannula was tied at each side. afterwards, the intestine was washed with nacl 0.9% and was blown using a syringe three times alternately while the cannulas were connected with an in situ perfusion tool. after everything was prepared, the was flown to be tested. there were three solutions to be tested in this experiment. the first solution was 25 ml of 3.0 x 10-3 m glucose solution. the second solution was 25 ml of 3.0 x 10-3 m glucose solution with 1 ml of psidium guajava infusion added. the third solution was 25 ml of 3.0 x 10-3 m glucose solution. the rats’ intestine were washed and blown again each time the solution was changed. the first samples were taken every 0, 15, 30, 45 and 60 minutes with a sixty minute duration of experiment . the samples to be measured were taken from the first samples as much as 50 µl. the samples were then added with trichloroacetic 8% for deproteinisation. next, the samples were centrifuged at 3000 rpm speed for 10 minutes. afterwards, about 100 µl supernatant were taken and added with 1 ml glucose reagent/ god-pap. then, the samples were incubated at 37oc for 10 minutes. finally, the samples were poured into a cuvet and measured at 505 nm absorbance using a spectrophotometer. the glucose level was quantified using the formula6 : sam. abs glu. con = x st. con st. abs note glu. con : glucose concentration (mg/dl) st. con : standard concentration (100 mg/dl) sam. abs: sample absorbance st. abs : standard absorbance results the absorption level of glucose (mg/dl) for all rats was presented in table 1. the means of the first and second solutions were calculated and compared to see if there was any effect of the second solution. there was quite a big difference between means of both solutions which might prove that the second solution could inhibit the glucose absorption process. thus, the level of glucose which was inhibited must be quantified, using the formula.6 table 1 absorption level of glucose (mg/dl) for each solution treatment absorption level of glucose (mg/dl) mean of absorption level of glucose (mg/dl) rat 1 rat 2 rat 3 rat 4 rat 5 1st solution (glucose) 8.728 5.984 9.009 3.789 3.119 6.126 2nd solution (glucose with infusion) 2.023 1.166 3.934 2.763 2.347 2.447 3rd solution (glucose) 5.954 6.736 6.847 3.842 3.344 5.345 rizda nurul zartiana, samsudin surialaga, hikmat permana: anti-hyperglycemic effect of psidium guajava leaf infusion glu. con = x st. con althea medical journal. 2015;2(4) 548 amj december, 2015 the level of glucose which was inhibited by the psidium guajava infusion was 60.056 % according to absorption level of the first solution. then, the first solution was compared to the third solution to find out if the effect was reversible or irreversible (figure 2). normality of the data were examined by using thesaphiro-wilk test. the result showed that the data were abnormally distributed (p < 0.05). furthermore, the transforming of data was performed however, the result of saphirowilk test was still abnormal. therefore, friedman and wilcoxon tests were carried out to analize the data statistically. the friedman test showed probability value was 0.022 (p<0.05), meaning at least two measurements were different significantly. then post-hoc wilcoxon test was performed and showed that the second solution, which contained psidium guajava infusion, had figure 1 comparison of means of absorption level of glucose between 1st and 2nd solution figure 2 comparison of means of absorption level of glucose between 1st and 3rd solution althea medical journal. 2015;2(4) 549 significant effect to inhibit glucose absorption compared with the first solution (p=0.043). on the other hand, the third solution has no differences with the first solution so that the effect of psidium guajava infusion was reversible. discussion the result of this study showed psidium guajava infusion was able to inhibit glucose absorption in wistar rats intestine. it can be associated with a previous study by deguchi and miyazaki5. the study used guava leaf extract or gvex as material for treatment. the rats were divided into control and treatment groups, then gave gvex per-oral to thetreatment group. at the end of the research, it was proved that gvex has anti-hyperglycemic effect. with a different method using streptozotocin-induce diabetic mice (type 1 diabetes mellitus), gvex is able to lower post prandial blood glucose level significantly. the same condition occurs in another study using human as subject.5, 7-9 the inhibitory effect that is produced by psidium guajava infusion derives from a group of phenolic hydroxil contained in the psidium guajava leaf. the phenolic hydroxil group is in the form of polyphenol such as peduncladgin, casuarinin, and isostrictin. in addition there are also polymerized polyphenol content consisting of ellagic acid, cyanidin, and others low molecular weight polyphenols.5,10 polyphenols are able to inhibit the enzyme α-amylase, maltase, and sucrose. those enzymes digest carbohydrates into a glucose form which will be absorbed through the intestines. by inhibiting this enzyme, no glucose or other monosaccharides are formed, so there is no absorption.5, 11 this study demonstrated that psidium guajava leaf infusion could also directly inhibit glucose absorption. psidium guajava not only inhibited the breakdown of carbohydrates into glucose but also inhibited the absorption of glucose itself. on the other hand, comparison between the first and second solution showed no significant difference for level of glucose absorption. this occurred because by washing the intestine using nacl 0.9% and blowing it could eliminate the inhibitory effect of polyphenol in psidium guajava infusion. it can be concluded that the effect of infusion is reversible. however, further study is needed to confirm this conclusion. references 1. gardner dg, shoback dm, greenspan fs. greenspan’s basic & clinical endocrinology. 8th ed. san francisco: mcgraw-hill medical; 2007. 2. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047−53. 3. willett w, manson j, liu s. glycemic index, glycemic load, and risk of type 2 diabetes. am j clin nutr. 2002;76(1):274s−80s. 4. gutierrez rm, mitchell s, solis rv. psidium guajava: a review of its traditional uses, phytochemistry and pharmacology. j ethnopharmacol. 2008;117(1):1−27. 5. deguchi y, miyazaki k. anti-hyperglycemic and anti-hyperlipidemic effects of guava leaf extract. nutr metab. 2010;7(1):9. 6. fortress diagnostic. glucose (god-pap) liquid stable. antrim: fortress diagnostics limited; 2009. p. 1−2. 7. ojewole jao. hypoglycemic and hypotensive effects of psidium guajava linn. (myrtaceae) leaf aqueous extract. methods find exp clin pharmacol. 2005; 27(10):689−95. 8. mukhtar hm, ansari sh, ali m, naved t, bhat za. effect of water extract of psidium guajava leaves on alloxan-induced diabetic rats. pharmazie. 2004;59(9):734−5. 9. wang b, liu hc, ju cy. study on the hypoglycemic activity of different extracts of wild psidium guajava leaves in panzhihua area. sichuan da xue xue bao yi xue ban. 2005;36(6):858−61. 10. deguchi y. effect of guava tea on postprandial blood glucose and diabetes. assoc j jpn soc med use funct foods. 2006;3(6):439−45. 11. wang b, liu hc, hong jr, li hg, huang cy. effect of psidium guajava leaf extract on alpha-glucosidase activity in small intestine of diabetic mouse. sichuan da xue xue bao yi xue ban. 2007;38(2):298−301. rizda nurul zartiana, samsudin surialaga, hikmat permana: anti-hyperglycemic effect of psidium guajava leaf infusion althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 38 amj march 2016 impact of near work activity on visual acuity among junior high school students raisha pratiwi indrawati,1 reni farenia,2 mayasari wahyu k.3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine, universitas padjadjaran, 3department of ophthalmology faculty of medicine universitas padjadjaran/national eye center cicendo eye hospital bandung abstract background: uncorrected refractive error is experienced by at least 45 million productive-aged adults (aged 16–45 years old) and 13 million children (aged 5–15 years old), and being the main cause of visual impairment in children worldwide and third cause of blindness in any age in indonesia. near work activity is estimated as one of environmental risk factor causing this refractive error, leading into decreased visual acuity. this study was conducted to analyse the impact of near work activity on visual acuity among junior high school students in jatinangor methods: this study was conducted in junior high school in jatinangor, using cross sectional method. total of 147 subjects were screened for visual impairment using rapid assessment of avoidable blindness (raab) tumbling e chart and assesed for near work activity using questionnaire-guided interview method after informed consent had been obtained. data were analysed using unpaired-t test and mann-whitney test. results: total diopter hours of near work activity among the group with visual acuity ≥6/18 and group with visual acuity <6/18 showed no significant difference (p=0.329), with latter group had less time-spent in near work activity. similarly, each activity such as reading, watching tv, and using computer also showed no significant difference , except for playing games where the group with better visual acuity had shown significantly longer time spent than another group (p=0.018). conclusions: near work activity does not have impact on visual acuity among junior high school students, except for playing games. [amj.2016;3(1):38–42] keywords: junior high school students, near work activity, visual acuity correspondence: raisha pratiwi indrawati, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 813 128 78247 email: raishapi@gmail.com introduction world health organization (who) estimates that 314 million people around the world are having vision imparment. one hundred and fifty three million of them are caused by uncorrected refractive error that happened in various ethnic, with at least 45 million productive-aged adults (aged 16–45 years old) and 13 million children (aged 5–15 years old) are affected. uncorrected refractive error is the main cause of visual impairment in children aged 5–15 worldwide, with significant increased on its prevalence, mostly among south-east asia children. in indonesia , this condition becomes the third cause of blindness. 1-3 in order to decrease the rate of visual impairment such as refractive error, possible risk factor should be known. thus the effective intervention could be implemented. according to environment health model proposed by blumm, the risk factor could be either genetic, environment, behavior, or health service. although a proportion of myopia (nearsightedness) is clearly genetic, there is currently no conclusive evidence of genetic contributions to mild or moderate myopia.4 thus, beside many factors that interfere vision such as genetic, environment should be considered as the factor that could be intervened to prevent the occurence of visual impairment. near work activity is assumed asone of the environtmental factors that causes the refractive error. near work activity, which is the combination between such activities performed in near distance, is assumed to increase accomodation of lens as an adaptation to the near distance.5 a continuous contraction of cilliary muscle althea medical journal. 2016;3(1) 39 during accomodative process leads to an accomodation spasm, causing the lens diverge hardly into its initial curve, then its ability to see distant object decreased. therefore, near work activity is often associated with myopia resulting in decreased visual acuity, since visual acuity would be impaired if there was any disturbance of visual such as refractive error.4-9 since there was lack of data about refractive error in jatinangor, also in order to discover one of the probable risk factors of this refractive error which should be prevented as early as possible, this study was conducted to know the impact of near work activity on visual acuity in junior high school students in jatinangor. methods this study was an analytical study conducted in cross-sectional approach, carried out in jatinangor district, from september–october 2013. all examination performed in this study was approved by health research ethics committee. samples of this study were chosen by multistage random sampling. from 11 junior high schools available, 3 junior high schools were chosen to represent the population. samples were taken from each available class. one hundred and forty three males and females of junior high school students varying in aged 11–15 from 7th, 8th, and 9th grade who fit inclusion and exclusion criteria were used as subjects. inclusion criteria was subjects who agreed to be involved in the study and aged below 15, and exclusion criteria was those who had organic visual disturbance or information raisha pratiwi indrawati, reni farenia, mayasari wahyu k.: impact of near work activity on visual acuity among junior high school students table 1 characteristic of subjects characteristic frequency (%) visual acuity≥6/18 visual acuity<6/18 p value gender male 56 (39.2%) 36 (64.3%) 20 (35.7%) 0.561 female 87 (60.8%) 60 (69.0%) 27 (31.0%) age 11 years 1 (0.7%) 1 0 12 years 22 (15.4%) 18 4 13 years 44 (30.8%) 32 12 1.072 14 years 45 (31.5%) 27 18 15 years 31 (21.7%) 18 13 total 143 (100%) 96 (67.1%) 47 (32.9%) of theirs could not be obtained completely. subjects were examined for visual acuity by a trained examiner at a distance of 6m using raab tumbling e chart, each eye separately started from right eye. subjects who passed the test were classified into ≥6/18 visual acuity group, while subjects who did not pass were classified into<6/18 visual acuity group. latter group then underwent a further examination using snellen tumbling e chart and pinhole to differentiate refractive error from any other cause of visual impairment. both groups were interviewed to fulfill near work activity questionnaire, that was adopted from sydney myopia study questionnaire. subjects were asked about average amount of time spent (hours/day) in near work activity such as reading and doing homework, reading for pleasure, watching television, using computer, and playing electronic games both in weekday and weekend separately. for each activity, time spent in near work per day were calculated into total time spent each week (hours/week). total diopter hours were counted as measurement of near work exposure based on accomodative weight required during each activity and its duration.10 this diopter hours was defined as 3 x (hours spent studying + hours spent reading for pleasure) + 2 x (hours spent playing electronic games + using computer) + 1 x (hours spentwatching television).11-14 all data obtained from both examination of visual acuity and questionnaire interview were processed using microsoft excel programme and were statistically analyzed using unpaired t-test and mann-whitney non-parametric test. statistically significant was considered when p≤0.05. analysis was performed by comparing althea medical journal. 2016;3(1) 40 amj march 2016 ≥6/18 visual acuity group and <6/18 visual acuity group. results total of 147 subjects involved in this study joined thevisual acuity screening and questionnaire interviewing. ninety six subjects had the visual acuity more than 6/18, and 51 subjects had the visual acuity less than 6/18. after latter group underwent further examination, 4 subjects were excluded because of organic causes, thus there were 47 subjects left in visual acuity less than 6/18 group. from 143 subjects, there were more female subjects than males, mostly in age of 14 years old, and no significant difference in the visual acuity between male and female (p=0.561) (table 1). mean of diopter hours in near work activity was 101.91±37.37 hours/week, with reading as an activity as the most time spent, both reading for study and reading for pleasure (16.0 hours/week), and playing electronic games as an activity with the least time spent (7.0 hours/week). in general, females spent a longer time in most near work activities, except playing electronic games. however, there was no significant difference between time spent in near work activity in males and females, except reading (including studying, doing homework, and reading for pleasure), where females significantly spent more time than males (p=0.007) (table 2). the group with visual acuity ≥6/18 showed longer time spent in near work activity than group with visual acuity <6/18. nevertheless, there was no significant difference in diopter hours of near work activity between both group (p=0.329). the same result was shown for time spent in each near work activity, where the group with better visual acuity spent longer time in reading (16.45chours/ week), watching tv (16.00 hours/week), using computer (7.25 hours/week), and playing electronic games (9.00 hours/week). similar to the diopter hours result, each activity did not have significant differences in time spent between both groups, except time spent in playing electronic games that showed significant difference (p=0.018) (table 3). discussions this study aimed to determine the impact of near work activity on visual acuity. based on the statistical result, time spent in near work activity did not have significant impact table 2 hours spent on near work activity by gender variables time spent (hours/week) p value total male female reading 16.0 (2.5–47.5) 15.83 (2.5–47.5) 19.0 (2.5–37.5) 0.007 watching tv 16.0 (0–39.0) 14.0 (0–39.0) 16.0 (0–36.0) 0.088 using computer 7.0 (0–25.0) 7.0 (0–25.0) 7.0 (0–23.0) 0.967 playing electronic games 7.0 (0–25.0) 9.0 (0–25.0) 7.0 (0–25.0) 0.195 near work activity (diopter hours) 101.91±37.37 95.69 ± 38.84 105.92 ± 36.05 0.110 table 3 hours spent on near work activity by visual acuity variables time spent (hours/week) p value visual acuity ≥6/18 visual acuity <6/18 reading 16.45 (2.5–37.0) 15.50 (3.5–47.5) 0.689* watching tv 16.00 (0–39.0) 15.00 (0–30.0) 0.120* using computer 7.25 (0–25.0) 7.00 (0–24.0) 0.326* playing electronic games 9.00 (0–25.0) 6.50 (0–24.0) 0.018* near work activity (diopter hours) 104.05 ±35.88 92.00 (36.0–203.5) 0.329** *mann whitney test **unpaired–t test althea medical journal. 2016;3(1) 41 on refractive error, which in this study was measured by visual acuity, where group with visual acuity ≥6/18 and group with visual acuity <6/18 had similar mean in diopter hours of near work activity. this result was consistent with the study conducted by lu et al.15 and ip et al.4 in rural china and in sydney respectively, where time and diopter hours on near work activities did not differ thechildren with and without myopia. moreover, another cohort study conducted in singapore13 which is aprevious cross-sectional study concluded that children who read more were in a higher risk of developing myopia. this study alsohad proved that reading book did not associate with incident of myopia. however, there were some similar studies that were contrary with this result, such as other study in singapore8 and india9 that showed children who spent more time on near work activity such as reading, using computer and watching television were more likely to be affected by refractive error. this difference could be resulted from any other behavior and environtment factor that were not assesed in this study, such as continuity in doing such activities, lighting, type of object seen, and any other factors, and also genetic factor. also, there were different range of age between the subjects in this study (11–15 years old) and in the previous study in singapore8 (7–9 years old). meanwhile, association between reading and myopia was predicted to be stronger in younger subjects, who were still in visual development period, than in the older one. this might explain why there were no significant difference in the time-spent on near work activity between both groups. it is because the subjects in this study were in a narrow age group and already at the age where eye was no longer developing. thus this study did not show any significant impact. hence, further study involving younger subjects might be needed in order to find the true impact of near work activity on refractive error development. this study also showed that time spent in playing electronic games gave a significant effect on visual acuity, where group with better visual acuity turned out having longer time spent than another group. this result was quite opposite with any other previous study that had shown no impact of time spent in playing games on refractive error16, but had similarity with lu et al.15 study where time spent on video games was significantly less in myopic children. moreover, study conducted by ip et al.4 showed that playing hand-held console games was associated with more hyperopic (farsightedness) refraction, although it was unlikely to have a protective influence on the development of myopia. in this study, some subjects were playing games on their gadget, such as handphone, frequently but only in short period of time. it may explain why group with better visual acuity had longer time spent on playing games without having visual impairment. this condition can happen because they did not do the activities mentioned above continuously, while continuity on near work activity suggested to be a significant factor for myopia.6 hence, further study considering continuity of near work activity might be needed. there were some limitations in this study that may had influenced those results. cross sectional study design was chosen rather than cohort due to limited time in conducting this study, so it could not really measure the impact of exposure, in this case is near work activity, on expected outcome in particular period of time. also, there could be inaccuracy in measurment of near work activity, since it assesed by interview, not direct observation, that could arise recall bias, and imprecision in subjects grouping due to limitation of tool used in measuring visual acuity. in conclusion, this study showed that longer time spent in near work activity does not result in lower visual acuity. therefore, it could not prove any impact of near work activity on visual acuity among junior high school students, even though there is no exact mechanism already known indeed. references 1. world health organization. vision2020: the right to sight. global initiative for the elimination of avoidable blindness: action plan 2006–2011. geneva. who; 2007. p. 2–17. 2. resnikoff s, pascolini d, mariotti sp, pokharel gp. global magnitude of visual impairment caused by uncorrected refractive errors in 2004. bull world health organ. public health. 2008;86(1):63–70. 3. kementrian kesehatan republik indonesia. gangguan penglihatan masih menjadi masalah kesehatan. pusat komunikasi publik sekretariat jenderal kementerian kesehatan ri; 2010 [cited 2013 february 9]; available from: http://www. depkes.go.id/index.php/berita/pressr e l e a s e / 8 4 5 g a n g g u a n p e n g l i h a t a n masih-menjadi-masalah-kesehatan.pdf. 4. ip jm, huynb sc, robaei d, rose ka, morgan raisha pratiwi indrawati, reni farenia, mayasari wahyu k.: impact of near work activity on visual acuity among junior high school students althea medical journal. 2016;3(1) 42 amj march 2016 ig, smith w, et al. ethnic differences in the impact of parental myopia: findings from a population-based study of 12-year-old australian children. invest ophtalmol vis sci. 2007;48(6):2520–8. 5. guyton ac, hall je. the nervous system: b. the special senses. textbook of medical physiology. 11th ed. philadelphia. elsevier saunders; 2005. p. 613–50. 6. ip jm, saw sm, rose ka, morgan ig, kifley a, wang jj, et al. role of near work in myopia: findings in a sample of australian school children. invest ophtalmol vis sci. 2008;49(7):2903–10. 7. pan cw, ramamurthy d, saw sm. worldwide prevalence and risk factors for myopia. ophthalmol physiol opt. 2012;32(1):3–16. 8. saw sm, tong l, chua wh, chia ks, koh d, tan dt, et al. incidence and progression of myopia in singaporean school children. invest ophtalmol vis sci. 2005;46(1):51–7. 9. prema n. causing factors of refractive error in children: heredity or environment? indian j sci technol. 2011;4:1773–4. 10. lorenz b, moore at, editors. pediatric ophthalmology, neuro-ophthalmology, genetics. berlin: springer; 2006. p. 9-10 11. saw sm, chua wh, gazzard g. eye growth changes in myopic children in singapore. br j ophtalmol. 2005;89(11):1489–94. 12. saw sm, cheng a, fong a. school grades and myopia. ophthalmol physiol opt. 2007;27(2):126–9. 13. saw sm, shankar a, tan sb, taylor h, tan dt, stone ra, et al. a cohort study of incident myopia in singaporean children. invest ophtalmol vis sci. 2006;47(5):1839–44. 14. jones la, sinnott lt, mutti do, mitchell gl, moeschberger ml, zadnik k. parental history of myopia, sports and outdoor activities, and future myopia. invest ophtalmol vis sci. 2007;48(8):3524–32. 15. lu b, congdon n, liu x, choi k, lam ds, zhang m, et al. associations between near work, outdoor activity, and myopia among adolescent students in rural china: the xichang pediatric refractive error study report no. 2. arch ophthalmol. 2009;127(6):769. 16. liang cl, yen e, su jy, liu c, chang ty, park n, et al. impact of family history of high myopia on level and onset of myopia. invest ophtalmol vis sci. 2004;45(10):3446–52. althea medical journal. 2015;2(3) 375 mother’s knowledge, attitude and practice toward safe water usage in baleendah, bandung district, west java from september–october 2012 eliza techa fattima,1 kuswandewi mutyara,2 yudith setiati ermaya,3 elsa pudji setiawati2 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: poor environmental conditions contribute to the high incidence of diarrhea, most of those caused by unsecure water and poor health knowledge. this study was conducted to evaluate the mother’s knowledge, attitude, and practice toward safe water usage in baleendah, bandung. methods: a cross sectional descriptive study was conducted in baleendah during september−october 2012, participated by 210 mothers with 12−59 months children, and using rapid survey method. this study used a questionnaire to measure the three domains, which consists of 8 questions of knowledge, 10 questions of attitudes, 16 questions of practice, and 7 questions of diarrhea. the collected data were analyzed and presented in table. results: as much as 168 (80%) of mothers were in moderate knowledge status, 126 (60%) of mothers were in moderate attitude status. practically, 127 (54.7%) of mothers used water from borehole/tube well. most of the mothers (54.6%) use drinking water from refillable water store. conclusions: most mothers who participated have varied moderate knowledge and attitude status, and practice toward safe water usage. [amj.2015;2(3):375–81] keywords: attitude, knowledge, practices, safe water usage correspondence: eliza techa fattima, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 853 247 193 65 email: elizatecha@yahoo.co.id introduction diarrhea is still one of the health problems in developing countries, such as in indonesia. an outbreak of diarrhea occurred in 11 provinces in 2010, including west java.1 some districts have tendency of high incidence of diarrhea, such as sukabumi, garut, bandung, and kuningan. in baleendah, bandung, more than eight thousand cases of diarrhea occur in 2011.2 according to a preliminary survey in 2011 there were 224,323 people living in baleendah. based on the data obtained from jelekong public health centre in baleendah in 2011, the incidence of diarrhea in children aged 12−59 months, were about 100 cases of diarrhea every month.3 diarrhea was commonly found in salmonellosis, shigellosis, amoebiasis, protozoal and viral intestinal diseases. poor environmental conditions contribute to the high incidence of diarrhea. about 88% of diarrhea cases in the world are caused by unsecured water use, lack of sanitation and lack of health knowledge.4,5 globally, improving water sanitation, hygiene and medical knowledge prevent at least 9.1% of disability, or 6.3% of mortality.6 the problem related to drinking water, hygiene and sanitation still being the main issues. the results of the who study in 2007, the incidence of diarrhea decreased 39% with the behavior management of drinking water in the household, 32% by improving people's access to sanitary excreta, and 45% with the behavior of washing hands with soap, while integrating all factors, the incidence of diarrhea decreased by 94% .7 in society, health problems are determined by two factors: behavioral factors and nonbehavioral factors (social, political, economic, etc.). behavioral factors are developed into knowledge, attitude and practice. health behavior also refers to knowledge, attitude and practice. many indonesians use water from the althea medical journal. 2015;2(3) 376 amj september, 2015 river for their daily needs. citarum river is the longest river in west java and about 25 million people from nine suburbs and three cities rely on this river while about 15 million people live on the bank of this river. citarum river is still inflood regularly every rainy season. baleendah is geographically located in bandung. this region is often flooded when the rainy season arrives, since two major rivers namely citarum and cisangkuy river cross in baleendah. so far, there are no studies on the relationship of mother’s knowledge, attitudes and practices toward safe water usage with the incidence of diarrhea in children in baleendah, bandung. therefore, this study concerned about mother’s knowledge, attitudes and practices toward safe water usage and the incidence of diarrhea in children in baleendah, bandung. methods a cross sectional descriptive study was carried out during the period of september−october 2012 on 210 mothers with 12−59 months table 1 characteristics of mothers and children in baleendah district characteristics frequency percentage (%) mother’s characteristic family income per month < rp. 1.223.800,00 127 60.5 >= rp. 1.223.800,00 83 39.5 education level elementary school (unfinished) 1 0.5 graduated from elementary school 47 22.4 graduated from junior high school 92 43.8 graduated from senior high school 63 30.0 graduated from college 7 3.3 father’s occupation labors 82 39.0 farmer 1 0.5 merchants street market 3 1.4 entrepreneurs 65 31.0 civil servants 5 2.4 private employees 33 15.7 tni/polri 2 1.0 others 19 9.0 child’s characteristics sex male 113 53.8 female 97 46.2 age 12−23 months 97 46.2 24−35 months 50 23.8 36−47 months 37 17.6 48−59 months 26 12.4 althea medical journal. 2015;2(3) 377 children in baleendah, bandung. the study was approved by the health research ethics committee of faculty of medicine univeristas padjadjaran, bandung. the rapid survey method prescribed minimum of 30 clusters with 7 subjects taken from each cluster.8 the clusters in this study were neighborhood associations (rt) in the district of baleendah. from each neighborhood association (rt), was selected randomly 7 houses that have children (simple random sampling). this study was conducted by first selecting a conspicuous place in the cluster, such as stalls or mosque as early benchmarks and then apply a nearby house system. researchers assumed one house is occupied by one family which only has one child, ideally after the data retrieval will be obtained from 210 children. if there is one house occupied by more than one family and one family has more than one child, only 1 child with the youngest age in the family becomes the subject of research. interviews were conducted in a cluster to get the 7 respondents who fit the criteria. this study used a questionnaire to measure the three domains, which consists of 8 questions of knowledge, 10 questions of attitudes, 16 questions of practice, and 7 questions of diarrhea. results the most of the subjects had a low family income and graduated from junior high school (table 1) and mostly had moderate level of knowledge toward safe water usage (table 2). table 3 showed that some respondents already knew that they should not use citarum water for drinking, bathing, washing clothes, and washing dishes because it is polluted, and the water should not be disposed of large and small household waste in the river due to table 2 mother’s knowledge toward safe water usage level of knowledge frequency (n) percentage (%) good 19 9 moderate 168 80 poor 23 11 table 3 mother’s attitudes toward safe water usage no characteristic frequency total strongly agree agree disagree strongly disagree 1 citarum river water potable. 0 3 122 85 210 2 citarum river water can be used to wash clothes 0 16 141 53 210 3 defecating and urinating can be done on river 1 62 114 33 210 4 household waste can be disposed on river 0 12 130 68 210 5 water consumed should be clear 60 149 1 0 210 6 before consumption, water should be boiled 94 115 1 0 210 7 drinking water stored in closed storage 56 154 0 0 210 8 up to 6 months, baby should only be given breast milk 82 122 6 0 210 9 milk bottles should be washed with soap and clean running water before used 62 124 24 0 210 10 milk bottles should be boiled with boiling water before used 85 123 2 0 210 eliza techa fattima, kuswandewi mutyara, yudith setiati ermaya, elsa pudji setiawati: mother’s knowledge, attitude and practice toward safe water usage in baleendah, bandung district, west java from september–october 2012 althea medical journal. 2015;2(3) 378 amj september, 2015 table 4 mother’s practices toward safe water usage characteristics frequency percentages(%) type of water source tap water/pam 15 6.5 tap water retail / buying 11 4.8 borehole/tube well 127 54.7 dug well 75 32.3 spring 3 1.3 rainwater 1 0.4 ownership of water resources personal 140 66.7 public 70 33.3 water resource availability always available 151 71.9 difficult in dry season 59 28.1 type of drinking water sources bottled water 19 7.3 water from refreshment stand 141 54.6 tap water/pam 11 4.2 tap water retail / buying 1 0.4 borehole/tube well 47 18.2 dug well 35 13.7 spring 4 1.6 location of drinking water sources indoor 141 67.1 outdoor 69 32.9 physical quality of drinking water cloudy 4 1.9 colored 10 4.7 smell 3 1.4 good 195 92.0 drinking water treatment methods boiled 156 48.9 uv 136 42.6 filtered 25 7.8 without treatment 2 0.6 water shelter dispenser 113 42.5 pot/kettle/thermos/jerry 128 48.1 pitcher 5 1.9 bucket/covered pot 13 4.9 others 7 2.6 althea medical journal. 2015;2(3) 379 water pollution can aggravate. most mothers (47.6%) knew that the source of water for daily needs can come from rain water, surface water, and groundwater. two mothers (1%) did not know that rain water, surface water, and ground water is the source of water that can be used for everyday needs. most of the mothers (94.8%) knew that the water was turbid, colorless, tasteless, foaming, and because of the smell it could not be used as drinking water sources. most mothers knew that there are other ways besides drinking water by boiling water, by irradiation with ultraviolet light, giving chlorine, and filtering. based on the data obtained, 187 mothers (89%) knew that regularly mopping the floor in the house is one way to prevent diarrhea in young children, while 23 mothers (11%) did not know that mopping the floor can prevent diarrhea. mother’s knowledge about breastfeeding for the first 6 months of life in infants is actually good. based on the data obtained, the 203 mothers (96.7%) knew that until the age of 6 months a baby should only be given breast milk. prior to use the milk bottle should be washed with soap and cleaned by running water and boiled. most of mothers (83.3%) knew how to use a milk bottle properly. based on the data obtained, 45 mothers (21.5%) had a good attitude in this category, most of the mothers with moderate levels of attitude in this category amounted to 126 people (60%), whereas women who belong to the poor category were more than 39 people (18.5%). none of the mothers used water from citarum river. there were some mothers (4.8%) who still threw garbage into citarum river. mostly, disposal drains in the house flowed into citarum river (69%). based on the data obtained from the field about the practice of mothers regarding water use of 210 respondents (table 4). discussions in general, the mothers have realized about using clean water. this study found that subjects had a moderate knowledge (80%). a research about using river water in ulu pekon krui and pekon laay west lampung9, shows the distribution of knowledge about the use of water good categories (30.6%), moderate category (16.3%), and poor category (53.1%). the difference in the level of knowledge in these two areas can be influenced by education level, hereditary habits and length of stay in the riverbank. in general, the level of maternal attitudes towards safe water usage was moderate. it is proven from the results of research showing that the average rate of the respondents attitude were in the moderate category (60%). most mothers agree the water used for daily needs, especially for drinking should be clean. attitude is a reflection of various psychiatric symptoms such as desires, interests, knowledge, emotions, motivation, and willing.10 based on the research conducted using river water in ulu pekon krui and pekon laay west lampung9, it shows the distribution of attitudes on the use of water good category (28.5%), moderate category (37%), and poor category (34.5%). human attitude or a society of health is determined by knowledge, beliefs, and traditions of the individual. based on this study, there were 127 mothers (54.7%) who used water from borehole/tube well for daily needs. water from borehole/tube well is known as ground water. ground water comes from rain water which had absorption and filtration into the soil. ground water is usually free of germs and contains substances mineral.11 based on data from basic health survey (riset kesehatan dasar, riskesdas) 2010, currently indonesia has some clean water that can be classified into a number of sources, including tap water (19.5%), protected dug wells (27.9%), unprotected dug wells (10.2%), boreholes/tube well (22.2%) and the river/lake/irrigation (4.9%).12 location of water sources should also be considered whether being around the house or outside the house. based on the data obtained, the majority of drinking water is inside the house (67.1%). based on data from riskesdas 2010, it shows that approximately 40% of contaminated water sources are unprotected. one form of pollution occurs due to seepage of dirty water activity which results sanitation.12 based on this study, there were still many people who used public water sources for their daily needs (33.3%). based on the observations of the current study, the limitation of many rented houses was comprised by several families who only provide a source of water. most mothers do not complain about the lack of water because water is always available in every season (71.9%). according to riskesdas 2010, most indonesian people claimed about easy access to clean water (81.7%).12 based on the data obtained, no mother used water from citarum river. water river/lake/ irrigation is the lowest level seen from the quality of the water, because these sources are eliza techa fattima, kuswandewi mutyara, yudith setiati ermaya, elsa pudji setiawati: mother’s knowledge, attitude and practice toward safe water usage in baleendah, bandung district, west java from september–october 2012 althea medical journal. 2015;2(3) 380 amj september, 2015 vulnerable contaminated likely condition of the water is below health standards.12 there are 10 mothers (4.8%) who threw householdgarbage into citarum river. mostly, the disposal drains in the house flowed into citarum river (69%). the disposal of household waste and water waste into citarum river increased the number of pollution in the river. restrictions on source of clean and safe water are free from contamination or germs, free from hazardous substances and toxic chemicals, the water is tasteless and odorless, and can be used to meet household needs, as well as meet the minimum standards set by the who or department of health ri.11 based on the data obtained, the majority of women used drinking water from a water depot (54.6%). while based on data from riskesdas 2010 in west java province, 27.3% of people who use non-piped water is not protected, 11.19% use piped water protected, and 61.59% using nonpiped water protected. drinking water from refreshment stand belongs to the category of non-piped water is not protected.12 based on the data obtained, the majority of the physical quality of drinking water is good (92%). the water which is used for drinking should be clear, colorless, odorless, and tasteless.13 based on the data obtained, mostly mothers boiled the water before drink it (48.9%), it was a good way to kill some germs in the water.11 most of the mothers use a pot/kettle/ thermos/jerry cans as storages of drinking water (48.1%). good water reservoirs should be closed in order not to be contaminated easily. most mothers breastfeed exclusively to their children (81.4%). according to riskesdas 2010, exclusive breastfeeding is higher in rural areas than in the town.12 according to the who study in geneva in 1992, the risk of developing diarrhea was greater in infants who are not breast-fed infants compared with breast-fed exclusively. it also increases the risk of death caused by diarrhea.14 some children are still using a bottle as many as 91 infants (43.3%). according to a research by the who in geneva, the use of this milk bottle facilitates the transmission of germs, because it will not be perfectly cleared.14 this study shows mothers washed milk bottles with soap and running water before using a bottle of milk (59%). most mothers boiled the milk bottles using boiling water before using a bottle (64.3%). washing and boiling the bottle before use is one way to prevent disease transmission. this study provides the conclusions that the level of knowledge toward safe water usage in baleendah is moderate (80%),the level attitudes toward safe water usage in baleendah is moderate (60%). in practice, 127 mothers (54.7%) use for daily needs water from borehole/tube well and most mothers use drinking water from depot water (54.6%). incidence of diarrhea in children in baleendah in the past month was 92 cases (43.8%). there should be another further study about the relationship of mother’s knowledge, attitudes, and practices toward safe water usage and incidence of diarrhea in children in baleendah. mothers need to be involved in good and safe water usage, because mothers have a very important role in the family. references 1. ministry of health republic of indonesian. profil kesehatan indonesia 2010. jakarta: ministry of health republic of indonesian; 2011. 2. lucyati a. hasil pencapaian pembangunan kesehatan di jawa barat. bandung: dinas kesehatan provinsi jawa barat; 2011. 3. jelekong public health centre. laporan tahunan 2011. bandung: jelekong public health centre; 2011. 4. esrey sa, feachem rg, hughes jm. interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities. bull world health organ. 1985; 63(4): 757−72 5. esrey sa, potash jb, roberts l, schiff c. health benefits from improvements in water supply and sanitation: survey and analysis of the literature on selected disease. 66th ed. arlington, va, usa: water and sanitation for health project (wash). 1990; p.66−83 6. world health organization. water, sanitation and hygiene. world health organization. 2012 [cited 2012 april 6]; available from: http://www.wpro.who. int/health_topics/water_sanitation_and_ hygiene/general_info.htm. 7. department of health republic of indonesia. strategi nasional sanitasi total berbasis masyarakat. jakarta: department of health republic of indonesia; 2008. 8. pusat data kesehatan departemen kesehatan ri. metode survei cepat untuk dinas kesehatan kabupaten/kotamadya. jakarta: department of health republic of indonesia; 1996. 9. saragi ov, setiawan b, ekayanti i. analisis althea medical journal. 2015;2(3) 381 penyediaan dan penggunaan air sungai pada rumah tangga di pekon ulu krui dan pekon laay kabupaten lampung barat. jurnal gizi dan pangan. 2008;3(3): 167–71 10. notoatmodjo s. konsep perilaku kesehatan: promosi kesehatan teori dan aplikasi. jakarta: rineka cipta; 2005. 11. mubaraq wi, chayatin n. ilmu kesehatan masyarakat: teori dan aplikasi. jakarta: salemba medika; 2009. 12. council for health research and development. riset kesehatan dasar 2010. jakarta: ministry of health republic of indonesian; 2010. 13. soemitrat j. kesehatan lingkungan. yogyakarta: gajah mada university press; 2004. 14. world health organization. reading on diarrhoea. geneva: world health organization; 1992. 15. pruss-ustun a, kay d, fewtrell l, bartram j. unsafe water, sanitation and hygine. in: ezzati m, lopez ad, rodgers a, murray cjl. comparative quantification of health risks vol 1. geneva: world health organization; 2004. p. 1321−52 16. simanjuntak ch, punjabi nh, wangsasaputra f, dazwir n, pulungsih sp, rofiq a, et al. diarrhoea episodes and treatment-seeking behaviour in a slum area of north jakarta, indonesia. j health popul nutr. 2004;22(2):119–29. eliza techa fattima, kuswandewi mutyara, yudith setiati ermaya, elsa pudji setiawati: mother’s knowledge, attitude and practice toward safe water usage in baleendah, bandung district, west java from september–october 2012 althea medical journal. 2015;2(2) 221 the teratogenic effect of the mindi (melia azedarach l) leaves ethanol extract on mice (mus musculus) fetus adisti erlina sutomo,1 trully d sitorus,2 adhi pribadi3 1faculty of medicine universitas padjadjaran, 2departement of pharmacology and therapy, faculty of medicine universitas padjadjaran, 3departement of obstetric and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: mindi leaves (melia azeradach l.) were used by indonesians as a traditional medicine for pregnant women because it was considered to be safe. mindi leaves contain several active compounds and one of them is suspected as a teratogen and can disrupt fetus growth in gestation. this research aims to know about the teratogenic effect of ethanol extract of mindi leaves by using mice. methods: this was a laboratory experimental study using 27 pregnant female mice (mus musculus) of swiss webster strain which were randomly assigned to 3 groups (n=9) controlled (carboxymethyl cellulose 1% for day 1–18 of pregnancy), group i (mindi leaves ethanol extract 3.22 mg+carboxymethyl cellulose 1% day 1–5 of pregnancy), and group ii (mindi leaves ethanol extract 3.22 mg+carboxymethyl cellulose 1% day 6–18 of pregnancy). observation was done to see total amount of fetus, live normal fetus count, length and weight of fetus, abnormal fetus count consisting of dead fetus count with normal and abnormal external morphology, and resorbed fetus count. this research was done from october to november 2012 in pharmacological laboratory of faculty of medicine universitas padjajdjaran. data analysis utilized unpaired t-test . results: the result showed a significant difference (p<0.05), seen from live normal fetus count and abnormal fetus count consisting of dead fetus count with normal and abnormal external morphology, and resorpted fetus count. conclusions: administration of mindi leaves extract during pregnancy of mices can cause teratogenic effect. [amj.2015;2(1):221–25] keywords: flavonoid, mindi leaves, teratogenic effect correspondence: adisti erlina sutomo, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81912745124 email: iniadisti@yahoo.com introduction consuming teratogenic substances during pregnancy may cause a miscarriage and birth defects if it is taken during organogenesis. it tends to have impacts that affect the function of certain organs or system such as the enzymatic system if it is taken a few weeks before childbirth. the impact will be visible in the neonatal period.1 herbal medicine as alternative medicine has been widely used by the public. adverse effects that can be caused by pharmacological drugs has encouraged people to choose traditional medicine which are considered more natural, safer, easy to get, and the price tends to be more affordable.2 world health organization (who) stated that 80% of people in developing countries have used herbal medicine and in 2000 estimated that worldwide sales of herbal medicines was around u.s. $60 billion.2 basically, all substances both natural and chemical ingredients are likely to cause harmful effects; hence pre-testing on animal to determine the safety of the substance is needed. safety test is a part of the preclinical requirements to assess the safety of a drug or substances to be used as supplement or food.3 toxic effect is a reaction that can lead to serious health problems since it disturbs physiological and biochemical body function. this reaction usually happens due to overuse of drugs or chemical substances.4 it is not yet confirmed officially that mindi leaves can be used as an alternative for the treatment of high blood pressure without causing certain side effects, especially when it is taken during pregnancy this is due to the presence of some althea medical journal. 2015;2(2) 222 amj june, 2015 toxic compounds speculated to be contained in mindi leaves. according to werler et al., physiologically toxic compounds can cause vasoconstriction of the vessels which connects the uterus to the placenta. this constriction of the vessels will lead to a decrease of nutritional supply that the embryo needs. as already known, all embryonic requirements must go through the placenta.5 the researchers are interested in conducting research teratogenic effects using mindi leaves due to the fact that many people, including pregnant women, o use mindi plants, especially the leaves, for antihypertensive remedy because they think it is safer than generic drugs. methods a total of 27 swiss webster female mice (mus musculus), 20–25 grams, 12–14 weeks, including 12 male mice, were used in this study. all mice were obtained from inter-university research center, itb (ppau-itb). before receiving treatment, the mice were adapted for seven days and then mated with male mice. the next day, if a vaginal plug was found, the day was designated as gestation day one. mice which were sick and otherwise not pregnant would be excluded. the research protocols and animal care procedure were approved by the health research ethics committee of the faculty of medicine, universitas padjadjaran, bandung. fresh mindi leaves are obtained from subangthen be processed into extract using ethanol. the leaves used were fresh mindi leaves which had been newly plucked from the plant. preparation of ethanol extract of mindi leaves in this study used cold maceration method, whereas the solvent used was ethanol 70%.9 the resulting extract were in paste form, then the resulting extract (paste form) was weighed as needed, and was dissolved with cmc 1% solvent, the goal was to dilute the extract. after adaptation period, female and male mice were put into the same cage, so that the female could be impregnated. then, male mice and female mice were being separated and undergoes vaginal plug in order to test for pregnancy. if the female mice were confirmed pregnant, the day was counted as day-1 gestational period. aside from that, physical condition was also examined as inclusion and exclusion criteria that taken as consideration. on day 18 of gestation the mice were terminated by cervical dislocation and then the abdomen and uterus were surgically removed. fetuses were removed from the membranes which wrapped them and then washed with the solution of physiological nacl 0.9% and 70% alcohol. observations were made of live normal fetus count and abnormal fetus count consisting of dead fetus count with normal and abnormal external morphology, and resorpted fetus count. fetus with abnormality would then be compared with normal mice embryology. statistics of this study used quantitative data that had been collected (not paired or unpaired, consisting of two groups), after that the normality of variance was tested first, followed with the parametric test of unpaired t-test (average difference test sample) and non-parametric test with mann whitney test if the data were not normally distributed. significance was determined by p-value of <0.05. results the results revealed that there were significant differences (p<0.05) between the control group against group i and group ii seen from the number of normal fetus (alive), the number of abnormal fetuses consisting of the number of dead fetuses with the normal external morphology and abnormal table 1 the group division group number of female mice dosage (mg/kg bb) substance given method of intervention time of intervention control 9 cmc 1% oral day 1−18 i 9 3.22 mg mindi leaves extract 3.22 mg+cmc 1% oral day 1−5 ii 9 3.22 mg mindi leaves extract 3.22 mg+cmc 1% oral day 6−18 cmc: carboxymethyl cellulose althea medical journal. 2015;2(2) 223 table 2 number of normal fetus (alive) group mean normal fetus (alive)±sd control 8.78±2.28 i 1.11±2.20 ii 2.44±3.81 control group=cmc 1% 2 ml, for 18 days, group i= implantation, given mindi leaves ethanol extract 3.22 mg+cmc 1% 2 ml at days 1−5, ii= organogenesis, mindi leaves extract 3.22 mg+cmc 1% 2 ml days 6−18 external morphology, and the number of fetus resorption. macroscopical observation of abnormal fetus consisted of fetus resorption, dead fetuses with normal morphology, and dead fetuses with abnormal morphology. from this study dead fetuses with abnormal morphology were found with hemorrhage, exencephaly, and abdominal wall defect. table 3 showed an increase in the number of abnormal fetus in group i and group ii compared to the control group. the number of abnormal fetus in the control group is much less when compared to group i and group ii. figure 1 is the result of observation was found one fetus with abdominal wall defect on mice included in group i and found one fetus with exencephaly on mice from group ii. in addition, some fetuses were found with hemorrhage. observation of fetus resorption seen in figure 1 as a yellow blob reddish or reddish-black inside the uterus of mice.10 table 4 showed an increase in the number of fetal resorption in group i and group ii compared to the control group. no fetal resorption was found in the control group. discussion mindi leaves (melia azedarach l.) were adisti erlina sutomo, trully d sitorus, adhi pribadi: the teratogenic effect of the mindi (melia azedarach l) leaves ethanol extract on mice (mus musculus) fetus empirically being used as traditional medicine to treat several diseases among indonesian community. there were many active components in mindi leaves such as alkaloid, flavonoid, saponin, steroid and kaemferol. based on the study, alkaloid and flavonoid were considered having teratogen effect as they can poison the embryo and also inhibit the contraction of smooth muscle on female mice. fetus total number consists of the all fetus, whether normal (alive) or abnormal. this study showed an increase in the total number of fetuses in each group. group ii generated the highest total number of fetus compared to the control group and the group i. the difference in the total number of fetuses between the control group and the group i with group ii control group was not too large. there was a decrease the number of normal fetus (alive) in group i and group ii compared to the control group. the number of normal fetus (alive) in group ii greater than the group i. in group i there was more abnormal fetus than the normal number of fetus (alive). at day 1 to day 5 of pregnancy, there was a process of zygote fission and attachment of blastocyst.6 a decrease of average length on group i and ii compared to control was observed. this decrease was the lightest teratogenic effect and an indication for a disruption in growth of fetus. inhibition of growth occurred when teratogenic agents affected cellular interaction, proliferation, and associated with inhibition of nucleic acid synthesis.7 the decline of nutritional supply from the mother to fetus caused the fetus to receive inadequate nutrition in its growth period, and made possible the disruption in the length growth of the fetus.5 mice of the group i and group iihad a lighter average weight compared to control. fetus weight was an important parameter to know the effect of teratogenic agent on fetus growth. the average body weight of normal table 3 average number of abnormal fetus group mean number of abnormal fetus±sd control 0.11±0.33 i 7.89±1.54 ii 7.33±4.15 control group= cmc 1% 2 ml, for 18 days group i= implantation, given mindi leaves ethanol extract 3.22 mg+cmc 1% 2 ml at days 1−5, ii= organogenesis, mindi leaves extract 3.22 mg+cmc 1% 2 ml days 6−18 table 4 average number of fetus resorption group mean number of abnormal fetus±sd control 0.11±0.33 i 7.89±1.54 ii 7.33±4.15 control group= cmc 1% 2 ml, for 18 days group i= implantation, given mindi leaves ethanol extract 3.22 mg+cmc 1% 2 ml at days 1−5, ii= organogenesis, mindi leaves extract 3.22 mg+cmc 1% 2 ml days 6−18 althea medical journal. 2015;2(2) 224 amj june, 2015 fetus at day 18 of gestation was 1.4 gram (wilson and warkany, 1965).7 the average weight of fetus in the control group, group i, and group ii were all under the normal value. another possibility than the teratogenic effect of ethanol extract of mindi leaves is intra-uterine growth retardation (iugr). retarded fetal growth is an event in intra-uterine growth in which the fetal weight is below the normal value for the age of gestation. retarded fetal growth is closely related to the health of the mother and number of carried fetus. there is an increased number of abnormal fetuses in group i and group ii compared to the control group. abnormal fetuses observed in the study were dead fetuses with normal external morphology, fetuses death with abnormal external morphology. fetuses dead with external morphological abnormalities found in this study were fetuses with bleeding, excencephaly, and abdominal wall defect. the gestation period between days 6 through to 15 is the period of organogenesis. exposure to teratogens agents during this time more frequently causes congenital anomalies than spontaneous abortion or resorption of the embryo.6 compounds found in the mindi leaves suspected to have embryotoxic potential is a flavonoid which can inhibit cell proliferation and cause dna damage.8 hemorrhage was found on the head, back, legs, and body. hemorrhage is a discharge of blood from the cardiovascular system, followed by accumulation in tissues (price and wilson, 1984). mindi leaves extract which has been given repeatedly lead to increase concentration in blood, causing an osmotic imbalance. osmotic imbalance may be caused by disturbances of pressure and viscosity of the liquid in different parts of the embryo. pressure disturbance occurred between extraembryonic and intraembryonic fluid, causing the blood vessels to rupture and bleed (wilson, 1073).7 in addition to bleeding, fetuses exencephaly found in group ii. fetuses with exencephaly are caused by degeneration of neuroepithelial cells and proliferation of mesenchymal cells was disrupted in the head. the number of mesenchymal cells was reduced, thus the neural ectoderm cannot fold to form the neural tube and resulted in exencephaly. abdominal wall defects was found in group ii, in which there had been inhibited growth of mesenchymal cells, due to the disruption of cellular proliferation.5 figure 1 fetus resorption, fetus with cephalic and whole body hemorrhage, and fetus with excencephaly and abdominal wall defec althea medical journal. 2015;2(2) 225 the research concluded that the administration of mindi leaves ethanol extract (melia azedarach.l) during gestation on mice caused teratogenic effect. references 1. lisanti e, suryono ia. teratologi. bandung: cv lubuk agung; 2011. 2. wahyuningsih msh. deskriptif penelitian dasar herbal medicine. majalah obat tradisional. 2011;16(3):174–181. 3. astuti pm, nurrochmad a. uji farmakologi dan uji toksisitas. yogyakarta: komite akreditsi nasional−laboratorium penelitian dan pengujian terpadu ugm; 2011 [cited 2012 may 15]. available from: http://lppt .ugm.ac.id/berita-200-ujifarmakologi-dan-uji-toksisitas.html. 4. purwantini, purwantiningsih, puspita oe. efek analgesik fraksi etanol dari ekstrak etanol daun mindi (melia azedarach l.) pada mencit jantan. jurnal ilmiah farmasi. 2007;4(2) [cited 2012 may 15]. available from: http://journal.uii.ac.id/index.php/ jif/article/view/2464. 5. susantin, mahriani, suprihantin. efek teratogenik 2,5 hexanadione terhadap perkembangan fetus mencit (mus musculus). jurnal ilmu dasar. 2006;1(7):52─58. 6. moore kl. the developing human clinically oriented embryology. 8th ed. philadelphia: saunders elsevier; 2008. 7. setyawati i. morfologi fetus mencit (mus musculus) setelah pemberian ekstrak daun sambiloto (andrographispaniculata nees). jurnal biologi. 2009;2:41−44 [cited 2012 december 6]. available from: http:// ejournal.unud.ac.id/abstrak/artikel3.pdf. 8. grotewold e, editor. the science of flavonoids. ohio: department of plant cellular and molecular biology; 2008. 9. fakultas farmasi universitas andalas. metode ekstraksi. 2012 [cited 2012 december 13]. available from: http:// ffarmasi.unand.ac.id/rpkps/metoda_ ekstraksi.pdf. 10. wijayanti ed, soenardiraharjo bp, utomo b. pengaruh pemberian ekstrak daun api-api (avicennia marina) terhadap resorpsi embrio, berat badan dan panjang badan janin mencit (mus musculus). unair journal. 2008;1(1) [cited 2012 december 10]. available from: http:// j o u r n a l . u n a i r. a c . i d / d e t a i l _ j u r n a l . php?id=2260&med=28&bid=5 adisti erlina sutomo, trully d sitorus, adhi pribadi: the teratogenic effect of the mindi (melia azedarach l) leaves ethanol extract on mice (mus musculus) fetus althea medical journal. 2015;2(3) 429 effect of regular exercise on anxiety and self-esteem level in college students zahra hamidah,1 putri teesa radhiyanti santoso,2 rm. haryadi karyono3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of psychiatry, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: regular exercise is often presented as an effective tool to influence the psychological aspect of a human being. recent studies show that anxiety and self-esteem are the most important psychological aspects especially in college students. this study aimed to determine the differences of anxiety and selfesteem level between students who joined and did not join regular exercise program, pendidikan dasar xxi atlas medical pioneer (pendas xxi amp), in the faculty of medicine, universitas padjadjaran. methods: a cross-sectional comparative study was carried out to 64 students who joined and did not join pendas xxi amp. thirty six students (12 females and 20 males) who joined pendas xxi amp participated in aerobic and anaerobic exercise sessions lasting for 30 minutes per session, three times in 5 months. the control group was 32 students who did not join pendas xxi amp, with matching gender composition as the case group (12 females and 20 males). two questionnaires, zung self-rating anxiety scale questionnaire and rosenberg’s self-esteem scale questionnaire, were administered to both groups. the data were analyzed using chi-square test (α=0.05). results: : there were statistically significant differences in anxiety level (p=0.016) and self-esteem level (p=0.039) between case and control groups. the students who joined pendas xxi amp have lower anxiety and higher self-esteem levels. conclusions: planned, structured, and repeated physical activities have a positive influence in anxiety and self-esteem levels. [amj.2015;2(3):429–32] keywords: anxiety, rosenberg’s self-esteem scale, self-esteem, zung self-rating anxiety scale correspondence: zahra hamidah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85721226847 email: zahrahamidah@yahoo.co.id introduction exercise and physical activity have different meanings, physical activity is motion of body produced by muscles and produces increasing out of energy, whereas exercise is planned, structured, and repeated physical activity which has the objectives to improve health.1 previous related studies revealed that regular exercise has benefits for health not only physiological aspect but also psychological aspect.2 anxiety and self-esteem are very important psychological aspects especially in college students. anxiety is defined as an alerting signal that warns of danger and enables a person to take measures to treat an unknown threat, internal vague, or conflictual.3 it is also defined as an uneasy feeling about something threatening but vague event.4 this is a normal and adaptive response to something threatening, but can be pathologist if it happens severely or in the long term.5 self-esteem is defined as a measurement of self-value based on her/his successes.3 in addition, self-esteem is a combination of self-respect and self-confidence which can stimulate self-motivation to reach the purpose. self-esteem can be enhanced also by exercise with influencing the way a person thinks about body image, and also exercise can increase neurotransmitter concentration in brain by stimulating sympathetic nerves. both exercise and self-esteem have important roles in improving quality of human resources and also in increasing their productivity.6 althea medical journal. 2015;2(3) 430 amj september, 2015 the optimal exercise recommended by the reference is performed at least performed during three months, three times a week, and twenty minutes each session.7,8 at the faculty of medicine universitas padjadjaran, there is an extracurricular known as atlas medical pioneer (amp) which performs a program named pendidikan dasar atlas medical pioneer (pendas amp) every two year. in 2012, the program pendas xxi amp performed exercise programs for approximately five months, three times a week, and at least thirty minutes exercise each session. therefore, the researcher wants to know the differences of anxiety and self-esteem levels between students who joined and did not join pendas xxi amp at the faculty of medicine universitas padjadjaran. methods a cross-sectional comparative study was carried out to 64 students who joined and did not join pendas xxi amp. thirty two students (12 female and 20 male) who joined pendas xxi amp participated in the aerobic and anaerobic exercise session lasting 30 minutes per session, three times a week for 5 months. the control group was 32 students who did not join pendas xxi amp, taken randomly with adjusted amount of subjects with the first group (12 female and 20 male). the inclusion criteria were students in faculty of medicine universitas padjadjaran, having good health, and were ready to fillthe informed consent and questionnaires, whereas theexclusion criteria were students who attending a regular exercise program besides pendas xxi amp and did not fill all of the questionnaire, and did not return the questionnaires. two questionnaires i.e. the zung self-rating anxiety scale questionnaire and rosenberg's self-esteem scale questionnaire, were given to both groups to be filled completely. the zung self-rating anxiety scale questionnaire consisted of 20 items with a range of total scores of 20–80, while the rosenberg's selfesteem scale questionnaire consisted of 10 items with a range of total scores of 0–30. the reliability and validity of the questionnaires were found to be acceptable. the data were analyzed using chi-square test (α=0.05). this study received the approval of the head of dewan pengurus xix atlas medical pioneer, and health research ethics committee faculty of medicine universitas padjadjaran. results subjects consisted of 64 students and were ranging in age from 17–22 years old. these subjects were divided into two groups, students who joined pendas xxi amp as the study group (n=32) and students who did not join pendas xxi amp as the control group (n=32). both groups had the same numbers of gender. there were 12 female students and 20 male students in each group. based on the zung self-rating anxiety scale, table 1 shows that the number of people who were anxious in the study group (9.4%) were less than in the control group (34.4%). table 1 anxiety level of students who joined and did not join pendas xxi amp based on zsas (zung self-rating anxiety scale) anxiety level anxious not anxious joined pendas xxi amp 3 (9.4%) 29 (90.6%) did not join pendas xxi amp 11 (34.4%) 21 (65.6%) table 2 self-esteem level of students who joined and did not join pendas xxi amp based on rses (rosenberg’s self-esteem scale questionnaire) self-esteem level low normal joined pendas xxi amp 2 (6.3%) 30 (93.7%) did not join pendas xxi amp 8 (25%) 24 (75%) althea medical journal. 2015;2(3) 431 to obtain a significant result, this study compared the anxiety level the self-esteem level of the study group to control group using chi-square test. the result showed the significant difference (p=0.016) which meant the anxiety level of students who joined pendas xxi amp were lower than of students who did not join pendas xxi amp. based on the rosenberg’s self-esteem scale questionnaire, table 2 shows that the number of people who had low self-esteem level in the study group (6.3%) were less than in the control group (25%). finally, to obtain a significant result of the researcher compared the self-esteem level of the study group to the control group using chi-square test, and the result showed the significant difference (p=0.039) which meant self-esteem level of students who joined pendas xxi amp were higher than of students who did not join pendas xxi amp. discussion based on the zung’s self-rating anxiety scale and rosenberg’s self-esteem scale questionnaires, the results showed that students who joined pendas xxi amp had higher anxiety and self-esteem levels compared to students who did not join pendas xxi amp. this result is appropriate to the research hypothesis because pendas xxi amp had a regular exercise program, but there are several other factors affecting anxiety and self-esteem which the researcher did not consider such as genetic, age, family, education level, endocrine variations, and environmental condition. many references and studies describe the benefits of regular exercise to psychological aspects, including anxiety and self-esteem. one of the references explains about the benefits of exercise which are significantly reducing depression and anxiety levels by diverting attention far from the sources of depression and anxiety. another benefit of exercise is increasing of self-esteem as the increasing of body satisfaction is associated with general self-esteem and confidence.1 regular exercise has an effect also on producing hormone known as endorphine, which stimulates serotonin to work in the limbic system and has a role as an emotion regulator. additionally, serotonin is an important neurotransmitter that is effective in reducing anxious and frightened symptoms. moreover, endorphine has the same chemical structure as morphine and produces an effect that is known as runner’s high which means a very glad feeling and is usually described as euphoric sensation or altered state of consciousness. this explains also why endorphin can alter the level of consciousness with reducing response to external stimulus. besides, exercises can increase the neurotransmitter concentration in the brain by stimulating sympathetic nerves, as well as influencing physiological aspect to better mental health.6 from some similar studies conducted, four hundred elderly people were randomly assessed with the intervention group who had exercises twice a week for two months, and the result was that intervention showed significant effect to prevent mental disorder such as anxiety, social dysfunction, depression, and somatization symptoms.10 another research conducted to forty three subjects aimed to observe the correlation between exercise and self-esteem showed there was positive significant correlation. the correlation between exercise and self-esteem is described by increasing the subjects’ comprehension of the importance of common health.11 the effect of regular exercise to psychological aspect has ever been compared to other activities such as relaxation, health education, social contact, and other activities which had the purpose to distract the mind from anxiety, depression, and also to increase self-esteem. the result was regular exercise has the same effective way as the other activities in giving benefits to psychological aspects.6 the limitation of this study was it did not consider other factors that contributed to the level of anxiety and self-esteem. in conclusion, this study reveals that there is a significant difference (p=0.016) in anxiety level of students who join pendas xxi amp, who have lower anxiety level than students who do not join pendas xxi amp. in addition, there is a significant difference also in self-esteem level (p=0.039) of students who join pendas xxi amp who have higher self-esteem level than students who do not join pendas xxi amp. finally, enhancing good psychological aspect regular exercise is recommended, because not only psychological but regular exercise also has benefits to physiological aspects, for a better quality of life. references 1. odgen j. health psychology. 3rd ed. new york city: mcgraw-hill international; 2004. 2. cohen ge, shamus e. depressed, low self-esteem: what can exercise do for zahra hamidah, putri teesa radhiyanti santoso, rm. haryadi karyono: effect of regular exercise on anxiety and self-esteem level in college students althea medical journal. 2015;2(3) 432 amj september, 2015 you?. internet j allied health sci pract. 2009;7(2). 3. sadock bj, kaplan hi, sadock va. kaplan & sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry. 10th ed. philadelphia: lippincott williams & wilkins and wolter kluwer health; 2007. 4. rachman sj. anxiety. in: brewin cr, editors. the nature of anxiety. 2nd ed. new york: psychology press; 2004. p. 3. 5. semple d, smyth r. oxford handbook of psychiatry. 1st ed. oxford: oxford university press; 2005. 6. craft ll, perna fm. the benefits of exercise for the clinically depressed. j clin psychiatry. 2004;6(3):104‒11. 7. haskell wl, lee im, pate rr, powell ke, blair sn, franklin ba, et al. physical activity and public health: updated recommendation for adults from the american college of sports medicine and the american heart association. med sci sports exerc. 2007;39(8):1423‒34. 8. whitelaw s, swift j, goodwin a, clark d. physical activity and mental health: the role of physical activity in promoting mental wellbeing and preventing mental health problems: an evidence briefing. edinburgh: nhs health scotland; 2008. 9. dahlan ms. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. 10. seyede s, kazem m, hassan e. mental disorder prevention and physical activity in iranian elderly. int j prev med. 2012;3 (suppl1):s64‒s72. 11. misraa r, alexyb b, panigrahi b. the relationships among self-esteem, exercise, and self-rated health in older women. j women aging. 2008;8(1):81‒94. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 213 identification of giardia lamblia, entamoeba histolytica and cryptosporidium sp. in feces of diarrheal patient at puskesmas jatinangor, september–november 2012 komathi palani,¹ lia faridah,² uun sumardi³ 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: diarrhea is one of the main public health problems occurring in west java. one of the affected areas is subdistrict jatinangor. inappropriate management of sanitation facilities around jatinangor area causes contamination of water. cikeruh river is one of the water sources in jatinangor area, from which people obtain water for daily activities. water borne illness due to poor sanitation condition can lead to parasitic infection such as giardia lamblia, entamoeba histolytica and cryptosporidium parvum which can cause a prolonged diarrhea. there has not been any study done regarding the presence of parasitical infection causing diarrhea around jatinangor. methods: in order to identify the parasitic infection, a descriptive study was carried out on 16 fecal samples collected from diarrheal patient who visited puskesmas jatinangor from september–november 2012. the parasites were checked by using wet mount method results: the parasites found were entamoeba histolytica, cryptosporidium parvum, but none of giardia lamblia. there were also other findings such as iodamoeba butschlii and entamoeba coli. conclusion: positive findings of entamoeba histolytica and cryptosporidium parvum in diarrhea patients is most probably due to contaminated water and food. measures need to be done to improve sanitary condition in cikeruh river to prevent diarrhea. [amj.2015;2(1):213–16] keywords: cryptosporidium parvum, diarrhea, entamoeba histolytica, giardia lamblia correspondence: komathi palani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827934648 email: kom_rocks@yahoo.com introduction every year, diarrhea cases occur around 2 billion and can affect people of different ages and sexes worldwide. diarrhea is defined as a passage of watery stool for three times or more in a day. diarrhea can be caused by infectious agents for example: bacteria, virus, and parasite that could be transmitted through poisoned food or polluted water or poor sanitation condition of a person. statistically, diarrhea is the second major causing death worldwide for children under age 5.1 mostly, more than eighty percent of mortality rate occurs in southeast asia and africa.2 approximately 1.5 billion people has poor management of improved water and 2.5 billion people has poor sanitation condition worldwide.1 parasites usually will be more prominent in areas that has dirty environment and they live most commonly in war and moist places thus they grow fruitly in tropical countries.3 basically, among the parasites that causes infection leading to diarrhea, there are three species that most commonly can be seen in feces of a diarrheal patient. they are giardia lamblia, entamoeba histolytica, and cryptosporidium parvum., based on previous research done in bekasi, west java, indonesia and bangladesh.4,5 diarrhea is one of main public health problems occur in west java. in year of 2006, the incidence of diarrheal cases occur in west java was 1.136.447 cases. this is due to poor sanitation condition, also due to improper water supply in the rural side.6 subdistrict jatinangor is a place in sumedang regency, west java province that consists of 12 villages.7 location of subdistrict jatinangor is in exactly in the center of sumedang and directly adjacent to cikeruh river. so, this makes cikeruh river is the one of the water supplies for this area. inappropriate management of the sanitation facilities in althea medical journal. 2015;2(2) 214 amj june, 2015 this area causes water in cikeruh river to be contaminated. previously, this has caused an increase percentage of people suffered from diarrhea in that area in august 2008.8 there has not been any study done regarding the presence of parasitical infection causing diarrhea around jatinangor. methods a descriptive study was done on fecal samples collected from diarrheal patient who visited public health center/pusat kesehatan masyarakat (puskesmas) jatinangor from september–november 2012. the parasites were checked by using wet mount method in parasitology laboratory in universitas padjadjaran. the inclusion criteria was people diagnosed with diarrhea who has signed their informed consent to cooperate with this study whereas the exclusion criteria was people who already had treated with drugs, like metronidazole. sixteen stool samples were collected with a clean, leak-proof plastic container with applicator of spoon attached to screw cup.9,10 using the spoon, stool was placed to a container and immediately transferred it into point of sample collection. then, sample was labeled and given to laboratory to check or determine the presence of parasites in their feces.9,10 before giving the specimen to laboratory, the specimen should be mixed with parasitology transport pack which was 10% formalin or polyvinyl isonyl alcohol (pva), 3 parts stool to 1 preservative part and transported the specimen in room temperature condition in containers sealed in plastic bags.10 stool examination can be done by using either direct method or concentrated techniques for the patients. direct method examination was carried out by taking direct smear and two preparations were made. the first one was with saline solution and another one was with lugol and iodine solution. one drop of saline solution was poured in center of first slide and one drop of 1 % lugol and 50 % iodine was poured into the second slide to check the presence of protozoa’s trophozoite and cysts. the stool specimen was taken using the applicator stick and was emulsified with the saline and iodine solution. thin film was prepared on each slide by mixing stool with a drop of normal saline and iodine solution. cover glass was added and preparation was observed under microscope with 10× objective and 40× objective.11 results from sixteen fecal samples collected from diarrheal patient, the parasites found were entamoeba histolytica (2), cryptosporidium parvum (3), but none of giardia lamblia. there were also other findings such as iodamoeba butschlii (1) and entamoeba coli (6). discussion the expected parasitic findings in this study are entamoeba histolytica, cryptosporidium parvum and giardia lamblia. however, based on table 1, this study only finds entamoeba histolytica in form of cyst and cryptosporidium parvum. there are also other findings which are entamoeba coli in form of cyst and iodamoeba butschlii in form of trophozoite. positive findings of entamoeba histolytica in cyst form are due to the ability of cyst to live in damp and wet conditions especially outside the host in water, food and soils.12 positive findings of cryptosporidium parvum table 1 result of parasitic findings on feces of diarrheal patient in puskesmas jatinangor species no. of sample expected findings giardia lamblia 0 entamoeba histolytica 2 cryptosporidium parvum 3 other findings iodamoeba butschlii 1 entamoeba coli 6 no findings 4 althea medical journal. 2015;2(2) 215komathi palani, lia faridah, uun sumardi: identification of giardia lamblia, entamoeba histolytica and cryptosporidium sp. in feces of diarrheal patient at puskesmas jatinangor, september–november 2012 are due to ability of oocyst of living in long duration in water even added with chlorine. cryptosporidium parvum is also known as ‘chlorine tolerant pathogen’ due to ability of the oocyst to survive in chlorine added water for 3.5 to 10.6 days.13 therefore, those carriers who are symptomatic who pass the cyst through feces become the main source of contaminated food and water. thus, patients affected by both these parasites are due to contaminated water and food which is at high risk of having poor sanitation condition.14 this is supported also by a research done in saudi arabia, where there were also findings on entamoeba histolytica in feces of diarrheal patient due to poor sanitation condition.11 there are negative findings on giardia lamblia because there is decrease test sensitivity in identifying giardia lamblia in single sample of feces, as proved by cartwright which was only to be 74%. decrease in test sensitivity in identifying giardia lamblia in feces of diarrheal patient can be caused by excretion that is varied and low level of shedding of the parasites on the patients.15 in order to increase test sensitivity in identifying giardia lamblia in sample of feces, three sample of feces must be collected on separate days which also known as ‘multiple stool collection.13,16 other findings are the presence of entamoeba coli in cyst and trophozoite form and iodamoeba butschlii. even though entamoeba coli and iodamoeba butschlii, entamoeba histolytica are in same class of amoeba, iodamoeba butschlii and entamoeba coli are known as nonpathogenic parasites.14,17 both species reside in gastrointestinal tract of human and have similar form of infection as pathogenic parasites, entamoeba histolytica.17 in this case, both of these species are noninvasive and present in form of cyst and trophozoite. usually, cysts of both of these species can be identified in formed stool meanwhile trophozoite of both this species can be identified in feces of diarrheal patients.12 even though they are commensal parasites in human, their structure morphological form are often confused/exchanged with the structure and morphological form of entamoeba histolytica, which looks similar.12 however those species of parasites which are nonpathogenic can turn out to be pathogenic in people who has hiv positive, as proved by a survey done in united states of america, more than 50 % of asymptomatic people who had hiv positive usually tested positive for at least one intestinal parasite. thus, all species of parasites compromise human immune system and worsen the condition of those with hiv positive.18 due to limitation of study, the number of sample was limited. measures should be done to improve sanitary condition around cikeruh river to prevent diarrhea. references 1. who. diarrhoeal disease ; fact sheet n0 330. 2009 [cited 2012 may2]. available from: http://www.who.int/mediacentre/ factsheets/fs330/en/index.html 2. unicef/who. why children are still dying and what can be done. new york/ geneva: 2009 [cited 2012 may 2]. available from: whqlibdoc.who.int/ publications/2009/9789241598415_eng. pdf 3. wilson l. parasites and how to eliminate them naturally. 2011[cited 2012 may 2]. available from: http://drlwilson.com/ articles/parasites.htm. 4. haque r, mondal d, karim a, molla ih, rahim a, faroque asg, ahmad n, kirkpatrick bd, houpt e, snider c, petri wa et al. prospective casecontrol study of the association between common enteric protozoal parasites & diarrhea in bangladesh.clin infect dis.2009;48(9):1191–7. 5. uga s, kimura d, kimura k, margono ss. intestinal parasital infections in bekasi district,west java,indonesia and a comparison of infection rates determined by different techniques for fecal examination. southeast asian j trop med public health. 2002;33(3):462–7. 6. hazet fa, roosmini d. priority determination in infrastructure improving location of water supply and sanitation technology based on public health condition. bandung: faculty of civil and environment engineering itb. [cited 2012 may 2]. available from: http://www. ftsl.itb.ac.id/kk/rekayasa_air_dan_limbah_ cair/wp-content/uploads/2010/11/ws2-15304071-frieda-a-hazet.pdf 7. kecamatan jatinangor. potensi kecamatan jatinangor triwulan ii tahun 2009. [cited 2012 may 2]. available from: http:// st288653.sitekno.com/article/33924/ potensi.html. 8. harindi ft, kamil im. application of small bore sewer di kecamatan jatinangor, kabupaten sumedang. bandung: faculty of civil and environment engineering althea medical journal. 2015;2(2) 216 amj june, 2015 itb. [cited 2012 may 2]. available from: http://www.ftsl.itb.ac.id/kk/rekayasa_ a i r _ d a n _ l i m b a h _ c a i r / w p c o n t e n t / uploads/2010/11/pe-ww3-finda-tantiaharindi-15305014.pdf 9. nkrumah b, nguah sb. giardia lamblia: a major parasitic cause of childhood diarrhoea in patients attending a district hospital in ghana. parasit vectors. 2011;4:163. 10. who. guidelines for the collection of clinical specimens during field investigation of outbreaks.2000.who/ cds/csr/edc/2000.4. [cited 2012 may 2] available from: http://apps.who.int/ iris/bitstream/10665/66348/1/who_ cds_csr_edc_2000.4.pdf ?ua=1&ua=1 11. zaglool dam, khodari yaw, gazzaz zj, dhafar ko, shaker has, farooq mu et al. prevalence of intestinal parasites among patients of al-noor specialist hospital, makkah, saudi arabia. oman med j. 2011;26(3):182–5. 12. cdc. amebiasis. atlanta: dpdx laboratory identification of parasites of public health concern; 2009.[cited 2012 december 9];available from: http://www.cdc.gov/ dpdx/amebiasis/ 13. centers for disease control and prevention. cryptosporidiosis surveillance-united states, 2009–2010 and giardiasis surveillance-united states, 2009-2010. mmwr. 2012;61(5):1–19. 14. assafa d, kibru e, nagesh s, gebreselassie s, deribe f, ali j et al.medical parasitology. 2004 [cited 2012 december 9].available from: http://www.cartercenter.org/ resources/pdfs/health/ephti/library/ lecture_notes/health_science_students/ medicalparasitology.pdf. 15. mank tg. the diagnosis and clinical importance of giardiasis. [online journal] 2005 [cited 2012 december 9]. available from: http://www.cli-online.com/ fileadmin/pdf/pdf_general/the-diagnosisand-clinical-importance-of-giardiasis.pdf. 16. cartwright cp. utility of multiple-stoolspecimen ova and parasite examinations in a high prevalence setting. j clin microbiol. 1999; 37(8):2408–11. 17. machado er, de souza ts, da costa jm, costa-cruz jmc. enteroparasites and commnensals among individuals living in rural and urban areas in abadia dos dourados, minas gerais state. parasitol latinoam. 2008;63(1–4):34–9. 18. kaiser jd. intestinal parasites. [online journal] 2010 [cited 2012 december 10]. available from: http://www.jonkaiser. c o m / e d u c a te / d ow n l o a d s / i n te s t i n a l _ parasites_6-05.pdf. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 241 enteropathogenic bacteria from padang food in jatinangor september–october 2012 syed anwar husain,1 sunarjati sudigdoadi,2 abdullah firmansah3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of medical nutrition faculty of medicine universitas padjadjaran abstract background: diarrhea is a food borne disease and still a major health problem in indonesia. padang food is a popular cuisine and is exposed on an opened display, sometimes for many hours in room temperature, catering favorable conditions for bacterial growth. this study is undertaken to identify enteropathogenic bacteria on food in padang restaurants located in jatinangor, sumedang methods: a laboratory study was conducted in the microbiology laboratory of the department of microbiology in the faculty of medicine, universitas padjadjaran, during september–october 2012. samples were collected from 5 padang restaurants located in jatinangor using systematic random sampling. from each restaurant, 4 wet samples were collected approximately 2–4 hours after being left open on the display shelves from sambal hijau, sambal merah, gulai babat and gulai nangka, cultured in tryptic soy broth (tsb) and incubated for 24 hours at 37 ºc, then inoculated in mac conkey agar and incubated for 24 hours at 37 ºc. gram-staining was performed to identify gram-negative rods. the bacteria were put through biochemical tests. results: four species bacteria from the enterobacteriaceae family were identified. the most frequent bacteria which was identified in the samples was shigella sp (4 from 20), followed by klebsiella pneumonia (3 from 20), escherichia coli and pseudomonas sp were less identified. conclusions: various padang foods have potential risks of bacterial contamination due to the preparation, handling, and serving. it should be considered that the prepared food should be covered and placed in food warmers, ensuring warm food for hours. [amj.2015;2(1):241–44] keywords: contamination, enteropathogenic, food-borne disease, padang food correspondence: syed anwar husain, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170208122 email: rawnadeys@gmail.com introduction food contains the essential nutrition that needed to maintain the functions of human body such as; metabolism, growth and repairement of cell damage, regulation and protection. inappropriate food preparation, handling and serving will result in food contamination. this situation can result the transmission of various communicable food borne diseases.1 diarrhea is a major disease which also acts as a major mortality agent worldwide. in 1998, diarrhea was the approximated cause of the mortality of 2.2 million people, where the majority of the people were under 5 years of age (who, 2000).1 annually, there is an estimated of 4 billion cases of diarrhea worldwide. the etiology of diarrhea can range from viruses, bacteria, parasites and may also occur after ingestion of drugs and chemical toxins. transmissions of these harmful bacteria are usually through means of vectors as well as improper preparation and handling.1 leaving food in certain temperatures for extensive periods of time can greatly contribute to bacterial growth.2 padang food is frequently consumed by indonesian community and are famous for their spicy food and their unique way of serving it.3 the food is displayed in an open display and is usually stacked on plates without any cover, leaving all the food exposed to the air and vectors such as flies.4 it is important to note that the food is usually kept in the open for many hours at room temperature, which caters to favorable conditions for bacterial growth.2 based on these obvious factors existing in many padang restaurants, this study was undertaken to isolate and identify any enteropathogenic bacteria on padang food in padang restaurants located in jatinangor, sumedang. althea medical journal. 2015;2(2) 242 amj june, 2015 methods a laboratory study was conducted in the microbiology laboratory of the department of microbiology in the faculty of medicine, universitas padjadjaran, jatinangor during september–october 2012. the samples used in this study were padang food from various padang restaurants located in jatinangor. from 10 padang restaurants, a systematic random sampling was conducted to get 5 samples of the restaurants.4 from each restaurant, 4 wet samples were collected from sambal hijau, sambal merah, gulai babat and gulai nangka. the samples were collected approximately 2–4 hours after being left open on the display shelves. the exclusion criteria were padang restaurants which covered their food properly. after being taken the samples were brought to the laboratory, and were cultured in tryptic soy broth (tsb) and incubated for 24 hours at 37 ºc. after 24 hours, the samples were inoculated in mac conkey agar and incubated for 24 hours at 37 ºc.5 growth of colonies in the macconkey agar were observed in order to distinguish between lactose and non-lactose fermenters. following that, gram-staining was performed in order to differentiate between gram-positive and gramnegative bacteria. once the gram-negative rods bacteria were found, the bacteria were put through biochemical tests which include kligler iron agar (kia), motility, indole and urease (miu) agar and citrate agar followed by incubation for 24 hours at 37 ºc. the results are then interpreted to identify the bacteria species.5 then the results were tabulated. results four species bacteria from the enterobacteriaceae family were identified (table 1). the most frequent bacteria which was identified in the samples was shigella sp. followed by klebsiella pneumonia. although other bacteria were less identified, escherichia coli and pseudomonas sp should be remained as an important bacteria that can cause diarrhea. based on table 2, only one restaurant that had no bacteria in their food sample. there was two restaurants that had various bacteria in their food samples. others restaurants had only one bacteria in their food samples, either klebsiella pneumoniae or shigella sp. discussions based on the data collected and interpreted, it can be concluded that the majority of food sampled from the padang restaurants did contain bacteria. about 4 out of 20 samples contained pathogenic bacteria, namely shigella. around 2 samples contained potentially pathogenic bacteria, which was escherichia coli.6 there are many ways the food was contaminated with these bacteria, such as improper handling, preparation, and storage of food. there also could have been possible contamination of food and utensils from vectors like flies, roaches, and other insects and pests. one of the most important catalysts for the bacteria growth was the temperature, since the food was kept in the open for more than 2 hours at room temperature.2 among the reasons why some of the samples had no growth of bacteria could be because the food was cooked properly at the right temperature until it was fully cooked. another probable reason was because the restaurant had taken strict measures to ensure bacterial vectors were reduced in the vicinity and that the cooks and workers practiced table 1 numbers of contaminated samples species number of contaminated samples escherichia coli 2 shigella sp 4 klebsiella pneumoniae 3 pseudomonas sp 2 none 9 total 20 althea medical journal. 2015;2(2) 243 good hygiene such as cleaning the utensils and apparatus properly as well as self-hygiene.7 when escherichia coli is present, it was suspected that there is some sort of fecal contamination present in the water or even food contaminated through vectors or feces around the food preparation site. escherichia coli is a frequent cause of bacterial infections in humans which often involve the intestine. the pathovars of the main intestinal infections include many such as enterohemorrhagic, enteroaggregative, and enterotoxigenic variants among others. however the danger posed by escherichia coli is only evident if the pathovar involved is a pathogenic type, such as the enterohemorrhagic variant.8 this is because escherichia coli is also a normal flora in the intestine of humans and animals alike. unfortunately in this research, the identification of the pathovars could not be done due to the lack of the facilities in the microbiology laboratory as well as the funds. the verification of the type of pathovar determines its potential to be a danger to humans.10 shigella is another enteropathogenic bacteria which is closely related to escherichia coli since they are capable in producing the harmful and potent shigatoxin during the course of an infection.8 it is a major cause of diarrhea throughout developing countries in the world, and leading cause of infant diarrhea and mortality. transmission occurs through the fecal-oral route primarily by contamination of hands. some of the subtypes include four species namely; shigella dysenteriae, shigella flexneri, shigella sonnei and shigella boydii. although harmful in nature, the degree of harmfulness is influenced by the infective dose, measured in number of microorganisms, which is on the order of 103 or 1000 organisms.8 perhaps another research should be conducted to find out the infective dose of the bacteria. therefore the measured number of microorganisms will influence the danger level of whether it can cause serious repercussions. pseudomonas is a common gram negative table 2 identification of bacteria according to the distribution of restaurants restaurant sample bacteria present 1 a none b none c none d none 2 a pseudomonas sp b klebsiella pneumoniae c escherichia coli d escherichia coli 3 a none b pseudomonas sp c shigella sp d klebsiella pneumoniae 4 a none b none c klebsiella pneumoniae d none 5 a shigella sp b shigella sp c none d shigella sp note: a: sambal hijau, b: sambal merah, c: gulai babat, d: gulai nangka syed anwar husain, sunarjati sudigdoadi, abdullah firmansah: enteropathogenic bacteria from padang food in jatinangor september–october 2012 althea medical journal. 2015;2(2) 244 amj june, 2015 bacteria which is an opportunistic human pathogen, meaning it seldom infects healthy individuals. it is mostly found in soil, water and man-made environments. klebsiella pneumoniae is similar in most aspects and is present in the respiratory tract as well as feces of about 5% of normal individuals.8 the presence of these bacteria proves that it could be normal occurring bacteria or perhaps it is an unanticipated contamination of the sample during transportation. however, it could also be related to the improper hygiene of the restaurant. the limitations of this study, it could not identify the species of the bacteria (pathogenic, non-pathogenic) due to limited laboratory facilities and funds. conclusively, various padang foods have potential risks of bacterial contamination due to the preparation, handling, and serving as mention in this study. it should be considered that the prepared food should be covered and placed in food warmers, ensuring warm food for hours. since there are various of padang foods prepared in the padang restaurants, a broader study should be conducted using other types of food and more samples should be added. moreover the samples of food should be collected several times in one day to identify the beginning of the emergence of the bacteria. references 1. who. water sanitation health. geneva: world health organization;2012 [cited 2012 may 10]. available from: http:// www.who.int/water_sanitation_health/ diseases/diarrhoea/en/. 2. food safety and inspection service. safe food handling. omaha: united states department of agriculture; 2011 [cited 2012 may 12]. available from: http:// www.fsis.usda.gov/factsheets/danger_ zone/index.asp. 3. expat web site association jakarta indonesia. indonesian food: a memorable southeast asian cuisine. jakarta: expat web site association jakarta indonesia; 2011 [cited 2012 may 15]. available from: http://www.expat.or.id/info/ indonesianfood.html. 4. kirk jh. flies and disease. davis: university of california; 2004 [cited 2012 may 15]. available from: http://www.vetmed. ucdavis.edu/vetext/inf-da.html. 5. pommerville j. alcamo’s laboratory fundamentals of microbiology. 8th ed. sudbury: jones & bartlett publishers; 2010. 6. brooks gf, butel js. jawetz, melnick, and adelberg’s medical microbiology. 25th ed. new york: mcgraw-hill medical; 2010. p. 237–8. 7. feist s. safe food handling. arlington: the partnership for food safety education; 2010 [cited 2012 may 12]. available from: http://fightbac.org/. 8. todar k. pathogenic escherichia coli. madison: university of wisconsin; 2011 [cited 2012 november 18]. available from: http://textbookofbacteriology. net/e.coli.html. 9. who. risk characterization of microbiological hazards in food. 17th ed. geneva: world health organization; 2009. p. 14–26. 10. parija sc. textbook of microbiology and immunology. 2nd ed. gurgaon: elsevier india; 2009 althea medical journal. 2015;2(3) 440 amj september, 2015 physical fitness component profiles of futsal team members of universitas padjadjaran in november 2011 r. muhammad tanri arrizasyifaa,1 juliati,2 vitriana3 1faculty of medicine universitas padjadjaran, 2department of physiology, faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: to be a good athlete, an athlete needs to possess good predominant components of physical fitness. futsal team of universitas padjadjaran has never won any competition. this study was conducted to identify the predominant component profiles of physical fitness of futsal team members of universitas padjadjaran. the predominant component profiles were classified based on the indonesian national sport committee (koni) standard. methods: this study was carried out at the faculty of medicine student center of universitas padjadjaran in november 2012. twenty two members of the futsal team were enrolled as subjects of the study. the study used the step test to examine aerobic endurance; the leg dynamometer to measure leg muscle strength; the squat jump test to test the leg muscle endurance; the vertical jump test to measure leg muscle power; and the sit and reach test to measure lower extremity flexibility. the data collected were analyzed using percentage. results: leg muscle strength was mostly in the fair category (95%). leg muscle power was mostly in the good category (41%). leg muscle endurance was mostly in the good category (82%). leg flexibility was mostly in the excellent category (91%) and aerobic endurance was mostly in the good category (41%). conclusions: only several members of universitas padjadjaran futsal team have an excellent physical fitness profile. most of the members fell into the fair and good category. [amj.2015;2(3):440–7] keywords: aerobic endurance, flexibility, futsal, muscle endurance, muscle power correspondence: r muhammad tanri arrizasyifaa, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285722519696 email: arrizasyifaa@gmail.com introduction sport has become an important part in people's lives. people do sport for various purposes. it can be a means of recreation, maintenance or improvement of health, education, and also a means of achievement.1,2 futsal is a popular sport, including on university and college level. in order to be capable for accomplishing good achievements, it is necessary for athletes to possess good predominant components of physical fitness. the predominant components of physical fitness for futsal players are muscle strength, muscle endurance, muscle power, flexibility, and aerobic endurance.3 the universitas padjadjaran futsal team has been active in recent years by participating in various competitions. however, up to now, the team has never won any competition. this study was undertaken to identify the profile of physical fitness components of the universitas padjadjaran futsal team which will be classified based on the indonesian national sport committee (koni) standard. methods this study was carried out at the faculty of medicine student center padjadjaran university in november 2012. twenty two members of the futsal team were enrolled as subjects of the study. the subjects received explanation about the study before it was conducted. it was confirmed that the subjects would not perform althea medical journal. 2015;2(3) 441 any strenuous activities two days before the test and have enough sleep (≥ 7 hours) the night before the data collection day. the subjects were weighed with weight scales and their heights were measured by a height gauge. resting pulse was calculated, and systolic and diastolic blood pressures at rest were measured using a sphygmomanometer. the subjects then warmed up and stretched for 15 minutes. afterward , assisted by a standardized examiner team, the measurement of predominant physical components was executed in the following order: astrandrhyming step test was performed to examine aerobic endurance; a leg dynamometer was used to measure lower extremity muscle strength; the squat jump test was performed to test the endurance of leg muscle; vertical jump test was performed to measure power of the lower leg muscles; and sit and reach test was performed to measure lower extremity flexibility.4 then, the results were compared to the indonesian national sport committee standard. next, data were analyzed using percentage. results out of 22 participants, 95% had fair category of muscle strength, 41% had good category of muscle power, followed by very good and excellent (18% and 5%, respectively). moreover, 82% of the participants had good category of muscle endurance, 91% had excellent flexibility and only half of them had good and excellent durability (41% and 5 %, respectively). discussion universitas padjadjaran futsal team members have leg muscle strength that is classified into the fair and good categories with the average value of 104.56. this shows that the leg muscle strength training that has been performed so far was sufficient. in order to achieve better scores, it is preferable to execute isokinetic contraction on muscle strength training exercises. isokinetic contraction exercise is proven to be more effective to strengthen muscle, compared to isometric contraction.5 moreover, they had leg muscle explosive power that varies with the average value of 54.64. this indicated that exercise which has been carried out was not in accordance with the needs of the athletes. referring to literatures, it states that muscle power is influenced by strength and speed. even though muscle strength of the futsal athletes fall into the category of fair and good, the varying explosive power found among the team members confirm that there is another predominant component of physical fitness which is also influential. these results illustrate that a combination of exercises are needed to form good explosive power of figure 1 profile of physical fitness components of universitas padjadjaran futsal team r. muhammad tanri arrizasyifaa, juliati, vitriana: physical fitness component profiles of futsal team members of universitas padjadjaran in november 2011 althea medical journal. 2015;2(3) 442 amj september, 2015 athletes’ muscles.5,6 the majority of the futsal team members’ leg muscle endurance is good, with an average value of 59.50. some fall into the category of fair and very good, thus indicating that the allotted trainings were adequate in meeting the needs. the limb flexibility of the futsal team members is almost entirely excellent with an average value of 35.98. only a small part is in the good category. this shows that the portion of the exercise to increase flexibility is already very adequate. aerobic metabolism is the primary energy system in soccer and highly important to a player’s recovery during a game.7 figure 1, shows that the aerobic endurance of universitas padjadjaran futsal team members vary with the average value of 46.55. in general, the team falls under the category of fair and good. furthermore, a small part of athletes are very good and excellent, but there are also athletes in the poor category. this shows that the allotted portion of practice has not fulfilled the needs of all athletes. nonetheless, poor value can also be caused by genetic factors and respiratory issues.8,9 the type of exercise that is recommended to improve physical fitness is aerobic which may activate at least 40% of the body muscles simultaneously within 30–60 minutes. the exercise should be done 3–5 times in a week.2 based on observations, universitas padjadjaran futsal team members currently regularly practice two times a week but with an uncertain duration of aerobic exercise. the poor measurement results of some athletes may also be caused by the duration of exercise they have endured and its propriety with the training periodization system. within the periodization training, it is recommended that the exercises are done for at least 4 months. muscular strength, general endurance, and flexibility must be trained during the first 6 weeks. meanwhile, the explosive muscles power should be trained on week 7 to week 12 and the muscular endurance on week 13 to week-to-16.2 limitation of this study is subjects are not distinguished by length of training while differences in length of training course can affect the test results. limitation in terms of the team’s physical examination may also lead to interobserver bias. in addition, this study also did not pay attention to other factors that can influence the results, such as nutritional factors.10 it can be concluded that not all membersof universitas padjadjaran futsal team have an excellent physical fitness profile. most of them, fall into fair and good category. references 1. giriwijoyo hyss, editor. olahraga dan olahraga kesehatan. 7th ed. bandung: fpok upi; 2007. 2. purba a. kardiovaskular dan faal olahraga. bandung: bagian ilmu faal/faal olahraga fakultas kedokteran universitas padjadjaran; 2006. 3. fifa. futsal. [cited 2012 november 12]; available from: www.fifa.com 4. purba a. prosedur pelaksanaan tes kondisi fisik/tes fisiologi atlet. in: albert hutapea, leonardo lubis, aep kusnandar, editors. bandung: perhimpunan ahli ilmu faal olahraga indonesia (paifori); 2011. 5. harsono. coaching dan aspek-aspek psikologis dalam coaching. jakarta: p2lptk; 1988. 6. wilmore jh, costill dl. physiology of sport and exercise. 10th ed. illinois: human kinetics; 1994. 7. reilly t, bangsbo j, franks a. anthropometric and physiological predispositions for elite soccer. j sports sci. 2000;18(9):669–83. 8. bompa to, haff gg. periodization: theory and methodology of training. 5th ed. illinois: human kinetics; 2009. 9. fox el, foss ml, keteyian sg. physiological basis for exercise and sport. 6th ed. new york: mcgraw-hill; 1998. 10. hinckson ea, dickinson a, water t, sands m, penman l. physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. res dev disabil. 2013; 34(4):1170–8. althea medical journal. 2015;2(3) 443 characteristics and predisposing factors of bacterial corneal ulcer in the national eye center, cicendo eye hospital, bandung from january to december 2011 astrid maharani putri,1 susi heryati,2 nursiah nasution3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/national eye center cicendo eye hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: corneal ulcer is an emergency condition in ophthalmology, causing visual impairment, mostly by bacterial infection with rapid pathogenesis. the aim of this study was to discover the characteristics of bacterial corneal ulcer patients in the national eye center, cicendo eye hospital, bandung.. methods: a total of 99 medical records consisted of patients diagnosed with bacterial corneal ulcer were selected in this descriptive study. the clinical patterns and predisposing factors of the patients were analyzed. the study also identified the pathogenic bacteria of the cases. this study was carried out in the national eye center, cicendo eye hospital, bandung from january to december 2011 clinical patterns. the collected data were analyzed and presented in frequency tabulation. results: the male to female ratio was 2:1, with the average age of 44.4 years. the most common presenting symptom was eye pain (70.7%). most patients came with decreased visual acuity that was categorized as (near-) blindness (78.8%) and the location of the ulcer was in central area of the cornea (56.5%). the most common predisposing factor was ocular trauma (74.7%) that was caused by exposed to plants. singlebacterial infection (67.7%) was predominant, with 56 cases (56.6%) of gram-positive cocci infection. conclusions: bacterial corneal ulcer contributes to 48.8% of all microbial corneal ulcers. most patients came with mild condition, centralized location, and poor visual function. the common predisposing factor was trauma associated with exposed to plants. keywords: bacterial infection, corneal ulcer, trauma, visual acuity correspondence: astrid maharani putri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287877558216 email: a.maharaniputri@gmail.com introduction corneal ulcer is a pathologic condition that develops in cornea, which is characterized by suppurative infiltrate and discontinuity of corneal tissue starting from epithelium to stroma. corneal ulcer is mostly caused by infection, with 90% of the corneal infection caused by bacteria. bacterial ulcers tend to have a more rapid pathogenesis. corneal ulcer is also an emergency condition in ophthalmology because it can form turbidity at the cornea. this may lead to visual impairment and even blindness.1-4 in many parts of the world, corneal ulcer is one of the major causes of blindness.5-9 dhakwa et al. 5 reported that out of 414 cases, bacterial cultures were positive in 300 cases. pure bacterial growth was present in 121 of all corneal ulcer cases, with single-bacterial infection more dominant than multiplebacterial infection. this study was intended to collect data related to epidemiological features, predisposing factors, causative microorganisms, and clinical manifestations for cases of bacterial corneal ulcers, which aimed to provide background information of bacterial corneal ulcers. methods the descriptive study was conducted in the national eye center cicendo eye hospital bandung in augusts to november 2012. medical records were reviewed for 203 patients with corneal ulcers who were treated althea medical journal. 2015;2(3) 444 amj september, 2015 or hospitalized at the indonesian national eye center (inec) – bandung cicendo eye hospital from 1st of january to 31st of december 2011. medical records were carefully examined; cases with viral or fungal infections and incomplete medical records were excluded, resulting in 99 patients with bacterial corneal ulcer out of the total 203 patients with corneal ulcer. medical records were reviewed to determine prominent features including sex, age, symptoms, visual acuity, predisposing factors, degree of severity, pathogenic bacteria, and location of ulcer. all these patients’ data were recorded in microsoft office excel and then analyzed with spss version 15.0. results the epidemiological characteristics’ distribution of patients diagnosed with bacterial corneal ulcer is presented in table 1. the male to female ratio was 2:1. the average age of all patients was 44.4 years. symptoms were also reviewed; the most frequent presenting symptom was eye pain, which was complained by 70 patients (70.7%) out of the total bacterial corneal ulcer patients. the next most frequent symptoms were red eye (61 patients; 61.6%) and white spot at black part of the eye (50 patients; 50.5%). most of the patients came with (near-) blindness (78 patients; 78.8%). predisposing factors were identified for 92 patients (92.9%). the most common predisposing factor for bacterial corneal ulcer was ocular trauma (74.7%) (table 2) corneal scrapping had been performed for patients with suspected microbial corneal ulcer. the result of microbiological examination with gram staining was written in the medical records. infection by single-bacteria (67 patients; 67.7%) was predominantly found in patients with bacterial corneal ulcer than with multiple-bacteria (32.3%). most of the cases of single-bacterial infection were caused by gram-positive cocci (table 3) table 1 characteristics of patients with bacterial corneal ulcer characteristic bacterial corneal ulcer n (%) sex male 66 (66.7) female 33 (33.3) age, y,ears, mean (sd) 44.4 (16.3) symptoms eye pain 70 (70.7) red eye 61 (61.6) white spot at black part of the eye 50 (50.5) decreased in vision 35 (35.4) watery eye 29 (29.3) propped eye 16 (16.2) exudate 14 (14.1) itchy eye 12 (12.1) swollen eye 7 (7.1) headache 7 (7.1) photophobia 5 (5.1) visual acuity (near-) normal vision 5 (5.1) low vision 16 (16.2) (near-) blindness 78 (78.8) althea medical journal. 2015;2(3) 445 the severity cases in this study was based on jones’, the most prominent degree of severity criteria of all patients with bacterial corneal ulcer was mild, as presented in table 4. the majority of bacterial corneal ulcer patients were (near-) blindness with the location of ulcer at the central cornea (53 patients; 53.5%). however, of all cases with low vision (n=16), 3 cases were at the central cornea, 10 cases were at paracentral, and others were at peripheral. of all cases with (near-) normal vision (n=5), no cases were identified at the central cornea. the distribution of visual acuity and ulcer location is presented in table 5. discussion table 2 predisposing factors of patients with bacterial corneal ulcer predisposing factors bacterial corneal ulcer n (%) trauma: 74 (74.7) plant matter 26 (26.3) dust 14 (14.1) soil 11 (11.1) wood 6 (6.1) stone 5 (5.1) metal 4 (4.0) insect 3 (3.0) unidentified source 5 (5.1) chronic ocular and systemic disorder: 12 (12.1) keratitis 3 (3.0) pterigium 2 (2.0) endophtalmitis 2 (2.0) diabetes mellitus 2 (2.0) panophtalmitis 1 (1.0) blepharitis 1 (1.0) trichiasis 1 (1.0) contact-lens wear 4 (4.0) recent ocular surgery 2 (2.0) unknown 7 (7.1) table 3 pathogenic bacteria of patients with bacterial corneal ulcer bacteria bacterial corneal ulcer n (%) single-bacteria 67 (67.7) gram-positive cocci 56 (56.6) gram-negative cocci 1 (1.0) gram-negative baccili 10 (10.1) multiple-bacteria 32 (32.3) astrid maharani putri, susi heryati, nursiah nasution: characteristics and predisposing factors of bacterial corneal ulcer in the national eye center, cicendo eye hospital, bandung from january to december 2011 althea medical journal. 2015;2(3) 446 amj september, 2015 corneal ulcer is an ophthalmic emergency requiring immediate diagnosis and treatment, especially bacterial corneal ulcer because of its rapid pathogenesis. diagnosis of corneal ulcer can be established by clinical examinations, whereas diagnosis of its etiology cannot be established only by clinical manifestations. diagnosis of etiology depends on laboratory examinations, like smears and cultures from direct scrapes of the corneal ulcer. the success of its treatment and prognosis depends on the appropriate diagnosis, etiology, and degree of severity.1,7,10,11 knowing the characteristics of patients with bacterial corneal ulcer including predisposing factors, etiology, and degree of severity may help in establishing diagnosis and treatment appropriately and promptly. in this study, the incidence of bacterial corneal ulcer was more predominant in male (66.7%) than female (33.3%). this finding is similar to other studies which have been conducted in indonesia and other countries. for example, in the studies in dr. sardjito hospital5, in nepal7, and in taiwan12, the majority of bacterial corneal ulcer patients were male. this may occur because male tends to have more outdoor activities like working, or those with certain occupations that puts them at high-risk locations for ocular trauma, i.e farmers and laborers.7,9 the average age of all patients was 44.4 years. this finding is similar to other studies. fong et al.12 reported in his study in taiwan during 1992–2001 that the mean age of all patients was 40.7 years. additionally, jeng et al.13 also reported in his study in northern california during 1998–1999 that the mean age was 42.8 years.12,13 according to the literatures, symptoms of bacterial corneal ulcer are decreased vision, red eye, photophobia, eye pain, and exudates.3,14 in this study, most of the symptoms found were similar to the literature, with the most frequent presenting symptom was eye pain (70.7%). most of patients in this study came with poor visual function which was categorized as (near-) blindness (78.8%). this finding is similar to the study conducted in dr. sardjito hospital, stating that most of the patients came with visual acuity <3/60, which was categorized as blindness according to who standard definition.2,7 the most common predisposing factor was ocular trauma, particularly by plant. based on the result of the study performed by dhakhwa et al.5, cases of corneal ulcer in western nepal frequently occurred as sequela of agricultural injury causing corneal abrasion. so this finding is similar to the studies mentioned previously. corneal ulcer due to single-bacterial infection is prominent, mainly by grampositive cocci bacteria (56.6%). this finding is also similar to other studies, as performed by dhakhwa et al.5 in western nepal in 2007. the study reported that bacterial corneal ulcer was mostly caused by gram-positive cocci single bacterial infection.5 according to jones’ criteria, clinical degree of severity of corneal ulcer is graded as mild, moderate, or severe. four essential aspects are required in assessing the severity, i.e ulcer size, ulcer depth, infiltrate, and scleral involvement15. most of the patients came table 4 severity of patients with bacterial corneal ulcer severity bacterial corneal ulcer n (%) mild 51 (51.5) moderate 16 (16.2) severe 32 (32.3) table 5 visual acuity and ulcer location of patients with bacterial corneal ulcer visual acuity ulcer location central n(%) paracentral n(%) periphery n(%) (near-) normal vision 4 (4.0) 1 (1.0) low vision 3 (3.0) 10 (10.1) 3 (3.0) (near-) blindness 53 (53.5) 20 (20.2) 5 (5.1) althea medical journal. 2015;2(3) 447 with mild severity (51.5%), and this is similar to the study in dr. sardjito hospital, as the tertiary eye care in d.i. yogyakarta, reporting that patients mostly came with mild severity (43.9%), followed by moderate (31.6%) and severe (24.7%).7 in this study, all of the ulcers located at the central cornea cause visual impairment and mostly cause (near-) blindness. this finding is similar to the literature stating that corneal ulcer is one of the emergency conditions in ophthalmology because cornea plays an important role in maintaining visual function, specifically as a refractive media which has optical properties (determined by its transparency, surface smoothness, contour and refractive index). if a turbidity is developed in the cornea, it will induce alteration in its optical properties and therefore interfere the entry of light, so it may cause impaired vision.1,4,16 there were some limitations in this study. this study was a cross-sectional retrospective study using secondary data; therefore, the quality of this research result totally depended on the quality of those data. some data were incomplete, so they must be excluded. in conclusion, the incidence of microbial corneal ulcer was 203 cases, with 48.8% was bacterial type. the characteristics of patients’ bacterial corneal ulcer found in this study mostly occurred to male patients. they came with eye pain, history of ocular trauma mostly caused by plant, and caused by gram-positive cocci bacterial infection. most of the patients were diagnosed with mild severity, with central location, and poor visual function. despite these limitations, this research is considered to be useful as a basis of upcoming research and essential information for health workers and the society. according to these findings, it is recommended that visual acuity to be included as an additional aspect to assess the clinical severity of corneal ulcer. references 1. ilyas s, editor. ilmu penyakit mata. 3th ed. jakarta: balai penerbit fkui; 2005. p. 4-167. 2. dijk kv. definition: visual impairment. 2012. [cited 2012 may 14]. available from: http://www.bpaindia.org/vib%20 chapter-i.pdf. 3. lang gk. cornea. in: lang gk, editor. ophtalmology: a short textbook. stuttgart: georg thieme verlag; 2000. p. 117–56. 4. kumar a, pandya s, kavathia g, antala s, madan m, jadvekar t. microbial keratitis in gujarat, western india: findings from 200 cases. pan afr med j. 2011;10:48. 5. dhakhwa k, sharma, bajimaya s, dwivedi ak, rai s. causative organisms in microbial keratitis, their sensitivity pattern and treatment outcome in western nepal. nepal j ophtalmol. 2012;4(1):119–27. 6. norina tj, raihan s, bakiah s, ezanee m, liza-sharmini at, wan hazzabah wh. microbial keratitis: aetiological diagnosis and clinical features in patients admitted to hospital university sains malaysia. singapore med j. 2008;49(1):67–71. 7. suhardjo, widodo f, dewi um. tingkat keparahan ulkus kornea di rs 8. dr. sardjito sebagai tempat pelayanan mata tersier. medika. 2003;29(3):148–52. 9. sinha r, sharma n, vajpayee rb. corneal blindness-present status.. cataract & refractive surgery today. 2005. [cited 2012 may 14] available from: http:// crstoday.com/2005/09/crst1005_14. php/ 10. bangun cyy. prevalensi kebutaan akibat kelainan kornea di kabupaten langkat (thesis). medan:university of sumatera utara; 2009. 11. biswell r. vaughan & asbury’s general ophtalmology. 16th ed. new york:mcgrawhill medical; 2007. 12. seal dv, pleyer u. ocular infection. 2th ed. boca raton, florida: crc press; 2008. 13. fong cf, tseng ch, hu fr,wang ij, chen wl, hou yc. clinical chracteristics of microbial keratitis in a university hospital in taiwan. am j ophtalmol. 2004;137(2):329–36 14. jeng bh, gritz dc, kumar ab, holsclaw ds, porco tc, smith sd, et al.. epidemiology of ulcerative keratitis in northern california. arch ophtalmol. 2010;128(8):1022–8 15. mielke j. cornea. in: schlote t, rohrbach j, grueb m, mielke j, editors. pocket atlas of ophtalmology. new york: thieme; 2006. p. 96–7. 16. cokingtin cd, hyndiuk ra. bacterial keratitis. in: tabbara kf, hyndiuk ra, editors. infections of the eye. 2th ed. new york: little, brown and company; 1996. p. 323–44. 17. nishida t. cornea. in: krachmer jh, mannis mj, holland ej, editors. cornea. 2th ed. new york: elsevier mosby; 2005. p. 3–22. astrid maharani putri, susi heryati, nursiah nasution: characteristics and predisposing factors of bacterial corneal ulcer in the national eye center, cicendo eye hospital, bandung from january to december 2011 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 50 amj march, 2015 hyperuricemia and proteinuria in type 2 diabetic patients fatya annisa haryandini1, tiene rostini2 1faculty of medicine, universitas padjadjaran, 2department of clinical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: type 2 diabetes mellitus (t2dm) is a metabolic disorder that has diabetic nephropathy as a complication characterized by proteinuria. when type 2 diabetic patient’s kidney is damaged, hyperuricemia occurs. this study evaluated the correlation of serum uric acid and proteinuria levels in type 2 diabetic patients from outpatient endocrine clinic at dr. hasan sadikin general hospital from january to december 2011. methods: in a cross-sectional study of 125 patients (55 male and 70 female) with type 2 diabetes mellitus, the data of serum uric acid, fasting plasma glucose, 2-h post oral glucose load plasma glucose, serum highdensity lipoprotein cholesterol, serum trygliceride, and proteinuria levels were accessed from the medical record. spearman test was used to calculate the correlation of serum uric acid and proteinuria levels. the research used secondary data taken from medical records of patients diagnosed with t2dm from outpatient endocrine clinic of department of internal medicine at dr. hasan sadikin general hospital bandung who had a laboratory examination at department of clinical pathology dr. hasan sadikin general hospital bandung from january to december 2011. results: the mean age of the type 2 diabetic patients was 61.5±9.2 years old, with mean serum uric acid level of 6.2±1,8 mg/dl, of whom 52.8% had microalbuminuric and 4.8% had proteinuria. in type 2 diabetic patients, serum uric acid level correlated positively (r=0.273) with proteinuria (p=0.002). conclusions: higher serum uric acid levels associated significantly positive with a greater probability of proteinuria in type 2 diabetic patients, indicating a potential marker for disease severity. key words: proteinuria, type 2 diabetes mellitus, uric acid. correspondence: fatya annisa haryandini, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628156137181 email: fatya.annisa.h@gmail.com introduction metabolic syndrome consists of constellation of metabolic abnormalities that increase risk cardiovascular disease (cvd) and diabetes mellitus (dm). the dm is a group of common metabolic disorder characterized by hyperglycemia resulting from insulin secretion disorder, insulin production disorder, or both of them.1 in 2030, the world health organization (who) and international diabetes federation (idf) predicted that the incidence of type 2 diabetes mellitus (t2dm) will increase 2-3 fold from now.2 without a good controlled therapy, t2dm can increases morbidity and mortality.3 the chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of different organs, especially the eyes, kidneys, nerves, heart, and blood vessels. long-term complications of diabetes include diabetic nephropathy leading to renal failure.1 diabetic nephropathy is the leading cause of end stage renal disease (esrd).4 a study in america5 reported that diabetic nephropathy was one of the highest mortality cause from the many complications of t2dm. uric acid is an end product of purine metabolism.6 hyperuricemia is associated with an increased risk of hypertension and cardiovascular disease.7 the experimental study with animal model, chronic hyperuricemia can induces kidney injury and hypertension.8 hyperuricemia can result from decreased elimination of uric acid which is caused by decreased of renal excretion, decreased glomerular filtration rate, increased tubular reabsorption, or anion althea medical journal. 2015;2(1) 51 exchange inhibition in diabetic ketoacidosis.7 hyperuricemia induce endothelial dysfunction, glomerular hypertension, renal hypertrophy and isalso associated with the development of glomerulosclerosis.9,10 glomerulosclerosis was founded on a histopathology examination on diabetic nephropathy.11 clinical manifestation of diabetic nephropathy is proteinuria that can be measured by dipstick reagent method.12,13 proteinuria and glomerulosclerosis may develop after prolonged hyperuricemia for 6 months.10 patients with t2dm who probably have diabetic nephropathy are recommended to have their protein levels in the urine examined. hyperuricemia in t2dm patients occur leading to diabetic nephropathy. the purpose of this study was to evaluate the relationship between serum uric acid and proteinuria in t2dm patients from outpatient endocrine clinic of department of internal medicineat dr. hasan sadikin general hospital bandung from january to december 2011. methods a cross-sectional study with retrospective approach using secondary data from medical records taken from patients diagnosed with t2dm from outpatient endocrine clinic of department internal medicine at dr. hasan sadikin general hospital who had a laboratory examination at the department of clinical pathology of dr. hasan sadikin general hospital from january to december 2011. inclusion criteria for subjects in this study was complete medical record data from t2dm patients which consists of age, sex, serum uric acid, fasting plasma glucose, 2-h post oral glucose load plasma glucose, serum high-density lipoprotein cholesterol (hdl-cholesterol), serum trygliceride, and proteinuria levels. simple random sampling was conducted to get 125 subjects, consisting of 55 male and 70 female, from the total patients with complete medical record data. the kolmogorov-smirnov test was used to evaluate the data distibution of age, serum uric acid, fasting plasma glucose, 2-h post oral glucose load plasma glucose, serum hdlcholesterol, and serum trygliceride levels. when data was normally distributed, mean±sd was evaluated and when data was nonnormally distributed, median (interquartile range) was evaluated. next, proteinuria levels were divided in 3 groups, normoalbuminuric, microalbuminuric and proteinuria. relationship between serum uric acid and proteinuria in t2dm patients was determined by using spearman test. the p values less than 0.05 were considered significant. study permission for this study was obtained from the research ethical committee of dr. hasan sadikin general hospital bandung. time provided for the study was table 1 clinical characteristics of t2dm patients parameters value gender male, n(%) 55 (44) female, n(%) 70 (56) age (years old) 61.5 ± 9.2 fasting plasma glucose, mg/dl 135 (51–372) 2-h post oral glucose load plasma glucose, mg/dl 180 (80–572) serum hdl-cholesterol, mg/dl 47 (24–90) serum trygliseride, mg/dl 136 (43–554) serum uric acid, mg/dl 6.2 ±1.8 proteinuria normoalbuminuria, n(%) 53 (42.4) microalbuminuria, n(%) 66 (52.8) proteinuria, n(%) 6 (4.8) data are presented as number (percentage), mean±sd, median (interquartile range), 2-h: two hours; hdl: high-density lipoprotein fatya annisa haryandini, tiene rostini: hyperuricemia and proteinuria in type 2 diabetic patients althea medical journal. 2015;2(1) 52 amj march, 2015 from november 20th, 2012–february 20th, 2013. results clinical characteristics were recorded from 125 patients with t2dm that consisted of 55 male and 70 female, aged 61.5±9.2 the mean of serum uric acid level was higher in male than in female (7.0±1.8 mg/ dl). furthermore, there were 53 subjects (42.4%) normoalbuminuric, 66 subjects (52.8%) microalbuminuric and 6 subjects (4.8%) proteinuria patients. serum uric acid for normoalbuminuric, microalbuminuric, and proteinuria patients were 5.8±1.6 mg/ dl, 6.6±1.9 mg/dl, 7.9±1.7 mg/dl. (table 1) there were significant relationship between serum uric acid and proteinuria among all subjects and female subjects (p=0.002 and p=0.008). serum uric acid also had significant relationship with fasting plasma glucose and serum hdl-cholesterol (p=0.007 and p=0.002) (table 2). discussions type 2 diabetes mellitus has diabetic nephropathy as a complication characterized by proteinuria.4 this study shows that serum uric acid and proteinuria have a significantly positive correlation.this result is inline with the study conducted by tseng et al.7 who reported a correlation between serum uric acid and urine albumin-creatinine ratio (uacr) in t2dm patients. increase of uacr can be prevented by lowering uric acid levels in t2dm patients. since protenuria is the sign of nephropathy diabetic,13 the association of hyperuricemia and uacr pointed out the effect of hyperuricemia on diabetic nephropathy. bonakdaran et al.9 also reported a positive correlation between increased serum uric acid and increased albuminuria level. in this study, the correlation between serum uric acid and proteinuria was significant among all subjects and female subjects, however not in male subjects, suggesting a different hormonal system between male and female. the age of female subjects can be classified as menopause women, therefore, the hormonal system might have imbalanced estrogen which made kidney injury worsen, as reported by maric et al.14 uric acid has an antioxidant effect, however, it becomes astrong oxidant in the environment of metabolic syndrome in which is induced high oxidative stress.15 metabolic syndrome components include hyperglycemia, hypertriglyceridemia, hypertension, obesity and low hdl-cholesterol.9 this study shows that serum uric acid has significant correlation with serum fasting plasma glucose and hdlcholesterol. this result is confirmed by madero et al.16 who reported serum uric acid was not affecting kidney damage in normal metabolic person. an experimental study in america8 reported that lowering serum uric acid with allopurinol can inhibit inflammation on kidney which can improve kidney function, proteinuria levels and tubulointerstitial damage, showing that uric acid has a role as a mediator in diabetic nephropathy.5,8 same results were also reported in korea17 and iran18 that uric acid had a role in kidney damage, because administration of low dosage allopurinol in table 2 correlation between serum uric acid and other variables parameters r p proteinuria all subjects 0.273 0.002* male 0.108 0.431 female 0.314 0.008* fasting plasma glucose -0.242 0.007* serum hdl-cholesterol -0.269 0.002* serum triglyceride 0.095 0.294 *: significant correlation correlation is significant at the 0.01 level (2-tailed). r: correlation; p: significant value; hdl: high-density lipoprotein althea medical journal. 2015;2(1) 53 t2dm patients for 4 months can decrease serum uric acid and proteinuria levels. limitations of the study were first, this study was incapable to conclude whether hyperuricemia was a cause or a consequence of diabetic nephropathy. second, this study could not adjust the confounding variables i.e. age, sex, duration t2dm, blood pressure, body mass index, and lipid profile. therefore, to adjust confounding variables and to know the development of the disease, the result should be confirmed by future prospective cohort and interventional studies. in conclusions, serum uric acid and proteinuria in t2dm patients were positively correlated. higher serum uric acid levels were associated with a greater probability of proteinuria which indicated t2dm patients had diabetic nephropathy, suggesting that controlling serum uric acid level in t2dm may prevent diabetic nephropathy. references 1. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care. 2012;35(suppl 1):s64–71. 2. perkeni. konsensus diabetes melitus tipe 2 indonesia 2011. jakarta: perkumpulan endokrinologi indonesia; 2011. 3. gardner dg, shoback d, editors. greenspan’s basic & clinical endocrinology. 8th ed. new york: the mc graw-hill companies, inc.; 2007. 4. zelmanovitz t, gerchman f, balthazar ap, thomazelli fc, matos jd, canani lh. diabetic nephropathy. diabetol metab syndr. 2009;1(1):10. 5. jalal di, maahs dm, hovind p, nakagawa t. uric acid as a mediator of diabetic nephropathy. semin nephrol. 2011;31(5):459–65. 6. murray rk, granner dk, rodwell vw, editors. harper’s illustrated biochemistry. 27th ed. boston: the mcgraw-hill companies, inc.; 2006. 7. tseng ch. correlation of uric acid and urinary albumin excretion rate in patients with type 2 diabetes mellitus in taiwan. kidney int. 2005;68(2):796–801. 8. kosugi t, nakayama t, heinig m, zhang l, yuzawa y, sanchez-lozada lg, et al. effect of lowering uric acid on renal disease in the type 2 diabetic db/db mice. am j physiol renal physiol. 2009;297(2):f481–8. 9. bonakdaran s, hami m, shakeri mt. hyperuricemia and albuminuria in patients with type 2 diabetes mellitus. iran j kidney dis. 2011;5(1):21–4. 10. nakagawa t, mazzali m, kang dh, kanellis j, watanabe s, sanchez-lozada lg, et al. hyperuricemia causes glomerular hypertrophy in the rat. am j nephrol. 2003;23(1):2–7. 11. tervaert tw, mooyaart al, amann k, cohen ah, cook ht, drachenberg cb, et al. pathologic classification of diabetic nephropathy. j am soc nephrol. 2010;21(4):556–63. 12. national kidney disease education program. urine albumin-to-creatinine ratio (uacr) and estimated glomerular filtration rate (egfr). in: u.s. department of health and human services nioh,.2010. 13. aryal m, jha b. assessment of proteinuria as a marker of nephropathy in type 2 diabetes mellitus. nepal med coll j. 2006;8(4):250. 14. maric c, sullivan s. estrogens and the diabetic kidney. gend med. 2008;5 suppl a:s103–13. 15. chien kl, chen mf, hsu hc, chang wt, su tc, lee yt, et al. plasma uric acid and the risk of type 2 diabetes in a chinese community. clin chem. 2008;54(2):310–6. 16. madero m, sarnak mj, wang x, greene t, beck gj, kusek jw, et al. uric acid and longterm outcomes in ckd. am j kidney dis. 2009;53(5):796–803. 17. jung dh, lee yj, lee hr, lee jh, shim jy. association of renal manifestations with serum uric acid in korean adults with normal uric acid levels. j korean med sci. 2010;25(12):1766–70. 18. momeni a, shahidi s, seirafian s, taheri s, kheiri s. effect of allopurinol in decreasing proteinuria in type 2 diabetic patients. iran j kidney dis. 2010;4(2):128–32. fatya annisa haryandini, tiene rostini: hyperuricemia and proteinuria in type 2 diabetic patients althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 502 amj december, 2015 ability and willingness to pay premium in the framework of national health insurance system aulia abdillah ramadhan,1 andri reza rahmadi,2 henni djuhaeni3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: the national health insurance is one of the government’s efforts to improve community access to health services. the government has fixed the premiums to be paid by community, except for underprivileged community. the aim of the study was to identify ability to pay (atp) and willingness to pay (wtp) of the national health insurance premium. methods: a descriptive study which involved 210 housewives who were chosen by rapid survey method was conducted from september to november 2013 in cipacing village, jatinangor, sumedang, west java. data collection was using questionnaire to obtain level of ability and willingness to pay the health insurance premium. the results were compared to the required premium by the government (rp 22,000,-). results: most of the respondents were only housewives, but there were still respondents who were private workers. most of them were 20–39 years old. about 57.6% of the respondents were able to pay for the required premium, but only 17.4% of the them were willing to pay according to the required premium. conclusions: the atp of the respondents are higher compared to the wtp, meaning that most of the respondents are able to pay the requires premium but are not willing to pay it. [amj.2015;2(4):502–5] keywords: ability to pay, indonesian health insurance, willingness to pay correspondence: aulia abdillah ramadhan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281212123285 email: aulia.abdillah.ramadhan@gmail.com introduction one of indonesian health problems is the difficulty in accessing health services due to limited resources.1 the out-of-pocket payment method urges community to have cash money when they get sick. this situation covered about 100 million people around the world in indonesia.2 to overcome the problem, indonesian government develops national health insurance system (nhi) which is a social insurance scheme that enables people to access the health services without any financial difficulty.3,4,5 the nhi requires the community to pay rp 22,000.00 per person every month (premium) to a third-party insurer.4,5,6 however, there are still people who cannot afford to pay the premium for various reasons, either they do not have the ability to pay or they do not want to pay the premium. ability to pay is when people pay according to their ability, either by paying from themselves or paying by borrowing from others. willingness to pay is when people pay according to their will. willingness to pay is influenced by other aspects, such as the quality of the service received, the amount of the price, and the community’s knowledge about the cost of the provided service .7 the aim of this study was to identify the ability and willingness to pay for social insurance premium in the framework of the national health insurance system. methods a descriptive study was conducted from september to november 2013 in cipacing village, jatinangor, sumedang, west java. cipacing village is one of the villages in jatinangor which is one of the research locations for medical students from faculty of medicine universitas padjadjaran. the subject was housewife and willing to participate by filling the validated questionnaire. from these criteria, 210 housewives were selected using rapid survey method. this study was approved althea medical journal. 2015;2(4) 503 by health research ethic committee and all data included will be concealed. the respondents were asked about the knowledge of nhi, total expenditure per month as an input to calculate atp, and how much the respondents want to pay for their health service cost (wtp). ability to pay was calculated and compared to the fixed premium and willingness to pay. the formula to measure ability to pay is 10% from tobacco and nonfood expenditure in a month. the results of willingness to pay were classified into groups filled by the chosen health services and the cost according to the health services. the collected data were presented by frequency distribution. results the majority of the respondents were 20−29 years old, but there were still housewives who were under 19 years old (11.9%). the majority of the respondents (78.1%) were housewives, but there were still 15.7% of the respondents who worked as private workers (table 2). aulia abdillah ramadhan, andri reza rahmadi, henni djuhaeni: ability and willingness to pay premium in the framework of national health insurance system table 1 distribution of respondents according to age age (years old) n (%) < 19 25 (11.9) 20−29 86 (41.0) 30−39 82 (39.1) 40−49 17 (8.0) total 210 (100.0) table 2 distribution of respondents according to occupation occupation n (%) labour 8 (3.8) farmer 2 (1.0) merchant 3 (1.4) private workers 33 (15.7) unemployed 164 (78.1) total 210 (100.0) table 3 distribution of respondents according to their ability to pay forthe social health insurance premium ability to pay n (%) mean standard deviation < rp 22,000.00 89 (42.4) rp 14,957.00 rp 4,719.00 = > rp 22,000.00 121 (57.6) rp 41,415.00 rp 20,883.00 table 4 distribution of respondents according to their willingness to pay for the social health insurance premium willingness to pay/ person/month primary health care n (%) hospitaln (%) primary health care and hospital n (%) total n (%) < rp 22.000,00 38 (21.8) 3 (1.7) 132 (76.5) 174 (82.6) >= rp. 22.000,00 1 (2.8) 2 (5.6) 34 (91.6) 36 (17.4) total 39 (18.6) 5 (2.4) 166 (79.0) 210 (100.0) table 5 comparison between atp and wtp ability to pay /person/month comparison atp and wtp n (%) total n (%) atp>wtp atp=wtp atp<wtp < rp22,000.00 76 (85.4) 13 (14.6) 89 (42.4) >= rp 22,000.00 110 (90.9) 11 (9.1) 121 (57.6) total 110 (52.38) 76(36.19) 24 (11.43) 210 (100.0) althea medical journal. 2015;2(4) 504 amj december, 2015 from table 3, most of the respondents were able to pay the premium determined by the indonesian government with an average of rp 41,415.-. it was much higher compared to rp 22,000.which is the required premium given by the government. moreover, there were still respondents who were not able to pay the premium. most respondents (79.0%) wanted to be served in a primary health service and hospital. the communities relied on those health services to receive the medical attention. while, there were 39 respondents (18.6%) who wanted to be served only in the primary health care (table 4). most of respondents (90.9%) derived from group who were able to pay the premium, but were willing to pay according to their ability (table 5). discussions ability and willingness to pay for the social health insurance premium are important tools to develop health policy in social insurance.this study discovered that most of the respondents had the ability to pay for the social health insurance premium that was equal to or higher than the government requirement, but most of them did not want to pay the required premium, although most of them had a higher atp than wtp. this findings are similar to the hidayat8 findings in purwokerto, central java, and rianti9 in padang, west sumatra. hidayat8 discovered that construction laborers in purwokertoare able to pay the tariff of specified services and have a higher ratio of atp than wtp. moreover, rianti9 discovered that atp of respondents in padangis higher compared to the wtp, but the they are unwilling to pay the health services they received. other studies in indonesia have different results. sihombing10 conducted a study about the impact of health financing towards ability to pay and catastrophic payment indicatings that most of the respondents have low level of atp. eighty six percent of the respondents are not able to afford the determined cost. this study is similar to the study conducted by dungga11 in gorontalo, sulawesi. in his study, the respondents are able to pay only rp 15,607.other study conducted by sofyan12 showed that 63% of the respondents are able to pay a specified tariff, and 51% of the them are willing to pay a specified tariff. besides, there is finding from djuhaeni13 study performed in bandung the capital city of west java, discovering that 93.3% of the respondents are able and willing to pay the required social health insurance premium (rp 22,000.-). in indonesia, the atp and wtp are different according to the location of the study. in many regions, the atp is higher than wtp, but in some regions, the wtp is higher than atp. this study has limitations. asking the respondents about their expenditures was a sensitive question and relied on their memory on how much cost they have been spending within one month. this situation had high bias in data collection. there should be a formula to help the family to calculate family’s expenditure within one month. it can be concluded that the majority of respondents are able to pay the premium on their own but they are unwilling to pay it. a further study should be performed in other regions so that the government can determine the more precise premium, not only to identify the the ability and willingness of the community but also to determine how much money the government must allocate to subsidy the payment of the premium. moreover, the government should act more in promoting the nhi to the community. references 1. badan pembangunan nasional. rencana pembangunan jangka menengah-nasional 2010-2014. jakarta: badan pembangunan nasional; 2009. 2. who. world health report 2012. swiss, geneva: who; 2012. 3. divisi penelitian dan pengembangan kementrian kesehatan republik indonesia. sistem kesehatan nasional 2009. jakarta: kementrian kesehatan republik indonesia; 2009. 4. kutzin j. a descriptive framework for country-level analysis of health care financing arrangements. health policy. 2001;11(1):171−204. 5. who. everybody business: strengthening health systems to improve health outcomes. geneva: who; 2007. 6. peraturan presiden no 12 tahun 2013 tentang jaminan kesehatan. presiden republik indonesia; 2013. [cited 2013 april 18]. available from: http://www. presidenri.go.id/dokumenuu.php/960. pdf 7. adisasmita w. rancangan peraturan daerah tentang penyelenggaraan pelayanan kesehatan. jakarta: fkm ui; althea medical journal. 2015;2(4) 505 2008. 8. hidayat f. analisis kemampuan dan kemauan membayar tarif pelayanan kesehatan pada kuli bangunan [thesis]. purwokerto, indonesia: universitas negeri jendral soedirman; 2010. 9. rianti a. kemampuan dan kemauan membayar pasien terhadap pelayanan rawat inap rsud dr. rasidin padang [thesis]. bandung, indonesia: universitas padjadjaran; 2012. 10. sihombing g. dampak pembiayaan kesehatan terhadap ability to pay dan catastrophic payment [thesis]. surabaya, indonesia: universitas airlangga; 2012. 11. dungga a. analisis kemampuan pembiayaan kesehatan masyarakat di kabupaten gorontalo [report]. gorontalo, indonesia: dinas kesehatan provinsi gorontalo; 2012. 12. sofyan h. analisis kemampuan (atp) dan kemauan (wtp) membayar masyarakat untuk pengembangan klinik ibnu sina menjadi rumah sakit [thesis]. medan, indonesia: universitas sumatra utara; 2005. 13. djuhaeni h. potensi partisipasi masyarakat menuju pelaksanaan jaminan kesehatan dalam rangka universal coverage di kota bandung [report]. bandung, indonesia: dinas kesehatan kota bandung; 2012. aulia abdillah ramadhan, andri reza rahmadi, henni djuhaeni: ability and willingness to pay premium in the framework of national health insurance system althea medical journal. 2015;2(3) 332 amj september, 2015 incidence of herpes zoster in relationship with climate factors from 2009 to 2011 herning adinda,1 dendi sandiono,2 ihrul prianza prajitno3 1faculty of medicine, universitas padjadjaran, 2department of dermatology and venereology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology, faculty of medicine, universitas padjadjaran abstract background: herpes zoster, or shingles, is a skin or mucous infection caused by the reactivation of varicellazoster virus (vzv). seasonal pattern of herpes zoster incidence was reported in some countries, indicating that emergence of this disease was caused by the reactivation of latent varicella-zoster virus (vzv) rather than new exposures to vzv. on the other hand, the vzv primary infection difference between tropical and temperate zones may have implications for virus reactivation as herpes zoster. the aim of this study was to identify the incidence of herpes zoster in dr. hasan sadikin general hospital bandung, west java related to the change of rainfall, air temperature and humidity from 2009 to 2011. methods: a descriptive retrospective study was carried out to 341 medical records of herpes zoster patients from dr. hasan sadikin general hospital bandung periode 2009 to 2011. data on climate factors, i.e. rainfall, air temperature, and relative humidity, were obtained from the indonesian meteorology, climatology, and geophysical agency. the collected data were presented using tables and figures. result: the highest number of herpes zoster cases occured during the period when the highest annually total rainfall and annually mean relative humidity occurred. conclusions: the finding of this study shows that herpes zoster cases have the same pattern with the rainfall and relative humidity. these findings can inform better prevention of herpes zoster. however, further research is needed to get more comprehensive understanding on this relationship. [amj.2015;2(3):332–38] keywords: air temperature, herpes zoster, rainfall, relative humidity correspondence: herning adinda, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8998928936 email: herning_adinda@yahoo.com introduction herpes zoster, or shingles, is a skin or mucous infection caused by the reactivation of varicella-zoster virus (vzv) and is characterized by unilateral radicular pain and vesiculars eruption that is generally limited to the dermatome innervated by a single spinal or cranial sensory ganglion.1,2 varicella-zoster virus is a ubiquitous herpes virus that causes two different syndromes, these are varicella (chickenpox) which is primary infection, and herpes zoster (shingles).3,4 patients with herpes zoster experience local neuritic pain and moreover, patients’ quality of life may significantly be impaired.3 the incidence of herpes zoster increases from 7.6 per 10,000 persons during 1945−1947, to 16.4 per 10,000 persons during 1980−1982, to 29.5 per 10,000 persons during 2005−2007.5 seasonal pattern of herpes zoster incidence was not seen in most studies, indicating that the disease was caused by the reactivation of latent vzv rather than new exposures to vzv.1,4,6 on the other hand, the vzv primary infection difference between tropical and temperate zones may have implications for virus reactivation as herpes zoster.7 indonesia is one of the tropical countries that has heavy rainfalls, high temperature rates, and high humidity levels.8,9 it is suspected that there are relationship betweeen the increase of high rainfall, high air temperature and high humidity level towards the high number of herpes zoster cases. the aim of this study was to identify the incidence of althea medical journal. 2015;2(3) 333 herpes zoster related to the change of rainfall, air temperature and humidity in dr. hasan sadikin general hospital bandung, west java during the period of 2009 to 2011.10,11 methods a descriptive retrospective study was conducted to investigate the pattern of herpes zoster in relationship to climate factors in dr. hasan sadikin general hospital bandung during the period of 1 january 2009 to 31 december 2011. total cases were obtained from medical records of dr. hasan sadikin general hospital bandung with total sampling technique. the inclusion criteria were medical records from patients of herpes zoster who were diagnosed based on clinical examination and patients being admitted for the first time during the period of 1 january 2009 to 31 december 2011. patients living outside bandung were excluded. medical records for all the cases fulfilling the inclusion criteria were retrieved. relevant demographic and admission data were extracted from medical records. relevant demographic data included address of the patients, while relevant admission data included the month and year of hospital admission. all collected data in dr. hasan sadikin general hospital bandung were approved by the health research ethics committee. the meteorological data including monthly total rainfall, monthly mean air temperature, and monthly mean relative humidity were obtained from the indonesian meteorology, climatology and geophysical agency during january 2009 to december 2011. the collected data were presented by tables and graphs. results four hundred and seventy two medical records from patients with herpes zoster were reviewed, 131 cases were excluded according to the exclusion criteria and 341 cases were included in this study. the monthly herpes zoster cases from 2009 to 2011 ranged from 1 to 16 per month. there were fluctuating numbers of monthly reports of herpes zoster cases in consecutive three years with the highest occurrence on june 2009, with 15 number of cases were reported, on february 2010 with 16 number of cases were reported, and 15 number of cases were reported on april and october 2011. the highest number reported in 2010 was 125 cases (table 1). there were fluctuating numbers of monthly total rainfalls. the highest total rainfall occured in march 2009, february 2010, and april 2011. the lowest total rainfall occurred in august 2009, april 2010 and august 2011. table 1 monthly distribution of herpes zoster cases in dr. hasan sadikin general hospital bandung from 2009−2011 month herpes zoster cases 2009 2010 2011 january 8 11 5 february 11 16 10 march 8 11 13 april 7 8 15 may 9 7 9 june 15 10 6 july 12 12 5 august 11 7 1 september 4 10 10 october 7 14 15 november 14 11 6 december 5 8 10 total 111 125 105 herning adinda, dendi sandiono, ihrul prianza prajitno: incidence of herpes zoster in relationship with climate factors from 2009 to 2011 althea medical journal. 2015;2(3) 334 amj september, 2015 there were fluctuating numbers of monthly mean temperatures with the highest monthly mean temperature occurred in september 2009, april 2010 and october 2011. the lowest monthly mean temperature occurred in february 2009, january, july and september 2010, and july 2011. there was a fluctuating amount of monthly mean relative humidity in table 2 rainfall, temperature, and relative humidity per month in 2009−2011 month rainfall (mm) temperature (oc) relative humidity (%) 2009 2010 2011 2009 2010 2011 2009 2010 2011 january 208,5 353,3 63,0 23,1 22,9 23,0 81 84 79 february 200,5 557,1 76,7 22,9 23,2 23,5 83 87 78 march 365,7 531,0 89,4 23,0 23,1 23,5 82 86 77 april 165,6 93,0 381,5 23,4 24,6 23,4 83 78 79 may 183,8 345,0 193,4 23,4 24,0 23,6 83 83 80 june 101,0 131,9 117,6 23,4 23,3 23,3 80 84 75 july 24,2 220,8 77,2 23,0 22,9 22,8 73 85 74 august 0,5 106,1 3,1 23,6 23,3 23,0 71 81 69 september 24,0 424,4 102,8 24,4 22,9 23,4 70 85 69 october 234,5 292,2 103,6 23,4 23,2 24,1 76 82 73 november 318,2 404,1 321,4 23,3 23,3 22,9 82 85 83 december 271,1 237,5 259,0 23,5 23,0 24,0 82 82 79 figure 1 monthly total rainfall and monthly distribution of herpesvzoster cases in dr. hasan sadikin general hospital bandung from 2009−2011 althea medical journal. 2015;2(3) 335 the consecutive three years with the highest monthly mean relative humidity occurred in february, april and mei 2009, february 2010, and november 2011. the lowest monthly relative humidity occurred in september 2009, april 2010, also august and september 2011. there were similarities between total rainfall, monthly mean temperature and monthly mean relative humidity in the consecutive three years and the highest number per month was reported in 2010 (table 2). the monthly distribution of herpes zoster cases in dr. hasan sadikin general hospital bandung is shown in figures 1, 2 and 3. the periodicity of various climatic factors, namely monthly total rainfall, monthly mean air temperature, and monthly mean relative humidity were also shown. there were pattern similarities between herpes zoster cases and rainfall in 2010–2011 shown by the highest number of herpes zoster cases in february and april, respectively. then, it was followed by the highest number of monthly total rainfall, and the lowest number of herpes zoster cases in august 2011 followed by the lowest number of monthly total rainfall (figure 1). in 2009, there was no pattern similarity between herpes zoster cases and monthly rainfall, which was most likely caused by the very low monthly total rainfall (0.5 mm) in august. there was no pattern similarity between herpes zoster cases and monthly mean temperature, because in 2009, the lowest number of herpes zoster cases in september was followed by the highest monthly mean temperature (figure 2). while in 2011, contrary to what happened in 2009, the highest number of herpes zoster cases in october was followed by the highest monthly mean temperature. there were pattern similarities between herpes zoster cases and monthly mean relative humidity in 2009 to 2011 shown by the lowest number of herpes zoster cases in september and august, respectively followed by the lowest monthly mean relative humidity (figure 3). there were pattern similarities between total annually rainfall, annually mean relative humidity and annually mean air temperature shown by the highest number of herpes zoster cases in 2010, followed by the highest total figure 2 monthly mean air temperature and monthly distribution of herpes zoster cases in dr. hasan sadikin general hospital bandung from 2009−2011 herning adinda, dendi sandiono, ihrul prianza prajitno: incidence of herpes zoster in relationship with climate factors from 2009 to 2011 althea medical journal. 2015;2(3) 336 amj september, 2015 annually rainfall, the highest annually mean relative humidity and the lowest annually mean temperature (figure 4). discussion the annually herpes zoster cases increased from 111 cases in 2009 to 125 cases in 2010, yet decreased to 105 cases in 2011. the total rainfall and mean relative humidity were found to have the same pattern with the number of herpes zoster cases. it has been suggested that the herpes zoster occurs without seasonal pattern and there is little evidence of seasonality in zoster incidence from the population-based studies.1,4,6 in some countries, the seasonal pattern was reported. meanwhile, scottish and english studies4 reported higher incidence of zoster in summer and autumn. a large-scale survey in japan6 clarified the epidemiology of herpes zoster with peak incidence in august and the lowest in winter in contrast to western countries. a korean study6 suggested that the most cases of herpes zoster were recorded during summer, and the least during autumn. data from a study in pakistan6 also support surge of the cases of herpes zoster noted with onset in summer season in april, may, and june. this pattern might be related to ultraviolet irradiation that peaks during the summer months can leads to a suppression in the cellular immune response to vzv, thus allowing reactivation of the virus from latency in some individuals.6,12 this study showed the different outcome from the above mentioned research, the herpes zoster cases had the same pattern with total rainfall and mean relative humidity. reactivation of latent vzv occurred after a variable period ranging from a few years to decades after primary varicella infection.6 it is unclear what induces reactivation of vzv, but it is assumed to occur as a result of aging-related decreasing of cell-mediated immunity to vzv, that is when cell-mediated immunity decreases below a crucial level.3,4 the depression of specific cell-mediated immunity may be triggered by age, genetic predisposition, trauma, sunburn, exhaustion, psychological stress, immunosuppression or irradiation.6 however, the exact mechanism for the potential association between rainfall and humidity and herpes zoster cases is figure 3 monthly mean relative humidity and monthly distribution of herpes zoster cases in dr. hasan sadikin general hospital bandung from 2009−2011 althea medical journal. 2015;2(3) 337 unknown. a hypothesize can be raised that climate change will affect human health in many ways and climate change is projected to increase threats to human health, particularly in lower income populations and tropical/ subtropical countries.13,14 people living in high climate change areas will be more susceptible to vzv reactivation. another possibility can be that developing countries are more sensitive to climate change, as they have poor public health infrastructure and more vulnerable populations.15 in addition, indonesia, particularly bandung, has a different season with other countries as mentioned in previous researches. however, all these hypotheses need further studies to explore the association between rainfall and relative humidity with herpes zoster. for temperature, there was no pattern similarity, because the highest herpes zoster case was followed by the highest temperature and the lowest temperature. the possibility could be that both extreme cold and hot temperatures had immediate negative impacts on all mortality types and age groups.15 this study has some limitations. first, it is based on medical records, and therefore, patients with mild disease were excluded due figure 4 annually total rainfall, mean air temperature, mean relative humidity and annually distribution of herpes zoster cases n dr. hasan sadikin general hospital bandung from 2009−2011 herning adinda, dendi sandiono, ihrul prianza prajitno: incidence of herpes zoster in relationship with climate factors from 2009 to 2011 althea medical journal. 2015;2(3) 338 amj september, 2015 to absence of hospital visit. second, longer data collection, as long as 5 years or more is recommended in order to obtain clearer patterns. third, we have not found appropriate references of similar research, which make it difficult to compare. apart from potential weather attributes, other environmental and host factors may also affect the herpes zoster cases. further studies to incorporate more variables such as age, sex and psychological stress state are warranted in the future. in conclusion, the findings of this study show that herpes zoster cases have the same pattern with the rainfall and relative humidity. these findings are useful for a further research of the relationship between herpes zoster with climate factors and also to enhance the prevention of herpes zoster. to ensure that there is a correlation of herpes zoster with climate factors, more advance research should be carried out by conducting an analytic study and analytic examination of that relationship in a longer period of 5 years or more. preventive measures against the spread of herpes zoster in conjunction with the rain factor can be programmed by educating people to maintain a healthy life style and to boost their immune system for the incoming rain season. while in conjunction with the high humidity can be conducted by educating them to maintain a healthy environment, and increasing more house openings to improve the house ventilation to let more sunlight flowing into the house. a dehumidifier, which can be purchased from local stores can be installed in the house to help reducing the humidity. references 1. freedberg im, eisen az, austen kf, goldsmith la, katz si, wolff k, editors. fitzpatrick’s dermatology in general medicine. 6th ed. new york: the mcgrawhill companies; 2003. 2. djuanda a, hamzah m, aisah s, editors. ilmu penyakit kulit dan kelamin. 6th ed. jakarta: fakultas kedokteran universitas indonesia;2010. 3. weinberg jm. herpes zoster: epidemiology, natural history, and common complications. j am acad dermatol. 2007;57(6 suppl):s130−5. 4. thomas sl, hall aj. what does epidemiology tell us about risk factors for herpes zoster? lancet infect dis. 2004;4(1):26−33. 5. yawn bp, wollan p, bialek sr, harpaz r. trends in herpes zoster prevalence in a population based cohort from 1945 to 2008. proceeding of the 48th annual meeting of the infectious diseases society of america; 2010 oct 21–24; vancouver, canada. arlington, va: infectious diseases society of america. 2010 6. suhail m, ejaz a, abbas m, naz s, suhail t. herpes zoster: seasonal variations and morphological patterns in pakistan. j pak assoc derma. 2011;21(1):22−6. 7. rice ps. ultra-violet radiation is responsible for the differences in global epidemiology of chickenpox and the evolution of varicella-zoster virus as man migrated out of africa. virol j. 2011;8:189. 8. rafi’i ds. meteorologi dan klimatologi. bandung: angkasa; 2010. 9. sungkawa d. geografi regional indonesia. bandung: universitas pendidikan indonesia; 2011. [cited 2011 november22]. available from: http://file.upi.edu/direktori/fpips/jur._ pend._geografi/195502101 980021-dadang_sungkawa/bahan_ ajar_gri/gri_gabungan_ cetak.pdf. 10. pusat inventarisasi dan statistik kehutanan badan planologi kehutanan departemen kehutanan. data dan informasi kehutanan propinsi jawa barat; 2002. [cited 2011 november22]. available from: http://www.dephut.go.id/ informasi/infprop/inf-jbr.pdf. 11. bmkg. informasi perubahan iklim dan kualtias udara. jakarta: badan meteorologi klimatologi dan geofisika; 2012. [cited 2012]. available from: http://www. bmkg.go.id/bmkg_pusat/datadokumen/ dokumen_buku_informasi_perubahan_ iklim_dan_kualitas_udara.pdf. 12. zak-prelich m, borkowski jl, alexander f, norval m. the role of solar ultraviolet irradiation in zoster. epidemiol infect. 2002;129(3):593−7. 13. haque am, yamamoto ss, malik aa, sauerborn r. households’ perception of climate change and human health risks: a community perspective. environ health. 2012;11:1. 14. forsberg b, braback l, keune h, kobernus m, krauss mkv, yang a, et al. an expert assessment on climate change and health–with a european focus on lungs and allergies. environ health. 2012;11(suppl1):s4. 15. guo y, punnasiri k, tong s. effects of temperature on mortality in chiang mai city, thailand: a time series study. environ health. 2012;11:36. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 78 amj march, 2015 role of exclusive breastfeeding in preventing diarrhea hanifah rohmah1, tisnasari hafsah2, lulu eva rakhmilla3 1faculty of medicine, universitas padjadjaran, 2department of child health, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of epidemiology and biostatistic, faculty of medicine, universitas padjadjaran abstract background: breast milk has protective factors for infants’ digestive tract. infants are vulnerable to diseases, one of which is diarrhea. this cross-sectional study was designed to determine the relation between the proportion of diarrhea in infants and the administration of exclusive breastfeeding in jatinangor. methods: this study was an observational study. data on mothers with 6 months old infants were collected from jatinangor primary health center (phc) infant records. the inclusion criteria applied were infants born in april 2012, alive, and living in jatinangor subdistrict. one hundred and seventy one infants were recorded in april of 2012 in the phc data. thirty five were excluded because they were not born in april 2012. another 45 were excluded because they were not permanent residents of jatinangor subdistrict, while 4 infants died, and 23 had incomplete data. therefore, only 66 infants were included as study subjects. those infants came from 12 villages in the subdistrict of jatinangor. data collection was then performed using a questionnaire to the parents during the period of 21–31 october 2012. results: from 66 infants, the proportion of diarrhea was 66.7%. only 27.3% of all infants received exclusive breastfeeding. there was a difference in the proportion of diarrhea between infants who were exclusively breastfed and those who were not. exclusive breastfeeding also reduced the risk of diarrhea (or= 0.26, 95% ci 0.08–0.83). conclusions: there is a relation between the proportion of diarrhea in infants and exclusive breastfeeding in jatinangor. breastfeeding has a protective effect against diarrhea in infants. keywords: diarrhea, exclusive breastfeeding, infants correspondence: hanifah rohmah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285311360123 email: hanifah.rohmah@gmail.com introduction immune system plays an important role against diseases, especially in infection.1 the immune system of a newborn infant is still under developing progress that makes infants as the most susceptible group to be afflicted by infection, especially in the first years of life. diarrhea is one of the most common diseases in infants, and toddlers as well. diarrhea in the children can be fatal and often becomes a cause of death when improperly handled. in africa and south east asia, more than 80% of children's death are due to diarrhea.2 the incidence of diarrhea and its consequences on other part of gastrointestinal tract can be prevented by breastfeeding. according to quigley et al.3 , the incidence of diarrhea in infants who were breastfed was lower than those who were fed formula milk, this shows the role of breastmilk to control the disease. in indonesia, the proportion and mortality rate of diarrhea in the children are still high. according to diarrhea morbidity survey which was done by the ministry of health in 2010, the greatest proportion of diarrhea patients in infants was the age group of 6–11 months which was 21.65%. according to the report of integrated disease surveillance 2009–2010, west java is one of the province which most frequently agonized by an extraordinary event of diarrhea in the year of 2009 and 2010.4 in sumedang regency, diarrhea makes the top ten of the most frequent diseases.5 the local government of sumedang's data in the year of 2011 reported that diarrhea and upper respiratory tract infection are the two biggest killers in the district of jatinangor.6 methods an observational study was performed on mothers with 6 months old infants. the althea medical journal. 2015;2(1) 79 data on these mothers were collected from jatinangor primary healthcare center (phc) infant records. the inclusion criteria applied were infants born in april 2012, alive, and living in jatinangor district. one hundred and seventy one infants were recorded in april of 2012 in the phc data. thirty five were excluded because they were not born in april 2012. another 45 were excluded because they were not permanent residents of jatinagor district, while 4 infants died, and 23 had incomplete data. therefore,only a total of 66 infants were included as the study subjects. those infants came from 12 villages in the district of jatinangor. data collection was then performed using a questionnaire to the parents during the period 21–31october 2012. the variables included in the questionnaire study were the incidence of diarrhea and exclusive breastfeeding. exclusive breastfeeding was defined as the consumption of breastmilk since the first day of life until the 6th month of age without any additional consumption. for infants who had baby formula, or had a mixture of breastmilk and formula diet were grouped as non-exclusive breastfeeding. diarrhea was defined as experiences of defecation of 3 times or more in one day, or had liquid feces. this study had received an ethical clearence from the health study ethics committe of faculty of medicine universitas padjadjaran, data were then analyzed using chi-square test. results out of 66 infants, the gender proportion was nearly balanced with 31 male infants and 35 female infants. diarrhea was found on 44 infants (66.67%), while 22 had never had diarrhea. all 6 months old infants in the villages of cisempur and jatiroke have had diarrhea infants. in this study 18 infants (27.3%) had an exclusive breastfeeding, while 48 had a nonexclusive breastfeeding.the village with the highest proportion of exclusive breastfeeding was the village of cileles which has 3 of 4 infants who were exclusively breastfed. meanwhile, in jatimukti, cisempur, and cibeusi there is no infant who was exclusively breastfed. an association between the proportion of diarrhea in 6 months old infants and the exclusive breastfeeding was found. from a total of 48 infants who were not exclusively breastfed, 37 (77.1%) had diarrhea and 11 infants (22.9%) had never had diarrhea. infants who were exclusively breastfed had table 1 general characteristics of infants in the district of jatinangor n (66) diarrhea(n=44) exclusive breasfeeding (n=18) gender male 31 18 (27.3%) 11 (16.7%) female 35 26 (39.4%) 7 (10.7%) village cilayung 8 3 (4.6%) 2 (3.0%) mekargalih 8 7 (10.6%) 3 (4.6%) sayang 8 5 (7.6%) 3 (4.6%) jatiroke 7 7 (10.6%) 1 (1.5%) hegarmanah 6 4 (6.1%) 2 (3.0%) cintamulya 5 3 (4.6%) 2 (3.0%) cileles 4 1 (1.5%) 3 (4.6%) cikeruh 4 1 (1.5%) 2 (3.0%) cipacing 4 3 (4.6%) 1 (1.5%) cibeusi 4 2 (3.0%) 0 jatimukti 4 3 (4.6%) 0 cisempur 4 4 (6.1%) 0 hanifah rohmah, tisnasari hafsah, lulu eva rakhmilla: role of exclusive breastfeeding in preventing diarrhea althea medical journal. 2015;2(1) 80 amj march, 2015 less diarrhea experiences(44.4%) a significant difference was observed between infants who were and were not exclusively breastfed (x2= 5.50, p= 0.01). exclusive breastfeeding also reduces the risk of diarrhea, exclusive breastfeeding has a protective effect against the diarrhea in infants. (or= 0.26, 95% ci 0.08-0.83). discussion from the study, the proportion of diarrhea in the district of jatinangor is still quite high (66.7%) compared to the national data. according to the diarrhea morbidity survey conducted by the ministry of health in 2012, the proportion of diarrhea in infants of age less than 6 months is 11.86%. the highest proportion of diarrhea in infants is the age group of 6–11 months at 21.65%. data from riskesdas in 2007 shows that the highest proportion of diarrhea according to age group in toddlers of 1–4 years old which was 16.7% and west java is the 9th most diarrhea afflicted province.4 the survey done by the local government of sumedang shows that diarrhea is one of the top ten diseases in the district.5 therefore, the local government of sumedang district should give more attention to this health problem. exclusive breastfeeding’s proportion in jatinangor is still quite low, only 27.3% of infants were exclusively breastfed. hoddinott et al.7 states that breastfeeding can reduce the risk of infection and has a long term effect that can reduce the risk for obestity, hypertension, and reduce cholesterol level. another study by ip et al.8 concludes that breastfeeding can reduce the risk of diarrhea on infants of less than one year of age compared to nonbreastfed infants (or 0.36, 95% ci 0.18 0.74). the event of diarrhea is lower in exclusively breastfed infants. according to suradi9, this is because of the presence of siga (secretory immunoglobulin a) in the breastmilk. siga has a role in the local protection on the mucous layer of the digestive tract. there are other protective contents in breastmilk such as igg, igm, igd, bifidobacterium bifidum, lactoferin, lactoperoxidase, lysozyme, macrophage, neutrophil, lymphocyte and lipids. the role of breastfeeding in reducing infection of diseases can also be seen in the cohortstudy of mihrshahi et al.10,stating that in infants who were exclusively breastfed for 6 months, the diarrhea proportion were 8.6% lower and the respiratory tract diseases are 20% lower (p = 0.03) compared to non exclusively breastfed. in another study, 150 infants were monitored and their enterovirus infection was monitored. forty three percent of infants under the age of 1 year experiences an enterovirus infection. breastfed infants of more than 2 weeks have lower rate of infection than those who were breastfed for less than two weeks (0.38 v 0.59 infections per infant).11 in this study it is found that there is a difference between the event of diarrhea in 6 months old infants who were exclusively breastfed and those who were not (x2= 5.50, p= 0.01). quigley et al.12performeda case control study with 167 cases and 137 controls, there is an association between nonbreastfed infants with the rise of diarrhea incidence. limitations of this study include the limited time and exclusion of factors such as social economy, parent’s occupation, parental education, and immunization status in the analysis of this study. as a conclusion, it is found that there is a relation between breastfeeding and the events of diarrhea in infants. references 1. baratawidjadja kg, rengganis i. imunologi dasar. jakarta: balai penerbit fkui; 2009. 2. unicef, who. diarrhea: why children are still dying and what can be done. 2009 [cited 2012 april 1]. available from: http://www.who.int/maternal_child_ adolescent/documents/9789241598415/ en/index.html. 3. quigley ma, kelly yj, sacker a. breastfeeding and hospitalization for diarrheal and respiratory infection in the united kingdom millennium cohort study. pediatrics.2007;119(4):e837–42. 4. kementerian kesehatan republik indonesia. situasi diare di indonesia. jakarta: kementerian kesehatan republik indonesia; 2011. 5. departemen kesehatan kabupaten sumedang. sepuluh besar penyakit di kabupaten sumedang. 2012 [cited 2012 november 10]. available from: http:// d i n ke s . s u m e d a n g k a b . g o . i d / s e p u l u h besar-penyakit-di-kabupaten-sumedang/. 6. departemen kesehatan kabupaten sumedang. jumlah kematian bayi 2011. 2012 [cited 2012 november 12]. available from: http://dinkes.sumedangkab.go.id/ jumlah-kematian-bayi-2011/. 7. hoddinott p, tappin d, wright c. breastfeeding. bmj.2008;336(7649):881 althea medical journal. 2015;2(1) 81 8. ip s, chung m, raman g, chew p, magula n, devine d, et al. breastfeeding and maternal and infant health outcomes in developed countries. evid rep technol assess (full rep).2007;153:1–186. 9. suradi r. spesifitas biologis air susu ibu. sari pediatri.2001;3(3):125–9. 10. mihrshahi s, oddy wh, peat jk, kabir i. association between infant feeding patterns and diarrheal and respiratory illness: a cohort study in chittagong, bangladesh. int breastfeed j. 2008;3:28. 11. wall g. outcome of breastfeeding versus formula feeding. la leche league international.2010 [cited 2012 november 14]. available from: http://www.llli. org/docs/outcomes_of_breastfeeding_ june_2007.pdf. 12. quigley ma, cumberland p, cowden jm, rodrigues lc. how protective is breastfeeding against diarrheal disease in infants in 1990s england? a case-control study. arch dis child. 2006;91(3):245–50. hanifah rohmah, tisnasari hafsah, lulu eva rakhmilla: role of exclusive breastfeeding in preventing diarrhea althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 123 pseudoexfoliation glaucoma in the national eye center, cicendo eye hospital, january–october 2012 rizki fasa ramdhani1, elsa gustianty2, fenny dwiyatnaningrum3 1faculty of medicine, universitas padjadjaran, 2department of ophthalmology, faculty of medicine, universitas padjadjaran/cicendo national eye center hospital, bandung, 3department of anatomy, faculty of medicine, universitas padjadjaran abstract background: pseudoexfoliation syndrome is characterized by the deposition of a distinctive fibrillar material in the anterior segment of the eye. this condition is a major risk factor for development of glaucoma, termed pseudoexfoliation glaucoma (pexg). the aim of this study was to describe the characteristic and management of pexg in the national eye center cicendo eye hospital. methods: a descriptive retrospective study was conducted in october–november 2012 using medical records of pexg patients in the national eye center cicendo eye hospital during january–october 2012. results: there were 32 patients (43 eyes) diagnosed as pexg, most of them were male (78.1%), age 70–74 years old (34.4%) and followed by those in the range of age 65–69 years old (21.9%). most of the cases were unilateral (65.6%) decrease of visual acuity less than 3/60 (76.7%), increase of intraocular pressure (iop) with majority in the range of 31–40 mmhg (32.6%) and 41–50 mmhg (32.6%), cup/disc ratio 0.9–1.0 (46.51%) and followed by those classified as majority which were hard to assess because of the presence of opaque media (34.89%). the type of glaucoma was open angle glaucoma (88.4%). the treatment received was a combination of two types of antiglaucoma medication and surgery iop conclusion: pexg is mostly found in elderly patients. while most of the patients come with high iop and late stage of the disease iop key words: characteristics, glaucoma, pseudoexfoliation, correspondence: rizki fasa ramdhani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281322498875 email: rizki.fasa@yahoo.com introduction pseudoexfoliation glaucoma (pexg) develops from the presence of pseudoexfoliation syndrome characterized by the deposition of a distinctive fibrillar material in the anterior segment of the eye. this condition is a predisposing factor for development of openangle glaucoma.1 the pexg is associated with highly elevated intraocular pressure (iop), glaucomatous nerve damage, difficulties to cure, and others like subluxation lens.2–7 the pexg was reported to be particularly common in scandinavia.8 the prevalence of pexg in various population was reported as follows: england (4%), germany (4.7%), norway (6.3%), eskimos (0%), russia (12%), finland (22%), iceland (29%), greece (16.1%), australia (0.98%), and iran (9.6%).9 pseudoexfoliation glaucoma includes as a type of secondary glaucoma with high incidence. onset of pexg is rarely found in the age before 50 and most cases occur in their late 60s and early 70s.6,7,10 the goals of treatment of glaucoma are to reduce iop and to correct the cause of glaucoma itself. the major therapy medication that reduces iop is by reducing aqueous humor production. if the drugs cannot relieve symptoms, surgery must be performed. the aim of this study was to describe characteristic and management of pexg in the national eye center cicendo eye hospital. methods a descriptive retrospective study was conducted using medical records of pexg patients in the national eye center cicendo eye hospital during january–october 2012. althea medical journal. 2015;2(1) 124 amj march, 2015 from these data, all 32 cases met the inclusion criteria of medical records that contained the patient’s characteristics including sex, age, residence, laterality, visual acuity, iop, cup/disc (cd) ratio in the first admission to hospital, and the anterior chamber angle. there were no cases excluded. these data were presented as frequency distribution. results out of a total of 32 patients, 43 eyes were diagnosed with pexg and included as subjects in this study. the patients were mostly male (78.1%); most pexg occurred in the range of age 70–74 years old (34.4%) and followed by those in the range of age 65–69 years old (21.9%). the youngest age of patient with this disease was 50 years old and the oldest was 84 years old. in this study, most of pexg were unilateral (65.6%). most patients (76.7%) had visual acuity <3/60 based on who visual acuity classifications (figure 1). table 1 showed pexg patients on their first admission to hospital had increase of iop > 20 mmhg, with most in the range iop of 31–40 mmhg (32.6%) and 41–50 mmhg (32.6%). funduscopy examination which measures cup/disc (cd) ratio indicated most patients were found with cd ratio 0.9–1.0 (46.5%) and followed by those that were classified as hard to assess because of the presence of opaque media (34.9%). there are two types of pexg, open angle and closure angle glaucoma. table 3 showed most patients had open angle (88.4%). some data from gonioscopy examination showed these patients could not be assessed (6.9%) because of presence of cornea edema. all pexg patients in this research received treatment. most patients were given medication only (68.75%), while surgical treatment was given to the patient who could not be treated by medication only. the most figure 1 visual acuity table 1 iop iop frequency percentage (%) 21–30 10 23.3 31–40 14 32.6 41–50 14 32.6 51–60 4 9.2 61–70 1 2.3 althea medical journal. 2015;2(1) 125rizki fasa ramdhani, elsa gustianty, fenny dwiyatnaningrum: pseudoexfoliation glaucoma in the national eye center, cicendo eye hospital, january–october 2012 common surgeries were combined surgery (18.75%) for treating glaucoma and cataract. discussions in this study, pexg mostly occured in elderly people. these findings agree with a study which found pexg onset was rarely found in the age before 50, but most cases occurred in their late 60s and early 70s, thus indicating that age was a risk factor of glaucoma.11,12 the majority of patients were male. a similar research stated on the prevalence of pexg in china. nevertheless, existing theories state that there is no relationship between gender and glaucoma incidence.5 in this study most of the glaucoma type ocurred unilateral. although other studies stated the same, yet the manifestation could be bilateral, therefore it is important to examine and treat another eye.10, 11 the result of this research showed, most of the patients came when their eyes were already blind. this might happen because the patients had no pain symptoms, therefore they ignored any symptoms which occured and did not realize until it was in the late stage. table 1 shows the iop from pexg patients were categorized as high (>21 mmhg). table 2 shows that most patients were with cd ratio of 0.9–1.0. some literatures stated that pathogenesis of pexg and its effect on visual acuity was in parallel with the involvement of the optic nerve as a consequence of high iop.3 high iop could damage the optic nerve because of direct pressure or its relation with ischemic theory and/or retinal blood vessel occlusion that can cause decreased visual acuity.3 glaucoma based on its pathogenesis can be divided into open angle and close angle glaucoma. both mechanisms can occur in pexg. table 3 shows that most patients suffered from open angle glaucoma. another study stated similar result, of which most cases of pexg was open angle glaucoma.3 the purpose of management on pexg patients was to reduce the iop. there are some variants of anti-glaucoma drugs with different mechanism of action. anti-glaucoma drugs are given based on severity of glaucoma and safety for the patient with the consideration of comorbidity such as heart disease, asthma, renal disease, and other diseases.2 in conclusion, pexg occurs in elderly patients and there may be a possible table 2 cd ratio cd ratio frequency percentage (%) <0.7 4 9.3 0.7–0.8 4 9.3 0.9–1.0 20 46.5 hard to asses 15 34.9 table 3 anterior chamber angle anterior chamber angle frequency percentage (%) open 38 88.4 closure 2 4.7 hard to asses 3 6.9 table 4 treatment treatments frequency percentage (%) medication only 22 68.75 medication + surgery : trabeculectomy 4 12.5 combined 6 18.75 althea medical journal. 2015;2(1) 126 amj march, 2015 relationship between iop, cd ratio, and decreased visual acuity. hence for further study, correlations between iop and visual acuity should be conducted. references 1. arvind h, raju p, paul pg, baskaran m, ramesh sv, george rj, et al. pseudoexfoliation in south india. br j ophthalmol. 2003;87(11):1321–3. 2. langston dp. manual of ocular diagnosis and therapy. 5th ed. boston: lippincott williams & wilkins; 2002. 3. schlote t, rohrbach j, grueb m, mielke j. pocket atlas of ophthalmology. 1st ed. new york: thieme; 2006. 4. rhee dj, pyfer mf. the wills eye manual: office and emergency room diagnosis and treatment of eye disease. 3rd ed. washington: lippincott williams & wilkins; 1999. 5. riordan-eva p, whitcher jp. vaughan & asbury’s general ophthalmology. 17th ed. san francisco: mcgraw-hill companies; 2008. 6. lang gk. ophthalmology: a short textbook (flexibook). 2nd ed. new york: thieme; 2000. 7. kanski jj, bowling b. clinical ophthalmology: a systematic approach e-book. 7th ed. london: saunders; 2011. 8. allingham rr, loftsdottir m, gottfredsdottir ms, thorgeirsson e, jonasson f, sverisson t, et al. pseudoexfoliation syndrome in icelandic families. br j ophthalmol. 2001;85(6):702–7. 9. foster pj, seah skl. the prevalence of pseudoexfoliation syndrome in chinese people: the tanjong pagar survey. br j ophthalmol. 2005;89(2):239–40. 10. yanoff m, duker js. ophthalmology. 3rd ed. london: mosby elsevier; 2009. 11. allingham rr. shields’ textbook of glaucoma. 6th ed. north carolina: lippincott williams & wilkins; 2005. 12. young al, tang wwt, lam dsc. the prevalence of pseudoexfoliation syndrome in chinese people. br j ophthalmol. 2004;88(2):193–5. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 268 amj june, 2015 dermatomycosis among elementary school children in jatinangor west java isni maulina sukmara1, risa miliawati2, hadyana sukandar3 1faculty of medicine universitas padjadjaran, 2department of dermatology and venerology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, 3department of epidemiology and biostatistics faculty of medicine universitas padjadjaran abstract background: dermatomycosis often occurs in tropical countries. many studies from tropical countries have reported high prevalence of dermatomycosis among elementary school children. despite being a tropical country, prevalence of dermatomycosis among elementary school children in indonesia is still unknown. the objective of this study was to determine the prevalence and characteristics of dermatomycosis among elementary school children in jatinangor, sumedang, west java in september–november 2012. methods: this study used a cross-sectional descriptive survey method. the 328 children from five elementary schools in jatinangor were included in the study using multistage sampling technique. medical history and physical examination was performed to all subjects. subjects who had skin lesion suspected for dermatomycosis were examined with direct microscopic examination using 10% solutions of potassium hydroxide (koh). data were presented as frequent analysis distribution using statistical package for social sciences (spss) version 17.0. results: of 328 children (174 males, 154 females; aged 5–14 years), 35 (10.6%) had lesions suggestive of dermatomycosis but only 5 children (1.5%) were positive for dermatomycosis. males are more prevalent than females, patients were in ≥10 years age group. four cases were pityriasis versicolor, while one was diagnosed with tinea facialis. conclusions: dermatomycosis among elementary school children in jatinangor had a low prevalence, with only 4 cases of pityriasis versicolor and one tinea facialis case. [amj.2015;2(1):268–75] keywords: dermatomycosis, elementary school children, prevalence correspondence: isni maulina sukmara, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285624179080 email: isnimaulina@gmail.com introduction dermatological infection is a disease which occurs within all classes of society, and yet gains little attention because it is considered as unthreatening and negligible. many factors influence the event of dermatological infection. the world health organization (who) epidemiology study about dermatological infection in children living in developing countries stated that several important factors can increase the risk of dermatological disease such as low hygiene, difficult access to clean water, climate factor, and population density. one of the dermatological infections which is promoted by hot and humid climate (tropical) is the superficial mycosis.1 dermatomycosis is widely reported in many studies around the world. the results showed that dermatomycosis affects 20–25% of the world’s population.2 a research in nigeria3 reported that 67% of the 82 dermatological cases found in a clinic was caused by fungi and the most afflicted age group is between 10–40 years old. dermatomycosis research on elementary school children is also widely conducted and showed a quite high prevalence, such as the research in dar es salam4, the research showed that out of 420 children being studied, 241 of them or 57.3% are afflicted by dermatological diseases. from all dermatological conditions found, dermatomycosis have a prevalence of 20% (84/420) with dermatophytosis as the most common type at 11.4% (48/420). despite being a tropical country, the study about dermatomycosis among elementary school children in indonesia is still limited. jatinangor, west java was chosen as the study area to see the prevalence of dermatomycosis among elementary school children in one of the regions in indonesia. althea medical journal. 2015;2(2) 269isni maulina sukmara, risa miliawati, hadyana sukandar: dermatomycosis among elementary school children in jatinangor west java figure 1 flow of research procedure methods this cross-sectional descriptive surveillance study was performed in public elementary schools (sekolah dasar negeri;sdn): sdn cileles, sdn jatiroke i, sdn jatinangor, sdn paripurna, and sdn sirahcai, jatinangor, sumedang district, west java. the study was conducted between september–november 2012. this study had been studied and approved by the health research ethic committee, faculty of medicine, universitas padjadjaran. three hundred and twenty eight children from a total of 8,462 elementary school children in jatinangor were chosen using multistage sampling method and simple random sampling method. the randomization started from village units of the 12 villages in jatinangor to randomly choose five villages. althea medical journal. 2015;2(2) 270 amj june, 2015 table 1 research subject characteristics characteristics n percentage (%) age <10 196 59.8 ≥10 132 40.2 gender male 174 53 female 154 47 body mass index very low 19 5.8 low 58 17.7 normal 226 68.9 overweight 14 4.3 obesity 11 3.4 frequency of bathing <2 times a day 12 3.7 2 times a day 306 93.3 >2 times a day 10 3 towel usage shared 46 14 not shared 282 86 wearing of head cover yes 101 30.8 no 227 69.2 layered clothing yes 154 47 no 174 53 sharing of clothing yes 36 11 no 292 89 habit of playing with dirt yes 101 30.8 no 227 69.2 pets yes 95 29 1 type 71 74.7 2 types 24 25.3 none 233 71 history of personal skin diseases present 51 15.5 none 277 84.5 althea medical journal. 2015;2(2) 271 the next randomization is in the scope of the elementary school in each village to be studied. after five elementary schools were chosen, randomization was furthered into the smaller scope of which children should be chosen. an inclusion criterion was all elementary school students who are present on the day of examination. permission, in the form of a signed informed consent from parents or guardian, was obtained before the students were included in the research. an exclusion criterion was the absence of children at the day of examination. in this study, subject history form was filled, and physical examination by a medical doctor was performed. direct microscopic examination to support the diagnosis of dermatomycosis was conducted so the prevalence and characteristics of the patients such as age, gender, risk factor body mass index (bmi), frequency of bathing, towel usage, head cover wear, habit to wear layered clothings or to share clothings, habit to play with soils, the ownership of pets, history of dermatological disease both on self and in the family, and immunocompromise condition) and also clinical picture (lesion location, efloresence, microscopic finding, type of dermatomycosis) were collected as depicted in the flowchart in the figure 1. specimen for direct microscopic examination was taken directly from the lesion of infected skin or hair. specimen from skin lesion was obtained using curette or celotape band while hair specimen was taken from a location near the hair roots. the specimens were then put on top of the object glass. specimens were then taken to the department of dermatology and venerology in dr. hasan sadikin general hospital to be examined. a drop of potassium hydroxide (koh) 10% was applied on the specimen and a cover glass is used to cover the speciment. fixation was performed by heating. specimens were then inspected using light microscope. dermatophytosis specimen would show a picture of branching hyphae with septa and arthospore. pityriasis versicolor specimens would show short hyphae and round spora, while cutaneous candidiasis would show pseudohyphae, blastospore, and/or budding cells. diagnostic criteria for dermatomycosis are: positive clinical pictures and direct microscopic examination. results from 328 subjects, 35 of them were suspected with dermatomycosis based on physical examination. direct microscopic examination with koh 10% solution showed that 5 of these subjects were positively confirmed of having dermatomycosis. as such from this research the prevalence of dermatomycosis among elementary school children in the district of jatinangor was 1.5%. characteristics of all subjects regarding their age, gender, and risk factors of dermatomycosis can be seen in table 1. the prevalence of dermatomycosis and its characteristics can be seen on tables 2–4. in this study, from 5 students afflicted of dermatomycosis, only one less than 10 years old, and the rest were characteristics n percentage (%) history of familial skin diseases present 1 0.3 none 327 99.7 immunocompromised condition present 2 0.6 none 326 99.4 table 2 prevalence of dermatomycosis among elementary school children in jatinangor on the period between september–november 2012 dermatomycosis n percentage (%) dermatomycosis (+) 5 1.5 dermatomycosis (-) 323 98.5 total 328 100 isni maulina sukmara, risa miliawati, hadyana sukandar: dermatomycosis among elementary school children in jatinangor west java althea medical journal. 2015;2(2) 272 amj june, 2015 10 years old or older. this research showed that dermatomycosis attacked males more frequently with a male:female ratio was 3 : 2. risk factors of dermatomycosis were not frequently found. the result of this study showed that the most common dermatomycosis was pityriasis versicolor (4 cases), followed by dermatophytosis (1 case), and no cutaneous candidiasis case were found. there was no individual suffered from more than one type of dermatomycosis. discussions the determination of the prevalence of dermatomycosis among elementary school children in this study area was conducted because this group is considered as being at risk for dermatomycosis. the risk considered is living in a humid tropical climate which can promote the growth of fungi.2 other than that, elementary school children also have the same range of age which is between 5–14 years old. in this age range, study results showed high incidence in this specific age group, which became the basis for this study. prevalence of dermatomycosis among elementary school children in this study area was about 1.5%. if compared to the results of zarrin et al.6, in iran, the prevalence that was found in this study was larger, dermatomycosis was 0.4% from 2,827 elementary school children who were examined. several studies gained even considerably larger results, such as that found in nigeria by emele et al.7, which showed a prevalence of 10.5% from 47,723 elementary school children, and in dar es salaam, tanzania, komba et al.4 found a 20% prevalence from 420 elementary school children. in indonesia, studies about dermatomycosis are less common, no data about prevalence from population at risk was found. according to the research conducted by the mycology division of the outpatient care unit of the dermatolo-venereology department of dr. soetomo teaching hospital, surabaya8, in the year of 2003–2005, dermatomycosis was the third most prevalent dermatological diseases found after dermatitis and acne. the difference in prevalence of each research can be attributed to the difference in geographical location which also affects the growth of the table 3 characteristics of dermatomycosis among elementary school children in jatinangor on the period between september–november 2012 patient 1 2 3 4 5 age (years old) 7 11 11 10 10 gender male male female male female bmi no very low no obesity no frequency of bathing 2 2 2 2 2 towel usage shared shared not shared not shared not shared wearing of head cover no no yes no no layered clothing yes yes yes no no sharing of clothing yes no yes no no habit of playing with dirt yes yes yes no no pets yes no yes no no history of personal skin disease none none none none none history of familial skin disease none none none none none immunocompromised condition none none none none none diagnosis pityriasis versicolor pityriasis versicolor pityriasis versicolor pityriasis versicolor dermatophytosis althea medical journal. 2015;2(2) 273isni maulina sukmara, risa miliawati, hadyana sukandar: dermatomycosis among elementary school children in jatinangor west java fungi as pathogens (such as environmental temperature and humidity), cultural and environmental factors. differences in the selection, collection, and number of samples in each study can also affect the difference in results.6 in this study, dermatomycosis was more prevalent in children 10 years and older. this age includes as prepuberty period.11 this is in line with the maturity of the sweat glands in the beginning of puberty which made possible a rise in the population of normal lipophilic flora such as malassezia furfur which is the etiology of pityriasis versicolor.10,11 this is in accordance with the findings of zarrin et al.6, in which most cases of dermatomycosis is within the range of 9–10 years old and also with the findings of uneke et al.12, which also stated that dermatomycosis afflicted individuals within the age range of 10–13 years old. this study found that male was at more risk of developing dermatomycosis, which is in agreement with the research of komba et al.4, in dar es salaam, in which dermatomycosis was found in 50 males and 34 females. even in the study conducted by enemuor et al.13, in nigeria, there was a stark difference with 129 males and 15 females were afflicted with dermatomycosis. this result may be due to much higher activity found in males rather than females.13 dermatomycosis is a disease influenced by a humid environment, personal and environmental hygiene, contact with infection spreading agents (man, animal, and incontaminated objects), and deficient immune system.5 a humid environment, aside of being affected by climate and weather, it can be argued that it can also be created from the wearing of head cover and layered clothing. self-hygiene in this research was determined by the frequency of bathing by the individual. contact of disease was defined as the sharing use of towel, sharing clothing, presence of pet, and playing with soil. pet and soil can be a source of infectious fungi which are either zoophilic or geophilic.5 generally, the hygiene of individual afflicted with dermatomycosis in this research was considered adequate and only a few of them have risk factors. immunocompromised condition in this research was defined as a low immune condition of the individual attributed to immunosuppresive medications or chronic disease. immunocompromised conditions such as diabetes mellitus patients is a predisposition factor for candida infection.2 the research showed that only 0.6% had the condition, which is in accordance to the event of dermatomycosis in this research which did not show any event of cutaneous candidiasis. in this study, the most common type of dermatomycosis was pityriasis versicolor, and only one case of dermatophytosis was found. this result was not in accordance with the study done by amoran et al.14, about the pediatric dermatological condition in school children of sagamu, nigeria, in which 159 (74.1%) of dermatological cases of fungal infection, were dermatophytosis. komba et al.4, in dar es salaam also showed less pityriasis versicolor than dermatophytosis at 36 (8.6%) and 48 (11.4%) from all samples in 420 students. the result of this study was in agreement with those of zarrin et al.6, in iran, in which pityriasis versicolor was more prevalent than dermatophytosis. this is possible because of table 4 clinical picture of dermatomycosis afflicted elementary school children in jatinangor on the period between september–november 2012 patient location of lesion efloresence koh type of dermatomycosis p-1 perioral hypopigmentation, scales short hyphae and round spora pityriasis versicolor p-2 back hyperpigmentation, scales short hyphae and round spora pityriasis versicolor p-3 back hypopigmentation short hyphae and round spora pityriasis versicolor p-4 right cheek hypopigmentation, scales short hyphae and round spora pityriasis versicolor p-5 forehead (bordering with scalp) erythematous macule, erythematous papule, plaque long branching hyphae, have septa dermatophytosis (tinea facialis) althea medical journal. 2015;2(2) 274 amj june, 2015 the less contact the afflicted individuals had with source of dermatophytosis infection such as pet, soil, and contacts with objects or people who have been in contact with an etiological agent.5 there is a characteristic difference between dermatophytosis and pityriasis versicolor case. lesion observed in dermatophytosis afflicted individual in this study was found in the border of face with scalp which was a border of the glabrous skin, a form of tinea corporis(tinea facialis).5,15 tinea corporis is a form of dermatophytosis which can occur in all ages and in some literature, it was mentioned that tinea corporis was one of the most common dermatophytosis cases in children after tinea capitis.5,16 tinea facialis happens more in children and often caused by anthropophilic dermatophyte which is spread all across the world, such as t. mentagrophytes and t. rubrum.5,15 transmission of antropophilic dermatophyte is usually through direct contact with other infected individual or with a contaminated object.5 but, for individuals afflicted with tinea facialis found in this study, the characteristics did not show contact with either other afflicted individual or contaminated object. lesions on pityriasis versicolor cases have difference regarding the location and its characteristics. location of lesion found is more in the back region, followed by perioral and buccal region. the lesions showed both hypo and hyperpigmentation type, but hypopigmentation was found more frequent. the location of pityriasis versicolor was similar with the finding of rijal et al.17, which stated that pityriasis versicolor lesion in children was more on the faces of children. but from the characteristics of lesion, pityriasis vesiclor in these researches showed hypopigmentation type, which is in agreement with this study.17 the conclusion of this study was that dermatomycosis among elementary school children in jatinangor in the period of september–november 2012 has low prevalence (1.5%), affecting those in prepubescent (10 years old or more) and most commonly occur in males. the most common type of dermatomycosis in this study is pityriasis versicolor. to know more about dermatomycosis prevalence among elementary school children in indonesia, further studies with greater sample size will be needed. a further study to recognize risk factors is also needed with a different study design. references 1. who. epidemiology and management of common skin diseases in children in developing countries. geneva: world health organization. 2005:54. 2. havlickova b, czaika va, friedrich m. epidemiological trends in skin mycoses worldwide. mycoses. 2008;51 suppl 4:2– 15.. 3. olasode oa, otu a, henshaw eb, akpan n. cutaneous infections in patients presenting in a skin clinic in the tropics. int j tropical med. 2009;4(3):119–22 4. komba ev, mgonda ym. the spectrum of dermatological disorders among primary school children in dar es salaam. bmc public health. 2010;10:765. 5. wolff k, johnson ra, fitzpatrick tb. fitzpatrick’s color atlas and synopsis of clinical dermatology. 6th ed. new york: mcgraw-hill medical; 2009 6. zarrin m, poosashkan m, mahmoudabadi a, mapar m. prevalence of superficial fungal infection in primary school children in ahvaz, iran. maced j med sci. 2011;4(1):89–92 7. emele fe, oyeka ca. prevalence and etiology of dermatomycoses among children in anambra state of nigeria. journal of biomedical investigation. 2007;5(1):1–8. 8. hidayati an, suyoso s, desy hinda p, sandra e. mikosis superfisialis di divisi mikologi unit rawat jalan penyakit kulit dan kelamin rsud dr. soetomo surabaya tahun 2003–2005. berkala ilmu kesehatan kulit & kelamin. 2009;21(1):1–8. 9. kliegman r. stanton b, gemelll j, schor n, behrman r. nelson textbook of pediatrics. 19th ed. philadelphia: elsevier; 2011 10. brooks gf, carroll kc, butel js, morse sa. jawetz, melnick & adelberg’s medical microbiology. 24th ed. new york: mcgrawhill medical; 2007. 11. mescher a. junqueira’s basic histology. 12th ed. new york: mcgraw-hill companies,incorporated; 2009. 12. uneke c, ngwu b, egemba o. tinea capitis and pityriasis versicolor infections among school children in the south-eastern nigeria: the public health implications. the internet journal of dermatology [online journal] 2006;4(2). 13. enemuor s, amedu a. prevalence of superficial mycoses in primary school children in anyigba, kogi state, nigeria. afr j microbiol res. 2009;3(2):062–5. althea medical journal. 2015;2(2) 275isni maulina sukmara, risa miliawati, hadyana sukandar: dermatomycosis among elementary school children in jatinangor west java 14. amoran o, runsewe-abiodun o, mautin a, amoran i. determinants of dermatological disorders among school children in sagamu, nigeria. educ res. 2011;2(12):1743–8. 15. brasch j, hipler uc. clinical aspects of dermatophyte infections. in: brakhage aa, zipfel pf, editors. human and animal relationship: the mycota vi. 2nd ed. : verlag berlin heidelberg: springer. 2008. p. 263–86 16. carod jf, ratsitorahina m, raherimandimby h, hincky vitrat v, ravaolimalala andrianaja v, contet-audonneau n. outbreak of tinea capitis and corporis in a primary school in antananarivo, madagascar. j infect dev ctries. 2011;5(10):732–6. 17. rijal a, agrawal s, bhattarai s. prevalence and clinical features of pityriasis versicolor in children. health renaissance. 2012;10(2):105–7. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 142 amj september 2018 correlation between serum uric acid and hba1c levels in patients with type 2 diabetes mellitus rifan nugraha,1 nina tristina,2 miftahurachman3 1faculty of medicine universitas padjadjaran, indonesia, 2department clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3departement of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: indonesia ranks fourth among countries with the highest number of diabetics. increasing evidence suggests that hyperuricemia is an independent risk factor for impaired fasting glucose (ifg) and type 2 diabetes. some observational studies have identified elevated uric acid concentration as a risk factor for diabetes, while others have found an inverse relationship. the present study was conducted to discover the strength and the direction of the correlation. methods: this study was an analytical cross-sectional study conducted from may to october 2014. the study subjects were 56 medical records of new outpatients diagnosed with t2dm in the internal medicine polyclinic who underwent laboratory examination at the clinical pathology unit of dr. hasan sadikin general hospital, january-december 2013. result: the correlation between hba1c and uric acid levels on the whole subject revealed a weak but significant negative correlation (r=-0.354, p=0.007). there was an insignificant negative correlation in male subjects (r=-0.405, p=0.120); in female subjects (r=-0.319, p=0.05), the correlation was a weak but insignificant negative correlation. conclusions: there is a weak correlation between hba1c and uric acid levels in patients with diabetes mellitus type 2. keywords: correlation, hba1c, t2dm, uric acid correspondence: rifan nugraha, faculty of medicine universitas padjadjaran, jalan raya bandung-sumedang km. 21, jatinangor, jawa barat, indonesia, email: rifan.nugraha@gmail.com introduction in 2010, indonesia ranks fourth among countries with the highest number of diabetics with estimated 8.4 million people, and these numbers are subject to increase in 2030 to a staggering 21.3 million people.1 type 2 diabetes mellitus (t2dm) is characterized by chronic hyperglycemia that causes the formation of early product of glycosylation, to which glycated hemoglobin (hba1c) is an analog. hba1c is a marker that reflects average plasma glucose over the previous 2-3 months. complications from chronic hyperglycemia manifest as microangiopathy and macroangiopathy, such as coronary artery disease, cerebral vascular disease, and peripheral artery disease. uric acid is the endproduct of purine metabolism. a previous study by ogbera et al. in 2010 reveals that the prevalence of hyperuricemia, defined as serum uric acid is higher than 7 mg/dl for men and 5.7 mg/dl for women, in t2dm patients is 25%.2 hba1c levels correlate with serum uric acid levels through competing mechanism in uric acid resorption in kidney, mediated by glycosuric effect on uricosuria.3 studies exploring the correlation between hba1c and serum uric acid levels are relatively scarce compared to the extensive research aiming to analyze the correlation between blood glucose and serum uric acid levels.3,4 the correlation between hba1c and serum uric acid levels was first studied by choi et al. in 2008, with the result showing a bell-shaped relation.5 it is crucial that this correlation is completely understood so that the clinician may predict when t2dm patients are at risk of hyperuricemia. a conflicting result is found by another study which states, uric acid concentration is emerging as a potential marker of diabetes risk.6 based on this background, this study amj.2018;5(3):142–5 althea medical journal. 2018;5(3) 143 explored the correlation between hba1c and serum uric acid levels in new outpatients diagnosed with t2dm in the internal medicine polyclinic who underwent laboratory examination at the clinical pathology unit, dr. hasan sadikin general hospital from january to–december 2013 and was conducted to discover the strength and the direction of the correlation. methods this study was a retrospective study conducted in an analytic cross-sectional method during the period may–october 2014. the subjects were new outpatients diagnosed with t2dm in the internal medicine polyclinic who underwent laboratory examination at the clinical pathology unit, dr. hasan sadikin general hospital from january to december 2013. materials used in this study were medical records which met the inclusion criteria that were subjects with complete data of fasting blood glucose levels (mg/dl), 2-hour postprandial glucose levels (mg/dl), hba1c levels (%), and serum uric acid levels (mg/dl). the sampling method used was consecutive sampling with a minimum of 30 samples. this study was approved by the ethical clearance committee of dr. hasan sadikin general hospital. the data collection process from medical records resulted in 1,275 outpatients diagnosed with t2dm at the internal medicine polyclinic, dr. hasan sadikin general hospital. out of these 1,275 outpatients, 231 were new in the period of january–december 2013. after consecutive sampling was carried out, the subjects who met the inclusion criteria were 56 patients. normality test was conducted on continuous variables, including continuous variables in baseline characteristics, fasting blood glucose levels, 2-hour postprandial glucose levels, hba1c levels, and serum uric acid levels. the variables were then foremost presented in a descriptive analysis. the statistical analysis in this study was correlation analysis with two continuous variables. if the serum uric acid and hba1c levels were normally distributed, the statistic test used would be pearson correlation coefficient; otherwise, spearman’s rho correlation coefficient would be used. table 1 the clinical characteristic of typ 2 diabetes mellitus patients characteristic men women total sex 16 (28.57%) 40 (71.43%) 56 (100%) age, years 57 ± 11.1* 57± 7.2* 56.7 ± 8.1* lipid profile total cholesterol, mg/dl 202 ± 52.7* 205 ± 44.5* 204 ± 46.6* hdl, mg/dl 40 ± 6.7* 50 ± 9.5* 47 ± 10* ldl, mg/dl 132 ± 46.6* 130 ± 43.2* 130.5** triglyceride, mg/dl 180 ± 84.8* 143** 149.5** sgot, u/l 19** 15.4 ± 4.3* 18** sgpt, u/l 19** 15 ± 6* 18** ureum, mg/dl 27** 22** 23** creatinine, mg/dl 1.2** 0.7** 0.7** proteinuria (%) 2 (15.4%) 23 (63.9%) 25 (51%) +/(%) 1 (7.7%) 3 (8.3%) 4 (8.2%) 1+ (%) 5 (38.5%) 6 (16.7%) 11 (22.45%) 2+ (%) 1 (7.7%) 1 (2.8%) 2 (4.2%) 3+ (%) 4 (30.8%) 2 (5.6%) 6 (12.24%) 4+ (%) 1 (2.8%) 1 (2%) note: * the data were normally distributed and presented in mean ± standard deviation ** the data were not normally distributed and presented in median. rifan nugraha, nina tristina, miftahurachman: correlation between serum uric acid and hba1c levels in patients with type 2 diabetes mellitus althea medical journal. 2018;5(3) 144 amj september 2018 table 2 laboratory test results of fasting blood glucose levels, 2-hour postprandial glucose levels, hba1c levels, and serum uric acid levels laboratory test men women whole subject fasting blood glucose (mg/dl) 167 (101-364) 156 (94-430) 158 (94-430) 2-hour postprandial glucose (mg/dl) 270 (137-590) 230 (101-539) 246 (101-590) hba1c (%) 8.8 (5.3-14.5) 8.6 (6.1-37.3) 8.65 (5.3-37.3) serum uric acid (mg/dl) 5.95 (3.6-11.5) 5.45 (2.8-12.7) 5.65 (2.8-12.7) note: the data were not normally distributed, and presented in median and range results this correlation study was divided between male and female due to the previous study found significant interactions affecting the correlation by sex.5. the correlation between hba1c and serum uric acid levels in the whole subject was revealed to be a weak negative correlation but significant (r=-0.354, p=0.007). there was a negative correlation but insignificant in male (r=-0.405, p=0.120) and in female, the correlation was weak negative and insignificant (r=-0.319, p=0.05). discussion in developing countries, the majority of diabetes patients are in the 45-64 age group.1 in this study, the mean ± standard deviation of ages on whole subject was 56.7±8.1 yearold, corresponding to the aforementioned age group. hyperglycemia in t2dm is too often asymptomatic, hence when the patients are diagnosed, especially in the age above 20-year-old, the patients have already suffered from complications.7 the effect of chronic complication, such as diabetic nephropathy, in this study might become one of the confounding factors to the result of the study. the correlation between hba1c and serum uric acid levels on the whole subject showed a weak negative correlation but significant between both variables (r=-0.354, p=0.007), which can be interpreted as the hba1c levels increased, then the serum uric acid levels decreased. the result of the study conducted by choi et al.5 in 2008, reveals a bell-shaped correlation; the serum uric acid levels increase along the increase of hba1c until the hba1c levels reach the interval 6-6.9%, further an increase in hba1c results in the decrease of serum uric acid levels. the median of hba1c levels on the whole subjects in this study was 8.65%; this value falls on the descending slope of the bell-shaped correlation curve of choi’s.5 this negative correlation may appear to be contra-intuitive compared to other studies that find the increase in serum uric acid levels on the hyperinsulinemic state which corresponds to the disturbance of uric acid excretion by kidney is due to the effect of insulin on the uric acid transporters, thus establishing a positive correlation between insulin and uric acid.8 however, li et al.9, in 2011, discovers that the t2dm patient with higher hba1c levels and longer duration of diabetes are more often associated with the worsening function of pancreatic β-cell to secrete adequate insulin, thus the correlation between hba1c and uric acid on the study shows a negative correlation.9 the mechanism responsible for the negative correlation in this study is associated with the mechanism of how the metabolism of glucose influences the metabolism of uric acid; given that hba1c levels reflect control value of individual blood glucose levels better. when the glucose levels overcome the threshold of table 2 laboratory test results of fasting blood glucose levels, 2-hour postprandial glucose levels, hba1c levels, and serum uric acid levels subjects of the study spearman’s correlation coefficient (r) significance (p) whole subject -0.354 0.007** male subjects -0.405 0.120 female subjects -0.319 0.05 note: **correlation was significant on 0.05 level althea medical journal. 2018;5(3) 145rifan nugraha, nina tristina, miftahurachman: correlation between serum uric acid and hba1c levels in patients with type 2 diabetes mellitus kidney for reabsorption, the glucose then starts to be excreted in urine (glycosuria). at this point, the kidney reaches transport maximum, a condition where all of the nephrons work on their maximal capacity to reabsorb glucose.10 one of the transporters that has a role in glucose reabsorption is glut9 which is also responsible for reabsorbing the uric acid.11 therefore, this competing mechanism decreases the reabsorption of uric acid, thus the negative correlation and the validation of the adage glycosuria causes uricosuria. this study has several limitations, they are (1) the method used is cross-sectional study, hence the result yields an association that is unable to explain the causative relationship between hba1c and uric acid levels; (2) confounding factors such as smoking status; bmi; on-going diuretic medication; hypertension; glomerular filtration rate; and protein intake are not pursued.5 from this study, we may conclude that there is a weak negative correlation between hba1c and serum uric acid levels in new outpatients diagnosed with t2dm in the internal medicine polyclinic who underwent laboratory examination at the clinical pathology unit, dr. hasan sadikin general hospital from january-december 2013. as the hba1c levels increase, the serum uric acid levels decrease indicating uricosuric effect on glycosuria, however this correlation is not strong, thus it can be interpreted as there are other factors contributing to the pathophysiologic mechanism of hba1c and serum uric acid levels. further studies are suggested to use the prospective method with statistical analysis that may elucidate the causative relationship between hba1c and serum uric acid levels in t2dm patients. the prospective method is used on the basis of its capability of analysing the confounding factors that may increase the validity of the study. references 1. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes: estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047–53. 2. ogbera ao, azenabor ao. hyperuricaemia and the metabolic syndrome in type 2 dm. diabetol metab syndr. 2010;2:24. 3. shabana s, sireesha m, satyanarayana u. uric acid in relation to type 2 diabetes mellitus associated with hypertension. journal of clinical and diagnostic research. 2012;6(7):1140–3. 4. yuan hj, yang xg, shi xy, tian r, zhao zg. association of serum uric acid with different levels of glucose and related factors. chin med j. 2011;124(10):1443–8. 5. choi hk, ford es. haemoglobin a1c, fasting glucose, serum c-peptide and insulin resistance in relation to serum uric acid levels—the third national health and nutrition examination survey. rheumatology. 2008;47(5):713–7. 6. juraschek sp, mcadams-demarco m, miller er. temporal relationship between uric acid concentration and risk of diabetes in a community-based study population. am j epidemiol. 2014;179(6):684-91. 7. longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j, editors. harrison’s principles of internal medicine. 18th ed. usa: mcgraw-hill companies; 2012. 8. gill a, kukreja s, malhotra n, chhabra n. correlation of the serum insulin and the serum uric acid levels with the glycated haemoglobin levels in the patients of type 2 diabetes mellitus. journal of clinical and diagnostic research. 2013;7(7):1295–7. 9. li q, yang z, lu b, wen j, ye z, chen l, et al. serum uric acid level and its association with metabolic syndrome and carotid atherosclerosis in patients with type 2 diabetes. cardiovasc diabetol. 2011;10:72. 10. hall je, guyton ac, editors. guyton and hall textbook of medical physiology. 12th ed. usa: saunders elsevier; 2011. 11. esparza martin n, garcia nieto v. hypouricemia and tubular transport of uric acid. nefrologia. 2011;31(1):44–50. althea medical journal. 2015;2(2) 281 physical profile of west java taekwondo athletes for pekan olahraga nasional xviii riau pynkan lafanda,1 ambrosius purba,2 tri damiati pandji3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine, universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, abstract background: taekwondo is a martial sport that is often included in competitions, especially in a national event such as pekan olahraga nasional (pon) xviii riau in september 2012. a taekwondo athlete must have maximum physical condition in order to achieve maximum performance. west java taekwondo athletes who will participate in this national sport event receive centralized exercises as a special preparation stage. this study aimed to determine the physical condition profile of male and female taekwondo athletes for pon xviii riau methods: a quantitative descriptive study was conducted in september 2012 to 15 west java taekwondo athletes for pon riau xviii consisting of 7 male athletes and 8 female athletes. physical conditions measured were strength, endurance, power, speed, flexibility, cardiorespiratory fitness, agility, and reaction time. the measurement results were then compared to the physical standards data from the head of national sports committee of indonesia (komite olahraga nasional indonesia/koni) and were analyzed by percentage category results: characteristics in less category were abdominal muscle endurance (male 71.43% and female 100%), cardio respiratory fitness (male 85.71%), and agility (female 37.50%). characteristics in far category were cardio respiratory fitness (female 62.50%) and agility (male 57.14%) conclusion: the ability of the physical condition of male and female west java taekwondo athletes for pekan olahraga nasional xviii riau still needs to be improved to maximize achievement. [amj.2015;2(1):281–86] keywords: athletes, physical condition, taekwondo correspondence: pynkan lafanda, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628122432396 email: pynkanlafanda@yahoo.com introduction taekwondo is a sport originated from korea. taekwondo is martial art that is very often competed at the national, regional, and international sport events.1-3 taekwondo is one of the sports included in the competition in the national sport competition (pekan olahraga nasional, pon) riau xviii 2012. taekwondo athletes using stance techniques such as guard position and ready stance. in addition, taekwondo athlete at the time of the defense uses rising block and knife-hand block. the same is also true when they dog strike movements such as taekwondo fist and side punch as well as in kicking movement such as side kick, front kick, and jumping round kick.2 motion patterns of taekwondo athletes during a match can be grouped as follows: stances, blocks, strikes, and kicks. according to these motion patterns, the muscle abilities need to be prioritized are arm muscles and leg muscles. based on the pattern of taekwondo athlete motions, experts agree that physical conditions need to be trained and upgraded are: leg muscle strength, muscle endurance (leg muscles and abdominal muscles), power (leg muscles and arm muscles), speed, flexibility, cardio respiratory fitness, agility, speed, and reaction time.4 to improve the physical condition of taekwondo athletes in accordance to the opinion of experts, three stages are needed: the preparation stage (general preparation stage and specific preparation stage), the match stage, and the resting stage.4 therefore, west java taekwondo athletes who will attend the national sport event (known as pekan olahraga nasional/pon riau xviii) were prepared with centralized training program that is currently at the stage of special preparation. althea medical journal. 2015;2(2) 282 amj june, 2015 related to the request of the coach and the deal with researchers, this study measured the physical conditions of male and female taekwondo athlete who is doing training at special preparation stage. to determine the physical condition abilities of taekwondo athlete who was training at a special preparation stage, it was measured: ability of leg muscles strength with leg dynamometer, ability of leg muscles endurance with squat jumps, ability of abdominal muscles endurance with sit-ups, ability of leg muscles power with vertical jumps, ability of arm muscles with medicine ball put, ability of speed with run 50 meters, ability of flexibility with flexometer, ability of cardio respiratory fitness with astrand (vo2max) test, ability of agility with beam side step, ability of reaction time with whole body reaction.5 to predict the effectiveness of training and the achievement of athletes, all measurement results are compared with physical standards data from head of national sports committee of indonesia (komite olahraga nasional indonesia/koni).6 according to the experts, an athlete specially taekwondo athlete who has a physical condition in either category of good or perfect will have maximum performance to get a gold medal on any particular sport events especially pon xviii riau.7 the purpose of this study is to determine the profile of the physical condition of male and female west java taekwondo athletes for pon xviii riau at special preparation stage age. the abilities of physical conditions are leg muscle strength, muscle endurance (leg muscles and abdominal muscles), power (leg muscles and arm muscles), speed, flexibility, cardio respiratory fitness, agility, speed, and reaction time. methods a quantitative descriptive study with the sample was 15 west java taekwondo athletes for pon riau xviii consisting of 7 male athletes and 8 female athletes. data is collected in september 2012 at west java koni office, bandung. data were taken from koni of west java which is the result of measurements made by sport medicine team of west java koni. the data consisted of age, gender, strength, endurance, power, speed, flexibility, cardio respiratory fitness, agility, and time reaction. the results of the data obtained and then compared with standard physical condition of koni pusat. results assessments were conducted in 15 west java taekwondo athletes. of this team, 7 male athletes with a lifespan range from 16 years to 27 years and 8 female athletes with a lifespan figure 1 body mass index of west java taekwondo athletes for pon xviii riau althea medical journal. 2015;2(2) 283pynkan lafanda, ambrosius purba, tri damiati pandji: physical profile of west java taekwondo athletes for pon xviii riau ranging from 16 years to 28 years. physical characteristics west java taekwondo athletes consisting of body mass index which stratified by the world health organization (who) body mass index criteria8 (figure 1). both of male and female athletes were included in normal category. for male athletes included in the perfect category was flexibility; the very good categories were leg muscle strength and arm muscles power; the good categories were leg muscle endurance, leg muscle power, and speed; the fairly category was agility; and the poor categories were abdominal muscle endurance and cardio respiratory fitness. then the ability of the reaction time was in the slow category. for female athletes who were in the perfect categories were leg muscle endurance, arm muscles power, and flexibility; the very good categories were leg muscle strength and leg muscles power; the good category was speed; the fairly category was cardio respiratory fitness; and the poor categories were abdominal muscle endurance and agility. then the ability of the reaction time in most female athletes was included in the slow category. discussions the results of strength component demonstrate that ability of leg muscle strength in mostly male athletes included in the very good category (42.86%) and mostly female athletes included in either good (42.86%) and very good (42.86%). even so, there were athletes who still had leg muscle strength in fairly categories, male (28.57%) and females (14.29%). the maximum ability of the leg muscle strength is required by a taekwondo athlete to achieve maximum performance. at the time of kick movements like side kick and jumping round kick when attacking an opponent in the game requires leg muscle strength.2 based on observations male and female west java taekwondo athletes at special preparation stage is done appropriate weight training, namely: exercise 2–3 times a week with the intensity of 8–12 rm and do as much as 3 set.4 weight training will increase the ability of muscle strength taekwondo athletes because of myofibril hypertrophy and increased of tendons and ligaments.4,9 muscle strength needs to be maintained and improved in order to achieve maximum performance especially in taekwondo athletes who has not reached the category well yet. because in a game required this ability to perform muscular strength when kick the opponent.3 the results of endurance component indicate that leg muscle endurance athletes in mostly male athletes included in good category (42.86%) and the majority of female athletes included in perfect category table 1 profile of the physical conditions of male west java taekwondo athletes for pon xviii riau at special preparation stage abilities category percentage (%) poor fairly good very good perfect strength leg muscles 0 28.57 28.57 42.86 0 endurance leg muscles 0 14.29 42.86 28.57 14.00 abdominal muscles 71.43 14.29 0 0 14.29 power leg muscles 0 14.29 71.43 14.29 0 arm muscles 0 14.29 28.57 57.14 0 speed 0 33.33 66.67 0 0 flexibility 0 14.29 14.29 28.57 43.00 cardio respiratory fitness 85.71 0 14.29 0 0 agility 28.57 57.14 0 0 14.29 reaction time slow: 14.29 fast: 85.71 althea medical journal. 2015;2(2) 284 amj june, 2015 (50.00%). even so, there were male athletes who still had leg muscle endurance in fairly categories (14.29%). based on observations on training program, male and female west java taekwondo athletes had an appropriate weight training, namely: exercise 2–3 times a week, as many as 20–25 rm intensity and do as much as 3 set.4 leg muscle endurance needed by a taekwondo athlete to perform maximally due to the repeatedly motion shot in a long time.9 in addition to maximum leg muscle endurance, also required abdominal muscle endurance abilities that taekwondo athletes could have a maximum achievement. the results demonstrate that abdominal muscle endurance in mostly male athletes included in poor category (71.43%) and female athletes are all included in the poor category (100%). the ability of abdominal muscle endurance of male and female west java taekwondo athletes is lacking, likely influenced by the lack of weight training which can increase abdominal muscle strength, such as sit-ups and push-ups exercises.9 from the above, it can explain the discovery of leg muscle endurance was good while abdominal muscle endurance were not maximized. the results of power component indicate that leg muscle power in mostly male athletes included in good category (71.43%) and the majority of female athletes fall into very good category (50.00%). even so, there were athletes who still had leg muscle power in fairly categories, male (14.29 %) and females (12.50 %). for those athletes who has not maximum leg muscle power yet, need appropriate weight training exercise 2–3 times a week and do as much as 12–15 rm intensity for 3 set.4 in addition to maximum leg muscles power, power ability which also necessary for taekwondo athletes is arm muscles power. the results demonstrate that arm muscles power on mostly male athletes fall into very good category (57.00%) and the majority of female athletes included in the perfect category (38.00%). even so, there were male athletes who still had arm muscles power in fairly categories (14.29 %). based on observations male and female west java taekwondo athletes had done appropriate weight training. but for those athletes who has not maximum arm muscles power yet, still need appropriate weight training like program for increasing leg muscles power, namely: exercise 2–3 times a week, as many as 12–15 rm intensity and do as much as 3 set.4 leg muscles and arm muscles power in taekwondo athletes needed for explosive movements in punching and kicking opponents. the results above show that the power of the leg muscles and arm muscles are excellent and perfect that need to be maintained and improved to achieve maximum performance. the results of speed component demonstrate the speed of the male athletes mostly included in good category (66.67%) table 2 profile of the physical conditions of female west java taekwondo athletes for pon xviii riau at special preparation stage abilities category percentage (%) poor fairly good very good perfect strength leg muscles 0 14.29 42.86 42.86 0 endurance leg muscles 0 0 37.50 12.50 50.00 abdominal muscles 100 0 0 0 0 power leg muscles 0 12.50 37.50 50.00 0 arm muscles 0 0 25.00 37.50 37.50 speed 12.50 12.50 62.50 12.50 0 flexibility 0 0 25.50 25.50 50.00 cardio respiratory fitness 12.50 62.50 25.00 0 0 agility 37.50 25.00 25.00 0 12.50 reaction time slow: 25.00 fast: 75.00 althea medical journal. 2015;2(2) 285pynkan lafanda, ambrosius purba, tri damiati pandji: physical profile of west java taekwondo athletes for pon xviii riau and either the majority of female athletes included in good category (62.50%). even so, there were male athletes who still had speed in fairly categories (14.29%) and female athletes who still have speed in poor category (12.50 %). athletes who still had speed ability in poor or fairly category maybe did not do appropriate training program such exercises with interval training run at a distance of 40 meters, break 3–5 minutes, and 3–5 times as much done a week.4 speed ability need to be maintained and improved in order to do some kicking and punching times in a row in the shortest possible time which can affect the success of winning.9 the results of flexibility component demonstrate that flexibility in mostly male athletes including in perfect category (43.00%) and the majority of female athletes are also included in the perfect category (50.00%). even so, there were male athletes who still have flexibility in fairly categories (14.29%). it was found that the perfect flexibility skills in west java taekwondo athletes based on field observations, the athletes had exercises with passive stretching or pnf (proprioceptive neuromuscular facilitation) as much as 3–5 times a week.4 the results of cardiorespiratory fitness component demonstrate that cardiorespiratory fitness of mostly male athletes fall into poor category (85.71%) and the majority of female athletes included in fairly category (62.50%). to achieve maximum performance in a game, taekwondo athlete should be able to achieve the maximum cardiorespiratory fitness in order to perform the game in a relatively long time. cardiorespiratory fitness means having the capacity of the heart, lungs, and circulatory both in delivering oxygen to the muscles so that they can work within long time.5,10 to maximize the ability of cardiorespiratory fitness of male and female west java taekwondo athletes who had poor or fairly category should be improved with aerobic exercise, such as running, jogging, swimming, and other.4 exercise which beneficial for improving pulmonary and heart endurance is done for 3–5 times a week, more than 1 hour workout, while exercise intensity 75–85% maximum pulse.11 according to the previous explanation, it can be explained that poor cardiorespiratory fitness (vo2max) was occurred because the coach did not provide intensive training to improve aerobic capacity. the results of agility component demonstrate the agility of mostly male athletes included in fairly category (57.14%) and the majority of female athletes included in the poor category (37.50%). in accordance with the pattern of motion of the taekwondo sport that requires agility in the game, such as the ability to change the position and direction of the body so fast. based on results, agility on male and female taekwondo athlete needs to be improved so that they can achieve maximum category. in connection with these exercises to improve agility are running back and forth, zig-zag run, squat thrust, and obstacle race.4 the results of reaction time component demonstrate the ability of the reaction time on mostly male athletes included in the slow category (85.71%) and the majority of female athletes are also included in the slow category (75.00%). the results of the above calculation show both male and female taekwondo athlete has slowly reaction time. while the reaction time is necessary in taekwondo, especially when it came under attacks from opponents and then athletes have to do fast respond.2 to improve the reaction time of taekwondo athletes should doing repetitive specific response exercises which suitable to taekwondo motions. another form of exercise can be interval run training which done 3–5 times a week and as much as 3 set.4 limitations of this study are limited sample size and time. a large enough and randomly selected sample, will help the analysis in this study to be more accurate. references 1. world taekwondo federation. what is taekwondo. gyeonggi-do: world taekwondo federation; 2009 [cited 2012 may 5]; available from: http://www.wtf. o rg / w t f _ e n g / s i te / a b o u t _ t a e k wo n d o / taekwondo.html. 2. park yh, park yh, gerrard j. tae kwon do: the ultimate reference guide to the world’s most popular martial art. 3rd ed. new york: facts on file; 2009. 3. kyong myong lee kjjk. the book of wtf poomsae competition. jakarta: pt gramedia pustaka utama; 2009. 4. bompa to. periodization: theory and methodology of training, 5th ed. champaign: human kinetics; 2009. 5. åstrand po. textbook of work physiology: physiological bases of exercise. champaign: human kinetics; 2003. 6. tim sport medicine. prosedur dan instrumen evaluasi fungsional atlet. standar koni pusat. jakarta: koni; 2011. 7. bidang sport science dan penerapan iptek althea medical journal. 2015;2(2) 286 amj june, 2015 olahraga. pemahaman dasar sport science & penerapan iptek olahraga, editor. jakarta: koni; 2012. 8. world health organization. bmi classification. geneva: who; 2012 [cited 2012 september 5]; available from: http://apps.who.int/bmi/index. jsp?intropage=intro_3.html. 9. heyward vh. advanced fitness assessment and exercise prescription: champaign: human kinetics; 2006. 10. guyton ac, hall je. textbook of medical physiology. 11th ed. philadelphia: elsevier saunders; 2006. 11. purba a. kardiovaskular dan faal olahraga. bandung: fakultas kedokteran universitas padjadjaran; 2012. althea vol 1 no 2 edit.indd althea medical journal. 2014;1(2) 86 amj december, 2014 role of knowledge and attitude toward perilaku hidup bersih dan sehat (phbs) of medical students 2009 universitas padjadjaran sufia permatasari syaefullah1,noorman herryadi2, elsa pudji setiawati3, henni djuhaeni4 1faculty of medicine, universitas padjadjaran, 2department of forensic and medico legal, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, 3department of public health, faculty of medicine, universitas padjadjaran, 4department of public health, faculty of medicine, universitas padjadjaran abstract background: perilaku hidup bersih dan sehat (phbs) is one of the main pillars of preventive measures in indonesia sehat and also a strategy to reduce health cost caused by illness based on the desire, willingness, and ability to be able to help themselves in medical aspects. the health provider including a doctor as a community leader should behave toward phbs which based on adequate knowledge and attitude. methods: this study have been conducted in february–november 2012 with cross-sectional design of 152 medical students 7th semester admission 2009 universitas padjadjaran, using questionnaires. data were analyzed using chi-square. results: the number of students with good knowledge and poor knowledge were not different (50.7%vs 40.3%). most of the respondens attitude are not in accordance with phbs program(p=0.805). conclusions: knowledge of phbs for all medical students needs to be improved and needs to investigated whether there are other factors which affect student attitudes toward phbs. [amj.2014;1(1):86–9] keywords: attitude, knowledge, phbs, student peranan pengetahuan dan sikap mahasiswa kedokteran universitas padjadjaran angkatan 2009 terhadap perilaku hidup bersih dan sehat (phbs) abstrak latar belakang: perilaku hidup bersih dan sehat (phbs) merupakan salah satu pilar utama pencegahan dalam program indonesia sehat serta strategi untuk mengurangi biaya kesehatan akibat penyakit yang berdasarkan keinginan, kemauan, dan kemampuan untuk membantu diri sendiri dalam aspek medis. pelayanan kesehatan termasuk dokter sebagai pemimpin kesehatan di masyarakat harus mempunyai sikap dan pengetahuan yang memadai mengenai phbs. metode: penelitian dilakukan pada bulan februari-november 2012 dengan desain potong lintang terhadap 152 mahasiswa kedokteran angkatan 2009 universitas padjadjaran semester 7 dengan menggunakan kuesioner. data dianalisis menggunakan chi-square. hasil: jumlah mahasiswa yang memiliki pengetahuan baik dan pengetahuan kurang tidak jauh berbeda (50,7% vs 40,3%). sebagian besar responden mempunyai sikap yang tidak sesuai dengan program phbs (p=0,805). simpulan: pengetahuan tentang phbs bagi semua mahasiswa kedokteran perlu ditingkatkan dan perlu diteliti lebih lanjut mengenai faktor-faktor lain yang memengaruhi sikap mahasiswa terhadap phbs. [amj.2014;1(1):86–9] kata kunci: sikap, pengetahuan, phbs, mahasiswa correspondence: sufia permatasari syaefullah, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62811234661, email: sufiapermatasari@gmail.com althea medical journal. 2014;1(2) 87 introduction perilaku hidup bersih dan sehat (phbs is a behavior that is based on the desire, willingness, and ability of people to help themselves in the field of health and can play an active role in health activities .1 the phbs is one of the main pillars in “indonesia sehat” and financing strategies to reduce health cost.2 the phbs is divided into five scopes which are household, health institutions, public places, schools, and workplaces.3 hygiene is not only written in the medical aspect, but also in the aspect of religion, and hygiene itself was written in the oath of hippocrates.according to some theories of hygiene, it can affect a person’s health level, therefore everyone should have clean and healthy living behaviors in order to improve their own health. in fact, many people still do not have awareness about hygiene and healthy behaviors. health education is required through individuals who know and understand healthy lifestyle to make people understand and apply phbs. individuals who understand healthy lifestyle health resources who canact as a facilitator, communicator, and dynamist in the process of community empowerment.4 theoretically, human resources who are capable of acting as a facilitator, communicator, and dynamist in the process of community empowerment are educated human resources in higher education , in this case is a medical school student who should be able to have knowledge and the attitude to be a community leader, communicator, decision maker, manager, and care provider for the community to be able to manage the health service. methods the study was approved by the health ethics research committee faculty of medicine, universitas padjadjaran and conducted in february–november 2012 which aims to reveal the knowledge and influence of knowledge on attitudes toward phbs. a survey with cross-sectional unpaired analytical design was used in this study. one hundred and fifty-two fourth year medical students 2009 universitas padjadjaran was enrolled according to the inclusion criteria and they have filled in a questionnaire which has been validated. the independent variable in this study is knowledge, while the dependent variable is attitude. knowledge-levels are categorized into good and bad. this study categorized attitude as strongly disagree, disagree, agree, and strongly agree. data that have been acquired are then processed by a computer program using chi square method as data analysis. then the data are presented in tables and pictures proportionally. result the respondents were predominantly (69.3%) female. good knowledge of phbs is found in 77 respondents, while remainder had a bad knowledge. nearly half of the respondents had an disagree attitude toward of every point phbs (49%). the effect of the level of knowledge toward attitude. all the variables were not statistically significant (p > 0.05) (table 1). disscussion figure 1 sex of respondent sufia permatasari syaefullah,noorman herryadi, elsa pudji setiawati, henni djuhaeni: role of knowledge and attitude toward perilaku hidup bersih dan sehat (phbs) of medical students 2009 universitas padjadjaran althea medical journal. 2014;1(2) 88 amj december, 2014 the phbs is a health promotion program which aims to “indonesia sehat”, where knowledge, desire, and behavior also play an active role in healthy life realizing optimal health.1 the implementation of the phbs program in the community is expected to increase the level of health as well as the funding for health. this program can be run through the promotion of health and human resources who are necessary to promote health as an educator, trainer, and as a model for the people. based on the results, the differences attitude between good knowledge and bad knowledge were not significant. thus might be due to lack of attention and observation of phbs as well as health promotion itself. knowledge is the result of sensing someone who influenced the intensity of attention and perception of the object after observing something.5 knowledge that has an object of study, methods of approach, is systematically arranged, and universal can form science.6 environment such as health promotion can affect a person’s knowledge. health promotion is a process to improve the ability of communities to figure 2 level of knowledge of phbs figure 3 attitudes towards phbs table 1 role of knowledge and attitude variable attitude p sd d a sa knowledge good 7 36 26 6 0.805 bad 4 39 28 6 althea medical journal. 2014;1(2) 89 maintain and improve their health.7 based on that theory, in indonesia health promotion is defined as to enhance community through learning from, by, for, and with the community, so they can help themselves and develop activities resourced communities, according to local socio-cultural conditions and supported by public health policy.8 doctors must have a role in promoting health in order to increase the level of health in communities. medical students as future doctors is one of the health care providers, should have a good knowledge of phbs. almost half of the respondents had an attitude that did not agree to the phbs program. medical students should have towards phbs program in order to act such as an example to the community indirectly. knowledge, experience, and environment will influence the formation of attitudes. attitude is a case or object that is still closed so manifestation of attitude cannot be seen directly but can only be interpreted from its behavior.9 attitude can form a variety of subjective, emotional aspects, and a tendency to behave.10 in this study, level of knowledge did not determine attitude significantly on phbs. this was probably due to some limitations of this study such as lack of opportunity for respondents to ask things that were not understood by the researcher, and there were other factors that played a role on attitude such as environment, behaviors, and other which were not studied yet by researchers. references 1. fauci as, weiner c, braunwald e, kasper dl, hauser sl, longo dl, et al. harrison’s value pack 17th ed. new york: mcgrawhill; 2008. p. 2277, 2282. 2. departemen kesehatan republik indonesia. tahun 2030 prevalensi diabetes melitus di indonesia mencapai 21,3 juta orang. jakarta: 2009 [cited 2012 april 30]; available from: http://www.depkes.go.id/ index.php/berita/press-release/414tahun-2030-prevalensi-diabetes-melitusdi-indonesia-mencapai-213-juta-orang. html. 3. world health organization. diabetes. 2011 [cited 2012 april 30]; available from: http://www.who.int/mediacentre/ factsheets/fs312/en/index.html. 4. khan a, safdar m. role of diet, nutrients, spices, and natural products in diabetes mellitus. pak j nutr. 2003;2(1):1–12. 5. lim tk. edible medicinal and nonmedicinal plants: volume 2, fruits. new york: springer; 2012. p. 239–47. 6. minaiyan m, zolfaghari b, kamal a. effect of hydroalcoholic and buthanolic extract of cucumis sativus seeds on blood glucose level of normal and streptozotocininduced diabetic rats. iran j basic med sci. 2011;14(5):436–42. 7. dixit y, kar a. protective role of three vegetable peels in alloxan induced diabetes mellitus in male mice. plant foods hum nutr. 2010;65(3):284–9. 8. ehrhardt c, kim kj. drug absorption studies: in situ, in vitro and in silico models. new york: springer; 2008. p. 48–50. 9. who. research guidelines for evaluating the safety and efficacy of herbal medicines. manila: world health organization regional office for the western pacific; 1993. p. 38. 10. achmad s. mechanism of membrane transport. jatinangor: universitas padjadjaran; 2006. p. 1–4. 11. dahlan ms. statistik untuk kedokteran dan kesehatan. 4th ed. jakarta: salemba medika; 2009. p. 60. sufia permatasari syaefullah,noorman herryadi, elsa pudji setiawati, henni djuhaeni: role of knowledge and attitude toward perilaku hidup bersih dan sehat (phbs) of medical students 2009 universitas padjadjaran althea medical journal. 2015;2(3) 387 visual acuity before and after treatment in patients with chemical injuries at the national eye center, cicendo eye hospital, bandung from 2010 to 2011 endi pramudya laksana,1 nina ratnaningsih,2 reni farenia s3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology, faculty of medicine, universitas padjadjaran/national eye center, cicendo eye hospital bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: chemical trauma is one of the emergency cases in ophthalmology since it can lead to severe, permanent blindness if not immediately treated. this study aimed to reveal preand post-therapy visual acuity on patients with chemical trauma at thenational eye center, cicendo eye hospital, bandung. methods: this study was performed on 40 patients’ medical records from the national eye center, cicendo eye hospital bandung from january 2010 to january 2011 as secondary data, using the descriptive retrospective method. the data were divided into two groups: acid and alkali trauma. the collected data were analyzed and presented in tables. results: chemical trauma cases were mostly caused by caustic soda (17/40) whereas the least were caused by vinegar (3/40) and commonly occurred on adult patients in the right eye on alkali trauma. patients with chemical trauma generally had normal eyesight before therapy.the number of patients with acid and alkali trauma who experienced improved eyesight after therapy alkali were similar (3 patients) while worsening symptoms occurred in one patient with alkali chemical trauma from mild to medium low vision. conclusions: there are some improvements of visual acuity after treatment in patients with chemical injuries. [amj.2015;2(3):387–90] keywords: acid trauma, alkali trauma, visual acuity correspondence: endi pramudya laksana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287737375353 email: endi_pramudya@yahoo.com introduction the eye function can be disrupted or even permanently vanished if exposed to foreign objects, including acid or alkali chemical substances.1-4 chemical trauma, either acid or alkali, on eyes can be an emergency case in ophthalmology since it can cause severe and permanent blindness if not immediately treated.2,5-7 according to data of the centers for disease control and prevention (cdc)8 in 1998, chemical trauma includes 84% eye trauma, and 80% of chemical trauma incidents commonly occur in workplaces. the frequency ratio of acid and alkali chemical trauma can vary, from 0.25 to 1. men have 4 times the risk of getting chemical trauma than women. notable main causes of acid trauma are sulfuric acid (h2so4) and hydrochloric acid (hci) often used as substances for household cleaning for floors and ceramics.9 acids tend to cause less severe damage since cornea proteins will react with acids, causing precipitations on cornea surface, thus preventing chemical substances from entering deeper into eye tissues. nevertheless, strong acids such as sulfuric acids can cause severe damages, since severe acid trauma can damage the ciliary body, thus lowering the ascorbate level in eye fluids and cornea.2,7 alkali trauma is commonly more severe than acid trauma since alkali substances have two characteristics: hydrophilic and lipophilic. both can quickly cause the penetration of the chemical into the anterior segment along with collagen hydration, malignant fibrial changes and trabecular changes.5 these conditions can cause a rapid and significant change in intraocular pressure second to a rapid rise in aqueous humor.5 alkali trauma can cause light althea medical journal. 2015;2(3) 388 amj september, 2015 or severe irritation on eyes and can cause emergency cases that can lead to blindness.5 blindness can occur if the patient is receiving delayed therapy, especially after being exposed to chemical trauma. the proper therapy to treat cyhemical trauma is by providing irrigation to the exposed eye by using sterile buffer solution such as ringer’s lactate or normal saline. according to studies by the american science in the united states6, approximately 70% of 50,000 patients with chemical trauma gained 20/20 vision after they were given the irrigation therapy. a lot of people consider exposures to chemical substances on the eyes as normal cases, and they only rinse their eyes with water after exposures. such notions are the result of lack of understanding among people about the effects resulted from chemical trauma, either acid or alkali, on the eyes. furthermore, eye protections in workplaces have often been neglected, either personally or institutionally.9 eye protection is actually the company’s responsibilty. neverhteless, it is advised to use our own eye protections in order to maintain protections for our eyes. chemical trauma which can cause permanent blindness, as well as the fact that there have been no adequate scientific data on visual acuity on patients with chemical trauma in bandung became the background of this study in revealing visual acuity, both pre and post-therapy, on patients with chemical trauma at the national eye, cicendo eye hospital, bandung,over the period of january 2010–january 2011. methods this study used the retrospective descriptive method, using cases of patients with chemical trauma who came to the emergency room of thenational eye center, cicendo eye hospital, bandung, from january 2010 to january 2011. secondary data were retrieved from medical records at cicendo eye hospital bandung. the subject of this study were the medical records of patients with chemical trauma at the emergency room of cicendo eye hospital, bandung which fulfilled both the inclusion and exclusion criteria. the inclusion criteria were all patients with chemical trauma who were treated at cicendo eye hospital, bandung, from 2010 to 2011. while the exclusion criteria were medical records without preand post-therapy visual acuity data. data were retrieved from cicendo eye hospital, bandung during september to november 2012. data processing was conducted during august–december 2012, using the microsoft excel software program to reveal frequency data. the results were presented in tables. results chemical trauma cases were mostly caused by caustic soda (17/40), whereas the least were caused by vinegar (3/40) (table 1). table 2 shows that acid and alkali chemical trauma cases based on age category of the patients commonly occurred on adult patients. meanwhile, based on location, the exposed mostly happened in the right eye on alkali trauma (table 3). table 4 shows that patients with chemical trauma generally had normal eyesight before therapy. approximately 8/12 patients with table 1 distribution of chemical trauma based on chemical substances chemical substance frequency caustic soda (naoh) 17 superglue 5 vinegar 3 albothyl 4 battery fluid 11 table 2 distribution of chemical trauma based on age category age acid alkali frequency frequency children (5–11 years old) 2 0 teen (12–17 years old) 2 1 adult (18–40 years old) 6 24 elderly (41–65 years old) 2 3 althea medical journal. 2015;2(3) 389 acid chemical trauma had normal eyesight, and only 3/12 had medium low vision. there were no patients with blind eyesight. on the other hand in alkali, approximately 20/28 patients with alkali chemical trauma had normal eyesight and only 2/28 had medium low vision. the number of patients who experienced improved eyesight after therapy was 3 patients with acid and alkali trauma while, worsening symptoms occurred on one patient with alkali chemical trauma from mild to medium lv. discussions caustic soda was the most frequent cause of chemical trauma in this study. it is a alkali chemical substance often used in thegarment industry for enhancing clothing colors. chemical trauma cases caused by caustic soda occurred more frequently than other chemical substances, since many laborers were coloring clothing without wearing eye protection. other studies revealed that chemical substances that mostly caused chemical trauma were caustic soda and ammonia.2,3 both of these chemical substances are the most dangerous ones as they can cause severe complications on theeyes which is also related to the occupations of patients with chemical trauma. the frequency of laborers in thegarment industry was more thanin any other occupations related to chemical substances.3,4 table 2 shows that both acid and alkali chemical trauma cases based on age category of the patients commonly occurred on adult patients. this was in accordance with the epidemiology data where chemical trauma cases mostly occur on adult patients due to their occupations. according to the epidemiology data, around 60% of such cases occured in their workplaces, 30% in their house, and 10% in other places.2 80% of cases occur adult patients whose occupations were related to chemical substances.10 table 3 shows that most of the distributions of chemical trauma on eyes based on the location of eyes exposed to chemical substances were as follows: 5 patients (42%) on the right eye, 5 patients (42%) on the left eye, and 2 patients (16%) on both eyes. table 3 also shows that most of the distributions of chemical trauma cases on patients basedon the location of the eye exposed to chemical substances at cicendo eye hospital, bandung, were on the right eye. this result was in line with other studies that also reported that chemical trauma on both eyes (bilateral) were rare.3 this study reported that improvements occurred in both chemical trauma. there were some lv improvements both in acid and alkali trauma but worsening symptoms also happened but in smaller number. according table 3 distribution of chemical trauma based on location of eyes exposed to chemical substances location acid alkali frequency frequency right eye 5 17 left eye 5 9 left and right eyes 2 2 table 4 pre and post therapy visual acuity visual acuity acid alkali pre therapy post therapy pre therapy post therapy normal (≥0.8) 8 9 20 23 mild lv (0.3-0.63) 1 3 7 3 medium lv (0.125-0.25) 3 0 1 2 severe lv (0.05-0.10) / nlp 0 0 0 0 *lv: low visio; nlp: no light perception endi pramudya laksana, nina ratnaningsih, reni farenia s: visual acuity before and after treatment in patients with chemical injuries at the national eye center, cicendo eye hospital, bandung from 2010 to 2011 althea medical journal. 2015;2(3) 390 amj september, 2015 to other studies, visual acuity of patients with chemical trauma given with therapy will 95% improve, 15% improve after 10-14 days, and 80% improve on thefifth to eighth week after therapy.3 it was noted that patients with chemical trauma who had not yet been given treatments or therapy stated they experienced blurred visions, with red, painful eyes. however, if they had previously performed simple treatments such as rinsing the exposed eye(s) with water or ringer lactate, their vision improved to normal and there were no further complications on exposed eye(s).3 such treatments only serve as temporary treatments. if patients suffers from chemical trauma on their eyes, it is highly recommended for them to visit the nearest hospital for therapy and to avoid further complications.12 the time range between chemical exposure and irrigation treatment is the most important factor in the improvement of visual acuity. there is one worsened symptom in alkali chemical trauma that may be caused by the longer time range between chemical exposure and irrigation treatment, thus the chemical substance have penetrated into deeper eye tissues and caused severe damage on their eye.2,11 the study concludes that the number of sample patients with acid chemical trauma who experienced improved visual acuity after therapy is similar in quantity, but there is a worsening symptom in alkali chemical trauma since alkali can quickly cause the penetration of the chemical into the anterior segment along with collagen hydration, malignant fibrial changes and trabecular changes.5 the study has several limitations by not including the detailed type of acid and alkali solution, time ranging between exposure and treatment, type of treatment, and the time of post treatment determination of visual acuity that may influence the improvement of visual acuity. furthermore, there should be counseling activities for people concerning causes, effects, and treatments of chemical trauma, thus they can directly obtain first aid and have their visual acuity improve to normal immediately after having their eye(s) exposed to chemical substances. references 1. lecuona k. assessing and managing eye injuries. community eye health journal. 2005;18(55):102–16. 2. venkatesh r, trivedi hl. ocular traumachemical injuries. bombay hospital journal. 2009;51(2):215–21. 3. trudo ew jr, rimm w. chemical injuries of the eye. in: thach ab, editor. ophthalmic care of the combat casuality. washington: office of the surgeon general united states army; 2003. p. 115–35. 4. pons j. eye trauma. cme. 2011;29(2):66–8. 5. kosoko a, vu q, kosoko-lasaki o. chemical ocular burns: a case review. am j clin med. 2009;6(3):41–9. 6. sesha h, hashem h, liang l, ramzy m, zaki a. amniotic membrane extract for acute ocular chemical burns. j am sci. 2010;6(11):427–33. 7. ilyas s. ilmu penyakit mata. jakarta: balai penerbit fkui; 1997:p.76-8. 8. centers for disease control and prevention. work-related eye injuries. 2010. (cited 2012 august 18). available from: http:// www.cdc.gov/features/dswork placeeye/ 9. centers for disease control and prevention. workplace safety & health topics: eye safety. 2007 (cited 2012 august 18). available from: www.cdc.gov/ niosh/topics/eye. 10. fish r, davidson rs. management of ocular thermal and chemical injuries, including amniotic membrane therapy. curr opin ophthalmol. 2010;21(4):317–21. 11. kobayashi a, shirao y, yoshita t, yagami k, segawa y, kawasaki k, et al. temporary amniotic membrane patching for acute chemical burns. eye (lond). 2003;17(2):149–58. 12. uҫakhan oo, kҫklü g, firat e. nonpreserved human amniotic membrane transplantation in acute and chronic chemical eye injuries. cornea. 2002;21(2):169–72. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 291 the effect of programmed physical exercise to attention and working memory score in medical students kevin fachri muhammad,1 anam ong,2 muhammad nurhalim shahib3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry and molecular biology, faculty of medicine universitas padjadjaran abstract background: attention and working memory are two cognitive domain crucial for activities of daily living. physical exercise increases the level of bdnf, igf-1, and vegf which contributes in attention and working memory processes.this study was conducted to analyze improvement of attention and working memory after programmed physical exercise of pendidikan dasar xxi atlas medical pioneer (pendas xxi amp). methods: an analytic observational study was conducted on 47 students from faculty of medicine, universitas padjadjaran during september-november 2012. attention was assessed using digit span backward test, stroop test, visual search task, and trail making test. working memory was assessed using digit span forward test and digit symbol test. assessment was done on the 11th and 19th week of pendas xxi amp. data distribution was tested first using a test of normality, and then analyzed using t-dependent test and wilcoxon test results: significant improvement was noted for attention in males based on working time for stroop test (26.50±5.66 to 22.03±3.78 seconds), working memory in males based on digit symbol test score (43.96±6.14 to 53.36±5.26 points), attention in females based on reaction time of visual search task for target absent (0.92±0.07 to 0.87±0.07 seconds), and working memory in females based on digit span forward score (5.42±1.30 to 6.63±1.07 points) and digit symbol test score (42.47±5.95 to 53.84±5.33 points. conclusions: exercise in pendas xxi amp improves attention and working memory for college students in faculty of medicine universitas padjadjaran. [amj.2015;2(1):291–97] keywords: attention, physical exercise, working memory correspondence: kevin fachri muhammad, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281317877792 email: kevinfachri@gmail.com introduction brain is human bodily organ which is responsible in controlling sensory function, behaviour, and cognitive attributes. by transforming external stimuli into neuronal impulses, human brain builds an internal representation of the outside environment.1sensory input will become a sequence of information and it will be processed in the brain until an internal representation is developed. this process is called cognitive function.2 cognitive domain derives attention and working memory, which are the most utilized function for activities of daily living.3 attention is defined as a maintenance of awareness toward external stimuli or internal thoughts within a certain amount of time while ruling out various sensation and thoughts that might interrupt this process. this ability enables a person to focus on a constant thought or action.3working memory is a more specific function in the prefrontal area of the brain that is defined by psychologist and neurologist as an elaboration of thoughts. prefrontal area has the ability to store various pieces of information together in a certain time and recall this information in a split second when needed. thus, working memory affects (1) the ability to predict, (2) to slow down incoming sensory signal so that information can be processed to determine the best response, (3) to consider consequences of motor actions prior to the implementation of motion, (4) to solve mathematical, legal, or philosophical question, (5) to correlate bits of information when a person faces problems that they never experienced before, and (6) activities controlling.2 attention and working memory capacity are varied for each individual. variations in the ability to manage attention and utilize working memory can be influenced by several althea medical journal. 2015;2(2) 292 amj june, 2015 things; namely gender, age, genetic, nutrition, emotion, motivation, job, education, and physical activity. there are anatomical and physiological differences in attention and working memory in men and women. this happened because women have more extensive connection between brain hemispheres in the corpus callosum than men have. women also have larger region of language associations, named wernicke and broca’s area. the neuropeptide vasopressin which are used to boost attachment of information is more readily found in men than in women. then, there is the difference in circulating sex hormones. estradiol, a steroid hormones which is circulating in women has been reported to improve verbal cognition, while testosterone which is circulating in men has the effect to improve spatial cognition.4 a person will experience a decreased body homeostatic function based on age. regulation of information, learning speed, and the reaction speed to simple and complex stimuli will continue to deteriorate. progression of this deterioration is influenced by genetic factors.5 nutrition is another factor that affects cognitive status. the brain requires glucose for metabolic function. decrease intake of glucose will decrease brain tissue performance and thus affecting cognitive function.6 caffeine and theanin, which is found in coffee and tea respectively, can increase locomotor activity, emotions, concentration, and attention because it can affect the neurotransmitter dopamine, serotonin, glutamate, and gammaamino butyric acid.7,8 the next factor, according to thompson and tulving, are emotion and motivation, that they are sharing part in the encoding specificity. when the information is stored in a particular emotional or motivational state it will be easier if the emotions and motivations are also reproduced if this information is to be recalled.9 sufficient sleep contributes in the well-being of prefrontal cortex area. according to horne in alhola and polo-kantola10, individuals who experience sleep deprivation will have decreased function governed by the prefrontal cortex such as executive function, language, and divergent thinking. work and education may affect a person’s attention and working memory especially in jobs that requires concentration and quick decision making, forcing the person to constantly use their attention and working memory so they become more adept in utilizing its function.11 kramer et al. in lambourne12 states that physical exercise in adults is associated with increased executive control function such as coordination, planning, attention, and working memory. in addition, exercise also influence aspects of inhibitory control that allows individual to restrict the access of information which is considered irrelevant to the response that will be given to the outside world. based on the study by hogervost et al. in pontifex et al.13, subjects undergoing acute aerobic exercise with intensity of 70% of maximal heart rate gives better results when performed the stroop effect test, a test that assess the ability of a subject in selecting information. while krus et al. in pontifex et al.13 study shows the increase in perceptual sensitivity from the subjects after they undergo anaerobic exercise in which subjects were asked to press a spring board for 20 seconds. according to lambourne12, who cited chodzko-zajko and madden et al. study, exercise can provide a positive effect on cognitive function because it can increase collateral vacularization, thus increasing blood flow to the brain, which provide an important supply of nutrients such as glucose and oxygen. while the results on animal models by black et al. and van praag et al. in lambourne12 showed that exercise affect cognitive function because it can induce the development of neuronal connections in the brain structures such as cerebral cortex and hippocampus. pendidikan dasar xxi atlas medical pioneer (pendas xxi amp) faculty of medicine universitas padjadjaran is one form of exercise that aims to train the physical abilities of its participants through programmed physical exercise that lasted for 19 weeks. the program consisted of aerobic exercise in a form of run and load-walk, and anaerobic exercise in a form of sprints, push-ups, sit-ups, bending, and pull-ups. participants of pendas xxi amp have uniformity in the form of exercise they undergo and they were also directed to be discipline in following the program, so the study population is very homogenous. exercise patterns performed on pendas xxi amp were different from exercise performed in previous studies whichonly emphasizes aerobic activity, because physical exercise in pendas xxi amp consisted of aerobic and anaerobic activity.14 in this study observation was done for 8 weeks, from week 11 to week 19 of pendas xxi amp, because in this time window the exercise was programmed to have constant duration, frequency, intensity, and type. in this study, subjects are divided by sex, which is men and women, because there althea medical journal. 2015;2(2) 293 table 1 profile of gender and age sex n average age median (minimum-maximum) male 28 19,36+1,2 19 (18-22) female 19 19,42+0,9 19 (18-21) are differences in the structure and cognitive abilities between the two. methods population of this study were students from faculty of medicine universitas padjadjaran who participated in physical exercise program of pendidikan dasar xxi atlas medical pioneer (pendas xxi amp). subjects were selected with a total sampling method, and were divided by sex. the inclusion criteria were, (1) subjects must registered and participated in pendas xxi amp, (2) subjects must completed an informed consent. while the exclusion criteria of this study were (1) attending aerobic or anaerobic exercises 3 times a week outside pendas xxi amp, (2) did not follow pendas xxi amp until the end, (3) performed strenuous physical activity 24 hours prior to measurement,(4) not getting enough sleep the night before measurement, (5) consumed food or beverages containing caffeine or theanin 48 hours prior to measurement. this study was analytic observational study to determine the increase in attention and working memory scores from measurements taken at week 11 and week 19 of pendas xxi amp. measurement of attention score was done using 4 type of tests, namely digit span backward test, stroop test, visual search task, and trail making test. measurement of working memory score was done using 2 type of tests, namely digit span forward test and digit symbol test. attention and working memory score were categorized as increased if there is at least one test which has significant increase at week 19 measurement and other tests did not decline. the study was conducted from september-november 2012 at campus of faculty of medicine universitas padjadjaran jatinangor. data distribution was tested first using a test of normality, and then analyzed using t-dependent test and wilcoxon test. processing of data was done using spss statistic software version 20.0 results this study deals with 47 subjects, consisted of 28 men and 19 women. the range of age of the subjects varied between 18-22 years old. the average age of these subjects are 19 years old (table 1). analysis of male students attention and working memory score from measurements taken at week 11 and week 19 are respectively (table 2,table 3). there was a significant improvement (p ≤ 0.05)from the scores of attention in male students according to stroop test working time (26.50±5.66 to 22.03±3.78 seconds) with an average working time reduction of 4.47±6.89 seconds. improvement also occurred in the result of digit span backward test scores (4.36±1.37 to 4.75±1.53 points), time spent on trail making test part a (21.51±11.47 to 18.51±11.97 seconds), time spent on trail making test part b (40.75±24.15 to 36.55±19.18 seconds), reaction time for visual search task for target present (0.95±0.79 to 0.94±0.11 seconds), and reaction time visual search task for target absent (1.29±0.81 to 1.30±0.15 seconds), but this improvement was not statistically significant (table 2). there was a significant increase (p ≤ 0.05) from the scores of working memory in male students according to digit symbol test score (43.96±6.14 to 53.36±5.26 points) with an average score increase of 9.39±8.27 points. improvement also occurred in the results of digit span forward test scores (5.64±1.34 to 6.21±1.23 points), but this improvement was not statistically significant (table 3). analysis of female students attention and working memory score from measurements taken at week 11 and week 19 are respectively (table 4, table 5). there was a significant improvement (p ≤ 0.05) from the scores of attention in female students according to visual search task for target absent reaction time (0.92±0 , 07 to 0.87±0.07seconds) with an average reaction time reduction of 0.05±0.08 seconds. improvement also occurred in the result of digit span backward test scores (4.47±1.65 to 5.16±1.38 points), time spent on trail making test part b (41.26±9.03 to 39.60±12, 28 seconds), time spent on stroop test (26.21±5.68 to 23.02±3.47 seconds), and reaction time forvisual search task for target kevin fachri muhammad, anam ong, muhammad nurhalim shahib: the effect of programmed physical exercise to attention and working memory score in medical students althea medical journal. 2015;2(2) 294 amj june, 2015 table 2 male students attention score difference between week 11 and week 19 variable type of test n mean score±s.d. mean difference±s.d. / median (minimummaximum) confidence interval 95% p digit span backward test (score) pre-test 28 4,36±1,37 0,39±2,30 -0,50-1,28 0,374* post-test 28 4,75±1,53 stroop test (seconds) pre-test 28 26,50±5,66 -4,47±6,89 -7,14-(-1,0) 0,002* post-test 28 22,03±3,78 trail making test part a (seconds) pre test 28 21,51±11,47 21,93 (11,47-29,36) 0,056** post test 28 18,51±11,97 17,84 (11,97-28,31) trail making test part b (seconds) pre test 28 40,75±24,15 36,56 (24,16-57,65) 0,127** post test 28 36,55±19,18 36,48 (19,18-55,98) visual search task for target present (seconds) pre test 28 0,95±0,79 0,93 (0,79-1,14) 0,873** post test 28 0,94±0,11 0,93 (0,74-1,11) visual search task for target absent (seconds) pre test 28 1,29±0,81 1,29 (0,81-2,45) 0,593** post test 28 1,30±0,15 1,31 (0,99-1,54) note: * = tested with t-dependent test, ** = tested with wilcoxon test table 3 male students working memory score difference between week 11 and week 19 variable type of test n mean score±s.d. mean difference±s.d. / median (minimummaximum) confidence interval 95% p digit symbol test (score) pre-test 28 43,96±6,14 9,39±8,27 6,19-12,60 0,000* post-test 28 53,36±5,26 digit span forward test (score) pre-test 28 5,64±1,34 6 (3-8) 0,100** post-test 28 6,21±1,23 6 (4-8) note: * = tested with t-dependent test, ** = tested with wilcoxon test present (0.84±0.05 to 0.80±0.07 seconds) but this improvement was not statistically significant (table 4). there were a significant increase (p ≤ 0.05) from the scores of working memory in male students according todigit symbol test scores (42.47±5.95 to 53.84±5.33 points) with an average score increase of 11.37±7.67 and digit span forward scores (5.42±1.30 to 6.63±1.07) (table 5). althea medical journal. 2015;2(2) 295 discussions the results showed that the students of faculty of medicine universitas padjadjaran who participates in physical exercise program of pendas xxi amp have increased attention and working memory scores. attention is the process that occurs when human brain is focused on one specific stimulus. the information obtained can be derived from the process of sensing and memory. attention capacity improves the ability to efficiently kevin fachri muhammad, anam ong, muhammad nurhalim shahib: the effect of programmed physical exercise to attention and working memory score in medical students table 4 female students attention score difference between week 11 and week 19 variable type of test n mean score±s.d. mean difference±s.d. / median (minimummaximum) confidence interval 95% p digit span backward test (score) pre-test 19 4,47±1,65 0,68±1,97 -0,27-1,64 0,148* post-test 19 5,16±1,38 stroop test (seconds) pre-test 19 41,26±9,03 -1,66±13,72 -8,27-4,96 0,605* post-test 19 39,60±12,28 trail making test part a (seconds) pre test 19 26,21±5,68 -3,19±7,52 -6,81-0,43 0,081* post test 19 23,02±3,47 trail making test part b (seconds) pre test 19 0,84±0,05 -0,04±0,09 -0,08-0,00 0,079* post test 19 0,80±0,07 visual search task for target present (seconds) pre test 19 0,92±0,07 -0,05±0,08 -0,08-0,01 0,011* post test 19 0,87±0,07 visual search task for target absent (seconds) pre test 19 19,98±5,70 19,06 (11,36-27,9) 0,528** post test 19 19,88±4,81 18,39 (13,14-27,78) note: * = tested with t-dependent test, ** = tested with wilcoxon test table 5 female students working memory score difference between week 11 and week 19 variable type of test n mean score±s.d. mean difference±s.d. / median (minimummaximum) confidence interval 95% p digit symbol test (score) pre-test 19 42,47±5,95 11,37±7,67 7,67-15,06 0,000* post-test 19 53,84±5,33 digit span forward test (score) pre-test 19 5,42±1,30 5 (3-7) 0,003** post-test 19 6,63±1,07 7 (4-8) note: * = tested with t-dependent test, ** = tested with wilcoxon test althea medical journal. 2015;2(2) 296 amj june, 2015 sort out which information is needed and which should be ignored. neuroimage studies documenting part of the frontal lobe, especially in the right hemisphere, is essential in maintaining attention.2,15,16 working memory is part of executive function that is useful for decision making when a person is exposed to a certain environment. working memory may manipulate the information and use it to achieve specific objectives.16 exercise induces neuronal changes. the regulatory mechanisms that initiate neuronal changes are brain-derived neurotrophic factor (bdnf), insulin growth factor 1 (igf-1), and vascular endothelial growth factor (vegf). bdnf mrna and bdnf protein increased in the area around the hippocampus after a few days working out and will remain high during sustained exercise. signalling by bdnf is what facilitates long-term potentiation and activate mapk (mitogen-activated protein kinase), a signal transduction pathway that is important for long-term potentiation in the hippocampus. bdnf also induce neurogenesis, where the neural progenitor will increase its number in the hippocampus. this young nerve cells have a low threshold of excitability that is effective in conducting action potential. the role of igf-1 is to increase levels of trk-b (tyrosinerelated kinase b), the receptor for bdnf, thus increases bdnf signalling and promotes neuronal plasticity. furthermore igf-1 is an important factor for oligodendrocyte and neuronal durability, as well as for the growth and differentiation of neurons. vegf induces potential mitotic activity of endothelial cells in blood vessels, thereby increasing proliferation, durability, adhesion, migration, and capillary tube formation.17, 18 exercise-induced neurotrophic effects varied between each different individuals, and is limited in some way. sibley and beilock describes through their study that acute aerobic exercise will only increase the capability of working memory in people which previously had a low working memory capabilities, while in people who already had a good working memory capacity this enhancement effect will not be significant.19 pontifex, et al.13 explained that exercise-induced development in cognitive abilites will be effective if the exercise was done with mild or moderate intensity according to the percentage of maximal heart rate of the individual. with the conditioning conducted for 11 weeks before the tests began, the subjects have already been accustomed with physical exercise program of pendas xxi amp. the physical exercise program conducted from the 11th through 19th week of pendas xxi amp was specifically constructed so its intensity ranged between moderate-to-somewhat hard based on exertion rating scale method of intensity measurement. tests of attention and working memory scores which shows insignificant results may not be caused by the exercise intensity, but may be caused by the subjects in general which already have a pretty good ability in the management of attention and utilization of working memory, so that the effect of exercise become more limited. references 1. sadock bj, sadock va. kaplan & sadock’s synopsis of psychiatry: behavioral science/ clinical psychiatry. 10th ed. new york: lippincot william & wilkins; 2007. 2. guyton ac, hall je. textbook of medical physiology. 11th ed. philadelphia: elsevier saunders; 2006. 3. ropper ah, brown rh. adams and victor’s principles of neurology. 8thed. new york: the mcgraw hill companies, inc.; 2005. 4. boureau y-l. developmental mechanism leading to cognitive disparities between men and women. 2005. [cited 2012 december 10]. available from: http:// cs.nyu.edu/~ylan/files/malesfemales05. pdf. 5. lee s, kawachi i, berkman l, grodstein f. education, other socioeconomic indicator and cognitive function. am j epidemiol. 2003;157(8):712–20. 6. bingham em, hopkins d, smith d, pernet a, hallett w, reed l, et al. the role of insulin in human brain glucose metabolism: an 18fluoro-deoxyglucose positron emission tomography study. diabetes. 2002;51(12):3384–90. 7. nobre ac, rao a, owen gn. l-theanine, a natural constituent in tea, and its effect on mental state. asia pac j clin nutr. 2008;17 suppl 1:167-8. 8. van boxtel mp, schmitt ja, bosma h, jolles j. the effect of habitual caffeine use on cognitive change: a longitudinal perspective. pharmacol biochem behav. 2003;75(4):921–7. 9. eysenck mw, keane mt. cognitive psychology: a student’s handbook. 5th ed. hove: psychology press; 2009. 10. alhola p, polo-kantola p. sleep deprivation: impact on cognitive performance. neuropsychiatr dis treat. 2007;3(5):553– althea medical journal. 2015;2(2) 297 67. 11. alvarado b, zunzunegui m, del ser t, beland f. cognitive decline is related to education and occupation in a spanish elderly cohort. aging clin exp res. 2002;14(2):132–42. 12. lambourne k. the relationship between working memory capacity and physical activity rates in young adults. j sports sci med. 2006;5(1):149–53. 13. pontifex mb, hillman ch, fernhall b, thompson km, valentini ta. the effect of acute aerobic and resistance exercise on working memory. med sci sports exerc. 2009;41(4):927–34. 14. muhammad kf. program pembinaan jasmani pendidikan dasar xxi atlas medical pioneer. 1st ed. bandung: dewan pengurus xix atlas medical pioneer; 2012. 15. sternberg rj. cognitive psychology. 5thed. bellmont: wadsworth thomson learning; 2009. 16. kay j, tasman a. essential of psychiatry. 1st ed. chichester: john wiley and sons, ltd; 2006. 17. cotman cw, berchtold nc, christie l-a. exercise builds brain health: key roles of growth factor cascades and inflammation. trends neurosci. 2007;30(9):464–72. 18. cotman cw, berchtold nc. exercise: a behavioral intervention to enhance brain health and plasticity. trends neurosci. 2002;25(6):295–301. 19. sibley ba, beilock sl. exercise and working memory: an individual differences investigation. j sport exerc psychol. 2007;29(6):783-391 kevin fachri muhammad, anam ong, muhammad nurhalim shahib: the effect of programmed physical exercise to attention and working memory score in medical students althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 474 amj december, 2015 profile of head and neck cancer patients at department of otorhinolaringology-head and neck surgery dr. hasan sadikin general hospital bandung inez aulia rakhmawulan,1 yussy afriani dewi,2 nursiah nasution3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaringology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: head and neck cancer is a health problem with a high mortality rate. head and neck cancer are increasing and effect many individuals from diverse backgrounds. usually patients come with advanced stages, therefore these conditions could lead to decrease their quality of life. aim of this study was to describe the profile of head and neck cancer patients at the otorhinolaringology-head and neck surgery department, dr. hasan sadikin general hospital bandung. methods: a descriptive cross-sectional method was used from medical records of head neck cancer patients at department of otorhinolaringology-head and neck surgery, dr. hasan sadikin general hospital bandung from 2008 to 2012 that used the total sampling method. results: there were 665 patients included in this study, which men who participated were 388 and women were 277. most of them were elementary educated (44.96%), housewives (32.03%), and those aged 46–55 years old (28.33%). there were nasopharyngeal (38.20%), sinonasal (17.29%), larnyx (13.08%), oropharnyx (6.32%), thyroid gland (6.17%), oral cavity (3.91%), hypopharynx (2.41%), and parotid gland (2.26%) cancer. the major histopathological findings were undifferentiated carcinoma (45.41%) and squamous cell carcinoma (22.26%), those were presented with stage i (7.4%), ii (13.5%), iii (24.4%), and iv (54.7%). conclusions: nasopharyngeal carcinoma was the most predominant cases which majority were presented in advanced stage and major histopathology features was undifferentiated carcinoma, while demografic characteristic mostly were in middle aged and older, men with low education background. [amj.2015;2(4):474–9] keywords: head and neck cancer, nasopharyngeal carcinoma, otorhinolaringology correspondence: inez aulia rakhmawulan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62811121291, email: inez.rakhmawulan@gmail.com introduction head and neck cancer is the fifth most common cancer worldwide.1 new cases of head and neck cancer are reported approximately 650,000 cases worldwide per year with a mortality rate of 350,000 cases per year.2 it is increasing in incidence over the past three decades.3 the term of head and neck cancer is usually used to describe all carcinoma arising from upper aerodigestive tract such as sinonasal tract, oral cavity, pharynx, and larnyx, usually reffered to squamous cell carcinoma due to the predominant histopathology.3 risk factors for this illness include a history of smoking, passive smoker, exposure to carcinogens, diet, oral hygiene, infectious diseases such as human papilloma virus (hpv), and epstein barr virus (ebv), family history, and alcohol consumption.4,5 age, gender, race, and social economic status are also important in determining the risk of head and neck cancer.6 head neck cancer is an important health problem. this kind of cancer is usually three to five times more prevalent among men than women. in one study in brazil7 from 427 patients, the most frequent tumor site in our series is the oral cavity (35.37%). a high frequency of head and neck cancer cases is diagnosed at an advanced stage, and the most representative histological type is the squamous cell carcinoma (96.7% of cases). the prognosis for head neck cancer depends althea medical journal. 2015;2(4) 475 on the stage of the illness.6 patients suffering from early stages of this cancer have a better quality of life post treatment compared to advanced stage patients. cancer patients will never regain a normal standard of health.8 if this fact does not receive appropriate attention, then an increase in the incidence of head neck cancer is possible. this study was conducted to determine the profile of head neck cancer patients specifically age, gender, occupation, staging, primary site and histopathological finding at the department of otorhinolaringology-head and neck surgery, dr. hasan sadikin general hospital bandung from 2008 to 2012 methods this study was carried out from august to october 2013 at the department of otorhinolaringology-head and neck, dr. hasan sadikin general hospital bandung used the cross sectional descriptive method. the population was all the head neck cancer patients who were hospitalized or received outpatient treatment. medical records from study subjects were served as the secondary data. a total sampling method was used to collect the sample. this study was approved by the health research ethics committee faculty of medicine, universitas padjadjaran, and dr. hasan sadikin general hospital. the samples were all the subjects that had the complete data. the inclusion criteria were the medical records that encompass all the variables analyzed such as age, sex, job, education, primary site, histopathological findings, and stage of cancer. the data were derived with descriptive statistics, using frequency and percentage calculations by the excel software (version 2011). the results of the study were illustrated in tables. head and neck cancer was chosen based on clinical diagnosis, according to the anatomical site such as nasopharynx, larynx, sinonasal, oropharynx, hypopharynx, oral cavity, thyroid gland, parotid gland, and neck based on the american joint committee on cancer (ajcc) of 2010. hodgkin lymphoma and non-hodgkin lymphoma cases are also included.9 age was grouped into 0–5, 5–11, 12–16, 17–25, 26–35, 36–45, 46–55, 56–65,and >65 years old. furthermore, education was grouped into uneducated, elementary school, middle school, and university. occupation was divided into unemployed, laborer, farmer, houswife, government worker, private worker, student, table 1 characteristics of head and neck cancer patients variables n=665 % education elementary school 299 45.0 high school 175 26.3 middle school 111 16.7 uneducated 40 6.0 university 40 6.0 occupation housewife 213 32.0 laborer 98 14.7 unemployed 97 14.6 entrepreneur 85 12.8 private worker 61 9.2 farmer 46 6.9 government worker 29 4.4 student 20 3.0 retired 9 1.4 other 7 1.1 age (years old) 46–55 197 29.6 36–45 131 19.7 56–65 127 19.1 >65 96 14.4 26–35 68 10.2 17–25 37 5.6 12–16 8 1.2 5–11 1 0.2 median age 46–55 mode of age 46–55 mean ± std. dev. age 49.4 ± 14.6 age range 11–87 inez aulia rakhmawulan, yussy afriani dewi, nursiah nasution: profile of head and neck cancer patients at department of otorhinolaringology-head and neck surgery dr. hasan sadikin general hospital bandung and others. histopathological findings were classified based on world health organization classification of tumor in 2005.10 tumor staging was grouped by the location and by the tnm criteria based on ajcc 2010 to stage i, ii, iii, iv.9 results during the study period, there were 1,006 head and neck cancer patients in the otorhinolaringology-head and neck surgery althea medical journal. 2015;2(4) 476 amj december, 2015 department, dr. hasan sadikin general hospital bandung from 2008 to 2012. only 665 were included due to the completeness of data in medical records, which 341 were excluded in this study. the predominant education level was elementary school. based on the background, housewives were highly affected (32.0%). patients in the group of 46–55 years old were predominantly found, accounted as 197 table 2 distribution of patients according to gender and cancer sites subsites males females n=388 % n=277 % nasopharynx 156 61.4 98 38.6 sinonasal 56 48.7 59 51.3 larynx 79 90.8 8 9.2 non hodgkin malignant lymphoma 37 59.7 25 40.3 oropharynx 25 59.5 17 40.5 thyroid gland 8 19.5 33 80.5 oral cavity 13 50.0 13 50.0 hypopharinx 7 43.8 9 56.3 parotid gland 2 13.3 13 13.0 neck 5 71.4 2 28.6 table 3 histopathological findings of head and neck cancer histopathology n (%) undifferentiated carcinoma 302 45.4 squamous cell carcinoma 203 30.5 non hodgkin malignant lymphoma 62 9.3 papillary carcinoma 19 2.9 folicullar neoplasm? non malignant? 18 2.7 adenoid cystic carcinoma 14 2.1 adenocarcinoma 11 1.7 pleomorphic adenoma 10 1.5 mucoepidermoid carcinoma 6 0.9 transitional cell carcinoma 6 0.9 anaplastic carcinoma 3 0.5 acinic cell carcinoma 2 0.3 angiosarcoma 2 0.3 adenosquamous cell carcinoma 1 0.2 basal cell carcinoma 1 0.2 hemangioperisitoma 1 0.2 melanoma maligna 1 0.2 myxofibrosarcoma 1 0.2 rabdomiosarcoma 1 0.2 spindle cell carcinoma 1 0.2 total 665 100 althea medical journal. 2015;2(4) 477 patients (29.6%) (table 1). there were more of male patients than female, with the ratio of 1.4:1. the predominant of head and neck clinical diagnosis were asopharyngeal carcinoma (38.2%), followed by sinonasal (17.3%), and larynx (13.1%) (table 2). the majority of histological findings found in this study were undifferentiated carcinoma in 302 patients (45.4%), followed by squamous cell carcinoma in 148 patients (22.3%) (table 3). there were more of advanced stage patients than the early stage’s (table 4). discussions a tumor is an abnormal growth of tissue, where cells multiply excessively and in an uncontrolled manner. there are two kinds of tumors, which are benign and malignant. a tumor is classified as malignant when the growth infiltrates the surrounding tissue and starts to metastasize , which is known as a carcinoma.11 the term of head and neck cancer is used to describe all types of cancers stemming from the upper aerodigestive tract, such as sinonasal tract, the oral cavity, the pharynx, or the larynx. it is normally reffered to squamous cell carcinoma, because it is the most common histopathology.3 out of the 15,138 patients in the department of otorhinolaringology-head and neck surgery, dr. hasan sadikin general hospital bandung, there were 1,006 patients of head and neck cancer from 2008 to 2012. the number of head and neck cancer cases was higher than the 427 cases in university hospital of northwestern são paulo state, from 2000 to 2005.7 from the 1,006 patients, only 665 patients were included in this study because their medical records had all the variables needed. the ratio of males to females was 1.4 to 1. a study by kim et al.6 also stated that the incidence of head and neck cancer is three-fold higher in men than in women. this is probably caused by the fact that men have a higher tendency to smoke inez aulia rakhmawulan, yussy afriani dewi, nursiah nasution: profile of head and neck cancer patients at department of otorhinolaringology-head and neck surgery dr. hasan sadikin general hospital bandung table 4 stages of head and neck cancer stage n % iv 364 54.7 iii 162 24.4 ii 90 13.5 i 49 7.4 total 665 100 ciggaretes and consume alcohol than women. a study by dahlstrom et al.12 also supports that smoking and drinking alcohol, which are risk factors for head and neck cancer, are behaviors observed more frequently in men (79.9%) than in women. in this study, the predominant head and neck cancer type was nasopharyngeal carcinoma (38.2%), followed by sinonasal cancer (17.3%), and laringeal cancer (13.1%). the percentage of nasopharingeal carcinoma cases were significantly higher compared to the other head and neck cancer types. a literature by munir et al.13 studied in indonesia, also found that almost 60% of head and neck cancer to be nasopharyngeal carcinoma, which 18% to be sinonasal carcinoma, and 16% to be laryngeal, while other types of cancer have very low percentages. the etiology of this cancer is probably due to the infection of epstein barr virus, and is influenced by lifestyle, bad dietary habits, and genetic factors. lutzky et al.14 reported that in 2000, more than 80% of cases of nasopharyngeal carcinoma in southeast asia are new. influencing risk factors for pathogenesis of nasopharingeal carcinoma include childhood diet, for instance, a diet of preserved meats and cantonese-style salted fish known containing carcinogenic nitrosamines. other environmental factors associated with the development of nasopharingeal carcinoma include smoking, alcohol, and chinese herbal medication.14 most of the patients were not highly educated, which 299 patients were only elementary school graduates (45%) and 111 patients were middle school graduates (16.7%). findings suggest that patients lacking higher education were more likely uninformed about head and neck cancer. people without higher education tended to have a lower socioeconomic status, which may affect their lifestyle; for examples, they might have a bad diet and bad oral hygiene. previous studies by the 2009 international head and neck cancer epidemiology (inhance) discovered that 38.7% of the 12,282 total cases have only a middle school education.15 although this cancer predominated in males than in females, the majority of the females who studied were housewives (32%), while male patients had various employments. a study in brazil reported that there are more rural workers among males, and more housewives among females.7 this suggests that the women might acquire the cancer from mutlifactorial cause such as genetics, exposure to carcinogenic agent, or they were exposed althea medical journal. 2015;2(4) 478 amj december, 2015 as passive smoker. it is also possibly due to changes in smoking and alcohol drinking habits in females.7,16 kim et al.6 also discovered that of the many studies from high and low income countries, patients with low socioeconomic status and a low level of education have a higher risk of cancer, especially oral cancer. the highest instances of head and neck cancer cases was among middle aged adults (46–55 years old), as many as 285 patients (29.6%) fell in this category, the median age being 46–55 years old, with a range of 11–87 years old. the study conducted in egypt by tawfik et al.17 also reported that the median age is 46–55 years old and the cancer is more common among people 46–55 years old and older. this study showed that a long exposure period to carcinogens, virus, dna genes, and accumulation of mutation increased the risk factor for cancer. syrigos et al.2 also found that the eldery may be effected by high exposure to risk factors over a long period of time, or by an accumulation of mutations, decrease in dna repair efficiency, and a weakening immune system. the majority, 302 patients (45.4%), of histological findings were classified as undifferentiated carcinoma, while 148 patients (22.3%) were classified as having squamous cell carcinoma. nevertheless, previous research studies by goon et al.3 kim et al.6 and syrigos et al.2 reported that 90% of head and neck cancer malignancies are squamous cell carcinoma. this finding is commonly linked to the infection of human papilloma virus (hpv).2,3,6,13 undifferentiated carcinoma is usually found in nasopharingeal carcinoma and sinonasal cancer, which often relate to an epstein barr virus (ebv) infection characterized by rapid metastasis and causing death.5,10,18 the majority of patients were diagnosed at advanced stage of cancer (stage iii and iv). according to ruback et al.19 and santos et al.20 a high proportion of cancer patients is only diagnosed at advanced stage, and demonstrates the difficulty in obtaining an early diagnosis. this is probably due to lack of patients’ knowledge about head and neck cancer, as the symptoms are not incapacitating in early stages, and the hospital fee is either too expensive or they choose alternative medicine instead of going to see a doctor. the prognosis of head and neck cancer is based on patient’s stage of cancer when it is first diagnosed. during the early stages, patients have a 60–95% chance of being healed by local treatment only, while patients in the advanced stages have over a 50% chance of recurrence or metastasisation of the cancer.6 limitation of this study is the incomplete and missing data, also data were only obtained from one hospital, most of the patients were reffered from other hospitals. this might be seen as an iceberg phenomenon because it could only be seen from the patients who came to dr. hasan sadikin general hospital instead of the total population at risk. further studies can be conducted with other variables such as address, race, chief complain, therapy, and history of smoking or to corelate the risk factors with head and neck cancer and to assess their quality of life. in conclusion, head and neck cancer occurred more commonly in males. it predominates in middle aged (46–55 years old) and older. a high proportion of head and neck cancer was presented in people with a low level of education specifically elementary school educated and low level of socioeconomic status. nasopharingeal carcinoma is found to be the most common type of head and neck cancer. the majority of patients are already on the advanced stage of cancer. the patients are found to have undiffferentiated carcinoma as their predominant histopathological finding. head and neck cancer can affect people from various backgrounds, which are education and prevention needed in the communities to decrease the incidence of head and neck cancer. it is suggested to do early detection on patients who have characteristics with a high incidence, by disseminating the study result to first-line health workers and educate them to achieve early detection of the disease, so the patients can get a proper early treatment, disability restriction and other prevention. usually patients come with advanced stages, beside of treatment options, which palliative care is also needed to improve their quality of life references 1. ferreira m, souza jad, cohen e. role of molecular markers in the management of head and neck cancers. curr opin in oncol. 2011;23(3):259–64. 2. syrigos kn, karachalios d, karapanagiotou em, nutting cm, manolopoulos l, harrington kj. head and neck cancer in the elderly: an overview on the treatment modalities. cancer treat rev. 2009;35(3):237–45. 3. goon pk, stanley ma, ebmeyer jr, steinsträsser l, upile t, jerjes w, et al. althea medical journal. 2015;2(4) 479 hpv & head and neck cancer: a descriptive update. head neck oncol. 2009;1:36. 4. hassan ma, lund vj, howard dj, sacker aa. are the demographics for squamous cell cancer in the head and neck changing in the united kingdom? j laryngol otol. 2007;121(2):154–7. 5. haddad ri, shin dm. recent advances in head and neck cancer. n engl j med. 2008;359(11):1143–54. 6. kim l, king t, agulnik m. head and neck cancer: changing epidemiology and public health implications. oncology. 2010;24(10): 915–9. 7. alvarenga ldm, ruiz mt, bertelli eco, ruback mjc, maniglia jv, et al. epidemiologic evaluation of head and neck patients in a university hospital of northwestern são paulo state. braz j otorhinolaryngol. 2008;74(1):68–73. 8. chaukar da, walvekar rr, das ak, deshpande ms, pai ps, chaturvedi p, et al. quality of life in head and neck cancer survivors: a cross-sectional survey. am j otolaryngol. 2009;30(3):265–70. 9. deschler dg, day t, editors. pocket guide to neck dissection classification and tnm staging of head and neck cancer and neck dissection classification. 3rd edition. alexandria: american academy of otolaryngology-head and neck surgery foundation, inc.; 2008. p. 16–28 10. who. pathology and genetics of head and neck tumours. lyon: iarc press; 2005. 11. dorland nw. dorland’s pocket medical dictionary. 28th ed. philadelphia: w.b. saunders; 2009.; p. 875–6. 12. dahlstrom kr, little ja, zafereo me, lung m, wei q, sturgis em. squamous cell carcinoma of the head and neck in never smoker–never drinkers: a descriptive epidemiologic study. head neck. 2008;30(1):75–84 13. munir m. keganasan di bidang telinga hidung tenggorok. in: soepardi ea, iskandar n, bashiruddin j, restuti rd, editors. buku ajar ilmu kesehatan telinga hidung tenggorok kepala & leher. 6th ed. jakarta: balai penerbit fkui; 2007. p. 132 14. lutzky vp, moss dj, chin d, coman wb, parsons pg, boyle gm. biomarkers for cancers of the head and neck. clin med insights ear nose throat. 2008;1:5–15. 15. hashibe m, brennan p, chuang s-c, boccia s, castellsague x, chen c, et al. interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the international head and neck cancer epidemiology consortium. cancer epidemiol biomarkers prev. 2009;18(2):541–50. 16. durazzo md, de araujo cen, neto jdsb, potenza ads, potenza ads, costa p, et al. clinical and epidemiological features of oral cancer in a medical school teaching hospital from 1994 to 2002: increasing incidence in women, predominance of advanced local disease, and low incidence of neck metastases. clinics (sao paulo). 2005;60(4):293–8. 17. tawfik hm, el-maqsoud nmra, hak bhaa, el-sherbiny ym. head and neck squamous cell carcinoma: mismatch repair immunohistochemistry and promoter hypermethylation of hmlh1 gene. am j otolaryngol. 2010;32(6):528–36. 18. powles t, powles j, nelson m, sandison a, peston d. head and neck cancer in patients with human immunodeficiency virus infection: incidence, outcome and association with epstein-barr virus. j laryngol otol. 2004;118(3):207–12. 19. ruback mcjc, galbiatti alv, arantes lmrb, marucci gh, russoi a, ruiz-cintraii mt, et al. clinical and epidemiological characteristics of patients in the head and neck surgery department of a university hospital. rev assoc med bras. 2012;130(5):307–13. 20. santos lc, cangussu mc, batista ode m, santos jp. oral cancer: population sample of the state of alagoas at a reference hospital. braz j otorhinolaryngol. 2009;75(4):524–9. inez aulia rakhmawulan, yussy afriani dewi, nursiah nasution: profile of head and neck cancer patients at department of otorhinolaringology-head and neck surgery dr. hasan sadikin general hospital bandung althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 100 amj march, 2015 larvicidal effects of tithonia diversifolia (hemsley) a. gray leaf water extract against culex sp. larvae hasan ali abdurrachman1, diah dhianawaty d.2, neneng syarifah s.3 1faculty of medicine, universitas padjadjaran, 2department of biochemistry, faculty of medicine, universitas padjadjaran, 3department of parasitology, faculty of medicine, universitas padjadjaran, bandung, indonesia abstract background: there are various vector mosquitoes that cause filariasis such as culex sp. controlling the number of vectors with larvacide can reduce the spread of this disease. the extracts of tithonia diversifolia (hemsley) a. gray leaves are known to have larvicidal effects on aedes aegypti larvae. the purpose of this study is to determine the larvicidal effects of tithonia diversifolia (hemsley) a. gray leaf water extract against culex larvae. methods: this was an experimental study conducted during the period of october to november 2012 at the laboratory of biochemistry, faculty of medicine, universitas padjadjaran. first trials were conducted to find the most effective larvicidal concentration of tithonia diversifolia (hemsley) a. gray leaf water extract in killing 25 culex larvae. a concentration of 100 ml was decided as the testing concentration which would be compared to a positive control containing abate® and a negative control containing distilled water. the number of dead larvae was calculated every hour for 48 hours. results: effective larvicidal concentration of tithonia diversifolia (hemsley) a. gray leaf water extract was 60% (p=0.000 compared to negative control), which was lower than abate®. result also showed lc50 and lc90 of 24% and 42%, respectively. conclusions: tithonia diversifolia (hemsley) a. gray leaf water extract has a larvicidal effect on culex sp. larvae, although it is not as effective as abate®, hence, this leaf may be used as an alternative larvacide as these plants are easily available in the community and inexpensive. key words: culex sp., filariasis, larvacide, tithonia diversifolia (hemsley) a. gray correspondence: hasan ali abdurrachman, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628562476 5992 email: hasanabdurrachman@gmail.com introduction filariasis is a disease caused by the filarial worm borne by vectors such as mosquitoes. there are 337 districts/cities in indonesia that become endemic sites for filariasis.1 one of the vectors is the genus of culex.2 one way to control the mosquito-borne diseases such as filariasis is by controlling the mosquitoes population itself.3 controlling the number of vector can be done by manipulating the mosquitoes breeding places or by using chemical materials.4 abate® has been used for about 30 years, since it is provisioned as the eradication program of aedes aegypti. with the use of abate® in long run, it is possible that the resistance of larvae has emerged. some studies mentioned that the resistance of mosquito culex sp., for some classes of insecticides, including organophosphates group occurs more rapidly compared to aedes aegypti.5 developing pesticides from natural materials still continues to rise as there are limited side effects arised compared to those of chemical pesticides. toxic effects that occur from the chemical larvacides are their effect to non-target organisms such as to humans, and there is also likelihood of mosquito resistance to the pesticide.6 the tithoniadiversifolia (hemsley) a. gray leaves or better known as the flower leaf moon, is regarded by the public as the weeds which grow wildly. tithoniadiversifolia (hemsley) a. gray leaves extract is well known to contain flavonoids, tannins, that possesss larvacidal effect against larvae of the mosquito aedes aegypti.7 the aim of this study is to investigate whether tithoniadiversifolia (hemsley) a.gray leaves are potential to be a green larvacide that althea medical journal. 2015;2(1) 101 can be used in the wider community or not. to determine the potential active compounds present in the tithoniadiversifolia (hemsley) a. grayleaves, the values of lc50 and lc90will also be determined.8 method this was an experimental study conducted during the period of october to november 2012 at laboratory of biochemistry faculty of medicine universitas padjadjaran. first trials were conducted to find the most effective concentration of water extract of tithoniadiversifolia (hemsley) a. gray leaves. the 100 ml of decided concentration was then tested for larvicidal effect of 25 culex larvae compared to a positive control containing abate® and negative control containing distilled water. the number of dead larvae was calculated in 48 hours once every hour. effective concentration was decided at most effective time of all larvae were found dead. culex sp., larvae was obtained from the school of life sciences and technology of bandung institute of technology (sith-itb) with inclusion criteria larvae culex sp. that reached instar iii or iv. the data were processed using spss 15.0 for windows. the larvacidal effect was analyzed table 1 effective concentration of water extract of tithoniadiversifolia (hemsley) a. gray leaves concentration number of larvae number of dead larvae time of dead larvae (hours) 15% 25 8 30% 25 8 45% 25 19 60% 25 25 30 75% 25 25 33 90% 25 25 34 100% 25 25 39 table 2 larvacidal effect of water extract of tithoniadiversifolia (hemsley) a. gray leaves group number of larvae number of dead larvae time of dead larvae (hours) 60% concentration 1 25 25 34 2 25 25 34 3 25 25 32 4 25 25 34 5 25 25 33 distilled water 1 25 1 2 25 0 3 25 0 4 25 1 5 25 0 abate® 1 25 25 2 2 25 25 2 3 25 25 1 4 25 25 2 5 25 25 1 althea medical journal. 2015;2(1) 102 amj march, 2015 using mann-whitney test. p value <0.05 was considered as significant. lc50 and lc90 values were analyzed using probit test. results first, there were 7 different concentration of water extract of tithoniadiversifolia (hemsley) a. gray leaves; 15, 30, 45, 60, 75, 90, and 100% evaluated for the most effective concentration. each concentration was tested into a well consists of 25 culex sp., larvae and the larvacidal effect was calculated in 48 hours once every hour. the 60% concentration was found to be the concentration that can kill all larvae culex sp., in most effective time. the 100 ml of 60% concentration was then tested for larvacidal effect compared to a positive control containing abate® and negative control containing distilled water. although less effective than abate®, there was a potential larvacidal effect of water extract of tithoniadiversifolia (hemsley) a. gray leaves compared to negative control. statistically, the 60% water extract of tithoniadiversifolia (hemsley) a. grayleaves concentration was effective in killing the culex larvae (p=0.000 compared to negative control), although we found a lower effect compared to abate®. research model probit y = -2.505 + 5.425 x, where y is the probit, and x is log concentration of the water extract was used to determine lc50and lc90. from the equation, the lc50 of water extract of tithoniadiversifolia (hemsley) a. gray leaves was 24%, while the lc90 was 42%. discussion the purpose of this study is to determine the larvacidal effects of boiled water of tithoniadiversifolia (hemsley) a. gray leaves against the mosquito larvae culex sp. the study also included lc50 and lc90 of the water extract as vegetable larvacide against larvae culex sp.. the results showed that the water extract has a significant effect to kill larvae culex sp., although it is not as effective as abate®. based on these results, the active substances contained in the water extract of tithoniadiversifolia (hemsley) a. gray leaves are flavonoids and tannins.9 flavonoids have larvacidal effects due to their mechanism of action to inhibit the respiratory system and disrupt the electron transport process in the larval body thus decreasing atp production and reducing the use of oxygen by mitochondria. besides, the tannins work by inactivating the enzymes and proteins in the larvae’s body.10 although the leaves contain flavonoids and tannins with larvacidal effect, the contents of both substances in the water extract of tithoniadiversifolia (hemsley) a. gray leaves are allegedly not too high, therefore, it takes a long time to kill all the larvae. wide variations in the number of dead larvae in each group may be due to the type instar of larvae which affects the larvae’s sensitivity to the decoction. the study itself was carried out in the rainy season that may influence the destruction the larvae. the study on the active substances contained in the water extract of tithoniadiversifolia (hemsley) a.gray leaves should be an important issue. references 1. ditjen pp & pl (pengendalian penyakit dan penyehatan lingkungan),direktorat p2b2, subdit filariasis & schistosomiasis. rencana nasional program akselerasi eliminasi filariasis di indonesia. jakarta: kementrian kesehatan republik indonesia; 2010. p. 5 2. james b. filariasis. in: eldridge bf, edman jd, editors. medical entomology: atextbook on public health and veterinary problems caused by arthropods. dordrecht: kluwer academic; 2004. p. 324–33 table 3 statistical analysis parameter significance value (2-tailed) alpha=5% tithoniadiversifolia (hemsley) a. gray leaves 60% concentrationdistilled water number of dead larvae 0,000 tithoniadiversifolia (hemsley) a.gray leaves 60% water extract-abate number of dead larvae 0,000 althea medical journal. 2015;2(1) 103hasan ali abdurrachman, diah dhianawaty d., neneng syarifah s: larvicidal effects of tithonia diversifolia (hemsley) a. gray leaf water extract against culex sp. larvae 3. upadhyaya sd. economic zoology. 2nd ed. new delhi: rastogi publications; 2009. p. 67–9 4. agoes r, oehadian h, djaenudin n. bunga rampai entomologi medik. 2nd ed. bandung: universitas padjadjaran; 2005. p. 87–91. 5. daniel. ketika larva dan nyamuk dewasa sudah kebal terhadap insektisida. jakarta. farmacia. 2008;7(7):44 6. nicoletti m, maccioni o, coccioletti t, mariani s, vitali f. neem tree (azadirachta indica a. juss) as source of bioinsectides. in: perveen f, editor. insecticides-advances in integrated pest management. rijeka. intech; 2012. p. 411–26 7. rahayu. pengaruh ekstrak daun paitan (tithonia diversifolia (hemsley) a.gray) terhadap mortalitas larva aedes aegypti instar iii [minor thesis]. malang: universitas islam negeri maulana malik ibrahim; 2007 8. arbiastutie y, muflihati. isolasi dan uji aktivitas kandungan kimia bioaktif dari biji duku (lansium domesticum corr). jurnal penelitian universitas tanjungpura. 2008;x(2):70–86 9. taofik m, yulianti e, barizi a, hayati ek. isolasi dan identifikasi senyawa aktif ekstrak air daun paitan (tithonia diversifolia) sebagai bahan insektisida botani untuk pengendalian hama tungau eriophyridae. alchemy. 2010;2(1):132–9 10. sudjari dh, agustin imk, telussa. as. pengaruh dekok daun mint (mentha arvensis var javanica) sebagai larvasida nabati nyamuk anopheles sp. di pantai balekambang, kecamatan bantur, kabupaten malang [online journal] 2008 [downloaded in 26 september 2012]. available at: http://elibrary.ub.ac.id althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 521 correlation between body mass index and age at menarche atika primandina putri,1 yulia sofiatin,2 r. m. ryadi fadil,3 hadyana sukandar,2 nugroho harry susanto,2 anggraini widjadjakusuma,2 lulu eva rakhmilla,2 lola ilona2 1faculty of medicine, universitas padjadjaran, 2department of epidemiology and biostatistics, faculty of medicine universitas padjadjaran 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the decline of age at menarche has been reported in several countries, it occurred because of genetic, ethnic, and socioeconomic improvement in nutritional status and environment. the improvement of nutritional status has occurred globally all over the world including in indonesia. one of the measuring tools in nutritional status is body mass index (bmi). the objective of the study was to assess the correlation between bmi and age at menarche. methods: a cross-sectional study was carried out among girls aged 9–15 years old in jatinangor, from may–november 2013. the sample of this study was chosen with cluster random sampling. age at menarche information was collected through a questionnaire. body mass index was calculated from measurement of body weight and height. data was analyzed using spearman correlation test. results: out of three hundred and sixty nine subjects participating in this study, sixty seven were included in the inclusive criteria. according to the classification of bmi of underweight, normal, overweight, and obese, there were 1, 55, 8, and 3 persons, respectively. mean of bmi was 19.04 and mean age at menarche was 12.72 years, which showed a non significant result (r=-0.013; p= 0.458). conclusions: age at menarche was not correlated with bmi. [amj.2015;2(4):521–4] keywords: adolescent girls, age at menarche, body mass index correspondence: atika primandina putri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 852 702 424 23 email: atikaprimandina@gmail.com introduction puberty is one of the crucial stages in human growth and development process. one of the signs of puberty is menarche.1 over last few decades, puberty has occurred earlier so that the age at menarche decreased. this situation occured in the unites states, south korea, and indonesia.2-4 in indonesia, there was a decline of age at menarche to 12.96 years from 13.22 years in 1996.4,5 this might be due to the evolving of better socioeconomic conditions, nutrition and health status.1 onset of menarche can be affected by various factors, such as ethnicity, socioeconomic, genetic and nutritional status.2,4,6,7 menarche is the first menstruation that occurred in a cycle. menarche is regulated by hormones, such as gonadotropin releasing hormone (gnrh).1 gonadotropin releasing hormone could be affected by leptin. the increasing level of leptin will trigger the activation of gnrh and accelerate the initiation of puberty.1,8 leptin can increase when there are elevated adipose cell and leptin resistance.9 elevated adipose cells can be associated with elevated bmi. the easiest way to measure nutritional status is by measuring the body mass index. body mass index is a ratio between weight and height that could indicate the composition of body fat.10 the decline of age at menarche can be the risk factor for various diseases, such as insulin resistance, depression in teenager, engages in risk behaviors, breast cancer and cardiovascular risk.11-13 the aim of the study was to analyze the correlation between body mass index and the age at menarche. methods a cross-sectional study was carried out among girls aged 9–15 years in elementary and junior high schools in jatinangor, sumedang. this research was conducted in may–november 2013. the inclusion criteria of this study were althea medical journal. 2015;2(4) 522 amj december, 2015 young girls living in jatinangor with maximum menstrual period less than four months, assumed that they had not been affected yet by growth spurt.14 then, the sample size was calculated by using calculation for analytic numeric study with minimum sample size of 53 subjects. subjects were selected by cluster random sampling, three elementary and five junior high schools in jatinangor were chosen. this study has been approved by the health research ethics committee of the faculty of medicine, universitas padjadjaran, department of education sumedang, and department of regional development sumedang. . in this study the independent variable was bmi which was derived by measuring height and weight. the height was measured by using microtoise, then the subjects were asked to take off their shoes and caps, and standup, with heels, buttock, shoulders and back of the head touching the wall. the frankfort area must be perpendicular to the wall and parallel to the floor. next, the weight was measured by using a weighing scale and subjects must take off their shoes, jackets, heavy clothes and other stuff. the dependent variable of this study was the age at menarche, determined by questionnaires that must be filled by the subjects. thecollected data were analyzed using spearman correlation results out of the 369 girls of the selected schools, 85 subjects met the inclusion criteria, and eighteen of them were excluded due to incomplete data. the rest of the subjects reached the minimum sample size and were analyzed. the earliest age at menarche was 11 and occurred in 3 adolescent girls with underweight and normal bmi. most of the girls got their first menstruation at age 13 and had normal bmi (table 1). according to the analysis of spearman correlation test, the correlation value (r) derived in this study was 0.013 and inversely correlate, p value was 0.458 (p>0.05). the result of this study indicated that there was no significant correlation between both variables. discussions the population and subject of this study were girls aged 9–15 years. the average age at menarche according to the survey, was 12–14 years old. the youngest age at menarche was 9 years and the oldest one was 18 years.4 the mean age of menarche in jatinangor in this study was 12.72 years which was younger than the national mean age at menarche in 1996 (13.22 years old).5 this decline could be due to improvement in nutritional status and environmental changes.6 the mean age of menarche in this study was higher compared to studies in kuwait15 (12.41 years old) and united states2 (12.32 years old), but was lower than the study in south korea3 (13.1 years old). the differences might be due to sexual maturity variation by race, ethnicity and nutritional status.16,17 out of 67 subjects, 83% had normal bmi and reached menarche at the age of 13 years. the table 1 distribution of age at menarche and body mass index (n=67) variable number of person percentage (%) age at menarche (years) 11 3 5 12 25 37 13 28 42 14 10 15 15 1 1 body mass index underweight 1 2 normal 55 82 overweight 8 12 obese 3 4 althea medical journal. 2015;2(4) 523 body mass index distribution in this study was widely varied, the overweight and obese group percentage were 12% and 4% respectively (table 1). the prevalence of overweight and obese in this study was different from studies in medan18 (27%) and in kuwait15 (18.3% and 25.8%). in this study, girls who got their first menarche were from underweight and normal bmi. normally, girls with earlier menarche has higher bmi, as shown in the bogalusa heart study17 and in the study of oh et al.3 in south korea. furthermore, this study showed that there was no correlation between age at menarche and bmi. this was contradictive to studies of oh et al.3 in seoul, south korea, the bogalusa heart study17 and of olivia in medan18, which reveals a correlation between bmi with onset at menarche. this difference might be due to different design, criteria, operational definition, and difference in obesity prevalence.19 additionally, robert et al.20 in chicago, illinois also stated that menarche shows significantly a tendency to occur in preteen girls with an elevated bmi which is related to the increasing level of leptin. based on a study by apter9 in female adolescence, leptin shows a correlation with body weight and puberty. ethnic, genetic and environment might be other reasons for this difference.6 there are some limitations and recommendation for this study. the body mass index on onset of menarche should be measured at the first menstrual period.1,10 therefore, the use of a cohort study design and consideration of lower overweight and obesity prevalence will reveal a better conclusion. leptin is more directly correlated with body fat composition and should be considered to be used in a further study as an independent variable for onset of menarche.9 other factors that can affect menarche, such as socioeconomic, genetic and ethnicity should be taken into account. based on this study, it can be concluded that there is no correlation between bmi and age at menarche in jatinangor. references 1. gardner dg, shoback dm, greenspan fs. greenspan’s basic and clinical endocrinology. san fransisco: mcgrawhill medical; 2007. 2. mcdowell ma, brody dj, hughes jp. has age at menarche changed? results from the national health and nutrition examination survey (nhanes) 1999–2004. j adolesc health. 2007;40(3):227–31. 3. oh cm, oh ih, choi ks, choe bk, yoon ty, choi jm. relationship between body mass index and early menarche of adolescent girls in seoul. j prevent med publ health. 2012;45(4):227–34. 4. batubara jr, soesanti f, van de waal hd. age at menarche in indonesian girls: a national survey. acta med indones. 2010; 42(3):78–81. 5. hendrawati ld, glinka j. age at menarche in indonesia. folia medica indonesiana. 2003;39(1):18–21. 6. karapanou o, papadimitriou a. determinants of menarche. reprod biol endocrinol. 2010;8:115. 7. wronka i, pawlinska-chmara r. menarcheal age and socio-economic factors in poland. ann hum biol. 2005;32(5):630–8. 8. molina pe. endocrine physiology. new orleans, louisiana: mcgraw-hill; 2006. 9. apter d. the role of leptin in female adolescence. annal ny acad sci. 2003; 997(1):64–76. 10. whitney en, rolfes sr. understanding nutrition. belmont, ca: thomson higher education; 2008. 11. parent as, teilmann g, juul a, skakkebaek ne, toppari j, bourguignon jp. the timing of normal puberty and the age limits of sexual precocity: variations around the world, secular trends, and changes after migration. endocr rev. 2003;24(5):668– 93. 12. sloboda dm, hart r, doherty da, pennell ce, hickey m. age at menarche: influences of prenatal and postnatal growth. j clin endrocrinol metab. 2007;92(1):46–50. 13. gaudineau a, ehlinger v, vayssiere c, jouret b, arnaud c, godeau e. factors associated with early menarche: results from the french health behaviour in school-aged children (hbsc) study. bmc public health. 2010;10(1):175. 14. kawulur eijj, suryobroto b, budiarti s, hartana a. association of sexual maturation and body size of arfak children. hayati j biosci. 2012;19(3):124–30. 15. al-awadhi n, al-kandari n, al-hasan t, almurjan d, ali s, al-taiar a. age at menarche and its relationship to body mass index among adolescent girls in kuwait. bmc public health. 2013;13(1):29. 16. reagan pb, salsberry pj, fang mz, gardner wp, pajer k. african-american/ white differences in the age of menarche: accounting for the difference. soc sci med. 2012;75(7):1263–70. atika primandina putri, yulia sofiatin, rm ryadi fadil, hadyana sukandar, nugroho harry susanto, anggraini widjadjakusuma, lulu eva rakhmilla, lola ilona: correlation between body mass index and age at menarche althea medical journal. 2015;2(4) 524 amj december, 2015 17. freedman ds, khan lk, serdula mk, dietz wh, srinivasan sr, berenson gs. relation of age at menarche to race, time period, and anthropometric dimensions: the bogalusa heart study. pediatrics. 2002;110(4):e43. 18. olivia d, deliana m, supriatmo, hakimi, lubis sm. body mass index and age of menarche in young girls. paediatr indones. 2012;52(6):309–12. 19. bralić i, tahirović h, matanić d, vrdoljak o, stojanović-špehar s, kovačić v, et al. association of early menarche age and overweight/obesity. pediatr endocrinol metab. 2012;25(1–2):57–62. 20. rosenfield rl, lipton rb, drum ml. thelarche, pubarche, and menarche attainment in children with normal and elevated body mass index. pediatrics. 2009;123(1):84–8. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 15 antiplatelet drugs and its gastrointestinal side effects among ischemic stroke patients in dr. hasan sadikin general hospital 2011 ananthakrishnan a/l rajendram1, ike rostikawati husen2, andi basuki3 1faculty of medicine, universitas padjadjaran 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of neurology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: antiplatelet drugs with known side effects are given in long term therapies to prevent secondary ischemic stroke. gastrointestinal side effect is the most prevalent issue. the aim of this study was to identify which antiplatelet drugs have the most gastrointestinal side effects and the duration of administration. methods: seven hundred twenty six medical records were obtained from the medical record department of dr.hasan sadikin general hospital bandung from august to december 2011. inclusion criteria were >18 years old and treated by long term antiplatelet drugs with complete medical records. data analyzed descriptively consist of antiplatelet type, gastrointestinal effects, and drug administration duration. results: of 726 medical records only 246 were enrolled this study. aspirin 80 mg was the most frequent drug given to ischemic stroke patients (65.9%). gastrointestinal (gi) bleeding and nausea were the two side effects mostly found in aspirin >80 mg group (90%; 95% respectively). the side effects was found after less than 3 months in the aspirin >80 mg group, while it took longer to appear in clopidogrel 75 mg group. conclusions: aspirin (>80 mg) presents the most frequent gastrointestinal side effect compared to low dose aspirin 80 mg , clopidogrel, and combination of clopidogrel and aspirin. keywords: antiplatelet, ischemic stroke, side effects correspondence: ananthakrishnan a/l rajendram, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628170209396 email: anan_16v@hotmail.com introduction by definition, a stroke is “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin”.1 if blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen causing ischemia and the brain cells can die, causing permanent damage to the brain.2 stroke is the second leading cause of death worldwide and the first in indonesia.3 worldwide number of deaths resulted by stroke is 150,000 per year. the prevalence of stroke in indonesia is 500 per 100,000 people. stroke incidence increases with age especially over 65 years old and the chances of stroke are more common in men than women and tend to run in the families.2,4,5 there are two major types of stroke, the ischemic stroke and the hemorrhagic stroke. ischemic stroke happens when a blood vessel that supplies blood to the brain is blocked by a blood clot. ischemic strokes may also be caused by clogged arteries which is due to plaque formation by atherosclerosis.1 there is many kinds of combination therapy used in the management of ischemic stroke. ischemic stroke patients are usually treated with the intravenous thrombolysis, antiplatelet and anticoagulant treatment and the stroke rehabilitation. the intravenous treatment is usually done in case within 3 hours of onset. the antiplatelets are used to prevent artherothrombotic events by inhibiting the formation of intra-arterial platelet aggregation. aspirin, clopidogel and the combination aspirin–dipyridamole are widely used to serve this purpose.6 aspirin acetylates platelet cyclooxygenase and irreversibly inhibits the formation of thromboxane a2 functioned to aggregate platelet and cause vasoconstriction. triclopidine and clopidolgel block the adenosine diphosphate (adp) receptor on platelets and prevent the activation of the glycoprotein iib/iiia receptor which causes althea medical journal. 2015;2(1) 16 amj march, 2015 fibrinogen binding to the platelet and platelet aggregation. dipyridamole is an antiplatelet which inhibits the uptake of adenosine. it can lead to the accumulation of adenosine which causes inhibition of aggregation.7 low dosages of these drugs are given as treatment for the ischemic stroke patients. whether these drugs are not continued nor the treatment fails, a secondary stroke is most likely inevitable and the patients prognosis is very poor with permanent disability.7,8 the treatment is very important to ensure a good prognosis for the patient, however, all these drugs result in side effects. most studied has agreed with long term usage of these drugs. these antiplatelet drugs cause gastrointestinal bleeding, nausea, skin rash, diarrhoea and neutropenia.8,9,10 in some cases, other drugs are given to counter the side effects of these antiplatelet drugs such as ranitidine and omeprazole. this has intrigued the researcher to find out about the side effects caused by these antiplatelet drugs of different types in its long term usage by stroke patients especially gastrointestinal effect. by this study, it can be found the evidence of the best regiment of drugs in preventing the gastrointestinal side effects caused by these antiplatelet drugs. this will enhance the management and monitoring plan of the doctor’s treatment of ischemic stroke patients to have a better effect. methods the study was done descriptively by analyzing the secondary data from the medical records of adult ischemic stroke patients aged >18 years, being treated with long term antiplatelet drugs in department of neurology in dr. hasan sadikin general hospital, bandung from january 2011 until december 2012 with complete medical records. long term of antiplatelet administration is defined as patients taking the drug for a period of >2 months. the data will be collected in a systemic random method where the interval is every 2 weeks and collected with the permission fromthe main director of dr. hasan sadikin general hospital, bandung and department of research and training of dr. hasan sadikin general hospital, bandung. the exclusion criteria were patients with history or present with idiopathic thrombocytopenic purpura (itp) or other genetic disorder, patients with history or present illness of bone marrow, patients with severe renal or hepatic insufficiency, patients with history of thrombocytopenia or neutropenia, patients with history of any antiplatelet drug sensitivity and any patient with an incomplete medical record. results of 726 medical records collected, 246 (33.8%) fulfilled the inclusion and exclusion criteria. table 1 showed that aspirin 80 mg was the most frequent drug given to ischemic stroke patient 65.9%. gastrointestinal (gi) bleeding and nausea two side effects were mostly found in aspirin>80 mg group which were 90%; 95% respectively (table 2). the earliest side effect observed was gi bleeding and nausea among aspirin>80mg groups which found less than 3 months and the furthest observed among clopidogrel 75mg users (table 3). discussion aspirin being a cox-1 inhibitor is known as having does have known side effects causing gi bleeding, nausea, rash and diarrhea. these side effects did not change among the ischemic stroke patients as well. thus, among the 76 cases reported having gi bleeding, 34 table 1 distribution of the type of antiplatelet drug types of antiplatelet number of patients percentage,% aspirin, > 80mg 40 16.3 aspirin, 80mg 162 65.9 clopidogrel, 75 mg 30 12.1 aspirin and clopidogrel , 80 mg & 75mg 14 5.7 total 246 100% althea medical journal. 2015;2(1) 17 patients (21 % ) were on 80mg aspirin, 36 ( 90 %) patients were on >80mg aspirin, 4 (13 %) patients were on clopidogrel and 2 (14 %) patients was given a combination of both aspirin 80mg and clopidogrel 75mg.. this showed that there is a difference of side effect morbidity in aspirin of 80 mg and clopidogrel. it can be seen that of 70 cases, patients taking aspirin of 80 mg has greater side effect than clopidogrel (only 4 cases) and both of them (only 2 cases). it can be concluded that clopidogrel causes lesser morbidity of gi bleeding than aspirin.11 aspirin is further divided into 2 regiments a dosage that less than 80 mg (21%) and more than 80 mg (90%). the highest incidence of gi bleeding occurred in the patients taking an aspirin with dosage more than 80 mg (90%) were. it was suggested that the gi side effect among ischemic patients is being influenced by the dosage of the aspirin used. even though, 80mg is considered as a low dose of aspirin, the data still suggests that there are side effects due to its administration to the ischemic stroke patient. nausea is being reported among the patients using aspirin 80mg (23 %), aspirin more than 80mg (95%), clopidogrel (7%) and the combination of them (14 %). this data showed that nausea often occurred in the patients taking the aspirin with dosage of more than 80 mg (95%) compared to clopidogrel (7%).it can be concluded that clopidegrol is a better antiplatelet drug than aspirin and the combination of them.11 the side effects in patients are influenced by a dosage of drug (table 3). it can be observed that the patients taking aspirin more than 80 mg are earlier to inform the side effects than those taking aspirin 80 mg. the patients taking clopidogrel are the last to inform the side effect. based on table 3, it can be said that the majority of gi bleeding and nausea side effects arise in patients taking aspirin of 80mg after 6 months until 9 months while in those takingmore than 80mg before 3 months. meanwhile, in clopidogrel and the aspirin and clopidogrel combination groups, the side effects only arise after 9 months. the side effects in patients taking clopidogrel, aspirin and the combination of them arise after 9 months. this data provides table 2 gastrointestinal side effects among antiplatelet drugs side effect/ drugs (n)% aspirin, 80mg aspirin, >80mg clopidogrel c&a gi bleeding 34 (21) 36 (90) 4 (13) 2 (14) nausea 38 (23) 38 (95) 2 (7) 2 (14 ) *note: c&a = clopidogrel 75mg and aspirin 80mg *note: gi= gastrointestinal table 3 duration antiplatelet drugs consumption duration aspirin 80 mg aspirin >80 mg clopidogrel c&a (months) n (%) n (%) n(%) n(%) gi bleeding <3 4 (12) 20 (56) 3-6 4(12) 5(14) 6-9 19 (56) 8 (22) 1(25) >9 7 (20) 3 (8) 3(75 2(100) nausea <3 4 (12.5) 23 (61) 3-6 4 (12) 3 (18) 6-9 19(56) 5(13) >9 7 (20) 3 (8%) 2 (100) 2 (100) ananthakrishnan a/l rajendram, ike rostikawati husen, andi basuki: antiplatelet drugs and its gastrointestinal side effects among ischemic stroke patients in dr. hasan sadikin general hospital 2011 althea medical journal. 2015;2(1) 18 amj march, 2015 the information that the patients taking aspirin more than 80mg, (56 %) should be monitored carefully in the first 3 months of the drug usage ,those taking aspirin 80mg (56 %) should be monitored carefully after 3 months to 6 months and those taking the combination of them (75 % and 100 %) only needs careful monitoring after 9 months. most of the patients are still given aspirin eventhough they know about the side effects of it. it is caused by patient’s economical status and the drug price. the price of aspirin tablet is ranged from rp 400 – rp1,200 while a clopidogrel is ranged fromrp22,000– rp24,000 per tablet.14 the price of aspirin is more economical and affordable for the patients. yet, clopidogrel showed that it has the lowest side effects of others. it is hoped that it can be a consideration for the doctors when determining about the drug for the patents. 11,12 the clopidogrel is the best regimen drug that has the least gil bleeding side effects. limitation of this study is the aspect of side effects observed only on gastrointestinal effect further study must carried out to widen other side effects of antitrombotic drug on ischemic stroke. since the gi effect of antitrombotic drug arise mostly before 3 months, administration of drugs that encounter gi bleeding like ranitidine and omeprazole must be considered before giving high-dosage aspirin. it can be concluded that high dose aspirin (>80 mg) had the most frequent gi side effect compared to low dose aspirin 80 mg , clopidogrel, and combination of clopidogrel and aspirin. references 1. thorvaldsen p, kuulasmaa k, rajakangas am, rastenyte d, sarti c, wilhelmsen l. stroke trends in the who monica project. stroke. 1997;28(3):500–6. 2. fauci a, braunwald e, weiner c, kasper d, hauser s, longo d, et al. harrison’s principal of internal medicine: selfassessment and board review. 17th ed. new york: mcgraw-hill medical;2008. 3. misbach j, ali w. stroke in indonesia: a first large prospective hospital-based study of acute stroke in 28 hospitals in indonesia. j clin neurosci.2001;8(3):245–9. 4. lloyd-jones d, adams r, carnethon m, de simone g, ferguson tb, flegal k, et al. heart disease and stroke statistics--2009 update: a report from the american heart association statistics committee and stroke statistics subcommittee. circulation. 2009;119(3):e21–181. 5. ingall t. stroke--incidence, mortality, morbidity and risk. j insur med.2004;36(2):143–52. 6. adams hp, jr., del zoppo g, alberts mj, bhatt dl, brass l, furlan a, et al. guidelines for the early management of adults with ischemic stroke: a guideline from the american heart association/american stroke association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: the american academy of neurology affirms the value of this guideline as an educational tool for neurologists. circulation.2007;115(20) :e478–534. 7. katzung b, masters s, trevor a. basic and clinical pharmacology. 11th ed. new york:mcgraw-hill medical; 2009. 8. patrono c, coller b, fitzgerald ga, hirsh j, roth g. platelet-active drugs: the relationships among dose, effectiveness, and side effects: the seventh accp conference on antithrombotic and thrombolytic therapy. chest.2004;126(3 suppl):234s–64s. 9. prichard pj, kitchingman gk, walt rp, daneshmend tk, hawkey cj. human gastric mucosal bleeding induced by low dose aspirin, but not warfarin. bmj.1989;298(6672):493–6. 10. derry s, loke yk. risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. bmj.2000;321:1183–7 11. caprie steering committee. a randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (caprie).. lancet.1996;348(9038):1329–39. 12. rostom a, moayyedi p, hunt r. canadian consensus guidelines on long-term nonsteroidal anti-inflammatory drug therapy and the need for gastroprotection: benefits versus risks. aliment pharmacol ther. 2009;29(5):481–96. 13. ray wa, murray kt, griffin mr, chung cp, smalley we, hall k, et al. outcomes with concurrent use of clopidogrel and protonpump inhibitors: a cohort study. ann intern med. 2010;152(6):337–45. 14. santoso a, pusponegoro ad, sani a, rani haa, kartasasmita r, harimurti gm, althea medical journal. 2015;2(1) 19ananthakrishnan a/l rajendram, ike rostikawati husen, andi basuki: antiplatelet drugs and its gastrointestinal side effects among ischemic stroke patients in dr. hasan sadikin general hospital 2011 editors. mims edisi bahasa indonesia. 10th ed, jakarta ;cmp medica asia pte ltd; 2009. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 506 amj december, 2015 effects of white turmeric infusion on the liver cells in carbon tetrachloride-induced mice fitria oktaviani,1 r. b. soeherman herdiningrat,2 herry yulianti3 1faculty of medicine universitas padjadjaran, 2department of anatoy and cell biology faculty of medicine universitas padjadjaran, 3department of anatomical pathology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the liver is an organ that has important functions in the body. liver damage can be caused by oxidative stress and free radicals. white turmeric (curcuma zedoaria l) contains antioxidants that can be used to neutralize the effects of free radicals. this study was conducted to determine the effect of white turmeric infusion on histological appearance of liver cells in male mice induced by carbon tetrachloride (ccl4). methods: this laboratory experimental study was conducted using male mice (mus musculus) with balb/c strain. thirty-three mice were randomly divided into 3 groups i.e.,group 1 as a control group was given standard food and drink, group 2 was given 10% of ccl4 0.1 ml by intraperitoneal injection on the first day and group 3 was given 10% of ccl4 0.1 ml by intraperitoneal injection on the first day, followed by the administration of 50% of white turmeric infusion 0.2 ml. kruskal-wallis test method was used to analyse the significant differences of the average percentage of damaged liver cells in the group given ccl4 alone with the group given ccl4 and white turmeric infusion and control group. results: the percentage of damaged liver cells between groups of mice given ccl4 alone and the group given ccl4 followed by white turmeric infusion were respectively(p <0.05) compared to group1. conclusions: administration of white turmeric infusion gave an influence by decreasing the percentage of damaged liver cells in ccl4-induced mice. white turmeric can serve as an alternative antioxidants that can be used to neutralize the effects of free radicals. [amj.2015;2(4):506–10] keywords: carbon tetrachloride, liver cells, white turmeric correspondence: fitria oktaviani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62812201106627 email: fitria.oktaviani@gmail.com introduction liver as an organ that bears important functions in the body is very susceptible to damage from metabolic disorders, circulation, toxic substances, microbes, and malignancy.1 one of the most serious liver diseases is hepatocellular carcinoma, with risk factors such as hepatitis b or c infections and longterm alcohol consumption.1 as many as 82% cases of hepatocellular carcinoma are found in an endemic area of hepatitis b and c, especially in asia and africa.2 hepatitis virus can cause liver tissue damage and inflammation through the formation of free radicals which induce mutation and transformation of normal hepatocyte cells into malignant cells.3 other agents that can cause liver damage are chemical agents. chemical agents often cause subclinical injury to the liver, which manifest only as abnormal liver enzyme tests. carbon tetrachloride (ccl4) is a chemical widely used as cleaning agents, solvents, as well as industrial materials.4 the ccl4 entering the body will be metabolized in the liver to form trichloromethyl radicals and further initiate lipid peroxidation process in liver cells to cause tissue damage.5 white turmeric (curcuma zedoaria l) is a plant of the genus curcuma contains various antioxidants such as phenolic and flavonoides, and terpenoides.6 such compounds can be used as an analgesic, anti-inflammatory, and may provide protection to the liver cells from damage caused by chemical agents.7 this study aimed to determine the effect of white turmeric infusion on the histological appearance of the liver cells ccl4-induced mice. althea medical journal. 2015;2(4) 507 methods this experimental study was conducted in the laboratory of the department of cell biology, faculty of medicine universitas padjadjaran from august to november 2012. the total of mice used as sample was determined by using the federer formula (r-1)(t-1)≥15, where r is the total of samples and t is the total of treatment groups. based on these calculations, we determined that the value of r or number of samples was ≥8.5. in this study, the total of samples used in each group was 11 mice to anticipate an event of exclusion during adaptation. inclusion criteria in this study, the mice had an average weight of 20−25 grams and age of 2 months old. mice in accordance with the inclusion and exclusion criteria were adapted for 7 days. during the adaptation period and throughout the experimental period, the mice were fed a standard pellets and water. after the adaptation period, the mice were put into 3 groups randomly. group 1 served as control group. mice from group 2 were given ccl4 injection on the first day only and then were observed for 7 days. mice from group 3 was given ccl4 injection on the first day and then followed by administration of white turmeric infusion 2 hours later. white turmeric infusion was given once daily until the 7th day of experiment. the ccl4 of 10% concentration was achieved by dissolving 0.3 ml of pure ccl4 with 0.7% of liquid paraffin. as much as 0.1 ml of ccl4 was injected intraperitoneally to induce liver tissue damage. for making the infusion, white turmeric rhizomes were peeled and cut into small pieces, weighed up to 50 grams and then mixed with 100 ml of water in a pot. a pan filled with water was heated until it reached a temperature of 90 ⁰c, and then placed the pot containing the mixture of white turmeric and water on it. heated for 15 minutes and stirred. then the mixture was filtered and poured into a tube. white turmeric infusion was given to the mice using a feeding tube as much as 0.2 ml per day, each day. by the end of the experiment, the mice were anesthetized using chloroform and then fixed on a surgical table. as much as 5 ml saline and formaldehyde solution were prepared in syringes. laparotomy began with an incision on the lower abdomen up to the lower neck. a wing needle was attached in the left ventricle and connected with the syringe. a cut the fitria oktaviani, rb. soeherman herdiningrat, herry yulianti: effects of white turmeric infusion on the liver cells in carbon tetrachloride-induced mice table 1 percentage of damaged liver cells in mice group average control 6.80 % ccl4 90.75 % ccl4 + white turmeric 37.7 % inferior vena cava was made to drain the blood while saline solution was injected, followed by liquid formalin, then the ligaments of the liver were cut and the middle third portion of the largest lobe was taken as the sample. the tissue was fixed using 37% of formaldehyde solution then rinsed and dehydrated with 100% of alcohol solution. then we used xylol and toluol to cleanse the specimen before infiltrating the paraffin. after the paraffin hardened, the specimen was cut using microtome. before staining procedure, specimens were cleaned with xylol and toluol followed by rehydration using alcohol solution. the staining procedure was done by using a solution of hematoxylin and eosin counterstain. microscopic observation was conducted to see the effect of treatment on the liver cells qualitatively and quantitatively. qualitative assessment was done microscopically with 400x magnification, while quantitative observation was done by counting the average percentage of injured cells. the data were then analysed using the non-parametric kruskal-wallis test on spss. it aimed to prove the significant differences of the average percentage of damaged liver cells in the group given ccl4 alone with the group given ccl4 and white turmeric infusion and control group as negative control was given standard food and drink. results the percentage of damaged liver cells from each group was presented (table 1). alteration of the liver tissue architecture in the group administrated with injection of ccl4 was shown by the presence of lightcolored cytoplasmic vacuoles and fusion of cell membranes. necrotic materials and lymphocyte cells were found mainly near the central vein (figure 1). in the group of mice treated with white turmeric infusion two hours following ccl4 injection, necrotic materials were abundant in surrounding central vein but not as many althea medical journal. 2015;2(4) 508 amj december, 2015 figure 1 liver cells of ccl4-induced mice figure 2 liver cells of the group treated with white turmeric infusion following ccl4 induction figure 3 liver cells of the group control althea medical journal. 2015;2(4) 509 as in the group given ccl4 alone. there were some evidences of mitotic activity. sinusoids were deranged but identifiable (figure 2). administration of white turmeric infusion significantly decreased the percentage of damaged cells in mice previously induced with ccl4 (p<0.05), 37.7 % from groups sample. discussions liver damage caused by hepatotoxic substances generally occurs in liver cells of the group treated with white turmeric infusion following ccl4 induction, reflecting the enzymes that play a role in the metabolism of such substances.8 ccl4 metabolism produced an accumulation of free radicals that can damage the cell membrane or dna directly.9 prolonged liver damage or cirrhosis is associated with the occurrence of hepatocellular carcinoma. risk factors for hepatocellular carcinoma itself include chronic liver infection, metabolic liver disease, and liver cirrhosis of any cause.3 in indonesia, 44−45% of patients with liver cirrhosis and hepatocellular carcinoma were positive for hepatitis b detection.10 hepatocellular carcinoma can also occur in conditions where the liver histological structure was altered.3 in mice and rats, administration of ccl4 may cause hepatocellular carcinoma.5 ccl4 is shown to have genotoxic and mutagenic effects associated with the cytotoxicity, lipid peroxidation, and oxidative stress.5 the effect of long-term exposure to ccl4in humans has not been widely reported, but acute exposure of ccl4 is associated with the onset of various signs and symptoms such as liver enlargement (hepatomegaly), increased aspartate aminotransferase and alanine transferase enzymes, and elevated levels of bilirubin.5 rhizome white turmeric (curcuma zedoaria l) has a variety of antioxidants that can be used as an analgesic and antiinflammatory. it also prevent the development of cancer cells and protect liver cells from the harmful effects of toxic chemicals.7 the effect of acetone extract and other ingredients isolated from white turmeric rhizome such as furanodiene, curdione, neocurdione, 13-hydroxygermacrone, zederone, and curcuminoid with a dose of 12.5−50 mg/kg through oral administration has revealed to protect liver cells from damage caused by d-galn/lps induction in mice, assessed by the levels ofaspartate aminotransferase (ast) and alanine transferase (alt) enzymes in serum.11 administration of curcumin to the spraguedawley strain rats at a dose of 200 mg/kg and 400 mg/kg has shown to provide protective and therapeutic effects on liver cells exposed to ccl4 by inhibiting the inflammatory process and oxidative stress.12 curcumin alters the transcription processes in the regulation of gene expressions that regulate the cell and inhibits the process of inflammation, tumor formation, angiogenesis, cell division and cellular invasion.13 administration of curcumin can inhibit inflammatory processes and fibrogenesis by suppressing the production of various cytokines such as tnf-α, ifn-γ, il-6. it also restrains the process of collagen deposition.12 curcumin is well tolerated in the body, thereby reducing the probability of toxicity.13 other antioxidant substances in white turmeric also play a role in inhibiting the cytotoxicity and the production of nitric oxide (no) produced in the process of inflammation.11 in this study, induction of ccl4 caused damage liver cells in mice shown by the widespread histological changes. while in the group of mice given white turmeric infusion following ccl4 induction, the average percentage of damaged liver cells were significantly lower. this is consistent with the previous studies proving that the antioxidant contents of white turmeric rhizome can be used in the prevention and treatment of damage to the liver cells.11 several studies have reported that the major histopathological parameters altered with ccl4-induced damage are degeneration in hepatocytes, the presence of necrosis and inflammatory infiltration. our histology analyses showed a positive effect of white turmeric in inhibiting the in the process of inflammation.12 this laboratory experimental study has several limitations, including a small size sample. in this study, induction of ccl4 caused damage liver cells in mice shown by the widespread histological changes. carbon tetrachloride (ccl4) is a chemical widely used as cleaning agents, solvents, as well as industrial materials future study with large size sample seems warranted to resolve these and other related issues. references 1. kumar v, abbas ak, fausto n, aster jc. robbins and cotran pathologic basis of disease. 8th ed. philadelphia: saunders elsevier; 2010. 2. el-serag hb. hepatocellular carcinoma. n engl j med. 2011;365(12):1118–27. fitria oktaviani, rb. soeherman herdiningrat, herry yulianti: effects of white turmeric infusion on the liver cells in carbon tetrachloride-induced mice althea medical journal. 2015;2(4) 510 amj december, 2015 3. fattovich g, stroffolini t, zagni i, donato f. hepatocellular carcinoma in cirrhosis: incidence and risk factors. gastroenterology. 2004;127(5 suppl 1): s35–50. 4. united states department of health and human services. toxicological profile for carbon tetrachloride. atlanta: united states department of health and human services; 2005 [cited 2012 september 20]; available from: http://www.atsdr.cdc. gov/toxprofiles/tp30.pdf. 5. united states environmental protection agency. toxicological review of carbon tetrachloride. washington, dc: united states environmental protection agency; 2010 [cited 2012 september 17]; available from: http://www.epa.gov/iris/ toxreviews/0020tr.pdf. 6. cho wy, kim sj. anti-oxidative actions of curcuma zedoaria extract with inhibition of inducible nitric oxide synthase (inos) induction and lipid peroxidation. j med plants res. 2012;6(22):3837–44. 7. lobo r, prabhu ks, shirwaikar a. curcuma zedoaria rosc. (white turmeric): a review of its chemical, pharmacological and ethnomedicinal properties. j pharm pharmacol. 2009;61(1):13–21. 8. ramachandran r, kakar s. histological patterns in drug-induced liver disease. j clin pathol. 2009;62(6):481–92. 9. panjaitan rgp, handharyani e, chairul, masriani, zakiah z, manalu w. pengaruh pemberian karbon tetraklorida terhadap fungsi hati dan ginjal tikus. makara kesehatan. 2007;11(1):11–6. 10. merican i, guan r, amarapuka d, alexander m, chutaputti a, chien r, et al. chronic hepatitis b virus infection in asian countries. j gastroenterol hepatol. 2000; 15(12):1356–61. 11. morikawa t, matsuda h, ninomiya k, yoshikawa m. potent protective effects of sesquiterpenes and curcumin from zedoariae rhizoma on liver injury induced by d-galactosamine/lipopolysaccharidase or tumor necrosis factor alpha. biol pharm bull. 2002;25(5):627–31. 12. fu y, zheng s, lin j, ryerse j, chen a. curcumin protects the rat liver from ccl4-caused injury and fibrogenesis by attenuating oxidative stress and suppressing inflammation. mol pharmacol. 2008;73(2):399–409. 13. rivera-espinoza y, muriel p. pharmacological actions of curcumin in liver disease or damage. liver int. 2009; 29(10):1457–66. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 42 amj march, 2015 description of posner schlossman syndrome patients in bandung, indonesia during the period of august 2009 to july 2011 kavitha arunasalam1, erna tjahjaningtyas2, ra.retno ekowati3 1faculty of medicine, universitas padjadjaran, bandung, indonesia, 2department of ophthalmology, faculty of medicine, universitas padjadjaran/national eye center cicendo hospital, bandung, indonesia, 3department of cell biology, faculty of medicine, universitas padjadjaran, bandung, indonesia abstract background: posner-schlossman syndrome (pss) is also known as glaucomatocyclitic crisis. it is a non– genetic, often misdiagnosed, and rare disease characterized by recurrent unilateral episodes of markedly elevated intraocular pressure which occurs simultaneously with mild inflammation of the uvea. the underlying cause of this disease is still unknown. this syndrome usually affects those who are 20 to 50 years old. the aim of this study was to perform a descriptive study on subjects diagnosed with pss at the national eye centre cicendo eye hospital bandung indonesia. methods: the method used was a descriptive study carried out on subjects diagnosed with pss at the national eye centre cicendo eye hospital bandung, indonesia during the period of august 2009 to july 2011. results: of 31 patients, 19 (61.3%) female patients participated in the study, 12 (38.7%) aged 31–40 years, 9 (29.0%) had recurrences. all (100%) complained of blurred vision, 24 (77.4%) with accompanying vision of rainbow halo surrounding light in, and 22 (71%) had headache. a total of 27 (87.1%) patients suffered from the disease unilaterally. after treatment, 17 (54.8%) patients’ visual acuity improved and 20 (64.4%) patients’ intraocular pressure (iop) were in normal range. conclusions: pss mostly affects females. the most prevalent age range is 31–40 years. most are affected unilaterally. all of them present with the symptom of blurred vision. visual acuity and iop are in normal limit after treatment. keywords: eye vision, posner schlossman syndrome, national eye centre cicendo eye hospital correspondence: kavitha arunasalam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170206640 email: kavi.5291@gmail.com introduction eyes are one of the important organs in our body. it is said to be the most complex and vital ones as they are crucial for our vision.1two hundred and eighty five million people are visually impaired worldwide and out of these, 38 million to 39 million are blind and 246 million have low vision. about 90% of the them live in developing countries. eighty percent of all visual impairment can be prevented or cured. 2,3 posner schlossman syndrome (pss), also known as glaucomatocyclitic crisis, is an uncommon inflammatory eye condition that classically affects unilateral at a time.4,5the majority of those who are affected are young to middle–aged adults, whose the eye develops to be increased pressureaccompanied by mild inflammation. previous studies have not found any racial or ethical predilections for pss. this disease is considered to be a rare disease. internationally, the incidence of pss is 0.4 and 1.9 is the prevalence of pss. it has the highest rate of occurrence in the age group of 20 years old and 50 years old. the pss rarely develops in individuals who are aged 60 years old and above as well as the young adults. 4,6–8 it is also possible for a pediatric patient to have pss. in case of pediatrics, a differential diagnosis of pss must be included in glaucoma and uveitis.9 the history of this rare disease had started in the 40s. abraham schlossman and adolf posner were the first one who identified pss in 1948. they gave a brief description of the condition, where schlossman and posner mentioned that pss had the characteristics of both uveitis and glaucoma. the exact underlying cause of pss was unknown.5although some althea medical journal. 2015;2(1) 43 researches have not been completely proven the cause, they identified a possible herpes virus or human cytomegalovirus association. according to a study conducted in singapore, out of 24 patients who have cytomegalovirus, 75% of them have pss.6, 7, 10 in order to treat the patient, personalization of the management can be conducted in accordance to the state the patient’s condition as well possibly recurrence can be avoided. the complications of pss in this case are said to be long–term increased in intraocular pressure secondary to aqueous outflow impairment, causing damage to the optic nerve head and compromising the visual field.6,7if this disease is handled and managed properly as it should be, then it is said that most of the anterior uveitis attacks will be better in a few days to a few weeks. nevertheless, it is common that relapses occur. the objectives of this study are to describe numbers of cases and characteristics of pss in national eye centre cicendo eye hospital. methods a descriptive study was conducted using 46 medical records. out of these 46 records, 15 were rejected because 9 were missing and 6 did not have sufficient necessary information. therefore, the total number of patients taken into account in this study were 31 patients. the study was conducted in the national eye centre cicendo eye hospital during the period from august 2009 to july 2011. the variables studied include age, gender, unilateral or bilateral, frequency of recurrences, and signs and symptoms. measurement of visual acuity, and intraocular table 1 characteristics of patients with posner schlossman syndrome characteristics n(n=31) % age(years) 0–20 3 9.7 21–30 4 12.9 31–40 12 38.7 41–50 7 22.6 51–60 3 9.7 60 and above 2 6.4 gender male 12 38.7 female 19 61.3 affected eye unilateral 27 87.1 bilateral 4 12.9 recurrence 9 29.0 signs and symptoms blurred vision 31 100 headache 22 71.0 headache (according to side of eye affected) 8 25.8 red eye 11 35.5 rainbow surrounding light 24 77.4 pain 13 41.9 watery eye 2 6.4 glare 3 9.7 kavitha arunasalam, erna tjahjaningtyas, ra.retno ekowati: description of posner schlossman syndrome patients in bandung, indonesia during the period of august 2009 to july 2011 althea medical journal. 2015;2(1) 44 amj march, 2015 pressure before and after treatment were also carried out. the data were analyzed using frequency distribution. results most patients were in the age group of 31– 40 years old (38.7%). out of 31 patients, majority were female (61.3%). most patients suffered from unilateral eye (87.1%). only 9 patients (29.0%) experienced recurrences. all patients (100%) complained of blurred vision, with accompanying vision of rainbow halo surrounding light in 24 (77.4%), and 22 (71%) had headache (table 1). after receiving treatment, all 31 patients were measured for visual acuity. the result showed 17 (54.8%) improved, and measurement of intraocular pressure showed about 20 (64.4%) improved. discussions among 31 patients were diagnosed of pss, those of middle age patients, who are under the age range of 31–40 years were the highest proportion. this data are in accordance with previous studies. narang and shah4 and harrington8 stated that pss is most commonly found in the age group of 20–50 years. another study from taiwan11even mentioned, 36.3 years is the average age of the patients. majority patients pss were female. this is not in accordance to a study conducted by shenet al.11that stated 58.4% of patients were male. also, a study conducted by japet al.12 found that majority of subjects studied 28 were male. this study, indicates that patients were found with unilateral affected. it is uncommon for bilateral pss found. several studies mentioned that characteristics of pss is unilateral affected.4,5 the study result showed that only 9 patients who had recurrence of the disease. from signs and symptoms observed, all 31patients came with complaining of blurred vision. this statement is supported by narang and shah4 that is also in accordance with dinakaran and kayarkar13. it was observed that this was the chief complain of all patients. twenty four patients (77.4%) have the symptom of seeing rainbow surrounding the light when they look at any lights (coloured halos), headache (71.0%), one side headache of the affected eyes (25.8%), red eyes (35.5), pain (41.9%), watery eyes (6.4%) and glare (9.7%). this is also mentioned by narang and shah 4,dinakaran and kayarkar13, as well as omoti and enock14. to test the outcome of the treatment, the visual acuity and intraocular examination were conducted. the results showed that only 17 patients had better visual acuity and 20 patients had better intraocular pressure. however, this study has limitation due to the using secondary data from medical records, as evidence that from 41 medical record, only 31 were used in this study. there were medical record missing, and incomplete necessary data. this study concluded that most of pss cases in national eye centre cicendo eye hospital bandung were female aged 31–40 years, affected on their left eye. all of them were presented with the symptoms of blurred vision, coloured halos, and headache. after treatment, the visual acuity and intraocular pressure were improved. table 2 visual acuity and intraocular pressure after treatment tests n % visual acuity increase 17 54.8 same with previous 9 29.0 decrease 5 16.2 intraocular pressure increase 20 64.6 same with previous 2 6.4 decrease 9 29.0 althea medical journal. 2015;2(1) 45 references 1. segre l. human eye anatomy: parts of the eye.2010. [downloaded in may 2012]. available at: http://www.allaboutvision. com/resources/anatomy.htm. 2. who. fact sheet no 282: visual impairment and blindness. 2011.[downloaded in may 2012]. available at:http://www.who.int/ mediacentre/factsheets/fs282/en/. 3. thylefors b, negrel ad, pararajasegaram r, dadzie ky. global data on blindness. bull world health organ. 1995;73(1):115–21. 4. narang sk, shah sj. glaucomatocyclitic crisis (posner--schlossman syndrome) case report.indian j ophthalmol.1972;20(1):25–7. 5. shazly ta, aljajeh m, latina ma. posner– schlossman glaucomatocyclitic crisis. seminophthalmol. 2011;26(4–5):282–4. 6. oakmanjh. posner-schlossman syndrome. webmd llc. 2012 [downloaded in may 2012]; available at: http://emedicine. m e d s c a p e . c o m / a r t i c l e / 1 2 0 5 9 4 9 – overview. 7. scott ks, wade nk. posnerschlossmansyndrome. the american uveitis society.2003; [downloaded on may 2012] available at: http://www. uveitissociety.org/pages/diseases/pss. html. 8. harrington jr. posner–schlossman syndrome: a case report. j am optom assoc. 1999;70(11):715–23. 9. burnstein y, shelton k, higginbotham ej. glaucomatocyclitic crisis in a child.am j ophthalmol.1998;126(1):136–7. 10. cheesp, bacsal k, jap a, se-thoesy, cheng cl, tan bh. clinical features of cytomegalovirus anterior uveitis in immunocompetent patients. am j ophthalmol. 2008;145(5):834–40. 11. shen sc, ho wj, wu sc, yu kh, lin hc, lin ys, et al. peripheral vascular endothelial dysfunction in glaucomatocyclitic crisis: a preliminary study.invest ophthalmol vis sci. 2010;51(1):272–6. 12. jap a, sivakumar m, chee sp. is posner schlossman syndrome benign? ophthalmology. 2001;108(5):913–8. 13. dinakaran s, kayarkar v. trabeculectomy in the management of posner-schlossman syndrome. ophthalmic surg lasers. 2002;33(4):321–2. 14. omoti ae, enock me. glaucomatocyclitic crisis in edo state, nigeria: report of two cases. niger j clinpract.2008;11(2):162–5. kavitha arunasalam, erna tjahjaningtyas, ra.retno ekowati: description of posner schlossman syndrome patients in bandung, indonesia during the period of august 2009 to july 2011 althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 555 relationship between body mass index with menstrual cycle in senior high school students rinasyah ganesh,1 lola ilona,2 ryadi fadil3 1faculty of medicine universitas padjadjaran, 2department of epidemiology and biostatistics faculty of medicine, universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: in recent years, there is an escalation of menstrual disorders in both developing and developed countries. one of the important factors that contribute to menstrual disorders is body fat content. in developing countries like indonesia, young women in certain cultures get married at average age of 16 years. at the same time, the number of malnourishment among adolescent is increasing. this study was conducted to analyze the relationship between body mass index (bmi) and menstrual cycle in senior high school students. methods: this study included 330 girls ages 15−17. this study was conducted in jatinangor, sumedang from the period of august–october 2013 using a cross-sectional study. questionnaires assessing their menstruation and their weight and height were collected after obtaining the respondents consent.the collected data were analyzed using the independent t-test. results: most of the respondents had normal bmi, menstrual interval, amount and duration. there was no relationship between bmi and menstrual interval and menstrual amount (0.74 and 0.878 respectively), however there was relationship between bmi and menstrual period (p= 0.036). conclusions: menstrual abnormalities among female adolescents are common. based on this study, bmi seems to be moderately associated with menstrual cycle, especially with menstrual period, although a possibility still remains that body fat affects the menstruation superiorly. [amj.2015;2(4):555–60] keywords: body mass index, menstrual cycle, senior high school students correspondence: rinasyah ganesh, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85624609741 email: pottersgirl04@yahoo.com introduction menstruation is a woman’s monthly bleeding caused by the reduction of hormones, estrogen and progesterone at the end of the monthly ovarian cycle.1,2 when menstruation occurs repeatedly, it is called the menstrual cycle.3 the menstrual cycle is important as female reproductive function which prepares the female body for conception and pregnancy.2,3 in recent years, there is an escalation of menstrual disorders in both developing and developed countries. however the exact prevalence or incidence of menstrual dysfunction is still very scarce.1 example of menstrual disorders are amenorrhea, which is lack of menstrual period, dysmenorrheal (painful periods), irregular cycles, heavy and excessive bleeding called menorrhagia.1,3-5 one of the important factors that contribute to menstrual disorders is body weight, more specifically body fat content. there are other factors as well, which are divided into external and internal factors. external factors such as caffeine and alcohol consumption, smoking,, stress, occupation, socioeconomic status, and ethnicity.1,3,5 while the internal factors are disorders of hormonal imbalance such as thyroid problems and polycystic ovarian syndrome, and body fat content is included in these factors too.6 in developing countries, like indonesia, young women in certain cultures get married at an average age of 16 years. as mentioned before, since the menstrual cycle is important for conception and pregnancy, it is crucial to assess the menstrual cycle in young women. parallel to this problem, the number of althea medical journal. 2015;2(4) 556 amj december, 2015 malnourished adolescents is increasing as the world population increases. both in developed and developing countries like indonesia, socioeconomic status and access to food as well as the influence of media determines malnourishment of a person. therefore, this study was conducted to analyze the relationship between body mass index (bmi) and the menstrual cycle in senior high school students in jatinangor, sumedang, indonesia from the period of august−october 2013. methods a cross-sectional study was conducted to 330 senior high school girl students aged 15−17 from a selected school out of the four schools in jatinangor sub-district sumedang, indonesia with the highest number of female students. the students were selected from different classes of the respective school by performing cluster randomization during the period of august−october 2013. after the subjects were excluded based on the exclusion criteria, the remaining three hundred and thirty students were included in the research after meeting the inclusion criteria. the inclusion criteria were aged 15−17 years and already reached menarche. while the exclusion criteria included if they were having hormonal disorders, taking hormonal medications, smoking, and were regular alcohol consumers, also those who had filled the questionnaires incompletely and did not give informed consent. after the subjects signed the informed consent, questionnaires were distributed to the students to assess their menstrual cycle and explanations were given to assist them in completing the forms. afterward, the height and weight was measured using a mobile weighing scale and a stadiometer respectively. to categorize the bmi into underweight, normal, overweight and obese, the bmi was plotted on the centers for disease control and prevention (cdc) chart for “bmi for age” percentiles. the menstrual interval/pattern was considered regular, if it is within the range of 21−35 days, and irregular if less than 21 days or more than 35 days. while the menstrual amount was categorized into scanty, normal flow or heavy which was 1−2, 3−5, >5 sanitary towels used respectively per day as revealed by respondents. then, menstrual duration was classified into short (1−2 days), normal (3−7 days), and prolonged (>8 days) based on the days bleeding occurs. furthermore, the collected data were statistically analyzed using independent t-test. analysis is performed using the menstrual interval, menstrual amount, and menstrual period among underweight, normal, overweight and obese students. this study was approved by the health research ethical committee of dr. hasan sadikin general hospital. this study was part of a bigger research called jatinangor cohort. results the characteristic of the research subjects shows that all the variables were not normally distributed except for height (table 1). the bmi of the respondents were classified into underweight, normal, overweight, and obese. it showed that the number of respondents with normal weight was more than the underweight and overweight/obese respondents. it also showed subjects with regular menstrual interval were more than the subjects with irregular menstrual interval. besides, there were a significant number of subjects with scanty menstruation compared to subjects with heavy menstruation. it was table 1characteristic of senior high school students in jatinangor variables mean p-value age 15.8 < 0.01 height(cm) 152.6 0.200* weight 47.3 < 0.01 body mass index (bmi) 20.3 < 0.01 menarche age 12.6 < 0.01 days bleeding occurs 6.7 < 0.01 number of sanitary towels used per day 2.8 < 0.01 note: *indicates normal distribution using kolmogorov-smirnov normality test althea medical journal. 2015;2(4) 557 also noted that among the three hundred and thirty subjects, none was reported of having a short menstrual duration. most of them reported of having a normal menstrual period and the rest reported of having prolonged menstruation (table 2). the majority of subjects reported of having a regular menstrual interval compared to irregular interval. on top of that, the percentage of obese students having either short or prolonged menstrual interval was higher compared to other bmi category subjects (figure 1). the analysis performed between bmi and menstrual interval revealed that there was no significance with p value=0.074. it also found that the mean bmi for subjects with short irregular menstrual interval was 20.4158 while the mean of bmi for subjects with regular and prolonged irregular was 20.2610. table 2 frequency of bmi, menstrual interval, menstrual amount & menstrual period status criteria (n=330) f % body mass index (bmi) underweight 39 11.8 normal 257 77.9 overweight 29 8.8 obese 5 1.5 menstrual interval short irregular 52 15.8 regular (normal) 247 74.9 prolonged irregular 31 9.4 menstrual amount scanty 130 39.4 normal flow 197 59.7 heavy 3 0.9 menstrual period short 0 0.0 normal 286 86.7 prolonged 44 13.3 rinasyah ganesh, lola ilona, ryadi fadil: relationship between body mass index with menstrual cycle in senior high school students figure 1 distribution of different menstrual intervals among different categories of bmi althea medical journal. 2015;2(4) 558 amj december, 2015 furthermore, higher percentage of obese subjects complained of abnormal menstrual amount, followed concurrently by underweight and overweight subjects and finally by normal weight subjects. besides, it discovered that very few subjects reported of having a heavy menstruation, in this case 3,4 % with none of overweight/ obese subjects reported so (figure 2). the analysis revealed that p value=0.878 which indicated there was no significance between bmi and menstrual amount. it also revealed that the mean of bmi for subjects with scanty menstrual amount was 20.2524 and 20.3069 for subjects with normal and heavy menstruation. none of the of the respondents revealed of having a short menstrual period, with majority falling into having a normal menstrual period, figure 2 distribution between different menstrual amounts with different categories of bmi figure 3 distribution of different length of menstrual period with different categories of bmi althea medical journal. 2015;2(4) 559 followed by a few subjects into prolonged menstrual period. subjects with prolonged period, were mainly reported by underweight subjects (figure 3). the relationship between bmi and menstrual period exposed that p value=0.036 indicating the moderate significance. the subjects with a normal menstrual period had a mean bmi of 20.3948 and for subjects with prolonged menstrual period was 19.5743. this evidently showed the difference of bmi mean between the normal and prolonged menstruation, which clearly signifies the relationship. discussion the bmi is a statistical measure which compares an individual’s height and weight. it was used as diagnostic tool in this study to identify the nutritional status within a population due to its ease of calculation. however, bmi does not take into account many factors like frame size, muscularity, body fat, bone, cartilage, and water weight.7 additionally, body fat content is one of the factors that affect menstruation by altering the hormones associated with menstruation. this could explain why the relationship between bmi and menstrual cycle was not so dominant since bmi did not accurately measure body fat. evidently, not all of the previous studies supported the association of bmi and menstrual disorderssince there were other factors that influenced the menstrual cycle. in a study conducted in singapore in 2009 to detect menstrual disorders in adolescent girls, it found that with the increase of bmi, there is significant increase in the prevalence of oligomenorrhea, whereas polymenorrhea is more prevalent in girls with low bmi.8 similar to this study, a study conducted in india among older girls studying in a medical teaching institution found correlation between irregular cycles and high bmi.9 contrary to above mentioned studies, a study conducted in japan among female workers in 2011, determined that stress is the major factor related to menstrual cycle irregularities and menstrual pain. in that study, factors such as smell of cigarettes, stress, age, bmi, smoking habits and sleeping hours were investigated if they were associated with menstrual disorders. furthermore, the factors that showed significance are stress, smell of cigarettes, age and smoking habits. stress activates the release of corticotrophin in the nervous system causing menstrual cycle irregularities and interferes with a mixture of endocrine profiles particularly gonadotropin and estrogen secretion.10 the bmi in this study showed no significance.10 supporting this, another study conducted in malaysia in 2006 among teenagers, showed that bmi is not one the factors associated with menstrual disorders such as abnormal period of menstrual flow, heavy menstrual flow, irregular menstrual cycle and dysmenorrheal however bmi is associated with premenstrual syndrome, that are more commonly among overweight or obese subjects. factors that are associated with menstrual disorders are smoking, followed by suicidal behavior, depression, anxiety which may be attributed to increased stress, then menarche within 2 years, age and ethnicity. it also finds that dieting behavior (eating less to lose weight) and those who are physically inactive affect the menstrual cycle as well.11 thus, based on the above mentioned sources, factors such as stress, emotions, smoking, ethnicity, age, eating habits or disorders, and physical activity could be the related factors affecting the respondents with menstrual disorders in this study, besides the possibility of having pathological conditions such as polycystic ovarian syndrome. one of the limitations of this study was that there were not enough underweight, overweight or obese subjects to assess the menstruation pattern among adolescents and therefore it was unable to accurately detect the various menstrual disorders. this was due to the lack of underweight or overweight population present in jatinangor compared to bandung city. the second limitation was that the results were based on the adolescents’ own reports of their behaviors, such as smoking and alcohol consumption. there was a possibility that some respondents might have not reported smoking and alcohol consumption to avoid judgment or a bad impression. it was also found that a few students, especially those in classes with poor academic levels, might not have been able to understand the questions. even though, they were assisted by the interviewers, still some invalid answers were received. however, these answers were not omitted from the analysis as it was difficult to determine which were invalid. finally, it can be concluded that menstrual abnormalities among female adolescents are common.11 based on this study, bmi seems to be moderately associated with menstrual cycle, especially with menstrual period, although a possibility still remains rinasyah ganesh, lola ilona, ryadi fadil: relationship between body mass index with menstrual cycle in senior high school students althea medical journal. 2015;2(4) 560 amj december, 2015 that body fat does affect the menstruation superiorly. a research should be conducted in the future about the influence of body fat on menstruation using an accurate measurement of body fat. besides, there are many factors that need to be discovered for prompt diagnosis and treatment to prevent infertility and complication later in life, especially where there are women in certain cultures who get married at an early age. moreover, health education on menstrual problems should be given to female adolescents when they approach the reproduction age and also to their parents; especially the mothers who are the main source of knowledge for their daughters, as well as regular screening for menstrual abnormalities should be performed. references 1. goldman mb, hatch mc, editors. menstruation and menstrual disorders. women & health. california,usa: acad. press. 2004. p. 99−113. 2. hall je. female physiology before pregnancy and female hormones. in: guyton and hall textbook of medical physiology. 12th ed. pennsylvania, usa: saunders elsevier. 2011. p. 987−1002. 3. lawrence m. nelson md. menstruation and menstrual cycle fact sheet. womenshealth. gov. 2009 [cited 2013 january 12]; available from: http://www.womenshealth.gov/ p u b l i c a t i o n s / o u r p u b l i c a t i o n s / f a c t sheet/menstruation.html. 4. harlow sd, campbell omr. epidemiology of menstrual disorders in developing countries : a systematic review. bjog. 2004;111(1):6−16. 5. liu y, gold eb, lasley bl, johnson wo. factors affecting menstrual cycle characteristics. am j epidemiol. 2004; 160(2):131−40. 6. panay n, dutta r, ryan a, broadbent jam. abnormal bleeding. obstetrics and gynaecology. pennsylvania, usa: elsevier. 2004. p. 1−10. 7. chauhan m, kala j. relation between dysmenorrhea and body mass index in adolescents with rural versus urban variation. j obstet gynaecol india. 2012; 62(4):442−5. 8. agarwal a, venkat a. questionnaire study on menstrual disorders in adolescent girls in singapore. j pediatr adolesc gynecol. 2009;22(6):365−71. 9. deshpande h, burute sb, dahiya p. relationship of body mass index and body fat percentage with menstrual cycle pattern in adolescents. int j pharm. 2013;4(4):114−7. 10. nohara m, momoeda m, kubota t, nakabayashi m. menstrual cycle and menstrual pain problems and related risk factors among japanese female workers. ind health. 2011;49(2):228−34. 11. lee l, chen p, lee k, kaur j. menstruation among adolescent girls in malaysia: a cross-sectional school survey. singapore med j. 2006;47(10):869−74. vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 187 clinical manifestations of systemic lupus erythematous in children at dr. hasan sadikin general hospital, bandung, indonesia reni ghrahani,1 priya darshani ganesan,2 reni farenia soedjana ningrat3 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia 3department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: reni ghrahani, department of child health, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km 21, indonesia, email: renighrahani@yahoo.com introduction systemic lupus erythematous (sle) is a systemic autoimmune disease that affects multiple organs such as kidneys and the central nervous system. pediatric sle occurs at a rate of 1-6/100,000 and occurs in children.1,2 types of manifestations most commonly found in pediatric sle differ slightly from adult sle. systemic lupus erythematous is very difficult to diagnose as it presents as a mimicry of multiple diseases.3,4 systemic lupus erythematous is a disease that is extremely chronic in nature, which can severely lower the patients’ quality of life. due to a delayed diagnosis, patients may be admitted with severe organ damage and complications, which results in a worse prognosis. systemic lupus erythematous in children is more severe than in adults as the progressivity of the disease in children is much faster than in adults.1,4 therefore, due to the difficulty in diagnosis and its chronicity, it is essential to elaborate clinical manifestations of childhood lupus to gain better detection and diagnosis. the objective of this study was to describe the various clinical manifestations of sle. the clinical manifestations may differ between ethnicities and countries and there is a need to explore the variations that apply to indonesia, specifically to those in bandung.5,6 the difference of clinical manifestation based on ethnicity and countries were not established. this would allow for better diagnosis and a better prognosis. methods a retrospective, descriptive study was conducted in 2015 and it involved the description of clinical manifestations in patients with sle in the department of child health at dr. hasan sadikin general hospital from the period of 2010 to 2014. this study amj. 2018;5(4):187–91 abstract background: systemic lupus erythematous (sle) is an autoimmune disease, characterized by production of autoantibodies, leading to damage caused by inflammation, directed toward multiple organs in the body. it is difficult to diagnose due to its mimicry with other diseases. the differential diagnosis of sle is broad, including infection, malignancy and other inflammatory disorders. it is important to recognize the clinical manifestation of sle from other possible diseases. methods: a descriptive study was conducted on 56 sle patientsfrom the department of child health in dr. hasan sadikin general hospital, bandung, indonesia, in which the medical records was collected from 2010 to 2014. a total sampling method was used and incomplete records were excluded. results: out of the 56 subjects, 82.1% were female, with female to male ratio was 4.6:1. most of the subjects (52%) was in the age category of 11 to 15 years old. hematologic involvement was the most common clinical manifestation based on the diagnostic criteria (83.9%), and fever was the most common chief complaint (41.1%). conclusions: from this study, fever, rash, and joint pain are the common chief complaints among sle patients in children with hematologic and renal disorders are also found to occur. keywords: children, clinical manifestations, systemic lupus erythematous althea medical journal. 2018;5(4) 188 amj december 2018 involved a total sampling method in the selection of subjects and all medical records of patients who fit the criteria in the given period were used. this study was approved by the health research ethics committee dr. hasan sadikin general hospital. medical records were used as a tool to obtain information required on each subject. medical records of 56 children in the department of child health at dr. hasan sadikin general hospital who had the disease from january 2010 to december 2014 were obtained and analyzed. the subjects were selected according to diagnosis by the clinician on the basis of the criteria by the american college of rheumatology 1997.7 any records that were incomplete were excluded. the age, gender, chief complaint, other symptoms, lab findings, radiologic findings, echocardiogram findings, and other findings were recorded for each patient. the frequency of each individual finding was determined by percentage and tabulated. results the results in the tables were obtained from medical records of 56 patients with sle who were admitted to the department of child health from 2010 to 2014. the frequencies were calculated based on epidemiological features and the individual manifestations were categorized according to the diagnostic criteria.7 the frequencies of gender and age ranges are tabulated in table 1. out of the 56 subjects, more females had sle and the female to male ratio was 4.6:1. patients in the age group of 11 to 15 who had sle were seen to be the greatest (51.8%), followed by patients between the ages of 6 to 10 (35.7%). the frequencies of the clinical manifestations based on the diagnostic criteria of the american college of rheumatology as been calculated and tabulated in table 2. as seen in table 2, hematologic involvement (83.9%) and malar rash (66.1%) were found to be the most common clinical manifestation. a high frequency of patients had associated symptoms of dermatologic changes, with 66.1% of them presented malar rash and 30.4% of them presented discoid rash (table 2). the manifestations have subsequently been described in more detail and categorized according to the clinical examinations in tables 3 and 4. a large number of patients had a chief complaint of fever (41.1%), followed by a rash (28.6%) and joint pain (25.0%) table 1 clinical characteristic of sle in children at dr. hasan sadikin general hospital from the period of 2010 to 2014 n(%) (n= 56) age (years) 1–5 7 (12.5) 6–10 20 (35.7) 11–15 29 (51.8) gender male 10 (17.9) female 46 (82.1) table 2 clinical manifestations in children with sle according to the diagnostic criteria manifestation n(%)(n= 56) malar rash 37(66.1) discoid rash 17(30.4) photosensitivity 8(14.3) oral ulcers 18(32.1) non-erosive arthritis 31(55.4) pleuritis or pericarditis 11(19.6) renal disorder 36(64.3) neurologic disorder 2(3.6) hematologic disorder 47(83.9) immunologic disorder 24(42.9) table 3 chief complaints in children with sle chief complaints n(%)(n= 56) fever 23(41.1) rash 16(28.6) joint pain 14(25.0) pale 6(10.7) palpebral edema 3(5.4) dyspnea 1(1.8) althea medical journal. 2018;5(4) 189 (table 3). laboratory examinations are shown in table 4. anemia (71.4%) was the most common anomaly from the complete blood count examination, followed by leukopenia (35.7%) and thrombocytopenia (23.2%) (table 4). from the antibody tests conducted on the patients, various patterns were found from the anti-nuclear antibody tests (table 4). the most common antinuclear antibody pattern was found to be the speckled pattern (41.1%) and followed by the homogenous pattern (17.9%). the radiologic examinations and results from echocardiography, if any, were also recorded in table 4. according to the abnormalities in the lungs and the heart, the most common abnormality in the lungs and the heart was found to be pleural effusion (10.7%) and pericardial effusion (10.7%) and cardiomegaly (10.7%) (table 4). reni ghrahani, priya darshani ganesan, reni farenia soedjana ningrat: clinical manifestations of systemic lupus erythematous in children at dr. hasan sadikin general hospital, bandung, indonesia table 4 laboratory and radiologic findings in children with sle manifestation n(%)(n= 56) laboratory examinations blood test complete blood count anemia 40 (71.4) leukopenia 20 (35.7) thrombocytopenia 13 (23.2) antibody tests reactive antinuclear antibody test 46 (82.1) pattern of antinuclear antibody by immunofluorescence: speckled pattern 23 (41.1) homogenous pattern 10 (17.9) positive titer of anti-dsdna 44 (78.6) urine tests proteinuria 28 (50.0) +1( ≥30mg/dl) 8 (14.3) +2(≥100mg/dl) 9 (16.1) +3(≥300mg/dl) 11 (19.6) hematuria (≥ 5 erythrocytes/ hpf ) 28 (50.0) presence of casts (granular casts) 6 (10.7) radiologic exams abnormalities in lungs pleural effusion 6 (10.7) pneumonia 2 (3.6) pneumothorax 1 (1.8) abnormalities in heart pericardial effusion 6 (10.7) cardiomegaly 6 (10.7) mitral regurgitation 1 (1.8) cardiomyopathy 1 (1.8) althea medical journal. 2018;5(4) 190 amj december 2018 discussion certain patterns can be derived from the results of the 56 patients. based on the results in table 1, there was a higher frequency of sle in children from the ages of 11 to 15 compared to the other age groups. systemic lupus erythematous (sle) was found to be rare in toddlers compared to children and adolescents. the age group of the children and adolescents also correlates with a study done by silverman8, in which the global mean age of sle in children was 12 to 13 years of age.2 there was also a higher frequency of sle in female children compared to male children as seen in table 1. this finding is consistent with previous studies that have proven that there is a predominance in sle in females compared to males and that the global male/female ratio has been reported to be of 1:2 to 1:5.2 these prove that the frequencies and patterns of epidemiological features displayed in the children in bandung, indonesia, are actually similar to previous studies conducted in the rest of the world. in this study, fever was the most common chief complaint. fever in sle tends to not have a specific pattern. the differential diagnosis of fever are chronic infections, autoimmune diseases, and malignancy.8 therefore, it is essential to investigate the cause of fever to ensure that it is due to sle. the rash on the face was the second most common chief complaint, as seen in table 3. in another study conducted by silverman8, 60–80% of patients had skin involvement. dermatologic involvement or changes that mostly found in sle are malar rashes and discoid rash.9 in addition, sle might also present other dermatologic changes, such as vasculitic skin lesions and bullous lesions.9 joint pain was also a common chief complaint among the patients (table 3). in the study done by silverman8, 60–88% of patients had arthritis. arthritis in sle is described as nonerosive and involving two or more peripheral joints.7 it is important to differentiate arthritis from arthralgia whilst examining the patient. this is key as non-erosive arthritis is stated as a criteria of diagnosis 7of sle, not arthralgia. in this study, patients had a chief complaint of paleness as seen in table 3. paleness is commonly due to a low hemoglobin level and subsequent anemia. normochromic, normocytic anemia is the type of anemia that is usually detected.8 however, hemolytic anemia has also been found in patients with sle. this can be detected by a blood smear and thereafter a positive direct coombs test.8 there was a significantly high frequency of dermatologic, renal and hematologic involvement, as seen in table 2. however, based on previous studies, renal involvement has been the most common clinical manifestation that was found in patients with sle.2,8,10 in this study, hematologic involvement was the most common. it could be argued that renal involvement in the patients in this study was also significantly high (64.3%). the difference in data may be attributed to the difference in the number of patients available in both studies, which may have resulted in the study done previously to have had a wider and more diverse array of manifestations compared to the one being done in this study. another reason for this difference may also have been that the patients in this study had been treated at an early stage before their disease could have progressed to a more severe one, which may have involved the renal system. in this study, the antinuclear antibody (ana) test used is an immunofluorescence test, which is directed towards human epithelial type 2 (hep-2) cells. the antinuclear antibodies (anas) target nuclear antigens such as histones, dna, non-histone proteins bound to rna and nucleolar antigens. the ana test displays several patterns of antibodies such as homogenous, speckled and rim/peripheral. in sle, the main patterns of staining is a homogenous pattern that reflects antibodies to chromatin and histones and a speckled pattern that reflects antibodies to ro/ss-a and la/ss-b.9 these patterns are reflected in table 4. in this study, the most commonly displayed pattern was speckled (41.1%) followed by homogenous (17.9%). this correlates with a study by ghrahani et al.11, which showed speckled pattern as the most common pattern with a frequency of 40.3%. the study by ghrahani et al.11 was also conducted in the department of child health at dr. hasan sadikin general hospital but it was during a different time period. the reactive ana test is sensitive to sle as it indicates the disease. however, it does not rule out other autoimmune diseases. the result of the presence of antibodies to double-stranded dna, as seen in table 4, is extremely specific to sle and confirms the diagnosis. the wide array of chief complaints and associated symptoms may be due to the disease involvement of multiple systems. this may also be seen in the involvement of the heart and lungs (table 4) where many subsequent disorders of the heart such as mitral althea medical journal. 2018;5(4) 191 regurgitation and dilated cardiomyopathy and disorders of the lung such as pneumothorax and pneumonia may occur. a drawback of this study is the inability to obtain an incidence rate or a prevalence rate. dr. hasan sadikin general hospital is a tertiary referral hospital, which means many patients may have been treated in previous healthcare services. therefore, the total population and the number of patients are not truly representative of the population of patients in bandung. this would subsequently lead to an inaccurate calculation of an incidence or a prevalence rate. to overcome the aforementioned drawback, a study could be conducted across multiple hospitals and healthcare services in bandung. this would allow for a more widespread representation of the patients with sle in bandung. based on this study, it can be summarized that females have a greater tendency to have sle and children between the ages 11 to 15 are the most likely to get sle. fever is the most common chief complaint among patients. hematologic involvement and renal involvement were also found to occur most commonly among the patients. systemic lupus erythematous is a disease with diverse and multiple presentations as seen in the data presented in this study. it is often hard to diagnose due to its mimicry with a vast number of diseases. therefore, there is a need to determine the true cause of this disease before a diagnosis can be obtained. the patterns and data obtained in this study would allow clinicians in the geographical location to be able to identify the warning signs or common presentations of a child with sle. references 1. jakes rw, bae sc, louthrenoo w, mok cc, navarra sv, kwon n. systematic review of the epidemiology of systemic lupus erythematosus in the asia-pacific region: prevalence, incidence, clinical features, and mortality. arthritis care res. 2012;64(2):159–68. 2. sadun re, ardoin sp, schanberg le. systemic lupus erythematous. in: kliegman rm, behrman re, jenson hb, stanton bf, editors. nelson textbook of pediatrics. 20th ed. philadelphia: saunders elsevier; 2016. p. 1622–7. 3. tsokos gc. systemic lupus erythematosus. n engl j med. 2011;365(22):2110–21 4. janwityanujit s, totemchokchyakarn k, verasertnlyom o, vanlchapuntu m, vatanasuk m. age-related differences on clinical and immunological manifestations of sle. asian pac j allergy immunol. 1995;13(2):145–9. 5. sánchez e, rasmussen a, riba l, acevedo-vasquez e, kelly ja, langefeld cd, et al. impact of genetic ancestry and sociodemographic status on the clinical expression of systemic lupus erythematosus in american indian– european populations. arthritis rheum. 2012;64(11):3687–94. 6. levy dm, peschken ca, tucker lb, chédeville g, huber am, pope je, et al. influence of ethnicity on childhood-onset systemic lupus erythematosus: results from a multiethnic multicenter canadian cohort. arthritis care res (hoboken). 2013;65(1):152–60. 7. hochberg mc. updating the american college of rheumatology revised criteria for the classification of systemic lupus erythematosus. arthritis rheum. 1997;40(9):1725. 8. silverman e, eddy a. systemic lupus erythematous. in: cassidy jt, petty re, laxer rm, lindsley cb, editors. textbook of pediatric rheumatology. 6th ed. philadelphia: saunders elsevier; 2011. p. 315-43. 9. craft j, peng s. in: firestein gs, budd rc, gabriel se, mcinnes ib, o’dell jr, editors. kelley’s textbook of rheumatology. 19th ed. philadelpia: elsevier saunders; 2013. 10. raj vms. an unusual presentation of lupus in a pediatric patient. case rep pediatr. 2013;2013:180208 11. ghrahani r , setiabudiawan b, sapartini . characteristic of antinuclear antibodies in childhood systemic lupus erythematosus and its association with the complication. journal of the indonesian medical association. 2012;62(7 july 2012). reni ghrahani, priya darshani ganesan, reni farenia soedjana ningrat: clinical manifestations of systemic lupus erythematous in children at dr. hasan sadikin general hospital, bandung, indonesia althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 111 factors related to malnutrition in children under five years with congenital heart disease amani sakinah augiani,1 sri endah rahayuningsih,2 dewi marhaeni diah herawati3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of public health faculty of medicine universitas padjadjaran abstract background: congenital heart disease (chd) is the most frequent type of heart disease that occurs in children. children with chd are more vulnerable to suffer impaired nutritional status related to morbidity and mortality. the nutritional status, however, may not be influenced only by chd, but also by other factors.. the study was conducted to identify factors related to malnutrition in children with chd methods: this cross-sectional study involved 86 children with chd recruited from dr. hasan sadikin general hospital bandung from october to november 2015. data collected in this study were obtained by conducting anthropometric measurements, interviewed the parents (obstetric history, patient’s medical history and socioeonomic status) and from medical records (the type and time of chd diagnosis, other diseases that accompanied the chd). the collected data were presented by frequency distribution. results: there were 46.5% patients who had nutritional disturbance. malnutrition in males and patients with tetralogy of fallot were higher than other groups. almost half patients with maternal history of passive smoking during pregnancy had nutritional disturbance. the most common disease found was diarrhea followed by lower respiratory infection. percentage of normal children in low-income parents group was lower than the high-income group. conclusions: nearly half of patients have nutritional disturbance. percentage of nutritional disturbance in male was higher compared to female. active and passive smokers, tetralogi fallot, diarrhea, lower respiratory infection and lower income were factors contributed to malnutrition. [amj.2017;4(1):111–7] keywords: children, congenital heart disease, nutritional status correspondence: amani sakinah augiani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281210006284 email: augianiamani@gmail.com introduction congenital heart disease (chd) is a cardiovascular structural abnormality1 and is the most common heart disease in children, which affects between 3.7 and 17.5 per 1000 live births.2,3 congenital heart disease also falls under the most frequently inherited disorders, encompassing one-third of all congenital abnormalities.3 it is a serious condition as it has significant effects on the rate of morbidity, mortality, and healthcare cost.4 infants with chd generally show symptoms shortly after birth, however, the remaining 25%, are diagnosed in childhood.4 children with chd are more vulnerable to have poor nutritional status and experience decrease of growth trajectory.5,6 some of the other factors that may influence a child’s nutritional status beside chd are age, gender, obstetrical history, illness.7,8 hence, this study was conducted to identify factors related to malnutrition in children under five with chd. methods a descriptive quantitative study was carried out to 86 children with chd and their parents who were seeking care in outpatient clinic of pediatric cardiology, dr. hasan sadikin general hospital bandung from october to november 2015. the inclusion criteria of this study were patients with chd ≤60 months old. the exclusion criteria for this study were patients with chd who had undergone surgical correction or parents who declined participating in this study. ethical clearance of this study was obtained from health research althea medical journal. 2017;4(1) 112 amj march 2017 ethical committee dr. hasan sadikin general hospital bandung (no. lb.04.01/a05/ ec/382/ix/2015). data collection was begun by requesting the patient’s parents to sign informed consent form. the parents were enquired about the patient’s personal data (patient’s name, medical record number, gender, and date of birth), obstetrical history (pregnancy and birth history, and risk factor during pregnancy), history of other diseases, and parental characteristic (educational level, income, and history of chd or other heart disease). diagnosis (type of chd and age of patient when diagnosed) and history of other diseases were obtained from the patient’s medical record with the approval of the parents. the patient’s age when he or she was examined and first diagnosed were classified into birth (only for time of first diagnosed), neonate (≤1 months), infant (1−24 months), and young child (24−60 months).9 obstetrical history was obtained by interviewing the parents. the gestational age were classified into three groups consisted of pre-term (<37 weeks), at term (37−41 6/7 weeks) and post-term (≥42 weeks).10 risk in pregnancy was divided into three groups consisted of active smoking, passive smoking, and alcohol consumption. the patient’s birth weight were divided into low birth weight (<2500 gram) and normal birth weight (≥2500 gram).11 history of other diseases were obtained from the patient’s medical record and interviewed the parents about diarrhea, measles, lower respiratory tract infection, and/or other diseases experienced by the patients. in addition to the data classifications, the education level of the patient’s parents was divided into undergraduate, diploma, senior high school, junior high school and primary school the income of both parents was divided into two large groups bounded by idr 1.131.862 which was the lowest regional minimum fee for west java province in 2015. the parents were also enquired about familial history of heart problems or/and chd. for the anthropometric measurements, the patient’s body weight and length/height were measured. weight measurements were recorded in kilograms (kg) to the nearest 0.1 kg by digital pediatric scale (for ≤2 years old children) and adult scale (for children ≥2 years old). the scale has been calibrated with proper position of the patient. the measurement was done based on minimal clothing used by the patient. length/height measurements were recorded in centimeters (cm) to the nearest 0.1 cm. a device for the measurement of recumbent length was used to measure patients with body length <85 cm. this technique required two examiners to keep the patient in the correct position (face was upward with the crown of the head toward the fixed end of the board and vertical frankfurt plane, the body was parallel to the board, the shoulder were rested, the feet was upward and without shoes). whereas, for patients with body height >85 cm, a microtoise was used instead. this technique was recorded in standing position, head looking straight with horizontal frankfurt plane, shoulder relaxed, legs extended with heels almost together. shoulder, blades, buttocks and heels should table 1 gender and age when examined in patients with congenital heart disease based on nutritional status characteristics nutritional status total (n = 86)normal (n = 46) wasted (n = 20) severely wasted (n = 20) n % n % n % n % gender male 16 34.8 11 55 11 55 38 44.2 female 30 65.2 9 45 9 45 48 55.8 age when examined neonate 0 0 0 0 0 0 0 0 infant 13 22.8 13 22.8 31 54.4 57 66.3 young child 15 51.7 7 24.1 7 24.1 29 33.7 althea medical journal. 2017;4(1) 113amani sakinah augiani, sri endah rahayuningsih, dewi marhaeni diah herawati: factors related to malnutrition in children under five years with congenital heart disease touch the measurement board. the interpretation of these anthropometric data in the form of world health organization (who) z-score value was obtained. the result of this interpretation was divided into six groups consist of obese (above 3), overweight (above 2), risk of overweight (above 1), normal (above 1 to below -1), wasted (below -2), and severely wasted (below -3).12 the collected data were analyzed and presented by frequency distribution in the form of tables. results of 86 patients, more than half, were patients with normal nutritional status. only fifth were severely wasted and wasted, respectively. there were no patients in this study who were obese, overweight, and risk of overweight status. (table 1). the number of female patients was higher than males. (table 1). however, the percentage of patient with wasted and severely wasted status was higher in male patients compared to females. infant group had higher percentage compared to young child group. this group had higher malnutrition cases compared to young child group. during the period of the study, there was no meonates who visited the hospital for seeking care. the most common type of chd are ventricular septal defect (vsd), patent ductus arteriosus (pda), atrial septal defect (asd) and tetralogy of fallot (tof), respectively (table 2). the highest percentage of nutritional disturbance was in the group of patient with tof. the peak age when diagnosed was in infant period consisted of 75 out of 86 patients (75.6%). for the history of gestational age, term patients (73.9%) were found with higher proportion of normal nutritional status patients than postterm (0.02%) and preterm patients (23.9%) (table 3). there was no patient with maternal history of alcohol consumption during pregnancy. only 2 out of 86 were patients with maternal history of active smoking during pregnancy. both of them were having normal nutritional status. there were 49 out of 86 patients with maternal history of passive smoking. more than half patients in this group were classified table 2 diagnosis characteristics in patients with congenital heart disease based on nutritional status characteristics nutritional status total (n = 86)normal (n = 46) wasted (n = 20) severely wasted (n = 20) n % n % n % n % type of chd* congenital heart disease 38 44.2 ventricular septal defect 18 56.2 9 2.8 5 15.6 32 37.2 patent ductus arteriosus 12 63.2 3 15.8 4 21 19 22.1 atrial septal defect 7 53.3 2 16.7 3 25 12 14 tetralogy of fallot 2 28.6 2 28.6 3 42.9 7 8.1 pulmonary stenosis 3 100 0 0 0 0 3 3.5 aortic stenosis 1 100 0 0 0 0 1 1.2 transposition of great arteries 0 0 1 100 0 0 1 1.2 > 1 type of chd* 3 27.3 3 27.3 5 45.4 11 12.8 age when diagnosed at birth 6 13 3 15 0 0 9 10.5 neonate 4 8.7 3 15 2 10 9 10.5 infant 33 71.7 14 70 18 90 65 75.6 young child 3 6.5 0 0 0 0 3 3.5 *chd = congenital heart disease althea medical journal. 2017;4(1) 114 amj march 2017 as normal. patients with history of normal birth weight had higher percentage of normal status (69.6%) compared to patients with low birth weight history (30.4%). the most common other diseases were diarrhea (65.1%), with more than half of total patients wasted and severely wasted (table 4). patients with lower respiratory infection had the lowest percentage of patient with normal status. two third of all patients with measles mitral or tricuspid regurgitation had normal nutritional status. all of the patients in this study who had hernia, rubella syndrome, epilepsy, aplastic anemia, and other congenital abnormalities also had normal nutritional status. table 3 obstetrical history and risk factor in patients with congenital heart disease based on nutritional status characteristics nutritional status total (n = 86)normal (n = 46) wasted (n = 20) severely wasted (n = 20) n % n % n % n % gestational age postterm 1 2.2 1 5 1 5 3 3.5 term 34 73.9 13 65 12 60 59 68.6 preterm 11 23.9 6 30 7 35 24 27.9 risk factor during pregnancy passive smoking 26 53.1 11 22.4 12 24.4 49 57 active smoking 2 100 0 0 0 0 2 2.3 alcohol consumption 0 0 0 0 0 0 0 0 birth weight normal birth weight 32 69.6 15 75 12 60 59 68.6 low birth weight 14 30.4 5 25 8 40 27 31.4 table 4 other diseases accompanied patients with congenital heart disease based on nutritional status characteristics nutritional status total (n = 86)normal (n = 46) wasted (n = 20) severely wasted (n = 20) n % n % n % n % diarrhea 27 48.2 15 26.8 14 25 56 65.1 lower respiratory tract infection 17 47.2 5 13.9 14 38.9 36 41.8 measles 4 66.7 1 16.7 1 16.7 6 7 mitral/tricuspid regurgitation 2 66.7 0 0 1 33.3 3 3.5 hernia 2 100 0 0 0 0 2 2.3 rubella syndrome 2 100 0 0 0 0 2 2.3 epilepsy 1 100 0 0 0 0 1 1.2 aplastic anaemia 1 100 0 0 0 0 1 1.2 other congenital malformation 1 100 0 0 0 0 1 1.2 althea medical journal. 2017;4(1) 115 patients with parent’s educational level both graduated from senior high school (shs) were the most prevalent (27.9%) and also had the highest percentage of patients with normal nutritional status (36.9%) (table 5). patients with low-income parents (26.1%) also had lower percentage of normal patients compared to patients with higher income parents (73.9%). there were only 2 out of 86 patients in this study with parental history of chd and/or other heart disease. from 84 patients without parental history, 54.2% patients had normal nutritional status. discussion this study revealed that the percentage of patient with normal nutritional status was slightly higher than patients with wasted and severely wasted status. this finding was different from the previous studies which stated that children with chd were more vulnerable to experience nutritional disturbance.5,6 although the proportion of normal patient was higher, almost all of the patient in this group had low z-score (below 0 or below -1). in this study, the number of female patients were higher than the number of male patients. however, nutritional impairment was more prevalent in male patients. previous study proved that male patients were more susceptible to have nutritional disturbance.8 the previous study concluded that the most frequently encountered types of chd were asd, vsd, pda, ps, tof, coa, tga, and as.1 according to the data obtained in this study, the type of chd are vsd (32%), pda (19%), asd (12%), and tof (7%), ps (3.5%), as (1.2%), and tga (1.2%). this was consistent with previous study that claimed all of the above chd are indeed included in the eight most common types of chd.1 previous study has shown that infants with chd generally exhibit symptoms at birth, however, about 25% are only diagnosed in childhood.4 in this study, the child’s age when first diagnosed peaked in the age group table 5 parental characteristics of patients with congenital heart disease based on nutritional status characteristics nutritional status total (n = 86)normal (n = 46) wasted (n = 20) severely wasted (n = 20) n % n % n % n % education level of parents* u-u 1 2.2 0 0 1 5 2 2.3 u-shs 5 13 0 0 4 20 9 10.5 d-d 1 2.2 0 0 0 0 1 1.2 d-shs 3 6.5 2 10 4 20 9 10.5 shs-shs 17 36.9 4 20 3 15 24 27.9 shs-jhs 8 17.4 8 40 1 5 15 17.4 jhs-jhs 3 6.5 4 20 3 15 12 13.9 jhs-jhs 5 13 2 10 2 10 9 10.5 ps-ps 3 6.5 0 0 2 10 5 5.8 income of parents <idr 1.131.862,00 12 26.1 8 40 9 45 29 33.7 >idr1.131.862,00 34 73.9 12 60 11 55 57 66.3 history of chd in parents present 1 50 1 50 0 0 2 3.5 not present 45 54.2 19 22.9 20 24.1 84 96.5 note: *u= undergraduate, d= diploma, shs= senior high school, jhs= junior high school, ps= primary school amani sakinah augiani, sri endah rahayuningsih, dewi marhaeni diah herawati: factors related to malnutrition in children under five years with congenital heart disease althea medical journal. 2017;4(1) 116 amj march 2017 of infant (75.6%). there is no patient that diagnosed after the age of 36 months. it can be deduced that chd is generally detected early but it is estimated that there are several driving factors which may influence the delay in the detection of chd in developing countries such as indonesia. this may also produce difference in research results as compared to developed countries. previous study state that chd patients hold better prospects if diagnosed and treated earlier.13 based on this study, the distribution of each age group is dominated by a group of diagnosed at infant period (75.6%), with the proportion of normal status (71.7%). the difference between the result of this study and the previous one may be caused by most patients diagnosed in infant period. previous studies revealed about irrespective of chd that there are other factors that may influence the nutritional status. for instance, age, gender, prenatal conditions, gestational age, birth weight, diseases, parents education and income.7,8 in general, children with chd who had gestational age approaching 40 months were considered to have good outcomes.8 in this study, percentage of normal children with history of term gestational age (73.9%) were much higher than preterm (23.9%) and postterm (2.2%) group. children with a history of low birth weight were more inclined to have impaired nutritional status.14 patients with history of low birth weight had lower percentage of normal status (30.4%) compared to patients with normal birth weight history (69.6%). mothers who smoked and consumed alcohol during pregnancy increase the risks of malnutrition in their child.8 none of the patient’s mothers consumed alcohol in this study. however, there were two active smokers and 49 passive smokers. from 49 mothers who smoked passively, there was 53.1% of the patients who have normal nutritional status, 22.4% wasted, and 24.4% severely wasted. the difference between the result of this study may be caused by unknown factors that affect the patient during antenatal period. nutritional disorders in children may occur both primarily and secondarily. primary nutritional disorder is one of the most basic types of disorders, and is mainly caused by nutrients insufficiency.5 secondary nutritional disorder is the nutritional disorder caused by certain diseases, such as chd, diarrhea, malaria, measles, and lower respiratory tract infection.15 in this study, the most prevalent other diseases were diarrhea, followed by lower respiratory infection. children with parents who have lower education and socioeconomic level have higher tendencies to suffer malnourishment.8 there were some variations of the patients’ nutritional status based on the educational level of the parents. in this study, patients with parents who earn less hold the lower percentage of the patient with normal status compared to patient with parents who were earning more. the results showed consistencies with the previous study. the etiology of chd was still remain unknown.2 previous study stated that chd was a result of genetic and environmental factors.2 there was only two patients in this study with parent’s history of chd or other heart problems. one patient was with normal status and one patient was with wasted status. most of the results in this study were consistent to the previous studies about chd and nutritional status, even though there were some differences in the result obtained. unfortunately, there were certain limitations in this study. there was a recall bias of some data obtained from the patient’s parents. it can be concluded that nearly half of patients with chd have malnutrition status (wasted and severe wasted, respectively). percentage of wasted and severe wasted in male patients was higher than female patients. most of the patients were diagnosed during infant. active and passive smokers, tetralogi fallot, diarrhea, lower respiratory infection and lower income were factors that suspected to contribute to malnutrition in chd patients. references 1. zheng jy, tian ht, zhu zm, li b, han l, jiang sl, et al. prevalence of symptomatic congenital heart disease in tibetan school children. am j cardiol. 2013;112(9):1468−70. 2. marelli aj, mackie as, ionescu-ittu r, rahme e, pilote l. congenital heart disease in the general population changing prevalence and age distribution. circulation. 2007;115(2):163−72. 3. van der linde d, konings ee, slager ma, witsenburg m, helbing wa, takkenberg jj, et al. birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. j am coll cardiol. 2011;58(21):2241−7. 4. aha. heart disease and stroke statistics−2015 update: a report from the althea medical journal. 2017;4(1) 117 american heart association. circulation. 2015;131(4):29−322. 5. sjarif dr, anggriawan sl, putra st, djer mm. anthropometric profiles of children with congenital heart disease. med j indonesia. 2011;20(1):40−5. 6. daymont c, neal a, prosnitz a, cohen ms. growth in children with congenital heart disease. j pediatr. 2013;131(1):236−42. 7. cnota jf, gupta r, michelfelder ec, ittenbach rf. congenital heart disease infant death rates decrease as gestational age advances from 34 to 40 weeks. j pediatr. 2011;159(5):761−5. 8. de lange jc. factors contributing to malnutrition in children 0-60 months admitted to hospitals in the northern cape [dissertation]. bloemfontein: university of the free state bloemfontein; 2012. 9. knoppert d, reed m, benavides s, totton j, hoff d, moffett b, et al. paediatric age categories to be used in differentiating between listing on a model essential medicines list for children. [online journal] 2007 [cited 2016 january 13] available from http://archives.who.int. 10. fleischman ar, oinuma m, clark sl. rethinking the definition of term pregnancy. obstet gynecol. 2010;116(1):136−9. 11. onis m, dewey kg, borghi e, onyango aw, blössner m, daelmans b, et al. the world health organization’s global target for reducing childhood stunting by 2025: rationale and proposed actions. matern child nutr. 2013;9(suppl2):6−26. 12. onis m. who child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. geneva: world health organization; 2006. 13. dawson al, cassell ch, riehle-colarusso t, grosse sd, tanner jp, kirby rs, et al. factors associated with late detection of critical congenital heart disease in newborns. pediatrics. 2013;132(3):604−11. 14. sarni ro, carvalho mdfc, do monte cm, albuquerque zp, souza fi. anthropometric evaluation, risk factors for malnutrition, and nutritional therapy for children in teaching hospitals in brazil. j pediatr (rio j). 2009;85(3):223−8. 15. shrivastava s. malnutrition in congenital heart disease. indian pediatr. 2008;45(7):535−46. amani sakinah augiani, sri endah rahayuningsih, dewi marhaeni diah herawati: factors related to malnutrition in children under five years with congenital heart disease althea medical journal. 2015;2(3) 414 amj september, 2015 enteric pathogen bacteria in non-broiler chicken egg shells from traditional market and supermarket, jatinangor subdistrict, west java kavita arumugam,1 sunarjati sudigdoadi,2 gaga irawan nurgraha3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of medical nutrition, faculty of medicine universitas padjadjaran abstract background: around 1.5 million of children dying annually due to diarrhea. contaminated food is one of the sources of the diarrhea incidence (food borne diseases). eggs are one of the least expensive forms of protein which is affordable by the community and is easily to find in either traditional or modern market/ supermarkets.the objective of this study was to identify enteropathogenic bacteria contamination on nonbroiler (ayam kampung) egg shell and to compare the findings between eggs sold in traditional and modern markets. methods: this was a descriptive study performed at the microbiology laboratory of the faculty of medicine, universitas padjadjaran. a total of 40 eggs were used, 20 from two traditional markets and 20 from two modern markets. the eggs were swabbed using saline, dipped in tryptic soy broth and streaked on mac conkey agar. the collected data were analyzed and presented in tables. results: out of 40 samples, there were 19 positive cultures found from the traditional market and 16 from the modern market. there were 30 pink colonies indicating that they were lactose fermented, 5 transparent colonies indicated non-lactose fermentation, 4 showed no colony growth, and 1 grew an unidentified colony. the most found bacteria were klebsiella sp. and enterobacter sp. in both market. conclusions: eggs shells from traditional and modern markets are contaminated with enteropathogenic microbes. [amj.2015;2(3):414–17] keywords: enterobacter sp., klebsiella sp., non-broiler (ayam kampung) eggs correspondence: kavita arumugam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170206265 email: nita_kav@yahoo.com introduction since a decade ago, there has been an increased rate of food illness being registered by asian countries. around 1.5 million of children were dying annually due to diarrhea. food can be contaminated due to several factors, bacteria, followed by virus, parasites and toxins. according to world health organization (who) data, over the 10 years, 75% of infectious diseases are caused by bacteria and other pathogens.1 food can be contaminated from farm to table, for instance, contaminated meat with fecal matter due to improper handling, inadequate food preparing, inappropriate personal hygiene and poor hygiene in the surrounding. any of this these factors can lead to food contamination and resulting in foodborne diseases to consumers. food-borne diseases that carry microorganisms, examples such as bacteria and viruses or toxins. the common symptoms of food-borne diseases are diarrhea, vomiting, cramps and nausea.2 the most common symptom of food-borne disease is diarrhea caused by enteropathogenic bacteria. the examples of these bacteria are eschericia coli, salmonella sp,. and shigella sp. and others.3 enteropathogenic eschericia coli is the main cause of diarrhea in infants these especially in developing countries. each year, around 105 million of shigella cases are reported worldwide.4 moreover, it is the most common cause of bloody diarrhea. more than 1 million cases of salmonella are being reported and their infections are more common in althea medical journal. 2015;2(3) 415 young children and elder people.4 e.coli, salmonella sp., and shigella sp. are chosen as the bacteria in this study, according to a surveillance study, ‘surveillance of bacterial pathogens of diarrhea disease in indonesia’ which was conducted in 2 years on 6.760 people. among 587 diarrhea patients who are positive for bacterial infection, 39% of them are affected by shigella and 26% are by salmonella.5 another study, ‘enterotoxigenic escherichia coli and other causes of infectious pediatric diarrheas in jakarta, indonesia’, conducted a stool survey among children, and discovered that e.coli is the second most frequent cause of diarrhea with highest prevalence (17.9%) among infants.6 the reason why eggs were chosen in this study is because eggs are one of the least expensive forms of protein, which is affordable to everyone. the american heart association stated that an egg a day for a normal healthy adult is good. 7 the contamination of these eggs can occur in a stage starting from the host itself (chicken) until it reaches consumers, especially nonbroiler chicken eggs. there are two types of breeding system, one is battery cage and another one is free range or aviaries. according to the centre of food safety of hong kong, egg contamination can occur via two different ways: vertical transmission through the ovary transmission and horizontal transmission.8 vertical transmission occurs when bacteria are transmitted from infected reproductive tissues to eggs during the shell formation and is mostly associated with pathogenic bacteria8, whereas horizontal transmission occurs when fecal contamination stained on the egg shell as when eggs are released via the cloaca. contaminations through environmental vectors such as pesticides, farmers are also categorized as horizontal transmission. at this point, numerous bacteria may gain entry through pores or cracks on shell of eggs. eggs with cracks on the shell allow the entry of bacteria into the egg content. in addition, bacteria may contaminate egg contents at breaking for cooking purpose when it is not being washed before cooking.8 the objective of this study was to identify enteropathogenic bacteria contamination on non-broiler (ayam kampung) egg shell and to compare the findings between eggs sold in traditional and modern markets. the results of this study serve as knowledge and can be used as a guide on preventive measures to be taken. this study will also help us to foresee if there is a need for a future table 1 percentage of bacteria found on non-broiler chicken egg shells from traditional market bacteria number of nonbroiler chicken eggs escherichia coli 1 enterobacter sp. 9 klebsiella sp. 7 citrobacter sp. 2 gram positive bacillus 1 study. methods this study was conducted at the microbiology laboratory in faculty of medicine universitas padjadjaran. samples were collected from four sources; two traditional markets and two supermarkets in jatinangor. a total number of 40 samples were taken from the four sources with ten non-broiler chicken eggs samples from each source. the number of samples that will be used in this study was determined using the ‘rule of thumb’ where the total sample size should be more than 30. nonbroiler chicken eggs that had cracked shell were excluded from this study. the eggs were swabbed using cotton swabs, dipped in physiologic saline, and then the cotton swabs were dipped in tryptic soy broth for 24 hours and incubated at 370c. the solutions were then cultured on mac conkey agar and incubated at 370c in the incubator for 24 hours. afterward colonies that grew on the agars were analyzed. the lactose fermenter and non-lactose fermenters were observed. gram staining was carried out in order to differentiate gram-positive and gram-negative. only the gram negative bacteria underwent the biochemistry test such as kligler iron agar (kia), motility, indole and urease (miu) agar and citrate agar. hereafter, the results were analyzed. results out of 40 samples, 19 positive growths were found on mac conkey agar from a traditional market and 16 positive growths found from a supermarket. during observation on mac conkey agar plate, from the total sample of 40, 30 pink kavita arumugam, sunarjati sudigdoadi, gaga irawan nurgraha: enteric pathogen bacteria in non-broiler chicken egg shells from traditional market and supermarket, jatinangor subdistrict, west java althea medical journal. 2015;2(3) 416 amj september, 2015 colonies were indicated lactose fermented, five transparent colonies were indicated non lactose fermented, four were with no colony growth, and 1 colony was found unidentified. discussion based on the results found, it was clearly proven that non-broiler chicken eggs shell contained several types of enterobacteriaceac. compared to previous study by wall et al.9, enterobacteriaceac was found in higher proportion on egg shells which supported this experiment results. e.coli a normal flora of intestine that can become pathogenic when it reaches outer tissues of its usual site is the most common bacteria that can cause diarrhea. the study which supports this experiment result is from ‘bacterial contamination on egg shells’ where the researcher analyzed eggs from few sources and the highest range of bacteria found was e.coli.10 although in this study, e.coli was found only 5.00%, it needs to take precaution. salmonella sp., a member of enterobacteriaceac family can cause enteric fever, diarrhea and systemic infection. however, there were no salmonella found from any of the samples, either traditional market or supermarket. according to scientist, it was estimated that on an average 1 of every 20,000 eggs might contain salmonella.2 based on this study, there was 10.00% of shigella found on chicken egg shells. although the percentage is small, serious precaution should be taken. the pathogenic bacteria, shigella, can cause bacillary dysentery. they are extremely communicable as the infective dose is around 103 organisms only. there were other enterobacteriaceac found in this experiment also. this can be due to their characteristics as a normal pathogen in intestinal tract of animals, so as in this study, it can be found in chicken or in the water sources, soil, sewage or using eggs handling method, by which lead to the contamination of egg shells. according to the results from musgrove and papadoude, they concluded that most frequently isolated gram negative bacteria from eggs are enterobacter sp.,e.coli, and klebsiella sp.11 apart from e.coli and shigella sp., most abundant enterobacteriaceac found in this study was enterobacter sp., followed by klebsiella sp., hafniaalvei and citrobacter sp. under previous analysis of types of bacteria found on eggs depending on their source, out of 184 samples, klebsiella sp and enterobacter sp. were found in 17 and 23 eggs, respectively.11 the most frequent enterobacter sp. found in traditional market eggs and supermarket eggs stood a total of 45% and 20%, respectively. enterobacter sp. is a nosocomial pathogenic bacterium which usually causes infection of urinary and respiratory tract. klebsiella sp. was found in quite a high percentage in this study, 35.00% from the traditional market and the supermarket respectively. this rod shaped, gram negative are pathogenic bacteria is involved in causing nosocomial infection, pneumonia and urinary tract infection. hafniaalvei was found 15.00% in supermarket eggs. these gram negative bacteria are rarely isolated from specimens. these bacteria can cause nosocomial infection. apart from enterobacteriaceac, there was 5.00% of gram positive bacillus found from the samples collected from the traditional market. presence of these bacteria can be due to contamination from the environments during the streaking procedure on mac conkey. there was also 20.00% of no colony growth found on agar, this can be due to no bacteria found on egg shells, or maybe there were bacteria which required other media to be cultured as in this experiment. only mac conkey agar was used. previously, haribudiman12 found three e.coli and one staphyloccus out of 30 samples. in conclusion, the comparison between traditional market and supermarket was chosen as part of this study. the difference between these two sources is the chicken breeding system. eggs sold in supermarket are from battery cage system and eggs sold in traditional market are free-range poultry or aviaries. there were no significant differences found in samples from those sources in this study. eggs from both places were equally contaminated. references table 2 percentage of bacteria found on non-broiler chicken egg shells from supermarket bacteria number of nonbroiler chicken eggs shigella sp. 2 enterobacter sp. 4 hafiniaalvei 3 klebsiella sp. 7 no growth 4 althea medical journal. 2015;2(3) 417 1. who. diarrhoeal disease.geneva: who. 2009 [cited 2012 may 1];available from: h t t p : / / w w w. w h o . i n t / m e d i a c e n t r e / factsheets/fs330/en/index.html. 2. american egg board. incredible egg. illinois, america: american egg board; 2012 [cited 2012 may 4]; available from: http://www.incredibleegg.org/egg-facts/ egg-safety/eggs-and-food-safety. 3. brooks gf, carroll kc, butel js, morse sa, editors. medical microbiology. 24th ed. new york,us: the mcgramhill company; 2004. 4. kumar v, abbas a, fausto n. pathologic basic of disease. 8th ed. philapedia: saunders elsevier; 2010. 5. oyofo ba, lesmana m, subekti d, tjaniadi p, larasati w, putri m sc, et al. surveillance of bacterial pathogens of diarrhea disease in indonesia. diagn microbiol infect dis.2002;44(3):227–34 6. subekti d, lesmana m, komalarini s, tjaniadi p, burr d, pazzaglia g. enterotoxigenic escherichia coli and other causes of infectious pediatric diarrheas in jakarta, indonesia. southeast asian j trop med public health. 1993;24(3):420–4 7. kurzrock d. ask the expert. sacramento, california [cited 2012 september 14]; available from: https://www.mylifestages. o r g / a s k t h e e x p e r t / q u e s t i o n a n s w e r. page?questionid=256. 8. chong k. bacteria on eggs-should eggs be washed. hong kong: centre for food safety; 2008 [cited 2012 june 25 ]; available from: http://www.cfs.gov.hk/ english/multimedia/multimedia_pub/ multimedia_pub_fsf_29_01.html. 9. wall h, tauson r, sorgjerd s. bacterial contamination of eggshells in furnished and conventional cages. j appl poult res (spring). 2008 17(1):11–6 10. world poultry. bacterial contamination on egg shells. 2012 ;[cited 2012 november 11]. available from: http://www. wo rl d p o u l t r y. n e t / b ro i l e r s / m a rke t s trade/2012/5/bacterial-contaminationon-egg-shells-wp010384w/ 11. pysniak s. occurence of gram-negative bacteria in hen’s eggs depending on their source. pol j vet sci. 2010;13(3):507–13. 12. haribudiman o. isolasi and identifikasi bakteri penyebab diare pada telur puyuh yang dijual di beberapa pasar di kelurahan sukajadi [minor thesis]. bandung: universitas padjadjaran; 2003. kavita arumugam, sunarjati sudigdoadi, gaga irawan nurgraha: enteric pathogen bacteria in non-broiler chicken egg shells from traditional market and supermarket, jatinangor subdistrict, west java vol 6 no 2 full text edit2.indd althea medical journal. 2019;6(2) 80 amj june 2019 annona muricata l leaf infusion effect on glucose absorption in the intestinal cells membrane of wistar rats model vycke yunivita,1 putra haqiqie adnantama lubis,2 augusta y. l. arifin3 1department of biomedical sciences faculty of medicine universitas padjadjaran, 2 faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: vycke yunivita, department of biomedical science, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: v.yunivita@unpad.ac.id introduction all parts of the annona muricata (a. muricata) tree are claimed to be used in herbal treatment, including the bark, leaves, root, and fruit-seeds. it commonly called “soursop”. the fruit is one of many fruits that extensively used to prepare candies, syrups, ice cream, and beverages and also provide benefits for our health. it has been long used as a herbal medicine for different purposes, like pain relief for arthritic pain, neuralgia, as an astringent for diarrhea, to cool fever, malaria, anticancer and it is also eaten to elevate a mother’s milk after childbirth. the bark, leaves, and roots are considered had anticonvulsant activity, antispasmodic, hypoglycemic, and hypotensive.1–4 several studies have been conducted to reveal the functions of soursop leaves. many bioactive compounds and phytochemicals have been found in a. muricata leaves, but the majority is annonaceous acetogenins, that play a role as antidiabetic. the leaf aqueous extracts proved beneficial as antioxidant, hypolipidemic and protection of β-cells that believes beneficial in diabetic.1,5 the soursop leaves (annona muricata) affect to lower the glucose level in our blood by inhibiting α-glucosidase that can delay enhancement of blood glucose level. however, as of today, there have been no data in situ using the perfusion method of soursop leaves on glucose absorption in the small intestines. with its capability to lower glucose level in the blood, it is very likely there will be any effects found in this research.1,3,6 amj. 2019;6(2):80–5 abstract background: diabetes mellitus (dm) is a chronic disease that disrupts the homeostasis of glucose. dm is the second of most causes of deaths in urban areas, as well as the sixth in rural areas. therefore, herbal medicine is constantly developed. soursop leaves have been long known to have good effects in lowering glucose levels in our blood. this study explored the soursop leaves infusion on glucose absorption in the intestinal cell membrane of the wistar rats model. methods: this was an exploratory study performed in october 2012 on five male rats wistar, aged 3-4 months, weighing about 150-300 grams. using the in situ perfusion method, each rat was given the following; 3 x 10-3 m glucose solution for one hour; 3 x 10-3 m glucose solution with 1 ml of infusion of soursop leaves (annona muricata l) for one hour; 3 x 10-3 m glucose solution for the last hour. the glucose absorption levels were measured using spectrophotometry method. the glucose level between treatments was analyzed using a paired sample t-test. results: the concentration of glucose absorption was decreased, the first treatment was 24.42+14.29 mg/dl, the second treatment was 18.63+10.37 mg/dl, and the third treatment was 18.24+8.02mg/ dl), however, the decrease of glucose absorption was statistically not significant. conclusions: there is a slightly decreased of the glucose absorption in the intestinal cell membranes of the wistar rats model after infusion of soursop leaves. further study is needed to explore the role of soursop leaves infusion in glucose absorption. keywords: diabetes mellitus, glucose absorption, soursop leaves, wistar rats althea medical journal. 2019;6(2) 81 methods this experimental research was an exploratory study in situ perfusion method.7 five adult male wistar rats were included, aged 3-4months, weighing 150–300 grams. the research was conducted at biochemistry laboratory, faculty of medicine, universitas padjadjaran, and approved by the health research ethics committee of faculty of medicine, universitas padjadjaran. about 200 g soursop leaves were mixed and heatedat 900c with 200 ml of aquadest for 15 minutes. after the adaptation period for 7 days, the rats were fasted for about 20 hours and were anesthetized with ketamine. rat abdominal was dissected and two cannulas inserted in the intestine; 10 cm from the pylorus and 25 cm from the first cannula. the intestines were cleaned by a 0.9% nacl solution and by blowing the cannulas three times. the cannulas were connected to the vessel filled with a solution. in the first hour, 25 ml glucose solution was given, continued in the next hour with 25 ml glucose solution and with additional the soursop leaves infusion, then table 1 the concentration of glucose absorption at baseline before soursop treatment rats no. time (minutes) glucose concentration (mg/dl) glucose absorption (mg/dl) average glucose absorption (mg/dl) 0 106.47 15 100.00 6.46 1 30 89.55 16.91 18.53 45 81.59 24.87 60 80.59 25.87 0 126.66 15 99.48 27.17 2 30 88.20 38.46 39.49 45 80.51 46.15 60 80.51 46.15 0 121.46 15 94.14 27.31 3 30 84.39 37.07 38.17 45 78.04 43.41 60 76.58 44.87 0 102.01 15 99.49 2.51 4 30 96.48 5.52 5.78 45 94.97 7.03 60 93.97 8.04 0 57.14 15 39.90 17.23 5 30 36.28 20.86 20.13 45 36.05 21.08 60 35.82 21.31 average 24.42 vycke yunivita et al.: annona muricata l leaf infusion effect on glucose absorption in the intestinal cells membrane of wistar rats model althea medical journal. 2019;6(2) 82 amj june 2019 followed by the last one hour of which 25 ml glucose solution was again given. the sample was taken every 15 minutes, consisting of the residual concentration of glucose absorption (peridochrom glucose/god-pap reagent kit). the concentration of glucose absorption was measured by a spectrophotometer with a wavelength of 505 nm, and calculated using the formula. 7–9 the analysis was performed using paired sample t-test, to compare the concentration of glucose absorption between treatments. results the concentration of glucose absorption before and during the treatment of soursop leaves infusion was shown in table 1 and table 2 to explore the effect of soursop leaves infusion. the average level of glucose absorption before treatment was 24.42 mg/ dl (table 1). the average level of glucose table 2 the concentration of glucose absorption during soursop treatment rats no. time (minutes) measured of glucose concentration (mg/dl) concentration of glucose absorption (mg/dl) average concentration of glucose absorption (mg/dl) 0 105.97 15 79.60 26.37 1 30 78.61 27.36 26.87 45 78.61 27.36 60 79.60 26.37 0 110.26 15 87.18 23.08 2 30 81.54 28.72 27.31 45 82.05 28.21 60 81.03 29.23 0 102.93 15 92.69 10.24 3 30 80.98 21.95 20.37 45 78.54 24.39 60 78.05 24.88 0 103.52 15 104.02 -0.50 4 30 103.02 0.50 1.88 45 102.01 1.51 60 97.49 6.03 0 53.06 15 36.28 16.78 5 30 36.28 16.78 16.72 45 36.51 16.55 60 36.28 16.78 average 18.63 althea medical journal. 2019;6(2) 83 absorption when used soursop leaves infusion in the second treatment was 18.63 mg/dl (table 2), whereas the average level of glucose absorption after soursop treatment was 18.24 mg/dl (table 3). furthermore, there was a tendency of the lower level of glucose absorption when soursop leaves infusion was given, however, the decrease was statistically not significant. the effect of soursop leaves infusion was further irreversible in one hour after the treatment (table 4). discussion soursop leaves infusion has a tendency to inhibit glucose absorption in the rat’s intestine cell membrane. our study has shown that the average concentration of glucose absorption is decreased even though the decrease is not statistically significant. the decrease in concentration of glucose absorption may be due to effect of bioactive substances of soursop leaves such as phenol, flavonoid, alkaloid, and triterpenoid. these components inhibit the table 3 the concentrations of glucose absorption after soursop treatment rats no. time (minutes) glucose concentration (mg/dl) glucose absorption (mg/ dl) average concentration of glucose absorption (mg/dl) 0 82.58 15 67.66 14.92 1 30 65.92 16.66 16.60 45 65.67 16.91 60 64.67 17.91 0 108.71 15 98.71 10.00 2 30 91.79 16.92 15.13 45 92.30 16.41 60 91.53 17.17 0 119.02 15 109.51 9.51 3 30 98.53 20.48 20.61 45 98.53 20.48 60 87.07 31.95 0 103.26 15 102.26 1.00 4 30 94.72 8.54 8.54 45 92.96 10.30 60 88.94 14.32 0 78.00 15 64.05 13.94 5 30 50.11 27.89 30.30 45 42.85 35.14 60 33.78 44.21 average 18.24 vycke yunivita et al.: annona muricata l leaf infusion effect on glucose absorption in the intestinal cells membrane of wistar rats model althea medical journal. 2019;6(2) 84 amj june 2019 activities of α-glucosidase, an enzyme that plays a role a key of breaking down starch or carbohydrates. the enzyme α-glucosidase is a hydrolase enzyme that catalyzes the reaction of the non-reductive terminal hydrolysis of substrates to produce α-glucose. inhibition of α-glucosidase activities may inhibit glucose absorption.6,10–12 however, soursop leaves contain a chemical substance glycoside, which is a molecule consisting of sugar group (glycone) and non-sugar group (aglycone or genin).with glucose content in the glycoside, it is most likely that soursop leaves affect the overall glucose levels, to disguise from the effectiveness of other compounds that help glucose absorption.6 the inhibitory effect of soursop leaves infusion is irreversible despite also not significant, indicating that after administration of soursop leaves infusion, glucose absorption levels do not return to normal. in conclusion, soursop leaves (annona muricata) has slightly an inhibitory effect on glucose absorption irreversibly. more studies are in need to explore further the role of soursop in the antihyperglycemic treatment. references 1. moghadamtousi sz, fadaeinasab m, nikzad s, mohan g, ali hm, kadir ha. annona muricata (annonaceae): a review of its traditional uses, isolated acetogenins, and biological activities. int j mol sci. 2015;16(7):15625–58. 2. adeyemi do, komolafe oa, adewole os, obuotor em, abiodun aa, adenowo tk. histomorphological and morphometric studies of the pancreatic islet cells of diabetic rats treated with extracts of annona muricata. folia morphol (warsz). 2010;69(2):92–100. 3. adewole s, caxton-martins e. morphological changes and hypoglycemic effects of annona muricata linn. (annonaceae) leaf aqueous extract on pancreatic β-cells of streptozotocintreated diabetic rats. afr j biomed res. 2006;9(3):173–87. 4. florence nt, benoit mz, jonas k, alexandra t, desire dd, pierre k, et al. antidiabetic and antioxidant effects of annona muricata (annonaceae), aqueous extract on streptozotocin-induced diabetic rats. j ethnopharmacol. 2014;151(2):784–90. 5. rahmawati s , rifqiyati n. efektivitas ekstrak kulit batang, akar, dan daun sirsak (annona muricata l) terhadap kadar glukosa darah. kaunia. 2014;10(2):81–91. 6. purwatresna e, roswiem ap, purwakusumah ed. aktivitas antidiabetes ekstrak air dan etanol daun sirsak secara in vitro melalui inhibisi enzim α-glukosidase [minor thesis]. bogor: institut pertanian bogor; 2012. 7. rohmawaty e, yunivita v. potensi quercetin-3o-glucoside (q3g) dan quercetin-4o-glucoside (q4g) dari daun mimba (azadirachta indica a.juss) terhadap ambilan glukosa. mkb. 2016;48(4):222–7. 8. johansyah ls, yunivita v, martiana a, arifin ay. inhibitory effect of neem leaves on glucose transport. althea medical journal. 2018;5(4):192–5. 9. fortress diagnostics. glucose god-pap. 2012 [cited 2012 dec 12]. available from: http://www.fortressdiagnostics.com/ online 10. adewole so, ojewole jao. protective table 4 the average of glucose absorption level before, during and after soursop treatment rats no. before (mg/dl) during (mg/dl) after (mg/dl) 1 18.53 26.87 16.60 2 39.49 27.31 15.13 3 38.17 20.37 20.61 4 5.78 1.88 8.54 5 20.13 16.72 30.30 mean ± sd. 24.42+14.29 18.63+10.37 18.24+8.02 p-value 0.26a 0.39b note: p-values of<0.05 were considered statistically significant, apaired sample t-test between first and second treatment (pre and during soursop treatment), bpaired sample t-test between first and third treatment (pre and after soursop treatment) althea medical journal. 2019;6(2) 85 effects of annona muricata linn. (annonaceae) leaf aqueous extract on serum lipid profiles and oxidative stress in hepatocytes of streptozotocin-treated diabetic rats. afr j tradit complement altern med. 2008;6(1):30–41. 11. adhi suastuti ngd, panca dewi iaksp, ariati nk. pemberian ekstrak daun sirsak (annona muricuta) untuk memperbaiki kerusakan sel beta pankreas melalui penurunan kadar glukosa darah, advanced glycation and product, dan 8-hidroksi-2-dioksiguanosin pada tikus wistar hiperglikemia. jurnal kimia. 2015;9(2):289–95. 12. hammado ni, seno dsh, hasan aez. aktivitas ekstrak daun sirsak sebagai inhibitor enzim alfa glukosidase (in vitro) dari sembilan lokasi di jawa barat [thesis]. bogor: institut pertanian bogor; 2015. vycke yunivita et al.: annona muricata l leaf infusion effect on glucose absorption in the intestinal cells membrane of wistar rats model althea medical journal. 2016;3(3) 446 amj september 2016 treatment of rheumatoid arthritis with methotrexate only or a combination of methotrexate and hydroxychloroquine natharubini nadarajah,1 riardi pramudyo,2 kuswinarti3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: rheumatoid arthritis (ra) is an autoimmune disease that causes significant morbidity in most patients and also premature mortality in some. to prevent this, therapeutic approaches call for the early treatment of ra by using disease-modifying antirheumatic drugs (dmardss), either as single therapy or combination therapy. although in the previous decade dmards were rarely used as combination, now they are used widely to treat ra. the objective of this study was to compare the effectiveness of methotrexate (mtx) on its own and the combination of mtx & hydroxychloroquine (hcq) in ra patients. methods: an analytic retrospective cohort study was conducted from may 2014 to october 2014, on 46 patients with ra at the rheumatology clinic of dr. hasan sadikin general hospital bandung in the period from january 2009 to october 2014, who were taking mtx or mtx & hcq for at least 1 year. the secondary data obtained from these patients’ medical record were then analyzed using the independent t-test and mann-whitney test. results: the study showed that female patients dominated than male patients which were 93.48%. the mean change in disease activity measures was not significant for any of the parameter (p-value for sjc = 0.337; tjc = 0.676; esr = 0.780). in addition, the comparisons of the disease activity score (das 28) before and after therapy were not significant (p-value = 0.584). conclusions: there is no difference in the effectiveness of dmard monotherapy with mtx and combination therapy with mtx & hcq in ra patients. [amj.2016;3(3):446–51] keywords: das 28, dmards, hydroxychloroquine, methotrexate, rheumatoid arthritis correspondence: natharubini nadarajah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81214588020 email: rubini.nadarajah@gmail.com introduction rheumatoid arthritis (ra) is an autoimmune disease1 and also a chronic systemic inflammatory disorder1,2 that causes joint swelling, joint tenderness, and destruction of synovial joints.1 even though the etiology seems to be unknown, however, there are certain risk factors said to be associated with ra, such as genetic and environmental factors.3 although ra affects people of all ages, its onset occurs between 30−55 years of age, with women more likely to suffer from ra compared to men.4 until today, there is no specific cure for ra. however, there are available certain drugs or medications to help decrease symptoms, reduce inflammation, and slow the progression of the disease.5 the treatment approach for ra has two main goals: first, the relief of symptoms (symptomatic treatment) and maintenance of function and second, the slowing of the tissuedamaging process (modifying treatment).6 disease-modifying antirheumatic drugs (dmards) have the capability to arrest or at least to control the disease process in ra by modifying the disease itself.7 diseasemodifying antirheumatic drugs have the ability to reduce signs and symptoms, disability, impairment of quality of life, and progression of joint damage and hence; they interfere with the entire disease process. disease-modifying antirheumatic drugs can be classified into two major groups: synthetic dmards (sdmards) althea medical journal. 2016;3(3) 447 and biologic dmards (bdmards).8 the disease activity score (das, das28) that is used to record disease activity and determine the therapeutic efficacy consists of four items; the number of swollen and tender joints (sjc, tjc), the visual analogue scale of patients’ assessment of their general health (vas-gh), and the erythrocyte sedimentation rate (esr) in the first hour.9 early treatment with dmards has shown improved outcomes of signs and symptoms and also slower progression of damage to joints10 by changing the course of ra itself.11 currently, mtx (methotrexate) is the most preferred synthetic dmard (dmard of first choice)12 because many patients on mtx have good response and serious toxicities are rare.13 however, not all patients have good treatment response with mtx monotherapy.12 this study was conducted to compare the effectiveness of mtx on its own and the combination of mtx & hcq in ra. methods an analytic retrospective cohort study was conducted from august 2014 to october 2014 at the rheumatology clinic of dr. hasan sadikin general hospital bandung. this study was conducted after it was approved by ethical clearance committee of dr. hasan sadikin general hospital bandung. the research population in this study was ra patients who came to the rheumatology clinic at dr. hasan sadikin general hospital bandung. however, the samples of this study were new ra patients in the rheumatology clinic from january 2009 to october 2013 who had a follow-up minimum one year. the inclusion criteria for the study were ra patients aged 19–80 years old whose cases were being followed up at the rheumatology clinic. all ra patients with complete data in their medical records and patients who had not previously received a combination therapy with any of the medications were studied in this study. the exclusion criteria for the study were patients who had stage iv disease. a concurrent therapy with systemic corticosteroids was allowed if the dosage remained stable throughout the study period and the patient took ≤ 10 mg of prednisone (or its equivalent) per day. based on these criteria, 46 samples were obtained from a calculated sample size of 92 whereby 23 of them took mtx monotherapy and the other 23 took the combination therapy of mtx & hcq. the starting dose for mtx was 7.5-10mg per week and was increased gradually depending on the patients’ respsonse to therapy meanwhile the dosage of hcq was 200mg per day. the type of study chosen to compare the effectiveness of the monotherapy and combination therapy was analytic retrospective cohort study. the response to treatment was studied in the 6th and 12th month. variables of this study were type of dmard therapy (monotherapy or combination therapy) and the disease activity table 1 characteristics of respondents according to study group* characteristics mtx mtx & hcq all patients no. of patients 23 23 46 gender male 2 (8.70%) 1 (4.35%) 3 (6.52%) female 21 (91.30%) 22 (95.65%) 43 (93.48%) age, years, mean (range) 44.1 (19−78) 43.8 (24−65) 44 (19−78) 19−28 years (n) 3 3 6 29−38 years (n) 5 6 11 39−48 years (n) 8 7 15 49−58 years (n) 3 5 8 59−68 years (n) 3 2 5 69−78 years (n) 1 0 1 mean dosage of corticosteroids, mg/ day ± sd 5.4 ± 2.1 5.6 ± 1.9 5.5 ± 2.0 note: * mtx = methotrexate; hcq = hydroxychloroquine althea medical journal. 2016;3(3) 448 amj september 2016 score, das28. the effectiveness of the therapy was seen based on the comparison of the das 28 before and after the dmard therapy (after 12 months of therapy) whereby the das 28 of each patient was calculated using the online das 28 calculator for three variables (sjc, tjc, and esr) at http://www.das-score. nl/das28/dascalculators/dasculators.html and then categorized as follows: low (das28 ≤ 3.2), moderate (3.2 < das28 ≤ 5.1), or high (das28 > 5.1). the data from the medical records were statistically analyzed using independent t-test for data that were normally distributed and mann whitney non-parametric test if there were anomalies in the data distribution. statistical significance was considered when p ≤ 0.05. analysis was performed by comparing the both treatment groups. results of the 46 patients in this study, 23 took mtx while the other 23 took mtx & hcq. the distribution of sex, age, and daily corticosteroid usage were roughly balanced across the treatment groups (table 1). the individual parameters of the disease activity measures were shown in table 2, representing the findings at study entry. both groups were roughly balanced in terms of these parameters in study entry. table 3 showed the mean change in the individual parameters of the disease activity measures at the end of the study, by treatment group. the comparison on the effectiveness of monotherapy with mtx and combination therapy with mtx & hcq based on das28 was shown in table 4 whereby a p-value ≥ 0.05 was obtained indicating the insignificant results discussion from the overall data obtained for the outpatients’ medical record installation, there were a total of 213 patients who visited the rheumatology clinic from january 2009 to october 2014 whereby the total of female patients were 165 (77.5%) and male patients were 48 (22.5%). the incidence was a lot higher in females compared to males with a ratio of 3:1. in fact, this is true whereby other autoimmune diseases, ra has a higher occurrence in females compared to males with a ratio of 2−3:1. meanwhile, studies from certain latin american and african countries showed a considerably greater predominance of ra in females compared to males with a ratio of 6−8:1. many theories have proposed the role of estrogens in this disease said that estrogens enhance the immune response by stimulating the production of tumor necrosis factor α (tnf−α) which is an important cytokine in the pathological process of ra.2 the average age of patients in this study was 44 years old and mostly (32.61%) were in the age range of 39−48 years old. most of the studies conducted on ra in europe showed that the average age of the patients is between 48.9−52.1 years.14,15 besides, a study by alam et al.16 in bangladesh to compare the effectiveness of mtx against hcq showed that table 2 initial values for disease activity measures by treatment group* parameters mtx mtx & hcq sjc (maximum 28) 2.52 ± 5.66 3.48 ± 4.22 tjc (maximum 28) 8.83 ± 7.42 9.57 ± 5.62 esr (mm/h) 44.83 ± 34.49 53.57 ± 31.20 note: * values are the mean ± sd. mtx = methotrexate; hcq = hydroxychloroquine; sjc = swollen joint count; tjc = tender joint count; esr = erythrocyte sedimentation rate table 3 changes in values for disease activity measures by treatment group parameters mtx mtx & hcq p-value sjc (maximum 28) 1.52 ± 4.73 2.22 ± 4.07 0.337** tjc (maximum 28) 5.74 ± 7.37 6.57 ± 5.85 0.676* esr (mm/h) 15.61 ± 33.68 13.09 ± 26.74 0.780** note: * mann whitney test; ** independent t-test . mtx = methotrexate; hcq = hydroxychloroquine; sjc = swollen joint count; tjc = tender joint count; esr = erythrocyte sedimentation rate althea medical journal. 2016;3(3) 449natharubini nadarajah, riardi pramudyo, kuswinarti: treatment of rheumatoid arthritis with methotrexate only or a combination of methotrexate and hydroxychloroquine the average age of patients in their two study groups is 41.7 and 42.9 years old respectively. it was said that ra mostly occurs between 40−70 years old and it als occurs later in life for men.2 this may be due to the fact that women begin to experience menopause around the fifth decade of life causing a decrease in their estrogen levels. hence, it can be said that women are likely to suffer from ra when their estrogen level is still high, which is before 50 years old (average). the changes in value for sjc and tjc at the end of this study were -1.5 and -5.7 for the mtx group and -2.2 and -6.6 for the combination therapy group, respectively. in a study conducted by o’dell et al,17 the mean changes in value for sjc and tjc after taking mtx & hcq are -14.0 and -10.0, respectively, which are higher compared to the results in this study. however, it should be noted that the study conducted by o’dell jr et al.15 used the 38 joint count compared to the 28 joint count used in this study. this difference in joints count could be one of the reasons for the low changes in sjc and tjc values in this study. many research and studies have been conductedto determine the effectiveness of dmards. o’ dell jr et al.17 conducted two different studies to determine the effectiveness of triple therapy against dual and monotherapy. in their first study, they demonstrated the superior efficacy of the triple combination therapy (mtx, hcq, & sulfasalazine, ssz) over both mtx on its own and the double combination of mtx & ssz.17 in their second study, they concluded that the efficacy of the triple combination of mtx, ssz, & hcq is superior to the double combination of mtx & ssz and marginally superior to the double cobination of mtx & hcq.15 this is supported by the treach trial conducted by de jong et al.18 that concluded that therapy with a combination of dmards is better than mtx monotherapy. in this study, it was showed that double therapy is similar in effectiveness to monotherapy. the results of this study contradict the results of previous studies. one of the main reasons is the small sample obtained in this study; larger samples increase the chance of finding a significant difference because they more reliably reflect the population mean. in this study, although the calculated sample size was 92, however, only 46 samples were obtained. comparing to other studies, the sample size used was large (about 150−200 patients).15 it is not known why certain patients with ra respond to treatment better compared to others. a study by anderson et al.19, showed certain factors to answer this question and one of the factors is the disease duration. their study showed that patients with longer disease duration have a poorer response to treatment compared to patients with shorter disease duration. in their study, they stated that there are indications that the biologic process of ra change early in the disease, so that patients may be less responsive to treatment over time. other factors that were said to decrease response to treatment were female sex, prior dmard use, and worse functional class. it was also stated that rheumatoid factor affects response to treatment.19 in another study table 4 comparison on the effectiveness of monotherapy with mtx and combination therapy with mtx & hcq based on das28 * category of das 28 score treatment group total p-valuemtx mtx & hcq f % f % f % before treatment low 0 0.00 1 100.00 1 100 moderate 17 58.62 12 41.38 29 100 high 6 37.50 10 62.50 16 100 after treatment low 9 60.00 6 40.00 15 100 0.584 moderate 13 46.43 15 53.57 28 100 high 1 33.33 2 66.67 3 100 note: * das 28 = disease activity score 28; mtx = methotexate; hcq = hydroxychloroquine; f = frequency althea medical journal. 2016;3(3) 450 amj september 2016 by radovits et al.20, to find out the influence of age and gender on das28 in rheumatoid arthritis, they concluded that age and gender do not affect the das28 of ra patients. due to the unavailable complete data in the medical record, this study could not conclude if these factors influence the response to treatment in ra. it was concluded that there is no difference in the effectiveness of dmard monotherapy with mtx and combination therapy with mtx & hcq in ra patients. the limitations of this study are some of the medical records were not available in the storage room where there are possibilities that the medical records are misplaced by the staffs of medical record. besides, some of the medical records also do not have the complete or required data and, hence, cannot be used in this study.the number of the study sample can be one of the limitations of the study which a larger number of study sample can be used reflecting the population clearly. lastly, time constraint is also one of the limitations with the tight academic schedules and short duration for data collection and analysis for this study. certain recommendations can be considered to improve this study. first and foremost is improving the management of medical record at rheumatology clinic of dr. hasan sadikin general hospital bandung so that the data of the patients that are obtained from the medical record can be used and analyzed properly. next a standardized medical form can be used so that physicians attending to patients at the rheumatology clinic will not forget or over look to fill up the relevant data in the medical record. increasing the period of data collection is also suggested to enable the researcher to get more patients to meet the targeted sample size. lastly, further studies about another dmard therapy for ra should be conducted to get more information about the effectiveness of other dmards. references 1. aletaha d, neogi t, silman aj, funovits j, felson dt, iii cob, et al. 2010 rheumatoid arthritis classification criteria: an american college of rheumatology/ european league against rheumatism collaborative initiative. ann rheum dis. 2010;69(10):1580−8. 2. shah a, clair ews. rheumatoid arthritis. in: longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j, editors. harrison’s principles of internal medicine. 18th ed. new york: mcgraw-hill companies, inc.; 2010. p. 2738−52. 3. mcinnes ib, schett g. the pathogenesis of rheumatoid arthritis. n engl j med. 2011;365(23):2205−19. 4. donahue ke, gartlehner g, jonas de, lux lj, thieda p, jonas bl, et al. systematic review: comparative effectiveness and harms of disease-modifying medications for rheumatoid arthritis. ann intern med. 2008;148(2):124−34. 5. o’dell jr. therapeutic strategies for rheumatoid arthritis. n engl j med. 2004;350(25):2591−602. 6. emery p. treatment of rheumatoid arthritis. bmj. 2006;332(7534):152−5. 7. swierkot j, szechinski j. methotrexate in rheumatoid arthritis. pharmacol rep. 2006;58(4):473−92 8. smolen js, landewé r, breedveld fc, buch m, burmester g, dougados m, et al. eular recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. ann rheum dis. 2014;73(3):492-509. 9. leeb bf, andel i, sautner j, nothnagl t, rintelen b. the das28 in rheumatoid arthritis and fibromyalgia patients. rheumatology. 2004;43(12):1504−7. 10. siegel j. comparative effectiveness of treatments for rheumatoid arthritis.ann intern med. 2008;148(2):162−3. 11. breedveld fc, kalden jr. appropriate and effective management of rheumatoid arthritis. ann rheum dis. 2004;63(6):627−33 12. smolen j, keystone ec. future of ra: building on what we know and tailoring treatment; biologic therapies beyond conventional dmards. rheumatology. 2012;51(suppl 5):v55−6 13. katchamart w, trudeau j, phumethum v, bombardier c. efficacy and toxicity of methotrexate (mtx) monotherapy versus mtx combination therapy with nonbiological disease-modifying antirheumatic drugs in rheumatoid arthritis: a systematic review and meta-analysis. ann rheum dis. 2009;68(7):1105−12. 14. breedveld fc, weisman mh, kavanaugh af, cohen sb, pavelka k, vollenhoven rv, et al. the premier study; a multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients althea medical journal. 2016;3(3) 451 with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. arthritis rheum. 2006;54(1):26−37. 15. o’dell jr, leff r, paulsen g, haire c, mallek j, eckhoff pj, et al. treatment of rheumatoid arthritis with methotrexate and hydroxychloroquine, methotrexate and sulfasalazine, or a combination of the three medications: results of a two year, randomized, double blind, placebo controlled trial. arthritis rheum. 2002;46(5):1164−70. 16. alam mk, sutradhar sr, pandit h, ahmed s, bhattacharjee m, miah a, et al. comparative study on methotrexate and hydroxychloroquine in the treatment of rheumatoid arthritis. mymensingh med j. 2012;21(3):391−8. 17. o’dell jr, haire ce, erikson n, drymalski w, palmer w, eckhoff pj, et al. treatment of rheumatoid arthritis with methotrexate alone, sulfasalazine and hydroxychloroquine, or a combination of all three medications. n engl j med. 1996;334(20):1287−91. 18. de jong ph, hazes jm, barendregt pj, huisman m, van zeben d, van der lubbe pa, et al. induction therapy with a combination of dmards is better than methotrexate monotherapy: first results of the treach trial. ann rheum dis. 2013;72(1):72−8 19. anderson jj, wells g, verhoeven ac, felson dt. factors predicting response to treatment in rheumatoid arthritis: the importance of disease duration. arthritis rheum. 2000;43(1):22−9. 20. radovits bj, fransen j, van riel plcm, laan rfjm. influence of age and gender on the 28-joint disease activity score (das28) in rheumatoid arthritis. ann rheum dis. 2008;67(8):1127−31 natharubini nadarajah, riardi pramudyo, kuswinarti: treatment of rheumatoid arthritis with methotrexate only or a combination of methotrexate and hydroxychloroquine althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 167 characteristic and knowledge among treatment supporter of children patients with tuberculosis at lung clinic bandung october–november 2012 kamelia utami suhada,1 sri yusnita irda sari,2 diah asri wulandari,3 elsa pudji setiawati4 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 4department of public health faculty of medicine universitas padjadjaran abstract background: children are the most vulnerable to get tb infection and infected by adult patients. one of the components of directly observed treatment short course (dots) is direct observation by treatment supporter who has important role in the success of tb’s treatment. the aim of this study was to identify the characteristics and knowledge among treatment supporter of children patients with tb at lung clinic bandung. methods: a descriptive study was conducted in october-november 2012 to 96 treatment supporters of child patients who were diagnosed with tb, either new or old cases. they were selected by consecutive sampling at lung clinic bandung. validated questionnaire with 14 questions was administered. the percentage of the correct answers was categorized as good, moderate, and poor. the characteristic variables included age, sex, education, occupation, relation with the patients, living at the same house, presence of other tb patients, and counseling given by providers. data was analyzed using frequency distribution. result: most of the respondents were 21-30 years old (42.7%), female (84.4%), elementary school graduate (33.3%), unemployed (69.8 %), mother of the child, living in the same house, had other tb patients, and had received counseling by providers at lung clinic. the knowledge about tb among the respondents was moderate (56.3%). the respondents who had good knowledge had underwent the counseling session. conclusions: the knowledge of the respondents was moderate. further study on the relationship between the level of knowledge of treatment supporter and the adherence of tb treatment should be conducted. [amj.2015;2(1):167–71] keywords: knowledge, treatment supporter, tuberculosis in children correspondence: kamelia utami suhada, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628562191992 email: kameliautami@gmail.com introduction tuberculosis (tb) is a bacterially infectious disease caused by mycobacterium tuberculosis (mtb), which is transmitted from person to person through the droplet from the throat and lungs of the people with active tb disease.1 at present time, tb remains a primary health problem which occurs in many parts of the world.2 according to the world health organization (who) in 2011, indonesia is the fourth largest contributor of tb in the world.3 as reported by the sub-directorate of tb of indonesian ministry of health, the province of west java has the highest prevalence compared to other regions.4 children are the most vulnerable age to get tb infection. most children are infected by tb from adult patients. difficult confirmation of tb diagnosis among children has resulted in difficult treatment of tb, hence tb in children was excluded from the priority of public health in many countries, including indonesia. however, in the last several years, along with recent studies conducted in the developing countries, control of tb in children had been provided with proper attention.5 the treatment of tb requires a long period of time and a lot of drugs, despite the fact that tb is one of the diseases that is curable and treatable .3,6 thus it leads to a primary problem in tb treatment, which is non-compliance in taking medicine that may result in treatment failure, relapse, and medicine resistance. to overcome the problem of tb in indonesia, the strategy of directly observed treatment short course (dots) is recommended by who althea medical journal. 2015;2(2) 168 amj june, 2015 table 1 the characteristics of treatment supporter characteristics frequency (n=96) percentage (%) age (years old) 21–30 41 42.7 31–40 40 41.7 >40 15 15.6 sex female 81 84.4 male 15 15.6 education no school 1 1.0 not completed elementary school 5 5.2 completed elementary school 32 33.3 junior high school 17 17.7 senior high school 29 30.2 university/college 12 12.5 occupation student 3 3.1 unemployed 67 69.8 civil servant 8 8.3 entrepreneur 8 8.3 farmer/fisherman 7 7.3 others 3 3.1 relation of treatment supporter and patients father 15 15.6 mother 77 30.2 grandmother 3 3.1 aunty 1 1.0 living in the same house with patient yes 93 96.9 no 3 3.1 other tb patients at home yes 59 61.5 no 37 38.5 respondent counseling yes 68 70.8 lung clinic 50 52.1 primary health care 14 14.6 dr. hasan sadikin hospital 4 4.2 no 28 29.2 althea medical journal. 2015;2(2) 169kamelia utami suhada, sri yusnita irda sari, diah asri wulandari, elsa pudji setiawati: characteristic and knowledge among treatment supporter of children patients with tuberculosis at lung clinic bandung october–november 2012 and the world bank.4 the dots is the most effective strategy to control the epidemic of tb throughout the world.7 one component of dots is the combination of short-term of tb’s drug and direct observation, that requires a person responsible for the observation of the patients in medicine-taking, which is called treatment supporter (pengawas menelan obat/pmo)8. the knowledge of the treatment supporter plays an important role in the success of tb’s treatment. poor knowledge of the treatment supporter might result in treatment failure. based on the explanation above, this study was conducted to identify the characteristics and knowledge among treatment supporters of children patients with tb at lung clinic bandung methods a descriptive study was conducted in october– november 2012 to 96 treatment supporters that were selected by consecutive sampling at lung clinic bandung. those respondents were treatment supporters of children patients who were diagnosed with tb, either new or old cases. the data were collected using validated questionnaire comprising 14 questions about tb and treatment supporter’s role. informed consent was given to respondents before the interview. the correct answer was scored as 1 and the wrong answer/not know was scored 0. the percentage of correct answers was calculated and interpreted as follows: good: 75–100%, moderate: 56–75%, and poor: < 56%.9 other variables collected were: age, sex, education, occupation, relation with the patients, living at the same house, presence of other tb patients, and counseling given by providers. data were analyzed using frequency distribution. results table 1 showed that nearly half of the respondents were at the age of 21-30 years (42.7%) and that 81 respondents (84.4%) were female. with regard to the education level, the majority of patients attending elementary school were (33.3%). most of the treatment supporters were unemployed (69.8 %). additionally, most of the respondents were the mother of the children, living in the same house with the patients and had other tb patients who lived at the same house. most of the respondents had already been given counselling by the providers at lung clinic. meanwhile there was 28 respondents(29.2%) who never received counselling. mostly the knowledge concerning tb among the respondents was moderate, followed by good and poor (table 2). most respondents (69.8%) did not know the definition of tb. they had ever heard about tb but did not know exactly the definition of tb. nearly all respondents (92.7%) knew that tb was a communicable disease. most of respondents (83%) made mistake when answering the questionwhether tb is a curable/treatable disease, they still assumed that tb was not a curable/treatable disease. all respondents (100%) were informed that the medicines had to be taken daily and they also knew about their task as treatment supporter (table 3). most of the respondents who had good knowledge had underwent the counselling session. discussions from all respondents, the youngest respondent was 23 years while the oldest was 59 years. there is no age limit to be treatment supporter. most importantly, treatment supporter can ensure that tb patients take the medicines, regardless to the age.10 most of the treatment supporters were mother of the patients, the distribution of treatment supporter in the study was all from family groups, including father, mother, grandmother, and aunt.10 the recruitment of treatment supporter in semarang was prioritized from the patients’ family since the family has the closest relation that enables table 2 knowledge of treatment supporter knowledge of treatment supporter frequency percentage good 21 21.9 moderate 54 56.3 poor 21 21.9 althea medical journal. 2015;2(2) 170 amj june, 2015 table 3 the percentage of knowledge on tb among treatment supporters questions correct answer wrong answer do not know n % n % n % 1. knowledge about the definition of tb 29 30.2 67 69.8 2. knowledge that tb is not a genetic disease 10 10.4 64 66.7 22 22.9 3. knowledge that tb is a communicable disease 89 92.7 3 3.1 4 4.2 4. knowledge that tb is a curable / treatable disease 12 12.5 80 83.3 4 4.2 5. knowledge that tb also attacks other than lungs 23 24.0 55 57.3 18 18.8 6. knowledge about the causes of tb 83 86.5 7 7.3 6 6.3 7. knowledge about the main transmission of tb 77 80.2 19 19.8 8. knowledge that the source of transmission of tb to children is adult with tb 85 88.5 4 4.2 7 7.3 9. knowledge that tb can be prevented by bcg immunization 30 31.3 39 40.6 27 28.1 10. knowledge that tb medicines have to be taken daily 96 100 11. knowledge about the duration of tb treatment 71 74.0 25 26.0 12. knowledge that tb needs treatment supporter 90 93.8 1 1.0 5 5.2 13. knowledge that treatment supporter might live in different home with the patient 42 47.0 47 49.0 7 7.3 14. knowledge that the task of treatment supporter is monitoring that the patient is taking the medicine regularly and completely 96 100 them to ensure that the patients take the medicine without any transportation cost.10 in addition, since there is an emotional relation between the patient and treatment supporter from the family, it is expected that the rate of treatment supporter’s practice will increase.10 the study showed that, most of the respondent already got the counseling about tb. the counseling is one of the obligatory programs in lung clinic bandung. each treatment supporter was obliged to attend the counseling about tb. the knowledge level among the respondents who had attended the counseling was higher compared to those who had not attended, as represented in the higher percentage of good and moderate knowledge among the respondents who had attended the counseling, and higher percentage of poor knowledge among those who had not attended the counseling. hoa et al.11 reported that there was significant relation between education level and the extent of information received by respondents. all respondents were informed that tb medicines had to be taken every day, but only some knew the length of tb treatment of 6 months. hermayanti12 stated all patients knew about the duration of the treatment (6 months), but only 50% of them knew the impact of incomplete adherence to the treatment.12 this is closely related to the information provided by the health staff.12 all patients stated that they already received the information from health workers, however, it was likely that the information about the impact of incomplete treatment was missed.12 several respondents still did not know that the tb patients should be accompanied by a althea medical journal. 2015;2(2) 171 treatment supporter. this implied that they did not know their role as the treatment supporter. the importance of treatment supporter should be disseminated to the community, especially to those who served as treatment supporters in order to increase their awareness. good level of knowledge among treatment supporters may improve one practice as the treatment supporter. widjanarko et al.10 said that there were strong correlation between the knowledge and practice of treatment supporter. ancok in widjanarko et al.10 suggested that one’s good knowledge of activities will result in positive attitude reflected in their activeness in taking part in the activities. the limitation of this study might be in the respondents who only rely on common sense in answering a questionnaire so that the results do not actually describe the knowledge of the respondents. in conclusion, mostly, the knowledge about tb among the respondents was moderate. based on the results of this study, it is suggested that lung clinic bandung should ensure that each treatment supporter has to get counseling session. such counseling should be provided periodically to treatment supporter. further study about the relationship between the level of knowledge of treatment supporter and the adherence of tb treatment had to be performed. references 1. who. tuberculosis. 2012 [cited 2012 april 11]; available from: http://www. who.int/topics/tuberculosis/en/. 2. andrus jk, quadros ca, bureau pas. recent advances in immunization. 2nd ed. washington, d.c: pan american health org; 2006. 3. who. tuberculosis fact sheets. 2012 [cited 2012 april 11]; available from: http:// www.who.int/mediacentre/factsheets/ fs104/en/index.html 4. departemen kesehatan republik indonesia. situasi epidemiologi tb indonesia. jakarta: departemen kesehatan republik indonesia; 2011. 5. kartasasmita cb. epidemiologi tuberkulosis. sari pediatri; 2009;11(2): 124–9. 6. elzouki ay, stapleton fb, whitley rj, william, harfi ha, nazer h. textbook of clinical pediatrics. 2nd ed. new york:springer; 2011. 7. tb alert. dots. 2005 [cited 2012 april 12]; available from: http://www.tbalert. org/worldwide/dots.php. 8. rahajoe nn, basir d, ms m, kartasasmita cb, editors. pedoman nasional tuberkulosis anak. 2nd ed. jakarta: ukk respirologi pp idai; 2008. 9. arikunto, suharsimi. prosedur penelitian: suatu pendekatan praktek. jakarta: rineka cipta; 2002. 10. widjanarko b, prabamurti pn, widyaningsih n. analisis faktor-faktor yang mempengaruhi praktik pengawas menelan obat (pmo) dalam pengawasan penderita tuberkulosis paru di kota semarang. jurnal promosi kesehatan indonesia; 2006;1(1):15–24 11. hoa np, diwan vk, co nv, thorson ae. knowledge about tuberculosis and its treatment among new pulmonary tb patients in the north and central regions of vietnam. int j tuberc lung dis. 2004;8(5):603–8. 12. hermayanti d. studi kasus drop out pengobatan tb di puskesmas kodya malang. jurnal saintika medika. 2010;6(13) table 4 the knowledge on tb and subject participation in counseling counseling level of knowledge good (%) moderate (%) poor (%) yes 19 (27.9%) 39 (57.4%) 10 (14.7%) no 2 (7.1%) 15 (53.6%) 11 (39.3%) kamelia utami suhada, sri yusnita irda sari, diah asri wulandari, elsa pudji setiawati: characteristic and knowledge among treatment supporter of children patients with tuberculosis at lung clinic bandung october–november 2012 althea medical journal. 2015;2(3) 382 amj september, 2015 physical fitness of cleaners in faculty of medicine universitas padjadjaran, november 2012 adi wibisono sulistijo,1 ambrosius purba,2 tri damiati pandji3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine, universitas padjadjaran, 3department of physical medicine and rehabilitation, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cleaning is an occupation that is carried out worldwide in many different environments. cleaning workers (cleaners) often have low occupational skills and belong to the less advantaged educational and socioeconomic groups. because of the high physical work demands and low cardiorespiratory fitness, cleaners have the risk to have cardiovascular diseases. the aim of this study was to measure the 5 components of physical fitness (cardiorespiratory endurance, muscle endurance, muscle strength, flexibility and body composition) of cleaners in faculty of medicine universitas padjadjaran. methods: a descriptive study was carried out to all cleaners (31 persons) of faculty of medicine universitas padjadjaran in november 2012. the subjects were tested for cardiorespiratory endurance, muscle endurance, muscle strength, flexibility and body composition. the results were categorized using the standard of ministry of health republic indonesia. results: from 31 subjects, cardiorespiratory endurance was in poor category (50%). shoulder and hand muscle endurance was in poor category (54.8%) and stomach muscle endurance was in very poor category (67.7%). hand−grip muscular strength was in very poor category: right hand (80.7%) and left hand (87.1%). back muscle strength was in poor category (58.1%). leg muscular strength was in very poor category (48.4%). flexibility was in a very good category (97%) and body composition was also in a good category (54.8%). conclusions: from 5 components of cleaners’ physical fitness, 3 components (cardiorespiratory endurance, muscle endurance and muscular strength) are in poor and very poor category. [amj.2015;2(3):382–86] keywords: cleaners, occupational health, physical fitness. correspondence: adi wibisono sulistijo, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281312516197 email: adi.wibisono.sulistijo@gmail.com introduction mens sana in corpore sano, “inside a healthy body resides a healthy mind”. this famous quote is similar to the world health organization (who) definition about health as quoted by the ministry of health of the republic of indonesia, health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.1,2 healthy body is essential in human life. there are many advantages in having a healthy body. for example, people will become more resistant to disease and less likely to get degenerative disease such as diabetes, stroke and hypertension at old age. other benefits by having healthy body or become physically fit are people become more productive in work and less likely to be absent from work. cleaning is an occupation that is carried out worldwide in many different environments. it can be done both indoors and outdoors.3 cleaning workers (cleaners) often have low occupational skills and belong to the less advantaged educational and socioeconomic groups.3 because of the high physical work demands and low cardiorespiratory fitness, cleaners have the risk to have cardiovascular diseases.4 dailytask of cleaners in faculty of medicine universitas padjadjaran are: cleaning the althea medical journal. 2015;2(3) 383 building, taking care of the gardens, picking up trash and put it in dump. cleaners walk about 100 meters everyday andcarry the trash bins from the buildings to the location of the dump. these activities probably affect the cardiorespiratory endurance (vo2 max), muscle endurance and strength. in order to be able to do these tasks, cleaners need good physical fitness. the aim of this study was to measure the 5 components of physical fitness 5,6 (cardiorespiratory endurance, muscle endurance, muscle strength, flexibility and body composition) among cleaners in the faculty of medicine universitas padjadjaran. methods a descriptive study was carried out to all cleaners (31 persons), of the faculty of medicine, universitas padjadjaran for 2 days, 8th and 11th november 2012. the subjects were tested for cardiorespiratory endurance, muscle endurance, muscle strength, flexibility and body composition. cardiorespiratory endurance was measured using rhyming step−up test.5 the subject stood in front of a rhyming chair and wore polar bracelet to assess heartbeat. the heartbeat of the subject before testing must be below 100 beat per minute (bpm). a metronome was set as a tempo for the subject to step up and down on the chair. at the researcher’s command, the subject put one leg on the chair and by using the metronome as the tempo, the subject continue to step up and down on the chair. the duration of the test was 5 minutes, after 5 minutes the subject was then allowed to take a rest. after 15 seconds rest, the bpm was collected. the result was then recorded into the astrand normogram to gain the vo2 max result. the muscle endurance test was divided into 2 categories: hand shoulder muscle endurance and abdominal muscle endurance. hand shoulder muscle endurance was assessed by doing push−up test in one minute duration.5 abdominal muscle endurance was assessed by doing sit up test in one minute duration. the results of both tests were the total frequency of sit−ups and push−ups in one minute. the muscle strength test was divided into several components, those were: hand grip muscle strength test, back muscle strength test and leg strength test.5 the procedure to test hand grip muscle strength: the subject stands up while holding the hand dynamometer. the subject than squeezed the hand dynamometer as hard as he can. the force resulted from squeezing the dynamometer would move the pointer in the scale. the number that was shown by the pointer was then recorded. to assess the back muscle strength, the subject stood on the back−leg dynamometer. the subject then lean forward while holding the handle with both arms (right hand in pronation position, left hand in supination position) at the height of thigh. the subject then pulled as hard as he could. the number that was shown in the dynamometer was recorded. the procedure for leg muscle strength test the subject stood on the back−leg dynamometer while bending his knee 130−1400. the subject held the handle with both arms and then pulled it as hard as he could. after that the number that was shown in the dynamometer was recorded. all the test was repeated 3 times.7 flexibility was assessed by using sit and reach test method.7 the subject sat in front of the scaling board (60x20cm) with both legs in full extension position and both feet touched the board. the back of the subject’s knees also touched the floor (knee extensiton). the subject leaned forward while pushing the plate as far as he could by using his fingertips. the number that was shown by the plate was recorded. this test was repeated twice.7 body composition was measured using skin fat-fold caliper. the location of assessment was on triceps and subscapula.5 the procedure assesses the skin fat−fold in triceps: first the researcher pinched the skin in the middle of an table 1 distribution of cardiorespiratory endurance category frequency (n) percentage (%) very poor 7 23.3 poor 15 50.0 average 6 20.0 good 2 6.7 very good 0 0.0 adi wibisono sulistijo, ambrosius purba, tri damiati pandji: physical fitness of cleaners in faculty of medicine universitas padjadjaran, november 2012 althea medical journal. 2015;2(3) 384 amj september, 2015 imaginary line between coracodeus processus and olecranon while the subject maintained hand in relaxation position (beside body). pinching was performed by using the thumb and index finger and then, the number shown on the scale was recorded. this test was done 3 times.7 the procedure to assess subscapula skin fat−fold: the researcher pinched the skin directly under the lateral left subscapula while the subject maintained standing position. the number shown on the scale was recorded. this test was repeated 3 times.7 afterward, the result of the tests were input into specific gravity formula (specific gravity = 1.0909 − (0.00101 x triceps + 0.0009 x subscapula)).7 then, the specific gravity was input into body fat percentage formula (body fat percentage = (5.548 ÷ sp.gr – 5.044) x 100%)7 the results of the measurement of 5 components of physical fitness were categorized using the standard in the ministry of health of the republic of indonesia. results the result of the cardiorespiratory endurance test showed that 50% of subjects had poor cardiorespiratory (table 1). as for the other physical fitness component, muscle endurance test was divided into hand and muscle endurance, and abdominal endurance. hand and shoulder muscle endurance is mostly poor (54.8%) while abdominal muscle endurance shows mostly in table 2 distribution of muscle endurance category hand and shoulder muscle endurance abdominal muscle endurance frequency (n) percentage (%) frequency (n) percentage (%) very poor 6 19.4 21 67.7 poor 17 54.8 6 19.4 average 5 16.1 1 3.2 good 2 6.5 1 3.2 very good 1 3.2 2 6.5 table 3 distribution of muscle strength category hand grip back muscle strength leg strengthright left n(%) n(%) n(%) n(%) very poor 25(80.7) 27(87.1) 10(32.3) 15(48.4) poor 3(9.7) 0(0.0) 18(58.1) 7(22.6) average 3(9.7) 4(12.9) 3(9.7) 7(22.6) good 0(0.0) 0(0.0) 0(0.0) 1(3.2) very good 0(0.0) 0(0.0) 0(0.0) 1(3.2) table 4 distribution of flexibility category frequency (n) percentage (%) very poor 0 0.0 poor 0 0.0 average 0 0.0 good 1 3.2 very good 30 96.8 althea medical journal. 2015;2(3) 385 very poor category (67.7%) (table 2). the muscle strength test was divided into: hand grip strength, back muscle strength and leg strength. the result of hand grip strength test in table 3 shows that almost all subjects were in very poor category (right hand=80.7%; left hand=87.1%). back muscle strength result was mostly dominated in poor category (58.1%) while majority of leg strength test result was in very poor category (48.4%). the result of flexibility test was almost every subject had a very good test result (96.8%) (table 4). as for body fat percentage, the result in table 5 shows that most of the subjects had good result (17%). discussions the physical fitness overviews of cleaners in the faculty of medicine universitas padjadjaran were poor. this was based on the result of cardiorespiratory endurance test that was dominated by poor category (50%) and very poor category (23.3%). many cleaners rarely did exercise. this statement was based on the interview with coordinator of the cleaners. a study by bonaiuto et al8, discovered that there was a positive relation between intense physical aerobic-anaerobic activity on cardiovascular autonomic system adjustments. a good cardiovascular autonomic system adjustment means a better cardiorespiratory endurance under physical stress. a good cardiorespiratory endurance can maximize the oxygen distribution, by increasing production of adenosin triphosphate (atp) and creatinine phosphate as the source of energy and increasing people tolerance towards lactic acid and delaying tiredness.9,10 moreover, the results of cleaner’s muscle endurance and muscle strength were poor and very poor. this could happen as the result of sedentary lifestyle or limited physical activity of the subjects so the muscle cells became untrained and easily become fatigued.9,10 on the other hand, flexibility and body fat percentage shows a remarkable result. the subjects had very good flexibility because the activity as cleaning service included many bending activities in order to clean difficult places. as the result, the tendon attached to the joint became more flexible and increased the joints range of movement (rom).6 body fat percentage describes how much fat was deposited in the whole body. body fat deposition depends on the balance between energy intake and energy output. most of the subjects had very good and good body fat percentage category, which means that there was an equilibrium between energy intake and energy expenditure.11 identification of factors that influence the cleaners’ poor physical fitness and comparison of the physical fitness with other occupational groups were not carried out, were the limitation of this study. it can be concluded that the physical fitness of the cleaners in faculty of medicine universitas padjadjaran were poor, and there are some recommendations in order to increase the physical fitness. to increase the capability of cardiorespiratory endurance, cleaning service workers should do physical activity continuously around 60 minutes which is performed 3−5 times a week with sub maximal intensity.7,8 to increase muscle endurance and strength, the cleaners collect the garbage in one big garbage plastic and increase the weight of garbage from time to time before putting it in the dump. to maintain the flexibility, cleaning service workers are recommended to do stretching before starting to work. references 1. world health organization. constitution table 5 distribution of body fat percentage category frequency (n) percentage (%) poor 0 0.0 very good 2 22.6 good 17 54.8 average 7 6.5 over 0 0.0 fat 4 12.9 adi wibisono sulistijo, ambrosius purba, tri damiati pandji: physical fitness of cleaners in faculty of medicine universitas padjadjaran, november 2012 althea medical journal. 2015;2(3) 386 amj september, 2015 of the world health organization. world health organization. 2006 [cited 2012 september 10]. available from: http:// www.who.int/about/definition/en/print. html. 2. ministry of health republic indonesia. constitution of health republic indonesia year 2009. ministry of health republic indonesia. 2009 [cited 2012 september 10]; available from: http://www.pppl. depkes.go.id/_asset/_regulasi/uu_36_ tahun_2009[1].pdf 3. zock jp. world at work: cleaners. occup environ med. 2005;62:581–4 4. korshøj m, krustrup p, jørgensen mb, prescott e, hansen am, kristiansen j, et al. cardiorespiratory fitness, cardiovascular workload and risk factors among cleaners; a cluster randomized worksite intervention. bmc public health. 2012;12:645 5. caspersen cj, powell ke, christenson gm. physical activity, exercise and physical fitness: definition and distinctions for health-related research. public health rep. 1985;100(2):126−31. 6. harsono. coaching dan aspek-aspek psikologis dalam coaching. jakarta: cv tambak kusuma; 1988 7. universitas padjadjaran, ministry of health republic indonesia. modul pelatihan kesehatan olahraga di balai kesehatan olahraga masyarakat (bkom). bandung: ministry of health republic indonesia west java. 2003. 8. bonaiuto m, di mauro d, speciale f, pagano f, buda d, vita g, magaudda l, trimarchi f. evaluation of heart rate recovery in relation to playing position in professional soccer player. j sports med phys fitness. 2012; 52(6):583–8. 9. guyton ac. textbook of medical physiology. 11th ed. pensylvania: elsevier saunders; 2006. 10. purba a. fisiologi kedokteran: kardiovaskular dan faal olahraga. bandung: department of physiology, faculty of medicine, universitas padjadjaran; 2012. 11. whitney e, rolfes sr. understanding nutrition. 10th ed. belmont: thomson wadsworth; 2005 althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 54 amj march 2016 clinical and histopathological characteristic of salivary gland carcinoma in dr. hasan sadikin general hospital in 2009–2012 fatimah lidya andriani,1 ismet muchtar nur,2 sally mahdiani3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of otolaryngology-head & neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: salivary gland neoplasm is one of the rare neoplasm. the frequency of this neoplasm is lower than 2% of all type of tumors in human. malignant salivary gland tumor comprises 6% of all head and neck tumors. data about salivary gland carcinoma are still limited. the aim of this study was to determine the frequency of malignant salivary gland based on the patients’ age, gender, site of lesion and histopathology type. methods: this study was conducted descriptively. there were 97 subjects found from histopathological form that had been examined in department of anatomical pathology, dr. hasan sadikin general hospital in 2009–2012. total sampling technique was used and all data about patients’ age, gender, site of lesion and histopathology type were collected and analyzed. results: of 97 cases, age group 50–59 years old had the highest frequency (29%). the prevalence in male was more frequent than female with male:female ratio was 1.4:1. the most common site of carcinoma was found in parotid gland (45%). mucoepidermoid carcinoma was the most common histopathology type found in this study (28%). conclusions: salivary gland carcinoma is still a rare malignant case in dr. hasan sadikin general hospital. carcinoma in parotid gland was the most common site and mucoepidermoid carcinoma was the most common histopathology type. [amj.2016;3(1):54–8] keywords: carcinoma, histopathology, salivary gland correspondence: fatimah lidya andriani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8127577725 email: lidyafla@gmail.com introduction salivary gland neoplasm is one of the rare neoplasms. department of ear nose throat (ent) wroclaw, polska reported that 304 salivary glands tumor patient were with 83.9% benign tumor and 16.1% malignant tumor in 2001–2010.1 its peak incidence was varied according to the previous studies. most of them reported that salivary gland tumor reached the incident peak in sixth-seven decade of life.2 five years life expectancy ranged between 5–95% depend on various factors including site of lesion, histopathology type, stage of tumor and the involvement of facial nerve or surrounding structure. original site of salivary glands cancer is one of significant factors. cancer that can be excised fully from parotid gland has the better result, followed by submandibular gland, sublingual gland and minor salivary glands.3 based on the background above and limited data about salivary gland carcinoma, the study was conducted concerning salivary glands carcinoma based on patients’ age, gender, site of lesion and histopathological type in department of anatomical pathology dr. hasan sadikin general hospital. methods this study was carried out from september– the subject of the study was taken from the histopathological form of the patients in department of anatomical pathology, dr. hasan sadikin general hospital from january 2009 to december 2012 that were selected using total sampling method. this method was carried out from september–october 2013 in department of anatomical pathology. this study was approved by health research ethics committe. the inclusion criteria was all the medical records of patients diagnosed althea medical journal. 2016;3(1) 55 as salivary gland carcinoma. the incomplete data of histopathological form was excluded from this study. this descriptive study used retrospective methods. variables of this study were patients’ age and gender, site of lesion and histopathology type. all cases were classified according to the criteria suggested by 2005 world health organization (who) histological classification. data were collected and analyzed using microsoft excel 2007. the frequency and percentage of the mentioned variable were calculated. collected data from medical records were kept confidentially and vanished after the research was done. results during 2009–2012, 97 cases of salivary gland carcinoma were found in department of anatomical pathology, dr. hasan sadikin general hospital. patients’ age for cases was ranged from 6–86 years old. the cases increased along with the increasing of age. the peak of salivary gland carcinoma was in the fifth decade of life. the lowest case were found in first and eighth decade of life. mucoepidermoid carcinoma was the most common of all carcinoma in salivary gland, followed by squamous cell carcinoma, adenoid cystic carcinoma and acinic cell carcinoma. mucoepidermoid carcinoma and squamous cell carcinoma were distributed widely in the age group and had the peak in fifth decade of life. the peak of acinic cell carcinoma was in third decade of life (table 1). salivary gland carcinoma was more frequent in male than female with male:female ratio was 1.4:1 and the most common histopathological type of tumor was mucoepidermoid carcinoma in both male and female (table 2). almost half of the cases were found in parotid gland, followed by minor salivary glands, submandibular gland and sublingual gland. mucopeidermoid carcinoma was mostly found in parotid gland. adenoid cystic carcinoma and squamous cell carcinoma fatimah lidya andriani, ismet muchtar nur, sally mahdiani: clinical and histopathological characteristic of salivary gland carcinoma in dr. hasan sadikin general hospital in 2009–2012 table 1 histopathological type of salivary gland carcinoma based on age group histophatology age (years) total 0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 acinic cell carcinoma 1 5 1 1 1 9 mucoepidermoid carcinoma 2 1 5 6 10 2 1 27 adenoid cystic carcinoma 2 1 2 5 3 13 polymorphous lowgrade adenocarcinoma 1 1 2 4 clear cell carcinoma 1 1 2 basal cell adenocarcinoma 1 1 2 oncocytic carcinoma 1 1 adenocarcinoma 1 1 2 myoepithelial carcinoma 1 1 2 carcinoma ex pleomorphic adenoma 1 1 1 1 1 2 7 squamous cell carcinoma 1 1 2 5 8 3 2 1 23 small cell carcinoma 1 1 large cell carcinoma 1 1 2 lymphoepithelial carcinoma 2 2 total (%) 2 (2) 7 (7) 6 (6) 16 (17) 18 (19) 28 (29) 10 (10) 8 (8) 2 (2) 97 (100) althea medical journal. 2016;3(1) 56 amj march 2016 table 2 histopathological type of salivary gland carcinoma based on gender histophatology gender male female acinic cell carcinoma 2 7 mucoepidermoid carcinoma 17 10 adenoid cystic carcinoma 6 7 polymorphous low-grade adenocarcinoma 2 2 clear cell carcinoma 2 basal cell adenocarcinoma 2 oncocytic carcinoma 1 adenocarcinoma 2 myoepithelial carcinoma 1 1 carcinoma ex pleomorphic adenoma 5 2 squamous cell carcinoma 15 8 small cell carcinoma 1 large cell carcinoma 1 1 lymphoepithelial carcinoma 2 total (%) 57 (59) 40 (41) widely distributed at each site of lesion. squamous cell carcinoma had the highest case in minor salivary glands. oncocytic carcinoma and adenocarcinoma only affected parotid gland. large cell carcinoma was only discovered in submandibular gland (table 3). discussion in the present review of 97 salivary gland carcinoma, group aged 50–59 years old was the highest case (29%). in 30–39, 40–49 and 60–69 years old group also showed significant number. this result is similar to the reference which reported that frequency of salivary gland carcinoma increase in fourth to seventh decade of life.3,4 the increase in case occured about 6.9% compared to the previous study by achmad thohir in department of anatomical pathology dr. hasan sadikin general hospital in 2003–2006. salivary gland carcinoma more often affected male, with male:female ratio was 1.4:1. this result is similar to the study in iran that reported predominance for men with male:female ratio was 1.4:1.5 in contrast, some references and prior studies reported that women were more often affected than men.4,6,7 according to site of lesion, carcinoma is more frequent in parotid gland, followed by minor salivary glands, submandibular gland and sublingual gland. this result was similar to the reference that reported that 65–80% salivary gland carcinoma occured in parotid gland, 9–23% in minor salivary glands, 10% in submandibular gland and less than 1% in sublingual gland.3,5 only 3 cases were identified in the sublingual gland. this confirmed the rarity of salivary tumors at this site, as mentioned in other studies.5,7–9 histopathological type that is mostly found was mucoepidermoid carcinoma. in the second place, there was squamous cell carcinoma, followed by adenoid cystic carcinoma. yu-long wang et al.10 reported that mucoepidermoid carcimona was the most common histophatology type (24.6%), followed by adenoid cyctic carcinoma (18%) in chinesse population. some reference also reported that mucoepidermoid carcinoma was the most common carcinoma.11 according to who, incidence of squamous cell carcinoma was less than 1% of all carcinoma in salivary gland.5 prior study by achmad thohir in dr. hasan sadikin general hospital reported that adenoid cystic carcinoma was the most common histopathology. in this study, acinic cell carcinoma occured in almost all age group and increased in 30– althea medical journal. 2016;3(1) 57fatimah lidya andriani, ismet muchtar nur, sally mahdiani: clinical and histopathological characteristic of salivary gland carcinoma in dr. hasan sadikin general hospital in 2009–2012 39 years old. this result was similar to the reference that reported that this carcinoma was distributed widely in any group of age.4,12 mucoepidermoid carcinoma is also distributed widely in age group. enhancement developed in third to fifth decade of life. this malignant tumor occured in child as well. some author reported that mucoepidermoid carcinoma is common in child and adult, distributed widely in age group, and had the peak in third to fifth decade of life.12 adenoid cystic carcinoma also spread in any age group and had the peak in 50–59 years old. this result was similar to the reference that reported that this carcinoma is distributed in all age group and increased in fourth to sixth decade of life.3,4,12 squamous cell carcinoma was found in almost all age group and increased in 40–79 years old. previous study reported that squamous cell carcinoma was found from 7–95 years old with peak in seventh decade of life.12 carcinoma ex pleomorphic and squamous cell carcinoma were most often affected men with male:female ratio was 2:1, as reported previously. acinic cell carcinoma had higher frequency in women with female:male ratio was 2.8:1. this result was similar to previous study by ilayaraja2 mucoepidermoid carcinoma were mostly found in men, while another study reported that it was more often found in women than men. polymorphous low-grade adenocarcinoma showed equal case between men and women. however, some authors reported that two to three times is common in women than men.4,12 according to site of lesion, acinic cell carcinoma more often occured in parotid gland and was followed by minor salivary glands, as had been documented that 80% in parotid gland and 17% in minor salivary glands. mucoepidermoid carcinoma was mostly found in parotid gland, similar to the reference that reported that it was common in major salivary glands, espescially parotid gland.4 the frequency in parotid gland is about 60%.12 adenoid cystic carcinoma was mostly found in parotid gland and submandibular gland, followed by minor salivary gland and sublingual gland, as mentioned in reference.4 however, other references reported that it was more often affected by minor than mayor salivary gland. carcinoma ex pleomorphic was also more often found in parotid gland, similar to the reference about 81.7%.12 polymorphous low-grade adenocarcinoma was more often affected minor salivary gland. this result was similar to the reference that reported 60% occured in minor salivary gland, especially table 3 histopathological type of salivary gland carcinoma based on site of lesion histophatology site of lesion (salivary gland) parotid submandibular sublingual minor acinic cell carcinoma 6 3 mucoepidermoid carcinoma 16 8 3 adenoid cystic carcinoma 5 5 1 2 polymorphous low-grade adenocarcinoma 1 3 clear cell carcinoma 2 basal cell adenocarcinoma 1 1 oncocytic carcinoma 1 adenocarcinoma 2 myoepithelial carcinoma 1 1 carcinoma ex pleomorphic adenoma 5 1 1 squamous cell carcinoma 5 4 1 13 small cell carcinoma 1 large cell carcinoma 2 lymphoepithelial carcinoma 1 1 total (%) 44 (45) 21 (22) 3 (3) 29 (30) althea medical journal. 2016;3(1) 58 amj march 2016 palatum.squamous cell carcinoma is mostly found in minor salivary gland as well, but in contrast with the previous study that reported was more often found in parotid gland and submandibular gland.4,12 limitations of the study were limited time for data collection and patients’ identity is not completely written in histopathological form. the conclusion of this study is the frequency of salivary gland carcinoma increased in age group 50–59 years old. male and parotid gland were the most affected and mucoepidermoid carcinoma was the most frequent lesion, followed by squamous cell carcinoma and adenoid cystic carcinoma. references 1. kubacka m, orendorz-fraczkowska k, pazdro-zastawny k, morawska-kochman m, kręcicki t. epidemiological evaluation of salivary gland tumors in the wroclaw ent department patients in the years 2001– 2010. polish otolaryngol. 2013;67(1):30– 3. 2. ilayaraja v, prasad h, anuthama k, sruthi r. acinic cell carcinoma of minor salivary gland showing features of high grade transformation. j oral maxillofac pathol. 2014;18(1):97–101. 3. faquin wc, powers cn. salivary gland cytopathology. new york: springer; 2008. 4. barnes l, eveson jw, reichart p, sidransky d, editors. world health organization classification of tumours pathology & genetics head and neck tumours. lyon: iarc press; 2005. 5. ansari mh. salivary gland tumord in an iranian population : a retrospective study of 130 cases. j oral maxillofac surg. 2007;65(11):2187–94. 6. kumar v, abbas ak, fausto n, aster jc. robbin and cotran pathologic basis of disease. 8th ed.philadelphia: elsevier saunders; 2010. p.756–9. 7. de oliveira fa, duarte ec, taveira ct, máximo aa, de aquino ec, alencar rde c, et al. salivary gland tumor: a review of 599 cases in a brazilian population. head neck pathol. 2009;3(4):271–5. 8. ito fa, ito k, vargas pa, de almeida op, lopes ma. salivary gland tumors in a brazilian population: a retrospective study of 496 cases. int j oral maxillofac surg. 2005;34:533–6. 9. al-kahteeb th, ababneh kt. salivary tumors in north jordanians: a descriptive study. oral surg med oral pathol oral radiol endod. 2007;103(5):e53–9. 10. wang yl, zhu yx, chen tz, wang y, sun gh, zhang l, et al. clinicopathologic study of 1176 salivary gland tumors in a chinese population: experience of one cancer center 1997–2007. acta otolaryngol. 2012;132(8):879–86. 11. ovchinsky a, har-el g. salivary gland enlargement. in: lucente fe, har-el g, editors. essentials of otolaryngology. 5thed. philadephia: lippincot williams & wilkins; 2004. 12. barnes l. surgical pathology of the head and neck. 3rd ed. new york: informa healthcare; 2009. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 49 characteristics of thyroiditis patients in dr. hasan sadikin general hospital in 2009–2013 sri maryanti,1 hasrayati agustina,2 miftahurachman3 1faculty of medicine universitas padjadjaran, 2department of pathology anatomy faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: it is reported that thyroid diseases affect around 200 milion people in the world. one of them is thyroiditis that may cause the risk of cancer. moreover, thyroiditis can also cause hormonal disorders, such as hypothyroid and hyperthyroid. it is assumed that thyroiditis has distinctive clinical characteristics. the aim of this study was to evaluate the characteristics of thyroiditis based on age, gender, location, and clinical features of the patient. methods: the study was conducted using descriptive-retrospective method. the data were collected from patients’ medical records through total sampling from january 2009 to desember 2013 in dr. hasan sadikin general hospital, bandung. results: it was found 35 cases of thyroiditis. based on the histopathological type, the most frequently found thyroiditis was hashimoto’s thyroiditis. based on age, thyroiditis mostly affected people at age 41–60 years old. based on the gender, thyroiditis mostly affected female and the location of lesions were bilateral. the majority clinical features of patients were hypothyroid in hashimoto’s thyroiditis, hyperthyroid in acute thyroiditis, and normothyroid in sub-acute granulomatous thyroiditis. conclusions: based on age, gender, and the location, the majority type of thyroiditis did not show specific characteristics. however, thyroiditis showed specific characteristics based on the clinical features of patient. [amj.2016;3(1):49–53] keywords: hashimoto’s thyroiditis, hyperthyroid, thyroiditis correspondence: sri maryanti, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 852 238 89774 email: srimaryanti027@gmail.com introduction it is predicted that about 200 million people in the world experienced thyroid diseases.1 in africa2 the phenomena of thyroid diseases are common phenomena. one of the thyroid diseases is called thyroiditis which can cause the imbalances of thyroid’ functions; both hypothyroid and hyperthyroid.3,4 moreover, thyroid gland disorders may also cause threatening cancer, thyroid cancer.5-7 the study about thyroid gland disorder in sri lanka showed that there were 6.51% cases of hashimoto’s thyroiditis. hashimoto’s thyroiditis is the fourth case of the most thyroid disorder cases occurred in india.8 in addition, the study conducted in utah, nevada and arizona showed that the prevalence of thyroiditis case are 5.13%.9 some types of thyroiditis diseases are assumed having certain characteristics based on age, location, clinical features and gender of the patient.4,10–12 hashimoto’s thyroiditis is one type of thyroiditis that mostly cause the decrease of thyroid hormone (hypothyroid).3,13 this disease has risk three times greater than other thyroiditis in threatening the thyroid gland.11,14,15 in addition, sub-acute thyroiditis also may increase the risk of myeloproliferative disorders, lymphoproliferative neoplasms and thyroid lymphoma.6 in indonesia, the study of thyroiditis disease is still rare. therefore, this study was conducted to evaluate and describe the characteristics of thyroiditis in bandung, indonesia. methods this was a descriptive quantitative retrospective study. the data were taken from althea medical journal. 2016;3(1) 50 amj march 2016 the medical records of pathology anatomy department and the medical records center of dr. hasan sadikin general hospital, bandung during five periods (1th january 2009-31th december 2013). the samples of the study were all the patients which were diagnosed thyroiditis based on histopathology such as hashimoto’s thyroiditis, subacute granulomatous thyroiditis, subacute lymphocytic thyroiditis, acute thyroiditis, riedel’s thyroiditis, and palpation thyroiditis (multifocal granulomatous folliculitis). the sampling technique used in the study was non-probability sampling, particularly total sampling. there was no exclusion in this study; the samples were the inclusion of all thyroiditis patients varied based on the age, gender, location, clinical features. thirty five samples taken from medical records had been permitted as the samples of this study by health research ethics committee. the data found were classified into several variable such as age, gender, clinical features (thyroid functions), and location of the occurrence of the lesion (lobes dextra, sinistra, or bilateral). thus, the data related to the clinical features about the condition of thyroid function of the patients such as hyperthyroid, normothyroid (euthyroid), and hypothyroid could be obtained. after that, the data was presented in form of frequency in a table. results based on the histopathology type, the most common type of thyroiditis was hashimoto’s thyroiditis, followed by acute thyroiditis, sub-acute granulomatous thyroiditis, subacute lymphocytic thyroiditis, and riedel’s thyroiditis. the case that was not found in this study was multi focal granulomatous folliculitis or thyroiditis palpation. according to the gender, from the 35 cases of thyroiditis, it was found that the thyroiditis cases were mostly occurred in women than men (table 2). the ratio between women and men were 4.8:1. however, subacute granulomatous thyroiditis, riedel’ thyroiditis, and subacute lymphocytic thyroiditis only occurred in women. based on the location, thyroiditis cases were mostly found at bilateral. meanwhile, subacute and acute thyroiditis was only found at dextra lobe (right lobe). thyroiditis frequency based on age, majority were found at age 41–60 years old. in this study, sub-acute lymphocytic thyroiditis and riedel’ thyroiditis was only found at table 1 frequency of thyroiditis based on histopathology thyroiditis n hashimoto 25 subacute granulomatous 3 subacute lymphocytic 1 acute 5 riedel 1 palpation 0 total 35 age 41–60 years old. according to clinical features, thyroiditis cases were mostly found in hypothyroid condition. thyroid function of acute thyroiditis was only found at hyperthyroid and in hashimoto’ thyroiditis was only found at hypothyroid. discussions hashimoto’ thyroiditis was the most frequently hyroiditis type in this study. it might be happened since hashimoto’ thyroiditis is an autoimmune disease so that the possibilities to be occurred is higher than other types of thyroiditis.3 the tsh receptor is antigenic site which has important role in the process of autoimmune disease. autoantibodies may act as an antagonists to the receptor tsh mimicking the actions of tsh in the case of hashimoto’s thyroiditis.13 according to the frequency of thyroiditis based on the gender, the ratio of hashimoto’ thyroiditis between women and men was 4:1. those data were in line with the study conducted by siriweera and ratnatunga5 at sri lanka, rosai and ackermen10 and ott et al.16 they stated that hashimoto’ thyroiditis case more frequently occurred in women than men. however, the ratio (4:1) was different from the result of the research conducted by siriweera and ratnatunga5 found that the ratio between women and men was 10.3:1. furthermore, acute thyroiditis mostly occurred on women than men with the comparison 4:1. it was contrast with wiyono’s12 statement that the ratio of acute thyroiditis of women and men was 1:1. based on the data, subacute granulomatous thyroiditis more often occurred on women than men. this result was related to rosai and ackermen10 who stated that sub-acute althea medical journal. 2016;3(1) 51 granulomatous thyroiditis mostly occurred on women than men with the ratio 4:1. the cases of subacute lymphocytic thyroiditis and riedel’ thyroiditis showed that both were mostly found on women. it was the same as wiyono’s12 statement that subacute lymphocytic thyroiditis and riedel’ thyroiditis more often occurred on women than men. the literature mentioned that the ratio of women and men in subacute lymphocytic thyroiditis is 2:1 while in riedel’ thyroiditis case is 3-4:1. the possible explanation for the fact that thyroiditis occurred much more often on women because of the relation between x chromosome and immune-related genes which can cause preservation of immune tolerance.11 it is mentioned that hormone affects the binding-hormone capacity, for instance, when estrogen increases then it will affect the escalation of binding protein synthesis for thyroid hormone.13 the difference between ratio in this research and ratio in the literature is probably caused by the different number of samples. according to the location of the inflammation, it was found 8 bilateral cases of hashimoto’ thyroiditis, 4 dextra cases of hashimoto’ thyroiditis, and 2 sinistra cases of hashimoto’ thyroiditis. it can be inferred that hashimoto’ thyrioditis frequently occurred in bilateral. however, the literature about such phenomenon has not discovered yet. furthermore, bilateral also became the most frequent location of subacute granulomatous thyroiditis. this result was accordance with rosai and ackermen10, which argued that sub-acute granulomatous thyroiditis mostly occurred in both of lobes or bilateral. in addition, subacute lymphocytic thyroiditis mostly occurred in dextra lobe (right lobe). cases of acute thyroiditis found occurred in dextra lobe (right lobe). it was in line sri maryanti, hasrayati agustina, miftahurachman: characteristics of thyroiditis patients in dr.hasan sadikin general hospital in 2009–2013 table 2 characteristics of thyroiditis based on gender, age, location and clinical features characteristics thyroiditis hsm sgr slf act rdl mgf n=25 n=3 n=1 n=5 n=1 n=0 gender male 5 0 0 1 0 0 female 20 3 1 4 1 0 not recorded 0 0 0 0 0 0 location dextra 4 1 1 2 0 0 sinistra 2 0 0 0 0 0 bilateral 8 2 0 0 1 0 not recorded 11 0 0 3 0 0 age (year) 0–20 0 0 0 0 0 0 21–40 7 2 0 2 0 0 41–60 16 1 1 3 1 0 >60 2 0 0 0 0 0 not recorded 0 0 0 0 0 0 clinical features hyperthyroid 0 0 0 2 0 0 normothyroid 0 2 0 1 0 0 hipothyroid 5 0 0 0 0 0 not recorded 20 1 1 2 1 0 note: *hsm: hashimoto, sgr: subacutegranulomatous,slf: subacute lymphocytic, act: acute,rdl: riedel, mgf: multifocal granulomatous foliculitis/palpation althea medical journal. 2016;3(1) 52 amj march 2016 with longo et al.3 who mentioned that acute thyroiditis occurred more often in a lobe (unilateral); it can be happened since the right part of ultimo branchial body atrophy and does not develop in the period of human thyroid gland formation. in addition, it was found one case of riedel’ thyroiditis occurred in bilateral. it was not in accordance with the study conducted by longo et al.3 and papi and livalsi17 who revealed that riedel’s thyroiditis mostly occurred in a lobe or unilateral, either dextra or sinistra. in sub-acute thyroiditis, the inflammation sometimes could attack a lobe which is then immigrated to the another lobe, called “creeping” thyroiditis.13 table 2 shows the frequency of thyroiditis based on age. it can be seen that hashimoto’s thyroiditis frequently occurred in the aged group of 41-60 years old. this result was in line with a result of the research conducted by siriweera and ratnantunga5 in sri lanka which revealed that hashimoto’ thyroiditis mostly happened in aged group of 41–60 years old. meanwhile, sub-acute granulomatous thyroiditis case mostly occurred in age 21– 40 years old and followed by the age 41–60 years old. this result was nearly similar with literature from longo et al.3 who argued that the cases frequently occurred in age 30–50 years old and age 20–60 years old and the study investigating 162 cases as samples conducted by woolner et al. in rosai and ackerman10 in contrast with wiyono12 who showed that sub-acute lymphocytic thyroiditis, mostly attack people aged 30–40 years old, this study showed that sub-acute lymphocytic thyroiditis was more often on people age 41–60 years old. as well as sub-acute lymphocytic thyroiditis, acute thyroiditis frequently occurred on people aged 41–60 years old. it was different from rosai and ackerman10 statement that acute thyroiditis mostly occurred in people aged 2140 years old. in addition, riedel’ thyroiditis mostly happened in people aged 41-60 years old. it was quite similar to longo et al.3 and rosai and ackerman10 who argued that riedel’ thyroiditis more frequently occurred on people aged 30–50 years old. some thyroiditis cases were mostly found in people aged 41–60 years old and were not found in group of people aged 0–20 years old. it could be happened since there were the descents of immune system in people aged above 40 years old so that they were more susceptible to the disease while thyroiditis in children was usually caused by physical and cognitive interference.18 frequency of thyroiditis based on clinical description was seen according to the function of thyroid; hyperthyroid, normothyroid, and hypothyroid. based on clinical features, the majority of hashimoto’ thyroiditis cases are in hypothyroid. it comports with the study conducted by staii et al.19 hypothyroid in adult patient can be caused by the decrease of cell in thyroid gland. furthermore, it can be caused by autoimmune disease that damages the parenchyme of thyroid gland and as the effect of surgery or radioactive iodine therapy. moreover, hypothyroid is also caused by the enlargement of the thyroid gland as the consequence of lymphocytic infiltration in hashimoto’ thyroidis case.13 in addition, in sub-acute granulomatous thyroiditis case, most patients experienced normothyroid. it is similar tothe study conducted by li et al.20 in china. the study mentioned that thyroid function in sub-acute granulomatous thyroiditis’ case is usually discovered in normothyroid condition. it might be happened since the major of thyroid gland was not damaged.20 however, sub-acute granulomatous thyroiditis was frequently found in hyphothyroid.13 thyroid function (clinical feature) showed that acute thyroiditis mostly occurred in hyperthyroid and acute thyroiditis was frequently revealed in hyperthyroid.13 based on the result of the study, it can be inferred that almost all types of thyroiditis have similar characteristics according to age, gender, and location. however, according to the clinical features (thyroid functions), thyroiditis has particular characteristics for each type. hashimoto thyroiditis was mostly found in hypothyroid; granulomatous thyroiditis was mostly found in normothyroid; and acute thyroiditis was mostly found in hyperthyroid. by founding those characteristics, it is expected that it can help the process of diagnosis and therapy of the patients. the limitation of this study is the samples that were 35 samples. meanwhile, in order to be able to represent the cases generally, the sample should be 74 samples. therefore, the results of this study do not represent the thyroiditis case. in addition, some variables in the medical record were not complete enough. the similar studies are still rarely conducted. therefore, they become another limitation of the study. thus, those studies led to the difficulties in finding related literature especially journal. the difference of the study’s results with the previous study might be arousen because of different samples. based on the results of the study it is recommended to conduct the study by althea medical journal. 2016;3(1) 53 involving minimum numbers of samples to be able to describe the case generally. it can be done by adding the samples from the period of the medical records, more hospitals and investigates thyroiditis beside on age, gender, location and clinical features (thyroid functions). references 1. lancet. thyroid diseases more research needed. the lancet. 2012;379(9821):1076. 2. ogbera ao, kuku sf. epidemiology of thyroid diseases in africa. indian j endocrinol metab. 2011;15(suppl 2):s82– 8. 3. longo d, fauci a, kasper d, hauser s, jameson j, loscalzo j. harrison’s principles of internal medicine. 18th ed. new york: mcgraw-hill; 2011. p. 2237–9. 4. vanderpump mp. the epidemiology of thyroid disease. br med bull. 2011;99(1):39–51. 5. siriweera eh, ratnatunga n. profile of hashimoto’s thyroiditis in sri langkans: is there an increased risk of ancillary pathologies in hashimoto’s thyroiditis? j thyroid res. 2010;2010:124264. 6. yoon yh, kim hj, lee jw, kim jm, koo bs. the clinicopathologic differences in papillary thyroid carcinoma with or without co-existing chronic lymphocytic thyroiditis. eur arch otorhinolaryngol. 2012;269(3):1013–7. 7. roh mh, jo vy, stelow eb, faquin wc, zou kh, alexander ek, et al. the predictive value of the fine-needle aspiration diagnosis “suspicious for a follicular neoplasm, hürthle cell type” in patients with hashimoto thyroiditis. am j clin pathol.2011;135(1):139–45. 8. unnikrishnan ag, menon uv. thyroid disorders in india: an epidemiological perspective. indian j endocrinol metab. 2011;15(suppl2):s78–81. 9. golden sh, robinson ka, saldanha i, anton b, ladenson pw. clinical review: prevalence and incidence of endocrine and metabolic disorders in the united states: a comprehensive review. j clin endocrinol metab. 2009;94(6):1853–78. 10. rosai j, ackerman lv. rosai and ackerman’s surgical pathology. 10th ed. new york: mosby elsevier; 2011. p. 491–6. 11. zaletel k, gaberscek s. hashimoto’s thyroiditis: from genes to the disease. curr genomics. 2011;12(8):576–88. 12. wiyono p. tiroiditis. in: sudoyo aw, setiyohadi b, alwi i, simadribrata m, setiati s, editors. buku ajar ilmu penyakit dalam. 5th ed. jakarta: interna publishing; 2009. p. 2016–21. 13. gardner d, shoback d. greenspan’s basic and clinical endocrinology. 9th ed. ney york: mcgraw-hill education; 2011. p. 264–7. 14. konturek a, barczynski m, wierzchowski, stopa m, nowak w. coexistence of papillary thyroid cancer with hashimoto thyroiditis. langenbecks arch surg. 2013;398(3):389–94. 15. larson sd, jackson ln, riall ts, uchida t, thomas rp, qiu s, et al. increased incidence of well-differentiated thyroid cancer associated with hashimoto’s thyroiditis and the role of pi3k/akt pathway. j am coll surg. 2007;204(5):764–75. 16. ott j, meusel m, schultheis a, promberger r, pallikunnel sj, neuhold n, et al. the incidence of lymphocytic thyroid infiltration and hashimoto’s thyroiditis increased in patients operated for benign goiter over a 31-year period. virchows arch. 2011;459(3):277–81 17. papi g, livolsi va. current concepts on riedel thyroiditis. am j clin pathol. 2009;121 suppl:s50–63. 18. kapelari k, kirchlechner c, högler w, schweitzer k, virgolini i, moncayo r. pediatric reference intervals for thyroid hormone levels from birth to adulthood: a retrospective study. bmc endocrine disorders. 2008;8:15. 19. staii a, mirocha a, todorova-koteva k, glinberg s, jaume jc. hashimoto thyroiditis is more frequent then expected when diagnosed by citology which uncovers a pre-clinical state. thyroid res. 2010;3:11. 20. li lx, wu x, hu b, zhang hz, lu hk. localized subacute thyroiditis presenting as a painful hot nodule. bmc endocrine disorders. 2014;14:4. sri maryanti, hasrayati agustina, miftahurachman: characteristics of thyroiditis patients in dr.hasan sadikin general hospital in 2009–2013 althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 143 red ear fungi (auricularia auricula) infusion reduces blood triglyceride level in dyslipidemic rats nareswara anugrah widi,¹ truly d. sitorus,² coriejati rita³ ¹faculty of medicine universitas padjadjaran, ²department of pharmacology and therapy, faculty of medicine universitas padjadjaran, ³department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: dyslipidemia is a risk factor in atherosclerosis. in the long run, it can cause complications such as coronary artery disease and stroke. dyslipidemia can be halted by beta glucan, a soluble fiber found in some species of fungi. this study was conducted to find the effect of red ear fungi infusion in reducing blood triglyceride level and the concentration that would give optimal reduction of blood triglyceride level. methods: this analytical study used experimental laboratory methods on 25 male wistar rats which were randomly divided into 5 groups. group 1 received normal food and water, while group 2 was given high lipid diet (hld) and propiltiouracil (ptu) 0.01% as drinking water. group 3, group 4, and group 5 were given the same food as group 2, with the additional red ear fungi infusion 18%, 36%, and 72% concentration respectively, for 14 days. blood cholesterol level was measured on thelast day of the experiment. the group means were compared using one-way anova (analysis of variance) and scheffe test as the post-hoc test. statistical differences were considered significant at p < 0.05. results: the result showed that themean difference of blood triglyceride level in all three treatment groups, i.e. group 3, group 4, and group 5 (87.08, 90.40, and 82.70 mg/dl respectively) was statistically significant compared to the positive control group (172.92 mg/dl). out of the three groups, group 4 with 36% infusion concentration had the lowest mean difference from all of the treatment groups. conclusions: red ear fungi infusion reduced blood triglyceride level, and infusion with 36% concentration was the optimal concentration in reducing blood triglyceride level. a further study can be conducted to find theconcentration range in which the infusion reduces blood triglyceride level optimally. [amj.2015;2(1):143–6] keywords: beta glucan, red ear fungi infusion, triglyceride correspondence: nareswara anugrah widi, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 857 101 26671 email: nares.anugrah@gmail.com introduction in this era of globalization, increasing work load and daily routines hold a significant effect to lifestyle changes, especially in urban areas. people have the tendency to ignore healthy lifestyle by consuming fast food and doing less exercise which are both risk factors for dyslipidemia. dyslipidemia is a condition of abnormal lipid level in blood, which can either be increased or decreased. currently, the mostly found condition is the increase of lipid called hyperlipidemia. hyperlipidemia is the increase of one or more lipid components in blood plasma, such as cholesterol, triglyceride, low density lipoprotein (ldl), and the decrease of high density lipoprotein (hdl). the increase of lipid level in plasma causes endothelial wall damage, which then can become atherosclerosis, which in the long run, will cause many other diseases such as coronary artery disease and stroke.1 from data of the world health organization (who) in 2002, coronary artery disease is the first cause of death in people aged60 years and older, followed by stroke in the second place.2 red ear fungi (auricularia auricula) are one of the fungi used in traditional medicine, especially by people of chinese-descent. these fungi can grow in any place, ranging from beaches to mountains. these fungi were believed to have effect in reducing blood sugar, alleviating sore throat, and reducing cholesterol level in blood. they are usually dispended by boiling 60 g of fungi with palm sugar as much as needed with 5 glass of water. all ingredients were boiled until the water althea medical journal. 2015;2(2) 144 amj june, 2015 evaporated enough to leave the amount for one glass. the resulting concoction would then be consumed once a day.3 in a study conducted in south korea, biopolymer extractions of red ear fungi were found to have triglyceride lowering effects. the triglyceride lowering effects were caused by a soluble fiber called beta glucan by inhibiting micelles production in the process of triglyceride absorption in small intestine.4-7 based on the explanation above, the author was interested to know the effect of red ear fungi in lowering triglyceride, as one of the risk factors in atherosclerosis. infusion was chosen because the usage of red ear fungi in society was using a method resembling infusion, besides the process of making infusion is more practicable in everyday society methods this analytical study used experimental laboratory methods during the period of september to october 2012 in the pharmacological laboratory of dr. hasan sadikin general hospital, bandung. the red ear fungi were obtained from the fungi cultivation of the indonesian institute of sciences or lembaga ilmu pengetahuan indonesia (lipi) in bogor, west java. first of all the fungi were dried before it was used in the study. the infusion was made by cutting the dried fungi into small pieces and put in a pot. next, water was added accordingly to the concentration made. the pot was then put into a bigger infusion pot with boiled water around 90° celsius. the fungi was then boiled in the pot and stirred constantly for 15 minutes. afterward, it was let to cool under room temperature and then filtered using filtration paper to get a red ear fungi infusion.8 male wistar rats (200–300 g) were used in the study. at the first week, all 25 rats underwent adaptation with a daily normal diet and water. the rats were then divided into 5 groups using random sampling method and given different treatment. group 1 was given normal food and water, group 2 was given high lipid diet (hld) as food and propiltiouracil (ptu) 0.01% as drinking water without red ear fungi infusion. group 3, group 4, and group 5 were given the same treatment as group 2, with the addition of red ear fungi infusion of 18%, 36%, and 72% concentration respectively. a schematic diagram depicting this can be seen in figure 1. at the end of the 2 weeks experiment, figure 1 experimental diagram althea medical journal. 2015;2(2) 145 blood was taken from the tail. the blood plasma triglyceride level was determined enzymatically using a colorimetric enzymatic test with gpo (glycerol-3-phosphate oxidase) afterwhich the resulted solution wasthen measured using a spectrophotometer with 546 nm wave length.9 data distribution was analyzed using shapiro-wilk and data homogenity of variance were analyzed using levene’s test. the means were compared using the one-way anova (analysis of variance) and scheffe test as the post-hoc test.10,11 statistical differences were considered significant at p < 0.05. results to evaluate the effect of infusion of red ear fungi to blood triglyceride level, 14 days post treatment, measurement of blood triglyceride level was done. the result of the study can be seen in table 1. the results showed infusion of red ear fungi (group 3, 4, and 5) indicated similar level of blood triglyceride (87.08, 90.40, and 82.70 mg/ dl respectively) was close to negative control (74.42 mg/dl) group. statistical analysis was conducted to recognize the significance of the findings in the study. the statistical analysis can be seen in table 2. after the test, it was identified that all groups had the same value of significance of 0.00 (p < 0.05) when compared with group 2. discussion this study was conducted using male wistar rats induced with hld and ptu 0.01%. the hld increased the rat lipid intake, thus increasing the triglyceride level in the blood. the ptu 0.01% was given to the water drank by the rats to block the synthesis of thyroxine hormone to down regulate lipid metabolism, increasing the triglyceride level in rats. the successful induction of rats could be seen by comparing group 1 (negative control) and group 2 (positive control). the mean of triglyceride level in group 2 (172.92 mg/dl) was higher than in group 1 (74.42 mg/dl). the effect of red ear fungi infusion could be seen by comparing the treatment group of group 3 (18% infusion), group 4 (36% infusion), and group 5 (72% infusion) with group 2 (positive control). the mean of the treatment group was lower than the positive control group, showing an effect of triglyceride lowering from red ear fungi infusion. to know the significance of these findings, a statistical analysis was performed. statistical analysis table 1 post-study triglyceride level rat number blood triglyceride level (mg/dl) group 1 group 2 group 3 group 4 group 5 1 62.5 177.3 76.8 77.1 104.5 2 73.2 155.6 119.2 78.3 95.9 3 62.1 193.6 86.4 100.6 108.1 4 94.7 135.5 96.9 76.9 60.8 5 79.6 202.6 49.4 79.7 81.8 mean 74.42 172.92 85.74 82.52 90.22 note: group 1: negative control, group 2: positive control, group 3: test group 1 (18% infusion), group 4: test group 2 (36% infusion), group 5: test group 3 (72% infusion) nareswara anugrah widi, truly d. sitorus, coriejati rita: red ear fungi (auricularia auricula) infusion reduces blood triglyceride level in dyslipidemic rats table 2 post-hoc scheffe test result group mean difference value of significance 1 98.50 .000 3 87.08 .000 4 90.40 .000 5 82.70 .000 note: statistical analysis compared to group 2 (positive control), group 1: negative control, group 3: test group 1 (18% infusion), group 4 : test group 2 (36% infusion), group 5: test group 3 (72% infusion) althea medical journal. 2015;2(2) 146 amj june, 2015 showed that there’s a significant value (p < 0.05) of treatment group 3, group 4, and group 5 compared to group 2 as the positive control group. the effects of triglyceride reduction were caused by beta glucan, soluble fiber that can reduce lipid absorption in the intestine.5-7 the result of this study was analogous with the study conducted by jeong et al.4 in south korea, who performed a research about the effect of biopolymer extracted from the different parts of red ear fungi to hyperlipidemic spraguedawley rats. the study showed that every part of red ear fungi has significant reduction of triglyceride level in hyperlipidemic rats. the study was performed using red ear fungi obtained from different geographical conditions and using a different type of rats from this study. also, the red ear fungi were given in the form of extraction, different from the infusion that was used in this study. this study proved that red ear fungi infusion from lipi bogor, west java, had similar triglyceride lowering effect. an effective dose is a dose that can give optimal pharmacological effect in certain amount. in pharmacological science, the effectiveness of a dose is corresponding with how many component of a drug binding with a specific receptor.12 this study used 3 different concentrations of infusion, 18% (group 3), 36% (group 4), and 72% (group 5). a statistical test was performed to compare the treatment group with group 2 as the control positive group. statistical test showed group 4 had the biggest mean difference of all treatment groups. iving higher concentrations in this study was not accompanied by increased blood tryglyceride-lowering effects. this condition was likely due to other active substances contained in the fungus, so that the effects were not only tryglyceride-lowering, but could also inhibit tryglyceride reduction effect. so that the effects obtained from this study were the effects of the accumulation of substances contained in the ear fungus infusion. based on the study conducted, red ear infusion reduced blood triglyceride level in dyslipidemic rats and red ear infusion with 36% concentration reduced blood triglyceride optimally in dyslipidemic rats. a further study can be performed to find the concentration range in which the infusion reduces blood triglyceride level optimally. references 1. mitchell rn, schoen fj. blood vessels. in: kumar v, abbas a, fausto n, aster j, editors. robbins and cotran pathologic basis of disease. 7th ed. philadelphia: saunders; 2010. p. 487–528. 2. mackay j, mensah ga. the atlas of heart disease and stroke. world health organization (who) & centers for disease control and prevention (cdc); 2004 [cited 2012 september15]; available at: http:// www.who.int/cardiovascular_diseases/ resources/atlas/en/. 3. rahmat p, editor. buku pintar bertanam jamur konsumsi. jakarta: pt agromedia pustaka; 2009. 4. jeong h, yang b-k, jeong y-t, kim g-n, jeong y-s, kim s-m, et al. hypolipidemic effects of biopolymers extracted from culture broth, mycelia, and fruiting bodies of auricularia auricula-judae in dietaryinduced hyperlipidemic rats. mycobiology. 2007;35(1):16–20 5. chen wl, anderson jw. hypocholesterolemic effects of soluble fiber. in: vahouny gv, kritchevsky d, editors. dietary fiber: basic and clinical aspects. new york: plenum press; 1986. p. 275–86. 6. khoury de, cuda c, luhovyy bl, anderson gh. beta glucan: health benefits in obesity and metabolic syndrome. j nutr metab. 2012;2012:851362. 7. ma z, wang j, zhang l, zhang y, ding k. evaluation of water soluble β-d-glucan from auricularia auricular-judae as potential anti-tumor agent. carbohydrate polymers. 2010;80(3):977–83. 8. syamsuni ha. ilmu resep. jakarta: penerbit buku kedokteran egc; 2005. 9. cole t, kotzsch s, mcnamara j. measurement of triglyceride concentration. in: rifai n, warnick g, dominiczak m, editors. handbook of lipoprotein testing. washington: aacc press; 1997. p. 115–26. 10. dahlan ms. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. 11. sudjana. desain dan analisis eksperimen. 4th ed. bandung: tarsito; 2002. 12. henry rb, zastrow mv. drug receptors & pharmacodynamics. in: katzung bg, editor. basic and clinical pharmacology. 10th ed. san fransisco: lange, mcgraw hill; 2007. p. 11–33. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 54 amj march, 2015 correlation between folate intake during pregnancy and preterm labor in mothers with 0-9 months old babies gufi george stefanus1, siti nur fatimah2, eppy darmadi achmad3 1faculty of medicine, universitas padjadjaran, 2department of medical nutrition, faculty of medicine, universitas padjadjaran 3department of obstetri&gynecology , faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: nutritional factors such as folate intake are important during pregnancy. satisfying nutritional needs of pregnant mothers is necessary to avoid complications during pregnancy such as preterm labor, high infant mortality rate in indonesia is still high. this study aimed to study the relationship between folate intake during pregnancy and preterm labor. methods: this study used a cross-sectional analytic approach by using semi-quantitative food frequency questionnaire, as an instrument on mothers with 0−9 months old babies living in the villages of sayang and hegarmanah, jatinangor, sumedang, indonesia. results: ninety mothers participated in this study. the result indicated that 25.55% respondents had low folate intake and high incidence of preterm labor (16.67%). significant association was found between folate intake during pregnancy and preterm labor (p=0.019). maternal age was not a confounding factor in this study. conclusions: there is an association between folate intake during pregnancy and preterm labor in mothers living in the villages of sayang and hegarmanah, jatinangor, sumedang, indonesia. key words: babies 0−9 months, folate, preterm labor correspondence: gufi george stefanus, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285692448500 email: gufi.george.s@gmail.com introduction prematurity cases in indonesia are considered high at 600,000 out of 4.3 million births each year. among these cases, 5% of the cases course are death causing increase of infant mortality rate (imr) in indonesia.1 in the year 2007, indonesian imr is at 34:1000 live birth and the highest in asean.2 these lead for a need in an integrated effort to reduce imr in indonesia especially to achieve the target for millennium development goals (mdg) at 23:1000 live births in 2015. such method can be achieved by satisfying the nutritional need of the pregnant mother.3 nutritional requirement of a pregnant woman will increase according to the need of cellular proliferation to support fetal growth and plasenta.4 one of the important nutrients for pregnant women is folate. folate is a vitamin b that plays a role in dna synthesis and maturation of cells to support the growth and fetus development.5 folate cannot be formed inside the body, thus it is important for each individual to fulfill the folate requirement by consuming food which contains folate. sources of folate are liver, green vegetable, nuts, and fruits. supplements and fortified food such as wheat product can also contribute to folate content of the body.5,6 in jatinangor, the number of high risk pregnancy women who were referred to a hospital was quite large and mostly happened in the villages of sayang and hegarmanah (unpublished data). based on this reason, this study was conducted to study on the association between folate intake during pregnancy and preterm labor in the villages of sayang and hegarmanah. methods this was an analytical cross-sectional study during the period of october to november 2012 in the posyandu of sayang and hegarmanah village. subjects were recruited with consecutive sampling. all mothers with 0–9 althea medical journal. 2015;2(1) 55 months old babies in sayang and hegarmanah villages who filled the informed consent form and brought mother and child health book (kia) fulfilled the inclusion criteria. if kia book was not filled completely then the subject would be excluded. data collection was conducted with permission by sumedang regional development planning board, sumedang district health office, jatinangor health centre and health research ethics committee of faculty of medicine universitas padjadjaran. semi quantitative food frequency questionnare (sffq) was used as an instrument for interview to give insight on the mothers' pattern of folate intake during pregnancy. questionnaires were filled with list of food types and frequency and also amount of intake in portion. data from sffq were converted from household measurement to dietary folate equivalent (dfe).6 folate content of each food was analyzed using usda national nutrient database for standard reference.8 the calculation determined total daily folate intake and then the concentration would then be compared to the recommendation dietary allowance (rda).9 date of birth and the first day of last menstrual period data from kia book would then be analyzed using excel 2007 program so that accurate gestational age at birth could be retrieved. the analytical method used in this study was comparative categorical hypothesis testing with unpaired fisher test by cellular union using computer. results the study was conducted on 90 mothers who 31 of them live in the village of sayang, while 59 were in the village of hegarmanah. the subjects characteristics were presented as mother’s age, folate intake during pregnancy, and time of birth (table 1). age group was determined from literature which explained that maternal age of below 18 years old and over 35 years old were one of the risk factors for preterm labor.10 from table 1, table 1 characteristics of subject characteristics n n(%) median (min-max) age (year)* 27 (16-43) <18 2 2.2% 18–35 76 84.5% >35 12 13.3% folate intake during pregnancy* 817 (229-4240) low (<600μg) 23 25.5% normal (600–1000μg) 34 37.8% high (>1000μg) 33 36.7% pregnancy age* 38,86 (30-45) preterm 15 16.7% term 72 80% post-term 3 3.3% data distributionbased on kolmogorov-smirnov is not normal gufi george stefanus, siti nur fatimah, eppy darmadi achmad: correlation between folate intake during pregnancy and preterm labor in mothers with 0-9 months old babies table 2 association between folate intake during pregnancy and preterm labor prematurity total p value term+post-term (%) preterm (%) folat normal+ high 60 (66.7%) 7 (7.8%) 67 (74.4%) 0.019 low 15 (16.7%) 8 (8.8%) 23 (25.6%) total (%) 75 (83.4%) 15 (16.6%) 90 (100%) althea medical journal. 2015;2(1) 56 amj march, 2015 it can be seen that respondents who had risk factors for preterm labor amounted to 15.5%. data of folate intake can be classified into three categories, which are low, normal, and high. table 1 indicated that 25.5 % of respondents had low quality folate intake. this study also showed that 16.7% had pretermlabours. this number approaches the epidemiologic number of who on prematurity in indonesia which is 15.45%.3 the alternative chi square test was performed to study the association between folate intake during pregnancy and preterm labor. a p-value of <0.05, indicated that there was an association between folate intake during pregnancy and preterm labor. one confounder factor was analyzed, which was the age of the mother. a p value> 0.05 indicated that age of mother did not affect preterm labor frequencies which also concluded not as a confounder of this study. discussions there are several similar studies in the association between serum folate level during pregnancy and risk of preterm labor conducted. from previous study conducted by bodnaret al.11 and hiroshi et al.12 there is an association between serum folate and risk of preterm labor. folate intake data collection was conducted after labor, that may cause a recall bias. yet, nature of events that relies on questionnaire can be applicable up to a year.6 confounder which can affect preterm labor such as age of mother has been identified and is excluded as a confounder in this study. according to this study, there is an association between folate intake during pregnancy and preterm labor of mothers with 0–9 months old babies in the villages of sayang and hegarmanah. references 1. liu l, johnson h. country data and rankings for preterm birth data embargo until may 2nd 2012.2012 [downloaded in 6 may 2012]; available at: http://www.who. int/pmnch/media/news/2012/201204 borntoosoon_countryranking.pdf. 2. rosita r. profil kesehatan indonesia 2010. jakarta: kementerian kesehatan republik indonesia. 2011. p.194. 3. united nations children’s fund. levels & trends in child mortality report 2011. 2011. [downloaded in 6 may 2012]; available at: http://www.unicef. o r g / m e d i a / f i l e s / c h i l d _ m o r t a l i t y _ report_2011_final.pdf 4. ladipo o. nutrition in pregnancy: mineral and vitamin supplements. am j clin nutr. 2000;72:2808-908. 5. murphy m. folate (folacin, folic acid). 2004 [downloaded in 30 april 2012]; available at: http://ohioline.osu.edu/hygfact/5000/5553.html. 6. whitney e, rolfes s. understanding nutrition. 11th ed. belmont california, usa: thomson wadsworth. 2008. 7. wrieden w, peace h, armstrong j, barton k. a short review of dietary assesment methods used in national and scottish research studies. scotland:working group on monitoring scottish dietary targets workshop. 2003. 8. u.s. department of agriculture ars. usda national nutrient database for standard reference, release 23. nutrient data laboratory home page; 2010. 9. shils me, shike m, ross c, caballero b, cousins rj. modern nutrition in health and disease. 10thed. philadelphia, united states of america: lippincot williams&wilkins. 2006. p.470–9. 10. the healthpages . risk factors for preterm birth. 2010 [downloaded in 3 december 2012]; available at: http://www. issues4life.org/pdfs/iariskptb023.pdf 11. bodnar l, himes k, venkataramanan r, chen jy, evans rw, meyer jl, et al.. maternal serum folate species in early pregnancy and risk of preterm birth. am j clin nutr. table 3 association between maternal age and preterm labor prematurity total p value term+post-term (%) preterm (%) maternal age no risk 64 (71.1%) 12 (13.3%) 76 (84.4%) 0.697 risk 11 (12.2%) 3 (3.4%) 14 (15.6%) total (%) 75 (83.3%) 15 (16.7%) 90 (100%) althea medical journal. 2015;2(1) 57 2010;92(4):864–71. 12. ihara h, watanabe t, aoki y, nagamura y, totani m, hashizume n. dietary folate intake and serum folate status in japanese women of childbearing age. j anal bio-sci. 2009;32(2):181–5. gufi george stefanus, siti nur fatimah, eppy darmadi achmad: correlation between folate intake during pregnancy and preterm labor in mothers with 0-9 months old babies althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 226 amj june, 2015 profile of physical fitness of young football players at sdn cibeusi subashini periasamy,1 reni farenia,2 pintoko tedjokusumo3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine universitas padjadjaran, 3department of cardiology and vascular, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: health-related physical fitness components are important in hypokinetic disease prevention and good sports performance. the aim of this research is to evaluate the physical fitness profile of the sdn cibeusi young football players based on fitnessgram. methods: this study was participated by 20 subjects ranging from 10 to 12 years old boys who played y for the school football team in sdn cibeusi. this descriptive study was conducted in the school field in the month of november 2012. physical fitness components that were tested are aerobic capacity,v02 max using the one-mile run test, muscle endurance by performing push-up and curl-up test, flexibility using the flexometer and body composition by measuring the body mass index and fat fold measurement. the mean and standard deviation of the results were tabulated. results: aerobic capacity and percentage of body fat showed 100% of them scored in the category of healthy fitness zone. for body mass index, 55% scored in healthy fitness zone, 25% ni-some risk, and 10% each for ni-high risk and very lean. for push-up test and curl-up test, 80% and 65% scored in the healthy fitness zone while the remaining 20% and 35% respectively scored in the not healthy fitness zone. for flexibility, 75% of them scored in healthy fitness zone and 25% scored in not healthy fitness zone. conclusions: the physical fitness level in these young football players is mostly in healthy fitness zone. [amj.2015;2(1):226–30] keywords: fitnessgram, football players, physical fitness correspondence: subashini periasamy, aculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170208744 email: subashiniperiasamy@gmail.com introduction currently mostly played and watched sport by millions of people each year is soccer, also known as football in many regions, which being top on the charts and surveys conducted by internet websites and polls. it has even been stated as the most popular pastime game on earth. people from all stages of life indulge into this sport, especially kids who start playing football at a very young age and progressively grow passion and become follower for this game. although football holds its unofficial title as “the world game” the immense popularity does not mean that it is a simple or easy game to play successfully.1 football requires various physical and mental challenges where participants must conquer the action of defending and attacking. ball control is crucial where variety of foot skills is involved and this is done under pressures or restricted space, limited time, determined challenges opposed by the opponents and the most important aspect is the physical fitness level of the individual. the fast phase or rapidly changing situations during game requires the aspect of decision making abilities as well as overall endurance.2 individual performance which is a major contributes to the team success rely on the importance of such aspects mentioned above. playing football either for recreational purpose or competition level will evidently enhance good physical condition and has direct positive effect on skills and strategy competency development and contribute to a successful game. in order to attain the maximum physical performances, continuous training and high endurance is compulsory for good achievements.2 regular and consistent physical training enhances health maintenance and indicates that a person has a good health and mind condition which is essential in preventing health risk factors at an early age.3 physical fitness of an individual which can be accessed from components like body composition, althea medical journal. 2015;2(2) 227 cardiovascular and musculoskeletal determines whether the individual fall in healthy fitness zone (hfz) and the “needs improvement” zone based on fitnessgram criterion-referenced standards battery. fitnessgram is the commonly used tool for childhood assessment.4 traditional fitness test has been criticized as evaluations of athletic ability rather than health-related fitness.5 these zones indicate minimum level of fitness that offers protection against diseases. these components in football players should be assessed in time to time so that the individual has an adequate fitness level to provide important health benefits and prevent any possible sports injury thus they will be able to excel in sports and gain victory in competitions.to attain the maximal health benefits and optimal performance by the young football players in elementary school, a few tests should be conducted to evaluate their physical fitness level.6 cardiorespiratory endurance can be evaluated by one-mile run test, body composition can be determined by body weight and height and body fat percentage can be determined by measuring the skin fold, and musculoskeletal can be tested by muscle endurance test such as curl-up test and pushup test. on the other hand, flexibility which is important for joints and back muscle can be measured using sit and reach test.7 the aim of this research is to evaluate the physical fitness profile of the sdn cibeusi young football players based on fitnessgram. methods this descriptive study involved 20 subjects ranging from 10 to 12 years old boys who played for the school football team in sdn cibeusi in november 2012. physical fitness components that were tested are aerobic capacity,v02max using the one-mile run test, muscle endurance by performing push-up and curl-up test, flexibility using the flexometer and body composition by measuring the body mass index and fat fold measurement. cardiovascular endurance is the body’s ability to continue exertion while getting energy from the aerobic system used to supply the body with energy. the aspect that will be used to measure the cardiovascular endurance is v02max. to evaluate this component, the test that will be used is the one-mile run test. the subjects required to run for one mile and the time taken to complete will be used to estimate the aerobic capacity based on given fitnessgram table.8 muscle endurance is the muscle’s ability to work continuously against resistance over a long period of time. push-up test was performed to evaluate the upper body strength which is the arm and shoulder muscle endurance, while the curl-up test was conducted to evaluate abdominal muscle endurance. this test was conducted in 60 seconds and the number of times the subject able to perform was recorded. flexibility is the range of motion possible around a specific joint or series of articulations. flexibility is specific to a given joint or movement. sit & reach test was used where the subject required sitting with the legs stretched and reaching out his fingers for the flexometer. the furthest distance the subject could reach out was recorded in inches.9 body composition describes the different components that, when taken together, make up a person’s body weight. using callipers, fat fold are measured in two parts of the body the triceps and subscapular and body fat percentage are calculated using the formula given by slaughter. body mass index was also calculated based on the subject’s weight and height and recorded as kg/ results based on table 1, this study showed that the mean age of the subjects are 11.25 (+ 0.85) years old with the criteria of body weight of 36.95 (+ 7.24) and body height of 140 (+ 7.39). the youngest subject involved in this study is 10 years old boy and the oldest subject was 12 years old. this subject’s lowest body weight is subashini periasamy, reni farenia, pintoko tedjokusumo: profile of physical fitness of young football players at sdn cibeusi table 1 physical characteristic of young football players in sdn cibeusi (n=20) characteristics mean ±sd age (years) 11.25±0.85 body weight (kg) 36.95±7.24 body height (cm) 140±7.39 sd: standar deviation althea medical journal. 2015;2(2) 228 amj june, 2015 21kg and maximum weight is 50 kg. whereas the tallest subject that involved in this study is 152 cm and the minimum height was 125 cm. from the table 2, it was showed that all respondents have aerobic capacity with standard healthy fitness zone which body fat percentage were in the category of healthy fitness zone (hfz). a number of 11/20 respondents have bmi on healthy fitness zone. two respondents were in the category of very lean and the other 5/20 and 2/20 were in nisome risk and nihigh risk respectevely. in the category muscle endurance which consisted of push up and curl up, mostly were in hfz each were (16/20 and 13/20). based on flexibility component, the majority of respondents were in hfz zone (15/20). discussions the aerobic capacity (v02 max) of these players were measured using one mile run test and the value is estimated based on the time taken to complete the run and the students body mass index. based on the table that had been given it can be interpreted that a percentage of 100% of these young football players fall in the category of healthy fitness zone where this zone promises a decrease in risk of coronary heart disease and early death. to maintain this zone, the students can keep fit by doing continues and regular exercise.8 in an unconditional individual, aerobic capacity can be improvised by getting involved in sustained regular activities involving large muscle groups. this improvement depends on frequency, intensity, and duration of training. as a result these athletes will have higher cardiorespiratory endurance during match and able to perform well. on the other hand, a low aerobic capacity will contribute to accumulation of lactic acid in the body due to decrease in distribution of oxygen to the cells in the whole body, and this will lead to low performance of the players. a good aerobic fitness is the basic component of fitness where an athlete can benefit as follows through training and exercise. the benefits are good oxygen supply to muscles, decreased stress level and body fat and increased removal of lactic acid from our body. on the other hand, a reduced aerobic endurance will eventually cause the lacking of other physical fitness components such as muscular endurance and these results in poor performance.10 estimated percent of body fat in these football players were calculated based on skin fold measurement. to maintain this healthy zone, a proper diet which is low in fat and regular physical activities are crucial. this standard represents boundaries for hfz. if the score fall either above or below this hfz, then this student must be given attention. these standards are known to have higher chances in developing health problem related to their level of fatness and leanness. in general if the students fall in the “very lean” category, they should be assessed for the reasons for low body fat to identify underlying problems such as nutritional problem or eating disorder. increased body fat where improvement is needed can lead to overweight or obesity. thus, to reduce problems or diseases in accordance to weight in future, it is important to identify the problems before the lifestyle patterns and physiological changes are established. high levels of physical exertion during training and activities tend to decrease body fat and help in gaining lean body mass.11 table 2 healthy fitness zone of young football players in sdn cibeusi based on physical fitness components (n=20) physical fitness components frequency hfz non-hfz ni-somerisk ni-high risk very lean aerobic capacity 20 percent body fat 20 body mass index 11 5 2 2 muscle endurance 1) push-up 16 4 2) curl-up 13 7 flexibility 15 5 note: hfz: health fitnetss zone, ni: need improvement althea medical journal. 2015;2(2) 229 the body mass index is calculated from weight and height of the students respectively. as a matter, students who are in the hfz have an ideal weight for height. they should try on maintaining this level to prevent any complications related to health. and for those in the “very lean” should be assessed for undernutrion problems to regain back the proper weight for their height. students who score in the area above this should be encouraged and motivated towards weight reduction steps such as increase in physical activity and diet control. improvements and changes in body composition which consist of both components, percent body fat and body mass index will generally result in improved performance in aerobic capacity, muscle strength and endurance, especially in the upper body, due to reduction in excess weight. muscle endurance in these young football players is evaluated based on push up-test and curl up-test. the abdominal or stomach muscle strength can be assessed by performing curl up-test. overall good muscle endurance is important for optimum performance of the student on the field. good muscle endurance is important because it is correlated with aerobic capacity as the upper body muscle like the muscles in the thorax develops, this will help in better respiratory systems thus has positive effect in individuals aerobic capacity.12 and if the students fall in the category of not healthy fitness zone, the trainer should encourage the students to involve in calisthenics as well as other muscle strengthening activities. exercising the muscle appropriately has the benefit of changing the ratio of fat to muscle fibers and thus helps in weight loss. by eating healthily and constant exercise, more muscle will be used in the process of exerting work and thus body will be able to burn more calories and maintain a high metabolic rate. weight training also improves ones speed and powerful movements by keeping more motor nerves connected to the muscles. flexibility of the students was evaluated in sit and reach test and measured using flexometer. flexibility is defined as the ability of the muscles, tendons and ligaments to elongate within the physical limitations of the joint which is reflected by the range of motion in a joint system. flexibility is important in football game as this game requires the students to run and maneuver with the ball where a lot of muscles and joints involvement is needed to perform and ease sudden runs and movements. with a good flexibility, athletes will be prevented from muscle or joint injuries and thus they will be able to stand longer in the field and perform well during a football match. injuries during training tends to occur due to the overstretching or movements that are beyond normal range of movements, thus flexibility training should be integrated as this process will gradually increases the range of motion and reduce the risk of injury.13 in conclusion, based on the excerpt above young footballers in sdn cibeusi physical fitness should be improved and enhance their health status in order to prevent hypokinetic diseases and game standard will be maximized to win a football competitions. references 1. the most popular journal. most popular sport in the world. 2006 [cited 2013 february 4]. available from: http://mostpopular.net/sport-played-world. 2. gerdsen w. investigating suitable pitch sizes for young football players in new zealand division of sport & recreation. [thesis].auckland: auckland university; 2008. 3. ortega fb, ruiz jr, castillo mj, sjöström m. physical fitness in childhood and adolescence: a powerful marker of health. int j obes (lond). 2008; 32(1):1–11. 4. welk gj, de saint-maurice maduro pf, laurson kr, brown dd. field evaluation of the new fitnessgram® criterionreferenced standards. am j prev med. 2011; 41(4 suppl 2): s 131–42. 5. brown sp, miller wc, eason jm. exercise physiology: basis of human movement in health and disease. philadelphia: lippincott williams & wilkins; 2006. p.378. 6. lee sm, burgeson cr, fulton je, spain cg. physical education and physical activity: results from the school health policies and programs study 2006. j sch health. 2007;77(8):435–63. 7. california department of education. 2011-12 california physical fitness test: reference guide. state of california: department of education. 2011. p. 2–21 8. cureton kj, plowm sa. aerobic capacity assessments. in: meredith gjwamd, editor. fitnessgram/activitygram reference guide. 3rded. dallas tx: the cooper institute; 2008.p. 9-7. 9. plowman sa. muscular strength, endurance, and flexibility assessments. subashini periasamy, reni farenia, pintoko tedjokusumo: profile of physical fitness of young football players at sdn cibeusi althea medical journal. 2015;2(2) 230 amj june, 2015 in: meredith gjwamd, editor. fitnessgram/ activitygram reference guide. 3rded. dallas, tx: the cooper institute.; 2008. p. 129. 10. stewart kj. physical activity and aging. ann n y acad sci. 2005;1055: 193–206 11. chaput jp, klingenberg l, rosenkilde m, gilbert ja, tremblay a, sjödin a. physical activity plays an important role in body weight regulation. j obes. 2011;2011:11. 12. laghi f, tobin mj. disorders of the resipiratory muscles. am j respir crit care med.2003;168:10-48. 13. wilk ke, obma p, simpson cd, cain el, dugas jr, andrews jr. shoulder injuries in the overhead athlete. j orthop sports phys ther. 2009; 39(2):38–54. althea medical journal. 2015;2(3) 433 profile of blood transfusion requests from hospitals to bandung blood transfusion unit, indonesian red cross in 2011 syahla nisaa amalia,1 nadjwa zamalek d,2 januarsih a. rachman3 1faculty of medicine universitas padjadjaran, 2department of clinical pathology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran bandung abstract background: blood transfusion as a part health services should be provided under appropriate indications and in a safe manner. in indonesia, blood collection is run by the blood transfusion unit of indonesian red cross, where the blood is screened, processed into blood components, and finally distributed to hospitals. the purpose of this study was to describe the profile of blood transfusion requests from hospitals that do not have blood bank facility to the bandung blood transfusion unit, indonesian red cross. methods: a descriptive study was carried out using secondary data from bandung blood transfusion unit indonesian red cross (utd pmi bandung). all blood request forms from hospitals during 2011 were collected and analyzed. variables in this study were the amount of blood units, blood components, blood type, and indications of blood transfusion. results: the number of blood units requested by hospitals were 35,841 units. the most blood units requested was in august 2011. the blood component requested was the packed red cell (61.1%), whole blood (17.4%), thrombocyte concentrate (10.6%), and fresh frozen plasma (7%). the total percentage of o, a, b and ab blood types were 36.1%, 28.6%, 27.5%, and 7.9% respectively. the most frequent indication for transfusion was anemia (61.7%), followed by surgery and other causes of bleeding. conclusions: the total blood units requested by hospitals vary each month. the most blood component requested is packed red cell and the type of blood is o blood type. the most frequent indication is anemia. [amj.2015;2(3):433–39] keywords: anemia, blood transfusion, blood type, packed red cell correspondence: syahla nisaa amalia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287823392175 email: syahla.nisaa_lima@yahoo.com introduction according to the world health organization (who), transfusion medicine is a part of a healthcare system that manages the supply and use of human blood. transfusion is performed to replace lost blood from the body, which can be caused by trauma or the body has lost its ability to produce blood properly.1,2 blood transfusion can give benefits to the recipients, but it can also carry risks or cause complications. dangerous infections might be transmitted to the recipients if the transfusion was given without following the correct procedures.3 blood transfusion has to be conductedaccording to the indication for each blood component.4,5 blood components given to recipients are whole blood, packed red cell, washed red cell, thrombocyte concentrate, fresh frozen plasma, liquid plasma, crypoprecipitate, and buffy coat.3,5 before requesting blood to a blood transfusion unit for transfusion purpose, a clinician should fill a blood request form. the form consists of information on patient's identity, indication for transfusion, type of blood component and its amount, blood transfusion time, and other related information which have to be submitted correctly and completely by the clinician.6 the next step is to take a blood sample from the patient. this blood sample will be used for compatibility testing to obtain the appropriate blood for optimum safety, efficiency of the transfusion, and to avoid destruction of the transfused blood.5,6 one of the most important steps in compatibility testing is to determine the blood type of the patient. the blood type is determined based on the abo and rhesus althea medical journal. 2015;2(3) 434 amj september, 2015 (rh) blood types.4-6 in the abo blood type system, there are four types of blood groups, which are: a, b, ab, and o. different from the abo blood type system, the rhesus system consists only two types, rhesus positive and negative.4,5 data from the american red cross show that, in average , in every two seconds a person requires blood in the united states. this means that 4.5 million americans need blood each year.7,8 in america, about 60% people are eligible to be blood donor, but only 5% of them become donors.9 in indonesia, about 4.5 million blood units are needed, but only 3.5 million can be fullfilled.10 the blood transfusion unit of the indonesian red cross (unit transfusi darah palang merah indonesia, utd pmi) is an organization that provides blood transfusion service in indonesia. blood transfusion service is provided by pmi, begins with mobilizing people to donate their blood, blood extraction, securing and storing the blood, processing blood into several components, as well as distributing them to the hospital blood bank (bank darah rumah sakit, bdrs). the hospital will distribute these bloods to the recipients who need the blood or its component. hospital blood bank is a working unit in a hospital, which assist in distributing blood transfusion to the recipients. the bdrs receives blood from the local blood transfusion unit. the establishment of bdrs has to follow specific criteria; however, not all hospitals can meet the criteria to establish a bdrs.11 the purpose of this study was to describe the profile of blood requests to utd pmi bandung from hospitals without bdrs facility in the year 2011. this included the amount of total blood requested based on blood type, components, and its indication. methods a descriptive study was carried out in utd pmi bandung. the study was performed using secondary data in blood request forms sent to the utd pmi bandung from hospitals without blood bank facility. the permission to conduct this study was given by utd pmi bandung before data collection began. all blood request forms from hospitals without blood bank facility to utd pmi bandung during 2011 were collected and analyzed. data from blood request forms were entered into computer and analyzed by using frequency distribution presented in either tables or figures. observed variables in this study were number of blood units, blood type, type of blood components, and indication of blood transfusion. the indications for blood transfusion were grouped into several categories. results the total number of blood request to the utd pmi bandung from hospitals without blood bank facility was 17,504, requesting table 1 number of blood requests per month month frequency (n) percentage (%) january 3,153 8.8 february 2,802 7.8 march 3,160 8.8 april 2,800 7.8 may 2,634 7.3 june 2,977 8.3 july 3,147 8.8 august 3,261 9.1 september 3,168 8.8 october 2,879 8.0 november 2,767 7.7 december 3,093 8.6 total 35,841 100 althea medical journal. 2015;2(3) 435 35,841 blood units (2 units per patient). only 7,872 (45%) were completely filled and only 15,202 (42.4%) blood unit requests included information on the indication. table 1 shows that the number of blood unit requested each month varies. most requests were made in august. the average number of blood units requested per month was 2,987 blood units. in table 2, the number of blood requested based on blood component in year 2011 is listed. twenty one thousand nine hundred and sixteen (61.1%) packed red cell units were requested, followed by whole blood of 6,249 (17.4%), thrombocyte concentrate of 3,782 (10.6%), fresh frozen plasma of 2,495 (7%), washed red cells of 1,211 (3.4%) blood units, cryoprecipitate of 120 (0.3%), liquid plasma of 53 (0.1%), and buffy coat of 5 (0%). figure 1 shows the percentage of each abo blood type requested in the year of 2011. figure 1 shows that the blood type most requested by hospitals without blood bank facility in 2011 was type o with a percentage of 36.1%, followed by type a, b, and ab (28.6%, 27.5%, and 7.9% respectively). the percentages of each indication can be seen in table 3. anemia was the highest indication followed by surgery. table 3 shows the amount of blood requested based on indications and blood components by hospitals without blood bank facility. some indications were grouped into several categories, such as other hematological disorder, other cause of bleeding, and others. for example, other hematological disorders are anaemia table 2 number of blood requests based on blood component blood component frequency (n) percentage (%) whole blood 6,249 17.4 packed red cell 21,916 61.1 washed red cell 1,221 3.4 thrombocyte concentrate 3,782 10.6 fresh frozen plasma 2,495 7 cryoprecipitate 120 0.3 liquid plasma 53 0.1 buffy coat 5 0 total 35,841 100 figure 1 percentage of blood requests based on blood type syahla nisaa amalia, nadjwa zamalek d, januarsih a. rachman: profile of blood transfusion requests from hospitals to bandung blood transfusion unit, indonesian red cross in 2011 althea medical journal. 2015;2(3) 436 amj september, 2015 and thrombocytopenia, disseminated intravascular coagulation, hemophilia, hereditary pyropoikilocytosis, idiopathic thrombocytopenic purpura, leukemia and thrombocytopenia, myeloid leukemia, pancytopenia, low pcv, ppt, thallassemia, and also prolonged bleeding. other causes of bleeding indications are epistaxis, bloody cough, hematemesis, gum bleeding, intrapartum bleeding, vaginal bleeding, postpartum bleeding, placenta previa, and rupture. in addition, other indications are acidosis and hipoalbumin, common cold, malaria, general recovery, sepsis, septic arthritis, cirrhosis, and many unknown abbrevitation. the result of this study presented in table 3 shows the highest amount of blood component requested by hospitals was packed red cell, followed by whole blood, thrombocyte concentrate and fresh frozen plasma.. indication for whole blood component was surgery (34.1%), followed by anaemia (32.7%). packed red cell was the most requested blood component in almost all indications. the three highest indications for packed red cell were anaemia (75.8%), surgery (12.7%), and other causes of bleeding (5.7%). the three highest indications for washed red cell were anaemia (88.9%), melena (4%), and other causes of bleeding (2.9%). the three highest indications thrombocyte concentrate were thrombocytopenia (58.9%), anaemia (26.7%), and other causes of bleeding (7.1%). the three highest indications for fresh frozen plasma were anaemia (33.8%), surgery (24.6%), and other causes of bleeding (15.6%). table 4 shows the number of each abo blood type requested by hospitals without blood bank facility based on indications. blood type o was the most requested by hospitals, followed by type b, a and ab. discussion packed red blood cell is the most requested component in theyear 2011. this finding was in accordance with thetheory proposed by kaplan and skerrett that the most transfused blood component is the packed red cell.12 the request for whole blood decreases, since requesting of specific blood component increases.13 packed red cell is a blood component given to increase the oxygencarrying capacity or to speed up the delivery of table 3 number of blood request based on indication and blood component indication blood component* total percentage (%) wb prc wrc tc ffp cryo lp bc anaemia 968 7,472 330 291 309 10 5 0 9,385 61.7 surgery 1,008 1,259 2 16 225 0 0 0 2,510 16.5 other cause of bleeding 226 562 11 78 143 0 0 0 1,020 6.7 caesarean section 667 171 0 3 2 0 0 0 843 5.5 trombocytopenia 8 41 2 642 111 0 0 0 804 5.2 other hematological disorder 12 70 1 44 27 0 0 1 155 1 melena 9 96 15 8 21 0 0 0 149 0.9 kidney disease 1 72 4 0 0 0 0 0 77 0.5 hypoalbuminemia 0 0 1 0 60 0 2 0 63 0.4 others 16 38 4 4 10 0 0 0 72 0.4 cancer 6 21 1 3 0 0 0 0 31 0.2 intervention preparation 12 27 0 0 4 0 0 0 43 0.2 transfusion 8 22 0 0 1 0 0 0 31 0.2 childbirth 17 2 0 0 0 0 0 0 19 0.1 total 2,958 9,853 371 1,089 913 10 7 1 15,202 100 *wb = whole blood; prc = packed red cells; wrc = washed red cells; tc = thrombocyte concentrate; ffp = fresh frozen plasma; cryo = cryoprecipitate antihemophilic factor; lp = liquid plasma; bc = buffy coat althea medical journal. 2015;2(3) 437 oxygen to the cells of the body. the condition with low oxygen-carrying capacity could be found such as in decreased bone marrow production, decreased life span of red blood cells, and chronic or acute hemorrhage (surgical or traumatic). administration of packed red cell does not only depend on the hemoglobin level, but also depends on the clinical symptoms and the status of hemodynamic. the hemoglobin level is not an absolute indicator for transfusion because the body has compensatory mechanism to adapt with low level of hemoglobin in the body. in that case, the transfusions are not necessary unless a sign of anemia is seen.3,15-17 packed red cell is often requested only based on anemic, without any information of the hemoglobin level or severity of anemia.15,16 whole blood can be given for active bleeding. in this case, the loss of red blood cells and decrease of blood volume can occur simultaneously, such as in surgery, childbirth, and caesarean section.4 in all these conditions, there was no information regarding active bleeding. in addition, table 3 shows that there was a demand for whole blood for thrombocytopenia. this situation is not in accordance with the theory. thrombocyte blood components should be given for thrombocytopenia.4 washed red cell is erythrocyte, which washed by using the sterile normal saline. theoretically, washed red cell is to prevent an allergic reaction, such as in people with iga deficiency were given transfusion of packed red cell, due to the presence of plasma containing iga.15,16 a total of 371 washed red cell was requested, most of them based on indication of anemia. thrombocyte concentrates are given to prevent or treat active bleeding associated with thrombocytopenia, however not all thrombocytopenia should be treated with thrombocyte concentrates. the administration of thrombocyte concentrate component depends on the clinical condition, the cause of thrombocytopenia, platelet count, and platelet function of patients.16 the indication of thrombocyte concentrate transfusion is in accordance with the indications of trombcytopenia, but the indication of thrombocytopenia was not clearly mentioned. additionally, there were 251 units of thrombocyte concentrate requested for anemia. fresh frozen plasma consists of many proteins, including coagulation factors, albumin, and immunoglobulins. furthermore, fresh frozen plasma administration is used to prevent or treat patients with active bleeding due to coagulation abnormalities caused by massive transfusion or liver disease, or prolonged prothrombin time and partial thromboplastine time.4,5,12,18 table 3 table 4 number of blood request based on indication and blood type indication blood type total percentage (%) a b ab o anaemia 2,587 2,648 726 3,424 9385 61.7 surgery 656 808 199 847 2510 16.5 other cause of bleeding 336 280 73 331 1020 6.7 caesarean section 257 201 87 298 843 5.5 trombocytopenia 234 303 53 214 804 5.2 other hematological disorders 29 49 11 66 155 1 melena 52 34 12 51 149 0.9 kidney disease 14 34 3 26 77 0.5 hypoalbuminemia 25 4 6 28 63 0.4 others 10 19 14 29 72 0.4 cancer 8 2 0 21 31 0.2 intervension preparation 9 10 9 15 43 0.2 transfusion 6 9 2 14 31 0.2 childbirth 5 5 1 8 19 0.1 total 4,228 4,406 1,196 5,372 15,202 100 syahla nisaa amalia, nadjwa zamalek d, januarsih a. rachman: profile of blood transfusion requests from hospitals to bandung blood transfusion unit, indonesian red cross in 2011 althea medical journal. 2015;2(3) 438 amj september, 2015 shows that many fresh frozen plasma were used for anemia, but there was no further information regarding thecoagulation status. cryoprecipitate is a blood component derived from fresh frozen plasma, which contains factor viii, von willebrand factor, factor xiii, fibrinogen and fibronectin. cryoprecipitate is usually used for patients with hemophilia a, von willebrand (vwd) disease, and hypofibrinogenaemia related bleeding.3,5,19 liquid plasma is the liquid component from fresh frozen plasma stored in 24 hours to 5 days after thawed.15 table 3 shows cryoprecipitate and liquid plasma were given to patients with anemia, but theoritically there is no indication for anemia. buffy coat is a concentrate of white blood cells and platelets obtained at the time centrifugation. indications for buffy coat are infants with septic neutropenic and less neutrophil counts, and in infants with sepsis and bad neutrophil function.20 due to limited data obtained, it was difficult to compare with the established theories. blood type o is the most requested with percentage as much as 36.1%. data from the american red cross shows that blood type o is the most requested by the clinicians.7 most people in the world have blood type o, followed by type a, b, and ab.14 this study had limitations. from a total of 35,841 blood units requested, only 15,202 (42.4%) blood units were known the indications. therefore, the results of this study could not definitively prove why the blood was needed. there were many forms filled with several terminology with the same meaning. based on the results, it can be concluded that the total blood units requested by hospitals varied each month, but the most requested was in august. the type of blood component most frequently requested is packed red cell and o bloodtype. the three frequent indications are anemia, surgery and other causes of bleeding. references 1. national heart, lung, and blood institute. what is a blood transfusion ?; 2012 [cited 19 april 2012]; available from: http:// www.nhlbi.nih.gov/health/health-topics/ topics/bt/. 2. natukunda b, schonewille h, sibinga cts. assessment of the clinical transfusion practice at a regional referral hospital in uganda. transfus med. 2010;20(3):134–9. 3. koh mbc, lee ys, chay j. appropriate blood component usage. isbt science series. 2011;6(2):249–56. 4. who. the clinical use of blood: handbook. geneva: who library cataloguing in publication data; 2002. 5. hillyer cd, shaz bh, zimring jc, abshire tc. transfusion medicine and hemostasis: clinical and laboratory aspects. oxford: elsevier; 2009. 6. roxby d. current concepts in pretransfusion serological compatibility testing. isbt science series. 2011;6(2):2659. 7. american red cross. blood facts and statistics [cited 2012 november 25]; available from: http://www. redcrossblood.org/learn-about-blood/ blood-facts-and-statistics. 8. health watch center. blood facts and statistics (infographics); 2011 [cited 2013 february 9]; available from: http://www. healthwatchcenter.com/2011/12/bloodfacts-and-statistics/ 9. new york blood center. blood statistics.; [cited 2012 december 2]; available from: http://www.nybloodcenter.org/bloodstatistics.do?sid0=85&page_id=202. 10. arriani a. ayo, bersama berbagi kebaikan. palang merah indonesia; 2012 [cited 2012 december 2]; available from: http://www.pmi.or.id/ina/news/default. asp?act=detail&p_id=847. 11. utd pmi pusat. pedoman pelayanan transfusi darah. 3rd ed. jakarta; 2007. 12. kaplan hs, skerrett dl. types of transfusion. merck manual home health handbook; 2007 [cited 2012 may 1]. available from: http://www.merckmanuals.com/home/ b l o o d _ d i s o rd e r s / b l o o d _ t ra n s f u s i o n / types_of_transfusions.html. 13. cronan km. surgeries and procedures: blood transfusion. the nemours foundation; 2012 [cited 2012 november 25]; available from: http://kidshealth. o r g / p a r e n t / s y s t e m / s u r g e r y / b l o o d _ transfusion.html#. 14. o’neil d. distribution of blood types. modern human variation:an introduction to contemporary human biological diversity;1998-2012 [cited 25 november 2012] available from: http://www.anthro. palomar.edu/vary/vary_3.htm. 15. harmening dm. modern blood banking & transfusion practices. 5th ed. melanie s. kennedy m, haifeng m. wu m, editors. philadelphia: f. a. davis company; 2005. 16. mccullough j. transfusion medicine. 2nd ed. philadelphia: elsevier; 2005. 17. liumbruno g, bennardello f, lattanzio a, althea medical journal. 2015;2(3) 439 piccoli p, rossetti g. recommendations for the transfusion of red blood cells. blood transfusion. 2009;7(1):49–64. 18. moiz b, arif fm, hashmi kz. appropriate and inappropriate use of fresh frozen plasma. j pak med assoc. 2006;56(8):356– 9. 19. droubatchevskaia n, wong mp, chipperfield km, wadsworth ld, ferguson dj. guidelines for cryoprecipitate transfusion. bcmj. 2007;49(8):441–5. 20. charge nurse newborn. buffy coat concentrate. newborn services clinical guideline;2003 [cited 2012 december 2] available from: http://adhb.govt. n z / n e w b o r n / g u i d e l i n e s / b l o o d / bloodproducts/buffycoat.htm. syahla nisaa amalia, nadjwa zamalek d, januarsih a. rachman: profile of blood transfusion requests from hospitals to bandung blood transfusion unit, indonesian red cross in 2011 althea vol 2 no 1 abstrk edit.indd althea medical journal. 2015;2(1) amj, april 2015 green tea and its effect on hemostasis measured by thrombelastography bryant alyzandyr eumhyn chua,1 trully d. sitorus,2 nadjwa zamalek dalimoenthe3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: increasing health problems may come from changes in lifestyle including stressful lifestyles, high calorie diets, and lack of physical activity. those may also lead to an increase occurrence of abnormal hemostasis. green tea has been well known for its many benefits, including its antithrombotic effect. the aim of this study was to determine whether the consumption of green tea actually affects hemostasis and to measure changes in hemostatic parameters after its consumption. methods: a preliminary explorative study was conducted on 3 healthy female subjects aged between 21 to 22 years old for 8 weeks from october to november 2012 in jatinangor, sumedang, indonesia. the subjects were subjected to initial thrombelastography analysis and started drinking green tea twice a day after meals. the solution was made by steeping a teabag in 250ml water of 70°c for 2 minutes. after 8 weeks, another thrombelastography analysis was performed to the subjects. results: preand post-intervention results of the analysis were averaged and compared according to the parameters. the results of this study showed prolonged r (reaction-time) and k (k-time), decreased α (angle) and ma (maximum amplitude), and increased ly30 (lysis at 30 minutes), showing an overall reduction in coagulability. conclusions: the consumption of green tea twice a day for 8 weeks affects hemostasis with hemostatic parameters measured by thrombelastography show differences before and after consumption. keywords: green tea, hemostasis, thrombelastography correspondence: bryant alyzandyr eumhyn chua, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628170205778, email: alyzandyr@gmail.com althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 82 amj march, 2015 effect of dates (phoenix dactilyfera l) on male infertility semalina wahyudi1, r.a. retno ekowati2, andi rinaldi3 1faculty of medicine, universitas padjadjaran, 2departmen of biology cell, faculty of medicine, universitas padjadjaran, 3department of obstetrics and gynecology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: infertility can be caused by prolonged use of paracetamol that leads to a decrease in the sperm concentration, motility, and morphology. dates (phoenix dactilyfera l) have natural antioxidant effects through several mechanisms, such as neutralizing free radicals, against no, oh, and h2o2, and also preventing lipid peroxidation. this study aimed to investigate the effect of dates on sperm concentration, motility, and morphology. methods: an experimental study was conducted in the laboratory of cell biology department, faculty of medicine, universitas padjadjaran, during october–november 2012. twenty two infertile male wistar rats were divided randomly into 2 groups. group a was given 72 mg paracetamol/rat/day orally and group b was given 72 mg paracetamol/rat/day orally and 80% dates infusion/rat/day orally for 28 days and on the 29th day, sperm concentration, motility, and morphology were measured. results were analyzed using unpaired t-testor mann whitney test. result: in the control group, 502.73(100.66) sperm concentrations were compared to 397.55(143.07) in the treatment group. however, the sperm concentration mean in the treatment group was not significantly decreased (p>0.05) compared to the control group. the percentage of progressive sperm motility in the treatment group increased significantly compared to the control group. meanwhile, the percentage of nonprogressive immotal sperm morphology was not significantly decreased. the percentage of normal sperm in the treatment group increased significantly (p<0.05) than the control group, while the percentage of abnormal sperm in the treatment group decreased significantly (p<0.05) compared to the control group. conclusion: the dates affect sperm motility and morphology of infertile rats. keywords: dates, infertility, paracetamol, sperm correspondence: semalina wahyudi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285295252263 email: semalinawahyudi@yahoo.com introduction infertility is the inability of a couple to have children after two years of regular intercourse without using a contraception.1 many causes of the infertility, one of which is contributed by male as much as 30–40% cases.2 one of the mechanism of infertility is caused by a male is the cell damage caused by the reactive oxygen species (ros). the extent of damage is caused by ros depends on the balance between oxidative stress and the defense system.3 according to agarwal et al.4 one of the causes of oxidative stress are drugs such as aspirin and paracetamol (acetaminophen) can increase the production oxidative stress by increasing activity of cytochrome p450, which will increase the formation ros. to overcome the problem of infertility caused by oxidative stress reactions that will generate reactive oxygen species (ros), also known as free radicals, should be given an antioxidant that can counteract free radicals. beside naturally contained in the body, antioxidants can be found from the food intake, in the form of nutrients and nonnutrients or phytochemicals contained in the fruits and vegetables.5 this study is conducted to counteract the oxidative stress caused by prolonged use of paracetamol by using date palm fruits that has high potential antioxidant activity to determine an effect on number, motility, and morphology of sperm in infertile adult male rat caused by longterm use of paracetamol. althea medical journal. 2015;2(1) 83 methods an experimental study was conducted to 22 male wistar rats 3 months with average weight 300 grams which has no anatomical abnormalities. the rats were randomized selected into 2 groups, group a, the control was given only 72mg/3ml/day paracetamol orally for 28 days and group b was given 80% of date palm fruits infusion orally as much as 3 ml/day, then given 72mg/3ml/ day paracetamol orally for 28 days. on the 29th, all rats were dissected to retrieve the ductus epididymis. (the date palm fruits used are ajwa dates/”prophet dates”). this experiment was conducted in accordance with the principles of the 3rs, which are replacement, reduction and refinement.6 ductus epididymis taken was dissolved and made homogeneous using a solution of phosphate buffered saline (pbs). assessment of sperm concentration per mm3 was carried out by dripping sperm solution into an improved neubauer haemocytometer and then covered with a cover glass and counted only if the sperm has a complete head and a tail. assessment of the sperm motility was made by the dripping solution on the object glass and covered with a cover glass, to observe the movement by its category; progressive motility, non progressive motility and immotile. assessment of the sperm morphology performed with fixation using 40% methanol for five minutes, rinse and then drop with 5% safranin for five minutes, then dip in a buffer solution, and then performed staining using crystal violet.7 normality of the data was tested using sapirowilk test, and the data was analyzed using a parametric unpaired t-test, or mann whitneytest. result in the control group, there was 502.73 sperm concentration compared to treatment group (397.55). while immotal sperms in group a were found more than in group b. moreover, the percentage of abnormal morphology in sperms of group b was less than in group a (table 1). however, the mean of sperm concentration in the treatment group were not significantly decreased (p>0.05) than the control group (figure 1). the percentage of progressive sperm motility in the treatment group increased significantly compared to the control group. meanwhile, the percentage of nonprogressive immotal sperm morphology were not significantly decreased. the percentage of normal sperm in the treatment group increased significantly(p<0.05) than the control group, meanwhile the percentage of abnormal sperm in the treatment group decreased significantly (p<0.05) than in the control group(figure 2). table 1 the sperm concentration, motility, and morphology in control and treatment groups parameters group mean (sd) sperm concentration (sperm count/mm3) a 502.73 (100.66) b 397.55 (143.07) sperm motility (%) pr a 7.45 (4.20) b 18.36 (7.46) np a 28.82 (9.86) b 25.45 (8.20) im a 63.73 (9.85) b 56.27 (12.93) sperm morphology (%) n a 85.64 (4.31) b 94.36 (4.10) ab a 14.36 (4.31) b 4.73 (2.28) note; pr (progressive motility), np (nonprogressive motility), im (immotile), n (normal), ab (abnormal), a(paracetamol), b (date palm fruits and paracetamol) semalina wahyudi, r.a. retno ekowati, andi rinaldi: effect of dates (phoenix dactilyfera l) on male infertility althea medical journal. 2015;2(1) 84 amj march, 2015 discussion according to wafaa et al.8 paracetamol decreases the number and motility of sperm that also triggering the apoptosis of sperm cells, which lowers testicular size indicating the occurrence of mild testicular toxicity. dates have a natural antioxidant such as provitamin a (beta carotene), vitamin c and other compounds such as flavonoids, minerals, pectin, phenolic, and sterols.9 it contains the free radical scavengers such as zinc, manganese, magnesium, selenium, carotenoids, phenolic and vitamin b complex.9 dates are believed to enhance the sexual performance in male, but there is a lack of information about the physiological effects and phytochemicals from dates in humans.10 the gonadotropin effect of dates can also increase the size of the testes and seminal vesicles which also shows an increase in plasma levels of estradiol and testosterone which will increase the number of sperm.11dates can be a source of antioxidants through several mechanisms, such as neutralizing free radicals, against no, oh, and h2o2 and preventing lipid peroxidation.12limiting the formation of free radicals, destroying free radicals or its precursor, and stimulates antioxidant enzymes activity.13 date palm fruits infusion contains the compounds to lessen the anti oxidant effects. figure 1 the effect of date palm fruits on sperm concentration. note; a (notsignificantly different from control p>0.05) figure 2 the effect of date palm fruits on motility and morphology of sperm note; pr (progressive motility), np (nonprogressive motility), im (immotile), n (normal), ab (abnormal), a (not significantly different from control p>0.05), b (significantly different from control p<0.05) althea medical journal. 2015;2(1) 85 paracetamol causes anti motility effects that works directly on spermatozoa by inhibiting the activity of nitric oxide or work indirectly by altering the environment in the epididymis through its action in inhibiting the enzyme cyclooxygenase. nitric oxide is important in hyper activation of sperm to the acrosome reaction and critical help in the process of fertilization to fertilize an egg. in addition, high doses of paracetamol can cause a lipid peroxidation which can damage the sperm fertilization potential by inhibiting glycolysis and reduced supply of atp in helping motility of sperm.8 paracetamol may increase the production of oxidative stress by increasing the activity of cytochrome p450 to increase the formation of reactive oxygen species (ros). oxidative stress occurs when the production of ros exceeds the body’s natural antioxidant resistance mechanisms which will cause a cellular damage. ros causes the infertility in two ways. first, it damages the sperm membrane, lower sperm the motility and ability to fuse with the oocyte. second, ros can alter the dna of the sperm, resulting in a defect in dna.4 dates have an antioxidant effect by increasing glutathione enzyme(gsh), superoxide dismutase (sod) and catalase (cat). dates also have an effect against the testicular dysfunction in the infertile rat by increasing normalization of estradiol and testosterone levels and other sperm parameters. dates protecting testicular tissue by decreasing abnormal cells and repair damaged dna.14 however, this study indicates that the effect of palm fruit was only on sperm motility and morphology. this study has no control group consisting of rats that were neither given paracetamol nor paracetamol and palm fruit, so that the data of sperm concentration, motility and morphology in normal rats cannot be obtained. as conclusion, dates can improve sperm motility and morphology of infertile rat induced by paracetamol, while the sperm concentration remained unchanged. reference 1. who. health topics: infertility.2012 [cited 2012 february 20]. available from: http:// www.who.int/topics/infertility/en/ 2. burney ro, schust dj, yao mw. infertility. in: berek js, editor. berek & novak’s gynecology.14thed.philadelphia: lippincot william & wilkins; 2006. p. 1185–259. 3. ford wc. biological mechanisms of male infertility. the lancet. 2001;357(9264):1223–4. 4. tremellen k. oxidative stress and male infertility–a clinical perspective. hum reprod update. 2008;14(3):243–58. 5. fayadh jm, alshowiman ss. chemical composition of date palm (phoenix dactylifera l.). jour chem soc pak. 1990;12(1):95–100. 6. hubrecht rc, kirkwood j. the ufaw handbook on the care and management of laboratory and other research animal. 8th ed. singapore: wiley-blackwell; 2010. 7. who, department of reproductive health and research. who laboratory manual for the examination and processing of human semen. 5th ed. switzerland: who library cataloguing data; 2010. p. 21–36. 8. ratnasooriya wd, jayakody jr. long term administration of large doses of paracetamol impairs the reproductive competence of male rats. asian j androl. 2000;2(4):247–55. 9. yasmina m, abdennour c, loudjani f. influence of palm date and vitamin c supplementation on testicular functions of domestic rabbit oryctolagus cuniculus under mercury exposure. ann biol res. 2011;2(3):359–67. 10. omar aa, shanawany mm, ismail aa, mohsen mk. the effect of palm pollen grains and date extract on the spermatogenic activity of male guinea pigs. proceeding of the second symposium on date palm; 2010 february 2nd; burydah. qassim: king saud university; 2010. 11. bahmanpour s, talaei t, vojdani z, panjehshahin mr, poostpasand a, zareei s, et al. effect of phoenix dactylifera pollen on sperm parameters and reproductive system of adult male rats. iran j med sci. 2006;31(4):208–12. 12. al-mamary m, al-habori m, al-zubairi, sa. the in vitro antioxidant activity of different types of palm dates (phoenix dactylifera) syrups. arabian journal of chemistry.[online journal]. 2010. [cited 2012 march 26]. available from: http:// www.sciencedirect.com. 13. whitney e, rolfes sr. understanding nutrition. 11th ed. belmont: thomson wadsworth; 2008. p. 390–1. 14. hasan wa, el-kashlan am, ehssan na. egyptian date palm pollen ameliorates testicular dysfunction induced by cadmium chloride in adult male rats. journal of american science.2012;8(4):659–69. semalina wahyudi, r.a. retno ekowati, andi rinaldi: effect of dates (phoenix dactilyfera l) on male infertility althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 250 amj june, 2015 nurses’ knowledge of blood culture sampling procedure wulan ardhana iswari,1 chrysanti murad,2 ida parwati 3 1faculty of medicine universitas padjadjaran, 2department of microbiology & parasitology, faculty of medicine universitas padjadjaran, 3department of clinical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: false-positive blood culture results due to contaminated samples have shown to increase patients’ health costs, including the use of broad spectrum antibiotics and prolonged hospital length of stay. while previous research have suggested that increasing staff knowledge on proper specimen collection lowers contamination rates significantly, staff ’s current knowledge of hospital-recommended sample collection procedure have yet to be assessed in dr. dr. hasan sadikin general hospital, bandung, indonesia. methods: this was a cross-sectional descriptive study on 81 emergency department nurses in dr. hasan sadikin general hospital, indonesia. subjects were asked to complete a questionnaire in order to measure their knowledge of blood culture sampling procedure in accordance with the hospital’s standard operating procedure. results: among 81 subjects enrolled, 51 managed to adequately describe the prerequisites in proper blood culture sampling procedure and their purpose as dictated by dr. hasan sadikin general hospital’s standard operating procedure. conclusions: up to 67% of nurses conducting blood sampling procedure in dr. hasan sadikin general hospital’s emergency department understood the prerequisites of hospital-recommended blood culture sampling procedure and their purpose. [amj.2015;2(1):250–2] keywords: blood culture, knowledge, nurses correspondence: wulan ardhana iswari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 821 1650 7473 email: wulanardhana@gmail.com introduction blood culture remains the most important diagnostic procedure to detect systemic bacterial infection1. however, contaminated samples resulting in false-positive cultures significantly increase patient’s financial burden compared to true negative results by prolonging hospital length of stay2, prompting the need for additional laboratory tests including second blood cultures3 and broad spectrum antibiotics2-4. contamination rates vary among institutions from 0.6–6% despite a set target rate of 3% 5 and tends to be higher in teaching hospitals where blood culture sampling is not conducted by a specialized phlebotomy team6. several prevention methods have been proposed, from procedure modifications, installing a dedicated phlebotomy team5, to supplementing instruction sheets on blood culture sampling kit7. roth et al.6 study found that in a setting where phlebotomy is conducted by nurses and auxiliary nurses, increasing the knowledge of the phlebotomy staff about proper blood culture procedure reduce the rate of contamination significantly (2.59% pre-intervention; 2.23% post-intervention, 95% ci, 0.76 to 0.98)6 this study aimed to measure the knowledge of nursing staff in dr. hasan sadikin general hospital’s emergency room on proper blood culture procedure according to the guidelines published by dr. hasan sadikin general hospital’s clinical pathology department8. methods this was a cross-sectional descriptive study conducted in dr. hasan sadikin general hospital bandung, indonesia, from october 2012 to december 2012. all 96 nurses in the emergency room were asked to fill a selfcompleted 11-item questionnaire on blood culture sampling procedure tailored according althea medical journal. 2015;2(2) 251 to the hospital’s standard operating procedure over a period of time; 15 were sampled to test the validity of the questionnaire for the first week of the study and the rest were taken until the second week of november 2012. the questionnaire, comprising of 11 items, was designed to measure participant’s knowledge on the following: (a). the purpose of blood culture sampling; (b). the purpose, procedure, and recommended materials used in disinfection in blood culture sampling; (c). other preventive measures against sample contamination as prescribed in the hospital’s guideline. the results were then classified into “adequate” (≥70% of responses correct) and “poor” (<70% of responses correct). questionnaire development took place in the beginning of october 2012, with questionnaires completed by 15 initial subjects and subsequently tested for reliability using cronbach’s alpha test. the remaining 81 subjects completed the questionnaires in the following weeks and responses were then recorded and measured results more female subjects (51.9%) participated in this study from a total of 81 subjects. as many as 46.9% were aged 30-39 years old, 30.9% between the ages 20-29, and 11.1% were 4049. twenty-nine point six percent of them had been working in dr. hasan sadikin general hospital for 11-19 years, 28.4% for less than 5 years, 22.2% for 5-10 years and a meager 7.4% had been working for more than 20 years. the majority of subjects (63%) managed to show an adequate level of knowledge regarding blood culture sample collection procedure. there were 79 subjects (97.5%) knew that blood culture is used to detect systemic bacterial infection; all of them understood the purpose of disinfection in blood culture sample collection (table 1). other prerequisites in proper blood culture collection were also understood by the majority (other prerequisites: 72.8%, 82.7%, 81.5%, and 72.8%). however, when asked to describe the steps of blood sample collection, only a mere 8 subjects or 9.9% were able to do so correctly. discussion aronson et al.9 suggested that blood culture as a diagnostic test is unusually dependent on human behavior (sterile technique, timing and volume) and clinical judgment. a lapse in these influencing behaviors might increase contamination rate; roth et al.6 study has shown that informational intervention, or increasing phlebotomy staff ’s knowledge, could significantly reduce the rate of blood culture contamination. in this study, the majority of nurses have adequately described the prerequisites table 1 nurses’ knowledge of blood culture sample collection items asked number of responses correct frequency % purpose of blood culture 79 97.5 difference between blood sample collection for cultures and other tests 42 51.9 draw blood for culture before other tests 54 66.7 purpose of disinfection 81 100 recommended disinfectant 67 82.7 sampling site 55 67.9 other prerequisites letting disinfectant to dry before drawing blood 59 72.8 recommended numbers of sampling site 67 82.7 swab bottle top with alcohol 66 81.5 bottles of media use 59 72.8 describe the steps of blood culture sampling procedure 8 9.9 wulan ardhana iswari, chrysanti murad, ida parwati: nurses’ knowledge of blood culture sampling procedure althea medical journal. 2015;2(2) 252 amj june, 2015 in proper blood culture sample collection according to the guidelines issued by dr. hasan sadikin general hospital. a question is raised, however, when only a scarce minority (9.9%) managed to describe the steps in sample collection correctly; this suggests more training in this area might be helpful for nurses who conduct blood culture sample collection. this study was limited due to the constraints of time and resources, the lack of deep interview method towards the subjects, which resulted in several missing characteristics data. further research is needed to improve the limitation and broaden the scope to compare practicing nurses’ knowledge to blood culture sampling procedure recommended by other, newer literatures references 1. brooks gf, carroll kc, butel js, morse sa. medical microbiology, 24th ed. new york: mcgraw-hill; 2007. 2. alahmadi y, aldeyab m, mcelnay j, scott m, darwish elhajji f, magee f, et al. clinical and economic impact of contaminated blood cultures within the hospital setting. j hosp infect. 2011;77(3):233–6. 3. waltzman ml, harper m. financial and clinical impact of false-positive blood culture results. clin infect dis. 2001;33(3):296–9. 4. gander rm, byrd l, decrescenzo m, hirany s, bowen m, baughman j. impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. j clin microbiol. 2009;47(4):1021–4. 5. hall kk, lyman ja. updated review of blood culture contamination. clin microbiol rev. 2006;19(4):788–802. 6. roth a, wiklund ae, palsson as, melander ez, wullt m, cronqvist j, et al. reducing blood culture contamination by a simple informational intervention. j clin microbiol. 2010;48(12):4552–8. 7. madeo m, jackson t, williams c. simple measures to reduce the rate of contamination of blood cultures in accident and emergency. emerg med j. 2005;22(11):810–1. 8. parwati i, turbawati d, andriyoko b. pengambilan spesimen untuk pemeriksaan mikrobiologi. bandung: upf patologi klinik rumah sakit dr. hasan sadikin; 2012. 9. mylotte j, tayara a. blood cultures: clinical aspects and controversies. eur j clin microbiol infect dis. 2000;19(3):157–63. althea vol 2 no 3 final.indd althea medical journal. 2015;2(3) 308 amj september, 2015 women’s opinion about women’s rights regarding family planning in hegarmanah village, jatinangor subdistrict, west java in 2013 suzanne saw,1 yoni syukriani,2 a. hussein s. kartamihardja3 1faculty of medicine universitas padjadjaran, 2department of forensic & legal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of nuclear medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: universal declaration of human rights stated that all mankind have equal right and dignity. both woman and man have rights regarding family planning. it is often assumed that in developing country, women do not consider their rights in family planning decision making process. this study was carried out to determine the opinion of women regarding women’s rights in family planning. methods: a descriptive study was carried out to 99 respondents during the period of august to october 2013, in hegarmanah village, jatinangor subdistrict. the inclusion criteria were women aged 15–49 years old, able to speak bahasa indonesia, and agreed to participate. variables for this study were the opinions of the respondents regarding woman’s rights in family planning which were represented in 12 questions. collected data were presented as percentages shown in tables. results: most of the respondents stated that they had the rights in family planning decision making, including choosing contraceptive methods, number of children, and spacing of each child. however, all of the respondents agreed that men should be involved in it. more than half of the respondents stated that they asked opinion from family member regarding family planning especially their mothers. cultural norms did not influence the family planning decision making. however, religion influenced the family planning decision making. conclusions: majority of the women in hegarmanah village have the role to make decision on family planning by considering the opinions of their spouses, other family members, friends and their religions. [amj.2015;2(3):308–13] keywords: cultural norms, family planning, men, religion, women’s rights correspondence: suzanne saw, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85793256929, email : suzannesaw91@hotmail.com introduction as stated in the universal declaration of human rights, all mankind have equal right and dignity. however, experts considered cultural and religious norms are still the barrier for women’s rights in decision making. from the human right perspective and through the millennium development goals, barriers to contraceptives can be recognized and reduced.1 according to traditional cultural norms, men are the most important factor in family life decision making. both woman and man have rights on family planning and decision making that should involve spouse. the ability of spouse to choose and decide on the number, spacing, and timing of children has become the main focus of current international family planning programmes.2 there were many studies conducted regarding family planning but no study was conducted on woman’s rights in family planning. west java is one of the provinces in indonesia which has the largest population. it is the first province that implemented family planning programme and by the end of 2012, about 55.7% reproductive age population practiced family planning.2 jatinangor as one of the subdistricts in west java, is designated by the faculty of medicine universitas padjadjaran to be a subdistrict where medical students carried out researches on various health issues including family planning. therefore, this study was conducted to determine the opinion of women regarding women’s rights althea medical journal. 2015;2(3) 309 in family planning in jatinangor. methods a descriptive study was carried out to 99 respondents during the period of august to october 2013, in hegarmanah village, one of the 12 villages in jatinangor subdistrict. the inclusion criteria were women aged 15–49 years old, able to speak bahasa indonesia, and agreed to participate. the exclusion criteria were respondents who were not at home when the data were collected. variables for this study were the opinions of the respondents regarding women’s rights in family planning consisting of 3 issues; first, the roles of men, women, and spouses, second, the roles of family and friends, third, the roles of cultural norms and religions. there were 12 questions that the respondents should respond in “yes” and “no” answers. the collected data were presented as percentages shown in tables. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. results most of the respondents (47%) were below 20 years old. all respondents were muslim. there were 52 unmarried women and 47 married women in this study. for the characteristic of married women, all married women had history of pregnancy and had children. only 9% had abortion and 91% of the respondents were using contraception. all of theunmarried women wanted to have children in the future and 87% planned to have 2–3 children. moreover, 85% of the respondents planned to use contraception and the majority of them preferred the pill as a contraceptive method. most of the respondents stated that they had rights in family planning decision making and played a role in deciding the number of children and spacing of each child. however, all respondents agreed that men should be involved in family planning decision making. only half of the respondents agreed that table 1 roles of men, women and spouses opinion of women regarding their right in family planning total (n) percentage (%) men involvement in family planning decision making yes 89 90 no 10 10 man involvement in contraception yes 52 53 no 47 47 women have the right in family planning decision making yes 91 92 no 8 8 role of woman in deciding the number of children, spacing of each pregnancy yes 90 91 no 9 9 spousal consent/inform spouses before access to contraceptives yes 94 95 no 5 5 women require to follow men’s decision in family planning even though woman do not agree with the decision yes 43 43 no 57 57 suzanne saw, yoni syukriani, a. hussein s. kartamihardja: women’s opinion about women’s rights regarding family planning in hegarmanah village, jatinangor subdistrict, west java in 2013 althea medical journal. 2015;2(3) 310 amj september, 2015 men should be involved in using contraception and did not agree that women required to follow men’s decisions in family planning. more than half of the respondents stated that they asked opinion from family members regarding family planning and some of the respondents were influenced by family members especially their mothers. cultural norms did not influence the family planning decision making. however, religion influenced the family planning decision making. discussion women represented by 90% agreed that men should be involved in family planning. out of 90% respondents, 60% of them thought that men play a role in family planning. besides, some women in hegarmanah village stated that men should make decision in family planning as man is the head of family (table 1). this result is similar to theinternational conference and demography population (iicpd) held in egypt3 that concluded in regard to women’s rights in family planning, it should involve men in decision making. furthermore, respondents were asked about involvement of men in contraception and 53% of the respondents agreed that men should be involved in contraception. out of 53% respondents, 34% of the women thought that men can use contraceptives method available for men. some women thought that men had thesame responsibility in family table 2 roles of families and friends opinion of women regarding their right in family planning total (n) percentage (%) ask the opinion from family member regarding family planning yes 60 61 no 39 39 ask the opinion from friends regarding family planning yes 51 52 no 48 48 influences from family members regarding perception in family planning yes 55 56 no 44 44 table 3 roles of cultural norms and religion opinion of women regarding their right in family planning total (n) percentage (%) more children one has, it will be better yes 42 42 no 57 58 if in the area less people were practicing family planning, the respondents would still use contraception in controlling fertility yes 89 90 no 10 10 religion influences decision making in family planning yes 65 66 no 34 34 althea medical journal. 2015;2(3) 311 planning besides women. a study conducted in tasikmalaya4 predicted that participation of men in contraception has increased from year to year, with rate 3.6% in 2010, 4.0% in 2011, 4.3% in 2012, 4.6 %, in 2013 and 5.0% in 2014. this study showed that participation of men in contraception has increased as one of the aims of themillennium development goals 3 was to promote gender equality and empower women. therefore, men have responsibility in using contraceptive methods available for men. however, around half of the respondents represented by 47% thought that men should not use contraception. whereas, around 41% stated that normally women used and men did not use contraception. respondents stated that there was less option available for men and it was uncomfortable if men used contraception during sexual intercourse. result in this study is similar to a study conducted in tasikmalaya,4 which stated that majority of acceptors of family planning are women and most women do not support participation of husband in usage of contraception, as 76% do not allow husband to use condom and 86% are uncomfortable if their husbands use condom during sexual intercourse. in addition, in a study conducted in the rural area of jammu district5, 74% of women and 67% of men think that only women should use contraception. in addition, a study conducted in nigeria6 only minority of respondents represented by 1.6% agree and 5.2% agree conditionally vasectomy as a method of contraception for men. regarding the women’s rights in family planning decision making, majority of respondents (92%) agreed that women have rights in family planning decision making. around 65% of the women thought that reproductive health decision making should involve women. women thought they have right to make decision in family planning because women are the ones who get pregnant, more contraceptive methods are available for women, and women bear the risks and burdens of pregnancy and childbearing. according to the respondents, if women have rights in family planning, then women play a role in deciding the number of children and spacing of each pregnancy. this was proved by the result of this study, where by 91% of the women agreed that women played a role in deciding the number of children and spacing of each pregnancy. in addition, some respondents (78%) stated that both husband and wife shared the same rights in family planning as well as in making a decision. in contrary to the study in calabar municipality3 more than half represented by 57% of women stated that their spouses should decide when to have thenext child. however, only 9% of women stated that the spouses have no right in deciding the number of children and spacing of each pregnancy. ninety four percent of women agreed that they should obtain spousal consent or inform spouses before access to contraception. out of 94%, around 60% agreed that men had rights to know and 33% stated that women must respect man as the head of family. a study in india7 shows that if a husband submits himself for an operation of sterilization without medical reason and consent or knowledge of his wife, and similarly if the wife undergoes vasectomy (read tubectomy) or abortion without medical reason and consent or knowledge of her husband, such an act of the spouses may lead to mental cruelty.” therefore, women in hegarmanah village respected their husbands in family planning decision making although they knew they had rights in family planning. this result is similar to a case study in sumedang, west java2 where most of the women ask their husband before making decision and it also stated that a man is the head of family and normally the decision makers. however, women and men discuss before decision making. in addition, a study in nigeria5,8 have proven that communication affects decision in family planning. respondents represented by 61% obtained opinion from family members regarding family planning (table 2). most of the respondents asked for opinion from family members to obtain a better option. about 56% of the respondents told that family members influence their decision making. besides, respondents stated that mother is the one who gives information and teaches them about family planning. this is similar to a case study conducted in sumedang2 where information regarding family planning were normally obtained fromthe mother. similarly, a study in india5 showed that 63% women from urban area and 35% of women from rural area obtain information regarding family planning from family members. moreover, respondents in this study asked opinion from friends regarding family planning besides from family members. around 52% of the respondents asked opinion from friends to get a better option. however, 48% of the respondents stated that friends should not be involved in family planning. suzanne saw, yoni syukriani, a. hussein s. kartamihardja: women’s opinion about women’s rights regarding family planning in hegarmanah village, jatinangor subdistrict, west java in 2013 althea medical journal. 2015;2(3) 312 amj september, 2015 from this point of view, not all women are influenced by friends regarding their rights in family planning decision making. in a study conducted in calabar municipality3 and obudu municipality3, 1.3% of the respondents are influenced by their friends in family planning decision making. the result is similar to this study as some of the respondents were influenced by friends in family planning decision making. respondents represented by 56% were influenced by their family members (table 2). while, the majority stated that mother taught them about family planning and this was represented by 30%. mother is the important factor in therespondents’ opinion regarding their rights in family planning in hegarmanah village. this result is in accordance with findings of a case study in sumedang, west java,2 where women use contraception as told by their mothers until they give birth to first child as they are ready and thereafter, their mother are not influencing their perception as it is up to them to decide. however, in calabar3 and obudu municipality3 represented by 65% and 58% respectively, women stated that influence by views of their spouses in family decisions are higher in comparison to family members, friends and relatives. more than half of therespondents (58%) did not agree with the statement that “the more children will be better” (table 3). while, economically, cannot sustain the children needs is one of the main reasons that caused respondents did not agree with the statement. besides, according to islamic family planning, it is stated in the qur’an that parents have responsibility towards their children 9 however, respondents represented by 42% agreed that “the more children will be better.” around 18% stated that a child is a gift from god. this perception is similar to a study conducted in nigeria10 that people believe having many children is an advantage and a blessing from god. respondents represented by 90% would still practice family planning if in the area less people used contraception in controlling fertility (table 3). this representation showed that in hegarmanah village, cultural norms did not influence women’s rights in decision making regarding family planning. this result is similar to a study conducted in nigeria9 where there are no influences on cultural norms towards choice of family planning. most of the respondents represented by 59% stated that they would still use contraception because it is their right. in this study, religion influenced decision making in family planning represented by 66%. most of the respondents told that they must respect their religion perspectives, moreover religion is important for them. this result is similar to a study conducted in zone 5 barracks of nigeria police10 where there is a relationship between religious belief and decision making in family planning in married women. in conclusion, majority of the women in hegarmanah village think that men and women play a role in family planning decision making but women stated that they have right to make decision for themselves. this study has limitations, therefore, a further study should be carried out involving men, family members especially mothers, friends and also religious leaders.. this study was carried out in one village that did not necessarily represent the entire jatinangor subdistrict and only explored the point of view of the women. . it can be concluded that women have a role in making decision in family planning by considering the opinions of their spouses, other family members, friends and their religions. references 1. cottingham j, germain a, hunt p: use of human rights to meet the unmet need for family planning. lancet. 2012;380(9837):172–80. 2. herarti, r. family planning decisionmaking: case studies in west java, indonesia. the 12th biennial conference of the australian population association. 2004 september 15–17; canberra: apa,2004; canberra,australia. 3. undelikwo va, osonwa ok, ushie ma, osonwa rh. family planning behaviours and decision making among couples in cross river state, nigeria. international journal of learning and development. 2013;3(1):100–20. 4. istiqomah a, novianti s, nurlina. male participation in family planning in tasikmalaya. [cited 2013 may 25 ] available from: http://journal.unsil.ac.id/ download.php?id=655. 5. dhingra r, manhas s, kohli n, mushtaq a. attitude of couples towards family planning. j hum ecol. 2010;30(1):63–70. 6. akpamu u, nwoke eo, osifo uc, igbinovia ens, adisa aw. knowledge and acceptance of vasectomy as a method of contraception amongst literate married men in ekpoma, althea medical journal. 2015;2(3) 313 nigeria. afr j biomed res. 2010;13(2):153– 6. 7. pai nb, rao s, kosgi s, undaru sb, hedge v. women reproductive rights in india: prospective future. online j health allied scs. 2011;10(1):1–5 8. oladeji d. communication and decision making factors influencing couples interest in family planning and reproductive health behaviours in nigeria. stud tribes tribals. 2008;6(2):99–103. 9. olaitan, lanre o. factors influencing the choice of family planning among couples in south west nigeria. int j med med sci. 2011;3(7):227–32. 10. igbudu u, okoedion so, peremene eb, eghafona ka. religious beliefs and family planning practises married women in zone 5, police barracks in nigeria. ozean journal of social sciences. 2011:4(2):55–6. suzanne saw, yoni syukriani, a. hussein s. kartamihardja: women’s opinion about women’s rights regarding family planning in hegarmanah village, jatinangor subdistrict, west java in 2013 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 127 indications of tonsillectomy and adenoidectomy in dr. hasan sadikin general hospital bandung dini atiyah,1 agung dinasti permana,2 rudy hartanto3 1faculty of medicine, universitas padjadjaran, 2department of otorhinolaryngology head and neck surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, 3departement of anatomy, faculty of medicine, universitas padjadjaran abstract background: tonsillectomy is the intervention to take out the palatine tonsils either whole or sub capsular, while adenoidectomy is the intervention of extraction of the adenoid gland which is commonly done with curettage method. both interventions are done to eliminate repeated infections and also obstructions due to inflammation and hypertrophy of the tonsils and adenoids. this study was conducted to examine the indications of tonsillectomy and adenoidectomy in the departement of otorhinolaryngology and head neck surgery dr. hasan sadikin general hospital bandung in the period of january 2009–december 2011. methods: a cross-sectional descriptive study was conducted in october–november of 2012 using 207 medical records of patients who had tonsillectomy and adenoidectomy executed in the department of otorhinolaryngology and head neck surgery dr. hasan sadikin general hospital, bandung in the period of january 2009–december 2011. data collected were age, gender, main complaint, tonsil size, history of repeated infections, history of snoring as well as of obstructive sleep apnea syndrome (osas). the indication for tonsillectomy and adenoidectomy such as infection, obstruction and neoplasia was selected. results: the indications of tonsillectomy and adenoidectomy were infection at 106 (51.2%) patients, obstruction at 100 (48.3%) patients, and neoplasia at 1 (0.05%) patient. conclusions: the most numerous indications for tonsillectomy and tonsilloadenoidectomy in the department of otorhinolaryngology and head neck surgery dr. hasan sadikin general hospital were infection. key words: adenoid, adenoidectomy, indication, tonsil, tonsillectomy. correspondence: dini atiyah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285782477705 email: dini.atiyah@gmail.com introduction tonsillectomy, adenoidectomy, or tonsilloadenoidectomy are surgical procedures to treat repeated episodes of chronic infections and tonsillitis. this procedure is also done to eliminate symptoms of obstructive sleep apnea syndrome (osas).1,2 in some patients, the inflammation of tonsils can also involve the adenoids, or lymphatic tissues of the nasopharynx. the involvement of inflammation of the adenoid can cause discomfort on the afflicted because of the addition to the infectious symptoms. symptoms which arise in tonsillitis and adenoiditis are among others: throat pain, difficulty to swallow, high grade fever, obstructed nose, and also repeated cough and cold.3 in other conditions, osas causes disturbance on normal ventilation in sleep due to prolonged partial obstruction as well as intermittent complete obstruction of the airway. this can be fatal, especially on children which can cause abnormalities in the neurodevelopment, growth disturbance, and cardiorespiratory functional failure.2 chronic and hyperplastic forms of tonsil and adenoid can cause decrease of quality of life on the afflicted because of the decrease in the physiological function of an afflicted body.4,5 as such, appropriate treatment and attention is needed in this case. the management of this case can be non–surgical or surgical, in which non–surgical treatments often use antibiotics and analgesics. surgical intervention can be in the form of tonsillectomy and adenoidectomy which can be done on patients who have fulfilled certain indications for the surgery, which commonly are: airway obstruction althea medical journal. 2015;2(1) 128 amj march, 2015 and also history of repeated infections.6 data from cipto mangunkusumo hospital, jakarta of this case showed a decrease in the surgical interventions from the year 1999–2003.7 although generally, statistical data shows decline in the surgical intervention for tonsillectomy and adenoidectomy, this treatment is still regarded able to increase the quality of life of the patients and can still be a treatment of choice for the afflicted considering poor response of medicinal treatments on chronic cases and hypertrophy. and as antibiotics developed, it became one of the factors which may change the indication for surgery. furthermore, data of indications for tonsillectomy and adenoidectomy are also needed so that patients know the indication for surgery from the most recent study, and thus patients indicated for the intervention will not be marginated. national data of tonsillectomy and adenoidectomy indications in indonesia had not been reported, especially in west java. the study was conducted to examine the indications for tonsillectomy and adenoidectomy in the department of otorhinolaryngology and head neck surgery dr. hasan sadikin general hospital in the period of january 2009– december 2011. methods a cross-sectional descriptive study was conducted in october–november of 2012 using 207 medical records of patients who had tonsillectomy and adenoidectomy executed in the department of otorhinolaryngology and head neck surgery dr. hasan sadikin general hospital, bandung in the period of january 2009–december 2011. data collected from medical record were age, gender, main complaint, tonsil size, history of repeated infections, history of snoring as well as of obstructive sleep apnea syndrome (osas). the indication for tonsillectomy and adenoidectomy such as infection was determined from the main complaint of patients, while obstruction was determined by history of osas and neoplasia was determined by complaints and tonsil biopsy were selected. results there were 2155 patients in the department of otorhinolaryngology and head neck surgery dr. hasan sadikin general hospital, bandung in the period of january 2009 to december 2011 and 897 (42%) of them were tonsillitis and adenoditis patients. from those 897 patients, 23% or 207 of them had tonsillectomy or tonsilloadenoidectomy executed on them. the number of patients who were treated in 2009 was 114 patients, in the year 2010 it was 26 patients, and in the year 2011 it was 67 patients. from patients who were treated, 94 (44.7%) of them were intervened with tonsillectomy without adenoid gland extraction, 114 (54.8%) had tonsilloadenoidectomy and no standalone adenoidectomy was found. the majority of patients were 9–15 years old (46.5%) and the least was >50 years old table 1 characteristics of patients based on age and sex characteristic frequency (n=207) % age (years old) 2–8 58 28 9–15 97 46.9 16–22 28 13.5 23–29 12 5.8 30–36 5 2.4 37–43 3 1.4 44–50 3 1.4 < 50 1 0.5 sex male 114 55.1 female 93 44.9 althea medical journal. 2015;2(1) 129dini atiyah, agung dinasti permana, rudy hartanto: indications of tonsillectomy and adenoidectomy in dr. hasan sadikin general hospital bandung (table 1). the average age of patients who had tonsillectomy or tonsilloadenoidectomy was 13.55, while the median was at 11, and a standard deviation of 8.7, with the youngest was at 2 years old and the oldest was 53. most of these patients were male (55.1%), while female patients was 44.9%. from all patients who had tonsillectomy or tonsilloadenoidectomy, 106 (51.2%) of them were patients with indications for surgery such as repeated infections, 100 patients (48.3%) had indication of airway obstruction, and 1 (0.5%) were with neoplasia indication (table 2) table 3 showed that 200 (96.6%) of 207 patients were treated for a main complaint of repeated infections. in which the repeated infections category was the result of the grouping of several signs such as enlarged tonsils, sensation of obstruction in the throat, repeated cough and cold, swelling in the neck, obstructed nose, and pain when swelling. while 7 (3.4%) complained of snoring. the tonsil size of patients who had tonsillectomy and adenoidectomy were related to the indication of surgery. in which the tonsil size were determined by comparing the tonsil size with the oropharynx space. here, size 0 indicates that the tonsil is inside the fossa tonsillary, 1 indicates that the tonsil fills <25% of the oropharynx, 2 indicates that the tonsil fills 25–50% of the oropharynx, 3 indicates that the tonsil fills 50–75% of the oropharynx, and 4 indicates that the tonsil fills >75% of the oropharynx. most patients had a tonsil size equivalent to grading t3 which was 147 patients (71%), t4 was 48 patients (23.2%), t2 was 10 patients (4.8%), and t1 was 1 patient (0.5%). discussions in this study, it was found that the indications for tonsillectomy and adenoidectomy were infection with the highest percentage at 51.2%, obstruction at 48.3%, and neoplasia at 0.5%. this result is in agreement with the recommendation of the american academy of otolaryngology–head and neck surgery that two of the most common indications found are repeated infections and airway obstructions such as sleep disturbance. however, the indications of patients in america were in opposite to those in germany where the majority of tonsillectomy and adenoidectomy were executed because of airway obstruction.8,9 this study showed that the majority table 2 indications for tonsillectomy or tonsilloadenoidectomy indications for surgery frequency % infections 106 51.2 obstruction 100 48.3 neoplasia 1 0.5 table 3 distribution of main complaint and tonsil size of patients who had tonsillectomy or tonsilloadenoidectomy distribution frequency % main complaint repeated infections 200 96.9 snoring 7 3.4 tonsil size t0 0 0 t1 1 0.5 t2 10 4.8 t3 147 71.0 t4 48 23.3 no information 1 0.5 althea medical journal. 2015;2(1) 130 amj march, 2015 of patients who underwent tonsillectomy or tonsilloadenoidectomy were in the age category of 9–15 years old. this is similar to a study done in america where the patients who underwent tonsillectomy and tonsilloadenoidectomy were 15 years old or younger. a study in pakistan also stated that this intervention was mostly done on patients who were 11–15 years old.10 but this is in contrast to ibadan who stated that this intervention was done mostly on patients aged 0–5 years old.11 this can be related to the immunological functions of tonsils which are active at the age of 4–10 years old and start to reduce after puberty.12 in this study, the patients who were treated with tonsillectomy and tonsilloadenoidectomy were mostly male. this study is similar to the ones conducted in brazil and finland in which the majority were male.2,10 however, this is in contrary with the studies done in america and switzerland in which the majority of patients treated were female, this is thought to be caused by the difference in the average age of patients at time of treatment.2,13 repeated infections were the main complaint amongst patients who were to be treated with tonsillectomy and tonsilloadenoidectomy aside from snoring. this study yielded different result than the one conducted in texas, united states of america which stated that the majority of patients were complaining of snoring, sleep apnea, and repeated infections were the least amongst these complaints .14 the size of tonsils of the patients in this study showed that the majority of them had tonsil sizes of t3 and t4. this is in agreement with the recommendation of the american academy of otolaryngology–head and neck surgery which stated that patients with tonsil sizes equivalent to grade t3 and t4 were of primary indication to have tonsillectomy.1 references 1. baugh rf, archer sm, mitchell rb, rosenfeld rm, amin r, burns jj, et al. clinical practice guideline: tonsillectomy in children. otolaryng head neck. 2011;144(1 suppl):s1–30. 2. rob mi. ear, nose and throat surgery among young australian children. new south wales: university of new south wales; 2005. 3. lalwani ak, editor. current diagnosis & treatment-otolaryngology, head and neck surgery. 2nd ed.new york: mcgraw-hill; 2007. 4. jack l. paradise md. tonsillectomy and adenoidectomy. in: bluestone cd, stool se, a.kenna m, editors. pediatric otolaryngology. 3rd ed. philadelphia, pennysylvania: w. b. saunders company; 1996. p. 1054–63. 5. laurie scudder d, np. clinical practice guideline : tonsillectomy in children. 2011 [downloaded in 3 may 2012]; available at: http://www.medscape.com/ viewarticle/739533. 6. brodsky l, poje c. tonsillitis, tonsillectomy, and adenoidectomy. in: t.j bbjj, editor. head & neck surgery-otolaryngology. 5th ed. philadelphia: lippincott williams & wilkins; 2006. p. 1184–97. 7. hermani b, fachrudin d, m.h. s, riyanto bu, susilo, nazar hn. health technology assessment indonesia : tonsilektomi pada anak dan dewasa. 2004 [downloaded in 3 may 2012]; available at: bu.depkes.go.id/index. p h p ? o p t i o n = c o m _ d o c m a n & t a s k = d o c _ download&gid=349&ltemid=112. 8. aao-hns. tonsillectomy facts in the u.s.: from ent doctors by the american academy of otolaryngology-head and neck surgery. 2009 [downloaded in 25 november 2012]; available at: http:// www.entnet.org. 9. boris a. stuck jpw, harald genzwürker, horst schroten, tobias tenenbaum, karl götte. tonsillectomy in children. deutsches ärzteblatt international; 2008, 105(49): 852–861. 10. khan mi, amanullah a, rasheed s. posttonsillectomy hemorrhage incidence: comparison between day case and inpatient surgery. gjms. 2012;10(1): 60. 11. onakoya p, nwaorgu o, abja u, kokong d. adenoidectomy and tonsillectomy: is clotting profile relevant? niger j surg. 2010;6(1–2). 12. campisi p, tewfik t. tonsillitis and its complications. canadian journal of diagnosis. 2003;20(3): 99–105. 13. ericsson e, hultcrantz e. tonsil surgery in youths: good results with a less invasive method. laryngoscope. 2007;117(4): 654–61. 14. werle ah, nicklaus pj, kirse dj, bruegger de. a retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications. int j pediatr otorhi. 2003; 67(5): 453–60. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 516 amj december, 2015 detection of fungi in hair-brushes in beauty salons at jatinangor susanna mitchelle edward,1 imam megantara,2 reiva farah dwiyana3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of dermato-venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: various beauty tools are used in beauty salons, among those is the hair-brush. the hair-brush can conceal various human skin pathogens although under harsh environmental conditions, most pathogens are killed; nevertheless, few microorganisms, such as the fungi can adapt and survive. moreover, the moist conditions of the hair-brush predisposes the growth of fungi, however the ability of these fungi to instigate disease in an individual is dependent on the portal of entry and the host immunological status. this study was conducted to determine the fungus that is present in the beauty salon’s hair-brushes. methods: this study was conducted in beauty salons located in jatinangor area during september–october 2013 using the descriptive laboratory method. fifteen beauty salons were included in this study based on sample size calculation for dichotomous variable. the specimens from all the hair-brushes were collected after the owner’s informed consent, then cultured onto 30 sabouraud agar, two for each beauty salon (dermatophyte and non-dermatophyte agar). the fungi were detected macroscopically and microscopically. results: overall, 93% revealed to be culture positive, with 90% of them were found to be non-dermatophytes, most of which are saprophytic fungi. the remaining 3% were dermatophytes. conclusions: beauty salon’s hair-brushes contain a wide range of fungi distribution which may be a source of fungal colonization. however, most of the fungi found in the beauty salons are saprophytic fungi, therefore it is unnecessary to be anxious about a small amount of pathogenic fungi are found in humans. [amj.2015;2(4):516–20] keywords: beauty salon, dermatophyte, non-dermatophyte, hair-brush correspondence: susanna mitchelle edward, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285624202258 email: susannamitchelle@gmail.com introduction hairdressing is aided by various tools, however, the hairbrush is the most commonly used tool in beauty salons. hair-brushes may conceal various human skin pathogens such as bacteria, fungi, ticks and nits due to contact with many customers with different types of hair and scalp conditions.1 consequently, when these pathogens come in contact with another human scalp the chances of infection and infestations is increased.2 on the other hand, disease manifestation varies, and is dependent on the portal of entry of microorganisms and the individual’s immune status.3 according to a study conducted in pakistan4 it notes that the third most common species found in the beauty salon’s beauty tools is the fungus. similar to bacteria, some of the fungus is also a part of the normal human flora. it becomes potentially pathogenic under various conditions, resulting into mycoses. on the other hand, fungus from the environment can also produce infection when it comes in contact with an exposed individual. the beauty salon hair-brushes being moist upon contact of usage create a favorable environment for the fungi growth. these fungi could originate either from the closed indoor environment or from the scalp and hair of an infected customer, predisposing the risk of transmission as the beauty salons often use the same hair-brushes to all the customers. in indonesia, current knowledge is lacking in this field thus limiting the perspectives of this potentially harmful human pathogens. jatinangor has become a crowded area since several universities are located there, and the number of visits of customers to salons is increasing. this study was conducted to determine the fungus that is present in the beauty salon’s hair-brushes at jatinangor. althea medical journal. 2015;2(4) 517 methods this study was carried out from september– october 2013, the samples were collected and then cultured in the microbiology laboratory of faculty of medicine, universitas padjadjaran, jatinangor, using the laboratory descriptive method. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. with consent of the participating beauty salons, samples were collected from all the hairbrushes used by scrapping the hair-brushes in the beauty salons. the scales were then collected in a black envelope, one envelope for each beauty salon. the inclusion criterion was all the hairbrushes that have been used on customers. above and beyond, samples were only collected from beauty salons operating during the period of research and located along in jatinangor area. along with the informed consent form, beauty salon operators were interviewed on frequency and methods of cleaning hairbrushes. from the 15 participating beauty salons, samples were obtained by scrapping the hairbrushes along its bristles. scales that had been collected in black envelopes were then examined in the laboratory were then transported to the laboratory directly. each sample from the beauty salons was cultured in two different culture media: an agar contained sabouraud agar with chloramphenicol, and table 1 type of fungi that grows on culture fungi number of culture positive dermatophyte 1 non-dermatophyte 27 none 2 the other agar contained sabouraud agar with chloramphenicol and cycloheximide. cultures were left at room temperature and observed daily macroscopically and microscopically for four weeks. based on morphology appearance of colony, fungi were detected macroscopically and then detection was pursued microscopically. then, microscopically, cultures were observed using 10–40x magnification with 10% potassium hydroxide solution and/or lactophenol cotton blue. the presence of hyphae and/ or spores was used to indicate positive fungi growth. the fungi was then grouped as dermatophytes and non-dermatophytes based on its characteristics. then, all mycological data obtained were tabulated and counted for its frequency and percentage using statistical program. results non-dermatophyte is higher in number than non-dermatophytes (table 1). the three most table 2 frequency of occurrence based on fungi colonies fungus colony number of colony percentage (%) aspergillus 13 24.07 fonsecaea 8 14.81 penicillium 7 12.96 candida 6 11.11 cephalosporium 5 9.26 mucor 5 9.26 rhodotorula 3 5.56 mycelia sterila 2 3.70 gliocaldium 1 1.85 malassezia 1 1.85 phialophora 1 1.85 rhizopus 1 1.85 trichophyton 1 1.85 total 54 100 note:* meaning colony of same genus in the same culture is counted as one susanna mitchelle edward, imam megantara, reiva farah dwiyana: detection of fungi in hair-brushes in beauty salons at jatinangor althea medical journal. 2015;2(4) 518 amj december, 2015 table 3 methods and frequency of cleaning hairbrushes with detected colonies beauty salon type of colony methods* frequency of cleaning per week a aspergillus i 1 b aspergillus,candida, cephalosporium,fonsecaea and penicillium i 1 c aspergillus,cephalosporium, fonsecaea and penicillium i 1 d aspergillus, candida,cephalosporium, fonsecaea and mucor x e aspergillus, candida and penicillium ii 1 f aspergillus, candida, fonsecaea, mucor, mycelia sterilia, rhodotrula and rhizopus ii 1 g aspergillus, mucor, penicillium, phialophora and rhodotorula ii 1 h apergillus, cephalosporium, fonsecaea and rhodotorula x i fonsecaea and penicillium i every 2 days j aspergillus i everyday k aspergillus, malassezia and penicillium i 1 l aspergillus, candida, fonsecaea and mycelia sterilia ii everyday m aspergillus and trichophyton x n aspergillus, gliocaldium, mucor and penicillium i 1 o candida, cephalosporium, fonsecaea and mucor ii 1 *note: i=beauty salons which clean using hot water and shampoo, ii= beauty salons whichclean using hot water with common washing detergent and x= beauty salons which clean without washing common fungi are the aspergillus, fonsecae and the penicillum species. the truly pathogenic fungi, trichophyton sp. was found as the lowest in number (table 2). furthermore, the types of colony found in each beauty salon as well as the cleaning method used and frequency of cleaning showed that all beauty salons had fungal contamination. most beauty salons cleaned the hair-brushes using hot water and shampoo, some cleaned with hot water and a common detergent and a few beauty salons did not clean in the context of washing. furthermore, most of the beauty salons cleaned the hairbrushes once a week (table 3). trichophyton species were found in beauty salons that never washed the hair-brushes and candida was mostly found in beauty salons that cleaned the hairbrushes by washing with a common detergent. in beauty salons that washed the hairbrushes once a week lesser candida wasfound (table 4). discussion it is observed that most of the fungi present are the saprophytic fungi. they are present everywhere or are in fact as laboratory contaminant. in contrast, the presence of the malassezia sp., candida and trichopyton sp. means that there are chances of an individual acquiring the superficial mycoses when the host defenses are overcome (table 2). furthermore, malassezia sp is part of anormal microbial flora in human. transmissions of malassezia are potentially high when the same fomites such as the hairbrushes are used on a healthy person. nonetheless, malassezia sp. can cause disease only when it takes the mycelium form. the change from normal flora, yeast phase to mycelium form is dependent on various factors such as increased sebum production, hyperhidrosis, malnutrition and immunocompromised conditions that assist the colonization of this species. thus it can lead althea medical journal. 2015;2(4) 519susanna mitchelle edward, imam megantara, reiva farah dwiyana: detection of fungi in hair-brushes in beauty salons at jatinangor to conditions such as dandruff and folliculitis.5 relevant to the research the cutaneous mycoses was discussed in depth as the fungi in this group could affect the keratinized hair structure and skin. in this study, candida and trichophyton dermatophyte were discussed. in addition, a similar study was conducted in turkey6 whereby barber’s tools were examined to detect fungi, and the fungi found found are mostly the non-dermatophytic molds, trichophyton rubrum and candida albicans. likewise, candida was also found in six of the beauty salons. its presence on the skin surfaces is not harmful in a healthy person since it isa normal flora of the skin. conversely, it may cause opportunistic infections such as folliculitis in immunocompromised persons. in comparison with previous studies, the dermatophytes that are mostly found as an etiologic agent for tinea capitis is the trichophyton sp.7,8 likewise, in the current research , the dermatophytes detected was the trichophyton rather than the microsporum sp.. in tropical regions such as in asia, the trichophyton violacelum is the most common cause of tinea capitis.8 furthermore, the findings of the trichophyton dermatophyte can be blamed on the fact that indonesia is located in thetropical region.9 therefore, the humidity, moisture and suitable temperature precipitate the growth of this fungus. it can be observed that candida sp. were present most in beauty salons that washed the hairbrushes using hot water and a common washing detergent, compared to beauty salons that never washed hair-brushes and those beauty salon that cleaned hair-brushes by using hot water and shampoo (table 3). the presence of fungi which appeared higher in number in beauty salons that washed with common washing detergent may be due to the detergent which does not have fungicidal properties hence, upon washing it created a wet, moist condition that favors the fungal growth.10 the poor distribution of fungi in cleaning methods using hot water and shampoo could be due to the fungicidal properties. beauty salons that never wash the hair-brushes conceal fungi that are invisible to the naked eyes; as a result chances of transmissions are increased. therefore, methods of cleaning might affect the nondermatophyte fungus growth. in this research, dermatophytes were the only truly pathogenic fungi found in beauty salons which never washed the hair-brushes. consequently, there are risks of transmission when the hair-brushes containing these species came in contact with the host. mostly, colonization of these species does not cause significant morbidity but it can cause psychological embarrassment to individuals.2 in conclusion, the beauty salons’ hairbrushes contain a wide range of fungi distribution which may be a source of fungal colonization. most hairbrushes from beauty salons in jatinangor contain the nondermatophyte fungi. regardless of some of the non-dermatophytes being a normal flora of the skin, it can become potentially pathogenic under various conditions such as hyperhydrosis, malnourishment and weakened immune status. the finding of the table 4 fungi capable of causing cutaneous mycoses with frequency and methods of cleaning hairbrushes fungi dermatophytes non-dermatophytes trichophyton, n (%) candida, n (%) methods of cleaning* wash with shampoo 1(14.29) wash with common detergent 1(14.29) 4(57.14) never wash 1(14.29) frequency of washing never 1(14.29) 1(14.29) 1x 4(57.14) every 2 days everyday 1(14.29) note:* shows methods of cleaning in the context of washing althea medical journal. 2015;2(4) 520 amj december, 2015 truly pathogenic fungi were low, nevertheless, the hygiene of beauty salon hair-brushes must be improved by implementing good practices of disinfection and sanitation such as periodic cleaning using a proper cleaning method can hinder the growth of microorganisms such as fungi. there are few weaknesses in this study since this study lacks the view of a mycologist. in addition, the sample size used was not large enough. therefore, in a further study on this topic, a larger sample size is recommended. there should be comprehensive studies related to the causal relationship of predisposing factors and distribution of fungi in beauty salon hair-brushes. references 1. henderson s. basic hairdressing: a course book for level 2. cheltenham: nelson thornes; 2003. p. 53–55 2. grimalt r. a practical guide to scalp disorders. j investig dermatol symp proc. 2007;12(2):10–4. 3. enemuor s, atabo a, oguntibeju o. evaluation of bacterial and fungal contamination in hairdressing and beauty beauty salons. sci res essays. 2013;7(14): 1222–25. 4. naz s, iqtedar m, ul ain q, aftab k. incidence of human skin pathogens from cosmetic tools used in beauty salons in different areas of lahore, pakistan. j sci res. 2012;4(2):523–7. 5. inamadar ac, palit a. the genus malassezia and human disease. indian j dermatol venereol leprol. 2003;69(4):265–70. 6. uslu h, uyanik m, ayyildiz a. mycological examination of the barbers’ tools about sources of fungal infections. mycoses. 2008;51(5):447–50. 7. foster kw, ghannoum ma, elewski be. epidemiologic surveillance of cutaneous fungal infection in the united states from 1999 to 2002. j am acad dermatol. 2004;50(5):748–52. 8. akbaba m, ilkit m, sutoluk z, ates a, zorba h. comparison of hairbrush, toothbrush and cotton swab methods for diagnosing asymptomatic dermatophyte scalp carriage. j eur acad dermatol and venereol. 2008;22(3):356–62. 9. hay rj. fungal infections. in: cook gc, zumla a. manson’s tropical diseases. london: elsevier health sciences uk; 2008. p. 1169–70 10. ahmed i, ahmed z, nasreen s. prevalence of tinea capitis and asymptomatic carriage amongst school going children. j pak assoc derma. 2006;16(4):215–9. althea vol 2 no 3 abstrak edit.indd althea medical journal. 2015;2(3) 22 amj september, 2015 health seeking behavior among patients with tuberculosis in dr. hasan sadikin general hospital bandung, indonesia in november 2012 maya valentina putrie,1 rovina ruslami,2 lika apriani3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine universitas padjadjaran, 3department of epidemiology and biostatistics, faculty of medicine universitas padjadjaran abstract background: dr. hasan sadikin general hospital is the main referral hospital in west java, indonesia, treating yearly 1.000 tuberculosis cases of whom most are in severe condition. the severity of the disease is probably affected by the poor patient’s health seeking behavior.the objective of this study was to assess the pattern of patients with tuberculosis’s health seeking behavior before being treated in dr. hasan sadikin general hospital, bandung. methods: a descriptive study was carried out in november 2012 on 56 patients in the drug observed treatment shortcourse (dots) clinic at dr. hasan sadikin general hospital (rshs) to assess the number and type of health services visited prior to rshs. the inclusion criteria were patients who were diagnosed with tb for the first time, aged at least 19 years old. the data were collected using an open-ended questionnaire and presented as percentage. results: a total of 32 respondents (57%) sought for initial treatment by going to professional health care centers (the medical doctors, puskesmas, or hospitals), the rests sought for traditional treatment (7%), selftreatment (29%), or no medication prior to the treatment at rshs (7%). fifty five percent of respondents did more than one type of health seeking behavior. the average time between the first complaint until the respondents got treatment was 5 months. conclusions: the patients with tuberculosis’s treatment seeking behavior is various prior to the treatment at rshs and there are still patients who seek treatments to the non-profesional health care. keywords: health seeking behavior, treatment, tuberculosis correspondence: maya valentina putrie, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6289607727249 email: putrie_valentina@yahoo.com althea medical journal. 2014;1(2) 90 amj december, 2014 nigella sativa infusion as an antioxidant agent against gentamicininduced kidney damaged in mice hamsiah binti halim1, achadiyani2, tjahjodjati3 1faculty of medicine, universitas padjadjaran, 2department of biology cell, faculty of medicine, universitas padjadjaran, 3department of urology, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin hospital bandung abstract background: gentamicin is one of the most common antibiotics related to nephrotoxicity. it has been proposed that the nephrotoxicity is associated with the generation of the reactive oxygen species. thymoquinone, an active compound of nigella sativa, shows to have an antioxidant property. the study aims to identify the possible nephroprotective action of nigella sativa infusion against gentamicin-induced kidney damaged in mice. methods:this experimental study was carried out in the department of cell biology laboratory, universitas padjadjaran, bandung from 10th november 2012 to 14th december 2012. there were four groups, each consisting of 6 mice. group i (control negative), group ii (gentamicin 100 mg/kg), group iii (3.9 mg nigella sativa infusion+gentamicin 100mg/kg) and group iv (7.8 mg nigella sativa infusion+gentamicin 100mg/ kg). the kidneys were evaluated histopathologically by light microscope. the percentage average number of normal proximal tubules in group i and the percentage average number of proximal tubules damaged in group ii, iii and iv were measured. results: the results showed the percentage average number of the proximal tubules damaged in group ii, iii and iv were 14.53%, 7.49% and 3.94% respectively. significant differences were observed between group ii and iii, group ii and iv, and group iii and iv. conclusion: nigella sativa infusion protects against gentamicin-induced kidney damage in mice. [amj.2014;1(2):90–3] keywords: gentamicin, kidney, nigella sativa infusion infusa nigella sativa sebagai antioksidan terhadap kerusakan ginjal pada tikus yang diinduksi gentamisin abstrak latar belakang: gentamisin adalah salah satu antibiotik yang paling sering dihubungkan dengan nefrotoksisitas. nefrotoksisitas yang terjadi berhubungan dengan pembentukan reactive oxygen species. thymoquinone, senyawa aktif nigella sativa, telah terbukti memiliki sifat antioksidan. penelitian ini bertujuan untuk mengidentifikasi sifat nefroprotektif infusa nigella sativa terhadap kerusakan ginjal pada tikus yang diinduksi gentamisin. metode: penelitian eksperimental ini dilakukan di laboratorium departemen biologi sel, fakultas kedokteran, universitas padjadjaran, bandung dari 10 november 2012 –14 desember 2012. ada empat kelompok masing-masing terdiri atas 6 tikus. kelompok i (control negatif ), kelompok ii (gentamisin 100 mg /kg), kelompok iii (3,9 mg infusa nigella sativa+gentamisin 100mg/kg) dan kelompok iv (7,8 mg infusa nigella sativa+gentamisin 100mg/kg). ginjal kemudian dievaluasi secara histopatologi dengan mikroskop cahaya. persentase rata-rata jumlah tubulus proksimal yang normal dalam kelompok i dan persentase ratarata jumlah tubulus proksimal rusak dalam kelompok ii, iii dan iv diukur. hasil: persentase rata-rata jumlah tubulus proksimal rusak dalam kelompok ii, iii dan iv adalah 14,53%, 7,49% dan 3,94%. perbedaan signifikan yang diamati adalah pada kelompok ii dengan iii, kelompok ii dengan iv, serta kelompok iii dan iv. correspondence: hamsiah binti halim, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6283820119781, email: hamsiah_halim@yahoo.com althea medical journal. 2014;1(2) 91 introduction gentamicin antibiotic is widely used to treat life-threatening infections caused by negative bacteria. however, it can cause nephrotoxicity. oxidative stress and nitrosative stress have been reported to contribute the nephrotoxicity. as a result, its clinical use is limited.1nephrotoxicity induced by gentamicin is an essential cause of renal failure.2 approximately 10–15% of all cases of acute renal failure are due to the gentamicin nephrotoxicity.3 metabolite products of the gentamicin are excreted through kidney. it may cause damage to the renal cells and resulting in renal dysfunction.4 the nephrotoxicity is due to the accumulation of the drug in the renal cortex. receptors in the proximal tubule cells are able to transport the drug into the cells through endocytosis. accumulation of the gentamicin in the cells disrupt cellular functions that results in apoptosis and necrosis of the proximal tubule. ultimately, acute kidney injury occurs.5 direct necrosis of the tubules are the characterization of the gentamicininduced nephrotoxicity, which occur mainly in proximal tubules.6 nigella sativa is one of the promising medicinal plants with many historical and religious backgrounds for curing several diseases.7the principle active compound of nigella sativa is thymoquinone. thymoquinone has most prominent activity of antioxidant. it neutralizes oxygen radicals by acting as an anion scavenger.8 this study was conducted to analyze the nephroprotective effect of nigella sativa infusion against gentamicin-induced kidney damaged in mice. methods this experiment was carried out in animal laboratory of department of cell biology in universitas padjadjaran, bandung from november 2012 to december 2012. a bottle of nigella sativa containing powdered-capsules was purchased in bandung indah plaza (bip), bandung. gentamicin was obtained from the general hospital dr. hasan sadikin general hospital bandung. galurbalb c strain mice (25–30g each) aged 7–8 weeks, healthy, and white male were used in this study. the mice were housed in homogenous temperature and dark-light cycle for 7 days (adaptation period) with unlimited to drink and food. in this study, nigella sativa infusion was made from the nigella sativa powders. nigella sativa powders were weighed to 3.9 mg and 7.8 mg.then the powders were added into a container containing 100 ml of aquadest. the infusion was brought to a boil and simmered for 15 minutes until the temperature reaches 90°c. after the infusion cooled down, it was filtered using filter paper into a beaker. four groups of six mice each were used for the study. group i, served as control negative, received isotonic normal saline throughout the experiment. group ii, served as control positive, received intraperitoneal injection of gentamicin 100 mg/kg/day for 8 days. group iii received gentamicin 100 mg/kg/day (intraperitoneally) for eight days and 3.9 mg of nigella sativa infusion for ten consecutive days. group iv received gentamicin 100 mg/ kg/day (intraperitoneally) for eight days and 7.8 mg of nigella sativa infusion for ten consecutive days. on the 11th day, the mice were sacrificed. the kidneys of the mice were collected for histopathological examinations after sacrifice. the kidneys were fixed in 10% of formalin solution and embedded in paraffin wax. the paraffin wax was cut into 5 micrometer sections and was stained with hematoxylin and eosin. the tissues were then examined under light microscope and the number of normal proximal tubules in group i and the number of proximal tubules damaged in group ii, iii and iv were measured. the data were expressed as average and percentage. the significance of differences among the four groups was assessed using kruskal-wallis followed by post-hoc mann whitney. the p value <0.05 indicated significant differences. results the average number of normal proximal tubules in group control negative was 56.10 simpulan: infusa nigella sativa melindungi terhadap kerusakan ginjal yang diinduksi gentamisin pada tikus. [amj.2014;1(2):90–3] kata kunci: gentamisin, ginjal, infusa nigella sativa hamsiah binti halim, achadiyani, tjahjodjati: nigella sativa infusion as an antioxidant agent against gentamicin-induced kidney damaged in mice althea medical journal. 2014;1(2) 92 amj december, 2014 table 1 average normal and damaged proximal tubules average normal proximal tubules average proximal tubules damaged percentage of the average proximal tubules damaged p group 1=56.10 group 2 =8.15 14.53% group 3 =4.20 7.49% 0.000* group 4 =2.21 3.94% note: *kruskal wallis test, % of the average proximal tubules damaged= average proximal tubules damaged divided average normal proximal tubules in group multiplied 100% (table 1). the average number of proximal tubules damaged in gentamicin-treated mice was 8.15 (14.53%). gentamicin plus 3.9 mgof nigella sativa infusion treated mice showed significant decreases in the average of the proximal tubules damaged. the average of the proximal tubules damaged was 4.20 (7.49%). also, there was a significant decrease in group 4 which received gentamicin and 7.8 mg of nigella sativa infusion. the average number of proximal tubules damaged in group 4 was 2.21 (3.94%). kruskal-wallis test was used because there was anomaly in data distribution. the results showed that at least there was a significant difference among groups. however, to know which group has significant differences in average of proximal tubules damaged, further tests must be conducted. for kruskal-wallis test, the post hoc is mann-whitney. when compared to positive group, there was significant difference in the group given nigella sativa infusion. in addition, significant differences between the two dosages of nigella sativa (3.9 mg and 7.8 mg) were observed. discussion gentamicin is aminoglycosides antibiotic commonly used against serious gramnegative bacterial infections. however, the antibiotic could result in nephrotoxicity. therefore, its clinical use is limited.1 gentamicin nephrotoxicity causes around 10-15% of all acute renal failure cases.3 it is believed that the accumulation of the drug in the renal cortex plays an essential role in nephrotoxicity. the cells of the proximal tubules have receptors that are capable of transporting gentamicin into the cells through endocytosis.5there are many factors which influence binding of the drug to biological membranes. for instance, ischemia favors the binding of the drug. however, it is competitively inhibited by ca2+.1 furthermore, there are interactions between gentamicin with cellular structures for examples mitochondria, lysosomes and microsomes.3 since the gentamicin concentrates in the proximal tubule cells, it disrupts cellular functions that results in the apoptosis and necrosis of the cells. hence, acute kidney injury occurs.5 apoptosis plays a role in the cell death leading to the removal of the cells which are damaged.9 from the previous research, an experiment with animals treated with gentamicin shows the presence of apoptosis10 and necrosis11 of tubular epithelial cells in vivo as well as in cultured cells.12 in this study, mice treated with gentamicin also showed damage to the tubular epithelial cells as the main renal morphological changes. the nephrotoxicity has been reported due to the role of oxidative stress.1reactive oxygen species (ros) has been suggested as the main key in the mechanisms that results in the necrosis of the tubular cells and the reduction in glomerular filtration rate.13 in the presence of the polyunsaturated lipids in the vitro studies, gentamicin stimulates the production of the ros that could contribute to the kidney injury.14 gentamicin changes the glomerular filtration rate. the changes are due to the contraction of the mesangial cell, glomerular filtration barrier selectively loss because of the neutralization by its negative charges, proliferation of mesangial cell and apoptosis.13 nigella sativa has been used to treat many diseases. the investigations of the pharmalogical use of the seeds have been conducted in many researches. from the previous research, it is found that nigella sativa exhibits anti-inflammatory, antioxidant, and anti-microbial properties.15 generation of the free radicals are important cause of renal injury induced by gentamicin antibiotic16. accordingly, the use of nigella sativa infusion with its antioxidant properties in this study althea medical journal. 2014;1(2) 93 may have protective effect against gentamicininduced nephrotoxicity. nigella sativa seeds have demonstrated protective effect against ccl4–induced liver damaged in experimental animals. from previous studies , thymoquinone, one of the active compounds of nigella sativa was found to have antioxidant properties.8 over 35 studies have been focused on antitoxic properties of thymoquinone in vivo and in vitro.7 thymoquinone is said to have potent scavenger activities against free radicals. it neutralizes oxygen radicals by acting as an anion scavenger.8 in this study, the administration of nigella sativa infusion ameliorated nephrotoxicity of gentamicin. the average number of proximal tubule damage in the prophylactic treatment of mice with nigella sativa one hour before the gentamicin 100 mg/kg injection was reduced. it may be due to the action of the thymoquinone as antioxidant protecting renal from gentamicin nephrotoxicity. in conclusion, nigella sativa infusion protects renal from damage due to gentamicin nephrotoxicity. references 1. dhanarajan r, abraham p, isaac b. protective effect of ebselen drug, against gentamicin-induced renal damage in rats. basic clin pharmacol toxicol. 2006;99(3):267–72. 2. perazella ma. drug-induced renal failure: update on new medications and unique mechanisms of nephrotoxicity. am j med sci. 2003;325(6):349–62. 3. rincon j, romero m, viera n, pedreanea a, mosquera j. increased oxidative stress and apoptosis in acute puromycin aminonucleoside nephrosis. int j exp pathol. 2004;85(1):25–33. 4. naughton ca. drug induced nephrotoxicity. am fam physician. 2008;78(6):743–50. 5. mladen k. drug-induced kidney injury. ejifcc. 2009;20(1). 6. pedrazachaverri j, gonzalez orozco ae, maldonado pd, barrera d, medina-campos on, hernández-pando r. diallyl disulfide ameliorates gentamicin-induced oxidative stress and nephropathy in rats. eur j pharmacol. 2003;473(1): 71–8. 7. salem ml. immunomodulatory and therapeutic properties of the nigella sativa l. seed. int immunopharmacol. 2005;5(13–14):1749–70. 8. ragheb a, attia a, eldin ws, elbarbry f, gazarin s, shoker a. the protective effect of thymoquinone, an anti-oxidant and anti-inflammatory agent, against renal injury: a review. saudi j kidney dis transpl. 2009;20(5):741–52. 9. servais h, van der smissen p, thirion g, van der essen g, van bambeke f, tulkens pm. gentamicin-induced apoptosis in llcpk1 cells: involvement of lysosomes and mitochondria. toxicol appl pharmacol. 2005;206:321–33. 10. li j, li qx, xie xf, ao y, tie cr, song rj. differential roles of dihydropyridine calcium antagonist nifedipine, nitrendipine and amlodipine on gentamicin-induced renal tubular toxicity in rats. eur j pharmacol. 2009;620:97–104. 11. edwards j, diamantakos e, peuler j, lamar p, prozialeck w. a novel method for the evaluation of proximal tubule epithelial cellular necrosis in the intact rat kidney using ethidium homodimer. bmc physiol. 2007;7:1. 12. pessoa e, convento m, silva r, oliveira a, borges f, schor n. gentamicin-induced preconditioning of proximal tubular llcpk1 cells stimulates nitric oxide production but not the synthesis of heat shock protein. braz j med biol res. 2009;42:614–20. 13. lopez-novoa jm, quiros y, vicente l, morales ai, lopez-hernandez fj. new insights into the mechanism of aminoglycoside nephrotoxicity: an integrative point of view. kidney int. 2011;79:33–45. 14. lesniak w, pecoraro vl, schacht j. ternary complexes of gentamicin with iron and lipid catalyze formation of reactive oxygen species. chem res toxicol. 2005;18:357– 64. 15. bayrak o, bavbek n, karatas of, bayrak r, catal f, cimentepe e, akbas a, yildirim e, unal d, akcay a. nigella sativa protects against ischaemia/reperfusion injury in rat kidneys. nephrol dial transpl. 2008;23(7):2206–12. 16. kadkhodaee m, khastar h, faghihi m, ghaznavi r, zahmatkesh m. effects of cosupplementation of vitamins e and c on gentamicin-induced nephrotoxicity in rat. exp physiol. 2005;90:571–6. hamsiah binti halim, achadiyani, tjahjodjati: nigella sativa infusion as an antioxidant agent against gentamicin-induced kidney damaged in mice althea vol 2 no 3 final.indd althea medical journal. 2015;2(3) 324 amj september, 2015 antimicrobial suspectibility of bacterial isolated from burn unit in dr. hasan sadikin general hospital bandung, indonesia from june to september 2013 yodya evila,1 sunarjati sudigdoadi,2 hardisiswo soedjana3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology, faculty of medicine universitas padjadjaran, 3department of plastic surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: development of infection in burned patients is a crucial matter because it may increase morbidity and mortality. factors contributing to high risk for infections are disrupted skin barrier, dysfunction of the immune system and prolonged hospitalization. crowded hospital condition and transfer of patients from one unit to another can affect development of infection caused by environmental factors. the aim of the study was to identify the antimicrobial suspectibility of bacterial isolated from burn unit in dr. hasan sadikin general hospital, bandung. methods: a descriptive study was carried out in burn unit dr. hasan sadikin general hospital bandung, indonesia, from june to september 2013. a total of 30 environment samples were collected and cultured to identify the bacterias. futhermore, the colonies found, underwent antimicrobial susceptibility test. results: most common bacteria found from the environmental samples in burn unit was staphylococcus saprophyticus (24%). other bacterias found were klebsiella pneumonia (17%), acinetobacter baumanii (15%), staphylococcus epidermidis (12%), bacillus sp.(12%), pseudomonas sp.(7%), staphylococcus aureus (5%), enterobacter aerogenes (5%) and serratia sp. (2%). some bacteria still had good sensitivity to antibiotics while the enterobacteriaceae were almost completely resistant to antimicrobial used in the study. conclusions: the most common bacteria found from the environment samples in burn unit is staphylococcuss aprophyticus. additionally, klebsiella pneumoniae as one of the enterobacteriaceae groups, appears as an emerging hospital associated infection pathogen with their resistant to many antimicrobials. [amj.2015;2(3):324–31] keywords: antibiotic susceptibility, bacteria, burn unit correspondence: yodya evila, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287823073772 email: yodyaev@hotmail.com introduction hospital associated infection is one of the causes of increased mortality and morbidity in hospitals, and it is an important health burden worldwide.1 the most common hospital associated infection is burn wound infection. out of 64.72% cases of hospital associated infections in burn patients, 62.02% of them are burn wound infections.2 in burn patients, infections arise from multiple sources such as from the wound itself, decreased immune system, and diagnostic procedures.3,4burn wound provides a place prone to colonization by opportunistic organisms from either endogenous or cross-infection due to disrupted of the skin barrier.5 this crossinfection arises among others by contact from patient to patient, and the environment to the patient.6 crowded condition of the hospital, transfer of patients from one unit to another and concentration of patients which is easy for being infected in one area, can affect development of hospital infections caused by environmental factors. avni et al 3 stated that septic shock is a major problem among burn patients because it precedes multi organ dysfunction and death. based on data from the study in the burn unit at dr. cipto mangunkusumo general althea medical journal. 2015;2(3) 325 hospital, jakarta in 2010, the bacteria most commonly found in the culture from environmental samples were k. pneumoniae, s. aureus, enterobacter sp, acinetobacter sp, bacillus sp, pseudomonas aeruginosa and citrobacter freundill.7 burn wound infections can be especially difficult to eradicate because of multidrug resistance. microorganisms that are resistant to antibiotics usually lead to an increase in considerable morbidity, and health care costs. the objective of this study was to identify the antimicrobial suspectibility of bacterial isolated from the burn unit at dr. hasan sadikin general hospital bandung. methods table 1 bacteria isolated from the environment samples bacteria frequency % staphylococcus s.saprophyticus 10 24.39 s. epidermidis 5 12.20 s. aureus 2 4.87 enterobacteriaceae klebsiellapneumoniae 7 17.07 enterobacteraerogenes 2 4.87 serratia sp. 1 2.44 non-enterobacteriaceae acinetobacterbaumanii 6 14.63 bacillus sp. 5 12.20 pseudomonas sp. 3 7.32 total 41 figure 1 antibiotic sensitivity of staphylococcus note: tmp-smx: trimetophrim-sulfamethoxazole yodya evila, sunarjati sudigdoadi, hardisiswo soedjana: antimicrobial suspectibility of bacterial isolated from burn unit in dr. hasan sadikin general hospital bandung, indonesiaf rom june to september 2013 althea medical journal. 2015;2(3) 326 amj september, 2015 this study was carried out from june to september 2013 in the burn unit at dr. hasan sadikin general hospital bandung and this study was approved by the health research ethics committee. environmental samples were collected from 4 care rooms with 2 m length and 3 m width each, a bathroom, nurse station and doctor’s room. a total of 30 surface swabs were taken, consisted of 4 samples from the floor, 4 samples from the bed sheet, 4 samples from the bedside table, 4 samples from the curtain, 4 samples from the exhaust fan, 2 samples fromthe air conditioner, 2 samples from the central room door handle, 1 sample from the bathroom door handle, 1 sample from the storage room door handle, 2 samples from the dressing cart, 1 sample from the nurse station and 1 sample from the table 2 distribution per sampling sites of bacteria isolated from environment samples bacteria location frequency staphylococcus s. saphrophyticus bedside table 4 bed sheet 2 nurse station 2 curtain 1 injection table 1 s. epidermidis central room door handle 2 bed sheet 1 bedside table 1 dressing car 1 s.aureus exhaust fan 1 dressing car 1 enterobacteriaceae k. pneumoniae exhaust fan 3 bed sheet 1 bedside table 1 enterobacteraerogenes curtain 1 air conditioner 1 curtain 1 central room door handle 1 serratia sp. bathroom door handle 1 non-enterobacteriaceae a. baumanii floor 3 curtain 2 bed sheet 1 bacillus sp. curtain 2 bathroom door handle 1 air conditioner 1 exhaust fan 1 pseudomonas sp. floor 2 exhaust fan 1 althea medical journal. 2015;2(3) 327 injection table. all the samples were collected in the afternoon. furthermore, sterile swabs filled with 0.5 ml of trypticase soy broth (tsb) were used to swab the floor, elevated surface and inanimate objects which were constantly in contact with health care workers and patients.8 all swabs were dipped into tsb as transport medium and were brought and processed in the microbiology laboratory faculty of medicine universitas padjadjaran, jatinangor. each sample was inoculated on both blood agar and mac conkey agar. all samples were incubated for 24 hours at 37⁰c. then, selected colonies with typical morphology and pigmentation on the blood agar and mac conkey agar were gram stained. next, the gram positive coccus which grew on blood agar was then subjected to catalase test and coagulation test. coagulase negative staphylococci was identified with novobiocin susceptibility test. the gram negative rod which grew on mac conkey agar then was identified with biochemical test including kligler iron agar (kia), motility indol urea (miu) and citrate test. the data were presented as frequency distribution and showed in tables. the procedure was then preceded to antibiotics susceptibility test which was performed on mueller-hinton agar by kirbybauer and stokes’ disk diffusion method recommended by the clinical laboratory and standard institute (clsi). antibiotics used for the susceptibility testing were based on the group a antibiotics from clsi which are considered appropriate for inclusion in a routine, primary testing and routine reporting and also cefotaxime which is given as initial treatment for all burn patients. the inhibition zone diameter was then measured and noted according to clsi 2012 criteria which was specific for each bacterium and antibiotics, and classified as susceptible (s), intermediate (i) and resistant (r).9 results this study indicated that staphylococcus saprophyticus was the most common gram positive bacteria found (24.39%), and the most common gram negative bacteria found was klebsiella pneumoniae (17.07%) (table 1). most common inanimate objects colonized by the bacteria were the curtains, as many as 7 colonies, followed by the bedside table and exhaust fan (6 colonies each) (table 2). additionally, antimicrobial suspectibility tests were carried out to all bacterial colonies isolated in the environmental samples. figure 1 shows that staphylococcus were completely resistant to penicillin. also, the highest number of sensitivity was toward clindamycin. figure 2 shows that enterobacteriaceae were completely resistant to almost all antibiotics tested, only gentamycin had a slight effect to the bacteria. bacteria a. baumanii found in this study was still sensitive to meropenem and ampicillinfigure 2 antibiotic sensitivity of enterobacteriaceae yodya evila, sunarjati sudigdoadi, hardisiswo soedjana: antimicrobial suspectibility of bacterial isolated from burn unit in dr. hasan sadikin general hospital bandung, indonesia from june to september 2013 althea medical journal. 2015;2(3) 328 amj september, 2015 sulbactam, but it had least sensitivity to cefotaxime (figure 3). discussion hospital environment provides a place for colonization of microorganisms and some of them were multi resistant to antibiotics. although health care workers and patients are considered as major sources of hospital infections, however some studies begin to show that the growing role of the environment is also important.10 results of this study indicated that bacteria commonly found in the environment of burn unit were staphylococcus saprophyticus (24%). this is consistent with the study which reported coagulasenegative staphylococcus as the most predominant organisms in burn infection.5 second, most common bacteria found in this study was klebsiellapneumoniae (17%), followed by acinetobacterbaumannii (15%). compared to the study that had been figure 3 antibiotic sensitivity of acinetobacterbaumanii figure 4 antibiotic sensitivity of pseudomonas sp althea medical journal. 2015;2(3) 329 conducted in the burn unit at cipto mangunkusumo hospital from january to december in 20107, bacteria found from the environment were k. pneumoniae, s. aureus, enterobactersp, acinetobacter sp, bacillus sp, pseudomonas aeruginosa and citrobacter freundill. the results are slightly in contrast with this study even though some bacteria were also found in this study. the differences in the findings of the bacteria between environment of burn unit at dr. hasan sadikin general hospital and cipto mangunkusumo hospital could be possibly due to the geographical factors, condition of the environment including temperature and different hygiene. another factor affecting the differences could be related to the antimicrobial usage policy.4 besides, staphylococci are pathogens causing hospital acquired infections and in particular for s. saprophyticus. it is gram positive coccus coagulase negative and common etiology of urinary tract infection.11 in this study, s. saprophyticus were most commonly found on the bedside table. lack of personal hygiene of patients and healthcare workers such as washing hands could cause these bacteria to spread from human to the environment and vice versa. bacteria s. saprophyticus is not the most common staphylococcus found in the cultures from blood or wounds of burn patients in the burn unit at dr. hasan sadikin general hospital, which is s. aureus, likely it is because staphylococcus found in the patient’s body are more pathogenic. other staphylococcus found in this study was s. epidermidis (12%) and s. aureus (5%). staphylococcus which is considered as the major pathogen in humans is s. aureus, it is commensal bacteria on the skin, nose, throat and it can survive on dry environmental surfaces. it can be spread through contact with pus from infected sores, skin to skin contact and contact with objects such as towels, bed linen, clothing used by infected patients.11 in this study, the susceptibility test of staphylococcus to antibiotics was performed, and it showed that these bacteria were sensitive to clindamycin, 7 out of 17 colonies were sensitive to clindamycin and fully resistant to penicillin. mechanism of resistance to penicillin is usually by producing betalactamase enzymes which is under control of plasmid.10 results from this study showed that s. epidermidis were most commonly found on central room door handle and s. aureus were found from exhaust fan and dressing car. enterobacteriaceae found in this study were klebsiellapneumoniae (17%) as the second most common bacteria found. this result is in accordance with other studies conducted in the burn unit at some hospitals in india.12 data from this study showed that k. pneumoniae isolated in this study were most commonly found from exhaust fan. another enterobacteriaceae found were enterobacteraerogenes (5%) and serratia sp. (2%). as the most common gram negative bacteria found in this study, k. pneumoniae is a pathogen causing hospital infections and is widely available in nature. the main source of infection in the hospital environment by k. pneumoniae are instruments that have been contaminated with the bacteria contact with patients.13 it showed resistance to many antibiotics, based on a research conducted in the neonatal and pediatric intensive care unit, out of the 130 isolates, 126 (97%) produced extended spectrum beta lactamase (esbl) and it related to the high mortality rates that occurred.14 although in this study we did not perform the esbl testing, enterobacteriaeceae found were subjected to the susceptibility testing and they also showed resistance to almost all antibiotics tested including ampicillin, gentamycin and cephalosporin class antibiotics. acinetobacterbaumannii were found as many as six (15%) in this study and most commonly isolated from the floors. it is gram negative bacilli and not motile. it is considered as a significant nosocomial pathogen with many infections concentrated in intensive care, burns or high dependency units treating severely ill or debilitated patients.5 high degree of resistance to drying and disinfectants, leading to long-term persistence in the hospital environment and to the occurrence of outbreaks of infections affecting immunosuppressant patients such as burn patients and increasing proportion of multidrug resistant isolates make this bacteria become an important problem in burn wound management. multidrug resistance of acinetobacter sp. is a cause of global outbreaks. it is probably as a consequence of increasing use of broad-spectrum antibiotics in hospitals.5 results from this study showed that a. baumannii found in the burn unit were fully sensitive to meropenem and still showed high levels of sensitivity to ampicillin-sulbactam, so those antibiotics are still effective to be used for patients in the burn unit at dr. hasan sadikin general hospital. pseudomonas sp. found in small amounts in this study were 7%. they are gram-negative yodya evila, sunarjati sudigdoadi, hardisiswo soedjana: antimicrobial suspectibility of bacterial isolated from burn unit in dr. hasan sadikin general hospital bandung, indonesia from june to september 2013 althea medical journal. 2015;2(3) 330 amj september, 2015 bacteria widely distributed in soil, water and plants. in this study, these bacteria were most commonly found on the floor. sometimes, pseudomonas is an opportunistic pathogen. the main pathogen and much reported as they existed in the hospital environment is p. aeruginosa, however it was not found in this study. pseudomonas sp. found on environmental swabs in the burn unit at dr. hasan sadikin general hospital showed high levels of sensitivity to all antibiotics tested including the cephalosporin group antibiotics and macrolide group antibiotics. another bacteria found from the environment of the burn unit was bacillus sp. (12%). however, bacillus sp. isolated from the environment in this study did not undergo the susceptibility testing, for it was known that the strain found in the environment is nonpathogenic bacteria. bacteria found in the environment were distributed in various inanimate objects, most bacteria colonized the curtains and as many as 7 colonies of bacteria were found there. the number of bacteria colonized on the bedside table and exhaust fan were 6, it made the bedside table and exhaust fan as the second most common objects being colonized by bacteria. in this study, the swabs were not taken from all environment surfaces of the burn unit because there were limitation of time and fund. in a further study, it might be needed to take swabs from all the surfaces to represent all bacteria colonized the entire environment of burn unit. this study showed that some bacteria could be ubiquitous in the environment of burn unit. results from the antibiotics susceptibility test showed that some bacteria still exhibited a high level of sensitivity. the main factors that caused an increase in the prevalence of resistant organisms in hospitals were changes on the organisms causing hospital infections, changes in the organism due to the changes in population characteristics of hospitals, procedures and medical devices used on patients. environmental contamination may reach considerable levels and this could result in contamination of the medical instruments, health care workers and patients. microbiological study and antibiotic susceptibility test from the environment of the burn unit should be conducted routinely to assist in monitoring the type of organisms involved in infections and antimicrobial resistance patterns. it is important to prevent hospital associated infections caused by environmental factors and reduce contamination and potential cross infection by disinfecting, careful isolation techniques and routine procedures, right antimicrobial choice and good hygiene of the environment, scheduled cleaning of environment in the burn unit using antiseptic solution that can keep infection rates and antimicrobial resistance rates low in burn patients. references 1. peleg, anton y, hooper d. hospital-acquired infections due to gram negative bacteria. n engl j med. 2010;362(19):1804−13. 2. chun-cui w. nosocomial infection in burn unit. chin med j. 2006;16(7):22−6. 3. avni t, levcovich a, ad-el dd, leibovici l, paul m. prophylactic antibiotics for burns patients: systematic review and metaanalysis. bmj. 2010;340:c241. 4. oncul o, ulkur e, acar a, turhan v, yeniz e, karacaer z, et al. prospective analysis of nosocomial infections in a burn care unit, turkey. indian j med res. 2009;130(6):758−64. 5. septiari bb. infeksi nosokomial. 1st ed. yogyakarta: nuha medika; 2012. p. 39−49 6. alaghehbandan r, azimi l, lari ar. nosocomial infections among burn patients in teheran, iran: a decade later. ann burns fire disasters. 2012;25(1):3−7. 7. wardhana a. nosocomial infection in burn unit of cipto mangunkusumo hospital, jakarta. jpr. 2012;1(3):352−6. 8. rutala w, katz e, sherertz r, sarubbi f. environmental study of a methicillinresistant staphylococcus aureus epidemic in a burn unit. j clin microbiol. 1983;18(3):683−8. 9. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing; twenty-second informational supplement. clsi document m100-s22. wayne, pa: clinical and laboratory standards institute; 2012. p. 35−121. 10. dakić i, morrison d, vuković d, savić b, shittu a, ježek p, et al. isolation and molecular characterization of staphylococcus sciuri in the hospital environment. j clin microbiol. 2005;43(6):2782−5. 11. lowy fd. staphylococcus aureus infections. n engl j med. 1998;339(8):520−32. 12. srinivasan s, vartak am, patil a, saldanha j. bacteriology of the burn wound at the althea medical journal. 2015;2(3) 331 bai jerbai wadia hospital for children, mumbai, india—a 13-year study, part i-bacteriological profile. indian j plast surg. 2009;42(2):213−8. 13. podschun r, pietsch s, höller c, ullmann u. incidence of klebsiella species in surface waters and their expression of virulence factors. appl environ microbiol. 2001;67(7):3325−7. 14. bratu s, landman d, haag r, recco r, eramo a, alam m, et al. rapid spread of carbapenem-resistant klebsiella pneumoniae in new york city: a new threat to our antibiotic armamentarium. arch intern med. 2005;165(12):1430−5. yodya evila, sunarjati sudigdoadi, hardisiswo soedjana: antimicrobial suspectibility of bacterial isolated from burn unit in dr. hasan sadikin general hospital bandung, indonesia from june to september 2013 althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 153 ear fungus (auricularia auricula) infusion reduces blood cholesterol level in dyslipidemic rats julius gunadi,1 herri s. sastramihardja,2 nina susana dewi3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hypercholesterolemia is a major risk factor for coronary heart disease. ear fungus (auricularia auricula) contains soluble fiber (beta glucan) which is believed to have an effect of reducing cholesterol level. the aim of this study was to determine the effect of fungus infusion in reducing blood cholesterol. methods: this study used the laboratory experimental method conducted in the pharmacology laboratory of dr. hasan sadikin general hospital bandung. the subjects were 25 male wistar rats which were randomly divided into 5 groups. the first group was given only distilled water as a negative control, the remaining groups were induced to be dyslipidemic and received fungus infusion with different doses of 18%, 36%, 72% and one group received no treatment. results: the comparison of different doses showed all had the effect of reducing cholesterol levels compared to the positive control group (p<0.05). each dose showed slight differences in their effectiveness, 18% (p=0.007; p<0.05), 36% (p=0.002; p<0.05), and 72% (p=0.014; p<0.05). conclusions: ear fungus infusion had the effect of reducing cholesterol with the most effective concentration was 36%. [amj.2015;2(1):153–61] keywords: beta glucan, cholesterol, ear fungus correspondence: julius gunadi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628176744415 email: julius.gunadi@hotmail.com introduction in this era of globalization, people in the world especially in the urban areas experienced significant lifestyle changes, especially in terms of eating behavior. changes in lifestyle can lead to health problems that cause a shift in the characteristic pattern of disease. in this case, there was a shift in the pattern of disease of which infectious disease used to dominate the mortality rate while nowadays it is replaced by non-communicable diseases such as coronary heart disease.1 the prevalence rate of coronary heart disease, especially in developing countries such as indonesia, increases from year to year. data from the world health organization (who) non-communicable disease country profile 2011 showed that 30% of the proportion of mortality are due to cardiovascular disease.2 profil kesehatan indonesia 2009 also states that 11.06% major disease causing death in hospital are diseases of the circulatory system.3 coronary heart disease has multiple risk factors such as dyslipidemia that could be controlled by lipid lowering drugs. these drugs have a variety of working mechanism consisting of several groups such as 3-hydroxy3-methyl-glutaril-coa reductase/hmgcoa reductase inhibitors (statins), niacin, cholesterol absorption inhibitors, fibrates and bile acid resins.4 however, although these have been proven effective in lowering blood lipid levels, lipid-lowering drugs have side effects, long time intake, and financially uneconomical. ear fungus (auricularia auricula) is a type of fungus that comes from china’s traditional medicine and people believed that it has many health benefits. a lot of people consume mushroom as food supplement such as for soup. some literatures has proved the health effects of this fungus, among which, as antithrombotic, anti-carcinogenic, hypoglycemic, and hypocholesterolemic.5,6 based on pharmacological evidence and its use in althea medical journal. 2015;2(2) 154 amj june, 2015 society, the researchers were interested in conducting a research to determine the effects of ear fungus on cholesterol reduction. methods this study used the laboratory experimental methods which took three weeks in the pharmacological laboratory of dr. hasan sadikin general hospital bandung. fresh mushrooms were obtained from cultivation in the biology building of the indonesian institute of sciences (lembaga ilmu pengetahuan indonesia /lipi), cibinong-bogor, west java. cultivation time began from july to august 2012. after been harvested the ear mushrooms were then dried. infusion was made by cutting up the ear fungus finely and put it into an erlenmeyer flask and 100 ml of distilled water was added. the mixture was put into a pot previously filled with heated (90oc) water. next, the mixture was boiled in an infusion pot for 15 minutes and stirred occasionally. afterward, the ear fungus was removed from the pot and waited to cool. then it was filtered by using a filter paper to obtain ear fungus infusion. twenty five male wistar rats with 200– 250 grams of weight were randomly divided into 5 groups. sick rats were excluded if they have lost 10% of body weight during the first week of adaptation. on the second week, each group was given different treatment. group 1 was given a normal diet and aquadest as the negative control group. group 2 was given a high lipid diet and propiltiouracil (ptu) 0.01% as the positive control group. group 3, group 4 and group 5 were given a high lipid diet and ptu 0.01% with additional ear fungus infusion with 18%, 36%, and 72% concentration respectively. a schematic diagram of this study is shown in figure 1. after two weeks of treatment, the rats were incubated in a warm basket in order to vasodilate their blood vessels, then blood was taken from each rat from their tails. next, the plasma sample was taken by centrifugation for 10 minutes in 12000 rpm. the cholesterol level was measured by using the enzymatic photometric test. the blood plasma was mixed with reagent which contained cholesterol oxidase, and peroxidase. this end product was quinoneimine. the cholesterol levels were proportional to the quinoneimine concentration. it was measured by using the spectrophotometer with 546 nm wavelength. the saphiro-wilk test was used to determine the distribution of data and the levene’s test to determine homogenity of variance. next, the one-way anova test was performed to compare the group means and lsd test to determine which group had the best effect to reduce cholesterol levels. figure 1 schematic diagram of the research althea medical journal. 2015;2(2) 155julius gunadi, herri s. sastramihardja, nina susana dewi: ear fungus (auricularia auricula) infusion reduces blood cholesterol level in dyslipidemic rats results the results of this study are presented in table 1. the means of positive control showed effective experimental-induced dyslipidemia. the intake of ear infusion showed lower mean cholesterol level in all doses. statistic analytical was done, and the result is shown in table 2 successful induction was shown by the negative control group which had a significant difference compared to the positive control group (p = 0.00, p <0.05). all treatment groups showed significant hypocholesterolemic effect compared to group 2 (p < 0.05) discussions this study aimed to determine the effects of ear fungus infusion on blood cholesterol levels of dyslipidemic rat models. based on the results showed on table 1, successful induction of dyslipidemia was indicated by significant difference of cholesterol level between the negative and positive control groups given high lipid diet and 0.01% ptu (p=0.00, p <0.05). the treatment group with ear fungus infusion showed that all three concentrations of treatment: 18% (p = 0.007, p <0.05), 36% (p = 0.002, p <0.05), and 72% (p = 0.014, p <0.05) had a significant difference compared to the positive control group. from these results we could affirm that the treatment of fungus had an effect of lowering cholesterol. the cholesterol-lowering effect was presumably due to its soluble fiber (beta glucan) contents on the mushroom. soluble fiber (beta glucan) can lower blood cholesterol levels by several mechanisms such as increasing the excretion of bile salts, increased catabolism of ldl and inhibit the absorption of cholesterol in the intestine.7, 8 increased excretion of bile salts can lower blood cholesterol levels due to the fact that cholesterol is the precursor of bile salt synthesis. with an increase in the excretion of bile salts will cause a reduction in reabsorption of bile salts in the ileum and liver will increase the production of bile salts that will increase cholesterol use. this supports some previous research on mushroom beta glucan which has the effect of lowering cholesterol levels in blood.9 the results of a comparative analysis of table 1 blood cholesterol level after treatment no. sample group 1 (mg/dl) group 2 (mg/dl) group 3 (mg/dl) group 4 (mg/dl) group 5 (mg/dl) 1 82.4 126.4 76 68.4 96.6 2 59.8 98.5 106.6 106.1 128 3 64.5 133.6 96.9 83.8 92.6 4 84.2 126.5 77.1 86 66.9 5 65.7 118.8 102.5 83.3 89.2 means 71.32 120.76 91.82 85.52 94.66 note: group 1: negative control, group 2: positive control, group 3: test group 1 (18% infusion), group 4: test group 2 (36% infusion), group 5: test group 3 (72% infusion) table 2 post-hoc lsd test result compared group (i) comparing group (j) mean difference (i-j) sig. 95% confidence interval upper bound lower bound 2 1 49.44 0.000 29.2192 69.6608 3 28.94 0.007 8.7192 49.1608 4 35.24 0.002 15.0192 55.4608 5 26.1 0.014 5.8792 46.3208 note: group 1: negative control, group 2: positive control, group 3: test group 1 (18% infusion), group 4: test group 2 (36% infusion), group 5: test group 3 (72% infusion) althea medical journal. 2015;2(2) 156 amj june, 2015 the effectiveness of three different treatment concentrations in this study suggested that ear fungus infusion with a concentration of 36% had the best effect in reducing cholesterol levels compared to the other treatment groups with different concentrations. giving higher concentrations in this study was not accompanied by increased blood cholesterollowering effects. this was indicated by a statistical test that there was no significant difference among the three treatment groups. this condition was likely due to other active substances contained in the fungus, so that the effects were not only cholesterol-lowering, but could also inhibit cholesterol reduction effect. so that the effects obtained from this study was the effect of the accumulation of substances contained in ear fungus infusion. another factor that might affect the outcome of the study was an error in the laboratory and technical errors in both the induction and the provision of infusion in the treatment groups. in the treatment groups, we determined that the volume of infuse given to each rat was as much as 3 ml per day via oral administration. this did not rule out giving infusion could be reduced, because after giving infusion subjects were likely to vomit or not all infusion entered the body so that the volume of ear fungus infusion was less than the specified volume references 1. direktorat jenderal pengendalian penyakit dan penyehatan lingkungan kementerian kesehatan republik indonesia. dari penyakit menular ke tidak menular. 2011 [cited 2012 january 26] ; available from: http://pppl.depkes.go.id/berita?id=137. 2. world health organization. noncommunicable diseases country profiles: who global report. 2011. geneva: who library cataloguing in publication data; 2011. p. 93. [cited 2012 january 26] ; available from: http://www.who.int/ nmh/publications/ncd_profiles_report. pdf. 3. pusat data dan surveilans epidemiologi kementerian kesehatan republik indonesia. profil kesehatan indonesia 2009. jakarta: kementerian kesehatan republik indonesia; 2010. 4. mahley rw, bersot, thomas w. drug therapy for hypercholesterolemia and dyslipidemia. in: brunton ll, goodman ls, blumenthal d, buxton i, editors. goodman and gilman’s manual of pharmacology and therapeutics. new york: mcgraw-hill; 2008. p. 605–20. 5. kim dh, yang bk, jeong sc, hur nj, das s, yun jw, et al. a preliminary study on the hypoglycemic effect of the exo-polymers produced by five different medicinal mushrooms. j microbiol biotechnol. 2001; 11(1):167–71. 6. yuan z, he p, cui j, takeuchi h. hypoglycemic effect of water-soluble polysaccharide from auricularia auricula-judae quel. on genetically diabetic kk-ay mice. biosci biotechnol biochem. 1998;62(10):1898– 903. 7. behall km, scholfield dj, hallfrisch j. diets containing barley significantly reduce lipids in mildly hypercholesterolemic men and women. am j clin nutr. 2004;80(5): 1185–93. 8. marlett ja. sites and mechanisms for the hypocholesterolemic actions of soluble dietary fiber sources. adv exp med biol. 1997;427:109–21. 9. jeong h, yang b-k, jeong y-t, kim g-n, jeong y-s, kim s-m, et al. hypolipidemic effects of biopolymers extracted from culture broth, mycelia, and fruiting bodies of auricularia auricula-judae in dietary-induced hyperlipidemic rats. mycobiology. 2007;35(1):16–20. althea medical journal. 2015;2(2) 157 factors affecting mortality in adult tetanus patients lohghinee krisnan,1 anam,2 ramdan panigoro3 1faculty of medicine universitas padjadjaran 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry faculty of medicine universitas padjadjaran abstract background: tetanus is a devastating disease that is associated with high mortality. the aim of this study was to analyze the prognostic factors that were associated with high mortality in tetanus. methods: this was an analytical study and the data was collected retrospectively from 1 january 2010–31october 2012 in the department of neurology, dr. hasan sadikin general hospital. results: out of hundred thirty two cases only 87 cases of tetanus patient have complete medical records. there were 54 male and 33 female. the age range was 35-49 years old. mortality rate was high (32.18%). the most frequent wound site is extremities (85.07 %). the absence of post-injury tetanus vaccination was 75.86%, period of onset <48 hours was 67.82% and the use of mechanical ventilation and tracheostomy 36.07%. mortality was significantly associated with an incubation period <7 days (p<0.05), presence of fever (p <0.05), co morbidity of autonomic storm (p<0.01), and the severity of the disease by grade 5 (p<0.05). conclusions: factors affecting the mortality in adult tetanus patients were significant for incubation period, fever, co morbidity and severity of the disease by grade. keywords: mortality, prognostic factors, tetanus correspondence: lohghinee krisnan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6283820120153 email: viloni_24@yahoo.com introduction tetanus, described by hippocrates as “a timeless human misery”, still exists in the 21st century especially in the developing countries. even with the invention of anti tetanus serum and tetanus toxoid by p. descombey in 1924, as prevention tetanus immunization is not well practiced in most of the countries. meanwhile, tetanus still remains as a public health problem in indonesia. this disease is triggered by a microbiological organism called clostridium tetani which causes muscle spasm and lock jaw. furthermore, in severe cases with increasing severity and frequency of spasms can lead to death. in 1995, the world health organization (who) had an intention to eradicate tetanus however, in developing countries it still remains as endemic.1 in indonesia, the surveillance data by the ministry of health showed the incidence of tetanus is about 0.2 per 100,000 populations annually. it is regarded as an even distribution of the disease in all provinces in the country.2 the incidence for the year 2011 in indonesia is 210, as stated by the who. however, the incidence has shown a decline since 2003.3 tetanus is treated with intensive care, muscle relaxant drugs, and often assisted ventilation. besides, anti-tetanus serum, tetanus toxoid and metronidazole are also administered. proper wound debridement and management are also carried out. active immunization of tetanus toxoid is given during childhood and continued with booster after 5 years to eradicate this disease. furthermore, passive immunization is given following wound or injury.4 despite the help of the current modern medical advances, the mortality for generalized tetanus is still high. therefore, this research was to analyze the prognostic factors affecting the mortality in adult tetanus patients. methods adult tetanus patients admitted in the department of neurology in dr. hasan sadikin general hospital, bandung, from 1 january 2010-31october 2012 were included in this analytical study. data were collected althea medical journal. 2015;2(2) 158 amj june, 2015 retrospectively. diagnosis of tetanus was based on patel and joag grading. patients were divided into five grades based on the criteria such as incubation period, period of onset, fever, and spasm and lock jaw. fever is defined as temperature > 37.5. grade i consisted of one of these criteria. for every additional criterion there will be alteration of the grade by one criterion. if all five criteria were present, it indicated grade v. while mild is range from grade i-ii, moderate range from iii-iv and severe was grade v. the collected data included patient’s details, age and sex, incubation period, period of onset, site of wound, immunization background, passive immunization, classification, grading, the comorbidity such as autonomic storm, cardiac arrest, aspiration pneumonia, and stress ulcer; and the use of mechanical ventilation. the incubation period was defined as a time period from time of injury to onset of symptoms, and the period of onset was defined as the time period from onset of symptoms to time of full blown disease / onset of general spasms. the patients also received passive immunization with anti tetanus serum 10,000 iu and active immunization with tetanus toxoid. patients were graded based on the severity of the disease: mild, moderate and severe according to patel and joag.5 the data will be analyzed using chi-squared tests or, when needed, the fisher’s exact test was used, to analyze the association between mortality and categorical variables.6 results out of a total of 132 cases of tetanus only 87 patients with complete records were included in this study. out of the 87 patients, 86 of them had generalized tetanus and only one of them had cephalic tetanus. all patients had spasms and lockjaw. there were 54 (67.07%) male and 33 (37.93%) female patients. the age range was between 20–80 years. the highest number of patients presented with tetanus was between 35–49 years which was 34 (39.08%). table 1 the distribution of the demographic data of tetanus patients demographic data no. of patients % sex male 54 67.07 female 33 37.93 age (years old) 20–34 10 11.49 35–49 34 39.08 50–64 29 32.18 >65 14 16.09 wound site extremities 74 85.07 face/nose/mouth 11 12.65 trunk 2 2.30 vaccine after injury yes 21 24.14 no 66 75.86 grading* 2 12 13.79 3 45 51.72 4 23 26.44 5 7 8.05 notes: * grading is according to patel and joag: 0-2=mild, 3-4=moderate, 5=severe althea medical journal. 2015;2(2) 159 table 2 the relationship between mortality and prognostic factors for tetanus factors total (n=87) died (n=28) mortality rate (%) p-value sex male 54 23 42.59 0.189 female 33 5 15.15 age <50 45 14 16.09 0.503 ≥50 42 14 16.09 wound site extremities 74 24 85.72 0.850 face/nose/mouth 1 4 14.28 trunk 2 0 0.00 vaccine after injury yes 21 9 42.86 0.286 no 66 19 28.79 incubation period* < 7days 32 15 46.88 0.033 >7days 55 13 23.64 period of onset* < 48 hours 59 21 35.59 0.28 >48 hours 28 7 25.00 fever yes 27 14 51.85 0.013 no 60 14 23.33 co morbidity stress ulcer 13 6 46.15 0.002 respiratory distress 2 0 0.00 respiratory failure 9 9 100.00 autonomic storm 15 12 80.00 cardiac arrest 2 2 100.00 aspiration pneumonia 2 2 100.00 none 44 0 0.00 grading 2 12 2 16.67 0.031 3 45 11 24.44 4 23 10 43.48 5 7 5 71.43 use of mechanical ventilation or tracheostomy yes 61 22 36.07 0.318 no 26 6 23.08 note:*incubation period is the period from injury to first symptom. period of onset is the duration of time between first symptom and occurrence of spasm lohghinee krisnan, anam, ramdan panigoro: factors affecting mortality in adult tetanus patients althea medical journal. 2015;2(2) 160 amj june, 2015 the second highest was between 50–64 years which was 29 (32.18%). the lowest was presented between 20–34 years which was 10 (11.49%), followed by the age > 65 years which was 14 (16.09%). the most common wound site was extremities which were presented in 74 (85.07%) patients, followed by face/nose/ mouth 11 (12.65%). the least common wound site was trunk which was two (2.30%). the absence of post-injury vaccination was shown as majority 66 (75.86%). only 21 (24.24%) were vaccinated after injury. based on the grading, most patient were presented with tetanus grade 3 which is 45 (51.73%) of them. it was followed by tetanus grade 4 which was 23 (26.44%), grade 2 which was 12 (13.79%) and grade 5 which was 7 (8.05%) of them. the mortality rate among cases with an incubation period of < 7 days was higher (46.88%). fourteen (51.85%) patients died with the presence of fever. in several comorbidities of autonomic storm have shown the highest mortality rate with 12 (80%) patients. mortality was high in patients for the period of onset < 48 hours which was 21 (35.59%). patients who had been through mechanical ventilation and tracheostomy and died were 22 (36.07%). table 2 showed the relationship between mortality and prognostic factors for tetanus. higher mortality rate was significantly associated with incubation period <7 days, presence of fever, co-morbidity of autonomic storm and more sever disease according to patel and joag grading. there were no significant association between age and sex, wound site, vaccine after injury, period of onset, and use of mechanical ventilation. discussion even though with the invention of tetanus toxoid, tetanus still cannot be eradicated in developing countries.7,8 the mortality rate is considered high at 32.18%. mortality was also proven high in a previous study by polhaupessy.9 a high rate of tetanus is shown in male than in female which is in line with the study by patel and mehtra10, also in the study by polhaupessy.9 this is due to higher exposure rate in dirty environment at work in male than in female.9,11 besides, female are immunized before pregnancy.1,12 in this study, gender was not shown significant to mortality rate. it is only common that tetanus occurres more in male than in female. the highest mortality rate of tetanus was shown in the age range between 35–49 years, 39.08%. this may be due to the patients’ activities at this age. therefore, they are more prone to risk of injury which can be related to their work or other causes.13 in previous studies it was shown that there were associations of older age with mortality due to the poor adherence to immunization schedule.6 the study by udwadia11 has stated that the response towards tetanus immunization declines at age more than 50 years old. vaccination after injury is important for preventing tetanus but in this study, the number of patients who were absence of postinjury vaccination is high (75.86%).6 it is also proven in the study by widjaya.13 post-injury vaccinations are important in tetanus patients to prevent complications. the factor wound site showed the highest number of patients was extremities with mortality rate 85.72%. the results differences could be because the patients in this study who were from allow socioeconomic background and also had low education were not aware about the safety at work. therefore, they were more likely to injure their extremities. usually tetanus is more severe if the site of wound is at the face or cranial than at extremities. the factor incubation period <7 days (46.88 %; p 0.033) had a higher mortality compared to >7 days. this result was in line with the previous studies by saltoglu et al.5,6,10 the shorter the incubation period, the higher the risk of getting an infection showed that the toxin production by c. tetani had not neutralized. this factor was proven to be significant. the patients who were presented with fever were higher than those without fever. it is significantly related to mortality in tetanus as the previous studies also showed presence of fever is related to mortality.6 in this study, fever was present because of the presence of microbiological organisms. therefore, until the c. tetani was not eradicated the fever would not subside. the co morbidity of autonomic storm had a p value of 0.002. this showed it was significantly related to mortality. the study by polhaupessy has proven that autonomic storm is significant to mortality with p<0.001.9 for severity of the disease by grade which is tetanus grade v shows as the highest mortality which is in line with the previous studies, the severer the disease the higher the mortality rate.6,10,14 grade v is the severest stage where there is presence of the five criteria as stated earlier. therefore, this shows the patient is althea medical journal. 2015;2(2) 161 in critical condition that will possibly lead them to further complications. this is proven significant to the mortality in tetanus. the deaths from tetanus can be related to the prognostic factors. the factors which were significantly related to mortality were incubation period, presence of fever (p<0.05), co morbidity (p<0.01) and severity by grade (p < 0.05). hopefully, this study could provide guidance for the physician to put much more effort on the prevention aspect of tetanus to reduce the mortality rate. the limitation to this study was management as a factor was not identified. a multivariate logistic analysis could be performed to identify the most significant factors affecting the mortality simultaneously. in conclusion, the mortality rate of adult tetanus was high (32.18%). the factors that were significantly affecting the mortality were incubation period less than 7 days, presence of fever, co morbid of autonomic storm and severity based by grade. references 1. who. immunization, vaccines and biological: tetanus. 2007 [cited 2012 april 20]. available from: http://www.who.int/ immunization/topics/tetanus/en/. 2. gunawan d. tetanus in adults in bandung, indonesia. neurol j southeast asia.1996;1:43-6. 3. who. immunization, vaccines and biological: immunization surveillance, assessment and monitoring. 2011 [cited 2012 april 20]. available from: http:// www.who.int/immunization/monitoring_ surveillance/en/. 4. russell rwr, wiles cm, editors. integrated clinical sciences series: neurology. london: butterworth-heinemann medical books ltd; 1985. 5. ramachandra l, shobha kl, kannan pa. a retrospective clinical study of factors affecting tetanus. the internet journal of microbiology. 2008;7(1) 6. saltoglu n, tasova y, midikli d, burgut r, dündar ih. prognostic factors affecting deaths from adult tetanus. clin microbiol infect. 2004;10(3):229–33. 7. who. tetanus. 2012 [downloaded in 20 april 2012]. available at: http://www. who.int/topics/tetanus/en/ 8. polhaupessy d. pola dan pengaruh disotonomia terhadap prognosis pasien tetanus [dissertation]. bandung: universitas padjajaran; 1999. 9. patel jc, mehta bc. tetanus: study of 8,697 cases. indian j med sci. 1999;53(9):393– 401. 10. udwadia f. tetanus [dissertation]. delhi: bombay oxford university press; 1994. 11. centers for disease control and prevention. vaccines and immunizations: vaccines & preventable diseases. 2009 [cited 2012 april 20]. available from: http://www.cdc. gov/vaccines/vpd-vac/tetanus/default. htm. 12. widjaya rk. perbandingan penggunaan htig 500 iu dengan ats equine10000 iu terhadap keluaran pasien tetanus [dissertation]. bandung: universitas padjadjaran; 2007. 13. owolabi lf, habib ag, nagoda m. predictors of mortality among adult tetanus patients in northwestern nigeria. neurology asia. 2011;16(3):199–203. lohghinee krisnan, anam, ramdan panigoro: factors affecting mortality in adult tetanus patients althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 157 factors affecting mortality in adult tetanus patients lohghinee krisnan,1 anam,2 ramdan panigoro3 1faculty of medicine universitas padjadjaran 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry faculty of medicine universitas padjadjaran abstract background: tetanus is a devastating disease that is associated with high mortality. the aim of this study was to analyze the prognostic factors that were associated with high mortality in tetanus. methods: this was an analytical study and the data was collected retrospectively from 1 january 2010–31october 2012 in the department of neurology, dr. hasan sadikin general hospital. results: out of hundred thirty two cases only 87 cases of tetanus patient have complete medical records. there were 54 male and 33 female. the age range was 35-49 years old. mortality rate was high (32.18%). the most frequent wound site is extremities (85.07 %). the absence of post-injury tetanus vaccination was 75.86%, period of onset <48 hours was 67.82% and the use of mechanical ventilation and tracheostomy 36.07%. mortality was significantly associated with an incubation period <7 days (p<0.05), presence of fever (p <0.05), co morbidity of autonomic storm (p<0.01), and the severity of the disease by grade 5 (p<0.05). conclusions: factors affecting the mortality in adult tetanus patients were significant for incubation period, fever, co morbidity and severity of the disease by grade. [amj.2015;2(1):157–61] keywords: mortality, prognostic factors, tetanus correspondence: lohghinee krisnan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6283820120153 email: viloni_24@yahoo.com introduction tetanus, described by hippocrates as “a timeless human misery”, still exists in the 21st century especially in the developing countries. even with the invention of anti tetanus serum and tetanus toxoid by p. descombey in 1924, as prevention tetanus immunization is not well practiced in most of the countries. meanwhile, tetanus still remains as a public health problem in indonesia. this disease is triggered by a microbiological organism called clostridium tetani which causes muscle spasm and lock jaw. furthermore, in severe cases with increasing severity and frequency of spasms can lead to death. in 1995, the world health organization (who) had an intention to eradicate tetanus however, in developing countries it still remains as endemic.1 in indonesia, the surveillance data by the ministry of health showed the incidence of tetanus is about 0.2 per 100,000 populations annually. it is regarded as an even distribution of the disease in all provinces in the country.2 the incidence for the year 2011 in indonesia is 210, as stated by the who. however, the incidence has shown a decline since 2003.3 tetanus is treated with intensive care, muscle relaxant drugs, and often assisted ventilation. besides, anti-tetanus serum, tetanus toxoid and metronidazole are also administered. proper wound debridement and management are also carried out. active immunization of tetanus toxoid is given during childhood and continued with booster after 5 years to eradicate this disease. furthermore, passive immunization is given following wound or injury.4 despite the help of the current modern medical advances, the mortality for generalized tetanus is still high. therefore, this research was to analyze the prognostic factors affecting the mortality in adult tetanus patients. methods adult tetanus patients admitted in the department of neurology in dr. hasan sadikin general hospital, bandung, from 1 january 2010-31october 2012 were included in this analytical study. data were collected althea medical journal. 2015;2(2) 158 amj june, 2015 retrospectively. diagnosis of tetanus was based on patel and joag grading. patients were divided into five grades based on the criteria such as incubation period, period of onset, fever, and spasm and lock jaw. fever is defined as temperature > 37.5. grade i consisted of one of these criteria. for every additional criterion there will be alteration of the grade by one criterion. if all five criteria were present, it indicated grade v. while mild is range from grade i-ii, moderate range from iii-iv and severe was grade v. the collected data included patient’s details, age and sex, incubation period, period of onset, site of wound, immunization background, passive immunization, classification, grading, the comorbidity such as autonomic storm, cardiac arrest, aspiration pneumonia, and stress ulcer; and the use of mechanical ventilation. the incubation period was defined as a time period from time of injury to onset of symptoms, and the period of onset was defined as the time period from onset of symptoms to time of full blown disease / onset of general spasms. the patients also received passive immunization with anti tetanus serum 10,000 iu and active immunization with tetanus toxoid. patients were graded based on the severity of the disease: mild, moderate and severe according to patel and joag.5 the data will be analyzed using chi-squared tests or, when needed, the fisher’s exact test was used, to analyze the association between mortality and categorical variables.6 results out of a total of 132 cases of tetanus only 87 patients with complete records were included in this study. out of the 87 patients, 86 of them had generalized tetanus and only one of them had cephalic tetanus. all patients had spasms and lockjaw. there were 54 (67.07%) male and 33 (37.93%) female patients. the age range was between 20–80 years. the highest number of patients presented with tetanus was between 35–49 years which was 34 (39.08%). table 1 the distribution of the demographic data of tetanus patients demographic data no. of patients % sex male 54 67.07 female 33 37.93 age (years old) 20–34 10 11.49 35–49 34 39.08 50–64 29 32.18 >65 14 16.09 wound site extremities 74 85.07 face/nose/mouth 11 12.65 trunk 2 2.30 vaccine after injury yes 21 24.14 no 66 75.86 grading* 2 12 13.79 3 45 51.72 4 23 26.44 5 7 8.05 notes: * grading is according to patel and joag: 0-2=mild, 3-4=moderate, 5=severe althea medical journal. 2015;2(2) 159 table 2 the relationship between mortality and prognostic factors for tetanus factors total (n=87) died (n=28) mortality rate (%) p-value sex male 54 23 42.59 0.189 female 33 5 15.15 age <50 45 14 16.09 0.503 ≥50 42 14 16.09 wound site extremities 74 24 85.72 0.850 face/nose/mouth 1 4 14.28 trunk 2 0 0.00 vaccine after injury yes 21 9 42.86 0.286 no 66 19 28.79 incubation period* < 7days 32 15 46.88 0.033 >7days 55 13 23.64 period of onset* < 48 hours 59 21 35.59 0.28 >48 hours 28 7 25.00 fever yes 27 14 51.85 0.013 no 60 14 23.33 co morbidity stress ulcer 13 6 46.15 0.002 respiratory distress 2 0 0.00 respiratory failure 9 9 100.00 autonomic storm 15 12 80.00 cardiac arrest 2 2 100.00 aspiration pneumonia 2 2 100.00 none 44 0 0.00 grading 2 12 2 16.67 0.031 3 45 11 24.44 4 23 10 43.48 5 7 5 71.43 use of mechanical ventilation or tracheostomy yes 61 22 36.07 0.318 no 26 6 23.08 note:*incubation period is the period from injury to first symptom. period of onset is the duration of time between first symptom and occurrence of spasm lohghinee krisnan, anam, ramdan panigoro: factors affecting mortality in adult tetanus patients althea medical journal. 2015;2(2) 160 amj june, 2015 the second highest was between 50–64 years which was 29 (32.18%). the lowest was presented between 20–34 years which was 10 (11.49%), followed by the age > 65 years which was 14 (16.09%). the most common wound site was extremities which were presented in 74 (85.07%) patients, followed by face/nose/ mouth 11 (12.65%). the least common wound site was trunk which was two (2.30%). the absence of post-injury vaccination was shown as majority 66 (75.86%). only 21 (24.24%) were vaccinated after injury. based on the grading, most patient were presented with tetanus grade 3 which is 45 (51.73%) of them. it was followed by tetanus grade 4 which was 23 (26.44%), grade 2 which was 12 (13.79%) and grade 5 which was 7 (8.05%) of them. the mortality rate among cases with an incubation period of < 7 days was higher (46.88%). fourteen (51.85%) patients died with the presence of fever. in several comorbidities of autonomic storm have shown the highest mortality rate with 12 (80%) patients. mortality was high in patients for the period of onset < 48 hours which was 21 (35.59%). patients who had been through mechanical ventilation and tracheostomy and died were 22 (36.07%). table 2 showed the relationship between mortality and prognostic factors for tetanus. higher mortality rate was significantly associated with incubation period <7 days, presence of fever, co-morbidity of autonomic storm and more sever disease according to patel and joag grading. there were no significant association between age and sex, wound site, vaccine after injury, period of onset, and use of mechanical ventilation. discussion even though with the invention of tetanus toxoid, tetanus still cannot be eradicated in developing countries.7,8 the mortality rate is considered high at 32.18%. mortality was also proven high in a previous study by polhaupessy.9 a high rate of tetanus is shown in male than in female which is in line with the study by patel and mehtra10, also in the study by polhaupessy.9 this is due to higher exposure rate in dirty environment at work in male than in female.9,11 besides, female are immunized before pregnancy.1,12 in this study, gender was not shown significant to mortality rate. it is only common that tetanus occurres more in male than in female. the highest mortality rate of tetanus was shown in the age range between 35–49 years, 39.08%. this may be due to the patients’ activities at this age. therefore, they are more prone to risk of injury which can be related to their work or other causes.13 in previous studies it was shown that there were associations of older age with mortality due to the poor adherence to immunization schedule.6 the study by udwadia11 has stated that the response towards tetanus immunization declines at age more than 50 years old. vaccination after injury is important for preventing tetanus but in this study, the number of patients who were absence of postinjury vaccination is high (75.86%).6 it is also proven in the study by widjaya.13 post-injury vaccinations are important in tetanus patients to prevent complications. the factor wound site showed the highest number of patients was extremities with mortality rate 85.72%. the results differences could be because the patients in this study who were from allow socioeconomic background and also had low education were not aware about the safety at work. therefore, they were more likely to injure their extremities. usually tetanus is more severe if the site of wound is at the face or cranial than at extremities. the factor incubation period <7 days (46.88 %; p 0.033) had a higher mortality compared to >7 days. this result was in line with the previous studies by saltoglu et al.5,6,10 the shorter the incubation period, the higher the risk of getting an infection showed that the toxin production by c. tetani had not neutralized. this factor was proven to be significant. the patients who were presented with fever were higher than those without fever. it is significantly related to mortality in tetanus as the previous studies also showed presence of fever is related to mortality.6 in this study, fever was present because of the presence of microbiological organisms. therefore, until the c. tetani was not eradicated the fever would not subside. the co morbidity of autonomic storm had a p value of 0.002. this showed it was significantly related to mortality. the study by polhaupessy has proven that autonomic storm is significant to mortality with p<0.001.9 for severity of the disease by grade which is tetanus grade v shows as the highest mortality which is in line with the previous studies, the severer the disease the higher the mortality rate.6,10,14 grade v is the severest stage where there is presence of the five criteria as stated earlier. therefore, this shows the patient is althea medical journal. 2015;2(2) 161 in critical condition that will possibly lead them to further complications. this is proven significant to the mortality in tetanus. the deaths from tetanus can be related to the prognostic factors. the factors which were significantly related to mortality were incubation period, presence of fever (p<0.05), co morbidity (p<0.01) and severity by grade (p < 0.05). hopefully, this study could provide guidance for the physician to put much more effort on the prevention aspect of tetanus to reduce the mortality rate. the limitation to this study was management as a factor was not identified. a multivariate logistic analysis could be performed to identify the most significant factors affecting the mortality simultaneously. in conclusion, the mortality rate of adult tetanus was high (32.18%). the factors that were significantly affecting the mortality were incubation period less than 7 days, presence of fever, co morbid of autonomic storm and severity based by grade. references 1. who. immunization, vaccines and biological: tetanus. 2007 [cited 2012 april 20]. available from: http://www.who.int/ immunization/topics/tetanus/en/. 2. gunawan d. tetanus in adults in bandung, indonesia. neurol j southeast asia.1996;1:43-6. 3. who. immunization, vaccines and biological: immunization surveillance, assessment and monitoring. 2011 [cited 2012 april 20]. available from: http:// www.who.int/immunization/monitoring_ surveillance/en/. 4. russell rwr, wiles cm, editors. integrated clinical sciences series: neurology. london: butterworth-heinemann medical books ltd; 1985. 5. ramachandra l, shobha kl, kannan pa. a retrospective clinical study of factors affecting tetanus. the internet journal of microbiology. 2008;7(1) 6. saltoglu n, tasova y, midikli d, burgut r, dündar ih. prognostic factors affecting deaths from adult tetanus. clin microbiol infect. 2004;10(3):229–33. 7. who. tetanus. 2012 [downloaded in 20 april 2012]. available at: http://www. who.int/topics/tetanus/en/ 8. polhaupessy d. pola dan pengaruh disotonomia terhadap prognosis pasien tetanus [dissertation]. bandung: universitas padjajaran; 1999. 9. patel jc, mehta bc. tetanus: study of 8,697 cases. indian j med sci. 1999;53(9):393– 401. 10. udwadia f. tetanus [dissertation]. delhi: bombay oxford university press; 1994. 11. centers for disease control and prevention. vaccines and immunizations: vaccines & preventable diseases. 2009 [cited 2012 april 20]. available from: http://www.cdc. gov/vaccines/vpd-vac/tetanus/default. htm. 12. widjaya rk. perbandingan penggunaan htig 500 iu dengan ats equine10000 iu terhadap keluaran pasien tetanus [dissertation]. bandung: universitas padjadjaran; 2007. 13. owolabi lf, habib ag, nagoda m. predictors of mortality among adult tetanus patients in northwestern nigeria. neurology asia. 2011;16(3):199–203. lohghinee krisnan, anam, ramdan panigoro: factors affecting mortality in adult tetanus patients althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 104 amj march, 2015 physical performance of west java soccer athletes during february to december 2012 army zaka anwary1, ambrosius purba2, tertianto prabowo3 1faculty of medicine, universitas padjadjaran, 2department of physiology, faculty of medicine, universitas padjadjaran, 3department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: soccer is one of the sports included in the 18th national sports week (pekan olahraga nasional, (pon) 2012, in riau. soccer requires a good physical condition to perform various football techniques such as running, shooting, dribbling, tackling, sliding, throw-in and heading. a good physical component can be achieved through a well-rounded program in accordance to the periodization training program. this study was conducted to describe the physical performance of the west java’s football athletes in order to develop periodization training program and to predict the athletes’ performance. methods: a descriptive study was carried out on 23 west java’s football athletes using secondary data from west java’s koni sports medicine team test reports during the period of february to december 2012. the variables in this study were 7 predominant physical components in football as follows: muscle strength, muscle endurance, speed, agility, flexibility, explosive leg muscle power, and general endurance (vo2 max). all components were categorized asinsufficient, fair, good, excellent, and perfect compared to the central koni standards. results: the leg muscle strength, abdominal muscle endurance, speed, agility of all athletes were not considered perfect. not one of the components was above 50% which was the excellent category. only arm and shoulder endurance (56.5%), speed (68.18%), and leg muscle power (52.17%) were in good category. the most of the results regarding the athletes’ leg muscle strength was categorized as fair. all results in the abdominal endurance were in insufficient category. conclusion: not all physical performance components are achieved perfectly by all of the football athletes. key words: athletes, football, physical performance correspondence: army zaka anwary, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628122028841 email: armyzaka@gmail.com introduction football is a popular sport that competes in all around the world. football has been played in china since 2nd century during the reign of the han dynasty by chinese soldiers. however, modern football and its rules are claimed and was formed in 1846 in cambridge, england.1 football is a sport that requires a good physical condition to perform a variety of football techniques such as running, shooting, dribbling, tackling, sliding, throwin and heading. by observing the athlete’s movement patterns, we determined the predominant physical components that is important in achieving the maximum athlete’s performance, which are: the leg muscle strength, arm and shoulder extensor muscle strength, arm and shoulder flexor muscle strength, leg muscle endurance, arm and shoulder muscle endurance, abdominal muscle endurance, speed, agility, flexibility, leg muscle power, and general endurance.2 a good physical component can be achieved through a well-rounded program in accordance to the periodization training program.3 in indonesia, football is one of the contested sports at the national sports week/pekan olahraga nasional (pon) 2012 held in province of riau. in previous pon (east kalimantan province, 2008), west java’s football athletes failed in qualification rounds. lack of physical traits is believed as the reason why the team althea medical journal. 2015;2(1) 105 could not match upin that competition. in the year 2012, there will be another pon conducted in riau. based on previous pon experiences and the relatively short periode of the team formation, the exact condition of the athletes’ physical performance should be measured in order to develop the periodization training program and to predict the athletes’ performance at pon xviii riau.3 methods a descriptive study was carried out on 23 west java’s football athletes using secondary data from komite olahraga nasional indonesia (koni)west java branch sports medicine team test reports during the period of february to december 2012. the variables in this study were 7 predominant physical components in football as follows: muscle strength using a dynamometer, muscle endurance by squats-jump tests, push-ups and situps for 60 seconds, speed with a 50-meter run tests, agility by beam side step test, flexibility by flexometer, explosive leg muscle power by vertical jump test, and general endurance (vo2 max) by astrand rhyming test. all components were categorized into insufficient, fair, good, excellent, and perfect compared to the central koni standards. results from table 1, all the athletes’ leg muscle strength, abdominal muscle indurance, speed, agility were not considered perfect. moreover, not one of the components were above 50%,which were in excellent category. only arm and shoulder endurance (56,5%), speed (68,18%), and leg muscle power (52,17%) were in good category. the most results in athletes’ leg muscle strength were in fair category. hundred percent of the abdominal endurance was in insufficient category. discussions an athlete must have a good physical condition to achieve the maximum performance.3,4 west java’s football athletes should have a maximum physical condition to obtain the gold medal at the pon xviii riau.5 the west java’s football athletes leg muscle strength measurements results show that most of the athletes are in fair category (60.87%). the maximum leg muscle strength ability is required by football athletes, especially to kick the ball optimally and increase the odds to score. however, based on the west java coach interviews results, the athletes has not achieved the maximum exercises to improve table 1 percentage of physical component ability category football athletes of west java, riau pon xviii physical component condition percentage insufficient fair good excellent perfect muscle strength: leg 17.39% 60.87% 17.39% 4.35% 0.00% arm & shoulder extensor 8.0% 39.13% 26.09% 13.04% 13.04% arm and shoulder flexor 17.39% 26.09% 34.78% 17.39% 4.35% muscle endurance: leg 0.00% 9.09% 22.73% 22.73% 45.45% arm and shoulder 0.00% 4.35% 56.52% 34.78% 4.35% abdominal 100.00% 0.00% 0.00% 0.00% 0.00% speed 4.55% 27.27% 68.18% 0.00% 0.00% agility 52.17% 43.48% 0.00% 4.35% 0.00% flexibility 0.00% 4.76% 14.29% 33.33% 47.62% leg muscle power 0.00% 13.04% 52.17% 30.44% 4.35% general endurance 17.39% 26.09% 34.78% 17.39% 4.35% army zaka anwary, ambrosius purba, tertianto prabowo: physical performance of west java soccer athletes during february to december 2012 althea medical journal. 2015;2(1) 106 amj march, 2015 muscle strength because they has not complete the strength training routine. according to the experts, muscle strength can be improved by doing a maximum of three sets of 8–12 reps weight training, and performed 2–3 times per weeks.3 in addition, the leg muscle strength, the arm and shoulder extensor muscles strength are also needed to achieve maximum performance. the arms and shoulders extensor muscle strength measurements results showed that majority athletes are in fair category (39.13%). in this case, an improvement in the arm and shoulder extensor muscles components are needed, because the arm and shoulder extensor muscles are the key to ensure the athletes’ ability to survive an opponent’s physical contact within the game. a routine muscle strength exercises will result in myofibril hypertrophy due to increased number and diameter of muscle fibers, and increased connective tissue and ligamen strength.4,6 combination of arm and shoulder extensor strength with arm and shoulder flexor muscles strength play an important role in football. the flexor muscles strength is needed to throw the ball. the arms and shoulders flexor muscle strength measurement results show that most athletes were in good category (34.78%). the arms and shoulders flexor muscle strength of the west java’s football athletes must be maintained so that they can perform optimally. the leg muscle endurance measurements results show that most of the west java’s football athletes are in the perfect category (45.45%). leg muscle endurance plays an important role in football because during the game, the leg muscles tend to contract continually either to run or to kick the ball. majority athletes reach the perfect category, although they do not made centralized training. besides of leg muscle endurance, the arm and shoulder muscle endurance are other components of the physical condition that are necessary for the maximum the football performance. the arm and shoulder muscle endurance measurements results of show that the majority athletes are in good category (56.52%) and no athletes are included in the insufficient category. this is consistent with field observations that west java’s football athletes have conducted programs to improve arm and shoulder muscle endurance corresponding to the periodization training program. the athletes’ abdominal muscle endurance need to be improved, because based on the measurement results, the west java’s football athletes’ abdominal muscle endurance are all in insufficient category (100.00%). to achieve an optimum performance, the abdominal muscular endurance component needs to be improved, because the abdominal muscles along with the leg, arm and shoulder muscles functione as the body balancer during dribbling movement, kicking, running, and other moves related to match training. according to expert opinions, muscular endurance can be increased by up to 20–25 reps, three sets of weight training, 2–3 times per weeks.3 the west java’s football athletes’ speed measurements results showed that most athletes are in good category (68.18%). there are not a single athlete reaches the perfect category, and it is because during the exercise, the athletes do not accelerate their running speed. so the athletes do not speed up their running capabilities. since the speed plays an important role in a football game, this component is needed to be improved. speed is needed as the ability to pursuit a ball or to run fast avoiding the opposing team defense. speed capability can be improved by running as far as 40–60 m with increasing acceleration.3,7 the west java’s football athletes’ agility measurement results showed that most athletes are in insufficient category (52.17%). agility is one of the physical abilities components required by football athletes to perform various techniques with agile. however, the results showed that the athletes’ agility is still in the insufficient category. this is consistent with field observations that training for agility is still well organized because the training is more focused on improving teamwork and tactics. according to experts, the agility can be improved with exercise the zigzag run, squatthrust, or steeplechase run.3,8 the flexibility measurements results showed that the majority of west java’s football athletes are in the perfect category (47.62%). the athletes’ flexibility ability reach the optimum condition because of their regular flexibility exercises. this condition should be maintained with regular flexibility exercises, because if not, the flexibility can be reduced and cause the decrease of athletes’ speed and agility.3,8 with good flexibility skills, athletes can enhance the movement ability so they can play football in the field with agile. flexibility can be maintained by practicing routine stretching.7,8 according to experts, stretching exercises that can increase the joint space to its maximum is a passive stretching or pnf (proprioceptive neuromuscular facilitation).3 althea medical journal. 2015;2(1) 107army zaka anwary, ambrosius purba, tertianto prabowo: physical performance of west java soccer athletes during february to december 2012 the leg muscle power measurements results showed that most west java’s football athletes are in good category (52.17%). the results showed good category and none are in insufficient category because of their proper and regular leg exercises. even so, the athletes’ leg muscle power still needs to be improved so that performance can be achieved more leverage. in order to increase the muscles power, a weight training with low to sub maximum intensity can be conducted under strict observation to strength and speed components.3,7 the combination of vertical jump exercises (pylometric exercises) accompanied by low-intensity weight training can increase the leg muscles power.3 a pylometric training goal is to improve the muscle coordination. the weight training goal is to increase the muscle power itself. the west java’s football athletes’ general endurance (vo2 max) measurements results showed that the athletes are in good category (34.78%). even so, there are still some athletes who are in the insufficient category, because they are not doing a regular aerobic exercise. if a football athlete is lack of general endurance ability, he cannot maintain his best performance during 90 minutes match. with increasing the aerobic workout, will result the increase of blood pumping capability of the heart, so that oxygen-rich blood supply to the muscles will also increase and the athletes will be able to exercise longer without excessive fatigue.9,10 according to experts, exercises to improve general endurance are by doing aerobic exercise. aerobic exercises that can increase general endurance are jogging, running, bike, and swimming. exercises can be done as much as 3–5 times a week, for more than an hour, with 75–85% maximum pulse intensity.3,9 the limitation of this study is there was not enough samples because of limitation of the number of football athletes that were trained to participate to pon riau. the conclusion, not all of the physical performance components are achieved perfectly by all of the football athletes. hence the description above, it is expected that west java’s football athletes of xviii pon riau can further enhance their athletes’ general endurance so that they all can achieve a better category for achieving the maximum results. references 1. orejan j. football/soccer: history and tactics.north carolina: mcfarland;2011. 2. tim sports medicine. prosedur dan instrumen evaluasi fungsional atlet, standar koni pusat. jakarta: koni; 2011. 3. bompa to, haff g. periodization: theory and methodology of training. 5thed. champaign: human kinetics; 2009. 4. american college of sports medicine. acsm’s guidelines for exercise testing and prescription. 7th ed. baltimore: lippincott, williams & wilkins; 2006. 5. komite olahraga nasional indonesiabidang sport science dan penerapan iptek olahraga. pemahaman dasar sport science & penerapan iptek olahraga. jakarta: koni; 2012. 6. giriwijoyo ys, editor. ilmu faal olahraga. 7th ed. bandung: rosda;2007. 7. mcardle wd. energi nutrition and human performance. baltimore. maryland: lipincott williams & wilkins; 2010. 8. purba a. kardiovaskular dan faal olahraga. bandung: universitas padjadjaran;2012. 9. brooks g, fahey t, baldwin k. exercise physiology: human bioenergetics and its applications. new york: mcgraw-hill; 2005. 10. guyton ac, hall je. textbook of medical physiology, 11th ed. philadelphia: elsevier saunders; 2006. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 480 amj december, 2015 detection of dermatophyte between toes of medical students wearing and not wearing socks in universitas padjadjaran using direct microscopic examination venna magarita,1 ramlan sadeli,2 hendra gunawan3 1faculty of medicine universitas padjadjaran 2department of microbiology faculty of medicine universitas padjadjaran, 3department of dermatology and venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: dermatophytes thrive in warm, humid, and moist areas. wearing the same socks more than a day is one predisposing factor. the aim of this study is to detect the dermatophyte between the fourth and fifth toes of medical students of universitas padjadjaran, who wear and do not wear socks. methods: this was a cross-sectional descriptive study performed in microbiology laboratory of faculty of medicine universitas padjadjaran from september to october 2013. direct microscopic examination using 10% potassium hydroxide (koh) was performed on 50 medical students, 25 students who wear socks and 25 students who do not wear socks. the samples were taken from scraped skin between the fourth and fifth toes using the cellophane tape method. the sample size is obtained via stratified random sampling. results: from all participants, two students (4%) showed positive result of dermatophyte hyphae and 1 student (2%) showed positive result of dermatophyte hyphae and arthrospore. of these three students, two students wear socks and one student does not wear socks. the two students who wear socks changed their socks more than a day. conclusions: dermatophyte was detected in only a few medical students of universitas padjadjaran, who wear and do not wear socks. [amj.2015;2(4):480–4] keywords: dermatophyte, direct microscopic examination, medical students correspondence: venna magarita, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827590863 email: veena_magarita@yahoo.com introduction dermatophytosis is a superficial fungal infection involving stratum corneum of the skin, hair, or nails.1 tinea pedis is one contagious dermatophyte infection of the toe webs and soles of the feet, mostly found between the fourth and fifth toes.2,3 dermatophytosis is common infection and occurs worldwide. it is estimated that over eight million people visit their primary health care physician for tinea related symptoms each year.4 dermatophytes thrive on warm, humid, and moist areas.5 some predisposing factors of getting infected include hot and humid weather, high perspiration, wearing occlusive footwear, and wearing the same socks for more than a day. transmission of dermatophytes like trichophyton rubrum, trichophyton interdigitale and epidemophyton floccosum is usually via feet. in this site, infections are often chronic and may remain subclinical for many years.4 based on the observation, there are medical students of universitas padjadjaran who wear and do not wear socks. few of them who wear socks do not replace it at least once a day, predisposing them to get dermatophyte infection. therefore, the aim of this study is to detect the dermatophyte between the fourth and fifth toes of medical students of universitas padjadjaran who wear and do not wear socks using 10% potasium hydroxide (koh) under direct microscopic examination. methods this was a cross-sectional descriptive study conducted during september to october 2013 in microbiology laboratory, faculty of medicine, universitas padjadjaran. with a stratified random sampling, a total of 50 male and female medical students althea medical journal. 2015;2(4) 481 of universitas padjadjaran class of 2010 participated in this study; 25 students wearing socks, and the other 25 students not wearing socks. from this number, 15 of them were males and 35 females. the samples of students’ informed consent were obtained for the study. samples were obtained using cellophane tape to collect the skin samples that had already been scraped between the fourth and fifth toes. the tape was then placed onto microscope slide that had a drop of 10% koh. the slide was labeled into two; those who wore socks and those who did not wear socks, using a label pen. the microscope slides were examined under a microscope (400×). here, the hyphae (long, branching, rod-shaped filaments of uniformed width with separation lines) or arthrospore was visualized. data was presented in a table in the form of frequency and percentage. results all 25 students who wore socks used cotton socks. as for the students who did not wear socks, all 25 of them wore closed shoes. the result of the direct microscopic examination using 10% koh showed positive findings in 3 out of the total 50 students (6%). from 25 students wearing socks, 2 students were positive for dermatophyte and from 25 students who did not wear socks only 1 student was positive for dermatophyte (table 3). out of all 50 students, 2 male students were table 1 respondent characteristic characteristic wear socks do not wear socks n=25 n=25 sex male 15 0 female 10 25 age (year old) 20 0 1 21 13 10 22 6 7 23 5 5 24 0 1 25 0 0 26 0 0 27 1 1 venna magarita, ramlan sadeli, hendra gunawan: detection of dermatophyte between toes of medical students wearing and not wearing socks in universitas padjadjaran using direct microscopic examination positive for dermatophyte (4%). one male student showed positive for dermatophyte hyphae and 1 male student showed positive for dermatophyte hyphae and arthrospore. in females, only 1 participant out of 35 females table 2 routine of participants wearing socks based on the frequency of their changing socks wearing socks n=25 changing socks everyday 11 more than a day 14 table 3 percentage of dermatophyte presence presence of dermatophyte n=3 wear socks (+) 2 hyphae 1 hyphae and arthrospore 1 arthrospore 0 do not wear socks (+) 1 hyphae 1 hyphae and arthrospore 0 arthrospore 0 note: positive (+): hyphae or arthrospore is found under the microscope althea medical journal. 2015;2(4) 482 amj december, 2015 showed positive for dermatophyte hyphae. of all 50 students, one female student was positive for dematophyte (2%). both students who wore socks and were positive for dermatophyte changed their socks more than a day (table 4). discussion out of 50 students who participated in this study, only 3 students were positive for dermatophyte (6%). this might be because the sensitivity for koh is only 73.3% and the specificity is 77.7%. therefore, koh is used only for complementary diagnosis of tinea pedis. the perfect gold standard for the diagnosis of the disease are positive koh smear, positive culture, and also clinical exam showing tinea pedis.6 furthermore, during microscopic view of koh smear, textile fibers from socks may obfuscate proper discernment of dermatophyte.7 however, koh smear is a good screening test for knowing the presence of the infection.6 in this study, hyphae itself was positive in 2 participants while arthrospore was not found in any participants under direct microscopic examination. arthrospores are the asexual spores formed by the hyphae in the pathologic stage.8 occasionally, hyphae are broken up into arthrospores that are first arranged as a string of pearls and later become detached. this phenomenon can be seen regularly in hair follicles, hair shafts, and nails, but less often in stratum corneum. in addition, hyphae and spores are transparent, and thus they are hard to detect.9 based on this study, dermatophyte were positive in only one female and two males. the result of this study was similar to a study performed in 2012 discussing the comparison of dermatophytes and other agents of human dermatitis between males and females in jos, plateau state, nigeria10. the study showed that 63.3% males had positive isolation for dermatophytes compared to 56.5% females. the reason underlying males to be more prone to dermatophyte infection than females is that male skin has larger pores, has more blood supply, and has more sebaceous glands that are active. thus, males will be more prone to sweating causing more oily skin than females. additionally, there is a difference between sex hormones, which make males more prone to be infected. other than that, females are known to mount more forceful immune responses especially humor responses. in addition, the age of the onset of tinea pedis is in late childhood or young adult.4 in this study, all of the students were between the ages of 20 until 27 years old. thus, it explains why in this age group positive result can be found. out of the three students who were positive for dermatophyte, two of the students wore table 4 percentage of routine of changing socks in students who were positive for dermatophyte hyphae or arthrospore presence of dermatophyte in those wearing socks n=2 changing socks everyday 0 more than a day 2 table 5 percentage of predisposing factors present in students who were positive for dermatophyte hyphae or arthrospore predisposing factors n=3 wear socks (+) 2 male 2 wear occlusive footwear 2 damp feet 1 have a pet at home (zoophilic) 2 always in contact with soil (geophilic) 0 live in hot and humid weather 2 allergies 0 immune compromise 0 do not wear socks (+) 1 male 0 wear occlusive footwear 1 damp feet 1 have a pet at home (zoophilic) 0 always in contact with soiln(geophilic) 0 live in hot and humid weather 1 allergies 0 immune compromise 0 note : positive (+): hyphae or arthrospore is found under the microscope althea medical journal. 2015;2(4) 483venna magarita, ramlan sadeli, hendra gunawan: detection of dermatophyte between toes of medical students wearing and not wearing socks in universitas padjadjaran using direct microscopic examination socks (66.7%) (table 3). those who did not wear socks were positive in one individual (33.3%). occlusion of the feet with socks can predispose one to a dermatophyte infection.11 furthermore, socks are a way in which dermatophytes can spread.12 however, the type of socks can influence the amount of dermatophytes presence. nylon socks shows larger number of dermatophyte isolated than the cotton and wool socks. fibers of socks made from nylon and cotton are loose enough for dermatophytes to go through and thus, both are not good enough in preventing the adhesion of dermatophytes.13 however, in this study the type of socks worn by both students wearing socks and showing positive result for dermatophyte were the cotton socks. socks worn should be replaced at least once a day.14 in this study, however, the students who wear socks and who were positive for dermatophyte changed their socks more than a day. dermatophytes grows predominantly in warm and humid areas. this is because warm and damp conditions help to promote the growth of dermatophytes.15 in this study, two students have damp feet, which consist of one student wearing socks and one student not wearing socks. tinea pedis is so contagious and is transmitted via direct or indirect contact with skin lesions of the infected people or contaminated environments.14,16 based on their ecology, dermatophytes can be classified into anthropophilic. dermatophytes spread from person to person either by direct contact or via fomites, zoophilic. dermatophytes spread to humans from animals or via fomites and geophilic. dermatophytes are found in the environment and spread when in contact with soil.4 zoophilic organisms of dermatophyte are chiefly found in animals and cause marked inflammatory reactions in humans who have contact with infected cats, dogs, cattle, horses, birds or other animals.10 the students in this study spent most of their time in the faculty of medicine together and therefore are in close contact almost every weekday. however, most students here do not open and share their shoes and socks in the faculty and thus, lesser chance for a transmission event to occur. this explains why the result was only positive for dermatophyte in 3 out of 50 participants (6%). those three students might have contracted dermatophyte from anthropophilic, zoophilic or geophilic sources. there are several limitations in this study. the detection of dermatophyte was done only using direct microscopic examination and not culture because culture of dermatophyte takes a very long time.17 therefore, culture is not performed in this study. other than that, the type of shoe material worn by the students is different. wearing non-porous material can increase the moisture and temperature of the feet unlike wearing the open shoes.12,17 all the students in this study wore closed shoes, however the type of material worn is different. thus, it might influence the presence of dermatophyte. furthermore, some students might wear socks and might not wear socks alternately but they informed the researcher regarding the one most frequently worn. some students might also forget if they were using any antifungal medication or having any underlying foot disease. therefore, they were excluded in the study. in this study, it can be concluded that dermatophyte was detected in only a few medical students of universitas padjadjaran, who wore and did not wear socks. it is recommended that proper and hygiene behavior should be sought in order to reduce and eliminate the number of people infected with dermatophyte. references 1. newman wa. dorlands pocket medical dictionary. 28th ed.philadelphia: elsevier saunders; 2009. p. 232. 2. tanaka k, katoh t, irimajiri j, taniguchi h, yokozeki h. preventive effects of various types of footwear and cleaning methods on dermatophyte adhesion. j dermatol. 2006;33(8):528−36. 3. fauci a, braunwald a, kasper d, hauser s, longo d, jameson j, loscalzo j. harrison`s principle of internal medicine. 17th ed. new york: mc graw hill medical; 2008. p.1264 4. wolff k, johnson ra. fitzpatricks color atlas and synopsis of clinical dermatology. 6th ed. new york: mc graw hill medical; 2009. p. 693, 4, 700, 1114. 5. pubmed health. athlete`s foot (tinea pedis). 2013; [cited 2013 may 14] available from: http://www.ncbi.nlm.nih. gov/pubmedhealth/pmh0001878/. 6. levitt jo, levitt bh, akhavan a, yanofsky h. the sensitivity and specificity of potassium hydroxide smear and fungal culture relative to clinical assessment in the evaluation of tinea pedis: a polled analysis. dermatol res pract. 2010; 2010:764843. 7. karan a, alikhan a, feldman sr. microscopically differentiating dermatophytes from sock fibers. j am acad dermatol. 2009; 61(6):1024−7. althea medical journal. 2015;2(4) 484 amj december, 2015 8. cervantas o. dermatophytosis. the center for food security and public health,iowa state university,institude for international cooperation in animal biologics, iowa state university college of veterinary medicine; 2005. 9. andersson eb. dermatopathology. berlin: springer verlag berlin heidelberg; 2006. p. 78. 10. aleruchi c, adesoji m, louisa t, james d, samson s, emenike i.comparison of dermatophytes and other agents of human dermatitis between males and females in jos, plateau state, nigeria. afr j cln exper microbiol. 2012;13(2):84−9. 11. gordon cc, alimuddin z. manson`s tropical diseases. 22nd ed. philadelphia: elsevier saunders. 2009. 12. carlo cj, macwilliams bp. tinea pedis (athlete’s foot); [cited 2013 may 13] available from: http://www.bhchp.org/ bhchp%20manual/pdf_files/part1_pdf/ tineapedis.pdf 13. watanabe k, taniguchi h, nishioka k, maruyama r, katoh t. preventive effects of various socks against adhesion of dermatophytes to healthy feet. nihon ishinkin gakkai zasshi. 2000;41(3):183−6. 14. justad j. athlete`s foot best practice guideline; 2012; [cited 2013 may 14] available from: http://www. d p h h s . m t . g ov / d s d / d d p / d o c u m e n t s / athletesfoot.pdf. 15. kumar v, tilak r, prakash p, nigam c, gupta r. tinea pedisan update. asian j medical sciences. 2011; 2(2):134−8 16. macit i, ferdi t, salih h, turker g, muhsin a. epidemiology of tinea pedis and toenail tinea ungium in worshippers in the mosques in adana, turkey. j dermatol. 2005;32(9):698−704. 17. hainer bl. dermatophyte infections. am fam physician. 2003;67(1):101−109. althea medical journal. 2016;3(2) 292 amj june 2016 antibacterial effect of pulsatilla chinensis towards staphylococcus aureus, shigella dysenteriae, and salmonella typhi sim chee fong,1 yanti mulyana,2 dolvy girawan3 1faculty of medicine universitas padjadjaran, 2department of microbiology faculty of medicine, universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, abstract background: pulsatilla (p.) chinensis is a kind of traditional chinese medicine (tcm) that has antibacterial effect. it is used to treat diarrhea, dysentery, and other diseases. the p. chinensis is composed of some potent antibacterial substances including protoanemonin, saponin, oleanolic acid. the study aimed to determine the antibacterial effect of p. chinensis towards staphlococcus aureus, shigella dysenteriae, and salmonella typhi. methods: this was an experimental descriptive study that was conducted in july 2014 using two methods, diffusion and dilution method. in diffusion method, 5 holes were made on the agar that bacteria were growing and different concentrations of p. chinensis infusion were placed in different hole. the inhibitory effect was measured by the inhibition zone. in dilution method, 8 test tubes with decreasing concentration of p. chinensis infusion were mixed with the bacteria suspension and mueller hinton solution. the minimal inhibitory concentration (mic) was measured by the last clear test tube. the test tube with solution that showed absence of bacteria on culture indicated the minimal bactericidal concentration (mbc). results: in diffusion method, p. chinensis infusion showed inhibitory effect towards s. aureus and bacteriostatic effect towards s. dysenteriae and s. typhi. in dilution method, there was no antibacterial activity detected. conclusions: p. chinensis infusion has inhibitory effect on s. aureus and bacteriostatic effect on s. dysenteriae and s. typhi. [amj.2016;3(2):292–7] keywords: antibacterial, infusion, pulsatilla chinensis, traditional chinese medicine correspondence: sim chee fong, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287726143636 email: cheefong0320@gmail.com introduction the traditional chinese medicine (tcm) remains the most common traditional medicine and some tcms have been proved to have antibacterial effect since long time ago. a study conducted in taiwan1 showed that tcm have potential to become natural antibiotic and even have synergistic effect with synthetic antibiotics. the intestinal bacteria can alter human health and many diseases development are associated with imbalance in intestinal microorganism.2 the common pathologic intestinal bacteria that are normally encountered can be staphylococcus aureus, shigella dysenteriae, and salmonella typhi. these bacteria can cause the disease such as diarrhea and dysentery. the pulsatilla chinensis is one of the tcms that have antibacterial effect on the intestinal bacteria. in tcm, it has been used to treat diarrhea, dysentery, and other diseases. the pulsatilla chinensis is composed of some potent antibacterial chemical substances including the protoanemonin, saponin, oleanolic acid, and anemonin. these chemical substances have antibacterial properties and have been proved in the previous studies.3-8 if pulsatilla chinensis proved to have antibacterial effect on pathogenic intestinal bacteria, it is not just provide a new alternative treatment for diarrhea and dysentery, but also for other intestinal infectious diseases. this study aimed to determine the antibacterial effect of p. chinensis towards staphlococcus aureus, shigella dysenteriae, and salmonella typhi. methods the research method was laboratory althea medical journal. 2016;3(2) 293 microbiology experiment and the type of study was experimental descriptive study. the study was conducted using two methods, diffusion method and dilution method. first, pulsatilla chinensis would be cut into small pieces and water-bathed with purified water. the amount of 25mg pulsatilla chinensis was boiled with 100ml of purified water to get infusion with concentration of 25%. the infusion was then mixed with purified water to get different concentrations of infusion which were 20%, 15%, and 10%. the bacteria used in the experiment included staphylococcus aureus, shigella dysenteriae, and salmonella typhi. all the bacteria used were directly taken from the microbiology laboratory of universitas padjadjaran. in dilution method, selected bacteria (staphylococcus aureus, shigella dysenteriae, and salmonella typhi) would be grown in mueller hinton agar. five holes were made on the agar and different concentrations (25%, 20%, 15%, 10%, and 0%) of pulsatilla chinensis infusion were placed in the different hole. the inhibitory effect would be measured by the zone around the holes where bacteria was not growing. in dilution method, 8 test tubes with decreasing concentration of pulsatilla chinensis infusion (6.25%, 3.125%, 1.6%, 0.8%, 0.4%, 0.2%, 0.1%, 0.05%) were mixed with the bacteria suspension and mueller hinton solution. there was one test tube that acted as the negative control which was only filled with mueller hinton solution and pulsatilla chinensis infusion. there was also another test tube that acted as the positive control which was only filled with bacteria suspension and mueller hinton solution. the minimal inhibitory concentration (mic) was measured by the last clear test tube because the clear test tube indicated that there was no bacterial growth. the solution from all test tubes was cultured on mueller hinton agar. the test tube solution with least concentration of infusion and showed no cultured bacterial growth would indicate the minimal bactericidal concentration (mbc). by using the diffusion method, the antibacterial effect was measured by the inhibition zone presented on the agar in which bacteria was growing. besides that, mic and mbc were measured to determine the minimal concentration of infusion that can inhibit and kill the bacteria. results in the diffusion method, the inhibition zone was presented in the mueller hinton agar sim chee fong, yanti mulyana, dolvy girawan: antibacterial effect of pulsatilla chinensis towards staphylococcus aureus, shigella dysenteriae, and salmonella typhi table 1 the inhibition zone produced by the pulsatilla chinensis infusion on mueller hinton agar where staphylococcus aureus was growing test diameter of inhibition zone (mm) concentration of pulsatilla chinensis infusion 0% 10% 15% 20% 25% 1st test 9.17 9.33 9.83 11.83 2nd test 9.17 9.33 10.67 12.00 3rd test 9.50 9.83 10.83 12.00 mean 9.28 9.50 10.44 11.94 note: = no inhibition zone table 2 the bacteriostatic zone produced by the pulsatilla chinensis infusion on mueller hinton agar where shigella dysenteriae was growing test diameter of bacteriostatic zone (mm) concentration of pulsatilla chinensis infusion 0% 10% 15% 20% 25% 1st test 13.83 16.33 19.16 22.67 2nd test 12.17 16.67 17.83 20.33 3rd test 12.83 16.00 18.33 19.67 mean 12.94 16.33 18.44 20.89 note: = no inhibition zone althea medical journal. 2016;3(2) 294 amj june 2016 where staphylococcus aureus was growing. for shigella dysenteriae and salmonella typhi, the inhibition zone was not detected but there was a presence of bacteriostatic zone. for mic, all the 3 bacteria tested was growing in all test tubes except 9th test tube which acted as a negative control. for mbc, the solutions of all 10 test tubes for 3 bacteria cultured. the result was there was a presence of bacterial growth in all test tube solutions except the 9th test tube of all 3 bacteria. in the diffusion test on staphylococcus aureus, pulsatilla chinensis infusion showed inhibitory effect on bacteria growth. there was visible inhibition zone on the agar and it had concentration dependence. in the diffusion test of shigella dysenteriae, there was no inhibition zone but there was bacteriostatic zone. the zone showed there was a secondary bacterial growth in which it seemed like initial bacteria that had been inhibited but was growing afterward. the bacteriostatic zone had concentration dependence. in the diffusion test of salmonella typhi, the result was the same as the one in shigella dysenteriae which there was a bacteriostatic table 4 the result of mic test on staphylococcus aureus, shigella dysenteriae, and salmonella typhi test test tube turbidity test tube for staphylococcus aureus 1st 2nd 3rd 4th 5th 6th 7th 8th negative control positive control 1st test + + + + + + + + + 2nd test + + + + + + + + + 3rd test + + + + + + + + + test tube for shigella dysenteriae 1st 2nd 3rd 4th 5th 6th 7th 8th negative control positive control 1st test + + + + + + + + + 2nd test + + + + + + + + + 3rd test + + + + + + + + + test tube for salmonella typhi 1st 2nd 3rd 4th 5th 6th 7th 8th negative control positive control 1st test + + + + + + + + + 2nd test + + + + + + + + + 3rd test + + + + + + + + + note: + = cloud solution, = clear solution table 3 the bacteriostatic zone produced by the pulsatilla chinensis infusion on mueller hinton agar where salmonella typhi was growing test diameter of bacteriostatic zone (mm) concentration of pulsatilla chinensis infusion 0% 10% 15% 20% 25% 1st test 12.17 13.33 16.17 17.17 2nd test 12.00 12.67 13.83 16.67 3rd test 11.17 13.00 14.33 17.17 mean 11.78 13.00 14.78 17.00 note: = no inhibition zone althea medical journal. 2016;3(2) 295sim chee fong, yanti mulyana, dolvy girawan: antibacterial effect of pulsatilla chinensis towards staphylococcus aureus, shigella dysenteriae, and salmonella typhi zone. the zone showed a secondary bacterial growth and had concentration dependence. in mic test of staphylococcus aureus, all the test tubes showed cloud solution which indicated that there was a bacterial growth except the test tube which acted as negative control. for the mic test of shigella dysenteriae and salmonella typhi, the result was same as the one for staphylococcus aureus. for the mbc test, the solution from all test tubes of staphylococcus aureus, shigella dysenteriae, and salmonella typhi had been cultured on mueller hinton agar. the solution from all test tubes contained bacterial growth except the test tube which acted as negative control for the three bacteria. discussion the study was conducted to test whether there is any antibacterial activity from pulsatilla chinensis infusion. the infusion was chosen because for most people, it is common to serve the pulsatilla chinensis by boiling it. extraction method in this study is more similar to the way society extracts the medicine. in the study, there was inhibition zone in staphylococcus aureus growing agar and also there was bacteriostatic zone on the agar which shigella dysenteriae and salmonella typhi were growing. the absence of inhibition in gram negative bacteria (shigella dysenteriae and salmonella typhi) may be caused by the more resistance of gram negative bacteria compared to gram positive bacteria. the gram-negative bacteria are more resistant because they are surrounded by outer membrane that contains lipopolysaccharide. this outer membrane can act as protective barrier and may exclude certain drugs and antibiotic from penetrating the cell.9 in fact, a study conducted by saeed et al.10 in 2009 showed that out of 54 gram negative bacteria obtained from various pathological laboratories and hospitals, 50 of them are resistant to one or more antibiotics. this result can show that there is high resistance in gram negative bacteria and it may be the cause that the pulsatilla chinensis infusion only inhibits gram positive bacteria but not gram negative bacteria. besides that, while testing mic and mbc, the result showed that there was no inhibitory and bactericidal activity by pulsatilla chinensis infusion towards all 3 bacteria in the study. table 5 the result of mbc test on staphylococcus aureus, shigella dysenteriae, and salmonella typhi test result of culture from test tube test tube for staphylococcus aureus 1st 2nd 3rd 4th 5th 6th 7th 8th negative control positive control 1st test + + + + + + + + + 2nd test + + + + + + + + + 3rd test + + + + + + + + + test tube for shigella dysenteriae 1st 2nd 3rd 4th 5th 6th 7th 8th negative control positive control 1st test + + + + + + + + + 2nd test + + + + + + + + + 3rd test + + + + + + + + + test tube for salmonella typhi 1st 2nd 3rd 4th 5th 6th 7th 8th negative control positive control 1st test + + + + + + + + + 2nd test + + + + + + + + + 3rd test + + + + + + + + + note: + = bacterial presence, = bacterial absence althea medical journal. 2016;3(2) 296 amj june 2016 the absence of inhibition in test tubes may be due to the low concentration of pulsatilla chinensis infusion that was used. the maximum concentration obtained during the study was 25%. in the mic test, the highest concentration of infusion was 6.25% which was very low and this could decrease the effectiveness of the infusion. the low concentration of infusion may have less chemical components that are required to kill the bacteria. besides that, in mic method, the infusion was in direct contact with the bacteria suspension and the effectiveness of inhibition may be different with inhibition of infusion in agar that bacteria were growing. besides that, the process of extracting the chemical substances from pulsatilla chinensis also led to the absence of inhibition in bacterial growth. this is because some chemical substances do not or are difficult to be extracted by water from dried pulsatilla chinensis using infusion method. certain chemical substances such as saponin need to be extracted by organic solvent such as ethanol, chloroform, or others. if using the correct extract method, the chemical substances may be extracted completely from the pulsatilla chinensis and the result can improve. other causes that led to absence of bacterial growth inhibition are the quality and quantity of chemical substances that are presented in the pulsatilla chinensis. the pulsatilla chinensis was mentioned as having chemical substances that can affect the bacteria growth such as protoanemonin, oleanolic acid, and saponin.3 the exact amount and quality of these chemical substances had not been tested by any study before this study was conducted. therefore, it is possible that the low concentrations or affected quality of these substances are presented in pulsatilla chinensis and cause no bacteria growth inhibition. another possible cause that brings about the presence of bacterial growth is the process of drying of pulsatilla chinensis. in the process of producing pulsatilla chinensis, the herb may be already contaminated by spore forming bacillus spp. or clostridium spp. the spore of these species will not die even boiled in the water. a study conducted by rice et al.11 in 2004 showed that the spores of some bacillus spp. were not inactivated even rolling boiled for 1 to 3 minutes in opened container. the spore of these bacteria may reactivate itself when environment is favorable. the activated spore may contaminate the infusion and cause the present of bacterial growth in the test tube and culture. the limitation of the study was the use of dried pulsatilla chinensis herb. more water is needed to be added while the dried herb was being boiled since it will absorb the water and causes the low concentration of infusion obtained. another limitation was that the herb used was dried and processed when brought. the use of processed dried herb causes the quality of dried herb cannot be ensured and there is a possibility of mixing of other herbs. one more limitation was that the herb cannot be found in indonesia and it has to be imported from another country. this also causes the quality cannot be ensured as well as the possibility of mixing herb presence. in conclusion, the pulsatilla chinensis infusion has inhibitory effect on staphylococcus aureus and bacteriostatic effect on shigella dysenteriae and salmonella typhi. in the study, there is no mic and mbc for staphylococcus aureus, shigella dysenteriae, and salmonella typhi since there is no inhibitory or bactericidal effect that has been observed in mic and mbc test. the recommendation for researcher referring on this study is to use the extraction method to make sure the substances in the pulsatilla chinensis are fully extracted by organic solvent. another recommendation is to conduct the study to investigate exact quantity and quality of substance presence in the pulsatilla chinensis. references 1. liu cs, cham tm, yang ch, chang hw, chen ch, chuang ly. antibacterial properties of chinese herbal medicines against nosocomial antibiotic resistant strains of pseudomonas aeruginosa in taiwan. am j chin med. 2007;35(6):1047–60. 2. chen t, xiong s, jiang s, wang m, wu q, wei h. effects of traditional chinese medicines on intestinal bacteria: a review. indian j tradit know. 2012;11(3):401–7. 3. hou j, jin y. the healing power of chinese herbs and medicinal recipes. new york: haworth integrative healing press; 2004. p. 530–1 4. bobadilla fazzini ra, skindersoe me, bielecki p, puchalka j, givskov m, martins sos santos va. protoanemonin: a natural quorum sensing inhibitor that selectively activates iron starvation response. environ microbiol. 2013;15(1):111–20. 5. arabski m, węgierek-ciuk a, czerwonka g, lankoff a, kaca w. effects of saponins against clinical e. coli strains and althea medical journal. 2016;3(2) 297 eukaryotic cell line. j biomed biotechnol. 2012;2012: 286216. 6. soetan k, oyekunle m, aiyelaagbe o, fafunso m. evaluation of the antimicrobial activity of saponins extract of sorghum bicolor l. moench. afr j biotechnol. 2006;5(23):2405–7. 7. fontanay s, grare m, mayer j, finance c, duval re. ursolic, oleanolic and betulinic acids: antibacterial spectra and selectivity indexes. j ethnopharmacol. 2008;120(2):272–6. 8. wolska k, grudniak a, fiecek b, kraczkiewicz-dowjat a, kurek a. antibacterial activity of oleanolic and ursolic acids and their derivatives. cent eur j biol. 2010;5(5):543–53. 9. silhavy t, kahne d, walker s. the bacterial cell envelope. new jersey: cold spring harbor perspectives in biology; 2010. p. 17. 10. saeed a, khatoon h, ansari fa. multidrug resistant gram-negative bacteria in clinical isolates from karachi. pak j pharm sci. 2009;22(1):44–8. 11. rice e, rose l, johnson c, boczek l, ardunio m, reasoner d. boiling and bacillus spores. emerg infect dis. 2004;10(10):1887–8. sim chee fong, yanti mulyana, dolvy girawan: antibacterial effect of pulsatilla chinensis towards staphylococcus aureus, shigella dysenteriae, and salmonella typhi althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 529 coronary risk factors and collateral circulation in acute myocardial infarction sheila sumargo,1 julius b. dewanto,2 syarief hidayat3 1faculty of medicine universitas padjadjaran, 2department of biochemistry and molecular biology faculty of medicine, universitas padjadjaran, 3department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: coronary arterial stenosis, the major cause of acute myocardial infarction (ami), induces shear stress to surrounding arteriolar endothelium. this stimulates changes in endothelial cells, smooth muscle cells and fibroblast to create collaterals that can provide alternative blood flow to the jeopardized myocardial area. however, coronary collateralization is various among ami patients. the aim of this study was to analyze the correlation between coronary risk factors and collateral sirculation in ami patients. methods: a retrospective cross-sectional study was carried out to 148 medical records of hospitalized ami patients in dr. hasan sadikin general hospital bandung, indonesia. all patients were assessed for coronary collateral circulation which were graded as good (rentrop score 2–3) and poor (rentrop score 0–1). risk factors noted in this study were age group, sex, hypertension, diabetes mellitus and diagnosis (st-segment elevation myocardial infarction (stemi) or non stemi (nstemi)) according to the medical record data. results: hypertension was found to be associated with the presence of good coronary collateral circulation (p=0.02, pr=1.410 [95% ci 1.030-1.930]). sex, age group, diabetes mellitus and stemi or nstemi diagnosis were not statistically significant. conclusions: hypertension was the only coronary risk factor associated to the presence of well-developed coronary collaterals. the increase of myocardial oxygen demand and flow of collateral feeding coronary artery in the setting of hypertension may contribute to the results. [amj.2015;2(4):529–33] keywords: acute myocardial infarction, coronary collateral, coronary risk factors correspondence: sheila sumargo, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81322230320 email: sheilasumargo@gmail.com introduction the majority of acute myocardial infarction (ami) is caused by coronary arterial occlusion which leads to the death of myocytes.1 age, sex, hypertension and diabetes mellitus are some important risk factors to the development of ami.1 the type and the nature of coronary occlusion also determine how ami develops, whether it is st−segment elevation myocardial infarction (stemi) or non stemi (nstemi).2 the presence of spontaneous coronary collaterals may be able to limit the expansion of infarction area, since they provide alternative blood flow to the threatened myocardium.3 the presence of functional coronary collaterals potentially lowers the infarct size, the development of heart failure and mortality rate after ami, thus is accountable for better prognosis.4,5,6 the development of coronary collaterals involves the arteriogenesis process, which is the arterial defense mechanism against the intermittent and gradual occlusion of the culprit artery.7 sudden arterial stenosis creates larger interarterial pressure gradient between arteries proximal and distal from it, inducing shear stress to surrounding arteriolar endothelial cells.1,8 this will stimulate arteriolar endothelial cells, smooth muscle cells and fibroblast leading to their remodeling to create larger collateral arteries that can provide alternative blood flow to the jeopardized myocardial area.9 however, the presence of coronary collateral circulation among ami patients is various and the determinants of this discrepancy remain althea medical journal. 2015;2(4) 530 amj december, 2015 controversial. this phenomenon is suspected to be the cause of the differences in ami risk factors. this study was undertaken to assess whether coronary risk factors were associated with the presence of well-developed coronary collateral vessels. methods a retrospective cross-sectional study was carried out in dr. hasan sadikin general hospital bandung indonesia from may– november 2013 using medical records of all hospitalized patients diagnosed with ami and underwent coronary angiography from january to december 2012. out of 276 medical records selected, 128 medical records were excluded since data of thepatients did not meet the inclusion criteria (history of old myocardial infarction, history of previous elective percutaneous coronary intervention (pci), history of previous coronary artery bypass graft (cabg), and missing medical record data). one hundred and forty eight medical records were enrolled to the final study population. this investigation obtained permission from the institutional ethics committee and all data regarding patients were concealed. the data of patients were classified according to the presence of visually apparent coronary collaterals in angiogram. coronary angiograms of the patients were evaluated and next, collaterals were t scored based on rentrop classification which were then further classified as good (rentrop score 2–3) and poor (rentrop score 0–1) coronary collaterals. the rentrop score description is as follow; score 0: no collaterals were visible; score 1: only side branches, but no major trunk, were visualized through collaterals; score 2: partial filling of the epicardial segment of the stenosed artery through collaterals; score 3: complete filling of the epicardial segment.10 the clinical risk factors noted from the patients were sex, age, hypertension, diabetes mellitus and diagnosis of ami (stemi and nstemi) based on the medical record data. age was then divided into two groups with the median age of patients as the cutoff point. other risk factors were not analyzed due to incomplete medical record data. all data were analyzed by using the computer based statistical product and service solutions (spss) version 20.0. furthermore, chi-square test was used to compare categorical variablesand the p-value <0.05 was considered statistically significant. table 1 baseline characteristics of study patients clinical features all patients (n=148) percentage (%) mean age (years) 58.1 age group (n) ≤58 years old 75 50.7 >58 years old 73 49.3 sex (n) male 125 84.5 female 23 15.5 hypertension yes 93 62.8 no 55 37.2 diabetes mellitus yes 38 25.7 no 110 74.3 diagnosis stemi 114 77.0 nstemi 34 23.0 althea medical journal. 2015;2(4) 531sheila sumargo, julius b. dewanto, syarief hidayat : coronary risk factors and collateral circulation in acute myocardial infarction results from 148 patients, there were more patients diagnosed with stemi than nstemi (table 1). table 2 shows that the study population was divided into 2 groups based on the coronary collateralization and there were more patients with good coronary collateral vessels (59.5%). among the 148 study patients, there were more male than female. there were more patients in the ≤58 years age group than in the >58 years age group. over 60% patients were hypertensive, while only a quarter of study patients were found to have diabetes mellitus. table 3 shows that hypertension was significantly associated with the presence of better coronary collaterals (p=0.020, pr=1.410 [95% ci 1.030-1.930]), however not for the younger age (p=0.124), male sex (p=0.541) and diabetes mellitus (p=0.192). there were more patients with welldeveloped collaterals among stemi patients (n=65) and so were among nstemi (n=23) patients (table 2). however, there was no significant relationship between the presence of good coronary collaterals and the incidence of stemi or nstemi (p=0.551) (table 3). table 2 coronary collaterals among study patients clinical features good collaterals poor collaterals (n=88) percentage (%) (n=60) percentage (%) mean age (years) 59.6 55.8 age group (n) ≤58 years old 40 45.5 35 58.3 >58 years old 48 54.5 25 41.7 sex (n) male 73 83.0 52 86.7 female 15 17.0 8 13.3 hypertension yes 62 70.5 31 51.7 no 26 29.5 29 48.3 diabetes mellitus yes 26 29.5 12 20.0 no 62 70.5 48 80.0 diagnosis stemi 65 73.9 49 81.7 nstemi 23 26.1 11 18.3 table 3 analysis of coronary collaterals based on clinical features clinical features p-value pr 95% ci min max ≤ 58 years old 0.124 0.779 0.570 1.066 male 0.541 0.895 0.642 1.249 hypertension 0.020 1.410 1.030 1.930 diabetes mellitus 0.891 1.214 0.925 1.593 stemi 0.268 0.843 0.636 1.117 althea medical journal. 2015;2(4) 532 amj december, 2015 discussions the study revealed that there was a significant relationship between hypertension and good collateralization. age group, sex and diabetes mellitus were not associated with coronary collaterals development. a previous study corresponded with this finding.11 however, some studies pointed that a younger age, male sex and the absence of diabetes mellitus contributed to the development of better coronary collateral vessels.12,13,14 additionally, age related endothelial dysfunction may contribute to the development of poor collaterals.12 while the ability of monocyte migration towards growth factor stimulation in diabetes mellitus was impaired, which contributes to poor collateralization in diabetic individuals.14 there is also no significant difference in collateralization between stemi and nstemi patients, as described in a previous study by majumder et al.15 thus the differences between the nature of coronary collaterals and pathophysiological process involving stemi and nstemi may contribute to the result. this study found that hypertension was associated to the development of better coronary collaterals (p=0.020, pr=1.410 [95% ci 1.030-1.930]). this finding was in accordance with a previous study.16 the pathophysiology of hypertension involves the increase of heart rate and peripheral resistance, which leads to the augmentation of the cardiac workload and myocardial oxygen consumption.1 chronic myocardial oxygen supply and demand imbalance contributes to the development of better coronary collateral circulation by increasing the expression of cytokine and growth factors needed to expand the coronary collaterals locally.17 a previous study by meisel et al.16 stated that the systemic blood pressure determines the flow in the feeding coronary arteries supply collateral circulation which generates the pressure distal to occlusion. thus, excessive lowering blood pressure in the setting of ami may decrease the collateral flow and aggravate myocardial ischemia.16 this explained how hypertension can contribute to the development of better collateralization. contrary to a previous study by koerselman et al.18 which showed that hypertension is associated with poorer coronary collateralization. it showed that hypertension causes arteriolar remodeling which may lead to the obliteration of naturally occurred collateral arterioles.19,20 nevertheless, certain limitations should be considered as history of risk factors treatments was not considered in this study. furthermore, other variables such as other ami risk factors (lipid profile, obesity or smoking), and their treatments as well as the degree of coronary occlusion, which might actually give better association with the development of collaterals, were not analyzed in the current study. the limited number of patients may also contribute to the study results. this study showed that among coronary risk factors analyzed there is a significant association between hypertension and better coronary collateralization in the setting of ami patients. the increase of myocardial oxygen demand and flow of the feeding coronary arteries supply collateral circulation in the setting of hypertensive state may contribute to the results. references 1. bonow ro, mann dl, zipes dp, libby p, braunwald e, editors. braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. philadelphia: saunders elsevier; 2012. 2. daga lc, kaul u, mansoor a. approach to stemi and nstemi. j assoc physicians india. 2011;59 suppl:19−25. 3. ng s. coronary collaterals: occurrence and functions [thesis]. utrecht: utrecht university; 2012. 4. plein s, younger jf, sparrow p, ridgway jp, ball sg, greenwood jp. cardiovascular magnetic resonance of scar and ischemia burden early after acute st elevation and non-st elevation myocardial infarction. j cardiovasc magn reson. 2008;10:47. 5. steg pg, kerner a, mancini gbj, reynolds hr, carvalho ac, fridrich v, et al. impact of collateral flow to the occluded infarctrelated artery on clinical outcomes in patients with recent myocardial infarction: a report from the randomized occluded artery trial. circulation. 2010;121(25): 2724−30. 6. meier p, hemingway h, lansky aj, knapp g, pitt b, seiler c. the impact of the coronary collateral circulation on mortality: a metaanalysis. eur heart j. 2011;33(5):614−21. 7. hershey jc, baskin ep, glass jd, hartman ha, gilberto db, rogers it, et al. revascularization in the rabbit hindlimb: dissociation between capillary sprouting and arteriogenesis. cardiovasc res. 2001; 49(3):618−25. 8. heil m, schaper w. influence of mechanical, althea medical journal. 2015;2(4) 533 cellular, and molecular factors on collateral artery growth (arteriogenesis). circ res. 2004;95(5):449−58. 9. seiler c. the human coronary collateral circulation. eur j clin invest. 2010;40(5): 465−76. 10. tanboga ih, topcu s, nacar t, aksakal e, kalkan k, kiki i, et al. relation of coronary collateral circulation with red cell distribution width in patients with non-st elevation myocardial infarction. clin appl thromb hemost. 2014;20(4):411−5. 11. nathoe hm, koerselman j, buskens e, van dijk d, stella pr, plokker thw, et al. determinants and prognostic significance of collaterals in patients undergoing coronary revascularization. am j cardiol. 2006;98(1):31−5. 12. kurotobi t, sato h, kinjo k, nakatani d, mizuno h, shimizu m, et al. reduced collateral circulation to the infarct-related artery in elderly patients with acute myocardial infarction. j am coll cardiol. 2004;44(1):28−34. 13. zorkun c, akkaya e, zorlu a, tandogan i. determinants of coronary collateral circulation in patients with coronary artery disease. anadolu kardiyol derg. 2013;13(2):146−51. 14. waltenberger j. impaired collateral vessel development in diabetes: potential cellular mechanisms and therapeutic implications. cardiovasc res. 2001;49(3):554−60. 15. majumder a, karim m, rahman m, uddin m. study of association of creactive protein with coronary collateral development. cardiovasc j. 2010;3(1):26−32. 16. meisel sr, frimerman a, blondheim ds, shotan a, asif a, shani j, et al. relation of the systemic blood pressure to the collateral pressure distal to an infarctrelated coronary artery occlusion during acute myocardial infarction. am j cardiol. 2013;111(3):319−23. 17. schirmer sh, van royen n, moerland pd, fledderus jo, henriques jp, van der schaaf rj, et al. local cytokine concentrations and oxygen pressure are related to maturation of the collateral circulation in humans. j am coll cardiol. 2009;53(23):2141−7. 18. koerselman j, jaegere pptd, verhaar mc, graaf yvd, grobbee de. high blood pressure is inversely related with the presence and extent of coronary collaterals. j hum hypertens. 2005;19(10):809−17. 19. humphrey jd. mechanisms of arterial remodeling in hypertension: coupled roles of wall shear and intramural stress. hypertension. 2008;52(2):195−200. 20. de marchi sf, gloekler s, meier p, traupe t, steck h, cook s, et al. determinants of preformed collateral vessels in the human heart without coronary artery disease. cardiology. 2011;118(3):198−206. sheila sumargo, julius b. dewanto, syarief hidayat : coronary risk factors and collateral circulation in acute myocardial infarction althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 615 factors influencing the success rate of cardiopulmonary resuscitation aisyah amanda hanif,1 iwan abdul rachman,2 hendro sudjono yuwono3 1faculty of medicine universitas padjadjaran, 2department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cardiopulmonary resuscitation (cpr) is a series of actions performed on cardiac arrest patients. not all patients receiving cpr can survive. the outcome of cpr is influenced by several factors. this study was conducted to determine the success rate of cpr and the factors influencing it in dr. hasan sadikin general hospital in 2013. methods: this study was conducted by using 168 patient medical records who underwent cpr and met the inclusion criteria in the resuscitation room of dr. hasan sadikin general hospital from january to december 2013. the collected data consisted of age, gender, pre-arrest diagnosis, initial rhythm, response time and clinical outcome of cpr. the results were expressed in frequencies and percentage. the data were analyzed using the chi-square test. results: the success rate of cpr was 15.5%. the success rate was higher in patients with cardiac prearrest diagnoses (8.33%, p=0.024). the most common initial rhythm was unshockable rhythms (83.92%), yet patients with shockable heart rhythms had higher success rates (40.74%, p<0.001). all of the surviving patients had response time within the first minute from cardiac arrest. conclusions: success rate of cpr in the resuscitation room of dr. hasan sadikin general hospital during 2013 is still low. the factors influencing the survival rate are the pre-arrest diagnosis and initial heart rhythm. [amj.2015;2(4):615–9] keywords: cardiopulmonary resuscitation, influencing factors, success rate correspondence: aisyah amanda hanif, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81312371875 email: aisyahahs@gmail.com introduction cardiac arrest is a condition in which there is an abrupt cessation of cardiac mechanical function. this condition may be reversible with a prompt intervention, and may cause death if the intervention is not delivered.1cardiac arrest is managed using basic life supports which consists of activation of emergency response system, cardiopulmonary resuscitation (cpr) and defibrillation with an automated external defibrillator (aed).2 in a hospital setting, advanced cardiac life support is used. the goal of cpr is to maintain the viability of vital organs until a definitive intervention can be done. to achieve this goal, resuscitation is done in a series of steps, those are, chest compressions, airway maintenance, and giving rescue breaths or ventilations.2 however, chest compression only produces below 30% of the normal blood flow.3 this is one of the reasons why cpr does not always yield a positive outcome. studies in turkey4 and iran5 reported that 13.4% and 12% patients survived until discharge. another study conducted in turkey and iran had an immediate survival of 49.3% and 19.9%.5,6 several factors are contributed to the outcome of cpr. literatures stated that the mechanism of cardiac arrest, initial rhythm after cardiac arrest, gender, clinical setting, response time, time of day during cardiac arrest, and duration of cpr are some of the few factors that influence the outcome of cpr.1,4,5,7 the aim of this study was to determine the factors influencing the success rate of cardiopulmonary resuscitation in dr. hasan sadikin general hospital during 2013. methods this analytical observational study was althea medical journal. 2015;2(4) 616 amj december, 2015 conducted by obtaining data from resuscitation reports and medical records of patients receiving cpr in the resuscitation room of dr. hasan sadikin general hospital from january to december 2013. this study was approved by the ethical clearance committee and data collection started from august to october 2014. the inclusion criteria were patients receiving cpr in the resuscitation room of dr. hasan sadikin general hospital in 2013, listed in the resuscitation report, and has a medical record containing the variables of interest. patients with do not resuscitate (dnr) orders, refusal of family to continue cpr, patients who arrived at the resuscitation room in a death on arrival (doa) condition and patients with medical records lacking the data needed were excluded. a total of 168 medical records were enrolled in this study. the clinical outcome at the end of cpr, prearrest diagnosis, initial rhythm, and response time were collected from resuscitation reports and medical records. clinical outcome at the end of cpr was categorized into successful and unsuccessful. successful cpr was defined as the patient leaving the resuscitation room was still alive. pre-arrest diagnoses were categorized into cardiac and non-cardiac, with non-cardiac diagnoses including respiratory disease, renal disturbance, sepsis, trauma, and cancer. initial heart rhythms were defined as shockable rhythms (ventricular fibrillation (vf) or pulseless ventricular tachycardia (pvt)) and unshockable heart rhythms (asystole or pulsesless electrical activity (pea)). response time was defined as the period of time from cardiac arrest until the start of cpr. response time was categorized into below 1 minute and above 1 minute. these data were then processed using a statistics computer program. the obtained results were expressed in frequencies and percentage. the significance of influencing factors were evaluated using the chi-square test. a particular influencing factor is considered significantly if the p-value was less than 0.05. table 1 general characteristics of patients receiving cpr characteristic frequency n (%) age (years) 0–10 12 (7.1) 11–20 13 (7.7) 21–30 17 (10.1) 31–40 19 (11.3) 41–50 29 (17.3) 51–60 40 (23.8) 61–70 23 (13.7) 71–84 15 (8.9) gender male 94 (56) female 74 (44) table 2 outcome distribution of cpr outcome frequency (n) percentage (%) successful 26 15.5 unsuccessful 142 84.5 total 168 100 results the collected data from the medical records showed that the patients underwent the cardiopulmonary resuscitation were 4 days to 84 years old (most were above 40 years old). the majority of the patients (56%) were male. of the 168 patients who underwent cpr, 26 patients (15.5%) survived while 142 patients (85.5%) were died at the end of cpr. the success rate of cpr did not differ significantly among gender and between patients below and above 60 years of age (p=0.274 and p=0.568) pre-arrest diagnoses were categorized as cardiac and non-cardiac. non-cardiac includes respiratory disease, renal disturbance, sepsis, trauma, and cancer. cardiac arrests with noncardiac as the pre-arrest diagnosis were more common (65.48%). however, the success rate was higher in patients with cardiac conditions since before the cardiac arrest, 14 of 26 patients with successful cpr. chi-square test was used to obtain the p-value (p=0024), althea medical journal. 2015;2(4) 617 which indicated that the differences of success rate among the pre-arrest diagnoses were statistically significant. the most common initial rhythm was unshockable heart rhythm, asystole/pea (83.92%) followed by shockable rhythm, vf/ pvt (16.08%). the success rate was higher in patients with shockable rhythms (40.74%–11 of 27 patients) than patients with unshockable rhythms (10.63%–15 of 141 patients).the p-value was obtained using the chi-square test and indicated that the differences of success rate among the initial heart rhythms were statistically significant (p<0.001). from 159 patients who received resuscitation within the first minute after cardiac arrest, only 26 (16.35%) patients had succesful outcome. moreover, all patients who received resuscitation after one minute after cardiac arrest were died. discussion this study discovered that only 15.5% patients receiving cpr in the resuscitation room of dr. hasan sadikin general hospital. had survived. compared to the studies in turkey and iran (49.3% and 19.9%, respectively), this result showed that a lower percentage than those studies.5,8 in this study, age and gender did not influence the cpr success rate. a study in turkey5 with a cut-off age over 65 years found similar results where age did not significantly influence the immediate survival and discharge rate. previous studies reported that a decrease in cpr success rate was seen in older patients.8 however, this may be caused by the co-morbidities rather than the increasing age itself. gender did not influence the success rate and this result is similar to other studies.5 however, a study in pakistan found that male gender was a negative predictor of return of spontaneous circulation (rosc).9 the majority of pre-arrest diagnoses were in the non-cardiac group (65.47%). this is in accordance to the previous study in iran that found only 19.2% cpr was caused by cardiac disease.4 however, in this study, 14 of the 26 successful cpr happened in the cardiac as the pre-arrest diagnosis group, showing a small difference between the cardiac and noncardiac group. this result was different from the previous study in san juan that found most cpr survivors suffered cardiac arrest of primarily respiratory origin.10 another study reviewing literatures about in-hospital cardiac arrest (ihca) found that some pre-arrest conditions such as cancer, sepsis and renal aisyah amanda hanif, iwan abdul rachman, hendro sudjono yuwono: factors influencing the success rate of cardiopulmonary resuscitation table 3 factors related with successful cpr variable total patients n (%) successful n (%) unsuccessful n (%) pvalue age ≤ 60 years 130 19 (14.6) 111 (85.4) ns >60 years 38 7 (18.4) 31 (81.6) sex male 94 (56) 12 (12.76) 82 (87.23) ns female 74 (44) 14 (18.92) 60 (81.08) pre-arrest diagnosis cardiac 58 (34.52) 14 (24.14) 44 (75.86) 0.024 non-cardiac 110 (65.48) 12 (10.9) 98 (89.1) initial heart rhythm shockable (vf/pvt) 27 (16.1) 11 (40.74) 16 (59.26) <0.001 unshockable (asystole/pea) 141 (83.9) 15 (10.64) 126 (89.36) response time <1 minute 159 (94.6) 26 (16.35) 133 (83.65) ns ≥ 1 minute 9 (5.4) 0 9 (100) note: vf = ventricular fibrilation, pvt = pulseless ventricular tachychardia, pea = pulsesless electrical activity, ns = not significant althea medical journal. 2015;2(4) 618 amj december, 2015 failure were correlated with lower survival.8 a meta-analysis about predictors of failure to survive after cpr found that cardiovascular diagnoses and co-morbidities (arrhythmia, admission for cardiovascular disease and hypertension) were associated with a higher chance of survival.11 the most common initial rhythm was unshockable heart rhythms, asystole/pea (83.92%) followed by shockable rhythms, vf/pvt (16.08%). the success rate was higher in patients with shockable rhythms (40.74%–11 of 27 patients) than in patients with unshockable rhythms (10.63%–15 of 141 patients). previous studies had similar results where the majority of cases had an initial rhythm of asystole/pea but the success rate itself was higher in vf/pvt.8-10,12 response time was categorized into below and above 1 minute. all 26 patients with successful outcomes received cpr within the first minute after cardiac arrest. all of patients received cpr after 1 minute died. however, the p-value was >0.05, showing that the response time did not significantly influence the success rate in this study. study conducted in thailand and other countries found that survival to discharge after cardiac arrest was significantly higher when cpr was given within the first minute after collapse.8,13 limitation of this study is that many medical records lacked the data needed causing a great number of cases being excluded. a better reporting system is required so that further studies can be done to determine other factors influencing the success rate in dr. hasan sadikin general hospital and discover a way to increase the number of patients surviving cpr. the conclusion of this study is the success rate in resuscitation room of dr. hasan sadikin general hospital during 2013 is still low (15.5%). the factors influencing the success rate of cpr in the resuscitation room of dr. hasan sadikin general hospital are the prearrest diagnosis and the initial heart rhythm. references 1. myerburg rj, castellanos a. cardiac arrest and sudden cardiac death. braunwald’s heart disease, a textbook of cardiovascular medicine. 9th ed. philadelphia: saunders; 2012. p. 845–72. 2. berg ra, hemphill r, abella bs, aufderheide tp, cave dm, hazinski mf, et al. part 5: adult basic life support: 2010 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. circulation. 2010;122(18 suppl 3):s685– s705. 3. kern kb. pathophysiology of cardiac arrest. the textbook of emergency cardiovascular care and cpr. philadelphia: lippincott williams & wilkins; 2009. p. 149–156. 4. saghafinia m, motamedi mhk, piryaie m, rafati h, saghafi a, jalali a, et al. survival after in-hospital cardiopulmonary resuscitation in a major referral center. saudi j anaesth. 2010;4(2):68–71. 5. pembeci k, yildirim a, turan e, buget m, camci e, senturk m, et al. assessment of the success of cardiopulmonary resuscitation attempts performed in a turkish university hospital. resuscitation. 2006;68(2):221–9. 6. hajbaghery ma, mousavi g, akbari h. factors influencing survival after inhospital cardiopulmonary resuscitation. resuscitation. 2005;66(3):317–21. 7. travers ah, rea td, bobrow bj, edelson dp, berg ra, sayre mr, et al. part 4: cpr overview: 2010 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. circulation. 2010;122(18 suppl 3):s676– 84. 8. sandroni c, nolan j, cavallaro f, antonelli m. in-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. intensive care med. 2007;33(2):237–45. 9. rehmani r, baqir m, amanullah s. return of spontaneous circulation and survival at hospital discharge in patients with outof-hospital and emergency department cardiac arrests in a tertiary care centre. j pak med assoc. 2007:278–81. 10. santos-llanos g, latalladi-ortega g, galera-santiago ã, torres-palacios a, rodriguez-cintron w. predictors of survival in resuscitation. crit care & shock. 2008;11:54–60. 11. ebell mh, afonso am. pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a metaanalysis. fam pract. 2011:505–15. 12. kaleja a, mikijanska d, vanags i. results of cardiopulmonary resuscitation during in-hospital cardiac arrest. acta chir latv. 2011;11(1):84–8. 13. siriphuwanun v, punjasawadwong y, lapisatepun w, charuluxananan althea medical journal. 2015;2(4) 619 s, uerpairojkit k, patumanond j. the initial success rate of cardiopulmonary resuscitation and its associated factors in patients with cardiac arrest within 24 hours after anesthesia for an emergency surgery. risk manag healthc policy. 2014; 7:65–71. aisyah amanda hanif, iwan abdul rachman, hendro sudjono yuwono: factors influencing the success rate of cardiopulmonary resuscitation althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 561 distribution of cartilage neoplasm based on histopathological types at dr. hasan sadikin general hospital bandung period 2008–2012 desy anggraini,1 anglita yantisetiasti,2 darmadji ismono3 1faculty of medicine, universitas padjadjaran, 2department of anatomical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung,, 3department of surgery, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cartilage neoplasms are less common compared to other neoplasms. its incidence is 22% among all the musculoskeletal neoplasms. despite many other studies about patient characteristics of the neoplasm in other regions, descriptive data in bandung city is still unknown. the objective of this study is to determine the distribution of both benign and malignant neoplasms based on their characteristics of histopathological type, gender, age and anatomical site. methods: the subjects of this descriptive study were taken from the medical records of the patients who had been examined histopathologically in anatomical pathology department at dr. hasan sadikin general hospital bandung, indonesia within the period of 2008 to2012. the sample was obtained using total sampling technique. patients diagnosed with cartilage neoplasms were included whereas incomplete medical records were excluded. histopathological type, gender, age and anatomical site of each patients were collected and analyzed. results: seventy cartilage neoplasm cases were found. the distribution of cases comprised of 48 (67%) benign and 23 (33%) malignant. the most common benign neoplasm was osteochondroma and chondroma. benign neoplasms were more prevalent among men and patients <30 years old, while malignant neoplasm was prevalent among women and patients >60 years old. femur was the most common site for all neoplasms except for chondroma. conclusions: pthere are differences in characteristic of benign and malignant cartilage neoplasm patients. both benign and malignant cartilage neoplasms showed differences on the distribution of patient characteristics. [amj.2015;2(4):561–7] keywords: benign neoplasm, cartilage neoplasm, histopathological types, malignant neoplasm correspondence: desy anggraini, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8997131532 email: desyanggraini92@yahoo.com introduction cartilage neoplasm is a primary bone neoplasm characterized by the presence of chondrocytes within and surrounded by cartilaginous matrix.1 it accounts for about 22% of all musculoskeletal neoplasm.2 yulianti3 in 2011 reported osteochondroma as the most common benign musculoskeletal lesion and chondrosarcoma as the second most common malignant lesion after osteosarcoma among patients in dr. hasan sadikin general hospital, bandung. another research conducted by solooki et al.4 in iran in 2011, it is reported that osteochondroma and enchondroma as the most frequent benign neoplasm. both commonly affect men and patients within the age of 15–24 years old. basic epidemiology data about cartilage neoplasms in the specific regions is needed to help doctors to diagnose and manage patients earlier. it also helps other researchers to find the risk factors of this neoplasms.4 despite many other studies about these neoplasms, descriptive data about patient’s characteristic distribution in bandung, west java is still unknown. based on this background, it was prominent to conduct the study to describe the distribution and characteristic of cartilage neoplasms’s patients in dr. hasan sadikin althea medical journal. 2015;2(4) 562 amj december, 2015 general hospital, bandung, indonesia methods this descriptive study collected and analyzed data from medical records of the patients who had undergone histopathological test in anatomical pathology department of dr. hasan sadikin general hospital, bandung, west java, indonesia from january 2008–december 2012. samples were selected by total sampling method. subject’s inclusion criteria of this study was all the medical records of patients diagnosed as cartilage-forming neoplasms. incomplete medical record was excluded from this study. histopathological type, gender, age and anatomical site of 70 patient’s medical records were collected and analyzed. based on pathological medical records, cartilageforming neoplasms were classified as benign and malignant according to world health organization (who) 2002 classification. benign neoplasms were osteochondroma, chondroma, chondroblastoma, and chondromyxoid fibroma. malignant neoplasm was chondrosarcoma. secondary data were gathered from each subject, which would then be organized and analyzed using descriptive statistical analysis. frequency and percentage of each variable were calculated. the ethical approval to conduct this study was obtained from health research ethics committee of the faculty of medicine, universitas padjadjaran. table 1 distribution of benign and malignant cartilage-forming neoplasm based on histhopathological type and gender histopathological types frequency (%) gender male (%) female (%) benign osteochondroma 36 (51) 21 (58) 15 (42) chondroma 10 (14) 5 (50) 5 (50) chondroblastoma 0 (0) 0 (0) 0 (0) chondromyxoid fibroma 1 (1) 1 (100) 0 (0) total benign cases 47 (67) malignant chondrosarcoma 23 (33) 10 (43) 13 (57) total malignant cases 23 (33) table 2 distribution of benign and malignant cartilage-forming neoplasm based on histopathological type and age histopathological types age 0–9 (%) 10–19 (%) 20–29 (%) 30–39 (%) 40–49 (%) 50–59 (%) >60 (%) total benign osteochondroma 2 (6) 25 (69) 3 (8) 5 (14) 0 (0) 0 (0) 1 (3) 36 (100) chondroma 1 (10) 2 (20) 3 (30) 2 (20) 1 (10) 1 (10) 0 (0) 10 (100) chondroblastoma 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) chondromyxoid fibroma 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) malignant chondrosarcoma 0 (0) 4 (17) 2 (9) 4 (17) 3 (13) 3 (13) 7 (30) 23 (100) althea medical journal. 2015;2(4) 563 result seventy cases had been analyzed. benign neoplasms were more common than malignant neoplasm (table 1). the most common histopathological type of benign neoplasm was osteochondroma (51%) and chondroma (14%). chondroblastoma was not found in this study. osteochondroma was more prevalent among males but chondroma showed equal number between male and female. on the other hand, chondrosarcoma was more common in female than in male. osteochondroma as the most common benign neoplasm was more frequent among patients within the age of 10–19 years old, whereas chondroma was prevalent among patients within the age of 20–29 years old. therefore, both neoplasms were dominant among <30 years-old patients. however, chondrosarcoma as the malignant neoplasm was most frequent among >60 years-old patients (table 2). overall, femur was the most common sites of osteochondroma and chondrosarcoma. it was followed by humerus and tibia in osteochondroma and humerus in chondrosarcoma. meanwhile, chondroma was more frequent in humerus, digitorum manus, and sternum (table 3). there were some cases involvingmore than one bone. three cases occurred with osteochondroma of tibia-fibula and metatarsal, humerus and femur, and radius and femur. there was also a case of chondrosarcoma involving femur and radius-ulna. table 2 distribution of benign and malignant cartilage-forming neoplasm based on histopathological type and anatomical site anatomical sites histopathological types oc* c* cb* cf* cs* cranium 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) columna vertebralis 0 (0) 0 (0) 0 (0) 0 (0) 1 (4) clavicula 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) scapula 3 (8) 1 (10) 0 (0) 0 (0) 0 (0) humerus 5 (14) 2 (20) 0 (0) 0 (0) 4 (17) radius 2 (6) 0 (0) 0 (0) 0 (0) 1 (4) ulna 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) radius-ulna 1 (3) 0 (0) 0 (0) 0 (0) 0 (0) carpal 0 (0) 0 (0) 0 (0) 0 (0) 1 (4) metacarpal 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) digitorum 0 (0) 2 (20) 0 (0) 0 (0) 0 (0) costae 1 (3) 1 (10) 0 (0) 0 (0) 2 (9) pelvis 0 (0) 0 (0) 0 (0) 0 (0) 1 (4) femur 13 (36) 0 (0) 0 (0) 0 (0) 6 (26) patella 0 (0) 0 (0) 0 (0) 0 (0) 2 (9) tibia 5 (14) 1 (10) 0 (0) 0 (0) 2 (9) fibula 2 (6) 0 (0) 0 (0) 0 (0) 1 (4) tibia-fibula 3 (8) 0 (0) 0 (0) 1 (100) 1 (4) tarsal 1 (3) 0 (0) 0 (0) 0 (0) 1 (4) metatarsal 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) digitorum 0 (0) 1 (10) 0 (0) 0 (0) 0 (0) total (%) 36 (100) 10 (100) 0 (0) 1 (100) 23 (100) * note: oc = osteochondroma, c = chondroma, cb = chondroblastoma, cf = chondromyxoid fibroma, cs = chondrosarcoma desy anggraini, anglita yantisetiasti, darmadji ismono: distribution of cartilage neoplasm based on histopathological types at dr. hasan sadikin general hospital bandung period 2008–2012 althea medical journal. 2015;2(4) 564 amj december, 2015 discussion general distribution of cartilage neoplasm based on histopathological type on this study’s result showed that benign neoplasms (68%) were more frequent than malignant neoplasm (32%). among all benign neoplasms, osteochondroma and chondroma were the most common types. this result was similar to those reported by yulianti3 in 2011 in dr hasan sadikin general hospital, bandung reporting that osteochondroma as the most common benign cartilage neoplasm accounted for 23.3% among other benign bone lesion. other study conducted by norahmawati5 in 2009 in malang, east java, also reported that osteochondroma and chondroma as the most common benign cartilage neoplasms can be diagnosed by fine needle aspiration biopsy technique. figure 1 microscopic appearance of osteochondroma from left distal femur (objective 10x) figure 2 microscopic appearances of chondroma (objective 2x and 10x) althea medical journal. 2015;2(4) 565 gender-specific incidence of cartilage neoplasm of this study showed that osteochondroma commonly affected male. this results similar to the study conducted by solooki et al.4 in 2011 in iran. they reported that 62.5% patients were men. the same number cases in male and female was shown by chondroma in this study and other study. who in 2002 stated that both gender are equally affected.6 males were more frequent to be affected by cartilage neoplasm because chondrocyte growth was influenced naturally by testosterone hormone.7 while osteochondroma occurred more commonly in males, chondrosarcoma showed different results. it was more commonly in females than males. this result was not similar to other study’s results. ocampo et al.8 in mexico 2009 reported chondrosarcoma was dominant in male. eyre et al.9 in northern england in 2010 also stated that chondrosarcoma was higher among males than females. oemiati10 in 2011 stated that tumours or cancers in indonesia were two times more frequent in females than males. these results are reffered to the data of indonesian population proportion based on gender from badan pusat statistik in 2007. the data showed that male and female proportion were almost equal in number.10 indonesia health data released by indonesia health ministry in 2011 reported that males was only accounted in 1.04 greater than females.11 beside that, tumours or cancers were reported more frequent in females due to the probability that females had more attentions to her health than males had.10 age-specific incidence among benign and malignant cartilage neoplasms of this study showed that osteochondroma was prevalent among the patient within the age of 10–19 years old (69%). this result is similar to the study conducted by solooki et al.4 in iran in 2011. they reported that osteochondroma was prevalent among patients within the age of 5–24 years old. lopez et al.12 in cuba in 2005 also reported that osteochondroma as the most commonly occurred cartilage neoplasm within the 11–15 years age group. chondroma as the second most common benign cartilage neoplasm, in this study, showed the peak incidence in the patients age of 20–29 years old (30%). despite its peak incidence, this neoplasm had stable incidence in the age of 10–39 years old. this result is similar to the reference reporting that chondroma commonly affects the patients within the age of 20–40 years old.2 while benign neoplasms commonly affected <30 years old patients, chondrosarcoma had a peak incidence in >60 years old patients. ocampo et al.8 in mexico in 2009 also reported that chondrosarcoma was more prevalent in patients older than 60 years old. who in 2002 also stated that the incidence of chondrosarcoma would increase as the age of the patients increase.6 these age-specific distribution differences between benign and malignant neoplasms could be explained by their pathogenesis. both osteochondroma and chondroma were figure 3 microscopic appearances of anaplastic chondrocytes within a chondrosarcoma (objective 10x) desy anggraini, anglita yantisetiasti, darmadji ismono: distribution of cartilage neoplasm based on histopathological types at dr. hasan sadikin general hospital bandung period 2008–2012 althea medical journal. 2015;2(4) 566 amj december, 2015 formed by abnormal growth of highly active bone structure in children. the patients may not become aware of the lesion until reaching their adolescence or early adult life.13 chondrosarcoma as the malignant one had older age as one of the risk factors because older people had undergone some somatic mutation and decreased immune response to prevent malignancy development.2 distribution of cartilage neoplasm based on anatomical sites in this study showed that most common sites of osteochondroma were femur, humerus, and tibia. this result was similar to the study conducted by solooki et al.4 in iran in 2011 statingthat femur, tibia, and humerus were the most common sites. osteochondroma was formed by abnormality of growth direction and remodeling in metaphyseal region, the most actively growing end of long bones.13 in this study, the second most frequent benign neoplasm was chondroma, and more commonly was formed in humerus, digitorum manus, and sternum. who in 2002 reported that chondroma most commonly affected digitorum manus and pedis, then long bones such as humerus and femur, but rarely in flat bones like pelvis, vertebrae, and sternum.7 chondroma is developed by growth abnormality of cartilaginous cells in epiphyseal plate in short bones during childhood. its pathogenesis explained that the tendency of chondroma to be developed was on small bones.13 in this study, chondrosarcoma most commonly affected femur and humerus. according to who, primary chondrosarcoma affected ileum, humerus, femur, and costae as the most common sites.6 qureshi et al.14 in pakistan in 2010 also reported that pelvis, femur, costae, and skull as the most common sites. the patient’s characteristic distributions shown by this study could not represent the real population because this study was done only in a general hospital. there were also the probabilitiesunder the diagnosed patients because not all patients in dr. hasan sadikin general hospital bandung underwent histopathological test. the conclusion of this study was both benign and malignant cartilage-forming neoplasms had different characteristical distributions. study showed that benign neoplasms were two times more than malignant neoplasm. among all the benign neoplasms, osteochondroma and chondroma were the most common types. patient’s characteristics showed that all benign neoplasms except chondroma commonly affected males, while chondroma showed the same ratio between males and females. chondrosarcoma commonly affected females in this study. benign neoplasms were more prevalent among <30 years old patients, while chondrosarcoma was prevalent among >60 years old patients. all neoplasms had femur as the most common anatomical site, except for chondroma that was dominant in humerus, digitorum manus and sternum. from this study, it can be suggested to study larger population and another point of study such as revealing the risk factor of cartilage neoplasm to be done in the further study. larger population was needed to obtain more accurate data. references 1. higuchi t, taki j, sumiya h, kinuya s, nakajima k, namura m, et al. characterization of cartilaginous tumors with 201tl scintigraphy. ann nucl med. 2005;19(2):95–9. 2. robbins sl, kumar v, abbas ak, cotran rs. robbins and cotran pathologicbasis of disease. 8th ed. philadelphia: saunders/ elseiver; 2010. p. 273, 1227–30. 3. yulianti ls. epidemiologi tumor muskuloskeletal di rumah sakit hasan sadikin bandung periode januari 2010– maret 2011. proceedings of the 58th continuing orthopaedic education conference; 2011 june 16–18; pekanbaru. bandung: universitas padjadjaran; 2011. 4. solooki s, vosoughi ar, masoomi v. epidemiology of musculoskeletal tumors in shiraz, south of iran. indian j med paediatr oncol. 2011;32(4):187–91. 5. norahmawati e. fine-needle aspiration biopsy has important role and high accuracy as preoperative diagnostic method for bone tumors. jurnal kedokteran brawijaya. 2009; 25(2):77–82. 6. fletcher cd, unni kk, mertens f, editors. world health organization classification of tumours, pathology and genetics of tumours of soft tissue and bone. lyon, france: iarc press, international agency for research on cancer (iarc); 2002. p.233–58. 7. mescher al. basic histology text & atlas. 12th ed. singapore: mcgraw-hill companies, inc; 2010. p. 116. 8. baena-ocampo ldelc, ramirez-perez e, linares-gonzalez lm, delgado-chavez r. epidemiology of bone tumors in mexico althea medical journal. 2015;2(4) 567 city: retrospective clinicopathologic study of 566 patients at a referral institution. ann diagn pathol. 2009;13(1):16–21. 9. eyre r, feltbower rg, james pw, blakey k, mubwandarikwa e, forman d, et al. the epidemiology of bone cancer in 0–39 year olds in northern england, 1981–2002. bmc cancer. 2010;10:357. 10. oemiati r, rahajeng e, kristanto ay. prevalensi tumor dan beberapa faktor yang mempengaruhinya di indonesia. bul penelit kesehat. 2011;39(4):190–204. 11. kementerian kesehatan republik indonesia. profil data kesehatan indonesia tahun 2011. jakarta: kementerian kesehatan republik indonesia; 2012 [cited 2013 february18]. available from: http://statkes@depkes.go.id. 12. lopez aa, lorenzo yg. cartilaginous bone tumors in children: a twenty-year epidemiological report from our hospital. acta ortopedica mexicana. 2005;19(suppl 1):s47–s50. 13. salter rb. textbook of disorders and injuries of the musculoskeletal system. 3rd ed. philadelphia: lippincott williams & wilkins; 1999. p. 392–95. 14. qureshi a, ahmad z, azam m, idrees r. epidemiological data for common bone sarcomas. asian pac j cancer prev. 2010; 11:393–95 desy anggraini, anglita yantisetiasti, darmadji ismono: distribution of cartilage neoplasm based on histopathological types at dr. hasan sadikin general hospital bandung period 2008–2012 althea medical journal. 2015;2(3) 369 knowledge, attitude and practice of hand washing among street vendors in campus of universitas padjadjaran, west java from junenovember 2012 tajul al adib,1 ardini s. raksanagara,2 dewi hawani,3 elsa puji setiawati2 1faculty of medicine, universitas padjadjaran, 2department of public health, faculty of medicine universitas padjadjaran 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hand washing is a moderate step in preventing communicable diseases. communicable diseases like diarrhea and respiratory tract infection can be reduced significantly just by practicing hand washing. most of the people already knew how to wash their hand, but some of them still did not understand the objective and the correct ways of performing hand washing. the aim of the study was to evaluate knowledge, attitude and practice of hand washing among street vendors. methods: a descriptive study was conducted to 30 street vendors at the gate of universitas padjadjaran campus from june to november 2012. the inclusion criterias were street vendors involved in food preparation, cooking, mixing, and willing to participate in this study. a questionnaire was developed to identify the knowledge, attitude and practice of hand washing. the level of the variable measured was divided into 3 categories: good, moderate, and poor. the collected data were analyzed and presented in table. results: there were 12/30 of street vendors classified as having moderate knowledge and 25/30 as having good attitude and good practice of hand washing. conclusions: the street vendors at the gate of universitas padjadjaran campus had moderate knowledge, good attitude and good practice of hand washing. [amj.2015;2(3):369–74] keywords: attitude, hand washing, knowledge, practice, street vendors correspondence: tajul al adib, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281910590338, +60194076912 email: are_deep89@yahoo.com introduction global burden of disease is a study conducted by the world bank since 1992.1 the main objective of the study is to assess mortality due to disease, injury and risk factor. according to this study, four out of ten in the top 10 causes of death in the world are communicable disease.2 a communicable disease is a disease that can be transmitted from a person, animal or inanimate source to another person. the transmission can be directly, via intermediate host or by vector.3 communicable disease that uses food as the medium is known as food borne disease. food borne disease is defined as a group of diseases that can be transmitted to human by consuming food already contaminated by pathogenic microorganisms. about 31 pathogens are known as the etiology of food borne disease and norovirus, salmonella nontyphoidal, clostridium perfringens, campylobacter spp. and staphylococcus aureus are in the top 5.4 there are more than 250 food borne diseases that have been known including cholera, typhoid fever and hepatitis a and most of the diseases come with symptom of diarrhea.5 diarrhea was characterized by unformed or liquid stool with more than 3 times of defecation a day. in 2004, there were about two millions of death caused by diarrhea.6 diarrhea can be transmitted between people, by poor personal hygiene, food and water.7 however, the incidence of this disease can be reduced by practicing hand washing. a study shows that hand washing can reduce the incidence of diarrhea by 25%.8 with proper practice of hand washing, the chance of transmitting and being infected can be reduced. street vendors are defined as a vendor althea medical journal. 2015;2(3) 370 amj september, 2015 with fixed stalls, or semi-fixed stalls that sell various kinds of items. the items sold by the vendors include food, drinks, merchandise and cloths.9 as street vendors sell food, they have the possibilities of becoming agent for food borne disease. in order to reduce the incidence of food borne disease, assessment of hand washing among street vendors needs to be conducted. in this study, the levels of knowledge, attitude and practice of hand washing among street vendors at the gate of universitas padjadjaran campus were evaluated. by knowing the information regarding hand washing among street vendors, a preventive measure can be taken to reduce incidence of diarrhea. methods a cross-sectional descriptive study was conducted at a single point of time. the respondents were street vendors at the gate universitas padjadjaran campus as most of the street vendors were located at this place. there were 33 workers eligible to participate in this study with inclusion criteria involved in food preparation, cooking and mixing. many street vendors who refused to participate were excluded. the study was performed from june to november 2012. knowledge of hand washing was defined as how much information the respondents have regarding hand washing such as the procedure, the objective and the timing of hand washing. the knowledge was later classified as good if the score ranged from 12–18, moderate if the score ranged from 6–11 and poor if the score ranged from 0–5. attitude of hand washing was defined as how they reflected towards the hand washing such as when they should perform hand washing. the level of attitude was classified as good if the score ranged from 40–55, moderate if the score ranged from 30– 49 and poor if the score ranged from 11–25. practice of hand washing was defined as how well the respondents washed their hands such as whether they performed all of the hand washing procedure. same with knowledge and attitude, the practice was also classified as good if the score ranged from 50–70, moderate if the score ranged from 30–49 and poor if the figure 1 flow of study althea medical journal. 2015;2(3) 371 score ranged from 14–29. a questionnaire has been used in conducting this study. the questionnaire was validated and undergoing a reliability test prior to the study. the questionnaire consisted of three sections which were 6 questions about knowledge, 11 statements about attitude and 14 statements about practice. the respondents were given informed consent before the interview session. the data collected were recorded and analyzed by using computer. the flow of the study can be seen in figure 1. results there were 30 people who participated in the study and 3 people refused. knowledge of hand washing was assessed by measuring how much the respondents knew about hand washing. the knowledge being assessed were the purpose of hand washing, preparation, material needed, the steps of hand washing and the timing of hand washing. in this section, there were 6 questions given, and the score can be seen in table 1. as the result, there were 9 respondents classified as good, 12 respondents classified as moderate and 9 respondents classified as poor. in the attitude section, the respondent’s reactions towards hand washing were evaluated. there were 11 statements used to assess the attitude of the respondents, divided into 2 parts, before and after certain events. by using their opinion, the respondents answered the question by choosing strongly agree, agree, neutral, disagree and strongly disagree. the results of the respondents’ attitude can be seen in table 2. in the last section, how well the respondents performed hand washing was assessed. there were 14 statements asked in this section, divided into 3 parts to evaluate the practice of the respondents regarding hand washing. the respondents answered this section by the table1 score of knowledge question according to sex sex totalfemale male (n) (n) objective of hand washing 0 3 23 26 1 2 2 4 characteristics of clean water 0 4 23 27 1 1 2 3 basic material for hand washing 1 1 16 17 2 4 9 13 example of diseases can be prevented by hand washing 0 0 4 4 1 5 15 20 2 0 6 6 basic steps of hand washing 0 2 9 11 1 0 3 3 2 2 4 6 3 0 1 1 5 0 1 1 6 0 1 1 7 1 6 7 timing of hand washing (before or after certain events 1 0 4 4 2 3 5 8 3 0 8 8 4 2 8 10 tajul al adib, ardini s. raksanagara, dewi hawani, elsa puji setiawati: knowledge, attitude and practice of hand washing among street vendors in campus of universitas padjadjaran, west java from june-november 2012 althea medical journal. 2015;2(3) 372 amj september, 2015 same manner in attitude section according to their practice. the result of the practice can be seen in table 4. discussions there are possibilities that the respondents still did not understand the reason of hand washing as seen from the questions regarding objective of hand washing in table 1. there were only 4 people who gave the correct answers while the others gave incorrect answers. basically hand washing is done to avoid someone from spreading disease to other person.10running water is a one of the characteristics of clean water. however, due to lack of facilities, most of them ignored about this and only used water from a bucket. this can be seen in the questions regarding characteristics of clean water, which 27 of them answered incorrectly and only 13 respondents attained full score for questions regarding basic material for hand washing. fortunately, they still understood the table 2 score for hand washing before certain events according to sex sex totalfemale male (n) (n) preparing food disagree 0 2 2 neutral 0 1 1 agree 3 13 16 strongly agree 2 9 11 processing food strongly disagree 0 1 1 agree 2 12 14 strongly agree 3 12 15 handling cooking utensils strongly disagree 0 1 1 disagree 0 4 4 neutral 0 5 5 agree 4 11 15 strongly agree 1 4 5 before cooking strongly disagree 0 1 1 neutral 0 1 1 agree 2 15 17 strongly agree 3 8 11 processing raw food disagree 1 3 4 neutral 0 2 2 agree 3 11 14 strongly agree 1 9 10 table 3 level of attitude and practice of hand washing attitude practice n n moderate 5 5 good 25 25 total 30 30 althea medical journal. 2015;2(3) 373 importance of using soap in hand washing.10,11 according to aseptic processing workbook, there are seven steps of hand washing. start with rubbing both palms together, then back of hands with interlacing fingers, and front of hands also with interlacing fingers. continue with clasping fingers and rub the back of finger, rub around thumbs and fingertips to palm in rotating manner. last but not least, rub around the wrists.12 only 7 respondents got full score in questions regarding the basic steps of hand washing, showing that they were still confused about the basic steps of hand washing. more than half of them achieved good score in the questions regarding timing of hand washing. it showed that they were aware when they should wash their hands. as food handlers, the respondents should wash their hands after using the toilet, after sneezing or coughing, after handling garbage and after doing activities that make their hands dirty such as handling money.10, 11 from the results, it can be seen that most of the respondents had a good understanding about the indication of hand washing before certain events. referring to question regarding whether the respondents should wash their hand before handling the utensils for cooking, it has the lowest number of respondents who agreed with the statements. however, still more than half of the respondents agreed with the statements of this question. the indications for hand washing are washing hand before, during, and after preparing food, handling ready-to-eat or raw foods, touching serving utensils, before handling different foods, serving foods and eating food.10, 11 furthermore in the question regarding whether they should wash their hand after handling garbage, all of the respondents agreed with the statements proving that they had a good attitude toward hand washing. in addition, the respondents also need to wash their hand after using the toilet, after touching bare human body parts, after handling cleaning chemicals and after doing other activities that make their hands dirty.10, 11 in the practice section, not only the basic steps of hand washing were assessed, but the preparation and extra step of hand washing for food handlers were also asked. the respondents needed to remove their jewelry before performing hand washing.11 only 13 respondents agreed with this statement, showing that they did not fully understand how to practice hand washing as a food handler. there were several questions regarding basic steps of hand washing, more than half of the respondents agreed with the statements of those questions. this shows that the respondents had a good practice of basic hand washing. the basic steps of hand washing start with rubbing the palm together. then, rub back of hands with interlacing fingers and front of hands also with interlacing fingers. after that, continue with clasping fingers and rub the back of finger, rub around thumbs and fingertips to palm in rotating manner. lastly, rub around the wrists.12 in conclusion, 12/30 respondents had a moderate level of knowledge of hand washing, while the other 18 respondents were distributed evenly to good and poor level of knowledge. for attitude and practice, 25/30 respondents were categorized as having good level of hand washing. only 5 respondents had a moderate level of hand washing for both attitude and practice. compared to a previous study on hand washing by housewives, both housewives and street vendors had moderate level of knowledge and good level of attitude of hand washing. however, the housewives had poor level of practice while the street vendors had good level of practice of hand washing.13 in order to improve the street vendors’ condition, a campaign regarding hand washing for food handlers should be conducted. education regarding the importance and the right way of performing hand washing can be also included in the campaign. providing better facilities also can promote hand washing among the respondents. other than improving the respondents condition, this study can be continued by assessing the source and the cleanliness of the water used by the respondents. furthermore, the healthy behavior of the respondents other than hand washing can be also assessed for a future study. references 1. lopez ad, mathers cd, ezzati m, jamison dt, murray cjl, editors. global burden of disease and risk factor. washington (dc): a copublication of the world bank and oxford university press; 2006. 2. who. global burden of disease (gbd). world health organization (who); 2011. [cited 2012 january 5]. available from: http://www.who.int/healthinfo/global_ burden_disease/. 3. webber r. communicable disease epidemiology and control: a global perspective. oxfordshire: cabi; 2009. 4. cdc. cdc 2011 estimates fooborne illness. tajul al adib, ardini s. raksanagara, dewi hawani, elsa puji setiawati: knowledge, attitude and practice of hand washing among street vendors in campus of universitas padjadjaran, west java from june-november 2012 althea medical journal. 2015;2(3) 374 amj september, 2015 centers for disease control and prevention (cdc); 2010 [cited 2012 september 12]. available from: http://www.cdc.gov/ f o o d b o r n e b u r d e n / 2 0 1 1 f o o d b o r n e estimates.html. 5. bjorklund r. food borne illnesses. new york: marshall cavendish benchmark; 2006. 6. who. the global burden of disease 2004 update; 2008 [cited 2012 september 12]. available from: http://www.who.int/ healthinfo/global_burden_disease/gbd_ report_2004update. 7. water sanitation health (wsh). waterrelated disease. who; 2012 [cited 2012 january 5] available from: http://www. w h o . i n t / w a t e r _ s a n i t a t i o n _ h e a l t h / diseases/diarrhoea/. 8. luby sp, agboatwalla m, painter j, altaf a, billhimer wl, hoekstra rm. effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in pakistan: a randomized controlled trial. jama. 2004; 291(21):2547-54. 9. women in informal employment: globalizing and organizing (wiego). street vendors; 2012 [cited 2012 may 9]. available from: http://wiego.org/ informal-economy/occupational-groups/ street-vendors. 10. cdc. handwashing: clean hands save lifes. [cited 2012 april 30] available from: http://www.cdc.gov/handwashing/. 11. simonne a. proper hand washing for food handlers. institute of food and agricultural sciences, university of florida; 2005 [updated october 2011]; [cited 2012 may 12] available from: http://edis.ifas.ufl. edu/. 12. alison b, tim s, editors. aseptic processing workbook. leeds: university of leeds; 2010. 13. pratama ik. gambaran pengetahuan, praktik dan sikap terhadap cuci tangan dikalangan ibu rumah tangga di desa hegarmanah dan sayang [minor thesis]. bandung: universitas padjadjaran; 2012. althea medical journal. 2015;2(3) 352 amj september, 2015 barriers to smoking cessation among medical students 2012–2013 academic year in the faculty of medicine, universitas padjadjaran reni yuditha kathrine,1 elsa pudji setiawati,2 lucky saputra3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of psychiatry faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: smoking is one of leading various diseases and even death globally. it is often difficult for smokers to stop smoking, even those who work as a medical professional because there are some barriers around them. the objective of this study was to get an overview of the barriers to smoking cessation among smoker students of faculty of medicine, universitas padjadjaran. methods: a descriptive study was carried out to 62 medical students 2012–2013 academic year in the faculty of medicine, universitas padjadjaran. before the respondents were selected, a survey using questionnaire was conducted to all medical students from the same academic year to determine their smoking status. a set of questions was developed, consisted of 4 components: physical or social, psychological or emotional, accessibility, and social contextual/life circumstances barriers to smoking cessation. the collected data were analyzed and presented in the form of percentages shown in the tables and figures. results: the most frequent barriers were from physical or social barriers (friends who smoke, 85%), psychological or emotional barriers (fear of losing enjoyment, 71%), barrier to access (lack of information about the way of smoking cessation, 42%) and social contextual/life circumstances barriers (having other priorities other than to stop smoking, 71%). conclusions: there are some barriers in medical students smokers make them difficult to stop smoking although they have more knowledge about health and the impact of smoking on health than other people. [amj.2015;2(3):352–58] keywords: barriers, medical students, smoking cessation correspondence: reni yuditha kathrine, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287879464719 email: reni.kathrine@gmail.com introduction smoking is a major public health problem as cigarette consumption contributes to the incidence of various disease and even death.1-3 this does not only affect the smokers themselves, but also people around them who unintentionally inhale cigarette smoke, known as passive smokers. starting to smoke since an early age has been known having a significant effect in increasing the risk of death.4 the problems of smoking need more attention because it is a risk factor of four leading non communicable diseases in the world and a cause of death. in 2009, indonesia placed the fourth ranked of the highest cigarette consumption. the cigarette consumption in that year was 260 billion. 1 doctors play an important role to promote smoking cessation program. a little simple advice from a doctor to stop smoking and the example from himself by not smoking can be an effective tool and has a great potential to help patients to stop smoking.1 however, smoking behavior can also be seen at some doctors and it becomes a barrier in promoting smoking cessation programs for patients. not just among doctors, smoking can also be found in medical students who actually will be a doctor in the future.1,5 doctors should be free from smoking to be a role model for their patients, so that a medical student who smokes should be able to stop smoking before he/she becomes a doctor. unfortunately, to stop smoking is not easy.6,7 this is because of some barriers that could be found around smokers. these barriers of smoking cessation are generally divided into 4 groups: physical or social, psychological or emotional, barriers to access programs/services/methods to althea medical journal. 2015;2(3) 353 stop smoking and social contextual/life circumstances.8 by these barriers, it can be said that the program of smoking cessation is difficult to be successful.9 based on what has been mentioned above, the author was interested in getting an overview of the barriers to smoking cessation in student smokers in the faculty of medicine, universitas padjadjaran. by knowing the barriers, the author hoped that smokers could choose the right approach in their attempt to stop smoking. methods this study was a descriptive study with a cross-sectional approach and conducted on student smokers in the faculty of medicine, universitas padjadjaran. respondents were obtained by doing survey first by distributing questionnaires to all medical students of the faculty of medicine, universitas padjadjaran, academic year 2012/2013 to determine their smoking status. from the survey, it was found a total population of 62 active smokers and they were taken as subjects for this study after being asked about their willingness to be respondents. the respondents were then given a questionnaire that contains some questions about barriers to smoking cessation. they were asked to identify the barriers faced by them. the collected data has been processed and presented in the form of percentages shown in the tables and diagrams. results based on the sex characteristics, it was found that the male respondents (95%) were more dominant than the female. based on their residence, most of the respondents live in a boarding house/rented (76%), not with their parents. respondents were chosen from the first to fourth year college students. the most respondents are from the third (36%) and four (34%) year college students. the age of the respondents were ranged from 17 to 24 years old. age of first time smoking was divided table 1 characteristics of respondents characteristics number (n) percentage (%) sex male 59 95 female 3 5 residence house 15 24 boarding house/rented 47 76 grade of college first year 7 11 second year 12 19 third year 22 36 fourth year 21 34 age (years old) 17 1 2 18 7 11 19 11 18 20 16 26 21 15 24 22 8 13 23 1 2 24 3 5 reni yuditha kathrine, elsa pudji setiawati, lucky saputra: barriers to smoking cessation among medical students 2012–2013 academic year in the faculty of medicine, universitas padjadjaran althea medical journal. 2015;2(3) 354 amj september, 2015 into four age groups (table 2). the results of this study showed that most respondents tried cigarettes for the first time was at the age of 15–19 years (53%), whereas, only one respondent started smoking for the first time at age <10 years. based on smoking cessation trial, 89% respondents said that they have tried to stop smoking. meanwhile, 82% of respondents expressed that they want to stop smoking. the results of this study showed that the most frequent physical or social barriers to smoking cessation was friends who smoke (85%), followed by lack of friends support (47%). the most frequent barrier from psychological or emotional factors was fear of losing enjoyment (71%). other barriers were the craving for cigarettes (65%) and fear of failure in smoking cessation (53%). meanwhile, fear of gaining weight (5%) was not stated as a barrier by many respondents. figure 3 about distribution of barrier to access, shows that 42% respondents had difficulty to stop smoking because they did not know how to stop smoking, 39% respondents were not aware of any programs/ services for smoking cessation, 23% stated that the price table 2 age at first smoking, trial and want to stop smoking number (n) percentage (%) age at first smoking <10 1 2 10–14 16 26 15–19 33 53 >19 12 19 ever tried to stop smoking? yes 55 89 no 7 11 want to stop smoking? yes 51 82 no 11 18 figure 1 distribution of physical or social barriers in respondents althea medical journal. 2015;2(3) 355 of the programs/services to stop smoking was too high for them, and 26% stated that they could not take smoking cessation class/ program because of their daily schedules. based on distribution of social contextual/ life circumstances barriers, 71% respondents had other priorities than stop smoking. besides having other priorities, respondents expressed their discomfort about the environment where they live now (18%). because of their discomfort, they did not focus on smoking cessation. discussions table 1 show that the majority of respondents of this study were men (95%). the majority of men among smokers also appeared in some studies or surveys, such as in the research conducted by qidwai10 who stated that 96% of its respondents were men. riset kesehatan dasar (riskesdas)11 also noted that the majority of smokers in indonesia were men. based on their residence, most respondents (76%) staying in boarding/rented room and not with their parents, were smokers. living outside their own house was also contributed to the development of a person, especially in adolescence or young adulthood, associated with the supervision from family or parents and parental involvement in children activity. parental supervision would help children in their development so it did not lead to negative behavior such as smoking.12 figure 2 distribution of psychological or emotional barriers in respondents figure 3 distribution of barriers to access in respondents reni yuditha kathrine, elsa pudji setiawati, lucky saputra: barriers to smoking cessation among medical students 2012–2013 academic year in the faculty of medicine, universitas padjadjaran althea medical journal. 2015;2(3) 356 amj september, 2015 according to the grade of college students, there were thirty-six percent respondents of third year college students and 34% of forth year who were smokers. even though the percentage of the third and fourth year were bigger that the first year (11%) and the second year (19%), it did not show any specific pattern as shown by riskesdas surveys in 2010.11 nevertheless, there was also a study which stated that smoking cessation increased along with education level of smokers.13 this study showed that the age at which most respondents try cigarettes for the first time was at 15–19 years old, occurring in 53% respondents. riskesdas (2010) also states the ages of 15–19 years old as the age group that the majority of indonesian smokers started smoking.11 eighty-nine percent of respondents have tried to stop smoking, but unfortunately they were failed or had a relapse so that at the moment when the study was conducted, their status were still smokers. the rate of smoking cessation itself was quite low and only a small number of smokers could stop smoking on his first attempt. the world health organization (who)7 and the research conducted by paavola et al.14 figured that the rate of smoking cessation was only 2.5% per year. desire of the respondents to stop smoking was also influenced by smoking cessation trials conducted by respondents. those who had previously tried to stop smoking and experienced failure would have low confidence, afraid and lost the will to stop smoking.2,10,15 in terms of physical or social barriers, a friend who smokes and lack of friends support were expressed by respondents as barriers to smoking cessation for them. this is related to a study stating that smoking cessation occurred less in those whose friends were smokers. in that study, adolescent smokers expressed their own thought that the success of smoking cessation in young people can be improved if they had a friend who also wanted to stop smoking. the results showed that the success of smoking cessation in those whose best friend also smoked are more likely than those whose best friend was not a smoker.14 the motivation to stop smoking from friends, family, or couples who do not smoke could be a reason for a person to stop smoking.16 in terms of psychological or emotional barriers, 71% respondents expressed their pleasure for cigarettes and 65% respondents expressed their addiction to cigarettes. those reasons were barriers to smoking cessation. the enjoyment of cigarettes was obtained from substances found in cigarettes, the nicotine. this substance also had addictive properties. administration of nicotine on the body could lead to tolerance and dependence. in the tolerance, dose response decreased so that when a smoker consumes cigarettes in his usual amount of consumption, he will not feel the effects of cigarettes he had expected. to get back the effects of cigarette, smokers have to increase the number of cigarettes consumed.3 smoking can affect the levels of dopamine figure 4 distribution of social contextual/life circumstances barriers in respondents althea medical journal. 2015;2(3) 357 in someone’s body which can give a pleasant effect and also amplify the effects of acetylcholine that affects the state of mind or mood, appetite, and memory.17 these pleasant effects can make a person feel able to cope with stress or problems in the life. therefore, one of the reasons why it is hard for people to stop smoking is the fear of inability to cope with stress if they stop smoking. fear of failure in smoking cessation trial could occur in smokers, especially in those who had experienced failure in smoking cessation trial previously. in the study, it was found that the confidence of people who had tried to stop smoking and failed was lower than those who had never tried.2,10,15 another barrier was the barrier to access information (lack of information about the way of smoking cessation). of these barriers, 42% respondents expressed they did not know how to stop smoking, and 39% respondents expressed that they were not aware of any programs/services of smoking cessation. to overcome their ignorance of what they should do, there were actually existing programs/ services of smoking cessation that could help them. unfortunately not all smokers knew of these programs/services. other smokers have known that there were programs that could help them to stop smoking, but nevertheless, some still could not reach these programs both in terms of place, time, or financing. the cost for the programs or price of medicine such as nicotine replacement agents was not cheap. in another study, smokers stated they were willing to take the program if it is covered by their health insurance.2,8,15 the faculty of medicine, universitas padjadjaran itself has already implemented a non-smoking area, but unfortunately the faculty has not provided program/services to help their students to stop smoking. although there is no smoking cessation program on campus, a smoking cessation clinic has already been established at the community health center in kopo, bandung. in addition to bandung, several hospitals in jakarta also have a provided smoking cessation services.18-20 in terms of social contextual/ life circumstances barriers, 71% respondents stated that they had other priorities so that they were more concerned on those things than thinking of smoking cessation. similarly, living in an unsafe or uncomfortable environment would make smokers prioritize overcoming the discomfort instead of focusing on smoking cessation. in general, social contextual/ life circumstances barriers make smoking cessation become a low priority for smokers.8 as a conclusion, there were some barriers in medical students which made them difficult to stop smoking, although they had more knowledge about health and the impact of smoking on health than the others. therefore, the faculty is expected to help the students to stop smoking by providing information about smoking cessation and programs or services. references 1. eriksen m, mackay j, ross h. the tobacco atlas. 4th ed. atlanta: american cancer society; 2012. 2. minnesota partnership for action against tobacco (mpaat), blue cross and blue shield of minnesota (blue cross), minnesota department of health. quitting smoking: nicotine addiction in minnesota. st. paul: minnesota department of health; 2001. 3. lewis k. smoking cessation. new york city: oxford university press; 2010. 4. kenfield sa, stampfer mj, rosner ba, colditz ga. smoking and smoking cessation in relation to mortality in women. jama. 2008;299(17):2037–47. 5. abdullah as, qiming f, pun v, stillman fa, samet jm. a review of tobacco smoking and smoking cessation practices among physicians in china: 1987–2010. tob control. 2011;22(1):9-14. 6. american cancer society. guide to quitting smoking. 2012 [cited 2012 may 8]; available from: http://www. cancer.org/acs/groups/cid/documents/ webcontent/002971-pdf.pdf. 7. who. quitting tobacco. 2012 [cited 2012 may 8]; available from: http://www.who. int/tobacco/quitting/en. 8. abrams db, niaura r. the tobacco dependence treatment handbook: aguide to best practices. new york city: guilford press; 2003. 9. vaszar lt, sarinas psa, lillington ga. achieving tobacco cessation: current status, current problems, future possibilities. respiration. 2002;69(5):381–4. 10. qidwai w. barriers to smoking cessation: results of a survey among family practice patients.mejfm [online journal]. 2004;5(5):1–12. 11. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar 2010. riskesdas; 2010 [cited 2012 april 17]; available from: reni yuditha kathrine, elsa pudji setiawati, lucky saputra: barriers to smoking cessation among medical students 2012–2013 academic year in the faculty of medicine, universitas padjadjaran althea medical journal. 2015;2(3) 358 amj september, 2015 http://www.riskesdas.litbang.depkes. go.id/download/tabelriskesdas2010.pdf 12. lowinson jh. substance abuse: a comprehensive textbook. 4th ed. philadelphia: williams & wilkins; 2005. 13. centers for disease control and prevention. quitting smoking among adults. mmwr. 2011;60(44):1513–9. 14. paavola m, vartiainen e, puska p. smoking cessation between teenage years and adulthood. health educ res. 2001;16(1):49–57. 15. university of wisconsin center for tobacco research and intervention. barriers to quitting smoking. madison: uw-ctri; 2005. 16. wiltshire s, bancroft a, parry o, amos a. i came back here and started smoking again: perceptions and experiences of quitting among disadvantaged smokers. health educ res. 2003;18(3):292–303. 17. marc galanter md, kleber emghd. the american psychiatric publishing textbook of substance abuse treatment. 4th ed.arlington: american psychiatric pub.; 2008. 18. direktorat jenderal informasi dan komunikasi publik. akibat perilaku warga, bandung sehat terhambat. 2012 [cited 13 december 2012];available from: http://infopublik.kominfo.go.id/m/index. php?scr=read_news&id=27634. 19. rumah sakit royal progress. klinik paru dan pernapasan. 2010 [cited 13 december 2012]; available from: http://www. royalprogress.com/excellence.php?id=4#. 20. arman, sim-rs persahabatan. pelayanan khusus di rsup persahabatan. 2013 [downloaded 8 february 2013]. available from: http://www.persahabatan.co.id/ index.php?option=com_content&view=art icle&id=95&itemid=515. althea medical journal. 2015;2(3) 403 clinical characteristic and outcome of acute lower respiratory tract infection in children with congenital heart disease krystle gabriela,1 rahmat budi kuswiyanto,2 fenny dwiyatnaningrum3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: acute lower respiratory tract infection (alrti) is the leading cause of deaths in children under 5 years of age worldwide, and has high morbidity and mortality in children with congenital heart disease (chd). the objective of this study was to obtain the incidence, clinical characteristic, and outcome of alrti children with chd. methods: a retrospective hospital-based study was conducted from january 2007–december 2011 to medical record of child patients with alrti and chd in the department of child health of dr. hasan sadikin general hospital, bandung. the diagnosis of chd was determined by echocardiography. the collected data was analyzed and presented in percentage shown in tables. results : from 3,897 children who had alrti, there were 149 children with chd (3.8%), with 11.4% of whom founded with recurrent episodes. this happened often in girls than boys with quite similar ratio of 1.37: 1.the majority of children (80%) was under 1 year old of age, 72.5% with malnutrition, and 24.8% with severe malnutrition. clinical symptoms mostly found were difficulty of breathing (98%), fever (85.2%), cough (75.2%), and runny nose (63.1%). the most common types of chd were patent ductus arteriosus (47.6%), followed by ventricular septal defect (47%). bronchopneumonia (86.6%) was the common type of alrti. the length of stay was mostly less than 10 days (70.5%). from all the children 43.7% had complications, and 6.7% died. conclusions: the alrti in children with chd is not common and has good outcome. the majority for chd lesions are patent ductus arteriosus and ventricular septal defect while for alrti is bronchopneumonia. [amj.2015;2(3):403–8] keywords: acute lower respiratory tract infection, congenital heart disease, outcome, malnutrition correspondence: krystle gabriela, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62811185314 email: krystle.gabriella@gmail.com introduction acute lower respiratory tract infection (alrti) is the most common cause of death in children under five. most cases of alrti in the world occurred in developing countries and indonesia is in the sixth place. in 2010, the national health profile showed that alrti is one of the ten most frequent cases among hospitalized patients in indonesia and has the highest mortality rate of 1,315 death.1,2 recurrent alrti often occurred in children with history of congenital heart diseases (chd). the chd is a disease that is most frequently found in children all over the world with a percentage of 28% of all types of congenital abnormalities, and the prevalence is about 9 per 1000 live-births in the last 15 years.3 children with chd are more vulnerable to recurrent respiratory tract infection. considering that the children with chd has an anatomy defect that causes hemodynamic disturbances of lung circulation, and it ultimately put them at higher risk to suffer from recurrent respiratory tract infection than those who has no history of chd.4-6 the objective of this study was to obtain the incidence, clinical characteristic, and outcome of alrti children with chd. the benefit of this study is to provide an early diagnosis for children with chd in order to have a proper management plan. methods a retrospective hospital based study was althea medical journal. 2015;2(3) 404 amj september, 2015 conducted to alrti children with chd at the department of child health of dr. hasan sadikin general hospital; the study was held from january 2007–december 2011. the inclusion criteria were all alrti children with chd who had undergone echocardiography (confirmed chd). the exclusion criteria were children who had not undergone echocardiography (chd suspect) or incomplete medical record. the medical records were evaluated and alrti children with confirmed chd were selected. the data were collected, tabulated, and analyzed by using thestatistical package for the social sciences (spss). the results were shown in proportion, mean, or median. table 1characteristics of alrti children with chd characteristics n = 149 % sex male 63 57.7 female 86 42.3 age groups 1 month 8 5.4 2 months – 1 year 111 74.5 2–5 years 18 12.1 6–18 years 12 8.1 nutritional status good 41 27.5 mild malnutrition 71 47.7 severe malnutrition 37 24.8 clinical symptoms difficulty of breathing 146 98 fever 127 85.2 cough 112 75.2 runny nose 94 63.1 others 37 24.3 physical examination chest retraction 133 89.3 tachypnea 130 87.2 tachycardia 112 75.2 systolic murmur 95 63.7 crackles 131 91.9 cyanosis 21 14.1 others 42 28.2 lab anemia 12 8.1 leucocytosis 36 24.2 chest x-ray cardiomegaly 92 61.7 increase bronchovascular pattern 113 75.8 infiltrate 120 80.5 althea medical journal. 2015;2(3) 405 results there were 3,897 children who suffered altri and 149 of them were with history of chd, who had already been confirmed by echocardiography and written on medical record, therefore, the incidence was (149/3,897) = 3.8%. out of 149 children, 17 (11.4%) children had recurrent alrti. the incidence of alrti in children with chd were often found in girls than in boys with quite similar ratio of 1.37:1, and it occurred more frequently in children under 1 year of age (80%). the median of age in this study was 6 months with the range of 1–156 month (one-month old–13 years old). most of the children (72.5%) had malnutrition of whom 47.7% with mild malnutrition and 27.5% with severe malnutrition. malnutrition was associated with additional diagnosis of failure to thrive (12.8%). almost entire children who came to the hospital were complaining about breathing difficulty (98%), cough (75.2%), fever (85.2%), and runny nose (63.1%). those are common signs and symptoms of altri. other symptoms were only complained by several children and probably associated with other common diseases that the children have e.g. diarrhea (10.1%), seizure (4.7%), vomit (4.7%), breast feeding difficulty (3.4%), decreased level of consciousness (0.7%), and icteric (0.7%). table 1characteristics of alrti children with chd chd n = 149 % acyanotic left to right shunt asd 27 18.1 vsd 70 47 pda 71 47.6 obstruction lesion aortic stenosis 2 1.3 pulmonary stenosis 13 8.7 interrupted aorta 1 0.7 coa 7 4.7 cyanotic decrease pulmonary blood flow tof 7 4.7 tricuspid atresia 1 0.7 pulmonary atresia 5 3.4 increase pulmonary blood flow tga 4 2.7 dorv 9 6 tapvr 3 2 single ventricle 1 0.7 dextrocardia 5 3.4 valve anomalies mitral regurgitation 20 13.4 tricuspid regurgitation 7 4.7 aortic regurgitation 1 0.7 pulmonary regurgitation 3 2 note: asd: atrial septal defect, avsd: atrioventricular septal defect, coa: coarctation of aorta, dorv: double outlet right ventricle, pda: patent ductusarteriosus, tapvr: total anomalous pulmonary venous return, tga: transposition of great arteries, tof: tetralogy of fallot, vsd: ventricular septal defect krystle gabriela, rahmat budi kuswiyanto, fenny dwiyatnaningrum: clinical characteristic and outcome of acute lower respiratory tract infection in children with congenital heart disease althea medical journal. 2015;2(3) 406 amj september, 2015 according to statistical data tabulation for vital signs, the median for pulse rate was 134 times/minute (64–182), the median for respiratory rate was 56 times/minute (18– 82), and the mean for temperature was 37.6oc + 0.95. tachypnea (87.2%) and tachycardia (75.2%) were the most common signs found for vital abnormality. most of the children (893%) had chest retraction, but cyanosis wasfound only in a small number (14.1%) of the children with cyanotic chd. abnormal heart sounds frequently heard on auscultation was systolic murmur (63.7%), and the most common additional breathing sound was crackles (91.9%). other findings on physical examination were found in a small number of children such as continuous murmur (16.7%), wheezing (10.7%) and stridor (0.7%). only few children were with leukocytosis (24.2%), so most of the children had a normal number of white blood cells. only a small number of children had anemia (8.1%). as shown in the chest x-ray, infiltrate (80.5%) and increase of broncho vascular pattern (75.8%) were the common findings in children with alrti. enlargement of the heart (cardiomegaly) was found in most of the patients (92%) related to chd. the chd was commonly found in children hospitalized with alrti, and the most common defect were pda (47.6%) and vsd (47%). both diseases defected with the presence of shunt from left to right. the most common type of altri was bronchopneumonia (86.6%). based on statistical data tabulation for length of stay, the median was 8 days (1–58). in this study, most of the children hospitalized were in range of 1–10 days (70.5%). as much as 83.9% of the children was discharged with good condition. some of the children had complications, such as heart failure (22.8%) and respiratory failure (16.1%), however, only few children died (6.75%). discussion the incidence of alrti in children with chd is lower than a previous study by owayed et al.7, which reported the incidence of chd children hospitalized because of recurrent pneumonia was 9%. the low result of this study is probable since not all of the children have undergone the echocardiography, or as this is a single center study. in indonesia, there are still many children who have no health service coverage table 3 type of altri altri n = 149 % bronchopneumonia 128 86.6 bronchiolitis 16 10.7 lobar pneumonia 4 2.7 laringotracheo bronchitis 1 0.7 table 3 type of altri outcome n = 149 % length of stay 1–10 days 105 70.5 11–20 days 33 22.1 21–30 days 10 6.7 >30 days 1 0.7 outcome good 125 83.9 death 10 6.7 complication heart failure 34 22.8 respiratory failure 24 16.1 althea medical journal. 2015;2(3) 407 because of the low socio economic status and the fact that the social health insurance does not cover the echocardiography cost yet. recurrent alrti in children with chd was more frequently in baby under 1 year of age. this fact is due to the low capacity of children immune system and the small size of respiratory tract. the lesion commonly found was left to right lesion, which caused low vascular resistance that would increase the vulnerability of infection in child with chd.5 nutritional disturbances will affect immune system, therefore it will increase the risk of infection and slowing down the healing process. study by caulfield et al.8 in 2004 showed that 52.3% of death due to alrti was associated with malnutritions.8 in the study generated by nataprawira et al.6, showed that malnutrition was one of risk factors for morbidity and mortality of severe pneumonia on children under age of 5. malnutrition associated with failure to thrive (ftt). in this study, ftt was found in 12.8% children. shah et al.9 reported ftt was found in 11.9% children with chd. the ftt is a major symptom of chd because of low energy expenditure, inadequate food intake, and malabsorption or feeding difficulties. according to who classifications for pneumonia; if difficulty of breathing occurred, then a child should be diagnosed with severe pneumonia and required hospitalization. tachypnea was symptoms of respiratory disturbance which has high both sensitivity and specificity in diagnosing pneumonia. crackles (wet ronchi) was specific additional breath sound found in children with pneumonia.10,11 the alrti, caused by neither virus nor bacteria, was often preceded by upper respiratory tract infection for several days.12 children with chd are at risk for increased morbidity from viral lower respiratory tract infections because of anatomical cardiac lesions than can worsen an already compromised respiratory status.13 however, it is difficult to differentiate between bacterial and viral infection only by clinical symptoms and physical examination. therefore, many broad spectrum antibiotics are empirically used in management of alrti.10 based on our study, the most frequent initial antibiotic given were ampicillin (35.6%) and combination between ampicillin and gentamicin (14.1%). in our institution, ampicillin is the initial antibiotic given, but in severe clinical condition, initial antibiotic given is combination of ampicillin and gentamicin or ampicillin and chloramphenicol.14 chest x-ray image inpatient with alrti can be in form of mild infiltrate in one lung until extensive consolidation in both lungs. the presence of infiltrate and the increase of broncho vascular pattern are specific radiologic findings for bronchopneumonia.10 if cardiomegaly was present, then a patient is more likely to be diagnosed as heart failure. this phenomenon happened because of wide shunt from right side to left side of the heart.15 if heart failure exist, the child should be given anti heart failure drugs such as diuretic (furosemide), vasodilator (captopril) and digitalis (digoxin).15 based on the study, the combination of those three drugs were the most frequent anti heart failure drugs given (11.4%). in the study generated by wilar and wantania5, acyanotic chd (61.7%) has greater number of patients than cyanotic chd (38.3%), and altri occurs more frequent in children with chd than in normal children, especially children with bronchopneumonia (86.6%). cahyono and rachman4 reported that 50% of death case in children with chd was underlined by pneumonia. the child who was hospitalized only for 1 day was due to severe complication that causes death. in alrti without complications, length of stay within antibiotic administration was 7–10 days less or more.10 the most common indicator for the use of ventilator was acute respiratory failure which was frequently caused by bronchopneumonia (31.1%) and the majority was under the age of 1 year.16 a child who died is suspected due to improper management or severe complications. respiratory and cardiac failure were two leading cause of death and death rate was significantly high in malnourished children.4 limitations of this study were unavailable medical record or incomplete medical record data. since this study was a hospital-based type, the data were obtained from a single health center only, therefore the result is not quite representative, and not all the patients underwent echocardiography. as a suggestion, a further study in children with chd who have been hospitalized due to alrti that involve several health centers is necessary. clear registration and administration of medical records should be enforced thus, all data in medical records can be completed. furthermore, improving the health services system in order to extend the coverage of health services especially for those with financial limitation is needed. also it is important to increase suspiciousness krystle gabriela, rahmat budi kuswiyanto, fenny dwiyatnaningrum: clinical characteristic and outcome of acute lower respiratory tract infection in children with congenital heart disease althea medical journal. 2015;2(3) 408 amj september, 2015 in the present of chd and encourage echocardiography test for children with recurrent alrti and failure of thrive. the incidence of alrti children with chd is 3.8%, in which 11.4% children had recurrent alrti. nutritional status for severe malnutrition, moderate malnutrition, and good nutritional status were 47.7%, 24.8%, and 27.5%, respectively. the most frequent clinical symptoms were difficulty of breathing (98%), fever (85.2%), cough (75.2%), and runny nose (63.1%). the most common type of chd was pda (47.6%) and vsd (47%), whilst type of alrti was bronchopneumonia (86.6%). the length of stay of patients was less than 10 days (70.5%) and the outcome was mostly good (83.9%) even though almost half of the patients present were with complications (43.7%), but only a small number resulted in death (6.7%). references 1. wardlaw t, johansson ew, hodge m. pneumonia: the forgotten killer of children. unicef. 2006 [cited 2012 april 15]. available from: http://www.unicef. org. 2. kementrian kesehatan ri. profil kesehatan indonesia. kementrian kesehatan ri. 2010 [cited 2012 april 15]. available from: http://www.depkes.go.id 3. van der linde d, konings eem, slager ma, witsenburg m, helbing wa, takkenberg jjm, et al. birth prevalence of congenital heart disease worldwide. j am coll cardiol. 2011;58(21):2241–7. 4. cahyono a, rachman ma. the cause of mortality among congenital heart disease patients in pediatric ward, soetomo general hospital (2004–2006). j kardiol ind. 2007;28(4):279–84. 5. wilar r, wantania jm. beberapa faktor yang berhubungan dengan infeksi saluran pernapasan akut pada anak dengan penyakit jantung bawaan. sari pediatri. 2006;8(10):154–8. 6. nataprawira hm, alwi eh, adriani n. faktor risiko morbiditas dan mortalitas pneumonia berat pada anak usia balita. maj kedokt indon. 2010;60(10):443–7. 7. owayed af, campbell dm, wang eel. underlying causes of recurrent pneumonia in children. arch pediatr adolesc med. 2000;154(2):191–4. 8. caulfield le, onis md, blossner m, black re. undernutrition as an underlying cause of childs death associated with diarrhea, pneumonia, malaria and measles. am j clin nutr. 2004;80(1):193–8. 9. shah g, singh m, pandey t, kalakheti b, bhandari g. incidence of congenital heart disease in tertiary care hospital. kathmandu univ med j. 2008;6(21):33–6. 10. said m. infeksi respiratori akut: pneumonia. in: rahajoe nn, supriyatno b, setyanto db, editors. buku ajar respirologi anak. 1st ed. jakarta: ikatan dokter anak indonesia. 2010. p. 350–64. 11. palafox m, guiscafre h, reyes h, munoz o, martinez h. diagnostic value of tachypnoe in pneumonia defined radiologically. arch dis child. 2000;82(1):41–5. 12. sectish tc, prober cg. pneumonia. in: kliegman rm, behrman re, jensen hb, stanton bf, editors. nelson textbook of pediatrics. 18th ed. philadelphia: saunders; 2007. p. 1795–800. 13. geskey jm, cyran se. managing the morbidity associated with respiratory viral infection in children with congenital heart disease. int j ped. 2012;2012:646780. 14. kartasasmita cb, suardi au, nataprawira hm, sudarwati s, wulandari da. respirologi. in: garna h, nataprawira hm, editors. pedoman diagnosis dan terapi ilmu kesehatan anak. bandung: departemen ilmu kesehatan anak fakultas kedokteran universitas padjadjaran; 2012. p. 781–878. 15. firman a, rahayuningsih se, kuswiyanto rb. kardiologi. in: garna h, nataprawira hm, editors. pedoman diagnosis dan terapi ilmu kesehatan anak. 4th ed. bandung: departemen ilmu kesehatan anak fakultas kedokteran universitas padjadjaran; 2012. p. 477–559. 16. hakim dl, ismawaty n. karakteristik penderita yang mendapat tindakan ventilasi mekanik yang dirawat di ruang perawatan intensif anak rumah sakit hasan sadikin bandung. mkb. 2007;39(2):75–9. vol 6 no 1 full text edit final.indd althea medical journal. 2019;6(1) 24 amj march 2019 cardiorespiratory endurance among end year student of faculty of pharmacy in jatinangor, bandung hemavahthy mani,1 tri damiati pandji,2 putri teesa3 1faculty of medicine universitas padjadjaran, indonesia, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia correspondence: putri teesa, dr., m.kes., aifo, department of biomedical sciences, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km 21, indonesia, email: putritessa@gmail.com introduction physical fitness is an important health marker that relates to the ability of a person to perform physical activity.1 components of physical fitness such as cardiorespiratory endurance are essential for total fitness of the body and mind.2 cardiorespiratory endurance is the body’s ability to supply the needed oxygen to large working muscles for an extended period of time.3 the degree of cardiorespiratory endurance shows how the heart and lungs respond to movement.4 there are three things that can affect a person’s cardiorespiratory endurance. these are how often they exercise, how intensely they exercise, and how long each workout lasts.5 the maximal oxygen consumption (vo2 max) is quantified in l min-1 or ml kg-1 min-1 as a measure of cardiorespiratory endurance.1,6 according to previous studies, about 40% to 50% of higher institute students are physically inactive.7 there have been consistent declines in cardiorespiratory endurance fitness performance across all studied asian nations over the past 10–15 years.8 several countries, including indonesia, have approximately 60–85% of adults that perform less physical activity to maintain their physical fitness.9 as higher institute students move toward their senior year, they significantly have a more sedentary lifestyle.10 the sedentary lifestyle may replace physical activity, promoting an energy imbalance, and subsequently, an increased risk for obesity with low cardiorespiratory endurance.11 generally, fresh graduates of higher-learning institutions are physically less active and weigh more compared to their freshman amj. 2019;6(1):24–9 abstract background: physical fitness indicates the ability of an individual to perform daily physical activities with ease. the major component of physical fitness is the cardiorespiratory endurance, which is assessed through maximal oxygen consumption (vo2 max). a decrease in cardiorespiratory endurance can be associated with a sedentary lifestyle. this study was conducted to determine the cardiorespiratory endurance among young adults in jatinangor, bandung. methods: this cross-sectional study had used total sampling method, conducted among end year student of faculty of pharmacy, universitas padjadjaran from october–november 2013. the inclusion criteria wasall end year students who had no health-related problems and the students had to agree to participate in the study. after obtaining written informed consent from the participants, astrandrhyming step test was performed to measure the level of vo2max. results: in total, 32 students were included of whom 14 students (43.7%) had an average level of vo2 max and 9 (28.2%) had just below average level. chi-square test results showed that there was no significant relationship (p>0.05) between vo2 max level and gender, bmi level, and smoking habit, but showed a significant relationship (p< 0.05) with exercising habit. conclusions: the majority of the participants had an average level of vo2 max. a significant relationship between the level of vo2 max and exercising habit, suggesting a regular exercise for a better lifestyle. keywords: cardiorespiratory endurance, pharmacy students, vo2 max althea medical journal. 2019;6(1) 25 year.10 therefore, this study was conducted to determine the cardiorespiratory endurance of end year students from universitas padjadjaran, jatinangor. methods this study was a cross sectional study performed among all end year students in the faculty of pharmacy, universitas padjadjaran, jatinangor, conducted from october– november 2013 after the ethical clearance was given after considering the inclusion and exclusion criteria, 32 students were recruited. the inclusion criteria were all end year students , and the exclusion criteria were students who had health-related problems according to a physical activity readiness questionnaire. the students must agree to participate in this study. after filled in questions regarding their health background, students were weighed using a weighing scale with precisely measurement to the nearest 0.1 kg. furthermore, height was measured using a stadiometer, precise to the nearest centimeter. using those values, body mass index (bmi) was calculated as weight in kilograms divided by the square of height in meters.12 resting pulse rate was measured for 15 seconds and multiplied by 4 to calculate the pulse rate in beats per minute. resting blood pressure of the participants was measured using sphygmomanometer and stethoscope with them while resting in sitting position. then, the participants performed astrand-rhyming step test; as for the male participants step up and down on a 40-centimeter bench and for female participants on a 33 cm bench both, for 5 minutes at the rate of 90 steps per minute. according to the metronome rhythm, the participant’s right leg had to be on the bench at the first sound followed by the left leg at the second sound. during the third sound, the right leg had to be down on the floor followed by the left leg at the fourth sound. throughout this procedure, the participant’s posture had to be upright. heart rate was measured from exactly 15–30 seconds following the completion of the test. recovery heart rate was measured each minute for five minutes and blood pressure was measured again at the end after completion of the test. the vo2 max of the participants were calculated using the astrand-rhyming nomogram.13 data were collected and analyzed to seek any significance relationship (p<0.05) between level of vo2max and gender, level of bmi, smoking and exercising habit, using the windows statistical product and service solutions 17.0 and microsoft excel program. the results were presented in tables for better view. table 1 characteristic of end year students from faculty of pharmacy jatinangor, bandung frequency (n) percentage (%) gender female 18 56.25 male 14 43.75 bmi (kg/m2) underweight 2 6.25 normal 24 75 overweight 4 12.5 obese 2 6.25 smoking habit no 26 81.25 yes 6 18.75 exercise regularly no 12 37.5 yes 20 62.5 putri teesa et al.: cardiorespiratory endurance among end year student of faculty of pharmacy in jatinangor, bandung althea medical journal. 2019;6(1) 26 amj march 2019 results based on the data obtained, the 32 participants in this study had an age range of 21–27 years old and the majority were female. most of the participants had normal bmi. majority of the participants did not smokeand more than half of them exercised regularly (table 1). most of the participants had an average level of vo2 max (43.7%) and just below the average (28.2%) (table 2). both male and female participants belong to the average category of vo2 max (table 3). based on chi-square analysis, there was no significant relationship between gender and level of vo2max (x2 = 5.70; df = 4; p = 0.22). of all the levels of vo2 max, a high number of participants have normal bmi (table 4). no significant relationship between level of bmi and level of vo2 max (x2 = 14.58; df = 12; p = table 2 classification of level of vo2 max among end year students from faculty of pharmacy, jatinangor, bandung vo2 max frequency (n) percentage (%) very high 4 12.5 high 4 12.5 average 14 43.7 below average 9 28.2 very low 1 3.1 table 3 classification of level of vo2 max among end year students from faculty of pharmacy, jatinangor, bandung based on gender vo2 max gender total (n)female male (n) (n) very high 4 0 4 high 3 1 4 average 7 7 14 below average 4 5 9 low 0 1 1 total 18 14 32 table 4 classification of level of vo2 max among end year students from faculty of pharmacy, jatinangor, bandung based on bmi vo2 max bmi (kg/m2) total (n)underweight normal overweight obese n n n n very high 4 4 high 1 3 4 average 1 12 1 14 below average 4 3 2 9 low 1 1 total 2 24 4 2 32 althea medical journal. 2019;6(1) 27putri teesa et al.: cardiorespiratory endurance among end year student of faculty of pharmacy in jatinangor, bandung 0.27). most of the participants with no smoking habit had an average and just below average levels of vo2 max (table 5). the chi-square test did not show any significant differences between smoking habit and level of vo2max (x2 = 6.26; df = 4; p = 0.18). most of the participants that exercise regularly had an average level of vo2 max. very high and high level of vo2 max could only be seen in participants that had the habit of exercising regularly, albeit there was one participant that exercised regularly but had a low level of vo2 max. below average vo2 max could only be seen in participants that did not exercise regularly (table 6). statistically, there was a significant relationship between habit of exercising and level of vo2 max (x2 = 21.94; df = 4; p = 0.00). discussion the data were collected to measure the level of cardiorespiratory endurance as expressed in vo2 max values, and to stratify according to gender, bmi, smoking habit and habit of exercising regularly. result shows that most of the end year students have an average level and just below the average level of vo2 max, despite that the end year students were involved in fewer physical activities, since they were more preoccupied with assignments and other academic work compared to their junior peers. in terms of gender, female participants have a generally higher vo2 max. females have 20 percent lower vo2 max than males, however, many female athletes have higher vo2 max values than most male.14 interestingly, our study result showed that no significant relationship between gender, level of bmi, smoking habit and level of vo2 max. in our study, female participants engage themselves in exercise more often than male participants. besides engaging in regular exercise, the female participants also filled their leisure time with dancing as well, which in itself is a vigorous physical activity as well. furthermore, most of the female participants walk to campus every day unlike most of the male participants who ride motorbikes to campus. unfortunately, table 5 classification of level of vo2 max based on smoking habit vo2 max smoke total (n)no yes n n very high 4 4 high 4 4 average 11 3 14 below average 7 2 9 low 1 1 total 26 6 32 table 6 classification of level of vo2 max based on the habit of exercising vo2 max regular exercise total (n)no yes n n very high 4 4 high 4 4 average 3 11 14 below average 9 9 low 1 1 total 12 20 32 althea medical journal. 2019;6(1) 28 amj march 2019 there were no further inquiries made about this activity, but it has been observed during the study. in accordance with our study, bmi may not be associated with cardiorespiratory fitness.15 on the other hand, lower waist circumference may be correlated with better cardiorespiratory fitness.15 this result agrees with the findings of other studies in which waist circumference was a superior predictor for cardiovascular disease and cancer risk.16,17 unfortunately, in our study, the waist circumference is not measured, that limits our analysis. other previous studies have found that level of vo2 max is most affected in heavy smokers group.18,19 interestingly, our finding has unexpected result; there is no significant relationship between smoking habit and level of vo2 max. a possible explanation for this might be that the smoking participants in this study are light or moderate/regular smokers, defined as 1-10 pack-y (packs•day * year(s) smoking) or 11-20 pack-y, respectively. a significant relationship confirmed in our study is that the exercising habit and the level of vo2 max. it has been suggested that doing exercise regularly improves cardiorespiratory endurance. exercise has significant improvement in vo2 max.20 regular exercise done by healthy sedentary and active adults show an improvement of their vo2 max.21 this study was limited by the absence of daily physical activity and waist circumference data. information about the number of cigarette’s packs and smoking duration of smoker’s participants were also not obtained, that makes further analysis about the relationship of the gender, body composition, and the smoking habit is lacking. to conclude, our findings indicate that in order to have a better level of vo2 max, participants must engage themselves in regular exercise. here we suggest for at least three times in a week with each session being more than 60 minutes. future research needs to examine more closely the relationship between vo2 max level and known factors affecting the vo2 max level increase. references 1. ortega fb, ruiz jr, castillo mj, sjostrom m. physical fitness in childhood and adolescence: a powerful marker of health. int j obes (lond). 2008;32(1):1–11. 2. eurenius e, stenström ch. physical activity, physical fitness, and general health perception among individuals with rheumatoid arthritis. arthritis rheum. 2005;53(1):48–55. 3. dutt s. health related physical fitness of boys aged 8 to 18 years. journal of exercise science and physiotherapy. 2005;1(1&2):12–22. 4. hoeger wwk, hoeger sa. lifetime physical fitness and wellness. 10th ed. belmont: yolanda cossio; 2009. 5. garcía-artero e, ortega fb, ruiz jr, mesa jl, delgado m, gonzález-gross m, et al. lipid and metabolic profiles in adolescents are affected more by physical fitness than physical activity (avena study). rev esp cardiol. 2007;60(06):581–8. 6. tarnus e, catan a, verkindt c, bourdon e. evaluation of maximal o2 uptake with undergraduate students at the university of la reunion. adv physiol educ. 2011;35(1):76–81. 7. keating xd, guan j, piñero jc, bridges dm. a meta-analysis of college students’ physical activity behaviors. j am coll health. 2005;54(2):116–25. 8. macfarlane d, tomkinson gr. evolution and variability in fitness test performance of asian children and adolescents. med sport sci. 2007;50(1):143–67. 9. rismayanthi c. tes kebugaran jantung paru dengan metode rockport bagi karyawan dinas kesehatan propinsi diy. 2012 [cited 2013 march 23]; available from: http://staff.uny.ac.id/sites/default/ files/pengabdian/cerika-rismayanthisor/tes-kebugaran-dinkes-2012-metoderockport.pdf. 10. indiana university. college days - more sedentary days. science daily. 2010 [cited 2013 march 5]; available from: http://www.sciencedaily.com/ releases/2010/11/101110073332.htm. 11. collins ae, pakiz b, rock cl. factors associated with obesity in indonesian adolescents. int j pediatr obes. 2008;3(1):58–64. 12. tate df, jackvony eh, wing rr. effects of internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. jama. 2003;289(14):1833–6. 13. sawada ss, lee im, muto t, matuszaki k, blair sn. cardiorespiratory fitness and the incidence of type 2 diabetes prospective study of japanese men. diabetes care. 2003;26(10):2918–22. 14. quinn e. vo2 max measures aerobic fitness and maximal oxygen uptake. 2011 [cited 2013 march 14]; available from: althea medical journal. 2019;6(1) 29 http://sportsmedicine.about.com/od/ anatomyandphysiology/a/vo2_max.htm. 15. pojskic h, eslami b. relationship between obesity, physical activity, and cardiorespiratory fitness levels in children and adolescents in bosnia and herzegovina: an analysis of gender differences. front physiol. 2018; 9:1734. 16. sawa sc, tornaritis m, sawa me, kourides y, panagi a, silikiotou n, et al. waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. int j obes relat metab disord. 2000; 24(11):1453–8. 17. barberio am, alareeki a, viner b, pader j, vena je, arora p, et al. central body fatness is a stronger predictor of cancer risk than overall body size. nat commun. 2019;10(1):383. 18. wier lt, suminski rr, poston ws, randles am, arenare b, jackson as, et al. the effect of habitual smoking on vo2max. 2008 [cited 2019 march 09]; available from: https://ntrs.nasa.gov/archive/nasa/casi. ntrs.nasa.gov/20080014280.pdf 19. suminski rr, wier lt, poston w, arenare b, randles a, jackson as. the effect of habitual smoking on measured and predicted vo2(max). j phys act health. 2009;6(5):667–73. 20. naves jpa, viana rb, rebelo acs, de lira cab, pimentel gd, lobo pcb, et al. effects of high-intensity interval training vs. sprint interval training on anthropometric measures and cardiorespiratory fitness in healthy young women. front physiol. 2018; 9:1738. 21. sloth m, sloth d, overgaard k, dalgas u. effects of sprint interval training on vo2max and aerobic exercise performance: a systematic review and meta-analysis. scand j med sci sports. 2013; 23(6):e341– 52. putri teesa et al.: cardiorespiratory endurance among end year student of faculty of pharmacy in jatinangor, bandung althea medical journal. 2015;2(3) 443 characteristics and predisposing factors of bacterial corneal ulcer in the national eye center, cicendo eye hospital, bandung from january to december 2011 astrid maharani putri,1 susi heryati,2 nursiah nasution3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/national eye center cicendo eye hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: corneal ulcer is an emergency condition in ophthalmology, causing visual impairment, mostly by bacterial infection with rapid pathogenesis. the aim of this study was to discover the characteristics of bacterial corneal ulcer patients in the national eye center, cicendo eye hospital, bandung.. methods: a total of 99 medical records consisted of patients diagnosed with bacterial corneal ulcer were selected in this descriptive study. the clinical patterns and predisposing factors of the patients were analyzed. the study also identified the pathogenic bacteria of the cases. this study was carried out in the national eye center, cicendo eye hospital, bandung from january to december 2011 clinical patterns. the collected data were analyzed and presented in frequency tabulation. results: the male to female ratio was 2:1, with the average age of 44.4 years. the most common presenting symptom was eye pain (70.7%). most patients came with decreased visual acuity that was categorized as (near-) blindness (78.8%) and the location of the ulcer was in central area of the cornea (56.5%). the most common predisposing factor was ocular trauma (74.7%) that was caused by exposed to plants. singlebacterial infection (67.7%) was predominant, with 56 cases (56.6%) of gram-positive cocci infection. conclusions: bacterial corneal ulcer contributes to 48.8% of all microbial corneal ulcers. most patients came with mild condition, centralized location, and poor visual function. the common predisposing factor was trauma associated with exposed to plants. [amj.2015;2(3):443–7] keywords: bacterial infection, corneal ulcer, trauma, visual acuity correspondence: astrid maharani putri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287877558216 email: a.maharaniputri@gmail.com introduction corneal ulcer is a pathologic condition that develops in cornea, which is characterized by suppurative infiltrate and discontinuity of corneal tissue starting from epithelium to stroma. corneal ulcer is mostly caused by infection, with 90% of the corneal infection caused by bacteria. bacterial ulcers tend to have a more rapid pathogenesis. corneal ulcer is also an emergency condition in ophthalmology because it can form turbidity at the cornea. this may lead to visual impairment and even blindness.1-4 in many parts of the world, corneal ulcer is one of the major causes of blindness.5-9 dhakwa et al. 5 reported that out of 414 cases, bacterial cultures were positive in 300 cases. pure bacterial growth was present in 121 of all corneal ulcer cases, with single-bacterial infection more dominant than multiplebacterial infection. this study was intended to collect data related to epidemiological features, predisposing factors, causative microorganisms, and clinical manifestations for cases of bacterial corneal ulcers, which aimed to provide background information of bacterial corneal ulcers. methods the descriptive study was conducted in the national eye center cicendo eye hospital bandung in augusts to november 2012. medical records were reviewed for 203 patients with corneal ulcers who were treated althea medical journal. 2015;2(3) 444 amj september, 2015 or hospitalized at the indonesian national eye center (inec) – bandung cicendo eye hospital from 1st of january to 31st of december 2011. medical records were carefully examined; cases with viral or fungal infections and incomplete medical records were excluded, resulting in 99 patients with bacterial corneal ulcer out of the total 203 patients with corneal ulcer. medical records were reviewed to determine prominent features including sex, age, symptoms, visual acuity, predisposing factors, degree of severity, pathogenic bacteria, and location of ulcer. all these patients’ data were recorded in microsoft office excel and then analyzed with spss version 15.0. results the epidemiological characteristics’ distribution of patients diagnosed with bacterial corneal ulcer is presented in table 1. the male to female ratio was 2:1. the average age of all patients was 44.4 years. symptoms were also reviewed; the most frequent presenting symptom was eye pain, which was complained by 70 patients (70.7%) out of the total bacterial corneal ulcer patients. the next most frequent symptoms were red eye (61 patients; 61.6%) and white spot at black part of the eye (50 patients; 50.5%). most of the patients came with (near-) blindness (78 patients; 78.8%). predisposing factors were identified for 92 patients (92.9%). the most common predisposing factor for bacterial corneal ulcer was ocular trauma (74.7%) (table 2) corneal scrapping had been performed for patients with suspected microbial corneal ulcer. the result of microbiological examination with gram staining was written in the medical records. infection by single-bacteria (67 patients; 67.7%) was predominantly found in patients with bacterial corneal ulcer than with multiple-bacteria (32.3%). most of the cases of single-bacterial infection were caused by gram-positive cocci (table 3) table 1 characteristics of patients with bacterial corneal ulcer characteristic bacterial corneal ulcer n (%) sex male 66 (66.7) female 33 (33.3) age, y,ears, mean (sd) 44.4 (16.3) symptoms eye pain 70 (70.7) red eye 61 (61.6) white spot at black part of the eye 50 (50.5) decreased in vision 35 (35.4) watery eye 29 (29.3) propped eye 16 (16.2) exudate 14 (14.1) itchy eye 12 (12.1) swollen eye 7 (7.1) headache 7 (7.1) photophobia 5 (5.1) visual acuity (near-) normal vision 5 (5.1) low vision 16 (16.2) (near-) blindness 78 (78.8) althea medical journal. 2015;2(3) 445 the severity cases in this study was based on jones’, the most prominent degree of severity criteria of all patients with bacterial corneal ulcer was mild, as presented in table 4. the majority of bacterial corneal ulcer patients were (near-) blindness with the location of ulcer at the central cornea (53 patients; 53.5%). however, of all cases with low vision (n=16), 3 cases were at the central cornea, 10 cases were at paracentral, and others were at peripheral. of all cases with (near-) normal vision (n=5), no cases were identified at the central cornea. the distribution of visual acuity and ulcer location is presented in table 5. discussion table 2 predisposing factors of patients with bacterial corneal ulcer predisposing factors bacterial corneal ulcer n (%) trauma: 74 (74.7) plant matter 26 (26.3) dust 14 (14.1) soil 11 (11.1) wood 6 (6.1) stone 5 (5.1) metal 4 (4.0) insect 3 (3.0) unidentified source 5 (5.1) chronic ocular and systemic disorder: 12 (12.1) keratitis 3 (3.0) pterigium 2 (2.0) endophtalmitis 2 (2.0) diabetes mellitus 2 (2.0) panophtalmitis 1 (1.0) blepharitis 1 (1.0) trichiasis 1 (1.0) contact-lens wear 4 (4.0) recent ocular surgery 2 (2.0) unknown 7 (7.1) table 3 pathogenic bacteria of patients with bacterial corneal ulcer bacteria bacterial corneal ulcer n (%) single-bacteria 67 (67.7) gram-positive cocci 56 (56.6) gram-negative cocci 1 (1.0) gram-negative baccili 10 (10.1) multiple-bacteria 32 (32.3) astrid maharani putri, susi heryati, nursiah nasution: characteristics and predisposing factors of bacterial corneal ulcer in the national eye center, cicendo eye hospital, bandung from january to december 2011 althea medical journal. 2015;2(3) 446 amj september, 2015 corneal ulcer is an ophthalmic emergency requiring immediate diagnosis and treatment, especially bacterial corneal ulcer because of its rapid pathogenesis. diagnosis of corneal ulcer can be established by clinical examinations, whereas diagnosis of its etiology cannot be established only by clinical manifestations. diagnosis of etiology depends on laboratory examinations, like smears and cultures from direct scrapes of the corneal ulcer. the success of its treatment and prognosis depends on the appropriate diagnosis, etiology, and degree of severity.1,7,10,11 knowing the characteristics of patients with bacterial corneal ulcer including predisposing factors, etiology, and degree of severity may help in establishing diagnosis and treatment appropriately and promptly. in this study, the incidence of bacterial corneal ulcer was more predominant in male (66.7%) than female (33.3%). this finding is similar to other studies which have been conducted in indonesia and other countries. for example, in the studies in dr. sardjito hospital5, in nepal7, and in taiwan12, the majority of bacterial corneal ulcer patients were male. this may occur because male tends to have more outdoor activities like working, or those with certain occupations that puts them at high-risk locations for ocular trauma, i.e farmers and laborers.7,9 the average age of all patients was 44.4 years. this finding is similar to other studies. fong et al.12 reported in his study in taiwan during 1992–2001 that the mean age of all patients was 40.7 years. additionally, jeng et al.13 also reported in his study in northern california during 1998–1999 that the mean age was 42.8 years.12,13 according to the literatures, symptoms of bacterial corneal ulcer are decreased vision, red eye, photophobia, eye pain, and exudates.3,14 in this study, most of the symptoms found were similar to the literature, with the most frequent presenting symptom was eye pain (70.7%). most of patients in this study came with poor visual function which was categorized as (near-) blindness (78.8%). this finding is similar to the study conducted in dr. sardjito hospital, stating that most of the patients came with visual acuity <3/60, which was categorized as blindness according to who standard definition.2,7 the most common predisposing factor was ocular trauma, particularly by plant. based on the result of the study performed by dhakhwa et al.5, cases of corneal ulcer in western nepal frequently occurred as sequela of agricultural injury causing corneal abrasion. so this finding is similar to the studies mentioned previously. corneal ulcer due to single-bacterial infection is prominent, mainly by grampositive cocci bacteria (56.6%). this finding is also similar to other studies, as performed by dhakhwa et al.5 in western nepal in 2007. the study reported that bacterial corneal ulcer was mostly caused by gram-positive cocci single bacterial infection.5 according to jones’ criteria, clinical degree of severity of corneal ulcer is graded as mild, moderate, or severe. four essential aspects are required in assessing the severity, i.e ulcer size, ulcer depth, infiltrate, and scleral involvement15. most of the patients came table 4 severity of patients with bacterial corneal ulcer severity bacterial corneal ulcer n (%) mild 51 (51.5) moderate 16 (16.2) severe 32 (32.3) table 5 visual acuity and ulcer location of patients with bacterial corneal ulcer visual acuity ulcer location central n(%) paracentral n(%) periphery n(%) (near-) normal vision 4 (4.0) 1 (1.0) low vision 3 (3.0) 10 (10.1) 3 (3.0) (near-) blindness 53 (53.5) 20 (20.2) 5 (5.1) althea medical journal. 2015;2(3) 447 with mild severity (51.5%), and this is similar to the study in dr. sardjito hospital, as the tertiary eye care in d.i. yogyakarta, reporting that patients mostly came with mild severity (43.9%), followed by moderate (31.6%) and severe (24.7%).7 in this study, all of the ulcers located at the central cornea cause visual impairment and mostly cause (near-) blindness. this finding is similar to the literature stating that corneal ulcer is one of the emergency conditions in ophthalmology because cornea plays an important role in maintaining visual function, specifically as a refractive media which has optical properties (determined by its transparency, surface smoothness, contour and refractive index). if a turbidity is developed in the cornea, it will induce alteration in its optical properties and therefore interfere the entry of light, so it may cause impaired vision.1,4,16 there were some limitations in this study. this study was a cross-sectional retrospective study using secondary data; therefore, the quality of this research result totally depended on the quality of those data. some data were incomplete, so they must be excluded. in conclusion, the incidence of microbial corneal ulcer was 203 cases, with 48.8% was bacterial type. the characteristics of patients’ bacterial corneal ulcer found in this study mostly occurred to male patients. they came with eye pain, history of ocular trauma mostly caused by plant, and caused by gram-positive cocci bacterial infection. most of the patients were diagnosed with mild severity, with central location, and poor visual function. despite these limitations, this research is considered to be useful as a basis of upcoming research and essential information for health workers and the society. according to these findings, it is recommended that visual acuity to be included as an additional aspect to assess the clinical severity of corneal ulcer. references 1. ilyas s, editor. ilmu penyakit mata. 3th ed. jakarta: balai penerbit fkui; 2005. p. 4-167. 2. dijk kv. definition: visual impairment. 2012. [cited 2012 may 14]. available from: http://www.bpaindia.org/vib%20 chapter-i.pdf. 3. lang gk. cornea. in: lang gk, editor. ophtalmology: a short textbook. stuttgart: georg thieme verlag; 2000. p. 117–56. 4. kumar a, pandya s, kavathia g, antala s, madan m, jadvekar t. microbial keratitis in gujarat, western india: findings from 200 cases. pan afr med j. 2011;10:48. 5. dhakhwa k, sharma, bajimaya s, dwivedi ak, rai s. causative organisms in microbial keratitis, their sensitivity pattern and treatment outcome in western nepal. nepal j ophtalmol. 2012;4(1):119–27. 6. norina tj, raihan s, bakiah s, ezanee m, liza-sharmini at, wan hazzabah wh. microbial keratitis: aetiological diagnosis and clinical features in patients admitted to hospital university sains malaysia. singapore med j. 2008;49(1):67–71. 7. suhardjo, widodo f, dewi um. tingkat keparahan ulkus kornea di rs 8. dr. sardjito sebagai tempat pelayanan mata tersier. medika. 2003;29(3):148–52. 9. sinha r, sharma n, vajpayee rb. corneal blindness-present status.. cataract & refractive surgery today. 2005. [cited 2012 may 14] available from: http:// crstoday.com/2005/09/crst1005_14. php/ 10. bangun cyy. prevalensi kebutaan akibat kelainan kornea di kabupaten langkat (thesis). medan:university of sumatera utara; 2009. 11. biswell r. vaughan & asbury’s general ophtalmology. 16th ed. new york:mcgrawhill medical; 2007. 12. seal dv, pleyer u. ocular infection. 2th ed. boca raton, florida: crc press; 2008. 13. fong cf, tseng ch, hu fr,wang ij, chen wl, hou yc. clinical chracteristics of microbial keratitis in a university hospital in taiwan. am j ophtalmol. 2004;137(2):329–36 14. jeng bh, gritz dc, kumar ab, holsclaw ds, porco tc, smith sd, et al.. epidemiology of ulcerative keratitis in northern california. arch ophtalmol. 2010;128(8):1022–8 15. mielke j. cornea. in: schlote t, rohrbach j, grueb m, mielke j, editors. pocket atlas of ophtalmology. new york: thieme; 2006. p. 96–7. 16. cokingtin cd, hyndiuk ra. bacterial keratitis. in: tabbara kf, hyndiuk ra, editors. infections of the eye. 2th ed. new york: little, brown and company; 1996. p. 323–44. 17. nishida t. cornea. in: krachmer jh, mannis mj, holland ej, editors. cornea. 2th ed. new york: elsevier mosby; 2005. p. 3–22. astrid maharani putri, susi heryati, nursiah nasution: characteristics and predisposing factors of bacterial corneal ulcer in the national eye center, cicendo eye hospital, bandung from january to december 2011 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 36 amj march, 2015 knowledge level of pregnant women in cipacing village on nutrition and benefits of colostrums haviz reddy1, siti nur fatimah2, zulvayanti3 1faculty of medicine, universitas padjadjaran, 2department of medical nutrition, faculty of medicine, universitas padjadjaran, 3department of obstetry and gynecology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: colostrums are the only natural food that is healthy for newborn infants since colostrums contain proper nutrition needed for infants’ growth. this study aimed to reveal the knowledge level of pregnant women on nutrition and benefits of colostrums. methods: this study used descriptive cross-sectional method on 73 pregnant women in cipacing village, jatinangor district, sumedang regency, west java, from october 18 to november 14, 2012. a questionnaire was used. results: the results showed that the characteristics of these pregnant women were as follows: 20-35 years old (53.4%), most were middle school graduates (42.5%), most were unemployed (72.6%), and some claimed to have never given birth before (37,0%). mostly, the knowledge level of these pregnant women was in the category of “favorable” (84.9 %). the knowledge level with the highest percentage (100%) came from pregnant women aged above 35 years old, college graduates, employed as private employees, civil servants, or self-employed, as well as having three biological children or more. conclusions: sustained health promotion and counseling programs are needed to maintain alreadyfavorable knowledge level; thus pregnant women’s knowledge on nutrition and benefits of colostrums can be applied and can also encourage these women themselves to provide colostrums for their newborn infants. keywords: benefits of colostrums, jatinangor, nutrition, women’s knowledge level correspondence: haviz reddy, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282125416781 email: havizreddy@gmail.com introduction colostrums are secretions similar to milk, produced in female human breasts during the final period of pregnancy until one to three days after laboring or before transitional breast milk is produced.1colostrums have a yellow hue in color and are more condensed than breast milk since colostrums contain beta-caroten.2 several benefits of colostrums for newborn infants are as follows: as a laxative-like substance to clean the colon of the infant, as well as cleaning the meconium to allow the digestive tract to digest food; as a substance rich in immunoglobulin, particularly immunoglobulin a (iga), which provides protections against bacterial infections, viruses, fungal infections, and allergens. colostrums can protect the infant’s body against infections and diseases for almost six months since colostrums are rich in leukocytes and bifidus factors that help stimulate the growth of good bacteria lactobacillus. colostrums consist of proteins and enzymes with much more quantity than breast milk, thus colostrums can also help stimulate good growth and metabolism of body cells. aside from proteins, colostrums also contain fat-soluble vitamins as well as minerals, particularly vitamin a and carotene that help maintain eye health. colostrums are low in fat and lactose than breast milk, thus providing balanced nutrients for newborn infants during their first days after birth. 1,3 low levels of colostrums feeding to infants become one of many factors that trigger disturbances in the infant’s overall growth. infants that do not consume enough colostrums and breast milk in a proper way can also increase the risks of suffering from nutrition disorder, and they become more prone to diseases such as indigestion, upper respiratory tract infection (urti), allergies, as althea medical journal. 2015;2(1) 37 well as affecting their viability and longevity. 4 low levels of colostrums-feeding to infants have also been included as one of many factors that affect infant mortality rate (imr), which becomes the indicator of the degree of public health. according to the data in 2004, infant mortality rate in several regions in southern regions of west java shows fairly high infant mortality rates, occurring in garut where it reaches 53.79 per 1000 live births, followed by tasikmalaya regency (48.75) as well as cianjur (50.87). in 2008, the imr is still above 40 per 1,000 live births in west java province, where there are 10 regions with the highest number of infant mortality.5-7 cipacing village is one of villages located in jatinangor district, sumedang regency, west java. according to health records retrieved from jatinangor local clinic (puskesmas jatinangor), in 2011 there are several cases recorded, namely upper respiratory tract infection (urti) on infants, nutrition disorder on infants, as well as high rates of pregnant women among other villages in jatinangor district. diseases such as urti and nutrition disorder can be resulted from many factors, which one of them is low levels of colostrumsfeeding to infants and toddlers, and this factor is also influenced dominantly by mothers’ knowledge level.8 based on the explanation above, depictions of the knowledge level of pregnant women in cipacing village, jatinangor district, sumedang regency, nutrition and benefits of colostrums were required since there were no adequate amount of data of knowledge level of pregnant women on nutrition and benefits of colostrums generally in west java province and particularly in sumedang regency. pregnant women were chosen as the main subject of the study since they are required to utilize their knowledge on nutrition and benefits of colostrums after giving birth to their newborn infants. the result, in the form of a depiction of knowledge on nutrition and benefits of colostrums, is expected to become a part of consideration made by health care providers in providing counseling activities, in order to improve or maintain the efforts in informing pregnant women to affect their decision in feeding colostrums to their infants after giving birth, particularly among pregnant women in cipacing village, jatinangor district, sumedang regency. methods this study used descriptive survey research method using cross-sectional approach to reveal the depiction of knowledge level of pregnant women in cipacing village, jatinangor district, sumedang regency, on nutrition and benefits of colostrums in such an objective way. this study was conducted on 73 respondents during the period from october 18 to november 14, 2012. all pregnant women in cipacing village, jatinangor district, sumedang regency based on records of pregnant women were retrieved from midwives and neighborhood health centres or ‘posyandu’in cipacing village, jatinangor district in september 2012, which was available and accepted the terms of this study. cipacing village itself is divided into 18 neighborhood councils or ‘rw’, with two midwives dividing these rw into two working areas. besides, cipacing village itself has 18 health centres or ‘posyandu’ run by health workers in each rw. based on questionnaires, the knowledge level of pregnant women on nutrition and benefits of colostrums was divided into three categories: favorable, mediocre, and less favorable. analysis was conducted in the form of frequency distribution or percentage of each variable. this univariate analysis aims to reveal frequency distribution and proportional amount of each characteristic examined in this research. numeric data were described by explaining the lowest score, the highest score, the average score, and the standard deviation. furthermore, category data were examined in the form of frequency distribution table or using formulas. result table 1 showed that pregnant women with table 1 knowledge level of pregnant women on nutrition and benefits of colostrums knowledge level frequency (people) percentage (%) favorable 62 84.93% mediocre 4 5.48% less favorable 7 9.59% haviz reddy, siti nur fatimah, zulvayanti: knowledge level of pregnant women in cipacing village on nutrition and benefits of colostrums althea medical journal. 2015;2(1) 38 amj march, 2015 favorable knowledge level were in the highest frequency, with a fairly huge difference with other categories, mediocre and less favorable. table 2 showed that all 73 pregnant women involved in the study, the favorable knowledge level on nutrition and benefits of colostrums with the highest percentage, come from pregnant women under the category of “above 35 years old”. the category of “below 20 years old” showed the highest frequency of mediocre knowledge level. based on these results, it can be inferred that there are certain tendencies: the younger these pregnant women, the lower the knowledge level on nutrition and benefits of colostrums. it can also be inferred that the older these pregnant women, the higher the knowledge level. table 3 showed that 73 pregnant women in this study, the favorable knowledge level on nutrition and benefits of colostrums with the highest percentage (100%) come from pregnant women with education levels of diploma-iii and bachelor degree. on the other hand, on the education levels of elementary school, junior high school, and senior high school, the knowledge levels are not entirely favorable. table 4 showed that 73 pregnant women table 2 knowledge level of pregnant women on nutrition and benefits of colostrums, based on age age (years) knowledge level favorable mediocre less favorable f* %* f* %* f* %* <20 4 66.70% 0 0.00% 2 33.30% 20-35 32 82.10% 3 7.70% 4 10.30% >35 26 92.90% 1 3.60% 1 3.60% table 3 knowledge level of pregnant women on nutrition and benefits of colostrums, based on education level education level knowledge level favorable mediocre less favorable f* %* f* %* f* %* elementary 6 60.00% 1 10.00% 3 30.00% junior high 24 88.89% 0 0.00% 3 11.11% senior high 27 87.10% 3 9.68% 1 3.23% diploma-iii 1 100.00% 0 0.00% 0 0.00% bachelor degree 4 100.00% 0 0.00% 0 0.00% table 4 knowledge level of pregnant women on nutrition and benefits of colostrums, based on occupation occupation knowledge level favorable mediocre less favorable f* %* f* %* f* %* housewife 44 83.02% 4 7.54% 5 9.43% private employee 11 100.00% 0 0.00% 0 0.00% labor 3 60.00% 0 0.00% 2 40.00% civil servants 2 100.00% 0 0.00% 0 0.00% self-employed 2 100.00% 0 0.00% 0 0.00% althea medical journal. 2015;2(1) 39 in this study can be inferred that knowledge level of pregnant women with occupation as civil servants, private employees, and selfemployed were in the category of “favorable”. pregnant women working as labors and housewives did not entirely have favorable knowledge level. table 5 showed that in this study, only pregnant women having three biological children or more had favorable knowledge level on nutrition and benefits of colostrums, with 100% percent. pregnant women who already had two children or less, had lesser percentage of favorable knowledge level. the data showed that in this research, there was a tendency that a pregnant mother having more biological children would have better knowledge level on nutrition and benefits of colostrums. discussions based on this study, most of pregnant women have favorable knowledge level. this is influenced by primary health care providers such as ‘puskesmas’ that gives counseling and socialization on nutrition and benefits of colostrums for newborn infants as well as how health care workers such as midwives in every health care center play a huge role in promoting and informing pregnant women to improve their knowledge on the importance of colostrums due to its nutrition and benefits for newborn infants. most of these pregnant women are in their optimum reproduction age.9 pregnancy during optimum reproduction allows the mother to give birth normally or per vaginam, thus having greater chances to breastfeed her newborn infant. the experience of breastfeeding newborn baby and the support from health workers who help the labor process and intervene the mother to immediately provide colostrums to her baby can also affect her knowledge level on nutrition and benefits of colostrums. 10 pregnant women with higher risks of labor due to young age (below 20 years old) can suffer from diseases or pathological conditions such as pre-eclampsia, eclampsia, or premature birth. pregnant women below 20 years old also tend to ignore pre-natal treatments, thus preventing them from getting informed on nutrition and benefits of colostrums from health workers.11this can lead to abnormal conditions both during pregnancy and labor, where there are greater chances of the mother to labor with pathological conditions, or non per vaginam.9,11this will also result in situations preventing the mother to immediately breastfeed her newborn baby with colostrums due to loss unconsciousness after laboring, thus affecting her knowledges on nutrition and benefits of colostrums.9, 10 based on this study, there is a tendency where the lower the education level, the lower the knowledge level on nutrition and benefits of colostrums. this is in accordance with the theory by notoatmodjo10, stating that one’s education level also determine their capability of getting information. however, it does not necessarily mean that those with education level of elementary school do not have proper knowledge level. with several other factors affecting knowledge level, it can also be concluded that education levels should not necessarily become the absolute benchmark to determine one’s knowledge level. 10nevertheless, education should always remain as the main, important point since studies conducted in many countries in asia and africa regions have shown that there are positive effects between mother’s knowledge level and the health table 5 knowledge level of pregnant women on nutrition and benefits of colostrums, based on the number of biological children number of biological children knowledge level favorable mediocre less favorable f* %* f* %* f* %* 0 19 70.40% 3 11.10% 5 18.50% 1 17 89.50% 1 5.30% 1 5.30% 2 17 94.40% 0 0.00% 1 5.60% 3 8 100.00% 0 0.00% 0 0.00% 4 1 100.00% 0 0.00% 0 0.00% haviz reddy, siti nur fatimah, zulvayanti: knowledge level of pregnant women in cipacing village on nutrition and benefits of colostrums althea medical journal. 2015;2(1) 40 amj march, 2015 condition of the mother and her children.12 based on this study, pregnant women working as labors and housewives do not entirely have favorable knowledge level. employed mothers indirectly allow themselves to get more interactions outside their home, thus they do not have a lot of time spent at home than housewives do. however, interactions with many people in their own communities also allow good circulations of information, thus there is a tendency that employed mothers can have broader knowledge and insights than those who are unemployed. most of 73 pregnant women in this study are pregnant women with nullipara. the least number found in this research is pregnant women with three children. any other factors that can contribute to the results of this study are the use of contraception or birth control, or the family planning program that has been widely spread among people in cipacing village. mothers with a first-time pregnancy or nullipara do not have experience of providing colostrums to the baby himself. women who have never given birth tend not to come into contact with health professionals who help the delivery process, so that it affects the low level of knowledge about the nutritional value and benefits of colostrums.10women who have given birth once or more will generally produce colostrum faster with higher numbers progressively compared to women who have never given birth. 12this may affect the level of experience and knowledge level of the mother, because the experience gained can later be converted into one knowledge. 10 sustained and continuous health promotion is required to maintain already-favorable knowledge level and improve less favorable knowledge level among pregnant women in cipacing village, jatinangor district. such health promotion by health workers is not the mere factor that affects the knowledge level of women, especially mothers, on nutrition and benefits of colostrums. notoatmodjo argued that apart from proper information, other factors that matter are as follows: age, education, experience, social life, and culture.10 health workers can minimize roles of other such factors, thus health promotion or counseling programs can always be maintained and improved frequently in the form of counseling programs for particular age, experience, education level, and culture of pregnant women themselves. further studies are required to determine the factors that affect infant mortality in district and subdistrict sumedang jatinangor and factors that influence the incidence of upper respiratory tract infections and nutritional disorders in infants in the village cipacing, district jatinangor. references 1. whitney e, rolfes sr. understanding nutrition. 11th ed. belmont: thompson wadsworth; 2008. p.550-1. 2. american pregnancy association. breastfeeding: overview. 2012; [update 2012; downloaded in 27 april 2012]; available at: http:// a m e r i c a n p r e g n a n c y. o r g / f i r s t y e a r o f l i f e / b r e a s t f e e d i n g o v e r v i e w / 3. american pregnancy association. what’s in breast milk?. 2012; [updated 2011; downloaded in 27 april 2012]; available at: http://americanpregnancy.org/ first-year-of-life/whats-in-breastmilk/ 4. pusat komunikasi publik sekretariat jenderal kementerian kesehatan ri. banyak sekali manfaat asi bagi bayi dan ibu. jakarta: pusat komunikasi publik, sekretariat jenderal kementerian kesehatan ri; 2011; [downloaded in 28 april 2012];available at: http://www.depkes. go.id/article/view/1450/banyak-sekalimanfaat-asi-bagi-bayi-dan-ibu--.html. 5. dinas kesehatan provinsi jawa barat. kematian bayi di indonesia banyak terjadi di masa neonatal. bandung: dinas kesehatan provinsi jawa barat 2012; [update 2012, downloaded in 26april 2012]; available at: http://www.diskes.jabarprov. go.id/index.php/post/read/2012/26/ k e m a t i a n b a y i d i i n d o n e s i a b a n ya k-te r j a d i d i m a s a n e o n a t a l / g 6. heryawan a. agenda pemerintah provinsi jawa barat triwulan iii juni–september 2008. bandung: pemerintah provinsi jawa barat; 2008. [donwloaded in 26 april 2012]; available at: http://jabarprov.org/docs/ p e re n c a n a a n / 2 0 0 8 0 7 0 2 _ 0 8 5 3 1 5 . p d f 7. pemerintah provinsi jawa barat. kesehatan. bandung: pemerintah provinsi jawa barat; 2004; [downloaded in 26april 2012]; available at: http://www. google.com/url?sa=t&rct=j&q=&esrc=s &source=web&cd=1&ved=0cdeqfjaa &url=http%3a%2f%2fwww.jabarprov. g o . i d % 2 f r o o t % 2 f i p m % 2 f b a b v. k e s e h a t a n 0 4 . d o c & e i = n j w a u a k l h o v x r q f u 6 o g i d w & u s g = a f q j c n e f q 9 3 q f d 0 3 9 r c x q k q s ztppbcoqw&bvm=bv.41524429,d.bmk althea medical journal. 2015;2(1) 41 8. hapsari d. telaah berbagai faktor yang berhubungan dengan pemberian asi pertama (kolostrum). 2001; [downloaded in 26 april 2012]; available at: file http:// c g i . f i s i p o l . u g m . a c . i d / i n d e x . p h p / i d / component/attachments/download/64. 9. saifuddin ab, rachimhadhi t, wiknjosastro gh. ilmu kebidanan sarwono prawirohardjo. 4th ed. jakarta: bina pustaka sarwono prawirohardjo; 2009. p. 375-6. 10. soekidjo n. prinsip-prinsip dasar ilmu kesehatan masyarakat. 5th ed. jakarta: rineka cipta; 2004. p. 127–30. 11. beers mh, porter rs, jones tv, kaplan jl, berkwits m. high-risk pregnancy. 2010; [downloaded in 19 november 2012]; available at: http://www.health. am/pregnancy/high-risk-pregnancy/#7 12. solihah i, lindawati, miradwiyana b, taufiqqurahman, suryati b, suryani, et al. faktor faktor yang berhubungan dengan pemberian asi dalam satu jam pertama setelah lahir di kabupaten garut, provinsi jawa barat: analisis survei data dasar pengembangan model pelayanan kesehatan neonatal esential di kabupaten garut, jawa barat, tahun 2007. media litbang kesehatan. 2010;20(2):79–90 haviz reddy, siti nur fatimah, zulvayanti: knowledge level of pregnant women in cipacing village on nutrition and benefits of colostrums althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 12 amj march 2016 association of body mass index to onset of puberty in male jeevithaambigai a/p subramaniam,1 yulia sofiatin,2 r.m ryadi fadil3 1faculty of medicine universitas padjadjaran, 2department of epidemiology and biostatistics faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: puberty is the period where the developmental process takes place, marks the transition from childhood to adulthood with physical and physiological changes. this study was conducted to discover association between body mass index (bmi) and onset of puberty in male. methods: a cross-sectional study was conducted from may to november 2013 using simple random sampling which was part of bigger research study by nutrition and metabolism working group on jatinangor cohort, especially puberty survey in jatinangor, by department of epidemiology and biostatistics faculty of medicine universitas padjadjaran. respondents were 286 males, 9‒15 years old from elementary school (sekolah dasar/sd) and junior high school (sekolah menengah pertama/smp). inclusion criteria were students who are healthy at the time and do did not have obvious disease, attained puberty within 1 year or did not yet attained it, and voluntarily followed the study procedure. the questionnaire was provided after getting informed consent from the respondents. the data analysis was done conducted using pearson correlation. results: the magnitude of association of bmi to the onset of puberty in male among school students in jatinangor was 0.243 which showed there was positive correlation coefficient between bmi to onset of puberty in male. test results with the t-test showed t-value of 2.683 with p-value of 0.008. conclusions: there is association of bmi to the onset of puberty in male among school students in jatinangor. positive correlation indicates that the higher the bmi, the faster the onset of puberty in male. [amj.2016;3(1):12–16] keywords: body mass index, male students, nutritional status, onset of puberty correspondence: jeevithaambigai a/p subramaniam, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281312354379 email: jeevithaambigai@gmail.com introduction the time of dramatic transformation in human lifecycle is termed as puberty.1,2 this is the period where there is the biologic transition between immature and adult reproductive function.3 the changes are not only in terms psychologically, but also rapid changes in size, shape, and composition which are sexually dimorphic.4 due to the changes, it is required to understand the physical changes that occur during puberty in order to evaluate and treat the aberrations of pubertal development.5 prospective studies for male puberty frequently use pubic and facial hair growth, voice change , and genital growth such as testicles and penis, but these changes can be unreliable and may be poorly recalled.6 these studies have disregarded such measures and examined self-perception of pubertal onset.6 for males, it is recommended to use first sexual attraction, first nocturnal emission or termed as wet dream and first masturbation as assessment for onset of puberty.6 there are a number of factors that acts independently to influence the growth and maturation. more recently nutrition status by assessing the body mass index (bmi) on the timing or onset of puberty in male has become topic of interest.7 leptin or fat cells and estradiol are the factors that will alter the onset of puberty in male if bmi is taken into account.7 there is a relatively extensive literature demonstrating or showing an inverse association between body fat and age at pubertal onset in girls, that is higher bmi leading to earlier age of menarche but the althea medical journal. 2016;3(1) 13 similar studies in male are still lacking.7 so this study enables to understand whether there is any association or correlation between bmi and the onset of puberty in male and how it is correlated. methods this cross sectional type of study was conducted from may to november 2013 in schools that were included in bigger study conducted by nutrition and metabolism working group in jatinangor cohort, especially puberty survey in jatinangor, by department of epidemiology and biostatics faculty of medicine universitas padjadjaran which collected data from all grade 7 and 8 students from several junior high school (sekolah menengah pertama, smp) and all grade 4 and 5 students from several elementary school (sekolah dasar, sd) in kecamatan jatinangor. the study was conducted after getting clearance from the health research ethics committee faculty of medicine universitas padjadjaran. validated and reliable questionnaires were provided to students after getting permission from the head of the school. the sampling method used was simple random method. the subjects were comprised of male school students aged 9‒15 years old. the total of 286 respondents were given questionnaires with their consent. the onset of puberty was accessed through the age of onset of wet dream and the bmi was measured by taking height and weight using stadiometer and weighing scale. the subject of the study were included if they were healthy at the time and did not have obvious illness, attained puberty in one year and voluntarily followed the research procedure. the subjects were excluded from the study if they did not attend the school when the survey was conducted and who refused to answer the questionnaires. in order to measure the height and weight for detecting bmi, it is essential to know the correct and reliable procedure or method to prevent error during recording. to measure height, the following procedure was followed. firstly, the procedure was started by asking the students identity such as name, age, school, and the students were asked to take off their shoes before the measurement, and to stand with their back against the board (part of the body touches the board such as heel, buttock, back of the body, and head), body weight was evenly distributed on both feet, arm hung freely by the sides of the body, palms faced the thighs, legs were placed together, brought knees or jeevithaambigai a/p subramaniam, yulia sofiatin, r.m ryadi fadil: association of body mass index to onset of puberty in male ankles together, the student stood erect; heads was up and faced straight ahead, verified the body position front and left by the examiner, positioned head in frankfort horizontal plane. the students were asked to inhale deeply and held their breath without moving head or body, brought headpiece down onto the upper most point on the head; compressed the hair, asked them to exhale, then height was recorded to the nearest 0.1 cm (or appropriate unit for the stadiometer) and the examiner had to convert into meter later. the standardized method to measure weight was shown below. the scale was adjusted to “zero” by examiner and if the scale was accurate and there was no any zero error, the assessment had begun. the students were asked to remove extra layers of clothing, and any heavy items in their pockets, the child is asked to stand in the scale to ensure that the body weight is evenly distributed between both feet, arms is hang freely by the sides of the body, palms toward thighs, head is up and facing straight ahead, weight is recorded to nearest 0.1 kg (or appropriate unit for the scale). after finding the average height and weight, the bmi was calculated using the formula weight (kg) over height (m2), so it can be categorized into underweight (<18.5 kg/m2), normal (18.5‒24.99 kg/m2), obese (25‒29.99 kg/m2) and finally obese (≥30 kg/ m2) to find the correlation of fat mass to the onset of puberty.8 the respondents were included only if the difference of age of onset of wet dream and the current age of the student was less than or equal to 1 year, students were healthy at the time and did not have obvious illness, and respondents voluntarily followed the research procedure. only students with difference of age of onset of wet dream and the current age less than or equal to 1 year were included because male with difference of age more than 1 year would attain the pubertal growth spurt which may alter the bmi measurement. from these criteria, 117 students were included in the study and the rest were excluded. the association of bmi and onset of puberty was found through correlation studies of bivariate variable using pearson method that was analyzed through statistical package for the service solutions (spss) programm. statistically, significant result was considered when p<0.05. results there were 117 subjects included in the big study and were assessed according to the althea medical journal. 2016;3(1) 14 amj march 2016 characteristics of the subjects which were bmi and age of wet dreams, which signified duration of puberty. the bmi assessment was according to world health organization (who) classification. the age of wet dreams or the duration of puberty was classified into 3 categories; early onset (<9 years), normal onset (9‒13 years old) and late onset (≥14 years). the bmi average of the respondent was 19.41 and standard deviation of bmi of the respondent was small enough which was equal to 2.64. students with late onset of puberty were far less if compared to normal onset of puberty. half of the students belonged to the bmi classification normal (table 1). those with normal onset of puberty, who were most of the students, were classified into normal bmi. the least number of students were from late onset of puberty with bmi classification obese (table 2). the magnitude of bmi association to the onset of puberty in male among school students in jatinangor analyzed by pearson correlation was 0.243. test results with the t-test showed t-value of 2.683 with p value of 0.008. if compared to significance level α=5%, the p value was worth less. discussions a tumor is an abnormal growth of tissue, based on the onset of wet dreams, there were about 93 students, 79.49% with normal onset of puberty in between 9‒13 years, whereas only 24 students which is 20.51% with late onset of puberty (≥14 years). there was no data available for early onset of puberty which table 2 cross tabulation of bmi and onset of puberty bmi onset total early normal late underweight na 43 7 50 % 0.00 36.75 5.98 42.74 normal na 47 12 59 % 0.00 40.17 10.26 50.43 overweight na 3 5 8 % 0.00 2.56 4.27 6.83 obese na 0 0 0 % 0.00 0.00 0.00 0.00 total na 93 24 117 % 0.00 79.49 20.51 100 note: na=not available table 1 respondent characteristic respondent characteristics frequency (n=117) percentage (%) onset of puberty early na na normal 93 79.49 late 24 20.51 bmi underweight 50 42.74 normal 59 50.43 overweight 8 6.84 obese 0 0 note: na=not available althea medical journal. 2016;3(1) 15 was <9 years old. this is because the study population did not comprise students aged <9 years old. the mean age of attaining puberty based on the study was 12.72 years. the students who earliest attain puberty were at the age of 9 years and those who latest reach puberty were at the age of 15 years. according to jaruratanasirikul and colleague in thailand9, the youngest boy who attains earliest onset of puberty is 8.2 and 9.2 years and the range of mean is around 10.8–12.4 years if assessed according to tanner 2 testicular enlargement and tanner 2 pubic hair. compared to the result in thailand9, onset of puberty in jatinangor is latter because the criteria used to assess onset of puberty was wet dreams. the onset of puberty according to tanner is faster than wet dreams. the mean of bmi was 19.41 with standard deviation of 2.64. around half of the subjects which is 59 students (50.43%) had normal range the data showed that there were big number of students who were underweight with a frequency of 50 students and a small number of students who were overweight. therefore, it can be concluded that half of the students in the population had poor nutritional status. a study conducted by rajeev10 in india showed that the mean of bmi is 17.36 (3.08%) in 2005. compared to that result, the bmi of jatinangor adolescence were higher than indians.10 based on the study, there was association between bmi and onset of puberty. the result signified positive correlation that high bmi correlated with early onset of puberty. this study result is similar to the longitudinal prospective study conducted by lee et al.7 on bmi and timing of pubertal initiation in male. study by lee et al.7 showed that there is strong association between bmi and onset of puberty in male. however, instead of using questionnaire, this particular study used tanner genitalia staging as main outcome measure to detect onset of puberty, even the reliability and validity of this method has been questioned. on the other hand, other similar studies by tremblay and lariviere11 found that there was no significant association in male. this study used validated questionnaire as an instrument and included 569 boys total aged between 9, 13, 16 years. the samples were taken as randomized stratified samples. besides that, this study used other environmental factors which may alter bmi such as peer influence during the study. there are several limitations in this study jeevithaambigai a/p subramaniam, yulia sofiatin, r.m ryadi fadil: association of body mass index to onset of puberty in male that may interrogate the variables that have been measured. instead of showing negative correlation, this study, showed positive association which high bmi had early onset of puberty. this correlation theoretically against the current proposed hypothesis. this study only measured the bmi after attaining the growth spurt because the bmi was not assessed during the onset of puberty, but within 1 year after attaining, the onset of wet dreams as the consequence the bmi may be altered by the growth spurt during the 1 year period of puberty. so, to overcome this problem, it is highly recommended to conduct cohort study embedded to usaha kesehatan sekolah (uks), the health monitoring in schools so the method will be effective in measuring the bmi on the onset and at the same time, the reproductive health education can be reached among school students. besides that, by selfanswering question, the respondents may feel uncomfortable which may alter the finding of the study. instead of self-answering monitored by the researcher, online questionnaire could be more reliable and effective. besides that, this study used secondary data to detect age of the onset of puberty where it may have recall bias. the school students probably faced difficulty in recalling the exact year at the first time they had wet dreams. furthermore, in order to get more accurate date of the onset of puberty it is required to educate male student on the importance of reproductive health. finally, the population samples of this study contained limited number of obese students. therefore, the bmi of the population were not normally distributed and mostly comprised of underweight and normal bmi. to overcome this problem, the study can be conducted in different setting with more obese male students or it is recommended to conduct cohort study. in conclusion, there is association of bmi to the onset of puberty in male among students in jatinangor sub district. positive correlation coefficient indicates that the higher the bmi, the faster the onset of puberty in male will be. it adds the controversies on the correlation of nutritional status and onset of puberty. further study with better design and measurement method is needed and it will be better to embed this study into established program such as uks. references 1. mendle j, ferrero j. detrimental psychological outcomes associated with pubertal timing in adolescent boys. dev althea medical journal. 2016;3(1) 16 amj march 2016 rev. 2012;32(1):49–66. 2. bond l, clements j, bertalli n, evanswhipp t, mcmorris bj, patton gc, et al. a comparison of self-reported puberty using the pubertal development scale and the sexual maturation scale in a schoolbased epidemiologic survey. j adolesc. 2006;29(5):709–20. 3. speroff l, fritz ma. clinical gynecologic endocrinology & infertility. 7th ed. philadelphia: lippincott williams & wilkins; 2005. 4. rogol ad, roemmich jn, clark pa. growth at puberty. j adolesc health. 2002;31(6):192–200. 5. berek js. berek & novak’s gynecology. 14th ed. california: lippincott will & wilkin; 2007. 6. downing j, bellis ma. early pubertal onset and its relationship with sexual taking, substance use and anti-social behaviour: a preliminary cross-sectional study. bmc public health. 2009;9(1):446. 7. lee jm, kaciroti n, appugliese d, corwyn rf, bradley rh, lumeng jc. body mass index and timing of pubertal initiation in boys. arch pediatr adolesc med. 2010;164(2):139–44. 8. gardner d, dolores s. greenspan’s basic & clinical endocrinology. 8th ed. san francisco: mcgraw-hill; 2007. 9. jaruratanasirikul s, yuenyongwiwat s, kreetapirom p, sriplung h. age of onset of pubertal maturation of thai boys. j pediatr endocrinol metab. 2014;27(3–4):215–20. 10. rajeev a. correlation of body mass index and total body fat with physical activity pattern in adolescents. int j diabetes dev ctries. 2009;29(3):139–42. 11. tremblay l, lariviere m. the influence of puberty onset, body mass index, and pressure to be thin on disordered eating behaviors in children and adolescents. eat behav. 2009;10(2):75–83. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 58 amj march, 2015 frequency of chronic venous disease among nurses cendy martanegara1, ra retno ekowati 2 , teguh marfen djajakusumah3 1faculty of medicine, universitas padjadjaran, 2department of biomolecular, faculty of medicine, universitas padjadjaran, 3department of surgery, faculty of medicine, universitas padjadjaran / dr. hasan sadikin general hospital bandung abstract background: chronic vein diseases are quite common and its prevalence is also quite high in community. one of the risk factors is occupation with prolonged standing. quality of life and work efficacy may become risk factors. this disease has not received any special consideration and response. methods: this is a cross-sectional study performed on nurses working in dr. hasan sadikin general hospital bandung (n=98; women=76, men=22). the study was conducted in november 2012 through collecting data on prevalence, risk factors, and clinical symptoms by using questionnaire. chronic venous disease was observed by direct inspection in lower extremities. diagnosis was concluded according to the clinical etiology anatomy pathophysiological criteria. results: there was a high frequency, i.e. 86.7% (n=71), of chronic venous disease among nurses, with the age group of 20–29 years old (34.1%) as the age group that was mostly affected. among female nurses, almost all of them experienced the disease (93.4%; n=71). clinical symptoms felt by most nurses were heavy feeling on legs (82.3%) and cramps (55.3%). conclusion: the frequency of chronic venous disease among nurses is high, 86.7% and almost all of the female nurses suffer from the disease. the high frequency in females could be caused by risk factors such as parity and hormonal contraception. those who are mostly affected by the disease are within range of age 20–29 years old of age. heavy legs and cramps are the most frequent clinical symptoms felt. keywords: chronic vein disease, frequency, nurses correspondence: cendy martanegara, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628985066418 email: cmartanegara@gmail.com introduction there are several risk factors for chronic venous disease (cvd) which can be endogenous or exogenous. endogenous risk factors are age, sex, multiple pregnancies, hormonal contraception, obesity, and exogenous risk factor are prolonged standing, high temperature and humidity.1 prevalence in the community is also high, between 40– 76%.1 some studies revealed that the clinical symptoms, such as heavy legs, cramps, feeling burnt or hot, and itch can affect psychological, financial, and work efficiency.2,3 a study in austria revealed a high prevalence of chronic venous disease among hospital employees and found a positive correlation between presence of chronic venous disease and mean periods of standing each day. the samples in this study were medical doctors and nurses, medical technician assistants, secretaries, scientific staff, cleaners and utility workers, with the highest prevalence was among medical doctors and nurses. 4 there are no published data about frequency of chronic venous disease in indonesia, also in dr. hasan sadikin general hospital bandung which is the national hospital that may indicate a high workload among the hospital employees. the samples included in this study were only nurses. the aim of this study was to determine the frequency of chronic venous disease among nurses in dr. hasan sadikin general hospital bandung. methods the study population were randomly selected from nurses working in dr. hasan sadikin hospital bandung from six different places; emergency department, central operating theatre, outpatient surgery clinic, and surgical ward. the total participants were 76 female and 22 male nurses. althea medical journal. 2015;2(1) 59 all participants agreed to sign the informed consent after receiving explanation about the study and procedure, and then filled the questionnaire regarding risk factors such as age, length of work in years, parity, hormonal contraceptive, and body mass index (bmi). next, the participant was examined for their lower extremities and stand–up for minimum 30 seconds. all examinations were performed by one examiner who classified the findings according to the clinical etiology anatomy pathophysiological (ceap) classification (table 1). participants were also asked for clinical symptoms, such as heavy feeling on legs, burning or hot sensations, edema, pruritus, and cramp. the data were presented as frequency analysis distribution and was statistically analyzed using computer. results confirmation of the presence of cvd was performed by visual inspection of the lower extremities, as well as obtaining information regarding signs and symptoms of cvd (table 2). from the entire clinical symptoms, heavy legs and cramps were the most symptoms felt by the nurses with cvd. there were table 1 clinical part of ceap classification5 c0 no visible or palpable sign of cvd c1 telangiectasis or reticular veins c2 varicose vein c3 edema c4a skin changes; pigmentation or eczema c4b lipodermatosis or atrophie blanchie c5 skin changes with healed ulceration c6 active ulceration 70 (82.4%) nurses who felt heavy legs and 47 (55.3%) felt cramps. only 8 (9.4%) felt burning and pruritus, and 2 (2.4%) had edema. the characteristics were of 98 nurses, consisting of 76 (77.6%) female and 22 (22.4%) male. the range of age was 22 to 56 years, with the mean age 34 years (sd 10.95). as regards duration of work, the range was between 1 to 36 years with mean of duration 11 years (sd 10.4) (table 3) the cvd was present in themajority (86.7%; n=85) of nurses in this hospital (figure 1), among both sexes indeed themajority suffered ofthe disease: 71 (93.4%) werefemale nurses and 14 (63.6%) were male nurses. table 4 evaluated several risk factors. the data showed more than one third of the nurses with cvd were in the range of age 20–29 years and only a minority were of older age. as regards the duration of work, the majority of them has worked less than 10 years (43.5%). among female nurses with this disease only a minority (8.2%; n=7) used hormonal contraception. when evaluation of thenumber of parity was obtained, among the female nurses who suffered cvd there were nulliparous and primiparous (52.6%; n=40) and less multiparous in female (43.7%; n=31). regarding body mass index (bmi), only the minority (7.1%; n=6) of all nurses with cvd was classified into obese. table 2 clinical symptoms symptoms chronic venous disease occurrence absence heavy legs 70 2 burning 8 0 edema 2 0 pruritus 8 1 cramp 47 0 table 3 study sample characteristics characteristics n (%) sex male 22 (22.4) female 76 (77.6) age (years) 20–29 37 (37.8) 30–39 26 (26.5) 40–49 18 (18.4) 50–59 17 (17.3) duration of works (years) 1–10 46 (46.9) 11–20 24 (24.5) 21–30 19 (19.4) 31–40 9 (9.2) cendy martanegara, ra retno ekowati, teguh marfen djajakusumah: frequency of chronic venous disease among nurses althea medical journal. 2015;2(1) 60 amj march, 2015 discussions this study aimed to determine the frequency of cvd among nurses. the presence of cvd was confirmed by visual inspection as well as evaluation of signs and symptoms of cvd among the patients. most of the nurses with cvd felt heavy legs (82.3%, n=70) and cramps (55.2%, n=40). these findings were slightly different compared to the study of ziegler et al.4, where heavy legs and edema are the most occuring common symptoms. there was a high frequency of cvd among nurses working in this hospital, of which the majority experienced this disease. this high frequency might also be influenced by the work environmental risk, such as a higher temperature and humidity. there was also possibility that higher orthostatic burdens were present due to the workload, since dr. hasan sadikin general hospital bandung is the reference hospital in the province.4,6 from the total of 85 nurses with cvd, the majority was found in women. this finding is similar with the result from a study of tuchsen et al.7 and carpantier et al.8 where cvd occurs predominantly in women. since the majority of nurses are women, therefore there was an imbalance proportion of population in this study. when the data was calculated separately between sexes, the frequency of occurrence was found in more than half of population of both sexes. when evaluation of risk factors among female nurses was obtained, parity did not become risk factors among these women. this is contradictive with a previous study which stated that this factor was associated with this disease.1 within this study, there were less multiparous women. moreover, there was other contradictive risk factors found compared to a study conducted by beebedimmer et al.1. older age and higher bmi did not become risk factors among these women. more nurses suffered from this disease at a younger age, and a majority had normal bmi. therefore the most possible risk factor may come from the orthostatic burdens as stated above.4,6 some research found that hormonal contraception could be the risk factors.1 this study had a contradictive result, where only a minority of nurses suffering from this disease used hormonal contraception. the result agrees with kostas et al.,9 who found that from 71 women nurses with cvd 34 (47.8%) used contraception; among them a minority used hormonal contraception. in conclusion, this high frequency of cvd should become a concern of the nurses. they should pay more attention to work-related health risk. risk of cvd could be lowered with more active life style; such as more sports and little simple movements of lower extremities after long standing. also for nurses who already had cvd they should seek for treatment (e.g.: table 4 risk factors of cvd risk factors chronic venous disease occurrence absence age (years old) 20–29 29 8 30–39 23 3 40–49 17 1 50–59 16 1 duration of work (years) 1–10 37 9 11–20 21 3 21–30 19 0 31–40 8 1 obesity (bmi >30) 6 0 hormonal contraception 7 0 multipara 31 0 althea medical journal. 2015;2(1) 61 schlerotherapy injection) or use compression stockings. references 1. beebe-dimmer jl, pfeifer jr, engle js, schottenfeld d. the epidemiology of chronic venous insufficiency and varicose veins. ann epidemiol. 2005;15(3):175–84. 2. rabe e, pannier f. societal costs of chronic venous disease in ceap c4, c5, c6 disease. phlebology. 2010;25 (suppl 1):64–7. 3. sritharan k, lane tra, davies ah. the burden of depression in patients with symptomatic varicose veins. eur j vasc endovasc surg. 2012;43(4):480–4. 4. ziegler s, eckhardt g, stöger r, machula j, rüdiger hw. high prevalence of chronic venous disease in hospital employees. wien klin wochenschr. 2003:115(15–16): 575–9. 5. pappas pj, lal bk, padberg ft, zickler rw, duran wn. handbook of venous disorders: edward arnold ltd.; 2009. [downloaded in 6 april 2012] available at: http://www.hoddereducation.com. 6. kroeger k, ose c, rudofsky g, roesener j, hirche h. risk factors for varicose veins. int angiol. 2004;23(1):29–34. 7. tuchsen f, krause n, hannerz h, burr h, kristensen ts. standing at work and varicose veins. scand j work environ health. 2000;26(5):414–20. 8. carpentier ph, maricq hr, biro c, poncotmakinen co, franco a. prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in france. j vasc surg. 2004;40(4):650–9 9. kostas ti, ioannou cv, drygiannakis i, georgakarakos e, kounos c, tsetis d, et al. chronic venous disease progression and modification of predisposing factors. j vasc surg .2010;51(4):900–7. figure 1 frequency of chronic venous disease cendy martanegara, ra retno ekowati, teguh marfen djajakusumah: frequency of chronic venous disease among nurses althea medical journal. 2015;2(1) 62 amj march, 2015 10. jawien a. the influence of environmental factors in chronic venous insufficiency. angiology. 2003;54 (suppl 1):s19–31. althea medical journal. 2016;3(4) 538 amj december 2016 effectiveness of allergic rhinitis management related to who guideline on allergic rhinitis and its impact on asthma (aria) atika aziza,1 arif dermawan,2 vycke yunivita kusumah dewi3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the standard procedure of allergic rhinitis (ar) management in indonesia is based on allergic rhinitis and its impact on asthma (aria) world health organization (who) 2008 guideline; however, it needs some adjustment to get an effective use locally in indonesia. the data related to the problem however did not exist in indonesia. the study aimed to evaluate the effectiveness of ar patient management based on the aria who guideline in the department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital bandung. methods: the study was conducted from september to october 2015 using quantitative descriptive design to observe the development of aria classification, total nasal symptom score (tnss), and quality of life (qol) during the first 6 months of therapy. the data were obtained from medical records of ar patients who visited the rhinology-allergy clinic department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital within one year. thirty three patients were included in the study using total sampling. results: there was significant improvement (p<0.001) in aria classification, tnss, and qol between the initiation of therapy, the third, and the sixth month. in contrary, there was no significant difference in aria classification (p=0.109), tnss (p=0.317), and qol (p=1.000) between the third and the sixth month of therapy. conclusions: allergic rhinitis patient management based on the 2008 aria who guideline is effective. [amj.2016;3(4):538–44] keywords: allergic rhinitis, asthma, effectiveness, management correspondence: atika aziza, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85624985907 email:atika.azii@gmail.com introduction allergic rhinitis (ar) is an inflammation of the nasal mucosa mediated by immunoglobulin e (ige) after exposure to allergen. the inflammatory reaction manifests as runny nose, nasal congestion, sneezing, and nasal itching. the clinical manifestation recurs after each exposure to the initiating allergen.1 although there are not yet data on the national prevalence of ar in indonesia, previous study conducted in 2010 at the department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital bandung showed the prevalence of ar is 24.5%.2 clinical manifestations of ar often cause impairment of quality of life (qol). the impairment of qol is caused by sleep disturbance and problems with social activities, school and work performance.1,3 this may lead to a decrease in productivity, and therefore impacts on the economy.3 according to the 2008 allergic rhinitis and its impact on asthma (aria) world health organization (who) guideline allergic rhinitis is classified based on disease severity and symptom duration. the classifications consist of mild intermittent ar (mi-ar), mild persistent ar (mp-ar), moderate/severe intermittent ar (msi-ar), and moderate/ severe persistent ar (msp-ar). these classifications determine the therapeutic plan of ar that includes allergen avoidance, patient education, pharmacotherapy and althea medical journal. 2016;3(4) 539 specific immunotherapy (sit). according to the 2008 aria who recommendations, all four categories should undertake allergen avoidance and receive patient education and pharmacotherapy. pharmacotherapy also differs from each classification and includes intranasal corticosteroid, h1 antihistamine, and leukotriene receptor antagonist (ltra) among others. for persistent ar, it is recommended that intranasal corticosteroid should be given as a first-line therapy. specific immunotherapy is only recommended for mpar, msi-ar, and msp-ar.1 hence, only the three categories are recommended for the complete combined therapy. even so, the management for ar patients may be adjusted accordingly if patients experience improvement or worsening in aria classification. the management for aria in indonesia has been performed according to the recommendations of the 2008 aria who. however, the 2008 aria who guideline is meant to be a guide to formulate an ar management guideline that is suitable to local environment and circumstances.1,4 up until now, there has been no data on the effectiveness of ar management based on the 2008 aria who guideline in dr. hasan sadikin general hospital or in any hospital in indonesia. therefore, an evaluation of the effectiveness of the 2008 aria who guideline in a local setting is needed. the evaluation of the 2008 aria who guideline recommendations effectiveness will be done based on guideline therapy goals that include improvements in aria classification, total nasal symptom score (tnss), and patient qol. hence, the aim of this study is to evaluate the effectiveness of ar patient management according to the 2008 aria who guideline in the rhinology-allergy clinic of the department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital. methods this study was conducted in the rhinologyallergy clinic of the department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital and used a quantitative descriptive research design. the study was conducted from september to october 2015. the study samples were ar patients managed in the rhinology-allergy clinic that fulfilled the following inclusion criteria: patients classified as mp-ar, msiar, and msp-ar; patients having started sit between march 1st 2014 and march 31st 2015; and patients having undertaken sit for a minimum of 6 months. the samples which were not included were: patients starting sit outside of the given time period, patients having undertaken sit less than 6 months’ time, and patients classified as mi-ar. study samples were taken according to total sampling method and this study included 33 ar patients who visited the rhinology-allergy clinic. the subject data were taken from medical records, and permission regarding information disclosure was obtained through the ethical committee of dr. hasan sadikin general hospital and faculty of medicine universitas padjadjaran. the data were analyzed statistically to discover the variable frequency. research variables that were evaluated included the ar classification according to the 2008 aria who guideline, tnss, and the qol disturbance. allergic rhinitis classifications consist of msp-ar, msi-ar, mp-ar, and miar. total nasal symptom score was divided into very mild (a score of 0-2), mild (3-6), moderate (7-9), and severe (10-12) according to score presented in the medical record. disturbance in qol was recorded as those impaired and those not impaired. these variables were taken from the records of the patient’s first visit (designated month 0), the third month of therapy (month 3) and the sixth month of therapy (month 6). the data were then analyzed to evaluate the frequency of each variable during each time frame to see differences between each time frame and also the significance of changes using wilcoxon signed-rank test and mcnemar’s test. the result would be deemed significant if p value was <0.05 and insignificant if p value was >0.05. the research variables were also included general characteristics such as age, gender and occupation, which would be presented as frequency. comorbidities were also taken into account and were shown as frequency of those with comorbidities and those without along with the frequency of the types of comorbidities present. results from 40 children, numbers of boy and girl in the subjects’ general characteristics were mostly women (69.7%) with the highest range of age in the 18–34 age group (42.4%), followed by 35–49 age group (33.3%) (table 1). a majority of the subjects were school/ college students (30.3%) and housewives atika aziza, arif dermawan, vycke yunivita kusumah dewi: effectiveness of allergic rhinitis management related to who guideline on allergic rhinitis and its impact on asthma (aria) althea medical journal. 2016;3(4) 540 amj december 2016 table 2 comorbidity distribution comorbidity ar patient (n=20) n % rhinosinusitis 10 50 nasal polyp 5 25 asthma 2 10 conjunctivitis 1 5 atopic dermatitis 1 5 otitis media 1 5 note: ar: allergic rhinitis; n:number of ar patient; %: percentage of ar patient (27.3%). comorbidities were also present in 60.6% of the subjects with the other 13 people without comorbidities. rhinosinusitis was the most prevalent comorbidity in the study with a frequency of 50% (table 2). the least prevalent comorbidity was conjunctivitis, otitis media, and atopic dermatitis with 5% each. at the beginning of the study the most common ar classification was based on the 2008 aria who guideline among the subjects was msp-ar with 42.4% with no subjects classified as mi-ar (table 3). all of the subjects had impaired qol and most had moderate symptoms (60.6%). by the 3rd table 1 subjects’ general characteristics variable ar patient n % gender female 23 69.7 male 10 30.3 age, range ≤17 5 15.2 18–34 14 42.4 35–49 11 33.3 50–64 3 9.1 ≥65 0 0 occupation civil servant 8 24.2 private employee 5 15.2 student/college student 11 33.3 housewife 9 27.3 unemployed 0 0 others 0 0 comorbidity present 20 60.6 absent 13 39.4 note; ar: allergic rhinitis; n: number of ar patient; %: percentage of ar patient althea medical journal. 2016;3(4) 541atika aziza, arif dermawan, vycke yunivita kusumah dewi: effectiveness of allergic rhinitis management related to who guideline on allergic rhinitis and its impact on asthma (aria) table 3 aria classification, tnss and qol impairment changes at month 0, 3, and 6 variable ar patient p value (a)* p value (b)** p value (c)#month 0 month 3 month 6 n % n % n % aria classification msp-ar 22 66.7 2 6.1 0 0 <0.001 0.109 <0.001 msi-ar 6 18.2 0 0 0 0 mp-ar 5 15.2 1 3 1 3 mi-ar 0 0 30 90.9 32 97 tnss severe 9 27.3 0 0 0 0 <0.001 0.317 <0.001 moderate 20 60.6 0 0 0 0 mild 4 12.1 1 3 3 9.1 very mild 0 0 32 97 30 90.9 qol impairment impaired 33 100 3 9.1 3 9.1 <0.001 1.000 <0.001 not impaired 0 0 30 90.9 30 90.9 note: ar: allergic rhinitis; aria: allergic rhinitis and its impact on asthma; msp: moderate severe persistent; msi: moderate severe intermittent; mp: mild persistent; mi: mild intermittent; n:number of ar patient; %: percentage of ar patient, *p value (a) is the differences in variables between month 0 and 3, **p value (b) is the differences in variables between month 3 and 6, #p value (c) is the differences in variables between month 0 and 6 month of therapy, the frequency of patients classified as msp-ar was reduced to 6.1% with the highest frequency belonging to the mi-ar classification (90.9%). the number of patients showing severe and moderate symptoms was decreased to zero and those with impaired qol decreased to 9.1%. more than a half of the subjects had no symptoms (69.7%) and no qol impairment (90.9%). after 6 months of therapy, no subjects were classified as moderate/severe and only 3% were mp-ar while the rest was mi-ar (97%). patients who did not present with qol impairment were 90.9%. the result of statistical analysis using the wilcoxon signed-rank test demonstrated figure profile of drug use althea medical journal. 2016;3(4) 542 amj december 2016 that the aria classification and tnss changes between start of therapy and the third month is significant with p value <0.001 (table 3). this was also true of statistical analysis of the changes in qol between the start of therapy with the third month of therapy using mcnemar’s test with p value <0.001. the difference between the start of therapy and the sixth month showed similar results to p value <0.001 for each variable. even so, it was found that the difference in aria classification, tnss, and qol between the third month and sixth month is not significant. the distribution of drug combinations used in pharmacotherapy of subjects at the start of therapy showed that the highest frequency of drug used is h1 antihistamine (figure). the other 18.2% was the combination of h1 antihistamine and intranasal corticosteroid. discussions this study reveals that the distribution of gender, age, occupation, and presence of comorbidity of the study subjects is similar to the previous study in 2014 of ar patients visiting department of otorhinolaryngologyhead and neck surgery dr. hasan sadikin general hospital.5 study subjects consist mostly of women (69.7%). this high prevalence in women is thought to be due to hormonal differences between genders, in which oestrogen is known to be pro-inflammatory and thus predispose to atopy.6 the occupation distribution is also similar, with the highest being school/college students (30.3%) and the second highest being housewives (27.3%). it is known that ar affects school age children and thus causes learning disturbance.1 the study subjects are mostly between 18–34 years of age (42.4%) and the trend declines with increase in age. the previous study showed a decrease in atopy with aging, it is suggested that a decrease in allergen-specific ige concentration is the cause of this phenomenon.7 most of the study subjects present with comorbidity (60.6%) with rhinosinusitis as the highest frequency (55.6%). this is in line with the previous study that rhinosinusitis is the most prevalent comorbidity in ar patients.2the presence of comorbidity may affect treatment outcome as the most of the comorbidity have the same pathophysiology as ar. the presence of comorbidity in study subjects may affect changes in aria classification, tnss, or qol disturbances in this study. there is a significant change in distribution of aria classification between the first month of therapy and third month, and also with the sixth month of therapy. the frequency of msp-ar and msi-ar decreases between the start of therapy and the sixth month in which the frequency of msp-ar is as high as 66.7% and msi-ar as high as 18.2% at the start and only 6.1% and none respectively in the sixth month (table 3). these findings indicate that patients given therapy according to aria who 2008 guideline experience an improvement in aria classification. these improvements are significant with p value <0.001. a previous study in spain8 support these findings that ar patients with moderate-severe classification experience a significant decrease in disease severity to mild after undergoing 4 weeks of pharmacotherapy with second generation h1 antihistamine. the tnss and qol also show significant improvement (p<0.001) before and after 6 months of therapy. at the start of therapy a majority of the patients experience severe symptoms while at the sixth month most of patients’ symptoms improve to very mild (table 3). quality of life impairment distribution also shows significant change (p<0.001) and by the sixth month of therapy 90.9% of patients experience no impairment. these findings are in line with a previous study in which aria recommended pharmacotherapy significantly improve patients’ tnss, qol score, and disease severity after 4 weeks’ time. a different study also shows that sit is effective in reducing symptoms and medication usage in ar patients.10 the distribution change between the start of therapy and the third month with the change between the third and sixth month shows disparity. the distribution change of aria classification, tnss, and qol between the start and third month of therapy is larger than the change between the third and sixth month. these differences are only significant between the start of therapy and third month but not between the third and sixth month. this occurrence may be explained by the discoveries in a previous study that the largest improvement of qol score occur in the first week of therapy and the largest improvement of tnss occur after two weeks of therapy using second generation h1 antihistamine.11 a different study shows that as much as 52.6% of ar patients with moderate-severe symptoms experience improvement after 4 weeks of pharmacotherapy (p<0.0001).9 on another note, the tnss of 2 subjects althea medical journal. 2016;3(4) 543 (6.1%) showed worsening between the third and sixth month of therapy, changing from very mild to mild. also, there is a persistence of qol impairment in 3 subjects (9.1%) in the same time frame. this tnss worsening and persistence of impairment may be due to the presence of comorbidity, which is prevalent in this study. comorbidity is known to affect therapy outcome, tnss and qol of ar patients.12 therefore, the worsening of subjects’ tnss and persistence of qol impairment is thought to be due to the presence of comorbidity, which affects the tnss and qol of subjects. a majority of the study subjects receive cetirizine, a second generation h1 antihistamine, as opposed to intranasal corticosteroid such as fluticasone propionate which is the first-line medication for mspar patients according to aria who 2008 guideline.1 it is known that intranasal corticosteroid is more effective in reducing ar symptoms than h1 antihistamine14, and yet patients are instead primarily given h1 antihistamine and is only given intranasal corticosteroid in combination with h1 antihistamine. this discrepancy is due to the availability of medication in the clinic and hospital policy where currently only h1 antihistamine is readily available rather than intranasal corticosteroid. during the course of this study there were several difficulties in obtaining data from the medical record. some of this is caused by poor documentation due to unintelligible handwriting. unsystematic medical record and storage also hindered data collection. this is the first study to evaluate the effectiveness of ar management based on 2008 aria who guideline in dr. hasan sadikin general hospital. there are many studies about the effectiveness and efficacy of pharmacotherapy or sit alone but none about the effectiveness of aria who 2008 guideline or the combined effectiveness of pharmacotherapy and sit. in summary, despite the discrepancy between practice and aria recommendations, ar patient management based on the 2008 aria who guideline proves to be effective. even if local circumstance, which in this case limits the drug availability, hinder the application of aria recommendation, the guideline is suitable for the local setting in dr. hasan sadikin general hospital. thus, the 2008 aria who guideline is appropriate for use in other healthcare facilities that resembles the setting of this study and as such may be used as guideline for management of local ar patients. references 1. bousquet j, khaltaev n, cruz aa, denburg j, fokkenswj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008. allergy. 2008;63(suppl86):s8–160. 2. achmad sodikin, teti madiadipoera. karakteristik penderita rhinitis alergi sesuai guideline allergic rhinitis and its impact on asthma (aria) di bagian thtkl rs. hasan sadikin bandung periode 1 januari 31 desember 2009. proceedings of the 6th jakarta international functional endoscopic sinus surgery course and workshop; 2010 mar 4-7; jakarta. jakarta: perhimpunan dokter ahli tht-kl; 2010. 3. katelaris ch, lai ck, rhee cs, lee sh, yun wd, lim-varona l, et al. nasal allergies in the asian-pacific population: results from the allergies in asia-pacific survey. am j rhinol allergy. 2011;25(suppl1):s3–15. 4. brożekjl, bousquet j, baena-cagnani ce, bonini s, canonicagw, casale tb, et al. allergic rhinitis and its impact on asthma (aria) guidelines: 2010 revision. j allergy clinimmunol. 2010;126(3):466–76. 5. raissa mentari moeis, melati sudiro, rb. soeherman herdiningrat. allergic rhinitis patient characteristics in dr. hasan sadikin general hospital bandung in indonesia. amj. 2014;1(2):75–80. 6. osman m, hansell al, simpson cr, hollowell j, helms pj. gender-specific presentations for asthma, allergic rhinitis and eczema in primary care. prim care respir j. 2007;16(1):28–35. 7. scichilone n, callari a, augugliaro g, marchese m, togias a, bellia v. the impact of age on prevalence of positive skin prick tests and specific ige tests. respir med. 2011;105(5):651–8. 8. valero a, izquierdo i, giralt j, bartra j, del cuvillo a, mullol j. rupatadine improves nasal symptoms, quality of life (esprint-15) and severity in a subanalysis of a cohort of spanish allergic rhinitis patients. j investig allergol clin immunol. 2011;21(3):229–35. 9. mullol j, bartra j, del cuvillo a, izquierdo i, muñoz-cano r, valero a. specialist-based treatment reduces the severity of allergic rhinitis. clin exp allergy. 2013;43(7):723– 9. 10. dretzke j, meadows a, novielli n, huissoon a, fry-smith a, meads c. subcutaneous atika aziza, arif dermawan, vycke yunivita kusumah dewi: effectiveness of allergic rhinitis management related to who guideline on allergic rhinitis and its impact on asthma (aria) althea medical journal. 2016;3(4) 544 amj december 2016 and sublingual immunotherapy for seasonal allergic rhinitis: a systematic review and indirect comparison. j allergy clinimmunol. 2013;131(5):1361–6. 11. holmberg k, tonnel ab, dreyfus i, olsson p, cougnard j, mesbah k, et al. desloratadine relieves nasal congestion and improves quality-of-life in persistent allergic rhinitis. allergy. 2009;64(11):1663–70. 12. feng ch, miller md, simon ra. the united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis. am j rhinol. 2012;26(3):187–90. 13. devillier p, dreyfus jf, demoly p, calderon ma. a meta-analysis of sublingual allergen immunotherapy and pharmacotherapy in pollen-induced seasonal allergic rhino conjunctivitis. bmc med. 2014;12(1):1– 12. 14. benninger m, farrar jr, blaiss m, chipps b, ferguson b, krouse j, et al. evaluating approved medications to treat allergic rhinitis in the united states: an evidencebased review of efficacy for nasal symptoms by class. ann allergy asthma immunol. 2010;104(1):13–29 althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 204 amj june, 2015 isolation of methicillin resistant staphylococcus aureus in midwifery students faculty of medicine universitas padjadjaran september–december 2012 robinee panirchelvam,1 imam megantara,2 melati sudiro3 1faculty of medicine universitas padjadjaran, 2department of microbiology faculty of medicine universitas padjadjaran 3department of otorhinolaryngology, head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: methicillin resistant-staphylococcus aureus (mrsa) is resistant bacteria to certain types of beta-lactam antibiotics. commonly, the mrsa infection is acquired in hospitals, long-term care facilities, or similar institutional settings. mid-wives are one of the health professional that have a major risk to get mrsa infection and could lead the infection among patients. this research is aimed to identify mrsa among the midwifery students methods: a descriptive study was conducted from september–december 2012 at the microbiology laboratory to identify the proportion of mrsa among the mid-wife students from faculty of medicine, universitas padjadjaran. twenty-five samples were chosen using simple random sampling based on their registration number. the inclusion criterias were healthy students, and 18 to 22 years old. both nostrils were sampled with a sterile culture swab on both the subject’s nostrils. gram staining was done in order to identify the gram positive bacteria, staphylococcus aureus. the samples were inaculated in mannitol salt agar (msa), incubated for 24 hours and at 37 ̊ c. after 24 hours, catalase and coagulase tests were done. moreover, for the susceptibility testing, the chosen media for this study was mueller hinton agar (mha) and with 30µg cefoxitin disk. after incubation, the zone of inhibition of the colony less than ≤ 21mm was considered resistant to methicillin. results: colonization of mrsa was about 3 out from 25 samples conclusions: the mrsa colonization in the anterior nasal does exist in midwife students, a further study with more samples should be conducted. [amj.2015;2(1):204–7] key words: midwife students, mrsa , nasal swab correspondence: robinee panirchelvam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827793465 fax: +6055279369 email: robineepanir@yahoo.com introduction people around the world are suffering from various types of infections mainly caused by many types of bacteria. there are many treatments according to the type of causative agent. the main treatment of choice to treat bacterial infections is antibiotics. some bacteria are resistant to the available antibiotics and their infections are difficult to be treated. methicillin resistant staphylococcus aureus (mrsa), causes a serious health problem.1 mrsa is resistant to certain types of betalactam antibiotics, such as methicillin and other antibiotics such as oxacillin, penicillin, and amoxicillin. the infection from mrsa is mainly manifested by skin infection.2 commonly, the infection is acquired in hospitals, longterm care facilities, or similar institutional settings. prior to antibiotic exposure, a long stay in hospital, treated in the intensive care unit, underwent surgery before and most importantly, the exposure from mrsa infected patients will be the predisposing factors to be infected by mrsa.2 disruption of normal skin structure and abnormal immunity due to improper hygiene and altered neutrophil function can make us to be more vulnerable to the infection.. in indonesia, a population-based survey was conducted recently by the antimicrobial resistance in indonesia, prevalence and prevention (amrin) study group in order to quantify human carrier of resistant microorganisms. a total of 3,995 individuals were screened between july and october 2001 in surabaya and between january and may 2002 in semarang, the rate of nasal carriage of staphylococcus aureus was 362 out of althea medical journal. 2015;2(2) 205 3,995 (9.1%) individuals and about 90/361 (24.9%) staphylococcus aureus strains were resistant to tetracycline and 2/361 (0.6%) were resistant to oxacillin.3 the prevalence of mrsa in atmajaya hospital , jakarta in the year 2003 was 47%.4 in bandung, a study had been done on the lecturers of medical faculty of universitas padjadjaran and the result was about 52.9% out of 20 samples were mrsa.5 another was also done on the students in medical faculty of universitas padjadjaran and the result was about 14.29% mrsa found among 70 samples taken.6 colonization of mrsa is usually on the anterior nasal. it can resides in the nasal without causing any illnesses to people who carrying the mrsa.7 this people can act as carriers that can readily transmit mrsa to other people. this situation may be harmful if they are transmitted to patients who are very ill or immuno-incompetent.2 when they are infected, there are possibilities that these patients will face some serious complications.8 in indonesia, the mid-wives are usually sent to the rural area to work and the community from the lower socio-economy usually seeks their service because it is much cheaper to get the services from a mid-wife compared to the service from a medical doctor. most importantly, the mid-wife students are those without the exposure of mrsa from health care settings, so it will be purely from the community based with and without health care exposure. so, a study has to be done in order to find out do mrsa really exist among these students before their working career. the data for mrsa prevalence in indonesia is still poor9; studies must be conducted to know the prevalence and the emerging of the mrsa infection in indonesia. by knowing the prevalence of the mrsa, we can prevent the mrsa associated infections by conducting public health programs to provide awareness to the medical personnel and to the public on the seriousness of this infection. this is to ensure a healthier living and a promising future for the community. moreover, the cost to treat mrsa infection is very expensive. so, the lower socio-economic income people will be stigmatized to get the proper medication and cure. so in conclusion, prevention is always better than cure. methods a descriptive study was conducted from september 2012 december 2012 at the microbiology laboratory to identify the proportion frequency of mrsa among the mid-wife students from faculty of medicine, universitas padjadjaran. 25 samples were choosen using a simple random sampling based on their registration numbers. the inclusion criteria were students who were still doing the diploma program in midwifery in faculty of medicine, universitas padjadjaran and healthy during the sample collection, all female and around the age of 18 to 22 years old. those who did not fill up the informed consent form, ill (having flu, sinusitis), having prior antibiotic exposure before and during sample collection and failed to present on the day of sample collection were excluded from the study to avoid bias. both nostrils were sampled with a sterile culture swab on both the subject’s nostrils.10 after getting the samples from the anterior nares, gram staining was done in order to identify the gram positive bacteria, staphylococcus aureus. gram positive bacteria retained the crystal violet stain, while the gram negative bacteria lose the crystal violet stain and stained by the safranin and appear red. the chosen medium for growth for this mrsa culture was mannitol salt agar (msa). after the inoculation, the agar was incubated for 24 hours and at 37 ̊ c. after 24 hours, the colonies were identified by the appearance of the color of the colony. the convex colonies with light to golden yellow colonies were assumed as staphylococcus aureus. 11 the catalase test was used to identify the gram positive cocci and some gram positive bacilli. so after gram staining, catalase was done to differentiate streptococcus and staphylococcus. when bubbles appeared, then it was recorded as positive catalase. 12 a coagulase test was done to differentiate staphylococcus aureus with staphylococcus epidermidis. clumping of cocci within 5-10 seconds was taken as positive for staphylococcus aureus. some strains of staphylococcus aureus may not produce a bound coagulase, and such strains were identified by tube coagulase test.13 positive result was indicated by gelling of the plasma, which remained in place even after inverting the tube. for the susceptibility testing , the chosen media for this study was mueller hinton agar (mha) and with 30µg cefoxitin disk14 because recent reports had shown that cefoxitin was a better agent for prediction of mrsa15. with disc diffusion method, each quadrant was placed with a 30µg of cefoxitin robinee panirchelvam, imam megantara, melati sudiro: isolation of methicillin resistant staphylococcus aureus in midwifery students faculty of medicine universitas padjadjaran september–december 2012 althea medical journal. 2015;2(2) 206 amj june, 2015 discs and incubated at 33–35ºc at ambient air for 16 to 18 hours. after incubation the zone of inhibition of the colony less than ≤ 21mm was considered resistant to methicillin. the others were considered as negative. results staphylococcus aureus were colonized in the anterior nasal of midwife students in the study and were proven in 11 samples with gram staining which showed gram positive diplococci in clusters under the microscope, growth of yellow colonies in the mannitol salt agar, positive catalase test and positive coagulase test done on the yellow colony. from 11 samples proven , 3 were mrsa positive. discussions it can be clearly seen that colonization of mrsa is still low among the midwife students because the frequency of mrsa in this study is 3 out from 25 samples. the fact that mrsa exists in the community is proven through this research. the result in this study similar with a study by rianti,6 who stated that frequency was 14.29% . this study concludes and supports the fact that community in faculty of medicine, universitas padjadjaran are exposed to mrsa colonization in the anterior nasal. it gives us the clue indirectly that, communities in jatinangor are exposed to mrsa too. more studies should be done to obtain data on prevalence of mrsa, in order to prevent unwanted complications due to mrsa infections. in contrast, in indonesia, a research done by antimicrobial resistance in indonesia, prevalence and prevention (amrin) study group in semarang, revealed that 0.6% were resistant to oxacillin in 2002 9. this could be the cause this research was done in the year 2002;. there is a huge gap of time, and maybe the mrsa would have increased by now. so, more researches must be conducted to obtain current and updated frequency of mrsa in the community of indonesia. besides that, the study which was conducted by nordin 5 in faculty of medicine, universitas padjadjaran , showed that the prevalence was 52.9% 5, this is contrary to the result obtained in this study and maybe it is due to the reason that the lecturers are exposed to hospital settings in daily basis. it could have influence the outcome due to the strong association of mrsa exposure in hospitals or health care centers 4. there are several limitations that would have caused bias in this research. the time and cost factor is one of the limitations. in a much stipulated time and small fund, data collection is done from small scale of samples. identification of frequency of mrsa among all the midwife students would have produced a better result. . in summary, it is known that the mrsa colonization in the anterior nasal do exist in midwife students with 3 out of 25. measures should be taken to further study on mrsa colonization among students who are going to pursue medical careers in order to prevent them from spreading it to the community in the future, both the health care settings and community based settings. serious actions have to be taken to stop the cycle of mrsa exposure. references 1. m’ikanatha nm, lynfield r, van beneden ca, de valk h, editors. infectious disease surveillance. 1st ed. oxford: wileyblackwell pub; 2007 2. centers for disease control and prevention. methicillin-resistant staphylococcus aureus (mrsa) infections. atlanta; 2010 [updated april 15, 2011] [cited 2012 april 25]. available from: http://www.cdc. gov/mrsa/definition/index.html. 3. crossley kb, jefferson kk, archer gl, fowler vg. staphylococci in human disease. 2nd ed. oxford: wiley-blackwell; 2009. [cited 2012 may 20]. available from: http://onlinelibrary.wiley.com/ doi/10.1002/9781444308464.fmatter/ pdf 4. noviana h. isolasi dan uji kepekaan isolat klinis orsa dan nonorsa terhadap vankomisin dan antibiotik lainnya. jurnal mikrobiologi indonesia. 2004;9(2):51–4. 5. nordin arb. detection of mrsa on nasal swab of lecturers in faculty of medicine, universitas padjadjaran [minor thesis]. bandung: universitas padjadjaran; 2012. 6. rianti n. deteksi mrsa dari apus hidung mahasiswa fk unpad angkatan 2007 [minor thesis];bandung: universitas padjadjaran; 2011. 7. hanumanthappa ar, chandrappa nr, rajasekharappa mg. prevalence of methicillin resistant staphylococcus aureus in karnataka. indian j pathol althea medical journal. 2015;2(2) 207 microbiol. 2003;46(1):129–32. 8. bevis m. mrsa evolves as it moves between humans and livestock. 2005 [cited 2012 may 14]. available from: http://knau.org/ post/mrsa-evolves-it-moves-betweenhumans-and-livestock. 9. lestari es, severin ja, filius pm, kuntaman k, duerink do, hadi u, et al. antimicrobial resistance among commensal isolates of escherichia coli and staphylococcus aureus in the indonesian population inside and outside hospitals. eur j clin microbiol infect dis. 2008;27(1):45–51. 10. standford hospital & clinics infection control and lucile packard children’s hospital. nares culture for mrsa screening. 2009.[cited 2012 june 17] available from: https://lane.stanford.edu/portals/cvicu/ hcp_misc._tools/nares_culture_for_ mrsa_screening.pdf. 11. clinical and laboratory standards institute. performance standards for antimicrobial susceptibility testing; twentieth informational supplement. clsi document m100-s20. wayne pa: clinical and laboratory standard institute; 2010 12. cdc. laboratory detection of oxacillin/ methicillin-resistant staphylococcus aureus. centres for disease control and prevention; 2010 [updated august 9, 2010] [cited 2012 may 20]. available from: http://www.cdc. g o v / m r s a / l a b / l a b d e t e c t i o n . h t m l . 13. asbell pa, sahm df, shaw m, draghi dc, brown np. increasing prevalence of methicillin resistance in serious ocular infections caused by staphylococcus aureus in the united states: 2000 to 2005. j cataract refract surg. 2008;34(5):814-8. 14. chingchingwu. disk diffusion susceptibility testing (kirby-bauer method). university west lafayette. 2002 [cited 2012 july 5]. available from: http://www.addl.purdue.edu/ n e ws l e t te r s / 1 9 9 7 / s p r i n g / d d s . s h t m l . 15. smyth rw, kahlmeter g. mannitol salt agar-cefoxitin combination as a screening medium for methicillinresistant staphylococcus aureus. j clin microbiol. 2005;43(8):3797–9. robinee panirchelvam, imam megantara, melati sudiro: isolation of methicillin resistant staphylococcus aureus in midwifery students faculty of medicine universitas padjadjaran september–december 2012 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 86 amj march, 2015 anonna muricata linn leaf effect in inhibiting sgpt elevation galih tanaya1, kuswinarti2, r nina susana dewi3 1faculty of medicine, universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of pathology clinic, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background : hepatitis is an infection or inflammation disease of the liver which is caused by virus, toxic substance, and immunological abnormalities. soursop plant as a medicinal plants is known to have an antioxidant effect and nowadays is used as an alternative drug for hepatitis. one of the methods to assess liver function is to measure the serum glutamate piruvate transaminase (sgpt) level. the purpose of this study was to find the effect of soursop leaf in inhibiting the sgpt elevation . methods: an experimental study was conducted on 25 white male rats of wistar strain in the pharmacology laboratory of faculty of medicine, universitas padjadjaran during the period of september to october 2012. the rats were divided into 5 groups (group 1 and 2 as control; group 3, 4, and 5 as treatment groups treated by 200, 400, 600 mg/kgbw soursop extract, respectively). the soursop extract was administered to the treatment groups for 8 days. on the 8th day, group 2, 3, 4, and 5 received 1.6 ml ccl410% intraperitoneally. after 18 hours, the mean sgpt levels from all groups were measured. anova test was used to analyze the result. results : the mean sgpt levels were lower in the 3rd, 4th, and 5th group compared to group 2. there was a significant difference among treatment groups. group 3 had the most significant result. conclusion: soursop leaf inhibits the elevation of sgpt level. keywords: hepatitis, sgpt, soursop leaf (annona muricata) correspondence: galih tanaya, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8157146851 email: tanaya701gt@gmail.com introduction liver is the largest gland in the body, the weight average is 1500 gram in adults. liver has a main function as a filter for blood.1 the blood circulating the body will be cleansed and filtered from toxins that enter the body through food or respiration.1,2,3 other hepatic functions are storing many forms of glucose, vit b12, and iron, energy provider (sugar) and protein, hormone secretion, insulin secretion, lipid and cholesterol forming and excretion.1,2 liver also functions in detoxification as a filter and excretor of toxins in blood through hemoglobin dismantling, and processing ammonia into urea.2 one of the methods to assess liver function is to measure the serum level of glutamate piruvate transaminase (sgpt). hepatitis is an infection or inflammation disease of the liver which is caused by virus, toxic substance, and immunological abnormalities.4 indonesia has many traditional medicines and medicinal plants. medicinal plants as herbal medicine is developing, aside from being relatively affordable, herbal raw materials are also easy to obtain and grow in the environment, and do not has any adverse effects known to man.5 herbal medicines are known to work as anti−oxidant, anti− inflammatory, analgesic, etc.6 this is related to the fitochemical substances contained in medicinal plants .3,7–9 anti−oxidant is substance which functions to protect the body from free radicals. some examples of anti-oxidant are vitamins, poliphenol, karotin, and minerals. naturally, these substances have a significant role to prevent diseases. anti-oxidant prevents diseases by suprressing the damage on cells due to oxidation of free radicals.3,7,8 free radicals have unpaired electrons which are not stable and will try to find electron pairings. environmental activities that can produce free althea medical journal. 2015;2(1) 87 radicals are as follows: radiation, pollution, etc. free radicals which circulate the body will try to find electron pairings with other molecules such as deoxyribo nucleatid acid (dna) and cells. if electron pairing is succesful, it will disrupt the cells and dna.10 anti−oxidant helps to inhibit this process by donating an electron to free radicals. anti−oxidants will neutralize the free radicals as such that they do not try to find electron from cells and dna.3,7,8 one of the substances that can produce free radicals is carbon tetrachloride (ccl4). the liver produces ccl4 into the free radical ccl3 which then oxidizes the unsaturated fatty acid in phospholipid layers of cellular or organel membranes, so then damages hepatic cells and can induce necrosis. the ccl4 is regarded as a hepatotoxin.11 liver cell damage can be inhibited by many hepatoprotector substances which are chemicals that can protect the liver cells.12 one of the easily obtained anti-oxidants is from soursop leaf.12 soursop plant is one of the vegetations functioning for health.8 in each region in indonesia, soursop plants have many different uses for diseases and are known used as an alternative drug for hepatitis and other diseases such as asthma, bronchitis, diabetes mellitus, etc.5,8,13 soursop have many useful substances such as the flavonoids and ascorbic acid in the leaves which are known to have anti-oxidant properties.3,6,7 according to the background stated above, this study aims to know the effect of soursop leaf extract (annona muricata) on hepatitis model rats which are induced by ccl4. 9,10,14,15 methods an experimental study conducted on 25 white male rats of wistar strain which were healthy, aged 2−3 months old with weight between 200−300 grams. this study was carried out in pharmacology laboratory of faculty of medicine universitas padjadjaran during the period from september to october 2012. preparation of soursop leaf ethanol extract (slee) was conducted through several steps as follows: 1) fresh soursop leaves were washed and dried by exposure to direct sunlight or indirectly through a black fabric, 2) the leaves were grinded and extracted using ethanol 70%(maseration method), 3) the extract liquid was evaporized until a viscous extract was obtained. the rats were divided into 5 groups (group 1 and 2 as control groups, group 3, 4, and 5 as treatment groups, were given each 200, 400, 600 mg/kgbw soursop extract). soursop extract was then administered to the treatment groups for 8 days. on the 8th day, group 2, 3, 4, and 5 were administrated 1.6 ml ccl410% intraperitoneally. the damage caused by ccl4 which is a hepatitis causing free radical is by increasing calcium influx from the swelling of smooth and rough endoplasmic reticulum. due to this calcium influx, the sgpt in cytosol rose in rats belong to groups ii − v which were induced with hepatitis by injection of ccl4 10% 1.6 ml per intra peritoneal (ip) in the abdomen. after 18 hours, mean sgpt levels from all groups ware measured. a shapiro test (p ≥ 0.05) was carried out and the data results were not normally distributed. in the relation in that results, data transformation was carried out. anova test was used to analyze the result. results after each treatment with soursop leaf extract, the mean sgpt level is lower in the 3rd, 4th, and 5th group compared to group table 1 sgpt level of each treatment after administration of soursop leaf extract group n mean level sgpt (x 103 iu/l) sd group 1 5 0.060 0.017 group 2 5 18.246 1.174 group 3 5 7.636 0.634 group 4 5 11.334 1.871 group 5 5 13.950 1.029 galih tanaya, kuswinarti, r nina susana dewi: anonna muricata linn leaf effect in inhibiting sgpt elevation althea medical journal. 2015;2(1) 88 amj march, 2015 figure 1 procedure ii. there was a significant difference (p<0.05) between treatment groups, in which the f value was 492.419 and had p<0.05 (table 1). the sgpt level was recorded to continuously rise in group ii. this is due to these rats that were not treated with slee as positive control. group iii had the most significant result on inhibiting the rise of sgpt on ccl4 induced rats with an inhibiting value of 10.609 x 103 iu/l or 58.34%. discussion according to a study from ghana16 stated that the study conducted with rats treated with soursop leaf extract with dose of 50 mg/ kgbw, 100 mg/kgbw, 200 mg/kgbw, and 400 mg/kgbw, showed that the smallest dose of 50 mg/kgbw have the highest effectiveness. meanwhile, the study that was conducted by the researcher in the smallest dose of 200 mg/kgbw has the highest effectiveness. soursop leaf extract contains acetogenins which functions as free radical scavenger (anti−oxidant) and are effective as anti−tumor agents. anti−oxidant is substance that works to protect the cells from the effect of free radicals. however, annona muricatalinn also contains ascorbic acid which have anti-oxidant althea medical journal. 2015;2(1) 89 effect in the body.3,8 this study concluded that soursop leaf ethanol extract have inhibiting effect of elevating the serum glutamat piruvat transminase level in rats. references 1. moore kl, dalley af. clinically oriented anatomy. 5th ed. philadelphia:lippincott williams & wilkins; 2006. p. 311,318. 2. murray rk, granner dk, mayes pa, rodwell vw. harper’s illustrated biochemistry. 28th ed. new york: mcgraw-hill; 2009. 3. ghany m, hoofnagle jh. approach to the patient with liver disease. in: kasper d, braunwald e, fauci as, hauser sl, longo dl, jamesoon jl, editors. harrison’s principles of internal medicine. 16th ed. new york: mcgraw-hill; 2004. p. 1808−13. 4. kumar v, abbas ak, fausto n. robbins and cotran pathologic basis of disease. 7th ed. philadelphia: elsevier saunders; 2005. 5. taufiq t. ampuhnya terapi herbal berantas berbagai penyakit berat. jogjakarta: najah; 2011. 6. de sousa ov, vieira gd-v, de jesus rg de pinho j, yamamoto ch, alves ms. antinociceptive and anti-inflammatory activities of the ethanol extract of annona muricata l. leaves in animal models. int j mol sci. 2010;11(5):2067−78. 7. baskar r, rajeswari v, kumar ts. in vitro antioxidant studies in leaves of annona species. indian j expbiol. 2007;45(5):480– 5 8. cone m. low doses, big effects: scientists seek ‘fundamental changes’ in testing, regulation of hormone-like chemicals. environmental health services; 2012 [cited 2012 november 10]; available from: http://www.environmentalhealthnews. o r g / e h s / n e w s / 2 0 1 2 / l o w d o s e b i g effects. 9. fang xp, rieser mj,gu zm, zhao gx, mclaughlin jl. annonaceous acetogenins: an updated review. phytochemanal. 1993;4(1):27–48. 10. the society of toxicology. animals in research: the importance of animals in the science of toxicology. reston:the society of toxicology; 2006 [cited 2012 november 10]; available from: http:// www.toxicology.org/ai/air/air_final.pdf. 11. world health organization. carbon tetrachloride: health and safety guide. geneva: who; 1998. 12. adewole s, caxton-martins e. morphological changes and hypoglycemic effects of annona muricata linn. (annonaceae) leaf aqueous extract on pancreatic β-cells of streptozotocintreated diabetic rats. afr jbiomed res. 2006;9:173−87 13. wu y, wang f, zheng q, lu l, yao h, zhou c, et al. hepatoprotective effect of total flavonoids from laggera alata against carbon tetrachloride-induced injury in primary cultured neonatal rat hepatocytes and in rats with hepatic damage. j biomed sci. 2006;13(4):569−78. 14. buchanan-smith h, rennie ae, vitale a, pollo s, prescott mj, morton db. harmonising the definition of refinement. animal welfare. 2005;14:379-84. 15. kamel hh, azza ha, walaa msa, amira hm. protective effect of some antioxidants against ccl4-induced toxicity in liver cells from brl3a cell line. journal of american science. 2010;6(10):992–1003. 16. arthur fk, woode e, terlabi eo, larbie c. evaluation of hepatoprotective effect of aqueous extract of annona muricata (linn.) leaf against carbon tetrachloride and acetaminophen-induced liver damage. j nat pharm. 2012;3(1):25−30. galih tanaya, kuswinarti, r nina susana dewi: anonna muricata linn leaf effect in inhibiting sgpt elevation althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 511 effect of breadfruit leaves infusion on acute renal failure rat model muhamad risdan hardani1, herri s. sastramihardja2, afiatin3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: empirically, breadfruit (artocarpusaltilis) leaves have been used as traditional medicine for several diseases, such as acute renal failure. this study aimed to find the effects of breadfruit leaves infusion on blood creatinine levels in rats to model acute renal failure. methods: this laboratory experimental study was conducted by using 30 male wistar rats, weighing150–250 g. the rats were divided into 5 groups. the first group is a negative control and the second group is a positive control. groups 2–5 were inducedby gentamicine and peroxicam for 7 days. groups 3–5 were given infusion of breadfruit leaves in different dosage for 7 days then the blood creatinine levels were tested at the 15th day. this data was analyzed using a multiple comparison dunnett t3 test because this data was not homogenous. this study was done in pharmacological laboratory universitas padjadjaran from october tonovember 2012. results: the average of creatinine levels was as follows 0.62, 0.87, 0.98, and 0.87 mg/dl observed from the different groups. it was statistically shown that the significantly different creatinine levels, differing by 0.038 (p<0.05) were observed for the control group and the group which was given an infusion of breadfruit leaves. the significant difference on the average of creatinine levels were among the groups with (p–value <0.05).comparison of group 1 and 3 (p < 0.05) gave a significant increase among the groups. conclusions: infusions of breadfruit leaves have some effects on blood creatinine levels in acute renal failure according to the dosage and duration of administration. [amj.2015;2(4):511–5] keywords: acute renal failure, breadfruit leaves, creatinine correspondence: muhamad risdan hardani, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285793185470, email: risdanhardani@gmail.com introduction renal disease is a decrease of renal function which is sudden within a couple hours to several days marked by urea, creatinine, potassium, and drugs retentions which are normally excreted by the kidneys.1,2 decrease of renal function can be due to the decrease of blood flow to the kidneys caused by infection, ischemia, or toxins such as drugs or nephrotoxic chemicals.3 drugs that are nephrotoxic are nonsteroidal anti-inflamatory drugs (nsaids), aminoglycoside antibiotics, amphotericin b, cisplatin, radiocontrast media, and other nephrotoxic drugs.4,5 drugs used in this study which are gentamycin and piroxicam are proven to be able to damage the kidneys for 7 days to cause renal failure.6 breadfruit leaves have anti– oxidant effects and are believed to be able to lessen renal damage because of its flavonoid contents that can decrease the creatinine levels in blood by inhibiting the activity of free radicals and lessening the damages.7 according to assumption that breadfruit leaves contain flavonoid compounds which are anti–oxidants. it was needed to study the effects of breadfruit leaves on creatinine levels using experimental animals induced by gentamycin and piroxicam. methods this study was conducted in the animal laboratory of the department of pharmacology and therapy of the faculty of medicine, universitas padjadjaran, bandung in october 2012. breadfruit leaves (artocarpusaltilis) were obtained from around bandung, and identified in the herbarium of jatinangor, universitas padjadjaran. the study used 30 male wistar rats as subjects (2–3 months old) althea medical journal. 2015;2(4) 512 amj december, 2015 which were healthy and weighing 150–250 g and divided into 5 groups. all rats were adapted for 7 days and given food and drink homogeneously. infusion water was made out of dried breadfruit leaves which were weighed according to the dose and 100 ml of water for treatment on each group. all base materials were mixed and interred to infusion pot for 15 minutes until the temperature reached 900 c and stirred for every 5 minutes. seventy milliliters of infusion water was obtained and used for treatment for 4 ml on each rats. after being adapted, each group was given different treatments. negative control group (i) were only fed and given water for 14 days, positive (ii) and treatment groups (iii, iv, and v) were induced by gentamycin and piroxicam for 7 days to promote inflammatory response so that the rats on each group experienced renal failure.6 after induction, the treatment groups were given breadfruit leaves infusion by per oral and with different doses of 4.25%, 9.5%, and 19% for 7 days. after the treatments were done, the rats were fasted for 24 hours and each group were entered to a heater to dilate their veins for 5 minutes, after their tails were cut off and the blood taken into a tube and labeled for plasma creatinine measurement. the data after measurement were analyzed statistically using multiple comparison tests with dunnett t3 because the data distribution table 1 creatinine levels average group creatinine levels average (mg/dl) standard deviation 1 0.62 0.05 2 0.87 0.27 3 0.83 0.10 4 0.96 0.18 5 0.89 0.22 note: group 1: negative control, group 2: positive control, group 3: 1 time dose treatment, group 4: ½ time dose treatment, group 5: 2 times dose treatment figure 1 creatinine levels average althea medical journal. 2015;2(4) 513 was not homogeneous. results after the creatinine levels measurement on control group and treatments for 14 days, the results were obtained with the lowest creatinine levels of group i (negative) at 0.62 mg/dl, while the largest creatinine levels were found in group iv (treatment 19%). the positive control group had wider ranges compared to other groups which means that the larger the range, then the more deviating from the truth (figure 1). the creatinine levels were normally distributed with p–value (p>0.05)8 homogenity test showed p−value 0.041 (p<0.05) (table 2). the data of creatinine levels was not homogenous. there was a significant difference on the average of creatinine levels among the groups with (p–value <0.05)8(table 3). multiple comparison dunnett t3 was done to recognize the difference among each group because the data was not homogenous. according to the result, between control groups and treatments had significant difference. this meant that the infusion of muhamad risdan hardani, herri s. sastramihardja, afiatin: effect of breadfruit leaves infusion on acute renal failure rat model table 2 the creatinine levels with normality test kolmogorov–smirnov* shapiro–wilk statistic df sig. statistic df sig. group1 .260 6 .200** .847 6 .148 group2 .211 6 .200** .887 6 .304 group3 .270 6 .195 .915 6 .472 group4 .188 6 .200** .942 6 .678 group5 .159 6 .200** .986 6 .976 note: *: lilliefors significance correction, **: this is a lower bound of the true significance, information:p≥0.05 --> data distributed normally, p<0.05 --> data distributed abnormally table 3 anova test creatinine levels sum of squares df mean square f sig. between groups .403 4 .101 2.992 .038 within groups .841 25 .034 total 1.243 29 table 4 dunnett t3 test comparison groups significance 1 2 0.379 1 3 0.014 1 4 0.035 1 5 0.181 2 3 1.000 2 4 0.997 2 5 1.000 3 4 0.690 3 5 0.997 4 5 0.999 note: p–value> 0.05: no significant difference, p–value< 0.05: significant difference, group 1: negative control, group 2: positive control, group 3: 1 time dose treatment, group 4: ½ time dose treatment, group 5: 2 times dose treatment althea medical journal. 2015;2(4) 514 amj december, 2015 breadfruit caused an increase of creatinine levels compared to the control groups, with the comparison of group 1 and 2 gave a significance of 0.379 (p > 0.05)there was no significant difference between both groups. comparison of group 1 and 3 (p < 0.05) gave a significant increase among the groups. there were no significant differences on average creatinine levels in group 2 and 5 (p > 0.05). comparison between group 2 and groups 3 and 4 (p > 0.05), group 3 and groups 4 and 5 (p>0.05) and comparison of group 4 and 5 (p > 0.05) showed that there was no significant difference on the average creatinine levels between the positive group and treatments. discussions from the result of this study, the breadfruit leaves test did not have effects to reduce the creatinin of acute renal failure model rats which were induced by gentamycin and piroxicam per intraperitoneal. according to a research done by walker and shah9, gentamycin and piroxicam can induce renal failure after induced for 7 days. gentamycin and piroxicam also cause an increase in reactive oxygen metabolites in the renal cortex mitochondria which causes lipid hidroxyperoxydase. this peroxydase causes the damage on renal tissue, and inflammation as such that causes renal dysfunction. renal dysfunction can be seen from creatinin examination which is one of the indicators to assess renal failure and confirms a person as having renal failure. in this study, there is an evidence on positive control group after induced by gentamycin and piroxicam compared to negative control group. cells or tissues experience damage and cause renal dysfunction because of these oxidative stress inducing molecules can be inhibited by a compound called anti–oxidants. anti–oxidants can inhibit or prevent oxidation in forming free radicals. one of the anti–oxidants contained in breadfruit leaves is flavonoid indonesianin. flavonoid can prevent covalent bonding on lipid. lipid peroxidation is inhibited which can lessen or prevent renal damage. according to the statistical tests between control and treatment groups, there were no significant difference with a p-value (p > 0.05) between group 2 and 3, 2 and 4, and group 2 and 5, because the average creatinine levels on treatment groups were higher than the control. from this study, it was known that the anti–oxidant effects on breadfruit leaves were considered as an agent to reduce renal damage but it had not been scientifically supported. this study is not in accordance with the research by saija et al.10 because it did not prove that the flavonoid content in breadfruit leaves had anti–oxidant effects that can lessen renal failure cells induced by nephrotoxic agents and the anti–oxidant effects of breadfruit leaves are dubious in reducing the renal damage. from this study, it was also possible that there were toxic effects from the breadfruit leaves that can increase renal damage and the creatinine levels on the experimental animals experiencing acute renal failure, it can be concluded that breadfruit leaves infusion did not effect to reduce blood creatinine levels on acute renal failure model rats after induced by gentamycin and piroxicam. however, breadfruit leaves infusion administration for 7 days had an effect on creatinin levels of rats. the creatinine levels on groups which were given breadfruit leaves infusion at dose 4.25%, 9.5%, and 19% were higher and significantly different compared to the negative control group. the highest creatinine levels were obtained from the group which were given an infusion dose of 4.25% as a conclusion, the breadfruit leaves infusion did not effect to reduce blood creatinine levels on acute renal failure model rats after induced by gentamycin and piroxicam. the breadfruit leaves infusion administration for 7 days had an effects on creatinin levels of rats according to the dosage and the duration of administration. references 1. longo d, fauci a. harrison’s principles of internal medicine, 18th ed. philadelphia: mcgraw−hill; 2011. p. 1639–44. 2. thadhani r, pascual m, bonventre jv. acute renal failure. n eng j med. 1996; 334(22):1448−60. 3. guyton ac, hall je. textbook of medical physiology. philadelphia: elsevier saunders; 2006. p. 1225–35. 4. stevenson f, datta s. crash course: renal and urinary systems. philadelphia: elsevier mosby; 2005. 5. wiener cm, nivatpumin pj, brown cd, hemnes ar. harrison’s principles of internal medicine: self−assessment and board review. philadelphia: mcgraw−hill, medical pub. division; 2005. p.1644–56. 6. hosaka em, santos ofp, seguro ac, althea medical journal. 2015;2(4) 515 vattimo mff. effects of cyclooxygenase inhibitors on gentamicin−induced nephrotoxicity in rats. braz j med biol res. 2004;37(7):979−85. 7. hariana ha. tumbuhan obat & khasiatnya. jakarta: niaga swadaya; 2008. 8. dahlan ms. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. p.26–7. 9. walker pd, shah sv. gentamicin enhanced production of hydrogen peroxide by renal cortical mitochondria. cell physiology. 1987;253(4):c495–9 [cited 2012 desember 1]; available from: http:// ajpcell.physiology.org/content/253/4/ c495.short. 10. saija a, scalese m, lanza m, marzullo d, bonina f, castelli f. flavonoids as antioxidant agents: importance of their interaction with biomembranes. free radic biol med. 1995;19(4):481−6. muhamad risdan hardani, herri s. sastramihardja, afiatin: effect of breadfruit leaves infusion on acute renal failure rat model vol 5 no 3 final.indd althea medical journal. 2018;5(3) 146 amj september 2018 correlation between physical fitness components and academic achievement in elementary school students tisnasari hafsah,1 nurul uyun,2 reni farenia3 1department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 2faculty of medicine universitas padjadjaran, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, bandung, indonesia abstract background: physical fitness is a degree of health status as a basic physical condition of someone to perform daily activity. elementary school students should have a good physical fitness to obtain satisfactory academic achievement. the purpose of this study was to examine the correlation between physical fitness and academic achievement. methods: this study used an observational analytical method with cross-sectional design, conducted from september−october 2013, using total sampling method. there were 82 students of the 4th−6thgrade from cikeruh 2 elementary school at jatinangor. the school was chosen by random selection. the physical fitness assessment in this study consisted of step test to measure cardiorespiratory endurance, body mass index (bmi) for body composition, push-up for muscular strength and sit-up for muscular flexibility. academic achievement was collected from the last examination result. each component of physical fitness test results were converted to a score and then categorized. results: most students (74.4%) had fair physical fitness, boys 68.3%, and girls 80.5%. no correlation was found between physical fitness and academic achievement (p=0.432 and r=0.162). conclusions: there is no significant correlation between physical fitness and academic achievement. keywords: academic achievement, physical fitness, students correspondence: tisnasari hafsah, department of child health faculty of medicine, universitas padjadjaran,/ dr hasan sadikin general hospital jalan pasteur no.38, bandung, indonesia, email: tisnasari_hafsah@yahoo.com introduction physical fitness is the degree of health status as a basic physical condition of someone to perform daily activity.1 there are some benefits for being physically fit, for example reduce the risk of metabolic syndrome and cardiovascular disease.2,3 students should have good physical fitness in order to obtain a satisfactory academic achievement. many factors may affect academic achievement including genetic, school environment, school facilities, teacher competency, curriculum, and socioeconomic status, physical activity, nutritional status and special sense system for example visual acuity.4-8 studies about physical fitness and academic achievement have been conducted previously,9-11 but was still rare in indonesia. particularly in jatinangor district, there were no data on the study about physical fitness and academic achievement. as there are many schools in this district, which is still developing to become a modern society, physical fitness performance among students should be investigated whether it affects the academic achievement. therefore, the purpose of this study was to examine the correlation between physical fitness and academic achievement. methods this study was conducted from september to october 2012 at the elementary school in cikeruh in jatinangor and used analytical method with cross-sectional design. the school was selected by simple random sampling, while subjects recruited in this study were students of 4th–6th grade. all procedures performed to the students was approved by the parents. and the approval for this study has been obtained from the health research ethics committee, faculty of medicine universitas padjadjaran. physical fitness measurement in this study amj. 2018;5(3):146–8 althea medical journal. 2018;5(3) 147 consisted of cardiorespiratory endurance, body composition and muscular fitness. cardiovascular fitness was measured by step test. body composition was measured by body mass index (bmi). muscular flexibility was measured by sit-ups and muscular strength by push-ups. kash method of step test was taken within 3 minutes. after the test, the pulse rate was measured within 60 seconds. the bmi was collected from measurement of body weight and height. the muscular fitness test was measured by push-up and sit-up. the objective of this measurement is to do sit-ups and pushups as many as possible within 1 minute. academic achievement was measured from the last examination result. each component of physical fitness was categorized and converted to a score, then the score of physical fitness was correlated with the last examination result using the spearman pearson correlation method. furthermore, data were analyzed using the statistical package for the social science (spss). p-value <0.05 was used for statistical significance. results the total sample was 82 students, including 41 boys and 41 girls aged 10−12 years from the 4th-− 6thgrade. from the characteristic of students at the elementary school in cikeruh in jatinangor and the physical result, most students (74.4%) had fair physical fitness, boys 68.3%, and girls 80.5%. the analysis result for correlation between physical fitness and academic achievement was p=0.432 and r=0.162, which means that the correlation was not significant (table 1 and table 2). discussion the result revealed that there was no significant correlation between physical fitness and academic achievement. this is contradictive with a previous study which states that there is correlation between physical fitness and academic achievement.9-10 the difference of method used in measuring the physical fitness and the academic achievement, sample size, and also characteristic and background of subject may influence this contradiction. in a meta-analysis by álvarez-bueno et al.11, physical education as a particular example of physical activity at school plays a positive role in academic achievement, specifically mathematics, reading, and composite scores among students.11 however, there were table 1 characteristic of the students from elementary school in cikeruh in jatinangor characteristics overall sample boys girls x±sd x±sd x±sd age (years old) 11.025±0.98 11.15±0.99 10.90±0.97 weight (kg) 51.76±14.44 34.55±7.52 28.98±6.92 height (cm) 140.22±7.29 140.47±7.29 139.96±7.29 body mass index(kg/m2) 13.91±3.97 13.45±3.67 14.38±4.25 step test (beat/minute) 128.33±17.80 127.68±15.90 128.98±19.69 sit─up (times/minute) 29.01±15.14 38.78±15.40 19.24±5.58 physical fitness score 12.5±2.09 13.02±9.06 11.9±2.13 last examination result 74.42±5.32 74.04±5.31 74.79±5.37 note : x = mean, sd = standard deviation table 2 physical fitness result of students at the elementary school in cikeruh in jatinangor category boys n (%) girls n (%) total n (%) poor 12 (29.3) 8 (19.5) 20(24.4) fair 28 (68.3) 33 (80.5) 61(74.4) good 1 (2.4) 1 (1.2) total 41(100) 41(100) 82 (100) note : n=number of sample tisnasari hafsah, nurul uyun, reni farenia: correlation between physical fitness components and academic achievement in elementary school students althea medical journal. 2018;5(3) 148 amj september 2018 limitations, including a variation of academic achievement measurement tools and lack of studies on the effect of physical activity interventions at after-school time. this study did not observe other factors such as genetic, socioeconomic status, physical activity, nutritional status, special sense system for example visual, which could affect the academic achievement.4-8 nutrition is important for children to reach their optimal physical and mental development. a study in ethiopia12, where children with undernourishment were prevalent revealed the correlation between nutritional status and level of educational performance. children with stunting, underweight and wasting showed low level of educational performance than normal children. our study also noted about the possibility of nutritional status impaction. the average of body mass index (bmi) particularly for boys was 13.45±3.67, which was less than -2 sd based on who child growth reference 2007, while in the girl group was 14.38±4.25 (less than -1 sd).13 body mass index <-2 sd can be determined as moderate malnutrition (wasted) and bmi <-1 sd can be determined as mild malnutrition. this study also showed that low physical fitness was less prominent in the girl group than in boy’s who impressed better physical fitness could be achieved if children had better nourishment, but correlation with academic performance was not yet explored. this was pointing out the limitation of the study. in conclusion, there is no correlation between physical fitness and academic achievement. therefore, further studies are needed to measure the association between academic achievement and related factors. references 1. giriwijoyo s. ilmu faal olahraga: fungsi tubuh manusia pada olah raga. 1st ed. bandung: fpok upi; 2007. p. 43. 2. lamonte mj, barlow ce, jurca r, kampert jb, church ts, blair sn. cardiorespiratory fitness is inversely associated with the incidence of metabolic syndrome. circulation. 2005; 112 (4):505−12. 3. gill jm, malkova d. physical activity, fitness and cardiovascular disease risk in adults: interactions with insulin resistance and obesity. clin sci (lond).2006; 110(4):409−25. 4. muhibin syah me. psikologi pendidikan. 1st ed. jakarta: raja grafinda persada; 2003. p. 89. 5. coe pw, pivarnik jm, womack cj, reeves mj, malina rm. effect of physical education and activity levels on academic achievement in children. med sci sports exerc. 2006;38(8):1515−9. 6. trudeau f, shephard rj. physical education, school physical activity, school sports and academic perfomance. int j behav nutr phys act. 2008;5(1):10−22. 7. sabia jj. the effect of body weight on adolescent academic perfomance. southern economic journal. 2007; 73(4):871−900. 8. maples wc. visual factor that significantly impact academic perfomance. optometry. 2003;74(1): 35−49. 9. grissom jb. physical fitness and academic achievement. jeponline. 2005;8(1):11−25. 10. eveland-sayers bm, farley rs, fuller dk, morgan dw, caputo jl. physical fitness and academic achievement in elementary school children. j phys act health. 2009;6(1):99−104. 11. álvarez-bueno c, pesce c, cavero-redondo i, et al. academic achievement and physical activity: a meta-analysis. pediatrics. 2017;140-6. 12. asmare b, taddele m, berihun m and wagnew f. nutritional status and correlation with academic performance among primary school children, northwest ethiopia. bmc res notes. 2018;11:805. 13. who intl. who child growth reference 2007. available at https://www.who.int/ growthref/en. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 525 breakfast composition in junior high school students sheila devi,1 aly diana,2 setiawan3 1faculty of medicine universitas padjadjaran, 2department of medical nutrition faculty of medicine universitas padjadjaran, 3department of physiology faculty of medicine universitas padjadjaran abstract background: adolescence is a time of rapid development that requires higher nutrient intake levels than in adulthood. however the habit of skipping breakfast has become very popular among adolescents. skipping breakfast has negative effects such as difficulty in concentrating, growth impairment and decrease academic performance. therefore, this study was conducted to identify the breakfast composisition of early adolescents in jatinangor, sumedang, indonesia. methods: a cross sectional study with non-probability sampling method, was conducted in a junior high school jatinangor during the month of july 2013. ninety six participants were included in this study. all the participants underwent an interview about the food intake for breakfast in seven days using eating pattern recall guidelines. results: overall, 37% of the respondents skipped breakfast. the mean of total calories among the adolescents who consumed breakfast was 286.06 (187.89) kcal. the amount of carbohydrate, fat and protein consumed was 29.23 (19.93) gram, 13.93 (13.29) gram and 8.78 (6.11) gram accordingly. the main reason for adolescent to skip breakfast was lack of time. conclusions: majority of the respondents have their breakfast before they go to school. overall, the total calories comsumed is sufficient however the amount of protein consumed is low. [amj.2015;2(4):525–8] keywords: adolescent, breakfast habit, breakfast composition correspondence: sheila devi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285721275390 email: sheila_d89@hotmail.com introduction breakfast is widely being promoted as essential for the nutritional well-being of children and adolescents.1 adolescence is a time of rapid development that requires nutrient intake levels higher than adulthood and behaviors developed during childhood and adolescence are typically carried over into adulthood.2 however, breakfast is the meal most often skipped by adolescents.1 a study conducted on family and personal predictors reported that skipping breakfast increases with age.1 in a study conducted on 540 fourth grade students from selected public schools in maryland, 20% reported skipping breakfast three or more times per week.3 breakfast is an important meal of the day because it provides higher energy contributions to the total daily energy intake compare to lunch and dinner. macronutrient intakes are higher in breakfast consumers in comparison with adolescents who regularly skip breakfast.4,5 a study conducted on low income african-american elementary school children showed that children who eat breakfast are more likely to achieve 24-hour dietary adequacy for nutrients than those who has skipped breakfast.6 a significantly higher proportion of children skipping breakfast has 24 -hour intakes below 50% of recommended dietary allowance for all nutrients compare to children who eat at breakfast.6 the objective of this study was to identify the breakfast composition among selected junior high schools students in jatinangor, sumedang, indonesia methods this study was conducted at pgri junior high school during the month of july 2013. the total number of participants were 100 (40 male and 60 female), selected by using the random sampling method after informed consent was obtained. the participants were selected althea medical journal. 2015;2(4) 526 amj december, 2015 randomly based on the age from thirteen to fifteen years old. four students were excluded from this study because of incomplete data and language barrier. data on food intake for breakfast in seven days were collected through interviews using eating pattern recall guidelines. the interview was performed by the researcher about the food consumed within one week. the guidelines was validated by the jatinangor cohort (department of epidemiology faculty of medicine, universitas padjadjaran). the guidelines consist of type of food (examples of a meal were given), kind of ingredients of the food (ingredients that were used in the meal), frequency in one week (the number of the same meal taken during seven days) and household measurements (the quantity of food taken in metric measurements, examples include in the form of a teaspoon, a tablespoon and a cup). furthermore, descriptive statistics was used to calculate the percentage of breakfast skippers and non-breakfast skippers. breakfast skippers were defined as consuming breakfast less than five times per week, whereas non breakfast skippers were defined as consuming breakfast five times and above. furthermore, the descriptive statistics is also used to determine the mean and standard deviation of the total calorie, carbohydrate, protein and fat consumed per day. the amount of calorie consumed was calculated using the data from eating pattern recall guidelines and nutrisurvey software. the study was approved by the health research ethics committee of faculty of medicine, universitas padjadjaran. results the percentage of adolescents who skip breakfast was 37%. the number of nonbreakfast skipper respondents was higher compared to breakfast skippers. furthermore, the proportion of male adolescents who skipped breakfast in jatinangor was higher than females. adolescents in jatinangor consumed sufficient calories as much as 286.06. they also consumed a high amount of fat and carbohydrate in their breakfast. although they consumed high amount of fat and carbohydrate, the amount of protein consumed was low. compared to all the reasons below, the main reason for the student’s to skip breakfast was lack of time. the second reason was laziness and followed by busy lifestyle of parents. discussions the percentage of adolescent who skipped breakfast was higher in this study (37%). this result is unlike a previous study in fiji7 on adolescent dietary patterns, where the total percentage of adolescent who skipped breakfast is 24%. in terms of gender, male table 1 percentage of breakfast consumption category male female total n(%) n(%) breakfast skippers 14(39) 21(35) 35 non breakfast skippers 22(61) 39(35) 61 total 36 60 96 table 2 nutrient intake in breakfast mean(sd) gram kilo calorie calorie 286.06 (187.89) protein 8.78(6.11) 35.10 (24.47) fat 13.93(13.29) 125.43 (119.69) carbohydrate 29.23(19.93) 116.91(79.73) note: *sd. standard deviation althea medical journal. 2015;2(4) 527 adolescents frequently skipped breakfast compared to female (39%) in this study. another study in fiji7 showed that females skip breakfast more often than males and this is inconsistent with this study. the gender difference in breakfast consumption is more prominent in adolescent is due to the increase of societal pressures and expectation to be thin in adolescence.4 since females are more likely to practice weight control behaviors, they are more likely to skip breakfast.4 according to the recommended dietary intake 2004, a normal healthy person should consume 2400 calories each day (this recommendation is for adult global people, which refer to 80-95 kg of bodyweight). in this study the breakfast meal provided 12% of daily energy intake , and the proportion of carbohydrate, protein and fat that contribute to energy in the breakfast was 41%, 12% and 44% respectively. this result is similar with the study performed on australian children and adolescents, the breakfast provided 1219% of daily energy intakes.8 the percentage of contributions to total daily intake of carbohydrate, protein and fat reported were 20%, 18% and 14%.8 compared to the previous study, the adolescents in jatinangor consumed high carbohydrate, low protein and high amount of fat. they consumed a high fat breakfast which has implications on their health. studies have found that low fat/ high carbohydrate meals are associated with a decline in fatigue compared to medium fat and high fat breakfast.9 a study by lloyd et al.10 reported that mood improved when respondents consumed low fat/high carbohydrate breakfast. high carbohydrate intake in breakfast is associated with more sustained improvement on memory task. intake of high fat breakfast also can lead to lower satiety. high fat diet is associated with suppression of appetite and food intake.11 beside this, high fat breakfast is found to have higher blood levels of glucose and insulin after eating, which can lead to obesity.12although breakfast is one of the weight control techniques and reduces the risk of obesity over four times, a nutrient composition is important in order to maintain health.4,13 additionally, the main reason for students to skip breakfast was lack of time. this result was consistent with the result reported in fiji.7 the second reason was laziness whereas the third one was that the parents are too busy. a review of 24 studies published in 2009 by pearson et al.4 found that there is relationship between family and breakfast. parents find it harder to prepare and eat breakfast with their children because of the early morning school bus schedule and non-traditional work hours.4 the other reasons are no money to buy breakfast, no appetite, vomiting problem and tendency to have stomach pain. some of the parents simply cannot afford to provide breakfast for their children. this explains the reason for adolescent to skip breakfast due to lack of money.4 there were several limitations in this study. first, since eating pattern recall questionnaire was used in the research, there was a recall bias in this study. the adolescents were not able to recall the frequent food they ate in one week period of time. recall bias can be minimized by reducing the period of food recall so that the recall period would be as short as possible. the second limitation is that the measurement of nutrient intake was done based on nutrisurvey software and the value may not be accurate as the value may vary depending on the type of food. furthermore, skipping breakfast have sheila devi, aly diana, setiawan: breakfast composition in junior high school students table 3 reasons for skipping breakfast reason percentage (%) parents are too busy 18 i am lazy to prepare breakfast 29 i had no money to buy breakfast 7 lack of time 30 i had no appetite 4 i prefer to eat lunch and dinner only 4 stomach pain 4 vomiting problem 4 althea medical journal. 2015;2(4) 528 amj december, 2015 major implications on adolescents such as nutrient deficiencies, poor physical and mental growth, malnutrition and low immunity.14 more emphasis should be placed on breakfast habits especially among adolescents. this study reinforce the role of parents in the development of healthy eating patterns since early adolescents depend on the parents for healthy eating knowledge, attitudes and behaviors. dietitians need to reinforce the importance of eating breakfast and consumption of healthy breakfast choices. the outcome found in this study also indicated the need for school breakfast programs. this offered potential for improved nutrient intake and academic performance. hence, schools might be an appropriate venue for promoting good breakfast habits. in conclusion, the majority of the respondents consume breakfast regularly with sufficient calorie. adolescents who skip breakfast are more favorable to have diets which are nutritionally inadequate. a future study about correlation between breakfast consumption and nutritional status should be done to identify the role of breakfast in nutritional status among adolescents. references 1. matthys c, de henauw s, bellemans m, de maeyer m, de backer g. breakfast habits affect overall nutrient profiles in adolescents. public health nutr. 2006;10(4):413−21. 2. brown sl, teufel j, gautam yr, norrick c, birch d. family and personal predictors of early adolescent eating patterns. californian j health promot. 2012;10:64− 70. 3. gross sm, bronner y, welch c, dewberrymoore n, paige dm. breakfast and lunch meal skipping patterns among fourthgrade children from selected public schools in urban, suburban, and rural maryland. j am diet assoc. 2004;104(3):420−423. 4. american dairy association and dairy council inc. the nutritional and academic implications of breakfast: supporting methods for increasing breakfast consumption among children and adolescents. new york: american dairy association and dairy council, inc; 2009 [cited 2013 november 5] available from: https://bestpractices.nokidhungry.org/ download/file/fid/465 5. kuck jm. differences in dietary patterns by breakfast consumption and weight status in us adolescence. [thesis]. ohio: the ohio state university; 2008. 6. vereecken c, dupuy m, rasmussen m, kelly c, nansel tr, al sabbah h, et al. breakfast consumption and its socio-demographic and lifestyle correlates in schoolchildren in 41 countries participating in the hbsc study. int j public health. 2009;54(suppl 2):180−90. 7. wate jt, snowdon w, millar l, nichols m, mavoa h, goundar r, et al. adolescent dietary patterns in fiji and their relationships with standardized body mass index. int j behav nutr phys act. 2013;10:45. 8. williams pg. breakfast and the diets of australian children and adolescents: an analysis of data from the 1995 national nutrition survey. int j food sci nutr. 2007; 58(3):201−16. 9. mahoney cr, taylor ha, kanarek rb, samuel p. effect of breakfast composition on cognitive processes in elementary school children. physiol behav. 2005;85(5): 635−45. 10. lieberman hr, kanarek rb, ‎prasad c, editors. nutritional neuroscience. boca raton: crc press; 2005. 11. acton qa. issues in eating disorders, nutrition and digestive medicine. atlanta, georgia: scholarly editions; 2013. 12. mcallister r. healthy lunchbox: the working mom’s guide to keeping you and your kids trim. los angeles: lifeline press; 2004. 13. smith ap. breakfast and adult’s and children’s behavior. in: kanarek rb, liebermean hr, editors. diet, brain, behavior: practical implication. boca raton: crc press; 2012. p. 53–70 14. onyechi ua, ugwunnadi g. comparative study of breakfast intake among school children in urban and rural areas of nsukka. animal research international. 2009;6(1):962−5. althea medical journal. 2015;2(3) 391 characteristics of patients with estrogen receptor (er)-negative, progesterone receptor (pr)-negative, and her2-negative invasive breast cancer in dr. hasan sadikin general hospital, bandung, indonesia from 2010 to 2011 nadytia kusumadjayanti,1 dharmayanti francisca badudu,2 bethy s. hernowo3 1faculty of medicine, universitas padjadjaran, 2departement of oncological surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3departement of anatomical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: breast cancer is the most common type of cancer that has been diagnosed among indonesian women. one of the subtypes that frequently being studied is the triple negative breast cancer which has poorer prognosis among all subtypes. the objective of this study was to investigate the incidents and the characteristics of triple negative breast cancer patients. methods: this study used triple negative breast cancer patients’ medical records in dr. hasan sadikin general hospital. some characteristics were identified, such as age at presentation, menopause status, tumor size, stage at presentation, grades of tumor, pathological features, and metastatic status. data were taken during 2010 and 2011 and presented in table. results: thirty women among 252 patients were identified as having triple negative breast cancer. based on those 30 cases, 11 patients were in the age group of 40‒55 years. fifteen out of 30 cases were premenopausal. from 30 cases, 14 patients had tumor size bigger than 5 cm. sixteen cases had stage iii tumor. most of the cases were invasive ductal carcinoma mammae as their histological features. two cases had metastized to pleura. conclusions: the incidence rate of triple negative breast cancer in dr. hasan sadikin general hospital is 11.9% with these common characteristics: range of age are between 40 to 45 years, have a premenopausal, had >5cm tumor , stage iii tumor and has histological feature idc, and only 2 patients were metastized to pleura. [amj.2015;2(3):391–94] keywords: breast cancer, characteristics, triple negative breast cancer. correspondence: nadytia kusumadjayanti, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281572242601 email: nadytiaks@yahoo.com introduction breast cancer is the most frequent type of cancer among women. according to the american cancer society, about 207,090 and 230,000 new cases of invasive breast cancer are predicted to occur in american women during 2010 and 2011, respectively. in indonesia, breast cancer is also the most frequent type of cancer that has been diagnosed among women, with incidence rate 26/100,000 people.1-3 breast cancer can be classified into histological classification, which is taken from the world health organization, and molecular classification, that can be obtained from an analysis of gene expression.4,5 molecular classification needs to be determined because the histological classification will not capture all clinical courses of the disease. in patients with identical tumor histologically, different clinical courses can be found on them. that is because they have molecular differences among cancers. detailed molecular analysis can obtain the information that will improve prognostic prediction.6 one of the molecular classification subtype that has been studied recently is triple negative breast cancer. this subtype of breast cancer has a negative expression of estrogen receptors, progesterone receptors, and heralthea medical journal. 2015;2(3) 392 amj september, 2015 2 (human epidermal growth factor 2). this subgroup does not respond to hormonal therapy or other targeted therapy. it makes the disease tend to have poor prognosis.7 this study aimed to find the incidence cases and the characteristics of triple negative breast cancer in dr. hasan sadikin general hospital, bandung. methods this study was conducted with the crosssectional descriptive method. data were taken from the medical records of triple negative table 1 characteristics of triple negative breast cancer (n=30) characteristics number of cases age at presentation (years) (range 31‒76) <40 10 40‒55 11 >55 9 menopausal status premenopausal 15 menopausal 6 postmenopausal 9 tumor size (cm) (range1‒15) <2 3 2‒5 12 >5 14 not listed 1 stage at presentation ii 8 iii 16 iv 2 not listed 4 tumor grade 2 10 3 16 not listed 4 histologic subtype idcm 24 ilcm 3 mixed idcm and ilcm 1 metaplastic carcinoma mammae 1 secretory carcinoma mammae 1 metastatic status yes (pleural effusion) 2 no 25 unknown 3 note: idcm= invasive ductal carcinoma mammae; ilcm= invasive lobular carcinoma mammae althea medical journal. 2015;2(3) 393 patients in dr. hasan sadikin general hospital during january 2010‒december 2011. the parameters such as age presentation, menopausal status, tumor size, stage at presentation, pathological features and grades, and metastatic status were evaluated. data collection was carried out in the department of anatomical pathology to collect the patients’ data where the immune histochemistry was tested. among 252 cases tested, 30 cases were triple negative. age at presentation, pathological features and grades, tumor size, stage of tumor, menopause status, and metastatic status were taken from the medical records of the patients. the collected data were analyzed using the statistical software spss version 20 and presented in tables. data were collected during september‒november 2012. results data from 1 january 2010‒31 december 2011 showed that 252 breast cancer patient were immunohistochemistry tested, and 30 cases (11.9%) were triple negative breast cancer. the characteristics of 30 cases triple negative breast cancer are shown in table 1. ten cases were below the age of 40, with the youngest age was 31. fifteen from 30 cases of triple negative breast cancer were premenopausal. tumor size of 14 cases was above 5 cm and most of the cases had stage iii tumor. in this study, triple negative breast cancer cases were mostly in grade 3 (16/30) and invasive ductal carcinoma mammae was the most common subtype (24/30). there were only 2 cases that were already metastized to pleura discussion the incidence of triple negative breast cancer in dr. hasan sadikin general hospital stands at 11.9%, within the range of 10‒17% reported in a literature written by reis-filho et al.8 the distribution of age in this study indicates that most of the cases are in the age group of 40‒55 years. this result is in line with the data results from british columbia, canada.9 besides, it must be noted that the youngest person in the case was 31 years old meaning that this subtype of breast cancer also can affect younger patients. this result is supported by the result of menopausal status distribution showing that 50% cases are premenopausal this result is similar to the a study in the carolina breast cancer study.10 however, this study result is different from the study result in singapore, which shows that most of the triple negative breast cancer cases were in postmenopausal group.11 most of the triple negative cases in our population had a tumor size more than 5 cm. this result is different from the data in canada, where most of these cases had tumor size in between 2‒5 cm.9 in this study, it can be concluded that half of the population (53.3%) had stage iii tumor on the day they went to the doctor’. these results were also varied from a previous study by keegan et al.12. it shows that in their population, triple negative breast cancer cases have come to the doctor’s when they had stage ii. histological type and grades in this study confirmed a morphologically aggressive phenotype, with most of cases had stage iii tumor, similar to the study carried out in canada.9,13 from these data, it can be concluded that triple negative breast cancer are highly differentiated so that this subtype has a poor prognosis. pathological features of triple negative breast cancer cases in dr. hasan sadikin general hospital are predominantly invasive ductal carcinoma mammae. this result confirms the study in singapore, as well as in nigeria and senegal.11,14 furthermore, metaplastic, medullary, and secretory carcinoma subtype are also found in triple negative breast cancer.14,15 the study explains about findings in our data, which had one case of metaplastic type and also secretory type of carcinoma. on metastatic status, from 30 cases, there were two cases that had already metastized and both of them metastized to pleura. those cases confirm the previous study in toronto. the study concludes that the triple negative breast cancer tends to metastize to visceral region, especially lungs and brain.16 these varied findings aimed to give information about metastatic status within the first year of the study. till the end of december 2011, there are only two cases metastized. based on this study, it can be concluded that the incidence of triple breast cancer and the characteristics of patients are in accordance with other previous studies. short period of time became the limitation for this study. the period during january 2010‒december 2011 was chosen because immunohistochemistry test for breast cancer in dr. hasan sadikin general hospital started in 2010. therefore, this study has only a few data, although it has used the total sampling nadytia kusumadjayanti, dharmayanti francisca badudu, bethy s. hernowo: characteristics of patients with estrogen receptor (er)-negative, progesterone receptor (pr)-negative, and her2-negative invasive breast cancer in dr. hasan sadikin general hospital, bandung, indonesia from 2010 to 2011 althea medical journal. 2015;2(3) 394 amj september, 2015 method. it is possible that this study does not illustrate the reality in the field. this study has not illustrated the majority race of triple negative breast cancer case because there is not enough information about it in the medical records. references 1. american cancer society. breast cancer facts & figures 2010‒2011. atlanta: american cancer society, inc.; 2011. 2. american cancer society. cancer facts & figures 2010. atlanta: american cancer society, inc.; 2010. 3. kementerian kesehatan republik indonesia. jika tidak dikendalikan 26 juta orang di dunia menderita kanker. kementerian kesehatan republik indonesia. 2012. [cited 2012 april 9]. available from: http://www.depkes.go.id/ index.php/berita/press-release/1060jika-tidak-dikendalikan-26-juta-orang-didunia-menderita-kanker-.html 4. tavassoli fa, devilee p, world health organization, international agency for study on cancer. pathology and genetics of tumours of the breast and female genital organs. lyon: iarc press; 2003. 5. yang xr, sherman me, rimm dl, lissowska j, brinton la, peplonska b, et al. differences in risk factors for breast cancer molecular subtypes in a population-based study. cancer epidemiol biomarkers prev. 2007;6(3):439‒43. 6. pusztai l, mazouni c, anderson k, wu y, symmans wf. molecular classification of breast cancer: limitation and potential. oncologist. 2006;11(8):868‒77 7. foulkes wd, smith ie, reis-filho js. triplenegative breast cancer. n engl j med. 2010;363(20):1938‒48 8. reis-filho js, tutt an. triple negative tumours: a critical review. histopatology. 2008;52(1):108‒18 9. voduc kd, cheang mcu, tyldesley s, gelmon k, nielsen to, kennecke h. breast cancer subtypes and the risk of local and regional relapse. j clin oncol. 2010;28(10):1684‒91 10. anders c, carey la. understanding and treating triple-negative breast cancer. oncology (williston park). 2008;22(11):1233‒9. 11. thike aa, cheok py, jara-lazaro ar, tan b, tan p, tan ph. triple-negative breast cancer: clinicopathological characteristics and relationship with basal-like breast cancer. mod pathol. 2010;23(1):123‒33. 12. keegan t, derouen m, press d, kurian a, clarke c. occurrence of breast cancer subtypes in adolescent and young adult women. breast cancer res. 2012; 14(2):r55. 13. dent r, trudeau m, pritchard ki, hanna wm, kahn hk, sawka ca, et al. triplenegative breast cancer: clinical features and patterns of recurrence. clin cancer res. 2007;13(15):4429‒34. 14. huo d, ikpatt f, khramtsov a, dangou j-m, nanda r, dignam j, et al. population differences in breast cancer: survey in indigenous african women reveals overrepresentation of triple-negative breast cancer. j clin oncol. 2009;27(27):4515‒21. 15. hudis ca, gianni l. triple-negative breast cancer: an unmet medical need. oncologist. 2011;16(suppl 1):1‒11. 16. dent r, hanna wm, trudeau m, rawlinson e, sun p, narod sa. pattern of metastatic spread in triple-negative breast cancer. breast cancer res treat. 2009;115(2):423‒8. vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 201 characteristics of elderly patients with sarcopenia at geriatric outpatient clinic dr. hasan sadikin general hospital period 2012–2014 sania putri darwita,1* yuni s. pratiwi,2 lazuardhi dwipa3 1rsud sayang cianjur, west java, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: sania putri darwita, rsud sayang cianjur, bojongherang, kec. cianjur, kabupaten cianjur, west java 43216, indonesia, email: saniaputridarwita@gmail.com *former address: faculty of medicine universitas padjadjaran introduction many changes occur during the aging process, one of them is the gradual loss of skeletal muscle mass which can cause the decrease of muscle strength and physical performance. muscle strength and physical performance are key components of muscle function. a reduction in skeletal mass and muscle function is known as sarcopenia and is one of the problems faced by the elderly.1 elderlies with sarcopenia have a higher chance of experiencing difficulties or dependency in doing physical activities, thus making the elderly unable to live independently.1 there are differences between prevalence of sarcopenia in men and women. most studies have shown that sarcopenia occurs more often in men than in women even though the number does not differ significantly. in japan3, the prevalence of sarcopenia is 11.3% and 10.7%, in taiwan2,4 is 9.4% and 9.8% for men and women respectively. there is an increase in the occurence of sarcopenia as a person ages. a study done by new mexico elder health survey reported an increase in the prevalence of sarcopenia with an increase in age, showing percentage of 13–24% in people of age 70 years or younger and 50% in people of age 80 amj. 2018;5(4):201–7 abstract background: sarcopenia can lead to difficulty in physical activities, therefore, elderly cannot live independently. however, data on sarcopenia are not yet available in dr. hasan sadikin general hospital. this study was conducted to identify the frequency of occurrence and characteristics of elderly patients with sarcopenia. methods: this study used descriptive method and was conducted from may to october 2014. total sampling method was performed to medical records of elderly patients with sarcopenia at geriatric outpatient clinic dr. hasan sadikin general hospital during the period 2012–2014. variables observed were age, gender, body mass index (bmi), activities of daily living (adl), timed up and go test (tug), mini nutritional assessment (mna), disease record, and medication record. patients with sarcopenia were then grouped based on characteristics of age, gender, bmi, adl, tug, mna, disease record, and medication record. results: out of 255 registered elderly patients, 22(8.63%) were with sarcopenia and one was excluded due to incomplete data. sarcopenia was most prevalent in patients aged 80 years and older (15.38%), and commonly in men (57.1%). most patients had hypertension history (66.6%), multiple comorbidities (61.9%), normal bmi (33.3%), normal adl (85.7%), normal mna (76.1%), and normal tug scores (80.9%), and polypharmacy (52.3%) history. conclusions: sarcopenia is prevalent in men aged 80 years and older. although sarcopenia patients have hypertension history, multiple comorbidities and history of polypharmacy, most patients live with normal daily activities and have good body mass index, however, quality of life of elderlies needs to be improved further. keywords: elderly, quality of life, sarcopenia althea medical journal. 2018;5(4) 202 amj december 2018 years or older.5-6 a study in rome7 reported that the average number of disease in elderlys with sarcopenia and those without sarcopenia are the same, but parkinson’s, chronic obstructive pulmonary disease, osteoarthritis, and cerebrovascular disease are diseases commonly suffered by patients with sarcopenia. a study in thailand8 showed that sarcopenia is related to higher body mass index (bmi). meanwhile, a study conducted in brazil9 showed that there is a significant relationship between sarcopenia with the timed up and go test (tug) score, whereby a lower muscle mass resulted in a higher tug score. a research in turkey10 reported that elderlys with sarcopenia are mostly dependent and that the mini nutritional assessment (mna) score is lower in sarcopenia patients who have malnutrition (10.4%) and risk of malnutrition (24.6%). polypharmacy can cause malnutrition which can lead to sarcopenia.6-11 sarcopenia has become an increasingly important problem, however studies about sarcopenia are rarely performed, especially in indonesia. information regarding sarcopenia was not even available at the geriatric oupatient clinic of dr. hasan sadikin general hospital. the objectives of the study was to identify the frequency of occurence and the characteristics of elderly patients with sarcopenia at the geriatric outpatient clinic of dr. hasan sadikin general hospital during the period of 2012–2014. methods this study was conducted using a descriptive method. total sampling method was performed to the medical records of elderly patients diagnosed with sarcopenia at the geriatric outpatient clinic of dr. hasan sadikin general hospital during the period of 2012–2014. this study was approved by the health research ethics committee of dr. hasan sadikin general hospital, bandung. the rate of occurence and characteristics of elderly patients with sarcopenia was obtained from the medical records of patients with sarcopenia which met the inclusion criteria i.e. the elderly patient’s entire medical record with sarcopenia was confirmed with a bioimpedance analysis (bia) test, a grip strength test and a 6 minutes walking test. medical records that did not contain data on the age, sex, disease record, bmi, activities of daily living (adl), mna, tug, and medication record were excluded from this study. from 22 elderly patients with sarcopenia, 21 patients had medical records which met the inclusion criteria. sarcopenia was defined as the gradual loss of muscle mass as written from the results of a bia test showing the index value of skeletal muscle less than 7 kg/m2 for men or less than 5.8 kg/m2 for women; a loss in the muscle function (strength or performance) showing the results of the grip strength test less than 30.3 kg for men or less than 19.3 kg for women; the 6 minutes walking test with a walking rate less than 1.27 m/s for men or less than 1.19 m/s for women; or are unable to complete this test at all.3,12 sarcopenia was then categorized into (i) presarcopenia of which there was a reduction in the muscle mass, (ii) sarcopenia, the reduction in the muscle mass as well as a loss in the muscle strength or physical performance, and (iii) severe sarcopenia, a loss in muscle mass, muscle strength, and physical performance. 13 age was categorized into ‘young old’ (60– 69 years old), ‘middle old’ 70–79 years old) and ‘very old’ (>80 years old) as described else where.14 disease record was analyzed by looking at the frequency and type of disease that was most common in patients with sarcopenia. table 1 frequency of occurence of sarcopenia in elderly patients at geriatric outpatient clinic dr. hasan sadikin general hospital during period 2012–2014 based on age category age total respondents sarcopenia frequency n n (%) 60–69 years old 109 8 (7.34) 70–79 years old 133 12 (9.02) ≥80 years old 13 2 (15.38) total 255 22(100) althea medical journal. 2018;5(4) 203sania putri darwita, yuni s pratiwi, lazuardhi dwipa: characteristics of elderly patients with sarcopenia at geriatric outpatient clinic dr. hasan sadikin general hospital period 2012–2014 body mass index (bmi) was obtained from the ratio of body weight (bw) (in kg) with height (bh) squared (in meters). bmi=bw/ bh2, the bh of elderly people was obtained from the conversion of knee height. bmi was categorized as being underweight (<17 kg/m2 for women and <18 kg/m2 for men), normal (17–23 kg/m2 for women and 18–25 kg/m2 for men), overweight (>23–27 kg/m2 for women and >25–27 kg/m2 for men), and obese (>27 kg/m2 for both men and women).15 functional independence in daily personal activities was tested by adl. the barthel index measured eating, bathing, self-care, dressing, urinating, defecating, using the toilet, transfering, mobility, and going up and down the stairs. the adl was categorized as independent (score 20), mild dependent (12–19), moderate dependent (9–11), severe dependent (5–8) and totally dependent (0– 4).16 the nutritional status of elderly people through 18 questions was tested by mna. the results of the mna test were categorized as normal nutritional status (score 24–30), risk of malnutrition (17–23.5) and malnutrition (16.5 or less).17 balance and stability of body posture of the elderly, and specifically assessing the risk of falling was measured by tug. the subjects table 2 characteristics of elderly patients with sarcopenia at geriatric outpatient clinic dr. hasan sadikin general hospital during period 2012–2014 variable sarcopenia (n=5) severe sarcopenia (n=16) total (n=21) sex(n) male 2 10 12 female 3 6 9 disease (n) –2 diseases 1 7 8 >2 diseases 4 9 13 bmi (n) underweight 2 2 normal 3 4 7 overweight 1 5 6 obese 1 5 6 adl (n) independent 5 13 18 mild dependent 3 3 mna (n) normal 4 11 15 risk of malnutrition 1 3 4 malnutrition 2 2 tug (n) high risk of falling 4 4 normal 5 12 17 medication (n) polypharmacy 3 8 11 non-polypharmacy 2 8 10 note : n=number of sample, bmi= body masss index, adl= activities of daily living, mna= mini nutritional assessment, tug= timed up and go test althea medical journal. 2018;5(4) 204 amj december 2018 were asked to stand up from a chair and then asked to walk 3 meters and turn around again until they returned to their initial seat. the results of the tug test were categorized as having a high risk of falling (score of >15s) and normal (<15s).18 the medication record was categorized as polypharmacy (the use of 5 or more medications) and non-polypharmacy.19 after the data was collected and categorized, it was presented in frequency table. results during the period of 2012–2014, 255 patients visited the geriatric outpatient clinic at dr. hasan sadikin general hospital and 22 (8.63%) of them were diagnosed with sarcopenia, consisting of 13 male (11.2%) and 9 female (6.4%). however, of the 22 patients with sarcopenia, only 21 patients met the inclusion criteria due to incomplete data. based on the age category, sarcopenia occured most often in the age of 80 and above (15.38%) as shown in table 1. the characteristics of elderly patients with sarcopenia showed that there was no patient found with presarcopenia, and most of the patients had severe sarcopenia, i.e 16 out of 21 (76.1%) patients. most of the patients were male (12 out of 21 patients), had a history of more than two diseases (12 out of 21 patients), had normal bmi (7 out of 21 patients) followed with bmi categorized as overweight and obese (each being 6 out of 21 patients). the patients with sarcopenia in this study mostly had an adl value of independent (18 out of 21 patients), had a normal tug (17 out of 21 patients), had a normal mna value (16 out of 21 patients), and had a history of polypharmacy (11 out of 21 patients) (table 2). furthermore, most of the patients (66.6%) table 3 disease record of elderly patients with sarcopenia frequency (n) stroke 1 cataract 5 angina 4 acute myocardial infarction 1 tuberculosis/chronic obstructive pulmonary disease/asthma 1 hypercholesterolemia 6 hypertriglyceridemia 2 obesity and fatness 12 (57.1%)* diabetes melitus 9 hypertension 14 (66.6%)* urolithiasis 1 benign prostatic hyperplasia (bph) liver problems (urinary tract infection, decrease in function) 1 osteoporosis 5 osteoarthritis 2 gout 1 anemia cancer gastritis 1 hepatitis 1 cholelitiasis 2 total 21 note: * hypertension and obesity were the most prevalent diseases in older patients althea medical journal. 2018;5(4) 205 had a history of hypertension (14 out of 21 patients) (table 3). discussion the prevalence of sarcopenia in patients attending the geriatric outpatient clinic of dr. hasan sadikin general hospital during the period of 2012–2014 is 8.63%, and male is being the most prevalent, in line with study in japan3 with 11.3% in males and 10.7% in females. however, this result differs with a study carried out in taiwan4 that sarcopenia occurs more often in females. many factors such as hormones, disorder of the nervous system, lack of nutrition, lack of physical activity, or chronic inflammation may play role in sarcopenia.13 interestingly, gender is not reported as a risk factor in the occurence of sarcopenia, thus, the possibility of sarcopenia for both sexes is the same.13 furthermore, sarcopenia in our study occurres more often in patients aged 80 years and older (15.38%), that is increasing compared to those occurring in patients aged 60–69 years (7.34%) and aged 70–79 years (8.27%), confirming that the prevalence of sarcopenia occurs as a person ages. this is in line with a study performed by the new mexico elder health survey which reported an increase in the prevalence of sarcopenia with an increase in age. between the ages of 50 to 60 years, a decrease in muscle strength occurs as much as 1.5% per annum and a sharper decrease occurs as much as 3% per annum for those aged 60 years or older.5-6 patients with sarcopenia at the geriatric outpatient clinic mostly had a similar disease record to most patients without sarcopenia, i.e. more than two diseases otherwise known as multiple comorbidity. the average amount of illnesses in elderly patients with sarcopenia and those without sarcopenia are the same.7 the patients in this study mostly have a history of hypertension, different then study result in western countries, showing that parkinson’s, chronic obstructive pulmonary disease, osteoarthritis, and cerebrovascular disease are diseases commonly suffered by patients with sarcopenia.7 this might be due to the difference in the population structure and geographic location and food and lifestyle behavior of the population. most of the patients with sarcopenia in this study has normal bmi, however, sarcopenia could occur even though patients has normal bmi with a lower muscle mass in body composition and a higher fat content, suggesting an unhealthy lifestyle lacking physical activities. physical inactivity may cause atrophy or loss in muscle fibers and fat build up, resulting in sarcopenia.6 interestingly, the occurence of sarcopenia in fat and obese patients is also quite high, in line with a study conducted in thailand8, showing that sarcopenia is related with a higher bmi. obesity is one of the conditions that can trigger the release of il-6 which increases glucocortoids and catecolamines, reducing the growth hormones and causing sarcopenia.6,13 elderly people with sarcopenia have a higher risk of suffering from physical disabilities if early intervention is not performed.13 there are still debates on the relationship between sarcopenia and functional status. elderly people with sarcopenia are mostly dependent, but there is no significant relationship between adl and sarcopenia.10 furthermore, people with sarcopenia do not experience a decrease in functional status.20 based on the adl value, most of the elderly patients with sarcopenia in this study has an independent functional status. since the elderly people in this study are still able to come to the outpatient clinic, thus they have a more controlled health and good independence. they may have a high risk of having a decreased adl in the future, thus, an early intervention should be done to prevent a decrease in independence. furthermore, poor nutritional status is one of the factors that can cause sarcopenia and it can result in a decrease of protein synthesis, increase of proteolysis, thus causing a decrease in the muscle mass and function.13 most of the patients with sarcopenia in this study has a normal nutritional status. the results of this study differs with the results of a study conducted in turkey10 that showed a low mna score in sarcopenia patients who has malnutrition and has risk of malnutrition. this difference may have been because the study conducted in turkey10 is a community based population, instead of out-patients in our study, who has more controlled health and thus probably had better nutritional status. poor nutritional status is just one of the risk factors of sarcopenia; in this study poor nutrition is probably not the main factor causing sarcopenia thus further research is needed on other factors which may have a more significant role in causing sarcopenia. the reduction in muscle mass and function can cause an increase in the risk of falling in elderly people. there is a significant relationship between sarcopenia with the tug score, resulting in a lower muscle mass results sania putri darwita, yuni s pratiwi, lazuardhi dwipa: characteristics of elderly patients with sarcopenia at geriatric outpatient clinic dr. hasan sadikin general hospital period 2012–2014 althea medical journal. 2018;5(4) 206 amj december 2018 in a higher tug score.9 in this study, most of the patients still had a normal tug score. this differs with the result of the study in brazil9 which is carried out in the community where the elderly people with sarcopenia already has a higher risk of falling. most of the patients with sarcopenia in this study has a history of polypharmacy, that may lead to malnutrition problems. elderlies with polypharmacy may have a decrease in fiber, vitamin, and mineral intakes as well as an increase in the consumption of cholesterol, glucose, and sodium. an increase in the consumption of saturated fats, carbohydrates and cholesterols along with a decrease in fibers and proteins can result in a deterioration of the physical health.11 malnutrition or the lack of vitamin d consumption itself can be one of the causes of sarcopenia.6 pre-sarcopenia is not prevalent in our study, however, most of the patients suffer from severe sarcopenia. a majority of the patients has more than two diseases, similar to most of the other patients at the geriatric outpatient clinic without sarcopenia, with the most prevalent disease such as hypertension and polypharmacy. the limitations of this study, among others, that the medical history of older patients are not complete. the data base of medical history need to be enhances since the cohort study for older people is interesting to be explored. in this study, the patients with sarcopenia were described as elderly patients who looked normal, had normal bmi, normal tug scores, normal nutritional status, and were still able to carry out their daily activities well. this should increase the amount of awareness and care in detecting sarcopenia at an earlier stage in elderlys who still look healthy and independent so that these elderly people can uphold their independence for as long as possible. in conclusion, sarcopenia is prevalent in male aged 80 years and older. although sarcopenia patients have history of hypertension, polypharmacy, and multiple comorbidities, most patients live with normal daily activities and have a good body mass index, however, the quality of life of the elderly needs to be improved further. in addition, further study should be conducted regarding the occurrence of sarcopenia in communities, since other studies have shown that the frequency of incidence of sarcopenia is higher in communities. it would be better if the study could be conducted in west java or integrated across indonesia. from such a study, it is hoped that we can know the prevalence of sarcopenia in a much larger range, i.e. west java or indonesia, and thus prevention and intervention of sarcopenia can be performed so that the elderly have a better quality of life. references 1. chien my, kuo hk, wu yt. sarcopenia, cardiopulmonary fitness, and physical disability in community-dwelling elderly people. phys ther. 2010;90(9):1277–87 2. lau emc, lynn hsh, woo jw, kwok tcy, melton lj, iii. prevalence of and risk factors for sarcopenia in elderly chinese men and women. j gerontol a biol sci med sci 2005;60a(2):213–6. 3. tanimoto y, watanabe m, sun w, sugiura y, tsuda y, kimura m, et al. association between sarcopenia and higher-level functional capacity in daily living in community-dwelling elderly subjects in japan. arch gerontology geriatr. 2012;55(2):e9–e13. 4. liu lk, lee wj, chen ly, hwang ac, lin mh, peng ln, et al. sarcopenia, and its association with cardiometabolic and functional characteristics in taiwan: results from i-lan longitudinal aging study. geriatr gerontol int. 2014;14(s1):36–45. 5. von haehling s, morley je, anker sd. an overview of sarcopenia: facts and numbers on prevalence and clinical impact. j cachexia sarcopenic muscle. 2010;1(2):129–33 6. baumgartner rn, waters dl. sarcopenia and sarcopenic-obesity. in: pathy msj, sinclair aj, morley je, editors. principles and practice of geriatric medicine. 4th ed. chichester,west sussex,england: john wiley & sons ltd; 2006. p. 909–47. 7. landi f, liperoti r, fusco d, mastropaolo s, quattrociocchi d, proia a, et al. prevalence and risk factors of sarcopenia among nursing home older residents. j gerontol a biol sci med sci. 2012;67(1):48–55. 8. pongchaiyakul c, limpawattana p, kotruchin p, rajatanavin r. prevalence of sarcopenia and associated factors among thai population. j bone miner metab. 2013;31(3):346–50. 9. falsarella gr, coimbra ib, barcelos cc, iartelli i, montedori kt, santos mnj, et al. influence of muscle mass and bone mass on the mobility of elderly women: an observational study. bmc geriatr. 2014;14:13. 10. bahat g, saka b, tufan f, akin s, sivrikaya althea medical journal. 2018;5(4) 207 s, yucel n, et al. prevalence of sarcopenia and its association with functional and nutritional status among male residents in a nursing home in turkey. aging male. 2010;13(3):211–4. 11. heuberger ra, caudell k. polypharmacy and nutritional status in elderlys. drugs aging. 2011;28(4):315–23. 12. chen lk, liu lk, woo j, assantachai p, auyeung tw, bahyah ks, et al. sarcopenia in asia: consensus report of the asian working group for sarcopenia. j am med dir assoc. 2014;15(2):95–101. 13. cruz-jentoft aj, baeyens jp, bauer jm, boirie y, cederholm t, landi f, et al. sarcopenia: european consensus on definition and diagnosis: report of the european working group on sarcopenia in older people. age ageing. 2010;39(4):412–23. 14. stuart-hamilton i. the psychology of ageing: an introduction. 5th ed. london: jessica kingsley publishers; 2012. 15. kementrian kesehatan republik indonesia. indeks massa tubuh. 2014 [cited 2014 february 18]. available from: http://www. depkes.go.id/index.php?vw=2&id=a-137. 16. houlden h, edwards m, mcneil j, greenwood r. use of the barthel index and the functional independence measure during early inpatient rehabilitation after single incident brain injury. clin rehab. 2006;20(2):153–9. 17. tsai ac, hsu hy, chang tl. the mini nutritional assessment (mna) is useful for assessing the risk of malnutrition in adults with intellectual disabilities. j clin nurs. 2011;20(23-24):3295–303. 18. reuben db, rosen s. principles of geriatric assessment. in: halter jb, ouslander jg, tinetti me, studenski s, high kp, asthana s, editors. hazzard’s geriatric medicine and gerontology. 6th ed. united states: the mcgraw-hill companies, inc; 2009. p. 141–5. 19. viktil kk, blix hs, moger ta, reikvam a. polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. br j clin pharmacol. 2007;63(2):187–95. 20. rolland y, lauwers-cances v, cristini c, van kan ga, janssen i, morley je, et al. difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in communitydwelling elderly women: the epidos (epidemiologie de l’osteoporose) study. am j clin nutr. 2009;89(6):1895–900. sania putri darwita, yuni s pratiwi, lazuardhi dwipa: characteristics of elderly patients with sarcopenia at geriatric outpatient clinic dr. hasan sadikin general hospital period 2012–2014 althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 231 knowledge, attitude and nutritional status in pregnant women wiwit widiastuti,1 kuswandewi mutyara,2 amillia siddiq3 1faculty of medicine universitas padjadjaran, 2departmen of public health faculty of medicine universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: nutrition during pregnancy is essential for a healthy pregnancy and childbirth. malnutrition during pregnancy may cause a negative impact for both mother and fetus. pregnant women have to replenish their nutritional intake so they have to know nutritional needs for pregnancy. this study aims to evaluate the association between knowledge towards the attitude and nutritional status among pregnant women in jatinangor primary health care. methods: this was a cross-sectional study and the subjects were 75 pregnant women selected by consecutive sampling while they attending puskesmas jatinangor for antenatal follow up in october until november 2012. knowledge and attitude was assessed using a questionnaire. the level of knowledge and attitudes were categorized into insufficient, sufficient and good. nutritional status was assessed by measuring the mid upper arm circumference. the level of nutritional status was categorized into good nutritional status and lower nutritional status. result: out of 75 respondents, 24 respondents had good knowledge, 39 respondents had sufficient knowledge and 12 respondents had insufficient knowledge. 15 respondents had good attitude, 51 respondents had sufficient attitude, 9 had insufficient attitude. 62 respondents had good nutritional status and 13 respondents had lower nutritional status conclusion: most of subjects have sufficient knowledge and attitude, and majority of the respondents have good nutritional status. there was significant relationship between knowledge and attitude (p=0.02) and no significant relationship between knowledge and nutrition status (p=0.666). based on this study, it is expected to conduct further study about other factors which affect the knowledge, attitude, and practice of pregnant women to improve the nutritional status. [amj.2015;2(1):231–4] keywords: attitude, knowledge, nutrition status, pregnancy correspondence: wiwit widiastuti, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285647428742 email: wwidiastuti7@gmail.com introduction adequate nutritional intake during pregnancy is important to achieve healthy pregnancy.1 during pregnancy the nutritional needs of pregnant women will increase. nutrition deficiency during pregnancy is harmful for both the mother and fetus. insufficient of nutrition during pregnancy may cause insufficient nutrition to reach the fetus, intrauterine growth retardation, growth retardation, preterm labors, some inherited malformations, and pregnancy complication.2 maternal nutritional problem that often occurs is anemic and chronic energy deficiency that could lead to high-risk pregnancies. common causes of maternal deaths are haemorrhage and pre-eclampsia.3 there are many anatomical and physiological changes in the pregnant women, so the need for energy also increased approximately 14%.4 pregnant women should pay more attention to nutritional intake, because they have to meet their own nutritional and also for the fetus. maternal dietary intake during pregnancy can be affected by several factors, including economic and social status, culture and educational level of the mother and her family. malnutrition can result from ignorance of the pregnant mothers to their nutritional needs. the level of knowledge about the nutritional needs during pregnancy will affect the attitude and behavior of the mother in selecting food and regulate her diet. therefore, research on the association between knowledge towards attitudes and nutritional status of pregnant women is needed. althea medical journal. 2015;2(2) 232 amj june, 2015 methods this research was an analytical research using cross-sectional method. the study was conducted at the jatinangor health center on october to november 2012 among pregnant women attended for antenatal care who are willing to be a subject of study, according to the consecutive sampling. total subjects were 75 pregnant women. prior to the study, the respondents received explanation about the purpose of the study and the respondents were asked to sign a consent form. the data were taken using a questionnaire that has been validated. demographic information was included at the first part of questionnaire. knowledge questionnaire consisted of 13 questions with choices of right or wrong answers. the second part was the attitude questionnaire consisted of 11 questions with the choices strongly disagree, disagree, agree, and strongly agree. scores of knowledge and attitude were obtained by summation of each group question. the level of knowledge and attitude will be divided into three groups: good, sufficient, and insufficient. nutritional status was obtained by measuring the circumference of the upper arm using a tape measure and the results were grouped into two categories, good nutritional status if the size of the upper arm circumference greater than or equal to 23.5 cm and malnutrition status if the size of the upper arm circumference of less than 23.5 cm. association between knowledge towards attitudes and nutritional status analyzed by fisher’s test. result the majority of respondents in this study were 20 to 35 years old. women in this study were either in first, second, or third trimester with more than half are in the third trimester. most respondents graduated from high school and did not work. the average value of the respondents knowledge was 10.37±1.761 with a range of values 0−13 and the average value of the respondents attitude was 32.17±3.387. distribution of respondents based on nutritional status indicated that the majority of respondents had a good nutritional status, as many as 62 respondents (82.7%) result of this study showed a significant association between nutrition knowledge and attitude (p=0.022) and no significant association between nutrition knowledge and nutritional status (p=0.666). discussions knowledge is the result of the senses (eyes, nose, ears, skin, etc.) and are influenced by the intensity of the attention and the perception of table 1 association between nutrition knowledge and attitude groups knowledge level attitude pgood sufficienta insufficientb n % n % n % good 9 12 13 17.3 2 2.6 0.022sufficienta 3 4 32 42.6 4 5.3 insufficientb 3 4 6 8 3 4 note; a and b are combined for purposes of data analysis table 2 association between nutrition knowledge and nutritional status knowledge level nutritional status pgood insufficientb n % n % good 21 28 3 4 0.666sufficienta 33 44 6 8 insufficientb 8 10.6 4 5.3 note; a and b are combined for purposes of data analysis relationship with althea medical journal. 2015;2(2) 233wiwit widiastuti, kuswandewi mutyara, amillia siddiq: effect of dates (phoenix dactilyfera l) on male infertility an object.5 knowledge influences the people’s behavior.5 knowledge is influenced by several factors such as level of education, employment, and age.6 attitude is a close response to a stimulus or a particular object involving opinions and emotions, for example, agreedisagree, good-bad, and so on.7 research conducted by jonathan8 in 2010 showed that there were several predictors that can affect a person’s attitude, such as ethnicity, education level, and level of knowledge. the act or practice is an embodiment of the attitude that supported by other factors such as facility or infrastructure. research conducted in 2007 mentioned that the social demographics, such as education level, residence, and age also affect the behavior.9 in this study, a significant association has been found between the knowledge level of nutrition with the attitude of respondents (p<0.05). this suggests that the level of knowledge of pregnant women in the study population is related to the readiness or willingness of respondents to act. research conducted in 2011 about the relationship of knowledge, attitudes, and practices of nutrition also showed similar results, that there is a correlation between knowledge and attitude.7 in the fisher’s test, there is no significant association between the level of knowledge and nutritional status of pregnant women (p>0.05). this suggests that the level of knowledge does not affect the nutritional behavior of pregnant women thus had no effect on nutritional status. similar results were also found in a study conducted in 2007 that the level of nutrition knowledge is not related to behaviour.10 study conducted in 2012 also showed similar results, it is due to the fact that some people may have strict rules with the diet so it is difficult to change, and due to economic conditions, irregular diet or because of the different flavors of food.11 similarly, in a study conducted in 2004 states that there were many factors can influence the behavior of a person, such as age, education, race, socioeconomic, cultural, and social support.12 someone with higher incomes and higher education levels have better behavior than those with lesser education and income. that study explains that attitudes, subjective norms, and views a person has a strong link with the behavior.12 in general, the level of knowledge will affect a person’s behavior. however, the level of knowledge is not related to the nutritional status. this could be due to many other factors that influence a person’s behavior, as already mentioned above, namely age, education level, occupation and income. in addition to external factors such as facilities and sociocultural factors and internal factors such as confidence and motivation also affect behavior.5 based on the results, it can be concluded that most of the respondents have a sufficient level of knowledge of as many as 39 people (52%), more than half of the respondents have a sufficient attitude as many as 51 people (68%), and as many as 62 people (82.7 %) had a good nutritional status. there is a significant relationship between the level of knowledge of nutrition with nutritional attitudes and there is no significant relationship between the level of knowledge of the nutritional status. the jatinangor public health center can organize counseling for pregnant women to increase their knowledge about the nutritional needs of pregnant women, to see how many respondents have sufficient levels of nutrition knowledge. in addition, the need to identify other factors that cause nutritional problems, which consist of the external and internal factors, should be determined in order to find a solution. references 1. abu-saad k, fraser d. maternal nutrition and birth outcomes. epidemiol rev. 2010;32(1):5–25. 2. hyatt ma, gardner ds, sebert s, wilson v, davidson n, nigmatullina y, et al. suboptimal maternal nutrition, during early fetal liver development, promotes lipid accumulation in the liver of obese offspring. reproduction. 2011;141(1):119–126. 3. ones. target penurunan angka kematian ibu (aki) sulit tercapai. bandung: dinas provinsi jawa barat; 2012. [cited 2012 mei 5]. available from: http://jabarprov.go.id/ index.php/submenu/informasi/berita/ detailberita/4097. 4. hanretty kp. obstetrics illustrated. london: churchill livingstone; 2003 5. notoatmodjo pds. ilmu perilaku kesehatan. jakarta: rineka cipta; 2010. 6. ganesh k. knowledge and attitude of mental illness among general public of southern india. national journal of community medicine. 2009; 2(5): 176-8. [cited 12 december 2012]. available from: http:// njcmindia.org/uploads/2-1_175-178.pdf 7. azizi m, aghaee n, ibrahimi m, ranjbar althea medical journal. 2015;2(2) 234 amj june, 2015 k. nutrition knowledge, the attitude, and practices of college students. facta universitatis: series physical education and sport. 2011;9(3):351-5. [cited 2 december 2012]. available from: http:// f a c t a . j u n i s . n i . a c . r s / p e / p e 2 0 1 1 0 3 / pe201103-12.pdf 8. yap j, lee vj, yau ty, ng tp, tor p-c. knowledge, attitudes, and practices toward pandemic influenza among cases, close contacts, and health care workers in tropical singapore: a cross sectional survey. bmc public health. 2010;10:442. 9. kusumastuti i. association between knowledge, attitudes and sexual practices among unmarried indonesian young adults: a study from indonesian young adult reproductive health survey [thesis]. bangkok: mahidol university; 2007. 10. shakkour e. the relationship between nutritional knowledge and application [thesis]. spring: liberty university; 2007. 11. verpuri j. breastfeeding knowledge, and attitudes, beliefs, and intentions regarding breastfeeding in the workplace among students and professionals in health-related fields [dissertation]. blacksburg: virginia polytechnic institute and state university ; 2004. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 43 frequency and clinical characteristics of tympanic membrane perforation outpatients at dr. hasan sadikin general hospital in 2011–2013 veronika ratih m,1 sally mahdiani,2 fenny dwiyatnaningrum3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology–head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and biology cell faculty of medicine, universitas padjadjaran abstract background: tympanic membrane perforation is a hearing problem that has become a health problem in the society. in indonesia, there are only a few studies regarding tympanic membrane perforation. this study was aimed to observe the frequency and clinical characteristics of tympanic membrane perforation patients. methods: this was a descriptive study performed from august to september 2014. the data was taken retrospectively from medical records of tympanic membrane perforation patients at dr. hasan sadikin general hospital from january 2011 to december 2013. results: of 579 tympanic perforation patients, there were only 214 medical records met the inclusion criteria. the frequency of tympanic membrane perforation patients increased in 2011 it was 28%, in 2013 it was 37.6%. the number of male patients (53.3%) was higher than female patients’. most patients were in productive age (83.2%). most patients came with the chief complaint of discharge from ear (36.4%) and the most common etiology was infection (84.1%). otological examination showed that most patients had unilateral perforation (73.8%). based on the size of perforation, central perforation (52.3%) was the most common otological finding. from audiogram, most patients had conductive hearing loss (41.5%) with moderate degree of hearing loss (30.4%). most patients were treated by medications (64.5%). conclusions: the frequency of tympanic membrane steadily increases with clinical characteristic mostly in male patients in productive age admitted with chieft complain of discharge of ear. the most common etiology is infection. majority of patients have unilateral central perforation that cause conductive hearing lost. [amj.2016;3(1):43–8] keywords: clinical characteristic, hearing lost, tympanic membrane perforation correspondence: veronika ratih m, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285624248322 email: veronika.ratih@gmail.com introduction hearing abnormality and deafness are still prevalent and have become a major problem in indonesia. globally, world health organization (who) estimated that 250 million (4.2%) of world populations suffered from hearing abnormality in 2000, 75–140 million (30– 56%) of them were in south–east asia.1 one of the etiologies of hearing disturbance is tympanic membrane (tm) perforation.2 incidence of tm perforation in the world is still unknown. however, according to the study conducted by kaftan et al.3 in germany, the prevalence of chronic tm perforation was 0.45%. in england, united kingdom4, study of hearing found that the prevalence of tm perforation in adult was 4.1%. hearing disturbance has already become a health problem in society.1 however, there is no available data yet regarding the prevalence or incidence of tm perforation in indonesia, especially in west java.thus, the researcher is interested to do a study about the frequency of tm perforation. moreover, the clinical characteristics of patients are also important to be studied. this study was conducted to observe the frequency and clinical characteristics of tm perforation, including the risk factors of perforation, clinical manifestations, audiogram results, and also the management. methods this was a quantitative-descriptive study althea medical journal. 2016;3(1) 44 amj march 2016 performed at otorhinolaryngology–head and neck surgery (orl-hns) polyclinic of dr. hasan sadikin general hospital. data was taken retrospectively from patients’ medical records. the method used was total sampling . this study was approved by ethical committee of dr. hasan sadikin general hospital. frequency was determined by the number of tm perforation patients at orlhnspolyclinic of dr. hasan sadikin general hospital from january 2011 to december 2013. the distributions and clinical characteristics of patients were observed from the medical records of tm perforation patients at orlhns polyclinic of dr. hasan sadikin general hospital from january 2011 to december 2013 which fulfilled the inclusion criteria. the inclusion criteria were medical records which contained patient’s identity, etiology, clinical manifestations, result of examination, and management. the missing and incomplete medical records were excluded from this study. among 579 tm perforation patients, 214 patients’ data (36.96%) were included in this study. patient’s sex, age at presentation, chief complains, etiology, side of perforation, size of perforation, audiogram, comorbid diagnosis, and management were documented. according to badan kependudukan dan keluarga berencana nasional (bkkbn), the age groups were classified into young age (0–14 years old), adult/productive age (15–64 years old), and old age (≥ 65 years old). chief complaints consisted of hearing loss, tinnitus, discharge from ear, clogged ear, and ear pain. etiologies were classified into infection, trauma, failure of operation, and malignancy. side of perforation was divided into unilateral (one side) or bilateral (both sides). according to bluestone (2007), size of perforation was classified into central perforation (< 25%), subtotal perforation (25–50%), and total perforation (>50%).5 the type of hearing loss was determined by using audiogram that was classified into conductive hearing loss (chl), sensorineural hearing loss (snhl), and mixed hearing loss (mhl). the degree of hearing loss was divided into normal, mild, moderate, severe, and profound. management was divided into pharmacotherapy, operative, mixed (pharmacotherapy and operative), and education. after being collected, the data was analyzed by computer. results in 2011–2013, the amount of outpatients at orl-hns of dr. hasan sadikin general hospital was 15,253 patients, 579 of them (3.8%) were diagnosed of having tm perforation. the frequency of tm perforation patients increased from 2011 to 2013. based on sex, the amount of male patients was higher than female patients. most patients were in adult age (83.2%). the youngest patient was 9 months old while the oldest patient was 92 years old. mostly, the patients’ chief complain was discharge from ear (36.4%).there were 4.7% of patients who reported other complains, such as itchy ear, nasal congestion, ear bleeding, sore throat, and lump in the ear . most perforations were caused by infection (88.3%). during 2011–2013, there was no perforation caused by malignancy. based on the side of perforation, 158 patients (73.8%) had tm perforation on one side of ear (unilateral). among them, 78 patients had perforation on the right ear (49%) and 80 patients (51%) had perforation on the left ear. based on the size of perforation, most patients had central perforation (52.3%). the result of this study showed that there were 42.5% of tm perforation patients with comorbid diagnosis, most of them were csom and aom. most tm perforation patients were treated by pharmacotherapy (64.5%). table 1 distribution of tm perforation patients based on sex and age group characteristics number of patients (n=214) sex male 114 (53.3%) female 100 (46.7%) age group young age (0–14 years old) 18 (8.4%) adult age (15–64 years old) 178 (83.2%) old age (≥ 65 years old) 18 (8.4%) althea medical journal. 2016;3(1) 45veronika ratih m, sally mahdiani, fenny dwiyatnaningrum: frequency and clinical characteristics of tympanic membrane perforation outpatients at dr. hasan sadikin general hospital in 2011–2013 table 2 clinical characteristics of tm perforation patients characteristics number of patients (n=214) chief complaint hearing loss 45 (21%) tinnitus 37 (17.3%) discharge from ear 78 (36.4%) clogged ear 25 (11.7%) ear pain 19 (8.9%) others 10 (4.7%) etiology trauma 25 (11.7%) infection 180 (84.1%) failure of operation 9 (4.2%) side of perforation unilateral 158 (73.8%) bilateral 56 (26.2%) perforation’s size central 112 (52.3%) subtotal 77 (36%) total 25 (11.7%) comorbid pharyngitis 1 (0.5%) lymphadenopathy 1 (0.5%) mastoiditis 2 (0.9%) oe 2 (0.9%) aom 16 (7.5%) csom 41 (19.1%) otomycosis 1 (0.5%) otosclerosis 1 (0.5%) post mastoidectomy 5 (2.3%) post tympanoplasty 4 (1.9%) rhinitis 9 (4.2%) tonsilitis 2 (0.9%) tumor 3 (1.4%) there was no comorbid diagnosis 126 (58.9%) management pharmacotherapy 138 (64.5%) operative 23 (10.7%) education 24 (11.2%) mixed 29 (13.6%) note: *oe: otitis externa, aom: acute otitis media, csom: chronic suppurative otitis media althea medical journal. 2016;3(1) 46 amj march 2016 among 214 tm perforation patients, 164 of them (76.6%) performed audiometry examination. based on the type of hearing loss, 114 patients (69.5%) suffered from hearing loss. most patients had conductive hearing loss (41.6%). and moderate hearing loss (30.4%). discussions the frequency of tm perforation patients increased from 2011 to 2013. this result indicated that the increase of ear infection in society due to most perforations were caused by ear infection.2 based on sex, male to female ratio was 1.14:1 this characteristic was considered relatively same as the previous study performed by pannu et al.2 in india that showed that 52% of the patients were male and 48% were female. the percentage of male patients slightly outnumbered the female patients.2 the study performed by sarojamma et al.6 in india also stated that the amount of female tm perforation patients (58%) was higher than the males. figure 1 frequency of tm perforation patients in 2011–2013 table 3 audiogram of tm perforation patients characteristics number of patients (n=164) type of hearing loss normal 50 (23.4%) chl 89 (41.6%) snhl 5 (2.3%) mhl 20 (9.3%) audiometry was not performed 50 (23.4%) degree of hearing loss normal 50 (23.4%) mild 18 (8.4%) moderate 65 (30.4%) severe 23 (10.7%) profound 8 (3.7%) audiometry was not performed 50 (23.4%) note: * chl: conductive hearing loss, snhl: sensorineural hearing loss, mhl: mixed hearing loss althea medical journal. 2016;3(1) 47veronika ratih m, sally mahdiani, fenny dwiyatnaningrum: frequency and clinical characteristics of tympanic membrane perforation outpatients at dr. hasan sadikin general hospital in 2011–2013 most tm perforation patients were in productive age group (83.2%). the tm perforation could affect patient’s quality of life, caused hearing loss and reduced their productivity.7 the result was different from the study performed by olowookere et al.8 in nigeria which stated that 50% of the tm perforation patients were children. most patients often complained of discharge from ear (36.4%). discharge from ear was caused by csom.9 clogged ear was caused by fluid accumulation in middle ear. moreover, the patients also complained of hearing loss. hearing loss was caused by the disturbance of sound wave conduction. other chief complaints, such as nasal congestion and sore throat, were caused by other diseases such as rhinitis, tonsillitis, or pharyngitis. pannu et al.2 also reported that the most common chief complaints were hearing loss and discharge from ear. allergic rhinitis, bacterial tonsilitis and pharingistis were risks of factor for developing complicated tympanic membrane. the tm perforation was mostly caused by infection. the infection could be caused by csom, aom, or oe. besides infection, another common etiology was trauma. tm trauma could be caused by high pressure when diving or flying and could also be caused by temporal bone trauma. this study was similar with the study conducted by pannu et al.2 that stated 84% of tm perforation was caused by infection and 16% was caused by trauma. after surgery, some patients still had tm perforation. this was caused by failure of tm grafting. based on the side of perforation, most patients had unilateral perforation. pannu et al.2 also reported that 80% of patients had unilateral perforation. olowookere et al.8 also stated that most patients had unilateral perforation. intact tm in another ear helped the patients to hear. patients with bilateral perforation would have more severe hearing loss. based on the size of perforation, the most common was central perforation. this study was similar to the study performed by pannu et al.2 which stated that 47% of patients had small size perforation, 34% had medium size perforation and 19% had large size perforation. olowookere et al.8 also stated that 60.6% of patients had central perforation. the size of perforation also has role in hearing loss. the larger the size of perforation, the degree of hearing loss would be more severe.10 there were 42.5% of tm perforation patients who had comorbid. the most common comorbid were csom and aom. middle ear infection and pressure caused by pus production could cause perforation.11 upper respiratory tract infection, such as rhinitis or pharyngitis could cause middle ear infection and, eventually, caused tm perforation. most patients were treated by pharmacotherapy. the patients were given antibiotic to stop fluid production in the ear and keep the ear dry.4 surgical treatments consisted of tympanoplasty and mastoidectomy. tympanoplasty was performed in 48 patients and mastoidectomy was performed in 4 patients. some patients were only given education because there was no indication for antibiotic usage or surgical intervention. central perforation and traumatic perforation would usually heal spontaneously, so surgical intervention was not needed.12 some patients were indicated to be given surgical intervention, but the patients rejected because of economic aspect. based on audiogram, there were 69.5% patients with hearing loss, most patients had conductive hearing loss. it happened because the perforated tm caused the disturbance of sound wave conduction. cross–sectional study conducted by ibekwe et al.13 concluded that 59% of tm perforation patients had conductive hearing loss. however, some patients suffered from sensorineural hearing loss. the occurrence of sensorineural hearing loss could be affected by age. neuron degeneration of cochlear nerve in old people caused sensorineural hearing loss.14 there were 30.5% patients without hearing loss. this happened because most patients had central perforation. moreover, 23.4% of patients did not perform audiometry examination. actually, this examination was very important to detect patient’s hearing loss but some patients did not perform this examination because of their limited budget. based on the degree of hearing loss, most patients had moderate hearing loss. this result was similar with the study performed by maharjan et al.15 in kathmandu. the study concluded that 52.9% of the patients had moderate hearing loss. in the other hand, pannu et al.2 and sarojamma et al.6 stated that most patients suffered from mild hearing loss. frequently, the patients with severe and profound hearing loss were accompanied by chronic infection such as csom. as the conclusion, there were 579 tympanic membrane perforation outpatients during 2011–2013 and chief complaint of most of patients in productive age group was discharge from ear. the perforation was mostly caused by althea medical journal. 2016;3(1) 48 amj march 2016 infection. the proportion between unilateral and bilateral perforation was 7:3. more than a half of patients had central perforation. the most common comorbidity at diagnosis was csom. most patients were treated by pharmacotherapy. most tm perforation was caused by infection. thus, infection prevention by giving education to society should be performed to increase their personal hygiene. for supporting examination, 23.4% of the patients did not perform audiometry examination because of economic aspect. simple and more affordable examinations such as turning fork test (rinne and weber test) were suggested. moreover, some patients rejected surgical interventionbecause of the expensive cost. thus, this study suggests the society to join universal health coverage, so all people are able to get a standardized health service. from this study, only 36.86% of data could be used as the subjects of study because of missing or incompletemedical record. medical record should be written completely and should be kept systematically. references 1. kementerian kesehatan republik indonesia. rencana strategis nasional penanggulangan gangguanpendengaran dan ketulian untuk mencapai soundhearing 2030. jakarta: biro hukum dan organisasi kementerian kesehatan republik indonesia; 2006. p. 4. 2. pannu kk, chadha s, kumar d, preeti. evaluation of hearing loss in tympanic membrane perforation. indian j of otolaryngol headneck surg. 2011;63(3):208–13. 3. kaftan h, noack m, friedrich n, völzke h, hosemann w. prevalence of chronic tympanic membrane perforation in the adult population. hno. 2008;56(2):145– 50. 4. hamilton j. chronic otitismedia in childhood. in: gleeson m, editor. scott– brown’s otorhinolaryngology, head and necksurgery. 7th ed. london: hodder arnold; 2008. p. 912–26. 5. bluestone cd, klein jo. otitis media in infants and children. 4th ed. shelton: w b saunders; 2007. 6. sarojamma, raj s, satish hs. a clinical study of traumatic perforation tympanic membrane. iosr j dent med sci. 2014;13(4):24–8. 7. speets a, wolleswinkel j, cardoso c. societal costs and burden of otitis media in portugal. j multidiscip health. 2011;4:53– 62. 8. olowookere s, ibekwe t, adeosun a. patterns of tympanic membrane perforation in ibadan: a retrospective study. ann ib postgrad med. 2008;6(2):31– 3. 9. kolo e, salisu a, yaro a, nwaorgu o. sensorineural hearing loss in patients with chronic suppurative otitis media. indian j otolaryngol head neck surg. 2012;64(1):59–62. 10. mehta rp, rosowski jj, voss se, o’neil e, merchant sn. determinants of hearing loss in perforations of the tympanic membrane. otol neurotol. 2006;27(2):136–43. 11. shaikh n, hoberman a, kearney dh, yellon r. tympanocentesis in children with acute otitis media. n engl j med. 2011;364(2):1– 3. 12. al-juboori an. evaluation of spontaneous healing of traumatic tympanic membrane perforation. gen med. 2014;2(1):1–3. 13. ibekwe ts, nwaorgu og, ijaduola tg. correlating the site of tympanic membrane perforation with hearing loss. bmc ear nose throat disord. 2009;9(1):1–4. 14. engle jr, tinling s, recanzone gh. age– related hearing loss in rhesus monkeys is correlated with cochlear histopathologies. plos one. 2013;8(2):9–12. 15. maharjan m, kafle p, bista m, shrestha s, toran k. observation of hearing loss in patients with chronic suppurative otitis media tubotympanic type. kathmandu univ med j. 2009;7(4):397–401. althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 5 comparison between palpation and superficial marking techniques in determining infraorbital foramen in chinese women lindawati1, arifin soenggono2, hardi siswo s.3 1faculty of medicine, universitas padjadjaran, 2department of anatomy, faculty of medicine, universitas padjadjaran, 3department of surgery, faculty of medicine, universitas padjadjaran/ dr. hasan sadikin general hospital bandung abstract background: difficulties in determining infraorbital foramen were often found in anesthesia procedures, reconstruction surgery, acupuncture, and botox insertion. the most common technique used is palpation technique. however, there are some disadvantages in this technique.the aim of this study was to establish a new superficial marking technique to determine the position of infraorbital foramen by making a horizontal imaginary line from the top part of nose wings. methods: this study was an analytical cross-sectional study conducted at the faculty of medicine, universitas padjadjaran in jatinangor-sumedang during the period of april to november 2012. a total of thirty chinese female students were assessed to measure the mean distance between the inferior orbital margin to the infra orbital foramen and inferior orbital margin to horizontal imaginary line from the top part of nose wings. the differences were then checked using paired t-test. results: there was a significance difference between the mean distance of the inferior orbital margin to the infra orbital foramen and the inferior orbital margin to the horizontal imaginary line from the top part of the nose wings on the right and left face of chinese women with p<0.05 (p=0.000). conclusion: infra orbital foramen cannot be determined by using superficial marking technique in chinese women. keywords: infra orbital foramen, palpation technique, superfacial marking technique correspondence: lindawati, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81394694098 email : chenciayi@rocketmail.com introduction infraorbital foramen is an opening where the infraorbital neurovascular pass through.1 infraorbital foramen is located on maxillary bone1, 4−13 mm from the inferior orbital margin2–5, parallel to the top part of nose wings6–8, and located 2 cm from the top part of nose wings.6,7 knowledge about the right location of infraorbital foramen provides data in anesthesia procedures for reconstructive surgery in maxillofacial trauma9,10; rhinoplasty surgery and withdrawing teeth surgery7; trigeminal neuralgia and facial palsy treatment in medical acupuncture11; and botox insertion in esthetic field.12 in determining the anatomical landmark of infraorbital foramen in human, the palpation technique is used.7 palpation starts from inferior orbital margin down to infraorbital foramen, which pass through the imaginary line from the middle of pupils vertically.7 palpation technique has some disadvantages such as difficulty in determining the location of the foramen if the patient has a thick skin.13 palpation technique also gives an uncomfortable feelings for the patient, caused by the pressure over the infraorbital nerve. infraorbital nerve is located superficially on the surface of the facial skin, because there is no deep fascial layer on the facial skin surrounding the infraorbital foramen.14 this study was undertaken to establish a new superficial marking technique to determine infraorbital foramen by making a horizontal imaginary line from the top part of nose wings. mean difference between the distance of inferior orbital margin to infraorbital foramen and inferior orbital margin to horizontal imaginary line from the top part of nose wings needs to be known. chinese women were chosen as the sample for the homogeneity of the subjects studies on chinese people are still low, so the anthropometry data are limited. the amount althea medical journal. 2015;2(1) 6 amj march, 2015 figure 1 the association of vertical imaginary line that pass through the middle of infraorbital foramen and inferior orbital margin with horizontal imaginary line that pass through the infraorbital foramen and the opening of piriformis3 of chinese people in indonesia are rising (4– 5% from the total citizens of indonesia),and two-thirds of it are women.15 chinese is one of the ethnic groups in indonesia which is still pure without any mixing with other ethnic groups, at least two generation.16 methods this research was conducted at the faculty of medicine, universitas padjadjaran in jatinangor–sumedang during the period of april to november 2012. thirty chinese female students from faculty of medicine, universitas padjadjaran batch 2009−2012 were taken as the subjects by using simple random sampling technique. the inclusion criteria were chinese subject with two generation before being pure chinese; aged 18 years old or older; body mass index (bmi) is 25 or under; and the subject should be never done any reconstruction surgery or do not have any damage and injury to the facial bones. the exclusion criteria were the subjects who refused to become a sample with any reason. every sample was given an informed consent form as an agreement letter to become the subject of this research. this research has been approved by the health research ethics committee. both sides of each face of the subjects were measured based on the mean distance of x (the distance of inferior orbital margin to infraorbital foramen) and y (the distance of inferior orbital margin to the top part of nose wings). the subjects must sit upright, the head must be straight, and the viewpoint of the eyes must be straight-forward. a vertical imaginary line from the middle of the pupils was made by using a plumb line. in palpation technique (technique a), the location of the inferior orbital margin was palpated which was on the vertical imaginary line, then marked by giving a dot. the infraorbital foramen was palpated down from the inferior orbital margin which was on the vertical imaginary line, then marked by giving a dot. the distance of inferior orbital margin to infraorbital foramen was measured by using vernier calipers, capable of measuring to the nearest 0.01 mm (figure 1). in superfacial marking technique (technique b), a horizontal imaginary line from the top part of nose wings was made by using a ruler. this horizontal imaginary line must be intersected with the vertical imaginary line from the middle of the pupils. the intersection point of these two imaginary lines was marked by giving a dot using a pen. the distance of the inferior orbital margin to the intersection point was measured by using vernier calipers (figure 2). all of the measurements of a and b were done bilaterally on the right and left face of the samples and repeated three times. the mean distance was calculated and analyzed by using paired t-test . althea medical journal. 2015;2(1) 7lindawati, arifin soenggono, hardi siswo s: comparison between palpation and superficial marking techniques in determining infraorbital foramen in chinese women figure 2 the association between inferior orbital margin, infraorbital foramen, vertical imaginary line from the middle of the pupils, and horizontal imaginary line from the top part of nose wings in the human’s face8 results the mean distance of inferior orbital margin to infraorbital foramen on the right face of the chinese women (technique a) was 14.48±1.787 mm and on the left face was 14.48±1.829 mm. the mean distance of inferior orbital margin to the horizontal imaginary line from the top part of nose wingson the right face of the chinese women (technique b) was 14.98±1.687 mm and on the left face was 15.00±1.751 mm. there is a significance difference between a and b on the right and left face of chinese women (table 1). discussions the superficial marking technique by making a horizontal imaginary line from the top part of nose wings yield a significant difference with the palpation technique. superficial marking technique cannot be used as an alternative for the palpation technique. every person has genetic, nutrition intake, hormone, and also physical activity variations. growth and development of the bone and cartilage of the face are influenced by genetic, nutrition, hormone, and physical variation.17 genetic plays an important role in influencing the shape, the velocity of the growth and development, and any physical changing of the bone and the cartilage.17 besides genetic, nutrition also plays an important role. a big amount of calcium and phosphorus and a small amount of magnesium, fluoride, and manganese are needed in the growing of the bone by helping the formation of the bone, strengthening the bone, and activating the enzymes needed to synthesize the extracellular matrix of the bone and cartilage.17 vitamin a, c, d, k, and b12 are needed to stimulate the activity of osteoblast to synthetize the collagen as the main protein of the bone, to help the absorption of the calcium from the food, and to synthesize the protein of the bone.17 some hormones are needed for the growth and development of the bone and cartilage. they are human growth hormone (hgh), insulin like growth factor (igfs), insulin, thyroid hormone, estrogen, and progesteron. these hormones are needed table 1 the mean distance of inferior orbital margin to infraorbital foramen and horizontal imaginary line technique a technique b left (mm) right (mm) left (mm) right (mm) mean (sd) 14.48 (1.829) 14.48 (1.787) 14.98 (1.687) 15.00 (1.751) p 0.000 0.000 0.000 0.000 althea medical journal. 2015;2(1) 8 amj march, 2015 to stimulate the growth of the bone and cartilage, to stimulate osteoblast, to increase the bone protein synthesis, to stimulate fast growing in adolescent, to stop the growth of epiphyseal plateat the age of ≥18 years old, and to stimulate the bone deposition by osteoblast.17 parathyroid hormone is needed for bone resorption byosteoclastand vitamin d formation.17 calcitonin is needed to hamper the bone resorption by osteoclast.17 the last factor that influences the growth and development of the bone and cartilage is physical activity or exercise.17 exercise or physical activity will stimulate the osteoblast activity.17 every person has different amounts of neurovascular which supply the bone and cartilage; different osteoblastic, osteoclastic, and chondroblastic activity; also different interstitial and a positional growth of the bone and cartilage.17 these will make a big variation from the shape of the face and nose, the length and width of the head, and the distance of interchantus of the eyes of every sample. nose wings are made from the flexible hyaline cartilage, so the shape of the nose of every sample will have a big variation. this explains about the reason of the intersection point between the horizontal imaginary line from the top part of nose wings and the vertical imaginary line from the middle of the pupils, will not fall accurately on the infraorbital foramen. it can be concluded that infraorbital foramen cannot be determined by using superficial marking technique in chinese women. the limitation of this study was the various factors that can influence of the anatomy of face was not considered in this study. furthermore, the shape of the nose and face, the length and width of the head, and the distance of the interchantus of the eyes from every sample are needed to be equated. further studies on other gender and ethnic groups also need to be undertaken. further studies on other alternative to determine the anatomical landmark of infraorbital foramen need to be explored. references 1. moore kl, dalley af, agur amr. clinically oriented anatomy. 6th edition. philadelphia: lippincott williams & wilkins; 2009. 2. apinhasmit w, chompoopong s, methathrathip d, sansuk r, phetphunphiphat w. supraorbital notch/ foramen, infraorbital foramen and mental foramen in thais: anthropometric measurements and surgical relevance. j med assoc thai. 2006;89(5):675−82. 3. elias mg, silva rb, pimentel ml, rivello vts, babinski ma. morphometric analysis of the infraorbital foramen and acessories foraminas in brazillian skulls. int j morphol. 2004;22(4):273−8. 4. ilayperuma i, nanayakkara g, palahepitiya n. morphometric analysis of the infraorbital foramen in adult sri lankan skulls. int j morphol.2010;28(3):777−82. 5. singh r. morphometric analysis of infraorbital foramen in indian dry skulls. anat cell biol. 2011;44(1):79–83. 6. salin mb, smith bm. diagnosis and treatment of midface fractures. in: foncesa rj, walker rv, betts nj, barber hd, powers mp, editors. oral and maxillofacial trauma. st. louis, missouri: elsevier saunders; 2005. p. 650−82. 7. gaertner e, nasser ba, choquet o, drizenko a, macaire p, martin r, et al. regional anesthesia: peripheral nerve blockade in adults. paris: arnette blackwell; 2004. 8. lian yl, ogal hp, stor w, editors. the seirin pictorial atlas of acupuncture. cologne: konemann verlagsgesellschaft mbh; 2000. 9. moedder u, cohnen m, andersen k, engelbrecht v, fritz b. head and neck imaging. new york: thieme; 2007. 10. curran j. anesthesia for maxillofacial trauma. in: shaw i, kumar c, dodds c, editors. oxford textbook of anaesthesia for oral and maxillofacial surgery. oxford: oxford university press; 2010. p. 186. 11. quirico pe, pedrali t. teaching atlas of acupuncture: channels and points. new york: thieme; 2007. 12. donath as. facial rejuvenation : a chronology of procedures. in: farage ma, miller kw, maibach hi, editors. textbook of aging skin. berlin: springer; 2010. p. 1175−6. 13. hughes cg, weavind l, pandharipande pp. sedation, paralysis, and pain management of the critically ill obese patients. in: solh ae, editor. critical care management of the obese patient. oxford: wiley – blackwell 2012. p. 49. 14. snell rs. clinical anatomy by regions 8th edition. philadelphia: lippincott williams and wilkins; 2008. althea medical journal. 2015;2(1) 9 15. maryati k, suryawati j. sosiologi untuk sma dan ma kelas xi. jakarta: esis; 2006. 16. waluya b. sosiologi: menyelami fenomena sosial di masyarakat. bandung: pt setia purna inves; 2007. 17. tortora gj, derrickson bh. principles of anatomy and physiology : organization, support, and movement, and control systems of the human body 12th edition. new york: john wiley & sons; 2009. lindawati, arifin soenggono, hardi siswo s: comparison between palpation and superficial marking techniques in determining infraorbital foramen in chinese women althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 69 impact of running exercise duration on leg muscle strength among the people joining indorunners bandung community agaprita eunike sirait,1 yuni susanti pratiwi,2 ginna megawati3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: indorunners bandung is a community for runners that has a routine exercise schedule for running around the city of bandung. exercise, like running, if is conducted in an accurate duration may improve physical fitness. one of the aspects of physical fitness is leg muscles strength. many people fail to fathom the importance of exercise duration, so, they fail to get the benefit. the aim of this study was to discover the impact of running exercise duration on leg muscles strength among the people joining indorunners bandung community. methods: a comparative study was conducted to 41 people, 31 males and 10 females, of indorunners bandung community from september to november 2015. each participant filled a questionnaire about his/her personal data, and then was grouped by his/her duration of exercise per week, which were 150 minutes/week, 150–299 minutes/week, and 300 minutes/week or more. the respondents were measured for their leg muscles strength. the data collected were analyzed using anova test. results: there was significant difference of lower extremities muscle strength both in men (p<0.001) and women (p=0.029). these results showed that there was a difference in leg muscles strength among the people joining indorunners bandung community with different exercise duration per week. conclusions: there is a difference in leg muscles strength among the people joining indorunners bandung community with different exercise duration per week. [amj.2017;4(1):69–72] keywords: exercise, indorunners, leg muscles strength, running correspondence: agaprita eunike sirait, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628125563001 email:agaprita@yahoo.com introduction exercise has several good benefits, for example, maintaining physical fitness.1 one of the most common physical activities is running. based on a statistical survey, the number of runners was increasing from less than five million people in 1990 to 13.8 million in 2011.2 to support the need to assemble and exercise together, runners make a specific community. the community, like indorunners bandung, usually consists of committed runners that have a routine schedule for exercising. muscles strength enhancement is one of the benefits of exercise. muscles significantly used in runners are leg muscles. many runners do not fathom the importance of duration of exercise per week to get the physical fitness benefit, like enhancing leg muscles strength. the previous study stated to enhance leg muscles strength, exercise must be executed at least 150 minutes in one week, and at least 300 minutes per week for more benefit.3 there has not been any study about the impact of duration of exercise per week on leg muscles strength in runners community; therefore, this study was conducted to discover that topic, and the runners community taken as samples are the people joining indorunners bandung. methods a cross-sectional study was approved by the health research ethics committee of faculty of medicine universitas padjadjaran (number: 434/un6.c1.3.2/kepk/pn/2015) and the chief of indorunners bandung community. the study was conducted from september to november 2015 in mg&co café bandung which was the meeting point of indorunners bandung althea medical journal. 2017;4(1) 70 amj march 2017 community, west java, indonesia. the subjects were all people joining indorunners bandung community. the population of indorunners bandung is not fixed because there was no membership data. therefore, the sampling method was consecutive sampling. the inclusion criteria was 18–64 years of age, not using drugs for muscle strength enhancement recently, not in a fatigue condition, not having chronic diseases, routinely running for three months, and no history of musculoskeletal trauma in the past six months. participants that could not complete the measurement procedure were excluded from the study. a total of 41 participants, 10 females and 31 males, were collected. the participants were given information about this study, and the participants agreeing to follow the study were given informed consent letter. a preliminary screening test using a questionnaire about their personal data, running history, and health history related to the inclusion criteria was conducted. moreover, the participants were measured for their leg muscles strength (kg) with a leg dynamometer three times with a standard procedure, knee bended to 130–140 degrees to ensure that only leg muscles were used. the highest value of the results was used for the muscle strength data. based on the data from the questionnaire, the subjects then were categorized into three groups based on their exercise per week’s duration. those were, group 1: less than 150 minutes/week consisting of 13, group 2: 150–299 minutes/week consisting of 17 participants, and group 3: more than or equal to 300 minutes/week consisting of 11 participants. all the data were analyzed by computer. the normality of data was tested by using saphiro-wilk, and the data were analyzed by analysis of variance (anova). the confidence interval used was 95%, and considered significant if the p≤0.05. the data for male and female were analyzed individually table 1 distribution of participants’ characteristics group 1* group 2** group 3*** total sex male 9 (21.9%) 12 (29.2%) 10 (24.3%) 31 (75.6%) female 4 (9.7%) 5 (12.1%) 1 (2.4%) 10 (24.3%) total 13 (31.7%) 17 (41.4%) 11 (26.8%) 41 (100%) sports no other exercises 7 (17%) 6 (14.6%) 4 (9.7%) 17 (41.4%) doing other exercises 6 (14.6%) 11 (26.8%) 7 (17%) 24 (58.5%) total 13 (31.7%) 17 (41.4%) 11 (26.8%) 41 (100%) note: *: exercise duration less than 150 minutes/week, **: exercise duration 150–299 minutes/week, ***: exercise duration more than equals to 300 minutes/week table 2 distribution of leg muscles strength and exercise duration per week n mean (sd) (kg) p value male group 1* 9 88.33 (4.87) <0.001 group 2** 12 127.50 (35.34) group 3*** 10 190.65 (36.63) female**** group 1* 4 48.25 (2.32) 0.029 group 2** 5 57.14 (12.94) note: *: group 1 for exercise duration less than 150 minutes/week, **: group 2 for exercise duration 150–299 minutes/ week, ***: group 3 for exercise duration more than equals 300 minutes/week, ****: leg muscles strength was constant in group 3 (n=1), it has been omitted. the muscle strength of one person in group 3 was 87 kg. althea medical journal. 2017;4(1) 71agaprita eunike sirait, yuni susanti pratiwi, ginna megawati: impact of running exercise duration on leg muscle strength among the people joining indorunners bandung community results male was the predominant sex in this study. moreover, most of the participants were doing other sports other than running. the varieties of sports exercised by the participants were weight lifting, tennis, swimming, futsal, cycling, aerobic dance, and martial arts. group 3, which consisted of people exercising for more than equals 300 minutes per week, had the highest mean of muscle strength in both sex. moreover, the male group had higher mean than the female group.. discussions one of the benefits of exercise like running is improving physical fitness. muscle strength is one of the physical fitness aspects. muscles significantly used in runners are leg muscles.4 leg is a part of lower extremities, which are extensions from the trunk that have several functions including to support body weight, to move from one place to another, and to maintain balance.5 in runners, leg muscle strength is also important for maintaining the running velocity and acceleration.6 muscle strength, specifically leg muscles strength was the variable measured in this study. if conducted in a correct duration, the leg muscles strength enhancement can be achieved.7 the result of this study was corresponding to the previous study which said there is a correlation of exercise duration per week to muscle strength.8 there was a difference between male and female’s muscle strength; in female the mean was lower than in male. this result was supported by the previous study that said sex is one of contributing factor in muscle strength. male usually has higher muscle strength due to the physical activity and physiologic factor.9 other than sex, variation in muscle strength may be caused by body mass index (bmi). higher bmi or obesity is associated in low muscle quality therefore causing a lower muscle strength.10 running is an aerobic activity. this activity is highly correlated to cardiovascular fitness. cardiovascular fitness is important for blood circulation control, to avoid heart diseases, and also for weight loss. in enhancing muscle strength, aerobic exercise has less impact than muscle strength training like weight lifting. therefore, to increase muscle strength, it is suggested to do muscle strength training two times in a week.11 public health experts and world health organization recommend people to do a moderate intensity exercise (cycling, running, swimming) at least 30 minutes a day or 150 minutes a week. to get additional benefit, like weight loss, the duration need to be increased to 60 minutes a day or 300 minutes a week.3 limitation of this study was due to a limited time, there were only a few female respondents of this study. from this study it can be concluded that there is a difference in leg muscles strength among the people joining indorunners bandung community with different exercise duration per week. this study showed that runners exercising at least 300 minutes per week have higher muscle strength. therefore, it is recommended for all runners to consider the duration of the exercise per week to get the benefit of running, like enhancing muscles strength. running with fellow runners in a community may help runners to commit to a routine schedule of running, so the target duration of exercise per week may be accomplished. for further research, the correlation of exercise duration to leg muscles strength may be explored. references 1. bredeweg sw, kluitenberg b, bessem b, buist i. differences in kinetic variables between injured and noninjured novice runners: a prospective cohort study. j sci med sport. 2013;16(3):205–10. 2. reinking mf, austin tm, hayes am. a survey of exercise and related leg pain in community runners. int j sport phys ther. 2013;8(3):269–76. 3. who. global recommendations on physical activity for health. geneva: who library cataloguing data; 2010. 4. rauner a, mess f, woll a. the relationship between physical activity, physical fitness and overweight in adolescents: a systematic review of studies published in or after 2000. bmc pediatrics. 2013;13(1):19–19. 5. moore kl, arthur fd, anne mr. moore clinically oriented anatomy. 6th ed. philadelphia: lippincott williams & wilkins; 2014. 6. chelly ms, chérif n, amar mb, hermassi s, fathloun m, bouhlel e, et al. relationships of peak leg power, 1 maximal repetition half back squat, and leg muscle volume to 5-m sprint performance of junior soccer players. journal of strength and conditioning research. 2010;24(1):266– 71. 7. gimenez p, arnal pj, samozino p, millet gy, morin j. simulation of uphill/downhill althea medical journal. 2017;4(1) 72 amj march 2017 running on a level treadmill using additional horizontal force. j biomech. 2014;47(10):2517–21. 8. willis fb, smith fm, willis ap. frequency of exercise for body fat loss: a controlled cohort study. journal of strength and conditioning research. 2009;23(8):2377– 80. 9. harbo t, brincks j, andersen h. maximal isokinetic and isometric muscle strength of major muscle groups related to age, body mass, height, and sex in 178 healthy subjects. eur j appl physiol. 2012;112(1):267–75. 10. cooper r, hardy r, bann d, aihie sayer a, ward k, kuh d, et al. body mass index from age 15 years onwards and muscle mass, strength, and quality in early old age: findings from the mrc national survey of health and development. j gerontol a biol sci med sci. 2014;69(10):1253–59. 11. knuttgen hg. strength training and aerobic exercise: comparison and contrast. journal of strength and conditioning research. 2007;21(3):973–8. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 597 demographic profile of knee osteoarthritis patients in a teaching hospital west java, 2013 tranggana nugrahaputra,1 tertianto prabowo,2 henny anggraini sadeli3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: osteoarthritis is the most common degenerative musculoskeletal diseases occur worldwide. it usually affects the weight-bearing joint such as knee and vertebra. osteoarthritis is influenced by various risk factors. the aim of the study was to identify the demographic profile of knee osteoarthritis patients. methods: a retrospective descriptive study was performed to 247 medical records of knee osteoarthritis patients who attended to physical medicine and rehabilitation of dr. hasan sadikin general hospital bandung in 2013. the inclusion criteria were medical records that consisted of age, sex and occupation of the patients, and payment methods. exclusion criteria were incomplete of the necessary data mentioned in the inclusion criteria. the study was conducted from august until november 2014. the collected data were analyzed and presented using frequency distribution. results: from all the patients, 40.9% was 60-69 years old, 77.7% were women and 82.6% were retired patients. most of the patients had a social health insurance. conclusions: majority of patients is 60–69 years old women, retired and has the financial protection. [amj.2015;2(4):597–600] keywords: demographic profile, knee osteoarthritis, social health insurance correspondence: tranggana nugrahaputra, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62811236349 email: twentyfivefour@yahoo.com introduction osteoarthritis is one of arthritic diseases which frequently causes a chronic musculoskeletal pain and movement disability to the elder in worldwide.1 knee osteoarthritis is influenced by various factors, such as age, sex, genetic factor, obesity, metabolic diseases, joint injury, activity that involved cumulative pressure on joints, and vigorous exercise. sign and symptoms of osteoarthritis are joint edema, pain, local warmness, crepitation, and movement limitation.2 osteoarthritis frequently affects weight bearing joints. the most common weight bearing joint is affected by osteoarthritis is knee.3 the prevalence of knee osteoarthritis is two times higher than hip osteoarthritis in people over 60 years old.4 around 35% people over 65 years old suffers from knee osteoarthritis.5 knee osteoarthritis cases require to be treated for a period of time and can cause financial implication. during the last two decades, indonesia implements a health payment restructuration by developing a social-health insurance.6 the existence of this health insurance can provide a financial protection for the patients so they can get their treatment regularly. knowing the demografic profile of the patients is considerably important in managing the disease. the aim of the study was to identify the demographic profile of knee osteoarthritis patients. methods this study was performed using a retrospective descriptive design. a number of 247 medical records on knee osteoarthritis patients was collected. the inclusion criteria were medical records of knee osteoarthritis patients in physical medicine and rehabilitation policlinic of dr. hasan sadikin general hospital bandung in 2013. it consisted of age, sex and occupation of the patients, and also the payment methods. althea medical journal. 2015;2(4) 598 amj december, 2015 an exclusion criterion was incomplete the necessary data mentioned in the inclusion criteria. the study was conducted from august until november 2014. this study had been approved by health research ethics committee of dr. hasan sadikin general hospital bandung and faculty of medicine, universitas padjadjaran. the collected data were analyzed and presented using a frequency distribution. results the collected medical records that met the inclusion criteria were 247 medical records. patient profiles were classified by age, sex, occupation, and payment methods. the most common age group of patient in physical medicine and rehabilitation policlinic of dr. hasan sadikin general hospital due to knee osteoarthritis was those who were 60– 69 years old, followed by 50–59 years old and 70-79 years old. moreover, female patients were higher than male (3.5:1) and most of the patients were retired. (table 1) from all of the payment methods, most of the patients had protected from financial burden either by health insurance or by figure 1 distribution of knee osteoarthritis patients according to age table 4 reasons for ideal age of marriage and childbearing characteristics n % sex male 55 22.3 female 192 77.7 occupation still working 43 17.4 retired 204 82.6 payment methods civil servants of social health insurance 192 77.7 national social health insurance (jaminan kesehatan masyarakat, jamkesmas) 9 3.6 payment by company/firm 34 13.8 out-of-pocket payment 12 4.9 althea medical journal. 2015;2(4) 599tranggana nugrahaputra, tertianto prabowo, henny anggraini sadeli: demographic profile of knee osteoarthritis patients in a teaching hospital west java, 2013 company payment, yet, there was still a small group of patients that paid their care by themselves. discussion knee osteoarthritis was one of the leading disability causes in worldwide.4 from this study, it is found that most of the patients were above 60 years old. this result was similar to the study conducted by nur aslyn et al,4 stated that knee osteoarthritis prevalence raise twofold on population above 60 years old. yoshimura et al.7 on his study conducted in japan, stated that knee osteoarthritis prevalence was most common (57.1%) on 60– 69 years old age group.7 there are 61 patients on 50–59 years old age group, (24.7%) which made this age group as the second age group with numerous knee osteoarthritic patient, which is quite interesting. squatting and sitting above limb performed every day, and praying procedure may causes the knee osteoarthritis development on younger age. moreover, most of the patients are female. in line with a study conducted by kusuma et al.8, it is stated that women were more frequent (66.2%) found to attend medical rehabilitation clinic. women have a further risk factor to be suffered from osteoarthritis due to the reduced estrogen level in menopause; which in the end, estrogen are important to delay the bone resorption. retired patients are easily found in this study (82.6%) compared to those who are still working (17.4%). it is possibly caused by the majority of respondent characteristic which mostly had exceeded his/her productive age, in addition to frequent of squatting that could overwhelm the knee joint burden. conversely andriyasa’s9 study states that only 16.7% of patient who were not working suffered from knee osteoarthritis. most of the patients have one of the financial schemes either by social insurance or company/firm payment. hidayat et al.10 states that this health insurance can expand the patient’s accesibility to health care. the existence of insurance has many benefits. knee osteoarthirtis patients could attend frequent rehabilitation in the hospital, in addition to drugs need to be consumed periodically without worrying about money they should prepared before coming to the hospital during this study, there are several limitations that possibly influence the results. one of them is the incomplete data in the patient’s medical records. it can be concluded that the demografic profile of knee osteoarthritis patients are above 60 years old, mostly female, retired and have the social health insurance. a further study should be conducted on clinical and sociodemographic profile of knee osteoarthritis, especially the risk factors , since there are lots of factor that could influence the disease. references 1. zhang w, moskowitz r, nuki g, abramson s, altman r, arden n, et al. oarsi recommendations for the management of hip and knee osteoarthritis, part ii: oarsi evidence-based, expert consensus guidelines. osteoarthritis cartilage. 2008;16(2):137–62. 2. yekti rp, mutiatikum d. faktor-faktor yang berhubungan dengan penyakit sendi berdasarkan riskesdas di indonesia 2007–2008. bul penelit kesehat. 2009; 37(suppl):32–9. 3. hui ay, mccarty wj, masuda k, firestein gs, sah rl. a systems biology approach to synovial joint lubrication in health, injury, and disease. wiley interdiscip rev syst biol med. 2012;4(1):15–37. 4. nor aslin mn, su lyn k. effects of passive joint mobilization on patients with knee osteoarthritis. sains malaysiana. 2011;40 (12):1461–5. 5. tarigan t, kasjmir yi, atmakusuma d, lydia a, bashiruddin j, kusumawijaya k, et al. the degree of radiographic abnormalities and postural instability in patients with knee osteoarthritis. acta med indonesia. 2009;41(1):15–9. 6. aji b, de allegri m, souares a, sauerborn r. the impact of health insurance programs on out-of-pocket expenditures in indonesia: an increase or a decrease? int j environ res public health. 2013;10(7):2995–3013. 7. yoshimura n, muraki s, oka h, mabuchi a, en-yo y, yoshida m, et al. prevalence of knee osteoarthritis, lumbar spondylosis, and osteoporosis in japanese men and women: the research on osteoarthritis/ osteoporosis against disability study. j bone miner metab. 2009;27(5):620–8. 8. kusuma w, angliadi e, angliadi l. profil penderita osteoartritis lutut dengan obesitas di instalasi rehabilitasi medik rumah sakit umum pusat prof. dr. r. d kandou manado. jurnal e-clinic (ecl). 2014;2(3):1–4. 9. andriyasa k, putra tr. korelasi antara derajat beratnya osteoartritis lutut dan althea medical journal. 2015;2(4) 600 amj december, 2015 cartilage oligometric matrix protein serum. j penyakit dalam. 2012;13(1):11–20. 10. hidayat b, thabrany h, dong h, sauerborn r. the effects of mandatory health insurance on equity in access to outpatient care in indonesia. health policy plan. 2004;19(5):322–35. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 191 mothers’ hand washing practice and diarrhea cases in children under five in baleendah, bandung m. syafril firdaus,1 insi farisa desy arya,2 dadang hudaya somasetia3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: diarrhea is a disease, especially in children, with high mortality and morbidity rate in developing countries, including indonesia. diarrhea can be prevented if people can apply clean and healthy behaviors, especially hand washing. hand washing is the cheapest, simplest, and the most effective methods for prevention of diarrhea. the objective of this study is to identify the knowledge, attitude, and practice of mothers’ hand washing and diarrhea cases in children under five in baleendah district, bandung. methods: a descriptive study was conducted during september−november 2012 to 210 mothers who had children (ages 12−59 months) in baleendah using rapid survey technique. the time allocated for each village was adjusted to the population proportion for each region. the data were analyzed using computer and was represented using frequency distribution. results: this study showed that the respondents had good level of knowledge and attitude of hand washing (83.8% and 61%, respectively), but only 21% of the respondents’ practices of hand washing was in good level. most of the respondents did not wash their hands according to the 7 steps of correct hand washing. moreover the percentage of children with diarrhea in baleendah was 43.8% (92 cases) during the study. conclusions: there should be dissemination of information about the benefit of washing hands with 7 steps of correct hands washing so that families can practice it and can prevent diarrhea in children under five. [amj.2015;2(1):191–8] keywords: diarrhea, hand washing, practice, mother correspondence: m. yafril firdaus, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285695792727 email: msyafrilfirdaus@yahoo.com introduction diarrhea is a major cause of children mortality and morbidity in the developing countries. based on data from the world health organization (who) in 2007, it was estimated that every year 100,000 indonesian children died from diarrhea. in addition, the data from health department of republic of indonesia in 2000 stated that 300 inhabitants from 1,000 people were affected by diarrhea each year.1,2 according to indonesian basic health research 2007, the leading cause of death on children in indonesia are diarrhea and upper respiratory infection.3diarrhea infection is more dominant in babies because their endurance is still weak so they are highly susceptible to viral and bacterial infections that cause diarrhea. according to united nations international children fund (unicef) in 2012, it was estimated that each day 2,000 children under five worldwide died from diarrhea. in developing countries, including indonesia, the baby suffering from diarrhea is more than 12 times per year, making the diarrhea as the causes of death by 15−34% than other causes of death. babies who grow up in rural areas are at risk of death 10 times greater than those who grow up in urban areas.4 in west java province, the incidence of diarrhea occurs up to 10%, surpassing the national average of 9%. from west java provincial health office report a few years back, it was stated that citarum watershed was given a special attention due to the incidence of diarrhea, one region is baleendah.5 baleendah district is located in south bandung with an area of 985,149,5 ha width. until now, the flood in citarum river routinely occurs every rainy season. baleendah and its surrounding areas are often flooded. diarrhea and respiratory problems often rise due to floods in baleendah.6 according to the health center in 2010; diarrheal diseases became the top three diseases for children under five in this district, with a number of case 2,179 patients.7 althea medical journal. 2015;2(2) 192 amj june, 2015 in general, clean and healthy lifestyle behaviors in indonesia are still lacking and it is not to be a community culture. the report from baleendah primary health care on clean and healthy lifestyle behaviors in 2010, it was shown that from 1,050 households, only 508 that met the clean and healthy lifestyle behaviors standard7. the clean and healthy lifestyle behaviors data also support the information that the diarrhea disease will continue occur every year when the public clean and healthy behavior does not change better. according to who, hands are the main lines of germ entry into the body, as the hands often have direct contact with the mouth and nose. hands can be exposed to germs when we come into contact with the body, others people, animals, or contaminated surfaces.1who shows that washing hands properly with soap at 5 critical times can reduce the incidence of diarrhea by 40%. the five critical times are before eating, after defecation and urination, before holding the child, after cleaning the child, and before preparing food.8 based on the above description, it can be recognized the important roles of mothers who are closest to their children, the five significant times on washing hands with soap, and the high incidence of diarrhea experienced by children under five in baleendah.therefore, the author is interested in studying the knowledge, attitude, and practice of mothers’ hand washing as well as the occurrence of diarrhea cases in the children under five in baleendah, bandung district. methods a descriptive study was conducted during september−november 2012 to 210 mothers who had children (ages 12−59 months) in baleendah using rapid survey technique.9 the time allocated for each village was adjusted to the population proportion for each region. table 1 questions about respondents’ hand washing knowledge (n=210) no. question category number of respondents (%) 1 benefits of hand washing is to prevent a person affected by disease correct answer 201 (95.7) wrong answer 5 (2.4) do not know 4 (1.9) 2 washing hands with soap is not only carried out when the hand looks dirty correct answer 62 (29.5) wrong answer 148 (70.5) do not know 0 (0.0) 3 hands are the main part of the body as media of germs enter the body correct answer 205 (97.6) wrong answer 1 (0.5) do not know 4 (1.9) 4 hand washing should use running water correct answer 58 (27.6) wrong answer 151 (71.9) do not know 1 (0.5) 5 there are 7 steps how to wash hands properly correct answer 37 (17.6) wrong answer 28 (13.3 do not know 145 (69.0) 6 washing hands with soap is one of clean and healthy behavior in households correct answer 13 (6.2) wrong answer 195 (92.9) do not know 2 (1.0) 7 hand washing is a simple way to do, inexpensive and can prevent disease correct answer 201 (95.7) wrong answer 4 (1.9) do not know 5 (2.4) althea medical journal. 2015;2(2) 193m. syafril firdaus, insi farisa desy arya, dadang hudaya somasetia: mothers’ hand washing practice and diarrhea cases in children under five in baleendah, bandung the results showed that baleendah village (49 respondents), andir village (28 respondents), manggahang village (28 respondents), jelekong village (21 respondents), wargamekar village (14 respondents), bojongmalakavillage (21 respondents), rancamanyar village (35 respondets), and malakasari village (14 respondents). the respondents had to meet the inclusion criteria: the child’s mother was at home during the study and agreed to participate in filling in validated questionnaire about hand washing. the questionnaire consisted of 5 questions about characteristic of the respondents, 7 questions about knowledge and attitude respectively, and 9 questions about hand washing practice. the data were analyzed using computer and was represented using frequency distribution. results questions about hand washing knowledge table 2 questions about respondents’ hand washing attitude (n=210) no. question category number of respondents (%) 1 mothers should wash their hands with soap before preparing food for their child, strongly agree 76 (36.2) agree 131 (62.4) disagree 3 (1.4) strongly disagree 0 (0.0) 2 mothers should wash their hands with soap after cleaning their babies strongly agree 87 (41.4) agree 122 (58.1) disagree 1 (0.5) strongly disagree 0 (0.0) 3 mothers do not have to wash their hands with soap before holding their child strongly agree 2 (1.0) agree 74 (35.2) disagree 120 (57.1) strongly disagree 14 (6.7) 4 hand washing should use soap strongly agree 48 (22.9) agree 146 (69.5) disagree 16 (7.6) strongly disagree 0 (0.0) 5 hand washing is not always using the running water strongly agree 13 (6.2) agree 65 (31.0) disagree 114 (54.3) strongly disagree 18 (8.6) 6 mothers do not have to wash their hands with soap before feeding their child strongly agree 1 (0.5) agree 62 (29.5) disagree 122 (58.1) strongly disagree 25 (11.9) 7 mothers should wash their hands with soap after cleaning the house strongly agree 42 (20.0) agree 162 (77.1) disagree 6 (2.9) strongly disagree 0 (0.0) althea medical journal. 2015;2(2) 194 amj june, 2015 consist of the benefit, ways of using soap, running water, washing hands properly, and preventing the disease. most of the respondents could answer the question about the benefit of hand washing (95.7%). hands are the main part of the body as media of germs to enter the body (97.6%). hand washing is a simple way to do, inexpensive and can prevent disease (95.7%). the majority of mothers (69%) did not know about the 7 steps of how to wash hands properly. the rest of the questions were answered wrong (table 1). for the question about respondents hand washing attitude, most of the respondents was agree about washing with soap before preparing food for their child (62,4%), after cleaning their babies (58.1%), and after cleaning the house (77.1%). therefore, the respondents were disagree with the question about do not have to wash their hands with soap before holding their child (57.1%), hand washing is not always using the running water (54.3%), do not have to wash their hands with soap before feeding their child (54.3%) (table 2). for the level of hand washing practices, from 210 respondents, 193 mothers (91.9%) said they never washed their hands by table 3 questions about respondents’ hand washing practices (n = 210) no. question category number of respondents (%) 1 mother washing hands with soap often 116 (55.2) sometimes 94 (44.8) never 0 (0.0) 2 mother washing hands with running water frequently often 139 (66.2) sometimes 66 (31.4) never 5 (2.4) 3 mother did not wash their hands with soap before handling the child often 18 (8.6) sometimes 153 (72.9) never 39 (18.5) 4 mother washing hands before preparing food for baby often 155 (73.8) sometimes 53 (25.2) never 2 (1.0) 5 mother drying hands with a clean towel after washing hands often 166 (79.0) sometimes 38 (18.1) never 6 (2.9) 6 mother washing hands after cleaning the baby often 206 (98.1) sometimes 4 (1.9) never 0 (0.0) 7 mother did not wash hands before feeding the child often 23 (11.0) sometimes 121 (57.6) never 66 (31.4) 8 mother did not wash hands after cleaning the house often 21 (10.0) sometimes 35 (16.7) never 154 (73.3) 9 mother washing hands with 7 steps how to wash hands well and correctly often 8 (3.8) sometimes 9 (4.3) never 193 (91.9) althea medical journal. 2015;2(2) 195m. syafril firdaus, insi farisa desy arya, dadang hudaya somasetia: mothers’ hand washing practice and diarrhea cases in children under five in baleendah, bandung following the 7 steps of how to wash hands properly (table 3). knowledge, attitude, and practice are essential in any clean and healthy behaviors. overall, a description about knowledge and attitude of the mothers regarding the importance of hand washing was in good category (83.8% and 61%), meanwhile for the description about respondent’s practice was in fair level (55.7%) (table 4). according to sociodemographic characteristics and affordability, it can be discovered that from 210 respondents, 92 of them had their children under five with diarrhea in the last month (table 5). based on the age group of children, the incidence of diarrhea is mostly experienced in the age group of 12−23 months, amounting to 58.7%, and at least in the age group of 48−59 months by 8.7%. discussions based on the study result, a description on knowledge level of the mothers regarding the importance of hand washing is in good level. this evident is derived from the study showing that the average level of respondent knowledge is in both categories (83.8%). however, the existing questionnaire questions, the question number 5 showed that the majority of mothers (69%) did not know about the 7 steps of how to wash hands properly. this suggests that mothers understand the importance of washing hands with soap as one way of preventing the entry of germs into the body, but they do not know how to wash the hands properly. these results are similar to studies in other villages, e.g. hegarmanah and sayang villages, jatinangor district, it was stated that 92.9% of women did not know about the 7 steps how to wash hands well and correctly.10 for the level of attitudes, the results of this study also showed that still there were mothers who had a relatively less stance on the importance of hand washing (29%). a study conducted in hegarmanah and sayang villages, jatinangor district, showed as much as 78.1% of women were categorized in good level.10 according to bloom, the attitude factors become the major influence on people’s health status. maternal attitudes in health is crucial to the health status of the families, including their children. this is because the mothers usually become the direct caregiver for the child so that more interaction occurs.11 for the level of hand washing practices, most mothers were in the category of enough (55.7%). this indicates that most mothers do not have good knowledge about hand washing practice. according to who report, people who do not have access to soap will be difficult to implement washing hands with soap.12 however, the absence of soap is not a barrier to washing hands with soap practice in this study. they have reason that the hand still looks clean. therefore they assumed that washing hands was a very time consuming, moreover the lack of nearby places to wash hands, such as a sink, had become the reason for the low level of the respondents’ hand washing practices in this study. according to the study performed in hegarmanah and sayang village, jatinangor district, the study showed that as much as 82.4% of women were categorized in poor level.10 it is also worth to highlight the questionnaire table 4 description about respondents’ hand washing knowledge, attitude, and practice (n = 210) no. question category number of respondents (%) 1 knowledge good 176 (83.8) fair 34 (16.2) poor 0 (0.0) 2 attitude good 128 (61) fair 22 (10) poor 60 (29) 3 practice good 44 (21.0) fair 117 (55.7) poor 49 (23.3) althea medical journal. 2015;2(2) 196 amj june, 2015 results about 7 hand washing practices steps that were performed well and correctly. from 210 respondents, 193 mothers (91.9%) said they never washed their hands by following the 7 steps of how to wash hands properly. it is caused by mothers’ lack of knowledge about good hand washing, given that the maternal ignorance about the 7 steps reaching 69%. these results are similar to studies in karachi, pakistan, which also stated that as many as 84% women never washed their hands with the 7 steps.13 overall, the study in indonesia showed that people know many germs on the hands. however, hand washing behavior has not become a daily habit, especially in the five critical times to wash hands: before eating, after defecation and urination, before holding the child, after cleaning the child, and before preparing food. there were only about 0−34% who washed hands at the critical times.14,15 the results are not much different from other studies on developing countries. according to the global public private partnership for hand washing, hand washing habits in india reached 34%, ghana 3%, senegal 31%, nigeria 10%, and burkina faso 13%.12 knowledge about health is the basis for behavior change, yet there is possibility of someone not to necessarily act on the knowledge base owned.16 according to the research in 11 major countries on hand washing behavior, there are three factors affecting the hand washing behavior: planned activity, motivation to conduct, and health behavior habits.17 based on the study result, the incidence of children under five with diarrhea in the last month were 210 respondents and 92 (43.8%) mother had children under five with diarrhea table 5 diarrhea cases in children under five in the last month according to sociodemographic characteristics and affordability characteristics diarrhea yes no n % n % mother's education not finished elementary school 0 (.0) 1 (100.0) elementary school graduates 26 (55.3) 21 (44.7) junior high school graduate 41 (44.6) 51 (55.4) senior high school graduate 20 (31.7) 43 (68.3) colleges graduate 5 (71.4) 2 (28.6) total 92 (43.8) 118 (56.2) family income <regional minimum wage (umr) 57 (44.9) 70 (55.1) >regional minimum wage (umr) 35 (42.2) 48 (57.8) total 92 (43.8) 118 (56.2) children age (months) 12−23 54 (55.7) 43 (44.3) 24−35 21 (42.0) 29 (58.0) 36−47 9 (24.3) 28 (75.7) 48−59 8 (30.8) 18 (69.2) total 92 (43.8) 118 (56.2) children sex male 48 (42.5) 65 (57.5) female 44 (45.4) 54 (54.6) total 92 (43.8) 118 (56.2) althea medical journal. 2015;2(2) 197 in the last month. the other studies conducted in the slums of north jakarta with household survey technique showed that children under five with diarrhea in the last month reached 13% children.18these results is in contrast with baleendah district although both areas are flooded areas. based on the age group of children, the incidence of diarrhea is mostly experienced in the age group of 12−23 months, amounting to 58.7%, and at least in the age group of 48−59 months by 8.7%. these results are consistent with the research in semarang. the research showed that the incidence of diarrhea in children under five in the age group <24 months was (58.68%), followed by age group 24−36 months with (24.65%) and the least in group aged of 37−60 months with (16.67%)16. similar results were also shown by the study of health primary center tetehosi foa, district gido, niasa regency, north sumatra19, stating that the largest proportion of children under five with diarrhea were in the age group of 1−3 years, which was equal to 46.8%. all cases of diarrhea in children under five in baleendah were acute diarrhea, the diarrhea that occurred with the duration of no more than 14 days. as conclusion, there should be information dissemination on the benefit of washing hands with 7 steps of correct hands washing through a simulation. in addition, the collaboration between health primary center and integrated health cares in the local community should also be made to promote the clean and healthy lifestyle behaviors campaign in the household. therefore, the families can practice the clean and healthy lifestyle behaviors to prevent diarrhea in children under five, especially with washing hands with soap. references 1. world health organization. diarrhoea: why children are still dying and what could be done. geneva: world health organization; 2009. 2. west java provincial health office. phbs di sekolah. 2006. [cited 2012 april 16]. available from: http://www.diskes. jabarprov.go.id/index.php?mod=&idmenu k=50&imenutab=52. 3. indonesian council for health research and development. riset kesehatan dasar provinsi jawa barat. jakarta: health department of indonesian republic; 2008. 4. health department of indonesian republic. profil kesehatan indonesia tahun 2008. 2008. [cited 2012 april 20]. available from: http://www.depkes. go.id/downloads/publikasi/profil%20 kesehatan%20indonesia%202008.pdf. 5. west java provincial health office. laporan hasil riset kesehatan dasar provinsi jawa barat tahun 2007. 2007. [cited 2012 april 20]. available from: http://www.diskes. jabarprov.go.id/index.php?mod=pubdow nload&idmenukiri=9&idkategori=7. 6. imanuel ns. baleendah, bandung. 2012 [cited 2012 april 25]. available from at: http://id.wikipedia.org/wiki/baleendah_ bandung. 7. bandung district health office. buku laporan tahunan puskesmas baleendah 2011. bandung: bandung district health office; 2012. 8. health department of indonesian republic. panduan penyelenggaraan hari cuci tangan pakai sabun sedunia (hctps). 2nd ed. jakarta; 2009.[cited 2012 april 25]. available from: http://digilib-ampl. net/file/pdf/panduan_hctps_09.pdf. 9. sabri l, ariawan i, hadi en, trihandini i, prasetyo s. aplikasi survei cepat. 2nd ed. depok: fakultas kedokteran universitas indonesia dan pusat data kesehatan departemen kesehatan; 1996. 10. ikhsanun kp. gambaran pengetahuan, sikap, dan perilaku ibu rumah tangga tentang cuci tangan di desa hegarmanah dan desa sayang kecamatan jatinangor tahun 2011 [minor-thesis]. bandung: universitas padjadjaran; 2012. 11. notoatmodjo s. konsep perilaku kesehatan, promosi kesehatan teori dan aplikasi. jakarta: pt. rineka cipta; 2010. 12. mach m. fighting child mortality through handwashing. 2012. [cited 2012 december 5]; available from: http://mirayafm.net/ index.php/special-reports/9932-fightingchild-mortality-through-provision-ofsafe-water. 13. sherwani sk, bashir a, ahmed h, alam si. knowledge, attitude, and practices of washing hands among mothers in karachi, pakistan. fuuast j biol. 2011;1(1):103−6. 14. sutriyanto e. pentingnya cuci tangan pakai sabun. 2011. [cited 2012 december 5]; available at: http://www.tribunnews. c o m / 2 0 1 1 / 1 0 / 1 4 / p e n t i n g n y a c u c i tangan-pakai-sabun. 15. team ccisc. who guidelines on hand hygiene in health care: a summary 2009. [downloaded in 5 december 2012];available at:http:// w h o . i n t / g p s c / 5 m a y / t o o l s / w h o _ m. syafril firdaus, insi farisa desy arya, dadang hudaya somasetia: mothers’ hand washing practice and diarrhea cases in children under five in baleendah, bandung althea medical journal. 2015;2(2) 198 amj june, 2015 guidelinehandhygiene_summary.pdf. 16. sinthamurniwaty. faktor-faktor risiko kejadian diare akut pada balita [minorthesis]. semarang: universitas diponegoro; 2006. 17. curtis va, danquah lo, aungerrv. planned, motivated and habitual hygiene behaviour: an eleven country review. health educ res. 2009;24(4):655−73. 18. simanjuntak ch. diarrhoea episodes and treatment-seeking behaviour in a slum area of north jakarta, indonesia. j health popul nutr. 2004:8(2):83−92. 19. mendrofa k. karakteristik balita penderita diare yang berobat di puskesmas tetehosi foa, kecamatan gido, kabupaten niasa tahun 2005 [minor-thesis]. medan: universitas sumatera utara; 2006. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 287 peripheral arterial disease among diabetic patients in dr. hasan sadikin general hospital bandung 2012 feriska fairuz azkiyah,1 teguh marfen djajakusumah,2 ra. retno ekowati3 1faculty of medicine universitas padjadjaran, 2department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, 3departement of biochemistry and molecular biology faculty of medicine universitas padjadjaran abstract background: as one of the most devastating complication in diabetes mellitus, peripheral arterial disease is still under detected in health care services. this study aimed to reveal the frequency of peripheral arterial disease in diabetic patients in endocrine and metabolism clinic in dr. hasan sadikin general hospital bandung. methods: a cross sectional descriptive study was conducted during the period of october to november 2012 in endocrine and metabolism clinic in dr. hasan sadikin general hospital bandung. as many as 54 patients who met the inclusion criteria and agreed to participate in this study signed the informed consent form then underwent history taking, simple physical examination of lower extremities, and ankle-brachial index (abi) measurement. normality of the data distribution was calculated by kolmogorov-smirnov test. results: from a total 54 diabetic patients enrolled, it was found 18 cases of peripheral arterial disease, consisted of 10 patients with ankle-brachial index measurement ≤0.9 and 8 patients with ankle-brachial index measurement >1.4. most of the cases occurred in the elderly group (>60 years old) and had been diagnosed diabetes less than 10 years. conclusions: the frequency of peripheral arterial disease in diabetic patients attended dr. hasan sadikin general hospital bandung is 33.3% and more prevalent in elderly patients. it occurred mostly in patients diagnosed with diabetes less than 10 years. [amj.2015;2(1):287–90] keywords: diabetes mellitus, frequency, peripheral arterial disease correspondence: feriska fairuz azkiyah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628122010004 email: feriskafairuz@yahoo.com introduction peripheral arterial disease (pad) is a vascular derangement where there is an obstruction or constriction in the aorta or artery of the extremities.1,2 it is mostly caused by atherosclerosis.1,3 one of the condition that promotes atherosclerosis is diabetes mellitus.4 moreover, diabetic patients who have pad tend to have more amputations, five times greater than normal population.5 in general population, multi ethnic study of atherosclerosis (mesa) study showed that the prevalence of pad is 3.7%.6 prevalence of pad in diabetic patients is higher, range from 3.2% in korea7 to 15.2% in singapore.8 in the united states9, the prevalence of pad in diabetic patients is two times higher compared with normal population. regardless the high prevalence, pad is undetected in healthcare services. indonesia ranks as the forth country with most people with diabetes mellitus after india, china and the united states. in 2030 prediction, indonesia will occupy the same rank.10 based on indonesian basic health research (riset kesehatan dasar/riskesdas)11 in 2007, prevalence of diabetes mellitus in indonesia was as high as 5.7%. according to a research conducted in primary health care services in medan12, prevalence of pad in diabetic patients is 44%. there is insufficient data about prevalence of pad in diabetic patients in other geographic setting in indonesia. this study was conducted to find the prevalence of pad in diabetic patients who visited the endocrine and metabolism clinic in dr. hasan sadikin general hospital bandung during the period of october-november 2012. methods this is a cross-sectional descriptive study which had been approved by health research althea medical journal. 2015;2(2) 288 amj june, 2015 ethics committee, faculty of medicine, universitas padjadjaran. the subjects in this study were diabetic patients who visited endocrine and metabolism clinic in dr. hasan sadikin hospital general bandung. the study was conducted from october to november 2012. patients with history of lower extremity amputation who had serious morbidity or in diabetic foot treatment were excluded from the study. patients who met the inclusion criteria and agreed to participate in this study signed the informed consent form then underwent history taking, simple physical examination of lower extremities, and ankle-brachial index (abi) measurement. as many as 54 patients underwent the study procedure. anamnesis consisted of patient’s identity and some of risk factor history. patient’s characteristics such as age and length of diabetes duration were documented for later grouping in intervals. physical examination consisted of inspection of lower extremity and palpation of lower extremity arterial pulses in dorsal for pedis artery and posterior tibial artery. measurement of abi had been done in both lower extremity with a calibrated mercury spigmomanometer and a handheld doppler ultrasound. the lower extremity pressures was compared with the brachial pressure and resulted the abi score. the score then grouped to pad definitive (abi≤0.9), normal (abi0.91– 1.30) and uncompressible (abi>1.3). for the importance of pad status determination, the uncompressible group divided into two more groups, uncompressible≤1.4 and uncompressible>1.4. pad defined as having abi score less than or equal to 0.9 or more than 1.4. patients with abi score >1.4 were included in pad criteria based on a research which stated that a high abi score (>1.4) could be considered as pad-equivalent. all data processed by microsoft excel 2007 and spss version 17.0. normality of the data distribution was calculated by kolmogorov-smirnov test. results total 54 diabetic patients enrolled in this study, consisted of 22 males and 32 females ranging from 36 years old to 81 years old with normal distribution. all patients followed abi measurement. the majority of the patients had normal abi score, 9 people had pad definitive, 15 people had uncompressible, and 1 person had both pad definitive and uncompressible result. in uncompressible group, 7 had abi score <1.4 and 8 had abi score ≥1.4 (table 1) the frequency of pad among diabetic patients was 33.3% (18 people), 10 people with pad definitive and 8 people with abi score ≥1.4 (table 2). half of the diabetic patients who had pad were in the elderly group (table 3). most of the patients who had pad were diagnosed as having diabetes ≤10 years (table 4). discussions measurement of abi is the most simple, nontable 1 results of abi measurement in diabetic patients abi result frequency percentage pad definitive 9 16.7 normal 29 53.7 uncompressible 15 27.8 abi<1.4 7 13.0 abi≥1.4 8 14.8 pad definitive and uncompressible 1 1.9 table 2 frequency of pad among diabetic patients criteria frequency percentage pad 18 33.3 pad definitive 10 18.5 uncompressible, abi≥1.4 8 14.8 non-pad 36 66.7 althea medical journal. 2015;2(2) 289feriska fairuz azkiyah, teguh marfen djajakusumah, ra. retno ekowati: peripheral arterial disease among diabetic patients in dr.hasan sadikin general hospital 2012 invasive method to document pad in lower extremities. a lower than normal abi score showed an occurence of abnormal vascular hemodynamic, thus diagnosed as pad.13 however, diabetic patients had a unique characteristic where they tend to have a higher abi score than expected. it occurred because of the calcification in the arterial wall causing the wall to be stiffened.4,13 a strong heart study revealed that a high abi score had a same mortality risk as a low abi score, so patients with high abi score should not be neglected.14 for diabetic patients, a high abi score could be categorized as pad-equivalent.15 it is the reason why in this study included the high abi score patients to the pad group along with patients with low abi score. this made our study is different with other study. this study showed that 33.3% percent of diabetic patients had pad, either pad definitive or high abi score. compared to another study conducted in indonesia12, this study showed a lower frequency. it should be due to demographical differences between our study places. a study conducted in sweden16 showed that pad prevalence can be varied within different geographical places, influenced by clinical setting, ethnicity, and other risk factors related. the same reason goes to the differences between our study result and other results in singapore, south korea and united states. unfortunately, this study did not cover and analyze a thorough data collection about risk factors. therefore, another comprehensive study is needed. data about age of diabetic patients who had pad showed a similar result with other previous study.13 frequency of pad rises along with the advanced of age. this study showed that pad occurred mostly in patients aged more than 60 years old. this study concerned with the duration of diagnosis showed an interesting result. a theory stated that chronic complication of diabetes usually appears at the second decade of hyperglycemia5, but it showed that majority of diabetic patients with developed pad were at the first ten years of diabetes. it should be due to that hyperglycemic condition had occurred long before the patient was diagnosed of having diabetes.5 also it should consider the influence of other risk factors such as smoking history, coronary arterial disease, and hypertension. despite this silent nature of pad, partners study which was conducted in united states showed that doctor’s attention to pad detection is low.17 although there is no explicit data about abi measurement in indonesia, it is done less likely because most of the study participants admitted never done a blood pressure measurement on lower extremities. this study has limitations including the sampling technique, biases, and collected data for the study. the study sample has the minimum sample size needed but this study used a convenience sampling thus bias is more likely to happen. it is suggested that another table 3 age characteristic of diabetic patients with pad pad group age groups (years old) total <40 40–49 50–59 ≥60 f % f % f % f % f % pad definitive 1 6 0 0 4 22 5 28 10 56 abi>1.4 1 6 0 0 3 17 4 22 8 44 total 2 11 0 0 7 39 9 50 18 100 table 4 duration of diagnosis characteristic from diabetic patients with pad pad group duration of diagnosis total ≤10 years >10 years f % f % f % pad definitive 8 44 2 11 10 56 abi>1.4 6 33 2 11 8 44 total 14 78 4 22 18 100 althea medical journal. 2015;2(2) 290 amj june, 2015 study with probability sampling method to be conducted with a larger scale in indonesia. it is expected that another study will be conducted about diabetes, pad, and all related risk factors related so the connections between all of it in indonesia can be identified. although this study has many limitations, it showed a generally similar result with other study except for the findings about duration of diabetes which is sooner in this study. this study should also be used for a stepping stone to another study concerning pad and diabetes and to help many diabetic patients to prevent developing pad. references 1. fauci as, braunwald e, kasper dl, hauser sl, longo dl, jameson jl, et al., editors. harrison’s principles of internal medicine. 17th ed. new york: mcgraw-hill; 2008. 2. dieter rs, jr. rad, iii rad, editors. peripheral arterial disease. new york: mcgraw-hill; 2009. 3. coffman jd, eberhardt rt, editors. peripheral arterial disease, diagnosis and treatment. new jersey: humana press; 2003. 4. cronenwett jl, johnston kw, editors. rutherford’s vascular surgery. 7th ed. philadelphia: saunders 2010. 5. jude eb, oyibo so, chalmers n, boulton ajm. peripheral arterial disease in diabetic and nondiabetic patients. diabetes care. 2001;24(8):1433–7. 6. mcdermott mm, liu k, criqui mh, ruth k, goff d, saad mf, et al. ankle-brachial index and subclinical cardiac and carotid disease, the multi-ethnic study of atherosclerosis. am j epidemiol. 2005;162(1):33–41. 7. yu jh, hwang jy, shin m-s, jung ch, kim eh, lee sa, et al. the prevalence of peripheral arterial disease in korean patients with type 2 diabetes mellitus attending a university hospital. diabetes metab j. 2011;35(6):543–50. 8. narayanan rml, koh wp, phang j, subramaniam t. peripheral arterial disease in community-based patients with diabetes in singapore: results from a primary healthcare study. ann acad med singapore. 2010;39(7):525–31. 9. gregg ew, sorlie p, paulose-ram r, gu q, eberhardt ms, wolz m, et al. prevalence of lower-extremity disease in the u.s. adult population >40 years of age with and without diabetes. diabetes care. 2004;27(7):1591–7. 10. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes, estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047–53. 11. the national institute of health research and development moh, republic of indonesia. report on result of national basic health research (riskesdas) 2007. jakarta: ministry of health, republic of indonesia, 2008. 12. sihombing b. prevalensi penyakit arteri perifer pada populasi penyakit diabetes melitus di puskesmas kota medan [thesis]. medan: university of sumatera utara; 2008. 13. norgren l, hiatt wr, dormandy ja, nehler mr, harris ka, fowkes fg, et al. intersociety consensus for the management of peripheral arterial disease (tasc ii). j vasc surg. 2007;45 suppl s(1):s5–67. 14. resnick he, lindsay rs, mcdermott mm, devereux rb, jones kl, fabsitz rr, et al. relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the strong heart study. circulation. 2004;109(6):733–9. 15. aboyans v, ho e, denenberg jo, ho la, natarajan l, criqui mh. the association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. j vasc surg. 2008;48(5):1197–203. 16. sigvant b, rolandsson o, wiberg-hedman k, andersson b, bergqvist d, persson e, et al. a population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences. j vasc surg. 2007;45(6):1185– 91. 17. hirsch at, criqui mh, treat-jacobson d, regensteiner jg, creager ma, olin jw, et al. peripheral arterial disease detection, awareness, and treatment in primary care. jama. 2001;286(11):1317–24. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 139 effects of calcium bentonite on high blood cholesterol level hendro sudjono yuwono,1 fadhli rajif tangke,2 reni farenia3 1department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia, 2faculty of medicine universitas padjadjaran, bandung, indonesia, 3department of biomedical sciences faculty of medicine universitas padjadjaran, bandung, indonesia abstract background: calcium bentonite has been known to decrease high blood cholesterol level. this study aimed to explore whether a local calcium bentonite from west java, indonesia, had effect on lowering total blood cholesterol level. methods: a laboratory experimental study was carried out on thirty adult male wistar rats’ at laboratory animals, department of pharmacology and therapy, universitas padjadjaran in 2012. the rats were divided into five groups with six rats in each group, consisting of group i (negative control) with standard diet and distilled water, group ii (positive control) with high lipid diet and distilled water, group iii with high lipid diet and ezetimibe 0.18 g/rat/day, groups iv with high lipid diet and calcium bentonite 0.25 g/rat/day, group v with high lipid diet and calcium bentonite 0.5 g/rat/day. ezetimibe as was used as this was an inhibitory agent of intestinal cholesterol absorption. blood cholesterol levels were measured and analyzed using analysis of variance and tukey’s post-hoc test. results: oral calcium bentonite at 0.25 g/rat/day and 0.5 g/rat/day significantly decrease total blood cholesterol level relative to the positive control group, 31.68% (p=0.018) and 32.87% (p=0.006) respectively, but its effect is inferior to ezetimibe 62.83% (p=0.000). conclusions: local calcium bentonite from west java, indonesia, has a significant lowering effect, however, the effect is less comparing to ezetimibe. keywords: blood cholesterol, calcium bentonite, ezetimibe, wistar rat correspondence: hendro sudjono yuwono, department of surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, jalan pasteur 38, bandung, indonesia, email: hsyabc47@gmail.com introduction consumption of high saturated fat could increase cholesterol level in blood.1 several studies have proven that bentonite could decrease high blood cholesterol level.2–4 bentonite is a kind of clay which has an adsorptive ability because of its structure.5 indonesia contains abundant bentonite in many areas.6 this study was conducted to analyze the effect of local calcium bentonite (ca-bentonite) on lowering total blood cholesterol level using hypercholesterolemic rats and was compared to ezetimibe which is an inhibitory agent of intestinal cholesterol absorption.7 methods this experimental method of study was carried out on laboratory animals, at the department of pharmacology and therapy, faculty of medicine, universitas padjadjaran from 24 october to 13 november 2012, was approved by the research ethics committee, faculty of medicine universitas padjdajaran. adult wistar rats weighting between 200–250 g were used. this study used ca-bentonite which was a gift from the indonesia university of education from excavation in the karangnunggal area, tasikmalaya, west java, indonesia. laboratory tests were performed to confirm the accuracy of the ca-bentonite substance at the chemistry laboratory, bandung institute of technology. the determination of ca-bentonite dose is based on the lethal dose which is more than 5 g/kg of body weight.8,9 the first dose is 1 g/ kg of body weight, 0.25 g/rat/day. the second dose is 2 g/kg of body weight, 0.5 g/rat/day. conversion dose of ezetimibe (10 mg of daily human dose) to rat dose is 0.18 g/rat/day. the high lipid diet used in this study was composed of 1.5% chicken egg yolk, 10% fat goat, 1% coconut oil and a mixed of standard diet till 100%.10 amj. 2018;5(3):139–41 althea medical journal. 2018;5(3) 140 amj september 2018 after seven days of adaptation time, in each group, six rats were randomly given intervention for fourteen days. group i (negative control) was given standard diet and distilled water, group ii (positive control) was given high lipid diet and distilled water, group iii was given high lipid diet and ezetimibe 0.18 g/rat/day, group iv was given high lipid diet and ca-bentonite 0.25 g/rat/day, and group v was given high lipid diet and ca-bentonite 0.5 g/rat/day. all diets were given ad libitum while ezetimibe and ca-bentonite were given once a day orally. blood was taken ofthe distal part of the tail, and then the total blood cholesterol level was measured using an enzymatic reaction and photometer after centrifugation. normality and homogeneity of the data were tested using the saphiro-wilk and levene test respectively, and then continued with analysis of variance (anova) and tukey’s post-hoc test. results the data were normal and homogenous. group ii (positive control) had an increase of total blood cholesterol level relative to group i (negative control). the intervention groups (group iii, iv, v) had a decrease of total blood cholesterol level relative to group ii. group iii had a decrease as much as 62.83% (p=0.000), group iv as much as 31.68% (p=0.018), and group v as much as 32.87% (p=0.006). statistic analysis using anova and tukey’s post-hoc test showed significant difference of the total blood cholesterol level between groups (table 1 and figure 1). table 1 mean of total blood cholesterol level group i ii iii iv v mean 82.8 105.0 62.8 79.7 76.3 ±sd 9.93 7.74 6.99 16.54 18.79 note: sd=standard deviation note: group i = negative control group ii = positive control group iii = ezetimibe 0.18 g group iv = ca-bentonite 0.25 g group v = ca-bentonite 0.5 g figure 1 mean of total blood cholesterol level althea medical journal. 2018;5(3) 141hendro sudjono yuwono, fadhli rajif tangke, reni farenia: effects of calcium bentonite on high blood cholesterol level discussion montmorillonite as a main part of bentonite contains three main layers, which comprise of two layers of silica tetrahedral and a layer of octahedral aluminum. it has an adsorptive ability due to an imbalance of electric charges between the ion.5 bentonite clay also has strong absorptive affinity with organic and inorganic elements.11 the study results were parallel to in vivo and in vitro studies by gershkovich et al.2 that show a decrease in the blood cholesterol level. it is associated with the redistribution and sedimentation of cholesterol as well as an interfering of micelles formation which is important in intestinal cholesterol absorption.2,4 likewise a twelve weeks study by sivak et al.3 also shows the same results. humans have used bentonite clay for various intoxication disorders without causing serious side effects when consumed in non-excessive doses. moosavi12 (2017) reveals that there are 100 scientific articles from the 2500 articles published by pubmed, showing the influence of the clay on various organs of the human body.12 the results do not cause side effects when used with the right dose. in several regions of indonesia, such as in jatiwangi (west java) the clay is named hampo, and in tuban (east java) it is called ampo. in those regions, for decades, there is a tradition of consuming clay as a snack without reports of side effects and they consider it as a health food. in that area, the clay is consumed by children, adults, and pregnant women. our results strengthened the truth of clay which was considered as food and traditional medicine that was useful for the health of the human body; thus encouraging further research so that it could be used officially as a drug. there are many advantages of using natural medicine, which do not need preservatives, while ezetimibe is a synthetic that requires a chemical preservative, and is much more expensive. in conclusion, we have found that local ca-bentonite from west java, indonesia, can decrease the total blood cholesterol level in hypercholesterolemic wistar rats but its effect is less effective than ezetimibe. further study is needed in clinical trials in order to utilize bentonite to be used as an alternative therapy. references 1. michelle mcguire pd, beerman ka. nutritional sciences: from fundamentals to food. 3rd ed. belmont: cengage learning; 2011. 2. gershkovich p, darlington j, sivak o, constantinides pp, wasan km. inhibition of intestinal absorption of cholesterol by surface-modified nanostructured aluminosilicate compounds. j pharm sci. 2009;98(7):2390–400. 3. sivak o, darlington j, gershkovich p, constantinides pp, wasan km. protonated nanostructured aluminosilicate (nsas) reduces plasma cholesterol concentrations and atherosclerotic lesions in apolipoprotein e deficient mice fed a high cholesterol and high fat diet. lipids health dis. 2009;8(1):30. 4. gershkovich p, sivak o, contreras-whitney s, darlington jw, wasan km. assessment of cholesterol absorption inhibitors nanostructured aluminosilicate and cholestyramine using in vitro lipolysis model. j pharm sci. 2012;101(1):291–300. 5. supeno m. bentonit terpilar dan aplikasi. medan: usu press; 2009. 6. pusat penelitian dan pengembangan teknologi mineral dan batubara. informasi mineral dan batubara. kelompok program teknologi informasi pertambangan; 2005 [cited 2012 may 4]; available at: http:// www.tekmira.esdm.go.id/data/bentonit/ ulasan.asp?xdir=bentonit&commid=8&co mm=bentonit. 7. katzung b, masters s. basic and clinical pharmacology. 12th ed. san fransisco: mcgraw-hill; 2011. 8. european chemical bureau. iuclid dataset-bentonite. livingston: european commission; 2000. 9. american colloid company. volclay hpm20. arlington heights: material safety data sheet; 2008. 10. hardiningsih r, nurhidayat n. the effect of consuming the hypercholesterolemia rationed food to the body weight of white rats wistar with administration of lactic acid bacteria. biodiversitas. 2006;7(2):127–30. 11. eba f, gueu s, eya’a-mvongbote a, ondo ja, yao bk, ndong nlo j, biboutou rk. evaluation of the absorption capacity of the natural clay from bikougou (gabon) to remove mn (ii) from aqueous solution. international journal of engineering science and technology. 2010;2(10):500116. 12. moosavi m. bentonite clay as a natural remedy: a brief review. iran j public health. 2017; 46(9):1176-83 althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 131 a study on knowledge, attitude and practice in preventing transmission of scabies in pesantren darul fatwa, jatinangor mahirah binti mohd yusof1, silvita fitri r2, yunita damopolii3 1faculty of medicine, universitas padjadjaran, 2department of parasitology, faculty of medicine, universitas padjadjaran, 3department of dermatology and venereology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: scabies is caused by infestation and sensitization of sarcoptess cabiei and is an endemic in tropical and subtropical regions around the world. several factors in the disease transmission are overcrowded living conditions, poor personal hygiene, unhealthy behaviors and population density. pesantren is a spesific name for an educational islamic institution in indonesia and which w could be one of the risk factors of the transmission the disease. most of the students (santri) are staying at the institution for a long time. the objective of this study was to know the level of knowledge, attitude and practice of santri in preventing scabies. methods: a descriptive study was conducted on 45 santri in pesantren darul fatwa in jatinangor during september–december 2012. a questionnaire was set up consisting of questions about age, sex, basic knowledge, attitude, and practice of preventing the transmission of scabies. data were analyzed using frequency distribution. results: the level of knowledge and attitude of the respondents to prevent the transmission of scabies were good, meanwhile the level of practice was moderate. there were still questions that could not be answer by the respondents those were the etiology (31.1%), the cut off chain of transmission (40%), and how to prevent scabies (37.8%). not washing the towel, changing the bed linen and pillow case every 2 weeks were the less good practice performed by the respondents. conclusions: the knowledge and attitude towards the prevention of transmission of scabies are good while the practices are moderate. a further study with more sample size should be carried out including enviromental assessment. key words: attitude, knowledge, practice, scabies correspondence: mahirah binti mohd yusof, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 838 2016 4451 email: mahirahmohdyusof@yahoo.com introduction scabies is a skin disease caused by infestation and sensitization to sarcoptess cabiei mites and is an endemic in tropical and subtropical areas such as egypt, central and south america, africa, india, and southeast asia.1 according to a world health organization (who) report scabies has a potential to bring about an epidemic condition in an area. this condition was found among others in bangladesh where children under-6-year-old were affected within a period of 12 months , india (13%), australian aboriginal communities (50%) and in sierra leone (86%).2 incidence in indonesia was 4.60–12.95% in 2002 and was in the thirdranking of the other 12 common diseases.3 scabies occurs mostly to very young, and older children, also young adults,because they are more vulnerable to many skin diseases and reflect reduced immunity.1,2 scabies often occur to children living in boarding schools as they live together with a group of people which will lead to an easy and high risk condition for contracting various contagious diseases especially skin diseases.4 scabies also most often is a result from unhealthy behaviors, such as hanging clothes in the room, exchanged clothes and personal items and also sharing bedding. the transmission of scabies can be divided into two: direct contact (skin to skin) such as by shaking hands, sleeping together and sexual relations, and indirect contact are such as sharing things like clothes, sheets, towels and others.3 several factors that also play a role in disease transmission are low socioeconomic conditions, poor personal althea medical journal. 2015;2(1) 132 amj march, 2015 and environmental hygiene, unhealthy behavior and population density.4 the lack of knowledge about personal hygiene affects the increased number of incidence of scabies 15% due to rarely taking a shower, and 42% due to frequently sharing clothes with friends.5 according to bloom’s theory in notoatmodjo6, behavior includes knowledge, attitude and practice of an individual. knowledge is a cognitive domain and is the result of knowing people’s sense of any particular object which is important for the formation of a person’s actions (overt behavior). meanwhile, attitude is a readiness or willingness to act, and not an implementation of a particular motive. pesantren or pondok pesantren is a spesific name for an educational islamic institution in indonesia, and throughout the malay region7. this institution is not only the center for islamic studies but also for the spreading of islam.7 during the day, students attend formal school like any other students outside of pesantren, and in the late afternoon and evening they have to attend religious rituals followed by religious studies and group studies to complete their education. most of the students stay at the institution for a long time according to the regulation of the pesantren. due to the unique epidemiology of scabies, pesantren could be one of the risk factors for the transmission of the disease. a study in kendal8 found that the prevalence was 27%. another study by ma’rufi9 in lamongan, east java, found the prevalence of scabies among students was high i.e. 64,20%. there are many factors contributing to this high prevalence, among others are the lack of knowledge, attitude and practice among the santri (pesantren students). this study was conducted to know the level of knowledge, attitude and practice of santri in pondok pesantren darul fatwa in jatinangor in efforts to prevent scabies. methods this study was conducted on 45 santri who studied and lived in pesntren darul fatwa in jatinangor for at least 2 months, during the period september–december 2012. the exclusion criteria included santri who couldnot complete the full process of data acquisition by a variety of reasons. a questionnaire was set up consisting of questions about age, sex, basic knowledge of scabies such as clinical etiology, symptoms, risk factors, prevention, treatment, attitude, and practice of santri towards scabies in order to prevent scabies in pondok pesantren. this questionnaire was tested to 30 respondents and cronbach’s alpha was performed . the test showed that coefficient reliability was 0.744. the level of knowledge, attitude, and practice was measured using a scoring system as follows: good : score is ≥75%, moderate : score is 40%−74%, and poor : when the score is <40%.10 . data were analyzed using frequency distribution. results male respondents with a mean age of 15 years old comprised the highest percentage of the respondents (55.6%). the level of knowledge of the respondents in the effort to prevent scabies was generally good (68.9%), the level of attitude was good (80.0%), and the level of practice based on personal hygiene was moderate (60%) (table 1). in general, the majority of respondents could answer all the questions about scabies correctly except for three questions, those were the etiology of scabies (31.1%), what to do to break the transmission of scabies (40%), and how to prevent scabies (37.8%) according to table 3, 28 respondents (62.2%) answer agree to dry mattress and pillows every week and it showed that the majority of them strongly agree that they should be aware of scabies even though it does not lead to death which comprised about 66.7% (30 respondents). however, 4 respondents (8.9%) showed less agree to the statement that good personal hygiene could keep the body free from scabies. majority of the respondents had a good practice of personal hygiene (table 4). for the questions of how many times the respondents change clothes during the day, mostly answered 2 or 3 times per day with 46.7% and 44.4% respectively. unfortunately, the highest percentage of practices to spread the disease was washing the towel, changing the bed linen and pillow case every 2 weeks. while there, were still 46.7% of respondents whopractised bed sharing. discussions according to notoatmodjo6, the level or quality of knowledge can be grouped into althea medical journal. 2015;2(1) 133 table 1 distribution of respondents based on level of knowledge & attitude frequency, percentage (%) (total, n = 45) level of knowledge good (score : ≥ 27 marks) 31 68.9 moderate (score : 15−26 marks) 14 31.1 poor (score : ≤14 marks) 0 0 level of attitude good (score : ≥ 23 marks) 36 80.0 moderate (score : 13−22 marks) 9 20.0 poor (score : ≤12 marks) 0 0 level of practice personal hygiene good (score : ≥ 16 marks) 17 37.8 moderate (score : 9−15 marks) 27 60.0 poor (score : ≤8 marks) 1 2.2 habits good (score : ≥ 16 marks) 31 68.9 moderate (score : 9−15 marks) 14 31.1 poor (score : ≤8 marks) 0 0 6 levels, where each level is a sequence of processes from the lowest to the highest level. the lowest level is knowing which is is defined as memorizing a material. in this stage, it involves recalling the things that have received stimuli before. the second level is called comprehension, the ability to correctly describe the disease of scabies. the third level is application, the ability in applying the knowledge in everyday life. the next levels are analysis, synthesis and evaluation. in this study, the level of the respondents’ knowledge was more than level one. because most of the respondents could apply the knowledge of preventing the transmission of scabies in daily life activities such as doing good practices of personal hygiene. however, health education should be carried out since there were still respondents who did not know about the etiology, what to do to break the transmission, and how to prevent scabies. furthermore, there was no unit kesehatan sekolah (uks ) provided for the santri in the pesantren. attitude is the assessment toward the stimulus or objects and in this case it is a matter of health, including illness. once a person knows the illness, the next process will be to assess or show attitude towards the illness. therefore, an indicator for the health attitude starts with the knowledge of health itself. the level of attitude of santri towards the scabies disease was good because they had a good knowledge about it.6 unfortunately, there were still 20.0% of santri under moderate level of attitude even they had a good level of knowledge. this is because the development of attitude is a process that is not only influenced by knowledge but also involves emotional, past experience and the environment of living conditions.11 in this study the level of practice of the respondents’ personal hygiene and habits were on a moderate and good level respectively. researchers assume this might be due to the facilities provided and there were good supports surrounding them in order to practice good personal hygiene and habits. besides that, according to the theory of so-r, practice is produced by the stimulus given (knowledge) and the attitude towards it.6 it can be proven that when someone has a good knowledge and a good attitude, then it will cause that person to have a good practice mahirah binti mohd yusof, silvita fitri r, yunita damopolii: a study on knowledge, attitude and practice in preventing transmission of scabies in pesantren darul fatwa, jatinangor althea medical journal. 2015;2(1) 134 amj march, 2015 table 2 distribution of respondents based on type of knowledge no question about knowledge answer frequency (n) percentage (%) 1 have you ever heard of scabies disease yes 28 62.2 no 17 37.8 2 what is the cause (etiology) sarcoptesscabiei 14 31.1 germs 28 62.2 the effect of scractching 3 6.7 3 what are the sign and symptoms got small to large spots which are reddish and wet 35 77.8 itching at night and feel the heat 10 22.2 with pus 0 0.0 4 parts of body that are affected between fingers, armpits, waist, genitals, elbows, and wrists 30 66.7 part that is often being covered 13 28.9 mostly at genital area 2 4.4 5 the transmission of scabies disease skin to skin contact and through clothes, towels, bed linen, and other things used by the patient 33 73.3 through skin contact only 4 8.9 through clothes and bed only 8 17.8 6 who can suffer from scabies all age groups but more common in teenagers 39 86.7 teenagers only 1 2.2 only in certain age groups 5 11.1 7 can exchanging clothes with an infected person spread scabies yes, can spread 22 48.9 when an immunity is low 17 37.8 no, cannot be spread 6 13.3 8 can scabies be harmful to the health of skin yes 37 82.2 no 8 17.8 9 does the patient need to be quarantined no, just need regular treatment 35 77.8 just keep a distance from patient 7 15.6 yes, need to be quarantined 3 6.7 10 what should we do to break the chain of scabies disease disinfection on clothing, bed linen and give treatment simultaneously 18 40.0 keep a distance with others when being infected by sarcoptess cabiei 6 13.3 need regular treatment only 21 46.7 11 can drying mattress and pillow prevent scabies yes 27 60.0 no 18 40.0 12 how to prevent scabies bath 2 times per day with soap and prevent direct contact with the patients 17 37.8 bath 2 times per day and keep the cleanliness of clothes 11 24.4 keep clothing, towels and bedding from being contaminated with scabies sufferers 17 37.8 althea medical journal. 2015;2(1) 135 table 3 distribution of respondents based on types of attitude no types of attitude answer frequency (n) percentage (%) 1 mattresses and pillows are dried every week strongly agree 28 62.2 agree 17 37.8 less agree 14 31.1 2 scabies sufferers have to be quarantined strongly agree 30 66.7 agree 13 28.9 less agree 2 4.4 3 did not exchange clothes, towels and bedding with others strongly agree 25 55.6 agree 20 44.4 less agree 0 0 4 scabies patients do not need to be avoided strongly agree 15 33.3 agree 22 48.9 less agree 8 17.8 5 personal hygiene is very necessary to keep the body free from scabies strongly agree 33 73.3 agree 8 17.8 less agree 4 8.9 6 to keep distance from scabies sufferers is really necessary or needed strongly agree 12 26.7 agree 18 40.0 less agree 15 33.3 7 scabies can be prevented by maintaining a good personal hygiene strongly agree 27 60.0 agree 18 40.0 less agree 0 0 8 if found cases of scabies, treatment should be done quickly to prevent the transmission of disease strongly agree 25 55.6 agree 18 40.0 less agree 2 4.4 9 besides personal hygiene, there must be a good environment in order to prevent scabies strongly agree 35 77.8 agree 10 22.2 less agree 0 0 as well. when someone has known or get information about something, he would do and practice it.10 however there were l respondents who still practiced bad personal hygiene such as washing towel and changing bed linen after 2 weeks or more. the reason was f lack of facilities. the pesantren was not provided with laundry facilities and they had to wash by themselves. besides that, there was no extra bed sheet available so that they can change it every week, and some of the respondents even did not use bed sheets. some of the respondents also practised bad habits by borrowing the towel, clothes and often sleep in other person’s bed. this might be due to insufficient toiletries owned by respondents and it already became a habit for a santri to sleep int other person’s bed as most of them were being influenced by their friend’s practice. according to a theory of the who, there are 4 factors for a person to have a certain practice or behavior. this mahirah binti mohd yusof, silvita fitri r, yunita damopolii: a study on knowledge, attitude and practice in preventing transmission of scabies in pesantren darul fatwa, jatinangor althea medical journal. 2015;2(1) 136 amj march, 2015 table 4 distribution of respondents based on types of practice types of practice answer f r e q u e n c y (n) p e r c e n t a g e (%) personal hygiene change clothes 3x 20 44.4 change clothes 2x 21 46.7 change clothes 1x 4 8.9 bath 3x 3 6.7 bath 2x 41 91.1 bath 1x 1 2.2 wash towel once a week 14 31.1 wash towel every 2 weeks 19 42.2 wash towel > 2 weeks 12 26.7 change bed linen < 1 week 12 26.7 change bed linen every 2 weeks 22 48.9 change bed linen > 2 weeks 11 24.4 change pillowcase every week 16 36.6 change pillowcase every 2 weeks 22 48.9 change pillowcase > 2 weeks 7 15.6 drying mattress once a week 11 24.4 drying mattress every 2 weeks 17 37.8 drying mattress once a month 17 37.8 drying pillow every week 14 31.1 drying pillow for every 2 weeks 16 35.6 drying pillow once a month 15 33.3 habits never borrow a friend’s towel 24 53.3 rarely borrow a friend’s towel 17 37.8 often borrow a friend’s towel 4 8.9 towel never being borrowed by friend 19 42.2 towel rarely borrowed by friend 19 42.2 towel often borrowed by friend 7 15.6 never sharing clothes with friends 21 46.7 rarely sharing clothes 22 48.9 often sharing clothes 2 4.4 clothes never being borrowed by friend 16 35.6 clothes rarely borrowed by friend 24 53.3 clothes often borrowed by friend 5 11.1 never sleep in other’s bed 18 40.0 rarely sleep in other’s bed 21 46.7 often sleep in other’s bed 6 13.3 friends never sleep in your bed 6 13.3 friends rarely sleep int your bed 30 66.7 friends often sleep in your bed 9 20.0 often drying towel after use 22 48.9 rarely drying towel after use 17 37.8 never drying towel after use 6 13.3 althea medical journal. 2015;2(1) 137 includes thought and feelings like knowledge, perception, attitude and belief, and other 3 factors are personal reference, resources (facilities) and culture.6 a small sample size could be one of the limitations in this study. another limitation was the possibility of bias data influenced by the relactance to answer questions related to the bad image of the pesantren. this study concluded that the knowledge and attitude towards the prevention of transmission of scabies were good while the practices were moderate. a further study with more sample size should be performed including an enviromental assessment. references 1. walton sf, currie bj. problems in diagnosing scabies, a global disease in human and animal populations. clin microbiol rev. 2007;20(2):268–79. 2. feldmeier h, heukelbach j. epidermal parasitic skin diseases: a neglected category of poverty-associated plagues. bull world health organ. 2009;87:152–9. 3. djuanda a, djuanda s, hamzah m, aisah s. ilmu penyakit kulit dan kelamin. 4th ed. jakarta: badan penerbit fkui; 2005. p. 122-125 4. saad s. pengaruh faktor higiene perorangan terhadap angka kejadian skabies di pondok pesantren an-najach magelang [dissertation]. semarang: diponegoro university; 2008. 5. kumalasari r. hubungan tingkat pengetahuan dengan timbulnya kejadian skabies di pondok pesantren modern islam (ppmi) assalam sukoharjo [dissertation]. surakarta: universitas muhammadiyah; 2011. 6. notoatmodjo pds. pendidikan dan perilaku kesehatan. jakarta: rineka cipta. 2003. p. 114–128 7. zakaria gan. pondok pesantren: changes and its future. journal of islamic and arabic education. 2010;2(2):45–52. 8. megawati r, santosa b, sumanto d. gambaran kejadian penyakit scabies di ponpes al itqon di patebon kendal. jurnal litbang universitas muhammadiyah semarang. 2005;5(2):18–22 9. ma’rufi i, keman k, notobroto hb. faktor sanitasi lingkungan yang berperan terhadap prevalensi penyakit scabies: studi pada santri di pondok pesantren kabupaten lamongan. jurnal kesehatan lingkungan. 2005;2(1):11–8 10. muzakir. faktor yang berhubungan dengan kejadian penyakit skabies pada pesantren di kabupaten aceh besar tahun 2007 [thesis]. medan: universitas sumatera utara; 2008 11. andayani ls. perilaku santri dalam upaya pencegahan penyakit skabies di pondok pesantren ulumu qur’an stabat. usu institutional repository. 2005;9(2):172–7. mahirah binti mohd yusof, silvita fitri r, yunita damopolii: a study on knowledge, attitude and practice in preventing transmission of scabies in pesantren darul fatwa, jatinangor althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 115 knowledge of housewives regarding non steroid anti inflammatory drug use on joint pain in hegarmanah village jatinangor adi mulyono gondopurwanto,1 kuswinarti,2 yusuf wibisono3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: joint pain is frequently found in daily life activities. the prevalence of joint pain increases within the age. one of the medicine used for joint pain is non-steroidal anti-inflammatory drug (nsaid). in connection with inappropriate usage and their side effects, this study aimed to seek the extent ofhousewives’ knowledge on the use of nsaid for joint pain in hegarmanah village, jatinangor subdistrict. methods: this cross-sectional descriptive study was conducted in october 2013 to the housewives resided in hegarmanah village, jatinangor subdistrict, west java. questionaire sheet was distributed to each of 110 housewives that had been stratifiedly with randomized sample. the questionaire contained identity, age, education level, and knowledge of nsaid in related to joint pain. results: based on the data collected, 73 subjects had adequate level of the knowledge and 37 subjects were in a poor level of the knowledge. the proportion of respondents who knew that joint pain was the pain occurs in the joint was 99.1%, the proportion of respondents who knew that the pain relieving drugs are called nsaid group was 40.9%, the proportion of respondents who knew that nsaid had a side-effect was 73.6%, and the proportion of respondents who knew that the side-effect of nsaid is abdominal pain was 61.8%. conclusions: most of the housewives in hegarmanah subdistrict have adequate knowledge in the use ofnsaid for joint pain relief. [amj.2016;3(1):115–9] keywords: housewife, joint pain, knowledge, nsaid correspondence: adi mulyono gondopurwanto, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285221517788 email: adithedidi@gmail.com introduction pain is a sensation of inconvenience and emotional experience with substantial or potential tissue damage or reflected by the damage.1 based on the localization, pain can be divided into head pain, joint pain, back pain, and neck pain.1 joint pain is a a type of pain with the highest prevalence as much as 28% and most frequently occurs in women.2 one of medicines that frequently used for treating joint pain is non-steroidal antiinflammatory drug (nsaid).3 ibuprofen is one of over-the-counter (otc) drug that is often use in worldwide.3 the nsaid are mostly used by women, both for one week and longterm use (more than 6 months).4 in indonesia, many nsaids have been distributed to the market with a variety of trademarks. in indonesia, nsaid which mostly used are ibuprofen, aspirin, diclofenac, mephenamic acid, naproxen, piroxicam, meloxicam, and celecoxib.1 long-term utilization of nsaid is very hazardous due to thevarious sideeffects of nsaid, especially to gastrointestinal system.5,6 therefore, people need to pay attention to the use of nsaid, including to not too often administering of nsaid in order to avoid the possibility of hazardous sideeffects. this study was conducted to seek the extent housewives’ knowledge on the use of nsaid for joint pain in hegarmanah village, jatinangor subdistrict. methods this cross-sectional descriptive study was conducted in october 2013 to the housewives resided in hegarmanah village, jatinangor subdistrict, west java. this study was approved althea medical journal. 2016;3(1) 116 amj march 2016 by health research ethics committee faculty of medicine uniuversitas padjadjaran. the sampling was taken by stratified random method on 110 subjects of the population meanwhile, the calculation sample size used was a descriptive categorical formula.7 one hundred and ten housewives were asked to fill in the validated questionaire sheet. there were 12 questionaires. the questionaire contained identity, age, education level, and knowledge of nsaid in related to joint pain. the knowledge levels are divided into adequate and poor based on the median of total score of knowledge by 10. the level is poor if the median of total scored true is less than 10. the level is adequate if the median of total scored true is more than 10. results from 110 respondents, most of respondents table 1 characteristic of the respondents respondents frequency (n=110) percentage the housewive’ age (years old) 20–29 17 15.5 30–39 35 31.8 40–49 29 26.4 50–59 19 17.3 ≥60 10 9.1 education level elementary school 30 27.3 junior high school 31 28.3 senior high school 42 38.3 bachelor/master 7 4.2 table 2 the total score of housewives’ knowledge on nsaid usage for joint pain. question true n(%) false n(%) joint pain is the pain on motion joint 109(99.1) 1(0.9) joint pain can affect the knee 106(96.4) 4(3.6) respondents knows the part of the body that frequently affected 100(90.9) 10(9.1) when suffering the joint pain, the respondents seeks for help from the health center. 97(88.2) 13(11.8) the joint pain medicine used torelief the pain in joint 109(99.1) 1(0.9) the respondents knows the examples of nsaid medicines 45(40.9) 65(59.1) the joint pain drugs must not be applied for long-term period (> 6 months) 59(53.6) 51(46.4) joint pain relief can be purchased in otc (without prescription) 83(75.5) 27(24.5) the joint pain drugs have side-effect 81(73.6) 29(26.3) one of the join pain drug side-effects is abdominal pain 68(61.8) 42(38.2) the people who suffers joint pain only gets one drug type 97(88.2) 13(11.8) joint pain relief can be bought at a dispensary (apotik) 108(98.2%) 2(1.8%) althea medical journal. 2016;3(1) 117adi mulyono gondopurwanto, kuswinarti, yusuf wibisono: knowledge of housewives regarding non steroid anti inflammatory drug use on joint pain in hegarmanah village jatinangor were 30–39 years old (31.8%), and the education level was senior high school (38.3%). almost all housewives in hegarmanah village knows the joint pain based on the definition (99.1%), part of body suffers joint pain (90.9%), visiting doctor when suffers joint pain (88.2%) and the indication of joint pain medicine (99.1%). the proportion of respondents who knew that the pain relieving drugs are called nsaid group was 40.9%, the proportion of respondents who knew that nsaid had a side-effect was 73.6%, and the proportion of respondents who knew that the side-effect of nsaid is abdominal pain was 61.8%. the nsaid which mostly used for joint pain was combination of ibuprofen and paracetamol (31.8%), while 34.5% used non-nsaid drugs. based on the data collected, 73 subjects had adequate level of the knowledge and 37 subjects were in a poor level of the knowledge. discussion almost all housewives in hegarmanah village knows the joint pain based on the definition (99.1%), part of body suffers joint pain (90.9%), visiting doctor when suffers joint pain (88.2%) and the indication of joint pain medicine (99.1%). the housewives still found difficulties in mentioning the name of joint pain medicines of nsaid group; only 45 (40.9%) subjects were able to mention nsaid joint pain names properly. the combination of ibuprofen and paracetamol were mostly mentioned by 31.5% of the housewives. the present study results are similar to that by wilcox et al.3 and lanas et al.6 it is suggested that ibuprofen is nsaid which frequently used. however, there are still greater number (69.1%) of subjects who did not recognize the names of nsaid joint pain relief. greater number of subjects who did not recognize the names of nsaid joint pain relief indicates a necessary education on nsaid medicine types for joint pain. the prevalence of joint pain increases within the age.1 age related to the disease affecting joint for example osteoarthritis which cause joint pain. this may cause an increasing in the use of nsaid on older housewives.1 about 59 housewives considered that nsaid medicines are not allowed to administer in long-term, for instance more than 6 months. using nsaid in long-term may rise harmful side-effects, such as gastric ulceration and hemorrage.3,8 the risk for a serious gastrointestinal complication isworse with the increasing of age on the subject.4,6 therefore, it is recommended to not usensaid for a long-term period. eighty-three housewives considered that joint pain medicines can be purchased without prescription. the joint pain medicines, table 3 the list of joint pain medicines used by housewives medicine (n=110) (%) nsaid ibuprofen and paracetamol 35 31.8 acetylsalicylic acid 2 1.8 piroxicam 5 4.5 ibuprofen 2 1.8 diclofenac 1 0.9 non-nsaid drugs 38 34.5 ignorance 27 24.5 table 4 housewives’ knowledge on nsaid usage for joint pain level of knowledge frequency (n) percentage (%) adequate 73 66.4 poor 37 33.6 total 110 100 althea medical journal. 2016;3(1) 118 amj march 2016 such as ibuprofen that is frequently used by housewives in hegarmanah village, is classified into otc drugs that are permitted to buy without a doctor prescription.3 almost all (73.6%) housewives know that nsaid joint pain medicines have sideeffects. one of the side-effects is gastric pain (61.8%). non steroid anti inflammation inhibits cyclooxygenase (cox)-1 and cox-2 in reducing prostaglandin level.9 inhibition in prostaglandin synthesis and direct cytotoxicity of nsaid provokes gastric acid secretion causing gastric irritation.10 chronic bleeding may result in anemia.11 this gastric irritation may cause bleeding, perforation, and pain of stomach,3,12,13 whereas the new, selective cox-2 has the lower probability to irritate the stomach.3 the risk of gastric irritation depending on the presence of three main risk factors. the three main risk factors are prior history of peptic ulcer, age and concomitant nsaid usage.14 this result is higher compared to the study by braund et al.15 describing that 70% of the subject were able to mention the nsaid side-effects. most housewives (88.2%) also know that the administering joint pain is one of the best type for relieving a joint pain. the combination of two types or more nsaid can enhance the occurrence of their side-effects in gastrointestinal tract. one hundred and eight housewives also prefer to choose buying the nsaid medicine at a dispensary. by purchasing the drugs in dispensary, the housewives expect the explanatory information about taking the medicine and to avoid the expiry date of the medicines. the whole results of this questionaire study indicates that most (66.4%) of the housewives have adequate knowledge. it is caused by high level of housewive education, such as, senior high school, an easy access to primary health care, and they also frequently got an education about health. in this study, there was a difficulty in communicative language. the language applied in the questionaire is indonesian, whereas the daily language of the related respondents is sundanese; therefore some respondents could not understand some of the sentences in the questionaire. as the consequence, it took a lot of time to explain the intention of the related questions for the respondents. in conclusion, the knowledge on nsaid use for joint pain of housewives in hegarmanah village, jatinangor subdistrict, mostly have adequate knowledge. though, most of the respondents have adequate knowledge, the knowledge of the nsaid names is still poor. for that reason, it is recommended to educate people about the use and the side effect of nsaid. this study is conducted descriptively, consequently there is no analysis of association is done between the knowledge and the education level. it is recommended to public health center of hegarmanah to apply a health education on drug utilization with a greater caution to the community. the related physicians, expectedly can carry out the education programme of nsaid, especially the types and their sideeffects as expectedby related communities. the researcher do not only explore the science but also behavior and attitude. references 1. purba js. patofisiologi dan penatalaksanaan nyeri. jakarta: balai penerbit fkui jakarta; 2011. 2. pfizer. the burden pain among adult in the united state. new york: pfizer medical division; 2008. 3. wilcox cm, cryer b, triadafilopoulos g. pattern of use and public perception of otc pain reliever: focus on nsaid.j rheumatol. 2005;32(11):2218–24. 4. motola d, vaccheri a, silvani mc, poluzzi e, bottoni a, de ponti f, et al. pattern of nsaid use in the italian general population : a questionnaire-based survey. eur j clin pharmacol . 2004; 60(10):731–8. 5. fosbol el, gislason gh, jacobsen s, abildstrom sz, hansen lm, schramm ken ss, et al. the pattern of use of nonsteroid anti drugs from 1997-2005: a nationwide study on 4.6 million people. pharmacoepidemiol drug saf. 2008; 17(8):822–33. 6. lanas a, ferrandez a. inappropiate prevention of nsaid-induced gastrointestinal event among long-term users in the elderly. drug aging. 2007; 24(2):121–31. 7. sopiyudin dm. besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan. jakarta: penerbit salemba medika; 2009. 8. cullen g, kelly e, murray fe. patients’ knowledge of adverse reactions to current medication. br j clin pharmacol. 2006; 62(2):232–6. 9. suleyman h, demircan b, karagoz y. anti inflammatory and side effect of cyclooxygenase inhibitors. pharmacol rep.2007;59:257–68 althea medical journal. 2016;3(1) 119 10. tomisato w, tsutsumi s, hoshino t, hwang hj, mio m, tsuchiya t, et al. role of direct cytotoxic effect of nsaid in the induction of gastric lesion. biochem pharmacol. 2004;67(3):575–85. 11. yilmaz h, gurel s, ozdemir o. turkish patients with osteoarthritis: their awareness of the side effects on nsaids. turk j gastroenterol. 2005;16(2):89–92. 12. graham dy, opekun ar, willingham ff, qureshi wa. visible small-intestinal mucosa injury in chronic nsaid users. clin gastroenterol hepatol. 2005; 3(1):55–9. 13. sostres c, gargallo cj, arroyo mt, lanas a. adverse effect of non-steroid antiinflammatory drugs (nsaids, aspirin and coxibs) on upper gastrointestinal tract. best prac res cl ga. 2010;24(2):121–32. 14. thiefin g, beaugerie l. toxic effect of nonsteroidal anti inflammatory drugs on the small bowel, colon and rectum. joint bone spine. 2005;72(4):286–94. 15. braund r, abbot jh. recommending nsaids and paracetamol: a survey of new zealand physiotherapists’ knowledge and behaviours. physiother res int. 2011; 16(1):43–9. adi mulyono gondopurwanto, kuswinarti, yusuf wibisono: knowledge of housewives regarding non steroid anti inflammatory drug use on joint pain in hegarmanah village jatinangor althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 217 methicillin-resistant staphylococcus aureus (mrsa) detection from the hands of jatinangor community health center’s health care providers jeevanisha patmanathan,1 sunarjati sudigdoadi,2 ricky adriansjah3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of urology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: methicillin-resistant staphylococcus aureus is a bacterium that is resistance towards β-lactam antibiotics, and it seems to be one of the leading causes of nosocomial infections. hands of the health care workers are said to be the main source for the nosocomial transmission. thus, the study aims to determine methicillin-resistant s. aureus from the hands of jatinangor community health center’s health care workers. methods: samples were taken from the hands of 30 jatinangor community health center’s staffs, including medical and paramedical; from october 2012 to november 2012. then, these samples underwent further laboratory examinations, starting from culture, identification and susceptibility test towards cefoxitin, in identifying methicillin-resistant s. aureus. results: out of the 30 samples taken, 6 samples (20%) were positive for s. aureus isolates. in which, 4 (13.33%) of the samples were positive for methicillin-resistant s. aureus. conclusions: since, health care workers are the main people in contact with patients and maintaining proper hand hygiene makes a huge difference; hand hygiene should be given adequate attention for the benefit of all. [amj.2015;2(1):217–20] keywords: hand hygiene, health care workers, methicillin-resistant staphylococcus aureus, nosocomial infection, staphylococcus aureus correspondence: jeevanisha patmanathan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: 08170206365 email: jeeva_nisha1111@yahoo.com introduction staphylococcus aureus (s. aureus) is one of the common strains of staphylococci. it can be found as a colony of the normal flora of the skin and the mucus of the nose. a person who is colonized by s. aureus can be asymptomatic, until it invades the body system and causes an infection. staphylococcal infection can cause minor problems such as skin disease to major problems such as pericarditis that can be deadly. however, these problems can be overcome easily by giving antibiotics.1 as years pass by, s. aureus has developed resistance towards antibiotics, starting from penicillin, then methicillin and more recently towards vancomycin. this feature of the bacteria makes it more difficult to be treated and hazardous to the ones whom are infected by it. methicillin resistant s. aureus (mrsa) is one of the strains, where it can be either a hospital acquired infection or a community acquired infection. hospital acquired infection is an infection acquired by the person due to or favored by the healthcare environment. thus, this infection concerns the most, referring to the fact that people who are admitted or coming to the hospital are already ill, which makes them more vulnerable to this sort of infections.2 according to cdc statistical data, the rate of mrsa infection has been decreasing for the past decade in general.3 however, according to who europehospital acquired infection: the european content, hospital acquired infection still covers 4 to 16% in these regions.4 in addition to that, according to a research conducted in indonesia itself, there is 22.9% of mrsa present among specimens obtained from the in-patients. proving that, it is still an issue that has to be taken into consideration.5 the mrsa can be easily transmitted from person to person either by direct contact with althea medical journal. 2015;2(2) 218 amj june, 2015 the person who is infected, a carrier or by touching contaminated things or substances. according to researches done, healthcare workers play a major role in the transmission of mrsa. as they are the people who are mainly in contact with the patients, in every possible step or procedure a patient undergoes in the healthcare settings. moreover, a healthcare worker has to handle their patients, somehow with hands. practically, every clinical procedure involves the usage of hand. thus, hand seems to be the main mode of transmission among the health care workers.4,6 in addition to the fact that hand is commonly colonized by the bacteria which are normal flora; one can contaminate his hand by touching a patient or things that are contaminated with bacteria and cause cross transmission as this could be dangerous.4,6 that is the reason why hand hygiene is a major protocol that should be followed in eradicating this problem; and studies prove that hand hygiene compliance have improved infection rates in hospitals; even though it differs from one health care setting to another and needs to be monitored closely. thus, this study is conducted to evaluate if mrsa can be found from the hands of healthcare workers of jatinangor community health center. methods an observational study using the descriptive statistical method was done at jatinangor community health center from octobernovember 2012. meanwhile, the lab examinations were carried out in microbiology laboratory of faculty of medicine, universitas padjadjaran (unpad). medical and paramedical of jatinangor community health center, were studying the population during the period of study. thirty samples of hand swabs were taken from them. the samples were selected using probability sampling method which was a simple randomization. the inclusion criteria for the samples were staffs of jatinangor community health center who were in contact or involved directly or indirectly with the patients. whereas, the exclusion criterion was staffs that already had an existing skin disorder or clinical conditions. the experiment contains 3 main steps; sample collection and isolation, s. aureus identification and susceptibility test towards cefoxitin. at first, hand swabs were taken by rolling the moisten cotton swab over the hand areas of the samples. the swabs were then transferred into the tube containing tryptic soy broth, which was the transport media; to be transported to the laboratory. the subjects were then asked to answer and performed 2 questions related to hand hygiene, that were in the inform consent form.7 next, the swab was cultured onto a mannitol salt agar plate using an inoculating loop and left to incubate overnight at a temperature of 37°c. staphylococcus aureus formed a yellowish colony.7then, bacterial smear was performed from the culture plate and gram staining procedure was carried out on it. the interpretation of the result was considered to be gram positive if it turned into purple colour; or gram negative if it turned into pink colour. gram positive cocci indicated s. aureus, which can be seen as clusters under the microscope.7 afterwards, bacterial smear was performed from the culture plate and catalase test was carried out on it. where, an inoculating loop was used to take a small amount of colony from the agar plate and mixed gently with the 3% hydrogen peroxide solution on the glass slide. the slide surface was then closely observed for any immediate formation of gas bubbles. immediate gas bubble formation indicated a catalase positive result. if there were no gas bubbles or few scattered bubbles released then it was considered as a catalase negative result. staphylococcus aureus gave a catalase positive result.8,9 the procedure was then continued with coagulase slide and tube test. where, for the coagulase slide test, bacterial smear was performed first. then, an inoculating loop was used to take a small amount of colony from the agar plate and mixed gently with the human plasma on the glass slide, if clump formed after 5-10 seconds, then it was considered coagulase positive result. if there was no clump formation then, it was considered coagulase negative result. for a slide negative result, we had to proceed by performing a coagulase tube test.8,9 for the coagulase tube test; using an inoculating loop, a small amount of colony was taken from the culture sample and transferred into a test tube containing 0.5 ml of human plasma; and mixed together. the test tube was then incubated at 37°c for about 4 hours. it was checked if the content had coagulated or solidified, every 1 hour to 4 hours. it indicated a coagulase positive result, if the content had solidified and it was a coagulase negative result, if the content did not solidify. althea medical journal. 2015;2(2) 219jeevanisha patmanathan, sunarjati sudigdoadi, ricky adriansjah: methicillin-resistant staphylococcus aureus (mrsa) detection from the hands of jatinangor community health center’s health care providers finally, susceptibility test against cefoxitin was performed. the swab was streaked onto the mueller-hinton agar; covering all area including edges of agar plate and left to dry. one cefoxitin disc was placed at the center of the inoculated surface by using a forceps. the cefoxitin disc was then pressed against the plate gently, using a needle. the agar plate was then placed in an incubator at 37°c for 24 hours. after 24 hours, the diameter of the zone was measured from the bottom of the plate by using a ruler in millimeter and the result was interpreted according to clinical and laboratory standard institute (clsi) zone diameter interpretive standards for staphylococcus sp. where, when we used a 30 µg cefoxitin; if its diameter was ≥ 22 mm it was susceptible and if its ≤ 21mm it was resistance.10, 11 results histopathological appearance of liver biopsy cthe research was conducted by obtaining 30 samples randomly at the times of visit, which was usually at the peak hours of work (9am12pm). the hands were swabbed and the samples were then taken to the microbiology laboratory of faculty of medicine of unpad jatinangor for further microbiological examination to identify the presence of mrsa in addition, out of the 30 samples that were asked on their awareness on existence of proper hand-washing technique, 28 of them (93.33%) acknowledged that they knew about it. however, out of these 30 samples, only 12 of them (40%) managed to perform the handwashing steps in an acceptable manner. discussion based on table 1, about 20% of the samples obtained are positive for s. aureus; which is not considered abnormal because s.aureus is usually found on the normal skin flora of humans. in addition, it does not cause any harm to the carrier until it manages to get into the body system via an open wound or cut, where it starts to be infectious. however, around 13.33% of the samples obtained are positive for mrsa. mrsa is a strain of s. aureus that is resistance towards β-lactam antibiotics. in fact, it has the tendency to develop resistance towards other type of antibiotics. one of the main reasons for the development of this resistance is the excessive usage of antibiotics which occurs very much in a health care settings nowadays. as a consequence, mrsa is more difficult to be treated. the mrsa which was found among the hands of the health care workers; may be due to the pattern of transmission. as it can be transmitted from a colonized person to a noncolonized person or contaminates the things in the surroundings which could come into contact with a person somehow and cause colonization. being colonized by mrsa is not dangerous until it manages to get into our body system and cause an infection. mrsa infection could be deadly at times as statistics shows that thousands have died of it yearly. that is why mrsa colonization has to be taken into high consideration, even before it becomes infectious. based on a previous study, 7.1% of the health-care workers were positive mrsa on their hand swabs. this proves that hand is one of the vehicles for mrsa transmission.12 one of the easiest steps to control the transmission of mrsa is by hand-washing, and when the samples were asked on their awareness of proper hand-washing technique 93.33% of them claimed to know it. however, when they were asked to perform the steps that they claim to know, only 40% of them managed to perform in an acceptable manner while other claimed to have forgotten them. this showed the lack of awareness on the importance of hand cleanliness. that is why hand-washing has received a great attention among many recently. there are many hand-washing campaigns that are being launched nowadays. for instance, the one launched october 2011 in jakarta by the ministry of health of indonesia entitled table 1 percentage of methicillin-resistant staphylococcus aureus (mrsa) from isolates of the hand swabs bacteria number of samples percentage % s.aureus (+) 6 (30) 20.00 mrsa (+) 4 (30) 13.33 mrsa (+) from s.aureus (+) 4 (6) 66.67 althea medical journal. 2015;2(2) 220 amj june, 2015 ‘indonesia welcomes sanitation month’ and a yearly celebration of ‘hand washing with soap day’ that holds on every 15 october in indonesia. everyone should take this opportunity and participate in it.13 thereby, more attention should be paid by every health care centers on their hand-washing protocols; as it is the key to infection-control. over the last decade improved hygiene has caused a drop in the mrsa cases globally. in fact, in a 9 year study conducted by virgina commonwealth university, revealed that hand-washing in conjugation with other simple hygiene measures, reduces the risk of mrsa infection by 95% in icu. this just proves the importance of hand-washing compliance.14 based on this study the researcher can conclude that there is a presence of mrsa among the health care workers of jatinangor community health center. however, further research should be done to find out the real cause behind the contamination and methods to improve them. references 1. harvey ra, champe pc, fisher bd. microbiology. philadelphia: lippincott williams & wilkins; 2006. p. 69−77. 2. ji y. methicillin-resistant staphylococcus aureus (mrsa) protocols. totowa, new jersey: humana press; 2007. p. 1−20. 3. behen m. hospital-acquired mrsa infections on the decline, cdc says. new jersey: bloomberg businessweek; 2010 [downloaded in 4 may 2012]. available at: http://www.businessweek.com/lifestyle/ content/healthday/642013.html. 4. who. who guidelines on hand hygiene in health care. georgia: who; 2009 [downloaded in 7 may 2012]; available at: http://www.safecarecampaign.org/handhygiene_files/whohandhygieneguide. pdf. 5. parwati i, turbawaty dk, editor. peta bakteri dan kepekaannya terhadap berbagai antibiotika di rumah sakit umum pusat dr.hasan sadikin bandung semester ii tahun 2010. 1st ed. bandung: patologi klinik rumah sakit umum pusat dr.hasan sadikin; 2011. p. 27. 6. cdc. guideline for hand hygiene in health care settings. atlanta: cdc; 2002; 51 [downloaded in 29 april 2012]. available at: http://www.cdc.gov/mmwr/pdf/rr/ rr5116.pdf. 7. isenberg hd. essential procedures for clinical microbiology. washington, dc: asm press; 1998. p. 1−36. 8. swamy ppm. laboratory manual on biotechnology. new delhi: rastogi publications; 2008. p. 256. 9. estridge bh, reynolds ap. basic clinical laboratory techniques. new york: cengage learning; 2011. p. 761−74. 10. vandepitte j, engbaek k, piot p, heuck cc. basic laboratory procedure in clinical bacteriology. geneva: who; 2003 [downloaded in 2 may 2012]; 2nd:[available at: http://whqlibdoc.who. int/publications/2003/9241545453.pdf. 11. clsi. performance standards for antimicrobial susceptibility testing; twentieth informational supplement. wayne, pa: clinical and laboratory standards institute; 2010. p. 70. 12. rosyati dof. pemeriksaan staphylococcus aureus resisten metisilin (mrsa) pada perawat bagian rsup dr hasan sadikin bandung [thesis]. bandung: universitas padjadjaran; 1998. 13. faizal eb. government launches hand washing campaign. jakarta: the jakarta post; 2011 [downloaded in 25 november 2012]. available at: http://www. thejakartapost.com/news/2011/10/10/ govt-launches-hand-washing-campaign. html 14. labs pm. handwashing may be the most effective way to reduce mrsa infections. dickson: private md labs; 2012 [downloaded in 20 november 2012]. available at: http://www.privatemdlabs. c o m / b l o o d te s t i n g n e ws / i n fe c t i o u s _ disea ses/ ha nd-wa shing-may-b e-t hem o s t e f fe c t ive wayto re d u c e m rsainfections$800892993.php. althea medical journal. 2015;2(3) 359 antidiabetic activity of calcium bentonite in alloxan monohydrateinduced diabetic wistar rat models galuh alviana,1 hendro sudjono yuwono,2 nova sylviana3 1faculty of medicine universitas padjadjaran, 2department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of physiology, faculty of medicine universitas padjadjaran abstract background: calcium bentonite is a natural clay that has the ability to absorb toxins and metabolite excess substances and often referred to as healing clay because it is used traditionally. this study aimed to determine the ability of local calcium bentonite to absorp high blood glucose.. methods: this study was an experimental study using 20 female wistar rats and divided into two groups consisting of group i (control group, n=10) and group ii (calcium bentonite group, n=10). diabetes in rats was induced by alloxan monohydrate 150 mg/kg body weight intraperitoneally. examination of blood glucose was performed three times; in the beginning of study, 72 hours after alloxan monohydrate induction, and four days after the given interventions. blood glucose levels in mean values were analyzed using t-independent test. statistically significance was considered when p<0.05. results: oral calcium bentonite of 1g/kg body weight significantly lowered blood glucose level relatively to the control group with average value of 131.30 mg/dl (p=0.01). conclusions: calcium bentonite significantly lowers blood glucose levels. [amj.2015;2(3):359–62] keywords: calcium bentonite, diabetes mellitus, hyperglycemia, traditional medicine, wistar rats correspondence: galuh alviana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81 221 563 89 email: galuh.alviana@gmail.com introduction calcium bentonite (ca-bentonite) is a type of natural clay which has the ability to absorb water and toxic substances and referred to as one of healing clays.1 in indonesia, cabentonite is traditionally used as a detoxifying agent in the gut, traumatic wounds, and skin disorders.1,2 previous study showed that the cabentonite has the ability to absorb blood ureum and creatinine in rats with acute renal failure and reduce high blood cholesterol level on rat.3–6 this study aimed to determine the ability of local ca-bentonite to absorp high blood glucose. methods a total of 20 adult female wistar rats weighing 150–250g obtained from pusat penelitian antar universitas (ppau), institute of technology bandung, were used in this study. the rats were housed at the animal laboratory of the department of pharmacology, faculty of medicine, univeristas padjadjaran, bandung, under standard condition of food and drinking water. the study protocols and animal care procedure were approved by the health research ethic committee of faculty of medicine universitas padjadjaran. ca-bentonite was obtained from chemistry laboratory faculty of mathematics and sciences education, universitas pendidikan indonesia. rats were given 1 g/kg body weight of ca-bentonite, the same dosage which can reduce excessive blood ureum and creatininein rats with acute renal failure from previous studiy.3 ca-bentonite weighs 0.25 gram was diluted with aquadest as much as 5 ml and ready to be given orally once daily for 3 days, starting 72 hrs after alloxan induction. alloxan monohydrate from sigma, singapore, is used as much as 150 mg/kg body weight dissolved in 10 cc aquadest to be injected althea medical journal. 2015;2(3) 360 amj september, 2015 intraperitoneally.7–9 the experimental animals were randomly allocated into 2 groups, group i was given aquadest as control group and group ii was given ca-bentonite as intervention, referred to as ca-bentonite group. before measuring the blood glucose, the rats were fasting for 18 hours. venous blood was taken from cutting of the tail end and the blood was dropped into the glucosemeter.7–9 the results will appear in 10 seconds. blood glucose measurement was performed three times in each groups: at the time after acclimatization as the initial blood glucose levels in normal rats (day 0), 72 hours after alloxan monohydrate induction (day 3), and four days after the interventions was given (day 7).7,9 blood glucose levels were analyzed using t-independent test. statistically significance was considered when p<0.05. results the anti-diabetic effect of oral administration of aquadest and ca-bentonite on rats glucose level were shown in table 1. this study revealed that 72 hours after induction of alloxan monohydrate produced a hyperglycemia state (day 3), and 3 day oralca-bentonite 1g/kg treatment resulted in a significant decrease of blood glucose level in the model of alloxantable 1 measurement of blood glucose levels group intervention measurement** blood glucose level (mg/dl)# i* aquadest 5 ml day 0 100.60 ± 3.406 day 3 291.70 ± 62.029 day 7 291.20 ± 155.108## ii* calcium bentonite 1g/kg bw day 0 103.60 ± 8.303 day 3 434.40 ± 113.416 day 7 131.30 ± 46.166## note: * n = 10 ** measurement: day 0 as initial blood glucose level day 3 as blood glucose level after induction of alloxan monohydrate day 7 as blood glucose level after intervention was given # all values are expressed as mean ± sd ## p = 0.01 and was considered statistically significant as compared to after treatment of their respective group figure 1 blood glucose levels after treatment on day 7 (mean ± sd) in alloxan monohydrate induced diabetic wistar rat treated with 1g/kg ca-bentonite (n=10) vs. aquadest as control (n=10). althea medical journal. 2015;2(3) 361 induced diabetes in rats (day 7). aquadest group that acts as a control group also showed a significant decrease in the blood glucose level. table 1 shows that blood glucose levels in all groups were increased after induction of alloxan monohydrate (day 3), then started to fall after the treatment was given (day 7). box-plots of mean blood glucose levels 4 days after treatment (day 7) can be seen on figure 1. from figure 1, the group given ca-bentonite had the smallest mean of blood glucose level. data was compared to the control group and analyzed using t-independent test which showed that the data was statistically significance (p=0.01) with mean of blood glucose level in ca-bentonite group was 131.30 mg/dl. this study has proved the effect of alloxan monohydrate to optimally induced diabetes mellitus three days after induction, after which the hyperglycemia state decreased after 3 days of treatment in both control and treatment groups. discussions management of diabetes with agents without any side effects is still a challenge. this concern has led to an increase and demand for natural products with anti-hyperglycemic activity. alloxan monohydrate as the diabetesinducing agent was known to produce diabetes mellitus irreversibly with a single dose administration through its ability to destroy the beta cells of the pancreas leading to insulin deficiency. several in vitro studies have shown that alloxan monohydrate is selectively toxic to pancreatic beta cells mediated by reactive oxygen species, leading to the induction of cell necrosis.8 this experimental study revealed that the local ca-bentonite orally administrated for three days produced a significant decrease in the blood glucose level in the model of alloxan monohydrate-induced diabetes in rats. cabentonite is known as a good absorbent and adsorbent, and has been proven in vitro.10–11 the in vivo mechanism of blood glucose reduction after administration of ca-bentonite is based on its good absorption and adsorption capacity. in intestinal lumen, ca-bentonite will absorb the glucose without getting into the bloodstream. this mechanism is similar to ca-bentonite in reducing blood ureum and creatinine in acute renal failure occurred in wistar rats, and high cholesterol level of highly fat diet wistar rats from previous studies.3–6,12 further studies should be performed to confirm that ca-bentonite could become useful in the treatment of diabetes mellitus through its unique therapeutic mechanism without any side effects. in conclusion, ca-bentonite significantly lowers blood glucose levels. references 1. eaton jr. healing clays of the world bentonite as used in pelotherapy, natural and alternative medicine. las vegas: avra; 2004 [cited 2012 may 13]; available from: http://www.eytonsearth.org/ introduction-clays.php. 2. eaton jr. green healing clay of the desert bentonite, illite, and montmorillonite: pelotherapy and natural medicine. las vegas: avra; 2004 [cited 2012 may 13]; available from: http://www.eytonsearth. org/. 3. cao yx, long lh, ma z, tao xj, liu j, zhou l. effect of montmorillonite on diffussion of urea between blood and intestine and on absorption of intestine in rats. zhong yao cai. 2009;32(2):249–53. 4. gershkovich p, darlington j, sivak o, constantinides pp, wasan km. inhibition of intestinal absorption of cholesterol by surface-modified nanostructured aluminosilicate compounds. j pharm sci. 2009;98(7):2390–400. 5. sivak o, darlington j, gershkovich p, constantinides pp, wasan km. protonated nanostructured aluminosilicate (nsas) reduces plasma cholesterol concentrations and atherosclerotic lesions in apolipoprotein e deficient mice fed a high cholesterol and high fat diet. lipids health dis. 2009;8(1):30. 6. gershkovich p, sivak o, contreras-whitney s, darlington jw, wasan km. assessment of cholesterol absorption inhibitors nanostructured aluminosilicate and cholestyramine using in vitro lipolysis model. j pharm sci.2012;101(1):291–300. 7. sunarsih es, djatmika, nilawati s. pengaruh infusa daun murbei (morus alba l.) terhadap penurunan kadar glukosa darah tikus putih jantan diabetes karena pemberian aloksan. trad med j. 2007;12(40):1–6 8. lenzen s. the mechanisms of alloxanand streptozotocin-induced diabetes. diabetologia. 2008;51(2):216–26. 9. sunarsih es, djatmika, utomo rs. pengaruh pemberian infusa umbi gadung (dioscorea hispida dennst) terhadap penurunan kadar glukosa darah tikus putih jantan galuh alviana, hendro sudjono yuwono, nova sylviana: antidiabetic activity of calcium bentonite in alloxan monohydrate-induced diabetic wistar rat models althea medical journal. 2015;2(3) 362 amj september, 2015 diabetes yang diinduksi aloksan. majalah farmasi indonesia. 2007;18(1):29–33. 10. irineo torres-pacheco, editor. comparative evaluation of different techniques for aflatoxindetoxification in poultry feed and its effect on broiler performance. pakistan:intech; 2011. 11. lynch dl, wright lm, cotnoir lj. the adsorption of carbohydrates and related compounds on clay minerals. soil sci soc am j. 1956;20(1):6–9. 12. kamalakkannan n, prince ps. antihyperglycaemic and antioxidant effect of rutin, a polyphenolic flavonoid, in streptozotocin-induced diabetic wistar rats. basic clin pharmacol toxicol. 2006;98(1):97–103. vol 5 no 4 full text fix.indd althea medical journal. 2018;5(4) 192 amj december 2018 inhibitory effect of neem leaves on glucose transport lia safitrie johansyah,1 vycke yunivita,2 anna martiana,2 augusta y. l. arifin3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: lia safitrie johansyah, faculty of medicine, universitas padjadjaran, jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia, email: safitrie.lia@gmail.com introduction diabetes mellitus is a disease with high morbidity and mortality rates in the world, not only in developed countries but also in developing countries, including indonesia.1,2 diabetes mellitus is a metabolic disease in which the patients have impaired insulin secretion, insulin action, or both that cause hyperglycemia and result in organ damage and organ failure.3 the goal of therapy in this disease is to restore blood glucose level to normal, as in a medical practice, there are four types of therapy given to patients with diabetes mellitus, lifestyle education, eating habits, physical exercise, and pharmacology.3,4 herbal treatment is one of the traditional medicines that uses different parts of the plant from the roots, stems and leaves.5 neem is one of diabetic herbal medicines and is popularly used, especially in india. many studies have been conducted to prove antihyperglycemic effect of neem, especially of the leaves.6-11 however, the mechanism of neem leaves in lowering blood glucose level is still unknown.10 quercetin is a flavonoid compound. according to research conducted by cermak et al.12, quercetin isolates were proven to inhibit sglt1 (sodium-dependent glucose transporter 1) in the small intestine. quercetin is found in many plants including in neem leaves, so it is possible that the antihyperglycemic effect of neem leaves is through the inhibition of glucose transporter.13 the study was conducted to verify the inhibitory effect of neem leaves infusion on glucose transporter and whether the effect was reversible or irreversible. methods this was an exploratory study, using five male wistar rats aged 3–4 months, weighing 150– 250 grams.14 the study was approved by the health research ethics committee of faculty of medicine universitas padjadjaran and was conducted in biochemistry laboratory of faculty of medicine universitas padjadjaran started in october to november 2012. amj. 2018;5(4):192–5 abstract background: neem leaf is known as a diabetic herbal treatment in india, however, its antihyperglycemic effect and the mechanism is still unknown. quercetin is proven to inhibit glucose transporter in the small intestine, and this active substance is present in neem leaves. the study was conducted to explore the inhibitory effect of neem leaves infusion on glucose transport and whether the effect was reversible or irreversible. methods: this study was conducted in the biochemistry laboratory faculty of medicine universitas padjadjaran in the period of october to november 2012 by using in situ perfusion method. five male wistar rats were given three treatments; glucose as initial control, glucose with neem infusion, and glucose again as last control. the samples of perfusion solution were taken for every treatment and were measured using spectrophotometry method. results: there was a reduction in glucose absorption (15.9%) between the first (47.28+17.57 mg/dl) and the second treatment (39.75+14.85 mg/dl). the transported glucose level in the third treatment was further reduced after the first treatment (37.15+13.15 mg/dl). conclusions: neem leaves infusion has inhibitory effect on glucose transport that irreversibly reduced further. further study is needed with a larger sample size to confirm this phenomenon. keywords: antihyperglycemic, glucose transporte, neem leaves althea medical journal. 2018;5(4) 193 this study used an in situ perfusion method. the tools were from the department of physics, institut teknologi bandung and it was designed by p. soedigdo and marsongkohadi. this tools flowed perfusion solution 6 times per minute and made the rat small intestine to function normally for 6–8 hours.14 neem leaves infusion was made by mixing 200 g neem leaves (azadirachta indica a. juss l) with 200 ml of aquadest and heated at 900c for 15 minutes. all rats were adapted for 7 days with food and drink and prior to the research, the rat was fasted for 18–24 hours. the rat was anesthetized with ketamine and rat limbs were fixed on board as a preparation at the laboratory of the department of biochemistry faculty of medicine, universitas padjadjaran. rat abdominal was cleaned with alcohol and dissected until the small intestine became visible. rat small intestine was mounted with two cannulas, the first cannula was placed 10 cm from the pylorus to the distal and the second was placed 25 cm from the first to the proximal. the small intestine was cleaned with a solution of nacl and blown three times. then cannulas were connected to the vessels of perfusion tools through rubber tubes. vessels were filled with a solution of the experiment and the sample was taken every 15 minutes.14 this study was an explorative study of the effect of infusion of neem leaves, no sample size calculation was performed. it used five male wistar rats and each rat was given three treatments. in the first treatment, rat small intestine was flowed with glucose, whereas in the second one, rat small intestine was given glucose with neem leaves infusion. the last treatment was similar to the first one. in every treatment, rat small intestine was always cleaned with a solution of nacl and blown three times.14 the samples of perfusion solution in every treatment were given peridochrom glucose/ god-pap reagent kit. then the samples were read using spectrophotometry with a wavelength of 505 nm.14,15 the glucose level of the samples was calculated using the formula.15 the glucose levels were shown into tables. one sample t-test was conducted to analyze the data. all of the data were processed by spss (statistics package for social science) version 15.16 results data analysis between the first and the second treatment aimed to determine the effect of neem leaves infusion on glucose transporter. data analysis between the first and the third treatment aimed to determine the nature of the barriers of neem leaves infusion. the transported glucose level in all treatments was presented in table 1. there was a reduction in glucose absorption (15.9%) between the first (47.28+17.57 mg/ dl) and the second treatment (39.75+14.85 mg/dl). the transported glucose level in the third treatment was further reduced after the first treatment (37.15+13.15 mg/dl) (table 1). the comparison of glucose level between first and second treatment was presented in figure 1. the comparison of glucose level between first and third treatment was presented in figure 2. from table 1 and figure 2 it was found the difference in transported glucose level between the first and the third treatment, in which transported glucose level in the third treatment was lower than the first one. table 1 transported glucose level in first, second and third treatment rats no. glucose level pretreatment glucose level with neem leaves infusion glucose level after treatment (mg/dl) (mg/dl) (mg/dl) 1 78.21 66.27 58.51 2 37.26 33.03 34.80 3 44.33 34.38 37.94 4 40.34 32.48 31.32 5 36.25 32.58 23.17 mean + sd. 47.28+17,57 39.75+14,85 37.15+13,15 note: sd=standard deviation lia safitrie johansyah, vycke yunivita, anna martiana, augusta y. l. arifin: inhibitory effect of neem leaves on glucose transport althea medical journal. 2018;5(4) 194 amj december 2018 discussion hypothesis testing in this study with a 95% confidence interval concluded that neem leaves infusion had an effect on glucose level. in this study, the result of statistical analysis was significant (p<0.05) between the first and the second treatment. from figure 1, it was found the difference in transported glucose level between the first and the second treatment in which the graph showed a reduction in glucose absorption while using neem leaves infusion. fromttable 1, it was calculated the percentage of inhibited glucose level by 15.9%. this result was similar with an earlier study by cermak et al.12, that suggested an interaction figure 1 mean of total blood cholesterol level figure 2 comparison of transported glucose level in first and third treatment althea medical journal. 2018;5(4) 195 of quercetin with sglt1. quercetin was one of the active substance in neem leaves and it acts as a competitive inhibitor of sglt1 that reduced glucose absorption and generated antihyperglycemic effect.12,13 the inhibitory effect of neem leaves infusion was irreversible. the result of statistical analysis in this study was significant (p<0.05) between the first and the third treatment. from table 1 and figure 2 it was found the difference in transported glucose level between the first and the third treatment, in which transported glucose level in the third treatment was lower than the first one. it indicated that after administration of neem leaves infusion, levels of glucose absorption did not return to normal in the first one hour of the treatment. in conclusion, neem leaves infusion has an inhibitory effect on glucose transporter irreversibly for one hour after the treatment. the results of this study can be socialized to the public, especially people who use herbal treatment of diabetes. study with larger sample size or other study related to dose and toxicity of neem leaves infusion need to be conducted to examine further the role of the leaves in diabetes treatment. references 1. who. 10 facts about diabetes. geneva; 2012 [downloaded in 15 april 2012]; available at: http://www.who.int/ features/factfiles/diabetes/facts/en/ index.html. 2. kementerian kesehatan republik indonesia. tahun 2030 prevalensi diabetes melitus di indonesia mencapai 21,3 juta orang. jakarta; 2009 [downloaded in 9 april 2012]; available at: http://www. depkes.go.id/index.php/berita/pressre l e a s e / 4 1 4 t a h u n 2 0 3 0 p reva l e n s i diabetes-melitus-di-indonesia-mencapai213-juta-orang.html. 3. who. about diabetes. geneva; 2012 [downloaded in 9 april 2012]; available at: http://www.who.int/diabetes/action_ online/basics/en/index.html. 4. perkumpulan endokrinologi indonesia. konsensus pengelolaan dan pencegahan diabetes mellitus tipe 2 di indonesia. jakarta: pb perkeni; 2006. 5. who. trips, cbd and traditional medicines: concepts and questions. geneva; 2012 [downloaded in 16 april 2012]; available at: http://apps.who.int/ medicinedocs/en/d/jh2996e/#jh2996e. 6. akinola ob, dosumu oo, akinola os, zatta l, dini l, caxton-martins ea. azadirachta indica leaf extract ameliorates hyperglycemia and hepatic glycogenosis in streptozotocin-induced diabetic wistar rats. ijop. 2010;2:320–31. 7. mostofa m, choudhury me, hossain ma, islam mz, islam ms, sumon mh. antidiabetic effects of catharanthus roseus, azadirachta indica, allium sativum and glimepride in experimentally diabetic induced rat. bangl j vet med. 2007;5(1 & 2):99–102. 8. dutta m, raychaudhuri u, chakroborty r, maji d. role of diet and plants on diabetic patients a critical appraisal. science and culture. 2011;77:115–22. 9. ayodhya s, kusum s, anjali s. hypoglycaemic activity of different extracts of various herbal plants. ijrap. 2010;1(1):212–24. 10. maithani a, parcha v, pant g, dhulia i, kumar d. studies on phytochemical investigation and hypoglycemic evaluation of azadirachta indica leaves extract on alloxan induced diabetic rats. jpr. 2011;4(3):759–60. 11. das ar, mostofa m, hoque me, das s, sarkar ak. comparative efficacy of neem (azadirachta indica) and metformin hydrochloride (comet®) in streptozotocin induced diabetes melitus in rats. bangl j vet med. 2010;8(1):75–80. 12. cermak r, landgraf s, wolffram s. quercetin glucosides inhibit glucose uptake into brush-border membrane vesicles of porcine jejunum. br j nutr. 2004;91:849–55. 13. shah w, rane n, kekare m.b, vaidya v. estimation of two bioactive compounds from azadirachta indica a.juss. leaves using hplc. ijpbs. 2010;1(2):1–7. 14. rohmawaty e, yunivita v, potensi quercetin-3o-glucoside (q3g) dan quercetin-4-o-glucoside (q4g) dari daun mimba (azadirachta indica a.juss) terhadap ambilan glukosa. mkb. 2016:48(4):222-7. 15. fortress diagnostic. glucose godpap. london; 2012 [downloaded in 12 december 2012]; available at: http:// www.fortressdiagnostics.com/online/. 16. dahlan ms. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. lia safitrie johansyah, vycke yunivita, anna martiana, augusta y. l. arifin: inhibitory effect of neem leaves on glucose transport althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 575 correlation between body mass index and body fat percentage muhammad ilman,1 yenni zuhairini,2 amillia siddiq3 1faculty of medicine universitas padjadjaran, 2department of medical nutrition faculty of medicine universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: body mass index (bmi) has been used to determine the nutritional status which is classified into low, normal, overweight or obese. the bmi only shows a comparison of height and weight instead of body composition which consists of fat mass and fat–free mass. most of people assumed that bmi overage means fat mass overage as well, yet it does not occur in all cases. this study was conducted to measure the correlation between bmi and body fat percentage. methods: an analytical study was conducted to 100 male and female students respectively from universitas padjadjaran jatinangor batch 2009 to 2013. the body weight was measured using scales , whereas the body height was measured using stature meter. the body fat percentage was measured using bioelectrical impedance analysis (bia). the bmi was calculated by dividing the body weight in kilogram divided by body height in meter square. data was collected from september to october 2013 and analyzed by pearson’s correlation test. results: the mean of bmi in male students and female students were 22.56 and 21.35 respectively. the body fat percentage was 16.44 for men and 28.09 for women. correlation score between bmi and fat mass in male students were 0.853 and female students are 0.834. conclusions: there is a strong and positive correlation between bmi and body fat percentage both in male and female students in universitas padjadjaran jatinangor. among this population, bmi can still be used to determine body fat percentage. [amj.2015;2(4):575–8] keywords: bioelectrical impedance analysis, body fat percentage, body mass index . correspondence: muhammad ilman, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85716630848 email: 071091milman@gmail.com introduction human body consists of fat mass and fat free mass. the fat free mass consists of total body protein stored in the muscle mass, total body water, and total bone mineral. level of fat mass varies between 13–21% in male and 23–31% in female.1-3 recently, the common method used to categorize overweight or obesity is body mass index (bmi), which is calculated by using a formula that consists of body weight in kilogram divided by body height in meter square.1 however, someone who uses bmi cannot determine his body composition of fat and muscle precisely.2,4,5 most of people assumed that a higher bmi means a higher composition of body fat mass as well, yet it does not occur in all cases. people who have active physical activity relatively possess less fat percentage than who do not do it.7,8 for example, an athlete will have solid bone and well-developed muscle resulting an over body weight based on standard of body weight, but have less body fat mass.1,2,3,7,8 therefore, it can be concluded that a higher bmi does not represent a higher body fat percentage. this study was developed to identify whether there was correlation between bmi and body fat percentage methods population and subjects of this study were students of universitas padjadjaran jatinangor, selected using stratified random sampling method. criteria of inclusion in the study were academically active students batch 2009 until 2013 and age of respondents from 18 to 22 years old. pregnant, in lactation, menstruated female students, athlete students, foreign students, students who were in strict diet, and did hard exercise before the measurement althea medical journal. 2015;2(4) 576 amj december, 2015 were excluded from the study. one hundred male and female respectively gathered from 14 faculties in universitas padjadjaran jatinangor. this study was carried out from september to october 2013 in universitas padjadjaran jatinangor. this study was approved by health research ethics commitee faculty of medicine universitas padjadjaran. body height measurement in this study used stature meter tool, while body weight measurement and body composition determination used bioelectrical impedance analysis (bia). the bia is known as rapid, non-invasive and relatively precise tool to measure body composition. 4-6,12 respondents who were eligible in the study were asked to fill informed consent form before the measurements were done. the measurements were bmi (score of body weight divided by body height in meter square), and the percentage of body fat. the measurement used bia was established by inserting age, gender, and body height of respondent into the bia tools, then respondent stood on the bia to generate result of the measurement that would be showed in the tool screen. after data were collected, statistical data analysis was established. normality of data was tested using logistic kolmogorov-smirnov method before being analyzed the correlation. data was separated based on gender and showed in numerical data for bmi and body fat percentage. the statistic result showed that data obtained from both male and female samples for bmi and body fat percentage were not normally distributed. moreover, data transformation was performed using logistic test and resulted normally distributed data. then, data were analyzed used pearson’s correlation test to define significant correlation between bmi and body fat percentage. results the average bmi in male was greater than average bmi in women,while the average body fat percentage was higher in women than men. most research subjects were aged 19 years old in men and women, while respondents aged 22 years were the least. table 1 characteristic of the respondents characteristic male (n=100) female (n=100) age (years) 18 13 20 19 32 28 20 25 27 21 20 20 22 10 5 bmi mean 22.56 21.35 sd 0.40422 0.31629 body fat percentage: mean 16.44 28.09 sd 0.62923 0.55762 note: bmi=body mass index, sd=standard deviation table 2 pearson’s rho test result for correlation between bmi and body fat percentage pearson’s rho test male female correlation coefficient 0.853 0.834 sig. (2-tailed) (p) 0.000 0.000 n 100 100 note: p<0.05=data was significant, p>0.05=data was not significant althea medical journal. 2015;2(4) 577muhammad ilman, yenni zuhairini, amillia siddiq: correlation between body mass index and body fat percentage result from the correlation of the study had a significant score with p score = 0.000 either in male respondent or female respondent. from the pearson test table above, pearson’s correlation value was 0.853 for male students and 0.834 for female students. this result indicated that positive correlation with high power of correlation because the score was range between 0.80–1.00. result of this study stated that the correlation between bmi and body fat percentage was positive, the higher bmi, the higher body fat percentage. discussion this study discovered that the mean of bmi and body fat percentage in male was higher than in female.the study conducted by by flegal et al.13 among u.s public research subjects showed a similar results. the average bmi in male was of 27.9 kg/m2 while in women was of 28.2 kg/m2 .subsequently, the percentageof body fat average was 28.1% in men and 39.9% in women. daud et al.7 in malaysia conducted a study that divided the respondents into three groups, namely: athlete, people who exercise regularly and those with sedentary activity. the study showed that the average bmi was higher in subjects sedentary activity (24.3 kg/m2), and the athlete has average bmi was lower than the other two groups (22.6 kg/m2).the body fat percentage on sedentary activities group (20.6%) was higher than the exercise group (18.9%) and the athlete group (15.7%). from these data, it can be concluded that the average of bmi and body fat percentage was influenced by age, race, and activities. from this study, there was a strong correlation between the bmi and body fat percentage either in male or female students. this results were similar with the study performed by ranasinghe et al.10 in the study in srilanka, the body fat percentage in adult people was measured by bia and the subjects of the study were classified based on gender and age interval, young (18–39 years), middle aged (40–59 years), and ederly (>60 years). based on the study, age and gender influenced the score correlation significantly. another study performed by rao et al.9 in south india showed that there was a strong correlation between bmi and body fat percentage. it was held in various socioeconomic conditions and ranged between 20 to 60 years old of india people. the study resulted 0.73 score of correlation in male and 0.70 in female. to obtain body fat percentage in the study, skin-fold method was established. it was concluded that the correlation between bmi and body fat percentage was various and was interfered by gender and age. moreover, study performed by ode et al.8 reported that there was a significant correlation in both groups of students, athlete students and unathlete students. unathlete respondentshad more significant correlation than athlete respondents. (r = 0.70 in non-athlete; r = 0.65 in athlete). furthermore, female students had more significant correlation than male. inversely, study by meeuwsen et al.4 showed less power correlation in the bmi (less than 27 kg/m2 ). the result were interfered by age of subject. from the previous researches, it could be concluded that the power correlation was influenced by some factors such as race, gender, age, and life style like as physical activity. the difference of mean in bmi from some studies also contributed to the different correlation result.4,10 according to rush et al.11,14 there was different relationship between body fat mass and bmi in asian, indian, european, maori, and pacific island people. on the contrary, asian indian people had higher body fat percentage than european, maori, and pacific island people. that study was held in new zealand with european, maori, and pacific island race as subjects. there are several limitations in this study. many of respondents were measured shortly after eating might be interfere result of study, whereas respondents should be fasting at least for 3 hours before the measurement. other limitations of the study might be from several factors that could influence subjects’ body composition and result such as eating style, socioeconomic and various physical activities which were not considered in selecting the subject of study. based on the result of study, it can be concluded that there is a strong correlation between bmi and body fat percentage either in male or female students. the bmi data from male students and female students in universitas padjadjaran can still be used to describe body fat percentage score. references 1. shils me, shike m, ross ac, caballero b, cousins rj, editors. modern nutrition in health and disease. 10th ed. baltimore: lippincot williams & wilkins; 2006. p. 751–68. 2. shah ah, bilal r. body composition, its significance and models for althea medical journal. 2015;2(4) 578 amj december, 2015 assessment. pakistan journal of nutrition. 2009;8(2):198–202. 3. gibson rs. principle of nutritional assessment. 2nd ed. new york: oxford university press; 2005. p. 273–90. 4. meeuwsen s, horgan gw, elia m. the relationship between bmi and percent body fat, measured by bioelectrical impedance, in a large adult sample is curvilinear and influenced by age and sex. clin nutr. 2010;29(5):560–66. 5. whitney e, rolfes sr. understanding nutrition. 11th ed. belmont: thomson wadsworth; 2008. p. 259–60. 6. hassan ne, el-masry sa, soliman nl, el-batran mm. different techniques for body composition assessment. j med. sci. 2008;8(1):15–21. 7. daud wnw, muda wamw, abdullah mr. body mass index and body fat status of men involved in sports, exercise, and sedentary activites. malays j med sci. 2009;16(2):22– 27. 8. ode jj, pivarnik jm, reeves mj, knous jl. body mass index as a predictor of percent fat in college athletes and nonathletes. med sci sports exerc. 2007;39(3):403–409. 9. rao km, arlappa n, radhika ms, balakrishna n, laxmaiah a, brahmam gnv. correlation of fat mass index and fatfree mass index with percentage body fat and their association with hypertension among urban south indian adult men and women. ann hum biol. 2012;39(1):54–58. 10. ranasinghe c, gamage p, katulanda p, andraweera n, thilakarathne s, tharanga p. relationship between body mass index (bmi) and body fat percentage, estimated by bioelectrical impedance, in a group of sri lankan adults: a cross sectional study. bmc public health. 2013;13(797):1–8. 11. rush ec, plank l, chandu v, laulu m, simmons d, swinburn b, et al. body size, body composition, and fat distribution: a comparison of young new zealand men of european, pacific island, and asian indian ethnicities. n z med j. 2004;117(1207):1– 9. 12. dehghan m, merchant at. is bioelectrical impedance accurate for use in large epidemiological studies? bmc public health. 2008;7(26):1–7. 13. flegal km, shepherd ja, looker ac, gaurbard bi, borrud lg, ogden cl, et al. comparison of percentage body fat, body mass index, waist circumference, and waist-stature ratio in adults. am j clin nutr. 2009;89:500–8. 14. rush ec, plank ld, freitas i. body size, body composition, and fat distribution: comparative analysis of european, maori, pacific island, and asian indian adults. br j nutr. 2009;102:632–41. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 541 solanum muricatum aiton juice as a hepatoprotective agent in wistar rats induced with carbon tetrachloride justine sim wei yang,1 istriati,2 tiene rostini3 1faculty of medicine universitas padjadjaran, 2departement of pharmacology and therapy faculty of medicine universitas padjadjaran, 3departement of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the liver participates in various metabolic processes in human body. exposures to toxins such as carbon tetrachloride (ccl4) result in hepatocyte destruction and release the cell contents. pepino (solanum muricatum aiton) contains antioxidants that protect the liver from hepatoxicity. the aim of this experiment was to determine the effect of pepino in protecting the hepatocyte from hepatotoxic effect of ccl4. methods: a total of 16 wistar rats were divided into control and therapeutic groups. the control group was given pepino juice for 10 days. for induction of hepatotoxicity, ccl4 10% was given at a dosage of 2.0 ml/kg intra-peritoneal. the therapeutic group was given 1.0 ml of 300 g/ml pepino juice via oral feeding. hepatoxicity was measured through sgpt level in both groups t-test was used to analyze the data. results: the therapeutic group showed a larger decrease (6898.9 iu/l–79.1 iu/l) in sgpt level compared to the control group (6469.8 iu/l–418.5 iu/l) p-value <0.05. the sgpt level in the therapeutic group reached normal baseline (50 iu/l–150 iu/l. conclusions: pepino juice at the dosage of 300 g/ml may have hepatoprotective effect. [amj.2015;2(4):541–5] keywords: carbon tetrachloride, hepatotoxicity, pepino, solanum muricatum aiton, sgpt correspondence: justine sim wei yang, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62818626924 email: masterpiece_jswy@hotmail.com introduction hepatotoxics are chemicals that are harmful to the liver. prolonged exposure towards these substances may lead to hepatotoxicity. carbon tetrachloride (ccl4) is a potent hepatotoxin. it is widely use in experiments as an inducer of hepatotoxicity to animal models.1,2 the ccl4 is metabolized by the liver enzyme family cytochrome p450 of the mixed function oxidase system. this process produces free radical of trichloromethylperoxyl (ooccl3) that could damage the hepatocyte.2,3 patients with ccl4 hepatotoxicity, most commonly experience symptoms such as jaundice, fatigue, lethargic, manifestation of hypersensitivity, nausea, vomiting, diarrhea, dyspnea and syncope. they might also experience pain and tenderness in right upper quadrant and abdominal distension due to hepatomegaly. other common findings in physical examinations are peripheral edema and ascites.3,4 in routine laboratory examinations, common findings in hepatotoxic patients are elevated liver enzymes, especially serum glutamic pyruvic transaminase (sgpt), serum glutamic oxaloacetate transaminase (sgot), and lactate dehydrogenase (ldh), leukocytosis, hypoalbuminemia, increased low density lipoprotein (ldl) and increased total cholesterol.3–5 the sgpt and sgot are essential for synthesis and degradation of amino acids. sgpt are usually found in the liver and a lesser extent in the kidney while sgot had a wider distribution in human body (liver, heart, brain, skeletal muscle, kidney, and erythrocyte). the sgpt has half-life of 47 hours compared to sgot which is 17 hours. this made sgpt a better indicator of hepatocyte damage.5,6 further, pepino (solanum murcatum aiton) is a fruit, categorized under the family of solanaceae, a shrub type of plant. pepino originated from the andeans, particularly peru. it is cultivated through its stem and althea medical journal. 2015;2(4) 542 amj december, 2015 will yield an edible fruit which smells great, juicy, mild sweetness and varies in intensity of color and shape (usually oval). currently, it is also being planted in some parts of china. in indonesia, pepino was introduced in the 19th century during the dutch’s colonization in the country. the known usage of pepino is for its antioxidants, anti-diabetic and anti-gastric ulcer.7–10 this study was conducted to study the effect of pepino juice on the sgpt level of hepatotoxic male wistar rats induced with ccl4. methods this experimental procedure was conducted in the pharmacology laboratory of faculty of medicine, universitas padjadjaran from november–december 2012. a total of 16 wistar rats about 7 weeks old, weighing approximately 130 gram–250 gram, was obtained from bandung institute of technology. the wistar rats were adapted for 7 days. throughout this study, the wistar rats were provided with adequate rat pellets and water.11,12 the wistar rats were divided into two groups and were housed in cages according to the assigned group. group 1 being the control group, the wistar rats were induced with ccl4 and they were not given pepino juice. on the other hand, group 2 was the therapeutic group. the wistar rats in the therapeutic group were induced with ccl4 and were given pepino juice. the pepino was obtained from carrefour, paris van java, in bandung. for 10 days, about 300 gram of pepino fruit were skinned, sliced and blended daily in a food processor to obtain the juice. about 280 ml of juice was obtained from the process. then, 1.0 ml of pepino juice was being fed to the wistar rats in the therapeutic group via oral feeding tube.9,10 after one week of adaptation, the wistar rats in both control and therapeutic group were injected with 2.0 ml/kg body weight of ccl4 intra peritoneal in a single dose. the wistar rats were allowed to rest for 24 hours before withdrawal of blood for sgpt assay. approximately 20 minutes prior to blood collection, the wistar rats were heated in the warming box at temperature of 39˚c to ensure vasodilatation. simultaneously, the wistar rats were observed for heat induced distress and also dehydration indicated by excess salivation.13 the wistar rats were taken out of the warming box, one at a time. the tail of the wistar rat was cleaned with cotton soaked in ethanol solution. this is the aseptic and antiseptic technique to prevent the wistar rat from infection. afterward, finger pressure was applied at 5 cm from the tip of the wistar rat’s tail to enhance the visibility of the blood vessel and venous blood was obtained by cutting the edge of the tail of the wistar rat with a sterile scalpel.1,13 then, about 1.0 ml of venous blood was collected in a test tube, centrifuged at 3,000 rpm for 15 minutes to separate the blood cells and serum. next, 0.05 ml of serum was transferred into a cuvette, and then 0.25 ml of substrate containing alanine and alpha ketoglutarate was added. the sample was incubated at 37˚c for 30 minutes. after 30 minutes, 0.25 ml of 2, 4–dinitrophenylhydrazine (dpnh) was added to the mixture. the sample was incubated at a temperature of 37˚c for another 20 minutes before inserted into the spectrophotometer.1,12,14 subsequently, the spectrophotometer was switched on, and the wavelength was adjusted to 340 nm. the cuvette containing yellow complex of wistar rat serum and substrate was inserted into the spectrophotometer to measure the sgpt level.12,14 this procedure was repeated on day 11 after the wistar rats in the therapeutic group completed their therapy [1.0 ml of pepino juice fed for 10 days]. furthermore, data about sgpt level of wistar rats in both groups were collected. the shaphiro wilk test was conducted first to ensure normal distribution of the data and statistical t test was used to compare the sgpt level for both groups. results the shaphiro-wilk test showed a normal distribution of the data. the data collected was summarized in figure 1. the wistar rats in both groups showed an increase in sgpt level 24 hours after ccl4 injection. the wistar rats in both groups also showed a decrease in sgpt level 11 days later. however, the sgpt level in the control group was still considered high because the normal sgpt range in wistar rats were 50 iu/l–150 iu/l. the unpaired t-test was performed to test whether there was a significant difference between sgpt levels of the wistar rats in both groups. the result of the unpaired t-test is shown in table 1. the result of unpaired t-test shows that the mean sgpt level of the wistar rats in the therapeutic group reached the normal althea medical journal. 2015;2(4) 543 baseline, which was between 50 iu/l–150 iu/l. meanwhile, the mean sgpt level of the wistar rats in the control group never reached the normal baseline. in addition, the result also showed that there was a significant decrease in sgpt level of wistar rats in therapeutic group. this deduction was indicated by the p value calculated to be 0.000, which was smaller in comparison to α = 5% (0.05). discussion according to a previous study, 2.5 ml/ kg concentration of body weight of ccl4 is enough to induce hepatotoxicity in wistar rats. however, considering the cost of the experiment, the dosage of ccl4 is adjusted to 2.0 ml/kg of body weight of the wistar rats. the wistar rats are considered hepatotoxic when their sgpt level increases beyond 160 iu/l for a male wistar rat.1,2,15 based on the data collected, the wistar rat in the control group showed a decreased in sgpt levels (6469.80 iu/l–418.50 iu/l). the increase in sgpt levels indicated that the hepatocyte was being damaged by ccl4. the mechanism of ccl4 to induce injury was caused by cytochrome p450 enzyme in the liver. this enzyme metabolized the ccl4, by firstly inducing homolytic fission. this homolytic fission yields trichloromethyl radical (ccl3). 2,12,15 the next step was an oxidation process which involved the combination of this ccl3 with oxygen (o2) and ooccl3 were produced. these free radicals of ooccl3 were responsible justine sim wei yang, istriati, tiene rostini: solanum muricatum aiton juice as a hepatoprotective agent in wistar rats induced with carbon tetrachloride figure 1 difference in sgpt level of wistar rats in both groups, pre-therapy and post-therapy note: •pre-therapy = sgpt level 24 hours after induction of hepatotoxicity •post-therapy = sgpt level 24 hours after wistar rats in therapeutic group completed the 10 days course of therapy with pepino juice table 1 unpaired t-test sgpt level n sgpt (iu/l) ± sd calculatedt p value post therapeutic control 8 418.5 ± 66.2 14.132 0.000 therapeutic 8 79.1 ± 15.5 sd: standard deviation althea medical journal. 2015;2(4) 544 amj december, 2015 for the damage to the semi permeable lipid membrane of the hepatocytes, altering the permeability of membrane. moreover, the increased permeability of membrane leads to swelling of hepatocytes, inactivation of mitochondria enzymes and necrosis of the hepatocyte that cause an increased sgpt level.2,12 the normal mechanism of a human body to metabolize the product ccl4 is to oxidize the ccl3 under aerobic condition. this process yields trichloromethanol (cl3coh) which is the precursor for phosgene (cocl3). cl3coh is then oxidized into cocl3. microsomal enzyme produced by the hepatocyte will react with cocl3 via hydrolytic chlorination to produce carbon dioxide (co2). 1,2,12,14 although the sgpt level of wistar rats in the control group decreased, it was still within abnormal range (beyond 160 iu/l), which means the wistar rats were still considered hepatotoxic. the decrease in sgpt level indicates that the hepatocyte of wistar rats regenerates rapidly in a period of 10 days to overcome the damage caused by ccl4. 1,12,14 the liver regained the function to metabolize protein through regeneration of hepatocytes. the sgpt level decreased in the wistar rats of the control group because it was being degraded. however, since the damaged caused to hepatocyte of the wistar rats in the control group was not fully reversible yet, thus the sgpt level never reached normal.1,2,14 on the other hand, the decrease in sgpt level of wistar rats from the therapeutic group (from an average of 6898.90 iu/l–79.10 iu/l) shows that the sgpt level of wistar rats that were being fed with pepino juice for 10 days, decreased to a normal baseline (50 iu/l–150 iu/l). the decrease in sgpt level of wistar rats in the therapeutic group is due to the antioxidants in pepino that protects the hepatocytes of the wistar rat from being damaged by ccl4. a previous research proposed that pepino contains antioxidant properties. pepino can reduce the reactive oxygen species level, increase glutathione level, retaining glutathione peroxidase and catalase activities in cardiac tissues. this shows that, antioxidant of pepino is able to protect organs from free radical damage.7–10 the synergistic effect from the antioxidants of pepino juice that protects the liver and also hepatocyte regeneration rapidly decreased the sgpt level of wistar rats in the therapeutic group to a normal baseline. therefore, this study concludes that pepino juice has a hepatoprotective effect on hepatotoxic wistar rats. references 1. akram e, olamafar s, zaringhalam j, rezazadeh s, eidi m. protective effect of walnut (juglans regia l.) extract against ccl4–induced hepatotoxicity in rats. pejouhesh. 2011;35(2):87–92. 2. weber lw, boll m, stampfl a. hepatotoxicity and mechanism of action of haloalkanes: carbon tetrachloride as a toxicological model. crit rev toxicol. 2003;33(2):105– 36. 3. navarro vj, senior jr. drug-related hepatotoxicity. n engl j med. 2006;354(7):731–9. 4. dooley js, lok a, burroughs a, heathcote j, editors. sherlock’s diseases of the liver and biliary system. 12th ed. oxford:wileyblackwell; 2011. 5. mcpherson ra, pincus mr, henry jb. henry’s clinical diagnosis and management by laboratory methods. 21st ed. philadelphia: saunders elsevier; 2007. 6. giboney pt. mildly elevated liver transaminase levels in the asymptomatic patient. am fam physician. 2005;71(6): 1105–10. 7. hsu c, guo y, wang z, yin m. protective effects of an aqueous extract from pepino (solanum muricatum ait.) in diabetic mice. j sci food agric. 2011;91(8):1517–22. 8. arindah d. fractionation and identification of compound in fruit meat of solanum muricatum aiton that has potential as antioxidants [dissertation]. malang: universitas islam negeri maulana malik ibrahim; in press 2010. 9. sudha g, priya ms, shree rb, vadivukkarasi s. antioxidant activity of ripe and unripe pepino fruit (solanum muricatum aiton). j food sci. 2012;77(11):1131–5. 10. saptarini n.m., suryasaputra d., a.m. s. analisis rasio proteksi antiulser sari buah pepino (solanum muricatum aiton) menggunakan mencit sebagai model hewan coba. majalah obat tradisional. 2011;16(2):75–80. 11. galal rm, zaki hf, seif el-nasr mm, agha am. potential protective effect of honey against paracetamol-induced hepatotoxicity. arch iran med. 2012;15(11):674–80. 12. feng y, siu k, ye x, wang n, yuen m, leung c, et al. hepatoprotective effects of berberine on carbon tetrachloride-induced acute hepatotoxicity in rats. chinese medicine. althea medical journal. 2015;2(4) 545 2010;5(1):1–6. 13. parasuraman s, raveendran r, kesavan r. blood sample collection in small laboratory animals. j pharmacol pharmacother. 2010; 1(2):87–93. 14. domitrović r, jakovac h, blagojević g. hepatoprotective activity of berberine is mediated by inhibition of tnf-α, cox-2, and inos expression in ccl4 intoxicated mice. toxicology. 2011;280(1-2):33–43. 15. wong ll, fan st, man k, sit wh, jiang pp, jor iw, et al. identification of liver proteins and their roles associated with carbon tetrachloride-induced hepatotoxicity. hum exp toxicol. 2011;30(9):1369–81. justine sim wei yang, istriati, tiene rostini: solanum muricatum aiton juice as a hepatoprotective agent in wistar rats induced with carbon tetrachloride althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 485 comorbidity among hospitalized patients with chronic obstructive pulmonary disease in a teaching hospital, west java indonesia dini qurrotu aini,1 hendarsyah suryadinata,2 r.b. soeherman herdiningrat3 1faculty of medicine universitas padjadjaran, 2department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: one of the most important causes that can increase the risk of hospitalization and death in chronic obstructive pulmonary disease is comorbidity. the aim of this study was to identify the proportion of comorbidity among hospitalized patients with chronic obstructive pulmonary disease in a teaching hospital, west java, indonesia, from january to december 2012. methods: a descriptive study was conducted from september to november 2013 in internal medicine department of dr. hasan sadikin general hospital bandung. the study used 107 medical records that consisted of data about patients with chronic obstructive pulmonary disease (copd) who were hospitalized between january to december 2012. the medical records were collected using simple random sampling. variables identified in this study were characteristics of the patients (age, sex, and smoking history) and comorbidity events. comorbidity events were coronary artery disease (cad), lung cancer, diabetes mellitus (dm) type 2, anemia, dyslipidemia, osteoporosis, depression, pulmonary artery hypertension (pah), and hypertension. age variable was divided into 3 categories with interval 20 years. all collected data were presented in frequency distribution. results: most of the patients in this study were 50–69 years old, male, and had smoking history. the highest proportion of comorbid condition was hypertension, followed by anemia and coronary artery disease. conclusions: patients with copd have one or more other diseases (comorbidity). three most frequent comorbidities are hypertension, anemia, and coronary artery disease. [amj.2015;2(4):485–91] keywords: chronic obstructive pulmonary disease, comorbidity, hospitalized patient correspondence: dini qurrotu aini, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285691236913 email: diniqurrotuaini@gmail.com introduction chronic obstructive pulmonary disease (copd) is a lung disease characterized by chronic airflow limitation that interferes with normal breathing and is not fully reversible. world health organization (who) stated that in 2004, 64 million people had copd and 3 million of them passed away caused by copd. who also predicted that in 2030, copd will become the third leading cause of death.1 among 12 asia-pacific region countries, indonesia became the fourth leading prevalence of copd with prevalence about 5.6%.2 the copd is a preventable and treatable disease and related to a systemic inflammatory response that may contribute to individual severity.3 in a majority of cases, increase in systemic inflammatory components may underlie many of the multiple comorbidity seen in people with copd.4 fabbri5 categorizes these comorbidity, caused by systemic inflammation, as chronic systemic inflammatory syndrome (csis). the most recognized comorbidities are hypertension, coronary artery disease (cad), lung cancer, osteoporosis, anemia, diabetes mellitus (dm) type 2, depression, and pulmonary artery hypertension (pah). comorbidity in patients with copd must be identified and evaluated because it can increase the risk of hospitalization and mortality.6,7 the objective of this study was to identify the proportion of comorbidity among hospitalized patients with copd in a teaching hospital, west java, indonesia methods a descriptive study was conducted from september to november 2013 at internal althea medical journal. 2015;2(4) 486 amj december, 2015 medicine department in dr. hasan sadikin general hospital bandung. the study used medical records that consisted of data about patients with chronic obstructive pulmonary disease (copd) who were hospitalized from january to december 2012. patients who had copd diagnosis either as the primary or secondary diagnosis on medical records were included, and patients whose medical record were not found and had no information about age, sex, and smoking history were excluded. research medical records for this study were collected using simple random sampling. during this study, from 337 medical records, only, 183 were selected, but only 153 patients whose medical record were found and identified having a copd diagnosis as primary or secondary diagnosis on medical records. moreover, 46 medical records were excluded because they had incomplete data on age, sex, or smoking history. therefore, the total medical records which could be analyzed in this study were 107 medical records. variables identified in this study were characteristics of the patients and comorbidity events. characteristic variables consisted of age, sex, and smoking history, whereas comorbidity events were coronary artery disease (cad), lung cancer, diabetes mellitus (dm) type 2, anemia, dyslipidemia, osteoporosis, depression, pulmonary artery hypertension (pah), and hypertension. age variable was divided into 3 categories with interval 20 years. cad, lung cancer, depression, osteoporosis, and pah were determined based table 1 characteristics of the copd patients characteristics n(%) age (yrs.) < 50 8 (7.48 %) 50–69 54 (50.47 %) ≥ 70 45 (42.06 % sex male 93 (86.92 %) female 14 (13.08 %) smoking history yes 95 (88.79 %) no 12 (11.23 %) figure 1 proportion of comorbidity on diagnosis on medical records. dm type 2 was confirmed according to ada 2010 criteria. anemia was confirmed with indonesian health department criteria. dyslipidemia was confirmed based on national cholesterol education program (ncep) adult treatment panel (atp) iii criteria and hypertension was confirmed based on joint national committee (jnc) 7 criteria. all collected data were presented in frequency tabulation and percentage. the study was approved by health research ethics committee, faculty of medicine universitas padjadjaran (no. 210/un6. c2.1.2.kepk/2013). collected data from medical records were kept confidentially and althea medical journal. 2015;2(4) 487dini qurrotu aini, hendarsyah suryadinata, r.b. soeherman herdiningrat: comorbidity among hospitalized patients with chronic obstructive pulmonary disease in a teaching hospital, west java indonesia vanished after the study was conducted. results most of patients in this study were 50–69 years old, male, and had smoking history. in this study, various conditions of comorbidity were identified and there was more than one comorbidity in each patient. the highest proportion of comorbid condition was hypertension, followed by anemia and coronary artery disease (55.14%, 45.79%, and 35.51%, respectively). pulmonary artery hypertension (pah) had the highest proportion of comorbity in patients aged under 50 years old, meanwhile hypertension was the highest proportion of comorbity in 50–69 years old patients. above 70 year old patients, anemia was the highest proportion of comorbidity. figure 2 distribution of comorbidity according to age figure 3 proportion of comorbidity according to sex althea medical journal. 2015;2(4) 488 amj december, 2015 if divided by sex, proportion of lung cancer, anemia, dyslipidemia, and depression, the number of male patients were higher compared to female patients. in contrary, a higher proportion of dm type 2, pah, and hypertension in female patients were identified compared to male patients. the proportion of cad in male subjects was almost same as in female subjects, which were 35.48% and 35.71% (figure 3). proportion of cad, lung cancer, dm type 2, anemia, dyslipidemia, and depression in copd patients with smoking history were higher compared to patients without smoking history. meanwhile, in pah and hypertension, the proportion was higher in patients without smoking history (figure 4). discussion hospital discharge with primary or secondary copd was mostly diagnosed with one or more comorbid conditions, including cardiac and pulmonary vascular disease, pneumonia, malignancies, chronic kidney disease, congestive heart failure, gastropathy, and others. some of the most common comorbid conditions described in association with copd include coronary artery disease (cad), lung cancer, diabetes mellitus (dm) type 2, anemia, dyslipidemia, osteoporosis, depression, pulmonary artery hypertension (pah), and hypertension. comorbid condition which had a highest proportion found in this study was hypertension. the proportion was about 55.14%. this result strengthened the prospective cohort study conducted by huiart8 in which among 5648 patients with copd, the prevalence is about 50%.8 moreover, mills et al.9 through the study, reported that twothirds of copd populations have a high arterial stiffness and blood pressure, and in one study conducted by maninno10 the prevalence of hypertension in copd patients is 40.1%. the major determinant of increased blood pressure in patients with copd was large artery stiffness. arterial stiffness was influenced by both structural and functional aspect of the artery. in structural aspect, impaired lung function and systemic inflammation could cause a premature ageing of vasculature and reduced elastic fiber contents in dermis leading to an arterial stiffness. whereas, in functional aspect, endothelial dysfunction happened in smoker could influence endothelial dependent vasomotor tone. if stratified by age, the proportion of hypertension in this study was higher in older group. it supports another study which reported that arterial stiffness in patients with copd increases with age. if stratified by sex, the proportion of figure 4 proportion of comorbidity according to smoking history althea medical journal. 2015;2(4) 489 hypertension was higher in females, contrary with previous study which said that male have a higher risk than female. if stratified by smoking history, the proportion was higher in non-smoking group. it is different from previous study which said that cigarette smoke can make a structural and functional abnormality of vasculature.9 two comorbid conditions with high proportion right after hypertension were anemia and coronary artery disease (cad). the mechanism why anemia could be occurred in people with copd was similar to the mechanism in other chronic diseases. the increased level of il-6 and tnf-α in copd patients, led to shortened red blood cell (rbc) survival. moreover, there was a demand to increase rbc production, but the bone marrow did not respond adequately because of erythropoietin resistance.11 the proportion of anemia in this study was 45.79%. three studies conducted reported that the anemia prevalences in copd are 23%, 21%, and 15%.6,11 anemia could be caused by many conditions or diseases, including bleeding, malignancies, chronic kidney disease (ckd). those conditions or diseases were found in subjects in this study and there was no control over those conditions. this might be a reason why the proportion of anemia in this study was higher than other studies. if stratified by sex and age, the proportion of anemia was higher in male and increased with age. this result supports a study conducted by yohannes12 which said that anemia in copd patients is more likely in male and older. if stratified by smoking history, this result also supports that study which said that cigarette smoking has a carboxyhemoglobin effect causing anemia.12 holguin13 explained that cad prevalence in copd is 15% and the proportion of cad found in this study was 37.25%. in people with copd, raising in inflammatory mediators such as tnf-α and il-6, could increase the level of c-reactive protein (crp). crp increased ldl uptake from circulation by macrophage. moreover, crp could adhere directly on arterial wall and interacted with inflammatory mediator forming foam cells which is an atherogenic plaque. beside crp, raising in fibrinogen level could increase blood viscosity and then contributed in atherosclerosis process.7 if stratified by smoking history and age, cad was more likely found in smoking group and in 50−69 year old group. sex, male, and female subjects had the same proportion about 35%. besides, copd patients had several other risk factors that might contribute to development of cad such as smoking. smoking habit is clearly a risk factor for both cad and copd, and can potentially interfere with our result because most of the subjects in this study had a smoking history.10 osteoporosis became the lowest-proportion co-morbid with proportion about 0.00%. this result was different compared to other studies. according to lidwien14 the prevalence of osteoporosis based on dual-energy x-ray absorptiometry dxa and spinal x-ray examination are 23.6% and 36.5%. however, copd patients have several other risk factors that might contribute to development of osteoporosis such as older, poor mobilization, smoking, poor nutrition, low bmi, and using oral or inhalation corticosteroid. furthermore, copd is a direct risk factor for osteoporosis through systemic inflammation process.15 in this study, the result was 0.00%. this is probably due to a fact that in general, osteoporosis is an asymptomatic disease and bmd examination is rarely done in clinical practice if there is no symptom or indication. therefore, a further study with primary data is needed. the proportion of dm type 2 reported from this study was 14.71%. it supports the previous study in which the prevalence of dm type 2 in copd patients is between 1.6– 16%.6 based on several studies, diabetes in copd is caused by pro-inflammatory cytokine (tnf-α and il-6) which can block signal through insulin receptor; as the result, insulin resistance is occurred. therefore, copd patient has a higher risk to have dm type 2. if stratified by age, the result supports a study conducted by mannino10 the study found that increasing age, a higher bmi, lower education status, and male sex relate to a higher risk of diabetes. contrarily, this study result is not in accordance with that study if compared by sex and smoking history because the author explained that there was no association between them. lung cancer and copd share a same risk factor, which is tobacco smoking. this statement is supported by this study because most of both copd patients and lung cancer patients were smoking. in this study, the proportion for lung cancer was 3.74%. de torres et al16 in his cohort study reported that 215 (8.58%) cases of lung cancer in 2507 patients with copd and conclude that older age is the independent risk factor for lung cancer. that study is supported by this study because in this study, lung cancer developed in patient in 50–69 years old group and ≥70 year old dini qurrotu aini, hendarsyah suryadinata, r.b. soeherman herdiningrat: comorbidity among hospitalized patients with chronic obstructive pulmonary disease in a teaching hospital, west java indonesia althea medical journal. 2015;2(4) 490 amj december, 2015 group. in one study, incidence of lung cancer in mild and moderate airflow obstruction is 6.8% for non-smoker and 10.8% for smoker. barnes and celli,15 through their study, explained that female has a higher risk to develop copd and lung cancer as a result from hormonestimulated metabolism of carcinogen within cigarette. male patients with copd were patients who had a lung cancer in this study. this contrary finding may be caused by a fact that in our study, the subjects are dominated by males. the total of female subjects was too small to represent the female population. in this study, pulmonary arterial hypertension was found about 16.82%. meanwhile, in most previous studies, the prevalence of pulmonary hypertension is ranging from 30−70%.17,18 the proportion of pah in this study was lower than several previous studies. this was probably due to pulmonary artery pressure (ppa) data that were not found in medical records and the definition of pah. this study was mostly made based on presence of cor pulmonale in the subjects. nine of eighteen subjects with pulmonary hypertension were in 50−69 year old group, supporting a study conducted by joppa18 which said that the mean of age is 68 years old. among 18 cases of pulmonary hypertension in this study, 13 male participated and 14 patients had smoking history. it also supports the previous study. in this study, only one case (0.93%) of depression was found and it was male who had a smoking history, and in 50−69 year old group. it is different from one review article which concluded that the prevalence of depression is 19−42%.15 this was probably caused by a diagnosis which was determined only from medical records and the subjects which were not screened for depression. seven cases of dyslipidemia were reported from this study, with proportion about 6.54%. the proportion of dyslipidemia was higher in male and smoking group, and the proportion increased with age. there are several limitations in this study. first, copd in this study was obtained from diagnosis on medical records in which most of them were defined clinically, not based on spirometry as a gold standard for copd. second, this study used secondary data from medical records which had limited information and could not be explored. some of them also had incomplete data causing difficulty in analyzing data and made the sample less represent the population. then, most of comorbidities were determined only from diagnosis on medical records causing there was a possibility to have a false negative result. third, other potential condition such as bleeding, malignancies which could interfere the result was not excluded. therefore, a further study which used primary data as the source of data and spirometry data as inclusion criteria is needed. based on the discussion in this paper, it is concluded that the proportion of several comorbidities in copd patients are high. three most frequent comorbidities are hypertension, anemia, and coronary artery disease. the distributions based on age, sex, and smoking history are obtained in this study. comorbidities in patients with copd can increase the risk of hospitalization and the mortality rate. therefore, in order to reduce the risk of hospitalization and the rate of mortality, identifying the presence of co-morbidities in copd patients based on patient’s age, sex, and smoking history should be routinely performed. references 1. world health organization. chronic obstructive pulmonary disease (copd). 2013 [cited 2013 february 7]; available from: http://www.who.int/respiratory/ copd/en/. 2. tan w, seale j, charaoenratanakul s, de guia t, ip m, mahayiddin a, et al. copd prevalence in 12 asia-pacific countries and regions: projections based on the copd prevalence estimation model. respirology. 2003;8(2):192−8. 3. gold. global strategy for the diagnosis, management and prevention of copd. global initiative for chronic obstructive lung disease (gold); 2001 [cited 2013 march 2]. available from: http://www. goldcopd.org/. 4. yawn b, kaplan a. co-morbidities in people with copd: a result of multiple diseases, or multiple manifestations of smoking and reactive inflammation. prim care respir j. 2008;17(4):199−205. 5. fabbri lm, rabe kf. from copd to chronic systemic inflammatory syndrome?. lancet. 2007;370(9589):797−9. 6. chatila wm, thomashow bm, minai oa, criner gj, make bj. comorbidities in chronic obstructive pulmonary disease. proc am thorac soc. 2008;5(4):549−55. 7. masna iak, kusmana d, antariksa b. effect of systemic inflammation in chronic obstructive pulmonary disease on althea medical journal. 2015;2(4) 491 cardiovascular system. j indon med assoc. 2011;61(5):225−9 8. huiart l, ernst p, suissa s. cardiovascular morbidity and mortality in copd. chest. 2005;128(4):2640−6. 9. mills nl, miller jj, anand a, robinson sd, frazer ga, anderson d, et al. increased arterial stiffness in patients with chronic obstructive pulmonary disease: a mechanism for increased cardiovascular risk. thorax. 2008;63(4):306−11. 10. mannino dm, thorn d, swensen a, holguin f. prevalence and outcomes of diabetes, hypertension and cardiovascular disease in copd. eur respir j. 2008;32(4):962−9. 11. john m, hoernig s, doehner w, okonko dd, witt c, anker sd. anemia and inflammation in copd. chest. 2005;127(3):825−9. 12. yohannes am, ershler wb. anemia in copd: a systematic review of the prevalence, quality of life, and mortality. respir care. 2011;56(5):644−52. 13. holguin f, folch e, redd sc, mannino dm. comorbidity and mortality in copd-related hospitalizations in the united states, 1979 to 2001. chest. 2005;128(4):2005−11. 14. graat-verboom l, van den borne be, smeenk fw, spruit ma, wouters ef. osteoporosis in copd outpatients based on bone mineral density and vertebral fractures. j bone miner res. 2011;26(3):561−8. 15. barnes p, celli b. systemic manifestations and comorbidities of copd. eur respir j. 2009;33(5):1165−85. 16. de torres jp, marín jm, casanova c, cote c, carrizo s, cordoba-lanus e, et al. lung cancer in patients with chronic obstructive pulmonary disease. am j respir crit care med. 2011;184(8):913−9. 17. minai oa, chaouat a, adnot s. pulmonary hypertension in copd: epidemiology, significance, and management pulmonary vascular disease: the global perspective. chest. 2010;137(suppl6):s39−s51. 18. joppa p, petrasova d, stancak b, tkacova r. systemic inflammation in patients with copd and pulmonary hypertension. chest. 2006;130(2):326−33. dini qurrotu aini, hendarsyah suryadinata, r.b. soeherman herdiningrat: comorbidity among hospitalized patients with chronic obstructive pulmonary disease in a teaching hospital, west java indonesia althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 59 effect of midnight prayer on sympathetic tone hadiyatussalamah pusfa kencanasari,1 achmad fauzi yahya,2 setiawan3 1faculty of medicine, universitas padjadjaran, 2department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung 3department of physiology faculty of medicine universitas padjadjaran abstract background: hypertension is one of the most dangerous ailments which most common risk factor is stress that can activate sympathetic system leading to increased blood pressure. midnight prayer is believed to calm mind. this study was conducted to discover the effect of midnight prayer on sympathetic tone. methods: this cross sectional study was conducted in bina siswa senior high schoolsma plus cisarua boarding school, lembang from october to november 2013. sixty eight participants were divided into 3 groups based on frequency; high, low, and non midnight prayer. blood pressure and pulse rate of participants were examined before, during, and after the cold pressor test is taken. blood pressure and pulse rate duration of recovery were also measured. results: this study showed no significant difference between 3 groups in term of systolic blood pressure, diastolic blood pressure, and pulse rate. however, the lowest mean of pulse rate (64.38±8.921 vs 66.69±11.482 vs 65.44±9.584 respectively), systolic blood pressure [107.19±6.945 vs 117.13±13.426 vs 104.25 (75–120) respectively], and diastolic blood pressure [70.38±7.719 vs 77.38±10.935 vs 70.63±7.491 respectively] were obtained in the high midnight prayer group. recovery duration of blood pressure [6.38 (6–8) vs 6.72 (6–11) vs 6.75 (6–11) respectively] and pulse rate (6.69±0.946 vs 7.03±1.341 vs 7.00±1.506 respectively) among the groups showed no significant difference respectively, however the shortest duration was obtained in the high midnight prayer group. conclusions: midnight prayer has no significant effect on sympathetic tone. [amj.2016;3(1):59–63] keywords: blood pressure, cold pressor test, midnight prayer, pulse rate, sympathetic tone. correspondence: hadiyatussalamah pusfa kencanasari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285793110035 email: hpusfak@gmail.com introduction hypertension is one of the most dangerous conditions especially when it is not controlled. this illness has caused 7.5 million deaths in the world, equal to 12.8% from total cause of death.1 based on riset kesehatan dasar badan penelitian dan pengembangan kesehatan 2007, the prevalence of hypertension in indonesia reaches 31.7%.2 one of the most common risk factors of hypertension is stress. stress response is the way of human body reacting to stress. sign of this response is the activation of sympathetic system that will lead to a rise in arterial pressure, bloodstream, cellular metabolism, blood glucose consentration, mental activity, glicolysis, muscle strength, and blood coagulation rate.3 when human’s body is experiencing stress, physically or mentally, one of body’s natural responses which is most measurable is the increased of blood pressure. midnight prayer, also known as shalat tahajud or qiyamul lail, is one of the sunnah prayers (optional prayer) that is believed to be able to affect mental condition. the process of praying (shalat) itself is quite close to a meditation, in addition, there are particular movements and reciting of al quran. regular midnight prayer will calm mind and also leads to lower the risk of stress condition. this calm condition will affect the body when it is stressed, due to the inavoidable nature of stress.4 therefore, theoretically, the risk of hypertension caused by stress can be prevented. cold sensation is one of the known physical stressor. this condition can be used to observe the body response by giving the stressor. there is a procedure called cold pressor test that is not only used to know the regulation althea medical journal. 2016;3(1) 60 amj march 2016 of sympathetic nerve to periphery and coronary circulation5 but also can be used as hypertension predictor.6 before conducting the test, blood pressure is measured and this measurement is considered as a base line. the rise in blood pressure of 15/10 mmhg or more from base line is considered as hyperreactor.5 on the other hand, normoreactor is considered if the rise in blood pressure is less than 15/10 mmhg from base line. according to this fact, the author see the possibility to discover stress response in someone who have been done midnight prayer regularly compared to those who have not done it. the present study aims to study the effect of midnight prayer to cold pressor test result in bina siswa senior high school (sekolah menengah atas, sma) plus cisarua boarding school student, lembang. methods this analytical study conducted in cross sectional approach was performed in bina siswa sma plus cisarua boarding school, lembang, from october to november 2013. this study was approved by the institutional ethics committee and all data regarding patients were concealed. fifteen to eighteen years old male participants, had normal bmi, normotensive, healthy, understand about this study, and signed the informed consent were included in this study. participants who had a history of cardiovascular disease, smoking, drinking alcohol, and open wound on the hand were excluded. sampling was conducted by total sampling. from those criteria, about 68 out of 144 male students participated in this study. participant filled-up the questionnaire about identity, medical history, life style, general condition, and midnight prayer performed within 1 last month. participants were categorized based on midnight prayer frequency’s standard deviation. participants who had done more than 14 times midnight prayer within 1 last month were considered as high midnight prayer group.participant who had done midnight prayer 1-14 times within 1 last month were considered as low midnight prayer group, and participants who had never done midnight prayer within 1 last month were considered as non midnight prayer group. blood pressure of each participant was measured by mercury sphygmomanometer. after taking rest for five minutes, the blood pressure and pulse rate was measured at the left hand of participants. the right hand of the participant was immersed in ice water (4–10 0c) for 1 minute. blood pressure and pulse rate were measured at the completion of 1 minute. after that, the participants were asked to remove his hand from the cold water. the particpant’s hand was dried up with dry towel and they are allowed to to take a rest. five minutes after the cold pressor test, blood pressure and pulse rate were noted once more. with 1 minute interval, blood pressure and pulse rate of participants were measured continuously until they reach the baseline. data were processed using microsoft excel and spss 15.0 programme. proportion of normoreactor data was statistically analyzed using chi square parametric test. the average height of increased blood pressure and pulse rate also the average blood pressure and pulse rate duration of recovery data were analyzed table 1 pulse rate and blood pressure characteristic of participant conditions pr* (time/minute) sbp** (mmhg) dbp# (mmhg) high midnight prayer baseline 64.38±8.921 107.19±6.945 70.38±7.719 (n=16) ice water exposure 66.69±11. 482 117.13±13.426 77.38±10.935 recovery 65.44±9.584 104.25 (75–120) 70.63±7.491 low midnight prayer baseline 67.25±8.497 110.64 (89–130) 70.31 (49–100) (n=36) ice water exposure 73.12±12.139 121.00±10.918 78.11±9.748 recovery 68.61±9.066 109.33±11. 432 70.33 (40–100) non-midnight prayer baseline 68.94±10.976 109.44±10.046 74.00 (49–100) (n=16) ice water exposure 74.44±10.801 122.19±13.477 81.75±9.842 recovery 71.50±10.640 111.88±11.200 73.00±7.127 note: *pr = pulse rate, **sbp = systolic blood pressure, #dbp = diastolic blood pressure althea medical journal. 2016;3(1) 61 using one way anova if the data distribution were normal. as an alternative, kruskalwallis non parametric test was also used if the distribution was not normal. statistically significant was considered when p≤0,05. analysis was performed by comparing those 3 groups. results from 144 male students, 68 participants fitted to criteria and agreed to be involved in this study. nineteen participants were considered as high midnight prayer group because they had done more than 10 times midnight prayer within 1 last month, 33 participants were considered as low midnight prayer group because they had done 1–10 times midnight prayer within 1 last month, and 16 participants were considered as non midnight prayer group because they never done midnight prayer within 1 last month. mean or median of pulse rate, systolic blood pressure, and diastolic blood pressure before, during, and after cold pressor test are shown in table 1. systolic blood pressure (sbp p=0.782) and diastolic blood pressure (dbp p=0.591) between 3 groups have shown no significant difference (table 2). height of increased sbp and blood pressure duration of recovery data distribution were not normal, therefore the data were analyzed using kruskal-wallis test. the height of increased dbp and pulse rate also the pulse rate duration of recovery were analyzed using one way analysis of variance (anova) because the data distribution were normal. there was no significant difference between the height of increased sbp among those 3 groups (p=0.626; 95% confidence interval, 8.84–12.80). height of increased dbp (p=0.939; 95% confidence interval, 5.75–9.46) and pulse rate (p=0.215; hadiyatussalamah pusfa kencanasari, achmad fauzi yahya, setiawan: effect of midnight prayer on sympathetic tone table 2 proportion of normoreactor between high midnight prayer group, low midnight prayer group, and non-midnight prayer group normoreactor hyperreactor p sbp* high midnight prayer 10 (63%) 6 (37%) 0.782 low midnight prayer 24 (72%) 10 (28%) nonmidnight prayer 11 (69%) 5 (31%) dbp** high midnight prayer 8 (50%) 8 (50%) 0.591 low midnight prayer 17 (65%) 19 (73%) nonmidnight prayer 10 (63%) 6 (37%) note: *sbp = systolic blood pressure, **dbp = diastolic blood pressure table 3 proportion of normoreactor between high midnight prayer group, low midnight prayer group, and non-midnight prayer group median of sbp* (mmhg) p mean of dbp** (mmhg) p mean of pr# (time/minute) p high midnight prayer 9.94 (-10–24) 0.626 7.00±7.950 0.939 2.31±6.887 0.215 low midnight prayer 10.36 (-7–30) 7.81±7.804 6.11±7.383 nonmidnight prayer 12.75 (4–32) 7.75±7.532 5.50±7.118 note: *sbp = systolic blood pressure, **dbp = diastolic blood pressure, #pr = pulse rate table 4 blood pressure and pulse rate duration of recovery median time of blood pressure (minute) p mean time of pulse rate (minute) p high midnight prayer 6.38 (6–8) 0.548 6.69±0.946 0.673 low midnight prayer 6.72 (6–11) 7.03±1.341 non-midnight prayer 6.75 (6–11) 7.00±1.506 althea medical journal. 2016;3(1) 62 amj march 2016 95% confidence interval, 3.31–6.83) also showed no significant difference (table 3). recovery duration of blood pressure (p=0.548; 95% confidence interval, 6.40–6.90) and pulse rate (p=0.673; 95% confidence interval, 6.63– 7.25) also showed no significant difference between those 3 groups (table 4). discussions one of the most common risk factors of hypertension is stress that can activate sympathetic system leading to increased blood pressure. stress reduction with trancedental meditation program has given an advantage to condition like hypertension and psychological stress7, which is caused bylower blood pressure and pulse rate. the improvement of blood pressure and pulse rate is associated with regularity of trancedental meditation practice.8 eventhough the underlying physiologic pathway of trancedental meditation advantageous on blood pressure was still unclear, the practice showed a a decreasing on sympathetic tones and reducing neurohormonal activity that decreased shear stress on the circulation and reduced heart load. therefore, blood pressure reactivity decreases, even when obtaining acute behavioral stress. 9 contact to cold will lead to increased blood pressure and pulse rate because it activates sympathetic nerve. according to the previous study, trancedental meditation gives effect to improve blood pressure and pulse rate.8 improvement on blood pressure in this study referred to cold pressor test result that interprets as normoreactor or hyperreactor. in theory, midnight prayer has a similar effect with trancedental meditation, although the study still has to be developed. in this study, the comparation between high midnight prayer group, low midnight prayer group, and non midnight prayer group showed a slight difference even though it did not reach a statistical significance. on the contrary, the other previous study had shown the effect of meditation on developed control over sympathetic function.10 pulse rate in this study also showed unsignificant difference. the result of pulse rate showed a similliarity to the study conducted by mendhurwar and gadakari.11 this unsignificant difference could be caused bythe limitation of this study. history of midnight prayer on the last one month taken by quessionaire, was not recorded every after the participant had performed midnight prayer. therefore, it could arise recall bias. this study does not prove the effect of midnight prayer on sympathetic tone. blood pressure and pulse rate result of this study among those three groups shows no significant difference. therefore, additional study with more frequent and longer period of midnight prayer should be conducted, because the other previous study which reported the reduction on blood pressure and pulse rate was done in a person practicing transcendental meditation for a long time.11 midnight prayer probably has no short term effect, but has long term effect similar to transcendental meditation. references 1. world health organization. raised blood pressure. 2013 [cited 2013 april 22]; available from: http://www.who.int/ gho/ncd/risk_factors/blood_pressure_ prevalence_text/en/. 2. badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia. laporan nasional riset kesehatan dasar 2007. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2008. 3. guyton ac, hall je. textbook of medical physiology. 11th ed. philadelphia: elsevier saunders; 2006. p. 758. 4. ibrahim bs. spiritual medicine in the history of islamic medicine. j int soc history islamic med. 2003;2:45 ̶ 9. 5. ritesh m, karia. blood pressure response to cold pressure test in normal young healthy subjects: a prediction of future possibilities of hypertension. j phys pharm adv. 2012;2(6):223–6. 6. pramanik t, regmi p, adhikari p, roychowdhury p. cold pressor test as a predictor of hypertension. j teh univ heart ctr. 2009;3:177–80. 7. schneider rh, grim ce, rainforth mv, kotchen t, nidich si, gaylordking c, et al. stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in blacks. circ cardiovasc qual outcomes. 2012;5:750–8. 8. anderson jw, liu c, kryscio rj. blood pressure response to transcendental meditation a meta-analysis. am j hypertens. 2008;21:310–6. 9. barnes va, treiber fa, johnson mh. impact of transcendental meditation on althea medical journal. 2016;3(1) 63 ambulatory blood pressure in africanamerican adolescents. am j hypertens. 2004;17(4):366–9. 10. deepak d, sinha an, gusain vs, goel a. a study on effects of meditation on sympathetic nervous system functional status in meditators. j clin diagn res. 2012;6(6):938–42. 11. mendhurwar ss, gadakari jg. effect of transcendental meditation on pulse rate and blood pressure. int j of medi and clin res. 2012;3(1):107–9. hadiyatussalamah pusfa kencanasari, achmad fauzi yahya, setiawan: effect of midnight prayer on sympathetic tone althea vol 2 no 1 edit.indd althea medical journal. 2015;2(1) 108 amj march, 2015 profile of patients with complicated chronic suppurative otitis media in dr. hasan sadikin general hospital bandung, indonesia january–december 2011 fitrie desbassarie w,1 arif dermawan,2 soeseno hadi3 1faculty of medicine, universitas padjadjaran, 2department of otorhinolaryngology head and neck surgery, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of clinical pathology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: the prevalence of chronic suppurative otitis media (csom) is still high in developing countries. according to the world health organization (who), the prevalence of csom is 2-4%. in 1994-1996, the prevalence of csom in various provinces in indonesia is diverse, with general prevalence of 3.9%. chronic suppurative otitis media can also lead to various complications. the objective of this study was to determine the profiles of csom patients with complications in dr hasan sadikin general hospital bandung. methods: secondary data was obtained from 117 medical records of the period january-december 2011 in dr hasan sadikin general hospital bandung. out of 117 medical records, 43 medical records consisted of csom patients who had complications. data of patients’demography, risk factor, chief and accompanying complaints, infected ears, pathological findings, complications, and treatments were collected and were analyzed with frequency distribution. results: there was 36.75% csom patients with complications, 55.8% are male, 30.3% were 30-39 years old, 62.8% level of education of patients was primary education. ear discharge (otorrhea) was the most common chief complaints (95.3%) and hearing loss was the most dominated accompanying symptom (53.5%), upper respiratory tract infection (urti) was the most common risk factors. most of the cases had unilateral complication (93%) and intratemporal (72%). both intratemporal and extratemporal was only 26% cases. granulation tissue was the most common intratemporal complication (32.5%). the most common procedure given was mastoidectomy without tympanoplasty (51.2%) followed by pharmacotherapy conclusions: percentage of csom with complication is still high in dr. hasan sadikin general hospital bandung. key words: chronic suppurative otitis media, complication, profile. correspondence: fitrie desbassarie, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282127725602 email: desbassarie@gmail.com introductions chronic suppurative otitis media (csom) is an infection that occurs in the middle ear it is chronic and ongoing. in this type of otitis, the inflammation of the middle ear mucosa occurs for ≥2 months, and is accompanied by perforation of the tympanic membrane. in addition, there is an ear discharge (otorrhea) in csom. the discharge can be clear, viscous, or purulent, and persistent or intermittent.1 based on the world health organization (who) regional classification in 2004, the prevalence of csom in developed countries is very low, in the united kingdom (uk) for example, it is only 0.9%. however, the prevalence in developing countries is still high, at around 2-4%.2 a total of approximately 164 million (90%) of the total cases of hearing loss in developing countries is due to csom.2 a survey conducted by the ministry of health in 1994-1996, showed that the prevalence of csom in various provinces in indonesia varies, with a general prevalence of 3.9%.3,4 in h. adam malik hospital, medan, indonesia5 the number of csom patients in 2008 was 154 patients, or 1.4% of the total patients visiting the otorhinolaryngology clinic. hearing impairment may occur in csom cases, and reducing the patients’ quality of life. patients usually come with chief complaint of otorrhea accompanied by hearing loss. inquiries should be performed about the potential risk factors, such as history of the althea medical journal. 2015;2(1) 109 upper respiratory tract infection (urti), recurrent acute otitis media (aom) and allergies.3 the most common causative agent found on csom are staphylococcus aureus, and pseudomonas aeruginosa or mixed flora.3,6 it also found perforation of the tympanic membrane, either in the attic, the central and/or the marginal part of the membrane.7 complications of csom occur when the infection has spread to structures surrounding the middle ear, which is normally confined to the bone.7 complications usually occur in malignant type of csom, which are accompanied by the formation of pathological tissue called cholesteatoma.1 the infection can spread from the middle ear to adjacent structures, in several ways, such as hematogenous, through bone erosion, or through the already established way (such as fracture of the skull, etc).7 those complications cause burdens for the patients.8 there are various classifications of complications, this studyused the souza et al.7 classification which divides the complications into intratemporal and extratemporal complications. the complications which are classified as intratemporal complication, includes mastoiditis, labyrintitis, facial nerve paralysis (fnp) and petrositis. while complication such as meningitis, extradural abscess, subdural abscess, brain abscess, bezold’s abscess, otitic hydrocephalus, sinus thrombophlebitis and retroauricular abscess are classified as the extratemporal complication.7 the treatment in cases with complications require a mastoidectomy procedure beside pharmacotherapy.3,7 the objective of this study was to determine the profiles of csom patients with complications in dr hasan sadikin general hospital bandung. methods secondary data were collected from 117 medical records of theperiod januarydecember 2011 in dr hasan sadikin general hospital bandung. out of 117 medical records, 43 medical records consisted of csom patients who had complications (intratemporal or extratemporal). data of thepatients’ demography (sex, age, education level), risk factor, chief complaint and accompanying complaints, infected ears (unilateral or bilateral), pathological findings (granulation tissue and/or cholesteatoma), complications (intratemporal or extratemporal), and treatments, were collected. intratemporal complications consisted of mastoid abscess, petrositis, labyrinthitis, and fnp. moreover, extratemporal complications consisted of meningitis, extradural abscess, subdural abscess, brain abscess, sinus thrombophlebitis, bezold’s abscess and otitic hydrocephalus. cases with acute exacerbation episode of csom with complications were excluded from this study. this study was approved by the ethical committee of dr. hasan sadikin hospital bandung. data were analyzed with frequency distribution. results based on this study, there were 43 patients of csom with complications out of 117 csom patients, this shows that the rate of complication in csom patients in dr. hasan sadikin hospital bandung was as much as 36.75%. the characteristics were obtained from 43 patients, 24 (55.8 %) were male and 19 (44.2%) female. most of the patients table 1 distribution of csom with complications in patients by age and sex age group (year) sex total male female number percentage n=24 % n=19 % n=43 % 10–19 3 7.0 3 7.0 6 14 20–29 7 16.3 5 11.6 12 27.9 30–39 7 16.3 6 14.0 13 30.3 40–49 2 4.7 2 4.7 4 9.4 50–59 4 9.3 1 2.3 5 11.6 >60 1 2.3 2 4.7 3 7.0 fitrie desbassarie w, arif dermawan, soeseno hadi: profile of patients with complicated chronic suppurative otitis media in dr. hasan sadikin general hospital bandung, indonesia january–december 2011 althea medical journal. 2015;2(1) 110 amj march, 2015 were 30-39 years old (30.3%) (table 1). according to the level of education most of the patients have entered primary education (elementary and junior high school) (62.8%). the clinical symptoms of all the patients were varied. ear discharge (otorrhea) was the most common chief complaint (95.3%) and hearing loss was the most dominated accompanying symptom (53.5%), followed by ear pain (20.9%) and sense of fullness in the ear (11.6%) (table 2). in this study, urti was the most common risk factor that occured in 19 patients (44.2%), only 16.3% was acute otitis media (aom), followed by allergy (11.6%). according to complications, most of the csom patients had unilateral complication (93%) and intratemporal complication (72%). both intratemporal and extratemporal complications only occured in 26% cases. granulation tissue was more commonly formed (32.5%), followed by both granulation tissue and cholesteatoma (20.9%). meanwhile, only 6.9% cholesteatoma were found. from the complications, mastoiditis was the most frequent complication found, followed by a combination of retroauricular fistule and mastoiditis. all the cases were given treatment, and the most common prosedure given was mastoidectomy without tympanoplasty (51.2%) followed by pharmacotherapy (figure 1). table 2 clinical symptoms in csom patients with complication complaints number (of person) percentage (%) chief complain ear discharge (otorrhea) 41 95.3 ear pain (otalgia) 2 4.7 accompanying condition hearing loss 23 53.5 ear pain (otalgia) 9 20.9 sense of fullness in the ear 5 11.6 headache 3 7.0 vertigo 1 2.3 pain behind the ear 1 2.3 tinnitus 1 2.3 table 3 distribution of complications complications frequency (person) percentage (%) extratemporal 1 2.3 retroauricular abscess 1 2.3 intratemporal 31 72.1 mastoiditis 30 69.8 facial nerve paralysis 1 2.3 extratemporal and intratemporal 11 25.6 bezold abscess, retroauricular fistule and mastoiditis 1 2.3 retroauricular abscess and mastoiditis 1 2.3 retroauricular fistule and mastoiditis 8 18.6 meningitis and mastoiditis 1 2.3 althea medical journal. 2015;2(1) 111fitrie desbassarie w, arif dermawan, soeseno hadi: profile of patients with complicated chronic suppurative otitis media in dr. hasan sadikin general hospital bandung, indonesia january–december 2011 discussions patients with complications in dr. hasan sadikin general hospital bandung were mostly aged between 30-39 years, as much as 13 patients or 30.3%. the results are consistent with the results of other studies, at the h. adam malik, hospital in medan, which showed that most csom patients were aged >20 years (71.2%).9 with a acomposition of 24 male patients (55.8%) and 19 female (44.2%), thus male was more dominant than female. also, the same study in h. adam malik, hospital in medan9, showed similar results, with 30 male and 29 female patients. in this study, the majority (62.8%) of csom patients with complications only had primary education. primary education in this study refers to 9-year compulsory education in indonesia, which includes elementary and junior high school. this is consistent with results of a study conducted by periasamy10 at h. adam malik hospital, which states that most csom patients have a low education level. based on the data above, it can be concluded that the csom tends to occur in people with a low education level, or knowledge. as we know, knowledge can affect behavior, so perhaps one of the causes of the high incidence of csom with complications is because the patient seeks for medical treatment when the complication has already arisen. in this study urti is the highest risk factor which is consistent with the result of lasisi et al.11 in nigeria, which showed that the most common risk factor in csom patients was urti by 45%. this study also found other risk factors, such as aom and allergies by 16.3% and 11.6% respectively. as much as 41 csom patients were with complications (95.3%), with ear discharge (otorrhea) as their chief complaint. the most common accompanying complaint was hearing loss in 23 patients or as much as 53.5%. this result is consistent with other studies conducted in pakistan.12 this is also consistent with a study in the republic of congo, where otorrhea became the chief complaint along with hearing loss as the accompanying complaint.13 most csom patients developed unilateral complications. this result is consistent with another study conducted by ghonaim et al.14 in children patients with csom in egypt in 2011. in this study, we found that granulation tissue was formed on 14 patients (32.5%), while cholesteatoma on 3 patients (6.9%). this result is different from another study, conducted by hossain et al.15 in mymensingh medical college hospital in bangladesh, who found cholesteatoma in all csom patients with complications . in this study intratemporal complications are more prominent than extratemporal complications (table 3). the most common intratemporal complication is mastoiditis found in 35 patients (97.7%). this result is consistent with other studies conducted in h. adam malik hospital, medan, which also shows that 25.4% of the complications that occurs in csom patients, was mastoiditis.9 in cairo, figure 1 distribution of treatment given to csom patients with complications althea medical journal. 2015;2(1) 112 amj march, 2015 egypt and in marocco, mastoiditis was also the most common intratemporal complication by 65%.16,17 further, from 12 patients with extratemporal complications, retroauricle fistule was the most common complication in 9 patients (20.9%). this result was different from a study conducted by ceylan et al.18 in turkey. in that study, retroauricle fistule occured only in 7 patients or 7.3% out of 97 csom patients with complications. also, multiple complications occured in 11 patients or as much as 25.6%. this result is consistent with a study conducted in turkey by yorgancilar et al.19 the most treatment given on csom patients with complications in dr. hasan sadikin general hospital bandung is mastoidectomy (figure 1). this result is consistent with the result of another study in the republic of congo13, where mastoidectomy was performed on majority of csom patients with complications. the limitation of this study is the data are obtained only from one teaching hospital in indonesia and should be compared to other teaching hospitals in indonesia. percentage of csom with complication in dr. hasan sadikin general hospital bandung is still high. data collected from other hospitals in west java should still be obtained so that a broader scope of this disease could be achieved. references 1. djaafar za, helmi, restuti rd. kelainan telinga tengah. in: soepardi ea, iskandar n, bashiruddin j, restuti rd, editors. buku ajar ilmu kesehatan telinga hidung tenggorok kepala & leher. 6th ed. jakarta: balai penerbit fkui; 2007. p. 64-77. 2. acuin j. chronic suppurative otitis media: burden of illness and management options. geneva, switzerland: who library cataloguing in publication data. 2004. 3. helmi. otitis media supuratif kronis: pengetahuan dasar, terapi medik, mastoidektomi, timpanoplasti. jakarta: balai penerbit fkui; 2005. 4. sirlan f, suwento r. hasil survei kesehatan indera penglihatan dan pendengaran pada 7 provinsi di indonesia tahun 1994-1996. jakarta: depkes; 1997. 5. kurniadi a. karakteristik penderita ottitis media supuratif kronis di rumah sakit umum pusat haji adam malik pada tahun 2008-2009 [minor thesis]. medan: universitas sumatera utara; 2012. 6. saputri rah. pola bakteri aerob pada pasien otitis media supuratif kronis dewasa di poliklinik tht-kl rsup dr. hasan sadikin bandung periode 31 maret-11 mei 2009 [minor thesis]. bandung: universitas padjadjaran; 2009. 7. helmi, djaafar za, restuti rd. komplikasi otitis media supuratif. in: soepardi ea dkk, editors. buku ajar ilmu kesehatan telinga hidung tenggorok kepala & leher. 6th ed. jakarta: balai penerbit fkui; 2007. p. 7885. 8. baumann i, gerendas b, plinkert pk, praetorius m. general and disease specific quality of life in patients with chronic suppurative otitis media--a prospective study. health qual life outcomes. 2011;9:48. 9. amaleen s. gambaran penderita otitis media supuratif kronis di rumah sakit umum pusat haji adam malik pada tahun 2009 [minor thesis]. medan: fakultas kedokteran universitas sumatera utara; 2011. 10. periasamy p. gambaran karakteristik penderita otitis media supuratif kronik yang dirawat inap di rumah sakit umum pusat haji adam malik, medan tahun 2009 [minor thesis]. medan: universitas sumatera utara; 2011. 11. lasisi ao, olaniyan fa, muibi sa, azeez ia, abdulwasiu kg, lasisi tj, et al. clinical and demographic risk factors associated with chronic suppurative otitis media. int j pediatr otorhinolaryngol. 2007;71(10):1549–54. 12. memon ma, matiullah s, ahmed z, marfani ms. frequency of un-safe chronic suppurative otitis media in patients with discharging ear. j liaquat uni med health sci. 2008;7(2):102-105. 13. matanda rn, muyunga kc, sabue mj, creten w, van de heyning p. chronic suppurative otitis media and related complications at the university clinic of kinshasa. b-ent. 2005;1(2):57–62. 14. ghonaim mm, el-edel rh, bassiony lm, alzahrani ss. otitis media in children: risk factors & causative organisms. ibnosina j med bs. 2011;3(5):172-181. 15. hossain mm, kundu sc, haque mr, shamsuzzaman ak, khan mk, halder kk. extracranial complications of chronic suppurative otitis media. mymensingh med j. 2006;15(1):4-9. 16. abada rl, mansouri i, maamri m, kadiri althea medical journal. 2015;2(1) 113fitrie desbassarie w, arif dermawan, soeseno hadi: profile of patients with complicated chronic suppurative otitis media in dr. hasan sadikin general hospital bandung, indonesia january–december 2011 f. complications of chronic otitis media. ann otolaryngol chir cervicofac. 2009; 126(1):1–5. 17. mostafa be, el fiky lm, el sharnouby mm. complications of suppurative otitis media: still a problem in the 21st century. orl j otorhinolaryngol relat spec. 2009;71(2):87-92. 18. ceylan a, bayazit y, yilmaz m, celenk f, bayramoglu i, uygur k, et al. extracranial complications of chronic otitis media. j int adv otol. 2009;5(1):51-5. 19. yorgancilar e, yildirim m, gun r, bakir s, tekin r, gocmez c, et al. complications of chronic suppurative otitis media: a retrospective review. eur arch otorhinolaryngol. 2013;270(1):69-76. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 69 detection of streptococcus pyogenes from throat swab in acute pharyngitis patients ibnu tsabit maulana,1 imam megantara,2 ike rostikawati husen3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine, universitas padjadjaran, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: pharyngitis is an inflammation of throat that may be caused by viral and bacteria. although streptococcus pyogenes is only responsible for 5−15% of cases of pharyngitis in adults. antibiotics are highly prescribed for this infection, thus it could lead to antibiotic resistance. the main reason for antibiotic overprescription is the difficulty to obtain a rapid and correct etiological diagnosis. this study aimed to determine the frequency of streptococcus pyogenes from throat swab in patient with acute pharyngitis in padjadjaran clinic. methods: this study was a descriptive study. specimen was taken from the patients in padjadjaran clinic on september until october 2014. thirty-five patients with acute pharyngitis that met the selection criteria were recruited for throat swab. then, specimens obtained were performed an identification testing to determine whether there was a colonization of streptococcus pyogenes. results: thirty five patients were found with acute pharyngitis consist of 14 male and 21 female, with age ranged between 16−34 years old. from the identification testing result, streptococcus pyogenes was not found from throat swabs of patient with acute pharyngitis in padjadjaran clinic. conclusions: this study found no colonization of steptococcus pyogenes in throat swabs of acute pharyngitis patients in padjadjaran clinic, however streptococcus pyogenes was not the causative fact of acute pharyngitis. [amj.2016;3(1):69–72] keywords: acute pharyngitis, streptococcus pyogenes, throat swab correspondence: ibnu tsabit maulana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285722332332 email: ibnutsabitmaulana@gmail.com introduction acute pharyngitis is an inflammation of the throat which is very common in primary health care facilities. an accurate diagnosis needs to be established so that the management given is appropriate. virus infection is a major cause of acute pharyngitis, whereas several are caused by bacteria. however, in 15−30% of acute pharyngitis in children, and 5−15% in adults, streptococcus pyogenes are found as the causative organism, which possibly cause a variety of serious complications, such as acute rheumatic fever and glomerulonephritis, if not dealt with accordingly.1 antibiotics are only needed in the management of acute pharyngitis caused by streptococcus pyogenes. although streptococcus pyogenes were found in only a few cases in adults, but the prescribing of antibiotics had reached 78−98%.2 in a research by shehadeh et al.3 it shows that the use of antibiotics among adults, especially students, are often caused by sore throat complaints, regardless the prescribing of antibiotics given. thus, in addition to microbial resistance to antibiotics, exposure to high antibiotic will also increase the duration of treatment, cost of treatment and the number of deaths; caused by the complication of infection that has not been dealt properly.4 centor criteria, consists of fever with temperature above 38.5oc, enlarged lymph nodes, tonsils exudation, with the absence of coughing, can be used to predict the likelihood of streptococcal pharyngitis. however, laboratory tests still need to be performed to determine the causative diagnosis. throat swab culture is the gold standard in diagnosing streptococcal pharyngitis with 90−95% althea medical journal. 2016;3(1) 70 amj march 2016 sensitivity compared to rapid antigen detection test (radt) which is only ranging about 70% sensitivity. high level of antibiotics prescription can be caused by various factors, such as difficulty in determining the causative diagnosis promptly, clinician assumptions about the patient’s desire to be prescribed antibiotics, as well as the tendency of clinicians to prescribe antibiotics even though the etiology is not clear.2 the frequency of streptococcus pyogenes found on acute pharyngitis might be considered by clinicians in prescribing antibiotics. padjadjaran clinic is a university clinic that provides a health care access for the students and the community in jatinangor. however, there were no studies on the frequency of streptococcal pharyngitis in this clinic. this study aimed to determine the frequency of streptococcus pyogenes from throat swabs of adult patients with acute pharyngitis in padjadjaran clinic. methods the study was a descriptive which conducted at the laboratory of microbiology, faculty of medicine, universitas padjadjaran in september to october 2014 after receiving approval from the health research ethics committee faculty of medicine, universitas padjadjaran. from the population who met the selection criteria, 35 people were selected as subjects by using consecutive sampling method. the selection criteria set out in this study were: acute pharyngitis patients with centor criteria in padjadjaran clinic, aged over 15 years old, and were not on antibiotics treatment in the last 2 weeks. the subjects were given an explanation of the purpose and the procedures to obtain the throat swabs and were asked to state their willingness by filling out and signing the informed consent. throat swab specimen collection was conducted on the research subjects who were willing. the throat swabs obtained were taken to the laboratory to be planted on blood agar medium, observed with gram staining, and confirmed by bacitracin test. throat swab culture is the method used in this study, because it is the gold standard in the diagnosis of streptococcal pharyngitis which had the highest sensitivity (90−95%) compared to other methods (radt).5 the minimum number of samples was determined using the minimum sample formula for descriptive categorical variables which resulted in 35 minimum samples. results from the 35 subjects, there were 14 male and 21 female with age ranging from 16 to 34 years old. the laboratory tests showed that, from the culture on blood agar media, the percentage of beta-hemolytic colonies were 23%. gram staining was done on those samples to identify the streptococcal colonies. from the gram staining test, 5% (2 out of 34) were positive streptococci, which both were confirmed by bacitracin test later. the bacitracin test showed negative results on both of the sample, which means the bacteria streptococcus pyogenes were not found in this study. based on the isolation and identification of bacteria, the results showed no bacterial colonization of streptococcus pyogenes in table 1 laboratory test results identification test total percentage (%) types of hemolysis α 9 25.7 β 8 22.9 non-hemolytic (-) 18 51.4 gramstaining on β hemolytic positive, cocci, chain (+) 2 5.72 positive, cocci, chain (-) 6 17.14 bacitracintest on β hemolytic and gram-positive cocci resistent (r) 2 5.72 sensitive (s) 0 0 althea medical journal. 2016;3(1) 71ibnu tsabit maulana, imam megantara, ike rostikawati husen: detection of streptococcus pyogenes from throat swab in acute pharyngitis patients throat swabs of all subjects. discussions this study showed that, from 35 patients with acute pharyngitis, there was no colonization of streptococcus pyogenes found in their throat swabs. this result is different when it is compared to similar studies conducted in other countries. in a study in pakistan6, from 137 throat swabs of acute pharyngitis patients, 4.4% of streptococcus pyogenes colonies were found. likewise, a study in taiwan7, 1% of streptococcus pyogenes were found from 294 patients with pharyngitis. this condition can be caused by the number of subjects and different sampling sites, in which patients who visited the hospital tend to have more severe symptoms compared with patients who came to the clinic. in addition, more number of samples in the other two study could lead to a higher probability of finding streptococcus pyogenes. in this study, the majority of subjects were students, whereas the rest are secondary school students and employees. this could be caused by the ownership of padjadjaran clinic, which is a clinic belonging to a university, so students are more likely to seek treatment at this clinic. in addition, dense population and interaction between individuals who have good health status on campus or residency area may be a risk factor of pharyngitis, allowing the subjects in this study to be mostly students.8 hence, this may be a factor that caused streptococcus pyogenes colonies were not found in this study. in this study, centor criteria was used in subjects selection. it consists of fever above 38.5oc, enlarged cervical lymph nodes, tonsillar exudates, without the presence of coughing.9 although the centor criteria are believed to predict the streptococcal pharyngitis, but a study conducted by roggen et al.10 indicated that the centor criteria are not effective in predicting the presence or absence of streptococcus pyogenes from throat swabs in children. therefore the study still includes all acute pharyngitis patients to become research subjects although they did not meet all the centor criteria.10 in laboratory testing, the specimens were planted on blood agar medium, and incubated for 24 hours to observe the growth of colony and the type of hemolysis formed. although β-hemolytic colonies were found in blood agar media, but in most of the gram staining, the bacteria found were gram-negative. this can be due to gram-negative such as haemophilus influenzae and e. coli, including the normal flora in the oropharynx, have characteristics of β-hemolysis.11 from the streptococci found in gram staining, no colonies were sensitive to bacitracin. this might because the streptococci found may not be streptococcus pyogenes, but were streptococcus agalactiae or streptococcus anginosus which also have the characteristics of β-hemolysis and residential flora in the throat, resulted in the colonies found were not sensitive to bacitracin.11 based on the survey in jordan, 60% of people have poor knowledge on antibiotic resistance, as well as the behavior of antibiotics without prescription to treat specific symptoms, especially sore throat.3 hence, it was suggested to conduct public education about the use of antibiotics, especially to students, in order to reduce the rate of antibiotic treatment without prescription in the community. the entire sampling and laboratory testing in this study was conducted in accordance with the standard procedures and carried out by trained staff, but do not exempt the possibility of error that streptococcus pyogenes did not grow in blood agar medium. further research can also be done with a larger scale, in order to obtain a more accurate percentage that can be compared to previous studies. in conclusion, this study found no colonization of steptococcus pyogenes in throat swabs of acute pharyngitis patients in padjadjaran clinic references 1. carapetis jr. the current evidence for the burden of group a streptococcal diseases. geneva: world health organization. 2004:1−57. 2. madurell j, balagué m, gómez m, cots jm, table 2 amount and percentage of streptococcus pyogenes colonization s. pyogenes colonization frequency percentage (%) positive (+) 0 0 negative (-) 35 100 althea medical journal. 2016;3(1) 72 amj march 2016 llor c. impact of rapid antigen detection testing on antibiotic prescription in acute pharyngitis in adults. faringocat study: a multicentric randomized controlled trial. bmc fam pract. 2010;11(1):1−5. 3. shehadeh m, suaifan g, darwish rm, wazaify m, zaru l, alja’fari s. knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of jordan a pilot study. saudi pharm j. 2012;20(2):125−33. 4. anis k, ariyani k, ikaningsih i, retno k. emerging resistance pathogen: recent situation in asia, europe, usa, middle east, and indonesia. maj kedok indones. 2011;57(03):75−9. 5. choby ba. diagnosis and treatment of streptococcal pharyngitis. am fam physician. 2009;79(5):383−90. 6. palla ah, khan ra, gilani ah, marra f. over prescription of antibiotics for adult pharyngitis is prevalent in developing countries but can be reduced using mcisaac modification of centor scores: a cross-sectional study. bmc pulm med. 2012;12(1):1−7. 7. hsieh th, chen py, huang fl, wang jd, wang lc, lin hk, et al. are empiric antibiotics for acute exudative tonsillitis needed in children? j microbiol immunol infect. 2011;44(5):328−32. 8. bope e. conn’s current therapy. philadelphia: saunders elsevier; 2013. p. 40−3. 9. wessels mr. streptococcal pharyngitis. n engl j med. 2011;364(7):648−55. 10. roggen i, van berlaer g, gordts f, pierard d, hubloue i. centor criteria in children in a paediatric emergency department: for what it is worth. bmj open. 2013;3(4):1−4. 11. brooks gf, butel js, morse sa. jawetz, melnick & adelberg’s medical microbiology. 24th ed. new york: the mcgraw-hill companies, inc.; 2007. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 620 amj december, 2015 prevalence of allergic rhinitis based on world health organization (aria-who) questionnaire among batch 2010 students of the faculty of medicine universitas padjadjaran fauzi,1 melati sudiro,2 bony wiem lestari3 1faculty of medicine universitas padjadjaran, 2department of otolaryngology-head & neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of epidemiology and biostatisticsfaculty of medicine universitas padjadjaran abstract background: allergic rhinitis (ar) is a common disease affecting 5–45% of asian population. although it is not a life-threatening disease, ar significantly hampers the quality of life of the sufferers. the prevalence of ar among adults in indonesia is still unknown. this study aimed to measure the prevalence of ar among batch 2010 students of the faculty of medicine, universitas padjadjaran. methods: a cross-sectional study was conducted during june–october 2013 involving indonesian class batch 2010 students of the faculty of medicine, universitas padjadjaran. the sampling was performed using total sampling approach. the measurement tool used in this study was the indonesian translation of the allergic rhinitis and its impact on asthma-world health organization (aria-who) questionnairee. those who were aware of being diagnosed with ar or had two/more ar defining symptoms in the questionnaire form were considered to have ar. the statistical analysis was conducted by calculating frequencies. results: a total of 207 questionnaire forms were adequately filled out and returned. based on the questionnaire, the prevalence rate of ar was 38.2%. of the 79 ar cases, 66% cases involved females. in addition, 54% of the the ar cases have a parental history of allergic diseases. nasal obstruction and itchy nose were the most frequent symptoms (90%), followed by rhinorrhea (89%), sneezing (82%), and eye symptoms (62%). based on the duration, the majority fell into the intermittent group (91%); whereas based on severity, the majority was in the moderate-severe group (71%). conclusions: the prevalence rate of ar obtained in this study is within the estimated range of asian population. [amj.2015;2(4):620–5] keywords: allergic rhinitis, prevalence, questionnaire correspondence: fauzi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85724030303 email: drfauzi@live.com introduction allergic rhinitis (ar) is a common disease defined as a symptomatic disorder of the nose resulting from ige-mediated inflammation of the nasal membranes after allergen exposure.1 frequent allergens include pollens, moulds, animal dander, and dust mites. the ar is characterized by rhinorrhea (watery runny nose), sneezing (especially violent and in bouts), nasal obstruction, itchy nose, and usually associated with eye symptoms.1,2 the ar can be diagnosed in several steps, consisting of anamnesis, physical examination, and supporting examination. allergic rhinitis and its impact on asthma-world health organization (aria-who) has developed a questionnaire as a screening tool for ar.1 due to its good validity and high sensitivity, ariawho questionnaire has been used widely for many studies related to ar.3 those with the abovementioned classical symptoms of ar are most likely to be allergic. physical examination can reveal the outward signs of allergy (e.g. allergic crease, allergic shiners, etc) and structural abnormality of the nasal cavities. furthermore, supporting examinations may include skin-prick test and/or serum-specific ige, which can confirm the diagnosis of ar.1 the common symptoms of ar often disrupt althea medical journal. 2015;2(4) 621 quality of life including the sleep pattern which may further cause exhaustion, drowsiness, emotional instability, and diminution of performance at the workplace. the ar also has a negative impact on productivity and socioeconomic conditions. according to a survey in the united states, 55% of 8,267 workers stated that ar symptoms had made them unproductive for 3.6 days per year.4 world allergy organization (wao) reported that in the united states alone, the indirect financial loss related to low productivity reached up to $9.7 billion in 2005, whereas the direct financial loss for expenditure on medications and health care provision reached $11.2 billion.2 the ar patients may develop other comorbidities, some of which include asthma, allergic conjunctivitis, and rhinosinusitis. the comorbidities have always been closely linked with ar, for there are histological and immunological similarities between the upper and lower respiratory tracts. the comorbidities can even be more severe that the disorder and may directly have an unfavorable impact on the quality of life.5 epidemiologically, ar affects 10–30% of world population and the prevalence is still increasing.2 according to the 2008 world allergy report6, the prevalence of ar in the low and middle income countries within asiapacific region was estimated to be around 5–45%. unfortunately, the prevalence rate among adults in indonesia is still unknown. meanwhile, it is shown that 64.6% of ar patients who visited the department of otolaryngology-head & neck surgery, dr. hasan sadikin general hospital bandung were between 10 to 29 years old, a relatively productive age group. besides, it is also found that, based on occupation, 45.1% of the patients were students.7 in line with the above explanation, ar is a prevalent devastating disorder that affects primarily young adults. the objective of this study was to measure the prevalence of ar among batch 2010 students of the faculty of medicine, universitas padjadjaran. methods this study was conducted during june– october 2013 using the cross-sectional method as the study design. the aria-who questionnaire that had been translated into indonesian language by an authorized and sworn translator from lia language center and vocational training (lbpp lia) was used. the population of this study was obtained from batch 2010 students of regular class of the faculty of medicine universitas, padjadjaran. the sampling was total sampling. there were thus a total of 207 respondents invited to participate as the subjects in this study. moreover, ethical clearance of this study was released by the health research ethics committee of the faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung. all 207 respondents were asked to fill out the aria-who questionnaire forms. informed consent was obtained from all participants. the questionnaires were then screened and those who answered yes to any of the ar defining symptoms were shortlisted. those who were aware of being diagnosed with ar or those who had two/more ar defining symptoms (rhinorrhea, sneezing, nasal obstruction, and itchy nose) were considered to have ar. the screened ar cases were subsequently classified based on some commonly observed characteristics including sex, parental history, symptoms, and aria-who classifications. eventually, the statistical analysis was performed by calculating frequencies. results all 207 respondents in this study filled out the questionnaire forms adequately. this study revealed that the prevalence of ar among respondents were 79 out of 207 respondents (38.2%), of which more than 60% cases involved female respondents. in addition, more than half of the ar cases have a parental history of allergic diseases (table 1). the ar cases were then classified according to the symptoms that they have or a history of suffering the disease. they might have chosen one or more symptoms provided in the ariawho questionnaire forms. this study revealed that the most frequent symptoms were nasal obstruction and itchy nose, followed by rhinorrhea, sneezing, and eye symptoms (table 2). furthermore, the prevalence of ar among respondents was categorized according to aria-who classification. based on the duration of the symptoms, the ar cases were divided into intermittent and persistent groups; whereas based on the quality of life hampered, they were divided into mild and moderate-severe groups. this study revealed that the majority of the cases were classified as intermittent based on the duration of the symptoms and moderate-severe based on the fauzi, melati sudiro, bony wiem lestari: prevalence of allergic rhinitis based on world health organization (aria-who) questionnaire among batch 2010 students of the faculty of medicine universitas padjadjaran althea medical journal. 2015;2(4) 622 amj december, 2015 quality of life hampered (table 3). discussion it was found that the prevalence rate of allergic rhinitis (ar) among respondents in this study was 38.2%, which is within the estimated range for asian population. world allergy report 2008 reported that in many parts of asia, especially in lowand middleincome countries, the prevalence rate of ar has increased from 5% to 45% as the society is being modernized.6 however, it was found that the actual number varied between countries. for example in the philippines, the overall prevalence of ar among adults based on the 2008 national nutrition and health survey was 20.0%.8 another study conducted in jaipur city, india showed that the prevalence of ar among school-children there was 33.5%.9 meanwhile, the result obtained in this study was actually slightly higher than the estimated range of the global population. the wao reported that ar is a common disease affecting an estimate of 10–30% population globally.2 until recently, the prevalence rate of ar among adults in indonesia is still unknown. in bandung, however, there were 7% perennial ar cases in the age group of more than 10 years old.10 the discrepancy of the result obtained in the current study compared to the global estimate can be due to the study design used. this study was a questionnaire only-based survey. the aria-who questionnaire has actually been widely used as a screening test for ar in many studies due to its high sensitivity. a study conducted in korea concluded that the questionnaire showed better validity compared to the conventional ones.3 however, it was found that the specificity of the questionnaire was not really high, so there might be many false positives included in the results.11 thorough examinations comprising physical examination and diagnostic testing would yield a better and more accurate result.1 another result of this study was the fact that the prevalence of ar among female respondents and male respondents was 66% and 34%, respectively. this is relevant to a study done by asha’ari et al.12 who found that 61.1% of newly-diagnosed ar cases in malaysia involve female patients. likewise, some studies conducted in dr. hasan sadikin general hospital bandung also present similar table 1 characteristics of respondents characteristics allergic rhinitis (n=79) non allergic rhinitis (n=128) sex male 27 (34%) 50 (39.1%) female 52 (66%) 78 (60.9%) parental history mother or father 34 (43%) 14 (10.9%) both parents 9 (11%) 2 (1.6%) no history 36 (46%) 112 (87.5%) total 79 (38.2%) 128 (61.8%) table 2 frequency of the identifiable symptoms identifiable symptoms number of respondents (percentage) nasal obstruction* 71/79 (90%) itchy nose 71/79 (90%) rhinorrhea** 70/79 (89%) sneezing# 65/79 (82%) eye symptoms## 49/79 (62%) note: the respondents may have chosen more than 1 symptom provided in the aria-who questionnaire. *feeling of being unable to breathe through nose **watery, runny nose #violent and in bouts ##watery, red itchy eyes althea medical journal. 2015;2(4) 623 findings, sudiro13 found that 55.3% of the ar cases involved female and, one year later, syukrie7 found 61.0% also involved female patients. moreover, 60.3% of ar cases detected among citizens in taif, saudi arabia14 involved females as well. hence, the high proportion of ar cases among women should be analyzed further to assess whether they are more prone to have ar compared to men. the result showing more female cases in this study could be due to the disproportionate distribution of the subjects. a total of 130 (62.8%) female subjects out of the 207 respondents were invited to participate in this study, so the result in this study could have been exaggeratedly reported in this regard. in the present study, more than half of the ar cases have a parental history of allergic diseases, such as asthma, atopic dermatitis, or ar itself. a western europe-based survey in 2004 showed that there were 68.1% of ar diagnosed patients who reported of having a family history of any allergic conditions.15 asha’ari et al.12 also found that 54.4% of ar patients in malaysia had a family history of allergic diseases. meanwhile, syukrie7 found that 50.4% of ar patients in dr. hasan sadikin general hospital bandung also had a positive family history. it has long been known that the genetic background is one of the most important factors for developing any allergic diseases.1 a child with one atopic parent would possess a 30% risk of having allergic diseases, whereas a child with both atopic parents would possess an additional 20% risk.16 furthermore, a study conducted by tamay et al.17 in istambul, turkey showed that a child with a positive family history carried a greater risk for developing ar. the present study applied the aria-who guidelines to define the diagnostic criteria for ar, which are characterized by having two or more nasal symptoms.9 other conditions that can be presence include eye symptoms. the aria-who questionnaire makes it possible for the respondents to choose more than one symptom that they have or have a history of suffering from. long18 conducted a survey on 1,000 ar patients and found that the majority experienced nasal obstruction (85%), followed by sneezing (63%), eye itchiness (60%), rhinorrhea (56%), watery eyes (51%) and nasal itchiness (41%). saini,9 on the other hand, found that the most frequent symptom was nasal obstruction (48.6%), followed by rhinorrhea (33.0%), sneezing (24.1%), and itchy nose (20.3%). another study conducted in boshroye, iran19 found that rhinorrhea was the most prevalent symptom among atopic group (33%), followed by sneezing (33%), nasal obstruction (28.8%), itchy nose and eyes (18.0%), and other eye symptoms. in the present study, however, it was revealed that nasal obstruction and itchy nose were the highest presenting symptoms (90%), followed by rhinorrhea (90%), sneezing (82%), and eye symptoms (62%). the discrepancy of each study is most likely due to common variations of symptoms within ar patients. the aria-who guidelines were also used as the classification system based on the duration of the symptoms and the quality of life hampered.1 the majority of the ar cases in some of the previous studies fell into persistent group.7,12 interestingly, more than 90% of the ar cases in the present study were in the intermittent group, similar to a study carried out in jaipur city, india,9 although in a much lower percentage. this contrast is most likely due to the different subjects involved table 3 prevalence of allergic rhinitis based on aria-who classification classification number of cases (percentage) based on duration intermittent* 72 (91%) persistent** 7 (9%) based on quality of life hampered mild# 23 (29%) moderate-severe## 56 (71%) total 79 (100%) note: *intermittent: <4 days/week or <4 consecutive weeks **persistent: >4 days/week or >4 consecutive weeks #mild: normal sleep and no impairment of daily activities, normal work or school, no troublesome symptoms ## moderate-severe: one or more: abnormal sleep, impairment of daily activities, abnormal work or school, troublesome symptoms. fauzi, melati sudiro, bony wiem lestari: prevalence of allergic rhinitis based on world health organization (aria-who) questionnaire among batch 2010 students of the faculty of medicine universitas padjadjaran althea medical journal. 2015;2(4) 624 amj december, 2015 in each study. the aforementioned studies involved ar patients who came to the hospital, and there would be a high possibility that they had persistent symptoms so they needed immediate medical interventions. this could also be due to the inconsistency in filling out the questionnaire form. the respondents might not be aware that the symptoms they encountered were in fact more long-lasting. based on the quality of life hampered, the majority of the ar cases fell into the moderatesevere group, which is similar to most studies.7,9,12 moderate-severe is characterized by several conditions such as abnormal sleep, impairment of daily activities, abnormal work/school, or troublesome symptoms.1 the respondents who participated in this study were students who stay mostly in bandung and nearby areas, in which the weather and humidity are suitable for the growth and development of dust mites, commonly dermatophagoides pteronyssinus (der p).1 therefore, it is probable that the subjects have been frequently exposed to the dust mite species. furthermore, the subjects involved in this study were all students and relatively do not have time to do sports or exercises and thus increases the risk to hamper their quality of life. it is known that doing a regular exercise could balance the type 1 and type 2 t helper cells (also known as th1 and th2 cells, respectively) so the hypersensitivity effect would be less severe.20 in conclusion, the prevalence rate obtained in the present study is within the estimated range of asian population. some of the characteristics of the ar cases, including sex, parental history, and aria-who classification were also considered to be relevant to most studies. since this was a questionnaire onlybased survey, further studies that include thorough examinations including physical examination and diagnostic testing would yield a better result on this matter. references 1. bousquet j, khaltaev n, cruz aa, denburg j, fokkens wj, togias a, et al. allergic rhinitis and its impact on asthma (aria) 2008 update (in collaboration with the world health organization, ga(2)len and allergen). allergy. 2008;63(s86):8–160. 2. pawankar r, canonica gw, holgate st, lockey rf, editors. world allergy organization (wao) white book on allergy 2011–2012: executive summary. milwaukee: wao; 2011. 3. chung yj, cho ik, lee ki, bae sh, lee jw, chung ps, et al. seasonal specificity of seasonal allergens and validation of the aria classification in korea. allergy asthma immunol res. 2013;5(2):75–80. 4. camelo-nunes ic, sole d. allergic rhinitis: indicators of quality of life. j bras pneumol. 2010;36(1):124–33. 5. meltzer eo, szwarcberg j, pill mw. allergic rhinitis, asthma, and rhinosinusitis: diseases of the integrated airway. j manag care pharm. 2004;10(4):310–7. 6. pawankar r, baena-cagnani ce, bousquet j, canonica gw, cruz aa, kaliner ma, et al. state of world allergy report 2008: allergy and chronic respiratory diseases. world allergy organ j. 2008;1(6 suppl):4–17. 7. syukrie a. hubungan antara klasifikasi aria-who 2008 dengan hasil tes kulit tusuk pada penderita rinitis alergi yang berobat di bagian ilmu kesehatan thtkl rshs/fk unpad periode 2010 [thesis]. bandung: universitas padjadjaran; 2011. 8. abong jm, kwong sl, alava hd, castor ma, de leon jc. prevalence of allergic rhinitis in filipino adults based on the national nutrition and health survey 2008. asia pac allergy. 2012;2:129–35. 9. saini a, gupta m, sharma bs, kakkar m, chaturvedy g. rhinitis, sinusitis and ocular disease–2085. prevalence of allergic rhinitis in urban school children, jaipur city, india. world allergy organ j. 2013;6(suppl 1):164. 10. sudiro m, madiadipoera th, purwanto b. eosinofil kerokan mukosa hidung sebagai diagnostik rinitis alergi. mkb. 2010;42(1):6–11. 11. hojo m, ohta k, iikura m, mizutani t, hirashima j, sugiyama h. clinical usefulness of a guideline-based screening tool for the diagnosis of allergic rhinitis in asthmatics: the self assessment of allergic rhinitis and asthma questionnaire. respirology. 2013;18(6):1016–21. 12. asha’ari za, yusof s, ismail r, che hussin cm. clinical features of allergic rhinitis and skin prick test analysis based on the aria classification: a preliminary study in malaysia. ann acad med singapore. 2010;39(8):619–24. 13. sudiro m. karakteristik penderita rinitis alergi di bagian i. kes tht-kl rs dr. hasan sadikin bandung/fk unpad tahun 20072009. proceeding of kongres nasional perhati-kl xv; 2010 jul 7–9; makassar. makassar: balai penerbitan universitas hasanuddin; 2010. althea medical journal. 2015;2(4) 625 14. sabry ey. prevalence of allergic diseases in a sample of taif citizens assessed by an original arabic questionnaire (phase i) a pioneer study in saudi arabia. allergol immunopathol (madr). 2011;39(2):96– 105. 15. bauchau v, durham sr. prevalence and rate of diagnosis of allergic rhinitis in europe. eur respi j. 2004;24(5):758–64. 16. male dk, brostoff j, roth db. immunology. 8th ed. philadelphia: saunders elsevier; 2006. 17. tamay z, akcay a, ones u, guler n, kilic g, zencir m. prevalence and risk factors for allergic rhinitis in primary school children. int j pediatr otorhinolaryngol. 2007;71(3):463–71. 18. long aa. findings from a 1000-patient internet-based survey assessing the impact of morning symptoms on individuals with allergic rhinitis. clin ther. 2007;29(2):342–51. 19. fereidouni m, abolhasani a, vahedi f, shakeri mt, varasteh a. a preliminary survey of the prevalence of allergic disorders in a questionnaire-based study in boshroye, a rural area of iran. j public health. 2010;18(2):119–21. 20. kidd p. th1/th2 balance: the hypothesis, its limitations, and implications for health and disease. altern med rev. 2003; 8(3):223–46. fauzi, melati sudiro, bony wiem lestari: prevalence of allergic rhinitis based on world health organization (aria-who) questionnaire among batch 2010 students of the faculty of medicine universitas padjadjaran althea medical journal. 2019;6(1) 42 amj march 2019 effect of carica papaya l leaf infusion on transporting glucose across small intestine cell membrane of wistar rats model srisathis renganatan,1 vycke yunivita,2* anna martiana,2 nida suraya3 1faculty of medicine universitas padjadjaran, indonesia, 2department of biomedical sciences faculty of medicine universitas padjadjaran, indonesia, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia correspondence: vycke yunivita, department of biomedical sciences faculty of medicine universitas padjadjaran, , jalan raya bandung sumedang km. 21 jatinangor, sumedang indonesia , email: v.yunivita@gmail.com introduction diabetes mellitus (dm) is a metabolic disorder with abnormal hyperglycemia due to insulin deficiency or decrease in the biologic effectiveness of insulin. there are two different types of dm, known as type 1 and type 2 dm. type 1 dm related with β-cell destruction in pancreas, whereas type 2 dm due to increased insulin resistance.1 the prevalence rate for dm worldwide is estimated about 8.8% and it will increase 2 to 3 times in 2030, therefore, the number of individual with dm is projected to rise from 171 million in 2000 to 366 million in 2030.2 the main goal of dm treatment is to decrease the glucose level in blood. the therapy management for type 1 and type 2 dm is quite different i.e. the therapy of type 1 dm is insulin treatment, whereas for type 2 dm is by giving hypoglycemic agents such as sulfonylureas, biguanides or alpha-glucosidase inhibitor.3 interestingly, there are various types of herbs that have been used as alternative treatment since olden days.4 one of the plants used in traditional treatment is carica papaya l which can be found in the tropical regions from mexico to panama and also in indonesia.5 the availability of carica papaya l leaf and the related products in the market is increasing recently. the carica papaya l leaf contains phenolics such as protocatechuic acid, caffeic acid, chlorogenic acid a and b, kaemferol and quercetin.6-8 phenolic acids found in the carica papaya l leaf decrease the glucose uptake by blocking the glucose transporters in small intestine.9 the aim of the study was to evaluate the effects of carica papaya l leaf infusion on glucose transport across cell membrane of small intestine. amj. 2019;6(1):42–5 abstract background: carica papaya l leaf is one of the common types of plant that has been used as treatment for diabetes mellitus (dm). the leaf possibly contain quercetin, which may inhibit glucose transport through cell membrane of small intestine. this study was conducted to determine the effect of carica papaya l leaf infusion on glucose transport in wistar rat model. methods: a one-group pretest-posttest explorative study was designed using perfusion method. nine male rats were fasted for 18-24 hours before dissected. a 25 ml glucose solution was given as early control, before carica papaya l leaf infusion treatment a 25 ml glucose solution was later given again after carica papaya l leaf infusion as late control. artificial perfusion equipment had been used to maintain the back and forth flow of glucose in the small intestine. sample was taken every 15 minutes for one hour for each treatment. results: carica papaya l leaf infusion did not decrease the concentration of glucose absorption significantly compared to early control. the mean absorption of glucose in early control was 85.39+4.42 mg/dl and during treatment was 84.51+4.20 mg/dl. conclusions: carica papaya l leaf infusion does not have significant inhibiting effect on glucose transport across small intestine cell membrane. further explorative study is required. keywords: carica papaya l leaf, cell membrane, glucose transport, small intestine, wistar rats. althea medical journal. 2019;6(1) 43 methods this study was one-group pretest-posttest experimental study using perfusion method as described earlier by sudigdo and marsongkohadi10 conducted throughout september 2013 in laboratory of department of biochemistry in faculty of medicine universitas padjadjaran. in brief, 9 healthy male wistar rats that met inclusion criteria were included as followed; 3–4 months old and weighing 150–400 gram. rats with body weight >10% changes during adaptation process were excluded from the study. all rats were adapted in department of pharmacology faculty of medicine, universitas padjadjaran, jatinangor for 7 days with good access to food and drink. carica papaya l leaves were collected from universitas padjadjaran campus area. around 200 g of carica papaya l leaves was weighed using digital scales. the carica papaya l leaves were then mixed with 200 ml of aquadest and heated at 90oc for 15 minutes. the extract of the carica papaya l leaves mix was filtered using filter paper up to 100 ml. rats were food fasted around 18−24 hours prior the experiment. they were anaesthetized with 0.5 ml ketamin before their abdomen was dissected. two cannulas were inserted in the intestine firmly on the distance of 10.0 cm from pylorus; first cannula and second cannula were apart for 25.0 cm. the intestine was then cleaned using 0.9% nacl solution to remove the dirt by blowing each end of the cannulas was fixed to two different test tubes. artificial perfusion equipment was used to maintain the back and forth flow of glucose in the small intestine. all the nine rats were given three treatments, which was 25 ml glucose solution as the early control, 25 ml glucose solution with 1 ml carica papaya l leaf infusion added, and 25 ml glucose solution as the late control. sample was taken every 15 minutes for one hour for each treatment. sample obtained from the experiment was the residual concentration of glucose absorption which was measured via the deproteinization method using spectrophotometer. the concentration of glucose absorption were calculated by decreasing the concentration of standard glucose (100 mg dl-1) with the residual concentration. all subjects were terminated using diethyl ether after the treatment and experiment were finished. as this was an explorative study, no figure 1 glucose absorption concentration between early control and treatment with carica papaya l leaf infusion vycke yunivita, et al.: effect of carica papaya l leaf infusion on transporting glucose across small intestine cell membrane of wistar rats model althea medical journal. 2019;6(1) 44 amj march 2019 sample size calculation was performed and in this study 9 rats were assigned. data of the concentration of glucose absorption were shown into table. the statistical analysis was performed by comparing the treatment group with the early control group to obtain the effect of infusion and by comparing the late control group with the early control group to obtain either the effect was reversible or irreversible using one sample t-test. the reversible and irreversible effect was checked to identify whether the effect the carica papaya l leaf to the small intestine was permanent or only for the treatment period. the protocol of the experiment performed on the laboratory in this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. results the level of glucose absorption for some of the rats had shown a higher absorption rate during the treatment with carica papaya l leaf infusion when compared to the early control (figure 1). however, the mean of glucose absorption in the early control and the treatment phase showed that carica papaya l leaf did not statistically significant decrease in glucose absorption (85.39 mg/dl+4.42) vs. (84.51 mg/dl+4.20) with p value was 0.372. interestingly, the absorption level for the late control group was increased after treatment with carica papaya l leaf infusion. as for the second hypothesis to test whether the effect of carica papaya l leaf was reversible or irreversible by comparing early control group and late control group cannot be tested. this was because there was no significant change in glucose absorption in early control group and treatment group with carica papaya l leaf infusion (figure 1). discussion our study has shown that carica papaya l leaf did not significantly inhibit glucose transport in small intestine cell membrane of rats model. this is possibly caused by the chemical properties quercetin in carica papaya l leaf, which is believed to decrease the glucose absorption in small intestine and did not reach the level of efficacy. besides, the preparation method of the active ingredient for the treatment (infusion, extraction, isolation), or the differences of climate, soil composition where the plant grow, and time of the harvest are possible as causes of the different study results. previous study has shown that carica papaya l leaf can decrease the blood glucose level.11 in this study streptozotocin (ctz) has been given to the rats to induce diabetic rats. furthermore, aqueous extract of carica papaya has been administered as drinking water for one month which may lead to a decrease in blood glucose level. this effect explains as either a decrease in the rate of intestinal glucose absorption or an increase in table 1 the mean of glucose absorption concentration of wistar rats treated with carica papaya l leaf infusion absorbed glucose (mg/dl) early control treatment with carica papaya l leaf infusion late control rat 1 80.00 78.35 79.38 rat 2 78.13 78.75 85.38 rat 3 86.13 86.63 89.50 rat 4 88.38 89.50 90.13 rat 5 85.00 82.41 87.76 rat 6 82.24 82.93 82.76 rat 7 90.28 89.39 89.16 rat 8 90.28 89.39 89.72 rat 9 88.03 87.61 89.72 mean±sd 85.38+4.42 84.99+4.20 87.06+3.79 althea medical journal. 2019;6(1) 45vycke yunivita, et al.: effect of carica papaya l leaf infusion on transporting glucose across small intestine cell membrane of wistar rats model peripheral glucose utilization. increased catabolism of glucose due to glucose transporter 4 (glut4) translocation to the plasma membrane in muscle and brown adipose cells, with up-regulation of the uncoupling protein-1 in brown adipose tissue and hepatic gluconeogenesis, causes hyperinsulinemia effect or increased peripheral glucose utilization. moreover, stimulator activity on β-cells also has been considered as the effect of aqueous extract of carica papaya l which could allow the release of more insulin.11 other study has used alloxan to induce diabetic rats, and aqueous extracts of carica papaya l leaves shows there is a significant decrease in blood glucose level for treated group due to increased secretion of insulin of beta cells or increase of glucose uptake due to increased insulin sensitivity.12 however, in this study there is no significant decrease of glucose absorption in small intestine epithelial cell membrane, suggesting that the effect of carica papaya l leaf to lower the glucose level might be influence by some other way. there were some limitations throughout the study. the effect of carica papaya l leaf whether it is reversible or irreversible by comparing early control and late control group cannot be tested, since there is no significant change in glucose absorption in early control group and treatment group with carica papaya l leaf infusion. in conclusion, carica papaya l leaf infusion in our study does not have significant inhibiting effect on glucose transport across cell membrane of small intestine in wistar rat. different method by using alcohol extract of carica papaya l leaf is of potential benefit, and further investigation with different routes of administration are needed. references 1. maharani u, german m. pancreatic hormones and diabetes mellitus. in: gardner d, shoback d, editors. greenspan’s basic and clinical endocrinology. 8th ed. san francisco: mcgraw hill; 2007. p. 661−747. 2. perkeni. konsensus pengendalian dan pencegahan diabetes mellitus tipe 2 di indonesia. 8th ed. jakarta: perkeni; 2015. p. 1-82 3. molina pe. endocrine physiology. 2nd ed. new york: mcgraw-hill medical; 2006. p. 173−8. 4. modak m, dixit p, londhe j, ghaskadbi s, devasagayam. indian herbs and herbal drugs used for the treatment of diabetes. j clin biochem nutr. 2007;40(3):163−73. 5. indran m, mahmood aa, kuppusamy ur. protective effect of carica papaya l leaf extract against alcohol induced acute gastric damage and blood oxidative stress in rats. west indian med j.2008;57(4):323−6. 6. lim tk. edible medicinal and nonmedicinal plants. carica papaya. 2nd ed. new york: springer;2012. p. 693−717. 7. canin a, alesiani d, d’arcangelo g, tagliatesta p. gas chromatography– mass spectrometry analysis of phenoliccompounds from carica papaya l. leaf . j food comp anal. 2007;20(7):580 ̶ 90. 8. abdullah nr., afzan a, halim sz, rashid ba, semail rh, abdullah n, et al. repeated dose 28-days oral toxicity study of carica papaya l. leaf extract in sprague dawley rats. molecules. 2012;17(4):4326−42. 9. gray n. phenolic compounds may regulate glucose transport: study. 2010;[cited 2013 february 24] available from: http://www. drpressman.com/phenolic-compoundsmay-regulate-glucose-transport-study/. 10. marsongkohadi, sudigdo. effect of herbal leaf infusion on transporting glucose across small intestine cell membrane of wistar rat [dissertation]. bandung: institut teknologi bandung;1988. 11. juarez-rojop ie, daaz-zagoya jc, blecastillo jl, miranda-osorio ph, castellrodraguez ase, tovilla-zarate ca, et al. hypoglycemic effect of carica papaya leaves in streptozotocin-induced diabetic rats. bmc complement altern med. 2012;12(1):236. 12. maniyar y, bhixavatimath p. antihyperglycemic and hypolipidemic activities of aqueous extract of carica papaya linn. leaves in alloxan-induced diabetic rats. j ayurveda integr med. 2012;3(2):70−4. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 6 amj march 2016 the distribution of pubertal age among male school students in jatinangor district from april to june 2013 karthik yogaswaran,1 anggraini widjajakusuma,2 juliati3 1faculty of medicine universitas padjadjaran, 2department of epidemiology and biostatistics faculty of medicine universitas padjadjaran, 3department of physiology faculty of medicine universitas padjadjaran abstract background: puberty is important and exciting lifetime changes in an individual. many new changes are experienced during puberty, such as physically, mentally, and emotionally. currently, young males worldwide have different onset of pubertal age. many factors may result in this change of pubertal age. the exact pubertal age was still unknown due to less study conducted previously. therefore, the aim of this study was to identify the distribution of pubertal age among male school students in jatinangor. methods: a descriptive study was conducted from april to june 2013. a secondary data were obtained from the jatinangor cohort study, from the department of epidemiology and biostatistics, faculty of medicine, universitas padjadjaran. the samples were taken via cluster random sampling from 48 schools around jatinangor. randomization was conducted and a total of 219 male students were finally obtained from the overall data which had at least single onset of pubertal changes. this presents a response rate of 82.33%. results: the earliest onset of pubertal age was identified as 9 years old and the oldest onset was 18 years old. the majority onset of pubertal age ranged from 12 to 15 years old with average mean of 13 years. voice changes were identified as the early sign of puberty among males. conclusions: majority of the students undergo puberty at age 13 which is earlier compared to previous studies. thus, this study indicates decreasing in onset of pubertal age among male school students in jatinangor. [amj.2016;3(1):6–11] keywords: jatinangor, male school students, pubertal age, puberty correspondence: karthik yogaswaran, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6283821350838, email: irthik_sujo22@yahoo.com introduction changing trends occurring between childhood and adulthood, in the transitional phase of growth and development varies in every individual. this period is known as pubertal phase.1 the development of physical growth is known as adolescence stage which roughly ranges from 11–19 years old.2 according to american academy of pediatrics (aap), currently, young males start puberty much more earlier compared to previous decades.1 now, males begin puberty six months to two years earlier. some males undergo precocious puberty (pp), as the development of pubertal changes, at an age younger than the accepted lower limits for age of onset of puberty.3 thus, united state boys reach puberty between ages of 9–10, compared to 25 years ago where the first sign of puberty occurs at ages of 11 years or more.4 black american boys start showing pubertal changes around age 9.1 years while white and hispanic boys undergo changes just after turning 10.5 similar trends towards earlier puberty in boys have been seen in studies in europe.4 however, in asian countries, the mean age for pubertal among males is 15 years old.6 several studies conducted stated that fewer data are available on the age and pattern of pubertal development in boys. this reflects less cultural awareness of male pubertal development.7 besides, the current reducing in the pubertal age is still left unknown and the exact time period of male puberty is not clearly stated. therefore, the aim of this study was to determine the pubertal age among male school students in jatinangor in order to give a hint what intervention should be given. althea medical journal. 2016;3(1) 7 methods the type of study conducted was descriptive study. this study was carried out from april to june 2013. a secondary data were obtained from the jatinangor cohort study from the department of epidemiology and biostatistics, faculty of medicine, universitas padjadjaran. jatinangor cohort study comprised of reproductive health among school students in jatinangor district and was approved by health research ethics committee. the samples were taken via cluster random sampling from 48 elementary school (sekolah dasar, sd), junior high school (sekolah menengah pertama, smp) and senior high school (sekolah menengah atas, sma) around jatinangor, which made up a total of 7542 male students. the six schools selected were sd negeri cibeusi, sd negeri cikopo ii, smp al-masoem, smp pgri, sma pgri and sma negeri jatinangor which had a total of 1250 male students. randomization was conducted by the jatinangor cohort study team by only selecting class iv–vi male students from elementary school, class vii–ix male students from junior high school and class x–xii male students from senior high school which had a total of 266 male students. these students were given an informed consent form to be filled by their parents or guardians. questionnaire forms which comprises of onset of pubertal age measured by secondary sexual characteristics were given to the students. the questionnaire was validated by the jatinangor cohort team. a total of 219 male students were finally obtained from the whole data which had at least single onset of pubertal changes. this presents a response rate of 82.33%. all the data collected from the questionnaires were composed into statistical product and service solutions (spss) software version 15. the distribution of pubertal age among male students was analyzed. all the results were presented in suitable graphs. results a total of 219 male students with onset of pubertal changes were divided according to their level of education. the highest number of onset of pubertal agewas experienced among junior high school students while the lowest number was from elementary school students (figure 1). the earliest age for voice changes among male students was at age 9 years old with a total of 6 students and the oldest occurs at age 18 with only 1 student. the highest number experiencing onset of voice changes was 53 students at age 12 years old. the age range for majority voice changes was 12–14 years old (figure 2). the onset of wet dream occurrence among male students began at age 9 years with a total of 4 students. there are 3 students with onset at age 16 years, while the highest number experiencing onset of wet dream as 66 figure 1 total male student with pubertal changes according to level of education karthik yogaswaran, anggraini widjajakusuma, juliati: distribution of pubertal age among male school students in jatinangor district from april to june 2013 althea medical journal. 2016;3(1) 8 amj march 2016 students at age 13 years old. the age range for majority wet dream occurrence was at 12–14 years old (figure 3). moustache and pubic hair showed earlier onset of growth at age 10 years old, while beard and axillary hair started growing at age 12 years. the highest onset of hair growth varied. the highest number experiencing onset of pubic hair growth was 56 students at age 13 years old. meanwhile, for onset of moustache and axillary hair growth, the highest number experiencing was at age 15 years, with 34 figure 2 number of students with onset of voice changes according to age figure 3 number of students with onset of wet dream occurrence according to age althea medical journal. 2016;3(1) 9karthik yogaswaran, anggraini widjajakusuma, juliati: distribution of pubertal age among male school students in jatinangor district from april to june 2013 students and 25 students respectively. onset of beard growth had the highest number at age 16 years with 27 students. thus, the majority age range for sexual hair growth among jatinangor boys was 12–15 years (figure 4). the earliest age for penis, scrotal, and testes enlargement among male students was at age 9 years old. penis and testes enlargement had the same highest number experiencing its onset which was at age 13 with 47 students figure 4 number of students with onset of sexual hair growth according to age figure 5 number of students with onset of sexual organ enlargements according to age althea medical journal. 2016;3(1) 10 amj march 2016 and 22 students respectively. meanwhile, the highest number experiencing onset of scrotal enlargementwas 19 students at age 15 years old. the majority age range for the enlargement was 12–15 years old (figure 5). discussion the study to find the distribution of pubertal age among the 219 students was conducted. the students were divided according to the onset of pubertal age corresponding with their pubertal changes. the pubertal changes that were taken in count were voice changes, moustache growth, beard growth, axillary hair growth, pubic hair growth, penis enlargement, scrotal enlargement, testes enlargement, and occurrence of wet dream. the range of pubertal age was based on the earliest onset of pubertal changes and the latest onset. the majority age range was also identified from this study. the result showed that the earliest onset of pubertal changes was at age 9 years old and the oldest onset occured at age 18 years old. this showed a wide range of pubertal onset among jatinangor males. in elementary school, there were 25 students with onset of pubertal changes and among them, the highest onset was seen in occurrence of wet dreams. fourteen students experienced these changes, while voice changes took second highest with 11 students experiencing it. meanwhile, among junior high school students, pubertal changes occured in 100 students. wet dreams occured mostly in all students, followed by voice changes and pubic hair growth. finally, there were 94 students obtained from senior high schools with onset of pubertal changes. wet dreams, voice changes, and pubic hair growth still remained the most frequent secondary sexual changes with onset of puberty. however, more students experienced voice changes prior to wet dream occurrence, resulting in voice changes as early sign of puberty in jatinangor male school students. the majority onset of pubertal changes occured at age 12–15 years old. this showed a clear decrease in the onset of pubertal age. previous study showed that the onset of puberty among asian males is 15 years old.6 now, males began puberty six months to two years earlier. similar trends towards earlier puberty in boys have been seen in studies in europe. united state boys reach puberty between ages of 9–10, compared to previous years where average boys undergo the first sign of puberty around 11 years old or more.4,7 voice changes had the highest number of students experiencing earlier onset which is at age 12 years old. study showed that generally aboy’s voice starts to change somewhere between ages of 11–15 years.2 thus, for males in jatinangor, the voice changed at age 12–14 years old. voice changes is a result of hormonal changes, the increase of testosterone level during puberty.6 the secondary sexual characteristic is due to the result from the stimulation of gonads by pituitary gonadotropin. testes enlargement are relatively constant untill age 11 years then the testicular enlargement begins.8 similar trend was seen among males in jatinangor. this sudden increment could be the result of the hormonal changes that takes place in the male students.2 therefore, certain studies classify the increase in testicular size as a definite sign of puberty.8,9 the distribution of hair growth is also similar to other secondary sexual characteristics. the majority age range for onset of hair growth is also 12–15 years old. pubic hair has the earliest growth at age 12 just after increase in the testicular volume. this showed the change in testosterone production in a male undergoing pubertal age.8 occurrence of wet dreams is also strongly related to change in body hormonal level. the factor that causes this decreasing trend of pubertal age is still unknown. although puberty is mostly due to the change in body hormonal level, but current lifestyle and environmental factor could be causes of early onset of puberty among younger generations.10 current lifestyle which includes the dietary pattern on an individual might be a predisposing factor to the decrease in onset of puberty in males. huge amount of fat intake is said to fasten the body metabolism to result in an early onset of puberty.4 the study proves that the distribution of pubertal age is at age 12–15 years old. however, the number of participants in this study was based on the data obtained from department of epidemiology and biostatistics faculty of medicine, universitas padjadjaran. thus, limited information was obtained from the data. additional information on the pubertal age could not be obtained as the data was collected prior to the study. for the upcoming study, other criteria of concluding the onset of puberty among males, such as tanner staging can be conducted with proper procedures to obtain a better result. tanner staging will give a more precise result on what stage of pubertal development does that the individual is going through. althea medical journal. 2016;3(1) 11karthik yogaswaran, anggraini widjajakusuma, juliati: distribution of pubertal age among male school students in jatinangor district from april to june 2013 in conclusion, the pubertal age in jatinangor is around age 9–18 years old with the majority age range of 12–15 years old. the overall mean age for onset of puberty is 13 years old. the sign of puberty that appears early is voice changes followed by wet dreams and pubic hair growth. references 1. abbassi v. growth and normal puberty. pediatrics.1998;102(2 pt 3):507–11. 2. elizabeth are, seth d. pubertal development: correspondence between hormonal and physical development. child dev. 2009;80(2):327–37. 3. carel jc, leger j. precocious puberty. n engl j med. 2008;358:2366–77. 4. herman-giddens me, steffes j, harris d, slora e, hussey m, dowshen sa, et al. secondary sexual characteristics in boys: data from the pediatric research in office settings network. pediatrics. 2012;130(5):e1058–68. 5. harris p. boys are reaching puberty earlier. new york: the guardian; 2012 [cited 2012 october 20]; available from: http://www. guardian.co.uk. 6. xenos p, sulistinah a, lin hs, luis pk, podhisita c, raymundo c, et al. delayed asian transitions to adulthood: a perspective from national youth surveys. asian population studies. 2006;2(2):149– 83. 7. euling sy, lee pa, selevan sg, juul a, sorensen t, dunkel l, et al. examination of us puberty-timing data from 1940 to 1994 for secular trends. pediatrics. 2008;121 suppl 3:s172–91. 8. fujienda k. pubertal development in japanese boys. clin pediatr endocrinol. 1993;2(suppl 3):7–14. 9. okuno a. physical growth and hormonal changes in late childhood and early adolescence. clin pediatr endocrinol. 1993;2(suppl 3):1–6. 10. louis gm, marcus m, ojeda sr, pescovitz o, selma fw, wolfgang s, et al. environmental factors and puberty timing. pediatrics. 2008;121 suppl 3:s192–207. althea vol 2 no 3 final.indd althea medical journal. 2015;2(3) 314 amj september, 2015 factors related to the intention to cigarette smoking among junior high school students in jatinangor subdistrict, west java ngu ling yee,1 deni kurniadi sunjaya,2 r. m. haryadi karyono3 1faculty of medicine universitas padjadjaran, 2department of public health, faculty of medicine universitas padjadjaran, 3department of psychiatry faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung abstract background: cigarette smoking is known to harm the health of smokers and causes the death of millions people around the world. smoking initiation in indonesia is begun early especially during teenagers year. the aim of the study was to analyze the factors related to the intention to cigarette smoking among junior high school students in jatinangor subdistrict. methods: a quantitative method with cross sectional study was conducted in the junior high school setting during the period of september to november 2013. inclusion criterias were students aged 13 15 years old and did not smoke. four factors were measured in this study, which were attitudes toward cigarette smoking, parents who smoke, peers influence and advertisement where each factor had 5 questions with ‘yes’ or ‘no’ answers. data were collected through self-administered questionnaire among 226 students using stratified random sampling. statistical analysis of the variables was using chi square test. results: as much as 44.25% of the respondents had intention and 55.75% had no intention to cigarette smoking. this study showed significant relation among attitudes, parents who smoke, peers influence and advertisements with the intention to cigarette smoking. conclusions: half of the respondents have intention to cigarette smoking and the most factors related to it are peers influence. [amj.2015;2(3):314–18] keywords: cigarette smoking, intention, junior high school students correspondence: ngu ling yee, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85956395002, email: lingyee501@gmail.com introduction cigarette smoking is widely known to cause health problems and is responsible for many diseases and premature death that reduce quality of life and life expectancy.1,2 in many developed countries, the number of smokers have declined rapidly, but in indonesia, smoking prevalence has increased substantially.2 approximately, 61 million indonesians smoke2 caused indonesia ranks the fifth of countries with the most cigarette consumption.3 the majority of smokers tend to start smoking at a young age usually during teenager’s period. about 78% smokers begin to smoke before 19 years old.4 the total percentage that smokes between 1995 –2007 is 0.3 2% aged 10– 14 years and 7.1–18.8% aged 15– 19 years.5 according to riset kesehatan dasar (riskesdas) 2007, the highest smoking prevalence above 10 years in the provinces of indonesia was bengkulu (29.5%), followed by lampung and west java (28.8% and 26.6%, respectively).7 according to survei sosial ekonomi daerah (suseda) 2008, the average age for smoking initiation in sumedang district, west java was 18.68 years old.8 the theory of planned behavior (tpb) is used to predict factors that affect individual intention to engage in behaviors such as cigarette smoking. tpb presumes intention to cigarette smoking is derived from behavioral attitude, subjective norms and perceived behavioral control with each contributes to achieve the cigarette smoking behavior.9 hence, with the high smoking prevalence and people start smoking at a young age, a study was conducted among junior high althea medical journal. 2015;2(3) 315 school students to analyze factors related to the intention to cigarette smoking in jatinangor subdistrict. methods a cross sectional study was carried out to 226 junior high school students aged 13–15 years old in jatinangor subdistrict. these students were selected using stratified random sampling from 11 junior high school madrasah tsanawiyah (mts) ma’arif (moslem junior high school and smp persatuan guru republik indonesia (pgri). the inclusion criteria in this study were junior high school students aged 13– 15 years who did not smoke, while exclusion criteria were students who did not agree to participate and did not fill in the questionnaire completely. the questionnaire comprised three parts. the first part contained items on the characteristics of the respondents including sex, class and age. the second part was to determine whether the respondents had tried cigarette smoking before and their intention to cigarette smoking. the last part was about the four factors measured in this study, these were attitudes toward cigarette smoking, parents who smoke, peers influence and advertisement where each factor had 5 questions with ‘yes’ or ‘no’ answers. a preliminary study was conducted to 20 respondents to test the feasibility of the research questionnaire validity and reliability. all ethical issues in this study were approved by the health research ethics committee faculty of medicine universitas padjajdjaran. data collection was conducted in a specific classroom. before the distribution of the questionnaire, the objective of the study was explained and the respondents were assured that all the information would be kept privately. furthermore, consent forms with the signature of the respondents were requested to those who agreed to participate. permission from the school authority to conduct this study was obtained previously. during the time of the questionnaire’s administration, there were no teachers involved. this study explained every item in the questionnaire in detail to ensure the understanding of each respondent. respondents who had difficulties in answering the questions, could ask for assistance from the representative of the research team. after the respondents completed answering the questionnaires, the questionnaires were checked thoroughly to determine every part of questions was answered. each factor was categorized into low risk or high risk depending on the median, as the data were not normally distributed. the data were analyzed using a computer and statistically analyzed using the chi-square test (p<0.05). results both genders almost evenly equivalent with 115 female and 111 male participated in this study. the majority of the respondents were table 1 respondents characteristics demographic frequency percentage (%) gender male 111 49.12 female 115 50.88 age (years old) 13 127 56.19 14 73 32.30 15 26 11.50 table 2 intention to cigarette smoking intention to cigarette smoking frequency percentage (%) yes 100 44.25 no 126 55.75 total 226 100 ngu ling yee, deni kurniadi sunjaya, r. m. haryadi karyono: factors related to the intention to cigarette smoking among junior high school students in jatinangor subdistrict, west java althea medical journal. 2015;2(3) 316 amj september, 2015 13 years old (56.19%). respondents who had the intention to cigarette smoking was less than respondents who did not have the intention to cigarette smoking (table 2). based on statistical analysis, there were significant relations among attitudes toward cigarette smoking, parents who smoke, peers influence and advertisements with the intention to cigarette smoking. the relation between peers influence with the intention to cigarette smoking had the strongest relation compared to attitudes toward cigarette smoking, parents who smoke and advertisements. discussions in this study, the number of respondents who had intention to cigarette smoking was considerably high. apparently, peers influence was the most prevailing factor associated with the intention to cigarette smoking among junior high school students in jatinangor subdistrict. according to the theory of planned behavior (tpb), attitudes toward cigarette smoking and parents who smoke were determined by the individual’s belief concerning the consequences of the cigarette smoking behavior and an evaluation of the values about the cigarette smoking consequences.10 peers influence using tpb suggest self-perception concerning others people expectation eventually acted as a source of pressure to individuals whether they should or should not engage in cigarette smoking behavior.9 the existence of advertisements may ease or hinder individuals to have intention to cigarette smoking.9 this study was consistent with the theory where attitudes toward cigarette smoking, parents who smoke, peers influence and advertisements were found to be associated with the intention to cigarette smoking. nurdin et al.11, showed that adolescents feel insecure about how their peers think about them and want to be somehow similar to their peers so that they would not be left out. students spend their time mostly at school with their peers and these are crucial since they are involved with each other in almost table 3 factors related to the intention to cigarette smoking factors intention to cigarette smoking p x2 contingency coefficient chave intention no intention f % f % attitudes toward cigarette smoking low risk 33 14.60 100 44.25 0.000 49.491 0.424 high risk 67 29.65 26 11.50 total 100 44.25 126 55.75 parents who smoke low risk 55 24.34 118 52.21 0.000 46.395 0.413 high risk 45 19.91 8 3.54 total 100 44.25 126 55.75 peers influence low risk 22 9.73 107 47.35 0.000 90.096 0.534 high risk 78 34.51 19 8.41 total 100 44.25 126 55.75 advertisements low risk 26 11.50 94 41.59 0.000 52.884 0.435 high risk 74 32.74 32 14.16 total 100 44.25 126 55.75 note: x2 table = 3.841 althea medical journal. 2015;2(3) 317 all of the daily activities. according to halil12, peers influence resulted in adolescence to engage in cigarette smoking behavior as a way to be accepted into a certain peer group. according to braverman and aarø13, most people initiate cigarette smoking behavior during adolescence. cigarette advertisements are the main tools emphasized by the tobacco industries to target this group of people by portraying positive images of cigarette smoking. thus, adolescents are more prone to smoke when they have more positive views on cigarette smoking. rapeah et al.14 showed that positive attitudes towards cigarette smoking cause an individual to engage in this behavior even though they know the danger of cigarette smoking. for instance, cigarette smoking can portray a cool image. according to gilman et al.15, parents who smoke either mother or father play an important role in initiation smoking behavior among adolescents because they tend to watch their parents smoke. the adolescents believe that cigarette smoking is a normal activity of an adult as they watch their parents smoke which in turn encourage them to initiate cigarette smoking. lastly, this study did not vary from the theory and the results found were consistent with other studies. however, there were limitations in this study. since the questionnaire was completed individually at school, there was a possibility that some respondents may have given inaccurate answers either on purpose or unintentionally on any of the questions inquired. furthermore, the research method conducted in this research was the quantitative method which did not enable the researcher to have more understanding on the associated factors with the desire to cigarette smoking. from this study, it can be concluded that there were relations among attitudes toward cigarette smoking, parents who smoke, peers influence and advertisements with the intention to cigarette smoking. in the end, it was found that peers influence had the strongest relation with the intention to cigarette smoking among junior high school students in jatinangor subdistrict. for future research, it is recommended to use qualitative measures to achieve a better understanding on how these factors involved are associated with desire to cigarette smoking among adolescents and also other factors that may be involved. health institutions were recommended to be more proactive in organizing campaign regarding the dangers of cigarette smoking. moreover, the school should share a vital part in promoting the danger of cigarette smoking where strong cooperation between education and health institutions are important in the school setting when promoting programs regarding the cigarette smoking prevention. most of the time is spent by the adolescents at school and effective cigarette smoking prevention programs need to be established before the students graduate from school. school based health programs especially the usaha kesehatan sekolah (uks) can integrate anti-smoking programs in any form into the school activities and carried out frequently where the students can be actively involved in it. references 1. centers for disease control and prevention. health effects of cigarette smoking. 2013 [cited 2013 february 2]; available from: h t t p : / / w w w. c d c . g o v / t o b a c c o / d a t a _ statistics/fact_sheets/health_effects/ effects_cig_smoking/ 2. adioetomo sm, djutaharta t, hendratno. cigarette consumption, taxation and household income: indonesia case study. in: de beyer j, editor. health, nutrition population discussion paper, economics of tobacco control no.26. washington: the international bank for reconstruction and development/the world bank; 2005. 3. ministry of health republic of indonesia. the tobacco source book: data to support a national tobacco control strategy (english translation). jakarta: ministry of health, republic of indonesia; 2004. 4. barber s, adioetomo sm, ahsan a, setyonaluri d. tobacco economics in indonesia. paris: international union against tuberculosis and lung disease. 2008. 5. reimondos a, utomo id, mcdonald p, terence hull, suparno h, utomo a. policy background no. 2: smoking and young adults in indonesia. in: australian demographic and social research insitute, editor. the 2010 greater jakarta transition to adulthood survey. canberra: the australian national university. 2012. 6. tobacco control support center, ikatan ahli kesehatan masyarakat indonesia (tcsciakmi). bunga rampai: fakta tembakau dan permasalahannya di indonesia tahun 2010. jakarta: tcsc-iakmi. 2010. 7. departemen kesehatan ri. riset kesehatan dasar (riskesdas) 2007: laporan nasional. ngu ling yee, deni kurniadi sunjaya, r. m. haryadi karyono: factors related to the intention to cigarette smoking among junior high school students in jatinangor subdistrict, west java althea medical journal. 2015;2(3) 318 amj september, 2015 jakarta; 2008 [cited 2013 january 28]. available from: http://www.riskesdas. l i t b a n g . d e p k e s . g o . i d / d o w n l o a d / tabelriskesdas2010.pdf. 8. bps provinsi jawa barat. penyusunan data sosial ekonomi daerah provinsi jawa barat tahun 2008.2008 [cited 2013 february 3]. available from: http://www. jabarprov.go.id/assets/data/menu/data_ sosial_ekonomi_provinsi_jawa_barat_ tahun_2008.pdf. 9. reinecke j. testing the theory of planned behavior with latent markov models. in: reinecke j, langeheine r, editors. applications of latent trait and latent class models in the social sciences. münster: waxmann; 1997. p. 398–411 10. brannon l, feist j. health psychology: an introduction to behavior and health. 7th ed. belmont: wadsworth, cengage learning; 2009. 11. nurdin, hongkrailert n, chompikul j. smoking behavior among senior high school students in banda aceh municipality, nanggroe aceh darussalam province, indonesia. journal of public health and development. 2008;6(3):85– 93. 12. halil e. examining the adolescents’ smoking according to their peer pressure levels and gender. acad med. 2003;3(1):179–88. 13. braverman mt, aarø le. adolescent smoking and exposure to tobacco marketing under a tobacco advertising ban: finding from 2 norwegian national samples. am j public health. 2004;94(7):1230–8. 14. rapeah my, munirah y, latifah o, faizahl k, norsimahl s, maryana m. factors influencing smoking behaviours among male adolescents in kuantan district. ann dent. 2008;15(2):77–81. 15. gilman se, rende r, boergers j, abrams db, buka sl, clark ma, et al. parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. pediatrics. 2009;123(2):e274–81. vol 5 no 3 final.indd althea medical journal. 2018;5(3) 149 knowledge and attitude as factors affecting regularity of antenatal care visits titania,1 elsa pudji setiawati,2 hadi susiarno3 1faculty of medicine universitas padjadjaran, indonesia, 2department of public health faculty of medicine universitas padjadjaran,bandung, indonesia, 3department of obstetric and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesia abstract background: maternal mortality ratio and infant mortality rate in indonesia are still high and far from the millennium development goals target. one of the solutions is by making regular antenatal care visits. factors affecting antenatal care are knowledge and attitude. this study aimed to analyze the influence of knowledge and attitude about antenatal care toward regularity of antenatal care visit. methods: this analytic study was conducted by using the rapid survey through cross-sectional approach. the study population was pregnant women in cipacing village, jatinangor sub-district, with 55 samples. questionnaires were distributed to evaluate the knowledge and attitude, and kartu menuju sehat observation was conducted to investigate antenatal care visit. results: out of 55 respondents, 26 had good knowledge, 25 had fair knowledge, and 4 had poor knowledge. only 13 respondents had a good attitude level, while 42 had fair attitude, and none with poor attitude. as many as 46 respondents did antenatal care visits regularly, while 9 did not. logistic regression analysis showed that knowledge and attitude had no significant influence towards regularity of antenatal care visit, with influence only approximately 2%. conclusions: knowledge, attitude, and regularity of antenatal care among respondents are good enough. knowledge and attitude are not the dominant factors that affect the regularity of antenatal care visit. thus a further study is needed to identify the other factors. keywords: antenatal care, attitude, knowledge, regularity of visit correspondence: titania, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: titan.titan12@gmail.com introduction maternal mortality ratio (mmr) and infant mortality rate (imr) are two indicators of the millennium development goals (mdgs), which are mdgs-4 and mdgs-5 respectively.1 based on indonesia demographic and health survey (idhs) 2007, mmr in indonesia was 228 per 100,000 live births.2 the idhs estimates the mmr will be reduced to 161 per 100,000 live births in 2015, which is far from the target of 102 per 100,000 live births.1,2 hence, more effort is needed to reduce mmr. one of the solutions is by applying the kesehatan ibu dan anak book, by making prenatal visits regularly.1,3 antenatal care (anc) refers to a comprehensive approach to optimal medical care and psychosocial support that ideally begins prior to conception and ends with the onset of labor.4 appropriate anc can be achieved by making prenatal visit regularly and periodically, referring to the first visit (k1) and fourth visit (k4).5 appropriate anc aims to reduce the mmr and imr, also the morbidity caused by complications in pregnancy.4 the minimum anc visit is 4 visits during the whole pregnancy, which is one visit during trimester 1 (0–3 month of pregnancy), one visit during trimester 2 (4–6 month of pregnancy), and two visits during trimester 3 (7–9 month of pregnancy).3,6 each visit must meet the minimum standard that covers “7t”. the “7t” includes height measurement, blood pressure measurement, fundal height measurement, tetanus toxoid injection, fe tablet consumption, sexually transmitted disease tests, and consultation to prepare the referral.7 it was reported by basic health research (riskesdas) 2010, that the k1 in pregnant women in indonesia was approximtely 92.7%. among them, about 72.3% has performed k1 during trimester 1. only about 64% pregnant amj. 2018;5(3):149–56 althea medical journal. 2018;5(3) 150 amj september 2018 women has performed k4 in health facilities. meanwhile, there is poor percentage of anc component’s performance in health facilities, that’s only 19.9% 6 in fact, the appropriate anc visit can help to quickly resolve the problems that arise in pregnancy, such as eclampsia, abortus, hemorrhage, and infection which are the major cause of maternal mortality in indonesia.2,3 there are many factors that affect practice, such as knowledge, attitude, health facilities, and infrastructure.8 hence, the regularity of anc visits (practice), can be affected by knowledge and attitude. a previous study in malang9 showed that there is a positive correlation between knowledge and attitude toward the regularity of anc visits. on the contratry, another study in sragen showed there is no relationship between knowledge and anc visits. knowledge and attitude only affect anc visits by 28.3%.10 therefore, this study was conducted to analyze the influence of knowledge and attitude about anc toward regularity of anc visits. methods this was an analytic study through crosssectional approach, which was conducted in cipacing village, jatinangor sub-district, sumedang regency, bandung, from october– november 2012. cipacing village was chosen because the discrepancy between k1 and k4 was 5.52%. besides, cipacing village has the most number of pregnant women in jatinangor; also it is not difficult to access. the population was pregnant women in cipacing village. samples were selected through inclusion and exclusion criteria. the inclusion criteria were residents of cipacing village, willing to participate and sign the informed consent, and had gestational age of at least 3 months at the time the sample was taken. the exclusion criteria were the respondents that could not finish the questionnaire at the time of data collection. among 120 pregnant women in cipacing village, 107 women met the inclusion criteria. table 1 characteristics of respondent variable category frequency (n) percentage (%) age (year) <20 4 7.3 20–35 47 85.5 >35 4 7.3 mean (sd) 28.55 (5.77) range 16–43 occupation not work 35 63.6 work 20 36.4 family income <rp 1,058,978 26 47.3 ≥rp 1,058,978 29 52.7 education none 0 0 primary school 5 9.1 junior high school 22 40 senior high school 23 41.8 college 5 9.1 parity 0 21 38.2 1–4 32 58.2 >4 2 3.6 mean (sd) 1.2 (1.325) range 0–6 althea medical journal. 2018;5(3) 151 the minimum sample was calculated by using the slovin formula because the number of the target population was known, giving a minimum sample of 51.69. as many as 55 samples were taken to anticipate the loss of participants in the course of the study, by using the simple random sampling method. the questionnaire was used to investigate the independent variables, which were knowledge and attitude. the women who consented were asked to fill out the structured questionnaire, which was developed by the researcher based on the kesehatan ibu dan anak book, in indonesian language. interviews by using the questionnaire were conducted for women who could not read. then, the respondents would ask them to show their kartu menuju sehat (kms) to assess the regularity of anc visits. to ensure internal consistency, a reliability test for the knowledge and attitude scale was performed, and given the cronbach’s alpha value of 0.634 and 0.859 respectively. the result showed that the questionnaires were realiable, because they had cronbach’s alfa >0.6. the validity test was carried out by using the corrected item-total correlation score. there were 6 knowledge’s questions and 2 attitude’s questions that had p-value<0.3, therefore, they must be excluded from the questionnaire. pretesting of the questionnaire was conducted to 30 pregnant women in hegarmanah village and cikeruh village, jatinangor sub-district. the respondent’s data, including name, age, occupation, income, last educational status, and parity were collected. the questions of knowledge were divided into several sections, which were knowledge about definition, purpose, frequency, components of anc visit, nutrition in pregnant woman, counseling, and high-risk pregnancy. the scoring used the guttmann scale, which are one point for the right answer and zero point for the wrong answer. the questions of attitude consisted of positive and negative statements. the scoring titania, elsa pudji setiawati, hadi susiarno: knowledge and attitude as factors affecting regularity of antenatal care visits table 2 distribution of anc knowledge based on characteristics of respondent level of knowledge poor fair good total respondents characteristics age (year) <20 1 1 2 4 20–35 3 23 21 47 >35 1 3 4 total 4 25 26 55 occupation not work 3 16 16 35 work 1 9 10 20 total 4 25 26 55 family income <rp1,058,978 3 12 11 26 ≥rp1,058,978 1 13 15 29 total 4 25 26 55 education none primary school 1 1 3 5 junior high school 3 10 9 22 senior high school 11 12 23 college 3 2 5 total 4 25 26 55 parity 0 4 11 6 21 1–4 13 19 32 >4 1 1 2 total 4 25 26 55 althea medical journal. 2018;5(3) 152 amj september 2018 table 3 distribution of right and wrong answers in each question of anc knowledge questionnaire no. question right wrong n % n % 1. know whether the antenatal care should be performed before 3 months of gestational age 31 56.4 24 43.6 2. know whether pregnant women need vitamin supplements 55 100 3. know whether pregnant women are allowed to consume herbal drinks 34 61.8 21 38.2 4. know whether a pregnant woman should do antenatal care at least four times during the whole complete pregnancy (9 months) 32 58.2 23 41.8 5 know whether a pregnant woman can do antenatal care in the village clinic 47 85.5 8 14.5 6. know whether a pregnant woman should have tetanus toxoid (tt) immunization 47 85.5 8 14.5 7. know whether it necessary for pregnant woman to reduce their activity during pregnancy 48 87.3 7 12.7 8. know whether a pregnant woman went to the doctor / midwife only when experiencing danger sign 26 47.3 29 52.7 9. know whether high blood pressure can affect the growth of the baby during pregnancy 47 85.5 8 14.5 10. know whether a pregnant woman need a consultation with physician or midwife to prepare the birth 50 90.9 5 9.1 11. knowing at least one test that should be done when attending antenatal checkup 50 90.9 5 9.1 12. knowing at least one danger sign during pregnancy 55 100 used the likert scale, ranging from 1–4 points. then, the scores of knowledge and attitude in the questionnaire were grouped into good, fair, and poor level; the scores were > 80%, 60–80%, and <60% respectively. the number of anc visits in kms was grouped into regular and irregular visits. a regular anc visit must have a number of anc attendance in kms that is in accordance with the supposed frequency for the respective gestational age. data analysis was processed by using spss version 15.0. the univariate analysis was performed by using frequencies, percentages, means and standard deviations. while the bivariate and multivariate analyseswere performed by using chi-square and logistic regression respectively. chi-square was used because the variables had an ordinal scale and not in pair. logistic regression was performed to test the hypothesis, which is to analyze the influence of knowledge and attitude about anc toward regularity of anc visits. logistic regression was used because this study had multivariables and the dependent variable had a categoric scale. a test was carried out to evaluate the feasibility of the logistic regression. the ethical approval to conduct the study was obtained from the medical research ethics committee of the faculty of medicine, universitas padjadjaran, number….. results a total of 55 pregnant women agreed to participate in this study. the characteristics of respondents were shown by age group; the majority of the respondents were 20–35 years, as many as 47 persons (85.5%). there were high-risk pregnant women who were aged <20 years, and aged> 35 years as many as 4 persons (7.3%) respectively. most of the respondents who did not work were 35 persons (63.6%). as many as 29 persons (52.7%) had a family income ≥ rp1,058,978. among 55 respondents, who were mostly senior high school graduates were 23 persons (41.8%), 22 persons (40%) were junior high school graduates, 5 persons (9.1%) were primary school graduates, and the rest were college graduates. most of the althea medical journal. 2018;5(3) 153 respondents (32 persons) had 1–4 parities, 21 respondents (38.2%) never gave birth, and the rest had >4 parity (table 1). the majority of pregnant women (47.3%) had good level of knowledge. only 7.3% pregnant women had poor level of knowledge whereas 45.5% had fair level of knowledge. the distribution of knowledge was based on the respondent’s characteristics (table 2). the respondents’ level of knowledge were distributed both in women aged 20–35 years and in women who did not work. respondents with poor knowledge were mainly junior high school graduates, had family income <rp1,058,978, and never gave birth. meanwhile, most of the respondents with fair and good knowledge were senior high school graduates, had family income ≥ rp1,058,978, and had 1-4 parities (table 2). furthermore, from the distribution of correct and incorrect answers by the respondents, a total of 47 respondents (85.5%) knew that pregnant women should have tetanus toxoid (tt) immunization. all respondents knew that pregnant women need vitamin supplements as well as knew at least one danger sign during pregnancy. as many as 50 respondents (90.9%) knew at least there was one test that should be carried out during antenatal care. however, only 31 respondents (56.4%) were aware that antenatal care must be performed before 3 months of gestational age. about 58.2% (32 respondents) knew that the antenatal care must be carried out at least 4 times during the whole course of pregnancy. only 26 respondents (47.3%) knew that antenatal care was not only done when they were having danger signs only (table 3). the frequency distribution of attitude based on maternal characteristics showed, the majority of respondents attitudes were fair as many as 42 people (76.4%). only 13 people (23.6%) had good level of attitude and no respondent had a poor attitude. (table 4). titania, elsa pudji setiawati, hadi susiarno: knowledge and attitude as factors affecting regularity of antenatal care visits table 4 frequency distribution of attitude of respondents based on characteristics of the respondents level of attitude poor fair good total respondents haracteristics age (year) <20 4 0 4 20–35 36 11 47 >35 2 2 4 total 42 13 55 occupation not work 30 5 35 work 12 8 20 total 42 13 55 family income <rp1,058,978 21 5 26 ≥rp1,058,978 21 8 29 total 42 13 55 education none 0 0 0 primary school 4 1 5 junior high school 22 0 22 senior high school 15 8 23 college 1 4 5 total 42 13 55 parity 0 18 3 21 1–4 22 10 32 >4 2 0 2 total 42 13 55 althea medical journal. 2018;5(3) 154 amj september 2018 moreover, the majority of the respondents with good and fair attitude was aged 20–35 years, did not work, and had 1–4 parity. respondents with fair level of attitude were mainly junior high school graduates. meanwhile, the respondents with good attitude were mainly senior high school graduates and had family income ≥ rp1,058,978 (table 4). based on the observation of frequency of the anc visits, the majority of the respondents as many as 46 persons (83.6%) carried out anc visits regularly. a total of nine persons (16.4%) had irregular anc visits. bivariate analysis was conducted by using chi-square test to determine the relationship between knowledge and regularity of anc visits (table 5). furthermore, the majority of the respondents on every level of knowledge carried out anc regularly. there were four cells (66.7%) that had expected count less than five, which means that the data were not qualified to be analyzed with chi-square. after the cells were merged and re-analyzed by using the chi-square, there were two cells (50%) that had expected count value less than five. hence, the alternative test which was the fisher exact test was used. the result showed p-value (significancy score) 1.00, which was less than 0.05. this score means that the relationship between knowledge and regularity of anc visits was not significant. the analysis of the relationship between attitude and regularity of anc visits was performed by using chi-square test. based on the data and results of the statistical calculations, the respondents with fair level of attitude mostly had regular anc visits, were as many as 34 people. since there was one cell (25%) with expected count value less than five, the fisher exact test was used as an alternative test. the result showed p-value (significancy score) 0.669, which was more than 0.05. this score indicated that there was no significant relationship between attitude and regularity of anc visits (table 6). the logistic regression analysis was performed to determine the influence of knowledge and attitude towards regularity of anc visits. normality test was not required because it had binary form of data, but it was necessary to test the feasibility of a logistic regression model (overall model fit). the feasibility test was conducted by using the likelihood test and hosmer and lemeshow’s test goodness of fit. based on the test result, this study was feasible to use the logistic regression. the result of the logistic regression analysis showed p-value (significancy score) 0.761, which was more than 0.05. this score indicated that the knowledge and attitude table 5 relationship between knowledge and regularity of anc visits regularity of visits irregular regular level of knowledge poor count 1 3 expected count .7 3.3 fair count 4 21 expected count 4.1 20.9 good count 4 22 expected count 4.3 21.7 table 6 relationship between attitude and regularity of anc visits regularity of visit irregular regular level of attitude fair count 8 34 expected count 6.9 35.1 good count 1 12 expected count 2.1 10.9 althea medical journal. 2018;5(3) 155 as one unit did not significantly affect the regularity of anc visits. meanwhile, the cox and snell r square test showed value 0.021, which means that the regularity of visits could be explained by knowledge and attitude only about 2.1%, while the remaining (97.9%) could be explained by other variables that were not used in this study. discussions this study aimed to determine the distribution of knowledge, attitude, and regularity of anc visits, as well as to analyze the effect of knowledge and attitudes towards regularity of anc visits. the result showed that most of the respondents had good and fair knowledge. the majority of the respondents with good knowledge was senior high scool graduates and had a family income ≥rp1,058,978. referring to the theory, knowledge is influenced by several factors such as education and economy.11 in this study, the attitude was mostly distributed at the fair level of attitude. this result might be due to the majority of the respondents also had fair level of knowledge. this referred to the theory of notoatmodjo8, which state that the knowledge can built the attitude. based on this study, there were 46 respondents (83.6%) who performed ancs visit regularly. from the test results of bivariate statistics, there was neither significant relationship between knowledge and regularity of anc visits nor between attitudes towards regularity of anc visits. meanwhile, based on the result of logistic regression, there was no significant influence of knowledge and attitude towards regularity of anc visits. knowledge and attitude only gave 2.1% influence toward regularity of anc visits, while another 97.9% was given by other factors that were not examined in this study. this result was contradictive with the theory of notoatmodjo8, which stated that practice is preceded by attitude, while attitude is built by knowledge. this indicates that knowledge and attitude are not the only factors that affect the regularity of anc visits. practice (action), which in this case was the regularity of visits, is influenced by other factors, such as the facilities and infrastructure that support the attitude become the practice.8 other external factors that could affect the regularity of anc visits were the levels of activities and time that were owned by the respondent, or the distance that was required for reaching health facilities. iksaruddin12 in his study results reported that the access time is associated with anc visits. maternal characteristics as the confounding factors in this study such as age, occupation, income, education level, and gestation could be the factors that affected the regularity of anc visits. however, it was not analyzed in this study. this study had limitations that could affect the result, such as data inconsistency. the pregnant women data from puskesmas were inconsistent with the actual number of pregnant women in cipacing village. to overcome this problem, the researcher had re-checked the data of pregnant women to the local midwife in cipacing village. the conclusions are, the majority of pregnant women has a good level of knowledge, fair level of attitude, and attends anc visits regularly. there is no significant effect of knowledge and attitude towards regularity of anc visits (p=0.570). further research is needed to identify other factors that influence the regularity of anc visits. the minimal influence of knowledge and attitude towards regularity of anc visits can be a reference for the local health government in planning an effective and efficient way to reduce mmr and imr, and obviously counseling for increasing knowledge alone is not enough. references 1. kementerian kesehatan republik indonesia. capai target mdg’s demi terwujudnya derajat kesehatan masyarakat yang tinggi. makassar: kementerian kesehatan republik indonesia; 2012 [downloaded in 15 april 2012]; available at: http://www.depkes.go.id/index. php/berita/press-release/1802-capaitarget-mdgs-demi-terwujudnya-derajatkesehatan-masyarakat-yang-tinggi.html. 2. hernawati i. analisis kematian ibu di indonesia tahun 2010. in: direktorat jenderal bina gizi dan kesehatan ibu dan anak, editor. jakarta: ministry of health republic of indonesia; 2011. 3. kementerian kesehatan republik indonesia. buku kesehatan ibu dan anak. jakarta: kementerian kesehatan republik indonesia; 2011. 4. cunningham f, leveno k, bloom s, hauth j, rouse d, spong c. williams obstetrics. 23rd ed. new york: mcgraw-hill; 2009. p. 189-237. 5. kementerian kesehatan republik indonesia. variabel dan indikator program titania, elsa pudji setiawati, hadi susiarno: knowledge and attitude as factors affecting regularity of antenatal care visits althea medical journal. 2018;5(3) 156 amj september 2018 gizi dan kia. jakarta: kementerian kesehatan republik indonesia; [cited 2012 april 15]; available at: http:// www.gizikia.depkes.go.id/wp-content/ uploads/downloads/2012/04/definisivariabel-sim-gizi-kia-terintegrasi.pdf. 6. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar (riskesdas) 2010. jakarta: kementerian kesehatan republik indonesia; 2010. 7. prawirohardjo s. pelayanan kesehatan maternal dan neonatal. jakarta: yayasan bina pustaka sarwono prawirohardjo; 2002. 8. notoatmodjo s. ilmu perilaku kesehatan. jakarta: rineka cipta; 2010. 9. candra s, praptono mgh, dewi ni. hubungan tingkat pengetahuan dan sikap tentang antenatal care dengan keteraturan kunjungan antenatal care pada ibu postpartum di posyandu wilayah kerja puskesmas arjowinangun kota malang [thesis]. malang; universitas brawijaya; 2008. 10. asihani d. hubungan antara pengetahuan dan sikap ibu hamil tentang antenatal care dengan kunjungan pemeriksaan kehamilan di rumah bersalin permata bunda sragen [thesis]. surakarta: universitas sebelas maret; 2009. 11. notoadmodjo s. pendidikan dan perilaku kesehatan. jakarta: rineka cipta; 2003. 12. iksaruddin. hubungan antara pengetahuan ibu hamil tentang pelayanan antenatal dengan kunjungan periksa hamil di puskesmas pintas tuo kabupatan tebo provinsi jambi [minor thesis]. semarang: universitas diponegoro; 2009. althea medical journal. 2015;2(3) 453 body mass index and western ontario & mcmaster universities osteoarthritis index in patients with knee osteoarthritis in dr. hasan sadikin general hospital, bandung in november 2012 ainna binti mohamad dat,1 tertianto prabowo,2 alwin tahid3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: osteoarthritis is one of the major disabilities among elderly. one of its well-recognized potent risk factors is obesity. the aim of this study was to identify the body mass index and severity of knee osteoarthritis patients who were treated in dr. hasan sadikin general hospital bandung. methods: a descriptive study was carried out to 9 patients of the medical rehabilitation policlinic at dr. hasan sadikin general hospital bandung in november 2012. patients were diagnosed as having knee osteoarthritis based on american college of rheumatology clinical classification. exclusion criteria were patient having previous trauma in spine and lower limb, having bleeding disorder like hemophilia, incomplete data in medical records and incomplete data in questionnaire. western ontario and mcmaster universities osteoarthritis index (womac) was used to measure the intensity of pain, stiffness, and functional difficulty. the weight (kg) and height (cm) of the patients were measured and the body mass index was calculated by weight (kg)/height² (m). the data were analyzed using frequency distribution. results: the patients who came to the medical rehabilitation policlinic had ranged in age from 57 to78 years, mostly female with knee osteoarthritis bilateral. out of 9 patients, 5 patients were overweight, followed by normal bmi and obese type i. patient with obese type 1 had the highest womac score. conclusions: most of the patients with knee osteoarthritis bilateral are overweight and the patient with obese type 1 has the highest womac score. [amj.2015;2(3):453–7] keywords: body mass index, osteoarthritis, womac score correspondence: ainna binti mohamad dat, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827935036 email: ainna.rockafella@gmail.com introduction in developed countries, osteoarthritis is one of the ten most disabling diseases commonly affecting the elderly and one of the major causes of disability among them. the incidence of knee osteoarthritis is 240 in 100 000.1,3 it is defined as degeneration of articular cartilage, hypertrophy of bone at the margins, and changes in the synovial fluid, making it as the non-inflammatory degenerative joint disease.4 cervical and lumbosacral spine, hip, knee, first metatarsal phalangeal joint, and interphalangeal joint are the commonly affected joints and it might also spread to the wrist, elbow and ankle.2 obesity is one of the well-recognized potent risk factors. this is because during single leg stance, three to six times body weight will be exerted across the knee. thus, in the overweight patient, it may cause an increased load in the axial loading at the knee joint due to repetitive application, leading to degeneration of articular cartilage and sclerosis at the subchondral bone.2,5 classification of obesity is made based on body mass index (bmi) classification. it is a simple index of weight-to-height and can be calculated by dividing weight in kilograms with the square of the height in meters (kg/ m2). therefore, if the patient’s bmi is 30.00 or more, it is already considered as obese.6 in assessing patient with chronic illness, their perceptions of their health status are important since the therapeutic goals include preserving and optimizing their althea medical journal. 2015;2(3) 454 amj september, 2015 health-related quality of life.7 therefore, to evaluate the severity of knee osteoarthritis, western ontario and mcmaster universities osteoarthritis index (womac) was being used since it has the ability to assess the pain, stiffness, and physical function of the patient.8 the aim of the study was to identify the body mass index and severity of knee osteoarthritis patients who came to medical rehabilitation policlinic at dr. hasan sadikin general hospital bandung. methods a descriptive study was carried out to 9 patients at the medical rehabilitation policlinic of dr. hasan sadikin general hospital bandung in november 2012. patients were diagnosed as having knee osteoarthritis based on american college of rheumatology clinical classification. to be included in this classification, at least 3 of the following symptoms occurred; aged of 50 years old or more, with stiffness, crepitus, bony tenderness, bony enlargement, and no palpable warmth. exclusion criteria were the patient having previous trauma in spine and lower limb, patient having bleeding disorder like hemophilia, incomplete data in medical records, and incomplete data in questionnaire. all patients were given informed consent before participating in this study. for evaluating the characteristics of severity, the pain and self-report function was observed, whereby womac will be used since it is a scale to measure the intensity of pain, stiffness, and functional difficulty in people with knee or hip oa.9 it consists of 3 subscales with 4 items total (5 pain, 2 stiffness and 17 physical function).10there are 5 response options offered from likert version ranging from ‘none’ which is scored as 0, ‘mild’ as 1, ‘moderate’ as 2, ‘severe’ as 3 and ‘extreme’ as 4.10 the scores are summed for each section to produce pain, stiffness, and physical function subscale score.10 thus, the subscale score for pain can vary from 0–20, subscale score for stiffness can vary from 0-8, and lastly subscale score for physical function can vary from 0–68.10 the total womac score range from 0–96 where 0 represents the best health status and 96 represents the worst health possible status.11 the time taken to administer the test is 5 minutes.10 to calculate the bmi, the weight (kg) and height (cm) of the patient will be taken. the patient will be wearing light clothing, and shoes will be taken off when measuring the weight and height. weight will be measured to the nearest 0.1 kilogram using an electronic scale while standing. height will be measured to the nearest 0.01 meter .to calculate the bmi, the formula is: table 1 bmi classification6 classification bmi(kg/m²) underweight <18.50 normal 18.50–24.00 overweight 25.00–29.99 obese class 1 30.00–34.99 obese class ii 35.00–39.99 obese class iii >40.00 table 2 characteristics of bmi bmi category frequency underweight 0 normal 3 overweight 5 obese 1 1 obese 2 0 total 9 althea medical journal. 2015;2(3) 455 bmi = weight (kg) height² (m) the classification of underweight, normal, overweight and obesity is based on the world health organization (who) recommendation (table 1). results the patients who came to the medical rehabilitation policlinic were 57–78 years old, mostly female with knee osteoarthritis genu bilateral. from 9 patients participating in this study, 5 patients were overweight, followed by normal bmi, and obese type i. the diagram shows that patients whose bmi in obese 1 category had highest mean of womac index score, indicating the highest severity. consecutively, the diagram shows findings followed by normal bmi patient and overweight bmi patient. discussion the patients who came were in age range of 57–78 years old. older age may increase the prevalence rates of 30–50% of the adults whose age were more than 65 years with osteoarthritis for all joints. this is one of the strongest determinants in osteoarthritis.5,12 body mass index (bmi), age, and inability to maintain balance are reported to have positive relation to these characteristics.5 joint vulnerability will increase with age because the cartilage matrix in young cartilage will be stimulated by chondrocytes due to dynamic loading of joints. however, in aged cartilage, it will be less responsive to these stimuli.2 meanwhile in gender, most patients who came to the medical rehabilitation policlinic at dr. hasan sadikin general hospital bandung were female. since women undergo menopause, it may contribute to the risk of hormonal loss which causes an increasing in joint vulnerability.2 in addition to that, the respondents with previous occupation history make up the highest frequency due to their daily activities that require them to move around actively. this biomechanical factor may cause the muscle exhausted gradually due to long days at work, which in turn may reduce the effectiveness in joint protector.2 most respondents came with knee osteoarthritis genu bilateral, whereby most of them having other accompanying diseases. instability, varus or valgus misalignment, chondrocalcinosis, and low intake of vitamin c and vitamin d are some of the risk factors that may progress to the severity of knee osteoarthritis, which present in these accompanying diseases.13 overweight patients are the highest at risk compared to the other bmi index patients coming to the medical rehabilitation policlinic. the disease progression in those who already have knee osteoarthritis may be influenced by being heavy, since a person’s weight may influence the incidence of osteoarthritis.5 during walking, the person with increasing weight receives excessive forces across the knee.2 thus, this in turn may lead to severity figure 1 the characteristics of bmi and mean of womac score index ainna binti mohamad dat, tertianto prabowo, alwin tahid: body mass index and western ontario & mcmaster universities osteoarthritis index in patients with knee osteoarthritis in dr. hasan sadikin general hospital, bandung in november 2012 althea medical journal. 2015;2(3) 456 amj september, 2015 progression of knee osteoarthritis. the obese type 1 patient has the highest mean total of womac index score. this is because the development of the disease is preceded by the obesity and is not only due to inactivity present to those with the disease. overweight patients with increased load in weight-bearing joints will mediate the obesity effect on the development and progression of the disease. therefore obese type 1 patients show higher womac score compared with others. it indicates that obese type 1 has severe knee osteoarthritis compared with normal and overweight patients. meanwhile, comparing normal and overweight patients, the normal bmi patients have higher mean of the total womac index score. this factor could probably occur due to one of the two normal patients is male. as reported from the previous study that it may affect the ability to balance, the severity of knee osteoarthritis is greater in men compared to that in women.5 in other perspective, the diagram shows that weight isnot the only factor that may influence the womac score, other factors may too. functional and pain related scores can also be influenced by low back pain; such as rising from a chair, getting out of bed, and more. thus, womac result cannot be indicated to reflect the lower extremity disease only. in addition, the patient may have referred pain whereby the pain is due to hip osteoarthritis. however, he/she may refer it to the knee.14 besides that, psychological factors also affect the womac scores; such as fatigue and depression. these elements may also lead to actual pain and dysfunction, as reported by the respondents.15 the limitation of this study was the method used, which was descriptive study. this was chosen due to time restriction. therefore, to obtain correlation, the study method that should be used was cohort or case-control. besides that, the samples obtained were very small due to time restriction. apart from that, the variables in this study were incomplete; such as the period of having knee osteoarthritis, the frequency of visiting medical rehabilitation policlinic, and medicine that had been taken to treat the symptoms of knee osteoarthritis disease. in addition, not all confounding factor can be avoided in this study; such as the treatment received by the patient to treat the disease, other accompanying disease, the psychology of the patient, and social-economic status of the patient. this may occur because most of the patients came with severe knee osteoarthritis. they could have already had the risk factors causing the knee osteoarthritis or other progressive factors other the bmi itself. these particular factors may give impact on the knee osteoarthritis severity. understanding further management taken by the patients to overcome the symptom, the treatments should be studied meticulously so that education on proper management to the patient can be done properly in the future. besides that, obesity without any accompanying disease should be studied in order to contribute to the development or progression of knee osteoarthritis. as a result, the management of knee osteoarthritis can be more definite. eventually, a different type of questionnaire should be used to assess the severity of knee osteoarthritis other than womac index score. as a conclusion, the characteristics of the bmi in the patients with knee osteoarthritis who came to the medical rehabilitation policlinic at dr. hasan sadikin general hospital bandung were mostly overweight. in addition, obese type 1 patients had the highest womac score among the other type of bmi index. references 1. who. chronic disease and health promotion, chronic rheumatic condition. 2012 [cited 2012 august 9]. available from: http://www.who.int/chp/topics/ rheumatic/en/. 2. fauci as, weiner c, braunwald e, kasper dl, hauser sl, longo dl, et al. harrison’s value pack. 17th ed. new york: mcgrawhill; 2008. 3. cdc. arthritis 2011 [cited 2013 january 27]; available from: http://www.cdc.gov/ arthritis/basics/osteoarthritis.htm. 4. dorland, editor. dorland’s pocket medical dictionary. 28th ed. philadelphia: elsevier health sciences; 2008. 5. pearson-coel j. literature review on the effects of obesity on knee osteoarthritis. orthop nurs. 2007;26(5):289–92. 6. who. bmi classification [cited 2012 august 10]. available from: http://apps. who.int/bmi/index.jsp?intropage=intro_3. html. 7. clark ja, spiro a 3rd, fincke g, miller dr, kazis le. symptoms severity of osteoarhritis of the knee: a patientbased measure developed in the veterans health study. j gerontol a biol sci med sci. 1998;53(5):m351–60. 8. american college of rheumatology. althea medical journal. 2015;2(3) 457 westen ontario and mcmaster universites osteoarthritis index (womac). 2011 [cited 2012 july 10]; available from: http://www.rheumatology.org/practice/ clinical/clinicianresearchers/outcomesinstrumentation/womac.asp. 9. harrison al. the influence of pathology, pain, balance and self-efficacy on function in women with osteoarthritis of the knee. phys ther. 2004;84(9):822–31. 10. morgan as, nordberg hs. western ontario mcmaster (womac) osteoarthritis index. [report] 2011 [cited 2012 august 9] ; available from: ptoutcome.com/ womac%20publish.doc. 11. hmamouchi i, allali f, tahiri l, khazzani h, mansouri le, alla sao, et al. clinically important improvement in the womac and predictor factors for response to nonspecific non-steroidal antiinflammatory drug in osteoarthritis patient. bmc res notes. 2012;5:58. 12. hunter dj, editor. osteoarthritis: an issue of clinics in geriatric medicine. 26th ed. philadelphia: elsevier health sciencies; 2010. 13. doherty m. risk factors for progression of knee osteoarthritis. lancet. 2001;358(9284):775–6. 14. brandt kd. diagnosis and nonsurgical management of osteoarthritis. new york: professional communications, incorporated; 2010. 15. wolfe f. determinants of womac function, pain and stiffness scores: evidence for the role of low back pain symptoms counts fatigue and depression in osteoarthrits, rheumatoid arthritis and fibromyalgia. rheumatology (oxford). 1999;38(4):355– 61. ainna binti mohamad dat, tertianto prabowo, alwin tahid: body mass index and western ontario & mcmaster universities osteoarthritis index in patients with knee osteoarthritis in dr. hasan sadikin general hospital, bandung in november 2012 althea medical journal. 2016;3(2) 239 existence of antibiotics in stalls at jatiroke village, jatinangor sub district elan jaelani,1 istriati,2 deni kurniadi sunjaya3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine, universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: improper use of antibiotics can lead to lack of drug efficacy against bacteria, and cause resistance to the antibiotics itself. antibiotics are classified into prescription drugs that should not be available over the counter because of its dangerous effect. it is important to study the presence of antibiotics in traditional stalls. objective of this study was to investigate existence of antibiotics in stalls, and to investigate reasons of stallowners for selling antibiotics. methods: this study used mixed method design, and sequential explanatory approach, and conducted direct observation, spatial mapping, and interview with stall-owners selling drugs in jatiroke village, jatinangor sub district from september to november 2013. total sampling was conducted in this study. results: fifty percent from 24 surveyed stalls sold antibiotics amoxicillin. the map showed stalls selling antibiotics at roadside. amoxicillin sold package with dexamethasone and non-steroid anti inflammatory drugs (nsaid) was soldby several stalls. shopkeepers sold antibiotics due to lack of knowledge about the drug, need for self-medication, demand, and availability of drugs supply. conclusions: antibiotics can be found in several stalls in jatiroke village, and improper of use of this drug can lead to resistance and less efficacy for treating infections. although the act for prescription drugs still exists, low of monitoring and enforcement the regulation by the badan pengawas obat dan makanan (bpom) may be one of many factors that influence the existence of antibiotics in the stalls. [amj.2016;3(2):239–43] keywords: antibiotics, existence, jatiroke, stalls correspondence: elan jaelani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: 085353032556 email: j.elan25@gmail.com introduction antimicrobial resistance is an increasing global crisis in developing countries. antibiotic use, particularly over the counter, is widespread.1 various kinds of bacteria that are resistant to antibiotics have been found almost all over the world.2 in poor countries there are multiresistant pathogens such as mycobacterium tuberculosis, pneumococci, uropathogenic escherichia coli (upec), and salmonella. some studies in indonesia conducted by lestari et al.1 and duerink et al.4 presented antibiotic resistant escherichia coli and staphylococcus aureus. from 3.275 individuals 54% has carried resistant escherichia coli. antibiotics are classified into prescription drug classes.5 antibiotics can only be given by the pharmacy with prescription from a doctor.6 many people take self medication which will increase the possibility of any improper use of antibiotics.7 meanwhile, antibiotics can be easily obtained from a pharmacy without a doctor’s prescription, from stalls and drug stores that do not have a license to sell antibiotics. research data in surabaya showed approximately 39 stalls are selling antibiotics.8 the objective of this study was to investigate the existence of antibiotics in stalls which were sold freely, and to investigate the reason of the stall owners for selling antibiotics. methods this study were food stalls that were selling drugs, and were willing to participate in the study by signing an informed consent form. a total of 24 stalls were included in the study, althea medical journal. 2016;3(2) 240 amj june 2016 and the total sampling was performed in this study. there were no inclusion or exclusion criteria for the stalls. this study used the mixed method, sequential explanatory (quantitativequalitative) type of study. meaning that the study collected observation quantitative data on the presence of antibiotics in the stalls first, then proceed with digging out qualitative data on reasons for selling antibiotics. this study also used spatial analysis with the global positioning system (gps) garmin to see the distribution of stalls selling antibiotics. furthermore, the quantitative data were analyzed using the microsoft office excel 2007 program and health mapper program, then displayed as percentages and spatial maps. the qualitative data were analyzed with thematic analysis that incorporated the findings from the interviews about the reasons presented by the shop-owners, and which were later proved by the behavioral theory. results the study revealed that 12/24 stalls sold the antibiotic drug amoxicillin 500 mg. table 1 shows the interview results from the merchants. all the stalls sold amoxicillin 500 mg both generic and patent/trade mark. the average of selling antibiotics in a stall could reach up to 20–40 caplets every month, or about 3 blisters of amoxicillin 500 mg. the price offered by the stallowners was around rp750–rp1000 for each caplet. from the direct observation, amoxicillin 500 mg with a total of 682 caplets was found in 9 stalls, and 3 stalls were out of stock. spatial analysis was performed to find out the distribution of antibiotics vendors amoxicillin was sold by the stallowners in retail, about 1–3 items. it wassometimes combined with dexamethasone and mefenamic acid. obviously, it can be more dangerous than antibiotics if these drugs were inappropriately used. at the time of the survey, several open questions about reasons for selling antibiotics were given to the stallowners. the data described reasons expressed by the stallowners. from the 12 stall-owners who were selling antibiotics, no one could explain the definition, function, and the use of antibiotics. although one of them gave a statement that antibiotics weredrugs for bacteria, but she could not explain more about theuse of antibiotics. most of the answers were “to cure itching, pain relief, toothache, and for chicken supplement”. moreover, it could be seen from the way of selling, most of them retailed the antibiotics per 3 caplets, or even per 1 caplet without giving any information about the dosage to the customers. all stall-owners who sold antibiotics, table 1 interview results variable quantity of stalls n=12 antibiotics sources pharmacy 1 salesman 2 grocery 1 pharmacy, grocery 5 salesman, grocery 1 pharmacy, salesman 2 profit < 20.000 1 20.000–40.000 5 > 40.000 6 customer neighbors, families 6 neighbors 5 retailer 1 althea medical journal. 2016;3(2) 241elan jaelani, istriati, deni kurniadi sunjaya: existence of antibiotics in stalls at jatiroke village, jatinangor sub district initially had no intention to sell them, however after requests, some offerings (salesman) came, and their knowledge that doctors and other health providers often gave antibiotics amoxicillin. it means, the intention for selling antibiotics existed after the request, supply, and their knowledge. several stall-owners also took antibiotics when they themselves or their family members got ill, but most of them preferred to visit health-care facilities such as theprimary health centers, physicians, and other health professionals. it means that they also need antibiotics for self-medication. all stall-owners of stalls selling antibiotics stated that they sold antibiotics because of the demand of residents/neighbors/community around their stall. a total of 7 stall-owners selling antibiotics admitted that they had been offered by a salesman, and sometimes purchased the antibiotics from thesalesman. several stall-owners also told that some family members gave suggestions to sell antibiotics in theirs stalls. it means that the demand, supply and suggestions influenced the stall-owners to sell antibiotics amoxicillin. discussions the results of this was in line with a study conducted in surabaya by hadi et al.8 the stallowner’s lack of knowledge caused customers who bought antibiotics from their stalls did not obtain the right information about the use of antibiotics. antibiotics are prescription drugs which have been set out in the act of prescription drugs (st. no. 419 th. 22, 1949) section 3. this act states that drugs listed in gevaarlijk (g) should not be used for personal use, and may not be given without a prescription from a doctor. based on the health ministry decree no. 167/kab/b.viii/1972 about drug retailers, stalls in this case drug retailers can only sell drugs listed in waarschuwing (w) and over the counter (otc). the ministry of health has developed guidelines for the use of antibiotics in the health ministry decree no.2406/menkes/ per/xii/2011.6 this guide is intended to protect the public from the improper use of antibiotics. all the reasons expressed by the sellers showed no indication that they had to note: the map shows the distribution of stalls which sold antibiotics (+) and did not sell antibiotics (▲). figure 1 spatial mapping of stalls distribution althea medical journal. 2016;3(2) 242 amj june 2016 sell antibiotics. it was more about the profit because of their customer’s demand. antibiotic use was only up to three times (three items) meaning, they did not achieve a minimum of antibiotic treatment. it can cause resistance and ineffectiveness of antibiotics.7 antibiotics could be easily obtained by the stall-owners. they could be bought at the pharmacy without a prescription, such as was described in the studies conducted by hadi et al.8, and puspitasari et al.9, as well as in food groceries, and sometimes there were the salesmen who supply the antibiotics. this means that the regulation which should be applied to these antibiotics was not going well. furthermore, stalls selling antibiotics were violating the rules. behavior of selling antibiotics was changed from behavior of not selling antibiotics. this behavior can be formed by a variety of things, among others by the theory of behavioral change among stimulus theory, dissonance, function, kurt lewin, and theory of action reasons.10 according to the theory of the stimulus by skinner, the behavior change is due to the stimulus, which is backed by the support facilities, and environment encouragement. this study found that the stimulus-backed demand of customers with ease of getting antibiotics, and driven by the absence of prohibiting the sale of antibiotics.10 according to the dissonance theory, behavioral change occurs because of imbalance between elements of cognition (knowledge) of a person. almost all stall-owners selling antibiotics have less knowledge of antibiotics.10 according to the functional theory, behavioral change depends on the need. based on the interviews, most of the sellers stated that they needed these antibiotics when a family member was ill.10 according to kurt lewin’s theory, behavioral change happened when there is imbalance between the driving force and the restraining force. the driving forces of behavior for antibiotics selling were the customer’s demand, supplier, and easiness of getting antibiotics. meanwhile, the restraining forces are lack of knowledge and lack of supervision of related parties.10 the theory of the cause of action stated that behavioral change is influenced by the attitude, desire, and faith. the will is the dominant factor, and is influenced by subjective norms (costbenefit). the stall-owners initially did not have any intention or desire to sell antibiotics, but after demands from customers, and the offer from the supplier raises intention to sell antibiotics.10 the existence of antibiotics in stalls was inappropriate with the regulation of antibiotics distribution. it may be due to monitoring and enforcement of the regulation was not running because the badan pengawas obat dan makanan (bpom or the food and drug administration) as the one responsible for distribution of drugs is only available at the province level, thus they cannot reach the traditional stalls. actually, the stalls are at the road side, and reachable for monitoring the antibiotics sold in the traditional stalls. this study only investigated the stalls and the owners; it needed triangulation for the qualitative study of the costumers, supplier, health district, and bpom. however, the triangulation was not conducted in this study, because it was hampered by time limitations, human resource, and financial resource. in conclusion, antibiotics can be found in several stalls in jatiroke village, and improper of use of this drug can lead to resistance and less efficacy for treating infections. although the act for prescription drugs still exists, low of monitoring and enforcement the regulation by the bpom may be one of many factors that influence the existence of antibiotics in the stalls. stalls selling antibiotics can be formed because it is preceded by a demand from its customers; reinforced by the lack of knowledge about antibiotics; facilitated by the availability of antibiotics in the wholesale (grocery), salean, and pharmacies (purchased otc). the bpom should cooperate with the health district or other parts to run the stewardship function for repairing the health system and giving education to the community about the prescription of drugs. assertiveness should be implemented to those involved in selling freely antibiotics in stalls, or to those who are acting against the existing rules. references 1. lestari e, severin j, filius p, kuntaman k, duerink d, hadi u, et al. antimicrobial resistance among commensal isolates of escherichia coli and staphylococcus aureus in the indonesian population inside and outside hospitals. eur j clin microbiol infect dis. 2008;27(1):45–51. 2. pradono j, senewe f, kristianti cm, sumantri s. transisi kesehatan di indonesia: kajian data surkernas. jurnal ekologi kesehatan. 2005;4(3):336–50. 3. amábile-cuevas cf. antibiotic resistance althea medical journal. 2016;3(2) 243 in mexico: a brief overview of the current status and its causes. j infect dev ctries. 2010;4(3):126–31. 4. duerink do, lestari es, hadi u, nagelkerke n, severin ja, verbrugh ha, et al. determinants of carriage of resistant escherichia coli in the indonesian population inside and outside hospitals. j antimicrob chemother. 2007;60(2):377– 84. 5. fernandes bam. study penggunaan antibiotik tanpa resep di kabupaten manggarai dan manggrai barat-ntt. calyptra: jurnal ilmiah mahasiswa universitas surabaya. 2013:2(2):1–17. 6. kementerian kesehatan ri. peraturan menteri kesehatan republik indonesia no. 2406/menkes/per/xii/2011 tentang pedoman umum penggunaan antibiotika. jakarta: kementerian kesehatan ri; 2011. 7. utami er. antibiotika, resistensi, dan rasionalitas terapi. el-hayah. 2011;1(4):191–8. 8. hadi u, van den broek p, kolopaking ep, zairina n, gardjito w, gyssens ic. cross-sectional study of availability and pharmaceutical quality of antibiotics requested with or without prescription (over the counter) in surabaya, indonesia. bmc infect dis. 2010;10:203. 9. puspitasari hp, faturrohmah a, hermansyah a. do indonesian community pharmacy workers respond to antibiotics requests appropriately?. trop med int health. 2011;16(7):840–6. 10. notoatmodjo s. promosi kesehatan dan perilaku kesehatan. jakarta: rineka cipta; 2012. elan jaelani, istriati, deni kurniadi sunjaya: existence of antibiotics in stalls at jatiroke village, jatinangor sub district althea medical journal. 2016;3(2) 244 amj june 2016 epidemiology of giant cell tumor in dr. hasan sadikin general hospital bandung from 2010-2013 kirtana gunasegaran,1 m.naseh sajadi budi irawan,2 anglita yantiasetiasti3 1faculty of medicine universitas padjadjaran, 2department of orthopaedic and traumatology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: giant cell tumor (gct) of bone is a primary bone tumor. it is commonly seen in south east asia and found in female around 20–45 years old. the gct mostly occurs in epiphysis around the knee. the patients normally suffer from pain, swelling, limitation of joint movement, and pathologic fracture. this study aimed to determine the epidemiology of gct of the bone based on age, sex, location, type, metastases, and recurrence in dr. hasan sadikin general hospital bandung. methods: a descriptive study with retrospective cohort using total sampling method was used to obtain 33 medical records of patients with gct of bone in department of orthopedic & traumatology and anatomical pathology dr. hasan sadikin general hospital bandung in the period of january 2010–december 2013. results: the gct of bone was mostly found in female of 20 to 29 years old and around 32 years old in male. distal femur will be the most common site while zygoma, mandibular vertebrae, proximal tibia were rare sites. twenty nine cases were benign lesion and the rest (4 cases) were malignant. the probability of gct of bone to metastasize to lungs was very low. four recurrences occurred within a year. conclusions: the gct of bone in male mostly occurs in the third and fourth decade of age. it is found around the knee, mostly benign, rarely metastasize to the lungs and recurrence happens within a year. [amj.2016;3(2):244–7] keywords: bone, epidemiology, giant cell tumor correspondence: kirtana gunasegaran, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87822004605 email: kirtana14@gmail.com introduction giant cell tumor of bone is an osteoclastic giant cell-rich tumor and it is also known as osteoclastoma. it is a type of primary tumor in which comprises about 4–5% of all bone tumors.1,2 giant cell tumor (gct) of bone is a benign but locally aggressive primary bone tumor which has significant tendency for local recurrence.3 it is a relatively common tumor happened in south east asia especially in china which has an incidence about 20%.4,5 females are more dominant in having gcts compared to males.1,6 the incidence of gct is highest in 20–45 years old. about 85% of the tumor occurs in those who are older than 19 years with the highest incidence in the third decade of life.7 the gct mostly happens in the end of long bones or metaepiphyseal location with extension to subchondral bone and nearly half of the lesion involve the region around the knee.5,8 patients with gct normally present with pain and swelling on the affected region, maybe with limitation of joint movement and pathologic fracture. there are two types of gct: benign and malignant. benign is the most common type of gct of bone whereas malignant gcts are very rare. when it comes to malignant, it can be further divided into primary and secondary. the recurrence of the tumor depends on the type of surgical interventions, localization of tumor and its extension to soft tissues.9 it accounts about 15– 50% of the cases.1 rarely, gct can metastasize to the pulmonary region and they only account about 2% of gcts.1 based on the background above, author is interested to find out about the epidemiology of gct of bone based on age, althea medical journal. 2016;3(2) 245 sex, location, type, metastases, recurrence and get a clear concept on the distribution of the disease. methods this was a descriptive study with retrospective cohort using 33 medical records of gct of bone patients at the department of orthopedic & traumatology and anatomical pathology dr. hasan sadikin general hospital bandung. total sampling method was used to take the samples. the inclusion criteria were those who had been diagnosed with gct of bone from 1st january 2010 until 31st december 2013. incomplete medical records were excluded. the variables studied were age which was divided into six categories based on the decades, sex, location, type, metastases and recurrences of the tumor. after permission letter and ethical clearance were taken from the health research ethics committee faculty of medicine universitas padjadjaran, and dr. hasan sadikin general hospital bandung, the data needed were recorded and classified accordingly to its variables using microsoft excel. results there were 33 gct of bone patients divided into different age categories. based on the age category, the third decade had the highest frequency with 13 patients. the lowest frequency was in the range of first decade with 1 patient out of 33 patients who was a 9 year old female. eighteen out of 33 patients were males (table 1). distribution of gct of bone patients were in different locations. the most common location based on the data taken was in distal femur (10 patients) and followed by proximal tibia with total of 9 patients. thus, gct of bone in 19 patients occurred at the common location which was situated around the knee region. the distal femur, proximal tibia, distal radius, and proximal humerus were normally affected site of gct while, zygoma, mandibular, vertebrae and distal tibia were the rare sites (table 2). most of the gct of bone in the patients were benign with total 29 out of 33 patients. malignant feature of typical gct was rare. it was seen in only 4 people. however, there was no description of transformation from benign to malignant gct of bone in the medical record but the patients were just diagnosed of having malignant gct of bone (table 2). there was only one patient out of 33 patients in which the gct of bone metastasized to the lungs (table 3). only 4 out of 33 patients with gct of bone had recurrence after the tumor remission or after they underwent the primary treatment since gct of bone became tendency to recur, the recurrence in the patients occurred within a year after the procedure (table 4). table 1 frequency of gct of bone patient based on sex and age variable frequency (n=33) age (years) 0–9 1 10–19 4 20–29 13 30–39 7 40–49 4 >50 4 sex male 18 female 15 table 2 frequency of gct of bone patient based on location and type variable frequency (n=33) location zygoma 1 mandibular 1 vertebrae 1 distal radius 2 distal ulna 2 ramus pubis 2 distal femur 10 distal tibia 1 proximal tibia 9 calcaneus 2 pedis tarsal 2 type benign 29 malignant 4 kirtana gunasegaran, m.naseh sajadi budi irawan, anglita yantiasetiasti: epidemiology of giant cell tumor in dr. hasan sadikin general hospital bandung from 2010-2013 althea medical journal. 2016;3(2) 246 amj june 2016 discussions according to this study, the highest frequency was found in 13 patients in the third decade of age. it was followed by fourth decade of age which consists of 7 people. subsequently, about 20 out of 33 patients with gct of bone were found in the third and fourth decade. this was because gct occurred in a skeletally matured bone. mostly the tumor occurred in those who were older than 19 years old with the highest incidence in the third decade of age.9 according to world health organization (who), most of the incidences occurred in patients between the ages of 20–45 years old. there is only one female patient in the first decade of age with gct of bone. the case is occurred due to arare occurrence in immature skeleton.1 there is a higher number of male patients diagnosed with gct of bone compared to female with the ratio of 1.2:1. however, in other study, the gct of bone is more prone to female compared to male with the ratio of 1.2:1. this is because females reach skeletal maturity 2 years in advance than male.10,11 based on another study conducted by few doctors from a cancer hospital in western india in 2007, it shows that males have apredominance of 57%.12 the most common location of gct of bone is proximal tibia and followed by distal femur. this is because it mostly occurred in the epiphysis or metaepiphyseal location with extension to subchondral bone and the most table 3 frequency of gct of bone patient based on metastases metastases location frequency (n=33) yes lung 1 others 0 no 32 commonly affected region is the knee which was about 50–55 %.2,5 in this study, the very rare site of gct of bone even occurs in one patient each, affecting zygoma, mandibular, vertebrae and distal tibia. besides that, there are only four patients with gct affecting the rare site, the bones of the feet. it is documented by who that less than 5% of gcts affects the tubular bones of both hands and feet.1 in this study, the benign type of gct of bone is the most common, that is 29 patients compared to malignant gct of bone that has only four patients. this is because the malignant-formed tumor is very rare.13,14 three patients out of four with malignant gcts are male. however, in this study, the patients were diagnosed with malignant gct of bone but the transformation of the gct of bone from benign to malignant was unclarified. the gct of bone metastasized only in one male patient out of 33 patients in accordance with the clinical information of the medical record of this study and the lungs is the common site for gct of bone to metastasize because of the systemic spread.15 recurrence rate of the tumor occurs in patients with gct of bone and after they underwent the treatment. it is reported that most of the recurrence occurred within two years following the treatment.3 based on this study, it is found that four patients who are two males and two females have recurrence of gct of bone within one year. recurrences depend on the type of surgical interventions, localisation of tumor and its extension to soft tissues.9 in conclusion, gct of bone patients occurs mostly in the third and fourth decade of age. male is more prone to gct of bone compared to females. furthermore, the knee region is the most common site for this tumor to occur. gct of bone is mostly in benign form and the probability of it to metastasize is very low. even if it metastasizes, it commonly goes to the lungs. the recurrence rate for gct of bone occurs within a year in four out of 33 patients according to this study. due to limited time, the medical records of gct of bone are only collected from 1st january 2010 until 31st december 2013 and are not taken from wide range of years. beside that, the recurrence status of patients with gct will be unknown unless they have been followed up for few months or years after the treatment. as the recommendations, the epidemiology of gct of bone should be known especially for those who are in their second or third decades and females should be aware of their risk of table 4 frequency of gct of bone patient based on recurrence recurrence duration (year) frequency (n=33) yes < 1 4 1–2 0 >2 0 no 29 althea medical journal. 2016;3(2) 247kirtana gunasegaran, m.naseh sajadi budi irawan, anglita yantiasetiasti: epidemiology of giant cell tumor in dr. hasan sadikin general hospital bandung from 2010-2013 having gct of bone and thus take precaution and seek early treatment before it is too late. incomplete medical records results in insufficient information. hence, good anamnesis, physical examinations, laboratory examinations and supporting evidences such as imaging studies should be done to get a better diagnosis and there are high chances for better management of the disease. this study can be used for further descriptive studies on gct of bone and this can assist the population of bandung to get to know about the disease and become more aware. references 1. fletcher cd, bridge ja, hogendoom pc, mertens f. osteoclastic giant cell-rich tumors. in: who. who classification of tumors of soft tissue and bone. 4th ed. lyon: international agency for research in cancer; 2013. p. 319–22. 2. bhatia s, miszczyk l, roelandts m, nguyen td, boterberg t, poortmans p, et al. radiotherapy for marginally resected, unresectable or recurrent giant cell tumor of the bone: a rare cancer network study. rare tumors. 2011;3(4):e48. 3. saikia kc, bhattacharyya td, bhuyan sk, bordoloi b, durgia b, ahmed f. local recurrences after curettage and cementing in long bone giant cell tumor. indian j orthop. 2011;45(2):168–73. 4. niu x, zhang q, hao l, ding y, li y, xu h, et al. giant cell tumor of the extremity retrospective analysis of 621 chinese patients from one institution. j bone joint surg am. 2012;94(5):461–7. 5. saikia kc, bhuyan sk, borgohain m, saikia sp, bora a, ahmed f. giant cell tumour of bone: an analysis of 139 indian patients. j orthop sci. 2011;16(5):581–8. 6. chakarun cj, forrester dm, gottsegen cj, patel db, white ea, matcuk gr. giant cell tumor of bone: review, mimics, and new developments in treatment. radiographics. 2013;33(1):197–211. 7. unni kk, inwards cy. giant cell tumor (osteoclastoma). in: unni kk, inwards cy. dahlin’s bone tumors. 6th ed. philadelphia: lippincott william & wilkins; 2010. p. 225-42. 8. muramatsu k, ihara k, taguchi t. treatment of giant cell tumor of long bones: clinical outcome and reconstructive strategy for lower and upper limbs. orthopedics. 2009;32(7):491–501. 9. heijden lv, dijkstra ps, sande mv, hogendoorn pc, kroep jr, nout ra, et al. the clinical approach toward giant cell tumor of bone. oncologist. 2014;19(5):550–61. 10. raskin ka, schwab jh, mankin hj, springfield ds, hornicek fj. giant cell tumor of bone. j am acad orthop surg. 2013;21(2):118–26. 11. federman n, brien ew, narasimhan v, dry sm, sodhi m, chawla sp. giant cell tumor of bone in childhood: clinical aspects and novel therapeutic targets. pediatr drugs. 2014;16(1):21–8. 12. gupta r, seethalakshmi v, jambhekar na, prabhudesai s, merchant n, puri a, et al. clinicopathologic profile of 470 giant cell tumors of bone from a cancer hospital in western india. ann diagn pathol. 2008;12(4): 239–48. 13. kadowaki m, yamamoto s, uchio y. late malignant transformation of giant cell tumor of bone 41 years after primary surgery. orthopedics. 2012;35(10):e1566– 70. 14. amanatullah df, clark tr, lopez mj, borys d, tamurian rm. giant cell tumor of bone. orthopedics. 2014;37(2):112–20. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 147 upper lower segment ratio comparison between obese and normal children aged 7 to 10 years old muhammad zulfikar azhar,1 rm. ryadi fadil,2 edhyana k. sahiratmadja3 1faculty of medicine, universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3departement of biochemistry and molecular biology faculty of medicine, universitas padjadjaran abstract background: upper lower segment ratio is an anthropometric measurement that often used to detect the presence of abnormal growth. growth is affected by many factor, one of them is nutrional status. obesity prevalence in indonesian children increases annually. these children show an accelerated growth in prepuberty compared to normal children in their age. this study aimed to analyze the difference in upper lower segment ratio between obese and normal children aged 7 to 10 years old. methods: a cross sectional study was carried out in children aged 7 to 10 years old in three elemantary school in bandung during september–october 2013. height and weight were measured to calculate body mass index (bmi) score and were grouped into obese (bmi >95th percentile) and normal (bmi 10th–85th percentile). the upper lower segment ratio was compared between obese and normal children and the level of the significant difference were analyzed by unpaired t-test. results: from a total of 200 children recruited, 90 were obese and 110 were normal. there was no significant difference between upper lower segment ratio in obese and normal children (p=0.603) with mean ratio 1.137 and 1.142 respectively. the mean of upper lower segment ratio in obese boys was higher than normal boys (mean ratio 1.15 and 1.14 respectively), but obese girls had a lower ratio compared to normal girls (mean ratio 1.12 and 1.14 respectively). conclusions: there is no difference between upper lower segment ratio in obese and normal children aged 7 to 10 years old. [amj.2016;3(1):147–51] keywords: children, obesity, upper lower segment ratio correspondence: muhammad zulfikar azhar, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6283829243963 email: mz.azhar@hotmail.com introduction upper lower segment ratio is a component of growth anthropometric measurement in children. this measurement is often used to detect the presence of abnormal growth especially in school-aged children.1 change of upper lower segment ratio can cause abnormal body proportions. this can affect psychosocial aspect in school-age children.2 the measurement of upper lower segment ratio is affected by several factors, such as age, gender, and race.1 obesity is one of nutritional status disorders that can affect growth in children. . obese children as those who have body mass index (bmi) more than 95th percentile in cdc bmi-for-age growth chart.3 world health organization (who) stated that obesity was ranked as the fifth leading cause of death globally. who estimates that there are more than 1.4 billion adults and 40 million children in the world considered overweight and obese.4 according to the study of de onis et al.5 the prevalence of overweight and obese children in southeast asia showed an increasing for every 5 years. according to riset kesehatan dasar (riskesdas) conducted by indonesia department of health in 2010, the number of obese children aged 6 to 12 years reached 12%.6 in pre-pubertal age, most of obese children experience growth velocity earlier than other children at their age.7 hormonal changes is one of the factor that caused obese. hormonal changes that occurs such as presence of abnormalities in the growth hormoneinsulin-like growth factor-1 axis (gh-igf-1 althea medical journal. 2016;3(1) 148 amj march 2016 axis), increased aromatization of androgen into estrogen, and increased level of leptin.8 this study aimed to observe the difference in upper lower segment ratio between obese and normal children aged 7 to 10 years old. methods a cross sectional study was carried out from october to november 2013 in 7 to 10 years old children from three elementary schools in bandung which were selected by multistage random sampling. the first stage randomization was done at subdistrict level, the 3 selected subdistricts were mandalajati, bandung kulon, and sumur bandung. each subdistrict represented east, west, and central bandung region, respectively. the second stage randomization was performed at the school level in each district, the 3 selected schools were elementary school (sekolah dasar/sd) negeri jatihandap 2, sd negeri tunas harapan, and sd kartika siliwangi ix-1. the primary data were collected with minimal sample of 84 children for each group, whether their bmi status were obese or normal. an informed consent regarding the procedure of this study was informed to the children’s parents a week prior to the measurement. this study included healthy boys and girls aged 7-10 years old who hadbmi designated as obese and normal in bandung. subject were excluded if their parents did not give consent, had chronic disease or other disease e.g. body dysplasia, klinefelter syndrome, marfan syndrome, or was undergoing specific therapy i.e. radiation therapy that could interfere upper lower segment ratio measurement. all measurements were performed by team of 3 medical students who had been trained and standardized. each measurement performed twice by the same observer, and the final value were the mean valueof these measurements. weight was measured by weight scales. the subjects were measured without shoes, and subjects were asked to remove any object from their pocket that could affect the measurement results. height was measured with microtoise. the subjects were asked to remove their shoes and socks. the observer made sure that the heels, buttock and occiput were contact to the wall or vertical measure. the subjects were instructed to look straight ahead, relax their shoulder, and place part of their lower margin of the eye parallel to external auditory meatus (frankfurt plane). sitting height was measured after height measurements were complete. a 40 centimeters chair was placed just below the location of microtoise and parallel to the wall. the subjects were asked to sit on the chair with their buttock and occiput were contact to the wall. they were asked to look straight table 1 characteristic of subjects characteristic obese n (%) normal n (%) total age (years old) 7–< 8 16 (17.8) 20 (18.2) 36 (18) 8–< 9 21 (23.3) 25 (22.7) 46 (23) 9–< 10 31 (34.4) 35 (31.8) 66 (33) 10–< 11 22 (24.4) 30 (27.3) 52 (26) sex male 45 (50) 55 (50) 100 (50) female 45 (50) 55 (50) 100 (50) height, mean (sd) in cm 133.8 (8.6) 125.03 (8.7) 128.98 (9.7) weight, mean(sd) inkg 44.3 (9.9) 25.28 (5.2) 33.84 (12.2) bmi, mean (sd) 24.46 (3.0) 15.99 (1.48) 19.80 (4.81) total 90 110 200 note: sd= standard deviation; obese= >95th percentile; normal= 10th–85th percentile althea medical journal. 2016;3(1) 149muhammad zulfikar azhar, rm. ryadi fadil, edhyana k. sahiratmadja: upper lower segment ratio comparison between obese and normal children aged 7 to 10 years old ahead, with their part of the lower margin of the eye parallel to external auditory meatus (frankfurt plane). the subjects were asked to relax the shoulder when the measurement was performed. upper segment was calculated by subtracting the sitting height with height of chair (40 cm). lower segment was calculated by subtracting height with upper segment. the upper lower segment ratio was calculated by dividing the upper segment with lower segment. the bmi was obtained after all measurements were completely performed. the bmi was calculated by dividing body weight with square of height in meters, then bmi was plotted to bmi for age based on centers for disease control and prevention (cdc) bmi-for-age growth chart to classify bmi category of all subject. obese category wasdetermined if bmi of the children was above 95th percentile, while normal category wasdetermined if bmi of children was in range of 10th to 85th percentile. the data that was obtained were analyzed to normality distribution test using kolmogorov-smirnov test. if the p value >0.05, it could be concluded that the data had normal distribution. moreover, the data were analyzed by unpaired t-test to assess the level of significantdifference upper lower segment ratio in obesity and normal children aged 7 to 10 years old. this study was approved by health research ethics committee, universitas padjadjaran (no.327/un6/c2.1.2/ kepk/2013) and bandung department of education (no.070/5511-disdik/2013). results from the three elementary schools, there were table 2 comparison of upper lower segment ratio between obese and normal children obese normal p-value us/ls ratio mean 1.13 1.14 0.60 sd 0.08 0.04 note: us/ls ratio= upper lower segment ratio; sd= standard deviation table 3 means of upper lower segment ratio in obese and normal boys based on age age obese normal p-value n us/ls ratio sd n us/ls ratio sd 7 9 1.19 0.03 10 1.20 0.02 0.61 8 7 1.13 0.07 10 1.18 0.03 9 18 1.13 0.11 20 1.14 0.03 10 11 1.15 0.04 15 1.09 0.02 total 45 1.15 0.08 55 1.14 0.05 note: us/ls ratio= upper lower segment ratio; sd= standard deviation table 4 means of upper lower segment ratio in obese and normal girls based on age age obese normal p-value n us/ls ratio sd n us/ls ratio sd 7 7 1.15 0.06 10 1.18 0.02 0.21 8 14 1.12 0.07 15 1.16 0.04 9 13 1.13 0.11 15 1.14 0.02 10 11 1.10 0.09 15 1.10 0.02 total 45 1.12 0.08 55 1.14 0.04 note: us/ls ratio= upper lower segment ratio; sd= standard deviation althea medical journal. 2016;3(1) 150 amj march 2016 200 children recruited in this study and ninety subjects defined as obese children. most of the children were above 9 years old. there was no significant difference between upper lower segment ratio in obese children and normal children aged 7 to 10 years (p>0.05, unpaired t-test). the upper lower segment ratio has no significant different (p=0.61) among obese and normal boys. interestingly, there was a tendency that the value decreased from aged 7 to 9. however, the ratio was increased again in the age of 10 (table 3). there was no significant different between both group obese and normal girls (p=0.21) (table 4). overall, the means of upper lower segment ratio in obese girls was lower than normal girls, and tendency, similar to the boys, that there were decreasing ratios from aged 7 to 10 discussion the upper lower segment ratio has been used for growth anthropometric measurement in children. this study reveals that the upper lower segment ratio decrease gradually from age 7 to 10 in both obese and normal children. these results are similar to a study conducted in healthy turkish children.9 these differences might be due to the age that influence the measurement upper lower segment ratio. the upper lower segment ratio at birth is about 1.7 and decrease to 1.3 at 3 years old. at the age 7 to 10, the ratio is decrease to 1.0, and in adult it gradually decreases to 0.9.10 the age influences on upper lower segment ratio were also be seen in the body proportion in sickle cell anemia11 and in dutch children origin at age 0 to 21 years old.12 the ratio in boys aged 7–10 years old in turkey shows higher upper lower segment compared to girls.9 these results were similar to this study. however, when comparing between turkish children with indonesian children, the result showed that the means of upper lower segment ratio in indonesian children is higher than turkish children. most likely, this is due to racial difference between turkey and indonesia, where race is one of the components that influence the measurement result of upper lower segment ratio. there is a significance racial difference in upper lower segment ratio, where caucasian and african american have a longer leg than asian.1, 13 therefore, when asian was compared to caucasian and african american, asian was more likely has higher upper lower segment ratio in the same age. furthermore, study performed in yucatecans and poles also has shown racial factor that influence upper lower segment ratio measurements.14 other factors contributing to difference measurement upper lower segment can be explained by secular trends, socioeconomic and environmental factor. in japanese children, it showed 10% secular increase in height and 40% secular increase in body weight in the period 1985 to 2000. secular increase in height was due to increased sub-ischial leg length that can affect the lower segment as well as the upper lower segment ratio.15 a study conducted in china16 also showed a significant secular increase in growth from 1985 to 2010. the study also revealed that there were different characteristic trends in socioeconomic levels. mean stature in small and moderate cities were lower than in big cities. study comparing maya children living in united states and guatemala showed different height, weight, and sitting height ratio for each group. this study revealed that maya children in united states were significantly taller at all ages than maya children in guatemala.17 in pre-pubertal age, most of obese children experience growth velocity earlier than normal children at their age.7 this study also revealed that same phenomenon. height difference did not significantly affect the upper lower segment ratio possibly because the upper segment grows as rapid as the lower segment. so, there was no significant difference between the upper lower segment ratio in obese and normal children. some other factors such as arm-span measurement, race, and socioeconomic status contributing to difference measurement of upper lower segment ratio in children were not analyzed, and it contributed to the limitations of this study. to conclude, this study shows no difference between upper lower segment ratio in obese and normal children aged 7 to 10 years. this ratio might impact other races and is served as anthropometric measurements. further study about exploring arm-span measurement, race, and socioeconomic status might reveal the significant difference. references 1. hall jg, allanson j. handbook of physical measurements. new york: oxford university press; 2006. 2. behrman re, kliegeman rm, jenson hb. nelson textbook of pediatrics. 18th ed. althea medical journal. 2016;3(1) 151 philadelphia: elsevier science health science division; 2007. 3. hellerstein mk, park ej. obesity & overweight. greenspan’s basic & clinical endocrinology. 8th ed. san francisco: mcgraw-hill medical; 2007. p. 796–7. 4. world health organization. obesity and overweight. 2013. [cited 2013 march 15]. available from: http://www.who.int/ mediacentre/factsheets/fs311/en/. 5. onis md, blossner m, borghi e. global prevalence and trends of overweight and obesity among preschool children. am j clin nutr. 2010;92:1257–64. 6. badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia. laporan nasional riset kesehatan dasar 2010. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2010. 7. lailani d, hakimi. pertumbuhan fisik anak obesitas. sari pediatri. 2003;5(3):99–102. 8. de leonibus c, marcovecchio ml, chiarelli f. update on statural growth and pubertal development in obese children. pediatri rep 2012. 2012;6(4):e35. 9. turan s, bereket a, omar a. upper segment/ lower segment ratio and armspan–height difference in healthy turkish children. acta pediatrica. 2005;94:407–13. 10. nwosu bu, lee mm. evaluation of short and tall stature in children. am fam physician. 2008;78(5):597–604. 11. diaku-akinwuni in, akodu so, njokanma of. upper body segment to lower body segment and arm span to height ratios among children with sickle cell anaemia in lagos. niger j paed. 2013;40(3):222–6. 12. fredriks am, buuren sv. nationwide age references for sitting height, leg length, and sitting height/height ratio, and their diagnostic value for disproportionate growth disorders. arch dis child. 2005;90:807–12. 13. batubara jr. practices of growth assessment in children: is anthropometric measurement important? pediatrica indonesiana. 2005;45:145–153.. 14. siniarska a, wolanski n. ethnic differences in body proportions genes or environment?. j hum ecol. 2002;13(5):337–43. 15. kagawa m, hills ap. secular changes in bmi obesity risk in japanese children: consideration from a morphologic perspective. the open obesity journal. 2011;3:9–16. 16. jiao ct, ye jc. secular changes in stature of urban chinese children and adolescent 1985–2010. biomed environ sci. 2013;26(1):13–22. 17. bogin b, smith p, orden ab. rapid change in height and body proportions of maya american children. am j hum biol. 2002;14:753–61. muhammad zulfikar azhar, rm. ryadi fadil, edhyana k. sahiratmadja: upper lower segment ratio comparison between obese and normal children aged 7 to 10 years old althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 79 association between exclusive breastfeeding and child development ghaniyyatul khudri,1 eddy fadlyana,2 nova sylviana3 1faculty of medicine, universitas padjadjaran, 2departement of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3departement of physiology, faculty of medicine, universitas padjadjaran abstract background: child development highly correlates with child’s quality. the fastest child development period is during the first three years, also called golden period. this research was aimed to discover correlation between exclussive breastfeeding and child development in cipacing village jatinangor, district of sumedang. methods: this research was conducted using cross-sectional method in thirteen pos pelayanan terpadu (posyandu) cipacing village in jatinangor. one hundred and two children aged 12−24 months with their caregiver were recruited as respondents by using cluster sampling method. hist ory of exclusive breastfeeding was assessed with questionnaire while child development status was assesed with kuesioner pra skrining perkembangan (kpsp) in september 2013 after informed consent was obtained. chi-square test analysis was performed to determine correlation between exclusive breastfeeding and child development status. results: overall, children in cipacing village had non-exclusive breastfeeding history (83.3%), and only 16.7% respondents had exclusive breastfeeding history. meanwhile, 89.2% of children had normal development status, and 10.8% had delayed development status. statistic analysis using chi-square test in the level of 95% confidence between exclusive breastfeeding and child development showed p=0.686 and odds ratio 2.133. conclusions: there is no significant relationship between history of exclusive breastfeeding and child development status. [amj.2016;3(1):79–84] keywords: child development, exclusive breastfeeding, one year old children correspondence: ghaniyyatul khudri, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 852 7492 5956 email: ghaniyyatul.khudri@gmail.com introduction development is a result from interaction between matured central nervous system and effected organs, biological changes to control gross and fine muscles, psychological changes in sosial relationship, language, and personality.1 delayed in this aspect indicates developmental delay on children, that is still a problem in developing country, especially indonesia. world health organization (who) in 2007 recorded that more than two hundreds million children in developing country did not reach complete development,2 while in indonesia about 12.8−28.5% children had delayed development.3 the only food source with complete nutrients that needed by children until six months is mother’s breastmilk. nutrient deficieny on children under two years old may reduce brain cells about 15−20%,4 disruption in brain cell maturation processes, interupted nerve interaction for development process, such as physcomotoric, cognitive and sosial behavior. in indonesia only 15.3% infants get exclusive breasfeeding.5 a survey on exclusive breastfeeding by world breastfeeding trends initiative (wtbi) on march 2012, indonesia ranked 3 of 81 countries.2 locally, prevalence exclusive breastfeeding in 2012 based on data in pusat kesehatan masyarakat (puskesmas) jatinangor is only 1.3%. a case control research conducted in lowokharu, malang6 in 2007, stated that there was no difference in developmental status among children aged 1−2 years old with or without exclusive breatfeeding. contrast to a prospective cohort study in krakow, poland7 in 2011, that showed exclusive breastfeeding in early infancy improve cognitive children development. in accordance to explanation above, this research was aimed to discover correlation between exclusive breastfeeding althea medical journal. 2016;3(1) 80 amj march 2016 and 12−24 months children development in cipacing, jatinangor. methods this was a cross-sectional research conducted in pos pelayanan terpadu (posyandu) cipacing village, jatinangor, in september 2013. after ethical clearance was approved by health research ethics committee, thirteen posyandu were choosen from eighteen posyandu in cipacing village. samples were obtained by cluster sampling. total respondents in this study were 102 children included their mother or caregiver. inclusion criteria was children aged one years old that registered in posyandu, cipacing village, with complete gestational age or birth weight >2500 grams, without congenital abnormality and chronic disease. meanwhile, children without caregiver’s permission or ill children when data collection were excluded. after caregivers were explained and understood about informed consent, they should sign the form. the instruments were validated questionnaires for exclusive breastfeeding history and kuesioner pra skrining perkembangan (kpsp) questionnare for children development. caregivers would answer five questions for children history of breastfeeding and makanan pendamping asi (mp-asi) then children development status was observed using kpsp questionnaire. four aspects assessed were gross motors, fine motors, language, and sosial behavior. after scoring kpsp scores, developmental status was divided into two groups, normal development (kpsp score nine to ten) and delayed development. delayed development itself was divided into suspect developmental delay for kpsp score seven to eightand delayed development for kpsp score equal or less than six. the collected data were analyzed by using chi-square test to discover correlation between exclusive breastfeeding and children developmental status results most mother’s age were ranged in 24−34 years old (52%), more than half of them did not complete senior high school (59.8%), and there were 74.5% respondents come from upper middle sosioeconomic status based on the regional minimum wage (upah minimum regional/umr) of sumedang. most of the mothers work as housewives (87.3%) (table 1). according to gender of children, it was found that boys are more than girls about 57.8%. children with age group 12−17 months have highest percentage (60.2%) than other age ranges. there were 55.9% respondents who had siblings (table 2). children in cipacing village had nonexclusive breastfeeding history (83.3%), table 1 maternal characteristics variable frequency percentage (%) maternal age (years old) 15−24 28 27.5 25−34 53 52 ≥35 21 20.6 mother’s education level <senior high school 61 59.8 ≥senior high school 41 40.2 occupation housewife 89 87.3 work 13 12.7 sosioeconomic status below umr 26 25.5 upper middle umr 76 74.5 note: umr= upah minimum regional/ regional minimun wage. umr of sumedang district rp 1.300.000,−/month althea medical journal. 2016;3(1) 81 and only 16.7% respondents had exclusive breastfeeding history. meanwhile, 89.2% of children had normal development status, and 10.8% had delayed development status. statistic analysis using chi-square test in the level of 95% confidence between exclusive breastfeeding and child development showed p=0.686 and odds ratio 2.133 (table 3). there are misconceptions on information about breastfeeding for children under six months old. thus, misconceptions arise from local belief when their child cries, it means that breaskmilk is not enough. some mothers complained that there was no breastmilk is produced, that may be caused by wrong breastfeeding technique, and others got recommendation from medical staffs nearby that combining breastmilk and formula milk even before six months were good for children nutritional status. based on maternal age groups, the highest developmental delay are mothers in aged range 15−24 years old (45.5%). statistically, there was no correlation between a mother’s age and the child’s development. (table 4,5) the occupational status of mothers showed no significant relationship (p=0.35) because all children with developmental disorders came from housewives who do not work. number of sibling’s respondents ghaniyyatul khudri, eddy fadlyana, nova sylviana: association between exclusive breastfeeding and child development table 3 correlation between exclusive breastfeeding and developmental status exclusive breastfeeding child development total n(%) p or good n(%) delayed n(%) no 75(88.2 %) 10 (11.8%) 85(83.3%) 0.686 2.133 exclusive 16 (94.1%) 1 (5.9%) 17(16.7%) total 91 (89.2%) 11(10.8%) note: or= odds ratio table 2 characteristics of children variable frequency percentage (%) sex boy 59 57.8 girl 43 42.2 children ages (month) 12−17 62 60.2 18−24 40 39.2 number of sibling none 45 44.1 ≥2 57 55.9 imd yes 82 80.4 no 20 19.6 mp-asi appropriate by age 89 87.3 not appropriate by age 13 12.7 head circumference appropriate by age 87 85.3 not apprpriate by age 15 14.7 note: imd= inisiasi menyusu dini/early initiation of breastfeeding,mp-asi= makanan pendamping asi/weaning food althea medical journal. 2016;3(1) 82 amj march 2016 showed no correlation with the child’s developmental status (p=1). weaning food feeding also showed no relationship with child’s development. therefore, none of the characteristics have a significant relationship with child development. table 4 correlation between developmental status and maternal characteristics variable child development p or good delayed maternal age (year) 15−24 23 5 0.20125−34 50 3 ≥35 18 3 mother’s education level <senior high school 54 7 1 1.199 ≥senior high school 37 4 occupation housewife 78 11 0.351 1.167 work 13 0 sosioeconomic status below umr 22 4 0.465 1.331 upper middle umr 69 7 note: or= odds ratio, umr= upah minimum regional/ regional minimun wage. umr of sumedang district rp 1.300.000,−/month table 5 correlation between developmental status and characteristics of children variable child development p or good delayed sex boy 52 7 0.757 1.313 girl 39 4 children ages (month) 12−17 53 9 0.194 3.22 18−24 38 2 number of sibling none 40 5 1 1.063 ≥2 51 6 earimd yes 73 9 1 0.901 no 18 2 mp-asi appropriate by age 81 8 0.146 0.329 not appropriate by age 10 3 head circumference appropriate by age 77 10 1 0.55 not appropriate by age 14 1 note: or= odds ratio, imd= inisiasi menyusu dini/ early initiation of breastfeeding, mp-asi= makanan pendamping asi/weaning food althea medical journal. 2016;3(1) 83 discussion golden period is the most important phase for child development. developmental distrubance in this phase affects worse than other period of time. basic needs for child development includes care, affection, and stimulation. while, development itself depends on many factors such as nutrition, health, genetic, race, and sex. there are internal factor and external factor. the internal factor consists of nutrition, endocrine, immunological, maternal pshycology, radiation and infection, while the external factor is chemical.1 in the development, brain cell grows continously until three years old,4 therefore besides exclusive breastfeeding, early initiation of breastfeeding and weaning food were assessed in this research to exlude the possibility of confounding factor that might arise.8 maternal breastmilk is the main nutrient for equal or less than six month old infant, and it was suggested to be continued until two years old. it is rich source of fatty acids and other bioactive components essential for the infant brain development. the breastmilk also contains docosahexaeoic acid and arachidonic acid that is not contained in cow’s milk.7 related to other studies that revealed infant who were breastfeed exclusively had better score in cognitive development test than nonexclusively breastfeed infants.9 in this study, children with good development at the first year in exclusive breastfeeding group were 94.1% and in nonexclusive breastfeeding group were 88.2%. children with delayed development were higher in non-exclusive breastfeeding group (11.8%), therefore, no correlation found between exclusive breastfeeding and child’s developmental status (p=0.686). it was similiar to the previous research that showed no significant correlation between exclusive breastfeeding and child’s developmental status, but there were higher risk possibilities of developmental disorders for non-exclusive breastfeeding infant than exclusive breastfeed infant.4,6,7 the correlation strengh parameter used to determine risk estimate in this research is odds ratio,10 which generates value about 2.133. the value was meant that the children with non-exclusive breastfeed had 2.133 times more risk for developmental delay than exclusive breastfeeding child. the percentage of developmental delays on children in cipacing was slightly lower (16.7%) than the average of indonesia developmental delays on children.3 based on maternal age groups, the highest developmental delay are mothers in aged range 15−24 years old (45.5%). nevertheless, most mother’s age were ranged in 24−34 years old (52%), this result was in accordance with the age of pregnancy and childbirth in indonesia.11 however, there was no correlation between a mother’s age and the child’s development, but mothers who have children less than 20 years old have a higher risk for having children with disorder and psychological health.7 maternal education is a significant predictor of child care. the education gives mothers more knowledge about what is needed for their children such as prenatal care, nutrition prenatal and postnatal, development stimulus, authoritative parenting, positive mother-child, and parental management that is important for child development.12 in this study, more than half of the mothers did not complete the nine years study program (59.8%), this data shows poor rate of maternal education in cipacing. most of the mothers work as housewives (87.3%). a profession as a housewive spends more time at home that gives more opportunity for interacting and caring their children, so her expectation provide a good stimulus for child development.13 according to sosioeconomic status, there were 74.5% respondents come from upper middle sosioeconomic status based on the regional minimum wage (upah minimum regional/umr) of sumedang, the recent study showed that sosioeconomic families were the external factors that could affect a child’s development.14 however there was no characteristic of respondent had significant correlation with children developmental status. even though, continual poverty is more harmful on cognitive ability, intelligence quotient, and other enviromental factors that affect child development.15 in conclusion, there is no correlation between exclusive breastfeeding and child development status. limitation for this study was insufficient number of respondents because it was restricted in one village area. also, there were recalled bias because it depended on caregiver’s memory to retrive history foods eaten by child during last one year. therefore, next research can be done using larger size sample and prospective cohort as research design. references 1. departemen kesehatan republik ghaniyyatul khudri, eddy fadlyana, nova sylviana: association between exclusive breastfeeding and child development althea medical journal. 2016;3(1) 84 amj march 2016 indonesia. pedoman pelaksanaan stimulasi, deteksi dan intervensi dini tumbuh kembang anak ditingkat pelayanan kesehatan dasar. jakarta: direktorat jenderal pembinaan kesehatan masyarakat; 2006. 2. who. early child development: a powerful equalizer. final report.vancouver: commission on the social determinants of health; 2007. p.5−12. 3. purwanti r, chair i, soedjamiko. penilaian perkembangan bayi risiko tinggi dan rendah pada usia 3 dan 6 bulan dengan instrumen bayley scales of infant and toddler development edisi iii. sari pediatri. 2012;14(1):24−9. 4. gunawan g, fadlyana e, rusmil k. hubungan status gizi dan perkembangan anak usia 1−2 tahun. sari pediatri. 2011;13(2):142−6. 5. kementrian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2010. jakarta: badan penelitian dan pengembangan kesehatan; 2010. 6. fitri le, putra kr. perbedaan tingkat perkembangan anak usia 1−2 tahun menurut ddst (denver development screening test) antara yang diberikan asi eksklusif dan yang diberikan non asi eksklusif di kelurahan sumber sari kecamatan lowokwaru malang [thesis]. malang: brawijaya university; 2008. 7. jedrychowski w, perera f, jankowski j, butscher m, mroz e, flak e, et al. effect of exclusive breastfeeding on the development of children’s cognitive function in the krakow prospective birth cohort study. eur j pediatr. 2012;171(1):151−8. 8. rajeshwari k, bang a, chaturvedi p, kumar v, yadav b, bharadva k, et al. infant and young child feeding guidelines: 2010. indian pediatr. 2010;47(12):995−1004. 9. syahrir l, fadlyana e, effendi sh. comparison of language and visual-motor developments between exclusively and non-exclusively breastfed infants through cognitive adaptive test/ clinical linguistic and auditory milestone scale. paediatr indones. 2009;49(6):337−41. 10. sopiyudin dm. statistik untuk kedokteran dan kesehatan. 5th ed. jakarta: salemba medika; 2011. 11. kementrian kesehatan republik indonesia. pendewasaan usia perkawinan dan hak-hak reproduksi bagi remaja indonesia. jakarta: badan penelitian dan pengembangan kesehatan; 2008. 12. augustine jm, cavanagh se, crosnoe r. maternal education, early child care and the reproduction of advantage. soc forces. 2009;88(1):1−29. 13. sinaga r. hubungan pola asuh ibu bekerja dengan perkembangan sosial anak usia prasekolah di kelurahan karang anyar gunung kecamatan candi sari semarang [thesis]. semarang: diponegoro university; 2008. 14. tanuwidjaya s. kebutuhan dasar tumbuh kembang anak. in: narendra mb, sularyo ts, soetjiningsih, editors. tumbuh kembang anak dan remaja. 1st ed. jakarta: sagung seto; 2002. p. 13−21. 15. schoon i, jones e, cheng h, maughan b. family hardship, family instability, and cognitive development. j epidemiol community health. 2012;66(8):716−22. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 29 relation between preinfarction angina and coronary collateral circulation in patients with acute myocardial infarction achmad shidiq,1 syarief hidayat,2 januarsih iwan a. rachman3 1faculty of medicine universitas padjadjaran, 2department of cardiology and vascular medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology, faculty of medicine, universitas padjadjaran abstract background: coronary collateral circulation conduits an alternative blood flow to the ischemic myocardium in the setting of coronary artery occlusion which can prevent the infarction area to extend more widely. well-developed coronary collaterals are closely related with the presence of preinfarction angina. however, the duration of preinfarction angina which can induce well-developed coronary collateralization is in controversy. the aim of this study was to evaluate the relation between duration of preinfarction angina and coronary collaterals circulation in patients with acute myocardial infarction. methods: this cross-sectional study was conducted from may to november 2013 in dr. hasan sadikin general hospital, bandung, indonesia. seventy three acute myocardial infarction (ami) patients were included in the study. the patients were divided into group 1 (<7 days) and group 2 (≥7 days) based on their preinfarction angina history. the coronary collaterals were assesed and graded as good (rentrop score 2−3) and poor (rentrop score 0−1).statistical analysis was performed using the chi-square test. result: the presence of a well-developed coronary collateral was not significantly different in <7days than ≥7 days duration of preinfarction angina [50.8% v 75.0%, p=0.124]. conclusions: there is no relation between the duration of preinfarction angina and coronary collaterals circulation in patients with acute myocardial infarction. [amj.2016;3(1):28–33] keywords: acute myocardial infarction, coronary collaterals, preinfaction angina correspondence: achmad shidiq, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85794808279 email: achmad.sna@gmail.com introduction acute myocardial infarction (ami) is the leading cause of mortality in the world. the ami occurs by the occlusion of coronary artery consequently blood perfusion fails to meet the myocardial oxygen demand, leading to the death of the myocardial area supplied by the culprit coronary artery.1 the existence of spontaneous coronary collaterals may be able to limit the expansion of the infarction area, since they provide alternative blood flow to the threatened myocardium. without significant coronary collaterals, the size of myocardial infarction will continually expand as long as the culprit coronary artery remains occluded.2,3 the presence of functional coronary collaterals also potentially lowers the development of heart failure4 and mortality rate5 after ami, thus accountable for better prognosis.6 several previous studies stated the coronary collaterals is stimulated by ischemia, increasing shear stress in the occluded vessels, and the presence of angiogenic growth factor.7,8 on the other hand coronary collateralization is impaired in patients with hypertension and diabetes mellitus. in the case of ischemia, the episode angina pectoris as a sign of myocardial ischemia becomes the important predictor of well-developed coronary collaterals vessels.9,10 however the duration of preinfarction angina which can induce well-developed coronary collateralization is in controversy. the current study was undertaken to evaluate whether the duration of preinfarction angina was related to the development of coronary collaterals circulation. methods this cross-sectional study was done at dr. hasan sadikin general hospital, bandung, indonesia from may to november 2013. a althea medical journal. 2016;3(1) 30 amj march 2016 consecutive series of 148 angiograms from patients with acute myocardial infarction in the period january to december 2012 were included for coronary collateral analysis. then, 75 patients were excluded due to theirhistory of old myocardial infarction, history of previous elective percutaneous coronary intervention (pci), history of previous coronary artery bypass graft (cabg), and missing medical record data. therefore, 73 patients were enrolled to the final study population. this investigation was reviewed and approved by the ethics committee and all data regarding patients were concealed. furthermore, the patients were divided into two groups according to the time interval between preinfarction angina and hospitalization as follows: group 1 represent time interval <7 days and group 2 represent ≥7 days. preinfarction angina (a history of angina pectoris prior to ami) was defined as a typical anginal chest pain occurring at rest or during exercise before the onset of ami. the diagnosis of ami was based on the typical chest pain lasting more than 30min, st-segment elevation of at least 1 mm in 2 contiguous precordial leads, and a subsequent increase in the serum creatine kinase concentration to more than twice the upper limit of normal.11 the patients were considered to have a history of hypertension if their systolic pressure was ≥140 mmhg, and the diastolic pressure was ≥90 mmhg, or if they were currently undergoing a treatment for hypertension. a diagnosis of diabetes mellitus was established on the basis of one of the following three factors: a history of taking insulin or an oral hypoglycemic agent, abnormal preinfarction fasting glucose levels (126 mg/dl), and positive results on a 75 g oral glucose tolerance test. the coronary angiograms of the patients were evaluated and collaterals were then scored based on rentrop classification as grade 0 (non-developed, no collaterals were visible), grade 1(less-developed, only side branches, but no major trunk, were visualized through collaterals), grade 2 (well-developed, partial filling of the epicardial segment of the stenosed artery through collaterals) or grade 3 (complete filling of the epicardial segment). then, further classified as good (rentrop score 2−3) and poor (rentrop score 0−1) coronary collaterals.12 moreover, the continuous variables are presented as themean and standard deviation (sd), and thecategorical data are summarized as frequencies or percentages. thechi-square test was used to examine the proportional differences between categorical variables. the result was considered statistically significant at p value <0.05 for 2-sided test. all data were analyzed by using the computer based statistical packages for social sciences version 20 for windows (spss, inc., chicago, il, usa). results among the 73 study patients, there was more male (n=61, 84%) than female. the overall mean age was 57 ± 10.5 with the youngest age at attack was 30 years. while hypertension, diabetes mellitus and critical occlusion were more than 90%, and were more prevalent in group 2 (table 1). table 1 baseline characteristics of study patients clinical features all patients (n=73) group 1 (<7 days) (n=61) group 2 (≥7 days) (n=12) n % n % n % age-yr 57 (±10.5) 56.1 (± 9.8) 61.2 (± 13.0) sex male 61 84% 53 87% 8 67% female 12 26% 8 13% 4 33% hypertension 38 51% 28 46% 10 83% diabetes mellitus 16 24% 10 16% 6 50% duration of preinfarction angina-days 3.4 (±3.2) 2.5 (±2.3) 8.8 (±2.0) degree of occluded vessels ≤ 90% occlusion 31 43% 29 48% 2 17% >90% occlusion 42 57% 32 52 % 10 83% althea medical journal. 2016;3(1) 31achmad shidiq, syarief hidayat, januarsih iwan a. rachman: relation between preinfarction angina and coronary collateral circulation in patients with acute myocardial infarction good coronary collateral vessels were found in 40 patients (54%). we found that there were more patients with well-developed collaterals among group 2 patients (n=9, 75.0%) and were likewise among group 1 patients (n=31, 50.8%). however, it found that there was no significant difference between duration of first preinfarction angina to hospitalization and the presence of well-developed coronary collaterals (p=0.124). discussion the current study revealed that there was more male than female study patients. this result is similar with many other studies which shows a higher prevalence of male among patients with acute myocardial infarction. the study also showed the proportion of welldeveloped collaterals was 54%. this result is in accordance with other recent data from patients with acute myocardial infarction. the documented prevalence of well-developed coronary collateral circulation in acute myocardial infarction intervention has varied from 15 to 55 %.13 on the other hand, it found longer duration of preinfarction angina particularly ≥7 days, which was not related to the presence of welldeveloped collateral as other studies. herlitz et al.6 showed that the patients with chronic angina pectoris before an acute myocardial infarction had smaller infarct compared with short duration angina pectoris before the episode of mi due to the presence of welldeveloped coronary collaterals.14 in addition, antoniucci et al.15 showed coronary collateral circulation were clearly visible 6 hours after myocardial ischemia. however, our finding can be explained by other experimental and clinical studies which revealed coronary collateral circulation developed perfectly 8 weeks after myocardial infarction or a period of 3 months of ischemic condition marked by preinfarction angina episode.13 these varied findings might be due to the different classification of duration preinfarction angina and the methods used to assess coronary collaterals. preinfarction angina is caused by myocardial ischemia, whereas myocardial ischemia can be a sufficient stimulus to induce coronary collateral development, possibly through biochemical preconditioning by releasing theangiogenic growth factor. additionally, the exposure to hypoxia stimulates theaccumulation of vascular endothelial growth factor (vegf) mrna. many other genes involved in angiogenesis are also upregulated in response to hypoxia including cardiac macrophage.16 however the development of collateral arteries through arteriogenesis is not dependent on ischemia. collateral arteries develop in non hypoxic tissue, and is induced by an increase of shear stress in the setting of coronary occlusion.17 preinfarction angina, is not only a specific marker of myocardial ishemia but is simultaneously a sign in the presence of severe coronary occlusion. the formation of coronary collateral vessels has initiated the development of an critically acute occluded coronary artery (>90%).17,18,19 an acutely reduction of the arterial diameter creates larger interarterial pressure gradient between the arterial segment before and after the stenoses, inducing shear stress to surrounding arteriolar endothelial cells.this will stimulate the arteriolar endothelial cells, smooth muscle cells and fibroblast leading to their proliferation, migration and remodeling to create larger functional muscular arteries that can provide an alternative blood flow to the jeopardized myocardial area.19,20 this explained that the pathophysiological process of preinfarction angina may lead to the development of good coronary collateral vessels through biochemical and mechanical pathways. there were several limitations in this study. first, the use of coronary angiography, by which some collateral vessels with a diameter of <100 µm were not visualized for the evaluation of collateral circulation. coronary collaterals may be more accurately table 2 distribution of the presence of coronary collaterals among studypatients all patients poor collateralization n= 33 (46%) good collateralization n= 40 (54%) p value* rr (95% ci) n % n % group 1 (<7 days) 30 49% 31 51% 0.124 0.334 (0.085−1.396) group 2 (≥7 days) 3 25% 9 75% *chi-square test althea medical journal. 2016;3(1) 32 amj march 2016 assessed by thecollateral flow index with the simultaneous measurement of aortic pressure and the distal pressure within the occluded segment of the culprit coronary artery. however, the angiographic approach to the classification of collateral flow still remain the standard of reference in the clinical setting. the second limitation was the difficulty to determine the exact origin of the symptoms of each patient since preinfarction angina is a subjective marker of myocardial ischemia. finally, myocardial ischemia, not angina, plays an important role in the development of collateral circulation as mentioned above. therefore, myocardial ischemia including silent ischemia that occurs before the onset of themyocardial infarction should have been evaluated. as more than half of the patients were admitted with a first symptom, it was difficult to document the presence or absence of myocardial ischemia. in conclusion, this study shows that there is no relation between duration of preinfarction angina (<7 days or ≥7 days) and coronary collateral circulation. the development and pathophysiological process of collateralization may explain the results. references 1. schoen fj, mitchell rn. the heart. in: kumar v, abbas ak, fausto n, aster jc, editors. robbins and cotran: pathologic basis of disease. 8th ed. philadelphia: wb saunders; 2010. p. 660−71. 2. plein s, john f younger, sparrow p, ridgway jp, ball sg, greenwood jp. cardiovascular magnetic resonance of scar and ischemia burden early after acute st elevation and non-st elevation myocardial infarction. j cardiovasc magn reson. 2008;10:47−56. 3. shen y, wu f, pan c, zhu t, zhang q, zhang r, et al. clinical relevance of angiographic coronary collaterals during primary coronary intervention sor acute stelevation myocaldial infarction. chin med j. 2014;127(1):66−71. 4. steg pg, kerner a, mancini gbj, reynolds hr, carvalho ac, fridrich v, et al. impact of collateral flow to the occluded infarctrelated artery on clinical outcomes in patients with recent myocardial infarction. a report from the randomized occluded artery trial. circulation. 2010;121(25):2724−30. 5. meier p, hemingway h, lansky aj, knapp g, pitt b, seiler c. the impact of the coronary collateral circulation on mortality: a metaanalysis. eur heart j. 2011;33(5):614−21. 6. herlitz j, karlson b, richter a. occurrence of angina pectoris prior to acute myocardial infarction and its relation to prognosis. eur heart j. 1993;14:484−91. 7. steen h, giannitsis e, futterer s, merten c, juenger c, katus ha. cardiac troponin t at 96 hours after acute myocardial infarction correlates with infarct size and cardiac function. j am coll cardiol. 2006;48(11):2192−4. 8. giannitsis e, steen h, kurz k, ivandic b, simon ac, futterer s, et al. cardiac magnetic resonance imaging study for quantification of infarct size comparing directly serial versus single time-point measurements of cardiac troponin t. j am coll cardiol. 2008;51(3):307−14. 9. traupe t, gloekler s, marchi sfd, werner gs, seiler c. assesment of the human coronary collateral circulation. circulation. 2010;122:1210−20. 10. ng s, soerianata s, andriantoro h, ottervanger jp, grobbee de. timing of coronary collateral appearance during st-elevation myocardial infarction. interv cardiol. 2012;4(1):137−43. 11. thygesen k, alpert js, white hd, jaffe as, katus ha, apple fs, et al. expert consensus document: third universal definition of myocardial infarction. j am coll cardiol. 2012;60(x):2528−38. 12. tanboga ih, topcu s, nacar t, aksakal e, kalkan k, kiki i, et al. relation of coronary collateral circulation with red cell distribution width in patients with non-st elevation myocardial infarction. clin appl thromb hemost. 2012;0(0):1─5. 13. schwartz h, leiboff rh, bren gb, wasserman ag, katz rj. temporal evolution of the human coronary collateral circulation after myocardial infarction. j am coll cardiol. 1984;4(6):1088−93. 14. lonborg j, kelbaek h, vejlstrup n, botker he. influence of preinfarction angina, collateral flow, and pre-procedural timi flow on myocardial salvage index by cardiac magnetic resonance in patients with st-segment elevation myocardial infarction. eur heart j. 2012;13:433−43. 15. antoniucci d, valenti r, moschi g. relation between preintervention angiographic evidence of coronary collateral circulation and clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction. j am coll cardiol. 2002;89:121−5. 16. koerselma j, graaf yvd, jaegere pptd, althea medical journal. 2016;3(1) 33 grobbee de. coronary collaterals: an important and underexposed aspect of coronary artery disease. circulation. 2003;107:2507−11. 17. lavine kj, kovacs a, weinheimer c, mann dl. repetitive myocardial ischemia promotes coronary growth in the adult mamalian heart. j am heart assoc. 2013;2(5):1−30. 18. schaper w. collateral circulation: past and present. basic res cardiol. 2009;104(1):5– 21. 19. pagonas n, gross cm, li meijing, bondke a, klauss v, buschmann e. influence of epocardial stenosis severity and central venous pressure on the index of microcirculatory resistance in a follow-up study. euro intervention. 2014;9(9):1063−8. 20. heil m, schaper w. influence of mechanical, cellular, and molecular factors on collateral artery growth (arteriogenesis). circ res. 2004;95:449−58. achmad shidiq, syarief hidayat, januarsih iwan a. rachman: relation between preinfarction angina and coronary collateral circulation in patients with acute myocardial infarction althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 534 amj december, 2015 relationship between exclusive breastfeeding and nutritional status of infants aged 12 months sheilla selvina,1 eddy fadlyana,2 nita arisanti3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: exclusive breastfeeding has a high nutrient content to fulfill the nutritional needs of infants aged 0−6 months. the aim of this study was to describe thenutritional status of infants aged 12 months and to determine the relationship of exclusive breastfeeding and nutritional status of infants aged 12 months in pos pelayanan terpadu (posyandu) cipacing village jatinangor. methods: a cross sectional study was carried out to 102 mothers with infants aged 12 months in posyandu cipacing village from september to october 2013. the infants’ body weight were weighed with weight scales which had been calibrated and the body length were measured with the seca 210 baby length measuring mat, then the mother was interviewed with a questionnaire which had been validated to inquire about the exclusive breastfeeding history. the fisher exact test was used to assess relationship between both variables. results: there were 81.3% of infants with good nutritional status and 83.3% of infants who did not get exclusive breastfeeding. the analysis test showed that the p-value of relationship between exclusive breastfeeding and nutritional status was 0.458 with odds ratio 3.343. conclusions: most of the infants are in good nutritional status although they do not get exclusive breastfeeding. consequently, there is not a significant relationship between exclusive breastfeeding and nutritional status. [amj.2015;2(4):534–40] keywords: infants aged 12 months, exclusive breastfeeding, nutritional status correspondence: sheilla selvina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81313100978 email: sheillaselvina@gmail.com introduction the nutritional status indicates if an adequate state of nutrition needs food intake, both in quantity and quality. it will determine the growth process in the body which occurs in a normal state or not, especially in childhood.1,2 the infant’s nutritional status is afffected by various factors, one of which can affect the infant’s growth is the nutritional factor.3 infants have a unique characteristic which is always growing and evolving since the time of conception until the end of adolescence so that an infant cannot be treated like a small adult, thus infants need appropriate nutrition.3 breast milk (air susu ibu/ asi) is the primary nutrition intake for newborn infants which have appropriate nutrition, especially for infants aged 0−6 months.2,3 as a developing country, indonesia still has problems concerning impaired nutritional status which can lead to growth disorder, failure to thrive, and obesity in children. according to the ‘basic health research’ (riset kesehatan dasar/ riskesdas) 2010, there were 17.9% of infants under five with underweight and severely underweight status and 14% of infants with obese status in indonesia.4 furthermore, exclusive breastfeeding in indonesia is still low, only 15.3% of mothers are still exclusively breastfeeding when the baby is 5 months old.4 out of 6.874 infants who were weighed in 2012 in jatinangor sub district, 7.65% of infants under five sufffered malnutrition.5 cipacing village was a region with the highest malnutrition in the jatinangor sub district in 2012.5 there were 5.52% infants who were severely underweight and 4.2% infants who were underweight in the cipacing village.5 the aim of this study was to describe the nutritional status of infants aged twelve althea medical journal. 2015;2(4) 535 months and to determine the relationship of exclusive breastfeeding on the nutritional status of infants aged twelve months in pos pelayanan terpadu (posyandu) cipacing village jatinangor. methods a cross sectional study was performed to mothers with infants aged twelve months in posyandu of cipacing village jatinangor sumedang indonesia from september to october 2013. the inclusion criteria were mothers who had infants aged 12 months, the history of a full term gestational age, infant’s birth weight was ≥2500 grams, infant was born without birth defects, and mothers who could follow the stages of the study and signed an informed consent. infants who were sick or mothers who refused to continue the data collection process had been excluded from this study. the cluster sampling technique was used to select a number of posyandu in cipacing village.6 the sample size in the study was calculated using the formula of an analytical study of an unpaired-dichotomous variable.6 the minimum sample size for this study was 93 respondents the instrument which was used in this study were infant weight scales which had been calibrated, seca 210 baby length measuring mats, the international world health organization (who) growth charts in 2006, questionnaires, and informed consent forms. researchers measured the body weight and length of the infants . results of measurement data on weight and body length were plotted into the who growth charts to determine the nutritional status of infants. then, researchers conducted interviews with the mothers using a questionnaire which had been validated to inquire about the exclusive breastfeeding history when the infant was aged 0−6 months. all steps of this study were approved by thehealth research ethics comittee of the faculty of medicine universitas padjadjaran. the nutritional status (dependent variable) is measurements of weight and height and are compared to the who growth charts. good nutritional status have z score weight for age (w/a), length for age (l/a), and weight for length (w/l) between ≥-2.0 and ≤2.0.7 bad nutritional status have z score w/a, l/a, and w/l<-2 sd or >2 sd.7 exclusive breastfeeding (independent variable) is the baby who was only given breast milk from the age of 0−6 months without additional fluid or food, except for vitamins, minerals, medications, and oral rehydration solution (ors).8 to determine the relationship between exclusive breastfeeding and infant’s nutritional status, the fischer exact test with significant level (α)<0.05 and β=0.20 twotailed was used.9 results the total number of respondens in this study was 102 pairs of mother and infants aged twelve months from 13 out of 18 posyandu in cipacing village, jatinangor subdistrict. the mean of mother’s age was 28.99 ranging from 19−50 years. most of them had graduated from junior and senior high schools. only few of them were working mothers so that most of them had a family income of <rp1,500,000.(table 1). most of the respondents were with normal nutritional status. there were 83.3% infants with good nutritional status (table 2). moreover, most of the infants with malnutrition status had a mother with low table 1 sociodemographic characteristic of respondent variable n (%) mother’s age <20 2 (2) 20–35 85 (83.3) >35 15 (14.7) mother’s level of education non-formal school 1 (1) elementary school 10 (9.8) junior high school 49 (48) senior high school 38 (37.3) higher education 4 (3.9) mother’s occupation employee 3 (2.9) laborer 4 (3.9) enterpreneur 1 (0.9) housewife 88 (86.3) family income >rp1,500,000.41 (40.2) <rp1,500,000.61 (59.8) sheilla selvina, eddy fadlyana, nita arisanti: relationship between exclusive breastfeeding and nutritional status of infants aged 12 months althea medical journal. 2015;2(4) 536 amj december, 2015 educational level, low family income and were housewife (table 3). the result of the analysis test indicates that exclusive breastfeeding were not significantly related to infant’s nutritional status. the odds ratio in this study showed that infants table 3 distribution of infant’s nutritional status and sociodemographic characteristics of respondents characteristics nutritional status p-value good bad mother’s age 0.049 >mean 1 1 <mean 67 18 mother’s level of education 0.259 basic education 9 years 38 6 non-basic education 9 years 45 13 mother’s occupation 1.000 working mother 12 2 housewife 70 17 family income 0.396 < rp 1.500.000,48 13 > rp 1.500.000,35 6 table 2 distribution of infant’s nutritional status nutritional status criteria n (%) weight for age overweight 2 (2.0) underweight 7 (6.8) severely underweight 0 (0.0) normal 93 (91.2) length for age stunted 11 (10.7) severely stunted 3 (2.9) normal 88 (86.4) weight for length obese 3 (2.9) overweight 1 (0.9) wasted 2 (2.0) severely wasted 1 (0.9) normal 95 (93.2) who did not get exclusive breastfeeding had 3.343 times risk to become infants with bad nutritional status (table 4). most of the infants got formula feeding or thawed food as complement to breastfeeding when the infants were aged 0−6 months. maternal factors were the cause infants got other intake when aged 0−6 months, which was not appropriate for the infants’ nutritional status. meanwhile, a number of mothers already gave appropriate complementary feeding to their infants when the infants were 6 months old (table 5). discussions an exclusive breastfeeding program was launched in the world, including in indonesia, where newborn infants should have sufficient intake of breast milk until the age of 6 months, subsequently infants can be given complementary food in addition to breast milk after the infants age are 6 months to meet body nutritional needs.8,10,11 this program was established to become one of the solutions to prevent infants from malnutrition, both undernutrition as well as overnutrition. the number of underweight and severely underweight infants based on w/a criteria in cipacing village (6.8%) was lower than in west java (13%) and indonesia (17.9%).4 additionally, the number of underweight and severely underweight infants in cipacing village had decreased since 2012 (9.72%).5 althea medical journal. 2015;2(4) 537 table 5 complementary feeding variable n (%) complementary feeding <6 months breastfeeding + others 48 54.5 breastfeeding + formula feeding 37 42 formula feeding 1 1.1 formula feeding + others 12 11.8 reason to stop exclusive breastfeeding infant 20 22.70 mother 57 64.80 others 11 10.70 complementary feeding >6 months appropriate 89 87.3 non-appropriate 13 12.7 sheilla selvina, eddy fadlyana, nita arisanti: relationship between exclusive breastfeeding and nutritional status of infants aged 12 months meanwhile, the number of excess nutrients in cipacing village was lower than inwest java (14.6 %).4 most of the infants with bad nutritional status were underweight based on w/a criteria. furthermore, the number of infants with stunted status based on l/a criteria in cipacing village was lower than in west java and indonesia (17.9%).4 distribution of nutritional status in w/l was similar. the number of children with bad nutritional status based on w/l was lower in cipacing village than in west java (24.6%) and indonesia (27.3%). the mother’s education is one of the important factors that can improve the infant’s nutritional status.3 mothers with higher education may have better knowledge regarding health which can affect the way mothers raise the the infants, such as providing the best nutrition and creating a healthy home environment, so infants are not often attacked by diseases that can interfere growth process.12 the number of infants with bad nutritional status in this study was more than in infants who had mothers with no education criteria of completed basic education for 9 years. the total revenue of rp 1,500,000.is close to the amount of the regional minimum wage (umr) in jatinangor district which is rp 1,300,000. working mothers have more infants with good nutritional status than mothers who do not working.13,14 mothers who do not work are able to freely monitor the growth and development of children however this is contrary to the readiness and good knowledge to provide appropriate nutrition for the children.14 mothers who do not work in certain circumstances affect the monthly family income that can be used to meet infant’s nutritional needs. most of the mothers in this study did not breastfeed immediately after delivery since they thought that the breast-milk should come out first before the early initiation of breastfeeding. the mothers tended to wait without obtaining directly assistance from the pumping process nursing techniques. a caesarian delivery was another condition table 4 relationship between infant’s nutritional status and breastfeeding status variable nutritional status ci 95% or p-value good bad exclusive breastfeeding 0.410 – 27.267 3.343 0.458 yes 13 1 no 70 18 althea medical journal. 2015;2(4) 538 amj december, 2015 that made mothers did not perform the early initiation of breastfeeding because mothers would meet the infant the next day, so the medical staff gave formula feeding to infants who cried. there were only few mothers who exclusively breastfed their infants aged 0−6 months. data of exclusive breastfeeding in cipacing village showed the mothers’ lack of knowledge regarding the definition of exclusive breastfeeding correctly (table 4). mothers who did not exclusively breastfeed their infants usually give water to their infant for the reason that the breast milk had not come out, the tongue of the infant appeared white and dirty from drinking milk or mothers thought that the infant was thirsty. the percentage of exclusive breastfeeding in cipacing village was higher than the percentage of exclusive breastfeeding in indonesia4 (15.3%)4. this percentage is lower than the percentage of exclusive breastfeeding in west java4 (17.6%). the number of mothers who were breastfeeding exclusively in cipacing village dropped dramatically compared to the data in 20125 (82.4%)5. this indicated that education on exclusive breastfeeding was still urgently needed since the definition of exclusive breastfeeding was still not understood well by the public. the most common reason of mothers who did not give exclusively breastfeeding was that they felt that the quantity of breast milk could not fulfill the needs of thebaby. this could occur because of the lack of attention from the local medical personnel to provide education or encourage mothers to breastfeed exclusively, and also of the widespread formula advertisements which were being marketed intensely. some of the reasons that mothers did not breastfeed exclusively were the infant’s situations who were often crying for unknown reasons or at the sight of food when they were feeling hungry. it was supposed to be prevented by the mother since mother was a decisive factor in this respect who had to control the nutrient intake and types of food that could be given to infants. another reason of the mother who did not breastfeed exclusively was the factors of hospitals or midwives. hospitals and midwives were providing nutritional advice contrary to the provisions that had been defined. the medical personnel should support every mother who had a delivery to give exclusive breastfeeding to the infant until the infant was 6 months old. the number of mothers who gave mineral water to their infants before aged 6 months in cipacing village were more than those in indonesia based on riskesdas 20104 (24.8%). the number of mothers who gave formula to their infants in cipacing village was fewer than those in indonesia4 (68.1%). this could be due to the lack of knowledge of mothers about the benefits of exclusive breastfeeding for infants (table 5). the mother’s awareness to give complementary feeding (makanan pendamping air susu ibu/ mp−asi) according to the age of the infant was good. most of the mothers were able to distinguish the type of food that could be given to children at a certain age range. there were 12.7 % of mothers who gave complementary feeding which was not age-appropriate. this occurred because the most common type of infant refused the kind of food given at that time. complementary feeding will help the growth of infants after the age is more than 6 months since the nutrients milk has decreased. the result of this study showed that exclusive breastfeeding did not have significant relation with the nutirional status of infants. results of this study were similar with results of studies in senuro village (south sumatra, indonesia), depok city (indonesia) and others places.11,12,15 on the other hand, the results of this study showed differences with others studies.16-19 in this study, here was only one infant out of 19 infants with bad nutritional status who got exclusive breastfeeding when the infants were 0−6 months old (5.26%). meanwhile, there were 18 infants out of 88 infants with bad nutritional status who did not get exclusive breastfeeding (20.5%). this result showed that exclusive breastfeeding affected the infant nutritional status and exclusive breastfeeding had important benefits for keeping the infant nutritional status. the analysis test showed that children who did not get exclusive breastfeeding have 3.343 times risk to become infants with bad nutritional status in the future (table 4). exclusive breastfeeding is one of theimportant factors for infants’ growth.2 exclusive breastfeeding in infants aged 0−6 months is already sufficient to fullfill the nutrional needs of the body.2 meanwhile, other food can cause infants’ intake become less than exclusive breastfeeding. it can cause the infant get involved in bad nutritional status, get lower intelligence quotient (iq) or bad immunity so that infants often become sick or althea medical journal. 2015;2(4) 539 died.2 infants’ nutritional status is affected by many factors. one of thefactor is mother’s nutrional status and mother’s food intake which will affect thequality of mother’s milk.3 the quantity and quality of mother’s milk will affect infants’ growth and nutritional status. thequality and frequency of breastfeedings have to be maintained. there is a need for more education which can give information about benefits of exclusive breastfeeding and infants’ nutritional status to mothers. the complementary food which is given to infants aged 6–12 months is one of the important factors. complementary food can fulfill the infant’s body needs for growth process of those who did not get exclusive breastfeeding. introducing a kind of food is an important factor to fulfill infant’s body needs. it can be anticipation for infants with malnutrition. this cross sectional study collected information once based on mother’s memories so it might cause a biased recall . meanwhile, the size of this study could not be representative because it was conducted only in one village. thus, other studies should be conducted with cohort or case control study design and more number of respondents. infants aged twelve months who were included in this study already has got other food intake in addition to breast feeding so there were others factors which affect their nutritional status. thus, other studies can be conducted to find other factors which can affect infants’ nutritional status in conclusion, the result in this study indicates that most of the infants aged twelve months in cipacing village have good nutritional status (81.3%) and do not get exclusive breastfeeding (83.3%). statistical evidence shows that there is not a significant relationship between exclusive breastfeeding and nutritional status (p=0.458 ; or=3.343). references 1. gardner d, shoback d. greenspan’s basic & clinical endocrinology. 8th ed. san francisco: mcgraw-hill medical; 2007. p. 174−82. 2. tumbelaka ar, sacharina man, hendarto a, hegar b, tridjadja b, latupeirissa d, et al. bedah asi. jakarta: ikatan dokter anak indonesia; 2008. 3. narendra mb, sularyo ts, soetjiningsih, suyitno h, ranuh ign gde, wiradisuria s. buku ajar i tumbuh kembang anak dan remaja. jakarta: sagung seto; 2008. p. 1−61. 4. badan penelitian dan pengembangan kesehatan kementrian kesehatan ri. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan; 2010. 5. puskesmas jatinangor. rekapitulasi hasil bulan penimbangan berat badan. jatinangor: puskesmas jatinangor; 2012. 6. dahlan ms. besar sampel dan cara pengambilan sampel. 3rd ed. jakarta: salemba medika; 2010. p. 46−60. 7. who. who child growth standard: training course on child growth assestment. geneva: who press; 2008. 8. who. indicators for assessing infant and young child feeding practices part 3 : country profiles. malta: who press; 2010. 9. dahlan ms. statistik untuk kedokteran dan kesehatan. in: suslia a, editor. 5th ed. jakarta: salemba medika; 2012. p. 129−38. 10. who. infant and young child feeding. geneva: who library cataloguing in publication data; 2009. 11. arpadi s, fawzy a, aldrovandi gm, kankasa c, sinkala m, mwiya m et al. growth faltering due to breastfeeding cessation in uninfected children born to hiv-infected mothers in zambia. am j clin nutr. 2009;90(2):344−53. 12. destriatania s, mutahar s, febry f, sari ip. maternal factors and children’s nutrition status in senuro village, south sumatera province, indonesia. ijphr. 2011;1:229− 32. 13. vaida n. impact of maternal occupation on health and nutritional status of preschoolers (in srinagar city). iosr-jhss. 2013;7(1):9−12. 14. vyas s, kandpal sd, semwal j. role of maternal education & occupation in the nutritional status of under three children. ijch. 2011;22(2):35−7. 15. meiliany, rasyad as, hilmanto d. faktor risiko status gizi kurang pada bayi usia enam bulan. j indon med assoc. 2011; 61(11):442−6 16. li s-c, kuo s-c, hsu y-y, lin s-j, chen p-c, chen y-c. effect of breastfeeding duration on infant growth until 18 months of age: a national birth cohort study. j exp clin med. 2010;2(4):165−72. 17. muchina e, waithaka p. relationship between breastfeeding practices and nutritional status of children aged 0−24 months in nairobi, kenya. afr j food agric nutr dev. 2010;10(4):2358−78. 18. meshram ii, a. laxmaiah, k. venkaiah, sheilla selvina, eddy fadlyana, nita arisanti: relationship between exclusive breastfeeding and nutritional status of infants aged 12 months althea medical journal. 2015;2(4) 540 amj december, 2015 v. brahmam gn. impact of feeding and breastfeeding practices on the nutritional status of infants in a district of andhra pradesh, india. natl med j india. 2012;25(4):201−6. 19. susilowati, kusharisupeni, fikawati s, achmad k. breastfeeding duration and children’s nutritional status at age 12−24 months. paediatr indones. 2010; 50(1):56−61. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 208 amj june, 2015 propolis as an anti-allergy based on decrease in total eosinophil count in rat models rashmika nambiar,1 enny rohmawaty,2 leni lismayanti3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy, faculty of medicine, universitas padjadjaran, 3department of clinical pathology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: propolis is a natural herb derived from plant resins by bees. propolis contains flavonoids that act as anti-allergy. the composition of flavonoids in propolis varies according to each region like brazilian, chinese, malaysian and indonesian propolis due to differences in medicinal plants in that area. the aim of this study is to determine the effect of propolis as an anti-allergy and to determine which is the most effective among propolis of brazilian, malaysian and indonesian origin. methods: an experimental study was performed on 28 wistar male rats divided into four groups, brazilian, malaysian, indonesian propolis and a negative control group. the used parameter was decreased in total eosinophil count in ovalbumin induced allergy in rats. propolis or aquadest as control were given orally 0.25ml once daily. results: all three groups of propolis showed statistically significant results (p<0.05), in decreasing eosinophil count. however, malaysian and brazilian propolis showed much more significant effects compared to that of indonesian propolis. this could be due to the difference in composition and concentration of flavonoids in indonesian propolis compared to the brazilian and malaysian propolis. conclusion:propolis has a significant effect as an anti-allergy. malaysian and brazilian propolis are more effective as an anti-allergy compare to indonesian propolis. propolis can thus be used as an alternative treatment for allergy. [amj.2015;2(1):208–12] keywords: anti-allergy, eosinophil count, propolis, rats correspondence: rashmika nambiar, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170205818 email: ngiaren31mika@hotmail.com introduction allergy is a hypersensitivity reaction initiated by the immune response of our body and indonesia is classified as one of the countries with low allergy prevalence prompting the researcher to think that probably traditional medicine is the reason behind this data.1 egg allergy is very common and known to contain ovalbumin due to many peptides that can trigger an allergic reaction. thus, it spurs the researcher to use ovalbumin to induce allergy for research.2 allergy causes itch, pain, and swollen areas (edema). the definite diagnosis of allergies are increased in total eosinophil count and ige level in blood.3 the currently available treatments for allergy are antihistamines and corticosteroids. both having side effects, but still used, due to the necessity and demand in society.4 natural herbs have been gaining popularity in the discovery of new alternative treatment recently due to scarce side effects and its common used in the society. indonesia is known to contain almost 30,000 herbs. in the last decades, propolis emerges as a natural herb rigorously researched to determine the treatment of allergy using propolis.5 propolis is derived from plant resins by bees and can act as anti-microbial, anti-inflammatory, and immunostimulatory.6 researchers have claimed that propolis containing similar active components worldwide but the composition is actually various depending on the area in which they are collected due to variation in wild plants in that area.7 there are many types of propolis, like brazilian, chinese, malaysian and indonesian propolis.8 according to a research done on chinese and brazilian propolis, the possible antiallergic components identified are flavonoids, which are kaempherol and chrysin.7,9 in another study, caffeic acid phenyl ester (cape) was also considered as possible antiallergic component.10,11 malaysia and brazilian althea medical journal. 2015;2(2) 209 propolis both contain flavonoids prompting the researcher to use these propolis and also indonesian propolis, in which there are fewer publications regarding its components and composition to determine the use of propolis as an anti-allergic. the aim of this research is to study the effect of propolis as an anti-allergy based on decrease in total eosinophil count in ovalbumin-induced allergy in rats and to determine which is the most effective among propolis of brazilian, malaysian and indonesian origin as an antiallergy that will induce further researches to determine the safety of propolis in the field of phytopharmaca and establish propolis as an easy obtainable anti-allergic drug in the future. methods an experimental study was done to investigate the effects of propolis as an anti-allergy in ovalbumin-induced allergy in rats. twenty eight adult wistar male rats were divided randomly into 4 groups containing 7 rats each. the experimental rats were obtained from bandung institute of technology and underwent an adaptation period for 7 days at pharmacology lab, faculty of medicine, universitas padjadjaran, bandung. they were fed pellets and drank distilled water. a preliminary test was done before the main research was conducted. the aim was to confirm whether ovalbumin 2% (sigmaaldrich) can induce allergy in rats. after 1 week adaptation, the total eosinophil count of 5 healthy rats was obtained. four rats were induced with ovalbumin 2% 3 times while 1 rat acted as control. total eosinophil count was obtained again and the rise in total eosinophil count compared to baseline indicated an allergic reaction. the control did not show a significant increase in eosinophil count concluding that ovalbumin 2% was sufficient to induce an allergic reaction in rats. the main experimental research started when the rats were adapted for 7 days and the total eosinophil count was obtained again as a baseline. the rats of groups a, b, c and d were then further induced by 0.5 ml ovalbumin 2% subcutaneously on day 0, 7, and 14. on day 16, the total eosinophil count was obtained again for all the four groups. after obtaining blood sample for total eosinophil count on day 16, the adult wistar male rats in the four groups continued once daily oral administration (0.25 ml) of propolis indonesia-trigona for group a, propolis malaysia-melia for group b, propolis brazilminas gerais for group c and aquadest for group d for a duration of 7 days. on day 23, the total eosinophil count was determined again. the total eosinophil count on day 16 and day 23 were further used as data for statistical analysis. total eosinophil count in blood were determined using the direct method of absolute eosinophil count which was the principle of hemocytometry and this used improved neubauer counting chamber and dunger’s solution. dunger’s solution comprised of aqueous eosin 1%, acetone 10 ml and distilled water 100 ml. blood was diluted 10 times in a wbc pipette with dunger’s solution which removed red cells and stained eosinophils. the diluted blood specimen was then placed in a counting chamber and the cells were counted under a high power objective lens of a microscope. eosinophil granules stained orange-red and other wbc nuclei stained bluegreen. eosinophils were then calculated for the undiluted blood. cells in 1 mm3 of undiluted table 1 mean decrease in total eosinophil count of rats (cell count/µl) no group a group b group c group d p 1 159 134 145 67 2 89 88 66 122 3 122 156 134 0 4 123 178 167 67 5 89 167 88 22 6 111 111 134 67 7 56 133 178 33 mean ± sd 107,00 ± 32,79 138,14 ± 31,71 130,29 ± 40,39 54,00 ± 39,82 0.001 sd = standard deviation rashmika nambiar, enny rohmawaty, leni lismayanti: propolis as an anti-allergy based on decrease in total eosinophil count in rat models althea medical journal. 2015;2(2) 210 amj june, 2015 blood = (10 x 10)/9 x 7. dunger’s solution comprised of aqueous eosin 1%, acetone 10 ml and distilled water 100 ml.12 all the data from group a,b, c and d were statistically analyzed using one way analysis of variance (anova) by spss 15.0 software, to compare differences between the four independent groups. the p value <0.05 was considered as significant. results based on the preliminary study, the 4 rats induced with ovalbumin 2% showed a significant increase in eosinophil count compare to the baseline. the main research was divided into two. first, to determine the effects of propolis from brazil, indonesia and malaysia compared to aquadest to test whether these propolis had anti-allergic effects and second, to determine which propolis showed most effective antiallergic effect. the data collected were analyzed for the decrease in total eosinophil count. all groups showed differences in total eosinophil count compared to baseline. the largest difference in mean decrease showed by group b (malaysia) and followed closely by group c (brazil). the effect of propolis indonesia (trigona), malaysia (melia) and brazil (minas gerais) as anti-allergic compared to aquadest was further tested by using one way analysis of variance (anova). the anova test produced a result p-value <0.05, indicating there was a significant difference between groups, thus, proving all three groups of propolis acts as anti-allergic. the best anti-allergic effect among propolis indonesia (trigona), malaysia (melia) and brazil was done by post hoc tukey test. groups b and c clearly showed statistically significant effect of propolis as an anti-allergic because the p-value was <0.05. if the standard error used was 10% instead of 5%, then group aindonesia would also be statistically significant. as a conclusion, propolis from malaysia, brazil and indonesia had statistically significant effects in acting as an anti-allergic, confirmed by a decrease in eosinophil count. (table 2) discussions ovalbumin was injected 3 times subcutaneously to ensure optimal sensitization for a healthy rat to have an allergic reaction. all propolis groups, indonesia, malaysia and brazilian propolis acted as anti-allergy, but in this study, malaysian and brazilian propolis, suggested that they were statistically much more significant as an anti-allergy compare to indonesian propolis. since active compounds in all propolis are the same, the difference in composition and concentration of propolis plays the role in explaining the difference in significance. table 2 effectiveness of each propolis source comparison groups p group a (trigona) group b (melia) 0.397 group c (brazil) 0.635 group d (aquadest) 0.054 group b (melia) group a (trigona) 0.397 group c (brazil) 0.977 group d (aquadest) 0.001* group c (brazil) group a (trigona) 0.635 group b (melia) 0.977 group d (aquadest) 0.003* group d (aquadest) group a (trigona) 0.054 group b (melia) 0.001* group c (brazil) 0.003* * p <0.05 althea medical journal. 2015;2(2) 211 the most important active components which plays a role as an anti-allergy are flavonoids, which are kaempherol and chrysin.13 both brazilian and malaysian propolis contain flavonoids. and in indonesian propolis, the active compounds are yet to be determined as there are fewer publications regarding indonesian propolis. however, they might have fewer amounts of flavonoids in 1 ml of indonesian propolis or perhaps the concentration or dilution of indonesian propolis is various compared to other propolis making it statistically less significant. chrysin and kaempherol act as antioxidant, whereby they stabilize the reactive oxygen species, preventing tissue damage in allergy.14,15 chrysin inhibits il-4 and decreases gene expression of pro-inflammatory cytokine expression preventing eosinophil activation causing decrease in total eosinophil count observed in this research.7 kaempherol also inhibits mapk (protein kinases) activation in il-4, decreasing proliferation of il-4, thereby decreasing eosinophil activation as above.16 furthermore, kaempherol suppresses cd23 mrna expression preventing second signal for mast cell degranulation to occur, and thus cytokine release decreases indirectly causing eosinophil count to decrease.7,17 as a summary, flavonoids like kaempherol and chrysin causes a decrease in eosinophil count as observed in this research. compared to other researches, a study conducted in japan, proved brazilian and chinese propolis had effects on mast cell degranulation and cytokine production explaining the decrease in eosinophil count in this case.7 another research in cihna exhibited an immunoregulatory activity in an ovalbumin sensitized airway inflammatory animal model thus indicating decrease in cytokine production leads to decrease in eosinophil count in this study.18 to conclude, propolis has an anti-allergic effect on ovalbumin induced allergy in rats based on the decrease in total eosinophil count. propolis from malaysia and brazil are more effective than propolis indonesia in acting as anti-allergy. thus, propolis can be used as an alternative medicine for anti-allergy. however, it would be better to determine the optimal dosage of propolis indonesia, malaysia and brazil based on toxicity test to determine the safe dosage to be used in the community. there should be further clinical investigations performed on humans so that propolis as antiallergy can be used as an alternative therapy in society. propolis as an anti-allergy should be promoted to the community so that the society can understand the benefits of propolis as an alternative to the modern drugs. references 1. yazdanbakhsh m, wahyuni s. the role of helminth infections in protection from atopic disorders. curr opin allergy clin immunol 2005; 5(5):386–91 2. huntington ja, stein pe. structure and properties of ovalbumin. j chromatogr b biomed sci appl. 2001;756(1-2):189–98. 3. oppenheimer j, nelson hs. skin testing. ann allergy asthma immunol. 2006;96(2 suppl 1):s6-12. 4. simons fe. advances in h1-antihistamines. n eng j med. 2004;351(21):2203–17. 5. sforcin jm, bankova v. propolis: is there a potential for the development of new drugs?. j ethnopharmacol. 2011;133(2):253–60. 6. khalil ml. biological activity of bee propolis in health and disease. asian pac j cancer prev. 2006;7(1):22–31. 7. nakamura r, watanabe k, oka k, ohta s, mishima s, teshima r. effects of propolis from different areas on mast cell degranulation and identification of the effective components in propolis. int immunopharmacol. 2010;10(9):1107–12. 8. simone-finstrom m, spivak m. propolis and bee health: the natural history and significance of resin use by honey bees. apidologie. 2010;41(3):295–311. 9. nijveldt rj, van nood e, van hoorn de, boelens pg, van norren k, van leeuwen pa. flavonoids: a review of probable mechanisms of action and potential applications. am j clin nutr. 2001;74(4):418–25. 10. park sg, lee dy, seo sk, lee sw, kim sk, jung wk, et al. evaluation of anti-allergic properties of caffeic acid phenethyl ester in a murine model of systemic anaphylaxis. toxicol appl pharmacol. 2008;226(1):22– 9. 11. jung wk, lee dy, choi yh, yea ss, choi i, park sg, et.al. caffeic acid phenethyl ester attenuates allergic airway inflammation and hyperresponsiveness in murine model of ovalbumin-induced asthma. life sci. 2008;82(13–14):797–805. 12. pagana kd, pagana tj. mosby’s diagnostic and laboratory test reference.. 10th ed. st. louis: elsevier mosby; 2010. 13. bankova v. recent trends and important rashmika nambiar, enny rohmawaty, leni lismayanti: propolis as an anti-allergy based on decrease in total eosinophil count in rat models althea medical journal. 2015;2(2) 212 amj june, 2015 developments in propolis research. evid based complement alternat med. 2005;2(1):29–32. 14. hamid f, wiria ae, wammes lj, kaisar mmm, lell b, ariawan i, et al. a longitudinal study of allergy and intestinal helminth infections in semi urban and rural areas of flores, indonesia (immunospin study). bmc infect dis. 2011;11:83. 15. nakajima y, tsuruma k, shimazawa m, mishima s, hara h. comparison of bee products based on assays of antioxidant capacities. bmc complement altern med. 2009;9:4. 16. hirose e, matsushima m, takagi k, ota y, ishigami k, hirayama t, et al. involvement of heme oxygenase-1 in kaempferolinduced anti-allergic actions in rbl-2h3 cells. inflammation. 2009;32(2):99–108. 17. bae y, lee s, kim sh.chrysin suppresses mast cell-mediated allergic inflammation: involvement of calcium, caspase-1 and nuclear factor-κb. toxicol appl pharmacol. 2011;254(1):56-64. 18. sy lb, wu yl, chiang bl, wang yh, wu wm. propolis extracts exhibit an immunoregulatory activity in an ovasensitized airway inflammatory animal model. int immunopharmacol. 2006;6(7): 1053–60. althea medical journal. 2016;3(2) 319 correlation between calorie intake and nutritional status of autism spectrum disorder in children aryo windaru,1 fifi veronica,2 dian marta sari3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine, universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: autism spectrum disorder (asd) is a severe pervasive developmental disorder with prevalence as high as one in sixty-eight children. children diagnosed with asd may have food intake problem and might affect their nutritional status in the future. the objective of this study was to analyze the correlation between total calorie intake and nutritional status of asd children. methods: this cross-sectional study was conducted in indigrow child development and autism center involving 16 patients from october to november 2015. total calorie intake was assessed by 24-hour food recall and nutritional status was measured by z-score. correlation was analyzed using spearman’s rho. results: overweight and obesity were found in 10 out of 16 asd children assessed. total calorie intake was not significantly correlated with nutritional status of asd children (r=0.021, p=0.940). conclusions: there is no significant relevance between total calorie intake and nutritional status in asd children at indigrow child development and autism center. [amj.2016;3(2):319–22] keywords: autism, calorie intake, nutritional status, z-score correspondence: aryo windaru, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85693260065 email: aryowindaru@gmail.com introduction autism spectrum disorder (asd) is a neurodevelopmental disability that is usually diagnosed before 3 years of age and is characterized by deficits in social reciprocity and in language skills that are associated with repetitive behaviours and restricted interests.1 according to centers for disease control and prevention (cdc), about 1 in 68 children identified with asd.2 rogers et al.2 reported that 46–75% children specifically diagnosed with asd have feeding, eating, and mealtime challenges. some study discovered that children with autism have anomalous habits relating to food and eating. these children are restricted by food category and texture, and also refused food more. weighing from the risk, feeding problems might affect the nutritional status of asd children themselves.3 one study conducted in japan4 with 140 samples of japanese children aged 7–18 years with autism discovers 25% obesity among those subjects. another study supports this evidence, curtin et al.5 concluded children with autism have 40% higher risk in suffering from obesity. overweight and obesity are not trivial issues considering the effect in increasing mortality of humankind. various complication may happen in consequence of obesity which are type 2 diabetes mellitus, hypertension, dyslipidaemia, and nonalcoholic steatohepatitis.6 despite of these concerns, scarcity in research related to nutritional status of asd children is still a problem.1 this study proposed hypothesis of correlation between nutritional intake and nutritional status on asd children in indigrow children development & autism center, bandung. methods research design used in this study was crosssectional. nutritional intake as independent variable was obtained by conducting interview to the parents of asd patients who came to the clinic. subjects included in this study were children with asd from 2 to 17 years old at althea medical journal. 2016;3(2) 320 amj june 2016 indigrow child development and autism center from october to november 2015. there were 16 children who met the inclusion criteria. every parent or guardian was given an informed consent about the procedures of this research and asked about the willingness to participate in this study. study was conducted after obtaining ethical clearance no: 485/un.c1.3.2/kepk/pn/2015 from health research ethics committee, faculty of medicine, universitas padjadjaran. calorie intake was acquired from 24hour food recall by interviewing the parents of asd children regarding foods and drinks consumed a day before. two separate interviews were necessary to acquire calorie intake in weekdays and weekends to minimize bias. calorie conversion guideline used in this study was indonesian food composition table (indonesian fct) which acquired from department of medical nutrition, faculty of medicine, universitas padjadjaran. nutritional status was measured in z-score, a scoring system to assess differences of child growth compared to references in the same age and gender. reference values of table 1 nutritional status based on z-score category z-score obese >2 sd overweight >1 to 2 sd normal ≥-2 sd to ≤1 sd underweight ≥-3 sd to<-2sd severe underweight <-3 sd note: based on keputusan menteri kesehatan (kepmenkes) indonesia no: 1995/menkes/sk/xxi/2010 z-score and body mass index (bmi) in this study were taken from keputusan menteri kesehatan (kepmenkes) indonesia no: 1995/ menkes/sk/xxi/2010 tentang standar antropometri penilaian status gizi anak. z-score was calculated after taking height and weight measurement at the first visit which transformed into bmi. z-score was acquired by calculating bmi together with age and gender. date of birth was taken in order to determine the age of asd patients at the first visit. correlation between calorie intake and z-score was analysed using spearman’s rho regarding the calorie intake was not normally distributed in shapiro–wilk test (p=0.003). results male participants were higher than female participants (14 out of 2 children). frequency of overweight and obesity among asd children in indigrow child development and autism center was 10 out of 16 children. spearman’s rho correlation test shows no significance of correlation between calorie table 2 characteristics of asd children aged 2–17 years at indigrow child development and autism center characteristics mean (sd) or median (min–max) frequency (n=16) gender males (n) 14 female (n) 2 total calorie per day (kcal) 1811.94 (1174.24–5073.95) 16 z-score 2.76 (0.74) 16 underweight (n) 0 normal (n) 6 overweight (n) 3 obese (n) 7 note: sd= standard deviation althea medical journal. 2016;3(2) 321aryo windaru, fifi veronica, dian marta sari: correlation between calorie intake and nutritional status of autism spectrum disorder in children intake and z-score (r=0.021, p=0.940). discussion this study showed that 14 of 16 participants were male, this results congruent with a previous study showing that autism occurs 4 to 5 times more in males compared to females.7 seven out of 16 participants were obese, but this study found that calorie intake was inconsistent with nutritional status. this phenomena can be explained in the way of obesity caused by multifactorial factors not just by a single etiology.8,9 other factors like physical activities, genetics, psychotropic drugs, and sleep hygiene may also contribute in manufacturing obesity. the most common genetic alteration associated with asd is genomic duplications and deletions at 16p11.2 gene. deletion in this region has recently been shown to play role in earlyonset childhood obesity. the pediatric carriers of 16p11.2 are 50% obese. psychotropic drugs are very commonly prescribed in children with asd. studies about children with asd treated by risperidone discovered significant weight gain versus placebo groups. yet the mechanisms by which antipsychotics cause weight gain are not fully understood. children with asd are often faced by sleep problems. several studies documented that overweight in children is inversely correlated with sleep duration. physical activity and sedentary behaviour are factors which contributed in obesity development of children and adolescent. nonetheless, children with asd may be particularly challenged to engage in physical activity in consideration of motor skill difficulties.8 evans et al.10 stated that asd children have higher levels consumption of energy dense foods than typically developing children. most calorie intake of asd children in this study consists of snacks or instant noodles (14 out of 16) according to the 24-hour food recall and 6 out of 16 patients have higher calorie diet based on age according to recommended dietary allowances: harmonization in southeast asia. this study had several limitations; recall bias may have occurred in this study (e.g., mothers’ reluctance to report “unhealthy” food intake), which would underestimate the true association between calorie intake and nutritional status. methods such as 24-hour recall or food diaries evaluate calorie intakes more accurately, yet estimate short-term not longterm intake.11 some of the asd children in this study were hardly receive instructions and cooperate in measurement which may affect the measurement accuracy and caused measurement bias. the largest methodological limitation presented among cross-sectional studies is a confounding factor because measurement of calorie intake only measured in one time only and it is difficult to ascertain whether calorie intake is contributing to nutritional status of asd children. however, cross-sectional studies are vital in facilitating hypothesis initiation to be further tested in observational or experimental studies.12 prospective cohort studies are better equipped than cross-sectional studies to adjust confounding factors but are still observational in nature and thus vulnerable to confounding factors as well.10 total sampling was used in this study, but still the sample was lacking (n=16) and may not representative for community. in conclusion, this study does not show any significant correlation between total calorie intake and nutritional status of asd in children. this result is consistent with some other studies stating that total calorie intake is statistically insignificant toward nutritional status. references 1. xia w, zhou y, sun c, wang j, wu l. a preliminary study on nutritional status and intake in chinese children with autism. eur j pediatr. 2010;169(10):1201–6. 2. rogers l, magill-evans j, rempel g. mothers’ challenges in feeding their children with autism spectrum disordermanaging more than just picky eating. j dev phys disabil. 2012;24(1):19–33. 3. nierengarten mb. managing autism symptoms through nutrition. contemporary pediatrics. 2014;31(4):23– 7. 4. sugiyama t. a research of obesity in autism. japanese journal on developmental disabilities. 1991;13:53–8 5. curtin c, bandini lg, perrin ec, tybor dj, must a. prevalence of overweight in children and adolescents with attention deficit hyperactivity disorder and autism spectrum disorders: a chart review. bmc pediatr. 2005;5:48–53. 6. batch ja, baur la. management and prevention of obesity and its complications in children and adolescents. med j aust. althea medical journal. 2016;3(2) 322 amj june 2016 2005;182(3):130–5. 7. lai mc, lombardo mv, baron-cohen s. autism. lancet. 2014;383(9920):896– 910. 8. hill jo, wyatt hr, peters jc. energy balance and obesity. circulation. 2012;126(1):126– 32. 9. curtin c, jojic m, bandini lg. obesity in children with autism spectrum disorder. harv rev psychiatry. 2014;22(2):93–103. 10. evans ew, must a, anderson se, curtin c, scampini r, maslin m, et al. dietary patterns and body mass index in children with autism and typically developing children. res autism spectr disord. 2012;6(1):399–405. 11. dehghan m, akhtar-danesh n, merchant at. childhood obesity, prevalence and prevention. nutr j. 2005;4:24. 12. rosenheck r. fast food consumption and increased calorie intake: a systematic review of a trajectory towards weight gain and obesity risk. obes rev. 2008;9(6):535– 47. althea medical journal. 2015;2(2) 199 effect of neem leaves extract (azadirachta indica) on wound healing naveen kumar chundran,1 ike rostikawati husen,2 irrarubianti3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of plastic surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: neem leaves (azadirachta indica) have active ingredients such as nimbidin and sodium nimbidate which possess/possesinganti-inflammatory, antibacterial, antifungal and antiviral properties that help in healing process and also contains an excellent nutrition which plays/playing a vital role in formation of collagen and formation of new capillaries. the aim of this experimental study is to evaluate healing activity of neem leaves. methods: this experiment was conducted in pharmacology lab of universitas padjadjaran on october 2012. twenty seven rats were grouped randomly into 3 groups and 1.5cm of excision wound was created. negative control group was treated with a topical application of saline solution (sodium chloride0.9%), treatment group with a topical application of neem leaves extract and positive control group had been treated with a topical application of povidone-iodine for 15 days. healing was assessed by the longest diameter of the raw surface of wound on days 0, 5, 10 and 15. the data were then analyzed using mann-whitney u test. results: there was a significant reduction in the longest diameter of wound in group of neem leaves extract, compared with group sodium chloride 0.9%,.and there was no significant difference in the longest diameter of wound between neem leaves, extract and povidone iodine. conclusions: neem leaves extract has the same wound healing rate compared to povidone iodine. a further study in human should be conducted in the future. [amj.2015;2(1):199–203] keywords: neem, povidone iodine, wound healing correspondence: naveen kumar chundran, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827969020 email: naveen_160888@yahoo.com introduction the skin, as the body’s largest organ consists of two layers, epidermis and dermis.1 human skin provides protection for the body from external environment, preventing dehydration, regulates body temperature, detects cutaneous sensation, and synthesizes vitamin d.2 the skin barrier can be broken, such as from a wound.3 there are many types of wound which have been classified into two major groups, open and closed wound.4 healing is a process to replace damaged tissue, organs, and biological system to normal function. injury will initiate a series of event to repair the damaged skin and reform its normal structure. there are four phases in wound healing process, haemostasis, inflammation, proliferation, and remodeling.5-8 neem (azadirachta indica) is a well known medicinal plants, having a wide spectrum of biological activity as a traditional medicine for household remedy against various human ailments in ayurveda and homoeopathic medicine. recent studies and research show that neem contains many therapeutic effects such as anti-inflammatory, anti-diabetic, antifungal, antiviral, antibacterial, and anti-malarial. neem contains many active ingredients such as nimbidin, nimbin, and nimbidol with anti-inflammatory, antibacterial, antifungal and antiviral properties that may help it accelerating the wound healing process. in addition, neem contains an excellent amount of amino acid, vitamin and mineral that is very important in wound healing processes in proliferation phase. 9 so, there is a possible effect that neem can accelerate the process. the aim of this study is to find out whether neem leaf extract can accelerate the duration of wound healing. althea medical journal. 2015;2(2) 200 amj june, 2015 methods an experimental study was conducted using 27 rats (rattus norvegicus) strain wistar. these rats were all male, aged between 2-3 months and weighing about 200-250 grams. the rats were divided randomly into 3 groups. each group contained 9 rats and was given intervention as followed: group 1 acted as the negative control group with a topical application of saline solution (sodium chloride 0.9%), group 2 was the treatment group with a topical application of neem leaves extract, group 3 acted as the positive control group with a topical application of povidone-iodine solution during the experiment period, rats were given foods and water ad libitum (free access to foods or water thereby allowing animals to self-regulate according to its biological needs). the neem leaves extract was made by using 1kg of neem leaves (azadirachtaindica). the leaves were washed with water and air-dried at room temperature. the leaves then were powdered by mixer, macerated in 10 liter of ethanol 96% and then kept for 72 hours away from lights and high temperature. it was filtered, evaporated, and dried with rotary evaporator. rats were anesthetized before and during the creation of the wounds, with 1ml of intravenous ketamine. the hairs around the area of dorsal midline region were shaved clean using a shaver. then, 1.5cm diameter was measured and marks were made on the rat. using a permanent marker, the marks of the diameter were all joined to make a circle. using a scalpel, excision was made all around the marked circle. then, using an anatomical pin set and a curved hemostat scissors, a full thickness of excision wound for 2 mm depth was created following the marked circle. wound was left uncovered throughout the experiment. then, apply either saline solution, neem leaves extract or the povidone-iodine solution topically according to the group the rats were placed. the intervention applied sufficiently until it covered all wound area. the wound was left uncovered and cleaned using water with gauze and applied with daily intervention.10 the longest diameter of the raw surface wound was calculated on days 0, 5, 10, 15 and the mean diameter of the raw surface of wound (red colour area) was compared to a control group at each time intervals. raw surface of the wound can be differentiated from epithelisation surface by the colour, wet look and shininess. epithelisation surface would be pink in colour with the formation of a new epidermis while raw surface would be red in colour. other than that, raw surface would be wet and shine table 1 longest diameter of the raw surface of wound after topical administration of sodium chloride 0.9% no longest diameter group 1 (sodium chloride) (cm) day 0 day 5 day 10 day 15 1 1.4 1.1 1.5 1.2 2 1.5 1.4 1.3 1.0 3 1.6 1.8 1.9 1.6 4 1.7 1.4 1.0 1.7 5 1.5 1.7 1.5 1.2 6 1.5 1.2 1.4 0.9 7 1.5 1.3 2.0 1.8 8 1.5 1.7 2.0 1.6 9 1.5 1.1 1.2 1.2 median 1.5 1.4 1.5 1.2 mean 1.52 1.41 1.53 1.36 minimum 1.4 1.1 1.0 0.9 maximum 1.7 1.8 2.0 1.8 althea medical journal. 2015;2(2) 201naveen kumar chundran, ike rostikawati husen, irra rubianti: effect of neem leaves extract (azadirachta indica) on wound healing if it is exposed to lights or the sun meanwhile epithelisation surface would be dry and had a pale appearance. the data were then analyzed between the groups using mann-whitney u test to compared the efficacy and potential of each treatment group. this statistic test used a significance level (α) = 0.05, two-tailed test, z table = 1.65 with 95% confidence level. this experiment was conducted in pharmacology lab of universitas padjadjaran on october 2012. the study was carried out with prior approval of the animal ethical committee, faculty of medicine,universitas padjadjaran. results on day 0 the longest diameter on wound in group 1 was 1.52 cm, whereas in group 2 was 1.62 cm and in group 3 was 1.57 cm. on day 5, the longest diameter on wound in group 1 was 1.41 cm, whereas in group 2 was 1.3 cm and in group 3 was 1.34 cm (table 1, 2, 3). on day 0 and day 5 there was no significant change in the longest diameter of wound between group sodium chloride 0.9% and group neem leaves extract (p> 0.05), where it can be seen from the p-value being 0.161 and 0.489. however, on days 10 and 15 there was a significant change in the longest diameter of wound from group sodium chloride 0.9% (1.53 and 1.36 cm) and group neem leaves extract (1.11 and 0.31 cm), where it can be seen from the p-value being 0.008 and 0.000 (p < 0.05). on day 0 and day 5 there was no significant change in the longest diameter of wound between groups sodium chloride 0.9% (1.53 and 1.41 cm) and group povidone iodine (1.57 and 1.34 cm), where it can be seen from the p-value being 0.546 and 0.730 (p > 0.05). however, on day 10 and 15 there was a significant change in the longest diameter of wound from group sodium chloride 0.9% (1.53 and 1.36 cm) and group povidone iodine (1.31 and 0.37 cm), where it can be seen from the p-value being 0.003 and 0.000 (p < 0.05). on days 0, 5, 10 and 15 there was no significant change in the longest diameter of wound between group 2 and group 3, where it can be seen from the p-value being 0.387, 0.666, 0.489 and 0.546 (p > 0.05). discussions wound healing is a process that involves several phases. the initial vascular response involves a period of vasoconstriction and haemostasis. the first phase is inflammation. inflammation will cause an increase in vascular permeability and resulting in migration of neutrophils and monocytes into the surrounding tissue. table 2 longest diameter of the raw surface of wound after topical administration of neem leaf extract no longest diameter group 2 (neem leaf extract) (cm) day 0 day 5 day 10 day 15 1 1.7 1.4 1.0 0.2 2 1.5 1.5 1.3 0.1 3 1.5 1.2 1.1 0.4 4 1.5 1.2 1.1 0.3 5 1.5 1.1 1.3 0.3 6 1.6 1.3 1.2 0.4 7 1.6 1.2 1.1 0.6 8 1.7 1.3 0.8 0.2 9 2.0 1.5 1.1 0.3 median 1.6 1.3 1.1 0.3 mean 1.62 1.3 1.11 0.31 minimum 1.5 1.1 0.8 0.1 maximum 2.0 1.5 1.3 0.6 althea medical journal. 2015;2(2) 202 amj june, 2015 infiltrating neutrophils cleanse the wounded area of foreign particles and bacteria. second phase is the proliferative phase which occurs from 2 days to 3 weeks’ time. in this phase formation of granulation tissue, contraction and epithelialization will take place. the final phase of wound healing is wound remodelling, including a reorganization of new collagen fibers, forming a more organized lattice structure that progressively continues to increase wound tensile strength. the remodelling process continues up to two years.5-8 in this study the wound contraction process did not begin before day 10 in all groups. on days 10 and 15, there was a significant change in wound healing between group 1 and 2, it was proved by the reduction of diameter of the wound in group 2. this shows that neem leaves extract has an active compound that has effects as anti-microbial, antioxidant and antiinflammatory. this proves that neem accelerates the healing process by prevent the infection which can prolong the healing duration. the antiinflammatory effect of neem can be seen more accurately if the histological examination had been performed. neem is also an excellent wound healer that helps the body to rapidly create collagen fibers to close the wound. on day 10 and 15, neem showed significant changes in the healing process by enhancing the proliferation phase. neem contains an excellent amount of amino acid, vitamin and mineral that is very important in wound healing process in proliferation phase. thus, neem accelerates the healing process by speeding up the proliferation phase. the result proves that neem leaves extract speeds up the proliferation phase in the entire wound healing process. as a positive control, povidone iodine is an uniquely effective antiseptic and used widely for the prevention and treatment of infection. the prolonged non selective antimicrobial action of povidone iodine is unparalleled for the surface microbiocidal activity and particularly effective in treating mixed infection. povidone iodine is suitable for hand disinfection, surgical hand disinfection, as well as preoperative and pre-puncture skin disinfection.11,12 the result proves that povidone iodine indeed increases the rate of wound healing by being a disinfectant to the wound. neem leaves extract and povidone iodine, both accelerate the rate of wound healing. the results shows that neem leaves extracts have the same wound healing rate compared to povidone iodine. thus, neem leaves extract can be considered to be made an alternative choice to povidone iodine because both groups give the same outcome. this study has limitation, histological examination of the wound was not examinated to see the inflamantory effect of neem. table 3 longest diameter of the raw surface of wound after topical administration of povidone-iodine (betadine) solution no longest diameter group 3 (povidone iodine) (cm) day 0 day 5 day 10 day 15 1 1.6 1.2 0.6 0.3 2 1.6 1.4 1.3 0.2 3 1.5 1.3 1.1 0.1 4 1.5 1.2 0.9 0.4 5 1.5 1.3 1.3 0.7 6 1.5 1.4 0.8 0.6 7 1.9 1.7 1.2 0.3 8 1.5 1.4 0.8 0.3 9 1.5 1.2 1.1 0.4 median 1.5 1.3 1.1 0.3 mean 1.57 1.34 1.01 0.37 minimum 1.5 1.2 0.6 0.1 maximum 1.9 1.7 1.3 0.7 althea medical journal. 2015;2(2) 203naveen kumar chundran, ike rostikawati husen, irra rubianti: effect of neem leaves extract (azadirachta indica) on wound healing references 1. mescher al. junqueira’s basic histology: text & atlas. 12th ed; new york:mcgraw hill companies;2010. p. 316¬–29 2. tortora gj, derrickson b. principles of anatomy and physiology. 12th ed. hoboken:john wiley &sons; 2008. p. 147– 74 3. torpy jm, burke a, glass rm. wound infections. jama. 2005; 294(16):2122. 4. chandler s. five types of wounds. 2011. [cited 2012 november 3]. available from: http://www.livestrong.com/ article/101274-five-types-wounds/ 5. singer aj, clark ra. cutaneous wound healing. n eng j med. 1999;34(10):738–46. 6. hees ct. understanding the barriers to healing. adv skin wound care. 2012;25(5):240 7. diegelmann rf, evans mc. wound healing: an overview of acute, fibrotic and delayed healing. front biosci. 2004;9:283–9. 8. mackay d, miller al. nutritional support for wound healing. altern med rev. 2003;8(4):359–77 9. subapriya r, nagini s. medicinal properties of neem leaves: a review. curr med chem anticancer agents. 2005;5(2):149–6. 10. nayak bs, sandiford s, maxwell a. evaluation of the wound-healing activity of ethanolic extract of morinda citrifolia l. leaf. evid based complement alternat med. 2009;6(3):351–6. 11. kumar jk, jayachandran e, reddy hk, gunashakaran v, ramesh y, babu kp, et al. application of broad spectrum antiseptic povidone iodine as powerful action: a review. journal of pharmaceutical science and technology. 2009;1(2):48–58. 12. khan mn, naqvi ah. antiseptics, iodine, povidone iodine and traumatic wound cleansing. j tissue viability. 2005;16(4):6– 10. figure 1 mean of the longest diameter of the wound in three groups on day 0, 5, 10, and day 15 althea medical journal. 2015;2(4) 463 health information and decision making preference on disease treatment muhammad hasif bin mohamed ali,1 yoni syukriani,2 bambang sulthana3 1faculty of medicine universitas padjadjaran, 2department of forensic & legal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: medical decision making is a complex cognitive process of choosing in establishing a diagnosis and selecting a management option in the context of healthcare. patients may desire to take part in obtaining and exchanging information, discussing over options and making the final decisions about treatment and or care. the focus of the study was to identify the health information and decision making preference on diseases treatment. methods: a descriptive study was conducted to 110 respondents from hegarmanah village, sumedang, indonesia, aged 18–65 years old who had the experience in consulting doctors for their medical problems. this study was carried out during the period of september to october 2013. the respondents were selected using random stratified sampling. a tested questionnaire, consisted of 2 sections, was used to collect the data. the collected data were presented using frequency tabulation. results: most of the respondents preferred to be offered choices and asked for their opinions by their doctors. furthermore, 55.45% preferred to rely on physicians for medical knowledge and 93.64% agreed that they had rights in getting all the information on their medical problems, so they submitted their decision to the doctors for care or treatment. conclusions: this study shows that preference of the patients varies with regard to how much patients want to participate as one, which may have different preference for different components of the decision making process, yet there is a shift of paradigm from paternalistic to collaborative decicion making between doctor and patient. [amj.2015;2(4):463–8] keywords: decision making, doctor patient communication, preference correspondence: muhammad hasif bin mohamed ali, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628170208929, email: haseefali90@gmail.com introduction autonomy is the paramount feature among four equal medical ethical principles1; thus, patient participation in decision making complement the legal requirement of informed consent. however, most of the patients may prefer to leave their final medical decisions up for their doctors.1,2 alternately, patient who plays active and collaborative roles in medical decision making in general are viewed as a precursor to a positive and improved health outcomes.3-5 therefore, every patient wants to participate with a different degree of preference. some may care for the active role in discussing during consultation, but in turn they may rely on their physicians to make the ultimate decisions.2 doctors can support the integrity of patient’s decision making process not only by offering them the opportunity to participate, but also by sharing responsibility and enhance their autonomy with respect to their own preferences.6 in addition, doctors should aware and require accurate information upon the patient desire to avoid inaccurate or biased assumptions about the patient’s wishes.2,7 thus, it is vital for the doctors and health care organizations to comprehend the magnitude and the degree of the patient preferences in order to design patient education and health althea medical journal. 2015;2(4) 464 amj december, 2015 promotion programs precisely.2 the aim of the study was to identify the health information and decision making preference on diseases treatment. methods a descriptive study was performed to 110 respondents living in hegarmanah village, jatinangor, sumedang, west java during the period of september to october 2013. hegarmanah village was selected in this study because it is one of the research location for medical students from faculty of medicine, universitas padjadjaran. the respondents were between 18–65 years old who had the experience in consulting doctors for their medical problems. with these inclusion criteria, the respondents were participating. the sample population was selected by random stratified sampling. this study constructed a questionnaire by referring to several tools tailored for medical decision making such as the work by levinson et al.2 , charles et al.8, flynn et al.9, and muller-engelmann’s10. the questionnaire consisted of three main sections, those were seeking information (5 items), doctor patient communication (3 items), and decision preference (4 items).2,8,9 moreover, there was a five-point scales questions for participation in treatment decision making preference, adapted from sutherland et al. in mullerengelmann’s10. all of these items were then translated into bahasa indonesia. after validity and reliability test, several items were modified following the feedbacks of the respondents regarding the clarity of the indonesian language. respondents were asked to rate each item justly by the multiple choice options, yes/no or agree/disagree. by frequency analysis, the results were tabulated. results female respondents who participated in this study were more than half (70.91%) compared to male (29.09%). most of the respondents were from 32–42 years old age group (39.09%). the majority of the respondents were married (86.36%) and almost half of the respondents classified themselves as housewives (49.09%). the level of education from this study indicated that most of the respondents did not graduate from high school as 36.36% were graduated from elementary school and 28.18% were graduated from junior high school. from 110 respondents who participated in this study, 91.82% had the experience as ambulatory patients, 20.00% were table 1 distribution of respondents according to decision making preference components items and alternative answers n % decision making preference who would you refer if you are in doubt making a medical decision? doctor 42 38.18 family 45 40.91 autonomous 14 12.73 other 9 8.18 i prefer to leave decisions about my medical care to my doctor agree 78 70.91 disagree 32 29.09 patients have to receive full information upon their disease but must submit to the doctor for treatment or care agree 103 93.64 disagree 7 6.36 respondent preference on who should choose the appropriate treatment or medication during consultation doctor 71 64.55 shared decision (doctor & patient) 30 27.27 family 4 3.64 autonomous 5 4.55 althea medical journal. 2015;2(4) 465 table 2 distribution of respondents according to health information components items and alternative answers n % seeking information preferences to rely on doctor's knowledge yes 61 55.45 no 49 44.55 knowledge reference husband/wife 20 18.18 shared decision (doctor & patient) 14 12.73 parent 7 6.36 autonomous 6 5.45 other 2 1.82 preferences in finding information about their conditions on their own yes 65 59.09 no 45 40.91 preferences in gaining information about all the benefits and harms of a medical treatment during consultation yes 90 81.82 no 20 18.18 preferences in trying to find the information about the benefits and harms of a medical treatment given on their own yes 65 59.09 no 45 40.91 doctor patient communication respondent options to be requested by the doctor to discuss upon the treatment given yes 94 85.45 no 16 14.55 i prefer that my doctor offers me choices and asks my opinion agree 80 72.73 disagree 30 27.27 patient's opinion is required upon the treatment given by their doctor agree 70 63.64 disagree 40 36.36 hospitalized, 3.64% underwent surgery, 1.82% had received other treatments, and 0.91% received blood transfusion. moreover, 63.64% of the respondents did not seek consultation with a specialist while there were 36.36% respondents who referred to a specialist. there were approximately more than half of the respondents (55.45%) choose to be passive as they prefer to rely on their doctor’s knowledge during consultation. from 44.55% respondents choosing not to rely completely on their doctor’s knowledge, there were 18.18% respondents refer red to their husband or wife. interestingly, 1.83% opted to choose others as they rely on god’s guidance to help them. moreover, 59.09% respondents were trying to search for an answer on their own as they are intrigue for an answer before consulting their doctor for further diagnosis. most of the respondents (81.82%) played an active role during consultation by trying to gain information about all benefits and harms of a medical treatment during consultation. furthermore, respondents (59.09%) were muhammad hasif bin mohamed ali, yoni syukriani, bambang sulthana: health information and decision making preference on disease treatment althea medical journal. 2015;2(4) 466 amj december, 2015 proactive in trying to find themselves on information about the benefits and harms of a medical treatment that were given by their doctor. during consultation, the majority of the respondent (85.45%) opted to be solicitous in deliberating with the doctor in charge of the medication or the treatment given when asked the option to be invited discussing the matters. moreover, about two-third of the respondent (72.73%) eager to speak out their own opinion when asked whether they prefer to be offered choices and voice out their opinions by their doctors. more than half respondents (63.64%) agreed that their opinions on the treatment given are crucial. in making the final decision, less than half of the respondent (40.91%) referred their decision to their family when in doubt making a medical decision, yet most of them agreed to leave the decision about their medical care to the doctor. from the five-point scales of participation in treatment decision making preference, it could be identified that about one-third of the respondents made their decision on medical treatment still according to the decision made by the doctor with the consideration from the patients. discussion this study showed wide variation in preferences for participation in medical decision making. more than half of the respondents still relied on their doctor’s knowledge during consultation. this result of the study shows similar results to studies conducted by levinson et al.2 and jahng et al.4 studies. they stated that the patient still relies on the doctor’s knowledge rather than collaborate to gain the information. charles et al.8 and emanuel et al.12 described this evidence as “paternalistic” in which the patient opts to be fiduciary in relationship with their doctors. yet, there was still respondents who were proactive to seek information other than from their doctors. there was a shift of paradigm from paternalistic approach to collaborative approach between doctors and patients. most of the other health information sources were coming from their family such as husband/ wife and parents. this is consistence with schneider13 findings. he stated that in asians, there are inclined in medical decision preference towards their family. interestingly, 1.83% opted to choose others as they rely on god’s guidance to help them. thus, religion also plays an important role in helping patients making their decisions. moreover, the respondents were also asked whether they were trying to find out about their condition on their own or not. more than half of them tried to search for an answer by their own as they intrigued for an answer before consulting their doctor for further diagnosis. this may have impact for doctors to be more persistent and wise during consultation because one might have prior knowledge and “view” on his or her disease weather their opinion are right or wrong. at the same time, people often have misconception on the key facts about important health decisions they make, and there are vital differences between what doctors think patients ought to know and what patients want to know.14 with that, doctors have to be educative and have primacy table 3 distribution of respondents according to the participation in treatment decision making preference10 decision preference n % the doctor should make the decision using all that is known about the treatment. 32 29.09 the doctor should make the decision but strongly consider the patients opinion. 34 30.91 the doctor and the patient should make the decision together on an equal basis. 24 21.82 the patient should make the decision but strongly consider the doctor's opinion. 14 12.73 the patient should make the decision using all he knows or learns about the treatment. 6 5.45 total 110 100 althea medical journal. 2015;2(4) 467muhammad hasif bin mohamed ali, yoni syukriani, bambang sulthana: health information and decision making preference on disease treatment knowledge in communication skills in order to harmonize patient’s perceptions.15 most of the respondents expected to be more involved in doctor patient communication. humans are curious always being asked for reasons and this is similar to hwa’s findings in malaysia7 that most of the patients did want to be fully informed on their condition or medication. respondents who want to be involved and informed regarding their healthcare decisions can be considered as progressive.16 therefore, to accommodate these “new paradigm” patients, doctors should ask on how they understand their condition and on which level they want to be involved in deciding the treatment. this approach method can be a foundation for doctors seeking an informed, shared decision or collaborative model of care.16 furthermore, respondents were proactive in trying to find themselves the information about the benefits and harms of a medical treatment given by their doctors. this denotes that the respondents were careful for medication they took. family and culture play significant roles in deciding health and communication between doctor and patient in most asian families.13,17 this norm concurrently comes to pass in this study. in making the final decision, less than half of the respondents refer their decision to their family when in doubt making a medical decision. interestingly, there was still a few repondents who chose others as they submit themselves to god’s guidance in making decision. this indicates that religion also plays a role in making decisions. all respondents agreed that they had rights in getting all information on their medical problem but still submit their decision to the doctors for care and treatment. these decision patterns showed that patient wanted to be fully informed on their diagnosis, medication and treatment option but at the same time forego their autonomy for doctor to decide.7 this is supported by their responses toward the question “who should choose the appropriate treatment or medication during consultation?” most of the respondents preferred that doctor is the one who obligated to choose the suitable treatment for them. this study has limitation. it did not identify the type and severity of respondents’ diseases that may cause different perception. it can be concluded that health information and decision making are preferred in treatment of disease vary, yet there is a shift of paradigm from paternalistic to collaborative decicion making between doctor and patient. the doctors must assess each and every individual preference in making medical decision to ensure that their treatment and care can be tailored and fit to measure. thus, doctors have to master communication skills to avoid misconception of patients’ perception about their medical problems. references 1. gillon r. ethics needs principles—four can encompass the rest—and respect for autonomy should be “first among equals”. j med ethics. 2003;29(5):307–12. 2. levinson w, kao a, kuby a, thisted r. not all patients want to participate in decision making. a national study of public preferences. j gen intern med. 2005;20(6):531–5. 3. hibbard jh. engaging health care consumers to improve the quality of care. med care. 2003;41(1suppl):i61–70. 4. jahng kh, martin lr, golin ce, dimatteo mr. preferences for medical collaboration: patient–physician congruence and patient outcomes. patient educ couns. 2005;57(3):308–14. 5. landon be, wilson ib, mcinnes k, landrum mb, hirschhorn l, marsden pv, et al. effects of a quality improvement collaborative on the outcome of care of patients with hiv infection: the eqhiv study. ann intern med. 2004;140(11):887–96. 6. anyfantakis d, symvoulakis ek. medical decision and patient’s preference:’much ethics’ and more trust always needed. int j med sci. 2011;8(4):351–352. 7. hwa ys. do patients want to be informed and be involved in decision-making?. kajian malaysia. 2004;xxii(1):19–46. 8. charles ca, whelan t, gafni a, willan a, farrell s. shared treatment decision making: what does it mean to physicians?. j clin oncol. 2003;21(5):932–6. 9. flynn ke, smith ma, vanness d. a typology of preferences for participation in healthcare decision making. soc sci med. 2006;63(5):1158–69. 10. müller-engelmann m, krones t, keller h, donner-banzhoff n. decision making preferences in the medical encounter–a factorial survey design. bmc health serv res. 2008;8:260. 11. harrington j, noble lm, newman sp. improving patients’ communication with doctors: a systematic review of intervention studies. patient educ couns. althea medical journal. 2015;2(4) 468 amj december, 2015 2004;52(1):7–16. 12. emanuel ej, grady c. four paradigms of clinical research and research oversight. camb q healthc ethics. 2007;16(1):82–96. 13. schneider sl. the influence of cultural diversity on medical, legal and financial decision-making. folo magazine. 2008; [cited 2012 december 2] available from: http://www.familiesoflovedones.com/ index.php?option=com_content&task=vie w&id=137&itemid=41 14. fraenkel l, mcgraw s. participation in medical decision making: the patients’ perspective. med decis making. 2007; 27(5):533–8. 15. epstein rm, alper bs, quill te. communicating evidence for participatory decision making. jama. 2004;291(19):2359–66. 16. kravitz rl, melnikow j. engaging patients in medical decision making: the end is worthwhile, but the means need to be more practical. bmj. 2001;323(7313):584–5. 17. mclaughlin la, braun kl. asian and pacific islander cultural values: considerations for health care decision making. health soc work. 1998;23(2):116–26. althea medical journal. 2016;3(2) 275 characteristics of patient with benign paroxysmal positional vertigo in dr. hasan sadikin general hospital bandung from 2009–2013 intan datya kirana,1 yussy afriani dewi,2 titing nurhayati3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: benign paroxysmal positional vertigo (bppv) is a vestibular disorder marked by episodes of vertigo and triggered by a change in the head position. it is characterized by short yet severe episodes of vertigo and possibly accompanied by nausea and vomiting. the bppv is usually idiopathic and found among people aged 46‒50 years old. there are pharmacological and non-pharmacological treatment used for bppv. non-pharmacological treatment includes epley, semont, lempert, forced prolonged position, and brandt-daroff maneuvers and pharmacological onebenzodiazepine and antihistamines. this study aimed to examine the characteristics of patient with bppv based on their complaint and prescribed treatment. methods: this was a descriptive-retrospective study conducted on april–june 2014 using secondary data from medical records of patient with bppv in dr. hasan sadikin general hospital bandung from 2009‒2013. the variables include gender, age, occupation, accompanying disease, complaints, supporting examinations, and treatment. results: there were 74 subjects; 66.22% were female and 33.78% were male. most of patients with bppv aged around 41–50 years old (39.19%). furthermore, 93.24% had a major complaint of headache and spinning sensation, and >60% nausea and vomiting. the most prescribed therapy was betahistine (86.49%). meanwhile, a maneuver of non-pharmacological treatment was rarely done (8.11%). conclusions: the bppv occurs more in older women. the major complaint is headache and spinning sensation affected by the head position and accompanied by nausea and vomiting. lastly, non-pharmacological treatment is rarely performed in handling patient with bppv. [amj.2016;3(2):275–9] keywords: bppv, clinical characteristic, treatment, vertigo correspondence: intan datya kirana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85352262206 email: intandatya@gmail.com introduction vertigo is a sensation of rhythmical, unidirectional movement of the surrounding environment or the spinning sensation in the head and body of a person.1 vertigo is classified into two types: central and peripheral. central vestibular vertigo occurs due to lesions in the central nervous system.1,2 in peripheral vestibular vertigo, there are problems in the semicircular canals in the ear. one of the most prevalent peripheral vertigo types is benign paroxysmal positional vertigo (bppv).3-6 the bppv is a vestibular disorder characterized by episodes of vertigo and triggered by the changes in the head position. it occurs in certain head positions, for example when one is sleeping upside down, changes in sleeping position or a quick wake-up movement. such an events usually occur in midnight or morning.1 the bppv is marked by short yet severe episodes of vertigo and possibly accompanied by nausea or vomitin. these episodes typically last less than 30–40 seconds, but mostly about 15 seconds. the bppv is usually idiopathic and found among people aged 46–50 year old.7 the method to diagnose bppv is dix-halpike maneuver. it is used to induce nystagmus which is one of the characteristics of bppv.8 treatment of bppv is divided into pharmacological and non-pharmacological therapies. the most frequently used in pharmacological treatments are benzodiazepine and antihistamines. nonpharmacological treatment is in the forms of althea medical journal. 2016;3(2) 276 amj june 2016 maneuvers, e.g. brandt-daroff, semont, and epley which is the most frequently performed maneuver.9–11 the incidence of vertigo amounted to 54.48% of the central type and 45.52% of the peripheral type.10 this study aimed to examine the characteristics of patient with bppv based on their complaint and prescribed treatment. methods this was a descriptive-retrospective study conducted on april–june 2014 using secondary data collected from the medical records of the patients with bppv in dr. hasan sadikin general hospital bandung from 2009‒2013. it was found 74 out of 107 patients who fulfilled the inclusion criteria. the studied variables include gender, age, occupation, accompanying disease, complaints, supporting examinations, and treatment. thirty three patients were excluded due to missing or incomplete variable data in their medical records. results there were 49 (66.22%) female patients with bppv and 25 (33.78%) were male. most of patients with bppv aged around 41–50 year old with 29 (39.19%) people, followed by patients aged 51–60 year old with 18 (24.32%) people. two patients with bppv aged under 20 year old was also found. the most primary occupation was housewives with 13 (17.57%) people, followed by civil servant and others with 6 (8.11%) people (table 1). hypertension was the most frequent accompanying disease in patients with bppv with 38 (51.35%) people. the second most frequent accompanying disease was hypercholesteronemia with 25 (33.78%) people (table 2). the most frequently complained by the patients is headache and spinning sensation with 69 (93.24%) cases. the rest include weakness of the limbs, and vomiting with 5 (6.76%) cases (table 3). the most major accompanying symptoms in patients with bppv are nausea with 50 (67.57%) cases and vomiting with 49 (66.22%) cases (table 3). table 4 shows the rarely-performed supporting examinations on bppv . the romberg test was only performed on 22 (29.73%) patients, resulting 4 (5.41%) positive responses and 18 (18.32%) negative responses. there were 52 (70.27%) patients in which the romberg test was not performed. table 1 characteristic of patients with bppv characteristic n % sex female 49 66.22 male 25 33.78 age (years old) <20 2 2.7 21–30 0 0 31–40 8 10.81 41–50 29 39.19 51–60 18 24.32 61–70 12 16.22 >70 5 6.76 type of job housewives 13 17.57 civil servant 7 9.46 others* 6 8.11 not listed 48 64.86 note: *others: retired, private workers althea medical journal. 2016;3(2) 277intan datya kirana, yussy afriani dewi, titing nurhayati: characteristics of patient with benign paroxysmal positional vertigo in dr. hasan sadikin general hospital bandung from 2009–2013 table 2 other accompanying diseases of patients with bppv accompanying disease n % hypertension 38 51.35 hypercholesteronemia 25 33.78 trauma 7 9.46 dm 12 16.22 tia/stroke 12 16.22 kidney disease 3 4.05 heart disease 4 5.41 gastric disease 12 16.22 other disease 32 43.24 note: *other diseases are osteoatrhitis, lung tuberculosis, gout arthritis, and neoplasia the gait test was only performed on 10 (13.52%) patients, resulting 5 (6.76%) positive responses and 5 (6.76%) negative responses. the remaining 64 (86.49%) patients did not receive thegait examination (table 4). the most frequently prescribed pharmacologic treatment was from the betahistine group in 64 (86.49%) cases. the examples of drugs from the betahistine group were merislon, betaserc, vastigo, mertigo, and metoclopramide, which were given in 28 (37.84%) cases. antihistamines such as dramamine and stugeron were also used in 27 (36.49%) cases. ranitidine was prescribed in 27 cases (36.49%) and vitamin b supplements such as neurodex were prescribed in 24 (32.43%) cases (table 5). a total of 68 patients (91.89%) did not perform in the form of treatment maneuvers. only 5 patients (6.76%) were given the treatment of epley maneuver and 1 patient (1:35%) was given the brandt-daroff treatment maneuvers. discussion gender was considered to be the risk factor of bppv; there were more female patients than male. this conformed to a study by von brevern et al.12 which states that females are more vulnerable to bppv even though the exact mechanism is still unknown. von breven et al.12 also discovers that the group of patients aged 46-50 years old had the highest frequency of bppv case. the large number of older patients table 3 major complaints of bppv patients n % major complaints headache and spinning sensation 69 93.24 others* 5 6.76 accompanying complaints nausea 50 67.57 vomiting 49 66.22 ringing ears 20 27.03 double vision 4 5.41 anesthesia 2 2.70 cold sweat 5 6.76 others** 18 24.32 note: * headache, weakness of the limbs, and vomiting, ** fever, epigastric pain, episodes of black out, and hearing problems althea medical journal. 2016;3(2) 278 amj june 2016 with bppv supported the “aging hypothesis” that theorizes degenerative changes in the utricles, usually due to chronic ischemia which causes the detachment of otoconia from the macule.12,13 in a study by parham14, it is discovered that the prevalence of bppv is quite large among the young age in america, i.,e. 9%. this can be caused by several factors such as trauma, surgery, or physical activities like sports. hypertension and hypercholesteronemia were the most frequent accompanying diseases in patients with bppv. this result is similar with the study by von bavern et al.12, that study explains that hypertension and hypercholesteronemia can result in vascular damages in the inner ears due to the ischemia of labyrinth, leading to the attachment of otoconia towards the otolith membrane. headache and spinning sensation were the most frequently complained that encouraged patients with bppv to ask for a treatment. in accordance to a study by bhattacharyya et al.16, most of patients complain of headache and spinning sensation accompanied by nausea and vomiting as the effects of vestibular imbalance on the afferent nerves of the extra medullary centers in the brain. positional change also has an effect on the vertigo as it causes displacement of otolith and makes it attach to the utricles and semicircular canals.9,15,16 betahistine and metoclopramide is the pharmacologic treatment for patients with bppv.17 the most frequently prescribed pharmacologic treatment was betahistine, which functions as an anti-vertigo and histamine precursor that repairs vestibular microcirculation.13 metoclopramide was frequently given to treat symptoms such as nausea and vomiting, e.g. primpenan. bhattacharyya et al.16 states that antihistamines such as dramamine and sturgeon were also frequently used. their anticholinergic properties can reduce vestibular stimulation, suppress the labyrinth’s functions, and table 4 supporting examination in bppv patient supporting test (+) % (-) % unrecorded % romberg test 4 5.41 18 24.32 52 70.27 gait test 5 6.76 5 6.76 64 86.49 table 5 treatment in patients with bppv treatment n % pharmacological treatment antihistaminic (dramamine, stugeron) 27 36.49 betahistine (merislon, betaserc, vastigo, mertigo) 64 86.49 metoclopramid (primpenan) 28 37.84 vitamin b (neurodex) 24 32.43 flunarizine (unalium, frego) 9 12.16 antihipertensi (amlodopin , captopril) 17 22.97 ranitidine 27 36.49 proton pump inhibitor (omeprazole) 15 20.27 simvastatin 18 24.32 ivfd 19 25.68 obat lain 30 40.54 non pharmacological treatment epley manuever 5 6.76 brandt-daroff manuever 1 1.35 not conducted manuever 68 91.89 althea medical journal. 2016;3(2) 279 suppress the conduction in vestibulocerebellar tract. in this study, it was found that maneuver was rarely used as a treatment for patients though it is a more effective treatments for bppv.16 the limitations of this study lies in the time insufficiency to access the central medical record facility in dr. hasan sadikin general hospital during the weekdays and the insufficiency of complete medical records kept in the facility. this study recommends the hospital to be more systematic in the fulfillment, safekeeping, and well-organized sorting of the medical records so as to expedite further researches. in addition, the provision of the maneuver as primary treatment of patients with bppv is more advisable than pharmacological drug delivery as it is more effective. from this study, it can be concluded that most bppv patients are females in the group of 41-50 years old. hypertension and hypercholesterolemia are the most frequent accompanying diseases in patients with bppv. the major complaint of the patients is headache and spinning sensation accompanied by nausea and vomiting. pharmacologic treatments including the use of betahistine, metoclopramide, and antihistamines involving maneuver is rarely prescribed. references 1. sura sd, newell s. vertigodiagnosis and management in primary care. bjmp. 2010;3(4):a351 2. alvarenga ga, barbosa ma, porto cc. benign paroxysmal positional vertigo without nystagmus: diagnosis and treatment. braz j otorhinolaryngol. 2011;77(6):799–804. 3. lai yt, wang tc, chuang lj, chen mh, wang pc. epidemiology of vertigo: a national survey. otolaryngol head neck surg. 2011;145(1):110–6. 4. wang h, yu d, song n, su k, yin s. delayed diagnosis and treatment of benign paroxysmal positional vertigo associated with current practice. eur arch otorhinolaryngol. 2014;271(2):261–4. 5. neuhauser hk, lempert t. vertigo: epidemiologic aspects. semin neurol. 2009;29(5):473–81. 6. garrigues hp, andres c, arbaizar a, cerdan c, meneu v, oltra j, et al. epidemiological aspects of vertigo in the general population of the autonomic region of valencia, spain. acta otolaryngol. 2008;128(1):43–7. 7. isaradisaikul s, navacharoen n, hanprasertpong c, kangsanarak j, panyathong r. causes and time-course of vertigo in an ear, nose, and throat clinic. eur arch otorhinolaryngol. 2010;267(12):1837–41. 8. parnes ls, agrawal sk, atlas j. diagnosis and management of benign paroxysmal positional vertigo (bppv). cmaj. 2003;169(7):681–93. 9. lee jd, shim db, park hj, song ci, kim mb, kim ch, et al. a multicenter randomized double-blind study: comparison of the epley, semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo. audiol neurootol. 2014;19(5):336–41. 10. purnamasari pp. diagnosis and management benign paroxysmal positional vertigo (bppv). e-jurnal medika udayana. 2013;2(6):1056–80. 11. brandt t, dieterich m, m. s. vertigo and dizziness: common complaints. 2nd ed. london: springer; 2013. 12. von brevern m, radtke a, lezius f, feldmann m, ziese t, lempert t, et al. epidemiology of benign paroxysmal positional vertigo: a population based study. j neurol neurosurg psychiatry. 2007;78(7):710–5. 13. lea p, kushnir m, shpirer y, zomer y, flechter s. approach to benign paroxysmal positional vertigo in old age. isr med assoc j. 2005;7(7):447–50. 14. parham k. benign paroxysmal positional vertigo: an integrated perspective. advances in otolaryngology. 2014;2014:792635. 15. kim js, zee ds. benign paroxysmal positional vertigo. n engl j med. 2014;370:1138–47. 16. bhattacharyya n, baugh rf, orvidas l, barrs d, bronston lj, cass s, et al. clinical practice guideline: benign paroxysmal positional vertigo. otolaryngol head neck surg. 2008;139(5 suppl 4):s47–81. 17. cash jc, glass ca. family practice guidelines. 3rd ed. new york: springer publishing company; 2014. p. 27. intan datya kirana, yussy afriani dewi, titing nurhayati: characteristics of patient with benign paroxysmal positional vertigo in dr. hasan sadikin general hospital bandung from 2009–2013 althea medical journal. 2016;3(2) 200 amj june 2016 pathogen profile of patients with sepsis in internal medicine dr. hasan sadikin general hospital, bandung 2013 afiq syazwan fauzi,1 h. uun sumardi,2 nina tristina3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, abstract background: sepsis is a continuous disease which begins with systemic inflammatory response syndrome (sirs), seen in association with a large number of clinical conditions. these include infectious insults that produce sirs, such as pancreatitis, ischemia, multiple traumas and tissue injury, hemorrhagic shock, immunemediated organ injury, and the exogenous administration of such putative mediators of the inflammatory process as tumor necrosis factor and other cytokines. a frequent complication of sirs is the development of organ system dysfunction, including such well-defined clinical conditions as acute lung injury, shock, renal failure, and multiple organ dysfunction syndrome (mods). hence, this study was conducted to identify the pathogen profile that often causes sepsis. methods: a retrospective study was performed to 152 medical records of patients diagnosed as sepsis from internal medicine department dr. hasan sadikin general hospital from january 2013 to december 2013. the variables observed from the medical records were age, sex, comorbidity, main infection, culture sample, type of gram bacteria, resistant bacteria, and antibiotic susceptibility test. after data collection was completed, the data were analyzed using computer. the data were presented in percentage. results: sepsis in male was higher than female. highest comorbid was chronic kidney disease (ckd). the main infection was health care acquired pneumonia (hcap). highest pathogen that caused sepsis was escherichia coli and highest multidrug-resistant organism (mdro) was extended spectrum beta-lactamase (esbl) escherichia coli. conclusions: the most common pathogen that causes sepsis is escherichia coli. [amj.2016;3(2):200–5] keywords: chronic kidney disease, escherichia coli, sepsis correspondence: afiq syazwan fauzi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628998000352 email: afiqsyazz@gmail.com introduction the mortality caused by sepsis, particularly related to organ dysfunction, remains a priority to clinicians worldwide and deserves greater public health attention.1 systemic inflammatory response syndrome (sirs) is a syndrome occurring in a patient having systemic response symptoms such as fever or hypothermia, leukocytosis or leukopenia, tachypnea and tachycardia.1 patients with sepsis are classically considered to be patients who have a high risk of morbid complications and death. this is in a large part owing to the organ dysfunction caused by sepsis, and the associated complications of organ dysfunction.3 septic patients tend to be high resource consumers in hospitals and icus, and their presence affects the outcomes of those icus overall.4 estimation from around the world that consistently report cases of sepsis costs from us$25,000 to $50,000 per episode.4 in some instances, bacteria can be resistant to multiple drugs; these strains are considered multi-drug resistant (mdr).5 every year, thousands of patients are admitted to dr. hasan sadikin general hospital. high percentages of them are admitted for episodes such as trauma, respiratory infections or gastrointestinal infections. blood culture examination remains as the ‘gold standard’ for the detection of bacteria and fungi.2 blood cultures are important in defining local spectra of pathogens and resistance in severe infections. this study was conducted to identify bacteria profile of patients with sepsis at dr. hasan sadikin general hospital. althea medical journal. 2016;3(2) 201 methods a retrospective study was performed to medical records of patients diagnosed as sepsis from internal medicine department dr. hasan sadikin general hospital from january afiq syazwan fauzi, h. uun sumardi, nina tristina: pathogen profile of patients with sepsis in internal medicine, dr. hasan sadikin general hospital, bandung 2013 table 1 distribution of patients accordance to sex, comorbidity, diagnosis of infection, pathogen involved and mdro factors frequency (n=100) percentage (%) sex male 84 55.3 female 68 44.7 comorbidity burn injury 6 3.9 cad 5 3.3 ckd 30 19.7 dm 17 11.2 gbs 5 3.3 peritonitis 6 3.9 pleural effusion 5 3.3 tb 7 4.6 main infection hcap 34 22.4 hap 15 9.9 cap 4 2.6 uti 33 21.7 cellulitis 30 19.7 bsi 2 1.3 perforation 28 18.4 meningitis 6 3.9 pathogen staphylococcus epidermidis 7 4.6 staphylococcus emolyticus 12 7.9 staphylococcus hominis 8 5.3 klebsiella pneumoniae 25 16.4 pseudomonas aeruginosa 15 9.9 escherichia coli 32 21.1 mdro mdr pseudomonas 16 10.5 esbl escherichia 32 21.1 esbl klebsiella 17 11.2 non esbl escherichia 6 3.9 non esbl klebsiella 8 5.3 mdr staphylococcus 22 14.5 non mdr staphylococcus 9 5.9 note: cad=coronary artery disease, ckd=chronic kidney disease, dm=diabetes mellitus, gbs=guillain-barre syndrome, tb=tuberculosis, hcap=health care acquired pneumonia, hap=hospital acquired pneumonia, cap=community acquired pneumonia, uti=urinary tract infection, bsi=blood stream infection, mdro=multi drug resistant organism, mdr=multi drug resistant, esbl=extended spectrum beta-lactamase 2013 to december 2013. the variables observed from the medical records were age, sex, comorbidity, main infection, culture sample, type of gram bacteria, resistant bacteria, and antibiotic susceptibility test. descriptive analysis for pathogen pattern and resistant mdro pattern were compiled. althea medical journal. 2016;3(2) 202 amj june 2016 after data collection was completed, the data were analyzed using computer. the data were presented in percentage, with permission from the health research ethics committee faculty of medicine universitas padjadjaran to perform the study. results from the 334 medical records, only 152 of them consisted of complete variables requested. the average of patient age was 43.57 (13.055). the minimum age was 15 years old and the maximum age was 60 years old. distribution of sex, comorbidity, main infection, pathogen, and mdro are presented in table 1. based on table 1, the occurrence of sepsis was higher in male (55.3%) compared to female (44.7%). the highest comorbidity in this study was chronic kidney disease (19.7%), followed by diabetes mellitus (11.2%). the highest main infection was health care acquired pneumonia (hcap) (22.4%), followed by 21.7% urinary tract infection (uti) and 19.7% cellulite. the most common pathogen that caused sepsis was escherichia coli (21.1%) and klebsiella pneumonia (16.4%). extended spectrum betalactamases (esbl) escherichia coli was found to be the highest multidrug-resistant organism (mdro) (21.1%). the second most common mdro was mdr staphylococcus (14.5%), followed by esbl klebsiella (11.2%). the resistant mdro patterns were presented in table 2, table 3, table 4 and table 5. the mdr pseudomonas, esbl escherichia coli, esbl klebsiella pneumonia and mdr staphylococcus were resistant to third generation cephalosporin such as cefotaxime and ceftriaxone. the mdr pseudomonas aeruginosa was sensitive to fourth generation cephalosporin like cefepime and ceftazidime only four mdr pseudomonas aeruginosa. all mdro pathogens were more susceptible to amikacin antibiotics as presented in table 4. all mdro pathogens were more susceptible to meropenem antibiotics as presented in table 5. discussions the average age of patients from this study table 2 drug resistance profile against 3rd generation cephalosporin antibiotics mdro resistance sensitive not tested total mdr pseudomonas 16 0 0 16 esbl escherichia 31 1 0 32 esbl klebsiella 17 0 0 17 non-esbl escherichia 1 5 0 6 non-esbl klebsiella 0 8 0 8 mdr staphylococcus 22 0 0 22 non mdr staphylococcus 0 9 0 9 note: mdro=multidrug-resistant organism, mdr=multidrug-resistant, esbl=extended spectrum beta-lactamase table 3 drug resistance profile against 4th generation cephalosporin antibiotics mdro resistance sensitive not tested total mdr pseudomonas 12 4 0 16 esbl escherichia 32 0 0 32 esbl klebsiella 17 0 0 17 non-esbl escherichia 1 5 0 6 non-esbl klebsiella 0 8 0 8 mdr staphylococcus 22 0 0 22 non-mdr staphylococcus 0 9 0 9 note: mdro=multidrug-resistant organism, mdr=multidrug-resistant, esbl=extended spectrum beta-lactamase althea medical journal. 2016;3(2) 203 was 43.57 years old with minimum age was 15 years old and maximum age was 60 years old. the incidence of sepsis increases disproportionately in older adults and more than half of severe sepsis cases occur in adults aged over 50 years old.6 on top of that, more than half of patients who develop severe sepsis also have at least one chronic health condition. male appears to be at higher risk of developing sepsis compared to female.7 the fact that the occurrence is higher in male compared to female may be explained by a combination of differences in chronic disease burden, particularly subclinical disease, social and environmental factors, and genetic predisposing causing difference in the host immune response towards infection that likely contributes to the observed difference. for example, a few healthy female volunteers showed a more pronounced pro-inflammatory response after endotoxin infusion compared to healthy men.8 on top of that, men usually tend to be treated by undergoing more invasive procedures whereas women frequently tend to not undergo invasive procedures.9 the role of estrogens and androgens in female and male respectively may account for the sex differences in sepsis outcomes where low levels of estrogen and high levels of androgens are more prone to infections.9 the most common comorbidity that was found in these septic patients was ckd (19.7%). however, in previous research, it showed that trauma or having history of previous surgery is the highest comorbid that was found in septic patients.10 this may be explained by the fact that after a traumatic injury or a previous surgery, the body produces a flood of white blood cells that can secrete a protein known as hmgb1. this protein contributes to septic inflammation which can be life-threatening.10 for the main infection in this research, hcap was the highest occurrence (22.4%). however, the highest main infection from previous research is cap. this may be explained by the observation that patients with hcap usually are from low socioeconomical level. these individuals are usually more susceptible to infections. patients with hcap usually have low immune system level due to incomplete vaccination or have not had any vaccination before.10 gram-negative organism was shown to be the largest pathogen that causes afiq syazwan fauzi, h. uun sumardi, nina tristina: pathogen profile of patients with sepsis in internal medicine, dr. hasan sadikin general hospital, bandung 2013 table 4 drug resistance profile against amikacin antibiotics mdro resistance sensitive not tested total mdr pseudomonas 2 14 0 16 esbl escherichia 0 32 0 32 esbl klebsiella 2 15 0 17 non-esbl escherichia 0 6 0 6 non-esbl klebsiella 0 8 0 8 mdr staphylococcus 0 0 22 22 non-mdr staphylococcus 0 9 0 9 note: mdro=multidrug-resistant organism, mdr=multidrug-resistant, esbl=extended spectrum beta-lactamase table 5 drug resistance profile against meropenem antibiotics mdro resistance sensitive not tested total mdr pseudomonas 1 15 0 16 esbl escherichia 0 32 0 32 esbl klebsiella 2 15 0 17 non-esbl escherichia 0 6 0 6 non esbl klebsiella 0 8 0 8 mdr staphylococcus 20 2 0 22 non-mdr staphylococcus 0 9 0 9 note: mdro=multi drug resistant organism, mdr=multi drug resistant, esbl=extended spectrum beta-lactamase althea medical journal. 2016;3(2) 204 amj june 2016 sepsis.11 escherichia coli (21.1%) was the highest gram-negative organism followed by klebsiella pneumonia (16.4%) and pseudomonas aeruginosa (9.9%). for grampositive organism, the highest pathogen was staphylococcus hemolyticus (7.9%) followed by staphylococcus hominis (5.3%) and staphylococcus epidermidis (4.6%). this is because, the gram-positive bacteria cell wall is composed of peptidoglycans and has two layers only while gram-negative bacteria cell wall is more complex as it has an outer membrane, a space and a layer of peptidoglycans. on top of that, the gram-negative bacteria cell wall also contains pore proteins which it can pump substance back out of the bacterium if it is harmful towards it.5 hence, that is why gramnegative bacteria are more likely to cause infection towards a person compared to grampositive bacteria.5.12 it was discovered that esbl escherichia coli isthe highest pathogen that causes mdr. this may be explained by which acquisition of escherichia coli’s genes that produces esbls, an enzyme that breaks down antibiotic and, hence, prevent them from working.5 escherichia coli are also able to change its cell wall structure until it prevents antibiotics from entering or limiting their activity against the cell wall, and the pore protein on its cell wall surface can affect most classes of drugs; these mechanisms are also seen in enterobacter species.5 third and fourth generation cephalosporin antibiotics are resistant against esbl escherichia coli while amikacin and meropenem antibiotics are sensitive against esbl escherichia coli. previous research proved that carbapenems are the drugs of choice for many infections caused by gam-negative and gram-positive bacteria and are found to be the most effective antibiotics which are the same in this research.13 however, previous research showed that low resistance to cephalosporins was seen. this may be explained due to plasmids harboring several resistance genes which are transferred from one bacterium to another and have linked such resistance pattern to the presence of integrons.13 amikacin and meropenem were sensitive in this study. amikacin binds to components of bacteria that produce important bacterial proteins, blocking protein synthesis which eventually leads to stopping further bacterial growth.14 amikacin is used to treat infections caused by bacteria that are resistant to gentamicin and tobramycin. amikacin treats infections caused by gram-negative bacteria such as pseudomonas species, escherichia coli, providencia species, indolepositive and indole-negative proteus species, klebsiella-enterobacter-serratia species, and acinetobacter. amikacin is also used in certain staphylococcal infections as well.13,14 meropenem is a broad-spectrum antibacterial agent of the carbapenem family, indicated as empirical therapy prior to the identification of causative organisms, or for disease caused by single or multiple susceptible bacteria in both adults and children with a broad range of serious infections.14 meropenem showed greater efficacy than ceftazidime or piperacillin/tazobactam in febrile neutropenia, and greater efficacy than ceftazidime plus amikacin or tobramycin in patients with nosocomial pneumonia. meropenem is well-tolerated and has the advantage of being suitable for administration as an intravenous bolus or infusion. its low propensity for inducing seizures means that it is suitable for treating bacterial meningitis and is the only carbapenem approved in this indication. thus, meropenem continues to be an important option for the empirical treatment of serious bacterial infections in hospitalized patients.15 there were some limitations of the study. not all of the medical records consisted of the variables requested, only 30% of the medical records met the requirement. other limitation was the outcomes of the treatment were not recorded. hence, without these data, it is hard to know the successful rate of treatment towards the patients. as a recommendation, end point of septic patient’s treatment should be recorded so that we can know the successful rate of antibiotic treatment. moreover, medical records should be written completely. it can be concluded that the most common pathogens that cause sepsis are escherichia coli, klebsiella pneumonia, pseudomonas aeruginosa and staphylococcus species. theses pathogens are also resistant against antibiotics due to their special characteristics. references 1. martin gs. sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes. expert rev anti infect ther. 2012;10(6):701–6. 2. lin ec, boehm km. positive predictive value of blood cultures utilized by community emergency physicians. int scholarly res notices infect dis. 2013;2013(135607): 1–5. althea medical journal. 2016;3(2) 205 3. degoricija v, sharma m, legac a, gradiser m, sefer s, vucicevic z. survival analysis of 314 episodes of sepsis in medical intensive care unit in university hospital: impact of intensive care unit performance and antimicrobial therapy. croat med j. 2006;47(3):385–97. 4. moerer o, plock e, mgbor u, schmid a, schneider h, wischnewskymb, et al. a german national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units. crit care. 2007;11(3):r69. 5. tam vh, rogers ca, chang kt, weston js, caeiro jp, garey kw. impact of multidrug-resistant pseudomonas aeruginosa bacteremia on patient outcomes. antimicrob agents chemother. 2010;54(9):3717–22. 6. vincent jl, rello j, marshall j, silva e, anzueto a, martin cd, et al. international study of the prevalence and outcomes of infection in intensive care units. jama. 2009;302(21):2323–9. 7. sakr y, elia c, mascia l, barberis b, cardellino s, livigni s, et al. the influence of gender on the epidemiology of and outcome from severe sepsis. crit care. 2013;17(2):r50. 8. van eijk lt, dorresteijn mj, smits p, van der hoeven jg, netea mg, pickkers p. gender differences in the innate immune response and vascular reactivity following the administration of endotoxin to human volunteers. crit care med. 2007;35(6):1464–9. 9. eachempati sr, hydo l, shou j, barie ps. sex differences in creation of do-notresuscitate orders for critically ill elderly patients following emergency surgery. j trauma. 2006;60(1):193–8. 10. ortiz g, duenas c, rodriguez f, barrera l, de la rosa g, dennis r, et al. epidemiology of sepsis in colombian intensive care units. biomedica. 2014;34(1):40–7. 11. vincent jl, sakr y, sprung cl, ranieri vm, reinhart k, gerlach h, et al. sepsis in european intensive care units: results of the soap study. crit care med. 2006;34(2):344–53. 12. phua j, ngerng w, see k, tay c, kiong t, lim h, et al. characteristics and outcomes of culture-negative versus culture-positive severe sepsis. crit care. 2013;17(5):r202. 13. manjula ng, math gc, nagshetty k, patil sa, gaddad sm, shivannavar ct. antibiotic susceptibility pattern of esblproducing klebsiellapneumoniaeisolated from urine samples of pregnant women in karnataka. j clin diagn res. 2014;8(10):dc08–11. 14. brooks g, carrol k, editors. antimicrobial chemotherapy. 25th ed. new york: mcgraw-hill; 2010. 15. baldwin cm, lyseng-williamson ka, keam sj. meropenem: a review of its use in the treatmen of serious bacterial infections. drugs. 2008;68(6):803–38. afiq syazwan fauzi, h. uun sumardi, nina tristina: pathogen profile of patients with sepsis in internal medicine, dr. hasan sadikin general hospital, bandung 2013 althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 579 familial predisposition of primary dysmenorrhea among senior high school girl students prema sharlini,1 hadyana sukandar,2 ryadi fadil,3 1faculty of medicine, universitas padjadjaran, 2department of epidemiology and biostatics faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: dysmenorrhea is a common female reproductive problem in women of active reproductive age which is characterized by menstrual pain or cramps in a women’s lower abdomen or back. dysmenorrhea can be classified into primary and secondary. one of the associated risk factor of primary dysmenorrhoea is the family history, however the study on the family history of primary dysmenorrhea with recurrent menstrual pain is limited. this study was conducted to identify the correlation between family history and primary dysmenorrhea in high school girls. methods: this cross sectional study was conducted at several senior high schools in jatinangor from april− june 2013. one hundred and sixty two students were included in this study. the sample size was calculated based on the unpaired−dichotomous variable for the two−sided formula. a self administered questionnaire was distributed to the senior high school girl students who were in their menarche age, menstrual cycle characteristics, presence or absence of dysmenorrhea, severity of pain and presence dysmenorrhea in mothers and in sisters were inquired. data were analyzed using chi square test. results: overall, there were association between positive family history and primary dysmenorrhea among the students with (p<0.001). the prevalence of dysmenorrhea in the students was 92.6% with 95% confidence interval which was 87.5−95.7%. the prevalence rate was 67.9% in mothers with 95% confidence interval which is 60.4−74.6% and 80.2% prevalence of primary dysmenorrhoea in sisters with 95% confidence interval which is 73.4−85.6%. conclusions: there is a significant association between positive family history and primary dysmenorrhea. [amj.2015;2(4):579–83] keywords: family history, senior high school students, primary dysmenorrhea correspondence: prema sharlini, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285722585984 email: prema1691@gmail.com introduction dysmenorrhea is a common female gynaecological problem defined as painful menstruation.1 dysmenorrhea can be classified into primary dysmenorrhoea which is a natural process of menstruation and usually described as colicky, spasmodic cramping felling in the abdomen, back and pelvic areas, while secondary dysmenorrhoea is caused by pelvic pathologic conditions.2 primary dysmenorrhea has a prevalence rate ranges from 40 to 90%.3 it is the foremost cause of frequent temporary absenteeism from school and work. in a previous study, it was reported that adolescent girls tend to have a higher prevalence of primary dysmenorrhea than older women.4 the exact cause of primary dysmenorrhea is not particularly understood, but the mechanism of the pain generation in patients with dysmenorrhea can be explained by the secretion of prostaglandin (pg) especially pge₂ and pgf₂α which will result in myometrial hyper contractility and pain. in some studies, it is also stated that it is resulted from uterus hypoxia, ischemic and vasopressin which results in myometrium hypersentivity and causes myometrium hypercontractility and producing pain.5 generally the risk factors mentioned in previous studies are early age of menarche, heavy menses, younger age (<20) years old, smoking and strong family history.6,7 the research on the association of family history in occurrence of dysmenorrhea and severity of condition is still limited. therefore, althea medical journal. 2015;2(4) 580 amj december, 2015 this study was conducted to determine the correlation between family history and primary dysmenorrhea among the senior high school girl students. . methods this cross sectional study was a part of bigger research conducted by nutritional and reproductive working group on jatinangor cohort, especially puberty survey by department of epidemiology and biostatics, faculty of medicine,universitas padjadjaran. it was carried out at several senior high schools from april−june 2013 in jatinangor. a total of one hundred and ninety nine students were participated in this study. the sample size was calculated based on the unpaired− dichotomous variable for the two−sided formula. therefore, the minimum sample size needed for this study was hundred and forty two participants. students were included from the age 15−17 years who already had menarche, healthy students without any other medical illness and has mother who was still in menstrual productive age and female siblings who has their menarche. the exclusion criteria were respondents with irregular menstrual cycles. this was determined based on the duration of the menstrual periods. the menstrual period was categorized as short menstrual period when it was less than 2 days, 2−6 days were categorized as normal duration of menstrual period and more than 6 days as longer duration of menstruation. respondents with other underlying diseases such as secondary dysmenorrhea were also excluded as this research was mainly concerned with primary dysmenorrhea to detect the familial risk. this was categorized based on the onset of painful menstruation, as primary when the menstrual pain present and started since menarche or 1 to 3 years after menarche and secondary if the pain present only 3−5 years after menarche. subjects were also excluded if they smoke cigarette, consuming alcohol and has menarche before 9 years old. the gap between two consecutive cycles was also questioned to inquire the regularity of the menstrual cycle. the regularity of the menstrual cycle was categorized based on the gap between the two consecutive cycles. short cycle was defined as less than 21 days, normal cycle as 21−35 days and a longer cycle was categorized as more than 35 days. students were included from the age 15−17 years who already had menarche, healthy students without any other medical illness and has mother who was still menstrual productive age and female siblings who has their menarche. thirty seven students were excluded from one hundred and ninety nine students participated. a self designed questionnaire was administered to the students from all the classes, who were chosen by simple random sampling. the subjects were between 15−17 years old who met the inclusion criteria and were not excluded based on the exclusion criteria. the students were asked about their menarche age, menstrual period, presence or absence and if it was presence, the characteristics of dysmenorrhea were also asked to determine whether primary or secondary. concerning the positive family history of dysmenorrhea, presence of dysmenorrhea in the student’s mothers and a female sibling were assessed with a self administered questionnaire. the severities of dysmenorrhea were determined by classifying pain into six classes based on wong-baker faces pain scale as 0 means no hurt, 2 means hurts a little, 4 means hurts a little more, 6 means hurts even more, 8 means hurts a whole a lot, and 10 means hurts worst.8 this study was approved by the health research ethic committee of dr. hasan sadikin general hospital, bandung. before conducting the survey, approvals were also obtained from the school’s top officials. the explanations on the objective, goals and techniques of answering the validated and reliable questionnaires were given to the respondents to obtain their informed verbal consent. there were 162 students who meet the inclusion criteria. for the statistical analysis, software package used was statistical analysis version 15 (spss 15). the content of each tool were categorized and analyzed by chi square test. it was also used to find the prevalence ratio and 95% confidence interval. the descriptive statistics was used to analyze the severities of dysmenorrhea in the respondents. statistically significance was considered when p<0.05. results painful menstruation due to primary dysmenorrhea was seen in 150 (92.6%). the number of cases with positive family history of primary dysmenorrhea was more than those without family history of dysmenorrhea. there were 85 students who both mothers althea medical journal. 2015;2(4) 581 table 1 association between positive family history and primary dysmenorrhoea in students with and without dysmenorrhea variables cases n (%) dysmenorrhea without dysmenorrhea p * mother yes 110(67.9%) 108(66.7%) 2(1.2%) <0.001 no 52(32.1%) 42(25.9%) 10(6.2%) sister yes 130(80.2%) 125(77.2%) 5(3.1%) <0.001 no 32(19.8% 25(15.4%) 7(4.3%) note: *chi square test and sisters had dysmenorrhea. a positive correlation was found between primary dysmenorrhea and positive family history as presented in (table 1). chi square test was significant with p<0.001. most of the students complained painful menstrual cramps suffer from moderate pain. there were also a number of students who had severe pain. most of the students reported severity of menstrual pain as hurts a little bit and hurts a little more (table 2). discussion dysmenorrhea which means painful menstrual cramps of uterine origin is a common reproductive illness of women in reproductive age.9 there were 150 students (92.6%) who suffered primary dysmenorrhea. this is a very high prevalence compare to a previous study reported in a study conducted among adolescent girls in suburban districts of tehran 10, 71.0%. similarly it was observed in a study conducted in new zealand11 stated that the prevalence rate of primary dysmenorrhea is estimated varies from 45.0% to 95.0%. this is because the subjective aspect of painful menstrual cramps is hard to determine because varied definitions of the condition. another study was performed in 2010 in omani12 which had as much as 94.0% of prevalence rate, whereas similar frequency were reported in present study, 92.6%.13 a study conducted among a group of female medical students in turkey12 reported that prevalence rate of primary dysmenorrhea is significantly higher in those who had a positive family history when compared to others. it was found 108 (66.7%) students with primary dysmenorrhea who had positive history in 110 (67.9%) mothers and 130 (80.5%) sisters were observed with dysmenorrhea. there are only 2 students without dysmenorrhea had positive history of dysmenorrhea in mothers. therefore, this is summarized that most of women suffer primary dysmenorrhea throughout their reproductive years. in another study done in selangor, malaysia 14 it also shows a significant correlation between a positive family history and primary dysmenorrhoea. it was also reported in a study conducted in kelantan, malaysia15 that maternal dysmenorrhoea as a risk factor for the occurrence of recurrent prema sharlini, hadyana sukandar, ryadi fadil: familial predisposition of primary dysmenorrhea among senior high school girl students table 2 frequency of severity of primary dysmenorrhoea in students pain scale frequency percent (%) no hurt 12 7.4 hurts little bit 40 24.7 hurts little more 67 41.4 hurts even more 20 12.3 hurts whole a lot 16 9.9 hurts worst 7 4.3 total 162 100 althea medical journal. 2015;2(4) 582 amj december, 2015 menstrual pain in a family. thus, present study shows a strong association between family history and primary dysmenorrhoea. this result is similar with previous studies done which also found a significant association between family history and recurrent painful menstruation.3,16,17 there are several weaknesses in this study. the data taken from the respondents are solely based on their memory. so, there might be a recall bias. the data regarding the respondent’s lifestyle such as smoking and alcohol consumption are inquired in this study. therefore, some of the respondents might have under reported their behaviour. this study shows a very high prevalence of dysmenorrhoea among the students, 92.6% with 95% confidence interval which is 87.5−95.7% explains that dysmenorrhoea is a common gynaecology problem. positive family history of dysmenorrhoea is a significant risk factor for the occurrence of primary dysmenorrhoea in a family. present study finds a significant association, which proposes that genetic factor is engaged in the pathogenesis of primary dysmenorrhoea and increases the familial predisposition. therefore, positive family history can be a strong predictor for incidence of dysmenorrhoea in children and siblings. it is suggested that more research should be done in order to get a better understanding of the positive family history in primary dysmenorrhoea as a risk factor. it is also found that majority of respondents suffered a degree of pain which might interfere the daily activities and reduce their quality of life. consequently, health care providers should be more sensitive in managing dysmenorrhoea by giving the information that dysmenorrhoea is a common menstrual disorder to the adolescent schoolgirls and encourage them to understand the possible risk factors of dysmenorrhoea and avoid unnecessary suffering and interruptions to their education. medical professionals also need to be educated about dysmenorrhoea, its severity and impact on adolescent schoolgirl’s daily activities and encourage the medical care providers to screen routinely for dysmenorrhoea among adolescent schoolgirls. they also can offer a treatment to the schoolgirl if it is necessary. references 1. jones r. oxford textbook of primary medical care: clinical management. reprint ed. united kingdom: oxford university press; 2004. p. 871−2. 2. balen ah. reproductive endocrinology for the mrcog and beyond 2nd ed. the royal college of obstetricians and gynaecologists, london: (rcog) press; 2007. p. 53−70. 3. unsal a, ayranci u, tozun m, arslan g, calik e. prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. ups j med sci. 2010;115(2):138−45. 4. titilayo a, agunbiade o, banjo o, lawani a. menstrual discomfort and its influence on daily academic activities and psychosocial relationship among undergraduate female students in nigeria. tanzan j health res. 2009;11(4):181−8. 5. french l. dysmenorrhea. am fam physician. 2005;71(2):285−91. 6. charu s, amita r, sujoy r, thomas ga. ‘menstrual characteristics’ and ‘prevalence and effects of dysmenorrhea’on quality of life of medical students. ijcrimph. 2012;4(4):276−94. 7. care c. primary dysmenorrhea consensus guideline. j obstet gynaecol can. 2005;27 (12):1117−30. 8. garra g, singer aj, taira br, chohan j, cardoz h, chisena e, et al. validation of the wong-baker faces pain rating scale in pediatric emergency department patients. acad emerg med. 2010;17(1):50−4. 9. proctor m, hing w, johnson tc, murphy pa, brown j. spinal manipulation for dysmenorrhoea (review). cochrane database syst rev. 2004;1(3):1−27. 10. poureslami m, ashtiani fo. assessing knowledge, attitude and behavior of adolescent girls in suburban districts of tehran about dysmenorrhea and menstrual hygiene. journal of international women’s studies. 2002;3(2):51−61. 11. proctor m, farquhar c. diagnosis and management of dysmenorrhoea. bmj. 2006;332(7550):1134−8. 12. unsal a, ayranci u, tozun m, arslan g, calik e. prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. ups j med sci. 2010;115(2):138−45. 13. al-kindi r, al-bulushi a. prevalence and impact of dysmenorrhoea among omani high school students. sultan qaboos univ med j. 2011;11(4):485−91. 14. liliwati i, verna l, khairani o. dysmenorrhoea and its effects on school althea medical journal. 2015;2(4) 583 activities among adolescent girls in a rural school in selangor, malaysia. med & health. 2007;2(1):42−7. 15. zukri sm, naing l, hamzah tnt, hussain nhn. primary dysmenorrhea among medical and dental university students in kelantan: prevalence and associated factors. international medical journal. 2009;16(2):93−9. 16. parveen n, majeed r, rajar ud. familial predisposition of dysmenorrhea among the medical students. pak j med sci. 2009; 25(5):857−60. 17. tavallaee m, joffres mr, corber sj, bayanzadeh m, rad mm. the prevalence of menstrual pain and associated risk factors among iranian women. j obstet gynaecol res. 2011;37(5):442−51. prema sharlini, hadyana sukandar, ryadi fadil: familial predisposition of primary dysmenorrhea among senior high school girl students althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 276 amj june, 2015 cruris fracture among child patients in dr. hasan sadikin general hospital bandung wenny dwi chandra,1 yoyos dias ismiarto,2 alwin tahid,3 nucki nursjamsi hidajat2 1faculty of medicine universitas padjadjaran, 2department of orthopaedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: cruris are lower extremity fractures commonly found in children. these dangerous fractures may alter the quality of life of the patients. this study was conducted to explore the characteristics of cruris fractures in children. methods: a descriptive cross-sectional study was performed by reviewing the medical records of children who were hospitalized at the department of orthopaedi and traumatology, dr. hasan sadikin general hospital bandung during 2010–2011. results: on two years study, 62 cases have been reported. most cases occurred among senior high school group (37.1%). boys (71.0%) have a higher rate of fractures than girls. fractures most frequently occurred by traffic accidents (87.1%). the fractures are mostly open (58.1%). the common fracture site was tibia (50.0%) rather than fibula (3.2%) and the most frequent location was on the right side (79.0%) and on the middle third of the leg (41.9%). majority of the patients went home in good condition (79.0%). conclusion: fractures are most frequently occurred in april because of high humidity. the causes and distribution of the fractures based on diagnosis were related to another study. furthermore, additional studies are needed to explore the characteristics of cruris fracture among children, not only in certain hospital but also in indonesia especially in west java. [amj.2015;2(1):276–80] keywords: characteristic, child, cruris, fractures correspondence: wenny dwi chandra, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: phone : +62 852 6121 6031 email: wenny.dwichandra@gmail.com introduction injury is an accident that causes someone’s daily activity to be disturbed.1 children are more vulnerable of experiencing injury than adults. injury can lead to many cases, one of them is fracture.2 a percentage of fractures in children is 20.6% of all kinds of injuries.2 the most often injuries occurred at lower extremities in children aged 5–14 years old (46.7%) and in children aged 1–4 years old (43.3%).1 injuries and fracture of lower extremity mostly occur on cruris area (292 cases), followed by femur (142 cases), foot (90 cases), and hip (9 cases).3 cruris area are mostly tibia and fibula. tibia has a function as weight bearing bones.4 child bones are more susceptible of experiencing fractures because they have less mineral and more vessels compared to adult bones. a pressure to child bones will create a heavier impact than adult bones on the same compression.5 the right preventive actions and treatment on fractures is very important. treating without a right treatment will make bones grow imperfectly, therefore affecting the quality of life when the child grow older.2 in indonesia, the ministry of health designed a guidebook to prevent accidents, even though in indonesia fracture cases is not a prime priority in medicare or health treatment in public.2 according to the data and explanation above, characteristics of cruris fractures in children which will provide baseline data for prevention program and treatment of cruris fracture cases on children need to be explored. therefore, this study aimed to explore these characteristics. methods this was a cross-sectional descriptive study conducted in october 2012 using 62 medical record in child patients (0–<18 years old) with althea medical journal. 2015;2(2) 277 cruris fractures at department of orthopaedi and traumatology dr. hasan sadikin general hospital bandung during 2010–2011. the exclusion criteria are child patients with cruris fractures at department of orthopaedi and traumatology at dr. hasan sadikin general hospital bandung during 2010–2011 with incomplete data or missing medical record. results from this study, 71 medical records were obtained, but only 62 data were appropriate with the selection criteria of the study. cruris fracture in children kept rising along with the growth of those children and reach the peak when they reach group age of senior high school (16–17 years old) where there are 23 patients (37.1%). the number of cruris fractures is dominated by male with 44 patients (71%). while female patients have a less number which was 18 patients (29%). the ratio between male and female were 22:9. child patients with cruris fractures on 2010 was 35 patients (56,5%) and decreased on 2011 as much as 27 patients (43.5%). fractures most frequently occurred on april with 10 patients (16.1%) and followed by june with 8 patients (12.9%). causes of cruris fracture in children were traffic accidents with 54 patients (87.1%) and other minor factors which were working accidents and surgical complication, each of wenny dwi chandra, yoyos dias ismiarto, alwin tahid, nucki nursjamsi hidajat: cruris fracture among child patients in dr. hasan sadikin general hospital bandung table 1 cruris fractures in children based on ages and gender frequency (f ) percentage (%) age (years old) pre-school (0–3 years old) 2 3.2 kindergarten (4–5 years old) 2 3.2 primary school (6–12 years old) 14 22.6 junior high school (13–15 years old) 21 33.9 senior high school (16–17 years old) 23 37.1 gender male 44 71.0 female 18 29.0 table 2 cruris fractures in children based on the time of occurrence month 2010 2011 frequency (f ) percentage (%) january 3 2 5 8.1 february 2 1 3 4.8 march 1 1 2 3.2 april 5 5 10 16.1 may 3 2 5 8.1 june 2 6 8 12.9 july 4 1 5 8.1 august 3 2 5 8.1 september 2 2 4 6.4 october 4 1 5 8.1 november 1 3 4 6.4 desember 5 1 6 9.7 total 35 27 62 100.0 althea medical journal. 2015;2(2) 278 amj june, 2015 factor only have 1 patients (1.65%). distribution of cruris fractures sufferer according to fractures diagnosis are divided based on: (1) type of fractures, whether it was open or close; (2) bones involved, whether only tibia, only fibula, or both of tibia and fibula; (3) location of fracture, divided into right or left, distal, medial, or proximal. the most often type of cruris fractures was open fracture with 36 patients (58.1%). bones that very often get cruris fracture in children are tibia with 31 patients (50.0%) and the less often are fibula with 2 patients (3.2%). the most often fracture were located on the right side with 49 patients (79.0%) and on the left side only 13 patients (21.0%). cruris fractures often occured on medial part of lower extremity as much as 26 patients (41.9%) the most cruris fractures patient’s condition when going home are getting better with 49 patients (79.0%) followed by recovered patients with 3 patients (4.8%) table 3 cruris fractures in children based on causes of fractures causes of fracture frequency (f ) percentage (%) traffic accident car accidents 1 1.6 motorcycle accidents 43 69.4 pedestrian accidents 9 14.5 without information 1 1.6 falling fall from high 3 4.9 fall from motorcycle 2 3.2 falling stumbled 1 1.6 working accidents 1 1.6 surgical complication 1 1.6 table 4 cruris fractures in children based on diagnosis frequency (f ) percentage (%) type of fracture close 26 41.9 open 36 58.1 fractured bone(s) fibula 2 3.2 tibia 31 50.0 tibia; fibula 29 46.8 location (r/l) right 49 79.0 left 13 21.0 location (distal/medial/proximal) distal 17 27.4 medial 26 41.9 proximal 17 27.4 different level 2 3.2 althea medical journal. 2015;2(2) 279 discussions based on group of age, cruris fractures in children are highest at the age of senior high school (16–17 years old), that was supported by rennie et al.6 in edinburg, scotland, they said that fracture incidence towards children are rises along with the ages growth. the high amount of cruris fracture accidents in senior high school ages often occur because nowdays high school students ride his own motor vehicles, particularly motorcycle so that the risk of incidents rises.7 based on gender, cruris fracture were dominated by male, supported by mayranpaa et al.8 at helsinki, finland and rennie et al.6 at edinburg, scotland. boys were vulnerable to cruris fracture because boys tend to ride motorcycles than girls. according to the period of time, fractures most often occur on april because indonesia has a monsoon season, where java island is included on region a, where the highest rainfall happens between november to march.9 according to data from meteorological and geophysical agency of west java10, the highest humidity occurs on april among other months, which can make the risk of accident and induce the fracture rises.11 also on june, number of fracture accidents rises because of holiday season were held almost nationally, much traffic happens while children play outdoor so that the risk of cruris fracture accidents rises. on march, cruris fracture accidents is the least of all months, this is maybe because the patients prefer to go to indigenous medical practitioner or altenative medicine.3 another possibility is the data which is missing from medical record. according to fracture causes, most often it was caused by traffic accidents and falling down. this is related with nwadinigwe et al.12, in nigeria said that fractures in children was most often caused by traffic accidents then followed by falling down. this is also appropriate with one study in a certain hospital by rennie et al.16 which said that one of the root causes of fracture at lower extremity in children are traffic accident. nowadays traffic accidents often occur because almost every family own a motor vehicles, particularly motorcycle. motor vehicles can cause the high number of accidents that caused fractures.13 the number of traffic accident cases in west java are the third highest after east java and central java.14 the most often traffic accident towards cruris fracture patients are motorcycle accidents then followed by accidents towards pedestrian. this study were related to tandon et al.15 said that most often fracture’s causes are accidents towards motorcycles then followed by accidents toward pedestrian. the most often type of cruris fractures in child patients was open fractures. this result were related to skaggs et al.16 who said that open fractures towards children were very often on tibia bones and fibula bones. open fracture occured because of the location of tibia bones were subcutaneous4 and in this study, cruris fracture often occur because of traffic accidents which included in the injury with high pressure.17 according to fractured bones, tibia is often the location of cruris fracture. this is because there was no tendon or ligament that stick on the anteromedial surface of tibia, the surface was only subcutaneous.4 fibula was the least occuring fracture because fibula is surrounded by tendon and fat tissues.11 fractures location often occurs on the right side of lower extremity. the right lower extremity were more often fractured than the left.11,18 cruris fractures often occur on the medial side of lower extremity. according to herring, fractures on the medial of tibia and fibula most often occur in children.18 on the medial side there were shaft of tibia. shaft of tibia is the thinest section of bones while the anterior side were the most prominent part, hence more prone to fractures.4,18 according to the patient’s condition when they are taken away from the hospital, unrecovered condition may happen because of they disagreed with the treatment from the doctor, or the family wanted to look for other medical alternative ways. as a conclusion, cruris fractures is found in high number in senior high school group wenny dwi chandra, yoyos dias ismiarto, alwin tahid, nucki nursjamsi hidajat: cruris fracture among child patients in dr. hasan sadikin general hospital bandung table 5 cruris fractures in children based on discharge from hospital disposition frequency (f ) percentage (%) get better 49 79.0 recovered 3 4.8 not recovered 10 16.1 althea medical journal. 2015;2(2) 280 amj june, 2015 and boys which are mostly caused by traffic accident. high number of open fractures, on tibia, on the right side and on the medial are also found with most of the patients are discharged in better condition. however, further studies are needed on cruris fracture in children in indonesia, especially in west java, using not only hospital-based data. further studies on people’s behavior in driving a motor vehicle are also needed. moreover, parents are encouraged to advise their children in riding motorcycle and also communities should give counseling about the danger of cruris fracture in children. people should also be advised that when a fracture occurs, the patient should be immediately taken to the health service as soon as possible to avoid more severe fracture and complications references 1. badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia. riset kesehatan dasar 2007. jakarta: departemen kesehatan republik indonesia; 2008. 2. ranuh ing. cedera & keracunan. in: narendra mb, sularyo ts, soetjiningsih, suyitno h, ranuh ing, wiradisuria s, editors. tumbuh kembang anak dan remaja. 1st ed. jakarta: sagung seto; 2005. p. 71–80. 3. minhas ms, ansari i, khalid, baig n, siddiqui e. musculo–skeletal trauma and the epidemiology of fractures in children. j pak orthop assoc. 2011;23(1):1–6. 4. moore kl, dalley af, agus amr. clinically oriented anatomy. 6th ed. philadelphia: lippincot williams & wilkins; 2010. 5. morrissy rt, weinstein sl, editors. lovell & winter’s pediatric orthopaedics. 6th ed. philadelphia: lippincott williams & wilkins; 2006. 6. rennie l, court-brown cm, mok jyq, beattie tf. the epidemiology of fractures in children. injury. 2007;38(8):913–22. 7. sihaloho eb. anak-anak sekolah: bebas dari aturan berkendara?. 2012 [cited 2012 november 22]: available from: h t t p : / / l i f e s t y l e . k o m p a s i a n a . c o m / catatan/2012/04/11/anak-anak-sekolahbebas-dari-aturan-berkendara/. 8. mayranpaa mk, makitie o, kallio pe. decreasing incidence and changing pattern of childhood fractures: a population-based study. j bone miner res. 2010;25(12):2752–9. 9. aldrian e, susanto rd. identification of three dominant rainfall regions within indonesia and their relationship to sea surface temperature. int j climatol. 2003;23:1435–52. 10. badan perencanaan pembangunan jawa barat. jawa barat dalam angka 2010. bandung: pemerintahan propinsi jawa barat. 2010. 11. beaty jh, kasser jr. rockwood and wilkins fractures in children. 7th ed. philadelphia: lippincott williams & wilkins; 2010. 12. nwadinigwe cu, ohezie co, iyidiobi ec. fractures in children. nigerian journal of medicine. 2006;15(1):81–4. 13. tripathi rb, sah rp, ali r, bachhar b, singh a. clinico epidemiological study on pediatric fractures at narayani sub regional hospital, birganj. journal of gmcnepal. 2009;2(2):39–44. 14. kementerian kesehatan republik indonesia. profil data kesehatan indonesia tahun 2011. jakarta: departemen kesehatan republik indonesia; 2011. 15. tandon t, shaik m, modi n. paediatric trauma epidemiology in an urban scenario in india. j orthop surg. 2007;15(1):41–5. 16. 16. skaggs dl, friend l, alman b, chambers hg, schmitz m, leake b, et al. the effect of surgical delay on acute infection following 554 open fractures in children. j bone joint surg. 2005;87:8–12. 17. david g, stewart j, kay rm, skaggs dl. open fractures in children: principal of evaluation and management. j bone joint surg am. 2005;87(12):2784–98. 18. herring ja. tachdjian’s pediatric orthopaedics. 4th ed. pennsylvania: saunders; 2008. althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 162 amj june, 2015 comparison of functional capacity using primary percutaneous coronary intervention with pharmacological therapy on st elevation acute coronary syndrome patients andini nurkusuma wardhani,1 chaerul achmad,2 sunaryo b. sastradimaja3 1faculty of medicine universitas padjadjaran, 2department of cardiology and vascular medicine faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: acute coronary syndrome (acs) is a shift manifestations pattern of ischemic myocardium. revascularization either with primary percutaneous coronary intervention (pci) or pharmacological therapy is an optional treatment for st elevation acute coronary syndrome (steacs) patients. the aim of the study was to compare the functional capacity using six-minute walking test on steacs patients who underwent primary pci or pharmacological therapy. methods: a cross sectional study was conducted from september to october 2012 to 35 steacs patients who were treated after two years. the samples were obtained from the list of patients at dr. hasan sadikin general hospital. inclusion criteria consisted of patients diagnosed as steacs, cooperative and not experiencing cognitive disturbance. the exclusion criteria were steacs patients with unstable angina or myocardial infarct in the last month, stable exertional angina, and pregnant women. the patients underwent 6 minutes walking test,vo2max was measured using thecalahin and cooper formula, then metabolic equation task (mets) was calculated. data were analyzed by unpaired t-test. results: there were 19 primary pci and 16 pharmacological therapy patients. the average of age between thetwo groups was distributed evenly. most of the steacs patients were male, had a college/academic degree and were retired. patients treated with pharmacological therapy had higher average of vo2 max and mets than patients with primary pci. there was no significantly differences of mets between those groups (p>0.05) conclusions: there were no significantly differences of functional capacity in steacs patients treated with primary pci or pharmacological therapy. [amj.2015;2(1):162–6] keywords: functional capacity, primary percutaneous coronary intervention, six minute walking test, st elevation acute coronary syndrome correspondence: andini nurkusuma wardhani, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285697571125 email: dhiniwardhani30@hotmail.com introduction cardiovascular diseases (cvds) are the number one cause of death globally.1 the world health organization (who) has predicted that by the year 2030, approximatelly 23–24 million people will die from cvds.1,2 coronary heart disease (chd) is one of cardiovascular disease in which there is an imbalance between the supply and demand of the myocardium, and the most common reason for this is caused by atherosclerosis on the coronary arteries.3 the chd itself has been the 5th out of 10 main causes of death in indonesia with a percentage of 26.7%.2 acute coronary syndrome (acs) is one out of a large group of chd patients, the shift of manifestations from myocardial ischemic includes the pattern from angina pectoris which then developed into myocardial infarction accompanied by a spreading, sharp, sudden appearance chest pain with long duration (of about 10 minutes).4 myocardial infarction needs an accurate procedure which is to reopen the tracts of the coronary vessels which are blocked by thrombosis and atherosclerosis, so that the myocardium can be handled before necrosis started to develop. these can be done via pharmacological therapies using fibrinolytic drugs to lyse the obstructing intra-coronary thrombus, so that the circulation can be normalized and limits the spread of the myocardial damage. an alternative procedure althea medical journal. 2015;2(2) 163 other than fibrinolytic is revascularization through percutaneous coronary intervention on the infarct-causing lesions which is referred as primary percutaneous coronary intervention (primary pci).4 a medical evaluation on acs patients is important to determine the stability of the patient’s conditions. this medical evaluation can be formed in an examination of the patient’s condition interview (to gain subjective information), direct measurement upon physical capacity (objectively through measuring strength, motility, sensation, coordination, balance, functional mobility, as well as cardiovascular capacity), diagnostic test, and functional capacity evaluation (including physical and workload capacity).5 the aim of the study was to compare the functional capacity using a sixminute walking test on st elevation acute coronary syndrome (steacs) patients who underwent primary pci or pharmacological therapy. methods a cross sectional study was conducted to 35 steacs patients who were treated after two years. the samples were obtained from the list of patients at dr. hasan sadikin general hospital. inclusion criteria consisted of patients diagnosed as steacs, who were cooperative and not experiencing cognitive disturbance so that they were able to go through the 6-minute walking test (6mwt), and agreed to participate in the research. the exclusion criteria were steacs patients with absolute contraindication for the 6mwt, which were unstable angina or myocardial infarct in the last month, stable exertional angina, and pregnant women. next, the patient’s functional capacity was measured employing the 6mwt. the 6mwt is an examination aimed to measure the maximal or submaximal capacity to know the fitness level or aerobic capability of a person using height, weight, age, and gender as well as length of the track as the predictor factors.6,7 steps of the 6mwt performed were: (1) the subject rested for a while when the subject was examined for contraindications, pulse rate, blood pressure, and levels of dyspnea with the borg scale which was felt by the subject before examination, (2) the timer was set on to 6 minutes, the subject was then positioned at starting point, and the timer was started whenever the subject was ready, (3) after 6 minutes, the subject was asked to stop, and had their pulse rate and degree of dyspnea examined using the borg scale for the second time, (4) observed the amount of laps which had been undergone, and the total distance which had been taken, and then recording them in the 6mwt worksheet.6 from the result of 6mwt, thevo2max of each subject was measured using thecalahin and cooper formula8,9 functional capacity was described using themetabolic equation task (mets)8,9 characteristics of the respondents were classified according to age, gender, educational status, occupation, weigh, height, and body mass index (bmi). this research was approved by the health research ethics committee of the faculty of medicine, universitas padjadjaran and was conducted from september to october 2012. the data were tested for their normality using shapiro-wilk test and analyzed by unpaired t-test. results out of sixty-five subjects from the patients list, only 35 patients could be followed up during the study. the distribution of patients were 19 primary pci patients and 16 pharmacological therapy patients (table 1). the average of age between thetwo groups was distributed evenly. most of the steacs patients were male, had a college/academic degree and were retired. the two groups had similar average of bmi and walking distance (table 1). the average of vo2 max measured by cooper formula was higher than by cahalin formula in both groups. moreover, patients treated with pharmacological therapy had higher average of vo2 max than patients with primary pci (table 2). metabolic equivalent tasks (mets) as one of theindicators of functional capacity was measured by dividing vo2 max with 3.5 for male and 2.7 for female (table 3). this study showed that the result of average of mets in thetwo groups was similar to the result of the average of vo2max. patients treated with pharmacological therapy had higher average of mets than patients with primary pci using either thecahalin or cooper formula. the result of thestatistical analysis using unpaired t-test, showed thatthere was no significantly differences of mets between those groups (p>0.05) andini nurkusuma wardhani, chaerul achmad, sunaryo b. sastradimaja: comparison of functional capacity using primary percutaneous coronary intervention with pharmacological therapy on st elevation acute coronary syndrome patients althea medical journal. 2015;2(2) 164 amj june, 2015 table 2 average of vo2max (ml/kg/minute) formula vo2max (ml/kg/minute)primary pci (n=19) pharmacological therapy (n=16) cahalin 13.68 (2.33) 13.99 (1.73) cooper 19.08 (5.12) 20.04 (3.90) table 1 characteristics of patients with steacs characteristics intervention primary pci (n=19) pharmacological therapy (n=16) age (years old) ≤ 57 4 5 58–60 6 3 61–64 4 5 ≥65 5 3 average age (standard deviation) 61.47 (7.81) 60.62 (6.23) gender male 13 11 female 6 5 education college/academy 12 4 high school/junior high 6 9 elementary school/none 1 3 occupation public servant 4 1 private 5 3 household 1 1 labor 0 2 retired 9 9 average weight (kgbw) 60.95 (8.85) 65.62 (11.99) average height (cm) 158.58 (6.34) 162.19 (7.46) average bmi 24.24 (3.39) 24.94 (4.11) average walk distance of the subjects (meter) 323.37 (77.59) 333.88 (57.65) discussions the acs is more common in male than female. men are more afflicted with acs attacks compared to women.10-13 the similarcondition was also found in this study. other characteristics of subject in the study was the subject were dominated by patients with age over 57 years. this is inaccordance with the framingham heart study in morrow12 which shows that the prevalence of acs is highest at the age of over 40 years old. in this study the walking distance of 6mwt of steacs patients managed with primary pci had an average of 323 meter or 66% of the predicted value of a healthy person. while those with pharmacological therapy in this research had an average of 334 meter or 65% of the predicted value of a healthy althea medical journal. 2015;2(2) 165 person. according to a study performed by nirwan11 on post-primary pci acs patients, the average is 358 m or 70% of the predicted value of a healthy person. the result of average distance of 6mwt in this research was not much different from those of nirwan’s study. the percentage of the predicted value of a healthy person on primary pci is higher than the pharmacological therapy is caused by age, height, and weight of various subjects that being an important predictor in the prediction of standard calculation of 6mwt by enright’s formula.14 furthermore, functional capacity is the ability of a person to do his daily activity in accordance with his function.15 functional capacity is often served in the form of mets (metabolic equivalents).16 mets can be defined as the use of maximal oxygen (vo2 max) in ml/kg/minute, the formula of one mets is the same as the oxygen needed at resting seated position, equals to 3.5 ml/kg/ minute for men, and 2.7 ml/kg/minute for women.8,9,14 this study showed that there was no significant difference of mets between patients treated by pharmacological therapy and primary pci. this finding is in accordance with a previous study performed by pilote et al.17 , comparing the quality of life on steacs patients, with physical component status (pcs) which consists of physical function, role limitation due to physical health, and body pain10, who found that both groups were not significantly different in regard of their quality of life on much of the pcs components. this result occured because of the functional capacity after an event of acs is significantly affected by the ability of the patient to follow his daily activity.17 conclusively, there was no significantly differences of functional capacity in steacs patients treated with primary pci or pharmacological therapy. this study had limitations, there is a need to use alarger sample and complete information concluded in themedical records. in this study, only 35 out of 65 patients could participate because of the lack of information about the patient’s identity, complete address with rt/ rw, regency, and district, and also phone numbers. to gain a better score on the 6mwt, learning or training effect is needed to let the patients adapt to the test because the learning effect can influence the psychological aspect of the subject against the fear of chest pain and also affect their motivation.14,15,19-20 a standardized and same track are needed to obtain optimal comparison of distance and functional capacity from 6mwt6. a further study should be conducted using 6mwt several times to measure the improvement of functional capacity time to time. references 1. world health organization. fact sheet of cardiovascular diseases (cvds). geneva: world health organization; 2011 [downloaded in 20 september 2012]; available at: http://www.who.int/ mediacentre/factsheets/fs317/en/ 2. mckay j, mensah ga, mendis s, greenlund k. the atlas of heart disease and stroke. geneva: world health organization; 2004 [cited 2012 september 15]. available from: ht t p :/ / w w w. who. in t / c a rdiova scu l a r_ diseases/resources/atlas/en/ 3. kumar v, abbas ak, fausto n, aster jc, editors. robbins and cotran pathologic basis of disease. 8th ed. philadelphia: saunders elsevier; 2010. 4. naik h, sabatine ms, lilly ls. acute coronary syndrome. in: lilly ls, editor. pathophysiology of heart disease. philadelphia: lippincott williams & wilkins; 2007. p. 168–96. 5. tan jc. work-related musculoskeletal problems. in: horn se, editor. practical manual of physical medicine and rehabilitation: diagnostics, therapeutics, and basic problems. missouri: geoff greenwood; 1998. p. 648–53. 6. american thoracic society committee on proficiency standards for clinical pulmonary function laboratories. andini nurkusuma wardhani, chaerul achmad, sunaryo b. sastradimaja: comparison of functional capacity using primary percutaneous coronary intervention with pharmacological therapy on st elevation acute coronary syndrome patients table 3 average of metabolic equivalent tasks (mets) formulas primary pci (n=19) pharmacological therapy (n=16) p value cahalin 4.20 (0.47) 4.32 (0.43) >0.05 cooper 5.81 (1.19) 6.15 (0.88) althea medical journal. 2015;2(2) 166 amj june, 2015 ats statement: guidelines for the sixminute walk test. am j respir crit care. 2002;166(1):111–7 7. american thoracic soicety, american college of chest physicians. ats/ accp statement on cardiopulmonary exercise testing. am j respir crit care. 2003;167(2):211–77. 8. cahalin l, pappagianopoulos p, prevost s, wain j, ginns l. the relationship of the 6-min walk test to maximal oxygen consumption in transplant candidates with end-stage lung disease. chest. 1995;108(2):452–9. 9. cooper kh. a means of assessing maximal oxygen intake: correlation between field and treadmill testing. jama. 1968;203(3):201–4 10. febrianora m. kualitas hidup pasien st elevasi miokard infark yang ditangani dengan primary percutaneous coronary intervention dibandingkan dengan terapi farmakologi di poliklinik kardiologi rumah sakit hasan sadikin bandung [minorthesis]. bandung: universitas padjadjaran; 2011. 11. nirwan i. jarak tempuh uji jalan 6 menit pasca sindrom koroner akut pasca intervensi koroner perkutan pada 1 pembuluh darah [dissertation]. jakarta: universitas indonesia; 2010. 12. morrow da, gersh bj. chronic coronary artery disease. in: libby p, editor: braunwald’s heard disease: a textbook of cardiovascular medicine. 8th ed: philadelphia:saunders; 2007. 13. karsiani p. jarak tempuh pasien pasca infark miokard akut menggunakan uji jalan 6 menit serta faktor-faktor yang mempengaruhi [dissertation]. jakarta: universitas indonesia; 2008. 14. enright p, sherill d. reference equations for six minute walk in healthy adults. am j respir crit care med. 1998;158(5 pt 1):1384–7. 15. nogueira p, leal acm, pulz c, nogueira idb, filho jao. clinical reability of the 6 minute corridor walk test performed within a week of a myocardial infarction. int heart j. 2006;47(4):533–40. 16. quinn e. met the standard metabolic equivalent. sports medicine; 2007 [updated 29 november 2007; cited 2012 september 13]; available from: http://sportsmedicine.about.com/od/ glossary/g/met.htm. 17. pilote l, lauzon c, huynh t, dion d, roux r, racine n, et al. quality of life after acute myocardial infartion among patients treated at sites with and without on-site availability of angiography. arch intern med. 2002;162(5):553–9. 18. ja¨rvinen o, julkunen j, saarinen t, laurikka j, huhtala h, tarkka mr. perioperative myocardial infarction has negative impact on health-related quality of life following coronary artery bypass graft surgery. eur j cardiothorac surg. 2004;26:621–7. 19. reybrouck t. clinical usefulness and limitations of the 6 minute walk test in patients with cardiovascular or pulmonary disease. chest. 2003;123:325–7. 20. fiorina c, vizzardi e, lorusso r, maggio m, de cicco g, nodari s, et al. the-6 min walking test early after cardiac surgery-reference values and the effects of rehabilitation programme. eur j cardiothorac surg. 2007;32(5):724–9. althea medical journal. 2015;2(2) 172 amj june, 2015 characteristic, emotional, and behavioral problems of street adolescent in bandung october–december 2012 annisa nurfitriani,1 veranita pandia,2 guswan wiwaha3 1faculty of medicine universitas padjadjaran, 2department of psychiatry faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: street adolescents were psychosocial problem that increased in number each year and was worsened by their low-moral subculture-value that could cause them more vulnerable in having emotional and behavioral problems. this study aims to describe the characteristics, emotional and behavioral problems of the street adolescent in bandung. methods: a descriptive study was carried out in october–december 2012. from 22 shelters in bandung, two shelters (rpa gank and pesantren kolong nurul hayat) were selected and organized into 4 areas: cihampelas, ‘samsat’, laswi street and kiaracondong. a hundred-seven street adolescents aged 11 to 16 years were participated in this study. they were divided into small groups and filled in the sociodemographic questionnaire and the indonesian version of standardized strength and difficulty questionnaires (sdq). only 100 questionnaires were filled in completely. data were analyzed using frequency tabulation and bar chart results: sixty-five percent were boys, 53% were aged 11–13 years, and 53% were students, 76% related to more than one sibling, still lived with their families (81%), and had parents. their parents had low educational background, had job, and implemented authoritative parenting pattern (41%). in becoming street adolescent, 63% were caused by their own motivation, 81% were children on street, and 55% had lived in the street more than 5 years. approximately 27% of street adolescents were rated as abnormal on the total difficulty score. conclusion: street adolescent in bandung still have emotional and behavioral problems, which mostly were boys, in the early adolescence stage, school student, had more than one sibling, permissive parenting pattern, and lived in the street for more than 5 years. [amj.2015;2(1):172–8] key words: emotional and behavioral problems, street adolescent, strength and difficulty questionnaires (sdq) correspondence: annisa nurfitriani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +622261311441 email: annisa.nurfitriani20@gmail.com introduction adolescence is a period of transition between childhood to adulthood, which develops one’s biological, psychological, and social changes. this developing period is associated with increased vulnerability to psychopathology.1 estimation of psychiatric disorder is approximately 20 percent of the adolescent population.2 recent research showed that emotional and behavioral problems such as conduct disorder, substance abuse, mood disorder, suicide, eating disorder, anxiety disorder, relational violence, attention deficit/hyperactivity disorder (adhd), and others uniquely present in adolescent period compared with other developing periods.3 street children or youth/young adolescent is commonly defined as “any girl or boy who has not reached adulthood, for whom the street has become her or his habitual abode and/or sources of livelihood, and who is inadequately protected, supervised, or directed by responsible adults”.4 according to the united nation children’s fund (unicef), there are two types of street children: “children of the street” are homeless children who lived on the street; “children on the street” earn living on the street and live at home.5 street adolescent is one of psychosocial problems that happens in indonesia. the term psychosocial problems althea medical journal. 2015;2(2) 173 are meant as a mental illness caused by social influences, such as: socioeconomic status and cultural background.6 stigma and other public opinion about street children and youth make them live socially marginalized.7 they live in group and create new sub-culture from street culture, such as theft, drinking, free sex, drug abuse, fighting, and so on. a study of street adolescent in ukraine discovered that more than 15% using drugs, 75% were sexually active, 15% adolescent were boys and 57% adolescent were girl working as sex worker , and more than 10% adolescent were forced to have sex.8 these street youths have limited competence to differentiate positive and negative behavior, they are just internalizing it as they must survive in this certain condition.9 these street adolescents are susceptible from negative influence from their environment and with their adolescent age make them vulnerable to get psychiatric problem. a study by pastor et al.10 to children 4-17 years old, one most common problem in their age is having emotional and behavioral problem.10 for the reason above, these street youths need psychiatric screening procedures that could help the situation by identifying whether a disorder is present. additionally, in indonesia, the research about psychological problems of adolescent street youth is scarce. therefore, this study aims to describe the characteristic, emotional and behavior problems of street adolescent in bandung. methods this descriptive study was carried out in october-december 2012. from 22 shelters in bandung, two shelters (rpa gank and pesantren kolong nurul hayat) were purposively selected by recommendation of bandung district social office. these shelters were organized into 4 areas: cihampelas, ‘samsat’, laswi street and kiaracondong. a hundred-seven street adolescents aged 11 to 16 years were participated in this study. after an explanation about this study, the research was conducted to the head of the shelters, their parents and the street adolescents themselves. furthermore, informed consent was obtained. the respondents were divided into small groups and filled in two self-report questionnaires. if they could not understand the questions, the researcher guided in interviewing manner. the questionnaire was divided into two types. first, a questionnaire consisting of sociodemographic aspects: gender, age, education, number of siblings, place of living, parents’ information. second, an indonesian version of standardized strength and difficulty questionnaires (sdq). the sdq contains 25 sentences that are scored on a three point scale (0=not true, 1=somewhat true, 2=certainly true). five subscales score are generated each from 5 questions, those are: hyperactivity/ inattentions, emotional symptoms, conduct problems, peer problems, and prosocial behavior. a total difficulty score is summed from four subscale scores (hyperactivity/ inattentions, emotional symptoms, conduct problems, peer problems). in general, high score represents greater difficulties, except for the prosocial scale score, lower score represents greater difficulties.11 (table 1) from 107 filled questionnaires, only 100 questionnaires were filled completely. data were analyzed using frequency tabulation and bar chart. the health research ethics committee of faculty of medicine, universitas padjadjaran, gave ethical approval for the study. results in total participants of 100 street adolescents, more than half participants were boys (65%)., 53% were aged 11–13 years, and 53% were still students. from the family factor, mostly (76%) came from big family, still lived with table 1 sdq score interpretation self completed normal borderline abnormal total difficulties score 0–15 16–19 20–40 emotional symptoms 0–5 6 7–10 conduct problems 0–3 4 5–10 hyperactivity 0–5 6 7–10 peer problems 0–3 4–5 6–10 prosocial behavior score 6–10 5 0–4 annisa nurfitriani, veranita pandia, guswan wiwaha: acharacteristic, emotional, and behavioral problems of street adolescent in bandung october–december 2012 althea medical journal. 2015;2(2) 174 amj june, 2015 table 2 characteristics of participants characteristics percentage (%) gender male 65.0 female 35.0 age (years) 11–13 53.0 14–16 47.0 educational background: none 6.0 drop out 41.0 -elementary (27.0) -junior high (12.0) -high school (2.0) students at: 53.0 -elementary (33.0) -junior high (14.0) -high school (6.0) number of siblings one 24.0 >1 person 76.0 living with: family 81.0 surrogate 11.0 alone 8.0 father’s condition alive 83.0 died 11.0 lost contact 6.0 father: has job 64.0 no job 36.0 father’s educational background: elementary school 32.0 junior high school 52.0 high school 16.0 mother’s condition: alive 94.0 died 2.0 lost contact 4.0 characteristics percentage (%) mother: has job 50.0 has no job 50.0 mother’s educational background: elementary school 55.0 junior high school 38.0 high school 7.0 parent marital status: married live together 77.0 married live separate 5.0 divorce 18.0 family condition: live in harmony 67.0 no communication 7.0 fights 26.0 parenting pattern: authoritative 41.0 permissive 34.0 authoritarian 18.0 neglectful 7.0 classification street children: ‘on street’ 81.0 ‘of street’ 19.0 reason going to street: self motivation 63.0 forced 11.0 environment 26.0 years as street youth: < 5 years 45.0 > 5 years 55.0 althea medical journal. 2015;2(2) 175 their families (81%) and had parents, with good condition of family. mostly their parents had low educational background, had job, conducted authoritative parenting pattern (41%). in becoming street children/youth, motivation was the most cause (63%), 81% were classified as children on street, and 55% have lived in the street for more than 5 years. (table 2) figure 1 shows the interpretation of score on 5 subscales of strength and difficulties questionnaires on emotional and behavioral problems, the percentages scoring within the borderline, and other ranges. in the abnormal range, the most significant is shown in the subscale of emotional symptom (33%) and in the borderline range is significaltly shown in peer problem subscale (46%). approximately 27% of street adolescents were rated as abnormal on total difficulties score. from street adolescents who had abnormality, 16% were males,, in the early adolescent stage (16%), with more than 5 years have lived in street (15%). no distinct differences discovered in educational background category between drop out (12%) and student (13%). however, the proportion of emotional and behavioral problem were varied by family categories: mostly lived in harmonious family (17%), had more than one siblings (24%), and implemented permissive parenting pattern (11%). discussions the study revealed that 27% street adolescents in bandung had abnormal on total difficulties score, 33% with abnormal on the emotional symptoms. a similar study in zambia12 reported that from 27% of children were rated abnormal on total difficulties score, 47.6% were abnormal on emotional symptoms. in gender differences was discovered that boys had higher proportion than girls. it is found that boys tend to exhibit more externalizing behavior in the early age (e.g: aggressive, forceful, and oppositional behaviors) that are risk factors for the development of more serious emotional and behavioral problems.13 compared to the adolescence stage, early adolescent had higher proportion than middle adolescent. during the early adolescence (10 through 14 years old) is an initial transition period of children to undergo many physical, emotional, and mental changes. children and parents, somehow, are often unprepared and just to get it through. this period is associated to increased risk of poor mental health, such as: some mood disorders, eating disorders, substance use, self-harm , and suicidal behavior.2,14 the obvious differences among the educational background of adolescent street youth were observed between participants who never went to school and participants who were still/ever in school. few studies have explored the differences of educational background on emotional and behavioral problems. however, according to the interview, they are more likely to have social problem with peer, while they are bullied most of the time at their school. participants with more than one sibling demonstrated a higher proportion compared to other participant with one sibling. it is annisa nurfitriani, veranita pandia, guswan wiwaha: acharacteristic, emotional, and behavioral problems of street adolescent in bandung october–december 2012 figure 1 strengths and difficulties questionnaires (sdq) result score althea medical journal. 2015;2(2) 176 amj june, 2015 figure 2 proportion of emotional and behavioral problems in adolescent street aged 11– 16 years by gender, adolescent stage, educational background, and years as street youth figure 3 proportion of emotional and behavioral problems in adolescent street youth aged 11–16 years by number of siblings, family condition, and parenting pattern althea medical journal. 2015;2(2) 177 suspected that large family size contributes to behavioral and emotional problems. former study revealed that large family size was associated with increasing risk of psychiatric morbidity, by the existence of the older and younger siblings.15 surprisingly, family in harmony condition had higher proportion on emotional and behavioral problem. likely, family factor is not a main influence for adolescence. study about parent-child connectedness among adolescent shows that they had difficulty talking to their parents and valuing their peer’s opinion is associated with their emotional and behavioral problems.16 according to baumrind17, there are 4 categories of parenting pattern: authoritative, authoritarian, permissive, and neglectful. in this study, it is suspected that permissive parenting pattern has caused emotional and behavioral problems compared to other parenting patterns. research findings show that authoritarian and permissive parenting have consistently negative outcome and authoritative parenting show positive outcome. street adolescent living or working on the street for more than 5 years had higher proportion in having emotional and behavioral problems. the longer they live on street, the more they are internalizing the negative influence from street subculture.9 furthermore, the stressful life that street adolescent has been through makes them at risk on having sort of psychiatric disorder, emotional problem, and others.5 from this study, it can be concluded that 27% of street adolescents have emotional and behavioral problems, which mostly are boys. the problems occurs to those who are in the early adolescence stage, school student, have more than one siblings, receive permissive parenting pattern, and live in the street for more than 5 years. the limitation of this study is the correlation among sociodemographic characteristics of the respondents, behavioral and emotional problems were not conducted. references 1. paus t, keshavan m, giedd j. why do many psychiatric disorder emerge during adolescence?. nat rev neurosci. 2008;9(12):947–57. 2. sadock bj, sadock va. kaplan & sadock’s synopsis of psychiatry: behavioral sciences/clinic psychiatry. 10th ed. philadelphia: lippincott williams & wilkins; 2007. 3. wolfe ad, mash je, editors. behavioral and emotional disorders in adolescent. new york: the guilford press; 2006. 4. inter-ngo programme on street children and street youth, sub regional seminar for the mediterranean. summary of proceedings; 1983 october 24–27. marseilles: 1983. 5. who. a profile of street children : a training package on substance use, sexual and reproductive health including hiv/aids and stds. 2000 [cited 2013 february 11]. available from: http://whqlibdoc.who. int/hq/2000/who_msd_mdp_oo.14_ module1.pdf 6. kementerian kesehatan republik indonesia. masalah psikososial. 2008 [cited 2013 february 3]. available from: http://www.depkes.go.id/downloads/ psikososial.pdf. 7. benitez sd. the state of the world’s children 2012. new york: unicef; 2012. 8. busza jr, balakireva om, teltschik a, bondar tv, sereda yv, meynell c, et al. street-based adolescents at high risk of hiv in ukraine. j epidemiol community health. 2011; 65(12): 1166–70. 9. saripudin d, suwirta a, komalasari k. resocialization of street children at open house: a case study in the city of bandung, indonesia. educare: international journal for educational studies. 2008;1(1):91– 102. 10. pastor pn, reuben ca, duran cr. identifying emotional and behavioral problems in children aged 4-17 years: united states, 2001-2007. natl health stat reports. 2012;(48):1–17. 11. sdq information for researchers and proffesionals about the strength and difficulties questionnaires.what is the sdq?. 2008; [cited 2013 february 4]. available from: http://www.sdqinfo.org. 12. imasiku ml, banda s. mental health problems in residential care for street children. med j zambia. 2010;37(3):174–9. 13. hill al, degnan ka, calkins sd, keane sp. profiles of externalizing behavior problems for boys and girls across preschool: the roles of emotion regulation and inattention. dev psychol. 2006;42(5):913–28. 14. spellings m. helping your child through early adolescence. washington d.c: u.s departerment of education; 2005. 15. riordan dv, morris c, hattie j, stark c. family size and perinatal circumstances, annisa nurfitriani, veranita pandia, guswan wiwaha: acharacteristic, emotional, and behavioral problems of street adolescent in bandung october–december 2012 althea medical journal. 2015;2(2) 178 amj june, 2015 as mental health risk factor in a scottish birth cohort. soc psychiatry psychiatr epidemiol. 2012;47(6):975–83 16. ackard dm, neumark-sztainer d, story m, perry c. parent-child connectedness and behavioral and emotional health among adolescents. am j prev med. 2006;30(1):59–66. 17. baumrind d. the influence of parenting style on adolescent competence and substance use. j early adolesc. 1991;11(1): 56–95. althea medical journal. 2015;2(3) 346 amj september, 2015 characteristics of childhood steroid-induced glaucoma patients in national eye center, cicendo eye hospital, bandung, indonesia from 2007 to 2011 indri nurul badriyah,1 irawati irfani,2 lulu eva rakhmilla3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine, universitas padjadjaran/cicendo eye hospital bandung, 3department of obstetry and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the prevalence of children’s blindness in developing countries is still high especially in asian countries. this children’s blindness influences their motoric, social and emotional developments and their chances to get education. one of the causes is steroid-induced glaucoma. the aim of the study was to identify the characteristics of childhood steroid-induced glaucoma in national eye center, cicendo eye hospital, bandung, indonesia. methods: a descriptive study was conducted to 22 medical records of childhood steroid-induced glaucoma patients in national eye center, cicendo eye hospital bandung from 2007−2011. the inclusion criterias were medical records contained complete demographic (age, sex, address and socioeconomic status), clinical (visual acuity, intraocular pressure, cup-disc ratio, underlying eye disease, working diagnosis, treatment and patient’s compliance to follow up) and risk factor (type and route of administration of steroid and duration of steroid usage). results: majority of patients were boys (73%), aged 4−7 years old (41%), from bandung (55%), with moderate socioeconomic condition (73%). most of the patients experienced blindness (64%), intraocular pressure around 20−30 mmhg (33%), cup-disc ratio above 0.4 (77%). the underlying eye disease was conjunctivitis vernalis (95%). they were treated by medicamentosa or trabeculectomy. the most common used steroid contained dexamethasone (100%) for more than 1 year of usage (64%). patients’s compliance to follow up was mostly good (59%). conclusions: most of the patients with steroid-induced glaucoma is still very young and the use of topical dexamethasone to treat conjunctivitis vernalis for a long time leads to steroid-induced glaucoma. [amj.2015;2(3):346–51] keywords: children, conjunctivitis vernalis, dexamethasone, steroid-induced glaucoma correspondence: indri nurul badriyah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285724555890 email: indrinurulbadriyah@yahoo.com introduction the prevalence of children’s blindness in developing countries is 1.0−1.5 in 1000 children. most of them live in asia.1 actually, the incident of children’s blindness is not as high as incident of adult’s blindness. however, the important impact is that children with blindness have much longer ‘blind years’ than adults do.1 blindness in children also influences their chance to get education and to develop their talent. moreover, blindness that occurs early in childhood interfere their motoric, social and emotional development.2 there are many causes of children’s blindness, one of them is glaucoma. compared with cataract, glaucoma becomes a more challenging public health problem, because blindness caused by glaucoma can be permanent.the incident of glaucoma can be decreased by involving the role of community. people’s awareness of children’s glaucoma should be increased because actually blindness caused by this disease can be prevented by early detection dan appropriate treatment. glaucoma can be caused by long term usage of steroid without doctor’s supervision. this causes a condition called steroid-induced glaucoma. steroid-induced glaucoma causes blindness by increasing the resistance of aqueous humor flow.3 some types of steroid whether it is topical, oral or periocular can raise intraocular pressure and lower the facility of althea medical journal. 2015;2(3) 347 aqueous humor flow. the intraocular pressure of 5−6% normal population increased more than 31 mmhg after 4−6 week treated by topical corticosteroid.4 children were more susceptibility to steroid than adults.3 this makes them susceptible for having steroidinduced glaucoma with blindness as the final complication. steroid-induced glaucoma has many important risk factors. there is an increase of intraocular pressure in children below 10 years old, who use dexamethasone or fluorometholone topical drops, two times or four times everyday.5 the increase of intraocular pressure happens after 10 days and also related to the intensity of steroid usage.5 furthermore, gender also determines the risk for having steroid-induced glaucoma. since the ‘blind years’ in children is higher than adult, steroid-induced glaucoma in children needs more attention. therefore, this study intended to find the characteristics of the disease through secondary data from medical records in cicendo eye hospital bandung. the aim of the study was to identify the characteristics of childhood steroid-induced glaucoma in cicendo eye hospital bandung in the period of january 2007−december 2011. methods a descriptive study was carried out to 22 medical records of childhood steroid-induced glaucoma patients in cicendo eye hospital bandung on the period of january 2007− december 2011. medical records that fulfill the inclusion criteria (comprised complete demographic, clinical dan risk factor data), were included in this study, while the exclusion criteria was the medical records with incomplete data. variables in this study were divided into three categories; there were demographic, clinical and risk factor variables. the demographic variable consisted of age, sex, address and socioeconomic status. the clinical variable consisted of visual acuity, intraocular pressure, cup-disc ratio, underlying eye disease, working diagnosis, treatment and patient’s compliance to follow up. the risk factor variable consisted of type and route of administration of steroid and duration of steroid usage. age in this study was the age of patients when they are diagnosed with steroid-induced glaucoma. the age of the patients were stated in year and in the range of children’s age in pediatric ophthalmology and strabismus outpatient clinic in cicendo eye hospital, 0−14 years old. sex consisted of male and female. patients’s residences were the address of patients when they came to hospital. it was classified into bandung and outside bandung. from this data, patients were divided into referral and nonreferral patients. patients were also grouped into moderate and low socioeconomic patients based on jaminan kesehatan masyarakat and non-jaminan kesehatan masyarakat (jamkesmas and nonjamkesmas). the working diagnosis was steroid-induced glaucoma either unilateral or bilateral. treatment of this case was all of the management given to the patients either medicamentosa or surgery (trabeculectomy) on the first visit, first follow up after one month, and second follow up after three months. the visual acuity was visual acuity when patients were diagnosed with steroidinduced glaucoma, and classified based on who classification, into normal visual acuity (0.33−1.0), visual impairment (<0.33−0.1), severe visual impairment (<0.1−0.05) and blind (<0.05).6 intraocular pressure, cup-disc ratio, underlying eye disease, type and route of steroid administration and duration of steroid usage were obtained from patients’s medical records. patients’s compliance was assessed from frequency of patient to follow up. it was classified into good compliance for the patients who came to follow up in the first month and third month, moderate compliance for patients who came to follow up in either the first month or third month and poor compliance for the patients who did not come to follow up at all. results there were 25 children diagnosed with steroid-induced glaucoma in cicendo eye hospital from january 2007−december 2011. however, there were only 22 patients with complete characteristic data on their medical records while three other patients’ medical records were incomplete, so the percentage of medical records studied was 88%. most of the patients were boys, under 11 years old, from moderate socioeconomic status and live in bandung. most of the patients from bandung came to cicendo eye hospital without referral from other health facilities, but on the other hand, patients from outside bandung were patients referred by other health facilities before coming to cicendo eye hospital. moreover, the clinical condition prior to steroid application was conjunctivitis vernalis. indri nurul badriyah, irawati irfani, lulu eva rakhmilla: characteristics of childhood steroid-induced glaucoma patients in national eye center, cicendo eye hospital, bandung, indonesia from 2007 to 2011 althea medical journal. 2015;2(3) 348 amj september, 2015 table 1 characteristic of childhood steroid-induced glaucoma patients characteristics number (n) percentage (%) sex boy 16 73 girl 6 27 age (years old) 4−7 9 41 8−11 7 32 12−15 6 27 socioeconomic status moderate 16 73 low 6 27 patients’s residence bandung referral patient 2 9.1 nonreferral patient 10 45.5 outside bandung referral patient 8 36.4 nonreferral patient 2 9.1 working diagnosis unilateral 5 23 bilateral 17 77 visual acuity normal 8 21 visual impairment 4 10 severe visual impairment 2 5 blind 25 64 intraocular presure 20−30 mmhg 13 33 31−40 mmhg 9 23 >40 mmhg 6 15 palpation n+ 10 26 hard to assess 1 3 cup-disc ratio 0.3−0.4 3 8 >0.4 30 77 hard to assess 6 15 underlying eye disease conjunctivitis vernalis 21 95 uveitis anterior 1 5 type of steroid: dexamethasone 22 100 route of administration: topical 22 100 althea medical journal. 2015;2(3) 349 the treatment of steroid-induced glaucoma in children patients at cicendo eye hospital when diagnosed, was followed up after one month and followed up after three months (table 2). discussions boys are the most common patients in this study. actually, there is no gender predilection in this disease. based on the literature, steroidinduced glaucoma can occur both in boys and girls4, it is more related to the underlying eye disease. in this study, most of underlying eye disease of the steroid-induced glaucoma is conjunctivitis vernalis suffered mostly by boys aged 3–16 years old.7 based on the age of patients, childhood steroid-induced glaucoma mostly occurs in age 4−7 years old. this study is appropriate with a literature which states that there is an increase of intraocular pressure in children under 10 years old treated by topical dexamethasone.8 in this study, steroid-induced glaucoma patients mostly come from bandung (55%). cicendo eye hospital is national referral hospital located in bandung. it is easier to be accessed by patients who live in bandung, although there are some patients referred from another city. from the referral information, most patients who come from outside bandung are referred by a general practitioner in the district hospital, primary health care or private practice of a general practitioner. it shows that the referral system of this case in the district area outside bandung is good. most of the general practitioners understand that this case should be referred to the ophthalmologist immediately. meanwhile, most patients who come from bandung are not referral patients because the cicendo eye hospital is easier to be accessed by them, although patients who come to this national referral hospital should be ‘referral patients’. there are 17 patients (77%) who have bilateral glaucoma and there are 5 patients (23%) who have unilateral glaucoma. so, in this study, there are 39 eyes (89%) with steroid-induced glaucoma, while other 5 eyes (11%) are normal. in this study, there are 25 blind eyes (64%), with visual acuity <3/60. this is appropriate with literature which states that mostly patients complain about the decreasing of visual acuity when intraocular pressure begin to raise and damage the optic nerve.9 this study shows that most of the table 1 characteristic of childhood steroid-induced glaucoma patients characteristics number (n) percentage (%) duration of steroid usage <6 months 3 14 6−12 months 5 22 >12 months 14 64 patient’s compliance good 13 59 moderate 7 32 poor 2 9 table 2 treatment of steroid-induced glaucoma patients treatment n(%) initial therapy follow up on month 1 follow up on month 3 antiglaucoma medicamentosa topical 18 (82%) 7 (32%) 11 (50%) combination (topical and oral) 4 (18%) 2 (9%) 1 (5%) surgery (trabeculectomy) 0 (0%) 4 (18%) 1 (5%) without medicamentosa antiglaucoma 0 (0%) 6 (27%) 2 (9%) did not follow up 0 (0%) 3 (14%) 7 (32%) indri nurul badriyah, irawati irfani, lulu eva rakhmilla: characteristics of childhood steroid-induced glaucoma patients in national eye center, cicendo eye hospital, bandung, indonesia from 2007 to 2011 althea medical journal. 2015;2(3) 350 amj september, 2015 patients came to the doctor only when they realized that there was something wrong with their vision, even they have had blindness. patients in this study mostly have intraocular pressure around 20−30 mmhg (33%). the increasing of intraocular pressure is appropriate with the literature which states that there is an increasing 5−10% intraocular pressure in general population who use steroid for 6 weeks.10 cup-disc ratios in this study are mostly above 0.4. literature states that patients diagnosed with glaucoma have higher cup-disc ratio both vertically and horizontally.11 this is appropriate with this study that showed an increasing cup-disc ratio in patients. the most common underlying eye disease for these cases is conjunctivitis vernalis. conjunctivitis vernalis is a chronic inflammation of conjunctiva that often happened in boys of 3−16 years old.12 medication for the disease is symptomatic, by giving topical steroid drops like prednisolone or dexamethasone.12 uncontrolled steroid medication for these cases can cause the increasing of patient’s intraocular pressure. there are some kinds of steroid that are used by 22 children diagnosed with steroid-induced glaucoma. they are xitroltm, polydextm, polydemycintm and corthontm. each of them contains a potent steroid. most of the patients in this study use xitroltm. xitroltm is an eye drop containing dexamethasone 0.1%, neomycin sulphate 3.5 mg/ml and polymyxin b sulphate 6000 iu/ml. xitroltm is indicated for eye inflammation, acute or chronic conjunctivitis, blepharoconjunctivitis, keratoconjunctivitis, superficial keratitis and other eye inflammation disease. the dosage is 4−6 times a day, 1−2 drops. xitroltm contains dexamethasone which is group of sintetic long acting glucocorticoid. another study states that dexamethasone and betamethasone both topical and oral are more potent to cause glaucoma compared with medrisone and prednisolone.13 this is proved by this study, that most of the steroid-induced glaucoma patients used dexamethasone. all of the routes of steroid administration of patients in this study were topical administration through eye drops. topical steroid administration is the most common cause of steroid-induced glaucoma. this study is appropriate with a literature which states that topical steroid therapy often causes the increasing of intraocular pressure than oral administration.14 in this study, there were 14 patients (64%) who used steroid for more than 1 year. the duration of steroid usage influenced the risk of steroid induced glaucoma incidence. these data were appropriate with the study held by saadia farooq and aslam malik15 who states that increasing of intraocular pressure can happen only in 2−6 weeks after steroid usage. based on this study, patients’s compliance to follow up is good. there were 13 patients (59%) who follow up twice, on the first and third month. the compliance to follow up is very important to keep the disease in control and does not getting worse.16 therefore, patients were suggested to follow up regularly. treatment for patients in this study on the initial therapy was topical medicamentosa with timololtm and dorzoltm. timololtm is nonselective beta aderenergic receptor blocker on eye and contains active substance oftimolol maleate. this drug is used to treat ocular hypertension by decreasing amount of aqueous humor that secreted by ciliary body. furthermore, this drug causes constriction of blood vessels that supply ciliary body and decreases the amount of fluid filtrated by blood vessel to produce aqueous humor. while dorzoltm is a group of carbonic anhidrase inhibitor, and contains active substance of dorzolamide hydrochloride. it inhibits carbonic anhidrase ii in ciliary processes on eye by slowing bicarbonate ion formation. thus, it also has the same function that is lowering intraocular pressure by decreasing aqueous humor production. oral therapies given to the patients were potassium l-aspartate and acetazolamide. in this study, timololtm and dorzoltm were given in the first time when the patients were diagnosed with steroid-induced glaucoma. these drugs were given on the initial therapy because the increasing of intraocular pressure in many cases can be decreased only by stopping the steroid or by giving topical antiglaucoma.8 however, on the next follow up, some patients still had high intraocular pressure so that trabeculectomy was needed. some patients were not given antiglaucoma therapy anymore on the next follow up because their intraocular pressures were getting better. these patients were treated only for their underlying eye disease. the underlying eye disease was treated by potassium pemirolast 0.1% and flurometholone 0.1%. both of the drugs inhibit allergic process in the eye. another variable that can be studied for steroid-induced glaucoma in children is thevisual field examination. it was held to know the specific location of patient’s visual althea medical journal. 2015;2(3) 351 field loss. this was hard to do possibly because the children were less cooperative for this examination. in this study, there was a bias information about the frequency of steroid usage by the patients. steroid usage duration was based on anamnesis of medical records, while the frequency of steroid usage along the duration is unknown. there were some patients who did not come to follow up so the data of patient’s follow up is incomplete. these conditions were the limitations of the study actually, childhood steroid-induced glaucoma can be prevented. a good follow up of the patients who used long term topical steroid is really suggested. therefore, parents should be educated about the risk of long term steroid usage for their children. the doctors should give a very clear informed consent to the parents, so that the parents will realize the risk of long term steroid usage without doctor’s supervision and do the follow up regularly. furthermore, the drugs potential to cause glaucoma should be only prescribed when the patient has an indication. for the long term usage, it can be started with less potential steroid and the intraocular pressure should be evaluated strictly. based on the data of this study, most of steroid-induced glaucoma patients were accompanied by high risk condition of blindness. references 1. kementerian sosial republik indonesia. pencapaian target mdgs keempat dan booming kebutaan anak. jakarta; kementerian sosial republik indonesia; 2012. 2. gilbert c, awan h. blindness in children. bmj. 2003;327(7418):760–1. 3. jones r, rhee dj. corticosteroid-induced ocular hypertension and glaucoma. curr opin ophthalmol. 2006;17(2):163–7. 4. albert dm, jakobiec fa. principles and practice of ophthalmology. 2nd ed. new york: w. b. saunders company; 1994. 5. stamper rl, lieberman mf, drake mv. beckershaffer’s diagnosis and therapy of the glaucomas. 8th ed. new york: mosby elsevier; 2009. 6. who. recommendations of the who consultation on “development of standards for characterization of visual loss and visual functioning”. san francisco:who. 2003. 7. barney np. epidemiology and genetics of ocular allergy. world allergy organization. [cited 2012 november 10]. available from: http://www.worldallergy.org/ educational_programs/world_allergy_ forum/berlin/barney.php 8. cohen a. steroid induced glaucoma. in: rumelts, editor. 2011 glaucoma -basic and clinical concepts. new york:intech; 2011. 9. zimmerman tj, kooner ks, editors. clinical pathways in glaucoma. new york: thieme; 2001. 10. blanco aa, costa vp, wilson rp. handbook of glaucoma. london: martin dunitz; 2002. 11. morrison jc, freddo tf, toris cb. clinical evaluation of the optic nerve head. in: morrison jc, pollack ip, editors. glaucoma science and practice. new york: thieme; 2003. p. 90-93. 12. hall a, shilio b. vernal keratoconjunctivitis. community eye health. 2005;18(53):76– 8. 13. mohan r, muralidharan ar. steroid induced glaucoma and cataract. indian j ophtalmol. 1989;37(1):13–6. 14. allingham rr, damji kf, freedman s, moroi se, shafranov g, editors. shield’s text book of glaucoma. philadelphia: lippincott william and wilkins; 2005. 15. farooq s, malik a. evaluation and management of steroid induced glaucoma in vernal keratoconjunctivitis patients. pak j ophthalmol. 2007;23(1):1–4 16. jackson a. understanding and living with glaucoma. glaucoma research foundation. 2012 [cited 2012 november 21]. available from: https://www.glaucoma.org/grf_ understanding_glaucoma_en.pdf. indri nurul badriyah, irawati irfani, lulu eva rakhmilla: characteristics of childhood steroid-induced glaucoma patients in national eye center, cicendo eye hospital, bandung, indonesia from 2007 to 2011 althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 73 knowledge and attitude of senior high school students toward human immunodeficiency virus/acquired immunodeficiency syndrome arnova reswari,1 kuswandewi mutyara,2 lynna lidyana3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran, 3department of psychiatry faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital bandung abstract background: indonesia has experienced more than 25% rise of human immunodeficiency virus/acquired immunodeficiency syndrome (hiv/aids) incidence. one of the provinces mostly affected is west java. proper knowledge of hiv/aids can develop attitude and practice to prevent the spread of hiv/aids, and in effect, its incidence. this study was conducted to describe the knowledge and attitude of senior high school (sekolah menengah atas, sma) students toward hiv/aids. methods: this descriptive study was conducted using a cross-sectional method and used secondary data with total sampling technique, from jatinangor cohort research team of the faculty of medicine, universitas padjadjaran. the samples were obtained by stratified cluster random sampling. two hundred and seventy seven students’ knowledge and attitude were assessed in senior high school in jatinangor, on may 2013 results: senior high school students in jatinangor mostly (50.2%) had a poor level of knowledge, yet 51.3% positive attitude toward hiv/aids. there were still misconception regarding transmission media of hiv/aids and mode of transmission hiv/aids. information source on hiv/aids were teachers (96.4%), followed by television (93.5%), internet (86.6%), friends (84.8%), health workers (69.7%), newspapers (62.1%), parents (61%), magazines (55.2%), and radio (33.2%). conclusions: although most of the senior high school students in jatinangor have a poor level of knowledge, they have a positive attitude toward hiv/aids. the main information source on hiv/aids is teacher. [amj.2016;3(1):73–8] keywords: attitude, hiv/aids, jatinangor, knowledge correspondence: arnova reswari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 89698281661 email: arnovareswari.fkunpad@gmail.com introduction human immunodeficiency virus/acquired immunodeficiency syndrome (hiv/aids) is a disease related to the decrease of immunological functions, and it has been a major problem in many countries.1,2 according to the joint united nations program on hiv/ aids (unaids) report in 2012, indonesia was included into the group of nations that have experienced hiv incidence more than 25% on adults (15−49 years of age) from 2001 to 2011.1 west java is the province with the highest prevalence of aids in indonesia after papua, jakarta region, and east java.3 one of the methods to prevent hiv/aids is by improving knowledge and attitude which can help to decrease the incidence of hiv/aids.4 the spread of hiv/aids in society can be determined by individual knowledge and attitude towards hiv/aids. as such, before implementing a public health policy to prevent hiv/aids, much information is needed on the knowledge and attitude towards hiv/ aids.4 a study conducted in 2005 regarding the knowledge and attitude of society and students towards hiv/aids in turkey, found a good level of knowledge to contribute a positive attitude towards hiv/aids.5,6 in accordance to that fact, this study aimed to describe the knowledge and attitude of senior high school (sekolah menengah atas, sma) students towards hiv/aids in jatinangor, in 2013. methods this descriptive study was conducted using althea medical journal. 2016;3(1) 74 amj march 2016 a cross-sectional method conducted in two senior high school in jatinangor, on may 2013. total sampling was taken from jatinangor cohort research team of the faculty of medicine, universitas padjadjaran. total respondents were the same as the total data appropriated by jatinangor cohort research team of the faculty of medicine, universitas padjadjaran, which were 277 respondents. samples were obtained by stratified cluster random sampling conducted at jatinangor cohort research team of the faculty of medicine, universitas padjadjaran. the first stage was to choose two schools from 10 senior high schools (sekolah menengah atas, sma) in jatinangor subdistrict. the sma negeri jatinangor and sma pgri jatinangor were chosen. in each school, a randomized method was employed to pick the classes that were the samples for the study. the study instrument was a questionnaire on knowledge and attitude prepared by the researcher. from the validation of the questionnaire, an alpha-cronbach value of 0.891 was retrieved. after signing an informed consent form, respondents would answer forty four questions in questionnaire, consisted of twenty seven questions on knowledge of hiv/aids, nine questions on information source on hiv/aids, and eight statements on attitude towards hiv/aids. for each question on knowledge, a correct answer was graded with value ten, while an incorrect answer or ‘do not know’ was graded zero; maximal grade in the knowledge questionnaire was 270, while the minimal was zero. the choices of information source on hiv/aids asked on the questionnaire were teachers, parents, health workers, friends, newspapers, magazines, television, radio, and internet. there were four positive attitude statements that were graded at thirty on strongly agree, twenty on agree, ten on disagree, and zero on strongly disagree. on the other hand, there were four negative attitude statements that were graded at zero on strongly agree, ten on agree, twenty on disagree, and thirty on strongly disagree. the maximal grade for the attitude questionnaire was 240, while the minimal was zero. after a scoring process, the data distribution of knowledge and attitude using the kolmogorov-smirnov method was reviewed. the level of knowledge was divided into two groups, which were good knowledge and poor knowledge. the grouping of the respondent’s knowledge level was based on the mean because the data distribution was normal (p-value was 0.116). the attitudes of the respondents were also grouped into positive attitude and negative attitude. the basis for this grouping was the median because the data distribution was not normal (p-value was 0.001). before conducting this study, ethical clearance was fulfilled to health research ethics committee by researcher and by jatinangor cohort research team of the faculty of medicine, universitas padjadjaran. results most students had a good knowledge on definition and causes of hiv/aids. as many as 219 respondents (79.1%) knew that hiv/ aids attacked the immunological functions of a human body. as many as 253 respondents (91.3%) knew that hiv/aids was categorized as a sexually transmitted infection. more than 70% of respondents knew that hiv/aids was caused by a virus (table 1). most respondents did not know the transmission media of hiv/aids. more than 65% of respondents knew that sperm, vaginal discharge, and blood were a transmission media of hiv/aids, but only 119 respondents answered that breast-milk was also a transmission media of hiv/aids. there were a few misconceptions on the transmission media of hiv/aids; some answered that tears, sweat, urine, saliva, and feces were transmission media of hiv/aids (table 2). the knowledge of respondents on mode transmission of hiv/aids was good, more than 80% of respondents knew that sexual table 1 characteristics of respondents variable n (%) gender male 115 (41.5) female 162 (58.5) senior high school sma negeri jatinangor 199 (71.8) sma pgri jatinangor 78 (28.2) age 15 years old 1 (0.4) 16 years old 41 (14.8) 17 years old 172 (62.1) 18 years old 61 (22.0) 19 years old 2 (0.7) althea medical journal. 2016;3(1) 75arnova reswari, kuswandewi mutyara, lynna lidyana: knowledge and attitude of senior high school students toward human immunodeficiency virus/acquired immunodeficiency syndrome intercourse with hiv afflicted individuals, usage of intravenous needle shared with hiv afflicted individuals, and blood transfusion contaminated with hiv were modes transmission of hiv/aids. there were 162 respondents recognized that tattooing needle and piercing are were a mode transmission of hiv/aids. however, some had misconceptions on the mode transmission of hiv/aids, such as mosquito bite, hand shaking, hugging, mouthto-mouth kissing, swimming in the same pool, and coughing/sneezing (table 3). the respondents’ knowledge level on prevention of hiv/aids was also good. more than 80% of respondents knew that avoiding multi-partnered sexual relationship, be faithful table 3 knowledge of respondents on mode transmission of hiv/aids mode transmission of hiv/aids true false do not know % % % sexual intercourse with hiv afflicted individuals 86.6 5.1 8.3 mother infected hiv to baby 67.9 4.7 27.4 usage of intravenous needle shared with hiv afflicted individuals 86.3 1.8 11.9 tattooing needle and piercing 58.5 9.4 32.1 mosquito bite 53.4 9.0 37.5 blood transfusion contaminated with hiv 80.9 3.2 15.9 hand shaking with hiv afflicted individuals 59.6 8.7 31.8 hugging with hiv afflicted individuals 55.6 10.1 34.3 mouth-to-mouth kissing 16.6 55.2 27.8 swimming in the same pool 41.2 9.0 49.8 coughing/sneezing 30.0 30.0 40.1 table 2 knowledge of respondents on the transmission media of hiv/aids the transmission media of hiv/ aids true false do not know % % % tears 44 0.7 55.2 sperm 81.2 0.7 18.1 vaginal discharge 68.6 1.1 30.3 blood 66.4 5.4 28.2 sweat 35.4 13 50.9 urine 16.6 38.6 44.8 breast-milk 43 12.6 44.4 saliva 25.3 35 39.7 feces 32.5 5.4 62.1 with one partner, and avoiding intravenous drug abuse were methods to prevent hiv/ aids (table 4). more than 80% respondents answered disagree and strongly disagree with negative statement that hiv/aids was a deprecation disease. most respondents (74.3%) had a positive attitude on statement that using condom when sexual intercourse could prevent transmission of hiv/aids. more than 80% respondents also had positive attitude on statement that having sexual partner more than one and using injecting drug abuse could improve risk of transmission of hiv/aids. however, more than 50% respondents stated negative attitude toward statement that the althea medical journal. 2016;3(1) 76 amj march 2016 table 5 attitude of respondents on definition of hiv/aids, prevention of hiv/aids, transmission of hiv/aids, and hiv/aids afflicted individuals attitude of respondents strongly agree agree disagree strongly disagree % % % % positive attitude in my opinion, using condom when sexual intercourse can prevent transmission of hiv/ aids 9.0 65.3 22.7 2.2 in my opinion, having sexual partner more than one person can improve risk of transmission of hiv/aids 51.3 47.7 0 1.1 in my opinion, using injecting drug abuse can do transmission of hiv/aids 41.9 49.5 7.9 0.7 in my opinion, hiv/aids is deprecation disease 3.2 13 52.7 30.3 negative attitude in my opinion, the only one way of transmission of hiv/aids is sexual intercourse 25.3 32.1 36.5 6.1 in my opinion, hiv/aids afflicted student cannot continue schooling 6.5 18.4 57.4 17.7 in my opinion, hiv/aids afflicted friend shall be isolated 5.1 9.0 57.4 28.5 in my opinion, hiv/aids afflicted women/men have done an immoral deed 20.9 50.2 21.7 6.1 only one of route transmission of hiv/aids was sexual intercourse. most students (more than 75%) had positive attitude and stated that students afflicted with hiv/aids could continue schooling and were not to be isolated. however, most respondents presented a negative attitude (71.1%) to the statement that men and women with hiv/aids had done an immoral deed (table 5). according to analysis using kolmogorovsmirnov method, total score of knowledge from respondents in this study had a normal distribution (p-value = 0.116). therefore, a grouping of knowledge of respondents on hiv/aids was based on the mean. however, total score of attitude from respondents in this study did not have normal distribution (p-value = 0.001). as such, the grouping of respondents’ attitude towards hiv/aids was determined using the median. the respondents’ knowledge and attitude toward hiv/aids were in the following (table 6). teachers (96.4%) were the most cited information source on hiv/aids, followed by television (93.5%), internet (86.6%), friends (84.8%), health workers (69.7%), newspapers (62.1%), parents (61.0%), magazines (55.2%), and radio (33.2%). table 4 knowledge of respondents on prevention of hiv/aids prevention of hiv/aids true false do not know % % % avoiding multi-partnered sexual relationship 93.5 1.4 4.7 be faithful with one partner 92.4 2.9 4.0 use condom when doing high risk sexual intercourse 37.9 15.5 46.6 avoiding intravenous drug abuse 81.2 3.2 15.5 althea medical journal. 2016;3(1) 77arnova reswari, kuswandewi mutyara, lynna lidyana: knowledge and attitude of senior high school students toward human immunodeficiency virus/acquired immunodeficiency syndrome discussions this study found that respondents mostly had poor knowledge (below the mean) on hiv/ aids (50.2%). there were still misconceptions on the media of transmission for hiv/aids. some of these misconceptions were found in previous studies in north west ethiophia, turkey, lao democratic republic, isfahan city, iran, sudan, sana’a city, and merkelle city.4,6-14 in this study, a poor knowledge on respondents was not necessarily accompanied by a negative attitude, because more than 50% of respondents had positive attitude towards hiv/aids. previous study on knowledge, attitude and risk behavior toward hiv/aids and other sexual transmitted infection among preparatory students in gondar town, north west ethiopia4 showed different results that poor knowledge are accompanied by negative attitude. poor knowledge are followed by negative attitude because in determine the whole of attitude, knowledge, mind, belief, and emotion hold the important role.15 on the other hand, previous studies in lao democratic republic7, isfahan city8, iran10, province of mazandaran, iran11, and ethiopia16 showed that a negative attitude can follow even an individual had a good knowledge. although the most of respondents had a positive attitude toward hiv/aids, a stigma remains that the hiv afflicted individual has conducted immoral deeds. this stigma was also presented in a previous study (north west ethiophia, 2011) which stated that students’ attitude towards hiv/aids was combined with their concept of sexual morality, which caused them to see hiv/aids as a consequence to moral deviation.4 a study in merakou10 on knowledge, attitude, and behavior after 15 years of prevention of hiv/aids in school showed different result, that only few students (5%) refuse to socialize with those afflicted with hiv/aids. teacher was the most frequently information main source on hiv/aids, which differed from the previous studies that found television or radio is the most information main source on hiv/aids.4-6,8,10-14,17 teachers were the best source of information on hiv/aids since television and radio were not the most trustable source due to their manipulation with cultural values and presumption on the situation of living with people with hiv/aids, and the information given were frequently shallow and misleading.10 this study concluded that the level of hiv/ aids related to knowledge is relatively poor, yet, most respondents show positive attitude. misconception regarding transmission media of hiv/aids and mode of transmission hiv/ aids still exist. although the most respondents received their information from teachers in school, the introduction to hiv/aids through a curriculum in school can give a better and a comprehensive knowledge. previous study have shown that educational intervention by schools have resulted higher knowledge and a more positive attitude towards hiv/aids.4 this study has confronted several limitations. first, because this study used secondary data from jatinangor cohort research team of the faculty of medicine, universitas padjadjaran, the researcher was not directly involved when data collected. second, the researcher was not directly involved in questionnaire validation. third, limitation in this study as the result of this study may only generalize to similar population of student. this study may not be applicable to students in another area because of demography factor, and also may not be applicable to adolescent who are not attending school. fourth, the other limitation is because this study used a self-report of questionnaire, the honesty of students’ responses may be questioned. the future study hopefully can answer relationship between knowledge and attitude toward hiv/aids that cannot be answered in this study. references 1. unaids. global report: unaids report on the global aids epidemic. geneva, switzerland: the joint united nation programme on hiv/aids; 2012. [cited table 6 knowledge and attitude of respondents toward hiv/aids knowledge attitude mean category frequency (%) median category frequency (%) <160.43 poor 139 (50.2) <150 negative 135 (48.7) ≥160.43 good 138 (49.8) ≥150 positive 142 (51.3) althea medical journal. 2016;3(1) 78 amj march 2016 2012 december 22]. available from: h t t p : / / w w w. u n a i d s . o r g / e n / m e d i a / u n a i d s / c o n t e n t a s s e t s / d o c u m e n t s / epidemiology/2012/gr/2012/20121120_ u n a i d s _ g l o b a l _ r e p o r t _ 2 0 1 2 _ w i t h _ annexes_en.pdf. 2. pusat data dan informasi departemen kesehatan republik indonesia. situasi hiv/aids di indonesia tahun 1987−2006. pusat data dan informasi departemen kesehatan republik indonesia; 2006. [cited 2012 december 22]. available from : www.depkes.go.id/downloads/publikasi/ situasi%20hiv-aids%202006.pdf. 3. direktorat jendral pengendalian penyakit dan penyehatan lingkungan. laporan kementrian kesehatan triwulan ketiga 2012. kementrian kesehatan republik indonesia; 2012. [cited 2012december 22]. available from: www.aidsindonesia.or.id/ ck_uploads/files/fixed_laporan%20 hiv-aids,triwulan%203,%202012(1). pdf. 4. shiferaw y, alemu a, girma a, getahun a, kassa a, gashaw a, et al. assessment of knowledge, attitude and risk behaviours towards hiv/aids and other sexual transmitted infection among preparatory students of gondar town, north west ethiopia. bmc res notes. 2011;4:505. 5. ayranci u. aids knowledge and attitude in turkish population : an epidemiological study. bmc public health. 2005;5:95. 6. koksal s, namal n, vehid s, yurtsever e. knowledge and attitude toward hiv/ aids among turkish students. infect dis j pakistan. 2005;14:118−23. 7. thanavanh b, harun-or-rashid m, kasuya h, sakamoto j. knowledge, attitude and practices regarding hiv/aids among male high school students in lao people’s democratic republic. j int aids soc. 2013;16:17387 8. ghojavand g, einali b, ghaeliniya m. hiv/aids knowledge and attitude of adolescent to prevent aids in isfahan city. ijeefus. 2013;3(1):63−70. 9. nur n. turkish school teacher’s knowledge and attitude toward hiv/aids. croat med j. 2012;7:271−7. 10. tavoosi a, zaferani a, enzevaei a, tajik p, ahmadinezhad z. knowledge and attitude toward hiv/aids among iranian student. bmc public health. 2004;4:17. 11. majdi mr, khani h, azadmarzabadi e, montazeri a, babamahmodi f, kariminasab mh, et al. knowledge, attitude and practice toward hiv/aids among iranian prisoner in mazandaran province in the south-coast area of the caspian sea. east mediterr health j. 2011;17(12):904–10. 12. khamis ah. hiv and aids related knowledge, beliefs and attitudes among rural communities hard to reach in sudan. health. 2013;5(9):1494−1501. [cited 2013 october 30]. available from: http:// dx.doi.org/10.4236/health.2013.59203. 13. al-rabeei na, dallak am, al-awadi fg. knowledge, attitude and belief toward hiv/aids among students of health institutes in sana’a city. east mediterr health j. 2012;18(3):221−6. 14. swati a, sushma b. knowledge, attitude, and sources of information for increasing awareness about hiv/aids among college student. healthline. 2013;4(1):50−7. [cited 24 october 2013]. available from: http://www.iapsmgc.org/index_pdf/114. pdf. 15. notoatmodjo s. ilmu perilaku kesehatan. 1st ed. jakarta: rineka cipta; 2010. p. 29−30. 16. tadese a, menasbo b. knowledge, attitude, and practice regarding hiv/ aids among secondary school students in mekelle city, ethiopia. afr j aids hiv res. 2013;1(1):001−7. 17. nasir ef, astrom an, david j, ali rw. hiv and aids related knowledge, sources of information, and reported need for futher education among dental students in sudan-a cross sectional study. bmc public health. 2008;8:286. althea medical journal. 2016;3(2) 170 amj june 2016 handwashing among schoolchildren in jatinangor, west java cheryl may chong sue faye,1 chrysanti murad,2 sharon gondodiputro3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology, faculty of medicine, universitas padjadjaran, 3department of public health, faculty of medicine, universitas padjadjaran abstract background: diarrhea and pneumonia accounts for an estimated 40% of all child deaths around the world each year. handwashing with soap could protect about 1 out of every 3 young children who get sick with diarrhea and almost 1 out of 6 young children with respiratory infections like pneumonia. although people around the world clean their hands with water, very few use soap to wash their hands. washing hands with soap removes germs much more effectively. this study was undertaken to determine the level of knowledge and practice regarding proper handwashing among elementary school children. methods: a descriptive study was conducted from august to october 2014 in jatinangor using primary data from respondents who are 5th graders from four schools. a total of 49 males and 50 females were chosen using cluster random sampling. schoolchildren who were present, able and well were given questionnaires after written informed consent was obtained from the schoolchildren and their guardians. then, respondents demonstrated hand-washing techniques which were evaluated using a checklist. results: overall, 52% of the schoolchildren had moderate level of hand -washing knowledge and 66% had bad handwashing practices. conclusions: despite having a moderate level of handwashing knowledge, the majority still had poor handwashing practices. handwashing programs should be carried out extensively to improve knowledge and practice. [amj.2016;3(2):170–4] keywords: handwashing, knowledge, practices, schoolchildren correspondence: cheryl may chong sue faye, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87822004679, email: cherylmaychong@gmail.com introduction handwashing is the simplest, most effective measure for preventing the spread of bacteria, pathogens, and viruses.1 people frequently touch their eyes, nose, and mouth without even realizing it. germs can enter the body through the eyes, nose and mouth and make us sick.2 diarrhea and pneumonia accounts for an estimated 40% of all child deaths around the world each year.3 handwashing has proven to be a cornerstone in preventing diarrheal infections.4 handwashing with soap could protect about 1 out of every 3 young children who get sick with diarrhea and almost 1 out of 6 young children with respiratory infections like pneumonia.5 although people around the world clean their hands with water, very few use soap to wash their hands. washing hands with soap removes germs much more effectively.6 however, many do not practice the habit of correct handwashing techniques with soap in their daily life. in indonesia, only 47% of the entire general public had correct handwashing habits which is usually only performed before eating and after defecating.7 this is still less than half of the entire indonesian population. this study was undertaken to determine the level of knowledge and practice regarding proper handwashing among elementary schoolchildren. methods an observational descriptive study was carried out from august to october 2014 in elementary schools (sekolah dasar/sd) located in jatinangor west java. the samples were taken using cluster random sampling from 28 schools that made up a total of 8.746 schoolchildren. out of this number, four althea medical journal. 2016;3(2) 171 schools were selected, namely sd neglasari, sd cikuda, sd sayang and sd cipacing i. next, randomization was performed only to fifth grade schoolchildren and 25 schoolchildren were selected randomly from each school. these schoolchildren were then given an informed consent form to be filled out by their parents or guardians. the selection criteria were based on the respondents’ willingness to participate in this study. schoolchildren who were absent on the day data was collected and those who did not complete the questionnaire appropriately were excluded from the study. in the end, 99 samples were obtained, comprising 49 males and 50 females. after a brief introduction, they were given validated open-ended questionnaires, to be filled out. the questionnaire consisted of six questions about whether they were washing their hands, from whom they learned to wash their hands, the frequency of handwashing a day, when they washed their hands and also the reasons for washing their hands and the benefits of it. after filling out the questionnaire, the schoolchildren were then asked to perform handwashing steps and were evaluated using a checklist. data from the students were then keyed into the windows excel and classified into gender and answers based on each question to identify the frequency and percentage for the questions. the answers were then categorized according to arikunto’s level of knowledge, which are good 76–100%; moderate 56–75%, and poor 40–55%.8 in support of the checklist, the data were classified into each step carried out by the schoolchildren to identify the frequency and percentage. only all handwashing steps which were carried out 100% correctly were considered good, less than that was considered otherwise. the health research ethics committee of the faculty of medicine, universitas padjadjaran has approved this study. results this study was grouped based on the characteristics of respondents by gender. according to the collected data, the respondents were 50.51% female and 49.49% male. the overview of level of proper handwashing knowledge among elementary schoolchildren showed that only 4.04% had good level of handwashing knowledge, while the majority of 51.52% had moderate level of handwashing knowledge, and 44.44% had poor level of handwashing knowledge (table cheryl may chong sue faye, chrysanti murad, sharon gondodiputro: handwashing among schoolchildren in jatinangor, west java table 1 overview of level of proper handwashing knowledge among elementary schoolchildren knowledge frequency percentage good 4 4.04 moderate 51 51.52 poor 44 44.44 total 99 100 table 2 questionnaire results for level of proper handwashing knowledge assessment no questionnaire adequate inadequate f % f % 1 like to wash hands 99 100.00 0 0.00 2 learn to wash hands from 95 95.96 4 4.04 3 frequency of handwashing 4 4.04 95 95.96 4 handwashing performed before and after 0 0.00 99 100.00 5 reason for washing hands 96 96.97 3 3.03 6 benefit of handwashing 56 56.57 43 43.43 althea medical journal. 2016;3(2) 172 amj june 2016 1). furthermore, based on the result of level of proper handwashing knowledge assessment, it showed that all elementary schoolchildren in jatinangor performed handwashing. however, 43% of the respondents did not know the benefits of handwashing (table 2). moreover, only 34,34% of the respondents had good handwashing practices while the other 65,66% had poor practices of proper handwashing (table 3). based on the result regarding handwashing practices among elementary schoolchildren through assessing the steps during handwashing, it showed that all respondents or 100% were always rubbing the back of their hands. meanwhile, as many as 58.59% did not scrub under the nails and 19.19% did not apply soap (table 4). discussion this study demonstrated a moderate level of knowledge regarding proper handwashing among elementary schoolchildren. however, this study also showed that most children had poor practice of handwashing. regarding the first question, most children answered yes, when asked if they performed handwashing. while a small number answered only sometimes, the researcher accepted this answer as adequate as a person’s likes and dislikes are the nature of a person. the study found that most schoolchildren stated parents as their source of knowledge for learning handwashing however; some also added that doctors and teachers had taught them. this showed the importance of role model figures within a community in promoting good health practices. moreover, parents, close family members and teachers play the most important role as schoolchildren spend most of their time at home and in school. those whom were unable to answer this question probably lacked the role model figures in their upbringing, thus affecting their knowledge. the answers on how often schoolchildren washed their hands a day, showed that the majority washed their hands less than 8 times a day. based on the interpretation of cdc’s criteria3 when handwashing should be carried out, a person should wash hands at least 8 times a day, considering that handwashing should be table 3 overview of level of practice regarding proper handwashing practice frequency percentage good 34 34.34 poor 65 65.66 total 99 100 table 4 handwashing practice performed by schoolchildren no step by step handwashing practices yes no f % f % 1 wet hands with running water 98 98.99 1 1.01 2 apply soap 80 80.81 19 19.19 3 lather hands 99 100.00 0 0.00 4 rub back of hand 99 100.00 0 0.00 5 rub between fingers 98 98.99 1 1.01 6 scrub under nails 41 41.41 58 58.59 7 perform steps 4-6 for both hands 34 34.34 65 65.66 8 scrub for 20 seconds 94 94.95 5 5.05 9 rinse under running water 96 96.97 3 3.03 10 dry hands using clean towel 97 97.98 2 202 althea medical journal. 2016;3(2) 173 carried out at least, before and after each meal, and after using the toilet. even though cdc did not specify washing hands after a meal, in this study it was taken into consideration as most indonesian people eat with their hands. therefore, washinghands after meals should be accounted for in the frequency of handwashing a day. the data showed that many schoolchildren did not wash their hands as often as they should. those who did not wash their hands at least 8 times a day were considered to have inadequate knowledge. the study also found that most children washed their hands before and after meals but only a small group reported washing their hands after hands were visibly dirty, after using the toilet, and on top was washing their hands before and after meals. while all answers might be correct, the researcher considered the answers to be inadequate. according to cdc’s specific activities which required handwashing are: the respondents should wash their hands before meals, after using the toilet, after playing and whenever their hands are visibly dirty, at the very least.3 additionally, most schoolchildren knew the reasons for washing their hands. their answers were considered to be adequate in this study. however, when asked about the benefits of handwashing, almost half of them were unable to answer. the study found that despite having a moderate level of knowledge regarding handwashing, the schoolchildren had poor handwashing practices. most of them did not perform the handwashing steps correctly; they especially omitted scrubbing under their nails. this condition was supported by observation findings which discovered that 28.28% of respondents had fingernails that were mostly dirty and long, while another 7.07% had short but dirty fingernails. even, if handwashing was performed frequently, these children with dirty fingernails were still at risk of getting ill due to dirt under their nails. therefore, educating children to keep their nails short is an important step. scrubbing under their nails each time they wash their hands can help remove dirt and especially reduce parasitic infections.1,9 there were also a notable number of schoolchildren who did not apply soap and some did not wash their hands for at least 20 seconds. some did not rinse their hands and few did not dry their hands with a towel. these findings could be due to lack of handwashing resources in their homes and schools such as soap and hand towel for drying their hands.10 further factors that could influence the schoolchildren’s handwashing practices include poor facilities within school compounds.11 the schools did not have a canteen or a proper place for the schoolchildren to eat during their break time. if such a place was provided with handwashing facilities, it can motivate and encourage more children to wash their hands frequently and at appropriate times.12 from observations conducted in this study, the schools did not have clean toilets and proper handwashing facilities. this could be a factor that hinders schoolchildren from carrying out better handwashing practices.12 adequate water and sanitation as part of a healthy school environment can significantly improve a child’s prospects to progress and flourish.13 based on the analysis of data and discussions, the conclusion that can be made is that most of the elementary schoolchildren in jatinangor, as many as 52% has moderate level of knowledge regarding proper handwashing and as many as 66% performs poor practices regarding proper handwashing. there were some limitations that the researcher encountered during this study. the researcher was unable to conduct individual interviews with the respondents as most respondents were very shy and preferred to write their answers in the questionnaire. the questionnaire also should contain more questions to enhance measuring the knowledge and practice of handwashing among schoolchildren. based on this study, the government should encourage handwashing resources and facilities at homes and in schools. handwashing practices could also be instilled by integrating handwashing education in schools as a part of extra-curriculum activities. additionally, teachers should encourage handwashing practices in schools through peer-to-peer education, since teachers play an important role in instilling good handwashing practices as children spend many hours each day in school.14 as a whole, handwashing practices should be promoted through various health and community programs for schoolchildren and their families and thus, help improve the health status in communities.15 references 1. centers for diseases control and prevention.vessel sanitation program: general information on hand hygiene. national center for environmental health, cheryl may chong sue faye, chrysanti murad, sharon gondodiputro: handwashing among schoolchildren in jatinangor, west java althea medical journal. 2016;3(2) 174 amj june 2016 division of emergency and environmental health services: atlanta, usa; 2009. 2. bauman rw. microbiology: with diseases by body system. new york, usa: pearson; 2012. 3. centers for diseases control and prevention. handwashing: clean hands save lives. cdc: atlanta; 2013. 4. tambekar d, shirsat s. hand washing: a cornerstone to prevent the transmission of diarrhoeal infection. asian j med sci. 2009;1(3):100–3. 5. rabie t, curtis v. handwashing and risk of respiratory infections: a quantitative systematic review. trop med int health. 2006;11(3):258–67. 6. burton m, cobb e, donachie p, judah g, curtis v, schmidt wp. the effect of handwashing with water or soap on bacterial contamination of hands. int j environ res public health. 2011;8(1):97– 104. 7. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. hasil riset kesehatan dasar (riskesdas) 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri ; 2013. 8. arikunto pds. prosedur penelitian: suatu pendekatan praktik. revision ed. jakarta: rineka cipta; 2010. 9. shrestha a, narayan k, sharma r. prevalence of intestinal parasitosis among school children in baglung district of western nepal. kathmandu univ med j (kumj). 2012;10(37):62–5. 10. saboori s, greene le, moe cl, freeman mc, caruso ba, akoko d, et al. impact of regular soap provision to primary schools on hand washing and e. coli hand contamination among pupils in nyanza province, kenya: a cluster-randomized trial. am j trop med hyg. 2013;89(4):698–708. 11. setyautami t, sermsri s, chompikul j. proper hand washing practices among elementary school students in selat subdistrict, indonesia. j pub health dev. 2012;10(2):3–20. 12. jasper c, le t-t, bartram j. water and sanitation in schools: a systematic review of the health and educational outcomes. int j environ res public health. 2012;9(8):2772–87. 13. bowen a, agboatwalla m, luby s, tobery t, ayers t, hoekstra rm. association between intensive handwashing promotion and child development in karachi, pakistan: a cluster randomized controlled trial. arch pediatr adolesc med. 2012;166(11):1037– 44. 14. rosen l, zucker d, brody d, engelhard d, manor o. the effect of a handwashing intervention on preschool educator beliefs, attitudes, knowledge and self-efficacy. health educ res.2009;24(4):686–98. 15. luby sp, agboatwalla m, feikin dr, painter j, billhimer w, altaf a, et al. effect of handwashing on child health: a randomised controlled trial. lancet. 2005;366(9481):225–33. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 34 amj march 2016 relationship between short term memory and cardiopulmonary fitness of administrative officers at universitas padjadjaran iswaran ampalakan,1 ambrosius purba,2 sunaryo b. sastradimaja3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilition, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: the work of administrative officers depends a lot on their capability in memorizing. increased fitness is strongly associated with a better memory. this study was conducted to determine the relationship between cardiopulmonary fitness and short term memory. methods: this analytical cross sectional study was carried out from august to september 2014. subjects from administrative offices within universitas padjadjaran were chosen by simple random sampling. 101 individuals were selected, comprising of 68 males and 33 females. data were obtained through digit span test for short term memory and the cardiopulmonary fitness was measured using harvard step test. the vo2 max obtained was correlated with the digit span test score. results: the mean for cardiopulmonary fitness of males was found to be 36.1, with standard deviation 8.63, whereas mean cardiopulmonary fitness for females was found to be 32.94, with standard deviation 7.5. for correlation analysis, the result of spearman’s rank analysis from the study showed that the p-value is 0.00. comparing to the significance level α=5%, the p value is worth less, thus the null hypothesis, ho is rejected. therefore, it could be concluded that there was a relationship between cardiopulmonary fitness and short term memory of male and female administrative officers at universitas padjadjaran. conclusions: there is a relationship between cardiopulmonary fitness and short term memory of male and female administrative officers at universitas padjadjaran. [amj.2016;3(1):34–7] keywords: administrative officers, cardiopulmonary fitness, short term memory correspondence: iswaran ampalakan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822004607 email: jhothiesvaren95@gmail.com introduction in today’s modern society, our daily routine is very much determined by administrative officers. every day, it can be seen that not every administrative officer has the same efficacy when it comes to getting the job done. some are much more diligent, yet some are just much sloppier. there are two possibilities that might be able to explain the reason behind this difference in behavior. one such reason is the individual’s attitude, while the other is being a physiologic explanation. this study is conducted to determine the existence of a physiologic explanation. physical fitness plays an important role in maintaining an optimum function of the human body. the cardiopulmonary system and nervous system, along with the network of blood capillaries function more effective with an increased level of physical fitness.1 increased physical fitness is associated with an increased short term memory, increased reaction time, decreased anxiety and also decreased stress levels.2 the human brain, capability of cognitive function is what makes all daily tasks possible. it keeps us alert and enables us to process information and make decisions.3 attention and short term memory are a core part of the brains cognitive function. two parts of attention helping the formation and storage of short term memory are protection and prioritization. protection, as its name implies, protects the memory from being degraded. this enables the information said to be recalled again. prioritization on the other hand, gives “importance” to the certain althea medical journal. 2016;3(1) 35 information, which then makes this particular information to be stored with higher priority when it is compared to other information.4 there are three theories which support the fact that exercise affects cognitive function. these theories are increased blood flow and angiogenesis which leads to increased oxygen saturation, increase in brain neurotransmitters which facilitate information processing, and regulation of neurotrophins such as brain derived neurotrophic factor (bdnf).5,6 many previous studies have compared the positive effects of fitness on cognitive function, which showing promising results.7,8 it also proved that older adults were less likely to develop dementia, if they exercised at least three times a week, thus, proving and association between exercise and cognitive were decline.9,10 by doing this research, the results may create the awareness about the importance of exercise. hopefully, the stigma that exercise is only good for physical health can be corrected by providing valid proof that exercise is beneficial to both physical and mental health. this may help to create a more holistic and healthy individuals within the society. besides, the results of this research may also provide the information for the decision makers that physical activity can influence the level of short term memory. methods this cross-sectional study was conducted from august to september 2014, after obtaining clearance from the health research ethics committee, faculty of medicine, universitas padjadjaran. participants were selected based on simple random sampling method. a total 130 individuals were interviewed during this study. there were 20 individuals who refused to take part into this study, while 2 individuals dropped out from the study because they could not complete the inclusion criteria and 1 individual was excluded due to exclusion criteria. administrative officers with a high school background within the age group 30–60years old were in the inclusion criteria. however, respondents currently or previously diagnosed with heart condition, psychological condition and/or neurodegenerative disorder were excluded as per exclusion criteria. later, 6 individuals were excluded from this study due to unsuccessful completion of the harvard step test. respondents’ name, age, gender, address, vo2 max and digit span test score were recorded down throughout the study. harvard step test was used to determine the cardiopulmonary fitness of participants. the astrand ryhming nomogram was then used to estimate vo2 max from the result of harvard step test. for male subjects within the age group 30–39 years old, cardiopulmonary fitness was considered to be ‘fair’ if the score was 23–30, ‘average’ if the score was 31–38, ‘good’ if the score was 39–48 and high if the score was more than 49. for male subjects within the age group 40–49 years old, cardiopulmonary fitness was considered as fair if the score was 20–26, average if the score was 27–35, good if the score was 36–44, and high if the score was above 45. for male iswaran ampalakan, ambrosius purba, sunaryo b. sastradimaja: relationship between short term memory and cardiopulmonary fitness of administrative officers at universitas padjadjaran table 1 characteristic of respondents characteristic frequency, n percentage, % gender male 68 67 female 33 33 age interval 30–39 years old 53 52 40–49 years old 43 43 50–59 years old 5 5 vo2 max score fair 23 23 average 33 33 good 32 32 high 13 12 althea medical journal. 2016;3(1) 36 amj march 2016 subjects within the age group 50–59 years old, cardiopulmonary fitness was considered as fair if the score was 18–24, average if the score was 25–33, ‘good’ if the score was 34– 42 and ‘high’ if the score was above 43. as for the female subjects within the age group of 30–39 years old, cardiopulmonary fitness was considered as fair if the score was 20–27, average if the score was 28–33, good if the score was 34–44 and high if the score was more than 45. female subjects within the age group 40–49 years old were considered to have a fair cardiopulmonary fitness if the score was 17–23, average if the score was 24–30, good if the score was 31–41, and high if the score was above 42. in addition to that, digit span test was used to determine the short term memory of participants. subjects were told a series of eight numbers randomly, and were asked to repeat the numbers in the same exact sequence. each participant was given two attempts. 1 point was given to each number repeated in the correct sequence. the raw score obtained was recorded. to determine the relationship between cardiopulmonary fitness and short term memory, the vo2 max was then correlated with the raw score from digit span test using spss window version 15.0. data were statistically analyzed using spearman’s rank analysis. the result was considered statistically significant when p≤0.05. results majority of the administrative officers, 27 out of all 68, had an average cardiopulmonary fitness. only a small amount of them had a high cardiopulmonary fitness. most of the female administrative officers, 16 out of 33 fall were under the good category. similarly, only a small amount of female administrative officers had a high cardiopulmonary fitness (table 2). the average short term memory score of female administrative officers were higher than male administrative officers. female administrative officers had an average memory score of 8.6, whereas the average memory score was only 7.9 for male administrative officers. it can also be seen that female administrative officers had a higher maximum score when it was compared to male administrative officers (table 3). to determine the relationship between short term memory and cardiopulmonary fitness of administrative officers, spearman’s table 2 cardiopulmonary fitness of administrative officers gender cardiopulmonary fitness mean n std. deviation fair 25.8 15 1.5 average 33.3 27 3.5 male good 41.6 16 3.8 high 50.4 10 3.2 total 36.1 68 8.6 fair 23.8 8 2.6 average 29 6 3.3 female good 36.5 16 3.6 high 46.3 3 0.6 total 32.9 33 7.5 table 3 short term memory score of administrative officers mean n memory score std. deviation minimum maximum male 7.9 68 2.9 3.0 14.0 female 8.6 33 2.6 5.0 16.0 althea medical journal. 2016;3(1) 37iswaran ampalakan, ambrosius purba, sunaryo b. sastradimaja: relationship between short term memory and cardiopulmonary fitness of administrative officers at universitas padjadjaran rank correlation analysis was used in this study. results of the calculation showed that the p-value obtained was 0.000. the test would reject ho if the p-value < α (0.05). when it is compared to the significant value (α) 5%, the p-value was much smaller that ho was rejected. according to that fact there is a relationship between short term memory and cardiopulmonary fitness of administrative officers at universitas padjadjaran. the value of spearman’s rank correlation coefficient (rs) was found to be 0.471 (table 4). discussion the result of this study is slightly stronger than the previous study conducted by walter swardfager et al.11 the correlation coefficient from the previous study was 0.281, while in this study, the correlation coefficient was 0.471. this can be due to several factors. firstly, in the previous study, respondents were patients with coronary artery disease, whereas in this study there were no respondents suffering with any coronary disease at the time. thus, the healthier individuals could provide better results. besides, one of the limitations in the previous study was a smaller sample size, using only 81 patients. however, this study does not have a similar limitation. this is due to the fact that the number of respondents in this study is 101, which is a larger quantity than the minimum sample size required. this gives a more precise correlation between short term memory and cardiopulmonary fitness. however, this study has its own limitations. the number of male respondents in this study outweighs the number of female respondents vastly. a balanced number of respondents between male and female administrative officers was failed to be achieved. this was due to the time constraint in completing this study. if there had been more time, a more precise selection could have been done to achieve a balanced number of respondents between both genders. as a conclusion, this study proves that there is a relationship between cardiopulmonary fitness and short term memory in male and female administrative officers at universitas padjadjaran. it shows that short term memory is better in individuals with higher cardiopulmonary fitness. therefore, based on the results obtained from this study, it is recommended that all administrative officers maintain a healthy lifestyle with proper physical activity. this way, they will be able to maintain, or even improve their short term memory. references 1. wisloff u, ellingsen o, kemi oj. highintensity interval training to maximize cardiac benefits of exercise training. exerc sport sci rev. 2009;37(3):139–46. 2. erickson ki, weinstein am, lopez ol. physical activity, brain plasticity, and alzheimer’s disease. arch med sci. 2012;43(8):615–21. 3. barrett ke, barman sm, boitano s, brooks h. ganong’s review of medical physiology, 24th edition, new york: mcgraw-hill; 2012. 4. matsukura m, luck sj, vecera sp. attention effects during visual short-term memory maintenance. percept. psychophys. 2007;69(8):1422–34. 5. erickson ki, voss mw, prakash rs, basak c, szabo a, chaddock l, et al. exercise training increases size of hippocampus and improves memory. proc natl acad sci u.s.a. 2011;108(7):3017–22. 6. ploughman m. exercise is brain food: the effects of physical activity on cognitive function. dev neurorehabil. 2008;11(3):236–40. 7. anderson-hanley c, arciero pj, brickman am, nimon jp, okuma n, westen sc, et al. exergaming and older adult cognition: a cluster randomized clinical trial. am j prev med. 2012;42(2):109–19. 8. chang y, labban j, gapin j, etnier j. the effects of acute exercise on cognitive performance: a meta-analysis. brain res. 2012;1453:87–101. 9. larson eb, wang l, bowen jd, mccormick wc, teri l, crane p, et al. exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. ann intern med. 2006;144(2):73–81. 10. bherer l, erickson ki, liu-ambrose t. a review of the effects of physical activity and exercise on cognitive and brain functions in older adults. j aging res. 2013;2013:657508. 11. swardfager w, herrmann n, marzolini s, saleem m, kiss a, shammi p, et al. cardiopulmonary fitness is associated with cognitive performance in patients with coronary artery disease. j am geriatr soc. 2010 aug;58(8):1519–25. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 492 amj december, 2015 association of obesity, parity, and history of knee injury with knee osteoarthritis in female ade triyadi,1 riardi pramudiyo,2 januarsih iwan a. r.3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology, faculty of medicine, universitas padjadjaran abstract background: osteoarthritis is the most joint disorder among elderly. there are a lot of risk factors of knee osteoarthritis. obesity and high frequent of parity can increase the load on knee joint. knee injury also decreases the stability of knee joint on bearing body load. this study was conducted to observe the association of obesity, parity ≥3 times and history of knee injury with the occurrence of knee osteoarthritis in female aged >50 years old. methods: case control design was chosen in this study. female patients with age >50 years were recruited by consecutive sampling from rheumatology clinic at dr. hasan sadikin general hospital bandung. data were collected from august to september 2013. minimal sample size was 60 samples calculated by rule of thumb formula. obesity was measured by body mass index (bmi). parity and history of knee injury were assessed by questionnaire. those variables were analyzed by logistic regression method. result: obesity did not associate with knee osteoarthritis in this study, p=0.549 (odd ratio (or) 1.32, 95% confidence interval (ci) 0.52–3.32). parity was associated with knee osteoarthritis in this study p=0.001 (or 4.7, 95% ci 1.89–11.68). history of knee injury was associated with knee osteoarthritis in this study, p=0.001 (or 6.19, 95% ci 2.01–18.99). conclusions: parity ≥3 times and history of knee injury were associated with the occurrence of knee osteoarthritis. obesity was not associated with the occurrence of knee osteoarthritis. [amj.2015;2(4):492–6] keywords: knee injury, knee osteoarthritis, obesity, parity correspondence: ade triyadi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285759754147 email: ade3yadi@gmail.com introduction osteoarthritis is the most joint disorder among elderly. worldwide, it is estimated to be the fourth of leading causes of disability.1 weight bearing joint (especially knee joint) is often involved in the disease process. currently, world health organization (who) estimated that 9.6% of male and 18% of female have painful osteoarthritis worldwide.2 in the asia-pacific region, the prevalence of knee osteoarthritis was 7.5% in china, 5.78% in rural india, and 10.20% in bangladesh.3 osteoarthritis has a substantial disease burden and affects quality of life. for instance, 1–2 million elderly in indonesia have disabilities because of osteoarthritis.4 people with osteoarthritis have more difficulties to perform activities of daily living that depend significantly more on family and friends for assistance and spend more money on health care.5 there are a lot of risk factors to develop knee osteoarthritis such as older age, female, genetic susceptibility, race factors, hard worker (high intense to weight bearing work), athlete, knee mal-alignment, knee injury and obesity.6 parity ≥3 times is also a risk factor of knee osteoarthritis.7,8 this study was conducted to observe the association of knee osteoarthritis with obesity, parity ≥3 times and history of knee injury. these risk factors were chosen to be analyzed in this study because mechanical forces exerted on the joint are a significant cause of knee osteoarthritis and one of the most modifiable risk factors. since these factors are modifiable risk factors, the morbidity of knee osteoarthritis will be reduced if these factors can be avoided althea medical journal. 2015;2(4) 493 methods female patients aged >50 years were recruited from rheumatology clinic at dr. hasan sadikin general hospital bandung. data were collected from august to september 2013 and the samples were recruited by consecutive sampling. case control method was chosen as study design. cases were female aged >50 years old, come to clinic and were diagnosed with knee osteoarthritis by physicians. controls selected who come to the clinic but did not diagnose knee osteoarthritis by physician. the inclusion criteria were patients who come to the rheumatology clinic at dr. hasan sadikin general hospital bandung, aged >50 years and female. besides, the exclusion criteria who did not want to participate in this study had genetic susceptibility to osteoarthritis who had history of weight bearing worker or athlete. samples were interviewed using structured questionnaires to determine medical history, including history of knee injury and number of life births. height and weight were measured two times to confirm the result. to determine the risk factor of knee osteoarthritis, only three factors included as independent variable were selected. obesity measured by body mass index (bmi), kementrian kesehatan republik indonesia (kemenkes ri) criteria of bmi was selected in this study. the bmi >27 was defined as obesity.9 parity was classified as woman who has complete ≥3 times pregnancies and woman who has complete <3 pregnancies, which the data were obtained by interview. history of knee injury, the usual characteristic of injury followed by redness, soft tissue swelling, pain over involved joint, fracture of cartilage, and muscle tear at knee joint10 could be defined as criteria, which the data were obtained by interview. sample size was determined by rule of thumb formula. total of independent variables were multiplied by 10. since this study had three independent variables, 30 minimal samples for each case and control were calculated. therefore, 60 samples as total minimal samples were defined in this study.11 since the scales of variables were categorical and all of independent variables were analyzed simultaneously, multivariate logistic regression was used as a statistic analysis in this study. the statistical analysis was adjusted for bmi, parity, and history of knee injury as independent variables towards knee osteoarthritis as dependent variable. significance test (p), odd ratio (or), 95% confidence interval (95% ci), and probability were analyzed by logistic regression. statistic product service solution (spss) version 18 was chosen as statistical program in this study. results from 60 samples as minimal sample size, collecting data in duration about one month had 101 female patients recruited in this study. forty six samples were included into case group, and another 55 samples were referred as control. complete data of bmi, parity, and history of knee injury distributed for each case and control. samples with obesity were higher in the case group, although there was only one table 1 distribution of patients classified by case and control variables osteoarthritis non osteoarthritis (n=46) f (%) (n=55) f (%) obesity yes 26 56 25 45 no 20 44 30 55 parity ≥3 times 27 59 15 27 <3 times 19 41 40 73 history of knee injury yes 17 37 6 11 no 29 63 49 89 ade triyadi, riardi pramudiyo, januarsih iwan a. r: association of obesity, parity, and history of knee injury with knee osteoarthritis in female althea medical journal. 2015;2(4) 494 amj december, 2015 sample difference from control group. parity three times or more and history of knee injury were higher in the group of case (table 1). obesity was not a risk factor of knee osteoarthritis in this study because of (p>0.05). although odd ratio (or) was more than 1, 95% confident interval (ci) reach value 1 meant that obesity was not a risk factor of knee osteoarthritis (or 1.32; 95% ci 0.52–3.32). parity was a risk factor of knee osteoarthritis in this study because of (p<0.05). female aged >50 years with parity ≥3 times had 4.7 fold risk to knee osteoarthritis (or 4.7; 95% ci 1.89–11.68), greater than female aged >50 years with parity <3 times. history of knee injury was a risk factor of knee osteoarthritis in this study because of (p<0.05). female aged >50 years with history of knee injury had risk to knee osteoarthritis elevated at 6.19 fold (or 6.19; 95% ci 2.01– 18.99) compared to female aged 50 years without history of knee injury. probability in this study was calculated based on formula p=1(1+e-y). since obesity was not significant and not included automatically by backward logistic regression program, analysis of probability was only for knee injury and parity towards knee osteoarthritis.11 female aged >50 years with history of parity three times or more and history of knee injury had probability 78% to suffer from knee osteoarthritis. then, female aged >50 years with history parity <3 times and no history of knee injury had probability 10% to suffer from knee osteoarthritis. discussion in this study, with case control design, obesity is not a risk factor of knee osteoarthritis. obesity in this study, according to health state in this country, is classified by bmi >27.9 different with other cohort study in british, 3035 women underwent examination for bmi, measured 10 times from 2−53 years. prolonged exposure with obesity from childhood throughout adulthood carried the highest risk to knee osteoarthritis in elderly.12 result from previous study which was established as literatures stated that obesity is a risk factor of knee osteoarthritis.4-6,13 the reason of the difference with this study result is this study used case control method and had fewer of samples, different sample size was also might considere different result. parity ≥3 times is a risk factor of knee osteoarthritis. the value of or in this study was high concluding that high elevated the risk (or=4.7). for the precision, this result had wide range of 95% ci, concluding that this study had less precision (95% ci 1.89–11.68). although the precision was less, the sample size had complete the minimal requirement (60 samples), instead the samples exceeded the minimal requirement, that was 101 samples. high frequency of parity is associated with decreasing cartilage volume, predominantly in the tibial compartment and more advance cartilage defected in the patella compartment in population based on sample of female aged 50−80 years.8 frequency of parity is associated with increased risk of having patella cartilage defects, with three or more births having a significantly increased risk of prevalent cartilage defects. these results are consistent with findings in older female, suggesting that parity may play a direct role in the development of knee osteoarthitis.7 indirectly, impact of parity had influence table 2 statistical value of knee osteoarthritis risk factors variable β p (sig.) or adjusted 95% ci phase i obesity 0.28 0.549 1.32 0.52 – 3.32 parity ≥ 3 times 1.51 0.001 4.54 1.81 – 11.34 history of knee injury 1.88 0.001 6.57 2.09 – 20.61 constanta β -1.26 phase ii parity ≥ 3 times 1.54 0.001 4.7 1.89 – 11.68 history of knee injury 1.82 0.001 6.19 2.01 – 18.99 constanta β -2.12 notes: β=value of variable; p(sig.)=significance result; or=odd ratio; ci=confidence interval althea medical journal. 2015;2(4) 495 in the loss of cartilage volume, while cartilage volume is important substance to protect joint from knee osteoarthritis. loss of cartilage volume on weight-bearing areas in the knee (especially medial condyle and plateau) was associated with knee osteoarthritis.14 tibiofemoral hyaline articular cartilage loss of volume evidence radiographic joint space narrowing had risk to knee osteoarthritis.15 history of knee injury was a risk factor of knee osteoarthritis in this study. according to this study, all types of knee injury were identified, such as redness, swelling, and pain involving the joint cartilage fracture and muscle tear at knee joint. the value of or in this study was high concluding that high elevated the risk (or=6.19). for the precision, this result had wide range of 95% ci, concluding that this study had less precision (95% ci 2.01–18.99). although the precision was less, the sample size completed the minimal requirement (60 samples), instead the samples exceeded the minimal requirement, that was 101 samples. this study has a similar design to casecontrol study conducted in previous studies. knees with meniscus tears with greater radial involvement and extrusion are at greater risk for later development of knee osteoarthritis.16 this result is the same as previous study which stated that knee injury increases the risk to develop knee osteoarthritis. the metaanalysis with twenty four observational studies (20,997 samples) included seven cohorts, five cross sectional and twelve case control studies. association between history of knee injuries and knee oa was significantly for specified injuries such as inflammation swelling of tissue and redness, ligament or tendon injuries, meniscus damage or menistectomy, and fracture of femur, knee or lower part of the leg (or=5.95, 95% 4.57–7.75).10 this study is limited to sample size which only got 101 samples compared to other studies worldwide that acquired thousands sample size. however, it completed the minimal sample size calculated by rule of thumb method.11 another limitation might occur in case control method, such as recall bias and measurement error. to anticipate that problem, confirmation two times in asking question and measurement of bmi is needed. the strength in this study is all of risk factors which were not analyzed have the same criteria for case and control samples to avoid bias by confounding variable, except for knee malalignment such as varus and valgus. beside of risk factor, it can be caused by knee osteoarthritis chronically; thus, the association between knee osteoarthritis and knee malalignment should not be defined clearly in this study. in conclusion, frequency of life birth ≥3 times and history of knee injury are associated with knee injury. on the contrary, obesity is not associated with knee osteoarthritis. for further study, it needs to identify the obesity in samples that might adjust to lifetime obesity which describes how long the samples have obesity, such as from age groups at teenager or adult with cohort study as established research worldwide. references 1. fansen m, bridgett l, march l, hoy d, penserga e, brooks p. the epidemiology of osteoarthritis in asia. int j rheum dis. 2011;14(2):113−21. 2. white d, editor. public health burden, epidemiology, importance of osteoarthritis as a health issue. proceedings of the 141st american public health association annual meeting; 2013 november 2−6; boston. massachusetts: apha; 2013. 3. zeng qy, zang ch, li xf, dong hy, zhang al, lin l. associated risk factors of knee osteoarthritis: a population survey in taiyuan, china. chin med j. 2006;119(18):1522−7. 4. sudoyo aw, setiyohadi b, alwi i, marcellus sk, setiati s. buku ajar ilmu penyakit dalam. jakarta: interna publishing; 2009. p. 2538−349. 5. peter wl, stephen bz. obesity and osteoarthritis. am j orthop. 2008;37(3):148−51. 6. longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j. harrison’s principle’s of internal medicine. 16th ed. new york: mcgraw-hill medical publishing; 2005. p. 2038−45. 7. wei s, jones g, venn a, cicuttini f, march l, otahal p, et al. the association between parity and knee cartilage in young women. rheumatology (oxford). 2012;51(11):2039−45. 8. wei s, venn a, ding c, martel-pelletier j, pelletier jp, abram f, et al. the associations between parity, other reproductive factors and cartilage in women aged 50−80 years. osteoarthritis cartilage. 2011;19(11):1307−13. 9. kementerian kesehatan republik indonesia. glosarium: data & informasi kesehatan. jakarta: pusat data dan ade triyadi, riardi pramudiyo, januarsih iwan a. r: association of obesity, parity, and history of knee injury with knee osteoarthritis in female althea medical journal. 2015;2(4) 496 amj december, 2015 informasi kementerian kesehatan ri; 2006. 10. muthuri sg, mcwilliams df, doherty m, zhang w. history of knee injuries and knee osteoarthritis: a meta-analysis of observational studies. osteoarthritis cartilage. 2011;19(11):1286−93. 11. dahlan ms. statistik untuk kedokteran dan kesehatan. 4th ed. jakarta: salemba medika; 2009. 12. wills ak, black s, cooper r, coppack rj, hardy r, martin kr, et al. life course body mass index and risk of knee osteoarthritis at the age of 53 years: evidence from the 1946 british birth cohort study. ann rheum dis. 2012;71(5):655−60. 13. soeroso j, dans lf, amarillo ml, santoso g. risk factor of symptomatic and a symptomatic osteoarthritis of the knee. folia medica indonesiana. 2005;41(2):118−29. 14. pelletier jp, raynauld jp, berthiaume mj, abram f, choquette d, haraoui b, et al. risk factors associated with the loss of cartilage volume on weight-bearing areas in knee osteoarthritis patients assessed by quantitative magnetic resonance imaging: a longitudinal study. arthritis res ther. 2007;9(4):r74. 15. amin s, lavalley mp, guermazi a, grigoryan m, hunter dj, clancy m, et al. the relationship between cartilage loss on magnetic resonance imaging and radiographic progression in men and women with knee osteoarthritis. arthritis rheum. 2005;52(10):3152−9. 16. badlani jt, borrero c, golla s, harner cd, irrgang jj. the effects of meniscus injury on the development of knee osteoarthritis data from the osteoarthritis initiative. am j sports med. 2011;41(6):1238−44. althea medical journal. 2016;3(3) 430 amj september 2016 correlation between forced expiratory volume one second and vital capacity with vo2 maximum siti khadijah rahmania,1 tertianto prabowo,2 putri tessa3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: medical students need to cope with their tight schedule, which also demand a good physical fitness to do those activities. insufficient leisure time and exhausting activities impede students’ capacity on having routine physical exercise to maintain their physical fitness. cardiopulmonary endurance describes a person physical fitness level, and lung function is one basic component of cardiopulmonary endurance. without optimal lung function, circulatory system in the body cannot work properly. this study aimed to determine whether lung function giving a significant correlation with the cardiorespiratory endurance which are measured by forced expiratory volume one second (fev1), vital capacity (vc), and vo2maximum (vo2max), respectively. methods: this study was conducted in september–october 2013 to the students of faculty of medicine at universitas padjadjaran academic year 2010–2012, using the cross-sectional method. sample was taken through simple random sampling process. there were 34 male and 34 female students after controlling for covariates. direct measurement using spirometer used to determine lung function and maximum oxygen uptake was measured by assessing rhyming step test result. correlation coefficient was then calculated by pearson correlation test. results: the correlation between fev1with vo2max of male students giving a value of p=0.442, while for vc obtained a value of p=0.259. female students result giving a value of p=0.746 for the fev1with vo2max, and p=0.489 for the vc with the vo2max. conclusions: there is no significant correlation between fev1 and vc with the vo2max of the respondents. [amj.2016;3(3):430–3] keywords: forced expiratory volume one second, maximum oxygen uptake, vital capacity correspondence: siti khadijah rahmania, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282120887117 email: skrahmania@gmail.com introduction cardiopulmonary endurance defined as the ability of the circulatory system, respiration, and muscles to deliver oxygen and nutrients efficiently into cells through the bloodstream during a constant physical activity.1 the vo2 maximum (vo2max) is one of the indicators in measuring the resistance level of the heart and lung which could determine a person’s physical fitness. the result of vo2max affected by oxygen transport capability, power of cardiac pumping, pulmonary ventilation, and the use of oxygen in the muscles.2 one basic component of cardiopulmonary endurance itself is the lung function. lung function at a young adult age, can predict airway obstruction in 20 years ahead.3 recent international survey identified an airway obstruction on nearly 4% of young adults aged 20–44 years.4 lung function is associated with respiratory processes, one of them is pulmonary ventilation. to keep the body work normally, it takes the optimal work of the heart and lungs.2 cardiopulmonary endurance requires a synchronized work between circulatory and respiratory systems. in regards to the lung function as the basic component of cardiopulmonary endurance itself, however, it is still quiet questionable about its significant correlation. as we know that there is another influencing factors related with person’s cardiopulmonary endurance which might giving more impact on the outcome. the pulmonary function, also has some determining components. for example, althea medical journal. 2016;3(3) 431 some of its important factors are lifestyle and physical activity. according to prakash et al.5 people with sedentary lifestyles have lowest pulmonary function. sedentary lifestyle is also associated with development of restrictive lung function and cardiovascular morbidity. improvement in pulmonary functions is noticed as a result of physical activity.6 this study aimed to determine whether lung function giving a significant correlation as one of the factors which underlie the cardiorespiratory endurance. those are measured by forced expiratory volume one second (fev1) and vital capacity (vc) to assess the pulmonary ventilation , and vo2 maximum (vo2max) for the cardiorespiratory fitness. methods this study has been approved by health research ethics and carried out from september until october 2013, where the samples were students of faculty of medicine at universitas padjadjaran academic year 2010–2012. the samples were taken by simple random sampling method. after meeting the inclusion criteria, student who had a good vital sign, body mass index (bmi) between 18.5–23 kg/m2, was not an active smoker, and ready to follow the study by filling the informed consent was participated in the study. student who could not attend the examination was excluded from the study. total number of samples for this study were 68 students, which consist of 34 females and 34 males. as this analytical study could obtain the data within one time measurement, the data was collected with cross-sectional design. lung function which represented by the fev1 and vc measured using spirometry method and vo2 maximum was determined using the astrand rhyming step test method.7 the data was analyzed through statistical tests to determine the correlation coefficient, calculated using statistical product and service solutions 15.0. by shapiro-wilk normality test and pearson correlation test. results among male subjects, 33 students showed a normal category of lung function, only 1 student had mild obstructive category. as many as 4 males showed the maximum vo2 values in the low category, 4 males is quite table 1 characteristic of the subjects mean (x) standard deviation (± sd) male (n= 34)* age 20 years 1.07 height 170.5 cm 4.90 weight 62 kg 5.97 bmi** 21.3 kg/m2 1.53 fev1*** 3462 ml/s 494.14 vc# 3853 ml/s 607.31 vo2 maximum 51.91 ml/kg/m 14.05 female (n= 34)* age 20 years 1.10 height 157.9 cm 4.71 weight 51 kg 5.24 bmi** 20.5 kg/m2 1.79 fev1*** 2338 ml/s 430.70 vc# 2653 ml/s 366.32 vo2maximum 46.01 ml/kg/m 10.87 note: *n=number of subjects,**bmi=body mass index, ***fev1=forced expiratory volume one second, #vc=vital capacity althea medical journal. 2016;3(3) 432 amj september 2016 table 2 correlation between fev1 and vc to the vo2 maximum vo2 maximum r (correlation coefficient) p (sig. 2 tailed)* male fev1 0.136 0.442 vc 0.199 0.259 female fev1 0.058 0.746 vc 0.123 0.489 note: *p value <0.05 giving significant correlation low, 12 medium, 4 high, and 10 very high. on the female subject, 32 students had normal category of lung function, and 2 students had mild obstructive category. as many as 5 females showed a quite low maximum vo2maxvalues, 10 moderate, 6 high and 13 very high. as the standard of lung function values (fev1 and vc) and cardiorespiratory endurance (vo2max) is difference between male and female, the correlation analysis will be separated by gender. age of the subjects ranged from 17 to 22 years old with the mean age 20 years old. each subject had a normal category of bmi, and the mean of vo2max was above the average value for each gender classification (table 1). it could be concluded that correlation between fev1 with vo2max in both male and female students result did not have a significant correlation (obtained a value of p=0.442 and p=0.746). there was also no significant correlation between vc with vo2max in both male and female students result (obtained a value of p=0.259 and p=0.489) (table 2). discussion gender was considered to be the risk factor as the result given, it is concluded that lung function does not contribute a significant correlation with the cardiopulmonary fitness, and other several factors must be taken into consideration. for example; the physical factors (age, height, weight, sex and body size), genetic, physical exercise, environment, diet and smoking.11,12 there are several factors that could not be controlled in this study which are genetic factors, environment and diet. thus, these uncontrolled factors can be biased the result and affected the outcome. the circulation system components such as oxygen carrying capacity, the heart pumps and the use of oxygen in the muscle might have a greater influence to the vo2max.1 based on doewes13 research about the most dominant contribution factor of body systems to the physical fitness, it is said that the respiratory system only contributed the effective contribution of 12.32% compared to 36.97% for the cardiovascular system and 49.29% oxygen carrier systems. the result was supported by the study conducted by charususin10 which stated that physical activity level as one of the determining factors on physical fitness, had no correlation with pulmonary function. the range of bmi on the subject have been grouped to matched the category of normal weight to minimize the bias, but the height and weight variations could still affect the results of cardiopulmonary fitness. the gender factor was also has been distinguished. lung function which was measured by fev1 and vc also had several influencing factors. the form factor is the anatomy of the body height and weight, the position for measurement of pulmonary function, respiratory muscle strength, also the lung and chest muscle development.8 some factors that could affect the vc are age, gender, physical exercise, pregnancy, and pathological state.9,10 spirometry results are also dependent to subjects’ effort and consistency. therefore, respiratory muscle strength and the range of respondent’s physical exercise must be taken into consideration. other limitations in this study included the time of measurement in the subjects. in relation to the academic schedule differences between subjects, the researcher’s ability to take the data could not be measured in the same day. according to some experimental studies about the effect of diurnal variation althea medical journal. 2016;3(3) 433siti khadijah rahmania, tertianto prabowo, putri tessa: correlation between forced expiratory volume one second and vital capacity with vo2 maximum in relation to circadian rhythm, it is suggested that vo2 responses are affected by the time of day and could be related to variability in muscle activity pattern. the time-of-day effect on performances is giving a better aerobic participation in energy production during afternoon than in the morning.14–16 therefore, the researcher suggests to measure subjects’ vo2 maximum in the same time to minimize the bias. statistical test results showed that lung function (fev1 and vc) had no significant correlation to the level of cardiorespiratory endurance (vo2max) in both male and female subjects. in a correlative analytical research, the sample size greatly affected the results of the correlation coefficient. in addition, the variability of the data was also one of the factors that can give significant correlation of coefficient results. in this study, the distribution of the data might not have a good variability due to sample size and the results were less centrally within normal values. those discussions above might be the reason why there was no significant correlation between fev1 and vc with the vo2max. therefore, further research with more precise measurement is needed. some other influencing factor might be giving a significant correlation to the cardiopulmonary endurance. references 1. lee d, arteroeg, sui x, blair sn. review: mortality trends in the general population: the importance of cardiorespiratory fitness. j psychopharmacol. 2010;24(4 suppl):27–35. 2. plowman sa, smith dl. exercise physiology for health, fitness, and performance. 2nd ed. philadelphia: wolters kluwer health/ lippincott williams & wilkins; 2008. p. 383–408. 3. kalhan r, arynchyn a, colangelo la, dransfield mt, gerald lb, smith lj. lung function in young adults predicts airflow obstruction 20 years later. am j med. 2010;123(5):468. e1–7. 4. de marco r, accordini s, cerveri i, corsico a, sunyer j, neukirch f, et al. an international survey of chronic obstructive pulmonary disease in young adults according to gold stages. thorax. 2004;59(2):120–5. 5. prakash s, meshram s, ramtekkar u. athletes, yogis and individual with sedentary lifestyles; do their lung function differ?. indian j physiol pharmacol. 2007;51:76–80. 6. fatima ss, rehman r, saifullah yk. physical activity and its effect on forced expiratory volume. j pak med assoc. 2013;63(3):310– 2. 7. balai kesehatan olahraga masyarakat. prosedur pengukuran rhyming step test bangku astrand. bandung, jawa barat: bkom;2003. 8. guyton ac, hall je. textbook of medical physiology. philadelphia, pennsylvania: elsevier inc; 2006.p. 471–82. 9. chakrabarty as, chakrabarty k. fundamentals of respiratory physiology. new delhi: i.k. international publishing house pvt. limited; 2007.p. 1–21. 10. pal gk. textbook of practical physiology. 2nd ed. chennai: orient black swan; 2006.p. 138–154. 11. noppawan c, suwannee j, pipop j, saipin p. the pulmonary function and respiratory muscle strength in thai obese children. siriraj med j. 2006;59:125–130. 12. sagiv ms. exercise cardiopulmonary function in cardiac patients. london: springer; 2012.p. 1–55. 13. jayaprakash cs. sports medicine. new delhi, india: jaypee brothers, medical publishers; 2003.p. 174–9. 14. doewes m, kiyatno, suradi. kontribusi sistem respirasi terhadap vo2 maks. j respir indo. 2011;31(1):10–3. 15. souissi n, bessot n, chamari k, gauthier a, sesboüé b, davenne d. effect of time of day on aerobic contribution to the 30-s wingate test performance. chronobiol int. 2007;24(4):739–48. 16. brisswalter j, bieuzen f, giacomoni m, tricot v, falgairette g. morning-toevening differences in oxygen uptake kinetics in short-duration cycling exercise. chronobiolint. 2007;24(3):495–506. 17. mosavi ss, nejati mm, akaberi s, jamaat k, nazari m, eghbalmoghanlou a. effect of time of day on aerobic responses with high intensity exercise in volleyball players euroj exp bio. 2012;2(4):872–74.. althea medical journal. 2015;2(2) 262 amj june, 2015 incidence of dengue hemorrhagic fever related to annual rainfall, population density, larval free index and prevention program in bandung 2008 to 2011 anggia karina,1 sri yusnita irda sari,2 h. uun sumardi,3 elsa pudji setiawati2 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: dengue hemorrhagic fever (dhf) remains one of health problems in all provinces in indonesia including west java. bandung as the capital of west java province has dengue prevalence that is above the average prevalence of all provinces. this study aimed to describe the pattern of dengue incidence rate, annual rainfall, population density, and larval free index as well as the implementation of prevention program in sub-districts with the highest incidence rate in bandung between 2008 and 2011. methods: a descriptive retrospective study was conducted in september 2012 using secondary data during the period of january 2008 to december 2011. the incidence rate was calculated based on dhf patients who live in bandung. data were analyzed using computer and arc view 3.3. pattern of incidence rate was characterized with red, yellow, and green region respectively. results: the highest incidence rate of dhf occurred in 2009. incidence increased in january to february and declined in the end of the year. subdistricts with highest incidence had no highest annual rainfall and the population density below the average of population density in bandung. the highest implementation of fogging program was not only performed in high incidence subdistricts but also in area with larval free index less than 95%. larval free index in subdistricts with highest incidence were not all below 95%. conclusions: incidence of dhf increases after months of highly rainfall. the pattern of incidence rate in all subdistrict is dynamic and suspected do not related to annual rainfall, population density, high larva free index, and frequency of fogging. [amj.2015;2(1):262–7] key words: dengue hemorrhagic fever, fogging, incidence, population density, rainfall. correspondence: anggia karina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282116826465 email: anggia.karina@yahoo.com introductions dengue hemorrhagic fever (dhf) is one of public health issues that becomes an international health problem. the spread of dengue has greatly increased since the last 30 years.1 back in 1970, it was only nine countries which reported dengue case. currently, it was estimated that arround 100 countries in tropical and subtropical climate known as endemic areas. approximately, 40% of the world’s population are at risk for dengue virus. from the total population in southeast asia, 87% are at risk of dengue.2,3 indonesia is a country in southeast asia included in dengue endemic areas. in 2006, indonesia had the highest incidence of dhf in southeast asia.4 since first discovered in 1968 in surabaya, dhf cases in indonesia have been increasing. nowadays, all provinces in indonesia have reported dengue cases. based on the reports of the indonesian ministry of health in 2009, it was noted that west java province was region with the highest number of dengue cases.5 basic health research survey in west java province in 2007 showed the prevalence of dengue in bandung, which is the capital of west java province, was above the average prevalence of all provinces.6 several factors which affect the increase and spread of dengue cases are high rate of population growth, unplanned and uncontrolled urbanization and lack of effective vector control in endemic areas. morbidity and mortality from viral infection are also influenced by other factors such as host immunity, density of vector mosquitoes, dengue virus virulency and local geographical conditions. pattern outbreak of dengue virus infection is also influenced by climate and althea medical journal. 2015;2(2) 263 humidity, where the hot temperatures (28– 32 degree celcius) and high humidity is an intermediate vector of dengue virus in order to stay alive.5 climatic factors and population density in bandung might affect the presence of mosquito as the vector for dengue transmission.6 the incidence of dhf patients is estimated to increase especially after flood and climatic changes. this leads to a large number of water shelters as puddles, in bottles, cans and other water reservoir which are close to settlement.5 this kind of fresh water shelters are good place for dengue vector breeding.7 this study aimed to describe the pattern of dengue incidence rate, average rainfall, and population density, as well as the implementation of prevention program in subdistricts with the highest incidence rate in bandung between 2008 and 2011. methods a descriptive retrospective study was conducted using secondary data which were obtained from bandung health office and health research unit in faculty of medicine, universitas padjadjaran. data of dhf patients were obtained from routine report in all subdistricts in bandung during the period of january 2008 to december 2011.12–15 the incidence rate was calculated based on new cases of dhf patients who live in bandung and were reported in primary health centers and figure 1 dhf incidence monthly in bandung during the period of 2008 to 2011 figure 2 average of rainfall in bandung during the period of 2008 to 2011 anggia karina, sri yusnita irda sari, h. uun sumardi, elsa pudji setiawati: incidence of dengue hemorrhagic fever related to annual rainfall, population density, larval free index and prevention program in bandung 2008 to 2011 althea medical journal. 2015;2(2) 264 amj june, 2015 hospitals in bandung. data were processed using computer and arc view geographic information system 3.3 then presented as tables, graphics and mapping based on subdistrict. in the mapping of incidence rate distribution each year was divided into 3 areas. red regions showed high incidence, yellow regions showed moderate incidence, while green regions indicated low incidence. the determination of this region was obtained from the calculation of the highest and lowest incidence from all subdistricts, then divided into 3 groups results incidence rate of dhf in bandung was fluctuated during the period of 2008 to 2011 with the highest incidence occurred in 2009. incidence rates of dhf during 2008 to 2011 (per 100.000 people) were 179, 277, 143 and 162, respectively. the highest incidence rate between 2008 to 2010 occurred in february, however in 2011 it occurred in january. the lowest incidence rate between 2008 to 2010 occurred in december, however in 2011 it occurred in january. the pattern of dhf incidence rate in bandung increased from january to february and declined at the end of the year, (figure 1). the highest rainfall in bandung during the period of 2008 to 2011 occurred in december, november, february and april, while the lowest rainfall occurred in july, august, april, august, respectively. the pattern of rainfall in 2008, 2009, and 2011 looked similar, which increased at the end of the year starting from october to december and declined in the midyear starts from june to september. however, in 2010, the rainfall patterns seemed different, where fluctuations occured throughout the year (figure 2). figure 3 mapping of dhf incidence in bandung during the period of 2008 to 2011 althea medical journal. 2015;2(2) 265anggia karina, sri yusnita irda sari, h. uun sumardi, elsa pudji setiawati: incidence of dengue hemorrhagic fever related to annual rainfall, population density, larval free index and prevention program in bandung 2008 to 2011 table 1 implementation of fogging in bandung during the period 2008 to 2011 highest lowest frequency subdistrict frequency subdistrict 2008 74 coblong 8 cinambo 2009 133 coblong 6 cinambo 2010 95 coblong 9 andir 2011 25 coblong 1 bandung kulon distribution of dhf incidence in bandung for the past 4 years showed a dynamic pattern. in the year 2008 to 2010, showed similar pattern, which the subdistricts with high incidence were exist in particular area, yet in the year 2011 the distribution dramatically change (figure 3). from 30 subdistricts, there were 4 subdistricts that always be categorized as high incidence between 2008 to 2011 namely sukajadi, sukasari, lengkong, and bandung wetan. the highest frequency of fogging in 2008 to 2011 implemented in coblong, where this subdistrict in the year of 2008 to 2010 was classified as high incidence area, although in the year of 2011, incidence rate in coblong was categorized as moderate. the lowest and highest frequency of fogging in bandung between 2008 to 2011 are showed in table 1. the highest incidence between 2008 to 2011 happened in subdistrict in bandung wetan in 2009 (ir: 786.6/100,000). during those periodes, high incidence rate neither followed by high population density nor high rainfall. even so, high incidence rate in the year 2009 was followed by low larval free index (lfi) while in other years lfi were above 95%, (table 2) discussions incidence rate of dhf in bandung between 2008 to 2011 experienced fluctuation every year. the highest incidence rate was found in year 2009 (ir: 276.6/100,000). this result shows that incidence rate in bandung is much higher compared to incidence rate in indonesia (ir: 66.83/100,000) according to data published by who.8 surveillance and data centre of indonesian ministry of health stated that in the year of 2009, west java province was one of the high risk area for dhf (ir: 89.41/100,000). it showed that dhf incidence rate in bandung which is the capital city of west java was higher than the incidence rate of west java province. it probably was influenced by the ease of access to healthcare centers and also the higher level of knowledge about dhf compared to other regions that made the cases better recorded in bandung.9 from the result of this study, dhf incidence rate in bandung for each month between 2008 to 2011 has similar pattern which raise in certain months. the highest incidence of dhf between 2008 to 2010 happened in february, while in 2011 happened in january. the table 2 relation of rainfall, population density and dhf prevention program in subdistrict with highest incidence highest incidence rainfall (mm) sub-district ir / 100.000 population density (people/ km2) larval free index (%) frequency of fogging 2008 163.8 lengkong 469.6 11,762 97.05 69 2009 159.6 bandung wetan 786.6 9,523 93.18 54 2010 307.8 bandung wetan 419.4 8,793 98.70 27 2011 139 buah batu 424.3 11,768 97.00 24 althea medical journal. 2015;2(2) 266 amj june, 2015 incidence pattern shows the same pattern with the who where dhf incidence in indonesia tends to raise in january and february.7 dhf incidence rate per month raise after months of highly rainfall. this study also shows similar pattern with the who searo, in which the research in jakarta from 2002 to 2006 showed that dhf incidence rate raised after high rainfall with the peak of 9 weeks after.10 mapping of dhf incidence from all subdistricts in bandung between 2008 to 2011 emerges a dynamic pattern. this can happen because many factors can influence dhf case in a region, just as stated in dhf bulletin published by the indonesian ministry of health where dhf can be affected by high population mobility and also adequate transportation in several regions.9 fogging is one of the government prevention program to eliminate dhf. the highest frequency of fogging is implemented in high incidence subdistrict during the period of 2008 to 2010. however, in the year 2011, fogging was not only implemented in high incidence subdistricts but also in area with larval free index less than 95%. this is according to the procedure of fogging and indicates that government already has a great response. the success of community participation in dhf prevention program is indicated by lfi which is above 95%.9 the average of lfi from all subdistricts in bandung from 2008 to 2011 shows that it reached above 95% only in 2008 in 2010, the average of larval free index reached the lowest point, nevertheless the incidence rate also reached the lowest point. this can happen because many factors can influence the event of dhf such as transportation facility and high mobility. those factors allow the spread of dhf in living quarters, as reported from a study of dhf risk factor in mojosongo village, boyolali regency, that the sedentary habit in the morning is not a risk factor of dhf.9,11 indonesian ministry of health stated that population density can influence dhf case.9 however, this study shows that subdistricts with the highest incidence rate in bandung during the period of 2008 to 2011 have population density below average of population density in bandung. there are limitations in this study, because it only describes dhf distribution with rainfall and population density. however, the association of those variables are not further analyzed and other factors which might influence dhf case is not explored. data used in this study were secondary data and there was a lack of data especially in rainfall data in december 2011. in conclusion, dhf incidence rate in bandung between 2008 to 2011 is fluctuative with dynamic pattern, and highest incidence occurred in 2009. incidence of dhf tends to be high in the months after highly rainfall (january and february) which then declines in the end of the year. dhf incidence rate distribution in every subdistricts in bandung is not related to population density. the government prevention program of dhf already shows great response. however, public participation to prevent dhf with elimination of breeding sites still has not been optimized yet. it is recommended that bandung health office should increase the effort to prevent dhf especially in subdistricts with high incidence by increasing community empowerment in eliminating breeding sites of dengue vector especially before rainy season. that effort should not be only performed in households, but also in public facilities such as schools or offices. cadre mentoring program is suggested to be conducted by primary healthcare centers. further study is needed to analyze other factors which might affect dhf incidence in bandung. references 1. who. situation of dengue/dengue haemorrhagic fever in south-east asia region. 2007 [cited 2012 march 20]. available from: http://www.searo.who. int/en/section10/section332_1103.htm. 2. who. disease: impact of dengue. [cited 2012 march 20]. available from: http:// w w w. w h o . i n t / c s r / d i s e a s e / d e n g u e / impact/en/ 3. who. situation of dengue/dengue haemorrhagic fever in south-east asia region. 2007. [cited 2012 march 20]. available from: http://209.61.208.233/ en/section10/section332_1098.htm 4. who. reported cases of df/dhf in selected countries in sea region (1985– 2005). 2007 [cited 2012 march 20]. available from: http://209.61.208.233/ en/section10/section332_1101.htm 5. kemenkes ri. waspada demam berdarah dengue. pusat komunikasi publik sekretariat jenderal departemen kesehatan. [cited 2012 march 20]. available from: http://www.depkes.go.id/ index.php/berita/press-release/439waspada-demam-berdarah-dengue.html. althea medical journal. 2015;2(2) 267 6. health research and development office, ministry of health ri. riset kesehatan dasar jakarta: ministry of health ri. 2nd ed. jakarta: health research and development office, ministry of health ri; 2009. 7. hauser k, longo b, jamerson f. harrison’s principles of internal medicine. 16th ed. new york: mc graw-hill; 2004. p. 1164. 8. who searo. situation update of dengue in the sea region. who library cataloguing-in-publication data. 2010 [cited 2012 october 15]. available from: http://209.61.208.233/linkfiles/ dengue_dengue_update_sea_2010.pdf 9. pusat data dan surveilans epidemiologi kementerian kesehatan republik indonesia. demam berdarah dengue di indonesia tahun 1968–2009. buletin jendela epidemiologi. 2010;2:1–9 [cited 2012 october 15]. available from: http:// www.depkes.go.id/downloads/publikasi/ buletin/buletin%20dbd.pdf 10. who. trend of dengue case and cfr in searo ccountries. 2007 [cited 2012 march 20]. available from: http://www. searo.who.int/en/section10/section332/ section2277_11960.htm. 11. azizah gama t, faizah betty r. analisis faktor risiko kejadian demam berdarah dengue di desa mojosongo kabupaten boyolali. eksplanasi. 2010:5(2):1–9 [cited 2012 october 20]. available from: http:// www.kopertis6.or.id/journal/index.php/ eks/article/view/12/10 12. bandung health office, west java province. health profile of bandung 2008. bandung: bandung health office; 2009. 13. bandung health office, west java province. health profile of bandung 2009. bandung: bandung health office; 2010. 14. bandung health office, west java province. health profile of bandung 2010. bandung: bandung health office; 2011. 15. bandung health office, west java province. health profile of bandung. bandung: bandung health office; 2012. anggia karina, sri yusnita irda sari, h. uun sumardi, elsa pudji setiawati: incidence of dengue hemorrhagic fever related to annual rainfall, population density, larval free index and prevention program in bandung 2008 to 2011 althea medical journal. 2016;3(3) 477 metabolic syndrome components and nutritional status among hypertensive outpatiens at dr. hasan sadikin general hospital bandung lira mirandus,1 hikmat permana,2 siti nur fatimah3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of medical nutrition faculty of medicine, universitas padjadjaran abstract background: metabolic syndrome and overnutritional status (overweight and obesity) are examples of determinants that can give rise to hypertension, so the three diseases are correlated with each other. this study aimed to reveal metabolic syndrome components and nutritional status among hypertensive outpatients. methods: this study involved 44 hypertensive outpatients who visited the nephrology and hypertension clinic of dr. hasan sadikin hospital, bandung in september to october 2013. anthropometric and blood pressure measurements, anamnesis, and medical record data collection were carried out to describe the patient’s metabolic syndrome components by using international diabetes federation criteria on south asian people and nutritional status by who classification in asian people. results: among respondents, 25 (57%) had abdominal obesity, 14 (32%) had hypertrygliceridemias, 14 (32%) had low hdl cholestrol, 19 (43%) were taking lipid-lowering medications, 20 (45 %) had high level of fasting blood glucose, 21 (48%) had been diagnosed as mellitus type 2, 15 (34%) had high blood pressure, 40 (91%) were taking antihypertensive medications, 19 (43%) had metabolic syndrome, and 31 (70%) were overweight or obese. conclusions: less than a half of the respondents meet the metabolic syndrome criteria and over two third of them are at overnutrition state (overweight or obesity). [amj.2016;3(3):477–81] keywords: hypertension, metabolic syndrome, nutritional status correspondence: lira mirandus, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628568517229 email: liramirandus@gmail.com introduction in recent years, the prevalence of noncommunicable diseases (ncds) in world population has grown rapidly. the ncds and all of its negative impacts were responsible for almost two third of the world’s 57 million death in 2008, yet more than a half ofthose occurred in low and middle income countries, including indonesia.1 hypertension, metabolic syndrome, overnutritional status (overweight and obesity) are ncds.2 hypertension is a condition where arterial blood pressure rises abnormally.5 metabolic syndrome is a cluster of some metabolic abnormalities that consists of diabetes melitus or increased fasting plasma glucose, abdominal obesity, high ldl cholesterol, low hdl cholesterol and high blood pressure.6 according to theinternational diabetes federation (idf), for a person to be defined with metabolic syndrome they must have central obesity plus any criteria of four following factors: raised tryglicerides (≥150 mg/dl), reduced hdl cholesterol (<40 mg/ dl in males and <50 mg/dl in females), raised blood pressures (systolic bp ≥130 mmhg or diastolic bp ≥85 mmhg or with treatment of previously diagnosed hypertension), and high fasting plasma glucose (≥100 mg/dl or previously diagnosed diabetes mellitus).6 nutritional status is a stratification reflecting whether physiologic needs of nutritions are being met. it can be assessed by some ways, one of them is body mass index (bmi) that furtherly divided into four cathegories, which two of them, overweight and obesity, reflects overnutritional status.7 metabolic syndrome can give rise to hypertension, as the presence althea medical journal. 2016;3(3) 478 amj september 2016 of insulin resistance activate renin angiotensin aldosteron system and symphatetic nervous system.5 through insulin resistance and proliferation of glomerular capillary endothelium, overnutritional status can also cause hypertension.5 those facts make the relationship of the three diseases very clear, yet there is no study that describes how metabolic syndrome components and overnutrition exist in hypertensive people, at least in west java, indonesia’s most populous province. the aim of this study was to describe the metabolic syndrome components and nutritional status among hypertensive patients. methods this cross-sectional study was carried out at thenephrology and hypertension clinic, dr. hasan sadikin general hospital bandung, in september–october 2013. it involved previously-diagnosed hypertensive outpatients who visited the clinic, regardless whether they were new or follow up patients. the aim and the way this study would be conducted had been approved by dr. hasan sadikin general hospital’s ethical committee. this study used non probability consecutive sampling as its data collection method. the amount of minimal samples was determined by using the minimal sample formula on cathegorical descriptive variables with deviation standard alpha of 1.96 of 95% confidence interval, 10% precision (d), and presumed proportion of 0.5 that was calculated as 43 samples. hypertensive outpatients were evaluated to define whether they fulfilled idf metabolic syndrome criteria on south asian people, and then the measurement of body height and weight were performed to define nutritional status based on their bmi for asian people.8 the idf defines metabolic syndrome as the presence of abdominal obesity (waist circumference ≥ 90 cm for south asian men and ≥80 cm for south asian women), plus at least two of these following factors: raised tryglicerides (≥150 mg/dl), reduced hdl cholesterol (<40 mg/dl in males and <50 mg/ dl in females), raised blood pressures (systolic bp ≥130 mmhg or diastolic bp ≥85 mmhg or with treatment of previously diagnosed hypertension), and high fasting plasma glucose (≥100 mg/dl or previously diagnosed diabetes mellitus).6 the nutritional status was classiffied into four categories according to world health organization (who) classification of body mass index in asian people thus underweight for bmi <18.5 kg/m2, normal for bmi 18.5– 22.9 kg/m2, overweight for bmi 23–24.9 kg/ m2, and obese for bmi ≥25 kg/m2.8 the patients were included in this study if they brought laboratory results paper of hdl cholesterol, tryglicerides, and fasting plasma glucose for follow up purpose, or intended to perform such tests by instruction of the clinic’s doctor in charge. exclusion criteria of this study were the patients who refused to get involved, the patients with noncomplete laboratory medical records, and the patients with vertebral abnormalities so the measurement of body height could not be performed. it was decided that laboratory data had been performed over two months before patient’s admission to the clinic, were also excluded. furthermore, blood pressure, waist circumference, body weight and height measurements were carried out directly to the patients. anamnesis was performed to collect the patient’s name, age, previous history of type 2 diabetes melitus, medications, and medical record numbers. for the patients who brought the laboratory test results paper, the data of hdl cholesterol, triglycerides, and fasting plasma glucose could also be performed at the clinic; for the patients who did not have them, those data were taken at the hospital’s clinical pathology department several weeks following the primary data collection. the previous history of type 2 diabetes melitus and medications were rechecked by data from the outpatient medical record department. however, 3 diabetes melitus history data were not successfully rechecked by medical record data because those were not available. results there were 69 hypertensive outpatients visiting the clinic included in this study, however only 44 of them who were free from the exclusive criteria andwhose data would be analized. the number of both male and female subjects were 22 respectively, or with male:female ratio of 1:1 (table 1). the 60– 66 age group was the largest group in total subjects and both sexes. male patients were relatively older than female patients, which was reflected by their means and median of age. moreover, abdominal obesity was present in the majority of subjects. there were almost a third of the whole subjects who had hypertriglyceridemias and low hdl althea medical journal. 2016;3(3) 479lira mirandus, hikmat permana, siti nur fatimah: metabolic syndrome components and nutritional status among hypertensive outpatiens at dr. hasan sadikin general hospital bandung cholesterol level. high fasting plasma glucose level existed in slightly less than a half of the whole subjects, as well as the amount of subjects who were previously diagnosed as type 2 diabetes mellitus. there were around a third of the whole subjetcs classified as having uncontrolled high blood pressure. nine out of ten hypertensive subjects were receiving antihypertensive medications, compared to only four of ten who were receiving lipidlowering medications. the prevalence of metabolic syndrome according to idf criteria was 43% of the total subjects, with the majority of female subjects categorized as metabolic syndrome compared to less than a third of male subjects. seventy per cent of the subject was classified as overnutrition (overweight and obese) according to the who bmi criteria for asian people.8 overnutritional status was also present in majority of both male and female subjects, both 86% and 54% respectively (table 3). discussion more than half of thehypertensive patients included in this study were aged above 60 table 2 idf metabolic syndrome components among hypertensive outpatients features total (n=44) male (n=22) female (n=22) waist circumference ≥90 cm for male and ≥80cm for female 25 (57%) 8 (36%) 17 (77%) triglycerides ≥150 mg/dl 14 (32%) 9 (41%) 5 (23%) hdl cholesterol <40 mg/dl for male and <50 mg/dl for female 14 (32%) 6 (27%) 8 (36%) with lipid-lowering medications 19 (43%) 10 (53%) 9 (47%) fasting plasma glucose >100 mg/dl 20 (45%) 14 (64%) 6 (27%) with previous diagnosis of type 2 diabetes mellitus 21 (48%) 14 (64%) 7 (32%) blood pressure ≥130/85 mmhg 15 (34%) 9 (41%) 6 (27%) with antihypertensive medications 40 (91%) 18 (82%) 22 (100%) fulfill idf criteria on metabolic syndrome 19 (43%) 7 (32%) 12 (55%) note : idf=international diabetes federation, hdl=high density lipoprotein table 1 general characteristics of subjects features total (n=44) male (n=22) female (n=22) age (years old) 39–45 1 (2%) 1 (5%) 0 (0%) 46–52 4 (9%) 2 (9%) 2 (9%) 53–59 11 (25%) 4 (18%) 7 (32%) 60–66 19 (43%) 11 (50%) 8 (36%) 67–73 6 (14%) 2 (9%) 4 (18%) 74–80 2 (5%) 1 (5%) 1 (5%) 81–87 1 (2%) 1 (5%) 0 (0%) patient’s status new 1 (2%) 1 (5%) 0 (0%) follow up 43 (98%) 21 (95%) 22 (100%) althea medical journal. 2016;3(3) 480 amj september 2016 table 3 nutritional status among hypertensive outpatients bmi classification results in total (n=44) results in male (n=22) results in female (n=22) underweight 1 (2%) 0 (0%) 1 (5%) normal 12 (27%) 3 (14%) 9 (41%) overweight 16 (36%) 10 (45%) 6 (27%) obese 15 (34%) 9 (41%) 6 (27%) note : bmi=body mass index years, both in male and female sex groups. that characteristic was considered relatively to be same with two previous studies conducted in taiwan.9,10 the predominance of follow-up patients group over new patients might be due to the function of the hospital as a referral destination from the primary health care which made thefirst diagnosis and initial management before referring. this study revealed that abdominal obesity was present in the majority of hypertensive outpatients. in spite of its different amount of prevalence (62.2%), a study published by hsu et al.9 in 2005 has also shown that phenomenon. both prevalences revealed in this study and in the study of hsu et al.9 were higher than thegeneral population according to indonesia’s national basic health research 2007 which reported only 18.8%.11 there were almost similar prevalence of hypertrygliceridemia according to this study and the different studies established by su et al.10 and hsu et al.9 as they reported that high plasma triglyceride level is present in 34.74% and 40.50% of hypertensive patients. nonetheless, su et al.10 and hsu et al.9 both have shown that low hdl cholesterol exist in 69.7% and 78.2% of the same subjects, which was quite different with this study. those variations could possibly be caused by differences in the amount of subjets who were receiving lipid-lowering drug administrations, and how data were collected. su et al.10 and hsu et al.9 carried out simultaneous blood sample collection to their subjects and used standardized laboratory examination method instead of taking secondary data from the subjects’ medical record with varying time. in this study, 43% of the subjects were receiving lipid-lowering medications. that results could possibly be influenced by a limitation such as 3 unrechecked medication history of anamnesis data because of the medical record incompleteness. furthermore, su et al.10 reported that high fasting plasma glucose (above 100 mg/dl) is present in almost two third of hypertensive patients, which wasquite varied from less than a half according to this study. however, that study only involved hypertensive outpatients from the cardiology and neurology department without those from theendocrinology department, as opposed to this study which included patients from the two departments, which could influence the results, since the endocrinology department had significant numbers of diabetic patients with uncontrolled fasting plasma glucose. moreover, hsu et al.9 stated that 30.11% of hypertensive outpatients were previously diagnosed as having type 2 diabetes mellitus, lower than what this study showed. having explained before, that the study have not involved patients in the departement of endocrinology, hence it could lower the number of hypertensive subjects. there were about one third of hypertensive outpatients who remained having high blood pressure, although the fact was 91% of them were receiving antihypertensive medications. the effectivity of such medication in reducing blood pressure depends on thepatient’s obedience, the patient’s condition, and medication completeness, while the subjects’ blood pressure were measured. according to this study, there was 43% of hypertensive outpatients who fulfilled the idf criteria on metabolic syndrome. a previous study revealed that metabolic syndrome (using idf criteria) is present in 54.67% of hypertensive outpatients, which was slightly different with this study.10 both two studies established higher prevalences than a study that used the same criteria and was conducted by zainuddin et al.13 in the malaysian general population which was 33.33%. a research established by kelishadi et al.14 from isfahan, iran, concluded that the prevalence of metabolic syndrome is rather higher in hypertensive than in normotensive population. it strongly reflects that metabolic syndrome tends to be more prevalent in althea medical journal. 2016;3(3) 481lira mirandus, hikmat permana, siti nur fatimah: metabolic syndrome components and nutritional status among hypertensive outpatiens at dr. hasan sadikin general hospital bandung hypertensive population than in the general one. rahajeng and tuminah3 reported that there are about 11.2% and 14.7% classified as overweight or obese among hypertensive population, which is much lower than this study revealed. their study involved over a hundred thousand rural and urban subjects taken from 33 provinces across indonesia which were very different from this study’s mostly urban and local subjects. the same study also revealed that overnutrition is more prevalent in hypertensive than in general population. as a conclusion, the metabolic syndrome components according to idf among hypertensive outpatients are more than a half have abdominal obesity, almost a third have hypertriglyceridemia and low plasma hdl cholesterol level, almost a half have high fasting blood glucose level, almost two third have uncontrolled high blood pressure. whereas, patients with antihypertensive medications are much higher than who are not with 9:1 ratio, and lipid-lowering medicated patients and patients with previous history of type 2 diabetes mellitus are less than a half. the prevalence of metabolic syndrome among hypertensive outpatients is 43%. there are more than 70% of hypertensive outpatients classified as overweight or obese. references 1. alwan a, armstrong t, bettcher d, branca f, chissholm d, ezzati m, et al. global status report of non communicable diseases 2010. in: who, editor. geneva: world health organization; 2011. 2. soewondo p, purnamasari d, oemardi m, waspadji s, soegondo s. prevalence of metabolic syndrome using ncep/ atp iii criteria in jakarta, indonesia : the jakarta primary non-communicable disease risk factors surveillance 2006. acta med indones-indones j intern med. 2010;42(4):199–203. 3. rahajeng e, tuminah s. prevalensi hipertensi dan determinannya di indonesia. maj kedokt indon. 2009;59(12):580–587. 4. pusat komunikasi publik kementerian kesehatan republik indonesia. penyakit tidak menular (ptm) penyebab kematian terbanyak di indonesia. jakarta: kementerian kesehatan ri; 2011; [cited 2 december 2012] available from: http://www.depkes.go.id/index.php/ berita/press-release/1637-penyakittidak-menular-ptm-penyebab-kematianterbanyak-di-indonesia.html. 5. kotchen ta. hypertensive vascular disease. in: longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j, editors. harrison’s principle of internal medicine. 18th ed. new york: mcgraw-hill; 2012. p. 2042–59. 6. alberti sg, zimmet p, shaw j, grundy sm. the idf consensus worldwide definition of the metabolic syndrome. in: international diabetes federation, editor. brussels: international diabetes federation; 2006. p. 1–23. 7. hammond k. assessment: dietary and clinical data in: mahan lk, escott-stump s, editors. krause’s food & nutrition therapy. 12th ed. st.louis: saunders elsevier; 2008. p. 383–410. 8. who expert consultation. appropriate body mass index for asian populations and its implications for policy and intervention strategies. the lancet. 2004;363:157–163. 9. hsu cn, chen yc, wang td. prevalence and characteristics of the metabolic syndrome in chinese hypertensive patients : a hospital-based observation. acta cardiol sin. 2005;21:89–97. 10. su ch, fang cy, chen js, po hl, chou lp, chiang cy, et al. prevalence of metabolic syndrome and its relationship with cardiovascular disease among hypertensive patients 55–80 years of age. acta cardiol sin. 2011;27:229–237. 11. departemen kesehatan republik indonesia. prevalensi obesitas sentral pada orang dewasa diatas 15 tahun menurut provinsi. in: riset kesehatan dasar 2007, editor. jakarta: departemen kesehatan republik indonesia; 2007. 12. departemen kesehatan republik indonesia. prevalensi asma, penyakit jantung, diabetes, dan tumor menurut provinsi. in: riset kesehatan dasar 2007, editor. jakarta: departemen kesehatan republik indonesia; 2007. 13. zainuddin lrm, isa n, muda wmw, mohamed hj. the prevalence of metabolic syndrome according to various definitions and hypertriglyceridemicwaist in malaysian adults. int j prev med. 2011;2(4):229–37. 14. lioudaki e, vrentzos ge, mavrogeni h, zeniodi m-h, ganatokis es, mikhalidis dp, et al. prevalence of metabolic syndrome according to different definitions in a hypertensive population. angology. 2011;63(1):39–47. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 141 anesthesia technique selection pattern in patients undergoing lower extremities surgery at dr. hasan sadikin general hospital from january–june 2013 keshia amalia mivina mudia,1 ezra oktaliansah,2 ihrul prianza prajitno3 1faculty of medicine universitas padjadjaran, 2department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: musculoskeletal problems of the lower extremities are becoming more frequent lately. this problem usually requires surgery to be dealt quickly . the role of the anesthesiologist is needed to determine which anesthesia technique that has to be performed. selection of proper anesthesia technique can reduce the incidence of complications . objective of this study was to determine anesthesia technique selection pattern in patients undergoing orthopedic surgery at dr. hasan sadikin general hospital from january–june 2013. methods: a quantitative study with retrospective descriptive method was conducted. this study was carried out from september–october 2013 at dr. hasan sadikin general hospital bandung. medical records were used as a research instrument. data collection was conducted using total sampling method. there were 228 data of all cases, but only 151 patients who met the inclusion and exclusion criteria. results: one hundred fifty one patients were identified. sixty five subjects (43%) were performed under general anesthesia, 83 subjects (55%) under regional anesthesia and 3 subjects (2%) under combination of general-regional anesthesia. regional anesthesia techniques consisted of spinal anesthesia (29%), epidural anesthesia (64%), combination of spinal-epidural anesthesia (5%), and peripheral nerve block (2%). conclusions: regional anesthesia is the most frequently technique used in lower extremities orthopedic surgery, with epidural anesthesia as the most common regional technique used because of all the benefits. [amj.2016;3(1):141–6] keywords: anesthesia techniques, epidural anesthesia, lower extremities, orthopedic surgery correspondence: keshia amalia mivina mudia, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 82182182192 email: keshia.amalia@yahoo.com introduction musculoskeletal problems which are the responsibility of orthopedic surgery, later are becoming more frequent. data obtained from a study in the united kingdom (2006) showed that the most common musculoskeletal problems occurring at any age are a problem on the back, with the second most common is on the knee. unlike in children, the most common complaint is on foot.1 complaint in the lower extremities is one of the most common musculoskeletal problems. lower extremities musculoskeletal problems in both adults and children usually require surgery. this action should be dealt quickly. the roles of anesthesiologists are needed to determine which anesthesia technique that has to be performed either in emergency surgery, or elective surgery. there are various anesthesia techniques that can be used in lower extremities surgery, thus general anesthesia, regional anesthesia, and combination of general-regional anesthesia techniques. many researchers have conducted studies to compare the most effective anesthesia technique, between general anesthesia, regional anesthesia, and combination of these two techniques.2,3 all types of anesthesia techniques have advantages and disadvantages of each. in general, all types of anesthetic techniques have risks. however, this can be reduced if the selection of anesthetic technique is conducted with careful consideration of all factors. the aims of this study were to know althea medical journal. 2016;3(1) 142 amj march 2016 the frequency of using various anesthesia techniques, and to determine the selection pattern of all anesthesia techniques based on variables. this study was conducted at dr. hasan sadikin general hospital bandung because it is considered as a top referral hospital in west java province. plenty of orthopedic surgeries in particular lower extremities surgery have been performed. methods this study was carried out from september– october 2013 at dr. hasan sadikin general hospital bandung. all data were taken from dr. hasan sadikin general hospital’s medical record department after approved by health research ethics committee. this retrospective study was conducted by collecting secondary data from medical records of all patients who underwent orthopedic surgery of the lower extremities under anesthesia techniques from january– june 2013. data collection was conducted using total sampling method. emergency and elective surgery cases were included. outpatients, patients who underwent one day surgery (ods), patients who received local anesthesia, and patients whose data were incomplete or unclear in medical record were excluded in this study. there were 228 data of all cases, but only 151 patients who underwent orthopedic surgery of the lower extremities under anesthesia techniques from january–june 2013 who were subjects who met the inclusion and exclusion criteria. data processing was conducted after data collection had been completed. first, it was calculated how many patients undergoing orthopedic surgery on the lower extremities under general anesthesia, regional anesthesia, or combination of general-regional anesthesia at dr. hasan sadikin general hospital from january–june 2013. then, anesthesia technique used, patient’s age, sex, part of body being operated, the american society of anesthesiologists (asa) score category, scope of orthopedic surgery, length of surgery, and hospital length of stay after surgery were recorded. calculation of each type anesthesia technique used was presented by using a single table. at the same time, the calculation for the characteristics of age, sex, part of the body being operated, asa score category, scope of orthopedic surgery, length of surgery and hospital length of stay were presented by using cross-tabulation table. then, the results would be described through discussion. results there were 151 patients who underwent orthopedic surgery of the lower extremities under anesthesia techniques from january– june 2013 who were identified. of a final 151 subjects identified, patients who underwent lower extremities orthopedic surgery under anesthesia techniques were divided into three groups. anesthesia technique used at most was regional anesthesia. of a total 83 subjects who were performed table 1 frequency of anesthesia technique usage anesthesia techniques f % general 65 43 regional 83 55 combination 3 2 total 151 100 table 2 frequency of regional anesthesia technique usage regional anesthesia techniques f % spinal 24 29 epidural 53 64 spinal epidural 4 5 peripheral nerve block 2 2 total 83 100 althea medical journal. 2016;3(1) 143keshia amalia mivina mudia, ezra oktaliansah, ihrul prianza prajitno: anesthesia technique selection pattern in patients undergoing lower extremities surgery at dr. hasan sadikin general hospital from january–june 2013 table 3 selection of anesthesia techniques based on characteristics anesthesia techniques combination general regional spinal epidural spinal-epidural peripheral nerve block f % f % f % f % f % f % age (years old) <18 36 23.8 2 1.3 2 1.3 0 0.0 0 0.0 0 0.0 ≥18 29 19.2 22 14.6 51 33.8 4 2.7 2 1.3 3 2.0 sex male 42 27.8 15 9.9 38 25.2 2 1.3 0 0.0 2 1.3 female 23 15.2 9 6.0 15 9.9 2 1.3 2 1.3 1 0.7 region gluteal 6 4.0 2 1.3 5 3.3 1 0.7 0 0.0 1 0.7 femoral 18 11.9 9 6.0 14 9.3 0 0.0 0 0.0 1 0.7 knee 3 2.0 2 1.3 4 2.7 1 0.7 0 0.0 0 0.0 leg 25 16.6 8 5.3 24 15.9 1 0.7 0 0.0 0 0.0 ankle 3 2.0 1 0.7 3 2.0 1 0.7 0 0.0 0 0.0 foot 10 6.6 2 1.3 3 2.0 0 0.0 2 1.3 1 0.7 asa score 1 45 29.8 16 10.6 25 16.6 2 1.3 0 0.0 2 1.3 1e 5 3.3 0 0.0 2 1.3 0 0.0 0 0.0 0 0.0 2 11 7.3 6 4.0 14 9.3 1 0.7 0 0.0 1 0.7 2e 2 1.3 0 0.0 2 1.3 0 0.0 1 0.7 0 0.0 3 1 0.7 2 1.3 9 6.0 1 0.7 1 0.7 0 0.0 3e 0 0.0 0 0.0 1 0.7 0 0.0 0 0.0 0 0.0 4 1 0.7 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 scope of orthopedic surgery cda 8 5.3 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 ii 3 2.0 1 0.7 3 2.0 0 0.0 0 0.0 0 0.0 ram 2 1.3 1 0.7 1 0.7 0 0.0 0 0.0 0 0.0 dbj 0 0.0 1 0.66 4 2.7 0 0.0 0 0.0 0 0.0 nd 1 0.7 3 2.0 5 3.3 1 0.7 2 1.3 0 0.0 tumor 6 4.0 1 0.7 2 1.3 0 0.0 0 0.0 0 0.0 trauma 45 29.8 17 11.3 38 25.2 3 2.0 0 0.0 3 2.0 length of surgery (min) <60 4 2.7 5 3.3 1 0.7 1 0.7 1 0.7 0 0.0 60–120 32 21.2 14 9.3 25 16.6 2 1.3 1 0.7 0 0.0 >120 29 19.2 5 3.3 27 17.9 1 0.7 0 0.0 3 2.0 hospital length of stay (week) <1 52 34.4 22 14.6 46 30.5 3 2.0 2 1.3 2 1.3 1–2 13 8.6 1 0.7 6 4.0 1 0.7 0 0.0 1 0.7 >2 0 0.0 1 0.7 1 0.7 0 0.0 0 0.0 0 0.0 note: asa=the american society of anesthesiologists; cda=congenital and developmental abnormalities; ii=infection and inflammation; ram=rheumatic disease, arthropathy, and metabolic arthritis; dbj=degenerative disorder of bones and joints; nd=neuromuscular disorder althea medical journal. 2016;3(1) 144 amj march 2016 under regional anesthesia, epidural anesthesia was the most common regional anesthesia technique used (64%). more than half of a total subjects were performed under epidural anesthesia (table 2). while the most common anesthesia technique used in adult group (≥18 years old) was regional anesthesia, particularly epidural anesthesia (33.8%), in children group (<18 years old) it was general anesthesia (23.8%). identified from patients’ sex, the most common anesthesia technique used in male subjects was regional anesthesia, particularly epidural anesthesia (25.2%). the same result was obtained in female group. epidural anesthesia (9.9%) was also the most common regional anesthesia technique used in female group. lower extremities were divided into six regions. surgery on the leg region (38.4%) was the most common with the most widely anesthesia technique used was regional anesthesia, particularly epidural anesthesia (15.9%). to assess the physical status of patients before surgery, asa physical status classification system was used. the most common asa score was asa 1, with the most widely anesthesia technique used was general anesthesia (29.8%). identified from scope of orthopedic surgery found in this study, trauma cases (70.2%) were the most common case, with the most widely anesthesia technique used was regional anesthesia, particularly epidural anesthesia (25.2%). most of the surgeries finished between 60–120 minutes (49.0%), which was nearly half of a total subjects, with the most frequent anesthesia technique used was regional anesthesia, particularly epidural anesthesia (16.6%) more than half of total subjects were hospitalized in less than one week after surgery (84.1%), with the most widely anesthesia technique used was regional anesthesia, particularly epidural anesthesia (30.5%). discussion the regional anesthesia (55%) was the major option of all subjects rather than general (43%) and combination anesthesia (2%). more than half of a total subjects were performed under regional anesthesia (table 1). the results of this study are consistent with literature suggesting that lower extremities orthopedic surgery is usually performed under regional anesthesia.4 regional anesthesia was shown to have lower complication and mortality incidences.5 furthermore, the systemic effects from drugs, respiratory depression, aspiration risks, and complications after major surgery, particularly orthopedic surgery, can be reduced. equipment and cost involved are also much less than other anesthesia techniques.6 surgery performed under regional anesthesia is the one option, with lowest risk surgery with the goal of patient safety. these benefits might be the reason why regional anesthesia tends to be performed in this study. the regional anesthesia used most frequently in this study was epidural anesthesia (63.86%). epidural anesthesia proved that it could reduce the incidence and severity of perioperative physiologic disturbance and postoperative morbidity.7 subjects in the study had a diverse age range. the youngest subject was one year old patient, and the oldest was 87 years old patient. of a total 151 subjects, there were 111 subjects (73.51%) in adult group (≥18 years old) and 40 subjects (26.49%) in children group (<18 years old). one study in netherlands8 also showed that lower extremities problems complain more in adults. there is a propensity to use epidural anesthesia rather than other techniques in adult group. this may be caused by all the benefits. in children, general anesthesia is the main option in performing lower extremities surgery. children who are usually extremely anxious or afraid and cognitively immature, will be best handled by using general anesthesia technique during surgery.9 there were 99 (65.56%) male and 52 (34.44%) female subjects. number of male subjects who exceeded half of a total subjects did not show any particular trend in selection of anesthesia technique, but only showed that there were more male subjects in number than female subjects who underwent lower extremities orthopedic surgery. it might be caused by the number of fractures because traffic accidents victims were mostly males. of a total 151 subjects who underwent lower extremities orthopedic surgery, there were 58 cases (38.41%) performed on leg region. leg region lies between knee and distal leg. it includes tibia and fibula bones. the narrowest part of shaft tibia, the junction of its middle and inferior thirds, is the most frequent site of fracture. moreover, because its anterior surface is subcutaneous, tibial shaft is the most common site for compound althea medical journal. 2016;3(1) 145 fracture.10 fibula fracture cases are usually caused by combination between tibia and ankle fractures.10 because of all the benefits, patients undergoing leg region surgery also tended to use epidural anesthesia. ninety subjects (59.6%) were asa 1 category patients who mostly performed under general anesthesia during the surgery. risks of complication due to general anesthesia were increasing in higher asa score category. general anesthesia performed in patients do not have lung disease, heart disease, certain organ failure, and elderly patients.11 it means general anesthesia is better given in healthy and cooperative patients, that is patients with asa 1 category. patients with asa 1 category are healthy patients with no psychological nor organic disease, as well as pathological process which becomes the reason for undergoing localized surgery and do not cause systemic disruption.6 selection of techniques and drugs of anesthesia is performed by anesthetists based on multifactorial assessment and also both patient and surgeon preferences. physical condition and patient’s general health is the most important consideration. the most common scoring system to classify the patient’s physical status according to asa is used. patients who classified in a higher score category have a higher risk of perioperative mortality.6 therefore, to know the physical status of the patients before selecting an appropriate anesthesia technique is very important to avoid complications. trauma, which is one of orthopedic surgery scope, was the most cases in this study. there were 106 trauma cases (70.20%) of a total 151 cases. most of trauma cases were performed under regional anesthesia. trauma is often caused by traffic accident12 and traffic accidents become the major cause of death in the world. passengers, drivers, or even pedestrians can be the victims. the causes of all are due to the increasing number of vehicles, the lack of public awareness in obeying traffic rules, the poor safety procedure, and the low safety driving training.13 traffic injury cases occupy more than 50% beds in many hospitals. an orthopedic surgeon commits in handling orthopedic cases and trauma musculoskeletal. scope of orthopedic surgery is not only limited to bones and joints, other structures such as muscles, tendons, ligaments, bursa, synovial, nerves and blood vessels are also handled by orthopedic surgeons.12 there were 74 subjects (49.01%) undergoing surgery in 60 to 120 minutes. this group was the largest group with nearly half of a total subjects. they were performed under regional anesthesia at most, particularly epidural anesthesia (16.56%). length of surgery under epidural anesthesia can be extended by adding dose through inserted epidural cathether.14 patients who have undergone any surgery usually need hospitalization for recovery. most of subjects (84.11%) in this study stayed for less than a week after surgery. anesthesia technique used in subjects with hospital length of stay less than a week was mostly regional anesthesia, particularly epidural anesthesia (30.46%). memtsoudis15 suggested that there is association between anesthesia used and hospital length of stay. more patients receiving general anesthesia have a prolong length of hospital stay. study in washington7 also suggested that surgeries performed under regional anesthesia are decreased in hospital length of stay rather than under general anesthesia. in conclusion, regional anesthesia is the most frequently technique used in patients undergoing lower extremities orthopedic surgery at dr. hasan sadikin general hospital from january–june 2013, with epidural anesthesia as the most common regional technique used due to all the benefits. references 1. jordan kp, kadam ut, hayward r, porcheret m, young c, croft p. annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. bmc musculoskelet disord. 2010;11:144. 2. neuman md, silber jh, elkassabany nm, ludwig jm, fleisher la. comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. anesthesiology. 2012;117(1):72– 92. 3. larson md. combined regional-general anesthesia. revista mexicana de anestesiologia. 2010;33:(suppl 1):265–9. 4. barash pg, cullen bf, stoelting rk, cahalan mk, stock mc. handbook of clinal anesthesia. 6th ed. philadelphia: lippincott williams & wilkins; 2009. p. 843–61. 5. imbelloni le, beato l. comparison between spinal, combined spinal-epidural, and continuous spinal anesthesias for hip surgeries in elderly patients: a retrospective study. rev bras anestesiol. 2002;52(3):316–25. 6. gwinnutt cl. anestesi klinis: catatan keshia amalia mivina mudia, ezra oktaliansah, ihrul prianza prajitno: anesthesia technique selection pattern in patients undergoing lower extremities surgery at dr. hasan sadikin general hospital from january–june 2013 althea medical journal. 2016;3(1) 146 amj march 2016 kuliah. 3rd ed. jakarta: penerbit buku kedokteran egc; 2009. 7. moraca rj, sheldon dg, thirlby rc. the role of epidural anesthesia and anelgesia in surgical practice. ann surg. 2003;238(5): 663–73 8. van der waal jm, bot sd, terwee cb, van der windt da, schellevis fg, bouter lm, et al. the incidences of and consultation rate for lower extremity complaints in general practice. ann rheum dis. 2006; 65(6):809–15. 9. silverman j, reggiardo p, litch cs. an essential health benefit: general anesthesia for treatment of early childhood caries. chicago: american academy of pediatric dentistry, pediatric oral health research and policy center. 2012 [cited 2013 november 14]. available from: http:// www.aapd.org 10. moore kl, dalley af, agur amr. lower limb. clinically oriented anatomy. 6th ed. philadelphia: lippincott williams & wilkins, a wolters kluwer business; 2010. p. 508–669. 11. siribaddana p. contraindications for general anesthesia. andover: living healthy360; 2010 [cited 2013 october 30]. available from: http://www. livinghealthy360.com/ 12. rasjad c. pengantar ilmu bedah ortopedi. 7th ed. jakarta: pt. yarsif watampone; 2012. 13. dewi ry, widjasena b, kurniawan b. perbandingan faktor risiko kecelakaan kerja antara brt (bus rapid transit) dan non brt jurusan mangkang-penggaron. semarang: jurnal kesehatan masyarakat fkm undip; 2013 [cited 2013 november 12]. available from: http://ejournals1. undip.ac.id/index.php/jkm 14. hawkins jl. epidural analgesia and anesthesia. in: duke j, editor. anesthesia secret. 3rd ed. philadelphia: elsevier; 2006. p. 440–7. 15. mamtsoudis. comparative effectiveness research identifies anesthesia technique that has lower rates of complications. new york: hospital for special surgery; 2013 [cited 2013 october 31]. available from: http://www.hss.edu/ althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 17 hypertension treatment and control in older adult at tanjung sari public health center rahmi fauziah,1 enny rohmawaty,2 lazuardhi dwipa,3 1faculty of medicine universitas padjadjaran 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of internal medicinefaculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: hypertension is considered as a major health problem in indonesia, especially in older adult population because of its prevalence increases by age. treatment strategy and control management of hypertension in public health center (pusat kesehatan masyarakat, puskesmas) as primary health care should be enhanced to overcome this issue. this study aimed to describe the pattern of antihypertensive agent in older adults. methods: this was a descriptive study with total sampling method for data collection. data were collected from medical record of older adult patients with diagnosis of hypertension at puskesmas tanjung sari from january to december 2013. the variables observed were gender, number of visits, the degree of hypertension, types of antihypertensive drug, combinations of antihypertensive drugs, and blood pressure control. results: the number of older adults with hypertension was 180 people. some of which, 120 women (66.7%) participated, 152 (84.4%) had hypertension stage 2, 100 (55.6%) had just one visit, and 80 (44.4%) had more than one visit. among 80 participants with more than one visit, 8 had achieved target blood pressure. there were 166 participants (92.2%) who received single antihypertensive agent (captopril was given the most), and 14 participants (7.8%) who received the combination of two antihypertensive agent (combination of captopril and hct (hydrochlorothiazide)) were given the most). conclusions: more than 75% of older adult with hypertension have stage 2 hypertension and are treated by single antihypertensive agent. ninety percent of the patient have uncontrolled blood pressure. [amj.2016;3(1):17–21] keywords: antihypertensive agent, hypertension, older adult, public health center correspondence: rahmi fauziah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285864622002 email: rahmi.fauziah31@gmail.com introduction increased life expectancy in few past century causes a continued increase of older adult population.1 the population of older adult in the world will increase from the estimated 810 million in 2012 to 2 billion in 2020.1 the population of older adult in indonesia is also expected to increase from 9% in 2012 to 25% in 2050.1 most of the causes of death in older adult in indonesia are non-communicable diseases such as heart disease, stroke, and diabetes.2 hypertension is a disease that increases the risk of heart disease, stroke, and kidney disease and its prevalence increases by age.3,4 hypertension causes death of 8 million people worldwide each year and is included as one of the 10 major causes of death in the older adult in indonesia.2,3the percentage of older adult who are treated in public health center (pusat kesehatan masyarakat, puskesmas) is 29.31% in 2012.2 the ministry of health made a policy aimed for puskesmas as a primary health care to improve control and treatment management of hypertension in indonesia.5 the characteristics of older adults include multi morbidity and physiological changes in various organs that can affect the pharmacokinetics and pharmacodynamics of drugs, hence, older adults are at high risk of drug accumulation.6-8 it contributes to the modification and influence the selection of drugs in the older adults.8 since the hypertension is one of the 10 major causes althea medical journal. 2016;3(1) 18 amj march 2016 of death in the older adults in indonesia, the control and treatment strategy become very important. in accordance with the background above, this study aimed to determine the treatment and control of hypertension in older adults in puskesmas. methods this study used descriptive study conducted at puskesmas tanjung sari with total sampling method for data collection. the subject used in this study was medical record of older adult patients with diagnosis of hypertension at puskesmas tanjung sari from january 1st to december 31st 2013. the instruments of this study used secondary data in the form of medical records at puskesmas tanjung sari. the minimum total sample was obtained by using descriptive categorical formula with a precision of 10% which is equal to 73 samples. the distribution of frequencies and percentages were calculated using microsoft excel. this study was conducted after obtaining permission from the health research ethics committee faculty of medicine universitas padjadjaran bandung. inclusion criteria of the objects in this study were older adult patients aged ≥ 60 years who were treated at puskesmas tanjung sari from january 1st to december 31st2013, with diagnosis of hypertension according to joint national committee 7 (jnc 7) criteria. the criteria are the results of measurement of systolic blood pressure ≥140 mmhg or diastolic blood pressure ≥90 mmhg, whether or not accompanied by other diseases and are given antihypertensive drug. exclusion criteria of the objects in this study were patients with uncompleted medical records in the first visit. study variables observed in this study were gender, number of visits, the degree of hypertension, types of antihypertensive drug, combinations of antihypertensive drugs, and blood pressure control. gender of the patients was classified as male and female. the number of visits was defined as how many times the patient went to the puskesmas to control blood pressure, and was divided into only one visit and more than one visit. the degrees of hypertension were classified based on jnc 7 criteria (normal: <120/80, prehypertension: 120–139/80–89, stage 1 hypertension: 140– 159/90–99, stage 2 hypertension: ≥ 160/100) and were taken in the first visit.9 types of antihypertensive drug and combinations of antihypertensive drugs used were taken in the first visit. blood pressure control was taken in the last visit of the patients who had more than one visit and used the nice clinical guideline criteria of hypertension in 2011 (age <80 years: <140/90 and age ≥80 years: <150/90).10 results during the study period from january 1st to december 31st2013, there were 41,205 patients treated at the puskesmas tanjung sari according to the data obtained from the summary report visit at puskesmas tanjung table 1 patient characteristics patient characteristics total (n=180) gender male 60 (33.3 %) female 120 (66.7 %) number of visits only 1 visit 100 (55.6 %) > 1 visit 80 (44.4%) degrees of hypertension prehypertension 3 (1.7 %) stage 1 hypertension 25 (13.9 %) stage 2 hypertension 152 (84.4 %) types of antihypertensive agent single 166 (92.2 %) combination 14 (7.8 %) althea medical journal. 2016;3(1) 19rahmi fauziah, enny rohmawaty, lazuardhi dwipa: hypertension treatment and control in older adult at tanjung sari public health center sari. among 41,205 patients, there were 180 older adult patients with hypertension who met the inclusion and exclusion criteria that have been determined. based on the distribution of gender, older adult patients with hypertension treated at the puskesmas tanjung sari were mostly women compared to men with a ratio 2:1, who visited only one time to control the blood pressure, and had stage 2 hypertension (table 1). the use of a single antihypertensive agent in the first visit was higher than a combinations of two antihypertensive agents. these results indicated that more than 75% of patients had stage 2 hypertension and were treated by a single antihypertensive agent. based on the distribution of a single antihypertensive agent in the first visit (table 2), the majority of older adult patients received captopril followed sequentially by reserpine, hct, and amlodipine. most of the older adult patients received combination of captopril and hct, followed by a combination of reserpine and hct, and the combination of captopril and reserpine (table 3). based on the distribution of controlled blood pressure, the result indicated that 90% of patients who had more than one visit had uncontrolled blood pressure (table 4). discussion the results of this study showed that women were the most of the older adults with hypertension. several factors that cause hypertension in older women who had menopause (postmenopausal) are genetic factors, environmental and the decrease of estrogen levels that can induce endothelial dysfunction, obesity, activation of the reninangiotensin-aldosterone system (raas), and oxidative stress. these factors contribute to the increase of renal vasoconstriction leading to hypertension.11 the number of older adult patients who had only one visit were more than patients who had more than one visit. the results of this study may indicate the low awareness of older adult patients to control their blood pressure. this is consistent with the study by brindel pauline et al.12 that showed that the frequency of visit in older adult patients with hypertension is associated with a high percentage of awareness, treatment and control of blood pressure. but things such as the patient visit which is not recorded at the medical record, the patient changes to private doctors or other health facilities and lack of education about the importance of controlled blood pressure, can cause the likelihood of the table 2 distribution of single antihypertensive agent types of drug total (n=166) hct (hydrochlorothiazide) 7 (4.2%) reserpine 24 (14.5%) amlodipine 3 (1.8%) captopril 132 (79.5%) table 3 distribution of combination of 2 antihypertensive agent types of drug total (n=14) captopril + hct 11 captopril + reserpine 1 reserpine + hct 2 table 4 distribution of controlled blood pressure blood pressure total (n=80) controlled 8 (10%) uncontrolled 72 (90 %) althea medical journal. 2016;3(1) 20 amj march 2016 higher number of patient with only one visit. the majority of patients who received antihypertensive agent in the first visit had stage 2 hypertension. the results are in accordance with the recommendation of 2013 european society of hypertension (esh)/european society of cardiology (esc) guidelines for the management of arterial hypertension that the initiation of antihypertensive drug administration in the older adult is recommended at stage 2 hypertension.13 in this study, older adult patients with hypertension mostly received a single antihypertensive agent in their first visit. this is in accordance with aha 2011 expert consensus document on hypertension in the elderly that initiation of antihypertensive drug treatment in the older adult begins with a single drug administration with the lowest dose. the dose gradually increases until it reaches the maximum dose that can be tolerated depending on the response of the patient’s blood pressure. however, if the blood pressure is more than 20 or 10 mmhg above the target blood pressure, the treatment should be initiated with two antihypertensive agents.14 the results of this study showed that a single antihypertensive agent most often given in older adult was captopril. according to the 2013 european society of hypertension (esh)/european society of cardiology (esc) guidelines for the management of arterial hypertension, all antihypertensive drugs recommended and can be used by the older adult, although diuretics and calcium antagonist is recommended in older adult patients with isolated systolic hypertension.13 based on the interview with the doctor on duty at puskesmas tanjung sari, captopril administration was most often because the availability of other antihypertensive drugs at puskesmas tanjung sari was limited in 2013, while after the national health coverage (jkn), the availability of antihypertensive agent at puskesmas tanjung sari is amlodipine (calcium antagonists). the combination of two antihypertensive drugs most frequently used in the older adults was captopril and hct. several studies have shown that the combination of ace-i (angiotensin converting enzyme inhibitors) and diuretics can lower systolic blood pressure in patients with transient ischemic attack or previous stroke, diabetes, and hypertension patients aged 80 years and over.13 older adult patients with hypertension who achieved target blood pressure in the last visit were 90% with more than one visit. the low number of controlled blood pressure can be caused by the poor compliance.15,16 in this study, poor compliance to antihypertensive drugs is likely affected by the lack of patient’s knowledge about the importance of blood pressure control, lack of education, long term and continuous treatment. in addition, based on the data from patients’ medical record who listed the number of antihypertensive drugs that were given, it can be concluded that the duration of captopril administration as antihypertensive drugs were most often given in 3 or 5 days. antihypertensive drugs that were given in small numbers caused the patient must often come back to the puskesmas in order to get an antihypertensive drug again, hence, it may affect patients’ compliance. this is consistent with other studies that the factors that contribute to poor adherence to antihypertensive agent include lack of patient understanding of the importance of achieving blood pressure control, lack of education to the patient, access to health facilities, drug adverse effects, drug cost, and low socioeconomic status.17-19 the conclusion of this study is more than 75% of older adults with hypertension have hypertension stage 2 and are treated by single antihypertensive agent (captopril), and ninety percent of the patients with more than one visit have uncontrolled blood pressure. the limitation in this study is incomplete data recorded in the medical record at puskesmas tanjung sari, in the form of blood pressure data, diagnosis, and antihypertensive drugs given. moreover, the medical recordkeeping system at puskesmas tanjung sari is not good enough, so it took times when that patients’ data were not recorded in the medical record. it is suggested that the completeness of data in the medical record and medical record-keeping system should be improved in order to ease the monitoring and reporting of treatment and medication at puskesmas tanjung sari. in addition, a primary health care providers and physicians who work in puskesmas are expected to improve the treatment management of hypertension, especially in the older adults. suggestion for further study is about factors that influence the number of visits and blood pressure control in older adult patients with hypertension at the puskesmas tanjung sari should be conducted. althea medical journal. 2016;3(1) 21rahmi fauziah, enny rohmawaty, lazuardhi dwipa: hypertension treatment and control 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force for the management of arterial hypertension of the european society of hypertension (esh) and of the european society of cardiology (esc). eur heart j. 2013;34(28):2159–219. 14. aronow ws, fleg jl, pepine cj, artinian nt, bakris g, brown as, et al. accf/ aha 2011 expert consensus document on hypertension in the elderly: a report of the american college of cardiology foundation task force on clinical expert consensus documents. j am coll cardiol. 2011;57(20):2037–114. 15. bramley tj, gerbino p, nightengale b, frech-tamas f. relationship of blood pressure control to adherence with antihypertensive monotherapy in 13 managed care organizations. j manag care pharm. 2006;12(3):239–45. 16. yiannakopoulou ec, papadopulos js, cokkinos dv, mountokalakis td. adherence to antihypertensive treatment: a critical factor for blood pressure control. eur j prev cardiol. 2005;12(3):243–9. 17. krousel-wood m, thomas s, muntner p, morisky d. medication adherence: a key factor in achieving blood pressure control and good clinical outcomes in hypertensive patients. curr opin cardiol. 2004;19(4):357–62. 18. roumie cl, elasy ta, greevy r, griffin mr, liu x, stone wj, et al. improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. ann intern med. 2006;145(3):165–75. 19. baroletti s, dell’orfano h. medication adherence in cardiovascular disease. circulation. 2010;121(12):1455–8. althea medical journal. 2016;3(3) 334 amj september 2016 intrinsic risk factors of falls in elderly yasmin amatullah,1 sunaryo b. sastradimaja,2 lazuardhi dwipa3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: falls are common geriatric problems. the risk factors of falls are the intrinsic and extrinsic risk factors. studies on falls are scarcely conducted in indonesia, especially in bandung. therefore, this study was conducted to identify the intrinsic risk factors of falls among elderly. methods: a descriptive study was carried out from august to october 2013 at the geriatric clinic of dr. hasan sadikin general hospital bandung. fifty three participants were selected according to the inclusion and exclusion criteria using consecutive sampling. the determined variables in this study were classification of the risk of falls, demographic profile, history of falls, disease, and medications. after the selection, the participants were tested by timed up-and-go test (tugt). moreover, an interview and analysis of medical records were carried out to discover the risk factors of falls. the collected data were analyzed and presented in the form of percentages shown in tables. results: from 53 patients, women (35.66%) were considered to have higher risk of fall than men (18.34%). the majority of patients (66%) with the risk of fall were from the age group 60–74 years. the major diseases suffered by patients were hypertension, osteoarthritis and diabetes mellitus. drugs that were widely used were antihypertensive drugs; analgesic and antipyretic drugs and antidiabetic drugs. conclusions: there are various intrinsic risk factors of falls in elderly and each of the elderly has more than one intrinsic risk factor of falls. [amj.2016;3(3):334–9] keywords: elderly, risk factor of falls, timed-up-and-go test correspondence: yasmin amatullah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282112954353, email: yazhmeen@gmail.com introduction the aging population increases around the world, especially in developing countries, among others in indonesia. it is predicted that the percentage of elderly in indonesia will increase from 7.59% in 2010 to 11.34% in 2020.1 the escalation of percentage of elderly indirectly increases geriatric problems. the most common geriatric problem is falls. falls are the main cause of morbidity, disability and mortality in elderly.2 older age is divided into four age groups based on the who classification. the first is the middle age, which is the age group of 45– 59 years. the second is the elderly, which is the age group between 60–74 years. the third is the old, which is aged between 75–90 years. the fourth is the very old, which is >90 years of age.3 in previous studies, risk factors of falling in elderly consist of two factors, namely the intrinsic and extrinsic factors. intrinsic factors include history of falls, age, gender, living arrangements such as living alone, ethnicity, medication, medical conditions, impaired mobility and gait, sedentary behaviors, psychological status, nutritional deficiencies, impaired cognition, visual impairment and foot problems. extrinsic factors include environmental status, footwear and clothing, and inappropriate walking aids or assistive devices.4 although many studies had explored the risk factors of falls worldwide, studies about falls were scarce in indonesia, especially about the intrinsic risk factors. by knowing the intrinsic risk factors of falls, the incidence of falls in elderly can be prevented. the objective of this study was to identify the intrinsic risk althea medical journal. 2016;3(3) 335 factors of falls in elderly. methods a descriptive study was carried out from august to october 2013 in the geriatric clinic of dr. hasan sadikin general hospital bandung. consecutive sampling was conducted involving 53 participants. the inclusion criteria for the participants were older adult patients aged >60 years and willing to participate in this study. the exclusion criteria were elderly who experienced disability and used assistive devices, such as wheelchairs and walking sticks. the determined variables in this study were classified into the following categories: the risk of falls (impaired mobility and gait), demographic profile, history of falls, disease, and medications. after being selected, the participants were tested by using the timed up-and-go test (tugt) to determine the risk of falls. the participants were instructed to sit on a chair and immediately instructed to get up again from the chair then walk about 3m. subjects were directed to turn around, return back to the chair and sit again. the examiner counted the duration of the subjects to finish the test. the tugt was chosen because it has sensitivity and specificity of 87% to identify the risk of people to fall.5 the tugt time calculation will be classified into three groups. the tugt results with <10 seconds are put in a normal group. the tugt results with a span of 10–20 seconds are put into a group with risk of falling. the tugt results with >20 seconds are put into a group with a higher risk of falling.6 moreover, an interview and analysis of medical records were carried out to discover the risk factors of falls. all procedures were performed after approval from the health research ethics committee. the collected data were analyzed and presented in the form of percentages shown in tables. results the demografic profile ofthis study revealed that most of the participants who attended the geriatric clinic were 60–74 years old and female. moreover, most of them still lived with other members of the family, such as brother, sister, husband, wife, children, and / or grandchildren. only a small percentage of them lived alone (table 1). most of the participants had history of falls especially among the 60–74 years old (table 2). out of 53 participants, the maximum tugt result was 53 seconds and the minimum tugt result was 10 seconds meaning that all participants had the risk of falls. the variation of mean at each group showed that the highest mean was at >90 years old group (table 3). there were three major diseases, namely hypertension (85%), osteoarthritis (70%) and diabetes mellitus (53%) and these distribution occured at the group of participants who had yasmin amatullah, sunaryo b. sastradimaja, lazuardhi dwipa: intrinsic risk factors of falls in elderly table 1 characteristics of participants characteristics n (%) age (years) 60–74 36 (68) 75–90 16 (30) >90 1 (2) gender male 34 (18) female 66 (35) living arrangement live with others 96 (51) live alone 4 (2) mean of age (years old) 72.43 standard deviation of age 6.643 althea medical journal. 2016;3(3) 336 amj september 2016 history of falls as well (table 4) there were three major medications widely used by numerous patients at the geriatric clinic of dr. hasan sadikin general hospital bandung, those were the antihypertensive agent (27%), analgesic and antipyretic (16%), and antidiabetic (11%) agent. other medications varied according to the treatment of the disease such as calcium supplements, anticidal drugs, vertigo drugs, anticoagulant drugs, antibiotic, bone resorption drug, and beningn prostate hyperplasia (bph) drugs and others. moreover, each participant used more than three drugs (table 5). discussion the risk factors for falls have been identified in numerous studies. this study was consistent with other studies implicating causal factors in falling. the group of 60–74 years old was the group with the highest risk of falls. based on previous studies, the increase in age would increase the risk of falls. the aging process in table 3 tug test according to age age group (years old) n mean of tugt results (seconds) 60-74 36 21.80 75-90 16 16.44 >90 1 43 note: tug test= timed-up-and-go test table 2 history of falls age group (years) history of falls n yes no inconclusive 60-74 15 9 12 36 75-90 6 7 3 16 >90 1 0 0 1 total 22 16 15 53 table 4 diseases and impairments diseases/impairments n (%) hypertension 45 (85) osteoarthritis 37 (70) diabetes mellitus 28 (53) hyperlipidemia 14 (26) coronary artery disease 10 (19) osteoporosis 5 (9) chronic obstructive pulmonary disease 4 (8) heart failure 3 (6) cognitive impairment 1 (2) visual impairment 11 (21) depression 4 (8) malnutrition 4 (8) althea medical journal. 2016;3(3) 337yasmin amatullah, sunaryo b. sastradimaja, lazuardhi dwipa: intrinsic risk factors of falls in elderly the elderly leads to less postural control that may play an important role in most of the falls incidents. aging makes impairment of balance and low of strength of the muscle and bone structures.7 changes involved during the aging process include proprioception, range of motion, and muscle strength. in addition, there is a change in posture, gait, functional mobility and sensory systems. these lead to the abnormality of balance that cause falls. another study stated that a person with impaired balance or gait had higher risk of falls compared to a person who did not have those kind of problems in the future.8 the world health organization (who) stated that elderly women and the elderly who lived alone had higher risk of falls.4 this study had a similar result with the who study. most of the participants were women. on the other hand, only a small percentage of the elderly lived alone. this situation is possibly related to the indonesian culture that it is the responsibility of the children to take care of their parents. a further study should be conducted to identify the factors contributing to falls in elderly who lived with other family members. the majority of patients at risk of falling had experienced previous falls. numerous studies claimed that the previous falls history is a strong risk factor for repeated falls in the future.4,7,9 one study suggested that the majority of chronic disease on older adult with risk of falling were osteoarthritis, hypertension, hearing deficits, and visual deficits.10 another study indicated that risk factors which are common in older adult are orthopedic abnormalities and neurologic diseases, because they affect gait and balance.11 meanwhile, multivariate logistic regression analysis in another study stated that the disease with highest odds ratio is stroke, followed by heart disease, osteoarthritis, kidney disease, and hypertension respectively.12 most of the patients with the risk of falls and most of the patients with a history of falls suffered from hypertension, osteoarthritis, and diabetes mellitus. the incidence of hypertension was the highest in elderly with risk of falls. this result is predicted to be caused by the effects of antihypertensive drugs. most antihypertensive drugs had side effects such as orthostatic hypotension.13 osteoarthritis caused a decrease in body function, muscle weakness and impaired balance.14 meanwhile, the risk of falls in patients with diabetes was associated with decreased proprioception sensory and reduced vision capabilities.15 in a previous study, elderly with diabetes are at high risk of developing hypoglycemia (blood glucose <4 mmol/l). hypoglycemia could lead to poor balance and increase risk of falls.16 a previous study found that the psychotropic drug was strongly associated with the risk of falling. the use of sedative and hypnotic drugs, antidepressants, and benzodiazepines are strongly associated with falls in elderly.17 another study stated the drugs that might increase the risk of falls were psychotropic drugs, such as antipsychotics, antidepressants, and sedatives, and cardiovascular drugs, such as diuretics, antiarrhythmics and digoxins.13 in a sample of hospitalized patients, central nervous system (cns) agents were significantly associated with falls.18 importantly, several of the most frequent manifestations of adverse drug incidents were risk factors themselves for falling, these table 5 characteristics of medications category n (%) antihypertensive 80 (27) analgesic and antipyretic 49 (16) antidiabetic 33 (11) calcium supplement 27 (9) antacidal, antireflux and ulceration 27 (9) vitamin 25 (8) antidyslipidemia 17 (6) antiasthma and copd 9 (3) others 24 (8) note: copd= chronic obstructive pulmonary disease althea medical journal. 2016;3(3) 338 amj september 2016 adverse drug effects include orthostatic/ postural hypotension), bradycardia, cognitive changes, and dizziness.17 antihypertensive drugs were most widely used by patients with high risk of falling. one side effect of antihypertensive drugs was orthostatic hypotension, which was the risk factor of fall.13 the second most used drugs were analgesic and antipyretic drugs. analgesics, including both opioid and nonsteroidal antiinflammatory drugs (nsaids), anticonvulsants, and antidepressants might cause side effects such as sedation, lethargy, confusion, double vision, motor incoordination, dizziness, and weakness.19 the third most used drugs were antidiabetic drugs. previous studies stated that several antidiabetic drugs had a strong relationship with falls. it was caused by long-term drug use which was closely linked to greater risk of hypoglycemia. patients typically use four or more drugs. it is called polypharmacy, which was also the risk factor of falling.20 however, this study faced major limitations. first, the study experienced major bias. patients less remember when answering questions due to collecting information that led to lack of information from the patients. bias also occurred on the contradiction between the information obtained directly from the patient and information obtained from medical records. second, the lack of samples and limited time of the study. third, the minimum overview information on risk factors of falls in elderly. therefore, researchers suggest that future studies should concern more deeply on falls risk factors. in conclusion, the clinical pattern of elderly with high risk of fall were advanced age and female. most of them had hypertension, osteoarthritis, and diabetes mellitus. pharmacological treatment being most used were antihypertensive, analgesic and antipyretic, and antidiabetic drugs. therefore, older adult patients should always be accompanied by family members or caregivers in their daily activities. for drug use, clinicians should seek to reduce the amount of medication, because this study found that patients at risk of falling were using four or more different kinds of drugs (polypharmacy). references 1. efendi f, makhfudli. kesehatan lanjut usia. in: nursalam, editors. keperawatan kesehatan komunitas: teori dan praktik dalam keperawatan. 1st ed. jakarta: salemba medika; 2009. p. 246. 2. world health organization. who global report on falls prevention in older age [online document ]. world health organization; 2007 [cited 2012 dec 12]. available from: http://www. who.int/ageing/publications/ falls_ prevention7march.pdf 3. world health organization regional office for europe. healthy ageing profiles: guidance for producing local health profiles of older people [online document]. world health organization; 2008 [cited 2014 jan 22 ]. available from: http://www.euro.who.int/__data/assets/ pdf_file/0011/98399/e91887.pdf 4. who regional office for europe. what are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? [online document]. world health organization; 2004 [cited 2012 dec 12 ]. available from: http://www.euro.who. int/__data/assets/ pdf_file/0018/74700/ e82552.pdf 5. picone en. the timed up and go test. am j nurs. 2013;113(3):56–9. 6. kimbell s. breaking the fall factor. nurs manage. 2002;33(9):22–5. 7. salzman b. gait and balance disorders in older adults. am fam physician. 2010;82(1):61–8. 8. ganz da, bao y, shekelle pg, rubenstein lz. will my patient fall. jama. 2007;297(1):77– 86. 9. deandrea s, bravi f, turati f, lucenteforte e, la vecchia c, negri e. risk factors for falls in older people in nursing homes and hospitals. a systematic review and meta-analysis. arch gerontol geriatr. 2013;56(3):407–15. 10. patidar ab, jasbir k, saini p, kaur m. contributing factors and safety related lifestyle changes among older persons with history of falls. international journal of nursing care. 2013;1(2):7–11. 11. shahar d, levi m, kurtz i, shany s, zvili i, mualleme z, et.al. nutritional status in relation to balance and falls in elderly. ann nutr metab. 2009;54(1):59–66. 12. hsu h, jhan l. risk factors of falling among the elderly in taiwan: longitudinal study. taiwan geriatr gerontol 2008;3(2):141– 54. 13. velde vn, stricker bh, pols ha, cammen vtj. withdrawal of fall-risk-increasing drugs in older persons: effect on mobility test outcomes. drugs aging. althea medical journal. 2016;3(3) 339 2007;24(8):691–99. 14. arnold cm, faulkner ra. the effect of aquatic exercise and education on lowering fall risk in older adults with hip osteoarthritis. j aging phys act. 2010;18(3):245–60. 15. schwartz av, vittinghoff e, sellmeyer de, feingold kr, de rekeneire n, strotmeyer se, et al. diabetes-related complications, glycemic control, and falls in older adults. diabetes care. 2008;31(3):391–96. 16. laubscher t, regier l, bareham j. diabetes in the frail elderly: individualization of glycemic management. can fam physician. 2012;58(5):543–46. 17. slattum pw, ansello ef. medications as a risk factor in falls by older adults with and without intellectual disabilities. age. 2013;28(1):1–20. 18. lamis r, kramer j, hale l, zackula r, berg g. fall risk associated with inpatient medications. am j health syst pharm. 2012; 69(21):1888–1894. 19. nancy c, crosby mk. medication’s impact on falls. aging well. 2009; 2(5):8. 20. ziere g, dieleman j, hofman a, pols ha, cammen vtj, stricker bh. polypharmacy and falls in the middle age and elderly population. br j clin pharmacol. 2006;61(2):218–23. yasmin amatullah, sunaryo b. sastradimaja, lazuardhi dwipa: intrinsic risk factors of falls in elderly althea medical journal. 2016;3(3) 359 comparison of tissue preservation using formalin and ethanol as preservative formula see woan shian,1 arifin soenggono,2 sawkar vijay pramod3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: tissue preservation can be performed through embalming, by providing the chemical embalming fluid to the human remains. formalin’s preservative formula is the foundation for modern methods of embalming. unfortunately, this preservative formula has several disadvantages. while ethanol’s preservative formula is a considerable agent to replace formalin’s preservative formula. the aim of this study was to compare the tissue preservation using formalin and ethanol as preservative formula. methods: this study was carried out from september–october 2014 in the laboratory of the department of anatomy, faculty of medicine, universitas padjadjaran. the study used the laboratory experimental method with consecutive sampling of 16 wistar rats. thirty two soleus muscles and thirty two colons were collected and divided into two groups. each group consisted of 16 soleus muscles and 16 colons. group 1 was preserved with formalin’s preservative formula and group 2 was preserved with ethanol’s preservative formula. the two groups were preserved for six weeks. the tissue’s color, consistency, odor and the growth of bacteria were determined before and after treatment. results: tissues preserved with ethanol’s preservative formula had better tissue preservation in the aspect of color and odor, compared with formalin’s preservative formula. both preservative formulas showed no growth of bacteria in tissues but failed to retain the consistency. all the data were analyzed with chi-square test. conclusions: ethanol’s preservative formula preserves better quality of tissue compared to formalin’s preservative formula. [amj.2016;3(3):359–63] keywords: ethanol, formalin, tissue preservation correspondence: see woan shian, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822004420 email: seewoanshian@gmail.com introduction in the framework of undergraduate medical education, cadavers are main educational tools which are intended for dissection and to demonstrate prosected specimen through visual, auditory and tactile pathways.1,2 hence, tissue preservation plays a pivotal role which is to preserve cadavers, maintaining its lifelike physical characteristics and prevents its decomposition.3 this can be done through embalming, which is an art and science in modern culture by giving the embalming fluid which is composed of chemical to the human remains.3 the aims of embalming for anatomical purposes are to prevent putrefaction progress on the cadavers, ensure that there is no risk of infection on contact with dead body, prevent over-hardening and retention of color of tissues and organs, prevent desiccation, inhibit fungal or bacterial growth and has lesser risk of being a potential environmental chemical hazards and biohazards.3,4 formalin, which is composed of a saturated water solution containing 39–40% of formaldehyde, is discovered in the year 1869.3 after formalin was determined to be an excellent preservative, it became the foundation for modern methods of embalming.3,4 however, formalin as preservative formula has several disadvantages for embalming purposes. formalin’s preservative formula will lead to health problems, causes over hardening of tissues, coagulates blood, convert tissues to a grey hue when it mixes with blood, fixes althea medical journal. 2016;3(3) 360 amj september 2016 discolorations, dehydrates tissues, constricts capillaries and has a suffocating odor.2,3,5,6 in addition, ethanol has been phased out for product type 22 ‘embalming and taxidermist fluids’ by 1 september 2006.3 based on several researches, ethanol has several advantages as preservative formula and has less risk to health problems.7 therefore, ethanol can be considered to replace formalin as preservative formula.3 this study was conducted to compare the tissue preservation using formalin and ethanol as preservative formula. methods this study was carried out from september– october 2014 in the laboratory of department of anatomy, faculty of medicine, universitas padjadjaran. all experiments performed on the laboratory animals in this study were approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. formalin and ethanol preservative formula were obtained from the laboratory of department of anatomy, faculty of medicine, universitas padjadjaran. the study used the laboratory experimental method with consecutive sampling of sixteen healthy male wistar rats as study subjects. the inclusion criteria for the study subjects were healthy wistar rats which were 8 weeks old male and weighing between 250g, whereby the exclusion criteria was the wistar rats which did not move actively. the preservative chemicals were prepared one week before the dissection by measuring the preservative chemicals according to the volume using a measurement beaker and beam balance. the formalin’s preservative formula consisted of 150ml of formalin, 200ml of glycerin, 50ml of phenol, 200g of sodium chloride and 600ml of water whereas the ethanol’s preservative formula consisted of 700ml of ethanol, 200ml of phenol, 40ml of glycerin, 10g of sodium chloride, 30ml of water and 30ml of formalin. then, the wistar rats were dissected to collect 32 soleus muscles and 32 colons. firstly, a wistar rat was put into an inverted beaker for anesthesia. the inverted beaker consisted of cotton that was soaked with the lethal volume of ether. next, the wistar rat was placed on a dissecting tray with needles to secure it. then, the dissection started by cutting down from the neck to the lower abdomen. another two lines were cut towards left and right from the end of the center line. the visceral organs were removed and the blood was washed with nacl 0.9%. afterward, the soleus muscles and colons were collected. the dissection procedure was repeated for all the wistar rats. after all the tissue samples were collected, the soleus muscles and colons were divided into two groups. group 1 was preserved with formalin’s preservative formula and group 2 was preserved with ethanol’s preservative formula. each tissue was preserved with 6ml of preservative fluid in one plastic container. the two groups were preserved for six weeks in a temperature of 100c. the tissue’s color, consistency, odor and the growth of bacteria were determined before and after the preservation. the colors of the tissues were accessed visually, the odors of the tissues were accessed by smelling and the consistencies of the tissues were accessed by tactile sensation. the growths of bacteria of the tissues were determined by the results on blood agar. the table 1 color of tissue before and after preservation color formalin’s preservative formula ethanol’s preservative formula p-value (chi-square test) before 0.599 pink 16 16 pale red 16 16 after 0.000 grayish chocolate 16 0 reddish pink 0 16 grayish white 16 0 yellowish white 0 16 althea medical journal. 2016;3(3) 361 procedure of detection of the growth of bacteria began by putting the tissue samples into test tubes which contained brain-heart infusion media. after the samples were incubated at a temperature of 370c for 24 hours, each sample was inoculated on blood agar. then, results were obtained after the incubation of blood agar for 24 hours at a temperature of 370c. furthermore, data of color, consistency, odor and growth of bacteria of the tissues before and after preservation were statistically analyzed using the chi-square test. statistically significant was considered when p<0.05. analysis was performed by comparing the tissue preservation between the formalin’s preservative formula group and the ethanol’s preservative formula group. results the comparison of color of the tissues before using formalin and ethanol as a preservative formula had no significant difference because the p-value was more than 0.05. however, for the comparison of color of the tissues after using formalin and ethanol as a preservative formula, it had a significant difference because the p value was less than 0.05. the color of the tissue that was preserved by the ethanol’s preservative formula was more similar to the color of the tissue before preservation rather than the formalin’s preservative formula. thus, the color of the tissue preserved by the ethanol’s preservative formula was better than the color of the tissue preserved by the formalin’s preservative formula (table 1). the comparison of odor of tissue preservation after using formalin and ethanol as a preservative formula had a significant difference because the p-value was less than 0.05. the odor of tissue preserved by ethanol’s preservative formula was better than the odor of tissue preserved by formalin’s preservative formula (table 2). the comparison of consistency of tissue before and after using formalin and ethanol see woan shian, arifin soenggono, sawkar vijay pramod: comparison of tissue preservation using formalin and ethanol as preservative formula figure 1 color of soleus muscle: (a) soleus muscle before preservation showed pink color. (b)soleus muscle preserved by formalin’s preservative formula preservation showed grayish chocolate color. (c)soleus muscle preserved by ethanol’s preservative formula preservation showed reddish pink color. figure 2 color of colon: (a) colon before preservation showed pale red color. (b)colon preserved by formalin’s preservative formula preservation showed grayish white color.(c)soleus muscle preserved by ethanol’s preservative formula preservation showed yellowish white color althea medical journal. 2016;3(3) 362 amj september 2016 as a preservative formula had no significant difference because the p-value was more than 0.05. thus, both preservative formulas had the same result in preserving the consistency of the tissue (table 3). both preservative formulas were able to inhibit the growth of bacteria on tissues (table 4). discussion better quality of tissue had been produced by using ethanol’s preservative formula compared to formalin’s preservative formula. firstly, in terms of color, tissues that were preserved by ethanol’s preservative formula were more similar to the tissues before preservation rather than formalin’s preservative formula. apparently in “substitution of formaldehyde in cross anatomy is possible” by hammer et al,8 tissues preserved by ethanol are better than tissues preserved by formalin, because tissues preserved by ethanol are easily distinguishable. tissues that were preserved by formalin’s preservative formula had grayish hue. this is because formaldehyde in formalin’s preservative formula converts hemoglobin into methaemoglobin which is purple or black in color.3 it will also cause the oxidation of ferrous iron which forms ferric oxide.3 therefore it gave the tissue a grayish appearance.3 hence, ethanol’s preservative table 2 odor of tissue before and after preservation odor formalin’s preservative formula ethanol’s preservative formula p-value (chi-square test) before no statistic computed because is constant stink 32 32 after 0.000 pungent 32 0 pleasant 0 32 table 3 consistency of tissue before and after preservation consistency formalin’s preservative formula ethanol’s preservative formula p-value (chi-square test) before 0.599 soft 16 16 moderate 16 16 after 0.599 moderate 16 16 hard 16 16 table 4 growth of bacteria on tissue before and after preservation growth of bacteria formalin’s preservative formula ethanol’s preservative formula before positive 32 32 after positive 0 0 negative 32 32 althea medical journal. 2016;3(3) 363see woan shian, arifin soenggono, sawkar vijay pramod: comparison of tissue preservation using formalin and ethanol as preservative formula formula showed better retention of color rather than formalin’s preservative formula. secondly, in terms of odor, the tissues that were preserved by ethanol’s preservative formula are pleasant because it contains high concentration of ethanol where its standard odor is pleasant.9 however, the odor of tissue preserved by formalin’s preservative formula is pungent because it contains formaldehyde where its standard odor is pungent or rather suffocating.3,6,8 however, both preservative formulas failed to retain the consistency of tissues. the reason of formalin’s preservative formula causes hardening of tissue is that formalin cross-links the protein and stabilizes the mass of tissue.3 on the other hand, ethanol’s preservative formula also causes hardening of tissue. this is because ethanol precipitates the protein molecules of tissues.10 both preservative formulas are able to inhibit the growth of bacteria on tissues. the reason of formalin’s preservative formula being able to inhibit the growth of bacteria is that formaldehyde acts as bactericides, germicides, and fungicides.1,4 this is because formaldehyde destroys the colloidal nature of molecule, and connects to amine group in protein molecules with nitrogen in a protein molecule by cross-linking.3,10 this will fix the cellular protein and therefore cannot be a nutrient source for bacteria.1 besides, ethanol’s preservative formula is also able to inhibit the growth of bacteria because it contains 70% ethanol which serves as antiseptic.4 this is due to its bactericidal activity by denaturation of proteins.10 in conclusion, ethanol’s preservative formula preserves better quality of tissue in color, odor and negative growth of bacteria. the limitation of this study was its inability to preserve all organs of the study subjects due to time limits. moreover, due to resource limitations, the method of humans killing laboratory animals can also be performed by administering xylazine or ketamine to reduce suffering of laboratory animals. besides, due to human resource limitations, there were only two observers to access the quality of tissues. apparently, the number of observers should increase to avoid bias. finally, a further study is recommended by changing the amount of sodium chloride in both preservative formulas into smaller percentage to improve the consistency of the tissue preservation. moreover, ethanol’s preservative formula can be recommended to replace formalin’s preservative formula to preserve cadavers for anatomy specimen due to lower health risk to the lecturers, technicians and students and its better quality of tissue preservation. references 1. natekar pe, desouza fm. a new embalming fluid for preserving cadavers. journal of krishna institute of medical sciences university. 2012;1(2):76–80 2. kalanjati vp, prasetiowati l, alimsardjono h. the use of lower formalin-containing embalming solution for anatomy cadaver preparation. med j indones. 2012;21(4):203–7 3. brenner e. human body preservation– old and new techniques. j anat. 2014;224(3):316–44. 4. bajrachary s, magar a. embalming: an art of preserving human body. kathmandu univ med j. 2006;4(4):554–7. 5. raja ds, sultana b. potential health hazards for students exposed to formaldehyde in the gross anatomy laboratory. j environ health. 2012;74(6):36–40. 6. onyije f,m avwioro og. excruciating effect of formaldehyde exposure to students in gross anatomy dissection laboratory. int j occup environ med. 2012;3(2):92– 5. 7. duval k, aubin ra, elliott j, gornhondermann i, birnboim hc, jonker d, et al. optimized manual and automated recovery of amplifiable dna from tissues preserved in buffered formalin and alcohol-based fixative. forensic sci int genet. 2010;4(2):80–8. 8. hammer n, löffler s, feja c, bechmann i, steinke h. substitution of formaldehyde in cross anatomy is possible. j natl cancer inst. 2011;103(7):610–1. 9. vincent jl, abraham e, kochanek p, moore fa, fink mp. textbook of critical care: expert consult premium. 6th ed. philadelphia: elsevier health sciences; 2011. 10. suvarna sk, layton c, bancroft jd. bancroft’s theory and practice of histological techniques. 7th ed. london: elsevier health sciences; 2012. althea medical journal. 2016;3(3) 392 amj september 2016 comparison of hip abductor and adductor muscle strength in taekwondo and non-taekwondo practitioners seet jia sheng,1 fachry ambia tandjung,2 marietta shanti prananta3 1faculty of medicine universitas padjadjaran, 2department of orthopedic & traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung , 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: taekwondo is an empty hand combat that entails the use of the whole body. spinning and turning kicks are the proper way of kicking in taekwondo which allow one to maximally perform the hip abductor and adductor muscles simultaneously. to measure the hip abductor and adductor muscles of taekwondo and non-taekwondo practitioners, hand-held dynamometer (hhd) is used. this study aimed to compare the hip abductor and adductor muscles strength in taekwondo and non-taekwondo practitioners. methods: this analytical study of paired continuous variable was conducted using cross-sectional method. thirty-two subjects were examined from september−october 2014 at the skills laboratory of faculty of medicine, universitas padjadjaran. sixteen of them were taekwondo practitioner and the other sixteen of them were non-taekwondo practitioner. gender, weight, height, body mass index (bmi) and maximum strength of hip abductor and adductor muscles were examined by using hand-held dynamometer (hhd). results: off all physical characteristics being examined, it showed that the p-values were above 0.5. the independent t-test showed that the average strength of hip abductors and adductors muscle in taekwondo and non-taekwondo practitioners were significantly different in which the both p-values were less than 0.05. conclusions: the maximum strength of hip abductor and adductor muscles of taekwondo and nontaekwondo practitioners were significantly different. the strength of hip abductors and adductors muscles is greater in taekwondo practitioners compared to non-taekwondo practitioners. [amj.2016;3(3):392–5] keywords: hand held dynamometer, hip abductor, hip adductor, taekwondo correspondence: seet jia sheng, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827563878 email: seetjiasheng@gmail.com introduction taekwondo is an empty hand combat that entails the use of the whole body. tae means “to kick” or “smash with the feet,” kwon implies “punching” or “destroying with the hand or fist,” and do means “way” or “method.”1 taekwondo is known for its use of high spin and jumping kicks. one of kind kicks, for instance, a roundhouse kick, requires one’s hip abductor and adductor muscles to strain and relax in order to perform a strong and quick kicks. given this, this study will focus on the hip abductor and adductor muscles, particularly in taekwondo and nontaekwondo practitioners.2 kisner and colby3 stated that strength is defined as the capability of either a single or a group of muscle, say by dynamically or can be statically, producing tension and a resulting force in one maximal effort, based on demands placed upon them. a dynamometer is a tool used specifically to measure the muscle strength. a hand-h dynamometer (hdd) is used in this study because the cost-is effective, affordable, and immensely reliable and valid compared to other dynamometers.4 two of the most basic kicks used in taekwondo are turning kick and roundhouse kick. both use more hip abductor and adductor muscles during the repeated training. in doing so, taekwondo practitioners might have a better development in strengthening their hip abductor and adductor muscles.5 therefore, this study t would like to examine the strength of hip abductor and adductor muscles in taekwondo practitioners and then compare it to non-taekwondo practitioners. althea medical journal. 2016;3(3) 393 methods this study was carried out from september− october 2014 at the skills laboratory, faculty of medicine, universitas padjadjaran. all subjects examined in this study were approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. hand-held dynamometer (hdd) was obtained from the department of physical medicine and rehabilitation, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung. the method used in this study was crosssectional study with random selection of sixteen taekwondo practitioners and sixteen non-taekwondo practitioners as subjects of the study. the inclusion criteria were yellowbelted and beyond taekwondo practitioners, students of universitas padjadjaran, bmi ranged from 18.5 to 24.9, aged 20 to 26 years old, and no current use of medication with cardiac or musculoskeletal effects; whereas, the exclusion criteria were white-belted taekwondo practitioners, overweight or underweight, and minimum history of extreme hip and ankle injury, and knee surgery. as for preparation, the subject was being assessed by the inclusion and exclusion criteria, the main goal and procedure of the examination were being explained. after agreeing to do the examination, the subject was asked to fill in the inform consent form. the dominant extremity was being confirmed, and then the subject was asked to lie on a flatsurface bed with their shoes taken off. the large curved transducer pad onto the hoggan microfet 2 hand-held dynamometer was installed and the power button was being turned on, finally the si unit was calibrated to 0.0 newton (n). after running the procedure, the first muscles group being examined was the hip abductor. the subject was asked to lay on sides with the lower extremity positioned straight and above the opposite limb, which was flexed to 90° at the hip and knee for stabilization. subsequently, the hand-held dynamometer transducer pad was placed on the distal femur close to the lateral knee.6 the subject was instructed to raise his/her examined limbs upward and rise as maximum as possible within 5 seconds, while the clinician directed the resistance to the subject’s abduction. the entire procedure was done three times on each subject. the first reading was not taken because it was a practice trial for the subjects to undergo the feeling of pushing against the dynamometer. the examination was then conducted twice at the same side with a total timing of 2 minutes. having finished the examination, the results were read from the lcd display, and being recorded in si unit of newton (n). afterwards, the hip adductor muscles were examined. the subject was asked to lay on sides with the lower extremity positioned straight and above the opposite limb, which was flexed to 90° at the hip and knee for stabilization. subsequently, the hand-held dynamometer transducer pad was placed on the medial surface of the distal femur close to the medial side of the knee.6 the subject was instructed to raise his/her examined limbs upward and rise as maximum as possible within 5 seconds, while the clinician directed the resistance to the subject’s abduction. the entire procedure was done three times on each subject. the first reading was not taken because it was a practice trial for the subjects to undergo the feeling of pushing against the dynamometer. the examination was then conducted twice at the same side with a total timing of 2 minutes. having finished the examination, the results were read from the lcd display, and being recorded in si unit of newton (n). the obtained data were numerical and paired variable, therefore, the strength of hip abductors and adductors muscles in taekwondo and non-taekwondo practitioners were analyzed statistically using the independent t-test. it was considered statistically significant when p< 0.05. the analysis was performed by comparing the strength of the hip abductors and adductors table 1 the physical characteristics of the subjects physical characteristics taekwondo practitioners non-taekwondo practitioners p-value weight (kg) 45-74 48-77 0.696 height (m) 1.5-1.83 1.53-1.8 0.668 bmi 1.87-24.2 18.8-24 0.797 note: bmi= body mass index seet jia sheng, fachry ambia tandjung, marietta shanti prananta: comparison of hip abductor and adductor muscle strength in taekwondo and non-taekwondo practitioners althea medical journal. 2016;3(3) 394 amj september 2016 muscles in taekwondo and non-taekwondo practitioners. results the p-value obtained for all physical characteristics were above 0.5. it indicated that the physical characteristics of the subjects were not significantly different; therefore, comparison can be made between both groups. the independent t-test showed that the average strength of hip abductors and adductors muscle in taekwondo and nontaekwondo practitioners were significantly different in which the p-values were less than 0.05. discussions the result showed that there were significant differences between the taekwondo and non-taekwondo practitioners. the null hypothesis which stated that there is no difference in the strength of hip abductors and adductors muscles among taekwondo and non-taekwondo practitioners is being rejected. there were few factors that led to the occurrence of this phenomenon. first, the difference occured due to the subjects’ physical characteristics, and the inclusion and exclusion criteria of this investigation. the chosen non-taekwondo practitioners were less active in exercising and working out in the day. although some of them were also athletes, they did not practice taekwondo in their daily life. in contrast, the maximum strength of abductors and adductors muscles was higher by comparing taekwondo practitioners to non-taekwondo practitioners. one of the most common and practiced kicks in taekwondo, dollyo chagi, a roundhouse kick, is a kick started with the foot moved upward upon the waist level bent in the knee and stand on the other foot, in which the practitioner turns his body around.7 when the knee of the attacking foot is in the same line pointing the target with the heel of the other foot, the round movement continues into a rapid stretching of the hitting foot.8 as the dollyo chagi is being performed, the kicking leg is being flexed first, and then extended. the adductors provide a useful source of flexor and extensor torque at the hip. the bidirectional torques is useful during high power kicking. the adductor longus has a flexor moment arm and generates a flexor torque similar to the rectus femoris. when the hip is near full flexion, the adductors are mechanically prepared to augment the extensors. the posterior fibers of the adductor magnus are powerful extensor of the hip, which have a similar function as the hamstrings muscles and the adductor longus has an extensor moment arm, and is capable of generating an extension torque similar to the posterior head of the adductor magnus.9 during kicking, a single limb in standing position is very dependent to the hip abductors. at this phase, the pelvis is comparable to a see-saw, with its fulcrum represented by the femoral head. when the see-saw is balanced, the hip abductor force (haf) is equal to the body weight (bw). balance of opposing torques is called static rotary equilibrium. during single limb support, the hip abductor muscles must produce a force twice of body weight in order to achieve stability.9 due to the repeated practice of hip abductors and adductors kinesiology, a taekwondo practitioner will have a greater strength in abductor and adductor muscles due to the repeated usage of hip muscles during the kicking in taekwondo.10 hence, taekwondo practitioners who often perform the kicks which frequently contract the hip abductors and adductors by repeatedly rotating the hip while swinging their legs, and the chances for the athletes in other fields such as tennis, badminton, table tennis, squash, bowling, basketball, and others to rotate table 2 the maximum strength of hip abductors and adductors in taekwondo and non taekwondo practitioners muscle strength range p-valuetaekwondo practitioners non-taekwondo practitioners hip abductors muscle strength (n) 298.972 225.956 0.000 hip adductors muscle strength (n) 246.109 187.841 0.001 note: bmi= body mass index althea medical journal. 2016;3(3) 395 their hips and contract hip abductors and adductors, are so much lesser.11 throughout the study, there were some exceptions. a futsal player and a swimmer were being examined for this study, and the results showed a big contrast between their abductor and adductor muscles strength compared to the nontaekwondo practitioners. the biases occurred due to the high strength of hip adductors muscle performance in futsal player, and high strength of both hip abductors and adductors muscles performance in swimmer, because a futsal player often kicks a ball with an external rotation of hip joint, and contractions of the hip adductors to produce a powerful kick12; whereas, a swimmer who always performs breaststroke, free-style stroke and butterfly style swimming, has the hip abductors and adductors that are developed well in order to produce a high hip rotational torque.13 fortunately, since the exception was a minor percentage in the large group, the average strength after all does not affect much. the limitation of the study was the difficulty in finding sufficient numbers of taekwondo practitioners who fulfilled the inclusion criteria to participate in the study. as at universitas padjadjaran, the taekwondo club has a very limited numbers of taekwondo practitioners, especially the female practitioners. it is recommended and preferred to obtain taekwondo practitioners from a larger taekwondo practitioner group, for example taekwondo indonesia, in order to gather sufficient numbers of taekwondo practitioner for future studies. in conclusion, the strength of hip abductors and adductors muscles in taekwondo practitioners is greater than in non-taekwondo practitioners. therefore, taekwondo training is also a recommended individual sport to build a better hip abductors and adductors muscle strength. nevertheless, universitas padjadjaran taekwondo club training method should be shared and implemented in other taekwondo communities in order to create more intense training and better development of hip abductors and adductors muscle in taekwondo practitioners. references 1. hsiao c, lin j, chang k. taekwondo sport development: the case of taiwan. or insight. 2010;23(3):154–71. 2. estevan i, falco c. mechanical analysis of the roundhouse kick according to height and distance in taekwondo. biol sport. 2013;30(4):275–9. 3. kisner c, colby la. therapeutic exercise: foundations and techniques. 6th ed. philadelphia: fa davis; 2012. 4. kelln bm, mckeon po, gontkof lm, hertel j. hand-held dynamometry: reliability of lower extremity muscle testing in healthy, physically active, young adults. j sport rehabil. 2008;17(2):160¬–70. 5. fong ss, tsang wwn, ng gy. lower limb joint sense, muscle strength and postural stability in adolescent taekwondo practitioners. international sportmed journal. 2013;14(2): 44–52. 6. chrisman sp, o’kane jw, polissar nl, tencer af, mack cd, levy mr, et al. strength and jump biomechanics of elite and recreational female youth soccer players. j athl train. 2012;47(6):609–15. 7. van dijk gp, lenssen a, leffers p, kingma h, lodder j. taekwondo training improves balance in volunteers over 40. front aging neurosci. 2013;5(10): 1–6. 8. lee kt, choi ys, lee yk, lee jp, young kw, park sy. extensor hallucis longus tendon injury in taekwondo athletes. phys ther sport. 2009;10(3):101–4. 9. neumann da. kinesiology of the musculoskeletal system: foundations for rehabilitation. 2nd ed. st. louis: elsevier health sciences; 2013. 10. bridge ca, da silva santos jf, chaabène h, pieter w, franchini e. physical and physiological profiles of taekwondo athletes. sports med. 2014;44(6):713–33. 11. cular d, krstulović s, katić r, primorac d, vucić d. predictors of fitness status on success in taekwondo. coll antropol. 2013;37(4):1267–74. 12. nasiri m, salehian mh. comparison of flexibility of pelvic and femoral muscles in futsal, weightlifting and swimming. annals of biological research. 2011;2(6):79–83. 13. grote k, lincoln tl, gamble jg. hip adductor injury in competitive swimmers. am j sports med. 2004;32(1):104–8. seet jia sheng, fachry ambia tandjung, marietta shanti prananta: comparison of hip abductor and adductor muscle strength in taekwondo and non-taekwondo practitioners althea medical journal. 2016;3(3) 411 comparison of age of thelarche between obese and normal girls yunitasari,1 r.m.ryadi fadil,2 fenny dwiyatnaningrum3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: childhood obesity has become a major concern in recent years. the increasing childhood obesity prevalence may occur as the result of food consumption with high content of calories, fat, cholesterol and the lack of physical activity. obesity in children will also affect their pubertal development. puberty is a period in which maturation of the reproductive function is achieved.in girls, the initial sign of puberty is thelarche, defined as the appearance of breast bud underneath the areola.the onset of puberty depends on many factors, one of them is nutritional status especially obesity. this study was conducted to compare the age of thelarche between obese and normal girls. methods: an analytical study using cross sectional method was conducted. this study was held in bandung, west java, indonesia, during the period of septemberoctober 2013. data were obtained from 3 elementary schools, selected by multistage random sampling.the total subject was 46. data were analyzed using the mann-whitney and chi-square test. results: thelarche occurred at age 9 years 4 months in the obese group compared to 11 years 2 months in the normal group. the analysis using mann-whitney test showed the difference was statistically significant (p<0.001). based on age group, 42% obese girls attained thelarche between ages 89 years, while 63% girls in the normal group attained thelarche between ages 1112 years. the analysis using chisquare test showed that the difference was statistically significant (p<0.001). conclusions: thelarche occurs earlier in obese girls compared to normal girls. [amj.2016;3(3):411–5] keywords: obesity, pubertal onset, thelarche correspondence: yunitasari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 82116222811 email: yunitasari2020@yahoo.com introduction childhood obesity has become a major concern in recent years. the world prevalence had increased from 4.2% in 1990 to 6.7% in 2010.1 in indonesia, based on data from the ministry of health in 2010, the national prevalence rate of obesity in children aged 6–12 years reached 9.2% with higher prevalence in boys (10.7%) compared to girls (7.7%).2 this may occur as the result of food consumption with high content of calories, fat, cholesterol and the lack of physical activity.3 obesity in children is associated with significant morbidities, such as obstructive sleep apnea syndrome, insulin resistance, hypertension, dyslipidemia, gallstones, and neurological problems. these complications may not become apparent until several years later.4 in addition, obesity in children will affect their pubertal development.5 puberty is a period of transition from childhood into adulthood in which development of secondary sexual characteristics starts to appear and maturation of the reproductive function is achieved. in general, girls start to develop puberty at 8–12 years of age. thelarche is the initial sign of puberty in girls, defined as the appearance of breast bud underneath the areola. based on tanner classification of breast development, thelarce is defined as tanner stage 2. the onset of puberty depends on many factors, one of them is the nutritional status especially obesity.5 a research in the united states by rosenfield et al.6 found that the prevalence of breast appearance (tanner stage 2) at ages 8–9.6 years was higher in girls with excessive body mass index (bmi) althea medical journal. 2016;3(3) 412 amj september 2016 compared to those with normal bmi. furthermore, abnormal puberty could also lead to various medical and psychological problems. short stature, polycystic ovary syndrome (pcos), menstrual disorder, and breast cancer may arise as the consequences of early puberty in girls. psychosocial effects are especially a major concern in girls with precocious puberty. these girls may have poor self-esteem resulting from feeling of being different from their peers. they are also at risk for depression, anxiety, sexual abuse, risky sexual behavior (such as multiple sexual partner), unwanted pregnancy, behavioral and eating disorder.7 the aim of this study was to compare the age of thelarche between obese and normal girls. methods an analytical study using cross sectional method was conducted. this study was held in bandung, west java, indonesia, during the period of september to october 2013. girls aged 8–12 years who experienced thelarche were included in this study. data were obtained from west, central and east bandung regions. each of the three regions was represented by one elementary school (sekolah dasar/sd) which was selected by multistage random sampling. in the first stage, randomization was done at the district level, the three selected districts were bandung kulon, sumur bandung and mandalajati, each represented west, central and east bandung regions, respectively. in the second stage, randomization was performed at the school level in each district, the three selected schools were sd negeri tunas harapan, sd kartika siliwangi ix–1, and sd negeri jatihandap 2. this study has been approved by the health research ethics committee and bandung education department. thelarche was defined as the appearance of breast bud underneath the areola, or tanner stadium 2. the thelarche status was not measured by physical examination because of ethical reasons. therefore, mothers were asked to fill a questionnaire which contained tanner stage images of breast development with description of every stage to be matched with her daughter’s condition. before the questionnaire fulfillment, mothers were invited to school and given adequate explanation about the study and how to fill the questionnaire to minimize misunderstanding. the age of thelarche was measured from the date of birth until the date of questionnaire fulfillment. the age of 8–8 years 11 months were included in the 8–9 age group, 9–9 years 11 months in the 9–10 age group, 10–10 years 11 months in the 10–11 age group, and 11–12 years in the 11–12 age group. the manual weighing scale was used to measure body weight (kg), while body height was measured by microtoise (cm), both were calibrated during the measurement. the world health organization (who) anthroplus software version 1.0.4 was used to calculate bmi according to sex and age. based on the 2007 who reference, standard deviation (sd) of >+2 were classified as obese, while +1 until -2 were classified as normal. moreover, subjects were excluded if the questionnaire fulfillment was incomplete, they had chronic disease(s) or other disease(s) which could interfere their growth and development (for example thalassemia, tuberculosis, or heart disease), or if they were undergoing hormonal treatment. from the three schools mentioned above, there were 376 girls aged 8–12 years. out of the 376 girls, 205 met the inclusion criteria after consent from their parents were obtained. from these 205 girls, 108 were excluded because of incomplete questionnaire fulfillment. from 97 girls who completed the questionnaire, 68 girls were in tanner stage 2. after the bmi according to sex and age was calculated, 19 girls were included in the obese group, and 27 girls with normal bmi were recruited for the comparison group. thus, the total subject in this study was 46. data were analyzed using the mann-whitney and chi-square test it was considered statistically significant when p≤0.05. results the distribution of data was not normal; therefore median was used to describe the findings in this study. the age of subjects was younger in the obese group compared to the normal group. when the age of subjects was divided into groups, most subjects came from the 8–9 age group in obese girls and the 11–12 age group in normal girls. the body weight was higher in the obese group compared to the normal group. conversely, body height was higher in the normal group compared to the obese group. body mass index according to sex and age was calculated using the z-score. based on this calculation, median bmi in the obese group was higher than the normal group (table 1). althea medical journal. 2016;3(3) 413yunitasari, r.m.ryadi fadil, fenny dwiyatnaningrum: comparison of age of thelarche between obese and normal girls when the age of subjects was divided into groups, the difference in the age of thelarche was clearly visible between the obese and normal group (table 3). in the obese group, most girls attained thelarche at the 8–9 age group; there was only one girl who attained thelarche at the 11–12 age group. otherwise, in the normal group, most girls attained thelarche at the 11–12 age group. the statistical analysis using chisquare test showed that the difference in the age of thelarche between the obese and normal group was statistically significant (p<0.001). discussion the data above showed that thelarche occured earlier in obese girls compared to girls with normal bmi, and the difference was statistically significant. this finding is consistent with a study in padang by rini et al.8 who found that obese girls started puberty at 121 months compared to 132.43 months in girls with normal bmi, although there was no table 1 respondents characteristics characteristics obese normal n (%) mean (sd) median n (%) mean (sd) median age (years old) 9.36 (1.00) 9.33 10.89 (0.96) 11.17 8–9 8 (42) 2 (7) 9–10 5 (26) 2 (7) 10–11 5 (26) 6 (22) 11–12 1 (5) 17 (63) body weight (kg) 42.80 (7.59) 45.00 34.15 (6.07) 36.00 body height (cm) 132.04 (8.25) 133.50 141.85 (8.46) 143.10 bmi-for-age(z-score) 2.49 (0.46) 2.28 -0.29 (0.83) -0.33 total 19 (100) 27 (100) note: sd=standard deviation table 2 comparison of age of thelarche between obese and normal girls n age of thelarche (years old) p mean (sd) median minimum–maximum obese 19 9.36 (1.00) 9.33 8.00–11.42 <0.001 normal 27 10.89 (0.96) 11.17 8.00–11.83 note: sd=standard deviation; mann-whitney test table 3 comparison of age of thelarche between obese and normal girls based on age group age of thelarche (years old) p8–9 9–10 10–11 11–12 total n (%) n (%) n (%) n (%) n (%) bmi obese 8 (42) 5 (26) 5 (26) 1 (5) 19 (100) <0.001 normal 2 (7) 2 (7) 6 (22) 17 (63) 27 (100) total 10 (22) 7 (15) 11 (24) 18 (39) 46 (100) note: chi-square test; bmi=body mass index althea medical journal. 2016;3(3) 414 amj september 2016 significant relationship between bmi and the age of pubertal onset (p=0.08). additionally, rosenfield et al.6 compared attainment of stage 2 breast development in girls with normal and excessive bmi from the third national health and nutrition examination survey (nhanes iii) subjects, and this study found that girls with excessive bmi were more likely to exhibit tanner stage 2 at ages 8 (or: 3.86) through 9.6 (or: 2.02) years compared to those with normal bmi. the critical weight hypothesis proposed by frischand revelle9 in 1971 may serve as an explanation for the above findings. according to this hypothesis, certain minimum body fat is needed for pubertal development. this theory emphasizes leptin, a hormone produced by adipocytes, as the main actor in this process. leptin has the capability to send signals to the hypothalamus regarding body fat storage. thus, as soon as the body fat storage is sufficient, leptin will send signal to the hypotalamus to activate gonadotropinreleasing hormone(gnrh) which will stimulate gonadotropin secretion. normally, thelarche in puberty reflects the activation of gnrh-gonadotropin axis. however, in obese children, a further study may be needed to find out whether or not the earlier thelarche is also preceded by maturation of this axis, because estrogen from any source can stimulate breast tissue development. furthermore, adipose tissue contains aromatase which is able to produce estrogen from adrenal androgen precursor. therefore, estrogenization in obesity may occur without hypotalamus-pituitary-ovarium axis maturation.5 this theory was supported by jasik and lustig10 who found that the tempo of pubertal development (time from thelarche to menarche) was slowed in obese girls, this may suggest estrogenization without central maturation. as a consideration, weight gain during puberty is physiologic since the increased estrogen secretion will stimulate the growth of adipose tissue. thus, early puberty from any cause could result in increase adiposity.5 current studies showed inconsistent results regarding the definite direction of causation between adiposity and sexual maturation. however, a longitudinal study by lee et al.11 examined the association between the weight status in early childhood and the onset of puberty. parents and children were recruited through hospital visits to mothers shortly after birth in 1991. anthropometric data were measured during laboratory visits at 36 months, 54 months, and grade 1, 4, 5, 6, while puberty status was measured when girls were in grade 4–6. the result of this study found that starting at 36 months of age, higher bmi z-score at all of the ages was strongly associated with an earlier onset of puberty. this finding showed that obesity preceded early onset of puberty rather than earlier puberty result in adiposity. there were several limitations in this study. the questionnaire filled out by mothers could lead to subjectivity in the assessment of thelarche, therefore physical examination (inspection and palpation) by experts is preferable to minimize subjectivity. the used of bmi as a measurement for nutritional status in this study could result in missclassification since it could not distinguish between weight caused by fat and muscle tissue. in addition, the method in this study could not be used to classify girls with earlier or later onset of thelarche as having precocious or delayed puberty, because the subjects of this study were taken from 8–12 years age range, which is the normal age range for puberty. in conclusion, thelarche occurs earlier in obese girls compared to normal girls. suggestions for a future study are to increase the sample size and involve other pubertal milestones (pubarche, menarche) in the measurement . references 1. de onis m, blössner m, borghi e. global prevalence and trends of overweight and obesity among preschool children. am j clinnutr.2010;92(5):1257–64. 2. badan penelitian dan pengembangan kesehatan kementerian kesehatan republikindonesia. status gizianakumur 6–12 tahun.dalam:riset kesehatan dasar 2010. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan republikindonesia; 2010. 3. hidayati sn, irawan r, hidayat b. obesitas pada anak. divisi nutrisi dan penyakit metabolik bagian/smf ilmu kesehatan anakfakultas kedokteran unair/rs dr soetomo. pediatrik[online journal] 2006 [cited in february17th 2013]. available at:http://old.pediatrik.com. 4. lee ys. consequences of childhood obesity. ann acad med singapore. 2009;38(1):75– 7. 5. solorzano cmb, mccartney cr. obesity and the pubertal transition in girls and boys. reproduction. 2010;140(3):399–410. 6. rosenfield rl, lipton rb, drum ml. althea medical journal. 2016;3(3) 415 7. rosenfield rl, lipton rb, drum ml. thelarche, pubarche, and menarche attainment in children with normal and elevated body mass index. pediatrics. 2009;123(1):84–8. 8. golub ms, collman gw, foster pm, kimmel ca, rajpert-de meyts e, reiter eo, et al. public health implications of altered puberty timing. pediatrics. 2008;121suppl3:s218–s30. 9. rini ea, desdamona e. usia awitan pubertas dan beberapa faktor yang berhubungan pada murid sd di kota padang. sari pediatri. 2007;9(4):227–32. 10. frisch re, revelle r. height and weight at menarche and a hypothesis of menarche. arch dis child.1971;46(249):695–701. 11. jasik cb, lustig rh. adolescent obesity and puberty: the “perfect storm”. ann n y acad sci. 2008;1135(1):265–79. 12. lee jm, appugliese d, kaciroti n, corwyn rf, bradley rh, lumeng jc. weight status in young girls and the onset of puberty. pediatrics. 2007;119(3):e624–30. yunitasari, r.m.ryadi fadil, fenny dwiyatnaningrum: comparison of age of thelarche between obese and normal girls althea medical journal. 2016;3(2) 212 amj june 2016 association between intrauterine growth restriction and pregnancy hypertension nada ardilla dwiayu febrina,1 aris primadi,2 bony wiem lestari3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of epidemiology and biostatistics, faculty of medicine universitas padjadjaran abstract background: intrauterine growth restriction (iugr) certainly poses health problems that leads to increase mortality and can cause mental and physiological disturbances to the infants. reduced organ perfusion is one of the etiologies of iugr which is caused by placenta obstruction. this happens because of pregnancy hypertension as a risk factor. furthermore, educational level, employment status, parity, and anemia are also its risk factors. the objective of this study was to analyze the prevalence of iugr and association between iugr and pregnancy hypertension. methods: a case control design was performed using medical records from neonatology department of child health at dr. hasan sadikin general hospital bandung in 2012. subjects were taken from 149 medical records of the mother who had iugr and 149 normal birth weight infant information about the characteristics of the mothers and the infants. the data were collected and analyzed by calculating the odds ratio (or). results: the prevalence of iugr at dr. hasan sadikin general hospital in 2012 was 149 cases (4.69%). there was association between pregnancy hypertension and iugr with or=1.72, 95% ci (1.044–2.836). conclusions: pregnancy hypertension is one of the risks that generates iugr. [amj.2016;3(2):212–5] keywords: intrauterine growth restriction, pregnancy hypertension, risk factor correspondence: nada ardilla dwiayu febrina, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281214700740 email: nadaardilla@gmail.com introduction intrauterine growth restriction (iugr) is still one of the health problems and is closely related to mortality.1-3 the mortality risk ratio of iugr ranges from six to ten times higher compared to a normal infant.1 the iugr can also cause retarded physiology as well as lower intellectual scale 1 level compared to infants with normal weight.4 in indonesia, during 2004–2005, the prevalence of iugr was 4.4 %.5 the iugr babies have been associated with cardiovascular disease in pregnancy. one of the factors that have been postulated to influence the iugr risk among the newborn is hypertension.6-8 furthermore, educational level, employment status, parity, and anemia are among others of the the risk factors. in pakistan, muhammad et al.7 discovered that in 2010, pregnancy hypertension had a high risk causing iugr with or (odds ratio)=3.8. this study was conducted to identify the association between iugr and pregnancy hypertension. methods this study was analytical study with case control design and used secondary data (medical records) from neonatology department of child health at dr. hasan sadikin general hospital bandung in 2012. the criteria of iugr interpreted by the lubchenco curve were inputted when the infant weight were less than 10% of the least weight that should be achieved at a particular gestational age. from 185 medical records consisting of iugr babies data, only 149 medical records that fulfilled the inclusion criteria, namely data of patient’s characteristic such as educational level, employment status, parity, anemia, and hypertension. the control group was medical records consisted of normal birth weight babies data that also met the similar inclusion criteria. the ratio of case and control group of this althea medical journal. 2016;3(2) 213 research was 1:1. the selected control group was matched by simple random sampling based on patients age from case group (16–44 years old). the exclusion criteria were those data of incomplete variable, double pregnancy, and infants whose weight are beyond 500 grams. clinical criteria of pregnancy hypertension table 1 prevalence of iugr at dr. hasan sadikin general hospital bandung intrauterine growth n % intrauterine growth restriction 149 4.69 normal and large for gestational age 3025 95.3 total 3174 100 implying bp ≥140/90 and all classifications of pregnancy hypertension were included. the collected data were analyzed using computer and presented by frequency distribution. statistical analysis was conducted by calculated odd ratio, confidence interval, and chi square test. table 2 characteristics of mothers with intrauterine growth restriction at dr. hasan sadikin general hospital bandung variable intrauterine growth restriction or(95%ci)yes no n % n % age (years old) < 18 2 50 2 50 1 18–34 111 50 111 50 ≥ 35 36 50 36 50 educational level elementary school 38 57.6 28 42.4 1.479 (0.852–2.569) junior high school 49 49.5 50 50.5 0.97 senior high school 43 47.8 47 52.2 0.88 diploma 11 52.4 10 47.6 1 bachelor 8 36.4 14 63.6 0.547 employment status employment 31 54.4 26 45.6 1.243 (0.696–2.218) unemployment 118 49 123 51 parity nullipara 65 48.9 68 51.1 0.922 primipara 47 58 34 41.9 1.559 (1.931–2.610) multipara 34 42.5 46 57.5 0.662 grand multipara 3 75 1 25 3.041 (0.313–29.574) anemia yes 34 22.8 34 22.8 1 no 115 77.2 115 77.2 gestational age (week) 36.83(2.26) 38.34(1.8) infant weight (gr) 2121.97(411.2) 2994(542.52) nada ardilla dwiayu febrina, aris primadi, bony wiem lestari: association between intrauterine growth restriction and pregnancy hypertension althea medical journal. 2016;3(2) 214 amj june 2016 results prevalence of iugr at dr. hasan sadikin general hospital bandung in 2012 was 185 cases from 3174 labor. from the total incidence of iugr, there were 149 cases put into criteria inclusion and the others (36 cases) put into criteria exclusion because the incomplete variables were requested. so, prevalence of iugr at dr. hasan sadikin general hospital bandung in 2012 was 4.69%. mothers with low education tend to have iugr 1.479 times compared to mother with higher education. based on employment status, iugr cases were discovered 1.243 times in employed mothers compared to non employed mothers. moreover, iugr cases were discovered in grand multipara mothers 3.041 times compared to non grand multipara cases. however, anemia was not the higher risk to generate iugr cases because the odds ratio was 1 (table 2). the iugr cases occured more often in pregnancy hypertension cases (59.3%) (table 3). statistical analysis using chi square test with 95% accuracy revealed that odds ratio of iugr cases in pregnancy hypertension was 1.72. discussions the prevalence of iugr at dr. hasan sadikin general hospital bandung in 2012 was 4.6%. this result was similar to a study in indonesia5 during 2004–2005 that revealed the prevalence of iugr was 4.4 %.5 the result in this study showed that iugr cases were discovered in mothers with low education. this study had result with the study conducted in pakistan.7 the study result showed that the majority of iugr cases were from illiterate mothers (88.8%). based on study in 2010 by muhammad et al.7, mother who was grand multipara was 12%. in this study, mother who was grand multipara was 75%. study by de farias aragao et al.9 also discovered that maternal education and parity were associated with iugr. the percentage in mothers with anemia associated with iugr in this study was 22.8% and this result had the similar result to the study in pakistan that in iugr cases, 15% mothers have anemia.7 the iugr cases occured more often in pregnancy hypertension cases. pregnancy hypertension tend to have iugr cases 1.72 times more than non pregnancy hypertension. a similar result was discovered in a study by kalanithi et al.2 in 2007, which explained that there was a significant relationship between hypertension in pregnancy and iugr (p<0.001), which means a high risk of hypertension in pregnancy will cause iugr. another study in norway11 in 2006, discovered that severe preeclampsia, one of the classifications of pregnancy hypertension, had risk of iugr with or=1.8. study from maryland12 also had a similar result that pregnancy hypertension was significantly associated with high risk of iugr with or=1.5 for preeclampsia-eclampsia as pregnancy hypertension. moreover, a study conducted by muhammad et al.7 in pakistan, discovered that hypertension in pregnancy has a higher risk of causing iugr with or=3.8. the study had limitation. using medical records as source of data has disadvantages. not all the information requested in this study were available. from 185 medical records selected, 36 of them were excluded. it can be concluded that pregnancy hypertension is the risk to generate iugr cases. references 1. prawirohardjo s. ilmu kebidanan. 4thed. jakarta: pt. bina pustaka; 2009. 2. kalanithi leg, illuzzi jl, nossov vb, table 3 iugr cases based on pregnancy hypertension at dr. hasan sadikin general hospital bandung variable intrauterine growth restriction p*) or(95%ci) yes no (n=149) (n=149) n % n % pregnancy hypertension yes 54 59.3 37 40.7 0.032 1.721(1.044–2.836) no 95 45.9 112 54.1 note: *) chi square test or = odds ratio ci = confidence interval althea medical journal. 2016;3(2) 215nada ardilla dwiayu febrina, aris primadi, bony wiem lestari: association between intrauterine growth restriction and pregnancy hypertension frisbaek y, abdel-razeq s, copel ja, et al. intrauterine growth restriction and placental location. j ultrasound med. 2007;26(11):1481–9. 3. bernstein im, horbar jd, badger gj, ohlsson a, golan a. morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. am j obstet gynecol. 2000;182(1 pt 1):198– 206. 4. sistiarani c. faktor maternal dan kualitas pelayanan antenatal yang berisiko terhadap kejadian berat badan lahir rendah [thesis]. semarang: universitas diponegoro; 2008. 5. christian hs. berat bayi lahir rendah sesuai untuk masa kehamilan [thesis]. jakarta: universitas kristen krida wacana; 2006. 6. sibai bm. intergenerational factors: a missing link for preeclampsia, fetal growth restriction, and cardiovascular disease? hypertension. 2008;51(4):993–4. 7. muhammad t, khattak aa, shafiqur-rehman, khan ma, khan a, khan ma. maternal factors associated with intrauterine growth restriction. j ayub med coll abbottabad. 2010;22(4):64–9. 8. baulon e, fraser wd, piedboeuf b, buekens p, xiong x. pregnancy-induced hypertension and infant growth at 28 and 42 days postpartum. bmc pregnancy childbirth. 2005;5:10. 9. de farias aragao vm, barbieri ma, moura da silva aa, bettiol h, ribeiro vs. risk factor for intrauterine growth restriction: a comparison between two brazilian cities. pediatr res. 2005;57(5 pt 1):674–9. 10. aghamolaei t, eftekhar h, zare s. risk factors associated with intrauterine growth retardation in bandar abbas. j med sci. 2007;7(4):665–9. 11. rasmussen s, irgens lm. the effects of smoking and hypertensive disorders on fetal growth. bmc pregnancy childbirth. 2006;6:16. 12. wen x, triche ew, hogan jw, shenassa ed, buka sl. prenatal factors for childhood blood pressure mediated by intrauterine and/or childhood growth? pediatrics. 2011;127(3):e713–21. althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 608 amj december, 2015 knowledge and risk factors for osteoporosis among pre-elderly muhammad ramdhani,1 dicky mulyadi,2 nita arisanti3 1faculty of medicine, universitas padjadjaran, 2department of orthopaedics and traumatology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung,, 3departement of public health, faculty of medicine, universitas padjadjaran abstract background: osteoporosis is a disease characterized by abnormal loss of bone density resulting in bones that are brittle and liable to fracture. most cases of fracture in the world are due to osteoporosis. in indonesia, the prevalence of osteopenia (early osteoporosis) and of osteoporosis are relatively high. one of the causes of this situation is the low level of public knowledge about how to prevent osteoporosis. this study was conducted to identify the knowledge and risk of osteoporosis among pre-elderly at cipacing village jatinangor district in 2014. methods: this descriptive study was conducted at cipacing village jatinangor district to 160 respondents who were classified as pre-elderly (aged 45-59 years) and assessed on knowledge and risk factors for osteoporosis through questionnaire-guided interviews after the informed consent was obtained.the collected data were presented using frequency distribution. results: a total of 100 respondents (62.5%) had good knowledge about osteoporosis-related information, including definitions, causes, risk factors, signs and symptoms, impacts, and prevention. most respondents, 79 respondents (49.4%), are at risk for osteoporosis. conclusions: knowledge of osteoporosis among pre-elderly at cipacing village jatinangor district are largely classified into “good knowledge” category. [amj.2015;2(4):608–14] keywords: knowledge, osteoporosis, pre-elderly, risk correspondence: muhammad ramdhani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 853 796 79900 email: ramdhani210294@gmail.com introduction osteoporosis is a disease which is characterized by reduced bone mass and increased bone fragility and the bone turned to be easily fractured.1 in 2005, the nutrition development and research center of the department of health, republic of indonesia collected data about the risk of osteoporosis using a sample of 65.727 people in sixteen regions in indonesia (including west java) by using the bone mass density (bmd) examination as the method and the clinical bone sonometer as diagnostic tool, and found the prevalence of osteopenia (early osteoporosis) was 41.7% and of osteoporosis was 10.3% respectively. this evidently showed that two out of five of the indonesian population, are at risk of osteoporosis.2,3 this high risk of osteoporosis in indonesia is caused by the increasing life expectancy of indonesian population, which in 2005 reached 67.68 years. unfortunately, the public knowledge about how to prevent osteoporosis is still low. this was proven by the low intake of calcium among indonesian population.2 in 2012, from the data of population based on age group in jatinangor district, it was found that cipacing village had the biggest number of population aged 40 years and older as many as 2,617 people. from interviews with the puskesmas (public health center) staff in jatinangor district, it was also known that data about risk of osteoporosis in thecommunity was not recorded because the bone mass density screening tool was not available. therefore, this study was conducted to assess the knowledge and risk of osteoporosis among pre-elderly at cipacing village, jatinangor district in 2014. methods this study was a descriptive method, conducted at cipacing village, jatinangor althea medical journal. 2015;2(4) 609 district, from september to october 2014. all the questions in the questionnaire which were delivered to the respondents in this study had been approved by the health research ethics committee faculty of medicine universitas padjdadjaran. the population of this study was people who lived at cipacing village jatinangor district. the inclusion criteria of this study were people who lived at cipacing village who pertained to the pre-elderly (aged 45–59 years) and were willing to be respondents. the exclusion criteria of this study were respondents who filled in the questionnaire incorrectly or incompletely. furthermore, the sample size in this quantitative study was calculated using the formula of sample size calculation in a descriptive categorical study. next, the samples were selected by using the simple random sampling technique. then, from the 18 rukun warga (rw) in cipacing village, the number of samples of each rw was determined by calculating the proportion. the proportion of each rw was calculated by multiplying the number of pre-elderly population in the rw with the minimum amount of sample (150 respondents) and then the result was divided by the total of pre-elderly population in cipacing village (2,794 people). from the calculation of the proportion, the number of samples was known to be 160 respondents. the primary data of this study, including the demographic characteristics of the respondents, knowledge, and the risk of osteoporosis, was obtained through a questionnaire-guided interview method. in this study, there were two questionnaires, one was about “knowledge of osteoporosis (questionnaire i)” and the other was about “one minute test of osteoporosis risk (questionnaire ii)”. questionnaire i which consisted of 10 questions with guttman scale (true or false) was associated with knowledge of osteoporosis: definitions, causes, risk factors, signs and symptoms, effects, and prevention. a value of 1 was given for each correct answer and 0 for each wrong answer so that the highest value was 10 and the lowest value was 0. in this study, the cut-off point was used to categorize the respondents’ knowledge. since the data distribution of the total knowledge score was not normal, the cut-off point of 7 was obtained from the value of the median total score of all respondents. good level of knowledge was if the total score obtained by the respondent was ≥ 7, while poor level of knowledge was if the total score obtained by the respondent was <7. this questionnaire was a modification taken from a previous study, which has been considered to meet the criteria of validity, while the reliability test was performed in this study.4 questionnaire ii which consisted of ten questions with guttman scale (yes or no) was associated with the risk of osteoporosis: family history, history of fractures, corticosteroid treatment, decrease in height, alcohol consumption and smoking, history of diarrhea and gastrointestinal diseases, premature menopause and menstruation disorders (for female respondents), and impotence or decreased of libido (for male respondents). the questionnaire was developed by the international osteoporosis foundation (iof) and has been translated into indonesian language by the ministry of health republic of indonesia.2 based on the iof, respondent who answered “yes” on at least one of the questions, belong to at risk for osteoporosis category, while respondent who answered “no” to all questions, belong to not at risk for osteoporosis category. the questionnaire was considered to meet the criteria of validity and reliability. furthermore, the collected data was processed by computer using the microsoft excel and statistical software. the data analysis, scoring, until the determination of the category was performed by using the microsoft excel. the frequency and percentage of respondents who belonged to each group of variables based on the category was then calculated. the calculation of the frequency and percentage of respondents who went to each group of variables were calculated and analyzed by using statistical software. the results of this study data was presented in tabular form. results this study was conducted in march–november 2014. the data collection was performed from 11to30 september 2014 in 18 rws in cipacing village, jatinangor district. the study involved 160 respondents who were classified as preelderly (aged 45–59 years old). table 1 shows the distribution of respondents’ characteristics involved in this study. variables in the table were age, sex, education, and occupation. the respondents’ age ranged from 45 years to 59 years (table 1). the mean, median, and mode were not on the same number, which showed that the age data in this study were not normally distributed. muhammad ramdhani, dicky mulyadi, nita arisanti: knowledge and risk factors for osteoporosis among pre-elderly althea medical journal. 2015;2(4) 610 amj december, 2015 therefore, the average age was using the median value, i.e. 50.5 years. most common age of the respondents was 45 years. the table also shows that the respondents were dominated by female with the percentage 84.4%, while male respondent were only 15.6%. most of the respondents’ education level was elementary school, with a total of 66 respondents (41.3%). three respondents who were not in school (1.9%) showed the education level for pre-elderly at cipacing village was not evenly distributed. the majority of female respondents were housewives (72.5%), so the percentage of unemployed respondents became large (77.5%). also, most of the respondents were entrepreneur (15%). one hundred respondents (62.5%) had a good knowledge of osteoporosis-related information, including definitions, causes, risk factors, signs and symptoms, effects, and prevention (table 2). however, a total of 60 respondents (37.5%) respondents had poor knowledge of osteoporosis-related information. from the distribution of respondents’ table 1 demographic characteristics of respondents characteristics frequency (n) percentage (%) age mean = 50,93 years old median = 50,5 years old mode = 45 years old range = 45–59 years old sd = 4,55 gender male 25 15.6 female 135 84.4 education none 3 1.9 elementary school 66 41.3 junior high school 43 26.9 senior high school 42 26.3 diploma (d1/d2/d3) 1 0.6 undergraduate /s2/s3 5 3.1 occupation not employed 124 77.5 housewife 116 72.5 employed 36 22.5 police 1 0.6 security guard 1 0.6 civil employee 2 1.3 farmer 4 2.5 teacher 4 2.5 entrepreneur 24 15 althea medical journal. 2015;2(4) 611 table 2 category of knowledge and risk for osteoporosis category frequency (n) percentage (%) knowledge good 100 62.5 poor 60 37.5 risk at risk 79 49.4 not at risk 81 50.6 knowledge questionnaire, more than 80% of respondents understood well the definition, causes, and effects of osteoporosis. however, the majority of respondents still believed that women and men had the same risk of osteoporosis, which in fact is women are more at risk of osteoporosis, especially those who have entered the menopausal stage. this could be seen since only 33 respondents (20.6%) were able to answer correctly to this question. in contrast, more than 80% of respondents knew that long term immobility affected the high risk of osteoporosis. seventy respondents (43.8%) knew that the sudden pain felt when bending is one of the symptoms of osteoporosis. related to the prevention of osteoporosis, 149 respondents (93.1%) knew that the morning sun was a good source of vitamin d that was good for bone density. a total of 105 respondents (65.6%) knew that simple exercises such as brisk walking, running, and rope jumping can help maintain bone density. however, only 55 respondents (34.4%) were aware that the source of calcium was not only milk. the majority of respondents still assumed that calcium can only be obtained by consuming milk. table 2 shows that almost half of the respondents were at risk for osteoporosis, with a total of 79 respondents (49.4%). table 3 shows 26 respondents (16.3%) had parents who were diagnosed with osteoporosis or had hip fractures due to falls or minor collision, either the father or the mother. in addition, 11 respondents (6.9%) claimed to have suffered fractures due to falls or minor table 3 distribution of respondents’ answer on risk for osteoporosis variables question answer “yes” frequency (n) percentage (%) 1. parents have been diagnosed with osteoporosis or have a hip fracture due to a relatively mild fall or collision 26 16.3 2. had fracture due to a relatively mild fall or collision 11 6.9 3. had been taking corticosteroids medication (cortisone, prednisone, etc.) for more than three months 9 5.6 4. height has reduced by more than 3 cm 18 11.3 5. drinking alcohol regularly (beer, palm wine, whiskey, etc.) 2 1.3 6. smoking more than 20 cigarettes a day 9 5.6 7. often suffering from diarrhea (e.g. gastrointestinal diseases) 17 10.6 8. have menopause before the age of 45 years (for female respondent) 18 13.3 9. menstruation has stopped (amenorrhea) for 12 months or more, except for pregnancy or menopause (for female respondent) 9 6.7 10. has experienced having impotence, decreased libido or other symptoms related to low testosterone levels (for male respondent) 8 32 muhammad ramdhani, dicky mulyadi, nita arisanti: knowledge and risk factors for osteoporosis among pre-elderly althea medical journal. 2015;2(4) 612 amj december, 2015 collision. out of 160 respondents, nine (5.6%) admitted to taking corticosteroid drugs within a period of more than three months, where as it is known that the use of corticosteroid medications for a long time can affect bone density. this can occur due to the purchase of corticosteroid drugs without a prescription. on the other hand, 18 respondents (11.3%) felt their height had reduced 3 cm from the previous heights. these 18 respondents felt their posture became slightly bent. drinking alcohol and smoking are unhealthy habits that can accelerate bone density loss.1 from the table above, it shows that two respondents (1.3%) drank alcohol regularly and nine respondents (5.6%) smoked more than twenty cigarettes per day. furthermore, gastrointestinal diseases also can be one of the risks of osteoporosis.5 in this study, 17 respondents (10.6%) often had diarrhea. out of 135 female respondents in this study, 18 respondents (13.3%) experienced menopause before the age of 45 years and nine (6.7%) had experienced menstruation stops (amenorrhea) for 12 months or more, which were not due to pregnancy or menopause. out of 25 male respondents, eight (32%) of them claimed to have a decreased libido or often called impotence. discussion the results showed that from 160 pre-elderly people at cipacing village, jatinangor district who were respondents of this study, 100 people (62.5%) had good knowledge related to osteoporosis, including definitions, causes, risk factors, prevention, and impact. furthermore, based on the education, most respondents with higher education level (senior high school, diploma, and undergraduate) had good knowledge of osteoporosis. according to notoatmodjo6, people with higher formal education have a higher knowledge level than those with lower formal education, because they are considered to be more capable to understand easily the meaning and importance of health and health care utilization. however, respondents with low educational level (none, elementary, and secondary) mostly were able to answer questions properly, hence they were also classified into good knowledge category. this finding indicates that knowledge is not only influenced by formal education, but can also be influenced by various information sources, such as family, print media, electronic media, and others. a cross-sectional study conducted in isfahan, iran, stated that respondents with higher education levels have significantly better knowledge related to osteoporosis when compares to respondents with lower education levels.7 in addition, knowledge of osteoporosisrelated study has also been performed on the nursing profession in singapore, and it concluded that the knowledge of nurses is still considered insufficient, especially in relation to the prevention and management of osteoporosis.8 meanwhile, endicott et al., showed that after the intervention in the form of specific education about osteoporosis to respondents, the respondents’ knowledge of osteoporosis has increased very significantly.9 although 62.5% of respondents had good knowledge of osteoporosis, there were several untrue answers to some questions in the knowledge questionnaire. more than 70% of respondents believed that women and men had the same risk for osteoporosis, whereas the appropriate literature states that women are at greater risk for osteoporosis, especially after menopause. a total of 90 respondents found that pain occurring when bending the body was not a symptom of osteoporosis, but a symptom of arthritis. additionally, back pain due to spinal deformity, decreased mobility of the body, decreased of appetite due to abdominal pressure could be signs and symptoms of osteoporosis, where there has been a compression fracture of the spine.2 in addition to the signs and symptoms, most respondents still assumed that calcium could only be obtained by consuming milk. the recommended daily intake of calcium is 1,200 mg and in fact, in addition to milk, calcium can also be obtained from other food ingredients: fish, vegetables (such as spinach, cabbage, and broccoli), beans, and cereal.2,10 over the past 20 years, at least 14 randomized clinical trials (rcts) were conducted in various countries to determine the effects of vitamin d with or without calcium on the incidence of fractures. four of them have shown a significant reduction of the incidence of fractures, two are in the borderline, and eight other studies have found no significant effect.11 on the other hand, a canadian study showed that calcium intake to 1,000 mg per day has a significant association with a decrease in the mortality rate in women statistically, although the results are inconclusive for calcium intake in excess of 1,000 mg per day.12 based on table 2, a total of 79 respondents (49.4%) had an increased risk for osteoporosis. out of the total of respondents which were included in the at risk group, 26 respondents althea medical journal. 2015;2(4) 613 (16.3%) had parents who have been diagnosed with a bone less density or have experienced a hip fracture due to collision or a relatively mild fall. furthermore, family history of osteoporosis is one of the risk factors and an estimated 80% genetically inherited bone density subsequently, it can be interpreted that osteoporosis can be lowered.1,2 based on a study in the united states, it concluded that a family history of osteoporosis is a significant and independent risk factor for osteoporosis in women aged 35 years and older.13 another research in theunited states conducted by meadows et al.14, discovers that out of the 1.800 women who have undergone treatment for osteoporosis, about half have reported a family history of osteoporosis. on the other hand, 18 respondents (11.3%) felt their height has reduced by 3 cm from the previous conditions. in their study, cunhahenriques et al.15, showed that the clinical characteristics height of postmenopausal women with osteoporosis are shorter than those without osteoporosis. out of 135 female respondents in this study, 18 people (13.3%) experienced menopause before the age of 45 years. moreover, a population-based observational study in sweden, which was conducted on 390 white european women, concluded that early menopause is a significant risk factor for osteoporosis, related to hormonal changes.16 additionally, a cross-sectional study in china, also found the result that women who experienced early menopause have a significant risk of osteoporosis compared to women who experienced menopause at the age of 50 years.17 table 5 shows that 79.7% of respondents were classified as at risk were women. meanwhile, from a cohort study in four us regions, it was obtained that 10% of women with moderate osteopenia, change into osteoporosis within five years and 10% of women with severe osteopenia change into osteoporosis within a year.18 on the other hand, burke-doe et al.19, conducted a research related to the risk for osteoporosis by using the osteoporosis selfassessment tool (ost), where the calculation of the risk index is obtained based on age and weight of the respondent the respondents will be grouped into “high risk “,” moderate risk “, or “low risk “. out of 49 respondents, aged 78-98 years, 60.9% of them have a high risk for osteoporosis.19 however, the osteoporosis self-assessment tool (ost) is considered to have a moderate sensitivity and low specificity for use in men.20 in this study, there were limitations that may affect the implementation of thestudy results since it has not conducted a search of the factors that affect the respondents’ knowledge of osteoporosis. sampling was carried out during working hours consequently, not all pre-elderly in cipacing village had a chance to be selected as respondents. the large area of cipacing village, led to the uneven sampling in each rw (neighborhood). this study concluded that the knowledge of osteoporosis in pre-elderly in cipacing village, jatinangor district are largely classified into “good knowledge” category, with a total of 100 respondents (62.5%) and 79 respondents (49.4%) are classified into “at risk” category for osteoporosis. further studies are therefore necessary to determine the relationship between knowledge and the risk of osteoporosis, the correlation between knowledge and the prevalence of osteoporosis, and others. although most respondents have good knowledge related to osteoporosis, there are still pre-elderly in cipacing village jatinangor district who has poor knowledge related to osteoporosis, hence it is advisable for health institutions to provide education about osteoporosis to the community at jatinangor district. this study also recommends health institutions to provide the puskesmas at jatinangor district with a bone mass density examination tool, so examination of bone mass density at jatinangor district can be performed periodically to determine the exact risk for osteoporosis in jatinangor district community. references 1. solomon l, warwick d, nayagam s, editors. apley’s system of orthopaedics and fractures. 9th ed. london: hodder arnold; 2010. 2. menteri kesehatan republik indonesia. pedoman pengendalian osteoporosis. jakarta: kementerian kesehatan ri; 2008. 3. jahari ab, prihatini s. risiko osteoporosis di indonesia. gizi indon. 2007;30(1):1–11. 4. damayanti ap. gambaran tingkat pengetahuan osteoporosis pada pegawai administrasi perempuan di universitas indonesia tahun 2012 [minor thesis]. depok: universitas indonesia; 2012. 5. katz s, weinerman s. osteoporosis and gastrointestinal disease. gastroenterol hepatol. 2010;6(8):506–17. 6. notoatmodjo s. promosi kesehatan dan ilmu perilaku. jakarta: pt rineka cipta; 2007. muhammad ramdhani, dicky mulyadi, nita arisanti: knowledge and risk factors for osteoporosis among pre-elderly althea medical journal. 2015;2(4) 614 amj december, 2015 7. etemadifar mr, nourian sm, fereidanesfahani m, shemshaki h, nourbakhsh m, zarezadeh a. relationship of knowledge about osteoporosis with education level and life habits. world j orthop. 2013; 4(3):139–43. 8. zhang rf, chandran m. knowledge of osteoporosis and its related risk factors among nursing professionals. singapore med j. 2011;52(3):158–62. 9. endicott rd. knowledge, health beliefs, and self-efficacy regarding osteoporosis in perimenopausal women. j osteoporos. 2013;2013:1–6. 10. setyohadi b, hutagalung eu, adam jmf, suryaatmadja m, budiparama nc, jatim sanm, et al. summary of indonesian guidelines for diagnosis and management of osteoporosis. jafes. 2014;27(2):147– 50. 11. lips p, bouillon r, van schoor nm, vanderschueren d, verschueren s, kuchuk n, et al. review article: reducing fracture risk with calcium and vitamin d. clin endocrinol. 2010;73(3):277–85. 12. langsetmo l, berger c, kreiger n, kovacs cs, hanley da, jamal sa, et al. calcium and vitamin d intake and mortality: results from the canadian multicentre osteoporosis study (camos). j clin endocrinol metab. 2013;98(7):3010–8. 13. robitaille j, yoon pw, moore ca, liu t, irizarry-delacruz m, looker ac, et al. prevalence, family history, and prevention of reported osteoporosis in u.s. women. am j prev med. 2008;35(1):47–54. 14. meadows e, mitchell b, bolge s, johnston j, col n. factors associated with treatment of women with osteoporosis or osteopenia from a national survey. bmc womens health. 2012;12(1):1–9. 15. cunha-henriques s, costa-paiva l, pintoneto am, fonsechi-carvesan g, nanni l, morais ss. postmenopausal women with osteoporosis and musculoskeletal status: a comparative cross-sectional study. j clin med res. 2011;3(4):168–76. 16. svejme o, ahlborg hg, nilsson jå, karlsson mk. early menopause and risk of osteoporosis, fracture and mortality: a 34-year prospective observational study in 390 women. bjog. 2012;119(7):810–6. 17. qiu c, chen h, wen j, pengli zhu, fenghui lin, baoying huang, et al. associations between age at menarche and menopause with cardiovascular disease, diabetes, and osteoporosis in chinese women. j clin endocrinol metab. 2013;98(4):1612–21. 18. gourlay ml, fine jp, preisser js, may rc, li c, lui l-y, et al. bone-density testing interval and transition to osteoporosis in older women. n engl j med. 2012;366(3):225– 33. 19. burke-doe a, hudson a, werth h, riordan dg. knowledge of osteoporosis risk factors and prevalence of risk factors for osteoporosis, falls and fracture in functionally independent older adults. j geriatr phys ther. 2008;31(1):11–7. 20. richards js, lazzari aa, teves qualler da, desale s, howard r, kerr gs. validation of the osteoporosis self-assessment tool in us male veterans. j clin densitom. 2013;17(1):32–7. althea medical journal. 2016;3(4) 509 knowledge and attitude about multidrug-resistant tuberculosis among healthcare workers in public health centres bony wiem lestari,1 arto yuwono soeroto2 1department of public health faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: multidrug-resistant tuberculosis (mdr-tb) is a significant public health problem and poses a threat to global tuberculosis (tb) control. in 2015, at least 504 new mdr-tb cases were identified in indonesia. treating mdr-tb patients is very challenging. it may take more than two years for mdr-tb treatment. therefore, it is crucial healthcare workers (hcws) are knowledgeable about mdr-tb. the aim of this study was to measure level of knowledge and attitude regarding mdr-tb among hcws in public health centres. methods: a cross-sectional study was conducted at 73 public health centres in bandung the capital of west java province from august until november 2015. the samples were 73 tb nurses and 32 laboratory staff. a self-administered questionnaire was given comprising 27 knowledge questions and 29 attitude questions. correlation between knowledge and attitude scores was calculated by pearson correlation test. results: the majority of study participants were women (82.9%), married (92.4%), nursing staff (65.7%) with history of tb training (98.1%). most of the participants were 40-59 years old (69.5%) with working experience in tb programme < 10 years (69.5%). less than half (38.1%) of study participants had good knowledge. in terms of attitude, more than half (53.3%) of study participants had a positive attitude towards mdr-tb. conclusions: the level of knowledge among hcws about mdr-tb is still at an unacceptable level. certain educational interventions aim to ensure prompt diagnosis, implement infection control and accurate treatment should be established among those hcws. [amj.2016;3(4):509–13] keywords: attitude, health care workers, knowledge, mdr-tb, public health centre correspondence: bony wiem lestari, dr., m.sc, department of public health faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8122375633 email: bony.wiem@gmail.com introduction tuberculosis (tb) is still a major health problem in the world. it has become one of the top ten causes of death worldwide in 2015.1 mycobacterium tuberculosis, as a causative agent of tb, is mostly susceptible to isoniazid (inh) and rifampin (rif) which both are known to be the most powerful antituberculosis drugs. strains of mycobacterium tuberculosis which are resistant to these drugs, are termed as multidrug-resistant tb(mdr-tb). currently, mdr-tb posed a significant thread to global tb control.2 in 2010, the world health organization (who) recommended the utilisation of xpert mtb rif (xpert) as a new automated molecular diagnostic test to rapidly identify rifampicin resistant-tb which can be a good proxy for mdr-tb.3 the use of xpert is upscaled globally since it provides accurate results for rif-resistance detection given pending results from conventional culture and drugsusceptibility testing (dst).4 as part of the indonesian national tb programme (ntp), efforts to upscale programmatic management of drug-resistant tb (pmdt), xpert is used as a routine test for presumptive mdr-tb patients.5 treating mdr-tb patients is very challenging since it has a longer course of treatment, more severe side effects, and is more toxic, more difficult to acquire and much more expensive. furthermore, it may take more than two years for mdr-tb treatment which leads to social isolation, loss of employment, socioeconomic crisis and psychosocial burden.6 althea medical journal. 2016;3(4) 510 amj december 2016 in 2015, at least 504 new mdr-tb cases were identified in indonesia. based on this alarming condition, it is crucial that healthcare providers in indonesia are knowledgeable about mdr-tb and certain measures to control its transmission. to control mdr-tb outbreak, prompt diagnosis, infection control and effective treatment are imperative. in general, it is assumed that healthcare workers (hcws) especially the tb nurse know about mdrtb and its consequences. however, evidence showed that hcws do not always have enough knowledge or the proper positive attitude; and do not consistently present correct practices about prevention and treatment about mdrtb.7 until now, no study has been found assessing the knowledge and attitude regarding mdrtb among hcws in indonesia. therefore, this study aimed to measure knowledge and attitude about mdr-tb amongst hcws working at public health centers in bandung municipality. methods this was a cross-sectional study in bandung municipality, an urban city that served as a capital city of west java which has approximately 2.5 millions inhabitants. the city has 73 public health centers which almost half of them (30 out of 73) are equipped with a microscopy laboratory. the study population were tb nurses and laboratory staff working at public health centres within bandung area. in this study, our sample comprised of 73 tb nurses and 32 laboratory staff. this study was carried out from august until november 2015. a modified questionnaire was developed based on who treatment guidelines for drug-resistant tb and national guidelines for pmdt.8 the questionnaire was semistructured and self-administered. considering the small number of study population, a research assistant delivered the questionnaire and asked the study participants to fill it out. once they had completed the questionnaires, the research assistant returned to the public health centers to collect them. besides questions about knowledge and attitude of mdr-tb, information about sociodemographic and professional data were also collected. the level of knowledge of mdrtb were obtained through a set of 27 questions about the definition of mdr-tb, referral criteria, transmission, symptoms, diagnosis and course of treatment. the knowledge level was classified as good if the study participants scored >75; fair if the score was between 5675; and poor if the score was less than 55. meanwhile, to assess the level of attitude towards mdr-tb, a set of 29 questions about risk factors, transmission, infection control and role of the public health centre were asked to the study participants. the study participants were categorised as having a positive attitude when they scored above the average; and a negative if they scored below the average. furthermore, the research assistant checked the returned questionnaires for their completeness. next, the data were captured in microsoft excel and imported into spss version 20 for data analysis. then the categorical variables were presented in frequency and percentages. the correlation between knowledge and attitude scores was obtained by pearson correlation test. the level of statistical significancy was determined when the p-value is <0.05. this study had obtained the ethics approval from the health research ethics committee faculty of medicine universitas padjadjaran number 712/un6.c2.1.2/kepk/pn/2014 and the permission to conduct the survey at public health centers from the municipal health office. results out of the 105 participants who received the questionnaire, 105 returned the completed questionnaire which provided a response rate of 100%. the majority of study participants were female (n=87; 82.9%), married (n=97; 92.4%), nursing staff (n=69; 65.7%) with history of tb training (n=103; 98.1%). the mean age of study participants was 44.84(7.73) years old with an age range from 26 to 58 years. based on age category, most of the participants were aged between 40-59 years (n=73; 69.5%) with working experience in tb programme < 10 years (n=73; 69.5%) (table 1). regarding the knowledge of mdr-tb, less than half (38.1%) of study participants had good knowledge. additionally, participants provided incorrect answers about definition of mdr-tb, how it is diagnosed, duration of treatment, role of public health centers in decentralised pmdt, and infection control. in terms of attitude, more than half (53.3%) of study participants had a positive attitude towards mdr-tb. while about 89.5% (n=94) of study participants mentioned that they were involved in providing health education about mdr-tb. concerning the use of xpert althea medical journal. 2016;3(4) 511bony wiem lestari, arto yuwono soeroto: knowledge and attitude about multidrug -resistant tuberculosis among healthcare workers in public health centres in diagnosing tb among people living with hiv, about 73.4% (n=77) of study participants stated that they would refer hiv patients to be checked by xpert whenever they had tb symptoms. with regard to negative attitudes, only 55.2% (n=58) of study participants had a correct understanding about the use of n-95 protective mask while in contact with mdr-tb patients. about 64.8% (n=68) of study participants believed that xpert table sociodemographic characteristics of study participants variables frequency (n) percentage (%) age category 20–29 years old 3 2.9 30–39 years old 29 27.6 40–49 years old 37 35.2 50–59 years old 36 34.3 gender male 18 17.1 female 87 82.9 professional category tb nurse 69 65.7 midwife 6 5.7 laboratory analyst 30 28.6 work experience category 1–5 years 32 30.5 6–10 years 41 39 11–15 years 16 15.2 15–20 years 10 9.5 >20 years 6 5.7 history of tb training yes 103 98.1 no 2 1.9 marital status single 4 3.8 married 97 92.4 divorced 3 2.9 widowed 1 1.0 knowledge level good 40 38.1 fair 55 52.4 poor 10 9.5 attitude level positive 56 53.3 negative 49 46.7 althea medical journal. 2016;3(4) 512 amj december 2016 would be sufficient to diagnose mdr-tb. this study discovered that there was a positive association between knowledge and attitude of the participants with a correlation coefficient (r) = 0.44 indicating a moderate degree of correlation between those two variables with p-value <0.01 which was statistically significant. discussion the findings of this study showed that the majority of participants were female, middle adults and nurses. this distribution is consistent with the structure of healthcare workforce in west java province where 48% are nurses and mostly women (66.7%).9 in order to achieve the aim of this study, it was discouraging that only 38.1% of study participants had a good knowledge about mdr-tb. the inadequacy in knowledge were identified within these fields namely 1) definition of mdr-tb; 2) how it is diagnosed; 3) duration of its treatment; 4) role of public health centers in decentralised pmdt; and 5) infection control. these gaps were similar with other findings from other investigators.10–13 based on personal characteristics of study participants such as age, gender, professional category, number of years of working experience, and history of tb training, there was no evidence from this study demonstrating that there was any significant difference among study participants with regard to their knowledge and attitude about mdr-tb. with regard to perceived benefit of using n-95 protective mask, about 44.8% of study participants reported that they felt uncomfortable using it when dealing with mdr-tb patients. this finding was similar with a study conducted in georgia usa whereas only 60% of hcws reported frequent use of respirators when in contact with tb patients.14 this perception is unacceptable since the use of n-95 mask is mandatory to prevent exposure with mdr-tb strains. transmission of drugresistant m. tuberculosis can cause public drug resistance among individuals with no prior history of tb, as well as among individuals with a history of prior tb treatment. therefore, by protecting hcws, their family members and all other persons whom they had contact with will also be protected.15 an important finding from this study was that about 50% of study participants with good knowledge of mdr-tb were reported using the n-95 mask which was higher compared to those with insufficient level of knowledge, however, this result did not reach statistically significant. this finding suggested that any interventions which purpose to increase the level of knowledge about mdr-tb might lead to better compliance about preventive measures among hcws. this study revealed that 89.5% of study participants were involved in giving health education about mdr-tb to tb patients. besides, several studies showed that there are some issues related to mdr-tb treatment which may introduce poor treatment outcomes. some factors were associated with loss-to-follow up such as 1) lack of social support; 2) dissatisfaction with hcws attitudes; 3) unstable socioeconomic status; 4) lack of counselling; and 5) poor response to therapy.16–19 moreover, qualitative studies showed the severe side effects of mdr-tb treatment were described to be “as bad as or worse than the illness itself ”.20 therefore, health education and adequate counselling related to mdr treatment especially about duration of injectable phase and total duration, also potential adverse events should be given thoroughly by hcws to mdr-tb patients. another finding in this study was a significant moderate correlation (r=0.44) between the level of knowledge and attitude among hcws with regard to mdr-tb. this demonstrated that educational intervention about mdr-tb combined with availability of protective equipment and monitoring practices based on clinical management guideline would support consistent behavior among hcws towards its implementation. moreover, systematic training and regular workshop about mdr-tb for hcws should be conducted for improving their knowledge. a series of profesional seminars about mdr-tb for general practitioners or nurses could be a good media to distribute current update on diagnosis and treatment of this disease. regular monitoring to health care facilities should help check hcw’s compliance regarding mdr-tb management. furthermore, this study noticed some limitations like less variations of healthcare professionals since general practitioners, pharmacists, and counsellors had not been included. the study participants were asked about knowledge and attitude but their current practice with regard to mdr-tb were not measured comprehensively. another limitation was that this study was a crosssectional survey; thus causal relationships could not be established. in conclusion, the level of knowledge among althea medical journal. 2016;3(4) 513 hcws about mdr-tb is still at an unacceptable level. certain educational interventions aim to ensure prompt diagnosis, implement infection control and accurate treatment should be established among hcws to make a success of pmdt references 1. who. global tuberculosis report. geneva: who library cataloguing data; 2015. 2. furin j. the clinical management of drugresistant tuberculosis. curr opin pulmmed. 2007;13(3):212–7. 3. who. xpert mtb/rif implementation manual. technical and operational ‘howto’: practical considerations. geneva: who library cataloguing; 2014. 4. steingart kr, schiller i, horne dj, pai m, boehme cc, dendukuri n. xpert® mtb/ rif assay for pulmonary tuberculosis and rifampicin resistance in adults. cochrane database syst rev. 2014;1(1):cd009593. 5. van kampen sc, susanto nh, simon s, astiti sd, chandra r, burhan e, et al. effects of introducing xpert mtb/rif on diagnosis and treatment of drug-resistant tuberculosis patients in indonesia: a pre-post intervention study. plos one. 2015;10(6):e0123536. 6. jacobson kr, tierney db, jeon cy, mitnick cd, murray mb. treatment outcomes among patients with extensively drugresistant tuberculosis: systematic review and meta-analysis. clin infect dis. 2010;51(1):6–14. 7. loveday m, thomson l, chopra m, ndlela z. a health systems assessment of the kwazulu-natal tuberculosis programme in the context of increasing drug resistance. int j tuberc lung dis. 2008;12(9):1042–7. 8. kemenkes ri. pedoman manajemen terpadu tb resistan obat. jakarta: subdit p2pl kementerian kesehatan republik indonesia; 2014. 9. dinas kesehatan provinsi jawa barat. profil kesehatan jawa barat. bandung: dinas kesehatan provinsi jawa barat; 2015. 10. malangu n, adebanjo od. knowledge and practices about multidrug-resistant tuberculosis amongst healthcare workers in maseru. african j prim health care fam med. 2015;7(1):774–9. 11. mahendradhata y, lestari t, probandari a, indriarini le, burhan e, mustikawati d, et al. how do private general practitioners manage tuberculosis cases? a survey in eight cities in indonesia. bmc res notes. 2015;8:564. 12. vandan n, ali m, prasad r, kuroiwa c. assessment of doctors’ knowledge regarding tuberculosis management in lucknow, india: a public–private sector comparison. public health. 2009;123(7):484–9. 13. kiefer em, shao t, carrasquillo o, nabeta p, seas c. knowledge and attitudes of tuberculosis management in san juan de lurigancho district of lima, peru. j infect dev ctries. 2009;3(10):783–8. 14. mirtskhulava v, whitaker ja, kipiani m, harris da, tabagari n, owen-smith aa, et al. determinants of tuberculosis infection control related behaviors among healthcare workers in the country of georgia. infect control hospital epidemiol. 2015;36(5):522–8. 15. zhao m, li x, xu p, shen x, gui x, wang l, et al. transmission of mdr and xdr tuberculosis in shanghai, china. plos one. 2009;4(2):e4370. 16. shringarpure ks, isaakidis p, sagili kd, baxi rk. loss-to-follow-up on multidrug resistant tuberculosis treatment in gujarat, india: the when and who of it. plos one. 2015;10(7):e0132543. 17. morris md, quezada l, bhat p, moser k, smith j, perez h, et al. social, economic, and psychological impacts of mdr-tb treatment in tijuana, mexico: a patient’s perspective. int j tuberc lung dis. 2013;17(7):954–60. 18. johnston jc, shahidi nc, sadatsafavi m, fitzgerald jm. treatment outcomes of multidrug-resistant tuberculosis: a systematic review and meta-analysis. plos one. 2009;4(9):e6914. 19. orenstein ew, basu s, shah ns, andrews jr, friedland gh, moll ap, et al. treatment outcomes among patients with multidrugresistant tuberculosis: systematic review and meta-analysis. lancet infectdis. 2009;9(3):153–61. 20. isaakidis p, rangan s, pradhan a, ladomirska j, reid t, kielmann k. ‘i cry every day’: experiences of patients co infected with hiv and multidrug resistant tuberculosis. trop med int health. 2013;18(9):1128–33. bony wiem lestari, arto yuwono soeroto: knowledge and attitude about multidrug -resistant tuberculosis among healthcare workers in public health centres althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 93 association of ascariasis with nutritional and anemic status in early school-age students chin annrie eidwina,1 lia faridah,2 yudith setiati ermaya,3 dida akhmad gurnida3 1faculty of medicine, universitas padjadjaran, 2departmen of microbiology & parasitologyfaculty of medicine universitas padjadjaran, 3department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: ascariasis is one of the most frequent helminthias is that occurred in school-age children. commonly, severe intensity of infection will seriously affect the nutritional and anemic status of the students. the aim of this study was to determine the association of ascariasis with nutritional and anemic status in early school-age students. methods: an analytical cross-sectional study was conducted based on the secondary data from jatinangor cohort. the secondary data of 74 students who met the criteria were included in this study. data collection was conducted in the department of epidemiology and biostatistics from august to september 2014. the data obtained was analyzed based on the characteristics of the students regarding gender, age, class, parents’ education, ascariasis, nutritional and anemic status. then, the data were further analyzed to determine the association of ascariasis with nutritional and anemic status of the students using the chi square test or fisher test if the requirement was not fulfilled. results: sixteen (22%) students were having ascaris lumbricoides infection, six (8.1%) students were thin and seventeen (23%) students were anemic. there was no statistically significant association found of ascaris lumbricoides infection with nutritional and anemic status in early school-age students (p value <0.05) in this study. conclusions: there is no statistically significant association of ascaris lumbricoides infection with nutritional and anemic status of the early school-age students. [amj.2016;3(1):93–8] keywords: anemia, ascariasis, nutritional status, early school-age students correspondence: chin annrie eidwina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81912765289 email: annrieidwina89@gmail.com introduction helminthiasis is a disease that is usually neglected by the community whereby it will not affect people when light intensity infection occurs. however, when the infection becomes more severe, it will give out a range of health symptoms.1 children are the most unprotected people from helminthiasis which usually comes from a poor sanitation area that lacks hygiene, clean water supplement and access to health care. it can become worse with a low family status with low educational level.2 among the types of helminthiasis, infection of ascaris lumbricoides is recorded the highest with 819.0 million people worldwide when compared to trichuris trichiura and hookworms in 2010.3 fulfilling all the risk factors of ascariasis such as high air humidity, poor sanitation and hygiene plus located in a tropical area with the community’s bad habits, has caused indonesia becomes one of the endemic countries with ascariasis. ascaris lumbricoides grows, feeds and breeds inside the human body. as theworm population increase exceeds 500, it covers most of the intestine of the child and may disturb the nutrient’s digestion and absorption. then, this will lead to protein-energy malnutrition, vitamin a deficiency and anemia.4 seemingly, the condition of the surroundings fulfilled the requirement for the ascariasis life cycle thus, this study was conducted to know the association of ascariasis with nutritional and anemic status in early school-age students. methods an analytical cross-sectional study was althea medical journal. 2016;3(1) 94 amj march 2016 conducted based on the secondary data from jatinangor cohort that was carried out from july to august 2013. the secondary data collection was from a larger study conducted at the department of epidemiology and biostatistics faculty of medicine universitas padjadjaran from august to september 2014. the population of this study was students aged 5 to 9 years who were in class i to class iii from 2 elementary schools in jatinangor. the selected subjects were all early school-age students particularly from class 1 to class 3 (aged 5-9 years) by using the total sampling technique. the subjects who had performed the fecal examination to identify presence of ascaris lumbricoides eggs with complete data about the nutritional (body mass index) and anemic (hemoglobin level) status were included in this study. however, in accordance with the part of knowledge, attitude and practices in the questionnaire of the study, the students who got other infections and incomplete data were excluded from this study. the minimal sample in this study was 105 students. besides, the secondary data of 74 students who met the criteria were also included in this study. the secondary data were analyzed based on the student’s characteristics of gender, age, class, parents’ education, ascariasis, nutritional and anemic status. further analysis was performed to determine the association of ascariasis with nutritional and anemic status of the student. the analysis of association was carried out by using the spss 15.0 software. the independent variable was ascariasis and the dependent variables were nutritional and anemic status of the students whereby both independent and dependent variables were classified based on the nominal classification. consequently, the data obtained were analyzed by using the chi-square test with p value<0.05. however, fisher’s exact test was the alternative way if the requirement of the chi-square test was not fulfilled. results more than half of the students in this study were female when compared to male students. the number of students involved according to age varied between 7-9 years old. it seemed that the higher class, the number of students also increased. the educational level of parents was mostly from senior high school followed by the second highest was from junior high school. this could indicate the educational level of the parents in this study was moderate (table 1). table 1 characteristic of students characteristic frequency (n) % gender male 34 46 female 40 54 age 7 years 21 28 8 years 25 34 9 years 28 38 class class i 19 26 class ii 25 34 class iii 30 40 parents’ education elementary school 19 26 junior high school 20 27 senior high school 32 43 college 3 4 althea medical journal. 2016;3(1) 95chin annrie eidwina, lia faridah, yudith setiati ermaya, dida akhmad gurnida: association of ascariasis with nutritional and anemic status in early school-age students table 2 prevalence of ascariasis in each class class ascariasis positive negative frequency,n percentage,% frequency,n percentage,% i 9 12 10 13 ii 5 7 20 27 iii 2 3 28 38 total 16 22 58 78 it showed that the most number of students infected by ascariasis was in class i, whereby the number of students in class i was the lowest among the 3 classes. however, the least infected with ascarisis were students from class iii, whereby the number of students in class iii was the highest (table 2). most of the students in this study had normal nutritional and anemic status. however, the number of students who were thin was less than the student who was anemic (table 3). there were no significant association of infection with ascaris lumbricoides and nutritional status based on the fisher’s exact test statistics with p-value was above α value=0.05 (table 4). there were no significant association of infection with ascaris lumbricoides and anemic status based on the fisher’s exact test statistics with p-value was above α value=0.05 (table 5). discussion it was found that the number of students infected with ascariasis showed a decrease as the class increased. this was supported by a study conducted in edo state, nigeria5 which stated that as the age of children increased, the prevalence of the child to get infected wih ascaris lumbricoides would decrease. however, there was one study conducted in osun state, southwest of nigeria by adefioye oa et al.6 who stated that the prevalence of ascariasis that occurred in students at osun5 was as much as 36.2%. the percentage was considered higher than the prevalence of ascaris lumbricoides infection in school-age students of this study. this could be influenced table 3 prevalence of nutritional and anemic status among students characteristic frequency (n) % nutritional status thin 6 8 normal 68 92 anemic status anemia 17 23 normal 57 77 table 4 distribution of students based on ascariasis and nutritional status infection nutritional status total (%) p-valuethin normal frequency percentage frequency percentage positive 1 2 15 20 16(22) 0.614 negative 5 7 53 71 58(78) althea medical journal. 2016;3(1) 96 amj march 2016 by several factors such as the timing of the fecal collection, surrounding conditions and other geographical factors that lead to the difference in the prevalence of ascariasis.6 in addition, it showed that the majority of students had a normal nutritional status. this number was nearly lower when compared to the statistics in ‘indonesia basic health research 2013’ by the ministry of health indonesia which showed that there was 11.2% of children aged 5 to 12 years who were having thin nutritional status.7 this could indicate that the nutritional status of the students in this study was good because of the balance between the nutrients intake and requirements of the body. this could be influenced by several factors such as the parent’s education level and the volume of food intakes. most of the parents in this study had a moderate educational level since most of them were from senior high school (sekolah menengah atas, sma) or junior high school (sekolah menengah pertama, smp). this was be supported by a previous study conducted by srivastava et al.8 in india who stated that mothers who had an educational level ≤6th standard were significant risk factor of malnutrition in their children. there was also another study conducted in banda aceh, indonesia9 which showed that the students who have healthy weight with mother who have middle and high educational level have higher prevalence than those who have mother with lower educational level. however, the percentage of the thin students in this study had not reached the standard of prevalence of the world health organization (who).10 the who has stated that the standard of prevalence of the underweight child in a population must be ≤5%.10 anemia is a pathological condition where the hemoglobin level is low. it was found that more than half of the students had normal hemoglobin level which means the students have no anemia. this condition might be considered good since most of the students had enough nutrition according to the statistical analysis above about nutritional status in this study that led to the avoidance of occurrence of anemia. however, the number of students who had anemia was lower than that in the ‘indonesia basic health research’ where it showed 29% of children aged 5 to 12 years have anemia.7 this may indicate the numbers of early school-age students who are anemic have decreased. this was supported by the study conducted in mexico by torres et al.11 who stated that the children with low body mass index have the highest prevalence of anemia. as in this study, the number of students who were thin was lower than students who were anemic. this can be influenced by the increased risk for the co-occurrence of anemia and obesity that is associated with gender and age of the children.11 based on the research conducted in mexico, the children who are aged 5 to 9 years are easier to have the condition of anemia and obesity that occurred at the same time.11 it showed that there was no significant association of ascariasis with nutritional status in this study. this can be supported by the study carried out in ethiopia12 which reported that ascariasis and malnutrition have no association significantly. in contrast, shang et al.13 have conducted a study in china reported that one of the risk factor to cause stunting is the moderate-to-heavy intensity infection of soil-transmitted helminth. when compared with this study, the method to identify the infection is different with which they had used to find the intensity of infection by using the kato-katz technique.13 however, in this study, the bigger research just used the saline wet mount technique to identify whether the eggs of ascaris lumbricoides was present or not. the kato-katz technique could not be performed in this study due to the stool sample given by the students was in little portion. to be more specific, a study conducted in nigeria14 proved that ascaris lumbricoides infection had associated with anthropometric measurement among 418 children who lived in both rural and urban area that meant the infection could table 5 distribution of students based on ascariasis and anemic status infection anemic status total (%) p-valueanemia non-anemia frequency percentage frequency percentage positive 3 4 13 18 16(22) 0.467 negative 14 19 44 59 58(78) althea medical journal. 2016;3(1) 97 cause worse effect of nutritional status. in addition, there was also no significant association between ascariasis and anemic status in this study. based on the study conducted in malaysia by ngui et al.15, it reported that there was no significant correlation between ascaris lumbricoides eggs and hemoglobin level of the children. besides, they also used the serum ferritin level in order to identify the anemia that is caused by ascaris lumbricoides infection which is the iron deficiency anemia.15 this was due to the sensitivity of the test which was higher when compared with the hemoglobin level in order to detect anemia in children.5 however, the study conducted in edo state, nigeria5 showed a significant association between ascariasis and anemia that used hemoglobin levels as the parameter. this was caused by the technique used to identify the ascaris lumbricoides infection. the study which was conducted in nigeria5 used the same technique as in this study. the difference between these two studies was that in the study conducted in nigeria5, a recheck was performed for the negative infection by using a formal ether concentration method. besides, the number of students in the study conducted in nigeria was higher than in this study.5 this was due to most of the data from the larger study was incompletely based on each variable in this study which led to more samples were excluded. as conclusion, this study finds that there is no significant association of ascariasis with nutritional and anemic status in early schoolage students. this is due to several limitations in the study such as the number of sample did not reach the minimal sample because of the incomplete data and the method used by the larger study to identify the ascaris lumbricoides eggs was not specific. there are several recommendations from this study. firstly, more samples are needed in order to find a very significant association of ascariasis with nutritional and anemic status. in addition, the technique used to identify the ascaris lumbricoides infection needs to be more specific either use the kato-katz technique to find the intensity of the infection or use a more concentrated method as suggested in the who. lastly, increase awareness of parents about the importance of the examination should be performed to the students in order to identify the types and the impact of the infection to nutritional and anemic status of the students and the filling out of data from the larger study should be completed according to actions or examinations performed to the students. references 1. ogbaini-emovon e, eigbedion a, ojide c, kalu e. prevalence and impact of socioeconomic/enviromental factors on soiltransmitted helminth infection in children attending clinic in a tertiary hospital in benin city, nigeria. ijbair. 2014;3(2):65– 70. 2. abossie a, seid m. assessment of the prevalence of intestinal parasitosis and associated risk factors among primary school children in chencha town, southern ethiopia. bmc public health. 2014;14(1):166. 3. pullan rl, smith jl, jasrasaria r, brooker sj. global numbers of infection and disease burden of soil transmitted helminth infections in 2010. parasit vectors. 2014;7(1):37. 4. paniker cj. textbook of medical parasitology. 6th ed. new delhi, india: jaypee brothers medical publishers (p) ltd; 2007. 5. osazuwa f, ayo om, imade p. a significant association between intestinal helminth infection and anaemia burden in children in rural communities of edo state, nigeria. n am j med sci. 2011;3(1):30–4. 6. adefioye oa, efunshile am, ojurongbe o, akindele aa, adewuyi i, bolaji o, et al. intestinal helminthiasis among school children in ilie, osun state, southwest, nigeria. sierra leone j biomed res. 2011;3(1):36–42. 7. kementerian kesehatan republik indonesia. riset kesehatan dasar. jakarta: kementerian kesehatan republik indonesia; 2013. 8. srivastava a, mahmood se, srivastava pm, shrotriya vp, kumar b. nutritional status of school-age children-a scenario of urban slums in india. arch public health. 2012;70(1):8. 9. badrialaily, jutatip sillabutra, pantyp ramasoota. nutritional status and related factors among elementary school students in banda aceh municipality, nanggroe aceh darussalam province, indonesia. journal of public health and development. 2008;6(1):102–12. 10. kementerian kesehatan republik indonesia. profil kesehatan indonesia tahun 2012. jakarta: kementerian kesehatan republik indonesia; 2012. 11. torres op, evangelista-salazar jj, martínezchin annrie eidwina, lia faridah, yudith setiati ermaya, dida akhmad gurnida: association of ascariasis with nutritional and anemic status in early school-age students althea medical journal. 2016;3(1) 98 amj march 2016 salgado h. coexistence of obesity and anemia in children between 2 and 18 years of age in mexico. bol med hosp infant mex. 2011;68(6):431–7. 12. amare b, ali j, moges b, yismaw g, belyhun y, gebretsadik s, et al. nutritional status, intestinal parasite infection and allergy among school children in northwest ethiopia. bmc pediatr. 2013;13(1):7. 13. shang y, tang lh, zhou ss, chen yd, yang yc, lin sx. stunting and soil-transmittedhelminth infections among school-age pupils in rural areas of southern china. parasit vectors. 2010;3(1):97. 14. opara kn, udoidung ni, opara dc, okon oe, edosomwan ue, udoh aj. the impact of intestinal parasitic infections on the nutritional status of rural and urban school-aged children in nigeria. ijma. 2012;1(1):73–82. 15. ngui r, lim yal, kin lc, chuen cs, jaffar s. association between anaemia, iron deficiency anaemia, neglected parasitic infections and socioeconomic factors in rural children of west malaysia. plos negl trop dis. 2012;6(3):e1550. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 64 amj march 2016 streptococcus pneumoniae drugs resistance in acute rhinosinusitis chong jie hao,1 chrysanti murad,2 trias nugrahadi3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of nuclear medicine faculty of medicine universitas padjadjaran/ dr. hasan sadikin general hospital, bandung abstract background: acute rhinosinusitis that usually caused by streptococcus pneumoniae becomes the reason why patients seek for medical care. drugs resistance in streptococcus pneumoniae is increasing worldwide. this study was conducted to determine drugs resistance of streptococcus pneumonia from acute rhinosinusitis in dr. hasan sadikin general hospital. methods: a descriptive laboratory study was conducted in june–october 2014 at the laboratory of microbiology faculty of medicine universitas padjadjaran. the sample was taken using nasopharyngeal swabbing from 100 acute rhinosinusitis patients in dr. hasan sadikin general hospital and planted on tryptic soy agar containing 5% sheep blood and 5 μg/ml of gentamicin sulphate and then incubated in 5% co2 incubator at 37°c for 24 hours. the identification of streptococcus pneumonia was performed by optochin test. the susceptibility test against streptococcus pneumoniae was done using disk diffusion method.the antibiotic disks were trimethoprim-sulfamethoxazole, oxacillin, levofloxacin, azithromycin, and doxycycline. results: out of 100 samples, 8 of them were tested positive for streptococcus pneumoniae. three of streptococcus pneumoniae isolates died with unknown reason after it were stored at -80 .the drugs resistance test showed the resistance of streptococcus pneumonia to oxacillin, azithromycin and trimethoprim were 6, whereas levofloxacin and doxycycline are 4. conclusions: streptococcus pneumonia drugs resistance in acute rhinosinusitis shows the resistance of streptococcus pneumoniae to oxacillin, azithromycin and trimethoprim are 6, whereas the resistance to levofloxacin and doxycycline are 4. [amj.2016;3(1):64–8] keywords: acute rhinosinusitis, drugs resistance, streptococcus pneumoniae correspondence: chong jie hao, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822004661 email: chongjiehao93@gmail.com introduction streptococcus pneumonia (s. pneumoniae) of acute bacterial rhinosinusitis occurs in adults is 20 to 45% whereas in children is 30 to 43%.1 according to european position paper on rhinosinusitis and nasal polyps 2012 (epos 12), rhinosinusitis is an inflammation on the nose and paranasal sinuses mucosa, characterized by two or more symptoms, with one symptoms should include nasal congestion, their nasal discharge, facial pain in the sinus area or reduction of smell. acute rhinosinusitis is when the symptoms last less than 12 weeks and experiencing complete resolution.2 data on the department otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital in 2008 found comorbid allergic rhinitis patients in the form of rhinosinusitis as much as 75%. whereas in 2010, the incidence of rhinosinusitis is about 44%.3 the first line therapy for acute bacterial rhinosinusitis in department of otorhinolaryngology-head and neck surgery, dr. hasan sadikin general hospital is penicillin beta lactam combine with beta lactamase inhibitor; second line is floroquinolone and macrolide. according to infectious disease society of america clinical practice guideline, the first line therapy for acute bacterial rhinosinusitis in adults is amoxicillinclavulanate.4 however, amoxicillin as the first-line therapy are recorded in american family physician.5 for patients who allergic to althea medical journal. 2016;3(1) 65 penicillin, trimethoprim-sulfamethoxazole, a macrolide such as azithromycin, doxycycline and levofloxacin may be used as an alternative to amoxicillin.5,6 high medical costs and high mortality rates are associated with high s. pneumoniae antimicrobial resistance rates.7,8 this study was aimed to describe the pattern of drugs resistance, s. pneumonia from acute rhinosinusitis in dr. hasan sadikin general hospital. it is beneficial to carry out a study on drugs resistance about s. pneumoniae from acute rhinosinusitis to provide information of drug sresistance s. pneumoniae, and the approach to the management of drugs resistance s. pneumoniae infections may change greatly in the next few years. methods this study was conducted using secondary data descriptive laboratory method. the susceptibility test was conducted from june to october 2014 at the laboratory of microbiology faculty of medicine universitas padjadjaran bandung. the study was already approved by health research ethics committee. the samples of this study were 8 s. pneumonia that was isolated from specimens of 100 adult patients with acute rhinosinusitis in dr. hasan sadikin general hospital that was done in a previous research from department of otorhinolaryngology-head and neck surgery. dr. hasan sadikin general hospital bandung. the specimens of 100 acute rhinosinusitis patients were taken by nasopharyngeal swabbing and were transported using amines medium. after that, swab specimens were inoculated on tryptic soy agar plates containing 5% sheep blood and 5 μg/ml of gentamicin sulfate. then, tryptic soy agar plates were incubated in 5% co2 incubator at 37°c for 24 to 48 hours. colonies of s. pneumoniae appears as a small, grey, moist (sometimes mucoidal), colonies and characteristically produce a zone of alpha-hemolysis (green) on tryptic soy agar plates.9 for confirmation of s. pneumoniae colonies, identification test of s. pneumoniae such as gram staining, catalase test,optochin test and bile solubility test should be done. after s. pneumoniae isolates were identified, antimicrobial susceptibility testing of s. pneumoniae isolates were started by disk diffusion method. mueller-hinton agar medium supplemented with 5% sheep blood is recommended. the agar plates should have a uniform depth of 3 to 4 mm. the inoculum for antimicrobial susceptibility testing of s. pneumoniae from fresh pure cultures of s. pneumoniae was grown overnight on blood or chocolateagar was prepared. cell suspensions of the bacteria were prepared to be tested in the sterile physiologicalsaline or muellerhinton broth. a cell suspension equal to a density of a 0.5 mcfarland turbidity standard was used for the inoculum. viable colonies from an overnight sheep blood agar plate were suspended in a tube of broth to achieve a bacterial suspension equivalent to a 0.5 mcfarland turbidity standard. this suspension should be used within 15 minutes. the density of the suspension was compared to the 0.5 mcfarland turbidity standard.9 after the plate was dry, the antimicrobial disks such as levofloxacin, doxycycline, trimethoprim-sulfamethoxazole, azithromycin and oxacillin were placed on the plates. sterile forceps was used to place the disks on the mueller hinton agar and tap them gently to ensure they adhere to the agar. the plates were incubated in an inverted position in 5% co2 atmosphere for 20 to 24 hours at 35°c. after an overnight incubation, the diameter of each zone of inhibition was measured by a ruler or callipers. the antimicrobial susceptibility of the test strain was interpreted by comparing the results to the clinical and laboratory standards (cls ) institute standard zone sizes and european committee on antimicrobial susceptibility testing (eucast) standard zone sizes.9 results out of 100 samples, 8 of them were tested positive for s. pneumoniae. three of s. pneumoniae isolates died with unknown reason after it was stored at -80 . the drugs resistance test showed the resistance of s. pneumonia to oxacillin, azithromycin and trimethoprim were 6, whereas levofloxacin and doxycycline are 4. (figure 1) discussions s. pneumonia was chosen in this study because s. pneumonia is one of the main etiology in acute rhinosinusitis. from previous study, it was described that there were 54% bacterial isolates from 100 patients with acute rhinosinusitis such as 17% staphylococcus epidermidis, 8% s. pneumoniae, 6% staphylococcus aureus, 5% enterobacterdoacae, chong jie hao, chrysanti murad, trias nugrahadi: streptococcus pneumoniae drugs resistance in acute rhinosinusitis althea medical journal. 2016;3(1) 66 amj march 2016 2 % streptococcus viridans, 2% staphylococcus saprophytious, 2% moraxella sp, 1% klebsiellapneumoniae, 1% haemophillus influenzae, 2% pseudomonas aeruginosa,1% other haemophillus, 1% pseudomonas luteola , and 1% serratialiquefaciens.3 the sample sizes that are needed for this study are 65 s. pneumoniae isolates. s. pneumonia occurs in acute bacterial rhinosinusitis in adults is 20 to 45%.1 in this study, 8% samples were positive for presence of s. pneumonia. this is because specimens of 100 acute patients with acute rhinosinusitis were taken using nasopharyngeal swabbing with dacron swabs and the swabs were transported and stored in amies medium based on the previous research from department of otorhinolaryngology-head and neck surgery dr. hasan sadikin general hospital bandung. there are some evidences that rayon swabs perform better than dacron swabs for the culture of pneumococci from nasopharyngeal swabs.10 besides, there is recommendation that rayon swabs are transported and stored in skim milk-tryptone-glucose-glycerin (stgg) prior to bacterial culture.11 all specimens should be processed within 6 hours after collection.12 s. pneumoniae isolates survived for at least 3 years in stgg (skim milk, tryptone, glucose, glycerol) medium at -80°c.13 however, out of 8 samples of s. pneumoniae isolates, there were 3 samples isolates died after it is stored at -80°c with stgg medium. furthermore, some evidences showed the toxins produced by bacteria that kill or inducesuicide (apoptosis and autolysis) in genetically identical members of their own species such as the murein hydrolases and the choline-binding proteins responsible for autolysis and allolysis in s. pneumoniae.14 in this study resistance of s. pneumoniae to oxacillin is 6. oxacillin that is an alternative to beta lactams group such as amoxicillinclavulanate which is the first line therapy for acute bacterial rhinosinusitis in adults.4 this condition is happen because beta lactams group do not provide reproducible results used in this study. if the zone of inhibition around the oxacillin disk is less than 20 mm which means resistant, additional minimum inhibitory concentration (mic) testing must be performed to assess whether the isolate is resistant or susceptible to penicillin.9 global surveillance studies have shown that -lactamnonsusceptibility rates of s. pneumoniae increased in the worldwide during 1990s and 2000s because structural changes in the penicillin targets, the penicillin-binding proteins 1a, 1b, 2x , 2a, 2b and 3.15 in addition, increased resistance among penicillinnon-susceptibility s. pneumoniae is due to a mutation in penicillin binding protein 3 that cannot be overcome by the addition of a lactamase inhibitor.4 on the other hand, similar results showed 56 % of the s. pneumoniae isolates were penicillin-resistant.16 the study in us showed that the highest penicillin-nonfigure 1 antimicrobial susceptibility test of five s. pneumonia isolates althea medical journal. 2016;3(1) 67chong jie hao, chrysanti murad, trias nugrahadi: streptococcus pneumoniae drugs resistance in acute rhinosinusitis susceptibility s. pneumoniae were found in south africa(74%),the far east( 63%) and the middle east (54%).15 resistance of s. pneumoniae to azithromycin is 6. according chow et al.4 and liñares et al.15 showed the emergence of s. pneumoniae that carry both ermb and mefe macrolide resistance genes is a cause for concern, especially in asia countries, russia, south africa, and the usa. on the other hand, the increasing in the prevalence of macrolide resistance is strongly correlated to prior antibiotic use, particularly macrolides such as azithromycin, lactams, and trimethoprim.4,15 some similar studies showed the rates of resistance to azithromycin range from 22% to 67% for s. pneumoniae.16 besides, macrolide resistance in europe was high in isolates collected such as france(55.6%) were also reported.15 in this study, the resistance rate of s.pneumoniae to trimethoprim is as the same as the result during oxacillin susceptibility test of s. pneumoniae. indeed, reports from similar studies showed the rates of resistance to trimethoprim range from 50% to 75% for s. pneumoniae. the study by chow et al.4 showed that the resistance to trimethoprim among s. pneumoiae isolates occurs because of the mutations in the dihydrofolate reductase gene and prior exposure to trimethoprim, macrolides or penicillin. in this study resistance of s. pneumonia to levofloxacin is 4, because the mutation point producing amino acid changes in the quinolone resistance-determining regions of the subunits of dna topoisomerase iv and dna gyrase.15 however, some studies showed that resistance rate of s. pneumoniae to levofloxacin was 1.4% to 1.6% in more than 500 s. pneumoniae isolates.17,18 doxycycline is active against s. pneumoniae. data from national surveys in canada showed that doxycycline is highly active against s. pneumoniae (93.2%).18 similar reports from england, wales, and northern ireland, reveal that invasive isolates of s. pneumoniae have remained highly susceptible to doxycycline(91%).3 however, susceptible rate of s. pneumoniae to doxycycline is 6 because of the tetracycline resistance determinant (tetm) related to ermb macrolide resistance gene.19 there are several limitations in this study. first, limited s. pneumoniae isolates because of the lack of time in collecting the data and lack of acute rhinosinusitis patients in dr. hasan sadikin general hospital. several steps that need to be considered for further improve the research include the use of larger sample size taken more different area which is the different hospital in bandung to yield a better result. there are also a few steps that need to be concerned in order to prevent the spread of drugs resistance s. pneumoniae in both community setting and health-care setting, so that the further complication can be prevented. for example, reduce antibiotic use in communities and increased understanding of other factors that contribute to the development and transmission of resistance. the most important way to reduce s. pneumoniae infections is to increase the use of existing polysaccharide vaccines and to begin to use of new polysaccharide-protein conjugate vaccines in young children. after that, educate the community and staff in health-care facilities about covering mouth and nose while sneezing and coughing and personal hygiene such as hand washing. as a conclusion, drugs resistance s. pneumoniae from acute rhinosinusitis patient in dr. hasan sadikin general hospital showed the resistance of s. pneumoniae to oxacillin, azithromycin and trimethoprim are 6 whereas resistance to levofloxacin and doxycycline are 4. references 1. benninger m, woodard t. microbiology of acute, subacute, and chronic rhinosinusitis in adults. in: chang cc, incaudo ga, gershwin me, editors. diseases of the sinuses: springer new york; 2014. p. 99 –107. 2. mullol, baroody, douglas, goossens, hopkins, kalogjera, et al. epos 2012: european position paper on rhinosinusitis and nasal polyps 2012. a summary for otorhinolaryngologists. rhinology. 2012;50(1):1–12. 3. pradana y, madiadipoera t, sudiro m, dermawan a. efektivitas imunoterapi terhadap gejala, temuan nasoendoskopik dan kualitas hidup pasien rinosinusitis alergi. oto rhino laryngologica indonesiana. 2012;42(2): 88–95. 4. chow aw, benninger ms, brook i, brozek jl, goldstein ej, hicks la, et al. idsa clinical practice guideline: acute bacterial rhinosinusitis in children and adults. clin infect dis. 2012;54(8):e72–e112. 5. lu i, eim h. acute rhinosinusitis in adults. am fam physician.2011;83:1057–63. 6. siow j, alshaikh n, balakrishnan a, chan k, chao s, goh l, et al. ministry of health clinical practice guidelines: management althea medical journal. 2016;3(1) 68 amj march 2016 of rhinosinusitis and allergic rhinitis. singap med j. 2010;51(3):190–7. 7. lynch iii jp, zhanel gg. streptococcus pneumoniae: epidemiology and risk factors, evolution of antimicrobial resistance, and impact of vaccines.curr opin pulm med. 2010;16(3):217–25. 8. jean, hsueh. high burden of antimicrobial resistance in asia. int j antimicrob ag. 2011;37(4):291–5. 9. who. manual for the laboratory identification and antimicrobial susceptibility testing of bacterial pathogens of public health importance in the developing world. 2003. p. 45–62. 10. rubin lg, rizvi a, baer a. effect of swab composition and use of swabs versus swabcontaining skim milk-tryptone-glucoseglycerol (stgg) on culture-or pcr-based detection of streptococcus pneumoniae in simulated and clinical respiratory specimens in stgg transport medium. j clin microbiol. 2008;46(8):2635–40. 11. hammitt ll, murdoch dr, scott jag, driscoll a, karron ra, levine os, et al. specimen collection for the diagnosis of pediatric pneumonia. clin infect dis. 2012;54(suppl 2):s132–s9. 12. neves fp, pinto tc, corrêa ma, dos barreto r, de moreira l, rodrigues hg, et al. nasopharyngeal carriage, serotype distribution and antimicrobial resistance of streptococcus pneumoniae among children from brazil before the introduction of the 10-valent conjugate vaccine. bmc infect dis. 2013;13(1):318. 13. kaijalainen t, ruokokoski e, ukkonen p, herva e. survival of streptococcus pneumoniae, haemophilus influenzae, and moraxella catarrhalis frozen in skim milktryptone-glucose-glycerol medium. j clin microbiol. 2004;42(1):412–4. 14. cornejo oe, rozen de, may rm, levin br. oscillations in continuous culture populations of streptococcus pneumoniae: population dynamics and the evolution of clonal suicide. p roy soc b-biol sci. 2009;276(1659):999–1008. 15. liñares j, ardanuy c, pallares r, fenoll a. changes in antimicrobial resistance, serotypes and genotypes in streptococcus pneumoniae over a 30-year period.clin microbiol infec. 2010;16(5):402–10. 16. puglisi s, privitera s, maiolino l, serra a, garotta m, blandino g, et al. bacteriological findings and antimicrobial resistance in odontogenic and non-odontogenic chronic maxillary sinusitis. j med microbiol. 2011;60(9):1353–9. 17. orr d, wilkinson p, moyce l, martin s, george r, pichon b. incidence and epidemiology of levofloxacin resistance in streptococcus pneumoniae: experience from a tertiary referral hospital in england. j antimicrob chemoth. 2010;65(3):449– 52. 18. patel sn, mcgeer a, melano r, tyrrell gj, green k, pillai dr, et al. susceptibility of streptococcus pneumoniae to fluoroquinolones in canada. antimicrob agents ch. 2011;55(8):3703–8. 19. varaldo pe, montanari mp, giovanetti e. genetic elements responsible for erythromycin resistance in streptococci. antimicrob agents ch. 2009;53(2):343– 53. althea medical journal. 2016;3(2) 280 amj june 2016 characteristics of patient with proliferative diabetic retinopathy underwent anti-vascular endothelial growth factors injection in cicendo eye hospital, bandung in january–december 2013 marsha rayfa pintary,1 arief s. kartasasmita,2 juliati3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/cicendo eye hospital, bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: proliferative diabetic retinopathy (dr) is one of the microvascular complications of diabetes mellitus (dm) that is prevalent to the blindness risk. the world health organization (who) considers proliferative dr one of the priorities of eye diseases. this disease is caused by angiogenesis brought about by vascular endothelial growth factors (vegf). the anti-vegf bevacizumab (avastin) injection is considered sufficient in preventing proliferative dr patients from blindness. this study aimed to identify the characteristics of patients with proliferative dr underwent anti-vegf injection at cicendo eye hospital, bandung. methods: this was a retrospective study conducted from august−october 2014 using 40 medical records of patients with proliferative dr underwent anti-vegf bevacizumab (avastin) injection at the cicendo eye hospital bandung from january−december 2013. inclusion criteria were the patients underwent anti-vegf injection with complete medical records with minimum follow up of 3 weeks. results: among 40 patients, 55% were male and 45% were female. furthermore, there was 100% found for dm type 2. moreover, random blood glucose varied among 140–200mg/dl (50%), while the hypertension was mostly at stage 2. some of these patients had proliferative dr with vitreal hemorrhage (25%), macular edema (40%), and/or tractionalablasio retina (22.5%). most patients had an improvement in their visual acuity (60%). conclusions: most of patients are male, aged 50–59 years old, random blood glucose among 140– 200mg/dl, followed dm type 2 and hypertension stage 2. anti-vegf injection improves visual acuity. [amj.2016;3(2):280–5] keywords: anti-vegf, bevacizumab, proliferative diabetic retinopathy correspondence: marsha rayfa pintary, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 82126982505 email: marsharayfa@icloud.com introduction diabetes mellitus (dm) is a chronic disease involving carbohydrates, lipid and protein metabolisms in the body. this chronic lifelong disease can lead to severe complications and even death.1 the global incidence of dm continues to spike up. indonesia is anticipated to be among the top 30 countries with high number of diabetes patients in the year 2030.2 the increasing cases of microvascular complications such as diabetic retinopathy (dr) corresponds with the increase of dm cases.3 the dr is a progressive degenerating disease of the retina and one of the main causes of blindness in the world especially in adults aged 20–74 years old in the developing countries.2,4 the world health organization (who) has taken prompt action in tackling this serious matter and included it into their program, vision 2020 the right to sight.3 proliferative dr is a severe complication which jeopardizes the eyesight which usually occurs during angiogenesis or formation of new pathologic blood vessels.5 it usually results from high level of vascular endothelial growth factor (vegf) in blood vessels.6 proliferative dr leads to its complications such as vitreous hemorrhage, tractional retinal detachment, and blindness if it is untreated. panretinal photocoagulation (prp), the gold standard treatment for proliferative dr takes a long time for neovascular regression and high risk in complications.5 in 2005, it was discovered althea medical journal. 2016;3(2) 281 that a safe and effective treatment becoming a trend in the world of ophthalmology is regressing vascular by injecting anti-vegf in the retina, one of them is bevacizumab (avastin; genentech, inc, south san francisco, california, usa).7 bevacizumab was initially used to treat colorectal cancer but now it is used off-label to treat eye diseases including proliferative dr.6 on a separate matter, bevacizumab has been shown to speed up neovascular regeneration and decrease macular edema in dr in previous studies.5,8 in addition to its low cost and repetitive usage, bevacizumab is able to prevent systemic complications by local application in low dosage.5,9 unfortunately, intravitreal anti-vegf injection increases the risk for endophthalmitis and retinal detachment in dm patients.10 in indonesia, there are no sound data regarding the characteristics of post injection antivegf in patient with proliferative dr. on the other hand, there are many published study regarding the efficacy of this treatment. given these facts, this study was aimed to identify the characteristics of post injection anti-vegf in patient with proliferative dr at cicendo eye hospital, bandung. methods a quantitative descriptive study was conducted from august–october 2014 using retrospective method in cicendo eye hospital, bandung. the health research ethics committee faculty of medicine, universitas padjadjaran had approved this study. the population was the patients with proliferative dr who underwent anti-vegf injection operation in cicendo eye hospital, bandung in the period of january to december 2013. the sample was selected using the total sampling. out of 490 patients with dr, 40 patients were included as samples in this study. the sample was selected from the medical record with certain inclusion and exclusion criteria. inclusion criteria includes all patients underwent anti-vegf injection with complete medical records with minimum follow up of 3 weeks while the exclusion criteria were all patients with medical records that do not contain data postoperative of anti-vegf injection. in this study, gender, age, types of dm, diagnosis, presence of macular edema, presence of tractional retinal detachment, vitreal hemorrhage, random blood glucose levels, blood pressure, frequency of anti-vegf injection, vision acuity before and after the operation, and post operation complication were also collected. random blood glucose levels were then divided into 3 categories; <140 mg/dl, 140–200 mg/dl, >200mg/dl. blood pressure was also categorized into normal (<120/<80mmhg), prehypertension (120– table 1 1demography characteristic of patients characteristic number of patients (n) % gender male 22 55 female 18 45 age (years old) 40–49 9 22.5 50–59 20 50 60–69 11 27.5 type of dm dm type 1 0 0 dm type 2 40 100 duration of dm < 5 years 8 20 5–10 years 14 35 > 10 years 18 45 note: dm: diabetes mellitus marsha rayfa pintary, arief s. kartasasmita, juliati: characteristics of patient with proliferative diabetic retinopathy underwent anti-vascular endothelial growth factors injection in cicendo eye hospital, bandung althea medical journal. 2016;3(2) 282 amj june 2016 table 2 clinical status of patients characteristic number of patients (n) % random blood glucose < 140 mg/dl 18 45 140–200 mg/dl 20 50 > 200 mg/dl 2 5 blood pressure normotension 5 12.5 prehypertension 5 12.5 hypertension stage 1 14 35 hypertension stage 2 16 40 eyes affected ocular dextra (od) 22 55 ocular sinistra (os) 18 45 diagnosis preproliferative dr 16 40 proliferative dr 24 60 vitreous hemorrhage yes 10 25 no 30 75 macular edema yes 16 40 no 24 60 tractional retinal detachment yes 9 22.5 no 31 77.5 note: dr: diabetic retinopathy 139/80–89mmhg), stage 1 hypertension (140–159/90–99mmhg), and stage 2 hypertension (>160/>100mmhg) based on jnc 7. visual acuity was categorized based on who blindness classification, normal (v/a 6/6-6/18-), visual impairment (v/a 6/18– 6/60), severe visual impairment (v/a <6/60– 3/60) and blind (v/a <3/60–npl). data were analyzed using computer and presented in table. results from 40 patients, the majority of the patients were male (55%) which > 40 years old with the highest range of age between 50–59 years old. there was no patient with dm type 1 and the average duration of dm was about >10 years. the number of patients with proliferative dr increased in accordance with the duration of dm (table 1). based on the clinical status, most patients had the blood glucose levels around 140200 mg/dl (50%), while the majority of hypertension was at stage 2. anti-vegf injection was given mostly to the right eye (55%). the majority of the patients were confirmed to have proliferative dr (60%) while those with preproliferative dr were only 40%. in a small number of patients, 10 people (25%) experienced vitreous hemorrhage, 16 people (40%) had macular edema and 9 people (22.5%) had tractional retinal detachment (table 2). there were about 20 patients (50%) experienced blindness after the treatment. most of these patients (34%), received only single anti-vegf avastin. on the other hand, most patients experienced improvement in althea medical journal. 2016;3(2) 283marsha rayfa pintary, arief s. kartasasmita, juliati: characteristics of patient with proliferative diabetic retinopathy underwent anti-vascular endothelial growth factors injection in cicendo eye hospital, bandung their vision after treatment (15%). however, there was one complicated case in which the patient got infected and bleeding (table 3). discussion there were 22 male patients and 18 female patients involved in this study. the total number of patients did not align with the actual general prevalence of proliferative dr which states females are more prone to proliferative dr compared to males. this was due to several factors, including low awareness, financial problems, limited access to health care, and mainly the insufficiency of time which leads to the attempt of acquiring knowledge and doing socialization regarding the diabetic retinopathy by the health providers in primary care.11 the examined patients were above 40 years old. a study conducted in the united states of america12 found that diabetic patients aged above 40 years old have higher prevalence of getting dr which would threaten their eyesight. this study shows that the highest number of patients with dr is dominated by patients aged 50-59 years old while patients above 60 years old are fewer. this could be due to the fact that dm is a degenerative disease and as it progresses, severe complications will occur which ultimately lead to death.13 in this study, dm type 2 was predominant and this corresponded to the fact that 90–95% of dm patients usually have type 2 dm.14 in addition, as shown in other studies, dm type 2 is dominant in asia compared to dm type 1.15 the duration of dm is a major risk factor for the occurrence of dr. the longer duration of dm, the higher the prevalence of dr in dm type 2.16 it was found that 45% of the patients have been experiencing dm for more than 10 years. severe hyperglycemia is the contributing key for dr and it can be prevented by controlling one’s blood glucose.14 it is crucial to control blood glucose level prior to surgery as it can delay the progression of the disease and decrease complications.14,16 half of the patients have blood glucose levels between 140–200 mg/dl and only 5% of them have blood glucose levels above 200 mg/dl. these patients are expected to have better outcomes. as stated earlier, patients with low blood glucose are expected to have better outcomes as hyperglycemia is the key to dr.17 on the other hand, most of the patients have hypertension stage 2 because they neglected the blood pressure control. strict control of blood pressure (<130/80 mmhg) has been shown to decrease the risk of blindness. furthermore, the risk of dr decreases by 10– 13% for every reduction in 10 mmhg of blood pressure.14 table 3 clinical status of patients characteristic number of patients (n) % visual acuity pre injection normal 6 15 visual impairment 3 7.5 severe visual impairment 11 27.5 blind 20 50 visual acuity post injection increase 24 60 not improved 10 25 decrease 6 15 frequency of injection 1x 34 85 2x 4 10 3x 2 5 complication yes 1 2.5 no 39 97.5 althea medical journal. 2016;3(2) 284 amj june 2016 based on the data obtained, most patients have pdr (60%) while the rest have preproliferative dr. moreover, it was found that some patients suffer from vitreous hemorrhage (25%), macular edema (40%), and tractional retinal detachment (22.5%) while some patients (50%) are found to be blind after visual acuity examination. blindness among dm patients normally is because of under-detection of dr at an early stage. in a previous study, dr has been shown to be under-detected among dm patients.18 the patients should be encouraged to routine their eye examination preventive care to avoid undesirable outcome. moreover, studies in australia19 and spain20 clearly showed that primary healthcare doctors are sufficient to help decreasing the prevalence of dr among patients with dm provided with adequate training. it is recommended for official guidelines to be published in indonesia and adequate training should be provided to primary health care providers in order to tackle this issue effectively. the limitation of this study was the improvement of visual acuity did not classify based on pre injection examination, that make it difficult to determine which group has significant improvement after the treatment. in conclusion, this study shows that the number of male patients is higher than female. these patients mostly aged 50–59 years old, random blood glucose among 140–200mg/ dl, suffer from dm type 2 and hypertension stage 2. this study also found that anti-vegf injection improves visual acuity. for further studies, it is recommended to use prospective design and classify the result of visual acuity before the treatment. references 1. suyono s. diabetes melitus di indonesia. in: sudoyo aw, setiyohadi b, alwi i, simadibrata m, setiati s, editors. buku ajar ilmu penyakit dalam. 5th ed. jakarta: interna publishing, pusat penerbitan ilmu penyakit dalam fakultas kedokteran universitas indonesia; 2009 2. wild sh, roglic g, green a, sicree r, king h. global prevalence of diabetes: estimates for the year 2000 and projections for 2030 response to rathman and giani. diabetes care. 2004;27(10):2568–9. 3. wang x, wang g, wang y. intravitreous vascular endothelial growth factor and hypoxia-inducible factor 1a in patients with proliferative diabetic retinopathy. am j ophthalmol. 2009;148(6):883–9. 4. pai a, el shafei mm, mohammed oa, al hashimi m. current concepts in intravitreal drug therapy for diabetic retinopathy. saudi j ophthalmol. 2010;24(4):143–9. 5. ma y, zhang y, zhao t, jiang y-r. vascular endothelial growth factor in plasma and vitreous fluid of patients with proliferative diabetic retinopathy patients after intravitreal injection of bevacizumab. am j ophthalmol. 2012;153(2):307–13.e2. 6. kohno r-i, hata y, mochizuki y, arita r, kawahara s, kita t, et al. histopathology of neovascular tissue from eyes with proliferative diabetic retinopathy after intravitreal bevacizumab injection. am j ophthalmol. 2010;150(2):223–9.e1. 7. gunther jb, altaweel mm. bevacizumab (avastin) for the treatment of ocular disease. surv ophthalmol. 2009;54(3):372–400. 8. waisbourd m, goldstein m, loewenstein a. treatment of diabetic retinopathy with anti-vegf drugs. acta ophthalmol. 2011;89(3):203–7. 9. raftery j, clegg a, jones j, tan sc, lotery a. ranibizumab (lucentis) versus bevacizumab (avastin): modelling cost effectiveness. br j ophthalmol. 2007;91(9):1244–6. 10. simó r, hernández c. intravitreous antivegf for diabetic retinopathy: hopes and fears for a new therapeutic strategy. diabetologia. 2008;51(9):1574–80. 11. munoz b, o’leary m, fonseca-becker f, rosario e, burguess i, aguilar m, et al. knowledge of diabetic eye disease and vision care guidelines among hispanic individuals in baltimore with and without diabetes. archophthalmol. 2008;126(7):968–74. 12. falcão m, falcão-reis f, rocha-sousa a. diabetic retinopathy: understanding pathologic angiogenesis and exploring its treatment options. the open circulation and vascular journal. 2010;3:30–42. 13. forbes jm, cooper me. mechanisms of diabetic complications. physiol rev. 2013;93(1):137–88. 14. american academy of ophthalmology retina panel. preferres practice pattern guidelines: diabetic retinopathy. san fransisco: american academy of ophthalmology; 2008 (4th printing 2012). 15. sivaprasad s, gupta b, crosby-nwaobi r, evans j. prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective. surv ophthalmol. 2012;57(4):347–70. althea medical journal. 2016;3(2) 285 16. schubert hd. retina and vitreous. in: skuta gl, cantor lb, cioffi ga, editors. basic and clinical science course. san fransisco: american academy of ophthalmology; 2012. p. 738–79 17. axer-siegel r, herscovici z, gabbay m, mimouni k, weinberger d, gabbay u. the relationship between diabetic retinopathy, glycemic control, risk factor indicators and patient education.isr med assoc j. 2006;8(8):523–6. 18. pedersen ml. management of type 2 diabetes mellitus in greenland, 2008: examining the quality and organization of diabetes care. int j circumpolar health. 2009;68(2):123–32. 19. askew d, schluter pj, spurling g, maher cm, cranstoun p, kennedy c, et al. diabetic retinopathy screening in general practice: a pilot study. aust fam physician. 2009;38(8):650–6. 20. andonegui j, berástegui l, serrano l, eguzkiza a, gaminde i, aliseda d. agreement among ophthalmologists and primary care physicians in the evaluation of retinographies of diabetic patients. arch soc esp oftalmol. 2008;83(9):527–31. marsha rayfa pintary, arief s. kartasasmita, juliati: characteristics of patient with proliferative diabetic retinopathy underwent anti-vascular endothelial growth factors injection in cicendo eye hospital, bandung althea medical journal. 2016;3(2) 216 amj june 2016 correlation between health perception, body image, and eating habits in high school students abdullah ichsan,1 irvan afriandi,2 dida akhmad gurnida3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: mental disorders, including eating disorders, mostly begin during youth. moreover, negative body image is found to cause unhealthy eating habits in the context of several cross-cultural settings. this study aimed to examine the correlation between health perception and body image with eating habits among high school students. methods: a structured, anonymous questionnaire was distributed to students of a private high school in bandung, indonesia in june-october 2014. the questionnaire included questions about health perception, body image, eating habits, body weight and height, and also other demographic parameters. the school was selected as the study object through purposive sampling, and 140 high school students (72 male and 68 female) were ramdomly selected. results: male and female did not show considerable differences in health perceptions. out of 13 statements, 12 statements of male respondents showed better body image than female. while in eating habits statements, female respondents seemed to maintain healthier eating habits than male respondents. no significant correlation was observed between body image and eating habits (r=-0.015, p=0.858). there was significant correlation between health perception and eating habits (r=0.374, p<0.001). correlation between sex and eating habits was found (p=0.020), there was not significant relationship between eating habits and body mass index (bmi) (p=0.368). conclusions: the negative relationship between body image and eating habits is not significant. however there was a significant positive relationship between health perception and eating habits. furthermore, there was correlation between sex and eating habits, while the positive relationship between eating habits and bmi was still not found. [amj.2016;3(2):216–21] keywords: body image, body mass index, health perception, high school students, nutritional habits correspondence: abdullah ichsan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6289617613761 email: ichsanlernt@gmail.com introduction while infections are continuously being eradicated in developed countries, the numbers of non-communicable diseases patients are arising as well. moreover, it is currently very common to hear about “double burden diseases” in developing countries. it means that those countries are not only facing communicable diseases, but also noncommunicable diseases. unfortunately, only a few people realize that those dangerous non-communicable diseases, such as cardiometabolic diseases, hypertension, cancers, can also be prevented by having proper nutrition.1 medical practitioners should realize that mental disorders mostly begin during youth, which is 12–24 years of age, although they are often diagnosed or detected later in life.2 moreover, a study involving british and malaysian women shows that bmi is the primary determinant of female physical attractiveness.3 the aim of this study was to examine the correlation between health perception and body image with eating habits among high school students. this study expected to obtain more appropriate intervention for reducing the risk of having eating disorder and improving positive health behaviors which can be well-planned. thus, it could be hypothesized that negative relationship would be observed between body image and eating althea medical journal. 2016;3(2) 217 habits; there would be positive relationship between health perception and eating habits; there would be correlation between sex and eating habits; and positive relationship would be observed between eating habits and body mass index (bmi). methods a structured, anonymous, self-administrated questionnaire was distributed to students of a private high schools in bandung, indonesia in june-october 2014. some questions were obtained from jessor’s survey of personal and social development, then it was translated and culturally adapted to suit local students population.4 the rest of the questions were developed prior to this study. the questionnaire included questions about health perception, body image, eating habits, body weight and height, and also other demographic parameters. for the participants’ comfort, the questionnaire was simplified and arranged into tables, and separated questions for each variable. the lists of students’ name from each class were obtained from the school’s administration sub-division, and then the classes where the questionnaire would be distributed were randomly selected. as many as 140 high school students (72 male and 68 female) became the respondents. as they were on the eleventh grade of senior high school, their ages ranged from 15–17 years. considering that the age of the respondents was still not sufficient to allow them to sign the informed consent letter by themselves; the teacher agreed to sign it for them as teachers are the students’ parents at school time. the health perception of respondents was measured by giving them nine statements, and letting them choose from “never” (scored 0 for positive statements and 3 for negative statements) until “always” (scored 3 for positive statements and 0 for negative statements). seven from the total nine statements were positive, and the rest two statements on health perceptions were negative. an index was then created for health perceptions (9 items, cronbach alpha=.78). to measure the respondents’ body image, there were thirteen negative statements, and the respondents could choose from “never” (scored 3) until “always” (scored 0). an index was also created for body image (13 items, cronbach alpha=.90). furthermore, the respondents eating habits were measured by administering eight statements. just like the health perceptions questionnaire, they could choose from “never” (scored 0 for positive statements and 3 for negative statements) until “always” (scored 3 for positive statements and 0 for negative statements). out of the eight statements, six were positive, and the rest two statements were negative. eating habits index was also created afterwards (8 items, cronbach alpha=.77). the respondents were recommended to use the healthcare facilities measurement tools in order to measure their body height and weight. after the ethical clearance was obtained from the health research ethics committee of faculty of medicine, universitas padjadjaran then, the questionnaires were distributed at learning time in the class for about ten until fifteen minutes. the purpose of the questionnaire distribution performed at learning was to prevent students from leaving the class or finishing the questionnaires in a rush. this was carried out by teachers after the teachers were given explanations how to distribute and fill in the questionnaire. from a total number of eight classes of grade eleven in the selected high school, the questionnaires were finally distributed to six randomly selected classes. every student who participated in this study would receive a brief result of this study, and a bookmark with some healthy diet information on it, and the school would receive a copy of the journal and the whole report of this study. the analysis in this study included descriptive data analysis, relationship tests for the first and second hypothesis using pearson correlation, simple linear regression for the third hypothesis, and simple logistic regression for the fourth hypothesis. all of those processes were conducted by using computer. results male and female did not show considerable differences in health perceptions (table 1). however, in body image and eating habits the differences between male and female were clearly shown (table 2 and 3). out of 13 statements, 12 statements of male respondents showed better body image than female. while in eating habits statements, female respondents seemed to maintain healthier eating habits than male respondents. the first hypothesis claimed that negative relationship could be observed between body abdullah ichsan, irvan afriandi, dida akhmad gurnida: correlation between health perception, body image, and eating habits in high school students althea medical journal. 2016;3(2) 218 amj june 2016 image and eating habits. unfortunately, the result of pearson’s correlation test showed that the relationship was not significant (r=0.015, with p=0.858) (table 4). the second hypothesis then suggested that a positive relationship would be observed between health perception and eating habits. the result was as expected. the result of a pearson’s correlation test had shown a quite strong and significant relationship (r=0.374, with p<0.001) (table 4). the third hypothesis indicated that there could be some correlations between sex and eating habits. by using the simple linear regression test, and looking at the distributions, the correlation could be observed (p=0.020) (table 3). the fourth, and also the last hypothesis claimed that positive relationship would be observed between eating habits and bmi. unfortunately, after using the logistic regression test there was no significant relationship found for those variables (p=0.368). discussion this study had provided several data which were not easily found, especially in indonesia. the data were health perception, body image, eating habits, and the associations between them. however, even the results showed little significant correlations between variables in this study, there were still some phenomena which should still be discussed. in the first hypothesis, it was claimed that negative relationships between body image and eating habits would be observed. this hypothesis was based on some previous studies, such as a research in poland5 which showed 63.9% of woman were dissatisfied with their figures, and 33.5% of them underwent slimming diets at least once. the tripartite model of body image and eating disorders (peer, parents, and media) had also been proven to be a useful framework for understanding processes that may predispose young women to develop negative body image and eating disorders.6 unfortunately, in this study, no strong relationship was revealed, whereas female respondents who had relatively negative body image maintained healthier eating habits than male respondents. this study even showed that among high school students, who were also a group of adolescents, there were no significant correlations between body image and eating habits. table 1 distribution of health perceptions by gender no measurements gender total (%) n=140male (%) n=72 female (%) n=68 1 always consider whether my body is in a healthy condition 17 (23.6) 4 (5.9) 21 (15) 2 always consider whether my body has enough energy to do daily activities 13 (18.1) 9 (13.2) 22 (15.7) 3 always consider whether my environments are away from diseases 5 (6.9) 6 (8.8) 11 (7.9) 4 always agree to do extra efforts or spend extra money to keep my body in healthy condition 10 (13.9) 11 (16.2) 21 (15) 5 always consider my health condition compared with others 15 (20.8) 10 (14.7) 25 (17.9) 6 always keep healthy eating habits, not too much, not too little 8 (11.1) 9 (13.2) 17 (12.1) 7 always clean myself and clean-up my surroundings 14 (19.4) 12 (17.6) 26 (18.6) 8 never do things i like if it endanger my health and safety 3 (4.2) 5 (7.4) 8 (5.7) 9 never ignore usual symptoms of disease i.e. runny nose, cough, headache if it occurred already for several days 16 (22.2) 16 (23.5) 32 (22.9) althea medical journal. 2016;3(2) 219 the different result between this study and the other ones might be due to several reasons. first, there were only relatively few studies that had focused on eating habits in adolescents or all age group in overall. second, this study was only focused on one private high school, in order to eliminate socio-economic confounding the number of samples of this study was somehow insufficient to represent all adolescents in bandung, moreover in whole indonesia. it seems that a further study should include a lot more samples in order to obtain more relevant and valid results. for example, a study conducted in israel7 which showed correlations between body image and eating habits included more than one thousand college students from several different faculties. the second hypothesis suggested that there would be a positive relationship between health perception and eating habits. as shown in the results, this hypothesis was accepted. another study in israel7 conducted with a similar objective also revealed the same results; there were positive relationships. although in detail, the study in israel showed a stronger correlation. this might be due to some reasons of the previous hypothesis in this study where there were only 140 samples, while in the study conducted in israel, there were more than 1,000 samples. however in overall, the result still revealed the same: a positive correlation between health perception and eating habits could be observed. besides, it is also in line with the literature which mentioned nutrition knowledge can help individuals choose what foods to eat.8 the third hypothesis then indicated there would be a correlation between sex and eating habits which was accepted. the numbers of female, male and the total sample which had good eating habits compared to all samples in this study were listed (table 3). it seemed that females had better eating habits compared to males. just like in another study which showed females tend to keep a more balanced diet.9 the last hypothesis claimed that a positive relationship would be observed between eating habits and bmi. surprisingly, in this study, the relationship was not significant. however, this phenomenon can be well explained, as another study had revealed that sex, genetics table 2 distribution of body image by gender no measurements gender total (%) n=140male (%) n=72 female (%) n=68 1 never feel ashamed with my body when facing someone special. 26 (36.1) 9 (13.2) 35 (25) 2 never feel that others think bad about my body 24 (33.3) 11 (16.2) 35 (25) 3 people never think about my weight the first time they meet me 50 (69.4) 34 (50) 84 (60) 4 never feel that my friends and family feel ashamed when they are with me 60 (83.3) 52 (76.5) 112 (80) 5 like my body 41 (56.9) 16 (23.5) 57 (40.7) 6 never quit sports or other outdoor activities because of feeling ashamed with my appearance 62 (86.1) 52 (76.5) 114 (81.4) 7 like to see my body on mirrors 33 (45.8) 31 (45.6) 64 (45.7) 8 being the center of attention in a crowd is never a problem for me. 9 (13.2) 17 (23.6) 26 (18.6) 9 never stop enjoying my activities because of unattractive appearance. 51 (70.8) 33 (48.5) 84 (60) 10 never think that shopping some outfits is a bad idea because i need to consider about my weight 60 (83.3) 54 (79.4) 114 (81.4) 11 never feel bad of my body weight 53 (73.6) 32 (47.1) 85 (60.7) 12 never feel bad even when i’m being fat 44 (61.1) 19 (27.9) 63 (45) 13 never looking down or bad about my body 53 (73.6) 31 (45.6) 84 (60) abdullah ichsan, irvan afriandi, dida akhmad gurnida: correlation between health perception, body image, and eating habits in high school students althea medical journal. 2016;3(2) 220 amj june 2016 or family history, physical activity and many other factors had also affected bmi.10 obviously, there is a strong need for the community to get health promotion in academic settings. in indonesia, mental diseases such as anorexia nervosa, bulimia nervosa, and other eating disorders are still being neglected. most people, especially in indonesia are not aware about mental health and it makes this problem become worse. community health professionals should also realize that health education programs help to support healthy choices among students. one study showed that interventions have the potential to reduce sick people, healthcare costs, and also to increase moral and efficiency.11 this study provided useful information to plan health education about eating behavior for high school students, which should also be focused on improving their health perception, besides giving education about healthy diets so that the intervention can be effective. thus by using that method, the intervention targets do not only know what to do, but also why they have to do it. lastly, this study has also three main limitations. first, as this study was based on cross-sectional data, it could not determine causal-effect relationships. this study could only determine whether the correlations between variables existed, and if it was possible, determine the strength of the relationship. however, a number of descriptive data and analysis results found in this study were interesting, and hopefully the data could contribute to the existing scientific knowledge regarding the lack of studies focusing on health perception, body image, and eating habits. the second limitation was that the sample of this study was only taken from one local private high school. even the purpose of this sample selection was to eliminate socioeconomic confounding. unfortunately, it made the data less representative for the real population which was high school students. the third limitation arose because the variables measured in this study were mostly the personal perception of the respondents; the questionnaire used in this study was selfreported. table 3 distribution of eating habits by gender no measurements gender total (%) n=140male (%) n=72 female (%) n=68 1 always reduce fatty foods 3 (4.2) 4 (5.9) 7 (5) 2 always eat fresh vegetables 7 (9.7) 14 (20.6) 21 (15) 3 always choose fruits for snacks rather than sweets, chocolates, or other snacks 7 (9.7) 11 (16.2) 18 (12.9) 4 always choose baked or boiled foods rather than fried ones 5 (6.9) 6 (8.8) 11 (7.9) 5 always consume fish, nuts, eggs, rather than meat for protein sources 7 (9.7) 13 (19.1) 20 (14.3) 6 always reduce sweet foods and beverages 2 (2.8) 3 (4.4) 5 (3.6) 7 never consume fast foods when eating outdoors 3 (4.2) 1 (1.5) 4 (2.9) 8 never think that being full is the only goal of eating foods 9 (12.5) 12 (17.6) 21 (15.) table 4 correlation between variables studied no 1 2 3 1 positive health perception 2 positive body image .211* (p < 0.05) 3 healthy eating habits .374* (p < 0.001) -.015 (p = 0.858) althea medical journal. 2016;3(2) 221 as conclusion, the negative relationship between body image and eating habits is not significant. however there was a significant positive relationship between health perception and eating habits. furthermore, it was found that there was correlation between sex and eating habits, while the positive relationship between eating habits and bmi was still not found. this study then suggested community health professionals to give more attention and education to induce positive health perception, positive body image, and healthy lifestyle including eating behavior. in addition, health education programs should also target parents and school teachers beside the adolescents themselves, since parents and teachers have a very strong effect on supervising their children or students’ behaviors. references 1. mokdad ah, marks js, stroup df, gerberding jl. actual causes of death in the united states, 2000. jama. 2004;291(10):1238–45. 2. patel v, flisher aj, hetrick s, mcgorry p. mental health of young people: a global public-health challenge. lancet. 2007;369(9569):1302–13. 3. swami v, tovée mj. female physical attractiveness in britain and malaysia: a cross-cultural study. body image. 2005;2(2):115–28. 4. jessor r, turbin ms, costa mf. survey of personal and social development at cu. institute of behavioral sciences, university of colorado. 2003; spring:1–36 5. przybyłowicz ke, jesiołowska d, obaragołębiowska m, antoniak l. a subjective dissatisfaction with body weight in young women: do eating behaviours play a role? rocz państw zakl hig. 2014;65(3):243–9. 6. keery h, van den berg p, thompson jk. an evaluation of the tripartite influence model of body dissatisfaction and eating disturbance with adolescent girls. body image. 2004;1(3):237–51. 7. korn l, gonen e, shaked y, golan m. health perceptions, self and body image, physical activity and nutrition among undergraduate students in israel. plos one. 2013;8(3):e58543. 8. kicklighter jr, koonce vj, rosenbloom ca, commander ne. college freshmen perceptions of effective and ineffective aspects of nutrition education. j am coll health. 2010;59(2):98–104. 9. stock c, wille l, krämer a. gender-specific health behaviors of german university students predict the interest in campus health promotion. health promot int. 2001;16(2):145–54. 10. sattar a, baig s, naveed ur rehman, bashir b. factors affecting bmi; assessment of the effect of sociodemographic factors on bmi in the population of ghulam mohammad abad faisalabad. professional med j. 2013;20(6):956–64. 11. lee rl, loke aj. health-promoting behaviors and psychosocial well-being of university students in hong kong. public health nurs. 2005;22(3):209–20. abdullah ichsan, irvan afriandi, dida akhmad gurnida: correlation between health perception, body image, and eating habits in high school students althea medical journal. 2016;3(4) 640 amj december 2016 age pattern at menarche as results from a puberty survey naereintheni a/p ganabathy,¹anggraini widjajakusuma,² dini hidayat3 1faculty of medicine universitas padjadjaran, 2department of epidemiology and biostatistics faculty of medicine universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: range age of menarche is 15 to 17 years old from 1950’s to 20th century. however, in the current generation, the menarche age ranges from 13 to 16 years old. the factors affecting the change in the age of menarche over time and individual variation are due to the genetic or environmental factors. this study was performed to determine age pattern at menarche in jatinangor, sumedang ,west java, indonesia. methods: the data for this descriptive study was obtained from a puberty survey performed by faculty members of faculty of medicine universitas padjadjaran from april–september 2013 in jatinangor, sumedang, west java. a total of 249 female respondents aged 11–70 years old were included in this study. the age and year onset of menarche was determined and analyzed using computer. results: the range age of menarche in jatinangor population from early 1963 until 2013 was 9–17 years old, with 0.8% (n=2) cases of precocious puberty in current generation (year onset of menarche, year 2004–2013). for the onset of menstruation, the current generation had a youngest age compared to the other older generations with a mean age of 12.28 years old. furthermore, most of the respondents from the current generation reached menarche at the age of 12 years old (37.4%). conclusions: the onset of menarche in current generation is earlier compared to the older generations with most of them reaching menarche at the age of 12 years old. [amj.2016;3(4):640–3] keywords: menarche, menstruation age pattern, puberty survey correspondence: naereintheni a/p ganabathy, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 83816734032 email: naerein_91@live.com introduction the development and interaction of hypothalamus-pituitary-ovarian axis with reproductive and endocrine system cause the onset of menarche. normally, the age at onset of menarche ranges from 11–15 years old.1 however, there are two main factors that cause this age to vary among individuals, and time, which are the genetic and environmental factors. examples of the environmental factors include nutritional status, adipose tissue composition, and socioeconomic status.2 from 1950’s to 20th century, the average age at menarche was 15 to 17 years old. however, in the current generation, the mean age at menarche can range from 13 to 16 years old.3 nevertheless, in indonesia, a multicenter survey conducted in 1992–1995 showed that the mean age at menarche was 12.96 with slight variation of the age in different regions in indonesia.4 jatinangor is a small town in indonesia and the place where many studies conducted by the faculty members of universitas padjadjaran. one of the studies was puberty survey. the inhabitants of this town have low socioeconomic status decreasing their accessibility to get proper food and health care especially for children and women. besides, a sedentary lifestyle experienced by children in this era leads to risks of obesity. moreover, the environmental factor such as stress is common among children nowadays. all these changes in environment, lifestyle, and nutritional level in this population could be influential factors in the common menarcheal age over time. therefore, this study was conducted to identify the age pattern at menarche. methods this study was a descriptive study, which was part of the puberty survey by faculty members althea medical journal. 2016;3(4) 641 of faculty of medicine universitas padjadjaran. the study was approved by health research ethics committee faculty of medicine universitas padjadjaran. this puberty survey was conducted from april–september 2013 in jatinangor. the population of this study consisted of all female students from elementary school (sekolah dasar, sd), junior high school (sekolah menengah pertama, smp), and senior high school (sekolah menengah atas, sma). the school locations were randomly selected; those were sdn cibeusi, sdn cikopo ii, smp pgri 1 jatinangor, smp al-masoem, smk pgri jatinangor, sma pgri jatinangor, and mts (islamic junior high school) ma’arif. moreover, the female family members of the selected students were also included in this study (female siblings, mother, and grandmother). the inclusion criteria were all of the female respondents who experienced menarche, and the exclusion criteria were those who had not experienced menarche. a total of 249 female respondents were obtained after inclusion and exclusion criteria. the age of menarche commonly referred as the age in which a female obtains her first onset of menstruation was taken to be analyzed for each individual. from the data obtained, the year of onset of menarche was calculated giving a range of 1960’s and earlier until 2013. the data were then classified into 6 groups based on the year of onset at menarche with 10 years gap range in each group. the mean age, range age, and common age at menarche in each group were identified and analyzed using computer. results data from 249 people aged 11–70 years old from the 7 participating schools were taken to be analyzed in this study. the onset of menarche in 2004–2013 showed that most girls attained their menarche at the age of 12 (n=65, 37.4%). however, compared to the previous years of menarche onset,1963 and earlier,1984–1993 and 1994– naereintheni a/p ganabathy, anggraini widjajakusuma, dini hidayat: age pattern at menarche as results from a puberty survey table 1 the distribution of age at menarche across generations age of menarche (years) generations (number of respondents) 1963 and earlier 1964–1973 1974–1983 1984–1993 1994–2003 2004–2013 9 0 0 0 0 0 2 10 0 0 0 0 0 6 11 0 0 0 1 0 27 12 0 2 1 6 1 65 13 0 0 3 10 7 56 14 0 0 1 5 2 16 15 1 1 2 17 2 2 16 3 1 2 5 0 0 17 0 0 1 1 0 0 total 4 4 10 45 12 174 table 2 the range and mean age at menarche according to generations generation 1963 and earlier 1964–1973 1974–1983 1984–1993 1994–2003 2004–2013 mean age of menarche 15.75 13.75 14.40 14.11 13.42 12.28 range age of menarche 15‒16 12‒16 12‒17 11‒17 12‒15 9‒15 althea medical journal. 2016;3(4) 642 amj december 2016 2003, most girls attained their menstruation at the age of 16 (n=3, 75%), 15 (n=17, 37.8%) and 13 (n=7, 58.3%) respectively (table 1). the current generation with year onset of menarche, 2004–2013 has the lowest mean age of menarche with value of 12.28 compared to the previous years (table 2). furthermore, the age range of menarche in female respondents in jatinangor (aged 11–70 years old) from early 1960–2013 was 9–17 years old (table 1). there were 2 (0.8%) female respondents with precocious puberty in the current generation (table 1). there was a clear drop in the mean age of menarche in the year onset of menarche,1964–1973 which was at 13.75 years followed by an increase in the mean age in the subsequent generation, year onset of menarche 1974–1983 with a mean age of 14.40. this rapid decline in the menarche age could be due to insufficient data obtained from the puberty survey. the age of menarche had reduced over time (figure 1). discussion the current generation (year onset of menarche 2004–2013) has an early onset of menarche with a mean age of menarche of 12.28 years old and with most number of respondents obtaining menarche at age of 12 years old (37.4%) compared to previous generations. this data can be supported with another woman health survey conducted in california5 in 2008 which showed that asians ethnicity in the 20th century has an onset of menstruation, 50.9% at the age of 12–13 years old. however, from another study conducted in bogor indonesia6, in 2007, among elementary school children showed that children of the current generation have menarche onset at the age of 10–11 years old. the difference between these data could be due to the difference in geographical location or the environmental condition. for the mean age of menarche, the respondents who obtained menarche in year range of 1963 and earlier had an older age of onset compared to the other generations, which was at the mean age of 15.75 years. the females in this group were born in 1945– 1946. according to a research in korea7, women born in 1945–1949 had a mean age of 15.84 (1.85). furthermore, with a value of 12.28, the current mean age of menarche in jatinangor population was younger compared to the mean age of menarche of females in indonesia4 based on a multicenter survey conducted in 1992–1995, which showed a value of 12.96 years old. this earlier onset of menarche can be due to the genetics or changes in environmental factors such as poor nutritional status (obesity), psychological stress, or poor economic status to maintain lifestyle. however, this current mean age of menarche in jatinangor is similar to a study condcuted in jakarta8 in 2009 among 57 high school students who had a mean menarche age of 12.2 (0.9). figure 1 the pattern of menarche age between generations althea medical journal. 2016;3(4) 643naereintheni a/p ganabathy, anggraini widjajakusuma, dini hidayat: age pattern at menarche as results from a puberty survey the presence of 2 female respondents with menarche age at 9 in the current generation indicated precocious puberty. this early onset of puberty can be due to hormonal imbalances, mainly due to abnormal gonadotropinreleasing hormone (gnrh) secretions or presence of increased gonadal hormones, androgen and estrogen secretions without direct involvement of gnrh. the presence of disorders such as tumors, infection, underlying syndrome, or genetic influence can lead to the conditions above.9 this 2 female respondents should be notified to seek medical attention, to avoid probability presence of underlying pathologic disorder, unless the early onset of menarche is genetically inherited. high level of estrogen in precocious puberty can stimulate early and increased maturation of skeletal system which can lead to compromised adult height, a long term complication.10 in addition, children with precocious puberty also may experience hormonal changes and early pubertal development compared to those of same age and sex, leading to psychosocial disorder.11 the limitation of this study was the low number of respondents participating in the survey which led to the uneven sample size in each group the feedback from the students and siblings was high (73.1%), because the data were collected on the spot by the interviewer. however, the data from the mother and grandmother were very limited (23.7% and 3.2%, respectively) due to the poor return rate of questionnaires brought back by the students to be filled at home. some of the questionnaires were also not filled up completely, thus the data could not be used in this study. in conclusion, the females in current generation in jatinangor have an earlier onset of menarche compared to the females from the older generations, at a most common age of 12 years old. the changes on the age at menarche can be due to genetic factors or changes in the environmental factors; however, this age is within the normal range of age of menarche references 1. guyton ac, hall je. female physiology before pregnancy and female hormones. in: guyton ac, hall je. textbook of medical physiology. 11th ed. philadelphia: elsevier saunders; 2006. p. 1011–26. 2. karapanou o, papadimitriou a. determinants of menarche. reprod biol endocrinol. 2010;8:115. 3. hillard pja. menstruation in adolescents: what’s normal? medscape j med. 2008;10(12):295. 4. batubara jr, soesanti f, van de waal hd. age at menarche in indonesian girls: a national survey. acta med indones. 2010;42(2):78–81. 5. windham g, fan c, california department of health services, california department of public health, office of women’s health. california women’s health survey: age at menarche (or first menses) among california women, 2008, by demographic characteristics and compared to 1997. spring 2012;7(6). 6. lusiana sa, dwiriani cm. age of menarche, food consumption, and nutritional status of female elementary school children in bogor. jurnal gizi dan pangan. 2007;3(2): 26–35. 7. ahn jh, lim sw, song bs, seo j, lee ja, kim dh, et al. age at menarche in the korean female: secular trendsand relationship to adulthood body mass index. ann pediatr endocrinol metab.2013;18(2):60–4. 8. sianipar o, bunawan nc, almazini p, calista n, wulandari p, rovenska n, et al. prevalensi gangguan menstruasi dan faktor-faktor yang berhubungan pada siswi smu di kecamatan pulo gadung jakarta timur. maj kedokt indon. 2009;59(7):308–13. 9. rebar rw. puberty. in: berek js, editor. berek and novak’s gynecology. 14thed. philadelphia: lippincott williams and wilkins; 2007. p. 991–1033. 10. nathan bm, palmert mr. regulation and disorders of pubertal timing. endocrinol metab clin north am. 2005;34(3):617–41. 11. kaltiala-heino r, marttunen m, rantanen p, rimpela m. early puberty is associated withmental healthproblems in middle adolescence. soc sci med.2003;57(6):1055–64. althea medical journal. 2016;3(4) 577 predictor of mortality in acquired immunodeficiency syndrome patients with central nervous system opportunistic infections agustina lestari,1 sofiati dian,2 chrysanti murad3 1faculty of medicine, universitas padjadjaran, 2departement of physiology faculty of medicine universitas padjadjaran, 3departement of physical and rehabilitation medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: indonesia’s increase of acquired immunodeficiency syndrome (aids) cases is one of the fastest. mortality cases of aids also increase per year. central nervous system (cns) opportunistic infection is one of the most likely manifestations on advanced stage of human immunodeficiency virus (hiv)/aids patients. common cns opportunistic infections are toxoplasma infection and tuberculous meningitis (tbm). the study aimed to analyze the predictor of mortality in aids patients with cns opportunistic infections. methods: this study reviewed 151 medical records from aids patients with cns opportunistic infection admitted to the department of neurology, dr. hasan sadikin general hospital bandung from 2007-2012. this study was conducted from april to november 2013. patients’ clinical manifestations (seizure, headache, altered consciousness), laboratory examination (cd4+ level count) and treatment history (antiretroviral or art and cotrimoxazole) were collected. chi-square and logistic regression test were used to determine the mortality predictor in patients. results: mortality rate was 37.7%. clinical manifestations from patients were seizure 29.8%, altered consciousness 66.2%, and headache 88.7%. patients had cotrimoxazole treatment 44.4% and 38.4% patients had art. cd4+ level count data from 86 patients were obtained, 94% had cd4+ level count ≤200. bivariate analysis showed altered consciousness had significant mortality predictor (odd ratio (or): 29.944; 95% confidence interval (ci) 6.9–129.945; p<0,0). multivariate analysis showed art had highest predictive mortality value (or: 2.968; 95% ci 1.236–7.126; p=0.015). conclusions: altered consciousness and no antiretroviral treatment are mortality predictors in aids patients with cns opportunistic infections. [amj.2016;3(4):577–82] keywords: acquired immunodeficiency syndrome, cns opportunistic infection, mortality, predictor correspondence: agustina lestari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8172375599 email: agustina.lestari@gmail.com introduction human immunodificiency virus (hiv)/ acquired immunodeficiency syndrome (aids) is one of the few diseases in which complete treatment is still elusive although prevention and treatment to control the virus have been well established for decades.1 in the last 30 years, data from the world health organization (who) and joint united nations programme on hiv/aids (unaids) showed that hiv infection caused 25 million deaths around the world. not like any other countries whose access to antriretroviral (art) treatment have reduced the number of aids related to death cases, reports from who and unaids database, in indonesia from 2006–2009 was recorded an increase in aids related to death as much as 3 times along with more than 2 times increase in new hiv infection cases from 2010 to 2011. with the advanced of science, it was known that the two main targets of hiv infection are the limphoid system and central nervous system (cns).2,3 infection of hiv markedly affected immune system was shown with immunodeficiency and level of cd4+ t cell, which made someone prone to opportunistic infection, neoplasm, and many other clinical conditions.2 from numerous earlier research in developing countries, the main cause of cns impairment among hiv/aids patients were cns opportunistic infections.4 severe immunodeficiency in a late phase of hiv infection with high virus load both on systemic and cns has a positive correlation althea medical journal. 2016;3(4) 578 amj december 2016 with the likelihood of cns opportunistic infection. environment and access to art become important factors to the variation of cns opportunistic infection between developed and developing countries.5 the common cns opportunistic infections in hiv/aids patients are toxoplasma infection, tuberculous meningitis (tbm), cryptococcus infection, progressive multifocal leukoencelopathy (pml) and primary cns lymphoma.2,6 the risk of cns opportunistic infection is different according to patient’s cd4+ t cell level; patients with cd4+ t cell level 200– 500/µl have risk being infected by tuberculous meningitis, patients with cd4+ t cell level <200/µl have risk being infected by toxoplasmosis encephalitis, cryptococcus meningitis, cytomegalovirus (cmv) infection, primary lymphoma cns, and pml.5 almost all cns opportunistic infections originate from activated latent pathogen, except pml that could be caused by direct hiv-1 virus infection.5 most of all cns opportunistic infections do not have specific symptoms like fever or lethargic. symptoms which usually arise are headache, seizure, altered consciousness, altered mental function, focal deficit and cranial neuropathy.5 a study in bangkok thailand5, showed that mortality rate of hiv/aids patients with cns opportunistic infections was 14.9% and in nigeria7 and ethiopia4 showed high case-fatality up to 45%. there were several predictors of mortality in hiv/aids cases. the study in ethiophia4, discovered that the area of the patients’ residency, altered consciousness, and seizure were predictors of mortality in hiv/aids cases. based on these evidences, the objective of this study was to analyze the predictors of mortality in acquired immunodeficiency syndrome patients with central nervous system opportunistic infections in bandung, indonesia. methods a retrospective cross-sectional study was conducted at dr. hasan sadikin general hospital, bandung, indonesia from april to november 2013. data were obtained from medical records of aids patients admitted to the neurology department of dr. hasan sadikin general hospital from january 2007–december 2012. the inclusion criteria were medical records of aids patients with cns opportunistic infection(s) consisting of information of altered consciousness, seizure, headache, cd4+ level count, art treatment, cotrimoxazole treatment and the outcome of the treatment. the exclusion criteria were imcomplete information in the patient’s medical records and unclear patient’s cause of death. from 2007 to 2012, there were 153 cases of aids with cns opportunistic infections from 342 cases of hiv/aids, but only 151 cases met the inclusion criteria. the collected data were analyzed statistically using the chi-square test for bivariate analysis and logistic regression for multivariate analysis with p value <0.05 and 95% confidence interval as statistical significance. the ethical approval for this study was obtained from the health research ethics committee of faculty of medicine of universits padjadjaran/dr. hasan sadikin general hospital. results this study discovered that male had table 1 characteristics of patients variable n=151 sex female 42 (28.1%) male 109 (71.9%) age (years old) <30 63 (41.7%) ≥30 88 (58.3%) mean 30.8 range 20¬–54 mortality rate 57 (37.7%) althea medical journal. 2016;3(4) 579agustina lestari, sofiati dian, chrysanti murad: predictor of mortality in acquired immunodeficiency syndrome patients with central nervous system opportunistic infections higher percentage of aids cases with cns opportunistic infections compared to female. morover, those cases occurred mostly to young people although the age range was wide. from all the cases, mortality was still high (table 1). in terms of cns opportunistic infections, most of the patients (106 cases) had only 1 infection. on the other hand, there were patients with multiple infections. one of the patients had 4 infections, 4 patients had 3 infections, and 40 patients had 2 infections. (table 2). the most infection occured in those patients was cerebral toxoplasmosis 93 (61.6%). other infections occured were tbm, followed by tuberculoma, cryptococcus meningitis and cmv infection (39.1%, 20.0%, 11.3%, 2.0%, respectively) (table 3). there were 86 recorded data for cd4+ level count: 81 patients (94,20%) had cd4+ level count ≤200 and 5 patients (5,80%) had cd4+ level count >200 (table 3). furthermore, there was 29.8% patients with seizure; 66.2% patients with altered consciousness; 88.7% patients with headache; 44.4% patients with cotrimoxazole treatment; and 38.4% patients with antiretroviral treatment (table 4). the highest case of fatality rateswas tuberculoma (60%), followed by cryptococcus meningitis (58.8%), tbm (47.5%), cerebral toxoplasmosis (35.5%), and cmv infection (33.3%) respectively (table 4). the bivariate statistical analysis was performed to determine which variables werecorrelated to mortality. this study discovered that altered consciousness was the predictor of mortality aids patients with cns opportunistic infection. other variables, such as seizure, headache, cd4+ level count, cotrimoxazole treatment were not predictors of mortality in these cases (p value ≥ 0.05. although no art treatment was significantly related to predictor of mortality in aids patients with cns opportunistic infections, the or was below 1 (table 5). moreover, the logistic regression analysis was performed to determine which variable was the strongest predictor among the variables. the logistic regression analysis was performed for five variables (seizure, altered consciousness, headache, cotrimoxazole and art). the variable cd4+ level count was not included into the analysis because the number of medical records that had the cd4+ level count information was only 86 medical records. the study showed that no treatment by art (or=2.968; 95% ci 1.236–7.126; p=0.015) was predictor for mortality aids patient with cns opportunistic infection. patients who table 2 distribution of cns opportunistic infections cns opportunistic infections total (n) cerebral toxoplasmosis, tbm, criptococcus meningitis, tuberculoma 1 cerebral toxoplasmosis, tbm, tuberculoma 1 cerebral toxoplasmosis, tuberculoma 19 cerebral toxoplasmosis, criptococcus meningitis, tuberculoma 1 cerebral toxoplasmosis, tbm, criptococcus meningitis 1 cerebral toxoplasmosis, criptococcus meningitis 2 cerebral toxoplasmosis, tbm, cmv infection 1 cerebral toxoplasmosis, tbm 8 cerebral toxoplasmosis, cmv infection 2 cerebral toxoplasmosis 57 tbm, criptococcus meningitis 6 tbm, tuberculoma 2 tbm 39 criptococcus meningitis 5 criptococcus meningitis, tuberculoma, 1 tuberculoma 5 note: tbm= tuberculous meningitis; cmv=cytomegalovirus althea medical journal. 2016;3(4) 580 amj december 2016 never had art treatment had a mortality risk 2.968 times higher compared to patients who had art treatment. although altered consciousness was significantly related to predictor of mortality in aids patients with cns opportunistic infections, the or was below 1 (table 6). discussion this study discovered that the mortality of aids patients with cns opportunistic infections was higher that the mortality in bangkok thailand.8 it was suspected that this condition occured because thailand had a good treatment protocol regarding hiv patients and also the level of the people’s and the government’s awareness about this disease was higher compared to indonesia. on the other hand, the mortality rate in this study was lower compared to a study in ethiopia, africa4 as this region had higher hiv/aids cases prevalence compared to indonesia. besides, the sex distribution showed that male outnumbered female and the majority of patients were at young age (mean age 30.8 years old). these findings were similar with several previous studies.4,7,9 interestingly, compared to a study in thailand10 which stated that cryptococcal meningitis was the most frequent aids-related opportunistic infection; in this study, cerebral toxoplasmosis had the highest prevalence among other infections. moreover, another study in indonesia11 stated that cryptococcal meningitis was the most important cns opportunistic infection. cryptococcal meningitis arises on patients with very low cd4+ level count and usually patients died before they are diagnosed for the disease. hiv patients often seek care only when they are already on their late stage and low awareness to follow up especially the measurement of their cd4+ level count. the percentage of cerebral toxoplasmosis in this study was higher compared with a study in ethiopia4 (36.6%) and a study in india12 (8.8%). this may be caused by the difference in the prophylaxis treatment protocol especially cotrimoxazole in indonesia and other countries. table 4 clinical manifestation, laboratory findings and treatment per infection cns opportunistic infections death altered conciousness headache cotrimoxazole art tbm (59) 28 (47.5%) 44 (74.6%) 52 (88.1%) 25 (42.4%) 16 (27.1%) cryptococcus meningitis (17) 10 (58.8%) 12 (70.6%) 17 (100%) 7 (41.2%) 8 (47.1%) cerebral toxoplasmosis (93) 33 (35.5%) 62 (66.7%) 81 (87.1%) 44 (47.3%) 39 (41.9%) tuberculoma (30) 18 (60.0%) 20 (66.7%) 26 (86.7%) 15 (50.0%) 8 (26.7%) cmv (3) 1 (33.3%) 1 (33.3%) 2 (66.7%) 1 (33.3%) 2 (66.7%) table 3 demographic and laboratory findings per infection cns opportunistic infections age (years old) sex cd4+ level tbm(59) <30: 29 (49.2%) male : 37 (62.7%) ≤200 : 28 (93.3%) ≥30 : 30 (50.8%) female : 22 (37.3%) >200 : 2 (6.7%) cryptococcus meningitis (17) <30: 7 (41.2%) male : 13 (76.5%) ≤200 : 17 (100%) ≥30 : 10 (58.8%) female : 4 (23.5%) >200 : 0 (0%) cerebral toxoplasmosis (93) <30: 36 (38.7%) male : 69 (74.2%) ≤200 : 53 (94.6%) female : 24 (25.8%) >200 : 3 (5.4%) tuberculoma (30) <30: 11 (36.7%) male : 18 (60.0%) ≤200 : 13 (92.9%) ≥30 : 19 (63.3%) female : 12 (40.0%) >200 : 1 (7.1%) cmv (3) <30: 0 (0%) male : 2 (66.7%) ≤200 : 3 (100%) ≥30 : 3 (100%) female : 1 (33.3%) >200 : althea medical journal. 2016;3(4) 581 table 5 bivariate (chi-square) analysis risk factor total (57) or (95% ci) p seizure 20 1.492 (0.733–3.037) 0.269 altered consciousness 55 29.944(6,900–129.945) 0.0 headache 51 1.127 (0.393–3.232) 0.825 cd4+level count (28) >200 2 1 0.714 ≤200 26 1.410(0.222–8.960) cotrimoxazole treatment 26 1.084(0.559–2.101) 0.811 art treatment 45 0.278(0.131–0.592) 0.001 note : or = odd ratio ; ci = confidence interval; art=anti retrovirus other infections identified in this study were tbm, tuberculoma, cryptococcus meningitis and cmv infection that were similar with the findings of other studies4,12,13, except a study in the united states4 where tbm and bacterial meningitis were rarely found.4 this different result showed that environment and access to art are important factors to cns opportunistic infection variations.5 in addition, headache was identified as the highest prevalence of clinical symptoms, followed by altered consciousness and seizure. these findings were similar with a study in ethiopia4. from 86 patients, the majority (94,20%) had cd4+ level count ≤200 and only 5,80% had cd4+ level count >200, the result showed consistency with studies in ethiopia and india.4,12 no patients with cryptococcus meningitis and cmv infections had cd4+ level count >200. this was in line with hivassociated opportunistic infections of the cns literatur.5 a total of 43.8% patients had a history of cotrimoxazole prophylaxis treatment or the treatment was given during admission. out of 57 mortality cases, 54.4% patients never had a cotrimoxazole treatment and it was higher compared to the study in ethiopia4 (44.6%). prior to this, early detection of hiv and early cotrimoxazole prophylaxis treatment as primary prophylaxis on hiv/aids patients may suggest a decrease in the prevalence cerebral toxoplasmosis and its mortality. thirty seven point nine percent patients had art treatment both before and after admission. among the mortality cases, 78.9% patients had no art treatment. this was much higher than the study in ethiopia (46.1%). the data support indonesia’s need for more effective prevention and detection of hiv infection as well as access to art treatment to improve cases of aids related to death.5,11 the bivariate analysis result showed altered consciousness (or=29.944; 95% ci 6.900– 129.945; p=0.0) as predictor and multivariate analysis showed art (or=2.968; 95% ci 1.236–7.126; p=0.015) as predictor. the multivariate analysis calculated 5 variables, to find which variable had the strongest relation to mortality cases. our study showed altered consciousness was the predictor mortality dependently and art treatment was the strongest predictor among all variables. the used of art was a predictor mortality for aids patients with cns opportunistic infection. patients who never had art treatment had more mortality risk than patients who had art treatment. decrease immune system markedly showed stage severity of the disease and make table 6 multivariate (logistic regression) analysis risk factor total (57) or (95% ci) p seizure 20 1.228 (0.536–2.814) 0.628 altered consciousness 55 0.037 (0.008–0.163) 0.000 headache 51 0.661 (0.187–2.335) 0.661 cotrimoxazole 26 0.718 (0.320–1.612) 0.422 art 45 2.968 (1.236–7.126) 0.015 note : or = odd ratio ; ci = confidence interval; art=anti retrovirus agustina lestari, sofiati dian, chrysanti murad: predictor of mortality in acquired immunodeficiency syndrome patients with central nervous system opportunistic infections althea medical journal. 2016;3(4) 582 amj december 2016 someone prone to opportunistic infection.2 antiretroviral treatment has functioned as disease severity suppressor to prevent the disease to an advanced stage and prevent opportunistic infections by increase immune system.2 in a future study, analysis about art treatment and cd4+ level count could be added to investigate more exact about the correlation between art treatment, cd4+ level count and disease severity and its outcome. this study had several limitations. both cotrimoxazole and art treatment were undifferentiated before and after admission. the study did not investigate the time of hiv infection confirmed diagnosis and multiple cns opportunistic infections that may affect patient’s outcome and mortality. medical records data recording could be improved to provide more complete data, especially for laboratory examination result such as cd4+ count level to support a better research in the future. in conclusion, the majority of the patients have cd4+ count level ≤200 and only onethird of the patients have art treatment. altered conciousness and no art treatment are suspected to be the predictor of mortality in aids patients with cns opportunistic infections. the improvement of hiv screening, earlier primary prophylaxis treatment, access to art and follow up of cd4+ count level will result into a better outcome. references 1. hoffmann c, rockstroh jk, kamps bs, editors. hiv medicine 2007. 15th ed. philadelphia. flying publisher; 2007. 2. anthony fs, clifford hl. human immunodeficiency virus disease: aids and related disorders. dan ll. harrion’s principle of internal medicine. 18th ed. alabama. mc graw hill; 2012. p. 1506–87. 3. vinay k, abul ak, nelson f, jon ac. robbin and cotran pathologic basics of disease 8th ed. philadelphia : saunders elsevier; 2010. 4. berhe t, melkamul y, amare a. the pattern and predictors of mortality of hiv/aids patients with neurologic manifestation in ethiopia: a retrospective study. aids res ther. 2012;9:11. 5. tan il, smith br, van geldern g, mateen fj, mcarthur jc. hiv-associated opportunistic infections of the cns. lancet neurol. 2012;11(7):605–17. 6. barley bc. acquired immunodeficiency syndrome (aids). in: lewis rp, editor. merritt’s neurology. 11th ed. philadelphia usa: lippincot williams & wilkins; 2005. p. 211–27. 7. ogun sa, ojini f, okubadejo n, danesi m, kolapo k, osalusi b, et al. pattern and outcome of neurological manifestations of hiv/aids-a review of 154 cases in a nigerian university teaching hospital-a preliminary report. african journal of neurological sciences. 2005;24(1):29–36. 8. kongsiriwattanakul s, suankratay c. central nervous system infections in hivinfected patients hospitalized at king chulalongkorn memorial hospital. j med assoc thai. 2011;94(5):551–8. 9. isezuo sa, sani az, ezunu e, maiyaki s, njoku ch, obembe a. clinical neuropathy in hiv/ aids: an eight-year review of hospitalized patients in sokoto, northwestern nigeria. trop doct. 2009;39(3):133–5 10. kantipong p, murakami k, moolphate s, aung mn, yamada n. causes of mortality among tuberculosis and hiv co-infected patients in chiang rai, northern thailand. hiv aids (auckl). 2012;4:159–68. 11. ganiem ar, parwati i, wisaksana r, van der zandeh a, van de beek d, sturm p, et al. the effect of hiv infection on adult meningitis in indonesia: a prospective cohort study. aids. 2009;23(17):2309–16 12. satya a, kumar g, pratap s, vivekananda v, madhukar r, shyam. neurological manifestations of hivinfected patients around varanasi, india. african journal of neurological sciences. 2006;25(1):33–40 13. almeida smd, ribeiro ce, luis felipe cavalli pessa, moreira sdr, vidal lr, nogueira mb, et al. incidence of neurological manifestations as aids defining clinical conditions in brazil. bmc proceedings. 2008:2:45. althea medical journal. 2016;3(4) 549 correlation of personal hygiene knowledge, attitude and practices among school children in sumedang, indonesia briska sudjana,1 irvan afriandi,2 julistio t. b. djais3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, abstract background: school-age children make up the largest proportion of indonesian youth population. one of the ways to maintain children’s health is by making personal hygiene as a habit. the aim of this study was to analyze the correlation of personal hygiene knowledge, attitude and practices among school children. methods: a cross-sectional analytic study, was carried out to 123 sixth graders at five elementary schools in jatinangor , sumedang, indonesia, who were selected using a multi-stage sampling technique. this study was carried out in october 2013. a validated questionnaire was used to collect data of demographic characteristics of the subjects, knowledge, attitude and practice related to personal hygiene.the collected data was analyzed using rank spearman correlation with the level of significance was set at p< 0.05. results: this study revealed that there was a significant correlation between knowledge and personal hygiene practice (p=0.016<0.05 and rs=0.358) and attitudes and personal hygiene practice (p=0.027<0.05 and rs=0.267). conclusions: there is correlation of personal hygiene knowledge, attitudes and practices, however, the correlation is weak. [amj.2016;3(4):549–55] keywords: attitude, elementary students, knowledge, personal hygiene, practice correspondence: briska sudjana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281312110611 email: briskasudjana@gmail.com introduction school-age children make up the largest proportion of indonesian youth population. the population census in 2010 indicated that indonesia had 237.6 million people. out of that number, around 81.4 million (34.26%) are children under 18 years of age. in 2011, people in elementary school education age group of 7−12 years old were recorded to be 27.3 million.1 considering the large number of school children, their health should obviously be a concern. the result of a preliminary research conducted in 2010 to 51 respondents comprising students of pasirlangu 01 elementary school in cisarua, west java,2 regarding the factors that promote the prevalence of ascariasis indicated that 50.98% involved personal hygiene. one of the ways to maintain children’s health is by making personal hygiene a habit. personal hygiene is the basic concept of cleaning, grooming and it is the first step to good health.3,4 it refers to practices that help to maintain health and prevent the spread of diseases, involves regular bathing, washing the hands, cutting the nails, changing the clothes, washing the hair and brushing the teeth.5,6 the process of behavior consists of knowledge, attitude and practice. the practice of personal hygiene is influenced by a number of factors which include, among others, the person’s knowledge and attitude. this study was intended to analyze whether there was correlation of personal hygiene knowledge,attitude and practice among school children.7 methods this study was a cross sectional analytic study, conducted in october 2013 among sixth grade of five elementary schools in jatinangor, sumedang, indonesia. the data were collected from 123 students using a multi-stage sampling technique. in the first stage, five public elementary schools were selected from the list of twenty-eight schools in jatinangor by althea medical journal. 2016;3(4) 550 amj december 2016 simple random sampling. in the second stage, based on the class register, the proportional random sampling was used to select children from each class in the five selected schools with the following inclusion criteria: sixth grades students of elementary school in jatinangor and willing to follow the studyprocedure. on the other hand, the exclusion criterion was that the subject was absent at the time the collecting of data was conducted. a validated questionnaire was used as an instrument to obtain demographic characteristics (gender, age), knowledge, attitude and practice toward personal hygiene that included regular bathing, washing the hands, cutting the nails, changing the clothes, washing the hair and brushing the teeth. the variables were scored for knowledge, under the requirement for each value of a correct answer was scored 2 (two) and scored 1 (one) for an incorrect answer; attitude, under the requirement for each “strongly agree” statement was scored 4 (four), for each “agree” statement was scored 3 (three), for each “disagree” statement was scored 2 (two), and was scored 1 (one) for each “strongly disagree” statement; practice, under the requirement for each value consistent answer scored 2 (two) and scored 1 (one) for inconsistent answer. a computer was used to input and process the collected data. data were analyzed by rank spearman correlation with the level of significance was set at p< 0.05. this study was approved by the health research ethics committee of universitas padjadjaran, bandung, and the informed consent was obtained from the local development planning agency of sumedang district, sumedang district department of education, and school authorities. results the majority of children (68.29%) were in table 2 personal hygiene knowledge question category n (123) % personal hygiene is self-treatment to maintain good health true 120 97.5 false 3 2.5 the purpose of maintaining personal hygiene to be healthy true 115 93.4 false 8 6.6 personal hygiene includes brushing teeth and cleaning the space between the teeth true 114 92.6 false 9 7.4 the best time to visit a dentist is once every six months true 84 68 false 39 32 the first thing to do before eating is washing hands with soap true 120 97.5 false 3 2.5 long and dirty nails show lack of attention to personal hygiene true 108 87.7 false 15 12.3 washing hands with soap can kill germs true 119 96.7 false 4 3.3 long and dirty nails may contain worm eggs true 114 92.6 false 9 7.4 washing hair may be done using common soap true 114 92.6 false 9 7.4 table 1 respondents’ characteristics variable frequency % age (years old) 10 4 3.25 11 84 68.29 12 35 28.46 gender male 71 57.72 female 52 42.28 althea medical journal. 2016;3(4) 551briska sudjana, irvan afriandi, julistio t. b. djais: correlation of personal hygiene knowledge, attitude and practices among school children in sumedang, indonesia the 11-year-old age group, while 28.46% and 3.25% of them were in the 12 and 10-year-old age group, respectively. based on the gender, over half of the students were male (table 1). questions regarding personal hygiene knowledge consisted of 9 questions. most of the students had good knowledge of personal hygiene. most of them answered the 9 questions correctly. for example, it revealed that 97.5% of the students understoond that the first thing to do before eating was washing their hands with soap. regarding visiting a dentist every 6 months, only 68.0% of them answered this question correctly (table 2). furthermore, there were 8 questions about attitude toward personal hygiene. the highest percentage of “strongly agree” answered by the students was the question about “information on personal hygiene is very important” (78.9%), followed by the table 3 attitudes toward personal hygiene question category n (123) % information on personal hygiene is very important strongly agree 97 78.9 agree 25 20.3 disagree 1 0.8 strongly disagree 0 0 although it is recommended to visit a dentist once every six months, i’m too lazy to do it strongly agree 3 2.4 agree 10 8.1 disagree 60 48.8 strongly disagree 50 40.7 washing hands with soap is necessary strongly agree 82 66.7 agree 35 28.5 disagree 3 2.4 strongly disagree 3 2.4 washing hands before eating is inconvenient strongly agree 5 4.1 agree 7 5.7 disagree 60 48.8 strongly disagree 51 41.4 i tend to be too lazy to cut my nails every week strongly agree 4 3.3 agree 10 8.1 disagree 49 39.8 strongly disagree 60 48.8 i’m worried that my hair will fall if i wash it once every two days strongly agree 12 9.8 agree 34 27.6 disagree 59 48 strongly disagree 18 14.6 i find it inconvenient to change clothes strongly agree 4 3.2 agree 12 9.8 disagree 61 49.6 strongly disagree 46 37.4 taking a bath twice a day is too much strongly agree 14 11.4 agree 14 11.4 disagree 56 45.5 strongly disagree 39 31.7 althea medical journal. 2016;3(4) 552 amj december 2016 question about “washing hands with soap is necessary” (66.7%). the rest of the questions were answered “strongly agree” or “strongly disagree” were below 50% (table 3). moreover, 90.2% of the students confessed they took a bath twice a day, but only 41.5% of them claimed to wash their hair according to the recommended frequency (table 4). the correlation between knowledge and personal hygiene practice was indicated by rank spearman correlation coefficient (rs) of 0.358 (p=0.016). meanwhile, the correlation between attitude and personal hygiene practice was indicated by rs of 0.267 (p=0.027) (figure 1 and 2). discussion this study discovered that the majority of students had the knowledge that the first thing to do before eating was washing their hands with soap. this result was similar to a study conducted on elementary school students in pekalongan, central java8, which also indicated that the majority of students washed their hands with soap before eating (94.0%). knowledge is a very important domain that determines a person’s actions. research shows that actions based on knowledge last longer than those not based on knowledge. this study result is also supported by the theory of green, stating that knowledge is a predisposing factor in shaping behavior. a person’s behavior regarding health matters is determined by his/her knowledge. it is important that health behavior is related to the process of shaping behavioral changes because these changes are the objectives of health education or health counseling to support other health programs. additionally, an action or behavior is an observable response against active stimuli. after the stimulus of health objects is known, a person may assess or give his opinion on what is known, and he is expected to perform or practice what is known or what he thinks is good in the next process.7 additionally, knowledge is generally table 4 personal hygiene practices question category n (123) % visit a dentist in the past year consistent 76 61.8 inconsistent 47 38.2 brush teeth after eating consistent 99 80.5 inconsistent 24 19.5 brush teeth before bed consistent 101 82.1 inconsistent 22 17.9 brush teeth after last meal consistent 88 71.5 inconsistent 35 28.5 always use soap when washing hands consistent 116 94.3 inconsistent 7 5.7 habit after going home from school consistent 103 83.7 inconsistent 20 16.3 daily bath frequency consistent 111 90.2 inconsistent 12 9.8 hair-washing frequency consistent 51 41.5 inconsistent 72 58.5 way of washing hair consistent 116 94.3 inconsistent 7 5.7 share the same towel with father/mother/brother/sister consistent 90 73.2 inconsistent 33 26.8 ask friends to practice personal hygiene (such as washing hands, taking a bath, brushing teeth, etc.) consistent 95 77.2 inconsistent 28 22.8 althea medical journal. 2016;3(4) 553 obtained through the sense of sight (the eyes) and hearing (the ears) as well as experience. students’ knowledge about personal hygiene is not entirely obtained through formal education, but most of the information they learn is collected outside formal education facilities. finally, information media may also provide the students with information to increase the level of their knowledge. these information media include public service advertisements, broadcast in television or other mass media. access to knowledge on personal hygiene may also be gained from external behavior such as that of friends, parents, and society members.9 besides, children’s knowledge can be obtained both from internal and external sources. internal knowledge is knowledge that comes from within based on life experience, while external knowledge is obtained from other people, including parents and teachers. knowledge obtained from internal and external sources will add to children’s knowledge on personal hygiene. in terms of attitude, this study showed that almost all of the students had a positive attitude towards the importance of washing hands before eating (90.2%). this result was similar to the study on elementary school students in bogota, columbia10, which also indicated that most of the students show a positive attitude towards washing hands (62.8%). this is likely because the attitude of those respondents is based on their briska sudjana, irvan afriandi, julistio t. b. djais: correlation of personal hygiene knowledge, attitude and practices among school children in sumedang, indonesia figure 1 correlation of personal hygiene knowledge towards personal hygiene practice figure 2 correlation of personal hygiene attitude towards personal hygiene practice althea medical journal. 2016;3(4) 554 amj december 2016 knowledge as well as well-developed daily habits. one of the ways to shape and change attitude is through repetitive activities that will gradually be absorbed by individuals, such as the patterns used by parents to raise their children. the resulting behavior will affect the individual’s behavior. on the personal hygiene level, the majority of respondents were in a good category. this showed that most respondents had practiced decent knowledge and attitude of personal hygiene that they already had. according to notoatmodjo7 behavioral development begins from the cognitive domain as the individual is already aware of stimuli in the form of objects, which then shapes their knowledge. furthermore, the resulting knowledge will bring about mental responses in the form of the individual’s attitude towards the objects they recognize. the resulting behavior will affect the individual’s behavior. moreover, school children are at the best age to form their character. elementary school children’s ways of thinking develop gradually. children are really in a learning stage. it starts from a family environment as the first environment for the children, especially their mother as the first educator.9 besides the family, the school also brings systematic influence on shaping children’s knowledge. additionally, cchildren’s memory are reaching the highest and strongest intensity. their ability to memorize and remember things is at its peak.11 this fact can be used to deliver knowledge to elementary school children so that they can learn to apply personal hygiene and understand the consequences of not implementing personal hygiene in their daily lives, such as to suffer from diarrhea, acute upper respiratory tract infection (urti), teeth and skin problems, and ascariasis. regarding the correlation of personal hygiene knowledge, attitude and practice, this study discovered that there was correlation between those variables, but the correlation was weak. another study conducted by oyibo5 in abraka, nigeria, reported that there is a significant relationship between knowledge and attitude regarding personal hygiene and its influence on practices of personal hygiene by elementary school students. this study had limitations. it was difficult to value the personal hygiene practices using a questionnaire. ideally, the data collection of personal hygiene practices should be performed by observation. it can be concluded that the majority of students have the knowledge, attitude and practices of their personal hygiene. thus, there is correlation between those variables, although the correlation is weak. in order for children to practice personal hygiene in a good way, it is important to instill personal hygiene knowledge and attitude in the early age to avoid any hygiene-related diseases and have a good living in the future. therefore, there is need for parents and teachers to maintain the values of personal hygiene in school children. besides, the school has also an important role such as to include personal hygiene studies into the curriculum at school. references 1. kementerian pemberdayaan perempuan dan perlindungan anak, badan pusat statistik republik indonesia. profil anak tahun 2012. jakarta: cv. miftahur rizky; 2012. 2. andaruni a. gambaran faktor-faktor penyebab infeksi cacingan pada anak di sdn 01 pasirlangu, cisarua. jurnal universitas padjadjaran. 2012;1(1):1−14. 3. hassan bar. importance of personal hygiene. pharmaceut anal acta. 2010;3:e126. 4. sheren na, kareem fa, abdulla sa. knowledge and attitudes of pupils in some of primary schools regarding personal hygiene in erbil city. kufa journal for nursing sciences. 2012;2(1):1−9. 5. oyibo pg, basic personal hygiene: knowledge and practices among school children aged 6−14 years in abraka, delta state. continental j. tropical medicine. 2012;6(1):5−11. 6. vivas ap, gelaye b, aboset n, kumie a, berhane y, williams ma. knowledge, attitudes and practices (kap) of hygiene among school children in angolela, ethiopia. j prev med hyg. 2010;51(2):73– 9. 7. notoatmodjo s. promosi kesehatan dan ilmu perilaku. jakarta: rineka cipta; 2007. 8. rosidi a, erma h, mita m. hubungan kebiasaan cuci tangan dan sanitasi makanan dengan kejadian diare pada anak sekolah dasar negeri podo 2 kecamatan kedungwuni kabupaten pekalongan. j kesehat masy indones. 2010;6(1):76−84. 9. siswanto h. informal health education for early childhood in indonesia. educare: international journal for educational studies. 2009;1(2):219−32. 10. lopez-quintero c, paul f, neumark y. hand althea medical journal. 2016;3(4) 555 washing among school children in bogota, colombia. am j public health. 2009; 14(1):94–101. 11. kartono k. psikologi anak. bandung: mandar maju; 2007. briska sudjana, irvan afriandi, julistio t. b. djais: correlation of personal hygiene knowledge, attitude and practices among school children in sumedang, indonesia althea vol 3 no 4 edit.indd althea medical journal. 2016;3(4) 610 amj december 2016 treatment evaluation of melasma patients in dr. hasan sadikin general hospital bandung in period of 2013–2014 ayu adzani sabila,1 reti hindritiani,2 dimas erlangga luftimas3 1faculty of medicine universitas padjadjaran, 2department of dermatology and venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of medical nutrition faculty of medicine universitas padjadjaran abstract background: melasma is hyperpigmentation of the skin especially located on face exposed to the sunlight. this condition was characterized by brown to gray-brown macula with irregular border. difficulties in treatment of melasma arise from high tendency for relapse, expensive cost, and high risk of side effects such as erythema, sores, scales, and acne eruption. study about evaluation of melasma therapy in dr. hasan sadikin general hospital bandung have not ever been done before. therefore, this study was conducted to evaluate therapy of melasma in the policlinic of dermatology and venereology, dr. hasan sadikin general hospital bandung. methods: this study was retrospectively descriptive. data were obtained from the new melasma patient medical records of policlinic of dermatology and venereology of dr. hasan sadikin general hospital bandung in period of january 2013–2014. sampling method used in this study was total sampling. treatments of melasma were evaluated by using melasma area severity index (masi) score. collected data were processed and presented in frequency distribution and percentage. results: the most used topical drugs were combination of hydroquinone and tretinoin, and all of patients received sunblock. most frequent time interval was two weeks (30.8%). the most common side effect was erythema (10 out of 22). decreased masi score was discovered in 48.1% and the most decreased category was mild (14 out of 25). conclusions: the very common topical drugs used are hydroquinone and tretinoin. the side effect of the treatment is erythema. the decreased masi score is mild. [amj.2016;3(4):610–5] keywords: evaluation, melasma, treatment correspondence: ayu adzani sabila, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282118094129 email: ayuadzani@gmail.com introduction melasma is skin hyperpigmentation especially located on face exposed to sunlight.1,2 this condition was characterized by brown to gray-brown macula with irregular border.1,3 melasma more frequently occurs in women compared to men and in the dark-skinned people.1,3 this disease can be found in the average age of 27.5±7.8 years old and rarely found in puberty.4 this condition affects more than five million people in america and 7760 patients have been found in ethiopia.4 another studies from peru and lebanon discovered 10.11% and 3.4% patients with melasma, respectively.4 in southeast asian, melasma was complained by 0.25-4% patients.5,6 a study in brazil using melasma quality of life scale showed that 65% of patients felt uncomfortable, 55% felt frustrated and 57% felt embarrassed experiencing melasma.5 the treatment of melasma in each person is different and needs long term treatment.3,8 difficulties in treatment of melasma arise from high tendency for relapse, expensive cost and high risk of side effects such as erythema, sores, scales and acne eruption.3,8 standard therapy of melasma in department of dermatology and venereology of dr. hasan sadikin general hospital bandung according to guideline melisma is divided into two parts; i.e general and specific. general part consists of the use of sunblock, photoprotection and avoidance of precipitating factors. specific part consists of depigmentation substances althea medical journal. 2016;3(4) 611 such as hydroquinone, kojic acid, and arbutine. procedure such as chemical peeling and laser procedure are part of specific therapy. treatment evaluation can be assessed by melasma area severity index (masi).3,5 this scoring is calculated by assessing three indicators, i.e area of involvement, darkness and hyperpigmentation homogeneity.2 to calculate masi score, the sum of severity grade for darkness and homogeneity is multiplied by numerical value areas (forehead, right malar, left malar, chin).9,10 this scoring ranges from 0–48.2 melasma is the second most frequent disease after acne vulgaris in the division of cosmetic dermatology of department of dermatology and venereology of dr. hasan sadikin general hospital bandung in the period of january 1st ,2011 to december 31st, 2014. study about evaluation of melasma therapy in dr. hasan sadikin general hospital bandung has not ever been done before. therefore, this study was conducted to evaluate therapy of melasma in the policlinic of dermatology and venereology dr. hasan sadikin general hospital bandung. methods this was a retrospectively descriptive study. data were obtained from medical records of the new melasma patients in policlinic of dermatology and venereology dr. hasan sadikin general hospital bandung for two years from january 2013 to december 2014. this study had been approved by the ethical committee of health study dr. hasan sadikin general hospital bandung through ethical clearance number: lb.04.01/aos/ec/258/ vii/2015 and had been given permission by dr. hasan sadikin general hospital bandung. variables in this study were medication, side effects, time interval, and masi score. medications of melasma patients were divided into some parts, i.e; applying single or combined depigmentation substance(s), application of sunblock, systemic medication and laser procedure or chemical peeling. time interval was several weeks between first and second visit. side effects were assessed during treatment. assessment of masi score was according to the score in the first visit (pre treatment) and the second visit (post treatment). the criteria of inclusion in this study were all of medical records with melasma along with the masi scoring in the period of january 2013 to december 2014. the criteria of exclusion in this study were medical records with only one visit. total medical records n = 132 met inclusion criteria n = 76 medical records with > 1 visit n = 52 sampling method used in this study was total sampling. the medical records which met the inclusion and exclusion criteria were then processed and grouped using statistic software. the results of this study were presented in frequency distribution and percentage. results one of the difficulties encountered in this study was the time interval between the first and the second visit which may affect outcome of the therapy and masi score. table 1 showed the medication type of melasma. during two visits, the most administered depigmentation substance was combination of hydroquinone and tretinoin. beside depigmentation substance, all the melasma patients were given sunblock. procedure was started in the second visit, and chemical peeling was done. distribution of time interval was showed in table 2. interval between the first and the second visit were two weeks, three weeks, and four weeks respectively. the side effects were presented in table 3. side effects was complained by 22 out of 52 patients. erythema was one of side effects frequently complained. the changes of masi score were calculated by subtracting the second visit’ss score from ≥0–25% : mild >25–50% : moderate >50% : remarkable reduction9 figure 1 formula used to calculate the decrease of the score ayu adzani sabila, reti hindritiani, dimas erlangga luftimas: treatment evaluation of melasma patients in dr. hasan sadikin general hospital bandung in period of 2013–2014 althea medical journal. 2016;3(4) 612 amj december 2016 discussion three main factors that influence the pathogenesis of melasma are genetic, hormonal, and ultraviolet exposure.1,4 ultraviolet exposure is a precipitating factor and it aggravates melasma due to its stimulation to melanocyte.8,11 therefore, photo the first visit’s score. the category of masi score changes were constant, decrease, and increase. masi score’s changes was often decreased. twenty five decreased of masi score was grouped into mild, moderate, and remarkable reduction. in the second visit, the mostly decreasing category was mild. table 1 distribution of treatment variation of melasma type of treatment visits i ii n % n % a.topical drugs 1.depigmentation substance a. single ka 1 1.9 2 3.8 tret 4 7.7 0 0.0 aha 0 0.0 0 0.0 b.combination hq+aa 1 1.9 1 1.9 hq+ka 0 0.0 1 1.9 hq+tret 30 57.8 28 53.9 ka+la 1 1.9 0 0.0 ka+tret 5 9.6 6 11.9 vitc+tret 1 1.9 1 1.9 aha+tret 0 0.0 3 5.8 hq+tret+aha 3 5.8 3 5.8 hq+tret+cor 2 3.8 2 3.8 hq+tret+vit c 3 5.8 3 5.8 ka+la+aha 1 1.9 1 1.9 ka+tret+aha 0 0.0 1 1.9 ka+tret+vitc 0 0.0 0 0.0 2.sunblock yes 52 100.0 52 100.0 b.procedure without procedure 52 100.0 43 82.7 chemical peeling 0 0.0 9 17.3 laser 0 0.0 0 0.0 total 52 100.0 52 100.0 note: *aa :azelaic acid, aha :alpha hydroxyl acid, cor : corticosteroid, hq :hydroquinone, ka :kojic acid, la :lactic acid,tret: tretinoin althea medical journal. 2016;3(4) 613ayu adzani sabila, reti hindritiani, dimas erlangga luftimas: treatment evaluation of melasma patients in dr. hasan sadikin general hospital bandung in period of 2013–2014 table 2 distribution of time interval among visits of melasma patients time interval n % 1 week 2 3.8 2 weeks 16 30.8 3 weeks 12 23.1 4 weeks 9 17.3 5 weeks 2 3.8 6 weeks 1 1.9 7 weeks 1 1.9 8 weeks 3 5.8 >8 weeks 6 11.6 total 52 100.0 protection is a part of melasma therapy.4,12 in this study, all patients received sunblock in every visit. the goal of melasma treatment is to inhibit the pigmentation process and remove or destruct the formed melanin.3,7 the usage of topical drugs is to inhibit the enzymatic process in pigment production.12 the combination of hydroquinone and tretinoin was often used in this treatment. hydroquinone plays role as the depigmentation agent by inhibiting tyrosinase enzyme, an enzyme used in pigmentation process,12,13 while tretinoin plays role in stimulating keratinocyte turnover, destroying formed melanin, and helping hydroquinone penetration to epidermal layer.3,12 table 3 distribution of side effects of melasma patients side effects n erythema 10 sore 5 scale 3 itchiness 2 burns 1 acne 1 total 22 table 4 distribution of changes and decreasing masi score of melasma patients category of masi score n % changes of masi score constant 21 40.4 decrease 25 48.1 mild 14 moderate 6 remarkable reduction 5 increase 6 11.5 total 52 100.0 althea medical journal. 2016;3(4) 614 amj december 2016 in several studies, this use of combination showed better improvement than single therapy.8,12,13 combined therapy can provide more optimal effect.3,4,12 other choices are the combination of hydroquinone, tretinoin and corticosteroid, also known as kligman formula.12,13 kligman formula is the most potent and frequent used by clinicians for melasma therapy.3,12 in the study of azzam et al.14 there was a significant decrease in masi score of patient group. however, the use of this formula is limited to 4 to 8 weeks because of the steroid side effects which can cause skin atrophy, telangiectasis and acneiform eruption.3,7 chemical peeling agents are beneficial in the treatment of melasma and may be used in combination with other forms of melasma treatment.3,6,7 the peel solution is selected according to patient’s needs, skin type, and sensitivities.3,6,7 many types of chemical peels solutions can be used.3,13 glycolic acids and salicylic acids have been used for many years in the treatment of melasma.13 in this study, chemical peeling is the most common procedure. laser and light therapies for the treatment of melasma have become increasingly popular.12,13 the function of laser treatment is to destroy melanin formed. laser treatment creates an increased risk of adverse effects via direct damage to the skin, so it can cause a paradoxical increase in pigmentation following treatment.12,13 the interval between the first and second visit is two weeks. certain rule about frequency and interval of melasma medication was not found in this study. to assess the evaluation of melasma therapy, kroon et al.15 conducted an observation in the third week, twelfth week and twenty fourth week.15 meanwhile, farshi16 conducted an observation of therapy result in the fourth and eighth week. the possible side effects after medication were erythema, burn, scale, itchiness, sore or even acne eruption.3,14 a study of farshi16 showed that as many as 46.6% patients complained about erythema after one month applying hydroquinone.16 a study of chowdury et al.9 showed that as many as 20% patients complained about erythema, 7% complained about itchiness, 7% complained about burn and 3% complained about scale. the masi scoring assesses three factors; area (a), darkness (d) and homogeniety of pigmentation (h).2,9,10 to calculate the masi scoring, face needs to be divided into four area; forehead, right malar, left malar and chin with their percentage of area (30%, 30%, 30% and 10%, respectively). the final score of masi is the addition of hyperpigmentation and homogenicity then multiplied by the melasma area.2,9,10 the average of masi score cannot be included due to the non-normal distribution. the average masi score in kroon et al.15 study was 8.5±3.6 while in ejaz et al.17 study was 6.5±3.84. decreased masi score means that the patients have improvement in their melasma.2,20 most patients in this study have decreased masi score in the second visit. in the study of kroon et al.15 there were 8 out of 10 patients experienced the improvement at the second visit after applying kligman formula. in this study, some patients had increase masi score. that condition may be caused by low compliance of using sunblock and other medication usages or by increased exposure to precipitating factors.11,12,14 a study in bangladesh9 showed that the average decrease of masi score in the twelfth week of therapy was as many as 24.20% or mild. based on category of decreasing masi, most patients in this study belong to the mild group at the second visit. data obtained in this study were based on medical record. limitation in this study is medical record fulfillment in every patient’s visit conducted by different resident doctors. therefore, different masi score assessment in every visit leads to the subjectivity of therapy evaluation.2,3 specific choice of treatment and time interval standard is needed for melasma treatment in every visit, therefore it will help in evaluating therapy. hopefully, data obtained from this study can be used as a consideration in arranging guidelines of melasma more specifically in the department of dermatology and venereology dr. hasan sadikin general hospital bandung. it can be concluded that the most frequent interval between the first and second visit on the melasma patients is two weeks. the combination of hydroquinone and tretinoin is the topical drugs often used for melasma patients. the patients got sunblock and chemical peeling treatment. the side effect often experienced by the patients is erythema. masi score was frequently decreased which is classified as mild at the second visit. references 1. lapeere h, boone b, schepper sd, verhaeghe e, gele mv, ongenae k, et al. hypomelanoses and hypermelanoses. in: goldsmith la, katz si, gilchrest ba, paller althea medical journal. 2016;3(4) 615 as, leffell dj, wolff k, editors. fitzpatrick’s dermatology in general medicine. 8th ed. new york: mcgraw-hill; 2012. p. 804–26. 2. pandya ag, hynan ls, bhore r, riley fc, guevara il, grimes p, et al. reliability assessment and validation of the melasma area and severity index (masi) and a new modified masi scoring method. j am acad dermatol. 2011;64(1):78–83. 3. damevska k. new aspects of melasma/ novi aspekti melazme. serbian journal of dermatology and venereology. 2014;6(1):5–18. 4. sheth vm, pandya ag. melasma: a comprehensive update: part i. j am acad dermatol. 2011;65(4):689–97. 5. handel ac, miot ldb, miot ha. melasma: a clinical and epidemiological review. anais brasileiros de dermatologia. 2014;89(5):771–82. 6. sarkar r, arora p, garg vk, sonthalia s, gokhale n. melasma update. indian dermatol online j. 2014;5(4):426–35. 7. shankar k, godse k, aurangabadkar s, lahiri k, mysore v, ganjoo a, et al. evidence-based treatment for melasma: expert opinion and a review. dermatology and therapy. 2014;4(2):165–86. 8. kang hy, ortonne j-p. what should be considered in treatment of melasma. annals of dermatology. 2010;22(4):373–8. 9. chowdhury w, wahab m, khondker l, khan m, shirajul i. efficacy and safety of hydroquinone, kojic acid and glycolic acid combination in the treatment of melasma. banglajol. 2012;11(3):191–6 10. ghersetich i, troiano m, brazzini b, arunachalam m, lotti t. melasma: treatment with 10% tretinoin peeling mask. j cosmet dermatol. 2010;9(2):117– 21. 11. rigopoulos d, gregoriou s, katsambas a. hyperpigmentation and melasma. j cosmet dermatol. 2007;6(3):195–202. 12. sheth vm, pandya ag. melasma: a comprehensive update: part ii. j am acad dermatol. 2011;65(4):699–714. 13. rivas s, pandya ag. treatment of melasma with topical agents, peels and lasers: an evidence-based review. am j clin dermatol. 2013;14(5):359–76. 14. azzam oa, leheta tm, nagui na, shaarawy e, hay rma, hilal rf. different therapeutic modalities for treatment of melasma. j cosmet dermatol. 2009;8(4):275–81. 15. kroon mw, wind bs, beek jf, van der veen jw, nieuweboer-krobotová l, bos jd, et al. nonablative 1550-nm fractional laser therapy versus triple topical therapy for the treatment of melasma: a randomized controlled pilot study. j am acad dermatol. 2011;64(3):516–23 16. farshi s. comparative study of therapeutic effects of 20% azelaic acid and hydroquinone 4% cream in the treatment of melasma. j cosmet dermatol. 2011;10(4):282–7. 17. ejaz a, raza n, iftikhar n, muzzafar f. comparison of 30% salicylic acid with jessner’s solution for superficial chemical peeling in epidermal melasma. j coll physicians surg pak. 2008;18(4):205–8. ayu adzani sabila, reti hindritiani, dimas erlangga luftimas: treatment evaluation of melasma patients in dr. hasan sadikin general hospital bandung in period of 2013–2014 althea medical journal. 2016;3(2) 286 amj june 2016 differences of clinical and laboratory presentation in positive and negative acid fast bacilli pulmonary tuberculosis patients amila hanifan muslimah,1 arto yuwono soeroto,2 enny rohmawaty3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: based on bacteria status, tuberculosis is classified into positive and negative acid fast bacilli. this study was conducted to determine the differences of clinical and laboratory presentation in positive and negative acid fast bacilli pulmonary tuberculosis patients. methods: this study was an observational analytic study with a cross-sectional approach which used 338 medical records of patients with pulmonary tuberculosis at direct observational treatment short-course (dots) clinic dr. hasan sadikin general hospital from january to december 2012. data collected were clinical and laboratory presentation for analytic study. data about comorbid were collected for descriptive data. results: from 338 medical records, 223 were medical records of patients with pulmonary tuberculosis and 105 medical records of patients with comorbid. twenty (18.01%) comorbid were human immunodeficiency virus (hiv). acid fast bacilli negative was more (121, 51.9%) than acid fast bacilli positive (112, 48.1%). differences of laboratory presentation were found in hemoglobin count (p=0.037), red blood cell count (p=0.022), and erythrocyte sedimentation rate (p=0.006) and not found in white blood cell count (p=0.073), thrombocyte count (p= 0.766), serum glutamic oxaloacetic transaminase (p=0.169), and serum glutamicpyruvic transaminase (p=0.309). difference of clinical manifestation was not found in fever (p=1), cough (p=0.608), night sweats (p=0.09), dyspnea (p=0.210), and weight loss (p=0.269). conclusions: differences between acid fast bacilli positive and negative are found in hemoglobin, red blood cell, and erythrocyte sedimentation rate laboratory examination. the highest comorbid of pulmonary tuberculosis patient is hiv. [amj.2016;3(2):286–91] keywords: acid fast bacilli, clinical presentation, comorbid, laboratory presentation, tuberculosis correspondence: amila hanifan muslimah, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285722974504 email: amila.hanifan@gmail.com introduction the world health organization (who) reported in 2011 that there were more than 8.7 million new cases of tuberculosis, 75 % which occurred in asia, including indonesia. increasing case and problem have made tuberculosis global emergencies since 1993. tuberculosis is diagnosed by finding acid fast bacilli in sputum specimen and classified into positive and negative acid fast bacilli.1 the amount of mycobacterium tuberculosis in pulmonary tuberculosis influences lesion condition. wide lesion area gives worse signs and symptoms, including the clinical and laboratory presentation.2 in several region, sputum examination could not be performed due to lack of facility or patient has a difficulty in generating sputum.1,3 data about clinical and laboratory presentation can be used as predictive value when sputum examination is not performed. these data can help physician to determine diagnosis and give appropriate treatment to reduce progression and transmission of diseases. another factor that influences the sputum examination is comorbid diseases. these data also help in as predictive value. recently, dr. hasan sadikin general hospital, a central referral hospital in west java, does not have data about the clinical and laboratory diagnosis of negative acid fast bacilli. this study was conducted to determine the differences of clinical and laboratory diagnosis in positive and negative acid fast althea medical journal. 2016;3(2) 287 bacilli to pulmonary tuberculosis outpatient. methods this study was an observational analytic study with a cross-sectional approach which used 223 medical records of patients with pulmonary tuberculosis at direct observational treatment short-course (dots) clinic dr. hasan sadikin general hospital from january to december 2012. this study was approved by health research ethics committee and all data included would be concealed. inclusion criteria were medical records of pulmonary tuberculosis patient. among 498 medical records of pulmonary tuberculosis patient, 105 medical records had comorbid diseases. data about comorbid were important as predictive value in acid fast bacilli examination, so it was collected as descriptive data. avoiding bias in analysis study, medical records patient with comorbid and had incomplete data diagnosis acid fast bacilli were excluded in analysis. two hundred and thirty three medical records of outpatient pulmonary tuberculosis patient without comorbid with complete acid fast bacilli data were selected. because of less number medical record, these data were selected as total sampling. clinical presentation variable in this study were fever, night sweating, weight loss, cough, and dyspnea. laboratory presentation variable in this study were hemoglobin (hb), white blood cell (wbc), red blood cell (rbc), thrombocyte, erythrocyte sedimentation rate (esr), serum glutamic oxaloacetic transaminase (sgot), and serum glutamic-pyruvic transaminase (sgpt). clinical and laboratory presentation in medical records were calculated by using prohibits analysis and then the results were classified based on each variable in negative and positive acid fast bacilli (afb). data about clinical presentation were made into table and statistical analysis using chi square test and kolmogorov smirnov test if chi square test was not required. statistically significant was considered when p≤0.05. the analysis was performed by comparing each group proportion and p value in the table presentation. data about laboratory presentation were made into table and statistical analysis used unpaired t-test and mann whitney test if there were anomalies in the data distribution. statistically significant was considered when p≤0.05. analysis was performed by comparing mean, standard deviation, confident interval (ci), and p-value in the table presentation. results there are 233 medical records of pulmonary tuberculosis without comorbid and extra pulmonary tuberculosis. acid fast bacilli negative was more than acid fast bacilli positive (table 1). among 233 pulmonary tuberculosis patients, most of them were 14–33 years old. there were more male populations than female (table 2). one hundred and five medical records of pulmonary tuberculosis patient had comorbid diseases. highest comorbid was human immunodeficiency virus (hiv) (table 3). for number of proportion in positive acid fast bacilli (afb), there were more cases in fever and fewer cases in dyspnea, while in negative afb, there were more cases in fever and fewer cases in night sweat (table 4). statistical analysis of fever used fisher test because chi square was not required. night sweat, cough, dyspnea, and weight loss variable were used in chi square test. statistically, there were no significant differences between positive and negative afb (p>0.05) in all clinical presentations of patient. saphiro-wilk test analysis showed normal data distribution in hemoglobin count, rbc count, and esr. using unpaired t test analysis, these variable showed statistically significant differences (p<0.05) between positive and negative acid fast bacilli. statistically, there were no significant differences between positive and negative afb (p>0.05) in wbc and thrombocyte count. using mann-whiteney as non parametric test analysis, sgot and sgpt statistically did not show significant difference amila hanifan muslimah, arto yuwono soeroto, enny rohmawaty: differences of clinical and laboratory presentation in positive and negative acid fast bacilli pulmonary tuberculosis patients table 1 acid fast bacilli diagnosis of pulmonary tuberculosis patient acid fast bacilli diagnosis n % acid fast bacilli negative 121 51.9 acid fast bacilli positive 112 48.1 total 233 100 althea medical journal. 2016;3(2) 288 amj june 2016 have hiv. different proportion can occur because of different hiv/tb co-infection rate between indonesia and india. proportion of positive and negative acid fast bacilli in hiv in this study are 10 (50.0%) and 9 (45.0%). several studies showed that hiv has higher rate acid fast bacilli negative than positive. these studies used positive hiv patient and perform algorithm to detect tuberculosis. so, it was discovered that most of them are smear negative patient.8,9 this study also showed that 19 (17.1 %) patients had diabetes mellitus. another study by alisjahbana et al.10 found that in indonesia, 13.2 % patients with tb have diabetes (p=0.169 and p=0.309) between positive and negative acid fast bacilli (table 5). discussion tuberculosis as an infectious disease may predispose or trigger some chronic noncommunicable diseases.4 several evidences describe the link between tuberculosis and several non-communicable diseases and their risk factors, such as diabetes mellitus, smoking, and pollution.5,6 in this study, 20 out of 85 (18.01 %) patient have human immunodeficiency virus (hiv). another study by mano et al.7 showed that 8.6% patients table 2 baseline characteristic pulmonary tuberculosis patient variable acid fast bacilli positive (n=112) n (%) acid fast bacilli negative (n=121) n (%) age (years old) 14–33 53 (47.32) 54 (44.63) 34–53 34 (30.36) 36 (29.75) 54–73 23 (20.53) 27 (22.31) 73–93 2 (1.79) 4 (3.31) gender female 44 (39.29) 55 (45.45) male 68 (60.71) 66 (54.55) table 3 comorbid diseases of pulmonary tuberculosis patient co morbid diseases of tuberculosis positive afb (n) negative afb (n) not perform sputum examination (n) total n (%) community acquired pneumonia 13 3 1 17 (15.3) asthma bronchial 1 3 0 4 (3.6) diabetes mellitus 14 5 0 19 (17.1) human immunodeficiency virus (hiv) 10 9 1 20 (18.01) hypertension 2 6 0 8 (7.2) pneumothorax 4 1 0 5 (4.5) chronic obstructive pulmonary diseases 2 0 2 4 (3.6) carcinoma 4 7 1 11 (9.9) systemic lupus erythematosus 1 1 1 3 (2.7) rheumatic heart diseases 2 1 0 3 (2.7) others* 8 9 0 17 (15.3) note: *others case of comorbid diseases were two chronic bronchitis cases, one bronchiectasis case, one bronchopneumonia, two chronic kidney diseases case, one chronic renal failure case, one dengue hemorrhagic fever case, one urinary tract infection case, two evans syndrome cases, one gastropathy cases, one laryngitis case, two osteomyelitis cases, one vaginal septum case. althea medical journal. 2016;3(2) 289amila hanifan muslimah, arto yuwono soeroto, enny rohmawaty: differences of clinical and laboratory presentation in positive and negative acid fast bacilli pulmonary tuberculosis patients mellitus, thus there was a strong association between diabetes mellitus and tuberculosis patients. a systematic review reported that case control studies have odd ratio (or) 1.16– 7.83 in ranged of tb patients with dm.6 early diagnosis and effective treatment of pulmonary tuberculosis cases that infect the community are the best ways in controlling tuberculosis. study in pakistan11 showed that the delay in diagnosis and inability to cure a high proportion of pulmonary smear positive cases are the main reasons of the increase of infection risk, high death rate, and multidrug resistance cases. diagnosis of tuberculosis is performed by sputum examination.1 this examination will detect acid fast bacilli with ziehl neelsen staining,3 and is classified into acid fast bacilli positive and acid fast bacilli negative.1 this study showed that among 235 pulmonary tuberculosis patients, 121 (51.4%) had acid fast bacilli negative and 47.6% had acid fast bacilli positive. study by ishaq et al.11 showed that 104 (52%) patients have acid fast bacilli positive and 96 (48%) patients have acid fast bacilli negative. different amount of data happened because of different sample size. mycobacterium tuberculosis amount in pulmonary tuberculosis influences lesion condition. wide lesion area gives worse signs and symptoms, including the clinical and laboratory presentation.3 the commonest symptoms on patient presentations complained were cough, 92.5% patient afb positive, and 78.8 % afb negative. another common symptom was weight loss, presented in 85.1% afb positive and 73.1% afb negative patients. night sweat was a symptom presented in 66.7 % afb positive patients and 57.4 % afb negative patients, fever in 60% afb positive patients and 60.8% afb negative patients, and dyspnea in 43.7% afb positive patients and 65.3 % afb negative patients. another study by ishaq et al.11, with 104 afb table 4 clinical presentation of pulmonary tuberculosis clinical manifestation n afb positive afb negative p fever 38 60 % 60.8 % 1 night sweat 71 66.7 % 57.4 % 0.608 cough 106 92.5 % 78.8 % 0.099 dyspnea 42 43.7 % 65.3 % 0.210 weight loss 79 85.1 % 73.1 % 0.269 table 5 laboratory presentation of pulmonary tuberculosis laboratory presentation n afb positive n afb negative p ci 95 % hemoglobin gr/dl (mean±s.d) 14 11.65±1.98 23 13.30±2.59 0.037 0.10–3.19 wbc count/dl (mean±s.d) 16 6488.50±2608.98 16 8395.65±3453.40 0.073 3453.40–863.35 rbc count trillion cell/l (mean±s.d) 9 4.19±0.71 12 4.94±0.62 0.022 0.12–1.38 thrombocyte count/l (mean±s.d) 13 315230.77±119635.66 22 302954.55±111126.90 0.766 96458.20–71905.80 esr mm/1st hr (mean±s.d)) 15 78.13±34.52 31 52.58±23.74 0.006 43.19-7.91 sgot, median (q1-q3) 49 20.00 (9–91) 48 21.00 (10-216) 0.169 22.62–33.30 sgpt, median (q1-q3) 49 16.00 (3–109) 48 21.00 (6-138) 0.309 21.37–31.68 sgot, median (q1-q3) 49 20.00 (9–91) 48 21.00 (10-216) 0.169 22.62–33.30 sgpt, median (q1-q3) 49 16.00 (3–109) 48 21.00 (6-138) 0.309 21.37–31.68 note : wbc=white blood cell, rbc=red blood cell, esr=erythrocyte sedimentation rate, sgot=serum glutamic oxaloacetic transaminase, sgpt=serum glutamic-pyruvic transaminase althea medical journal. 2016;3(2) 290 amj june 2016 positive patients, showed that 84.61% have cough and 53.84%xperience night sweating. this study was conducted through primary data collection and the increased frequency as compared to our study that can be as a result of complete data information. a study by alavi-naini et al.12, with 350 afb negative patients, showed that 79.1% have fever, 45.4% have dyspnea, 26.2% experience weight loss, 14.8 % experience night sweating. different symptom frequency compared to our study can be as a result if data sample is larger. other factors that influence clinical manifestation of tuberculosis patient are immunology factor, the quality of host defense, and mycobacteria.13,14 statistical analysis of clinical presentation resulting fever (p=1), cough (p=0.608), night sweats (p=0.09), dyspnea (p=0.210), and weight loss (p=0.269) do not differ between acid fast bacilli positive and negative. another study by alavi-naini et al.12 showed association between night sweat and acid fast bacilli negative. this study used afb negative patient with culture confirmation. siddiqi et al.15 reviewed systematically that patients with smear-negative tuberculosis experience night sweats for a longer time. smear-positive patients have longer fever and experience weight loss than the smearnegative group. the studies have used four clinical criteria for diagnosis of smear-negative tuberculosis that have high sensitivity but low specificity. the main limitation of this study was large number of incomplete data. among 233 patients, complete data were found in 38 (16.3%) patients having fever, 71 (30.4%) patients experiencing night sweat, 106 (45.4%) patients having cough, 42 (18.0%) patients having dyspnea, and 79 (33.9%) patients experiencing weight loss. result from such an analysis should be used as a larger data sample. this study also showed mean hemoglobin count, white blood cell, and red blood cell count that were higher in afb negative than afb positive. mean thrombocyte count and erythrocyte sedimentation rate at the first hour was higher in afb positive than afb negative. median for sgot was 20.00 in afb positive and 21.00 in afb negative. median for sgpt was 16.00 in afb positive and 21.00 in afb negative. there were statistically significant difference of hemoglobin count, red blood cell count, and esr first hour between afb positive and negative (p=0.037, p=0.022, p=0.006). there was no statistically significant difference in white blood cell, thrombocyte count, sgot, and sgpt between afb positive and negative. laboratory examination of pulmonary tuberculosis can show mild anemia, white blood cell count within normal limit, sgot and sgpt above normal level.3 another study by naini et al.12 showed there is association between acid fast bacilli negative and erythrocyte sedimentation rate > 45 mm and white blood cell count < 11000/ml. there were also large numbers of incomplete data. among 233 patients, the patient with the complete data found was 37 (15.8%) in hemoglobin count, 39 (16.2%) in white blood cell count, 21 (8.5%) in red blood cell, 35 (15.0%) in thrombocyte count, 46 (19.7%) in erythrocyte sedimentation rate, and 95 (40.7%) in sgot-sgpt. statistically, the insignificant result could be caused by limited data sample. in conclusion, there are statistically significant differences in laboratory presentation of hemoglobin count, red blood cell count, and erythrocyte sedimentation rate. there are no statistically significant differences in any clinical manifestation. differences in the variable are needed to be assessed in adequately large study. data about clinical and laboratory presentation can be used as a predictive value for acid fast bacilli examination. these data can help physician to determine diagnosis and give appropriate treatment to reduce progression and transmission of diseases. references 1. departemen kesehatan republik indonesia. pedoman nasional penanggulangan tuberkulosis. jakarta: depkes ri; 2012. 2. brooks g, carrol k, butel j, morse s. jawetz, melnick & adelberg’s medical microbiology. 24th ed. new york: the mcgraw–hill; 2007. p. 322. 3. schlossberg d. tuberculosis and nontuberculous mycobacterial infections. 6th ed. washington, dc: asm press; 2011. 4. alisjahbana b, sahiratmadja e, nelwan ej, purwa am, ahmad y, ottenhoff th et al. the effect of type 2 diabetes mellitus on the presentation and treatment response of pulmonary tuberculosis. clin infect dis. 2007; 45(4):428–35. 5. lin hh, ezzati m, murray m. tobacco smoke, indoor air pollution and tuberculosis: a althea medical journal. 2016;3(2) 291 systematic review and meta-analysis. plos medicine. 2007;4(1):e20. 6. jeon cy, murray mb. diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. plos medicine. 2008;5(7):e152 7. mano r, muhammad gm. study on hiv coinfection among pulmonary tuberculosis at a private medical college hospital. asian student medical journal. 2013;13(6):1–11. 8. nguyen dtm, nguyen hq, beasley rp, ford ce, hwang ly, graviss ea. performance of clinical algorithms for smearnegative tuberculosis in hiv-infected persons in ho chi minh city, vietnam. tuberculosis research and treatment. 2012;2012:360852. 9. cain kp, mccarthy kd, heilig cm, monkongdee p, tasaneeyapan t, kanara n, et al. an algorithm for tuberculosis screening and diagnosis in people with hiv. n engl j med. 2010;362(8):707–16. 10. alisjahbana b, van crevel r, sahiratmadja e, den heijer m, maya a. diabetes mellitus is strongly associated with tuberculosis in indonesia. int j tuberc lung dis. 2006;10(6):696–700. 11. ishaq km, ihsanullah, amir m, nisar k, zaman m. frequency of sputum positive acid fast bacilli cases among patients of pulmonary tuberculosis in tertiary care hospitals of northern pakistan. j ayub med coll abbottabad. 2010;22(2):56–60 12. alavi-naini r, cuevas le, squire sb, mohammadi m, davoudikia aa. clinical and laboratory diagnosis of the patients with sputum smear-negative pulmonary tuberculosis. arch iran med. 2012;15(1):22–6. 13. van crevel r, ottenhoff thm, van der meer jwm. innate immunity to mycobacterium tuberculosis. clin microbiol rev. 2002;15(2):294–309. 14. goyot-revol v, innes ja, hackforth s, hinks t, lalvani a. regulatory t cells are expanded in blood and disease sites in patients with tuberculosis. am j respir crit care med. 2006;173(7):803–10. 15. siddiqi k, lambert m, walley j. clinical diagnosis of smear-negative pulmonary tuberculosis in low-income countries. lancet infect dis. 2003;3(5):288–96. amila hanifan muslimah, arto yuwono soeroto, enny rohmawaty: differences of clinical and laboratory presentation in positive and negative acid fast bacilli pulmonary tuberculosis patients althea medical journal. 2016;3(2) 222 amj june 2016 knowledge and attitude towards prevention and management of hypertension in jatinangor sub-district kartika malahayati,1 rudi supriyadi,2 herri s. sastramihardja3 1faculty of medicine, universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: there is an increase in prevalence of hypertension all over the world as well as indonesia. hypertension affects almost all body organs and systems. hypertension prevention and management are influenced by knowledge and attitude towards the disease. the aim of this study was to assess knowledge and attitude towards prevention and management of hypertension. methods: this was a descriptive study with cross–sectional approach conducted in jatinangor sub-district in 2013. sample sizes were determined based on proportion of the case in population and precision estimates (95% confidence intervals). one hundred twenty respondents aged 18–60 year-old were selected from population using stratified random sampling method. hypertensions knowledge and attitude were assessed using validated questioner as the scale measurement. frequency of knowledge level was presented as three ordinal categories; good, moderate, and poor. attitude of hypertension was presented as frequency in two categories; relatively positive and relatively negative. results: out of 120 respondents administered the questioner, 42.50% had good knowledge; 41.67% had moderate knowledge; 15.83% had poor knowledge related to hypertension prevention and 21.67% had good knowledge; 19.17% had moderate knowledge; 59.17% had poor knowledge related to management of hypertension. hypertension attitude of respondents were 60.83% relatively positive in topics of hypertension prevention and 39.17% in topics of hypertension management. conclusions: respondents are knowledgeable about hypertension prevention but are less knowledgeable about its management. respondents have relatively positive attitudes towards hypertension prevention. in the other hand, respondents have more relatively negative attitudes towards its management. [amj.2016;3(2):222–9] keywords: attitude, hypertensions, knowledge, prevention, treatment. correspondence: kartika malahayati, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85279085993 email: kartika.malahayati@gmail.com introduction according to world health organization (who), in 2008, hypertension had prevalence of 40% in worldwide adult population.1 furthermore, the number of adults with hypertension in 2025 was predicted to increase 60% to a total of 1.56 billion adults.2 the other studies report that hypertension is one of the leading causes of premature death worldwide, accounting 7.5 million deaths, about or 12.8% of the total of all annual deaths. this accounts for 57 million disability adjusted life year (dalys) or 3.7% of total dalys.1,3,4 hypertension is a common disease in indonesia. the disease still occupies the seventh position of the top ten outpatients in hospitals in 2010. the incidence of hypertension reached 80,615 cases in that year.5 according to riset kesehatan dasar (riskesdas) indonesia 2007, there are at least 31.7% of the total population, equivalent to 74 million people in indonesia have hypertension.6 in addition, hypertension is often referred to the silent killer due to the character of the disease that does not cause symptoms until complication appeared, such as cerebrovascular disease, ischemic heart disease, heart failure and kidney failure.3,4 the high rates of hypertension and the dangers posed by its complications make hypertension as one of the major health burden in indonesia. in this context, a strategy to improve the health level of indonesians should include the prevention and management of hypertension. althea medical journal. 2016;3(2) 223 prevention and treatment of diseases are form of health behavior that is a normal response to a health stimulus. there are three areas of health behavior, namely knowledge, attitude, and practice. first is to find out the stimulus, and then gives a response in the form of attitude, followed by practice and the application. the purpose of this study was to assess hypertension knowledge and attitude of people who lived in jatinangor sub-district related to prevention and treatment of the disease. methods this was a descriptive study with a crosssectional approach. this study had been approved by health research ethics committee with a letter numbered 212\un6. c2.1.2\kepk\2013 to be conducted between august–september 2013 in jatinangor subdistrict. hypertensions knowledge and attitude was assessed using questioner as the scale measurement. the final scale had 22 items with four sub-dimensions of preventionknowledge, prevention-attitude, managementknowledge, and management-attitude. in order to determine qualification measured by scale, validity and reliability of the questioner was pilot tested to 30 randomly–selected participants out of the respondents of the study. sample size was determined based on proportion of the case in the population and precision estimates (95% confidence intervals). after being stratified based on villages, respondents were selected from population using random sampling method. the inclusion criteria for respondent of this study are aged between 18–60 year-old and lived in jatinangor. one hundred twenty respondents were involved in this study. statistical product and service solution (spss) version 16.0 for windows and microsoft excel 2010 were used for data analysis. from the analysis, knowledge of hypertension was kartika malahayati, rudi supriyadi, herri s. sastramihardja: knowledge and attitude towards prevention and management of hypertension in jatinangor sub-district table 1 the distribution of the study group according to various demographic and medical characteristics of respondents characteristics of respondents frequency (n = 120) percentage (%) gender male 51 42.50 female 69 57.50 age group (years old) 18–30 41 34.17 30–40 27 22.50 40–50 20 16.67 50–60 32 26.67 education level no formal education 2 1.7 elementary school 15 12.5 junior high school 47 39.2 senior high school 50 41.7 college 6 5.0 personal history of hypertension absent 101 84.17 present 19 15.83 family history of hypertension absent 93 77.50 present 27 22.50 althea medical journal. 2016;3(2) 224 amj june 2016 divided into two sub-dimension, knowledge to prevention and knowledge to management of hypertension. the knowledge outcome measurement was the percentage of the accumulation score. this score then was put into three ordinal categories, good, moderate, and poor. if the total right answer was 76– 100%, then knowledge of respondents would be categorized as good. if the total right answer was 56–75%, interpretation of respondents’ knowledge about hypertension would be categorized as moderate. if the total right answer was ≤55%, respondents’ knowledge about hypertension was classified as poor. attitude of hypertension was divided into two sub-dimension, attitude to prevention and attitude to management of hypertension. this variable was presented using ordinal measurement scale. attitude measurement in this study used a likert scale, where each response to an attitude questionnaire has a composition degree from very negative to very positive. results of likert scale model answers were categorized in two categories, positive attitude and negative attitude. to be analyzed, the results were expressed in units of standard deviation of all respondents using a score-t, follows: description: x = score of respondents on a scale of attitude to be converted into a score-t = the mean score of all respondents s = standard deviation score group respondents’ attitude towards prevention were relatively positive when the t-score is greater than the mean-t, while the relatively negative attitude were categorized when the t-score less than or equal to the mean-t. table 2 knowledge of hypertension prevention based on characteristics of respondents characteristics of respondents knowledge of hypertension prevention good moderate poor n % n % n % gender male 22 43.14 22 43.14 7 13.73 female 29 42.03 28 40.58 12 17.39 age group (years old) 18–30 15 36.59 16 39.02 10 24.39 30–40 12 44.44 12 44.44 3 11.11 40–50 4 20.00 11 55.00 5 25.00 50–60 20 62.50 11 34.38 1 3.13 education level no formal education 1 50.00 1 50.00 0 0.00 elementary school 9 60.00 5 33.33 1 6.67 junior high school 21 44.68 20 42.55 6 12.77 senior high school 20 40.00 22 44.00 8 16.00 college 0 0.00 2 33.33 4 66.67 personal history of hypertension present 7 36.84 9 47.37 3 15.79 absent 44 43.56 41 40.59 16 15.84 family history of hypertension present 12 44.44 11 40.74 4 14.81 absent 39 41.94 39 41.94 15 16.13 althea medical journal. 2016;3(2) 225kartika malahayati, rudi supriyadi, herri s. sastramihardja: knowledge and attitude towards prevention and management of hypertension in jatinangor sub-district results one hundred twenty respondents were included in this study. of these, 57.5% were female. the mean age of the respondents was 37.63 years. a personal history of hypertension was observed in 15.8% and family history in 22.5% respondents. out of 120 respondents administered the questioner, 42.50% had good knowledge related to prevention of hypertension and 21.67% had good knowledge related to management of hypertension. about 41.67% and 19.17% had a moderate knowledge on prevention and management of hypertension. forty percent respondents knew that hypertension is a disease related to the high blood pressure; 64.17% respondents correctly answered the normal value of human blood pressure. most of respondents were knowledgeable about prevention of hypertension, accounting 97.5% respondents believed hypertension can be prevented; 90% respondents knew that doing some exercise can prevent the hypertension; averagely 78.3% respondents agreed low salt diet and low fat diet is a good prevention of the disease. about 59.17% respondents had poor knowledge about management of hypertension. although 93.33% respondents believed that hypertension treatment is very important, only 20.83% respondents knew that hypertension treatment should be done over a lifetime. when respondents were asked for more specific question related to the management of hypertension, 72.5% respondents correctly answered that hypertension patient need to consume anti– hypertensive medicines and 40.83% knew that non-pharmaceutical management is also important to increase hypertensive patients’ health. results of hypertension attitude were table 3 knowledge of hypertension management based on characteristics of respondents characteristics of respondents knowledge of hypertension management good moderate poor n % n % n % gender male 14 27.45 8 15.69 29 56.86 female 12 17.39 15 21.74 42 60.87 age group (years old) 18–30 3 7.32 9 21.95 29 70.73 30–40 5 18.52 6 22.22 16 59.26 40–50 4 20.00 2 10.00 14 70.00 50–60 14 43.75 6 18.75 12 37.50 education level no formal education 2 100.0 0 0.00 0 0.00 elementary school 5 33.33 3 20.00 7 46.67 junior high school 12 25.53 9 19.15 26 55.32 senior high school 6 12.00 10 20.00 34 68.00 college 1 16.67 1 16.67 4 66.67 personal history of hypertension present 7 36.84 6 31.58 6 31.58 absent 19 18.81 17 16.83 65 64.36 family history of hypertension present 8 29.63 7 25.93 12 44.44 absent 18 19.35 16 17.20 59 63.44 althea medical journal. 2016;3(2) 226 amj june 2016 expressed in units of standard deviation of all respondents using score-t. mean-t for attitudes towards hypertension prevention was 49.89 whereas mean-t for attitudes towards hypertension management was 50.00. from the analysis, it was known that 60.83% respondents had relatively positive attitude towards prevention of hypertension; 37.17% respondents had relatively negative attitude towards hypertension. this value was much bigger than attitude value of hypertension management; only 37.50% respondents were categorized as having a relatively positive attitude. sixty two percent respondents had a relatively negative attitude, primarily on adherence therapy patients have to follow and strict lifestyle changes. discussions death and disability that occurs in hypertensive patients was mostly caused by its complications, such as cerebrovascular disease, ischemic heart disease, heart failure and kidney failure. hypertension caused 54% mortality of stroke patients and 47% of ischemic heart disease deaths. in addition, hypertension is called as silent killer due to its character that will not cause symptoms until complication appear.3,4 a lack of knowledge about hypertension negatively influences patients’ awareness and behaviors, and is a major obstacle in controlling the disease.7,8 out of 120 respondents, 19 respondents (15.83%) had history of hypertension. this number was a little bit higher than hypertension prevalence in jatinangor subdistrict in 2012 which is 9.61%.9 this study result shows that respondents were knowledgeable about prevention of hypertension, but were less knowledgeable about treatment and management of the disease. out of 120 respondents administered table 4 attitude of hypertension prevention based on characteristics of respondents characteristics of respondents attitude of hypertension prevention relatively positive relatively negative n % n % gender male 31 60.78 20 60.78 female 42 60.87 27 60.87 age group (years old) 18–30 32 78.05 9 78.05 30–40 16 59.26 11 59.26 40–50 14 70.00 6 70.00 50–60 11 34.38 21 34.38 education level no formal education 2 100.00 0 100.00 elementary school 3 20.00 12 20.00 junior high school 25 53.19 22 53.19 senior high school 38 76.00 12 76.00 college 5 83.33 1 83.33 personal history of hypertension present 13 68.42 6 68.42 absent 60 59.41 41 59.41 family history of hypertension present 19 70.37 8 70.37 absent 54 58.06 39 58.06 althea medical journal. 2016;3(2) 227 the questioner, 42.50% had good knowledge related to prevention of hypertension and 21.67% had good knowledge related to management of hypertension. this result contradicted to some other studies stated that people, especially in urban and sub-urban area, had tendency to have good knowledge of hypertension prevention as well as hypertension management.7,10 generally, there were many views about definition of hypertension; about 40% of our respondents knew hypertension indicated by high blood pressure. interestingly, there was a commonly held notion in population that hypertension might be indicated by excessive worries, thinking or stress (55% respondents). this was contrary to another similar study denying the presence of that notion in the population. from study conducted by iyalomhe in sub-urban population, majority of population (61%) knew exactly about definition of hypertension. 7 based on age, the majority percentages of respondents who had good knowledge of hypertension prevention are on age >40 years, which is as much as 54%. however, for knowledge of hypertension management there was a tendency that the younger the age, the higher the knowledge. this trend contradicted to the theory of knowledge formation. age is one factor that affects the formation of knowledge, the older the age of a person, the more constructive he is in using the coping problems encountered.11 there was no compelling difference in level of knowledge of hypertension prevention gratified based on respondent’s educational background. yet, there were some inclinations in level of hypertension management knowledge. the results of this study suggested that the lower educational level of respondents, the higher level of knowledge they must have. based on further observation, it is known that most of respondents gathered the information about hypertension not from formal educational institution, but from kartika malahayati, rudi supriyadi, herri s. sastramihardja: knowledge and attitude towards prevention and management of hypertension in jatinangor sub-district table 5 attitude of hypertension management based on characteristic of respondents characteristics of respondents attitude of hypertension management relatively positive relatively negative n % n % gender male 17 33.33 34 66.67 female 28 40.58 41 59.42 age group (years old) 18–30 15 36.59 26 63.41 30–40 13 48.15 14 51.85 40–50 8 40.00 12 60.00 50–60 9 28.13 23 71.88 education level no formal education 0 0.00 2 100.00 elementary school 4 26.67 11 73.33 junior high school 19 40.43 28 59.57 senior high school 20 40.00 30 60.00 college 2 33.33 4 66.67 personal history of hypertension present 6 31.58 13 68.42 absent 39 38.61 62 61.39 family history of hypertension present 8 29.63 19 70.37 absent 37 39.78 56 60.22 althea medical journal. 2016;3(2) 228 amj june 2016 the clinic of family health care attendance. this inclination also could be caused by the limitation of educational background distribution in respondents’ variables. hypertension attitude of respondents were relatively positive in topics of hypertension prevention, but more negative in the topics of management of hypertension. this is similar to another study conducted by lukoschek which stated that people have inclination to have more negative attitude towards management of hypertension though this inclination is influenced by races and socio–demographic factors.12 seventy percent respondents who had personal history of hypertension strongly agreed that hypertension should be prevented. in contrast, when attitude towards management of hypertension were measured, only 29.63% of these respondents agreed to the lifestyle change as the treatment of hypertension. some studies have reported that there is a strong correlation between personal histories of hypertension to the attitude of respondents.7,8 oliveria et al.10 suggested those people who have history of hypertension tend to give positive response towards both prevention and management of the disease. this difference might be happened because respondents of this study had different concept of hypertension treatment. respondents had inclination to answer that hypertension only have to be treated until patients are cured. unfortunately, until now, there is no curative treatment to cure hypertension. the treatments available nowadays are only able to control blood pressure and to prevent further complication of hypertension.3 this study is limited due to the ability of researcher for the first time to do research so there were still many shortcomings in data collecting, processing, interpretation and writing results of the research. design used in this study was descriptive, so it was only able to describe phenomenon without the ability to count the significance of variables for broader results. in addition, although questioner used in this study has been validated, there were still some probabilities of informational bias because questioner consisted of two different scales, so itcould confuse the respondents who filled it. in conclusion, this study results suggest that respondents have good knowledge about the prevention of hypertension, but are less knowledgeable about the treatment of the disease. hypertension attitude of the respondents are relatively positive in the topics of hypertension prevention. on the other hand, respondents have much more negative in the topics of management of hypertension. this study suggested that it is better that the government together with all health care provider paying more attention in controlling hypertension by increasing people’s knowledge and awareness towards the disease. it is also important to conduct further analytical research to correct this study’s limitations and broaden the scope of research to result a better comprehension of hypertension knowledge and attitude. references 1. who. global status report on noncommunicable diseases. geneva: who press; 2010. 2. chobanian av, bakris gl, black hr, cushman wc, green la, izzo jl, et al. seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. hypertension. 2003;42(6):1206–52. 3. whitworth ja, who, ish. 2003 world helath organization (who)/international society of hypertension (ish) statement on management of hypertension. j hypertens. 2003;21(11):1983–92. 4. lawes cmm, hoorn sv, rodgers a. global burden of blood-pressure-related disease, 2001. lancet. 2008;371(9623):1513–8. 5. kementrian kesehatan republik indonesia. profil kesehatan indonesia tahun 2011. jakarta: kementrian kesehatan republik indonesia; 2012. 6. badan penelitian dan pengebangan kesehatan kementrian kesehatan indonesia. riset kesehatan dasar indonesia 2007. jakarta: kemenkes ri; 2010. 7. iyalomhe gbs, iyalomhe si. hypertensionrelated knowledge, attitudes and life-style practices among hypertensive patients in a sub-urban nigerian community. j public health epidemiol. 2010;2(4):71–7. 8. buendía j. attitudes, knowledge and beliefs of patient about anti-hypertensive drugs. biomedica. 2012;32(4):578–84. 9. dinas kesehatan kab. sumedang. profil puskesmas dtp jatinangor tahun 2012. jatinangor: dinas kesehatan kab. sumedang. 2013. 10. oliveria sa, chen rs, mccarthy bd, davis cc, hill mn. hypertension knowledge, awareness, and attitudes in a hypertensive population. j gen intern med. 2005;20(3):219–25. althea medical journal. 2016;3(2) 229 11. jha n, bajracharya o, shankar pr. knowledge, attitude and practice towards medicines among school teachers in lalitpur district, nepal before and after an educational intervention. bmc public health. 2013;13:652. 12. lukoschek p. african americans’ beliefs and attitudes regarding hypertension and its treatment: a qualitative study. j health care poor underserved. 2003;14(4):566– 87. kartika malahayati, rudi supriyadi, herri s. sastramihardja: knowledge and attitude towards prevention and management of hypertension in jatinangor sub-district althea medical journal. 2016;3(4) 520 amj december 2016 correlation between sperm motility and morphology in the success rate of in vitro fertilization procedure praditya virza ramadhan,1 andri rezano,2 wiryawan permadi3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine universitas padjadjaran, 3department of obstetric and gynecology, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: in vitro fertilization (ivf) is one of the assisted reproductive technology that has been used in treating infertility. unfortunately, not every ivf procedure achieves 100% success in fertilizing the oocyte. it has been studied that the percentage of normal motile sperm and percentage of normal sperm morphology play a key role in this process. this study was conducted to evaluate correlation between sperm motility and morphology in the success rate of ivf. methods: this study was an observational analytic involving medical records of infertile couples who were treated by ivf procedure in dr.hasan sadikin general hospital bandung in 2009–2014. the variables that were used in this study were percentage of sperm motility, percentage of sperm morphology and fertilization rate.the collected data was analyzed using nonparametric mann whitney test and spearman correlation test. result: this study showed that there was a significant difference between the fertilization rate group and sperm motility (p=0,048) but there was no significant correlation between motility and the entire fertilization rate (p=0,319). this study also indicated that there was no significant difference between fertilization rate group and sperm morphology (p=0,232) and there was no significant correlation between sperm morphology and fertilization rate (p=0,720). conclusions: motility might has a role in determining the success rate of in vitro fertilization; meanwhile morphology does not have any role in determining the success rate of in vitro fertilization. [amj.2016;3(4):520–5] keywords: fertilization rate, in vitro fertilization, sperm morphology, sperm motility correspondence: praditya virza ramadhan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281224341516 email: p.virza.r@gmail.com introduction infertility is a condition affecting married couples who have failed to achieve conception after 12 months or more of having unprotected sex.1 infertility occurs in 10–15% of couples.2 the first line therapy for infertility is by treating the cause of infertility.3 assisted reproductive technologies (art) is used if other medicines fail to treat the cause of infertility.3 in vitro fertilization (ivf) is one of the art that is commonly used as it is safer than other assisted reproductive technologies.4 fertilization in ivf is performed outside the female body and helps facilitating sperm to fertilize oocytes. unfortunately, ivf is not always successful.5 a number of factors, from both males and females, influence the success of ivf. one of the male factors that affects the success of ivf is the quality of sperm used.6,7 sperm quality can be evaluated using semen analysis parameters. parameters of semen analysis which are most frequently examined and are affiliated to fertility success are concentration, motility, and morphology.8 in vitro fertilization is considered to have a low success rate when sperm parameter results are below the world health organization (who) reference.9 however, it is still debatable whether sperm parameters are directly related to the success of in vitro fertilization.10 the main objective of this study was to assess correlation between the percentage of sperm morphology and althea medical journal. 2016;3(4) 521 motility towards in vitro fertilization success. methods this study used an analytic correlative– comparative method with a cross–sectional study design. the population of this study consisted of medical records of married couples who had used assisted reproductive technology in the form of ivf at aster fertility clinic, dr. hasan sadikin general hospital bandung, in the period of 2009–2014. samples were taken from population using total sampling method. the sample was divided into two types. the first samples (n1) were taken to analyze correlation between sperm motility and fertilization success rate analysis and the other samples (n2) were taken to analyze correlation between sperm morphology and fertilization success rate analysis. the samples was also arbitrarily divided into 2 groups based on available data precentage of their fertilization success rate; high fertilization success rates (≥50%) and low fertilization success rates (<50%). medical records were compiled based on the inclusion and exclusion criteria. the inclusion criteria was age of female partner <35 years old, age of female partner ≥35 years old with a follicle stimulating hormone (fsh) rate <10 miu/ml on the 3rd day of hormone therapy. the exclusion criteria was an fsh rate ≥10 miu/ml on the third day of hormone therapy as this may cause a decrease in quality of the ovarian reserve,2 and incomplete data in medical records on the percentage of sperm motility, percentage of sperm morphology, number of oocytes collected and the number of successful fertilized oocytes. variables in this study were the percentages of sperm motility, sperm morphology, and fertilization success rate. the percentage of sperm motility was defined as the percentage of sperm that moved progressively against the total number of sperm. according to who, sperm motility below 40% was considered low. the percentage of sperm morphology was defined as the percentage of sperm with normal morphology as compared to the total number of sperm. according to who, sperm morphology below 4% was considered low. motility and morphology were assessed using computer aided-sperm analysis (casa). the percentage of fertilization success was determined by comparing the total number of fertilized ovum, defined by formation of 2 pronuclei, with the total number of ovum collected. the percentage of successful fertilization was then categorized into low fertilization success (<50%) and high fertilization success (≥50%). data was presented in the form of averages ±sd if the data was normally distributed; whereas, the data was presented in the form of medians and ranges between minimum– maximum if data was not normally distributed. nonparametric mann whitney test was used to compare 2 groups of fertilization success figure 1 sample selection process praditya virza ramadhan, andri rezano, wiryawan permadi: correlation between sperm motility and morphology in the success rate of in vitro fertilization procedure althea medical journal. 2016;3(4) 522 amj december 2016 rates. spearman correlation test was used to analyze the correlation between the percentage of sperm morphology and fertilization success rate and the same test was also used to analyze the correlation between the percentage of sperm motility and fertilization success rate. this study had been approved by the health research ethic committee dr. hasan sadikin general hospital bandung. results total of 84 medical records obtained, 63 medical records met the inclusion criteria. from 63 which met the inclusion criteria, there were 2 and 16 exluded data for n1 and n2 consecutively (figure 1). female partners who did not have data on fsh levels but were below the age of 35 years old were included in this study as female who were younger than 35 usually have fsh rate <10 miu/ml on the 3rd day of hormone therapy.11 in samples that were used to analyze correlation between motility and fertilization success rate, female factors were the most frequent cause of the infertility. fallopian tube disorders were the most frequent infertilty disorder followed by endometriosis and asthenozoospermia. in sampels that were used to analyze correlation between morphology and fertilization success rate, female factors were the most frequent cause of the infertility. fallopian tube disorders were the most frequent infertilty disorder followed by asthenozoospermia and endometriosis. analysis showed that there was a significant difference (p=0,048) between fertilization success rate group and the percentage of sperm motility, but eventhough the sperm motility was normal (>40%) the fertilization success rate could still be low (<50%) (table 3). however, there was no significant difference (p=0,232) between fertilization success rate group and the percentage of sperm morphology (table 4). based on the correlation test, there was no significant correlation (p=0,319) between the percentage of sperm motility and the fertilization success. based on the correlation test, there was no significant correlation (p=0,720) between the percentage of sperm morphology and the fertilization success (table 4). table 1 sample characteristics in correlation between motility and fertilization success rate characteristics total female age 35(25–44)* male age 37+–6** total sample 61 factors affecting infertility female 39 male 9 male and female 6 unexplained 7 infertility disorders adenomyosis 3 endometriosis 9 fallopian tube disorders 32 ovulation disorders 3 asthenozoospermia 9 teratoozoospermia 6 unexplained 7 note: *median and range (minimum–maximum)**average ±standard deviation althea medical journal. 2016;3(4) 523praditya virza ramadhan, andri rezano, wiryawan permadi: correlation between sperm motility and morphology in the success rate of in vitro fertilization procedure discussion theoretically, the difference between ivf and the natural fertilization process is the environment where fertilization takes place; however, the ability of sperm to penetrate the ovum is still required.6 the results from this study showed that there was a significant difference between the fertilization success rate group and the percentage of sperm motility (table 3). this result was similar to a study by langlois et al.8 low in vitro fertilization success rates can be attributed to the percentage of sperm motility that is below the who reference (<40%).4,8 nonetheless, in this study, low fertilization success rates occurred in males with a sperm motility percentage above 40%, and high table 2 sample characteristics in correlation between morphology and fertilization success rate characteristics total female age 34±4* male age 37±6* total sample 47 factors causing infertility female 28 male 9 male and female 6 unexplained 4 infertility disorders adenomyosis 3 endometriosis 7 fallopian tube disorders 26 ovulation disorders 3 asthenozoospermia 8 teratoozoospermia 6 unexplained 4 note: * median and range (minimum–maximum) table 3 comparison between fertilization success rate groups with sperm motility and morphology percentage sperm parameters fertilization success rate p–value <50% ≥50% motility (%) 60 (37–70)*** 50(30–96) p=0,048* morphology (%) 13 (2–41)*** 17 (2–41) p=0,232** note: *mann–whitney u–test, **independent t–test,***median and range (minimum–maximum) table 4 correlation between sperm motility and morphology percentage with fertilization success rate sperm parameters fertilization success rate correlation coefficient motility (%) p=0,319* –0,130 morphology (%) p=0,720* 0,054 note: *spearman correlation althea medical journal. 2016;3(4) 524 amj december 2016 fertilization success rates can occur in males with a sperm motility percentage below 40% (table 3). this showed that the number from a parameter analysis was not the only factor that affects fertilization success rates. aside from a parameter analysis, a deeper evaluation on sperm function should be conducted.4,6,7 other studies also suggested that the total number of motile sperm has more influence as compared to the percentage of motile sperm.5,12 nevertheless, there was no significant correlation between the percentage of sperm motility and fertilization success rate (table 4) and this result was in contrast to the study by langlois et al.8 this could be due to an uneven distribution of samples and an inadequate sample size in this study. based on the analysis results, there was a significant difference between the percentage of sperm morphology and fertilization success rates group (table 3) and no significant correlation between the percentage of sperm morphology and fertilization success rate (table 4). low and high fertilization success rates occurred in males with a sperm morphology percentage of 41% (table 3). low and high fertilization success rates can occur in males having a sperm morphology percentage below the who reference (<4%). these results were contradict with studies by langlois et al.8 and van der westerlaken et al.13 which stated that the percentage of sperm morphology influences fertilization success rates in vitro because abnormalities in sperm morphology influences the ability of sperm to penetrate an oocyte. on the other hand, studies by lewis,10 brita söderlund and lundin,14 and ghirelli–filho et al.15 concluded that sperm morphology did not influence fertilization success rates in ivf. the reason why the results were different could also because of the cause of the infertily in this study’s sample (both female and male factors) and the other studies. this shows that sperm morphology is not an absolute factor in determining fertilization success rates. in previous studies by keegan et al.16 and van der westerlaken et al.13 it was described that in vitro fertilization was still possible with a low percentage in sperm morphology as long as the percentage of sperm motility and the total motile sperm count was within the normal limits.13,16 correlation between morphology and fertilization success rate is still debatable.4,10 technological advancement in this field of study, especially in the use of media and materials, has provided positive impact towards fertilization success rates in males with a low sperm morphology percentage.16 the uncertainty of the influence of the percentage of sperm morphology can be attributed to the difficulty in having an objective evaluation in determining the total percentage of normal sperm morphology during semen analysis which may cause misinterpretation of results.14,15 the conclusion of this study is that the percentage of sperm motility influences the fertilization success rate. however, this study has not yet established relationship between the percentage of sperm motility and fertilization success rate whereas, the percentage of sperm morphology does not influence or has a significant relationship towards fertilization success rate. this study had a number of limitations. the total number of samples collected did not meet the minimum sample size. other functional sperm factors, which are rarely examined such as sperm dna fragmentation, acrosin activity, and sperm chromatin conditions were not controlled and could influence fertilization success. previous studies reported that these functional factors highly influence the success of sperms to fertilize ovum. it recommended to use a larger sample size and investigate other sperm factors in further study. references 1. zegers–hochschild f, adamson gd, de mouzon j, ishihara o, mansour r, nygren k, et al. international committee for monitoring assisted reproductive technology (icmart) and the world health organization (who) revised glossary of art terminology, 2009. fertil steril. 2009;92(5):1520–4. 2. fritz ma, speroff l. clinical gynecologic endocrinology and infertility. 8th ed. philadelphia: wolters kluwer health/ lippincott williams & wilkins; 2011. 3. nieschlag e, behre hm, nieschlag s. andrology: male reproductive health and dysfunction. 3rd ed. berlin: springer; 2010. 4. chen x, zhang w, luo y, long x, sun x. predictive value of semen parameters in in vitro fertilisation pregnancy outcome. andrologia. 2009;41(2):111–7. 5. tournaye h. male factor infertility and art. asian j androl. 2012;14(1):103–8. 6. aitken r. sperm function tests and fertility. int j androl. 2006;29(1):69–75. 7. simon l, lewis se. sperm dna damage or progressive motility: which one is the althea medical journal. 2016;3(4) 525 better predictor of fertilization in vitro?. syst biol reprod med. 2011;57(3):133–8. 8. langlois mr, oorlynck l, vandekerckhove f, criel a, bernard d, blaton v. discrepancy between sperm acrosin activity and sperm morphology: significance for fertilization in vitro. clin chim acta. 2005;351(1):121– 9. 9. wang j, sauer mv. in vitro fertilization (ivf): a review of 3 decades of clinical innovation and technological advancement. ther clin risk manag. 2006;2(4):355–64. 10. lewis se. is sperm evaluation useful in predicting human fertility? reproduction. 2007;134(1):31–40. 11. gardner dk, weissman a, howles cm, shoham z. textbook of assisted reproductive techniques. 4th ed. london: informa healthcare; 2012. 12. wiser a, ghetler y, gonen o, piura e, berkovits a, itskovich a, et al. re– evaluation of post–wash sperm is a helpful tool in the decision to perform in vitro fertilisation or intracytoplasmic sperm injection. andrologia. 2012;44(2):73–7. 13. van der westerlaken l, naaktgeboren n, verburg h, dieben s, helmerhorst fm. conventional in vitro fertilization versus intracytoplasmic sperm injection in patients with borderline semen: a randomized study using sibling oocytes. fertil steril. 2006;85(2):395–400. 14. söderlund b, lundin k. choosing fertilization method by analyzing sperm morphology or by performing swim–up preparation. acta obstet gynecol scand. 2006;85(3):306–11. 15. ghirelli–filho m, mizrahi fe, pompeo acl, glina s. influence of strict sperm morphology on the results of classic in vitro fertilization. int braz j urol. 2012;38(4):519–28. 16. keegan br, barton s, sanchez x, berkeley as, krey lc, grifo j. isolated teratozoospermia does not affect in vitro fertilization outcome and is not an indication for intracytoplasmic sperm injection. fertil steril. 2007;88(6):1583–8. praditya virza ramadhan, andri rezano, wiryawan permadi: correlation between sperm motility and morphology in the success rate of in vitro fertilization procedure althea vol 2 no 2 final.indd althea medical journal. 2015;2(2) 179 herniated nucleus pulposus in dr. hasan sadikin general hospital bandung indonesia annisa ikhsanawati,1 bambang tiksnadi,2 arifin soenggono,3 nucki nursjamsi hidajat4 1faculty of medicine universitas padjadjaran, 2, 4department of orthopaedic and traumatology, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of anatomy faculty of medicine universitas padjadjaran abstract background: herniated nucleus pulposus (hnp) is one of the most common diseases of the spine. for an optimal management and prevention, there’s a need for data on factors related to the onset of complaints because this disease lowers the quality of life and increases morbidity. this study is aimed to see the scale and pattern of the hnp in dr. hasan sadikin general hospital, bandung. methods: this is a descriptive study with the design of case series, data was obtained from medical records of patients with the diagnosis of hnp in the inpatient care of dr. hasan sadikin general hospital in the period of 2007–2011. results: according to the study on 79 patients, with 43 men and 36 women, the highest incidence was at the age group of 51–60 years old (31.6%) and most common occupation was civil servant (11.4%). the most common clinical symptoms were sciatica (51.9%) and low back pain (51.9%). most frequent location was in the lumbar vertebrae at the level of l5–s1 (58.2%). trauma was found to be the highest relatable history in the patients (39.2%). therapy of choice was primarily conservative (58.2%) and most patients went home after the progression (84.8%). the year 2007 showed the highest prevalence of hnp at 25.3%. the most common clinical symptoms were sciatica (51.9%) and low back pain (51.9%) conclusions: the most common clinical symptoms were sciatica and low back pain. most frequent location was in the lumbar vertebrae at the level l5–s1. [amj.2015;2(1):179–85] keywords: event pattern, herniated nucleus pulposus, prevalence correspondence: annisa ikhsanawati, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281323077560 email: annisa.ikhsanawati@yahoo.com introduction herniated nucleus pulposus (hnp) is an occurrence of protrusion from the nucleus pulposus through the annulus fibers of intervertebral disc.1 this disease is one of the most common causes for neural root pain in which the patient complains of low back pain.2 the prevalence of hnp is about 1–3% in finland and italia. in the us, 1–2% of the population are afflicted with hnp.3 aside from that, the incidence of hnp in some developing countries is about 15–20% of the total population. this disease mainly attacks adults in the age of 30–50 years old and peaks at 40– 45 years old.4,5 the ratio of hnp between men and women is 2:1. yet, in general populace, the incidence appears to be similarly distributed between men and women.2 women tend to complain about low back pain, and radiating pain from the hip to the leg is reported more commonly by men.5 the hnp is most commonly found in the lumbar vertebrae, and only a small percentage of it is found in the cervical region. hnp in the thoracic vertebrae is very rare and happens only in 1:1 million patients.6,7 in individuals of age between 25–55 years old, 95% of hnp occurs in the lumbar vertebrae in the l4–l5 region or l5–s1 while hnp above the l4 vertebrae happens more in individuals aged more than 55 years old.3,8 the most common symptoms of hnp is sciatica, which occurs in 40% of hnp patients.9 in about half of the hnp patients, a form of trauma causes back pain. and yet, an experimental study and statistical analysis of a case did not support the concept that direct trauma or increase of weight on the vertebrae could be the cause of disc rupture, even when the condition worsened the existing degeneration.2 risk factors of hnp include smoking, weight training, and work related althea medical journal. 2015;2(2) 180 amj june, 2015 to activity that requires multiple occurrences of heavy lifting. sedentary lifestyle, frequent driving, and chronic cough are frequently regarded as risk factors. an individual whose occupation requires more than 50% of the time being inside a vehicle (such as drivers) has higher risk to hnp.5,10 according to the information above, it was known that there had not been many studies of hnp in indonesia. the rise of incidence of the disease can lower the quality of life of a person and increase the morbidity. incidence will keep rising as the indonesian populaces are increasingly sedentary and the lack of awareness of the disease. as such, there is a need for early detection and prevention on the population at risk and for faster and more accurate therapy on those already afflicted. this study aims to further research the scale and pattern of hnp in the department of orthopaedic and traumatology of the dr. hasan sadikin general hospital in the period of 2007–2011. methods this study used a retrospective descriptive method with case serie design on patients of hnp in the department of orthopaedic surgery and traumatology in dr. hasan sadikin hospital in the period of 2007–2011. secondary data were obtained from medical record of the patients whose diagnosis were hnp in the inpatient care of. dr. hasan sadikin general hospital. data collection was done in dr. hasan sadikin general hospital starting from august to november 2012. research population was defined as all patients diagnosed with hnp. the department of orthopaedic and traumatology dr. hasan sadikin general hosptial made this diagnosis in the period of 2007–2011. inclusion criteria was every patient diagnosed with hnp and treated in the inpatient care of the department of orthopaedic and traumatology of dr. hasan sadikin general hospital during 2007–2011. while the exclusion criteria was patients with incomplete medical record data. all patients that met the inclusion criteria had their age, occupation, clinical symptoms, location of abnormality, activity and condition history, therapy, and status at the checkout list. data analysis was done using the software of microsoft excel and spss version 17.0. the data obtained from medical record were then processed and categorized into tables, and had the frequency and percentage of each characteristic calculated. result within the period of 5 years, during 2007– 2011, according to the medical record data, table 1 distribution of herniated nucleus pulposus patients according to age and gender characteristics n (79) % age mean (sd) : 50 (12,89) median (range) : 51,00(20–77) <=20 years old 1 1.3 21–30 years old 6 7.6 31–40 years old 15 19.0 41–50 years old 17 21.5 51–60 years old 25 31.6 61–70 years old 13 16.5 71–80 years old 2 2.5 gender men 43 54.4 women 36 45.6 althea medical journal. 2015;2(2) 181annisa ikhsanawati, bambang tiksnadi, arifin soenggono, nucki nursjamsi hidajat: herniated nucleus pulposus in dr. hasan sadikin general hospital, bandung indonesia 79 hnp patients were in the inpatient care of department of orthopaedic and traumatology dr. hasan sadikin general hospital (table 1). afterward, a discussion of pattern of disease according to age, gender, occupation, clinical symptoms, location of abnormality, history of activity and patient’s condition, therapy and status when checking out was required. the highest incidence was at the age group of 51–60 years old (31.6%). the median age of the patients was 51 years old, ranging from 20–77 years old. the number of men was more than that of women (54.4% to 45.6%). table 2 shows that most subjects had no record of work in their medical record with 37 individuals (46.8%). the distribution of patients with hnp was discovered that they mostly worked as a civil servant, with 9 individuals (11.4%). table 3 shows that the patients had one or more clinical symptoms. clinical symptoms most widely shown in patients were low back pain and sciatica, each by 41 individuals (51.9%) and least pain spreading to the shoulders and neck pain, each by 1 individual (1.3%). table 3 distribution of herniated nucleus pulposus patients according to clinical symptom clinical symptoms yes no n % n % brachialgia 2 2.5 77 97.5 radiating pain towards the shoulder 1 1.3 78 98.7 localized pressure pain 4 5.1 75 94.9 cervical pain 1 1.3 78 98.7 pain in lower limb 4 5.1 75 94.9 low back pain 41 51.9 38 48.1 defecation and urination disturbance 7 8.9 72 91.1 paresthesia 18 22.8 61 77.2 hipoesthesia 23 29.1 56 70.9 motoric disturbance 29 36.7 50 63.3 sciatica 41 51.9 38 48.1 table 2 distribution of herniated nucleus pulposus according to occupation occupation n % civil servant 9 11.4 professional 2 2.5 pensioner 7 8.9 housewife 8 10.1 laborer 8 10.1 employee 2 2.5 merchant 1 1.3 builder 2 2.5 private worker 3 3.8 no data 37 46.8 total 79 100.0 althea medical journal. 2015;2(2) 182 amj june, 2015 the most often hnp happened were located on the lumbar vertebrae at l5–s1 by 46 individuals (58.2%) and on the cervical vertebrae at c5–c6 by 3 individuals (3.8%). one located on the thoracic vertebrae was only 1 individual (1.3%). the number of abnormalities in the patient can be single (one location of abnormality) or multiple (more than one location of abnormality). nevertheless, the most, the patients have one-location disorders, as many as 45 people (57%). the most common history of activity and patient’s condition is trauma with 31 individuals (39.2%), followed by heavy lifting with 19 individuals (24.1%). the mostly done therapy is the conservative therapy to 26 individuals (58.2%) and the most patient’s condition when going home are improvement on 67 individuals (79.0%). discussions age is one of the most important factors in the case of hnp. according to malanga5, incidence of this case is the largest in adults of age 30–50 years old, and peaks at 40–45 years old. on the contrary, according to moskovich (2006), the prevalence of this case rises at the age of more than 50 years old in the population of the united states of america.4 table 1 showed that from 79 patients of hnp, 43 (54.4%) were men and 36 (45.6%) were female. the incidence peaked at the age group of 51–60 years old, with 25 individuals table 4 distribution of herniated nucleus pulposus patients according to location of disturbance location of disturbance yes no n % n % c3–c7 2 2.5 77 97.5 c5–c6 3 3.8 76 96.2 c5–c7 1 1.3 78 98.7 c6–c7 1 1.3 78 98.7 t8–t9 1 1.3 78 98.7 t10–t12 1 1.3 78 98.7 t11–t12 1 1.3 78 98.7 l3–l4 11 13.9 68 86.1 l4–l5 43 54.4 36 45.6 l5–s1 46 58.2 33 41.8 amount of location n % single 45 57 multiple 34 43 total 79 100,0 table 5 distribution of herniated nucleus pulposus patients according to activity history and condition activity history and condition yes no n % n % heavy lifting 19 24.1 60 75.9 trauma 31 39.2 48 60.8 chronic disease 7 8.9 72 91.1 no data 7 8.9 72 91.1 althea medical journal. 2015;2(2) 183annisa ikhsanawati, bambang tiksnadi, arifin soenggono, nucki nursjamsi hidajat: herniated nucleus pulposus in dr. hasan sadikin general hospital, bandung indonesia (31.6%). this study showed that this disease is less likely to occur at less than 30 years old of age, while that in the increasing age is in concordance with the increasing amount of hnp cases. according to wong2, this is because with increasing age, there will be a degeneration of disc and joint facets due to diminishing water content. while in the age group of less than 30 years old, the spring force resilience of the discus protects it from herniation. according to table 1, more men were afflicted than women. according to wong (2006), hnp tends to be similarly afflicting to men and women. the incidence is also known to occur more likely on workers who were exposed with heavy work such as grinding or heavy lifting. men works more in industries requiring heavy work, therefore the incidence of the case is more numerous in men.2 occupation is an important factor on the incidence of hnp. occupations that carry risk to the occurrence of this case involve heavy work that is defined as a work requiring great physical strength or energy needs. examples of these are as follows: lifting, twisting, bending, and jobs that can affect the whole body vibration. this kind of job includes workers who spend more than 50% of their work time in the car (eg driver) and workers who use the equipment and the construction industry (eg laborers).5 according to table 2, it can be seen that from most of the 79 patients, those working as civil servants are 9 individuals (11.4%). 37 individuals (46.8%) are of unknown occupation because of the incomplete medical records. therefore, the risks of the work to the case of hnp cannot deliver significant picture. this study shows that the largest employment is the civil servant. this may be linked to a person’s body ergonomic factors at work. it is expected that civil service workers observe good posture while working. however, further research needs to be done about the most influential risk factors for civil servants. according to hirsch11, hnp is one of the most common causes of nerve root pain, which causes the patient to complain of lower back pain that can be accompanied by sciatica.11 this is consistent with the research that has been done, as suggested in table 3 proving that the patients experienced one or more clinical symptoms. clinical symptoms most widely shown in patients were low back pain and ischialgia, each with 41 individuals (51.9%). hernia on the cervical vertebrae often causes pain in the neck, shoulders, and arms.12 based on literature, this disease occurs unilaterally, but it can also occur bilaterally if there is a large central herniated disc pressing some nerve roots at the same level.13 according to skinner9, the most common clinical symptoms is sciatica, occurring in 40% of patients with hnp. sciatica is a pain that is felt throughout the radicular leg and the course of nerve ischiadicus and continues to the peripherals.14 based on the writings by maheswari15, one most common symptoms of hnp is low back pain with or without sciatica. the radiation pattern depends on the root compression pain and body dermatome pattern. moreover, it can cause neurological symptoms corresponding with the dermatome of the affected nerve. in the case of a large herniated disc pressing some nerve roots, the patient will experience paralysis of the lower limbs, hypoesthesia on dermatomes l5–s4, and disturbance of urination and defecation. according to table 4, it can be seen that patients had one or more locations of abnormality. however, the most numerous table 6 distribution of herniated nucleus pulposus patients according to therapy and status at check out therapy n(79) % conservative 46 58.2 operative 33 41.8 status at check out improvement 67 84.8 cured 7 8.9 not cured 4 5.1 dead 1 1.3 althea medical journal. 2015;2(2) 184 amj june, 2015 of them, patients who had a single location, amount to 45 individuals (57%). in contrast, patients with multiple locations amount to 34 individuals (43%). from the location on the level of cervical vertebrae, the most numerous were at the level of c5–c6, which amounts to 3 individuals (3.8%). in the level of thoracic vertebrae, there was a spreading out numerosity, while in the lumbar vertebrae level, the most numerous was in the l5–s1 that amounts to 46 individuals (58.2%). but as a whole, from a total of 79 patients, the most numerous location was in the lumbar vertebrae at l5–s1 which amounts to 6 individuals (58.2%) and the second most numerous was at the level l4–l5 at 43 individuals (54.4%). this is because the lumbar vertebrae supports most of the weight force of the body compared to other vertebrae, has the highest pressure, and thinner annulus fibrous fibers in the posterior of the disc. in lumbar vertebrae, posterior longitudinal ligaments are stronger medially and laterally only contain a little fibers. lateral posterior longitudinal ligaments would be the weakest part and prone to herniation.2 this result is in accordance with the report written by jordan et al.3, that about 95% of hnp occur in lower lumbar vertebrae such as l4–l5 and l5–s1, and the incidence is smaller in the cervical region. the process of the occurrence of hnp pathology starts because of a degeneration in the nucleus pulposus. according to wong2, approximately half of the patients of hnp experiencing the back pain symptom is due to various forms of trauma. activity history and the condition that induced the symptoms of degenerative disease were obtained from the medical records of history taking of the patients. the history is like trauma, such as heavy lifting occupation, and chronic diseases such as chronic cough, prostate hypertension, and osteoporosis. according to table 5, the data showed that the most common history of activity and patient’s condition is trauma by 31 individuals (39.2%), followed by heavy lifting with 19 individuals (24.1%). in this research, the type of trauma was not known and such for a better prevention, a more complete study is needed. the standard procedure of hnp therapy can be divided into conservative and operative therapy. operative therapy is mostly done when the conservative therapy does not show a satisfying result, continuous pain, and neurological disturbance. table 6 showed that the mostly done therapy is the conservative therapy to 26 individuals (58.2%). according to the study conducted by marquardt8, 75% of the hnp case will spontaneously be cured in 6 months and only 19% requires operative intervention. according to benjamin and zieve6, the majority of hnp patients will improve without medication, but a small minority will complain of back pain even after the medication. this can take months or even years to return to normal activity without pain in the vertebrae region. according to table 6, the data showed that the status of patient when checking out is in improvement, by 67 individuals (84.4%). this improvement can be clinically assessed such as the pain, sensory disturbance, and motoric disturbance that all are receding. according to this study, it can be concluded that the case of hnp mostly afflicts individuals within the age of 51–60 years old, men, working as civil servant, and has history of trauma. the distribution in regard of age, gender, clinical symptoms and location of disturbance is similar to other studies. nevertheless, it is hoped that further research would be done using analytic study to see other factors that influence the case of hnp. other than that, it is hoped that healthcare institutions can give counseling to public about hnp so that the people can know the signs and symptoms of this disease. references 1. viere rg. elderly patients. in: cole aj, herring sa, editors. the low back pain handbook: a guide for the practicing clinician. 2nd ed. philadelphia,pa: hanley & belfus; 2003. p. 437–52. 2. wong da, transfeldt e, macnab i. macnab’s backache. 4th ed. philadelphia,pa: lippincott williams & wilkins; 2006. 3. jordan j, konstantinou k, o’dowd j. herniated lumbar disc. bmj clin evid. 2009;2009:pii–1118. 4. awad jn, moskovich r. lumbar disc herniations: surgical versus nonsurgical treatment. clinical orthop relat res. 2006;443:183–97. 5. malanga ga, nadler sf, agesen t. epidemiology. in: cole aj, herring sa, editors. the low back pain handbook: a guide for the practicing clinician. 2nd ed. philadelphia,pa: hanley & belfus; 2003. p. 1–7. 6. benjamin ma, zieve d. herniated disk. a.d.a.m. medical encyclopedia; 2011 [downloaded in 10 september 2012]; althea medical journal. 2015;2(2) 185 available at: http://www.ncbi.nlm.nih. gov/pubmedhealth/pmh0001478/. 7. deckey je. thoracic disc herniation. in: devlin vj, editor. spine secrets. philadelphia: hanley & belfus; 2003. p. 264–6. 8. marquardt ca, cole aj, herring sa, m i, stratton s. clinical presentation and diagnostic subsets. in: cole aj, herring sa, editors. the low back pain handbook: a guide for the practicing clinician. philadelphia,pa: hanley & belfus; 2003. p. 95–115. 9. skinner hb. current diagnosis & treatment in orthopedics. 4th ed. new york: lange medical books/mcgraw-hill; 2006. 10. fast a. low back pain during pregnancy. in: cole aj, herring sa, editors. the low back pain handbook: a guide for the practicing clinician. philadelphia,pa: hanley & belfus; 2003. p. 405–12. 11. hirsch ja, singh v, falco fj, benyamin rm, manchikanti l. automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence. pain physician. 2009;12(3):601–20. 12. al-sayyad ahf, ali mh, abdul-hamied emh. degenerative lumbar spine disease: assessment of changes in epidural infusion pressure and clinical outcome after epidural steroid injection. egypt rheumatol rehab. 2007;34(4):526. 13. kasper dl, braunwald e, longo d, longo dl, hauser s, fauci as, et al. harrison’s principles of internal medicine. 16th ed. new york: mcgraw-hill; 2004. 14. mardjono m, sidharta p. neurologi klinis dasar. 6th ed. jakarta: dian rakyat; 2006. 15. maheshwari j. essential orthopaedics. 3rd ed. new delhi: mehta publishers; 2005. annisa ikhsanawati, bambang tiksnadi, arifin soenggono, nucki nursjamsi hidajat: herniated nucleus pulposus in dr. hasan sadikin general hospital, bandung indonesia althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 120 amj march 2016 knowledge and intention to use personal protective equipment among health care workers to prevent tuberculosis hasanah,1 elsa pudji setiawati,2 lika apriani3 1faculty of medicine, universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of epidemiology and biostatistic faculty of medicine universitas padjadjaran abstract background: tuberculosis (tb) is one of the main world health problems. indonesia has the fourth highest incidence in the world. tuberculosis is very infectious, but it can be prevented in high risk group such as health care worker by using personal protective equipment (ppe). this study aimed to reveal knowledge and intention to use ppe among health care worker to prevent tb transmission in public health center (pusat kesehatan masyarakat, puskesmas) in bandung. methods: descriptive study was conducted from september to october 2014 in 15 puskesmas in bandung. those 15 puskesmas had been reported as having the highest incidence in tb cases. ninety seven health care workers were assessed using questionnaire. samples were obtained using purposive sampling method. data were collected and analyzed for frequency and proportion. results: among 97 health care workers, 76 (78.4%) had good knowledge, 16 (16.5%) had sufficient knowledge, and 5 (5.2%) had poor knowledge. based on intention of ppe usage among health care workers, it was found that 41.2% had positive intention and 58.8% had negative intention. conclusions: most of health care workers have good knowledge about tb transmission, however, intentions to use ppe are low. [amj.2016;3(1):120–5] keywords: intention, knowledge, personal protective equipment, tuberculosis correspondence: hasanah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285720846550 email: hasanah3711@gmail.com introduction tuberculosis (tb) is one of the diseases with high mortality rate. indonesia is ranked as the fourth country with highest cases of tb worldwide. there are 0.4–0.5 million new cases of tb in indonesia. in 2013, the prevalence of tb was 0.4%.1 tb is an infectious disease caused by mycobacterium tuberculosis. risk of tb transmission infection in indonesia every year is calculated using annual risk of tuberculosis infection (arti) and the result is 1–3%. tb infects various groups of people and health care workers are included as a high risk group. annual incidence of tb infection in health care workers is 69–5,780 in 100,000.2 tb is an occupational hazard among health care workers. several efforts have been initiated to reduce tb transmission in health care facilities, such as administration control, environmental control, and use of personal protection equiment (ppe). use of ppe is influenced by predisposing factors, such as knowledge, enabling factors, reinforcing factors, and intention is the best predictor of a behavior.3 considering ppe usage is important for health care workers, this study aimed to reveal knowledge and intention to use ppe among health care workers to prevent tb transmission in public health center (pusat kesehatan masyarakat, puskesmas) in bandung. methods this was a descriptive study. purposive sampling was conducted to select research subjects. based on sample size calculation, minimum sample of 97 subjects were required. among 73 puskesmas in bandung city, 15 centers with highest incidence of tb cases were selected as research population. althea medical journal. 2016;3(1) 121 puskesmas workers such as doctors, nurses, and laboratory workers were involved in this study. this study was approved by health research ethics committee faculty of medicine universitas padjadjaran. the permission to conduct research was also given by local government and bandung district health office. data collection using validated questionnaire was conducted from september to october 2014. questionnaire was given to health care workers who had agreed to participate in this study. besides, verbal and written informed consents were given. the questionnaires assessed knowledge and intention. knowledge questionnaire consisted of 10 questions regarding tb transmission, including transmission media, modes, control, and high risk groups in puskesmas. intention questionnaire consisted of 17 questions about the intention to use ppe, such as mask and gloves, and the responds were recorded using likert scale (5, strongly agree; 4, agree; 3, neutral; 2, disagree; 1, strongly disagree).4-7 data were collected and analyzed for frequency and proportion. knowledge was grouped into 3 categories based on accumulated score percentage (good, 76– 100%; sufficient, 56–75%; poor, ≤55%), while intention was classified as positive and negative. results total respondents from appointed puskesmas were 154. only 97 subjects qualified according inclusion criteria who participated in this study. these numbers were appropriate to minimum sample size required. most of health care workers were female. age range of health care workers were 22–55 years old. most of health care workers were 31–40 years old and the least subjects were table 1 subjects’ characteristics subject numbers of p a r t i c i p a t i n g health care workers (%) sex male 21 (21.6) female 76 (78.4) age, year <31 27 (27.8) 31–40 31 (32.0) 41–50 26 (26.8) >50 13 (13.4) public health center babatan 5 (5.2) caringin 6 (6.2) cetarip 6 (6.2) cibuntu 5 (5.2) cijagra lama 6 (6.2) cijerah 5 (5.2) garuda 11 (11.3) kopo 6 (6.2) kujangsari 3 (3.1) moch. ramdan 5 (3.1) padasuka 7 (7.2) puter 16 (16.5) sukajadi 5 (5.2) talagabodas 6 (6.2) tamblong 5 (5.2) highest level of education senior high school 13 (13.4) diploma 39 (40.2) bachelor’s degree 17 (17.5) medical doctor 27 (27.8) master’s 1 (1.0) length of employment, years <1 9 (9.3) 1–5 26 (26.8) 6–10 13 (13.4) 11–15 11 (11.3) 16–20 5 (5.2) 21–25 17 (17.5) >25 16 (16.5) occupation physician 29 (29.9) nurse 57 (58.8) laboratory assistant 11 (11.3) tb history yes 7 (7.2) no 90 (92.8) tb history on contacted or lived with family members yes 7 (7.2) no 90 (92.8) hasanah, elsa pudji setiawati, lika apriani: knowledge and intention to use personal protective equipment among health care workers to prevent tuberculosis althea medical journal. 2016;3(1) 122 amj march 2016 care workers varied from senior high school until master’s degree. most of them were diploma 1 and diploma 3. based on length of employment, there were health care workers that had been working for 7 months. on the contrary, there were health care workers that had been working for 33 years. in this study, most of them had been working for 1–5 years and the least subjects had been working for 16–20 years. the doctors, nurses, and laboratory figure 1 proportion of participants based on knowledge over than 50 years old (table 1). most of health care workers were from puskesmas puter followed by puskesmas garuda, and the least subjects were from puskesmas kujangsari. numbers of subjects from each puskesmas were affected by the presence of doctors or nurses who were doing internship program and the event of bulan imunisasi anak sekolah (bias) program in puskesmas during data collection. highest level of education among health figure 2 proportion of participants based on intention althea medical journal. 2016;3(1) 123hasanah, elsa pudji setiawati, lika apriani: knowledge and intention to use personal protective equipment among health care workers to prevent tuberculosis table 2 cross tabulation participant characteristic, knowledge and intention number of participating health care workers (%) knowledge intention good sufficient poor positive negative highest level of education senior high school 9 (69.2) 4 (30.8) 0 (0) 5 (38.5) 8 (61.5) diploma 32 (82.1) 5 (12.8) 2 (5.1) 19 (48.7) 20 (51.3) bachelor’s degree 11 (64.7) 3 (17.6) 3 (17.6) 5 (29.4) 12 (70.6) medical doctor 23 (85.2) 4 (14.8) 0 (0) 11 (40.7) 16 (59.3) master’s 1 (100.0) 0 (0) 0 (0) 0 (0) 1 (100.0) length of employment, yr <1 7 (77.8) 1 (11.1) 1 (11.1) 3 (33.3) 6 (66.7) 1-5 22 (84.6) 3 (11.5) 1 (3.8) 11 (42.3) 15 (57.7) 6-10 9 (69.2) 4 (30.8) 0 (0) 6 (46.2) 7 (53.8) 11-15 9 (81.8) 2 (18.2) 0 (0) 5 (45.5) 6 (54.5) 16-20 3 (60.0) 2 (40.0) 0 (0) 1 (20.0) 4 (80.0) 21-25 13 (76.5) 3 (17.6) 1 (5.9) 7 (41.2) 10 (58.8) >25 13 (81.3) 1 (6.3) 2 (12.5) 7 (43.8) 9 (56.3) occupation physician 25 (86.2) 4 (13.8) 0 (0) 12 (41.4) 17 (58.6) nurse 46 (80.7) 6 (10.5) 5 (8.8) 22 (38.6) 35 (61.4) laboratory assistant 5 (45.5) 6 (54.5) 0 (0) 6 (54.5) 5 (45.5) tb history yes 6 (85.7) 1 (14.3) 0 (0) 4 (57.1) 3 (42.9) no 70 (77.8) 15 (16.7) 5 (5.6) 36 (40.0 ) 54 (60.0) tb history on contacted or lived with family members yes 6 (85.7) 1 (14.3) 0 (0) 5 (71.4) 2 (28.6) no 70 (77.8) 15 (16.7) 5 (5.6) 35 (38.9) 55 (61.1) workers were included in this study because they worked in clinic in which their interactions with tb patients might increase the risk of acquiring infection. most of subjects (58.8%) were nurses, followed by doctors (29.9%), and laboratory workers (11.3%) (table 1). according to tb history among health care workers, 7.2% had tb infection previously. similar to tb history among health care workers, 7.2% contacted or lived with family members who had been infected with tb previously. this number was similar but it happened to different subject. there were 76 subjects (78.4%) had good knowledge, 16 subjects (16.5%) had sufficient knowlege, and 5 subjects (5.2%) had poor knowledge (figure 1). based on intention, 57 subjects (58.8%) were classified as having negative intention and 40 subjects (41.2%) were classified as having positive intention to use ppe (figure 2). after stratification based on highest level of education, 32 subjects with good knowledge had diploma degree but proportionally most of subjects who had good knowledge were medical doctors and had master’s degree. these findings indicated that good knowledge was related to education level. in each education level, more than half subjects had negative intention (table 2). based on employment, most subjects (46 nurses) had good knowledge, followed by doctors and laboratory workers. proportion of doctors with good knowledge washigher althea medical journal. 2016;3(1) 124 amj march 2016 compared with nurses and laboratory workers. according to length of employment, most of subjects with positive intention to use ppe had been working for 1–5 years, followed by subjects who had been working for 21–25 years and more than 25 years. based on occupation, most of subjects with positive intention to use ppe were nurses. in proportion, laboratory assistants, whose proportion of positive intention to use ppe was more than fifty percents, had highest proportion compared to nurses and doctors. table 3 showed among subjects with positive intention to use ppe, 29, 9, and 8 subjects had good, sufficient, and poor knowledge, respectively. among subjects with negative intention to use ppe, 47, 8, and 2 subjects had good, sufficient, and poor knowledge, respectively. many subjects who had good knowledge regarding tb transmission, in contrast did not have positive intention to use ppe. discussion tb is transmitted via inhalation of respiratory droplet in which high amounts of bacteria are contained. the droplet is spread when active tb patients are coughing, sneezing, talking, or spitting. use of ppe in high risk group is one of tb prevention methods. in this study, females were the most subjects participating. similar result to 88% female subjects was found in study about perception of health care worker regarding the use of ppe conducted by gralton et al.8 based on employment, doctors have a higher proportion of good knowledge compared to nurses and laboratory workers. significant differences in level of knowledge based on employment were also found in study conducted by woith et al.9 most of subjects had good knowledge regarding transmission of tb, including transmission media, modes, control, and high risk groups in puskesmas. similar results were found in study conducted by hashim et al.10 which stated that 98.4% health care workers have good knowledge. level of knowledge is influenced by education level, age, and length of employment. national tb training or health promotion program may also modify level of knowledge.10 knowledge may be reached by a person through experience of an object using special senses. knowledge or cognition influences a person’s behavior. good knowledge about tb transmission will determine someone’s behavior in attempt to prevent the disease. a person with a good knowledge about tb transmission should have better prevention action compared to a person with poor knowledge. the results from intention questionnaire stated that 41.2% subjects have positive intention, while 58.8% have negative intention. these suggested that majority of health care workers do not have self awareness to use ppe, like masks or hand gloves, to prevent tb transmission in puskesmas in where they work. previous study with similar findings showed that health care workers’ intention to wear mask during contact with patients are low.8 this may be related to application of prophylaxis or vaccination before contacts with patients. there is also ethical consideration regarding the use of mask. some doctors believe that wearing a mask may disrupt doctor-patient relationship and communication. other study stated that intention to vaccination as an attempt to prevent infection is also low.11 specific study about the use of ppe by health care workers to prevent tb have not been conducted previously. according to planned behavior theory and reasoned action theory, negative intention is associated with negative behavior because intention is a best predictor of behavior. an action of wearing ppe was the behavior considered in this study. by using this approach, it was assumed that in this study, the action of wearing ppe was low in health care workers. in conclusion, majority of subjects have good knowledge regarding tb transmission. however, this knowledge was not followed with positive intention. limitation of table 3 cross tabulation knowledge and intention number of participating health care workers (%) total positive negative good 29 (38.2) 47 (61.8) 76 sufficient 8 (50.0) 8 (50.0) 16 poor 3 (60.0) 2 (40.0) 5 althea medical journal. 2016;3(1) 125 this study is that this study cannot explain the relation between the variables. health care workers should protect themselves when they have contacts with tb patients. one of the protection methods is by using ppe. although the knowledge about tb transmission is good, in contrast the intention to wear ppe is poor. it is recommended to conduct health promotion program about tb transmission for all workers, not limited only for health care workers in puskesmas facilities. district health office needs to provide adequate and satisfactory ppes to prevent tb. provision of ppes might improve the willingness to wear them. further study to determine the reasons health care workers, despite having a good knowledge, do not have a positive intention to use ppe needs to be done. a qualitative study is recommended to explore the causes. references 1. who. global tuberculosis report. geneva: who. 2013. 2. joshi r, reingold al, menzies d, pai m. tuberculosis among health-care workers in low-and middle-income countries: a systematic review. plos medicine. 2006;3(12):2376–91. 3. glanz k, rimer bk, viswanath k, editors health behavior and health education: theory, research, and practice. in:, editors.. 4th ed. san fransisco:jossey bass; 2008. 4. bryce ea, scharf s, walker m, walsh a. the infection control audit: the standardized audit as a tool for change. am j infect control. 2007;35(4):271–83. 5. mphahlele mt, tudor c, van der walt m, farley j. an infection control audit in 10 primary health-care facilities in the western cape province of south africa. int j infect control. 2012;8(3):1–5. 6. baig as, knapp c, eagan ae, junior ljr, gainesville, florida. health care workers’ views about respirator use and features that should be included in the next generation of respirators. am j infect control. 2010;38:18–25. 7. pratt rj, pellowe c, wilson j, loveday h, harper p, jones s, et al. epic2: national evidence-based guidelines for preventing healthcare-associated infections in nhs hospitals in england. j hosp infect. 2007;65:s1–s59. 8. gralton j, rawlinson wd, mclaws m-l. health care workers’ perceptions predicts uptake of personal protective equipment. am j infect control. 2013;41(1):2–7. 9. woith wm, volchenkov g, larson jl. russian healthcare workers’ knowledge of tuberculosis and infection control. int j tuberc lung dis. 2010;14(11):1489-92. 10. hashim ds, al kubaisy w, al dulayme a. knowledge, attitude and practises survey among health care workers and tuberculosis patients in iraq. east mediterr health j. 2003;9:718–30. 11. maltezou hc, dedoukou x, patrinos s, maragos a, poufta s. determinants of intention to get vaccinated against novel (pandemic) influenza a h1n1 among health-care workers in a nationwide survey. j infect. 2010;61:252–8. hasanah, elsa pudji setiawati, lika apriani: knowledge and intention to use personal protective equipment among health care workers to prevent tuberculosis althea medical journal. 2016;3(2) 190 amj june 2016 vegetables contamination by parasitic helminth eggs in malaysia and indonesia reashnaa loganathan,1 ridad agoes,2 insi farisa desy arya3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of public health, faculty of medicine, universitas padjadjaran abstract background: soil-transmitted helminth infection is known to be a serious issue in south east asia when the farmers use night soil and contaminated water for their plants. in indonesia, some of the farmers still use human feces and sometimes also mixed it with urine from the latrines as fertilizers. on the contrary, in malaysia these contamination occured at a lower rate due to strict rules by the authorities.the objective of this study was to identify the helminth eggs in vegetables from traditional markets in indonesia and malaysia. methods: three traditional markets were selected by non-random sampling, namely pasar ampang in malaysia and 2 traditional markets in indonesia, i.e pasar tanjungsari and jatinangor. cabbages and lettuce were bought from 15 different vegetable sellers per market. the samples were examined at the laboratory of the medical faculty, universitas padjadjaran. the method to obtain the specimen was in accordance with khairul anwar and ramachandran. this study was carried out from july to october 2014. the collected data was analyzed by percentage and frequency tabulation. result: most of the samples are contaminated by helminth eggs. in pasar ampang, 13.3% in cabbage and 6.7% in lettuce. in pasar tanjung sari, 46.7% in cabbage and 40% in lettuce. moreover, in pasar jatinangor, 33.3% in cabbage and 26.7% in lettuce. most of the helmint eggs were ascaris lumbricoides. conclusions: the helminthes eggs contamination is higher in indonesian traditional markets compared to in malaysia. [amj.2016;3(2):190–4] keywords: ascaris lumbricoides, brasicca oleracea (cabbage), contamination, lactuca sativa (lettuce), traditional markets correspondence: reashnaa loganathan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6283820568730 email: reash1992@hotmail.com introduction soil transmitted infection is known to be very common by consuming food, especially fruits or vegetables that has not been properly washed. contaminated vegetables play a major role in the transmission of helminths. this is due to the usage of sewage water for watering the plants by the farmers and natural fertilizers.1 different farmers have different ways of cultivating plants. some farmers use natural fertilizers like animal feces however, some others use synthetic fertilizers. the vegetables prone to the usage of natural fertilizers are more likely to be contaminated.2 furthermore, the vegetables vendors in some indonesian markets claimed that the farmers from whom they bought the vegetables , used human feces and sometimes also mixed them with urine from the latrines as fertilizers.3 these farmers did not have enough money to buy chemical fertilizers. on the contrary, in malaysia these contamination occured at a lower rate due to strict rules by the authorities.4 these fecal materials are the object of parasitic eggs contamination such as ascaris lumbricoides, trichuris trichura, necator americanus ancylostoma duodenale and others.2 when these eggs are left for a period of time, the eggs will mature and reach its infective stages which may cause helminth infection.5,6 the objective of this study was to identify the helminth eggs contamination in vegetables bought in traditional markets in indonesia and malaysia. methods three respective traditional markets were selected using the non-random sampling, althea medical journal. 2016;3(2) 191 namely pasar ampang in malaysia and 2 traditional markets in indonesia, i.e pasar tanjungsari and jatinangor. then, cabbages and lettuce were bought from these three respective markets, consisting of 50 grams of each vegetable from 15 different vegetable vendors. the locations of vegetable planting were traced by the vendors. the samples bought in pasar ampang, malaysia were packed with zip lock bags then sealed with a plastic bag. they were then kept in the refrigerator and examined two days later. the samples from the other two markets were immediately brought to the laboratory of the faculty of medicine, universitas padjadjaran to be examined. they were kept in a large basin and chopped into small pieces then washed with 500 ml of 0.95% normal saline. the water used to wash the vegetables was collected in beakers. next, the water in both beakers were mixed and kept aside for 20 minutes to allow sedimentation. then, the top layer of the water was discarded and the suspension was kept. it was used to fill up 15 centrifuge tubes for each vegetable and centrifugation was performed. it was centrifuged at 2,000 rpm for 5 minutes. subsequently, the supernatant was discarded and the residue was used for microscopic examination. a drop of the residue was placed on a slide with a glass cover. microscopic examination was then carried out. the samples had been inspected qualitatively to identify if the samples observed have given a positive or negative result.7 this study was carried out from july to october 2014. ethical clearance was given for this study. the method used in this study was similar to the method prescribed by anwar and ramachandran in their previous study.7 results prior to the purchase of vegetables, the author personally interviewed the vegetable vendors in all three markets. the vegetables sold in tanjung sari market were grown by the farmers themselves. when enquired about how they kept the vegetables fresh, the farmers claimed that they used ditch -water. this ditch was flowing in the market itself and was connected to almost all the stalls in the market. thus, there was a possibility that every stall in the market disposed rubbish and waste material in the ditch throughout the buying and selling process in the market. the water flowing in the ditch also came from the nearby housing area. the farmers argued that they only used the water when it looked clear. they also claimed that there was not a common tap for the use of everyone. although there was a tap at the main entrance, it was time consuming to collect water with a pail and walk up to their stall. some of the vegetable vendors in pasar jatinangor mentioned that they used well -water to wash the vegetables at home before selling them in the market. however, when in the market, they still used ditchwater to keep the vegetables fresh. some of them still used ditch water throughout the whole process. one vegetable vendor mentioned that he used tap water since his stall was near the tap in front of the market. in pasar ampang, every vegetable stall where the samples were bought had their own tap. this was one of the steps taken by the dewan bandaraya kuala lumpur of the state government of wilayah persekutuan state. they play an important role in maintaining cleanliness in the market. a few workers were in charge of cleaning the markets every day after they were close, and for this service each stall will have to pay a particular sum of money at the end of each month. based on the results of this study, it can be deduced that from the respective selected traditional markets, all of thevegetables were contaminated by helminth eggs. moreover, the cabbage (brasicca oleracea) had a higher contamination of soil -transmitted helminths compared to the lettuce (lactuca sativa). the different species of soil -transmitted helminths eggs which had been found: in cabbage and lettuce were brasicca oleracea, ascaris lumbricoides, hookworm, trichuris trichura and other (in cabbage), and brasicca oleracea, ascaris lumbricoides, trichuris table 1 percentage of contamination of helminth eggs in 15 samples of cabbage (brasicca oleracea) and lettuce (lactuca sativa) type of vegetables pasar ampang pasar tanjung sari pasar jatinangor cabbage (brasicca oleracea) 13.3% 46.7% 33.3% lettuce (lactuca sativa) 6.7% 40% 26.7% reashnaa loganathan, ridad agoes, insi farisa desy arya: vegetables contamination by parasitic helminth eggs in malaysia and indonesia althea medical journal. 2016;3(2) 192 amj june 2016 trichura and other (in lettuce) (table 2, 3). the most helminths eggs detected were ascaris lumbricoides, followed by trichuris trichiura and hookworm (table 2). discussion although malaysia is a developing country, soil -transmitted helminth infections still exist. this can be deduced based on the study conducted by anwar and ramachandran,7 which identified the prevalence of soil -transmitted helminths among lettuce leaves sold in local markets in penang, malaysia. the study has been carried out in 12 different markets in penang, malaysia. all of these markets showed a high contamination with ascaris lumbricoides. however, there were also contamination with hook worms, trichuris trichura and other species of soil -transmitted helminths. the similarity to this study was the high number of contamination with ascaris lumbricoides which was detected in both kinds of vegetables. another study was carried out in barru, sulawesi, indonesia to identify the intestinal helminth infections. this study showed that people were highly infected with trichuris trichuria8 and ascariasis lumbricoides. infection reduces with people who are highly educated, and the farmers were people who were not educated properly. hence, they were unaware of the infection which can be caused by night soil.9 in pasar ampang, helminth eggs contamination was low compared to the 2 traditional market in indonesia. this is probably due to the strict action of the dewan bandaraya state government in keeping the markets clean during and after the operational hours. the presence of a tap in each stall enhances the cleanliness of the vegetables as it can be washed more often with a clean source of water. however, there is still a slight contamination due to the carelessness of the stall keeper in not cleaning the vegetables thoroughly under the running water as the vegetables are washed in bulk and not one by one. therefore, there is a possibility that the eggs do not fall off the vegetables. moreover, the district health department plays an important role in checking on the fertilizers used for cultivating the vegetables in malaysia. the results show that not all farmers are competent in using fertilizers free of fecal material throughout the whole process. the watering system of plants in the whole of malaysia is controlled by indah water. this company is responsible in only providing water that has gone through the processes in the water plant to produce clean water for consumption. the farmers have been given a subsidy so that they can use it to water their plants at a lower price. the government of malaysia has taken many steps to increase the cleanliness level of the vegetables sold in the market and to reduce the parasitic helminth infection. however, there were some black dots which caused the continuous presence of infection with parasitic helminths. based on the study of anuar and salleh the two main risk factors found to be associated with hookworm infection was consuming raw vegetables and eating contaminated fresh food. infections with ascaris lumbricoides and table 2 distribution of soil -transmitted helminths eggs in cabbage (brasicca oleracea) and lettuce (lactuca sativa) species pasar ampang pasar tanjung sari pasar jatinangor cabbage (brasicca oleracea) ascaris lumbricoides 2 4 5 hookworm 1 trichuris trichiura 1 others 1 lettuce (lactuca sativa) ascaris lumbricoides 1 5 3 hookworm trichuris trichiura 1 others 1 althea medical journal. 2016;3(2) 193 trichuris trichura are age dependent and the infections are mostly seen in communitiesaged lesser than 15 years old, belonging to a large household members and of low socioeconomic background.10 furthermore, the vegetables sold in both markets in indonesia, pasar tanjung sari and pasar jatinangor, showed a higher contamination of parasitic helminths eggs compared to pasar ampang. when comparing both pasar tanjung sari and pasar jatinangor, pasar tanjung sari showed a higher number of positive results. pasar tanjung sari is known to be one of the biggest markets in sumedang area. the presences of only one tap at the entrance of the market hascaused more farmers to use the ditch water to keep the vegetables fresh. the ditch water may contain fecal material which will increase the contamination with the soil -transmitted parasitic helminth. on the other hand, pasar jatinangor is a smaller market compared to pasar tanjung sari. here, the distance from the main tap at the entrance is not too far. therefore, more farmers from pasar jatinangor use clean water from the tap to keep the vegetables fresh. only those who have their stalls at a further distance from the main tap may use ditch water. thus, this might explain why pasar tanjung sari had a higher contamination with soil -transmitted parasitic helminthes compared to pasar jatinangor. some of the vendors in pasar jatinangor claimed that they purchased their vegetables in pasar tanjung sari. however, these vegetables were washed again before being sold in pasar jatinangor. most of the vendors used the existing tap water for washing the already contaminated vegetables. although the vegetables were washed and cleaned again, they have a lesser number of positive results. the vendors claimed that the officials from the health ministry occasionally carried out their rounds. this enabled the farmers to use human excreta and other animal excretes as manure for their plants since this was the cheapest and most convenient way to obtain fertilizers. the farmers also came from low socioeconomic background, so that, they could not afford to buy expensive fertilizers. to water the plants they used water from the river which was also dirty. the vendors claimed that the river water was known to be clean since it originated from the hills. however they failed to understand that many people uses the river water for domestic purposes. people use it for cleaning, washing and people also openly defecate in the river. this causes the water to be highly contaminated. in this study, the limitation is the difficulty in identifying of the eggs since the ascaris lumbricoides eggs looked similar to the dicrocoelium dendriticum eggs at a glance. it can be concluded that soil -transmitted helminths exist in both vegetables. the cabbage is more contaminated with soil -transmitted helminths than the lettuce. ascaris lumbricoides, trichuris trichura, hookworms and others have been found in the samples. references 1. al-megrin wai. prevalence of intestinal parasites in leafy vegetables in riyadh, saudi arabia. int j trop med. 2010;5(2):20– 3. 2. daryani a, ettehad g, sharif m, ghorbani l, ziaei h. prevalence of intestinal parasites in vegetables consumed in ardabil, iran. food control. 2008;19(8):790–4. 3. abougrain ak, nahaisi mh, madi ns, saied mm, ghenghesh ks. parasitological contamination in salad vegetables in tripoli-libya. food control. 2010;21(5):760–2. 4. zeehaida m, zairi n, rahmah n, maimunah a, madihah b. strongyloides stercoralis in common vegetables and herbs in kota bharu, kelantan, malaysia. trop biomed. 2011;28(1):188–93. 5. mennan s, handoo za. plant-parasitic nematodes associated with cabbages (brassica oleracea) in samsun (middle black sea region), turkey. nematropica. 2006;36(1):99–106. 6. donkur k, lundberg s. trichuris trichiura (whipworm) infection (trichuriasis). new york: medscape; 2011. [cited: 2014 february 11] available from: h t t p : / / e m e d i c i n e . m e d s c a p e . c o m / article/788570-overview. 7. anuar ak, ramachandran cp. a study on prevalence of soil transmitted helminths among lettuce leaves sold in local markets in penang, malaysia. med j malaysia. 1977;31(4):262–5. 8. haburchak dr, dhawan vk, watson cm. hookworms disease. 2011 [cited 2014 february 11]. available from: h t t p : / / e m e d i c i n e . m e d s c a p e . c o m / article/218805-overview. 9. toma a, miyagi i, kamimura k, tokuyama y, hasegawa h, selomo m, et al. questionnaire survey and prevalence of intestinal helminthic infections in barru, sulawesi, indonesia. southeast asian j trop med reashnaa loganathan, ridad agoes, insi farisa desy arya: vegetables contamination by parasitic helminth eggs in malaysia and indonesia althea medical journal. 2016;3(2) 194 amj june 2016 public health. 1999;30(1):68–77. 10. anuar ts, salleh fm, moktar n. soiltransmitted helminth infections and associated risk factors in three orang asli tribes in peninsular malaysia. scientific reports. 2014;4(4101):1–7 vol 4 no 3 full text.indd althea medical journal. 2017;4(3) 335 quality of life in children with atopic dermatitis muhammad akbar wicaksana,1 oki suwarsa,2 fenny dwiyatnaningrum3 1faculty of medicine universitas padjadjaran, 2department of dermatology and venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, indonesi, 3department of anatomy, physiology and biology cell faculty of medicine universitas padjadjaran abstract background: atopic dermatitis (ad) is the most common chronic skin disease in children which caused significant morbidity and impaired quality of life (qol). the main goal of ad therapy is to prevent flare -ups, prolong remission and increase qol. therefore, the study aimed to discover qol in children with ad. methods: the study was conducted at pasundan public health centre, al islam general hospital and kimia farma private dermatology clinic, from september to november 2015. this descriptive study used consecutive sampling with 24 outpatients who were admitted to the health facility and diagnosed as ad. a questionnaire on infant dermatitis quality of life for infants aged 0–4 years, and children dermatology life quality index for children aged 5–16 years was used in this study to measure qol. results: out of 24 patients, 9 patients aged 0–4 years had mean score of 4.44±4.36, and 15 patients aged 5–16 years had mean score of 5.80±3.95. mean scorad objective in patients aged 0–4 and 5–16 was 15.61±7.75 and 17.44±11. conclusions: the qol in children with ad vary among patients. most of the patients have mild-moderate impairment in qol. keywords: atopic dermatitis, children, infant, quality of life correspondence: muhammad akbar wicaksana, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: wicaksanakbar@gmail.com introduction atopic dermatitis (ad) prevalence in indonesia reached 23.67%, thus making ad the most common skin disease in children.1 atopic dermatitis in children occurred 65% before patients reached the age of 18 months and only 60% had resolution in adulthood.2 atopic dermatitis is a chronic relapsing disease which may cause redness, itch, stinging sensation that makes major impairment in quality of life (qol).3 quality of life is a concept that includes a person subjective well-being of their life.4 quality of life in patients can be assessed by the family and/or themselves and can evaluate aspects such as emotional, social, work / role related sign and symptoms, and medication.5 the main goals of ad therapy are to prevent flares, reduce severity and to improve patients qol. it is important for clinicians to measure the qol for evaluating the therapy of the patients.6 therefore, this study aimed to evaluate the qol in ad patients. methods this study was conducted in bandung, west java, indonesia. this descriptive study was carried out from september to november 2015 at pasundan public health center, al islam general hospital, and kimia farma private dermatology clinic. consecutive sampling was performed with participants who had been diagnosed atopic dermatitis with hanifin and rajka criteria. the minimum sample size was calculated with proportion sampling formula with 90% confidence interval and 15% precision. questionnaires to measure infant dermatitis quality of life (idqol) and children dermatology life quality index (cdlqi) cartoon version in bahasa indonesia were used to determine the qol in infants (0-4 years old) and children (5-16 years old) respectively. both questionnaires have a minimum score of 0 and maximum score of 30, each question in the questionnaire has 0 points at the minimum and 3 points at the amj. 2017;4(3):335–9 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.652 althea medical journal. 2017;4(3) 336 amj september 2017 maximum. prior to using the questionnaire, 8 patients were selected for each questionnaire for validity and reliability testing. the validity test result of both questionnaires used the spearman test. while, the reliability test used chronbach’s alpha value for cdlqi cartoon version and idqol in bahasa indonesia, the result was 0.749 and 0.759 respectively. therefore, the questionnaires were reliable. furthermore, self-admission or interview was conducted for the qol in patients. all procedures performed in the study were approved by the health research ethics committee, faculty of medicine, universitas padjajaran. this study used questionnaires to evaluate the degree of impairment from the disease to qol. in idqol, parents were asked about dermatitis severity and the child’s daily activities that had been impaired due to ad such as itch, mood, sleep, playing, mealtime, bath time and medication. in cdlqi the child was asked about activities that had been impaired by ad such as itch, feelings, friendship, playing, hobbies and exercise, studying, bath time, and medication. every patient was examined for objective scorad using the etfad form to determine the severity of ad.7 the inclusion criteria for this study were children aged 0–16 diagnosed with ad and willing to fill in the questionnaire or to be interviewed which was shown by signing informed consent by parents. the exclusion criteria in this study were children that had secondary infection or had other difficulties to be interviewed. the study was divided into age group, previous medication, gender, scorad objective, and admission place. after the study, all the participants were treated with emollients and corticosteroids depending on the severity of the disease. results the samples in this study were 24 patients. furthermore, ad severity score mean value for children aged less than 5 years and children aged 5–16 year was 15.61±7.75 and 17.44±11.09 respectively (table 1). the total mean of cdlqi was 5.80±3.95. there was slightly different in gender (male vs female, 6.33±2.09 vs 5.44±1.08), significant different in patient’s previous medication (had medication vs had not 6.73±1.28 vs 3.25±0.47) and slightly different in location (primary care vs private clinic, 5.88±1.67 vs 6.40±1.63). the hospital category was omitted because only 2 persons were recorded. there was no significant different in disease severity (mild vs moderate, 5.00±1.15 vs 5.13±1.09). severe table 1 subject characteristics, number, and scorad scores parameter total infant (0–4) children (5–16 ) number of patients 24 9 15 gender male 11 5 6 female 13 4 9 age (yr) (mean±sd) 6.67±4.54 1.91±1.59 9.53±3.02 number of patients per place primary care 12 7 5 hospital 2 0 2 private clinic 10 2 8 number of patients per follow up follow up patients 16 5 11 new patients 8 4 4 number of patients per scorad mild 11 5 6 moderate 12 4 8 severe 1 1 althea medical journal. 2017;4(3) 337muhammad akbar wicaksana, oki suwarsa, fenny dwiyatnaningrum: quality of life in children with atopic dermatitis categories were omitted because only 1 person was recorded. the minimum and maximum score of cdlqi were 2 and 16 respectively. the items in cdlqi with the highest score were itch 1.6±0.63, and problem with sleep 1.2±1.01, the lowest score were medication 0.07±0.25, and calling names, bullying 0.07±0.25 (table 2). the total mean of idqol score was 4.44±4.36. there was slightly different in gender (male vs female, 4.00±2.28 vs 5.00±1.95), slight different in patients previous medication (had medication vs hadnot 4.60±2.08 vs 3.25±2.32) and significant different in location (primary care vs private clinic, 5.57±1.63 vs 0.50±0.5). there were also significant different between disease severities (mild vs moderate, 2.20±1.11 vs 7.25±2.42). furthermore, minimum and maximum score of idqol were 0 and 12 respectively. the items in idqol highest score were itch 1.78±1.20, bath time and mood both of them scored 0.67±0.86 and the lowest score was mealtime which is 0 (table 3). discussion this study discovered that the mean score of cdlqi was 5.8±3.95, classified as mild impairment quality of life for children aged 4–16 years. this study was slightly different from previous comparable studies, which reported the score of cdlqi by kim et al.8 (mean 6.6±6.3), gånemo et al.9 (mean 7.1). this study reported lower mean score on clothing, table 2 children dermatology life quality index minimum, maximum, mean and standard deviation each component of quality of life scores point described min–max mean±sd itch, stinging 1–3 1.6±0.63 mood 0–2 0.4±0.73 friendship 0–1 0.2±0.41 clothing 0–1 0.2±0.41 hobby 0–1 0.47±0.51 exercising / swimming 0–3 0.73±0.96 school / holidays 0–2 0.87±0.83 bullying / calling names 0–1 0.07±0.25 sleep 0–3 1.2±1.01 medication 0–1 0.07±0.25 table 3 infant dermatitis quality of life minimum, maximum, mean and standard deviation each component of quality of life scores point described min–max mean±sd itch, scratch 0–3 1.78±1.20 mood 0–2 0.67±0.86 time need to sleep 0–2 0.22±0.67 sleep disturbance 0–1 0.22±0.44 playing, swimming 0–1 0.22±0.44 family activity 0–2 0.33±0.70 meal time 0–0 .00 medication 0–1 0.11±0.33 clothing 0–1 0.22±0.44 bath time 0–2 0.67±0.86 althea medical journal. 2017;4(3) 338 amj september 2017 leisure, hobby, bullying and medication than in previous studies, compared to other questions with almost the same mean score. itch and scratch also have the highest score in the other studies, making scratch the most impairing aspect in qol. moreover, this study discovered that mild and moderate ad did not have significant differences. this study agrees with the previous study that there are no correlation in qol and severity indexes.10 in another study, hon et al. state that moderate-severe ad is less sensitive in showing correlation to qol than mild-moderate ad.11 this study finds out idqol score was 4.44±4.36. several studies reported higher score, such as alvarenga et al.12 (mean 9.2), kim et al. (mean 7.6)8 and beattie et al.13 (median 8). this study reported lower points on almost every question except the itch. itch also have the highest score in other studies, making scratch the most impairing aspect in qol. moreover, in infants aged 0–4 years, most impairment occurred in itch and bath time, parents were also asked about the soap product for their children at bath time, 2 parents used non-soap cleanser, which may cause dryness of the skin, and thus recommendation for ad patients is to use non-soap cleanser.14 this study was also related to a previous study which reports that atopic eczema also impaired not only on physical but also on physiological treatment such as support from families, educational for long term management and chronic nature of the disease.13,15 however, this study on quality of life in ad patients faced major limitations. first, limitation on the time of study. second, the patients are selected at the dermatology division in hospital;in indonesia hospitals cannot be accessed without the referral from a lower health care facility, while private clinics can only be accessed by the moderatehigh socioeconomic status, this caused very low subjects were gathered. third, most of the patients have mild-moderate severity, thus people who have severe disease are not evaluated. further studies with larger number of subjects and correlation between severity indexes may provide more information. in conclusion, quality of life in children is ad mildly-moderately impaired. this study corresponds with previous studies which have discovered that ad has an impact on patients qol even though slightly lower. references 1. sularsiro s, djuanda s. dermatitis. in: djuanda a, editor. ilmu penyakit kulit dan kelamin. 6th ed. jakarta: badan penerbit fakultas kedokteran universitas indonesia; 2011. p. 129–53. 2. spergerl j. epidemiology of atopic dermatitis and atopic march in children. immunol allergy clin north am. 2010;30(3):269–80. 3. lifschitz c. the impact of atopic dermatitis on quality of life. ann nutr metab. 2015;66(suppl 1):34–40. 4. theofilou p. quality of life: definition and mesaurement. eur j psychol. 2013;9(1):150–62. 5. burckhardt c, anderson k. the quality of life scale (qols): reliability, validity, and utization. health qual life outcomes. 2003;1(1):60. 6. eichenfield lf, tom wl, berger tg, et al. guidelines of care for the management of atopic dermatitis. j am acad dermatol. 2014;71(1):1–17. 7. oranje a, ej g, wolkerstorfer a, de waard-van der spek f. practical issues on interpretation of scoring atopic dermatitis: the scorad index, objective scorad and the three-item severity score. br j dermatol. 2007;157(4):645–8. 8. kim dh, li k, seo sj, jo sj, yim hw, kim kh, et al. quality of life and disease severity are correlated in patients with atopic dermatitis. j korean med sci. 2012;27(11):1327–32. 9. gånemo a, svensson a, lindberg m, wahlgren c. quality of life in swedish children with eczema. acta derm venerol. 2007;87(4):345–9. 10. hon kl, kam wy, leung t, ng pc. cdlqi, scorad and ness: are they correlated? qual life res. 2006;15(10):1551–8. 11. hon kl, leung tf, wong ky, chow cm, chuh a, ng pc. does age or gender influence quality of life in children with atopic dermatitis. clin exp dermatol. 2008;33(6):705–9. 12. alvarenga tm, caldiera a. quality of life in pediatric patients with atopic dermatits. j pediatr. 2009;85(5):415–20. 13. beattie p, lewis-jones ms. an audit of the impact of a consultation with paediatric dermatology team on quality of life in infant with aropic eczema and their families: further validation of he infants dermatitis of life index and dermatology family impact score. br j dermatol. 2006;155(6):1249–55. althea medical journal. 2017;4(3) 339 14. ring j, przybilla b, ruzicka t. handbook of atopic eczema. new york: springer-verlag berlin heidelberg; 2006. p.525. 15. mozaffari h, pourpak z, pourseyed s, et al. quality of life in atopic dermatitis patients. j mucrobiol immunol infect. 2007;40(3):260–4. muhammad akbar wicaksana, oki suwarsa, fenny dwiyatnaningrum: quality of life in children with atopic dermatitis althea medical journal. 2017;4(3) 340 amj september 2017 visual impairment screening in cibeusi elementary school students dea aprilianti permana,1 feti karfiati memed,2 putri teesa radhiyanti santoso3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/cicendo eye hospital, 3department of anatomy, physiology and biology cell faculty of medicine universitas padjadjaran abstract background: the world health organization (who) shows that there are around 153 million people with visual impairment due to uncorrected refractive error, mostly in 8–10 years. screening of visual function in earlier age is important, because it is treatable. correction of refractive error by using eye-glasses is the easiest and the cheapest way. this study aimed to identify the frequency of visual impairment and eyeglasses-used in children aged eight to ten in cibeusi elementary school. methods: a descriptive study was conducted. this study was held in august 2014. data were obtained from cibeusi elementary school in jatinangor; simple random sampling technique was used to select 8–10 years old students. the total number of respondent was 101 students. screening for visual impairment was performed using e-chart. result: eleven eyes (5.44%) from a total of 202 eyes had visual impairment. six (5.94%) students had visual impairment, whereas only 1 (1%) student used eye-glasses for improving his visual function. visual impairment was considerably high in boy-students aged 8 years and was most prevalence in 3rd grade students. conclusions: there are visual impairments which are not corrected with sunglasses. keywords: children, corrected refractive error, eye-glasses-used, visual impairment screening correspondence: dea aprilianti permana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81809869488 email: deaaprilianti@gmail.com introduction visual impairment is one of the health problems which has a long-term effect and has not been solved completely by the government and health care providers. based on the world health organization (who) in 2006, 153 million people had visual impairment due to uncorrected refractive error. thirteen million of them were 5–15 years old.1 based on basic health research (riset kesehatan dasar, riskesdas) in 2013, the prevalence of visual impairment in ≥6 years old was 0.9% in indonesia. lampung had the highest prevalence of visual impairment (1.7%), on the other hand, the lowest prevalence was in yogyakarta (0.3%). in west java, the prevalence of visual impairment was 0.8%.2 a study conducted in nigeria shows that in the 5–15 years old age group, 8–10 years old (40.7%) children had the greatest number of visual impairment.3 uncorrected refractive error causes visual impairment, affects communication and learning, loss of productivity causing poverty and even quality of life.4 correction of refractive error by using eye-glasses is the easiest and the cheapest way than using contact lenses or performing an operation. it should be easily accessed by the community. in fact, there are limitations for perfoming that strategy especially in developing countries which are lack of infrastructure of eye-glasses providers, lack of training for eye-care givers, and lack of education for both parents and teachers about the importance of doing correction of refractive error. india was one of the countries that have conducted the eye examination for school-children and provided eye-glasses for children who have visual impairment as the way to decrease the number of avoidable blindness.1,5,6 furthermore, to find out whether schoolaged children have visual impairment or not, the visual function screening program is held to support vision 2020 by who.1 the awareness of parents, teachers, and community to avoid blindness in their children especially caused by refractive error is poor. since refractive amj.2017;4(3):340–4 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1178 althea medical journal. 2017;4(3) 341 error does not show specific symptoms, this screening program is important to be carried out.1,6 training for teachers to screen visual function in school should be developed to detect visual impairment in early age. this study aimed to recognize the frequency of visual impairment and eye-glasses-used in students aged 8–10 years at cibeusi elementary school in jatinangor, in 2014. methods this descriptive study was conducted at cibeusi elementary school jatinangor in august 2014 and. this study was approved by the health research ethic committee faculty of medicine, universitas padjadjaran. students aged 8–10 years were selected by using simple random sampling, and 101 students met the inclusion criteria. the age of the 8–10 years students were calculated from their last birthday to the date of examination held. the students were permitted by their parents to be involved in this study after signing informed consent letter. on the other hand, students who were having a red eye were excluded from this study. the researcher did the visual impairment screening by using the e-chart on a distance of 3m; each eye separated starting from the right eye. students with eye-glasses still used eye-glasses when screening was performed. students had to adjust four large e-letters and four small e-letters with different directions. those who were able to adjust at least three small e-letters were categorized as having normal eyes. while those who were able to adjust two or less small e-letters were categorized as having visual impairment. data obtained in this study were input to statistics software. moreover, this study was conducted based on ethical aspects. this study may benefit to screen visual impairment, so both parents and teachers could give interventions, for example correction by using eye-glasses. additionally, this study did not harm the students and they were all treated with similar manners. the involvement of the students in this study was voluntary. results a total of 101 students consisting of 49 (48.5%) boys and 52 (51.5%) girls were included in this study. students were of 3rd to 5th grade. those who were 8 years old (39.6%) were the most common in this study. only 1 (1%) student table 1 clinical eye examination based on student’s characteristics characteristic n (%) eye examination normal n(%) visual impairment n(%) gender boys 49 (48.5) 87 (43.1) 11 (5.4) girls 52 (51.5) 104 (51.5) 0 (0) age (years old) 8 40 (39.6) 74 (36.6) 6 (3.0) 9 38 (37.6) 72 (35.6) 4 (2.0) 10 23 (22.8) 45 (22.3) 1 (0.5) grade 3rd 47 (46.5) 86 (42.6) 8 (3.9) 4th 29 (28.7) 55 (27.2) 3 (1.5) 5th 25 (24.8) 50 (24.8) 0 (0) eyeglasses-used yes 1 (1%) no 100 (99%) total 101 (100.0) 191 (94.6) 11 (5.4) dea aprilianti permana, feti karfiati memed, putri teesa radhiyanti santoso: visual impairment screening in cibeusi elementary school students althea medical journal. 2017;4(3) 342 amj september 2017 already used eye-glasses during screening. by using e chart as a screening tool, out of a total of 202 eyes, 191 (94.55%) eyes had normal visual function whereas 11 (5.44%) eyes had visual impairment. the data showed that boys (5.94%) had greater number of visual impairment than girls. students with visual impairment were considerable high in 8 years old students (3.0%) and were of 3rd grade (3.9%). frequency of students with visual impairment was not similar with frequency of eye-glasses-used students (table 1). results of clinical eye examinations showed that there were small differences of right and left eye with visual impairment. five students had visual impairment in their both eyes and one student had one eye with visual impairment (tabel 2). discussion eye examination in infant and children is conducted by eye-care providers in the eye hospital by using pictures, and one of them is e-chart. it is similar with the tool used in this study to screen visual impairment. e-chart is used to assess the visual function in four years old and older verbal children.2,7 prevalence of school-aged children in the age group 6-14 years with visual impairment is 0.03% in a study conducted by riskesdas 2013. the study by teerawattananon et al.8 in thailand (2014) has showed that 6.6% students have visual impairment. an other study held in ethiopia by sewunet et al.9 shows that 11.6% schoolaged children have visual impairment. in this studythe frequency of visual impairment among students was 5.94%. the variations of result in several studies can be due to different sampling technique methods, size of population screened, and geographical area.10 furthermore, boys (5.94%) with visual impairment were in greater number than girls (table 1). this is similar with the study conducted by opubiri et al.3 in nigeria (2013), which shows visual impairment is the most common problem in age group 8˗10 years , and 7 from 11 children were boys. in contrast, a study conducted in saudi arabia proves that refractive error occurs more in girls (12%) than boys (7.7%).10,11 while a study conducted by teerawattananon et al.8 in thailand (2014) has concluded that there is no significant difference of occurrence of visual impairment in boys (51%) and girls (49%). there is no difference of eye development both in preschool-age and school-age children based on their gender.7 according to who that proved that most children affected by visual impairment due to refractive error were in age group 5–15 years, this study focused on students aged 8–10 years. moreover, 8 years old students had the greatest number of visual impairment and students were of 3rd grade (table 1). this data is similar with a study conducted in saudi arabia11 which shows visual impairment is most common in students aged 7–8 years and were of 3rd to 4th grade. one of the reason is students are actively growing in that age group.11 the study conducted by opubiri et al.3 in nigeria (2013) also shows that visual impairment is considerably high in age group 8–10 years (40.7%). a study in thailand8(2014) reports that screening program has already been conducted in pre-school and primary elementary school children. the teachers get difficulties during the screening process that is performed in pre-school children, due to lack of cooperative and lack of knowledge of the children.8 eye examination in early age needs parents participation to get children focus while doing the examination.7 so that children aged 8˗10 years old were involved in this study. the alteration of eye diameter and its curvature affects the clearance of image captured by the retina. the changes of axial length occur faster in the first three years of life, after that the changes occur slowly. in the second decade of life, the cornea will be flattened, keratinocyte will be thinner, and the endothelial cell will be changed. lens crystalline affecting lens capability in refraction also changes in the second decade of life. lens fiber will be produced along the table 2 clinical eye examination characteristic right eye n (%) left eye n (%) eye examination normal 95 (94.1) 96 (95.0) visual impairment 6 (5.9) 5 (5.0) total 101 (100) 101 (100) althea medical journal. 2017;4(3) 343 life, so it becomes thicker in older age.7 moreover, data showed 1 (1%) student used eye-glasses during screening, in contrast to 6 students with visual impairment (table 1). the study conducted by riskesdas indonesia in 2013 in age group 6-14 years, shows that there are 1% cases of corrected refractive error.2 the study conducted in 2012 by ghosh et al.12 in kolkata, india, shows that 4 (1.46%) students from the total of 273 students with visual impairment already used eye glasses. three other studies conducted in saudi arabia11 that have a similar purpose with this study shows three different results. first, from 18.6% students with refractive error, 16.3% students have uncorrected refractive error.11 econd, in 2012, according to a study conducted by al wadaani et al.10 in al hassa, saudi arabia, 9.4% students with refractive error have used eye-glasses to avoid early blindness. data in the study of compliance of eye-glasses-used in primary school children by aldebasi13 shows that boys (30.87%) have poor compliance than girls (35.97%). another study conducted in ethiopia9 reports that 9.3% students with refractive error have used eye-glasses. there are several factors affecting the differences in number of eye-glasses-used in students with visual impairment. it depends on the education level and the age of people.2 besides, there is underestimation from the eye care provider in health care facilities and policy maker in the government about the importance of using eye-glasses for visual impaired children. the other factor is people of low socioeconomic level have difficulties in getting health care facilities from the eye care provider.14 this study concludes that frequency of visual impairment and eye-glasses-used students at cibeusi elementary school is considerably different. there are some limitations in this study. e-chart used as a tool in screening of visual impairment does not give information about the visual acuity. this screening program provides information whether the students has visual impairment or not. data were obtained during school time so that the number of students involved in this study was limited. there is no analysis about factors affecting visual impairment in aged 8–10 years . the frequency of visual impairment was not similar with the frequency of eye-glassesused in this study, so there should be an approach not only to the health and education department but also to both teachers and parents to make visual screening as a school program to support vision 2020 of who. it may also decrease the number of avoidable blindness in early age. education is important to increase the awareness of teachers and parents that visual impairment can affect learning, communication, productivity, and quality of life. next study should be conducted to analyze whether there is an association of student’s characteristics and visual impairment or not, and factors affecting visual impairment. references 1. world health organization. global initiative for the elimination of avoidable blindness: action plan 2006-2011. geneva: world health organization. 2007:1–25. 2. kementerian kesehatan republik indonesia. pokok-pokok hasil riskesdas 2013. jakarta: kemenkes ri. 2013: 270–7. 3. opubiri i, pedro-egbe c. screening for refractive error among primary school children in bayelsa state, nigeria. pan afr med j. 2013;14(1):74. 4. pi l-h, chen l, liu q, ke n, fang j, zhang s, et al. prevalence of eye diseases and causes of visual impairment in school-aged children in western china. j epidemiol. 2011;22(1):37–44. 5. smith t, frick k, holden b, fricke t, naidoo k. potential lost productivity resulting from the global burden of uncorrected refractive error. bull world health organ. 2009;87(6):431–7. 6. padhye as, khandekar r, dharmadhikari s, dole k, gogate p, deshpande m. prevalence of uncorrected refractive error and other eye problems among urban and rural school children. middle east afr j ophthalmol. 2009;16(2):69–74. 7. harley rd, nelson lb, olitsky se. harley’s pediatric ophthalmology. philadelphia: lippincott williams & wilkins; 2005. 8. teerawattananon k, myint c-y, wongkittirux k, teerawattananon y, chinkulkitnivat b, orprayoon s, et al. assessing the accuracy and feasibility of a refractive error screening program conducted by school teachers in preprimary and primary schools in thailand. plos one. 2014;9(6):1–8. 9. sewunet sa, aredo kk, gedefew m. uncorrected refractive error and associated factors among primary school children in debre markos district, northwest ethiopia. bmc ophthalmol. 2014;14(1):95. 10. al wadaani fa, amin tt, ali a, khan dea aprilianti permana, feti karfiati memed, putri teesa radhiyanti santoso: visual impairment screening in cibeusi elementary school students althea medical journal. 2017;4(3) 344 amj september 2017 ar. prevalence and pattern of refractive errors among primary school children in al hassa, saudi arabia. glob j health sci. 2012;5(1):125–34. 11. aldebasi yh. prevalence of correctable visual impairment in primary school children in qassim province, saudi arabia. j optom. 2014;7(3):168–76. 12. ghosh s, mukhopadhyay u, maji d, bhaduri g. visual impairment in urban school children of low-income families in kolkata, india. indian j public health. 2012;56(2):163–7. 13. aldebasi yh. a descriptive study on compliance of spectacle-wear in children of primary schools at qassim province, saudi arabia. int j health sci (qassim). 2013;7(3):291–9. 14. mcclure tm, choi d, wooten k, nield c, becker tm, mansberger sl. the impact of eyeglasses on vision-related quality of life in american indian/alaska natives. am j ophthalmol. 2011;151(1):175–82. althea medical journal. 2017;4(3) 345 characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital oldi caesario,1 shinta fitri boesoirie,2 alwin tahid3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology-head and neck surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy, cell biology and physiology faculty of medicine universitas padjadjaran abstract background: maxillofacial fracture is a serious injury in the head region which is frequently found in the emergency room. in indonesia, the road traffic accident is the main etiology. epidemiological assessments are important to assess trends and set the priorities for treatment and prevention of the injury. this study was conducted to identify the characteristics of maxillofacial fracture resulting from road traffic accidents. methods: this descriptive retrospective study involved hospitalized patients with maxillofacial fracture resulting from road traffic accidents at dr. hasan sadikin general hospital in 2011–2013 using the total sampling technique. data were collected in the period august–october 2014 which included patient demographics, detailed description of the accident and the fracture. results: a total of 187 patients with male/female ratio of 5:1 and a mean age of 26.78 year. the majority of patients were motorcyclists (92%) with most of them were not wearing safety equipment. most of the accidents took place in 2011 in bandung. mandible was the most common site of injury followed by the maxilla and nasal bone. open reduction was performed in 69.52% patients). conclusions: maxillofacial fracture is more common in men with the mean age of 26.78 years. the majority of patients are motorcyclists. most of them are not using safety equipment. most of the accidents occurred in bandung in 2011. mandible is the most common site of fracture. open reduction is the most commonly performed treatment. keywords: head injury, maxillofacial fracture, road traffic accident correspondence: oldi caesario, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: oldi.caesario@gmail.com introduction maxillofacial fracture is a serious injury in the head region which is frequently found in the emergency room.1 the maxillofacial region is more vulnerable to fractures because it is the most exposed part of the body.1 besides maxillofacial fracture still becomes a serious clinical problem because of its specific anatomical area, where the important organs such as respiratory, neurologic, and digestive system are located.2 a study in uganda2 stated that 20% of maxillofacial fracture patients have cranio-cerebral injury. it also can affect the patient’s quality of life, such as the psychological and esthetical aspect.2 the etiology of maxillofacial fractures are road traffic accident, assault, fall, sport injury, domestic violence, and other.1,3,4 in developing countries, road traffic accident is still the main etiologic factor of maxillofacial fractures. in indonesia5 especially west java, 84.2% cases of maxillofacial fracture are caused by road traffic accidents. a road traffic accident is caused by many factors. human factor is one of the main reasons for traffic accidents. driving while sleepy, fatigue, at inappropriate speed, or without using protective gears (such as helmet and safety belts) and poor compliance to traffic laws are examples of human factors contributing to road traffic accidents. the development of roads and other transport infrastructures which did not keep up with the rapid pace of increase in the number of vehicles also contributes to road traffic accidents.6 amj. 2017;4(3):345–52 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1179 althea medical journal. 2017;4(3) 346 amj september 2017 epidemiological assessments are important to assess trends and set the priorities of treatment protocols and prevention programs against the injury.7 the aim of this study was to identify the frequency and characteristics of patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital. methods population of the study were patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital. the subjects of the study were hospitalized patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital in the period 2011–2013. the inclusion criteria were hospitalized patients with maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital in the period 2011–2013. this study excluded patients whose detailed data were not completed in the medical record such as identity, type of fracture and the treatment. this study used total sampling as data collection method. this descriptive retrospective study was using the cross-sectional method. this study was conducted by using data in medical records of hospitalized patients with maxillofacial fractures resulting from road traffic accidents treated in otorhinolaryngology-head and neck surgery department, oral and maxillofacial surgery department, plastic surgery department and neurosurgery department at dr. hasan sadikin general hospital in the period 2011–2013. data were collected between august and october 2014. this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran and dr. hasan sadikin general hospital, bandung. the collected data included patient’s identification and demographic features, detailed description of the accident (time and location of accident, role of patient in vehicle, the vehicle and safety equipment used), detailed description of the injury (type of fracture, treatment of the fracture and location of concomitant injury). information of patient identification and demographic features were obtained from the identity form of the patient’s medical record. detailed data descriptions of the accident were obtained from the anamnesis written in the medical record. while data regarding the detailed description of the injury (type of fracture and location of concomitant injury) were obtained from the anamnesis, physical examination, and supportive examination written in the medical record. data concerning the treatment of the patient were collected from the information written in the medical record. the etiology of maxillofacial fractures was grouped into road traffic accidents and other causes. the time of accidents were grouped into year 2011, 2012 and 2013. the locations of accidents were grouped into bandung and outside bandung region. bandung region included bandung city, kabupaten bandung and kabupaten bandung barat (regencies), other than that was outside bandung region. the type of vehicles used by patients were grouped into pedicab, bus, car, bicycle, motorcycle, and truck. patients who did not have a description about the location of accident and type of vehicle were included into the no-details group. the roles of patient who used vehicles were grouped into driver and passenger. the safety equipments used by the patient at the time of accident were classified into using the safety equipment, were not using the safety equipment and have no-details group. the injuries which patients suffered were grouped into maxillary fracture, mandible fracture, nasal fracture, orbital fracture, frontal sinus fracture, zygoma fracture, and multiple maxillofacial fractures. the mandibular fractures were grouped by their anatomical location into angular, condyle, coronoid, corpus, parasymphysis, ramus, symphysis, and subcondyle. the maxilla fractures were grouped into unilateral fracture and le fort classification. in addition patients having a combination of more than one type of isolated maxillofacial fractures were grouped into multiple maxillofacial fractures. the treatment of fractures were classified into open reduction, closed reduction, conservation, and refused treatment. all data obtained were input using the microsoft excel 2007 program. the data analysis was conducted using descriptive statistics, while statistical software was used for statistical analysis. results the total data obtained in this study was 368, but only 211 cases with maxillofacial fractures were treated at dr. hasan sadikin general hospital bandung, in the period january 2011 althea medical journal. 2017;4(3) 347oldi caesario, shinta fitri boesoirie, alwin tahid: characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital table 1 demographic characteristics of maxillofacial fracture characteristics frequency percentage (%) etiology 211 road traffic accident 187 88.63 other 24 11.37 sex 187 male 156 83.4 female 31 16.6 age mean+sd = 26.78+11.64years median = 24 years mode = 17 years range = 5–70 years time of accident 187 2011 88 47.1 2012 55 29.4 2013 44 23.5 location of accident 187 bandung region 110 58.8 outside bandung region 72 38.5 no details 5 2.7 type of vehicle used 187 pedicab 0 0 bus 2 1.1 car 5 2.7 bicycle 1 0.5 motorcycle 172 92 pedestrian 6 3.2 truck 0 0 no details 1 0.5 role of patient 180 driver 158 92.94 bicycle 1 bus 0 car 4 motorcycle 153 passenger 22 7.06 bicycle 0 bus 2 car 1 motorcycle 19 althea medical journal. 2017;4(3) 348 amj september 2017 to december 2013. out of the 211 cases, only 187 cases (88.63%) met the inclusion criteria and 24 cases (11.37%) resulted from other causes such as interpersonal violence, sport injury, work injury, falls, etc. there were 156 (83.4%) males and 31 (16.6%) females, causing a male to female ratio of approximately 5:1 and an age range from 5–70 years (mean = 26.78 years; sd = 11.64 years) (table 1). the distribution of patients with maxillofacial fractures resulting from traffic accidents according to the time of accident revealed that most accidents occurred in 2011 (88 patients, 47.1%) and least in 2013 (44 patients, 23.5%). the distribution according to the location of the accidents revealed that most accidents occurred in bandung region (110 patients, 58.8%). based on the statistics of patients with the type of vehicle used showed most of the patients were using a motorcycle at the time of the traffic accident, causing maxillofacial fractures (172 patients, 92%). while other patients were using car, bus, bicycle, or were table 2 distribution of the type of vehicle and the safety equipment used type of vehicle safety equipment used totalusing not using no details f % f % f % car 0 0 4 80 1 20 5 motorcycle 84 48.8 81 47.1 7 4.1 172 total 84 47.5 85 48 8 4.5 177 table 3 types of maxillofacial fracture type of fracture frequency percentage (%) maxillary 21 11.2 unilateral 7 33.3 le fort i 5 23.8 le fort ii 7 33.3 le fort iii 2 9.5 mandibular* 89 47.6 angular 20 16.95 condyle 11 9.32 coronoid 1 0.85 corpus 17 14.41 parasymphysis 48 40.68 ramus 2 1.7 symphysis 15 12.71 subcondyle 4 3.39 nasal bone 15 8 orbital 4 2.1 frontal sinus 4 2.1 zygoma 8 4.3 multiple fracture 46 24.6 total 187 100 note: * more than one type can be present for each patient althea medical journal. 2017;4(3) 349 pedestrians. furthermore, the statistics of patients with reference to their role in using a vehicle revealed that the majority of patients were motorcycle drivers (153 patients), followed by motorcycle passengers (19 patients), and car drivers (4 patients) (table 1). the distribution of type of vehicle according to the safety equipment used by maxillofacial fracture patients revealed, most of the patients who used a motorcycle at the time of accident were not wearing safety equipment (85 patients, 48%). there were no data available in the patient’s medical record regarding the safety equipment worn by patients who were using a bycicle and bus (table 2). the distribution of patients with maxillofacial fracture resulting from road traffic accidents according to the type of fracture showed that the multiple maxillofacial fracture is the combination of more than one type of isolated maxillofacial fractures. the most common site of fractures were mandible (89 patients–47.6%), maxilla (21 patients–11.2%), and nasal (15 patients–8%) (table 3). the distribution of the type of maxillofacial fracture in multiple maxillofacial fracture patients revealed that the common sites of fractures were mandible, maxilla, nasal and zygoma (table 4). the statistics of patients in relation to the treatment of maxillofacial fractures showed that open reduction was performed in 69.52% of patients, while 10.6% of patients had close reduction (table 5). discussion in this study, road traffic accident was the main etiology of maxillofacial fractures compared to other factors. this result was in accordance with the study conducted by adeyemo et al.1 in nigeria and leles et al.7 in brazil which showed most patients with maxillofacial fractures resulted from road traffic accidents, however it was inconsistent with a similar study conducted by pham-dang et al.4 in france that showed interpersonal violence as the main cause of maxillofacial fracture. the study conducted in azerbaijan8 stated that the road traffic accident is still the main reason for maxillofacial fractures ,due to the rapid increase in the number and type of vehicle and table 4 distribution of multiple maxillofacial fractures type of fracture* frequency maxillary 24 unilateral 11 le fort i 3 le fort ii 9 le fort iii 6 mandibular 25 angular 1 condyle 4 coronoid 0 corpus 3 parasymphysis 13 ramus 1 symphysis 6 subcondyle 1 nasal bone 20 orbital 16 frontal 12 zygoma 20 note: * more than one type can be present for each patient oldi caesario, shinta fitri boesoirie, alwin tahid: characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital althea medical journal. 2017;4(3) 350 amj september 2017 along with poor driver’s compliance with the traffic law. this study exhibited that most of the patients were males. more males were involved in maxillofacial fractures than females which were in accordance with other previous international studies.3,7,9,10 the predominance of male patients could be due to the fact that males are the breadwinner of the family and mostly work outdoors, consequently have a high risk to road traffic accidents. even though in past decades, there is an increase in the prevalence of female patients especially of those aged below 40 years due to changes in their social behavior, for example their participation in non-domestic work. cultural and socioeconomic factors of certain regions determine the prevalence of male to female ratio of maxillofacial fracture patients.7 in countries where women are extensively active in social activities such as in brazil7, the male to female ratio is 3:1. on the other hand, in the united arab emirates10 the male to female ratio is 7:1, due to the fact that mostly men are working outdoors and few women are driving vehicles. the mean age of the subjects in this study was 26.78 year with most cases below the age of 24 years. these results are consistent with the study conducted by leles et al.7 in the brazil which showed that 32.3% of the patients are in the age group of 21–30 years. other international studies also had similar results with this study. this was possibly due to their behavioral changes into independent individuals, high mobility, careless driving on the roads and economically active segment of society. on the other hand, in this age group, their compliance to the traffic law is poor and their inexperience in driving.1,2,7,9-11 the frequency of maxillofacial fracture resulting from road traffic accidents in this study steadily decreased from year to year. whilst a study conducted in kenya11 had similar results. there is a decrease in the number of maxillofacial trauma resulting from road traffic accidents in 2004 compared to 2003. it might be due to an increase of awareness among the road users about the importance of compliance to the traffic law including wearing safety equipment while driving. according to the location of the traffic accident, more traffic accidents occurred in bandung region than outside bandung region. nevertheless, there was no other study concerning the location of road traffic accidents which caused maxillofacial fractures in west java. our results demonstrated that the maxillofacial fractures resulting from traffic accidents were most common in the group of patients who were using motorcycle as their table 5 distribution of treatment of fractures characteristics frequency percentage (%) concomitant injury 187 upper extremity injury 4 2.1 lower extremity injury 6 3.2 ocular injury 1 0.5 mild head injury 59 31.6 moderate head injury 7 3.7 severe head injury 0 0 thorax injury 3 1.6 abdominal injury 0 0 multiple injury 7 3.7 without injury 100 53.5 treatment of fracture 187 open reduction 130 69.52 close reduction 20 10.7 conservative 7 3.74 refuse treatment 30 16.04 althea medical journal. 2017;4(3) 351 vehicle when the accident occurred. based on the role of the patients with vehicles, most of the subjects were motorcycle drivers followed by motorcycle passengers and next, car drivers. it is in accordance with the study conducted by leles et al.7 in brazil which showed 41.32% of patients are motorcyclist. it can be explained by the fact that in indonesia, the prevalent number of people is using a motorcycle as means of transport. it was proven by data from statistic indonesia (badan pusat statistik, bps) that showed in 2012 motorcycle is the most common used vehicle in indonesia.13 it occupied 80.95% of all vehicle transport in indonesia; however, this result was different with the study conducted by akama et al.11 in kenya that showed most of the subjects are 72.5% pedestrians. furthermore, most of the maxillofacial fracture patients in this study were not wearing safety equipment such as safety belts and helmets. however the number was not significantly different with the subjects who were wearing safety equipment, indicating that the compliance of road users for wearing safety equipment was still low. this study result is lower than another study result in malaysia12, which reported 60% of motorcyclist are wearing helmets. however, it is higher than in the study conducted by oginni et al.14 which showed only 3% patients are wearing helmets. the application of safety equipment by the vehicle users was important. data showed that there was a significant decrease in the occurrence of road traffic accidents in developed countries after the enforcement of the traffic law. the best protection against injuries as indicated by vehicle accident statistics includes safety awareness and a personal commitment to ride safely all the time. another study showed that the usage of safety belts can reduce 42% of fatalities, while the motorcyclist who are not wearing helmets are five times more likely to have severe head injury.7,11 in this study, mandible fracture was the most common type of maxillofacial fracture. this agrees with the result of a study from al khateeb10 in united arab emirates (uae). the locations of mandible fractures in this study were more common in the parasymphysis and corpus region. the study conducted by leles et al.7 in brazil revealed that the most common affected region was condyle of the mandible. the tendency is due to the prominence of mandible and is the only movable bone in the maxillofacial region.9 whilst a different study revealed that the most affected region of maxillofacial fractures are nasal and zygomatic-orbital complex.7 this study showed that more patients received open reduction as their fracture treatment than others, which was also reported elsewhere.4 contrary, this study results was different with the study conducted by adriane2 in uganda which showed that most of the fracture patients are performed by closed reduction. in uganda2, it is due to the cost of open reduction and the scarce of plates and theater space to perform the procedure. this study concluded that maxillofacial fractures resulting from road traffic accidents are more common in male than in female patients. the mean age of the patient is 26.78 years. the highest prevalence of fracture occurs in the bandung region, in 2011. the majority of patients are motorcycle drivers, followed by motorcycle passengers, pedestrians, car drivers, and car passengers, respectively and most of them are not wearing protective equipment. the frequent type of maxillofacial fracture resulting from road traffic accidents includes mandibular fracture, maxillary fracture, and nasal bone fracture. open reductions are more frequently performed than close reductions or conservative methods. the limitations of study are mainly caused by the high number of incomplete data on the patient medical records regarding to the variable seek in this study. improvements of the medical record system including the registry and storage system are highly recommended. references 1. adeyemo wl, ladeinde al, ogunlewe mo, james o. trends and characteristics of oral and maxillofacial injuries in nigeria: a review of the literature. head face med. 2005;1:7. 2. kamulegeya a, lakor f, kabenge k. oral maxillofacial fractures seen at a ugandan tertiary hospital: a six-month prospective study. clinics (sao paulo, brazil). 2009;64(9):843–8. 3. alves ls, aragao i, sousa mj, gomes e. pattern of maxillofacial fractures in severe multiple trauma patients: a 7-year prospective study. braz dent j. 2014;25(6):561–4. 4. pham-dang n, barthelemy i, orliaguet t, artola a, mondie jm, dallel r. etiology, distribution, treatment modalities and complications of maxillofacial fractures. med oral patol oral cir bucal. 2014;19(3):e261–9. oldi caesario, shinta fitri boesoirie, alwin tahid: characteristics of maxillofacial fractures resulting from road traffic accidents at dr. hasan sadikin general hospital althea medical journal. 2017;4(3) 352 amj september 2017 5. daniel angel laura, syamsudin endang, fathurrahman. characteristics of maxillofacial fractures in hasan sadikin hospital within period 2009–2011. proceeding of the international symposium on oral and dental sciences; 2012 march 1–3; yogyakarta. yogyakarta: faculty of dentistry universitas gajah mada; 2013. 6. peden m, scurfield r, sleet d, mohan d, hyder aa, jarawan e, et al., editors. world report on road traffic injury prevention. geneva: world health organization; 2004. 7. leles jl, dos santos ej, jorge fd, da silva et, leles cr. risk factors for maxillofacial injuries in a brazilian emergency hospital sample. j appl oral sci. 2010;18(1):23–9. 8. hasanova gf. maxillofacial injuries resulting from road traffic accidents. ліки україни. 2014;2(178):22–3. 9. maliska mcd, marcia b, luciana a, de moraes m, moreira rwf. oral and maxillofacial surgery-helmet and maxillofacial trauma: a 10-year retrospective study. braz j oral sci. 2012;11(2):125–9. 10. al-khateeb t, abdullah fm. craniomaxillofacial injuries in the united arab emirates: a retrospective study. j oral maxillofac surg. 2007;65(6):1094–101. 11. akama mk, chindia ml, macigo fg, guthua sw. pattern of maxillofacial and associated injuries in road traffic accidents. east afr med j. 2007;84(6):287–95. 12. ramli r, abdul rahman r, abdul rahman n, abdul karim f, krsna rajandram r, mohamad ms, et al. pattern of maxillofacial injuries in motorcyclists in malaysia. j craniof surg. 2008;19(2):316–21. 13. badan pusat statistik indonesia. produksi kendaraan bermotor dalam negeri (unit), 2008-2013. jakarta: badan pusat statistik indonesia; 2015. 14. oginni fo, ajike so, obuekwe on, fasola o. a prospective multicenter study of injury profile, severity and risk factors in 221 motorcycle-injured nigerian maxillofacial patients. traffic inj prev. 2009;10(1):70–5. althea medical journal. 2017;4(3) 353 correlation between short-term memory and achievement of athletes ryandika elvereza mustari,1 leonardo lubis,2 nani kurniani3 1faculty of medicine universitas padjadjaran, 2department of anatomy, cell biology and physiology faculty of medicine, universitas padjadjaran, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: human activity is largely related to thought processing or cognition. one of the most important components of cognition is memory. individuals who undergo heavy activities, such as athletes, use a lot of memory in the subject’s activities, especially during competitions. the purpose of this study was to find out whether there was a correlation between the capability of short term memory with the performance of an athlete during a competition, especially those measured by achievements. methods: this study was an analytic observational correlation study with a cross-sectional design and involved 201 athletes as respondents from 12 branches of sports. the study was conducted in the indonesian national sports committee (koni) building from september to november 2015. digit span forward and backward were used to collect short term memory data and was performed after a consent form and the respondent’s identity was recorded. the athlete’s achievements data was gathered by an interview and recapitulation of athlete’s achievements in the last five years. results: oa total of 186 data was analyzed and found a negative and insignificant correlation between achievement and short-term memory based on digit span tests both forward (r=0.095 p=0.196) and backward(r=0.039 p=0.196). conclusions: there is no correlation between short term memory and the achievements of an athlete. keywords: achievement, athlete, short term memory correspondence: ryandika elvereza mustari, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, email: ryand1195@gmail.com introduction the mind’s ability is the competence for thinking and processing thought from all sources. the received information will be processed and attained systematically in the human mind.the capability of thought arrangement is called cognition.1 a study by bull et al.2, shows that there is a relationship between the cognitive ability and achievements in grade 4 students in an elementary school in usa, especially in reading and mathematics. this proves the importance of cognition especially in an individual’s life performance, one of them being achievements.2 the most important part in information processing is memory. after processing, the information will be stored in the brain for future reuse in many daily activities. there are three types of memory which is differentiated by the length of time in the memory storage named longterm, intermediate and short-term memory.3 short term memory has a storage capacity of about seven items for 20–30 seconds.4 short term memory is needed in the recalling of information that originated from long term memory, the selection of information, repetition of information that are received and stored, and also as a choosing response, which plays a vital role in all the individual activities. a study by swanson5 proves that the short term verbal memory has a relationship with achievements especially in language studies and mathematics in children and adults. furthermore, short term memory is also needed in a special community, such as athletes. a few studies have proven that routine exercises could increase the cognitive function including memory.6,7 athletes undergo routine exercises to improve the performance on the field during a competition and to maintain good physique. an athlete’s sports performance on the field consists of the athlete’s capability and achievement, the characteristics of their performance in a competition, a fair behavior, integrity, and an appreciation for friend or foe.8 amj. 2017;4(3):353–7 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1180 althea medical journal. 2017;4(3) 354 amj september 2017 short-term memory plays a role in an athlete’s performance, for example, an athlete is required to remember strategic tactics instructed by the coach either before or during a break in competitions to maximize the athlete’s performance. the performance of an athlete can be clearly seen and measured through the achievements, namely the medals. to our knowledge, there is not a study that shows a correlation between short term memory and an athlete’s achievements. this study aimed to discover and analyse the correlation between short term memory and the athlete’s achievements. methods a cross-sectional analytic study was conducted from september to november 2015 in the indonesian national sports committee (komite olahraga nasional indonesia, koni) west java building, and approved by the health and research ethics committee, faculty of medicine, universitas padjadjaran. the subjects for this study were 201 athletes of west java koni from 12 branches of sports comprising pencak silat, judo, athletics, archery, fencing, taekwondo, rock climbing, boxing, heavy lifting, gymnastics, wrestling and kempo. the sample collection in this study was obtained used the total sampling method and the correlative analysis sample size formula with α 5%, β 10%, and r 0,7 from previous studies, and turned out to be 14.5 the inclusion criteria were athletes who were willing to participate in the study, had filled out an informed consent form, and completed 90– 100% of their training program. short term memory was assessed by using the digit span forward and backward instrument that was part of the wechsler adult intelligence scale (wais) iv and wechsler intelligence scale for children (wisc) iv cognition test which was validated.9–12 additionally, training before handling, suitability test for intra-observers and inter-observers, and athlete identification was conducted before data collection. digit span forward test was performed by requesting the athlete to repeat a sequence of numbers stated by an examiner. a score of 2 was given if the athlete repeated the sequence correctly, while a score of 0 was given if the sequence could not be repeated accurately. the questionnaire with two wrong answers was considered finish, and the athlete’s score was written on an evaluation form. digit span backward test was then carried out, where an athlete repeated the numbers stated by an examiner but in a backwards table 1 characteristics of participants variables frequency percentage (%) sex male 91 49 female 95 51 sport pencak silat 23 12 judo 21 11 athletics 12 6 archery 14 8 fencing 15 8 taekwondo 14 8 rock climbing 20 11 boxing 6 3 pabbsi 12 6 gymnastics 15 8 wrestling 4 2 kempo 30 16 althea medical journal. 2017;4(3) 355ryandika elvereza mustari, leonardo lubis, nani kurniani: correlation between short-term memory and achievement of athletes sequence. a score of 2 was given if the athlete repeated the backwards sequence correctly, while a score of 0 was given if the backwards sequence could not be repeated accurately. the questionnaire with two wrong answers was considered finish, and the athlete’s score was written on an evaluation form. the achievement data was about the latest medals attained by the athletes from previous competitions, and information was obtained from interviews with the athletes. the medals might be gold, silver or bronze that the athlete received in state, national or international events. the data was analyzed using statistical application. the normality test was performed using the kolmogorov-smirnov test. the normality results were used to determine the type of correlation test that would be conducted. results out of 201 athletes included in the study, 186 eligible athletes were recruited, and 15 were excluded as they had not completed the tests. according to the branch of sports, the highest frequency of respondents was from the kempo branch (16.1%) and was dominated by female athletes (51.1%) (table 1). the results showed that either the independent or dependent variables presented a data distribution which was not normal. thus, to display the statistics of this study in a descriptive way, a median was used as a measurement of central tendency and a minimum maximum as a measurement of table 2 measurement of study data dispersion median minimum maximum score achievement 3 1 16 digit span forward 10 6 16 digit span backward 6 4 16 dispersion (table 2). moreover, results of the spearman’s test showed an insignificant negative correlation between digit span forward and achievements, as well as between digit span backward and achievements (table 3). discussions the spearman correlation test showed that there was a negative and insignificant correlation between the short term memory and the athlete’s achievements. additionally, a study by cdc13 showed that physical activities could influence the cognitive ability of someone by an increase in the growth of brain capillaries, oxygenation, blood pressure, neurotrophin production, number of neurotransmitters, growth of nerve cells in the hippocampus, development of nerve connections, volume of brain tissue and density of interneuron relationships. this causes an increase in the functionality of attention, information processing, information storage and repetition; it also increases coping mechanism, heightens positive behavior and reduces the sensation of pain.this study also showed that there was an influence of physical activity to academic performance. aerobic exercises in the form of group games, especially those that needed complex motoric activities (example; football), could increase prefrontal cortex activities, and increased the positive marginal effect in mathematical achievements. furthermore, sun et al.14 stated that the brain’s functional magnetic resonance table 3 correlation analysis test result digit span forward digit span backward achievement spearman correlation -0.095 -0.039 p-value (2-tailed) 0.196 0.594 n 186 186 althea medical journal. 2017;4(3) 356 amj september 2017 imaging (fmri) test results on the prefrontal cortex activitiy especially in the dorso lateral prefrontal cortex has a major role in the short term memory function. short term memory has a correlation with achievements in language studies and mathematics in children and adults.5 this shows that short term memory influences an individual’s achievement. there are a few factors that influence the memory function of an individual, one of it is concentration. duration, intensity and time of stress as intrinsic factors could also influence memory.15 stress will activate the hypothalamic-pituitary-adrenal (hpa) axis and increase the rate of glucocorticoid, cortisol in humans. the increase of the glucocorticoid rate could decrease memory function.15,16 athletes are people who experience a lot of physical activities with specific training regimes. the main purpose of an athlete is to win competitions and to garner achievements in the form of medals.17 sports performance of athletes are influenced by cognitive function, stress factor, confession of physical or mental mistakes on the field, frequent endurance of pain and unease on the field, seeing successful or cheating rivals on the field, getting a violation from the referee, and being reprimanded by the coach. the failure of the coping mechanism with acute stress levels could lead to change in the psycho-behavioral processes of the athlete.18 this study was not focused on the measurement of short term memory quality as an effect of an athlete’s physical activity. this study was focused on the short term memory and the achievement of athletes due to a relationship between athletes who endure loads of exercise and the increase of cognitive function, especially the short term memory. in conclusion, there is no correlation between the west java koni athlete’s short term memory capability and their achievements, and this may occur due to a few factors that in turn influenced the athlete’s performance on the field aside from the short term memory. there are also factors that influenced short term memory when the test is conducted, such as concentration. this study has several limitations. the researcher did not measure the stress factor and the concentration that may influence the athlete’s achievements in competitions and memory function during data collection. this is due to the insufficient study time. recommendations for athletes are to maintain factors that can influence the athlete’s performance on the field. one of them is the role of koni to measure also the cognitive function and stress factor of the athletes regularly before a match. recommendations for a future study are to conduct carry out a study with cohort method by measuring the short term memory of the athletes before a competition and to observe the development of the athlete’s performance. further recommendations are to measure and to control positive factors that may influence the short term memory or an individual’s performance. additionally, to evaluate the part of the brain that activates the short term memory directly during the study by using fmri. references 1. singh m, narang m. cognitive enhancement techniques. int j inf technol knowl manag. 2014;7(2):49–61. 2. bull r, espy ka, wiebe sa. short-term memory, working memory, and executive functioning in preschoolers: longitudinal predictors of mathematical achievement at age 7 years. dev neuropsychol. 2008;33(3):205–28. 3. guyton a, john eh. thoughts, consciousness,and memory. in: schmitt w, rebecca g, folcher ma, editors. textbook of medical physiology. 11st ed. philadelphia, pa : saunders/elsevier; 2011. p. 723–6. 4. cowan n. what are the differences between long-term, short-term, and working memory? prog brain res. 2008;169(1):323–38. 5. swanson hl. short-term memory and working memory: do both contribute to our understanding of academic achievement in children and adults with learning disabilities? j learn disabil. 1994;27(1):34–50. 6. nanda b, balde j, manjunatha s. the acute effects of a single bout of moderateintensity aerobic exercise on cognitive functions in healthy adult males. j clin diagn res. 2013;7(9):1883–5. 7. mayers lb, redick ts, chiffriller sh, simone an, terraforte kr. working memory capacity among collegiate student athletes: effects of sport-related head contacts, concussions, and working memory demands. j clin exp neuropsychol. 2011;33(5):532–7. 8. arai a, ko yj, ross s. branding athletes: exploration and conceptualization of athlete brand image. sport manag rev.2014;17(2):97–106. 9. drozdick lw, cullum cm, antonio s. althea medical journal. 2017;4(3) 357 expanding the ecological validity of wais-iv and wms-iv with the texas functional living scale. hhs public access. 2015;18(2):141–55. 10. holdnack j, zhou x, larrabee g, millis s, salthouse t. confirmatory factor analysis of the wais-iv/wms-iv. nih public access. 2013;18(2):178–91. 11. mcfarland dj. modeling individual subtests of the wais iv with multiple latent factors. plos one. 2013;8(9):1–7. 12. kaufman a. test review: wechsler intelligence scale for children, fourth edition (wisc-iv). j psychoeduc assess. 2006;24(3):278–95. 13. cdc. the association between schoolbased physical activity, including physical education, and academic performance. 2010;2(1):1–84. 14. sun x, zhang x, chen x, zhang p, bao m, zhang d, et al. age-dependent brain activation during forward and backward digit recall revealed by fmri. neuroimage. 2005;26(1):36–47. 15. sandi c, pinelo-nava mt. stress and memory: behavioral effects and neurobiological mechanisms. neural plast. 2007;1(3):1–20. 16. sandi c. glucocorticoids act on glutamatergic pathways to affect memory processes. trends neurosci. 2011;34(4):165–76. 17. yarrow k, brown p, krakauer jw. inside the brain of an elite athlete: the neural processes that support high achievement in sports. nat rev neurosci.2009;10(8):585–96. 18. bahramizade h, besharat ma. the impact of styles of coping with stress on sport achievement. procedia–social behav sci. 2010;5(2):764–9. ryandika elvereza mustari, leonardo lubis, nani kurniani: correlation between short-term memory and achievement of athletes althea medical journal. 2017;4(3) 358 amj september 2017 early detection of suspected systemic lupus erythematosus in community-dwellings in west java indonesia nadia gita ghassani,1 soeseno hadi,2 laniyati hamijoyo3 1faculty of medicine universitas padjadjaran, 2department of anatomical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: prevalence of systemic lupus erythematosus (sle) has been known in almost all countries around the world. contrary to this, in indonesia, neither a national epidemiologic study on sle nor any direct study on sle in the general population has been conducted. early detection of sle is needed as a first step to determine prevalence of sle in indonesia as well as to prevent further complications. this study aimed to obtain the prevalence of suspected sle in community-dwellings. methods: this study was conducted in the period september to november 2015 and used the descriptive cross-sectional method. the respondents were people who were at least 18 years old and lived in selected blocks in three different villages in jatinangor, west java. data were obtained from secondary sources of a previous sle screening study that was incorporated in a study on “epidemiology of hypertension and albuminuria in jatinangor” in 2014, using the multistage sampling method. suspected sle was based on the liang screening questionnaire. the collected data were presented in tables. results: there were 72 respondents (8%) suspected to have sle. most of the cases were female (odds ratio:1.47) and 51–60 years old. the most clinical manifestation was painful swollen joints >3 months. conclusions: the existence of suspected sle cases in jatinangor’s population, as an example of indonesian population should be a concern so that examinations could be carried out to make sure that respondents with sle can be provided prompt interventions to prevent further complications. keywords: early detection, liang screening questionnaire, systemic lupus erythematosus correspondence: nadia gita ghassani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, email: nadiagitag@gmail.com introduction systemic lupus erythematosus (sle) is a chronic multisystem autoimmune disease with broad clinical features, ranged from minor skin manifestation to serious organ damage.1 due to the sle chronic features, the financial burden of sle is expected to increase.2–4 the annual healthcare cost in asia for sle patients without nephritis is estimated to reach us$16,638 per patient/year.4 the prevalence of sle in asia-pacific countries varies between 4.3–45.3 per 100,000 population per year.1 on the other hand, in indonesia, neither an epidemiologic study on sle nor any direct study on sle in the general population has been conducted. the only available data are mostly obtained from local health care centers. for those two reasons, sle screening is needed as a first step to determine the prevalence of sle in indonesia. systemic lupus erythematosus screening is one of the efforts which allows early detection of lupus; hence, immediate intervention of suspected sle patients can be given, so that they will have a better life. a previous multidisciplinary study has been conducted in jatinangor, west java, indonesia to survey the health of communities in jatinangor, including performing sle screening. however, the previous sle screening study has not been published yet. by using data of the mentioned study, this study aimed to obtain the number of people with suspected sle in jatinangor. methods this study used secondary sources obtained from a previous sle screening study amj. 2017;4(3):358–362 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.1181 althea medical journal. 2017;4(3) 359 entitled “epidemiology of hypertension and albuminuria in jatinangor” which has been conducted since 2014. this study utilized the previous data using the descriptiveobservational method with a cross-sectional approach and was conducted in the period september to november 2015. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the respondents of both the previous and this current study were the population of jatinangor who lived in three different villages namely, cipacing, hegarmanah and cilayung. the previous study used the multistage sampling technique as study design where samples were taken until the blocks were selected. the minimum sample size was calculated using sample size formula for descriptive categorical study. the assumed prevalence used in the calculation originated from a previous study in birmingham, uk, which was 307 suspected sle patients out of 1153 population (26,6%).6 based on the formula, a minimum of 834 samples should be obtained. the data were selected randomly from the secondary source. the inclusion criteria of this study were (1) all people who were at least 18 years old, lived in the selected blocks, had already participated in the “epidemiology of hypertension and albuminuria in jatinangor” study, and (2) had already signed the informed consent paper. those with incomplete data would be dismissed as an exclusion criteria of this study. the exclusion criteria of this study was based on previous studies in birmingham and israel which included only people who were at least 18 years old.6,7 the total number of respondents of this study was 857 respondents. the collected data on this study consisted of respondent demography (age and gender), and some of the answers toward the questionnaire given in the previous study was consistent with the liang questionnaire. the liang questionnaire comprised 10 questions concerning clinical manifestations of sle which utilized the american rheumatism association preliminary criteria for sle and had been validated as one of the two stages of sle screening study design.5,6 data collection of the study was conducted by medical students as the surveyors who had previously received adequate training and standardized instructions from the experts. furthermore, the respondent demography was described in general, and then categorized into suspected sle and not suspected sle. the operational definition for suspected sle is as follows: if there is a ‘positive’ or ‘yes’ answer on more than 3 questions of the liang questionnaire, then the respondent would be categorized as suspected sle.5 the collected data were then presented in tables. results eight hundred and fifty seven valid data were obtained after the exclusion and inclusion criteria were met. the authors used all the valid data to increase the intensity of this study instead of using only the minimum samples. among the total respondents, 69% were female respondents . the highest number was found in the age group 41–50 years (26%), followed by the age group 31–40 years (23%) (table 1). this study discovered that among the 785 respondents, approximately 8 % (72 cases) were suspected to have sle (table 2). the most common clinical manifestation in suspected sle respondents was pain and swollen joints, which was found in 76% of the respondents. most other clinical manifestations found in this study were changes on finger/toes, pleurisy for a few days and photosensitivity (table 2). the number of females with suspected sle were higher compared to the number of males (55 out of 595 vs 17 out of 262 respondents) with 1.47 as the odds ratio. in addition, the highest number of suspected sle was discoversed in the age group 51–60 years (table 3). nadia gita ghassani, soeseno hadi, laniyati hamijoyo: early detection of suspected systemic lupus erythematosus in community-dwellings in west java indonesia table 1 demography distribution of respondents characteristics frequency (n(%)) gender male 262 (31%) female 595 (69%) age ≤20 25 ( 3%) 21–30 118 (14%) 31–40 201 (23%) 41–50 225 (26%) 51–60 >60 153 (18%) 135 (16%) total 857 althea medical journal. 2016;3(3) 425 comparison of maternal health service satisfaction level of national health coverage and non national health coverage patients in bandung mother and child hospital rika yuntiani,1 eppy darmadi achmad,2 henni djuhaeni3 1faculty of medicine universitas padjadjaran, 2department of obstetric and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of public health faculty of medicine universitas padjadjaran abstract background: healthcare is financially inaccessible to some people. this results in deterioration of patients’ condition or even death, which is proven by the high level of maternal death rate in indonesia. the government implemented the national health coverage (nhc) system to ensure the provision of quality health care for the entire community. this study aimed to examine the nhc and non-nhc patients’ perception to quality maternal healthcare services. methods: this study was an analytic cross-sectional study conducted from august–october 2014. one hundred and twenty six respondents from kota bandung mother and child hospital were included. the tool used in this study was a validity and reliability-tested questionnaire encompassing five dimensions of service quality: tangibles, reliability, responsiveness, assurance, and empathy. the kolmogorov-smirnov test was used to test the hypothesis. results: the study showed that the majority of nhc(75%) and non-nhc patients (89%) ware unsatisfied with the maternal healthcare services. most patients felt unsatisfied towards the reliability dimension which involved complicated referral procedures and examination time that failed to comply with what was promised. conclusions: there is no difference between nhc and non-nhc patients’ level of satisfaction of maternal health care service in bandung mother and child hospital. [amj.2016;3(3):425–29] keywords: national health coverage, maternal health, satisfaction correspondence: rika yuntiani, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85759866015 email: rikayuntiani@gmail.com introduction health care service that is not readily available financially has caused some parts of the community are unable to get suitable care. this causes the patient’s condition to worsen or even death, which is reflected by the high number of maternal mortality rate (mmr) in indonesia. in west java in 2007, the mmr was 95.81 per 100,000 live births; while in bandung it was 20 per 36,122 live births.1 the government started the jaminan kesehatan nasional (national health coverage-nhc) system on 1 january 2014 which covered maternal care. the universal health coverage and nhc aim to ensure all indonesians of quality health care without any financial risk.2,3 one of the indicators for health care quality is patient’s satisfaction.4,5 satisfaction over the services is determined by the patient’s perception of the quality of service which comprises of five dimensions: tangibles, reliability, responsiveness, assurance, and empathy.6 a study by dalinjong and laars7 and fenny8 in ghana showed that both universal health coverage (uhc) clients and non-clients feel satisfied with the service they receive. bandung mother and child hospital is a public hospital which handles advanced maternal problems and has already implemented the nhc system. this study was aimed to find out the difference in levels of satisfaction between nhc and non-nhc patients over maternal health care service in bandung mother and child hospital. methods this analytic cross-sectional study was carried out in bandung mother and child hospital althea medical journal. 2016;3(3) 426 amj september 2016 from august-october 2014, and it had been approved by the health research ethics committee, faculty of medicine universitas padjadjaran. the population of this study was all maternal patients of the obstetrics and gynecology polyclinic. the subjects were selected by consecutive sampling, including nhc and non-nhc outpatients. the minimum sample size required was 104 people. the subjects enrolled in this study were nonaid-awardee (non-penerima bantuan iuran) nhc patients and non-nhc patients who had experienced maternal health care service at least once. subjects who failed to complete the questionnaire or were unwilling to participate in the study were excluded, 134 respondents were selected, but there were 5 incomplete questionnaires and 3 first-time visitors, as such the total samples comprised of 126 respondents. the variable measured in this study was the patient’s satisfaction. satisfaction is measured based on the patient’s perception of the quality of service which comprises of five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. the data was collected by using the satisfaction questionnaire whose validity and reliability had been tested. the questionnaire was made up of 25 questions with 5 topics according to the dimensions of service. the questionnaire asked the patient’s expectations and real experience, each was valued from 1 to 4. the satisfaction score was calculated by determining the gap between the expectations and real experience. satisfaction table 1 respondent’s characteristics characteristics nhc non-nhc f % f % age (years) 15–20 2 3 2 3 21–25 11 18 16 25 26–30 16 25 19 30 31–35 20 32 12 19 36–40 10 16 11 18 41–45 4 6 3 5 education elementary school 4 6 5 8 middle school/ equal 13 21 9 14 high school/equal 37 59 41 65 higher education 9 14 8 13 occupation housewife 50 80 48 76 self-employed 4 6 3 5 employee 9 14 8 13 teacher 0 0 2 3 others 0 0 2 3 service grade(nhc) grade i 11 18 grade ii 21 33 grade iii 31 49 total 63 100 63 100 note: *nhc: national health coverage (jaminan kesehatan nasional) althea medical journal. 2016;3(3) 427rika yuntiani, eppy darmadi achmad, henni djuhaeni: comparison of maternal health service satisfaction level of national health coverage and non national health coverage patients was achieved if there was no gap. the smaller the gap was (or the more negative it was), the higher the patient’s level of satisfaction was, and vice versa. furthermore, the collected data was analyzed with computer. normality test was not performed because the data were either nominal or ordinal in nature. the kolmogorovsmirnov test was used because the data did not fulfill the requirement for using the chisquared test. the analysis was performed to find out the difference in satisfaction level between nhc and non-nhc patients. the result was interpreted by looking at the p-value: null hypothesis would be rejected if p-value was less than 0.05 and vice versa. result the subject’s characteristics examined in this study were age, education, occupation, and the service grade chosen by nhc respondents. for details, refer to table 1. the majority of the nhc respondents in this study were mothers 31-35 years of age while for the non-nhc respondents, most were 26-30 years of age. the most prominent educational level of the respondents from both groups was high school or the equal. the majority of the respondents were housewives with no occupation. almost 50% of jnk respondents chose grade iii service which required a monthly fee of rp25,500.00 (table 1). the difference in the levels of satisfaction between nhc and non-nhc patients regarding maternal health care service showed thatthe respondents from both groups declared unsatisfied by the maternal health care service; the difference between the proportions of the each group was insignificant (table 2). moreover, most respondents from either group were unsatisfied with all the service dimensions, with highest number of unsatisfied patients were discovered in the reliability dimension. there was a difference in the proportion of level of satisfaction between table 2 patient’s level of satisfaction over maternal health service satisfaction level phighly satisfied satisfied unsatisfied n % n % n % type of funding nhc 6 9 10 16 47 75 0.541 non-nhc 2 3 5 8 56 89 note: *nhc: national health coverage (jaminan kesehatan nasional) table 3 level of satisfaction over 5 service dimensions satisfaction level phighly satisfied satisfied unsatisfied n % n % n % tangibles nhc 6 9 10 16 47 75 1.00 non-nhc 3 5 16 25 44 70 reliability nhc 6 10 14 22 43 68 0.938 non-nhc 3 5 11 17 49 78 responsiveness nhc 2 3 21 33 40 64 0.405 non-nhc 2 3 11 18 50 79 assurance nhc 2 3 28 44 33 53 0.832 non-nhc 4 6 19 30 40 64 empathy nhc 3 4 30 48 30 48 0.137 non-nhc 4 6 16 26 43 68 note: *nhc: national health coverage (jaminan kesehatan nasional) althea medical journal. 2016;3(3) 428 amj september 2016 nhc and non-nhc respondents; however, the difference was insignificant (table 3). meanwhile, about 73% of nhc respondents concurred that there had been improvement in the service quality, where they perceived a better service after the implementation of nhc. the other 23% did not perceive any difference in service quality even after the implementation of nhc. discussion in overall, this study discovered that most patients, both nhc and non-nhc, were unsatisfied by the maternal health care service in kota bandung mother and child hospital. this finding was not in agreement with a study by dalinjong and laars7 and fenny8 which discovered that both nhis (national health insurance scheme) and non-nhis patients in ghana express satisfaction over the service they receive. the service quality is one of the factors that determine patient’s satisfaction.4 satisfaction can be achieved if the patient experienced the service they expect; therefore, it reflected that kota bandung mother and child hospital must improve its service quality so as to achieve the patient’s satisfaction. the result showed that there was a difference in the size of the proportion with respect to the respondent’s satisfaction: the proportion of the unsatisfied respondents was larger in the non-nhc group compared to the nhc group. this was also not in agreement with the finding of dalinjong which states that the proportion of satisfied patients is higher in non-insurance patients than in insured patients.7 moreover, most nhc respondents perceived a better service after the nhc implementation, expressing their relief concerning financial problems. this was appropriate with the objective of the nhc in indonesia, which is to provide the whole country with health care service without risks of financial difficulties. this finding was different with a study by volp which states that how the service is given to the patient has a larger influence on the patient’s perception of service quality than less financial cost.9 the difference in the above-mentioned proportion was further analyzed, giving rise to p-value of 0.541, which deemed the particular proportion insignificant. this was congruent to the finding of dalinjong and laars7 and fenny8 which states that the difference in level of satisfaction between insured and non-insured patients in ghana is insignificant. another study by devadasan et al.10 in india also produced the same finding of no significant difference in the level of satisfaction between insured and non-insured patients under the community health insurance scheme. furthermore, parasuraman in satsanguan6 states that service quality can be measured in 5 major dimensions: tangible, reliability, responsiveness, assurance, and empathy. a study by mosahab et al.4 also shows a significant correlation between the 5 service dimensions and patient’s satisfaction, in which assurance and tangible have respectively the most and the least correlation to the patient’s satisfaction. this study discovered insignificant difference in the proportion of the level of satisfaction in each dimension, unlike a study by syahdat et al.11 involving general and askes patients which discovered significant difference in the responsiveness and tangibles dimensions, and insignificant difference in the reliability, assurance, and empathy dimensions. the dimension of reliability, which involved the experience of receiving suitable service in the promised time, was the dimension with the highest proportion of dissatisfaction. this was caused by the large number of nhc patients complaining about complicated referral procedures and the long waiting time prior to examination by a doctor which failed to comply with the promised meeting for examination. other dimensions with high proportions of dissatisfaction are tangible and responsiveness; tangible involved the condition of the administration room, waiting room, examination room, and pharmacy, and the availability of the examination instruments. while responsiveness involved the responsiveness of health care providers in meeting the patient’s needs and appropriate waiting time. this was caused by the large number of visiting patients which led to crowded waiting and administration rooms and long waiting time prior to receiving the service. assurance and empathy were the dimensions with the largest proportions of satisfaction. both dimensions involved interpersonal relationships that had an instrumental role in determining patient’s level of satisfaction, including the doctor-patient interaction and the attitude and attention given by other health workers.8 larson and yao12 states that as empathy is very essential for quality care, the healing relationship between physicians and patients is important as well. asefa et al.13 and rao et al.14 showed that patient’s satisfaction is related to financial althea medical journal. 2016;3(3) 429 and interpersonal factors. based on the results and discussion above, it could be concluded that there was no significant difference in the level of satisfaction over maternal health care service between nhc and non-nhc patients in kota bandung mother and child hospital. the limitations of this study were insufficient time, which prevented the inclusion of other factors which might be confounding variables such as family income, transportation cost, level of education, age and other socio-demographic factors. a study by quintana et al.15 states that there are several factors with relation to satisfaction, which include socio-demographic variables and length of stay, previous admission, and the timing of response to the questionnaire. it is recommended that further studies take into account other factors that can influence the patient’s level of satisfaction. the result of this study can hopefully be an evaluative material for kota bandung mother and child hospital to improve its maternal health care services so as to achieve satisfaction of each patient. the service dimensions requiring more attention are tangible, reliability, and responsiveness. badan penyelenggara jaminan sosial (bpjs) has to do further evaluation on the service quality in the nhc era in other health care facilities in order to gain materials for consideration so that the quality of nhc-covered health care service can be improved, bringing indonesia closer to an ideal universal health coverage. references 1. dinas kesehatan jawa barat. profil kesehatan provinsi jawa barat tahun 2007. bandung: dinas kesehatan provinsi jabar; 2008. 2. kieny m-p, evans db. universal health coverage. east mediterr health j. 2013;19(5):305–6. 3. republik indonesia. undang-undang republik indonesia nomor 40 tahun 2004 tentang sistem jaminan sosial nasional. jakarta: republik indonesia; 2004. 4. mosahab r, mahamad o, ramayah t. service quality, customer satisfaction and loyalty: a test of mediation. international bussiness research. 2010;3(4):72–80. 5. aldebasi yh, ahmed mi. patient’s satisfaction with medical services in the qassim area. j clin diagn res. 2011;5(4):813–7. 6. satsanguan l, fongsuwan w, trimetsoontorn j. structural equation modelling of service quality and corporate image that affect customer satisfaction in private nursing homes in the bangkok metropolitan region. res j bus manag. 2015;9(1):68–87. 7. dalinjong pa, laar as. the national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of ghana. health economics review. 2012;2(1):1–13. 8. fenny ap, enemark u, asante fa, hansen ks. patient satisfaction with primary health care–a comparison between the insured and non-insured under the national health insurance policy in ghana. glob j health sci. 2014;6(4):9–21. 9. volpp kg. designing a model health care system. am j public health. 2007;97(12):2126–8. 10. devadasan n, criel b, van damme w, lefevre p, manoharan s, van der stuyft p. community health insurance schemes & patient satisfaction-evidence from india. indian j med res. 2011;133(1):40–49. 11. syahdat nurkholiq, suharto, hari peni julianti, ani margawati. perbandingan tingkat kepuasan pasien umum dengan pengguna kartu askes di pelayanan dokter keluarga pt. askes. semarang: diponegoro university; 2011. 12. larson eb, yao x. clinical empathy as emotional labor in the patient-physician relationship. jama. 2005;293(9):1100–6. 13. asefa a, kassa a, dessalegn m. patient satisfaction with outpatient health services in hawassa university teaching hospital, southern ethiopia. j public health epidemiol. 2014;6(2):101–10. 14. rao kd, peters dh, bandeen-roche k. towards patient-centered health services in india—a scale to measure patient perceptions of quality. int j qual health care. 2006;18(6):414–21. 15. quintana jm, gonzález n, bilbao a, aizpuru f, escobar a, esteban c, et al. predictors of patient satisfaction with hospital health care. bmc health serv res. 2006;6(1):102. rika yuntiani, eppy darmadi achmad, henni djuhaeni: comparison of maternal health service satisfaction level of national health coverage and non national health coverage patients althea medical journal. 2016;3(3) 340 amj september 2016 tinea capitis among elementary school students in jatinangor,sumedang, west java dilla aprilia,1 lies marlysa ramali,2 ramlan sadeli3 1faculty of medicine universitas padjadjaran, 2department of dermatovenereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of microbiology and parasitology faculty of medicine universitas padjadjaran abstract background:fungal infection is a common disease in tropical and subtropical countries. warm and humid climates provide a favourable environment for organism causing superficial mycosis. one of the fungal infections that commonly occurred in children is tinea capitis. tinea capitis is a superficial fungal infection of the hair and scalp caused by dermatophytes. the age predilection of this disease is children aged 3 until 14 years . the purpose of this study was to detect the presence of tinea capitis among elementary school students in jatinangor, sumedang, indonesia. methods: this cross-sectional descriptive study involved 391 students from thefirst until sixth grade at four elementary schools in jatinangor, in the period of september until october 2013. anamnesis, physical examination, wood’s lamp examination and direct microscopic examination were conducted to diagnose the disease. the collected data were analyzed and presented in the form of frequency distribution and percentages shown in tables. results: out of 391 students participating in this study, 194 were boys and 197 were girls. the age range was 6 until 16 years. based on the screening results, 74 students were known to have complaints about their hair and scalp and only 49 students could continue the study as they have no positive result of tinea capitis. conclusions: there is no positive findings of tinea capitis according to anamnesis, physical examination, wood’s lamp examination and direct microscopic examination. further examination by culture with sabouraud’s dextrose agar should be carried out. [amj.2016;3(3):340–4] keywords: dermatophytosis, elementary school students, tinea capitis correspondence: dilla aprilia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62817201898 email: dilla.aprilia.s@gmail.com introduction fungal infection is a relatively common problem especially in the tropical and subtropical regions of the world. warm and humid climates provide a favourable environment for organism causing superficial mycosis.1 one of the fungal infections that commonly occurred in children is tinea capitis.1–4 tinea capitis is a superficial fungal infection of the hair and scalp caused by the dermatophytes. trichophyton and microsporum are the caused of this disease.1,3,4 it is commonly found in children from age 3–14 years old. humans (anthropophilic) and animals (zoophilic) are the source of transmission of this disease.3,5 the risk of infection in school children was increasing along with the total numbers of infected children because they can easily infected each other.2,6 hygiene was known to be the most important predisposing factor of the development of the disease. overcrowded environment and low socioeconomic status were also considered as influencing factors of tinea capitis.3,5 early diagnosis of tinea capitis is needed because if it was not detected and left untreated, it may cause destruction of hair and pilosebaceous structures, and may cause further complications such as alopecia and even various forms of hypersentivity reactions.1,7 as a tropical country, indonesia would be a potential place for the occurence of this disease. the avalaibility of the latest data about tinea capitis was still limited especially in indonesia so that the study about tinea capitis still needed to be conducted. the purpose of this study was to detect the presence of tinea althea medical journal. 2016;3(3) 341 capitis among elementary school students in jatinangor, west java. methods this study was conducted in september until october 2013 at four elementary schools, namely cikopo i, sinarjati, cikuda, and jatiroke, in jatinangor, sumedang, west java. the subjects were students, boys and girls from the first until sixth grade. based on multistage sampling, 391 students were obtained. the inclusion criteria were defined as first until sixth grade students in elementary schools in jatinangor. the exclusion criteria of this study were students who did not attend school and students who refused to participate in this study. a cross sectional descriptive study was carried out. data collection was conducted after approval by the education office of sumedang and the principal of each school had been obtained. informed consent was given to the principal of each school and the parents of the students. this study was divided into two steps. first, the researcher conducted a screening to the total number of students. anamnesis and physical examination such as inspection were performed to the students in order to separate healthy students from students with hair and scalp complaints. moreover, further physical examination and wood’s lamp examination by the dermatovenereologists team were carried out to specify the diagnosis of student’s hair and scalp. yellow-green fluorescence image reflected ectothrix organism and figure 1 study procedures dilla aprilia, lies marlysa ramali, ramlan sadeli: tinea capitis among elementary school students in jatinangor,sumedang, west java althea medical journal. 2016;3(3) 342 amj september 2016 in the other hand, no fluorescence image reflected endothrix organism. if there was positive findings from anamnesis, physical examination, and wood’s lamp examination, samples of the hair and scalp were collected for further examination. samples of the hair were collected by pulling 1-2 strands of hair using a pinset or hand. the sample of the scalp was collected by using a cellophone tape and blunt scalpel. then the samples were put in specimen envelopes to be transported to the laboratory of microbiology, faculty of medicine, universitas padjadjaran. before the collected samples were further examined by direct microscope, the preparation of the samples were conducted. the hair-strands or the scalp curettage were put in the labeled object glass, a drop of lactophenol cotton blue was given and finally the object glass was closed with a cover glass. the prepared samples were heated using bunsen burners. if arthrospores were found surrounding the hair shaft, it showed an ectothrix infection. if arthrospores were found inside the hair shaft, it showed an endothrix infection. hyphaes and arthrospores were found in the scalp curettage samples. the interpretation of the specimens was confirmed by the microbiologists. positive findings were diagnosed from combination of clinical manifestations and microscopic examination. the collected data were analyzed and presented in the form of frequency distribution and percentages shown in tables. results this study was participated by 391 elementary school students who came from four elementary schools in jatinangor. the distribution of students were classified based on school, gender, and age (table 1). from the 391 students, seventy four students were discovered to have complaints about their hair and scalp conditions (table 2). from the 74 students with complaints, 14 students were not permitted by their parents to continue the study and 11 students were not present during the day of examination. this situation caused only 49 students could table 1 characteristics of elementary school children variables frequency (n) percentage (%) school cikuda 85 21.7 sinarjati 126 32.2 jatiroke i 98 25.0 cikopo i 82 20.9 gender boy 194 49.6 girl 197 50.4 age (years old) 6 27 6.9 7 54 13.8 8 61 15.6 9 77 19.7 10 71 18.2 11 62 15.9 12 29 7.4 13 5 1.3 14 4 1.0 15 0 0 16 1 0.3 althea medical journal. 2016;3(3) 343dilla aprilia, lies marlysa ramali, ramlan sadeli: tinea capitis among elementary school students in jatinangor,sumedang, west java continue for further examination. further physical examination and wood’s lamp examination by the dermatovenereologists team, discovered that most of the selected students did not have any hair and scalp abnormalities. furthermore, pediculosis capitis was the most case that was discovered (table 3). from the 49 students, there was no positive result of tinea capitis. discussions tinea capitis, a fungal infection of the scalp, is the most common dermatophyte infection in children.5 the distribution of tinea capitis has been spread all over the world but usually happened in tropical and sub-tropical countries.1 a study by ayaya et al.8 in a primary school in kenya showed that the prevalence rate of tinea capitis was 33.3%. meanwhile, woldeamanuel et al.9 in ethiopia reported that 463 (90.3%) students were clinically diagnosed with tinea capitis from 513 students diagnosed with dermatophytosis. in non-tropical countries, the study by cuetara et al.10 in spain revealed that 0.52% children had dermatophytes with 0.33% children had tinea capitis as the most common type of dermatophytes. the study was conducted with samples comprising 10,000 randomly selected school-children in madrid aged between 2 and 16 years. furthermore, ghannoum et al.11 determined the prevalence of dermatophyte-positive scalp cultures among elementary school-children in cleveland, ohio. from 8 cleveland elementary schools, 937 children were cultured for the presence of dermatophytes, and 122 children (13%) had dermatophyte-positive cultures of the scalp. a wide variety of numbers in the prevalence rate of tinea capitis can be found worldwide. it was also known that infections are more common in the developing countries rather than in the developed countries.8 indonesia which is a tropical country with high humidity and warm climate may become a good place for the development of this disease. elementary school-children were also considered to be the most susceptible subjects since the highest prevalence rate of tinea capitis was known between the age of 3 until 14 years old.5 however, in this study, there was no positive diagnosis of tinea capitis. on the other hand, other infections were discovered and most of them were pediculosis capitis. there were several limitations during the process of this study. the culture with sabouraud’s dextrose agar was not conducted, whereas, culture may identified the etiologic agents of tinea capitis infection.3 table 2 total numbers of students with complaints about their hair and scalp conditions complaints* frequency (n) percentage (%) yes 74 18.9 no 317 81.1 total 391 100 note: * complaints : students with complaints about hair and scalp including itch, hair loss, dandruff, scale, white patch, wound, erythema, and other type of lesions table 3 distribution of hair and scalp disorders among students diagnosis frequency (n) percentage (%) no abnormalities 25 6.4 pediculosis capitis 16 4.1 insect bite 2 0.5 pityriasis alba 1 0.3 seborrheic dermatitis 2 0.5 atopic dermatitis 1 0.3 xerosis cutis 1 0.3 pit sika 1 0.3 total 49 100 althea medical journal. 2016;3(3) 344 amj september 2016 furthermore, the possibility of respondent or volunteer bias might happened because there were 14 students who were not permitted and 11 students were not present during the examination. as a conclusion, the presence of tinea capitis can not yet be found. even though there is no positive diagnosis of tinea capitis, concerned still need to be put towards the students’ hygiene because the possible discovery of other skin diseases such as pediculosis capitis. the researcher suggested to conduct a program for clean and healthy lifestyle including the education and evaluation. it aims to ensure that in the future tinea capitis and any other skin diseases will not occur in the school environment. in a further study, culture may be conducted so that the etiologic agents of tinea capitis can be found. references 1. uneke c, ngwu b, egemba o. tinea capitis and pityriasis versicolor infections among school children in the southeastern nigeria: the public health implications. the internet journal of dermatology. 2005;4(2):1¬–7. 2. van schoor j. superficial fungal infections. sa pharmacist’s assistant. 2011;11(4):13– 4. 3. hainer bl. dermatophyte infections. am fam physician. 2003;67(1):101–10. 4. gupta ak, ryder je, nicol k, cooper ea. superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis. clin dermatol. 2003;21(5):417–25. 5. wolff k, goldsmith l, katz s, gilchrest b, paller a, leffell d. fungal diseases. fitzpatrick’s dermatology in general medicine. 8th ed. san diego: mcgraw-hill companies incorporated; 2012. p. 1807– 22. 6. naafs b, padovese v. rural dermatology in the tropics. clin dermatol. 2009;27(3):252–70. 7. isa-isa r, arenas r, isa m. inflammatory tinea capitis: kerion, dermatophytic granuloma, and mycetoma. clin dermatol. 2010;28(2):133–6. 8. ayaya s, kamar k, kakai r. etiology of tinea capitis in schoolchildren. east afr med j. 2001;78(10):531–5. 9. woldeamanuel y, leekassa r, chryssanthou e, menghistu y, petrini b. prevalence of tinea capitis in ethiopian schoolchildren. mycoses. 2005;48(2):137–41. 10. cuetara m, palacio a, pereiro m, amor e, alvarez c, noriega a. prevalence of undetected tinea capitis in a school survey in spain. mycoses. 2009;40:131–7. 11. ghannoum m, isham n, hajjeh r, cano m, al-hasawi f, yearicka d, et al. tinea capitis in cleveland: survey of elementary school students. j am acad dermatol. 2003;48(2):189–93. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 103 characteristics of older adult with balance disorder in rehabilitation clinic of dr. hasan sadikin general hospital 2014 ku shi yun,1 irma ruslina defi,2 lazuardhi dwipa3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung,, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: older adult population is increasing worldwide. balance has an important role in conducting daily activity and mobility. impaired balance can lead to negative impacts, for example falling. this study was conducted to obtain common factors and characteristics of older adult with balance disorder to provide better rehabilitation services. methods: a descriptive study was conducted at physical medicine and rehabilitation clinic of dr. hasan sadikin general hospital bandung, from august to october 2014 using total sampling method and a 5 times sit-to-stand (5sts) test was conducted. the total samples obtained were 34. results: the characteristics of older adult with balance disorder in this study were mostly from young old (n=17), male gender (n=19), and mean 5sts test which was 18.48 seconds. most of the patients had high blood pressure (n=29), normal body mass index (bmi) (n=22), independent activity of daily living (adl) (n=21), and use of greater than 3 drugs (n=21).the most common disease found was musculoskeletal disease and majority of patients had one medical disease. conclusions: older adult categorized as young old have the greatest frequency of having balance disorder. increase in age, increases the duration of 5sts test conducted. the most common problem among older adult is high blood pressure, musculoskeletal disease, and hypertension, and majority of the patients consume greater than 3 drugs. lastly, most of the bmi and the adl of the older adults are normal. [amj.2016;3(1):103–9] keywords: balance disorder, five time-sit-to-stand, older adult correspondence: ku shi yun, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 1221682051 email: shiyunku@gmail.com introduction the older adult population is increasing, based on world health organization (who), it is approximated that in 2050, the population of older adults will be 16% of the total population in the world.1 in indonesia, the aging population increases with the country development and it is predicted to rise four times of the origin of year 2010 around 18.04 million (7.59%).2 older adult is defined as people who are 60 years old and above, or in some countries, are 65 years and above.1 older adult categorization is divided into young old (60–69 years), middle-aged old (70–79 years), old old (80–89 years), very old old (greater than 90 years).3 aging is a normal physiological process; increase in age causes physiological changes and may affect the ability to conduct the activity of daily living (adl). balance disorder is commonly faced by older adults, and they often encounter instability leading to negative impacts, for example falling.4 this problem is often neglected among older adults and much effort is required to visit the physician’s office.5 balance involves a complex multisensory system which includes vision, auditory, and proprioception. balance control is required in everyday life, which includes the ability to carry out daily activities.4 balance disorder is a “condition that makes you feel unsteady or dizzy, as if you are moving, spinning, or floating, even though you are standing still or lying down” as stated by national institute on deafness and other communication disorders althea medical journal. 2016;3(1) 104 amj march 2016 (nidcd).6 there are many factors that may affect balance, these include age, gender, underlying diseases, body weight, multiple use of drugs and many others.4 based on previous study, balance is much common among female gender and increasing age. moreover, hypertension, diabetes, and arthritis are common among common underlying diseases.7 the main objective of this study was to obtain the common characteristics that present among older adults with balance disorder and to provide better rehabilitation services to patients. early identification of older adults with balance disorder can prevent negative impacts and precautionary steps should be taken. methods the study conducted was a descriptive study using total sampling methods of patients who visited the physical medicine and rehabilitation outpatient clinic of dr. hasan sadikin general hospital bandung from august to october 2014. subjects were selected based on inclusion criteria where patients were 60 years old and above, signed inform consent, were willing to cooperate, and able to follow the instructions, had the ability to ambulate their household, and lastly, based on the 5 times sitto-stand test (5sts) of 12 seconds or greater. the exclusion criteria were those who were using walking aid, numerating pain scale of 5 or above, and cognitive problems. therefore, there were 34 older adults who met inclusion critera. the ethical clearance was obtained from the dr. hasan sadikin general hospital bandung before the study was conducted. patients were approached and inform consent was done before conducting the study. simple instructions were explained to patients in conducting the 5sts test. the patients were asked to be seated with backs leaning on the chair with arms folded throughout the test, using a standardized chair with height 43cm. patients were asked to sit and stand as fast as possible for 5 times, and the time required to complete the task was recorded. the cut-off point used for this 5sts test was 12 second or more; patients with 12 seconds and above during test were regarded as having balance disorder. the 5sts test does not require specialized equipment and has the ability to measure balance, muscle strength, and also risk of fall.8 the adl questionnaire was measured using the barthel index to assess the independence of the older adult. blood pressure, height, and weight were measured and converted into body mass index (bmi).the numbers of drug consumed and current medical illness were asked through interviewing the patients and some were read of the charts. the data collected were recorded in a research formula, and were transferred into microsoft excel. the variables of the study are age, gender, bmi, blood pressure, adl, numbers of drug used, and current medical disease. the results are presented in table form with frequency. result the numbers of sample obtained were 34 older adults aged 60 years and above. the mean 5sts test was 18.48 seconds among older adults with balance disorder with a minimum of 12.03 seconds and a maximum of 44.54 seconds. the characteristics studied were gender, age, 5sts test, blood pressure, body mass index (bmi), activity of daily living (adl), numbers of drug used and medical disease. the table below showed the general characteristic of the data. table 2 shows that male older adults with balance disorder were greater compared to female older adults, whereas the mean 5sts among both genders was above 12 seconds, table 1 general characteristics of older adult with balance disorder general characteristics frequency(n) gender (n=34) male 19 female 15 age (n=34) young old (60–69 years) 17 middle-aged old ( 70–79 years) 11 old old (80–89 years) 6 very old old (>90 years) 0 althea medical journal. 2016;3(1) 105 table 2 characteristic based on gender of older adult with balance disorder gender age (year) 5 sts (seconds) bmi (kg⁄((m)2 )) (mean ± sd) (mean ± sd) (mean ± sd) male (n=19) (70 ± 8) (16 ± 4) (24 ± 3) female (n=15) (70 ± 8) (22 ± 9) (22 ± 4) note: *sd: standard deviation and in female older adults the mean time required to complete the 5sts was greater than males. in this study, the bmi was of a normal range in both genders. table 3 shows that with increasing age, the mean time required to complete the 5sts was greater, the range of the test was differed by 5 seconds from the minimum time required to the maximum time required. table 4 shows the majority of the older adults with balance disorder who had abnormal blood pressure which was high, whereas, bmiolder adults with balance disorder which was greater than half had normal bmi. in the abnormal category, bmi of older adults who are overweight was 8 and underweight 4. the results of adl were typically independent for older adults with balance disorder and none of the older adult was presented with moderate, severely, and very severe disability. whereas, the numbers of drug consumed among 34 older adults with balance disorder were 4 kinds or more drugs. the table 5 shows most of the older adult present in the clinic had musculoskeletal, cardiovascular, and neurological disease. osteoarthritis, hypertension, and past history of stroke were common among older adults. ku shi yun, irma ruslina defi, lazuardhi dwipa: characteristics of older adult with balance disorder in rehabilitation clinic of dr. hasan sadikin general hospital 2014 table 3 characteristics of mean 5sts test based on age age frequency(n) 5sts( second) young old (60–69) 17 17 middle-aged old (70–79) 11 19 old old (80–89) 6 22 very old old (>90) 0 0 table 4 characteristics of older adult with balance disorder characteristic frequency (n) blood pressure normal* 5 abnormal** 29 bmi normal (18.5–24.9) 22 abnormal ( <18.5 and 25 >) 12 adl mild disability (15–19) 13 independent adl (20) 21 numbers of drug used 4 or more (>3) 21 less than 4 (<4) 13 note: *normal: systolic < 120) and diastolic <80) **abnormal: (systolic >120 or diastolic >80) or (systolic <90 and diastolic<60) althea medical journal. 2016;3(1) 106 amj march 2016 besides, from the results, it was shown that majority of older adults had one current medical disease compared to 3 medical diseases. discussion this study aimed to observe the characteristics of older adults with balance disorders. table 2 showed balance disorder among gender. in this study, it was found that 19 out of 34 were male (55.88%), which was more than females. in previous studies, it was stated that female possess a greater risk compared to males with an approximation of 56.9% (± 0.9%). this result differed from the previous study where the number of females is lesser than males. this is because the difference of sample size used and the numbers of patient that are limited due to the change in health referral system.4 table 2 showed that young older adults had an average reading of 17 seconds. older adults categorized as old old had an average of 22 seconds. in this study, with the increase in age, the mean 5 sts test results was longer. the result is similar to previous studies where prevalence rate increases with age for balance disorder.4,9 in mean 5sts, older adults with 12.5 seconds are categorized as non-multiple fallers and those with 14.8 second are multiple fallers based on previous study. this test not only has the ability in measuring balance, but also the fall risk, because older adults with longer test result have higher risk of having multiple falls. the test has a relative risk of 2.0 in predicting subjects of multiple falls and a reliability of 0.89.8 table 3 showed that, 28 out of 34 older adults were aged from 60 to 79. the mean age from previous studies of older adults with balance disorder is 74.46 ± 0.1 years. table 3 showed that those among young old adults had a greater frequency by 6 individual from middle-age. the total mean age of this study was 69.79 years which differed from the previous study around 4.67 years. the previous study were based on a larger population where the age used is older adults who are 65 and above. the study may vary due to sample size and variation of human samples where samples used are asians.4 from a study conducted by whitney et al.10, the mean age of the patients with balance disorder is 75 years old (sd ± 7) with an age range of 61–90 years old. the result supports this study because it is within the age range.10 another study found that balance disorder increases with age, with an odd ratio of 6.99 for older adults aged 80 and above, whereas dizziness do not associate with increase in age. the reason is unclear but is likely allied to physiological changes in aging. similarly, the reason relates to the study; increase in age, increases the time required to complete the 5sts. therefore, this condition increases the risk of balance disorder.7 in this study, 29 older adults had high blood pressure and balance disorder. increase in age, increases blood pressure where the physiologic regulation of blood pressure decreases. a study conducted on orthostatic hypotension and ability to maintain balance in standing, showed that older adults have table 5 current medical disease of older adults with balance disorder current medical disease frequency (n) type of disease musculoskeletal disease 26 cardiovascular disease 14 neurological disease 11 metabolic disease 6 gastrointestinal disease 3 infectious and other disease 3 number of current medical disease/person 1 disease 17 2 disease 9 3 disease 5 4 or more disease 3 althea medical journal. 2016;3(1) 107 decreased ability to maintain balance if the systolic pressure drops at least 20mmhg or 10mmhg of diastolic change from supine position to standing position. moreover, it was found that the ability of balance from eyes open to closed, and narrower base have increased difficulty in maintaining balance for patients with orthostatic hypotension. the inability to regulate the blood pressure fluctuations causes transient hypoperfusion to the brain, where blood flow and oxygen supply to the brain is reduced, thus, ability to maintain standing balance is affected. therefore, decrease of blood pressure from supine to standing position plays a role in maintaining balance and this can be taken into account for future study.11,12 in this study, the results of bmi showed that most of older adults had normal bmi which was a total of 22 older adults. other studies showed that with weight increase during older age increases the risk of physical impairment which impairs the quality of life. it means the greater the bmi, the greater the physical mobility burden.13,14 individuals who are obese have lower muscle strength and more fat mass, but in this study, most patients were in range of normal bmi. even with normal bmi, the patient’s definite muscle mass is not known, with increase in age muscle mass may have been loss. results of majority of the older adults are categorized as normal bmi.13 in older adults, many physiological changes occur, where body weight was found to decrease after the age of 60 years and the fat free mass decreases due to loss of skeletal muscle. from the study, it was found that older adult loses 0.5% of body weight per year, and this can be due to multiple causes, for example sedentary lifestyle, decreased metabolic rate, hormones and physiologic changes of increase catabolism in older adults.15 obesity causes adaptation in rising and sitting where older adults tend to have greater trunk flexion when shifting position. individual obesity also causes shift in the center of mass anteriorly, and a greater effort is required to transfer from different positions. thus, it increases the balance impairment.16 table 4 showed that 21 out of 34 older adults with balance disorder had independent adl which was a full score of 20, and mild disability with a total of 13 older adults. the patients were still able to do their daily activities without assistance, even with balance disorder, precaution remained be taken to prevent and support them to avoid injuries and falls. there were not many studies about the impact of balance disorder on adl. lower scores of adl affects the functional impact, that the daily activities will be limited and it causes increase dependency and care required.4 in previous studies, the samples used for the balance study were based on older adults who did independent adl as the inclusion criteria. in this study, the samples obtained were based on total sampling to avoid bias, and this study also had similar result where most of the samples had independent adl, even without limiting patients in doing independent adl.7 older adults with balance disorder who consume 4 or more drugs are 21 out of 34 older adults. polypharmacy, where an individual consumes 4 or more medication, causes balance problems and increases the risk of falling. increase use of drugs may cause interactions among medication prescribed and may causesdizziness, postural instability and fall. it is important for the medications to be checked, to prevent any drug interactions. removal or increased medication used should be assessed frequently to prevent adverse outcome.4,17 in another study it is noted that 87% of patients consumed 1 or 2 drugs and 13% take greater than 2 medications.7 a study conducted in taiwan18; increase in medication use from 0 until greater than 4 or more medication, the odd ratio admission for fall-related fractures varies from 1 until 2.4 with the increase in numbers of drug used. the study also categorize medication used into different categories which include alimentary tract and metabolism, blood and blood forming organs, cardiovascular system, musculoskeletal system and nervous system.18 in this study, only the numbers of drug consumed were noted. thus, in future study, researcher can divide the types of drug into categories for comparison. table 5 showed that the presence of medical disease also contributed to balance disorder. the most common disease was musculoskeletal disease, cardiovascular, and neurological disease. majority of the patients had 1 disease with a total 17 older adults from 34 older adults, and decrease in frequency with increase in numbers of disease present. in musculoskeletal disease, the most common problem was osteoarthritis. in a previous study, in gait and balance disorder, it had been found that the most common cause among older adults with balance disorder who had difficulty in walking had arthritis and postural hypotension. the presence of joint pain and stroke affects the older adult’s gait. in arthritis, ku shi yun, irma ruslina defi, lazuardhi dwipa: characteristics of older adult with balance disorder in rehabilitation clinic of dr. hasan sadikin general hospital 2014 althea medical journal. 2016;3(1) 108 amj march 2016 there is limited range of motion and the shift of weight bearing position due to the presence of pain thus, affecting the ability in maintaining balance, showing antalgic gait in older adult. the change in gait and displacement of the posture affects the ability of balance.16,19 in this study, cardiovascular disease is common among older adults, it is found that most patients suffers from hypertension and some interventions were done for example coronary bypass, cardiac rehabilitation and others. patients who came to the clinic are referral patient and also patients that required physiotherapy. it is thought that increase in number of disease increases with balance disorder but in this study most of the patients had one medical disease. however this may not be accurate as some patients were unsure of their current medical problems and some patients stated they were healthy. a study conducted by stevens et al.7, it is found that patients with poor balance had diabetes, hypertension, hyperlipidemia, heart disease and renal disease. in the previous study, it is found that there is association between balance disorder with increasing age, diabetes (or=1.53), arthritis (or=1.33), eyesight (or=1.94) this is similar to the disease present in our study.7 the limitations in this study were total number of sample size obtained. a small sample size was used, due to the limited time range of the study. moreover the change in health system has decreased the number of patients present as the hospital is currently a tertiary hospital. bias is present in the study, questionnaire were used to obtain patients information which includes the activity of daily living (adl), numbers of drug used and current medical disease. there were difficulties in recalling the numbers of drug and current medical diseases, and some diseases were read off the medical charts. there may be human error in measuring blood pressure, height, and weight; for the 5sts test, some patient’s feet were not able to reach the ground, therefore, they were seated more forward to allow the feet to be at ground level. standardized height chairs were used in this study, the common height chairs may vary in various studies from 40 to 46 cm. inappropriate height chairs which is too low will affect the result of the study because it requires greater trunk flexion. this does not greatly affect the test result as it showed 2% of variance in the test performance.20 from this study, it can be concluded that increase in age among older adults have balance disorder. the mean age of older adults with balance disorder is 70 years. the mean score of the 5 times sittostandtest is 18 seconds which exceeds the cut-off point of the test which is set at a minimum of 12 seconds or more. the most common problems among older adults are high blood pressure and majority of the patients consuming 4 or more types of drug. the most common medical diseases encountered by the older adults were musculoskeletal disease and hypertension, and patients who visited the clinic were subjected to physiotherapy. thus, the quality of life of the older adults is important in maintaining selfindependence than the quantity. the suggestion for this study is to consider screening for older adults for their balance to allow early prevention and care to avoid falls, fractures, or even any disability. besides, patients should be accessed constantly to attain the types of drug used as they can cause drug to drug interactions. home saving and also support should be given to patients to build older adults’ confidence. some interventions can be done, for example, the use of walking canes or walking aids to increase balance support, and in home support, bars can be placed in bathrooms to prevent slips as well squat toilets can be replaced with seated toilets. families, physicians, and nurses play an important role in keeping the patients motivated for more regular follow up and in increasing physical exercise, and also awareness of the current diseases and problems encountered by the older adults. in future, the study cut-off point of the sit-to-stand-test for each age range should be determined and used as a reference for balance disorder. patients who have fallen or have had multiple falls can be used as samples for furtherstudy as well as a reference. a larger sample size can be used for future study and use of other methods to assess balance disorder. moreover, more study and test should be conducted to assess patients’ balance problems. references 1. world health organization. global health and ageing. geneva: who;2011. 2. badan pusat statistik republik indonesia. statistik penduduk lanjut usia indonesia tahun 2010. 2010 [cited 2013 april 13]; available from: http://www.bps.go.id/ hasil_publikasi/stat_lansia_2010/index3. php?pub=statistik%20penduduk%20 l a n s i a % 2 0 i n d o n e s i a % 2 0 2 0 1 0 % 2 0 althea medical journal. 2016;3(1) 109 %28hasil%20sp%202010%29. 3. stuart-hamilton i. the psychology of ageing: an introduction. 5th ed. philsdelphia: jessica kingsley. 2012. 4. lin hw, bhattacharyya n. balance disorders in the elderly: epidemiology and functional impact. laryngoscope. 2012;122(8):1858–61. 5. roberts ds, lin hw, bhattacharyya n. health care practice patterns for balance disorders in the elderly. laryngoscope. 2013;123(10):2539–43. 6. national institute on deafness and other communication disorders. balance disorders. 2009 [cited 2013 february 20]; available from: http://www.nidcd. nih.gov/health/balance/pages/balance_ disorders.aspx. 7. steven kn, lang ia, guralnik jm, melzer d. epidemiology of balance and dizziness in a national population: findings from the english longitudinal study of aging. age ageing. 2008;37(3):300–5. 8. tiedemann a, shimada h, sherrington c, murray s, lord s. the comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. age ageing. 2008;37(4):430– 5. 9. jönsson r, sixt e, landahl s, rosenhall u. prevalence of dizziness and vertigo in an urban elderly population. j vestib res. 2004;14(1):47–52. 10. whitney sl, wrisley dm, marchetti gf, gee ma, redfern ms, furman jm. clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the five-times-sit-to-stand test. physther. 2005;85(10):1034–45. 11. pasma jh, bijsma ay, klip jm, stijntjes m, blauw gj, muller m, et al. blood pressure associates with standing balance in eldery outpatients. plos one. 2014;9(9):1–9. 12. hart ec, joyner mj, wallin bg, charkoudian n. sex, ageing and resting blood pressure: gaining insights from the integrated balance of neural and haemodynamic factors. j physiol (lond). 2012;590(9):2069–79. 13. lang ia, llewellyn dj, alexander k, melzer d. obesity, physical function, and mortality in older adults. j am geriatr soc. 2008;56(8):1474–8. 14. villareal dt, chode s, parimi n, sinacore dr, hilton t, armamento-villareal r, et al. weight loss, exercise, or both and physical function in obese older adults. n engl j med. 2011;364(13):1218–29. 15. ahmed t, haboubi n. assessment and management of nutrition in older people and its importance to health. clin interv aging. 2010;5:207–16. 16. porto hcd, pechak cm, smith dr, reedjones jr. biomechanical effects of obesity on balance. int j exerc sci. 2012;(4):301–9. 17. ziere g, dieleman jp, hofman a, pols hap, van der cammen tj, stricker bhch. polypharmacy and falls in the middle age and elderly population. br j clin pharmacol. 2006;61(2):218–23. 18. pan hh, li cy, chen tj, su tp, wang ky. association of polypharmacy with fallrelated in older taiwanese people: age and gender -specific analyses. bmj open. 2013;4(3):1–7. 19. salzman b. gait and balance disorders in older adults. am fam physician. 2010;82(1):61–8. 20. thaweewannakij t, wilaichit s, chuchot r, yuenyong y, saengsuwan j, siriatiwat w, et al. reference values of physical performance in elderly thai people who are functioning well and dwelling in the community. phys ther. 2013;93(10):1312– 20. ku shi yun, irma ruslina defi, lazuardhi dwipa: characteristics of older adult with balance disorder in rehabilitation clinic of dr. hasan sadikin general hospital 2014 althea medical journal. 2016;3(2) 265 oto–acoustic emission and auditory brainstem response profile in children with speech delay at dr. hasan sadikin general hospital bandung liani mulasari gunawan,1 wijana,2 yuni s. pratiwi3 1faculty of medicine universitas padjadjaran, 2department of otorhinolaryngology–head and neck faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: language and speech delay are the most common developmental disorders found in children. hearing loss is the most common cause of speech delay among children. hearing loss can be detected by subjective and objective examinations. oto–acoustic emission (oae) and auditory brainstem response (abr) are objective electrophysiological examination with 100% sensitivity and 99% specificity. this study was aimed to describe oae and abr profile in children with speech delay at dr. hasan sadikin general hospital bandung methods: this study was conducted in 2014 used the descriptive cross–sectional design with a total sampling of 333 medical records of children diagnosed with speech delay with inclusion criteria patients aged 1–5 years at the hearing disorders clinic of otorhinolaryngology–head and neck surgery policlinic at dr. hasan sadikin general hospital bandung during the period of 2011–2012. results: out of all of the samples, there were 176 boys (52.9%) and 157 girls (47.1%). most of children aged 24–35 months. eighty children (24%) with normal hearing and 253 children (76%) with hearing loss. hearing loss with sensorineural hearing loss (snhl) type most occured at the profound degree with 244 cases. conclusions: hearing loss is the most common cause of speech delay in children. speech delay can be prevented by conducting the oae and abr examinations as early as possible. [amj.2016;3(2):265–8] keywords: auditory brainstem response examination, hearing loss, oto–acoustic emission examination, speech delay correspondence: liani mulasari gunawan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62811958787 email: lianimulasari@gmail.com introduction language and speech delay are the most common developmental disorders found in children.1,2 speech and language in children can give negative impacts to the socialisation, personality, behaviour and school attainment. these disorders are experienced by 5–8% preschool age children. in indonesia prevalence of speech delay in children is between 5–10% in school age children.3-5 speech and language disorders are disorders or delay in children in speaking or using language in the daily life. hearing loss is one of the most common causes of the speech delay.6,7 the joint committee on infant hearing (jcih) decided that hearing loss in children should have been detected at the age of three months and the proper intervention is started before six months or less.8 this priority is in concert with the national initiative. it is shown in the result of a study conducted by yoshinaga–itano et al.9 hearing loss can be detected by subjective and objective examinations. oto-acoustic emission (oae) and auditory brainstem response (abr) are objective electrophysiological examinations with 100% sensitivity and 99% specificity. for children, oae is an ideal screening from the ear to the cochlea, since it can examine babies from the age of one day in a fast, easy, and unpainful way. the abr examination measures the brainstem auditory pathway and can estimate the threshold of hearing and the type of hearing loss (conductive, sensorineural, or mixed).1,6 this study was aimed to describe oae and abr profile in children with speech delay at dr. hasan sadikin general hospital bandung. althea medical journal. 2016;3(2) 266 amj june 2016 methods this study was conducted in 2014 using a descriptive cross-sectional design to 333 medical records of children diagnosed with speech delay at the hearing disorders clinic of otorhinolaryngology–head and neck surgery policlinic at dr. hasan sadikin general hospital bandung during the period of 2011–2012. the inclusion criteria were medical record data of speech delay patients aged 1–5 years and exclusion criteria were patients with craniofacial, congenital anomali and other problems. table 2 results of oto-acoustic emission (oae) examination . result number % pass 80 24 refer 253 76 total 333 100 table 1 incidence of hearing loss. age (months) normal hearing loss boy(s) girl(s) total boy(s) girl(s) total 12–23 2 0 2 12 10 22 24–35 25 8 33 56 45 101 36–47 16 9 25 27 45 72 48–59 12 2 14 12 22 34 > 60 2 4 6 12 12 24 total 57 23 80 119 134 253 table 3 results of auditory brainstem response (abr) examination type of hearing degree of hearing threshold of hearing (db) right ear left ear n % n % normal normal 0–25 80 24 80 24 snhl mild 26–40 10 3 10 3 moderate 41–60 7 2,1 13 3.9 severe 61–80 72 21.6 75 22.5 profound 81 or > 155 46.6 146 43.9 chl mild 26–40 4 1.2 3 0.9 moderate 41–60 0 0 0 0 severe 61–80 2 0.6 1 0.3 profound 81 or > 3 0.9 5 1.5 mhl mild 26–40 0 0 0 0 moderate 41–60 0 0 0 0 severe 61–80 0 0 0 0 profound 81 or > 0 0 0 0 total 333 100% 333 100% note: snhl = sensorineural hearing loss; chl = conductive hearing loss; mhl = mixed hearing loss althea medical journal. 2016;3(2) 267 results out of all of the samples, there were 176 boys (52.9%) and 157 girls (47.1%). most of children aged 24-35 months. based on the result of oae examination there were 80 children (24%) with normal hearing (pass in examination) and 253 children (76%) with hearing loss (refer in examination). based on the result of abr examination, hearing loss with sensorineural hearing loss (snhl) type most occured at the profound degree with 244 cases. discussion it is shown that the least number of patients were the one-year-old patients, meaning that the parents had not realized the hearing loss of their children (table 1). this might be caused by the lack of awareness and knowledge of the parents regarding the children’s reaction to sound and the impact of hearing in children. if the children were diagnosed with hearing loss before the age of 6 months, those children would still have bigger chances to be able to speak and communicate optimally, since they would obtain earlier managements. this is shown in the result of a study conducted by yoshinaga–itano et al.9 which stated that earlier identification and management of permanent childhood hearing loss is known to result in improved developmental outcomes, children with hearing loss who got intervention before six months of age got improved results in language at 3 years of age. from the results of oae and abr examinations, the ratio of children with hearing loss and normal children is 3:1. there were 253 children (75.98%) with speech delay who got “refer” or “not pass” in their oae examination, which means that hearing loss is the most common cause. the results of abr examination is categorized based on the degree of hearing loss and location of the disorder, whether at the left or right ear.10 the most frequently found hearing loss was the profound hearing loss, in which the children were not able to hear a loud sound from a nearby place. the hearing loss which most commonly occurred was the snhl i.e. 244 cases and conductive hearing loss (chl) i.e 9 cases. the snhl is the sensorineural hearing loss, i.e. a disorder at the cochlea or the inner ear. children are indeed identified with snhl, a variety of diagnostic tests can be recommended depending on the patient’s history and physical examination.11 for infants/children with profound hearing loss, probability exists by use of hearing aids or cochlear implantation (ci) and speech therapy. children with mild hearing loss should also be monitored for developmental and behavioral problems (attention deficit/hyperactivity disorder, autism, and learning disabilities), speech therapy and use of hearing aids. speech and language disorders seem to have more impact on motor performance than only language disorders, and it seems that when speech production is affected, motor problems are more pronounced. the results support the need to give early and more attention to motor development. moreover, special attention should be given to children with speech and language disorders.12 as a conclusion, this study found that hearing loss is the most common cause of speech delay in children (76%). speech delay can be prevented by conducting the oae and abr examinations as early as possible. references 1. american speech–language–hearing association. preferred practice patterns for the profession of speech–language pathology.2004 [cited 2013 october 12]. available from: www.asha.org/ uploadedfiles/pp2004-00191.pdf 2. american academy of pediatrics, committee on practice and ambulatory medicine and bright futures steering committee. recommendations for preventive pediatric health care. pediatrics. 2007;120(6):1376 3. law j, garrett z, nye c. speech and language therapy intervention for children with primary speech and language delay or disorder. cochrane database syst rev. 2003;(3):cd004110 4. nelson hd, nygren p, walker m, panoscha r. screening for speech and language delay in preschool children: systematic evidence review for the us preventive service task force. pediatric.2006;117(2):e298–319 5. gunawan g, destiana r, rusmil k. gambaran perkembangan bicara dan bahasa anak usia 0–3 6. futures steering committee and medical home initiatives for tahun. sari pediatri. 2011;13(1):21–5. 7. council on children with disabilities; section on developmental behavioral pediatrics; bright children with special liani mulasari gunawan, wijana, yuni s. pratiwi: oto–acoustic emission and auditory brainstem response (abr) profile in children with speech delay at dr. hasan sadikin general hospital bandung althea medical journal. 2016;3(2) 268 amj june 2016 needs project advisory committee. identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. pediatrics. 2006:118(1):405–20. 8. soepardi ea, iskandar n, bashiruddin j, rastuti rd, editors. buku ajar ilmu kesehatan–telinga hidung tenggorok kepala & leher. 6th ed. jakarta: fakultas kedokteran universitas indonesia, 2007.p.31–40 9. american academy of pediatrics; joint committee on infant hearing. year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. pediatrics. 2007;120(4):898 –921 10. yoshinaga–itano c, sedey al, coulter dk, mehl al. language of early– and later– identified children with hearing loss. pediatrics. 1998:102(5):1161–71. 11. moeller mp, white kr, shisler l. primary care physicians’ knowledge, attitudes, and practices related to newborn hearing screening. pediatrics. 2006;118(4):1357– 1370. 12. harlor jr adb, bower c. hearing assessment in infants and children: recommendations beyond neonatal screening. pediatrics. 2009;124(4):1252– 63. 13. visscher c, houwen s, scherder ej, moolenaar b, hartman e. motor profile of children with developmental speech and language disorders. pediatrics. 2007;120(1):e158–63. althea medical journal. 2016;3(3) 396 amj september 2016 relationship between physical activity and age on flatfoot in children carmellia janice jasrin,1 wulan mayasari,2 lulu eva rakhmilla3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cellular biology faculty of medicine universitas padjadjaran, 3department of epidemiology and biostatistics faculty of medicine universitas padjadjaran abstract background: modern technology has decreased physical activities of most people, especially children. a low physical activity is one of the risk factors of flatfoot. flatfoot is a flattening of medial longitudinal arch of the foot (mla) affecting human’s body posture and gait. the objective of this study was to analyze the relationship between physical activity and age on flatfoot. methods: this study selected 271 children from the elementary school of cikeruh 1, jatiroke 1, and paripurna using cluster random sampling method. data were collected from august to november 2015. the primary data were collected using questionnaire to determine the physical activity level and footprint method to measure mla height which was counted using arch index (ai). if the ai>0.26, it was considered low arch/flatfoot. statically, the collected data were analyzed by fisher’s exact test. results: from a total of 271, 151 (55.7%) children had a low activity level with 120 of them (44.3%) were flatfoot, whereas in 113 (41.7%) children with an intermediate activity level, 76 children (28.0%) were flatfoot; and from a total of 7 (2.6%) children with a high activity level, 4 children (1.5%) were flatfoot. there was a negative correlation between age and arch index, right foot (r=-1.67;p=0.006), left foot (r=1.56;p=0.01). this study proved that there was a relationship between the level of physical activity and flatfoot (fisher=6.125/p=0.040). conclusions: the arch index of the foot becomes smaller with age with an inverse correlation and low physical activities have been proved to have contibution to flatfoot occurrence. [amj.2016;3(3):396–400] keywords: arch index of the foot, children, flatfoot, medial longitudinal arch of the foot, physical activity correspondence: carmellia janice jasrin, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628971908593 email: carmelliajanice@gmail.com introduction modern technologies influence the development of new practical approaches to perform tasks that make many changes in human behaviour and lifestyles. nowadays, people prefer to use any form of transportation than walking. moreover, people tend to use entertainment devices such as gadgets in mobile phone, watch television, or play video games to refresh their mind. such activities are seen in children who prefer playing video games than running, exercising, and other forms of outdoor/physical activities. when playing video games, children often play it for hours. this behavior causes children spend more time sitting and lacking of physical activities.1,2 in the united states, a decreased physical activity issue has become a consideration and some studies revealed that schools have the most potential in increasing physical activity in children.3 physical activity can reduce the risk of stroke, diabetes mellitus type 2, and severe injuries from falling.1 moreover, physical activity is one of the factors relating to flatfoot.4 flatfoot is a condition of a decrease in the medial longitudinal arch of the foot (mla).5 medial longitudinal arch of the foot development begins between ages 2 and 3 when children start walking, and stops 6 years after initial development between ages 12 and 13. flatfoot is considered normal in children up to the age of 13 because the mla structure still undergoes development. however, if flatfoot persists after the age of 13, it was feared to be permanent or further complications can possibly arise in adulthood such as fractures, scoliosis, and abnormal body posture.6,7 althea medical journal. 2016;3(3) 397 physical activity is one of many factors that influences flatfoot. in children having poor physical activities, fat in the soles of the feet break at a slower rate causes the foot to be flat.4 the aim of this study was to determine the relationship between physical activity and age on flatfoot in elementary school children. methods this study was carried out as a part of a study of teenager health conducted by the community health and wellness (kesehatan dan kebugaran komunitas) research center at faculty of medicine universitas padjajaran. a crosssectional study was chosen and sample were collected using the cluster random sampling method. twenty nine elementary schools in jatinangor, west java were compiled into 3 big groups based on location. an elementary school was selected from each location and 3 elementary schools were obtained randomly (1:3). the study population of this sample was students of sd cikeruh 1, sd jatiroke 1 and sd paripurna. the minimum samples of this study were 323 calculated for independentcontinuous analytic study. however, this study did not meet the minimum sample size. the inclusion criteria of this study were students from elementary schools in jatinangor from class 4 and class 5, who had completed the informed consent form and were presented during data collection. students who had other anatomical feet abnormalities besides flatfoot were excluded. the mla was obtained by measurements based on the footprint method to determine the arch index.8 arch index was measured based on the footprint by locating the axis and drawing a line from the middle of the heel to the end of the index toe. then, a straight line was constructed from the protruding part of the metatarsal. lines formed between the medial point of the heel and the point of the protruding part of the metatarsal were obtained and divided into three equal parts. measurements were made using the following equation.9,10 the criteria to determine the height of the foot arch were ai ≤0.21 = high arch, 0.21≤ai≤0.26 = normal arch and ai ≥0.26 = flat arch or flatfoot. the criteria of flatfoot stated that if one of both feet was positive for flatfoot, the individual was said to have flatfoot. physical activities of the subjects were determined by using the physical activity questionnaire for older children (paq-c). this questionnaire was used to evaluate daily activities of subjects in the last 7 days and was only reserved for children between the ages of 8 to 12 years old.11 the questionnaire was validated (cronbach alpha’s = 0.751) before being used in this study. physical activities in children were divided into 3 categories. from the questionnaire, a score of 1 and 2 were categorized as low, a score of 3 was categorized as average, and a score of 4 and 5 were categorized as high. this study involved 271 children as subjects. seventeen children were not included figure 1 arch index measurements10 note: ai=(b )/(a+b+c) carmellia janice jasrin, wulan mayasari, lulu eva rakhmilla: relationship between physical activity and age on flatfoot in children althea medical journal. 2016;3(3) 398 amj september 2016 table 1 characteristics of elementary school students in jatinangor characteristics n=271 age, years, median 10 sex, male (%) 50.9 school (%) sdn cikeruh 1 25.1 sdn jatiroke 1 29.5 sdn paripurna 45.4 physical activity (%) low 55.7 medium 41.7 high 2.6 in the analysis of results because they did not meet the inclusion criteria and data of these subjects were incomplete. the data were analyzed statistically. the data distribution for numerical variable was already normal. medial longitudinal arch of the foot and age were analyzed using hypothesis bivariate correlation. physical activity and flatfoot occurrence were analyzed using fisher’s exact test. this study was approved by the health research ethical committee from faculty of medicine, universitas padjadjaran no. 350/ un6.c2.1.2/kepk/pn/2013. results this study discovered that more than half of the 271 subjects were boys, between 8 and 13 years old. a majority of students, as much as 135, were from sdn paripurna and the lowest numbers of student were from sdn cikeruh 1. subjects had varying levels of physical activity. one hundred and fifty one subjects were characterized as having the low level of activity, 113 (41.7%) were characterized as having the average level of activity, and 7 (2.6%) subjects were characterized as having the high level of activity. figure 2 correlations between age and arch index note: (a) left foot (b) right foot althea medical journal. 2016;3(3) 399 the arch index of the left foot in children aged 8 years old had a mean of 0.343, a minimum value of 0.333, and a maximum value of 0.354. children aged 9 years old had a mean of 0.295, a minimum value of 0.170, and a maximum value of 0.366. children aged 10 years old had a mean of 0.282, a minimum value of 0.130, and a maximum value of 0.430. children aged 11 years old had a mean of 0.279, a minimum value of 0.190, and a maximum value of 0.363. children aged 12 years old had a mean of 0.241, a minimum value of 0.198 and a maximum value of 0.330. the arch index of the right foot in children aged 8 years old had a mean of 0.325, a minimum value of 0.322, and a maximum value of 0.329. children aged 9 years old had a mean of 0.292, a minimum value of 0.214, and a maximum value of 0.354. children aged 10 years old had a mean of 0.282, a minimum value of 0.182, and a maximum value of 0.570. children aged 11 years old had a mean of 0.272, a minimum value of 0.176, and a maximum value of 0.356. children aged 12 years old had a mean of 0.251, a minimum value of 0.216, and a maximum value of 0.338. the arch index of the foot became smaller with age with an inverse correlation in the right foot (r = -1.67) and in the left foot (r = -1.56). there was a strong relationship between arch index and age (p = 0.006) in the right foot and (p = 0.01) in the left foot. both feet shared the same relationship. (figure 2) this study proved that there was a significant relationship between the level of physical activity and the occurrence of flatfoot (p value = 0.040) discussions subjects from this study were between 8–13 years old with a median age of 10. the age described in this study was the development period of mla which begins between ages 2–3 years old, when children begin to walk, and stops between ages 12–13 years old.4 there were more boys (50.9%) than girls (49.1%) in this study. a study in hong kong7 discovered that the occurrence of flatfoot is more common in boys than in girls. the occurrence of flatfoot in boys is higher because of the greater rear foot valgus and late development of the rear foot in boys.7 moreover, this study discovered that a majority of students had the low level of activity (55.7%) and a minority of students had the high level of activity (2.6%). there was a strong correlation between arch index with age on the right foot (p value = 0.006) and on the left foot (p value = 0.01). an inverse correlation between age and arch index with the right foot and left foot indicated a decrease in arch index with an increase in age. a low arch index indicated an increased mla. these results reflected previous studies which reported that mla increases with an increase in age.7,12 however, in this study, the twelve year old children were only 4 children and thirteen year old child was only 1 child, thus, this study could not detect if the children aged 12 and 13 had a higher or lower mla compared to others. the occurrence of flatfoot was the highest among children with the low level of activity (44.3%). previous study reported that fat breaks at a slower rate at the soles of the feet in children with a low level of physical activity and ultimately results in a decreased mla.3 however, this study was unable to describe whether flatfoot occurrence was high among children with the low level of activity because the numbers of children with the low level of activity were the highest among other activity levels. the low activity level was the highest because there was no routine sport activity and no specific exercise to train foot muscle in school such as football, basketball, running, etc. this study proved that there was a significant relationship between the level of physical activity and the occurrence of flatfoot, and was in accordance with literature reporting that there was a relationship between level of physical activity and the occurrence of flatfoot.6 this study had several limitations. the table 2 flatfoot based on levels of physical activity physical activity flatfoot (+) flatfoot (-) significance (n=200) (n=71) low 44.30% 11.40% intermediate 28.00% 13.70% *6.215 (0.040) high 1.50% 1.10% note: *fisher exact carmellia janice jasrin, wulan mayasari, lulu eva rakhmilla: relationship between physical activity and age on flatfoot in children althea medical journal. 2016;3(3) 400 amj september 2016 footprint method had measurement bias, where the thickness of the stamp really determines the result of arch index measurement. the questionnaire described children’s activities in the last 7 days. however, activities in the last 7 days did not describe the whole activities. in conclusion, there is an inverse correlation between the arch index and age, meaning that mla decreases with age. physical activity can be concluded to be a factor influencing the occurrence of flatfoot. this study suggests that schools have to add routine sport activities which also exercise foot muscle. schools can record health status of the children and report to the primary health care if there is any abnormality. therefore, if there is any abnormality, it can be treated immediately. the government also plays a role in this issue, also can promote and have routine exercise programs in schools. primary health care can have screening programs for flatfoot which provide early detection and management. references 1. miles l. physical activity and health. nutrition bulletin. 2007;32(4):314–63. 2. parizkova j, chin m-k, chia m, yang j. an international perspective on obesity, health and physical activity: current trends and challenges in china and asia. j exerc sci fit. 2007;5(1):7–23. 3. pate rr, davis mg, robinson tn, stone ej, mckenzie tl, young jc. promoting physical activity in children and youth a leadership role for schools: a scientific statement from the american heart association council on nutrition, physical activity, and metabolism (physical activity committee) in collaboration with the councils on cardiovascular disease in the young and cardiovascular nursing. circulation. 2006;114(11):1214–24. 4. ali m, asadullah m, amjad i. prevalence of the flatfoot in 6-10 years old school going children. rmj. 2013;38(4):385–7. 5. harris ej, vanore jv, thomas jl, kravitz sr, mendelson sa, mendicino rw, et al. diagnosis and treatment of pediatric flatfoot. j foot ankle surg. 2004;43(6):341– 73. 6. pauk j, ezerskiy v, raso jv,rogalski m. epidemiologic factors affecting plantar arch development in children with flat feet. j am podiatr med assoc. 2012;102(2):114– 21. 7. ezemaci, abaraoguuo, okaforgo. flatfoot and associated factors among primary school children : a cross-sectional study. hong kong physiotherapy journal. 2014;32(1):13–20. 8. queen rm, mall na, hardaker wm, nunley ja. describing the medial longitudinal arch using footprint indices and a clinical grading system. foot ankle int. 2007;28(4):456–62. 9. mandal s, mandal p, basu r. study of variations in the medial longitudinal arch leading to development of adult acquired flat foot. int j med pharm sci. 2013;3(11):28–37. 10. menz hb, fotoohabadi mr, wee e, spink mj. visual categorisation of the arch index : a simplified measure of foot posture in older people. j foot ankle res. 2012;5(1):1–7. 11. kowalski kc, crocker pre, donen rm. the physical activity questionnaire for older children (paq-c) and adolescents (paq-a) manual. saskatoon, sk, canada: college of kinesiology, university of saskatchewan; 2004. 12. potaliya p, chowdhary ds, dadhich a, kataria sk. study of plantar medial longitudinal arch and its pattern of development in western rajasthan population. int j anat res. 2014;2(1):187– 90. althea medical journal. 2016;3(3) 364 amj september 2016 pattern of energy and protein intake among stunted children aged 3–5 years in jatinangor geraldo laurus,1 siti nur fatimah,2 dida akhmad gurnida3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: a child’s optimal growth can be indicated by many factors, among them is body height, therefore stunting is one of the evidences of undergrowth. nutrition, on the other hand, is one of variables affecting growth. this study aimed to examine the nutrition intake, in the form of energy, carbohydrate, protein, and fat in stunted children aged 3–5 years in jatinangor. methods: this cross sectional study was carried out in september to october 2014 using the random sampling method. dietary data from 70 stunted children aged 3–5 years in pre–school and kindegarten located in 9 urban areas in jatinangor were collected through 3x24 recall and food frequency questionaire and analyzed. results: mean energy intake was 1113.6 kcal and mean carbohydrate intake was 137.4 grams. mean protein intake was 38.4 gram and mean fat intake was 38.2 gram. types of food highly consumed as the source of carbohydrate were white rice and biscuit, and as the source of protein were meatball, sausage, and egg. highest consumed vegetables, fruits and snack were water spinach, cabbage, watermelon, banana, and milk respectively. conclusions: mean energy intake, mean carbohydrate intake, and mean fat intake are all below the recommended dietary allowance (rda) 2013 with individual value of mean energy intake is below rda 2013 for all subjects. mean protein intake is slightly above rda 2013. [amj.2016;3(3):364– 70] keywords: child, nutrition, stunting correspondence: geraldo laurus, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281806910993 email: geraldolaurus@yahoo.co.id introduction the preschool period during developmental task of children should be followed by a good growth function so it can be optimal. stunting is one of the indications which shows growth is not optimal.1 recent finding suggest that stunting affect a high percentage of children worldwide.2 indonesia basic health research (riset kesehatan dasar, riskesdas indonesia) in 2013 stated that the prevalence of stunted and very stunted children below 5 years old was 19.2% and 18.0% respectively.3 this should be anticipated because stunting during early childhood would affect a person in later life.4 nutrition intake was one factor that influenced growth. a good nutrition intake, divided into energy and protein, would optimize growth.5 later, the nutrition intake would be influenced by the sosioeconomical status.6 the recommended dietary allowances (rda) provided by the indonesian ministry of health in 2013 was a tool used to determine the nutritional intake status.7 jatinangor is an area located in west java and classified as a low socioeconomic area.8 there was no specific study which determined the nutritional intake among stunted children in indonesia. however, there was only one study that stated low socioeconomic area are related to a high prevalence of stunting children.6 this study was conducted to determine the intake of energy and protein among stunted children aged 3–5 years in jatinangor. althea medical journal. 2016;3(3) 365geraldo laurus, siti nur fatimah, dida akhmad gurnida: pattern of energy and protein intake among stunted children aged 3–5 years in jatinangor methods this was a cross sectional study which described the mean intake of energy and protein among stunted children aged 3–5 years in jatinangor. this study was conducted during september–october 2014. all procedures were approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the study started by selecting one kindergarten in each district in jatinangor using the random sampling method. next, each student was asked for an ethics approval, then asked for the date of birth and performed a height measurement, using a microtoise staturemeter with 200 cm measurement capacity with 0.1 cm precision. the height and birth date were analyzed using the world health organization (who) anthroplus software to determine whether the subject was stunted, very stunted or normal. children who were not healthy or under treatment of a chronic disease were excluded in the study. there were 70 subjects included in the study by using this method. the second data collection was conducted to measure the mean intake and type of food consumed by the subjects. the method used for this second data collection were 3x24 hours food recall and food frequency questionnaire. the interviews were carried out to the subjects’ parents or primary care guide who accompanied subjects to school. later on, the data were matched by using the buku foto makanan, survei konsumsi makanan individu published by the ministry of health, republic of indonesia. the data were counted in gram, then analyzed using nutrition software. each mean intake was matched with the rda provided by the indonesian ministry of health in 2013, published in peraturan menteri kesehatan (permenkes) nomor 75 tahun 2013. all complete data were finalized using a computer analysis software. results based on the subjects’ distribution according to gender and age, the subjects were mostly boys (61%) and 5–year–old (64%) (table 1). the highest energy intake in stunted subjects aging 3–5 years in jatinangor was 1381.5 kcal, came from a 5-year-old. the lowest energy intake, 922 kcal, came from a 4–year–old. the highest carbohydrate intake in stunted subjects aged 3–5 years in jatinangor was 180.7 g, came from a 5–year–old. the lowest carbohydrate intake, 87.7 g, came from a 4– year–old. the mean of protein intake in stunted subjects aged 3–5 years in jatinangor was 38.4 g. the highest protein intake, 58.9 g, came table 1 child subjects distribution according to gender and age characteristics n % gender boy 43 61 girl 27 39 age (years) 3 2 3 4 23 33 5 45 64 table 2 values of energy, carbohydrate, protein, and fat intake variables n median max min var energy intake (kcal) 70 1090 1381 922 122 carbohidrate intake (gram) 70 137 181 88 24 protein intake (gram) 70 38 59 17 9 fat intake (gram) 70 39 68 20 10 althea medical journal. 2016;3(3) 366 amj september 2016 table 4 protein food source food type never 1–3 times a day 4–6 times a week 1–3 times a week 1–3 times a month meatballs 5 6 47 9 3 squid 47 1 10 5 7 chicken 12 3 10 36 9 beef 11 2 6 17 36 sausage 4 12 38 11 5 chicken egg 2 11 41 9 7 quail egg 33 0 8 8 21 chicken satay 13 0 3 12 42 mutton satay 65 0 0 3 2 fresh water fish (gurame, mas, nila, lele, patin) 17 0 16 23 14 tofu 2 11 47 6 4 tempeh 5 9 39 10 7 mung bean 8 2 24 28 9 peanut 13 0 5 46 6 chinese long bean 16 3 23 21 7 table 3 carbohydrate food source food type never 1–3 times a day 4–6 times a week 1–3 times a week 1–3 times a month plain rice 0 70 0 0 0 cassava 10 7 25 17 11 fresh corn 30 5 15 7 13 potato 5 11 3 33 18 wet noodle 9 11 24 21 6 instant noodle 3 12 38 15 2 rice noodle 40 1 6 2 21 white bread 26 12 17 15 10 biscuits 21 25 13 7 4 rice flour 13 3 35 17 2 prawn/fish crackers 8 17 32 5 8 cilembu sweet potato 57 0 1 3 9 cereal 27 4 5 20 14 wheat bread 60 0 3 3 4 sweet potato 49 1 5 7 8 althea medical journal. 2016;3(3) 367 from a 5–year–old. the lowest protein intake, 16.7 g, came from a 3–year–old. the highest fat intake, 68 g, came from a 5–year– old. the lowest fat intake, 19.6 g, came from a 4–year–old (table 2). this study also collected additional data on the carbohydrate and protein food source, vegetables, fruits, and snacks which could also affect the mean of energy and protein intake. the mostly consumed carbohydrate food sources among stunted 3–5 year -old subjects were plain rice, instant noodle, and white bread. cereals, cilembu sweet potato, sweet potato, and potato were the least consumed types, or not consumed at all (table 3). meatballs, tofu, tempeh, sausage, and chicken egg were the 5 protein sources with highest consumption. while, seafood such as fresh prawns, squids, and salt water fish were very rarely consumed by children in jatinangor. fresh water fish such as gourami, common carp, catfish, and mozambique tilapia were consumed by stunted 3–5 year-old children in jatinangor 3 times a month at most (table 4). the types of vegetable with highest consumption were spinach, cabbage, water spinach, and carrot. the fruits with highest consumption were guava, cantaloupe, papaya, and watermelon (table 5). the snacks with highest consumption were ice cream, condensed mild, packaged milk, and cheese, on average 2 times a day. dairy products that were rarely consumed were yogurt and cheese (table 6). discussion the frequency of stunted children in this study was in agreement with a study by bose et al.9 which states that the frequency of stunted children increases with age.9the mean energy intake was still far below the rda for 4–6 years old children (1660 kcal) and slightly below the rda for 1–3 years old (1125 kcal). the mean geraldo laurus, siti nur fatimah, dida akhmad gurnida: pattern of energy and protein intake among stunted children aged 3–5 years in jatinangor table 5 vegetables and fruit types food type never 1–3 times a day 4–6 times a week 1–3 times a week 1–3 times a month spinach 12 2 21 25 10 common bean 21 4 17 2 26 cassava leaf 61 0 0 0 9 mushroom 11 3 3 36 17 water spinach 7 5 51 5 2 cucumber 4 1 2 13 50 cabbage 10 2 36 12 10 water cabbage 6 1 21 18 24 carrot 3 17 15 19 16 beansprouts 16 2 13 21 18 avocado 21 0 1 18 30 guava 7 2 2 14 45 wax apple 15 1 17 13 24 orange 2 4 11 19 34 mango 26 0 4 2 38 cantaloupe 12 0 7 28 23 banana 15 0 11 23 21 snakefruit 34 0 2 1 33 watermelon 2 9 27 10 22 althea medical journal. 2016;3(3) 368 amj september 2016 carbohydrate intake of the subjects was still far below the rda for 4-6 years old children (220 g). this value is also below the rda for 1–3 years old children (155 g). the mean protein intake was slightly above the rda for 4-6 years old (35 g). this is also far above the rda for 1–3 years old children (26 g). the mean fat intake of the subjects was far below the rda for 4–6 years old children (62 g) and the rda for 1–3 years old children (44 g). a study in egypt has some correlation with this study. the similarities between the two studies are that there are no other diseases or symptoms other than stunting, identical measuring tool for body height, and the same data collection procedure on nutritional intake. the differences are that the study in egypt10 includes subjects of 2 years of age or older and uses a nutritional conversion standard issued by the national nutrition institute of egypt. the similar findings are that the mean energy and fat intake are both below the value recommended by the egypt’s authority. the mean energy and fat intake in the egyptian study are 927.35 kcal and 25.04 kcal respectively, which are quite different from the result of this study. that study also shows a mean protein intake that is below the recommended value, while this study discovered that the daily protein requirement was met. however, it is similar in the sense that the percentage of protein requirement is the highest compared to energy and fat.10 reddy et al.11 have conducted a study in india which discovers a similar result that the prevalence of protein intake fulfillment is slightly higher than other nutrition.11 this finding is also supported by a study in belgium12 which states that preschool children have mean nutritional intake that is below the recommended value. furthermore, the most consumed carbohydrate food source was the same with the one discovered by a study in bogor, that were rice and noodles. the most consumed protein food source also conformed to the study in bogor were milk, eggs, tofu, and tempeh. table 6 types of snack food type never 1–3 times a day 4–6 times a week 1–3 times a week 1–3 times a month ice cream 3 3 24 27 13 powdered milk 16 11 29 14 0 packaged milk 21 23 6 20 0 condensed milk 4 39 20 7 0 goat milk 68 0 0 0 2 yogurt 23 1 1 12 33 cheese 33 0 2 4 31 jelly 10 2 2 16 41 chocolate 13 4 7 15 31 baso tahu 7 7 14 31 11 wafer 11 24 31 2 1 pudding 12 1 4 29 24 biscuits 21 25 13 7 4 ciki box 2 29 31 5 3 sweet martabak 41 0 0 12 17 meat martabak 45 0 2 9 14 althea medical journal. 2016;3(3) 369 the most consumed vegetables and fruits were water spinach, cabbage, watermelon and banana. the study in bogor13 also discovers carrots and oranges to be two of the most consumed food. the low consumption of carrots and oranges in jatinangor was probable due to their limited availability compared to the study in bogor.8 the most consumed snack in jatinangor was also the same with bogor: milk and biscuits. the main limitation of this study was that the parents or wardens interviewed in this study were not able to recall the type or amount of food that their children had consumed. this limitation had been minimalized by asking them to take notes on whatever food the children consumed in the last 3 days prior to the interview. another limitation was the usage of 3x24 hours food recall and food questionnaire was unable to calculate the absolute amount of energy and protein intake when correlated with certain diseases, and was only able to moderately measure the relative risk and short-term protein intake even though body height was affected by protein intake in a long term. this method was used because compared to other dietary intake interview method, 24 hours recall were recommended to estimate the amount of food taken in a short period of time.14 as a conclusion, the mean energy, carbohydrate, and fat intake are all below rda 2013. the mean protein intake is slightly above rda 2013. the possible interventions in 3-5 years old children with stunting and unfulfilled rda can refer to petunjuk teknis pelaksanaan gizi buruk (technical guidelines for malnutrition) that was issued by the program nasional pemberdayaan masyarakat (pnpm). this program starts with case finding and is consecutively followed by management and further examinations, coordination with local health authorities, and lastly by intervention and follow-ups. food intake and physical activity should also be adjusted so that a child can achieve optimal growth.15 references 1. golden mh. proposed recommended nutrient densities for moderately malnourished children. food nutr. 2009;30(3):s267–342. 2. de onis m, onyango a, borghi e, siyam a, blössner m, lutter c. worldwide implementation of the who child growth standards. public health nutr. 2012;15(09):1603–10. 3. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri;2013. 4. walker sp, chang sm, powell ca, simonoff e, grantham-mcgregor sm. early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation. j nutr. 2007;137(11):2464–9. 5. dewey kg, begum k. long-term consequences of stunting in early life. matern child nutr. 2011;7(s3):5–18. 6. ulfani dh, martianto d, baliwati yf. faktorfaktor sosial ekonomi dan kesehatan masyarakat kaitannya dengan masalah gizi underweight, stunted, dan wasted di indonesia: pendekatan ekologi gizi. jurnal gizi dan pangan. 2011;6(1):59–65. 7. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 75 tahun 2013. jakarta: departemen kesehatan republik indonesia; 2013. 8. badan pusat statistik provinsi jawa barat. jawa barat dalam angka 2012. jawa barat: badan pusat statistik provinsi jawa barat; 2012. 9. bose k, biswas s, bisai s, ganguli s, khatun a, mukhopadhyay a, et al. stunting, underweight and wasting among integrated child development services (icds) scheme children aged 3–5 years of chapra, nadia district, west bengal, india. matern child nutr. 2007;3(3):216–21. 10. mikhail wz, sobhy hm, el-sayed hh, khairy sa, salem hya, samy ma. effect of nutritional status on growth pattern of stunted preschool children in egypt. academic journal of nutrition. 2013;2(1):01–9 11. reddy cg, arlappa n, kumar rh, kumar s, brahmam g, balakrishana n, et al. diet and nutritional status of rural preschool children in the state of orissa. j hum ecol. 2006;19(3):205–14. 12. huybrechts i, matthys c, vereecken c, maes l, temme eh, van oyen h, et al. food intakes by preschool children in flanders compared with dietary guidelines. int j environ res public health. 2008;5(4):243– 57. 13. welasasih bd, wirjatmadi rb. beberapa faktor yang berhubungan dengan status gizi balita stunting. the indon j of ph. 2012;8(3):99–104. geraldo laurus, siti nur fatimah, dida akhmad gurnida: pattern of energy and protein intake among stunted children aged 3–5 years in jatinangor althea medical journal. 2016;3(3) 370 amj september 2016 14. holmes b, dick k, nelson m. a comparison of four dietary assessment methods in materially deprived households in england. public health nutr. 2008;11(05):444–56. 15. nicklas t, hayes d. position of the american dietetic association: nutrition guidance for healthy children ages 2 to 11 years. j am diet assoc. 2008;108(6):1038–44. althea medical journal. 2016;3(3) 371 score of fine motor skill in children with down syndrome using nintendo wii puspasari,1 marietta shanti prananta,2 eddy fadlyana3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: down syndrome occurs due to an extra chromosome 21, known as trisomy 21. in addition to delayed cognitive and speech development, children with down syndrome may also experience delayed gross and fine motor development. virtual reality therapy, such as nintendo wii is a computer-based technology that allows users to interact with a virtual three-dimensional scenario and the most innovative physical rehabilitation method. high scores indicate that the player has a good motor skill. this study aimed to examine the difference between the score of fine motor skill in children with and without down syndrome. methods: an analytic cross-sectional study was conducted from august to november 2015 to 40 children aged between 9–12 years old who came from public primary schools and special needs schools in bandung, west java. they were divided into 2 groups using random gender and age pairing; one group was children with down syndrome and another other group was normal children. the children’ scores of nintendo wii game were collected three times. the collected data were statistically analyzed by chi-square test. results: the proportion of children with low-grade fine motor skill in down syndrome group was larger than those with high-grade fine motor skill. in the other hand, in normal children group, the proportion was reversed compared to down syndrome group. there was a significant difference in score of fine motor skill between children with down syndrome and normal children (p=0.000). conclusions: the fine motor skill of children with down syndrome is poorer than normal children’s. [amj.2016;3(3):371–5] keywords: down syndrome, fine motor skill, nintendo wii correspondence: puspasari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85722652965 email: puspass11@gmail.com introduction down syndrome is a genetic condition which can cause delayed cognitive and motor development as well as physical impairments.1 down syndrome occurs due to the presence of an extra chromosome 21, a condition also known as trisomy 21.1 children with down syndrome are subject to varying degree of cognitive developmental delay: mild (iq 50– 70), moderate (iq 35–50), and severe (iq 20– 35).2 bruni3 stated that the cognitive level of a child will influence his motor skills. children with low cognitive skills have a high probability to experience a delay in achieving certain motor skills.3 santos et al.4 pointed out that fine motor skill is one of the most affected aspects in children with down syndrome, and impairment of speech skills as well. virtual reality therapy (vrt) is one of the latest and most innovative physical rehabilitation methods.5 this therapy method is a computer-based technology that allows users to interact with a virtual threedimensional scenario.5 the therapy method that is able to provide a real simulation during practice can be easily adjusted to the need of patient, can be done repetitively, increase patient motivation in doing practice, and can be done at home. it can also be used to monitor and evaluate the treatment.6 ortizcatalan et al.6 stated that the advantage of this therapy focuses on some important aspects to repair the defective motor skill. this defect repair requires the presence of a functional movement in relevant particular althea medical journal. 2016;3(3) 372 amj september 2016 environmental simulation with high intensity repetition in great numbers, and informative feedback response. thus, vrt can be concluded as a therapy for motor skills that provide all the necessary components, such as necessary therapeutic environment and an interesting and relevant practice that can be adapted to the patient’s needs. nintendo wii, one of modern examples of virtual reality for gaming, is an interactive virtual game console which is proven effective as a tool for motor skill therapy.5–8 in addition to improve motor skill, nintendo wii can also be used to measure the degree of motor skill via informative feedback response6, based on the score gained after a game is over. high scores indicate that the player has a good motor skill. based on the description above, the objective of the study was to analyze the difference between the fine motor skill in children with and without down syndrome by using in-game scores of nintendo wii virtual game. methods an analytic cross-sectional study was conducted from august to november 2015 by collecting nintendo wii in-game scores as a measure of fine motor skill from all children with down syndrome in special needs school (sekolah luar biasa, slb) c budi daya, slb abcd caringin, slb c cipaganti, and slb c sumbersari antapani kota bandung and all normal children in public primary school (sekolah dasar negeri, sdn) babakan ciparay 4 kota bandung west java. total sampling was used in the population mentioned above with random gender and age pairing in the members of the two groups. the minimum sample size was determined by performing a pilot study on 20 normal children in sdn babakan ciparay to measure the proportion in the normal children group (p1). the minimum sample size which consisted of 20 children for each group was calculated by using the formula for unpaired categorical variables. the study subjects were selected based on inclusion and exclusion criteria which were confirmed via interview with their caretakers. the inclusion criteria were normal children and children with down syndrome aged 9 to 12 whose minimal exposure to nintendo wii were less than 4 hours a month. the exclusion criteria in this study were orthopedic limitations in performing exercises, such as deformities in neck, shoulder, arm, and wrist; and positive history of seizures. selected subjects were given explanation in the study procedures. the subjects and their caretakers were given a chance to ask questions about the procedures. the caretakers and the subjects who agreed to participate in a signed informed consent form were included in this study. the subjects from the two children groups were matched based on their age and gender. the overall sizes of the two groups were also matched. fine motor skill was measured by collecting in-game scores in the virtual game cooking mama©, a part of nintendo wii. this cooking simulation game making the player simulate cutting, dicing, peeling, and mixing move was selected with the consideration that this study aimed to examine fine motor skill. such movements require precise upper extremities coordination depending on fine motor skill. before each measurement, each subject was introduced to the method of using nintendo wii for two 10-minute sessions by the operator. all subjects were to finish three game sessions whose scores would be averaged and then collected as data. the scores were further categorized into two categories: 0–50 and 51– 100. the score categories were interpreted as low fine motor skill and high fine motor skill respectively. the collected data were analyzed statistically by chi-square test. the purpose and the methods adopted by table 1 gender and age distribution of the children (n= 40) gender age (years) total 9 10 11 12 children group down syndrome male 2 3 4 1 10 female 2 4 2 2 10 normal male 2 3 4 1 10 female 2 4 2 2 10 total 8 14 12 6 40 althea medical journal. 2016;3(3) 373puspasari, marietta shanti prananta, eddy fadlyana: score of fine motor skill in children with down syndrome using nintendo wii table 2 comparison of fine motor skill in children with or without down syndrome fine motor skill p-valuelow high scores = 0–50 scores = 50–100 children group down syndrome 18 2 0.0000* normal 1 19 note: *chi-squared test table 3 fine motor skill based on the children’s age age (years) fine motor skill low high scores = 0–50 scores = 50–100 children groups down syndrome 9 4 0 10 7 0 11 5 1 12 2 1 normal 9 1 3 10 0 7 11 0 6 12 0 3 this study had been approved by the health research ethics committee of the faculty of medicine universitas padjadjaran no. 587/ un6.c1.3.2/kepk/pn/2015. results from 40 children, numbers of boy and girl in each group were equal (n=10). most of the children were 10 years old (35%), followed by 11 years (30%), 9 years (20%) and 12 years (15%), respectively (table 1). in normal children group, there were more children with high-grade fine motor skill (19 of 20 children) than low-grade fine motor skill (1 of 20 children). in the other hand, in down syndrome group, there were more children with low-grade fine motor skill (18 of 20 children) than high-grade fine motor skill (2 of 20 children). the fine motor skill difference between the children with down syndrome and normal children was highly significant (p=0.000). there was also a significant difference in the ratio of low-grade fine motor skill cases to high-grade fine motor skill cases in the two groups. in the down syndrome group, the ratio was 9:1 while in the normal group, it was 1:19. among the children with down syndrome, there were 2 subjects (aged 11 and 12) who showed high-grade fine motor skill. in the normal children group, there was only 1 subject (aged 9) with low-grade fine motor skill. discussions this study revealed a highly significant fine motor skill difference between the two groups. children with down syndrome had a lower fine motor skill compared to normal children. this study has a similar result compared to a study by ferreira-vasques and lamônica9 using denver ii test. moreover, santos et al.4 mentioned that speech and fine motor coordination are the two worst affected aspects in children with down syndrome. one limitation of this study was that several children with down syndrome have a very limited speech capability. in addition, ferreiravasques and lamônica9 discovered that children with down syndrome have difficulty in forming a complete sentence, althea medical journal. 2016;3(3) 374 amj september 2016 this study had been approved by the health research ethics committee of the faculty of medicine universitas padjadjaran no. 587/ un6.c1.3.2/kepk/pn/2015. results from 40 children, numbers of boy and girl in each group were equal (n=10). most of the children were 10 years old (35%), followed by 11 years (30%), 9 years (20%) and 12 years (15%), respectively (table 1). in normal children group, there were more children with high-grade fine motor skill (19 of 20 children) than low-grade fine motor skill (1 of 20 children). in the other hand, in down syndrome group, there were more children with low-grade fine motor skill (18 of 20 children) than high-grade fine motor skill (2 of 20 children). the fine motor skill difference between the children with down syndrome and normal children was highly significant (p=0.000). there was also a significant difference in the ratio of low-grade fine motor skill cases to high-grade fine motor skill cases in the two groups. in the down syndrome group, the ratio was 9:1 while in the normal group, it was 1:19. among the children with down syndrome, there were 2 subjects (aged 11 and 12) who showed high-grade fine motor skill. in the normal children group, there was only 1 subject (aged 9) with low-grade fine motor skill. discussions this study revealed a highly significant fine motor skill difference between the two groups. children with down syndrome had a lower fine motor skill compared to normal children. this study has a similar result compared to a study by ferreira-vasques and lamônica9 using denver ii test. moreover, santos et al.4 mentioned that speech and fine motor coordination are the two worst affected aspects in children with down syndrome. one limitation of this study was that several children with down syndrome have a very limited speech capability. in addition, ferreira-vasques and lamônica9 discovered that children with down syndrome have difficulty in forming a complete sentence, or even a word, and expressing their thoughts. in practice sessions, such children tended not to ask questions even when they did not understand something. this might be because these children realized that the operator would probably not understand what they were trying to communicate. as such, it would be preferred if their teachers or parents accompany them throughout data collection so as to facilitate easier communication. fine motor skill got better as the children got older (table 3). in the down syndrome group, the only 2 children with high-grade fine motor skill were 11 and 12 years old. compared to other children in the same group, the 2 children had a better speech skill and a faster grasp of how to play nintendo wii. meanwhile, the only normal child with lowgrade fine motor skill was 9 years old. by observation, that particular child had a low enthusiasm in playing nintendo wii. the child also confessed to never playing any video game console before and did not have any interest in such games. the child might have a fine motor skill disorder or a lower cognitive skill when compared to other normal children, a condition that surely demands further investigations. comparison between members with the same age of two groups revealed that children with down syndrome had a delay on achieving the level of fine motor skill shown in their corresponding age. the youngest child with down syndrome who had a highgrade fine motor skill was 11 years old. this delay is consistent with the study by frank and esbensen.10 the developmental delay in children with down syndrome was not only found in fine motor skill but also in cognitive aspect.1 in cognitive developmental delay, the severity varies from mild (iq 50–70), moderate (iq 35–50), to severe (iq 20–35).3 bruni3 stated that the cognitive levels of a child affects his motor skill development and vice versa. consequently, a child with a low cognitive capability has a high probability of having delayed motor development.3 the statement corresponding with this study findings that established the cognitive level was linearly correlated with the fine motor skill in both groups of children. the unavailable information on cognitive capabilities was one of the limitations of this study, since only few parents knew what their children’s iqs were. interviews revealed that some parents had already forgotten it while some children had never been tested before. further analysis on the relationship between the cognitive levels and delayed fine motor development, especially in children with down syndrome, was therefore not performed. in this study, fine motor skill was measured via in-game scores in a nintendo wii game. other than being used as a therapy modality, nintendo wii can also be used to measure althea medical journal. 2016;3(3) 375 motor skill levels, as retrieved from informative feedback.7 informative feedback from this type of therapy gave information on the patient’s performance in fulfilling exercises in the form of in-game scores.7 the score information displayed on screen represented the player’s ability in finishing the game.7 even though the game cooking mama© has more appeals to the girls, there was no observable difference of the general level of enthusiasm between the boys and the girls when playing the game. several children from the control group admitted to frequently playing other video game consoles, such as the playstation®. such children achieved higher scores compared to children who had never or infrequently played the playstation®. the finding led to one limitation of this study, i.e. different baseline of the two groups. no children in the study group (children with down syndrome group) had ever played a video game while some subjects in the control group (normal children) had played video games before. based on the presented discussion above, the limitations of this study were the unavailable information on speech skill, cognitive skill, and history of exposure to virtual reality or video game consoles, which might have a close relationship and a significant influence on the measurement procedure in this study. meanwhile, interviews with caretakers of children with down syndrome revealed that some children did not complete their therapies. the mentioned reasons were the high cost of therapy, the high frequency and long period of therapy, lack of caretakers that can accompany the children throughout therapy sessions, and the children’s refusal to go to therapy sessions. the short period of the study was also one of the limitations of this study. data collection from children with down syndrome required much more time compared to normal children. a child with down syndrome needed, in average, 45 minutes to finish data collection. in conclusion, there is a significant difference in fine motor skill between the two groups, where the fine motor skill of children with down syndrome is lower than normal children. with increasing age, the fine motor skill of children was also increasing. nintendo wii, an established physical therapy modality, can also be used to measure fine motor skill. however, in fine motor skill measurement using nintendo wii, consideration should also be given to the subject’s speech skill, cognitive skill, and history of playing virtual reality games or video game consoles. references 1. van gameren-oosterom hb, fekkes m, buitendijk se, mohangoo ad, bruil j, van wouwe jp. development, problem behavior, and quality of life in a population based sample of eight-year-old children with down syndrome. plos one. 2011;6(7):1– 8. 2. bull mj. clinical report-health supervision for children with down syndrome. pediatrics. 2011;128(2):393–406. 3. bruni m. fine motor skills in children with down syndrome: a guide for parents and professionals topics in down syndrome. 2nd ed. bethesda: woodbine house; 2006. 4. santos apm, weiss sli, almeida gmf. assessment and intervention in the motor development of a child with down syndrome. rev bras educ espec. 2010;16(1):19–30. 5. samia a, rahman a, rahman. efficacy of virtual reality-based therapy on balance in children with down syndrome. j appl oral sci. 2010;10(2):254–61. 6. ortiz-catalan m, nijenhuis s, ambrosch k, bovend’eerdt t, koenig s, lange b. virtual reality. in: pons jl, toricelli d, editors. emerging therapies in neurorehabilitation. 1st ed. heidelberg: springer-verlag; 2013. p. 249–65. 7. berg p, becker t, martian a, primrose kd, wingen j. motor control outcomes following nintendo wii use by a child with down syndrome. pediatr phys ther. 2012;24(1):78–84. 8. hammond j, jones v, hill el, green d, males i. an investigation of the impact of regular use of the wii fit to improve motor and psychosocial outcomes in children with movement difficulties: a pilot study. child care health dev. 2014;40(2):165–75. 9. ferreira-vasques at, lamônica da. motor, linguistic, personal and social aspects of children with down syndrome. j appl oral sci. 2015;23(4):424–30. 10. frank k, esbensen aj. fine motor and self-care milestones for individuals with down syndrome using a retrospective chart review. j intellect disabil res. 2015;59(8):719–29. puspasari, marietta shanti prananta, eddy fadlyana: score of fine motor skill in children with down syndrome using nintendo wii althea medical journal. 2016;3(3) 469 prevalence and characteristics of low back pain among productive age population in jatinangor dini diwayani novitasari,1 henny anggraini sadeli,2 arifin soenggono,3 yulia sofiatin,4 hadyana sukandar,4 rully m. a. roesli5 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran, 4department of epidemiology and biostatistic faculty of medicine universitas padjadjaran, 5department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: low back pain is one of the global health issues which prevalence is high among productive ages. it oftentimes corresponds with one’s physical activity during work . the purpose of this study was to determine theprevalence and characteristics of low back pain among productive age population in jatinangor, west java, indonesia. methods: this study was a cross-sectional descriptive study conducted during the period of august to october 2014 in the three villages in jatinangor, west java, indonesia. in order to determine the demographic data and history of low back pain in the last three months, about 1075 productive age populations were selected through validated questionnaire as the secondary data. these data consisting of 310 subjects were then described according to the pain characteristics and physical activity during work. results: during three months of examination, s the prevalence of low back pain was 38.4%, with the average age 50–59 years old. furthermore, about 22.3% subjects were indicated chronic low back pain. the most prevalent qseverity of the pain was dull pain (29.4%), followed with pins and needles pain (23.1%), as the intensity of the pain increased, there was a tendency of increasing interference in daily activities. static posture was also the most frequent physical activity during work (53.2%). conclusions: the prevalence of low back pain is more than one third (38.4%) among productive age populations in jatinangor, west java, indonesia.[amj.2016;3(3):469–76] keywords: characteristic, low back pain, prevalence, productive age correspondence: dini diwayani novitasari, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281310168480 email: dini.diwayani@yahoo.com introduction low back pain (lbp) is common among populations worldwide, and one of the main causes of disability, absenteeism, and poor performance at work.1 a systematic review which measures global prevalence of low back pain reveals that point prevalence of activitylimiting low back pain lasting for more than one day is estimated to be 11.9±2.0%, and the one-month prevalence is estimated to be 23.2±2.9%.2 in asia, a study in japan3 identified that one-month prevalence and lifetime prevalence of low back pain are approximated to be 35.7% and 83.4%, respectively. it can be said that the prevalence of low back pain varies around the world. a hospital-based prevalence of low back pain as stated in multi-center research in 14 hospitals in indonesia claimed that 18.37% of patients visited are diagnosed low back pain.4 productive age populations have the highest prevalence.it increases at the age 30 and slightly declines at 60.5 such increase may be caused by greater physical activity at work which includes several body positions. this is claimed to be the risk factors of low back pain.6,7 the prevalence of low back pain in general populations in indonesia has not been widely investigated, moreover the characteristics of it. a population-based on research is thus needed to determine such prevalence and characteristics and also to serve early althea medical journal. 2016;3(3) 470 amj september 2016 prevention of disability caused by low back pain. therefore, the aim of this study was to determine the prevalence and characteristics of low back pain among productive age populations in jatinangor, west java, indonesia. methods this descriptive study used a cross-sectional approach and was conducted in three villages in jatinangor, west java, indonesia, during the period of august to october 2014. a total of 1075 data were collected from the secondary data of community health and wellness working group titled ‘epidemiologi hipertensi dan albuminuria pada masyarakat jatinangor’. the main study used multi-stage random sampling as data collection method. based on sample size calculation using cross-sectional approach, 97 subjects as minimum sample are needed. the study population consisted of productive age populations. according to indonesian ministry of health (2009), productive age is defined as those aged 15 to 64 years old.8 this study categorized the criteria of people aged at least 18 years old who already owned an identity card. inclusion criteria of this study were (1) 18 to 64 years old subjects whose residence located near to the study was carried out, (2) willing to be a sample in the study by filling in informed consent. whereas, the exclusion criteria were (1) subjects whose demographic data were not complete, (2) subjects who were absent t at the time the research conducted. this study was based on validated guidedquestionnaire. the questionnaire consisted of self-reported information including demographic data and current or previous history of low back pain in the last three months, along with characteristics of the pain, physical activity during work, and effort done to relieve the pain of those indicated low back pain. ethical approval was obtained from the health research ethics committee of faculty of medicine, universitas padjadjaran, bandung. the study consent was also obtained from the development planning agency at sub-national level (badan perencanaan pembangunan daerah) of sumedang. demographic characteristics of interest in this study included gender, age, and occupation. low back pain was defined by pain felt at posterior aspect of the body from the lower margin of the twelfth ribs to the lower gluteal folds or lumbal and lumbo-sacral area4, which was measured by pain drawing. characteristics of this pain were low back pain, onset, frequency, severity, and intensity of the pain, along with effort done to relieve the pain. based on types, low back pain was categorized by low back pain with inclination of red flags syndrome, low back pain with accompanying radicular pain, and non-specific low back pain with no red flags symptoms and radicular pain. based on onset and frequency, low back pain was classified into acute and chronic. chronic low back pain had more than 12 weeks onset as a cut-off and more often frequency.4the severity of pain was described by sharp pain, electric shock pain, dull pain, burning pain, pins and needles pain, stiff pain, and others if any. the intensity of pain was measured by faces pain scale-revised with 0–10scale and pain interference in daily activities.9 physical activities during work which stated as the risk factors of low back pain were categorized by lifting heavy object, bending and twisting, bending, static posture, and others if any. the collected data were inputs and managed using red cap electronic data capture tools hosted at faculty of medicine, universitas padjadjaran.10 research electronic data capture (red cap) is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources. furthermore, the data were analyzed using computer program. descriptive analysis was then performed to investigate all variables. results data were collected at desa hegarmanah, desa cilayung, and desa cipacing, jatinangor. from total of 1075 subjects, 172 samples had to be excluded due to incomplete demographic data, and among them, only 808 subjects fit the inclusion criteria. from total of 808 subjects, the numbers of both male and female subjects were 272 and 536, or with male:female ratio of 1:2 (table 1). more than half of the subjects who claimed to have low back pain history were female (64.5%); however, the proportion of low back pain in male and female were amounted to 40.4% and 37.3%, respectively. the age group of 30–49 years old was most frequently found in total subjects (n=445, 55.0%). the highest prevalence of low back pain were in althea medical journal. 2016;3(3) 471dini diwayani novitasari, henny anggraini sadeli, arifin soenggono, yulia sofiatin, hadyana sukandar, rully m. a. roesli: prevalence and characteristics of low back pain among productive age population in jatinangor table 1 demographic characteristics and prevalences of low back pain based on gender, age, and occupation demographic data lbp history lbp proportions n % n / total % gender (n=808) male 110 35.5 110/272 40.4 female 200 64.5 200/536 37.3 age (n=808) < 20 years old 2 0.6 2/19 10.5 20–29 years old 36 11.6 36/130 27.6 30–39 years old 87 28.1 87/225 38.6 40–49 years old 84 27.1 84/220 38.1 50–59 years old 79 25.5 79/162 48.7 > 60 years old 22 7.1 22/52 42.3 occupation (n=808) unemployedt 9 2.9 9/23 39.1 housewives 146 47.1 146/396 36.8 entrepreneurs 72 23.2 72/172 41.8 private employees 20 6.5 20/51 39.2 government employees 6 1.9 6/21 28.5 labors 38 12.2 38/85 44.7 manufactory workers 12 3.9 12/40 30.0 construction workers 5 1.6 5/10 50.0 farmer and farm workers 14 4.5 14/23 60.8 laundry workers 1 0.3 1/2 50.0 janitors 6 1.9 6/10 60.0 others 19 6.1 19/60 31.6 the age group of 50–59 years old (48.7%). half of the subjects who had low back pain were housewives (n=396, 47.8%), but in comparison to the total of the subjects, farmer and farm workers had the highest prevalence of low back pain. there were 310 subjects who claimed to have low back pain in the last three months; therefore, the three month prevalence of low back pain in this population-based study were 38.4%. among those who claimed to have low back pain, 130 subjects (41.9%) were suspected to have low back pain with red flags syndrome (table 2). low back pain with red flags syndrome was classified as having fever in accordance with the pain to suspect infection, traumatic back injury, neoplasia, and also having urinary retention to suspect cauda equine syndrome and neurologic deficit. low back pain with radicular pain was found in one fifth of the subjects, and 51.2% of them were classified as non-specific low back pain due to no radicular pain and no red flags syndrome. the proportion of chronic low back pain was reported more than one fifth (22.3%) of total low back pain. the severity of the pain which had the highest prevalence was dull pain (29.4%), followed by pins and needles pain (23.1%). the most frequent intensity of pain based on faces pain scale was moderate. as the intensity of the pain increased, there was a tendency of increasing interference in daily activities (table 4). low back pain caused absenteeism in one fourth of the subjects (25.8%). it is estimated althea medical journal. 2016;3(3) 472 amj september 2016 table 2 prevalence of low back pain based on types types of low back pain results n % low back pain with suspected red flags symptoms (n = 288) infection 52 18.0 trauma 33 11.4 neoplasia 5 1.7 cauda equine syndrome and neurologic-deficit 40 13.8 low back pain with radicular pain (n = 283) 56 19.7 non-specific low back pain (n = 291) 149 51.2 table 3 prevalence of low back pain based on pain characteristics features results (n) proportions (%) severity of pain (n=302) sharp pain 68 22.5 electric shock pain 18 5.9 dull pain 89 29.4 burning pain 50 16.5 pins and needles pain 70 23.1 stiff pain 55 18.2 others 9 2.9 intensity of pain (n=298) mild 105 35.2 moderate 157 52.7 severe 36 12.1 to 20.6% for absenteeism of one to three days and 5.2% for more than three days of absenteeism. static posture such as sitting and standing in longer duration had the highest proportion of physical activity during work which claimed to be the risk factor of low back pain (table 5). hardly, there were one fifth of the subjects which reported seeking medical attention to relieve the pain (20.6%). there were 32.3% of them who had spontaneous healing and about one third preferred to treat themselves, for instances, by taking over-the-counter medication, getting massage, and lying down. discussion this study was conducted at the three villages in jatinangor, one of the districts in sumedang, west java, indonesia. one university and three colleges were located in jatinangor, thus, it has been known as an educational district. it further escalates physical and social development, as well as economic growth which shifts some of the subdistricts in jatinangor into urban. on the other hand, many productive age residents still have occupation commonly found at rural area such as labor, consisting of manufactory worker, construction worker, farmer and farm worker, laundry worker, and janitor, as well as microentrepreneur such as peddler and craftsman. the vast majority of subjects in productive age who claimed to have low back pain in the last three months were female. however, in comparison with total subjects, the proportion of both male and female were almost the same. high prevalence in male who claimed to have althea medical journal. 2016;3(3) 473dini diwayani novitasari, henny anggraini sadeli, arifin soenggono, yulia sofiatin, hadyana sukandar, rully m. a. roesli: prevalence and characteristics of low back pain among productive age population in jatinangor to 20.6% for absenteeism of one to three days and 5.2% for more than three days of absenteeism. static posture such as sitting and standing in longer duration had the highest proportion of physical activity during work which claimed to be the risk factor of low back pain (table 5). hardly, there were one fifth of the subjects which reported seeking medical attention to relieve the pain (20.6%). there were 32.3% of them who had spontaneous healing and about one third preferred to treat themselves, for instances, by taking over-the-counter medication, getting massage, and lying down. discussion this study was conducted at the three villages in jatinangor, one of the districts in sumedang, west java, indonesia. one university and three colleges were located in jatinangor, thus, it has been known as an educational district. it further escalates physical and social development, as well as economic growth which shifts some of the subdistricts in jatinangor into urban. on the other hand, many productive age residents still have occupation commonly found at rural area such as labor, consisting of manufactory worker, construction worker, farmer and farm worker, laundry worker, and janitor, as well as microentrepreneur such as peddler and craftsman. the vast majority of subjects in productive age who claimed to have low back pain in the last three months were female. however, in comparison with total subjects, the proportion of both male and female were almost the same. high prevalence in male who claimed to have low back pain may be caused by occupational exposures as explained by punnett et al.11, such as heavy lifting in labor workers. whereas, study published by fernández-de-las-peñas et al.12 stated that female also has risk factors to develop low back pain, one of the major causes may be due to postmenopausal osteoporosis. doing housework can also be a risk factor for female. a study by hoy et al.5 claimed that the most frequent age group is 50–59 years old with the tendency of increasing prevalence and slight decrease afterwards. this possibly table 4 prevalences of low back pain according to pain interference in daily activities based on intensity of pain intensity of pain pain interference in daily activities total (n = 298) still able to do daily activities begin to distract disturb daily activities n % n % n % n % mild pain 0-3 scale 91 86.7 9 8.6 5 4.7 105 100 moderate pain 4-7 scale 122 77.7 21 13.4 14 8.9 157 100 severe pain 8-10 scale 14 38.9 7 19.4 15 41.7 36 100 total 227 76.2 37 12.4 34 11.4 298 100 table 5 prevalence of low back pain based on physical activities during work physical activities during work results n =310 proportions % lifting heavy objects 104 33.5 bending and twisting 52 16.8 bending 117 37.7 static posture 165 53.2 others 13 4.2 althea medical journal. 2016;3(3) 474 amj september 2016 is caused by high occupational exposure in early years of productive age and degenerative disease in older productive age population. this population-based study revealed three month prevalence of low back pain that was 38.4%. this finding was higher than the previous population-based study conducted in taiwan13 whose finding is 25.7%. whereas, lifetime prevalence of low back pain is two times higher (79.3%) as published by ozdemir et al.14 in a study in central malatya, turkey. low back pain with inclination of red flags syndrome was found in one third of the subjects, which was higher than expected. beside questionnaire, physical examination at health facility is needed to further diagnose low back pain with red flags syndrome. in addition, an immediate plan for therapy needs to be reckoned to minimize possible paralysis . other types of low back pain were low back pain with radicular pain and non-specific low back pain. these were found respectively in one fifth and half of the subjects. according to indonesian national consensus 2011 by indonesian neurological association (perhimpunan dokter spesialis saraf indonesia), prevalence of non-specific low back pain was found as the major cases. it was estimated to be 85% of all types of low back pain.15 those variations can be caused by different instruments used in the study. the most common etiology of low back pain with radicular pain was due to discogenic. physical activities such as standing, bending, sitting, heavy lifting, and twisting motion can aggravate the pain, whereas, in non-specific low back pain, the predisposing factor may be due to mechanism.15 prevalence of chronic low back pain was found in more than one fifth of the subjects. it was higher than a population-based study by meucci et al.16 in brazil whose finding was reported only 9.6%. ten percent of acute low back pain can also progress to chronic low back pain.15 it can increase absenteeism at work and multiply health care costs two times greater compared to people without low back pain, consisting of physician fees, investigations, medications, and hospitalizations.17,18 the intensity of the pain varied among the subjects. although there was a tendency of increasing pain interference in daily activities,some subjects who claimed severe pain still had no disturbance in their daily activityies. this is possibly caused by different threshold of pain among the subjects. another cause would probably due to financial issue which requires one to fulfill daily fees so that they are not allowed to skip work. the severity of pain can determine specific types of pain, which consist of nociceptive pain and neuropathic pain, and therefore, the types of low back pain according to its etiology, such as radicular pain would be caused by neuropathic lesion. despite its etiology, one can experience several severities of pain simultaneously.4 the quality of pain in the result of this study varied in all types of low back pain,probably due to different subjects’ interpretations on the questioner. it was believed that the answer was also influenced by a high subjectiveness of the pain. descriptions of the quality of the pain in local language is highly advisable to avoid different interpretation. physical activities during work can predispose to low back pain due to minor injury of low back anatomy structure. a study by mohseni-banpei et al.19 reported that prolonged standing, repeated movements, and awkward postures are the most prevalent aggravating factors (85.2%, 50.2%, and 48.4, respectively). whereas, murtezani et al.20 published that main risk factors of low back pain are extreme trunk flexion (or = 3.5, 95% ci 1.7-7.3), as well as lifting of loads (or = 3.5, 95% ci 1.9-6.2), pushing or pulling heavy loads (or = 3.5, 95% ci 1.9-6.2), and exposure to whole body vibration (or = 1.7, 95% ci 1.0 -3.0). the results of this study are consistent with previous studies, specifically static posture in most of the subjects. prolonged sitting, standing, and bending, such as in peddler and craftsman can increase pressure in intervertebral disk and also cause muscle tension, which further increase the risk of having low back pain. only one fifth of the subjects were seeking medical attention (20.6%); therefore, hospitalbased study revealed lower prevalence compared to prevalence in general population, as published by multi-center research in 14 hospitals in indonesia (18.37%).4 one third of the subjects preferred to treat themselves, the vast majority of them were taking over-thecounter medication that probably because the analgetic medication is easily purchased. as a conclusion, this study demonstrated that the population-based prevalence of low back pain is more than one third (38.4%) among productive age population. age category of 50–59 years old is the most prevalent. more than one fifth has chronic low back pain. severity of the pain which has the highest prevalence is dull pain, followed by pins and needles pain. as intensity of the pain increased, there is a tendency of increasing interference in daily activities. static posture althea medical journal. 2016;3(3) 475dini diwayani novitasari, henny anggraini sadeli, arifin soenggono, yulia sofiatin, hadyana sukandar, rully m. a. roesli: prevalence and characteristics of low back pain among productive age population in jatinangor is the most frequent physical activity during work, and only one fifth of the subjects are seeking medical attention. there were some limitations of this study. the study design was a cross-sectional study, and therefore, was unable to prove causation. there were subjects who did not answer several questions, thus, there were differences in total subjects in statistical analysis. this study was also limited in methods by using secondary data from questionnaire, which might led to information bias. slightly higher prevalence of low back pain in productive age population in indonesia should more focus. health education in the population such as proper body mechanism to be applied in daily activities is needed to lower the risk of low back pain and to minimize the possible paralysis caused by low back pain. references 1. kaplan w, wirtz vj, manteel-teeuwisse a, stolk p, duthey b, laing r. low back pain. priority medicines for europe and the world 2013 update. geneva: who; 2013. p. 165–8. 2. hoy d, bain c, williams g, march l, brooks p, blyth f, et al. a systematic review of the global prevalence of low back pain. arthritis rheum. 2012;64(6):2028–37. 3. fujii t, matsudaira k. prevalence of low back pain and factors associated with chronic disabling back pain in japan. eur spine j. 2013;22(2):432–8. 4. meliala l, pinzon r. patofisiologi dan penatalaksanaan nyeri punggung bawah. in: meliala l, editor. kumpulan makalah pain symposium: toward mechanism based treatment. yogyakarta: perhimpunan dokter spesialis saraf indonesia; 2004. p. 109–16. 5. hoy d, brooks p, blyth f, buchbinder r. the epidemiology of low back pain. best pract res clin rheumatol. 2010;24(6):769–81. 6. yue p, liu f, li l. neck/shoulder pain and low back pain among school teachers in china, prevalence and risk factors. bmc public health. 2012;12:789. 7. klipstein a, nydegger a. back pain in the working age population. ther umsch. 2013;70(9):515–21. 8. data penduduk sasaran program pembangunan kesehatan tahun 2007– 2011. pengertian dan kegunaan data penduduk sasaran program. jakarta: pusat data dan informasi kementrian kesehatan republik indonesia; 2009. p. 3–10. 9. tomlinson d, von baeyer cl, stinson jn, sung l. a systematic review of faces scales for the self-report of pain intensity in children. pediatrics. 2010;126(5):e1168– 98. 10. harris pa, taylor r, thielke r, payne j, gonzales n, conde jg. research electronic data capture (redcap) a metadatadriven methodology and workflow process for providing translational research informatics support. j biomed inform. 2009;42(2):377–81. 11. punnett l, prüss-utün a, nelson di, fingerhut ma, leigh j, tak s, et al. estimating the global burden of low back pain attributable to combined occupational exposures. am j ind med. 2005;48(6):459–69. 12. fernández-de-las-peñas c, hernándezbarrera v, alonso-blanco c, palacios-ceña d, carrasco-garrido p, jiménez-sánchez s, et al. prevalence of neck and low back pain in community-dwelling adults in spain: a population-based national study. spine (phila pa 1976).2011;36(3):e213–9. 13. chou yc, shih cc, lin jg, chen tl, liao cc. low back pain associated with sociodemographic factors, lifestyle and osteoporosis: a population-based study. j rehabil med. 2013;45(1):76–80. 14. ozdemir f, karaoğlu l, özfirat ö. [the lifetime and point prevalence of neck, upper back and low back pain of the people living in central malatya with influencing factors]. agri. 2013;25(1):27–35. 15. suryamiharja a. nyeri punggung bawah. in: suryamiharja a, purwata te, suharyanti i, yudiyanta, editors. konsensus nasional 1 diagnostik dan penatalaksanan nyeri neuropatik. surabaya: perhimpunan dokter spesialis saraf indonesia; 2011. p. 29–51. 16. meucci rd, fassa ag, paniz vm, silva mc, wegman dh. increase of chronic low back pain prevalence in a medium-sized city of southern brazil. bmc musculoskelet disord. 2013;14:155. 17. gore m, sadosky a, stacey br, tai k-s, leslie d. the burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. spine (phila pa 1976). 2012;37(11):e668–77. 18. depont f, hunsche e, abouelfath a, diatta t, addra i, grelaud a, et al. medical and non-medical direct costs of chronic low back pain in patients consulting primary care physicians in france. fundam clin althea medical journal. 2016;3(3) 476 amj september 2016 pharmacol. 2010;24(1):101–8. 19. mohseni-bandpei ma, ahmad-shirvani m, golbabaei n, behtash h, shahinfar z, fernández-de-las-peñas c. prevalence and risk factors associated with low back pain in iranian surgeons. j manipulative physiol ther. 2011;34(6):362–70. 20. murtezani a, ibraimi z, sllamniku s, osmani t, sherifi s. prevalence and risk factors for low back pain in industrial workers. folia med (plovdiv). 2011;53(3):68–74 althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 110 amj march 2016 success rate of trabeculectomy in primary glaucoma at cicendo eye hospital on january–december 2013 erva monica saputro,1 maula rifada,2 rb. soeherman3 1faculty of medicine universitas padjadjaran, 2department of ophtalmology faculty of medicine universitas padjadjaran/national eye center cicendo eye hospital, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: trabeculectomy is a surgical therapy for glaucoma to preserve visual function by lowering intraocular pressure (iop). in some studies, the success of trabeculectomy in lowering iop is greater than medication. success is defined by iop <21 mmhg, with or without glaucoma medication. primary glaucoma based on the mechanism of aquous humor outflow is divided into primary open-angle glaucoma (poag) and primary angle-closure glaucoma (pacg). this study aimed to know the success rate of trabeculectomy in poag and pacg. methods: this study was a descriptive study conducted at cicendo eye hospital using medical record of poag and pacg patients who underwent trabeculectomy surgery on january–december 2013 with minimal one month follow-up. data collection was conducted during september 2014. data processed in this study were 100 eyes from 76 patients with diagnosis poag and pacg. results: the success rate for trabeculectomy in poag was 79% and pacg was 86%, failure (iop ≥ 21 mmhg) 21% in poag, and 14% in pacg for period 2013 at cicendo eye hospital. conclusions: the success rate of trabeculectomy at cicendo eye hospital is good in one month, with or without glaucoma medication after surgery. [amj.2016;3(1):110–4] keywords: primary angle-closure glaucoma, primary open-angle glaucoma, trabeculectomy correspondence: erva monica saputro, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81313516911 email: erva.monica@yahoo.com introduction glaucoma is the second most leading cause of blindness in the world after cataract.1 glaucoma still become the global concern because early diagnosis is difficult to make and can cause permanent visual impairment. most common type of glaucoma is primary open-angle glaucoma (poag) and primary angle-closure glaucoma (pacg).2 in 2013, 64.3 millions cases of glaucoma were estimated and 60% were in asia, with poag cases 54.3% and pacg 74.7%.3 the goal of glaucoma treatment is to preserve visual function by lowering intraocular pressure below a level that is likely to produce further damage to the optic nerve.4 the most common surgical therapy for glaucoma is trabeculectomy. as increasing prevalence of glaucoma, trabeculectomy is needed to help reduce the number of blindness in the world. in some studies, the success of trabeculectomy in lowering iop is greater than medication.5 success is defined by iop <21 mmhg with/or decrease of >30% iop with or without glaucoma medication.6 success rate of trabeculectomy in poag in england is 80% without medication.7 in indonesia, success rate of trabeculectomy in pacg at cipto mangunkusumo hospital is 18.8% for success without medication and 68.8% for success with medication.8 at cicendo eye hospital, as a referral hospital, there has not been a recent study about the success of trabeculectomy, therefore, this research aimed to evaluate the success rate of trabeculectomy in poag and pacg at cicendo eye hospital in 2013. methods this was a descriptive retrospective study, using medical record from patients with poag and pacg, who underwent trabeculectomy althea medical journal. 2016;3(1) 111 surgery from january to december 2013 at cicendo eye hospital, bandung, west java, indonesia. data collection was conducted during september 2014 after permitted by health research ethics committee faculty of medicine universitas padjadjaran. of 89 medical records, 76 patients (24 poag and 52 pacg) were met in inclusion criteria which had minimal follow up for one month. the rests were excluded because incomplete follow up and the medical record cannot be accessed when collecting data. of 76 patients, 100 eyes underwent trabeculectomy surgery (34 poag and 66 pacg). data collected from medical record were sex; age; address; diagnosis; pre-operative visual acuity; pre-operative iop; one week, one month, three months post-operative iop; and also the numbers of medication given after trabeculectomy surgery. the success rate was defined by iop that is lower than 21mmhg with or without medication in one month after surgery. failure was defined by iop that is higher than 21 mmhg one month after surgery. data were processed using microsoft excel and analyzed using statistical analysis program. results the characteristics in this research were sex, age, and address. patients’ characteristics erva monica saputro, maula rifada, rb. soeherman: success rate of trabeculectomy in primary glaucoma at cicendo eye hospital on january–december 2013 table 1 characteristic of respondents characteristics poag pacg total sex male 16 (67%) 15 (29%) 31 (41%) female 8 (33%) 37 (71%) 45 (59%) age (years) mean±sd 61±10 60±10 range 43-85 40-82 median 60 58 address bandung 10 (42%) 16 (31%) 26 (34%) other cities 14(58%) 36 (69%) 50 (66%) total 24 (100%) 52 (100%) 76 (100%) note: * poag: primary open-angle glaucoma; pacg: primary angle-closure glaucoma; sd: standard deviation table 2 subjects’ clinical characteristics characteristics poag pacg total pre-operative visual acuity normal ( 6/6–6/18) 10 (29%) 21 (32%) 31 (31%) visual impairment(<6/18–6/60) 6 (18%) 7 (11%) 13 (13%) severe visual impairment (<6/603/60) 0 (0%) 4 (6%) 4 (4%) blind (<3/60) 18 (53%) 34 (52%) 52 (52%) pre-operative iop(mmhg) mean ±sd 38±18 41±12 laterality od 16 (47%) 36 (55%) 52 (52%) os 18 (53%) 30 (46%) 48 (48%) total 34 (100%) 66 (100%) 100 (100%) note: * iop: intraocular pressure; od: oculus dextra(right eye); os: oculus sinistra (left eye) althea medical journal. 2016;3(1) 112 amj march 2016 showed that males were more common in poag and females were more common in pacg. minimum age for patient was 40 years old with the mean age of 61 years old in poag and 60 years old in pacg. the origin of patients were commonly from other cities than bandung (table 1). patients’ characteristics of pre-operative visual acuity were mostly categorized as blind. pre-operative iop was higher in pacg with mean iop 41 mmhg than poag with mean iop 38 mmhg (table 2). figure 1 showed the decrease of iop after trabeculectomy. the mean of iop after surgey in pacg was slightly lower than poag in one week, one month, and three months after surgery. this study showed the success rate of trabeulectomy in poag and pacg at cicendo eye hospital in 2013 that was 79% and 86% (table 3), yet, the success still needed glaucoma medication to control the iop after surgery (table 4), mostly one item of medication (table 5). discussion primary glaucoma based on onaquous humor drainage mechanism was divided into primary open-angle glaucoma and primary angleclosure glaucoma; the ratio in asia was higher in pacg than poag, as mentioned in the study by tham et al.3 in this study, males were common in poag and females were common in pacg.4,6,9 the distribution of sex in some studies showed that there is no significant difference, but according to american academy of ophtalmology (aao), females were more common in pacg, probably because of the shallow anterior chamber in female compared to male. some studies also mentioned that males are common in poag.6,10,11 the distribution of poag and pacg based on theory figure1 graphic of tio from pre-surgery, 1 week after surgery, 1 month after surgery, 3 months after surgery table 3 success rate of trabeculectomy (one month post-trabeculectomy) iop (mmhg) poag pacg total <21 27 (79%) 57 (86%) 84 (84%) ≥21 7 (21%) 9 (14%) 16 (16%) total 34 (100%) 66 (100%) 100 (100%) althea medical journal. 2016;3(1) 113 will increase with age, meanwhile, the mean of age in this study was 60 years old, same as the results in some studies in asia that showed the mean age of glaucoma patients which above 50 years old.12 patients mostly came from other cities than bandung to cicendo eye hospital as national eye center. it can be one of the reasons to undergo trabeculectomy surgery for patients who live far from health facility to ease the accomodation and to get the best iop result, to control the visual function. the same consideration was also mentioned in a study at cipto mangunkusumo hospital.8 poag and pacg patients who came to cicendo eye hospital were categorized as blind (<3/60), based on who classification for blindness. in a study in nigeria conducted by adegbehingbe et al.13 pre-operative visual acuity below 6/18 is 93%, and did not show any significant changes in follow up after surgery. the high blindness prevalence caused by glaucoma definitely will increase number of blindness in the world so that glaucoma becomes the second most leading cause of blindness in the world.1 the mean of iop in this tudy before surgery in poag and pacg was 38 mmhg and 41 mmhg, high enough compared to other studies. a study in singapore showed that the mean iop is higher in pacg than in poag (26 mmhg and 24 mmhg).14 at cipto mangunkusumo hospital, the mean of preoperative iop is 29 mmhg.8 the higher iop in pacg may be caused by shallow anterior chamber.4 based on kanski, usually the preoperative iop in pacg patients will be higher than poag between 50–100 mmhg.15 post surgery mean iop in this study was slightly lower in pacg, as mentioned by mahar that mean iop in pacg is 12.17±7.23 and in poag is 12.83±5.71.16 in a study by tabassum et al., the decrease of mean iop after surgeryis 15.78 mmhg and effective to control iop in one year.17 in this study, the success rate of trabeculectomy in poag and pacg was 79% and 86%, but it still needed glaucoma medication to control iop. the success rate in poag with medication was 67%, without medication was 12%,, and success rate in pacg with medication was 71%, without medication was 15%. in indonesia, a study conducted at cipto mangunkusumo hospital showed that success rate of trabeculectomy in pacg with medication is 68.8% and without medication is 18.8%.8 in malaysia, success rate for trabeculectomy (6 months post trabeculectomy) in poag with medication is 12.2%, without medication is 85.1%, and in pacg, success rate with medication is 22.2%, without medication is 72.2%.18 success rate of trabeculectomy in england without medication is 80%.7 failure of trabeculectomy can be caused by the length of use of glaucoma medication before surgery and also by extensive scar in conjunctiva and thin sclera, because it might increase fibroblast and inflammatory cells which cause scar after surgery.19,20 in conclusion, the success rate of trabeculectomy in poag and pacg at cicendo erva monica saputro, maula rifada, rb. soeherman: success rate of trabeculectomy in primary glaucoma at cicendo eye hospital on january–december 2013 table 4 success rate of trabeculectomy with or without glaucoma medication success rate poag pacg total success without medication 4 (12%) 10 (15%) 14 (14%) success with medication 23 (67%) 47 (71%) 70 (70%) failure 7 (21%) 9 (14%) 16 (16%) total 34 (100%) 66 (100%) 100 (100%) table 5 medication given to poag and pacg patients after surgery number of medication poag pacg total without medication 5 (15%) 10 (15%) 15 (15%) 1 item 17 (50%) 29 (44%) 46 (46%) 2 items 12 (35%) 25 (38%) 37 (37%) 3 items 0 (0%) 2 (3%) 2 (2%) total 34 (100%) 66 (100%) 100 (100%) althea medical journal. 2016;3(1) 114 amj march 2016 eye hospital from january to december 2013 is good in one month follow up. limitation in this study is the limited time to collect data. suggestions for further studies, it will be better if the length of follow up is longer to evaluate the long term success rate of trabeculectomy and to increase the numbers of data collection by increasing the duration of study. references 1. pascolini d, mariotti sp. global estimates of visual impairment: 2010. br j ophthalmol. 2011;96(5):614–8. 2. who. vision 2020: the right to sight: a global initiative to eliminate avoidable blindness: action plan 2006–2011. geneva: who library cataloguing-in-publication data; 2007. 3. tham y-c, li x, wong ty, quigley ha, aung t, cheng c-y. global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. ophthalmology. 2014;121(11):2081–90. 4. cioffi ga. 2011–2012 basic and clinical science course, section 10: glaucoma. 1st ed. san fransisco: american academy of ophtalmology; 2011.. 5. burr j, azuara-blanco a, avenell a, tuulonen a. medical versus surgical interventions for open angle glaucoma. cochrane database syst rev. 2012(9):cd004399. 6. yanoff m, duker js. ophthalmology.. 3rd ed. philadelphia mosby/elsevier; 2009. 7. kirwan jf, lockwood aj, shah p, macleod a, broadway dc, king aj, et al. trabeculectomy in the 21st century: a multicenter analysis. ophthalmology. 2013;120(12):2532–9. 8. artini w. outcome of primary angle closure glaucoma management in indonesian population. j indonmed assoc. 2011;61(7):280–4 9. thapa ss, paudyal i, khanal s, twyana sn, paudyal g, gurung r, et al. a populationbased survey of the prevalence and types of glaucoma in nepal: the bhaktapur glaucoma study. ophthalmology. 2012; 119(4):759–64. 10. kim c-s, seong gj, lee n-h, song k-c. prevalence of primary open-angle glaucoma in central south korea. ophthalmology. 2011;118(6):1024–30. 11. yamamoto s, sawaguchi s, iwase a, yamamoto t, abe h, tomita g. primary open-angle glaucoma in a population associated with high prevalence of primary angle-closure glaucoma. ophthalmology. 2014;121(8):1558–65. 12. cho h, kee c. population-based glaucoma prevalence studies in asians. surv ophthalmol. 2014;59(4):434¬47. 13. adegbehingbe b, majemgbasan t. a review of trabeculectomies at a nigerian teaching hospital. ghana med j. 2007;41(4):176-80. 14. ngo cs. a prospective comparison of chronic primary angle-closure glaucoma versus primary open-angle glaucoma in singapore. singapore med j. 2013;54(3):140–5. 15. kanski jj, bowling b. clinical ophthalmology: a systematic approach 7th ed. philadephia: elsevier health sciences uk; 2011. 16. mahar p, laghari a. intraocular pressure control and post operative complications with mitomycin-c augmented trabeculectomy in primary open angle and primary angle-closure glaucoma. pak j ophthalmol. 2011;27(1):35–9. 17. tabassum g, ghayoor i, ahmed r. the effectiveness of conventional trabeculectomy in controlling intraocular pressure in our population. pak j ophthalmol. 2013;29(1):26. 18. hah mh, omar rnr, jalaluddin j, jalil nfa, selvaturai a. outcome of trabeculectomy in hospital melaka, malaysia. int j ophtalmol. 2012;5(3):384–8. 19. bhatia j. outcome of trabeculectomy surgery in primary open angle glaucoma. oman med j. 2008;23(2):86–9. 20. landers j, martin k, sarkies n, bourne r, watson p. a twenty-year follow-up study of trabeculectomy: risk factors and outcomes. ophthalmology. 2012;119(4):694–702. althea medical journal. 2016;3(4) 514 amj december 2016 five years data of clinical and histopathological characteristics of skin adnexal tumors in dr. hasan sadikin general hospital bandung jessica oktavianus trisaputra,1 hermin aminah usman,2 reti hindritiani3 1faculty of medicine universitas padjadjaran, 2department of anatomic pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia, 3department of dermato-venerology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, indonesia abstract background: skin adnexal tumors arise from skin adnexal differentiation. very limited number of study has been performed on their clinical and histopathological characteristics in dr. hasan sadikin general hospital. the objectives of this study was to identify the clinical and histopathological characteristic of skin adnexal tumors during the period of 2009 to 2013. methods: aa descriptive study performed on 79 medical records of patients with skin adnexal tumors at the department of anatomic pathology in dr. hasan sadikin general hospital bandung from 2009 to 2013. data were collected during the period of september to october 2014. the inclusion criteria were medical records containing information on skin adnexal tumors confirmed by histopathological examination results, patient characteristics (age and gender), and the tumor characteristics (size, location, malignancy, type, and histopathological origin). collected data were processed using computer and presented in tables. results: this study showed that tumors occured during productive age with male to female ratio was 1.2:1. most skin adnexal tumors were ≤5 cm in size and were distributed in the head-neck region. most of the tumors were benign and arised from hair follicle differentiation with pilomatricoma type while the malignant tumors commonly arised from sebaceous gland differentiation with sebaceous carcinoma type. conclusions: most skin adnexal tumors occur in productive age with no gender prediclation. they are small in size and are distributed in the cephalic region. most are benign tumors arising from hair follicle differentiation with some malignant tumors arising from sebaceous gland differentiation. [amj.2016;3(4):514–9] keywords: clinical characteristic, histopathologic characteristic, skin adnexal tumor correspondence: jessica oktavianus trisaputra, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6281298598525 email: jessicaoktavianus@gmail.com introduction skin adnexal tumors (sat) arise from skin adnexal differentiations that take place in, among others, sebaceous gland, hair follicle, and eccrine/apocrine sweat glands.1 the incidence of skin adnexal tumors is low as seen in iran (3.3%), netherland (1.23%), and nigeria (0.9%).2–4 the mean age of patients is in the third decade of life for benign tumors and above 50 years old for malignant tumors.2 the clinical characteristics of benign skin adnexal tumors include nodules or papules, skin-colored, ≤5 cm in size while for the malignant tumors, there are plaques or ulcers, >5 cm in size.5 the most common location of the skin adnexal tumors is the head-neck area due to the presence of many skin adnexals in that area.1 the etiology are mostly genetics, such as seen in trichoepithelioma (ptch1 gene mutation) or cylindroma (cyld mutation) with some cases are triggered by ultraviolet radiation or immunesuppresed condition.6,7 skin adnexal tumors can be classified into benign and malignant tumors.5 the incidence of benign skin adnexal tumors is higher than that of the malignant tumors.2,4,8–10 skin adnexal tumors are classified based on world health organization (who) histological classification of appendageal tumours which includes tumors from sebaceous gland differentiation, hair follicle differentiation, and eccrine/apocrine sweat gland differentiation.5 very limited studies have been performed on the clinical and histopathological characteristics of skin adnexal tumors in dr. althea medical journal. 2016;3(4) 515 hasan sadikin general hospital yet. hence, the objectives of this study was to identify the clinical and histopathological characteristics of skin adnexal tumors in dr. hasan sadikin general hospital during the period of 2009 to 2013. methods this descriptive study reviewed medical records of patients with skin adnexal tumors at the department of anatomic pathology of dr. hasan sadikin general hospital bandung which dated from 2009 to 2013. samples were collected using total sampling method from september–october 2014. data were collected based on the inclusion criteria: medical records containing information on skin adnexal tumors confirmed by histopathological examination, patient characteristics (age and gender), and tumor characteristics (size, location, malignancy, type and histopathological origin of the lesions). the histopathological origin was determined based on the who histological classification of appendageal tumours, namely sebaceous gland differentiation origin, hair follicle differentiation origin, and eccrine/ apocrine sweat gland differentiation origin. the collected data were processed by using a computer program and were presented in tables. this study had been approved by the ethical comittee and the president director of dr. hasan sadikin general hospital bandung. results there were 105 medical records collected from january 2009 to december 2013, but only 79 medical records were eligible based on the inclusion criteria of this study. this study showed that the incidence of skin adnexal tumors occured in all ages but mostly occured in the productive age. the interesting finding in this study was that this tumor was also discovered in a very young age (table 1). most tumors found were ≤5 cm and located in the cephalic (head-neck) area. in terms of malignancy and the origin of the tumor, most of them were benign and originated from hair follicle differentiation. most of the benign skin adnexal tumors arised from hair follicle differentiation and most of the malignant skin adnexal tumros arised from sebaceous gland differentation. (table 2). there were 29 cases of skin adnexal tumors with hair follicle differentiation with pilomatricoma, trichoepithelioma and tricholemmal carcinoma, in descending order, as the most common types (table 3). there were 25 cases of skin adnexal tumors with eccrine/apocrine sweat gland differentiation with porocarcinoma, syringocystadenoma papilliferum and eccrine carcinoma, in descending order, as the most common types (table 4). there were 25 cases of skin adnexal tumors with sebaceous glands differentiation and the most common type was sebaceous carcinoma (table 5). jessica oktavianus trisaputra, hermin aminah usman, reti hindritiani: five years data of clinical and histopathological characteristics of skin adnexal tumors in dr. hasan sadikin general hospital bandung table 1 characteristics of patients with skin adnexal tumors characteristics frequency (%) n=79 age 0–9 years 6 (8%) 10–19 years 12 (15%) 20–29 years 6 (8%) 30–39 years 12 (15%) 40–49 years 13 (16%) 50–59 years 12 (15%) 60–69 years 9 (11%) 70–79 years 6 (8%) 80–89 years 2 (3%) 90–99 years 1 (1%) gender male 40 (51%) female 39 (49%) althea medical journal. 2016;3(4) 516 amj december 2016 there were 13 cases of paget’s disease of breast which were excluded from the study because all of paget’s disease of breast were found with ductal mammae carcinoma and none was isolated from the ductal mammae carcinoma. the mean age of patients with paget’s disease of breast was 49.4 years old and all were female. most of this tumors were found with size ≤5 cm and all in non-cephalic area/breast (table 6). table 3 distribution of hair follicle differentiation of skin adnexal tumors based on clinical characteristics hair follicle differentiation of skin adnexal tumors n (%) mean age (years) gender size location m f ≤5 cm >5 cm cephalic noncephalic benign pilomatricoma 12 (15%) 20.5 5 7 11 1 8 4 tricholemmoma 1 (1%) 26 1 1 1 trichoepithelioma 9 (11%) 39.3 5 4 9 9 trichofolliculoma 1 (1%) 10 1 1 1 malignant trichoblastic carcinoma 1 (1%) 55 1 1 1 tricholemmal carcinoma 3 (3%) 42 1 2 1 2 3 pilomatrix carcinoma 1 (1%) 52 1 1 1 proliferating tricholemmal cyst 1 (1%) 80 1 1 1 table 2 skin adnexal tumor characteristics characteristics frequency (%) n=79 gender male 40 (50.63%) female 39 (49.37%) size ≤5 cm 63 (79.75%) >5 cm 16 (20.25%) location head-neck (cephalic) 59 (74.68%) non head-neck (non-cephalic) 20 (25.32%) malignancy benign 43 (54.43%) malignant 36 (45.57%) histopathological origin hair follicle 29 (36.71%) eccrine/apocrine sweat gland 25 (31.65%) sebaceous gland 25 (31.64%) benign tumor hair follicle 23 (53.49%) eccrine/apocrine sweat gland 13 (30.23%) sebaceous gland 7 (16.28%) malignant tumor hair follicle 6 (16.67%) eccrine/apocrine sweat gland 12(33.33%) sebaceous gland 18 (50%) althea medical journal. 2016;3(4) 517jessica oktavianus trisaputra, hermin aminah usman, reti hindritiani: five years data of clinical and histopathological characteristics of skin adnexal tumors in dr. hasan sadikin general hospital bandung discussion there were 79 eligible cases of skin adnexal tumors at the department of anatomic pathology of dr. hasan sadikin general hospital between january 2009 and december 2013. the finding of this study showed a low frequency of skin adnexal tumors in the 5-year study. other authors in south india only found 56 cases of skin adnexal tumors in a 6-year study.11 skin adnexal tumors have low frequency compared to others skin tumors.3 kamyab-hesari et al.2 stated that the frequency of skin adnexal tumors iss higher than reported because many skin adnexal tumors only appeared as asymptomatic benign skin lesions like papules or nodules.2 in this study, most skin adnexal tumors were diagnosed in the third to sixth decade of life. this is similar to a study conducted in aga khan university, pakistan12 where kamyab-hesari et al.2 mentioned that patients in second or third decade of life often seek medical attention.2 there was no significant sexual predilection between males and females in this study. this finding was similar to what was found in a study by kamyab-hesari et al.2 and sharma et al.11 the finding of female predominance in the work of saha4, gayatri et al.8 and nair13 is still unclear. they suspected that this condition occured because of bias in biopsy selection due to social or esthethic factor, especially among females.2 most of the sizes of the skin adnexal tumors in this study were ≤5 cm (78%) with the benign type being the most common. this is in accordance with jindal et al.14 who stated that most benign skin adnexal tumors are table 4 distribution of eccrine/apocrine sweat gland differentiation of skin adnexal tumors based on clinical characteristics eccrine/apocrine sweat gland differentiation of skin adnexal tumors n(%) mean age (years) gender size location m f ≤5 cm >5 cm cephalic noncephalic benign syringoma 3 (3%) 37.6 1 2 3 1 2 syringocystadenoma papilliferum 4 (5%) 19.5 3 1 1 3 4 spiradenoma 2 (2%) 29 2 2 2 poroma 2 (2%) 29 1 1 2 2 adenoma 1 (1%) 22 1 1 1 hidradenoma 1 (1%) 12 1 1 1 malignant spiroadenocarcinoma 1 (1%) 47 1 1 1 hidradenocarcinoma 1 (1%) 47 1 1 1 carcinoma 4 (5%) 45.5 3 1 3 1 4 porocarcinoma 5 (6%) 61 1 4 3 2 2 3 malignant cylindroma 1 (1%) 67 1 1 1 table 5 distribution of sebaceous gland differentiation of skin adnexal tumors based on clinical characteristics sebaceous gland differentiation of skin adnexal tumors n(%) mean age (years) gender size location m f ≤5 cm >5 cm cephalic noncephalic sebaceous adenoma 7 (8%) 42.8 3 4 7 7 sebaceous carcinoma 18 (22%) 52.7 9 9 12 6 14 4 althea medical journal. 2016;3(4) 518 amj december 2016 usually ≤2 cm in size. skin adnexal tumors with a size of ≤5 cm are not always considered benign. there are some malignant tumors, namely sebaceous carcinoma or trichilemmal carcinoma which might be ≤5 cm but they are aggressive and can spread to other organs rapidly.5 the most common anatomic location for the skin adnexal tumors in this study was in the cephalic (head-neck) area (75%). the same situation was also reported by other authors in iran2, nigeria4, india10,11, and pakistan.12 skin in cephalic area has more adnexal structure like sweat glands, sebaceous glands, or hair follicles and there will be more progenitor cells for differentiation into skin adnexal tumors. in addition, ultraviolet radiation may contribute to the formation of skin adnexal tumors by damaging the dna by mutation in signaling pathway due to reactive oxygen species (ros) or mutation in p53 tumor suppressor gene which enables carcinogenic cells to proliferate without control.1,2,6 the ratio between benign and malignant skin adnexal tumors in this study was 1.2:1 with hair follicle differentiation (32%) becoming the most common histopathological type of the skin adnexal tumors, followed by eccrine/apocrine sweat gland differentiation and sebaceous gland differentiation with the same frequency (32%). a study in aga khan university, pakistan12 also discovered that skin adnexal tumors with hair follicle differentiation are the most common histopathological type; however studies by samaila4, gayatri et al.8, sharma et al.11 have shown different results with eccrine/ apocrine sweat gland differentiation being the most common histopathological type of skin adnexal tumors. it is stated that the diagnosis of skin adnexal tumors is difficult because there are many classification of skin adnexal tumors. skin adnexal tumors can also arised from more than one differentiation, and there are many and different names are given for skin adnexal tumors. the greatest number of skin adnexal tumors arise from hair follicle differentiation with pilomatricoma type (15%) as the most common followed by trichoepithelioma (11%), and trichillemal carcinoma (3%). in this study, pilomatricoma was the most common benign skin adnexal tumors (28%). other studies in iran2 and india10,11 also show the same result with pilomatricoma as the most common benign skin adnexal tumors. in this study, patients with pilomatricoma have a mean age of 20.5 years old with female predominance, most of them were ≤5 cm in size. pilomatricoma is the benign skin adnexal tumors with hair follicle matrix differentiation usually found in children and adult in second decade of life. pilomatricoma is usually found in cephalic area because there are many hairs there.5,15 the most common type of skin adnexal tumors in eccrine/apocrine sweat gland differentiation of skin adnexal tumors is porocarcinoma (6%), followed by syringocystadenoma papilliferum (5%) and syringoma (3%). the most common type of sebaceous gland differentiation of skin adnexal tumors is sebaceous carcinoma (22%), which is followed by sebaceous adenoma (8%). in this study, sebaceous carcinoma was the most common malignant skin adnexal tumors rising from sebaceous gland differentiation. the mean age of patient was 52.7 years old with the same gender comparison. most sebaceous carcinomas had a size of ≤5 cm and were located in the cephalic area. this is in line with le boit, et al.5 that sebaceous carcinoma is found in adult aged 62 years old. athough the size is small and appeared as ulcerative lesions, they are aggressive and can spread to other organs rapidly. the limitation of this study includes incomplete medical record data leading to inability to describe the course of the illness and clinical characteristics of lesion-like papules or nodules which will be helpful for diagnosis. it can be concluded that skin adnexal tumors occur in productive age with no gender predilection. most of the skin adnexal tumors table 6 distribution of paget’s disease of breast-based on clinical characteristics n(%) mean age (years) gender size location m f ≤5 cm >5 cm cephalic noncephalic paget’s disease of breast 7 (8%) 42.8 3 4 7 7 althea medical journal. 2016;3(4) 519 are ≤5 cm in size and are distributed in cephalic area. the most common skin adnexal tumors are benign and hair follicle differentiation iss the most common histopathological type of skin adnexal tumors with pilomatricoma type. sebaceous gland differentiation with sebaceous carcinoma type becomes the most common histopathological type of malignant skin adnexal tumors. it is recommended that data entered into medical records should include complete information the course of illness and clinical characteristics of lesion-like papules in order to enable clinicians to make a proper diagnosis. skin lesion should be photographed for clearer explanation. the size of the skin adnexal tumors cannot be used as a guide to conclude the behavior of tumors as benign or malignant. histopathological examination is needed for diagnosis to ensure that the patient receives a proper treatment. references 1. srivastava d, taylor rs. appendage tumors and hamartomas of the skin. in: goldsmith la, katz si, gilchrest ba, paller as, leffell dj, wolff k, editors. fitzpatrick’s dermatology in general medicine. 8th ed. new york: mcgraw-hill companies, inc.; 2012. p. 1337–76 2. kamyab-hesari k, balighi k, afshar n, aghazadeh n, rahbar z, seraj m, et al. clinicopathological study of 1016 consecutive adnexal skin tumors. acta med iran. 2014;51(12):879–85. 3. holterhues c, vries ed, louwman mw, koljenovic s, nijsten t. incidence and trends of cutaneous malignancies in the netherlands, 1989–2005. j invest dermatol. 2010;130(7):1807–12. 4. samaila m. adnexal skin tumors in zaria, nigeria. ann of afr med. 2008;7(1):6–10. 5. leboit pe. appendageal tumor. in: leboit pe, burg g, weedon d, sarasin a, editors. pathology and genetics skin tumor world health organization classification of tumor. lyon: international agency for research on cancer; 2006. p. 121–63. 6. blake pw, bradford pt, devesa ss, toro jr. cutaneous appendageal carcinoma incidence and survival patterns in the united states: a population-based study. arch dermatol. 2010;146(6):625–32. 7. almeida s, maillard c, itin p, hohl d, huber m. five new cyld mutations in skin appendage tumors and evidence that aspartic acid 681 in cyld is essential for deubiquitinase activity. j invest dermatol. 2007;128(3):587–93. 8. gayathri ss, alavandar e, kumar sa. an analysis of skin appendageal tumors in south india. j evol med dent sci. 2012;1(6):907–12. 9. saha a, das nk, gharami rc, chowdhury sn, datta pk. a clinico-histopathological study of appendageal skin tumors, affecting head and neck region in patients attending the dermatology opd of a tertiary care centre in eastern india. indian j dermatol. 2011;56(1):33–6. 10. marla nj, naik r, kumar p, fernandes h, cs j, pailoor k. clinico-pathological study of adnexal tumors of skin. adv lab med int. 2014;4(4):122–7. 11. sharma a, paricharak dg, nigam js, rewri s, soni pb, omhare a, et al. histopathological sudy of skin adnexal tumours 2014;institutional study in south india 2014. journal of skin cancer [online journal] 2014 [cited 2014 desember 29]. available from: http://www.hindawi.com/ journals/jsc/2014/543756/. 12. yaqoob n, gill m, soomro i, ahmad z, muzaffar s. spectrum of cutaneous appendage tumors at aga khan university hospital. j pak med assoc. 2003;53:427. 13. nair p. a clinicopathologic study of skin appendageal tumors. indian j dermatol venereol leprol. 2008;74:550. 14. jindal u, patel r. study of adnexal tumors of the skin: a three year study of 25 cases. internet j pathol. 2012;13(3):1. 15. alsaad k, obaidat n, ghazarian d. skin adnexal neoplasms part 1: an approach to tumours of the pilosebaceous unit. j clin pathol. 2007;60(2):129–44. jessica oktavianus trisaputra, hermin aminah usman, reti hindritiani: five years data of clinical and histopathological characteristics of skin adnexal tumors in dr. hasan sadikin general hospital bandung althea medical journal. 2016;3(4) 644 amj december 2016 characteristics of renal cell carcinoma in dr. hasan sadikin general hospital bandung, 2010–2014 dicky suryana putra,1 sri suryanti, aaron tigor sihombing3 1faculty of medicine universitas padjadjaran, 2department of pathology anatomy faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: data characteristics for renal cell carcinoma are mostly derived from developed countries. however, data from developing countries, specifically in indonesia have not been fully described. this study aimed at describing renal cell carcinoma (rcc) characteristics based on age, gender, and histopathology type in dr. hasan sadikin general hospital bandung. methods: this was a descriptive study conducted in august–october 2015. the data were collected from histopathology medical records of patients who had been diagnosed with rcc at department of pathology anatomy dr. hasan sadikin general hospital bandung, from 2010 to 2014. total sampling was used as sampling method. only rcc records that had complete variables; which were age, gender, and histopathological type; included in this study. results: there were 25 cases of renal cell carcinoma discovered in this study, 17 cases discovered in men and 8 cases discovered in women. the histopathology type found in this study was clear cell renal cell carcinoma (12 cases), papillary renal cell carcinoma (8 cases), chromophobe renal cell carcinoma (3 cases), and carcinoma of the collecting ducts of bellini (2 cases). there were no cases found below the age range 2–29 years old and above the age range 70–79 years old. conclusions: men have higher incidence than women with the ratio of 2:1. peak incidence is found on the age range 50–59 years old. the most common histopathology type is clear cell renal cel carcinoma. [amj.2016;3(4):644–8] keywords: age, gender, histopathology type, renal cell carcinoma correspondence: dicky suryana putra, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: 085223306888 email: trickydickky@gmail.com introduction renal cell carcinoma is the most common renal cancer (85–90%). its incidence and mortality rate continue to increase in many developed and developing countries.1-3 developed countries have higher incidence and mortality rate than developing countries do.1,3 the characteristics of data for renal cell carcinoma are mostly derived from developed countries that have already had a good system for medical record registration or better health services. therefore the characteristics of data have not yet described the situation in developing countries, specifically indonesia.1,3-6 west java, which is the most populous province in indonesia, from statistical data has high level of risk factors for renal cell carcinoma. some of the risk factors are smoking, obesity, and hypertension.7-10 west java is the second highest province in terms of proportion of daily active smokers who are older than 10 years (27.1%).11 the prevalence of hypertension and obesity in west java are 29.4% and 15.4%.11 dr. hasan sadikin general hospital bandung is the main referral hospital for cancer in west java. therefore, it is indicated that the characteristics of renal cell carcinoma based on age, gender, and histopathology type in dr. hasan sadikin general hospital bandung are abundant. this condition meets the aim of the study, which is to describe the data characteristics. althea medical journal. 2016;3(4) 645 methods this was a descriptive study conducted in august–october 2015. the data were collected retrospectively from histopathology medical records of the patients who had been diagnosed with renal cell carcinoma at department of pathology anatomy, dr. hasan sadikin general hospital bandung in 2010– 2014. the sampling method used was total sampling. this study had been approved by the health research ethics committee dr. hasan sadikin general hospital, bandung. the inclusion criteria in this study were all histopathology medical records of the patients with complete medical record (age, gender, and histopathology type), started table 1 distribution of renal cell carcinoma based on year year total 2010 3 2011 1 2012 3 2013 8 2014 10 total 25 from january 2010 to december 2014. there were 25 inclusion data and 0 exclusion data. however, since, some medical records were table 2 distribution of renal cell carcinoma based on age, gender, and type of histopathology variable total (n=25) age (years) 0–9 0 10–19 0 20–29 2 30–39 3 40–49 5 50–59 8 60–69 6 70–79 1 >80 0 gender male 17 female 8 histopathology type clear cell renal cell carcinoma 12 multilocular clear cell renal cell carcinoma 0 papillary renal cell carcinoma 8 chromophobe renal cell carcinoma 3 carcinoma of the collecting ducts of bellini 2 renal medullary clear cell 0 xp11 translocation carcinoma 0 carcinoma associated with neuroblastoma 0 mucinous tubular and spindle cell carcinoma 0 renal cell carcinoma, unclassified 0 dicky suryana putra, sri suryanti, aaron tigor sihombing: characteristics of renal cell carcinoma in dr. hasan sadikin general hospital bandung, 2010–2014 althea medical journal. 2016;3(4) 646 amj december 2016 lost; the data then could not be included in the study. the data that had been collected were presented in table form. results there were 25 cases of renal cell carcinoma found in the department of pathology anatomy dr. hasan sadikin general hospital in 5 years, from 2010 until 2014 (table 1). table 2 showed that the lowest number of renal cell carcinoma cases occurred in the age range from 20 to 29 years old. then, the number of renal cell carcinoma cases steadily increased and reached its peak in the age range from 50 to 59 years old. renal cell carcinoma cases were discovered more frequently in men than women, with the highest type of renal cell carcinoma was clear cell renal cell carcinoma. table 3 showed that based on histopathology, age, and gender rcc was mostly common in male for clear cell and papillary rcc. in addition, the age range was varied among types of histopathology. discussion the highest number of renal cell carcinoma cases in this study occurred in the age range of 50–59 years old, followed by the range of 60–69 years old. this result was different from the that of the who data stating that the age range with the highest number of renal cell carcinoma cases was at the age range of 60 to 69 years old.1 this result may be attributed by the high exposure of renal cell carcinoma’s risk factors at young age.2,7 some of the renal cell carcinoma risk factors are smoking, hypertension, and obesity.2,7 data from riset kesehatan dasar (riskesdas) in 2013 stated that the proportion of daily active smokers in indonesia within the age range of 15–19 years old was 11.2 %, with the highest proportion of daily active smokers was in the range of 30–34 years old (33.4%), followed by the range of 35–39 years old (32.2%).11 in this study, there was only 1 case found in the range of 70–79 years old. this may be related to the life expectancy in indonesia which was only 70 years. thus the chances for renal cell carcinoma patients diagnosed at the age of 70 years were relatively smaller.12 in this study, the distribution of renal cell carcinoma was discovered more common in men than in women, with the ratio of men and women is 2:1. this result was similar to the data released by the who.1 the higher number of patients with renal cell carcinoma in men compared to those in women, may be attributed to the higher prevalence of smoking in men than in women.13 the prevalence of smokers in indonesia in 2011 was 31.1% in men and 6.2% in women.11 the highest number of renal cell carcinoma types in dr. hasan sadikin general hospital table 3 distribution of carcinoma based o histopathology, age and gender variable clear cell renal cell carcinoma papillary renal cell carcinoma chromophobe renal cell carcinoma carcinoma of the collecting ducts of bellini age (years) 0–9 0 0 0 0 10–19 0 0 0 0 20–29 0 2 0 0 30–39 2 0 1 0 40–49 4 0 1 0 50–59 3 3 1 1 60–69 2 3 0 1 70–79 2 0 0 0 >80 0 0 0 0 gender male 9 7 1 0 female 3 1 2 2 althea medical journal. 2016;3(4) 647dicky suryana putra, sri suryanti, aaron tigor sihombing: characteristics of renal cell carcinoma in dr. hasan sadikin general hospital bandung, 2010–2014 is clear cell renal cell carcinoma (12 cases), followed by papillary renal cell carcinoma (8 cases), chromophobe renal cell carcinoma (3 cases), and carcinoma of the collecting ducts of bellini (2 cases). theorder of this highest number of renal cell carcinoma type was similar to the data from who.1 in this study, the highest number of clear cell renal cell carcinoma cases occurred in the 4th decade (40–49 years old age range). these results are different from that of the who saying that the highest number of cases occurred in the 6th decade (60–69 years old age range).1 this may also be attributed by the high exposure of renal cell carcinoma’s risk factor occurred at young age, as had been described above.2,7,11 the youngest age of the case of renal cell carcinoma in this study, occurred at 26 and 29 years old. both cases were the cases of papillary renal cell carcinoma. this result may be caused by mutations of the fumarate hydrogenase gene that would increase a person’s risk for developing papillary renal cell carcinoma type 2 at young age.14, 15 in this study, in contrast to clear cell renal cell carcinoma and papillary renal cell carcinoma, chromophobe renal cell carcinoma and carcinoma of the collecting ducts of bellini were more common in women than men. the ratio of men to women in chromophobe renal cell carcinoma was 1:2.the result was different from that of the who saying that the comparison between men and women was relatively equal, with slightly more common cases found in men.1 however, there was other study which stated that chromophobe renal cell carcinoma occurred more frequently in women.16 this study found several obstacles in the research: there were some missing medical records so the author could not do complete data collection. additionally, the handwriting on medical records was unclear to read, so it could cause errors in the data collection. the conclusion of this study is that men have higher renal cell carcinoma’s incidence than women with the ratio of 2:1. peak incidence of this case is on the age range of 50–59 years old. the most common histopathology type is clear cell renal cell carcinoma. further cohort study should be undertaken in order to describe the burden of the disease completely. references 1. kaplan w, wirtz vj, manteel-teeuwisse a, moch h, lash lh, scelo g. world cancer report : kidney cancer. 2014. lyon: international agency for research on cancer, who; 2014. p. 631–44. 2. chow w–h, dong lm, devesa ss. epidemiology and risk factors for kidney cancer. nat rev urol. 2010;7(5):245–57. 3. znaor a, lortet–tieulent j, laversanne m, jemal a, bray f. international variations and trends in renal cell carcinoma incidence and mortality. eur urol. 2015;67(3):519– 30. 4. agnihotri s, kumar j, jain m, kapoor r, mandhani a. renal cell carcinoma in india demonstrates early age of onset & a late stage of presentation. indian j med res. 2014;140(5):624–9. 5. valsecchi mg, steliarova–foucher e. cancer registration in developing countries: luxury or necessity? lancet oncol. 2008;9(2):159–67. 6. thun mj, delancey jo, center mm, jemal a, ward em. the global burden of cancer: priorities for prevention. carcinogenesis. 2010;31(1):100–10. 7. brennan p, van der hel o, moore le, zaridze d, matveev v, holcatova i, et al. tobacco smoking, body mass index, hypertension, and kidney cancer risk in central and eastern europe. br j cancer. 2008;99(11):1912–5. 8. lipworth l, tarone re, lund l, mclaughlin jk. epidemiologic characteristics and risk factors for renal cell cancer. clin epidemiol. 2009;1(1):33–43. 9. 9. hunt jd, van der hel ol, mcmillan gp, boffetta p, brennan p. renal cell carcinoma in relation to cigarette smoking: meta– analysis of 24 studies. int j cancer. 2005;114(1):101–8. 10. setiawan vw, stram do, nomura am, kolonel ln, henderson be. risk factors for renal cell cancer: the multiethnic cohort. am j epidemiol. 2007;166(8):932–40. 11. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2013. jakarta: badan penelitian dan pengembangan kesehatan kementerian kesehatan ri; 2013. 12. badan pusat statistik nasional. indonesia population projection. jakarta: badan pusat statistik; 2013. 13. jonasch e, futreal a, davis i, bailey s, kim wy, brugarolas j, et al. state–of–the– science: an update on renal cell carcinoma. mol cancer res. 2012;10(7):859–80. 14. linehan wm, bratslavsky g, pinto pa, schmidt ls, neckers l, bottaro d, et al. molecular diagnosis and therapy of kidney althea medical journal. 2016;3(4) 648 amj december 2016 cancer. annu rev med. 2010;61(1):329– 43. 15. kuroda n, ohe c, kawakami f, mikami s, furuya m, matsuura k, et al. clear cell papillary renal cell carcinoma: a review. int j clin exp pathol. 2014;7(11):7312–8. 16. steffens s. clinical behavior of chromophobe renal cell carcinoma is less aggressive than that of clear cell renal cell carcinoma, independent of fuhrman grade or tumor size. virchows arch. 2014;465(4):439–44. althea medical journal. 2016;3(2) 254 amj june 2016 prevalence and predisposing factors of pediculosis capitis on elementary school students at jatinangor arani karimah,1 risa miliawati nurul hidayah,2 anisah dahlan3 1faculty of medicine universitas padjadjaran, 2department of dermatovenerology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry faculty of medicine universitas padjadjaran abstract background: pediculosis capitis is a lice infestation on scalp with high prevalence on the age of elementary school students. it is one of neglected diseases. predisposing factors such as hair type and length, self higienities, and sosioeconomic can influence prevalence of pediculosis capitis. the aim of the study was to reveal pediculosis capitis prevalence and its predisposing factors on elementary school students at jatinangor. methods: this study used cross-sectional descriptive method which conducted in september 2014 at jatinangor. the study subjects were elementary school students graded 1 to 6 taken from two elementary schools by multistage random sampling technique. data was presented in a table. results: the prevalence of pediculosis capitis from 123 study subjects was 55.3%. the prevalence found on girls (81.3%), students with long hair (76.9%), students with curly hair (52.9%), students of third grade (66.7%), students with washing hair three times or more in a week (59.3%), students with mothers only graduated from elementary school (60%), students parents with income less than one million rupiah (63.3%), students staying with four or more persons in the same house (56.3%), and students with having previous this disease (60.2%). conclusions: pediculosis capitis prevalence on elementary school students is quite high. the prevalence based on subject characteristics and sosioeconomic is suitable with previous studies. [amj.2016;3(2):254– 8] keywords: elementary schools, pediculosis capitis, predisposing factors, prevalence correspondence: arani karimah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628562081408, email: aranikarimah@gmail.com introduction pediculus var.capitis is one of ectoparasite obligate that manifest on scalp.1-2 this parasite has no swing, but can transmit directly through direct contact with infected person, or indirectly through equipment likes comb, hair accessories, and clothes.3 more frequent pediculosis capitis affected to 3-11 years old children with highest incidence on elementary school students.3,4 twenty five percent of elementary school students in worldwide infected by pediculus var.capitis.2 some studies that have been conducted in some countries, reported that there are many predisposing factors such as gender, class grade, hair length, hair type, hair wash frequency, parents education, parents income, students who stay with four or more persons in the same house , and students who have previous this disease influence the prevalence of pediculosis capitis.2,3,5 the data about spreading of pediculosis capitis in indonesia is still limited. thus, the aim of this study was to determine prevalence of pediculosis capitis and its predisposing factors on elementary school students at jatinangor. methods this was a cross-sectional descriptive study on elementary school students at jatinangor in the period of september 2014. this study has got permission from health research ethics committee faculty of medicine universitas padjadjaran. population of this study were elementary school students at jatinangor. samples of this study was selected althea medical journal. 2016;3(2) 255 using multiple random sampling technique. therefore, elementary school was selected through cluster random sampling. two elementary schools that have been selected are mekarsari and cikopo ii elementary schools. while, 123 students was selected through simple random sampling from grade 1 to 6. inclusion criteria were students who wanted to involve in this study and who had complete personal and family database. exclusion criteria were students who have incomplete personal and family database. the subject was examined by history taking and physical examination. history taking was performed to identify symptoms in subject which lead to pediculus var.capitis infestation. in addition, physical examination was done by doctor and researcher through visual examination using fine-tooth combing. history taking and physical examination results were recorded on medical record. the presence of eggs, larva, or adult pediculus var.capitis indicated positive result. subject with positive results were treated with hexachlorocyclohexane 0.5%. data was presented in a table form. the pediculosis capitis prevalence and its predisposing factors was determined from grade 1 to 6 students results one hundred and twenty three students of grade 1 to 6 from two elementary schools at jatinangor were involved in this study. pediculosis capitis has been found on 55.3% study subject (table 1). prevalence of pediculosis capitis was higher on girls. besides that, the highest prevalence were among 3rd grade students and the lowest table 1 prevalence of pediculosis capitis pediculosis capitis n % positive 68 55.3 negative 55 44.7 total 123 100 table 2 prevalence of pediculosis capitis based on subject characteristics subject characteristics pediculosis capitis total positive n(%) negative n(%) gender girl 52 (81.2) 12 (18.8) 64 boy 16 (27.1) 43 (72.9) 59 grade 1 14 (63.6) 8 (36.4) 22 2 14 (56) 11 (44) 25 3 14 (66.7) 7 (33.3) 21 4 9 (50) 9 (50) 18 5 9 (42.9) 12 (57.1) 21 6 8 (50) 8 (50) 16 were among 5th grade students (table 2). prevalence of pediculosis capitis was higher on students who has long hair, students who has curly hair, students who wash hair three times or more a week, and students who had history of pediculosis capitis (table 3). prevalence of pediculosis capitis was higher on students whose mother graduated from elementary school, parents income is lesser than one million rupiah and students who stay with four people or more in one house (table 4). discussion in this study, prevalence of pediculosis capitis among elementary school students were 55.3%. the high prevalence of pediculosis capitis was indicated by some studies such as in in kelantan, malaysia2 with prevalence 35%, 28.48% in thailand3, 49% in penang, malaysia7, and 26% in dera ismail khan8. furthermore, some previous studies indicated that low on prevalence of pediculosis capitis i.e in iran5 8.1%, in france9 3.3%, and in peru10 9.1%. prevalence of pediculosis capitis is found higher (81.2%) on girl. it is caused by girls habit that interact longer and closer with each other, thus increases risk of transmission for pediculus var.capitis transmission.2,3,4 moreover, study by rassami and soonwera3 arani karimah, risa miliawati nurul hidayah, anisah dahlan: prevalence and predisposing factors of pediculosis capitis on elementary school students at jatinangor althea medical journal. 2016;3(2) 256 amj june 2016 proved that girls are 40 times more commonly infected by pediculus var.capitis than boy. students with long hair had prevalence for pediculosis capitis infection higher (76.9%) than students with short hair (49.5%). this was caused by longer hair provides warm and humid environment which favors the living pediculus humanus var.capitis.1 in addition, study by bachok et al.2 showed that elementary school students whose hair below shoulder has higher prevalence (62.8%) than whose hair above the shoulder (16.1%). in this study, prevalence of pediculosis capitis on curly hair students were 68.4%, while student with straight hair had lower prevalence (52.9%). results obtained from this study was almost similar to the previous study by bachok et al.2 study where prevalence were higher on students with curly hair (57.1%). moreover, student by manrique et al.11 showed that students with straight hair had higher prevalence (34%) than students with curly hair (25%). the highest prevalence of pediculosis capitis was on 3rd grade students (66.7%). the lowest prevalence was on 5th grade students (42.9%). rukke et al.12 research showed that the highest prevalence of pediculosis capitis is among students age ≤15 years old. moreover, study by manrique et al.11 proved that students ≤ 9 years old (37%) students on 3rd grade or under 3rd grade (37.6%) has higher prevalence. according to sim et al.6, subject who wash hair less than three times (0.23%) has higher prevalence than who wash hair three or more in a week (0.12%). thus, washing hair three times or more in a week decreases the prevalence. in this study prevalence of pediculosis capitis was higher among students who wash hair three times or more in a week table 3 prevalence of pediculosis capitis based on risk factors risk factors pediculosis capitis total positive n(%) negative n(%) hair length long 20 (76.9) 6 (23.1) 26 short 48 (49.5) 49 (50.5) 97 hair type straight 55 (52.9) 49 (47.1) 104 curly 13 (68.4) 6 (31.6) 19 hair wash frequency in one week ≥ 3x 48 (59.3) 33 (40.7) 81 ≤ 2x 20 (47.6) 22 (52.4) 42 had previous disease yes 56 (60.2) 37 (39.8) 93 no 12 (40) 18 (60) 30 table 4 prevalence of pediculosis capitis based on sosioeconomic sosioeconomic pediculosis capitis total positive n(%) negative n(%) mother education level elementary school 12 (60) 8 (40) 20 junior high school 24 (51.1) 23 (48.9) 47 senior high school 28 (59.6) 19 (40.4) 47 university 4 (44.4) 5 (56.6) 9 parents income < rp. 1.000.000,00 21 (60) 14 (40) 35 rp 1.000.000,00–rp 3.000.000,00 42 (54.5) 35 (45.5) 77 >rp. 3.000.000,00 5 (45.5) 6 (54.5) 11 number of family memberwho stay in the same house ≥ 4 63 (56.3) 49 (43.7) 112 < 4 5 (45.5) 6 (54.5) 11 althea medical journal. 2016;3(2) 257arani karimah, risa miliawati nurul hidayah, anisah dahlan: prevalence and predisposing factors of pediculosis capitis on elementary school students at jatinangor (59.3%) than students who wash hair less than three times a week (47.6%). students whose mother graduated from elementary school had the highest prevalence, while those whose mother graduated from university had the lowest prevalence. therefore, parents education level, especially mother, influenced students personal hygine. study in iran5 indicated that highest prevalence of pediculosis capitis (2.3%) were among students whose mother graduated from elementary schools and junior high schools. besides, students whose mother graduated from university had the lowest prevalence (0.2%). parents income influenced prevalence of pediculosis capitis infection among students. it was caused by poverty, lack of knowledge about disease, lack of parents attention to warns students, and occupied house.2,12,13 in this study, the highest prevalence of pediculosis capitis among student whose parents income was less than one million rupiah (60%). this income was low or under the average in indonesia. study conducted in mexico11 showed that prevalence of pediculosis capitis was higher (56%) on student whose parents income is less than four thousand dollar than students whose parents income four thousand dollar or more (15.6%). number of family member who stays in the same house also influences prevalence of pediculosis capitis. prevalence will be higher on big family, especially on students who has many elementary school students, because close contact with each other and density of the house more facilitated transmission of pediculus humanus var.capitis.2,12,13 in this study, prevalence of pediculosis capitis was higher (56.3%) on students who stay with four persons or more in one house than students who stay with less than four persons (4.,5%). study in iran5 in 2008 showed that prevalence of pediculosis capitis was higher (3.51%) on students who stay with more than ten people than students who stay with five until ten people (2.28%) and those who stay with less than five people in one house (0.68%). in addition, study by lesshafft et al.10 proved that prevalence is higher among students who stay with more than four persons than those who stay with less than four persons in one house. prevalence of pediculosis capitis was also higher among students who had previous history of pediculosis capitis infection (60.2%) than who do not have past history (40%). this study was similar to the study by motovaliemami et al.5 i.e which prevalence was higher on students who had history of the disease (5%) than students who do not had history of the disease(0,9%). it can be concluded that prevalence of pediculosis capitis on elementary school students is quite high and prevalence of pediculosis capitis and its predisposing factors are suitable with previous studies. one of the limitation from this study is difficulty in interviewing the students about their personal identity, because not all students were accompanied by their parents. in addition, the limited student data which is related to predisposing factors on administration, exlude students from this study. this study was not an analitical statistic. thus, the correlation between pediculosis capitis prevalence and its predisposing factor can not be determined. for other researchers, it is better to conduct study about the existence of pediculosis capitis prevalence and predisposing factors in other parts of indonesia. furthermore, it is required to give routine counseling about pediculosis capitis to all the students, teachers, and parents. thus, they have more knowledge about pediculosis capitis and its predisposing factors. therefore, risk of transmission can be prevented. finally, since the prevalence of pediculosis capitis is considerable, public health service committee and communit’ss attention is needed to eradicate pediculosis capitis infection. references 1. canadian paediatric society. head lice infestation: a clinical update. paediatr child health. 2008;13(8):692–6. 2. bachok n, nordin rb, awang cw, ibrahim na, naing l. prevalence and associated factors of head lice infestation among primary schoolchildren in kelantan, malaysia. southeast asian j trop med public health. 2006;37(3):536–43. 3. rassami w, soonwera m. epidemiology of pediculosis capitis among school children in the eastern area of bangkok, thailand. asian pac j trop biomed. 2012;2(11):901– 4. 4. nutanson i, steen cj, schwartz ra, janniger ck. pediculus humanus capitis: an update. acta dermatovenerol alp pannonica adriat. 2008;17(4):147–54. 5. motovali-emami m, alfatoonian mr, fekri a, yazdi m. epidemiological aspects of pediculosis capitis and treatment evaluation in primary school children in althea medical journal. 2016;3(2) 258 amj june 2016 iran. pak j biol sci. 2008;11(2):260–4. 6. sim s, lee wa, yu jr, lee sh, oh sy, seo m, et al. risk factors associated with head louse infestation in korea. korean j parasitol. 2011;49(1):95–8. 7. muhammad zayyid m, sayyidatul saadah r, adil ar, rohela m, jamaiah i. prevalence of scabies and head lice among children in a welfare home in pulau pinang, malaysia. trop biomed. 2010;27(3):442–6. 8. ali n, ramzan f. head lice infestation in school children at dera ismail khan. pakistan j zool. 2004;36(4):273–80. 9. durand r, millard b, bouges-michel cb, bruel c, bouvresse s, izri a. detection of pyrethroid resistance gene in head lice in school children from bobigny, france. j med entomol. 2007;44(5):796–8. 10. lesshafft h, baier a, guerra h, terashima a, feldmeier h. prevalence and risk factors associated with pediculosis capitis in an impoverished urban community in lima, peru. j glob infect dis. 2013;5(4):138–43. 11. manrique p, norma, c. j, pilger d, herrera h. prevalence of pediculosis capitis in children from a rural school in yucatan, mexico. rev inst med trop sao paulo. 2011;53(6):325–7. 12. rukke ba, birkemoe t, soleng a, lindstedt hh, ottesen p. head lice prevalence among households in norway: importance of spatial variables and individual and household characteristic. parasitology. 2011; 138(10): 1296–304. 13. al-shawa rm. pediculus capitis, infestation according to sex and social factors in gaza governorate. the islamic univ j. 2008;16(1):75–83. althea medical journal. 2016;3(4) 556 amj december 2016 clinical and histopathological characteristics of psoriasis in dr. hasan sadikin general hospital bandung from 2009 to 2013 willy chandra hermawan,1 hermin aminah,2 dendi sandiono3 1faculty of medicine, universitas padjadjaran, 2department of pathological anatomy faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of dermato-venereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: psoriasis is a chronic inflammatory skin disease characterized by alterations in epidermal growth and differentiation. its primary cause remains unknown, and its clinical and histopathological characteristics sometimes change from time to time. the study aimed to reveal the clinical and histopathological characteristics among psoriasis patients in dr. hasan sadikin general hospital bandung. methods: this study involved 162 medical records of psoriasis patients who visited the department of dermato-venereology and 40 medical records of psoriasis patients who visited the department of pathological anatomy of dr. hasan sadikin hospital, from 2009 to 2013. medical record data were collected to describe the patient’s clinical and histopathological characteristics of psoriasis. the collected data were analyzed by frequency distribution. results: from the clinical medical records, the characteristics found among the psoriasis patients were: 14 (8.6%) having familial history, 160 (98.8%) having reddish plaque, 155 (95.7%) having silvery scale, 40 (24.7%) having pustules, 6 (3.7%) having positive auspitz sign, 48 (29.6%) having nail involvement, and 20 (12.4%) having tongue involvement. in addition, from the histopathological medical records, the characteristics of epidermis among the psoriasis patients found were: 36 (90%) having hyperkeratosis with parakeratosis, 39 (98%) having rete ridge elongation and/or acanthosis, 35 (88%) having munro’s microabcess and/or micropustules of kogoj, 15 (38%) having thin stratum granulosum, and 30 (75%) having blood vessels dilatation. conclusions: in psoriasis, the most common clinical characteristics are reddish plaque while the most common histopathological characteristics are elongation of the rete ridges and/or acanthosis. [amj.2016;3(4):556–61] keywords: clinical characteristics, histopathological characteristics, psoriasis correspondence: willy chandra hermawan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628112036688 email: willychermawan@gmail.com introduction psoriasis is a chronic inflammatory skin disease with abnormal epidermal growth and differentiation characteristics. it is indicated by an increasing of proliferation and a shortening of keratinocyte maturation period. the exact cause of psoriasis has not been yet defined.1 based on its clinical characteristics, psoriasis can be further categorized as psoriasis vulgaris, sebopsoriasis, pustular psoriasis, guttate psoriasis, and erythrodermic psoriasis.1 the onset of psoriasis has a close link to family history, especially in early onset psoriasis patients. previous studies did not find any significant difference in the disease prevalence between genders.2 clinical and histopathological characteristics are derived from inflammation, which causes hyperproliferation and a failure in keratinocyte differentiation.3 hyperproliferation in histopathological characteristics affects hyperkeratosis with parakeratosis, the thinning of stratum granulosum, and rete ridge elongation and/or acanthosis; moreover, in clinical characteristics, it causes plaque and scales on the skin. the plaque is reddish in color due to vasodilation.4 newly formed blood vessels althea medical journal. 2016;3(4) 557 are easily damaged, resulting in bleeding if the overlying skin is detached (auspitz sign).5 when neutrophils collect in the stratum corneum, it is called munro’s microabcess. it is called kogoj’s micropustules when they collect in the stratum spinosum.6 nails and tongue, both having cells derived from keratinocytes, can also be affected.4 this study aimed to examine the clinical and histopathological characteristics of psoriasis patients. methods this was a descriptive study. the data were collected retrospectively from secondary data in the form of patients’ medical records in the department of dermato-venereology and department of pathological anatomy dr. hasan sadikin general hospital bandung from 1 january 2009 to 31 december 2013 (5year data). the aim and methods of this study had been approved by ethics committee of dr. hasan sadikin general hospital bandung. the samples used in this study were selected by total sampling (162 clinical and 40 histopathological medical records). the samples in this study were all medical records from the patients first visit that were clinically or histopathologically diagnosed psoriasis. psoriasis patients who had got previous medical care were excluded. the characteristics examined in this study were the clinical characteristics including age, gender, types of psoriasis, family history, lesion distribution, reddish plaque, silvery scales, pustules, auspitz sign, nail involvement, and tongue involvement; besides, the histopathological characteristics were including hyperkeratosis with parakeratosis, rete ridge elongation and/ or acanthosis, munro’s microabcess and/or kogoj’s micropustules, thinning or depletion of stratum granulosum, and dilatation of blood vessels. the collected data were calculated using frequency tabulation and percentage. results based on the inclusion criteria, a total of 162 cases from clinical medical records were included in this study. from this cases which were diagnosed clinically as psoriasis, 46 cases underwent biopsies and the samples were sent for histopathological examination. from the 46 cases, 33 cases were diagnosed psoriasis based on histopathology and 13 cases were not psoriasis. there were 7 cases which were diagnosed psoriasis based on histopathology but were not sent with psoriasis clinical diagnosis. as a result, a total of 40 medical records from histopathology were diagnosed psoriasis. the mean age of patients who were the subjects of this study is 39.7 years old. the gender of patients showed relatively proportionate comparison, in which 90 (56%) cases were females and 72 (44%) were males, with proportion of 1.25 for female to male cases. psoriasis vulgaris was the most commonly diagnosed type of psoriasis, with its proportion exceeding half of total cases of psoriasis table 1 type and lesion distribution of psoriasis clinical characteristics n(%) psoriasis type psoriasis vulgaris 88 (54.4%) sebopsoriasis 16 (9.9%) pustular psoriasis 29 (17.9%) guttate psoriasis 7 (4.3%) erythrodermic psoriasis others 2 (1.2%) lesion distribution regional 77 (47.5%) generalized 63 (38.9%) universal 22 (13.6%) willy chandra hermawan, hermin aminah, dendi sandiono: clinical and histopathological characteristics of psoriasis in dr. hasan sadikin general hospital bandung from 2009 to 2013 althea medical journal. 2016;3(4) 558 amj december 2016 (54.4%). the most common distribution of lesion was regional distribution (table 1). the most common clinical characteristics of psoriasis were reddish plaques (98.8%) and silvery scales (95.7%) (table 2). the most common histopathological characteristics were elongation of rete ridge and/or acanthosis which were found in 98% of cases, followed by hyperkeratosis with parakeratosis which were found in 90% of cases (table 3). discussions psoriasis has close link to genetic factors, and the gene that has been considered important in the development of psoriasis is hla-cw6. this gene encodes the surface proteins of antigen presenting cell to be presented to cd8+ t-cells, the dominant type of white blood cells in psoriatic lesions.1 the mean age of onset in this study was 39.7 years; it is higher than griffith’s finding, which is 32 years.4 this can be explained by stuart’s theory which states that a younger age of onset (under 40 years) has a close relationship with hereditary aspect of hla-cw6 gene.7 in this study, the risk factor of having hla-cw6 was probably low, as indicated by the rate of family history of similar diagnosis or symptoms (8.6%) that was even lower than a previous study by altobelli et al.8 in italy (45.9%) although there were many cases of unknown family history due to incomplete anamnesis (39.6%). this was also supported by a study from jin et al.9 which discovers that hla-cw6 gene is less prevalent in asian populations than in european populations. in this study, the proportion of gender was relatively proportionate, which was 1.25. this conformed to the finding of augustin et al.10 which describes the ratio of the female and male psoriasis case prevalence was close to 1. a previous study by griffith and barker4 discovers psoriasis vulgaris to be the type with the largest proportion, which was about 80%. psoriasis vulgaris has clinical presentations of reddish plaques with silvery scales.1 in this study, psoriasis vulgaris was also the most frequent type, but with a smaller proportion (54.5%). this was due to the higher proportions of the other types of psoriasis compared to the findings of griffith and barker.4 the type with a higher proportion than the one described by griffith and barker4 was generalized pustular psoriasis (van zombusch) (15%) and erythrodermic psoriasis (12.3%). generalized pustular psoriasis has a clinical presentation of generalized or universal reddish plaques, with overlying silvery scales and pustules. erythrodermic psoriasis has a table 2 clinical characteristics of psoriasis clinical characteristics positive negative not stated family history 14 (8.6%) 84 (51.9%) 64 (39.6%) reddish plaque 160 (98.8%) 2 (1.2%) 0 (0%) silvery scale 155 (95.7%) 7 (4.3%) 0 (0%) pustule 40 (24.7%) 0 (0%) 122 (75.3%) auspitz sign 6 (3,7%) 0 (0%) 156 (96.3%) nail involvement 48 (29.6%) 46 (28.4%) 68 (42%) tongue involvement 20 (12.4%) 59 (36.4%) 83 (51.2%) table 3 histopathological characteristics of psoriasis histopathological characteristics positive negative not stated hyperkeratosis with parakeratosis 36 (90%) 0 (0%) 4 (10%) rete ridge elongation / acanthosis 39 (98%) 0 (0%) 1 (2%) kogoj’s / munro’s sign(s) 35 (88%) 1 (2%) 4 (10%) lost / thinning of stratum granulosum 15 (37%) 0 (0%) 25 (63%) blood vessels dilatation 30 (75%) 0 (0%) 10 (25%) althea medical journal. 2016;3(4) 559willy chandra hermawan, hermin aminah, dendi sandiono: clinical and histopathological characteristics of psoriasis in dr. hasan sadikin general hospital bandung from 2009 to 2013 clinical presentation of reddish plaques or macules which cover at least 90% of the total skin surface.4 generalized pustular psoriasis and erythrodermic psoriasis were types that have clear precipitating factors, which are infections, unprescribed corticosteroid use, and irrational use of cream medication.1,11 regional distribution (47.5%) was the most frequent type of distribution, with main predilections in the elbows and knees. such predilections can be attributed to the frequent physical contact in those parts of the body (koebner phenomenon).1,4 generalized (38.9%) and universal (13.6%) types had quite high proportions, probably due to the high frequency of generalized pustular and erythrodermic psoriasis in this study. psoriasis is included as papulosquamous dermatitis, which is the inflammation of the skin with epidermal hyperkeratosis and desquamation. the diseases of this condition include seborrheic dermatitis, lichen planus, pityriasis rosea, and tinea corporis. the clinical presentation of psoriasis often resembles other papulosquamous dermatitis diseases, and hence requires histopathological examination, especially in psoriasis with atypical presentation, such as sobopsoriasis, pustular psoriasis, dan erythrodermic psoriasis.1,4 reddish plaque is an elevated skin lesion, with a diameter larger than 0.5 cm, which is reddish in color. silvery scales is defined as the presence of detached outer skin tissue which results in rough and silvery skin surface. pustules are elevated skin lesions with pus content.12 in this study, reddish plaques were found in 160 cases (98.8%) and silver scales in 155 cases (95.7%). this was in line with griffith and barker4, who states reddish plaques and silvery scales are as the most representative characteristics of psoriasis. reddish plaques and silvery scales are caused by keratinocyte hyperproliferation in the epidermis overlying dilated and tortuous blood vessels.1 pustules were found in 40 patients (24.7%), which was higher than the one reported by griffith and barker.4 this was due to the high proportion of pustular psoriasis in this study (17.9%). auspitz sign is a characteristic clinical manifestation of psoriasis that is rarely found among other papulosquamous dermatitis conditions. auspitz sign is the bleeding that occurs when the scaly skin in psoriatic lesion is detached. this is because the newly formed blood vessels are fragile and because of the thinning of stratum granulosum. both processes are due to the inflammatory patterns of psoriasis that involves ifn-γ, il-2, il-6, and tnf-α, which stimulate hyperproliferaiton of keratinocytes and hence disrupt the differentiation of stratum granulosum and endothelial differentiation which result in the formation of new, yet fragile and tortuous blood vessels.1,4,13 in this study, auspitz sign examination was only performed on 6 cases (3.7%). the very few number of auspitz examination was probably due to the fact that this examination inflicts pain on the patient. patients who had auspitz sign examination were all inpatients and recommended to proceed to histopathological examination. this indicated that auspitz sign examination was treated on patients whose diagnosis had not been able to be confirmed as psoriasis. beside the skin, psoriasis can also involve the nails and tongue which have keratinocytes in their epithelium. in the nails, psoriasis can manifest in the forms of pitting nail, oil spot, and onychodystrophy. in the tounge, it can manifest as geographic tongue.4 pitting nail is the detachment of some or all parts of the nail from the nail bed. oil spot is a reddish-yellow discoloration under the nail that extends in the direction of the hyponicium. onychodystrophy is the destruction of nail’s morphology.14 geographic tongue is the partial thickening of some parts of the tongue surface which results in islands-like formation.12 in this study, 29.6% of the cases had nail involvement while 12.4% had tongue involvement. out of the 162 who were clinically diagnosed psoriasis, 46 had undergone biopsy. after biopsy, 33 cases were histopathologically confirmed as psoriasis while the other 13 were confirmed as no psoriasis. the histopathological types of the 13 cases were subcorneal pustular dermatosis (2), spongiotic dermatitis (2), pemphigous (2), psoriasiform reactions (2), pityriasis rosea (1), pityriasis chronic lichenoides (1), pityriasis rubra pilaris (1), lenticular hyperkeratosis (1), and neurodermatitis (1). on the other hand, there were 7 cases which had other diagnosis, but then were histopathologically confirmed as psoriasis. these 7 were initially diagnosed as tuberculosis cutis (2), pityriasis rosea (2), syphilis (1), seborrheic dermatitis (1), and leprosy (1). in this case, hyperkeratosis was found in 90% of all cases. this was similar to a previous study by mehta et al.15 (82%). the high rate of hyperkeratosis with parakeratosis in psoriasis patients conforms with the inflammatory pattern of psoriasis which is dominated by t-cells. inflammatory cells, especially t-cells, will produce cytokines althea medical journal. 2016;3(4) 560 amj december 2016 (ifn-γ, il-2, il-6, and tnf-α) and growth factors which will induce proliferation of keratinocyte.3,4,13 these inflammatory factors are also the reason to the high rate of rete ridge elongation and/or acanthosis (98%), which was congruent to a study by moorchung et al.6 (100%). keratinocyte hyperproliferation pushes the basal membrane and the dermis vertically, which is often described like a test tube in its rack.6 the inflammatory pattern of psoriasis also causes neutrophil infiltration into the skin tissue.16 neutrophils in the stratum corneum are called munro’s microabcess while those located in the stratum spinosum are called kogoj’s micropustules.1 in this study, munro’s microabcess and/ or kogoj’s micropustules were observed in 88% of all cases. this conformed to a previous study by kassi et al.17 (90.9%), but was higher than the finding of mehta et al.15 (62.3%). the high proportion of cases with the presence of munro’s microabcess and/or kogoj’s micropustules was probably caused by the large proportion of generalized pustular psoriasis and erythrodermic psoriasis cases, which are the psoriasis types with a pattern of inflammation that is activated by infections, unprescribed corticosteroid use, and irrational use of cream medication.1,11 stratum granulosum can appear thinner or absent in psoriasis cases due to the high rate of keratinocyte proliferation which disrupt the process of keratinocyte differentiation into stratum granulosum.1 thinning or absent stratum granulosum was observed in 15 cases (37%), lower than what is reported by mehta et al.15 (83.6%). thinning or absent stratum granulosum was also the reason why bleeding can readily happen if the scaly skin on psoriatic lesion is removed, as supported by the low proportion of auspitz sign in this study. as previously explained, there is new formation of blood vessels that are fragile, tortuous, and dilated.6 in this study, the dilatation of blood vessels were observed in 75% of the cases, which was comparable to the studies by mehta et al.15 (86.9%) and kassi et al.17 (63.6%). there were some missing status in the histopathological medical records, namely: 4 (10%) had missing information on hyperkeratosis with parakeratosis, 1 (2%) had missing information on rete ridge elongation and/or acanthosis, 4 (10%) had missing information on munro’s microabcess and/or kogoj’s micropustules, 25 (63%) had missing information on the thinning or absence of stratum granulosum, and 10 (25%) had missing information on dilated blood vessels. the conclusion of this study was that there were 162 cases with clinical diagnosis of psoriasis, with reddish plaques and silvery scales as the most frequent characteristics (98.8% and 95.7% respectively). meanwhile, out of the 40 cases that were histopathologically diagnosed psoriasis, the most prevalent characteristics were rete ridge elongation and/or acanthosis (98%) and hyperkeratosis with parakeratosis (90%). one limitation of this study was the presence of medical records with incomplete or missing data in the department of dermatology and venereology and the department of pathological anatomy dr. hasan sadikin general hospital bandung. based on the study, the author recommends histopathological examinations to be performed on atypical psoriatic lesions, as such lesions had histopathological diagnosis that was different from the clinical diagnosis. another recommendation is that the patient examination and medical record writing, both clinical and histopathological, should be performed more extensively and systematically. lastly, an integrated information system should be implemented in dr. hasan sadikin general hospital as it will be of great use in cases that involve multilple departments. references 1. gudjonsson je, elder jt. psoriasis. in: wolff l, goldsmith la, katz si, gilchrest ba, paller as, leffell dj, editors. fitzpatrick’s dermatology in general medicine. 7th ed. new york: the mcgraw-hill; 2008.169–93. 2. szczerkowska-dobosz a, placek w, szczerkowska z, roszkiewicz j. the age of onset of psoriasis and the relationship to clinical presentation of psoriasis: study of 404 patients from northern poland. int j dermatol. 2014;53(8):e367–8. 3. krueger jg, bowcock a. psoriasis pathophysiology: current concepts of pathogenesis. ann rheum dis. 2005;64 (suppl2):s30–6. 4. 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case-control study in china. j eur acad dermatol venereol. 2009;23(2):132–7. 10. augustin, reich k, glaeske g, schaefer i, radtke m. co-morbidity and age-related prevalence of psoriasis: analysis of health insurance data in germany. acta derm venereol. 2010;90(2):147–51. 11. brenner m, molin s, ruebsam k, weisenseel p, ruzicka t, prinz jc. generalized pustular psoriasis induced by systemic glucocorticosteroids: four cases and recommendations for treatment. br j dermatol. 2009;161(4):964–6. 12. dorland wan. dorland’s illustrated medical dictionary. 28th ed. philadelphia: saunders elsevier; 2009. 13. purnak t, purnak s. the inflammatory markers in psoriasis. br j dermatol. 2012;167(2):457–8. 14. tan es, chong ws, tey hl. nail psoriasis: a review. am j clin dermatol. 2012;13(6):375–88. 15. mehta s, singal a, singh n, bhattacharya sn. a study of clinicohistopathological correlation in patients of psoriasis and psoriasiform dermatitis. indian j dermatol venereol leprol. 2009;75(1):100. 16. rocha-pereira p, santos-silva a, rebelo i, figueiredo a, quintanilha a, teixeira f. the inflammatory response in mild and in severe psoriasis. br j dermatol. 2004;150(5):917–28. 17. kassi k, mienwoley oa, kouyate m, koui s, kouassi ka. severe skin forms of psoriasis in black africans: epidemiological, clinical, and histological aspects related to 56 cases. autoimmune dis. [online journal] 2013 [cited 2014 december 15]. available from: www.hindawi.com/journals/ ad/2013/561032. willy chandra hermawan, hermin aminah, dendi sandiono: clinical and histopathological characteristics of psoriasis in dr. hasan sadikin general hospital bandung from 2009 to 2013 althea medical journal. 2016;3(2) 206 amj june 2016 knowledge, attitude, and practice on food safety among senior high school students in jatinangor from august−november 2013 hamizah sabrina binti ahamad naina,1 ine kuswardinah,2 sumartini dewi3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: food safety is defined as the confidence level that food will not cause sickness or harm to consumer when it is prepared, served, and eaten according to its intended use. this study was conducted to describe the pattern of knowledge, attitude, and practice on food safety among high school students in jatinangor. methods: one hundred and two respondents were involved in this study. the data were collected from the high school students in jatinangor, west java from august to november 2013 through the methods of questionnaire after the informed consent was obtained from the respondents. the questionnaire was translated from the five keys to safer food manual by world health organization. the collected data were then presented in percentage. results: overall, 60.78% of respondents had moderate knowledge, 85.29% had good attitude, and 71.57% had good practice in food safety. among the five main points on food safety in all aspects, most of the respondents were unaware of the safe temperature to store food; hence, they did not practice it. conclusions: even though most of the students have the knowledge, attitude, and practice on food safety, a need for relevant and motivating education should be performed for spesific indicators of food safety. [amj.2016;3(2):206–11] keywords: attitude, food safety, high school students, knowledge, practice correspondence: hamizah sabrina binti ahamad naina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827571484 email: sabrina.naina@gmail.com introduction food is a product that is rich of nutrients required by microorganisms and may be exposed to contamination due to the changes in food production, handling, storage, and preparation techniques as well as eating habits.1 food safety is defined as the confidence level that food will not cause sickness or harm to consumer when it is prepared, served, and eaten according to its intended use.2 contaminated raw food, inadequate cooking, and consumption of food from an unsafe source are factors associated with food-borne diseases in homes, restaurants, school canteen, and street. little interest has been given to school students’ understanding of safe food-handling. one of the many reasons to highlight this issue is because high school students represent an important population; they will be responsible soon for food preparation for themselves and others. in addition, most of high school students nowadays take a part time job in fast food restaurant to earn extra pocket money. at home, most parents work until late hours, so their children tend to prepare their own food. therefore, the knowledge (k), attitude (a) and practice (p) on food safety among the high school students are very important. they need to have the right mindset because they are the future food handlers. in developed countries, a lot of studies about this topic have been conducted among university students, adults, and food hawkers.3-5 studies on knowledge, attitude, and practice on food safety among high school students are scarce.6,7 on the other hand, in indonesia, this study has not been widely studied. in regard to this, a study was performed to describe the pattern of knowledge, attitude, and practice on food safety among high school students in jatinangor. althea medical journal. 2016;3(2) 207 methods a descriptive study was conducted to determine the knowledge, attitude, and practice on food safety among high school students in jatinangor, west java from august to november 2013. a total of 102 respondents were selected from four high schools; senior high school (sekolah menengah atas, sma) pgri jatinangor, vocational school (sekolah menengah kejuruan, smk) darul fatwa, sekolah menengah atas plus al-falah, and public senior high school (sekolah menengah atas negeri, sman) jatinangor. four schools were chosen out of 10 schools using random sampling. the numbers of student chosen from each school were calculated using proportion method. the inclusion criteria were students attending the four schools respectively and the exclusion criteria were students who did not attend school on the day questionnaires were distributed. a self-administered questionnaire for this study was prepared based on world health organization (who) food safety questionnaire. the modified questionnaire included four parts. the first part has been designed to obtain information about the demographic characteristics of the respondents. the second part consisted of 10 questions covering aspect of knowledge about food safety (keep clean, separate raw and cooked, cook thoroughly, keep food at safe temperatures and use safe water and raw material). the students were asked to choose from two options; true or false. the third and four parts consisted of 8 questions consecutively on attitude and practice towards food safety. respondents were asked to choose from among three options; agree, disagree, or do not know, to reduce response bias on the attitude section. for the practice section, respondents were asked to indicate their level of agreement to the statements using five-point rating scale (5=always, 4=most times, 3=sometimes, 2=not often, 1=never). the reliability and validity of the food safety questionnaire designed were determined by preliminary study on 30 respondents. these respondents were not included in this study. by using cronbach alfa test, the reliability coefficient test on knowledge, attitude, and practice was 0.760, 0.938 and 0.840 respectively after several questions were modified to improve clarity. level of knowledge was described using on guttman scale. level of attitude and practice used the score range made from the minimum and maximum score. this study was conducted with ethical clearance from the health research ethics committee of the faculty of medicine universitas padjadjaran and under permission from jatinangor authorities. results there were 45 male students and 57 female students who participated in this study. majority of the students were 17 years old (table 1). table 1 characteristics of subjects variables numbers of student (n) (n=102) percentage (%) sex male 45 44.12 female 57 55.88 age (years) 16 34 33.33 17 62 60.78 18 6 5.88 school sma pgri jatinangor 9 8.82 smk darul fatwa 19 18.63 sma plus al-falah 9 8.82 sman jatinangor 65 63.73 note: sma=sekolah menengah atas; smk= sekolah menengah kejuruan; sman= sekolah menengah atas negeri hamizah sabrina binti ahamad naina, ine kuswardinah, sumartini dewi: knowledge, attitude, and practice on food safety among senior high school students in jatinangor from august−november 2013 althea medical journal. 2016;3(2) 208 amj june 2016 table 2 food safety knowledge in senior high school students in jatinangor statement responses n (%) true false it is important to wash hands before handling food (1) 101(99.02) 1(0.98) wiping cloths can spread microorganisms (2) 97(95.10) 5(4.90) the same cutting board can be used for raw and cooked foods provided if it looks clean (3) 34(33.33) 68(66.67) raw food needs to be stored separately from cooked food (4) 101(99.02) 1(0.98) cooked foods do not need to be thoroughly reheated (5) 57(55.88) 45(44.12) cooked meat can be left at room temperature overnight to cool before refrigerating (6) 79(77.45) 23(22.55) cooked food should be kept very hot before serving (7) 75(73.53) 27(26.47) refrigerating food only slows bacterial growth (8) 11(10.78) 91(89.22) safe water can be identified by the way it looks (9) 15(14.71) 87(85.29) wash fruit and vegetables (10) 101(99.02) 1(0.98) majority of the respondents (99.02%) answered correctly for item 1, 4, and 10 which indicated that they realized the importance of hand washing, separation of raw and cooked food, and that fruit and vegetables need to be washed. however, there were very low percentage of those who answered correctly for item 6 and 8 which only reached about 22.55% and 10.78% respectively. this condition showed that many students did not know how to keep food at safe temperature (table 2). there were 61.76% of the students washed their hands before and during food preparation. nevertheless, almost one third (32.46%) of the students did not practice to keep leftover cooked meals in a cool place after two hours (table 4). this study discovered that from all of the respondents, most of them had moderate knowledge of food safety, but good attitude and practice (table 5). table 3 food safety attitudes in senior high school students in jatinangor statement responses n (%) agree not sure disagree frequent hand-washing during food preparation is worth the extra time (1) 94(92.16) 7(6.86) 1(0.98) keeping kitchen surfaces clean reduces the risk of illness (2) 100(98.04) 2(1.96) 0(0.00) keeping raw and cooked food separated helps to prevent illness (3) 76(74.51) 25(24.51) 1(0.98) using different knives and cutting board for raw and cooked food is worth the extra effort (4) 80(78.43) 18(17.65) 4(3.92) soups and stews should always be boiled to ensure safety (5) 62(60.78) 34(33.33) 6(5.88) i think it is unsafe to leave food out of the refrigerator for more than two hours (6) 29(28.43) 65(63.73) 8(7.84) inspecting food for freshness and wholesomeness is valuable (7) 97(95.10) 5(4.90) 0(0.00) i think it is important to throw away food that has reached its expiry date (8) 92(90.20) 6(5.88) 4(3.92) althea medical journal. 2016;3(2) 209hamizah sabrina binti ahamad naina, ine kuswardinah, sumartini dewi: knowledge, attitude, and practice on food safety among senior high school students in jatinangor from august−november 2013 discussions senior high school students in selected schools demonstrated that they had basic knowledge on food safety. about 99.02% of the respondents answered correctly that it was important to wash hands before handling food. this was supported by a previous study that was conducted in malaysia8 where 93.9% answered correctly on personal hygiene. hand washing has been shown to reduce the risk of diarrhea disease in child care institutions9 and can certainly do the same in school. as for practice, 61.76% ‘always’ and 14.71% ‘most of the times’ wash their hands before and during food preparation. many previous studies proved that it is crucial to practice self-hygiene especially hand hygiene because hand is the major agent that transmits microorganisms and intestinal parasites to foods.10 however, there were a few differences between the respondents’ knowledge and their attitude towards food safety. for instance, for item 4 on knowledge and item 3 on attitude, it was stated that 99.02% answered correctly that raw food needed to be stored separately from cooked food. however, only 74.51% agreed to the statement that keeping raw and cooked food separated helped preventing illness respectively. this evidently showed that even though respondents had the understanding on the specific material, they were not willing to practice it in daily life. this corresponded perfectly with their practice as well, where only 54.90% ‘always’ separated raw and cooked food during storage. another study also revealed that although respondents demonstrated significant knowledge on good personal hygiene, it is not always done into table 4 food safety practices in senior high school students in jatinangor statement responses n (%) always most times sometimes not often never i wash my hands before and during food preparation (1) 63(61.76) 15(14.71) 24(23.53) 0(0.00) 0(0.00) i clean surfaces and equipment used for food preparation before re-using on other food (2) 58(56.86) 21(20.59) 22(21.57) 1(0.98) 0(0.00) i use separated utensils and cutting boards when preparing raw and cooked food (3) 29(28.43) 22(21.57) 34(33.33) 9(8.82) 8(7.84) i separate raw and cooked food during storage (4) 56(54.90) 26(25.49) 16(15.69) 3(2.94) 1(0.98) i reheat cooked food until it is piping hot throughout (5) 37(36.27) 24(23.53) 32(31.37) 6(5.88) 3(2.94) after i have cooked a meal, i store any leftovers in a cool place within 2 hours (6) 14(13.73) 11(10.78) 44(43.14) 14(13.73) 19(18.63) i check and throw away food beyond expiry date (7) 62(60.78) 20(19.61) 7(6.86) 10(9.80) 3(2.94) i wash fruit and vegetables with safe water before eating them (8) 79(77.45) 13(12.75) 7(6.86) 2(1.96) 1(0.98) table 5 level of knowledge, attitude, and practice on senior high school students in jatinangor aspect number of students n (%) poor moderate good knowledge 18 (17.65) 62 (60.78) 22 (21.57) attitude 0 (0.00) 15 (14.71) 87 (85.29) practice 1 (0.98) 28 (27.45) 73 (71.57) althea medical journal. 2016;3(2) 210 amj june 2016 good practice. it was also stated that although many youth reported that they have been taught how to prevent food poisoning, they reported that they do not always practice safe food handling because of barriers, such as hunger (for example, too hungry to spend time on precautionary steps).11 in addition, the presence of parents appears to be a cue to perform safe food handling procedures, whereas in the absence of parents presents a temptation to neglect these procedures.11 some find the topic irrelevant and not interesting as well as peer pressure (for example, peers are important, so if peers do not practice safe food handling habits, they will also comply in order to fit in).11 respondents seem not to know about keeping food at the safe temperature. for item 6 and 8 on knowledge, about 77.45% answered wrong stating that cooked meat can be left at room temperature overnight to cool before refrigerating and only 10.78% answered correctly stating that refrigerating food slows bacterial growth respectively. this trend was seen in the attitude and practice section regarding the similar questions, whereby only 28.43% presumed it was unsafe to leave food out for more than two hours and only 13.73% ‘always’ stored leftover food in the refrigerator within two hours. this was also seen in previous study where only 28% of the respondents managed to prove that they know the right temperature for storage of hot and cold ready to eat foods.8 this result was also supported by bas et al.12 that reported the knowledge of critical temperatures of these aspects are low among their respondents. overall, respondents’ knowledge is moderate (60.78%), but they have good attitude (85.29%) and good practice (71.57%). these findings were consistent with previous study as well. respondents were reported to have high confidence levels in their ability to engage in safe food handling practices, but their knowledge levels indicate otherwise.13 according to byrd-bredbenner et al.11, their data also indicated that youth have broad knowledge base related to safe food handling.11 however, the data also suggested that this knowledge was primarily at the knowledge (recall) level of cognitive domain with limited comprehension as to why safe food handling was important and how to practice safe food handling.11 the limitation of this study was that the respondents answered the questions subjectively. although the questionnaire was anonymous and the participation was voluntarily, however, some of the questions may have been answered dishonestly. this issue may raise the possibility of measurement bias. it can be concluded that most of the students have the knowledge, attitude, and practice on food safety that should be enhanced. food safety programs need to be fun, engaging, visually intense and hands on learning that incorporates technology. according to health belief model, knowledge affects beliefs related to perceived susceptibility and severity of disease, benefits of and barriers to practicing preventive health behaviors and self-efficacy.14 therefore, education materials should be developed to assist them in building a solid knowledge base and integrate appreciation for why food safety is imperative, so they would become keen and able to practice safe food handling on their own accord. the value of food safety education for this group is crucial not only because they are preparing food now, but also they will have increase food preparation responsibilities in the future. it will be a good investment that would progress into adulthood and can benefit those around them. references 1. codex alimentarius comission, fao, who. food hygiene. 4th ed. rome: food and agriculture organization of the united nations; 2009. 2. who. five keys to safer food manual. switzerland: department of food safety, zoonoses and foodborne diseases; 2006. 3. sharif l, al-malki t. knowledge, attitude and practice of taif university students on food poisoning. food control. 2010;21(1):55−60. 4. abdul patah mor, issa zm, nor kn. food safety attitude of culinary arts based students in public and private higher learning institutions (ipt). international education studies. 2009;2(4):168−78. 5. turnbull-fortune s, badrie n. perception, attitude and practices to food safety among university students living in residence halls, trinidad, west indies. online int j food sci. 2012;1(1):1−11. 6. norazmir mn, hasyimah man, shafurah as, sabariah bs, ajau d, norazlanshah h. knowledge and practices on food safety among secondary school students in johor bahru, johor, malaysia. pak j nutr. 2012;11(2):110−5. 7. yoon hj, yoon ks. elementary school althea medical journal. 2016;3(2) 211 students’ knowledge, behavior and request for educational method associated with food safety. j korean diet assoc. 2007;13(2):169−82. 8. nee so, sani na. assessment of knowledge, attitudes and practices (kap) among food handlers at residential colleges and canteen regarding food safety. sains malaysiana. 2011;40(4):403−10. 9. xavier cac, oporto cfo, silva mp, silveira ia, abrantes mr. prevalência de staphylococcus aureusemmanipuladores de alimentos das crechesmunicipais da cidadedo natal/rn. rev bras anal clin. 2007;39(3):165−8. 10. aarnisalo k, tallavaara k, wirtanen g, maijala r, raaska l. the hygienic working practices of maintenance personnel and equipment hygiene in the finnish food industry. food control. 2006;17(12):1001−11. 11. byrd-bredbenner c, abbot jm, quick v. food safety knowledge and beliefs of middle school children: implications for food safety educators. journal of food science education. 2010;9(1):19−30. 12. bas m, ersun as, kivanc g. the evaluation of food hygiene knowledge, attitudes and practices of food handlers in food businesses in turkey. food control. 2004;17(4):317−22. 13. stein se, dirks bp, quinlan jj. assessing and addressing safe food handling knowledge, attitudes, and behaviors of college undergraduates. journal of food science education. 2010;9(2):47−52. 14. champion vl, skinner sc. the health belief model. in: glanz k, rimerbk, viswanath k, editors. health behavior and health education. theory, research and practice. 4th ed. san francisco, california: josseybass; 2008. hamizah sabrina binti ahamad naina, ine kuswardinah, sumartini dewi: knowledge, attitude, and practice on food safety among senior high school students in jatinangor from august−november 2013 althea medical journal. 2016;3(2) 165 dermatophytosis among elementary school students in jatinangor west java dwi bandang saskia,1 lies marlysa ramali,2 ramlan sadeli3 1faculty of medicine universitas padjadjaran, 2department of dermatovenereology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of microbiology and parasitology faculty of medicine universitas padjadjaran abstract background: dermatophytosis is a common skin disease in tropical countries. in indonesia, the incidence of dermatophytosis is quite high. epidemiological studies showed that prevalence of dermatophytosis in children were higher than in adults. the aim of this study was to identify dermatophytosis cases among elementary school students in jatinangor west java. methods: a descriptive study was carried out, involving 391 students aged 6–16 years from four elementary schools in jatinangor west java, who were selected by multi-stage sampling method. six classes were chosen from each school. in every class, students were chosen to obtain the minimum number of samples. the inclusion criteria was elementary school students who were willing to participate in this study. the exclusion criteria were students who did not attend school at the time when the study wasperformed. the study’s procedure consisted of six steps i.e. preparation, interview, screening, physical examination, specimen collection and microscopic examination. the collected data was processed by calculating the frequency and percentage. results: the study discovered that out of 391 students, 197 suffered from non specific skin lesions. after confirmed by a dermatologist, three students were suspected to have dematophytosis lesion. from microscopical examinations by a microbiologist, two students had positive dermatophyte hyphae. the number of dermatophytosis cases in elementary school students, in jatinangor was 0.5% (2/391). conclusions: the incidence of dermatophytosis cases in this study is relatively low compared with other studies. clinical features are tinea corporis. both patients with positive dermatophyte hyphae are ten -year -old females. [amj.2016;3(2):165–9] keywords: dermatophytosis, elementary school students, tinea corporis correspondence: dwi bandang saskia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285721393696, email: dwibandangsaskia@gmail.com introduction common fungal infection is a superficial fungal infection which affects the skin. while superficial fungal infection is a common infection occurring worldwide this is most often caused by dermatophyte fungi which are called dermatophytosis.1-4 this infection affects thepart of body that contains keratin (such as skin, hair, and nail).1,4 dermatophyte infection appears after direct and indirect contact with patients.3 although dermatophytosis is a contagious disease, it is not life-threatening.1-3 the transmission of dermatophytosis in humans is commonly from animals to humans, from humans to other humans, and from soil to humans. many factors contribute to the occurrence of dermatophytosis such as lack of personal hygiene, hot and humid climate, availability of source of infection in the surrounding areas, long term use of antibiotic drugs and steroid, age factor and socioeconomic status.5 furthermore, dermatophytosis is common throughout the world especially in tropical countries.6 about 20–25% of the population in the world suffers from this disease and the incidence continues to rise.2,7 a study in arochukwu, nigeria5 revealed that out of a total of 4.287 elementary school students, 1.740 males and 2.547 females were examined for clinical signs of dermatophytosis. there were 873 (20.4 %) students consisting of 505 males and 368 females who had althea medical journal. 2016;3(2) 166 amj june 2016 dermatophytosis lesion. another study from dar es salaamtanzania,8 discovered that out of 420 elementary school students, 48 were positive with this disease. different results from amazonas, brazil showed that out of 590 samples analysed, 210 showed positive dermatophytosis.9 other broad literature resources showed different results from different parts of theworld. 2,5,8 in indonesia,10 dermatophytosis infection becomes a national problem because the number of patients is quite high. a study conducted by kurniati10 discovered that incidence of dermatophytosis was the highest among other superficial dermatomycosis infections. additionally, epidemiological studies showed that prevalence of dermatophytosis in children was higher than in adults because they were more susceptible to infection.5 in accordance with the previous explanation, the objective of this study was to identify the dermatophytosis infection among elementary school students in jatinangor west java. methods a descriptive study was performed involving all elementary schools in jatinangor from thefirst grade until the sixth grade in septemberoctober 2013. the total number of sample needed was 385 respondents and a multistage sample technique was carried out to fulfill the number of sample. out of a total of 29 elementary schools in jatinangor subdistrict, four elementary schools were selected, namely sdn cikuda, sdn sinarjati, sdn jatiroke i and sdn cikopo i. next, six classes were selected from each school and from these classes students were selected to obtain the minimum number of sample. the inclusion criteria were elementary school students who were willing to participate in this study. the exclusion criteria were students who did not attend school at the time when the study was conducted .this study consisted of two variables, namely the dermatophytosis case and the characteristics of the dermatophytosis patients. the dermatophytosis case was defined as the finding of dermatophytosis lesion in the physcal examination and the description of a long septate and branched hypha/arthrosphore in the microscopic examination. furthermore, the characteristics of the dermatophytosis patients comprised three components, i.e. age, sex and clinical feature. the collected data were processed by calculating the frequency and percentage. the study’s procedure consisted of six steps regarding preparation, interview, screening, physical examination, specimen collection and microscopic examination. the six steps were: 1) the activites of the preparation process such as giving explanations to the principal of the selected schools about the study and requesting consent from the respective school principal. furthermore, the sampling process was performed to all elementary school children from the selected classes to meet the required number of sample (table 1), then, an interview was carried out to all the selected samples; 2) screening was carried out to all samples to detect whether there were skin diseases or not before a physical examination was performed, 3) out of the 391 samples, 197 samples had skin lesion. those samples performed anamnesis and physical examinations supervised by adermatovenerologist to confirm whether there was dermatophytosis lesion or not. lesion on the scalp was confirmed by wood’s lamp examination.11 4) specimen collection for microscopic examination was carried out to table 1 distribution of samples distribution of samples class sdn cikuda sdn cikopo i sdn sinarjati sdn jatiroke i total i 0 16 22 15 53 ii 17 0 21 16 54 iii 17 17 20 16 70 iv 17 16 25 18 76 v 17 17 22 17 73 vi 17 16 17 16 66 total 85 82 126 98 391 althea medical journal. 2016;3(2) 167 the sample who had dermatophytosis lesion in various locations i.e. infected hair was plucked with tweezers, lesion on scalp was scrapped with a scalpel, lesion on skin was scrapped with adhesive tape or a blunt scalpel, and debris under infected nail was taken with a blunt scalpel.12-14 each specimen was put into an envelop and labelled according to the identity of the respondents. 5) all specimens were taken to themicrobiology laboratory to be identified by a microbiologist. then, each specimen was put on an object glass, dripped with lactophenol cotton blue liquid, covered with a cover glass and warmed slide over a bunsen burner. the prepared specimen was examined through a microscope. dermatophytosis was identified if long branched and septate hyphae or arthrospores were discovered. afterward, the diagnostic criteria for dermatophytosis were determined in accordance with the physical examinations and microscopic findings. all procedures in this study were approved by the health research ethical committee of the faculty of medicine, universitas padjadjaran results the total of 391 students included in this study was among 6–16 years old (table 2). the age ranged from 6 to 16 years and was not normally distributed. the median age was 11 years and covered about 15,8% of the total sample. the number of male was similar to female with the ratio 1:1 (table 2). out of 391 students from four elementary schools in jatinangor, 197 students were suspected to have skin disorders. after physical examinations were carried out by a dermatologist, only 3 students were suspected dwi bandang saskia, lies marlysa ramali, ramlan sadeli: dermatophytosis among elementary school students in jatinangor west java table 2 distribution of samples according to age and sex variables total (n=391) percentage (%) age 6 27 6.9 7 54 13.8 8 67 17.1 9 77 19.7 10 66 16.9 11 62 15.8 12 28 7.2 13 5 1.3 14 4 1 15 0 0 16 1 0.3 sex male 200 51.2 female 191 48.8 table 3 number of dermatophytosis cases in elementary school students in jatinangor, dermatophytosis n percentage (%) dermatophytosis (+) 2 0.5 dermatophytosis (-) 389 99.5 total 391 100 althea medical journal. 2016;3(2) 168 amj june 2016 to have dermatophytosis lesion. moreover, after microscopical examinations were performed by a microbiologist, this study discovered that only two students (0.5%) had positive dermatophyte hyphae indicated by long septate hyphae. both patients were tenyear-old female students (table 3). both patients had lesions in the form of macules and categorized as tinea corporis, but at different locations. one was located on her trunk and the other one on her neck. discussion according to the study, many students had skin disorders such as pediculosis capitis and other skin diseases in addition to dermatophytosis. this situation was caused by poor hygiene of the school environment, since jatinangor is a tropical area with hot and humid climate. the low number of dermatophytosis case among elementary school students in jatinangor was caused by the absence of source of infection. the occurence and transmission of infection need the existence of infection sources and its close contact with the patients.6,15 for instance, sleeping next to pets. the incidence of dermatophytosis cases among elementary school students in jatinangor was relatively low compared to studies conducted by various researchers, such as a study by adefemi et al.16 in kwara state, nigeria discovered that the prevalence was about 5% (30/602). in addition, komba and mgonda8 in dar es salaam, tanzania, stated that the prevalence was 11.4 % (48/420). those studies had a similar subject as this study. the low number of dermatophytosis cases in this study might be influenced by many factors, namely the host factor, environmental factor, and availability source of infection.5 the characteristics of both patients in this study was based on age of ten years old. the result was similar to the study conducted by komba and mgonda8. they discovered that dermatophytosis cases in 6–10 years old children was about 21.8%. however, the result of this study showed that the disease affected only female respondents. nevertheless, the result from another study showed that dermatophytosis affected male more than female. for instance, the study by ngwogu and otokunefor5 in nigeria, showed that about 39% male suffered of high prevalence of dermatophytosis . moreover, sex is an important epidemiologic factor where dermatophytosis in male is five times greater than female.10 it may be caused by the host factor which is more active and sweating excessively. the clinical features in this study was tinea corporis, while the study by adefemi et al.16 showed that the majority of cases were tinea capitis followed by tinea corporis. another study by komba and mgonda8 showed that the majority of cases were tinea pedis and tinea corporis. the different results by various studies were due to the different climate and behaviour. most of the countries where the studies were conducted have hot and humid climate along the year and they always wear full-covering shoes making the higher risk to have tinea pedis.8 the different clinical features are influenced by important factors such as the infecting fungus, the site of the body infected and the keratinisation at that site.17 this study had limitations. not all the parents allowed their children to be examined after the screening phase. this condition made the next phase, namely the physical examination, could not be conducted that led to the undetected cases of dermatophytosis. it can be concluded that the incidence of dermatophytosis is relatively low compared with other studies. the clinical feature is tinea corporis and both patients are ten years old females. references 1. mitchell tg. medical mycology. in: brooks gf, carroll kc, butel js, morse sa, editors. jawetz, melnick & adelberg’s medical microbiology. 24th ed. new york: the mcgraw-hill companies; 2007. p. 626–30. 2. ameen m. epidemiology of superficial fungal infection. clin dermatol. 2010;28(2):197–201. 3. hogg s. essential microbiology. new delhi,india: wiley; 2005. 4. hainer bl. dermatophyte infections. am fam physician. 2003;67(1):101–9. 5. ngwogu ac, otokunefor tv. epidemiology of dermatophytoses in a rural community in eastern nigeria and review of literature from africa. mycopathologia. 2007;164(4):149–58. 6. madhavi, rao r, jyothsna k. mycological study of dermatophytosis in rural population. ann biol res. 2011;2(3):88– 93. 7. tsoumani m, jelastopulu e, bartzavali c, vamvakopoulou s, dimitracopoulos g, anastassiou ed, et al. changes of dermatophytoses in southwestern greece: an 18-year survey. mycopathologia. althea medical journal. 2016;3(2) 169dwi bandang saskia, lies marlysa ramali, ramlan sadeli: dermatophytosis among elementary school students in jatinangor west java 2011;172(1):63–7. 8. komba ev, mgonda ym. the spectrum of dermatological disorders among primary school children in dar es salaam. bmc public health. 2010;10:765. 9. cortez ac, de souza jv, sadahiro a, de oliveira ja. frequency and aetiology of dermatophytosis in children age 12 and under in the state of amazonas, brazil. rev iberoam micol. 2012;29(4):223–6. 10. kurniati, rosita csp. etiopatogenesis dermatofitosis. berkala ilmu kesehatan kulit & kelamin. 2008;20(3):243–50. 11. andrews md, burns m. common tinea infection in children. am fam physician. 2008;77(10):1415–20. 12. schieke sm, garg a. superficial fungal infection. in: goldsmith la, katz si, gilchrest ba, paller as, wolff k, leffell dj, editors. fitzpatrick’s dermatology in general medicine. 8th ed. new york: the mcgraw-hill companies; 2012. p. 2277– 87. 13. ghannoum ma, isham nc. dermatophytes and dermatophytoses. in: anaissie ej, mcginnis mr, pfaller ma, editors. clinical mycology. 1st ed. london: churcill livingstone elsevier; 2009. p. 375–7. 14. tullio v, banche g, panzone m, cervetti o, roana j, allizond v, et al. tinea pedis and tinea unguium in a 7-year-old-child. j med microbiol. 2007;56(pt 8):1122–3. 15. mendez-tovar lj. pathogenesis of dermatophytosis and tinea versicolor. clin dermatol. 2010;28(2):185–9. 16. adefemi sa, odeigah lo, alabi km. prevalence of dermatophytosis among primary school children in oke-oyi community of kwara state. niger j clin pract. 2011;14(1):23–8. 17. degreef h. clinical forms of dermatophytosis (ringworm infection). mycopathologia. 2008;166(5–6):257–65. althea medical journal. 2016;3(4) 583 correlation between substance use and anxiety-depression spectrum among senior high school students in bandung achmad samjunanto,1 lucky saputra,2 ra. retno ekowati3 1faculty of medicine universitas padjadjaran, 2department of psychiatry faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and biology cell faculty of medicine universitas padjadjaran abstract background: both substance use and anxiety-depression spectrum are the problem that currently faced by adolescents especially among senior high school students. moreover, there is a high comorbidity between both problems. this study was conducted to discover the substance use’s prevalence and to find out anxietydepression spectrum proportion among adolescent, and more importantly to determine whether there is correlation between both variables. methods:during october–november 2013, four hundred and fifty two students from five senior high schools located in karees sub-district, bandung were included in this cross-sectional analytic study. among whom, only 425 students filled the questionnaire properly. data were collected using kessler-10 (k10) to explore anxiety-depression spectrum and addiction severity index lite version (asi-lite) to identify substance use. the correlation between both variables was analyzed by gamma correlation test. results: the study revealed that there were 93 (21.9%) students that used substance. in addition, there were 244 students (57.4%) that screened as having anxiety-depression spectrum. statistical analysis, according to gamma correlation test, showed that there was a weak correlation between alcohol use and anxiety-depression spectrum (p=0.041; r=0.316). the remaining substances gave no statistically significant result (p>0.05). conclusions: there is a high prevalence in substance use and psychological distress in anxiety-depression spectrum among high school student. in addition, alcohol is the only substances that correlated with anxietydepression spectrum. [amj.2016;3(4):583–9] keywords: adolescents, anxiety-depression spectrum, high school student, substance use correspondence: achmad samjunanto, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285716571677 email: samjunanto@gmail.com introduction senior high school students apparently are adolescents who get a formal education in either state or private senior high school whose age usually ranges from 14 to 18 years old. regarding to their development, this age belongs to adolescent phase. adolescents are people in transition phase from a child phase toward an adult one.1 this is a phase of life in which ones try to determine their identity and to explore themselves both socially and psychosexually.1 regarding to their exploration and independency-establishment, there are some problems that arise among adolescent. one of which is substance use that result from risk-taking behavior; a behavior where there is no certainty about its benefits nor harms. risk-taking behavior actually leads to confidence and competence needed to establish new relationship and to get achievement in either sport, social, or academic. nevertheless, recently risk-taking behavior is associated with negative behaviors such as careless driving, risky sexual behavior, and especially substance use.1 substance refers to any chemical substances that could affect the process in the human either physically or mentally.1 those substances include alcohol, heroin, methadone, opium, cocaine, amphetamine, cannabis, hallucinogen, inhalant, barbiturate, meth, or any other substances.1 likewise, anxiety and depression is also a prominent adolescents’ problem beside the substance use. some experts stated that there is a common territory between anxiety and depression symptom.2 anxietyalthea medical journal. 2016;3(4) 584 amj december 2016 depression spectrum is a symptom of psychological distress and could be measured by an instrument named kessler-10.3 among adolescents whose age ranges from fifteen to twenty four years old, there were 8.7 percents prevalence of emotional mental disorder, as stated at riset kesehatan dasar (riskesdas) 2007,4 a quinquennial national health survey conducted by indonesian ministry of health. mental problems that might be faced by highschool student are mood disorder, learning disorder and disruptive behavior disorder. according to study conducted by pillai et al.5 the most common mental disorder that occurred in adolescent were anxiety disorder (54%), depressive disorder (27%), behavioral disorder (24.3%) and attention deficithyperactivity disorder (10.8%). comorbidity of substance use and mental disorder is quite high. forty four percents of patients in community mental health team over united kingdom was reported as an alcohol or substance user.6 in addition, a study conducted by merrill et al.7 stated that among overdosed decedents in utah, anxiety and sadness were the most frequent past psychological disorder they had. study that correlates both disorders was needed to make a policy regarding those problems’ prevention, albeit.there is a lack of such study in indonesia especially bandung despite of their high comorbidity. this study, therefore, was conducted to describe the cases of substance use and anxiety-depression spectrum among senior high school students in bandung, and more importantly, to determine the correlation between both cases. methods this analytical cross-sectional study was conducted in five state senior high schools in karees sub-district, bandung from october–november 2013 after getting an ethical approval from health research ethics committee, faculty of medicine, universitas padjadjaran and permission from bandung municipal government, bandung municipal education department and also from each school in which this study was conducted. this study was conducted in karees sub-district, where highest prevalence of substance abuse was reported based on data from nongovernment organization, named yayasan graha prima karya sejahtera (grapiks) that cooperates with dr. hasan sadikin general hospital to handle substance abuser. classes from each school were chosen ramdomly from each grade: grade x, xi, and xii. every student from the chosen classes that satisfied the inclusion criteria and were not excluded based on exclusion criteria was taken as a sample study. the inclusion criteria of this study involved an active student during data collection’s period. absent student, student who refused to be a sample, and student who did not fill in the questionnaire properly were excluded from this study. from fifteen classes, there were only 452 students who met the inclusion criteria, presented at the data collection’s day and signed the informed consent with permission of their teacher. among whom, however, only 425 filled the questionnaire properly. the questionnaire for this study consisted three parts: identity part, mental health part and substance-use part. kessler-10 (k-10) was used as an instrument to measure the psychological condition from sample study. k-10 is used to be a non-specific screening test to detect psychological distress based on ten questions about anxiety and depression and it has been validated in indonesia.3 it classifies person into four categories: likely to be well, likely to have mild psychological distress, likely to have moderate psychological distress and likely to have severe psychological distress. addiction severity index lite version (asi-lite) was used to determine the substance use from the sample study. the asi-lite is a short version from addiction severity index (asi) which is a guide for professional mental health worker to interview the client. the asi involved several aspects such as health status, financial status, substance-abuse status, criminal status, social status and psychiatric status. the asi-lite contains 22 fewer questions than the asi, and omits items related to severity ratings, and a family history grid.8 there might be some bias and confounding factors in this study. student’s dishonesty might be one of prominent bias that could be found in this study. this study, therefore, used several steps to minimize it, such as not putting name column in the questionnaire, sealing the questionnaires in opaque envelop before them, asking them to fill the questionnaire alone without involving their teachers, and emphasizing that the result would not be exposed to another person. some confounding factors that might affect correlation between anxiety-depression spectrum and substance use are age and demographic status., this study used some restriction. this study only conducted in adolescent who currently enrolled formally in senior-high-school althea medical journal. 2016;3(4) 585 table 1 sample’s characteristic profile characteristic grade total n (%) x (n) xi (n) xii (n) age (years old) 14 7 1 0 8(1.9) 15 83 11 0 94 (22.1) 16 9 125 30 164(38.6) 17 1 9 141 151(35.5) 18 0 0 8 8(1.9) gender male 50 61 65 176(41.4) female 50 85 114 249(58.6) living with parents 98 139 174 411(96.7) other* 2 7 5 14(3.3) total ** 100 (23.5) 146 (34.4) 179 (42.1) 425 note: *involved living with brother, sister, grandfather, or another relatives,** the number and percentage in parentheses achmad samjunanto, lucky saputra, ra. retno ekowati: correlation between substance use and anxietydepression spectrum among senior high school students in bandung academic activity, not to mention only state high school. collected data were analyzed by a computerized statistical calculation. since the variables were ordinal categorical variable and both variables were equal where there were neither dependent nor independent variable, the gamma correlation test was used in this study to find the r value. the r value measured the correlation power and determined whether the correlation is positive or negative. the p value was also calculated to determine whether the result is statistically significant. if p value was below 5%, the result was statistically significant. hence, the null hypotheses could be rejected. results among 425 samples, the numbers of female students were higher than male (table 1). furthermore, the number of students who had anxiety-depression spectrum was higher than students who used substance (table 2). further information about substance user and anxiety-depression spectrum were illustrated in figure 1 and figure 2, respectively. nicotine, alcohol and cannabis/marijuana were the most used substances with 88 cases (94.6%), 31 cases (33.3%) and 7 cases (7.5%) respectively (figure 1). in addition, there were only 2 cases for methamphetamine user, and only 1 case for each barbiturate, cocaine, amphetamine, hallucinogen, and magic mushroom user. moreover, there were no heroin, methadone and inhalant users. in addition, the male to female ratio of substance use in this study was 4.5:1. more than half students were likely to have psychological distress in anxiety-depression spectrum according to k-10 assessment (figure 2). yet, only 28 students (6%) were likely to have severe psychological distress. moreover, this study revealed that there was 1:1.6 as male to female ratio of students that were likely to have anxiety-depression spectrum. correlation between the psychological distress in anxiety-depression spectrum and each substance that were used by the sample were determined by gamma correlation test (table 3). among which, only correlation from alcohol use was statistically significant (p=0.041). the result, however, showed weak correlation between alcohol use and anxietydepression spectrum (r=0.316). moreover, beside alcohol, there was no substance that gave a statistically significant result. discussion normal range for urinary sodium level is 40– 220 meq/l. in this study, there were 96 subjects from total 111 samples which 86.5% of them althea medical journal. 2016;3(4) 586 amj december 2016 had urinary sodium level higher than normal. the percentage of subjects that had normal sodium in urine was 13.5 % from overall samples. the results of urinary sodium level proved that sodium intake among cipacing resident were still higher than normal limit. high exposure of sodium in the daily food can make the taste buds adaptation of salt taste perception.5 the adaptation makes someone become insensitive with salty taste in low concentration, so he can only taste the saltiness in the higher sodium concentrations. high sodium intake in daily food contributes in high urinary sodium levels. level of sodium in urine is used as the gold standard for assessing a daily sodium intake. this study proved the relationship between the threshold of saltiness that can be perceived by the subjects and assessed the levels of sodium intake in the urine (p< 0.01). salt taste threshold is influenced by various factors such as age, history of alcohol and long term drug consumption.6,7 sensitivity of salt taste threshold in elderly will decrease because of reduction sensitivity of sensory function of tongue.8 thus, subjects that were chosen in this study were individuals aged 18-60 years old.9 in individuals who consume alcohol also decreased sensitivity of taste because the cytotoxic properties of alcohol can damage the cells. while the decrease sensitivity in the individuals who consume long term drugs (for certain drugs) can cause dry mouth or xerostomia. in this study, to reduce confounding, the individuals who had history of long term drugs consumption or alcohol consumption were eliminated. results of correlation test showed moderate correlation between urinary sodium levels with salt recognition threshold (r= 0.597; p <0.01). this result shows that the higher the salt recognition threshold will cause the higher sodium levels in urine. correlation test results also showed moderate correlation between the absolute threshold with urinary sodium levels (r = 0.407: p<0.01). this showed that the higher the threshold level of saltiness chosen by research subjects in their daily diet, the higher level of sodium they had in their urine. the results of this study had the same results with the study conducted in a teaching hospital campina, brazil by paula et al.10 that there was a relationship between the salt taste threshold and sodium in the urine (r= vf0.20; p=0.046) for recognition threshold and (r=0.23;p=0.015) for absolute threshold.10 table 2 anxiety-depression spectrum and substance use prevalence regarding its sample’s age, sample’s grade, sample’s gender and people whom lived with sample anxiety-depression spectrum* n(%) substance use** n(%) both n(%) age (years old) 14 7 (1.6) 0 (0) 0 (0) 15 56 (13.2) 15 (3.5) 10 (2.4) 16 98 (23.1) 32 (7.5) 19 (4.5) 17 75 (17.6) 44 (10.4) 26 (6.1) 18 8 (1.9) 2 (0.5) 2 (0.5) grade x 62 (14.6) 15 (3.5) 11 (2.6) xi 88 (20.7) 31 (7.3) 18 (4.2) xii 94 (22.1) 47 (11.1) 28 (6.6) gender male 94 (22.1) 76 (17.9) 44 (10,4) female 150 (35.3) 17 (4.0) 13 (3.1) total 244 (57.4) 93 (21.9) 57 (13.4) note: *everyone except those diagnosed as ‘likely to be well’ by k-10 (likely to have mild, moderate or severe psychological distress in anxiety-depression spectrum),** every substances use regardless its substances althea medical journal. 2016;3(4) 587 this showed that the higher the threshold level of saltiness of the salt solution, the higher the sodium consumed daily. results of research conducted in lagos, nigeria by ec azinge et al.11 with 40 study subjects classified threshold becoming low salt taste threshold and high salt taste threshold. the concentration of salt solution used in the low salt taste threshold was 5–30 mmol/l and high salt taste threshold was 60–90mmol/l. sodium excreted in the urine for low salt taste threshold was 19.5±2 mmol/l/ mmol creatinine and 30.3±0.7 mmol/l/mmol creatinine for high salt taste threshold.11 figure 1 substance use cases chart regarding its type figure 2 proportion of anxiety-depression spectrum based on kessler-10 assessment achmad samjunanto, lucky saputra, ra. retno ekowati: correlation between substance use and anxietydepression spectrum among senior high school students in bandung althea medical journal. 2016;3(4) 588 amj december 2016 levels of sodium in the body vary every time. standards used to assess the levels of sodium in the body were a 24 hours urine laboratory tests. however, in this study, that was not carried out and only used the predicted urine 24 hours using the tanaka’s formula. tanaka’s study used laboratory results of urine in the morning and afternoon because the difficulty of collecting urine for 24 hours as well as the inconvenience of research subjects to collect urine for 24 hours. the reason for using predicted formula by tanaka et al.12 in this study was due to the fact that subject of research studies on the formula tanaka were asians that had resembled characteristics with the subjects in this study which were indonesians. limitations of this study was the result of calculation of predicted 24 hours urinary sodium in the urine results as inadequate to accurately estimate the amount of sodium intake of a person because there was a difference in the results of which approximately 24.0 mmol/day.13 suggestion that could be given based on this research was further using the results of sodium in urine for 24 hours. in addition, the researchers did not supervise the subject of research in decision urine in the morning and evening, so that researchers could not guarantee that the research subjects had collected urine samples with the correct method. advices to be given based on this research are to health workers who can help the villagers of cipacing to regulate the amount of sodium intake in their daily diet. health workers can quickly detect the sodium intake of salty taste threshold of someone by using salt taste threshold. rapid detection of the sodium intake is expected to reduce the incidence of hypertension by modifying risk factors.14 controlled sodium intake to table 3 cross-tabulation between anxiety-depression spectrum in anxiety-depression spectrum and substance use for each substance substances* anxiety-depression spectrum total p** r*** severe moderate mild well nicotine (+) 6 13 34 35 88 0.859 0.017 (-) 21 63 107 146 337 alcohol (+) 4 9 9 9 31 0.041 0.313 (-) 23 67 132 172 394 methampheta-mine (+) 0 1 0 1 2 0.894 0.086 (-) 27 75 141 180 423 barbiturate (+) 0 0 0 1 1 0.316 -1.0 (-) 27 76 141 180 424 cocaine (+) 0 0 0 1 1 0.316 -1.0 (-) 27 76 141 180 424 amphetamine (+) 0 0 0 1 1 0.316 -1.0 (-) 27 76 141 180 424 cannabis (+) 0 3 3 1 7 0.129 0.414 (-) 27 73 138 180 418 hallucinogen (+) 0 0 1 0 1 0.326 0.275 (-) 27 76 140 181 424 other (magic mushroom) (+) 0 0 0 1 1 0.316 -1.0 (-) 27 76 141 180 424 multisubstance**** (+) 3 8 9 10 30 0.159 0.218 (-) 24 68 132 171 395 total 28 27 76 141 181 note: *heroin, inhalant and methadone was not included since the absence of user,**the result was statistically significant if p <0.05, ***the r described the correlation power (0.00–0.199: very weak; 0.20–0.399: weak; 0.4–0.599: fair; 0.6–0.799: strong; 0.8–1.00: very strong), ****substance usage more than 1 substance althea medical journal. 2016;3(4) 589 minimize the incidence of hypertension due to a reduction in sodium intake of 77 mmol/day can lower systolic blood pressure 1.9 mmhg and 1.1 mmhg diastolic. from this study, it can be concluded that there is moderate correlation of salt taste threshold and urinary sodium excretion which mean subjects that have high salt taste threshold may have high sodium intake. references 1. sadock bj, sadock va. kaplan & sadock’s comprehensive textbook of psychiatry. 9th ed. philadelphia: lippincott williams & wilkins; 2009 2. andreescu c, lenze ej. comorbid anxiety and depression: bête noire or quick fix? br j psychiatry. 2012;200(3):179–81. 3. kessler rc, andrews g, colpe lj, hiripi e, mroczek dk, normand sl, et al. short screening scales to monitor population prevalences and trends in non-specific psychological distress. psychol med. 2002;32(6):959–76. 4. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2007. jakarta: departemen kesehatan ri; 2008 5. pillai a, patel v, cardozo p, goodman r, weiss ha, andrew g. non-traditional lifestyles and prevalence of mental disorders in adolescents in goa, india. br j psychiatry. 2008;192(1):45–51 6. weaver t, madden p, charles v, stimson g, renton a, tyrer p, et al. comorbidity of substance misuse and mental illness in community mental health and substance misuse services. br j psychiatry. 2003; 183:304–313 7. merrill rm, johnson em, sloan a, lanier wa. characterizing unintentional nonillicit and illicit substance-related deaths. journal of drug issues. 2013;43(2):144–53. 8. cacciola js, alterman ai, mclellan at, lin y-t, lynch kg. initial evidence for the reliability and validity of a “lite” version of the addiction severity index. substance alcohol depend. 2007;87(2):297–302. 9. rohrbach la, sussman s, dent cw, sun p. tobacco, alcohol, and other substance use among high-risk young people: a fiveyear longitudinal study from adolescence to emerging adulthood. journal of drug issues. 2005;35(2):333–56. 10. miller jw, naimi ts, brewer rd, jones se. binge drinking and associated health risk behaviors among high school students. pediatrics. 2007;119(1):76–85. 11. blanchard lt, gurka mj, blackman ja. emotional, developmental, and behavioral health of american children and their families: a report from the 2003 national survey of children’s health. pediatrics. 2006;117(6):e1202–e12. achmad samjunanto, lucky saputra, ra. retno ekowati: correlation between substance use and anxietydepression spectrum among senior high school students in bandung althea vol 2 no 4 final.indd althea medical journal. 2015;2(4) 584 amj december, 2015 clinical presentation and laboratory features in pediatric typhoid fever patient susceptibility to first-line antibiotic therapy dewi ratnasari,1 djatnika setiabudi,2 lulu eva rakhmilla3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of epidemiology and biostatistics faculty of medicine universitas padjadjaran abstract background: rtyphoid fever remainsa serious health problem in the world. the main cause of this disease is salmonella enterica serovar typhi. these microbes have developed resistance to first-line antibiotics (chloramphenicol, ampicillin, and co-trimoksazol) since 1950. clinical presentation and laboratory features conducted in children infected with resistant strains tend to be more severe. the objective of this study was to determine the differences of clinical presentation and laboratory features in pediatric typhoid fever patient susceptibility to first-line antibiotics. methods: this was an analytical cross-sectional study of total 119 typhoid fever children with positive blood culture of salmonella typhi based on medical data in department of child health dr. hasan sadikin general hospital, bandung during 2008–2012. inclusion criteria included 76 patients with age range 1–15 years old, given an antibiotic, and had susceptibility test done. numerical variable was the duration of fever in patients after given an antibiotic. categorical variable included hepatomegaly, diarrhea, platelet count at admission, and leukocyte count at admission. data were analyzed using a mann-whitney and chi-square test. results: there was no statistically significant difference in the duration of fever, leucocyte count at admission, and thrombocyte count at admission between sensitive and resistant response to chloramphenicol, ampicillin, and co-trimoksazol (p>0.05). leucocyte count at admission in children with sensitive and resistant strain to ampicillin almost showed a difference (p=0.07) but still not statistically significant difference. conclusions: there is no difference of clinical presentation and laboratory features in pediatric typhoid fever patient susceptible to first-line antibiotics. [amj.2015;2(4):584–90] keywords: clinical presentation, first line antibiotics, laboratory features, salmonella typhi correspondence: dewi ratnasari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 878 277 9846 email: deardewir@live.com introduction typhoid fever is an infection caused by salmonella enterica serovar typhi (s. typhi), a gram-negative bacteria. it remains as a serious health problem due to high mortality rate in the world.1,2 based on world health organization (who) study in 2000, typhoid fever is accounted for over 2.16 million cases worldwide with at least 216.000 annual death. in indonesia, based on basic health research institution (riset kesehatan dasar/ riskesdas) study, held by the indonesian ministry of health, there are 1,6 % mortality cases caused by typhoid fever from 4552 total mortality cases in all ages in 2007.3 based on a study conducted in kathmandu medical college teaching hospital from july 2004–june 2005, clinical presentation in children with typhoid fever were fever (100%), headache (82.6%), vomiting (21.7%), diarrhea (28.3%), hepatomegaly (18.1%), and splenomegaly (28.3%).4,5 besides, laboratory test shows leukopenia (3%) and thrombocytopenia (4.8%) according to a study from may 2002–april 2004 in batra hospital and medical research center, new delhi, india. 6 the first treatment used in 1948 for typhoid fever was chloramphenicol. chloramphenicolresistant salmonella typhi cases is first reported in england (1950) and followed by india (1972).4,7 in resistant cases to firstline antibiotics, severe presentation could be present in children with typhoid fever.4,8 in aga khan university, karachi, pakistan, during althea medical journal. 2015;2(4) 585 2010 a resistant case in children with typhoid fever had severe presentation including fever (100%), hepatomegaly (88%), splenomegaly (46%), diarrhea (74%), encephalopathy (8%), and pneumonia (3.2%).9 laboratory features such as leukopenia (18.66%) and thrombocytopenia (2.66%) were shown in government medical college in pediatric ward, ahmedabad, gujarat.11 10 there are many resistant cases of first-line antibiotics around the world. chloramphenicol, ampicillin, and co-trimoksazol resistant cases are serious problems that need to be concerned beacuse it could elevate the mortality rate. this study aimed to determine the differences of clinical presentation and laboratory test based on susceptibility of salmonella typhi to firstline antibiotic (chloramphenicol, ampicillin, and co-trimoksazol) at dr. hasan sadikin general hospital, bandung, indonesia. clinical presentation of this study includes duration of fever after given an antibiotic, diarrhea and hepatomegaly. a laboratory test in this study includes platelet count at admission and leukocyte count at admission. methods patients with positive blood culture of salmonella typhi had susceptibility test done during january 2008–december 2013 in the child health department of dr. hasan sadikin general hospital, bandung, indonesia were chosen as a subject of the study. inclusion criteria in this study included 76 patients with age range 1–15 years old, given an antibiotic, and had susceptibility test done. the exclusion criteria included 43 patients with other infection, had not susceptibility test done, and incomplete data. analysis of the characteristics, clinical, and hematologic features of patients diagnosed with typhoid, as well as an analysis of sensitivity profiles of salmonella typhi isolates were collected. data were collected from medical record in clinical pathology department and medical record installation with permission from health research ethics committee of dr. hasan sadikin general hospital, bandung, indonesia. in this study, it is used susceptibility on antibiotics as an independent variable and figure 1 study profile dewi ratnasari, djatnika setiabudi, lulu eva rakhmilla: clinical presentation and laboratory features in pediatric typhoid fever patient susceptibility to first-line antibiotic therapy althea medical journal. 2015;2(4) 586 amj december, 2015 clinical presentation and laboratory features as a dependent variable. each variable was susceptibility to first-line to antibiotics that shown in culture test result, body temperature >40 oc as a fever, excessive and frequent evacuation (>3x/day) of watery feces as a diarrhea, abnormal enlargement of liver as a hepatomegaly, total of white cells count <5000/ mm3 as a leukopenia, and total thrombocyte count <150000/mm3 as a thrombocytopenia. based on normality test analysis, the data were not a normal distribution therefore it was used median with minimum and maximum data to describe all the cases based on the variable. total sampling method was collected from the medical record. the data were analyzed using the mann-whitney test and chi-square analysis test for numerical and categorical variable. numerical variable in this study was the duration of fever in patients after given an antibiotic. categorical variable in this study included hepatomegaly, diarrhea, platelet count at admission, and leukocyte count at admission. the analysis was performed using statistical software applications. results in this study, data were collected from 119 children with positive blood culture of salmonella typhi, of which 43 data were excluded based on exclusion criteria. there were 76 analyzed data based on susceptibility test to first-line antibiotics. (figure 1) figure 2 characteristics of typhoid fever in children patients with positive culture of salmonella typhi based on categorical variable table 1 characteristics of typhoid fever in children patients with positive culture of salmonella typhi based on numerical variable variable median (min-max) age (years) 8 (1–15) duration of hospitalization (days) 7.50 ( 2–28) duration of fever (days) 4 (0–16) leukocyte count during hospitalization (/mm3) 5,250 (1,700 –11,200) leukocyte count at admission (/mm3) 5,550 (1,700–68,000) platelet count during hospitalization (/mm3) 139,500 (1,200– 379,000) platelet count at admission (/mm3) 142,000 (3,000 – 406,000) althea medical journal. 2015;2(4) 587dewi ratnasari, djatnika setiabudi, lulu eva rakhmilla: clinical presentation and laboratory features in pediatric typhoid fever patient susceptibility to first-line antibiotic therapy the susceptibility tests were performed using chloramphenicol, ampicillin, and co-trimoxazole with the results grouped as sensitive and resistant (figure 1). susceptibility test to chloramphenicol had been done to 67 patients (88.2%) included patients had susceptibiliy test to all first-line antibiotics done (25.4%), to chloramphenicol and ampicilllin (6%), and patients had susceptibility test done to chloramphenicol and co-trimoksazol (68.7%). besides, susceptibility test to ampicillin had been done to 30 patients (39.5%) included patients had susceptibility test done only to ampicillin (13.3%), to all first-line antibiotics (56.7%), to ampicillin-chloramphenicol (13.3%), and to ampicillin-co-trimoksazol (16.7%). susceptibility test to co-trimoksazol had been done to 65 patients (85.5%) included patients had susceptibility to all first-line antibiotic (26.2%), to cotrimoksazol-chloramphenicol (66.2%), and patients had susceptibility to table 2 clinical presentation and laboratory features in typhoid fever due to salmonella typhi infection in children based on their susceptibility to first-line antibiotics based on numerical variable duration of fever (days)* p** leucocyte count at admission (103/mm3)* p** platelet count at admission (103/mm3)* p** chloramphenicol sensitive 4 0.76 5.6 0.26 138 0.1 resistant 4.5 3.8 81 ampicillin sensitive 3 0.6 5.8 0.07 150 0.93 resistant 2 6.8 143 co-trimoksazol sensitive 4 0.25 5.2 0.44 138 0.65 resistant 2.5 3.6 125.5 note: *median result of each variable , **p value based on mann-whitney analysis table 3 clinical presentation and laboratory features in typhoid fever due to salmonella typhi infection in children based on their susceptibility to first-line antibiotics based on categorical variable diarrhea (%)* p** hepatomegaly (%)* p** leukopenia at admission (%)* p** thrombocytopenia at admission (%)* p** chloramphenicol sensitive 36 0.53 47 1 43 0.19 52 0.49 resistant 0 50 100 100 ampicillin sensitive 44 0.6 34 0.36 38 1 48 1 resistant 0 100 0 100 co-trimoksazol sensitive 41 0.24 44 1 44 1 52 0.49 resistant 0 50 50 100 note: *frequency of each variable , ** p value based on chi-square analysis althea medical journal. 2015;2(4) 588 amj december, 2015 cotrimoksazol-ampicillin (7.7%). the average age of all cases was 8 years old. clinical presentation and laboratory features such as diarrhea (39.5%), hepatomegaly (46.1%), leucopenia at admission (42.1%), and thrombocytopenia at admission (51.3%) were presented (table 1 and figure 2). based on the analysis using mann-whitney method, there were no statistically significant difference in the duration of fever, leucocyte count at admission, and thrombocyte count at admission between sensitive and resistant response to chloramphenicol, ampicillin, and co-trimoksazol (p>0.05). leucocyte count at admission in children with sensitive and resistant strain to ampicillin almost showed a difference (p=0.07) but still not statistically significant difference (table 2). comparison of clinical presentation and laboratory features (diarrhea, hepatomegaly, leukopenia at admission, thrombocytopenia at admission) in typhoid fever due to salmonella typhi infection in children based on their susceptibility to first-line antibiotics (sensitive and resistant) were analyzed using chi-square method. all the p values were above 0.05 for all clinical presentation. it was shown that there was no statistically significant difference in the clinical presentation and laboratory features of sensitive and resistant salmonella typhi isolates to first-line antibiotics (table 3). discussion in this study, overall cases of typhoid fever in children due to salmonella typhi infection during january 2008–december 2012 are 119 cases. but, there is another infection that can alter the results of clinical presentation and a few of data that are incomplete, so the data are excluded from this study. there are only 76 cases included in the study. the average age is 8 years old. it is similar to a study conducted in government medical college in 2011 shown that fever was frequently presented on 6–12 years old children hospitalized in pediatric ward.11 hepatomegaly is more frequent than diarrhea (42% vs 23%) in typhoid children patients based on study in ward of pediatric infectious diseases in turkey in 2001.6 based on this study, there are similar frequency for hepatomegaly (46.1%) and diarrhea (39.5%). a study in dr. hasan sadikin general hospital, bandung, conducted by alam, during 2006–2010 and study in apollo hospital, india during 2009–2011 showed that resistant cases to first-line antibiotics (ampicillin, chloramphenicol, and co-trimoksazol) were low. both study discovered that the first-line antibiotics could remain as a treatment for typhoid fever in children.12,13 in this study, first-line antibiotics also could remain as first choice of tratment for typhoid fever in children. in 2012, there were also evidence that first-line antibiotics remain as a choice for typhoid treatment in carolus hospital, jakarta. the sensitivity rate to first-line antibiotics remained high from 247 isolates collected during 2002–2010.14 based on study in chennai, india, an increased sensitivity was also reported for chloramphenicol (97.5%), ampicillin (67.5%), and co-trimaxazole (97.5%).15 based on study in karachi, pakistan on 2011, there was a different result which are resistant cases to first-line antibiotics presented above 50%. in 2011 there were 89.7%, 82.8%, and 31.0% resistant cases to first-line antibiotics to ampicillin, chloramphenicol and cotrimozaxole respectively based on study in general hospital, funtua, katsina state of nigeria.16,17 many factors could lead to the emergence of resistant strains or resistant cases such as lack of knowledge, physicians change, different antibiotics unnecessarily during the treatment of typhoid fever, and indiscriminate use of drugs.8,18 a study conducted in king edward memorial hospital, mumbai, from the data isolates in early 1990s, showed the presence of fever >104of, toxemia, hepatomegaly, splenomegaly, abdominal tenderness and abdominal distension in significantly higher proportion of cases with multi-drug resistant salmonella typhi (mdrst) as compared to typhoid fever due to sensitive strains. this could be due to the association of typhoid fever outbreaks with malnutrition, commonly seen in children under the age of five in developing countries. the presence of malnutrition enhances susceptibility to typhoid infection by alterations in the intestinal flora or other host defenses.8 in this study, nutritional status in patients are not obtained. clinical presentation and laboratory features present between sensitive and resistant strain to first-line antibiotics (one or more) do not statistically show a significant difference. differences of susceptibility response to first-line antibiotics could be influenced by compliance of antibiotic consumption, self hygiene, cooked food and clean water consumption. another important factor was genome from salmonella typhi itself. different strains of salmonella typhi from althea medical journal. 2015;2(4) 589 all over the world and decreased outer membrane permeability that could lead to differences in clinical presentation and their susceptibility to antibiotic based on study in 5 cities of indonesia (medan, jakarta, pontianak, makassar, and jayapura).14,15,19 limitation of this study is incompleted and the arrangement of data is unsystematic. besides, unstandardized culture test procedure for typhoid fever in children also becomes a limitation in this study. based on data analysis, it can be concluded that there is no significant differences of clinical presentation in sensitive and resistant salmonella typhi isolates to the first-line antibiotics. laboratory features in sensitive and resistant salmonella typhi isolates to first-line antibiotics also shows no significant differences. further research is needed to get more and better data and should be done prospectively so that clinical presentation and laboratory features could be shown more clearly and chosen antibiotic for children with typhoid fever could be more accurate. procedure of susceptibility test to first-line antibiotics for typhoid fever in children should be decided by physician. reported data should be arranged more clearly. references 1. dewan am, corner r, hashizume m, ongee et. typhoid fever and its association with environmental factors in the dhaka metropolitan area of bangladesh: a spatial and time-series approach. plos negl trop dis. 2013;7(1):e1998. 2. crump ja, luby sp, mintz ed. the global burden of typhoid fever. bull world health organ. 2004;82(5):346–53. 3. triono s. riset kesehatan dasar. laporan nasional 2007. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan; 2008. 4. chowta. study of clinical profile and antibiotic response in typhoid fever. indian j med microbiol. 2005;23(2):125–7. 5. mathura, chaudhary d, simmkhada r, pradhan m, shresta p, gurubacharya d. study of clinical profile and antibiotic sensitivity pattern in culture positive typhoid fever cases. kathmandu univ med j. 2005;3(4):376–9. 6. kumar r, gupta n, shalini. multidrugresistant typhoid fever. indian j pediatr. 2007;74(1):39–42. 7. khandeparkar p. reemergence of chloramphenicol in typhoid fever in the era of antibiotic resistance. j assoc physicians india. 2010;58(12):45–6. 8. zaki sa, karande s. multidrug-resistant typhoid fever: a review. j infect dev ctries. 2011;5(5):324–37. 9. onyango d, machoni f, kakai r, waindi en. multidrug resistance of salmonella enterica serovars typhi and typhimurium isolated from clinical samples at two rural hospitals in western kenya. j infect dev ctries. 2008;2(2):106–11. 10. rahman, ahmad, begum. multidrug resistant typhoid fever in children: a review. j dhaka med coll. 2008;17(2):121– 6. 11. mehul g, hareshwaree h, payal p, abeda m. a study of clinical profile of multidrug resistant typhoid fever in children. natl j integr res med. 2011;2(3)87–90. 12. alam a. pola resistensi salmonella enterica serotipe typhi, departemen ilmu kesehatan anak rshs, tahun 2006 2010. sari pediatr. 2011;12(5):296–301. 13. choudhary a, gopalakrishnan r, p. sn, ramasubramanian, ghafur a. antimicrobial susceptibility of salmonella enterica serovars ina tertiary care hospital in southern india. indian j med. 2013; 137(4)800–2. 14. moehario lh, tjoa e, kalay vnkd, abidin a. antibiotic susceptibility patterns of salmonella typhi in jakarta and surrounding areas. in: kumar my, editor. salmonella-a divers. superbug. 2012. p. 91–8. 15. muthu g, suresh a, sumathy g. studies on antimicrobial susceptibility pattern of salmonella isolates from chennai, india . int j pharma bio sci. 2011;2(2):435–42. 16. saha sk, darmstadt gl, baqui ah, ruhulamin m, santosham m, nagatake t, et al. rapid identification and antibiotic susceptibility testing of salmonella enterica serovar typhi isolated from blood implications for therapy. j clin microbiol. 2001;39(10):3583–5. 17. khan mi, soofi sb, ochiai rl, khan mj, muhammad s, habib ma, et al. epidemiology ,clinical presentation, and patterns of drug resistance of salmonella typhi in karachi, pakistan. j infect dev ctries. 2012;6(10):704–14. 18. dimitrov t, udo ee, albaksami o, al-shehab s, kilani a, shehab m, et al. clinical and microbiological investigations of typhoid fever in an infectious disease hospital in kuwait. j med microbiol. 2007;56(4):538– dewi ratnasari, djatnika setiabudi, lulu eva rakhmilla: clinical presentation and laboratory features in pediatric typhoid fever patient susceptibility to first-line antibiotic therapy althea medical journal. 2015;2(4) 590 amj december, 2015 44. 19. moehario lh. the molecular epidemiology of salmonella typhi across indonesia reveals bacterial migration. j infect dev ctries. 2009;3(8):579–84. althea medical journal. 2016;3(2) 269 knowledge and attitude towards antibiotic use among college students in jatinangor brama fimanggara,1 istriati,2 rizki diposarosa3 1faculty of medicine universitas padjadjaran, 2department of pharmacology and therapy faculty of medicine universitas padjadjaran, 3department of surgery faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: lack of knowledge about antibiotics cause people to have a misconception about the use of antibiotics. this may potentially lead to inappropriate use of antibiotics in the community, which is the major reason for the spread of antibiotic resistance. this study aimed to assess knowledge and attitudes toward antibiotic usage among non-medical students in jatinangor. methods: this study used a cross-sectional, questionnaire based survey conducted among non-medical college students in jatinangor, sub-district of sumedang regency, from september to october 2013. samples were selected using convenience sampling method, with a total number of 250 samples. results: more than half of the respondents (56.4%) had a poor knowledge regarding antibiotic use. respondents who knew that antibiotics was indicated to treat bacterial infections reached 75.2%, although 58.4% of respondents still believed that antibiotics could be used in viral infection. in terms of antibiotic resistance, 72% of respondents were aware that overused of antibiotics could cause antibiotic resistance. in addition, respondents were generally found to have more positive attitudes toward antibiotics with results over 50%, whereas more than one-third of the respondents wrongly self-medicated themselves with antibiotics. conclusions: this study reveals that most of the respondents have poor knowledge regarding antibiotics. almost half of the respondents have a negative attitude regarding the use of antibiotics. educational interventions are needed to promote prudent use of antibiotics among the college students. [amj.2016;3(2):269–74] keywords: antibiotic use, attitude, jatinangor, knowledge correspondence: brama fimanggara, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285720383699 email: fimanggara.brama@gmail.com introduction infectious diseases are one of the major causes of death in the world. death due to acute respiratory infection, diarrhea, measles, acquired immune deficiency syndrome (aids), and tuberculosis account for 85% of all mortality from infection worldwide.1 antibiotic is the most used drug in infection caused by bacteria.2 currently, high intensity in irrational use of antibiotics has caused development of antibiotic resistance. it causes pathogen that cannot be cured by the same antibiotics and needs a different class of antibiotics, which makes the effectiveness of antibiotics decreases.3 besides mortality and morbidity, antibiotic resistance also affected the economic and social aspects. according to the world health organization (who), 440.000 new cases of resistance occur each year. this issue has become a global problem and needs serious attention.4 irrational use of antibiotics can be selfmedication by the community. self-medication by the community has been increasingly widespread4, and the prevalence is quite high varying between 9˗˗18% in various european countries,5 as well as in indonesia6 where about 16% of antibiotics is obtained without prescription. in indonesia, uncontrolled use of antibiotics is mainly due to insufficient control on the sale, whereas the indonesian government restrict antibiotic availability that it could only be prescribed by a practitioner.7 people’s misconception of antibiotics can althea medical journal. 2016;3(2) 270 amj june 2016 also potentially lead to inappropriate selfmedication practice.8 this is in accordance with some studies conducted in penang malaysia and yogyakarta which revealed 55% and 49% of respondents respectively who have less knowledge about the appropriate use of antibiotics. knowledge and beliefs are social cognitive factors that influence health-related behavior, including attitude and behavior of using antibiotics. although knowledge itself is not sufficient to change behavior, but it plays an important role in shaping believe and attitude regarding an appropriate behavior. reducing misconceptions regarding antibiotic use among the community members is important.9-10 non-medical students in jatinangor region were one of the components of the community who had high knowledge but might be less exposed to problems associated with the use of antibiotics. additionally, they were expected to be the generation that would encourage community to have good health behavior. thus, the study aimed to assess the current knowledge and attitudes towards antibiotic usage among non-medical students in jatinangor, which could serve as baseline data and provided further insight in planning and developing strategies for local health education purposes. methods this study was a cross-sectional survey using a validated questionnaire from previous studies and was conducted from september to october 2013.9 this study has been approved by the health research ethics commitee faculty of medicine, universitas padjadjaran. the study population was college students in jatinangor sub-district. the confidence interval was determined at 95% with 10% of margin of error. the minimum effective sample size estimated for the survey was 97 samples.11 a total of 250 questionnaires were distributed to the respondents and samples were selected by using the convenience sampling method. the samples were eligible to be included if they lived in jatinangor in the period of may–november 2013; were 18–23 years old; and studied in a non-medical faculty. the medical faculties are faculty of medicine, faculty of pharmacy, faculty of nursing, faculty of psychology, and faculty of dentistry. those who did not meet any of those criteria were excluded from the study. the distributed questionnaire was adapted from previous studies and had been modified to adjust to this study.9 the questionnaire comprised two parts. part 1 of the questionnaire consisted of 14 statements to evaluate knowledge towards antibiotic use. respondents were requested to choose among the three options provided: “right”, “wrong”, or “i do not know”. furthermore, eight statements concerning the respondent’s attitudes toward antibiotic use were included in part 2. a fivepoint likert scale ranging from “strongly agree” to “strongly disagree” was used to assess the responses of respondents. positive attitudes would imply the appropriateness of antibiotic usage. the option “disagree” for statements 1 to 6 and “agree” for statements 7 and 8 indicated a positive attitude.12 the respondents for the attitude domain were taken from respondents who knew antibiotics, in this case only the respondents who had chosen the correct answer for question no 1 in the knowledge domain. then, all data were coded, entered and analyzed using microsoft excel 2007. for each correct answer, one point was given, and zero if it was the incorrect answer and “i do not know”, with a maximum obtainable correct score of 14. respondents with a total score of 75–100% from the maximum score were considered to have good knowledge, 56–75% were considered to have moderate knowledge, while those with a total score of < 55% were considered to have poor knowledge.12 for the attitude domain, the maximum score was 40 and the result was divided into two categories, “positive” and “negative”. result this study consisted of 250 respondents, and the majority of them (55.6%) were female. more than half of the respondents (75.2%) knew that antibiotics were indicated to treat bacterial infections, however, 58.4% of respondents believed that antibiotics could be used in viral infection. meanwhile, 62 % of respondents believed that antibiotics could be used to relieve pain or inflammation, and 36.4 % of respondents agreed that antibiotics could be used to treat fever. when asked about antibiotic resistance, 72% of respondents knew that overused of antibiotics could cause antibiotic resistance. a total of 73 respondents (29.2%) believed stopped taking antibiotics when the symptom had improved was right, and 12% of respondents still believed that not taking a full course of antibiotics would not affect its effectiveness. althea medical journal. 2016;3(2) 271 table 1 knowledge of respondent regarding antibiotic use questions right wrong i do not know n (%) n (%) n (%) antibiotics are medicines that can kill bacteria. 188 (75.2) 28 (11.2) 34 (13.6) antibiotics can be used to treat viral infections. 146 (58.4) 57 (22.8) 48 (19.2) antibiotics can cure all infections. 23 (9.2) 136 (54.4) 91 (36.4) antibiotics are indicated to relieve pain/ inflammation. 157 (62.8) 55 (22) 38 (15.2) antibiotics are used to stop fever. 91 (36.4) 95 (38) 64 (25.6) penicillin is an antibiotic. 133 (55.2) 22 (8.8) 95 (38) aspirin is a new generation of antibiotic. 51 (20.4) 115 (46) 84 (33.6) paracetamol is considered as an antibiotic. 110 (44) 95 (38) 45 (18) diphenhydramine / benadryl is not an antibiotic. 49 (19.6) 40 (16) 161 (64.4) overuse of antibiotics can cause antibiotic resistance. 180 (72) 20 (8) 50 (20) antibiotics may cause allergic reaction. 182 (72.8) 10 (4) 58 (23.2) all antibiotics do not cause side effects. 10 (4) 199 (79.6) 41 (16.4) you can stop taking a full course of antibiotics if your symptoms are improving. 73 (29.2) 158 (63.2) 19 (7.6) the effectiveness of treatment is reduced if a full course of antibiotics is not completed. 162 (64.8) 30 (12) 58 (23.2) most of the respondents (72.8%) were aware of the harmful effect due to antibiotic allergy. as for the identification of antibiotics, more than half of the respondents (55.2%) could identify penicillin as an antibiotic; however 44% of respondents had a misconception regarding paracetamol which they identified as an antibiotic (table 1) more than half of the respondents (56.4%) had poor knowledge regarding antibiotic use, and only 17.2% of respondents had good knowledge, and the rest (26.4%) had moderate knowledge about antibiotic use (table 2). regarding the attitude of respondents towards antibiotic use a total of 188 respondents gave the correct answer in the knowledge section (part 1). respondents were generally found to have more positive attitudes toward antibiotics with over 50% of the results (table 4). meanwhile, the respondents’ answer for each statement in the attitude domain shows that more than half of the respondents (52.1%) disagreed to stop using antibiotics when they felt better. however, 23.9% of respondents still agreed to take antibiotics when they had a common cold, 38.3% of respondents believed antibiotics would always be effective in the treatment of the same infection in the future, and 21.3% respondents agreed to take leftover brama fimanggara, istriati, rizki diposarosa: knowledge and attitude towards antibiotic use among college students in jatinangor table 2 knowledge level of respondent regarding antibiotic use level of knowledge number percentage (%) good 43 17.2 moderate 66 26.4 poor 141 56.4 total 250 100 althea medical journal. 2016;3(2) 272 amj june 2016 antibiotics to treat respiratory tract infection (table 3) when asked about the compliance, 72.8% of respondents would take an antibiotic in accordance with the instructions on the drug label or from the doctor’s prescription, and 81.9% of respondents would look to the expiration date of the antibiotics before using (table 3). discussion in this study, most of the respondents (75.2%) had appropriate knowledge regarding antibiotic use for bacterial infection which was a little bit lower than the surveys conducted in malaysia9 (76.7%) and in yogyakarta10 (76%) but this proportion was higher than the study in netherlands13 (44.6%). it means, the public in general already knew the indication of antibiotics, but they knew less about the appropriate use of antibiotics as it was proven in this study. in general (56.4%), respondents had poor knowledge regarding antibiotic use, this was different with the survey conducted in yogyakarta10 which shows that most participants had moderate to adequate knowledge regarding antibiotic use. this issue could be taken as our concern because many students who studied in a non-medical faculty received no further instructions on this topic and they were less exposed to the problems of antibiotics. the misconceptions regarding the indications of antibiotic use, whether bacterial or viral infections seen in this study conformed to other reports in other literatures. the findings showed that the study population was more knowledgeable regarding the indication of antibiotics for the treatment of viral infections. the proportion of respondents table 3 attitude of respondent regarding antibiotic use attitude very disagree disagree not sure agree very agree n(%) n (%) n (%) n (%) n (%) when i get a cold, i will take antibiotics to help me get well more quickly. 50 (26.6) 44 (23.4) 49 (26.1) 31 (16.5) 14 (7.4) i expect antibiotics to be prescribed by my doctor if i suffer from common cold symptoms. 65 (34.6) 38 (20.2) 42 (22.3) 25 (13.3) 18 (9.6) i normally stop taking antibiotics when i start feeling better. 69 (36.7) 29 (15.4) 18 (9.6) 41 (21.8) 31 (1.5) if my family member is sick, i usually will give my antibiotics to them. 41 (21.8) 52 (27.7) 56 (29.8) 26 (13.8) 13 (6.9) i normally keep antibiotic stocks at home in case of emergency. 42 (22.3) 36 (19.1) 38 (20.2) 49 (26.1) 23 (12.2) i will use leftover antibiotics for a respiratory illness. 79 (42) 36 (19.1) 33 (17.6) 28 (14.9) 12 (6.4) i will take antibiotics according to the instruction on the label. 9 (4.8) 11 (5.9) 31 (16.5) 48 (25.5) 89 (47.3) i normally will look at the expiry date of antibiotics before taking it. 19 (10.1) 4 (2.1) 11 (5.9) 35 (18.6) 119 (63.3) table 4 attitude of respondent regarding antibiotic use attitude number percentage (%) positive 100 53.2 negative 88 46.8 total 188 100 total 250 100 althea medical journal. 2016;3(2) 273 who thought that antibiotics were effective for viral infections (58.4%) was comparable with a survey conducted in penang, malaysia9 and in yogyakarta, indonesia,10 but was higher than proportions reported from jordan.14 “the possible reason for inadequacy of knowledge in this area could be due to the term germ, which was normally used by general practitioners or medical staff during medical advice to the public instead of using the microbiological term bacteria or virus”.9 it was found that the respondents generally lacked the knowledge to differentiate between antibiotics and other commonly used medicines. although more than half of the respondents (55.2%) could identify penicillin as an antibiotic but 44% of respondents thought that paracetamol is an antibiotic, which was higher than the proportion reported from penang, malaysia.9 this problem could be caused by several factors, the respondents might be more familiar with trade names than the drug’s generic name, due to the lack of information from health care providers as well as from general practitioners. in the present study 36.4% of respondents believed that antibiotics was used to stop fever, which was comparable with a survey conducted in yogyakarta, indonesia10 and also in penang, malaysia.9 this study revealed that 62.8% of respondents believed that antibiotics could be used to relieve pain which was close with the survey conducted in new zealand15 (66%). furthermore, most of the respondents (63.2%) had correct knowledge of the need to take the full course of antibiotics when symptoms were improving which was higher than the study conducted in jordan14 (40%). but it was different from their attitude which showed only 52.1 % agreed that they would continue the medication although the symptoms were improving. therefore, the fact shows that respondents who knew the need to take complete medication of antibiotics did not practice it. this showed that respondents did not completely understand why they needed to take the full course of antibiotics. this study also revealed that 24.4% of respondents agreed that antibiotics could treat common cold which had lower proportion than surveys conducted in jordan14, turkey16, and new york.17 frequent misuses of antibiotics to treat viral infections which were actually cured by self-medication practice would increase the risk factor of antibiotic resistance. the uncontrolled use of antibiotics is a well-established reason for antibiotic resistance.1,3 interestingly, from this study most of the respondents (72%) knew that overused of antibiotics could lead to antibiotic resistance, this finding was comparable with a survey in portugal8 which reported that 70% of respondents knew that inappropriate use of antibiotics could lead to antibiotic resistance, and which was also comparable with a survey in yogyakarta.10 in contrast, a study in new zealand15 showed just a few (8%) respondents were aware that misused of antibiotics could cause resistance. this study showed 38.3% of respondents believed antibiotics would always be effective in the treatment of thesame infection in the future. based on a study in jordan, the possible reason for this statement was their experience on the efficacy of previous treatment.18 meanwhile, 21.3% of respondents agreed to take leftover antibiotics to treat upper respiratory tract infection. leftover antibiotics might be available because of the over-prescription from the doctor or noncompliance of the respondent to complete the treatment. so, it is necessary for physicians to give prescription with the right dosage and also tell the patient to take a full course of treatment and not to use the leftover antibiotics.19 moreover, inadequate control over the distribution and sale of antibiotics might contribute to inappropriate antibiotic use. this occurred in several studies, which indicated that antibiotics could be obtained without a prescription at both a pharmacy or over the counter (otc).20 antibiotic use without prescription will not only cause resistance but also have another impact such as, adverse effect of the drugs, and high cost of treatment. this means that although the respondents knew the dangers of improper use of antibiotics, they still buy antibiotics without a prescription. another possible factor that could explain self-medication is the economic aspect, that is to save the clinicians fees.15 this fits with another study conducted by buke et al.16 which stated that knowledge regarding antibiotic usage cannot be evaluated alone since it is not always correlated with behavior. this study had some limitations. it used convenience sampling, therefore the results couldnot represent the population. another limitation was this study had limited time allocation which was only one to two months to collect data. in conclusion, this study reveals that most of the respondents have poor knowledge brama fimanggara, istriati, rizki diposarosa: knowledge and attitude towards antibiotic use among college students in jatinangor althea medical journal. 2016;3(2) 274 amj june 2016 regarding antibiotic use but are still aware of its consequences, such as allergy and resistance. almost half of the respondents have poor attitude regarding antibiotic use. therefore, it is necessary to educate the residents of jatinangor about the worldwide existing problems of antibiotic resistance. further educational interventions are needed to promote prudent use of antibiotics among the college students and also to improve their understanding and perceptions on antibiotic resistance as well as their attitude towards antibiotic use in jatinangor area. references 1. bhanwra s. a study of non-prescription usage of antibiotics in the upper respiratory tract infections in the urban population. j pharmacol pharmacother. 2013;4(1):62–4. 2. goosens h, ferech m, stichele vr, elseviers m. outpatient antibiotic use in europe and association with resistance: a crossnational database study. emerg infect dis.2005;365(9459):579–87. 3. chambers, hf. beta-lactam antibiotics and other inhibitors of cell wall synthesis. in: katzung bg. basic and clinical pharmacology. 8th ed. new york: lange medical books/mcgraw-hill; 2001.p.754– 73. 4. who. media centre: antimicrobial resistance. 2012.[cited 2013 june 10]. available from: http://www.who.int/ mediacentre/factsheets/fs194/en/. 5. grigoryan l, haaijer-ruskamp fm, burgerhof jg, mechtler r, deschepper r, tambic-andrasevic a, et al. self-medication with antimicrobial drugs in europe. emerg infect dis. 2006. 12(3):452–9. 6. hadi u, broek pvd, kolopaking ep, zairina n, gardjito w, gyssens ic. cross-sectional study of availability and pharmaceutical quality of antibiotics requested with or without prescription (over the counter) in surabaya, indonesia. bmc. 2010;10:203. 7. byarugaba dk. a view on antimicrobial resistance in developing countries and responsible risk factors. int j antimicrob agents. 2004;24(2):105–10. 8. azevedo m m, pinheiro c, yaphe j, baltazar f. portuguese students’ knowledge of antibiotics: a cross-sectional study of secondary school and university students in braga. bmc. 2009;9:359 9. oh al, hassali ma, al-haddad ms, sulaiman sa, shafie aa, awaisu a. public knowledge and attitudes towards antibiotic usage: a cross-sectional study among the general public in the state of penang, malaysia. j infect dev ctries. 2011;28;5(5):338–47. 10. widayati a, suryawati s, crespigny cd, hiller je. knowledge and beliefs about antibiotics among people in yogyakarta city indonesia: a cross sectional population-based survey. antimicrob resist infect control. 2012;1(1):38 11. dahlan ms. statistik untuk kedokteran dan kesehatan. 4th ed. jakarta: salemba medika; 2009. 12. wawan a, dewi m. teori dan pengukuran pengetahuan, sikap dan perilaku manusia. yogyakarta: nuha medika; 2010. p. 3–99. 13. cals jwl, boumans d, lardinois rj, gonzales r, hopstaken rm, butler cc, et al. public beliefs on antibiotics and respiratory tract infections: an internetbased questionnaire study. br j gen pract. 2007;57(545):942–7. 14. suaifan gary, shehadeh m, darwish da, al-ijel h, yousef am, darwish rm. a crosssectional study on knowledge, attitude and behaviour related to antibiotic use and resistance among medical and nonmedical university students in jordan. j pharm pharmacol. 2012;6(10):763–70. 15. norris p, churchward m, fa’alau f, va’al c. understanding and use of antibiotics amongst samoan people in new zealand. journal primary health care. 2009;10(3):112–9. 16. buke c, hosgor-limoncu m, ermertcan s, ciceklioglu m, tuncel m, köse t, et al. irrational use of antibiotics among university students. j infact. 2005;51(2):135–9. 17. jodi ve, marcus r, hadler jl, imhoff b, vugia dj, cieslak pr, et al. consumer attitudes and use of antibiotics. emerg infect dis. 2003;9(9):1128–35. 18. al-azzam sl, al-husein ba, alzoubi f masadeh mm, al-horani ma. selfmedication with antibiotics in jordanian population. int j occup med environ health. 2007;20(4):373–80. 19. cliodna am, boyle p, nichols t, clappison dp, davey p. antimicrobial drugs in the home,united kingdom. emerg infect dis. 2006;12(10):1523–6. 20. toogobaatar g, ikeda n, ali m, sonomjamts m, dashdemberel s, mori r, et al. survey of non-prescribed use of antibiotics for children in an urban community in mongolia. bull world health organ. 2010; 88(12):930–6. althea medical journal. 2016;3(2) 175 iron intake and hemoglobin levels in stunting in adolescent addistyane puristasari,1 siti nur fatimah,2 faisal3 1faculty of medicine universitas padjadjaran, 2department of medical nutrition faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: growth problem, such as stunting is still a major issue in the world. the prevalence of stunting in indonesia increases throughout the years. chronic undernutrition in adolescent with stunting, low socioeconomic, and education levels in a family can contribute to low iron intake. low iron intake leads to low hemoglobin level. this study aimed to compare iron intake and hemoglobin level between stunting and non-stunting adolescent. methods: this study was conducted to 59 respondents aged 11–14 years old from a junior high school in jatinangor, west java from september to october 2014. those respondents were divided into two groups: stunting and non-stunting group. this study was an analytic comparative study using cross-sectional method. data were collected through body height measurement, hemoglobin level examination, and interviews of iron-containing food intake. the collected data were analyzed using t-test and mann-whitney u test. results: twenty eight of 59 subjects were stunting and 31 were normal. the mean of hemoglobin level was 12.95 (0.95) in stunting adolescent and 13.66 (1.35) in non-stunting adolescent. the mean iron intake was 23.9 (24.39) mg/day in stunting adolescent and 23 (22.6) mg/day in non-stunting adolescent. there was a difference of hemoglobin between those groups, but not in iron intake. conclusions: stunting adolescent has lower hemoglobin levels compared to non-stunting adolescent. there is no difference of iron intake levels between stunting and non-stunting adolescent. [amj.2016;3(2):175– 80] keywords: hemoglobin, iron intake, stunting correspondence: addistyane puristasari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 857 3283 5296 email: addistyane@gmail.com introduction growth problems in children and adolescents, such as stunting, is still a major problem in the world.1 stunting is an indicator of long-term chronic malnutrition with the characteristics of height/age under -2sd. according to the health research association in 2013, the national prevalence of stunting in 2013 was 37.2%. in adolescents, the prevalence is in the range of 32.3–40.2%.2 genetic factors, nutrients, and hormones are the major factors in the height growth. environmental factors such as socioeconomic, malnutrition, and chronic diseases play important roles in this process.3 nutrition is an important factor in the growth, especially in a period of rapid catch-up growth that occurs during early adolescent. increasing of nutritional needs is not only on macro-nutrients, but also occurs on micronutrients, such as iron.4,5 iron is an essential trace mineral for linear growth and body tissue proliferation.4 chronic malnutrition obtained in stunting adolescent can be accompanied with a condition where a good source of iron intake is low, so that the iron levels in the body become lower.6 low irons in the body will interfere hemoglobin synthesis, so that the subtraction of hemoglobin and oxygenation to the cells for the anabolic process in early adolescent will be intruded and cause a growth delay or failure.4 this situation makes hemoglobin levels in stunting adolescents lower than the hemoglobin levels in non-stunting adolescent. this study aimed to compare the iron intake and hemoglobin levels in stunting and nonstunting adolescents. methods this study was a comparative analytical study with cross-sectional method. the study althea medical journal. 2016;3(2) 176 amj june 2016 was conducted in jatinangor, west java from september to october 2014. all examinations which were performed in this study was approved by the health research ethics committee of faculty of medicine universitas padjadjaran . minimum sample size in this study was 23 samples for each group, stunting and nonstunting adolescents. samples were selected by cluster random sampling technique. junior high school 2 located in cisempur village, jatinangor was selected from 11 junior high schools in jatinangor for representing the population. the students of this school spread in 4 villages in jatinangor. samples were taken from classes vii and viii. subjects were students whose height had been measured, aged 10–14 years, physically fit, and agreed to take peripheral blood sampling and interviewing food frequency questionnaire. if the subjects were known by anamnesis as taking iron supplement enhancer, were menstruating and had been suffering from chronic diseases, they were excluded in this study. six of 66 students were excluded because they were menstruating when the examination was being held and the other subject was resigned, so the total numbers of samples in this study were 59 subjects. participants from eight classes of 14 existing classes conducted initial height measurement using a stadiometer seca which were measured 3 times and took the average to determine the subject’s stunting and nonstunting status. subjects were classified in the stunting category when their height or age was deficit -2 standar deviation who z-score and the non-stunting category was in -2 standar deviation of z-score using the who anthroplus application. hemoglobin examination used hemocue tool. hemocue works in spectrophotometer. precision and accuracy of the tool will be proportional to the hemoglobin by using cyanmethemoglobin. hemoglobin levels obtained were expressed in grams/deciliter. both groups of subject were interviewed to fill the food intake questionnaires, semiquantitative food frequency questionnaire (semi ffq). semi ffq can describe the eating habits of a specific nutrient and will determine the amount of the estimated total daily intake of individuals. in this study, it was conducted a market survey and interviewed daily intake with the 24 hours recall method after a high iron content was selected from food composition table (daftar komposisi bahan makanan, dkbm) indonesia to identify the food source availability and the general public consumption. the populations of a market survey were who had similar characteristics to the subjects in the study area. unusual food consumed was removed from the list. the average of daily intake obtained was expressed in units of milligrams/day. the total of daily intake was categorized into two categories, those were the sufficient intake category and the less intake category based on the national of recommended dietary allowances 2013, which were in accordance with their respective age. the intake category was considered to be sufficient if the total intake for female aged 10–12 was 20 mg/day, female aged 13–14 was 26 mg/day, male aged 10–12 was 13 mg/day, and male age 13–14 was 19 mg/day. the intake category was less if the amount was less than the total intake of nutritional adequacy rate according to age respectively. the collected data were tested for the normality of the data distribution with shapirowilk test. the distributed data were commonly analyzed using t-test and occasionally were analyzed using mann whitney u rank test. t-test results showed significant if p <0.05. results the height measurement results obtained from an average subject’s height was 146.9 (7.45), with an average male height 150.5 (8.8) and female height 144.6 (5.4). most of the respondents were female with a median age of 13 (11–14), while male students were 13 (12–14). nearly 50% of subjects’ parental education only completed primary school. most of the subjects’ parents (39%) worked in private sectors, followed by entrepreneur and employee. the mean of hemoglobin level was 13.32(1.21) g/dl. normality of data test was conducted on hemoglobin levels according to sex distribution and the result was these data that were normally distributed. as the result of this study, the average of hemoglobin level in male was 13.73 (1.47) g/dl and in female was 13.06 (0.94) g/dl. a t-test was conducted to analyze if there was a difference average of hemoglobin level between male and female. the p-value (0.060) showed that there was no significant difference between hb levels in both male and female. the hemaglobin level of stunting and non stunting was calculated and tested for the data distribution. the result was the average of hemoglobin level in stunting group which althea medical journal. 2016;3(2) 177addistyane puristasari, siti nur fatimah, faisal: iron intake and hemoglobin levels in stunting in adolescent was 12.95 (0.90) g/dl and non-stunting group which was 13.66 (1.35) g/dl. the t-test was applied to determine differences of hemoglobin (hb) levels in stunting and nonstunting group. the data of the stunting group were not normally distributed, therefore, t-test could not be performed. the alternative of t-test was mann-whitney u test. from table 2, it could be concluded that there was a significant differences in hemoglobin levels between stunting adolescent and non-stunting adolescent. the result showed that the hb levels in stunting adolescent were lower than hemoglobin levels in non-stunting adolescent. the results of dietary intake interview showed that 24 from 59 respondents consumed fried tofu as the most common food in their daily intake. chicken parts like thigh, wing, and chest were consumed by more than 15% of the participants, while the chicken liver that had the highest source of iron was consumed by less than 15% of the subjects. twelve subjects (20.3%) consumed water-spinach sautéed as the iron intake from vegetable. dumplings, cilok, and bakwan were snacks which were most widely consumed by the subject. after conducting the normality test of the data, the data of iron intake for each category were not normally distributed with p-value table 1 characteristics of subjects and their parents variable f height per age p-value stunting non-stunting sex male 23 9 14 0.306 female 36 19 17 age (years old) 11 1 1 0 1.000 12 12 6 6 13 30 13 17 14 16 8 8 parent’s occupation employee 16 8 8 0.786 private sector 23 8 15 entrepreneur (self-employee) 16 10 6 farmer 2 1 1 government officer 1 1 0 house wife 1 0 1 parent’s educational background not graduated from elementary school 2 2 0 1.000 graduated from elementary school 29 12 17 graduated from junior high school 14 8 6 graduated from senior high school 11 4 7 graduated from university 3 2 1 number of family member 3–4 25 12 13 0.943 5–9 34 16 18 total 59 28 31 althea medical journal. 2016;3(2) 178 amj june 2016 = 0.000, so the data were analyzed using a mann-whitney u test. data in table 3 showed that there was no significant difference in iron intake in stunting and non-stunting adolescents in this study. data intake was categorized into less intake and adequate intake as recommended by national recommended dietary allowances 2013. this was followed by data analysis of the iron intake to hemoglobin concentration to determine the differences in hemoglobin level between normal and low iron intake groups. similar to the previous data, these categories were not normally distributed, so a mannwhitney test was performed. this study discovered that there was no difference of hemoglobin level between normal and low iron intake groups. discussions the results of this study showed a significant difference in hemoglobin levels between stunting and non-stunting adolescent. this indicated that the iron status in stunting adolescent was lower than non-stunting adolescent. this result was consistent with the study conducted by yustina et al.7 the study stated that female adolescents aged 10–12 years who suffer from anemia have body weight, body height, and bmi that are significantly lower than female adolescents aged 10−12 years who are not anemic.7 other study conducted by yuniar8 discovered that there is no significant difference between hemoglobin level and anthropometric status in stunting and non-stunting adolescent. the lower concentration of hemoglobin in adolescents with stunting will cause impairment in the process of oxygenation to the cells and tissues, so that metabolism in the body will be disturbed, such as the kreb’s cycle stage in the process of formation of energy metabolism which plays an important role in generating 2 succynil co-a. 2 succynil co-a is the basic ingredient in the further formation of hemoglobin. if it is not treated immediately, it will cause hemoglobin levels always low and the process of metabolism for rapid growth that occurs in early adolescent will be impaired.4 this study showed that iron intake of female subjects aged 12–14 years was below standard of the national recommended dietary allowance 2013 which is 26 mg/day. nevertheless, the other age groups and male subjects had an average which fulfilled the national recommended dietary allowances table 2 hemoglobin level between stunting and non-stunting group height per age hemoglobin levels (g/dl) p-value* f mean(sd) median (min – maks) stunting 28 12.95 ( 0.90) 13.05 (11.3 – 14.4) 0.025 non-stunting 31 13.66 ( 1.35) 13.5 (11.4 – 16.3) note: sd=standard deviation, * mann-whitney test analysis table 3 iron intake between stunting and non-stunting group height per age iron intake (mg/day) p-value* f mean (sd) median (min – maks) stunting 28 23.9 (24.39) 15.35 (3-115) 0.457 non-stunting 31 23 (22.66) 17.6 (4-116) note: * mann–whitney test analysis table 4 hemoglobin level between normal and low iron intake iron intake hemoglobin levels (g/dl) p value* f mean(sd) median (min – maks) low 37 13.38 (1.08) 13.5 (11.3 – 16.2) 0.182 normal 22 13.23 (1.42) 13.0 (11.4 – 16.3) note: * mann–whitney test analysis althea medical journal. 2016;3(2) 179 2013 standard. the analysis of the iron intake towards height status showed the value of p = 0.457, so it can be concluded that there is no significant difference in the iron intake between stunting and non-stunting adolescents. this is in line with the study conducted by aubuchon-endsley et al.9 that there is no significant difference in the average of the iron intake between the stunting and non-stunting adolescents.9 this contrasts with the results of lyfia et al.10 study, which reported that there is an increase of height in elementary school students who have been given iron therapy. this can occur because the growth process is not only a factor of iron, but the growth involves various factors, such as hormonal factors which play a lot at the time of adolescent, genetic factors, environmental factors, and other nutrient factors which are interrelated each other.6,11 this study showed that hemoglobin in stunting adolescent was lower than nonstunting adolescent, although the amount of iron intake in both groups showed no difference. according to a theory, when iron intake is low, the effect will reduce the hemoglobin levels in the blood and low hemoglobin level is an indicator of the decrease of ferritin concentration in the body. however, the intake of iron can be affected by various factors; one of them is the iron absorption factor iron which can be inhibited by the intake of other food. adequate iron intake will still inhibit the absorption process when inhibiting food intake is consumed simultaneously.4 this causes hemoglobin levels still low despite everyday iron intake is fulfilled. in addition, the protein also plays an important role in the hemoglobin synthesis. if iron intake is adequate but insufficient protein intake is less, the binding of heme and globin stage is not going to happen, so hemoglobin concentration will be still low.4 this study showed that there was no significant difference in hemoglobin levels in adolescents who had less iron intake and those who had adequate iron without considering both normal height or shorter, with p = 0.182. however, study conducted by arifin et al.12 showed that iron intake has a significant relation with the incidence of anemia among primary school students. this difference is probably due to the consumption of food containing iron is different in every place and the iron absorption is strongly influenced by the type of source of heme and non-heme iron as well as the presence or absence of inhibitors in food containing iron, such as phytate which was contained in tea and factors that help increased absorption iron such as vitamin c.4,12 limitation of this study was the method of taking dietary intake. the accuracy of dietary history method was higher than the other method, such as semi quantitative food frequency questionnaire that was used in this study. although the accuracy was lower, semi quantitative food frequency questionnaire was effective for measuring long-term intake and specific food that was appropiate for the objective of study. the food intake such as protein, vitamin c, calcium, and other nutrients that influence metabolism, synthesis of fe content and synthesis of erythrocytes were not analyzed in this study. interviewing parents or guardians was not conducted, so the presupposition of information could not be avoided in the study. the limited time and cost made the numbers of sample that were taken limited, although the minimum total sample had been fulfilled. this study concluded that the level of hemoglobin in stunting adolescent was lower than non-stunting adolescents. the iron intake in stunting and non-stunting adolescents did not show any significant difference. a suggestion for further research is the study should be conducted by using a dietary history interview so that the intake can be more accurate and detailed. furthermore, the dietary intake of other nutrients, such as protein, vitamin c, calcium, and the types of food that can enhance and inhibit the absorption of iron can be added in the data collection questionnaire. references 1. black re, allen lh, bhutta za, caulfield le, de onis m, ezzati m, et al. maternal and child undernutrition: global and regional exposures and health consequences. the lancet. 2008;371(9608):243−60. 2. badan penelitian dan pengembangan kesehatan. riset kesehatan dasar 2013. jakarta: kementrian kesehatan republik indonesia;2013. 3. souganidis e. the relevance of micronutrients to the prevention of stunting. sight and life. 2012;26 (2):10−8. 4. shils me, shike m, ross ac, caballero b, cousins rj, editor. modern nutrition in health and disease. 10th ed. philadelphia: lipincott william and wilkins; 2006. 5. ramakrishnan u, nguyen p, martorell r. effects of micronutrients on growth of children under 5 y of age: meta-analyses of addistyane puristasari, siti nur fatimah, faisal: iron intake and hemoglobin levels in stunting in adolescent althea medical journal. 2016;3(2) 180 amj june 2016 single and multiple nutrient interventions. am j clin nutr. 2009;89(1):191−203. 6. arnelia. karakteristik remaja dengan riwayat gizi buruk dan pendek pada usia dini. j gizi pangan. 2011;6(1):42−50. 7. yustina anie indriastuti kurniawan, siti muslimatun, endang l. achadi, soemilah sastroamidjojo. nutritional status of adolescent girls in rural coastal area of tangerang district. maj kedok indon. 2007;57(5):140−5. 8. yuniar rosmalina, fitrah ernawati. hubungan status zat gizi mikro dengan status gizi pada anak remaja sltp. penel gizi makan. 2010;33(1):14−22. 9. aubuchon-endsley nl, grant sl, berhanu g, thomas dg, schrader se, eldridge d, et al. hemoglobin, growth, and attention of infants in southern ethiopia. child dev. 2011;82(4):1238−51. 10. lyfia d, deliana m, hakimi nr, lubis b. growth velocity in elementary school children with iron deficiency anemia after iron therapy. paediatr indones. 2009;49(5):249−52. 11. kusuma ke, nuryanto n. faktor risiko kejadian stunting pada anak usia 2-3 tahun (studi di kecamatan semarang timur). journal of nutrition college. 2013;2(4):523−30. 12. arifin su, mayulu n, rottie j. hubungan asupan zat gizi dengan kejadian anemia pada anak sekolah dasar di kabupaten bolaang mongondow utara. jurnal keperawatan. 2013;1(1):1–8. althea medical journal. 2016;3(1) 156 amj march 2016 age at menarche and eating pattern among high school students in jatinangor in 2013 fani fitrya nafisah,1 insi farisa desy arya,2 eppy darmadi achmad3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of obstetrics and gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: age at menarche has notably declined over the past several decades; the fact is in line with the improvement of nutritional intake. age at menarche can affect health outcomes in adulthood. this study aimed to describe the age at menarche and eating pattern among students in jatinangor. methods: data were obtained from survey of adolescent reproductive health in jatinangor in 2013 with total sampling technique. the sample criteria were data from students who had started their periodwhen the study was conducted. dietary information was collected by eating pattern recall questionnaire and was taken by trained enumerators. nutrient intakes and proportion of energy intake were divided into groups according to recommended dietary allowance 2012. results: in total, 59 data were analyzed. the age at menarche were ranged from 9 (n=1) to 15 (n=1). most of students had their menarche at 12 (37.3%). intake of energy (49.2%), protein (64.4%), fat (61%), and carbohydrate (54.2%) were mostly deficient, but the proportion of energy intake from fat (49.2%) and carbohydrate (66.1%) were mostly adequate. the student with youngest age at menarche had adequate energy intake, excess protein intake and excess proportion of energy intake from fat. student with the oldest age had deficient energy, fat, and protein intake and excess proportion of energy intake from carbohydrate. conclusions: this study shows that student with youngest age at menarche has different eating pattern compared to the oldest, while the others seem similar. [amj.2016;3(1):156–63] keywords: eating pattern, jatinangor, menarche correspondence: fani fitrya nafisah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85294164130 email: fanifitryanafisah@gmail.com introduction puberty is the period of sexual function maturation to reach the capability of sexual reproduction. the first menstruation (menarche) occurred at the end of puberty.1 over the past several decades, age at menarche has notably declined, particularly in western.2 early age at menarche has been associated with adverse health outcomes in adulthood, including greater body mass index, insulin resistance, metabolic syndrome, breast cancer, cardiovascular disease, and depression, while the later age at menarche has been associated with osteoporosis and increased risk of bone fracture.3-8 national report on basis health research 20109 reported that 37.5% indonesian girls had started their period at 13 to 14, 0.1% at age 6 to 8 years, 19.8% at 15 to 16 years, and 4.5% at older age than 17 years. another study showed that 0.4% girls in bandung10 had started their period at 9 and 6.2% at age older than 15 years. age at menarche changed in line with the improvement of nutritional intake.2 consumption of fruits and vegetables were declined, while consumption of foodstuffs from animals were increased. this alteration of eating pattern was allegedly caused by the increasing of vegetable oil availability and due to the advertisement which influence people to consume many products containing sugar.11 previous studies reported that high intake of energy, protein, and fat were associated with the early age at menarche, while high intake of carbohydrate was associated with the late age at menarche.12,13 energy and protein intake in indonesia were still deficient, as reported althea medical journal. 2016;3(1) 157 by national report on basis health research, 9 on the contrary the proportion of energy intake from fat and carbohydrate are higher than recommendation of dietary guidelines for indonesian. over the past several decades, the economy has improved in jatinangor. this happens because jatinangor which was once the plantation area is now the site of several universities. agricultural land has turned into rental houses for students and shops along the road. even now there are apartments and shopping malls.14 the changes may affect the alteration of eating pattern as well as the age at menarche. there were only a few studies were conducted in jatinangor about age at menarche and eating pattern. regarding those issues, this study used data from survey of adolescent reproductive health in jatinangor to assess the age at menarche and eating pattern among high school students in jatinangor. methods data for this descriptive study was obtained from survey of adolescent reproductive health in jatinangor at 2013 which was done by research team of faculty of medicine, universitas padjadjaran. this study was approved by health research ethics committee. samples were obtained by stratified cluster random sampling. the first fani fitrya nafisah, insi farisa desy arya, eppy darmadi achmad: age at menarche and eating pattern among high school students in jatinangor in 2013 figure 1 dietary information’s schem note: rda = recommended dietary allowance althea medical journal. 2016;3(1) 158 amj march 2016 stage was to choose two schools from junior high school and two schools from senior high school in the subdistrict of jatinangor. the second stage was a randomized method to pick the classes. data for this study were obtained with total sampling techniques. the inclusion criteria were the data from students who were residents of jatinangor or at least 2 years in school and had started menstruation when the study was conducted. the exclusion criteria were incomplete data and energy intake was less than 50% from recommended dietary allowance (rda). the dietary information used in this study was collected by eating pattern recall questionnaire, comprised of energy, protein, fat, and carbohydrate intake. data were taken by trained enumerators. the questionnaires included questions about the quantity and type of food which is frequently consumed every week, included meal time, brand name, the process of preparation, composition, weekly frequency, and portions of food and beverage. food model was used as the standard portion sizes. data from the questionnaires were converted to nutrient intake using nutrisurvey 2007, augmented with manufacturers’ and food nutritive value information. to predict daily mean of nutrient intake, each type of food was multiplied by weekly frequency of consumption and then was summed to all food consumed. nutrient intakes and proportion of energy intake from fat and carbohydrate were divided into groups according to rda 2012. the groups for nutrient intakes were deficient intakes (less than 80% of rda), adequate intakes (between 80−100% of rda), and excess intakes (greater than 100% rda). the groups for proportion of energy intake from fat were deficient proportion (less than 25% of total energy), adequate proportion (25−35% of total energy), and excess proportion (higher than 35% of total energy intake). the groups for proportion of energy intake from carbohydrate were deficient proportion (less than 40% of total energy), adequate table 1 characteristic of subject based on school, age and age at menarche variable n (n=59) (%) school junior high school 26 44 senior high school 33 66 age (years old) 12 1 1.7 13 9 15.3 14 14 23.7 15 2 3.4 16 8 13.6 17 20 33.9 18 5 8.5 age at menarche 9 1 1.7 10 2 3.4 11 9 15.3 12 22 37.3 13 17 28.8 14 7 11.9 15 1 1.7 althea medical journal. 2016;3(1) 159 proportion (40−60% of total energy), and excess proportion (higher than 60% of total energy intake).15 results not all the sample of survey of adolescent reproductive health in jatinangor were taken to this study due to some missing data. in total, 83 eating pattern recall questionnaire were reviewed, 18 questionnaires were excluded due to energy intake less than 50% of rda and 6 questionnaires were excluded due to incomplete data. subjects ranged in age from 12 to 18 years, mostly 17 years (33.9%) with median 16 years. the youngest age at menarche was 9 (n=1) and the oldest was 15 (n=1), mostly were 12 (37.3%). intake of energy, protein, fat, and carbohydrate was mostly deficient, respectively 49.2%, 64.4%, 61%, and 54.2%, but the proportion of energy from fat and carbohydrate was mostly adequate, respectively 49.2% and 66.1%. energy intake of girls who had menarche at 9, was different to the girls who had menarche at 15 (table 3). the student who had menarche at 9 had adequate energy intake and proportion of energy intake from carbohydrate but proportion of energy intake from fat was excess. the student who had menarche at 15 table 2 characteristic of subject based on eating pattern variable n (n=59) (%) energy intake deficient 29 49.2 adequate 18 30.5 excess 12 20.3 protein intake deficient 38 64.4 adequate 11 18.6 excess 10 16.9 fat intake deficient 36 61 adequate 10 16.9 excess 13 22 carbohydrate intake deficient 32 54.2 adequate 12 20.3 excess 15 25.4 proportion of energy from fat deficient 18 30.5 adequate 29 49.2 excess 12 20.3 proportion of energy from carbohydrate deficient 1 1.7 adequate 39 66.1 excess 19 32.2 fani fitrya nafisah, insi farisa desy arya, eppy darmadi achmad: age at menarche and eating pattern among high school students in jatinangor in 2013 althea medical journal. 2016;3(1) 160 amj march 2016 table 3 distribution of energy intake and proportion of energy from fat and carbohydrate based on age at menarche age at menarche total 9 10 11 12 13 14 15 energy intake deficient count 0 1 5 12 5 5 1 29 % within age at menarche 0 50 55.6 54.5 29.4 71.4 100 49.2 adequate count 1 1 3 5 7 1 0 18 % within age at menarche 100 50 33.3 22.7 41.2 14.3 0 30.5 excess count 0 0 1 5 5 1 0 12 % within age at menarche 0 0 11.1 22.7 29.4 14.3 0 20.3 total count 1 2 9 22 17 7 1 59 % within age at menarche 100 100 100 100 100 100 100 100 proportion of energy from fat deficient count 0 1 2 6 4 4 1 18 % within age at menarche 0 50 22.2 27.3 23.5 57.1 100 30.5 adequate count 0 0 6 10 10 3 0 29 % within age at menarche 0 0 66.7 58.8 58.8 42.9 0 49.2 excess count 1 1 1 6 3 0 0 12 % within age at menarche 100 50 11.1 17.6 17.6 0 0 20.3 total count 1 2 9 22 17 7 1 59 % within age at menarche 100 100 100 100 100 100 100 100 proportion of energy from carbohydrate deficient count 0 0 0 1 0 0 0 1 % within age at menarche 0 0 0 4.5 0 0 0 1.7 adequate count 1 2 6 13 11 6 0 39 % within age at menarche 100 100 66.7 59.1 64.7 85.7 0 66.1 excess count 0 0 3 8 6 1 1 19 % within age at menarche 0 0 33.3 36.4 35.3 14.3 100 32.2 total count 1 2 9 22 17 7 1 59 % within age at menarche 100 100 100 100 100 100 100 100 althea medical journal. 2016;3(1) 161fani fitrya nafisah, insi farisa desy arya, eppy darmadi achmad: age at menarche and eating pattern among high school students in jatinangor in 2013 table 4 distribution of nutrient intake based on age at menarche age at menarche total 9 10 11 12 13 14 15 protein intake deficient count 0 1 7 15 9 5 1 38 % within age at menarche 0 50 77.8 68.2 52.9 71.4 100 64.4 adequate count 0 1 1 2 6 1 0 11 % within age at menarche 0 50 11.1 9.1 35.3 14.3 0 18.6 excess count 1 0 1 5 2 1 0 10 % within age at menarche 100 0 11.1 22.7 11.8 14.3 0 16.9 total count 1 2 9 22 17 7 1 59 % within age at menarche 100 100 100 100 100 100 100 100 fat intake deficient count 0 1 6 13 10 5 1 36 % within age at menarche 0 50 66.7 59.1 58.8 71.4 100 61 adequate count 0 0 3 6 1 0 0 10 % within age at menarche 0 0 33.3 27.3 5.9 0 0 16.9 excess count 1 1 0 3 6 2 0 13 % within age at menarche 100 50 0 13.6 35.3 28.6 0 22 total count 1 2 9 22 17 7 1 59 % within age at menarche 100 100 100 100 100 100 100 100 carbohydrate intake deficient count 0 2 5 13 8 4 0 32 % within age at menarche 0 100 55.6 59.1 47.1 57.1 0 54.2 adequate count 1 0 1 3 4 2 1 12 % within age at menarche 100 0 11.1 13.6 23.5 28.6 100 20.3 excess count 0 0 3 6 5 1 0 15 % within age at menarche 0 0 33.3 27.3 29.4 14.3 0 25.4 total count 1 2 9 22 17 7 1 59 % within age at menarche 100 100 100 100 100 100 100 100 althea medical journal. 2016;3(1) 162 amj march 2016 had deficient energy intake and proportion of energy intake from fat but the proportion of energy intake from carbohydrate was excess. students who had menarche at 11 and 12 shows identical pattern, i.e. deficient energy intake (55.6%, 54.5%) with adequate proportion of fat (66.7%, 58,8%) and carbohydrate (66.7%, 59.1%). intake of protein and fat in thegirls who had menarche at 9,was excess, conversely girls who had menarche at 15 had deficient intake (table 4). carbohydrate intake was adequate for both of them. girls who had menarche at 11 to 14 mostly had deficient intake of protein, fat, and carbohydrate. discussion most of the subjects in this study had startedtheir menstruation at 12 (37.3%), the age is earlier compared to age at menarche of bandung girls (2010) which mostly had started their menstruation at 13 (37%). this difference indicated the possibility role of nutrition and socioeconomic status in age at menarche.10 this study showed that girls in jatinangor mostly had a deficient nutritional intake. adequate intake of energy and other nutrients are required for teenagers, such as time of rapid growth and developmental changes at multiple levels, including shifts in fat distribution, increases in height and weight, and emergence of secondary sex characteristics.16 adolescents who had deficient intake of energy and other nutrients may not achieve optimal growth and development; moreover sub clinical deficits of nutrient may cause impaired immune response.17 girl with youngest age at menarche had an adequate energy intake with protein intake and proportion of energy intake from fat was excess. these findings are in accordance to the previous study, which suggested that higher fat intake and lower carbohydrate intake associated with accelerated menarche.12 the mechanism of fat in affecting age at menarche is mediated by leptin. excessive fat intake will be stored in adipose tissue which secrete the leptin. leptin can affect the reproduction system by triggering the release of gonadotropin releasing hormone (gnrh) from hypothalamus. in response to gnrh secretion, anterior pituitary cells secreting follicle-stimulating hormone (fsh) and luteinizing hormone (lh). the fsh and lh were circulated through the blood vessels and stimulate the secretion of ovarian steroid hormones.18 in addition the availability of circulating estrogen may be enhanced by high consumption of fat, thereby influencing pubertal development.12 in the puberty stage, hypothalamic gonadotropin-releasing hormone secretion systems are re-activated and cause an enhancement in amplitude and frequency of gnrh pulses. it increased the gonadotropin circadian rhythms and gonadal steroid secretion. at the final stage of hypothalamicpituitary development, apositive feedback occurs from the rise of estradiol that cause a midcycle lh surge and then menarche occurs.1,2 excessive protein intake will increase the frequency of peak lh and elongation of the follicular phase, so as to accelerate a person to enter the puberty stage; the fact is consistent to the previous studies which suggested that higher protein intake person at 5 to 6 was related to an early age at menarche.13,19 furthermore high consumption of protein, especially animal protein, stimulates the secretion of insulin and insulin-like growth factor 1 (igf-1). then, insulin and igf-1 will affect the production of somatopedin, which is an activator of sexual maturity, so as to accelerate a person to enter the puberty stage too.13 another finding in this study is girls with oldest age at menarche had an excess proportion of energy intake from carbohydrate. the result is consistent to the previous studies which suggested that higher intakes of carbohydrate in girls were associated with the later timing of menarche.12 eating pattern of adolescence may associate with nutritional knowledge, but there were misconceptions about personal dietary intake levels; in addition, the eating patterns can be affected by innate food preferences, familiarity, and social and environmental influence.17 this study showed that most girls eat food sold in schools which most of them are fried food and snack containing salt or sugar. limitations of the study are the sample size which were small because of the high frequency of missing data, eating pattern recall on the subject to both underand overreporting and it may not represent the habitual dietary intake, weight of the subject was not considered to calculate the nutritional needs instead of using rda which is not specific, and current dietary data may not be an accurate marker of long term intake in childhood. althea medical journal. 2016;3(1) 163 the conclusions of this study are the age at menarche in jatinangor girls ranged from 9 to 15 and the student with youngest age at menarche had a different eating pattern compared to the oldest, while the others seem similar. further studies is recommended to determine the relationship between age at menarche and eating pattern by considering other factors such as genetic, body mass index, and physical activity and the impact of early and late menarche need to be observed so further morbidity can be prevented. references 1. rebar rw. puberty. in: berek js, editor. berek & novak’s gynecology. 14th ed. philadelphia: lippincott williams & wilkins; 2007. p. 992. 2. styne d. puberty. in: gardner dg, shoback d, editors. greenspan’s basic & clinical endocrinology. 8th ed. san francisco: the mcgraw-hill companies; 2007. p. 611. 3. feng y, hong x, wilker e, li z, zhang w, jin d, et al. effects of age at menarche, reproductive years, and menopause on metabolic risk factors for cardiovascular disease. atherosclerosis. 2008;196(2):590−7. 4. remsberg ke, demerath ew, schubert cm, cameron wc, sun ss, siervogel rm. early menarche and the development of cardiovascular disease risk factors in adolescent girls: the fels longitudinal study. j clin endocrine metab. 2005;90(5):2178−724. 5. kaltiala-heino r, kosunen e, rimpela m. pubertal timing, sexual behaviour and selfreported depression in middle adolescent j adolescence. 2003;26(5):531−45. 6. chevalley t, bonjour jp, ferrari s, rizzoli r. influence of age at menarche on forearm bone microstructure in healthy young women. j clin endocrinol metab. 2008;93(7):2594−601. 7. chevalley t, bonjour jp, ferrari s, rizzoli r. the influence of pubertal timing on bone mass acquisition: a predtermined trajectory detectable five years before menarche. j clin endocrinol metab. 2009;94(9):3424−31. 8. yang xr, sherman me, rimm dl, lissowska j, brinton la, peplonska b, et al. differences in risk factors for breast cancer molecular subtypes in a population-based study. cancer epidemiol biomararkers prev. 2007;16(3):439−43. 9. badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia. laporan nasional riset kesehatan dasar 2010. in: indonesia dkr, editor. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2010. 10. batubara jrl, soesanti f, van de waal hd. age at menarche in indonesian girls: a national survey. indonesia j intern med. 2010;42(2):78−81. 11. caballero b. the nutrition transition: global trends in diet and disease. in: shils me, shike m, ross ac, caballero b, cousins rj, editors. modern nutrition in health and disease. 10th ed. philadelphia: lippincott williams & wilkins; 2006. p. 1718. 12. cheng g, gerlach s, libuda l, kranz s, gunther alb, karaolis-danckert n, et al. diet quality in childhood is prospectively associated with the timing of puberty but not with body composition at puberty onset. j nutr. 2010;140:95−102. 13. gunther alb, karaolis-danckert n, kroke a, remer t, buyken ae. dietary protein intake throughout childhood is associated with the timing of puberty. j nutr. 2010;140:565−71. 14. badan perencanaan pembangunan daerah. laporan akhir studi kelayakan kawasan jatinangor sebagai kawasan perkotaan. sumedang: badan perencanaan pembangunan daerah; 2009. 15. hardinsyah, riyadi h, napitupulu v. kecukupan energi, protein, lemak dan karbohidrat. widya karya nasional pangan dan gizi. jakarta;2012. 16. treuth ms, griffin ij. adolescence. in: shils me, shike m, ross ac, caballero b, cousins rj, editors. modern nutrition in health and disease. 10th ed. philadelphia: lippincott williams & wilkins; 2006. p. 819. 17. moreno l, gonzales-gross m, kersting m, molnar d, de henauw s, beghin l, et al. assessing, understanding and modifying nutritional status, eating habits and physical activity in european adolescents: the helena (healthy lifestyle in europe by nutrition in adolescence) study. public health nutr. 2008;11(3):288−99. 18. quennell jh, mulligan ac, tups a, liu x, phipps sj, kemp cj, et al. leptin indirectly regulates gonadotropinreleasing hormone neuronal function. endocrinology. 2009;150(6):2805−12. fani fitrya nafisah, insi farisa desy arya, eppy darmadi achmad: age at menarche and eating pattern among high school students in jatinangor in 2013 althea medical journal. 2016;3(1) 164 amj march 2016 19. susanti av, sunarto. faktor risiko kejadian menarche dini pada remaja di smp n 30 semarang. journal of nutrition college. 2012;1(1):115−26. althea medical journal. 2017;4(3) 321 health related quality of life and residual symptoms in prostatic surgical treatment at bethesda hospital yogyakarta: a retrospective study daniel mahendra krisna,1 hariatmoko,2 rizaldi taslim pinzon1 1faculty of medicine duta wacana christian university yogyakarta, 2department of surgery bethesda hospital yogyakarta abstract background: the incidence of prostate enlargement (pe) has been increasing over the years. the satisfaction towards the treatment result and life quality (qol) improvement must be the key point of pe treatment. qol is affected by many conditions, such as age, socioeconomic status, comorbid disease, and type of surgery. the objective of the study was to assess the qol in pe patients post surgery, to explore the predictor factor, and to assess the satisfaction related to urinary functionality in the indonesian context. methods: a retrospective study was conducted and the subjects were all pe patients who underwent surgical treatment. eq-5d-5l/eq-vas and index quality of life (iql) were used to assess the patient’s qol & treatment satisfaction. the subjects were divided into several sub-groups based on age, type of surgery, comorbid condition, type of ward, funding source, histopathological result, and the year of treatment. the collected data wee analyzed using mann-whitney test, kruskal wallis test, or chi-square test, spearman’s rho test and multiple linear regression. results: all the 149 subjects were at the average age of 69.09 years . there were no significant statistical differences in qol between age, comorbid conditions, and histopathology result. health insurance (hi) was significantly associated with qol. there were improvements of iql subjects. the most symptoms remaining was frequency (47.4%). conclusions: life improvement must be the major purpose of pe therapy. the association between hi with qol suggests that a better hi in developing countries can ensure a better quality of life outcome. keywords: health-related quality of life, prostate enlargement, surgery correspondence: dr. daniel mahendra krisna, faculty of medicine, duta wacana christian university yogyakarta, jalan dr. wahidin sudirohusodo no 5-25 yogyakarta, indonesia, email: danielkrisna24@yahoo.com introduction prostatic enlargement either benign prostate hyperplasia (bph) or prostate cancer, is the most common urologic disorder in the elderly population.1 the incidence of bph has been increasing over the years. the risk of bph increases with age and several studies have shown that bph incidence is as high as 90% in people over 70 years old.2 prostate cancer prevalence in indonesia was 0.2% in 2013 which equals to 25,012 patients. this makes prostate cancer the second most common high-mortality rate disease experienced in indonesia.3,4 the bph usually is not a life threatening disease, but rather affects people’s quality of life (qol). therefore the primary goal of treatment should be improving the patient‘s qol,1 especially related to social activities and general feeling of well-being. the qol affected by many conditions, such as age, socioeconomic status, comorbid disease, and type of surgery.5,6 health related quality of life (hrqol) assessment tools can be used to evaluate patient satisfaction before and after treatment. there are several questionnaires used to evaluate patients hrqol in patients who suffer from prostate disease such as the international prostate symptom score (ipss); sexual functioning index (sfi); bph impact index (bii) and eq-5d index (eq-5d index).7-9 the diagnosis and treatment of prostatic enlargement disease have made significant advances in past years. the gold standard of radical prostatectomy has nowadays been amj. 2017;4(3):321–8 issn 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v4n3.968 althea medical journal. 2017;4(3) 322 amj september 2017 largely replaced by endourological treatment. for example, transurethral resection of the prostate (turp), when compared to radical prostatectomy and medical treatment is far less invasive, and is associated with fewer complications, shorter hospitalization, better outcomes, better quality of life improvement and reduced cost.10 both medical and surgery treatments are known to increase the hrqol of patients with prostatic disease, especially those who have moderate-severe lower urinary tract symptoms (luts) but no significant difference in effect is observed between the two modalities.8,11,12 in addition hrqol is affected by other factors such as culture and geographic area. it has been shown that hrqol differs between european and asian men with hepatocellular carcinoma13 but no such study of hrqol in patients with prostate disease exists. the aim of this study was to asses the hrqol in patients with prostatic enlargement disease post surgery, to explore possible predictor of worse hrqol following prostatic surgery, and to assess patient satisfaction related urinary functionality post surgery, in the indonesian context. methods this study evaluated bph surgical data recorded by medical records at bethesda hospital, yogyakarta. the subjects were all patients with bph and/or prostate cancer who underwent surgical treatment, either turp or radical prostatectomy, in the period of january 2014–january 2016. the study was approved by the ethics committee of the faculty of medicine, duta wacana christian university. data collection included age, phone number, address, admission date, date of surgery, date of hospital discharge, type of surgery, comorbid conditions, ward type, funding source, histopathological result, and functional status. the outcomes were followed up by phone interviews. subjects were asked to answer the questionnaire over the phone. exclusion criteria were those patients with incomplete medical data, those who did not answer the phone or had passed away. the eq-5d-5l/eq-vas was used to assess the subject’s hrqol. eq-5d-5l is an international questionnaire consisting of 5 questions that evaluates mobility, self-care, daily activity, pain, and depression. each item is evaluated using a 5 point likert scale with answers ranging from 1 to 5 points (no problems, slight problems, moderate problems, severe problems, and extreme problems). the summary index was calculated using the eq-5d-5l crosswalk index value calculator. this tool was downloaded from the euroqol website. the eq-5d-5l index ranges from 1 (full health related quality of life) to 0 (death).15 the specific values were derived from thailand samples because there were no specific sets available for the indonesian population. eq-vas (visual analog score) was used to evaluate the health related quality of life using the subject’s personal assessment, ranging from 0 (worst health state) to 100 (best health state). permission for the use of this instrument in the study was granted by the euroqol group. furthermore, urinary function related quality of life was assessed using the index quality of life questions in ipss (ipss-q8). the question “if you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?” was translated into indonesian language accounting for the fact that a few people speak english. the subjects were asked to recall their feelings 3 months post surgery, 6 months post surgery, and on the day of the phone call. the question was answered according to a 7 point likert scale, with 1 being ‘delighted’ 2: ‘pleased’, 3: ‘mostly satisfied’, 4: ‘mixed’, 5: ‘mostly dissatisfied’, 6: ‘unhappy’, and 7: ‘terrible’. the possible factor of worse eq-5d-5l was assessed by dividing them based on the following sub-group: 1) age (≤ 60 y.o. vs > 60 y.o.), defined as age when surgery was performed. the group was divided based on who and indonesian law definition of elderly, 2) comorbid (with comorbid vs without comorbid), defined as the presence of one or more additional disease, 3) type of surgery (open prostatectomy vs turp), defined as the surgery technique which was used as pe treatment, 4) functional status, was based on instrumental activities of daily living (iadl), 5) funding source (family vs askes/bpjs (national health insurance), vs bumn (stateowned enterprise), vs other), represented the socioeconomic status, 6) ward type (class 1 vs class 2 vs class 3 vs vip vs vvip), represented the socioeconomic status and in-hospital environment, 7) histopathological result (bph vs adenocarcinoma), histopathological result was proven by specimen biopsy, and 7) year althea medical journal. 2017;4(3) 323 table 1 subject’s characteristics variable frequency (n) mean±sd range (years) age 149 69.09 52-91 category frequency (n) percentage(%) length of stay 1-3 days 135 90.6 4-6 days 10 6.7 >7 days 3 2 preoperation waiting time 1-3 days 12 8.1 4-6 days 96 64.4 >7 days 40 26.8 type of ward class 1 36 24.2 class 2 22 14.8 class 3 44 29.5 class vip 36 24.2 class vvip 1 0.7 funding source family 50 33.6 nhi 71 47.7 dhi 7 4.7 others 11 7.4 functional status fully active 141 94.6 restricted activity 4 2.7 partial dependent 3 2 completely disabled 1 0.7 type of surgery radical prostatectomy 11 7.4 turp 138 92.6 histopathology result bph 105 70.5 adenocarcinoma 19 12.8 note: vip=very important person; vvip=very very important person; nhi=national health insurance; dhi=district health insurance; jvp=jugular venous pressure; ecg=electrocardiograph; rpm=rate per minute; turp=trans urethral resection of prostate; bph=benign prostate hyperplasia daniel mahendra krisna, hariatmoko, rizaldi taslim pinzon: health related quality of life and residual symptoms in prostatic surgical treatment at bethesda hospital yogyakarta: a retrospective study of treatment (2014 vs 2015), defined as one year or two years after surgery. besides , the frequency of answers from iql index were also compared between 3 and 6 months post surgery and on the day when answering the questionnaire. the sample size was determined by the n=[(zα+zβ)/c]2+3. zα was the standard normal deviate for α, zβ was the standard normal deviate for β, and c was 0.5 * ln[(1+r)/ (1-r)]. the number of samples for this study was 123 subjects. as for the statistical analysis, categorical data were presented as frequency and percentage. continuous data were presented as a mean or standard deviation. kolmogorov-smirnov test was used to determine the data distribution. mannwhitney test , kruskal wallis test, or chi-square test was used, whether it was appropriate to asses the difference or not. the correlation between outcomes and variables were assessed using spearman’s rho test. multiple linear regression was used to asses predictor influences. moreover, p value less than 0.05 and p value less than 0.001 (spearman) were considered significant. results there were 149 subjects with an average age of 69,09 years . specifically, the youngest althea medical journal. 2017;4(3) 324 amj september 2017 age was 52 years, while the oldest was 91 years old. moreover, 24.2% of subjects were patients of class 1 ward and vip. while, 47.7% of subjects used the national health insurance as their funding source. furthermore, 92.4% of subjects underwent turp surgery with 70.5% of them showing bph on their histopathological result (table 1). about 54.4% of the subjects answered 11111 in the eq-5d-5l questionnaire and 14.1% of them answered 11222. the results of eq-5d showed there were moderate problems in the usual activities and anxiety components. the eq-5d-5l index relationship was analyzed with each variable based on the sub-group, following age, comorbid, type of table 2 eq-5d index correlation between variables variables mean (sd) p-value* p-value** age 0.413 0.000 ≤ 60 years 81.2(0.174) > 60 years 73.87(0.145) comorbid conditions 0.368 0.000 without comorbid 77.7(0.178) with comorbid 71.87(0.165) type of surgery 0.994 0.000 radical prostatectomy 74.91(0.187) turp 75.01(0.165) functional status 0.184 0.000 fully active 75.6 restricted activity 36.63 partial dependent 86.83 completely disabled 109 funding source < 0.05 0.000 family 67.37(0.175) national health insurance 76.00(0.158) district health insurance 37.47(0.240) others 63.95(0.142) type of ward 0.403 0.000 class 1 68.14(0.173) class 2 59.66(0.193) class 3 76.64(0.163) vip 69.19(0.170) vvip 101.5 histopathology result 0.292 0.000 bph 63.18(0.169) adenocarcinoma 55.24(0.181) year of treatment 0.819 0.000 2014 (≤ 1 year) 75.71(0.167) 2015 (> 1 year) 74.23(0.175) note: p-value*=p-value of spearman correlation test, p-value**=p-value of kolmogorov-smirnov test althea medical journal. 2017;4(3) 325 table 3 responses to eq-5d by variables variables n mobility self care usual activities pain/ discomfort anxiety/ depression age ≤ 60 years 23 70.5 72.74 70.37 65.93 72.35 > 60 years 126 75.82 75.41 75.85 76.65 75.48 pvalue 0.188 0.546 0.446 0.193 0.706 comorbid conditions without comorbid 87 73.93 74.64 75.56 74.76 74.9 with comorbid 62 76.51 75.51 74.21 75.34 75.14 p-value 0.383 0.789 0.797 0.923 0.969 type of surgery radical prostatectomy 11 77.27 76.27 70.95 80.36 72.23 turp 138 74.82 74.9 75.32 74.57 75.22 p-value 0.66 0.822 0.66 0.611 0.795 functional status fully active 141 75.26 75.31 74.94 74.94 74.59 restricted activity 4 70.5 69.5 94.5 94.5 100.63 partial dependent 3 70.5 69.5 57.5 57.5 70 completely disabled 1 70.5 69.5 57.5 57.5 45.5 p-value 0.91 0.88 0.435 0.067 0.446 funding source family 50 69.67 71.45 71.44 73.08 70.48 national health insurance 71 68.44 67.44 66.13 65.01 65.23 district health insurance 7 95.29 94.29 105.14 92.14 90.79 others 11 65.5 64.5 66.05 74.09 85.41 p-value 0.001 0.003 0.01 0.169 0.105 type of ward class 1 36 69.36 68.36 72.67 73.89 70.39 class 2 22 74.98 73.98 76.2 77.75 78.48 class 3 44 68.66 69.24 64.48 63.53 66.35 vip 36 69.36 70.29 70.75 70.03 69.64 vvip 1 65.5 64.5 53.5 43 43 p-value 0.683 0.841 0.541 0.429 0.646 histopathology result bph 105 62.04 62.22 62.56 60.67 62.07 adenocarcinoma 19 65.03 64.03 62.18 72.63 64.89 p-value 0.434 0.67 0.954 0.109 0.708 year of treatment 2014 (≤ 1 year) 78 74.32 74.28 75.53 73.24 75.47 2015 (> 1 year) 71 75.75 75.8 74.42 76.93 74.49 p-value 0.625 0.635 0.832 0.536 0.87 daniel mahendra krisna, hariatmoko, rizaldi taslim pinzon: health related quality of life and residual symptoms in prostatic surgical treatment at bethesda hospital yogyakarta: a retrospective study althea medical journal. 2017;4(3) 326 amj september 2017 surgery, functional status, funding source, ward type, histopathological result, and year of treatment (table 2 and 3). kolmogorovsmirnov normality test was used to determine data distribution in all variables (p=0.000). based on eq-vas measurement, this study discovered that the average of vas results in male population aged 40-49 years was 78,3, aged 50-59 years was 75,5, while aged 60-69 years was 72. the mean of eq-5d vas was 74.06 and standart deviation was 6.350. furthermore, the eq-5d index correlation between variables showed age below 60 years, subjects without comorbid, used national health insurance as the funding source, and histopathological result with changing bph had higher average compared to their comparators, but was not statistically significant (age 81.2 vs 73.87, p=0.413; comorbid condition 77.8 vs 71.87, p=0.368; type of surgery 74.91 vs 75.01, p=0.994; functional status 75.6 vs 36.63 vs 86.83 vs 109, p=0.184; type of ward 68.14 vs 59.66 vs 76.64, vs 69.19 vs 101.5, p=0.184; histopathology result 63.18 vs 55.24, p=0.292; year of treatment 75.71 vs 74.23, p = 0.819). the funding source was the only variable that was statistically significant different (funding source 67.37 vs 76.00 vs 37.47 vs 63.95, p<0.05). the result was similar when we assessed variables to each eq-5d components. there was no relationship between each variables (table 4). moreover, the subjects’ iql-ipss-q8 correlation based on the period were: 3 months after surgery, 6 months after surgery, and the recent condition during filling out the questionnaire revealed that there was an increase of “pleased” and a decrease of “mostly dissatisfied” answers from 3 months after surgery to the recent condition during filling out the questionnaire . in addition, an increase of urinary frequency (47.4%), nocturia (21.1%), and dysuria (10.5%) became the most frequent complaints post surgery (table 5). discussions the average age of subjects in this study was 69.06 years. this was in line with the rate of table 4 multiple analysis regression between eq-5d index with variables variables p-value age 0.094 comorbid conditions 0.352 type of surgery 0.46 functional status 0.256 funding source 0.162 type of ward 0.357 histopathology result 0.215 year of treatment 0.298 table 5 bothersome symptoms in the follow-up after surgery variable frequency (n) precentage (%) frequency 18 47.4 nocturia 8 21.1 dysuria 4 10.5 hematuria 2 5.3 obstruction 2 5.3 erectile dysfunction 1 2.6 urgency 2 5.3 retrograde ejaculation 1 2.6 althea medical journal. 2017;4(3) 327 life expectancy in 2012 (70,1 years).3 the definition of elderly varied in each country. according to who, elderly means male or female aged over 60 years. the subjects were divided into several categories, including age. the number of subjects aged over 60 years was the majority. this was surely in accordance with the incidence of prostate enlargement that increase in the age of over 60 years.16,17 almost all of the subjects (32%) only experienced less than 3 days hospitalization and brought the catheter along to their home. this was shorter than in the study of khan18, which has found that the average duration of hospitalization is 3.5 days. changes in the urine color to clearer one, or urine is free from visible blood trace, may be the indicator of the patients’ hospital discharge.19 it might occur to almost all of the subjects who used the national health insurance (askes/bpjs) as their funding source, which highly affected their duration of hospitalization since it could decrease the patients’ total charge. there were different eq-5d-5l average between age (sub-group) and comorbid, even though it was not statistically significant. mobility impairment, previous history of stroke, respiratory disorder, and cardiovascular disease such as hypertension played a critical role in affecting the patients’ quality of life after surgery, both surgical and medical. this finding is obviously in accordance with the study conducted by cortez-diaz et al.19 furthermore, the funding source became the only variable that significantly affected the patients’ quality of life. this fact shows that patients living in developing countries such as indonesia, where most of the citizen depends on the national health insurance, really need such assurance to get the best medication from government programs so that they can reach their therapy targets. again, this fact is supported by a study conducted by jo et al.20 which revealed that the influence of status of social-economy, culture, ethnic, and religious background is real. the subjects’ vas correlation based on sub-group with populations, generally could help the researcher to interpret the result. this study discovered that the eq-vas was lower than the general population which is in line with what cortez-diaz et al.11 has found. this fact showed that prostate enlargement affects the patients’ quality of life. furthermore, there was a clear change in the iql questionnaire. the “pleased” answer of 3 months post surgery with recent condition on the day when answering the questionnaire showed a degree of increase, while the “mostly dissatisfied” answer experienced the opposite. however, as the subjects had not reached their better condition yet at the time the researcher gave the questionnaire, there was a change over the 6 months after surgery, such as the decrease in “pleased” answer and increase in “mostly satisfied” answer. this was due to the clinical perception of adapting or accepting urination quality by patients, or by the improvement on patients’ remaining complaints after surgery. the most frequent complaint was what the patients described as overactive bladder. even more, a subject suffered from erectile dysfunction or retrograde ejaculation. as a conclusion, life improvement must be the major purpose of prostate enlargement therapy, especially bph. the researcher figures out that the existing therapy can improve the patients’ quality of life, even though it still has many weaknesses so the optimal therapy cannot be obtained. it is also necessary to prevent complaints that affect the patients’ quality of life after surgery as much as possible. furthermore, the government in developing countries should consider about the financial guarantee of medication, in order to establish healthy citizens with good quality of life, especially of the elderly. the limitation of this study was the questionnaire data had been collected only via phone call so that perception or understanding over the questions could be varied in each subject. in addition, long term medication, and the number of subjects living outside the city were considered as the obstacle which occurs in this study. however, this study has several advantages to point out such as: it was conducted in indonesia as one of the developing countries in the world, and provided subjects who had undergone surgery in the previous one or two years, so that health providers could observe their patients’ treatment results accordance with their quality of life. references 1. unnikrishnan r, almassi n, fareed k. benign prostatic hyperplasia: evaluation and medical management in primary care. cleve clin j med. 2017;84(1):53-64. 2. groves h, chang d, palazzi k, cohen s, parsons j. the incidence of acute urinary retention secondary to bph is increasing among california men. prostate cancer and prostatic dis. 2013;16(3):260-5. 3. badan pusat statistik. angka harapan hidup di indonesia tahun 2015. bps 2015 daniel mahendra krisna, hariatmoko, rizaldi taslim pinzon: health related quality of life and residual symptoms in prostatic surgical treatment at bethesda hospital yogyakarta: a retrospective study althea medical journal. 2017;4(3) 328 amj september 2017 [cited 10 january 2017]. available from: https:/www.bps.go.id/linktabelstatis/ view/id/1517. 4. baade pd, youlden dr, cramb sm, dunn j, gardiner ra. epidemiology of prostate cancer in the asia-pacific region. prostate int. 2013; 1(2): 47–58. 5. kosilov k, loparev s, kuzina i, kosilova l, ivanovskaya m, prokofyeva a. healthrelated quality of life’s dependence on socio-economic status and demographic characteristics among men with benign prostatic hyperplasia. andrologia. 2017;e12982. 6. ferreira ft, daltoé l, succi g, cunha f, ferreira jm, lorenzetti f, dambros m. relation between glycemic levels and low tract urinary symptoms in elderly. aging male. 2015 ;18(1):34-7. 7. fryback dg, dunham nc, palta m, hanmer j, buechner j, cherepanov d, et al. u.s. norms for six generic healthrelated quality-of-life indexes from the national health measurement study. medical care. 2007;45: 1162–70 8. al-rawashdah sf, pastore al, salhi ya, fuschi a, petrozza v, maurizi a, et al. prospective randomized study comparing monopolar with bipolar transurethral resection of prostate in benign prostatic obstruction: 36-month outcomes. world j urol 2017:2(1):1–7. 9. fourcade r. lacoin f, rouprêt m, slama a, fur cl, michel e, et al. outcomes and general health-related quality of life among patients medically treated in general daily practice for lower urinary tracts symptoms due to benign protatic hyperplasia. world j urol. 2012;30(3):419-26. 10. castro-díaz d, díaz-cuervo h, pérez m. hiperplasia benigna de próstata y su tratamiento: impacto en calidad de vida y function sexual (english vers). actas urol esp. 2013;37(4):233-41. 11. milicevic s. the impact of benign prostatic hyperplasia surgical treatment with turp method on the quality of life. acta inform med. 2011;19(3):142-5. 12. hadi n, aminsharifi a, sadeghi a, tourchi a. superselective α-adrenergic blockers versus transurethral resection of the prostate: a prospective comparison of health-related quality of life outcome after treating patients with benign prostatic hyperplasia. qual life res. 2012;22(6):1287-93. 13. chie w, blazeby j, hsiao cf, chiu hc, poon rt, mikoshiba n, et al. differences in health-related quality of life between european and asian patients with hepatocellular carcinoma. asia pac j clinic onco. 2016;4(1):1-8. 14. alvarado-bolaños a, cervantes-arriaga a, rodríguez-violante m, llorens-arenas r, calderón-fajardo h, millán-cepeda r, et al. convergent validation of eq-5d-5l in patients with parkinson’s disease. j neurol sci. 2015;358(1-2):53-7. 15. van hout b, janssen mf, feng ys, kohlmann t, busschbach j, golicki d, et al. interim scoring for the eq-5d-5l: mapping the eq-5d-5l to eq-5d-3l value sets. value health. 2012;15(5):708-15. 16. torz c, poletajew s, radziszewski p. a prospective, randomized trial comparing the use of ktp (greenlight) laser versus electroresection-supplemented laser in the treatment of benign prostatic hyperplasia. cent european j urol. 2016;69(4):391-5. 17. mahmood sn, aghaways i. safety of overnight hospitalization after transurethral resection of prostate. oju. 2016;6(1):1-6. 18. khan a. day care monopolar transurethral resection of prostate: is it feasible?. urol ann. 2014;6(4):334-9. 19. castro-díaz d, callejo d, cortés x, pérez m. estudio de calidad de vida en pacientes con hiperplasia benigna de próstata en tratamiento con silodisina. actas urológicas españolas. 2014;38(6):361-66. 20. jo jk, kim ks, nam jw, choi by, moon hs. sociodemographic factors related to lower urinary tract symptoms in men: a korean community health survey. int neurourol j. 2017;21(2):143-51. althea medical journal. 2016;3(3) 345 effects of psidium guajava leaf infusion on streptococci viridans hing yi chen,1 ine kuswardinah,2 laili aznur3 1faculty of medicine universitas padjadjaran 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of oral health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: dental caries is recognized as the most important oral burden. it is caused by the formation of lactate acid formed through reaction of bacteria and carbohydrates. streptococci viridans has been proven as the primary etiologic agents for dental caries. low accessibility in oral care services leads the indonesian community to use plants in order to prevent dental caries. one of those plants is psidium guajava (pink guava). the leaves were suggested to have antimicrobial effects on some gram-positive bacteria. when the organism is resistant to specific substance tested on media, a circular/inhibition zone around a disc containing antimicrobial substance was formed. the purpose of this study was to identify the presence of inhibition zones by infusion of psidium guajava leaf on streptococci viridians in vitro. methods: this laboratory experiment was carried out in september to october 2014 at the microbiology laboratory, faculty of medicine, universitas padjadjaran. infusions of psidium guajava leaf were made into four different concentrations (10%, 25%, 50% and 100%, respectively) and the identification of inhibition zones on streptococci viridans obtained from the laboratory was tested using modified disk diffusion test. distilled water acted as negative control. the results were then interpreted after 24 hours of incubation. every procedure was repeated three times. results: all four concentrations of psidium guajava leaf infusions have formed inhibition zones on the media, with the highest concentration (100%) producing largest average diameter. conclusions: the infusion of psidium guajava leaf produces inhibition zones on streptococci virdans in vitro. [amj.2016;3(3):345–8] keywords: dental caries, psidium guajava, streptococci viridans. correspondence: hing yi chen, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81394116717 email: yichenhing@gmail.com introduction the world health organization (who) has identified dental caries as the most important oral burden especially in developing countries, affecting 60-90% of school-aged children and a majority of adults. this is mostly due to sociobehavioural and environmental factors.1 indonesia’s ministry of health previously reported that the prevalence of health problems of teeth and oral cavity to be 23.4%, which occurred more frequently in suburban areas (24.4%). it may be consequence of the poor personal oral hygiene and lack of knowledge about oral health.2 dental caries formed through acid by colonizing flora colonies in plaque on enamel later demineralize enamel and streptococci viridans is the main etiologic agent. this streptococci species constitutes 39% in normal human oral cavity, making them opportunistic pathogens to human.3 dental caries is both chronic and systemic diseases when untreated, can cause myocardial infarction, endocarditis and stroke.4 furthermore, low accessibility to oral care services leads to treatment using traditional/ herbal medicine, which is cheaper and more accessible. most of the indonesian community use psidium guajava (pink guava).5 the fruits, leaves, bark and roots are parts of the plant that were utilized in oral care.6 the leaves were suggested to have antimicrobial effects on some gram-positive bacteria. these effects were attributable to the presence of essential oil in the leaves which can penetrate the lipid bilayer of cell membrane causes leakage of vital cell contents.7 when the organism althea medical journal. 2016;3(3) 346 amj september 2016 is resistant to specific substance tested on media, a circular/inhibition zone around a disc containing antimicrobial substance was formed. this study was conducted to illustrate the presence of inhibition zones by infusion of psidiumguajava leaf on streptococci viridans in vitro. this study could provide the indonesian community, especially those living in rural areas, as an alternative prevention action on dental caries which is cheaper and more accessible. methods this study was conducted from september– october 2014 in the microbiology laboratory, faculty of medicine, universitas padjadjaran. all experiment procedures have been approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the leaves of psidium guajava were obtained from jatinangor area, sumedang, west java. the infusion of leaves was made into four different concentrations, which were 100%, 50%, 25% and 10%. according to the national agency of drug and food control, republic of indonesia, the concentration for herbal leaves in order to make infusion was supposed at 10%.8 the tested streptococci viridans was obtained from the microbiology laboratory of faculty of medicine, universitas padjadjaran. before a disk diffusion test was carried out, leaves of psidium guajava were prepared to be made into infusion. the leaves were first weighed to a total of 25 gram, before being washed and minced. the minced leaves were then put into an erlenmeyer container and mixed with water of 25 ml. the container was later put into a pan that had been filled with boiling water. then, the temperature was measured, and when the temperature has reached 90°c, it was maintained for 15 minutes. after 15 minutes, the container was removed from the pan and the mixture was poured and filtered through a flannel cloth to a bowl.8 a 100% concentration of psidium guajava leaves infusion was formed. next, the infusion was diluted with distilled water to obtain three concentrations of infusion, namely 50%, 25% and 10%. those infusions were placed into 4 different test tubes. furthermore, the bacteria suspension was prepared using the direct colony suspension method where five samples from different areas of a colony of s. viridans had been cultured in blood agar for 24 hours at 35 ± 2 °c were mixed with 5 ml of sterile nacl (8.5 g/l nacl; 0.85% normal saline) 0.145 mol/l for about 15 seconds. then, the turbidity of the suspension was measured visually. the suitable turbidity was proportional to mcfarland 0.5.9 the susceptibility effect procedure referred to the guidelines from the clinical and laboratory standard institute (formerly nccls) and the european society of clinical microbiology and infectious disease (eucast). prior to the inoculation of the testing of microbe was performed a petri dishe containing blood agar was prepared. then, the cotton swab was swapped on the surface of blood agar. the petri dish was left open for about 3 to 5 minutes to reduce humidity on the agar’s surface before being closed by a cover lid.9 five small areas on the media were marked with holes, at four sides and one at the center of the petry dish. the leaves infusions were applied into these 4 areas using different concentrations respectively. the one in the center acted as a negative control with the application of distilled water only. those steps were repeated three times. finally, those petri dishes were incubated at a temperature of 35 °c (±2°c) for 24 hours. furthermore, after incubation of the media for 20 to 24 hours, the diameters of inhibition zones were measured.9 the results were then analyzed and shown in a table. results the test using distilled water showed negative results with no inhibition zones being formed in all three tests. the 10% of psidium guajava leaf infusion showed the average diameter of inhibition zones to be 11.7 mm. while for the infusion of 25%, the average diameter was recorded as 18.3 mm. the leaf infusions of 50% and 100% were measured as 21.7 mm and 23.3 mm respectively. the diameters of the inhibition zones presented increased from lowest at 10% concentration of leaf infusion and ranged highest when the leaf infusion concentration is at 100%. this result was consistent for all the three tests. discussion many studies had been conducted on the effects of psidium guajava leaves as antimicrobial substance. a previous study using similar methods showed that different concentration of this plant extract had doubled acted as antimicrobial substance streptococcus species.10 another study used psidium althea medical journal. 2016;3(3) 347hing yi chen, ine kuswardinah, laili aznur: effects of psidium guajava leaf infusion on streptococci viridans guajava ethanol-extract ranging from 10% to 100% on actinomyces species to observe the morphological changes and inhibition zone’s diameter. this study demonstrated that there were presence of inhibition zones and morphological changes.11 in order to determine whether similar results could be revealed using psidium guajava leaves, the infusion of 100% concentration was diluted with distilled water to obtain the remaining three concentrations of infusion, which were 50%, 25% and 10%. the presence of the inhibition zones was identified at the end of the study. the diameter of the inhibition zones formed by all the concentrations of infusion of psidium guajava, increased in accordance to the level of concentrations used. the higher the concentration, the wider the inhibition zone was. meanwhile, a previous study on phytochemical analysis with the usage of four different extraction methods: n-hexane, ethanol and methanol, and distilled water was reported. the extraction with distilled water demonstrated as the only method that was able to demonstrate positive presence compared to the other chemical substances. these chemical contents were expected to contribute to antibacterial effect of the psidium guajava leaves tested on gram-positive microorganisms, which were staphylococcus aureus and bacillus cereus. through the action of flavanoids in penetrating cell membrane’s lipid bilayer; saponins inhibiting gram-positive microorganisms and tannins interfere their production of protein, antibacterial effects were presented.5 therefore, these chemical contents within the leaves have been suggested in producing inhibition zones in vitro. the study has also illustrated that when psidium guajava ethanol-extracts were tested on other microorganisms, for example streptococci mitis and actinomyces species, it disrupted the morphology of these bacteria. introduction of the extracts into the growth environment of these microbes has produced a hostile condition for them to grow. the bacteria needed a longer period of time in order to adapt and synthesize new essential enzymes to metabolise the substrates introduced into the growth medium. therefore, the extract disrupted the physiological activities of the cells and may lead to cell death, contributing the presence of inhibition zones in tests.11 this study was limited by the time provided in order to complete the whole study. the results should be further analyzed with statistical analysis in order to determine the antibacterial effect of infusion of psidium guajava leaves on streptococci viridans in vitro. the study had also been restricted when the validations of the results should be identified using other extraction methods, to compare whether similar results would be produced in the presence of inhibition zones when other extraction methods of psidium guajava leaves were used. previous studies provided comprehensive explanations on the production of inhibition zones formed by psidium guajava leaves chemical contents. these studies corresponded to the results of this study. thus, from this study, it can be concluded that the infusion of leaves of psidium guajava produces inhibition zones on streptococci viridans in vitro. the study can be further improved through comparing the inhibition zones formed with observation under microscopes in order to determine the colony affected by the infusion, thus comparing the numbers of bacteria affected and the morphological changes on streptococci viridans. the results could be verified further with a statistical analysis in order to determine the antibacterial effect of infusion of psidium guajava leaves on streptococci viridans in vitro and in vivo, in table diameter of inhibition zones results from different concentrations of infusion of psidium guajava on streptococci viridans in vitro concentration (%) inhibition zone (mm) test i test ii test iii average distilled water 10 10.0 15.0 10.0 11.7 25 15.0 20.0 20.0 18.3 50 20.0 22.0 23.0 21.7 100 21.0 24.0 25.0 23.3 note: *(-) is when there was no inhibition zone found althea medical journal. 2016;3(3) 348 amj september 2016 addition to determine the minimal inhibition of concentration. references 1. petersen pe, bourgeois d, ogawa h, estupinan-day s, ndiaye c. the global burden of oral diseases and risks to oral health. bull world heath organ. 2005;83(9):661–9. 2. deprtemen kesehatan ri. riset kesehatan dasar (riskesdas) 2007. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan ri;2008. 3. grusell en, dahlen g, ruth m, ny l, quiding-jarbrink m, bergquist h, et al. bacterial flora of the human oral cavity, and the upper and lower esophagus. dis esophagus. 2013;26(1):84–90. 4. hujoel p. dietary carbohydrates and dental-systemic diseases. j dent res. 2009;88(6):490–502. 5. mailoa mn, mahendradatta m, laga a, djide n. tannin extract of guava leaves (psidium guajava l) variation with concentration solvents. int j sci technol res. 2013;2(8):106–10. 6. kumar a. importance for life ‘psidium guava’. int j res pharm biomed sci. 2012;3(1):137–43. 7. biswas b, rogers k, mclaughlin f, daniels d, yadav a. antimicrobial ctivities of leaf extracts of guava (psidium guajava l.) on two gram-negative and gram-positive bacteria. int j microbiol. 2013;2013:7. 8. badan pengawas obat dan makanan ri. acuan sediaan herbal vol 5. 1st ed. jakarta: direktorat obat asli indonesia, deputi ii, bpomri; 2010. p. 1–7. 9. matuschek e, brown dfj, kahlmeter g. development of eucast disk diffusion antimicrobial susceptibility testing method and its implementation in routine microbiology laboratories. clin microbiol infect. 2014;20(4):255–66. 10. nzeako bc, al-kharousi zsn, al-mahrooqui z. antimicrobial activities of clove and thyme extracts. sultan qaboos univ med j. 2006;6(1):33–9. 11. fathilah ar, yusoff m, rahim zha. the effect of psidium guajava and piper betle extracts on the morphology of dental plaque bacteria. pak j med sci. 2009;25(6):928–33. althea medical journal. 2016;3(3) 421 role of kletik oil, ginger and garlic extracts towards soft tissue injury benjamin yong qing nan,1 yoyos dias ismiarto,2 adhi kristianto sugianli3 1faculty of medicine universitas padjadjaran, 2department of orthopedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: there is an increased consumption of herbal medicines throughout the world as an alternative treatment for curing health problems. several herbal medicines are believed to contain anti-inflammatory properties that could trigger healing process. but little is known about the combination effect of herbal medicines. therefore, the objective of the study was to determine the effects of garlic, ginger and coconut oil (kletik oil) on soft tissue injury (swelling). methods: the study was held in the research laboratory of faculty of medicine universitas padjadjaran, from 24th september until 1st october 2014. this experimental study used 7 healthy rabbits (lepus curpaeums, ±2.5kg) as animal models for each control and intervention group with induced soft tissue injury in the dorsal ear to mimic swelling (inflammation). the mixture of herbs was applied on the injured site in the trial group, while the healing process was denoted by the thickness of edema and time of observation. the data was analyzed using wilcoxon test. results: the study results showed that after observation time of 0.5 hour, 2 hours, and 5 hours, edema thickness was unvaried. onset of action of the herbal mixture began 24 hours after induced injury, with significant difference of edema thickness on both groups; hence the p-value 0.019 (p<0.05). conclusions: the herbal mixture of ginger, garlic, and coconut oil (kletik oil) contains anti-inflammatory properties to enhance the healing process of soft tissue injury. [amj.2016;3(3):421–4] keywords: ginger, herbal medicine, inflammation, kletik oil, soft tissue injury correspondence: benjamin yong qing nan, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822004705 email: poornoob159@gmail.com introduction there is an increased consumption of herbal medicines throughout the world as an alternative treatment for curing health problems such as heart diseases, diabetes, high blood pressure and certain types of cancer.1herbs such as garlic, ginger and coconut oil (topical) are chosen because these herbs are able to alleviate and provides antiinflammatory effect towards cell injury.2−4 furthermore, garlic (allium sativum) contains a sulfur natural compound, allicin, a substance that have effect as antibacterial, antiviral and antifungal properties.5 ginger (zingiber officinale) has been used in traditional medicine for its therapeutic properties. according to the results in vitro studies, the rhizome of ginger contains gingerols, which inhibits synthesis of pro-inflammatory cytokines, il-1, tnf-α, il-8, prostaglandin (pg) and leukotriene (lt), and also inhibits the inducible enzyme cyclo-oxygenase-2 (cox2).6 moreover, coconut (cocos nucifera l), is capable of increasing antioxidant enzymes, reduces lipid peroxidation content and also has antithrombotic effect. it is reported that it also has anti-nociceptive and anti-inflammatory properties.3 the skin is part of soft tissue composed of epidermis, and dermis.7 in acute soft tissue injury, sign and symptoms occur rapidly and occur from a known or unknown incident.8 in this study, it has never been proven that these three topical herbs mixture will provide an anti-inflammatory effect towards soft tissue injury. so from these three different types of herb, coconut oil will be used as a topical cream that is able to refine and moisturize skin conditions, whereas garlic will be added to act as emulsifier for the fat inside the coconut oil, with generation of heat to provide althea medical journal. 2016;3(3) 422 amj september 2016 optimal vasodilation, ginger is added. due to their individual anti-inflammatory properties, when mixed together, these topical agents will have enhanced anti-inflammatory properties in treating soft tissue injuries.3,4,9,10 therefore, the objective of the study was to determine the effects of garlic, ginger and coconut oil (kletik oil) on soft tissue injury (swelling). methods the research was conducted from september until october 2014 at the research laboratory faculty of medicine, universitas padjadjaran. this study was an experimental study on 7 healthy rabbits (lepus curpaeums ±2.5kg). the herbal mixture was prepared from 15ml of coconut oil, 5g of crushed garlic, 5g of crushed ginger. next, it was mixed together into a container, then stored in the refrigerator for 24 hours. in both two groups: the control and intervention group, the rabbits were induced soft tissue injury (edema) by using a soft tissue clamp onto the rabbit’s ear to mimic injury of the human body. the injury’s site (rabbit’s ears) was left to undergo swelling (sign of inflammation). there were 6 consecutive periods to observe the swelling: 0.5 hours, 2 hours, 5 hours, 24 hours, 120 hours and 168 hours. on the intervention group, the topical herbal mixture of ginger, garlic and coconut oil was applied onto the animal models and left for the healing process observation. the reapplication of the herbal mixture was designated on each observation period. the healing process was identified and measured with a measuring caliper (mm) through the thickness of edema and time of observation (hours). the result was expressed as mean ± sd and was denoted by the thickness of edema caused by inflammation reaction. the groups were compared using the wilcoxon statistical testing. the data collected will be plot into a graph.11 during the observation time, all animal models were placed in a secure and hygienic animal rabbit cage where sustenance was provided. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. results the result of experiments on 7 rabbits during the 168 hours showed the comparison result between control group and intervention group based on the thickness of edema and time of observation. in both control and intervention group, it was found that during 0.5 hours up to 5 hours, there was no difference in the edema thickness, whereas, the differences only occured from 24 hours up to 168 hours; the biggest difference occurred on the 168 hours during observation time. the thickness of edema in the control group was higher (0.134 mm) than in the intervention group (0.121 mm) (figure 1). the observation time was compared figure 1 comparison of the thickness of edema and time of observation between two groups: control and intervention althea medical journal. 2016;3(3) 423benjamin yong qing nan, yoyos dias ismiarto, adhi kristianto sugianli: role of kletik oil, ginger and garlic extracts towards soft tissue injury between the control and intervention animal models, and the statistical analysis showed the p-value of the intervention group was 0.019 (p<0.05). this result indicated that there was a difference between the control group and intervention group during the observation time, and this happened as the effect of applying the herbal mixture onto the intervention group. discussion in this study, it was found that the herbal mixture could significantly prevent the deterioration of injury and decrease the edema formation in rabbit ears. the results suggested that the herbal mixture of ginger, garlic and coconut oil (kletik oil) had active medical ingredients for activating the blood and removing stasis, hence promoting wound healing. wound healing of the skin can be divided into 3 phases: inflammatory, proliferative and remodeling phase. the inflammatory phase is the initial phase which ranges from 2−6 days. the observation time started at 0.5 hours up to 5 hours, and showed there was no difference in the thickness of edema between the two groups. beginning from 24 hours until 168 hours, the difference of thickness of edema was shown between the two groups. meanwhile, the intervention group showed less edema formation. this explained that the mixture of garlic, ginger and coconut oil (kletik oil) had anti-inflammatory properties that could decrease the inflammation reaction hence decreased edema formation. a previous study suggested that other types of herbal mixtures had also proved to decrease the thickness of inflammatory reaction (edema) on soft tissue injury.11 furthermore, other herbal mixtures (four china’s tibetan medical herbs, including lamiophlomis rotata, oxytropis falcate bunge, curcuma longa linn, and myricaria bracteata.) applied onto test rabbits showed the onset of action for these herbal mixtures was on the 24 hours as well. moreover, the effect on inhibition of tnf-α production by the ginger extract was earlier reported because ginger is known to have a moderate effect on osteoarthritis in vivo, and it also has a promising effect of ginger extract in experimental arthritis in rats. additionally, another previous study stated that, ginger extract ev77/15 is as effective an anti-inflammatory agent as betamethasone in this in vitro cell model of cultured fibroblastlike synoviocytes.10,11 in this study, it was found that ginger and its main components, gingerols, can inhibit synthesis of several pro-inflammatory cytokines including il-1, tnf-α and il-8 along with inhibiting prostaglandin (pg) and leukotriene (lt) synthesis enzymes. furthermore, ginger also exerted effect on several genes encoding cytokines, chemokines and the inducible enzyme cyclo-oxygenase-2 (cox-2).6 kletik oil (coconut oil) is rich in fatty acids of medium chain length (6–12 c) of which the major fatty acid is lauric-acid (12 c). fatty acids are bioactive molecules, which have been proved to modulate cellular proliferation, cell signaling and growth factor activities. kletik oil contains higher amounts of antioxidant polyphones, catechins, ferulic acid, p-coumaric acid, caffeic acid, and unidentified phenolic acid and unidentified flavonoids. hence, the cumulative effect of these compounds may fasten and prove to be beneficial to the wound healing process which was able to decrease the swelling in this study.3 lastly, garlic that contains a reactive compound (allicin), inhibited the migration of neutrophilic granulocytes into epithelia, which was a crucial process during inflammation and also inhibited tnfα-dependent proinflammatory cytokines. furthermore, allicin also acted on t-cell lymphocytes by inhibition of the sdf1α-chemokine-induced chemotaxis and this effect was correlated with an impaired dynamic of the actin-cytoskeleton.5 in conclusion, the usage of herbal mixture consisting of ginger, garlic, and coconut oil (kletik oil) somehow possesses antiinflammatory properties which can help the healing process in soft tissue injury. this was an animal model experiment, which could differ when applied onto human’s soft tissue injury. it is important to perform further studies on humans. references 1. kaur j, kaur s, mahajan a. herbal medicines: possible risks and benefits. ajpct. 2013;2:226–39. 2. fraenkel l, bogardus st, concato j, wittink dr. treatment options in knee osteoarthritis ( the patient’s perspective ). arch intern med. 2004;164:1299–304. 3. rajamohan t, nevin kg. effect of topical application of virgin coconut oil on skin components and antioxidant status during dermal wound healing in young rats. skin pharmacol physiol. 2010;23:290–7. 4. zar c, das s. potential effect of herbs on diabetic hypertension: alternative althea medical journal. 2016;3(3) 424 amj september 2016 medicine treatment modalities. la clinica terapeutica. 2013;164(6):529–35. 5. borlinghaus j, albrecht f, gruhlke mch, nwachukwu id, slusarenko aj. allicin : chemical and biological properties. molecules. 2014;19:12591–618. 6. mahluji s, ostadrahimi a, mobasseri m, ebrahimzade attari v, payahoo l. antiinflammatory effects of zingiber officinale in type 2 diabetic patients. adv pharm bull. 2013;3(2):273-6. 7. mescher al., editor, skin,. 2010 junqueira basic histology text and atlas. 12th ed. bloomington: mcgraw-hill education; 2010. p. 316–23. 8. kumar v, abbas ak, fausto n, aster jc. general pathology. in: abbas ak, editor. 2010 robbins and cotran: pathologic basis of disease. 8th ed. philadelphia: elsevierhealth science division; 2010. p. 3–43. 9. nieman dc, shanely ra, luo b, dew d, meaney mp, sha w, et al. a commercialized dietary supplement alleviates joint pain in community adults: a double-blind, placebo-controlled community trial. nutr j. 2013;12(1):1–9. 10. ribel-madsen s, bartels em, stockmarr a, borgwardt a, cornett c, danneskioldsamsoe b, et al. a synoviocyte model for osteoarthritis and rheumatoid arthritis: response to ibuprofen, betamethasone, and ginger extract-a cross-sectional in vitro study. arthritis. 2012;2012:1-9. 11. wang yz, guo cy, zhong hg, wn. z, wang dl, wang x, et al. in vivo effects of pain relieving plaster on closed soft tissue injury in rabbit ears. bmc complement altern med. 2008;8:1-7. althea medical journal. 2016;3(4) 616 amj december 2016 characteristics of anterior segment dysgnesis in pediatric and strabismus ophthalmology unit at cicendo eye hospital 2012-2014 sarah nurul ramadanti,1 irawati irfani,2 astrid feinisa khairani3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/national eye center cicendo hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: developmental anomalies in congenital anomalies cause malformation, such as anterior segment dysgenesis (asd). disorder in maturation of anterior segment of the eye occurs in asd, associated with increased risk of glaucoma. this relation is not supported with enough data about characteristics pediatric patients with asd in indonesia. the aim of the study was to describe characteristics asd in pediatric patient cicendo eye hospital based on patients’ identity, clinical profile and obstetrics profile. methods: this study used a descriptive method and conducted retrospectively. data were collected from medical records of patient with asd in pediatric ophthalmology and strabismus unit at cicendo eye hospital, from january 2012 to december 2014. this study was conducted from july to november 2015. total sampling based on inclusion criteria were used in this study. statistic software was used to analyze data. results: this study used a descriptive method and conducted retrospectively. data were collected from medical records of patient with asd in pediatric ophthalmology and strabismus unit at cicendo eye hospital, from january 2012 to december 2014. this study was conducted from july to november 2015. total sampling based on inclusion criteria were used in this study. statistic software was used to analyze data. conclusions: characteristics pediatric patients with asd at cicendo eye hospital based on patients identity are mostly patients diagnosed in infant age group, from outside bandung, and mostly boys. based on clinical profile most diagnosis is congenital glaucoma, bilateral dominantly, and without complication. based on obstetric profile most patients with asd were born at term without difficulties. [amj.2016;3(4):616–70] keywords: anterior segment dysgenesis, anterior segment of the eye, cicendo eye hospital, glaucoma congenitals correspondence: sarah nurul ramadanti, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282115338277 email: sarahnurul73@gmail.com introduction malformation occurs in congenital anomalies. it is the same with what occurs in anterior segment dysgenesis (asd). this malformation occurs during organogenesis, which is in the third up to eighth week of pregnancy.1 environmental and genetic factors affect malformation, which cause the incomplete development in structure, or loss of certain structures.1,2 the asd involves the migration process and mesenchymal tissue differentiation, which makes anterior structure of the eye including iris, cornea, lens, and drainage structure. this anomaly affects the maturity of the functions for anterior segment of the eye. this condition enhances the risk of getting glaucoma, cataract, and the increased risk of corneal opacities.3,4 the asd has single type such as posterior embryotoxon, iris hypoplasia, corneal opacities, or the combination of the types which results in new diagnosis such as axenfeld-rieger syndrome (ara). this new diagnosis is the combination of iris hypoplasia, posterior embryotoxon, and/ or the adhesion of irido–cornea.4 the relation between asd and other abnormalities is not supported by the presence of inadequate data about characteristics of asd, especially in indonesia. therefore, the aim of study was to describe characteristics asd based on patients’ identity, clinical profile, and obstetric profile. status national referral hospital of cicendo eye hospital supports this althea medical journal. 2016;3(4) 617 study.5 methods this study used a descriptive method retrospectively. the samples of this study were taken from medical records secondary data of patients with asd during the period of january 2012 to december 2014 in pediatric ophthalmology and strabismus unit at cicendo eye hospital. this study was conducted from july to november 2015. this study was conducted after getting approval of collecting data from the president director of the cicendo eye hospital and the ethical approval from the committee of ethical health research of faculty medicine universitas padjajaran, no: 438/un6.c1.3.2/kepk/pn/2015. this study used total sampling method. the inclusion criteria of this study were the medical record of pediatric patients with the range of age between 0–18 years old with diagnosis of asd classifications, information about lateralization, visual acuity, complication, pregnancy history, age of pregnancy, delivery history, and the management. exclusion criteria were damaged and/ incomplete data of the medical records. data collected then, were grouped into three characteristics. the first characteristic was based on the patients’ identity such as age, gender, and address. the second characteristic was based on the clinical profile of the patient, which included the diagnosis, the type of diagnosis, lateralization, visual acuity, complication, and management. the third characteristic was based on the obstetric profile of the patient, which include pregnancy history, age of pregnancy, and delivery history. spss was used to analyzed data and presented in tables and charts. results there were 99 data (n = 99 asd patients) who met the inclusion criteria from the 125 medical records. there were 24 medical records, which were excluded due to the incomplete obstetric profile. first characteristics of asd patients were characteristics based on patients’ identities, included gender, age, address, and the diagnosis. based on gender, the number of male patients was bigger than the female ones, which was 51.52% (n = 51 male patients) and 48.48% (n = 48 female patients) (table 1). based on age group, asd occurred more in patients who belong to infant group (28 days–12 months), (55.56% (n = 55 patients)). based on their address, patients who came to pediatric ophthalmology and strabismus sarah nurul ramadanti, irawati irfani, astrid feinisa khairani: characteristics of anterior segment dysgnesis in pediatric and strabismus ophthalmology unit at cicendo eye hospital 2012-2014 table 1 characteristics asd based on patients’ identity patients’ identity amount (n= 99) percentage (%) gender boys 51 51.52 girls 48 48.48 age group neonates (0–27 days) 9 9.09 infant (28 days–12 months) 55 55.56 toddler ( 13 months–3 years ) 15 15.15 early childhood (4–5 years) 11 11.11 middle childhood ( 6-11 years) 8 8.08 adolescent (12–18 years).6 1 1.01 address bandung city 21 21.21 bandung district 6 6.06 cimahi city 2 2.02 outside bandung 70 70.71 althea medical journal. 2016;3(4) 618 amj december 2016 unit at cicendo eye hospital with asd were mostly from out of bandung, (70.71% (n = 70 patients)) (table 1). second characteristics of asd patient were characteristics based on clinical profiles included diagnosis, type of diagnosis, lateralization in eyes, systemic complication, examination of visual acuity, and the management. asd abnormality was classified into 18 diagnoses, in the diagnosis profiles of the patients with asd; they could have single diagnosis or multiple diagnoses.3,4the variation of diagnosis types results were 150 diagnoses from the total of 99 asd patients in this study. based on type diagnosis 63.64% (n = 63 patients) were diagnosed with single diagnosis, while 36.36% (n = 36 patients) were diagnosed with multiple diagnoses (table 2). based on the medical records in pediatric ophthalmology and strabismus unit at cicendo eye hospital, from 18 classifications of asd diagnosis, there were 11 diagnoses which appeared in this study. they included asd, iris hypoplasia, congenital glaucoma, ara, limbal dermoid, congenital megalocorneal, microcornea, aniridia, peter’s anomaly, sclerocornea, and microphtalmos. meanwhile, there were seven diagnoses which did not appear in this study which included posterior embryotoxon, congenital iris ectropion, congenital hereditary endothelial dystrophy, posterior polymorphous dystrophy, ice syndrome, cornea plana and autosomal dominant keratitis. the distribution of 11 diagnoses presented in patients’ characteristics based on their diagnosis profiles (table 3). the most appearing diagnosis occurred in asd patients in pediatric ophthalmology and strabismus unit at cicendo eye hospital was congenital glaucoma, (30.67% (n= 46 diagnoses)). the distribution of other diagnoses presented (table 3). the distribution of diagnosis along with table 2 characteristics asd based on clinical profile type of diagnosis amount (n) percentage (%) single diagnosis 63 63.64 multidiagnosis 1 concomitant 22 22.22 2 concomitant 13 13.13 3 concomitant 1 1.01 total 99 100 table 3 characteristics asd based on diagnosis profile diagnosis profile number of patients (n) percentage (%) asd* 14 9.33 iris hypoplasia 2 1.33 congenital glaucoma 46 30.67 ara** 1 0.67 limbal dermoid 2 1.33 cm*** 3 2 microcornea 19 12.67 aniridia 3 2 peter’s anomaly 16 10.67 sclerocornea 14 9.33 microphthalmos 30 20 total 150 100 note: *anterior segment dysgenesis (asd); **axenfeld rieger syndrome (ara); ***congenital megalocornea (cm) althea medical journal. 2016;3(4) 619sarah nurul ramadanti, irawati irfani, astrid feinisa khairani: characteristics of anterior segment dysgnesis in pediatric and strabismus ophthalmology unit at cicendo eye hospital 2012-2014 the type of diagnosis described (figure 1). congenital glaucoma was mostly found single diagnosis, 22.7% out of the appearing total diagnoses. the diagnosis with one concomitant was microphtalmus, (7.3%). the diagnosis with two concomitant was microphtalmus and sclerocornea, (5.3%). meanwhile, the diagnosis with three concomitant was the combination of each asd diagnosis; congenital glaucoma, cm, and micropthalmos. the lateralization in asd patients’ eyes were dominantly bilateral, (69.7% (n = 69 patients)) (table 4). the examination of asd patients’ visual acuity mostly used single examination which was 68.7% (n = 68 patients), with the most type of examination was blink reflex (33.3% (n = 33 patients)) (table 4). in 99 asd patients, there were 80.8% (n= 80 patients) who did not have systemic complication. most patient with asd were treated with single management 57.6% (n= 57 patients) (table 4). the type of single management mostly done was conservative , which is 45% (n = 45 patients). meanwhile, the combined management mostly used was surgical with medicamentosa which is 23% (n= 23 patients) (table 4). the third characteristics of asd patients were characteristics based on obstetric profiles. the particular patients’ obstetric profiles included pregnancy history, age of pregnancy, and delivery history (table 5). based on the pregnancy history, asd patients dominantly had one obstacle during pregnancy, (80.8% (n= 80 patients)). there were 14.1% (n= 14 patients) who had two obstacles during pregnancy, and 5.1% (n= 5 patients) had three obstacles during pregnancy. the most appearing obstacle during asd patients’ pregnancy was the consumption of teratogenic medicines, (29.3% (n= 23 patients)) (table 5). based on medical record, asd patients were born mostly when the age of pregnancy was full term, (68.7% (n = 68 patients)). based on the delivery history, asd patients who obtained assistance from midwife were 67.7% (n = 67 patients). based on the difficulty that the asd patients faced during delivery, there were 83.8% (n = 83 patients) without any difficulty (table 5). discussion the asd patient’s characteristics based on their identities in pediatric ophthalmology and strabismus unit at cicendo eye hospital revealed the number of male patients was higher than the female ones. based on a study in australia, the identification of pitx3 gene interpolation in asd excludes the x-linked theory. however, the tendency of dominant gender which occurs in asd needs further study because each region has its own variation.9 based on age category, asd disease is diagnosed more in the age group of neonates (28 days–12 months), which is 55.56% (n= 55 patients). this is due to the figure 1 distribution diagnosis of asd along with type of diagnosis note: *anterior segment dysgenesis (asd); **axenfeld rieger syndrome (ara);***congenital megalocornea (cm). althea medical journal. 2016;3(4) 620 amj december 2016 table 4 characteristics asd based on clinical profile clinical profiles amount (n= patient) percentage (%) lateralization 30.3 unilateral 30 69.7 bilateral 69 100 total 99 visual acuity examination single 33.3 blink reflex 33 19.2 fix and follow object/light 19 3 decoration cake 3 3 tumbling c/e 3 3 wall chart 3 7.1 others 7 combination 15.2 blink reflex& ff* 15 2 blink reflex & dc** 2 3 blink reflex &others 3 6.1 ff*& tumbling c/e 6 1 ff *& wall chart 1 4 wall chart & others 4 100 total 99 systemic complication 19.2 yes 19 80.8 no 80 100 total 99 management single 8.1 medicamentosa 8 4 surgical 4 45 conservative 45 combination 23.2 medicamentosa & surgical 23 10.1 medicamentosa & conservative 10 2 surgical & conservative 2 7.1 medicamentosa, surgical and conservative 7 total 99 100 note: *fix and follow light/object (ff); **decoration cake (dc) significant development from eyes occurs during 6 months of postnatal, including the visual behavior developing when babies are 6–8 weeks old. if the visual behavior of children has not appeared within the first three months, it indicates that consulting to althea medical journal. 2016;3(4) 621 eye specialist needs to be done immediately.10 based on the patients’ addresses; they are dominantly from outside bandung. this fact is supported by the status of the cicendo eye hospital which becomes the national center of referral hospital.5 in pathophysiology of asd, the mechanism of gene mutation can be dominantly autosomal, recessively autosomal, or both.4 the gen that plays important role in pathophysiology of asd can cause various manifestations. this particular manifestation in asd can be in the form of visual disturbance or cosmetic disturbance with or without the visual disturbance itself. meanwhile, the clinical profiles of asd have the form of single anomaly and or associated by concomitant.2,7,11 type of diagnosis of asd patients in pediatric and starbismus unit of the cicendo eye hospital is mostly the single diagnosis, which is 63.64% (n= 63 patients). the characteristics of asd patients based on their diagnosis profiles in this study found that there are 11 types of asd classifications in 99 patients. the asd is a combined diagnosis of which the clinical manifestation heterogeneous both in genotype and phenotype way. however, each of the type of classification of asd has its own characteristic in relation with the origin of its embryology.2,7 classification of asd appeared in 99 patients becomes a special variation in the sample taken from the cicendo eye hospital. there are 150 diagnoses in 99 patients asd. the most appearing diagnosis in patients is congenital glaucoma, which is 30.67% (n= 45 diagnoses). this is because one of the genes playing role in pathophysiology of asd lacks of cypb1 gene. this very gene experiences mutation in congenital glaucoma. the existence of these genes’ similarity stimulates congenital glaucoma appears frequently in asd. one of the malformations caused by cypb1 gene is trabecular dysgenesis. in the process, the flow of aqueous liquid is obstructed that resulting in increase of the iop. thus, the possibility of getting congenital glaucoma is increased up to 50%.2,3,12 the distribution of diagnosis types towards the appeared diagnoses in this study is presented, which shows in single diagnosis congenital glaucoma appeared dominantly in patients. anterior segment dysgenesis is malformation which involves cornea, lens, and anterior space. in pathophysiology of congenital glaucoma, it occurs because of the increased intraocular pressure, which is caused by the imparity between the production of aqueous liquid by the ciliary body and the drainage to the anterior space. the high level of intraocular pressure also occur in microcornea anomaly, sclerocornea, peter’s anomaly, and ara.2,12 meanwhile, microphtalmos diagnosis is the most diagnosis with 1–2 concomitant, followed by sclerocornea which is the most diagnosis with 2 concomitant. in micropthalmus pathophysiology, micropthalmus has gene with sox2 dominant and pax6, chx10, otx2 gene which play roles in micropthalmos formation in other anomalies such as sclerocornea, microcornea, iris hypoplasia, ara, and peter’s anomaly. the same gene regulation can cause one patient likely develops micropthalmos and sclerocornea with same concomitant diagnosis.7,12–14 the lateralization characteristic in patients’ eyes with asd diagnosis is mostly bilateral, (69.7%). this is because there are three anomalies that mostly occurred in this study. those are the dominantly bilateral anomalies; congenital glaucoma, micropthalmus, and microcornea.3 in asd anomalies appeared in this study, the existence of systemic complication is found. one of the forms of systemic concomitant condition is the slow development in children, abnormality in teeth (dental hypoplasia), and so forth. based on medical record, there are 80.8% of asd without systemic complications. based on medical record single most method used to examine visual acuity in asd patient is blink reflex, (33.3%). this examination is mostly used due to the fact that patients with asd diagnosis dominantly on age group of infant. the visual examination in this age group is still in the process of maturation; therefore, the most effective examination is by using the reflex towards light (blink reflex). in asd management, the mostly with conservative method, that is up to 45%. congenital anomaly is caused by genetic material defect, teratogen reaction, or obstetric complication, which results in various clinical profiles.5 based on asd patients’ characteristics towards their obstetric profiles, it is found that there are 29.3% of patients consuming medicines during pregnancy, which is the most found obstetric factor. the type of medicines mostly consumed during pregnancy by the mother of asd patients are antibiotics and herbal medicines. based on previous study in canada, there are correlation between consumption hydroxychloroquine, methotrexate, and 2-chloro-2’-deoxyadenosine into asd formation.15 based on medical sarah nurul ramadanti, irawati irfani, astrid feinisa khairani: characteristics of anterior segment dysgnesis in pediatric and strabismus ophthalmology unit at cicendo eye hospital 2012-2014 althea medical journal. 2016;3(4) 622 amj december 2016 records, infection (torch) and hypertension are two diseases mostly occur in patients’ mother. in microphtalmos diagnosis, torch infection is a strong evidence of the interaction between external factors and micropthalmos occurrence.6 in asd patients’ obstetric profiles, the age of pregnancy mostly full term. the formation of anterior segment in embryology occurs in the twenty-second day of gestation until eighth month of gestation. however, the birth at normal term can still results in malformation if the genetic factor interacts with external factors.2,4 the delivery history becomes one of the important things, knowing that troubles during maternity or lacking of hygiene can result in transmission of infection. another possibility that can happen is lesion caused by the tools used by the paramedics when babies were difficult to deliver, for instance forceps lesion in cornea.7 based on the delivery history of asd patients, those who were helped by midwife were 67.7% and 83.8% of asd patients were born without facing any difficulties. after conducting the study to determine characteristics of anterior segment dysgenesis in pediatric patients in the cicendo eye hospital in the period of january 2012– december 2014, there are several conclusions. first, based on the patients’ identity profiles, there are 99 samples obtained proportionally with the fact that male patients are more than female. second, the diagnoses of asd mostly occur in the age group of neonates. third, diagnosed patients are dominantly from outside of bandung. based on the clinical profiles, type of asd diagnosis is mostly single diagnosis with the appeared asd classification as much as 11 diagnoses. the most appeared diagnosis is congenital glaucoma, (30.67%). in asd patients’ clinical profiles, the characteristic of asd patients’ eyes is dominantly bilateral and not accompanied by systemic complication. the dominance of asd patients in this study is examined through their visual acuity by using blink reflex method. in this study, asd patients are treated mostly by using conservative management. obstetric factors and gynecology are the factors which affect the congenital anomaly. based on the pregnancy history of the asd pediatric patients, this study found that consuming medicines or herbal medicines during pregnancy is mostly done by the patients’ mothers. however, based on the age of pregnancy, the asd pediatric patients were born full term, being helped by midwife, and faced no difficulties. the asd is a kind of disease which is related to the genetic material and external factors during pregnancy and maternity. therefore, early precaution is needed, for instance by doing genetic counseling, screening, and routine antenatal examination that the risk of developing congenital disease can be minimized. mothers need to increase their awareness towards their own health and the fetus’ by paying attention to the nutrition, not consuming medicines or herbal medicines without consultation, and taking care of both their physical and psychological health optimally. referring to the picture of asd in pediatric patients in the cicendo eye hospital, the clinicians and paramedics need to be more knowledgeable in doing anamnesis, examining visual acuity and other supportive actions. this is needed due to the fact that the factors causing asd can be detected earlier. the risk factors such as history of previous illnesses and obstetric history should be included in the inquiry list to the patients’ parents or guardians. it would be better to use standard abbreviations, which can be understood by both the clinicians and other paramedics for medical records. it is desirable that this study is published disseminated in order to improve the societies’ knowledge and can be used to the further investigation. analytical study can be done in further study, to see relation risk factor and pathophysiology of asd. . references 1. sadler tw, editor. langman’s medical embryology. 12thed. baltimore: lippincot williams & wilkins; 2012. p. 329–38. 2. idrees f, vaideanu d, fraser sg, sowden jc, khaw pt. a review of anterior segment dysgeneses. surv ophthalmol. 2006;51(3):213–31. 3. sowden j. moleculr and developmental mechanisms of anterior segment dygenesis. eye. 2007;21(10):1310–18. 4. reis lm, semina ev. genetics of anterior segment dysgenesis disorders. curr opin opthalmol. 2011;22(5):314–336. 5. pusat komunikasi publik, sekertariat jenderal kementrian kesehatan ri. menkes resmikan rs mata cicendo sebagai pusat rujukan nasional. depkes [online article] 2012 [cited 2012 may 12]. available from: althea medical journal. 2016;3(4) 623 http://www.depkes.go.id. 6. william k, thomson d, seto i, contopoulosioannidis dg, ioannidis jp, curtis s, et al. standard 6: age groups for pediatric trials. pediatrics. 2012;129(suppl3):s153–60. 7. guercio jr, martyn lj. congenital malformation of the eye and orbit. otolaryngol clin north am. 2007;40(1):113–40. 8. hoyt cs, taylor d, editors. pediatric ophtalmology and strabismus. 3rded. london: elsevier health sciences;2011. p. 244–63 9. summer km, withers sj, gole ga, piras s, taylor pj. anterior segment mesenchymal dysgenesis in a large australian family is associated with the recurrent 17bp duplication in pitx3. mol vis. 2008;14:2010–5. 10. ramasubramanian a, johnston s. neonatal eye disorders requiring ophthalmology consultation. neoreviews. 2011;12(4):e216–22. 11. ito ya, walter ma. genomics and anterior segment dysgenesis: a review. clin exp ophthal. 2014;42(1):13–24. 12. wiggs jl. genetic etiologies of glaucoma. arch ophthalmol. 2007;125(1);30–7. 13. chassaing n, causse a, vigouroux a, delahaye a, alessandri jl, boespflugtanguy o, et al. molecular findings and clinical data in cohort of 150 patients with anopthalmia/micropthalmia. clin genet. 2014;86(4):326–34. 14. verma as, fitzpatrick dr. anopthalmia and micropthalmia. orphanet j rare dis. 2007;2(2):47–52. 15. mulholland cp, pollock tj. the peters anomaly following antenatal exposure to methotrexate and hydroxychloroquine. can j ophthalmol. 2011;46(3):289–90. sarah nurul ramadanti, irawati irfani, astrid feinisa khairani: characteristics of anterior segment dysgnesis in pediatric and strabismus ophthalmology unit at cicendo eye hospital 2012-2014 althea medical journal. 2016;3(3) 401 gestational age conformity between new ballard score and last menstrual period in newborn with respiratory distress syndrome wulan dwi sakinah,1 aris primadi,2 ihrul prianza prajitno3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cellular biology faculty of medicine universitas padjadjaran abstract background: gestational age is required to determine diagnosis and optimal management of newborns. the gold standard for gestational age determination is the first day of last menstrual period (lmp). however, not all mothers remember their lmp. another method for gestational age determination after birth is the new ballard score (nbs). this method measures gestational age using two main components, namely neorumuscular and physical maturity. in premature infants, surfactant deficiency leads to hypoxia which eventually leads to neuromuscular disorders. this situation may cause younger gestational age estimation when using nbs. the objective of this study was to analyze the conformity between nbs and lmp in determining gestational age in newborns with respiratory distress syndrome (rds). methods: a cross-sectional study was conducted on 35 newborns with rds that were recorded in 2012 database in dr. hasan sadikin general hospital bandung. data on the date of birth, lmp, nbs soon after birth, sex, birth weight, type of delivery and diagnosis were collected and analyzed statistically using wilcoxon test. results: the study showed that there was a significant difference (p<0.05) between gestational age determination done using nbs soon after birth and lmp in newborns with rds. conclusions: gestational age determination based on nbs soon after birth does not conform the lmp in newborns with rds. [amj.2016;3(3):401–4] keywords: gestational age, last menstrual period, new ballard score, respiratory distress syndrome correspondence: wulan dwi sakinah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85353060379 email: wulan.dwie21@gmail.com introduction birth weight and gestational age have been known to be the primary determinants of neonatal morbidity and mortality.1 gestational age is required to determine diagnosis and optimal management of the newborns.2 the gold standard for gestational age assessment is the first day of last menstrual period (lmp).35 however, not all mothers know exactly their lmp. thus, another method is required to assess the gestational age to be used if the lmp is unknown or doubtful. another methods for gestational age determination of newborns are new ballard score (nbs) and ballard score. in a previous study, it is suggested that nbs (r=0.97) has a strong correlation with lmp than ballard score (r=0.95), and nbs was more accurate and had a higher association coefficient (k=0.85) when compared to lmp in identifying premature babies, more than the ballard score (k=0.82).3 the assessment of the gestational age based on nbs is obtained from scoring of both neuromuscular and physical maturity in newborns.6 the policy of dr. hasan sadikin general hospital bandung requires that the five priority areas to be carefully recorded, including thesmanagement of respiratory distress syndrome (rds). surfactant deficiency is the primary cause of prematurity in in rds.1,7,8 this circumstance leads to hypoxia which affects neuromuscular conditions which relates to the fact that one of the aspects assessed in nbs is the neuromuscular maturity. the gestational age determination of newborns with rds when performed using nbs, is lower than that of the lmp.2 the objective of this study was to analyze the conformity of gestational age determination between nbs and lmp in newborns with rds. althea medical journal. 2016;3(3) 402 amj september 2016 methods this was a cross-sectional study. samples were taken from the 2012 database of newborns at the division of neonatology, department of child health, dr. hasan sadikin general hospital, bandung. this study was conducted after obtaining approval from the health research ethics committee of the faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung. the minimum samples size required for 95% confident interval (ci) and 90% power test was 35 subjects. the inclusion criterion was newborns with rds. data on date of birth, lmp, nbs that obtained soon after birth, birth weight, type of delivery, and diagnosis were collected from the database. newborns with marked congenital anomaly and incomplete data, with no lmp or nbs soon after birth data, were excluded from this study. the collected data were analyzed statistically using the nonparametric wilcoxon test. results from 68 newborns with rds, only 38 newborns were included in this study. of the 38 newborns included in this study, most of them were born with low birth weight and through spontaneous delivery (table 1). in this study, the subjects were not only diagnosed with rds but were also diagnosed according to the complications they had, such as asphyxia, sepsis, and both of asphyxia and sepsis. most of the subjects were diagnosed with rds that was accompanied with asphyxia with a different gestational age determination using nbs and lmp (table 2). according to nbs, all subjects were preterms, while lmp showed that 35 subjects were preterms and 3 subjects were full terms. the analysis using the wilcoxon test confirmed that there was a significant difference (p<0.05) between the gestational age based on lmp and nbs in newborns with rds (table 3). discussions according to engle7 and liu et al.8, rds is one of the most common causes of neonatal respiratory failure and neonatal death. this table 1 characteristics of newborn with respiratory distress syndrome characteristics n=38 sex male 22 female 16 birth weight nbw 1 lbw 18 vlbw 15 elbw 4 delivery spontaneous 27 caesarian section 8 vacuum extraction 3 note: nbw=normal birth weight; lbw=low birth weight; vlbw=very low birth weight; elbw=extremely low birth weight table 2 gestational age based on clinical diagnosis n(38) gestational age based on lmp (wk) gestational age based on nbs (wk) rds 6 median (min–max) 33 (31–34) 32.5 (32–34) rds with asphyxia 23 median (min–max) 31 (23–40) 30 (26–36) rds with sepsis 1 median (min–max) 30 30 rds with asphyxia & sepsis 8 median (min–max) 32.5 (29–35) 32.5 (28–36) note: lmp=first day of last menstrual period; nbs=new ballard score; rds=respiratory distress syndrome althea medical journal. 2016;3(3) 403wulan dwi sakinah, aris primadi, ihrul prianza prajitno: gestational age conformity between new ballard score and last menstrual period in newborn with respiratory distress syndrome study discovered that most of the subjects were male infants with low birth weight. this result was similar to a previous study conducted by roth-kleiner et al.9 and a theory stated by kliegman et al.1 that the main cause of rds is prematurity and its risk factors aremale gender, low birth weight, and caesarean section. according to limawal et al.3 there was a strong correlation between gestational age determination by lmp and new ballard score (r=0.97) for healthy infants, including preterm, full-term and post-term infants. the nbs is more accurate and has a higher association coefficient (k=0.85) than the ballard score (k=0.82), when associated to lmp, in identifying premature baby. according to ballard et al.6 the nbs is a valid and accurate gestational assessment tool for extremely premature infants and remains valid for the entire newborn infant population. according to sashidaran et al.5 nbs in 5th to 7th day provides better results than nbs 24 hours after birth. in this study, the nbs was obtained only soon after birth and the results showed that of the 38 subjects, 35 subjects were preterms according to the first day of lmp, while according to the nbs after birth, subjects were preterms. there was no conformity of gestational age determination between the nbs after birth and lmp in newborns with rds (p<0.05). the results of this study are similar to a study conducted by mujawaret al.2 which stated that in full-term newborns with asphyxia and without asphyxia, there were gestational age differences, when determination was performed using lmp and nbs on the first and second day after birth. in that study, there were 62 subjects, with 32 subjects suffered from asphyxia and 30 subjects without asphyxia. these subjects had their gestational age calculated using the nbs from the 1st to 7th day after birth, which was then adjusted to lmp. the results showed that the nbs to lmp conformity in newborns with asphyxia was lower than in newborns without asphyxia with zk-s=3.681 (p<0.001).2 table 3 comparisons of gestational age between lmp and nbs in newborns with rds classification lmp (n=38) nbs (n=38) p term 3 0 0.038 preterm 35 38 median (min–max) 32 (23–40) 32 (26–36) the condition of a newborn is greatly affected by rds. surfactant deficiency is the primary cause of rds.1,7,8 lack of surfactant causes high alveolar surface tension and decreased compliant.1,10 this condition leads to failure to attain an adequate functional residual capacity (frc) and alveolar atelectasis.1,10 in rds, lung cell inflammation also contributes to respiratory failure.11 this circumstance triggers hypoxia and hypercapnia.1,10 hypoxia might cause anaerobic metabolic processes that ended up in impaired muscle contractility, making the infant experience hypotonia.2 muscle contractility is affected by the availability of adenosine 5-triphosphate (atp). limited oxygen in the body might lead to derivation of atp syinthesis.2 this condition influences the scoring of neuromuscular maturity in nbs; thus, the gestational age determination based on nbs in neonatal with rds is lower than the gestational age determined using lmp. there were several limitations in this study such as nbs was only obtained soon after birth and was not repeated, subjects were not only diagnosed with rds but also with accompanying asphyxia, sepsis, or both of asphyxia and sepsis, and possible bias of lmp due to the fact that the data were secondary data (only from a database). it is concluded that there is no conformity between nbs soon after birth and lmp in gestational age determination in newborns with rds. further study to determine the conformity and appropriate time to assess the gestational age using nbs in newborn with rds without asphyxia or sepsis is needed. this study may gain more advantages if it is done in cohort to minimize recall bias of lmp. references 1. kliegman rm, stanton bf, schor nf, iii jwsg, behrman re, editors. nelson texbook of pediatrics. 19th ed. philadelphia: elsevier saunders; 2011. p. 581–90. 2. mujawar ij, somasetia dh, effendi sh. kesesuaian skornew ballard terhadap hari althea medical journal. 2016;3(3) 404 amj september 2016 pertama haid terakhir ibu pada bayi cukup bulan yang lahir asfiksia dan tidak asfiksia. j indon med assoc. 2011;61(10):400–4. 3. limawal f, madjid da, daud d. the accuracy of determining newborn’s maturity between new ballard’s score, ballard’s score, and first day of last menstrual period. paediatr indones. 2008;48(2):59– 63. 4. rosenberg re, ahmed as, ahmed s, saha sk, chowdhury ma, black re, et al. determining gestational age in a low-resource setting: validity of last menstrual period. j health popul nutr. 2009;27(3):332–8. 5. sashidaran k, dutta s, narang a, boyd e. validity of new ballard score until 7th day of postnatal life in moderately preterm neonates. arch dis chil fetal neonatal ed. 2009;94:39–44. 6. ballard jl, khoury jc, wedig k, wang l, eilers-walsman b, lipp r. new ballard score, expanded to include extremely premature infants. j pediatr. 1991;119(3):417–23. 7. engle wa. surfactant-replacement therapy for respiratory distress in the preterm and term neonate. pediatrics. 2008;121(2):419–32. 8. liu j, shi y, dong jy, zheng t, li jy, lu ll, et al. clinical characteristics, diagnosis and management of respiratory distress syndrome in full-term neonates. chin med j. 2010;123(19):2640–4. 9. roth-kleiner m, wagner bp, bachmann d, pfenninger j. respiratory distress syndrome in near-term babies after caesarean section. swiss med wkly. 2003;133(19–20):283–8. 10. hermansen cl, lorah kn. respiratory distress in the newborn. am fam physician. 2007;76(7):987–94. 11. lukkarinen hp, laine j, kaapa po. lung epithelial cells undergo apoptosis in neonatal respiratory distress syndrome. pediatr res. 2003;53(2):254–9. althea medical journal. 2016;3(2) 195 pattern of bacteria and its susceptibility of ventilator-associated pneumonia patients in icu at dr. hasan sadikin general hospital, bandung achmad faisal jundi,1 nurita dian kss,2 yanti mulyana3 1faculty of medicine universitas padjadjaran, 2department of anesthesiology and intensive care faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of microbiology and parasitology, faculty of medicine universitas padjadjaran abstract background: incidence of ventilator-associated pneumonia (vap) is common in intensive care unit (icu). this pneumonia, becomes important due to its association to increased length of hospital stay, increased costs, and increased mortality. irrational administration of antibiotics can lead to development of bacterial resistance. the objective of this study was to describe the pattern of bacteria and the susceptibility of vap patients. methods: a descriptive study was carried out to 10 medical records of vap patients in the icu at dr. hasan sadikin general hospital, bandung in january–june 2014. microbiological culture results and antibiotics susceptibility testing of patients’ sputum were identified and the collected data were analyzed in form of tables and percentages by using a computer program. results: out of 44 cultures taken from 10 patients with vap, 43 cultures had microbiological findings. gram negative bacteria were found in 90.6% cultures, the rests were gram positive bacteria and fungi. the majority of findings were: acinetobacter baumannii (41.9%), pseudomonas aeruginosa (18.6%), and klebsiella pneumoniae (16.9%). the laboratory test result showed varied degrees of antimicrobial resistance to antibiotics. conclusions: bacteria found in sputum cultures of icu patient with vap are mostly of gram negative. the result of susceptibility testing of bacteria shows many of the bacteria have resistance to antibiotics in icu at dr. hasan sadikin general hospital. [amj.2016;3(2):195–9] keywords: bacteria pattern, intensive care unit, susceptibility, ventilator-associated pneumonia correspondence: achmad faisal jundi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85715024740 email: kennjashouto@gmail.com introduction ventilator-associated pneumonia (vap) is one of the most common infections found in the intensive-care unit (icu). a study by aly et al.1 in a hospital icu, showed vap as the most common nosocomial infection. this pneumonia, becomes important due to its association to increased length of hospital stay, increased costs, and increased mortality.2 chung et al.3 explained that the most common bacteria causing pneumonia in hospitals were acinetobacter spp., pseudomonas aeruginosa, staphylococcus aureus, and klebsiella pneumoniae. there is no “gold standard” method to determine accurately the cause of pneumonia in the icu, so that selection and use of antibiotics therapy for its management is based on empirical use.4 whereas development of bacterial resistance to antibiotics which have a multifactorial cause has shown to have high correlation to irrational use of antibiotics.5 the data which is not integrated in hospital has made the correct prescription of drugs becoming difficult and thus may lead to irrational use of drugs in management for vap. the aim of this study was to identify the bacteria pattern of vap patients in dr. hasan sadikin general hospital. methods a descriptive study was carried out based on althea medical journal. 2016;3(2) 196 amj june 2016 medical records of vap patients in the icu of dr. hasan sadikin general hospital, bandung during the period january–june 2014. the study was conducted after obtaining approval from the health research ethics committee of the faculty of medicine, universitas padjadjaran and dr. hasan sadikin general hospital. the study population was all medical records of patients who suffered nonspecific pneumonia during their stay in the icu, and the sample to be examined was taken based on total sampling. the inclusion criterion of this study was the medical records of patients who had a diagnosis of vap, either as primary diagnosis or additional diagnosis. the exclusion criteria were patients with respiratory infections other than vap before admission to the icu, and whose laboratory test results were neither complete nor available. after having determined the samples, it was required to gain access to the database of the clinical pathology laboratory of dr. hasan sadikin general hospital, bandung to observe data of microbiological culture results and antibiotics susceptibility testing of patients’ sputum. then, the collected data were analyzed in form of tables and percentages by using a computer program. results there were 35 patients with unspecified pneumonia hospitalized in the icu of dr. hasan sadikin general hospital in the period january–june 2014. among them, were 10 patients diagnosed as vap. from those patients 44 sputum samples were taken for culture to be examined at different times, and in 43 were found microorganisms that later were cultured and tested for its susceptibility to antibiotics. most of the bacteria detected were gramnegative bacteria, namely acinetobacter baumannii, followed by pseudomonas aeruginosa and klebsiella pneumoniae. furthermore, achromobacter was known to be sensitive to piperacillin-tazobactam and ceftazidime. acinetobacter baumannii had ≥ 50% sensitivity to amikacin, cotrimoxazole, or tigecycline. while, burkholderia cepacia was found only fully sensitive to cefepime. enterobacter cloacae was found only sensitive to tigecyclin. klebsiellap neumoniae was fully sensitive to ertapenem and cefmetazone; and showed a slight degree of resistance to amikacin, meropenem, and tigecyclin. pseudomonas aeruginosa had the lowest resistance against meropenem. serratia marcescens was fully sensitive to the fluoroquinolone class, carbapenem class, cefepime, and tigecycline. while staphylococci was only sensitive to cotrimoxazole, linezolid, moxifloxacin, tetracycline, tigecycline, and vancomycin (table 2). discussion incidence of vap is associated with the table 1 bacterial pattern of sputum cultures from 10 patients diagnosed with vap microorganisms found number of findings (n=43) percentage (%) gram-negative bacteria achromobacter 1 2.3 acinetobacter baumannii 18 41.9 burkholderia cepacia 1 2.3 enterobacter cloacae 2 4.7 klebsiella pneumoniae 7 16.9 pseudomonas aeruginosa 8 18.6 serratia marcescens 2 4.7 gram-positive bacteria staphylococcus aureus 1 2.3 staphylococcus haemolyticus 1 2.3 others candida sp. 2 4.7 althea medical journal. 2016;3(2) 197achmad faisal jundi, nurita dian kss, yanti mulyana: pattern of bacteria and its susceptibility of ventilatorassociated pneumonia patients in icu at dr. hasan sadikin general hospital, bandung table 2 pattern of sensitivity of microorganisms to antibiotics (%) of sputum cultures from patients diagnosed with vap (n=43) antibiotics gram-negative bacteria (90.6%) gram-positive bacteria (4.6%) others (4.6%) a ch ro m ob ac te r a ci n et ob ac te r ba u m an n ii b u rk h ol de ri a ce p ac ia e . c lo ac ae k . p n eu m on ia e p se u do m on as ae ru gi n os a se rr at ia m ar ce n ce n s st ap hy lo co cc u s au re u s st ap hy lo co cc u s h ae m ol yt ic u s ca n di da s p . aminoglycoside amikacin 0 66.7 0 0 71.4 37.5 75 gentamycin 0 19.4 0 0 28.6 25 0 0 aztreonam 0 0 0 0 28.6 31.3 0 β-lactam/ with adjuvant ampicillin-sulbactam 0 28 0 0 14.3 0 0 0 0 oxacillin 0 piperacillin-tazobactam 100 0 0 0 35.7 25 50 erythtromycin 100 0 fluoroquinolone ciprofloxacin 0 0 0 0 42.9 12.5 100 0 0 levofloxacin 0 5.6 0 0 57.1 12.5 100 0 0 moxifloxacin 100 carbapenem ertapenem 100 imipenem 0 0 meropenem 50 5.6 0 0 71.4 75 100 0 0 cotrimoxazole 100 50 0 0 42.9 0 0 100 100 linezolid 100 100 cephalosporin cefadroxil 0 cefazoline 0 0 0 0 28.6 0 0 0 0 cefepime 0 0 100 0 28.6 25 100 0 0 cefmetazone 100 0 cefoxitine 0 cefoperazone 50 0 0 cefotaxime 0 ceftazidime 100 0 0 0 28.6 25 0 0 0 ceftriaxone 0 0 0 0 28.6 0 50 0 0 cefuroxime 0 0 0 tetracycline 100 tigecycline 50 63.9 50 100 85.7 0 100 100 100 vancomycin 100 100 note: e. cloacae: enterobacter cloacae, k. pneumonia: klebsiella pneumoniae althea medical journal. 2016;3(2) 198 amj june 2016 use of ventilator and or endotracheal tube, particularly within the icu environment. the vap occurs 48–72 hours or more after installation of ventilators or intubation procedures.6 adequate and immediate antibiotic therapy is essential in the management of vap. porzecanski et al.7 explained about the adequate antibiotic therapy with the administration of at least one type of antibiotics in an appropriate dose, to sensitive organisms. selection and the use of antibiotics in management of vap should be based on the risk of developing drug resistance in microorganisms.8 moreover, the minimum duration recommended for the treatment of vap vary from 7–21 days depending on bacteria found which caused vap. the de-escalation method is also recommended for an antibiotics therapy, by giving early broad spectrum followed by narrowing the spectrum or decreasing the dose once the laboratory result identifying the bacteria is known. antibiotics need to be adjusted after bacterial culture and antibiotic susceptibility testing of specimens obtained from patients were revealed. the use of local antibiogram based on patterns of bacteria and its sensitivity to antibiotics is important in determining the initial selection of empiric therapy.6,9,10 this study found most of the bacteria that cause vap in icu of dr. hasan sadikin general hospital were gram-negative bacteria (90.6%), with the most common findings were acinetobacter baumannii (41.9%), pseudomonas aeruginosa (18.6%), and klebsiella pneumoniae (16.9%) (table 1). this was in accordance with the study conducted by aly et al.1 which showed the majority of microorganisms found in their research about nosocomial infections were gramnegative bacteria (68%), with most findings: pseudomonas aeruginosa (17%), acinetobacter baumannii (13%), klebsiella spp. (11%). the results of this study also determined the resistance of bacteria through the results of antibiotics susceptibility tests in the clinical pathology laboratory of dr. hasan sadikin general hospital, in the form of sensitivity patterns which are listed in table 2. amikacin, tigecycline, meropenem, and levofloxacin showed lower percentages of bacterial resistance in susceptibility tests; therefore they were recommended to be considered as empirical antibiotics therapy in patients with clinical diagnosis of vap. these findings, according to microbiology culture and antibiotics susceptibility tests, showed varied degrees of resistance to antibiotics. due to this, it was important to perform microbiological examination and antibiotics susceptibility tests on every patient with vap. the limitations of this study were the small scales used and the short period of time it was performed; thus it was considered inaccurate to know about the real state of the case. the recommendations that can be proposed from this study is to consider a further study with a larger scale and more comprehensive, so it can properly document the present circumstances, especially in dr. hasan sadikin general hospital. another limitation was the availability of data in hospitals, as well as neat and systematic documentation. it can be concluded that microorganisms causing infection in patients with diagnosis of vap in icu of dr. hasan sadikin general hospital are mostly gram-negative bacteria (90.6%). acinetobacter baumannii (41.9%), pseudomonas aeruginosa (18.6%), and klebsiella pneumoniae (16.9%) are the most common microorganisms found. references 1. aly ny, al-mousa hh, al asar el sm. nosocomial infections in a medicalsurgical intensive care unit. med princ pract. 2008;17(5):373–7. 2. hunter jd. ventilator associated pneumonia. postgrad med. 2006;82(965):172–8. 3. chung dr, song j-h, kim sh, thamlikitkul v, huang s-g, wang h, et al. high prevalence of multidrug-resistant nonfermenters in hospital-acquired ppneumonia in asia. am j respir crit care med. 2011;184(12):1409– 17. 4. marino pl. the icu book. 3rd ed. philadelphia: lippincott williams & wilkins; 2007. 5. van zanten arh, polderman kh. rational use of antibiotics in the icu: optimum efficacy for the lowest costs. in: vincent j-l, editor. yearbook of intensive care and emergency medicine 2005. new york:springer; 2005. p. 337–48. 6. niederman m, craven d. guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia. am j respir crit care med. 2005;171(4):388– 416. 7. porzecanski i, bowton dl. diagnosis and treatment of ventilator-associated pneumonia. chest. 2006;130(2):597–604. 8. garnacho-montero j, corcia-palomo y, althea medical journal. 2016;3(2) 199 amaya-villar r, martin-villen l. how to treat vap due to mdr pathogens in icu patients. bmc infect dis. 2014;14(1):135. 9. charles mvp, kali a, easow jm, joseph nm, ravishankar m, srinivasan s, et al. ventilator-associated pneumonia. australas med j. 2014;7(8):334–44. 10. morrow bm, argent ac, jeena pm, green rj. guideline for the diagnosis, prevention and treatment of paediatric ventilatorassociated pneumonia. s afr med j. 2009;99(4 pt 2):255–67 achmad faisal jundi, nurita dian kss, yanti mulyana: pattern of bacteria and its susceptibility of ventilatorassociated pneumonia patients in icu at dr. hasan sadikin general hospital, bandung althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 99 visual acuity of patients after neodymium:yttrium-aluminium-garnet laser at cicendo eye hospital in 2013-2014 lee pei yie,1 budiman,2 ihrul prianza prajitno3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine, universitas padjadjaran/national eye center cicendo eye hospital, bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: indonesia ranks the second highest in blindness worldwide. one of the factors that may cause blindness is posterior capsule opacification (pco), a secondary cataract that developed after cataract surgery. pco eventually leads to visual impairment. the common management for pco is neodymium:yttriumaluminium-garnet (nd:yag) laser posterior capsulotomy. it is an effective, non-invasive, and painless procedure. the aim of this study was to describe the visual acuity of pco patients after nd: yag laser posterior capsulotomy. methods: a descriptive study was conducted based on simple randomized secondary data from cicendo eye hospital, bandung from january 2013 to august 2014. results: out of 102 patients, 53 patients (51.96%) were male and 49 (48.04%) were females. the male to female ratio was 1:1. the maximum number of patients was at age group of 60−69 years (33.33%). sixty− nine patients (67.65%) presented mild or no visual impairment uncorrected visual acuity (ucva) postlaser. eighty-nine patients (87.25%) presented mild or no visual impairment best-corrected visual acuity (bcva) post-laser. generally, 94 patients (92.16%) showed improvement of visual acuity after nd:yag laser posterior capsulotomy. three patients (2.49%) were suffering from blindness ucva post-laser and 1 patient (0.98%) falls at blindness bcva post-laser respectively. conclusions: improvement of visual acuity is achieved after nd:yag laser posterior capsulotomy in pco patients. [amj.2016;3(1):99–102] keywords: nd:yag laser, posterior capsule opacification, visual acuity correspondence: lee pei yie, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282115211528 email: peiyielee@gmail.com introduction according to the world health organization (who), approximately 285 million people in the world are visually impaired. this includes 39 million people are blind and 246 million people are having low vision. globally, cataract is the second major cause of visual impairment, which occupied 33%.1,2 indonesia is the second country with the highest rate of blindness in the world, which is around 1.5 percent of the population, or 3.5 million people , who are listed as legally blind. cataract is an opacity of the crystalline lens of the eye or its capsule.3 to remove the opacification a cataract surgery is needed. however, there is a common complication for this surgery, the posterior capsule opacification (pco).4 the pco is a development of opacity or clouding at the posterior part of the capsule. it obstructs the light passage, and causes visual impairment. the incidence of pco around the world is 20% within a year after cataract surgery and 50% five years after surgery. the risk factors of pco are the type of lens and young age. some studies show the growth of the epithelial cells of young people is more than elderly.4 there is a simple and effective procedure, neodymium:yttrium-aluminiumgarnet (nd:yag) laser posterior capsulatomy, which is indicated to treat posterior capsule opacification. this nd:yag laser is focus at the center of the opacified posterior capsule, and an opening is formed, therefore the light can pass though the capsule, and lead to a clear vision.5 therefore, a study was conducted to describe the visual outcome of nd:yag laser posterior capsulatomy in posterior capsule opacification patients at cicendo eye hospital althea medical journal. 2016;3(1) 100 amj march 2016 from january 2013 to august 2014. methods a descriptive study was conducted and data collected from january 2013 to august 2014 by using the retrospective method at cicendo eye hospital bandung. the study population was the patients who were admitted to cicendo national eye hospital bandung with posterior capsule opacification and were treated with nd:yag laser posterior capsulatomy from january 2013 to august 2014. the samples were selected using the simple random sampling method. the samples were taken from the medical records with certain inclusion and exclusion criteria. inclusion criteria were such as the medical records of posterior capsule opacification patients with completed visual acuity data and completed with 1 week postoperative follow up. the medical records of posterior capsule opacification patients with eye diseases other than posterior capsule opacification or treated with operations other than nd:yag laser posterior capsulatomy were excluded from the study. the variables included gender, age, and visual acuity. thus, the patients were categorized into male and female. for the age group, the patients were categorized into age 0−9, 10−19, 20−29, 30−39, 40−49, 50−59, 60−69, 70−79, and 80−89 years old. meanwhile, the visual acuity of the patients was categorized according to the who visual acuity classification, no light perception, 0−˂0.02, 0.02−˂0.05, 0.05−˂0.1, 0.1−˂.03, 0.3−1. the study instrument was the medical records of posterior capsule opacification patients who were treated with nd:yag laser posterior capsulatomy at cicendo eye hospital from january 2013 to august 2014. furthermore, the medical records that met the inclusion and exclusion criteria were categorized into variables and calculated to obtain the percentage. data collected from the medical records included the gender, age, preoperative ucva, preoperative bcva, postoperative ucva, and postoperative bcva. then, the percentage of each variable in the total of patients was calculated. additionally, the information of patients taken from medical records was confidential to protect the patients’ privacy. results out of 102 patients, 53 patients (51.96%) were male and 49 (48.04%) were females. the male to female ratio was 1:1. the maximum number of patients was at the age group of 60-69 years, which occupied by 34 patients (33.33%). sixty-nine patients (67.65%) presented mild or no visual impairment uncorrected visual acuity (ucva) post-laser. eighty-nine patients (87.25%) presented mild or no visual impairment best-corrected visual acuity (bcva) post-laser. three patients (2.49%) were suffering from blindness ucva postlaser and 1 patient (0.98%) falls at blindness bcva post-laser respectively. generally, 94 patients (92.16%) showed improvement of visual acuity after nd:yag laser posterior capsulotomy. discussion the emergence of nd:yag laser in the management of pco, has improved the visual outcome of cataract surgeries. fifty three patients (51.96%) were males and 49 patients (48.04%) were females (table 1). the male to female ratio was 1:1. based on a previous study, there were 47 male patients (52.2%) and 43 females patients (47.8%), the male to female ratio was equal to 1:1, these results were the same as in this study. another study also showed almost similar sex ratio.6 this is due to the leading cause of blindness worldwide, that cataract occurs equally among male and table 1gender of patients who had undergone nd: yag laser posterior capsulotomy from january 2013 to august 2014. gender frequency % male 53 51.96 female 49 48.04 total 102 100.00 althea medical journal. 2016;3(1) 101 female, thus when routine cataract surgeries are performed, complications such as pco can also occur in equal proportions.7 the maximum number of patients was in the age group of 60−69 years (33.33%), the second was in the age group of 50−59 years (21.57%) with 22 patients, then in the age group of 70−79 years (16.17%) with 17 patients. a total 71.07% of patients were at the range of 50-79 years, this may due to these patients had consulted the ophthalmologist with age related cataract (table 2). based on a previous study, most patients (77.8%) were in the 41−80 years age range. it showed a wider age range, this was due to wider setting of age range (20 years) in the previous study, whereas this study applied a smaller age range (10 years) to show more accurate and precise results.7 at the same time, another previous study showed that the average age of patients was 76.49 years.8 after the treatment of nd: yag laser posterior capsulotomy, both number of patients in mild and no visual impairment of bcva and ucva were the highest numbers, which were 69 patients (67.65%) and 89 patients (87.25%) respectively. in general, 94 patients (92.16%) had significant improvement of vision outcome after nd: yag laser capsulotomy (table 3). based a on previous study, 97% patients were having improved visual acuity, which was higher than in this study, this was probably due to the threemonth follow-up after the nd: yag laser capsulotomy. meanwhile, the data available for this study was limited, which was one week follow-up after the nd: yag laser capsulotomy.9 based on another previous study, most of the patients (86%) showed improved visual acuity, which was lower than in this study (92.16%), but this may be due to table 2 age of patients who had undergone nd: yag laser posterior capsulotomy from january 2013 to august 2014. age (in years) frequency % 0−9 3 2.94 10−19 6 5.88 20−29 3 2.94 30−39 1 0.98 40−49 10 9.80 50−59 22 21.57 60−69 34 33.33 70−79 17 16.17 80−89 6 5.88 total 102 100.00 lee pei yie, budiman, ihrul prianza prajitno: visual acuity of patients after neodymium:yttrium-aluminiumgarnet laser at cicendo eye hospital in 2013-2014 table 3 ucva dan bcva 1 week pre-laser and post-laser ucva frequency (%) ucva bcva pre-laser post laser pre-laser post-laser nlp 0 0 0 0 0−˂0.02 0 0 0 0 0.02−˂0.05 12 (11.76) 3 (2.49) 7 (6.86) 1 (0.98) 0.05−˂0.1 14 (13.73) 4 (3.92) 7 (6.86) 2 (1.96) 0.1−˂0.3 38 (37.52) 26 (25.49) 25 (24.51) 10 (9.80) 0.3−1.0 38 (37.52) 69 (67.65) 63 (61.76) 89 (87.25) total 102 (100.00) 102 (100.00) 102 (100.00) 102 (100.00) note: *ucva=uncorrected visual acuity, *bcva=best-corrected visual acuity althea medical journal. 2016;3(1) 102 amj march 2016 the larger sample size, the 86% means 160 patients out of 200 patients.10 however, 3 patients (2.49%) were having bcva blindness and 1 patient (0.98%) was having ucva blindness respectively, even though they were treated with the laser. these non-improvements in vision outcome may be attributable to the presence of media opacities or other ocular pathology which were not detected earlier before the procedure. based on a previous study, 5 patients (5.6%) presented with visual acuity of blindness post laser procedure, which was higher than in this study, which probably means currently, indonesia can provide doctors with better skills, environments for better healing, or increase awareness of public the importance of eyes caring.7 due to lack of time and the great number of uncompleted medical records data may cause the limitations of this study. a few recommendations are suggested after conducting this study. the time assigned for data collection can be prolonged for the sake of adequate sample size. follow up by the patients after treatment should be demanding to assess the condition of recovery phase, since a lot of patients did not return to the hospital for a follow up in this study. a computerized storage of medical records will provide a lot benefit, such as saving space, easy to look for, neat and tidy. in conclusion, the improvement of visual acuity is achieved after the nd:yag laser posterior capsulotomy in pco patients at cicendo eye hospital from january 2013 to august 2014. references 1. who. visual impairment and blindness. 2013 [cited 2014 october 28]. available from: http://www.who.int/mediacentre/ factsheets/fs282/en/index.html. 2. vision 2020 australia. towards 2020. 2010 [cited 2014 october 28]. available from: http://www.vision2020australia. org.au/. 3. wormstone im, wride ma. the ocular lens: a classic model for development, physiology and disease. philos trans r soc lond b biol sci. 2011;366(1568):1190−2. 4. hashemi h, mohammadi sf, majdi m, fotouhi a, khabazkhoob m. posterior capsule opacification after cataract surgery and its determinants. iranian journal of ophthalmology. 2012;24(2):3−8. 5. khanzada ma, jatoi sm, narsani ak, dabir sa, gul s. is the nd:yag laser a safe procedure for posterior capsulotomy. pak j ophthalmol. 2008;24(2):73−8. 6. bari kn. nd:yag laser posterior capsulotomy and visual outcome. delta med col j. 2013;1(1):16−9. 7. ajite ko, ajayi ia, omotoye oj, fadamiro co. visual outcome of patients with posterior capsular opacificationn treated with nd:yag laser. jmmr. 2013;1(4):23−7. 8. hawlina g, olup bd. nd: yag laser capsulotomy for treating posterior capsule opacification. journal of the laser and health academy. 2013;2013(1):s34−s5. 9. gupta ml. visual benefits of nd yag laser capsulotomy study in south eastern rajasthan. int j biol med res. 2012;3(4):2507−14. 10. gregor vs. the sudy of complications of nd:yag laser capsulotomy. int j bioinformatics res. 2012;4(2):265−8. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 152 amj march 2016 correlation between oxygen saturation and hemoglobin and hematokrit levels in tetralogy of fallot patients farhatul inayah adiputri,1 armijn firman,2 arifin soenggono3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy and cell biology faculty of medicine universitas padjadjaran abstract background: hemoglobin and hematocrit levels increase in tetralogy of fallot (tof) but the oxygen saturation declines. reduced hemoglobin in circulating blood as a parameter of cyanosis does not indicate rising hemoglobin due to the ‘not-working’ hemoglobins that affect the oxygen saturation. increasing hematocrit is the result of secondary erythrocytosis caused by declining oxygen level in blood, which is related to the oxygen saturation. this study was conducted to find the correlation between oxygen saturation and hemoglobin and hematocrite levels in tof patients. methods: this study was undertaken at dr. hasan sadikin general hospital in the period of january 2011 to december 2012 using the cross-sectional analytic method with total sampling technique. inclusion criteria were medical records of tof patients diagnosed based on echocardiography that included data on oxygen saturation, hemoglobin, and hematocrite. exclusion criteria was the history of red blood transfusion. results: thirty medical records of tof patiens from dr. hasan sadikin general hospital bandung were included in this study. due to skewed data distribution, spearman correlation test was used to analyze the data. there was a significant negative correlation between oxygen saturation and hematocrit level (r= -0.412; p=0.024) and insignificant correlation between oxygen saturation and hemoglobin (r=-0.329; p= 0.076). conclusions: there is a weak negative correlation between oxygen saturation and hematocrite levels. [amj.2016;3(1):152–5] keywords: hematocrit, hemoglobin, oxygen saturation, tetralogy of fallot correspondence: farhatul inayah adiputri, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6285720471165 email: tijannisa@gmail.com introduction tetralogy of fallot (tof) is the most frequent disease found in patients with cyanotic congenital heart disease. nevertheless, not all tof patients experience cyanosis because it depends on the severity of the disease.1 cyanosis occurs due to several factors, including decreased pulmonary blood flow resulting in the obstruction of the pulmonary valve, known as pulmonary stenosis, making oxygen distribution to the tissue inadequate and increasing right to left shunt.2 in addition, another factor that may cause cyanosis is drastically reduced hemoglobin level in circulating blood that affects oxygen saturation.3 oxygen saturation indicates the amount of oxygen bound by hemoglobins in a percentage of maximum binding at the time of measurement. one of the variables that affect oxygen saturation is hemoglobin concentration. however, it is not sure whether there is a correlation between oxygen saturation and hemoglobin in tof. hematocrit increases in tof patients as a response to hypoxia. the oxygen delivery to tissues depends on many factors, particularly the total number of circulating erythrocytes, systemic arterial oxygen tension (pao2), oxygen saturation, oxygen-hemoglobin dissociation curve position, cardiac output, and regional blood flow.4,5 theoretically, rising hematocrit with declined oxygen saturation indicate increase in erythrocyte production to supply increased demand of oxygen in the tissue.5 it is postulated that there might be a correlation between oxygen saturation and hematocrit. this study aimed to find the althea medical journal. 2016;3(1) 153 correlation between oxygen saturation with hemoglobin and hematocrit levels in patients with tof. methods this study was performed in october 2013 through the use of secondary data, i.e. medical records. this study has been approved by the health reasearch ethics committee, faculty of medicine, universitas padjadjaran and dr. hasan sadikin general hospital bandung. the inclusion criterion in this study was medical records from patients with tetralogy of fallot diagnosed by echocardiography that includes information on hemoglobin, hematocrit, and saturation oxygen levels. the exclusion criteria were incomplete medical record and tof patients who received packed red cell transfusion. in this study, data were not classified by age or sex. from the medical records, we obtained data on oxygen saturation and hematologic examination (hemoglobin level and hematocrit level) in which the results of hematologic data were taken from the clinical pathology department of dr. hasan sadikin general hospital, bandung. oxygen saturation was measured using pulse oximeter by the examiner. oxygen saturation value collected was the first value noted in the medical record by the examiner. data were analyzed using statistical product and service solutions (spss) with a normality test by shapiro-wilk. since two of the variables did not have normal distribustion, spearman correlation test was then used. table 1 baseline characteristics of the subjects characteristics n (%) age 0-28 days 1 1-12 months 10 1-2 years 4 2-6 years 3 6-12 years 12 sex boy 14 girl 16 table 2 mean and standard deviation of the variables variable mean standard deviation oxygen saturation (%) 82.45 9.88 hemoglobin (g/dl) 15.55 11.34 hematocrit (%) 48 10.63 results there were thirty medical records of tof in dr. hasan sadikin general hospital bandung during the period of january 2011–december 2012 that were included in this study. one patient was excluded because he received packed red cell transfusion. the age range of the subjects when they first visited the hospital was very large. the youngest was 15 days old and the oldest was 12 years old. the average age of the samples was 4.44 years. the sample consisted of 14 boys and 16 girls. before the correlation was analyzed, data were tested for the the normality of their distribution using shapiro-wilk test. it was revealed that the data distribution of hematocrit was normal, but the data on oxygen saturation and table 3 spearman correlation test between oxygen saturation and hemoglobin and hematocrit levels hemoglobin (g/dl) hematocrit (%) r -0.329 -0.412 oxygen saturation p 0.076 0.024 n 30 30 note: r = correlation coefficient; p = p-value; n = sample size farhatul inayah adiputri, armijn firman, arifin soenggono: correlation between oxygen saturation and hemoglobin and hematokrit levels in tetralogy of fallot patients althea medical journal. 2016;3(1) 154 amj march 2016 hemoglobin level were not normal. data were then analyzed using bivariate analysis. most of the subjects were in 6–12 years old category. the mean for the oxygen saturation was low with the normal range of healthy children’s oxygen saturation of 96–100%.7 table 2 shows that the oxygen saturation correlated negatively with hemoglobin (r=0.329); however, the the correlation was not statistically significant (p>0,05). there was a significant correlation between the oxygen saturation and hematocrit (p<0.05). both correlative values revealed negative and moderate correlations. discussion the statistic results showed that oxygen saturation and hematocrit correlated inversely. this is in line with a study that reveals that the best correlation was obtained between oxygen saturation and hematocrit, r=-0.74.5 the increased hematocrit level due to secondary erythrocytosis usually occurs in cyanotic congenital heart disease (cchd) because of the physiological response when the tissue experiences hypoxia. patients experience hypoxemia due to reduced oxygenated blood which is represented as the oxygen saturation. consequently, this stimulates bone marrow to produce erythrocytes by first excreting erythropoietin from kidney. increased erythrocyte level, known as erythrocytosis, will increase red blood cell mass, hematocrit, and viscosity. this condition causes hyperviscosity in cyanotic congenital heart diseases, marked by increased hematocrit.4 iron deficiency anemia also becomes a preciptitating factor for hyperviscosity.9 finally, hiperviscosity can decrease blood flow to the tissue; thus, the amount of oxygen delivered to the tissue declines. furthermore, in tof patients, the pulmonary blood flow (pbf) decreases because of the anatomy malformation in the development of heart during pregnancy, i.e. pulmonary stenosis. it causes reduced perfussion to the tissue. the manifestation includes cyanosis, in addition to the rising of hematocrit.10 therefore, the inverse correlation between the oxygen saturation and hematocrit level in tetralogy of fallot was moderate in this study. clinically, the increased hemoglobin can decrease the degree of right to left shunt and systemic vascular resistance as well as increasing the pulmonary blood flow, oxygen transport to the tissue, and aortic oxygen saturation as the physiologic responses to cyanosis.11 thus, oxygen saturation often relates to hemoglobin as the compensation because decreased oxygen saturation will led to higher erythrocyte production to comply to the oxygen need. however, the statistical test results showed no correlation between oxygen saturation and hemoglobin level despite the fact that studies on cyanotic congenital heart diseases reveals that correlation between oxygen saturation and hemoglobin has the same pattern as the correlation between oxygen saturation and hematocrit.5 this means that there was a correlation between oxygen saturation and hemoglobin level albeit insignificant. in another study, cyanosis affects the rise in hemoglobin level but no significant change in oxygen saturation. the increased hemoglobin level will increase the oxygen capacity binding without any change in oxygen saturation and provide greater oxygen supply for the tissue. however, clinical manifestations, such as cyanosis, still exists in an even more severe state despite the clinical improvement in this phase. this is known as relative anemia phenomenon.3 this occurrs due to many factors. not all tof patients experience cyanosis or relative anemia. if cyanosis presents, the degree of cyanosis is different among patients depending on the severity of the obstruction pulmonary valve, the degree of right ventricular outflow tract obstruction (rvoto), and the status of the systemic vascular resistance relative to the degree of right ventricular obstruction.2 the ratio of pulmonary to systemic blood flow leads to patient’s condition, which can be fully saturated, cyanotic, or severely cyanotic.3 the irregular changes in oxygen saturation and hemoglobin level result in different degree of cyanosis. in conclusion, this study shows that tof oxygen saturation correlates negatively with hemoglobin and hematocrit levels. patient’s condition can be monitored and the cause of cyanosis, whether it is due to heart disease or not, can be determined using this correlation. further research on oxygen saturation, hemoglobin, and hematocrit levels as the parameters for selecting the best management for tof patients, either by surgery or blood transfusion, is needed. references 1. bailliard f, anderson rh. tetralogy of fallot. orphanet j rare dis. 2009, 4:2 althea medical journal. 2016;3(1) 155farhatul inayah adiputri, armijn firman, arifin soenggono: correlation between oxygen saturation and hemoglobin and hematokrit levels in tetralogy of fallot patients 2. qu jz. congenital heart diseases with right-to-left shunts. int anesthesiol clin 2004;42(4):59–72. 3. rudolph am, nadas as, borge wh. hematologic adjustment to cyanotic congenital heart disease. pediatricts. 1953;11: 454–464. 4. puspitasari f, harimurti gm. hyperviscoucity in cyanotic congenital heart disease. jurnal kardiologi indonesia. 2010;31:41–7. 5. haga p, cotes p, till j, minty b, shinebourne e. serum immunoreactive erythropoietin in children with cyanotic and acyanotic congenital heart disease. blood.1987;70(3):822–6. 6. soetjiningsih s. tumbuh kembang anak. jakarta: egc; 2007. 7. balfour-lynn djf, gringras p, hicks b, jardine e, jones rc, magee ag,, et al. bts guidelines for home oxygen in children. thorax. 2009;64(suppl 2):ii1–26. 8. adamson jw, longo dl. anemia and polycythemia. in: longo dl, fauci as, kasper dl, hauser al, jameson jl, loscalzo j. harrison’s principles of internal medicine. 18th ed. new york: mc graw hill; 2012. p. 450. 9. rose ss, shah aa, hoover dr, saidi p. cyanotic congenital heart disease (cchd) with symptomatic erythrocytosis. j gen intern med. 2007;22(12):1775–7 10. murphy pj. the fetal circulation. contin educ anaesth crit care pain. 2005;5(4):107–12. 11. beekman rh, tuuri dt. acute of hemodynamic effects of increasing hemoglobin concentration in children with right to left ventricular and relative anemia. j am coll cardiol. 1985;5(2 pt1):357–62. althea medical journal. 2016;3(3) 376 amj september 2016 bacterial resistance pattern to cephalosporin in patient with chronic osteomyelitis at dr. hasan sadikin general hospital bandung daniel christian fernandez,1 ghuna arioharjo utoyo,2 adhi kristianto suganli3 1faculty of medicine universitas padjadjaran, 2department of orthopaedic and traumatology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: chronic osteomyelitis remains difficult to treat and has a high rate of relapse after apparently succesful treatment. cephalosporin has been greatly used for the antibiotic intervention for patient with osteomyelitis. the objective of this study was to explore bacterial profile and its microbial resistance pattern of each generation of cephalosporin from patients with chronic osteomyelitis at dr. hasan sadikin general hospital. methods: a descriptive study was conducted to 39 medical records from patients with chronic osteomyelitis at dr. hasan sadikin general hospital that met both inclusion and exclusion criteria. the bacterial pattern and antimicrobial susceptibility test results were obtained from both medical record and laboratory database for five years, during the period of januari 2009 to december 2014. data of bacterial species, type of gram staining, and numbers of resistance isolates to antiobiotic were taken from the collected data and analyzed in form of frequency tabulation and percentages. results: as high as 43−52% of staphylococcus aureus isolates were resistant to all generation of cephalosporin. coagulase-negative staphylococci and streptococcus spp. showed resistance to cephalosporin as high as 29% and 67%, respectively. this study also discovered that 5 of 23 staphylococcus aureus isolates were methicillin-resistant staphylococcus aureus (mrsa). klebsiella pneumoniae showed a leading number of resistance pattern for both third and fourth generation of cephalosporin (77%). enterobacter cloacae showed highly resistance for both first and third generation of cephalosporin, between 57−86%. conclusions: there is the high resistance of all bacteria to cephalosporin among chronic osteomyelitis patients. [amj.2016;3(3):376–81] keywords: antimicrobial resistance, cephalosporin, chronic osteomyelitis correspondence: daniel christian fernandez, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285276077912 email: danielchristianfernandez@gmail.com introduction chronic osteomyelitis is one of the most challenging and expensive diseases to treat, despite advances in antibiotics and new operative intervention techniques.1 specific diagnostic strategies are ill-defined and lack of prospective evidence. it is difficult to detect the acute phase symptoms of osteomyelitis, therefore, it is more likely to treat the patient when the disease progresses to the chronic phase.2 the gold standard to establish a diagnosis remains by a bone culture, but falsenegative rates are reported as high as 40%.3 the invasive procedure has to be conducted to take the sample for microbial culture, and it is more likely having a delay since it is commonly taken during surgical procedure e.g adjacent tissue reconstruction, drainage, and repair. as the result, the patient is given an empiric antibiotic treatment before knowing the etiological agent for the disease. studies showed that patient receiving antibiotic regimen without bone culture-guidance is more likely to have worst outcome than those with any bone culture-guided antibiotic regimen.4 in the antibiotic era, chronic osteomyelitis remains difficult to treat and has a high rate of relapse after apparently succesful treatment.1,3 since it has the same characteristic as penicillin for antimicrobial treatment in osteomyelitis, cephalosporin has been greatly used for the antibiotic intervention to kill bacteria that infect the patient with osteomyelitis.5,6 klebsiella pneumoniae, as one of the etiological agents of chronic osteomyelitis, was reported to be resistant as high as 44% to third generation of cephalosporin.7 in the althea medical journal. 2016;3(3) 377 united states, patients with the infection due to antibacterial-resistance organism, has a higher cost of treatment compared to patients with antibacterial-susceptible organism.8 the increase of bacterial resistance gives a great influence on mortality rate, substantial cost of the treatment, and the length of stay in hospital.9,10 the objective of this study was to explore bacterial profile and its microbial resistance pattern of each generation of cephalosporin from patients with chronic osteomyelitis at dr. hasan sadikin general hospital, bandung, indonesia. methods the descriptive design was chosen to accomplish this study that was performed at dr. hasan sadikin general hospital. the population of the study was taken from all patients’ medical records which had been diagnosed as having osteomyelitis and admitted to hospital for five years during the period of januari 2009 to december 2014. the inclusion criterion of this study was all patient medical records admitted to dr. hasan sadikin general hospital for the first time and diagnosed to have chronic ostemyelitis, either as primary diagnosis or additional diagnosis. the exclusion criteria of this study were chronic osteomyelitis patients without complete nor available antimicrobial susceptibility testing result. the data collection process was divided into two procedures.the first procedure was gathering all the primary information about patient’s demographic profile with chronic osteomyelitis. the first procedure was taken from digital medical record database with disease group categories: chronic osteomyelitis (diagnosis code: m86.6), according to international classification of diseases (icd) 10. after getting the lists of patient and medical record number, full set hard copies of each patient’s medical record was taken and evaluated for inclusion criteria. the second procedure was matching the first admission of patient with the date of the sample sent to laboratory for antimicrobial susceptibility testing from laboratory database system. from januari 2009 to december 2014, there were 332 patients with chronic osteomyelitis who had been admitted to dr. hasan sadikin general hospital. among them, there were only 98 patients with chronic osteomyelitis, which had complete medical record. from 98 patients with complete medical record, there were only 39 patients who had antimicrobial daniel christian fernandez, ghuna arioharjo utoyo, adhi kristianto suganli: bacterial resistance pattern to cephalosporin in patient with chronic osteomyelitis at dr. hasan sadikin general hospital bandung figure 1 the study procedure chart althea medical journal. 2016;3(3) 378 amj september 2016 susceptibility testing result, in concordance with first admission of patient. there were 67 bacteria identified from the 39 patients with chronic osteomyelitis (figure 1). data of bacterial species, types of gram staining, numbers of resistance isolates to antiobiotic were taken and analyzed in form of frequency tabulation and percentages. this study was conducted with the ethical standard approval from both faculty of medicine universitas padjadjaran and dr. hasan sadikin general hospital, with ethical letter no. lb.04.01/a05/ec/312/vii/2015. results the distribution of bacteria isolated from chronic osteomyelitis was described in table 1. in this study, the most gram-positive bacteria isolated were staphylococcus aureus and the most gram-negative bacteria isolated were klebsiella pneumoniae. table 2 shows the number of bacteria as the etiology of chronic osteomyelitis with the antimicrobial susceptibility testing. based on the result, almost all bacteria were resistant to cephalosporin group. cephazoline, as a part of first generation of cephalosporin, had a high range of resistance pattern for both gram-positive and gram-negative bacteria, with a value between 29−86%. as high as 86% of enterobacter cloacae were resistant to cephazoline and had the highest resistance pattern compared to any bacteria to the first generation of cephalosporin. cefadroxil, which was tested only to grampositive bacteria, had a range of resistance between 13−33%. meanwhile, the second generation of cephalosporintested only for the gram-positive bacteria, showed both cefoxitin and cefuroximehave resistance value of aprroximately 48% and between 29−48% respectively. in third generation of cephalosporin, there were ceftriaxone, ceftazidime, and cefotaxime that were tested for both gram-positive and gram-negative bacteria. ceftriaxone had a high pattern of resistance, with a value range between 29−77%. ceftazidime had the same high resistance pattern as ceftriaxone, with a value range between 29−77%. meanwhile, there were only slight differences of resistance pattern between ceftriaxone and ceftazidime found in gram-negative bacteria. even though cefotaxime had an absence of resistance pattern for the major etiological bacteria, italso had the highest resistance pattern for the minor etiological bacteria, both gram-positive and gram-negative, with a value range between 33−67%. cefoperazone and cefotaxime, as parts of third generation of cephalosporin tested only for gram-positive bacteria, had high class of resistant pattern, with value range between 29−67% and 33−35%, respectively. in fourth generation of cephalosporin, cefepime used to test the resistance pattern of bacteria for both positive and negative bacteria, showed a high resistance pattern, with a value range between 29−77%. table 1 bacteria isolated from 39 patients with chronic osteomyelitis bacteria numbers of isolates (n=67) percentages (%) gram-positive staphylococcus aureus 23 34.3 coagulase-negative staphyloccocus 7 10.4 streptococcus spp. 3 4.4 gram-negative enterobacter cloacae 7 10,.4 escherichia coli 5 7.4 klebsiella pneumoniae 9 13.4 morganella morganii 2 2.9 proteus mirabilis 3 4.4 pseudomonas aeruginosa 6 8.9 serratia marcescens 2 2.9 althea medical journal. 2016;3(3) 379 table 2 percentage resistance of bacteria causing chronic osteomyelitis antibiotics s. a u re u s (n = 2 3 ) c o a gu la se -n e ga ti ve ta p h yl o co cc u s (n = 7 ) st re p to co cu s sp p (n = 3 ) k . p n e u m o n ia e (n = 9 ) e . c lo a ca e (n = 7 ) p. a e ru gi n o sa ( n = 6 ) e . c o li (n = 5 ) p ro te u s m ir a b il is (n = 3 ) m . m o rg a n ii (n = 2 ) se rr a ti a m a rc e sc e n s (n = 2 ) %r %r %r %r %r %r %r %r %r %r β-lactam/ with adjuvant amoxicillin-clav 1(4.3) 4(44.4) 3/6 1/3 2/2 ampicillin-sulbactam 3(33.3) 4(57.1) 5/6 5/5 1/3 2/2 2/2 oxacillin 6(26.0) piperacillin-tazobactam 3(13.0) 5(55.6) 2(28.5) 1/3 cephalosporin cefadroxil* 3(13.0) 1/3 cefazoline* 10(43.4) 2(28.5) 2/3 4(44.4) 6(85.7) 3/6 1/5 1/3 1/2 2/2 cefoxitine** 11(47.8) cefuroxime** 11(47.8) 2(28.5) 1/3 cefoperazone*** 11(47.8) 2(28.5) 2/3 ceftriaxone*** 12(52.1) 2(28.5) 2/3 7(77.8) 5(71.4) 2/6 2/5 2/3 ceftazidime*** 12(52.1) 2(28.5) 2/3 7(77.8) 4(57.1) 3/6 2/5 1/3 1/2 cefixime*** 8(34.7) 1/3 cefotaxime*** 2/3 2/6 1/3 cefepime**** 11(47.8) 2(28.5) 2/3 7(77.8) 2(28.5) 2/6 1/5 2/3 carbapenem imipenem 11(47.8) 2(285) 1/6 meropenem 12(52.1) 2(28.5) 1(11.1) 1/6 aminoglycoside amikacin 2(22.2) gentamycin 10(43.4) 2(28.5) 6(66.7) 3(42.8) 4/6 1/5 2//3 1/2 tetracyclins tetracyclin 3(13.0) 2/3 tigecyclin 2(22.2) 6/6 3/3 2/2 macrolides erythromycin 10(43.4) 1(14.2) 1/3 oxazolidonones linezolid 1(4.34) fluoroquinolone ciprofloxacin 10(43.4) 3(42.8) 2/3 6(66.7) 3(42.8) 3/6 4/5 2/3 2/2 levofloxacin 10(43.4) 2(28.5) 5(55.6) 3(42.8) 3/6 3/5 1/3 1/2 moxifloxacin 3(13.0) 1(14.2) folate pathway inhibitors cotrimoxazole 7(30.4) 1(14.2) 2/3 6(66.7) 3(42.8) 2/6 2/5 2/3 note: *first generation cephalosporin; **second generation cephalosporin; ***third generation cephalosporin; ****fourth generation cephalosporin; %r is percentage of resistance result, for those samples ≤ 6 total resistance/total test is used daniel christian fernandez, ghuna arioharjo utoyo, adhi kristianto suganli: bacterial resistance pattern to cephalosporin in patient with chronic osteomyelitis at dr. hasan sadikin general hospital bandung althea medical journal. 2016;3(3) 380 amj september 2016 discussions chronic osteomyelitis, though uncommon, causes serious morbidity such as permanent disability, paralysis, and rarely death. management of this disease can be challenging for many physicians, mainly due to an unfamiliarity and poor evidence base.11 despite the treatment, diagnosing chronic osteomyelitis faces a dilemma of the accepted range of time to give an empirical antibiotic treatment before conducting the invasive procedure to take sample for culture test. the exposure of culture-nonguided antibiotic seems to increase the resistance pattern of bacteria. more recent study showed that the increased bacterial resistance result suggested the changing of the microbiology of this disease.12 this study discovered that infection caused by gram-positive bacteria was relatively proportional compared to gram-negative bacteria (49% versus 51%). staphylococcus aureus was found in 23 isolates or over one third of microbial culture. as comparison, recent studies showed that staphylococcus species was the most common pathogen responsible for osteomyelitis.12-14 staphylococcus aureus is the typical pathogen responsible for both acute and chronic ostemyelitis, and it has great potential to develop antimicrobial resistance and virulence factor expression, regardless of patient’s immune status. due to its high virulence, staphylococcus aureus may cause several complications, from localized superficial infection to the most severe forms of bacteremia, such as septic arthritis, endocarditis, and septic shock syndrome. this situation becomes more complex due to high incidence of methicillinresistant staphylococcus aureus (mrsa).14 this study also discovered that 5 of 23 isolates staphylococcus aureus were methicillinresistant staphylococcus aureus (mrsa). methicillin-resistant staphylococcus aureus (mrsa) appears to be biologically succesful and commonly causes severe soft tissue infections, complicated by musculoskeletal involvement in some cases.11 almost half of staphylococcus aureus isolates were resistant to all generation of cephalosporin, between 43−52%, followed by coagulase-negative staphylococci and streptococcus spp. with 29% and 67% of overall percentage resistance, respectively. it also showed that staphylococcus aureus was more susceptible to penicillin with adjuvant. as predicted from a recent study by tuchscherr et al.15, it showed that the majority of beta-lactam group lose activities against staphylococcus aureus. klebsiella pneumoniae and enterobacter cloacae were the first and second most common gram-negative bacteria found in cultures with 13.4% and 10.4%, respectively. gramnegative bacteria have grown in importance as causative agents due to the increasing number of orthopaedic surgeries related to fractures with the use of implants.16 as used in recent study by kevin et al.17, 10% of resistance pattern were classified as the low resistance pattern, and 10% or more of resistance pattern were termed as high resistance pattern. this resistance classification was used to identify the degree of the resistance pattern. based on the study, klebsiella pneumoniae showed the leading number of resistance pattern for both third and fourth generation of cephalosporin with a value of approximately 77%. enterobacter cloacae also showed highly resistance pattern for both first and second generation of cephalosporin, with a value range between 57−86%. as comparison, recent study by kronenberg et al.18 also showed the increased resistance pattern of gram-negative pathogen to the extended spectrum of cephalosporin (third and fourth generation). the limitation of this study was the small range of population involved with short period of time to accomplish the study. it is recommended to perform a study with larger scale of population which involves many hospital around the district and more comprehensive method to get more accurate and reliable result as a current circumstances. the availability of medical documentation and antimicrobial susceptibility test results from laboratory was another limitation needed to be considered. the potential bias that can happen during this study was a selection bias of medical record. since after the first procedure, the study should gather detailed information in the full hand-writing medical record (e.g unreadable); this could potentially make a bias. however, the crosscheck combination between medical record data with antimicrobial susceptibility data in the laboratory database, greatly reduced this bias. detailed sorting, carefully date checking, and sequence of the test were the steps to eliminate the selection bias. in conclusion, high resistance to cephalosporin occurs almost in all bacteria, specifically in first, third and fourth generation of cephalosporin among patients with chronic althea medical journal. 2016;3(3) 381 osteomyelitis, at dr. hasan sadikin general hospital. due to high resistance pattern of the bacteria to cephalosporin, it is useful to consider the antimicrobial susceptibility test result as the major point for antibiotic treatment in chronic osteomyelitis. integrating and establishing patients’ clinical demographic data and their antibiogram in concodance to chronic osteomyelitis is a mandatory. furthermore, good communication between physian, laboratory staff, and pharmacist is also needed to generate a better patient’s outcome and proper medical documentation. references 1. spellberg b, lipsky ba. systemic antibiotic therapy for chronic osteomyelitis in adults. clin infect dis. 2012;54(3):393–407. 2. stoesser n, pocock j, moore ce, sona s, putchhat h, poda s, et al. the epidemiology of pediatric bone and joint infections in cambodia, 2007–11. j trop pediatr. 2013;59(1):36–42. 3. hake m, oh j, kim j, ziran b, smith w, hak d, et al. difficulties and challenges to diagnose and treat post-traumatic long bone osteomyelitis. eur j orthop surg traumatol. 2015;25(1):1–3. 4. kim p, rosenblum b. diagnosing osteomyelitis. podiatry management. 2014;33(6):99–102. 5. kasper dl, longo dl. osteomyelitis. in: kasper dl, longo dl, braunwald e, fauci as, hauser hl, jameson jl, editors. harrison’s principle of internal medicine. 16th ed.new york: mcgraw-hill companies, inc; 2005. p. 745–9. 6. hatzenbuehler j, pulling tj. diagnosis and management of osteomyelitis. american family physician. 2011;84(9):1027–1033. 7. johnson ap. surveillance of antibiotic resistance. phil trans r soc b. 2015;370(1670):20140080. 8. cosgrove se. the relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. clin infect dis. 2006;42(2):82–9. 9. de kraker mea, wolkewitz m, davey pg, koller w, berger j, nagler j, et al. clinical impact of antimicrobial resistance in european hospitals: excess mortality and length of hospital stay related to methicillin-resistant staphylococcus aureus bloodstream infections. antimicrob agents chemother. 2011;55(4):1598–605. 10. world health organization. antimicrobial resistance: global report on surveillance 2014. geneva: who; 2014. 11. brady ra, leid jg, calhoun jh, costerton jw, shirtliff me. osteomyelitis and the role of biofilms in chronic infection. fems immunol med microbiol. 2008;52(1):13– 22. 12. livorsi dj, daver ng, atmar rl, shelburne sa, white ac jr, musher dm. outcomes of treatment for hematogenous staphylococcus aureus vertebral osteomyelitis in the mrsa era. j infect. 2008;57(2):128–31. 13. gogia js, meehan jp, di cesare pe, jamali aa. local antibiotic therapy in osteomyelitis. semin plast surg. 2009;23(2):100–7. 14. jorge ls, chueire ag, rossit arb. osteomyelitis: a current challenge. braz j infect dis. 2010;14:(3):10–5. 15. tuchscherr l, kreis ca, hoerr v, flint l, hachmeister m, geraci j, et al. staphylococcus aureus develops increased resistance to antibiotics by forming dynamic small colony variants during chronic osteomyelitis. j antimicrob chemother. 2016;71(2):438–48. 16. gomes d, pereira m, bettencourt af. osteomyelitis: an overview of antimicrobial therapy. braz j pharm sci. 2013;49(1):13– 27. 17. holvoet k, sampers i, callens b, dewulf j, uyttendaele m. moderate prevalence of antimicrobial resistance in escherichia coli isolates from lettuce, irrigation water, and soil. appl environ microbiol. 2013;79(21):6677–83. 18. kronenberg a, hilty m, endimiani a, muhlemann k. temporal trends of extended-spectrum cephalosporinresistant escherichia coli and klebsiella pneumoniae isolates in inand outpatients in switzerland, 2004 to 2011. euro surveill. 2013;18(21).pii:20484 daniel christian fernandez, ghuna arioharjo utoyo, adhi kristianto suganli: bacterial resistance pattern to cephalosporin in patient with chronic osteomyelitis at dr. hasan sadikin general hospital bandung althea medical journal. 2016;3(4) 562 amj december 2016 effect of spondias dulcis leaves infusion on glucose transport rate through rat intestine epithelium cell membrane krisna destia,1 anna martiana,2 sylvia rachmayati3 1faculty of medicine universitas padjadjaran, 2department of biochemistry faculty of medicine universitas padjadjaran, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: nowadays, people consume herbal remedies made from plants which are believed to be able to relieve certain symptoms and restore normal metabolic functions. golden apple (spondias dulcis) leaf has the potential to lower blood glucose. the purpose of this experiment was to observe the anti–hyperglycemic effect of s. dulcisleaves infusion on glucose transport rate through intestinal mucosal membrane of wistar rats. methods: an experimental study was conducted from october 2013 to november 2014. nine male wistar rats were selected aged 12–16 weeks, weighted 250–400 grams, healthy, actively moving, and had never been used in experiments. the rats were anesthetized, cut open and given three kinds of treatments: three kinds of glucose solutions were flowed through the intestinal tract using in situ perfusion method. samples obtained from the rat’s intestine were measured with a spectrophotometer to obtain glucose rate transported through intestinal membrane from every treatment. the results of condition 1 and 2, and condition 1 and 3 were then compared. results: the means of glucose transported through rat intestines epithelium cell membrane were 6.43 mg/ dl, 9.40 mg/dl and 9.81 mg/dl. statistic test result showed there was no significant difference on the glucose transported in every treatment. conclusions: glucose absorption rate in rat intestine doesnot decrease after they are given s. dulcis leaves infusion. therefore, this experiment concludes that s. dulcis leaves do not affect the glucose transport rate in rat intestines epithelium cell membrane. [amj.2016;3(4):562–5] keywords: antihyperglycemic effect, glucose transport rate, spondias dulcis leaves. correspondence: krisna destia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281573871018 email: krisna.destia@gmail.com introduction for centuries, people consume herbal remedies made from plants which are believed to have certain effects that are able to relieve certain symptoms and restore normal metabolic functions and balance.1 besides the nutritional values, herbs also have low toxicity and economic feasibility. in the last few decades the demand in studies of plants has increased due to people’s awareness of the benefits. golden apple (spondias dulcis forst. syn. or spondiascythereasonn.) is a native plant in melanesia and polynesia. although commonly used as a food source, it is also used as a remedy for diarrhea, eye infection,2 itchiness,3 sore throat, antidote, and internal ulceration. a study concluded s. dulcis contains a lot of phytochemicals with many pharmacological activities. one function of s. dulcis less explored is as an antihyperglycemic agent. the photochemical responsible for the effect is thought to be flavonoid.4 flavonoid is a chemical substance commonly found in plants which are known to have an antihyperglycemic effect. the mechanism of action is by inhibiting sodium-glucose linked transporter 1 (sglt1), protein transporter of intestinal membrane which plays a role in the active transport of glucose.5,6 by inhibiting glucose entering the bloodstream, the glucose in the blood is used first without the additional glucose from food intake and therefore lowers the blood glucose level. an invitro study in 2010 has proved althea medical journal. 2016;3(4) 563 thatleaves of the plant have shown antihyperglycemic activity. however, there are no further studies to ensure the effect on living organisms. therefore, an insitu experiment using wistar rats as the objects was conducted. the purpose of this experiment was to observe the antihyperglycemic effect of s. dulcisleaves on glucose transport rate through wistar rats’ intestinal mucosal membrane. this study might be a model and early step for future experiments regarding the development of herbal remedies for treating hyperglycemia patients, or even a prevention of people with risk factors from developing hyperglycemia. methods this study was a laboratory experimental study, performed during the period of october 2013 to november 2014. the experiment itself was held at the biochemistry laboratory, universitas padjadjaran and reviewed by the health research ethics committee, faculty of medicine universitas padjadjaran. the objects used were male wistar rats aged 12–16 weeks , weighted 250–400 grams, healthy and actively moving, and have not been used in any other experiments. the rats were under observation for three months and conditioned with dark/light cycle, and enough space and ventilation. they were fasted overnight for 9 hours before the experiment was conducted the next day. the sample size was calculated using federer formula. from these criteria, 9 rats were selected to be used in the experiment. the leaves were obtained from thespondiasdulcis tree at cinangka village, ujungberung. seven youngest leaves were selected from the sprout. next they were cut into small pieces, and then were added into an infusion pot containing aquadest with 1:1 ratio, and boiled for 15 minutes to create an infusion. furthermore, an experimental type of study was conducted since the data for glucose transport rate influenced by thes. dulcis leaves infusion were not available, and by doing the experiment we could observe and obtain the samples firsthand. this study used in situ perfusion method which enabled the intestine to function normally for 6–8 hours.7 the overnight fasted rats receivedketamin 0.4 ml by intramuscularanesthetic injection route. after half an hour, a rat was fixated onto a board. the abdomen was sterilized using an alcohol swab before cut open to gain access to their intestines. then a cannula was inserted at 10 cm under pylorus and another one at 25 cm from the first site. the intestine underwent three times washing of nacl 0.9% and blowing. then the cannulas were attached to the perfusion machine by elastic tubes. moreover, three kinds of treatments were executed: a 25 ml glucose solution was flowed for 60 minutes, a 25 ml glucose solution mixed with 1 ml s. dulcis leaves infusion for the next 60 minutes, and 25 ml glucose for the last 60 minutes. between each treatment, the intestine underwent three times washing and blowing. as a result,1 ml samples were obtained from the rat intestine every fifteen minutes at 0th, 15th, 30th, 45th, and 60th minute. krisna destia, anna martiana, sylvia rachmayati: effect of spondias dulcis leaves infusion on glucose transport rate through rat intestine epithelium cell membrane table means of glucose rat solution i (mg/dl) solution ii (mg/dl) solution iii (mg/dl) 1 1.84 16.67 8.52 2 7.72 2.94 14.34 3 2.69 10.04 12.12 4 10.57 9.14 8.29 5 1.61 6.87 5.99 6 11.32 10.14 11.32 7 10.57 11.10 5.98 8 7.72 10.12 14.34 9 3.82 7.54 7.40 means 6.43 9.40 9.81 note: solution i: glucose solution (mg/dl), solution ii: glucose solution and s. dulcis infusion (mg/dl), solution iii: glucose solution (mg/dl). althea medical journal. 2016;3(4) 564 amj december 2016 the measurement of glucose samples was performed by using the reagent kit. trichloroacetic acid (tca) 8.0% was used to deproteinize the samples, then they were centrifuged at 3000 rpm for 10 minutes. the supernatant was mixed with the glucose reagent and incubated in water at 37°c for 10 minutes. the absorbance rate of the sample was read using a spectrophotometer at 500 nm wavelength. the results of each treatment were then compared to know the effect of s. dulcis leaves on glucose transport rate in the rat intestine epithelium cell membrane. the data distribution was checked using the normality test kolmogorov-smirnov and homogeneity test, and was analyzed by the analysis of variance (anova) test using statistic software. the data distribution and homogeneity were considered normal if p-value> 0.05. the result of anova was considered statistically significant if the p-value< 0.05.8 results the means of glucose transport rate of solution i (glucose solution), solution ii (glucose solution and s. dulcis infusion), and solution iii (glucose solution) were 6.43 mg/dl, 9.40 mg/dl, and 9.81 mg/dl (table 1). after the data of glucose absorbance was obtained, the results were analyzed using statistic software. the kolmogorov-smirnov test showed that p-values of solution i, ii and iii were0.906, 0.819 and 0.832. the test of homogeneity of variances also showed that p-valuewas 0.505. the anova test showed thatp-valuewas 0.125. discussions after the data of glucose absorbance was obtained, the results were analyzed using statistic software. kolmogorov–smirnov test was used because the normality test result showed p-valuesof solution i, ii and iii were 0.906, 0.819 and 0.832 (p-value>0.05) meaning that the distribution of the data was normal. the test of homogeneity of variances also showed p-valuewas 0.505 (p-value> 0.05) which informed us of the homogeneity of the data. the anova test was used to test the significance of the means of the glucose transport rate. the result showed p-value was 0.125 (p-value> 0.05) meaning that the result was not significant statistically, or that the effect of s. dulcis was not significant to the glucose transport rate through the intestinal membrane. the result from the analysis showed there was no statistically significant difference between the glucose transport rate in solution i and ii. this result is different with the result of the in–vitro experiment from 2010. this may happen because of a few possibilities which are: (a) flavonoid is highly metabolized, which alters the structure and the antihyperglycemic capacity;9 (b) as flavonoid enters the body, it is recognized as a strange substance and modified in order to be excreted through urine or bile;9 (c) the antihyperglycemic effect of s. dulcis works on other processes of glucose metabolism;10 (d) the antihyperglycemic effect of s. dulcis is only effective after prolonged treatment; and/or there were human errors on the data collection, such as faulty reading in reagent mixing or in spectrophotometer results. there was also no statistical difference between glucose transport rate in solution i and iii, meaning that the effect of s. dulcis was reversible. this result may happen because the effect will be permanent only after long–term exposure, or that the effect is really temporary and only appears with the consumption. from this experiment, it can be concluded that s. dulcis does not have any significant effect on the glucose transport rate through intestinal mucosal membrane. further studies are still needed to know the antihyperglycemic mechanism of s. dulcis. this study had limitations which were: the experiment used only one type of dose; it also did not explore other things such as effective dose of s. dulcis for human consumption. with this conclusion, other experiments should be conducted with several different doses of s.dulcis to discover the effective doses of s. dulcis.another suggestion is to use alcohol instead of aquadest to pull the flavonoid content out of the leaves, since s. dulcis is an alkaloid. references 1. sumngern c, azeredo z, subgranon r, matos e, kijjoa a. the perception of the benefits of herbal medicine consumption among the thai elderly. j nutr heath aging. 2011;15(1 ):59–63. 2. rahmatullah m, ferdausi d, mollik mah, azam mnk, rahman m, jahan r. ethnomedicinal survey of bheramara area in kushtia district, bangladesh. am althea medical journal. 2016;3(4) 565krisna destia, anna martiana, sylvia rachmayati: effect of spondias dulcis leaves infusion on glucose transport rate through rat intestine epithelium cell membrane eurasian j sustain agric. 2009;3(3):534– 41. 3. rahmatullah m, ferdausi d, mollik a, jahan r, chowdhury m, haque w. a survey of medicinal plants used by kavirajes of chalna area, khulna district, bangladesh. afr j tradit complement alter med. 2010;7(2):91–7. 4. islam sma, ahmed kt, manik, wahid ma, kamal csi. a comparative study of the antioxidant, antimicrobial, cytotoxic and thrombolytic potential of the fruits and leaves of spondias dulcis. asian pac j trop biomed. 2013;3(9):682–91. 5. drozdowski la, thomson ab. intestinal sugar transport. world j gastroenterol. 2006;12(11):1657–70. 6. wright em, hirayama ba, loo df. active sugar transport in health and disease. j intern med. 2007;261(1):32–43. 7. volpe da. application of method suitability for drug permeability classification. aaps j. 2010;12(4):670–8. 8. dahlan s. statistik untuk kedokteran dan kesehatan. 3rd ed. jakarta: penerbit salemba medika; 2008. 9. de la rosa la, alvarez-parilla e, gonzalez-aguilar ga. fruit and vegetable phytochemicals: chemistry, nutritional value and stability. new jersey: wiley; 2009. 10. pamunuwa g, karunaratne d.n, waisundara v.y. antidiabetic properties, bioactive constituents, and other therapeutic effects of scoparia dulcis. evid based complement alternad med.2016; 2016(0):8243215. althea medical journal. 2016;3(3) 460 amj september 2016 health promotion activities in bandung public health centre (puskesmas) siti fairuz nadya,1 insi farisa desy arya,2 anggraini alam3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: health promotion is one of public health centre (pusat kesehatan masyarakat, puskesmas) essential health effort able to increase community health status. the purpose of this study was to describe health promotion activities in bandung public health centre (puskesmas). methods: this study was a cross sectional descriptive study using questionnaire as data collection instrument. the questionnaires were distributed to 24 puskesmas in bandung that were selected randomly using simple random sampling method. the process of questionnaire filling was performed by health promotion officer after informed consent was done. the variables were basic health promotion strategies, health promotion supports, health promotion in health facility and health promotion in community. results: most of the puskesmas showed that basic health promotion strategies, health promotion in health facility and health promotion in community were already done. support media that was mostly used was printed media while lectures was the most used method. human resources practitioner and coordinator of health promotion were dominated by mid level health workers consists of midwife and nurse. this study showed that the majority of health promotion coordinator had underwint training and certificate related to health promotion. the availability of funds were possessed by 13 out of 24 sample. while, health promotion guideline were possessed by less than half of the sample. conclusions: health promotion is done in almost all sample. there is lack of health promotion support in the form of the availability of funds and guideline of health promotion method. [amj.2016;3(3):460–8] keywords: health promotion, health promotion support, puskesmas correspondence: siti fairuz nadya, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: 085316488993 email: fairuz.nadya@gmail.com introduction public health centre (pusat kesehatan masyarakat, puskesmas) is the executive unit of a municipal (city or regency) health office which holds the primary role for providing health services, particularly stressing on promotive and preventive aspects. puskesmas is responsible for both essential and developmental health services. health promotion is an example of the former group able to contribute to increase the public level of health. according to who, health promotion is a process of increasing an individual’s capabilities to improve health.1-3 in 1980, an innovation known as “quit campaign” was introduced in australia and it was a nationwide campaign aiming to reduce smoking-related mortality. the campaign reduced the prevalence of smoking from 40% in 1983 to 15.9% in 2010 among adult men. it is thus implicitly concluded that health promotion leads to the improving of public health status. another example from australia also demonstrates that innovations in health promotion leads to fewer interventions on teenagers with cigarette and alcohol abuse.5 in indonesia, the success of health promotion leads to clean and healthy behaviors (perilaku hidup bersih dan sehat, phbs) in public. in bandung’s 2011 health profile, 65.64% households were reported to practise the behavior but interestingly there was no yearly increasing in the percentage of households practising such behavior. 6,7 indonesia has adopted the nationwide health insurance (jkn) per 1 january 2014. according to regulation of the president of the republic of indonesia number 12 year 2013 on the nationwide health insurance, althea medical journal. 2016;3(3) 461 every citizen is entitled to (1) primary level healthcare, consisting of general health care, (2) advanced level healthcare based on referrals and (3) other forms of health care as laid out by the minister of health. promotive and preventive efforts form the bulk of primary level healthcare. additionally, the nationwide health insurance adopts a system of capitation based on the number of applicants regarding to the type and number of provided healthcare services. in order to prevent medical personnels defaulting on the capitation fees, health promotion becomes top priority in an attempt to curb down costs on curative efforts.8 therefore, this study on the degree of health promotion done by various puskesmas in bandung in 2011 should help us to face the era of nationwide health insurance with its own set of demands on health promotion, challenges on managing the limited capitation fees and the relatively stagnant adoption of clean and healthy behavior by the people. the purpose of this study was to describe health promotion activities in bandung public health centre. methods this was a cross-sectional descriptive study which employed a simple randomized sampling method by choosing 24 out of 73 puskesmas in bandung. data collection were carried out from september to november 2014. this study had been approved by health research ethics committee of faculty of medicine of universitas padjadjaran. primary data were recorded using validated questionnaires based on the standardized protocol on health promotion in puskesmas published by the ministry of health republic of indonesia. the questionnaires contained questions on health promotion strategies in indonesia, supportive measures of such strategies, and health promotive activites both on healthcare centre premises and in the community. the questionnaires were self-administered by 24 officers from the aforementioned 24 puskesmas. informed consent was collected by the healthcare officers prior to filling out of the questionnaires. the same officers also filled out another informed consent form stating their willingness to participate in this study. respondents with incomplete questionnaires were later contacted. data analysis were carried out using microsoft excel 2010. results data were collected from 24 puskesmas in bandung. four variables in this study and the results for the first variable which was basic strategies of health promotion are presented in table 1. from four facets of basic strategy, optimising the environment was practised the least. additionally, the questionnaires revealed that not all of the primary health centres exercised all four strategies and there were centres practicing none. table 2 demonstrated that midwives contributed the most in the implementation of basic health promotional strategies while community health officers contributed the least. the public formed the main target when it came to empowerment and optimisation of the environment. public organizations were at the last of advocacy. there was not primary healthcare centres picked political organizations as their targets of advocacy. in the meantime, partnerships with religious elders were commonly practised. empowerment and optimisation of the environment were done mostly on a monthly basis. on the second variable, i.e. health promotion supportive instruments, there were 5 investigated subvariables. table 3 demonstrated that 6 puskesmas utilized the guideline-directed individual, group and masstargeted approaches. mass media also formed the most widely utilized health promotion instrument. out of 24 puskesmas, 13 had enough funds to carry out health promotional programs table 1 basic strategies of health promotion basic strategy frequency empowerment 21 environment optimisation 18 advocacy 19 partnership 22 althea medical journal. 2016;3(3) 462 amj september 2016 table 2 basic strategies of health promotion and their implementation basic strategy empowerment (n) environment optimisation (n) advocacy (n) partnership (n) implementor community health personnels 2 2 2 2 doctor 12 11 13 17 nurse 14 13 13 15 midwife 18 15 16 18 sanitarian 7 8 9 11 others 7 7 5 3 targets individual 17 11 family 17 9 community 19 17 state officials 6 entrepreneurs 6 political organizations 0 public organizations 14 professional groups 12 religious elders 15 independent public institutions 11 mass media 4 others 10 5 frequency daily 8 6 weekly 12 7 monthly 16 13 others 1 3 and 10 had a midwife(s) to coordinate such programs. over half of study samples had a health promotional efforts coordinator who had undergone training and gained certification. table 4 demonstrated that health promotion in the inpatient wards was the least in number among all forms of health promotion within the healthcare premises. table 5 showed that approaches to individuals and families formed the bulk of health promotion in the community. all types of health personnels contributed to these approaches with doctors, nurses and midwives contributing the most. discussion as demonstrated in table 1, more than half of the participating healthcare centres (puskesmas) had performed the basic strategies of health promotion. a study conducted by rezeki and mulyadi10 in puskesmas sei kijang, pelalawan regency demonstrated a significant association between health promotional strategies, i.e. advocacy, empowerment and optimisation of environment, and the adoption of clean and healthy behaviors (perilaku althea medical journal. 2016;3(3) 463siti fairuz nadya, insi farisa desy arya, anggraini alam: health promotion activities in bandung public health centre (puskesmas) table 3 health promotion supportive instruments (1) supportive instruments number method individual approach health education 23 counselling 20 others 0 group approach lectures 20 seminar 5 group discussions 15 snow-ball 0 buzz group 11 simulations 2 role play 2 others 0 mass approach lectures 19 talkshows 9 simulation 9 films 4 articles in the media 3 billboard 17 others 1 media printed 7 booklet 21 leaflet 12 flyer 17 flipchart 6 rubric 20 poster 18 photos 3 others 0 no assisting material electronic 7 television 3 radio 1 video 13 slides 2 film strip 1 althea medical journal. 2016;3(3) 464 amj september 2016 hidup bersih dan sehat, phbs). even though more than half of the participating healthcare centres have implemented the basic strategies of health promotion, the health profile of the city of bandung in 2011 only stated 65.64% adoption rate of clean and healthy behavior by the public and the rate was relatively stagnant for several years.7 this study also found that health promotional efforts are dominated by nurses and midwives classified as mid-level health workers. such observation had also been confirmed by the 2011 bandung health profile data.7 additionally, a study by lassi et al.11 from 1973-2012 showed that there was no difference in the degree of effectiveness of health service carried out by mid-level health workers and higher level health workers.11 table 3 demonstrates that only 2 health promotional officers have a degree in public health. in 2011, there were only 74 people working at various puskesmas in bandung focusing on public health. health profile data in 2011 also stated that there was only one public health officer for every 3 puskesmas in bandung.7 data on table 3 shows that 23 centres have coordinators on health promotion who previously has undergone training on health promotion and 16 of the coordinators have a certificate on health promotion. most of these coordinators were either midwives or nurses and this observation was already in accord with the regulations on health promotional officers qualifications.9 a study by yuniarti12 stated that the level of education, training, knowledge, skill and leadership capabilities of the officers influenced their performances.12 this study has revealed that more than half of the participating coordinators have already fulfilled the criteria on education and training. from table 3 it can be showed that on the table 3 health promotion supportive instruments (2) supportive instruments number others 2 no assisting material 0 media boards billboard 9 others 3 no assisting material 0 guideline 6 funds 13 human resources coordinators community health personnels 3 doctor 2 midwife 10 nurse 5 human resources coordinators sanitarian 0 others 4 qualitifcations d1 2 d3 17 s1 3 professional 2 training 23 certification 16 althea medical journal. 2016;3(3) 465siti fairuz nadya, insi farisa desy arya, anggraini alam: health promotion activities in bandung public health centre (puskesmas) table 4 health promotion in health facility (1) health promotion in health facility number registration sites type of information service flow 22 service type 18 map of clinic 10 problem info 16 regulations 19 media leaflet 11 poster 20 flyers 13 other media 7 polyclinic interview with officers 24 models flipchart 19 poster 14 leaflet 21 pictures 17 polyclinic models other media 7 information dispersal media in waiting rooms 24 contraception and mother-child health wards interview with patients 24 health information media 24 inpatient wards education 2 preventive readings 2 group-based health promotion 1 media in waiting rooms 2 centre yards information on clean and healthy behavior 21 family drug plants 16 health promotion on the walls 24 national health day information 9 health information at the canteen 5 health information at religious sites 5 althea medical journal. 2016;3(3) 466 amj september 2016 one hand, lectures are the preferred method when approaching the groups and the masses. harsono13 lengthily explained that utilizing animations during lectures influenced the effectiveness of the lectures. thus, health promotional officers should come up with innovations on improving the dispersal of health-related information. on the other hand, guidelines are the least favored method of health promotion. the collected data demonstrate that mass media dominates health promotion while board medias are the least utilized. from 18 out of 24 participated healthcare centres used electronic media. according to a study by pramono14, knowledge on clean and healthy behavior (is improved significantly by the use of electronic media. then, a study by rahmawati15 in 2007 stated that mothers with young children exhibited better improvements on knowledge and behavior after being taught using audiovisual media than conventional media (e.g., modules). another study by sweeney16 in 2012 also stated that technology presents an ideal means for healthcare centrees to improve public health status. thus, healthcare officers should be familiar in using technology to promote health and better disperse health information. table 3 also states that the availability of funds for health promotion-related activities are only found in 13 centres. currently, there is no standard on the amount of funds allocated for such activities.9 a previous study stated that universal health coverage can only be achieved if the government invests sufficient political table 4 health promotion in health facility (2) health promotion in health facility number laboratories health information media 11 drug storage rooms health information media 9 cashiers hospitality toward patients 12 specialist clinics counselling service 18 table 5 health promotional activites in the community health promotion in the community number performed activities individual approach 24 family approach 23 approach to public organizations 6 activities involving the community 10 others 4 parties involved health community personnels 3 doctor 20 nurse 22 midwife 22 sanitarian 16 others 14 althea medical journal. 2016;3(3) 467siti fairuz nadya, insi farisa desy arya, anggraini alam: health promotion activities in bandung public health centre (puskesmas) and monetary support for effective and widereaching programs.17 such recommendation should be implemented in indonesia, which has only recently adopted a nationwide health insurance, in order to achieve effective health promotion. table 4 indicates that out of the 24 participated centres, health promotion in inpatients wards are practised the least. such data are explained by the lack of such wards in the puskesmas.7 according to table 5, health promotion in the community focuses on the approaches to individuals and families. gogia and sachdev18 explained that home visits in the name of antenatal and neonatal care contributed to the reduction in neonatal mortality in southeast asia. besides that, health promotion in the community focuses on the approaches to individuals and families can be the solution of barriers to health care access among elderly.19 these further highlight the importance of health promotion in the community. this study has revealed that at least some form of health promotions had been done in most participating health centres. the lack of public health officers is tackled by the presence of nurses and midwives who have undergone training and earned certification on health promotion. limited funds and lack of established guidelines on health promotion form the primary shortcomings of health promotional efforts. the limitation of this study is primarily on the lack of cooperations by the respondents in filling out the questionnaires completely. furthermore, this study has not gone as far as investigating the quality of the health promotional materials presented both in the healthcare centres and in the community. further studies are required to investigate the performance of the health promotional officers. references 1. smith bj, tang kc, nutbeam d. who health promotion glossary: new terms. health promot int. 2006;21(4):340–5. 2. kementerian kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor 128/menkes/ sk/ii/2004 tentang kebijakan dasar pusat kesehatan masyarakat. jakarta: kementerian kesehatan republik indonesia; 2004. 3. kementerian kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 75 tahun 2014 tentang pusat kesehatan masyarakat. jakarta: kementerian kesehatan republik indonesia; 2014. 4. howat p, hallett j, kypri k, maycock b, dhaliwal s, mcmanus a. tobacco smoking in an australian university sample and implications for health promotion. prev med. 2010;51(5):425–6. 5. kementerian kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor 585/menkes/ sk/v/2007 tentang pedoman pelaksanaan promosi kesehatan di puskesmas. jakarta: kementerian kesehatan republik indonesia; 2007. 6. dinas kesehatan kota bandung. profil dinas kesehatan kota bandung tahun 2011. bandung: dinas kesehatan kota bandung; 2012. 7. presiden republik indonesia. peraturan presiden republik indonesia nomor 12 tahun 2013 tentang jaminan kesehatan. jakarta: republik indonesia; 2013. 8. hartono b. promosi kesehatan di puskesmas dan rumah sakit. 1st ed. jakarta: rineka cipta; 2010. 9. rezeki s, mulyadi a, nopriadi. strategi promosi kesehatan terhadap peningkatan perilaku hidup bersih dan sehat individu pada masyarakat perkebunan di wilayah puskesmas sei kijang kabupaten pelalawan. jurnal ilmu lingkungan. 2013;7(1):38–48. 10. lassi zs, cometto g, huicho l, bhutta za. quality of care provided by mid-level health workers: systematic review and meta-analysis. bull world health organ. 2013;91(11):824–33i. 11. yuniarti y, shaluhiyah z, widjanarko b. kinerja petugas penyuluh kesehatan masyarakat dalam praktek promosi kesehatan di dinas kesehatan kabupaten pati. jurnal promosi kesehatan indonesia. 2012;7(2):165¬–73. 12. harsono b, soesanto, samsudi. perbedaan hasil belajar antara metode ceramah konvensional dengan ceramah berbantuan media animasi pada pembelajaran kompetensi perakitan dan pemasangan sistem rem. jurnal pendidikan teknik mesin. 2009;9(2):71–9. 13. pramono ms, paramita a. peningkatan pengetahuan anak anak tentang perilaku hidup bersih dan sehat, dan penyakit menular melalui teknik kie berupa permainan elektronik. buletin penelitian sistem kesehatan. 2011;14(4 okt):311–9. 14. rahmawati i, sudargo t, paramastri i. althea medical journal. 2016;3(3) 468 amj september 2016 pengaruh penyuluhan dengan media audio visual terhadap peningkatan pengetahuan, sikap dan perillaku ibu balita gizi kurang dan buruk di kabupaten kotawaringin barat provinsi kalimantan tengah. jurnal gizi klinik indonesia. 2007;4(2):1–7 15. sweeney sa, bazemore a, phillips rl jr, etz rs, stange kc. a re-emerging political space for linking person and community through primary health care. am j prev med. 2012;42(6 suppl 2):s184–90. 16. coe g, de beyer j. the imperative for health promotion in universal health coverage. glob health sci pract. 2014;2(1):10–22. 17. gogia s, sachdev hs. home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review. bull world health organ. 2010;88(9):658–66b. 18. fitzpatrick al, powe nr, cooper ls, ives dg, robbins ja. barriers to health care access among the elderly and who perceives them. am j public health. 2004;94(10):1788–94. althea medical journal. 2016;3(2) 309 detection of enteropathogenic bacteria under fingernails of canteen workers at universitas padjadjaran, jatinangor nalinie nalammah nahenthran,1 imam megantara,2 ardini s. raksanagara3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: food poisoning is a major problem in indonesia as most people do not clean under their fingernails to remove bacteria. this study was designed to detect enteropathogenic bacteria under the fingernails of canteen workers in universitas padjadjaran, jatinangor. methods: a cross-sectional study was conducted from october−november 2014 at the faculty of medicine’s microbiology laboratory to detect enteropathogenic bacteria under the fingernails of canteen workers in universitas padjadjaran, jatinangor. based on the inclusion and exclusion criteria of the study, 30 canteen workers were selected by random sampling from three canteens. samples were collected from the fingernails of both the right and left hands by using a cotton swab. sixty specimens were cultured for identification of the enteropathogenic bacteria by using gram staining method and biochemical tests. results: the highest percentage of enteropathogenic bacteria found under the fingernails of canteen workers was klebsiella pneumoniae with a percentage of 45% followed by enterobacter aerogenes with a percentage of 25.7%, salmonella paratyphii with a percentage of 9.7%, e. coli with a percentage of 6.4%, and serratia sp, proteus mirabillis, klebsiella oxytoca and shigella sp. with a percentage of 3.2%. conclusions: the highest number of bacteria found under the fingernails of the canteen workers is klebsiella pneumoniae, followed by enterobacter aerogenes, salmonella paratyphii and e. coli which has potential to cause gastroenteritis if cross-contamination occurs between the fingernails and the food. [amj.2016;3(2):309–13] keywords: canteen workers, fingernails, klebsiella pneumoniae, resistance correspondence: nalinie nalammah nahenthran, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87726442964 email: nalinienn@gmail.com introduction the enteropathogenic bacteria usually inhabit the intestinal gut of humans and animals. these bacteria are regularly pathogenic and can cause disease in humans. genera like escherichia, shigella, salmonella, enterobacter, klebsiella, serratia and proteus are included in the enteropathogenic bacteria family.1 transmission of enteropathogenic bacteria is affected directly or indirectly through objects contaminated with feces and these include food, water, nails, and fingers, indicating the importance of faecal-oral human-to-human transmission. thus, food-handlers with poor personal hygiene are potential sources of infections of many enteropathogenic bacteria. food may be contaminated by foodhandlers who harbour and excrete intestinal enteropathogenic bacteria from their feces via their fingers to food processing, and finally to healthy individuals. the area beneath the fingernails harbours the most microorganisms and is the most difficult area to clean compared to other parts of the hand.2 the spread of infections obtained by external contact can be greatly reduced by hand washing. hand washing can cause a reduction between 12% and 40% of all gastrointestinal diseases and over 20% of all infections.3 unfortunately, most people do not wash their hands properly and do not use the correct methods of hand washing in their daily lives.4 this study was designed to detect enteropathogenic bacteria under the fingernails of canteen workers in universitas padjadjaran, jatinangor. methods this study was carried out from october− november 2014 at the faculty of medicine’s althea medical journal. 2016;3(2) 310 amj june 2016 microbiology laboratory. the entire study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. this study was a descriptive cross-sectional study and samples were obtained from under the fingernails of thirty canteen workers who were selected from three canteens, namely of the faculty of medicine, faculty of dentistry and faculty of pharmacy at universitas padjadjaran, based on the inclusion criteria that all subjects must be canteen workers working in canteens at universitas padjadjaran and should be involved in the preparation of food in the canteens. while the exclusion criteria were canteen workers with presence of trauma or injury under their fingernails and onychomycosis. the inform consent was given to the canteen workers before obtaining their samples. the hyponychium part of their fingernails was then swabbed with a sterile cotton bud and placed in tryptic soy broth as an enrichment media. the samples were brought to the laboratory for culturing on mac conkey agar and testing. sixty specimens from under the fingernails of the left hand and the right hand of each canteen worker were cultured and the presence of enteropathogenic bacteria was identified. enteropathogenic bacteria were identified through gram staining, microscopic exam and biochemical tests. the three biochemical tests performed were the kliger iron agar test (kia), motility indole urease test (miu) and citrate test. the data was presented in a table. the data of the presence of enteropathogenic bacteria were classified based on the type and frequency of bacteria detected under the fingernails. results the highest number of bacterial colony was found in the left hand with klebsiella pneumoniae as the most bacteria found in the hands (table 1). based on the total percentage of enterobacteriaceae that was isolated on the left hand, the highest isolated bacteria was klebsiella pneumoniae followed by enterobacter aerogenes, salmonella paratyphii, e. coli, shigella sp and serratia sp. the highest percentage of enterobacteriaceae isolated on the right hand was klebsiella pneumoniae, followed by enterobacter aerogenes, proteus mirabillis and klebsiella oxytoca (figure 1). discussion in this study, 12.9% of the 30 respondents were positive for enteropathogenic bacterial species comprising salmonella paratyphii (9.7%) and shigella sp (3.2%). in addition, other enterobacteriaceae like the klebsiella sp, enterobacter sp, e. coli sp, proteus mirabillis and serratia sp were also isolated from their fingernail contents. the presence of enteric bacteria under the fingernails of the canteen workers indicated faecal contamination as these bacteria are found in the gastrointestinal system. the presence of enteropathogenic bacteria such as salmonella paratyphii and shigella sp under the fingernails of the table 1 types and percentage of enterobacteriaceae isolated under the fingernails of canteen workers at universitas padjadjaran, jatinangor bacterial colony results of bacterial culture left (n=30) right (n=30) total (n=60) n % n % n % salmonella paratyphii 3 9.7 0 0 3 9.7 shigella sp. 1 3.2 0 0 1 3.2 e. coli 2 6.4 0 0 2 6.4 klebsiella pneumonia 10 32.2 4 12.9 14 45.1 klebsiella oxytoca 0 0 1 3.2 1 3.2 enterobacter aerogenes 6 19.3 2 6.4 8 25.8 serratia sp. 1 3.2 0 0 1 3.2 proteus mirabilis 0 0 1 3.2 1 3.2 total 23 74 8 25.7 31 100 althea medical journal. 2016;3(2) 311 canteen workers at universitas padjadjaran, jatinangor in this study was in agreement with the findings of other studies in the region and other parts of the country. however, the number of klebsiella pneumoniae isolated from under the fingernails of the canteen workers had the highest percentage compared to other enterobacteriaceae. as already known, klebsiella strains can be found in the respiratory tract and feces of about 5% of healthy adults and the bacteria become pathogenic only when they reach tissues outside of their normal intestine.1 a pathogen’s opportunity for infectivity depends upon its ability to survive on surfaces. most microorganisms and enteric pathogen that colonize the human intestinal tract have adapted to moist conditions. they either die or grow slowly in a dry environment.5 this explains why shigella sp, salmonella paratyphii and other enterobacteriaceae were found at a lower percentage under the fingernails of the canteen workers. however, according to a study conducted in michigan state university6, usa, klebsiella pneumoniae which is also called klebsiella aerogenes in some countries has a higher survival rate on the fingertips compared to other enteric bacteria. this is simply because klebsiella pneumoniae is also found in the normal flora of skin. human skin bacteria are adapted to a dryer existence and this ability may be one reason why klebsiella pneumoniae survive better on fingertips than other enteric bacteria like e. coli although klebsiella strains colonize the gastrointestinal tract primarily.5 nevertheless, the higher percentage of klebsiella pneumoniae found under the fingernails of the left hand compared to the right hand supported the notion of contamination by faecal bacteria due to ineffective hand washing of canteen workers where the usage of a nailbrush might have been abandoned. however, klebsiella pneumoniae plays a minimal role in causing food borne or water borne infections.1 klebsiella pneumoniae is an opportunistic pathogen frequently associated with nosocomially acquired infections of the respiratory tract such as acute bronchopneumonia, typical lobar pneumonia, chronic klebsiella pneumonia and urinary tract in compromised individuals. in a study conducted in cambodia12, klebsiella pneumoniae continues to be the second pathogen responsible for community acquired pneumonia in developing countries and asia. this bacteria is also characterized by its ability to produce adherence factors and acidic polysaccharide capsule that is an important virulence factor which confers resistance to antimicrobial peptides.7 thus, serious concerns should be given by the public health authorities in order to prevent outbreaks of infections and diseases caused by klebsiella pneumoniae in the community as there were figure 1 types and percentage of enterobacteriaceae isolated under the fingernails nalinie nalammah nahenthran, imam megantara, ardini s. raksanagara: detection of enteropathogenic bacteria under fingernails of canteen workers at universitas padjadjaran, jatinangor althea medical journal. 2016;3(2) 312 amj june 2016 high chances for the bacteria to be transferred into the food that was being served to the students. furthermore, in a study performed in malaysia5, it is proven that klebsiella pneumoniae can be transferred to vegetables through poor hygiene practices and improper handling of food. klebsiella pneumoniae is found to contaminate salad vegetables and fruit juices which has the potential to cause gastroenteritis. these reports show the possibility of the bacteria to survive on food, therefore causing infections especially to those who are immune compromised or has a higher susceptibility towards infection. the ability of the bacteria to form biofilm makes it even a more dangerous threat to the society as it possesses resistance towards antibiotics. it is known that certain strains of klebsiella pneumoniae produce a βlactamase enzyme which is an antibiotic degrading enzyme that is responsible to the reduced susceptibility of antibiotics to the biofilm produced by the bacteria.1,10 klebsiella pneumoniae has become typically resistant to extended-spectrum penicillin such as ampicillin, ticarcillin, and piperacillin and also to many cephalosporins due to the production of extended spectrum beta-lactamases (esbl).10 klebsiella betalactamases are usually susceptible to carbapenems, such as imipenem, and to betalactamase inhibitors, such as clavulanic acid, sulbactam and tazobactam.10 however, most recently, klebsiella bacteria have developed resistance to these class of antibiotics as well. when klebsiella pneumoniae produce an enzyme known as a carbapenemase, they are referred to as carbapenem-resistant klebsiella pneumoniae (crkp).13 this is considered a threat to the safety of the community because carbapenem antibiotics are often the last line of defense against gram-negative infections that are resistant to other antibiotics. on the other hand, enterobacter aerogenes, which was the second most enterobacteriaceae that was isolated under the fingernails, ferments lactose and causes a wide range of nosocomial infections which includes pneumonia and urinary tract infections when they reach tissues outside of their normal intestine such as the urinary tract and lungs.1 enterobacter aerogenes may be found living freely as well as in the intestinal tract. this explained the reason why enterobacter aerogenes was also found under the fingernails of the canteen workers at universitas padjadjaran, jatinangor. it is also known as an opportunistic pathogen. this is when normal host defenses are inadequate particularly in old age, in the terminal stages of other diseases, after immunosuppression, or ith indwelling venous or urethral catheters that can result in localized clinically important infections. the bacteria may reach the blood stream and cause sepsis.1 in the process of the study, one limitation was found which was the sample size used that was only 30. this was due to the cost of microbiological examinations and time constraint. therefore, the author was unable to use advanced analysis to make associations with the risk factors found in this study. it can be concluded that the highest number of bacteria found under the fingernails of the canteen workers at universitas padjadjaran, jatinangor is klebsiella pneumoniae, followed by enterobacter aerogenes, salmonella paratyphii and e. coli which has potential to cause gastroenteritis if cross-contamination occurs between the fingernails and the food. however, other enterobacteriaceae which are also part of the normal flora of the gastrointestinal system that incidentally cause diseases such as serratia sp, proteus mirabillis, shigella sp. and klebsiella oxytoca are also isolated under the fingernails of these canteen workers. this study may give an impression that there is a microbial contamination under the fingernails of the canteen workers at universitas padjadjaran, jatinangor that may cause public health problems references 1. brooks gf, carroll kc, butel js, morse sa. jawetz, melnick, adelbergs medical microbiology. 24th ed. new york: mcgrawhill companies; 2007. 2. andargie g, kassu a, moges f, tiruneh m, huruy k. prevalence of bacteria and intestinal parasites among food-handlers in gondar town, northwest ethiopia. j health popul nutr. 2008;26(4):451–5. 3. kim ej, pai aj, kang ne, kim wk, kim ys, moon hk, et al. the effects of food safety education on adolescents’ hand hygiene behavior: an analysis of stages of change. nutr res pract. 2012;6(2):169–74. 4. setyautami t, sermsri s, chompikul j. proper hand washing practices among elementary school students in selat sub-district, indonesia. j pub health dev.2012;10(2):3–20. 5. todd ec, greig jd, bartleson ca, michaels bs. outbreaks where food workers have been implicated in the spread of foodborne althea medical journal. 2016;3(2) 313 disease, part 6: transmission and survival of pathogens in the food processing and preparation environment. j food prot. 2009;72(1):202–19. 6. ryan kj, editor. sherris medical microbiology: an introduction to infectious diseases. 4th ed. new yorks: mcgraw-hill companies; 2004. 7. campos ma, vargas ma, regueiro v, llompart cm, albertí s, bengoechea ja. capsule polysaccharide mediates bacterial resistance to antimicrobial peptides. infect immun. 2004; 72(12):7107–14. 8. tumbarello m, spanu t, sanguinetti m, citton r, montuori, leone f, et al. bloodstream infections caused by e x t e n d e d s p e c t r u m β l a c t a m a s e producing klebsiella pneumoniae: risk factors, molecular epidemiology, and clinical outcome. antimicrob agents chemother. 2006;50(2):498–504. 9. bagian mikrobiologi fakultas kedokteran universitas padjadjaran. penuntun praktikum bagian mikrobiologi fakultas kedokteran universitas padjadjaran. jatinangor: bagian mikrobiologi fakultas kedokteran universitas padjadjaran; 2010. 10. pusapanadan s, afsah-hejri l, loo yy, nillian e, kuan ch, goh sg, et al. detection of klebsiella pneumoniae in raw vegetables using more probable number-polymerase chain reaction (mpn-pcr). international food research journal. 2012;19(4):1757– 62. 11. arnold rs, thom ka, sharma s, philips m, johnson jk, morgan dj. emergence of klebsiella pneumoniae carbapenemase (kpc)-producing bacteria. south med j. 2011;104(1):40–5. nalinie nalammah nahenthran, imam megantara, ardini s. raksanagara: detection of enteropathogenic bacteria under fingernails of canteen workers at universitas padjadjaran, jatinangor althea medical journal. 2016;3(4) 649 knowledge and attitude on febrile seizure among mothers with under-five children jihan alifa syahida,1 nelly amalia risan,2 vita murniati tarawan3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology faculty of medicine, universitas padjadjaran abstract background: febrile seizures frequently occur in children under 5 years old and usually create fear and anxiety among parents. poor understanding of febrile seizure among parents contributes to mismanagement of seizure. the objective of this study was to identify the knowledge and attitude on febrile seizure among mothers of under five children. methods: this descriptive community-based survey comprised of 96 mothers with under 5 children who were chosen through randomization. this survey was, conducted in hegarmanah village, jatinangor, west java, indonesia in october 2013. data were collected using a questionnaire and analyzed using frequency analysis. results: fifty nine respondents (61%) considered that high fever in their children will result in seizure and 63 mothers (65%) stated that this condition was a life-threatening situation which could lead to brain damage (50%) and paralysis (50%). there were some respondents who would manage seizure by shaking (27%) or holding the child tightly during seizure (22%) and putting spoon into the children mouth (59%). sixty respondents (62.5%) prevented febrile seizure by giving them coffee. conclusions: knowledge and attitude regarding febrile seizure is good, but the knowledge and attitude towards the outcome and what to do during febrile seizures occasion are still poor. [amj.2016;3(4):649– 54] keywords: attitude, children under five, febrile seizure, knowledge, mother correspondence: jihan alifa syahida, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81214660606 email: jihan_alifa@yahoo.com introduction febrile seizure (fs) is a common type of acute seizure occurred in children within one episode of high fever.1 it usually happens when the body temperature is above 38.4oc.1,2 febrile seizure is divided into two types, simple and complex febrile seizures. simple seizure is usually defined based on the following criteria: 1) takes less than 10–15 minutes and 2) generalized tonic-clonic, tonic, clonic or atonic. complex seizure is defined based on one or more of the following features: 1) a focal onset or showing focal deficit during seizure attack, 2) a duration longer than 15 minutes and 3) occur more than once during the first 24 hours.3 the onset of febrile seizure reaches its peak between the age of 18–22 months years and most cases occurred between 6 month–3 years of age.1,3 most febrile seizures occur in the first 24 hours of an illness.4 the most common disease that triggers a febrile seizure is ear infections of any cold or viral infection.5 a febrile seizure can be very frightening for parents.2 in consequence, parents’ ignorance and poor understanding about how to deal with seizure and their anxiety will lead to mismanagement of febrile seizure. knowledge on febrile seizure is improtant for parents, especially knowledge regarding febrile when it will occur, seizure characteristics, how to manage seizure, and how seizure can be prevented. febrile seizure does not usually last long; however, correct management can prevent complications such as head injury, mouth and teeth injury, and neck suffocation. parents also have to understand the right time to bring their children to the nearest health althea medical journal. 2016;3(4) 650 amj december 2016 facility when febrile seizure occurs. hence, the aim of this study was to identify the knowledge and attitude on this disease among mothers with under five children experiencing febrile seizure. methods this descriptive study was conducted during the period of 8th–19th october 2013 in desa hegarmanah, jatinangor, west java, indonesia. this village was one of the villages in jatinangor used as the site for the research of the medical students of universitas padjadjaran. mothers with under five children were included in this study. a minimum sample size of 96 was calculated using the rapid survey formula. sampling was performed using stratified random sampling method with 7 mothers were selected as respondents from each area of the 14 village areas of desa hegarmanah. ninety six mothers were asked to fill out a questionnaire. the questionnaire included items regarding mother’s identity (age, education, residency status), history of having children who experienced febrile seizure, as well as their knowledge and attitude about febrile seizure. respondents who could not read had their questionnaire explained and read out by a facilitator to ensure good understanding of the questions and the same perception as the researcher’s. the questionnaire was validated using nonparametric correlation spearman’s rho method. all data were entered and analyzed for frequency using a computer software. this study was approved by the health research ethics committee of the faculty of medicine universitas padjadjaran results a total sample of 96 mothers was selected, but 5 respondents did not complete information on mother’s identity, such as missing information on maternal education and febrile table 1 demographic characteristics of mothers items frequency (n=96) percentage (%) mother’s age (years old) ≤20 4 4 21–30 41 43 31–40 44 46 >40 7 7 maternal education no entry 1 1 elementary 15 16 junior high school 32 33 senior high school 42 44 diploma 4 4 college 2 2 residency status native 86 90 immigrant 10 10 febrile seizure history in their children no entry 4 4 yes 19 20 no 73 76 althea medical journal. 2016;3(4) 651jihan alifa syahida, nelly amalia risan, vita murniati tarawan: knowledge and attitude on febrile seizure among mothers with under-five children seizure history in their children. however, this does not interfere with the results of mother’s knowledge and attitude. average age of the respondents was between 31–40 years old with most of them graduated from senior high school, lived in jatinangor sub district and had no history of having children with febrile seizuren (table 1). from the knowledge-related items, it was discovered that some respondents thought that high fever would not always lead to seizure (47%), febrile seizure equals to epilepsy (55%), it is a life-threatening disease (66%), it is caused by evil spirit (85%), it is not related to genetic factors (58%), children iss unconscious during seizure (83%) and this condition may cause brain damage (50%) or paralysis (50%). they had no idea whether febrile seizure would outgrow as the children grow older (43%) (figure 1). fifty three mothers (55.2%) agreed that seizure can occur during high fever, and that periodic temperature measurement is needed during fever (56%) while antipyretic medicine is compulsory (51%). they agreed to put spoon into children mouth (59%) in febrile seizure occasion, but they disagreed to shake the children (54%) or to hold the children tightly (60%) to cease the seizure. they also disagreed on whether their children will be alright if experiencing febrile seizure (59%) while they strongly agreed to take the children to the nearest health care facilities or physicians (65%). sixty mothers agreed that giving coffee can prevent the seizure during high fever and that seizure can recur during next febrile occasion (69%) (figure 2). discussion this study revealed that most respondents believed that high fever always leads to seizure. according to other studies, seizure most commonly occurs when children have risk factors such as upper respiratory infection and acute otitis media, parental history of febrile seizure, neonatal hospitalization >30 days, and delayed development.5,6 on the contrary, one study reported by parmar et al.7 in mumbai, india stated that 77.9% parents do not know that seizure can occur during one febrile occasion. as many as 23 respondents (24%) believed that febrile seizure meant epilepsy. this result is similar to that of a study done by kayserili8 in 2007 in turkey, that 35 parents (28.7%) have the same opinion. febrile seizure is different from epilepsy but epilepsy can be a complication of febrile seizure when there are several risk factors. the risk factors are family history of epilepsy, any atypical appearance during seizure or afterwards, figure 1 mother’s knowledge chart regarding febrile seizure. 1. high fever will always lead to seizure; 2. febrile seizure is epilepsy; 3. febrile seizure is a life-threatening disease; 4. febrile seizure caused by evil spirit; 5. febrile seizure caused by genetic; 6. child is unconscious during seizure; 7. febrile seizure can cause brain damage; 8. febrile seizure can cause paralysis; 9. febrile seizure will outgrow althea medical journal. 2016;3(4) 652 amj december 2016 first febrile seizure occurs before the age of 9 months, delayed development according to age milestone or any previous neurologic impairment. epilepsy incidence is 9% in children experiencing simple febrile seizure with risk factors but only 1% in children without risk factors. there are 15–70% risks of seizure recurrence during the first two years after the first seizure. this risk will increase in children less than 18 month of age, have low grade fever and short duration before the seizure onset, and family history of febrile seizure.9 another finding reveals that more than half respondents still considered that genetic factors do not play a role in febrile seizure. moreover some respondents thought that febrile seizure is due to evil spirit. other studies depicted that there is a genetic factor that contributes to febrile seizure, i.e. mutation of sodium and gamma-aminobutyric acid (gaba) channel.2 sodium channel plays an important role in the process of nerve excitation and gaba channel influences inhibitory responses.8 mutation causes hyperexcitation of neurons and results in seizure. poor environment in pregnancy also contributes to the development of febrile seizure.10 a study in nigeria by anigilaje11 in 2010 shows that the subjects also attribut it to “angry gods” (51.8%), “evil spirit” (49.0%) as the cause of childhood seizure. more than 50% respondents considered febrile seizure as a life-threatening condition and relate it to unconsciousness, brain damage and paralysis of the child. these findings are similar to study in turkey8 which revealed 107 (87.7%) parents believed the same. however, morbidity and mortality caused by febrile seizure are considered low. there is no mortality and cognitive impairment reported by the us national collaborative perinatal projects (ncpp). moreover there is no intelligent quotient (iq) difference in children with history of febrile seizure from their siblings. british cohort study reported similar result in the prognosis of children with febrile seizure compared to other children without the condition.1 other retrospective study revealed that any neurological deficit in few cases occurs only in long-lasted and frequent febrile seizure.12 most respondents have already understood that febrile seizure will outgrow usually after five years old, similar to a study in turkey8 which stated 75.4% parents knew febrile seizure can be outgrown. in terms of respondents’ attitude toward febrile seizure, more than half respondents figure 2 mother’s attitude chart regarding febrile seizure. 1. seizure can occur during high fever; 2. during fever it is important to do periodic temperature measurement; 3. during fever, it is obligatory to give antipyretic medicine; 4. if my child experiencing febrile seizure, he/she will be alright; 5. to cease the seizure, i will wake my child up or shake him/her; 6. i will hold tightly my child during seizure; 7. i will insert a spoon or other items into child’s mouth to prevent tongue biting; 8. giving coffee powder can prevent or stop the seizure; 9. at febrile seizure incident i have to take my child to the physician or health care facilities; 10. febrile seizure can re-occur during next febrile occasion. althea medical journal. 2016;3(4) 653 believed that seizure occurs during high grade fever. study in nigeria by oche and onankpa13 in 2012 showed only 28% mothers know that fever can lead to seizure. febrile seizure may occur if there is an elevation of body temperature in children (rectal temperature of 38o due to extracranium process)12 with 38.40c as the lowest temperature to reach to be considered as febrile seizure.1 this study also shows that almost all respondents measure their children body temperature periodically during fever and try to decrease the fever by giving antipyretic medicine. they believed that these actions will prevent seizure. a similar result is also found in one study, showing that 119 parents (97.5%) will measure child body temperature periodically during fever.8 another study in japan by sakai et al.14 in 2009 shows that mothers whose children have febrile seizure history know that high fever can cause seizure and antipyretic is used to prevent it. seizure in febrile seizure is always triggered by fever; therefore, antipyretic should be given to control the fever.1 other study revealed that antipyretic could reduce the risk of recurrence seizure. no recommendation is given for giving anti-epilepsy or antipyretic medication continuously to prevent the recurrence of febrile seizure.9 more than 75% respondents did not agree that their children will be alright during febrile seizure and this finding also reflects respondent’s anxiety when their children experience febrile seizure. anxiety increases when febrile seizure occurs in the first time when they do not know what to do and how the prognosis of febrile seizure would be. studies in india by parmar et al.7 in 2001 and nigeria by anigilaje15 in 2012 exhibited that mortality is the most feared among mothers whose children experiencing seizure. few parents try to cease seizure by waking up, shaking the children, or holding them tightly. most of them would insert spoon into child mouth to prevent tongue-biting. this practice is unfortunately harmful for children because it may injure the children. in nigeria15 and turkey8, improper management of seizure has also been found such as inserting hand or spoon into children mouth (74, 61.2%) and 48 (39.3%) parents will find any items to put into the children’s mouth during seizure. as many as 43 (35.2%) parents will shake their children during seizure.8 proper management of seizure includes making sure that the child is away from harmful object to prevent injury, lie the children down on one side of their body, loosen their clothes especially in the neck area, put pillow or soft object below children head, do not put anything into mouth, and count the seizure duration in minute.8,16 there are 70% respondents who believed that giving coffee could prevent the occurrence of febrile seizure. there are no studies to support this theory. this practice was done by respondents during febrile occasion and in normal condition as they received this information from their parents. all respondents agreed to take their children to the physician while experiencing febrile seizure. this finding is in line with a nigerian15 study in which parents will take their children to hospital at the onset of febrile seizure (414, 82.8%). however, due to the short duration of febrile seizure, usually the seizure has already ceased at the hospital arrival. proper management of seizure other than the above is to give diazepam suppository (rectally).1 more than 80% respondents agreed that febrile seizure will recur in the next febrile occasion. this possibility is supported by the fact that seizure is always triggered by fever. this study is a descriptive study so no analysis on the relationship between mother’s characteristics and mother’s knowledge and attitudes was performed. stratified randomized sampling was used by collecting 7 respondents from each area of the village, which does not relate to the proportion of mothers in each area. this was because of the limited time to do the study. most of the references are from turkey, nigeria, and india, because they have approximately the same characteristics as indonesia as developing countries. moreover, studies regarding knowledge, attitude, and practice towards febrile seizure is quite a few. in overall, most mothers have good knowledge and attitude on the cause and prevention of febrile seizures, but some mothers still do not have the knowledge on what to do during febrile seizures occasion and the prognosis of febrile seizures. further analytical study with bigger sample is needed to do analytical study in jatinangor to evaluate the association between mother’s characteristics and the knowledge and attitude regarding febrile seizure. a multicenter study is also needed to include the diversity of culture, belief, and education to show if there is any different in knowledge and attitude toward febrile seizure. public education about febrile seizure and what to do during febrile seizures occasion should be included in health care facility program. jihan alifa syahida, nelly amalia risan, vita murniati tarawan: knowledge and attitude on febrile seizure among mothers with under-five children althea medical journal. 2016;3(4) 654 amj december 2016 references 1. wolf p, shinnar s. febrile seizures. in: maria bl, editor. current management in child neurology. 3rd ed. hamilton : bc decker inc; 2005. p. 83–7. 2. shinnar s. febrile seizures. in: swaiman kf, ashwal s, ferriero dm, schor nf, editors. swaiman’s pediatric neurology. 5th ed. philadelphia: elsevier saunders; 2012. p. 790–97. 3. aliabad gm, khajeh a, fayyazi a, safdari l. clinical, epidemiological and laboratory characteristics of patients with febrile convulsion. j compr ped. 2013;3(4):134–7. 4. daoud a. febrile seizures: review article. j med j. 2008;42(3):170–3. 5. kundu gk, rabin f, nandi e, sheikh n, akhter s. etiology and risk factors of febrile seizure – an update. bangladesh j child health. 2010;34(3):103–112. 6. sankar r, menkes jh, koh s, wu j. febrile seizures. in: menkes jh, sarnat hb, maria bl, editors. child neurology. 7th ed. philadelphia: lippincott williams & wilkins; 2006. p. 919–22. 7. parmar rs, sahu dr, bavdekar sb. knowledge, attitude and practices of parents of children with febrile convulsion. j postgrad med. 2001;47(1):19–23. 8. kayserili e, unalp a, apa h, asilsoy s, hizarcioglu m, gulez p, et al. parental knowledge and practices regarding febrile convulsions in turkish children. turk j med sci. 2008;38(4):343–50. 9. graves rc, oehler k, tingle le. febrile seizures: risks, evaluation, and prognosis. am fam physician. 2012;85(2):149–53. 10. visser am, jaddoe vw, hofman a, moll ha, steegers ea, tiemeier h, et al. fetal growth retardation and risk of febrile seizures. pediatrics. 2010;126(4):919–25. 11. anigilaje ea, anigilaje oo. perception of childhood convulsion among women in a peri-urban community in ilorin, nigeria. iosr-jdms. 2010;4(5):32–8. 12. pusponegoro hd, widodo dp, ismael s. konsensus penatalaksanaan kejang demam. 2nd ed. jakarta: badan penerbit idai; 2006. 13. oche om, onankpa ob. using women advocacy groups to enhance knowledge and home management of febrile convulsion amongst mothers in a rural community of sokoto state, nigeria. pan afr med j. 2013;14(1):49. 14. sakai r, niijima s, marui e. parental knowledge and perceptions of fever in children and fever management practices: differences between parents of children with and without a history of febrile seizures. pediatr emerg care. 2009;25(4):231–7. 15. anigilaje ea, anigilaje oo. childhood convulsion: inquiry about the concerns and home management among mothers in tegbesun, a periurban community in ilorin, nigeria. isrn pediatr. 2012;2012:209609. 16. jones t, jacobsen sj. childhood febrile seizures: overview and implications. int j med sci. 2007;4(2):110–4. althea medical journal. 2016;3(4) 493 level of dependency based on barthel and lawton score in older people living in panti werdha, ciparay rizky nurwan diyanto,1 marina a. moeliono,2 lazuardhi dwipa3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilition faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background:the population of older people continues to increase. thus, many kinds of health-related problems can occur, such as a decrease independence level in performing activities of daily living (adl) which can be assessed by using barthel and lawton index. barthel index assesses basic adl such as mobility function, continence, and self-care. lawton index assesses instumental adl that are a person’s ability to use tools and face other people. there are no data available reflecting the dependency of the older people at panti werdha, ciparay . this study aimed to observe the level of dependence of the older people in panti werdha using barthel and lawton index. methods: this study was a descriptive study and was conducted at panti werdha, ciparay from september to november 2015 using the total population. the level of dependence in the older people was assessed by barthel and lawton index. barthel index was divided into independent, mild dependent, moderate dependent, severe dependent, and totally dependent. lawton index was divided into independent, low dependent, high dependent, and totally dependent. results: a total of 144 older people participated as respondents in this study. based on the barthel index score, it showed that 51.4% of the subjects were dependent. as for the lawton index scor¬¬e, it showed that 81.2% of the subjects were dependent. conclusions: most of the older people in panti werdha, ciparay are categorized as dependent, where they will need help in performing basic and instrumental adl. [amj.2016;3(4):493–8] keywords: activities of daily living, older people, panti werdha correspondence: rizky nurwan diyanto, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285315265858 email: rizky.x5@gmail.comoo.co.id introduction older people are those who are aged 60 years and older. the population of older people continues to increase every year worldwide. the number of older people in indonesia in 2013 reached 20.04 million people, or approximately 8.05% of the population. it is estimated that by 2020, the population of older people would reach 11.34% of the entire population in indonesia.1 it may lead to many problems that commonly arise in older people. one of which is a decrease in functional status.2 furthermore, the functional status can be described as a person’s level of independence in performing activities of daily living (adl). the functional status of a person can be assessed by using adl score.2,3 adl are divided into basic adl and instrumental adl.4–7 basic adl is associated with a person’s ability to meet the needs of selfcare (eating, bathing, toileting, dressing, etc.), continence, and mobility (walking).4,8,9 while instrumental adl is more complex than basic adl. instrumental adl relates to a person’s ability to perform task and use of tools such as using a telephone, shopping, preparing meals, housekeeping, washing, transportation use, drug use, and managing finances.6,7 basic adl can be assessed using the barthel index, whereas instrumental adl can be assessed using the lawton index.5,6 moreover, independence in adl is a basic althea medical journal. 2016;3(4) 494 amj december 2016 need for older people.10panti werdha is a residence for older people.11 they will accept those who are physically independent. during their stay, those older people can become dependent. besides panti werdha, ciparay has a special room (ruang rawat kerja, rrk) for older people who are considered unable to perform adl independently. additionally, the data profile reflecting the independence or dependence of the older people in panti werdha, ciparay is unavailable. this profile is needed to plan programs conducted in the panti werdha and for reporting to the government on the functional status of the older people in panti werdha. the implementation of the panti werdha’s program for the older people’s activities is one of the strategy to increase or maintain the level of independence of older people in performing daily activities.2 this study aimed to observe the level of dependence of the older people using the barthel and lawton index at panti werdha, ciparay, bandung district. methods this study was a descriptive study, where the subjects were older people who were enrolled in the panti werdha, ciparay, bandung district. this study was approved by the health research ethics committee, faculty of medicine, universitas padjadjaran. the older people were selected as subjects in this study by using the total population. data were collected during the period of september to november 2015. the total number of respondents was 144 older people who signed the informed consent form. the inclusion criterion for this study was older people residents. the exclusion criterion for this study was older people who refused to participate in the study. this study used the barthel index to assess basic adl and lawton index to assess instrumental adl by interviewing the table 1 respondent characteristics characteristics n=144 (%) age (years old) 60–69 35 (24.3%) 70–79 69 (47.9%) ≥ 80 40 (27.8%) sex male 49 (34%) female 95 (66%) education level not finished elementary school 51 (35.4%) elementary school 66 (46.5%) junior high school 14 (9.7%) senior high school 8 (5.6%) diploma 2 (1.2%) bachelor 2 (1.2%) duration of stay in panti werdha <1 year 54 (37.5%) 1–5 year 55 (38.2%) >5 year 35 (24.2) residence in pantiwerdha wisma 108 (75%) ruang rawat kerja (rrk) 36 (25%) althea medical journal. 2016;3(4) 495 respondents directly. when the respondents had difficulty answering the question, they would be aided by a nurse of panti werdha. the barthel index is one of the tools to assess the mobility function, continence and selfcare such as eating, bathing, and dressing. the lawton index assesses a person’s ability to use tools or face other people or the environment, such as preparing meals, using the telephone, writing, typing, shopping and housekeeping.12 the minimum score of barthel index is 0 and the maximum is 20. the minimum score of lawton index is 0 and the maximum is 8. the interpretation of barthel index scores are as follows, independent (20) and dependent (0–19). the level of dependency in the barthel index were divided into categories: mild dependent (12–19), moderate dependent (9–11), severe dependent (5–8), and totally dependent (0–4). the lawton index scores were divided into independent (8) and dependent (0–7). the level of dependency in the lawton index were divided into three categories, low dependent, high dependent, and totally dependent.13 results a total of 144 older people participated as respondents in this study. the characteristics of the older people at panti werdha, ciparay showed that nearly half of the older people were aged 70–79 years (47.9%). the number of female respondents was higher than male respondents. the majority of the respondents were elementary school graduates (45.8%). the number of respondents who have lived in the panti werdha for 1–5 years were 55 (38.2%).while the majority of the residents lived in wisma (80%) (table 1). furthermore, the majority the older people were categorized as dependent based on the barthel index. the older people categorized as dependent are further divided into sub categories: mild dependent, moderate dependent, severe dependent, and totally dependent. the majority of the older people were categorized as mild dependent and totally dependent (table 2). according to the lawton index, the majority of the older people were categorized as dependent in performing instrumental adl (81.2%). based on this results, most of the older people need help in performing instrumental adl (table 3). the majority of the independent older people were in the age groups of 60–69 years and 70–79 years, whereas the majority of the dependent older people were in the age category of ≥80 years. the percentage of independent male (53%) was higher than female (46.3%). the majority of the older rizky nurwan diyanto, marina a. moeliono, lazuardhi dwipa: level of dependency based on barthel and lawton score in older people living in panti werdha, ciparay table 2 frequency level of dependency of older people based on barthel index score in performing basic adl independence level score category frequency percentage (%) independent 20 70 48.6 dependent 0–19 74 51.4 mild dependent 12–19 55 74.32 moderate dependent 9–11 3 4.05 severe dependent 5–8 1 1.35 totally dependent 0–4 15 20.28 table 3 frequency level of dependency of older people based on lawton index score in performing instrumental adl independence level score category frequency percentage independent 8 27 18.8% dependent 0–7 117 81.2% low dependent 5–7 48 33.3% high dependent 2–4 30 20.8% totally dependent 0–1 39 27.1% althea medical journal. 2016;3(4) 496 amj december 2016 people who did not graduate and graduated from elementary schools were dependent. there was a decrease in the independence level of those who have lived at panti werdha for more than 5 years. there was a significant difference in dependency levels when comparing older people living in wisma to those living in ruang rawat kerja (rrk). the majority of the people living in wisma were independent while the others living in rrk were dependent (table 4). additionally, the level of independence of the older people based on the lawton index showed that the majority of them were dependent, with no independent older people in the age group of ≥80 years . the percentage of independence level in female (21%) was higher than those in male (14.3%). older people who did not complete elementary school had a lower percentage of independence level. the older people who had lived at the panti werdha for more than 5 years had the lowest percentage of independence level. everyone living in rrk was categorized as totally dependent based on the lawton index (table 5). discussion the majority of the older people were in the age category of 71–79 years (47.9%). the majority of the dependent older people were in the age category of ≥80 years. it can be concluded that older residents of the panti werdha have lower level of independence. this is consistent table 4 profile level of dependency of older people based on their characteristics and barthel index category characteristics barthel index category independent n (%) dependent mild n(%) moderate n(%) severe n(%) totally n(%) age (years old) 60–69 24 (68.5) 7 (20) 1 (2.9) 0 (0) 3 (8.6) 70–79 39 (56.5) 25 (36.2) 1 (1.4) 0 (0) 4 (5.8) ≥80 7 (17.5) 23 (57.5) 1 (2.5) 1 (2.5) 8 (20) sex male 26 (53) 15 (30.6) 2 (4.1) 0 (0) 6 (12.3) female 44 (46.3) 40 (42.1) 1 (1.1) 1 (1.1) 9 (9.4) education level not finished elementary school 23 (44.2) 21 (40.4) 2 (3.8) 1 (2) 5 (9.6) elementary school 31 (47) 28 (42.4) 0 (0) 0 (0) 7 (10.6) junior highs chool 7 (50) 5 (35.8) 1 (7.1) 0 (0) 1 (7.1) senior high school 5 (62.5) 1 (12.5) 0 (0) 0 (0) 2 (25) diploma 2 (100) 0 (0) 0 (0) 0 (0) 0 (0) bachelor 2 (100) 0 (0) 0 (0) 0 (0) 0 (0) duration of stay in pantiwerdha <1 year 30 (55.5) 18 (33.3) 1 (1.9) 1 (1.9) 4 (7.4) 1–5 year 27 (49) 18 (32.8) 2 (3.6) 0 (0) 8 (14.5) >5 year 13 (37) 19 (54.3) 0 (0) 0 (0) 3 (8.6) residence in panti werdha wisma 69 (64) 39 (36) 0 (0) 0 (0) 0 (0) ruang rawat kerja (rrk) 1 (2.8) 16 (44.5) 3 (8.3) 1 (2.8) 15 (41.7) althea medical journal. 2016;3(4) 497 with a theory which states that age is the most affecting factor in independence.2,12,13 furthermore, the number of female was higher than male residents. this was due to the population of older women was higher than older men which is consistent with the epidemiology of older people population.the population of older women reaches 10.67 million people (53.2%) and older men reaches 9.37 million (46.7%) due to the fact that the life expectancy of women is higher than men, based on three key factors: genetic, hormonal, and heart disease risk.1,14 based on the barthel index, the percentage of independent male (53%) was higher than female (46.3%). while based on the lawton index the percentage of independent female (21%) was higher than that of male (14.3%). the majority of the older people who had low education level were dependent based on the barthel and lawton index. this result was similar with a previous study by punet et al.15 in india.this study stated that education level have a positive impact on dependency status.15 a total of 108 older people were living in wisma, while 36 others were living in rrk. the wisma at panti werdha, ciparay was occupied by older people who were able to perform adl independently and were able to join in several activities held by the panti werdha, while rrk was occupied by older people who were considered unable to perform adl independently or in need of special monitoring. panti werdha does not have the instruments which the older people should be nursed in rrk. this was consistent with the study result table 5 profile level of dependency of olderpeople based on their characteristics and lawton index category characteristic lawton index category independent n(%) dependent low n(%) high n(%) totally n(%) age (years old) 60–69 15 (42.8) 7 (20) 4 (11.4) 9 ( 25.8) 70–79 12 (17.4) 29 (42) 12 (17.4) 16 (23.2) ≥80 0 (0) 12 (30) 14 (35) 14 (35) sex male 7 (14.3) 22 (44.9) 6 (12.2) 14 (28.6) female 20 (21) 26 (27.4) 24 (25.3) 25 (26.3) education level not finished elementary school 6 (11.8) 16 (31.4) 12 (23.5) 17 (33.3) elementary school 12 (17.9) 24 (35.8) 15 (22.4) 16 (23.9) junior high school 4 (28.6) 5 (35.7) 2 (14.3) 3 (21.4) senior high school 3 (37.5) 1 (12.5) 1 (12.5) 3 (37.5) diploma 0 (0) 2 (100) 0 (0) 0 (0) bachelor 2 (100) 0 (0) 0 (0) 0 (0) duration of stay in panti werdha < 1 year 15 (27.8) 16 (29.6) 8 (14.8) 15 (27.8) 1-5 year 8 (14.5) 20 ( 36.4) 7 (12.7) 20 (36.4) > 5 year 4 (11.4) 12 (34.4) 15 (42.8) 4 (11.4) residence in pantiwerdha wisma 27 (25) 48 (44.4) 30 (27.8) 3 (2.8) ruang rawat kerja (rrk) 0 (0) 0 (0) 0 (0) 36 (100) rizky nurwan diyanto, marina a. moeliono, lazuardhi dwipa: level of dependency based on barthel and lawton score in older people living in panti werdha, ciparay althea medical journal. 2016;3(4) 498 amj december 2016 indicating that the older people living in rrk had lower level of independence compared to those living in wisma. the percentage of independent older people in wisma was 63.89% in accordance with barthel index and 25% using lawton index. as for those living in rrk, it was 2.8% based on barthel index and 0% using lawton index. based on the study result, a conclusion can be made that 51.4% of older people are categorized as dependent in performing basic adl and the majority of the older people in panti werdha, ciparay (81.2%) are categorized as dependent in performing instrumental adl. this shows that most of the older people in panti werdha,ciparay need help to perform their basic and instrumental adl. panti werdha has a big burden for caring dependent older people. this is interesting for conducting a further study about intervention that can increase the level of independence of older people. the limitation of this study was that it was only conducted in one panti werdha. it can be suggested for a further study to observe the level of dependency of the older people in more than one panti werdha. moreover, it can be suggested to the panti werdha to conduct programs that would improve, maintain, and monitor the level of independence of the older people in performing daily activities in the panti werdha. besides, panti werdha needs instruments to determine older people who should live in rrk. these study results can be reported to the government to show the profile level of independence residents in panti werdha, ciparay. references 1. badan pusat statistik. statistik penduduk lanjut usia. jakarta: badan pusat statistik indonesia; 2013. 2. setiati s. geriatri dan gerontologi. in: siti setiati, idrus alwi, aru w. sudoyono, marcellus simadibrata, bambang setiyohadi afs, editors. buku ajar ilmu penyakit dalam. 6th ed. jakarta: interna publishing; 2014. p. 3669–893. 3. millán-calenti jc, tubío j, pita-fernández s, gonzález-abraldes i, lorenzo t, fernández-arruty t, et al. prevalence of functional disability in activities of daily living (adl), instrumental activities of daily living (iadl) and associated factors, as predictors of morbidity and mortality. arch gerontol geriatr. 2010;50(3):306–10. 4. de paula jj, bertola l, de ávila rt, assis ldo, albuquerque m, bicalho m, et al. development, validity, and reliability of the general activities of daily living scale: a multidimensional measure of activities of daily living for older people. rev bras psiquiatr. 2014;36(2):143–52. 5. lee y-c, chen s-s, koh c-l,hsueh i-p, yao k-p, hsieh c-l. development of two barthel index-based supplementary scales for patients with stroke. plos one. 2014;9(10):1–8. 6. graf c. the lawton instrumental activities of daily living scale. am j nurs. 2008;108(4):53–62. 7. park b, jun jk, park j. cognitive impairment and depression in the early 60s: which is more problematic in terms of instrumental activities of daily living? geriatr gerontol int. 2014;14(1):62–70. 8. weening e. frail institutionalized older persons : a comprehensive review on physical exercise. am j phys med rehabil. 2015;90(1):156–68. 9. kruse rl, petroski gf, mehr dr, banaszak-holl j, intrator o. activity of daily living trajectories surrounding acute hospitalization of long-stay nursing home residents. j am geriatr soc. 2013;61(11):1909–18. 10. matsui y, fujita r, harada a, sakurai t, nemoto t, noda n, et al. association of grip strength and related indices with independence of activities of daily living in older adults, investigated by a newlydeveloped grip strength measuring device. geriatr gerontol int. 2014;14(2):77–86. 11. darmojo b. berbagai pelayanan pada usia lanjut. in: hadi martono kp, editor. buku ajar geriatri (ilmu kesehatan usia lanjut). 4th ed. jakarta: balai penerbit fkui; 2009. p. 717–800. 12. mohanty s, gangil op, kumar s. instrumental activities of daily living and subjective wellbeing in elderly persons living in community. indian j gerontol. 2012;26(2):193–206. 13. dolai mc, chakrabarty f, emmanuel d, bordoloi h, butt ti, awoyemi-arayela t, et al. functional status of the elderly santal people. indian j gerontol. 2013;27(4):610– 20. 14. eskes t, haanen c. review: why do women live longer than men? eur j obstet gynecol. 2007;133(2):126–33. 15. ohri p, gupta sk, upadhyai n. a study of daily living dependency status among elderly in an urban slum area of dehradun. indian j comunity heal. 2014;26(4):420–5 althea medical journal. 2016;3(3) 487 pattern of nutritional intake among obese undergraduate in faculty of communication studies universitas padjadjaran nilavenmalar perianan,1 dewi marhaeni diah herawati,2 yudi wahyudi3 1faculty of medicine universitas padjadjaran, 2department of medical nutrition faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: obesity has become the 5th leading cause of death worldwide in 2010. it is a combination of genetic susceptibility, increased availability of high energy food intake and decreased requirements for physical activity in modern society. the increase in calorie intake among obese people often leads to many chronic diseases. therefore, the aim of this study was to observe calorie intake pattern among obese undergraduates. methods: this study was conducted at faculty of communication studies universitas padjadjaran, from september to november 2013. this cross-sectional study used anthropometric measurement based on asian body mass cut-off points, which the screening was conducted on 512 undergraduate students, consisting of 103 undergraduates, overweight (50) and obese (53). from 53 undergraduates, 30 respondents were randomly selected. the respondents were then interviewed using 3x24 hours food recall questionnaire, conducted on two weekdays and one weekend to observe their pattern of nutritional intake. total number of calories was categorized into few groups according to the recommended dietary allowance (rda) 2012. results: from the thirty obese undergraduates, both male (11) and female (9) consumed more excess protein in daily life. consumption of carbohydrate and energy was significantly normal. common consumption of food as daily basis contained more carbohydrate then protein, fats or energy. conclusions: prevalence of obesity is still high. frequent meal and high intake of carbohydrates has become factors to nutritional imbalance of obese undergraduates. types of food most widely consumed are white rice, fried chicken, tofu, tempe (asian food made from fermenting soybeans) and sweetened tea. [amj.2016;3(3):487–92] keywords: food pattern, obesity, undergraduate correspondence: nilavenmalar perianan, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8170209313 email: nila_nvm@hotmail.com introduction obesity has become the 5th leading cause of death worldwide in 2010. world health organization (who) stated that there are more than 1 in 10 of the world population who are still obese.1 based on the report of basic health research (riskesdas) 2010, the prevalence of obesity of adults who are more than 18 years old is 11.7 % according to the modified asian body mass cut-off points. meanwhile, the prevalence of obesity of west java is 12.8 in 2010 according to the modified asian body mass index cut-off points.2 obesity is the global epidemic, it is a combination of the genetic susceptibility, due to high consumption of energy food and less physical activity in current modern society. it should no longer be regarded as simple cosmetic problem affecting certain individuals but it is an epidemic that threatens global wellbeing.3 therefore, this study was conducted to observe the calorie intake pattern among obese undergraduates. methods this cross-sectional study was conducted at faculty of communication studies (fikom) universitas padjadjaran, jatinangor campus from september to november 2013. since there was no similar study conducted earlier, fikom randomly picked from other faculties by considering many steps. initially, an observation step was conducted in many faculties at universitas padjadjaran, althea medical journal. 2016;3(3) 488 amj september 2016 jatinangor where the researcher counted per 10 undergraduates with big size. after significant big size undergraduates were identified, an interview session was conducted with the academic officer and study program coordinator as a conformational step. in the study from 2009−2013, 513 strata 1 (s1) undergraduates were randomly selected to undergo screening process to measure anthropometric measurements. body weight and height were measured with informed consent. subsequently, they were categorized using asian body mass index (bmi) classification. according to the asian bmi classification, 53 undergraduates were identified as obese class i and ii. according to central limit theorem with minimal sample 30, it is normally disturbed; therefore, 30 obese undergraduates were randomly selected. their body weight and height were remeasured to avoid instrument bias. they were given 3x24 hours food recall questionnaire to observe their eating pattern. the 3x24 hours food recall was conducted on a particular week which was on two weekdays and one during the weekend. the respondents were interviewed using food model and ukuran rumah tangga (urt). all data collected were the key in nutrisurvey program 2007 and additional information regarding the calorific value was obtained from food composition table (daftar komposisi bahan makanan, dkbm) and the food packets. from the program, the total number of calorie uptake was recorded by categorizing the uptake of energy, carbohydrate, protein, and fat. the data were then categorized into 3 groups according to the recommended dietary allowance (rda) 2012; less if intake per rate of diet index (rdi) was less than 80%, normal if the intake per rdi 80 was untill 100%, and more if intake per rdi was greater than 100%. the categorization was then analyzed using computer. results from 512 undergraduates, 10% undergraduates were obese i and ii. thirty undergraduates were chosen, from the fifty obese undergraduates who underwent the survey. characteristics of the respondents were selected from prevalence optimum based on gender that the equal was 1:1. the respondents were undergraduates with age range 17 to 22 years old. since the study was conducted on asian obese undergraduates, the undergraduates were categorized according to asian bmi classification. risk fall in range of 23.0–24.9 kg/m2, 25.0–29.99 kg/m2 was considered as obese class i and if more than 30 kg/m2, it was considered as obese class ii. based on sex, there were 60% male undergraduates with low energy intake and 60 % female undergraduates with normal energy intake. based on the protein intake, both male and female undergraduates generally had over/excess protein intake. based on the fat intake, 40% male undergraduates had excess fat intake and 40% less fat intake. as figure 1 distribution of bmi category note: *bmi= body mass index althea medical journal. 2016;3(3) 489nilavenmalar perianan, dewi marhaeni diah herawati, yudi wahyudi: pattern of nutritional intake among obese undergraduate in faculty of communication studies universitas padjadjaran for female undergraduates, there were 46.7% with excess and normal fat intake, and only a small proportion with less fat intake (6.7%). based on the adequacy of carbohydrate intake, 46.7% male undergraduates with normal carbohydrate sufficiency; as well as male undergraduates, female undergraduates had more carbohydrate intake to normal levels. from the study, commonly consumed food was also taken into consideration, the results showed that the uptake of food containing carbohydrate was mostly consumed by obese undergraduates, for example, rice, bread, makassar dried noodle,wet noodle, porridge, fries, rice cake (lontong asian cuisine), and rice vermicelli. rice was most widely consumed by obese undergraduates with 59.9 %. animal protein which was highly consumed by obese undergraduates was chicken 52.9%, followed by egg (29.3%), fish (5.7%), meat (7.9%), and chicken liver (4.3%); light meal and beveragewere sweetened tea (29. 8% ), biscuit (19.0%), tea (13.2%), snacks (11.6%), chocolates (9.1%), coffee (7.1%), tago (6.6%), and meatball (3.3%). frequency of consumption of vegetables and fruits and vegetable protein showed 11.55% and 10.76%, respectively. highly consumed vegetables such as sayur ubi, kale, etc were 49.3% and fruits such as banana, orange, corn, apple, watermelon, etc were 11.9%. frequency of fat intake shows that 3.32%. discussion considering indonesia that is an asian developing country, asian bmi classification was used to identify the obese undergraduates. based on the report of basic health research (riskesdas) 2010, the prevalence of obesity of adults who are more than 18 years old is 11.7% as if figure 1 proved that 10% undergraduates were still obese.2 mainly, they were categorized as obese class i and were more in male compared to female. in current global epidemic of obesity accuracy appearance from a combination of genetic susceptibility, availability of high table 2 bmi category and sex sex total male female n n n bmi at risk 1 3 4 obese i 11 10 21 obese ii 3 2 5 total 15 15 30 note: *bmi : body mass index table 1 respondent characteristics characteristics n age (years old) 17 2 18 4 19 9 20 11 21 3 22 1 sex male 15 female 15 althea medical journal. 2016;3(3) 490 amj september 2016 energy food increases and requirements for physical activity decrease in modern society. obesity should no longer be neglected as simply as a cosmetic problem affecting certain individuals, but it is an epidemic that threatens global well-being. it is important to assess eating pattern of any population in order to have a broader idea of nutrient intake and nutritional status of any population. review of literature showed that there is no sufficient study available for such data in jatinangor. this survey reflects a general eating pattern subjected to obese undergraduates.4 the term used for nutritional adequacy rate varies between countries. indonesia uses the term angka kecukupan gizi (akg) as a translation of the recommended dietary allowance (rda). the most excess intake was protein diet, 66.1% (table 3). excess consumption of protein will be converted table 3 eating pattern and recommended dietary allowances according to sex no sex energy protein fat (g) carbohydrate (g) energy (kkal) % rda protein (g) % rda fat (g) % rda carbohydrate (g) % rda 1 male 1929.20 75.7 68.03 109.7 101.90 112.0 238.43 63.6 2 male 2205.00 86.5 46.93 75.7 78.90 86.7 272.80 72.7 3 female 2533.33 133.3 57.37 102.4 63.37 84.5 182.37 59.0 4 female 1884.15 99.2 57.50 102.7 98.50 131.3 265.70 86.0 5 female 1283.87 67.6 31.37 56.0 62.23 83.0 184.57 59.7 6 male 1606.07 63.0 66.40 107.1 83.07 91.3 230.87 61.6 7 male 2122.43 83.2 15.77 25.4 39.63 43.6 252.93 67.4 8 male 1402.00 53.9 91.83 139.1 97.00 109.0 373.50 101.5 9 male 1997.50 78.3 30.10 48.5 104.83 115.2 320.30 85.4 10 female 2078.90 94.5 51.97 88.1 40.45 57.0 253.30 86.7 11 male 1781.77 69.9 52.93 85.4 73.23 80.5 319.47 85.2 12 male 1942.77 74.7 81.47 123.4 10.67 12.0 277.33 75.4 13 female 1382.43 72.8 36.60 65.4 72.00 96.0 117.30 38.0 14 male 2236.43 87.7 63.90 103.1 57.40 63.1 261.00 69.6 15 female 1739.63 91.6 63.37 113.2 88.43 117.9 264.20 85.5 16 female 1448.50 76.2 52.73 94.2 71.53 95.4 259.30 83.9 17 female 1608.47 84.7 26.93 48.1 65.70 87.6 262.67 85.0 18 female 2278.77 103.6 66.97 113.5 64.10 90.3 85.70 29.3 19 female 1868.97 98.4 41.00 73.2 78.67 104.9 251.60 81.4 20 male 2555.13 100.2 102.03 164.6 146.93 161.5 277.70 74.1 21 male 2867.30 112.4 149.27 240.8 181.57 199.5 337.60 90.0 22 female 2226.40 117.2 132.10 235.9 118.50 158.0 326.03 105.5 23 female 1546.93 81.4 81.13 144.9 83.57 111.4 771.10 249.5 24 male 2383.37 91.7 118.00 178.8 122.93 138.1 292.43 79.5 25 female 1652.77 87.0 132.37 236.4 101.97 136.0 329.03 106.5 26 male 1740.23 68.2 78.50 126.6 63.83 70.1 214.46 57.2 27 female 2526.77 133.0 144.37 257.8 94.30 125.7 276.73 89.6 28 male 1801.00 70.6 113.20 182.6 50.20 55.2 350.73 93.5 29 male 1801.00 70.6 113.20 182.6 49.83 54.8 312.80 83.4 30 female 1949.87 88.6 99.50 168.6 86.37 121.6 238.97 81.8 note: recommended dietary allowance (rda) althea medical journal. 2016;3(3) 491nilavenmalar perianan, dewi marhaeni diah herawati, yudi wahyudi: pattern of nutritional intake among obese undergraduate in faculty of communication studies universitas padjadjaran table 4 pattern of energy consumption according to sex sex total male female n n n energy low 9 3 12 normal 4 9 13 over 2 3 5 total 15 15 30 protein low 3 4 7 normal 1 2 3 over 11 9 20 total 15 15 30 fat low 6 1 7 normal 3 7 10 over 6 7 13 total 15 15 30 carbohydrate low 7 3 10 normal 7 9 16 over 1 3 4 total 15 15 30 figure 2 frequency of food consumed althea medical journal. 2016;3(3) 492 amj september 2016 into amino toxic inside the body which is a risk factor for cardiovascular diseases, degenerative disease, and also neural tube defect in pregnant woman.5 inadequate protein intake also can cause frailty which is also known as geriatric syndrome among elderly women, therefore, all the nutritional intake should be consumed appropriately according to requirements.6 energy and carbohydrate intake were normal according to akg 43.3% and 53.5%. the findings from previous study gave a picture that overweight and obesity development on child influence by various factors besides diet, as well as genetic, environmental factor including individual, familial and structural variables.7 vegetables and fruits are less consumed by obese undergraduates, 11.55% consumed fruits as juice and mostly sayur ubi and kale. vegetables and fruits containing fibers function in regulation of body hunger and saturation and hence, body weight. increased intake of vegetables and fruit may reduce burden disease such as ischemia heart disease, ischemia stroke, and also many cancer diseases.8 beside carbohydrates and protein, the most commonly consumed food is snacks. intake of sweets, desserts and snacks, bread, and dietary restraint were high in obese subjects with metabolic risk factors.9 many other factors can contribute to obesity besides eating pattern, for example, genetic predisposition or physical activity that may have a greater influence on the development of overweight and obesity than diet.10 there were many limitations during the period study conducted to obtain the sample and view of undergraduates’ food pattern. the stadiometer and weighing scale were not accurate and sensitive for screening process; therefore, the body weight and height of undergraduates were remeasured before the interview. screening process took longer time frame. the 24 hour recall interview method required approaches to the respondents but timing and the environment were not appropriate because the interview during class hours was conducted. in addition, the 24 hour recall interview method required approaches to respondents and quiet environment during interview. in conclusion, findings in this study indicated that prevalence of obesity is still high among undergraduate which is 10%. common food and high intake of carbohydrates becomes factors of nutritional imbalance of obese undergraduates. types of food which most widely consumed are white rice, fried chicken, tofu, tempe (an asian food made from fermenting soybeans) and sweetened tea. future study should be conducted in communities. nutritional status impacts the health issues, so it needs special care. it is pertinent to focus on improvement of the eating pattern of adults in order to prepare a future healthy nation. references 1. who. fact sheet n°311: obesity and overweight [cited 2013 april 1]. available from: http://www.who.int/mediacentre/ factsheets/fs311/en/. 2. department kesehatan, republik indonesia. laporan nasional riset kesehatan dasar ( riskesdas 2010). jakarta: menteri kesehatan republik indonesia; 2010. 3. skinner ac, perrin em, moss la, skelton ja. cardiometabolic risks and severity of obesity in children and young adults. n engl j med. 2015;373(14):1307–17. 4. yahia n, achkar a, abdallah a, rizk s. eating habits and obesity among lebanese university students. nutr j. 2008;7:32. 5. jakubowsk h. pathophysiological consequences of homocysteine excess. j nutr. 2006;136(6 suppl):1741s–9s. 6. kobayashi s, asakura k, suga h, sasaki s. high protein intake is associated with low prevalence of frailty among old japanese women: a multicenter cross-sectional study. nutr j. 2013;12:164. 7. oellingrate im, svendsen mv, brantsaeter al. eating patterns and overweight in 9to 10-year-old children in telemark county: norway a cross-sectional study. eur j clin nutr. 2010;64(11):1272–9. 8. lock k, pomerleau j, causer l, altmann r, mckee m. the global burden of disease attributable to low consumption of fruit and vegetables: implications for the global strategy on diet. bull world health organ. 2005;83(2):100–8. 9. svendsen m, tonstad s. accuracy of food intake reporting in obese subjects with metabolic risk factors. br j nutr. 2006; 95(3):640–9. 10. libuda l, alexy u, sichert-hellert w, stehle p, karaolis-danckert n, buyken ae, et al. pattern of beverage consumption and long-term association with bodyweight status in german adolescents: results from the donald study. br j nutr. 2008;99(6):1370–9. althea medical journal. 2016;3(2) 323 correlation between computer workstation and location of musculoskeletal disorders hafiz ambyo bagaskoro,1 tertianto prabowo,2 setiawan3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: the use of computer has been widely increased. this intensifies the risk of musculoskeletal disorders on long-term office workers. this study aims to find out the characteristics of musculoskeletal disorders in office workers with computer workstation which then lead to the presence or absence of the correlation between the two in order to avoid the pains endured. methods: this was a cross-sectional study carried out from september–november 2014 in faculty of medicine, universitas padjadjaran, bandung, indonesia. seventeen samples were obtained from three different departments (finance and academics) by total sampling. the data was collected by validated questionnaire and it was analyzed by using simple linear regression method. results: from 17 samples in total, 16 claimed that their workstation needs to be evaluated. furthermore, the prevalent areas of musculoskeletal were shoulders (12 persons), lower back (10 persons), neck (9 persons), knee (9 persons), upper back (7 persons). the analysis using simple linear regression method showed no significant correlation between workstation characteristics and musculoskeletal disorders (p-value = 0.515). conclusions: there is no correlation found between workstation characteristics and musculoskeletal disorders. [amj.2016;3(2):323–8] keywords: musculoskeletal disorders, office workers, workstations correspondence: hafiz ambyo bagaskoro, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 83825557878 email: hafizbagaskoro@gmail.com introduction computer usage has been widely increased recently. in united states1, computer users increased from 8.2% in 1984 to 75.6% in 2011. this increase was accompanied by the increased risk of musculoskeletal disorders. from various studies, it was discovered that musculoskeletal disorders were common in office workers using computers.2,3 previous studies reported that musculoskeletal disorders were the most common occupational diseases and accounted for 60% of all occupational diseases.2,4-6 several studies proved that musculoskeletal disorders were responsible for declining productivity.7,8 those decline reported by prevalence of 56%, by a study in finland.8 poor ergonomic conditions were known to play roles in the incidence of musculoskeletal disorders.2 meanwhile good ergonomic conditions help reduce the number of musculoskeletal disorders.3,9,10 until now, research on risk factors for musculoskeletal disorders on computer operators are more focused on the human factors (e.g. age, sex, body mass index (bmi)) and environment (e.g. work duration).4,6,11 meanwhile other studies discovering factors that related to technology (e.g. computer, computer workstation components such as tables and chairs) were less common.3 therefore, this study aimed to investigate the characteristics of computer workstations and musculoskeletal disorders in office workers as well as to determine whether there is a correlation between these variables in order to avoid musculoskeletal disorders. methods this study was carried out from september althea medical journal. 2016;3(2) 324 amj june 2016 to november 2014 in faculty of medicine, universitas padjadjaran, bandung, west java, indonesia. this research used observational cross-sectional design, with descriptive and analytic properties. data were obtained through nordic musculoskeletal questionnaire (nmq) to determine the location characteristics of musculoskeletal disorders.12 after that, to determine the characteristics of computer workstations, a questionnaire based on computer workstation etool from osha that has been modified with pictures and direction to complete the questionnaire was used.13 the questionnaire had undergone validity test respectively. ethical exemption had been approved by health research ethics committee, faculty of medicine, universitas padjadjaran. the study population was obtained from three sub-sections, considered as the representative of the administrative workers of the faculty of medicine, universitas padjadjaran who works in long-term at their workstations. through total sampling, 23 samples obtained from financial and academics department, in faculty of medicine universitas padjadjaran consisting of 13 from division of finance, 10 from academics subdivision (5 from unit program studi profesi dokter and 5 from unit evaluasi program studi sarjana kedokteran). unit program studi profesi dokter were responsible for academic administration of clinical clerkship program, while unit evaluasi program studi sarjana kedokteran were responsible to evaluate academic progress of undergraduate program. from 23 samples, 21 were able to be included in the study after accepting to participate in the research. the selected samples work 2 years minimum with>4 hour/day use computer as the work tool.11 meanwhile, 2 samples could not complete the questionnaire. from 21 samples selected, 4 must be excluded due to history of musculoskeletal disorders diagnosed by doctors. hence, total samples analyzed are 17. workstations were defined as the place of workers doing their activities such as typing, editing, and processing data. workstation components analyzed in this study were desk and chair. musculoskeletal disorders were defined as pain, complaints, or discomfort that was felt according to workers from his/ her job. results were categorized in nominal scale 0 for answer “no” and 1 for answer “yes” at the questionnaire then transformed into score. maximal score for workstations are 10 and that means good. meanwhile, maximal score for musculoskeletal disorders are 28 and that means poor. criteria for workstation to be “good” are when every question was answered “yes”. whereas if there is one “no” answers the table 1 respondent characteristics characteristics n mean (standard deviation) minimum maximum sex male 14 female 3 age (years) 36.65(6.32) 29 49 <35 8 ≥35 9 bmi (kg/m2) 23.48(3.97) 17.53 33.06 underweight (<18.5) 2 normal (18.5-24.9) 11 overweight (≥25) 4 department/sub-division finance 8 unit pspd 5 unit evaluasi pssk 4 althea medical journal. 2016;3(2) 325hafiz ambyo bagaskoro, tertianto prabowo, setiawan: correlation between computer workstation and location of musculoskeletal disorders workstation needs to be evaluated. the same criteria applies in evaluating component of desks and chairs.13 data from the sample were calculated using statistical software. statistical analysis method used was simple linear regression. results were presented in table and graphic with explanation and discussion. results the result showed that the majority of respondents are male (14 of 17). based on age group, it was discovered that 9 people aged above 35. based on bmi, it was found that 2 people were underweight, 11 were normal, and 4 were overweight. furthermore, based on department/sub-division of workplace, respondent were distributed into 8 people from finance, 5 people from unit program studi profesi dokter (pspd), and 4 people from unit evaluasi program studi sarjana kedokteran (pssk) (table 1). computer workstation characteristics were presented above (table 2). generally, respondents considered their workstation as need evaluation (16 of 17). observed from the components, seat condition and work area (area above the desk) were mostly considered by the respondent as need evaluation (11 of 17) meanwhile the majority of respondents admit their backrest as good (12 of 17). in finance division, work area (area above the desk) were considered mostly as need evaluation (5 of 8) whilst backrest and armrest were considered good (6 of 8). from unit pspd it was found that (3 of 5) respondents stated that their backrest, seat, armrest, and work area need evaluation, table 2 workstation characteristics based on department/sub-division components total respondent department/sub-division (n=17) finance unit pspd unit evaluasi pssk good need evaluation good need evaluation good need evaluation good need evaluation chair 3 14 backrest 12 5 6 2 2 3 4 0 seat 6 11 4 4 2 3 0 4 armrest 8 9 6 2 2 3 4 0 desk 5 12 work area 6 11 3 5 2 3 1 3 below work area 10 7 5 3 3 2 2 2 work-station 1 16 table 3 characteristic of location of musculoskeletal disorders complaint yes no n=17 neck 9 8 shoulders 12 5 upper back 7 10 elbows 3 14 lower back 10 7 wrist-hands 6 11 hips-tighs 6 11 knees 9 8 ankles/feet 6 11 althea medical journal. 2016;3(2) 326 amj june 2016 then below work area (area below the desk) were admittedly good by the respondent (3 of 5). in unit evaluasi pssk sub-division, it was discovered that (4 of 4) respondents stated that their seat need evaluation and (4 of 4) stated that backrest, and armrest on their workstation are good. table 3 showed the characteristic of location of musculoskeletal disorders. body location that were generally affected by musculoskeletal disorders were shoulders (12 of 17), lower back (10 dari 17), neck (9 of 17), knees (9 of 17), and upper back (7 of 17). respondents are less likely had complaints in wrist-hands (6 of 17), hips-thighs (6 of 17), ankles/feet (6 of 17), and elbows (3 of 17). based on respondents characteristics, it was found that location of musculoskeletal table 2 workstation characteristics based on department/sub-division respondent characteristics (n= 17) age (years) sex bmi (kg/m2) <35 ≥35 male female <18.5 18.5-24.9 ≥25 total 8 9 14 3 2 11 4 musculoskeletal d i s o r d e r s location neck 5 4 7 2 0 6 3 shoulders 5 7 10 2 1 7 4 upper back 4 3 6 1 1 4 2 elbows 1 2 3 0 0 2 1 lower back 5 5 9 1 2 6 2 wrist-hands 1 5 4 2 1 4 1 hips-thighs 2 4 6 0 1 2 3 knees 3 6 8 1 1 6 2 ankles/feet 3 3 5 1 1 3 2 note: *bmi : body mass index figure 1 correlation between computer workstation and location of musculoskeletal disorders althea medical journal. 2016;3(2) 327hafiz ambyo bagaskoro, tertianto prabowo, setiawan: correlation between computer workstation and location of musculoskeletal disorders disorders in the age group below 35 were generally shoulders, lower back, and neck (5 of 8) respectively, while in the age group above 35 usually were shoulders (7 of 9). result showed that male were mostly suffering from complaints of the shoulders (10 of 14) while female are mostly suffering from complaints of the shoulders, neck, and wrist-hands (2 of 3) respectively. observed from the bmi, underweight respondent (bmi <18.5 kg/m2) were more frequently experiencing complaints in lower back (2 of 2) while in normal weight (bmi 18.5-24.9 kg/m2) and overweight respondents (bmi ≥25 kg/m2) complaints were more frequent on the shoulders (7 of 11) and (4 of 4) respectively (table 4). correlation between computer workstation and location of musculokeletal disorders (msd) were analyzed in form of workstation score and musculoskeletal disorders score using simple linear regression statistical test. those score were plotted against scatter plot graphic in order to do the statistical test. afterwards, it was found that there was a tendency of increase workstation score proportionate to the musculoskeletal disorders scores (figure 1). however, after statistical analysis of simple linear regression was done it was found that (p value = 0.515), because of p > 0.05 therefore the interpretations are there is no meaningful correlation between computer workstation and location of musculokeletal disorders. discussion results of this study show that the majority of respondent consider their workstation conditions need to be evaluated (16 of 17). this finding differs from previous study in lampung, indonesia11 which stated that the respondents already had good workstation. this study reveals that musculoskeletal disorders usually affect office workers who use computers like the previous studies.2,3 musculoskeletal disorders with high prevalence occur at the back region and upper extremities such as head/neck, and shoulders. this finding corresponds with previous studies.2,4,6,14 based on age of the respondent, this study shows a tendency of increasing age proportionate to the increase of musculoskeletal disorders similar to the previous studies.6,14 based on bmi of respondents, this study shows a tendency of increasing bmi proportionate to the increase of musculoskeletal disorders in line with a study from india.15 however, this study did not show any difference that states female tend to have more complaints at the region of back and upper extremities such as head/neck, and shoulders like the study in thailand.2 good workstation characteristics are one of the ergonomic components in the office workers who operate a computer to produce good seating position. this can significantly reduce the incidence of musculoskeletal disorders. 3,9,11,14 the results of this study differ from other studies that state good ergonomic factors could reduce musculoskeletal disorders. this study found no significant correlation between the workstation characteristics and musculoskeletal disorders. this is due to the sample size of this study that was too small compared to the previous studies.2,11,14 there are several limitations of this study. questionnaire given to the respondents tends to be subjective in assessing the condition of the computer workstation thereby increasing the possibility of bias. moreover, seating posture, physical activity outside of working hours, and the number of breaks during work hours is not considered in this study. this can be a confounding variable that can change the results. then, due to the time and resources limitation, the researchers obtained too small samples to get significant correlation. it is expected that further research could increase the sample size to obtain a significant results, use standardized surveyor to minimize bias, assess seating posture, and assessing physical activity outside working hours to minimize confounding variables. for office workers, it is recommended to improve seating position at work, rest and stretch every 30-60 minutes while using the computer to avoid the incidence of musculoskeletal disorders. for the office management, it is recommended to evaluate the workstation because it is important to support the posture/ seating position of the workers. therefore, it is expected to reduce the incidence of musculoskeletal disorders. references 1. file t. computer and internet use in the united states: population characteristics. washington, dc.: u.s. census bureau; 2013 [cited 2014 march 12] available from: https://www.census.gov/ prod/2013pubs/p20-569.pdf 2. janwantanakul p, pensri p, jiamjarasrangsri v, sinsongsook t. prevalence of selfreported musculoskeletal symptoms among office workers. occup med (lond). 2008;58(6):436–8. althea medical journal. 2016;3(2) 328 amj june 2016 3. van niekerk sm, louw qa, hillier s. the effectiveness of a chair intervention in the workplace to reduce musculoskeletal symptoms: a systematic review. bmc musculoskelet disord. 2012;13(1):145. 4. lusianawaty t, delima, sulistyowati t. hubungan lama kerja dan posisi kerja dengan keluhan otot rangka leher dan ektremitas atas pada pekerja garmen perempuan di jakarta utara. bul penel kesehatan. 2009;37(1):12–22. 5. siu dch, tse la, yu its, griffiths sm. computer products usage and prevalence of computer related musculoskeletal discomfort among adolescents. work. 2009;34(4):449–54. 6. kim kh, kim ks, kim ds, jang sj, hong kh, yoo s-w. characteristics of work-related musculoskeletal disorders in korea and their work-relatedness evaluation. j korean med sci. 2010;25(suppl):s77–86. 7. hagberg m, vilhemsson r, tornqvist ew, toomingas a. incidence of selfreported reduced productivity owing to musculoskeletal symptoms: association with workplace and individual factors among computer users. ergonomics. 2007;50(11):1820–34. 8. martimo kp, shiri r, miranda h, ketola r, varonen h, viikari-juntura e. self-reported productivity loss among workers with upper extremity disorders. scand j work environ health. 2009;35(4):301–8. 9. adiatmika ipg, manuaba a, adiputra n, sutjana dp. perbaikan kondisi kerja dengan pendekatan ergonomi total menurunkan keluhan muskuloskeletal dan kelelahan serta meningkatkan produktivitas dan penghasilan perajin pengecatan logam di kediri-tabanan. ijbs. 2007;1(3):45–7. 10. rasoulzadeh y, gholamnia r. effectiveness of an ergonomics training program on decreasing work-related musculoskeletal disorders risk among video display terminals users. health promot perspect. 2012;2(1):89. 11. dyah ws, deny n. nyeri punggung pada operator komputer akibat posisi dan lama duduk. mkb. 2010;42(3):123–7. 12. crawford jo. the nordic musculoskeletal questionnaire. occup med (lond). 2007;57(4):300–1. 13. osha. ergonomic solutions: computer workstations etool washington, dc.: united states department of labor; [cited 2014 march 12 ]. available from: h t t p s : / / w w w. o s h a . g ov / s ltc / e to o l s / c o m p u t e r w o r k s t a t i o n s / p d f f i l e s / checklist1.pdf. 14. jomoah im. work-related health disorders among saudi computer users. scientificworldjournal. 2014;2014:27. 15. sethi j, sandhu js, imbanathan v. effect of body mass index on work related musculoskeletal discomfort and occupational stress of computer workers in a developed ergonomic setup. sports med arthrosc rehabil ther technol. 2011;3(1):22. althea vol 4 no 1 full text.indd althea medical journal. 2017;4(1) 6 amj march 2017 characteristics of eye tumor in children diagnosed at the national eye center cicendo eye hospital pieter juanarta,1 mohamad rinaldi dahlan,2 andri rezano3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology, faculty of medicine, universitas padjadjaran/national eye center cicendo eye hospital, 3department of anatomy, cellular biology and physiology, faculty of medicine, universitas padjadjaran abstract background: eye tumors are commonly found and fatal among pediatric patients. the immediacy of management depends on the diagnosis, and is increased when the patient’s characteristics are known. this study aimed to describe the characteristics of pediatric patients diagnosed with eye tumors. methods: this was a descriptive retrospective study using secondary data involving 102 medical records of pediatric patients diagnosed with eye tumors at the national eye center cicendo eye hospital bandung in the period of january 2013 to december 2014. results: the characteristics of 102 subjects: 54 (52.9%) were female, 59 (57.8%) were 1 to 4 years old, and 79 (77.5%) were from west java. the characteristics of the tumors: 42 (41.2%) presented with a chief complaint of leukocoria, 73 (71.6%) were malignant, 68 (66.7%) were retinal, and the most common managements were surgery (64.7%). the most common malignant tumors were retinoblastoma (93.2%) while the most common benign tumors were dermoid cyst (31%). conclusions: patients are frequently 1–4 years old and the most common diagnosis was retinoblastoma for malignant tumor and dermoid cyst for benign tumor. [amj.2017;4(1):6–10] keywords: characteristics, children, eye tumors correspondence: pieter juanarta, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81905501090, email: pieter.juanarta@yahoo.com introduction tumors that occur in children are about 2% of all tumors. tumors cause a mortality rate of 10% among children, second only to accidents. tumors frequently damage cognitive, growth, social, and also sexual functions of the children.1 in the united states in 2005, there were 2,120 new eye tumor cases, comprising 1,090 males and 1,030 females, and causing 230 deaths. the average eye tumor annual incidences in the uk were 3.5/1,000,000 for children under 15 and 11.8/1,000,000 for those under 5. based on studies conducted on children, retinoblastoma is the most commonly found eye malignancy (61.33%) while dermoid cyst is its benign counterpart (13.33%). this study aimed to describe the characteristics of pediatric patients diagnosed with eye tumors.2–4 the diagnosis of a tumor is confirmed by a tissue biopsy. tumors that have been diagnosed earlier, have higher cure rates due to more immediate treatments.5–6 eye tumors can be treated with enucleation, radiotherapy, and chemotherapy. how fast treatments can start depends on how early the patient is diagnosed, which can be performed even quicker if the characteristics of the pediatric eye tumor patients are known.1,6–7 this study aimed to describe the characteristics of pediatric patients diagnosed with eye tumors. methods this descriptive retrospective study utilized total sampling using secondary data of the medical records of pediatric patients diagnosed with eye tumors at the national eye center cicendo eye hospital in the period of january 1, 2013 to december 31, 2014. the inclusion criterion was pediatric patients aged althea medical journal. 2017;4(1) 7 0–14 years old, while the exclusion criterion was those without anatomical pathology examination. this study was conducted from september to november 2015 at the national eye center cicendo eye hospital bandung. it had been approved by the health research ethics committee faculty of medicine universitas padjadjaran. the collected data comprised the characteristics of the patients and the eye tumor. the collected patients’ characteristics were gender, age, and residence. meanwhile, the collected tumor characteristics were chief complaint, tumor classification, tumor diagnosis, and treatment performed. the data were input to the microsoft excel software. then, calculated and grouped based on the characteristics. the results were presented in tables. results were then compared to the findings of previous studies. results out of 102 respondents, a tendency towards a gender type was not observed; only subjects under 15 years old were recruited, in accordance with the age limit of pediatric patients by the hospital. the age grouping was conducted according to the world health table 1 demography of pediatric eye tumor patients at the national eye center cicendo eye hospital in the period of 2013–2014 variable frequency percentage (n=102) (%) gender male 48 47.1 female 54 52.9 age (years) 0–1 11 10.8 1–4 59 57.8 5–14 32 31.4 residence west java 79 77.5 the rest of java 11 10.7 outside java island 12 11.8 table 2 chief complaint of pediatric eye tumor patients at the national eye center cicendo eye hospital in the period of 2013–2014 variable frequency percentage (n=102) (%) mass 27 26.5 strabismus 1 1.0 leukocoria 42 41.2 eyeball enlargement 20 19.6 ocular pain 1 1.0 membrane covering the eye 8 7.9 blurred vision 1 1.0 red eyes 1 1.0 bleeding 1 1.0 pieter juanarta, mohamad rinaldi dahlan, andri rezano: characteristics of eye tumor in children diagnosed at the national eye center cicendo eye hospital althea medical journal. 2017;4(1) 8 amj march 2017 organization (who) age classification for general purpose.8 the age group with the most members was the 1–4 group (57.8%). the patients’ residence had a high variation, yet the majority of the patients came from west java (77.5%) (table 1). the largest group of patients came due to leukocoria (41.2%). the second and third largest groups had chief complaints of ocular mass (26.5%) and eye enlargement (19.6%) respectively (table 2). the type of tumor was either malignant or benign, which could be determined by physical examination, laboratory examination, and primarily anatomical pathology examination. there were more malignant tumors (71.6%) table 4 malignant tumor diagnosis of pediatric eye tumor patients at the national eye center cicendo eye hospital in the period of 2013–2014 tumor name frequency percentage (n=73) (%) melanoma 2 2.8 retinoblastoma 68 93.2 rhabdomyosarcoma 2 2.7 squamous cell carcinoma 1 1.4 table 5 benign tumor diagnosis of pediatric eye tumor patients at the national eye center cicendo eye hospital in the period of 2013–2014 tumor name frequency percentage (n=29) (%) granuloma 1 3.4 capillary hemangioma 4 13.8 dermoid cyst 9 31.0 epidermoid cyst 3 10.3 lipodermoid 4 13.8 nevus 6 20.7 papilloma 1 3.4 schwannoma 1 3.4 table 3 tumor classification of pediatric eye tumor patients at the national eye center cicendo eye hospital in the period of 2013–2014 variable frequency percentage (n=102) (%) tumor type malignant 73 71.6 benign 29 28.4 tumor location palpebra 14 13.7 conjunctiva 15 14.7 orbit 5 4.9 retina 68 66.7 althea medical journal. 2017;4(1) 9pieter juanarta, mohamad rinaldi dahlan, andri rezano: characteristics of eye tumor in children diagnosed at the national eye center cicendo eye hospital found and the most tumors were located in the retina (66.7%) (table 3). retinoblastoma (93.2%) was the most common malignant tumor and squamous cell carcinoma was the least common malignant tumor found in pediatric eye tumor patients (table 4). the diagnosis of benign tumor was more spread out than malignant tumor. the two most common types of benign tumor found were dermoid cyst (31.0%) and nevus (20.7%) (table 5). the treatments prescribed for eye tumors are usually surgery, chemotherapy, and/ or radiotherapy. nevertheless, in this study, many patients virtually underwent surgery (64.7%), and some also went for surgery with chemotherapy (28.4%) (table 6). discussion studies on pediatric eye tumor are frequently conducted in several countries. in taiwan6 and china9, eye tumors are more commonly found among males. this is due to their culture, in which boys are prioritized over girls by their families. as such, more boys receive medical attention and the mortality rates are lower among them.6,9 referring to the studies mentioned, cultural characteristics of a country can possibly contribute to the results of a study. in indonesia, a tendency towards a gender has not been found, hence, the similar number of male and female patients was found in this study. similar finding was also found in the united states.2,10 the majority of the patients were in the 1–4 age group. this finding is in accordance with studies conducted in the us and china which stated that tumor cases have the highest incidence in developing countries, especially among children under 4. however, several studies mentioned the highest incidence occurs in children under 8.3,6,9,11–13 genetic changes and viral infections in early stages of life will cause clinical symptoms to be visible in this age group.14 in this study, the most prevalent chief complaint was leukocoria. congruent findings were also in china and the us.3,9 the high frequency of this complaint was due to the high number of retinoblastoma cases, in which the eyes do appear to have a glare like a cat’s eyes.3,5,15 malignant tumors were more prevalent in this study, which is similar to the finding in a korean study. however, this contrasts with the findings in ireland and the us which revealed that benign tumors are more common.3,5,16–17 anatomical pathology examination affected the proportion of malignancy in this study as this examination is more frequently performed in cases where malignancy and visual capabilities are likely threatened.6 table 3 also showed that most of tumors were located in retina, which was attributed to the high number of retinoblastoma, as also found in the us. 3,5,15,18 retinoblastoma was the most commonly found malignant tumor in this study, in agreement with the findings in the us.3,5,15,17 however, this differs from a study conducted in korea which found rhabdomyosarcoma to be more common than retinoblastoma.16 the most common benign tumor in this study was dermoid cyst, followed by nevus. similarly, dermoid cyst is also the most common type of benign orbital tumor found in american studies.3,5 this study discovered that almost all of the subjects underwent surgery, which some of them also had chemotherapy. chemotherapy can be performed both before surgery to reduce the tumor size, and after surgery to prevent tumor regrowth.6,9,19 surgery is frequently performed to prevent tumor table 6 treatment of pediatric eye tumor patients at the national eye center cicendo eye hospital in the period from 2013–2014 treatment frequency percentage (n=102) (%) surgery 66 64.7 surgery and chemotherapy 29 28.4 chemotherapy 4 3.9 observation 3 2.9 radiotherapy 0 0.0 althea medical journal. 2017;4(1) 10 amj march 2017 growth inside the eyeball and optic nerve infiltration.2,6,20 in this study, no subjects underwent radiotherapy. doctors often decide to only observe when the tumor mass is still very small, seems unthreatening, and has a probability of spontaneous regression.15 based on the results and the discussion above, the conclusions of this study are as follows: the subjects are balanced genderwise, mostly in the 1–4 age group, and mostly residents of west java. the characteristics of the tumors in this study are: the most common chief complaint is leukocoria; the most common malignant tumor is retinoblastoma; and the most common benign tumor is dermoid cyst. based on its location, the majority of the tumors are located in the retina. besides, the most prescribed treatment is surgery. this study only comprised the characteristics recorded in medical record. it is suggested for the next study to take primary data so that patients’ characteristics can be described thoroughly. references 1. kumar v, abbas ak, fausto n, aster jc. robbins and cotran pathologic basis of disease, professional ed: expert consult -online. philadelphia: elsevier health sciences; 2009. p. 677–859. 2. kivelä t. the epidemiological challenge of the most frequent eye cancer: retinoblastoma, an issue of birth and death. br j ophthalmol. 2009;93(9):1129–31. 3. modi pj, shah na, bhalodia jn, gonsai rn. orbital tumors in children : a descriptive study at tertiary care centre. natl j med res. 2013;3(4):362–6. 4. jemal a, murray t, ward e, samuels a, tiwari rc, ghafoor a, et al. cancer statistics, 2005. ca cancer j clin. 2005;55(1):10–30. 5. ophthalmology aao. fundamentals and principles of ophthalmology 20122013. singapore: american academy of ophthalmology; 2012. p. 1–455. 6. li sy, chen scc, tsai cf, sheu sm, yeh jj, tsai cb. incidence and survival of retinoblastoma in taiwan: a nationwide population-based study 1998–2011. br j ophthalmol. 2015;10(1):1–4. 7. nemet ay, deckel y, martin pa, kourt g, chilov m, sharma v, et al. management of periocular basal and squamous cell carcinoma: a series of 485 cases. am j ophthalmol. 2006;142(2):293–7. 8. world health organizations. provisional guidelines on standard international age classifications. new york: publishing service united nations; 1982. p. 32. 9. zhao j, li s, shi j, wang n. clinical presentation and group classification of newly diagnosed intraocular retinoblastoma in china. br j ophthalmol. 2011;95(1):1372–5. 10. chung em, specht cs, schroeder jw. pediatric orbit tumors and tumorlike lesions: neuroepithelial lesions of the ocular globe and optic nerve. radiographics. 2007;27(1):1159–86. 11. ramasubramanian a, shields cl, kytasty c, mahmood z, shah su, shields ja. resection of intraocular tumors (partial lamellar sclerouvectomy) in the pediatric age group. ophthalmology. 2012;119(12):2507–13. 12. shields cl, manjandavida fp, lally se, pieretti g, arepalli sa, caywood eh, et al. intra-arterial chemotherapy for retinoblastoma in 70 eyes. ophthalmology. 2014;121(7):1453–60. 13. yousef ya, finger pt. squamous carcinoma and dysplasia of the conjunctiva and cornea. ophthalmology. 2012;119(2):233– 40. 14. balmer a, zografos l, munier f. diagnosis and current management of retinoblastoma. oncogene. 2006;25(38):5341–9. 15. ophthalmology aao. ophthalmic pathology and intraocular tumors: 20092010. singapore: american academy of ophthalmology; 2009. p. 251–65. 16. lee cs, rim tht, kwon hj, yi jh, lee sc. partial lamellar sclerouvectomy of ciliary body tumors in a korean population. am j ophthalmol. 2013;156(1):36–42. 17. broaddus e, topham a, singh ad. incidence of retinoblastoma in the usa: 1975-2004. br j ophthalmol. 2009;93(1): 21–3. 18. soomro t, kehar si, anwar m. frequency and morphological patterns of malignant intra orbital tumors in various age groups. pak j ophthalmol. 2011;27(4):203–207. 19. wilson mw, halk bg, billups ca, galindo cr. incidence of new tumor formation in patients with hereditary retinoblastoma treated with primary systemic chemotherapy: is there a preventive effect?. ophthalmology. 2007;114(11):2077–82. 20. rahman i, cook ae, leatherbarrow b. mortality following exenteration for malignant tumours of the orbit. br j ophthalmol. 2005;89(1):1444–8. althea medical journal. 2016;3(2) 259 isolated bacteria from hemodialysis water distribution systems in hemodialysis centers in bandung mohd hafeez bin mohd rafee,1 sunarjati sudigdoadi,2 julius b. dewanto3 1faculty of medicine, universitas padjadjaran, 2departmen of microbiology & parasitology faculty of medicine universitas padjadjaran, 3department of biochemistry & molecular biology faculty of medicine, universitas padjadjaran abstract background: despite the advent of water treatment technology for the past few decades, bacterial contamination is still an everlasting issue that requires solid intervention. many studies across the world have identified myriad of bacteria that colonized the hemodialysis water distribution system. this study was conducted to identify common bacteria that colonized the hemodialysis water distribution systems in bandung. methods: this was a descriptive laboratory study conducted at the department of microbiology faculty of medicine universitas padjadjaran in 2014. sterile bottles were used to collect 16 samples of reverse osmosis water from 2 hemodialysis centers in bandung. approximately 15 ml of water volume was collected in each bottle from 7 standard points for water sampling in hemodialysis system. the samples were first inoculated into r2a agar by pour-plate method and colonies grew were sub–cultured onto macconkey and blood agar and the identification was based on gram stain morphology, colony characteristics, and biochemical tests. results: micrococcus luteus and pseudomonas sp. were the two predominant organisms which colonized the hemodialysis water distribution system. in addition, some genus of the enterobacteriaceae such as enterobacter aerogenes, klebsiella pneumoniae, and yersinia pseudotuberculosis were also isolated from the entire system based on the standard points of sampling. conclusions: bacterial contamination in the hemodialysis water distribution system in bandung is still a major problem regardless of the efforts utilized to minimize it. [amj.2016;3(2):259–64] keywords: bacteria, hemodialysis, reverse osmosis, water correspondence: mohd hafeez bin mohd rafee, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827958720 email: hafeezrafee@gmail.com introduction it is widely acknowledged that one of the biggest challenges in hemodialysis is sustaining optimal sterility of the prepared water. in the era before the birth of reverse osmosis system, tap water was used for dialysis fluid to mainly treat acute cases.1 hemodialysis is an extra-corporeal therapy that is prescribed to reduce the signs and symptoms of uremia and to replace partially a number of the key functions of the kidneys when they are no longer sufficient to maintain patient’s wellbeing or life.2 it is estimated that patients of hemodialysis are generally exposed to 400 liters of water which is utilized for dialysis fluid weekly.3 this colossal exposure places the patients at risk of infection by a plethora of pathogenic and opportunistic bacteria. theoretically, reverse osmosis water used in hemodialysis should be free of microorganisms. unfortunately, even with the minute pore-sized filtration membranes, bacterial contamination is still an everlasting issue in the field of hemodialysis. many studies across the globe have isolated many bacteria from reverse osmosis water distribution systems and most of them were opportunistic bacteria that might cause in hemodialysisrelated infections.4 the most predominant isolated bacteria were pseudomonas aeruginosa and acinetobacter species.5 there is no data found exist, however, regarding bacterial contamination in hemodialysis water distribution systems in indonesia. thus, it is important to explore the possibility of contamination of the hemodialysis water distribution systems in hemodialysis centers located in bandung. in addition to that, this althea medical journal. 2016;3(2) 260 amj june 2016 study was specifically carried out to determine the species of bacteria that colonize the hemodialysis water distribution systems in bandung. methods this was a descriptive laboratory study conducted in 2014. the samples were collected from the hemodialysis water distribution systems in 2 separate hemodialysis centers in bandung. this study had been approved by the health research ethics committee faculty of medicine, universitas padjadjaran bandung. first of all, 11 samples of water were collected from center a and 5 samples were collected from center b using sterile bottles at the beginning of a dialysis treatment. each sample was collected at approximately 15 ml and was taken using clean-catch method. the samples consist of a series of sampling in each of the 7 points in the water system: (i) point where water leaves the reverse osmosis machine, (ii) point where water leaves the reverse osmosis tank, (iii) return line of reverse osmosis loop, (iv) point where water enters the dialyzer, (v) point where water enters equipment used to prepare bicarbonate and acid concentrate, (vi) point where dialysis machine is hooked up to the product water loop, and (vii) point where municipal water supply enters the hemodialysis water system.6 in center a, one sample was collected from point 1, 2, 3, 5, and 7, two samples were collected from point 4, and four samples were collected from point 6 as there were several circuits of dialysis machines. on the other hand, in center b, a sample was collected from point 1, 3, 4, 6, and 7. each sample was collected after 3−5 minutes of free flow in high flow rate.7 samples were then processed at the department of microbiology, faculty of medicine, universitas padjadjaran within 2 hours. the samples were inoculated into r2a agar using pour-plate method while the agar was still in liquid form at approximately 40oc and were incubated for 24 hours at 37oc. colonies were then sub–cultured onto macconkey agar (mac) and blood agar (bap) for 24 hours at 37oc and colony characteristics were distinguised. gram staining was conducted for all grown colonies on mac and bap. after that, colonies that grew on mac were cultured into citrate agar, motility–indole–urease agar, and klieger iron agar for biochemical tests to determine genus and species based on the growth characteristics. on a separate matter, colonies grew on bap were tested for catalase and then tested for novobiocin susceptibility figure 1 schematic diagram of the sampling points from the hemodialysis circuits in the centers studied municipal water network depth filter carbon filtersoftener 5 µm filter reverse omosis acid and bicarbonate compartments reserve hemodialysis machine and its dialyzer storage tank 5 7 4 6 3 1 2 althea medical journal. 2016;3(2) 261mohd hafeez bin mohd rafee, sunarjati sudigdoadi, julius b. dewanto: isolated bacteria from hemodialysis water distribution systems in hemodialysis centers in bandung on mueller-hinton agar and incubated for 24 hours at 37oc. results from the 16 collected water samples, it was found out that there were 41 isolates of bacteria with 10 isolates identified as micrococcus luteus and 6 isolates identified as pseudomonas species. three gram of positive bacteria was identified; micrococcus luteus, bacillus sp., s. epidermidis, and s. saphrophyticus. eight gram of negative bacteria were identified as; (a) non-enterobacteriaceae; pseudomonas sp., moraxella sp., and acinetobacter sp.; and (b) enterobacteriaceae; serratia sp., yersinia pseudotuberculosis, enterobacter aerogenes, citrobacter diversus, and klebsiella pneumoniae. discussion hemodialysis is a promising therapy in ensuring the continuing health of endstage renal disease (esrd) patients. it was designed to improve patient’s quality of life yet economically attenuated the cost for endstage renal disease treatment expenditure. subsequently, the enhancement of patient safety with more than one dialysis session per week led to the adoption of the current standard of the thrice-weekly dialysis regimen.8 the water which is supposed to be ultrapure and contains less than 100 cfu/ ml bacteria has somewhat been proven quite the opposite.4,9 in this study, myriad of bacteria has been found to contaminate the hemodialysis water distribution systems in hemodialysis units at bandung. these bacteria were abundantly found in the municipal water networks in hospitals or distribution pipes which they usually colonized and formed biofilms as shown by previous studies.4,10 all of the seven points of standard sampling points used in this study were contaminated and dreadfully up to the point where the municipal water supply enters the hemodialysis system in hemodialysis, the source of water used to make up the dialysate is basically drinking water which is first purified by various methods; the composition and quality of this water depends on its origin.3 over the last two decades, there has been considerable progress in our understanding of microbial pathogenesis related to hemodialysis in which the current emphasis is on patient immunity, bacterial virulence, and the dialysis process itself. this study prognosticates the upcoming problems to the patients as they concurrently suffer from weakened immune system primarily from the firsthand effects of uremia making them prone to infections.4 in addition to direct tissue damage by infection, a number of bacterial products such as lipopolysaccharides (lps), exotoxins, and peptidoglycans share the ability to induce cytokines release and are table 1 identified bacteria genus/species and their corresponding isolates bacteria genus/species number of isolates micrococcus luteus 10 pseudomonas sp. 6 acinetobacter sp. 5 bacillus sp. 5 serratia sp. 3 yersinia pseudotuberculosis 3 enterobacter aerogenes 2 citrobacter diversus 2 klebsiella pneumoniae 2 moraxella sp. 1 staphylococcus epidermidis 1 staphylococcus saphrophyticus 1 total 41 note: sp.: species althea medical journal. 2016;3(2) 262 amj june 2016 known activators of immune functions.11 in the beginning of water treatment, municipal water supply will be distributed through mechanical filters, water softener, carbon filters, deionizers, reverse osmosis modules, and finally to the storage tanks that is ready to be distributed to the whole system using polyvinyl chloride (pvc) tubing.2,4 reverse osmosis module itself is a ground breaking membrane-based technology to purify water by separating the dissolved solids from the feed stream resulting in permeate and reject stream, where water permeates the minute pores of the membranes and is delivered as purified water called permeate water.12,13 despite their capacity to even filter bacteria and their products, contamination is not impossible to remain as a major stirring issue in hemodialysis water treatment system.1 astonishngly, it has been shown by goosen et al.14 in their study that bacteria are able to pass through the microfiltration membranes in waste water applications. in addition, membranes with pore sizes smaller than 0.2 µm are still capable of transmitting secondary effluent cells. it is significant to point out that the study showed up to 1% of the bacteria in the feed which can pass to the permeate side. nonetheless, while a significant portion of the cells in the permeate side showed biological activity, none of the cells were able to reproduce. besides that, it has been speculated that certain naturally occurring gram-negative bacteria are able to multiply in relatively pure reverse osmosis water and stagnant water in the distribution pipes downstream which can be a major source of bacterial contamination and endotoxin products.4,5,15 in addition to that, stagnant water provides felicitous niche for the bacteria to form biofilms on the membrane and further lead to the fouling of the reverse osmosis system.5 conventional spiral wound modules in most reverse osmosis system use brine seals to separate the feed and side-product of the membrane in the pressure vessel. consequently, the use of these materials creates stagnant areas surrounding the membrane which are difficult to be disinfected adequately. as a result, contamination of this area often leads to bypass of bacteria through the brine seals causing contamination to occur in the entire system. it has been proposed that the use of membrane module designs that eliminate brine seals is more effective in cleaning and sanitizing which eventually reduces the possibility of bacteria bypassing the membrane.16 based on the association for the advancement of medical instrumentation (aami) and japanese society for dialysis therapy, the high viable counts (>100 cfu/ ml) detected in this study indicate that the microbiological quality of the water analyzed was well beyond the limit.4,17 the water was contaminated by both gram positive bacteria and gram negative bacteria. the most predominant bacteria was micrococcus luteus. besides that, the water in hemodialysis distribution systems was also abundant with enterobacteriaceae and other gram negative bacteria such as pseudomonas species and acinetobacter species. most of these bacteria are environmental bacteria and abundantly found in soil, water, skin, and medical equipment where they tend to colonize. montanari et al.4 discovered similar bacteria found in hemodialysis water distribution system in são paolo. furthermore, various studies across the globe showed that the most predominant bacteria in hemodialysis water were acinetobacter sp. and pseudomonas aeruginosa. it is important to note that these bacteria often form biofilms and exhibit remarkable resistance to common disinfectants used at most hemodialysis centers.5 as previously stated, bacteria and their products are known to be the activator of immune system. furthermore, many of these products have been shown to bypass high-flux membranes and could be transferred by backdiffusion from the dialysis fluid to the blood compartment in the hemodialysis machine.18 this direct contamination of dialysate and the subsequent shift of bacterial products to the blood site is an important cause for microinflammation in hemodialysis patients.19 this is an alarming issue as hemodialysis patients are exposed to huge amount of water each week which directly makes contact with the circulatory system. moreover, bacterial contact and their products have significant impact to patients in both short and long term. as such, patients with end-stage renal disease have weak immune system and infection caused by these bacteria is unavoidable. this will result in prolonged hospitalization and ultimately increases the cost of treatment. health care providers need to allocate more resources on this matter and will disrupt the balance of service provided. in addition, inappropriate patient’s management, such as antibiotics and ineffective disinfectant used to clean the althea medical journal. 2016;3(2) 263 system, will further deteriorate the condition of the patients and ultimately lead to increase in bacterial resistance to both antibiotics and disinfectant. unfortunately, there were several limitations for this study. firstly, this study received limited research fund causing identification of most species of bacteria difficult to be carried out. secondly, one of the hemodialysis centers studied lack several standard points for water sampling common in hemodialysis. therefore, adequate sampling for the study of the hemodialysis water distribution systems was not possible and samples were only taken from points that were available during sampling. this study hopefully will unearth the problems in hemodialysis and in the long run, reduce hemodialysis-related infections and systemic inflammatory response syndrome (sirs) observed in patients on dialysis treatment. it is widely accepted that the dialysis fluid quality depends on a complex chain of devices, procedures and the quality control implemented.4 in most official recommendations, no claims for disinfection are highlighted, but the major focus is on microbiological analysis. it is indeed a step backward since recommendations for disinfection are more important since quality comes from action not verification.20 this study showed that the hemodialysis centers have yet to achieve the microbiological standard in hemodialysis. periodic monitoring of the systems should be carried out to maintain the optimal sterility of the water. thus, it is crucial to determine the appropriate disinfectant to be used in cleaning the distribution systems and regular maintenance of the system should be carried out. in conclusion, hemodialysis water distribution systems in bandung are colonized with myriad of bacteria consisting both gram negative and gram positive bacteria. as this is the first official study conducted in bandung, this elucidates that the standard of water used in the hemodialysis centers do not reach the benchmark provided by aami and japanese society of dialysis therapy.4,17 this will result in many unwanted complications as hemodialysis patients are categorized as immunocompromised.11 further studies need to be conducted to identify the species of bacteria that colonize hemodialysis water treatment system and therefore deduce the appropriate methods for maintaining optimal condition for water used in hemodialysis. references 1. ledebo i. purification of dialysis fluid: historical background and perspective. blood purif. 2009;27(suppl1):17–9. 2. hakim rm. hemodialysis. in: gilbert sj, weiner de, gipson ds, perazella ma, tonelli m, editors. national kidney foundations’s primer on kidney diseases. 6th ed. philadelphia: elsevier; 2014. p. 508–19. 3. sartori fg, leandro lf, montanari lb, de souza mg, pires rh, sato dn, et al. isolation and identification of environmental mycobacteria in the waters of a hemodialysis center. curr microbiol. 2013;67(1):107–11. 4. montanari lb, sartori fg, cardoso mjdo, varo sd, pires rh, leite cqf, et al. microbiological contamination of a hemodialysis center water distribution system. rev inst med trop são paulo. 2009;51(1):37–43. 5. suman e, varghese b, joseph n, nisha k, kotian ms. the bacterial biofilms in dialysis water systems and the effect of the sub–inhibitory concentrations of chlorine on them. j clin diagn res. 2013;7(5):849– 52. 6. northwest renal network. monitoring your dialysis water treatment system. seattle, washington: northwest renal network; 2005. 7. american public health association. in: eaton ad, clesceri ls, greenberg ae, editors. standard methods for the examination of water and wastewater. 21st ed. washington: american public health association; 2005. 8. pierratos a. long and daily hemodialysis. in: henrich wl, editor. principles and practice of dialysis. 4th ed. philadelphia: lippincott williams & wilkins; 2009. p. 136–48. 9. kawanishi h, masakane i, tomo t. the new standard of fluids for hemodialysis in japan. blood purif. 2009;27(suppl1):5–10. 10. ekrami a, kayedani a, jahangir m, kalantar e, jalali m. isolation of common aerobic bacterial pathogens from the environment of seven hospitals, ahvaz, iran. jundishapur j microbiol. 2011;4(2):75–82. 11. elkabbaj d, bahadi a, cherrah y, errasfa m, eljaoudi r. impact of improving quality of dialysis fluid on oxidative stress and lipid profile in hemodialysis patients. isrn nephrology. 2013;2013:e717849. mohd hafeez bin mohd rafee, sunarjati sudigdoadi, julius b. dewanto: isolated bacteria from hemodialysis water distribution systems in hemodialysis centers in bandung althea medical journal. 2016;3(2) 264 amj june 2016 12. garud r, kore s, kore v, kulkarni g. a short review on process and applications of reverse osmosis. univers j environ res technol. 2011;1 (3):233–8. 13. abid mf, zablouk ma, abid-alameer am. experimental study of dye removal from industrial wastewater by membrane technologies of reverse osmosis and nanofiltration. iranian j environ health sci eng. 2012;9(1):17. 14. goosen m, sablani s, al-hinai h, alobeidani s, al-belushi r, jackson d. fouling of reverse osmosis and ultrafiltration membranes: a critical review. separ sci technol. 2005;39(10):2261–97. 15. ward ra. avoiding toxicity from water– borne contaminants in hemodialysis: new challenges in an era of increased demand for water. adv chronic kidney dis. 2011;18(3):207–13. 16. ward ra. quality management of dialysis fluid for online convective therapies. contrib nephrol. 2011;168:78–88. 17. kawasaki t, uchino j, shinoda t, kawanishi h. guidance of technical management of dialysis water and dialysis fluid for the japan association for clinical engineering technologists. blood purif. 2009;27 (suppl1):41–9. 18. glorieux g, neirynck n, veys n, vanholder r. dialysis water and fluid purity: more than endotoxin. nephrol dial transplant. 2012;27(11):4010–21. 19. schindler r. clinical effect of purification of dialysis fluids, evidence and experience. blood purif. 2009;27(suppl1):20–2. 20. nystrand r. microbiology of water and fluids for hemodialysis. j chin med assoc. 2008;71(5):223–9. althea medical journal. 2016;3(4) 624 amj december 2016 correlation between body mass index and disability in patient with chronic low back pain tiang soon teck,1 tertianto prabowo,2 nani kurniani3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: low back pain is discomfort presented below the margin of the 12th thoracic rib and above the inferior gluteal fold with or without leg pain. it is also a major cause of disability. several risk factors have been identified for contributing low back pain. it is important to determine whether body mass index (bmi) can affect the disability in patients with chronic low back pain. oswestry disability index (odi) questionnaire has been used to measure the severity of disability. thus, the focus of study was to determine correlation between bmi and disability in patients with chronic low back pain. methods: sixty two patients aged 18 years old or more who were clinically diagnosed as having low back pain at least 3 months participated in this study in the period of october to november 2015 in the department of physical medicine and rehabilitation of dr. hasan sadikin general hospital bandung. total sampling method was used. gender, age, weight, height, bmi and disability were recorded using odi questionnaire. this analytical study was cross sectional study and the ordinal variable was analyzed using linear regression analysis. results: females had higher proportion (77). chronic low back pain patients were equally distributed on normal weight and overweight categories. patient with chronic low back pain had higher chances of developing moderate disability. there were positive correlation between bmi and disability. nevertheless, there was no statistically analysis difference between model 1 and 2. conclusions: the bmi affects the disability in patients with chronic low back pain. [amj.2016;3(4):624–8] keywords: body mass index, disability, low back pain, oswestry disability index questionnaire correspondence: tiang soon teck, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287726068500 email: thompson_0511@hotmail.com introduction disability is defined as any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being according to the world health organization (who). there are over one billion people (15%) with disabilities in the world. between hundred and ten million and hundred and ninety million people aged fifty years old and older have obvious problem in functioning.1 body mass index (bmi) is a reliable indicator of body fat for most people but bmi is not a diagnostic tool. furthermore, bmi is cheap and easy to use for doctors and even general population. the bmi is categorized into few groups which are underweight, normal, overweight, and obese.2 low back pain is one of the very common health problem worldwide and it is also a major cause of disability which affecting performance at work and general wellbeing. low back pain can be categorized into three types, i.e. acute, sub-acute, and chronic. back pain is not a disease but more like a symptom thus it is considered neither a disease nor a diagnostic entity of any sort.3,4 the 2010 global burden of disease study has showed that low back pain is among the top 10 diseases and injuries with the highest number of disabilityadjusted life year (dalys) worldwide, and ranked sixth in term of the overall disease burden. in industrialized countries, the lifetime prevalence of non-specific (common) low back pain is estimated 60% to 70% in adult. while one-year prevalence is 15% to 45% and adult althea medical journal. 2016;3(4) 625 incidence is 5% per year. cases of low back pain increase in a considerable amount due to deterioration of the intervertebral discs in older people as the world populations aged.3,5,6 besides, obesity is one of the lifestyle factors that causes low back pain and the excessive body weight has mechanical ill effects on the back caused by excessive weight bearing causing disability.7 excessive height also increases pressure on the spine thus limiting the range of motion of back which results in disability. thus, the focus of this study was to identify the correlation between bmi and disability based on oswestry disability index (odi) in patient with chronic low back pain at physical medicine and rehabilitation department, dr. hasan sadikin general hospital, bandung. methods cross sectional study was carried out in the period of october to november 2015. this study was performed with approval from health research ethics committee, faculty of medicine, universitas padjadjaran. the instruments used were odi questionnaire indonesian version, measuring tape, and electronic weighing scale. total sampling method was used in which patients that administered to department of physical medicine and rehabilitation, dr. hasan sadikin general hospital, bandung were selected and filtered through several inclusion and exclusion criteria. patients aged 18 years old or more who were clinically diagnosed by doctor as having low back pain at least 3 months were included in the study; furthermore, patients with neck cancer or trauma which cause radiating back pain were excluded to prevent alteration of the data collected. eligible subjects were approached. those willing to participate then received explanation about the procedure and purpose of the test were explained, and then asked to fill up consent form. after consent was obtained, height and weight of the subjects were measured using standard scales and recorded, further interpreted into bmi based on who guidelines. then, based on calculated bmi, subjects were categorized into four groups: below 18.5; 18.5 to 24.9; 25 to 29.9; and 30 and above indicating obese, indicating underweight, normal weight, overweight, and obese, consecutively. the disability specifically from low back pain was measured using indonesian version of odi questionnaire. the odi has ten items including: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex, social, and travel. there are six statements in each item with scores of 0 through 5 and the patient chose the statement that was appropriate to his or her ability or current condition. the statement correlating to score of 5 represented the greatest disability and the statement correlating with a score of 0 indicated the least disability. the questionnaire was filled by subjects, but they could ask for explanation during the process. the odi was interpreted into 5 group: 0% to 20% (minimal disability), 21% to 40% (moderate disability), 41% to 60% (severe disability), 61% to 80% (crippled), and 81% to 100% (bed bound ).8,9 data obtained were ordinal and continuous variables, therefore, the correlation between bmi and odi was analyzed using linear regression method. the result was statistically significant when the p-value was < 0.05. results during study period, there were 62 subjects recruited. females had higher proportion (77 vs. 23). patients with older age than the mean age had increased chances to develop low back pain (table 1). chronic low back pain patients were equally table 1 general characteristics of patient characteristics n(%) mean(sd) gender male 14 (23) female 48 (77) age(years) 54.21(14.52) weight(kg) 60.92(7.67) height(cm) 155.92(7.48) tiang soon teck, tertianto prabowo, nani kurniani: correlation between body mass index and disability in patient with chronic low back pain althea medical journal. 2016;3(4) 626 amj december 2016 between model 1 and 2 because both of them were significant and showed positive correlation (table 4). discussion in this study, the subjects were patients who were clinically diagnosed as low back pain for more than 3 months and must be from aged 18 to elderly. it was in accordance with the other study which stated that the incidence of low back pain increases on people aged toward their 50–60s.10 the result showed that females had higher proportion, it was indicating that women had higher chances to develop low back pain. distributed on normal weight and overweight categories, but when added obese category, it had showed that abnormal weight patients had higher odds to get low back pain (table 2). patient with chronic low back pain had higher chances of developing moderate disability. this result occurred because it had the highest proportion of people (table 3). no subjects were bed bound. linear regression was used to analyzed bmi and disability. the total variability was explained by linear regression with bmi as predictor (figure 1). after sex and age were adjusted, there were positive correlation between bmi and disability as indicated in model 2. nevertheless, there was no statistically analysis difference table 2 distribution of chronic low back pain patient according body mass index bmi* category n=62 % normal 29 47 overweight 29 47 obese 4 6 *bmi= body mass index table 3 distribution of chronic low back pain patient according disability disability category n= 62 % minimal disability 10 16 moderate disability 36 58 severe disability 15 24 cripple 1 2 figure 1 distribution of disability according to bmi althea medical journal. 2016;3(4) 627tiang soon teck, tertianto prabowo, nani kurniani: correlation between body mass index and disability in patient with chronic low back pain people with higher value than mean weight and mean height had greater possibilities to develop disability. there was positive correlation between the bmi and disability in patients with chronic low back pain. several factors might contribute to the occurrence of this significant result. the correlation between body weight and both morbidity and mortality has been examined extensively but relatively few researches have investigated on the correlation between body weight and disability in low back pain. although few studies have been conducted, obesity has shown higher prevalence of disability in cross-sectional and longitudinal study. additionally, the correlation between bmi and disability is the strongest among those who are underweight and obese. besides, obesity may lead to disability as a consequence of increased body weight, associated co-morbidities, environmental factors, or a combination of these. obesity causes greater mechanical stress on joints and the spine of patients, the risk of back pain and osteoarthritis that may in turn limit mobility of the body. furthermore, obesity also leads to increase protein glycation in connective tissue or atherogenesis which decreases blood flow to the spine. thus, some obese people face difficulties in performing several movements such as walking, climbing steps, driving, or stressing. this problem in turn leads to physical inactivity, pain and discomfort, functional limitations and mental distress and range of motion decrease.5,11,12 however, in this study, bmi causes increased disability in chronic low back pain patients. furthermore, there is a study showed that when whole body and upper and lower limbs of an individual have a greater fat mass, it has higher tendency to have higher levels of low back pain intensity and disability. based on the analysis of data collected, it has proven that there is correlation between fat mass and pain intensity and disability. thus, this study revealed that there is correlation between bmi and disability. in this study, body composition was not measured, however, the bmi has been used and does not provide specific information on fat and lean tissue mass.13 however, there are some limitations in this study. the sample biased because this study used self-reporting questionnaire to measure the quality of pain and disability. of this study, each individual has different endurance level on pain which can affect the result of the study. short research period also may affect the result of study because more subjects are usually needed to represent the populations in order to increase the validity of result. the validation of the indonesian version odi questionnaire from the expert has not yet been conducted, thus it may affect the answers given by patient further altering the result of study. in conclusion, there is positive linear correlation between bmi and disability in patients with chronic low back pain. since the result showed positive correlation, this study suggested that chronic low back pain patients need to decrease their weight and maintain it at normal value. besides, the physicians can plan a routine exercise for the low back pain patients. references 1. klemenc ketiš z. predictors of healthrelated quality of life and disability in patients with chronic nonspecific low back pain. slovenian med j. 2011;80(5):379–85. 2. smeets r, köke a, lin cw, ferreira m, demoulin c. measures of function in low back pain/disorders: low back pain rating scale (lbprs), oswestry disability index (odi), progressive isoinertial lifting evaluation (pile), quebec back pain disability scale (qbpds), and rolandmorris disability questionnaire (rdq). arthritis care res. 2011;63(s11):s158–73. 3. duthey b. background paper 6.24 low back pain. geneva: who; 2013. table 4 effect of body mass index to disability model 1* model 2** bmi* coefficient(sd) 0.472 (0.130) 0.433 (0.143) sex 0.097 age 0.002 p-value 0.001 0.004 note: * before adjusted for sex and age, ** after adjusted for sex and age, *** bmi= body mass index, # analyzed using linear regression method althea medical journal. 2016;3(4) 628 amj december 2016 4. murray cj, vos t, lozano r, naghavi m, flaxman ad, michaud c, et al. disabilityadjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990– 2010: a systematic analysis for the global burden of disease study 2010. lancet. 2013;380(9859):2197–223. 5. koyanagi a, stickley a, garin n, miret m, ayuso-mateos jl, leonardi m, et al. the association between obesity and back pain in nine countries: a cross-sectional study. bmc public health. 2015;15(1):123–37. 6. lionel k. risk factors forchronic low back pain. j community med health educ. 2014;4(271):2161–0711. 7. tobin d, shaw t, daly e. obesity and low back pain a review of the literature. greater glasgow back pain service (ggbps). 2009;10(1):1–25. 8. mehra a, baker d, disney s, pynsent p. oswestry disability index scoring made easy. ann r coll surg engl. 2008;90(6):497– 99. 9. jeremy c. t. fairbank. why are there different versions of the oswestry disability index? a review. j neurosurg spine. 2014;20(1):83–6. 10. kwon ma, shim ws, kim mh, gwak ms, hahm ts, kim gs, et al. a correlation between low back pain and associated factors: a study involving 772 patients who had undergone general physical examination. j korean med sci. 2006;21(6):1086–91. 11. zdziarski la, wasser jg, vincent hk. chronic pain management in the obese patient: a focused review of key challenges and potential exercise solutions. j pain res. 2015;8(1):63–77. 12. gatineau m, hancock c, dent, m. adult disability and obesity. london: public health england; 2013. 13. urquhart dm, berry p, wluka ae, strauss bj, wang y, proietto j, et al. 2011 young investigator award winner: increased fat mass is associated with high levels of low back pain intensity and disability. spine. 2011;36(16):1320–5. althea medical journal. 2016;3(4) 526 amj december 2016 clinical characteristics and side effects of multidrug resistant tuberculosis therapy at top referral hospital west java indonesia rika nurlaily rahmawati,1 emmy hermiyanti pranggono,2 rovina ruslami3 1faculty of medicine universitas padjadjaran, 2department of internal medicine, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: the efficacy of multidrug resistant tuberculosis (mdr tb) therapy is still being questioned. it has lesser quality, longer duration therapy and high toxicity level. this study was conducted to identify clinical characteristics and side effect of mdr tb therapy at dr. hasan sadikin general hospital, bandung, indonesia as the top referral hospital in west java. methods: a retrospective descriptive study was performed to 142 medical records of mdr tb inpatient and outpatient at dr. hasan sadikin general hospital from january 2012–july 2013. data was collected on october–november 2013. data about clinical characteristics and side effects of mdr tb therapy were collected and was analyzed in the form of percentage. results: from 142 patients, 96% had history of tuberculosis therapy. eighty (56%) of them had positive acid fast bacilli (afb) sputum that still remained after 5th month or more with category 2. seventy (49%) patients used combination of pyrazinamide, capreomycin, levofloxacin, ethionamide and cycloserine (pzcm-lfx-eto-cs). all patients experienced side effects during therapy and the majority of them (91%) had gastroenteropathy and rheumatism. tentamen suicide was detected in one patient. conclusions: the mdr tb patients had history of tuberculosis therapy. the majority of patients used combination of pz-cm-lfx-eto-cs. all patients experienced side effects during mdr tb therapy. [amj.2016;3(4):526–32] keywords: characteristics, multidrug resistant tuberculosis therapy, side effect correspondence: rika nurlaily rahmawati, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8561574163 email: rika_nr@ymail.com introduction multidrug resistant tuberculosis (mdr tb) is defined as tuberculosis infection that caused by resistant microorganism to isoniazid and rifampisin.1 it is global emergency case with approximately 3.7% of new case and 20% of previous tuberculosis case in 2011.1,2 there are 22.2 % of mdr tb cases in developing country.1,2 actually, indonesia is at the eight rank among 27 burden mdr tb countries.2 therapy of mdr tb has given 56−59% good prognosis.3,4 the most contributing factor is known as man made phenomenon, which included health care facilitators, medications and patients.3,5,6 the efficacy of mdr tb therapy, which uses category 4, is still questionable. the regimen has lesser quality and availability in health care. it is also more expensive and more side effects occur compare to other category.6 longer duration therapy and high toxicity level cause the patients uncompliance to therapy. the spread of mdr tb cases is still unkown. updates of research data regarding mdr tb are needed to evaluate the therapy outcomes. registration of mdr tb patients at dr. hasan sadikin general hospital bandung as the top referral hospital in west jaca indonesia, just started on january 2012. therefore, the aim of this study was to identify clinical characteristics and side effects of mdr tb therapy at dr. hasan sadikin general hospital. methods a descriptional retrospective study was conducted to medical records of 142 patients with mdr tb, consisted of inpatients and althea medical journal. 2016;3(4) 527 outpatients at dr. hasan sadikin general hospital, bandung, indonesia, on october– november 2013. data collection was performed on medical records from january 2012–july 2013 (19 months data) that fullfilled the diagnosis of mdr tb, included sputum culture test and drug susceptibility test (dst). variable were included in this study, comprised of clinical characteristics and side effects of mdr tb therapy. the clinical characteristics that defined as suspected criteria of mdr tb at early diagnosis were categorized into 8 categories:7 1) sputum that still remained positive of acid fast bacilli (afb) during previous category 2 tuberculosis (tb) therapy at 5th month or more; 2) sputum that still remained positive of afb during previous category 2 tb therapy at 3rd month or more; 3) sputum that still remained positive of afb during previous category 1 tb therapy at 5th month or more; 4) sputum that still remained positive of afb during previous category 1 with additional 1 month tb therapy; 5) history of tuberculosis therapy for >1 month in nondirectly observed treatment short-course (dots) facility, using second line regimen, such as fluoroquinolone and kanamycin; 6) default case; 7) relapse case (category 1 or 2); and 8) close contact to mdr tb patients. therapy of mdr tb was defined as anti tuberculosis category 4 regimen therapy of mdr tb patients at dr. hasan sadikin general hospital. the therapy was categorized into 3, namely 1) pyrazinamide, kanamycin, levofloxacin, ethionamide, cycloserine (z-kmlfx-eto-cs); 2) pyrazinamide, kanamycin, levofloxacin, ethionamide, cycloserine, ethambutol (z-km-lfx-eto-cs-e) and 3) pyrazinamide, levofloxacin. ethionamide, cycloserine, capreomycin (z-lfx-eto-cscm). side effects of mdr tb therapy defined as side effect that occurred during mdr tb therapy. data were analyzed in the form of percentage this study had been approved by health research ethics committee, faculty of medicine, universitas padjadjaran (number 208) and dr. hasan sadikin general hospital, bandung, indonesia (number 3002). table 1 characteristics of mdr tb patients characteristics of mdr tb patients number of patients n=142 gender male 81 (57%) female 61 (43%) age (years old) median (sd) 36 (12.565) range 15–71 comorbid 11 (8%) diabetes mellitus 2 8 (5%) chronic hepatitis 1 (1%) lupus and pregnant 1 (1%) hiv 1 (1%) no comorbid 110 (77%) no data 21 (15%) current condition still in therapy at dr. hasan sadikin general hospital 94 (66%) died 27 (19%) drop out 13 (9%) become xdr tb 7 (5%) reffered to other hospital 1 (1%) notes: hiv=human immunodeficiency virus; sd=standard deviation; xdr tb=extremely drugs reistant tuberculos rika nurlaily rahmawati, emmy hermiyanti pranggono, rovina ruslami: clinical characteristics and side effects of multidrug resistant tuberculosis therapy at top referral hospital west java indonesia althea medical journal. 2016;3(4) 528 amj december 2016 results half of patients (57%) were male, with median age 36. among 142 patients, 110 (77%) patients had no comorbid. the majority of patients (66%) were still in therapy of mdr tb at dr. hasan sadikin general hospital (table 1). among 142 patients, 96% of them had previous history of tuberculosis therapy. the majority of them (81%) still had positive afb sputum on 5th month or more during previous category 2 tuberculosis therapy, at early diagnosis. rarely, one (1%) patients had no history of tuberculosis therapy (table 2). majority patients (70, 49%) used regimen figure 1 regimen mdr tb therapy and its modification during therapy table 2 clinical characteristics of mdr tb patients clinical characteristics (at early diagnosis) number of patients (%) n=142 history of previous tb therapy 137 (96%) sputum that still remained positive afb during previous category 2 tb therapy at 5th month or more 80 (56%) sputum that still remained positive afb during previous category 2 tb therapy at 3rd month or more 19 (13%) sputum that still remained positive afb during previous category 1 tb therapy at 5th month or more 15 (11%) relapse case (category 1 or 2) 14 (10%) default case 6 (4%) sputum that still remained positive afb during previous category 1 with additional a month tb therapy 2 (1%) history of tb therapy for >1 month in non-dots facility, using second line regimen, such as fluoroquinolone and kanamycin. 1 (1%) no history of tb therapy 1 (1%) close contact to mdr tb patients 1 (1%) no data 4 (3%) notes: tb=tuberculosis; afb=acid fast bacilli; mdr tb=multidrug resistant tuberculosis; dots=directly observed treatment short-course notes: z=pyrazinamide; km=kanamycin; lfx=lefofloxacin; eto=ethionamide; cs=cycloserine; cm=capreomycin; e=ethambutol; pas=p-aminosalycilate acid althea medical journal. 2016;3(4) 529rika nurlaily rahmawati, emmy hermiyanti pranggono, rovina ruslami: clinical characteristics and side effects of multidrug resistant tuberculosis therapy at top referral hospital west java indonesia therapy of z-cm-lfx-eto-cs. from 142 patients, 10 (7%) patients did not have any written data regarding regimen therapy on medical records. few (4%) patients had regimen modification (figure 1). all patients (100%) experienced side effects during therapy. the most common side effects were gastroenteropathy, rheumatism and headache in 113 patients (79%). among 113 patients that experienced gastroenteropathy and rheumatism, 64 of them used z-cm-lfxeto-cs. one (1%) patient had experienced tentamen suicide and it was the most severe side effect of mdr tb therapy (table 3). few patients experienced other side effects of mdr tb therapy. less than 10% patients experienced hematologic abnormalities (leucopenia and thrombocytopenia), visual disorder, vertigo, epilepsy, etc (table 4). discussion this study discovered that most of mdr tb patients had history of tb therapy, the majority of them still experienced positive afb sputum on 5th month or more during previous category 2 tb therapy, at early diagnosis. all patients experienced side effects from mdr tb therapy, while the most common side effects were gastroenteropathy, rheumatism and headache. gastroenteropathy was manifested by nausea, vomit, anorexia, diarrhoea, dan other gastric-enteric disturbance. all patients used combination of pyrazinamide, levofloxacin, ethionamide and cycloserine. in addition to that, 49% patients used capreomycin and 42% patients used kanamycin in their combination regimen therapy. it was the first study in dr. hasan sadikin general hospital, bandung, indonesia. other common side effects were hyperuricemia, nephrotoxicity, audiometric abnormality, hypothyroidism and drug induced liver intoxination. manifestations of drug induced liver intoxination were fatigue, nausea, vomit, anorexia, fever and abdominal pain through anamnesis that were written on medical records. elevation of creatinin and ureum monitored routinely to evaluate side effect of nephrotoxicity. some patients also experienced psychiatric status abnormality. in this study, a patient experienced tentamen suicide and it was the most severe side effects of therapy. few patients experienced regimen modification by stopping or adding regimen to their therapy. in line with this study, a study conducted by tarek et al.8 showed that prevalence of retreatment case was 97.3%, while the remaining were new cases. based on world health organization (who) surveillance research data,1 15% of patients had history table 3 most common side effects of mdr tb therapy side effects regimen z km lfx eto cs (n=60) z cm lfx eto cs (n=70) e z km lfx eto cs (n=3) gastro-enteropathy (n=113) 47 (42%) 64 (57%) 2 (2%) rheumatism (n=113) 49 (43%) 64 (57%) 2 (2%) headache (n=113) 48 (42%) 63 (56%) 2 (2%) hyperuricemia (n=71) 29 (41%) 42 (59%) 0 (0%) hypokalemia (n=67) 26 (39%) 39 (58%) 2 (3%) audiometry abnormality (n=49) 26 (53%) 21 (43%) 2 (4%) nephrotoxicity ureum (n=35) 13 (37%) 21 (60%) 1 (3%) creatinine (n=25) 11 (44%) 13 (52%) 1 (4%) pain at site of injection (n=25) 8 (32%) 16 (64%) 1 (4%) psychiatric status abnormality (n=26) 12 (46%) 14 (54%) 0 (0%) tentamen suicide (n=1) 0 (0%) 1 (1%) 0 (0%) hypothyroidism (n=21) 9 (43%) 12 (57%) 0 (0%) notes: z=pyrazinamide; km=kanamycin; lfx=lefofloxacin; eto= ethionamide; cs=cycloserine; cm=capreomycin; e=ethambutol althea medical journal. 2016;3(4) 530 amj december 2016 of tb therapy and 3% of patients were new case. this study showed that 1% patient had no history tb therapy. specifically, new case is caused by close contact to mdr tb patients (infected by patients).5 according to previous study, there were 36% of patients still experienced positif afb sputum during 5th month or more of category 2 tb therapy usage and 32% of patients experienced relapse case.1 it is different from this study whereas fewer (10%) of patients were experienced relapse. these findings were caused by man made phenomenon, which did not follow standardized therapy appropriately. the reason were multifactorial, included patients factor (mostly by uncompliance case, human immunodeficiency virus/ hiv patient), health care facilitators factors (quality of dots implementation, access to diagnosing and therapy), and regimen factors (quality of regimen, determination of regimen dose).5,9,10 in this study, the side effects of therapy was similar to the previously study by munawwarah et al.11 that 100% of mdr tb patients had side effects. from surveillance data who 2011 research, the most common side effects were nausea/vomit (32.8%)1 , followed by arthralgia (16.4%), hearing disturbance (12%), headache (1.7%) and electrolyte disturbance (11.5%).1 inappropriate dosage played important role that contributed to side effects of mdr tb patients.1 from result findings, rheumatism was manifested with arthralgia, myalgia, gout arthritis through anamnesis and hyperuricemia through laboratory examination. pyrazinamide has 2 main side effects: drug induced liver intoxication dan gout-like arthralgia (manifested by rheumatism and hyperuricemia).1,12,13 persistent nausea and vomit were caused by ethionamide or p-aminosalicylic acid (pas), whereas transient nausea & vomit were caused by pyrazinamide.14,15 gastrointestinal table 2 clinical characteristics of mdr tb patients side effects number of patients (n=142) anemia 17 (12%) insomnia 17 (12%) fatigue 17 (12%) lymphocytopenia 15 (11%) drug induced liver injury sgot 13 (9%) sgpt 2 (1%) peripheral neuropathy 14 (10%) skin inflamation manifestation 12 (8%) fever 11 (8%) leukocytosis 7 (5%) thrombocytosis 6 (4%) palpitation 4 (3%) visual disorder 4 (3%) dehydration 4 (3%) vertigo 3 (2%) leukopenia 2 (1%) cardiac rhythm abnormality 2 (1%) thrombocytopenia 1 (1%) epilepsy 1 (1%) taste and smell abnormality 1 (1%) polycythemia sekunder 1 (1%) metabolic acidosis 1 (1%) notes: sgot=serum glutamic-oxaloacetic transaminase, sgpt=serum glutamic-pyruvic transaminase althea medical journal. 2016;3(4) 531 disturbance can be caused by levofloxacin.1 meanwhile, pyrazinamide can cause headache, but chronic headache can be probably caused by cycloserine. headache also can be caused by levofloxacin.1 in this study, some patients experienced electrolyte imbalance, specifically hypokalemia. hypokalemia can be caused by injecting drugs (capreomycin), vomit, diarrhea and other causes.15 patients were usually manifested by fatigue, palpitation, paresthesia, muscle cramp and numbness. nephrotoxicity can be seen through laboratory examination of ureum and creatinine.15 injecting drugs, such as kanamycin (frequently) and cycloserine, can have direct effect on kidney, that can cause electrolyte imbalance.13 capreomycin and kanamycin can cause auditory abnormality.1,16 according to reviono et al.17 that 57.6% of mdr tb patients experienced hearing disturbance. out of them, 54.2% used kanamycin. cycloserine can affect psychiatric status of patients, that manifested as depression, anxiety or psychosis (hallucination, delirium).13,14,16 high level of tsh can be caused by ethionamide and pas combination.18,19 few patients had other side effects during mdr tb therapy. visual disorder can be caused by ethionamide. on the other hand, the most common side effect of ethambutol is neuritis opticus.13 therefore, patients should be monitored by visual acquity test monthly. rarely, levofloxacin can cause leukopenia and eosinophillia in <1% patients.1 the pas also causes thrombocytopenia, agranulocytosis, leukopenia and hemolytic anemia.14 patients had baseline examinations before mdr tb therapy was started. the baseline examinations were laboratorium examination (blood test, urine macroscopic and microscopic test), rontgen, audiometric test, psychiatric status test, thyroid function test, etc.1,14 there were also several examinations for follow up the patients during mdr tb therapy routinely. those examinations were rontgen, laboratorium examination (blood and urine), thyroid function test, audiometric test, psychiatric status test, etc.1,6,8 by those baseline examinations and follow up examinations routinely, physicians can evaluate condition of patients, whether side effects and its management or regimen modification during therapy.14 the therapy modifications depend on severity of patients’s condition. it can be caused by some condition, such as nontolerated side effects or new drug resistant.1 usage of kanamycin can be stopped if the side effects are worsened, for example severe ototoxicity or nephrotoxicity. ototoxicity can be observed monthly by follow up and audiometric test, while nephrotoxicity can be monitored by creatinine level. kanamycin also can cause vertigo. usage of ethionamide can be stopped if the side effects are worsened, for example severe nausea and vomit, that leads to dehydration. monitoring electrolyte is needed in this case. capreomycin is indicated, if there is no improvement (resistant) to kanamycin, based on dst result.20 the pas has welltolerated and no cross resistance. data about baseline and clinical characteristics, regimen and mainly side effects of mdr tb patients were still not completely written in medical records.this condition was the limitation of this study. in conclusion, most of mdr tb patients in dr. hasan sadikin general hospital had previous history of tuberculosis therapy. the majority of them still experienced positive afb sputum on 5th month or more during previous category 2 tuberculosis therapy, at early diagnosis. the majority of patients used combination of pyrazinamide, capreomycin, levofloxacin, ethionamide and cycloserine. the majority of them had gastroenteropathy and rheumatism. all patients experienced side effects during mdr tb therapy. the most common side effects were gastroenteropathy, rheumatism and headache. the most severe side effect was tentamen suicide. few patients had regimen modification during therapy depends on their condition for better therapy outcomes. in this secondary data based survey, complete written findings of status patients during therapy by health care facilitators were needed to evaluate patient condition. by that process, updates of research data regarding mdr tb can be achived to monitor the effectivity of therapy. further study needed to be conducted for evaluation of mdr tb patients, either by primary and secondary data collection. references 1. falzon d, jaramillo e, schünemann hj, arentz m, bauer m, bayona j, et al. who guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update. eur respir j. 2011;38(3):516−28. 2. who. global tuberculosis report. rika nurlaily rahmawati, emmy hermiyanti pranggono, rovina ruslami: clinical characteristics and side effects of multidrug resistant tuberculosis therapy at top referral hospital west java indonesia althea medical journal. 2016;3(4) 532 amj december 2016 switzerland: world health organization; 2012. 3. munir sm, nawas a, soetoyo dk. pengamatan pasien tuberkulosis paru dengan multidrug resistant (tb-mdr) di poliklinik paru rsup persahabatan. j respir indo. 2010;30(2):92−104. 4. eker b, ortmann j, migliori gb, sotgiu g, muetterlein r, centis r, et al. multidrug-and extensively drug-resistant tuberculosis, germany. emerg infect dis. 2008;14(11):1700−6. 5. aditama t, kamso s, basri c, surya a. pedoman nasional penanggulangan tuberkulosis. 2nd ed. jakarta: departemen kesehatan ri. 2007. p. 1–33. 6. burhan e. peran istc dalam pencegahan mdr. jurnal tuberkulosis indonesia. 2010;7:12−5. 7. depkes ri. petunjuk teknis penatalaksanaan pasien tb-mdr. jakarta: departemen kesehatan ri. 2009. 8. safwat tm, elmasry aa, mohamed akm. prevalence of multidrug resistant tuberculosis in abbassia chest hospital from july 2006 to december 2009. ejb. 2011:5(2):124−30. 9. novizar d, nawas a, burhan e. identifikasi faktor resiko tuberkulosis multidrugresistant (mdr-tb). maj kedokt indon. 2010;60(12):537. 10. van deun a, salim ma, das ap, bastian i, portaels f. results of a standardised regimen for multidrug-resistant tuberculosis in bangladesh. int j tuberc lung dis. 2004;8(5):560−7. 11. munawwarah r, leida i, wahiduddin. gambaran faktor resiko pengobatan tbmdr rs labuang baji kota makassar tahun 2013 [thesis]. makassar: hasanuddin university. 2013. 12. younossian ab, rochat t, ketterer jp, wacker j, janssens jp. high hepatotoxicity of pyrazinamide and ethambutol for treatment of latent tuberculosis. eur respir j. 2005;26(3):462−4. 13. torun t, gungor g, ozmen i, bolukbasi y, maden e, bicakci b, et al. side effects associated with the treatment of multidrugresistant tuberculosis. int j tuberc lung dis. 2005;9(12):1373−7. 14. shin ss, pasechnikov ad, gelmanova iy, peremitin gg, strelis ak, mishustin s, et al. adverse reactions among patients being treated for mdr-tb in tomsk, russia. int j tuberc lung dis. 2007;11(12):1314−20. 15. shin s, furin j, alcántara f, hyson a, joseph k, sánchez e, et al. hypokalemia among patients receiving treatment for multidrug-resistant tuberculosis. chest. 2004;125(3):974−80. 16. chan ed, laurel v, strand mj, chan jf, huynh m-ln, goble m, et al. treatment and outcome analysis of 205 patients with multidrug-resistant tuberculosis. am j respir crit care med. 2004;169(10):1103−9. 17. reviono, widayanto, harsini, aphridasari j, sutanto ys. steptomisin dan insidensi penurunan pendengaran pada pasien multidrug resistant tuberculosis di rumah sakit dr. moewardi. j respir indo. 2013;33(3):167−72. 18. satti h, mafukidze a, jooste pl, mclaughlin mm, farmer pe, seung kj. high rate of hypothyroidism among patients treated for multidrug-resistant tuberculosis in lesotho. int j tuberc lung dis. 2012;16(4):468−72. 19. muchtar a. farmakologi obat antituberkulosis (oat) sekunder. jurnal tuberkulosis indonesia. 2006;3(2):23−9. 20. njaramba p, naidoo s. managing multidrugresistant tuberculosis in hospitalised patients: a review of treatment outcomes. south afr j epidemiol infect. 2007;22(2,3):39−44. althea medical journal. 2016;3(4) 590 amj december 2016 correlation between mid upper arm muscle area/size and muscle strength tan yong bin,1 vitriana,2 titing nurhayati3 1faculty of medicine, universitas padjadjaran, 2department of physical medicine and rehabilition faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung 3department of cardiovascular faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: muscle area/size reflects the true magnitude of muscle tissue changes. muscle strength is an active tension generated by muscle that depends on its capacity to exert force on an object. the relation between the quantity of muscle area and the amount of muscle strength is suggested. the aim of this study was to analyze the correlation between mid-upper arm muscle area/size and muscular strength. methods: this analytic study with ten subjects (medical students) who met the inclusion and exclusion criteriawas conducted at the faculty of medicine universitas padjadjaran in jatinangor campus from 22th of april to 1st of november 2014. a skinfold calliper was used to measure triceps skinfold while a measuring tape measured the mid-upper arm circumference and a dynamometer measured the muscle strength. a formula was used to determine the mid-upper arm muscle area/size using mid-upper arm circumference and triceps skinfold. the collected data were analyzed statistically using correlation test and simple linear regression. results: there was a strong correlation between mid-upper arm muscle area/size and muscular strength (correlation cooefficient 0.746). moreover, the higher the body mass index, the stronger the muscle strength was to some point. if the bmi was more than 25 kg/m2, this findings did not occurred. conclusions: there is a strong positive correlation between mid-upper arm muscle area/size and arm muscle strength. [amj.2016;3(4):590–5] keywords: mid-upper arm, muscle area/size, muscle strength correspondence: tan yong bin, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287827571509 email: y1b2t3a4n5@gmail.com introduction muscle is an organ that produces movement of an organism by contractions.1 muscular strength is produced by contraction of muscles. it is the ability of an animal or human to exert force on physical objects using muscle depends on its capacity to generate active tension.2 mid upper arm muscle area reflects the true magnitude of muscle tissue changes.3 training the muscle to increase its area can have many advantages, among others is in preventing limb muscle dysfunction in chronic obstructive pulmonary disorder.4 it is widely accepted that the muscle force produced is directly proportional to its crosssectional area. ikai and fukunaga5 discovered that there was a positive relationship between cross-sectional area and maximum isometric strength of musculus biceps brachii. somehow, brad jon’s study showed that a small to moderate muscle hypertrophy did not have significant effect on muscle strength.6 this contradiction leads to the need of this study. this study was conducted among medical students from the faculty of medicine universitas padjadjaran to discover the correlation between mid-upper arm muscle area and muscular strength. methods this study was carried out using an analytic study with numeric variables of independent and dependent variables. the study population was the medical students in the faculty of medicine universitas padjadjaran and was conducted at the faculty of medicine universitas padjadjaran, in jatinangor campus from 22th of april to 1st of althea medical journal. 2016;3(4) 591 november 2014. the random sampling method was used in this study. a total of 10 medical students/ subjects based on the sample size calculation and who met the inclusion criteria participated in this study. the inclusion criteria of the subject selections were male, age 18-25 years, normal healthy status, body mass index within normal weight to overweight, and agreed to participate in this study by signing the informed consent. the exclusion criteria were a person with arm impairment and disability which caused he/she could not do the test, drug user such as hormones, fatigue and alcoholic. furthermore, body mass index was calculated as weight divided by height squared. body mass index 20 kg/m2 and below was defined as underweight, normal weight was 18.5–24.9 kg/m2, overweight was 25–29.9 kg/m2 and obesity was above 30 kg/ m2.7 the normal value of triceps skin fold for normal weight men was 12.0mm (standard deviation: 0.5mm) and for overweight men was 18.2mm (standard deviation: 0.6 mm).7 the normative mean value for muscle strength was 265 newton (standard deviation:38) for male.8 moreover, fatigue was defined as a feeling of lack of energy, weariness and aversion to effort. the assessment of fatigue was through interviewing.10 muscle fatigue is a decline in muscle performance associated with muscle activity. prolonged high-frequency stimulation applied focally to only one region of a muscle fibre produces greater and faster loss of force than does stimulation applied all along fibre which failure of longitudinal action potential transmission is an important fatigue mechanism.11 the subjects were asked whether they performed any vigorous physical activity in the previous 2 hours. the data was collected with the hand held dynamometer readings (recorded in newton), callipers and measuring tapes. the mid-upper arm muscle area was calculated through the formula involving mid-upper arm circumference and triceps skin-fold. furthermore, the subjects were prepared before the test and were made sure that they did not have vigorous physical activity in the previous 2 hours and were in good health status and well condition. the subjects’ basic information was collected and informed consent. next, the subjects were required to lie down on a flat surface bed. then, the midupper arm circumference was measured with a measuring tape. first, the midpoint of the upper-arm was defined by the location of the shoulder and tip of the elbow by bending the elbow 90 degree. the tape was placed at the tip of the shoulder to the elbow and marked the midpoint. then, the measuring tape was measured around the mid-upper arm between the shoulder and the tip of the elbow while arm lay beside the side of body and relaxed. after measuring the mid-upper arm, the subject was measured for triceps skinfold by the caliper. then, the midpoint of the upper arm was defined. the fold of skin with underlying fat was pulled out and held with thumb and index finger as a c-shaped. with the caliper in the other hand, the jaws of the caliper were placed on the skin-folds about 7.5mm away from the measuring thumb. the trigger of the caliper was released and the measurement was read within 5 seconds. the fingers or caliper should not be released before the reading of the measurement. the procedure was repeated for 3 times to get the average results. the subject was stabilized on superior aspect of shoulder or arm. the limb position was set as shoulder in neutral with elbow flexed 90 degree and the forearm in neutral. the dynamometer was placed just proximal to styloid process on the dominant arm. the subject was requested to flex his/her elbow against the dynamometer fixed on the tester’s hand and resisted the movement. the maximum flexing force was encouraged by the tester through words. the action of testing procedure was practiced for a few times until subjects were able to do it correctly. the test was conducted twice at the same side. the reading was recorded in newton (n). the collected data were analyzed using correlation test and simple linear regression. ethical clearance was agreed by the health research ethics committee, faculty of medicine universitas padjadjaran. results the subjects were apparently healthy men figure 1 the formula to calculate mid upper arm muscle area tan yong bin, vitriana, titing nurhayati: correlation between mid upper arm muscle area/size and muscle strength althea medical journal. 2016;3(4) 592 amj december 2016 figure 2 scatter plot of the correlation between body mass index and muscle strength with a mean age of 21.9 years. their mean body mass index (bmi) was laid in normal weight category. the mean measurement for mid-upper arm circumference was 31.4, triceps skin folds was 1.87, mid-upper arm muscle area was 51.51 and muscle strength was 238.74 (table 1). the statistical test of this study revealed that there was a strong positive correlation (the pearson correlation coefficient was 0.746) between arm muscle area/size and arm muscle strength. moreover, by using simple linear regression test, it showed that the higher the bmi, the stronger the muscle strength to some point was. if the bmi was more than 25 kg/m2, this findings did not occurred (figure 1). discussion the initial findings in this study showed that there was a positive correlation between mid-upper arm muscle area/size and muscle strength, meaning that the more mid-upper arm muscle area/size will produce more arm muscle strength. a study by newman et al.12 stated that muscle strength was closely related to the absolute quantity of muscle mass. this statement was parallel with the study of abe et al.13 who reported that the combination of resistance training and kaatsu-walk training, would increase the muscle cross sectional area table 1 table of physical characteristic of subjects characteristics mean standard deviation age(y) 21.9 0.875 weight(kg) 70.7 12.302 height(cm) 171.8 7.405 body mass index(kg/m2) 23.9 3.311 mid-upper arm circumference(cm) 31.4 3.315 triceps skinfold(cm) 1.87 0.795 mid-upper arm muscle area/size(cm2) 51.51 8.828 muscle strength(n) 238.74 25.708 althea medical journal. 2016;3(4) 593tan yong bin, vitriana, titing nurhayati: correlation between mid upper arm muscle area/size and muscle strength (4–7%) and at the same time one repetition maximum isometric strength was increased (8–10%). those studies strengthened the relationship between muscle size and muscle strength. the positive correlation between muscle size and muscle strength could explain a phenomenon that occurred in the elderly. a study by goodpaster et al.14 reported that the reduced muscle mass leads to age-related decline of strength in older adults. the muscle weakness decreases older adults’ basic life function and diminishes physical activity. the loss of muscle mass was both the cause and the result of the loss of strength.14 in this study, a contradictory findings was discovered. some subjects with higher mid-upper arm area muscle (55.3 cm2), had lower muscle strength compared to those with lower muscle arm area (49.8 cm2). it was suspected that to reach a certain value of muscle strength could be influenced by many factors. one of the factors was physical activity. physical activity was associated with the increase of muscle strength despite the muscle mass. hughes et al.15 discovered that a certain level of physical activity has a direct effect on muscle strength. people with regular physical activity expenditure rate will have more muscle strength than those without.14 it could be presumed that the subjects who had higher muscle arm area and lower muscle strength compared to other subjects used to exercise periodically, but stopped for unknown reasons. due to young age, the muscle mass/ size did not reduce. not all studies had the same results as this study. according to callaghan et al.16, who conducted a study about the existence of quadriceps atrophy in patellofemoral pain syndrome, stated that muscle strength may not be related to muscle size. it could be other factors that cause this difference.16 it was suspected that patients with patellofemoral pain syndrome had more reduction in muscle strength. this condition was not due to decrease of the muscle size but painful sensation resisted its movement while having muscle peak torque testing. so, pain may be one of the factors that influence muscle strength. in this study, the overweight and obese subjects could show lower muscle strength and muscle size than those who were normal weight. people with overweight and obese have different skeletal muscle structure and function than normal weight people, such as less type i and more type ii muscle fibers, impaired muscle oxidative capacity, lower fuel utilization and increase lipid accumulation. it showed that at the same body mass, overweight subjects had lesser muscle voluntary contractions and muscle strength. obese people had less peripheral muscle strength than those who were normal weight. excess adiposity could limit muscle strength gains due to hyper production of proinflamatory cytokines in obesity impairs glucose disposal in muscle.7 there were some limitations in this study. some technical difficulties such as the rigid dynamometer placement sites, which would cause reflex of subjects to reduce maximum force in order to prevent pain. the calculation of muscle area was less reliable than measuring muscle area using magnetic resonance imaging. moreover, this study was limited to the subjects from medical students with small sample size, so the results could not be generalized to the general population. it can be concluded that there is a strong positive correlation between mid-upper arm muscle area/size and muscle strength. the higher the mid-upper arm muscle area/size, the stronger the muscle arm will be. recommendation from this study is that healthy individuals should maintain or improve muscle area to improve muscle strength by resistance exercise 3 times a week. individuals restricted by disease can perform light exercise and simple cardio workouts according to their body conditions. future study can include the general population and conduct in a wide scale to get more accurate and reliable results. additionally, there are many more factors that may interfere with the result such as tools and equipment. magnetic resonance imaging scan can be used to find the muscle area precisely. peak torque, isokinetic dynamometer, resistance testing can be used to measure muscle strength. references 1. dorland wan. dorland’s illustrated medical dictionary. 28th ed. philadelphia: saunders;2008. 2. houglum pa, berttoti db, editors. muscle activity and strength. brunnstrom’s clinical kinesiology. 6th ed. philadelphia, pa: f.a. davis company; 2012. p.126–55 3. chomtho s, fewtrell ms, jaffe a, williams je, wells jc. evaluation of arm anthropometry for assessing pediatric body composition: evidence from healthy and sick children. pediatr res. 2006;59(6):860–5. althea medical journal. 2016;3(4) 594 amj december 2016 4. maltais f, decramer m, casaburi r, barreiro e, burelle y, debigare r, et al. an official american thoracic society/european respiratory society statement: update on limb muscle dysfunction in chronic obstructive pulmonary disease. am j respir crit care med. 2014;189(9):e15–62 5. waugh c, blazevich a, fath f, korff t. age-related changes in mechanical properties of the achilles tendon. j anat. 2012;220(2):144–55. 6. schoenfeld bj, aragon aa, krieger jw. the effect of protein timing on muscle strength and hypertrophy: a meta-analysis. j int soc sports nutr. 2013;10(1):53. 7. pescatello ls, kelsey bk, price tb, seip rl, angelopoulos tj, clarkson pm, et al. the muscle strength and size response to upper arm, unilateral resistance training among adults who are overweight and obese. j strength cond res. 2007;21(2):307–13. 8. woods jl, iuliano-burns s, king sj, strauss bj, walker kz. poor physical function in elderly women in low-level aged care is related to muscle strength rather than to measures of sarcopenia. clin interv aging. 2011;6:67–76. 9. akagi r, takai y, ohta m, kanehisa h, kawakami y, fukunaga t. muscle volume compared to cross-sectional area is more appropriate for evaluating muscle strength in young and elderly individuals. age ageing. 2009;38(5):564–9. 10. mead g, lynch j, greig c, young a, lewis s, sharpe m. evaluation of fatigue scales in stroke patients. stroke. 2007;38(7):2090– 5. 11. allen dg, lamb g, westerblad h. skeletal muscle fatigue: cellular mechanisms. physiol rev. 2008;88(1):287–332. 12. newman ab, kupelian v, visser m, simonsick em, goodpaster bh, kritchevsky sb, et al. strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort. j gerontol a biol sci med sci. 2006;61(1):72–7. 13. abe t, kearns cf, sato y. muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, kaatsu-walk training. j appl physiol (1985). 2006;100(5):1460– 6 14. goodpaster bh, park sw, harris tb, kritchevsky sb, nevitt m, et al. the loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. j gerontol a biol sci med sci. 2006;61(10):1059–64. 15. hughes va, frontera wr, wood m, evans wj, dallal ge, roubenoff r, singh ma. longitudinal muscle strength changes in older adults: influence of muscle mass, physical activity, and health. j gerontol a biol sci med sci. 2001;56(5):b209–17. 16. callaghan m, oldham j. quadriceps atrophy: to what extent does it exist in patellofemoral pain syndrome. br j sports med. 2004;38(3):295–9. althea medical journal. 2016;3(4) 595 health belief model theory application on voluntary counseling and testing among homosexual men in bandung greater area argya nareswara,1 chrysanti murad,2 irvan afriandi3 1faculty of medicine universitas padjadjaran, 2department of microbiology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: the number of human immunodeficiency virus (hiv) cases is high and is constantly increasing. homosexual men as a transmission niche is not only significant in terms of numbers, but also in natural aspects of anal sex, tropism of hiv-1, and high-risk behavior. voluntary counseling and testing (vct) is important for accelerating diagnosis and management plan; yet the uptake on high-risk population in indonesia is low. a behavior-reasoning theory, health belief model (hbm), attempts to explain whether or not individuals engage in certain health behavior. this study tries to assess participation rate of vct, to portray hbm variables perception, and to depict significance of hbm variables towards vct uptake or vct intention. methods: this study was conducted in october-november 2014 using cross-sectional design; 127 respondents were gathered according to respondent driven snowball sampling. this study used an internet-based questionnaire derived from champion’s 1984 mammogram hbm questionnaire. privacy and compensation were obtained. the chi square test and logistic regression of hbm variables were done. results: the vct uptake was low (15.7%). certain sexual experience and commitment were significant (commitment to men p=0.027, oral sex experience with men p=0.001, anal sex experience with men p=0.038). chi square test revealed significance on perceived susceptibility, perceived benefit, and cues to action. conclusions: uptake of vct is considerably low compared with total high risk population and other similar studies. personal susceptibility to hiv/aids is recommended to be emphasized; while vct benefit and cues to action in young homosexual men communities are better encouraged. [amj.2016;3(4):595–604] keywords: health belief model, hiv, homosexual, vct correspondence: argya nareswara, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6289656067175 email: rgynrswr@gmail.com introduction since 2014, infection of human immunodeficiency virus (hiv) has been a global problem that has not been solved. with 30.000.000 positive individuals globally and 2.500.000 global case incidence per year, the number of hiv-positive individual is increasing day by day.1 in indonesia, the prevalence of hiv infection has reached 0.2% among general population. in addition, cumulative hiv cases reported until june 2012 reached 86.762 cases, whereas cumulative acquired immunodeficiency syndrome (aids) cases reported from 1987 until june 2012 was 32.103 cases.2,3 homosexual men are considered more susceptible to be infected by hiv because of hiv-1 tropism in large intestine endothelial cells, low condom usage, and high promiscuity which make the odds of being infected by hiv 18.7 times higher compared with those in heteronormative adult population in asia.1,4-8 with the lowest estimation of 2.2% proportion from the total male population, men who have sex with men (msm) is hiv-transmitting niche that is quite big.9 in indonesia, for instance, hiv/aids is positive in around 2.1 % msm in bandung, 5.6% in surabaya, and 8.1 % in jakarta.10 voluntary counseling and testing (vct) is a serial of rapid test, education, and counseling regarding hiv/aids intended to helping individuals to know their hiv status, to understand the behavior they might althea medical journal. 2016;3(3) 416 amj september 2016 knowledge, attitude and practice of diabetes mellitus type 2 patients towards compliance to treatment in pusat kesehatan masyarakat asila zahiri binti zahari,1 vycke yunivita k.d,2 januar wibawa martha3 1faculty of medicine, universitas padjadjaran, 2departmen of pharmacology & therapy faculty of medicine universitas padjadjaran, 3department of cardiovascular faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: diabetes mellitus (dm) is one of the top ten chronic diseases in the world and the prevalence of this disease will increase in the future including in indonesia. treatment of dm needs collaboration between the patients and the providers to prevent multiorgan complications and increase the compliance to treatment. the correlation among the level of knowledge (k), attitude (a) and practice (p) plays an important role of patients towards compliance to treatment. the objectives of this study was to identify the level of knowledge, attitude and practice of dmt2 patient towards compliance to treatment at a primary care facility. methods: this study was carried out by using cross sectional descriptive study from august until november 2013 in public health center (pusat kesehatan masyarakat/puskesmas) tanjungsari, sumedang, west java. there were 49 respondents and the sampling method used was non-probability sampling. the data was collected through face to face interview using questionnaire which consist of 27 questions about knowledge, attitude and practice. the collected data was anayzed using computer and was presented in the form of tables and a figure. results: this study discovered that 22 patients had moderate knowledge, 17 patients had good knowledge and 10 patients had poor knowledge. as for attitude, there were 32 patients had good attitude and 17 patients had moderate attitude. whereas, for practice, 44 patients were good and 5 patients were moderate. conclusions: majority of respondent had moderate knowledge, good attitude and practices. [amj.2016;3(3):416–20] keywords: attitude, compliance to treatment, diabetes mellitus type 2, knowledge, practice correspondence: asila zahiri binti zahari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81910344530 email: asila_zahiri@yahoo.com.my introduction the prevalence of diabetes mellitus (dm) was 171 million people in the year 2000 and is expected to increase to 366 million people in the year 2030 worldwide.1 diabetes mellitus is divided into two types, which are dm type 1 (dmt1) and dm type 2 (dmt2). the last type (dmt2) accounts about 90% of all dm cases in the world.2 the dmt2 is a metabolic disorder that relates with increase of blood sugar level and other vital risk concerning blood pressure, cholesterol and coagulation.3 indonesia is counted at number four of 10 countries with diabetes after india, china and united states of america (usa) and accordingly, is predicted that there will be about 21.3 million people with dm in the year 2030.1 according to a report from ministry of health of indonesia or riset kesehatan dasar (riskesdas) 2007, the frequency of diabetes in indonesia was 5.7%, which 70% of them were not properly diagnosed.4 when the disease is poorly controlled, it will affect multiple organ disorders such as kidney, brain, heart and eyes that contribute to higher morbidity and mortality.5,6 the development and acceleration of diabetic complication are due to patient’s non-compliance to treatment that lead to the insufficiency of metabolic control.7 since dmt2 is associated with complication that influence many organ systems, they may have great effect on the patient’s quality of life.8 the complication ultimately lead to increase the health care visits and cost.5 diabetes care of dmt2 patients focuses on althea medical journal. 2016;3(3) 417 improving quality of life through controlling glycemic index, risk factor control, changes in lifestyle, education about diabetes and complication prevention.2 dm education is the key element of diabetes care.2,9 since the management is complicated, proper training of both dm patients and primary care providers can bring a great advantage.2 the ability to attain treatment goals is suggested with lifestyle changes and drug therapy correlated with general knowledge about treatment and risk factor.8 the knowledge and skills of patients can affect their compliance to treatment.8 medication compliance is found highly correlated with attitudes and beliefs towards medication.8 treatment failure is commonly believed due to non-compliance.7 since dm requires long life treatment, dm patients need more discipline in their compliance of drugs in daily basis. only about fifty percent of dmt2 patients that comply with long term treatment has been showed.7 this also may cause disadvantageous to patients on compliance of anti-diabetes drugs, the correlation among the level of knowledge (k), attitude (a) and practice (p) plays an important role of patients towards compliance to treatment. in regard to this situation, the objectives of this study were to identify the level of knowledge, attitude and practice of dmt2 patient towards compliance to treatment at a primary care facility. methods the study design was cross-sectional descriptive study and conducted in october 2013 in public health center (pusat kesehatan masyarakat/puskesmas) tanjungsari, sumedang, west java. a total of 50 respondents of dmt2 patients were involved in this study. all procedures in this study were performed after being approved by health research ethics committee, faculty of medicine universitas padjadjaran. patients with gestational diabetes mellitus (gdm) and mentally incompetent were excluded from the study. sampling technique was purposive non-probability. the respondents were given explanation about aim of the study. respondents that were willing to participate were required to fill the informed consent form. respondents were directly interviewed by using questionnaire which consist of 27 questions regarding knowledge, attitude and practice of dmt2 patients towards compliance to treatment. the total score of each variable was classified into 3 categories: 1) knowledge: good (76–100%), moderate (56–75%) and poor (≤65%), 2) attitude: good table 1 respondent’s characteristics variables number (n=49) percentage (%) gender male 23 46.94 female 26 53.06 age group (years old) 38–48 15 30.61 49–58 15 30.61 59–67 10 20.41 68–77 9 18.37 education level elementary school 13 26.53 junior high school 20 40.82 senior high school 16 32.65 diabetes duration (years) 1–7 39 79.59 8–14 5 10.20 15–20 5 10.20 asila zahiri binti zahari, vycke yunivita k.d, januar wibawa martha: knowledge, attitude and practice of diabetes mellitus type 2 patients towards compliance to treatment in pusat kesehatan masyarakat althea medical journal. 2016;3(3) 418 amj september 2016 figure 1 knowledge, attitude and practice of dm type 2 patients towards compliance to treatment in puskesmas tanjungsari (>6 points), moderate (3–6 points) and poor (<3 points), 3) practice: good (>12 points), moderate (6–12 points) and poor (<6 points). the collected data was analyzed by using statistical product and service solution software and microsoft excel and presented in the form of table and bar chart. results from 50 respondents, only 49 respondents participated in this study. this study discovered that more female had dmt2 compared to male. the average age for patients was between 38– 48 years old and 49–58 years old. education level of dmt2 patients who came to puskesmas tanjungsari was junior high school and most of the patients have had diabetes for about 1–7 years (table 1). dmt2 patients who came to puskesmas tanjungsari mostly had hypertension and family member who had dmt2 (table 2). most of the respondents did not exercise regularly. from 49 dmt2 patients who came to puskesmas tanjungsari, most of them had moderate knowledge, good attitude and good practive (figure 1). discussion the result of the study showed that, the respondents mostly had middle school education which was up to 40.82%, the second largest group was from high school (32.65%) and lastly was from primary school (26.53%). this showed that most of the subjects came from similar community and social background. the risk factors for dmt2 patients in this study, such as hypertension, family history of diabetes and physical table 2 risk factors of dm type 2 patients in puskesmas tanjungsari statements response yes no n % n % exposure on dm 16 32.65 33 67.35 smoking 17 34.69 32 65.31 hypertension 31 63.27 18 36.73 family history 25 51.02 24 48.98 exercise 8 16.33 41 83.67 althea medical journal. 2016;3(3) 419 inactivity contribute to the frequency of dmt2.10 most of the respondents were only having under moderate level of knowledge. the knowledge about compliance of drugs include dosage, time taken and side effects of dm medication. according to notoatmodjo11 knowledge can be grouped into 6 levels of domain cognitive which are important to take action. as for this research, dmt2 patients who came to puskesmas tanjungsari, were given information regarding disease and compliance of drugs prescribed from the doctor they should take. other than that, laboratory workers would always be there if patients wanted to have regular check-up like blood glucose test. according to american diabetes association (ada), someone will be diagnosed as dm patient if the fasting plasma glucose is ≥7.0 mmol/l or 126 mg/dl.10 beside checking the glucose level routinely to dmt2 patients, laboratory workers also would give them knowledge regarding their condition and what should they do based on their current condition.12 instead of compliance towards medication, patient’s lifestyle changes and risk factor should be controlled.2 the doctor and the laboratory workers in puskesmas tanjungsari would also use understandable non-medical term language when they explained to dmt2 patients.12 it was needed to make sure that the dmt2 patients who came to puskesmas tanjungsari understood the given instructions. one of the factors that affected the compliance of patients was quality interaction between professional healthcare and patients.12 in the level of knowledge, knowing is the first. patients can develop their knowledge by being given good information. understanding or comprehension is the second level of knowledge, here, patients were able to describe concisely about compliance of drugs that have been informed to them. the third level is application, which is dmt2 patients’ ability to apply their knowledge that they get from the doctor by following directions and instructions in terms of dosage, time taken for drugs and precautions when taking drugs. the level of knowledge then, followed by analysis, synthesis and evaluation which was resulted, when majority dmt2 patients who came to puskesmas tanjungsari had moderate and some good knowledge level. patients’ educational background also plays an important to knowledge. this was shown from study by sweileh et al.13, it was stated that educated people with higher education were more conscious of the result of non-compliance and amount of compliance. other research by mahfouz and awadalla14 stated that lower regimen compliance high number diabetes morbidity related with low socioeconomic status and low education level. this is related with patients’ understanding on what the doctors and laboratory workers informed them. it is concluded, that there were also some of dmt2 patients that did not understand the given information. the level of good attitude of dmt2 patients in compliance of drugs was more than 50%. attitudes is from stimulation or respond from someone.11 for example, the reaction of dmt2 patients when they were diagnosed. patients’ attitudes towards compliance of dm treatment are based on dosage, complication and side effects. on this research, dmt2 patients who came to puskesmas tanjungsari knew and understood about compliance of treatment they were taking. it showed various attitudes towards compliance of drugs. attitude itself can be divided into 4 levels, the lowest is receiving, and the highest level is responsible.11 as this research illustrated, dmt2 patients who came to puskesmas tanjungsari felt responsible in terms of taking dm medication. as for knowledge, this important role is only obtained through education.9 they could get it from consultation that organized by puskesmas tanjungsari. according to notoatmodjo11 attitudes consists of trust, emotion and action. it is shown in this research that the knowledge of patients was mostly moderate, however, the attitude was good. therefore, it was related with one of the component stated by notoatmodjo11 which is the dmt2 patients’ beliefs towards compliance of medication.8 it is also shown in other study in an urban area of south india15 that if the patient were having high risk and affected with diabetes, they would change their behaviour and attitude on diabetes accordingly. it is also shown that the practice level of dm patients from time taking, health control and dosage towards compliance dm medication. most of dmt2 patients who came to puskesmas tanjungsari had good practice. the characteristic of drugs that is well known also made the patients trust the medication. patients followed the rules of dosage drugs intake. it can be stated, that most of the patients followed the instructions because patients understand the instructions, dosage, side effects and complications of drugs intake. based on stimulus organism theory (s-o-r), practice will appear when the comprehension and understanding change into an attitude by stimulus.11 it is deducted asila zahiri binti zahari, vycke yunivita k.d, januar wibawa martha: knowledge, attitude and practice of diabetes mellitus type 2 patients towards compliance to treatment in pusat kesehatan masyarakat althea medical journal. 2016;3(3) 420 amj september 2016 that based on notoatmodjo11 patients behave based on what the doctor told them and trust the effectiveness of drugs they were taking. other than that, they were getting support and motivation from health practitioners, family and friends. it is also stated in study by kasznicki et al.7 that advantage role to increase quality of compliance is also support provided by family and friends.7 therefore, it made the dmt2 patients who came to puskesmas tanjungsari have good practices in compliance towards drugs. this is one of the components that play important role towards compliance of dm medication. the process of dmt2 patients toward compliance of drugs includes 3 elements. they are knowledge (k), attitude (a) and practice (p), all applied toward their compliance on dm medication. in conclusion, among 49 respondents, the level of knowledge of dmt2 patients was moderate. meanwhile, for the attitude level, most of the patients were having good attitude and practice. education program should be conducted to increase awareness for dmt2 patients. other than that, education of health and illness about dm should be done to increase the level of knowledge of dm patients, since knowledge is an important factor to influence someone’s attitude and practice. the limitations in this study were the time available for data collection and data analyzed. since the sample is small, it is recommended to increase the sample amount as a suggestion for other researcher who would like to do further research study or in the same field. references 1. wild s, roglic g, green a, sicree r, king h. global prevalence of diabetes: estimates for the year 2000 and projections for 2030. diabetes care. 2004;27(5):1047–53. 2. gul n. knowledge, attitudes and practices of type 2 diabetic patients. j ayub med coll abbottabad. 2010;22(3):12–31. 3. blackburn df, swidrovich j, lemstra m. non-adherence in type 2 diabetes:practical considerations for interpreting the literature. patient prefer adherence. 2013;7:183–9. 4. widyahening is, soewondo p. capacity for management of type 2 diabetes mellitus in primary health centers in indonesia. j indon med assoc. 2012;62(11):439–43. 5. marian ao, joy io. knowledge, attitudes and practices of people with type 2 diabetes mellitus in tertiary health care centre, umuahia, nigeria. j diabetes metab. 2012;3(3):1–4. 6. khattab m, khader ys, al-khawaldeh a, ajlouni k. factors associated with poor glycaemic control among patients with type 2 diabetes. j diabetes complications. 2010;24(2):84–9. 7. kasznicki j, glowacka a, drzewoski j. type 2 diabetic patients compliance with drug therapy and glycaemic control. diabetologia. 2007;7(4):199–203. 8. kheir n, greer w, yousif a, geed ai, okkah ra. knowledge, attitude and practices of qatari patients with type 2 diabetes mellitus. j pharm pract. 2011;19(3):185– 91. 9. shah vn, kamdar pk, shah n. assessing the knowledge, attitudes and practice of type 2 diabetes among patients of saurashtra region, gujarat. int j diabetes dev ctries 2009;29(3):118–22. 10. kasper dl, fauci as, longo dl, braunwald e, hauser sl, jameson jl. harrison’s principles of internal medicine. 16th ed. new york: mcgraw-hill; 2005. 11. notoatmodjo pds. promosi kesehatan dan ilmu perilaku. 1st ed. jakarta: pt rineka cipta; 2007.p.249 12. niven n. psikologi kesehatan pengantar untuk perawat dan profesional kesehatan lain. 2nd ed. jakarta: egc; 2012.p.345 13. sweileh wm, aker o, hamooz s. rate of compliance among patients with diabetes mellitus and hypertension. an-najah univ j res (n.sc). 2005;19:1–12. 14. mahfouz em, awadalla hi. compliance to diabetes self-management in rural elminia, egypt. cent eur j public health. 2011;19(1):35–41. 15. hawal np, shivasmamy, kambar s, patil s, hiremath mb. knowledge, attitude and behaviour regarding self-care practices among type 2 diabetes mellitus patients residing in an urban area of south india. international multidisciplinary research journal. 2012;2(12):31–5. althea medical journal. 2016;3(2) 230 amj june 2016 knowledge, attitude and practice of menstrual hygiene among high schools students in jatinangor maryam balqis,1 insi farisa desy arya,2 mulya nusa a ritonga3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of obstetric & gynecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: menstruation is a physiological process in female adolescents which usually started at age of 9–12 years. menstrual hygiene is a hygienic practice during menstruation which can prevent women from the infection in reproductive and urinary tract. lack of knowledge regarding menstruation and menstrual hygiene lead to poor attitude and practice. this study was conducted to assess the level of knowledge, attitude and practice of menstrual hygiene among high schools students in jatinangor. methods: this descriptive cross-sectional study was conducted from may until june 2013 in high schools around jatinangor. this study population was taken from four schools selected through cluster random sampling from 17 junior and senior high schools available in jatinangor. total sampling from four schools was undertaken and a total of 238 female high school students’ data were established. the respondents aged between 13–19 years old. results: the level of knowledge, attitude and practice among participants were 180 (75.63%), 186 (78.15%) and 210 (88.24%) respectively which were mostly good. conclusions: overall, most of the participants in this study have good knowledge, attitude and practice about menstrual hygiene, but a few of them still have poor and moderate knowledge and attitude, although there is no poor practice among them. [amj.2016;3(2):230–8] keywords: adolescent, knowledge, menstrual hygiene, practices correspondence: maryam balqis, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81809832502 email: miss_alamandas@yahoo.com introduction menstruation is a physiological process in female adolescent which usually started at age of 9–12 years old.1 first menstruation experience would be different among adolescent girl but if they aware about menstruation before menarche, they can prepare themselves to accept and build good attitude towards menstruation. mother as the nearest and capable person to educate their children should give information about menstruation and also hygiene prior to menarche so that adolescent girls know the importance of taking care of hygiene during menstruation and how to manage menstrual hygiene issues. menstrual hygiene is a hygienic practice during menstruation and good menstrual hygiene such as adequate cleaning of the external genitalia, the use of sanitary pad and frequently changed pad every 3–4 hours to prevent odor.2 unhygienic practices during menstruation predispose to higher chances to get infection or gynecological problems among adolescent girls.3 the prevalence of reproductive tract infections are 3 times higher among girls who have poor menstrual hygiene.4 therefore, hygiene related to practices during menstruation considered as important to decrease the risk of infection among female. however, in a way to achieve safe practices, they need a satisfactory knowledge about menstruation and menstrual hygiene; women having good knowledge and practices regarding menstrual hygiene are less exposed to rti and its consequences.5 besides that, there are factors that affects the person’s hygiene such as socioeconomic status that influenced person’s ability to regularly maintain hygiene, health beliefs and motivation about importance of hygiene, and cultural behavior which depends on person’s cultural belief and personal values althea medical journal. 2016;3(2) 231 hygiene care.6 having knowledge regarding to menstruation and menstrual hygiene does not guarantee that the girls have good attitude and practice toward menstrual hygiene because they need to motivate themselves to maintain self-care. so, this study was conducted to assess the level of knowledge, attitude and practice of menstrual hygiene among high school students in jatinangor. methods this descriptive cross-sectional study was conducted from may until june 2013 in high schools around jatinangor. the data were taken under the permission of faculty of medicine universitas padjadjaran research programme named “jatinangor cohort”. there are several studies conducted under jatinangor cohort. the conducted study such as puberty in female and male, nutritional status in school students, menarche, dysmenorrhea, menstrual hygiene and other topics were included. jatinangor cohort involved large population study including elementary school students, junior high school students, senior high school students and others but in this study, the study population was taken from four schools selected through cluster random sampling from 17 junior and senior high schools available in jatinangor by jatinangor cohort. total sampling from four schools was done and a total of 238 female high school students’ data was established. the respondents age were between 13–19 years old. the inclusion criteria were female students who had menarche and regularly menstruate whereas the exclusion criteria were respondents whom the data were incomplete. questionnaires were distributed to the study subjects in indonesian language. the questionnaire consists of demographic characteristics, knowledge of menstruation and hygiene, attitude and practice towards menstrual hygiene. the demographic data consist of five questions, five questions for knowledge, nine questions for attitude and nine questions for practice respectively to each variable. these questionnaires had been validated by jatinangor cohort. the data were taken from jatinangor cohort as the secondary data and the data were analyzed. the scales to measure the knowledge according to nursalam7 where the level of knowledge considered as good when total score is 76–100%, moderate when the score is 56–75% and poor when it is <56%. whereas for attitude and practice were measured according to arikunto.8 for this study, the attitude contains 9 questions, then multiplied by 4 which the highest score for each of attitude, so that the total scores were 36 marks. then, 36 was divided by 3 categories which is good when total scores is 25–36 marks, moderate when 13–24 marks, poor when ≤ 12 marks.8 same calculation was used for practice. then the result was presented in tables. results the majority of study subjects’ age were 16 years old 102 (42.86%) and about 3 (1.26%) of the participants still do not have toilet facilities at home. furthermore, most of the girls were the first child in the family and do not have sisters who live together. meanwhile, the table shows the main source of knowledge regarding menstruation and menstrual hygiene came from their mothers as well as friends and teacher. for the source of information about menstruation, the participants were allowed to answer more than 1 the source of their knowledge (table 1). all of the participants knew that menstruation was a normal process for women but about 19.33% of them do not know that menstruation occurs because of hormone. however, 32.77% of the girls answered that they do not know the source of blood during menstruation. despite so, 8 of participants do not know that taking care of personal hygiene is important things and 1.68% still do not know which good absorbent should be used during menstruation and 5.88% stated that old cloths or towels were good absorbent (table 2). table 3 showed that the attitute toward menstrual hygiene was quite good. most of the girls were agree that taking care of personal hygiene during menstrual periode can prevent disease. taking care personal hygiene including using soap and water when cleaning genital body and washing panties and also using panties made from cotton material to absorb sweat (table 3). most of the respondents performed menstrual practice hygiene (table 4). the level of knowledge, attitude, and practice among participants were divided into 3 categories:poor, moderate and good. after that the results depict most of the participants knowledge, attitude and practice were good in 180 (75.63%), 186 (78.15%) and 210 (88.24%) respectively (figure 1). maryam balqis, insi farisa desy arya, mulya nusa a ritonga: knowledge, attitude and practice of menstrual hygiene among high schools students in jatinangor althea medical journal. 2016;3(2) 232 amj june 2016 discussions hygienic practices during menstruation is an important action which needs to be done because start from the first menstruation (menarche) until ceasing of menstruation (menopause), throughout the women’s life, menstruation event continuously comes and table 1 demographic characteristic of the study subjects characteristics n=238(%) age (years old) 13 6(2.52) 14 34(14.29) 15 37(15.55) 16 102(42.86) 17 56(23.53) 18 2(0.84) 19 1(0.42) toilet facilities at home yes 235(98.7) no 3(1.26) position in siblings 1 106(44.54) 2 69(28.99) 3 33(13.87) 4 17(7.14) 5 7(2.94) 6 4(1.68) 7 2(0.84) number of sisters who live together 0 164(68.91) 1 62(26.05) 2 9(3.78) 3 0(0.00) 4 2(0.84) 5 1(0.42) source of information about menstruation mother 222(93.28) father 6(2.52) sister 54(22.69) teachers 87(36.55) friends 95(39.92) television/radio 27(11.34) newspaper/magazine 18(7.56) others 19(7.98) althea medical journal. 2016;3(2) 233 goes approximately 3–7 days every month. based on this women cycle, by ignoring the practices during this period will affect their health and thus increase susceptibility to infection of their reproductive and urinary organ. in a study conducted by dasgupta and sarkar9, about half of the respondents did not have a covered toilet, which causes the limitation for participants to change pad regularly, cleaning genital, washing underwear and pad as well as bathing during menstruation. however in this present study, there are different findings which is about 236 (99.16%) out of 238 total participants were having toilet facility at home which make them easier to have hygienic practices. another study by thakre et al.10, 335 (86.56%) have toilet facility at home and 52 (13.43%) does not have the facility in their home. the main source of knowledge regarding menstruation and menstrual hygiene among respondents in this study was the mother 222 (93.28%), followed by friends 95 (39.92%) and teachers 87 (36.55%). this result might be caused by the good literacy of the mother, and proper relationship between respondents and their mother. in study conducted by thakre et al.10, it is similarly found the majority of the respondents stated that mother 102 (71.33%) was the source of their knowledge but differently followed by sisters 34 (23.78%) and then friends 26 (18.18%). the difference between thakre et al.10 study and this present study is due to the most of the respondents in this study, 106 (44.54%) are the first child in the family, so that their friends become the source of knowledge after their mother. meanwhile, according to juyal et al.11, mostly friends 93 (31.8%) were the first source of information then followed by mother 91 (31.2%) and sisters 82 (28.1%). furthermore, it was observed in this table 2 knowledge of menstruation and hygiene knowledge n=238(%) menstruation is a normal process for women yes 238(100.00) no 0(0.00) do not know 0(0.00) cause of menstruation disease 2(0.84) hormone 188(78.99) past sins 1(0.42) curse 0(0.00) do not know 46(19.33) origin of blood ovary 41(17.23) uterus 60(25.21) vagina 59(24.79) do not know 78(32.77) important to take care of personal hygiene yes 230(96.64) no 0(0.00) do not know 8(3.36) good absorbent during menstruation sanitary pad 220(92.44) old cloths/towels 14(5.88) do not know 4(1.68) maryam balqis, insi farisa desy arya, mulya nusa a ritonga: knowledge, attitude and practice of menstrual hygiene among high schools students in jatinangor althea medical journal. 2016;3(2) 234 amj june 2016 present study that all respondents 238 (100.00%) believed that menstruation is a physiological process whereas in a study conducted by sudeshna and aparajita4, 87% of study subjects believed that menstruation is part of physiological process. even though the study showed the large percentage of girls answered correctly, the remaining 13% of girls do not believe the statement. in another study conducted in india5, about 50 (16.6%) of the respondents believed that menstruation occur because of curse from god. meanwhile in this present study there is no respondent who believe to statement. the differences may be due to the lack of knowledge of the participants, mother and less exposure to mass media but vice versa in the present study. in the present study, it is revealed the large number of respondents, 188 (78.99%) knew that the cause of menstruation was hormone and 46 (19.33%) answer that they did not know. meanwhile nearly similar finding was reported in other study carried out by sudeshna and aparajita4, 114 (60%) answered hormone as the cause of menstruation and 64 (34%) did not know. this study stated only 60 (25.21%) of the girls answered correctly that uterus was the source of blood during menstruation while 78 (32.77%) did not know. almost similiar to kamath et al.12 study, 103 (20.5%) knew the source of menstrual blood and 201 (36.6%) did not know. but in another study, 219 (43.5%) knew uterus as the source of blood.13 in the present study, it is presented that most of the study subjects 220 (92.44%) knew that the most appropriate absorbent should be used during menstruation was sanitary pad. only a few of them 14 (5.88%) preferred to use old cloths/towels rather than sanitary pad. this may be due to the location of this study in jatinangor. jatinangor is more likely urban area because this area have universities, big central markets, so many small shops near the neighborhood, and higher population density especially students. therefore, this might be easier for adolescent girls to buy sanitary pad because it is usually more available in table 3 attitude towards menstrual hygiene (n=238) attitude strongly agree n(%) agree n(%) disagree n(%) strongly disagree n(%) do not take care of hygiene during menstruation can cause disease 132(55.46) 93(39.08) 9(3.78) 4(1.68) access to clean water and used of soap for cleaning genital are important to keep genital in clean condition 83(34.87) 135(56.72) 19(7.98) 1(0.42) panties which made of cotton is the best material to absorb sweat 44(18.49) 134(56.30) 56(23.53) 4(1.68) need to dry genital with towel to keep genital area in dry condition after bathing/urinate 96(40.34) 117(49.16) 23(9.66) 2(0.84) washing hand before cleaning genital area can prevent reproductive infection 85(35.71) 134(56.30) 18(7.56) 1(0.42) washing hand after cleaning genital area can prevent reproductive infection 61(25.63) 138(57.98) 31(13.03) 8(3.36) menstruation occurs because of disease 0(0.00) 7(2.94) 144(60.50) 87(36.55) cleaning panties using only water is enough as the blood disappear 8(3.36) 19(7.98) 135(56.72) 76(31.93) drying the panties inside room is enough as the panties dry 4(1.68) 53(22.27) 137(57.56) 44(18.49) althea medical journal. 2016;3(2) 235 these markets and small shops. besides, the participants in this study might not came from low socioeconomic status of the family which couldafford to buy and understood the importance of sanitary pad for their reproductive health from the advertisement or from other sources. meanwhile, it is found in other study that about 145 (44.1%) which not attain half of the total population, chose sanitary pad as their menstrual absorbent.3 mudey et al.14 stated that most of respondents 111 (37.00%) reused old cloths as menstrual table 4 practice of menstrual hygiene practice n=238 (%) taking bath during menstruation using only water 1(0.42) using water and soap 237(99.58) no bathing 0(0.00) wash hand before cleaning genital yes 223(93.70) no 15(6.30) cleaning genital after urinate/defecate yes 235(98.74) no 3(1.26) cleaning genital before changing pad yes 225(94.54) no 13(5.46) clean genital using only water 123(51.68) water and soap 114(47.90) only tissue 1(0.42) changing pad at school yes 40(16.81) no 198(83.19) changing pad per day 1 time 11(4.62) 2 times 88(36.97) 3 times 122(51.26) > 3 times 16(6.27) do not change 1(0.42) place of drying panties inside the room 2(0.84) inside the bathroom 36(15.13) under sunlight 200(84.03) wash panties using water only 4(1.68) water and soap 234(98.32) maryam balqis, insi farisa desy arya, mulya nusa a ritonga: knowledge, attitude and practice of menstrual hygiene among high schools students in jatinangor althea medical journal. 2016;3(2) 236 amj june 2016 absorbents; they prone to develop vaginal discharge, itching and burning micturition as symptoms of infection. furthermore, this study found most of the respondents 132 (55.46%) strongly agree that do not take care of hygiene during menstruation can cause disease. different findings in other study comparing urban and rural area are revealed. in urban area 56 (18.98%) and rural area 52 (18.06) they believed that menstrual hygiene have effect on reproductive life of girl.15 this may be due to lack of knowledge of respondents about the importance of hygiene to their reproductive organ. however, most of the respondents 135 (56.72%) in this present study agree to the statement that access to clean water and the use of soap for cleaning genital are important to keep genital in clean condition. the researcher expected more respondents to answered strongly agree with the statement. however only 83 (34.87%) strongly agree, a few of respondents disagree 19 (7.98%) and strongly disagree 1 (0.42%). nearly all of the girls have good personal hygiene. approximately 237 (99.58%) take bath daily during menstruation using water and soap. this is may be because the majority residents in jatinangor are muslims and this religion wanted muslims to take care of their personal hygiene especially before going prayer but even though during menstruation they are restricted to perform prayer, they are still required to take care of their hygiene. in omidvar and begum2 study was found, the number of girls do not taking bath during menstruation about 55 (16.1%). in another study, comparing bathing practice during menstruation between urban and rural area revealed that more respondents in rural area 83 (34.7%) taking bath on alternate day compared to urban area 53 (24.8%).16 about 235 (98.74%) clean their genital every time after urinate or defecate among participants in this study. however, in omidvar and begum2 study, the percentage was lesser than present study which around 290 (82.9%). most of the girls 123 (51.68%) in this study clean their genital using water only without soap but about another half of them 114 (47.90%) using water and soap for cleaning purpose. otherwise in thakre et al.10 study, revealed that the girls 225 (58.18%) using water and soap and 157 (40.57%) using only water as material used for cleaning their external genitalia. in another study, it is stated that 17 (11.3%) clean their genital using soap and water and the rest about 133 (88.7%) using plain water only.17 the study subjects in present study mostly 198 (83.19%) do not change pad at school and similar result was found in the omidvar and begum2 and thakre et al.10 study. this could be because of lack of toilet facilities in school, lack of access to clean water and lack of appropriate bin to dispose pad in school. all of these conditions might prevent or inhibit them to change pad during school time. in this study, it is also presented that most of the figure 1 level of knowledge, attitude and practice of menstrual hygiene althea medical journal. 2016;3(2) 237 respondents 122 (51.26%) change pad 3 times a day as well as 88 (36.97%) change 2 times a day. this variation of regularly change pad may depend on the respondents’ type of pad used, amount of blood comes out and attitude of respondent to remain clean and hygienic. in other study carried out in mumbai observed that 68 (40.96%) of the girls who use sanitary pad, change pad 2 times a day.18 mostly the level of knowledge, attitude and practice among study subjects were good. this result describes that they have good knowledge, attitude and also practice. this might be because they livein urban area which often expose to the media, frequently along with the educated people, and averagely came from stable socioeconomic status family. this study has limitation of time, number of respondents and no statistical analysis. due to limited of time given by faculty of medicine universitas padjadjaran, and school regulation; certain classes of the students that cannot be disturbed during school learning time, so that the number of respondens are less. for further study, the next researcher can do the research in a longer time and great number of respondents with the statistical analysis for each result. this statistical analysis may be useful to observe the correlation between each variable. besides that, the next researcher can ask about type of pad used by the respondents because the good quality of pad can prevent bad odour and itching, thus it can be used longer than the cheaper one. furthermore, the next researcher can ask about the quantity of blood comes out because some people may have irregularity in menstruation; those who menstruate with not so much blood tend to ignore changing pad regularly. in conclusion, most of the participants in this study have good knowledge, attitude and practice towards menstrual hygiene, but a few of them still have poor and moderate knowledge and attitude, although there is no poor practice among them. however, awareness concerning the need for knowledge on hygienic menstrual practices is very important to increase their knowledge about the importance of genital cleanliness also, designing a mechanism to help students to improve their hygienic practices especially during menstruation. early awareness can prevent students from suffering the infection to the female reproductive organ. this can be achieved through a health programme about the importance of hygienic practice during menstruation to the school girls and it will be more effective if public health department can conduct a programme to educate mother to enhance their knowledge about menstruation, menstrual hygiene and personal hygiene so that they can educate their daughter prior to menstruation or their practice. in other way, teachers may benefits the readily available programme in school called school health efforts society. teachers can educate and train the members of the society, meanwhile the student leader later may ask the group to help other students. for the stakeholder in school, it is necessary for them to fix or improve the availability of the toilet facilities so it becomes more comfortable and easier for students to regularly change pad even though during school time. references 1. hall je. guyton and hall textbook of medical physiology. 12th ed. philadephia: saunders elsevier; 2010. 2. omidvar s, begum k. factors influencing hygienic practices during menses among girls from south india-a cross sectional study. international journal of collaborative research on internal medicine & public health. 2010;2(12):411–23. 3. shanbhag d, shilpa r, d’souza n, josephine p, singh j, goud b. perceptions regarding menstruation and practices during menstrual cycles among high school going adolescent girls in resource limited settings around bangalore city, karnataka, india. international journal of collaborative research on internal medicine & public health. 2012;4(7):1353–62. 4. sudeshna r, aparajita d. determinants of menstrual hygiene among adolescent girls: a multivariate analysis. national journal of community medicine. 2012;3(2):294– 301. 5. kamaljit k, arora b, singh gk, neki n. social beliefs and practices associated with menstrual hygiene among adolescent girls of amritsar, punjab, india. jimsa. 2012;25(2):69–70. 6. clement i. textbook of nursing foundations. new delhi, india: jaypee brothers medical publishers; 2011. 7. nursalam. konsep dan penerapan metodologi penelitian ilmu keperawatan. jakarta: salemba medika; 2008. 8. arikunto s. manajemen penelitian. jakarta: rineka cipta; 2007. 9. dasgupta a, sarkar m. menstrual hygiene: maryam balqis, insi farisa desy arya, mulya nusa a ritonga: knowledge, attitude and practice of menstrual hygiene among high schools students in jatinangor althea medical journal. 2016;3(2) 238 amj june 2016 how hygienic is the adolescent girl?. indian j community med. 2008;33(2):77–80. 10. thakre sb, thakre ss, reddy m, rathi n, pathak k, ughade s. menstrual hygiene: knowledge and practice among adolescent school girls of saoner, nagpur district. journal of clinical and diagnostic research. 2011;5(5):1027–33. 11. juyal r, kandpal s, semwal j, negi k. practices of menstrual hygiene among adolescent girls in a district of uttarakhand. indian journal of community health. 2012;24(2):124–8. 12. kamath r, ghosh d, lena a, chandrasekaran v. a study on knowledge and practices regarding menstrual hygiene among rural and urban adolescent girls in udupi taluk, manipal, india. global journal of medicine and public health. 2013;2(4):1–9. 13. singh s, singh m, arora m, sen p. knowledge assessment regarding puberty and menstruation among school adolescent girls of district varanasi. indian j prev soc med. 2006;37(1&2):9–14. 14. mudey ab, kesharwani n, mudey ga, goyal rc. a cross-sectional study on awareness regarding safe and hygienic practices amongst school going adolescent girls in rural area of wardha district, india. global journal of health science. 2010;2(2):225– 31. 15. patle r, kubde s. comparative study on menstrual hygiene in rural and urban adolescent girls. int j med sci public health. 2014;3(1):111–4. 16. juyal r, kandpal s, semwal j. social aspects of menstruation related practices in adolescent girls of district dehradun. indian journal of community health. 2013;25(3):213–6. 17. adhikari p, kadel b, dhungel s, mandal a. knowledge and practice regarding menstrual hygiene in rural adolescent girls of nepal. kathmandu university medical journal. 2007;5(19):382–6. 18. nemade d, anjenaya s, gujar r. impact of health education on knowledge and practices about menstruation among adolescent school girls of kalamboli, navimumbai. hppi. 2009;32(4):167–75 althea medical journal. 2016;3(3) 349 oropharyngeal colonization by streptococcus pneumoniae among medical students in indonesia stella valencia,1 yanti mulyana,2 diah dhianawaty3 1faculty of medicine universitas padjadjaran, 2department of microbiology and parasitology faculty of medicine universitas padjadjaran, 3department of biochemistry and molecular biology faculty of medicine universitas padjadjaran abstract background: streptococcus pneumoniae may colonize the upper respiratory tract without causing any symptoms. medical students may be inhabited by these bacteria and transmit them to patients who were prone to infections. streptococcus pneumoniae resistance to antibiotics was recently reported. this study was conducted to determine whether there was streptococcus pneumoniae colonization among medical students of the faculty of medicine universitas padjadjaran batch 2011 and analyze its susceptibility patterns towards several antibiotics. methods: a descriptive study was conducted involving 75 medical students of the faculty of medicine universitas padjadjaran batch 2011 that met the selection criteria. after informed consent, oropharyngeal throat swab was taken and further identification was carried out. once streptococcus pneumoniae colony was identified, susceptibility testing would be performed. results: the identification results indicate that 7 students (9%) were colonized by streptococcus pneumoniae. the susceptibility test showed that out of 7 isolates, 2 were resistant to 1 antibiotic, 1 was resistant to 2 antibiotics, and 4 were resistant to 3 antibiotics. meanwhile, streptococcus pneumoniae was resistant to trimethoprim-sulfamethoxazole (71%), oxacillin (71%), erythromycin (57%), and levofloxacin (14%). conclusions: streptococcus pneumoniae colonization is found among medical students. all streptococcus pneumoniae are resistant to one or more antibiotics, mostly to trimethoprim-sulfamethoxazole and oxacillin. [amj.2016;3(3):349–54] keywords: medical student, streptococcus pneumoniae, susceptibility pattern correspondence: stella valencia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81394133310 email: valenz_stell@yahoo.co.id introduction streptococcus pneumoniae infection results in various diseases from the mild ones to the life-threatening diseases such as bacteremic pneumonia and meningitis, thus making this infection an important cause of morbidity and mortality worldwide.1 addition to causing diseases, these bacteria may colonize the human upper respiratory tract without causing any symptoms.2 a healthy human being that has this bacteria colonization without causing any symptoms is called a carrier. in developing countries, the prevalence of streptococcus pneumoniae carriers could reach 70–90% in children under five years old and more than 40% in adults. carriers play a major role in the spread of those bacteria through droplets when sneezing or coughing.1 medical students can also be exposed to streptococcus pneumoniae, become a carrier, and transmit those bacteria to others, particularly patients who are prone to infections. in early 2015, medical students of the faculty of medicine universitas padjadjaran batch 2011 enrolled in the program studi profesi dokter (pspd) at dr. hasan sadikin general hospital in bandung. their enrollment to the hospital environment would play a role in the streptococcus pneumoniae transmission at the hospital. this bacterial infection can be treated by antibiotics, but its resistance to antibiotics was recently reported.3 based on the explanation above, it is considered necessary to conduct a study to determine whether there was streptococcus pneumoniae colonization among medical students of the faculty of medicine universitas padjadjaran batch 2011 and identify its althea medical journal. 2016;3(3) 350 amj september 2016 susceptibility patterns toward several antibiotics. methods this descriptive study was conducted at the microbiology laboratory, faculty of medicine, universitas padjadjaran from september to october 2014 after an approval from the health research ethics committee of the faculty of medicine, universitas padjadjaran. population of this study was all medical students of the faculty of medicine universitas padjadjaran batch 2011. based on the sample formula for a descriptive study with dichotomous variables, the minimum sample size required was 62 persons. the sample size was set to 75 persons to compensate dropped out participants. participants were chosen by using the simple random sampling method from the population that met the selection criteria, namely the inclusion and exclusion criteria. the inclusion criterion was medical students of the faculty of medicine universitas padjadjaran batch 2011 who were studying in the fourth year during the study, while the exclusion criteria were medical students who refused to participate; were not available when the study was held; had been suffering from respiratory tract infections during the study; had been treated by antibiotics in the last 2 weeks prior figure 1 streptococcus pneumoniae identification procedures althea medical journal. 2016;3(3) 351stella valencia, yanti mulyana, diah dhianawaty: oropharyngeal colonization by streptococcus pneumoniae among medical students in indonesia to specimens collections. participants were given explanations about the aim of the study and its procedures, then asked to declare their agreement by signing the informed consent sheet. once the participant agreed to participate, a throat swab from the oropharynx was performed. the specimens were obtained using a sterile cotton swab that was passed via the mouth without touching any surfaces then swabbed over the oropharyngeal tonsils and posterior wall. furthermore, those specimens were directly inoculated in 5% sheep blood agar with gentamycin to inhibit the growth of normal flora that can also be found in the throat swab. candle jars were used in order to create an anaerobic ambience (3–5% co2). the growth media that had been inoculated and put into candle jars were incubated for 24–48 hours at ±37oc. after this procedure was conducted, identification of colonies that grew on the growth media which was suspected as the streptococcus pneumoniae colony underwent the following steps as shown in figure 1.2 the streptococcus pneumoniae colonization was interpreted as positive if on the growth media at least one suspected colony of streptococcus pneumoniae was discovered which met all the following criteria: alpha hemolysis; gram-positive cocci; and optochin test results were sensitive or intermediate with positive results in the bile solubility test. when the colonies were not alpha hemolysis; or were not a gram-positive cocci; or optochin test results were resistant or intermediate with a negative result in the bile solubility test, the colonization of streptococcus pneumoniae were interpreted as negative results.2 colonies that were identified as streptococcus pneumoniae enrolled in antimicrobial susceptibility testing towards four different antibiotics from different classes which were widely used to treat streptococcus pneumoniae infections, were: oxacillin (to assess beta-lactams and cephalosporins), erythromycin, trimethoprimsulfamethoxazole, and levofloxacin.2,4 the susceptibility testing in this study followed the disk diffusion (kirby-bauer) method which was assessed by zone of inhibition diameter formed by each antibiotic disc.2 the results were interpreted as resistant, intermediate or sensitive based on the clinical and laboratory standards institute (clsi).4 finally, the collected data were processed and presented by frequency distribution and percentage shown in tables. results all participants that have been given an table 1 streptococcus pneumoniae colonization s. pneumoniae colonization n % positive 7 9 negative 68 91 total 75 100 table 2 antimicrobial susceptibility testing no. susceptibility testing total ox e sxt lev r i s 1 r s r s 2 0 2 2 r r r s 3 0 1 3 s r i r 2 1 1 4 r r r s 3 0 1 5 s s r s 1 0 3 6 r r r s 3 0 1 7 r s s s 1 0 3 note: ox=oxacillin, e=erythromycin, sxt=trimethoprim-sulfamethoxazole, lev=levofloxacin. r=resistant, i=intermediate, s=sensitive althea medical journal. 2016;3(3) 352 amj september 2016 informed consent were agreed to participate in this study. from 75 medical students, 25 were men and 50 were women with age ranged from 19 to 24 years old. the results of isolation and identification of streptococcus pneumoniae performed to 75 subjects showed that 7 medical students (9%) were colonized by streptococcus pneumonia (table 1). susceptibility testing was performed towards 7 isolates that were positive for streptococcus pneumoniae. the results were obtained as showed in table 2. no specific pattern was found, such as the resistance pattern that always occurs together in certain antimicrobial agents. from 7 isolates enrolled in susceptibility testing, 2 (29%) were resistant to 1 antibiotic, 1 (14%) was resistant to 2 antibiotics, while 4 (57%) were resistant to 3 antibiotics. streptococcus pneumoniae found in this study was resistant mostly to trimethoprimsulfamethoxazole and oxacillin, followed by erythromycin and levofloxacin (table 3). discussion this study showed that 9% of medical students of the faculty of medicine universitas padjadjaran batch 2011 were colonized by streptococcus pneumoniae. this finding was lower compared to hill et al.5 in rural gambian village, where streptococcus pneumoniae carriers were found in more than 60% adults aged 15–39 years. a study by reis et al.6 towards urban slums population in brazil found that 16.2% residents aged over 17 years were colonized by streptococcus pneumoniae. additionally, in 2002, mackenzie et al.7 also conducted a survey and discovered that 26% adults were streptococcus pneumoniae carriers. those studies mentioned above obtained specimens from different locations compared to this study. they obtained specimens from nasopharynx rather than oropharynx.5–7 the different locations where the specimens was taken could affect the percentage of streptococcus pneumoniae colonization. this was proven by watt et al.8, the study stated that specimens which were taken from nasopharyngeal swabs were more commonly colonized by streptococcus pneumoniae (11.1%) rather than specimens which were taken from oropharyngeal swabs (5.8%). moreover, odutola et al.9 found those bacterial colonies by 76.1% from nasopharyngeal swabs and 21.3% from oropharyngeal swabs in infants. furthermore, a study in uganda10 obtained specimens that were taken from the oropharynx, but on the contrary, their participants were hiv-positive adults with a result that indicate 18% of them were colonized by streptococcus pneumoniae. the higher result obtained when compared to this study may be due to hiv-positive people who were more at risk of streptococcus pneumoniae colonization two times greater than hiv-negative people.11 according to some sources, factors such as geographical conditions, smoke exposures, socio-economic conditions, weathers, seasons, ages, population densities, respiratory tract infections that have been suffered previously, and hiv status also can affect the incidence of carrier.6,7,12 other reason for low percentage of streptococcus pneumoniae colonization in medical students was that they were more concerned about hygiene and health rather than the community in general. decreased in sensitivity found to at least one antibiotic was observed by susceptibility testing performed to 7 isolates that were colonized by streptococcus pneumoniae, even 5 isolates (71%) were resistant to 2 antibiotics and more (multi drug resistance). this findings were higher than the study conducted in gambia5, which only reached 26.3%. the high number of resistance in our study might be due to the participants who were already exposed to the resistant strains table 3 percentage of antimicrobial susceptibility testing antibiotic discs resistant intermediate sensitive n % n % n % oxacillin 5 71 0 0 2 29 erythromycin 4 57 0 0 3 43 trimethoprimsulfamethoxazole 5 71 1 14 1 14 levofloxacin 1 14 0 0 6 86 althea medical journal. 2016;3(3) 353 of streptococcus pneumoniae. other possible causes may be an irrational use of antibiotics such as: people could obtain antibiotics easily without a prescription, patients noncompliance in completing a series of antibiotic treatment, or unwise prescribing that has been done by physicians or pharmacists.13 this irrational use of antibiotics commonly occurred in indonesia. the antimicrobial susceptibility testing results showed resistance to trimethoprimsulfamethoxazole, oxacillin, erythromycin, and levofloxacin with percentage 71%, 71%, 57%, and 14% respectively. meanwhile, a study conducted by oteo et al.3 stated streptococcus pneumoniae resistance were 14.1% to oxacillin, 26.6% to erythromycin and 0.4% to levofloxacin. in a study performed by reis et al.6, streptococcus pneumoniae resistance were 28% toward trimethoprim-sulfamethoxazole, 22% toward oxacillin and 2% toward erythromycin. bacterial susceptibility patterns to antibiotics were different in each area and this can be caused by the difference of antibiotics usage patterns in every different locations.1 while decreased in streptococcus pneumoniae sensitivity to certain antibiotics may be due to the common use of those antibiotics in infections treatment.2 high resistance against trimethoprim-sulfamethoxazole in this study may be due to the widely used of trimethoprimsulfamethoxazole as a first choice of antibiotics to treat pneumoniae in children under five years old. moreover, streptococcus pneumoniae that was resistant to optochin might be found in this study but their presence were not detected by the identification procedures that have been performed. nunes et al.14 discovered that streptococcus pneumoniae isolated was resistant to optochin in healthy children. the specimens of this study were not taken from the nasopharynx but from the oropharynx due to the limitations of the author’s competence, because the nasopharynx specimen’s collections are more invasive. even though oxacillin is not used for treatment of human infections, this antibiotic was used in the study because of its benefit in the assessment of streptococcus pneumoniae sensitivity toward beta-lactams and cephalosporins. if oxacillin resistant isolates were found, further assessment should be conducted to determine streptococcus pneumoniae sensitivity toward each antibiotics from each class, mainly those which were commonly used for streptococcus pneumoniae infections treatment.4 however, because of time and funding limitations, it was not performed. a further study with larger scales should be carried out to identify the most common streptococcus pneumoniae serotypes in indonesia or a study about bacterial susceptibility patterns toward more types of antibiotics so that more comprehensive patterns would be obtained. furthermore, it is important to perform transmission control, such as promoting the use of masks among health care workers when dealing with patients who are susceptible to infection and also promote pneumococcal vaccination as a basic immunization for children, since it has been associated with decreased of the adults streptococcus pneumoniae carriage indirectly.15 rational use of antibiotics should also be improved, either rational antibiotics prescription by physicians or pharmacies, as well as its regulation by government. from this study, it can be concluded that streptococcus pneumoniae colonization is found among medical students of the faculty of medicine universitas padjadjaran batch 2011. all streptococcus pneumoniae found are resistant to one or more antibiotics, mostly to trimethoprim-sulfamethoxazole and oxacillin. references 1. longo dl, fauci as, kasper dl, hauser sl, jameson jl, loscalzo j, editors. harrison’s principles of internal medicine. 18th ed. new york: mcgraw-hill education; 2012. 2. forbes ba, sahm df, weissfeld as. bailey & scott’s diagnostic microbiology. 12th ed. st. louis: elsevier science health science division; 2007. 3. oteo j, lázaro e, abajo fjd, baquero f, campos j. trends in antimicrobial resistance in 1,968 invasive streptococcus pneumoniae strains isolated in spanish hospitals (2001 to 2003): decreasing penicillin resistance in children’s isolates. j clin microbiol. 2004;42(12):5571–7. 4. clsi. performance standards for antimicrobial susceptibility testing; twenty-fourth informational supplement. clsi document m100-s24. wayne, pa: clinical and laboratory standards institute; 2014. 5. hill pc, akisanya a, sankareh k, cheung yb, saaka m, lahai g, et al. nasopharyngeal carriage of streptococcus pneumoniae in gambian villagers. clin infect dis. 2006;43(6):673–9. 6. reis jn, palma t, ribeiro gs, pinheiro rm, ribeiro ct, cordeiro sm, et al. transmission of streptococcus pneumoniae in an urban stella valencia, yanti mulyana, diah dhianawaty: oropharyngeal colonization by streptococcus pneumoniae among medical students in indonesia althea medical journal. 2016;3(3) 354 amj september 2016 slum community. j infect. 2008;57(3):204– 13. 7. mackenzie ga, leach aj, carapetis jr, fisher j, morris ps. epidemiology of nasopharyngeal carriage of respiratory bacterial pathogens in children and adults: cross-sectional surveys in a population with high rates of pneumococcal disease. bmc infect dis. 2010;10(1):304. 8. watt jp, o’brien kl, katz s, bronsdon ma, elliott j, dallas j, et al. nasopharyngeal versus oropharyngeal sampling for detection of pneumococcal carriage in adults. j clin microbiol. 2004;42(11):4974– 6. 9. odutola a, antonio m, owolabi o, bojang a, foster-nyarko e, donkor s, et al. comparison of the prevalence of common bacterial pathogens in the oropharynx and nasopharynx of gambian infants. plos one. 2013;8(9):e75558. 10. blossom db, namayanja-kaye g, nankyamutyoba j, mukasa jb, bakka h, rwambuya s, et al. oropharyngeal colonization by streptococcus pneumoniae among hivinfected adults in uganda: assessing prevalence and antimicrobial susceptibility. int j infect dis. 2006;10(6):458–64. 11. gill c, mwanakasale v, fox m, chilengi r, tembo m, nsofwa m, et al. impact of human immunodeficiency virus infection on streptococcus pneumoniae colonization and seroepidemiology among zambian women. j infect dis. 2008;197(7):1000–5. 12. adegbola ra, deantonio r, hill pc, roca a, usuf e, hoet b, et al. carriage of streptococcus pneumoniae and other respiratory bacterial pathogens in low and lower-middle income countries: a systematic review and meta-analysis. plos one. 2014;9(8):e103293. 13. sharma r, sharma cl, kapoor b. antibacterial resistance: current problems and possible solutions. indian j med sci. 2005;59(3):120–9. 14. nunes s, sá-leão r, lencastre hd. optochin resistance among streptococcus pneumoniae strains colonizing healthy children in portugal. j clin microbiol. 2008;46(1):321–4. 15. hammitt ll, bruden dl, butler jc, baggett hc, hurlburt da, reasonover a, et al. indirect effect of conjugate vaccine on adult carriage of streptococcus pneumoniae: an explanation of trends in invasive pneumococcal disease. j infect dis. 2006;193(11):1487–94. althea medical journal. 2016;3(3) 405 correlation between physical activity level and health–related quality of life among elderly ricky anguda,1 setiawan,2 irma ruslina defi3 1faculty of medicine, universitas padjadjaran, 2departement of physiology faculty of medicine universitas padjadjaran, 3departement of physical and rehabilitation medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: the elderly population will keep growing in indonesia. decreased body function in elderly will affect their health–related quality of life. the aim of this study was to know the correlation between physical activity level and health–related quality of life among elderly methods: a cross-sectional analytical study was conducted from september to november 2014 in panti sosial tresna wredha budi pertiwi. the level of physical activity was measured with general practice physical activity questionnaire (gppaq) and health–related quality of life using the 36–item short form health survey version 2 (sf–36v2). there were 14 out of 29 female elderly who met the inclusion criteria. the data were collected using validated questionnaires and tested with simple linear regression. results: the physical activity level includes one inactive, three moderately inactives, eight moderately actives, and two actives. the average score of the health–related quality of life was 41.121±8.88 for the physical component scale (below average) and 57.629±7.54 (above average) for the mental component scale. no significant correlation was found between the level of physical activity with the physical component scale (p–value = 0.731) and mental component scale (p–value = 0.901). conclusions: the most frequently found physical activity level is the moderately active level. the score for the physical component scale is under average, while the mental component scale is above average. there is no correlation between the physical activity level and health–related quality of life for the physical component scale and the mental component scale. [amj.2016;3(3):405–10] keywords: gppaq, health–related quality of life, physical activity, sf–36v2 correspondence: ricky anguda, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 818601171 email: rickyanguda93@gmail.com introduction globally, it is predicted that there will be rapid increase in elderly population growth. in indonesia, this growth is expected to exceed the asian and global population after 2050. act number 13 year of 1998 on elderly welfare stated that elderly is defined as people 60 years old and over (ministry of social affairs, 2004).1 indonesian population census in 1990 showed that the percentage of young people in indonesia was 36.6 percent, and it is projected to continue declining down to 23.9 percent in 2025, while the elderly population will continue to increase.1,2 a survey conducted in 2014 showed that there are more elderly women than elderly men. indonesian life expectancy is increasing every year, in which the average life expectancy for is longer, i.e. 74.88 years, than men, i.e. 69.59 years.3 based on previous studies, older women tend to have a lower health–related quality of life than men in general and are vulnerable to physical and mental disorders.4,5 who recommendation of physical activity for elderly includes a minimum of 150 minutes of moderate intensity aerobic activity such as brisk walking or yoga, 75 minutes for heavy– intensity aerobic activity such as jogging or running, or a balanced combination for the whole week. active physical activities will affect the health–related quality of life positively.6,7 maintaining health–related quality of life in elderly is one of the main public health issues.8 this study aimed to reveal the correlation between the level of physical activity and health–related quality of life. methods a cross-sectional analytical study was conducted from september to november althea medical journal. 2016;3(3) 406 amj september 2016 2014 in panti sosial tresna wredha budi pertiwi, bandung, west java, indonesia. data were obtained through two different types of validated questionnaires. to determine the level of physical activity, the general practice physical activity questionnaire (gppaq) was used.9,10 the gppaq has been translated and validated by the researchers in panti tresna werdha bina bhakti. to determine the health– related quality of life score, 36–item short form health survey version 2 (sf–36v2) was used.11 the sf–36v2 has been translated and validated by the rheumatology department of dr. hasan sadikin general hospital. the study was conducted after obtaining the approval from the health research ethics committee faculty of medicine universitas padjadjaran. the population of study includes all residents of panti sosial tresna wredha budi pertiwi. this study used the total sampling technique. the inclusion criteria were women aged 60–74 years, based on the who classification age categories for elderly and the age category for gppaq, resided in panti sosial tresna wredha budi pertiwi, were still actives and able to communicate well, and were able to walk independently without assistance. the exclusion criteria were older women who have any physical disability that made it difficult to move normally (amputee and immobility of limbs), and impaired cognition. the data collected through the gppaq that describe the level of physical activity were entered into a statistical software and divided into four types which were then converted into several nominal scales, i.e. 1 for inactive, 2 for moderately inactive, 3 for moderately active, and 4 for active. data collected from the sf–36v2 for the health quality of life level were also entered into the software and were divided into eight scales of measurement, i.e. pf for physical functioning, rp for role– physical, bp for body pain, gh for general health, vt for vitality, sf for social functions, re for role–emotional, and mh for mental health. from the eight scales, pf, rp, bp, and gh were classified into the physical health scale, while vt, sf, re, and mh were classified into the mental health scale. the higher the scores are, the better the health–related quality of life. the statistical analysis used to examine the correlation between the two variables was the simple linear regression. the final results of this study were then displayed in tables and graphs and further discussed. results from the total of 29 respondents, 13 were excluded because their age was >74 years and 2 were excluded because of mental disorder and inability to communicate well resulting in 14 respondents participated in this study. the age of the respondents were grouped into three age groups to facilitate the data processing. all residents are women. by age group, most of the respondents were 71–74 years old with most of them were elementary school graduates. the majority of residents had moderately inactive physical activity level. the highest pf score of was found in the age group of 71–74 years while for rp, the highest score was found in the age group of 60–65 years old. the highest bp and gh scores was in the age group of 71–74 years old and the best scores for vt, sf, re, and mh were found in the age group of 71–74 years old. in general, for both physical table 1 respondent characteristics variable n (14) age (years) 60–65 3 66–70 5 71–74 6 education level no formal education 3 elementary school 7 junior high school 3 senior high school 1 althea medical journal. 2016;3(3) 407ricky anguda, setiawan, irma ruslina defi: correlation between physical activity level and health–related quality of life among elderly and mental health components, the best scores were mostly found in the age group of 71–74 years compared to other age groups. the result showed that the age group of 71–74 years old had better scores than the other age groups in both scales. based on the norm–based scoring (nbs), the score below 50 is defined as below average or poor. after the summary scale scores for the health–related quality of life physical component scale (pcs) and mental component scale (mcs) grouping was performed, it was revealed that the age group of 71–74 years old had the best scores. the physical activity levels in the graph were coded into numbers: 1 for inactive, 2 for moderately inactive, 3 for moderately active, and 4 for active. in figure 1a, the correlation between the physical activity level and physical component scale shows a tendency that the higher physical activity level is, the better the physical component scale; thus, it is directly proportional to the scatter plot graph. after conducting simple regression testing between the two variables, it was revealed that the p–value was 0.731, so no significant correlation between the physical activity level and the physical component scale can be established. the physical activity level and mental component scale were then put into a scatter plot graph as shown in the figure 1b. the figure also shows a straight comparison between the physical activity level and mental component scale. after testing using the simple linear regression, the p–value was 0.901; hence, there isno significant correlation between the physical activity level and mental component scales. discussion this study shows that in terms of the physical activity level, the majority of respondents are moderately active, as all residents are table 2 physical activity level age (years) n physical activity level inactive moderately inactive moderately active active 60–65 3 0 0 2 1 66–70 5 1 1 2 1 71–74 6 0 2 4 0 total 14 1 3 8 2 table 3 health–related quality of life scores age (years) health–related quality of life pf mean (sd) rp mean (sd) bp mean (sd) gh mean (sd) vt mean (sd) sf mean (sd) re mean (sd) mh mean (sd) 60–65 44.4(7.3) 47.1(7.4) 43.1(2.6) 43.4(10.9) 50.0(1.8) 55.0(3.1) 45.5(14.7) 55.6(7.5) 66–70 41.0(9.7) 36.3(13.6) 52.2(9.0) 48(5.8) 56.5(10.7) 48.1(16.6) 48.1(11.0) 56.7(4.3) 71–74 46.8(9.2) 40.6(14.8) 57.4(7.5) 50.0(9.0) 57.8 (5.4) 55.9(2.2) 50.1(14.3) 60.3(5.0) note: *pf: physical functioning, rp: role–physical, bp: bodily pain, gh: general health, vt: vitality, sf: social function, re: role– emotional, mh: mental health table 4 health–related quality of life scores summary age (years) health–related quality of life scales pcs mean (sd) mcs mean (sd) 60–65 42.3 (3.5) 54.6 (10.0) 66–70 40.7 (11.0) 57.1 (4.1) 71–74 45.6 (9.5) 59.6 (9.1) note: *pcs: physical component scale, mcs: mental component scale althea medical journal. 2016;3(3) 408 amj september 2016 not working or have retired and they are actively involved in regular exercise scheduled twice a week but they never cycle anymore (because gppaq scoring focuses on works that involve physical activity, exercise, and cycling throughout a week).9 there is a regular exercise program of twice a week with a total of two hours of exercise; hence, one hour per session. most of residents who actively participate in the exercise are in the moderately active group and some of them who add their own exercise schedule into the routine schedule are in the active group. respondents who exercise independently with a duration that is less than the duration of the weekly routine exercise are categorized into the moderately inactive group while those who never exercise independently and never participate in the routine exercise are categorized into the inactive group. this is in contrast with results from a previous study showing that the majority of physical activity level performed by the majority of elderly is moderately inactive. this previous study was performed in east padang on a study population aged ≥60 years who live in jati village of east padang district.12 this may be caused by differences in routine physical activities, such as the weekly exercise for elderly conducted by panti sosial tresna wredha budi pertiwi because the respondents of the east padang study live in their home and do not have routine physical activity. in the measurement of health–related quality of life, the best score for both component scales are found in the age group of 71–74 years old. this is in contrast with previous studies in brazil on a population of elderly fromfour states of sao paulo4 who lived in their house and in germany5 on a population of citizens that show that health–related quality of life scores in older respondents decreases. this difference may be caused by environmental figure 1 correlation between the physical activity level and physical component scale and mental component scale of health–related quality of life table 5 health–related quality of life score grouping by norm–based scoring age (years) n health–related quality of life scales pcs < 50 mcs < 50 pcs ≥ 50 mcs ≥ 50 60–65 3 3 1 0 2 66–70 5 5 0 0 5 71–74 6 4 1 2 5 total 14 12 2 2 12 note: *pcs: physical component scale, mcs: mental component scale althea medical journal. 2016;3(3) 409 factors of the respondents participating in the study, who generally live in their home, have cultural and religious differences, and different races. after the scores are grouped according to the norm–based scoring to simplify the conclusion, the majority of the physical component scale for each age group is under average, which is below 50.0, while the mental component scale is above average. this can be caused by the environmental situation of panti sosial tresna wredha budi pertiwi which allows bias in terms of mental health, as the subjects live together with their peers. this is one of the factors that could influence the mental component scale in accordance with previous studies that showed social activities could improve the mental health of the elderly significantly.13 a systematic review research also shows that social interventions for health promotion in the elderly who are lonely and isolated elderly will create happiness.14 the result regarding the correlation between the physical activity level and health– related quality of life in the physical and mental component scales is not significant. this is in contrast with previous studies that show a significant correlation between a high physical activity level and better health–related quality of life.15,16 this result was expected because the number of respondents in this study was small and did not represent each group of the study. there was also a tendency for subjective answers on the questionnaire by the respondents, such as they were not able to determine the appropriate response to describe their current condition when they are being interviewed about the health–related quality of life. there are other limitations in the implementation of this study. this study does not include any medical history details and respondent background that could affect the outcome of the health–related quality of life. the number of respondents in this study is too few and the distribution of data for each group is uneven, allowing for bias and failure in gaining significant correlations between the variables studied. time constraint is also one of the problems faced during the study. for further research, it is expected to increase the sample size ad to include subjects’ detailed medical history and background to minimize the possibility of bias and to obtain significant results. in conclusion, based on the data obtained from the respondents, the highest level of activity in the group is moderately active while the physical component scale is below the average. the mental component of the respondents is above average. there is no correlation between the physical activity level and health–related quality of life in physical and mental component scales. references 1. pusat data dan informasi kementerian kesehatan republik indonesia. gambaran kesehatan lanjut usia di indonesia. buletin jendela data dan informasi kesehatan. jakarta. 2013;1:1–19. 2. noveria m. challenges of population ageing in indonesia. paper presented at: conference on impact of ageing: a common challenge for europe and asia; 2006 june 27–28; vienna, austria. 3. central intelligence agency. the world factbook. washington, dc: central intelligence agency; 2014 [cited 2014 october 14]. available at: https://www. cia.gov/library/publications/resources/ the-world-factbook/ 4. lima mg, barros mbda, césar clg, goldbaum m, carandina l, ciconelli rm. health related quality of life among the elderly: a population-based study using sf-36 survey. cad saúde pública. 2009;25(10):2159–67. 5. ellert u, kurth bm. [health related quality of life in adults in germany: results of the german health interview and examination survey for adults (degs1)]. bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz. 2013;56(5-6):643–9. 6. moore sc, patel av, matthews ce, berrington de gonzalez a, park y, katki ha, et al. leisure time physical activity of moderate to vigorous intensity and mortality: a large pooled cohort analysis. plos medicine. 2012;9(11):e1001335. 7. elsawy b, higgins ke. physical activity guidelines for older adults. am fam physician. 2010;81(1):55–9. 8. acree ls, longfors j, fjeldstad as, fjeldstad c, schank b, nickel kj, et al. physical activity is related to quality of life in older adults. health qual life outcomes. 2006;4(1):37. 9. heron n, tully ma, mckinley mc, cupples me. physical activity assessment in practice: a mixed methods study of gppaq use in primary care. bmc fam pract. 2014;15:11. 10. dalrymple j, bullock i. diagnosis and management of irritable bowel syndrome in adults in primary care: summary of nice ricky anguda, setiawan, irma ruslina defi: correlation between physical activity level and health–related quality of life among elderly althea medical journal. 2016;3(3) 410 amj september 2016 guidance. bmj. 2008;336(7643):556–8. 11. bayliss m, rendas-baum r, white mk, maruish m, bjorner j, tunis sl. healthrelated quality of life (hrql) for individuals with self-reported chronic physical and/ or mental health conditions: panel survey of an adult sample in the united states. health qual life outcomes. 2012;10:154. 12. muzamil ms, afriwardi, martini rd. hubungan antara tingkat aktivitas fisik dengan fungsi kognitif pada usila di kelurahan jati kecamatan padang timur. jurnal kesehatan andalas. 2014;3(2):202– 4 13. forsman ak, nordmyr j, wahlbeck k. psychosocial interventions for the promotion of mental health and the prevention of depression among older adults. health promot int. 2011;26(suppl 1):i85–107. 14. cattan m, white m, bond j, learmouth a. preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. ageing soc. 2005;25(01):41–67. 15. kaupuzs a. a cross-sectional analysis of physical activity, psychological determinants and health related variables of latvian older adults. eujapa. 2012;5(1):31–52. 16. setiawan gw, wungouw his, pangemanan dhc. pengaruh senam bugar lanjut usia (lansia) terhadap kualitas hidup penderita hipertensi. jurnal ebm. 2013;1(2):760–4. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 85 knowledge, attitude, and practice survey among nurses in dr. hasan sadikin general hospital toward tuberculosis-human immunodeficiency virus collaboration program helen oktavia sutiono,1 arto yuwono soeroto,2 bony wiem lestari3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of epidemiology and biostatistics faculty of medicine universitas padjadjaran abstract background: one of the barriers on implementation of tuberculosis-human immunodeficiency virus (tbhiv) collaboration is lack of health care workers’ knowledge to this program. this study aimed to measure level of knowledge, attitude, and practice among inpatient nurses in dr. hasan sadikin general hospital toward tb-hiv collaboration program and to measure their correlation. methods: this was a cross-sectional study with total sampling method which started on may–october 2013 at internal medicine department ward in dr. hasan sadikin general hospital. knowledge, attitude, and practice of research subjects were measured using modified questionnaire about tb-hiv collaboration program, based on guidelines from who and national ministry of health. results:of 88 respondents, there were no respondent had high level, 33 respondents (38%) had moderate level, and 55 respondents (63%) had low level of knowledge toward collaboration. for attitude, 53 respondents (60%) had positive attitude and 35 respondents (40%) had negative attitude. the study also showed 48 respondents (55%) had positive practice and 40 respondents (46%) had negative practice. the correlation between knowledge and attitude, knowledge and practice, and attitude and practice were not statistically significant (p>0.05). conclusions: the level of knowledge among inpatient nurses in dr. hasan sadikin general hospital toward tb-hiv collaboration program was low but they showed positive attitude toward the collaboration itself. there was no correlation between knowledge, attitude, and practice among inpatient nurses toward collaboration. further efforts were needed to improve nurses’ knowledge, attitude, and practice on tb-hiv collaboration. [amj.2016;3(1):85–92] keywords: attitude, knowledge, nurses, practice, tb-hiv correspondence: helen oktavia sutiono, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 817 9622 266 email: helen.sutiono@yahoo.com introduction tuberculosis (tb) is the most common opportunistic infection among human immunodeficiency virus (hiv) infections.1 in 2012, 320,000 people died of tb-hiv and there were an estimated 1.1 million new tbhiv cases.2 indonesia was included as one of the high tb-hiv burden countries and ranked fourth as a country with the most tb-hiv cases in southeast asia region.3 the prevalence of hiv infection among new tb cases was 3% while according to second quarterly report in 2011 the prevalence of tb among aids cases was 50%.4 indonesia was increasingly important in the global tb-hiv control.5 the world health organization (who) and stop tb partnership devised an international policy guideline toward tb-hiv collaboration which important to monitor tb-hiv collaboration and to decrease the mortality of tb-hiv patients.6-8 nevertheless, there were still some barriers in implementation of collaboration. lack of knowledge and skill of health care workers are one of some barriers in collaboration beside the limitedness of health care workers, infrastructure of the hospital, drug supply, referral system, and internal factors of patients.5,9-11 this lack of knowledge among health care workers could lead to denied access among patients to health services, suboptimal health care services and lead to an increasing non communicable disease burden and death.12 the studies althea medical journal. 2016;3(1) 86 amj march 2016 regarding level of knowledge, attitude, and practice among health care workers toward tbhiv collaboration at dr. hasan sadikin general hospital have yet never been done. this study aimed to measure level of knowledge, attitude, and practice among inpatient nurses in dr. hasan sadikin general hospital toward tbhiv collaboration program and to measure their correlation. methods this cross-sectional study was conducted in may–december 2013. inpatient nurses in dr. hasan sadikin general hospital who actively involved in tb-hiv collaboration had been given informed consent. the nurses willing to complete a questionnaire were selected as research subjects. total sampling or survey method was used in this study because of a few researches discussing specifically about knowledge, attitude, and practice survey among health care workers toward this program. the study used primary data, a modified questionnaire based on guidelines from who and national ministry of health, which was proved by health research ethics committee and applied in october 2013 at internal medicine department ward of dr. hasan sadikin general hospital. the questionnaire consisted of questions about characteristics of respondent and questions about knowledge, attitude, and practice among inpatient nurses toward tb-hiv collaboration program. knowledge questions were 21 items in multiple choice questions. attitude questions were 21 items and practice questions were 9 items, in likert scale. validation of questionnaire had been conducted on july–september 2013. validity testing conducted were face validity, a validity test by consultation with the experts about the contents, either by tb or hiv doctors’ team, and content validity resulting a strong and very strong correlation. reliability testing was also measured using α-cronbach value (α=0.749) which means strong or high correlation. afterward, the valid questionnaire was applied with an agreed mechanism by the room leaders in each department. the collected data was then analyzed. in the beginning, an investigation whether the data is distributed normally (parametric test) or not (nonparametric test) using kolmogorovsmirnov was done. level of knowledge was categorized into high, moderate, and low level based on classification of knowledge by arikunto. it can be called as high if percentage ≥75%, moderate if 56% ≤ percentage <75%, and low if percentage <56%. attitude of respondents was categorized into positive attitude (percentage ≥median) and negative attitude (percentage <median). practice was assessed based on respondents assumption and was categorized into positive practice (percentage ≥median) and negative practice (percentage <median). when data distribution is normal, correlation bivariate analyses test or correlative hypothesis testing uses pearson test. instead of that, test used spearman test. results from 111 research subjects, 88 questionnaires had been obtained from nurses who agreed to become respondents and signed informed consent sheet. other 23 nurses could not fill the questionnaire because of study and pilgrimage issues. from 88 respondents, only 12 nurses (14%) had attended tb-hiv training, including dots (directly observed treatment, shortcourse) training, collaborative tb-hiv, pmdt (programmatic management of drug-resistant tb), hdl (hospital dots linkage), pitc (provider-initiated counseling and testing) & vct (voluntary hiv counseling and testing), mdr-tb (multi-drug-resistant tuberculosis), imai (integrated management of adolescent and adult illness), palliative care for plwa (people living with hiv/aids), and treatment compliance. survey presented there were no respondent had high level, 33 respondents (38%) had moderate level, and 55 respondents (63%) had low level of knowledge toward collaboration. median of attitude percentage in this study was 80% with minimum 67% and maximum 95%. this survey results stated that 53 respondents (60%) had positive attitude and 35 respondents (40%) had negative attitude. median of practice percentage in this study was 40% with minimum 20% and maximum 80%. in 88 inpatient respondents, 48 respondents (55%) had positive practice and 40 respondents (46%) had negative practice. in kolmogorov-smirnov test, knowledge, attitude, and practice score have p=0.000. because of p<0.05, these three variables had not normal distribution. in spearman test, the correlation between knowledge and attitude of the respondents was negative and very weak (r=-0.069), not statistically significant althea medical journal. 2016;3(1) 87helen oktavia sutiono, arto yuwono soeroto, bony wiem lestari: knowledge, attitude, and practice survey among nurses in dr. hasan sadikin general hospital toward tuberculosis-human immunodeficiency virus collaboration program (p>0.05). the correlation between knowledge and practice of the respondents was positive and very weak (r=0.153), not statistically significant (p>0.05). the correlation between attitude and practice of the respondents was also positive and very weak (r=0.155), not statistically significant (p>0.05). in kolmogorov-smirnov test, knowledge, attitude, and practice score have p=0.000. because of p<0.05, these three variables had not normal distribution. in spearman test, the correlation between knowledge and attitude table 1 characteristic of respondents variable frequency percentage (%) age 20–29 years 33 38 30–39 years 41 47 40–49 years 12 14 50–59 years 2 2 sex male 22 25 female 66 75 employment status civilian employee 62 71 contract staff 22 25 others 4 5 length of civilian employee <2 years 2 2 2–10 years 37 42 >10 years 23 26 department 1st floor fresia 14 16 2nd floor fresia 24 27 3rd floor fresia 23 26 flamboyan 11 8 1st floor kemuning 7 10 5th floor kemuning 9 13 profession s1 keperawatan 17 19 d3 keperawatan 70 80 spk/spr 1 1 length of work ≤10 years 71 81 >10 years 17 19 tb-hiv training which had been accepted ever 12 14 never 76 86 althea medical journal. 2016;3(1) 88 amj march 2016 of the respondents was negative and very weak (r=-0.069), not statistically significant (p>0.05). the correlation between knowledge and practice of the respondents was positive and very weak (r=0.153), not statistically significant (p>0.05). the correlation between attitude and practice of the respondents was also positive and very weak (r=0.155), not statistically significant (p>0.05). discussion survey presented that there were no respondent had high level, 33 respondents (38%) had moderate level, and 55 respondents (63%) had low level of knowledge toward collaboration. the study showed that the level of knowledge of respondents was mostly low and lower if compared to the research conducted by tikuye13 about knowledge, table 2 description of level of knowledge among respondents toward tb-hiv collaboration program know do not know n % n % 1. objectives of tb-hiv collaboration implementation in indonesia 61 69 27 31 2. model of tb-hiv collaboration program service in dr. hasan sadikin general hospital 5 6 83 94 3. example of tb-hiv collaboration activities to decrease tb burden for plwas 38 43 50 57 4. example of tb-hiv collaboration activities to decrease hiv burden for tb patients 48 55 40 46 5. control of tb infection in health care services and specific places. 75 85 13 15 6. role of health care workers in tb-hiv collaboration 66 75 22 25 7. role and function of nurses in tb unit 86 98 2 2 8. screening of tb in plwa 66 75 22 25 9. thorax x-ray examination for tb suspects afb negative in diagnosis of tb for plwh 43 49 45 51 10. strategy of hiv testing and counseling in tb patients to decrease hiv burden in tb patients 4 5 84 96 11. definition of pitc (provider initiated testing and counseling) 37 42 51 58 12. principal of pitc implementation 60 68 28 32 13. action of pitc implementation in dots unit 69 78 19 22 14. referral system in tb-hiv collaboration services 6 7 82 93 15. indication of cotrimoxazole therapy 20 23 68 77 16. recording of hiv cases in tb program 28 32 60 68 17. reporting of collaborative tb-hiv program 33 38 55 63 18. reporting of collaborative tb-hiv program from hiv unit 19 22 69 78 19. the success indicator of tb-hiv collaboration program 75 85 13 15 20. the success indicator of tb-hiv collaboration activities in hiv unit 42 48 46 52 21. the success indicator of tb-hiv collaboration activities in tb unit 45 51 43 49 althea medical journal. 2016;3(1) 89helen oktavia sutiono, arto yuwono soeroto, bony wiem lestari: knowledge, attitude, and practice survey among nurses in dr. hasan sadikin general hospital toward tuberculosis-human immunodeficiency virus collaboration program table 3 description of attitude of respondents toward tb-hiv collaboration program statement va n (%) a n (%) d n (%) na n (%) vna n (%) 1. implementation of tb-hiv collaboration in indonesia is important to decrease tb and hiv burden in society. 72 (82) 15 (17) 1 (1) 0 (0) 0 (0) 2. model of tb-hiv collaboration service should be appropriate with health care facility condition. 36 (41) 51 (58) 1 (1) 0 (0) 0 (0) 3. in my opinion, tb-hiv collaboration program increases my work burden as health care worker. 19 (22) 48 (55) 16 (18) 2 (2) 3 (3) 4. in my opinion, tb-hiv collaboration activities purposed to decrease hiv burden in tb patients are important to do, beside to decrease tb burden in plwa. 51 (58) 37 (42) 0 (0) 0 (0) 0 (0) 5. in my opinion, effort to control both of tb infection and hiv infection will make stigmatization and discrimination to tb and hiv patients. 8 (9) 17 (19) 12 (14) 38 (43) 13 (15) 6. in my opinion, just counselor and doctor had a right to do tb screening, whereas nurses had not. 19 (22) 48 (55) 11 (13) 5 (6) 5 (6) 7. in my opinion, assessment of hiv risk factor in tb patients and patient reference to hiv unit can be done by both doctors and nurses in tb services. 19 (22) 59 (67) 6 (7) 3 (3) 1 (1) 8. in my opinion, tb screening only needs to do to plwh who complain tb sign and symptom. 13 (15) 40 (46) 3 (3) 22 (25) 10 (11) 9. afb examination is important to diagnose tb for plwh. 43(49) 38(43) 0(0) 7(8) 0(0) 10. one of hiv testing and counseling strategy for tb patients in indonesia is toward screening of risk factor. 22 (25) 58 (66) 5 (6) 3 (3) 0 (0) 11. pitc which had been done to tb patients is an effort to decrease hiv burden in tb patients. 25 (28) 50 (57) 12 (14) 1 (1) 0 (0) 12. communication, information, and education about tb-hiv is important to give to patients before doing pitc. 29 (33) 54 (61) 1 (1) 3 (3) 1 (1) 13. in my opinion, hiv risk factor screening in tb patients is very important for early tb-hiv cases finding. 24 (27) 63 (72) 1 (1) 0 (0) 0 (0) 14 in my opinion, it is important to know whether the tb patients are hiv positive or not to determine the appropriate treatment. 32 (36) 54 (61) 1 (1) 1 (1) 0 (0) 15. cotrimoxazole therapy for plwh is purposed to decrease the number of morbidity and mortality because of co-infected or not with tb. 16 (18) 62 (71) 8 (9) 2 (2) 0 (0) 16. recording and reporting of tb-hiv collaboration program is important to do in tb and hiv unit. 36 (41) 52 (59) 0 (0) 0 (0) 0 (0) 17. in my opinion, monitoring and evaluating of tb-hiv collaboration program is important to determine the accomplishment of program by indicator of program success. 24 (27) 63 (72) 0 (0) 0 (0) 1 (1) 18. in my opinion, important components in monitoring and evaluating of tb-hiv collaboration program are recording and reporting process. 20 (23) 65 (74) 3 (3) 0 (0) 0 (0) 19. in my opinion, data in tb-hiv collaboration report should be integrated between tb and hiv unit, so it makes easier data tabulation and analysis. 37 (42) 47 (53) 2 (2) 1 (1) 1 (1) 20. in my opinion, total of plwh receiving tb service is one of important indicator for tb-hiv collaboration program success in hiv care unit. 28 (32) 57 (65) 2 (2) 0 (0) 1 (1) 21. in my opinion, total of hiv positive patients receiving cotrimoxazole preventive therapy is important indicator for tb-hiv collaboration program success in tb care unit. 20 (23) 45 (51) 19 (21) 2 (2) 2 (2) althea medical journal. 2016;3(1) 90 amj march 2016 attitude, and practice of health care providers towards isoniazid preventive therapy (ipt) provision in addis ababa, ethiopia. that research concluded that from 104 health care providers, 74 respondents (71%) had high knowledge towards ipt, 29 respondents (28%) had moderate knowledge, and only one respondent (1%) had low knowledge. this could be caused by many respondents who had been trained in collaborative tb-hiv, including ipt. 13 in dr. hasan sadikin general hospital, tbhiv training had always been conducted but only a few nurses had attended tb-hiv training. from 88 respondents, only 12 respondents (14%) who had attended tb-hiv training and 76 respondents (86%) had not. a research in uganda by okot-chono14 and uwimana et al.15 explained that collaborative tb-hiv activities might had not been well implemented due to lack of training of tb-hiv collaboration for all health care workers related to this collaboration, besides minimal follow-up supervising after training, lack of structural collaborative tb-hiv mechanism in facilities, low and unstandardized collaborative tbhiv stipend for health care workers leading demotivation, and lack of manual for tb-hiv collaboration. in addition, a study from pakenhamwalsh et al.12 stated that lack of knowledge of health care workers was due to little access to information among health care workers and failure of international information policies. a clear, authoritative, referenced manual was also important for avoiding discrepancies between recommended services and practice. a study also revealed that active participation like training of health care workers was fundamental.12 this study illustrated that over 50% of respondents seemed did not know about model of tb-hiv collaboration service in dr. hasan sadikin general hospital that was a parallel model because of the independent between unit tb and unit hiv.4 this study also found that over 50% of respondents appeared did not know about the strategy of hiv testing and the definition of pitc. a study of okot-chono14 said that it is important to know pitc in tbhiv collaboration since the implementation of pitc will increase the number of tb-hiv patients who were screened for hiv resulting in lower rates of morbidity and mortality of tb-hiv patients. over 50% respondents also appeared did not know about referral system, therapy, recording, and reporting in tb-hiv collaboration. an analysis of interaction between tb-hiv programs in sub-saharan africa16 established by who showed that the lack of knowledge of health care workers was caused by low national awareness to tb-hiv interaction, lack of priority to collaborative tb-hiv activity, lack of resources, lack of ability from an organization in implementation of tb-hiv collaboration program, and lack of communication between two units. this survey revealed that there were 53 respondents (60%) had positive attitude and 35 respondents (40%) had negative attitude. the study has the same result with a study conducted in ethiopia by tikuye13 which attitude of health care workers toward ipt practice in average was positive attitude (69%). this is due to the high level of knowledge of table 4 description of practice of respondents toward tb-hiv collaboration program statement a n (%) o n (%) s n (%) se n (%) n n (%) 1. attending the tb-hiv collaboration meeting in dr. hasan sadikin general hospital. 1(1) 4(5) 6(7) 14(16) 63(72) 2. doing tb screening to plwhs. 7(8) 19(22) 16(18) 27(31) 19(22) 3. doing hiv risk factor screening to hospitalized tb patients. 12(14) 13(15) 24(27) 22(25) 17(19) 4. asking tb patients to be done hiv examination. 2(2) 13(15) 11(13) 31(35) 31(35) 5. giving information about the result of hiv testing in tb patients. 0(0) 3(3) 16(18) 18(21) 51(58) 6. giving information about tb screening to plwhs. 3(3) 14(16) 21(24) 23(26) 27(31) 7. giving communication, information, and education to hospitalized tb patients about hiv/aids. 2(2) 12(14) 26(30) 22(25) 26(30) 8. attending the collaborative tb-hiv training. 0(0) 1(1) 8(9) 11(13) 68(77) 9. filling the tb05 form for sputum examination demand. 9(10) 11(13) 26(30) 14(16) 28(32) note: * a=always; o=often; s=sometimes; se=seldom; n=never althea medical journal. 2016;3(1) 91 the ipt.13 awareness of duty and authority of respondents in tb-hiv collaboration program were might had been good. it was evidenced by more than 50% respondents’ statement that they were willing to give service for tbhiv patients and nurses have rights doing tb and hiv screening. the study revealed that there were 48 respondents (55%) had positive practice and 40 respondents (46%) had negative practice. practice of respondents of the study in tbhiv collaboration generally was relatively less when compared to practice of health care providers towards ipt practice in the study by tikuye13 that good practice in average (81.7%) and the rest had fair practice. over 50% of respondents stated that they have never attended tb-hiv collaboration meeting and training as well as have been given information about result of hiv testing to tb patients. most of respondents also stated that they hardly or have never done tb screening to plwhs and hiv risk factor screening to hospitalized tb patients. they also have never asked tb patients for doing hiv examination have never given information about tb screening and hiv/aids, and have never filled the tb05 form for sputum examination. this was similar to a research conducted by okot-chono14 which explained that the implementation of tb-hiv collaboration in the recording and reporting of tb-hiv cases was somewhat poor. then, from sample of 28 patients with hiv in the forum group discussion (fgd), 21% had never been screened for tb.14 one of the causes was due to the lack of knowledge among health care providers about the program and policy of the collaboration and the role of each health care providers in collaboration itself.14 negative practice of these respondents might be caused by different program and policy structure between dr. hasan sadikin general hospital and national ministry of health, as well as lack of an internationally agreed package of care for tb-hiv patients.16 this study found that there was no correlation between knowledge, attitude, and practice among respondents toward collaboration itself. it might indicate that their knowledge, attitude, and practice were built independently each other.17 a research of ipt practice by tikuye13 explained that there was a significant relationship between knowledge and attitude (p=0.000), which meant a high level of knowledge would form a positive attitude. however, there was no significant relationship between knowledge and practice (p=0.368) as well as between attitude and practice (p=0.257) ipt. limitations of this study were restricted time for data collection. therefore, questionnaires were applied to each room leader and took one week later. because of the self-report questionnaires, the honesty of respondents’ answers should be questioned. in conclusion, knowledge among inpatient nurses in dr. hasan sadikin general hospital toward tb-hiv collaboration program was mostly low, attitude among most inpatient nurses toward this program was positive, but practice among inpatient nurses toward this program was still lacking. nevertheless, there was no statistically significant correlation between knowledge, attitude, and practice among inpatient nurses toward tb-hiv collaboration program. suggestion from this study was there is a need to increase tb-hiv collaboration training and enclose more health care workers who active in this program for joining the training, provisioning of follow up after tbhiv collaboration training, constructing specific modules for the program, increasing communication and integration of tb-hiv collaboration, involving tb & hiv community in every tb-hiv workshops, and integrating political commitment in tb-hiv collaboration. for the next research, it was suggested to prolong time of data collection for more reliable data collection method, by an example to gather the respondents in a room for answering the questionnaires collectively. references 1. corbett e, watt c, walker n, maher d, williams b, raviglione m, et al. the growing burden of tuberculosis: global trends and interactions with the hiv epidemic. arch intern med. 2003;163:1009–21. 2. who. tuberculosis. saudi med j. 2013;34(11):1205–7. 3. aung m, moolphate s, paudel d, jayathunge m, duangrithi d, wangdi k, et al. global evidence directing regional preventive strategies in southeast asia for fighting tb/hiv. j infect dev ctries. 2013; 7(3):191–202. 4. mustikawati d, wandra t, surya a, rizkiyati n, nugrahini n, sampoerno h, et al. manual pelaksanaan kolaborasi tbhiv di indonesia. jakarta; kementerian kesehatan ri; 2012. 5. mahendradhata y, ahmad r, lefevre p, boelaert m, stuyft p. barriers for introducing helen oktavia sutiono, arto yuwono soeroto, bony wiem lestari: knowledge, attitude, and practice survey among nurses in dr. hasan sadikin general hospital toward tuberculosis-human immunodeficiency virus collaboration program althea medical journal. 2016;3(1) 92 amj march 2016 hiv testing among tuberculosis patients in jogjakarta, indonesia: a qualitative study. bmc public health. 2008; 8:385. 6. harries a, zachariah r, corbett e, lawn s, santos-filho e, chimzizi r, et al. the hivassociated tuberculosis epidemic. lancet. 2010; 375:1906–19. 7. getahun h, gunneberg c, granich r, nunn p. hiv infection-associated tuberculosis: the epidemiology and the response. clinical infectious diseases. 2010; 50(s3): s201–7. 8. eang m t, vun m c, eam k k, sovannarith s, sopheap s, bora n, et al. the multi-step process of building tb/hiv collaboration in cambodia. health research policy and systems. 2012; 10: 34 9. nansera d, bajunirwe f, kabakyenga j, asiimwe pk j, mayanja-kizza h. opportunities and barriers for implementation of integrated tb and hiv care in lower level health units: experiences from a rural western ugandan district. african health sciences. 2010; 10(4): 312–9. 10. njozing b, edin k, sebastián m, hurtig a. voices from the frontline: counsellors’ perspectives on tb-hiv collaborative activities in the northwest region, cameroon. biomed central. 2011;11:328. 11. wandwalo e, kapalata n, tarimo e, corrigan c, morkve o. collaboration between the national tuberculosis programme and a non-governmental organization in tb-hiv care at a district level: experience from tanzania. african health sciences. 2004; 4(2):109–14. 12. pakenham-walsh n, bukachi f. information needs of health care workers in developing countries: a literature review with a focus on africa. human resources for health. 2009; 7: 30. 13. tikuye a. knowledge, attitude, and practices of health care providers towards isoniazide preventive therapy (ipt) provision in addis ababa, ethiopia [dissertation]. south africa: university of south africa; 2013. 14. okot-chono r, mugisha f, adatu f, madraa e, dlodlo r, fujiwara p. health system barriers affecting the implementation of collaborative tb-hiv services in uganda. int j tuberc lung dis. 2009; 13(8):955–61. 15. uwimana j, zarowsky c, hausler h, jackson d. engagement of nongovernment organisations and community care workers in collaborative tb/hiv activities including prevention of mother to child transmission in south africa: opportunities and challenges. bmc health services research. 2012; 12: 233. 16. stop tb department communicable diseases programme. an analysis of interaction between tb and hiv/aids programmes in sub-saharan africa. geneva: who; 2001. 17. chendake m, mohite v. assess the knowledge and attitude of nursing students towards hiv/aids. indian j sci res. 2013; 4(1): 69–74. althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 126 amj march 2016 functional status of stroke patients at neurologic outpatient clinic dr. hasan sadikin general hospital lee shok chen,1 marina a. moeliono,2 lisda amalia3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, abstract background: functional status refers to the ability of an individual to perform normal daily activity required to meet basic needs, fulfill usual roles, and maintain health and well-being. the objective of this study was to evaluate the level of disability and independency of stroke patients who had undergone rehabilitation therapy as the routine activity using instrumental activity of daily living (iadls) and basic activity of daily living (badls). methods: this descriptive study carried out from september to october 2014 at neurologic outpatient clinic dr. hasan sadikin general hospital bandung with a total 33 subjects. barthel index and iadls questionnaire was used as an instrumental tool. barthel index was used to measure the level of disability and iadls was used to measure the level of independency of an individual. results: from the 33 patients, 20 patients completed their rehabilitation therapy; 5 patients showed a moderate disability and 15 patients showed a mild disability at the barthel index of adls. the result of iadls showed that 7 patients who completed the therapy had moderate level of independency, and 3 patients were at the category of high level of independency. conclusions: most of the stroke patients have moderate disability in barthel index and had low level of independency in iadls. [amj.2016;3(1):126–31] keywords: barthel index, disability, functional status, independent instrumental activity of daily living correspondence: lee shok chen, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822004580 email: shokchen91@gmail.com introduction stroke is defined as rapidly developing signs of focal disturbances of cerebral functions, leading to death or disability, lasting longer than 24 hours, with no apparent cause other than vascular. globally, it is the second most common cause of death with total 5.7 million deaths around the world.1 stroke is no longer a disease in developed country. about 85% of all stroke deaths are caused by low and middle income worldwide. stroke in terms of disability-adjusted life years, calculated worldwide in 72 million per year, accounts for 87% of total lost.2 the basic activity of daily living (adls) of post stroke patients is measured by barthel index and instrumental activity of daily living (iadls) to assess the functional abilities as in complex task. barthel index is an instrument to measure basic self-care of the individual. the iadls are defined as activities which are necessary to accomplish to continue independent residence in a community. those activities are household activities include answering telephone call, having responsibility to own medication, preparing meal, going shopping, washing clothes, and handling household finances. stroke recovery depends on many factors: the specific site of brain injury, the patients’ condition. stroke rehabilitation begins during the acute hospitalization, when the diagnosis is established and life-threatening events are under control. to prevent complications, early intervention is encouraged. rehabilitation is to promote proper management of functional outcome, encourage resumption of self-care activities, and provide mental support to the patients and their family.3 functional status refers to the ability of an individual to perform normal adls required althea medical journal. 2016;3(1) 127 to meet basic needs, fulfill usual roles, and maintain health and well-being.4 disability is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society where he or she lives.5 functional is classified as iadls and basic adls.6 they use to evaluate the functional status and their disability after stroke in routine activity, and to measure the level of independency. basic adls are self-maintenance abilities such as dressing, grooming, or bathing. instrumental iadls are more complex on everyday tasks, which are skills beyond basic self-care skills needed to function independently at home and in the community.7 effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. the reviews above address have found some of the inconsistent findings in assessing the functional abilities of stroke patients. there is a lack from previous researches convincing evidence on the compliance of rehabilitation therapy improvement of the functional status of stroke patients. the purpose of this study was to evaluate the level of disability and independency of stroke patients who had undergone rehabilitation therapy as the routine activity. this study was conducted in dr. hasan sadikin general hospital, one of national hospitals referred in indonesia whose the rehabilitation department has useful equipment and physiotherapist to guide patients in rehabilitation therapy. methods this was a descriptive study about the functional status of stroke outpatients carried out from september to october 2014 at neurologic outpatient clinic dr. hasan sadikin general hospital bandung. this study conducted under the ethical clearance issued by the health research ethics committee lee shok chen, marina a. moeliono, lisda amalia: functional status of stroke patients at neurologic outpatient clinic dr. hasan sadikin general hospital table 1 demographic characteristic demographic characteristic total (n) percentage % age range (years old) < 30 3 9.09 30–39 1 3.03 40–49 9 27.27 50–59 8 24.24 > 60 12 36.36 education level elementary school 8 24.24 junior high school 12 36.36 senior high school 7 21.21 diploma/bachelor 7 21.21 sex male 14 42.42 female 19 57.57 marital status married 30 90.90 single 3 9.09 address city town 22 66.66 outskirts 11 33.33 total 33 100 althea medical journal. 2016;3(1) 128 amj march 2016 faculty of medicine universitas padjadjaran. the participants in this study were stroke patients who came to the neurologic outpatient clinic. sampling method of this study was minimal total sampling which was minimal 30 patients. the inclusion criteria were the participants who signed the informed consent. however, the subjects with aphasia, severe heart disease, hemodialysis, severe pulmonary disease, and visual field defect were excluded. the study used barthel index of adl and iadl questionnaire. the demographic characteristic, age, sex, educational level, marital status, and house address were recorded. the participants took part in interview after they agreed to sign the informed consent. there were ten domains of function assess with barthel index. besides, there were eight domains that corresponded to the patient’s current functional ability for each task on iadls. the writer interviewed patients witnessed by family members and medical staffs. the barthel index of adl is classified according to level of disability: very severe disability (0–4), severe disability(5–9), moderate disability (10–14), mild disability (15–20).8 the iadl is classified according to level of independency: low (0–3), moderate (4–6), and high (7–8). 7 the results were analyzed by categorized barthel index into very severe disability, severe disability, moderate disability, and mild disability. iadls were categorized into high, moderate, and low level of independency. results the total of 33 subjects, 12 stroke patients were above 60 years old which had the highest number of patients. mostly patients completed their junior high school. seven of the patients had a diploma or bachelor’s degree. from the interview, male and female had the slight equal number of patients and the marital status mostly was married (table 1). the results of the interview using barthel index of adl, 23 patients had moderate disability on basic self-care activities. only 2 patients had very severe disability (table 2). the result from the iadl questionnaire, 13 patients had low level of independency in performing more complex daily tasks. however, 8 patients had low level of independency. most of the educated patients had mild disability on basic adls with a total 12 patients. the patients, who had highest number of mild disability, were 40–49 years old. among the patients who completed the rehabilitation therapy, 15 patients had mild disability on basic self-care activity (table 4). the iadl presented by the patients who completed elementary school had low level of independency with a number of six patients. the patients at the age range 40–49 and 50–59 showed equal number of low level of independency. table 2 barthel index of the stroke patients level of disability total (n) very severe disability (0–4) 2 severe disability (5–9) 0 moderate disability (10–14 ) 8 mild disability (15–20 ) 23 total 33 table 3 instrumental activities of daily living (iadl) level of independency total (n) low (0–3) 13 moderate (4–6) 12 high (7–8) 8 total 33 althea medical journal. 2016;3(1) 129lee shok chen, marina a. moeliono, lisda amalia: functional status of stroke patients at neurologic outpatient clinic dr. hasan sadikin general hospital discussion educational level is associated with a better functional outcome, measured by the ability to perform self-maintenance and mobility.9 all the educated patients and thirty-one patients showed a moderate and mild disability on basic adls at this study. the remaining two patients only completed elementary school and showed a very severe disability in barthel table 4 characteristic of barthel index level of disability very severe severe moderate mild education level elementary school 2 0 0 6 junior high school 0 0 5 6 senior high school 0 0 2 5 diploma/bachelor 0 0 1 6 age (years old) < 30 0 0 1 2 30–39 0 0 0 1 40–49 0 0 3 6 50–59 1 0 3 4 > 60 1 0 1 10 complete therapy yes 2 0 5 15 no 0 0 3 6 not yet 0 0 0 2 total 2 0 8 23 table 5 instrumental activity of daily living (iadl) level of independency low moderate high education level elementary school 6 1 1 junior high school 4 4 3 senior high school 2 3 2 diploma/bachelor 1 4 2 age (years old) < 30 1 1 1 30–39 0 0 1 40–49 5 2 2 50–59 5 0 3 > 60 2 9 1 complete therapy yes 10 7 3 no 3 4 4 not yet 0 1 1 althea medical journal. 2016;3(1) 130 amj march 2016 index. however, the patients who had a diploma or bachelor’s degree were presented with a better outcome compared to the others slight lower educational level patients. the stroke patients who had a higher education showed that they had a higher functional status compared to the poor educated patients.2 from the iadls, the patients who had completed elementary school had low level of independency. a study of examination of iadls, a lower education is associated with a low level of functional status.6 age is a non-modifiable risk factor for stroke; aging will slow down the motor function and strength of the elderly.10 thus, from table 1, twenty out of thirty-three patients who were at the age above sixty encountered stroke events in this study. two elderly had severe disability at barthel index and two elderly had low level of independency. based on study by holloway et al.3 there are more elderlies who have disability on iadls to adl. it does not correspond with this study. rehabilitation is a strategy to enhance functional independence in patients with stroke.11 based on study by holloway et al.3 rehabilitation that is started earlier and completed will reduce the complication and have a good compliance with a better outcome. in this study, the fifteen stroke patients who completed rehabilitation had mild disability on basic adls. mild disability indicates an individual has mild dysfunctional on performing basic self-care daily activity.6 eight out of 33 patients with moderate disability in this study are comparable to 40% of stroke patients with moderate disability in a similar study at barthel index.6 this study established that the stage of recovery of various impairments provides significant prognostic indicators for outcomes. the outcomes considered were adls, recovery of the arm, leg, and postural control and gross motor function and gait.1 according to this study, full recovery of motor function after stroke was incomplete. however, stimulation can facilitate on the motor function of a human and thus facilitate the motor performance.12 the functional status of the stroke patients depends on the frequency of rehabilitation and compliance of rehabilitation. the iadls are skills beyond basic selfcare skills needed to function independently at home and in the community. patients who were staying alone, are required to evaluate iadls.13 from table 5, patients completed the rehabilitation; three patients had high level of independency. this indicated the ability of the patients to perform complex tasks such as prepare a meal, use safety precaution, take medicines, and get emergency aid when it is necessary. there are some limitations of this study; the questionnaire for barthel index and iadls were written in english, whereas, interviewer had to interview in bahasa indonesia. the study will observe along the patients on the adls to obtain the accuracy of data. the recomendation for future study is starting a study using bahasa version of instrumental activity. in conclusion, rehabilitation therapy shows improvement from the functional status of stroke patients and a transition from dependent to independent on their daily living. the patients should be educated about the benefits of therapy and being encouraged to obtain good compliance of therapy. therefore, increasing the awareness and understanding of stroke patients and family members on rehabilitation therapy improves the functional status of stroke patients. prevention of stroke are made by detection of early disease, identification of risk factors, a combination of pharmacological and psychosocial interventions, and a long term follow up with regular monitoring and promotion of adherence to treatment.14 references 1. canning cg, ada l, adams r, o’dwyer nj. loss of strength contributes more to physical disability after stroke than loss of dexterity. clin rehabil. 2004;18(3):300–8. 2. di carlo a. human and economic burden of stroke. age ageing. 2009;38(1):4–5. 3. holloway r, arnold r, creutzfeldt c, lewis e, lutz b, macann r, et al. pallitative and end of life care in stroke. am heart j. 2014;45(6):1887-916. 4. davenport r, manson j, de’ath h, platton s, coates a, allard s, et al. functional definition and characterisation of acute traumatic coagulopathy. crit care med. 2011;39(12):2652–8. 5. kwon s, hartzema ag, duncan pw, min-lai s. disability measures in stroke relationship among the barthel index, the functional independence measure, and the modified rankin scale. stroke.2004;35(4):918–23. 6. gold ad. an examination of instrumental activities of daily living assessment in older adults and mild cognitive impairment. j clin exp neuropsychol. 2012;34(1):11–34. 7. graf c. the lawton instrumental activities of daily living scale. ajn. 2008;108(4):52– althea medical journal. 2016;3(1) 131 62. 8. sangha h, lipson d, foley n, salter k, bhogal s, pohani g, et al. a comparison of the barthel index and the functional independence measure as outcome measures in stroke rehabilitation: patterns of disability scale usage in clinical trials. int j rehabil res. 2005;28(2):135–9. 9. kusuma y, venketasubramanian n, kiemas l, misbach j. burden of stroke in indonesia. int j stroke. 2009;4(5):379–80. 10. ferri cp, acosta d, guerra m, huang y, llibre-rodriguez jj, salas a, et al. socioeconomic factors and all cause and cause-specific mortality among older people in latin america, india, and china: a population-based cohort study. plos med. 2012;9(2):e1001179. 11. dobkin bh. rehabilitation after stroke. n eng j med. 2005;352(16):1677–84. 12. hummel f,celnik p,giraux p, floel a,wan hsun w, gerloff c, et al. effects of noninvasive cortical stimulation on skilled motor function in chronic stroke. brain j neurol. 2005;128(3):490–9. 13. duncan pw, zorowitz r, bates b, choi jy, glasberg jj, graham gd, et al. management of adult stroke rehabilitation care a clinical practice guideline. am heart j. 2005;36(9):100–43. 14. beaglehole r, epping jordan j, patel v, chopra m, ebrahim s, kidd m, et al. improving the prevention and management of chronic disease in lowincome and middle-income countries: a priority for primary health care. lancet. 2008;372(9642):940–9. lee shok chen, marina a. moeliono, lisda amalia: functional status of stroke patients at neurologic outpatient clinic dr. hasan sadikin general hospital althea vol 3 no 1 full text final.indd althea medical journal. 2016;3(1) 132 amj march 2016 clinical and cerebrospinal fluid abnormalities as diagnostic tools of tuberculous meningitis fiona lestari,1 sofiati dian,2 ida parwati3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital,bandung, 3department of clinical pathology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital,bandung abstract background: tuberculous meningitis (tbm) is the most severe form of extrapulmonary tuberculous (tb) disease and remains difficult to diagnose. the aim of the study was to determine the diagnostic value of clinical and laboratory findings of cerebrospinal fluid (csf) examinations for diagnosing tbm using bacterial culture result as the gold standard. methods: a prospective cross sectional study was carried out to 121 medical records of hospitalized tbm patients in neurological ward at dr. hasan sadikin general hospital bandung, from 1 january 2009–31 may 2013. the inclusion criteria were medical records consisted of clinical manisfestations and laboratory findings. the clinical manisfestations were headache and nuchal rigidity, whereas the laboratory findings were csf chemical analysis (protein, glucose, and cells) and csf microbiological culture. validity such as sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv) for clinical and laboratory findings were calculated, using bacterial culture result as the gold standard. results: the most clinical findings of tbm was nuchal rigidity and it had the highest sensitivity value, but the lowest spesificity value. decreased of csf glucose had the highest sensitivity value compared to other laboratory findings, but the value was low. conclusions: the clinical manisfestations and the laboratory findings are not sensitive and specific enough for diagnosing tbm. [amj.2016;3(1):132–6] keywords: cerebrospinal fluid, clinical manisfestations, diagnostic tools, laboratory findings, tuberculous meningitis correspondence: fiona lestari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81931207624 email: fiona.lestari@hotmail.com introduction tuberculous (tb) is one of the major health problems in the world, especially in developing countries.1,2 manifestations of tb can be pulmonary and or extrapulmonary, which 20.4% cases are extra-pulmonary tb.3,4 based on data from centers for disease control and prevention (cdc) in 2011, it was indicated that 5.7% extrapulmonary tb involved the central nervous system (cns).4,5 the most severe manifestation of cns tb is tuberculous meningitis (tbm) which causes high mortality in children and adult.5-8 the mortality rate of tbm in bandung, the capital city of west java, indonesia, is 50% in the first week of admission to the hospital and increases to 67% after one month treatment in the hospital.9 early diagnosis and accurate treatment are promptly needed in order to improve the outcomes.8,10,11 standardized diagnostic criteria for tbm have not been established, because the clinical manifestations of tbm are not specific, especially in the early stages of disease.12 patients usually come to the hospital after having headache, fever, nuchal rigidity, irritability, vomiting or even after having many neurologic symptoms and signs within a few days.9,12 many patients come with history of typical systemic symptoms of tb infection, such as cough, lethargy, weight loss, and night sweating that might be suggestive of tb, but also non-specific.12 lumbar puncture is the first procedure to be conducted for patients who are suspected with cns infections. routine analysis of cerebrospinal fluid (csf) althea medical journal. 2016;3(1) 133 in most patients with tbm shows clear appearance, increased protein, decreased glucose concentration (a csf glucose to plasma ratio or absolute value) and pleocytosis with lymphocyte predominance.12 the aim of the study was to analyze the sensitivity and specificity of tbm clinical manifestations and cerebrospinal fluid abnormalities compared to bacterial culture result. methods a restrospective cross sectional study was carried out to medical records of tbm patients in neurological ward at dr. hasan sadikin general hospital bandung, top referral hospital for west java province, indonesia from 1 january 2009 to 31 may 2013. the inclusion criteria in this study were medical records of hospitalized tbm patients, consisted of clinical manisfestations and laboratory findings. the clinical manisfestations were headache and nuchal rigidity, whereas the laboratory findings were csf chemical analysis (protein, glucose, and figure 1 the inclusion criteria among 509 tbm patients cells), csf microbiological culture. from 509 available medical records, only 121 medical records which met the inclusion criteria (figure 1). the operational variables in this study were defined as nuchal rigidity defined by a resistance to flexion of the neck due to muscle spasm of the extensor muscles; increased csf protein defined by positive in concentration >100 mg/dl; decreased csf glucose defined by positive in csf to plasma glucose ratio of <50%; csf pleocytosis with lymphocytic predominance defined by positive in csf cells count 10 ̶ 500 /µl and lymphocyte >50%; csf abnormalities defined by positive for all three csf findings in increased csf protein, decreased csf glucose and csf pleocytosis with lymphocytic predominance. sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) were calculated for each variable using bacterial culture result as the gold standard. all of the clinical data were entered and calculated using computer. prior to this study, ethical approval was obtained from the health research ethics committee of dr. hasan sadikin general hospital/faculty of medicine, fiona lestari, sofiati dian, ida parwati: clinical and cerebrospinal fluid abnormalities as diagnostic tools of tuberculous meningitis althea medical journal. 2016;3(1) 134 amj march 2016 universitas padjadjaran, bandung, indonesia (no.lb.02.01/c02/9324/viii/2013). results this study discovered that from 121 tbm cases, most of the patients had nuchal rigidity and headache. from the laboratory findings, the highest percentage of laboratory abnormalitiy was the decrease of the glucose level in csf (table 1). moreover, only 28.93% had positive bacterial culture. among 6 variables identified and measured, the symptom of nuchal rigidity had the highest positive culture result, compared to other variables. this study discovered that nuchal rigidity was the highest sensitivity among 6 variables, but the lowest specificity value. this study revealed that csf abnormalities was the best variable which incorrectly identified the negative cultural result. all variables in this study showed low percentages for ppv, on the other hand the npv showed higher percentages (table 3). discussion in this study, nuchal rigidity had the highest sensitivity and csf abnormalities had the highest specificity among 6 analyzed variables. among 121 patients, 93.39% patients had positive sign of nuchal rigidity and 88.43% patients complained of headache. in previous tbm study, it was reported on 77.2% patients with nuchal rigidity and 67% patients with headache.8 there was an increase number of nuchal rigidity sign and headache in tbm patients. according to rock et al.7, adult tbm patients normally come with classic signs of meningitis such as fever, headache, and meningismus/nuchal rigidity.7 this study revealed that sensitivity for all of the variables was quite high but less specificity. diagnosing tbm persistence is still difficult.13 sensitivity of nuchal rigidity in this study was 97% positive when cultural result was positive either. nevertheless, specificity for nuchal rigidity was very low as 8%. it described that nuchal rigidity was not specific to identify the positive culture of tbm. ideally, the greater sensitivity and specificity table 1 clinical manisfestations and laboratory findings total n (%) clinical manifestation nuchal rigidity 113 (93.39) headache 107 (88.43) laboratory findings decreased of csf* glucose 100 (82.64) increased of csf protein 79 (65.29) csf pleocytosis lymphocytic predominance 60 (49.59) csf abnormalities 37 (30.58) positive bacteria in csf culture 35 (28.93) note: *csf= cerebrospinal fluid table 2 clinical manifestations and laboratory findings according to bacterial culture positive culture negative culture total nuchal rigidity 34 79 113 headache 30 77 107 decreased csf glucose 30 70 100 increased csf protein 22 57 79 csf pleocytosis lymphocytic predominance 16 44 60 csf abnormalities 9 28 37 althea medical journal. 2016;3(1) 135fiona lestari, sofiati dian, ida parwati: clinical and cerebrospinal fluid abnormalities as diagnostic tools of tuberculous meningitis of test will make a better diagnostic tool from identifying a disease. a prospective cross sectional study which comparing signs of meningeal inflammation (nuchal rigidity, head jolt accentuation of headache, kernig’s sign and brudzinski’s sign) to the reference csf white cell count >5 cells as the gold standard concluded that physical signs of meningeal inflammation do not accurately discriminate between patients with meningitis from those without it accurately regarding the poor accuracy.11 moreover, headache and nuchal rigidity in meningitis caused by m. tuberculosis and in meningitis caused by other etiological factors cannot be differentiated. laboratory findings of csf examinations revealed that csf glucose have the highest sensitivity value but the lowest specificity value. a prospective cross-sectional study in the philipines5, using culture or acid fast staining or basal meningeal enhancement on computerized axial tomography (ct) head contrast as gold standard for analyzing the laboratory findings showed similar results.5 this study revealed that 35 patients have positive result for m. tuberculosis. the culture results explained that 28.93% patients have definite diagnosis of tbm, and the remaining patients are categorized as probable or possible diagnosis tbm based on the scoring systems. however, the absence of mycobacterial findings in culture result does not exclude the patients from diagnosis of tbm.12 one study in philipine5 reported that among 68 patients who were diagnosed with tbm, 5.9% culture positive or acid fast staining were found. another study by chaidir et al.8 discovered that 36% tbm patients have positive culture. study in shanghai13 reported that 12% of 25 patients tbm have positive culture. the cdc informed that culture was used as the gold standard for laboratory confirmation of tb disease.14 culture result positive established that patients have positive tbm infections. ideally, sensitivity of a good culture media is 100% which it will grow the etiologic factor in whole tbm infections cases. nonetheless, culture is an imperfect gold standard. literature studies informed that m. tuberculosis culture has low sensitivity. it is limited because of the low concentration of bacilli in csf, characteristic of mycobacterial itself with the need of high enrichment media, or because the patients have already taken the anti tuberculosis drugs before the lumbar puncture done.5,13,15,16 the chances of positive diagnosis can be increased by doing more lumbar punctures.12 there are some limitations of this study. first, acid fast staining and polymerase chain reaction (pcr) method were not used to identify bacteria in csf. polymerase chain reaction was not routinely done because it is expensive. second, some medical records were not written completely enough and available to be analyzed in this study. third, there is no separation calculation for the human immunodeficiency virus (hiv)-co infection patient, which it possibly affects the clinical presentation and laboratory findings in tbm patients. the ideal diagnostic tests which are validated, rapid, sensitive, and specific are absolutely needed so that appropriate and accurate therapy can be started early, toxicities of unnecessary treatment can be avoided, morbidity and mortality prevalences can be lowered. in conclusion, from clinical findings and laboratory examinations, we found that the sensitivity was quite high but lack for specificity. combination of all csf examinations abnormalities showed higher specificity, but less sensitivity. culture result has low sensitivity. table 3 sensitivity, specificity, ppv and npv of clinical manifestations and laboratory findings. sensitivity (%) specificity (%) ppv* (%) npv** (%) nuchal rigidity 97 8 30 88 headache 86 10 28 64 decreased csf glucose 86 19 30 76 increased csf protein 63 34 28 69 csf pleocytosis lymphocytic predominance 46 49 27 69 csf abnormalities 26 67 24 69 note: *ppv= positive predictive value; **npv= negative predictive value althea medical journal. 2016;3(1) 136 amj march 2016 references 1. who. global tuberculosis report 2012. geneva: world health organization, 2012. 2. tai mls. tuberculous meningitis: diagnostic and radiological features, pathogenesis and biomarkers. neuroscience & medicine. 2013;4(2):101–7. 3. pedoman nasional pengendalian tuberkulosis. in: indonesia kkr, editor. 2nd ed. jakarta: kementrian kesehatan republik indonesia direktorat jenderal pengendalian penyakit dan penyehatan lingkungan; 2011. p. 1–99. 4. cdc. reported tuberculosis in united states 2011. atlanta: central for disease control and prevention; 2012. p. 1–154. 5. pasco pm. diagnostic features of tuberculous meningitis: a cross-sectional study. bmc res notes. 2012;5:49. 6. galimi r. extrapulmonary tuberculosis: tuberculosis meningitis new developments. eur rev med pharmacol sci. 2011;15(4):365–86. 7. rock rb, olin m, baker ca, molitor tw, peterson pk. central nervous system tuberculosis: pathogenesis and clinical aspects. clin microbiol rev. 2008;21(2):243–61. 8. chaidir l, ganiem ar, van der zanden a, muhsinin s, kusumaningrum t, kusumadewi i, et al. comparison of real time is6110-pcr, microscopy, and culture for diagnosis of tuberculous meningitis in a cohort of adult patients in indonesia. plos one. 2012;7(12):e52001. 9. basuki a, dian s, editors. neurology in daily practise. 2nd ed. bandung: bagian/upf ilmu penyakit saraf fakultas kedokteran unpad/ rs. hasan sadikin; 2011. 10. christie lj, loeffler am, honarmand s, flood jm, baxter r, jacobson s, et al. diagnostic challenges of central nervous system tuberculosis. emerg infect dis. 2008;14(9):1473–5. 11. waghdhare s, kalantri a, joshi r, kalantri s. accuracy of physical signs for detecting meningitis: a hospital-based diagnostic accuracy study. clin neurol neurosurg. 2010;112(9):752–7. 12. marais s, thwaites g, schoeman jf, torok me, misra uk, prasad k, et al. tuberculous meningitis: a uniform case definition for use in clinical research. lancet infect dis. 2010;10(11):803–12. 13. quan c, lu c-z, qiao j, xiao b-g, li x. comparative evaluation of early diagnosis of tuberculous meningitis by different assays. j clin microbiol. 2006;44(9):3160– 6. 14. cdc. diagnosis of tuberculosis. atlanta: central for disease control and prevention; 2005. p. 75–107. 15. velenzuela pb, mendoza mt, ang c, guzman jd. validation of the thwaites’ diagnostic rule in the diagnosis of tuberculous meningitis in adults at the philippine general hospital. philippine j microbiol infect dis. 2008;37(1):11–9. 16. thwaites ge, tran th. tuberculous meningitis: many questions, too few answers. lancet neurol. 2005;4(3):160– 70. althea medical journal. 2016;3(2) 304 amj june 2016 misdiagnosis of epilepsy attributed to inadequate history taking levina tri ratana,1 suryani gunadharma,2 arifin soenggono3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of anatomy faculty of medicine universitas padjadjaran abstract background: there was a noticeable amount of patient with epilepsy who were misdiagnosed at dr. hasan sadikin general hospital. misdiagnosis of epileptic seizure will expose patients to inappropriate managements, and subsequently leads to complications. history taking is an important part for the diagnosis of epileptic seizure. this study aimed to see the improvement of diagnosis based on the adequacy and inadequacy of history taking attributed to misdiagnosis of epileptic seizure by the epilepsy consultant at dr. hasan sadikin general hospital. methods: this was a descriptive study using medical records of misdiagnosis of epilepsy. it was indicated by different initial (before epilepsy consultant’s confirmation) and final (after epilepsy consultant’s confirmation) seizure diagnosis at epilepsy outpatient clinic at dr. hasan sadikin general hospital during the period of january 2007−october 2012. results: there were 61 medical records with different initial and final seizure diagnosis. this study indicated inadequate history taking in 83.6% patients. misdiagnosis occurred due to incomplete history taking, absence of reliable witnesses, and misinterpretation of history taking result. history taking by epilepsy consultant improved the misdiagnosis in 27.9% patients. while it is used simultaneously with electroencephalography (eeg), the result increased to 72.2%. conclusions: the adequate history taking improved the accuracy of epileptic seizure diagnosis. the simultaneous used of history taking and eeg increased the result. [amj.2016;3(2):304–9] keywords: eeg, epileptic seizure diagnosis, history taking. correspondence: levina tri ratana, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285797249757 email: levinatriratana@gmail.com introduction epilepsy is one of the world’s most common neurological diseases. incidence of epilepsy in developing countries reached 114 per 100,000 population per year.1 consequently, the number of people living with epilepsy in indonesia is estimated to rise to 250,000 each year.2 epilepsy is a condition characterized by repeated epileptic seizure that occurs without provocation.3 diagnosis of epilepsy consists of 3 steps; recognizing a paroxysmal event as an epileptic seizure, differentiating type of epileptic seizure according to international league against epilepsy (ilae) 1981 classification, and later, determining epileptic syndrome according to ilae 1989 classification.2 each step is prone to misdiagnosis. diagnosis of epileptic seizure is primarily a clinical one,4 in 90% cases, information obtained from history taking alone is enough to diagnose epilepsy and determine the type of epileptic seizure.5 a complete and accurate history taking is not always easy and poses a great challenge to general physicians. although there is a guideline from indonesian neurology association 2011 for history taking in epilepsy, human error or absence of reliable witness make inadequate history taking inevitable. interpretation of information obtained from the history taking itself is also challenging. electroencephalography (eeg), despite of its importance, could not always be obtained. in addition, eeg in people with epilepsy does not always show abnormality,6 so it cannot be used as a sole basis for epilepsy diagnosis. mistakes in history taking is the major cause of epilepsy misdiagnosis.7 misdiagnosis rate in the united kingdom is high, around 16.3% althea medical journal. 2016;3(2) 305 to 41.9%.4, 7-10 misdiagnosis of epilepsy and epileptic seizure gives a big impact to the patients, such as continuing seizure, side effects of unnecessary medication, ban of getting driving license, and employment difficulties.7 in a broader scope, epilepsy and epileptic seizure misdiagnosis is a major obstacle in the prevention of epilepsy.2 this study aimed to seethe improvement of diagnosis based on the adequacy and inadequacy of history taking attributed to misdiagnosis of epileptic seizure by the epilepsy consultant at dr. hasan sadikin general hospital bandung. methods this study was a descriptive case series study conducted at epilepsy outpatient clinic at dr. hasan sadikin general hospital during the period of september−october 2012. the subjects were selected from the medical records of epilepsy patients from outpatient clinic at dr. hasan sadikin general hospital bandung. inclusion criteria for this study were medical records of misdiagnosis of epilepsy indicated by difference in initial (before history taking by epilepsy consultant and/or supportive investigations) and final seizure diagnosis by further history taking done by an epilepsy consultant and/or further investigations (eeg, imaging, lab test). history taking by epilepsy consultant was in accordance with guideline of epilepsy by indonesian neurology association 2011.2 exclusion criteria were the medical records containing no obvious reasons upon changing the diagnosis. there were 93 medical records with different initial and final diagnosis. thirty two data were missing and 61 met the inclusion criteria and none of them has the exclusion criteria when the patients first came to epilepsy outpatient clinic, they were seen by neurology residents who make an initial diagnosis with or without eeg result. the patients then were consulted to an epilepsy consultant for diagnosis confirmation and therapy planning. epilepsy consultant assesses the patient by history taking and/or asked for further investigations and established a final diagnosis. in order to achieve the objective of this research, this study recorded initial and final diagnosis, inadequacies in history taking made by neurology resident, and investigation used in establishing final diagnosis (history taking by epilepsy consultant alone or with further investigations). in addition, these inadequacies in history taking were then used to compile a history taking question list to improve future epileptic seizure diagnosis accuracy. statistical analysis was analyzed by computer. results median age of subjects was 28 years old, ranging from 14–72 years old. the number of female was more than male (59.1% to 40.9%) (figure 1). levina tri ratana, suryani gunadharma, arifin soenggono: misdiagnosis of epilepsy attributed to inadequate history taking figure 1 final diagnosis in patients initially diagnosed as having generalized seizure althea medical journal. 2016;3(2) 306 amj june 2016 as presented in figure 1, from 61 patients, 53 were initially misdiagnosed as having generalized seizure, 49 were finally diagnosed as having partial seizure, while the remaining 4 were finally diagnosed as having non-epileptic seizure. figure 2 showed 8 patients were initially misdiagnosed as having partial seizure, 3 were finally diagnosed as having another type of partial seizure and the remaining 5 were diagnosed as having non-epileptic seizure. non-epileptic seizures initially misdiagnosed as epilepsy are syncope, narcolepsy, migraine, spasmophilia, and hyperglycemic seizure. most of the subjects were initially diagnosed with history taking. from 11 subjects diagnosed after eeg exam, misdiagnosis occurred because the clinicians carrying out the diagnosis neglected the eeg expertise (table 1). further history taking by an epilepsy consultant contributed to diagnosis improvement in 83.6% of patients, while for the remaining subjects, diagnosis were made on the basis of eeg result with or without laboratory test(s) (table 2). mistakes occurred in history taking were incomplete history taking, absence of reliable witness, and misinterpretation of history taking. history taking inadequacies that was found was history taking without reliable witness (27.5%), incomplete history taking (27.5%), absence of aura information (25.5%), and misinterpretation of history taking (19.5%) (table 3). history taking without reliable witness happened when patients came alone, patients came with a person who never witnessed the seizure or did witness but gave wrong information. questions not asked in incomplete history taking were related to patient’s level of consciousness, focal symptoms, sequence of symptoms, postictal confusion, accompanying symptoms, circadian rhythm of seizure, and presence of seizure trigger factors. meanwhile, misinterpretation of history taking was characterized by patients with adversive symptoms but diagnosed with generalized seizure, patients with aura but diagnosed with generalized seizure, patients without loss of consciousness but diagnosed as secondarily generalized seizure, patients table 1 investigations used in initial diagnosis investigations frequency percentage history taking 50 82.0 history taking and eeg 11 18.0 figure 2 final diagnosis in patients initially diagnosed as having partial seizure althea medical journal. 2016;3(2) 307levina tri ratana, suryani gunadharma, arifin soenggono: misdiagnosis of epilepsy attributed to inadequate history taking with loss of consciousness but diagnosed as partial complex seizure, and patients without convulsion but diagnosed as partial complex seizure. this study compiled a list of questions essential to differentiate epilepsy from nonepileptic seizure and determine it into several types: 1) was there anything felt before the seizure or the patient know that seizure was about to happen?; 2) were there any unnoticed symptoms before seizure (such as eye blinking/ gasping)?; 3) in the beginning of the seizure, was the position of the head straight or did it turned to one side?; 4) did the seizure always start from one part/side of extremity(ies)?; 5) how long was the duration of seizure?; 6) how often and in what circumstances did the seizure happen? was there any trigger factor for the seizure?; 7) did the patient loss consciousness during the seizure?; 8) did the patient fully conscious after the seizure? were there any symptoms after seizure (such as nausea or eye blinking)?; 9) what was the sequence of events during the seizure? discussion in this study, the majority of patients initially diagnosed as having generalized seizure were finally diagnosed as having partial seizure. this result was in line with literature stating that adult-onset epilepsy is rarely a generalized seizure.6,11 non-epileptic seizure most often misdiagnosed as epilepsy was syncope. this result is not in accordance with a research carried out by benbadis12 suggesting that psychogenic seizure is the most common disease misdiagnosed as epilepsy in tertiary care center, syncope places number two. in contrast, scheepers et al. and zaidi et al.10 suggest that syncope is the most common medical condition misdiagnosed as epilepsy. other non-epileptic seizure misdiagnosed as epilepsy in this research were quite different with findings in the previous study.7 history taking inadequacies occurred in 83.6% of patients with different initial and final diagnosis. this result is in concordance with a research in england7 stating that history taking inadequacies are the main cause of misdiagnosis. most patients were initially diagnosed based on history taking, this is in line with a research carried out by ferrie13 in england stating that misdiagnosis in epilepsy can be caused by diagnosis based on history taking only, without confirmatory investigations. research by anderson and smith14 also confirm this finding by stating that epilepsy misdiagnosis is primarily caused by history taking and examination inadequacies and premature diagnosis. investigations needed to improve misdiagnosis were further history taking by epilepsy consultant, eeg, mri, ecg, and laboratory tests. this is quite similar with the methods that some researchers used to detect misdiagnoses in previous published researches.4,7,9,10 table 2 investigations that improve diagnosis investigations frequency percentage further history taking and eeg 27 44.3 further history taking alone 17 27.9 further history taking, eeg, mri 5 8.2 further history taking , eeg, mri, ecg 1 1.6 further history taking , blood calcium level 1 1.6 eeg only 9 14.8 eeg and random blood glucose 1 1.6 table 3 inadequacies in history taking history taking inadequacies frequency percentage history taking without reliable witness 14 27.5 incomplete history taking 14 27.5 absence of aura information 13 25.5 misinterpretation of history taking 10 19.5 althea medical journal. 2016;3(2) 308 amj june 2016 history taking inadequacies found in this research were history taking without reliable witness, incomplete history taking, absence of aura information, and misinterpretation of history taking. this finding is in concordance with previous research by smith et al.7 suggesting that misdiagnosis occurred because of history taking without reliable witness, misinterpretation of motoric signs, and inadequate history of past medical and psychiatric illness. this result is also supported by bromfield et al.15 who suggested that patient’s and witness’ memory regarding aura and focal symptoms is very important. questions that this study compiled are important in differentiating epileptic seizure from non-epileptic one and differentiate each type of epileptic seizure. questions regarding frequency and duration of seizure are essentially important in differentiating epilepsy and spasmophilia and absence and partial complex seizure.6,11 questions regarding sequence of symptoms during seizure are important in differentiating epilepsy from syncope. questions regarding aura, focal symptoms, head turning, patient’s consciousness, and postictal symptoms are important in differentiating generalized seizure from partial one.6 in conclusion, this study showed that adequate history taking improved accuracy of epileptic seizure diagnosis. adequate history taking has to be a combination of autoanamnesis and alloanamnesis from reliable witness and includes questions regarding auras, focal signs, accompanying symptoms, patients’ consciousness, and sequence of symptoms during seizure. the eeg increased the yield of epileptic seizure diagnosis improvement. references 1. banerjee pn, hauser wa. epidemiology: incidence and prevalence. in: dichter ma, hauser wa, vinters hv, pedley ta, editors. epilepsy: a comprehensive texbook. 2nd ed. philadelphia: wolters kluwer/ lippincott williams & wilkins; 2007. p. 45–57. 2. harsono, kustiowati e, gunadharma s, editors. pedoman tatalaksana epilepsi. jakarta: persatuan dokter spesialis saraf indonesia; 2011. 3. engel j, pedley ta. introduction: what is epilepsy. in: engel j, pedley ta, editors. epilepsy: a comprehensive textbook. 2nd ed. philadelphia: lippincot williams & wilkins; 2008. p. 1–7. 4. scheepers b, clough p, pickles c. the misdiagnosis of epilepsy: findings of a population study. seizure. 1998;7(5):403– 6. 5. knezevic-pogancev m. diagnosis and therapy mistakes in child epileptology. the romanian journal of child and adolescent neurology and psychiatry. 2011;xvi(4):1 6. ropper ah, brown rh. adams and victor’s principles of neurology. 8th ed. new york: mcgraw-hill companies, inc.; 2005. 7. smith d, defalla ba, chadwick dw. the misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. qjm. 1999;92(1):15–23. 8. juarez-garcia a, stokes t, shaw b, camosso-stefinovic j, baker r. the costs of epilepsy misdiagnosis in england and wales. seizure. 2006;15(8):598–605. 9. leach jp, lauder r, nicolson a, smith df. epilepsy in the uk: misdiagnosis, mistreatment, and undertreatment? the wrexham area epilepsy project. seizure. 2005;14(7):514–20. 10. zaidi a, clough p, cooper p, scheepers b, fitzpatrick ap. misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. j am coll cardiol. 2000;36(1):181–4. 11. bergen dc, madden ta. episodic disorder. american academy of neurology [electronic book] 2012 [downloaded 2012 september 20]. available from: https:// www.aan.com/uploadedfiles/website_ library_assets/documents/4.cme_and_ training/2.training/4.clerkship_and_ course_director_resources/fm_chp7.pdf 12. benbadis s. the differential diagnosis of epilepsy: a critical review. epilepsy behav. 2009;15(1):15–21. 13. ferrie cd. preventing misdiagnosis of epilepsy. arch dis child. 2006;91(3):206– 9. 14. anderson j, smith p. collapse? cause’avoiding misdiagnosis in falls. acnr [review article] 2007 [downloaded 2012 september 21]. available from: http:// w w w. a c n r. c o . u k / s o 0 7 / a c n r _ s o 0 7 _ collapse.pdf 15. bromfield e, cavazos j. an introduction to epilepsy. west hartford: american epilepsy society [electronic book] 2006 [downloaded 2012 september 21]. available from: http://www.ncbi.nlm.nih. gov/books/nbk2511/. althea medical journal. 2016;3(4) 499 vo2 max and back and leg muscle strength profile of universitas padjadjaran swimming team pitriyani nurul pajar,1 reni farenia,2 rahmat budi kuswiyanto3 1faculty of medicine universitas padjadjaran, 2department of physiology faculty of medicine universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cardiorespiratory endurance (vo2 max) and back and leg muscle strength are a few components required to support the performance of swimming athlete during competition. the objective of this study was to determine the vo2 max and back and leg muscle strength in high category level of universitas padjadjaran swimming team period 2014. methods: a descriptive study was conducted to 19 swimmers of universitas padjadjaran in september 2014. the variables of this study were vo2 max and back and leg muscle strength. then, the data were categorized based on the standard of the national sports committee of indonesia. results: the data obtained showed that the vo2 max of the majority of subjects was in the very good category (6/19 subjects) and the back muscle strength of the majority of subjects was in the very good category (10/19 subjects). in contrast, the leg muscle strength of majority of subjects was in the low category (11/19 subjects). conclusions: the vo2 max and back muscle strength in high category level of the swimming team fulfilled the standard of the national sports committee of indonesia. [amj.2016;3(4):499–502] keywords: muscle strength, swimming, the national sports committee of indonesia, vo2 max correspondence: pitriyani nurul pajar, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6282121780234, email: pitriyani.nurul@yahoo.com introduction the performance of swimmers during competition is affected by the training that have been performed.1 training performed could affect the cardiorespiratory endurance and muscle strength.2−3 swimming requires cardiorespiratory endurance (vo2) max and optimal muscle strength to support movement in water.4−5 the vo2 max of a swimming athlete tends to be higher compared to other sport athletes because the respiratory system in swimming athletes has a higher role.6−7 a few muscle strengths with an important role in a swimmer are back and leg muscle strength. leg muscle is required to kick, skim, and move faster in the water.8 back muscle is used to help rotating hands in and out, and also to help hands pulling the body in the water.9 the purpose of this study was to determine the vo2 max, back and leg muscle strength profile of universitas padjadjaran swimming team period 2014. methods a measurement of physical fitness components was conducted to 19 students from universitas padjadjaran swimming team in september 2014 at department of physiology, faculty of medicine universitas padjadjaran, jatinangor. this study was approved by health research ethics committee of the faculty of medicine, universitas padjadjaran. this study was conducted to all active swimming team members in the high category level who met the inclusion and exclusion criteria. the inclusion criteria were students registered as member of high category level of the swimming team period 2014, aged between 18–25 years, and healthy. exclusion criteria were participants in a state of fatigue, taking drugs and drinks althea medical journal. 2016;3(4) 500 amj december 2016 that could increase the work of the heart and muscle strength, other drugs causing palpitations, coffee, tea, and energy enhancer supplements. there were 19 students met the inclusion criteria consisting of 16 males and 3 females. before performing the test, the subjects were given an adequate explanation about the purpose, objective, and procedure of examination. then the subjects filled a willingness form to participate in the test and the subjects underwent physical examination measurement included height measurement, weight measurement, breathing rate measurement, and blood pressure measurement. after that, the subjects underwent measurement of muscle strength by using dynamometer. the proccess was then continued with measurement of vo2 max using astrandrhyming chair test for 5 minutes. the pulse rate was measured by pressing radial artery in wrist in a line with thumb, immediately after completing astrand-rhyming chair test. the result was applied to astrand nomogram according to age, sex, and weight of subject to determine the level of vo2 max. the results were calculated to get median, minimum, and maximum value of vo2 max, back and leg muscle strength with statistics software, and then were categorized based on the standard of the national sports committee of indonesia. results the range of male subject’s age was 19−25 years old, range of male subject’s weight was 49−78 kg, range of male subject’s height was 158−183 cm, and range of male subject’s pulse rate in maximum activity was 100−184 pulse/ minute. the range of female subject’s age was18−19 years old, range of female subject’s weight was 46−70 kg, range of female subject’s height was 153−162 cm, and range of female subject’s pulse rate in maximum activity was 136−164 pulse/minute. respiratory rate, systole, and diastole of all subjects were in normal limits (table 1). based on table 2, range of male subject’s table 1 general characteristics of high category level of universitas padjadjaran swimming team male (n=16) female (n=3) median min* max** median min max age (years) 20.50 19 25 18.00 18 19 weight (kg) 60.00 49 78 56.00 46 70 height (cm) 168.00 158 183 161.00 153 162 pulse rate in maximum activity (pulse/minute) 138.00 100 184 160.00 136 164 respiratory rate (frequency/ minute) 70.00 60 75 70.00 62 70 systole (mmhg) 110.00 98 124 100.00 90 114 diastole (mmhg) 75.00 60 88 72.00 70 75 note: * minimum value **maximum value table 2 vo2 max, back and leg muscle strength in high category level of universitas padjadjaran swimming team male (n=16) female (n=3) median min* max** median min max back muscle strength (kg) 123.75 86 220.5 80.50 60 80.5 leg muscle strength (kg) 141.00 92 202 95.50 72.5 134 vo2 max (o2/kg weight/minute) 54.50 32 109 39.00 37 50 note: * minimum value **maximum value althea medical journal. 2016;3(4) 501pitriyani nurul pajar, reni farenia, rahmat budi kuswiyanto: vo2 max and back and leg muscle strength profile of universitas padjadjaran swimming team back muscle strength was 86−220.5 kg, range of male subject’s leg muscle strength was 92−202 kg, and range of male subject’s vo2 max was 32−109 o2/kg weight/minute. the range of female subject’s back muscle strength was 60−80.5 kg, range of female subject’s leg muscle strength was 72.5−134 kg, and range of female subject’s vo2 max was 37−50 o2/ kg/min. the vo2 max of 6 of 16 male subjects and all female subjects were in very good category based on standard of the national sports committee of indonesia. based on table 4, back muscles strength of 7 of 16 male subjects and all female subjects were in very good category based on standard of the national sports committee of indonesia. based on table 5, leg muscle strength of 9 table 3 results of vo2 max in high category level of universitas padjadjaran swimming team based on standard of the national sports committee of indonesia category frequency (person) male female less 2 0 enough 3 0 good 2 3 very good 6 0 perfect 3 0 no data 0 0 total 16 3 table 4 results of back muscle strength in high category level of universitas padjadjaran swimming team based on standard of the national sports committee of indonesia category frequency (person) male female very less 0 0 less 0 0 average 6 0 good 3 0 very good 7 3 total 16 3 table 5 results of leg muscle strength in high category level of universitas padjadjaran swimming team based on standard of the national sports committee of indonesia category frequency (person) male female very less 0 0 less 9 2 average 7 1 good 0 0 very good 0 0 total 16 3 althea medical journal. 2016;3(4) 502 amj december 2016 of 16 male subjects and 2 of 3 female subjects were in the low category based on standard of the national sports committee of indonesia. discussion the result of swimming team’s vo2 max showed that most of the subjects were in the very good category based on standard of the national sports committee of indonesia. this result was in accordance with the study conducted by doewes et al.6 which stated that swimming athletes have higher vo2 max compared to other athletes because they have higher tidal volume contributions. the high condition of vo2 max in swimmers is also affected by supplying and demanding oxygen in the body which increases every minute.10 the strength of back muscle of the swimming team met the standard of the national sports committee of indonesia. the result showed that most of the subjects were included in the very good category. this result is in accordance with the study conducted by su et al.9 which stated that back muscle strength is needed by swimmers to support hand movements in rotating out or in and to support hands pulling the body in water. hand movements to pull the body are also affected by high training intensity.11 however, the swimmers’ leg muscle strength was far below from the standard of the national sports committee of indonesia. a swimmer needs a good strength of leg muscle when skimming which also affects the speed of swimming.11 a low category of the swimmers’ leg muscle strength was believed to occur because they had not reached the same training as the national swimming athletes. the conclusion of this study is the vo2 max and the strength of back muscle of most subjects are in the very good category based on standard of the national sports committee of indonesia, while leg muscle strengths of most subjects are in the low category. limitation of this study was the small sample size. from this study, it is suggested that universitas padjadjaran swimming team is required to train periodically especially weight training 8–12 repetition maximum (rm) to increase the strength of the leg muscles. references 1. sperlich b, zinner c, heilemann i, kjendlie pl, hilmberg hc, mester j. high-intensity interval training improves vo2peak, maximal lactate accumulation, time trial and competition performance in 9–11-year-old swimmers. eur j appl physiol. 2010;110(5):1029−36. 2. sieverdes j, sui x, blair s. associations between physical activity and submaximal cardiorespiratory and pulmonary responses in men. j sport med doping stud. 2011;1(1):102. 3. chahal j, lee r, luo j. loading dose of physical activity is related to muscle strength and bone density in middle-aged women. bone. 2014;67:41−5. 4. peeling p, bishop d, landers g. effect of swimming intensity on subsequent cycling and overall triathlon performance. br j sport med. 2005;39(12):960−4. 5. schnitzler c, seifert l, chollet d, toussaint h. effect of aerobic training on inter-arm coordination in highly trained swimmers. hum mov sci. 2014;33:45−53. 6. doewes m, kiyatno, suradi. kontribusi sistem respirasi terhadap vo2 maks. j respir indo. 2011;31(1):10−3. 7. roels b, schmitt l, libicz s, bentley d, richalet j, millet g. specificity of vo2 max and the ventilatory threshold in free swimming and cycle ergometry: comparison between triathletes and swimmers. br j sport med. 2005;39(12):965−8. 8. willems t, cornelis j, deurwaerder ld, roelandt f, mits sd. the effect of ankle muscle strength and flexibility on dolphin kick performance in competitive swimmers. hum mov sci. 2014;36:167−76. 9. su kp, johnson mp, gracely ej, karduna ar. scapular rotation in swimming with and without impingement syndrome: practice effects. med sci sports exerc. 2004;36(7):1117−23. 10. rowland t, bougault v, walther g, nottin s, vinett a, obert p. cardiac response to swim bench exercise in age group swimmers and non athletic children. j sci medsport. 2009;12(2):266−72. 11. aspenes s, karsel t. execise-training intervetion studies in competitive swimming. sport med. 2012;42(6):527−43. althea medical journal. 2016;3(3) 482 amj september 2016 hepatoprotective effect of trigona spp. bee propolis against carbon tetrachloride-induced liver injury in rats rachel amelia,1 achadiyani,2 begawan bestari3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine, universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: oxidative stress reaction can cause liver injury. this process can be prevented by antioxidant activities which can break the destructive chain caused by free radical substances in the liver. propolis produced by trigona spp. bee is known to have a high level of antioxidant. the aim of this study was to examine the effect of trigona spp. bee propolis on liver histological toxicity caused by carbon tetrachlorideinduced oxidative stress. methods:this experimental study was conducted in september 2013 at the animal laboratory of departement of pharmacology and therapy, faculty of medicine universitas padjadjaran. twenty-four healthy male wistar rats as objects were adapted for one week and randomly divided into 3 groups. group i was the control negative, group ii was given carbon tetrachloride on day 14, group iii was given trigona spp. bee propolis on day 1-14. on day 14, group iii was injected ccl4 intraperitoneally. the quantitative data were statistically analyzed using the one way anova and tukey test with p value < 0.05. results: group i showed the liver contained normal cells, without significant injury of the membrane, round and complete nucleus. the average number of liver cell was 464 ± 9.59281 cells/field; group ii underwent necrosis and the average of the cells was 146 ± 7.56885 cells/field; group iii showed some normal liver cells, and some necrotic area with the normal liver cells average was 263 ± 14.10860 cells/field. the p-value=0.00. conclusions: trigona spp. bee propolis has a hepatoprotective effect against ccl4-induced liver injury histologically. [amj.2016;3(3):482–6] keywords: carbontetrachloride, hepatoprotective, propolis, trigona spp. correspondence: rachel amelia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281222475898 email: rachel-rere@hotmail.com introduction hepatitis is still a serious health problem in indonesia. according to riset kesehatan dasar (riskesdas) nasional 2007, indonesia was placed as the second largest country among other searo countries with hepatitis patients.1 in october 2007–2009, the ministry of health of the republic of indonesia reported about 17.999 positive hepatitis c cases. infection with hepatitis c is associated with increased levels of reactive oxygen species (ros)/reactive nitrogen species (rns) and decreased antioxidant levels.2 ros/rns is a cause of oxidative stress. oxidative stress is a condition where there is a high level of free radicals; one of the potential substance is carbon tetrachloride which has strong connection with pathologic process like cell destruction.3 currently, it is commonly used for inducing hepatitis model in laboratory experimental animals. when carbon tetrachloride enters the body, this substance will be metabolized in the liver and will produce free radical such as trichloromethyl radical (ccl3) and trichloromethyl peroxy radical (ccl3o2) that induce lipid peroxidation and death of the cell.4 one substance that can prevent lipid peroxidation is antioxidant. furthermore, propolis is a natural product, which is a mixture of resin and beeswax collected from plants particularly from flowers and leaf buds by honey bees (apis spp. and trigona spp.). it contains many chemical substances and varies depending on the plants resin geographically. the trigona spp. bee are found on many islands in the indonesian region and it has already been studied that it has more antioxidant substance than the althea medical journal. 2016;3(3) 483 propolis produced by the apis mellifera.5,6 until now, there has been only few studies about its hepatoprotective effect.7 the objective of this study was to examine whether the trigona spp. bee propolis has a hepatoprotective effect against oxidative stress mechanism, hence after further preclinical and clinical studies has been performed, it expected that this propolis could be used effectively by hepatitis high risk patients and also by patients with chronic hepatitis. methods this experimental research was conducted at the animal laboratory of the pharmocology department, faculty of medicine universitas padjadjaran, in september 2013. twentyfour healthy male wistar rats as objects were used.4 all laboratory experimental animals in this study was approved by the health research ethics committee faculty of medicine universitas padjadjaran. the table 1 average number of normal hepatocyte from each group group number of normal hepatocyte (mean±sd) p * group i 463.50±9.59281 0.00 group ii 146.07±7.56885 0.00 group iii 263.24±14.10860 0.00 note: p* = one way anova animals were randomly divided into 3 groups and given standard food and water. this study was performed in fifteen days, excluded from the one week of adaptation. group i was the control negative, which was given standard food and water. group ii was the control positive which was given 1ml/kgbw ccl4 50% intraperitoneally at day 14 to induce necrosis of hepatocytes.8 group iii was given 1ml/ kgbw trigona spp. propolis on day 1–14, and on day 14, three hours after given propolis, the rats were injected with 1 ml/kgbw ccl4 50% intraperitoneally.9 twenty-four hours after the last treatment, all rats from all groups were sacrificed. first the animals were anaesthetized using ketamine intramuscularly, and then laparotomy was performed to expose the liver organ. afterward, the liver was perfused using nacl 0.9% through the left ventricle, and blood was cleared from the body through inferior vena cava. the liver was also washed with 10% formalin, then excised and transferred to a 10% formalin fixative figure 1 liver histologic view from group i note: h=normal hepatocyte rachel amelia, achadiyani, begawan bestari: hepatoprotective effect of trigona spp. bee propolis against carbon tetrachloride-induced liver injury in rats althea medical journal. 2016;3(3) 484 amj september 2016 figure 2 liver histologic view from group ii note: h=normal hepatocyte, n=necrotic area figure 3 liver histologic view from group iii note: h=normal hepatocyte, n=necrotic area solution. the liver tissues were processed for paraffin embedding and sections (5 µm thick) were taken in a microtome. after staining with hematoxylin and eosin, slides were examined under the microscope (400x) for histopathological changes and counted for the average of the normal cells in each group the existence of a necrotic area on hepatocytes, was characterized by rupture of the cell membrane, vacuolization of the cytoplasm, karyolisis, pyknosis, and karyorrhexis. moreover, the quantitative data were statistically analyzed using the one way analysis of varian (anova) followed by the tukey test using the statistical product and service solutions (spss) for windows version 13.0. a p-value of less than 0.05 was considered as statistically significant. althea medical journal. 2016;3(3) 485 solution. the liver tissues were processed for paraffin embedding and sections (5 µm thick) were taken in a microtome. after staining with hematoxylin and eosin, slides were examined under the microscope (400x) for histopathological changes and counted for the average of the normal cells in each group the existence of a necrotic area on hepatocytes, was characterized by rupture of the cell membrane, vacuolization of the cytoplasm, karyolisis, pyknosis, and karyorrhexis. moreover, the quantitative data were statistically analyzed using the one way analysis of varian (anova) followed by the tukey test using the statistical product and service solutions (spss) for windows version 13.0. a p-value of less than 0.05 was considered as statistically significant. results the data analyzed by the one way anova statistical test showed p = 0.00; it means, the difference of the average number of normal hepatocytes between groups was significant. the tukey test also showed the difference of the average number of normal hepatocytes between groups were significant one by another. the result from group i showed the liver contained normal cells, without significant injury of the membrane, round and complete nucleus. the average number of liver cell in this group was 464 ± 9.59281 cells / field (figure 1); group ii underwent necrosis and the average of the cells was 146 ± 7.56885 cells / field (figure 2); group iii showed some normal liver cells, and some necrotic area with the normal liver cells average was 263 ± 14.10860 cells / field (figure 3). discussion the effect of ccl4 in 24 hour acute exposure in the control positive group was marked by the existence of necrotic area on hepatocytes, characterized by the rupture of cell membrane, vacuolization of the cytoplasm, karyolisis, pyknosis, and karyorrhexis. these findings are further supported by earlier reports by girish et al.8 that ccl4 produced various histological changes in the hepatocytes after 24 hours of administration.8,9 the analytic study of the average number of normal hepatocytes showed the difference between the control negative and control positive group were significantly different (p=0.00). it could be concluded that ccl4 that was given to group ii made significant injury to the liver cell. this process began from ccl4 turned into ccl3 and reacted with the oxygen forming more reactive substance ccl3o2 and then, it reacted with membrane cell phospholipid and initiated an extensive intrahepatic peroxidation reaction chain. in the end, there was necrosis of the hepatocytes.4 group iii had more normal hepatocytes compared to group ii. the data were significant after being analyzed statistically. the protective effect of this propolis was about 37%. according to chanchao et al.10, the propolis itself is non-toxic to the normal cells. the condition of oxidative stress is established due to insufficient defense capacities against reactive oxygen species (ros). the ros also affect the antioxidant defense mechanism, and reduce intracellular concentration of antioxidant produced by the body. although our body has its own antioxidant and regulation to this substance capacity physiologically, other source of antioxidant is important as well for scavenging free radicals that are formed in the body. additionally, propolis consists of more than 300 different compounds including flavonoids, phenolics, wax, vitamins, and minerals.5 it has been proved that bees do not change its chemical composition. in propolis, the major antioxidant is flavonoids. it could give protection to the liver cells by decreasing formation of ccl3 and ccl3o2. 11 it has already been studied that trigona spp. bee propolis has a high level of antioxidant, especially flavonoid 4% which is higher than in another propolis that is produced by apis mellifera bee is 1.5%.5,6 besides, the propolis contains another substance that is known for its antioxidant and antiinflammatory activities such as caffeic acid phenethyl ester (cape) where it showed a free radical scavenging effect.12 it can be concluded that trigona spp. bee propolis has a hepatoprotective effect against ccl4-induced liver injury in male wistar rats histopathologically. references 1. kementerian kesehatan republik indonesia. masyarakat dunia peringati hari hepatitis. [cited 28 july 2010]. available from: www.depkes.go.id/index. php?vw=2&id=1156. 2. muriel p. role of free radicals in liver diseases. hepatol int. 2009;3(4):526–36. 3. kumar v, k.abbas a, fausto n, aster jc. cellular responses to stress and toxic insults: adaptation, injury, and death. in: schmitt w, gruliow r, editors. robbins and cotran pathologic basis of disease. 7th ed. rachel amelia, achadiyani, begawan bestari: hepatoprotective effect of trigona spp. bee propolis against carbon tetrachloride-induced liver injury in rats althea medical journal. 2016;3(3) 486 amj september 2016 philadelphia: elsevier saunders; 2010. p. 20–2. 4. u.s environmental protection agency washington d. toxicological review of carbon tetrachloride. washington dc: united states environmental protection agency; 2010. 5. surendra ns, bhushanam m, ravikumar h. antimicrobial activity of propolis of trigona sp. and apis mellifera of karnataka, india. prime journal of microbiology research. 2012;2(2):80–5. 6. mahani, karim r, nurjanah n. keajaiban propolis trigona. jakarta: pustaka bunda grup puspa swara; 2011. 7. umthong s, puthong† s, chanchao c. trigona laeviceps propolis from thailand: antimicrobial, antiproliferative and cytotoxic activities. am j chin med. 2009;37(05):855–65. 8. girish c, koner bc, jayanthi s, rao kr, rajesh b, pradhan sc. hepatoprotective activity of six polyherbal formulation in ccl4-induced liver toxicity in mice. indian j exp biol. 2009;47(4):257–63. 9. xu j-y, su y-y, cheng h-s, li s-x, liu r, li w-x, et al. protective effects of fullerenol on carbon tetrachloride-induced acute hepatotoxicity and nephrotoxicity in rats. carbon. 2010;48(5):1388–96. 10. chanchao c, umthong s, phuwapraisirisan p, puthong s. trigona laeviceps propolis: chemical compositions and antiproliferative activity on cancer cell lines. planta med. 2011;77:49. 11. shukla s, bhadauria m, jadon a. effect of propolis extract on acute carbon tetrachloride induce hepatotoxicity. indian j exp biol. 2004;42(10):993–7. 12. wu w-m, lu l, long y, wang t, liu l, chen q, et al. free radical scavenging and antioxidative activities of caffeic acid phenetyl ester (cape) and its related compounds in solution and membranes: a structure-activity insight. food chem. 2007;105(1):107–15. althea medical journal. 2016;3(4) 566 amj december 2016 salmonella species detection in chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran luk lee zia,1 imam megantara,2 suryosutanto3 1faculty of medicine universitas padjadjaran, 2department of microbiology faculty of medicine universitas padjadjaran, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: salmonellae is gram negative enterobacteriaceae which are commonly found in water. it can cause diseases in human through improper hygiene and sanitation practice, contamination of poultries, cross contamination from other food during storage, and also from salmonella species carriers. chicken noodle toppings are usually prepared early in the morning and not heated up upon serving. there are possibilities for bacterial contamination if the food vendors lack of hygienic practices. the risk of salmonella species contamination is increased too as it can be spread through inappropriate hygiene and sanitation. hence, the objective of the study was to detect the presence of salmonella species in the chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran. methods: a descriptive laboratory study was conducted in september 2013. a total of 44 samples of chicken noodle toppings were collected from the food vendors in jatinangor. the samples were cultured on salmonella-shigella agars. then, gram staining and biochemical tests were performed. results: the chicken noodle toppings were not contaminated by salmonella species, but other bacteria species such as klebsiella pneumoniae, serratia, enterobacter, escherichia coli, and shigella species were found. conclusions: there is no salmonella species found. however, there are some other bacteria found such as klebsiella pneumoniae, serratia, enterobacter, escherichia coli, and shigella species. it means that the food vendors lack of hygienic and sanitation aspects. thus, proper actions should be taken to educate and increase the awareness of food vendors on the importance of sanitation. [amj.2016;3(4):566–9] keywords: chicken noodle toppings, salmonellae contamination, salmonella species correspondence: luk lee zia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6285624609711 email: luklz@live.com.my introduction salmonellosis is still frequently reported and always be a public health concern. food hygiene and sanitation are important in avoiding food borne disease in human beings. according to indonesian food and drug regulatory agency, there are previous studies proved that the food safety condition is still below standard in indonesia. approximately, 43% of food poisoning cases are frequently caused by street food and catering services.1 moreover, according to the study conducted in bogor, indonesia, by kusumaningrum et al.2, 24.8% of food products examined are contaminated by salmonella species in open markets and supermarkets. besides, the incidence of typhoid fever in children aged less than 5 years old is quite high as reported by department of child health of dr. hasan sadikin general hospital, bandung.3 this shows that salmonellae contamination is still a major problem. majority of salmonella species are pathogenic in human beings. improper hygiene and sanitation can cause salmonellosis. moreover, contamination of poultries, cross contamination from other food during storage time, and salmonella species carriers are also the factors that cause salmonellosis.4-6 the timeline from the preparation of chicken noodle toppings until they are being served has an increase risk of bacterial contamination. if the food handling practice by the food vendors is improper, the risk of salmonellae althea medical journal. 2016;3(4) 567 contamination would increase. therefore, this study was conducted to detect the presence of salmonella species in the chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran. methods this descriptive laboratory study was approved by health research ethics committee faculty of medicine universitas padjadjaran. total sampling was used to collect the samples. the samples used for this study were the chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran. the samples were collected from shops and mobile food vendors selling chicken noodles in september 2013. sellers with proper lights and electricity, tables and chairs, proper water source to wash plates and glasses were classified as shops, while sellers with food at roadside with no proper water source to clean the plates and glasses were classified as mobile food vendors. in this study, one sample was taken from each shop and mobile food vendors around lunch time (12.00–13.00). the samples were collected in clean plastic pockets. the study was conducted for three times. the inclusion criteria were fresh chicken noodle toppings that were taken straight from the place where the food vendors kept them, and shops that agreed to sell or give small amount of chicken noodle toppings. the exclusion criterion was the chicken noodle topping that was already put on the noodles. the study variable was the presence of salmonella species in the chicken noodle toppings prepared by the food vendors. the samples of this study were immediately transported to the microbiology laboratory at faculty of medicine universitas padjadjaran. at the microbiology laboratory, the samples were transferred from the plastic pockets into the trypticase soy broth (tsb) (3 ml) in a test tube left for 24 hours in 37°c incubator. on the next day, an inoculating loop was used to take the samples and then streaked on the salmonella-shigella (ss) agars. the culture medias were then incubated (37°c) for 24 hours and observed for colonies growth after 24 hours. on the following day, gram staining and biochemical tests were performed to identify the organisms that grew on the ss agars. moreover, the interview were performed to obtain the factors that can cause salmonellae contamination from each food vendor. it included the water sources used for cooking, luk lee zia, imam megantara, suryosutanto: salmonella species detection in chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran table identification of bacteria from the colonies of chicken noodle toppings bacteria samples salmonella species 0 klebsiella pneumoniae 5 serratia species 3 enterobacter 3 escherichia coli 1 shigella species 1 typhoid fever history of the cook, and also the ways of food handling, such as, washing hands before cooking, the use of gloves during cooking, and also the method of keeping and heating up the leftover chicken noodle toppings and the location to buy raw chicken. results this study showed that there was no salmonella species found, but discovered other different types of organisms (table 1). moreover, the presence of bacteria in the samples of chicken noodle toppings prepared by shops and mobile food vendors were then compared. the percentage of positive bacterial growth and negative bacterial growth on ss agars for shops were 35.1% and 64.9% respectively. while for mobile food vendors, there was no positive growth of bacteria on ss agars. the information obtained from the surveys was interpreted. there were only 14 shops which underwent the interview and got two missing data. it showed that most of the shops used underground water to cook and followed by water from pump and mineral water (aqua®). among the food vendors, 12 of them never got typhoid fever and two of them did not know. all of the food vendors washed hands before cooking and only four of them used hand gloves during food handling. according to the information obtained, the food vendors kept the leftover chicken noodle toppings covered in freezers and also in fridge and all of them heated up the chicken noodle toppings until boiling point. most of them bought the raw chickens from market and some from the supplier. discussions there was no salmonella species found in the althea medical journal. 2016;3(4) 568 amj december 2016 chicken noodle toppings. this may be because the water source was not contaminated by salmonella species. besides, there was no food handler who was previously infected by salmonella species which would result in becoming a carrier. on the other hand, there was no cross contamination of salmonella species from other food sources during storage time. however, other bacteria such as klebsiella pneumoniae (k. pneumoniae), serratia, enterobacter, escherichia coli (e. coli), and shigella species were found. all of the bacteria found were from the enterobacteriaceae family. this can be due to improper food handling by the food vendors. moreover, it could also because the water sources used were contaminated by those bacteria. the results showed that k. pneumoniae was found in most of the samples, but, it cannot be concluded that k. pneumoniae was the most abundant bacteria found in the chicken noodle shops in jatinangor. this was because it did not represent the condition that it should be and the bacteria did not culture according to standard agars to confirm the actual situation since the study objective was to find salmonella species only. hence, only ss agars were used to culture. the k. pneumoniae is a natural enteric flora in normal humans. it can cause bacterial pneumonia which is about 1%. if it exists in a huge quantity, it can cause diseases such as extensive hemorrhagic consolidation of lungs, urinary tract infections, and bacteremia with focal lesions in debilitated patients. klebsiella usually causes nosocomial infections.7 this organism is often transmitted through body contacting with the water supply especially during bathing, eating, or poor hygiene. klebsiella has an infective dose of 3.5–7.9×105 cells/ml. hence, a susceptible individual who consumes 3.5×105 klebsiella per ml of 100 ml drinking water will be at risk of getting infection.8 serratia sp. is a saprophytic organism which is commonly found in humans and animals intestinal tracts, and also in the environment, especially in water sources.9 at the present time, most commonly serratia marcescens is known as opportunistic pathogens which cause hospital-acquired infections such as bacteremia, pneumonia, wound and urinary tract infections. it usually infects respiratory tracts and genitourinary tracts of human being. the risk factors of getting infected by serratia marcescens are unhygienic infection control practice by the health care workers, catheterization of hospitalized patients, exposure to contaminated substances, and also increased antibiotic usage in compromised human.10 the next bacteria found were enterobacter sp.. they are normal inhabitants found in water and soil. they are also free-living organisms in the intestinal tracts of humans and animals. these organisms are often associated with opportunistic and hospital acquired infections.9 they can produce diseases such as sepsis and urinary tract infections.7 the e. coli is a normal flora found in the intestine tract of human. the organism does not produce disease unless it reaches the tissues outside the intestinal tract or the parts which have lesser common normal flora. e. coli can cause urinary tract infections, e.coli-associated diarrheal disease, sepsis and meningitis.7 according to world health organization (who) in guidelines for drinkingwater quality, this organism is used as fecal contamination indicator for enteric bacterial pathogens. the infective dose of e. coli can be lesser than 100 organisms. as stated in the guideline values for verification of microbial quality, e. coli should not be detectable in any 100 ml samples from all water that are directly intended for drinking, treated water entering as well as in the distribution system.11 since this organism was found in the food sample, this showed that the food has a recent contamination from fecal. if people consumed this food, they will have a chance to get infected. however, the strain of e. coli found cannot be determined because no further test has been conducted. furthermore, shigella species was found in this study. this showed that it was quite harmful since this organism is highly communicable. the natural habitat of shigella species is limited to the gastrointestinal tract. it is transmitted from an individual to another through feces, contaminated food, unhygienic practice, and flies. the infective dose for shigella species is relatively low, that is 103 organisms. shigella dysenteriae can cause severe disease such as dysentery.7 this bacteria can be found may be due to improper hygiene and sanitation during food preparation by the food vendors. the presence of bacteria in the samples of chicken noodle toppings prepared by shops and mobile food vendors were then compared. it showed that there was no positive bacterial growth on ss agars for the mobile food vendors while there was 35.1% of positive bacterial growth on ss agars for shops. however, it cannot be concluded that the mobile food althea medical journal. 2016;3(4) 569luk lee zia, imam megantara, suryosutanto: salmonella species detection in chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran vendors’ food was cleaner as there was no confirmation test being performed. the results showed that the shops had more bacterial contamination. this may be because they were contaminated from the objects which had a contact with the chicken noodle toppings, for example, the forks and spoons, and also the chop sticks. in order to reduce the risk of getting bacterial contamination, clean wooden chop sticks are recommended to use. it is only used once and being discarded afterwards. furthermore, the utensils were recommended to be rinsed with boiling water before they were being used. the results showed that the mobile food vendors were not contaminated by bacteria. this may be because the way of food handling by particular mobile food vendors were really up to standard. however, this did not reflect the real situation as the number of mobile food vendors were limited during the period of the study being conducted. there were some limitations in this study. first, there was no direct observation of the way chicken noodle toppings prepared. moreover, the numbers of mobile food vendors were limited in jatinangor and there was also a limitation of time in conducting this study. in conclusion, no salmonella species were found in the chicken noodle toppings prepared by the food vendors around jatinangor campus of universitas padjadjaran. however, other bacteria species such as k. pneumoniae, serratia, enterobacter, e. coli, and shigella species were found. the government should monitor the food vendors from time to time and spontaneously on their hygiene practices and the way of food handling. this suggestion is to increase the awareness of the food vendors on the importance of hygiene and sanitation. therefore, they will keep up the standard of cleanliness and hygiene on food preparation process. it is recommended that a further study should be conducted by directly observing the way chicken noodle toppings prepared. moreover, the number of samples from mobile food vendors and also the time to conduct the study should be increased. this would provide more significant results on food contamination by salmonella species. references 1. mariana rr, santoso i, wignyanto bs. the situation analysis of food safety to formulate policy of food safety opertional for food street vendors in malang, indonesia. j agric food tech. 2011;1(10):194–9. 2. kusumaningrum h, dewanti-hariyadi r. multidrug resistance among different serotypes of salmonella isolates from fresh products in indonesia. international food research journal. 2012;19(1):57–63. 3. setiabudi d, madiapermana k. demam tifoid pada anak usia di bawah 5 tahun di bagian ilmu kesehatan anak rs hasan sadikin, bandung. sari pediatri. 2005;7(1):9–14. 4. vandeplas s, dubois dauphin r, beckers y, thonart p, thewis a. salmonella in chicken: current and developing strategies to reduce contamination at farm level. j food prot. 2010;73(4):774–85. 5. monack dm. salmonella: persistence and transmission strategies. curr opin microbiol. 2012;15(1):100–7. 6. podolak r, enache e, stone w, black dg, elliott ph. sources and risk factors for contamination, survival, persistence, and heat resistance of salmonella in low-moisture foods. j food prot. 2010;73(10):1919–36. 7. brooks g, carroll kc. bacteriology. in: malley j, lebowiz h, editors. 2007 jawetz, melnick, & adelberg’s medical microbiology. 24th ed. new york: mcgrawhill companies, incorporated; 2007. p. 253-56 8. percival s, embrey m, hunter p, chalmers r, sellwood j, wyn-jones p. microbiology of waterborne diseases: microbiological aspects and risks. 1st ed. oxford: elsevier science; 2004. p. 136 9. walker ke, horneman aj, mahon cr, manuselis g. enterobacteriaceae. in: wurm-cutter e, editor. 2011 textbook of diagnostic microbiology. 4th ed. philadelphia: saunders w b company; 2011. p. 435 10. mahlen sd. serratia infections: from military experiments to current practice. clin microbiol rev. 2011;24(4):755–91. 11. who. guidelines for drinking-water quality. geneva; 2011. [cited 2013 december 24]. available from: http://whqlibdoc.who. int/publications/2011/9789241548151_ eng.pdf. althea medical journal. 2016;3(3) 382 amj september 2016 relationship between menstrual profile and psychological stress with dysmenorrhea maryam,1 mulyanusa amarullah ritonga,2 istriati3 1faculty of medicine universitas padjadjaran, 2department of obstetrics and gynaecology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: dysmenorrhea or menstrual cramps is the most common menstrual complaint among reproductive women in developing countries. the prevalence of dysmenorrhea is ranged from 19–91%. many studies showed that factors associated with dysmenorrhea include a younger age, nulliparity, family history of dysmenorrhea, prolonged menstrual duration, high menstrual flow, psychological factors, and lifestyle. the objective of this study was to compare female medical students with dysmenorrhea and without dysmenorrhea regarding menstrual profile and psychological stress, also to examine the relationship between psychological stress and dysmenorrhea specifically.. methods: this cross-sectional study was conducted among 136 fourth year female medical students of universitas padjadjaran. it used a structured, self-assessment, validated, and reliable questionnaire, such as wong baker faces® pain rating scale in combination with numeric scale pain, and depression, anxiety, stress scale (dass-42). then, the descriptive data analysis and chi-square hypothesis test were used to explore the relationship between the severity of psychological stress and the presence or severity of dysmenorrhea. results: family history of dysmenorrhea had a strongest relationship with dysmenorrhea. nevertheless, there was no statistically significant interaction between the severity of stress and the presence of last menstrual cramps (p 0.745, odd ratio 1.15, 95% confidence interval 0.5–2.66). however, a positive relationship between the severity of stress and dysmenorrhea in last menstruation was found in this study (p 0.033, odd ratio 3.69, 95% confidence interval 1.06–12.8). conclusions: the severity of stress and dysmenorrhea in last menstruation is related among the subjects with dysmenorrhea. [amj.2016;3(3):382–7] keywords: dysmenorrhea, medical students, menstrual profile, psychological stress correspondence: maryam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +628562082155 email: maryam.abdr@gmail.com introduction dysmenorrhea which is defined as a pain in lower abdomen and often accompanied by other symptoms occurring during menstruation, is the most common menstrual complaint among reproductive women in developing countries compared to amenorrhea, polymenorrhea, and menorrhagia.1,2 the prevalence of dysmenorrhea is ranged from 19–91%.3-5 its varieties may be caused by different pain perception and lack of standard methods to define dysmenorrhea.3 dysmenorrhea can cause economic losses due to the cost of medications, medical care, and decreased productivity.1 previous study in 2009 among female medical students in malaysia6 showed that the prevalence of dysmenorrhea reaches 52.2% of 235 subjects with their mean age 21.4 years old. disability among students with dysmenorrhea is also worse in aspect of social activities, responsibilities, time spent resting, class absenteeism, and normal daily life compared to students without dysmenorrhea.6 dysmenorrhea may be viewed as a multifactorial condition. many studies showed that factors associated with dysmenorrhea include a younger age, nulliparity, family history of dysmenorrhea, prolonged menstrual duration, high menstrual flow, psychology, and lifestyle such as smoking habits, high alcohol, and caffeine intake.3,7 so far, few studies associating with psychological stress and dysmenorrhea have been carried out. the objective of this study was to compare female medical students with dysmenorrhea and without dysmenorrhea regarding menstrual characteristics, gynecological althea medical journal. 2016;3(3) 383 problems, family history of dysmenorrhea, lifestyle, and psychological stress, specifically to examine the relationship between psychological stress and dysmenorrhea. methods this cross-sectional study was conducted in september 2015 using total sampling among 136 fourth year female medical students of universitas padjadjaran bandung, west java, aged 19–22 years old who had agreed to participate in this study and gave their consent. the subject who did not fill the questionnaire completely was excluded from this study. the ethical clearance was obtained from the health research ethic committee faculty of medicine universitas padjadjaran. the distribution was then taking place at skills lab during class break. primary data from a structured, selfassessment, validated, and reliable questionnaire was used for this study. its questions consisted of psychological stress condition as an independent variable; pain scale of dysmenorrhea as a dependent variable; and other characteristics that might be considered as confounding variables such as age; gynecologic factors including regularity, cycle, duration, amount of bleeding, presence of gynecologic problems, and family history of dysmenorrhea; and lifestyle including smoking habit, alcohol and coffee consumption. depression anxiety stress scale (dass-42) that has been translated into bahasa indonesia (α= 0.95) was used for measuring psychological stress. this questionnaire consisted of 42 questions including 14 questions to measure a range of common symptoms of stress subscale (α=0.88). the scores were on a four-point likert scale scored from zero to three. therefore, the total score of stress subscale ranges from 0 to 42. the cut-off for stress severity subscale was considered as follows, 0–18, no-mild stress; >19, moderate-severe stress.8 combination of wong-baker faces® pain rating scale and numeric pain rating scale was used to measure the severity of dysmenorrhea on last menstruation. it consists of six different facial expressions, from a very smiling face to a very sad face, in combination with elevenpoint scale scored from zero to ten, indicating no pain to worst pain intensities. cut-off 0 for no dysmenorrhea, 1–3 for mild dysmenorrhea, 4–6 for moderate dysmenorrhea, and 7–10 for severe dysmenorrhea were used in this study.9,10 a structured questionnaire used to assess other characteristics that may be considered as confounding variables, consists of ‘demographic factors’ including age, ‘gynecologic factors’ such as regularity, cycle, duration, amount of bleeding, presence of gynecologic problems, and family history of dysmenorrhea; the regularity of each menstrual cycle was considered as regular menstruation. the menstrual cycle was classified into <25 days, 25–32 days, and >32 days. the menstrual duration was classified into <7 days, 7–14 days, and >14 days. the amount of bleeding was classified into <3 pads/day, 3–7 pads/day, and >8 pads/day. the presence of gynecological pathology such as endometriosis and ovarian cyst that have been diagnosed by gynecologist was considered as positive gynecological problems. the presence of dysmenorrhea in student’s sister or mother was considered as a positive family history of dysmenorrhea. in addition, the ‘lifestyle factors’ including daily smoking habit, alcohol and coffee intake were also assessed. the collected data were statistically using analyzed chi-square test a p-value <0.05 that was considered statistically significant, meanwhile odd ratio and 95% confidence intervals were presented for the main association results the overall incidence of dysmenorrhea in last menstruation was 74 subjects (54.4%) with the mild, moderate, and severe dysmenorrhea that reached 9 (12.1%), 27 (36.5%), and 38 (51.4%), respectively. the average age was 20.57 years old; it was similar to women with dysmenorrhea and without dysmenorrhea. the general characteristics of subjects are shown in the table 1. irregular menstrual cycle was reported by 30 subjects (22%) and 60% of those was having dysmenorrhea on their last menstruation. menstrual cycle was <25 days in 14 subjects (10%), 25–32 days in 105 subjects (77%), and >25 days in 17 subjects (13%). menstrual duration was <7 days in 73 subjects (54%) and 56% of those was having dysmenorrhea on their last menstruation. the amount of bleeding was assessed according to pads usage in a day, there were <3 pads/day in 58 subjects (43%) and 3–8 pads/day in 78 subjects (57%). there were only 5 subjects (4%) who had any gynecological problems such as endometriosis and ovarian cyst. in this study, there was no statistically significant characteristic between dysmenorrhea and non-dysmenorrhea group, maryam, mulyanusa amarullah ritonga, istriati: relationship between menstrual profile and psychological stress with dysmenorrhea althea medical journal. 2016;3(3) 384 amj september 2016 table 1 general characteristics of the study population characteristics dysmenorrhea (n=74) normal (n=62) total p value or 95% ci age mean 20.54 20.6 20.57 0.56 median 20.5 21 21 regularity regular 56 (53%) 50 (47%) 106 (78%) 0.49 0.75 0.33–1.70 no 18 (60%) 12 (40%) 30 (22%) menstrual cycle <25 days 8 (57%) 6 (43%) 14 (10%) 0.80 1 1 25–32 days 58 (55%) 47 (45%) 105 (77%) 0.67 0.16-2.77 >32 days 8 (47%) 9 (53%) 17 (13%) 0.72 0.26-2.01 duration <7 days 41 (56%) 32 (44%) 73 (54%) 0.66 1.17 0.59–2.29 7–14 days 33 (52%) 30 (48%) 63 (46%) amount of bleeding <3 pads/day 32 (55%) 26 (45%) 58 (43%) 0.88 1.06 0.53–2.09 3–8 pads/day 42 (54%) 36 (46%) 78 (57%) gynecological problems yes 2 (40%) 3 (60%) 5 (4%) 0.51 0.55 0.08–3.38 no 72 (55%) 59 (45 %) 131 (96%) family history of dysmenorrhea yes 45 (66%) 23 (34%) 68 (50%) 0.006 2.63 1.31–5.27 no 29 (43%) 39 (57%) 68 (50%) smoking habit yes 2 (100%) 0 (0%) 2 (2%) 0.19 1.86 1.59–2.18 no 72 (54%) 62 (46%) 134 (98%) coffee consumption yes 24 (49%) 25 (51%) 49 (36%) 0.34 0.71 0.35–1.43 no 50 (57%) 37 (43%) 87 (64%) alcohol consumption yes 2 (50 %) 2 (50%) 4 (3%) 0.86 0.83 0.11–6.09 no 72 (55%) 60 (45%) 132 (97%) note: * based on chi – square test, if p value ≤ 0.05 significant except family history of dysmenorrhea (p 0.006). lifestyle characteristics in the subjects also had no statistically significant differences. table 2 shows that among 136 female medical students were included in analysis, the overall proportion subjects with moderatesevere, and no-mild stress were 21% (28 subjects) and 79% (108 subject), respectively. the relationship between the severity of stress and the presence of last menstrual cramps was not statistically significant (p 0.745). the women with more severe stress had 54% probability to have dysmenorrhea in general population (odd ratio [or] 1.15, 95% confidence interval [ci] 0.5–2.66). table 3 shows that among 74 female medical althea medical journal. 2016;3(3) 385 students with dysmenorrhea, the overall proportion subjects with moderate-severe and no-mild stress were 22% (16 subjects) and 78% (58 subjects). the relationship between the severity of stress and the severity of dysmenorrhea in last menstruation was statistically significant (p 0.033). the women with more severe stress had 79% probability to have more severe dysmenorrhea in population with dysmenorrhea (or 3.69, 95%ci 1.06– 12.8). discussion this study revealed that the overall incidence of dysmenorrhea was 54.5% of 136 subjects with the mild, moderate, and severe dysmenorrhea that reached 12.1%, 36.5%, and 51.4%. it was similar to the previous study by zukri, et al.6, in 2009 that reached 52.2% of 235 subjects. it seems that the medical student characteristics in malaysia and indonesia were similar. among all factors assessed in this study, family history of dysmenorrhea had a strongest association with dysmenorrhea than other factors (or 2.63, 95%ci: 1.31–5.27). this study result is in the line with the previous study by unsal et al.11 in 2010 that stated family history seems to be an important factor to affect women having dysmenorrhea (or 20.7, 95% ci: 11.5– 37.4). a study by tavallae, et al.5 in 2011 also found a relation between family history of dysmenorrhea and having dysmenorrhea (or 2.60, 95% ci 1.50–4.70). the relationship between psychological stress and dysmenorrhea on last menstruation in this study showed no statistically significant result (p 0.745), but the women with more severe stress had 54% probability to have dysmenorrhea in general population (or 1.15, 95% ci 0.5–2.66). in addition, the relationship between the severity of stress and the severity of dysmenorrhea in last menstruation among those having dysmenorrhea was statistically significant (p 0.033), it also means that the women with more severe stress have 79% probability to have more severe dysmenorrhea in population with dysmenorrhea (or 3.69, 95%ci 1.06–12.8). these results are consistent with the previous study by wang, et al.7 that found higher risk of having dysmenorrhea in women with high stress compared to women with low stress (or 10.4, 95% ci: 4.9–22.3). in addition, yamamoto et al.12 in their study, revealed that women having menstrual cramps have higher score of stress than those who do not have menstrual cramps (or 1.02, 95% ci 0.99– 1.04). moreover, a study by nohara et al.13 showed a significant relation between high level stress and menstrual cramps (or 1.46, 95% ci: 1.13–1.87). the previous observed study revealed that the mechanisms of psychological stress and dysmenorrhea relationship are not completely table 2 relationship between the severity of psychological stress and the presence of dysmenorrhea in last menstruation last menstrual cramps total p value or 95% ci yes no stress moderate-severe 16 12 28 0.745 1.15 0.5-2.7 no-mild 58 50 108 total 74 62 136 note: * based on chi – square test, if p value ≤ 0.05 significant table 3 the relationship between the severity of stress and the severity of dysmenorrhea in last menstruation among subjects with dysmenorrhea last menstrual cramps total p value or 95% cisevere mildmoderate stress moderate-severe 12 4 16 0.033 3.69 1.06-12.8 no-mild 26 32 58 total 38 36 74 note: * based on chi – square test, if p value ≤ 0.05 significantt althea medical journal. 2016;3(3) 386 amj september 2016 understood. however, a person who is under stress undergoes a neuroendocrine response. cortisol that is regulated by corticotrophin releasing hormone (crh) as the major hypothalamic regulator stress response will mediate its secretion through pituitary adrenocorticotrophic hormone (acth); and progesterone that takes a part in follicular development may be disrupted due to follicular stimulating hormone and luteinizing hormone impairment. these conditions were assumed to play important roles in dysmenorrhea mechanisms that have been shown to influence both of prostaglandin pge2 and pgf2 synthesis as well as their binding on myometrial receptors that will affect uterine muscle and vascular tone.3,7 this study might be the first study that associates with psychological stress and dysmenorrhea specifically and used more validated questionnaire for assessed variable. previously, the study used self-perception to assess whether they felt menstrual cramps or not and in a high or lower stress. in addition, the subjects were almost remarkably homogenous in their age and nulliparous that made the results were not influenced by parity and wide range of age. there were some limitations in this study. first, it was a cross-sectional study that could not determine the causality among variable, but it only could determine the relationship and its strength. the seconds, since this study was a self-assessment questionnaire, it might result an underreporting condition. lastly, it was conducted in a single university with few subjects, therefore, the sample might not be representative of all indonesian female medical students. for further studies, it is suggested to arrange larger study that more represents the real population. in addition, since there was a positive relationship between psychological stress and severity of dysmenorrhea, a study associating with stress management as a method to prevent more severe conditions among dysmenorrhea women might be conducted in the next studies. in conclusion, the menstrual profile that has the strongest relation with dysmenorrhea is the family history of dysmenorrhea. there is also a positive relationship between the severity of stress and dysmenorrhea in last menstruation among those having dysmenorrhea. so, the stress management might be arranged to reduce the stress level, prevent more severe dysmenorrhea, and increase the productivity among women with dysmenorrhea. references 1. lentz gm, lobo ra, gershenson dm, katz vl. comprehensive gynecology. philadelphia, pa: mosby elsevier; 2012. 2. patel v, tanksale v, sahasrabhojanee m, gupte s, nevrekar p. the burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in goa, india. bjog. 2006;113(4):453–63. 3. ju h, jones m, mishra g. the prevalence and risk factors of dismenorrhea. epidemiol rev. 2013:36(10):104–13. 4. ohde s, tokuda y, takahashi o, yanai h, hinohara s, fukui t. dysmenorrhea among japanese women. int j gynaecol obstet. 2008;100(1):13–7. 5. tavallaee m, joffres mr, corber sj, corber sj, bayanzadeh m, rad mm. the prevalence of menstrual pain and associated risk factors among iranian women. j obstet gynaecol res. 2011;37(5):442–51. 6. zukri sm, naing l, hamzah tnt, husain nhn. primary dysmenorrhea among medical and dental university students in kelantan: prevalence and associated factors. international medical journal. 2009:16(2):93–9. 7. wang l, wang x, wang w, chen c, ronnennberg a g, guang w, et al. stress and dysmenorrhoea: a population based prospective study. occup environ med. 2004:61:1021–6. 8. damanik ed. the measurement of reliability, validity, items analysis and normative data of depression anxiety stress scale (dass) [thesis]. jakarta: faculty of psychology: universitas indonesia, indonesia; 2011.p. 60. 9. hjermstad mj, fayers pm, haugen df, caraceni a, hanks gw, loge jh, et al. studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. j pain symptom manage. 2011;41(6):1073– 93. 10. garra g, singer aj, domingo a, thodejr hc. the wong-baker pain faces scale measures pain, not fear. pediatr emerg care. 2013;29(1):17–20. 11. unsal a, ayranci u, tozun m, arslan g, calik e. prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. ups j med sci. 2010:115(1):138–45. 12. yamamoto k, okazaki a, sakamoto y, funatsu m. the relationship between althea medical journal. 2016;3(3) 387 premenstrual symptoms, menstrual pain, irregular menstrual cycles, and psychosocial stress among japanese college students. j physiol anthropol. 2009.28(1):129–36. 13. nohara m, momoeda m, kubota t, nakabayashi m. menstrual cycle and menstrual pain problems and related risk factors among japanese female workers. ind health. 2011;49(2):228–34. maryam, mulyanusa amarullah ritonga, istriati: relationship between menstrual profile and psychological stress with dysmenorrhea althea medical journal. 2016;3(2) 181 computer vision syndrome among call center employees at telecommunication company in bandung ghea nursyifa,1 putri teesa radhiyanti santoso,2 ine renata musa3 1faculty of medicine universitas padjadjaran 2department of physiology faculty of medicine universitas padjadjaran, 3department of ophthalmology faculty of medicine universitas padjadjaran/national eye center, cicendo eye hospital bandung abstract background: the occurrence of computer vision syndrome (cvs) at the workplace has increased within decades due to theprolonged use of computers. knowledge of cvs is necessary in order to develop an awareness of how to prevent and alleviate itsprevalence . the objective of this study was to assess the knowledge of cvs among call center employees and to explore the most frequent cvs symptom experienced by the workers. methods: a descriptive cross sectional study was conducted during the period of september to november 2014 at telecommunication company in bandung using a questionnaire consisting of 30 questions. out of the 30 questions/statements, 15 statements were about knowledge of cvs and other 15 questions were about the occurrence of cvs and its symptoms. in this study 125 call center employees participated as respondents using consecutive sampling. the level of knowledge was divided into 3 categories: good (76– 100%), fair (75–56%) and poor (<56%). the collected data was presented in frequency tabulation. results: there was 74.4% of the respondents had poor knowledge of cvs. the most symptom experienced by the respondents was asthenopia. conclusions: the cvs occurs in call center employees with various symptoms and signs. this situation is not supported by good knowledge of the syndrome which can hamper prevention programs. [amj.2016;3(2):181–5] keywords: call center employees, computer vision syndrome, knowledge correspondence: ghea nursyifa, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8562200155 email: gheanursyifa8@yahoo.com introduction a prolonged computer use may cause vision problems and eye discomfort, namely computer vision syndrome (cvs).1,2 the level of discomfort seems to increase with the amount of computer use.1 the american optometric association (aoa) describes cvs as a group of eye and vision-related problems that result from prolonged computer use.1 blehm et al.3 classified cvs symptoms into four main categories; asthenopia, ocular surface, visual, and extra ocular symptoms. most of the symptoms are temporary and will disappear after the computer user stops working with thecomputer, yet the symptoms remain in some individuals.4 moreover, cvs occurs in 70–75% of computer users.4 even though this syndrome is not life threatening and no research has proven nor confirmed that cvs might cause permanent eye damage or harm an individual’s life, the occurrence of this syndrome may disturb work productivity.5 the call center employee has a high risk on experiencing cvs due to excessive work demands and prolonged exposure to the computer screen.6 hence, sufficient knowledge about cvs especially about its prevention is essential in order to enhance theindividual’s awareness about the proper timing in using computers and most importantly about visual ergonomic so that it can minimize or prevent the occurrence of cvs.7 the objective of this study was to assess the knowledge of cvs among call center employees and to explore the most frequent symptom experienced by them. methods a descriptive cross sectional approach was althea medical journal. 2016;3(2) 182 amj june 2016 used in this study. this study was conducted at the telecommunication company in bandung during the period of september to november 2014 with call center employees as the respondents. based on the minimal sample size calculation, 125 respondents were included in this study using theconsecutive sampling technique. respondents who had filled the questionnaire incompletely were excluded. the validated and translated questionnaire consisting of 30 questions was used in this study.7,8 out of the 30 questions/statements, 15 statements were about knowledge of cvs and other 15 questions were about the occurrence of cvs and its symptoms. the level of knowledge was divided into 3 categories, i.e. good (76–100%), fair (75–56%) and poor (<56%).9 the collected data was presented in frequency tabulation. results the demographic data of respondents was assessed by sex, age, and educational level (table 1). the table shows that thepercentage of female call center employees was similar to the percentage of male call center employees. most of the respondents were aged less than 25 years and from high school level. knowledge of cvs was classified into three categories which are good, fair, and poor (table 2). the table shows that most of the respondents had poor knowlege of cvs and none of them had good knowledge. knowledge of cvs was assessed by the aspects of definition, etiology, risk factor, sign and symptom, prevention, complication, and visual ergonomics (table 3). the table shows that 97.6% respondents knew about the definition of cvs but only 16% knew about the complication of cvs. the symptom of cvs perceived by respondents were divided into four main symptoms; asthenopia, ocular surface, visual, and extraocular symptoms3 (table 4). based on table 4, 77.8% respondent experienced eye fatigue and the least symptom experienced by the respondent was hard to focus counts. discussion the knowledge of cvs among call center employees was poor. a study conducted by akinbinu et al.7 in nigeria showed a similar result. the percentage of respondents who had sufficient knowledge was only 27%, and only 40% of them had awareness of the occurrence of cvs. in contrast to a study conducted by table 1 demographic profile of respondents frequency (n=125) percentage (%) gender male 61 48.8 female 64 51.2 age (year) <25 82 65.6 25–40 41 32.8 >40 2 1.6 level of education high school 92 73.6 diploma 17 13.6 bachelor 16 12.8 table 2 level of cvs knowledge score frequency (n=125) percentage (%) good (76–100%) 0 0 fair (75–56%) 32 25.6 poor (<56%) 93 74.4 althea medical journal. 2016;3(2) 183ghea nursyifa, putri teesa radhiyanti santoso, ine renata musa: computer vision syndrome among call center employees at telecommunication company in bandung zainuddin and isa10 in malaysia, there were only 35.6% of respondents who had poor knowledge about cvs. almost all respondents knew the definition of cvs but only a few were aware of theetiology, causes, risk factors, symptoms, prevention, complications, and visual ergonomics. according to a research conducted by mujaddidi11 in semarang showed that none of the respondents were aware of the risk factors of the cvs incidence. a research conducted by chiemeke et al.12 in nigeria showed that only 32% of respondents knew about theprevention of cvs. furthermore, another research on visual ergonomics conducted by zainuddin and isa10 in malaysia showed that the respondents had less knowledge about visual ergonomics. a similar study conducted by khan et al.13 in pakistan showed that only 30% were aware of the visual ergonomics at the workplace. a previous study conducted by logaraj et al.14 in table 3 assessment of cvs based on components of cvs knowledge cvs theory respondents’ answer correct incorrect n % n % definition 122 97.6 3 2.4 etiology 31 24.8 94 75.2 risk factor 37 29.6 88 70.4 sign and symptom 31 24.8 94 75.2 prevention 21 16.8 104 83.2 complication 20 16 105 84 visual ergonomics 37 29.6 88 70.4 table 4 symptoms of cvs symptoms frequency (n=107) percentage (%) asthenopia eye fatigue 97 77.6 eye strain 24 19.2 eye pain 38 30.4 dry eye 42 33.6 headache 57 45.6 ocular surface watery eye 60 48 irritation 52 41.6 visual blurred vision 48 38.4 doubled vision 32 25.6 hard to focus 2 1.6 extra ocular neck pain 51 40.8 shoulder pain 54 43.2 back pain 59 47.2 althea medical journal. 2016;3(2) 184 amj june 2016 chennai found that only 58.7% of respondents applied appropriate visual ergonomics, in the form of an ideal distance eye with monitor. a poor knowledge of cvs among respondents in this company might be caused by two factors. firstly, the terminology of cvs was unfamiliar in the community, meanwhile aoa stated that approximately 70–75% of computer users experienced cvs symptoms. secondly, there has never been a socialization program about cvs among them. in fact, a call center occupation is one of the jobs that is frequently exposed to a monitor that has a high risk to experience cvs.6 good knowledge of cvs especially about its prevention may help to reduce the number of incidence of cvs in a population.7 the most complaint perceived by the respondents was asthenopia. this result is consistent with a similar study conducted by bali et al.15 in india, franz and erizone16 in jakarta and reddy et al.17 in malaysia. the vision problem which occurred when an individual works in front of a computer iscaused by the combination of the vision problems owned by the individual and poor ergonomics. those might cause uncomfortable working environment and an unfavorable attitude while working in front of thecomputer.18 moreover, a previous research conducted by zakiuddin and isa10 in malaysia showed that 50% of respondents indicated a bad habit in using a computer at the workplace. a similar study conducted by mvungi et al.19 in africa showed that the occurrence of cvs was mainly caused by poor knowledge about the proper attitude when working with the computer. the occurrence of cvs among respondents was high however, the knowledge about it is still poor, the respondents were unaware that they suffered from cvs and they also, did not know about its prevention. if cvs is left untreated it might cause an individual to experience obstacles in their daily activities, decrease work productivity, increase in the level of error in their work, as well as a decrease in job satisfaction.4 this study had limitations, among others were the sampling method and the number of questions about the knowledge of cvs. the consecutive sampling was performed because firstly, the sample size was too large; secondly, the questionnaire should be filled out under supervision and should not be taken home. due to different shift work schedules it was quite difficult for the researcher to meet with the night shift respondents. based on this study, it can be concluded that the knowledge of cvs among call center employees is still poor. the most sign and symptom experienced by the workers were asthenopia. for further research, the sampling method should be conducted randomly in order to avoid a biased selection and give equal opportunity to all employees to be included in the study. the company should be more concerned about the occurrence of cvs among the workers because it can affect the quality and productivity of the workers in the workplace. good knowledge about cvs is necessary to conduct early prevention. references 1. american optometric assosciation. computer vision syndrome. 2011 [cited 2014 jun 7]. available from http://www. a o a . o r g / p a t i e n t s a n d p u b l i c / c a r i n g for-your-vision/protecting-your-vision/ computer-vision-syndrome 2. madhan mr. computer vision syndrome. the nursing journal of india. 2009;c(10):236–7. 3. blehm c, vishnu s, khattak a, mitra s, yee rw. computer vision syndrome: a review. surv ophthalmol. 2005; 50(3):253–62 4. american optometric association. the effects of video display terminal use on eye health and vision. 2011 [cited 2014 jun 4]. available from: http://www.aoa.org/ x5380.xml. 5. charpe na, kaushik v. computer vision syndrome (cvs): recognition and control in software professionals. j hum ecol. 2009;28(1):67–9. 6. australian government comcare. call centres: a guide to safe work. canberra: commonwealth of australia; 2012. 7. akinbinu tr, mashalla yj. knowledge of computer vision syndrome among computer users in the workplace in abuja, nigeria. j physiol pathophysiol. 2013;4(4):58–63. 8. azkadina a. hubungan antara faktor risiko individual dan komputer terhadap kejadian computer vision syndrome [undergraduate thesis]. semarang: universitas diponogoro; 2012. 9. rustaman ny. basic science inquiry in science education and its assessment. seminar proceeding of the first international seminar of science education; 2007 october 27; bandung. 2007. althea medical journal. 2016;3(2) 185ghea nursyifa, putri teesa radhiyanti santoso, ine renata musa: computer vision syndrome among call center employees at telecommunication company in bandung 10. zainuddin h, isa mm. effect of human and technology interaction: computer vision syndrome among administrative staff in a public university. international journal of business, humanities and technology. 2014;4(3):38–44. 11. mujaddidi hra. analisis faktor-faktor terhadap kejadian computer vision syndrome (cvs) pada pekerja layout editor di cv. x tembalangkota semarang. jurnal kesehatan masyarakat. 2012;1(2):731–7. 12. chiemeke sc, akhahowa ae, ajayi ob. evaluation of vision-related problems amongst computer users: a case study of university of benin, nigeria. proceedings of the world congress on engineering; 2007 july 2–4; london. 2007. 13. khan r, surti a, rehman r, ali u. knowledge and practices of ergonomics in computer users. j pak med assoc.2012;62(3):213–7. 14. logaraj m, priya vm, seetharaman n, hedge sk. practice of ergonomic principles and computer vision syndrome (cvs) among undergraduates students in chennai. national journal of medical research. 2013;3(2):111–6. 15. bali j, navin n, thakur br. computer vision syndrome: a study of the knowledge, attitude and practices in indian ophthalmologists. indian j ophthalmol. 2007;55(4): 289–94. 16. suharyanto fx, safari e. asthenopia pada pekerja wanita di call centre-x. bul penelit kesehat. 2010;38(3):119–30. 17. reddy sc, low ck, lim yp, low ll, mardina f, nursaleha mp. computer vision syndrome: a study of knowledge and practices in university students. nepal j ophthalmol. 2013;5(2):161–8 18. anshel j, editor. visual ergonomics handbook. boca raton: crc press; 2005. 19. mvungi vp, mcharo j, mmbuji me, mgonja le, kitua ay. health hazards related to computer use: experience of the national institute for medical research in tanzania. international journal of social, behaviour, educational, bussines and industrial engineering. 2008;2(12):1283–8. althea medical journal. 2016;3(2) 186 amj june 2016 cyanosis as mortality risk among children with severe pneumonia herza fadlinda,1 adi utomo,2 henni djuhaeni3 1faculty of medicine universitas padjadjaran, 2department of child health, faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of public health medicine faculty of medicine universitas padjadjaran abstract background: pneumonia is the second leading cause of infant death in indonesia. the mortality of pneumonia in children is associated with cyanosis, malnutrition, and age less than 4 months. the aim of this study was to determine the relationship between cyanosis, malnutrition, and age less than 4 months with the mortality of infant patients with severe pneumonia at dr hasan sadikin general hospital. methods: a case-control study has been conducted using medical records of 80 patients with pneumonia at dr. hasan sadikin general hospital, period january 2007 to december 2013. the inclusion criteria were medical records consisting of information about infants with severe pneumonia, without comorbid diagnoses, who died during hospitalization. while controls were infants who have been discharged from hospital. the independent variables of this study were cyanosis, malnutrition, and age less than 4 months, while the dependent variable was the mortality. data were analyzed by using univariate and bivariate analysis. results: the study reported that only cyanosis was associated with mortality. malnutrition and age less than 4 months were not associated with mortality. conclusions: cyanosis is known to be the only factor that has affected the mortality of infants with pneumonia who are hospitalized at dr. hasan sadikin general hospital. [amj.2016;3(2):186–9] keywords: children, cyanosis, pneumonia correspondence: herza fadlinda, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281319833987 email: herza.fadlinda@gmail.com introduction pneumonia stands for lung tissue-damaging inflammation caused by atypical infectious agents such as m. pneumoniae, c. pneumoniae and l. pneumophila.1,2 according to the world health organization (who), severe pneumonia in children is indicated by chest indrawing. pneumonia kills many children under-five with an annual incidence of 150.7 million cases worldwide.3 incidence of pneumonia in southeast asia’s children is really high.4 in 2013, theprevalence of pneumonia in indonesia was 4.5%. according to the indonesian health demographics survey in 2009, west java province had a high incidence of pneumonia of more than 4%.5 neonatal deaths areascribed to 3 major causes: premature birth, sepsis, and pneumonia.6 pneumonia is deemed to be responsible for the loss of lives at least in 2 million children annually (20% of all child deaths) with 70% of all deaths occuring in africa and southeast asia.7 high incidence of deaths among children under-five are associated with many factors, e.g. cyanosis, hepatomegaly, inability to eat, malnutrition, mental status changes, prolongation of sickness duration, comorbid chronic diseases, and age less than 4 months.8,9 those associations have been confirmed by multiple studies abroad however, in indonesia, particularly in west java, such associations are still open to dispute. the high incidence of deaths among children under-five due to pneumonia and lack of studies investigating the validity of the above-mentioned associations become the background of this study. the objective of this study was to investigate the influence of cyanosis, malnutrition, and age of less than 4 months on death among children with severe pneumonia. the fore-mentioned factors were chosen as research variables because the data were always recorded in thepatient’s medical althea medical journal. 2016;3(2) 187 records while other factors e.g. hepatomegaly, mental status changes, comorbid chronic diseases, and inability to eat were rarely recorded. hopefully, the results of this study could aid clinicians in formulating prognosis for children with severe pneumonia. this study should also provide greater details on clinically deteriorating factors among children with severe pneumonia. methods this study had employed a case-control study design utilizing medical records of pediatric in patients with severe pneumonia at dr. hasan sadikin general hospital from january 2007 to december 2013. the cases in this study were pediatric inpatients who died of severe pneumonia, while control patients were also pediatric in patients with severe pneumonia but were later discharged. the samples were medical records of pediatric patients who fulfilled the inclusion criteria. the inclusion criteria in this study for thecase group was complete medical records consisting of information about patients with severe pneumonia who had been treated at the department of pediatrics of dr. hasan sadikin general hospital from january 2007 to december 2013; maximum age of 5 years; and had died, meanwhile the inclusion criteria for the control group was similar to the case group however the patients werelater discharged. the implemented exclusion criteria were medical records consisting ofinformation about pediatric inpatients with comorbidities. the simple randomized sampling was used and the study eventually involved 80 patients who were divided into equal groups of cases and controls. the data were then subjected to a chisquared statistical test. all the statistical calculations were executed using statistics software results the results of this study were presented in tables displaying the frequency of the risk factors among patients and the relationship between each risk factor and mortality. table 1 demonstrates that cyanosis was only rarely encountered among the study population as only a meager 10% of the population reported such finding. of such lean number, the majority of cyanosis was encountered in those who died of pneumonia (cases). patients with malnutrition were higher in number than those without but the difference in their numbers was not significant. only a few of the patients included in the study herza fadlinda, adi utomo, henni djuhaeni: cyanosis as mortality risk among children with severe pneumonia table 1 frequency of cyanosis, malnutrition, and age of less than 4 months among cases and controls risk factors patient category case (n=4) (%) control (n=40) (%) cyanosis yes 7 17.5 1 2.5 no 33 82.5 39 97.5 malnutrition yes 25 62.5 21 52.5 no 15 37.5 19 47.5 age less than 4 months yes 6 15 4 10 no 34 85 36 90 table 2 relationship between cyanosis and mortality cyanosis mortality p-value*yes (n=40) no (n=40) f % f % yes 7 17.5 1 2.5 0.025 no 33 82.5 39 97.5 note: *chi-squared test althea medical journal. 2016;3(2) 188 amj june 2016 were less than 4 months old and out of the few, the case patients contributed more than the control patients (15% against 10%). furthermore, thechi-squared test was then used to analyze the relationship between cyanosis and children mortality. a p-value of 0.025 established that the hypothesis of a relationship between cyanosis and mortality among children with pneumonia was significant. the chi-squared test was also used to analyze the relationship between malnutrition and mortality among children. a p-value of 0.366 failed to establish any significant association and the hypothesis of malnutrition influencing mortality was not significant. a p-value of 0.499 failed to establish such influence and the hypothesis of such young age having an influence on mortality was not significant. discussion according to djelantik et al.9 and lutala et al.10, age of less than 4 months and cyanosis [95% ci, 0.21 (0.10-0.42), p-value = 0.00] are associated with deaths among patients with pneumonia. deaths due to pneumonia can be reduced by strict attention to the forementioned risk factors.4,10 this study has investigated the association between cyanosis and deaths among children with pneumonia and the statistical analysis revealed that such association in fact existed among patients at dr. hasan sadikin general hospital which wasproven by the p-value of 0.025. a different finding was reported concerning the child’s age. a p-value >0.05 between age of less than 4 months and mortality among children suggested that the two variables lack definitive association. such finding might have been due to the limited number of patients of such age being referred to and treated at dr. hasan sadikin general hospital. this finding was also at odds with the current data that mortality due to pneumonia among children under-five in indonesia was still high. future studies with larger populations involving multiple centers are deemed necessary to produce more accurate findings. moreover, scott et al.12 revealed in their study that mortality due to pneumonia could be lessened by improvements in nutrition. meanwhile, caulfield et al.13 who demonstrated that poor nutrition was responsible for many pneumonia deaths also confirmed such revelation. another study in india performed by ghimire et al.14 four years ago demonstrated that malnutrition has increased the proportion of deaths among patients with pneumonia. in addition, according to divyarani et al.11, low birth weight among children under-five is also associated with pneumonia.11-14 however, all of these findings were at odds with the findings of this study. according to the data, no significant relationship could be established between malnutrition and mortality among pediatric inpatients at dr. hasan sadikin general hospital. such finding could have been due to malnutrition being so widespread among both case and control patients and this presented a potential bias that may corrupt the findings of table 3 relationship between malnutrition and mortality malnutrition mortality p-value*yes (n=40) no (n=40) f % f % yes 25 62.5 21 52.5 0.366 no 15 37.5 19 47.5 note: *chi-squared test table 4 relationship between age less than 4 months and mortality age less than 4 months mortality p-value*yes (n=40) no (n=40) f % f % yes 6 18 4 10 0.499 no 34 85 36 90 note: *chi-squared test althea medical journal. 2016;3(2) 189 this study. on one side, malnutrition presents itself as a risk factor but on the other side, it may also act as a comorbidity that worsens the prognosis of a child with pneumonia. in some way, a study performed by yudhi et al.15 in the province of west nusa tenggara resonated with this study’s findings as they revealed in 2010 that most pediatrics patients with pneumonia under their care actually had normal nutritional status.15 in conclusion, cyanosis has a significant association with mortality among children with pneumonia at dr. hasan sadikin general hospital. both malnutrition and age of less than 4 months show no such association. this study though is not without limitations. lack of sample is attributable to the mostly incomplete data and sometimes lost medical records. thus, it is suggested that further studies should pay close attention to the confounding factors, such as comorbidities, geographic location, completeness of medical records, and study methods. in addition, better computerization of the medical records should be pursued to minimize both the inaccuracies and the losses of medical records at dr. hasan sadikin general hospital. references 1. kending c. disorders of the respiratory track in children. 8th ed. china: elsevier saunders; 2012. 2. ngeow yf, suwanjutha s, chantarojanasriri t, wang f, saniel m, alejandria m, et al. an asian study on the prevalence of atypical respiratory pathogens in communityacquired pneumonia. int j infect dis. 2005;9(3):144–53. 3. rudan i, tomaskovic l, boschi-pinto c, campbell h. global estimate of the incidence of clinical pneumonia among children under five years of age. bull world health organ. 2004;82(12):891–970. 4. turner c, turner p, carrara v, burgoine k, htoo stl, watthanaworawit w, et al. high rates of pneumonia in children under two years of age in a south east asian refugee population. plos one. 2013;8(1):e54026. 5. weber, handy f. situasi pneumonia balita di indonesia. buletin jendela epidemiologi. 2010;3(1):1–10. 6. bryce j, shibuya k, boschi-pinto c, black re. who estimates of the causes of death in children. lancet. 2005;365(9465):1147– 52. 7. singh v. the burden of pneumonia in children: an asian perspective. paediatr respir rev. 2005;6(2):88–93. 8. narayanan m, falade ag. clinical risk factor for death in children with pneumonia. australia: international child health review collaboration; 2006 [cited 2015 may 6]; available from: http://www.ichrc. org/sites/default/files/riskpneumo.pdf. 9. djelantik ig, gessner bd, sutanto a, steinhoff m, linehan m, moulton lh, et al. case fatality proportions and predictive factors for mortality among children hospitalized with severe pneumonia in a rural developing country setting. j trop pediatr. 2003;49(6):327–32. 10. lutala pm, suzgo m, maurice m, raphael t, eric k. pneumonia in rural malawians under five years old: treatment outcomes and clinical predictors of death on admission. afr j prim health care fam med. 2009;1(1):112–7. 11. divyarani dc, patil gr, ramesh k. profile on risk factors of pneumonia among under-five age group at a tertiary care hospital. int j curr microbiol appl sci. 2014;3(6):750–4. 12. scott ja, brooks wa, peiris js, holtzman d, mulholland ek. pneumonia research to reduce childhood mortality in the developing world. j clin invest. 2008;118(4):1291–300. 13. caulfield le, de onis m, blössner m, black re. undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. am j clin nutr. 2004;80(1):193–8. 14. ghimire m, bhattacharya sk, narain jp. pneumonia in south-east asia region: public health perspective. indian j med res. 2012;135(4):459–68. 15. yudhi kurniawan, sang ayu kompyang indriani. karakteristik pasien pneumonia di ruang rawat inap anak rumah sakit umum provinsi nusa tenggara barat. cdk. 2012;39(3):196–7. herza fadlinda, adi utomo, henni djuhaeni: cyanosis as mortality risk among children with severe pneumonia althea medical journal. 2016;3(4) 661 comparison of effectiveness between rifampicin ofloxin-minocycline regimen and multidrug therapy-world health organization in multibacillary leprosy patients octawyana moestopo,1 hendra gunawan,2 anisah dahlan3 1faculty of medicine universitas padjadjaran, 2department of dermato-venerology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of biochemistry faculty of medicine universitas padjadjaran abstract background: multidrug therapy (mdt) which is recommended by the world health organization (who) for multibacillary (mb) leprosy patients has some side effects; it is given in 12 doses over 12–18 months. patients who refuse or are contraindicated in undertaking mdt-who can be given alternative rifampicinofloxacin-minocycline (rom) regimen for 24 months, whose side effects are less but more expensive. this study was conducted to compare the effectiveness between rom and mdt-who regimen in the first 12 months based on the derivation in morphological index (mi) of acid-fast bacilli (afb) in mb leprosy patient. methods: this was an observational analytical study with retrospective cohort method. data was collected from medical records of mb leprosy patients in the medical record installation and morbus hansen clinic, dr. hasan sadikin general hospital bandung. the overall derivation in mi in 12 months was assessed according to the type of therapy undertaken by the patient. data was analyzed by mann-whitney u test. results: a total of 59 data were selected out of 800 data of new leprosy patients based on the inclusion and exclusion criteria. among those, 20 patients were treated by rom and 39 by mdt-who. derivation of mi occurred among both groups, but rom regimen had higher percentage (94.83%) compared with mdt-who regimen (79.57%) with p value=0.003 (p<0.05). conclusions: rom regimen has better effectiveness than mdt-who regimen in the first 12 months in mb leprosy patients. [amj.2016;3(4):661–5] keywords: multibacillary leprosy, multidrug therapy, rifampicin-ofloxacin-minocycline (rom) correspondence: octawyana moestopo, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85220700888 email: octawyana@gmail.com introduction leprosy is an infectious disease which attacks peripheral nerves, skin, and other organs such as eyes, respiratory tract, and kidney.1 based on the world health organization (who) report, 232.857 new cases were found in 2012 , which can be considered high.2 leprosy control effort was done by who to resolve the problem by giving antileprosy medicines. in 1982, the who study group on chemotherapy of leprosy for control progammes recommended multidrug therapy (mdt) that was given based on type of leprosy.3 for multibacillary (mb) patients, rifampicin 600 mg, clofazimine 300 mg, and dapsone 100 mg are given each month, continued by clofazimine 50 mg and dapsone 100 mg every day. regimen is given in 12 doses for 12–18 months freely.4 rifampicin is a strong bactericidal drug, which can eliminate mycobacterium leprae (m. leprae) quickly, while dapsone and clofazimine are bacteriostatic drugs.3 the mdt-who for mb type leprosy has several weaknesses, such as darkening of skin color (copper-like), hemolytic anemia, methemoglobinemia, hypersensitivity, and low patient compliance.5 thus, for leprosy patients who refuse or have contraindication in using mdt-who, in 1997, who recommended alternative regimen consisting of 600 mg rifampicin, 400 mg ofloxacin 400 mg, and 100 mg minocycline given each month for 24 months.4 those medicines have bactericidal effect on m. leprae and rifampicin has the best bactericidal effect.15 besides, rom regimen has althea medical journal. 2016;3(4) 662 amj december 2016 less side effect, such as nausea and vomiting, better patient compliance, but higher price compare to mdt-who regimen.6 evaluation of leprosy treatment can be performed by evaluating skin the slit smear examination, especially the morphological index (mi) of acid–fast bacilli (afb) that might give useful information about medication response.7 furthermore, villahermosa et al.9 conducted a study comparing the effectiveness between rom and mdt-who regimen for 24 months in mb type leprosy patients in the philippines. both regimens showed the same result on both groups in every aspects examined such as clinical, bacteriological, and histopathological examination.9 additionally, lockwood et al.4 suggested that a study comparing both regimens on mb type leprosy patients for 12 months to increase patient compliance, is needed.4 this study was conducted to compare the effectiveness between rom and mdt-who regimen for the first 12 months based on the mi score in mb type leprosy patients. methods this was an observational analytical study using the retrospective cohort method from mb type leprosy patients’ medical records who received rom or mdt-who regimen medication for 12 months (12 doses). this study was reviewed and approved by the health research ethics committee, faculty of medicine universitas padjadjaran bandung. table 1 characteristics of patients who got rom regimen therapy and mdt-who regimen therapy characteristics rom regimen mdt-who regimen (n=20) % (n=39) % sex male female 17 3 85.0 15.0 32 7 82.1 17.9 age group (year) 34.2 34.8 education elementary junior high school senior high school bachelor 4 4 10 2 20.0 20.0 50.0 10.0 12 8 19 0 30.8 20.5 48.7 0.0 occupation photographer teacher labor retiree fruit merchant food merchant satay merchant street vendor meatball merchant farmer tombstone maker factory worker army employee entrepreneur unemployed housewife student professional worker 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 2 5 5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 10.0 25.0 25.0 1 1 1 1 1 1 1 1 0 0 0 2 2 3 4 9 5 2 4 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 0.0 0.0 0.0 5.1 5.1 7.7 10.3 23.1 12.8 5.1 10.3 leprosy type bb bl ll 4 14 2 20.0 70.0 10.0 1 27 11 2.6 69.2 28.2 althea medical journal. 2016;3(4) 663 octawyana moestopo, hendra gunawan, anisah dahlan: comparison of effectiveness between rifampicin ofloxin-minocycline regimen and multidrug therapy-world health organization in multibacillary leprosy patients data were taken from the medical record installation and morbus hansen clinic, dr. hasan sadikin general hospital bandung. this study was conducted from march to november 2012. the period of data included in this study was from 1999 to 2013, including patients’ identity, type of medication, and mi score. all samples were included by total sampling method. inclusion criteria in this study were new mb type leprosy patients who received rom regimen therapy for minimal 12 months (12 doses) and mdt-who regimen for 12 months (12 doses), aged over 15 years , and had completed mi. patients whose initial therapy were different from the last therapy (mdt-who regimen therapy changed to rom regimen therapy or vice versa) were excluded from the study. the final data was divided into two groups, rom regimen group and mdt-who regimen group. the minimal data from each group was 20 samples based on the sample size formula for unpaired analytic-categorical study. all groups’ afb mi scores were determined before the medication started and after the medication was completed after twelfth month of medication. after all the data needed was complete, an analysis was firstly started with data of normality test, continued with the bivariate analysis, namely mann-whitney u test. data analysis was performed using a statistical software while tables were made in microsoft excel. results in this study, there were 800 new leprosy cases during the period of 1999 to 2013. there were 59 out of 800 data of new leprosy patients which met the inclusion and exclusion criteria consisting of 20 patients who were included in the rom regimen group, while 39 patients were placed into the mdt-who regimen group. furthermore, the disease affected male more than female in both groups, with not much mean age difference between those two groups. the majority of the patients’ latest education for both groups was senior high school, with various occupations in each group. while, the borderline lepromatous was the leprosy type with the highest prevalence for both groups according to ridley-jopling classification (table 1). the initial and final mi mean score of both groups showed that each regimen had a gradual decrease of mi score. based on those mean, the decrease of the mi percentage was counted. the decrease of mi score for rom regimen and mdt-who regimen groups were 94.83% and 79.97% respectively (table 2). moreover, normality test was performed on both groups using shapiro wilk test. p value of shapiro wilk test for both regimens was below 0.05, thus, the data was assumed to be abnormally distributed. then, mann-whitney u test was performed to compare both groups. the comparison of the effectiveness between rom regimen and mdt-who regimen’s p value in the final month was 0.003 (p<0.05). this indicated that the effectiveness of rom regimen was significantly better compared to mdt-who regimen for the first 12 months based on mi score decrease in mb type leprosy patients. discussion based on the patients’ characteristics showed in table 1, most patients who received mdtwho regimen therapy were unemployed. the drug price may become a differentiating factor in choosing the drug regimen for the leprosy patients despite the side effect and drug consumption frequency.9 the rom regimen has a higher price with less side effects (nausea and vomiting), with once in a month drug consumption, making it more simple for the patients compare to mdt-who regimen which needs to be consumed every day with more side effects (skin hyperpigmentation, hemolytic anemia, methemoglobinemia, hypersensitivity reaction), but given freely.10 based on those considerations, occupations table 2 mi mean value in the beginning and in the end for rom regimen group and mdt who regimen group variable rom regimen (%) mdt-who regimen (%) mean stdev mean stdev initial mi 27.6 ± 19.0 41.8 ± 24.2 final mi 1.4 ± 5.4 8.5 ± 12.3 note: rom = rifampicin-ofloxacin-minocycline; mdt-who = multidrug therapy who; mi = morphological index, stdev = standard deviation althea medical journal. 2016;3(4) 664 amj december 2016 might be considered as an influencing factor in choosing leprosy medication regimen, therefore a further study needs to be conducted to prove this. therapeutic effectiveness comparison between rom regimen and mdt-who regimen based on mi score decrease in 12 months for mb type leprosy patients was performed in this study. the result showed that mi score was decreased in both regimens, but it was more significant in rom regimen (p value=0.003). both rom and mdt-who regimens have rifampicin as a strong bactericide, therefore comparing other drugs in both regimens (ofloxacin and minocycline to dapsone and clofazimine) needs to be done.11 a previous experimental study in neonate rats without thymus gland and infected with m. leprae showed that ofloxacin and minocycline were significantly more potent compared to dapsone and clofazimine in eliminating m. leprae.12 dapsone and clofazimin are bacteriostatic agents while minocycline and ofloxacin are strong bactericidal agents, thus, the latter two medicines can eliminate m. leprae quickly and significantly.13 furthermore, a clinical trial study about pefloxacin and ofloxacin conducted by fajardo et al.15 in cebu, the philippines on m. leprae injected footpad mouse showed that m. leprae viability was decreased in the fourteenth to twenty-eighth day of study. in the fifty-sixth day, all patients who received ofloxacin did not have morphologically completed m. leprae on skin slit examination. this implied that fluoroquinolon medications, which includes pefloxacin or ofloxacin are strong bactericidal and act to eliminate m. leprae more quickly compared to dapsone dan clofazimin.15 however, fluoroquinolon given in a single dose is not significant in eliminating m. leprae and it becomes more significant when combine to rifampicin. moxifloxacin and pefloxacin have better bacterial eliminating ability compared to ofloxacin.16 even so, these days, ofloxacin is still more widely used compared to the other two medicines. this result can become a consideration for usage of moxifloxacin or pefloxacin in the future.15 a study conducted by gelber and grosset 16 also showed that minocycline can eliminate m. leprae more quickly compared to dapsone and clofazimin, slower than rifampicin, and similar with ofloxacin/pefloxacin.16 based on a clinical study in rats, showed that less m. leprae live in rats who received minocycline compared to rats who received dapsone dan clofazimin.17 despite having a strong bactericidal property, rom regimen also has lesser side effects compared to mdt-who regimen. several studies stated that rom regimen side effects are less common to mdt-who which contains dapsone and clofazimin.18 limitations of this study were the loss of many medical records which lead to smaller sample size, incomplete mi records, and difference in patients’ compliance to control their ilness regularly. it is recommended to conduct similar study with histopathological and serological examinations using prospective cohort design. in conclusion, rom regimen is more effective compared to mdt-who regimen for the first 12 months based on mi score on mb type leprosy patients. this study implies that rom regimen may be considered to be used for 12 months in clinical practice. references 1. rea t, modlin rl. leprosy. in: wolff k, goldsmith la, katz si, editors. fitzpatrick’s dermatology in general medicine. 7th ed. new york: mc.graw-hill; 2008. p. 1787–92. 2. who. global leprosy situation 2012. weekly epidemiological record. 2012; 87(34):317–28. 3. williams dl, gillis tp. drug-resistant leprosy: monitoring and current status. lepr rev. 2012;83(3):269–81. 4. lockwood dnj, cunha mdg. developing new mdt regimens for mb patients; time to test rom 12 months regimens globally. lepr rev. 2012;83(3):241–4. 5. deps pd, nasser s, guerra p, simon m, birshner rdc, rodrigues lc. adverse effect from multi-drug therapy in leprosy: a brazillian study. lepr rev. 2007; 78(3):216–22. 6. setia ms, shinde ss, jerajani hr, boivin jf. is there a role for rifampicin, ofloxacin, and minocycline (rom) therapy in the treatment of leprosy? systemic review and analysis. trop med int health. 2011; 16(12):1541–51. 7. jopling wh. handbook of leprosy. 3rd ed. london: william heinemann medical books ltd; 1984. p. 40–1. 8. withington sg. leprosy. in: cook gc, sumla ai editors. manson’s tropical disease. 22nd ed. edinburgh: elsevier limited; 2014. p. 1053–73. 9. villahermosa lg, fajardo tt, abalos rm, cellona rv, balagon mv, cruz ecd, et al. parallel assessment of 24 monthly doses of rifampicin, ofloxacin, and minocycline althea medical journal. 2016;3(4) 665 versus two years of world health organization multi-drug therapy for multibacillary leprosy. am j trop med hyg. 2004;70(2):197–200. 10. pardillo fe, burgos j, fajardo tt, dela cruz e, abalos rm, paredes rm, et al. powerful bactericidal activity of moxifloxacin in human leprosy. antimicrobiol agents chemother. 2008; 52(9):3113–7. 11. dogra s, kumaran ms, narang t, radotra bd, khumar b. clinical characteristics and outcome in multibacillary (mb) leprosy patients treated with 12 months who mdt-mbr: a retrospective analysis of 730 patients from a leprosy clinic at a tertiary care hospital of northern india. lepr rev. 2013;84(1):65–75. 12. cunha mdgs, vrimond m, schettini ap, cruz rc, ura s, ghuidella c, et al. ofloxacin multicentre trial in mb leprosy fuammanaus and ilsl-bauru, brazil. lepr rev. 2012; 83(3):261–8. 13. weiand d, thoulass j, smith wcs. assessing and improving adherence with multidrug therapy. lepr rev. 2012;83(3):282–91. 14. saunderson p. chemotherapy. in: masanao makino mm, masamichi goto, kentaro hano, editor. leprosy: science working toward dignity. kanagawa: tokai university press; 2011. p. 145–51. 15. fajardo jr tt, villahermosa lg, cruz ecd, cellona rv, balagon mvf, abalos rm, et al. a clinical trial of pefloxacin and ofloxacin in lepromatous leprosy. lepr rev. 2004;75(4):389–97. 16. gelber h, grosset j. the chemotherapy of leprosy: an interpretive history. lepr rev. 2012;83(3): 221–40. 17. gelber rh, fukuda k, byrd s, murray lp, siu p, tsang mr, et al. a clinical trial of minocycline in lepromatous leprosy. bmj. 1992;304(6819):91–2. 18. deps p, guerra p, nasser s, simon m. hemolytic anemia in patients receiving daily dapsone for the treatment of leprosy. lepr rev. 2012; 83(3):305–7. 19. girdhar a, kumar a, girdhar bk. a randomised controlled trial assessing the effect of adding claritomycin to rifampicin, ofloxacin, and minocycline in treatment of single lesion paucibasillary leprosy in agra district, india. lepr rev. 2011;82(1):46–54 octawyana moestopo, hendra gunawan, anisah dahlan: comparison of effectiveness between rifampicin ofloxin-minocycline regimen and multidrug therapy-world health organization in multibacillary leprosy patients althea medical journal. 2016;3(2) 248 amj june 2016 association between mothers’ characteristics, knowledge, attitude, and practice and intestinal helminthes infection on children nadhira permata hakiki,1 lia faridah,2 meita dhamayanti,3 dida akhmad gurnida3 1faculty of medicine, universitas padjadjaran, 2departement of microbiology & parasitology faculty of medicine, universitas padjadjaran, 3departement of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: the prevalence of soil-transmitted helminthes infection in indonesia is still high, especially in children aged 3 to 8 years old. helminthes infection cause loss of nutrition, delay physical development, intelligence, and labor productivity and decrease immunity. mothers’ characteristics, knowledge, attitude, and practice are some of the factors that influence the occurrence of intestinal helminthes infection on children. this study was aimed to find the association between mothers’ characteristics, knowledge, attitude, and practice and the occurrence of intestinal helminthes infection on children. methods: the study was conducted at jatinangor cohort’s research center from august to september 2014 using cross sectional analysis. one hundred and forty five secondary data were collected using validated questionnaire that filled by mothers and results of feces on children were tested. the amount of data excluded due to incomplete was 8, the data utilized was then analyzed by chi square evaluation. results: mothers’ characteristics such as age (p = 0.611), education (p = 0.952), occupation (p = 0.876), income (p = 0.199), and knowledge (p = 0.424; or = 1.333), attitude (p = 0.236; or = 0.808), practice (p = 0.333; or = 4.625) did not have a significant association with the occurrence of intestinal helminthes infection on children. conclusions: characteristics, knowledge, attitude, and practice of the mothers towards the intestinal helminthes infection do not associate with the occurrence of intestinal helminthes infection on children. [amj.2016;3(2):248–53] keywords: attitude, characteristics, intestinal helminthes infection, knowledge, practice correspondence: nadhira permata hakiki, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 81311260236 email: nadhiraph@gmail.com introduction globally, more than 1 billion people are infected by soil-transmitted helminthes, especially in warm yet moist climate area. in indonesia, the occurrence of intestinal helminthes infection is a public health problem, especially for the children with the age of elementary school student. study showed that 60 out of 100 elementary school students in south tapanuli1 were infected by helminthes. study in palu2 showed that 93 out of 180 subject infected by helminthes were elementary school students. study in bandung3 showed that 22 out of 142 elementary school students were infected by helminthes. children are more often infected than adults, with the most frequent range of age from 3 to 8 years old.4 helminthes infection causes loss of nutrition, delay physical development, level of intelligence, labor productivity and decrease in immunity system.4 society level of healthiness are influenced by four factors. knowledge, attitude, and practice are the most dominant influential factors on the dynamic of society’s level of healthiness.5 study showed that health status is also influenced by family, included parent’s characteristics such as level of education, income, etc.6–8 according to those conceptions, mothers’ characteristics, knowledge, attitude, and practice towards a certain kind of disease play its role in the occurrence of the particular disease itself. hence, this study was conducted to discover the association between mothers’ characteristics, knowledge, attitude, and practice towards the helminthes infection and the occurrence of intestinal helminthes infection on children. althea medical journal. 2016;3(2) 249 methods the study was conducted in jatinangor cohort’s research center from august to september 2014 using cross sectional analysis. the study have been approved by the health research ethics committee, faculty of medicine universitas padjadjaran. population was secondary data retrieved from jatinangor cohort study. inclusive requirements were applied in the process of collecting the secondary data that were going to be used, as the data used was the complete data. thus, according to the aforementioned requirements, the number of subject was only 137 mothers whom children aged an elementary school student in jatinangor which included the first, second, and third grade of elementary school students (aged 6–8 years old) in two elementary schools. the amount of subject has reached the minimum sample that should be obtained. the free variables used as the main elements of the study were mothers’ characteristics, knowledge, attitude, and practice. the tied variables used as other elements of the study were the occurrence of intestinal helminthes infection on children. the measurement technique for the data of mothers’ characteristics, including age, education level, occupation, and income used for biography questionnaire. the questionnaire consisted of five choice answers. the measurement technique for the data of knowledge, attitude, and practice used validated questionnaire. getting data of knowledge was conducted using a questionnaire containing 10 questions. favorable questions got 1 point if it was correct and 0 points if it was incorrect, while for the nadhira permata hakiki, lia faridah, meita dhamayanti, dida akhmad gurnida: association between mothers’ characteristics, knowledge, attitude, and practice and intestinal helminthes infection on children table 1 mothers’ characteristics variable frequency (n=137) percentage (%) age (years old) 21–30 19 13.9 31–40 72 52.6 41–50 41 29.9 51–60 3 2.2 61–70 2 1.5 education uneducated 0 0 elementary school 32 23.4 junior high school 49 35.8 senior high school 46 33.6 college 10 7.3 occupation with monthly salary 10 7.3 entrepreneur 32 23.4 freelancer 6 4.4 unemployed 50 36.5 others 39 28.5 monthly income (average in rupiahs) under 1.050.000 15 10.9 1.050.001–2.000.000 49 35.8 2.000.001–6.000.000 58 42.3 more than 6.000.000 15 10.9 althea medical journal. 2016;3(2) 250 amj june 2016 unfavorable questions, those got 1 point if it is incorrect and 0 point if it is correct (guttmann scale) so that the highest and lowest score would be 10 and 0 point. group of good and bad knowledge was categorized based on median. the results were considered as good if the amount of the score was higher than median and categorized as bad if the amount of the score was lower than median. data of attitude was acquired using a questionnaire containing 6 questions where the point would be worth 4 points if it was “highly agree”, 3 points if it was “agree”, 2 points if it was “disagree”, and 1 point, if it was “highly disagree” (likert scale) so that the highest score would be 24 points and the lowest would be 6 points. group of positive and negative attitude were categorized based on median. the results were considered as positive if the number of the score was higher than median. those were considered as negative if the number of the score was lower than median. data of practice was got using a questionnaire with 6 questions where the highest and lowest score would be 120 and 29 points (ordinal scale). group of good and bad practice were categorized based on median. the result was considered as a good result if the score was higher than median and considered as a bad one if the score was lower than the median. the process of data in this study used computerized analysis. to determine whether there was an association between mothers’ characteristics, knowledge, attitude, and table 2 association between mother’s characteristic and the occurrence of helminthes infection on children characteristic helminthes infection total p positive n (%) negative n (%) age (years) 21–30 3 (15.8) 16 (84.2) 19 p= 0.611 31–40 11 (15.3) 61 (84.7) 72 41–50 9 (22) 32 (88) 41 51–60 1 (33.3) 2 (66.7) 3 61–70 1 (50) 1 (50) 2 education uneducated 0 0 0 p = 0.952 elementary school 5 (15.7) 27 (84.3) 32 junior high school 10 (20.4) 39 (79.6) 49 senior high school 8 (17.4) 38 (82.6) 46 college 2 (20) 8 (80) 10 ocupation with monthly salary 2 (20) 8 (80) 10 p= 0.876 entrepreneur 4 (12.5) 28 (87.5) 32 freelancer 1 (16.7) 5 (83.3) 6 unemployed 11 (22) 39 (78) 50 others 7 (18) 32 (82) 39 income under 1.050.000 3 (20) 12 (80) 15 p= 0.199 1.050.001–2.000.000 5 (10.2) 44 (89.8) 49 2.000.001–6.000.000 15 (25.9) 43 (74.1) 58 more than 6.000.000 2 (13.3) 13 (86.7) 15 althea medical journal. 2016;3(2) 251nadhira permata hakiki, lia faridah, meita dhamayanti, dida akhmad gurnida: association between mothers’ characteristics, knowledge, attitude, and practice and intestinal helminthes infection on children practice and intestinal helminthes infection on children, chi square evaluation was then implemented. in the process of its interpretation, the p value was observed; if the p value is >0.05. the association will be significant, if the p value is <0.05, the association will be significant. results the result showed that helminthes egg was found in 25 children’s feces sample. it indicated that that prevalence of helminthes infection on children in jatinangor is 18.2%. most of mother were in the range of 31 to 40 years old, junior high school graduated, unemployed, had average monthly income 2.000.001 to 6.000.000 rupiahs per month. (table 1) mother’s characteristics including age, education, income, and occupation were not associated with the occurrence of intestinal helminthes infection on children (table 2). the mean and median for the knowledge variable were 7.4 and 5.5. the highest score acquired by the subjects for the knowledge variable was 10, while the lowest score was 3. the mean and median for the attitude variable were 20.3 and 15. the highest score acquired by the subjects for the attitude variable in the study was 24, while the lowest score was 7. the mean and median for the practice variable were 102.4 and 72.5. the highest score acquired by the subjects for the behavior variable in the study was 121, while the lowest score was 64. the result of analysis using the chi square test showed that the p value for the association between knowledge, attitude and practice of the mother and the helminthes infection was more than 0.05 so that the association was considered not significant. discussion according to the result of the study, most of the subjects involved were mothers who were aged range from 31 to 40 years old, junior high school graduated, unemployed, and had income range from 2 to 6 million rupiahs per month. the result of analysis using chi square showed that the mothers’ characteristics had p value >0.05 and the association between the mothers’ characteristics and the occurrence of intestinal helminthes infection on children was considered not significant. from 18 subjects who had low level of knowledge, 4 (22.2%) of them have children who have helminthes eggs in their feces. the p value for the association between mothers’ level of knowledge and the occurrence of helminthes infection on children was 0.424 with 1.333 odd ratio. it signified that mothers with bad knowledge concerning the helminthes infection had high risk of their children infected. it was 1.333 times bigger than the mothers who have good knowledge about the disease. according to the analysis with chi square, it was discovered that there were no significant association between mothers’ knowledge about the infection and the occurrence of intestinal helminthes infection on children because the p value >0.05. the results of this study was not in line with the study in amazon9 on 329 children table 3 association between mothers’ knowledge, attitude, and practice and the occurrence of helminthes infection on children variable helminthes infection or ci 95% p value positive n (%) negative n (%) min max knowledge bad 4 (22.2) 14 (77.8) 1.333 0.399 4.458 0.424 good 21 (17.7) 98 (82.3) attitude negative 0 25 (100) 0.808 0.894 0.983 0.236 positive 7 (6.3) 105 (93.7) practice bad 1 (4) 24 (96) 4.625 0.279 76.56 0.333 good 1(0.9) 111 (99.1) althea medical journal. 2016;3(2) 252 amj june 2016 samples which found that mothers’ knowledge had negative association with the occurrence of helminthes infection on children. it was probably caused by different study location and the amount of sample. referring to the results of study, from 25 subjects with negative attitude towards the problem, there were no subjects whose children had helminthes eggs in their feces. the p value for the association between mothers’ attitude and the occurrence of helminthes infection on children was 0.236 with 0.808 odd ratio. this indicated that mothers with negative attitude towards the helminthes infection had high risk of their children infected. it was 0.808 times bigger than the mothers who had positive attitude about the disease. as much as 25 mothers with bad practice, 1 (4%) of them having children who was positively infected on helminthes eggs in their feces. the p value for the association between mothers’ practice and the occurrence of helminthes infection on children was 0.333 with 4.625 odd ratio. it signified that mothers with bad practice towards the helminthes infection had the risk of their children infected the disease 4.625 times bigger than the mothers who had good practice. referring to the result of chi square evaluation, there were no significant association between mothers’ practice towards the infection and the occurrence of intestinal helminthes infection on children because the p value was >0.05. there has not been yet similar study that discovered an association between mothers’ characteristics, knowledge, attitude and practice and the actual occurrence of intestinal helminthes infection on children in west java. the irrelevance between mother’s knowledge, attitude, and practice and the occurrence of intestinal helminthes infection on children was probably caused by the multidimensionality of the disease. in other words, the knowledge, attitude and practice factors were not the only influential factors in the occurrence of helminthes infection. there were other factors that caused the helminthes infection such as social-economy, sanitary, mother’s level of education, the condition of floor in houses, and many others.6,10–14 in this study, it has been discovered that in socialeconomy aspect, which was measured through income, 58 (42.3%) out of 137 subjects have income above the average regional payment (upah minimum regional/ umr) of sumedang as 1.735.470 rupiahs. from the educational aspect of the mother, 49 (35.8%) and 46 (33.6%) subjects were graduated from junior high school and senior high school. from occupational aspect, 50 (36.5%) out of 137 subjects are unemployed. from all the different aspects, most of the subjects have decent educational and social–economy level, hence these factors are indeed possible to become one of the causes that situate the low prevalence level of helminthes infection in jatinangor. the limitation of the study did not measure other factors that can influence the intestinal helminthes infection. the degree of healthiness of people is influenced by four factors, which are environment, behavior correlated with the balance of ecology, lineage influenced by the population and distribution of the residents, and health services.5 knowledge, attitude and practical factors are only included within behavior factors that correlate with the balance of ecology, while three of other factors were not measured in this particular study. this certain situation was not in line with the result of analysis on subjects’ characteristics in this study. from this study, it was then discovered that the characteristics of the mothers including educational level and income did not have any association with the occurrence of helminthes infection on children. this was probably caused by one single factor that did not influence the occurrence of helminthes infection. from the study, it can be concluded that there were no association between the mothers’ characteristics, knowledge, attitude and practice towards the helminthes infection and the occurrence of intestinal helminthes infection on children. further study should be conducted with wider area to represent suburban and urban area with elaborated the other factors that cause the occurrence of intestinal helminthes infection on children. references 1. fitri j, saam z, hamidy my. analisis faktorfaktor risiko infeksi kecacingan murid sekolah dasar di kecamatan angkola timur kabupaten tapanuli selatan tahun 2012. jurnal ilmu lingkungan. 2012;6(2):146– 61. 2. chadijah, sumolang ppf, veridiana nn. hubungan pengetahuan, perilaku, dan sanitasi lingkungan dengan angka kecacingan pada anak sekolah dasar di kota palu. media litbangkes. 2014;24(1):50–6. 3. silitonga mm, sudharmono u, hutasoit m. prevalensi kecacingan pada murid sekolah dasar negeri di desa cihanjuang althea medical journal. 2016;3(2) 253 rahayu parongpong bandung barat. mkb. 2009;41(2):260–4. 4. usaid’s neglected tropical diseases program. soil transmitted helminthiasis. 2014. [cited 2014 september 2]; available from: https://www.neglecteddiseases. gov/target_diseases/soil_transmitted_ helminthiasis/. 5. notoatmodjo s, editor. promosi kesehatan teori dan aplikasi. jakarta: rineka cipta; 2005. 6. omoigberale a, airauhi l. aspects of the epidemiology of intestinal parasitosis (ip) in children: knowledge, practice and perceptions of mothers. niger j clin pract. 2006;9(2):109–13. 7. ferrer rl, palmer r, burge s. the family contribution to health status: a population–level estimate. ann fam med.2005;3(2):102–8. 8. kattula d, sarkar r, ajjampur ssr, minz s, levecke b, muliyil j,et al. prevalence & risk factors for soil transmitted helminth infection among school children in south india. indian j med res. 2014;139(1):76– 82. 9. tanner s, chuquimia-choque me, huanca t, mcdade tw, leonard wr, reyes-garcía v. the effects of local medicinal knowledge and hygiene on helminth infections in an amazonian society. soc sci med. 2011;72(5):701–9. 10. strunz ec, addiss dg, stocks me, ogden s, utzinger j, freeman mc. water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and metaanalysis. plos med. 2014;11(3):e1001620. 11. huat lb, mitra ak, jamil nin, dam pc, mohamed hjj, muda wamw. prevalence and risk factors of intestinal helminth infection among rural malay children. j glob infect dis. 2012;4(1):10–4. 12. faridan k, marlinae l, al audhah n. faktorfaktor yang berhubungan dengan kejadian kecacingan pada siswa sekolah dasar negeri cempaka 1 kota banjarbaru. buski. 2013;4(3):121–7. 13. rahayu n, ramdani. faktor risiko terjadinya kecacingan di sdn tebing tinggi di kabupaten balangan provinsi kalimantan selatan. buski. 2013;4(3):150–154. 14. andaruni, fatimah, simangunsong b. gambaran faktor–faktor penyebab infeksi cacingan pada anak di sdn 01 pasirlangu cisarua. students e–journal. 2012;1(1):28–42. nadhira permata hakiki, lia faridah, meita dhamayanti, dida akhmad gurnida: association between mothers’ characteristics, knowledge, attitude, and practice and intestinal helminthes infection on children althea medical journal. 2016;3(4) 629 electrocardiogram profile in children with dengue infection at dr. hasan sadikin general hospital and bandung city hospital sakinah binti shabbir hussain,¹ rahmat budi kuswiyanto,² januarsih iwan,3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3 departement of anatomy and cell biology, faculty of medicine, universitas padjadjaran abstract background: dengue is a mosquito-borne infection which causes many manifestations on the organs, mainly heart. according to the histopathological analysis in heart, there is a direct action of dengue virus towards myocardium. this study was an initial study of cardiac involvement in dengue infection using electrocardiogram as a measurement tool. methods: this study was a descriptive cross-sectional study and data collection were performed consecutively. a total of 17 children was taken which had been diagnosed with dengue infection according to world health organization criteria and had fulfilled inclusion and exclusion criteria of this study in dr. hasan sadikin general hospital and bandung city local hospital. once informed consent was obtained, the electrocardiogram procedure was performed according to standard electrocardiogram procedure in pediatrics. data were analyzed by a pediatric cardiology consultant. data were interpreted based on the electrocardiogram characteristics according to the type of dengue infection. results: p wave amplitude was getting shorter as the severity of dengue infection increased. p wave duration increased slightly with increased severity of dengue infection. there was a significant increase in pr interval as the severity of dengue infection increased. the same was also true for st and qtc wave. conclusions: the pattern of electrocardiogram profile in children with dengue infection were within normal range. [amj.2016;3(4):629–32] keywords: cardiac involvement, dengue infection, electrocardiogram correspondence: sakinah binti shabbir hussain, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6287822004447 email: sweetycramel1991@yahoo.com introduction one of the most important mosquito-borne viral diseases in world is dengue infection.1 dengue is a member of flaviviridae family consisting of a single stranded rna virus with four serotypes: denv-1, denv-2, denv-3 and denv4.2 the transmission was facilitated by a specific mosquito called aedes aegypti.3 dengue virus has been reported to infect many organs in human body, mainly heart.4 few cardiac complication has been reported including atrial fibrillation,5 atrioventricular block,6 and myocarditis.7 according to the histopathological analysis, dengue virus has a direct action on myocardium8 through autoimmune response against cardiac epitopes.9 therefore, to detect myocarditis, electrocardiogram widely is used as a screening tool, not only because it is easily available but also due to its ability to indicate the extend of acute myocardial injuries.10,11 several studies had been carried out earlier, including the one in columbia12 where out of 102 dengue hemorrhagic fever patients, 11 of them diagnosed as suffering from myocarditis, which was confirmed by electrocardiogram and echocardiograph analysis, and another study in sri lanka13 where an elevation of cardiac enzyme in patients with dengue infection had been proven to include cardiac involvement in dengue infection patients. hence, an initial study of cardiac involvement due to dengue infection using electrocardiogram as a tool of measurement is necessary. the objective was to know the electrocardiogram profile in patients with dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. this type of study has never been carried out before in this hospital. althea medical journal. 2016;3(4) 630 amj december 2016 methods this was a descriptive cross sectional study. data collected in this study were primary data collected through standard electrocardiogram procedure in children suffering from dengue infection. this study was carried out during early september until early november 2014 in the pediatric ward in dr. hasan sadikin hospital and bandung city local hospital after approval was gained from the ethic committee of the respective hospitals. children with dengue infection who met inclusion and exclusion criteria were sampled consecutively. the inclusion criteria are all children who had been diagnosed with dengue virus infection at the pediatric department whose age was 14 years old or younger in both hospitals. parents and guardians of these children were given written and verbal informed consent and they had agreed to the electrocardiogram procedure. the exclusion criteria consisted of children detected having any congenital heart disease, abnormal genetic condition, disease around patient’s chest area, and also other health conditions like pneumothorax and sepsis. children with dengue infection was diagnosed according to the world health organization ( who ) guidelines.14 the ecg-12 monitoring was used with 12 leads attached to the subject according to the manufacturer’s instruction. six precordial leads and six extremities leads are used.15 then the electrocardiogram data were recorded: pulse rate, respiratory rate, and heart rate. data on the temperature were also, and t obtained during electrocardiogram procedure by placing a thermometer under the axilla. initial haemoglobin, hematocrit, and thrombocyte counts were also recorded. once data have been recorded, the electrocardiogram data were analyzed by a pediatric cardiologist consultant. data from the electrocardiogram profile were tabulated according to the type of infection, including dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. the characteristics of electrocardiogram were recorded according to rhythm, p wave amplitude, p wave duration, qrs complex amplitude, qrs complex axis, qrs complex duration, st segment, t wave, and qtc interval respectively, according to the type of infection. data from the interpreted electrocardiogram of the children according to the type of infections were analyzed results during the study period, a total of 29 children that were admitted and diagnosed as suffering from dengue infection in both hospitals. however, out of 29 only 17 children met the requirements of the inclusion criteria. from these 17 children, the proportion of boys to girls was 1 to 1. out of 17 children, 7 children table 1 characteristics of vital signs and laboratory examination mean/median dengue fever n=7 dengue hemorrhagic fever n=6 dengue shock syndrome n=4 age (years) 5.6±2.4 5.67±4.0 8.5(7-12) weight (kilograms) 17.0(12.0-68.5 14.0(11.0-31.0) 31.5(20-36) temperature (˚c) 36.8±0.4 35.6±0.9 36.9(36.5-37.4) respiratory rate (times per minute) 25.9±2.3 27.0(26-30) 25.5(23-30) pulse rate ( times per minute) 100.9±4.5 108.3±9.2 99.0(72-128) heart rate (bpm) 103.9±19.4 100.5±23.5 91.0(76-97) blood pressure (mmhg) systole 90.0(90-100) 89.2±9.2 90.0(80-108) diastole 60.0(60-70) 60.0(50-65) 55.0(50-90) haemoglobin(g/dl) 14.3±3.1 13.7±2.4 14.1(11-18) hemotocrit(%) 36.2±4.0 39.8±6.1 41.3(31-51) thrombocyte(ul) 89.6±51.4 58.3±30.1 23.0(13-83) note: x±sd= mean±standar deviation, y(min-max)= median( minimum value-maximumvalue) althea medical journal. 2016;3(4) 631sakinah binti shabbir hussain, rahmat budi kuswiyanto, januarsih iwan: electrocardiogram profile in children with dengue infection at dr. hasan sadikin general hospital and bandung city hospital were diagnosed as suffering from dengue fever, 6 children were diagnosed as having dengue hemorrhagic fever, and 4 children experienced dengue shock syndrome. prior to electrocardiogram procedure was, vital signs and laboratory examination results had been assessed. as shown in table 1, age and weight were recorded from the medical status. overall vital signs, such as temperature, vital sign, pulse pressure, heart rate, and blood pressure were shown to be in the normal range. the laboratory data included initial haemoglobin,hematocrit, and haemoglobin counts. from the data in the table, the p wave amplitude became shorter as the severity of the dengue infection increased, i.e. from a mean of 0.12 milivolt in dengue to 0.09 milivolt in dengue hemorrhagic fever and much horter shorter in dengue shock syndrome. p wave duration increased slightly from dengue fever to dengue shock syndrome. however, the pr interval duration, duration increased as the severity of the infection increased. the duration of st segment increased as the severity of infection increased, i.e. from 80.00 milisecond in dengue fever to 140.00 milisecond in dengue hemorrhagic fever and dengue shock syndrome. lastly, for qtc, the duration became shorter as severity of dengue infection increased. discussion the electrocardiogram profile patterns in children with dengue infection in this study were within normal range. however there were certain changes in the value of electrocardiogram profile as the severity of dengue infection increased, which might show early signs of cardiac involvement. the p wave duration increased as severity dengue infection increased, indicating the probability of atrial enlargement. atria enlargement causes a delay in depolarization from sinoatrial node. the increment of pr interval might show an early sign of some cardiac problems due to a delay in conduction impulse from atrioventricular node, bundle of his, or bundle branch. the st segment encompassed the end of ventricular depolarization to the beginning of ventricular repolarization.15 this increased in dengue hemorrhagic fever and dengue shock syndrome, compared to dengue fever. although the range of increase was still in the normal range, there was a possibility that this showed early signs of acute myocarditis as shown in many studies that suggested dengue viral infection causes abnormalities in st segment and a case report that had proven this assumption.16 moreover, the proportion of boys to girls was approximately in this study, which supports a study carried out in southern vietnam17 showing that sex does not play much role in getting dengue infection. although the outcomes from this study show changes in electrocardiogram profile as the severity of infection increases, all values are still in the normal range and there is no evidence of cardiac involvement as shown in the previous study in colombo.12 this condition might be due to a small number of table 2 electrocardiogram profile according to who dengue infection classification mean / median dengue fever n=7 dengue hemorrhagic fever n=6 dengue shock syndrome n=4 p wave amplitude (mv) 0.12(0.08-0.30) 0.09( 0.05-0.10 ) 0.08( 0.05-0.10) duration (ms) 80.3( 80-82 ) 81.0±12.9 82.0( 80-88 ) pr interval (ms) 129.7±17.4 151.7±50.1 179.0(114-224) qrs amplitude(mv) 1.99±0.6 1.7±1.0 1.6(1.1-3.2) complex axis(˚) 63.9±32.0 72.0±34.1 87.5(32-156) duration (ms) 80.0±3.9 74.5(68-103) 77.0(66-82) st segment (ms) 80.0(80-125) 140.0±56.2 140.0(120-160) t wave (ms) 160.0(120-160) 146.7±41.3 150.0±50.3 qtc interval (ms) 414.0(60-470) 413.7±36.1 398.5(397-420) note: x±sd= mean±standard deviation, y(min-max)= median( minimum value-maximumvalue), mv= millivolt, ms= millisecond, ˚= degree althea medical journal. 2016;3(4) 632 amj december 2016 dengue cases in this study which emphasizes the needs for a study with large sample size to reflect the population clearly. despite insignificant findings in this study on cardiac involvement in dengue infection, the pattern of the electrocardiogram profile indicates that there is a possibility of cardiac involvement. therefore, a future study with more subjects and other measurement tools to show the cardiac involvement in dengue infection is necessary and may utilize this study as a starting point references 1. guzman mg, halstead sb, artsob h, buchy p, farrar j, gubler dj, et al. dengue: a continuing global threat. nat rev microbiol 2010;8:s7–16. 2. simmons cp, farrar jj, van vinh chau n, wills b. dengue. n eng j med. 2012;366(15):1423–32. 3. salazar mi, richardson jh, sánchez-vargas i, olson ke, beaty bj. dengue virus type 2: replication and tropisms in orally infected aedes aegypti mosquitoes. bmc microbiol. 2007;7(1):9. 4. satarasinghe rl, arultnithy k, amerasena nl, bulugahapitiya u, sahayam dv. asymptomatic myocardial involvement in acute dengue virus infection in a cohort of adult sri lankans admitted to a tertiary referral centre. br j cardiol 2007;14(3):171–3. 5. veloso hh, ferreira júnior ja, paiva jmbd, honório jf, bellei ncj, paola aavd. acute atrial fibrillation during dengue hemorrhagic fever. braz j infect dis. 2003;7(6):418–22. 6. sharma jk, zaheer s. variable atrioventricular block in dengue fever. j indian acad clin med. 2014;15(3–4):252–4. 7. lee i-k, lee w-h, liu j-w, yang kd. acute myocarditis in dengue hemorrhagic fever: a case report and review of cardiac complications in dengue-affected patients. int j infect dis 2010;14(10):e919–22. 8. miranda ch, de carvalho borges m, schmidt a, pazin-filho a, rossi ma, ramos sg, et al. a case presentation of a fatal dengue myocarditis showing evidence for dengue virus-induced lesion. eur heart j acute cardiovasc care. 2013:2(2):127–30. 9. shauer a, gotsman i, keren a, zwas dr, hellman y, durst r, et al. acute viral myocarditis: current concepts in diagnosis and treatment. isr med assoc j. 2013;15(3):180–5. 10. fairweather d, abston ed, coronado mj. biomarkers of heart failure in myocarditis and dilated cardiomyopathy. in: cihakova d, editor. myocarditis. rijeka, croatia: intech open access publisher; 2011. p. 323-48. 11. ukena c, mahfoud f, kindermann i, kandolf r, kindermann m, böhm m. prognostic electrocardiographic parameters in patients with suspected myocarditis. eur j heart fail. 2011;13(4):398–405. 12. salgado dm, eltit jm, mansfield k, panqueba c, castro d, vega mr, et al. heart and skeletal muscle are targets of dengue virus infection. pediatr infect dis j. 2010;29(3):238–42. 13. wichmann d, kularatne s, ehrhardt s, wijesinghe s, brattig nw, abel w, et al. cardiac involvement in dengue virus infections during the 2004/2005 dengue fever season in sri lanka. southeast asian j trop med public health 2009;40(4):727– 30. 14. ranjit s, kissoon n. dengue hemorrhagic fever and shock syndromes. pediatr crit care med 2011;12(1):90–100. 15. thaler ms. the only ekg book you’ll ever need. philadelphia: lippincott williams &wilkins; 2010. 16. rajapakse s. dengue shock. j emerg trauma shock. 2011;4(1):120–7. 17. thai kt, binh tq, giao pt, phuong hl, hung lq, nam nv, et al. seroprevalence of dengue antibodies, annual incidence and risk factors among children in southern vietnam. trop med int health. 2005;10(4):379–86. althea medical journal. 2016;3(2) 298 amj june 2016 nutritional status of tetralogy of fallot patients at dr. hasan sadikin general hospital bandung gabriella chafrina,1 armijn firman,2 gaga irawan nugraha3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital,bandung, 3department of medical nutrition faculty of medicine universitas padjadjaran abstract background: undernutrition is common in children with congenital heart disease (chd), especially in developing countries including indonesia. the objective of the study was to describe the nutritional status of children patients with tetralogy of fallot. methods: this was a cross-sectional descriptive study using 41 medical records of children aged 0–14 years old with tetralogy of fallot that visited pediatric outpatient department of dr. hasan sadikin general hospital in period of january to december 2013. the variable was anthropometric measurement, namely weight-for-age, height-for-age, weight-for-height, and body mass index-for-age. these anthropometric data were analyzed using statistics software, who anthro, and who anthroplus and were classified based on nutritional status according to who. the collected data were displayed in percentage. results: there were more boys (60.98%) who had tetralogy of fallot compared to girls (39.02%). the percentage of undernutrition was 39.02% with 43.75% in 5–14 year old children. the percentage of stunting was 70.73% with 72% in 0–5 year old children. meanwhile, the percentage of underweight was 52% in children aged 0–5 years old. conclusions: the percentage of undernourished children with tetralogy of fallot is quiet high. undernutrition occurs more often in 5–14 year old children, while stunting occurs more often in 0–5 year old children. [amj.2016;3(2):298–303] keywords: children, nutritional status, tetralogy of fallot correspondence: gabriella chafrina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281316777415 email: gab.chafrina@gmail.com introduction undernutrition is common in children with congenital heart disease (chd), especially in developing countries including indonesia.1 tetralogy of fallot, cyanotic congenital heart defects, accounts up to 10% from all chd.2 this case consists of 4 combinations of structural heart abnormalities, namely ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta.3 undernutrition can be caused by inadequate nutritional intake or absorption, excessive energy expenditure, frequent respiratory infections, limitation of growth potential and genetic syndromes.4 generally, children need energy for synthesis of proteins that really confluence for their growth and development. tetralogy of fallot will cause low level oxygen in blood that can disrupt the energy formation that leads to growth retardation.5,6 treatment by surgery for tetralogy of fallot cases is recommended in young age, so that significantly improve the children’s nutritional status.1,7,8 the aim of this study was to describe the nutritional status of children with tetralogy of fallot. methods a descriptive cross-sectional study was conducted in 2014 using medical records of children aged 0–14 years old with tetralogy of fallot that visited pediatric outpatient department of dr. hasan sadikin general hospital from january–december, 2013. the study variables were described after getting permission from health research ethics committee. the medical records should meet the inclusion criteria which consisted of children’s anthropometric results and the diagnosis of tetralogy fallot was confirmed althea medical journal. 2016;3(2) 299 by history taking, physical examination, and echocardiography. the medical records were excluded when there were data about other chronic diseases, other congenital heart defects, or the medical records were incomplete. samples were taken using total sampling method. the anthropometric measurement, namely weight-for-age, height-for-age, weight-forheight, and body mass index-for-age were analyzed using statistics software, who anthro, and who anthroplus and were classified based on nutritional status according to who into well-nutrition (z score >1 sd), adequate nutrition (z score 1 to -1 sd), at risk from undernutrition (z score -1 to -2 sd), moderately undernutrition (z score -2 to -3 sd), severely undernutrition (z score<-3 sd). stunting and underweight based on heightfor-age and weight-for-age were classified into normal (z-score >-2 sd), stunted and underweight (z-score -2 to -3 sd), and severely stunted and severely underweight (z score <-3 sd).9 the collected data were displayed in percentage results there were 41 medical records that met the inclusion criteria. there were more boys (60.98%) who had tetralogi of fallot compared to girls (39.02%), and this case occured in a very young age (table 1). according to nutritional status, most of the patients were underweight (median z-score for weight-for-age for 0–5 years old was -2.03, median z-score weight-for-age based on sex for boys was -2.03 and for girls were -2.09). gabriella chafrina, armijn firman, gaga irawan nugraha: nutritional status of tetralogy of fallot patients at dr. hasan sadikin general hospital table 1 characteristics of tetralogy of fallot patients characteristics n=41 (%) sex boys 25 (60.98%) girls 16 (39.02%) age groups 0–5 years old 25 (60.98%) boys 15 (36.59%) girls 10 (24.39%) 5–14 years old 16 (39.02%) boys 10 (24.39%) girls 6 (14.63%) age (years) median 3.92 (min-max) (0.08–12.75) z-score for weight-for-age 0–5 years old median -2.03 (min–max) ((-6.09)–0.47) z-score for height-for-age median -2.72 (min–max) ((-5.84)–1.47) z-score for body mass index-for-age median -0.72 (min–max) ((-4.77)–2.26) althea medical journal. 2016;3(2) 300 amj june 2016 moreover, most of the patients were from stunted to severely stunted (median z-score for height-for-age for 0–14 years old was -2.72 , for 0–5 years old was -3.1, and for 5–14 years was -2.35 (stunted). patient’s median z-score for height-for-age based on sex for boys and girls were -2.68 and -2.73 respectively). on the contrary, the result of body mass index-for-age measurement showed a different result. most of the patients had adequate nutrition. figure 1 to 5 represents the nutritional status according to various measurement, age groups (0–5 years old and 6–14 years old), and gender. the percentage of underweight (underweight and severely underweight) was 13 from 25 patients (52%). in boys, the percentage of underweight was higher than in girls (figure 1). the percentage of stunting cases (stunted and severely stunted) were 18 from 25 patients (72%). similar to the previous nutritional status result, the percentage of stunting in boys was higher compared to girls (73.3% and 70%, respectively) (figure 2). most of the patients were in adequate figure 1 weight-for-age in 0–5 year old children with tetralogy of fallot figure 2 height-for-age in 0–5 year old children with tetralogy of fallot althea medical journal. 2016;3(2) 301gabriella chafrina, armijn firman, gaga irawan nugraha: nutritional status of tetralogy of fallot patients at dr. hasan sadikin general hospital nutritional status (15 from 25 patients), but there were still 9 patients who were undernourished (at risk from undernutrition, moderately undernutrition, and severely undernutrition) (figure 3). from the undernourished cases, most of the patients were boys (40%) including 3 patients who were at risk from undernutrition, 1 patient was moderately undernutrition, and 2 patients were severely undernutrition. on the other hand, the percentage of undernourished girls was 30% including 2 patients who were moderately undernutrition and 1 patient was severely undernutrition. the percentage of stunting cases (stunted and severely stunted) was 11 from 16 patients (70.73%). the percentage of stunting in boys were 7 from 10 patients (70%)including 4 stunted patients and 3 severely stunted patients. the precentage of stunting in girls was 4 from 6 patients (66.67%) (figure 4). the percentage of undernutrition (at risk from undernutrition, moderately undernutrition, and severely undernutrition) was 7 from 16 patients (43.75%). the percentage of undernutrition in boys was 4 from 10 patients (40%)including 3 patients at risk from undernutrition and 1 patient moderately undernutrition. the percentage of undernutrition in girls was 3 from 6 patients (50%) including 1 patient at risk from undernutrition and 2 patients severely figure 3 weight-for-height in 0–5 year old children with tetralogy of fallot figure 4 height-for-age in 5–14 year old children with tetralogy of fallot althea medical journal. 2016;3(2) 302 amj june 2016 undernutrition. most of the patients were in adequate nutritional status (9 from 16 patients) (figure 5). discussion in this study, the percentage of undernutrition cases was 39.02%, which was 36% in children aged 0–5 years old and 43.75% in children aged 5–14 years old. this percentage was lower than another study conducted in bandung10 (78.57%).this result might likely occured due to different methods for calculating nutritional status. the percentage of stunted children was 70.73%, which was 72% in children aged 0–5 years old and 68.75% in children aged 5–14 years old. this result was higher than another study conducted in bandung (25%).10 this result might likely occured due to different methods for calculating nutritional status as well. the percentage found in this study showed variability of nutritional status. this was explained by okoroigwe11 that children whose nutritional intakes are met with needs have normal nutritional status, but those whose nutritional intakes are not met with needs are stunted, underweight, and have undernutrition. some children with normal weight-for-height, low weight-for-age, and low height-for age will have underweight as a result of their short stature (stunting), perhaps arising from a history of past malnutrition. in contrast, children with low weight-for-height, low weight-for-age, and normal height-for-age will indeed have currently malnutrition with underweight and undernutrition, even though they are not stunting.12 the result of this study showed the importance of various nutritional status measurements in children, namely height, weight, and body mass index measurement to analyze comprehensively of children’s nutritional status. those simple measurements could give important inputs or information to physicians and family members in early detection of malnutrition and tetralogy of fallotin developing countries. if malnutrition is undetected, it can worsen the disease.1 furthermore, physicians should refer the patient to the hospital for surgery as soon as possible because early treatment of tetralogy of fallot defects can have significant results in acceleration of weight and height, with normalization of long-term growth and usually living a life free of major symptoms.2,8 this study had limitation, which was among other studies, this study was using medical records as source of data that could play an impact role in validity of the study. there were many medical records that did not meet the inclusion criteria. moreover, there were no data of the growth and development measurements of the patients who underwent surgery. it can be concluded that the percentage of undernourished children with tetralogy of fallot is quiet high. undernutrition occurs more often in children aged 5–14 years old, while stunting occurs more often in children aged 0–5 years old. figure 5 body mass index-for-age in 5–14 year old children with tetralogy of fallot althea medical journal. 2016;3(2) 303 references 1. vaidyanathan b, radhakrishan r, sarala da, sundaram kr, krishna r. what determines nutritional recovery in malnourished children after correction of congenital heart defects? j am acad pediatr. 2009;124(2):e294–9. 2. bailiard f, anderson rh. tetralogy of fallot. orphanet j rare diseases. 2009;4(2):2–12. 3. park mk. pediatric cardiology for practitioner. 5th ed. philadelphia: mosby; 2008 4. sjarif dr,anggriawan sl, putra st, djer mm. anthropometric profiles of children with congenital heart diseases. med j indones. 2011;20(1):40–5. 5. baaker rh, abass aa, kamel aa. malnutrition and growth status in patients with congenital heart disease. iraqi postgrad med j. 2008;7(2):152–6. 6. nydeggera and bines je. energy metabolism in infants with congenital heart disease. nutrition. 2006;22(78):697–704. 7. vaidyanathan b, nair sb, sundaram kr, shivaprakasha k, rao sg, et al. malnutrition in children with congenital heart disease (chd): determinants and short-term impact of corrective interventions. indian pediatr. 2008;45:541–6. 8. tokel k, azak e, ayabakan c, varan b, aslamaci s, mercan s. somatic growth after corrective surgery for congenital heart disease. turk j pediatr. 2010;52(1):58–67. 9. world health organization. who child growth standart. geneva: world health organization; 2006. 10. rahayuningsih se, garna h. status gizi dan rasio mcgoon pada tetralogi fallot. mkb. 2011;43(4s):83s–7s. 11. okoroigwe fc and okeke ec. nutritional status of preschool children aged 2-5 years in aguata l.g.a of anambra state, nigeria. int j nutr metab. 2009;1(1):9–13. 12. daymont c, neal a, prosnitz a, cohen ms. growth in children with congenital heart disease. am acad pediatr. 2013;131(1):e236–42. gabriella chafrina, armijn firman, gaga irawan nugraha: nutritional status of tetralogy of fallot patients at dr. hasan sadikin general hospital althea medical journal. 2016;3(3) 452 amj september 2016 supplement consumption among post stroke patients in dr. hasan sadikin general hospital bandung annisa rahayu,1 novitri,2 novi vicahyani utami3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilitation faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: stroke is one of the leading causes of global disability. post stroke rehabilitation program becomes the key to gain functional recovery. thus it minimizes disabilities. multiple studies have been carried out to gain greater functional outcomes for post stroke patients, including medical therapy such as supplements. however, supplement effectiveness in providing stroke recovery or prevention is still debatable. there is no data of supplement consumption among post stroke patients; therefore, the aim of this study was to determine the supplement consumption among post stroke patients. methods: this study was a cross sectional descriptive study using primary data with a consecutive sampling method. minimum samples for this study were 42 post stroke respondents who followed rehabilitation program. this study was conducted at physical medicine and rehabilitation clinic of dr. hasan sadikin general hospital bandung from june until november 2013. the interviews were done after written informed consent was obtained. descriptive statistics such as frequency distributin and proportion were used to analyze the data. results: from 42 respondents, 23 (55%) respondents consumed the supplement. from 34 supplements recorded, 56% were herbs supplements; followed by multivitamin (29%), mineral (6%), multivitamin and mineral (6%), and other supplement (3%). the most frequent ingredients composed in the supplements were b1, b6 and b12 vitamin (7%). conclusions: more than a half of post stroke patients at physical medicine and rehabilitation clinic dr. hasan sadikin general hospital are supplement users, with herbal supplements as the majority. the most frequent ingredients used are b1, b6 and b12 vitamin. [amj.2016;3(3):452–9] keywords: herbal supplements, post stroke, supplement consumption correspondence: annisa rahayu, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 85692641930 email: annisarahayuannisa@gmail.com introduction a great number of new stroke events every year unwittingly steps up the total number of post stroke patients. stroke sequelae, disabilities, handicaps, and recurrence events become the burden for these stroke survivors.1 from 15 million people who suffer a stroke annually, one third leftward is permanently disabled.2 disability is the lack of ability to perform an activity or task in the range considered normal for a human being.3 maximizing the functional recovery after stroke event is the main key to minimize the burden that emerges from disabilities. recent studies show the existence of neuronal repair after stroke, such as neurogenesis, reorganization, and axonal sprouting.4, 5 early functional recovery takes place on the first few days once the surrounding edema subsided. later recovery tends to be slower, but progressive, especially with repetitive exercises in rehabilitation program.6, 7 rehabilitation programs have become the main approach for stroke recovery in several decades. the primary goals are to prevent complications, minimize impairments, and maximize function. stroke rehabilitation program consists of physiotherapy, speech and language therapy, occupational therapy, and vocational therapy.8 effective rehabilitation interventions that initiated early after stroke can enhance greater the recovery process and minimize the functional disability.9 althea medical journal. 2016;3(3) 453 nowadays, researchers try to improve functional recovery by medical approach, especially by developing dietary supplements. united states dietary supplement health and education act (dshea) defines dietary supplements as any product (other than tobacco) intend to supplemented the diet that bears or contains one or more: a vitamin, a mineral, a herb or other botanical, an amino acid, a supplement used by man to supplemented the diet by increasing the total dietary intake, or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above.10 not with standing, supplements effectiveness such as vitamin b1, b6, b12, vitamin d, vitamin e, vitamin k, folic acid, fish oil, and calcium for stroke recovery and recurrent prevention are debated. one of the arguments is the effectiveness of consuming vitamin b1, b6 and b12 and folic acid. saposnik et al.12 concludes that lowering of homocysteine with folic acid and vitamin b6 and b12 reduces the risk of overall stroke, but not stroke severity and disability11 while vitamin intervention for stroke prevention (visp) trial shows that vitamin b has no effect on cardiovascular risk.12 on the other side, supplement manufactures are already marketed and advertised their products to the patients. by massive marketing strategies, the percentage of the united states (us) population who used at least one dietary supplement has increased from 42% in 1988–1994 to 53% in 2003–2006.13 however, there is still no data about supplement utilization among post stroke patients in indonesia. this study was conducted to measure the consumption of supplement by post stroke patients in physical medicine and rehabilitation clinic dr. hasan sadikin general hospital bandung. methods this study was a cross sectional descriptive study with consecutive sampling method. by 15% precision, 42 respondents were settled as the minimum sample size of this study. the study was conducted in physical medicine and rehabilitation clinic at dr. hasan sadikin general hospital from june–november 2013. all post stroke patients of physical medicine and rehabilitation department, dr. hasan sadikin general hospital were the population of this study. post stroke patients who followed rehabilitation program routinely and came to physical medicine and rehabilitation clinic were determined as the study subjects. participation of this study was voluntary and all process performed in this study were approved by health research ethics and dean of faculty. patients who unwilling to participate, incompletely answered the questions, or uncooperative, were excluded from the study. before the interviews were conducted, the content of questions was revised and validated to 20 respondents outside the study subjects. the interviews were performed every tuesday and thursday at physical medicine and rehabilitation clinic’s waiting room. after the informed consents were obtained, two sections of interview were begun. first section of interview included the general demographic information such as age, sex, address, occupation, education, stroke diagnosis, history of previous stroke events, date of last stroke events, and phase of stroke (sub-acute or chronic). then, qualitative measure of supplement consumption question was asked. the second section of interview was given to the respondents who had consumed supplement since the date of first stroke events. for respondents who had never consumed supplement after the events, the interview was ended. the second section of interview recorded a number of variables related to supplement consumption: category of supplement (vitamin, mineral, herbs, or others), compositions of supplement, people who recommend the supplement, reason for using supplements, and the effect after consuming supplements that felt subjectively. frequency of distribution and proportion were calculated. data were presented in tables and figures. results this study was participated by 21 (50%) male and 21 (50%) female. the most common age of respondents was 55–59 years old (23.8%). one third of respondents were graduated from elementary school. only 23.8% were graduated from universities, either with bachelor degree or more. nearly two third of the respondents were jobless (16.7% unemployed; 26.2% housewife; 21.4% retired). the majority of the respondents (88.1%) were recorded as ischemic stroke patients on the medical records, and 52.4% were on their first stroke event. according to the natural history of stroke, 61.9% of respondents were althea medical journal. 2016;3(3) 454 amj september 2016 classified in sub-acute phase (2 weeks to 6 months after stroke event) and 38.1% in chronic phase (more than 6 months) (table 1). after all interviews were performed, the data showed that 23 (54.8%) respondents consumed supplement, while the rest 19 (45.2%) were not. more than half of supplements used by post stroke patients were categorized into herbs supplements (55.8%), followed by multivitamin supplements table 1 general characteristic of respondents variable frequency (n) percentage (%) sex male 21 50 female 21 50 age category (years old) 40–44 2 4.8 45–49 5 11.9 50–54 8 19.0 55–59 10 23.8 60–64 5 11.9 65–69 6 14.3 70–74 5 11.9 80–84 1 2.4 education un-graduated elementary school 2 4.8 elementary school 14 33.3 junior high school 4 9.5 senior high school 12 28.6 college 10 23.8 occupation unemployed 7 16.7 housewife 11 26.2 retirement 9 21.4 labor 2 4.8 business 8 19.0 government worker 5 11.9 diagnosis ischemic stroke 37 88.1 hemorragic stroke 5 11.9 stroke event first 22 52.4 recurrent 20 47.6 stroke phase subacute 26 61.9 chronic 16 38.1 althea medical journal. 2016;3(3) 455annisa rahayu, novitri, novi vicahyani utami: supplement consumption among post stroke patients in dr. hasan sadikin general hospital bandung table 2 distribution of supplements compositions composition frequency (n) percentage (%) multivitamin vitamin a 3 4.29 vitamin b1, b6 and b12 5 7.14 vitamin c 2 2.86 vitamin d 3 4.29 vitamin e 2 2.86 vitamin k 1 1.43 mineral calcium 2 2.86 chlor 1 1.43 copper 1 1.43 iodine 1 1.43 iron 1 1.43 magnesium 1 1.43 manganese 1 1.43 phosphorus 1 1.43 potassium 2 2.86 sodium 1 1.43 zinc 1 1.43 herbs akar wangi 1 1.43 alfafa 1 1.43 aloevera 1 1.43 angelicae 1 1.43 apple vinegar 1 1.43 astragali 1 1.43 barley grass 1 1.43 brown rice powder 1 1.43 chlorella 1 1.43 chlorophyll 1 1.43 cinnamon 3 4.29 cistanchis 1 1.43 fish oil 1 1.43 dewa leaves 1 1.43 epimedii 1 1.43 eucommiae 1 1.43 gamat stichopus hermanii 1 1.43 garcina cambogia 1 1.43 garciniae pericarpium 1 1.43 ginseng 2 2.86 glucosamine sulphate 1 1.43 green tea 1 1.43 lignum 1 1.43 lycii 1 1.43 althea medical journal. 2016;3(3) 456 amj september 2016 (29.41%), mineral supplements (5.9%), multivitamin and mineral supplement (5.9%), and other supplements (2.9%) which was choline. among 23 supplement users, 34 supplements were recorded in this study. most common used ingredients were b1, b6 and b12 vitamin. from 34 supplements, there were 5 unknown herbs supplements that had been consumed by respondents and circulated in the market without any label of information on it (table 2). the most common given reason for consumption was ‘try supplement on in order to gain better health status’ (52.9%). the second most common reason for utilization was ‘prescribed by doctor’ (38.3%) (figure 1). some doctors at physical medicine and rehabilitation clinic dr. hasan sadikin general hospital prescribed multivitamin or minerals supplements. the most frequent person or parties who suggested or recommended users to consume supplements were doctors (38.24%) and relatives (26.47%) (figure 2). from 34 supplements used in this study, 44.12% supplements led respondents to greater health status, subjectively. respondents felt that they had a better health condition after consuming supplements such as more energized, mobilization and ambulation improvement, appetite increasing, and decreasing blood pressure. in contrast, respondents who consumed 55.88% other supplements felt that there was no difference between consuming or not consuming supplements. they feel there was no effect emerged after consuming the supplements. discussion demographic information between respondents in this study shows some similarities with indonesian and south east asia population. the possibility can be figure 1 reasons for using supplement lycii 1 1.43 nigella sativa 3 4.29 psolarae 1 1.43 rosela flowers 1 1.43 spirulina plantesis 2 2.86 white grass 1 1.43 other choline 1 1.43 without label composition 5 7.14 althea medical journal. 2016;3(3) 457annisa rahayu, novitri, novi vicahyani utami: supplement consumption among post stroke patients in dr. hasan sadikin general hospital bandung relevant to the same race or ethnicity, lifestyle, and behavior. the equal proportion between male (50%) and female (50%) respondents may represent the sex ratio of stroke patients in indonesia (male 54.7% : female 45.3%).14 the respondent’s mean age is 58.1 years old, nearly similar with mean age of south east asia region stroke patients (59.9 years old). the distribution of stroke diagnosis in the study is dominated by ischemic (infarct) stroke (88.1%), just the same as in south east asia region although with different proportion (77.7%).15 higher mortality rate of hemorrhagic stroke might be the reason behind this phenomenon.16 most respondents in this study were poorly educated; one third of them stopped their formal education after they graduated from elementary school. moreover, there were still respondents who had not finished elementary school (4.8%). the preponderance of respondents (64.3%) had a low or minimum income (unemployed, housewife, and retirement). this scene could be corresponded with indonesia’s 107th ranking position on human development index united nations development programme (undp) 2007 that indicated low health, educational, and income level.17 educational and occupational status might influence respondents’ preferences and purchasing power on supplements. this study showed that more than half of post stroke patients (54.8%) consume one or more supplements after their stroke event. there is no data explain about supplement use among post stroke patients, either in indonesia nor global. the finding in this study is nearly compatible to some other study results, such as data collected by the food and drug administration (fda) that indicated 55% of the adults surveyed used some type of dietary supplements; and national health and nutrition examination survey (nhanes) data collected from 2003 to 2006 that covered all types of dietary supplements indicated 53% of american adults took at least one dietary supplement, which mostly used multivitamin/ mineral supplement.13 the most common used supplements by post stroke patients in this study were categorized into herbs supplements (55.8%), followed by multivitamin supplements (29.41%). there was no previous data measured herbs supplements utilization among stroke patients. but, according to the 2007 national health interview survey, which included questions on americans’ use of natural products (exclude vitamins and minerals), 17.7 percent of american adults had used these types of products in the past 12 months.10,18 the most common herbs composed in the herbs supplements of this study were nigella sativa, cinnamon, ginseng, and spirulina. study in pakistan19 found that nigella sativa produced antiatherogenic effect by decreasing lipoprotein cholesterol level and increased high density lipoprotein level. medicinal plants of asia and the pacific mentioned that cinnamon had an anti-spasmodic and figure 2 supplement consumption recommendations althea medical journal. 2016;3(3) 458 amj september 2016 anti-diabetic effects. foster et al.20 concludes in their book that ginseng prevents platelet aggregation, improves physical performance and quality of life. spirulina is known to have twice much vitamin b12 as liver, in addition to have many other b vitamins, vitamin a and e, and minerals.20 these explanations are possibly the reason of high herb supplement used in stroke patients. even though herbs supplement was the most frequent supplement used, from all 34 supplements, the most common used ingredients were vitamin b1, b6 and b12. there were several large and small-scale randomized clinical trials assess the effect of vitamin b supplementation on cardiovascular mortality and morbidity, including stroke. a trial was implemented on 3680 cerebral infarction patients from 1997 to 2001 which given randomized daily dose of 2.5 mg folic acid, 0.4 mg vitamin b12 and 25 mg vitamin b6; or 20 µg, 6 µg, and 200 µg respectively for 2 years. the trial showed that vitamin b had no effect on cardiovascular risk. women’s antioxidant and folic acid cardiovascular study (wafacs) follow up study which assessed the effect of b-vitamins (2.5 mg folic acid, 50 mg b6 vitamin and 1 mg vitamin b12) to 5442 women with cardiovascular disease history for median duration of 7.3 years concluded that there was no difference between placebo and active vitamin b treatment groups in terms of myocardial infarction and stroke risks despite an 18.5% decrease in homocysteine level.12 saposnik et al.11 outcome analysis on heart outcomes prevention evaluation (hope) 2 trial participants concluded that lowering of homocysteine with folic acid and vitamin b6 and b12 reduced the risk of overall stroke, but not stroke severity and disability. most of supplements in this study were purchased over of the counter (otc), not based on doctor’s prescription or suggestion. relatives including friends and neighbors, family, pharmacy, advertisement, or even health care workers such as nurse and acupuncturist were the agents who informed, recommended, and persuaded respondents to use selected supplements. only 38% supplements were suggested by doctor. this tangibility possibly correlates with patients’ health seeking behavior. health seeking behavior is any action undertaken by individuals who perceive themselves to have a health problem or to be ill in order to find an appropriate remedy. health seeking behavior correlates with age, gender, education, socioeconomic status, geographic and culture, health belief, experience, and satisfaction to quality service received. most respondents felt no improvement after using supplements, subjectively. moreover, from respondents who felt gaining a better health status, there was only one patient who felt improvement in ambulation; which ambulation improvement is one of stroke recovery outcomes. however, respondent’s perception did not represent their real health status. because this study only conducted subjective feelings, so what respondents felt might be just placebo effects, or maybe there was an effect in patients’ body but the effect could not be felt. in conclusion, more than a half of post stroke patients at physical medicine and rehabilitation clinic in dr. hasan sadikin general hospital were supplement users. majority of supplements used were herbs supplements, followed by multivitamin supplements, mineral supplements, multivitamin and mineral supplements, and other. the most frequent ingredients used in this study were vitamin b1, b6, and b12. most of supplements users in post stroke patients get the supplements over the counter (otc). supplements users got all of herbs supplements otc, while all of the multivitamin supplements were taken from doctor’s prescription and pharmacy. one fourth of the herbs supplements in this study were circulated in the market without brand label and information. the most common given reason for supplement consumption was trying supplement in order to gain better health status. but, more than a half of the users did not feel any effect of improvement. limitation of this study were the small number of respondents caused by inadequate time in collecting data; and the outcome parameter after consuming supplements that only measure the subjective effects felt by respondents. what respondents felt might be just placebo effects; effects from another medication and rehabilitation treatment, not from supplements; or maybe there was a supplement effect in respondents’ body, but the effect could not be felt. references 1. hardie k, hankey gj, jamrozik k, broadhurst rj, anderson c. ten-year risk of first recurrent stroke and disability after first-ever stroke in the perth community stroke study. stroke. 2004;35(3):731–5. 2. who. global burden of stroke. geneva: world health organization; 2004. althea medical journal. 2016;3(3) 459annisa rahayu, novitri, novi vicahyani utami: supplement consumption among post stroke patients in dr. hasan sadikin general hospital bandung 3. sturm jw, dewey hm, donnan ga, macdonell ral, mcneil jj, thrift ag. handicap after stroke: how does it relate to disability, perception of recovery, and stroke subtype?: the north east melbourne stroke incidence study (nemesis). stroke. 2002;33(3):762–8. 4. carmichael st. themes and strategies for studying the biology of stroke recovery in the poststroke epoch. stroke. 2008;39(4):1380–8. 5. benowitz li, carmichael st. promoting axonal rewiring to improve outcome after stroke. neurobiol dis. 2010;37(2):2559– 2566. 6. snell rs. clinical neuroanatomy. 7th ed. baltimore: lippincott williams & wilkins; 2010. p 542. 7. fitzgerald mjt, gruener g, mtui e. clinical neuroanatomy and neuroscience. 5th ed. philadelphia: elsevier saunders; 2007. 8. frontera wr, silver jk, thomas d. rizzo j. essentials of physical medicine and rehabilitation: musculoskeletal disorder, pain, and rehabilitation. 2nd ed. canada: saunders elsevier; 2008. 9. duncan pw, zorowitz r, bates b, choi jy, glasberg jj, graham gd, et al. management of adult stroke rehabilitation care: a clinical practice guideline. stroke. 2005;36(9):e100–43. 10. onel s. dietary supplements: a definition that is black, white, and gray. american journal of law & medicine. 2005;31(2– 3):341–8. 11. saposnik g, ray jg, sheridan p, mcqueen m, lonn e. homocysteine-lowering therapy and stroke risk, severity, and disability: additional findings from the hope 2 trial. stroke. 2009;40(4):1365–72. 12. ntaios g, savopoulos c, grekas d, hatzitolios a. the controversial role of b-vitamins in cardiovascular risk: an update. arch cardiovasc dis. 2009;102(12):847–54. 13. gahche j, bailey r, burt v, hughes j, yetley e, dwyer j, et al. dietary supplement use among us adults has increased since nhanes iii (1988–1994). nchs data brief. 2011;61:1–8. 14. bppk. riset kesehatan dasar (riskesdas) 2007. jakarta: kemenkes ri. 2007. 15. venketasubramanian n. the epidemiology of stroke in asean countries a review. neurol j southeast asia. 1998;3:9–14. 16. truelsen t, begg s, mathers c. the global burden of cerebrovascular disease. global burden of disease. 2006. [cited 2013 november 9] available from: http:// www.who.int/healthinfo/statistics/bod_ cerebrovasculardiseasestroke.pdf 17. kemenkes ri. keputusan menteri kesehatan indonesia nomor 263/menkes/ sk/ii/2010 tentang pedoman rehabilitasi kognitif. jakarta: kemenkes ri; 2010. 18. ayranci u, son n, son o. prevalence of nonvitamin, nonmineral supplement usage among students in a turkish university. bmc public health. 2005;5:47. 19. bhatti iu, rehman fu, khan ma, marwat sk. effect of propheitic medicine kalonji (nigella sativa l.) on lipid profile of human beings: an in vivo approach. world appl sci j. 2009;6(8):1053–7. 20. foster s, varoo e, tyler p. tyler’s honest herbal a sensible guide to the use of herbs and related remedies. 4th ed. new york: the hawsworth press, inc. 1999. althea medical journal. 2016;3(3) 355 profile of knowledge on stroke among paramedics at jatinangor and tanjungsari public health centers rangga kusuma wardhana,1 andi basuki,2 suryosutanto3 1faculty of medicine universitas padjadjaran, 2department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of pharmacology and therapy, faculty of medicine, universitas padjadjaran abstract background: a knowledge of stroke is important for paramedics, to minimize delays and increase the numbers of potentially treatable patients. paramedics are health workers who devote themselves in the field of health, have knowledge and/or skills through education in the health field that requires authority in running health services. the aim of this study was to measure the level of knowledge of paramedics about stroke in jatinangor and tanjungsari public health center. methods: a cross–sectional descriptive study was conducted from august to october 2013. an 11-item questionnaire has been established and were submitted to 43 paramedics at jatinangor and tanjungsari public health center.the determination of level of knowledge was based on the t–score of each respondent compared with the mean t–score of the subject population. result: the most respondents were female. midwifery had the highest frequency of respondents. largely, the source of information about stroke derived from education.the mean of t-score was 50. there were 28 respondents had a good level of knowledge about stroke and 15 respondents had a poor level of knowledge about stroke. conclusions: most paramedics have a good level of knowledge of stroke. [amj.2016;3(3):355–8] keywords: level of knowledge, paramedics, stroke correspondence: rangga kusuma wardhana, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +6283816082740 email: ranggawardhana92@gmail.com introduction stroke was classically characterized as a neurological deficit attributed to an acute focal injury of the central nervous system (cns) by a vascular cause, including cerebral infarction, intracerebral hemorrhage (ich), and subarachnoid hemorrhage (sah), and is a major cause of disability and death world wide.1 a fall in the cerebral blood flow caused ischemia. in temporary ischemia, brief moderate ischemia induced disseminated selective neuronal necrosis, whereas longer and severer ischemia produces an infarction then brain death occurred.2 paramedic stroke recognition and hospital prenotification were associated with shorter prehospital times from the ambulance call to hospital arrival and in hospital times from hospital arrival to first medical assessment.3 paramedics are health workers who devote themselves in the field of health, have knowledge and/or skills through education in the health field that requires authority in running health services.4 paramedics had not only a potential to reduce delays, but also to ensure patients were assessed in the field appropriately and transported to a hospital with suitable acute stroke care facilities.3 additionally, early presentation at a hospital and increased of control of stroke risk factors will provide greater opportunity for effective stroke treatment and prevention.5,6 the management of stroke must be done immediately to prevent death and long-term disability.6 moreover, establishment of stroke centers, combined with accurate paramedic diagnosis and rapid transport, was essential to deliver acute stroke therapy.7 therefore the paramedics should had a good knowledge about stroke to prevent a delay in acute management of stroke.8 the aim of this study althea medical journal. 2016;3(3) 356 amj september 2016 was to measure the level and the profile of knowledge of paramedics about stroke at jatinangor and tanjungsari public health center. methods this study was conducted from august to october 2013 in jatinangor and tanjungsari public health center. this study used the cross–sectional descriptive design. all of the data collection and validation have been approved by the health research ethics committee, faculty of medicine universitas padjadjaran. the subject population of this study was 43, while the inclusion criteria of the study were the paramedics working in jatinangor and tanjungsari public health center and the paramedics who had directly contact with the patients. the exclusion criteria of the study were the paramedics who did not work in jatinangor and tanjungsari public health center. a questionnaire consisting of 11 questions about stroke had been established to assess the level of knowledge of the paramedics in the public health center. the questions consisted of definition, classification, risk factors, signs and symptoms, treatment and management of stroke. furthermore, the univariable analysis was conducted to describe the characteristic of the respondent and the level of the respondent’s knowledge. the determination of level of knowledge about stroke among paramedics was based on the t–score of each respondent compared with the mean t–score of the subject population. if the t–score of respondents was above the mean t–score then, the level of knowledge of the respondents was good, otherwise if the t– score was below the mean t–score. results the data showed that the most respondents in the study were female. the midwifery also had a greater frequency than others in educational level. education was the most source of information about stroke among the respondents (table 1). based on the result of the analysis, it was found that 28 respondents had a good level of knowledge about stroke and 15 respondents had a poor level of knowledge about stroke. the mean of t–score was 50. this score was used to determined the level of knowledge about stroke (table 2). discussion based on the result of the analysis, it was found that most of respondents had a good level table 1 distribution of frequency based on respondents characteristic variable frequency (n=43) percentage (%) sex male 8 19 female 35 81 education midwifery 29 67 nursing 8 19 pharmacy 1 3 analyst 1 3 public health 1 3 senior high school 2 5 source of information education 31 72 seminar 4 9 media 8 19 althea medical journal. 2016;3(3) 357reashnaa loganathan, ridad agoes, insi farisa desy arya: knowledge of stroke of paramedics at jatinangor and tanjungsari public health center of knowledge about stroke. the midwifery was the highest frequency of respondents, this might be due to the paramedics of the midwifery were the most widely available in the public health center compared with other paramedics. furthermore, the importance of knowledge about stroke for paramedics was to diagnosed the stroke patients accurately, then transport them to the hospital rapidly, thus an acute stroke therapy could be delivered in time.7 alexandrov et al.8 reported that in their study on the pre-intervention phase of study, accuracy of paramedics diagnosis of stroke was 61% cases, compared with 79% accuracy in the active–intervention phase. other studies reported, the knowledge of stroke was correlated with a delay in the acute management of stroke patients. according to the general public, 911 dispatchers/ communicators, and ems (emergency medical services) personnel that have less knowledge of stroke caused delay to reach medical facilities in a timely manner in patients with acute stroke.9 immediate recognition of stroke symptoms and activation of the medical system is a crucial factor in improving outcome for acute stroke patients.10 additionally, limitation of this study was the lack of data that showed the delay of consultation time to the doctors of the public health center, therefore this study cannot determine the correlation of the level of knowledge about stroke with the first acute management of stroke. moreover, this study could not compare the level of knowledge about stroke among each profession of the paramedics. it was recommended that the data about acute management of stroke in the public health center or during the patient’s transport to the hospital should be recorded to evaluate the factors that influence the delay of stroke acute management. the conclusion of this study is most of the paramedics already have a good knowledge about stroke, but the paramedics cannot determined the accuracy of stroke diagnosis due to the authorisation for the diagnosis can be only obtained by the doctor of the public health center. moreover, education about stroke is important to improve recognition of stroke symptoms by the paramedics. to minimize delays and increase the numbers of potentially treatable patients, the american stroke association recommends rapid access to ems or paramedics that use diagnostic algorithms to efficiently identify, triage, and transport patients with acute stroke to an appropriate center. table 2 characteristic of data and level of knowledge variable level of knowledge good poor (n=28) (%) (n=15) (%) sex male 4 (50) 4 (50) female 24 (68.6) 11 (31.4) education midwifery 24 (82.8) 5 (17.2) nursing 4 (50) 4 (50) pharmacy 0 1 (100) analyst 0 1 (100) public health 0 1 (100) senior high school 0 2 (100) source of information education 24 (77.4) 7 (22.6) seminar 3 (75) 1 (25) media 1 (12.5) 7 (87.5) althea medical journal. 2016;3(3) 358 amj september 2016 references 1. sacco rl, kasner se, broderick jp, caplan rl, connors b, culebras a, et al. an updated definition of stroke for 21st century: a statement for healthcare profesionals from the american heart association/ american stroke association. stroke. 2013;44(7):2064–89. 2. ito u, hakamata y, kawakami e, oyanagi k.temporary focal cerebral ischemia results in swollen astrocytic end-feet that compress microvessel and lead to focal cortical infarction. j cereb blood flow metab. 2011;31(1):328–38. 3. handschu r, poppe r, rauß j, neundörfer b, erbguth f. emergency calls in acute stroke.stroke. 2003;34(4):1005–9. 4. kementrian hukum dan hak asasi manusia republik indonesia. laporan akhir tim pengkajian hukum tentang hak dan kewajiban tenaga kesehatan. jakarta. 2011. p. 1–85. 5. yoon ss, heller rf, levi c, wiggers j, fitzgerald pe. knowledge of stroke risk factors, warning symptoms, and treatment among an australian urban population. stroke. 2010;32(8):1926–30. 6. jauch ec, saver jl, adams hp, bruno a, demaerskchalk bm, khatri p, et al. guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the american heart association/ american stroke association. stroke. 2013;44(3):1–87. 7. mosley i, nicol m, donnan g, pattrick i, kerr f, dewey h. the impact of ambulance practice on acute stroke care. stroke. 2007;38(10):2765–70. 8. alexandrov aww, alexandrov av, rodriguez d, persse d, grotta jc. houston paramedic and emergency stroke treatment and outcomes study. stroke. 2005;36(7):1512–18. 9. williams i, mears g, raisor c, wilson j. an emergency medical service toolkit for improving system of care for stroke in north california. prev chronic dis. 2009;6(2):a67. 10. frendl dm, strauss dg, underhill bk, goldstein lb. lack of impact of paramedic training and use of the cincinnati prehospital stroke scale on stroke patient identification and on–scene time. stroke. 2009;40(3):754–56. althea medical journal. 2016;3(3) 329 correlation between cognitive functions and activity of daily living among post-stroke patients kurniawan prakoso,1 vitriana,2 anam ong3 1faculty of medicine universitas padjadjaran, 2department of physical medicine and rehabilition faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of neurology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: cognitive impairment is one of the most common post-stroke complications; however, neither patients nor health professionals are often aware of this complication. the impact of cognitive impairment on quality of life is reflected through basic activity daily living (badl) and instrumental activity daily living (iadl). prior studies concerning the correlation between cognitive impairment and activity daily living has shown contradictive results. this study was conducted in order to analyze the correlation between the cognitive functions and activity daily living in post stroke patients at dr. hasan sadikin general hospital. methods: this cross-sectional study was carried out to 23 post-stroke patients from september–november 2015. samples were collected through consecutive sampling at dr. hasan sadikin general hospital. mini mental state examination (mmse) was used to assess the cognitive functions and lawton and brody scale to assess both badl and iadl. spearman correlation was selected to analyze the existing correlation between each cognitive domain and activity daily living. results: spearman statistical correlation showed an insignificant correlation between the cognitive functions and badl (r2=0.181, p=0.408) and a significant correlation with iadl was obtained (r2=0.517, p=0.03). the only cognitive domain positively correlated with iadl was orientation to time and verbal recall. conclusions: there is a correlation between cognitive functions and iadl among post-stroke patients at dr. hasan sadikin general hospital. [amj.2016;3(3):329–33] keywords: activity of daily living, cognitive function, post stroke correspondence: kurniawan prakoso, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6281320325048 email: kurniawan_prakoso94@yahoo.co.id introduction stroke is one of a cerebrovascular diseases defined as a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral functions that lasts more than 24 hours or leading to death with no apparent cause other than a vascular origin.1 even though there is a decline in stroke mortality in america, it is still the fourth leading cause of death there.2 stroke has many complications that may lead to neurological disorders, infections of several organs, immobility, thromboembolism, pain, and psychological disorders.3 unfortunately, not all stroke patients and health professionals are aware of the impact induced by all those complications, especially the insidious complications such as cognitive impairment which may not be life threatening but will result in diminished quality of life, depicted by a lower score in basic and/or instrumental daily activities.3-4 there are two different types of daily activities, namely, basic activity of daily living (badl) and instrumental activity of daiy living (iadl). basic activitiy of daily living consists of several activities responsible for self care. the components of badl are bathing, toileting, dressing, feeding, functional mobility, personal device care, personal hygiene, grooming, sexual activity, and toilet hygiene.5 on the other hand, iadl consists of several activities althea medical journal. 2016;3(3) 330 amj september 2016 that are responsible for living independently in social life, such as care for others, care for pets, child rearing, communication management, community mobility, financial management, health management and maintenance, meal preparation and clean-up, religious observation, safety procedures and emergency responses, and shopping.5 some of the studies conducted previously on the relation between cognitive impairment and badl or iadl following stroke have shown contradictive results. a study by akbari et al.6 concluded that there was no correlation between thinking process and badl measured by barthel index (bi), but the study of ghosal et al.7 had discovered an opposite result. the description on the correlation between the cognitive functions and both badl and iadl may be necessary for planning rehabilitation for post-stroke patients so that they have fulfilling quality of life. ironically, there are not many studies about the correlation between cognitive functions and badl or iadl in indonesia. for that reason, this study was conducted to analyze the correlation between the cognitive functions and both badl and iadl. methods this study was conducted from september to november 2015 using cross-sectional study design. samples were collected through consecutive sampling from all post-stroke patients who visited the neurology clinic at dr. hasan sadikin general hospital bandung from september–november 2015. the samples were directly assessed for inclusions and exclusions criteria to minimize bias and confounding factors. initial minimum sample size of 42 subjects was set before conducting this study. patients who were aphasic, older than eighty five years old, or did not graduate from elementary school were not recruited in this study.7 after checking the patient’s manual muscle testing (mmt) results, there were only 23 eligible respondents with mmt ≥3 recruited as this study subjects. those subjects would then be assessed for cognitive functions, badl, and iadl. the cognitive functions were evaluated using the mini-mental state examination (mmse) that has been applied to evaluate global cognitive functions for many years. the highest possible score of 30 can be obtained from eleven items of five cognitive domain (orientation, registration, attention and calculation, recall, and language).8 activity daily living in this study was measured using m.p. lawton and e.m. brody scale consisting of six items for badl (toileting, feeding, dressing, grooming, mobility, and bathing) and eight items for iadl (using telephone, food prepration, shopping, house keeping, laundry, mode of transportation, responsibility for own medication, and handling finances).9 each item of both badl and iadl in lawton score has 1 point. a total score of 6 and 8 will be obtained as a perfect score for badl and iadl respectively. simple correlation statistical analysis was carried out to check the correlation between the cognitive functions and badl and iadl. since normality testing showed abnormal data distribution for both badl and iadl, spearman correlation was selected to check the correlation between the cognitive functions and badl or iadl. ethics approval was obtained from dr. hasan sadikin general hospital ethics committee. results table 1 describes the demographic characteristics of the subject. the average age of this study population was 58.26±2.658 years and the median for the years of education is 12 years, which was above the minimum requirement for this study recruitment. the most frequent type of stroke occured in this study was the ischemic stroke. the mean cognitive functions based on the mmse assessment was 23. after checking the data distribution using saphiro-wilk normality test, spearman correlation test was used to analyze the correlation strength and significance between the cognitive functions and both badl and iadl. the mmse had a significant positive correlation with iadl (r2= 0.517, p= 0.03). on the contrary, the correlation between cognitive functions and badl was insignificant (r2 = 0.181, p= 0.408). results from further evaluation of the correlation between each cognitive function and iadl are listed in table 3. out of five cognitive domains, only two had significant correlations with iadl. orientation to time had a stronger positive correlation with iadl (r2= 0.517, p= 0.011), while recall had a slightly weaker positive correlation with iadl (r2= 0.424, p= 0.044). as the orientation to time and recall were the only cognitive domains that were correlated with iadl, further analysis regarding these two domain correlations with each iadl althea medical journal. 2016;3(3) 331 items was conducted. out of 8 items of iadl, only using telephone, handling finances, and responsibility for own medication were significantly correlated with the orientation to time. verbal recall was also significantly correlated with food preparation (r2= 0.597, p= 0.003). discussion cognitive impairment is often discovered in stroke patients as a complication following the stroke. prior descriptive study held in korea10 revealed that out of 353 samples, 221 (62.6%) were cognitively impaired. the other study discovered that the average mmse score was 23, indicating a mild cognitive impairment.11 this condition might lead to interference for post-stroke patients in doing their daily activities.12 daily activities are divided into basic daily activities (badl) and instrumental daily activites (iadl). basic activity daily living (badl) is essential for a person to get their basic daily needs.5 these activities need a good executive cognitive function in order to be carried out.13 executive function is essential in planning and implementing basic daily activities, which, unfortunately, cannot be assessed using mmse.5,13 there are many suitable instruments for assessing the executive function such as modified wisconsin card sorting test, the trail making test a and b, the stroop interference test, and verbal fluency test; however, the translated and validated indonesian version of those instruments are not available yet.13 hence, kurniawan prakoso, vitriana, anam ong: correlation between cognitive functions and activity of daily living among post-stroke patients table 1 patient characteristics characteristics mean (sd), or median (min-max) n age (years, sd) 58.26 (2.658) 23 gender male (n) 9 female (n) 14 education (years) 12 (6-15) 23 type of stroke ischemic (n) 18 hemorrhagic (n) 5 duration after stroke (months) 10 (1-15) 23 cognitive function (0-30, sd) 23 (1.085) 23 badl (0-6) 6 (3-6) 23 iadl (0-8) 5 (0-8) 23 note : iadl = instrumental activity daily living; badl = basic activity daily living table 2 cognitive domain correlation with iadl cognitive domain iadl r2 p orientation to time 0.517* 0.011 orientation to place 0.342 0.110 registration 0.261 0.229 atention and calculation 0.328 0.127 recall 0.424* 0.044 language 0.224 0.305 note: *correlation is significant at the 0.01 level (2-tailed), iadl = instrumental activity daily living althea medical journal. 2016;3(3) 332 amj september 2016 mmse is selected in this study to assess the cognitive functions since it is a tool capable of evaluating global cognitive functions, though superficially. at the same time, badl activities that are not as complex as iadl, may be correlated with the cognitive functions if the subjects assessed had a very high dependency.14 thus, it is assumed that the insignificant relationship between badl and cognitive functions in this study is resulted from the inappropriate use of instrument responsible, for evaluating cognitive functions and badl total score average that shows little or no dependency. unlike badl which consists of simple activities that require good motoric and executive functions, instrumental activity daily living (iadl) consists of more complex activities closely related to cognitive functions.15 these activities are needed for a person to adapt to their environment and social life.5 the activities presented in lawton and brody iadl scale consist of ability to use telephone, shopping, food preparation, house keeping, laundry, mode of transportation, responsibility for own medications, and ability to handle finance.9 in this study, these activities were generally correlated with cognitive functions especially with orientation to time and verbal recall. this possibly might be due to the correlations between several activities of iadl, like using telephone, handling finance, and responsiblity for own medication with orientation to time. food preparation was also significantly correlated with verbal recall. this results are coherent with a previous study claiming that using technology, in this case, using telephone and handling finance, correlates with memory function which, in this study, is reflected by the orientation to time and verbal recall.13 orientation to time is also essential for a person to make a schedule, and in the case of drug consumption, to make a person responsible for his own medication. the other four items in lawton and brody iadl may not correlate with the cognitive functions assessed by mmse, due to the same reason, as the absence of correlation between adl and cognitive functions in this study. even though shopping, housekeeping, laundry, and mode of transportation are included as iadl activities due to their roles in a person’s adaptation to his/her environment and social life, they are more likely to be influenced by motor function and executive function.13 it is clearly shown that these activities are not parts of complex activities which require memory function. this study has several limitations due to the narrow time frame for data collection resulting in inadequate sample size compared to the size originally calculated of a minimum of 42 participants. furthermore, the inability of mmse for assessing executive cognitive functions which are supposed to be correlated with badl may lead to underrated results of the study. in conclusion, there is a correlation between the cognitive functions and iadl in post-stroke patients at dr. hasan sadikin general hospital bandung. thus, it is essential for post-stroke patients or, at the very least, health professionals, to be more concern about cognitive impairments as a prevalent complication following stroke due to its effect on the post-stroke quality of life. rehabilitation on post-stroke patient should not only focus on motor functions that may be crucial for table 3 correlation between iadl items and both orientation to time and recall iadl items orientation to time recall r2 p r2 p using telephone 0.580** 0.004 0.203 0.353 shopping 0.239 0.271 0.146 0.499 food preparation 0.328 0.126 0.597** 0.003 house keeping 0.059 0.788 0.207 0.344 laundry 0.100 0.650 0.294 0.174 mode of transportation 0.254 0.243 0.113 0.609 responsibility for own medication 0.493* 0.017 -0.008 0.971 handling finances 0.493* 0.017 0.214 0.326 note: *correlation is significant at the 0.05 level (2-tailed), **correlation is significant at the 0.01 level (2-tailed), iadl = instrumental activity daily living; r2 = correlation strength from spearman correlation althea medical journal. 2016;3(3) 333kurniawan prakoso, vitriana, anam ong: correlation between cognitive functions and activity of daily living among post-stroke patients the patient to conduct basic daily activities but also on cognitive functions as they are essential for performing complex activities. this is important because the respondents of this study are on average, still in their productive age. further studies regarding the correlation between cognitive functions and activity daily living may be needed in order to further explore the involvement of each cognitive domain to every activity daily living items; hence, appropriate rehabilitation approaches can be given to support the post-stroke patients with cognitive impairment and dependency. references 1. aho k, harmsen p, hatano s, maquardsen j, smirnov ve, strasser t. cerebrovascular disease in the community: results of a who collaborative study. bull world health organ. 1980;58(1):113–30. 2. burke jf, lisabeth ld, brown dl, reeves mj, morgenstern lb. determining stroke’s rank as a cause of death using multicause mortality data. stroke. 2012;43(8):2207– 11. 3. pandian jd, kaur a, jyotsna r, padma mv, venkateswaralu k, sukumaran s, et al. complications in acute stroke in india (cast-i): a multicenter study. j stroke cerebrovasc dis. 2012;21(8):695–703. 4. cumming tb, brodtmann a, darby d, bernhardt j. the importance of cognition to quality of life after stroke. j psychosom res. 2014;77(5):374–9. 5. buzaid a, dodge mp, handmacher l, kiltz pj. activities of daily living evaluation and treatment in persons with multiple sclerosis. phys med rehabil clin n am. 2013;24(4):629–38. 6. akbari s, lyden pd, kamali m, fahimi ma. correlations among impairment, daily activities and thinking operations after stroke. neurorehabilitation. 2013;33(1):153–60. 7. ghosal mk, burman p, singh v, das s, paul n, ray bk, et al. correlates of functional outcome among stroke survivors in a developing country–a prospective community-based study from india. j stroke cerebrovasc dis. 2014;23(10):2614–21. 8. tatari f, farnia v, kazemi f. mini mental state examination (mmse) in first episode of psychosis. iran j psychiatry. 2011;6(4):158–160. 9. pohjasvaara ti, jokinen h, ylikoski r, kalska h, mantyla r, kaste m, et al. white matter lesions are related to impaired instrumental activities of daily living poststroke. j stroke cerebrovasc dis. 2007;16(6):251–8. 10. yu kh, cho sj, oh ms, jung s, lee jh, shin jh, et al. cognitive impairment evaluated with vascular cognitive impairment harmonization standards in a multicenter prospective stroke cohort in korea. stroke. 2013;44(3):786–8. 11. pezzotti p, scalmana s, mastromattei a, di. lallo d. the accuracy of the mmse in detecting cognitive impairment when administered by general practitioners: a prospective observational study. bmc fam pract. 2008;9:29–30. 12. feigin vl, forouzanfar mh, krishnamurthi r, mensah ga, connor m, benett da, et al. global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010. lancet. 2014;383(9913):245–54. 13. mograbi dc, faria cda, fichman hc, paradela em, lourenço ra. relationship between activities of daily living and cognitive ability in a sample of older adults with heterogeneous educational level. ann indian acad neurol. 2014;17(1):71–6. 14. helvk a-s, høgseth ld, bergh s, šaltytėbenth j, kirkevold ø, selbæk g. a 36-month follow-up of decline in activities of daily living in individuals receiving domiciliary care. bmc geriatr. 2015;15(47):1–13. 15. haaland ky, mutha pk, rinehart jk, daniels m, cushnyr b, adair jc. relationship between arm usage and instrumental activities of daily living after unilateral stroke. arch phys med rehabil. 2012;93(11):1957–62. althea medical journal. 2016;3(4) 533 spatial ability differences in athletes and non-athletes jessica cynthia,1 leonardo lubis,2 vitriana3 1faculty of medicine universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine, universitas padjadjaran, 3department of physical medicine and rehabilition faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung abstract background: cognitive processes, specifically spatial abilities, are responsible for integration of daily activities. many factors contribute to the plasticity of the brain which, furthermore, alter the spatial ability. physical activity, which can be further grouped into sport and exercise, is a modifiable factor that enhances the cognitive processes through a divergent mechanism. this study aimed to gain further understanding on whether sport differs from exercise in altering spatial ability in athletes and non-athletes. methods: this observational study compared the spatial ability score of athletes of indonesia national sport comitte (komite olahraga nasional indonesia, koni) in west java (n= 21) and non-athletes (n= 21). sampling were performed using stratified random technique and data were collected between august and october 2015 which included spatial scores and demographic of subjects. results: the difference in spatial scores between athletes and non-athletes were not significant (p=0.432). conclusions: this study suggests an insignificant difference in spatial ability in athletes performing sport and non-athletes performing exercise. hence, the cognitive component skills in sport experience do not alter the spatial ability. [amj.2016;3(4):533–7] keywords: athlete, cognitive, exercise, spatial, sport correspondence: jessica cynthia, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 878 219 11198 email: jessica.cynthia94@gmail.com introduction spatial ability is a subcategory of cognitive processes which affects various aspects of human’s life. it is not of a definite value since it is formed by persistent changes occured in brain neurones and involves more than one part of the brains. many factors take part in the morphological changes of the brain, among them are sport and exercise which are parts of physical activities.1,2 although they may seem similar, they affect the spatial ability through different mechanisms. exercise which is performed by nonathletes has long been supported by a lot of scientific evidence to increase the physical fitness, hence spatial ability.3 the mechanisms proposed include transient increase of brain-derived neurotrophic factor (bdnf) that promotes the plasticity of brain, increased hippocampal volume, and increased cardiovascular health, which in turn increases the vo2 max in the brain.2,4,5 athletes performing sports, in addition to having physical fitness, are hypothesized to be superior in cognitive skills than those who are sedentary. although athletes are known to have “expert performance” or “narrow transfer” which leads tocognition expertise within a particular field, i.e. sports, limited knowledge is available on whether the “broad transfer” or “cognitive component skills” also occur and contribute to increased spatial ability of athletes outside the sport field.6,7,8 this study aimed to further the knowledge on how sport differs from exercise in altering the spatial ability in general setting between athletes and non-athletes through spatial ability score measurement. methods this was an observational study involving athletes and non-athletes recruited during the period of august to october 2015. ethical approval was given by the health research ethics committee, faculty of medicine, universitas padjadjaran and informed consent was signed prior to participation in this study. althea medical journal. 2016;3(4) 534 amj december 2016 athletes were recruited from of the indonesian national sport comitte (komite olahraga nasional indonesia, koni) west java which who were going to participate in the national tournament, the national sport weeks (pekan olahraga nasional, pon) 2016. a total of 32 athletes from 11 types of sports were sampled using the stratified random sampling method. non-athletes were students of the faculty of medicine, universitas padjadjaran. a total 21 students who fullfilled the criteria of routine exercise based on the american college of sport medicine (acsm) standard for at least 6 weeks were recruited. the inclusion criteria of the subjects were 18–25 years old, did not consume illicit drugs based on self-report, and no history of neurological disorders. athlete subjects were excluded if they did not follow sport programs routinely, while non-athlete subjects were disqualifed if there was a history of being an athlete in any institution. physical activities weremeasured for nonathletes to eliminate sedentary subjects using global physical activity quistionaire (gpaq) issued by world health organization (who) that already being translated and tested to 20 participants with similar characteristics to the study subjects and had been shown to be valid and reliable. through interview with subjects, the metabolic equivalent (met) score showing level of physical activities was gained. the acsm classified exercise into four domains; aerobic exercise, resistance exercise, flexibility exercise, and neurologic exercise.9 each exercise is aimed at different aspects of physical fitness and is unique in terms of the recommended frequency to achieve its goal; yet, all exercises has been demonstrated to increase the cognition, specifically the spatial cognitive ability. for cardiorespiratory exercise, the evidence-based recommendations for frequency are ≥5 days per week of moderate exercise or ≥3 days per week of vigorous exercise, moderate and/or vigorous intensity and 30–60 minutes per day (<150 minutes per week) of purposeful moderate exercise or 20– 60 minutes (75 minutes per week) of vigorous exercise. the type of exercises include regular, purposeful exercises that involve the major muscle group and are continuous and rhytmic in nature. for resistance exercise, the evidence-based recommendations are each major muscle group should be trained 2–3 days per week, with an intensity of 60–70% of 1 repetition maximum (rm). the resistance exercise involves major muscles with no specific duration of time for one exercise period. for the flexibility exercise, the evidencebased recommendations are ≥2–3 days per week, stretch to a point of feeling thightness or slight discomfort, then hold a static stretch for 10–30 seconds and exercise for each major muscle-tendon. sport is defined as different from other physical training; it is a structured, gradual, and continous program that construct and encourage athletes through competitions to achieve accomplishment.10 therefore, athletes have a distinct characteristic, that is a high tendency to upgrade themselves to a very high level of exertion for a long period of time and beyond their native physical abilities. this is achieved through a systematic training program given by an institution. the institution, koni in this study, provided a training program consisting of two components: health related physical fitness and skill related physical fitness specific to the sport type.11 there were 11 sport types in this study; fencing, athletic, wrestling, judo, kempo, weight lifting, archery, rock climbing, silat, gymnastic, and taekwondo. the spatial ability was measured for both athletes and non-athhletes, using helen bristoll spatial ability test. this written test is consisted of several types of question regarding spatial abilities with a total of 45 questions to be answered in up to 20 minutes. the types are shape matching, group rotation, combining shapes, cube views in 3d, solids in 2d, solids in 3d, and maps. each correct answet will get one point, while wrong or emptied answer will get zero point. the questions were translated and tested to 30 participants with similar characteristics of the subjects of this study and has been shown to be valid and reliable (α= 0.703). for athlete participants, after confirming the participation in koni, physical features were measured, i.e. weight and height. spatial testing was performed in koni office with sufficient lighting and closed doors and windows to prevent distractions. before the test, instructions were given and the participants were ensured to have understood the tasks. for non-athletes participants, gpaq was given first to measure the physical activities and only eligible participants can pass the spatial test. spatial testing and physical feature measurement were conducted in one of the classroom of the faculty of medicine sufficient lighting. instructions were also given before the test begin. althea medical journal. 2016;3(4) 535jessica cynthia, leonardo lubis, vitriana: spatial ability differences in athletes and non-athletes results average age of athletes and non-athletes was similar, that was in their 20s. this also applied to characteristics of weight and height. bmi was higher for athletes, probably due to the presence of weight training athletes with large figures. the physical activities of non-athletes showed no sedentary participants and all were in moderate physical activity range (600≤ x <3000). the physical exercises completed by non-athletes were more than 6 weeks which was the inclusion criteria, with a minimum value of 6 weeks and a maximum value of 152 weeks. the spatial scores were analyzed using mann whitney test. in table 2, non athlete group was shown to have better spatial scores with a margin of 1 compared to the athlete group. nevertheless, the difference was not significant (p>0.05), thus failed to prove that there was a difference in spatial ability between athletes and non-athletes. discussions currently, an agreement is not yet achieved on the cognitive transfer skills and impact. this study aimed to acknowledge whether skills table 1 characteristics of athlete and non-athlete groups characteristics athlete (n=21) non-athlete (n=21) mean standard deviation mean standard deviation age, years 22 1.97 21.10 0.44 height, m 164.19 7.64 167.76 9.67 weight, kg 68.14 20.76 65.24 12.69 bmi, kg/m2 24.71 7.56 22.43 3.04 physical activity, met -minutes –week 2703.81 1481.83 physical exercise, weeks 37.57 49.37 sport experience, years 6.72 3.10 figure 1 sport compositions of athlete group althea medical journal. 2016;3(4) 536 amj december 2016 obtained from sport can be transferred to increase spatial ability. the specific population that does sport is athlete population, but they are not only trained in specific skills regarding their sport field but also do physical exercise to increase physical fitness. physical exercise, mainly cardiorespiratory exercise and resistance exercise, has been observed to increase spatial abilities. to eliminate the effect of exercise on spatial ability and, in order to highlight the effect of sport only, exercised non-athlete control was chosen. the hypothesis of the current study is not supported by the results obtained. the spatial ability of the athletes and non athletes is not significantly differ from one another. this may suggests that exercise may or may not increase the spatial ability of both groups but specific sport skills did not additionally affect the spatial ability of athletes. the result of this study is in concordance with a previous study regarding cognitive transfer skill. in a study by jansen and lehman12, a comparison between soccer players (n= 40), gymnasts (n= 40), and non athletes (n = 40) was performed. the non-athlete controls also do sport with less training experience period. there is no significant difference of mental rotation performance between athletes and non-athletes. a previous study by chaddok et al.13 has mentioned the presence of cognitive transfer skill as the results of different characteristics between athletes and non-athletes in the study. the groups compared were athletes (n= 18) and non-athletes (n= 18), in which the nonathlete group was close to none in sport and weight training experience, while the athlete group was superior in both exercise and sport period. the result showed that the athlete group was superior than the non-athlete group in every day task such as crossing road, which is not a sport skill. this suggested the presence of cognitive transfer; yet, this may be misleading due to the assumption that the excellent cognitive of the athletes was due to sport skills only, when actually athletes were also superior in exercise. exercise only has been proposed by many studies to have significant effects in increasing cognitive.2 a mechanism that is proposed as a mechanism that can increase the spatial cognition is increasing the grey matters of the brain, specifically hippocampus, which is involved in the spatial processing.14 the increasing size may be related to the increase of bdnf. thus increasing the synaptic connection and the physical fitness that increases the oxygen flows to the brain.4,5 nevertheless, studies showed that both athletes and exercised non-athletes have superior hippocampal volume than that of sedentary control.15 this may explain the result findings in this study, in which no significance difference inspatial ability is found in subjects who do sports and exercises although future studies might be needed to clarify the difference in the alteration of hippocampal volume between subjects who do sports only, and subjects who only do exercises without sport using the pre and postintervention design. other alteration occured is the alteration of the higher integrative function which is in line with the cognitive component skills. one most widely examined component is p3 (also called p300 or p3b), which is an important component of information integration in working memory. spatial working memory is the highlight in this study, among other type of working memories. in both exercise and sport subjects, when compared to sedentary subjects, studies showed the presence of superior p3 process, faster p3 latency associated with cognitive processing speed, and larger p3 amplitude associated with attention in engaging a stimulus or task.1 this may indicate that exercise and sport exert the same pathway in increasing spatial with no cognitive transfer skills occured. yet, similar to the case of increased grey matter volume clarification through direct comparison of p3 values between sport and exercise groups is needed through preand post-intervention study. this study has limitations in scope and depth. the number of participants is more than the minimum number of sample size required by sample size calculation for independent table 2 mann whitney analysis result spatial score spatial score zm-w p valueathlete (n=21) non athlete (n=21) median ± sd 33 ± 5.03 34 ± 3.45 range 20 11 althea medical journal. 2016;3(4) 537 numeric analysis. yet, bigger sample size could yield stronger statistical power. moreover, non-athlete group consists of medical college students which might not be representative of general population, since the athlete counterparts come from different majors in college. for future studies, bigger number of participants with diverse background is recommended. lastly, since this study is a cross sectional expertiment, no causality can be determined and the justification for the results can only be speculated from literatures. a study using pretest-posttest experimental design for athletes and non athletes, which also compares types of different sport, is recomended for a future study using homogenous frequency and intensity of exercise. in summary, this study proves that cognitive transfer skills in sports towards the spatial ability is either non-existance or insignificant. this study proposes that sport and exercise increase the spatial ability through the same mechanisms, though future study may clarify the different magnitude of effect from both groups in order to obtain the optimal dose in which sport or exercise could have beneficial effect on cognition, specifically for the spatial ability. references 1. nakata h, yoshie m, miura a, kudo k. characteristics of the athletes’ brain: evidence from neurophysiology and neuroimaging. brain res rev.2010;62(2):197–211. 2. erickson ki, voss mw, prakash rs, basak c, szabo a, chaddock l, et al. exercise training increases size of hippocampus and improves memory. proc natl acad sci u s a. 2011;108(7):3017–22. 3. voss mw, heo s, prakash rs, erickson ki, alves h, chaddock l, et al. the influence of aerobic fitness on cerebral white matter integrity and cognitive function in older adults: results of a one year exercise intervention. human brain mapping. 2013; 34(11):2972–85. 4. piepmeier at, etnier jl. brain-derived neurotrophic factor (bdnf) as a potential mechanism of the effects of acute exercise on cognitive performance. j sport heal sci. 2014;4(1):14–23. 5. young j, angevaren m, rusted j, tabet n. aerobic exercise to improve cognitive function in older people without known cognitive impairment. cochrane database of syst rev. 2015;4(1):cd005381. 6. jin h, xu g, zhang jx, gao h, ye z, wang p, et al. neuroscience letters eventrelated potential effects of superior action anticipation in professional badminton players. neurosci lett. 2011;492(3):139– 44. 7. voss mw, kramer af, basak c, prakash rs, roberts b. are expert athletes “ expert ” in the cognitive laboratory? a meta-analytic review of cognition and sport expertise. appl cognit psychol.2009;24:812–826 8. alves h, voss mw, boot wr, deslandes a, cossich v, salles ji, et al. perceptualcognitive expertise in elite volleyball players. front psychol. 2013;4(1):36. 9. garber ce, blissmer b, deschenes mr, franklin b a., lamonte mj, lee im, et al. quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. med sci sports exerc. 2011;43(7):1334– 59. 10. presiden republik indonesia, dewan perwakilan rakyat. undang-undang republik indonesia no 3 tahun 2005 tentang sistem keolahragaan nasional. jakarta: negara republik indonesia; 2005. 11. bushman ba,editor. acsm’s complete guide to fitness &health. illinois: human kinetics; 2011. 12. jansen p, lehmann j. mental rotation performance in soccer players and gymnasts in an object-based mental rotation task. adv cogn psychol. 2013;9(2):92–8. 13. chaddock l, neider mb, voss mw, gaspar jg, kramer af. do athletes excel at everyday tasks?. med sci sport exerc. 2011;43(10):1920–6. 14. hartley t, lever c, burgess n, o’keefe j. space in the brain: how the hippocampal formation supports spatial cognition. philos trans r soc lond b biol sci. 2013;369(1635):20120510. 15. wei g, zhang y, jiang t, luo j. increased cortical thickness in sports experts: a comparison of diving players with the controls. plos one. 2011;6(2):e17112. jessica cynthia, leonardo lubis, vitriana: spatial ability differences in athletes and non-athletes althea medical journal. 2016;3(3) 440 amj september 2016 comparison of life quality between diabetic and diabetic with tuberculosis patients widuri wita andriati shariefuddin,1 sri yusnita irda sari,2 tri damiati pandji3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine universitas padjadjaran, 3department of physical medicine and rehabilitation faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: there are increasing double burden disease in the world. one of the double burden problems is diabetes mellitus (dm) and tuberculosis (tb). dm is a metabolic disease while tb is an infectious disease. the increasing number of people with dm and tb will affect the relationship between the two diseases (dmtb). dm is an incurable disease that if it is not controlled properly will affect the person’s quality of life. this study was conducted to determine the quality of life (qol) in people with diabetes compared to diabetic patients who also suffer from tuberculosis at dr. hasan sadikin general hospital, bandung. methods: this was a cross sectional study which included fifty three respondents in each dm and dm-tb group using the consecutive sampling method. the world health organization quality of life (whoqolbref) questionnaire was given after written informed consent was obtained from respondents. this study was conducted from april to november 2014 at the endocrine and metabolism policlinic in dr.hasan sadikin general hospital. results: the result showed that the total qol score of dm patients was 58.8, dm-tb patients was 53.59 which was significantly different between the two groups (p=0.004). out of four domains, physical (p=0.008), psychological (p=0.008) and environmental health (p=0.001) were significantly different between the two groups. there was no significant difference in social relationships domain (p=0.771). conclusions: lower qol among dm-tb patients indicates that improvement in education or counseling particularly about physical, psychological and environment changes is recommended. [amj.2016;3(3):440– 5] keywords: diabetes mellitus, life quality, tuberculosis correspondence: widuri wita andriati shariefuddin, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +62 8986961291 email: widuriwita@gmail.com introduction diabetes mellitus (dm) is a metabolic disorder that causes changes in several organs. disturbance of these organs will cause a person suffering from diabetes has a big burden in daily life.1 meanwhile, tuberculosis (tb) is still a major health problem in the world, in 2012 it was reported 8.6 million people were with tb and 1.3 million of them died.2 indonesia ranks 4th highest number of people with diabetes in the world after india, china and the united states. according to the global tuberculosis report 2013, the incidence of tb in indonesia was ranked 4th in the world. the increasing number of people with tb and dm will affect the relationship between these two diseases. a study conducted in indonesia, jakarta and bandung region, showed the frequency rate of dm in tb (dm-tb) patients was 13.2%.3 dm is a lifelong disease which if not handled with proper care can reduce the quality of life (qol) of patients. results of a study on quality of life in patients with dm shows that the overall quality of life is good and their perception about health is satisfactory however dm patients are still not satisfied with the psychological side and feel more satisfied when given social support.4 furthermore, studies on quality of life in patients with dm-tb were very limited, thus a study on comparison of life quality between dm patients and dm with tb patients in bandung, particularly at dr. hasan sadikin general hospital as the main referral hospital in west java was highly required. this study was conducted to determine the quality of althea medical journal. 2016;3(3) 441 life (qol) in people with diabetes compared to diabetic patients who also suffer from tuberculosis at dr. hasan sadikin general hospital, bandung. methods this study was a comparative analytic study with a cross-sectional approach. from april to november 2014, 53 patients with diabetic type-2 and 53 patients with diabetic type2 with tuberculosis at dr.hasan sadikin general hospital bandung were enrolled in this study using the consecutive sampling method. the inclusion criteria for this study were registered dm patients and diagnosed with diabetes mellitus type-2 at the endocrine and metabolism polyclinic and willing to participate. for the dm-tb group, the inclusion criteria were dm patients who were diagnosed with tuberculosis. dm-tb patients in this study were taken from another study that was conducted at dr. hasan sadikin general hospital. meanwhile, the exclusion criteria for this study were patients who did not want to participate and patients who due to mental disorder could not understand and answer the questionnaire. in this study, participants provided informed consent after being acquainted with the purpose of this study. the questionnaire and respondent’s identity have been filled by the participant except in some special situations such as the participant could not read clearly or understand the questions. furthermore, the whoqol-bref questionnaire had been validated and translated to the indonesian language.4 the questionnaire consists of 26 questions, two questions from the perspective of participants about their general quality of life and general health; the other 24 questions were divided into four domains which were physical health, psychological health, social relationships, and environmental health. the answer of each question was being rated on a 5-point likert scale. the raw score in each domain was then transformed to 1-100 score according to the whoqol-bref guideline.5 data were analyzed using statistical software. the characteristics of respondents were assessed using descriptive statistics and examined then transformed into scores of dm group and dm-tb group using mann-whitney test, and the p values less than 0.05 were regarded as significant. ethical clearance was obtained from dr. hasan sadikin general hospital before the study was performed. results the normality test was performed and showed the data were not normally distributed. the characteristic of the study population showed significance differences between the two groups regarding age, sex, level of education, comorbidity and duration of dm participants (table 1). overall, the participant’s perception toward their quality of life was similar. the result showed that out of 53 participants, 33 participants from dm group and 32 participants from dm-tb group reported their quality of life was moderately. moderate health status was reported by 27 respondents (50.9%) from both groups. there were differences in the physical health domain between the two groups, particularly in the dependence on medicinal substances and medical aids to do daily activities (p=0.002), energy requirement and fatigue (p=0.001), and ability to do activities in daily live (p=0.004) (table 2). in the psychological health domain there were significant differences between both groups in thinking, learning, memory and concentration (p=0.002), and self-esteem (p=0.010) (table 3). in the social relationships domain, both groups showed a significance difference in their satisfaction on personal relationships factor (p=0.009) (table 4). the environmental health domain showed that there were significance differences between the two groups in physical environment factor related facilities and infrastructure (p=0.001), opportunity for acquiring new information and skills (p=0.001), recreation factor (p=0.010) and participant satisfaction toward their home environment (p=0.001) (table 5). furthermore, there was a significant difference in the physical health domain (p = 0.008), psychological health domain (p = 0.008) and environmental health domain (p = 0.001). in all four domains, the dm group has higher mean score than the dm-tb group (table 6). discussion previous studies on quality of life in patients with dm-tb were difficult to be found, so this study could not compare the quality of life among the dm-tb group with other studies. the total qol score in each four domains of qol among dm patients in this study were althea medical journal. 2016;3(3) 442 amj september 2016 table 1 characteristic of participants groups p-value * diabetes melitus diabetes – tuberculosis (n = 53) (n = 53) n(%) n(%) age (years) ≤ 35 0 (0) 1 (1.9) 0.004 36 – 45 1 (1.9) 12 (22.6) 46 – 55 24 (45.3) 22 (41.5) 56 – 65 19 (35.8) 11 (20.8) ≥ 66 9 (17) 7 (13.2) sex female 36 (67.9) 23 (43.4) 0.011 male 17 (32.1) 30 (56.6) education no formal education 1 (1.9) 2 (3.8) 0.025 primary school 13 (24.5) 17 (32.1) junior high school 9 (17) 17(32.1) senior high school 16 (30.2) 11(20.8) university 14 (26.4) 6(11.3) financial income yes 15 (28.3) 24 (45.3) 0.071 no 38 (71.7) 29 (54.7) comorbidity yes 36 (67.9) 22 (41.5) 0.007 no 17 (32.1) 31 (58.5) history of diabetes (years) < 1 10 (18.9) 19 (35.8) 0.001 1 – 5 21 (39.6) 27 (50.9) 6 – 10 9 (17.0) 5 (9.4) >10 13 (24.5) 2 (3.8) note: *mann-whitney saudi arabia8 where more than half of the respondents have a history of diabetes, the average score in physical health domain was 54.65, psychological health domain was 63.76, social relationships domain was 65.23, and the environment health domain was 64,26.8 the study in saudi arabia8 showed different results from this study because most of the respondents have higher education and socioeconomic status. additionally, in that study, most of the respondents have an higher than in studies conducted at cianjur district hospital4 which is one of the hospitals in west java province also in iran6, and nigeria7. there was a big difference in the physical and psychological domain between this study and the study in iran. the studies in iran6 and nigeria7 were conducted among respondents who have dm between 6 to 8 years and have low socioeconomic and education level. moreover, a study of the quality of life among people with tb was conducted in althea medical journal. 2016;3(3) 443widuri wita andriati shariefuddin, sri yusnita irda sari, tri damiati pandji: comparison of life quality between diabetic and diabetic with tuberculosis patients occupation. therefore, it could not compare the result with this study since only half of the respondents had a history of dm. results of the average score between the dm group and dm-tb group showed that the dm group had higher average score of quality of life, thus it could be concluded that the quality of life in thedm group was better than in the dm-tb group.5 this result might be due to a person who had been suffering from a chronic disease such as diabetes, then also had other diseases or comorbidities such as tb, which could imply worsen of the condition and would result in the reduction in score of quality of life. moreover, dm and tb can cause decrease in immunity. it will make the person with dm-tb has limited activity and ability to work. other things that can provide an effect of a decrease in the quality of life is that people with dm who also suffer from tb is psychological termed because a person who has tb still received a bad stigma from the community.9 moreover, tuberculosis patients can reduce their quality of life in terms of physical health domain, a person who has tb will have more symptoms such as cough and night sweats so it will affect their comfort in daily activities or sleep. dm patients with tb will receive a number of medical therapy more than dm patients so it can reduce the level of compliance of participants, tb treatment can also give side effects such as tiredness, nausea, psychological disorders, disorders of the kidneys and liver,10,11 this condition can also cause the quality of life in terms of physical health and psychological table 2 participant quality of life based on physical health domain groups p-value * diabetes melitus diabetes – tuberculosis (n = 53) (n = 53) mean (sd**) mean (sd) physical health domain pain 3.04 (0.96) 2.83 (0.935) 0.232 medical therapy 2.64 (0.879) 2.17 (0.545) 0.002 energy 3.19 (0.786) 2.72 (0.662) 0.001 socialize 3.64 (0.762) 3.62 (0.627) 0.740 rest 3.21 (0.817) 2.94 (0.770) 0.630 activity 3.26 (0.684) 2.94 (0.534) 0.004 ability to work 3.19 (0.786) 3.00 (0.650) 0.144 note: *mann-whitney, **sd=standard deviation table 3 participant quality of life based on psychological health domain groups p-value * diabetes melitus diabetes – tuberculosis (n = 53) (n = 53) mean (sd**) mean (sd) psychological health domain positive feelings 3.34 (0.586) 3.21 (0.6890 0.354 spirituality 3.55 (0.774) 3.30 (0.607) 0.102 thinking 3.32 (0.803) 2.79 (0.840) 0.002 bodily image 3.30 (0.845) 3.26 (0.655) 0.704 self esteem 3.42 (0.692) 3.13 (0.590) 0.010 negative feelings 4.08 (0.805) 3.85 (0.818) 0.141 note: *mann-whitney, **sd=standard deviation althea medical journal. 2016;3(3) 444 amj september 2016 table 4 participant quality of life based on social relationships domain groups p-value * diabetes melitus diabetes – tuberculosis (n = 53) (n = 53) mean (sd**) mean (sd) social relationships domain personal relationships 3.32 (0.613) 3.00 (0.555) 0.009 sexual life 3.08 (0.874) 3.21 (0.600) 0.408 social support 3.70 (0.799) 3.79 (0.613) 0.518 note: *mann-whitney, **sd=standard deviation table 5 participant quality of life based on environmental health domain groups p-value * diabetes melitus diabetes – tuberculosis (n = 53) (n = 53) mean (sd**) mean (sd) environmental health domain physical safety 3.26 (0.984) 2.96 (0.587) 0.061 physical environment 3.57 (0.694) 3.11 (0.640) 0.001 financial resources 2.98 (0.604) 3.00 (0.392) 0.650 new information 3.42 (0.9490 2.58 (0.770) 0.001 recreation 2.72 (0.928) 2.26 (0.788) 0.010 home environment 3.66 (0.706) 3.25 (0.617) 0.001 health and social care 3.62 (0.713) 3.72 (0.662) 0.180 transport 3.28 (0.794) 3.21 (0.532) 0.271 note: *mann-whitney, **sd=standard deviation table 6 comparison between transformed scores of the whoqol-bref in total and its four domains groups p-value * diabetes melitus diabetes – tuberculosis (n = 53) (n = 53) mean (sd**) mean (sd) domain physical health 54.32 (13.68) 47.42 (9.754) 0.008 psychological health 62.43 (12.19) 56.25 (11.021) 0.008 social relationship 58.94 (14.58) 58.64 (11.196) 0.771 environmental health 59.49 (11.09) 52.06 (6.860) 0.001 total 58.80 (10.70) 53.59 (7.12) 0.004 note: *mann-whitney, **sd=standard deviation althea medical journal. 2016;3(3) 445 health reduce and can make the patients become depressed.12 necessary provision of information and monitoring of the side effects of a given drugs, social support from family and other close friends to patients with dm or dm-tb is needed especially for dm-tb group.13 there was a time limit in this study which caused some of the dm-tb participants were in the intermittent phase of tb treatment, and it might cause any tb sign or symptom diminished and their quality of life began to increase. based on this study, it can be concluded that the average life quality score in the diabetic group is higher than in the diabetic with tuberculosis group in all four domains. moreover, there is a significant difference in the total life quality, physical health, psychological health and environmental health domain. from these study findings, it is suggested to conduct follow up studies to identify the quality of life because the quality of life is related with how the patients are treated and linked with their psychological health. additionally, hospitals/primary health cares need to maintain and improve their care for patients by improvements in information and health education about the relation between diabetes and tuberculosis. references 1. longo dl, kasper dl, jameson jl, fauci as, hauser sl, loscalzo j, editors. harrison’s™ principle of internal medicine. 18th ed. united states of america: the mcgraw-hill companies, inc.; 2012. 2. world health organization. global tuberculosis report 2013. geneva: who, 2013. 3. bachti alisjahbana, van crevel r, edhyana sahiratmadja, den heijer m, anugrah maya, erita istriana, et al. diabetes mellitus is strongly associated with tuberculosis in indonesia. int j tuberc lung dis. 2006;10(6):696–700. 4. kurniawan yudianto, hana rizmadewi, ida maryati. kualitas hidup penderita diabetes melitus di rumah sakit umum daerah cianjur. jurnal keperawatan padjadjaran. 2008;10:76–86. 5. world health organization. whoqolbref: introduction, administration, scoring and generic version of the assessment. geneva: who; 1996. 6. gholani a, azini m, borji a. quality of life in patients with type 2 diabetes: application of whoqol-bref scale. shiraz e medical journal. 2013;14:162–71. 7. kolawole ba, mosaku sk, ikem rt. a comparison of two measures of quality of life of nigerian clinic patients with type 2 diabetes mellitus. african health sciences. 2009;9(3):161–6. 8. al-qahtani mf, el.mahalli aa, al dossary n, al muhaish a, al otaibi s, al baker f. health-related quality of life of tuberculosis patients in the eastern province, saudi arabia. journal of taibah university medical sciences. 2014;9(4):311–7. 9. courtwright a, turner an. tuberculosis and stigmatization: pathways and interventions. public health reports (washington, dc : 1974). 2010;125 suppl 4:34–42. 10. gulbay be, gurkan ou, yildiz oa, onen zp, erkekol fo, baccioglu a, et al. side effects due to primary antituberculosis drugs during the initial phase of therapy in 1149 hospitalized patients for tuberculosis. respiratory medicine. 2006;100(10):1834–42. 11. torun t, gungor g, ozmen i, bolukbasi y, maden e, bicakci b, et al. side effects associated with the treatment of multidrugresistant tuberculosis. int j tuberc lung dis. 2005;9(12):1373–7. 12. pan a, lucas m, sun q, van dam rm, franco oh, manson je, et al. bidirectional association between depression and type 2 diabetes mellitus in women. arch intern med. 2010;170(21):1884–91. 13. melisa prisilia terok, jeavery bawotong, frenly muntu untu. hubungan dukungan sosial dengan kualitas hidup pada pasien tuberkulosis paru di poli blu rsup prof. dr. r. d kandou manado. e journal keperawatan. 2012;1:1–10. widuri wita andriati shariefuddin, sri yusnita irda sari, tri damiati pandji: comparison of life quality between diabetic and diabetic with tuberculosis patients althea medical journal. 2016;3(3) 388 amj september 2016 effect of mangosteen pericarp extract on gastric mucosal damage induced by aspirin jansen budiono,1 achadiyani,2 dolvy girawan3 1faculty of medicine, universitas padjadjaran, 2department of anatomy and cell biology faculty of medicine universitas padjadjaran, 3department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: peptic ulcer disease is commonly found in the community. nonsteroidal anti-inflammatory drug (nsaid) such as aspirin is one of the predisposing factors to ulcers. according to various studies, plant extracts have been shown to produce promising results in the treatment of peptic ulcers. xanthone, the active substance contained in the mangosteen pericarp extract has been extensively studied for its role in various diseases. the present study was undertaken to identify the effect of mangosteen pericarp extract on gastric mucosal damage. methods: this study was carried out from september−november 2014 in the animal laboratory of the department of pharmacology and therapy, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung. thirty two rats were randomly divided into 2 groups with different treatments and were induced by aspirin. histologic studies were conducted to determine the score of gastric mucosal damage. the parameters used were wattimena’s criteria for damage of gastric mucosa. data was analyzed using chi square test and the outcome was measured in relative risk. results: the study revealed a significant association between pretreatment with mangosteen pericarp extract and incidence of gastric mucosal damage induced by aspirin (p < 0.05). calculation with a modified 2 × 2 table revealed a relative risk of 0.625. conclusions: rats pretreated with mangosteen pericarp extract exhibit less gastric mucosal damage, in experimentally aspirin-induced ulcer. [amj.2016;3(3):388–91] keywords: aspirin, gastric mucosal damage, mangosteen pericarp extract correspondence: jansen budiono, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287883083019 email: jansenbudiono@hotmail.com introduction peptic ulcer is commonly found in the community. its impact has been substantial proven to increase morbidity, and serious complications lead to mortality. nonsteroidal anti-inflammatory drug (nsaid) such as aspirin is one of the predisposing factors to ulcers.1 unfortunately, aspirin and nsaids are among the most frequently used drugs worldwide.2 prevention of peptic ulcer due to nsaid use is an important clinical issue. furthermore, herbal medicine is still widely used until presently due to better cultural acceptability. according to various studies, plant extracts have been shown to produce promising results in the treatment of peptic ulcers.3 mangosteen pericarp extract which contained xanthone as its active substance, has now become widely available as a nutraceutical (or food supplements) and further studies on its therapeutic benefits would considerably benefit the general population.4 the present study was conducted to identify the effect of mangosteen pericarp on gastric mucosal damage. methods this animal experimental study was carried out from september−november 2014 in the animal laboratory of department of pharmacology and therapy, faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital, bandung. experimental protocols had been approved by the health research ethics committee of the althea medical journal. 2016;3(3) 389 faculty of medicine, universitas padjadjaran. mangosteen pericarp extract in this study employed the standardized herbal mastin. mastin was purchased from drug stores in bandung, indonesia. thirty two adult male rats (rattusnorvegicus), wistar-strain, age 2-3 months, weighing 175−200g were used as subjects. the federer formula was used to calculate the number of rats. meanwhile, the adaptation performed in this study was based on the protocol used by nainwal et al.5 the rats were housed under the same conditions and fed with the standard chow diet and water ad libitum for 2 days before the study, maintained with light/dark cycle of 12/12 hours in room temperature. the exclusion criteria were weight loss >10% during adaptation period. after the adaptation period, the rats were randomly divided into 2 groups of 16 rats each. group i (control group) received 4ml corn oil (vehicle) orally for 7 consecutive days. group ii (pretreated group) received pretreatment with mangosteen pericarp extract (500 mg/ kg body weight) suspended in 4ml corn oil orally for 7 consecutive days. the mangosteen pericarp extract dosage was determined by nainwal et al.5 furthermore, at the end of the study, the rats fasted for 24 hours. thirty minutes after the last treatment; the rats received aspirin (200mg/kg body weight). the duration of treatment and aspirin dosage for the above mentioned groups were sufficient to induced gastric mucosal damage as showed by a study performed by jainu et al.3 after 4 hours of aspirin induction, the rats were sacrificed under diethyl ether anesthesia; then the stomach was dissected out and processed for histologic preparation. the histologic study was carried out at the department of anatomy-biocellular, faculty of medicine, universitas padjadjaran by using the light microscope. each rat specimen was analyzed under 10 high-power fields (hpf). then, each group was analyzed with 160 fields and the total of fields examined was 320. the parameter used was wattimena’s6 criteria for damage of gastric mucosa as follows: 1) score 1: no erosion, 2)score 2: erosion was limited to surface epithelium, 3)score 3: erosion was extended to 1/3 upper gastric gland, 4)score 4: erosion was extended to 1/3 middle gastric gland, 5)score 5: erosion was extended to 1/3 lower gastric gland, 6)score 6: erosion with extension to muscularis mucosae. the association between two variables was tested using chi-square test. the nullhypothesis would be accepted if p-value<0.05. should there be a significant association between the two variables; the relative risk for the modified category would then be calculated. score 1 was categorized as no erosion while scores 2−6 were categorized as erosion. results incidence of gastric mucosal damage induced by aspirin in each group was varied (table 1). the results showed significant relationship between pretreatment with mangosteen pericarp extract and incidence of gastric mucosal damage induced by aspirin (p-value: 0.000).the data was then modified to fit a 2 × 2 table for relative risk calculation (table 2). the calculation then revealed a relative risk of 0.625. discussions furthermore, the result based in table 1 shows that there was significant association between two variables. however, this result couldnot explain which group exhibited little or extensive difference in incidence of gastric mucosal damage. relative risk calculation could determine whether mangosteen pericarp extract could provide protection or adverse effects. modification of table 1 to fit a 2 × 2 table was necessary in order to calculate relative risk. additionally, calculation based on table 2 revealed a relative risk of 0.625, table 1 score of gastric mucosal damage in each group group gastric mucosal damage score total %1 2 3 4 5 6 n % n % n % n % n % n % i 24 15 45 28.1 23 14.4 24 15 16 10 28 17.5 160 100 ii 78 48.8 37 23.1 23 14.4 8 5 9 5.6 5 3.1 160 100 total 102 31.9 82 25.6 46 14.4 32 10 25 7.8 33 10.3 320 100 jansen budiono, achadiyani, dolvy girawan: effect of mangosteen pericarp extract on gastric mucosal damage induced by aspirin althea medical journal. 2016;3(3) 390 amj september 2016 meaning that erosion was less likely to occur in group ii than in group i. in other words, mangosteen pericarp extract possessed protective effects. in the current study, upon examination group ii demonstrated gastric mucosal damage with a score of 6. it was estimated that mangosteen pericarp extract could not preserve gastric mucosa integrity perfectly or mangosteen pericarp extract dosing was not optimal. moreover, aspirin and other nsaids may lead to mucosal damage by several mechanisms: endothelial effect causing ischemia, direct toxicity from ion trapping which inhibits oxidative phosphorylation, and interruption of prostaglandin synthesis which impairs mucosal defense and repair. ion trapping toxicity causes mitochondrial dysfunction as demonstrated from decreased stage-3 respiration, dehydrogenase activity, and transmembrane potential.7 mitochondrial dysfunction leads to the prolific generation of reactive oxygen species (ros) which in turn, causes cellular injury and increase opening of the permeability transition complex pores, eventually culminating in apoptosis.8 additionally, ros scavenging by other chemicals restores the mitochondrial respiration, dehydrogenase activity, and transmembrane potential, indicating restoration of mitochondrial function. these scavengers also prevent the activation of mitochondrial pathway of apoptosisby inhibiting caspase-9 and caspase-3 activities.7 besides, xanthones present in mangosteen pericarp extract possess very good antioxidant capabilities and thus, could act as free radical– scavenging systems.4,8 at least 50 distinct xanthones have been identified present in the mangosteen pericarp at higher concentrations than in the aril or edible portion of the fruit.9 diverse array of xanthone compounds open possibilities in search of the most potent xanthone. the present study was consistent with a study performed by nainwal et al.5 which showed that mangosteen pericarp extract displayed an antiulcerogenic effect at a dose of 500 mg/kg body weight. nainwal et al.5 suggested that the antiulcerogenic effects were associated with the cytoprotective activity caused by the increased synthesis of mucus and/or prostaglandins. previous animal studies demonstrated that vitamin c reduced gastric mucosal damage induced by aspirin.they argued that these effects were due to vitamin c antioxidant activity by mechanisms involving preservation of gastric microcirculation, attenuation of lipid peroxidation and release of proinflammatory cytokines. increased expression and activity of hemeoxygenase-1 (ho-1) played an important role in gastro-protection against nsaid by making cells more resistant to apoptotic death.10 furthermore, different explanations from several studies indicated there were numerous possible mechanisms by which mangosteen pericarp extract could reduce the incidence of gastric mucosal damage. further studies are needed to determine the mechanism of mangosteen pericarp extract in reducing gastric mucosal damage. the primary limitation of this study was measurement bias incurred when determining the gastric mucosal damage scores based on wattimena’s criteria. several studies used camera and image analyzer computer system to determine the gastric mucosal damage accurately and thus, could eliminate possible bias.5,10,11 further studies are recommended to use better parameters such as the lesion index for morphometric examination with aid of computer systems. in conclusion, rats pretreated with mangosteen pericarp extract exhibit less gastric mucosal damage, in experimentally aspirin-induced ulcer. table 2 modified table for relative risk calculation group erosion total %erosion (disease +) no erosion (disease -) n % n % ii (exposure +) 82 51.2 78 48.8 160 100 i (exposure -) 136 85 24 15 160 100 total 218 68,1 102 31,9 320 100 althea medical journal. 2016;3(3) 391 references 1. yuan y, padol it, hunt rh. peptic ulcer disease today. nat rev gastroenterol hepatol. 2006;3(2):80–9. 2. ramakrishnan k, salinas rc. peptic ulcer disease. am fam physician. 2007;76(7):1005–12. 3. jainu m, mohan kv, devi cs. gastroprotective effect of cissus quadrangularis extract in rats with experimentally induced ulcer. indian j med res. 2006;123(6):799–806. 4. obolskiy d, pischel i, siriwatanametanon n, heinrich m. garcinia mangostana l.: a phytochemical and pharmacological review. phytother res. 2009;23(8):1047– 65. 5. nainwal p, nanda d, kalra k, tripathi sm. antiulcerogenic effect on the ethanol extract of the fruits of garcinia mangostana on experimental gastric ulcer in rats. int j toxicol pharmacol res. 2010;2(1):6–9. 6. wattimena jr. l-hypoprotenemie experimentale chez le rat, explotation pharmacocinetique du modele. these doct´eur d´etat es sciences pharmacetiques. montpellier: faculte de pharmacie, universite montpellier; 1982. p. 17–23. 7. maity p, bindu s, dey s, goyal m, alam a, pal c, et al. indomethacin, a non-steroidal antiinflammatory drug, develops gastropathy by inducing reactive oxygen speciesmediated mitochondrial pathology and associated apoptosis in gastric mucosa: a novel role of mitochondrial aconitase oxidation. j biol chem. 2009;284(5):3058– 68. 8. kumar v, abbas ak, fausto n, aster jc. robbins & cotran pathologic basis of disease. 8th ed. philadelphia: elsevier health sciences; 2009. 9. gutierrez-orozco f, failla ml. biological activities and bioavailability of mangosteen xanthones: a critical review of the current evidence. nutrients. 2013;5(8):3163–83. 10. seleem hs, ghobashy ha, zolfakar as. effect of aspirin versus aspirin and vitamin c on gastric mucosa (fundus) of adult male albino rats. histological and morphometric study. egypt j histol. 2010;33(2):313–26. 11. wang z, hasegawa j, wang x, matsuda a, tokuda t, miura n, et al. protective effects of ginger against aspirin-induced gastric ulcers in rats. yonago acta medica. 2011;54(1):11–9. jansen budiono, achadiyani, dolvy girawan: effect of mangosteen pericarp extract on gastric mucosal damage induced by aspirin althea medical journal. 2016;3(4) 503 antibiotic conformity with culture results of hospitalized pneumonia patients in melati ward at dr. hasan sadikin general hospital bandung, indonesia randhi rinaldi,1 yana akhmad supriatna,2 truly sitorus,3 primal sudjana2 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: pneumonia is an infection with the highest mortality rate in indonesian hospitals. according to the american thoracic society and the infectious diseases society of america (ats/idsa), empirical use of antibiotics is still effective for pneumonia treatment. inappropriate use of antibiotics would cause negative effects such as prolonged hospitalization, a high cost of treatment, and increased antibioticresistant bacteria. the goal of this study was to clarify the empirical use of antibiotic conformity with a bacteria culture. methods: this study was conducted from august to october 2013 using a descriptive retrospective method based on 116 medical records of pneumonia patients hospitalized in melati ward, dr. hasan sadikin general hospital bandung during 2011–2012. the type of bacteria, conformity with antibiotics given to patients, and type of antibiotics were analyzed. the conformity of antibiotics was assessed based on the resistance test. if the results were sensitive, they would be put in the conforming group and in the non-conforming group if the results were resistant or intermediate. data was derived with descriptive statistics, using percentage and frequency distribution, illustrated in tables and figures. results: based on culture results and sensitivity of antibiotic empirical therapy given, 55.17% cases were conformed. the most widely used antibiotic group was third-generation cephalosporin (60.34%). the most common bacterias were klebsiella pneumonia (34.5%) and acinetobacter baumanni (13.8%). conclusions: most of the antibiotics given to pneumonia patients are still appropriate with results of the bacteria culture test and resistance test. [amj.2016;3(4):504–8] keywords: antibiotic, conforming group, nonconforming group, klebsiella pneuomonia, pneumonia correspondence: randhi rinaldi, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 812 1449 4374 email: randhirinaldi@gmail.com introduction pneumonia is the inflammation of the distal parenchyme lung from terminalis bronchioles; it also includes respiratory bronchiolus, which causes lung tissue consolidation and the filling of alveoli by the inflammation exudate and the fibrin.1 pneumonia is still a severe problem with high morbidity and mortality.2,3 there are a wide variety of bacteria that cause pneumonia, depending on how pneumonia is transmitted. pneumonia infections have the highest mortality rate in indonesian hospitals.4 antibiotics are used to treat pneumonia. around 80−90% of antibiotics are used as treatment and prophylaxis for infection in clinics and hospitals, contributing to antibiotic resistance and one of the causes of the high mortality rate.5,6 according to the guidelines from the american thoracic society and the infectious diseases society of america, empirical use of antibiotic is still effective to treat pneumonia.2 whenever the patient had been diagnosed of pneumonia, they have to be hospitalized to be given the appropriate antibiotic empirical therapy.7−9 the inappropriate use of antibiotics causes negative consequences such as prolonged hospitalization, a high cost of treatment, and increased antibiotic resistance in bacteria.10 therefore, the goal of this study was to althea medical journal. 2016;3(4) 504 amj december 2016 clarify the conformity results of antibiotics with the bacteria culture in hospitalized pneumonia patients in melati ward at dr. hasan sadikin general hospital, bandung from 2011–2012. methods this study was conducted during august– october 2013 and used a descriptive retrospective method. the population of the study was all medical records of pneumonia patients who were hospitalized in melati ward representing the internal medicine department at dr. hasan sadikin general hospital, bandung during 2011–2012. pneumonia was defined based on chest radiography proof of a new pulmonary infiltrate, and at least two of the following symptoms and signs. there were cough, pleuritic chest pain, shortness of breath, temperature >38ºc, and crackles on auscultation.10 medical records from this study subjects served as the secondary data. data was collected by used of the total sampling method. the samples were all subjects that had the complete data and all the variables. furthermore, the type of bacteria, their conformity with antibiotics given to the patients, and type of antibiotics were analyzed variables in this study. the inclusion criteria were medical records of hospitalized patients with a diagnosis of pneumonia that had gone through the sensitivity test culture and were given medicine as written in the medical records. while medical records with incomplete data were excluded. out of 478 medical records of pneumonia patients, only 116 medical records met the inclusion criteria. next, the conformity was grouped into a conforming and non-conforming group. the conformity of antibiotics was assessed based on the resistance test. if the results were sensitive, they would be put in the conforming group and in the non-conforming group if the results were resistant or intermediate. moreover, data was derived with descriptive statistics, using percentage and frequency calculations by the microsoft excel software (version 2010); the results of the study were illustrated in tables and figures. this study had been approved by the health research ethics committee, faculty of medicine, universitas padjadjaran, dr. hasan sadikin general hospital. results of the 116 patients who were given antibiotics, 55.17% were given the antibiotics that conformed with the bacteria culture test. the antibiotics that were appropriate with the gram-negative bacteria were 53.25%, while 59.46% were appropriate with gram-positive bacteria and 50% for the other bacteria (figure 1). the predominantly used antibiotic groups figure 1 bacteria distribution and resistance test of culture results in hospitalized pneumonia patients at melati ward in dr hasan sadikin hospital bandung 2011– 2012 althea medical journal. 2016;3(4) 505randhi rinaldi, yana akhmad supriatna, truly sitorus, primal sudjana: antibiotic conformity with culture results of hospitalized pneumonia patients in melati ward at dr. hasan sadikin general hospital bandung were third-generation cephalosporin in 70 patients (60.34%), followed by fluoroquinolone in 33 patients (28.45%). the antibiotic groups that were most appropriate were third-generation cephalosporin (51.43%), followed by fluoroquinolone (54.55%), based on the results of the resistance culture (table 1). the antibiotic was given due to the sign and symptom from patients that indicated pneumonia. the use of broad-spectrum antibiotics was still used as an empirical therapy before the culture test was performed, to determine the definitive therapy. furthermore, antibiotics given to the hospitalized pneumonia patients were ceftazidime 50/116 (43.1%), followed by levofloxacin 26/116 (22.4%), ceftriaxone 10/116 (8.6%), cefotaxim 9/116 (7.8%), ciprofloxacin and erythromicin 7/116 (6.0%) (figure 2). the culture results of hospitalized pneumonia patients showed that the predominant type of bacteria was gram table 1 antibiotic groups distribution and resistance of culture results in hospitalized pneumonia patients at melati ward in dr. hasan sadikin hospital bandung 2011–2012 antibiotic groups conforming non-conforming σ % n % n % third-generation cephalosporin 36 51.43 34 48.57 70 60.34 fluoroquinolone 18 54.55 15 45.45 33 28.45 macrolide 6 85.71 1 14.29 7 6.03 carbapenem 2 100.00 0 0.00 2 1.72 penicillin 0 0.00 1 100.00 1 0.86 fourth-generation cephalosporin 1 100.00 0 0.00 1 0.86 second-generation cephalosporin 0 0.00 1 100.00 1 0.86 aminoglycoside 1 100.00 0 0.00 1 0.86 σ 64 55.17 52 44.83 116 100 figure 2 distribution of antibiotic types used on hospitalized pneumonia patients at melati ward in dr hasan sadikin hospital bandung 2011–2012 althea medical journal. 2016;3(4) 506 amj december 2016 negative (-) bacteria (66.38%) (figure 3). the predominant types of bacteria were klebsiella pneumonia 40/116 (34.5%), followed by acinetobacter baumannii 16/116 (13.8%) (figure 4). discussions pneumonia can occur in the primary tissue of normal lung tissue or in abnormal lung tissue. it could also be an advanced phase of acute lower respiratory tract infection. the etiology of pneumonia depends on the type of pneumonia. bacteria characteristics that cause pneumonia depend on the patient’s context of exposure to pollution, immunity disturbance, and irrational use of antibiotics.1,11 based on the results of specimen cultures from this study, the predominant sources of gram-negative bacteria were klebsiella pneumonia, followed by acinetobacter baumannii (13.8%). only 6.0% were from the gram-positive bacteria staphylococcus aureus.12 a study about pneumonia prevalence in asian countries by chung et al.6 in 2011, also stated the predominant causes of pneumonia are acinetobacter spp (36.5%), pseudomonas aeruginosa (25.9%), and klebsiella pneumonia (16.8%), all of which are gram-negative bacteria; only 12.2% is caused by the grampositive bacteria staphylococcus aureus. according to the 2007 guidelines of the figure 3 bacteria distribution on hospitalized pneumonia patients at melati ward in dr hasan sadikin hospital bandung 2011–2012 figure 4 distribution of pneumonia bacteria type in hospitalized pneumonia patients at melati ward in dr hasan sadikin hospital bandung 2011–2012 althea medical journal. 2016;3(4) 507 infectious disease society of taiwan on the use of antibiotics for pneumonia, infections of klebsiella pneumonia, sterptococcus pneumoniae, pseudomonas aeruginosa and acinetobacter spp are best treated with thirdgeneration cephalosporin (or fluoroquinolone as the alternative).13 in this study, 70 out of 116 patients (60.34%) were given thirdgeneration cephalosporin antibiotics, and 33 out of 116 (28.45%) patients were given fluoroquinolone. the results showed that the empirical use of antibiotics on the pneumonia patients supported the guidelines from the infectious disease society of taiwan.13 it is important to consider, giving ceftazidime for the empirical treatment of hospitalized pneumonia patients is equivalent in term of efficacy and is well tolerated. nevertheless, the use of fluroquinolone needs a tighter supervision to prevent the complication that might happen or the treatment can be substituted with tigecycline as an alternative.14 the empirical antibiotic therapy should be considered with the condition of the patients, monitoring of microbial pathogens and bacterial resistance are possible things to avoid bacterial resistance.15 this study had several limitations. first, data were obtained only from one hospital; this might not reflect the overall antibiotics conformity. also, there were some missing data from the medical records. in conclusion, most of the empirical use of antibiotics are still appropriate. the most given antibiotics are third-generation cephalosporin and fluoroquinolone group, which are ceftazidime and levofloxacin. based on this study, the prominent bacteria that caused pneumonia was gram negative (-) bacteria, which were klebsiella pneumonia and acinetonacter baumannii. therefore , ceftazidime and levofloxacin can still be used as the empirical antibiotics in dr. hasan sadikin general hospital. references 1. mandell la, wunderink r. pneumonia. in: longo dl, kasper dl, jameson jl, fauci as, hausen sl, loscalzo j. harrison’s principles of internal medicine. 18th ed. new york: mcgraw-hill; 2008. 2. kett dh, cano e, quartin aa, mangino je, zervos mj, peyrani p, et al. implementation of guidelines for management of possible multidrug-resistant pneumonia in intensive care: an observational, multicentre cohort study. lancet infect dis. 2011;11(3):181–9. 3. jennie jde, sumit m, yan maj, thomas m. long-term morbidity and mortality after hospitalization with community-acquired pneumonia: a population-based cohort study. medicine. 2008;87(6):329. 4. ministry of health republic indonesia. indonesia health profile 2010. in: brahim r, sitohang v, zulkarnaen i, editors. 2011 health status situation. jakarta: ministry of health republic indonesia; 2011. p.40-1 5. bisht rka, singh r, mittal p. antibiotic resistance-a global issue of concern. asian j pharm clin. 2009;2(2):34–9. 6. chung dr, kim sh, thamlikitkul v, huang sg, wang h, so tm, et al. high prevalence of multidrug-resistant nonfermenters in hospital-acquired pneumonia in asia. am j respir crit care med. 2011;184(12):1409– 17. 7. peleg ay, cooper hd. hospital-acquired infections due to gram-negative bacteria. n engl j med. 2010;362(19):1804–13. 8. brito v, niederman ms. healthcareassociated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. curr opin infect dis. 2009;22(3):316–25. 9. siegel re. emerging gram-negative antibiotic resistance: daunting challenges, declining sensitivities, and dire consequences. j am assoc respir care. 2008;53(4):471–9. 10. ott sr, hauptmeier bm, ernen c, lepper pm, nüesch e, pletz mw, et al. treatment failure in pneumonia: impact of antibiotic treatment and cost analysis. eur respir j. 2012;39(3):611–8. 11. brooks gf, carroll kc, butel js, morse sa. jawetz, melnick, & adelberg’s medical biology. 24th ed. new york: mcgraw-hill medical, 2007. p.223−44. 12. chan yj, chang sc, chang fy, chen py, chen yc, chuang yc, et al. guidelines on antimicrobial therapy of pneumonia in adults in taiwan, revised 2006. j microbiol immunol infect. 2007;40:279–83. 13. carratala j, mykietiuk a, fernandez-sabe n, suarez c, dorca j, verdaguer r. health care–associated pneumonia requiring hospital admission. arch intern med. 2007;167(13):1393–9. 14. tanaseanu c, milutinovic s, calistru pi, strausz j, zolubas m, chernyak v, et al. efficacy and safety of tigecycline versus levofloxacin for community-acquired pneumonia. bmc pulm med. 2009;9(1):44. randhi rinaldi, yana akhmad supriatna, truly sitorus, primal sudjana: antibiotic conformity with culture results of hospitalized pneumonia patients in melati ward at dr. hasan sadikin general hospital bandung althea medical journal. 2016;3(4) 508 amj december 2016 15. hashemian smr, tabarsi p, mohammad mm, marjan m, shamei m, nadji sa, et al. a prospective study of antibiotic susceptibility in patients with ventilator associated pneumonia. anaesth pain & intensive care. 2012;16(1):31–7. althea medical journal. 2016;3(4) 595 health belief model theory application on voluntary counseling and testing among homosexual men in bandung greater area argya nareswara,1 chrysanti murad,2 irvan afriandi3 1faculty of medicine universitas padjadjaran, 2department of microbiology faculty of medicine universitas padjadjaran, 3department of public health faculty of medicine universitas padjadjaran abstract background: the number of human immunodeficiency virus (hiv) cases is high and is constantly increasing. homosexual men as a transmission niche is not only significant in terms of numbers, but also in natural aspects of anal sex, tropism of hiv-1, and high-risk behavior. voluntary counseling and testing (vct) is important for accelerating diagnosis and management plan; yet the uptake on high-risk population in indonesia is low. a behavior-reasoning theory, health belief model (hbm), attempts to explain whether or not individuals engage in certain health behavior. this study tries to assess participation rate of vct, to portray hbm variables perception, and to depict significance of hbm variables towards vct uptake or vct intention. methods: this study was conducted in october-november 2014 using cross-sectional design; 127 respondents were gathered according to respondent driven snowball sampling. this study used an internet-based questionnaire derived from champion’s 1984 mammogram hbm questionnaire. privacy and compensation were obtained. the chi square test and logistic regression of hbm variables were done. results: the vct uptake was low (15.7%). certain sexual experience and commitment were significant (commitment to men p=0.027, oral sex experience with men p=0.001, anal sex experience with men p=0.038). chi square test revealed significance on perceived susceptibility, perceived benefit, and cues to action. conclusions: uptake of vct is considerably low compared with total high risk population and other similar studies. personal susceptibility to hiv/aids is recommended to be emphasized; while vct benefit and cues to action in young homosexual men communities are better encouraged. [amj.2016;3(4):595–604] keywords: health belief model, hiv, homosexual, vct correspondence: argya nareswara, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6289656067175 email: rgynrswr@gmail.com introduction since 2014, infection of human immunodeficiency virus (hiv) has been a global problem that has not been solved. with 30.000.000 positive individuals globally and 2.500.000 global case incidence per year, the number of hiv-positive individual is increasing day by day.1 in indonesia, the prevalence of hiv infection has reached 0.2% among general population. in addition, cumulative hiv cases reported until june 2012 reached 86.762 cases, whereas cumulative acquired immunodeficiency syndrome (aids) cases reported from 1987 until june 2012 was 32.103 cases.2,3 homosexual men are considered more susceptible to be infected by hiv because of hiv-1 tropism in large intestine endothelial cells, low condom usage, and high promiscuity which make the odds of being infected by hiv 18.7 times higher compared with those in heteronormative adult population in asia.1,4-8 with the lowest estimation of 2.2% proportion from the total male population, men who have sex with men (msm) is hiv-transmitting niche that is quite big.9 in indonesia, for instance, hiv/aids is positive in around 2.1 % msm in bandung, 5.6% in surabaya, and 8.1 % in jakarta.10 voluntary counseling and testing (vct) is a serial of rapid test, education, and counseling regarding hiv/aids intended to helping individuals to know their hiv status, to understand the behavior they might althea medical journal. 2016;3(4) 596 amj december 2016 have to adopt in the future, and to motivate them in defending seronegative status; or at least avoiding the progression of diseases for seropositive individuals. regardless of psychological benefit and acceleration of management plan, vct has not covered up to 70% of high-risk population, including straight-acting msm, transgender, and sex worker.11 msm health seeking behavior percentage also only reaches 42.6%; regardless hiv/aids knowledge among indonesian msm categorized as quite good.10 based on health belief model (hbm), the tendency for an individual to do certain health behavior is a result from six perceptions conflicting inside the individual’s mind. those perceptions are: 1) perceived severity, how individuals see certain disease could give irresistible harm; 2) perceived susceptibility, how individuals see themselves being prone to acquire the disease; 3) perceived benefit, how individuals see benefit from adopting the behavior; 4) perceived barrier, how individuals oversee particular reasons to not doing so or foreseen harms that may exist from adapting the behavior ; 5) cues to action, how certain events stimulate individuals’ motivation; and 6) self efficacy, on how individuals must have a belief that they will be able to adopt a behavior before they try to. this study attempts to reveal vct uptake on homosexual individuals in bandung; their intention in undergoing vct on individual who have not undertaken vct. in addition, it is also intended to picture the health belief model variables as well as the association between the hbm variables over the intention in undertaking the vct. methods this study was an analytic study with crosssectional approach. it was carried out from october to november 2014 by using internetbased questionnaire. ethical clearance had been reviewed by health research ethics committee of universitas padjadjaran, issued on 6 october 2014 (no. 0114070642). permission had been secured from all participating respondents. confidentiality was maintained during and after the study. this study was performed in bandung greater area (kota bandung, kota cimahi, kabupaten bandung, kabupaten bandung barat, kabupaten sumedang). bandung greater area was chosen due to 1) easy access towards vct services, 2) availability of hiv epidemiology data, particularly on msm population, 3) logistical advantages for researcher, 4) availability of good internet for conducting online-based questionnaire filling. sample size was determined by the rule of thumb analysis; how it was estimated by the amount of variables. it was considered that 20 respondents were enough to represent one variable, and it was estimated that required sample size was 120. sampling size under regression logistic procedure was also conducted yet it was assumptive, since there was no data concerning the proportion of homosexual population in indonesia. the sampling procedure used was respondent-driven snowball sampling targeted on self-declared ‘men who love men’ rather than “homosexual men”. it was done in order to prevent possible technical conflicts due to unclear limitations between homosexuals and bisexuals. rds was used due to wide-spread stigma against homosexuality in indonesia. the sampling procedure used several seeds (respondent contributing other respondent with 1$ incentive per respondent given) to increase the trust between respondents and researcher. gay finder mobile applications, such as grindr and jack’d, were also used. personal information and health belief model perception were collected by onlinebased form to maintain the privacy of respondents. questionnaire was composed in bahasa, and was derived from champion’s questionnaire for mammograms. the questionnaire had been validated with statistic processor (cronbach alpha for perceived seriousness: 0.731; perceived susceptibility: 0.739; perceived benefit 0.759; perceived barrier 0,804, cues to action 0.795; and self efficacy 0.700). the questionnaire consisted of 32 questions (6 questions for each perception, with the exception of 4 questions for perceived susceptibility and self efficacy). perceptions under health belief model were illustrated by likert’s scale; ranging from strongly agree to strongly disagree; and were classified into two groups; 1) good, if the score passed the means from well-distributed data, or the median from not well-distributed data, and 2) bad, if perception score was below the means or the median. completeness of inspections was done by investigator before statistical analysis. chisquare test was used in order to portray the association between hbm perceptions and socio-demographic characteristics (education background and occupation, abstinence status, history of relationship, and engagement of sexual activity) against respondents’ althea medical journal. 2016;3(4) 597argya nareswara, chrysanti murad, irvan afriandi: health belief model theory application on voluntary counseling and testing among homosexual men in bandung greater area willingness to undertake the vct. logistic regression later was used to determine the most influential factor. results initial respondents had amounted to 143 individuals, however eventually only 127 (88.8%) of the respondents completed the online questionnaires. thirteen respondents were excluded from the study, 4 respondents were below 18 years old, 2 respondents had different gender construct (transgender), and 7 respondents filled in the questionnaire from 2 or more different seeds]. there were 27 first degree respondents, 19 second degree respondents, and 81 third degree respondents. among them, 99 (77.9%) respondents were university student, and 15 of these were studying in health-related faculty. private employee amounted to 14 respondents (11%), while artist and self-employed respondents amounted to 3 respondents (2.3%). the rests consisted of the small portion of governments’ worker, university lecturer, prostitute, and engineer. the total population means age was 21.13 + 2.254 years. most of the respondents, 87 respondents (68.5%), had finished their general high school, while 5 respondents (3.9%) had finished their vocational high school degree. only 1 (0.8%) respondent had the background of junior high school, while 20 respondents (15.7%) had finished their bachelor degree and 8 people (6.3%) had finished their diploma degree. the rest 6 respondents (4.7%) had finished their postgraduate education. ninety one respondents (71.7%) had engaged in same-sex sexual activity, with oral sex as the most common activity (85 persons or 66.9%) . anal sex was experienced by 58 (45.7%) respondents. the history of same-sex commitment was lower compared with oral sex engagement, with only 80 respondents (63.0%) engaging into it. heteronormative relationship and sexual engagement were observed in the small proportion of respondent. heteronormative commitment was reported by 62 respondents (48.8%), while oral sex with women was experienced by 15 respondents (11.8%), and genital sex or anal sex was reported by 9 respondents (9.1%). uptake of vct was positive only on 20 respondents (15.7%), while 120 (84.3%) respondents had not undertaken the vct serial. the vct uptake was commonly higher in sexually active group of homosexuals, with 90% (18 out of 20) respondents who had undertaken the vct originating from this group. the intention for undertaking vct was taken from the population who had not undertaken the vct. sixty eight (53.5%) out of 107 respondents who had not undertaken table 1 characteristics of vct uptake stratified by abstinence status abstinence status no vct uptake (%) positive vct uptake (%) total (%)no intention for vct uptake positive intention for vct uptake have been engaged in same sex activity. 19 (15%) 54 (42.5%) 18 (14.2 %) 91 (71.7 %) have not been engaged in same sex activity; and planned to do so in the future. 2 (1.6 %) 5 (3.9 %) 0 7 (5.5 %) and planned not to do so in the future. 3 (2.4 %) 2 (1.6%) 0 5 (3.9 %) and have been thinking about doing it in the future. 6 (4.7 %) 3 (2.4 %) 0 9 (7.1 %) and have never been thinking about doing it in the future. 9 (7.1%) 4 (3.1 %) 2 (1.6 %) 15 (11.8 %) total 39 (30.7 %) 68 (53.5 %) 20 (15.7 %) 127(100 %) althea medical journal. 2016;3(4) 598 amj december 2016 vct had the intention to undertake the vct. positive intention for vct uptake was noted in every group; 74.0% (54 out of 73) on sexually active group, 71.4% (5 out of 7) on group who planned to engage sexual activity in the future, 40% (2 out of 5) on group who planned not to engage in sexual activity in the future, 33% (3 out of 9) on group who had been thinking about engaging in sexual activity in the future, and 26% (4 out of 15) from group who had not been thinking about engaging in sexual activity. over seventy percent of the respondents believed that hiv/aids would inflict irresistible pain, harmed onto relationship with partner, and harmed onto their career. the idea of hiv/aids that is hard to be cured was also perceived well on above seventy percent respondents. perceived susceptibility scores were not well distributed (kolmogorovsmirnov value=0.021). the median for perceived severity for total respondent was 23 and 24 for the respondents who had not committed to do the vct. the means was 23.23 + 3.971 for the total population and 23.64 + 3.689 for those who had not committed to do the vct. there were 41 respondents with high level of perception and 66 respondents with low level of perception. the assumption on susceptibility due to sexual orientation, perception of inability to control behavior, and fear of getting infected unconsciously were observed on over half of the respondents. perceived susceptibility scores were not well distributed (kolmogorovsmirnov value=0.001). median for perceived susceptibility for total respondent was 13 for both groups; while the means was 13.08 + 2.311 for the total population and 13.04 + 2.343 for those who had not committed to do the vct. there were 49 respondents with high level of perception, and 58 respondents with low level of perception. personal emotional benefit and relieve, trust from partner, and sexual health awareness were also discovered in majority (70%) of the respondents as personal benefit of undertaking the vct. perceived benefit scores were well-distributed (kolmogorovsmirnov value=0.106). the means for perceived benefit for the total respondent was 23.15 + 3.326 and 23.00+3.232 for the respondents who had not committed to do the vct. additionally, the median was 23.00 for the total population and 23.00 for the respondents who had not committed to do the table 2 distribution of perceived severity and perceived susceptibility in the total population statements strongly agree agree do not know disagree strongly disagree perceived severity fear of discussing hiv/aids 19 (15) 37 (29.1) 47 (37.0) 15 (11.8) 9 (7.1) pain experienced when acquired with hiv/aids 36 (28.3) 65 (51.2) 12 (9.4) 11 (8.7) 3 (2.4) damage on relationship with partner 42 (33.1) 54 (42.5) 18 (14.2) 11 (8.7) 2 (1.6) damage on career 47 (37) 45 (35.4) 11 (8.7) 18 (14.2) 6 (4.7) hard to be cured 44 (34.6) 61 (48.0) 9 (7.1) 12 (9.4) 1 (0.8) assumption that information regarding hiv/aids are very important 59 (46.5) 41 (32.3) 8 (6.3) 14 (11.0) 5 (3.9) perceived susceptibility assumption of susceptibility due to sexual orientation 17 (13.4) 53 (41.7) 29 (22.8) 18 (14.2) 10 (7.9) fear of unconsciously taking high-risk behavior 30 (23.6) 68 (53.5) 21 (16.5) 6 (4.7) 2 (1.6) inability to control behavior 5 (39) 26 (20.5) 39 (30.7) 46 (36.2) 11 (8.7) assumption of hiv/aids infection inclusivity 7 (5.5) 34 (26.8) 47 (37.) 32 (25.2) 7 (5.5) althea medical journal. 2016;3(4) 599 vct. over half of the respondents (n=61) was categorized as having high perception; while the rest, 46 respondents were categorized as having low perception. barriers to undertaking the vct were commonly observed. feeling of shame and laziness were observed in over 40% of the respondents. additionally, feeling of fear getting mocked by others and fear of being gossiped by health care provider were observed in over half of the respondents. perceived barrier scores were not well distributed (kolmogorovsmirnov value=0.033). the median for perceived barrier of the total respondents and for the respondents who had not committed to do the vct was 17; while the means was 17.29 + 4.053 for the total population and 16.96 + 3.843 for those who had not committed to do the vct. the scores of perceived barrier had been converted into positive measurement as other variables for easiness in handling data. there were 45 respondents with high perception of perceived barrier (having little or no barrier) and 62 respondents with low perception of perceived barrier (having a lot of barrier). partner’s hiv status and partner request were more appreciated (both observed in over 60% of the respondents) as a cue to action compared with family hiv status, family support, and public figure with hiv status (observed only around 50%, 30%, and 20% within each of the respondent). cues to action scores were not well distributed (kolmogorovsmirnov value=0.007). the median for perceived severity for the total respondent and for the respondent who had not committed to do the vct was 21; while the means was 20.59 + 3.878 for the total population and 20.89 + 3.596 for those who had not committed to do the vct. there are 48 respondents with low level of perception and 59 respondents with high level of perception. trust to health care provider professionalism and self-trust to finish the whole vct series were commonly observed in around 50% of the respondents. on the contrary, self-trust in deciding to undertake table 3 distribution of perceived benefit and perceived barrier in total population. statements strongly agree agree donot know disagree strongly disagree perceived benefit relieved feeling when knowing hiv status 29 (22.8) 69 (48.8) 23 (18.1) 10 (7.9) 3 (2.4) personal benefit from knowing hiv status 26 (20.5) 70 (55.1) 24 (18.9) 7 (5.5) 0 peer support on vct uptake 18 (14.2) 53 (41.7) 47 (37.0) 8 (6.3) 1 (0.8) partner’s trust 30 (23.6) 62 (48.8) 28 (22.0) 6 (4.7) 1 (0.8) emotional state (stability, no guilt) difference from knowing hiv status 15 (11.8) 76 (59.8) 36 (28.3) 0 0 reproductive health awareness 30 (23.6) 78 (61.4) 17 (13.4) 2 (1.6) 0 perceived barrier no shame for starting vct uptake 4 (19.7) 25 (19.7) 38 (29.9) 44 (34. 6) 16(12.6) no financial insecurity 10 (7.9) 26 (20.5) 50 (39.4) 37 (29.1) 4 (3.1) no fear of gossip come from others if somebody knew about vct history 3 (2.4) 22 (17.3) 36 (28.3) 50 (39.4) 16 (12.6) no laziness for vct uptake 4 (3.1) 24 (18.9) 47 (37.0) 44 (34.6) 8 (6.3) belief on counselor integrity that would not gossiping about 10 (7.9) 20 (15.7) 36 (28.3) 48 (37.8) 13 (10.2) no assumption of time-waste 2 (1.6) 11 (8.7) 44 (34.6) 57 (44. 9) 13 (10.2) argya nareswara, chrysanti murad, irvan afriandi: health belief model theory application on voluntary counseling and testing among homosexual men in bandung greater area althea medical journal. 2016;3(4) 600 amj december 2016 the vct or not was only observed in around 40% of the respondents. self-efficacy mean scores were not well distributed (kolmogorovsmirnov value=0.000). the median for perceived severity on the total respondents and the respondents who had not committed to do the vct was 14; while the means was 13.72 +2.031 for the total population and 13.82 + 1.994 for those who had not committed to do the vct. there were 70 respondents with low level of self-efficacy and 37 respondents with high level of selfefficacy. significance of the vct intention was shown from several socio-demographic status and sexual activity engagement. age only showed its significance on the age of 19 when it was compared with the age of 18 as the reference value, without any significance on further older age. education background and occupation did not show any significance. significances were revealed on history of same-sex relationship [or=2.924, 95% ci (1.278, 6.688); p=0.010], history of oral sex with same-sex partner [or=4.206, 95% ci (1.806, 9.794); p=0.001], and history of anal sex with same-sex partner [or=2.391, 95% ci (1.038, 5.504); p=0.038]. no significance was observed from any heteronormative commitment or sexual activity. chi-square analysis also portrayed the significance of cues to action when adjusted with the vct intention [or=2.531, 95% ci (1.104, 5.806); p value=0.026]. significance was also shown by perceived susceptibility and perceived benefit, with [or=3.224, 95% ci (1.384, 7.531); p value=0.006] and [or 3.345, 95% ci (1.472, 7.605); p value=0.003] respectively. perceived barrier, self-efficacy, and perceived severity did not depict significant statistic association with the intention to undertake the vct. only perceived susceptibility showed significance when tested using logistic regression [exp(b)=3.223, ci 95% (1.350, 7.691); p=0.008)]. discussion the use of online-based questionnaire was preferred due to recommendation issued by health ethic research committee of universitas padjadjaran. in addition, the preference was also because several crime cases done in homosexual community weeks before ethical clearance had been issued. nevertheless, the use of online-based questionnaire had been implemented to hidden and privacy-needing community, such as what had been done in madrid, spain.12 the uptake of vct in this study population table 4 distribution of cues to action and self efficacy in total population statements strongly agree agree do not know disagree strongly disagree cues to action motivated by family request 10 (7.9) 36 (28.3) 40 (31.5) 35 (27.6) 6 (4.7) motivated by partner request 17 (13.4) 56 (44.1) 29 (22.8) 18 (14.2) 7 (5.5) motivated by family with hiv status 17 (13.4) 54 (42.5) 36 (28.3) 15 (11.8) 5 (3.9) motivated by partner with hiv status 50 (39.4) 57 (44.9) 11 (8.7) 6 (4.7) 3 (2.4) motivated by sudden increase of hiv cases 24 (18.9) 56 (44.1) 32 (25.2) 9 (7.1) 6 (4.7) motivated by public figure’s/ role model’s hiv status 4 (3.1) 25 (19.7) 51 (40.2) 32 (25.2) 15 (11.8) self-efficacy bravery to uptake vct 22 (17.3) 33 (26.0) 51 (40.2) 14 (11.0) 7 (5.5) trust on other actors on vct 13 (10.2) 62 (48.8) 43 (33.9) 7 (5.5) 2 (1.6) trust that vct doesn’t intimidate self-past 6 (4.7) 39 (30.7) 54 (42.5) 23 (18.1) 5 (3.9) self-trust to commit and to be able to finish vct until the end. 13 (10.2) 58 (45.7) 46 (36.2) 10 (7.9) 0 althea medical journal. 2016;3(4) 601 was low, compared with unaids statement. that coverage was still lacking, coveredonly up to 30% of the total high risk population.11 however, this number was taken from all participants, regardless their sexual experience. if vct uptake was analyzed only from the population who had experienced sex, which we shifted the population from homosexual onto msms, the proportion would be 19.78%. yet even if it was higher, it was still lower compared with the study conducted by van griensvenet al.10 in indonesia stating that the vct coverage towards msm reached 31.9%. in the other hand, it is considered higher if we compared with the study conducted by pisaniet et al.4 in jakarta, stating that less table 5 willingness for having vct among homosexuals who have not undertaken¬ vct versus socio-demographic variables, bandung, 2014 (n=107) variable willingness to vct crude or 95% ci yes no age 18** 4 5 1.00 19 13 2 8.125 (1.115, 59.212)* 20 16 15 1.333 (0.300, 5.926) 21 19 6 3.958 (0.796, 19.674) 22 11 3 4.583 (0.733, 28.646) over 22 5 8 0.781 (0.139, 4.387) educational status have not finished tertiary education ** 54 27 1.00 have finished tertiary education 14 12 0.583 (0.247, 1.433) history of partnership with men no** 18 20 1.00 yes 50 19 2.924 (1.278, 6.688)* history of oral sex with men no** 16 22 1.00 yes 52 17 4.206 (1.806, 9.794)* history of anal sex with men no** 32 27 1.00 yes 34 12 2.391 (1.038, 5.504)* history of partnership with women no** 30 19 1.00 yes 38 20 1.203 (0.546, 2.650) history of oral sex with women no** 60 33 1.00 yes 8 6 0.733 (0.234, 2.294) history of genital/anal sex with women no** 62 36 1.00 yes 6 3 1.161 (0.274, 4.928) note: *=significance with p value <=0.05 **=reference category argya nareswara, chrysanti murad, irvan afriandi: health belief model theory application on voluntary counseling and testing among homosexual men in bandung greater area althea medical journal. 2016;3(4) 602 amj december 2016 than 3% of any msm group had undertaken vct regardless their exposure onto health promotion campaign. however, 15.8% of the total homosexual population – or even 19.78% for high risk msm –was considerably very low if we compared with the national strategy 2010-2014, since it was targeted to cover 56.0% high risk msm in 2013.13 it was also lower compared with the study conducted by chariyalertsaket al.8 in northern thailand, where vct uptake reached 55.9% coverage on the total msm communities. compared with other study that targeted heteronormative men, this number is still lower; for example, compared with the study conducted by kabiru et al.14 in kenya (19%), and the study conducted by bwambale et al.15 in uganda (23.3%). studies about health belief model variables against vct, which extensively conducted in africa and other developing countries, rarely touched homosexual men; while the study about homosexual reproductive health that extensively conducted in developed countries with low stigma regarding homosexuality rarely analyzed the decisionmaking psychology and frequently ended on descriptive statistic about health-seeking behavior. this study gave deeper analysis on it, thus allowed us to see hbm variables on these vulnerable group. perceived severity was observed insignificant, different from the study conducted by abebe et al.16 targeting high school students in ethiopia. yet on the other hand, perceived severity characteristics were remarkably good. perceived barrier also revealed significant results on the study conducted by abebe et al.16, which possibly caused by difference stigma and epidemiology of hiv between sub-saharan africa and south east asia; with the addition of different characteristic from homosexual and heteronormative samples. perceived susceptibility was observed significantly positive, in contrast with the study conducted by abebeet al.16 which discovered significantly negative. in the other hand, perceived susceptibility is also positively significant on the study conducted by moges et al.17 regarding the vct uptake on pregnant table 6 willingness for having vct among homosexuals who have not undertaken the vct versus hbm variables, bandung, 2014 (n=107) variable willingness to vct crude or 95% ci adjusted or 95% ci yes no perceived severity low** 40 26 1.00 1.00 high 28 13 1.400 (0.615, 3.187) 1.146 (0.441, 2.978) perceived susceptibility low** 30 28 1.00 1.00 high 38 11 3.224 (1.384, 7.513)* 2.786 (1.112, 6.975)* perceived benefit low** 22 24 1.00 1.00 high 46 15 3.345 (1.472, 7.605)* 2.322 (0.927, 5.817) perceived barrier low** 37 25 1.00 1.00 high 31 14 1.496 (0.666, 3.363) 1.719 (0.679, 4.353) cues to action low** 32 27 1.00 1.00 high 36 12 2.531 (1.104, 5.806)* 2.196 (0.862, 5.546) self-efficacy low** 41 29 1.00 1.00 high 27 10 1.910 (0.802, 4.547) 1.185 (0.445, 3.158) note: *=significance with p value <=0.05 **=reference category althea medical journal. 2016;3(4) 603 women. qualitative study is needed to portray high risk population’s perceived susceptibility, other factors that probably interfere perceived susceptibility, and psychological defense mechanisms of being susceptible. perceived benefit was discovered significantly positive, in line with the study conducted by abebe et al.16 on high school students and the study conducted by mogeset al.17 on pregnant women. perceived barrier in this study was different compared with other study, which in this study, perceived barrier was a score of the total perception regarding all barrier. in other study, every single barrier was tested against intention of vct uptake thus made this variable incomparable. cues to action in this study is also incomparable with other study extensively done in africa with different hiv-aids epidemiology. this might give different perception of getting infected or died by hiv. deeper studies that could differentiate hiv perception on region with higher and lower death rate might be needed to reveal whether cues to action from these different regions could be comparable. self-efficacy was observed insignificance, in contrast with the study conducted by berendes et al.18 on heterosexual community in malawi. not only that, berendes et al.18 even proved that self-efficacy was significant on population who had previous vct uptake. in the other hand, study conducted by berendes et al.18 in malawi was exclusively discussing self-efficacy as independent variables, not as a part of hbm variables. this difference might be caused by more number of question berendes et al.18 offered, and wider range of hiv/aids preventive measurements involved (vct was included). similar difference was found on the study conducted by andrinapulous et al. in jamaica.19 in the end, the difference of self-efficacy on homosexual population and heteronormative population needed to be analyzed deeper. the limitation of this study concerns about age variability among respondents. this study revealed high number of data regarding young age homosexuals; and mostly university students homosexual. it was considered as normal consequences of respondent driven snowball sampling, and most of the seeds contributing in this study were university students. it strengthened the results of this towards the needs of young homosexuals who were discovered active sexually to undertake vct as emerging subgroup of homosexual as high risk population. even so, this study might not represent the whole homosexual community. for instance, long term relationship which is possibly common on older homosexual, could strengthen cues to action due to more intense compassion coming from partner. on the other hand, it also might lessen compromise on high risk behavior due to trust onto partner. additionally, it might lessen compromise on high risk behavior such as in heteronormative marriage, and might interfere with perceived susceptibility. the problem is not only coming from hbm variables, but also from the hiv epidemiology point of view. newly diagnosed homosexuals was increased on men older than 34 years old but not in younger men was revealed in amsterdam.20 engagement of this new trend was not achieved in this study, and might become the cause of insignificancy of age group, occupation, and educational background. this study also needs improvements to be implemented in the future. higher sampling seeds variability is recommended. history of using condoms, number of previous sex partner, swallowing sperm from partner, and other non-sexual hiv high risk behavior such as intravenous drugs, piercing, and tattoo history need to be noted down to strengthen the study history of first sexual experience also needs to be analyzed and might explain anomaly on age significance on this study. from the above mentioned explanation, it can be concluded that vct uptake was low on homosexual community in bandung, with uptake rates of 15.74%. intentions to undertake vct were observed on 68 respondents, or 63.55% among those who had not undertaken vct. there were high engagement on same-sex sexual activities and even engagement of same sex sexual activities were higher compared to engagement onto same-sex relationship. perceived susceptibility is significance on both chi square and logistic regression test, while perceived benefit and cues to action were significance on chi square test. based on our findings, perceived susceptibility strengthening in advocating vct coverage was recommended, so were with personal benefit encouragement, and opportunity taking in every cue. references 1. beyrer c, baral sd, griensven fv, goodreau sm, chariyalertsak s, wirtz al, et al.. global epidemiology of hiv infection in men who have sex with men. lancet. argya nareswara, chrysanti murad, irvan afriandi: health belief model theory application on voluntary counseling and testing among homosexual men in bandung greater area althea medical journal. 2016;3(4) 604 amj december 2016 2012;380(9839):367–77. 2. irvan afriandi, tjandra yoga aditama, dyah mustikawati, martiani oktavia, bachti alisjahbana, pandji riono. hiv and injecting drug use in indonesia: epidemiology and national response. acta med indones. 2009;41(suppl1):75–8. 3. tri paryati, ardini s. raksanegara, irvan afriandi. factors influencing stigmatization and discrimination of plha (people living with hiv/aids) among health workers : literature review. pustaka unpad [online journal] 2012. 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pregnant women attending antenatal clinics in northwestern ethiopia: a health belief model approach. ethiop j health sci. 2011;21(suppl 1):107–15. 18. berendes s, rimal rn. addressing the slow uptake of hiv testing in malawi: the role of stigma, self-efficacy, and knowledge in the malawi bridge project. j assoc nurses aids care. 2011;22(3):215–28 19. andrinopoulos k, kerrigan d, figueroa jp, reese r, ellen jm. hiv coping self efficacy: a key to understanding stigma and hiv test acceptance among incarcerated men in jamaica. aids care. 2010;22(3):339-47. 20. hamers ff, downs am. the changing face of the hiv epidemic in western europe: what are the implications for public health policies?. lancet. 2004;364(9428):83–94. althea medical journal. 2016;3(4) 655 profile and behaviour of mother as factor of increasing diarrhea incidence children under five at jatinangor district in 2013 rahayu widhyasti,1 nita arisanti,2 ina rosalina3 1faculty of medicine universitas padjadjaran, 2department of public health faculty of medicine, universitas padjadjaran, 3department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital bandung abstract background: in 2012, data from health center of jatinangor district showed nearly 50% of diarrhea cases occured in children under five at sayang village and cilayung village. diarrhea cannot be separated from several factors that influence it, thus to reduce the incidence rate of diarrhea needs description of factors that affect diarrhea in children so that prevention can be done maximally. objective of this study was to describe profile and behavior of mother as one factor of increasing diarrhea incidence in children under five at jatinangor. methods: this study was descriptive with cross-sectional design conducted at sayang village and cilayung village in october–november 2013. the respondents of this study were 102 mothers who have infants aged 0–59 months thorough cluster sampling methods. respondent will be interviewed and given validated questionnaire. results: the result showed that 57.8% of mother aged 25–35 years, mostly graduated from junior high education (41.2%), and 81.4% as a housewife. most of diarrhea occurred in children under 2 years and female. there were 73.5% mother who exclusively breastfed, 94.1% have good behavior of clean water usage, 61.8% with good hand washing behavior, and 60.8% respondents utilized healthy latrine. conclusions: this study showed good results in behaviour of exclusive breastfeeding, behavior of clean water usage, behaviour of hand washing with clean and water flow, and behaviour of healthy latrine usage. other factors might be contributed to increasing diarrhea incidence. [amj.2016;3(4):655–9] keywords: children under five, diarrhea incidence, maternal factor correspondence: rahayu widhyasti, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87821403330 email: rahayu.widhyasti@gmail.com introduction nowadays, in the globalization era, diarrhea becomes one of the main factor in child mortality. the incidence of diarrhea has been recorded as the highest mortality level and contributed to higher morbidity rate in indonesia. in developing country as indonesia, the incidence of diarrhea has been registered as one of public health problems which need a biggest attention. the subsector of diarrhea, ministry of health republic of indonesia recorded data from 2000 to 2010 noted that there were trends of increasing incidence of diarrhea.1 the main factor that frequently involved in diarrhea incidence are mother and environmental factors. the breast feeding behavior factors from mothers have been investigated as the highest risk that caused diarrhea incidence followed by poor water and poor sanitation condition. another factor that also involves in diarrhea incidence is poor water-sanitation system and lack of standardized latrines.1 the diarrhea incidence about 13% that had been recorded occurred more frequently in rural area compared to urban area. moreover, this number is higher in the lower education and lower income level.2 jatinangor has a high level of diarrhea incidence. in order to decrease and eliminate the diarrhea, several informations and data of risk factors in children are highly needed. the study’s objective was to find factors related to the incidence of diarrhea in children under five at jatinangor district. althea medical journal. 2016;3(4) 656 amj december 2016 methods this study was conducted from october to november 2013 in district jatinangor, west java, indonesia, specifically in sayang village and cilayung village with cross-sectional method. this study was approved by public health ethics commitee faculty of medicine, universitas padjadjaran. this data was taken from 102 respondents,mothers who have children with diarrhea, in sayang village and cilayung village used as subject. from the sampling frame, the respondents was included to the study by sampling and posyandu cluster. then, mothers with children under five fulfilling the inclusion criteria became the respondents. hereinafter, the respondents were interviewed about incidence of diarrhea and given questionnaires validated based on observation conditions. presentation of data were showed by a frequency distribution table about behaviour of exclusive breastfeeding, behaviour of clean water usage, behaviour of hand washing with clean & water flow, and behaviour of healthy latrine usage. the practice of clean water usage was assessed according to three aspects; (1) all of the source assumed to be the source of clean water, (2) drinking water process, and (3) place of storage water.9,14 the practice of good hand washing is when respondents wash their hands at least three times when their hands are dirty,i.e, (1) before eating, (2) before taking care of the child, and (3) after defecation.11 the good behaviour of clean and healthy latrine utilized were if respondents used latrines to dispose of feces daily, latrine and sources of water were within 10 meters, and cleaned up the latrine at least once in a week.2 results the result was obtained from mother characteristics, mostly aged 25 to 35 years (57.8%). most respondents have low education level. they only complete their junior high. based on respondents occupation, 81.4% are housewives. characteristic children of diarrhea are 58.4% occured in children aged less than or equal to 2 years and 52.9% of respondents were girls with diarrhea. the result showed that 73.5% respondents had exclusively breastfed (table 1). from practice of clean water usage, it was obtained 94.1% of the respondents that had good behaviour and only 5.9% were bad. all of these hand washing techniques must be under flowing water and use a soap. the result from this study obtained 61.8% that have good hand washing behaviour and 38.2% behave badly. as much as 60.8% respondents were included in the category of healthy latrine usage behaviour while 39.2% were still not in good behaviour. in jatinangor district, most respondents have already given exclusive breastfeeding to their children. exclusive breastfeeding was viewed from two aspects, i.e. whether children were breastfed for 6 months or not and whether breastfeeding for 6 months were given additional food intake or not (table 2). seen from source of water, water processing method, and storage of drinking water, most respondents were included in good behaviour (table 3). from the result of this study, behavior of hand washing with clean and water flow showed more than 50% in good behaviour. washing hands were conducted before eating, before treating a child, and after defecation with soap and under water flow (table 4). having a latrine at home and using it for defecation with distance of latrine with water source 10 meters and cleaning the latrine at least once in a week has been already owned by most of the respondents (table 5). discussion the study was conducted by 102 respondents and the results showed description of factors that influence the diarrhea incidence in children under five at sub jatinangor. based on the characteristics of the mothers and their education level, it was showed that 41.2% had passed the 9 –year basic education, although 15.7% of 21.6 % just graduated from elementary school and the rest 5.9% did not complete elementary school. the higher the education level, the higher the level of knowledge especially in the field of health and also the ability to develop the information that has been obtained from the education. based on researched by kasman,it was mentioned that there is significant correlation between the level of knowledge from the mother with diarrhea.3 on the results of the study, there were 81.4% of respondents as a housewife. diarrhea in the bulletin issued by the ministry of health, explained that 8.7% of women who are not working or housewives tend to have a higher frequency of diarrhea than those who have occupation.4 it is assumed that mothers have job outside the house are more aware althea medical journal. 2016;3(4) 657 table 1 characteristic of respondents characteristic frequency % age of respondents 27 26.5 less than 25 years 59 57.8 25 to 35 years 16 15.7 more than 35 years education level 6 5.9 ungraduated elementary school 16 15.7 elementary school 42 41.2 junior high school 31 30.4 senior high school 7 6.9 scholar occupation 1 1.0 public servants 7 6.9 employee 2 2.0 labor 1 1.0 farmer 8 7.8 entrepreneur 83 81.4 housewife age of children 30 29.4 1–12 months 30 29.4 13–24 months 26 25.5 25–36 months 12 11.8 37–48 months 4 3.9 49–59 months gender of children 48 47.1 boy 54 52.9 girl 100.0 total 102 100.0 rahayu widhyasti, nita arisanti, ina rosalina: profile and behaviour of mother as factor of increasing diarrhea incidence children under five at jatinangor district in 2013 and familiar with the health information, particularly about diarrhea.5 in the terms of the toddler characteristic, 58.4% aged under 2 years most commonly got diarrhea. based on report that presented by directorate general of communicable disease control and environmental health, first 2 years of life more frequently suffered diarrhea compared to age 2 to 5 years. it was caused infants that are more susceptible exposed to feces containing bacteria and direct contact with human feces during crawling. there were 52.9% girls had it. it means that there were girls who were more susceptible to diarrhea than boys.4 exclusive breastfeeding is one of mother’s behavior that can lead to diarrhea. exclusive breastfeeding is a natural food that suits the baby’s digestive system. in addition, breastfeed can replace baby immune protection.6 based on the study, 94.1% of respondents had breastfed and 73.5% respondents actually gave exclusive breastfed. jatinangor district had good feeding behavior. contrasted to the significant relationship that the diarrhea incidence affected by exclusive breastfeeding, the child whom exclusively breastfed had lower odds of diarrhea than children who are not exclusively breastfed.7 the difference may be due to the lack of mother’s knowledge that althea medical journal. 2016;3(4) 658 amj december 2016 terminate breastfeeding when the mother is sick. based on that condition, terminating breastfeeds when a mother gets sick can lead lack of nutrition and immunity which gained from asi.8 based on who jounal, clean water source that has been processed and screened can reduce mortality due to infection in general and enteric bacteria.17 based on the results from wells pump water sources and the springs have the same percentage are 38.2% . if the terms of drinking water process, 96.1% of respondents have boiled water before using, and 98 % use a sealed container for storage. so, it was concluded that 94.1% was included in the category of good clean water usage behavior because the water was cooked in advance and kept in covered container, while the remaining 5.9% was still quite poor. study of basic human services (bhs), the study of household drinking water process, explained that although 47.5% still contain bacteria escherichia coli, 99.2% have been boiled before cooking or used.9 this difference may be based on this study only assessed from a questionnaire given to the respondents and did not directly assess the quality of water in the form of physical features such as the water’s colorless, odorless, and tasteless ; water should be free of elements that can be dangerous for health such as arsenic cyanide and lead ; microbiological elements examination of the water seen the appearance or absence of the pathogens that can cause illness.10 this study might be affected by these factors . factor that cause diarrhea according to the behavioral factors is hand washing. based on this study, 61.8 % respondents who have children suffering from diarrhea have conducted a good hand washing behavior, and the remaining 38.2% were still bad in conducting hand washing. other factors, including trigger malabsorption diarrhea factors, food intake & food processing factors, table 2 behaviour of exclusive breastfeeding frequency % exclusively breastfed 75 73.5 not exclusively breastfed 27 26.5 total 102 100.0 table 3 behavior of healthy water usage behavior of healthy water usage frequency % good 96 94.1 bad 6 5.9 total 102 100.0 table 4 behavior of hand washing with clean and water flow behavior of hand washing with clean and water flow frequency % good 63 61.8 bad 39 38.2 total 102 100.0 table 5 behavior of healthy latrine usage behaviour of healthy latrine usage frequency % good 62 60.8 bad 40 39.2 total 102 100.0 althea medical journal. 2016;3(4) 659 and psychological factors may influence incidence of diarrhea. fecal–oral contact is the one of the way on how diarrhea spread in children. stool that is not managed properly can pollute the water and the surrounding environment, so that using latrines to dispose feces daily is one form of preventing diarrhea. at least a good latrine is the one with distance of 10 meters away from the water and it aims to reduce environmental pollution and desecration of the surrounding.11 of the study’s result, 1% of respondents were still using the river to defecate, while 99% were using latrines/ toilets. the distance of the latrines with water source is more than 10 meter as much as 77.5% and 22.5% are less than 10 meters. there were 77.5% of respondents cleaned the toilet at least 4 times a month. according to the three things above, 60.8% had good behaviour of latrine usage. based on researched by fandiarta ar, condition of family latrines and diarrhea incidence were not significantly influenced, p value >0:05 (p=0.581).12 environmental and behavioral factors were related to diarrhea. thoses factors are interacted each other. diarrhea can occur if guided by environmental factors and healthy behavior.13 if intervention of clean water, defecate disposal facilities manufacture, and behavioral of hand washing is improved, the incidence of diarrhea can be decreased significantly.14 similarly, the behavior of exclusive breastfeeding, in early giving and at least 4–6 months will help to prevent the baby from diseases. it was caused colostrum and breastmilk containing antibodies.15 for environmental factors, clean water facilities, sanitation, latrine, sewerage, housing conditions, and bacteriological factors are highly involved the incidence of diarrhea. bacteria e. coli contamination is suspected as the primary cause of the fresh water consumed by the public which indicates the existence of human fecal contamination. besides that, contamination is derived from the extraction and use of groundwater as a main source and river water also.16 therefore, the incidence of diarrhea occurs in the presences of behavioral and environmental factors. the limitation of this study is the lack of time so that this study is unable to perform the observation optimally. from the discussion above, the incidence of diarrhea in children under five in jatinangor district is still high although the results of this study showed good results in behaviour of exclusive breastfeeding, behavior of clean water usage, behavior of hand washing cleanly and under water flow, and behaviour of healthy latrine usage. it can be caused by other factors that are not examined in this study. references 1. agtini md. morbiditas dan mortalitas diare pada balita di indonesia. buletin jendela data dan informasi kesehatan.2011:2(2):26–32. 2. badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2007. jakarta: badan penelitian dan pengembangan kesehatan kementrian kesehatan republik indonesia;2008. 3. kasman. faktor-faktor yang berhubungan dengan kejadian diare pada balita di puskesmas air dingin kecamatan koto tangah kota padang sumatera barat [minor thesis]. medan; universitas sumatera utara; 2004. 4. subdit pengendalian diare dan infeksi saluran pencernaan kemenkes ri. pengendalian diare di indonesia. buletin jendela data dan informasi kesehatan. 2011:2(2);19–25. 5. setya n. faktor-faktor yang berhubungan dengan diare pada anak umur 6¬–24 bulan. banda aceh: universitas syiah kuala; 2008. 6. wijayanti w. hubungan antara pemberian asi eksklusif dengan angka kejadian diare pada bayi umur 0–6 bulan di puskesmas gilingan kecamatan banjarsari surakarta [minor thesis]. surakarta: universitas sebelas maret; 2010. 7. diwati ng. hubungan pemberian asi eksklusif terhadap kejadian diare pada bayi 0–6 bulan di puskesmas kecamatan duren sawit jakarta timur [minor thesis]. jakarta: universitas pembangunan nasional “veteran” jakarta; 2011. 8. tumbelaka ar, karyanti mr. air susu ibu dan pengendalian infeks. depok: ikatan dokter anak indonesia; 2013. 9. departemen kesehatan republik indonesia. strategi nasional sanitasi total berbasis masyarakat. jakarta: departemen kesehatan republik indonesia; 2008. 10. departemen kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia tentang syarat-syarat dan pengawasan kualitas air minum. jakarta: departemen kesehatan republik indonesia; 2002. rahayu widhyasti, nita arisanti, ina rosalina: profile and behaviour of mother as factor of increasing diarrhea incidence children under five at jatinangor district in 2013 althea medical journal. 2016;3(4) 660 amj december 2016 11. direktorat jenderal lingkungan pengendalian penyakit menular & penyehatan lingkungan. pedoman pemberantasan penyakit diare. jakarta: direktorat jenderal pengendalian penyakit menular & penyehatan lingkungan; 2005. 12. fandiarta ar. pengaruh faktor sanitasi air minum dan jamban keluarga terhadap kejadian diare pada balita di desa sayang dan desa cibeusi kecamatan jatinangor. bandung: universitas padjadjaran; 2010. 13. direktorat jenderal p2pl. profil pengendalian dan penyehatan lingkungan tahun 2011. jakarta: kementrian kesehatan republik indonesia; 2012. 14. cairncross s, boisson s, bostoen k, curtis v, fung ic, et al. water sanitation and hygiene for the prevention of diarrhoea. int j epidemiol. 2010;39:(suppl1):193–205. 15. departemen kesehatan republik indonesia. strategi nasional peningkatan pemberian asi tahun 2001-2005. jakarta: departemen kesehatan republik indonesia ; 2001. 16. adisasmito w. faktor risiko diare pada bayi dan balita di indonesia: systematic review penelitian akademik bidang kesehatan masyarakat. makara kesehatan. 2007;11(1):1–10. 17. who. assesing microbial safety of drinking water. [online journal] 2012 [cited 2012 may 12]. available from: http://www.who. int/water_sanitation_health. althea medical journal. 2016;3(4) 570 amj december 2016 lipid profile in type 2-diabetic women with central obesity and noncentral obesity scholastica diana nurvitasari,1 nanny natalia ms,2 yovi yoanita3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital bandung, 3department of clinical nutrition faculty of medicine universitas padjadjaran abstract background: type 2 diabetes mellitus and central obesity are associated with higher risk of cardiovascular diseases especially in women. lipid profile may reflect dyslipidemia which includes hypertriglyceridemia, increased level of ldl-c, total cholesterol, and reduced hdl-c level in the blood. patients with central obesity tend to have dyslipidemia compared to those without central obesity counterpart. the study aimed at comparing lipid profile in central-obese diabetic women and non–central-obese diabetic women. methods: this study was an analytical study with cross–sectional approach conducted in dr. hasan sadikin general hospital, bandung, indonesia in 2013. a total of 160 data contained of waist circumference (wc) and the level of total cholesterol, triglyceride, hdl-c and ldl-c were obtained from medical record of diabetic patients within the period of january 2010–january 2012. women patients whose wc of ≥80 cm were classified as central obesity while wc of <80 cm were classified as non-central obesity. the t-test was used to compare means of different variables, p<0.05 was considered as statistically significant. results: central obese diabetic women when compared to non-central obese diabetic women showed statistically significant increase in the level of total cholesterol serum, triglyceride serum and decrease in hdl-c serum level (p<0.05). the ldl-c serum level did not show statistical significant difference in the two groups (p>0.05). conclusions: diabetic patients with central obesity tend to have higher level of total cholesterol and triglyceride and lower level of hdl-c compared to diabetic patients without central obesity. [amj.2016;3(4):570–6] keywords: central obesity, diabetic women, lipid profile correspondence: scholastica diana nurvitasari, faculty of medicine, universitas padjadjaran, jalan raya bandungsumedang km.21, jatinangor, sumedang, indonesia, phone: +628989807909 email: scholasticadiana@gmail.com introduction diabetes mellitus (dm) is a common metabolic disorder in the world which is associated with risk of cardiovascular disease especially in women.1 based on international diabetes federation (idf), there were approximately 366 million dm patients in 2011 and the number was predicted to increase years by years.2 increasing number of type 2 dm is directly consistent with the increasing number of obesity. obesity can be defined based on body mass index (bmi) and waist circumference (wc). women patient with excessive wc (≥80 cm) can be classified as central obesity.3 data from indonesian basic health research (riset kesehatan dasar, riskesdas) 2007, reported that women had higher number of suffering central obesity compared to men.4 central obesity reflects higher risk of cardiovascular disease than bmi.5 there is a significant correlation between the accumulation adipocyte tissue with numerous abnormality of metabolism and lipid profile.5 there is relation between dm and central obesity, even in patient whose bmi is lower than 25 kg/m2.6 lipid profile in both disease would reflect dyslipidemia.7 a study conducted by nieves et al.8 discovered that patients with higher level of abdominal fat had higher total cholesterol, triglyceride, and ldl-c; and lower hdl-c compared to patients who had lower abdominal fat. the study aimed at comparing lipid profile in central-obese diabetic and noncentral-obese diabetic women in indonesia, especially in dr. hasan sadikin general hospital, bandung where the setting and condition are different from the previous althea medical journal. 2016;3(4) 571 study. methods this study was an analytical study with crosssectional design conducted in dr. hasan sadikin general hospital, bandung indonesia in 2013. before its implementation, the aim and the way this study would be conducted had been approved by health research ethics committee dr. hasan sadikin general hospital, bandung indonesia (lb.02.01/ c02/9529/ix/2013). data were obtained by consecutive sampling from medical records of diabetic patients within the period of january 2010–january 2012. a total of 160 medical records consisting of eighty data of diabetic type-2 women patients were associated with central obesity and eighty data of non-central obese diabetic women were taken to assess their lipid profile. plasma level of total cholesterol, triglyceride, high density lipoprotein–cholesterol (hdl-c), and low density lipoprotein–cholesterol (ldl-c) were analyzed. it was decided that the inclusion criteria was newly diagnosed type 2 diabetic women patients with complete medical records consisting of the variables needed for this study. the independent variable was waist circumference (wc) which can be measured from the midpoint between the lower tip of lowest ribs and highest part of iliac crest.5 these data also obtained from medical record. patients who had wc of ≥80 cm were classified as central obesity and patients who had wc of <80 cm were classified as noncentral obesity.5 exclusion criteria included pregnancy, receiving insulin treatment, heart failure, renal failure, and cirrhosis. this study used asian cut–off of bmi value calculated as kilograms per meter square. the reference of serum lipid level was national cholesterol education program (ncep) adult treatment iii (atp iii) guidelines. the population of the study was normal distribution based on kolmogorov-smirnov test. the t-test was used to compare means of variables. due to certain consideration, p<0.05 was considered as statistically significant.. results the most age group of being confirmed diabetes mellitus in both groups was 55–64 years group. it can be found that the highest proportion of central obese in central obese– diabetic women was also in the same level of age group. results from this study showed that patient with central obesity tended to have higher bmi score than the patients without central obesity group (table 1). frequency of obesity i in central obese patients was forty (50%) whereas obesity ii was sixteen (20%) patients. in non-central obese diabetic group, it was found that more than 50% of them had normal bmi score. only eighteen (22.5%) respondents of non-central obese diabetic who confirmed as overweight and obese i (table 2). results of this study showed that the mean of total cholesterol of the study subject was 220.2. this value could be classified as hypercholesteronemia (>200 mg/dl). table 1 characteristic of type 2 diabetic women patients as the study subject age waist circumference (wc) total n (%)wc ≥80 cm (diabetic women with central obesity) wc <80 cm (diabetic women without central obesity) age mean (sd) 55.9 (8.4) 55.4 (9.8) – minimum – – 28 years maximum – – 82 years < 35 years old 2 (2%) 4 (5%) 6 (3.7%) 35–44 years old 3 (4%) 3 (4%) 6 (3.7%) 45–54 years old 27 (34%) 27 (34%) 54 (33.8%) 55–64 years old 34 (42%) 34 (42%) 68 (42.5%) ≥ 65 years old 14 (18%) 12 (15%) 26 (16.3%) scholastica diana nurvitasari, nanny natalia ms,yovi yoanita: lipid profile in type 2-diabetic women with central obesity and non-central obesity althea medical journal. 2016;3(4) 572 amj december 2016 frequency of high level of total cholesterol in diabetic with central obesity group was thirtysix (45%) patients while in diabetic without central obesity were only twenty-three (29%) patients. the mean of ldl-cholesterol level of the study subject was in borderline level (138.1 mg/dl). highest proportion of ldl-c level in both groups was in borderline level. the mean of triglyceride level of study subject was in borderline level (167.9 mg/dl). this value could be classified as hypertriglyceridemia (>150 mg/dl). highest proportion of triglyceride level in diabetic with central obesity group was in high level meanwhile in diabetic without central obesity group was in optimal group. the hdl cholesterol of most respondents remained within normal value. there was only 19% of the study subject who had lower hdl-c level (table 3). diabetes mellitus type 2 with central obese patients when compared to type 2-diabetic without central obese subjects showed statistically significant increase in the levels of total cholesterol serum (p = 0.042) and triglyceride serum (p=0.000), while hdl-c serum showed significant increase in non-central obese type 2 diabetic patients (p=0.002). serum ldl-c level did not show statistically significant difference in the two group (p=0.l62) (table 4). a comparison of lipid profile of central-obese type 2 diabetic patients and non-central obese type 2 diabetic patients is represented in figure 1. discussions based on the table of age distribution of respondents, it can be found that the highest proportion of patient who had been confirmed dm was 55–64 years group. in central obesity group, the highest proportion also came from 55–64 years group. this result was relatively similar to the study by hillier et al.9 that reported the greater frequency of being diagnosed type 2 dm were respondents within 56–65 years group (29%) compared to the respondents within 46–55 years group (27%). it’s likely because women within 55–64 years group were already in their menopause period. estrogen deficiency in menopause women was associated with an increase in abdominal fat.10 elevated fat accumulation in abdomen, especially visceral fat could lead to peripheral insulin resistant and further lead to dm.11 this finding was in contrast with the results from basic health research/riset kesehatan dasar (riskesdas) in 2007 that stated the highest proportion of patients who were classified as central obesity was patients in 45–54 years group.4 most of the respondents who suffered dm were non-obese patients based on bmi classification. there were 102 (64%) study subjects whose bmi score were under 25. the study by son et al.12 in vietnam, and yoon et al.13 in korea also stated that most of the patients with type 2 dm in their country were not obese. recent pathogenesis of type 2 dm found that abnormal insulin secretions might be because of changes in nature morphology of β-cells and β-cell loss in these diabetic patients are more prominent than insulin resistance.13 the dm had strong association with impaired of metabolism that caused abnormality of lipid and lipoprotein serum.14 diabetic patients had table 2 body mass index of type 2 diabetic women patients body mass index (bmi) kg/m2 waist circumference (wc) total n (%)wc ≥80 cm (diabetic women with central obesity) wc <80 cm (diabetic women without central obesity) mean (sd) 27.1(4.5) 20.9 (2.9) – minimum – – 14.5 maximum – – 43.6 < 18.5 (underweight) 0 (0%) 14 (18%) 14 (8.8%) 18.5–22.5 (normal) 17 (21%) 48 (60%) 65 (40.6%) 23–24.9 (overweight) 10 (13%) 13 (16%) 23 (14.4%) 25–29.9 (obesity i) 36 (45%) 5 (6%) 41 (25.6%) >30.00 (obesity ii) 17 (21%) 0 (0%) 17 (10.6%) ≥ 65 years old 14 (18%) 12 (15%) 26 (16.3%) althea medical journal. 2016;3(4) 573 higher risk of cardiovascular disease because of dyslipidemia than people without dm.15 the study by yadav et al.16 in india showed that lipid profile of diabetic was worse than subject control. triglyceride, total cholesterol and ldl-c was significantly higher in diabetic patients, leading to dyslipidemia.17 this study showed the mean of total cholesterol, triglyceride and ldl-c of the subjects were reflected as dyslipidemia. another study by mahantesh14 in karnataka, india also stated that triglyceride, total cholesterol and ldl-c level were higher in diabetic patients while hdl-c was relatively higher in control.14 the triglyceride and total cholesterol were significantly higher in central-obese diabetic patients). nieves et al.8 also found similar result in their study that patients with the greater level of abdominal fat had higher total cholesterol, triglyceride, and ldl-c compared to patients who had the minimum abdominal fat (p<0.001). the hdl-c level was lower than the minimum abdominal fat group (p<0.001). in this study, hdl-c in central obese diabetic was also significantly lower than non-central obese diabetic group while ldl-c was higher in central-obese diabetic, but was not statistically significant. the relation between central obesity and lipid profile may be explained by the uncommon character of abdominal adipocyte. lipolytic exertion in abdominal adipocyte is different from the visceral and subcutaneous compartment.18 lipolytic force in the omental table 3 lipid profile in type 2 diabetic women patients parameters (mg/dl) waist circumference (wc) total n (%)wc ≥80 cm (diabetic women with central obesity) wc <80 cm (diabetic women without central obesity) total cholesterol <200 (optimal) 21 (26%) 29 (36%) 50 (31.2%) 200–239 (borderline) 23 (29%) 28 (35%) 51 (31.9%) >240 (high) 36 (45%) 23 (29%) 59 (36.9%) mean (sd) 220.2 (42.1) ldl cholesterol <100 (optimal) 7 (9%) 12 (15%) 19 (11.9%) 100–129 (near optimal) 20 (25%) 24 (30%) 44 (27.5%) 130–159 (borderline) 29 (36%) 30 (38%) 59 (36.9%) 160–189 (high) 18 (23%) 9 (11%) 27 (16.9%) >190 (very high) 6 (7%) 5 (6%) 11 (6.9%) mean (sd) 138.1(35.6) triglyceride <150 (optimal) 23 (29%) 44 (55%) 67 (41.9%) 150–199 (borderline) 16 (20%) 24 (30%) 40 (25.0%) 200–499 (high) 41 (51%) 12 (15%) 53 (33.1%) >500 (very high) 0 (0%) 0 (0%) 0 (0.0%) mean (sd) 167.9(64.8) hdl cholesterol <40 (low) 16 (20%) 15 (18%) 31 (19.4%) 40–59 (borderline) 58 (73%) 39 (49%) 97 (60.6%) >60 (high) 6 (7%) 26 (33%) 32 (20.0%) mean(sd) 50.7 (14.7) scholastica diana nurvitasari, nanny natalia ms,yovi yoanita: lipid profile in type 2-diabetic women with central obesity and non-central obesity althea medical journal. 2016;3(4) 574 amj december 2016 (visceral fat) is more active than in the subcutaneous depot in women because these visceral fats are more sensitive to β-adrenergic agonist incitement and less to insulin overriding. therefore the more free faty acids (ffa) is released directly into liver.18 high level of interleukin-6 which is generated by visceral fat also plays role in releasing ffa into liver by increasing sensitiveness of β-adrenergicdependent lipolysis. the further effect of those process is hypertriglyceridemia state among central obese patients.18 this explanation is related to the result of the study that triglyceride and total cholesterol in central obese-diabetic women were significantly higher than non-central obese-diabetic group. this study was in agreement with the study conducted in pakistan stating that the mean of total cholesterol in obese (bmi>30, waist to hip ratio–whr>0.85 in women, wc>88cm in women) women respondents were higher than non-obese (bmi<25, whr<0.85 in women, wc<88 cm in women) women subjects. the mean of triglyceride was also higher in obesefigure 1 comparison of lipid profile between type 2 diabetic women with central obesity and type 2 diabetic women without central obesity table 4 statistical test of mean differences of lipid profile of diabetic type 2 women with central obesity and without central obesity parameters waist circumference (wc) p valuewc ≥80 cm (diabetic women with central obesity) wc <80 cm (diabetic women without central obesity) total cholesterol mean (sd) 226.9 (36.6) 213.4 (46.3) 0.042 hdl cholesterol mean (sd) 47.1 (11.1) 54.3 (16.8) 0.002 ldl cholesterol mean (sd) 142.0 (33.8) 134.1 (37.2) 0.162 triglyceride mean (sd) 194.3 (61.2) 141.6 (57.5) 0.000 ≥ 65 years old 14 (18%) 12 (15%) 26 (16.3%) althea medical journal. 2016;3(4) 575 women subject.19 according to this study, hdl-c level in central obese-diabetic patients were significantly lower than in non-central obesediabetic patients. this result was in consistent with the study by nieves et al.8 that stated hdl-c level of patient who had greater abdominal fat were lower than patient who had fewer abdominal fat. a study conducted by shah19 also showed the similar pattern that obese women subjects had lower level of hdl-c compared to non-obese women subjects. decreased hdl-c level in serum was associated with hypertriglyceride in central obesity. high concentration of triglyceriderich lipoprotein caused elevated lipid carriage by cholesterol ester transfer protein (cetp) between vldl particles and ldl as well as hdl particles. then drained of hdl particles appearingin cholesterol ester and triglyceride was dominant.18 numerous vldl and hdlaccomodating triglyceride are hydrolyzed by hepatic lipase enzyme which elevates in plasma. products of those process are small dense ldl and hdl particle and as chain reaction, reduced hdl2 sub fraction is found in patients.18 the ldl-c level between both groups did not show significant difference. this finding was in contrast with the study by nieves et al.8 that showed ldl-c level of patients who had higher number of abdominal fat was significantly increased, compared to patients who had fewer number of abdominal fat (p<0.001). it is likely because this study could not identify the hsitory of dryg consumption from the medical record of the patients. consumption of statin in previous treatment could be bias to the level of ldl patients. another limitation of this study was the subject may have suffered another disease that affected the result of lipid profile. however, this condition was not recorded. in conclusion, diabetic women patients with central obesity tend to have higher total cholesterol level, higher triglyceride level and lower hdl-c level compared to non-central obese subject. prolonged abnormal lipid metabolism in central-obese diabetic patients could lead into serious complication of dm especially cardiovascular mortality. health dietary food and adequate physical activity can prevent those complication and also improve insulin sensitivity of the patients.18 references 1. hu g. gender difference in all-cause and cardiovascular mortality related to hyperglycaemia and newly-diagnosed diabetes. diabetologia. 2003;46(5):608– 17. 2. whiting dr, guariguata l, weil c, shaw j. idf diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. diabetes res clin pract. 2011;94(3):311– 21. 3. alberti k, zimmet p, shaw j. metabolic syndrome-a new world-wide definition. a consensus statement from the international diabetes federation. diabet med. 2006;23(5):469–80. 4. badan penelitian dan pengembangan kesehatan. laporan hasil riset kesehatan dasar ( riskesdas ) indonesia tahun 2007. jakarta: badan penelitian dan pengembangan kesehatan departemen kesehatan republik indonesia; 2008. 5. world health organization. waist circumference and waist-hip ratio: report of a who expert consultation. geneva: world health organization (who). 2008. 6. balkau b, deanfield je, després jp, bassand jp, fox ka, smith jr sc, et al. international day for the evaluation of abdominal obesity (idea). circulation. 2007;116(17):1942– 51. 7. krauss rm. lipids and lipoproteins in patients with type 2 diabetes. diabetes care. 2004;27(6):1496–504. 8. nieves dj, cnop m, retzlaff b, walden ce, brunzell jd, knopp rh, et al. the atherogenic lipoprotein profile associated with obesity and insulin resistance is largely attributable to intra-abdominal fat. diabetes. 2003;52(1):172–9. 9. hillier ta, pedula kl. characteristics of an adult population with newly diagnosed type 2 diabetes the relation of obesity and age of onset. diabetes care. 2001;24(9):1522–7. 10. carr mc, brunzell jd. abdominal obesity and dyslipidemia in the metabolic syndrome: importance of type 2 diabetes and familial combined hyperlipidemia in coronary artery disease risk. j clin endocrinol metab. 2004;89(6):2601–7. 11. grundy sm, cleeman ji, daniels sr, donato ka, eckel rh, franklin ba, et al. diagnosis and management of the metabolic syndrome: an american heart association/national heart, lung, and blood institute scientific statement. circulation. 2005;112(17):2735–52. 12. son lntd, hanh ttm, kusama k, ichikawa y, hung ntk, yamamoto s. vietnamese type 2 diabetic subjects with normal scholastica diana nurvitasari, nanny natalia ms,yovi yoanita: lipid profile in type 2-diabetic women with central obesity and non-central obesity althea medical journal. 2016;3(4) 576 amj december 2016 bmi but high body fat. diabetes care. 2003;26(6):1946–7. 13. yoon kh, ko sh, cho jh, lee jm, ahn yb, song kh, et al. selective β-cell loss and α-cell expansion in patients with type 2 diabetes mellitus in korea. j clin endocrinol metab. 2003;88(5):2300–8. 14. mahantesh gp. lipid profile in diabetes mellitus [dissertation]. bangalore: adichunchanagiri institute of medical sciences; 2010. 15. sultana r. impact of duration of type 2 diabetes mellitus on lipid profile. gomal j med sci. 2010;8(1):57–9. 16. yadav n, thanpari c, shrewastwa m, mittal r. comparison of lipid profile in type-2 obese diabetics and obese non-diabetic individuals: a hospital based study from western nepal. kathmandu univ med j. 2012;10(39):44–7. 17. samantha p, venkateswarlu m, siva pv. lipid profile levels in type-2 diabetes mellitus from tribal population of adilabad in andhra pradesh, india. j clin diagn res. 2012;6(4):590–2. 18. kopelman pg, caterson id, dietz wh. clinical obesity in adults and children. 3rd ed. london: wiley; 2009. 19. shah s, devrajani b, devrajani t, bibi i. frequency of dyslipidemia in obese versus non-obese in relation to body mass index (bmi), waist hip ratio (whr) and waist circumference (wc). pak j sci. 2008;62(1):27–31. althea medical journal. 2016;3(4) 545 refractive errors in state junior high school students in bandung sabila tasyakur nikmah,1 raden maula rifada,2 putri teesa radhiyanti santoso3 1faculty of medicine universitas padjadjaran, 2department of ophthalmology faculty of medicine universitas padjadjaran/national eye center, cicendo eye hospital, bandung, 3department of physiology faculty of medicine universitas padjadjaran abstract background: uncorrected refractive error is one of the avoidable causes of vision impairment in children and adults. vision problem in children has been shown to affect their psychological and academic performance. this study aims at identifying and gaining more insights on the characteristic of the refractive errors in state junior high school students in bandung to avoid uncorrected refractive errors. methods: a cross-sectional study was conducted in september–november 2015 in state junior high schools in bandung, west java, indonesia. sample was selected using multistage random sampling technique. children were examined using tumbling e examination; then students with visual acuity worse than 6/12 underwent snellen chart test, refractometry without pupil dilatation, correction with trial lens, then was followed by direct ophthalmoscopy. results: from a total of 435 children who completed all the examination, 80 children (18.39%) had refractive errors; consisted of 151 eyes (94.38%) with myopia and 9 eyes (5.62%) with astigmatism. refractive errors were found to be more common in female children (73.7%) than male children (26.3%). among those with refractive errors, 45 children (56.3%) did not use any corrective glasses before the examination. conclusions: routine refractive error test in vision screening examination is needed for students. it is equally important to raise more awareness toward eye disease in community. [amj.2016;3(3):545–8] keywords: children, refractive errors, visual impairment correspondence: sabila tasyakur nikmah, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62811247071 email: sabilatasyakur@gmail.com introduction refractive error (re)is defined as a condition where the eye fails to bring parallel rays of light to focus in the retina that further causes decreasing visual acuity (va).1 according to the data from the world health organization (who), more than 464 million people in the world have vision loss; with approximately 153 million people have it due to uncorrected refractive error. uncorrected refractive error is one of the avoidable cause of vision loss in children and adult.2 in general, there are two types of eye conditions: emmetropia and ametropia. emmetropia is a condition with the absence of refractive errors while ametropia is the presence of refractive error. refractive error could happen when there is a mismatch between the refractive power of the lens and cornea with the axial length of the eyeball. the three types of ametropia are myopia (nearsightedness),hyperopia (farsightedness), and astigmatism.3 therefore, these can be said as eye problems. specifically, vision problem in children might affect their psychological and academic performance.4 collaborative longitudinal evaluation of ethnicity and refractive error (cleere) study reported that the largest number of new cases of myopia (18.2%) occurred at the age of 11 with the majority of them were found in asians (27.3%) followed by hispanics (21.4)%.5 in another study conducted in australia, prevalence of myopia in the 12-year-old children was also higher than other refractive error.6 similar studies, have not yet been conducted for children in indonesia, specifically in bandung. therefore, this study is intended to identify and to gain more insights on the characteristic of refractive errors among 7th grade state junior high school students in bandung to avoid uncorrected refractive errors in children. althea medical journal. 2016;3(4) 546 amj december 2016 methods this study was a cross-sectional study conducted from september through november 2015 in several state junior high schools in bandung, west java, indonesia. the subject of this study was 7th graders. the analysis of the study was based on the primary data from vision screening conducted by community ophthalmology division, national eye center, cicendo eye hospital, bandung this study employed multistage random sampling technique to select the school and classes in which this study was conducted. the samples were collected from six state junior high schools from six different regions in bandung. the inclusion criteria for this study were three folds: registered as a 7th grade in state junior high school student in bandung in academic year 2015/2016, aged 11–15 years old on the day of the examination, and agreed to participate in the study. the instrument used in this study was an informed consent, followed by a series of vision screening consisting of tumbling e examination. additionally, the students with visual acuity worse than 6/12 underwent snellen chart test, refractometry without pupil dilatation, correction with trial lens, then was followed by direct ophthalmoscopy. the refractive errors were expressed as spherical equivalent (se) sphere power plus half negative cylinder power. myopia was defined as se of at least -0.50 d, hyperopia was defined as se of +2.00 d or more, and astigmatism was defined as cylinder of at least -0.50 d. myopia was also categorized as mild (-0.50 d to -3.00 d), moderate (-3.10 to -6.00 d) and high (more than -6.00 d). the main outcomes gathered were the visual acuity, the correction and the history of correction use. the collected data were then analyzed using the epiinfo software. ethical approval was obtained from health research ethics committee faculty of medicine, universitas padjadjaran, bandung. the study permit was obtained from the kantor kesatuan bangsa dan politik bandung, the department of education and culture bandung and the school authorities. results from the randomized six schools there were a total of 435 subjects consisting of 192 male students and 243 female students from randomly selected classes. from the examination, it was discovered 80 subjects with refractive errors (18.39%). table 1 showed that refractive errors were found more common in female students than male students. this study also showed the classification of refractive errors among state junior high school students according to sex. table 2 showed both myopia and astigmatism were found higher in female than male children. from this study, hyperopia case was not found. mild myopia was found in 118 eyes (78.15%), moderate myopia was found in 33 eyes (21.85%), and no high myopia was found in this study. table 1 demographic characteristic of junior high school students in bandung, west java, indonesia with refractive errors sex frequency (n=80 people) percentage (%) male 21 26.3 female 59 73.7 table 2 type of refractive errors by sex among junior high school students in bandung, west java, indonesia characteristic type of refractive error (n=160 eyes) myopia astigmatism male 41 (25.62%) 1 (0.63%) female 110 (68.75%) 8(5%) total 151 9 althea medical journal. 2016;3(4) 547sabila tasyakur nikmah, raden maula rifada, putri teesa radhiyanti santoso: refractive errors in state junior high school students in bandung table 3 showed that most of refractive error cases in this study was myopia simplex. however, there was only 6.8% difference between the prevalence of myopia simplex and astigmatism myopia compositus. table 4 showed that most of the students with refractive error did not use any correction glasses before the examination. the response for correction on the visual acuity was also checked. most of the students reached maximum visual acuity; yet two students (2.5%) had visual acuity less than 6/9 on snellen chart in either one or both eyes after correction. this suggested that these students might have amblyopia or known as lazy eyes. discussions in this study, it was found 80 subjects with refractive errors (18.39%). most children with refractive errors were female (73.7%) than in male (26.3%).this result mirrored those obtained from studies in ethiopia, china, thailand and cambodia where refractive errors were observed more in female children. however, the difference between female and male children with refractive errors appeared to be higher in bandung than in those other studies mentioned above.7-10 it can therefore be concluded that female children were more vulnerable to refractive errors than male children. possibly, this condition was associated with the puberty and earlier maturation in female.11 a study in jordan12 reported that the common types of refractive errors in children were myopia, then followed by hyperopia and astigmatism. as a comparison, this study exposed that common type of refractive errors in children were myopia (94.38%) followed by astigmatism (5.62%), but none hyperopia case. this could be caused by the type of the examination and also the age of sample involved in this study; hyperopia was more common in younger children aged less than 10 years old.13 some children could indeed have a slight hyperopia. however, this may not have been detected through the screening using a snellen chart and history taken by the ophthalmologist. in this study, the term myopia was used for both myopia simplex and astigmatism myopia compositus. both had been converted with the spherical equivalent to get more general classification on the refractive errors. on the other hand, we also showed the refractive errors based on the sub-classification. it further revealed that the refractive errors in state junior high school students found in this study were myopia simplex (50.6%), astigmatism myopia simplex (5.6%), and astigmatism myopia compositus (43.8%). it can then be concluded that actually there was only a slight difference between children who only had myopia and the children who also had astigmatism alongside with their myopia. a study in karachi14 also discovered the same result, astigmatism myopia compositus was the most frequent refractive error in children aged 6-15 years old and followed by myopia with a slight difference between the prevalence. most children (56.3%) did not use any correction before this examination and the rest of the children who have already used correction still need more suitable correction. table 3 type of refractive errors by sub-classification among junior high school students in bandung, west java, indonesia sub-classification of refractive errors frequency (n=160 eyes) percentage (%) myopia simplex 81 50.6 astigmatism myopia simplex 9 5.6 astigmatism myopia compositus 70 43.8 table 4 history of correction use among junior high school students with refractive errors in bandung, west java, indonesia history of correction use frequency (n=80 people) percentage (%) yes 35 43.7 no 45 56.3 althea medical journal. 2016;3(4) 548 amj december 2016 from these data, it can be concluded that children were not fully aware of their refractive errors and that they had not yet undergone routine eye examination. this could provoke new insight for the government, schools, parents and doctors. it can be suggested that routine refractive error test in vision screening examination is needed for students, and therefore every school needs to improve their student health unit program. it is important to raise more awareness toward eye disease in community by focusing on early detection of refractive errors and referral procedure. the limitation of this study was the type of screening that had low sensitivity on detecting children with slight hyperopia. additionally, the sample in this study was limited to the 7th grade students from six schools in bandung. for further study, it is recommended that the sensitivity of the screening test should be improved by using other type of vision screening such as using cycloplegic refraction test to detect the refractive errors. this way, the chance of undiagnosed cases such as hyperopia may be reduced. in addition, it would be better to extend more samples to wider group of population, rather than strictly on 7th grade state junior high school students in bandung. references 1. jobke s, kasten e, vorwerk c. the prevalence rates of refractive errors among children, adolescents, and adults in germany. clin ophthalmol. 2008;2(3):601–7. 2. holden ba. uncorected refractive error: the major and most avoidable cause of vision loss. community eye health. 2007;20(63):37–9. 3. optics and refraction. in: riordan-eva p, whitcher jp, editors. vaughan & asbury’s general ophthalmology. 17th ed. new york: mcgraw-hill; 2008. p. 377–92 4. fatouhi a, khabazkhoob m, hashemi h, yekta aa, mohammad k. importance of including refractive error test in school children’s vision screening. arch iran med. 2011;14(4):250–3. 5. kleinstein rn, sinnott lt, jones-jordan la, sims j. new cases of myopia in children. arch ophthalmol. 2012;130(10):1274–9. 6. robaei d, kifley a, mitchell p. refractive error and patterns of spectacle use in 12 years old australian children. ophthalmology. 2006;113(1):1567–73. 7. gao z, meng n, muecke j, chan wo, piseth h, kong a, et al. refractive error in school children in an urban and rural setting in cambodia. ophthalmic epidemiol. 2012;19(1):16–22. 8. wu jf, bi hs, wang sm, hu yy, wu h, sun w, et al. refractive error, visual acuity and causes of vision loss in children in shandong, china. the shandong children eye study. plos one. 2013;8(12):1–12. 9. yared aw, belaynew wt, destaye s, ayanaw t, zelalem e. prevalence of refractive errors among shool children in gondar town, northwest ethiopia. middle east afr j ophthalmol. 2012;19(4):372–76. 10. yinyong p. refractive errors survey in primary school children (6–12 year old) in 2 provinces : bangkok and nakhonpathom (one year result). j med assoc thai. 2010;93(10):1205–10. 11. czepita d, mojsa a, ustianowska m, czepita m, lachowicz e. role of gender in the occurence of refractive errors. annales academiae medicae stetinensis. 2007;53(2):5–7. 12. albashtawy m, hameed s, mansi k, aljezawi me, tubaishat a. refractive errors among 7–16 year old children. british j sch nurs. 2012;7(7):350–54. 13. kostovska v, stanković-babić g, smiljkovićradovanović k, cekić s, vujanović m, bivolarević i. analysis of refractive errors in children aged up to 15 years. acta medica medianae. 2013;52(2):33–40. 14. ayoob m, dawood z, mirza sa, ain qu. refractive errors and their relation to age and sex. med channel. 2011;17(2):28–31. althea medical journal. 2016;3(4) 633 polypharmacy treatment of hypertensionin public health centers vasanthi a/p nayagam,1 afiatin,2 herri s. sastramihardja3 1faculty of medicine universitas padjadjaran, 2department of internal medicine faculty of medicine, universitas padjadjaran/dr. hasan sadikin general hospital,bandung, 3department of pharmacology and therapy faculty of medicine universitas padjadjaran abstract background: hypertension is one of the most prominent global diseases. despite the availability of effective therapies, hypertension remains poorly controlled in indonesia. in many cases, patient’s noncompliance may be attributable to the low patients’ knowledge, attitude, and life-style practices such as polypharmacy. polypharmacy is defined as the administration of many drugs at in one prescription. polypharmacy increases expenses, possible adverse reaction to a single agent, incidence of drug interactions, and decreases patient’s compliance this study aimed to identify the practice of polypharmacy in hypertension treatment in primary health centers. methods: a cross-sectional descriptive observational study was carried out on 60 patients from two primary health centers in jatinangor, west java, indonesia in october 2013. sociodemographic profile, degree of hypertension, types of antihypertensive drugs, concomitant drugs given together with antihypertensive drugs, and treatment compliance data were collected and presented in tables and figures. results: the incidence of hypertension was more common among male patients compared to female patients. thirty-three patients (55%) have low compliance to their medication. twenty-nine patients (48%) received single drug and 31 patients (52%) received more than one drugs. conclusions: the percentage of polypharmacy practice in treating hypertension in primary health centers is 52%. the most frequently prescribed anti-hypertensive are angiotensin-converting enzyme (ace) inhibitors and calcium-channel blockers (ccb). most of hypertensive patients have low compliance to therapy. [amj.2016;3(4):633–9] keywords: compliance, hypertension, polypharmacy, public health center correspondence: vasanthi a/p nayagam, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 87827571504 email: anu4390@yahoo.com introduction the prevalence of hypertension or blood pressure in indonesia is quite high. despite the availability of effective therapies, hypertension remains poorly controlled in indonesia. too often patients forget to take their medications as prescribed, stop taking a medicine without informing their health care provider, or only take their medications when they think they need them, which are all referred to as noncompliance.1 one of the central reasons for the failure to control hypertension in those receiving therapy is patient’s noncompliance with prescribed treatments. in many cases, patient’s failure to comply may be attributable to poor knowledge, attitude, and life-style practices such as polypharmacy.2 polypharmacy is defined as the administration of many drugs in one prescription. it is also defined as mixing various drugs in one prescription.3 polypharmacy increases the expense for multiple drugs, possible adverse reactions to a single agent incidence of drug interactions, and decreases patient’s compliance. the aim of this study was to analyze the practice of polypharmacy among hypertensive patients in health care centers in jatinangor. methods a cross-sectional descriptive observational study was used in determining polypharmacy althea medical journal. 2016;3(4) 634 amj december 2016 practice in hypertension treatment in jatinangor public health center and clinic padjadjaran in october 2013. sampling was performed using consecutive sampling technique. the inclusion criteria were hypertension patients that visited the health care centers and who were cooperative and willing to be interviewed after giving an adequate informed consent. thirty patients were sampled from each health care center. variables used in this study comprise of polypharmacy practice and compliance to antihypertensive treatment. polypharmacy is defined as administration of many drugs together in one prescription. compliance to treatment is defined as the extent to which a patient acts in accordance with the prescribed interval and dose of dosing frequency. patients with hypertension were identified from the medical records of the selected health care centers in jatinangor. the identified patients who were visiting the health care centers for control were given consent. then, those patients who met the inclusion criteria were interviewed on their compliance of antihypertensive treatment. all data collected was grouped according to sociodemographic profile, distribution of degree of hypertension, types of antihypertensive drug, concomitant drugs given together with antihypertensive drugs, and compliance to medication using computer. the collected data were presented in percentage. the study was performed after approval from the health research ethics committee of faculty of medicine universitaspadjadjaran no. 369/un6.c2.1.2/ kepk/2013. results most of hypertensive respondents were between 50−59 years old which accounts for 25% of total population. the incidence of hypertension was more common among the male respondents (52%). about 26 respondents (43%) were employed, while 34 respondents (57%) were unemployed (table 1). most patients were diagnosed as suffering from stage 2 hypertension, which accounted for 33 respondents (55%). meanwhile, 25 respondents (42%) suffered from stage 1 hypertension consisted of 25 respondents (42%). out of 60 respondents, 29 of them (48%) received single drug and 31 respondents (52%) received combination therapy. furthermore, 25 respondents (42%) from both the health care centers received a combination of 2 drugs. only 6 respondents (10%) received a combination of 3 drugs (table 2). in this study, the compliance to antihypertensive medication was found to be low. out of 60 respondents, 33 respondents (55%) had low compliance to their medication. meanwhile, 16 respondents (27%) had medium compliance and 11 respondents (18%) had high compliance (figure 1). table 1 respondent characteristics characteristics categories jphc (n=30)(%) cp (n=30)(%) total (n=60)(%) age(years old) 10−19 2(7) 2(3) 20−29 3 (10) 1(3) 4(7) 30−39 2 (7) 7(23) 9(15) 40−49 9 (30) 3(10) 12(20) 50−59 6 (20) 9(30) 15(25) 60−69 6 (20) 5(17) 11(18) 70−79 3 (10) 3(10) 6(10) >80 1 (3) 1(2) gender male 15(50) 16(53) 31(52) female 15(50) 14(47) 29(48) employment employed 10(3) 16(53) 26(43) unemployed 20(67) 14(47) 34(57) note: jphc=jatinangor public health center, cp=clinic padjadjaran althea medical journal. 2016;3(4) 635vasanthi a/p nayagam, afiatin, herri s. sastramihardja: polypharmacy treatment of hypertensionin public health centers single drug therapy was given mostly to hypertension stage 1 patients, i.e. 20 (69%) patients. twenty-one respondents (84%) were given a combination of 2 drugs. one of the reasons for promoting the use of two antihypertensive agents is that the probability for achieving more effective blood pressure-lowering is increased. meanwhile, a combination of 3 drugs was given to more severe hypertension respondents (table 3). most commonly given single drug was the ace inhibitor (59%). this is usually the firstline choice in hypertension treatment. calcium channel blockers (ccb) also weregiven to the respondents, which are about 8 respondents (27%). calcium channel blockers are particularly effective against large vessel stiffness, one of the common causes of elevated systolic blood pressure in elderly respondents. it relaxes and opens up narrowed blood vessels, reduce heart rate and lower blood pressure (table 4). the combination of two antihypertensive drug classes given mostly was the aceinhibitor with ccb, which accounts for 12 respondents (48%). this combination is usually given to respondents with diabetes or lipid abnormalities. the second highest combination is the aceinhibitor with diuretics. this combination was given to 8 respondents (32%). this combination have particular role in the presence of heart failure or post stroke. based on the heart foundation, approximately 50% of hypertensive respondents require triple-drug therapy that is combination of three different classes of antihypertensive drugs. six respondents were given triple-drug therapy. the combination of aceinhibitor, calcium channel blocker and diuretics was given to 4 respondents (67%). other types of drugs given with antihypertensive medication were prescribed based individual complaints of the respondents. from the results above, the drugs that are most frequently given together with antihypertensive drug were the antiinflammatory drugs (18%). analgesics and antipyretics (16%) may be given to overcome the side effects like headache caused by the antihypertensive drugs. discussion based on this study it is discovered that, about 48% of respondents were given single drug treatment. in a study in southwestern ontario4, most patients with hypertension received monotherapy (63%). a previous study in south carolina showed that 74.2% of patients received one antihypertensive pill and medication category.5 this might be because the target blood pressure could be obtained table 2 distribution of degree of hypertension and type of antihypertensive drugs characteristics categories jphc (n=30)(%) cp (n=30)(%) total (n=60)(%) degree of hypertension prehypertension 2(7) 2(3) stage 1 10(33) 15(50) 25(42) stage 2 20(67) 13(43) 33(55) types of antihypertensive drugs single 13(43) 16(54) 29(48) combination of 2 15(50) 10(33) 25(42) combination of 3 2(7) 4(13) 6(10) note: jphc=jatinangor public health center, cp=clinic padjadjaran table 3 distribution of type of antihypertensive drugs by degree of hypertension degree of hypertension type of drug (n=60)(%) single combination of 2 combination of 3 prehypertension 2(67) stage 1 20(69) 4(16) 1(17) stage 2 7(24) 21(84) 5(83) althea medical journal. 2016;3(4) 636 amj december 2016 table 1 respondent characteristics type of drug total percentage (%) single (n=29) acei 17 58.62 captopril beta-blocker 2 6.90 bisoprolol diuretic 2 6.90 hydrochlorothiazide calcium channel blocker 8 27.58 amlodipine combination of 2 (n=25) acei – vasodilator 2 8 captopril + isosorbidedinitrate acei – diuretics 8 32 captopril + hydrochlorothiazide acei – β-blocker 1 4 captopril + bisoprolol acei – calcium channel blocker 12 48 captopril + amlodipine calcium channel blocker – diuretics 1 4 amlodipine + hydrochlorothiazide calcium channel blocker – β-blocker 1 4 amlodipine + bisoprolol combination of 3 (n=6) acei – calcium channel blocker – β-blocker 2 33.33 captopril + amlodipine + bisoprolol acei – calcium channel blocker – diuretics 4 66.67 captopril + amlodipine + hydrochlorothiazide other drugs (n=131) antibiotics 10 7.63 anti-inflammatory 23 17.56 antihistamine 12 9.16 anti-diabetics 14 10.69 gastrointestinal 17 12.98 analgesic & antipyretics 21 16.03 antitussive, expectorant and mucolytic 13 9.92 vitamin 9 6.87 anti-hyperlipidemia 6 4.58 note:acei= angiotensin-converting enzyme inhibitor althea medical journal. 2016;3(4) 637 using a single drug therapy. from the current study, a single drug therapy with ace inhibitors (58.62%) was more strongly associated with good control of blood pressure than monotherapy with beta-blockers, ccbs, diuretics, or the use of multiple drugs. a study conducted in southwestern ontario4 showed that the frequency of monotherapy by class was ace inhibitor (34%). moreover, to support this study, a study in south carolina5 stated that 28% of the hypertensive patients were given ace inhibitor. the ace inhibitors lower the blood pressure by reducing the peripheral vascular resistance. it blocks the conversion of angiotensin i to the potent vasoconstrictor angiotensin ii. vasodilation occurs as a result of lower vasoconstriction caused by decreased levels of angiotensin ii. by reducing circulating angiotensin ii levels, ace inhibitors also decrease the secretion of aldosterone, resulting in decreased sodium and water retention.6 the most commonly used of two drugcombination were the ace inhibitors with ccbs. in patients with both diabetes and hypertension, ace inhibitors provide clinical benefits that appear to be independent of blood pressure reduction. in a previous study, in ace inhibitors with ccbs cardiovascular events trial in patients with hypertension and diabetes, it was found that those receiving this combination were approximately 50% less likely to experience a major cardiovascular event.7 however, a study conducted in canada shows that the primary combination includes an ace inhibitor and diuretic (78%), followed by an arb and diuretic (16%), and an ace inhibitor and ccb (6%).4 about 67% of respondents were given a combination of 3 drugs which comprises of ace inhibitor, ccb and diuretics. a study in the united states stated that, 69.9% patients reach the blood pressure target of <140/90 mm/ hg with triple combination therapy.8recent data indicated that few patients may require a third or fourth drug to adequately manage blood pressure. preference should be given to the selection of an agent from a different class from the initial 2 drugs in the combination therapy. the highest age group having hypertension was between 50−59 years old. the risk of having high blood pressure increases as the age increases. this is also shown in a previous study conducted in indonesia,9 where the highest number of patients having hypertension is in the age category of between 50−59 years old. the prevalence of hypertension is higher in males. out of 60 respondents, 31 of them are males, comprising about 51.67%. the hypertension prevalence in males in this study is comparable to a study conducted in india,10 where the prevalence of males having hypertension is higher than females. in a study in arab,11 there were 243 (52.4%) and 221 (47.6%) male and female hypertensive patients, respectively. current evidence suggests that estrogen may modulate vascular endothelial function, resulting in vasodilation which, in women, may, in part, contribute to lower blood pressures. figure 1 distribution of patient’s compliance vasanthi a/p nayagam, afiatin, herri s. sastramihardja: polypharmacy treatment of hypertensionin public health centers althea medical journal. 2016;3(4) 638 amj december 2016 about 34 (57%) respondents were unemployed. based on a study conducted in ghana,12 over 60.33% of the patients were unemployed. unaffordable prices for antihypertensive drugs were the reason for this high number of patients. another previous study in arab11 stated that hypertension seems to cluster more among those who are unemployed (32.6%). in addition, stress due to a low or absent of income could also be a contributing factor to the development of high blood pressure either directly or indirectly by causing depression and anxiety. more than half of the respondents (55%) in the current study were determined or classified as poor compliers with antihypertensive medication. however, a survey in new orleans shows that 59% of patients reported perfect antihypertensive medication compliance.13 the most common reasons for non-compliance include forgetfulness, busy schedule, and insufficient supply of medication. when patients do not comply to their medications, their blood pressure tend to rise. this in turn causes their physician to add on another drug in their present medication which causes taking many drugs in one prescription which is called polypharmacy. stage 2 hypertension was diagnosed in 33 respondents. this is supported by a cohort study in india,14 where there is an increase in stage 2 hypertension. earlier study in the united states15 shows, approximately 9.1 million adults had stage 2 hypertension, representing 25.4% from 51.8% of those with uncontrolled hypertension. the genetic and environmental factors can be responsible for the large increase in stage ii hypertension in this population. the limitation of this study was the use of observational, community-based practice data. the study was done in a public health center, which may not represent all population in that area because of time restrictions. as this was a small study using cross-sectional design, the effect of polypharmacy in patients could not be analyzed. so, further study could be done to see the effect of practicing polypharmacy in patients. in conclusion, hypertension is an asymptomatic disease which needs lifelong lifestyle modifications and drug therapy. the prevalence of hypertension respondents whom were given polypharmacy in treating hypertension in the health centers is 51.67%. the antihypertensive drugs that mostly prescribed are the ace inhibitors and ccb. most of the hypertensive respondents have low compliance to medication which causes the blood pressure to be raised although they undergo drug therapy. the most important cause of noncompliance is the lack of knowledge about the illness and its medication. the physician should explain the benefits and adverse effects of a medication effectively to the respondents. effective communication between the primary care physician and the patient with a chronic disease compromises the patient’s understanding of his or her disease, its potential complications, and the importance of medication adherence. this study has attempted to approach polypharmacy from a patient perspective and future studies could aim at identifying polypharmacy from the provider’s side, improving patient’s awareness on polypharmacy, and empowering them with the knowledge and tools they need to successfully reduce chances of adversities due to polypharmacy. references 1. setiati s, sutrisna b. prevalence of hypertension without anti-hypertensive medications and its association with social demographic characteristics among 40 years and above adult population in indonesia. acta med indones-indones j intern med. 2005;37(1):20−5. 2. iyalomhe gbs, iyalomhe si. hypertensionrelated knowledge, attitudes and life-style practices among hypertensive patients in a sub-urban nigerian community. j public health epidemiol. 2010;2(4):71−7. 3. dorland wan. dorland’s medical dictionary. 28th ed. philadelphia: elsevier saunders. 2009. polypharmacy. 4. petrella rj, merikle ep, jones j. prevalence, treatment, and control of hypertension in primary care: gaps, trends, and opportunities. j clin hypertens. 2007;9(1):28−35. 5. egan bm, bandyopadhyay d, shaftman sr, wagner cs, zhao y, yu-isenberg ks. initial monotherapy and combination therapy and hypertension control the first year. hypertension. 2012;59(6):1124−31. 6. atlas sa. the renin-angiotensin aldosterone system: pathophysiological role and pharmacologic inhibition. j managed care pharm. 2007;13(8):9−20. 7. kalra s, kalra b, agrawal n. combination therapy in hypertension: an update. j diabetol metab syndr. 2010;2(1):44. 8. calhoun da, lacourcière y, chiang yt, althea medical journal. 2016;3(4) 639 glazer rd. triple antihypertensive therapy with amlodipine, valsartan, and hydrochlorothiazide. hypertension. 2009;54(1):32−9. 9. rahajeng e, tuminah s. prevalence of hypertension and its determinants in indonesia. maj kedokt indon. 2009;59(12):580−7. 10. yuvaraj by, nagendragowda mr, umakantha ag. prevalence, awareness, treatment, and control of hypertension in rural areas of davanagere. indian j community med. 2010;35(1):138−41. 11. tohme ra, jurjus ar, estephan a. the prevalence of hypertension and its association with other cardiovascular disease risk factors in a representative sample of the lebanese population. j hum hypertens. 2005;19(11):861–8. 12. ohenebuabeng k, matowe l, plange-rhule j. unaffordable drug prices: the major cause of non-compliance with hypertension medication in ghana. j pharm pharm sci. 2004;7(3):350−2. 13. hyre ad, krousel-wood ma, muntner p, kawasaki l, desalvo kb. prevalence and predictors of poor antihypertensive medication adherence in an urban health clinic setting. j clin hypertens(greenwich). 2007;9(3):179−86. 14. gupta r, sharma ak, gupta vp, bhatnagar s, rastogi s, deedwania pc. increased variance in blood pressure distribution and changing hypertension prevalence in an urban indian population. j hum hypertens. 2003;17(8):535−40. 15. valderrama al, gillespie c, king sc, george mg, hong y. vital signs: awareness and treatment of uncontrolled hypertension among adults. morbidity and mortality weekly report. 2012;61(35):703−9. vasanthi a/p nayagam, afiatin, herri s. sastramihardja: polypharmacy treatment of hypertensionin public health centers althea medical journal. 2016;3(3) 434 amj september 2016 relation between risk factors of pyoderma and pyoderma incidence lila indria depari,1 unwati sugiri,2 lola ilona3 1faculty of medicine universitas padjadjaran, 2department of dermato-venerology faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of epidemiology and biostatistic faculty of medicine universitas padjadjaran abstract background: pyoderma is a purulent bacterial infection of the skin. in developing countries, pyoderma is the most common skin disease in children. pyoderma attacks male more often than female. factors influencing pyoderma are low socioeconomic level, low education, low personal hygiene and unhygienic house. this study was conducted to assess the relation between risk factors of pyoderma and pyoderma incidence. methods: this study used cross-sectional study design and was conducted from august–november 2013. the sample collection was done with multistage random sampling, where 196 primary school children in jatinangor subdistrict were randomly taken to be admitted into this study. the data collection procedure consisted of physical examination and questionnaire filling. the data were statistically analyzed using independent t and chi-square test. results: upon examining 196 subjects, four were found with pyoderma. as such, the prevalence of pyoderma on primary school children in jatinangor in 2013 was 2%. there was relation between personal hygiene and pyoderma incidence (p=0.041). sex (p=0.623), healthy housing (p=0.097), socioeconomic level (p=0.742) and education level of parents (p=0.989) were not related with pyoderma. conclusions: personal hygiene is the risk factor that had relation with incidence of pyoderma. [amj.2016;3(3):434–39] keywords: personal hygiene, pyoderma, risk factors correspondence: lila indria depari, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +62 857 7447 8892 email: lila_indria@yahoo.co.id introduction pyoderma is a purulent bacterial infection of the skin. pyoderma can be classified into primary and secondary types.1 within bacterial skin disease, primary and secondary pyoderma are the most common condition. based on 18 prevalence studies in developing countries, all reported that pyoderma was the most common skin disease in children (0.2–35%). the prevalence of pyoderma in indonesia was 1.4% on adults, and 0.2% on children.2 pyoderma is most prevalent in the age group of below 10 years old (48%).3 studies about skin disorder prevalence in elementary schools in kerala4 stated that the prevalence of pyoderma on elementary school students was 4.2%. pyoderma attacks male more often than female.2,3,5 factors influencing pyoderma are low education, low socioeconomic level, low personal hygiene and unhealthy house.2,6,7 low levels education may contribute to the low level of socio-economic families.8 pyoderma is more frequent on the lower social-economic class.2,3 low socioeconomic level will cause low nutrient intake, hence causing the immune system of the body decrease. lower body immune has higher chance of getting skin infection. low socioeconomic level can also cause a person to live in unhygienic home and crowded environment.6 previous study stated that most of the subjects who suffered pyoderma lived in unhygienic house or environment (43.3%) and had poor personal hygiene (66.7%).7 poor personal hygiene facilitates colonization, infection, and transmission of staphylococcus aureus, as a causative organism of pyoderma.9 since there was insufficient data about pyoderma in jatinangor sub district, this study was conducted to assess the relation between risk factors of pyoderma and pyoderma incidence. methods this study used a cross-sectional study design. althea medical journal. 2016;3(3) 435 the population was primary school children in jatinangor sub district, in the academic year of 2013–2014. this study was conducted on 4 state primary schools in jatinangor. the study was conducted from august–november of 2013. the sample collection was done with multistage random sampling. from 12 village in jatinangor subdistrict, cipacing village was randomly selected. there were four elementary schools in cipacing village, where 196 students were randomly taken from those 4 elementary schools to be admitted into this study. inclusion criteria was students of first through third grade of the state primary school in the sub district of jatinangor. students aged 6–10 years old were consented to the study with permission from the headmaster to become a subject of this study. while the exclusion criteria was nonattendance at the time of physical examination. before the data were collected, informed consent was obtained. the subjects of this study had the right to agree or disagree on admitting into the study. this study had been approved by health research ethics, the local directorate of education, and the headmaster. the data collection procedure in this study consisted of physical examination and questionnaire filling. physical examination was conducted on the subjects. the examination was done in enclosed room which were attended by the researcher, the dermatologist and a teacher to accompany the subjects. at the time of examination, all subjects were asked to take off all of their clothes so that all parts of their body can be examined. physical examination was done accompanied by a dermatologist. the aim of the physical examination is to support the diagnosis of pyoderma on subjects. a questionnaire containing closed questions was designed. data of the questionnaire consisted of personal hygiene, socioeconomic level, home hygiene, parents’ level of education, as well as identity of the subjects consisted of age and sex. the questionnaire was subjected to a pilot trial on 30 parents for content validation purpose before it was distributed to the parents of the subjects. questionnaire filling was done by the parents of the subjects. questionnaire was given to the parents in two ways, first as directly from the researcher to the parents who accompanied their children to school, the second was to ask the subjects to give the questionnaire to their parents and to bring the questionnaire back in one to two weeks. all questions on the form had to be answered. socioeconomic level was calculated from the monthly income of parents. high socioeconomic level was stated when the monthly income is more or equal with minimal wage rate of the sub district of sumedang, which was rp1,380,000.00. for the personal hygiene of the subjects, a calculation of three hygiene scores were conducted. hygiene score consisted of daily frequency of handwashing (1=<6 times, 2=6–12 times, 3=>12 times), number of personal items being shared with other people (1=≥ 2 items, 2=1 item, 3=none) and weekly frequency of bathing (1=<7 times, 2=7–13 times, 3=>13 times). a poor personal hygiene was stated when the sum of those three scores is less or equal with 6.10 home hygiene was assessed with three aspects of scoring, which consisted of the components of house, sanitation and behavior. a house would be categorized into hygienic house when it reached score of 1068–1200. this hygienic house scoring was based on the technical guide to assess healthy houses, by the ministry of health indonesia in 2012. primary data of every subject that have been collected would be processed and analyzed using computerized statistical programs. personal hygiene and hygienic house data were statistically analyzed using independent t-test. sex, socioeconomic level and parents’ education level data were statistically analyzed using chi-square test. statistically significant was determined when p≤0.05 results the result of the study was obtained from questionnaire filling and physical examination on 196 students from the first through the third grade of primary schools in jatinangor. most of the study subjects were boys. the age range for subjects was 6–10 years old, averaging at 7.15 years old. most of the subjects had a low socioeconomic level (56.6%). the level of education on the parents was dominated by high school graduate (44.9%). from 196 research subjects, only few had poor personal hygiene (34.2%) and unhygienic houses (46.4%) (table 1). upon examining 196 subjects, four were found with pyoderma. as such, the prevalence of pyoderma on primary school students on elementary school students from first through third grade in the jatinangor sub district in 2013 was 2.0%. seen from a clinical presentation of pyoderma subjects, the types of pyoderma found in this study was lila indria depari, unwati sugiri, lola ilona: relation between risk factors of pyoderma and pyoderma incidence althea medical journal. 2016;3(3) 436 amj september 2016 table 1 respondent characteristic variable n (%) age (years old) 6 50 (25.5) 7 78 (39.8) 8 57 (29.1) 9 10 (5.1) 10 1 (0.5) sex male 103 (52.6) female 93 (47.4) socioeconomic level low 111 (56.7) high 85 (43.3) education level of parent not going to school 0 (0.0) elementary school 43 (21.9) junior high school 49 (25.0) senior high school 88 (44.9) college 16 (8.2) personal hygiene good 129 (65.8) poor 67 (34.2) healthy housing healthy 105 (53.6) unhealthy 91 (46.4) ecthyma (3 cases), bullous impetigo (1 case) and folliculitis (1 case). from four subjects who were found with pyoderma in physical examination, most suffered from the ecthyma type. the most commonly found location of pyoderma was the lower extremity (3 cases). there was no relation between sex and pyoderma (p=0.623). most of subjects with and without pyoderma in this study were male. education level of parents was also not related with pyoderma incidence (p=0.989). most of education level of parents in subject with and without pyoderma was senior high school. based on chi-squared test, there was no relation between socioeconomic level and pyoderma (p=0.742). socioeconomically, most subject with and without pyoderma had low socioeconomic level (table 2). according to independent t-test, personal hygiene was related with pyoderma incidence (p=0.041). subjects with pyoderma had lower mean of personal hygiene score. however, this study also found that there was no relation between healthy housing and pyoderma incidence (p=0.097). discussion this study found that the prevalence of pyoderma in the primary school children was 2.0%. this prevalence was still higher than the world health organization (who) reference on the prevalence of pyoderma among indonesian children in sumatra of 0.2%.2 higher prevalence in this study might be caused by the low socioeconomic and poor hygiene level of subject in this study. but the prevalence of this study was lower than the previously reported prevalence among elementary school students in arab saudi11 (11.6%) and in kerala4 (4.2%). this was probably due to most of the subjects having good personal hygiene and hygienic houses. apart from that, all the subjects from pyodema prevalence research in saudi arabia11 were male. therefore, higher prevalence of pyoderma was possible to be achieved compared to the prevalence of pyoderma achieved in this study, because pyoderma occured mostly in male compared to female.2,3 this study showed there was no relationship between sex and pyoderma. khalifa et al.8 study, among primary school children in baghdad, was also mentioned that there was no significant sex variations in the prevalence of skin diseases, included pyoderma (p=0.74). pyoderma in this study was more common in male than female. this results supported the previous study conducted by gandhi et al.3 in india and data who.2 personal hygiene was related to pyoderma incidence in this study. this result supported the previous studies by sutisna et al.7 who conducted a study in sultan agung hospital, in indonesia. the study also showed that there was association between personal hygiene and pyoderma (p<0.05). study conducted by el gilany et al.12 in mansoura university hospital, stated that furunculous recurrence was associated with poor personal hygiene. study in mali2 also stated that there was significant correlation between personal hygiene and pyoderma (odd ratio=1.68). the study about effect of handwashing on child health said about incidence of impetigo was 36% lower in children that received antibacterial soap and taking a bath every day.13 according to althea medical journal. 2016;3(3) 437 data who in 2005, higher use of water for washing was associated with reduced rate of impetigo (odd ratio=0.45).2 poor personal hygiene facilitates colonization, infection, and transmission of staphylococcus aureus, as a causative organism of pyoderma.1,2,9 most children with pyoderma in this study had a poor level of personal hygiene and most children without pyoderma had good personal hygiene. research in guwahati conducted by hazarika et al.14 also said that 48.0% of children with pyoderma had a poor level of hygiene. this study revealed that there was no relation between hygienic housing and pyoderma. this result was slightly different from the previous study conducted by sutisna et al.7 in sultan agung hospital, in indonesia. that study mentioned that there was significant correlation between environmental hygiene with pyoderma (p<0.05) and most of the subjects who suffer pyoderma were having an unhygienic house or environment.7 it might be caused by the different study design that used to find the relation between hygienic house and pyoderma. sutisna et al.7 study used casecontrol study design. according to indonesia health profile in 2010, hygienic housing was also influenced by house density level.15 high house density level or overcrowding can increase the likelihood of interpersonal contacts, which is one way of transmission for pyoderma.1,2 however, in this study, house density level was not assessed. there was no relation between socioeconomic levels with pyoderma incidence in this study. most children with and without pyoderma in this study had low socioeconomic level. from the previously reported study conducted by libu et al.4 in kerala, there was no significant difference between socioeconomic level and skin disease. however, study conducted by kharel et al.6 stated that there was significant risk ratio of socioeconomic status with recurrence of pyoderma. the different result from the two table 2 relation between sex, socioeconomic level and education level of parents and pyoderma incidence characteristic pyoderma (+) pyoderma (-) p(n=4) (n=192) n n(%) sex male 3 100 (97.1) 0.623 female 1 92 (98.9) socioeconomic level low 3 108 (97.3) 0.742 high 1 84 (98.8) education level of parent not going to school 0 0 (0.0) 0.989 elementary school 0 43 (100) junior high school 1 48 (98.0) senior high school 3 85 (96.6) college 0 16 (100) table 3 relation between personal hygiene and healthy housing and pyoderma incidence characteristic pyoderma (+) pyoderma (-) p 95% confidence intervalmean mean personal hygiene 6.25 7.07 0.041* 0.06–1.59 healthy housing 904.8 1043.2 0.097 44.26–321.20 note: *p<0.05 = significant lila indria depari, unwati sugiri, lola ilona: relation between risk factors of pyoderma and pyoderma incidence althea medical journal. 2016;3(3) 438 amj september 2016 previous study mentioned above might be caused by the different method that used to assess and determine socioeconomic level of subject. the previous study conducted by kharel et al.6 in nepal, used kuppuswamy scale to measure and determine socioeconomic level includes monthly wage, education level and occupation. whereas this study only assessed monthly wage to determined socioeconomic level. the difference of method used might cause different result of socioeconomic level of the subjects. this study also found that the educational level of parents was not related with pyoderma incidence. study among primary school children in kerala4 also found there was no significant association between education level of parents and skin disease, included pyoderma. however, study in baghdad8 stated there was significant association between education level of parents and skin disease. this difference could be resulted from any other parental factor that was not assessed in this study, such as parental care and number of children in the family. parental care would affect the child’s hygiene. number of children was significantly associated with skin disease in children. as the number of children increase, parental attention and care may decrease.4 this study had several limitations in the process. the first limitation of the study was recall bias. subjects’ parents may have difficulty in memorizing the particular conditions that were asked in the questionnaire. therefore, their answers on the questionnaire might not accurate. the second limitation of the study was non response bias. subjects’ parents might give subjective answer on the questionnaire that differs from their actual condition. these conditions might happen in this study, because they did not want to be wrongly judged by their bad condition if they had given the real answers. from this study, it could be concluded that personal hygiene is one of the risk factors that related with incidence of pyoderma among primary school children in jatinangor sub district. the suggestion is school should make education program concerning cleanliness and hygienic life to students. it aims to prevent the occurrence of pyoderma. as well as education on the importance of treatment of pyoderma and pyoderma in students; therefore, students who are exposed will not transmit their disease. furthermore, there is a need for further research to identify risk factors pyoderma by using different research designs. references 1. wolf k, goldsmith la, katz si, gilchrest ba, paller as, leffell dj, editors. fitzpatrick’s dermatology in general medicine. 7th ed. new york: mcgraw-hill companies; 2008. p.1689–709. 2. who. epidemiology and management of common skin disease in children in developing countries. geneva: who; 2005. p. 4–19. 3. gandhi s, ojha ak, ranjan kp, neelima. clinical and bacteriological aspects of pyoderma. n am j med sci. 2012;4(10):492–5. 4. libu, bina t, raphael l, e.balakrishnan s, george b, samson jf, et al. prevalence and socio-demographic determinants of skin disease among lower primary school children in calicut, kerala. kerala med j. 2010;10(5):185–90. 5. emodi ij, ikefuna an, uchendu u, duru ua. skin disease among children attending the out patient clinic of the university of nigeria teaching hospital, enug. afr health sci. 2010;10(4):362–6. 6. kharel c, pandey ss, agrawal s, bhattarai m. socioeconomic and nutritional status of children with pyodermas. njdvl. 2012;10(1):11–5. 7. sutisna ia, harlisa p, zulaikhah st. hubungan antara hygiene perorangan dan lingkungan dengan kejadian pioderma. sains medika. 2011;3(1):24–30. 8. khalifa ka, al-hadithi ts, al-lami fh, aldiwan jk. prevalence of skin disorders among primary school children in baghdad governorate, iraq. east mediterr health j. 2010;16(2):209–13. 9. leekha s, diekema dj, perencevich en. seasonality of staphylococcal infections. clin microbiol infect. 2012;18(10):927– 33. 10. turabelidze g, lin m, wolkoff b, dodson d, gladbach s, zhu bp. personal hygiene and methicillin-resistant staphylococcus aureus infection. emerg infect dis. 2006;12(3):422–7. 11. amin t, ali a, kaliyadan f. skin disorders among male primary school children in al hassa, saudi arabia: prevalence and sociodemographic correlates-a comparison of urban and rural populations. rural remote health. 2011;11(1):1517. 12. el-gilany ah, fathy h. risk factor of reccurent furunculosis. dermatol online j. 2009;15(1):16. 13. luby sp, agboatwalla m, feikin dr, althea medical journal. 2016;3(3) 439 painter j, billhimer w, altaf a, et al. effect of handwashing on child health: a randomised controlled trial. lancet. 2005;366(9481):225–33. 14. hazarika n. a clinico-epidemiological study of pyoderma in children. nat j res com med. 2012;1(4):178–241. 15. rosita r, soepardi j, brahim r, sitohang v, zulkarnaen i, sunaryadi, et al. indonesia health profile 2010. in: indonesia ministry of health republic of indonesia, editor. jakarta: ministry of health republic of indonesia; 2011. p. 26. lila indria depari, unwati sugiri, lola ilona: relation between risk factors of pyoderma and pyoderma incidence althea medical journal. 2016;3(4) 605 five-year data of clinical characteristics and laboratory findings of hospitalized hemophilic patients in dr. hasan sadikin general hospital dina marlina,1 lelani reniarti,2 fifi veronica3 1faculty of medicine universitas padjadjaran, 2department of child health faculty of medicine universitas padjadjaran/dr. hasan sadikin general hospital, bandung, 3department of anatomy faculty of medicine universitas padjadjaran abstract background: hemophilia a has the highest incidence, more than 80% of 172.323 cases worldwide in 2012. it is stated that clinical characteristics of hemophilia a is worse than others, so it is required to prove and to know further about the clinical characteristics and severity likelihood in all hemophilic patients in order to prevent re-bleeding and re-injury and also for a better medical response. methods: a retrospective cross-sectional study was carried out to 43 medical records of hospitalized hemophilic patients from 2009 to 2013 in dr hasan sadikin general hospital. the inclusion criteria were a complete patient identity (name, age, sex), written chief complaint, complete physical examination (bleeding, edema, hematoma, hemarthrosis, anemic symptoms) and laboratory test results (factor level, hemoglobin, hematocrit, platelet and activated partial thromboplastin time). the data was collected from august‒october 2014, analyzed and presented using frequency distribution. results: most of the patients were 5-10 years old, male and had hemophilia a. the most common complaint was external bleeding, followed by edema. from 43 patients, 38 (88%) cases were classified as severe factor deficiency, had mild to severe anemia, however the platelet count in most of the cases was in normal value. about 91% cases had prolonged activated partial thromboplastin time in moderate to severe level. conclusions: similar with other studies worldwide, most of the hospitalized hemophilic patients have hemophilia a. most of the patents has moderate to severe bleeding with laboratory test result between moderate to severe level as well. [amj.2016;3(4):605–9] keywords: bleeding, hemophilia, laboratory findings, severity correspondence: dina marlina, faculty of medicine, universitas padjadjaran, jalan raya bandung-sumedang km.21, jatinangor, sumedang, indonesia, phone: +6287821281609 email: dinamarlinaa@gmail.com introduction hemophilia is an x-linked disease caused by mutation in sex chromosome resulting in protein deficiency named coagulation factors.1,2 among several type of coagulation factors, deficiency factor viii, ix, and xi occur in hemophilic patients. deficiency of those factors contributed to a certain type of hemophilia, namely hemophilia a for factor viii deficiency, hemophilia b for factor ix deficiency, and hemophilia c for factor xi deficiency.2 from 172.373 hemophilic cases worldwide in 2012, about 80% cases were hemophilia a, 16% cases were hemophilia b, and the rest was hemophilia c and other bleeding disorders. because it is an x-linked disease, hemophilia is more common found in male than female. moreover, incidence of this disease in children is quite high, about 1 in 5.000 children.3 furthermore, clinical manifestation in hemophilia is bleeding. bleeding can occur spontaneously or is caused by any injury or surgery. bleeding may happen in many parts of the body, usually it is found in gum, nose (epistaxis), skin (echymosis), and joints either in upper or lower extremities which may cause hematoma etc. bleeding can also occur in vital organs such as kidney (causing hematuria), gastrointestinal tract (causing hematemesis), and the most dangerous bleeding is in the retroperitoneal space, causing blood accumulation in abdomen.4,6 althea medical journal. 2016;3(4) 606 amj december 2016 besides the bleeding sign, the patient will experience pain in joint, causing immobility. additionally, laboratory abnormality also found such as factor level, sometimes hemoglobin, hematocrit level, and platelet deficiency, and also prolonged activated partial thromboplastin time (aptt).4 currently, management for hemophilia is only limited by replacement therapy and symptomatic drugs, which means that there is no definitive therapy yet. so, aggravating sign and symptoms have to be prevented starting from the first time the patients come. one of the ways to provide better care is by knowing the characteristics of each clinical manifestation and the likelihood of severity. the aim of this study was to identify the severity likelihood of clinical manifestation in hemophilic patients. methods a retrospective cross-sectional study was carried out during august-october 2014 at the hemato-oncology child health department, dr. hasan sadikin general hospital bandung. a total of 87 medical records of hospitalized hemophilic patients from 2009 to 2013 were succesfully collected, but only 43 (49.42%) medical records met the inclusion criteria, which were a complete patient identity (name, age, sex), written chief complaint, complete physical examination (bleeding, edema, hematoma, hemarthrosis, anemic symptoms) and laboratory test result (factor level, hemoglobin, hematocrit, platelet and aptt). forty four samples (50.57%) were excluded due to incomplete data and having other chronic diseases affecting the laboratory result such as typhoid, dengue, meningitis, thalassemia, tbc, etc.7 the data was collected from august‒ october 2014 and was classified into hemophilia a, b, and c. next, characteristics of clinical manifestation based on the severity were distributed to each type of hemophilia. the result was a frequency distribution of each type of hemophilia with severity likelihood for every clinical manifestation and laboratory findings. meanwhile, ethical clearance has been approved by the health research ethics committee, faculty of medicine, universitas padjadjaran in order to access the patient medical records. result most of the hospitalized hemophilic patients table 1 characteristics and type of hospitalized hemophilic patients characteristic and type of hemophilia total (%) (n=43) age (years) 0‒4 14 (33) 5‒10 25 (58) 11‒14 4 (9) sex male 42 (98) female 1 (2) type of hemophilia hemophilia a 35 (81.4) hemophilia b 4 (9.3) hemophilia c 4 (9.3) table 2 chief complaint of hospitalized hemophilic patients (n=43) chief complaint total (%) bleeding (external) 25(58.14) edema 12(27.90) hematoma 4(9.30) joint pain 1(2.33) unconsciousness 1(2.33) total 43(100%) who met the inclusion criteria were 5-10 years old and male. in terms of the type of hemophilia, most of the patients had hemophilia a (table 1). as mentioned in the introduction, the most common complaint of hemophilia is bleeding. this study showed that about 58.14% cases had external bleeding, followed by edema. hematoma and joint pain only occurred in a small percentage (table 2). the factor level deficiency proved to be the main cause for hemophilic patients to experience bleeding. among 43 patients, 38 (88%) cases were classified as severe factor deficiency, in terms of bleeding severity, 19 (44%) cases were distributed in moderate level, the remaining (mild and severe level) was almost equally distributed. the hemophilic patients are commonly tested for anemic sign due to blood lost. the anemic state is seen from the result of the measurement of hemoglobin althea medical journal. 2016;3(4) 607dina marlina, lelani reniarti, fifi veronica: five-year data of clinical characteristics and laboratory findings of hospitalized hemophilic patients in dr. hasan sadikin general hospital and hematocrit level. most of the cases had mild to severe anemia and only 42% cases had no anemia. this situation also occurred in hematocrit level. moreover, the platelet count in most of the cases was in normal value. moreover, an interesting result was discovered in this study, about 91% cases had prolonged aptt in moderate to severe level. discussion this study showed that most of the hospitalized hemophilic patients in dr hasan sadikin general hospital from 2009-2013 had hemophilia a. this result was similar with previous studies conducted by the world federation for hemophilia (wfh)3 and josephson8 which stated that among the total of hemophilia patients, more than 80 % of them were hemophilia a. a study by shawky et al.9 recorded that there were more hemophilia a patients (6.26%) than hemophilia b patients (0.55%) at pediatric clinic, ain-shams university hospitalin in egypt. the most common clinical sign that become the chief complaint of the patients was external bleeding. this finding is similar with a study conducted by liu et al.7 besides this study discovered the severity level of various laboratory test results. most of the cases had severe factor deficiency. similar result was discovered in a study carried out by the national hemophilia foundation (nhf)10. about 60–70% from the total hemophilic population worldwide is in the severe factor level deficiency. regarding the type of hemophilia, a previous study by liras et al.2 showed that 40% of cases of hemophilia a and hemophilia b, respectively, contributes to severe level of factor deficiency. in this study, about 75–80% of patients for each type was distributed in the severe level. on the other hand, another study conducted by ghaniema et al.11 showed a different result. they mentioned that 60% of their samples were in the moderate level of factor deficiency. moreover, the bleeding sign was also classified into mild, moderate and severe level. the bleeding sign for hemophilic patients who were hospitalized in dr. hasan sadikin general table 3 clinical manifestation and laboratory findings based on type of hemophilia clinical manifestation severity hemophilia total a(%) b(%) c(%) factor level mild (6‒46%) 1 (2) 1 (2) moderate (1‒5%) 3 (7) 1 (2) 4 (9) severe (<1%) 31 (72) 3 (7) 4 (9) 38 ( 88) bleeding mild (no spontaneous bleeding) 11 (26) 1 (2) 12 (28) moderate (sometimes spontaneous bleeding) 13 (30) 3 (7) 3 (7) 19 (44) severe (often spontaneous bleeding) 11 (26) 1 (2) 12 (28) hemoglobin level normal (≥115 g/l) 15 (35) 1 (2) 2 (5) 18 (42) mild (110‒114 g/l) 2 (5) 1 (2) 3 (7) moderate (80‒109 g/l) 4 (9) 2 (5) 1 (2) 7 (16) severe (≤80 g/l) 14 (33) 1 (2) 15 (35) hematocrit level normal (35‒48%) 10 (23) 1 (2) 2 (5) 13 (30) mild (32‒35%) 9 (21) 9 (21) moderate (28‒32%) 2 (5) 2 (5) 4 (7) severe (<28%) 14 (33) 1 (2) 2 (5) 17 (40) platelet level normal (150.000‒450.000/mm3) 25 (58) 3 (7) 28 (65) increase (>450.000/mm3) 10 (23) 4 (9) 1 (2) 15 (34) aptt normal (18‒28 second) 1 (2) 1 (2) 2 (4) mild (<40 second) 1 (2) 1 (2) 2 (4) moderate to severe (>40 second) 33 (77) 3 (7) 3 (7) 39 (91) althea medical journal. 2016;3(4) 608 amj december 2016 hospital from 2009 to 2013 was distributed in moderate level. this study showed that most of the hemophilia a cases had moderate to severe level of bleeding compared to the hemophilia b cases that had mild to moderate level of bleeding severity. additionally, fasulo et al.12 stated that hemophilia b had a milder manifestation than hemophilia a. another laboratory test for hemophilia patients was the measurement of hemoglobin level. this study discovered that most of the patients had mild to severe level of anemia, although there were still 42% cases that had no anemia. besides, significant hemoglobin and hematocrit level decrement resulted in anemic sign and were related to bleeding sign. a previous study conducted by buchanan and holtkamp13 stated that hemoglobin level decrement could occur in hemophilic patients, while in fact, blood lost due to bleeding in hemophilia rarely causes anemia. there was another factor causing anemia in hemophilia cases which was still unknown. the number of patients with a normal platelet level was higher than a decreased or increased platelet level. the interesting finding discovered in this study was that the platelet level mostly increased. a study conducted by yee14 stated that the platelet level decrement likelihood would be found in severe hemophilia unless hemophilia is still in a mild stage. furthermore, appt prolongation occurred in most cases. this condition occurred due to the severity of factor level deficiency or bleeding. if the factor level deficiency and bleeding sign were in severe level, it would cause significant aptt prolongation. previous studies conducted by tantawy6 and cuker et al.15 stated that aptt would be normal in mild hemophilia while prolonged aptt would be found in severe hemophilia. this study still had limitations. the sample size was very small, so it was difficult to compare the severity of each type of hemophilia. moreover, this study was carried out in a top referral hospital so it was suspected that most cases which came to this hospital were already in the moderate to severe state. it can be concluded that most of the hospitalized hemophilic patients has hemophilia a. most of the patients has moderate to severe bleeding with laboratory test result between moderate to severe level as well. references 1. hussain r, abid 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